hrev_master [page 8] [healthcare in low-resource settings 2014; 2:1785] growth chart: passport to child health care in low-resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, under the united nations millennium declaration, 189 countries had adopted the target to achieve millennium development goals (mdg) by the year 2015.1 the prevalence of underweight children under-five years of age is an indicator to measure progress towards mdg-1, which aims to halve the proportion of people who suffer from hunger between 1990 and 2015.1 globally, underweight prevalence has declined from 25% in 1990 to 16% today. the greatest reductions have been achieved in central and eastern europe, however the situation still remains grim in developing nations and in low-resource settings.2 in 2011, an estimated 101 million under-five children were underweight worldwide with the highest contributions from south asia (59 million) and sub-saharan africa (30 million).2 the physical growth of infants and underfive children has been recognized as an important parameter to assess health and wellbeing.2,3 multiple interventions – specific (such as use of growth charts, prevention and treatment of acute malnutrition/micronutrient deficiencies, safeguarding the maternal nutritional status, compliance with the infant and young child feeding practices exclusive breastfeeding for six months followed by complementary feeding, etc.) as well as general (such as promotion of good sanitation practices and access to clean drinking water, promotion of utilization of healthcare services by community involvement, etc.) have been implemented to counter the problem of undernutrition.4,5 in low-resource settings, supervision and monitoring of growth of under-five children is of immense significance, as it can aid in early detection of acute malnutrition. the growth chart or road-to-health chart is a visual display of the child’s physical growth. it is designed primarily for the longitudinal follow-up of a child, so that changes over time can be interpreted.5 growth chart has a unique role in rural and tribal areas where people do not have access to specialists/tertiary care centers/laboratory services readily.3,4 growth charts help in detecting whether a child is receiving adequate nutrition required for the basic physiological need of growth and development.3,6 different types of growth charts have been developed and utilized in varied settings for accurate monitoring of growth of children.3,6,7 apart from growth monitoring, the chart has many potential uses such as a diagnostic tool for identifying high risk children; for planning and designing of policies at the local and central level based on extent of malnutrition prevalent in an area; as an educational aid to illiterate mothers by encouraging her to participate actively in growth of her child; for assisting health worker to decide the type of intervention needed for specific children; and for evaluating the effectiveness of corrective measures / special interventions employed.3,5,6 to conclude, growth chart is a scientifically sound, robust tool for monitoring health, well-being and nutritional status of infants and young children in different settings. it is an irreplaceable tool in low-resource settings where if used diligently, can significantly minimize the prevalence of malnutrition and associated complications. references 1. who. millennium development goals. geneva: world health organization ed.; 2013. available from: http://www.who. int/mediacentre/factsheets/fs290/en/ 2. cole tj. the secular trend in human physical growth: a biological view. econ hum biol 2003;1:161-8. 3. grummer-strawn lm, reinold c, krebs nf. use of world health organization and cdc growth charts for children aged 0-59 months in the united states. mmwr morb mortal wkly rep 2010;59:1-13. 4. unicef. improving child nutrition: the achievable imperative for global progress. new york, ny: unicef ed.; 2013. available from: http://www.unicef.org/ publications/ index_68661.html 5. park k. preventive medicine in obstetrics, pediatrics and geriatrics. in: park k, eds. text book of preventive and social medicine. 21st ed. jabalpur: banarsidas bhanot; 2011. pp 502-5. 6. who. who child growth standards. geneva: world health organization ed.; 2006. available from: http://www.who.int/ childgrowth/standards/technical_report.p df 7. gulati ak, kaplan dw, daniels sr. clinical tracking of severely obese children: a new growth chart. pediatrics 2012;130:1136-40. healthcare in low-resource settings 2014; volume 2:1785 correspondence: saurabh rambiharilal shriva stava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: growth chart, underweight, lowresource settings, millennium development goals. contributions: ss: conception and design, drafting of the article, review of literature, guarantor; ps: drafting the article, review of literature, revising it critically for important intellectual content; jr: general supervision of the research, overall guidance in writing the manuscript. conflicts of interests: the authors declare no potential conflict of interests. received for publication: 29 june 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1785 doi:10.4081/hls.2014.1785 non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:2151] [page 39] advanced bilateral breast cancer, stage t4c n3 m1 poras chaudhary, hemant khowal lady hardinge medical college and associated dr. ram manohar lohia hospital, new delhi, india abstract the present study reports a case of advanced bilateral breast cancer with distant metastasis of 4 years for which the patient did not seek any medical advice. the aim of reporting this case is to highlight the fact that such advanced cases are still seen in developing countries. introduction a 40-year-old lady had bilateral breast lump of 4 years over right side and 3 years over left side, involving almost the entire breast on both sides, for which she did not consult any clinician. she then developed multiple ulceration and nodules over right breast followed by left breast with complete distortion of nipple areola complex over right side followed by development of similar nodules over anterior abdomen (figure 1). case report breast biopsy was suggestive of invasive ductal carcinoma, estrogen and progesterone receptors were negative and her-2-neu was also negative, and biopsy from abdominal wall nodules was suggestive of metastatic deposits. imaging revealed metastasis to lungs and lumbar spine. this was a case of bilateral breast carcinoma, stage t4c n3 m1, and the prognosis is poor in such a case.1,2 chemo and radiotherapy with toilet mastectomy were the only option.1,2 bilateral toilet mastectomy was done and the patient received 3 cycles of chemotherapy (fec regime – 5-fluorouracil, epirubicin, and cyclophosphamide). after completion of 6 cycles of chemotherapy, the patient was reassessed and radiotherapy was given to the bony metastasis. a written consent for publishing her case was obtained from the patient. discussion it is not rare to see such locally advanced inoperable breast cancers with multiple distant metastases in many developing countries such as india. breast cancer accounts for 1934% of all cancer cases among women in india and carries a high mortality due to presentation at late stage of the disease. the reason for this kind of scenario is lack of awareness and non-existent breast cancer screening programs.3 somdatta et al.3 concluded that awareness about breast cancer is low amongst women even in urban community and there is a need for awareness generation programs. awareness regarding breast self examination among young generations is useful and it is the most important viable tool for early detection.4 gupta5 concluded that health education programs through various channels are needed to increase the awareness and knowledge about breast self examination. conclusions in underdeveloped and developing countries, there is a need for awareness generation programs to educate about breast cancer to decrease mortality due to this common cancer. references 1. novoa va. toilet mastectomy: palliative treatment in women with advanced breast cancer. ginecol obstet mex 2002;70:392-7. 2. russell rcg, norman sw, christopher jkb. bailey and love’s short practice of surgery. london, uk: crc press; 2004. 3. somdatta p, baridalyne n. awareness of breast cancer in women of an urban resettlement colony. indian j cancer 2008;45: 149-53. 4. shalini, varghese d, nayak m. awareness and impact of education on breast self examination among college going girls. indian j palliat care 2011;17:150-4. 5. gupta sk. impact of health education intervention program regarding breast self examination by women in a semi-urban area of madhya pradesh, india. asian pac j cancer p 2009;10:113-7. healthcare in low-resource settings 2014; volume 2:2151 correspondence: poras chaudhary, lady hardinge medical college and associated dr ram manohar lohia hospital, baba kharak singh marg, new delhi 110001, india. tel./fax: +91.9891.4473.358. e-mail: drporaschaudhary@yahoo.com key words: bilateral breast cancer, toilet mastectomy, india. received for publication: 23 november 2013. revision received: 31 january 2014. accepted for publication: 2 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. chaudhary and h. khowal 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:2151 doi:10.4081/hls.2014.2151 figure 1. ulceration over bilateral breast with distortion of nipple areola complex over right side and nodules over anterior abdominal wall. non -co mmerc ial us e o nly hrev_master [page 22] [healthcare in low-resource settings 2013; 1:e6] safety of dispensing prescribed iron formulation in childresistant containers among pharmacies in saudi arabia: a cross-sectional survey nahar d. alruwaili,1 mohammed alomar,1 ismaeel sabei,1 abdelmoneim eldali2 1department of emergency medicine, king faisal specialist hospital and research centre, riyadh; 2department of biostatistics and epidemiology, research centre, king faisal specialist hospital and research centre, riyadh, saudi arabia abstract iron overdose remains a significant public health threat to young children. unit dose packaging of potent iron supplements is expected to reduce the frequency of severe pediatric iron overdose incidents. interna tional regulations require child-resistant iron packages. we aim to know if iron is dispensed in child-resistant containers (crcs) and to emphasize the importance of using them. a prospective cross-sectional observational study assessing the proper dispensing of ferrous sulfate tablets in crcs from major city pharmacies. forty government and private pharmacies were visited. ferrous sulfates with a total of 600 to 6500 mg elemental iron per package were found. the package of 6000 mg was the most commonly found. most of the packages with high concentrations are dispensed from the government hospitals and primary healthcare centers pharmacies. none of the pharmacies dispensed iron in crcs. to conclude, pharmacies dispensed iron in non-crcs. public health efforts on increasing awareness and improving packaging are highly needed. authority regulations to use child-resistant iron packaging are required. introduction iron poisoning is a common pediatric toxicological emergency and this is related to the common uses of iron supplementation in substances for both children and adults. iron toxicity is usually described in four stages, although the clinical manifestations may overlap. shortly after ingestion, the corrosive effects of iron cause vomiting and diarrhea, usually bloody. massive fluid or blood loss may cause shock and death. patients who survive this phase may experience a latent period of apparent improvement over 12 h. this may be followed by an abrupt relapse with coma, shock, seizures, metabolic acidosis, coagulopathy, hepatic failure, and death. the severity of iron poisoning is based on the amount of elemental iron ingested which can be calculated based on elemental iron in the salt. children may show signs of toxicity with ingestions of 10-20 mg/kg of elemental iron. serious toxicity is likely with ingestions of more than 60 mg/kg.1 approximately 70% of the poisonings involved children younger than two years of age and approximately 59% of the poisonings involved oral prescription, and non-prescription drugs, or supplements.2 most substances involved in accidental ingestion had been stored where it was convenient to take, which made it readily accessible to children. children younger than six years make up the largest percentage of iron exposures.3 in 1970, the poision prevention packaging act (pppa) authorizes the united states (us) consumer product safety commission (cpsc) to require the use of special child-resistant containers (crcs) for a wide range of toxic substances used in or around the home including most oral prescription drugs.4 the pppa defines special packaging as packaging that is designed or constructed to be significantly difficult for children under 5 years of age to open or obtain a toxic or harmful amount of the substance contained therein within a reasonable time and not difficult for normal adults to use properly, but does not mean packaging which all such children cannont open or obtain a toxic or harmful amount within a reasonable time.5 unit-dose packaging of potent iron supplements is expected to reduce the frequency of severe pediatric iron overdos incidents 6 consumer product safety commission regulations require child-resistant packaging for retail packages containing 250 mg or more of elemental iron.7 the use of crcs yield no reported pediatric deaths in usa from iron poisoning in 2010 in the usa.8 though exposures to iron and iron-containing products in the developed countries have been slowly dropping during the previous decade and due to significant public health efforts at increasing awareness and improving packaging, iron overdose remains a significant public health threat to young children. there are more than seventy governmental and private hospitals, 377 governmental and 758 private dispensaries and 1924 private pharmacies in riyadh region.9 however, there is a lack of research that examines the use of crcs when dispensing oral iron tablets in local pharmacies in riyadh. currently, there are no laws regulating the use of crcs in saudi arabia. we hypothesized that crcs are not used to dispense oral iron tablets. hence, this study was to examine the use of crcs when dispensing oral iron tablets at local pharmacies in riyadh. the primary goal of this study was to survey the safety of dispensing prescribed iron formulations in crcs among pharmacies in riyadh city. the secondary goal of this study was to emphasize the importance of using crc, as one of the best-documented successes in preventing the unintentional poisoning of children from pharmaceutical agents toxicity. materials and methods this was a prospective cross-sectional observational study of using crcs in dispensing prescribed oral iron. the study was based on a structural unified questionnaire that was filled by the investigator during each visit to the pharmacies. a research participant information sheet was distributed to all participants. informed consent was taken verbally by the investigator at the beginning of the study. forty pharmacies from governmental, private hospitals and dispensaries as well as commercially pharmacies were randomly selected from five different quarters in riyadh. investigators were taught about different types and shapes of crcs and each one of them was responsible to collect the data from the specific type and region of the pharmacies healthcare in low-resource settings 2013; volume 1:e6 correspondence: nahar d. alruwaili, department of emergency medicine, king faisal specialist hospital and research center, p.o. box 3354 mbc 84, takhassusi street, 11211 riyadh, saudi arabia. tel. +966.1.442.4425 fax: +966.1.442.3429. e-mail: nalrowaily@kfshrc.edu.sa key words: child-resistant containers, iron poisoning, pediatric poisoning, child-resistant closures. contributions: na, ma, and is, proposal writing and data collection; ae, data analysis; na and ma, manuscript writing. conflict of interests: the authors declare no potential conflict of interests. received for publication: 17 december 2012. revision received: 24 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. alruwaili et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e6 doi:10.4081/hls.2013.e6 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e6] [page 23] to avoid any duplication. ferrous sulfate tablets were selected as they are commonly precribed in oral form for adults. the data were collected including: type of pharmacy, strength of the tablets, total amount of elemental iron per tablets, total amount of elemental iron per package and the use of crcs. the confidentiality of collected data was protected. the office of research affairs approval was obtained and verbal consent was obtained from participants. each pharmacy was given a serial number without mentioning the name of the pharmacy during the data collection. data collected were presented as mean standard deviation (sd) for continuous variables, and as percentages for categorical variables. the sas version 9.2 was utilized to analyze the data. results forty government and private pharmacies were visited. ferrous sulfates with a total of 600 to 6500 mg elemental iron per package were found (elemental iron range was 20-65 mg/tablet). the packages of 6000 mg (16 pharmacies) and 1800 mg (14 pharmacies) were the most commonly found (table 1). most of the packages with high concentrations are dispensed from the government hospitals and primary healthcare center pharmacies (figure 1). all of the governmental hospitals dispensed iron with an amount equal or more than 4500 mg per package; all of government primary healthcare centres dispensed iron with an amount of 6000 mg per package; and all of the private pharmacies dispensed iron in amout equal or less than 300 mg per package. in this study we found that none of the pharmacies dispensed iron in crcs. discussion unintentional child poisoning is an important public health concern and we need to implement strategies to prevent it by using crc in dispensing iron tablets. a review of mortality data in children younger than 5 shows a significant descrease in deaths after enforcement of the child-resistant packaging legislation.10-13 one of the cpsc studies done by rodgers showed that there is a reduction in the rate of fatalities of up to 45% from levels in the absence of special packaging requirements for orally prescriped medications, resulted in about 24 fewer child deaths annually.5 another study done by the same researcher found that the use of child-resistant packaging was associated with a 34% reduction in the aspirin-related child mortality rate and this mortality rate reduction equates to the prevention of about 90 child deaths during the 1973-1990 post-regulatory period.11 walton found that unintentional poisoning of substances requiring child-resistant closures has declined from 5.7/1000 children in 1973 to 3.4/1000 children in 1978 and concluded that child-resistant closures have prevented nearly 200,000 accidental ingestions since 1973 till the time of his study. over a 20-year period, the death rate due to poisonings of children has declined from 2.0/100,000 children to 0.5/100,000.14 though this is the first pilot study in determining the use of crcs in saudi arabia, we found that none of governmental or private pharmacies dispensed pakcages containing more than 250 mg of elemental iron in crcs. article table 1. iron per tablet and per package by pharmacy type. iron per tablet amount per package pharmacy type total (mg) (mg) private hospital government hospital government primary private pharmacy healthcare centre 20 600 1 0 0 0 1 30 900 1 0 0 0 1 45 1800 4 0 0 10 14 47 3000 4 0 0 0 4 60 4500 0 1 0 0 1 65 4700 0 1 0 0 1 100 6000 0 6 10 0 16 65 6500 0 2 0 0 2 total 10 10 10 10 40 use of crc no no no no crc, child-resistant container. figure 1. maximum elemental iron per package (mg) dispensed from different healthcare structures. non -co mmerc ial us e o nly [page 24] [healthcare in low-resource settings 2013; 1:e6] most of the packages with high concentrations were dispensed from the governmental hospitals and primary healthcare centers pharmacies and this is related to the fact that we used the duration of 4-6 weeks instead of testing only one package in the other pharmacies to estimate the total of elemental iron per package.even though it is recommended to use crcs for prescribed oral medications there are several factors known to limit the effectiveness of crc packaging regulations, including that crcs are not childproof and the testing protocol requires only 80% of children less than 5 years of age to be unable to open child-resistant packages. hence, even with the introduction of crc in pediatrics, unintentional poisoning remains an important public health concern. since iron poisoning is one of the fatal poisonings and needs to be dispensed in crcs, we can generalize our study findings that other fatal medications are not dispensed in crcs too in our region. the findings in this study are subject to several limitations. one of these is our sample size, but since we found all of the pharmacies not dispensing iron in crcs, we think that increasing the sample size will not change the fact that there is no regulation to enforce its use. conclusions pharmacies dispense iron in non-crcs. public health efforts on increasing awareness and improving packaging are highly needed. authority regulations to use child-resistant iron packaging are required. references 1. perrone j. iron. in: flomenbaum ne, goldfrank lr, hofman rs, howland ma, lewin na, nelson ls, eds. goldfrank’ toxicologic emergencies. 8th ed. new york, ny: mcgraw-hill; 2006. pp 629-42. 2. franklin rl, rodgers gb. unintentional child poisoning treated in united states hospital emergency departments: national estimates of incident cases, populationbased poisoning rates, and product involvement. pediatrics 2008;122:1244-51. 3. bronstein ac, spyker da, cantilena lr, et al. annual report of the american association of poison control centers’ national poison. alexandria, va: american association of poison control centers ed.; 2008. 4. american regulation. application of the public law 91-601, 84 stat. 1670, poison prevention packaging act of 1970. 15 u.s.c, pp. 1471-1477. available from: http://www.cpsc.gov/global/pdf/statues/pp pa.pdf 5. rodgers gb. the safety effect of childresistant for oral prescription drugs. two decades of experience. jama-j am med assoc 1996;275:1661-5. 6. morris c. pediatric iron poisoning in the united sates. south med j 2000;93:352-8. 7. office of the federal register. certain preparations containing iron. amendment to child-resistant packaging standards, 43 federal register 17332 (1978). codified at 16 cfr, § 1700. washington, dc: office of the federal register ed.; 1976. 8. bronstein ac, spyker da, cantilena lr, et al. annual report of the american association of poison control centers’ national poison. alexandria, va: american association of poison control centers ed.; 2010. 9. ministry of health, saudi arabia. statistical book of the year 2009. riyad: ministry of health ed.; 2009. available from: http://www.moh.gov.sa/en/ministry/ s tat is t ics /book/pages /defaul t .aspx accessed: 25/11/2011. 10. schwartz mk. poison prevention. j pediatr health car 1993;7:143-4. 11. rodgers gb. the effectiveness of childresistant packaging for aspirin. arch pediat adol med 2004;156:929-33. 12. liebelt el, shannon mw. small doses, big problems: a selected review of highly toxic common medications. pediatr emerg care 1993;9:292-7. 13. us consumer product safety commission. cpsc requires child-resistant packaging for common household products containing hydrocarbons, including some baby oils. bethesda, md: us consumer product safety commission; 2002. available from: http://www.cpsc.gov/ cpsc pub/prerel/prhtml02/02015.html accessed: 25/11/2011. 14. walton ww. an evaluation of the poison prevention packaging act. pediatrics 1982;69: 363-70. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:5465] [page 45] surrogacy: blessing or curse to poor society in india venkatashivareddy b,1 arti gupta,1 viviktha ramesh2 1department of community medicine, veer chandra singh garhwali government medical sciences and research institute, uttarakhand; 2centre for community medicine, all india institute of medical sciences, new delhi, india abstract the advances of childbirth in the form of test tube babies and surrogate have introduced undreamt possibilities. the reproductive tourism in india is enhancing. globally, india is one of the popular providers of surrogates and commercial surrogacy is legalized. moreover, the cost is a mere one third of the cost in developing countries. surrogacy raises ethical issues like medical advocacy and consent. many social factors like unemployment, literacy, and others play a key role in surrogacy. surrogacy is a public health problem related not only to the medical burden but also to sex ratio deterioration, female feticide, domestic violence, and others. introduction the human body is an incredibly complex and intricate system, one that wonders doctors on a regular basis. complex biological, cultural, and psychological relations, hence reproductive health, govern reproductive behavior and rights must be understood within the context of relationships between men and women, communities and societies. the advances of childbirth in the form of test tube babies and surrogate motherhood have introduced undreamed possibilities. the literal meaning of surrogate is substitute. the word surrogate means appointed to act in the place of another.1 surrogacy agreement is the carrying of a pregnancy for intended parents. women who are infertile or unable to carry a pregnancy to term use this. there are three main types of surrogacy, gestational surrogacy, traditional surrogacy, and donor surrogacy. in gestational surrogacy, an egg is removed from the intended mother or an anonymous donor and fertilized with the sperm of the intended father or anonymous donor. in traditional surrogacy, a surrogate mother is artificially inseminated, by either the intended father or an anonymous donor, and carries the baby to term. in donor surrogacy, there is no genetic relationship between the child and the intended parents as the surrogate is inseminated with the sperm, not of the intended father, but of an outside donor.2 in its quest, the paper reviews the legal, ethical, commercial and public health aspects of surrogacy in india. india as a provider infertility is an emerging public health problem. this is contrasted with our conception over populated world.3 the large industry of intercontinental reproductive service provision has come mainly due to increased demand and advanced reproductive technologies from the developed world.4 delay in starting of families by educated and working women reduces their ability to become pregnant. the rise of lifestyle disorders like obesity, diabetes has certainly contributed to infertility.5 the united states is one of the world’s best provider of reproductive services. globally, india is one of the most popular providers of reproductive services. the reproductive tourism in india is enhancing for several reasons. there is easy availability of english speaking, and highly trained doctors. there is the presence of well-developed and recognized medical tourism infrastructure, and medical care integrated travel, hotel, and insurance services. also, lower costs of medical treatment in india attract the foreigners to utilize the benefits of medical tourism, especially surrogacy. in addition, the advantageous currency exchange rate leads to lower prices. due to the restrictiveness of their own countries, foreigners engage in a surrogacy contract arrangement in india. moreover, the maternal surrogacy presents an opportunity for very poor women to make easy improvements in their financial crisis. therefore, globally increasing prevalence of infertility and enlarging poor society of india assures reproductive tourism industry continues to grow in india.6 surrogacy: legislative and financial aspects law, at a particular time, represents the societal mindset and undergoes radical changes to align itself with social change. in uk and japan, commercial surrogacy arrangements are prohibited by the surrogacy arrangement act 1985. however, in the usa and australia, the surrogacy legal issues fall under state jurisdiction and the situation for surrogacy differs from state to state. in russia commercial surrogacy is legal, but lacks medical indication.7 surrogacy has turned into a baffling legal quagmire and the views on its legalization have been highly divergent. commercial surrogacy remains a controversial issue across the world. it is banned in many countries. nevertheless, in india, the supreme court legalized the commercial surrogacy in 2002.8 artificial reproduction technology (regulation) bill, 2010 requires addressing the need of legislation directly on the subject of surrogacy arrangements. indian courts are still grappling with the issues involved in surrogacy.9 the essential elements of surrogacy are childbearing by a surrogate mother, the termination of her parental rights after his birth, and payment of money by the genetic parents. if the money paid is merely to recompense the surrogate for the pain undertaken and includes reimbursement of medical and other expenses, then it is non-commercial surrogacy. in contrast, commercial surrogacy involves payment of money as income to the surrogate for the service offered. a maternal surrogate in india is handsomely paid.10 the cost for surrogates in india as reported ranges from 2500 to 7000 us $. this is a mere one third of the cost to be paid by parents in developing countries.11 most indian surrogate mothers are paid in installments over the antenatal period. inability to conceive even debars them from any payment sometimes. furthermore, sometimes they forfeit a part of their fee if they suffer miscarriage.12 healthcare in low-resource settings 2015; volume 3:5465 correspondence: arti gupta, department of community medicine, veer chandra singh garhwali government medical sciences and research institute, distt. pauri garhwal, 246174 uttarakhand, india. tel: +91.9412902976. e-mail: guptaarti2003@gmail.com key words: surrogacy; commercial; ethics; risk. conflict of interest: the authors declare no potential conflict of interest. contributions: vrb conceived the study; ag and vr extracted, reviewed, and synthesized the data; ag and vrb wrote the manuscript draft; ag, vrb and vr reviewed the manuscript; ag approved the final draft. received for publication: 30 july 2015. accepted for publication: 13 august 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright v.b., et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5465 doi:10.4081/hls.2015.5465 [page 46] [healthcare in low-resource settings 2015; 3:5465] surrogacy: ethical and social aspects surrogacy raises quite profound ethical issues. the clinician is directly responsible for the medical advocacy of both the client and the surrogate. the lack of an independent medical advocate is exploitation.13 gestational surrogacy requires in vitro fertilization, which normally involves the production of multiple embryos. several embryos are implanted in the surrogate’s womb, but the other embryos are either destroyed or frozen. the primary ethical guidelines for the frozen embryos state to treat them in a manner where there is no harm to them.14 commercialization of surrogacy creates several social conflicts. the surrogate is often poor, uneducated, or semi-literate; this further complicates the uncertainty of true informed consent. illiteracy is but one barrier preventing the communication of such risks.15 women who have low-income or a lack of financial resources are typically recruited to be surrogates. indian women are also less likely engaged in drinking alcohol or smoking, which can be detrimental to a successful pregnancy. in addition, such women are rarely fully informed about the potential health risks associated with surrogacy (e.g., hormone injections) or with the emotional damage that can come from giving up a child. many are unaware, for example, that during pregnancy, the female body is biologically, hormonally, and emotionally programmed to bond with the child. maternal surrogacy is where india dominates in giving her abundance of young, poor women. economic exploitation easy for the agents working for commissioning parents, secrecy, and anonymity creates a negative environment that affects human relations.16 however, when human reproduction meets commerce, gender inequality, and wealth disparity, the potential for ethical and social transgression becomes great indeed. the public health risk of surrogacy childbirth is a natural process. pregnancy is an innately dangerous state for a woman, especially in low-income countries. in india, surrogates are implanted with multiple embryos in order to increase the chances of pregnancy, which however increases health risk for babies and the mother. it can also harm the female donors as well as the surrogate causing multiple pregnancy, low birth weight, and malformed babies.17 although rare, there is a small risk of ovarian hyper-stimulation syndrome, leading to abdominal pains, nausea, vomiting, breathlessness, and fainting. there is rare risk of transfer of human immunodeficiency or hepatitis virus. ante-natal, intranatal and post-natal period inherently pose a risk of complications like pre-eclampsia and eclampsia, urinary tract infections, stress incontinence, haemorrhoids, gestational diabetes, life-threatening haemorrhage and pulmonary embolism.18 in addition, grand multiparity has been known to be an obstetric risk. the occurrence of caesarean section is also common.19 surrogate mothers risk metabolic and circulatory complications, such as diabetes or hypertension. death is though a small but real risk. the prevalence of anemia and malnutrition is higher in multiparity.20 domestic violence and household strife occur on surrogate mothers due to dislikes of male partners. in addition, uncertainty exists whether the surrogate will be able to enjoy sexual relations with her husband. these are all downstream negative consequences of the surrogacy procedure that need to be considered. surrogacy can lead to the distortion of family relationships and society that result from breaking the marital bond in order to overcome infertility. on the other hand, the impact of surrogacy on mother-child relationships and children’s psychological adjustment is undetermined.21 the demand for surrogacyrelated medical tourism interferes with ongoing healthcare services. the public sector is busy to provide advanced artificial reproductive technology rather to build basic facilities that prevent infertility. surrogacy is also grounds for declining sex ratio and female feticide22 and interferes with the registration system of births in the country. increasing industry of reproductive tourism poses poor young women at a higher risk of trafficking. conclusions in india surrogacy is purely a contractual understanding between the parties, so care has to be taken while drafting an agreement to avoid violation of human laws. we conclude that the government of india should address the factors influencing surrogacy. there is an urgent call for enacting a law to regulate surrogacy in india: communication and knowledge of the medical process involved in surrogacy should be clear and open between all parties. emotional responses occurring during the process of surrogacy should be managed with sensitivity. all parties should fairly discuss on the payment of the expenses of the surrogate by commissioning parents and should be comfortable with the surrogacy agreement. however, the birth mother has the right to manage her own pregnancy and it is no doubt that commercial surrogacy is a bane to women health in india. hence, important legal measures should be taken. references 1. tuininga k. the ethics of surrogacy contracts and nebraska's surrogacy law. creighton law rev 2008;41:185-206. 2. niekerk av, zyl lv. the ethics of surrogacy: women's reproductive labour. j med ethics 1995;21:345-9. 3. fidler at, bernstein j. infertility: from a personal to a public health problem. public health rep 1999;114:494-511. 4. bahamondes l, makuch my. infertility care and the introduction of new reproductive technologies in poor resource settings. reprod biol endocrin 2014;12:87. 5. sharma r, biedenharn kr, fedor jm, agarwal a. lifestyle factors and reproductive health: taking control of your fertility. reprod biol endocrin 2013;11:66. 6. sarojini n, marwah v, shenoi a. globalisation of birth markets: a case study of assisted reproductive technologies in india. glob health 2011;7:27. 7. anu kp, inder d, sharma n. surrogacy and women’s right to health in india: issues and perspective. indian j public health 2013;57:65-70. 8. sreenivas k, campo-engelstein l. domestic and international surrogacy laws: implications for cancer survivors. cancer treat res 2010;156:135-52. 9. parry b. narratives of neoliberalism: ‘clinical labour’. med hum ser 2015;41:32-7. 10. saxena p, mishra a, malik s. surrogacy: ethical and legal issues. indian j commun med 2012;37:211-3. 11. gaur k, garg s. reproduction rights of women: ethical or viable role of surrogate mother. 2012;2012:2-13. 12. ruth m. surrogates and other mothers: the debate over assisted reproduction. philadelphia, pa: temple university press; 1994. 13. leo rj. competency and the capacity to make treatment decisions: a primer for primary care physicians. prim care companion j clin psychiatry 1999;1:13141. 14. suzuki m. in vitro fertilization in japan. early days of in vitro fertilization and embryo transfer and future prospects for assisted reproductive technology. p jpn acad b-phys 2014;90:184-201. 15. qadeer i. social and ethical basis of legislation on surrogacy: need for debate. indian j med ethics 2009;6:28-31. 16. sarojini nb, preeti a, deepa a. commercialisation of surrogacy in the indian context. available from: review [healthcare in low-resource settings 2015; 3:5465] [page 47] www.mfcindia.org/mfcpdfs/mfc330.pdf 17. kondapalli la, perales-puchalt a. low birth weight: is it related to assisted reproductive technology or underlying infertility. fertil steril 2014;99:303-10. 18. sharma rs. social, ethical, medical & legal aspects of surrogacy: an indian scenario. indian j med res 2014;140 (suppl.1):13-6. 19. jacobson b. advanced maternal age and adverse perinatal outcome. obstet gynecol 2004;104:727-33. 20. nordin nm, fen ck, isa s, symonds em. is grandmultiparity a significant risk factor in this new millennium? malaysian j med sci 2006;13:52-60. 21. van de akker oba. psychosocial aspects of surrogate motherhood. hum reprod update 2007;13:53-62. 22. malpani a. are we exploiting the infertile couple? indian j med ethics 2000;8:24-5. review hrev_master [healthcare in low-resource settings 2014; 2:1891] [page 35] intestinal parasitic infections in okada rural community, edo state, nigeria: a four year retrospective study bankole h. oladeinde, 1 richard omoregie,2 mitsan olley,3 ahamdi j. anunibe,3 ikponmwosa odia4 1department of medical microbiology, college of health sciences, igbinedion university, okada; 2school of medical laboratory sciences, university of benin teaching hospital, benin city; 3department of pathology, igbinedion university teaching hospital, okada; 4institute of laser fever research and control, irrua specialist hospital, irrua, nigeria abstract intestinal parasitic infections are associated with morbidity and mortality worldwide. data on prevalence of intestinal parasitic infection is sparse in rural nigeria. against this background, this study aimed at determining the prevalence of intestinal parasitic infections within a four year period in the rural community of okada, edo state, nigeria. fecal samples obtained from 1528 patients (consisting of 740 males and 788 females) presenting with signs and symptoms of gastroenteritis at the igbinedion university teaching hospital, okada were examined for presence of ova, cyst and trophozoites of parasites using standard methods. patient’s age ranged from 6 months to 73 years. study was conducted between 2007 and 2010. the prevalence of intestinal parasitic infections increased significantly (p=0.003) from 14.7% in 2007 to 22.5% in 2010. in the study period, gender did not affect the prevalence of intestinal parasitic infection (p>0.05). patients within <1-10 years had significantly higher prevalence of intestinal parasitic infection. ascaris lumbricoides was the most predominant parasitic agent, while schistosoma japonicum was the least prevalent. with respect to parasite, males were observed to have consistently higher prevalence of entamoeba histolytica infection. the prevalence of intestinal parasitic infection was observed to significantly increase from 2007 to 2010. age was a risk factor for acquiring intestinal parasitic infection. ascaris lumbricoides was the most predominant parasitic agent in all years of study. control and prevention measures are advocated. introduction intestinal parasitic infections are among the most common infections worldwide and about 3.5 billion persons, mostly children, are estimated to be infected.1 intestinal parasitic infections affect nutritional status, physical development, mental function and alertness, verbal ability, and inhibition control aspects of cognitive behaviour in children.2 intestinal parasitic infections deprive the poorest of health, contributing to economic instability and social marginalization.3 death and other serious complications can occur if cases of intestinal parasitosis are left untreated especially in children.1 in nigeria, intestinal parasitic infection constitutes a major public health challenge.4 poorly planned housing, improper waste disposal, gross environmental pollution and poor environmental situations among others are driving forces for this observation.5 illiteracy, absence of clean drinking water, and poverty has been shown to promote infection with intestinal parasites3 and these factors are rife in most rural communities in nigeria.6,7 although data on prevalence of human intestinal parasitic infection in nigeria is common, there is no published data from okada community, edo state, nigeria. monitoring of disease and assessment of effectiveness of intervention effort in any community is largely enhanced by the availability of local prevalence statistics over a period of time. this type of data is missing in okada community, and very sparse in many rural communities of nigeria. against this background, this study aimed at determining the prevalence of intestinal parasitic infection in okada (a rural community in edo state, nigeria) within a 4 year period. materials and methods study area okada, a rural community, is the headquarters of ovia north east local government area of edo-state, nigeria. the local government has an estimated population of 155,344 people.8 majority of the residents of okada are farmers with few civil servants, lecturers and students making less than 5% of the community. the study was carried out at igbinedion university teaching hospital, okada, edo state, nigeria, from january 2007 to december 2010. some neighboring rural communities (villages) also attend the hospital. study population this is a laboratory retrospective study. a total of 1528 patients aged 6 months to 73 years with signs and symptoms of gastroenteritis were included in this study. they consisted of 740 males and 788 females. informed consent was obtained from all patients or their parents/guardian in case of children prior to specimen collection. the study was approved by the ethical committee of the igbinedion university teaching hospital, okada, edo state, nigeria. collection and processing of specimens stool specimens were collected from each patient in wide mouthed containers and examined microscopically for ova, cysts or protozoa using saline and iodine mount as previously described.9 statistical analysis the data obtained were analyzed using chi square (c2) test and odds ratio analysis using the statistical software instat® (graphpad software inc., la jolla, ca, usa). statistical significance was set at p<0.05. results a total of 278 (18.2%) of the 1528 patients healthcare in low-resource settings 2014; volume 2:1891 correspondence: bankole henry oladeinde, department of medical microbiology, college of health sciences, igbinedion university, okada, nigeria. tel./fax: +234.80253096120. e-mail: bamenzy@yahoo.com key words: intestinal parasite, rural community, nigeria. contributions: bho, mo and aja took part in study design, generated and analysed data, and substantively drafted the article. ro and io took part in study design, analysed data and substantively drafted the article. conflict of interests: the authors declare no potential conflict of interests. acknowledgements: the authors acknowledge all members of the ethical committee of igbinedion university teaching hospital for giving their approval for this study. received for publication: 18 august 2013. revision received: 13 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright b.h. oladeinde et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1891 doi:10.4081/hls.2014.1891 non -co mmerc ial us e o nly [page 36] [healthcare in low-resource settings 2014; 2:1891] were infected with at least one intestinal parasite. the prevalence of intestinal parasitic infections was observed to significantly (p=0.003) increase from 2007 to 2010. among patients with intestinal parasitic infection, 30 (10.8%) had more than one parasite in their stool. no statistically significant difference (p=0.733) was observed over the years with respect to the prevalence of mixed intestinal parasitic infection (table 1). gender was not significantly associated with intestinal parasitic infection in all the study period (table 2). the prevalence of intestinal parasitic infections was significantly higher in the age group <1-10 years from 2007 to 2010. among participants aged <1-10 years, the prevalence of intestinal parasitic infection was observed to significantly increase from 2006 to 2010 (table 3). a total of 308 intestinal parasites were identified in 278 patients. generally, and in all the years of study, ascaris lumbricoides was the most predominant parasitic agent identified in patients stool, followed by entamoeba histolytica. schistosama. japonicum was the least prevalent intestinal parasitic agent (table 4). the prevalence of entamoeba histolytica infection was observed to be higher among male participants in all years of study (table 5). discussion intestinal parasitic infections are globally endemic and have been described as constituting the greatest single cause of illness and disease worldwide.3 factors that promote intestinal parasitic infections, i.e. illiteracy, poverty, absence of clean drinking water,3 are rife in rural communities in nigeria. against this background and the paucity of reports on intestinal parasitic infections in rural communities of edo state, nigeria, this study was conducted. the overall prevalence of intestinal parasitic infection in this study was 18.2%. this is lower than reported figures in other nigerian studies.5,10,11 the prevalence of intestinal parasitic infections varies with different geographical regions.12 the variation could be due to differences in geographical location: in ikeh et al.,5 nduka et al.,10 and awolaju and morenikeji,11 studies were conducted in north central, south eastern, and south western nigeria respectively, in contrast to our study which was conducted in mid western nigeria. the prevalence of intestinal parasitic infection was observed to significantly increase from 14.7% in 2007 to 22.5% in 2010. igbinedion university, nigeria’s first private university in okada, has witnessed an unprecedented influx of persons into the community, without corresponding increases in social amenities, like portable drinking water amongst others. this is likely to result in more people sharing limited social amenities such as portable drinking water, and housing which in turn could precipitate the spread of intestinal parasitic infections observed over the years in this study. thirty patients representing 10.8% of the total number of patients with intestinal parasitic infection in this study had more than one parasite recovered from their stool. however, the prevalence of mixed infection did not differ significantly from 2007 to 2010. irrespective of year of study, gender did not significantly affect the prevalence of intestinal parasitic infection. this is consistent with other reports.5,10 age was found to significantly affect the prevalence of intestinal parasitic infection with participants within the age group of <1-10 years consistently observed to have the highest prevalence within each year of study. similar findings have been reported elsewhere.13 among patients within the age group of <1-10 years, the prevalence of intestinal parasitic infection was observed to significantly (p=0.001) increase from 21.2% in 2007 article table 1. four year prevalence of intestinal parasitic infection in okada. year no. of tested no. of infected mixed infection p patients patients (%) (%) 2007 218 32 (14.7) 5 (15.6) 0.003 2008 454 72 (15.9) 7 (9.7) 2009 350 60 (17.1) 5 (8.3) 2010 506 114 (22.5) 13 (11.4) total 1528 278 (18.2) 30 (10.8) table 2. effect of gender on prevalence of intestinal parasitic infection in okada. year gender no. of tested no. of infected or 95% ci p patients patients (%) 2007 female 113 21 (18.6) 1.951 0.890, 4.273 0.134 male 105 11 (10.5) 0.513 0.234, 1.123 2008 female 265 43 (16.2) 1.069 0.639, 1.785 0.902 male 189 29 (15.3) 0.936 0.560, 1.563 2009 female 186 33 (17.7) 1.094 0.626, 1.913 0.861 male 164 27 (16.5) 0.913 0.523, 1.597 2010 female 282 65 (23.0) 1.070 0.702, 1.630 0.836 male 224 49 (21.3) 0.935 0.614, 1.424 or, odds ratio; ci, confidence interval. table 3. effect of age on prevalence of intestinal parasitic infection in okada. age 2007 2008 2009 2010 p (year) no. of no. of no. of no. of no. of no. of no. of no. of tested infected tested infected tested infected tested infected patients patients (%) patients patients (%) patients patients (%) patients patients (%) ≤1-10 80 17 (21.2) 155 38 (24.5) 115 29 (25.2) 168 68 (40.4) 0.001 11-20 47 8 (17.0) 80 15 (18.8) 58 13 (22.4) 77 18 (23.4) 0.326 21-30 19 2 (10.5) 44 5 (10.6) 30 2 (6.6) 65 6 (24.6) 0.727 31-40 23 1 (4.3) 41 4 (9.7) 39 4 (10.2) 48 5 (10.4) 0.490 41-50 14 1 (7.1) 47 3 (6.3) 41 3 (7.3) 60 4 (6.7) 0.995 51-60 18 0 (0.0) 33 4 (12.1) 25 3 (12.0) 44 6 (13.6) 0.207 ≥60 17 3 (17.6) 54 3 (5.6) 42 6 (14.3) 44 7 (15.9) 0.411 p=0.036 (2007); p<0.0001 (2008); p=0.007 (2009); p<0.0001 (2010). non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1891] [page 37] to 40.4% in 2010. this represents increasing risk of acquiring intestinal parasitic infection for children of this age group living in study location. children within this age group are likely to be involved in domestic chores of getting water for household use, and this increases exposure to water borne diseases. also infants may consume food and water of poor hygienic quality, thus increasing their susceptibility to infection. these may explain the high prevalence of intestinal parasitic infections in the age group of <1-10 years. however this observation is not consistent with reports elsewhere.5,10 ascaris lumbricoides was the most predominant parasitic agent generally and in all the years of study, followed by entamoeba histolytica. this finding agrees with a previous report.14 poor socio-economic conditions are among the key factors linked with higher prevalence of ascariasis, as are poor defaecation practices, agricultural factors, housing style, and social class.15 residents of okada and neighboring villages are mostly farmers, who may engage in agricultural practices that fuel the spread of ascaris lumbricoides among the population. the finding that entamoeba histolytica was higher among male participants, have been reported in an earlier study.16 the reason for this however is unclear. conclusions this study reports a high prevalence of intestinal parasitic infection in okada rural community, which was observed to increase steadily from 2007 to 2010. children between 1-10 years had the highest risk of being infected with intestinal parasites. provision of essential social amenities such as housing and portable drinking water for the teeming population of okada community by relevant agencies will help in curbing the spate of the disease. regular screening and treatment of persons infected with intestinal parasites by local health authorities and other intervention agencies are also advocated. increased public enlightenment on the need for the development of a culture of general environmental cleanliness and personal hygiene among residents of okada community and environs will also help in stemming intestinal parasitic infections in the bud. references 1. houmisou rs, amita eu, olusi ta. prevalence of intestinal parasites among primary school children in makurdi, benue state, nigeria. internet j infect dis 2010;8:97-106. 2. nokes cl, bundy dap. does helminthes infection affect mental processing and educational achievement? parasitol today 1994;11:14-8. 3. mehraj v, hatcher j, akhtar s, et al. prevalence and risk factors associated with intestinal parasitic infections among children in an urban slump of karachi. plos one 2008;3:1-7. 4. uneke cj, nnachi mi, arua u. assessment of polyparasitim with intestinal parasitic infections and urinary schistosomiasis among school children in a semi-urban area of south eastern nigeria. internet j health 2009;9:1. 5. ikeh ej, obadofin mo, brindeiro b, et al. intestinal parasitism in rural and urban areas of north central nigeria: an update. internet j microbiol 2006;2:1. 6. imoh an, isaac kj, nwanchukwu eo. comparative analysis of poverty status of community participation in rural development projects of akwa-ibom state, nigeria. new york sci j 2009;2:68-75. 7. aderamo aj, magaji sa. rural transportation and the distribution of public facilities in nigeria: a case of edu local government area of kwara state. j hum ecol 2010;29: 171-9. 8. national population commission. population and housing census of the federal republic of nigeria. 2006. available from: http://www.population.gov. ng/index.php/publications/list-of-publications 9. akinbo fo, okaka ce, omoregie r. prevalence of intestinal parasitic infections among hiv patients in benin city, nigeria. libyan j med 2010;5:5506. 10. nduka fo, nwango vo, nwanchukwu nc. human intestinal parasitic infection in ishiagua lead mining area of abia state. anim res 2006;3:505-7. 11. awolaju ba, morenikeji oa. prevalence and intensity of intestinal parasites in five communities in south-west nigeria. afr j biotechnol 2009;8:5542-6. 12. ramana kv. intestinal parasitic infections: an overview. ann trop med pub health 2012;5:279-81. 13. akinbo fo, omoregie r, eromwon r, et al. prevalence of intestinal parasites among patients of a tertiary hospital in benin city, nigeria. n am j med sci 2011;3:462-4. 14. dibua ue, awagu oj, esimone co. prevalence of intestinal parasitoses in the nsukka community of south eastern nigeria. int j trop med 2007;2:33-40. 15. o’lorcain p, holland cv. the public health importance of ascaris lumbricoides. parasitology 2000;121:61-71. 16. acuna-soko r, maguire jh, wirth df. gender distribution in asymptomatic and invasive amebiasis. am j gastroenterol 2000;95:1277-83. article table 4. yearly distribution of intestinal parasites in okada. parasite no. of infected patients (%) 2007 2008 2008 2009 2010 a. lumbricoides 21 (56.7) 46 (58.2) 33 (50.8) 62 (48.8) 162 (52.6) hookworm 5 (13.5) 10 (12.7) 11 (16.9) 22 (17.3) 48 (15.6) e. vermicularis 2 (5.4) 3 (3.8) 1 (1.5) 3 (2.3) 9 (2.9) s. stercoralis 0 (0.0) 2 (2.5) 1 (1.5) 3 (2.3) 6 (1.9) s. japonicum 0 (0.0) 1 (1.3) 0 (0.0) 1(0.8) 2 (0.6) e. histolytica 8 (21.6) 15 (18.9) 18 (27.7) 34 (26.8) 75 (24.4) g. lamblia 1 (2.7) 2 (2.5) 1 (1.5) 2 (1.5) 6 (1.9) total 37 (12.0) 79 (25.6) 65 (21.1) 127 (41.2) 308 (0.1) table 5. gender distribution of intestinal parasites in okada. parasite no. of infected patients (%) 2007 2008 2009 2010 m f m f m f m f a. lumbricoides 7 (58.3) 14 (56.0) 15 (48.4) 31 (64.6) 12 (37.5) 21 (63.6) 35 (49.3) 27 (48.2) hookworm 1 (8.3) 4 (16.0) 3 (9.6) 7 (14.5) 9 (28.1) 2 (6.1) 10 (14.1) 12 (21.9) e. vermicularis 1 (8.3) 1 (4.0) 2 (6.5) 1 (2.1) 0 (0.0) 2 (6.1) 2 (2.8) 1 (1.8) s. stercoralis 0 (0.0) 0 (0.0) 1 (3.2) 1 (2.1) 1 (3.1) 1 (3.0) 3 (4.2) 0 (0.0) s. japonicum 0 (0.0) 0 (0.0) 0 (0.0) 1 (2.1) 0 (0.0) 0 (0.0) 0 (0.0) 1 (1.8) e. histolytica 3 (25.0) 5 (20.0) 8 (25.8) 7 (14.6) 9 (28.1) 9 (27.2) 21 (29.6) 13 (23.2) g. lamblia 0 (0.0) 1 (4.0) 2 (6.5) 0 (0.0) 1 (3.1) 0 (0.0) 0 (0.0) 2 (3.6) m, male; f, female. non -co mmerc ial us e o nly hrev_master [page 30] [healthcare in low-resource settings 2021; 9:9710] attitude of the first year medical students towards medicine as career: motivations and apprehensions of being a doctor saurabh sharma,1 pawan parashar,2 chandra mohan,3 alka singh,2 sartaj ahmad4 1medical education unit; 2department of community medicine, subharti medical college, meerut; 3department of cardiology, himalayan institute of cardiology, dehradun; 4medical sociology, department of community medicine, subharti medical college, meerut, india abstract the choice of a career as a doctor is a complex personal decision influenced by a multitude of factors. these include family background, role models, media, and personal experiences. the present study was done with the objectives to know the reasons for first-year medical students for joining mbbs and their apprehensions. a cross-sectional study carried out among first-year students of batch 2018, 2019, and 2020 of a medical college of north india. the data was collected within 10 days of admission in mbbs. a total of 278 students were given pre-designed and pre-validated questionnaire after informed consent. out of multiple reasons for being doctor respect in society was the largest, i.e. 83%, while 72% joined because of high earning by the doctor. more than 80% had a professional image of the doctor as a calm, helping and well-groomed person, while 60% thought doctors don’t listen properly, and 57% had a perception that doctors are not much concerned about the problems of patient. sixtyeight percent (68%) thought media doesn’t portray a good image of doctors. according to students outrage in the community and lack of trust for doctors were the major reasons for violence against doctors. munnabhai mbbs, anand and patch adams, sanjeevani and house md were the movies and series motivated most students to be a doctor. respect in society was the prime motivator to be a doctor among students still they feel media doesn’t justify the image of doctors. movies and television series can be used to keep the students high in morale and excitement. introduction there are more than 76928 mbbs (bachelor of medicine and bachelor of surgery) seats in 532 medical colleges in india for pursuing the mbbs course. this is not enough as india is yet to achieve the world health organization (who) recommended the doctor-patient ratio. medicine is still not the first choice for students of this era. the perspective of the students and the rationale for choosing a particular career are of great importance for councilors around the world.1-2 the students have many career options and thus they may feel confused what to choose. the decision process may involve many aspects like personal interest, peer pressure, self-motivation, financial reasons etc.3 a career in medicine is unique as it is believed to be very virtuous providing a chance to serve humanity more than any other career.4 many factors affect the choice of medicine as career and career choices are influenced both by the graduate’s inclination before starting medical school as well as any exposure during training in medical school.5-6 these include gender and residency conditions e.g. part-time work and parental leave availability, family background, parent’s socioeconomic status, prestige, income and role models, controllable lifestyle versus non controllable lifestyle, local market forces committed relationship and the of employment availability.7-12 the final choice results from an integrated interplay between external and internal factors of the prime motivation of medical students by asking students about the personal reasons for being a doctor.13 a reflective analysis of doctor s’ reasons for entering medicine found five main factors being good in science stream, ambition of being a doctor, wanting a good interesting career, influenced by friends and relations, and desire to serve community.14 sometimes possible motivations fall into conflict. serving people and doing scientific research are both admirable motivations, but very often both activities cannot be carried out at the same time requiring a decision as to which is the more important for a particular doctor.15 considering all these aspects the present study has been undertaken with the objectives to assess the reasons for joining mbbs. students were also questioned about the image of a doctor in mind developed because of their personal experience and media before joining medical school because by this we will come to know by what mindset they entered medical school and can work to correct the same. materials and methods the present study was a cross-sectional study and it has been carried out among first-year students of a medical college of swami vivekanand subharti university, situated in northern part of india. a total of 278 students were given a pre-designed and healthcare in low-resource settings 2021; volume9:9710 correspondence: alka singh, department of community medicine, subharti medical college, subhartipuram, nh-58, delhiharidwar, meerut bypass rd, meerut, uttar pradesh 250005, meerut, india. e-mail: alkasingh24593@gmail.com key words: medical students; attitude; career; motivation; media and movies. acknowledgements: the authors acknowledge the respondents who had truly given their views and participated openly regarding questions asked by them on different aspects of choosing the career. contributions: ss, pp, as: research idea, design, data collection, data analysis, manuscript writing; cm: research idea, design, data collection, manuscript writing; sa: research idea, design, data analysis, manuscript writing. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the ethics committee of institution approved this study (smc/iec/2018/189). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all participants in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 27 february 2021. revision received: 19 november 2021. accepted for publication: 19 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9710 doi:10.4081/hls.2021.9710 pre-validated questionnaire. the questionnaire was designed after reviewing previously published content about the similar topic5-12 and after a thorough discussion among the research team members. the face validity of questionnaire was done by distributing the questionnaire to senior medical faculty after explaining them the intent of the study. they were then asked to evaluate whether the questions effectively capture the topic under investigation and whether the questionnaire was free of confusing or leading questions. later a pilot study was done on 30 medical students other than those who would have been participating in the study, and retrospective approach with verbal probes were used to test and validate it. the questionnaire included gender, age, presence of doctors in the family and the questions regarding reasons for choosing a medical school, professional image of doctors they have in mind influenced by their personal experience and media. the questionnaire had multiplechoice (multiple options allowed) and openended questions. the study was done from april 2018 to feb 2021.all the 278 students (88 students in 2018, 83 students in 2019, and 107 in 2020) present on the day of data collection were given questionnaire and everyone responded. informed consent was taken from the students. data entry and analysis were done by using microsoft excel and the chi-square test of association was used. results the present study was conducted among 278 students in the first year of college. among them, 65% and 35% were males and females respectively. in the study, only 28.9% of students have at least one member of the family who is a doctor and lives in the same household. table 1 shows the reasons for the choice of medicine as a career among students. table 2 shows the professional image of doctors among students by their personal experiences in interactions with doctors. figure 1 shows the view of students regarding the media putting the correct image of doctors in public. figure 2 shows the causes of violence against doctors as perceived by students. table 3 shows the list of movies/series, which most inspired the students to be a doctor. there was no statistical article table 1. reasons behind the choice of medicine as career among students (n=278). reasons (multiple options chosen) percentage (%) frequency passion for this profession 47 130 respect in society 83 230 parents’ choice 41 114 monetary benefits 72 200 others 7 19 table 2. professional image of doctors among students (n=278). professional image positive number (%) negative number (%) behavior calm 85 arrogant 15 nature helping 80 non helping 20 dressing well dressed 68 clumsily dressed 32 grooming well groomed 90 badly groomed 10 communicator soft spoken 66 harsh 34 listener patient listener 40 non listener 60 empathy pacifier 43 not concerned 57 table 3. movies/series which inspired students most to be a doctor. sr no name of the movies/ tv serials 1 munabhai mbbs 2 anand 3 patch adams 4 awakenings 5 contagion 6 sanjeevani (series) 7 kabirsingh 8 bhoolbhulaiya 9 house md 10 sherlock holmes 11 the good doctor 12 kahaan hum kahaan tum (series) 13 savitridevi college and hospital 14 kyonki its fate figure 1. students views media portraying good image of doctors. figure 2. according to students reasons of violence against doctors. [healthcare in low-resource settings 2021; 9:9710] [page 31] [page 32] [healthcare in low-resource settings 2021; 9:9710] difference observed among students of 2018, 2019, and 2020 batch regarding their attitude and motivation towards being a doctor (χ2-2.5, p-0.27). when both the genders were compared regarding their attitude and motivation towards being a doctor the difference was not found to be statistically significant (χ2-7.9, p-0.094). discussion medical education in india is regulated by national medical commission (nmc). as per nmc guidelines, undergraduate medical education includes 4.5 years of college and 1 year of compulsory rotatory internship. the first year is of premedical subjects while from the second year onwards there are clinical rotations in the wards along with theory lectures. undergraduate students are assessed by term exams and final university exams for 4 phases, which includes both theory and practical exam. practical exams happen after every clinical rotation. in 2019 nmc launched aetcom (attitude, ethics and communication module) and foundation course to enhance the prospect of human dignity and welfare in medical education. post-graduation (md/ms) lasts three years. the study was done on first-year undergraduate medical students in the first month of joining the course as by this time these students are not influenced by the environment in medical college and express the perceptions and views close to those of a layman non-medical person. twenty-eight percent (28.9%) of students had medical background and they have seen the life of doctors in their family, so their views may not match with that of the students who were first doctors in their family. eighty-three percent (83%) of the students have chosen medicine because they have seen very high respect for doctors in society. this finding matches with a systemic review by sonu goel et al.16 where it was observed that the main reason in uppermiddle-income countries was respect for themselves and social and professional status. forty-seven percent (47%) of the students joined because they love the profession the result is close to 61% which was observed in the study done by seetharaman and logaraj17 in south india. self-interest was found to be the main reason for 82.6% of the students in a study done by jothula.18 in a systemic review by sonu goel et al.16 interest in science and medicine was the reason for joining medical studies in most of the high-income countries. fortyone percent (41%) of the students in our study chose this profession because of the pressure by parents and they were not interested in the stream, while in their studies seetharaman and logaraj17 and jothula18 found parental wish or pressure to be 53% and 26.6% respectively; 72% in our study sought monetary benefits for choosing a profession in comparison of 44% and 54% of jothula18 and seetharaman and logaraj17 respectively. usually in childhood or young age, a person gets inspired to be in a profession by observing someone successful in that profession or a role model. in our study, we asked for the professional image of the doctor to get an idea of the mindset with which they are joining the medical school. in our study behavior, nature, dressing, grooming, communication, and empathy were considered and results show most of the students had a positive professional image of doctors except for two aspects (being a good listener and empathy). only 40% of students have seen a doctor being good listener and 43% felt they have empathy. empathy to students was described as an intellectual quality that permits an understanding of the experience, concerns, and perspectives of a patient, as well as the skill to communicate that understanding. the students should be taught about the importance of empathy to be a successful doctor.19 discussion about empathy among students regularly becomes more important after it was found in multiple researches that clinical empathy level declines while getting more experienced and older.20-24 media these days play a big role in shaping the thought process of a person so the image of doctors shown in media may affect the decision of a student to pick medicine as a career. sixty-eight percent (68%) of students were of the opinion that media portray a bad image of doctors and most of the things in media create a bad image of doctors. in their opinion, this has an impact on a lack of trust among patients and doctors and thus could be one of the reasons for violence against doctors. in an article, gupta25 expressed that in india an important factor responsible for assault against doctors is the unpleasant image of medical professionals projected by the media, leading to the general belief that doctors exploit patient’s distress to mint money. violence against doctors has been reported from all over the world, with negative media reports about hospitals and doctors, out-of-pocket medical expenditures by the patients, and lack of trust in doctors and hospitals have been reported to be some of the causative factors.26-27 fictional diseases and treatments are rare to occur, but when extraordinary themes are repeated many times they become routine in the general person’s view. so people come to expect either wonder or tragedy, whereas, in reality, both are unusual.28 the disparity between fictional and actual medical accounts can influence patients’ perceptions of physicians’ ability to find a solution. news about violence for the people of profession students aspires to be in for whole life creates fear among students and 63% of students had the perception that every doctor has to go through these types of incidences at least once in their professional life. according to the view of students while media generally play a bad plot for doctors there are some movies and television series, which creates a very good image of doctors and inspired the students to be a doctor. some of these are munnabhai mbbs, anand, sanjeevani (series), kabirsingh, bhoolbhulaiya, house md, sherlock holmes, the good doctor, kahaan hum kahaan tum (series), savitri devi college and hospital, kyonki its fate, patch adams, awakenings, contagion, etc. this aspect can be used further to educate medical students on various aspects of humanity and profession. movies are increasingly being used to educate students about many of the essential values of the medical profession.29 movies may address various consequences of disease such as suffering, emotions, social conflicts, and ethical dilemmas.30 movies have been used as teaching-learning aids in diverse subjects/areas such as microbiology, pharmacology, medical ethics, doctor-patient relationship, clinical research, mental illness, and professionalism among others.31 conclusions students enter medical school with high enthusiasm and expect to have a good reputation in society as doctors. in medical school, movies can be used as a tool to create empathy among students and to develop a sense of pride in their profession. references 1. pruthi s, pandey r, singh s, et al. why does an undergraduate student choose medicine as a career. national med j india 2013;26:147-9. 2. barber s, brettell r, perera-salazar r, et al. uk medical students’ attitudes towards their future careers and general practice: a cross-sectional survey and qualitative analysis of an oxford cohort. bmc med educ 2018;18:160. article [healthcare in low-resource settings 2021; 9:9710] [page 33] 3. sharma d, pattnaik s. carrier choices and the factors influencing it among medical students in a private medical college in tamilnadu. int j community med public health 2017;4:1110-2 4. woodward a, thomas s, jalloh mb, et al. reasons to pursue a career in medicine: a qualitative study in sierra leone. glob health res policy 2017:2:34. 5. ie k, murata a, tahara m, et al. what determines medical students’ career preference for general practice residency training? a multicenter survey in japan. asia pac fam med 2018:17:2. 6. yang y, li j, wu x, et al. factors influencing subspecialty choice among medical students: a systematic review and meta-analysis. bmj open 2019;9: e022097. 7. marchand c, peckham s. addressing the crisis of gp recruitment and retention: a systematic review. br j gen pract 2017;67:e227-37. 8. kunanitthaworn n, wongpakaran t, wongpakaran n, et al. factors associated with motivation in medical education: a path analysis. bmc med educ 2018;18:140. 9. guraya sy, almaramhy hh. mapping the factors that influence the career specialty preferences by the undergraduate medical students. saudi j biol sci 2018:25:1096-101. 10. pfarrwaller e, audétat mc, sommer j, et al. an expanded conceptual framework of medical students' primary care career choice. acad med 2017;92:153642. 11. woolley t, larkins s, sen gupta t. career choices of the first seven cohorts of jcu mbbs graduates: producing generalists for regional, rural and remote northern australia. rural remote health 2019;19:4438. 12. alavi m, ho t, stisher c, et al. factors that influence student choice in family medicine: a national focus group. fam med 2019;51:143-8. 13. moir f, yielder j, sanson j, chen y. depression in medical students: current insights. adv med educ pract 2018;9:323–33. 14. cleland ja, johnston p, watson v, et al. what do uk medical students value most in their careers? a discrete choice experiment. med educ 2017;51:839-51. 15. martin aj, beska bj, wood g, et al. widening interest, widening participation: factors influencing school students’ aspirations to study medicine. bmc med educ 2018;18:117. 16. goel s, angeli f, dhirar n, et al. what motivates medical students to select medical studies: a systematic literature review. bmc med educ 2018;18:16. 17. seetharaman n, logaraj m. why become a doctor? exploring the career aspirations and apprehensions among interns in south india. nat j res com med 2012;1:178-241 18. jothula ky, ganapa p, sreeharshika d, et al. study to find out reasons for opting medical profession and regret after joining mbbs course among first year students of a medical college in telangana. int j community med public health 2018;5:1392-6. 19. haque m. importance of empathy among medical doctors to ensure highquality healthcare level. adv hum biol 2019;9:104-7 20. igde fa, sahin mk. changes in empathy during medical education: an example from turkey. pakistan j med sci 2017;33:1177–81. 21. hojat m, shannon sc, desantis j, et al. does empathy decline in the clinical phase of medical education? a nationwide, multi-institutional, cross-sectional study of students at do-granting medical schools. acad med 2020;95:911–8. 22. piumatti g, abbiati m, baroffio a. et al. empathy trajectories throughout medical school: relationships with personality and motives for studying medicine. adv in health sci educ 2020;25:1227– 42. 23. nair s, shetty rs, guha s, et al. assessing empathy among undergraduate medical students: a cross sectional analysis using the jefferson scale in a medical school in coastal karnataka. int j community med public health 2018;5:953-95. 24. tariq n, rasheed t, tavakol m. a quantitative study of empathy in pakistani medical students: a multicentered approach. j primary care community health 2017:8:294-299. 25. gupta vk. is changing curriculum sufficient to curb violence against doctors? indian heart j 2016;68:231-41. 26. sen m, honavar sg. it's a doc's life workplace violence against doctors. indian j ophthalmol 2019;67:981–4. 27. reddy ir, ukrani j, indla v, ukrani v. violence against doctors: a viral epidemic? indian j psychiat 2019;61:782– 5. 28. bitter cc, patel n, hinyard l. depiction of resuscitation on medical dramas: proposed effect on patient expectations. cureus 2021;13:e14419. 29. ortiz mb. commercial cinema as a learning tool in medical education, from potential medical students to seniors. amee med ed publish 2018;7:17. 30. shankar pr. cinemeducation: facilitating educational sessions for medical students using the power of movies. arch med health sci 2019;7:96-103. 31. kadeangadi dm, mudigunda ss. cinemeducation: using films to teach medical students. j sci soc 2019;46:73-4 article hrev_master [healthcare in low-resource settings 2022; 10:10376] [page 45] why measure the retention of health workers within borders? lessons learned from the etatmba program in measuring health workforce retention in malawi and tanzania mselenge mdegela,1 chimwemwe joe mvula,2 ndemetria vermand,3 barbara madaj,1 joseph paul o’hare4 1liverpool school of tropical medicine, liverpool, uk; 2kamuzu central hospital, lilongwe, malawi; 3morogoro college of health and allied sciences, morogoro, tanzania; 4warwick medical school, the university of warwick, coventry, uk abstract health workforce retention is a recognised strategy for alleviating the health workforce scarcity in lowand middleincome countries. however, there is a lack of clarity on what retention is and how it is measured. we followed up with health workers who participated in the etatmba program, an in-service training program from selected healthcare facilities in malawi and tanzania, once per quarter, for five years, to determine their retention. we measured retention in three aspects: i) duration of stay in target healthcare facilities, ii) retention in clinical roles, and iii) retention in government employment. we tracked 127 participants, 46 in malawi and 81 in tanzania. at the end of tracking, the retention in each aspect measured was different. in malawi, the retention in target facilities was 47.2%, the retention for clinical roles was 69.5%, and retention for government employment was 76.1%. in tanzania, the rates were 45.7%, 72.8%, and 76.5%, respectively. the extent of workforce retention depends on the parameters chosen to measure it. standard indicators for workforce retention needs to be outlined to streamline retention measurement, inform health policies and improve human resources for health planning. introduction since the first global conference on human resources for health (hrh) in kampala in 2008, health workforce retention has become a recognised strategy for alleviating the deficit of health workers.1 likewise, subsequent global fora on hrh2,3 and later workforce 2030 – the current global strategy on hrh considers enhanced health workforce retention to be critical for improving the availability and access to hrh, and strongly stresses the role of hrh in attaining the universal health coverage (uhc).4 in the same way, health policies in many countries, including malawi and tanzania, mention health workforce retention as a crucial strategy for improving hrh.5,6 but what is health workforce retention? how is it measured? moreover, how can improved workforce retention improve hrh? unfortunately, these documents do not provide sufficient answers to these questions. multiple definitions of health workforce retention exist; there appears to be no consensus on the definition for health workforce retention or its opposite – attrition. for example, wilson et al. defines retention as a stay of more than five years in a healthcare facility, or more than two years beyond the termination of a contractual agreement,7 while humphreys et al. refers to health workforce retention as the length of time between the commencement and termination of employment. the “length of time” referred to by humphreys et al. is not specified, making the definition arbitrary. 8 attrition, on the other hand, refers to the rate at which people leave the organisation.9 castro lopes et al. define attrition as exits from the workforce for reasons other than death or retirement and notes the commonly used synonyms for attrition – “brain drain,” “turnover,” “drop-outs,” “losses,” “separation,” and “premature departure,”10 adding to the complexity of the definition. external brain-drain, commonly referred to as “brain-drain,” is the most documented form of attrition which, in most cases, involves the flow of health workers from lowto high-income countries.11 however, movements of health workers within borders, also referred to as internal brain-drain,9 internal occupational mobility12 or intersectoral mobility,13 are common. they can equally disrupt access to the health workforce, especially in rural and remote areas,14 and needs addressing. a better understanding of patterns of health workforce mobility within countries and their linkage to retention is needed to determine the extent to which health workforce movements occur, the reasons behind such movements, and how to harness such movements to optimize hrh access. for example, should movements from public to private healthcare facilities or changing the health worker’s main roles from clinical to non-clinical roles – such as administrative or managerial be regarded as attrition if healthcare in low-resource settings 2022; volume 10:10376 correspondence: mselenge mdegela, liverpool school of tropical medicine, pembroke place, l3 5qa, liverpool, uk. tel.: +44.774.588.9310 e-mail: mselenge.mdegela@outlook.com key words: health workers; health workforce; malawi; retention; tanzania. acknowledgements: the authors thank professor nynke van den broek for her contribution to the study design and caroline hercod at liverpool school of tropical medicine for proofreading the manuscript. contributions: mm: conceptualized the study, wrote the proposal, performed data collection and analysis, drafted and revised the manuscript. bm provided expert advice in all stages of conducting the study, and revised the manuscript. cjm, nv, and jpo provided support during data collection, revised manuscript and advised on content. funding statement: the study was done as part of the etatmba program, which is funded by the european union. the first author received financial support from etatmba for travel and stipend during data collection. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are available from the corresponding author on reasonable request. ethics approval and consent to participate: ethical clearance was obtained through the etatmba program from the university of warwick (rego-2013-572), the university of malawi (p.07/11/1102) and ifakara health institute (ihi/irb/no:35). consent was obtained from each participant before enrolment into the study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 21 january2021. revision received: 28 april 2021. accepted for publication: 5 may 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10376 doi:10.4081/hls.2022.10376 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non commercial use only they occur within borders? similarly, there are no specific internationally agreed indicators to measure health workforce retention, attrition, or mobility. the world health organization (who) proposes seven parameters of measuring health workforce market flows: i) graduates starting practice within a year, ii) replenishment rate from domestic sources, iii) entry rate of the foreign health workforce, iv) voluntary exits, v) involuntary exits, vi) vacancy rate, and vii) health care worker’s unemployment rate. the who also proposes the numerator and denominator for measuring these indicators, suggests the data sources required, and the reporting frequency.15 however, these parameters are not in everyday use in most countries, in part due to the lack of awareness on these indicators and poor hrh monitoring practices, especially in low-resource countries.16 russell et al. describes five parameters for measuring health workforce retention: i) the turnover rate, ii) stability rate, iii) survival probability, iv) median survival years, and v) cox-proportional hazard ratio.17 however, studies that have attempted to measure retention using these parameters choose numerators and denominators differently, making it difficult to compare or synthesize the reported parameters.18,19 we describe our experience in measuring retention among health workers who took part in the etatmba program in malawi and tanzania. we briefly describe the etatmba program below; however, details are available elsewhere.20,21 the enhancing training and appropriate technologies for mothers and babies in africa (etatmba) program was an in-service training program that was implemented in malawi and tanzania between 2011 and 2014. health authorities chose two to six health workers from target healthcare facilities to be trained in emergency obstetric care, new-born care, and leadership skills. the training took 18 months in total and was organized into six modules. each module was taught for two weeks. the time in between the modules was to allow participants to return to their health facilities and implement the skills they had acquired. we followed up with the participants of the etatmba program for five years to determine their retention. we present their retention pattern and argue the relevance of measuring health workforce retention for movements within borders. materials and methods study design we conducted a longitudinal quantitative study with a retrospective arm from may 2012 to october 2014 and a prospective arm from october 2014 to april 2017. study participants and selection the participants were health workers from 14 districts in malawi and 16 districts in tanzania. data collection we got in touch with the participants for the first time in october 2014. we collected participants’ details at recruitment into the etatmba program in 2011 as the reference point for the follow-up. we then contacted participants once every three months to establish location (healthcare facility), their key role (clinical, administrative, public health, private clinic, non-governmental organisation, etc.), and their employment details (who their employer was). in addition, we made telephone calls, wrote emails, and used social media such as whatsapp® and messenger® to obtain information from participants. we made 22 observations per participant, the first observation in may 2012 and the last in april 2017. data analysis we entered data into an excel® spread sheet for analysis. we determined the participant’s mobility by recording the change in location (healthcare facility), role, or employer. we used histograms and line graphs to present the data. results the study recruited 127 participants, 36.2% (46/127) in malawi and 63.8% (81/127) in tanzania. measuring retention of health workers in the course of the tracking, the majority of participants changed location (healthcare facility), employer, roles or a combination of these. of the 22 observations made, we present the tracking data at six timepoints: may 2012, april 2013, april 2014, april 2015, april 2016, and april 2017. retention in target healthcare facilities the retention of health workers declined steadily in both countries over the five years. figure 1 shows the number of participants remaining in target healthcare facilities during the tracking period per country. the attrition rate in both countries was almost similar. after five years, 46.5% (59/127) of health workers were still in the target healthcare facilities, 47.8% (22/46) in malawi, and 45.7% (37/81) in tanzania. the attrition rate was relatively higher between april 2013 and april 2016. some participants changed their article figure 1. the number of health workers in the target healthcare facilities per year. [page 46] [healthcare in low-resource settings 2022; 10:10376] non commercial use only employer and continued working at the same facility; others changed roles, e.g., from clinical to non-clinical duties such as administrative or managerial roles, but remained at the same healthcare facilities as at the start of the etatmba program. the retention pattern for the employer and the main roles are presented in the following two sections. retention in government employment figure 2 shows the number of health workers who remained in government employment over the tracking period. we considered those health workers who got transferred across to non-target healthcare facilities, promoted to leadership positions, changed roles to perform administrative duties, or coordinated specific programs as retained (in this instance), as long as their employment contract with the government was maintained. for example, the ministry of health in malawi seconded four participants to nonprofit private healthcare facilities. we considered these as retained in government employment, but attrition had occurred as far as the location was concerned. there was steady attrition of health workers in government employment from 100% (127) at the start of the tracking to 74% (94/127). the attrition rate was higher between april 2014 and april 2016 in both countries and slightly higher in tanzania, 27.2% (22/81), than in malawi, 23.9% (11/46). retention in clinical roles in this respect, we considered retention to have occurred if the health worker continued in the role of providing clinical patient care as their main role, even after relocating to another healthcare facility or had changed employers (figure 3). the number of health workers performing clinical roles decreased in both countries, from 100% (127) at the start of the tracking to 74% (94/127) at the end, the decrease being slightly higher in malawi 30.4% (14/46) than in tanzania 23.5% (19/81). in malawi, 30.4% (14/46) of the participants were no longer in clinical patient care; the highest attrition happened between april 2015 to april 2016, with six participants leaving clinical practice. in tanzania, 23.5% (19/81) of participants had left clinical roles by the end of the tracking period. retention of health workers at healthcare facilities, employer and clinical care roles figure 4 compares the retention rate in all the three aspects of retention considered in this study. in both countries, the proportion of health workers retained in target healthcare facilities was relatively lower than the employer’s and clinical roles’ retention. at the end of tracking, the retention in government employment in malawi was higher than in clinical roles, whereas in tanzania retention in the clinical role was higher than in the government employment. discussion we have determined the retention rate of health workers by presenting the proportion of health workers who, for whatever reason, left target healthcare facilities, government employment, or clinical roles during the tracking period. the attrition rate per year was different in each aspect considered. it is essential to state that none of the participants left their countries (no brain drain). apart from the involuntary attrition due to retirement or death, the remaining health workers continued to provide healthcare in their countries in different capacities and roles or with a different employer. for article figure 2. the number of health workers in government employment per year. figure 3. the number of health workers in clinical roles per year. [healthcare in low-resource settings 2022; 10:10376] [page 47] non commercial use only [page 48] [healthcare in low-resource settings 2022; 10:10376] example, in malawi, participants left target healthcare facilities to work for public health programs in the government or ngos, and others went to serve in the military. however, healthcare facility retention was 46.5% (figure 1). the migration of health workers from one country to another, also called brain drain, is the most common form of attrition documented. the movement is usually from a lowto a high-resource country.11,22–27 however, the tendency to overemphasise the international migration of the health workforce diverts attention from focusing on the attrition/mobility of the health workforce within countries, the internal occupational mobility, or internal brain drain,12,27,28 which affects not only health workforce availability and distribution, but also its accessibility, acceptability and quality.29 this aspect needs to be explored further along with the interventions to mitigate its effects. for this study, we chose three aspects of health workforce retention as a platform to determine health workforce movements within countries. we could have chosen or added other parameters, e.g., retention within sub-national geographical areas (district/region/province), in the maternity or other departments within the health facility, etc. we feel that these “intercountry” movements need to be explored, measured, and tangible indicators developed. rather than measuring health workforce retention and attrition at the national level, we propose that health mobility within countries is also measured comprehensively to specify the individual (or cadre, etc.) involved, the role, and employer, where health workers are leaving from, and where they are moving to. most studies state health workforce retention in arbitrary terms without specifying the duration of employment that would amount to “adequate” retention. for example, although the duration of the etatmba program was four years, the program expected that, following the training, participants would stay in target healthcare facilities for a “considerable” time.19 however, since the duration of this “considerable” time was not specified, it would be challenging to determine what constitutes retention in this instance. however, movements across the different facets of the health system within the country could precisely be determined, as is the case in this study. had this study tracked all available health workers in target healthcare facilities, it would have been possible to determine parameters suggested by russell or the who, including the stability rate, median survival years, replenishment rate from domestic sources, vacancy rate and health care worker’s unemployment rate. we could not obtain this information, which was one of the reasons for embarking on a prospective study, highlighting the urgent need for improvements in hrh monitoring at all levels of healthcare delivery in lowresource settings.15–17 health authorities should develop locally relevant indicators to capture health workforce movements at national and subnational levels. for example, they could adopt indicators suggested by the who or russell, informed by the local context, clearly defining the numerator, denominator, and the relevant data source(s). the health system could integrate these data through the existing health information management systems (hmis) to improve efficiency. such data would be a valuable contribution to hrh planning. similarly, such data would allow for the monitoring and comparing of hrh availability and distribution and enable a better understanding of the dynamics at play in the hrh labour market within and across countries. improving the working conditions or formulating and implementing cohesive employment policies could help minimise the unnecessary staff transfers across healthcare facilities, departments, or programs. for example, the traffic between public and private healthcare facilities seen in this study could have been reduced by enhancing the public-private partnership, which was successfully done in uganda in a similar program.30 we propose that internal mobility of the health workforce does not amount to attrition as long as such movements are controlled and occur within the health sector. for low-resources countries like malawi and tanzania, curbing the external migration of the health workforce is a challenge.22 hence, optimizing the access to the available workforce through managing internal movements could be a suitable, less costly alternative. a dynamic health system that allows health workers to change jobs or locations, within countries, based on local labour market forces is likely to promote a healthy contention among employers, boost the competitive advantage to attract and retain the required health workforce. hopefully, such competition will improve access to the health workforce, improve healthcare delivery, and accelerate the attainment of universal health coverage. conclusions measuring workforce movements within a country appears to be more practical and informative to the health system than measuring health workforce retention. developing indicators for in-country workforce mobility and promoting their use will likely streamline hrh research and planning and improve health workforce availability, distribution and access. references 1. world health organisation. the kampala declaration and agenda for global action. who; 2008. available from: https://apps.who.int/iris/ handle/10665/43898 2. campbell j, dussault g, buchan j, pozo-martin f. a universal truth: no health without a workforce. in: forum report, third global forum on human resources for health, recife, brazil, 2013 nov 10-13. who; 2013. available from: https://www.euro.who.int/en/mediacentre/events/events/2013/11/third article figure 4. proportion of health workers retained by facility, employer and clinical roles per year. non commercial use only [healthcare in low-resource settings 2022; 10:10376] [page 49] global-forum-on-human-resources-forhealth 3. world health organization. making health workers count. the global workforce alliance 2012 annual health report. who, 2012. available from: https://apps.who.int/iris/bitstream/handle/10665/250330/97892415 11407-eng.pdf 4. world health organization. global strategy on human resources for health: workforce 2030. who library cataloguing-in-publication data; 2018. available from: https://apps.who.int/iris/bitstream/handle/10665/250368/9789241511131eng.pdf 5. ministry of health and social welfare, united republic of tanzania. health sector strategic plan, july 2015 – june 2020 (hssp iv): reaching all households with quality health care. ministry of health and social welfare, united republic of tanzania, 2015. available from: h t t p s : / / w w w . p r b . o r g / w p content/uploads/2020/06/tanzaniahealth-sector-strategic-plan-iv-20152020-1-4.pdf 6. ministry of health, malawi. health sector strategic plan ii (2017-2022). ministry of health, malawi; 2017. available from: https://extranet.who.int/countryplanningcycles/sites/default/files/planning_cycle_repository/malawi/health_s ector_strategic_plan_ii_030417_smt_d ps.pdf 7. wilson n, couper i, vries e, et al. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9:1060. 8. humphreys j, wakerman j, kuipers p, et al. improving workforce retention: developing an integrated logic model to maximise sustainability of small rural & remote health care services. australian primary health care research institute; 2009. available from: https://nceph.anu.edu.au/files/full_repo rt_10797.pdf 9. armstrong m, taylor s. resourcing practice: retention planning. in: armstrong’s handbook of human resource management practice. 14th ed. dorset press; 2017. p.252-3. 10. castro lopes s, guerra-arias m, buchan j, et al. a rapid review of the rate of attrition from the health workforce. hum resour health 2017;15:21. 11. kollar e, and buyx a. ethics and policy of medical brain drain: a review. swiss medical weekly 2013;143:w13845. 12. chen l. striking the right balance: health workforce retention in remote and rural areas. bull world health org 2010;88:323-4. 13. shemdoe a, mbaruku g, dillip a, et al. explaining retention of healthcare workers in tanzania: moving on, coming to ‘look, see and go’, or stay? hum resour health 2016;14:2. 14. o’sullivan bg, couper i, kumar p, mcgrail mr. editorial: effective strategies to develop rural health workforce in lowand middle-income countries (lmics). front public health 2021;9:702362. 15. world health organisation. national health workforce accounts: a handbook. geneva. 2017. https://apps.who.int/iris/bitstream/handle/10665/259360/9789241513111eng.pdf 16. world health statistics 2021: monitoring health for the sdgs, sustainable development goals. geneva: world health organization; 2021. available from: https://apps.who.int/iris/bitstream/handle/10665/342703/9789240027053eng.pdf 17. russell d, humphreys j, wakerman j. how best to measure health workforce turnover and retention: five key metrics. aust health rev 2012;36:290-5 18. gupta j, patwa mc, khuu a, creanga aa. approaches to motivate physicians and nurses in lowand middle-income countries: a systematic literature review. hum resour health 2021;19:4. 19. russell d, wakerman j, and humphreys j. what is a reasonable length of employment for health workers in australian rural and remote primary healthcare services? aust health rev 2013:37;256-61. 20. ellard d, simkiss d, quenby s, et al. the impact of training non-physician clinicians in malawi on maternal and perinatal mortality: a cluster randomised controlled evaluation of the enhancing training and appropriate technologies for mothers and babies in africa (etatmba) project. bmc pregnancy childbirth 2012:12;1. 21. ellard d, shemdoe a, mazuguni f, et al. can training non-physician clinicians/associate clinicians (npcs/acs) in emergency obstetric, neonatal care and clinical leadership make a difference to practice and help towards reductions in maternal and neonatal mortality in rural tanzania? the etatmba project. bmj open 2016;6:e008999. 22. cometto g, tulenko k, muula as, krech r. health workforce brain drain: from denouncing the challenge to solving the problem. plos medicine 2013;10:9. 23. deressa w, azazh a. attitudes of undergraduate medical students of addis ababa university towards medical practice and migration, ethiopia. bmc medical education 2012;12:1. 24. karan a, deugarte d, barry m. medical “brain drain” and health care worker shortages: how should international training programs respond? ama journal of ethics 2016;18:1:665–75. 25. labonté r, sanders d, mathole t, et al. health worker migration from south africa: causes, consequences and policy responses. hum resour health 2 0 1 5 ; 1 3 : 9 2 . https://doi.org/10.1186/s12960-0150093-4. 26. mandeville k, ulaya g, lagarde m, et al. early career retention of malawian medical graduates: a retrospective cohort study. trop. med. int. health 2015;20:106-14. 27. poppe a, jirovsky e, blacklock c, et al. why sub-saharan african health workers migrate to european countries that do not actively recruit: a qualitative study post-migration. glob health action 2014;7:24071. 28. sirili n, and simba d. understanding the rural–rural migration of health workers in two selected districts of tanzania. adv public health 2020;4910791. 29. campbell j, buchan j, cometto g, et al. human resources for health and universal health coverage: fostering equity and effective coverage. bulletin of the world health organisation 2013;91:11. 30. paina l, bennett s, ssengooba f, peters d. advancing the application of systems thinking in health : exploring dual practice and its management in kampala, uganda. health res policy and syst 2014;12:41. article non commercial use only hrev_master healthcare in low-resource settings 2024; volume 12:11731 frequency, amount, and supplementation of vitamin a food sources to enhance vitamin a sufficiency status among toddlers aged 12-59 months dewi mey lestanti mukodri,1 ristina rosauli harianja,1 neny san agustina siregar2 1politeknik kesehatan kemenkes tanjungpinang; 2poltekkes kesehatan kemenkes jayapura, indonesia abstract vitamin a plays a crucial role as a micronutrient, particularly in relation to vision and growth. however, excessive intake of vitamin a can lead to impaired vision and growth in toddlers. this study aimed to examine the impact of the frequency and amount of vitamin a from food sources, as well as the intake of vitamin a supplements, on the sufficiency status of vitamin a in toddlers aged 12-59 months. the research design employed a quantitative approach using an analytical cross-sectional survey with a sample of mothers and toddlers aged 12-59 months, totaling 100 respondents. the relationship between the independent variables and the dependent variable was analyzed using the chi-square (α=0.05) statistical test with a 95% confidence interval. quantitative results indicated a vitamin a sufficiency status (71%), frequency of intake (56%), amount of intake (64%), and intake of vitamin a supplements (60%) in the ‘more’ category. the results of the chisquare test showed the effect of vitamin a food source intake on vitamin a sufficiency status with a p-value of 0.002. optimizing vitamin a sufficiency among toddlers aged 12-59 months requires a multifaceted approach, focusing on frequency, amount, and appropriate food sources. introduction vitamin a is the most essential nutrient for health restoration and survival. vitamin a deficiency will increase morbidity and mortality, susceptibility to infectious diseases such as diarrhea, pneumonia, and ultimately death. the most serious consequence of vitamin a deficiency is night blindness, another form of xerophthalmia that includes corneal damage and blindness.1,2 research conducted by the world health organization (who) showed that half of the 20 million toddlers in indonesia suffer from vitamin a deficiency. according to data from who, indonesia is one of the countries where vitamin a fulfillment is relatively low.3 the problem of sub-clinical vitamin a deficiency in some provinces is still quite a concern, as 50% of children under five still have low vitamin a status. lack of vitamin a will result in decreased body resistance to disease, which affects the survival of the child. tackling the problem of vitamin a deficiency is currently not only to prevent blindness but is also associated with efforts to spur growth and child health to support the reduction of infant and toddler mortality rates, which potentially increases the labor productivity of adults.3-5 the main functions of vitamin a are related to vision, differentiation of epithelial cells, growth, and reproduction. vitamin a deficiency is globally recognized by the public from year to year, but in general, the general public is more aware of the effects of insufficient intake of various types of vitamins, and conversely, knowledge of the consequences of excess vitamin intake is very low, even though medically the impact is very dangerous. excess vitamin a can occur at all ages, especially during growth, due to its effect on protein synthesis, which can affect cell growth.6-8 factors that can influence growth in children under five in indonesia, based on the results of a survey by the ministry of health, are that there are several areas of good quality complementary foods so that micronutrients such as vitamin a are fulfilled.9,10 vitamin a is very useful, especially for children under five. the benefits that can be obtained from vitamin a sources include maintaining the health of the sense of vision, helping bone growth, protecting the body from infection, and helping the growth of body cells and tissues, especially in hair, nails, and correspondence: dewi mey lestanti mukodri, politeknik kesehatan kemenkes tanjungpinang, indonesia. e-mail: dewimey@poltekkes-tanjungpinang.ac.id key words: food sources, toddler, vitamin a. contributions: dmlm, conceptualization, data curation, methodology, validation, visualization, writing – original draft, review & editing; rsh, formal analysis, methodology, validation, and writing – original draft, review & editing; nsas, review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee faculty of medicine universitas padjajaran, as indicated by ethical approval no 427/un6.c2.1.2/kepk/pn/2014. throughout the research, the researcher has adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: the patient's informed consent for publication was made in writing with anonymized patient information. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 9 september 2023. accepted: 15 february 2024. early access: 16 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11731 doi:10.4081/hls.2024.11731 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 438] [healthcare in low-resource settings 2024;12:11731] non -co mmerc ial us e o nly skin.11eating habits in children are derived from experiences gained during infancy. the frequency and portion of vegetable and fruit intake were collected by counting the number of days of consumption in a week and the average number of servings in a day. a person is said to be adequate in vegetable and/or fruit intake if they eat at least 5 servings of vegetables and/or fruits per day for 7 days a week.9,12 the aim of the study was to analyze the effect of frequency, amount of vitamin a food source intake, and vitamin a supplement intake on vitamin a sufficiency status and explore the intake of vitamin a food sources in toddlers aged 12-59 months. materials and methods research design the research used in this study used a quantitative approach, and the research design was an analytical cross-sectional survey. the quantitative approach examined the frequency of intake of vitamin a sources, the amount of intake of vitamin a sources, and the provision of vitamin a supplement intake in toddlers 12-59 months. study participants the population in this study consisted of mothers who had toddlers aged 12-59 months in west bandung regency, indonesia, which consisted of 7 villages. the quantitative research sample used stratified random sampling by determining the population, allocating samples by separating based on sample characteristics, determining the number of samples for each sub-cluster, then randomizing each sub-cluster of 6699 children aged 12-59 months in 7 villages which meets the inclusion criteria of 100 mothers who have children aged 12-59 months. variable, instrument, and data collection the variables in this study consisted of independent variables and dependent variables. the independent variable consisted of frequency of intake of vitamin a sources, amount of intake of vitamin a sources, and intake of vitamin a supplements, while the dependent variable was vitamin a sufficiency status. confounding variables were education, occupation, and family income. the research instrument used for data collection in this study is quantitative research; the research instrument uses a semi-quantitative food frequency form. the data collection tools used to measure changes in improving maternal nutrition behavior included questionnaires and checklist sheets for cognitive, affective, and psychomotor aspects. in this study, the nutritional status of toddlers was assessed using anthropometric indices, which included measuring the child’s growth in length or height relative to their age and utilizing scales and body length gauges. data analysis the researcher, assisted by two enumerators, began conducting research regarding the frequency of intake of vitamin a food sources, the amount of intake of vitamin a sources, and vitamin a supplementation. the household size used household tools such as spoons, plates, bowls, and glasses; besides that, the researcher also used photo aids of food ingredient sizes to make it easier for subjects to answer. the researcher fills in the form according to the subject’s answer and then estimates the size of the portion eaten by the subject into weight (grams), converting all the frequency of the list of food ingredients for a day. for example, rice is eaten 3x per day, tofu is eaten 4x per week 4/7 per day =0.57, ice cream 5x per month 5/30 per day =0.17, and for seasonal fruits, the annual category is used, for example mango 10x, equivalent to 10/365 per day =0.03 per day. multiplying the frequency per day by the serving size (grams) to get the weight consumed in grams/day. counting the list of food ingredients consumed by the subject according to what was filled out in the form. after all food ingredients are known to be consumed in grams/day, then all item weights are summed to get the total nutrient intake of the subject. after all the data was collected, the analysis was carried out using the nutrisurvey, namely by entering the food ingredients to be analyzed in the food column in the nutri-survey program, then entering the weight of the food ingredients that have been calculated in the average per day in the amount column, after that select extras, choose nutrient, select the nutrient you want to analyze, enter it into the order of selected nutrient column, then the results of the analysis of the nutrient to be studied come out, namely vitamin a. the association between the independent variables and the dependent variable was evaluated using the chi-square and multivariate linear regression statistical test, with a significance level of α=0.05 and a confidence interval of 95%. results table 1 indicates that the majority of children fall within the age range of 12-36 months (61.0%). furthermore, it revealed that the predominant demographic among mothers of toddlers was aged over 35 years (47%), with a primary level of education (73%). additionally, 15% of mothers were identified as housewives, a percentage lower than that of fathers who are unemployed (44%). moreover, the data shows that 85% of households have an income below the minimum wage of 1.531.000. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondents’ characteristics. variable frequency % toddler age 12-36 months 61 61 37-59 months 39 39 mother’s age <20 years 22 22 20-35 years 31 31 >35 years 47 47 mother’s education elementary sschool 73 73 senior high school 15 15 college 12 12 father’s education elementary school 49 49 senior high school 40 40 college 11 11 mother's job employed 73 73 unemployed 15 15 father’s job employed 56 56 unemployed 44 44 parents’ income ≤regional minimum wage idr 1.531.000 15 15 ≥regional minimum wage idr 1.531.000 85 85 total 100 100 [healthcare in low-resource settings 2024;12:11731] [page 439] non -co mmerc ial us e o nly table 2 revealed that the consumption of vitamin a sources, measured by frequency of intake (56%), amount of intake (64%), and vitamin a supplementation (60%), falls within the “more” category, exceeding 100% of the nutritional adequacy rate on average. food items significantly contribute to vitamin a intake among children under five. in table 3, out of 100 children under five, 71 (71.0%) were categorized as having adequate levels of vitamin a consumption, while the remaining 17 (17.0%) were categorized as having inadequate levels. table 4 illustrated that among toddlers with a lower frequency of intake of vitamin a sources, the proportion of those with insufficient vitamin a status was 41.2%, whereas, among those with a higher frequency of intake, 64.3% have sufficient status. regarding the amount of intake, 29.4% of toddlers with lower intake have insufficient vitamin a status, compared to 70.4% with higher intake, indicating sufficiency. the analysis revealed a significant influence of vitamin a source intake frequency (p=0.000) and intake amount (p=0.002) on vitamin a sufficiency status among toddlers aged 12-59 months. moreover, 59.3% (42 individuals) of toddlers with vitamin a supplementation exhibit sufficient status. the analysis suggests a significant correlation between vitamin a supplementation and vitamin a sufficiency status (p=0.004) in this age group. in table 5, the results of multivariate linear regression analyses indicated that total source vitamin a has a coefficient b value of 2.241. this suggests that the total source of vitamin a has a twofold effect on the vitamin a sufficiency status in toddlers aged 12-59 months in batujajar district, west bandung regency (p=0.000). discussion the result showed that the characteristics and sociodemographic factors of mothers may have an impact. specifically, mothers with lower levels of education and those from low-income families appear to be at higher risk of their children having inadequate intake of vitamin a-rich foods. one possible explanation is that transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 4. effect of frequency of intake of vitamin a sources on vitamin a sufficiency status. variable vitamin a sufficiency status p less enough more n % n % n (%) vitamin a source 0.039 less 7 41.2 4 33.3 14 (19.7) enough 6 35.3 1 8.3 12 (19.9) more 4 23.5 7 58.3 45 (64.3) vitamin a intake 0.002 less 5 29.4 5 41.7 6 (8.5) enough 4 23.5 1 50.0 15 (75.0) more 8 47.1 6 50.0 50 (70.4) vitamin a supplement 0,004 less 0 0 1 8.3 0 (0) enough 8 47.1 2 16.7 29 (40.8) more 9 52.9 9 75.0 42 (59.2) table 5. influence of frequency, amount, and vitamin a supplementation on vitamin a adequacy status of toddlers aged 12-59 months. variable coefficient b se p frequency source vitamin a 1,892 0,911 0,002 total source vitamin a 2,241 0,694 0,000 supplement vitamin a 2,220 0,666 0,004 [page 440] [healthcare in low-resource settings 2024;12:11731] table 3. frequency distribution of vitamin a sufficiency status. adequacy status frequency % deficient (<80%) 17 17 adequate (80-100%) 12 12 more (>100%) 71 71 total 100 100 table 2. frequency distribution of vitamin a food source intake. food source intake vitamin a frequency % frequency of intake less 25 25 enough 19 19 more 56 56 total intake less (<80% rda) 16 16 sufficient (80-100% rda) 20 20 more (>100% rda) 64 64 vitamin a supplement less (<80% rda) 1 1 sufficient (80-100% rda) 39 39 more (>100% rda) 60 60 total 100 100 rda, recommended dietary allowance. non -co mmerc ial us e o nly more educated women possess better skills to access modern health services and are more likely to comprehend messages regarding dietary diversity and healt.13,14 numerous studies have found that children of working mothers have a lower nutrition status than those whose mothers remain at home. others, however, have found maternal employment outside the home to have a positive impact on children’s nutrition status.15,16 it is also believed that economically independent women are more likely to be able to use their knowledge to maintain good nutrition and health for their children than economically dependent women.17,18 the frequency of food intake is used to calculate the amount of nutrient intake that enters the body so that the needs that enter that day can be known.17 the frequency of eating is required 3 times a day with an adequate amount of food intake according to the needs of the body.19 the frequency of intake of vitamin a sources is obtained from fruits and vegetables. the vegetables most consumed by children under five in this area are carrots and fruit, which are generally consumed frequently, namely bananas; this is because these types of vegetables and fruits are quite available in households to be consumed every day. the frequent intake of vegetables is due to the large number of vegetables consumed by children from their habit of liking vegetables. parents get a variety of vegetables from their own farm income, and some buy them.20 sources of vitamin a vegetables and fruit in the family are not something that is rarely found in the daily diet; in general, children do not like vegetables and fruit. the results of this study are inversely proportional because parenting patterns that often provide a rich intake of vitamin a from childhood, with a frequency of more than 3 times a day can result in excessive intake of vitamin a sources obtained by the toddler.21 the results of the study indicate the influence of the amount of intake of food sources of vitamin a on the status of vitamin a adequacy. in theory, micronutrient needs can be met through food intake if consumed in an amount that is in accordance with the daily nutritional requirement so that it can meet the nutritional adequacy rate for toddlers. this indicates that food intake has a direct effect on the nutritional status of children under five.22 the results of this study showed that respondents had a good vitamin a adequacy status. infancy is the most important period in the process of growth and development. vitamins and minerals in infancy are needed in high amounts for physical growth, brain and intelligence development, and the body’s resistance to disease. vitamins and minerals are not enough only to be obtained from food intake, so people get used to taking supplements to meet the need for vitamins and minerals.21 activities to overcome vitamin a deficiency are carried out by intervening in vitamin a capsules for children under five through the distribution of vitamin a capsules. given the low intake of nutrients, including vitamin a, it is necessary to provide additional vitamin a through vitamin a supplements that are consumed every day.4 nutritional status is the result of a balance between food that enters the body (nutrition intake) and the body’s needs (nutrition output) for certain nutrients. toddlers whose food intake is not good enough will weaken their immune systems and will be susceptible to disease. for toddlers who are sick, their weight will decrease, which will affect the nutritional status of the child.20 nutritional needs can be met through food intake if consumed in an amount that follows the number of nutritional needs per day so that it can meet the nutritional adequacy rate for toddlers. based on the results of research on the intake of natural sources of vitamin a in children under five, it was found that the adequacy level of vitamin a consumption was mostly low, caused by wrong eating habits, not eating vegetables and fruit, or because of poor purchasing power. low, unable to buy animal foods rich in vitamin a. vitamin a derived from animals is generally consumed in small amounts because it is expensive.17 conclusions children between the ages of 12 and 59 months who consume vitamin a regularly have a positive impact on their vitamin a adequacy. the level of vitamin a adequacy in toddlers aged 12-59 months was influenced by the total source of vitamin a sources they consume. measuring the proportion of children who have received two doses of vitamin a within the past year can be used to monitor coverage of interventions aimed at increasing child survival rates. government programs are needed to control vitamin a deficiency to increase children’s chances of survival, reduce the severity of childhood illnesses, ease the strain on health systems and hospitals, and contribute to the well-being of children, their families, and communities. references 1. adriani p. faktor-faktor yang berhubungan dengan pemberian vitamin a pada balita di wilayah kerja puskesmas kandai kota kendari. j smart kebidanan. 2019;6:20. 2. adriani m, wirjatmadi b. the effect of adding zinc to vitamin a on igf-1, bone age and linear growth in stunted children. j trace elem med biol. 2014;28:431-5. 3. kemenkes ri. petunjuk teknis pelaksanaan bulan kapsul vitamin a terintegrasi program kecacingan dan crash program campak. 2019. available from: http://repo. upertis.ac.id/1092/1/8%20petunjuk%20teknis%20pel aksanaan%20bulan%20kapsul%20vitamin%20 a%20terintegrasi%20program%20kecacingan%20dan%20crash%20program%20campak.p df 4. pratiwi ys. kekurangan vitamin a (kva) dan infeksi. indones j heal sci. 2013;3:207-10. 5. suryawan a, jalaludin my, poh bk, et al. malnutrition in early life and its neurodevelopmental and cognitive consequences: a scoping review. nutr res rev. 2022;35:136-49. 6. sanif r, nurwany r. vitamin a dan perannya dalam siklus sel. jkk. 2017;4:83-8. 7. sugianto ma, suyasa ik, weta iw, et al. determinant factors related to decreasing stunting rates in garbasari village, badung regency, bali province. univers j public heal. 2022;10:627-32. 8. irwadi i, kinandita h, mahmud j, herawati l. profile of blood glucose and insulin after vitamin c and vitamin e supplemen. tation on active teenagers. int j eng technol. 2018;7:136-40. 9. wadhani lpp, wijaya sm. konsumsi protein, vitamin a dan status gizi serta kaitannya dengan hasil belajar anak sekolah dasar. j nutr coll. 2021;10:181-8. 10. has emm, nursalam, arief ys. improving complementary feeding practice and child growth in indonesia through family empowerment intervention. j pak med assoc. 2023;73:s7-12. 11. nurly qurrota aini yw. 93657-id-kontribusi-mp-asi-biskuitsubstitusi-tep. j nutr coll. 2013;2:458-66. 12. rinda fithriyana. hubungan pengetahuan ibu tentang vitamin a dengan pemberian vitamin a pada balita di desa kuantan transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11731] [page 441] non -co mmerc ial us e o nly sako tahun 2016. energies. 2018;6:1-8. 13. seboka bt, hailegebreal s, yehualashet de, et al. exploring spatial variations and determinants of dietary diversity among children in ethiopia: spatial and multilevel analysis using edhs (2011–2016). j multidiscip healthc. 2021;14:2633-50. 14. beyene m, worku ag, wassie mm. dietary diversity, meal frequency and associated factors among infant and young children in northwest ethiopia: a cross-sectional study. bmc public health. 2015;15:1-9. 15. thalib ku, suryani as’ad, healthy hidayanti, et al. efektivitas pemberian biskuit ikan teri terhadap peningkatan kadar hemoglobin pada remaja putri. oksitosin j ilm kebidanan. 2021;8:44-56. 16. arini d, nursalam n, mahmudah m, sari ey, cahyani fd. the effect of maternal role identity application on cognitive development in stunting children aged 1-3 years in a public health center. gac med caracas. 2022;130:s913-20. 17. rokhmah f, muniroh l, nindya ts. hubungan tingkat kecukupan energi dan zat gizi makro dengan status gizi siswi sma di pondok pesantren al-izzah kota batu. media gizi indones. 2017;11:94. 18. putri mg, irawan r, mukono is. the relationship of vitamin a supplementation, giving immunization, and history of infection disease with the stunting of children aged 24-59 months in puskesmas mulyorejo, surabaya. media gizi kesmas. 2021;10:72. 19. emilia e, juliarti j, akmal n. analisis konsumsi makanan jajanan terhadap pemenuhan gizi remaja. j gizi dan kuliner (journal nutr culinary). 2021;1:23. 20. maslakhah nm, prameswari gn. pengetahuan gizi, kebiasaan makan, dan kebiasaan olahraga dengan status gizi lebih. indones j public heal nutr. 2021;1:52-9. 21. wiliyanarti pf, wulandari y, nasrullah d. behavior in fulfilling nutritional needs for indonesian children with stunting: related culture, family support, and mother’s knowledge. j public health res. 2022;11. 22. indonesia mkr. peraturan menteri kesehatan republik indonesia nomor 21 tahun 2015. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 442] [healthcare in low-resource settings 2024;12:11731] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11195 family health task implementation and the health status of diabetes mellitus patients: a correlational study niko dima kristianingrum,1 delfira arizda,2 setyoadi,1 yati sri hayati,1 michael leo parchman3 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2undergraduate program, department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 3kaiser permanente washington health research institute, united states abstract introduction: chronic conditions due to diabetes cause changes in patients’ health status and their family has important roles in the health care. therefore, this study aimed to analyze the relationship between family health task implementation and the health status of diabetics. design and methods: an observational analytic design with a cross-sectional approach was used, while the respondents consisted of 327 family caregivers and 327 diabetes mellitus patients. this study used both family health task implementation and short form health survey (sf-12) questionnaires. results: the result of the pearson product moment test showed a correlation coefficient of 0.593 and a 0.000 p-value (α 0.05). conclusions: it was concluded that there was a fairly strong relationship between family health task implementation and the health status of diabetes mellitus patients. nursing intervention is needed to improve the implementation of family health tasks. introduction the international diabetes federation (idf) estimated the global prevalence of diabetes mellitus to be 151 million in 2000, 366 million in 2011, and 415 million in 2015.1-3 the prevalence of this disease in 2017 in adults aged 18-99 years around the world was 451 million and it is predicted to increase to 693 million in 2045.1-3 moreover, it was 1.5% to 2% based on a doctor’s diagnosis in the population aged 15 years from 2013 to 2018 in indonesia. the basic health research 2018 results showed an increasing prevalence of diabetes mellitus from 6.9% to 8.5% based on blood tests performed in the population aged 15 years from 2013 to 2018.4 diabetes mellitus (dm) is a serious threat to the world of health today due to being a lifelong chronic disease that cannot be cured. this causes complications such as cardiovascular disease, stroke, peripheral arterial disease, neuropathy, nephropathy, and retinopathy once not controlled.5 dm also has an impact on health status, where old age, unemployment and being single and widower had a significant association with lower health related quality of life (hrqol).6 dm patients need to check their health status because it is one of the main goals in treating incurable chronic diseases. besides, low health status and psychological problems worsen metabolic disorders, either directly through hormonal stress reactions, or indirectly through complications.7 dm patients are dependent on other people for support, particularly their family because they experience a decrease in mental and physical function. this causes the diabetics to be unable to carry out activities independently, specifically those related to self-processing in keeping blood sugar levels stable, therefore they need support from others, especially family as the closest people they have.8 family is the primary support system that provides care directly in every healthy and sick condition to its members for improvement in the health status of the sick and other persons.9 additionally, the health care tasks consist of knowing family health problems, making decisions to take appropriate action, providing care to the members who have health problems, modifying the environment to maintain good health, and using health facilities.10 the family has a major role in maintaining health and helping diabetics in the care and control of diabetes mellitus, giving encouragement and motivation, and convincing patients to improve their health status to a good state by managing their disease properly.11 a study reported the implementation of good family health care tasks in hypertensive individuals with good health status in 83 respondents (54.6%) and stated that there was a relationship between the implementation process and the patients’ health status.12 but other qualitative study found that the family habits which highly risky to increase blood glucose older people.13 increasing blood glucose impact on health status with worsen metabolic disorders.7 particularly, this study aims to analyze the relationship between family health task implementation and the health status of diabetes mellitus patients. significance for public health a family is regarded as the smallest unit of the society that lives together and depends on each other. furthermore, the members with diabetes mellitus require long-term care and the assistance of a caregiver at home. family health task is important for diabetics considering its relation to the patients’ health status and impact on morbidity, mortality, and the degree of public health. this study contains the basic data of policy created for public health services to improve public health status, specifically in diabetic patients and their families. article [page 100] [healthcare in low-resource settings 2023; 11(s1):11195] non -co mmerc ial us e o nly design and methods a cross-sectional design was used, while the study population was 1,787 diabetes mellitus patients and their family caregivers obtained from malang city health office. furthermore, a cluster random sampling technique was employed and the inclusion criteria for diabetes mellitus patients were people diagnosed with diabetes mellitus and being able to communicate verbally well. family inclusion criteria were living with diabetics, minimum age 17 years old, and being able to communicate verbally well. this study was conducted in malang city in january-february 2020. the number of subjects was 327 diabetes patients and their families, while the instrument used to measure the diabetics’ health status was short form 12 (sf-12). family health tasks were measured using a questionnaire containing 21 questions that have been tested for validity and reliability before. this instrument consisted of 5 questions about the family’s health problems recognition, another 5 about the ability to decide on the right action, 5 about the ability to provide care, 2 about the ability to modify the family environment to support the healing process, and 4 concerning the ability to use health service facilities. demographic data were also collected and the pearson product moment test results showed that the calculated r-value was 0.48 – 0.79 (> 0.44) and the cronbach alpha coefficient was 0.932 > 0.600. the data collection was performed at the respondent’s house where questions read from the instrument were answered and filled accordingly. ethical approval was received from the health ethics committee faculty of medicine universitas brawijaya with ethical clearance number 06/ec/kepk/01/2020 and the participants were given informed consent before participating in this study. results and discussions table 1 shows that most caregivers aged less than 45 years old (48.3%), were moslem (96.9%), male (51.4%), with senior high school education level (48.6%), had private jobs (57.5%), and with children (47.1%). also, most diabetes mellitus patients aged between 45-65 years old (63.3%), were moslem (96.9%), female (80.4%), with last education being elementary school (51.7%), did not work (68.8%), suffered for 1-5 years (48.6%) and their last blood sugar level was >125 mg/dl (86.9%). table 2 shows that caregivers with good family health tasks were 189 people (57.8%), while up to 138 people (42.2%) lack family health care implementation. based on the components of family health care tasks, the best was that 65.4% family made decisions and the lowest with 57.8% modified the environment (table 3). based on table 4, diabetes mellitus patients were in the category of good health status, up to 196 people (59.9%). once viewed from the domain of health status, the best domain was social function (91.4%), while the poorest was general health (44.3%) as can be seen in table 5. according to table 6, the statistical test results showed a significant relationship between family health task implementation and the health status of diabetics with a 0.000 pvalue (alpha 0.05). family health care tasks consist of knowing the health problems, as well as the ability to make decisions, demonstrate good health care, modify the environment, and access health centers. the caregiver’s ability to provide health care is influenced by several factors, namely education, occupation, economic status, and distance to health services. the first domain of the family health care tasks is knowing about health problems. additionally, the article [healthcare in low-resource settings 2023; 11(s1):11195] [page 101] table 1. characteristics of family caregivers and people with diabetes mellitus. demographic characteristics family caregivers people with dm n % n % age <45 years old 158 48.3% 7 2.1% 45-65 years old 123 37.6% 207 63.3% >65 years old 46 14.1% 113 34.6% gender male 168 51.4% 64 19.6% female 159 48.6% 263 80.4% last education no school 1 0.3% 2 0.6% elementary school 71 21.7% 169 51.7% middle school 54 16.5% 76 23.2% senior high school 159 48.6% 65 19.9% undergraduate or postgraduate 42 12.8% 15 4.6% profession does not work 120 36.7% 225 68.8% labor 9 2.8% 3 0.9% farmers 1 0.3% 0 0% civil servants 7 2,1% 3 0.9% army / police 2 0.6% 1 0.3% etc 188 57.5% 95 29.1% relationship with patients husband and wife 153 46.8% child 154 47.1% son in law 3 0.9% sister 6 1.8% niece 1 0.3% grandchild 9 2.8% mother 1 0.3% non -co mmerc ial us e o nly caregiver’s education level is directly proportional to their level of knowledge and information possessed. educational background affects a person’s mindset and cognitive abilities have a role in recognizing health problems.11 education is a change in human beings, hence it is one of the factors influencing a person’s perception to easily make decisions and act.14 decision-making in family health care task implementation is influenced by social and psychological factors.15 behavior is one of the social factors, and good behavior is caused by a person’s experiences as well as physical and non-physical environmental factors.16 well-educated caregivers tend to provide good care to family members who have health problems.17 environmental modification is carried out by reducing the physical hazards existing at home to minimize health risks.18 in theory, caregivers’ ability to modify the environment is a form of emotional support that provides comfort and helps the healing process, besides it can be conducted by providing a comfortable and conducive home atmosphere.12 the family’s ability or behavior in using health facilities is influenced by education level article [page 102] [healthcare in low-resource settings 2023; 11(s1):11195] table 2. family health tasks implementation. family health tasks implementation n % good (score ≥75.46) 189 57.8% poor (score <75.46) 138 42.2% table 3. domain of family health task. domain of family health task good poor n % n % recognizing the problem 181 55.4% 146 44.6% making decision 214 65.4% 113 34.6% provide care 207 63.3% 120 36.7% encironmemtal modification 138 42.2% 189 57.8% take advantage of the facilities health 201 61.5% 126 38.5% table 5. domain of health status of people with diabetes mellitus. domain good not good n % n % physical dimension physical function 310 94.8% 17 5.2% physical role 279 85.3% 48 14.7% body pain 296 90.5% 31 9.5% general perception 182 55.7% 145 43.3% mental dimension emotional role 301 92% 26 8% vitality 230 70.3% 97 29.7% mental wellness 323 98.8% 4 1.2% social function 321 98.2% 6 1.8 table 6. correlation analysis between the burden of family caregivers and the health status of dm patients. variable correlation coefficient p-value the family health tasks implementation 0.593** 0.000 health status table 4. health status category. health status n % good (score ≥61.91) 196 59.9% poor (score <61.91) 131 40.1% non -co mmerc ial us e o nly because both parameters have a significant relationship.19 busyness and economic level also influence the use of health facilities. one of the factors that have a significant effect on health facilities usage is distance, hence people with middle economic level are not necessarily disobedient in the treatment and care program.20 the health status of dm patients is influenced by several factors including age, gender, education, length of suffering, and occupation.21 as age increases, it becomes more difficult to control blood sugar levels which are increasing due to a decrease in the function of body organs, thereby affecting dm patients’ health status.22 based on the result, the gender of the subjects used was mostly female. this is not in line with another study that states women’s health status is lower compared to men, specifically in mental or psychological aspects because they are more prone to anxiety and depression once exposed to chronic diseases. health status increases along with higher levels of education obtained by the patients, and vice versa.23 education is an important factor in understanding disease, dm management and blood sugar control, self-care, overcoming symptoms that arise with appropriate treatment, and preventing complications. additionally, patients with higher education tend to develop coping mechanisms and a good understanding of information, hence they respond positively and take self-beneficial actions. health status consists of the physical health component scale (pcs) and the mental health component scale (mcs). the pcs has four domains, namely general health, physical function, physical role, and discomfort. the msc also has four domains, including the role of emotions, mental health, vitality, and social functioning. changes in physical roles caused by fatigue in diabetics are a cellular compensatory process to maintain cell function due to the impact of cellular starvation.24 besides, dm patients experience a decrease in the amount of physical activity due to discomfort in the form of pain or tingling that occurs. lack of physical activity is initiated by other reasons, such as the fear of getting ulcers or wounds on the feet.25 mental health is a condition where individuals are free from all forms of symptoms of mental disorders.26 individuals with good mental health function normally in life, but their counterparts experience disturbances in mood, thinking ability, and self and emotional control. positive self-control in dealing with various situations affect one’s mental health and a person’s emotions are said to be healthy once they are controllable.27 in this study, a significant relationship was discovered between family health care task implementation and the health status of diabetes mellitus patients. the relationship is unidirectional, indicating the better the implementation of family health care tasks, the better the diabetic’s health status. a relationship was also found between the implementation of family health care tasks and the health status of hypertensive patients (p-value 0.009).12 families who have good abilities in carrying out health care tasks have a 12.03 times higher chance to improve health status than their counterparts. a study stated that reported family health task implementation before and after being carried out with family nursing care had a significant effect on health status with a p-value of 0.000.28 the family role is needed to improve the health status of its members according to health care function. these include five nursing tasks, namely the ability to recognize health problems, take appropriate health action decisions, care for the members, maintain a pleasant home atmosphere and modify the environment to ensure good health, and the ability to reach health service facilities.29 based on a study, family and nurses provide effective health care interventions to improve health status outcomes in the elderly with memory impairment and cancer.30 it is evident that family involvement in the intervention improves patient outcomes in efficacy, specificity, and effectiveness. families according to several studies in the field of family health have a big influence on the members’ health status. moreover, they have a role in the form of health promotion and risk reduction.9 once there are health problems, the majority of individuals receive more care from their families. the family is the most important source of care for sick members, which influences a health-oriented lifestyle. in this case, it prevents, corrects, causes, or ignores health problems in the members.9 the family has a major role in maintaining all members’ health and in trying to achieve the desired health status. health problems in the family are interrelated where the family is an effective and efficient intermediary from which to seek good health status for its members. there may be some possible limita article correspondence: niko dima kristianingrum, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: nikodima.fk@ub.ac.id key words: family health tasks, health status, diabetes mellitus. acknowledgment: the author is grateful to the faculty of medicine, universitas brawijaya for providing support and encouragement during this study. the author is also grateful to the malang city health office and participants. contributions: all authors contributed equally to this article, and then read and approved the final manuscript such that ndk wrote, managed, and reviewed the final article. da was responsible for data collection, while ysh & s served as supervisors and also conducted the review. mlp review the article. conflict of interests: the author declares no conflict of interest. funding: faculty of medicine, universitas brawijaya. clinical trials: this study has been approved by the health research ethics committee of the faculty of medicine, universitas brawijaya malang with ethical clearance number 06/ec/kepk/01/2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 13 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11195 doi:10.4081/hls.2023.11195 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11195] [page 103] non -co mmerc ial us e o nly tions in this study. some respondents may have difficulty in understanding the question in sf 12 questionnaire. having observed this problem, the researcher gave more detailed explanation to the respondents so they can understand the questions. the data generated was only from the questionnaire instrument which is based on the perception of respondents’ answers. a qualitative approach is needed to strengthen conclusions because research instruments are vulnerable to respondents’ perceptions that do not describe the actual situation conclusions based on the results showed, there is a relationship between family health care task implementation and the health status of diabetes mellitus patients, hence both parameters are directly proportional. nurses need to carry out family-centered care to improve the health status of dm patients. further study needs to analyze the factors influencing family health care tasks, as well as develop and carry out interventions to change family health tasks. references 1. cho nh, shaw je, karuranga s, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diabetes res clin pract 2018;138:271-281. 2. international diabetes federation. idf diabetes atlas ninth edition 2019; 2019. [cited 2021 oct 10]. available from: https://diabetesatlas.org/atlas/ninth-edition/ 3. international diabetes federation. idf diabetes atlas seventh edition 2017; 2017. [cited 2021 oct 10]. available from: https://diabetesatlas.org/atlas/seventh-edition/ 4. papatheodorou k, banach m, bekiari e, et al. complications of diabetes 2017. j diabetes res 2018;2018:e3086167. 5. qinglan d, funk m, spatz es, et al. association of diabetes mellitus with health status outcomes in young women and men after acute myocardial infarction: results from the virgo study. j am heart assoc 2019;8:e010988. 6. aschalew ay, yitayal m, minyihun a. health-related quality of life and associated factors among patients with diabetes mellitus at the university of gondar referral hospital. health quality life outcomes 2020;18:62. 7. anizar rds, pudjiastuti e. studi deskriptif mengenai resiliensi istri sebagai caregiver pada penderita diabetes melitus (dm) tipe ii di rsud sejiran setason. [descriptive study of wife's resilience as caregiver in type ii diabetes mellitus (dm) patients at sejiran setason hospital] prosiding psikologi 2017;0:1–6. 8. yeni f, handayani t. hubungan peran keluarga dengan pengendalian kadar gula darah pada pasien diabetes melitus di wilayah kerja puskesmas pauh padang. [relationship between the role of the family and the control of blood sugar levels in patients with diabetes mellitus in the work area of the pauh padang health center.] ners jurnal keperawatan 2013;9:136–42. 9. friedman mm, bowden, vr, jones eg. buku ajar keperawatan keluarga: riset, teori & praktik. [textbook of family nursing: research, theory & practice.] (5th ed.). jakarta: egc; 2010. 10. farida l, purwaningsih p, rosalina. peran informal keluarga dalam pengendalian kadar glukosa darah pada penderita diabetes mellitus. [the informal role of the family in controlling blood glucose levels in patients with diabetes mellitus.] jurnal ilmu keperawatan komunitas 2018;1(1):5– 17. 11. potter pa & perry ag. buku ajar fundamental keperawatan: konsep, proses dan praktik (4 volume 1). [nursing fundamental textbook: concepts, processes and practices (4 volume 1).] jakarta: egc; 2005. 12. amigo tae. hubungan karakteristik dan pelaksanaan tugas perawatan kesehatan keluarga dengan status kesehatan pada aggregate lansia dengan hipertensi di kecamatan jetis yogyakarta. [correlation between characteristics and implementation of family health care tasks with health status in aggregate elderly with hypertension in jetis district, yogyakarta.] universitas indonesia; 2012. 13. badriah s, sahar j, gunawijaya j, et al. pampering older people with diabetes in sundanese culture: a qualitative study. enfermería clínica 2019;29:733–8. 14. notoatmodjo s. promosi kesehatan dan ilmu perilaku. [health promotion and behavioral sciences.] jakarta: rineka cipta; 2007. 15. kamaluddin r. pertimbangan dan alasan pasien hipertensi menjalani terapi alternatif komplementer bekam di kabupaten banyumas. [considerations and reasons for hypertension patients undergoing complementary alternative therapy for cupping in banyumas regency.] sjn 2010;5:95–104. 16. nugroho w. keperawatan gerontik. [gerontic nursing.] buku kedokteran egc: jakarta; 2008. 17. sahar j, courtney m, edwarsd h. improvement of family carers’ knowledge, skills and attitudes in caring for older people following the implementation of a family carers’ training program in the community in indonesia. international journal of nursing practice 2002;9:246 – 254. 18. kaakinen jr, coehlo dp, steele r, robinson m. family health care nursing: theory, practice, and research [internet]. f.a. davis company; 2018. available from: https://books.google.co.id/books?id=wnfjdwaaqbaj. 19. mandias r. hubungan tingkat pendidikan dengan perilaku masyarakat desa alam dalam memanfaatkan fasilitas kesehatan di desa pulisan kecamatan likupang timur minahasa utara. [relationship between education level and community behavior in alam village in utilizing health facilities in pulisan village, east likupang district, north minahasa.] minahasa: universitas klabar; 2012. 20. suhadi. analisis faktor-faktor yang mempengaruhi kepatuhan lansia dalam perawatan hipertensi di wilayah puskesmas srondol kota semarang. [analysis of factors affecting elderly compliance in hypertension treatment in the srondol health center, semarang city.] jakarta: ui; 2011 21. moons, p. why call it health-related quality of life when you mean perceived health status. eur j cardiovasc nurs 2004;3(4):275-7. 22. suardana ik, rasdini a, kusmarjathi nk. hubungan dukungan sosial keluarga dengan kualitas hidup pasien diabetes mellitus tipe ii di puskesmas iv denpasar selatan. [the relationship between family social support and quality of life of patients with type ii diabetes mellitus at puskesmas iv denpasar selatan.] jurnal skala husada 2015;12:96 – 102. 23. gautam y, sharma a, agarwal a, et al. a cross-sectional study of qol of diabetic patients at tertiary care hospitals in delhi. indian j community med 2009;34:346–50. 24. riyadi s, sukarmin. asuhan keperawatan pada pasien dengan gangguan eksokrin dan endokrin pada pankreas. [nursing care of patients with exocrine and endocrine disorders of the pancreas.] yogyakarta: graha ilmu; 2008. article [page 104] [healthcare in low-resource settings 2023; 11(s1):11195] non -co mmerc ial us e o nly 25. lemaster jw, mueller mj, reiber ge, et al. effect of weightbearing activity on foot ulcer incidence in people with diabetic peripheral neuropathy: feet first randomized controlled trial. phys ther 2008;88:1385–98. 26. putri aw, wibhawa b, gutama as. kesehatan mental masyarakat indonesia (pengetahuan, dan keterbukaan masyarakat terhadap gangguan kesehatan mental). prosiding penelitian dan pengabdian kepada masyarakat. [indonesian people's mental health (knowledge, and community openness to mental health disorders). proceedings of research and community service.] 2015;2:13535. 27. hamid a. agama dan kesehatan mental dalam perspektif psikologi agama. [religion and mental health in the perspective of the psychology of religion.] healthy tadulako j 2017;3:1–14. 28. yuliyanti t, zakiyah e. tugas kesehatan keluarga sebagai upaya memperbaiki status kesehatan dan kemandirian lanjut usia. [family health tasks as an effort to improve the health status and independence of the elderly.] profesi (profesional islam): media publikasi penelitian. 2016;14(1): 49–55. 29. andarmoyo s. keperawatan keluarga konsep teori, proses dan praktek keperawatan. [family nursing concepts theory, process and practice of nursing.] yogyakarta: graha ilmu; 2012. 30. griffin jm, meis la, macdonald r, et al. effectiveness of family and caregiver interventions on patient outcomes in adults with cancer: a systematic review. j gen intern med 2014;29:1274–82. article [healthcare in low-resource settings 2023; 11(s1):11195] [page 105] non -co mmerc ial us e o nly hrev_master [page 24] [healthcare in low-resource settings 2022; 10:9928] covid-19 pandemic and quick evolution of telemedicine: a gap analysis jayagandan jayamani,1 pugazhenthan thangaraju,2 ravish gowda,3 srinivas huchegowda4 1laboratory, new mowasat hospital, alsalmiya, kuwait; 2department of pharmacology, all india institute of medical science, raipur; 3department of neurochemistry, nimhans, bangalore; 4department of biochemistry, shri atal bihari medical college and research institute, bangalore, india abstract telemedicine though not a newer concept to healthcare community, it is relatively a new acquaintance to both healthcare providers and the general public. since 11th of march 2020, the day when who declared covid-19 infection as pandemic, the telemedicine services had achieved quick popularity. in fact this pandemic boosted a solid foundation for telemedicine and now it is one among the scope of services offered by any reputed healthcare organization globally. this article aims to emphasize how a symbiosis between telemedicine, poct and mobile health units can help to deliver a high quality healthcare eliminating the risk of infection spread to both patients and health care providers. the methodology adopted includes collective viewpoints of authors which are based upon working experience gained during the current pandemic and literature review of recent and relevant articles related to process and pitfalls of telemedicine. literature search was conducted by searching using key words and phrases like ‘telemedicine’, ‘covid-19 and telemedicine’ and ‘noncommunicable diseases management during pandemic’. the scope and gaps observed by literature survey and personal experience included infrastructure, awareness and training of both health care providers and patient population, utilization of poct devices, internet connectivity, need for an nationwide unified health information management system (hims) to aid easy access to patient health information and easy referrals to higher centers. in summary telemedicine is an absolute necessity during this on-going pandemic and its enhancement by integration with artificial intelligence and machine learning algorithms is a real need of hour. introduction the unprecedented covid-19 pandemic situation and its coexistent risk of contracting infection during hospital visits actually had given a kick start to telemedicine services which was otherwise not so popular among the general public. even before this covid-19 pandemic, actually health systems worldwide were very actively managing the silent pandemic of non-communicable diseases. health policies and programs of both developed and developing nations gave greater emphasis to control non-communicable diseases (ncds) namely diabetes, cardiovascular diseases like coronary artery disease, stroke and cancers.1 now the biggest question is that “are these non-communicable diseases left unmonitored focusing only on covid19 pandemic?” and a very simple answer to this question would be “no”, because this is where telemedicine evolved quickly forming a major pillar of support. most nations adopt the concept of ‘health for all’ and are striving to deliver equally higher quality healthcare to all levels of community. now with the existing pandemic situation it is a challenging task for nations to maintain continuity of patient care especially to their rural population. also now we know that the covid-19 virus is constantly mutating and mutated variants are capable of causing fresh waves of infections. so it becomes an absolute necessity that countries should improve their telemedicine infrastructure in order to provide uninterrupted healthcare services. this article aims to reflect and reveal why we are in need of expansion of scope of telemedicine services; what do we currently have in terms of technology to deliver this service to general public; what initiatives can improve the delivery of telemedicine services at all levels of health system starting from tertiary centers to primary care centers and finally having addressed the existing gaps, how potential is telemedicine to emerge as a definitive allied medicine science in nearest future. materials and methods the material and method is achieved by the exploring the working experience and literature review of recent and relevant articles related to process and pitfall of telemedicine. the article constitutes the collective opinion of the authors based on individual experience gained while working during the current pandemic situation. however published literature search were also conducted by searching using key words and phrases like ‘telemedicine’, ‘covid-19 and telemedicine’, ncd management during pandemic. articles focusing current telemedicine scenario in india and other similar developing countries were referred preferentially the literature review is mentioned in table 1. what we have and what we need in developing countries like india telemedicine services at present have achieved a considerable popularity and awareness in urban areas and among its residents.2 a vast majority of healthcare organizations both government and private are currently offering telemedicine consultation.3–5 most of video consultations are through free video call platforms like facebook, whatsapp, skype and zoom. though few of these applications offer end to end encryptions these are per user’s selection of privacy settings during installation in their personal computer (pc) or smartphones which may be inappropriate. few private hospitals have their own dedicated telemedicine software applications that are sophisticated and handcrafted to healthcare in low-resource settings 2022; volume 10:9928 correspondence: srinivas huchegowda, department of biochemistry, shri atal bihari medical college and research institute, hospital road, shivajinagar, bangalore, karnataka state, 560001 india. e-mail: drsrinibiochem@gmail.com key words: covid-19, pandemic, telemedicine, point of care testing, healthcare conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable informed consent: not applicable received for publication: 21 june 2021. revision received: 21 february 2022. accepted for publication: 22 february 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:9928 doi:10.4081/hls.2022.9928 non -co mmerc ial us e o nly ensure the privacy and patient data safety but come with a huge initial investment which may translate into hefty consultation charges.6,7 in contrast to urban cities and towns in most rural areas and villages the sole provider of healthcare services is government run chain of primary health centers (phcs) and infrastructure to implement telemedicine practices really a distant dream. major challenge for effective implementation of telemedicine practices at rural areas starts from its awareness and education about refraining visiting phcs for simple ailments that can be treated by home remedial measures. discussion about devising strategies to implement telemedicine in rural areas would be beyond scope of this article. currently healthcare providers through telemedicine services manage to cater variety of consultations services like physician follow-up for ncds, diet advice from nutritionist, demonstration of home based physiotherapy exercises, all forms of expert counseling etc.2,5,7–10 it is evident that effective disease management through telemedicine services is impossible without conducting relevant medical investigations. these investigations may be necessary for initial assessment of the patient or as follow-up to previous consultations. blood investigations required may be anything starting from simple glucose monitoring for diabetes to complex therapeutic drug monitoring for chemotherapy. similarly non-invasive investigations may include blood pressure, electrocardiography (ekg), echocardiography, ultrasonography etc.11,12 currently to overcome this challenge there are plenty of fda approved and ce marked in vitro diagnostics (ivd) point of care testing (poct) available in markets for tests like glucose, including continuous glucose monitors (cgms), ketones, cholesterol, haemoglobin, creatinine, urine routine strips etc. that are easy to use and maintain domestically at home.2,11–13 most of poct manufacturers have come out with step by step demonstration videos that are indexed and freely available in social network platforms like youtube.14–19 though such equipment adds additional expenses at the beginning, however in a long run this would workout cheaper as it saves time and resources spent for hospital visits. likewise there are many fda approved ecg monitors that are capable transmitting the results to treating physician’s pc and smartphones.20 in situation where continuous monitoring of ekg is required online sellers like amazon have started renting medical devices like holters monitors, which appears to be a promising initiative. similarly scope of such renting services shall be broadened to include certain portable poct devices like i-stat alinity that are capable testing wide spectrum of blood analyses. in case of complex investigations telemedicine services must handshake with mobile health units, which again have evolved swiftly during this pandemic. developed nations provide province wise a fleet of mobile health units starting from ground ambulances to air ambulances that are fully equipped with a comprehensive set of poct devices. scientific societies like american association for clinical chemistry (aacc) and canadian society of clinical chemists (cscc) have issued guidance for poct testing in such mobile health units21–24. similar guidance and policies must be issued or adopted and compliance of the same needs to be monitored in developing nations. technology based strategies telemedicine services in order to be considered as a sustainable solution, it requires a strong support of technology. as the name implies firstly telemedicine requires an internet connected communication devices. governments of developing nations should start investing to improve their communication infrastructure. countries like india, which claims rural areas and villages as its backbone, should achieve 100% internet connectivity to all its phcs irrespective of its location. this should be the first initiative to be prepared for any upcoming waves of existing covid-19 or any such pandemic in future.25 every nation should develop their own unified hims and sufficiently large databases for archiving health records of its entire population. the records of each individual can be linked to their social security number like aadhar number in india or to medical insurance numbers. clear policies and protocols should be established to access such archived health records by a governing medical council registered treating physicians working for either public or private healthcare organization. data security and patient confidentiality shall be ensured through safe authentication procedures as demonstrated in figure 1. next step would be investing in largescale production of short range and longrange drones and establishing adequate number of control rooms to monitor drone traffic. these drones shall be deployed for swift delivery of prescription medications26 (even portable oxygen cylinders) to patients and for pickup of samples like dried capillary blood, urine samples, variety of swab samples packed in appropriate storage containers. patient identification before drone based deliveries and pickups shall be ensured with help of biometric data or face recognition or qr code based software developed incorporating artificial intelligence and machine learning. virtual software technology have tremendously improved and scaled up to meet the increasing demand of telemedicine article figure 1. safe authentication enabled health information management system (hims). [healthcare in low-resource settings 2022; 10:9928] [page 25] non -co mmerc ial us e o nly article table 1. literature review of the prior studies related to telemedicine adaptation. article authors and year conclusions and remarks 1. telemedicine during the covid-19 pandemic: hong, z, et al. ( 2020)27 the authors explains the success of telemedicine experiences from western china. journal of medical in western china using the network synergizes internet research with 5g service, a smartphone app, and an existing telemedicine system 2 exploring the adoption of telemedicine and virtual bokolo, a. j. (2021)28 the author have explored the factors impacting software for care of outpatients during and after the adoption of telemedicine and virtual covid-19 pandemic software platforms and highlighted funds, training, workforce integration, data privacy, wi-fi quality , licensure requirements and health insurance and reimbursement policies 3 use of telemedicine and virtual care for remote jnr, b. a. (2020)29 the authors have provided practical guide to use treatment in response to covid-19 pandemic virtual care during the covid-19 pandemic an also highlighted the gaps such as necessary infr structure, inadequate funds, lack of experience among health professionals in optimal use of telemedicine 4 telemedicine in neurosurgery: lessons learned mouchtouris, nikolaos, et al. the study is focused on use of telemedicine and transformation of care during the covid-19 pandemic (2020)30 in surgery field and describes various adaptation of effective utilization 5 telemedicine in india: current scenario and the future mishra sk, et al. they have described indian space research (2009)31 organization mediated satcom-based telemedicine network and also mentioned the inclusion curriculum in telemedicine training programs at various levels 6 telemedicine: history and success story of remote yadav sk, et al.(2021)32 they emphasized on tele-education in surgical surgical education in india field in indian scenario and propose integration of telemedicine within the framework of routine medical education. 7 a survey of awareness, knowledge, attitude, rakeshdatta, et al. they have analyzed the “telemedicine practice and skills of telemedicine among healthcare (2021)33 guidelines were promulgated in india professionals in india in 2020” for akas and concluded the requirement of training and education about the skills and provisions for effective use to avoid medico-legal issues 8 current scenario, future possibilities and nidhikaeley, et al. they have highlighted the need of telemedicine applicability of telemedicine in hilly and remote (2021)34 in hilly and remote area and to implement areas in india: a review protocol telehealth by effective collaboration of primary and secondary health care setups and to reach population staying in underserved areas 9 telemedicine as techno-innovation to tackle covid-19: carlo drago, et al. (2021)35 they describe a “semantic cores” a bibliometric analysis in the literature which represents the relevant results on telemedicine themes which will aid in evidence based literature analysis, necessary for policy making and implementation 10 are state telemedicine parity laws associated with greater kori s. zachrison, et al. the authors examined the use of telemedicine in use of telemedicine in the emergency department? ( 2021)36 emergency and the payment policy from issuers, effect the use of telemedicine and also described factors for implementation, such as regulatory environment, ease of interstate credentialing, and even the extent of payment parity 11 africa turns to telemedicine to close mental health gap paul adepoju (2020)37 the article draws attention to increase use of telemedicine during pandemic in most african country as seen by increase in traffic in help-lines and effectiveness of telemedicine for mental health is on par with one-on –one counseling 12 telemedicine for mental health in the united states: michael l. barnett, et al. the authors have explore facility adoption of making progress, still a long way to go (2019)38 telemedicine using national survey conducing in united state and suggested telemedicine as most effective option to utilize the workforce and provide service to patients needing to reach the health centers by hours away in vehicle [page 26] [healthcare in low-resource settings 2022; 10:9928] non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:9928] [page 27] in order to deliver quality medical opinions on outpatient basis even to the remotest areas during covid-19 pandemic. brief review of the literature describing utility and limitation of various aspect of telemedicine done in many countries such as norway, africa, australia, usa, india and china is presented in (table 1).27-42 conclusions we authors believe that for sustainable successful telemedicine practice a perfect blend of technology and medical science is mandatory. in addition an improved awareness and education to public about benefits of telemedicine also plays a vital role. imparting computer education into curriculum of all medical and allied medical science should be considered on highest priority as a way forward. during this pandemic developing countries are redistributing their healthcare workers serving in rural villages to urban areas in order to handle high patient loads in thickly populated cities. such redistributions to a greater extent cripple delivery of primary health care services in villages. such crisis can be to some extent managed with help of having well connected video conferring rooms in phcs for outpatient consultations. with advent of newer technologies in the field of biomedical science it is evident that telemedicine has huge scope to transform into an unavoidable field of medical science. now it’s right time to well integrate all advancements in information technologies, artificial intelligence and machine learning technologies and medical sciences to fill existing gaps in current telemedicine practices. references 1. srivastava rk, bachani d. burden of ncds, policies and programme for prevention and control of ncds in india. indian j community med 2011;36:s7– 12. 2. dinakaran d, manjunatha n, kumar cn, math sb. telemedicine practice guidelines of india, 2020: implications and challenges. indian j psychiat 2021;63:97. 3. agarwal n, jain p, pathak r, gupta r. telemedicine in india: a tool for transforming health care in the era of covid-19 pandemic. j educ health prom 2020;9:190. 4. ministry of health and family welfare, goi. e-health & telemedicine. accessed 2021 jun 13. available from: https://main.mohfw.gov.in/organisation /departments-health-and-family-welfare/e-health-telemedicine 5. chellaiyan vg, nirupama ay, taneja n. telemedicine in india: where do we stand? j family med prim care 2019;8:1872–6. 6. zhang k, liu w-l, locatis c, ackerman m. mobile videoconferencing apps for telemedicine. telemed j e health 2016;22:56–62. 7. sood sp, bhatia js. development of telemedicine technology in india: “sanjeevani”’-an integrated telemedicine application. j postgrad med 2005;51:308. 8. reimagining the indian government’s telemedicine platform [internet]. microsave 2021. accessed 2021 jun 13. available from: https://www.microsave.net/2021/02/10/ reimagining-the-indian-governmentstelemedicine-platform/ 9. dasgupta a, deb s. telemedicine: a new horizon in public health in india. indian j community med 2008;33:3–8. 10. govt. of india’s telemedicine service completes 3 million consultations. accessed 2021 jun 13. available from: pib.gov.in/pressreleaseshare.aspx?pri d=1705358 11. sherling d, sherling m. the promises and pitfalls of telemedicine. ajmc. accessed 2021 jun 13. available from: ht tps: / /www.ajmc.com/view/thepromises-and-pitfalls-of-telemedicine 12. iyengar k, jain vk, vaishya r. pitfalls in telemedicine consultations in the era of covid 19 and how to avoid them. diabetes metabsyndr 2020;14:797–9 13. mehta sj. telemedicine’s potential ethical pitfalls. ama j ethics 2014;16:1014–7. article table 1. literature review of the prior studies related to telemedicine adaptation. article authors and year conclusions and remarks 13 telemedicine adoption during the covid-19 pandemic: jake luo, et al. (2021)39 they study was done in milwaukee area of wisconsin, gaps and inequalities united states and identified several reasons for disparities in telemedicine adoption such as income, education level, race, and insurance type. 14 telemedicine across the globe-position paper from sonubhaskar, et al. the consortium has looked into telemedicine related the covid-19 pandemic health system resilience (2020)40 issues during the pandemics across various region program (reprogram) international consortium (part 1) including india, they team has pointed out the lack of infrastructure and lack of regulation is the major drawback in india. however they have concluded the positive role for telehealth or telemedicine in improving health systems 15 revisiting health information technology ethical, legal, bonnie kaplan the author describes extensively the ethical and legal and social issues and evaluation: telehealth/telemedicine (2020)41 issues and how to develop the framework for and covid-19 effective utilization of telemedicine in usa and also highlighted the need for cyber security and informatics infrastructure 16 the covid-19 catalyst: analysis of a tertiary academic clayton davis, et al the authors analyzed the patients’ utilization institution’s rapid assimilation of telemedicine (2020)42 of telemedicine in virginia. usa. the observed 82% of patients surveyed were the view to use telemedicine over a face-to-face encounter for a routine visit during future flu seasons. non -co mmerc ial us e o nly [page 28] [healthcare in low-resource settings 2022; 10:9928] 14. francis aj, martin cl. a practical example of poct working in the community. clinbiochem rev 2010;31:93– 7. 15. shaw jlv. practical challenges related to point of care testing. practical lab medi 2016;4:22–9. 16. malcolm s, cadet j, crompton l, degennaro v jr. a model for point of care testing for non-communicable disease diagnosis in resource-limited countries. glob health epidemiol genom 2019;4:e7. 17. st john a, price cp. existing and emerging technologies for point-of-care testing. clinbiochem rev 2014;35:155–67. 18. hayward g, dixon s, garland s, et al. point-of-care blood tests during home visits by out-of-hours primary care clinicians; a mixed methods evaluation of a service improvement. bmj open 2020;10:e033428. 19. clifford lj. the pros and cons of pointof-care testing vs laboratory testing. medical laboratory observer, 2018. accessed 2021 jun 13. available from: https://www.mlo-online.com/continuing-education/article/13017084/thepros-and-cons-of-pointofcare-testingvs-laboratory-testing 20. bansal a, joshi r. portable out-of-hospital electrocardiography: a review of current technologies. j arrhythm 2018;34:129–38. 21. füzéry ak, kost gj. point-of-care testing by ambulance teams: an opportunity for a new standard. aacc.org. accessed 2021 jun 13. available from: https://www.aacc.org/cln/articles/2021/ may/point-of-care-testing-by-ambulance-teams-an-opportunity-for-a-newstandard 22. aacc. guidance document on management of point-of-care testing. aacc.org. accessed 2021 jun 13. available from: https://www.aacc.org/science-andresearch/aacc-academy-guidance/management-of-point-of-care-testing 23. nichols jh, alter d, chen y, et al. aacc guidance document on management of point-of-care testing. j appl lab med 2020;5:762–87. 24. yip pm, venner aa, shea j, et al. point-of-care testing: a position statement from the canadian society of clinical chemists. clin biochem 2018;53:156–9. 25. jayamani j, thangaraju p, thangaraju e, venkatesan s. decentralisation of healthcare system due to covid-19 and its impact on hospital based laboratories pandemic panic patients’ reflection? j responsible technol 2020;1:100003. 26. hii msy, courtney p, royall pg. an evaluation of the delivery of medicines using drones. drones 2019;3:52. 27. hong z, li n, li d, et al. telemedicine during the covid-19 pandemic: experiences from western china. j med internet res 2020;22:e19577. 28. bokolo aj. exploring the adoption of telemedicine and virtual software for care of outpatients during and after covid-19 pandemic. irish j medical sci 2021;190:1-10. 29. bokolo aj. use of telemedicine and virtual care for remote treatment in response to covid-19 pandemic. j med syst 2020;44:132. 30. mouchtouris n, lavergne p, montenegro ts, et al. telemedicine in neurosurgery: lessons learned and transformation of care during the covid-19 pandemic. world neurosurg 2020;140:e387–94. 31. mishra sk, kapoor l, singh ip. telemedicine in india: current scenario and the future. telemedicine and ehealth 2009;15:568–75. 32. yadav sk, mishra a, mishra sk. telemedicine: history and success story of remote surgical education in india. indian j surg 2021; available from: https://doi.org/10.1007/s12262-02103020-9 33. datta r, singh a, mishra p. a survey of awareness, knowledge, attitude, and skills of telemedicine among healthcare professionals in india. med j armed forces india 2021; available from: https://www.sciencedirect.com/science/article/pii/s0377123721002550 34. kaeley n, choudhary s, mahala p, nagasubramanyam v. current scenario, future possibilities and applicability of telemedicine in hilly and remote areas in india: a review protocol. j family med prim care 2021;10:77–83. 35. drago c, gatto a, ruggeri m. telemedicine as technoinnovation to tackle covid-19: a bibliometric analysis. technovation 2021;102417. 36. zachrison ks, boggs km, cash re, et al. are state telemedicine parity laws associated with greater use of telemedicine in the emergency department? j am coll emerg physicians open 2021;2:e212359. 37. adepoju p. africa turns to telemedicine to close mental health gap. lancet digital health 2020;2:e571–2. 38. barnett ml, huskamp ha. telemedicine for mental health in the united states: making progress, still a long way to go. psychiatr serv 2020;71:197–8. 39. luo j, tong l, crotty bh, et al. telemedicine adoption during the covid-19 pandemic: gaps and inequalities. appl clin inform 2021;12:836–44. 40. bhaskar s, bradley s, chattu vk, et al. telemedicine across the globe-position paper from the covid-19 pandemic health system resilience program (reprogram) international consortium (part 1). front public health 2020;8:556720. 41. kaplan b. revisiting health information technology ethical, legal, and social issues and evaluation: telehealth/telemedicine and covid-19. int j medical inform 2020;143:104239. 42. davis c, novak m, patel a, et al. the covid-19 catalyst: analysis of a tertiary academic institution’s rapid assimilation of telemedicine. urol pract 2020;10.1097/upj.0000000000000155 article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11207 correlation between family support with work productivity of people with severe mental disorders (psmd) in bantur community health center, malang, indonesia renny nova, heni dwi windarwati, erik meidianto department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: one impact on people with mental disorders (psmd) is decreased productivity. as the closest people, families are expected to support psmd to be productive in the community. therefore, this study aimed to identify the correlation between family support and the work productivity of people with mental disorders. design and methods: this observational analytical study with a cross-sectional approach was conducted in the working area of the bantur community health center. purposive sampling was used to obtain 107 samples. data on family support were collected using a questionnaire and tested for validity, while the endicott work productivity scale (ewps) questionnaire was used to measure psmd work productivity. results: the results showed a significant correlation between family support and psmd work productivity, p = 0.028. the correlation was negative, meaning lower psmd work productivity implied higher family support. furthermore, emotional support was the most form of support provided by family members to psmd. work productivity is generally low, with psmd work attitudes in the high category only in sub-variables. conclusions: family support is needed for people with mental disorders to be productive. future studies should examine other factors that affect psmd work productivity. additionally, health services should innovate to create work programs that stimulate psmd’s potential and ability. introduction the mental health problem is global, with about 35 million people with depression, 60 million with bipolar, 21 million with schizophrenia, and 47.5 million with dementia. in 2018, the estimated number of people with mental disorders in indonesia was 18.5 million. east java had 2,370,000 people, while malang regency had 156,000 people with mental disorders.1 people with mental disorders experience decreased work and social abilities and cannot sustain their lives.2 mental disorders affect work productivity in patients.3 world health organization estimated the aggregate cost of all mental disorders in the uk at £32 billion (1996/97 prices), 45% of which is lost productivity. the estimated total burden of mental health problems in canada for 1998 was at least can$14.4 billion, with can$8.1 billion and can$6.3 billion for lost productivity and treatment, respectively.1 furthermore, who-led studies estimate that depression and anxiety disorders cost the global economy us$1 trillion annually in lost productivity. mental disorders cause productivity problems that result in economic losses. the global cumulative impact of mental health problems on lost economic output is estimated to reach $16.3 trillion between 2011 and 2030.4 indonesia aims to realize optimal mental health degrees for every individual, family, and community with promotive, preventive, curative, and rehabilitative approaches.5 according to indonesian law number 18 of 2014, mental health rehabilitation efforts aim to prevent or control disability, restore social and occupational functions, and empower psmd to be independent in the community. caring for a family member diagnosed with mental illness requires a holistic support system because some families experience burden, loss, and stigma. therefore, studies on the family experiences of mental illness are crucial. family empowerment emerged as the grand theme from the perceived effects of mental illness, coping, and their perspectives on empowerment grounded on family experiences.6 the factors supporting the recovery process in bipolar sufferers are religious values, family support, the presence of friends, and drugs.7 family support contributes 69.9% to the social functioning of schizophrenic patients, while 30.1% is influenced by factors such as environment, culture, genetics, treatment, and disease severity.8 therefore, family support is the closest supporting factor for psmd. previous studies found that 51.04% of family support did not provide care for schizophrenic patients. this study also found that support for patients is low.9 in a study on stigma and family support, 60% of respondents stated that family support in caring for psmd was poor.10 shankar and collyer (2002) found that some families did not support psmd to work.11 article significance for public health the work productivity of people with mental disorders affects their quality of life, prevents relapse, and reduces social stigma. families should recognize the patient's needs and empower them to be financially independent. moreover, community or primary health care centers should formulate strategies to increase family support for people with mental disorders to be productive. this study aimed to describe the correlation between family support and the work productivity of people with mental disorders. [healthcare in low-resource settings 2023; 11(s1):11207] [page 115] non -co mmerc ial us e o nly a preliminary study on september 13, 2019, found that the number of psmd in the work area of the bantur health center, malang, indonesia was 146 people as of july 2019. these people are spread over bantur, wonorejo, srigonco, bandungrejo, and sumberbening. regarding the independence level of psmd assessed based on the barthel index, 105 people (72%) showed independent dependency, 28 people (19%) showed partial dependence, and 13 people (9%) indicated total dependence. from the 105 psmds with independent dependency levels, 39 people (37%) could meet their daily needs but could not work and produce, while 66 people (63%) could return to work. in interviews with 10 family members of psmd, 7 people convey that it is okay when family members with mental disorders cannot work and produce, while 3 stated that psmd must be supported to become productive. the respondents were asked about the reasons for family members not supporting psmd to work and be productive. three people were worried that psmd fatigue would cause a relapse, while two stated that family members with mental disorders could not be invited to work. also, two other people asserted that it was important when psmd did not experience pain and disturb the work environment. eight psmds stated that they received good support from their families, such as being reminded to take medicine and taking them to health services for health control. people with psmd feel they receive better support to work from health workers, mental health cadres, and friends. the care programs aim to help psmd comply with treatment, conduct self-care, socialize, perform daily activities, and work productively. based on the family reasons for not supporting psmd to work, studies examine the relationship between family support and work productivity of people with mental disorders (psmd) in the work area of the bantur health center, malang, indonesia. design and methods the study was conducted from november 28 to december 03, 2019, using an observational design with a cross-sectional approach. inclusion criteria were used to select 107 respondents comprising people with mental disorders (schizophrenia) in the bantur health center working area. purposive sampling was conducted with inclusion criteria to select respondents, including: i) the patient undergoing treatment and outpatient treatment at the bantur health center; ii) the patient that communicate well (communicative); iii) the patient with family members, such as parents, spouse, children, or siblings; iv) the patient living with their families; v) the patient willing to become respondents by signing in the respondent’s consent form; vi) the patient approved by family members to be respondents. this study passed the ethical test in the research ethics committee faculty of medicine, brawijaya university no.319/ec/kepk-s1-psik/11/2019. family support was assessed using a questionnaire with assessment, instrumental, informational, and emotional support parameters. the assessment used a likert scale of 1 to 4, with information (1) never, (2) rarely, (3) sometimes, and (4) often. information on scores obtained were further categorized into low family support (score < 50), moderate (score 50-75), and high (score > 75). the work productivity of psmd was measured using the endicott work productivity scale (ewps) questionnaire adapted and translated into indonesian and tested for validity. the questionnaire had 22 negative statements using a likert scale. the four parameters assessed on work productivity were attendance, attitude, potential and abilities, and results. moreover, the psmd work productivity was assessed using a questionnaire with a likert article [page 116] [healthcare in low-resource settings 2023; 11(s1):11207] table 1. demographic data of respondents based on gender, age, marital status, education, occupation, length of sickness, and family members living with psmd. characteristic f % gender male 54 50.5 female 53 49.5 age < 20 years old 5 4.7 20-40 years old 49 45.8 41-60 years old 48 44.9 > 60 years old 5 4.7 marital status not married yet 61 57.0 married 26 24.3 divorced 12 11.2 death divorce 8 7.5 education no school 32 29.9 elementary school 42 39.3 junior high school 25 23.4 senior high school 8 7.5 occupation farmer 48 44.9 seller 4 3.7 breeder 6 5.6 etc 49 45.8 length of sickness < 6 months 2 1.9 6 months1 year 4 3.7 1-5 year 42 39.3 > 5 year 59 55.1 family members living with psmd parents 57 53.3 wife/husband 16 15.0 child 8 7.5 brother/sister 26 24.3 total 107 100% non -co mmerc ial us e o nly scale of 1 to 4, with information (1) often, (2) sometimes, (3) rarely, and (4) never. the range of scores obtained for the overall work productivity of psmds was 22-88. information on the scores obtained was further categorized into low work productivity (score < 44), medium (score 44-66), and high (score > 66). the questionnaire was tested for validity using product moment from pearson on 20 psmd in november 2019, with validity on all statement items > r table (0.4227) and p-value < 0.05. additionally, reliability was conducted by cronbach’s alpha test, resulting in a value of 0.957. researchers carried out the process of analyzing univariate and bivariate data using the spss 24 for windows program. results and discussions table 1 shows the socio-demographic characteristics of people with mental disorders (psmd). the data shows that 50.5% of the respondents are male, 45.8% are aged between 20-40 years, 57.0% are unmarried, and 39.3% have elementary education. moreover, 44.9% of the respondents were farmers, 55.1% had been ill for > 5 years, and 53.3% lived with their parents. table 2 shows the level of family support for people with a mental disorder (psmd). the data shows that 70.1% of the respondents have a high level of family support. table 3 shows the support given by family members to psmd. it shows that 66.4% of the assessment support, 58.4% of the instrumental support, 60.7% of the informational support, and 73.8% of the emotional support are high. table 4 shows the level of work productivity of psmd. the data shows that 35.5% of the respondents have low work productivity. table 5 shows the level of sub-variables of psmd’s work productivity. the data shows that 56.1% of the respondents have low work attendance, 38.3% have a high work attitude, 38.3% have high potential and ability, and 41.1% have medium work results. the results showed that most respondents had high family support. this is consistent with a previous study that most psmds received good family support to prevent recurrence at the mental polyclinic of r.s dr. achmad mochtar bukittinggi.12 also, ambari (2010) stated that family support is high in social functioning in post-treatment schizophrenic patients at menur hospital surabaya, indonesia.8 one impact of stigmatization on mental disorders was the increasing community-based psychiatric mental health restrictions in indonesia from 2007 until 2012. the lack of family support caused improper care for schizophrenia patient.13 families have the assessment, instrumental, informational, and emotional support. appraisal support occurs through positive assessment of individuals, such as encouraging, motivating, giving positive ideas.14 the results showed that most respondents had high assessment support. this is consistent with a previous study in 2011 which found that most respondents in rskd, south sulawesi, indonesia, received good assessment support.15 another study stated that assessment support through positive responses, such as encouragement and praise motivates psmd to strive and improve themselves. psmds need positive assessment support such as motivation and encouragement to increase their confidence in doing something.16 instrumental support is the provision of services and financial and material assistance. this includes direct assistance, such as giving or lending money, helping with daily work, and providing transportation and needed tools.14 the results showed that most respondents had high instrumental support. this is in line with a previous study that found that most psmd respondents in rskd south sulawesi, indonesia, received good instrumental support.15 other studies found that instrumental support is an important predictor of psmd’s recovery at home.17 furthermore, a family with a good economic status is more easily fulfilled than one with a low economic status. a higher economic level of a family increases the level of instrumental support for the recovery of schizophrenic patients.18 informational support includes a communication network and shared responsibilities, such as solving problems, giving advice, directions, suggestions, or feedback about someone’s actions.14 the results showed that most respondents had high informational support. this is in line with a previous study that informational support for psmd in the rskd of south sulawesi, indonesia, was mostly good. another study stated the informational support provided by families to schizophrenic patients. this was seen in how the family sought information from health workers, social and mass media, and magazines.16 furthermore, tempier et al. (2013) article table 3. the form of support given by family members to psmd. family support f % assessment support high 71 66.4 moderate 25 23.4 low 11 10.3 instrumental support high 63 58.9 moderate 30 28.0 low 14 13.1 informational support high 65 60.7 moderate 32 29.9 low 10 9.3 emotional support high 79 73.8 moderate 15 14.0 low 13 12.1 table 2. the level of family support to psmd. level of family support f % high 75 70.1 moderate 22 20.6 low 10 9.3 total 107 100 [healthcare in low-resource settings 2023; 11(s1):11207] [page 117] non -co mmerc ial us e o nly found that perceived informational support mediates social resources and the recovery of schizophrenic patients.19 emotional support entails giving individuals comfort, love, empathy, trust, and attention, making them feel valuable.14 the results showed that most respondents had high emotional support. this is in line with a previous study that found that the emotional support for psmd in the rskd of south sulawesi, indonesia was mostly good. another study in 2018 found that emotional support is the greatest form of support that involves encouraging psmd to remain strong and to pray to achieve better health development.16 in 2016, a study found that the highest emotional support is when families accept the patients’ condition, accompany them until recovery, and help them sincerely.17 most families sympathize with schizophrenic patients, and warmth indirectly improves recovery in people with mental disorders.20 the results showed that most psmd are male, consistent with a previous study on stigma and family support in caring for psmd.21 nursia examined family support for repeated treatment of psmd and found that most respondents were male.15 another study stated that men have wider problem-solving abilities than women and use more effective coping strategies.13 most respondents in this study live with their parents. this result contradicts a previous study which found that almost half of the respondents live with their siblings.15 however, it is in line with hannighofer which found the role of parents is needed in the healing process of mental patients.18 it also supports the study of magfiroh and khamida discovering that the family’s role is essential in nurturing, loving, and caring for schizophrenic clients.22 this study revealed that most psmd has suffered from mental disorders for more than five years. the results are in line with nursia’s study, which found that almost all respondents had suffered from mental disorders for more than one year.15 another study stated that almost all psmd suffered from mental disorders for more than three years. the length of time caring for psmd causes family members to risk experiencing stress and psychological pressure, resulting in family support.20 this study showed that almost half of the respondents were in the low productivity category. the results support videbeck (2011), which stated that psmd lacks the social or communication skills needed to maintain relationships with others. this social functioning disorder causes difficulty in meeting social demands.23 most work attendance of psmd in this study was in a low category, and almost half of the respondents had a high work attitude, medium work results, and low potential and abilities.24 this supports fithriyah, which stated that the work evaluation using the global assessment of functioning scale (gaf scale) showed that psmds with a fairly good gaf scale complete their work.11 this study found that almost half of the respondents were aged between 20-40 years. the results are in line with mclaughlin’s study on family support for repeated treatment of psmd, which found that most respondents are between 20-37 years old.25 similarly, ambari found that age affects social functioning in schizophrenic patients. their functioning increases with age due to treatment that helps them be more stable.8 this study found that most respondents experienced mental illness for more than five years. the result is in line with mclaughlin (2012), which found that almost all respondents had suffered from mental disorders for more than one year.25 the onset or duration of schizophrenia is an important factor affecting the patient’s ability to perform social functions.23 this study found that most respondents lived with their parents. the results support ambari (2010), which found that posttreatment schizophrenic patients living with their families with high emotions show low social functioning.8 analysis of the results using the spearman-rank correlation test showed a p-value of 0.028 (<0.05), meaning ho was rejected. this implies a significant relationship between family support and work productivity of psmd in bantur health center, malang, indonesia. the results are consistent with a previous study that psmd experiences increased social adaptability with family and social support.13 furthermore, ambari (2010) stated that high social functioning in post-hospitalized schizophrenia patients at menur hospital surabaya, indonesia, is influenced by family support8. this indicates a significant positive relationship between family support and the social functioning of schizophrenic patients. higher family support increases the social functioning of schizophrenic patients.26 a different result from this study is the negative relationship between family support and work productivity of psmd in the work area of the bantur health center, malang, indonesia. this shows that high family support does not necessarily increase psmd’s work productivity. in line with this, latipun (2016) stated that it is not easy for schizophrenic patients to have positive and adaptive social functioning abilities.26 this study examined the work productivity variable of psmd, heavily influenced by factors article table 5. the level of sub-variables of people with mental disorder’s work productivity. work productivity f % work attendance high 10 9.3 moderate 37 34.6 low 60 56.1 work attitude high 41 38.3 moderate 30 28.0 low 36 33.6 skill and ability high 31 29.0 moderate 35 32.7 low 41 38.8 work result high 23 21.5 moderate 44 41.1 low 40 37.4 table 4. the level of work productivity of psmd. level of work productivity f % high 34 31.8 moderate 35 32.7 low 38 35.5 [page 118] [healthcare in low-resource settings 2023; 11(s1):11207] non -co mmerc ial us e o nly such as knowledge that contributes to problem-solving and creativity in completing work. skills are operational, technical abilities, and mastery regarding certain fields of work formed from the competencies mastered by individuals.27 attitude is a patterned habit profitable when it has positive implications in one’s work behaviors or vice versa. behaviors are habits embedded in a person.28 this study could help psychiatric nurses and mental health cadres increase their awareness and efforts to support families in empowering psmd to be independent in the community. nursing should aim to help psmd comply with treatment, take care of themselves, socialize, perform daily activities, and work productively. this study is the first to examine the relationship between family support and work productivity of people with mental disorders in the work area of bantur health center, malang, indonesia. therefore, it could be developed with further studies. this study does not specifically look at each sub-variable of family support. it is hoped that other researchers can examine more deeply for the sub-variables of family support and work productivity of people with mental disorder. conclusios most respondents stated that psmd in the working area of the bantur health center, malang, indonesia received high family support. the highest number of all sub-variables of family support is emotional support, and almost half of the respondents have low work productivity. moreover, only the sub-variables of psmd’s work attitudes are high, and there is a significant relationship between family support and work productivity of psmd. health services should innovate to create continuous work programs that stimulate the potential and abilities of psmd. also, health workers should educate and prepare family members of psmd to provide good support. mental health cadres should provide mutual support to families and the community to help psmd become independent. references 1. who. investing in mental health. department of mental health and substance dependence, noncommunicable diseases and mental health. geneva: who; 2019. 2. notosoedirdjo m, latipun. kesehatan mental konsep dan penerapan. [mental health concept and application.] malang: universitas muhammadiyah malang (umm) press; 2016. 3. suryanto, harwanti s, ekowati w. peningkatan produktivitas dan pencegahan kekambuhan gangguan jiwa dengan pendekatan pelatihan emotional freedom technique (eft) dan home care di rsud banyumas. [increasing productivity and prevention of recurrence of mental disorders with the emotional freedom technique (eft) training approach and home care at banyumas hospital.] jurnal kesmasindo 2012;5:180190. 4. permenkes ri. pedoman penyelenggaraan program indonesia sehat dengan pendekatan keluarga nomor 39. [guidelines for implementing the healthy indonesia program with a family approach number 39.] jakarta: depkes; 2016. 5. eni ky, herdiyanto, y. k. dukungan sosial keluarga terhadap pemulihan orang dengan skizofrenia (ods) di bali. [family social support for the recovery of people with schizophrenia (ods) in bali.] jurnal psikologi udayana 2018;5:486-499. 6. panes ii, tuppal cp, reñosa mdc, et al. family experiences of mental illness: a meta-synthesis. nurse media journal of nursing 2018;8:102-112. 7. fauziah, n. n. faktor-faktor pendukung pemulihan pada penderita gangguan bipolar. [factors supporting recovery in patients with bipolar disorder.] 2008. naskah publikasi. 8. ambari pkm. hubungan antara dukungan keluarga dengan keberfungsian sosial pada pasien skizofrenia pasca perawatan di rumah sakit. [relationship between family support and social functioning in schizophrenia patients after hospital treatment.] depok: universitas indonesia; 2010. 9. hartanto d. gambaran sikap dan dukungan keluarga terhadap penderita gangguan jiwa di kecamatan kartasura. article correspondence: renny nova, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: reva.fk.psik@ub.ac.id key words: family support, work productivity, people with severe mental disorders (psmd) acknowledgment: the author thanks the department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia for their support and encouragement during this study. contributions: all authors contributed equally to this article. em conducted the study while rn & hdw supervised and reviewed the final article. the author thanks rn for kindly and thoughtfully managing this study. conflict of interests: the author declares no conflict of interest. funding: this study was funded by the school of nursing, faculty of medicine, universitas brawijaya, malang, indonesia. clinical trials: this study has been approved by the health research ethics committee of faculty of medicine, universitas brawijaya, malang, indonesia. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 16 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11207 doi:10.4081/hls.2023.11207 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11207] [page 119] non -co mmerc ial us e o nly [description of attitudes and family support for patients with mental disorders in kartasura district.] semarang: universitas diponegoro; 2014. 10. nasriati r. stigma dan dukungan keluarga dalam merawat orang dengan gangguan jiwa (psmd). [stigma and family support in caring for people with mental disorders (psmd).] medisains: jurnal ilmiah ilmu-ilmu kesehatan 2017;15:56-65. 11. fithriyah i. empowering self esteem orang dengan gangguan jiwa melalui griya mandiri sebagai program rehabilitasi sosial. surabaya: fk unair; 2018. 12. sari fs. dukungan keluarga dengan kekambuhan pada pasien skizofrenia. [family support with relapse in schizophrenic patients.] jurnal pembangunan nagari 2017;2:1–18. 13. erawati e, keliat ba. the family support for schizophrenia patients on community a case study. eur psychiatr 2015;30:917. 14. friedman mm, bowden vr, jones eg. buku ajar keperawatan keluarga: riset, teori dan praktik. [textbook of family nursing: research, theory and practice] ed.5 (alih bahasa : hamid, a. y. et al. editor edisi bahasa indonesia : tiar, s). jakarta: egc; 2010. 15. nursia. hubungan antara dukungan keluarga dengan perawatan berulang pasien gangguan jiwa di rumah sakit khusus daerah (rskd) provinsi sulawesi selatan. [the relationship between family support and repeated treatment of mental disorder patients at the regional special hospital (rskd) of south sulawesi province.] makassar: universitas islam negeri alauddin makassar; 2011. 16. yunindra c. gambaran dukungan keluarga kepada penderita gangguan jiwa skizofrenia di rsjd dr. rm soedjarwa di klaten jawa tengah. [family support for sufferers of mental disorders of schizophrenia at rsjd dr. rm soedjarwa in klaten, central java.] surakarta: universitas muhammadiyah surakarta; 2018. 17. karmila l. dukungan keluarga dengan kepatuhan minum obat pada pasien gangguan jiwa di wilayah kerja puskesmas banjarbaru. [family support with compliance with taking medication in patients with mental disorders in the work area of the banjarbaru health center.] jurnal dunia keperawatan 2016;4:88-92. 18. hannighofer j, foran h, hahlweg k, et al. impact of relationship status and quality (family type) on the mental health of mothers and their children: a 10-year longitudinal study. frontiers in psychiatry 2017;8:266. 19. tempier r, balbuena l, lepnurm m, et al. perceived emotional support in remission: results from an 18-month follow-up of patients with early episode psychosis. soc psychiatry psychiatr epidemiol. 2013;48(12):1897–904. 20. magaña sm, ramírez garcía ji, et al. psychological distress among latino family caregivers of adults with schizophrenia: the roles of burden and stigma. psychiatr serv 2007;58:378–84. 21. nasriati r. stigma dan dukungan keluarga dalam merawat orang dengan gangguan jiwa (psmd). [stigma and family support in caring for people with mental disorders (psmd).] medisains: jurnal ilmiah ilmu-ilmu kesehatan 2017;1:56-65. 22. maghfiroh l, khamida k. peran keluarga dalam peningkatan kemampuan interaksi sosial bermasyarakat klien skizofrenia pasca perawatan di rumah sakit. [the role of the family in improving the ability of social interaction in the community of schizophrenic clients after hospital treatment.] j health sci 2015;8:224. 23. videbeck sl. psychiatric mental health nursing. 5th ed. philadelphia: lippincott williams & walkins; 2011. 24. shankar j, collyer f. support needs of people with mental illness in vocational rehabilitation programs-the role of the social network. int j psychosoc rehab 2002;7:15-28. 25. mclaughlin ka, gadermann am, hwang i, et al. parent psychopathology and offspring mental disorders: results from the who world mental health surveys. br j psychiatry 2012;200:290–299. 26. latipun fs. hubungan dukungan keluarga dan keberfungsian sosial pada pasien skizofrenia rawat jalan. [relationship of family support and social functioning in outpatient schizophrenia patients.] jurnal ilmiah psikologi terapan 2016;4(2). 27. teguh a, rosidah. manajemen sumber daya manusia. [human resource management.] yogyakarta: graha ilmu; 2003. 28. patel v. where there is no psychiatrist. london: the royal college psychiatrist; 2001. article [page 120] [healthcare in low-resource settings 2023; 11(s1):11207] non -co mmerc ial us e o nly hrev_master [page 22] [healthcare in low-resource settings 2016; 4:5525] healthcare sector efficiency in gujarat (india): an exploratory study using data envelopment analysis brijesh c. purohit madras school of economics, kottur, india abstract the importance of efficiency in resource utilization in healthcare sector has been recognized globally. in this paper we focus on efficiency of healthcare system at sub-state level (i.e., district level) in india using gujarat state and its district level data for 2012-13. in spite of being an economically advanced state, in terms of infant mortality rate (imr) the state is not the lowest. we explore the reasons for relative performance of different districts with data envelopment analysis (dea). we used imr as output variables. using principal component analysis we tried a sub-set of variables, which had low correlations. thus, four factor scores relating to medical officer, lady medical officer, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy doctor, pharmacist, were used for dea. we have focused on charnes, cooper, and rhodes scores (or constant returns to scale technical efficiency score), and discussed efficiency rankings based on these. thus, our results pertaining to district level health system efficiency in gujarat state indicate that some of the districts have low efficiency in utilization of inputs like doctors, beds and workload per health institutions. there are also other districts, which need more of these inputs, which may enhance their output and efficiency. thus, it is suggested that the efficiency in valsad needs an improvement much more than other districts, whereas districts like ahmadabad and surat need more of both medical manpower and facilities. even in case of vadodara and rajkot, the ranking in terms of most of medical manpower and facilities is low and thus these districts may also be benefitted by additional inputs. hence, there is a mix of both inefficiency and inadequacy of inputs, which is reflected in our results. introduction the importance of efficiency in resource utilization in healthcare sector has been emphasized by a number of empirical studies.1,2 both a unit level and the aggregate level analyses have been attempted. some researchers have focused on hospitals, nursing homes, health maintenance organizations (hmos) and district health authorities.3-9 generally either of the methods, namely, nonparametric or parametric is employed. among the former, data envelopment analysis (dea) is popular. among the latter, an idealized yardstick is developed that is used to evaluate economic performance of health system. these methods provide a production possibility frontier depicting a locus of potentially technical efficient output combination that an organization or health system is capable of producing at a point in time. an output combination below this frontier is termed as technically inefficient.10-12 there exists an exhaustive array of reviews which provides us in detail the steps followed and empirical problems that have been faced by the researchers.13,3 nonetheless, there are a very few studies in the developing countries’ context. in the indian context, the focus has mostly remained either on the allindia rural or urban sector or the analysis has been carried out up to the state level aggregates only. so far, a district level analysis has been attempted for a few states including punjab, maharashtra, karnataka, west bengal and madhya pradesh.14 we extend our analysis in this paper to focus on efficiency of the healthcare system at sub-state level (i.e., district level) in india using gujarat state and its district level data. we explore the reasons for relative performance of different districts with dea. gujarat is one of the high-income indian states and with its above national average income at inr per capita 59,157 at constant prices, is third next to maharashtra and harayana (table 1). situated in the western part of india with capital city as gandhinagar, the state covers an area of 196,204 km2 (75,755 sq miles) and a population above 60 million. the state is bordered by the states of rajasthan, maharashtra, and madhya pradesh. in terms of literacy (2011 census), growth in literacy (between 20012011) and per capita health expenditure the state occupies a rank of 5, 6 and 7 respectively among the major indian states (table 1). in terms of infant mortality rate (imr) (total): rural and urban, in 2013, it is 8th, 11th and 4th rank (table 2). the imr in various districts of gujarat varies considerably. the relative position of different districts in terms of imr, often considered as an important indicator of health status leaving aside the case of exception of sabar kantha district, varies from 2 (in banas kantha, dohad, panch mahals and porbandar) to 14 (in ahmadabadand surat).16 in this paper, we make an attempt to find out technical efficiency using a non-parametric approach known as dea.11,12 materials and methods the dea methodology, originating from farrell’s (1957) and further by charnes, cooper and rhodes (1978), assumes the existence of a convex production frontier. the production frontier in the dea approach is constructed using linear programming methods. the term envelopment stems from the fact that the production frontier envelops the set of observations.11,12 the general relationship that we consider is given by the following function for each district i: yi = f (xi), i=1.........n(1) where we have yi – our output measure; xi – the relevant inputs. if yi<f (xi), it is said that unit i exhibits inefficiency. for the observed input levels, the actual output is smaller than the best attainable one and inefficiency can then be measured by computing the distance to the theoretical efficiency frontier. the variable-returns to scale hypothesis, which we use here for an output-oriented specification, is described as below. suppose there are k inputs and m outputs for n decision management units (dmus). for the i-th dmu, we can define x as the (k x n) input matrix and y as the (m x n) output matrix. the dea model is then specified with the following mathematical programming problem, for a given i-th dmu: max δ,λ δ subject to –δyi + yλ ≥ 0 xixλ ≥ 0…….(2) n1’λ’= 1 λ≥0 healthcare in low-resource settings 2016; volume 4:5525 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai 600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: efficiency; healthcare system; district level; imr. received for publication: 20 september 2015. revision received: 4 march 2016. accepted for publication: 7 march 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright b.c. purohit, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5525 doi:10.4081/hls.2016.5525 non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 23] in problem (2), δ is a scalar (that satisfies 1/δ≤1), more specifically it is the efficiency score that measures technical efficiency. it measures the distance between a unit and the efficiency frontier, defined as a linear combination of the best practice observations. with 1/δ<1, the unit is inside the frontier (i.e., it is inefficient), while δ=1 implies that the unit is on the frontier (i.e., it is efficient). the vector λ is a (n x 1) vector of constants that measures the weights used to compute the location of an inefficient dmu if it were to become efficient, and n1 is an n-dimensional vector of ones. the inefficient dmu would be projected on the production frontier as a linear combination of those weights, related to the peers of the inefficient dmu. the peers are other dmus that are more efficient and are therefore used as references for the inefficient dmu. the restriction n 1’ λ=1 imposes convexity of the frontier, accounting for variable returns to scale. dropping this restriction would amount to admit that returns to scale were constant. problem (2) has to be solved for each of the n dmus in order to obtain the n efficiency scores. figure 1 presents the dea production possibility frontier in the simple one input-one output case. states a, b and c are efficient. their output scores are equal to 1. state d is not efficient. its score [d2/(d1+d2)] is smaller than 1. there are some advantages in using dea relative to a parametric method. this framework of estimation has the ability, for instance: i) to incorporate inputs and outputs that have different units; ii) to capture multiple input outputs; iii) to not necessitate specification of functional form relating inputs and outputs; and iv) to make a direct comparison between a dmu and other peers easily possible. despite the advantages dea imbibes some limitations in it. these include: i) it is a relative efficiency measure of a dmu and does not provide a theoretical maximum; ii) it is a non-parametric approach in dea and thus a statistical hypothesis test may be difficult; and iii) it involves large computational problems as it creates for each dmu a linear program separately. results and discussion we used the imr as an output variable. this measure is chosen as an indicator of output at district level for three reasons. first, it is presumed that given a normal circumstance (of article table 1. rank of gujarat among major indian states in terms of per capita income, literacy and public expenditure on health. state nsdp rank* literacy rate (%) rank* decadal rank* per capita total public rank* per capita 2011 census difference (%) expenditure on in 2012-13 (inr) health 2009-10 (inr) andhra pradesh 39,645 9 67.41 17 7.19 12 459 9 assam 22,273 17 73.18 11 9.93 7 715 2 bihar 14,356 19 63.82 19 16.82 1 210 19 chhattisgarh 28,087 13 71.04 12 6.38 17 380 15 gujarat 59,157 3 79.31 5 10.17 6 480 7 haryana 64,052 2 76.64 8 8.73 9 483 6 jammu and kashmir 30,035 12 68.74 15 13.22 4 1073 1 jharkhand 27,010 14 67.63 16 14.07 2 264 18 karnataka 43,266 8 75.6 9 8.96 8 468 8 kerala 55,643 5 93.91 1 3.14 19 580 4 madhya pradesh 24,867 16 70.63 13 6.89 14 312 17 maharashtra 65,095 1 82.91 2 6.03 18 420 11 odisha 25,163 15 73.45 10 10.37 5 405 13 punjab 47,854 7 76.68 7 7.03 13 401 14 rajasthan 30,839 11 67.06 18 6.65 16 457 10 tamil nadu 58,360 4 80.33 3 6.88 15 579 5 uttar pradesh 18,635 18 69.72 14 13.45 3 372 16 uttarakhand 55,375 6 79.63 4 8.01 11 625 3 west bengal 34,177 10 77.08 6 8.44 10 410 12 all india 38,856 74.04 64.83 nsdp, net state domestic product; inr, indian rupee. part of data is taken from purohit, government of india and of gujarat.14-17 *the highest in value is denoted as 1. figure 1. data envelopment analysis production possibility frontier in one input-one output case. non co mmerc ial us e o nly [page 24] [healthcare in low-resource settings 2016; 4:5525] no calamities, etc.), the allocation of government budget at district level within the state might get reflected in better budgetary allocation at district level. second, since district level budgetary estimates for life expectancy or budgetary allocation are not available, we presume that imr is related to survival rate [since infant survival rate=(1000-imr)/(imr)], and thus it is a representative output variable for the health sector and it captures the impact of economic development as well. third, it is necessary to keep in view the trend in health efficiency literature, which has focused on either life expectancy or imr as output at country, state, or district levels. using a principal component analysis we tried a sub-set of variables, which had low correlations. the choice of input variables is guided by the basic classification of input variables used in healthcare provision, viz., manpower, capital investment (equipments, buildings, etc.) and materials. among these, the manpower in the health sector is represented by the availability of medical and paramedical personnel. these included medical officer, lady medical officer, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy doctor (i.e., a doctor who practices either of ayurvedic or unani or siddha system of treatment; the acronym ayush is used by the indian ministry of health), and pharmacist. the second major input category in the health sector, namely, capital investment is represented by tribal beds, community health centers (chcs), sub-divisional hospital. since the utilization of these facilities is possible only if both the adequate manpower and material resources exist, we considered some of the utilization variables like ante-natal care (anc) registered, percentage of anc 3 checkup against anc registered, delivery in governmental institutions and home delivery. the correlation matrix for these variables is presented below in table 3. based on these results, we calculated the principal components or factors and criteria of eigen value greater than one to select the factors for dea article table 3. correlation matrix. medical officer 1 lady medical officer -0.0257 1 ayush doctor 0.1193 -0.3024 1 pharmacist 0.5279 0.0598 0.4052 1 tribal beds -0.2397 0.1277 0.3335 0.2082 1 chcs 0.289 0.1835 0.587 0.5706 0.4887 1 sub divisional hospital -0.1687 0.5017 0.1073 0.0341 0.2194 0.4798 1 anc registered -0.5342 0.3497 -0.2834 -0.2655 0.3601 -0.1061 0.2098 1 percentage of anc 3 checkup against anc registered 0.4534 0.0371 0.1399 0.1918 0.0523 0.0135 -0.1177 -0.4523 1 delivery in governmental institutions -0.4324 0.0859 -0.2213 -0.2052 0.2885 -0.2108 -0.0731 0.4571 -0.3059 1 home delivery -0.353 -0.0032 -0.1119 -0.5539 -0.1952 -0.2773 0.0428 0.4308 -0.3997 0.2289 1 ayush, ayurveda, yoga and naturopathy, unani, siddha and homoeopathy; chcs, community health centers; anc, ante-natal care. table 2. rank of gujarat among major indian states in terms of infant mortality rate in 2013. india/states/union territories imr total rank* rural rank* urban rank* andhra pradesh 39 11 44 12 29 11 assam 54 18 56 18 32 13 bihar 42 13 42 10 33 15 chhattisgarh 46 14 47 14 38 17 gujarat 36 8 43 11 22 4 haryana 41 12 44 12 32 13 jammu and kashmir 37 9 39 9 28 10 jharkhand 37 9 38 8 27 9 karnataka 31 5 34 6 24 7 kerala 12 1 13 1 9 1 madhya pradesh 54 18 57 19 37 16 maharashtra 24 3 29 4 16 2 odisha 51 17 53 16 38 17 punjab 26 4 28 3 23 6 rajasthan 47 15 51 15 30 12 tamil nadu 21 2 24 2 17 3 uttar pradesh 50 16 53 16 38 17 uttarakhand 32 7 34 6 22 4 west bengal 31 5 32 5 26 8 india 40 44 27 imr, infant mortality rate. part of data is taken from government of india.15 *the lowest imr (in value) is denoted as 1 (or top rank). non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 25] and these are presented in table 4. four factor scores relating to medical officer, lady medical officer, ayush doctor, pharmacist were used for dea. the results of dea are presented in table 5. these results pertain to the variable returns to scale (vrs). however, the constant returns-toscale (the charnes, cooper, and rhodes score, i.e. ccr) is a kind of global efficiency measurement that can be decomposed as: ccr score=(pure) efficiency score x scale efficiency=vrs score x scale efficiency. the results in this sheet show ccr scores and the scale efficiencies as defined above. note that if a unit is fully efficient under the constant returns-toscale assumption, it is also fully efficient under the vrs one, but the converse is not necessarily true. the returns-to-scale column contains the characterization of the area where each unit operates, that is, whether scale inefficiencies are due to an increasing or a decreasing returns-to-scale. in table 5 we have focused on the ccr scores, and efficiency rankings based on these are discussed. as presented in table 5, except for banas kantha and porbandar, all districts fall below the ccr score of one. hence, the districts are compared to their peers using rank one as the highest efficiency and numerical higher values of ranks relatively indicate a more inefficient district. to explore further this efficiency aspect, we considered an all-district (24 districts) group average (or mean) and compared with the individual district’s ccr. we also present the group averages for the ccr scores in the last row (column 5) of table 5. by using deviations from these group averages, it can be observed that there is a substantial scope for an improvement in efficiency of low ranking districts. there are 14 districts that have the ccr scores lower than the group average of 0.4105. the lowest among these remains surat followed by valsad. so, among all the districts there seems to be the highest need for these districts to enhance their efficiency even to catch up with the all-district average. there are another 10 districts, which are above the group average. dohad district, followed by article table 4. principal components. component eigen value difference proportion cumulative comp1 3.3372 0.9565 0.3034 0.3034 comp2 2.3807 0.9713 0.2164 0.5198 comp3 1.4094 0.2657 0.1281 0.6479 comp4 1.1437 0.3245 0.1040 0.7519 comp5 0.8192 0.2054 0.0745 0.8264 comp6 0.6138 0.1391 0.0558 0.8822 comp7 0.4746 0.1482 0.0431 0.9253 comp8 0.3264 0.0763 0.0297 0.9550 comp9 0.2501 0.1042 0.0227 0.9777 comp10 0.1459 0.0468 0.0133 0.9910 comp11 0.0991 0.0090 1.0000 table 5. data envelopment analysis results for gujarat districts. districts imr scale efficiencies returns-to-scale ccr score ranks* deviations from average ahmadabad 14 0.9178 increasing 0.1777 20 -0.2327 amreli 5 0.7568 increasing 0.5236 6 0.1132 anand 6 0.5656 decreasing 0.1885 19 -0.2219 banas kantha 2 1.0000 constant 1.0000 1 0.5895 bharuch 5 0.6390 decreasing 0.2556 14 -0.1549 bhavnagar 3 0.9291 increasing 0.8072 4 0.3968 dohad 2 0.8541 decreasing 0.8541 3 0.4437 gandhinagar 6 0.5968 decreasing 0.1989 17 -0.2115 jamnagar 11 0.3354 increasing 0.3354 11 -0.0751 junagadh 5 0.7815 decreasing 0.3126 12 -0.0978 kachchh 7 0.6764 decreasing 0.1933 18 -0.2172 kheda 4 0.8214 decreasing 0.4107 10 0.0003 mahesana 4 0.4171 decreasing 0.2085 16 -0.2019 narmada 4 0.6172 decreasing 0.3086 13 -0.1019 navsari 4 0.4337 decreasing 0.2168 15 -0.1936 panch mahals 2 0.7950 decreasing 0.7950 5 0.3846 patan 3 0.7332 decreasing 0.4888 8 0.0784 porbandar 2 1.0000 constant 1.0000 1 0.5895 rajkot 12 0.9852 increasing 0.1740 21 -0.2365 surat 14 0.9926 decreasing 0.1418 24 -0.2687 surendranagar 5 0.9144 increasing 0.4435 9 0.0331 the dangs 7 0.5636 decreasing 0.1610 22 -0.2494 vadodara 10 0.4982 increasing 0.4982 7 0.0878 valsad 10 0.7836 decreasing 0.1567 23 -0.2537 imr, infant mortality rate; ccr, charnes, cooper, and rhodes. *the highest rank is denoted as 1 (top rank). non co mmerc ial us e o nly [page 26] [healthcare in low-resource settings 2016; 4:5525] bhavnagarare, is thus among those which remain better and higher than the other 6 (excluding two districts having ccr as one) in the above average group. further, if we look at the workload in these districts in terms of outdoor (opd) and indoor patients (ipd), we find that it is very high in the districts of vadodara and rajkot followed by ahmadabad. however, the low performing districts like ahmadabad and surat are also having very low availability of medical manpower per 10 thousand people. this is presented in appendix tables 1 and 2. it could be observed that all these three districts have very low ranking in terms of medical officers, lady medical officer, ayush doctors and pharamacists (columns 1 to 4 and rows 3 and 26). likewise, these two districts are also very low in terms of physical inputs like tribal beds, non-tribal beds, total beds, sub-centers, primary health centers (phcs) and chcs (columns 6-12). by contrast, valsad district is much better off in terms of all these inputs (appendix table 2, last row). this suggests that the efficiency in valsad needs an improvement much more than the other districts, whereas districts like ahmedabad and surat need more of both medical manpower and facilities. even in the case of vadodara and rajkot, the ranking in terms of most of medical manpower and facilities is low and these districts may also receive benefit by additional inputs. we calculated further rank correlations of different variables with ccr deviations from group average. these are presented in appendix table 3. the variables for which this correlation was calculated included total literacy rural, male literacy rural, female literacy rural, total literacy urban male literacy urban, female literacy, urban, total literacy, total male literacy, total female literacy, phc opd, chc opd, sub-district/district+civil hospital opd, total opd, phc ipd, chc ipd, sub-district/district+civil hospital ipd, total ipd, inhabitated villages, drinking water whole year, drinking water fair season, population in thousands, population density sq.km., sex ratio per ‘000 males, and urban population percent. out of these, a statistically significant rank correlation at 5% level with ccr deviations was observed for the total literacy rural, male literacy rural, female literacy rural, total literacy urban male literacy, urban femalel iteracy, urban total literacy, total male literacy, total female literacy and sex ratio per ‘000 males (appendix table 4). we used these variables to explain the deviations from mean of individual district ccr scores. the results presented in appendix table 4 indicate that increasing the male total literacy and female literacy urban has led to a decline in deviations across districts with a very small magnitude (coefficients are low; appendix table 4). the major variations as seen in ccr scores in table 5 are due to the differences in an efficient utilization of major health inputs in some districts like valsad, whereas for some districts like ahmadabad and surat lower availability of medical manpower and facilities seem to be the reason for their relative low efficiency. fourteen districts, which have the ccr scores lower than the group average of .4105, need to improve their input effectiveness to come up to an average level. another 10 districts, which are above the group average, should aim towards bridging the gap between them and the top-ranking district. our results of gujarat sub-state level analysis are also in line with similar studies in india. for instance, results are similar to a study conducted in another rich income state like punjab,14 where poorer performance in some districts was also attributed to a scarcity of adequate medical and para-medical manpower. likewise, inequitable distribution of beds and dispensaries, availability of skilled attention at birth and inadequate staffing relative to patient load in less urbanized districts of another high income, namely maharashtra, are in line with our analysis of district level in gujarat. however, unlike other district level indian studies like the one conducted in karnataka, here we have not considered factors external to the healthcare system in detail. conclusions our results pertaining to district level health system efficiency in gujarat state indicate that some of the districts, like valsad, have a low efficiency in utilization of inputs given their workload per health institutions. there are also other districts, like rajkot, vadodara, ahmedabad and surat, which need more of these inputs to enhance their output and efficiency. one policy factor, namely freeze in permanent recruitment of doctors in gujarat, might also have aggravated the problem in the latter districts.17 increased inputs, however, may not always guarantee the desirable outcomes. the utilization of these incremental inputs is also required to be optimal, as is presumed here. however, our analysis has the limitation to look into optimal utilization levels, as it is a matter of additional data and an estimation of that kind, which is not attempted here. another limitation of our study is that we have used a cross section analysis. more validation of these benefits may be possible if it is extended using panel data models. further applicability of our results can be confirmed only if there exists additional information on case mix, pattern of utilization and outcome of certain time-motion studies on different treatment procedures. there is a mix of both inefficiency and inadequacy of the inputs, which is reflected in our results. further exploration to observe individual input utilization efficiency – with additional budgetary resources – may help the gujarat state health system to achieve the lowest imr across the indian states in a short period of time, thus leading to more efficient health outcomes. references 1. who. the world health report, 2000, health systems: improving performance. geneva: world health organization; 2000. 2. murray cjl, frenk j. a who framework for health system performance assessment. global programme on evidence and information for policy. washington, dc: world bank; 1999. 3. worthington ac. frontier efficiency measurement in health care: a review of empirical techniques and selected applications. med care res rev 2004;61:135-70. 4. hollingsworth b, wildman j. the efficiency of health production: re-estimating the who panel data using parametric and nonparametric approaches to provide additional information. clayton: monash university; 2002. 5. jamison dt, sandbu m, wang j. cross country variation in mortality decline, 1962-87: the role of country specific technical progress. geneva: world health organization; 2002. 6. salomon ja, mathers cd, murray cjl, ferguson b. method for life expectancy and healthy life expectancy uncertainty analysis. global programme on evidence for health policy. geneva: world health organization; 2001. 7. evans db, tandon a, murray cjl, lauer ja. the comparative efficiency of national health systems in producing health: an analysis of 191 countries. geneva: world health organization; 2001. 8. wang j, jamison dt, bos e, et al. measuring country performance on health: selected indicators for 115 countries. washington, dc: ibrd/world bank; 1999. 9. sankar d, kathuria v. health system performance in rural india. efficiency estimates across states. econ polit weekly 2004;39:1427-33. 10. fried ho, lovell ca, schmidt ss. the measurement of productive efficiency: techniques and applications. new york, ny: oxford university press; 1993. 11. charnes a, cooper ww, lewin ay, seiford lm. data envelopment analysis: theory, methodology and applications. boston, article non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5525] [page 27] ma: kluwer; 1995. 12. coelli t, rao dsp, battese g. an introduction to efficiency and productivity analysis. boston, ma: kluwer; 1998. 13. hollingsworth b, dawson pj, maniadakis n. efficiency measurement of health care: a review of non-parametric methods and applications. health care manage sci 1999;2:161-72. 14. purohit bc. efficiency of social sector expenditure in india. london: routledge/francis and taylor; 2014. 15. government of india. annual health survey bulletin, 2012-13. new delhi: ministry of home affairs, government of india; 2015. 16. government of gujarat. health statistics, gujarat, 2010-11. gandhinagar: government of gujarat; 2012. 17. government of india. managing human resources for health in india: a case study of gujarat and madhya pradesh. new delhi: central bureau of health intelligence; 2007. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2021; 9:10002] [page 13] barriers to dietary modifications for people living with type 2 diabetes in a rural indigenous guatemalan community julia wilson,1 james svenson,2 sean duffy,3 jessica schmidt2 1department of internal medicine, medical college of wisconsin; 2department of emergency medicine university of wisconsin; 3department of family medicine, university of wisconsin, wi, usa abstract in guatemala, the prevalence of diabetes continues to increase with a disproportionate burden falling on indigenous rural communities. in this study, we assessed barriers to making dietary modifications for people living with type 2 diabetes in a rural indigenous guatemalan population. structed interviews (n=32) were conducted with participants selected from a convenience sample of adults with type 2 diabetes living in villages in and around san lucas tolimán, guatemala. frequencies were calculated for closed-ended questions and content analysis was used to evaluate open-ended questions. most participants (81%) were women with low-levels of formal education and average daily food expenditure of just over $1 usd. the majority of participants were able to identify foods important in a diabetic diet, however, with significant barriers to making dietary modifications. commonly cited perceived barriers included high costs of food due to travel and storage, inadequate local access to fresh fruits and vegetables and incompatibility with traditional diet. several structural and cultural barriers exist to prevent dietary modifications for people living with type 2 diabetes in this rural indigenous population. introduction the prevalence of type 2 diabetes has been increasing over the past few decades; roughly 463 million adults are living with diabetes worldwide; and the majority live in low and middle income countries.1 although medical care plays in an important role in type 2 diabetes management, modifiable lifestyle factors, especially diet, are essential in maintaining improved health outcomes and decreasing patients’ risk for other serious health conditions such as cardiovascular disease.2 barriers to dietary modification for people with diabetes may be magnified for those living in remote and rural areas such as the indigenous populations of guatemala. studies from other rural populations found barriers to maintaining a healthful diet included lack of understanding of the diet plan, cost of diet, the perception of diabetic foods as bland or flavorless, and the burden of eating a different diet than the rest of the family.3,4 in guatemala, indigenous communities living in rural areas may face even greater challenges as they also suffer from historical and ongoing discrimination with poor access to care and documented abuse and discrimination when utilizing public health services.5-8 the guatemalan minister of health has reported that rates of diabetes are increasing more rapidly in indigenous populations.9 the purpose of our study was to explore barriers to dietary modification for people living with diabetes in a primarily indigenous population in rural guatemala. to our knowledge, this is the first study to exclusively explore barriers to dietary modifications in an indigenous guatemalan population. materials and methods study site san lucas tolimán is a town of mostly indigenous highland maya with a population of 17,000 people in south-central guatemala on lake atitlan. there is an additional population of about 14,000 spread among 19 rural communities scattered around san lucas (isem 2020). the average income is less than $1,000 usd per year, or about $3 usd per day (ine 2015). a health promoter program, coordinated by a local religiously-affiliated ngo hospital and physician, provides basic medical care and health education, including diabetes care, to these surrounding communities. participants in the diabetes program undergo regular education with community health promoters and attend a monthly diabetes clinic where blood glucose and hemoglobin a1c are monitored and medications adjustment accordingly.10 the health promoters are community members with basic training in disease identification and treatment of common illnesses including type 2 diabetes.11 the closest government district hospital is in sololá, 40 km away. study population participants were identified and recruited by health promotors in a convenience sample from a group people known to have type 2 diabetes. inclusion criteria were: adults (age >18 years) with type 2 diabetes and spanish speaking. most individuals in this area are bilingual, speaking both kaqchikel, the local mayan language, and spanish. individual interviews were con healthcare in low-resource settings 2021; volume 9:10002 correspondence: jessica schmidt, department of emergency medicine, university of wisconsin, 800 university bay drive, suite 310, 53705madison, wi, usa. tel.: +1.608.890.8682 fax +1.608.265.8241 e-mail: jschmidt@medicine.wisc.edu key words: diabetes; indigenous; diet. acknowledgments: we wish to thank dr. rafael tun at san lucas hospital and the health promotors, cesia castro chuta, dominga pic salazar, and rogelio coroxon. we would also like to thank the friends of san lucas. contributions: jw conducted interviews, analyzed data and contributed to writing the manuscript, jes contributed to study design and editing manuscript, sd contributed as content expert and to manuscript editing, and js contributed to study design, data analysis and manuscript writing. all authors read and approved the final manuscript. conflict of interests: the authors have no conflicts of interest to declare. further information: jw was supported by an educational research scholarship for travel by the herman and gwen shapiro foundation. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the study was determined exempt by the institutional review board of the university of wisconsin. patients gave their consent to participate. informed consent: informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 27 july 2021. revision received: 30 august 2021. accepted for publication: 1 september 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:10002 doi:10.4081/hls.2021.10002 non -co mmerc ial us e o nly ducted at diabetic clinics held monthly in several villages in the area or during home visits. interviews were conducted entirely in spanish by a member of the research team (jw). jw had extensive knowledge of the local community and health promoter structure and was fluent in spanish. health promoters fluent in kaqchikel were also available to clarify questions as necessary. verbal consent was obtained for all participants in spanish due to low literacy and consent was witnessed by the health promoters. responses to questions were collected by the researcher using detailed handwritten notes at the time of the interview. notes were taken instead of audio recording based upon cultural preferences identified by health promoters. the study was determined exempt by the institutional review board of the university of wisconsin. the project was supported by the friends of san lucas organization and their health promoter program. data collection the study employed a concurrent triangulation mixed-method design.12 we conducted structured interviews with questions designed to generate a combination of quantitative and qualitative results. the first portion of the 20-question interview guide contained close-ended questions regarding demographics, history of diabetes, and current medical treatment. the second set of questions involved a mix of open and closed-ended questions related to dietary consumption and food purchasing. the final set of open-ended questions focused on participants’ understanding and beliefs about healthful foods for people with diabetes, perceived obstacles to dietary changes, and potential facilitators for maintaining a healthful diet. in addition to responding to the structured questions, participants often willingly elaborated on their answers. conversations also occurred around answers that were unclear. these additional comments were also captured in the researcher’s notes, with relevant sections included for use in the qualitative analysis or to support quantitative results. data analysis the answers to closed-ended questions were descriptively calculated as frequencies and means. open-ended questions were analyzed qualitatively using content analysis.13 two reviewers (jw and js) performed coding with frequent cross-checks for accuracy. questions relating to food purchasing and dietary behaviors (e.g.,”can you tell me what you eat on a typical day for breakfast?”) were coded into predetermined categories to determine response frequencies. other open-ended responses were coded by themes such as diet, food purchasing, cost, access, cultural norms, food preparation knowledge and healthful diet knowledge. results thirty-two participants were approached and all agreed to be interviewed (table 1). the majority of the participants were middle-aged women with low levels of formal education. participants were from six named communities (san lucas toliman 5 , patulul 2, san juan 4, xexuju 1, totolya 3, tierra santa 2). the remaining 15 participants described their community as ‘rural’ without an associated named community. food purchasing the mean weekly per capita expenditure on food was reported to be 58.8 gtq (7.85 usd). the majority of participants (89%, n=28) shopped for food at an openair market. of those who shopped at markets, most reported having to travel to an outside community, necessitating use of public transportation. large open-air markets were only available at two of the local communities (patulul and san lucas tolimán). dietary patterns the typical diet of participants consisted primarily of tortillas and beans at mealtimes and occasional fruits for snacks throughout the week. nearly all participants reported eating tortillas with all three of their daily meals (94%, n=30); the average number of tortillas eaten per day by the individuals surveyed was 14. the majority of participants also named beans as a central component of at least one meal of the day, with many having beans for two or more meals per day. several participants reported eating fruits (the most commonly mentioned fruits being banana, mango, watermelon, and papaya) and liquados (fruit smoothies) several times per week for snacks. several participants did incorporate hierbas (leafy greens) into a meal at least once per day, however, the majority of these participants admitted that this was typically not more than once a day and it was not daily. the most common beverage was atol (a milk based beverage made from ground corn that is often sweetened), and coffee, which were the main beverages aside from water. most reported they drank unsweetened atol, whereas a small number had atol with sugar added. there was a wide variation in frequency of intake of atol, ranging from several ‘cups’ a week to 5 cups per day (‘cups’ were reported as a subjective measure). dietary understanding when asked what foods were consistent with a healthful diet for people with diabetes, most participants answered with one or more of the following food groups: vegetables, hierbas (usually meaning leafy greens), lean meats, and “foods without sugar.” several participants cited changes they had made to incorporate healthful foods into their diet. for instance, one woman noted she no longer puts sugar in her coffee. several others commented that they no longer ate soup broth or tried to eat comidas sin grasa (foods without fat.) four participants stated they did not know what foods were appropriate or that they had not changed diet at all. one participant noted that he just takes his medications and continues to eat the same foods. perceived barriers when the participants were asked what prevented them from eating the foods they perceived as important to a healthful diet every day, the responses fell into several common groups: cost, access, family support and time required to prepare different foods, and lack of knowledge for food preparation. cost a majority of participants (59%, n=19) reported that foods compatible with a healthful diet (namely vegetables and lean meats) were too costly. one patient, when asked what kept her from eating the foods important for a healthful diet, stated that she did not have enough money to buy enough food for her family in general. another answered that he did not have enough money to afford many vegetables; if he is still hungry after he eats the vegetables his family does have, he just fills up on tortillas. article table 1. demographic characteristics of participants n (%). characteristic total n=32 gender male (%) 6 (19) female (%) 26 (81) average age (years) 53.5 average age at diagnosis (years) 46.5 level of formal education none (%) 20 (63) elementary school (%) 10 (31) high school (%) 2 (6) any college or higher education (%) 0 positive family history of t2dm (%) 7 (22) [page 14] [healthcare in low-resource settings 2021; 9:10002] non -co mmerc ial us e o nly [healthcare in low-resource settings 2021; 9:10002] [page 15] participants also cited fluctuations in income levels throughout the year with three “off-seasons” where cash was short. several participants stated they had limited finances in general, not specifically constrained to diet. for participants who did not perceive increased costs, few elaborated on reasons. one woman stated that initially costs were higher, but now she is “used to it.” others were unable to comment on cost because they did not monitor the food-related finances or did not do the shopping. access participants reported several factors that contributed to poor access to foods compatible with a healthful diet. travel time and travel cost to the closest market were the most commonly cited barriers. a majority of the participants interviewed reported using public transportation to get to a market located between 5 and 30 km from their homes each time they wished to buy fresh foods. because of difficulty with access and financial costs associated with this travel, participants typically only visited the fresh air market once every 7 to 15 days. in addition, participants did not have home refrigeration and foods would perish quickly. one patient stated that it was hard to buy enough vegetables to eat every day because they rot by the time he goes to the market again. many participants explained that traveling for these types of foods is necessary because most perishable foods are not available at the corner stores in their home communities. incompatibility with family and traditional diet many participants commented that eating a diabetic diet was difficult because they were preparing food differently for the person or people in the household with diabetes and the rest of the family members. most participants were the only ones in their family with diabetes. no participants reported changing dietary habits for the entire family. one woman stated that eating a different diet was difficult because she had to prepare different foods for her husband and children and herself. another stated it was difficult during festivals because family members may be eating foods like cake and he cannot. potential facilitators when asked what would help them adhere more closely to a healthful diet, participants noted a variety of mediators including improved local access, local gardens, communal support, and improved knowledge of food preparation. improved access many participants commented on the lack of availability of fruits and vegetables in their home communities making travel to regional markets necessary. they also cited difficulties in acquiring fruits and vegetables year round due to variations in cost and travel time. participants noted that they can buy several other items such as coffee and sugar at local corner shops and suggested stocking fruits and vegetables at these shops. local gardens participants proposed solutions to improved access by growing their own fruits and vegetables. one participant noted that he would benefit from land to grow his own vegetables. another proposed a community garden be built at the rural diabetic clinics. the patient who presented this idea explained how the garden would both facilitate access to, and reduce the cost of, fresh vegetables for the people with diabetes living in his community. communal support several participants stated that having a community support group or small meetings would be beneficial. often participants were the only ones in their family or small community with diabetes and only saw other people with diabetes at monthly diabetic clinic. one woman stated a support group would be helpful because it is difficult to do it all on her own. improved knowledge in food preparation several participants mentioned that they knew what foods to eat but did not know how to prepare them. participants described how foods important in a diabetic diet are often different from foods they traditionally eat such as tortillas, caldos (broths) and atol. they were also concerned that new foods would take more time to prepare and would have to be made separately from food for the rest of the family. many participants suggested that videos or classes to teach them how to prepare healthful foods at home would be helpful. discussion this study found that, despite a basic understanding of which foods are consistent with a healthful diet, indigenous people with type 2 diabetes living in rural guatemala face significant barriers in complying with such a diet. nearly all the participants interviewed in this study reported a diet that consisted primarily of corn tortillas and black beans, with only occasional fresh fruits and vegetables. these foods were typically prepared in the home and therefore a great degree of individual variation existed between serving size and ingredients. participants stated that it was difficult to limit carbohydrate intake, primarily tortillas, as they are served ubiquitously at meals and are a part of the staple diet. participants described difficulty in modifying their diet due to financial limitations, lack of access to fresh fruits and vegetables, lack knowledge of food preparation, and incompatibly with family norms. the cost of maintaining a healthful diet can be a significant financial burden in this population. nearly eighty percent of the indigenous population in guatemala lives below the poverty line and 40% of this population lives in extreme poverty. participants in this study reported spending little more than $1 per person per day, on average, for food. unsurprisingly, many cited the cost of recommended foods as a barrier to following a healthful diet. these answers are consistent with previous studies in indigenous populations in guatemala; perishable foods such as fruits, vegetables, meats, and dairy products have consistently been perceived as too expensive to purchase regularly.3,14,15 lack of access to fresh fruits and vegetables was also commonly cited as a barrier to eating a healthful diet. participants reported that the small stores present in their communities do not regularly stock fruits, vegetables, and other fresh foods. this necessitated time-consuming and costly travel to larger communities using public transportation to purchase such foods. most were only able to make this trip once every 1-2 weeks and did not have the means to store perishable food, resulting in poor availability and low consumption of such food. these findings are also supported by webb et al., 15 who described striking similarities between an indigenous rural community of guatemala and the urban food deserts of the united states; there is an abundance of pre-packaged snack foods and sugar-rich beverages available, contrasted with an almost complete absence of fruits, vegetables, dairy, and fresh foods.given the ubiquity of small stores in these rural communities, interventions to improve the availability of healthy, fresh food in these stores is another potential approach for improving the food environment. such programs have been successful in improving access to fruits and vegetables in both urban and rural settings in high-income countries.16,17 participants also suggested sustainable local models for ongoing access to fresh article non -co mmerc ial us e o nly [page 16] [healthcare in low-resource settings 2021; 9:10002] fruits and vegetables. these proposed solutions included increased access to land for gardens or community gardens. community gardens have been shown to increase intake of fruits and vegetables for those with free access to the produce grown in the garden in high-income countries such as the united states.18 similarly, studies conducted in guatemala have found that families who maintain home gardens have superior nutritional status and access to fresh produce.19,20 other possible changes that may improve adherence to a healthful diet for people with diabetes in this area include community-based outreach with community support groups and classes in cooking and food preparation. flood et al described a program in a similar population in the highlands of guatemala where home visits were conducted with bilingual educators and, in addition to other interventions, improved outcomes for people with diabetes.21 additional studies have shown that support groups can increase healthy lifestyle modifications for people living with diabetes.22,23 limitations this study has several weaknesses that may limit its generalizability even within other indigenous mayan populations. first, the participants in the study were identified by health promoters and may have held different views than the general population. in addition, the subset of participants were primarily middle-aged women, likely reflected by the fact that most indigenous men in this area are working in the fields during the day and may have different views from other people with type 2 diabetes in this area. the participants were not blinded to the interviewer, a foreign woman. this may have biased the responses either due to concerns for trust or discretion. health promoters were present during interviews in an effort to improve rapport and trust. additionally, most participants are primary kaqchikel speaking, with spanish as a second language, and interviews were primarily conducted in spanish with limited clarification by health promoters. this may have influenced participants understanding of questions or ability to adequately respond. finally, only one interviewer was present and took notes due to limitations in travel for the entire research team. this could lead to biases in recording and recall which would have downstream effects on data interpretation. copious notes were taken in an effort to mitigate this bias. conclusions a high-quality healthful diet is one of the most important modifiable lifestyle factors in preventing early mortality from type 2 diabetes; however, this is difficult and often unrealistic for rural indigenous people living in guatemala. participants in our study cited high costs of food due to travel and storage, inadequate local access to fresh fruits and vegetables, and incompatibility with traditional diet as barriers to dietary modications. future studies are needed to assess strategies to help mitigate costs and improved access to allow these communities to improve and maintain a healthful diet. references 1. world health organization. diabetes. world health organization. accessed: august 2021. available from: https://www.who.int/news-room/factsheets/detail/diabetes 2. liu g, li y, hu y, et al. influence of lifestyle on incident cardiovascular disease and mortality in patients with diabetes mellitus. j am coll cardiol 2018;71:2867-76. 3. nagelkerk j, reick k, meengs l. perceived barriers and effective strategies to diabetes self-management. j am nursing 2006;54:151-8. 4. juarez-ramirez c, theodore f, villalobos a, et al. the importance of cultural dimension of food in understanding the lack of adherence to diet regimens among mayan people with diabetes. public health nutr 2019;17:3238-49. 5. dean m, bendfeldt g, lou h, et al. increased incidence and disparity of diagnosis of retinoblastoma patients in guatemala. cancer lett 2014;351:5963. 6. ippolito m, chary a, daniel m, barnoya, et al. expectations of health care quality among rural maya villagers in sololá department, guatemala: a qualitative analysis. int j equity health 2017;16:51. 7. chomat am, solomons nw, montenegro g, et al. maternal health and health-seeking behaviors among indigenous mam mothers from quetzaltenango, guatemala. rev panam salud publica 2014;35:113-20. 8. ministry of food and nutritional security (sesan). análisis de situación, nutricional de guatemala 2014. accessed: jan 2020. available from: http://www.sesan.gob.gt/wordp r e s s / w p c o n t e n t / u p l o a d s / 2017/07/pesan-2016-2020.pdf 9. world health organization ministry of public health and social assistance. plan de acción 2008–2012 para la prevención y el control integral de las enfermedades crónicas y sus factores de riesgo. world health organization. available from: https://www.mindbank.info/item/4622 10. duffy s, norton d, kelly m, et al. using community health workers and a smartpohne application to improve diabetes control in rural guatemala. glob health sci pract 2020;8:699-720. 11. friends of san luca. health promoter program. accessed: june 2020. available from: https://sanlucasmission.org/programs/healthcare/ 12. creswell j, plano clark v. designing and conducting mixed methods research. 2nd ed. sage. thousand oaks, ca; 2011. 13. elo s, kyngäs h. the qualitative content analysis process. j adv nurs 2008;62:107-15. 14. chary a, greiner m, bowers c, et al. determining adult type 2 diabetes-related health care needs in an indigenous population from rural guatemala: a mixed-methods preliminary study. bmc health serv res 2012;12:476. 15. webb m, chary a, de vries t, et al. exploring mechanisms of food insecurity in indigenous agricultural communities in guatemala: a mixed methods study. bmc nutr 2016;2:55. 16. fry c. health on the shelf: a guide to healthy small food retailer certification programs. accessed: june 2020. available from: http://changelabsolutions.org/sites/default/files/health_ on_the_shelf_final_20130322web.pdf 17. gittelsohn j, laska m, karpyn a, et al. lessons learned from small store programs to increase healthy food access. am j health behav 2014;38:307-15. 18. barnidge e, baker e, schootman m, et al. the effect of education plus access on perceived fruit and vegetable consumption in a rural african american community intervention. health educ res 2015;30:773-85. 19. luna-gonzález d and sørensen m. higher agrobiodiversity is associated with improved dietary diversity, but not child anthropometric status, of mayan achí people of guatemala. public health nutr 2018;2:2128-41. 20. bodzio j, nemeth e, dellavalle d. assessing food insecurity and family gardens in rural indigenous article non -co mmerc ial us e o nly [healthcare in low-resource settings 2021; 9:10002] [page 17] guatemala. j acad nutr diet 2018;118:a81. 21. flood d, mux, s, martinez, et al. implementation and outcomes of a comprehensive type 2 diabetes program in rural guatemala. plos one 2016;11:e0191152. 22. manning k, senekal m, harbron j. group-based intervention in a primary healthcare setting was more effective for weight loss than usual care. health sa 2019;24:1172. 23. thankappan k, sathish t, tapp r, et al. a peer-supported lifestyle intervention for preventing type 2 diabetes in india: a cluster-randomized controlled trial of the kerala diabetes prevention program. plos med 2018;15: e1002575. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:10642] [page 11] fear of covid-19 among critical care nurses of public hospitals in lahore: empirical evidence during third wave asma nadeem,1 rubina jabeen,2 shehla nazir,3 shahbaz haider4 1services hospital lahore; 2superior college of nursing, lahore; 3mayo hospital, lahore; 4superior university, lahore, pakistan abstract the world has seen a pandemic that disrupted life. till now there are aftershocks of covid-19 such as omicron instilling fear among individuals. healthcare staff is on alert specifically the nurses have suffered a lot mentally due to this issue by developing fatigue. the study was conducted during the deadly 3rd covid-19 wave. the data were collected by developing the questionnaire of the previously validated measures related to the variables under study from nurses working in the intensive care unit, critical care unit, and floor wards of covid-19 at services hospital, lahore. a total of 140 questionnaires were used for data analysis. the study used statistical package for social sciences for frequency and descriptive statistics. whereas the outcomes of fear of covid-19 were assessed by using the latest smart partial least squares software which allows to assess the complex research frameworks. the results of the study revealed that the fear of covid-19 results in poor quality of life among nurses and fatigue. resilience among nurses can reduce the negative consequences but did not get statistical support. introduction the world has been changed due to the pandemic situation of covid-19 that affected countries globally, after the primary epidemic in wuhan, china1 due to which globally on may 20th, 2021, the affirmed instances of coronavirus (covid-19) recorded 84,780,171 with 1,853,525 deaths. in pakistan, the confirmed cases were 893,461, with 20,089 deaths.2 the government of pakistan took a quick decision in the form of a complete lockdown in the country, to stop the spread of the virus. all educational institutes, universities, and public and private schools are completely closed. the government applied smart and micro-smart lockdowns to prevent the spreading of the virus. however, 3rd wave started in march 2021 day by day new affirmed cases and death cases rising rapidly. the third wave essentially influenced the areas of punjab and khyber pakhtunkhwa. the deadly disease was not just caused by a high passing rate from the viral contamination yet additionally disturbed mental relaxation.3 notably, the healthcare professionals remained on duty since they work under high tense climate resulting in emotional wellness issues.4 in emergency and outdoor departments the healthcare staff is at high risk instead of other departments5 as they have to deal with the patients. more importantly, nurses are being the frontline employees of healthcare and are confronted with the massive difficulties caused by covid-196 for instance, the death rate due to the covid-19 may disturb them mentally7 because they are the ones who have to deal with the patient first. notably, covid-19 presence resulted in mental illness and fear of getting affected by the virus8-9 as they directly provide patient care to the patients affected by covid-19 due to the shortage of ppe (personal protective equipment). additionally, higher fear of covid-19 was found to reduce mental well-being and higher emotional suffering.10 in other words, nurses are found at the edge of developing higher fatigue while treating patients affected by covid-19. it is supported by the previous study which reported that covid-19 resulted in mental health issues for instance, fatigue and reduced professional quality of life,6 nervousness, melancholy, and fanatical habitual indications among nurses.11 fear of covid-19 also results in decreased professional quality of life among nurses. notably, nurses may encounter an undeniable degree of fatigue12 due to the decreased professional quality of life as they are always triggered by the fear of getting affected by covid-19 while serving such patients. in such circumstances, resilience emerges to be the solution for increasing the quality of life along with decreasing fatigue among nurses. resilience denotes the ability of an individual to manage adversity and positively respond to it without having long-lasting mental illness or stress.13 the fatigue could be reduced by developing resilience because it helps to fight tension14 and adversity.15 besides nursing is a challenging profession, it requires a great deal of dedication, determination, and devotion for a better tomorrow. accordingly, nurses’ ability to bounce back in difficult times is necessary to ensure their superior professional quality of life along with decreasing their fatigue. along these lines, the capacity of nursing understudies to bounce back or individual versatility is fundamental to secure inner control, sympathy, helpful self-idea, association, and good faith in their regular difficulties. so it becomes necessary to address these issues so they can be prevented as the healthcare frontline staff cannot be sent home on leave. therefore, the study considered that fatigue occurs due to fear of covid-19 since it damages the professional quality of life which further can be reduced by developing resilience among healthcare in low-resource settings 2023; volume 11:10642 correspondence: shahbaz haider superior college of nursing, lahore, pak town kamoke, pakistan. tel.: +92.3086149902. e-mail: shahbazhaider199@gmail.com key words: nursing practice environment, staffing adequacy, nurse leader, quality of care, patient care. contribution: all the authors have equally contributed to this paper. funding: this research study is not funded by any institute/agency. conflict of interest: the authors declare no conflict of interest. ethics approval: the research study is approved by the research committee of superior college of nursing, lahore (ref. # scn/rc/2021-rn07) patient consent for publication: not applicable to the present study as data were not collected from the patients. availability of data and materials: the underlying data are available from the corresponding author on request acknowledgments: we acknowledge all the nurses who participated in the study voluntarily. received for publication: 28 may 2022. accepted for publication: 23 april 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10642 doi:10.4081/hls.2023.10642 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly nurses. materials and methods population and sample size the target population was the nurses both males and females, working in services hospital, lahore. data were collected by using convenience sampling from the nurses working the covid-19 intensive care units (icu), critical care units (ccu), and ward floor of the services hospital, lahore. as the population of the study is finite, the yamane16 formula was used17 to determine the minimum sample size. according to the formula, the sample size for the present study should be 150 at ±5%. below is the formula we used: in this formula n = sample size; n = total population; e = precision level as per the calculations, the minimum sample for the study is 150 respondents. however, to address the non-response bias sample size was inflated by 20%. previously it is recommended to inflate the sample size to attain the minimum required responses.18 therefore, the sample size of the present study is 180 respondents. according to hair et al.19 100 is the minimum sample size when there are five or fewer constructs in the model. questionnaire and measurement data were collected by using the questionnaire. it contained questions related to the demography of the respondents and variables as well. all of the questions were adapted from the previous studies, the details of which are as follows; fear of covid-19 was assessed by using a 7-item measure. covid-related quality of life was measured by a 12-item measure. it is the brief version adapted from the world health organization-quality of life brief scale.20 the scale used for quality of life was modified by adding the following at the start of each item “covid-19 pandemic”. for instance, the covid-19 pandemic disturbed your quality of life. to measure the resilience among the nurses 6-item brief resilience questionnaire was adapted.14 the scale of resilience was adopted as its original version. finally, fatigue among nurses was measured by 10 items.21 point 5-likert scale used for all the measures ranging from 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree. the questionnaire was then sent to two nursing professionals and an academic expert to see article table 1. descriptive statistics and correlation. mean sd fc ql ft rs skewness kurtosis fc 3.20 0.779 1 -0.574 0.153 ql 3.72 0.607 0.410** 1 -1.320 2.666 ft 3.43 0.663 0.455** 0.554** 1 -0.924 0.655 rs 3.08 0.889 0.295** 0.277 0.202** 1 -0.469 -0.264 [page 12] [healthcare in low-resource settings 2023; 11:10642] table 2. confirmatory factor analysis. constructs items loadings alpha rho_a cr ave fear of covid-19 fc1 0.717 0.819 0.821 0.868 0.522 fc2 0.72 fc3 0.74 fc4 0.72 fc6 0.692 fc7 0.746 fatigue ft1 0.717 0.886 0.888 0.909 0.555 ft2 0.759 ft3 0.699 ft5 0.785 ft6 0.727 ft7 0.784 ft8 0.751 ft9 0.735 quality of life ql1 0.776 0.866 0.874 0.894 0.514 ql10 0.676 ql11 0.724 ql2 0.76 ql3 0.726 ql4 0.666 ql8 0.723 ql9 0.675 resilience rs1 0.739 0.878 0.912 0.904 0.612 rs2 0.881 rs3 0.775 rs4 0.808 rs5 0.8 rs6 0.674 non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:10642] [page 13] whether it matches the context of the study. few changes were made and a total of 180 questionnaires were distributed among the nurses working the covid-19-related wards floors, icu, and ccu wards as well. a total of 140 questionnaires were collected from the respondents. ethical considerations all of the participants were informed about their volunteer participation in the study without any reward or gift. they were not forced to participate in the study as well. additionally, all of the questionnaires were designed in such a way that they do not reveal the participant’s identity to the researcher or others (complete secrecy of the data collected). it was ensured that the data collected would be used for research purposes only. all of the necessary permissions were obtained from the superior college of nursing as well. results demographic profile of the respondents the study sample comprised 140 respondents working in the critical care units and ward floors with covid-19. males constituted 15% and females constituted 85% of the sample size. the majority of the sample of the study belonged to the age group of 21-30 years (54.3%). whereas, 32.1%, 12.1%, and only 1.4% of the respondents belonged to the 31-40 years, 4150years and 51-60 years of age groups respectively. moreover, 62.1% and 37.9% of the respondents belonged to islam and christianity. the majority of the respondents were having bps 16 (87.9%) and bps 17 (21.1%). regarding duties 41.1%, 33.6%, and 25% of the respondents were assigned to provide services at covidicu, covid-isolation, and covidwardfloor respectively. most of the respondents had experience working as a nurse from 4 years to 6 years (27.9%). whereas only 17.1% of nurses were having more than 12 years of experience. descriptive statistics and correlation the following table 1 shows the descriptive statistics and correlation. as per the findings reported in table 1 mean values for the variables namely; fear of covid19, quality of life, fatigue and nurse resilience were 3.20, 3.72, 3.43, and 3.08 respectively. additionally, the table also shows the values of skewness and kurtosis. notably, all of the values for skewness and kurtosis ranged from +2 to -2 which establishes the data normality. all of the variables were found to be significantly correlated with the highest correlation between fatigue and quality of life valued at 0.557. confirmatory factor analysis tables 2, and 3 shows the results for the confirmatory factor analysis. first of all, cronbach’s alpha values for all the variables are greater than 0.7 indicating reliability. secondly, the values of the factor loadings are greater than 0.5 along with average variance extracted (ave) greater than 0.50 indicating the convergent validity of the constructs. finally, the results also show the value of the composite reliability (cr) for the variables which is greater than 0.8 indicating the reliability. discriminant validity conducting cross-sectional research where the relationship between the variables it becomes necessary to assess the discriminant validity to assure that variables are different from each other. accordingly, the present study has used the heterotraitmonotrait correlation ratio (htmt) to assess the discriminant validity. the values of htmt for all the variables less than 0.85 indicates that all of the constructs are different.22 as per the findings reported in table 3 all of the values are less than 0.85 established the discriminant validity. path coefficients the following table 4 shows the values for the path coefficients, explained variance, and collinearity statistics. as per the results of the study r2 for fear of covid19 regarding fatigue is valued at 0.346, indicating that fear of covid-19 has captured the 34.6% variance in fatigue while it captured the 22.2% variance in quality of life of nurses. additionally, the vif value for variables ranged between 1.088 and 1.195 indicating no multi-collinearity issue in the data. moreover, the table also shows the path coefficients for the relationship between the variables. as per the results reported in table 4, fear of covid-19 was found to positively influence both fatigues among nurses (β=0.251, t=2.377, p=0.017) and quality of life (β= 0.332, t=3.969, p=0.000) indicating that one unit increase in fear of covid-19 will increase in poor quality of life and fatigue among nurses working at covid-19 icu, ward floors and isolations. additionally, the poor quality of life among nurses was found to be a signification mediator between the fear of covid-19 and fatigue among nurses (β= 0.146, t=2.512, p=0.012). whereas resilience was found too weak in the relationship between the fear of covid-19 and quality of life among nurses but did not find statistical support (β= article table 3. htmt. foc ft qol rs foc ft 0.493 qol 0.446 0.589 rs 0.356 0.238 0.348 table 4. path coefficients standardized estimates significance decision explained variance collinearity hypotheses β sd t value p value s/us r2 vif foc -> ft 0.251 0.106 2.377 0.017 s 0.346 1.195 foc -> qol 0.332 0.084 3.969 0 s 0.222 1.088 qol -> ft 0.44 0.097 4.552 0 s 1.195 foc -> qol -> ft 0.146 0.058 2.512 0.012 s foc*rs -> qol -0.019 0.117 0.163 0.87 us s, supported; us, unsupported; foc, fear of covid-19; qol, quality of life; ft, fatigue; rs, resilience. non -co mmerc ial us e o nly [page 14] [healthcare in low-resource settings 2023; 11:10642] 0.019, t=0.163, p=0.87). discussion nurses play a significant role by providing humanitarian services to our healthcare centers.23 they face different adversities at the workplace such as emotional labor, deaths, violence, harassment, etc. the rise of some critical social, psychological, and economic impacts globally due to the covid-19 pandemic.24 it has been proven by recent studies that the symptoms of anxiety and depression are getting more common in people25 as well as in nurses. considering the importance of the issue the aim of the study was to examine the outcomes of fear of covid19 among nurses who are providing healthcare services to the covid-19 affected patients during the 3rd wave in services hospitals of pakistan. it was hypothesized that the fear of covid-19 among nurses will result in a poor quality of life. in support of our hypothesis, the study results revealed a positive influence of covid-19 on the poor quality of life among nurses. it may be the scenario that a nurse who is doing duty in the covid-19 ward icu or isolation or ward floor may get worried about getting affected by covid-19 or maybe worried to communicate the infection to his/her family members at home after duty is over. healthcare workers were found to have depression, anxiety, and low well-being during covid-19, especially, the workers working in icus26 because the pandemic changed the structure of icus as compared to other departments. and, approximately 10% of front-line professionals were found to have stress.27 on the other hand, covid19 has resulted in different changes in the daily life of individuals due to lockdowns and strict compliance with the standard operating procedures (sops).28 accordingly, the study has provided evidence of the influence of the fear of covid-19 and fatigue among nurses. additionally, the study results also supported the relationship between poor quality of life and fatigue among nurses. poor quality of life tends positively drive fatigue among nurses.29-30 previously available empirical evidence also supports this assertion that covid-19 results in poor quality of life,31-33 for instance,34 contended that covid-19 has affected the quality of life among nurse students resulting in poor well-being and mental health as well. the results not only supported the hypothesis but also enriched the empirical evidence from the nurse practitioners’ perspective serving the covid-19 affected patients. results of the study revealed that the poor quality of life among nurses positively mediates the relationship between the fear of covid-19 and fatigue among nurses. these results are consistent with the previous studies, for instance, previous evidence has put forward that the quality of life of nurse students has been adversely impacted by covid-19 resulting in negative consequences such as stress.35 the study results also revealed that the poor quality of life among the nurses results in fatigue among them due to covid-19. finally, the study also revealed that resilience among nurses tends to weaken the relationship between the fear of covid-19 and poor quality of life. but it did not obtain statistical support and the reason may be attributed to the fact that all of them are not fully aware of resilience or data were collected from only a single hospital. limitations and future directions the study has accomplished its objectives, but still, some limitations need to be addressed and serve as a future research area. for instance, the study has examined the influence of the fear of covid-19 on mental health by considering fatigue but due to its cross-sectional nature, it did not result in the causality. so future studies are suggested to consider the longitudinal research design. the sample of the study was dominated by female participants, thus, future studies while considering more inclusion of male nurses will enrich the insights into the fear of covid-19. notably, we are still living in covid-19 affected community and since the omicron is there, future studies may explore the role of media in creating fear among the healthcare staff. conclusions based on the results of the study it is stated that the nurses reported fear of covid-19 while caring for the patients infected with covid-19. they feared getting infected and carrying that infection to their family members as well. additionally, results also revealed that it triggers fatigue. considering the limitations of the study, the findings demonstrate that the pandemic has exerted a negative influence on nurses in the form of fear of either getting infected or carrying the infection to their family members, ultimately, having a poor quality of life. therefore, the frontline nurses dealing with the infected patients should be provided with the appropriate safety equipment by the hospitals so they may feel safe and develop less fatigue. the findings also demonstrate that the negative outcomes can be tacked or reduced by developing positive personality attributes such as resilience. so hospitals should provide training to develop adaptability among nurses to enrich fearless and safe patient care. the study is not establishing any cause-and-effect relationship since it is not an experimental research study, so the conclusions must be made by considering this fact. references 1. jones ds. history in a crisis – lessons for covid-19. new engl j med 2020;382:1681-3. 2. government of pakistan. covid-19 situation! government of pakistan; 2021. available from: https://covid.gov.pk/ 3. xiao h, zhang y, kong d, et al. the effects of social support on sleep quality of medical staff treating patients with coronavirus disease 2019 (covid-19) in january and february 2020 in china. med sci monitor 2020;26:e923549-1. 4. banerjee d. the covid-19 outbreak: crucial role the psychiatrists can play. asian j psychiatry 2020;50:102014. 5. trzebiński j, cabański m, czarnecka jz. reaction to the covid-19 pandemic: the influence of meaning in life, life satisfaction, and assumptions on world orderliness and positivity. j loss trauma 2020;25:544-57. 6. li x, song y, wong g, cui j. bat origin of a new human coronavirus: there and back again. sci china life sci 2020; 63:461. 7. labrague 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hochard kd, hulbertwilliams nj. perceived stress and professional quality of life in nursing staff: how important is psychological flexibility? j contextual behav sci 2019; 14:11-9. 31. mohamadzadeh tabrizi z, mohammadzadeh f, davarinia motlagh quchan a, bahri n. covid-19 anxiety and quality of life among iranian nurses. bmc nursing 2022;21:27. 32. keener ta, hall k, wang k, hulsey t, piamjariyakul u. quality of life, resilience, and related factors of nursing students during the covid-19 pandemic. nurse educ 2021;46:143-8. 33. alhawatmeh h, alsholol r, dalky h, et al. mediating role of resilience on the relationship between stress and quality of life among jordanian registered nurses during covid-19 pandemic. heliyon 2021;7:e08378. 34. guillasper j, oducado rm, soriano g. protective role of resilience on covid19 impact on the quality of life of nursing students in the philippines. belitung nurs j 2021;7:43-9. 35. aslan h, pekince h. nursing students' views on the covid-19 pandemic and their percieved stress levels. perspect psychiatric care 2021;57:695-701. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11168 the effects of a ‘covid nurse assistant’ application on patient satisfaction in covid isolation rooms evi harwiati ningrum,1 annisa wuri kartika,1 ahmad hasyim wibisono,1 ike nesdia rahmawati,1 linda wieke noviyanti,1 ahsan ahsan,1 kuswantoro rusca putra,1 ungky agus setyawan,2 lusia titik andayani,1,3 ririn widayanti,1,3 arif jati purnanto,1,3 gatot subroto,1,3 nurul laili,1,3 judith anderson4 1department of nursing, faculty of health sciences, universitas brawijaya, indonesia; 2specialist pulmonology study program, faculty of medicine, universitas brawijaya, indonesia; 3dr. saiful anwar general hospital, indonesia; 4charles sturt university, australia abstract introduction: the covid-19 pandemic has caused a major shift in the healthcare delivery system. with the limited personal protection equipment and a nursing service shortage caused ineffective nursing care delivered to covid-19 patients. wearing full personal protective equipment (ppe) hinders nurse-patients communication and inhibiting the achievement of treatment goals. this study aims to examine the effect of a ‘covid nurse assistant’ (cna) application on patient satisfaction in covid-19 isolation rooms. design and methods: this was a comparative study with an experimental and control group design. the participants were patients confirmed positive with covid-19 receiving care in an isolation room for at least three days and were fully conscious. the intervention used was accessing health information related to covid-19 through a mobile-friendly application namely‘covid nurse assistant’. the instrument used was the patient satisfaction questionnaire (psq-18) translated into bahasa indonesia. in addition, an independent t-test was used to perform statistical analysis. results and discussions: a total 158 respondents completed the online survey among of 219 eligible patients (72% response rate). the score in the general and financial satisfaction sub-scales reported by patients in the experimental group were significantly different from the control with p-values of 0.032 and 0.018 respectively. however, other subscales were not significantly different between the two groups. conclusions: the implementation of the cna online application has noteworthy implications on patient satisfaction. however, further studies examining similar system in different clinical areas would provide better information for the optimal use of technology in patient education. introduction covid-19 was declared a pandemic by the world health organization (who) on march 11, 2020, after its first appearance in wuhan, china in december, 2019.1 the increased prevalence of cases indicates the need for specific policies for handling and preventing transmission. the symptoms of covid-19 characterized by fever and dyspnea due to acute respiratory dysfunction have led to an increase in the number of patients requiring treatment in the hospital.2 meanwhile, the hospital treatment varies according to the symptoms experienced by patients, with approximately 20% requiring oxygen therapy and 5% being treated in the intensive care unit.3 in indonesia, the number of positive cases reached 66,226 between march to july october 2020 with 30,785 recovered and 3,309 deaths spread over 497 regencies/cities in 34 provinces.4 the increase in covid-19 cases has led to problems due to the increasing number of patients requiring hospitalization and the burden on health services. overcrowding has caused increased stress and burden on health care workers, especially nurses who are on the front line.5 nurses are the health workers with the greatest patient contact and play an important role in managing and responding quickly to patients.6 in treating patients with covid19, strict protocols must be implemented to minimize the risk of transmission. the use of protective equipment such as gloves, long-sleeved disposable gowns, respirators, and eye protection such as goggles or face shields is standard procedure for all nurses caring for these patients.7 aside from preventing infection, the use of ppe also has several negative impacts, such as physical discomfort and difficulty in interacting with patients, especially communication and orientation.8-10 nurses stated that patients are often unable to recognize them when they are wearing ppe. this difficulty in interacting with patients disrupts therapeutic communicasignificance for public health covid-19 pandemic drives significant shifting and numerous emerging problems in the global health system. health education and promotion that focuses on covid-19 care for the patient, infection transmission, and prevention strategies were urgently provided publicly in hospital and community settings. however, it cannot be conducted in the conventional method, as printed flyers or brochures can be media for transmission. the nurse working in the covid-19 isolation room is experiencing the most difficulties in educating and communicating with patients and family. the study provided innovation in delivering health education using cna's integrated online platform. the study will provide important information on whether the cna is effective as health education media for covid-19 patients and their families. positive results may become a helpful consideration to develop a better application to enhance health education in the community. article [page 32] [healthcare in low-resource settings 2023; 11(s1):11168] non -co mmerc ial us e o nly tion and implementation of care needed by patients, including informed consent and discharge planning. the needs of patients hospitalized due to covid-19 include emotional support and orientation on the scheduled services. emotional support and the accompanying hope enhance healing, while orientation to services provides a sense of security and collaboration with therapeutic interventions.8 orientation to services can improve engagement and motivate patients to participate in treatment.8 in addition, the process of providing information regarding discharge planning is very important to patients. discharge planning for patients with covid-19 includes providing information regarding the recommendation for self-isolation at home which is expected to increase transmission prevention behavior. it also ensures continuity of care11 and includes a discussion of home remedies, self-care instructions, and follow-up care arrangements. this involves engaging with the patient and family at least 24 hours before discharge. when dealing with patients infected with covid-19, the problem that arises is related to the use of several paper-based tools which require effective communication. paper-based tools pose a risk of infection when handled by both nurses and patients, while social distancing and ppe inhibit effective communication. the use of technology media in the provision of care has become an important strategy in health services since the advent of the covid-19 pandemic. the utilization of technology for screening, diagnosis, delivery of information and patient monitoring has become more useful. this can be in the form of applications on smartphones or website-based.12,13 the development of the ‘covid nurse assistant’ (cna) application is in the form of a website containing health information for covid-19 patients. the information contains patient service orientation materials from admission to discharge and can be accessed from the patient’s smartphone. furthermore, it includes treatment that will be carried out, the hospital and the staff available to provide services with names and photographs, as well as complete discharge planning information. it is expected that this innovation can overcome some of the problems of providing information to patients treated in the covid-19 isolation rooms. design and methods this was a comparative study with experimental and control group design to examine differences in patient satisfaction regarding health care provided by nurses in covid-19 isolation rooms. the respondents were patients diagnosed with covid-19 and receiving care in the isolation rooms of dr. saiful anwar hospital, malang, east java, indonesia. the inclusion criteria included respondents who were fully conscious with the glasgow coma scale of 4, 5, or 6, and had received care in an isolation ward for a minimum of three days.14 patients who met these criteria were considered to have been adequately exposed to nursing care and capable of providing evaluation regarding the quality of care being provided. dr. saiful anwar hospital is the second-largest referral hospital in east java. during the pandemic, it was appointed by the provincial government to be a referral hospital for covid-19 patients. in march 2020, the isolation unit consisted of 2 wards with 30 and 40 beds, respectively. due to the increasing number of patients confirmed positive with covid-19, the hospital added four wards with 200 overall beds. during the second wave in julyaugust 2021, the bed occupation rate (bor) reached 100% forcing the hospital to add another 250 beds to serve patients not only from malang but also neighboring cities such as blitar, pasuruan, probolinggo and sidoarjo. the ‘covid nurse assistant’ (cna) is a mobile-friendly application that provides online education for patients with covid-19 and their families. the application was developed by the study team in collaboration with nurses in the isolation unit and was officially introduced by the hospital in january 2021. it consists of two major sections namely education for patients and families. both sections display posters and videos related to covid19 such as, how to select a diagnostic test for covid-19; patient orientation in isolation rooms; healthcare provided in isolation rooms, stress management, hospital chaplain services, diet, as well as medication and exercise recommendations. it also introduces patient discharge information, thereby making the transition of care to be implemented smoothly. a video about handling the deceased is also included in the education for the family section to give them an understanding of the respect placed on their religion. the hospital promoted the application through banners and posters displayed in the isolation wards and their surroundings. recruitment although frequently promoted by nurses and staff, some patients did not access the application. therefore, the experimental and control groups were self-selected with patients that decided to access the application or not. data collection data collection was conducted by study team members who are nurses working in isolation rooms. the survey in a google form was accessible in the cna application, hence, patients who accessed the application were able to complete the survey after accessing information. for the control group, the survey was distributed online by a link sent by whatsapp to patients which is similar to the normal procedure in this hospital to collect patient satisfaction data. a consent form was included as part of the google form and the participants were required to agree and proceed to complete the survey. moreover, this study received ethical approval from the health research ethics committee of the faculty of nursing, university of jember (number 68/un25.1.14/kepk/2021). measurement of patient satisfaction patient satisfaction data were collected using the patient satisfaction questionnaire (psq-18) that has been translated to bahasa indonesia using backward translation. the instrument was validated using content validity with items selection considered by the correlation coefficient > 0,3 and reliability estimation of 0.928.15 the indonesian version of the psc-18 consists of 18 items that are divided into seven subscales namely general satisfaction, technical quality, interpersonal manner, communication, financial aspects, time spent with nurses, as well as accessibility and convenience.15 the psq-18 uses a five-point likert scale that ranges from 1 representing strongly disagree to 5 meaning strongly agree to reflect patient satisfaction toward healthcare services. items numbered 4, 7, 9, 10, 12, 13, 14, 16, and 17 are negatively worded and reversely scored. the patient satisfaction score is derived from the average score within the seven subscales,16,17 higher scores indicate greater patient satisfaction. furthermore, additional demographic questions such as gender, age, educational level, occupation, and marital status were included for further information. questions about the benefit of the cna application to improve patient knowledge and confidence to manage self-care at home were also added. statistical analysis the characteristics of respondents in the control and experimental groups were examined using descriptive analysis, while the article [healthcare in low-resource settings 2023; 11(s1):11168] [page 33] non -co mmerc ial us e o nly effects of the cna application on patient satisfaction were compared between the two groups using an independent t-test with a significance level of 0.05. the p-value of less than 0.05 indicates a significant difference in patient satisfaction scores. results and discussions a total of 219 covid-19 patients were eligible to participate in this study and 158 respondents staying in covid isolation rooms for a minimum of three days completed the online survey providing a total response rate of 72%. furthermore, 53.8% or n=85 of the patients accessed the cna application and formed the experimental group, while 46.2% or n=73 did not access the application and formed the control. the majority of respondents were female n=80; 51%, the largest age group was between 51-60 years old with n=40; 25%, most were married n=129; 81%, worked in private businesses n=57; 36% while the most common highest level of education was a high school diploma n=65; 41%. the respondents’ characteristics are shown in table 1, while the opinions on how the access to the cna application improved knowledge and confidence in home-based self-care after discharge are shown in figure 1. the majority of respondents who accessed the application reported improvement in knowledge related to covid-19 namely 62.7% and increased confidence to manage self-care at home with 61.6%. furthermore, the aspects of improvement experienced by patients presented in figure 2 include patients’ medication adherence 67%, ability to practice exercise at home 58.5%, more healthy diets consumption 66%, better understanding of self-isolation 51,1%, and covid-19 article table 1. respondents’ characteristics. characteristics experimental group (n=85) control group (n=73) demographic factors n % n % gender male 46 54 32 44 female 39 46 41 56 age ≤ 20 years old 1 1 1 1 21-30 years old 12 14 8 11 31-40 years old 23 27 15 21 41-50 years old 14 17 16 22 51-60 years old 19 22 21 29 >60 years old 16 19 12 16 marital status not married 8 9 7 10 married 69 82 60 82 widowed 8 9 6 8 educational level elementary/middle school 8 9 3 4 high school diploma 29 34 36 49 college degree 48 57 34 47 occupation private organization/company 33 39 24 33 civil servant 12 14 5 7 entrepreneurs 13 15 13 18 students 3 4 2 3 retirement 10 12 7 10 not working 14 15 22 18 [page 34] [healthcare in low-resource settings 2023; 11(s1):11168] figure 1. patients’ opinion about can. figure 2. improvement aspects patients experienced after accessing cna. non -co mmerc ial us e o nly transmission prevention procedure 61.7%. this indicates a positive implication of the cna application to patients. the respondents also mentioned several advanced features of the cna application that differ from conventional education media, including ease of accessibility 80.9%, attractive and easily understood 64.9%, educational 56.4%, and comprehensive 67%. patient satisfaction levels table 2 displays the patient satisfaction levels of both the control and experimental groups. the experimental group’s subscale score ranged between 3.83 for time spent with nurses to 4.19 for interpersonal manner, while the control group scored lower overall, with a range of 3.41 for financial aspects to 3.95 for interpersonal manner. the comparison of patient satisfaction scores between the two groups is presented in figure 3. in all seven subscales, the experimental group reported a higher average score of satisfaction than those in the control. this implies that patients who accessed health information related to covid through the cna application are more likely to be satisfied with their healthcare than those who did not. the effect of the ‘covid nurse assistant’ (cna) application on the patient satisfaction level the differences in patient satisfaction scores between the control and experimental group were examined in table 3 and figure 4. the patient satisfaction scores in the general and financial satisfaction subscales reported by those in the experimental group were article table 2. patient satisfaction level between control and experimental group. patient satisfaction subscales groups mean std. deviation general satisfaction control group 3.77 0.408 experimental group 3.94 0.569 technical quality control group 3.68 0.463 experimental group 4.01 0.451 interpersonal manner control group 3.95 0.528 experimental group 4.19 0.567 communication control group 3.87 0.527 experimental group 4.12 0,528 financial aspects control group 3.41 0.436 experimental group 3.93 0.632 time spent with nurses control group 3.48 0.724 experimental group 3.83 0.750 accessibility and convenience control group 3.76 0.437 experimental group 3.99 0.571 table 3. table independent t-test patients satisfaction level between control and experimental groups. patient satisfaction subscale p-value mean difference 95% confidence interval of the difference general satisfaction 0.032 -0.17 -0.33 -0.02 technical quality 0.932 -0.33 0.07 -0.48 interpersonal manner 0.366 -0.24 0.09 -0.42 communication 0.875 -0.25 0.08 -0.42 financial aspects 0.018 -0.52 0.09 -0.69 time spent with nurses 0.594 -0.35 0.12 -0.58 accessibility and convinience 0.093 -0.23 0.08 -0.39 [healthcare in low-resource settings 2023; 11(s1):11168] [page 35] figure 3. the advantage features of cna as online education media. figure 4. patient satisfaction score control vs experimental group. notes: patient satisfaction score is an average score within subscales. non -co mmerc ial us e o nly significantly different from the control group with p-value 0.032, and 0.018 respectively. however, other subscales such as technical quality, interpersonal manner, communication, time spent with nurses, accessibility and convenience were not significantly different between the two groups. this study examined the effects of online education media on patient satisfaction in isolation rooms. the emerging problems during the covid-19 crisis required rapid and innovative measures to overcome predicaments involved in providing healthcare in isolation rooms. in the education sector, there has been a major shift from conventional to virtual classes,18 a strategy which can also be implemented to deliver patient education in healthcare settings19. the creation of cna, a mobile-friendly application to provide audio-visual information related to covid-19 is a suitable adjunct to patient education, especially in isolation rooms. although the strategy seems promising, an apprehensive assessment of its impact will provide better evidence to support further implementation. the number of patients who accessed and did not access the cna application was not the same, but several characteristics between the two groups were similar. the majority of patients who accessed the application reported gaining more knowledge related to covid-19 and that the overall information provided was attractive and easy to understand. most of the information provided in the cna application was in visual or audio-visual form. previous studies stated that videos as educational tools improve patients’ knowledge20, 21 and awareness related to their conditions.21 a recent study into the impact of video-assisted education reported that it improves activities of daily living and quality of life for postoperative patients.22 this implies a promising positive benefit of technology for patient education in the future. the cna application compiles all flyers and videos related to covid-19 into a single integrated system that can be accessed by both patients and family members anywhere and anytime. it also allows patients to have multiple logs in and all materials contained are reviewable. a study stated that education using video and printed material can improve knowledge retention for patients when properly utilized.23 these advantages were also confirmed in this study as the participants underlined the unique features of the cna application which include comprehensiveness, attractiveness, and accessibility. a similar application that educates maternal and child patients using videos accessed on mobile phones was shown to be handy for health workers.24 the cna provides the same assistance for nurses in isolation room as it enhances their authority to educate patients in a restricted environment. based on the results, patients who accessed the cna application were more satisfied in general than those who did not. in the financial aspects subscale, the patient satisfaction scores in the experimental group exceeded that of the control. the financial aspect focuses on the assumption of equality in care regardless of the patient economic status.16, 17 in indonesia, patients confirmed positive with covid-19 are automatically covered for healthcare by the indonesia ministry of health which provides equal care to all patients.25 although financial cost is not an issue, in this case, patients who did not access the information application might not receive sufficient education or fully understand the reason for the limited visits by nurses during their stay in the isolation rooms. despite the insignificant difference in the score of time spent with nurses between the two groups, patients in the control group scored lower, stating that nurses were in hurry during their visit and only provide limited attention. this dilemmatic phenomenon is prevalent during the covid-19 pandemic. massive escalation of patients confirmed positive were not balanced with a sufficient number of nurses assigned in isolation rooms.26 moreover, due to shortage of ppe and rapid transmission, cdc suggests that the nurse work duration be shortened,27 thereby reducing the number of available nurses taking care of patients in the isolation room. usually, four nurses are assigned to the isolation room wearing ppe consisting of ffp2 respirator face mask, and googles7 to handle approximately 70 patients. with this full ppe, nurses can only endure for five hours at most, hence, they might not spend sufficient time to care for their patients or prioritize more critical cases. patients who access the cna application were informed about this arrangement and were slightly more supportive towards this chaotic situation. technical quality, interpersonal manner, communication, accessibility, and convenience were not significantly affected by patient education using the cna application. this is presumably because patients with covid-19 are more likely to restrict themselves from using cellphones. in addition, pain, respiratory distress, and severe anxiety experienced are quite overwhelmed. several studies showed a high prevalence of anxiety, depression, and psychotic disorder in covid-19 patients.28, 29 this is probably triggered by inflammatory reactions in the body causing the elevation of tnf-alpha levels that potentially contributes to the mechanism for psychosis.28 although the effect of acute hypoxia on cognitive processes remains debatable, evidence shows that it potentially impair cognitive function.30 this indicates that covid-19 symptoms and the patient’s clinical condition remain uncontrollable factors that impede information transfer, regardless of the advanced media being used. based on the results, patients that accessed the cna application are more confident to take care of themselves after discharge. this individual belief to perform a particular task often referred to as self-efficacy31, 32 directly influences behavioral intention and behavior. although the influence of education on self-efficacy remains unclear, its effects on behavioral intention have been proven.33 this is also consistent with the results obtained in this study where the majority of patients with improved confidence of self-care claimed a better medication adherence, consume healthier diets, have a more active lifestyle, and better implementation of health procedures related to covid-19. when patients are wellinformed, they have better self-efficacy towards healthier behaviors. furthermore, sufficient health education leads to patient engagement meaning that patients are capable of making shared decisions related to their preferred treatments.34 several studies stated that this strategy is a promising intervention to improve health outcomes and quality such as adherence to treatment recommendation,35 mortality from major events,36 and patient satisfaction.37 this highlights the importance of adequate health education for better patient outcomes and the achievement of quality healthcare. this study has certain notable limitations, first, the use of technology reduced participation due to the cost, thereby limiting people from lower socioeconomic backgrounds. second, the study was conducted only in one referral hospital for covid-19 in east java, indonesia. the implementation of multi-center studies is expected to allow better generalization of results. conclusions the implementation of the cna application as an integrated online education medium has noteworthy implications on patient satisfaction as a healthcare quality indicator. however, further studies are needed to examine the effects of online applications in the form of health education platforms in different clinical areas such as medical and surgical wards. this study can also be expanded to explore the implication of online educational media on patient engagement or other health outcomes. article [page 36] [healthcare in low-resource settings 2023; 11(s1):11168] non -co mmerc ial us e o nly references 1. cucinotta d, vanelli m. who declares covid-19 a pandemic. acta bio medica: atenei parmensis 2020;91:157. 2. huang c, wang y, li x, et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. lancet 2020;395:497-506. 3. lin s, pan h, wu h, et al. epidemiological and clinical characteristics of 161 discharged cases with coronavirus disease 2019 in shanghai, china. bmc infect dis 2020;20:1-10. 4. kahar f, dirawan gd, samad s, et al. the epidemiology of covid-19, attitudes and behaviors of the community during the covid pandemic in indonesia. ijisrt 2020;5:1681–7. 5. lin s, pan h, wu h, et al. epidemiological and clinical characteristics of 161 discharged cases with coronavirus disease 2019 in shanghai, china. bmc infect dis 2020;20:780. 6. arasli h, furunes t, jafari k, et al. hearing the voices of wingless angels: a critical content analysis of nurses’ covid-19 experiences. int j environ res public health 2020;17:8484. 7. world health organization. rational use of personal protective equipment for coronavirus disease 2019 (covid-19) and considerations during severe shortages. geneva: who; 2020. 8. purcell ln, charles ag. an invited commentary on “world health organization declares global emergency: a review of the 2019 novel coronavirus (covid-19)": emergency or new reality? int j surg 2020;76:111. 9. galehdar n, toulabi t, kamran a, et al. exploring nurses’ perception about the care needs of patients with covid-19: a qualitative study. bmc nursing 2020;19:1-8. 10. wong ckm, yip bhk, mercer s, et al. effect of facemasks on empathy and relational continuity: a randomised controlled trial in primary care. bmc fam pract 2013;14:1-7. 11. yam ch, wong el, cheung aw, et al. framework and components for effective discharge planning system: a delphi methodology. bmc health serv res 2012;12:1-16. 12. nguyen ot, tabriz aa, huo j, et al. impact of asynchronous electronic communication–based visits on clinical outcomes and health care delivery: systematic review. j med internet res 2021;23:e27531. 13. abd-alrazaq a, hassan a, abuelezz i, et al. overview of technologies implemented during the first wave of the covid-19 pandemic: scoping review. j med internet res 2021;23:e29136. 14. nursalam d. nursing management: applications in professional nursing practice. jakarta: salemba medika; 2014. 15. imaninda v, azwar s. modification of patient satisfaction questionnaire short form (psq-18) into indonesian. jurnal psikologi ugm 2016;2:229467. 16. marshall gn, hays rd. the patient satisfaction questionnaire short form (psq-18). santa monica, ca: rand corporation; 1994. 17. thayaparan aj, mahdi e. the patient satisfaction questionnaire short form (psq-18) as an adaptable, reliable, and validated tool for use in various settings. medical education online 2013;18:21747. 18. leigh j, vasilica c, dron r, et al. redefining undergraduate nurse teaching during the coronavirus pandemic: use of digital technologies. br j nurs 2020;29:566-9. 19. woolliscroft jo. innovation in response to the covid-19 pandemic crisis. acad med 2020;95:1140-1142. 20. gagne m, legault c, boulet l-p, et al. impact of adding a video to patient education on quality of life among adults with atrial fibrillation: a randomized controlled trial. patient educ counsel 2019;102:1490-8. 21. idriss nz, alikhan a, baba k, et al. online, video-based patient education improves melanoma awareness: a randomized controlled trial. telemedicine and e-health 2009;15:9927. 22. peker sv, yılmaz e, baydur h. the effect of preoperative video-assisted patient education on postoperative activities of daily living and quality of life in patients with femoral fracture. j clinical experiment investigat 2020;11:em00736. 23. wilson ea, park dc, curtis lm, et al. media and memory: the efficacy of video and print materials for promoting patient edu article [healthcare in low-resource settings 2023; 11(s1):11168] [page 37] correspondence: evi harwiati ningrum, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: evi_harwiati@ub.ac.id key words: covid nurse assistant; patient education; covid-19; patient satisfaction. acknowledgment: the authors would like to thanks to department of nursing, faculty of health sciences, universitas brawijaya, malang who provided support for this study. contributions: all authors actively contributed to the technical help, writing assistance, statistical analysis and reviewing manuscript. they all agreed on the name arrangements, and gave full support to publish this article. conflict of interests: the authors declare no conflict of interest. funding: this project was fully funded by research and community service agency of faculty of medicine universitas brawijaya. clinical trials: ethical approval was obtained through health research ethics committee of the faculty of nursing, university of jember (number 68/un25.1.14/kepk/2021). the authors had received participants’ written consent, and distributed prior to the commencement of the study. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11168 doi:10.4081/hls.2023.11168 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co 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staffing shortages. 2020 apr 30; available from: https://stacks.cdc.gov/view/cdc/88616 28. lim st, janaway b, costello h, et al. persistent psychotic symptoms following covid-19 infection. b j psych open 2020;6:e105. 29. yohannes am. copd patients in a covid-19 society: depression and anxiety. expert rev respir med 2021;15:5–7. 30. nakata h, miyamoto t, ogoh s, et al. effects of acute hypoxia on human cognitive processing: a study using erps and seps. j appl physiol 2017;123:1246-55. 31. bandura a. guide for constructing self-efficacy scales (revised) [internet]. researchgate. [cited 2022 jan 1]. available from: https://www.researchgate.net/ publication/233894825_guide_for_constructing_self-efficacy_ scales_revised 32. heslin pa, klehe u-c. self-efficacy. 2006 sep 22; cited 2022 jan 1; available from: https://papers.ssrn.com/ abstract=1150858 33. bastani f. the effect of education on nutrition behavioral intention and self-efficacy in women. health scope 2012;1: 12-7. 34. coulter a. patient engagement—what works? j ambulatory care manag 2012;35:80-9. 35. nieuwlaat r, wilczynski n, navarro t, et al. interventions for enhancing medication adherence. cochrane database syst rev 2014;2014:cd000011. 36. meterko m, wright s, lin h, et al. mortality among patients with acute myocardial infarction: the influences of patient-centered care and evidence-based medicine. health services research 2010;45:1188-204. 37. loh a, simon d, wills ce, et al. the effects of a shared decision-making intervention in primary care of depression: a cluster-randomized controlled trial. patient educ counsel 2007;67:324-32. article [page 38] [healthcare in low-resource settings 2023; 11(s1):11168] non -co mmerc ial us e o nly hrev_master [page 94] [healthcare in low-resource settings 2023; 11:11647] maternal knowledge and prescribing practices of antibiotics for childhood infections: a cross-sectional survey in jordan ruaa abdeljawad,1 osama abu-hammad,2 omayyah dar-odeh,1 farhan alkouz,1 raghad abdeljawad,3 abdalla abu-hammad,4 rahaf abdeljawad,3 najla dar-odeh2 1private practice, amman, jordan; 2school of dentistry, university of jordan, amman; 3school of medicine, the hashemite university, alzarqa; 4school of medicine, university of jordan, amman, jordan abstract this article aims to assess the knowledge and practices of jordanian mothers regarding antibiotic consumption by their children. a questionnaire was distributed to mothers during hospital visits in februarymay 2020. questions were on socio-demographics; knowledge of antibiotic indications/complications; and prescribing practices. a total of 1926 mothers participated. most mothers were aware that antibiotics are not indicated for viral infections (72.0%), and that abuse leads to complications like antibiotic resistance (82.1%). however, their knowledge regarding antibiotic complications was not satisfactory particularly complications of obesity (11.7%), caries (29.9%), and allergy (43.4%). the most important clinical indications for antibiotics were perceived to be otitis media (89.8%), and sore throat (44.4%). a proportion of 21.7% admitted self-prescribing, significantly among families of ≤2 children, and poor antibiotic knowledge (p<0.01). lower antibiotic knowledge scores were impacted mostly by grandparents who selfprescribe antibiotics (p<0.01). jordanian mothers show satisfactory knowledge of pediatric antibiotic consumption, however, their knowledge of complications is not sufficient. antibiotic self-prescribing is identified mainly in families with lower income and less antibiotic knowledge, therefore these families should be identified and targeted in antibiotic awareness campaigns. introduction children may use substantial amounts of antibiotics due to their high susceptibility to infections, particularly those affecting the upper respiratory tract. exposure of children to factors that predispose them to infections is promoted by the surrounding environment such as nurseries, daycare facilities, and schools which facilitate the spread of antibiotic-resistant bacteria.1 although a substantial proportion of childhood illnesses are viral in origin, it is estimated that 78% of children with acute upper respiratory tract infections (auris) receive antibiotic prescriptions that are mostly based on broad-spectrum antibiotics.2 misuse of antibiotics in children has been associated with the development of several complications particularly antibiotic resistance which has many serious consequences including increased mortality.3,4 situated in the heart of a turbulent middle east, jordan represents a politically stable country that continues to host refugees, immigrants, and workforce from neighboring countries such as palestine, syria, iraq, egypt, yemen, and more recently sudan.5 it is estimated that more than 40% of the jordanian population, or 3.8 million, are children; approximately 30% of these are of non-jordanian origin. this may represent a real challenge for the national healthcare system which may be burdened by the fluctuating demographics and the associated challenges of drug prescribing and use. previous research in jordan and the neighboring countries of the eastern mediterranean showed several alarming findings regarding antibiotic abuse including their unjustified use for viral infections, parental pressure in prescribing, and excessively long antibiotic courses.2,6,7 it is estimated that approximately 77.5% of prescriptions to the outpatient pediatric population are antimicrobials.8 it was also concluded that pneumococcal carriage rate and resistance among 2to 4-year-old children reached an alarming rate.9 another important finding was the noticeable impact of social factors and parental involvement in treatment plans which were identified in this geographic region.10 since antibiotics are among the most commonly used drugs by the pediatric population, and considering the influence of mothers in the consumption of antibiotics, and shaping prescribing practices of clinicians, it is crucial to investigate their knowledge and self-prescribing practices of antibiotics. therefore, this cross-sectional survey aims to evaluate the knowledge and practices of jordanian mothers regarding antibiotic consumption by their children. materials and methods the study was a questionnaire-based cross-sectional survey. the questionnaire was a modified version of a similar questionnaire used in a previous study.11 it was composed of 36 closed-ended questions and organized into three sections. the first section consisted of six questions on sociodemographics. the second section consisted of 19 knowledge questions answered by (yes, no, don’t know), and eight questions on appropriate antibiotic uses answered by (yes, no). there were five knowledge ques healthcare in low-resource settings 2023; volume 11:11647 correspondence: najla dar-odeh, school of dentistry, university of jordan, amman, jordan. tel.: +962.792005197 e-mail: najla_dar_odeh@yahoo.com key words: antibiotics; awareness; children; jordan; parents; practices; self-prescribing. ethics approval: ethical approval was obtained from the ibn alhaitham hospital, amman, jordan. availability of data and material: data are available upon request from the corresponding author. conflict of interest interest: authors declare no conflict of interest. contributions: conceptualization, ruaa a.; n. d-o, o a-h: data curation, o. d-o; formal analysis: o a-h; investigation, f. a., raghad a.;. writing-original draft, ruaa a.a. a-h; rahaf a; writing-review and editing, n. d-o, o a-h; all authors have read and agreed to the published version of the manuscript. received: 9 august 2023. accepted: 3 november 2023. early view: 10 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11647 doi:10.4081/hls.2023.11647 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly tions on five types of common childhood medications and whether these constitute antibiotics. these types included the following drug categories with common locally recognized brand names (penicillins: augmentin, amoclan, curam; cephalosporins: suprax, cefix, omnicef; macrolides: zomax, azicure; non-steroidal anti-inflammatory agents: brufen/ aspirin; corticosteroids: decadron, predone). the third section consisted of prescribing aspects specifically antibiotic storage for future use and self-prescribing by parents and grandparents. questionnaire items were entered onto google forms and a link was created. ethical approval was obtained from the ibn alhaitham hospital, amman, jordan. mothers who attended the hospital for treatment of their children were invited in a consecutive order to participate in the study. those who gave their consent received the link for the questionnaire on their smartphones and they were guided throughout the questionnaire by the investigators without influencing their responses. invitation of the participants and the questionnaires were completed in four months from february 1st, 2020 to may 31st, 2020. knowledge and practice answers were scored by assigning one mark for each appropriate answer (whether yes or no) while the incorrect and the “don’t know” answers were marked by “zero”. questions about understanding antibiotics and their [healthcare in low-resource settings 2023; 11:11647] [page 95] article table 1. sociodemographic characteristics of mothers (n=1926) participating in the survey and their families. sociodemographic characteristics no (%) marital status married 1905 (98.9) divorced 19 (1.0) widowed 2 (0.1) residence urban 1713 (88.9) rural 213 (11.1). health insurance yes 1425 (74.0) no 501 (26.0) monthly household income (jod) low (<500) 476 (24.7) moderate (500-1000) 732 (38.0) high (>1000) 718 (37.3) education of parents mothers fathers school 189 (9.8) 396 (20.6) college 209 (10.9) 191 (9.9) university 1310 (68.0) 1048 (54.4) postgraduate 218 (11.3) 291 (15.1) jod, jordanian dinar (equivalent to 1.41 usd). table 2. knowledge and prescribing practices of antibiotics for children among participating mothers. knowledge and practice items frequency (%) yes no don’t know knowledge: indications, advantages, complications abs are useful for viral infections 438 (22.7) 1386 (72.0)* 102 (5.3) abs are indicated for bacterial infection 1583 (82.2)* 187 (9.7) 156 (8.1) abs abuse complicates treatment 1582 (82.1)* 177 (9.2) 167 (8.7) abs abuse causes bacterial resistance 1596 (82.9)* 258 (13.4) 72 (3.7) expensive abs are more effective 336 (17.4) 1353 (70.2)* 237 (12.3) new abs are more effective 516 (26.6) 614 (31.7) 809 (41.7) abs may induce obesity in children 226 (11.7)* 473 (24.6)* 1227 (63.7) abs may induce dental caries 575 (29.9)* 414 (21.5) 937 (48.7) abs may induce sensitivity 835 (43.4)* 347 (18.0) 744 (38.6) abs may induce diarrhea 1342 (69.7)* 188 (9.8) 396 (20.6) abs enhance child recovery 1216 (63.1)* 631 (32.8) 79 (4.1) abs ease flu 269 (14.0) 1563 (81.2)* 94 (4.9) abs abuse makes future use difficult 1456 (75.6)* 272 (14.1) 198 (10.3) abs should be stopped after recovery 171 (8.9) 1733 (90.0)* 22 (1.1) palatable abs are better 330 (17.1) 1548 (80.4)* 48 (2.5) knowledge: these medications are abs penicillins 1551 (80.5)* 375 (19.5) 0 cephalosporins 1441 (74.8)* 485 (25.2) 0 macrolides 1069 (55.5)* 857 (44.5) 0 corticosteroids 269 (14.0) 1657 (86.0)* 0 nsaids 113 (5.9) 1813 (94.1)* 0 prescribing practices i have a background on childhood infections 1397 (72.5) 528 (27.5) na i use abs for sore throat 855 (44.4) 1071 (55.6) na i use abs for flu 105 (5.5) 1821 (94.5) na i use abs for diarrhea 152 (7.9) 1774 (92.1) na i use abs for fever 699 (36.3) 1227 (63.7) na i use abs for otitis media 1729 (89.8) 197 (10.2) na i use abs for dental pain and caries 236 (12.3) 1690 (87.7) na i prescribe abs to my children 417 (21.7) 1509 (78.3) na grandparents prescribe abs to my children 460 (23.9) 1466 (76.1) na i store abs for future use 417 (21.7) 1509 (78.3) na abs: antibiotics; na: not applicable; penicillins: augmentin, amoclan, curam; cephalosporins: suprax, cefix, omnicef; nsaids: brufen/ aspirin; corticosteroids: decadron, predone; and macrolides: zomax, azicure. *correct statements non -co mmerc ial us e o nly indications were marked for all participants and were calculated as knowledge scores for antibiotics. the sum of all marks for each participant comprised the total score in antibiotics knowledge. statistical analysis was performed using the ibm spss software version 21.0 (armonk, ny: ibm corp). analysis was done to obtain descriptives in the form of frequencies and percentages. cross-tabulation was performed to determine significant associations between sociodemographics on the one hand and antibiotic knowledge scores and self-prescribing practices on the other hand. the level of significance was set at p≤0.05. multiple linear regression was carried out to investigate significant factors influencing knowledge scores. results socio-demographics of the sample a total of (1926) mothers participated in the survey. sociodemographic characteristics of marital status, number of children in the family, education status of parents, availability of medical insurance, and other sociodemographics of the sample are presented in table 1. most of the sample were married (98.9%), urban dwellers (88.9%), had health insurance (74.0%), and had moderate-high income (75.3%). a higher percentage of mothers than fathers (90.2% versus 79.4%) had higher education. items related to knowledge and practice about antibiotics use among children are shown in table 2 together with the responses of participants. knowledge scores ranged from a minimum (3) to a complete score of (27) with a mean value of (19.4±3.4). accordingly, scores ≤18 were considered low, while scores >18 were considered high scores. knowledge items with the highest correct response rate (>82%) were: abs are indicated for bacterial infection, ab abuse complicates treatment, and ab abuse causes bacterial resistance. on the other hand, knowledge items with the highest “don’t know” response rate were: antibiotics may induce obesity and dental caries in children (63.7% and 48.7% respectively) (table 2). approximately 22.0% of the sample practiced antibiotic self-prescribing for their children and storing medications for future use. a higher percentage of grandparents (23.9%) than mothers (21.7%) prescribed antibiotics to their grandchildren (table 2). the practice of self-prescribing was cross-tabulated with sociodemographic factors and total knowledge scores. results are presented in (table 3). health insurance was found to be the only variable not significantly correlated to self-prescribing behavior (p=0.068). having ≤2 children, low antibiotic knowledge scores, parents’ university education level, urban residence, low-middle income, and self-prescribing grandparents were all significantly associated with the practice of antibiotic self-medication among participants (p<0.05) (table 3). results of cross-tabulation between antibiotic knowledge scores and sociodemographic factors are displayed in table 4. there were significantly higher antibiotic knowledge scores when: parents’ education was university (p=0.000 for both), urban residence (p=0.002), having health insurance (p=0.002), non-prescribing grandparents (p=0.000) and moderate-high household income (p=0.000) (table 4). for the regression model (table 5) an “enter” method was implemented and independent variables were identified as follows: monthly household income, number of children in the family, prescribing grandparents, health insurance, residence, mother’s education, and article table 3. cross-tabulation of sociodemographics with the practice of antibiotic self-medication among participating mothers. sociodemographics do you prescribe abs to your children? p no n=1509 (%) yes n=417 (%) number of children in the family 1-2 1121 (74.3) 246 (59) 0.000 > 2 388 (25.7) 171 (41) ab knowledge ranks low (≤18) 442 (29.3) 249 (59.7) good (> 18) 1067 (70.7) 168 (40.3) 0.000 mother education school 122 (8.1) 67 (16.1) 0.000 college 153 (10.1) 56 (13.4) university 1051 (69.6) 259 (62.1) higher education 183 (12.1) 35 (8.4) father education school 262 (17.4) 134 (32.1) 0.000 college 144 (9.5) 47 (11.3) university 868 (57.5) 180 (43.2) higher education 235 (15.6) 56 (13.4) residence rural 144 (9.5) 69 (16.5) 0.000 urban 1365 (90.5) 348 (83.5) health insurance no 378 (25) 123 (29.5) 0.068 yes 1131 (75) 294 (70.5) grandparent/s prescribe/s abs no 1172 (77.7) 294 (70.5) 0.003 yes 337 (22.3) 123 (29.5) monthly household income low 316 (20.9) 160 (38.4) 0.000 middle 572 (37.9) 160 (38.4) high 621 (41.2) 97 (23.3) [page 96] [healthcare in low-resource settings 2023; 11:11647] non -co mmerc ial us e o nly father’s education. the “enter” method used forced all variables into the regression model. the results of multiple linear regression are shown in table 5. significant variables in the model were: monthly income, prescribing grandparents, father’s education, and mother’s education (p<0.01). all other variables were not significant (p>0.05). regression analysis showed an r-value of 0.325, r2=0.106, and adjusted r2=0.102 (close to the r square value indicated that the sample size was satisfactorily sufficient). durban watson test value of 1.919 indicated that 10.6% of the variability in antibiotics knowledge scores could be accounted for by variations of independent variables in the model. durban watson test value was > 1.5 indicating that we do not have meaningful serial correlation or multicollinearity between independent variables. anova results indicated an f=58.270 and p<0.001. coefficients in the regression model are shown in table 5. coefficients (b weights) show that grandparents’ contribution to medication had the highest impact on ab knowledge scores which was a negative effect, indicating that prescribing grandparents were associated with knowledge scores that were lower by 0.904 score) followed by monthly income then mother’s education and finally father’s education. all entered variables were significant at p≤0.001. tolerance of more than 0.2 for all included variables indicated that multicollinearity is not an issue in this regression model. article table 4. cross-tabulation of sociodemographic characteristics with antibiotic knowledge scores among participating mothers. ab knowledge score ranks of mothers p low (%) good (%) no of children 1-2 475 (68.7) 892 (72.2) 0.116 > 2 216(31.3) 343 (27.8) marital status widow 1(0.1) 1 (0.1) 0.528 married 681(98.6) 1224 (99.1) divorced 9(1.3) 10 (0.8) mother education school 116(16.8) 73 (5.9) 0.000 college 80(11.6) 129 (10.4) university 440(63.7) 870 (70.4) higher education 55(8) 163 (13.2) father education school 203(29.4) 193 (15.6) 0.000 college 82(11.9) 109 (8.8) university 334(48.3) 714 (57.8) higher education 72(10.4) 219 (17.7) residence rural 97(14) 116 (9.4) 0.002 urban 594(86) 1119 (90.6) health insurance no 208(30.1) 293 (23.7) 0.002 yes 483(69.9) 942 (76.3) grandparents participating in medication no 480(69.5) 986 (79.8) 0.000 yes 211(30.5) 249 (20.2) monthly income low 254(36.8) 222 (18) 0.000 middle 262(37.9) 470 (38.1) high 175(25.3) 543 (44) table 5. coefficients in the regression model. independent unstandard. coeff. standard. t sig. 95.0% conf. correlations collinearity variables b std. coeff. intervalfor b statistics error beta lower upper zero-order partial part tolera vif (constant) 15.19 0.579 26.23 0 14.05 16.32 monthly income 0.708 0.117 0.161 6.07 0.000 0.479 0.936 0.269 0.137 0.131 0.660 1.515 no. of children 0.000 0.075 0 0.003 0.998 0.148 0.147 0.008 0 0.000 0.884 1.131 self-prescribing grandparents 0.904 0.175 0.113 5.16 0.000 1.248 0.560 0.156 0.117 0.111 0.969 1.032 residence 0.448 0.250 0.041 1.79 0.073 0.042 0.939 0.108 0.041 0.039 0.881 1.136 health insurance 0.066 0.178 .008 .370 .712 .416 .284 .071 .008 .008 .884 1.131 mother’s education 0.426 0.116 0.095 3.67 0 0.198 0.654 0.209 0.083 0.079 0.694 1.442 father’s education 0.308 0.094 0.088 3.27 0.001 0.124 0.493 0.226 0.075 0.071 0.647 1.547 a, dependent variable: antibiotics knowledge scores. [healthcare in low-resource settings 2023; 11:11647] [page 97] non -co mmerc ial us e o nly [page 98] [healthcare in low-resource settings 2023; 11:11647] discussion this study was conducted on a large sample of jordanian mothers, the primary caregivers for children in jordan to explore their knowledge of antibiotics, awareness of antibiotic uses and complications, and finally the self-prescribing practices towards their children. a close look at the sociodemographics of this sample indicates that more than 75% of the sample were settled financially and socially being mostly married, educated, with health insurance, and urban dwelling. it was interesting to identify that more mothers had college or higher education than fathers. this is undoubtedly a close representation of the actual data that report that approximately 56% of students in jordanian universities are women.12 perhaps that is why most respondents had good knowledge about the uses and complications of antibiotics as most of them believed that antibiotics are not indicated for viral infections and that antibiotics should be used for bacterial infections. this reflects that jordanian mothers have acceptable levels of awareness regarding the main uses of antibiotics. this was further confirmed by >80% of the sample who acknowledged that antibiotic abuse is a problem that results in increasing antibiotic resistance and complicating treatment outcomes. it was important to explore mothers’ knowledge of the possible complications of antibiotic use. their knowledge is expected to increase their appreciation of the treatment outcomes that could be adverse making its avoidance necessary. however, not all participants were aware of some antibiotic complications known to affect the pediatric population. whereas most participants agreed with the fact that antibiotics may induce diarrhea and sensitivity, a substantial proportion did not recognize that antibiotics may induce obesity or dental caries. this is perhaps related to the acute and prevalent nature of antibiotic-associated diarrhea which is estimated to be 11%.13 whilst, any antibiotic is capable of inducing diarrhea, the most common agent involved is amoxicillin followed by clindamycin because of the spectrum of action and widespread use.14 further, antibiotics use in children may be associated with the risk of developing allergies and asthma.15 the association between asthma and antibiotic use has been debatable for a long period, however, in the past decade more studies emerged that concluded that excessive use of systemic antibiotics in infancy may play a role in the development of asthma in children.16,17 therefore, the association between antibiotic use in children and allergy and asthma cannot be overlooked. other complications associated with less awareness among our sample included obesity and dental caries, probably due to the common belief of their association with nutritional and lifestyle factors. an association between antibiotic use on the one hand and obesity and dental caries on the other hand has been suggested previously.18,19 a recent meta-analysis reported that early-life antibiotic exposure was associated with the risk of childhood overweight or obesity in a dose-response manner.19 children who are exposed to antibiotics early in their life may be at risk of changing the composition of their intestinal microbiota, with subsequent adverse long-term effects like obesity.20 therefore, with the high prevalence of obesity among children in jordan,21 more studies are warranted to investigate the role of antibiotics and other childhood medications as a contributory factor to obesity. on the other hand, several dental problems associated with pediatric antibiotic use are identified, and these when associated with the poor oral health practices common among children in the eastern mediterranean region22 would worsen the oral health outcomes. it was also shown that exposure to amoxicillin during early infancy may predispose to dental defects in the form of defective enamel.23 participants were generally knowledgeable about the antibiotic brand names prescribed to children locally in jordan. however, a small percentage identified corticosteroids (14%) and nsaid analgesics (6%) as antibiotics probably because of their anti-inflammatory nature, and their versatile applications in the management of childhood infections.24 regarding the effectiveness of antibiotics and associated factors, the study revealed that seven out of 10 respondents did not perceive that there was a relation between the cost of antibiotics and their effectiveness. on the other hand, 30% of respondents did not consider that new antibiotics are more effective as opposed to a slightly higher proportion of 40% who expressed uncertainty about the comparative effectiveness of new antibiotics. these results suggest that our respondents have a keen understanding of the price-quality relationship of drugs. however, it is worth noting that multiple studies have indicated that higher-priced drugs are often associated with higher efficacy judgment.25 clearly, new antibiotics have been developed to target more resistant strains of bacteria. nevertheless, this does not imply that the older antibiotics are any less effective than the new ones against the original strains of bacteria.26 participants used antibiotics to treat a variety of childhood infections and diseases. the most frequently cited diseases were otitis media followed by sore throat, while the least frequently cited diseases for antibiotics use were dental pain, diarrhea, and flu in descending order. this generally indicates good practice since operative treatment, for dental pain,27 and palliative treatment for flu are the appropriate measures that should be followed rather than antibiotic consumption. one in five of the participants practiced self-medication with their children. selfmedication with antibiotics is a serious common practice in jordan and other eastern mediterranean populations.10 a recent systematic review reported that the prevalence of antibiotic self-medication among children was highest in the middle east and lowest in europe.28 it was noticed that small families (≤2 children), and lowmiddle income were significantly associated with this practice. this is consistent with recent systematic reviews that concluded that low income and having more than one child were associated with this practice.29 unfortunately, the non-prescribed dispensing of antibiotics in jordan is not yet wellcontrolled, which facilitates obtaining medications for self-prescribing parents. this may have serious implications particularly that this practice was significantly associated with participants who had low antibiotic knowledge scores. expectedly, there was a significant association between higher antibiotic knowledge scores and favorable socioeconomic status in terms of education, residence, health insurance, and monthly income. education is usually paralleled by socioeconomic well-being, and both are generally associated with improved access and retrieval of required information about childhood medications. it was important to explore grandparents’ involvement in the child’s treatment plan because of the primary role that grandparents in arabic societies play in contributing to their grandchildren’s upbringing issues such as health aspects. albeit the small difference, a higher percentage of grandparents than parents participated in self-medication. on the other hand, prescribing grandparents were significantly associated with prescribing mothers and mothers who had low antibiotic knowledge scores. this was confirmed by regression analysis which showed that self-prescribing grandparents had the strongest association with low knowledge scores of mothers followed by other less significant factors such as monthly income, and parents’ education. this confirms previous findings of the essential role of the family in promoting health behaviors including appropriate drug use.30 this study therefore showed that good antibiotic knowledge and article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11647] [page 99] non-self-prescribing go hand in hand to leave the practice of prescribing to physicians to promote patient safety and avoid the anticipated side effects of antibiotic abuse. the study has limitations. it was a single-center study conducted in a private city hospital. however, a large sample of mothers with different socioeconomic profiles has participated. the cross-sectional selfperceived nature of the survey may represent another limitation. however, the anonymous nature of the questionnaire and the assistance that researchers provided to participants during the completion of the survey are two main factors that helped provide reliable responses. conclusions jordanian mothers seem to have satisfactory knowledge of antibiotics consumed by their children. however, their knowledge of complications is not sufficient, and some of them show poor practices in obtaining the medication and practicing self-medication. most parents showed their interest in improving their education on antibiotics issues, and this could be utilized to design parent-oriented interventions that increase the awareness of parents and improve antibiotic use among the pediatric population. references 1. nyquist ac, gonzales r, steiner jf, et al. antibiotic prescribing for children with colds, upper respiratory tract infections, and bronchitis. respir care 1998;279:875-7. 2. ababneh ma, al-azzam si, ababneh r, et al. antibiotic prescribing for acute respiratory infections in children in jordan. int health 2017;9:124-130. 3. moore am, patel s, forsberg kj, et al. pediatric fecal microbiota harbor diverse and novel antibiotic resistance genes. plos one 2013;8:e78822. 4. korpela k, salonen a, virta lj, et al. intestinal microbiome is related to lifetime antibiotic use in finnish pre-school children. nat commun 2016;7:10410. 5. al ryalat n, ryalat s, al-abdalla m, et al. women in maxillofacial surgery and otolaryngology; career obstacles and success factors. j craniofac surg 2021;32:874-877 6. al-niemat si, aljbouri tm, goussous ls, et al. antibiotic prescribing patterns in outpatient emergency clinics at queen rania al abdullah ii children’s hospital, jordan, 2013. oman med j 2014;29:250-4. 7. dar-odeh n, al-abdalla m, al-shayab mh, et al. antibiotics for pediatric dental patients in jordan; knowledge and attitudes of dentists. int arab j antimicrob agents, 2013;3:4. 8. al-shatnawi sf, al-hosban sy, altawalbeh sm, et al. antibiotic prescribing patterns for childhood infections in ambulatory settings in jordan. int j clin pract 2021;75:e14740 9. lahham a. multicenter study of pneumococcal carriage in children 2 to 4 years of age in the winter seasons of 2017-2019 in irbid and madaba governorates of jordan. plos one 2020;15:e0237247. 10. dar-odeh ns, othman bm, bahabri rh, et al. antibiotic self-medication for oral conditions: characteristics and associated factors. pesqui bras odontopediatria clin integr 2018;18:3890. 11. yu m, zhao g, stålsby lundborg c, et al. knowledge, attitudes, and practices of parents in rural china on the use of antibiotics in children: a cross-sectional study. bmc infect dis 2014;14:112. 12. jordan news. 56% of students in jordanian universities are women. https://www.jordannews.jo/section109/news/56-of-students-in-jordanianun ive r s i t i e s a r e -women-18548 . accessed june 4 2023 13. alam s, mushtaq m. antibiotic associated diarrhea in children. indian pediatr 2009;46:491-6. 14. kumar p. pharmacology of specific drug groups: antibiotic therapy. in dowd fj, johnson bs, mariotti aj (eds.), pharmacology and therapeutics for dentistry, 7th ed. 2017; pp. 457– 487. 15. droste jh, wieringa mh, weyler jj, et al. does the use of antibiotics in early childhood increase the risk of asthma and allergic disease? clin exp allergy 2000;30:1547-53. 16. pitter g, ludvigsson jf, romor p, et al. antibiotic exposure in the first year of life and later treated asthma, a population based birth cohort study of 143,000 children. eur j epidemiol 2016;31:8594; 17. bentouhami h, bungwa mk, casas l, et al. asthma occurrence in children and early life systemic antibiotic use: an incidence density study. allergy asthma clin immunol 2023;19:18. 18. alaki sm, burt ba, garetz sl. the association between antibiotics usage in early childhood and early childhood caries. pediatr dent 2009;31:31-7. 19. meng x, zhu y, di h, et al. doseresponse association of early-life antibiotic exposure and subsequent overweight or obesity in children: a metaanalysis of prospective studies. obes rev 2021;22:e13321. 20. yallapragada sg, nash cb, robinson dt. early-life exposure to antibiotics, alterations in the intestinal microbiome, and risk of metabolic disease in children and adults. pediatr ann 2015; 44:e265-9. 21. subih hs, abu-shquier y, bawadi h, et al. assessment of body weight, maternal dietary knowledge and lifestyle practices among children and adolescents in north jordan. publc health nutr 2018;21:2803-2810. 22. hashem d, abu hammad oa, farran j, et al. oral health practice of primary school children in the region of madinah, saudi arabia: a cross-sectional study. j int oral health 2021;13: 449-55. 23. hong l, levy sm, warren jj, et al. association of amoxicillin use during early childhood with developmental tooth enamel defects. arch pediatr adolesc med 2005;159:943-8. 24. kim sy, chang yj, cho hm, et al. non-steroidal anti-inflammatory drugs for the common cold. cochrane database syst rev 2015;2015: cd006362. 25. díaz-lago m, blanco f, matute h. expensive seems better: the price of a non-effective drug modulates its perceived efficacy. cogn research 2023;8:8. 26. burki tk. development of new antibacterial agents: a sense of urgency needed. lancet respir med 2021;9:e54. 27. ramadan am, rikaby oaa, abuhammad oa, et al. knowledge and attitudes towards antibiotic prescribing among dentists in sudan. pesqui bras odontopediatria clín integr 2019;19:e4430. 28. bert f, previti c, calabrese f, et al. antibiotics self medication among children: a systematic review. antibiotics (basel) 2022;11:1583. 29. bi b, qin j, zhang l, et al. systematic review and meta-analysis of factors influencing self-medication in children. inquiry 2023;60:46958023 1159744. 30. ho yl, mahirah d, ho cz, et al. the role of the family in health promotion: a scoping review of models and mechanisms. health promot int 2022;37: daac119. article non -co mmerc ial us e o nly hrev_master [page 50] [healthcare in low-resource settings 2013; 1:e13] barriers to the importation of medical products to russia: in search of solutions sergei v. jargin department of pathology, people’s friendship university of russia, moscow, russia abstract barriers to the importation of foreign medical products to russia contribute to higher prices on the domestic market, which is a disadvantage for healthcare. such barriers, valid also for the import of professional literature, resulted in persistence of some outdated concepts and methods in medicine. policies promoting domestic medical products can result in their biased characterization in scientific reports. in conclusion, more international trust is needed for successful co-operation on the lawful basis and elimination of unfair practices in the interests of healthcare and medical research. introduction some papers1,2 have already discussed the complicated mechanisms of registration, certification and custom clearance of medical products imported to russia. indeed, in order to be sold in russia, a medical product must be registered with the ministry of health. for that purpose, the manufacturer must provide numerous documents translated into russian, certified by a notary or court, and for some countries also by the consular section of a russian embassy. documents and translations, often bearing more than 10 seals on both sides, expire after some time, and the procedures must be repeated. obviously, it is time for the authorities engaged in international economical relations to consider acceptance of documents in english, which is an international language. red-tape and corrupt practices for a medical product to be registered, technical, hygienic, toxicological, clinical and other assessments must be performed in a center for expertise of medical products and other institutions. the person presenting the documents to the authorities must be a russian subject, registered with the official structures. furthermore, custom clearance becomes more intricate with time, thus requiring voluminous paperwork. there is a policy of preference for domestic products, e.g. in the presence of a domestic analogue, a foreign product is not allowed to be presented, although its quality might be higher. furthermore, apart from lawful custom duties, which are relatively high, unofficial payments are taken not only by customs but also by other involved authorities. in some cases, foreign manufacturers are informed about it by mediator firms, though, having no choice but to pay, they become embroiled in corrupt interactions.1,2 there are many additional difficulties making the procedures of registration, certification and custom clearance more intricate. a former custom official and co-director for relation with the customs said from the tribune (at the conference localization of the medical equipment in russia held in moscow on 5 december 2012)(deutsch-russische auslandshan delskammer 2012, unpublished data) that the process of custom clearance is so intricate that it is in any case advisable to hire a custom broker or engage a mediator firm in order to export a medical product to russia. mediator firms offer assistance in registration, certification, and custom clearance of medical products. in return, exclusive distributor’s rights are sometimes requested from the manufacturer. in this way, the mutuality principle of exclusive rights is violated: some mediator firms make use of exclusive distributor’s rights from several manufacturers at the same time. numerous custom brokers and mediator firms are profiting from the artificial barriers to the importation of medical products. unofficial payments are sometimes overtly mentioned in business correspondence. the documents shown in jargin,2 together with other evidence, were forwarded to the ministry of health. as far as we know, no measures have been taken. moreover, the manager of the mediator firm, where the informant had been employed, was informed about his letter to the ministry, which resulted in mobbing and dismissal. this scenario was repeated later in another firm, after the authorities were informed about bribes at the customs. protectionism can be justified under certain conditions in order to protect domestic manufacturers. however, when protectionism is coupled with corruption, it is hardly acceptable from the viewpoint of medical ethics: difficulties and excessive expenditures in the process of import result in price elevation for medical products in the domestic market, thus making them less available for the patients. the policy promoting domestic medical products can include indirect pressure on researchers, resulting in a biased characterization of such products in scientific publications,3-5 which, in turn, are used for official registration of suboptimal products. misleading advertising of medical products and services is widespread and regarded as a norm. some physicians manipulate their patients to make them purchase the medicines they promote. distributing, mediating, brokerage and other firms are proliferating. moreover, invasive procedures without sufficient clinical indications are sometimes applied with the actual purpose of registering a suboptimal domestically-produced medici ne.3 on the occasion of the above-mentioned conference, another speaker answered the question why not to simplify the custom clearance and certification procedures in the interests of patients? with the following: then domestic manufacturers will have no chance (deutsch-russische auslandshandelskammer 2012, unpublished data). at the same conference, the fact of corruption was mentioned several times as if it were a norm. certainly, imported products need to be evaluated before admittance to the domestic market; however, in conditions of corruption and insufficient competence of supervising authorities, placebos and doubtful medications, both domestic and imported ones, are permitted for the clinical use.4,5 there is also the reverse of the medal. fraud is widespread all over the world, and skills are developing not only in the field of fraud itself but also for its adaptation to laws and regulation, so that fraudulent intentions are difficult to prove.6 there is a dichotomy in the intellectual endeavor: some experts improve their professional knowledge in the interests of science and public health, while others develop their fraudulent skills. moreover, considering judicial proficiency of some fraudsters and free time they dispose of, it can be difficult and healthcare in low-resource settings 2013; volume 1:e13 correspondence: sergei v. jargin, department of pathology, people’s friendship university of russia, miklukho-maklaya str. 6, 115184 moscow, russia. tel. +7.495.434.5300 fax: +7.495.433.1511. e-mail: sjargin@mail.ru key words: international trade, russia, medical products. conflict of interests: the author declares no potential conflict of interests. received for publication: 14 december 2012. revision received: 19 february 2013. accepted for publication: 28 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.v. jargin, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e13 doi:10.4081/hls.2013.e13 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e13] [page 51] frustrating to prosecute them in conditions of strict lawfulness. under such circumstances, societal institutions and authorities should dispose of mechanisms to defend public interests from fraudsters, if even the latter act prima facie in accordance with the laws and regulations. paradoxically, some arguments in favor of lawlessness and even corruption are not easy to dismiss: if fraud is invincible on a global scale, there is no point in locally upholding lawfulness for its own sake. therefore, more international trust is needed for a successful co-operation on the strictly lawful basis and the elimination of unfair practices in the interests of healthcare and medical research. import of professional literature and plagiarism another topic that should be mentioned is plagiarism. limited access to foreign professional literature, whose import is also hampered by protectionist barriers, has been one of the causes of plagiarism in the former soviet union (su). in a sense, plagiarism has been a substitute for the import of foreign books. some handbooks issued in russia have been compiled from foreign editions with verbatim translations and no references given to the sources. such editions are often poorly illustrated or not illustrated at all, contain mistranslations causing distortion of the meaning and misleading medical practice and research.7 admittedly, professional editions in the international trade are not always perfect, sometimes apparently being of a rough-andready nature, which seems to have worsened during the last decades. what is obviously needed is a kind of a centralized international mechanism supervising research and publication, ensuring their quality, independence from vested interests, and preventing needless parallelism with repetition of experiments, clinical studies and publications. some physicians in russia purchase foreign literature with their own funds. moreover, books ordered via post or express mail are detained by customs (if the total price is more than 10,000 rubles or about 320 us dollars), and the addressee must go personally to the custom office, pay the vat (30% of the price) and a custom fee, and spend much time in queues. the payment is received in another quite distant office, and the receipt is then accepted (stamped for some purpose) in the third office in another part of moscow. documentary evidence thereof was published in jargin.2 there is no reasonable explanation why fees cannot be collected at the same place. the procedure takes 2-3 working days, but for a doctor living in a remote place it can be more complicated. the procedure is so intricate that a busy doctor is, in effect, forced to hire a broker. at the same time, it impedes the import of professional literature, which is a disadvantage for healthcare. consequences for medical practice protectionism and partial isolation of russian medicine and medical research from the international community has not remained without consequences for the healthcare. obviously, it is one of the causes of the relatively low life expectancy.8 according to my estimates after practicing pathology abroad for more than seven years, an average size of malignant tumors in routine surgical specimens was at least 2-3 times larger in central moscow clinics as compared to provincial hospitals in some west european countries, which means that early detection of malignancies is less efficient in russia. abroad, almost all mastectomy specimens were without muscle. in moscow hospitals, the modified radical mastectomy (patey) with the removal of the pectoralis minor muscle was the standard procedure in the last decades, but the halsted operation with the removal of both major and minor pectoralis muscles was applied as well. the halsted operation prevailed earlier; it was recommended by russian textbooks of surgery and oncology for all types of breast cancer until the late 1990s. it was presented as a key treatment modality for breast cancer even in some handbooks edited after the year 2000.9,10 the shift towards conservation in the treatment of breast cancer in the whole world, including less developed countries, remained largely unnoticed in the former su for a long time. moreover, the negative appendectomy rate is higher in russia than abroad obviously because of persistent outdated concepts of catarrhal, chronic, and non-destructive appendicitis not requiring histopathological evidence of acute inflammation for the diagnosis.11 furthermore, partial gastrectomy was applied for the treatment of duodenal and gastric ulcers abroad much more rarely than in the former su, and its volume was less extensive. the approach to surgical treatment of gastric and duodenal ulcers in the former su deviated from international practice.12,13 use of partial gastrectomy for ulcer treatment has remained disproportionately high in many institutions,14 owing to technical problems, conservatism among surgeons,12 and limited availability of medical therapy.14 in the 1960s, when gastrectomy (removal 2/3–3/4 of the stomach) was almost a single surgical treatment modality for ulcer,15 about 60,000 of such operations were performed yearly in ulcer patients, while significant complications became obvious.13 later, when adequacy of this concept of ulcer treatment was doubted, responsibility for the hyperradicalism in surgery was, in a veiled form, ascribed to the well-known surgeon sergei yudin, who indeed advocated gastrectomy for ulcer treatment, including primary gastrectomy for perforated ulcers.16 one of his arguments was the limited availability of regular medical treatment of ulcer in the 1940s’ su, while gastrectomy promised good chances of cure.17 s. yudin died in 1954; however, instructive publications presenting gastrectomy as a main or single surgical method of ulcer treatment continued to appear long time thereafter.15,18 in a textbook of surgery issued in 1995, the billroth’s operations with removal of 2/3 to 3/4 of the stomach are listed in the first place among the surgical treatment modalities of gastroduodenal ulcers.19 noticeably, a yudin’s paper from the late 1940s, recommending gastrectomy for the treatment of duodenal and gastric ulcers, was reprinted by the main journal of russian surgeons khirurgiia in 1991 without criticism but with approving words in the preface.17 the so-called administrative factor obviously played its role:12 the support of certain methods by healthcare authorities, who sometimes favored less individualized approaches applicable to a large group of patients. this factor obviously contributed also to the high negative appendectomy rate in former su and the persistence of some outdated practices in other fields of medicine, such as the routinely performed diathermocoagulation or cryotherapy of cervical pseudo-erosions (endocervical ectopia or ectropion) regardless of the presence of epithelial dysplasia. administrative decisions were efficiently introduced into practice due to the authoritative management style ingrained in russia. conclusions in conclusion, barriers to the import of medical products, insufficient availability of international literature and the partial isolation of russian medicine from the rest of the world have contributed to the persistence of outdated methods in everyday practice.20 admittedly, scientific and educational institutions can have online access to some editions, but many practical physicians and patients have not, thus being easy victims of misleading advertising. at the same time, limited access to international literature has been compensated by russian editions. for example, a handbook of immunohistochemistry bearing the logo of the international academy of pathology21 contains references to questionable and potentially misleading publications,22-27 some of which were previously criticized.28-30 review non -co mmerc ial us e o nly [page 52] [healthcare in low-resource settings 2013; 1:e13] references 1. jargin sv. barriers to importation of medical products in russia. lancet 2008;372: 1732. 2. jargin sv. barriers to importation of medical products in russia: a comment. dermatopathol pract concept 2010;16:21. 3. jargin sv. surfactant preparations for tuberculosis and other diseases beyond infancy: a letter from russia. tuberculosis 2012;92:280-2. 4. jargin sv. discussion of evaluation of cholesterol-lowering and antioxidant properties of sugar cane policosanols in hamsters and humans. appl physiol nutr me 2009;34:75-7. 5. jargin sv. testing of serum atherogenicity in cell cultures: questionable data published. ger med sci 2012;10:doc02. 6. jargin sv. use of mathematical statistics for quality control of surface lapping and detection of fraud: a case study. journal of tribology and surface engineering 2012; 3:109-17. 7. jargin sv. plagiarism in radiology: a substitute for importation of foreign handbooks. j med imag radiat on 2010;54:50-2. 8. jargin sv. health care and life expectancy: a letter from russia. public health 2013;127:189-90. 9. kovanov vv, perelman mi. operations on the chest and thoracic organs. in: kovanov vv, ed. operative surgery and topographic anatomy. moscow, russia: meditsina; 2001. pp 297-321. 10. semiglazov vv, topuzov ee. breast cancer. moscow, russia: medpress-inform; 2009. 11. jargin sv. unnecessary operations: a letter from russian pathologist. int j surg 2010;8:409-10. 12. balalykin da. [introduction of pathogenic principles of surgical treatment of ulcer disease in russian surgery]. [article in russian]. khirurgiia (mosk) 2004;10:73-8. 13. balalykin da. history of surgical treatment of gastric and duodenal ulcers in russia. khirurgiia (mosk) 2001;3:64-6. 14. lobankov vm. surgery of ulcer disease on the boundary of xxi century. khirurgiia (mosk) 2005;1:58-64. 15. makarenko tp. is it necessary to improve the classical method of gastric resection in peptic ulcer? sov meditsina 1973;36:46-50. 16. petrovsky bv. about sergei sergeiievich yudin. in: yudin ss, ed. selected works. moscow, russia: meditsina; 1991. pp 35675. 17. iudin ss. essays on gastric surgery. khirurgiia (mosk) 1991;7:159-66. 18. korolev mp. [the surgical treatment of duodenal peptic ulcer. (materials from the discussion of the problem at the 8th allrussian congress of surgeons, krasnodar, 21-23 september 1995)]. [article in russian]. vestn khir im grekov 1996;1:96100. 19. kuzin mi, chistova ma. the stomach and duodenum. in: kuzin ma, ed. surgical diseases. moscow, russia: meditsina; 1991. pp 337-407. 20. jargin sv. limited access to the international medical literature in russia. wien med wochenschr 2012;162:272-5. 21. petrov sv, raikhlin nt, eds. manual on immunohistochemical diagnosis of human tumors. 4th ed. kazan, russia: titul; 2012. 22. kogan ea, ugriumov da. correlation between proliferative processes and cell death in non-small cell lung cancer with glandular differentiation at different stages of tumor progression. ark patol 2002;64:33-6. 23. kogan ea, mazurenko nn, iushkov pv, et al. the immunohistochemistry of cellular oncogenes in precancer and cancer of the lung. ark patol 1990;52:3-11. 24. paltsev ma, kogan ea, tuntsova oi. immunohistochemistry of biomolecular markers of early thyroid cancer. ark patol 1997;59:18-23. 25. pal’tsev ma, kogan ea, tuntsova oi, et al. morphologic and molecular-genetic characteristics of carcinoma, adenoma and surrounding tissue of the thyroid gland. ark patol 1998;60:5-10. 26. kogan ea, sagindikova gs, sekamova sm, jack g. morphological, cytogenetic and molecular biological characteristics of lung cancer in persons exposed for a long time to radionuclide radiation pollution in the semipalatinsk region of kazakhstan. ark patol 2002;64:13-8. 27. vozianov af, romanenko am, saidakova na, et al. [ecological pathomorphosis of renal cell carcinoma in the inhabitants of radiocontaminated regions of ukraine]. [article in russian]. journal of the academy of medical sciences of ukraine 2002;8:120-31. 28. jargin sv. over-estimation of radiationinduced malignancy after the chernobyl accident. virchows arch 2007;451:105-6. 29. jargin sv. overestimation of chernobyl consequences: biophysical aspects. radiat environ bioph 2009;48:341-4. 30. jargin sv. pathology in the former soviet union: scientific misconduct and related phenomena. dermatol pract concept 2011;1:16. review non -co mmerc ial us e o nly hrev_master [page 66] [healthcare in low-resource settings 2023; 11:11527] clinical manifestation and microbial profiling of recurrent mdr microorganisms associated with head and neck infectiona retrospective study smarita lenka,1 debasmita dubey,2 shakti rath,3 somadatta das,4 santosh kumar swain5 1department of otorhinolaryngology, ims & sum hospital, siksha o anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 2department of medical research, ims and sum hospital, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 3central research laboratory, institute of dental sciences, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 4central research laboratory, ims and sum hospital, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha; 5department of otorhinolaryngology, all india institute of medical sciences, bhubaneswar, odisha, india abstract head and neck infection (hni) can lead to life-threatening complications, including death. the purpose of this study is to look at the entire clinico-demographic profile of patients with hni as well as the microbiologic profile of recurring bacterial infection cases with a variety of symptoms. a retrospective cross-sectional study was conducted on 1080 hni patients in a tertiary care hospital in bhubaneswar, odisha, india, from january 2018 to december 2022. of the 1080 cases, 771 (71.39%) were males, 309 (28.61%) were females, and 603 (55.83%) were from rural areas reporting to a tertiary care hospital. 62% of the cases were between the ages of 31 and 60. neck abscesses account for 570 (52.78%) of all cases, with parotid abscesses accounting for 233 (21.57%), peritonsillar abscesses accounting for 170 (15.74%), otitis media 32 (2.96%), and oral cavity infection accounting for 26 (2.41%). in 854 (79.07%) cases, the etiology was odontogenic, followed by sinus in 188 (17.41%) and otogenic in 38 (3.52%). the most common presenting features were neck swelling in 537 (49.72%) cases and face swelling in 238 (22.04%) cases, followed by jaw pain in 26 (2.41%) cases and others. patients were hospitalized for an average of 11.82±4.38 days. treatment and recurrence had a strong significant relationship (p 0.001). microbiologic investigation of recurrent patients revealed 12 microorganisms, including bacteria and fungus, mainly multidrug-resistant in given ascending order staphylococcus aureus (26.74%), klebsiella pneumoniae, pseudomonas aeruginosa, acinetobacter baumannii, escherichia coli, candida albicans (4.65%), aspergillus fumigatus, a. flavus, a. niger, c. tropicalis, c. glabrata, c. krusei. apart from colistin, almost all antibiotics were highly resistant to gramnegative bacteria, whereas against s. aureus, benzylpenicillin, and oxacillin showed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%), and ciprofloxacin (82.61%). this exploratory study would aid in determining the hni burden and epidemiology, as well as their treatment status. introduction head and neck infections (hni) commonly arise through the odontogenic, oral, or otological region and come up with various complications.1-3 the treatment procedure is developing, but the infection rate is also increasing instead of its downfall. it may be initiated by poor hygienic habits, smoking, alcohol consumption, or environmental factors like polluted air and water.4 different studies have shown the mirror of these factors to society, but there have yet to be successful mass effects. infections involving the sites are initially much more complicated to diagnose as their anatomical construction is a little complex. patients of all ages, particularly children and young adults, frequently have facial and cervical infectious processes, which pose a clinical concern. a complication of infection increases when it spreads beyond the primary site of origin, like the oral cavity, odontogenic region, rhinitis, or otitis media, where the infection is only at cellulitis or abscess formation adjacent to the sites of infection.5,6 infection symptoms and signs are clinically apparent in the head and neck, allowing for a presumptive diagnosis. the most frequent cause in children and young people is a tonsillar infection, but the most frequent cause in older is an odontogenic infection. the other potential head and neck infection sources are salivary glands, nasal sinuses, middle ear, mastoids, cervical lymph nodes, and trauma.7 head and neck infections are becoming more common and have significant death rates and consequences. it can migrate from the skull base to the mediastinum and affect the other spaces. nevertheless, it is clinically difficult to identify the implications, such as acute air healthcare in low-resource settings 2023; volume 11:11527 correspondence: shakti rath, central research laboratory, institute of dental sciences, siksha ‘o’ anusandhan deemed to be university, kalinga nagar, bhubaneswar, odisha, india. e-mail: dr.shaktirath@gmail.com key words:head and neck infection; manifestation; recurrence, multi-drug resistance. contributions: all authors made substantial contributions to the conception and design, acquisition of data, or analysis and interpretation of data; took part in drafting the article or revising it critically for important intellectual content; agreed to submit to the current journal; gave final approval of the version to be published; and agreed to be accountable for all aspects of the work. all the authors are eligible to be an author as per the international committee of medical journal editors (icmje) requirements/guidelines. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: appropriate ethical clearance has been obtained from the institute ethical committee, ims, and sum hospital, siksha o anusandhan (deemed to be) university, bhubaneswar, odisha, india. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: accepted for publication: this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11527 doi:10.4081/hls.2023.11527 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly way obstruction and mastoids, cervical lymph nodes, and trauma.8-11 patients with diabetes, compromised immune systems, and advanced age are more susceptible to complex head and neck infections.4 according to a study conducted in the us, 11% adult population is diagnosed with sinusitis, and 2.1% of the population accounts for sore throat, which is an early sign of a significant head and neck infection.12 particularly in diabetic individuals, it has been demonstrated that there is a higher risk of suppuration, multi-space infections, and the requirement for numerous surgical treatments. refusing to have head and neck abscesses surgically treated sooner increases the risk of complications and lengthens hospital stays.5,13 in these populations, for the prompt identification of clinical problems, better analysis of epidemiology, and to fix problems regarding treatment failure, there should be analytical, clinical profiling of recent year visiting patients for a new step towards better treatment. various analyses were done worldwide to estimate the overall clinical profiling of head and neck infections. still, in some regions, it needs to be addressed by people underestimating the severity beyond the infection or sometimes by self-medications which may increase infected cases and recurrence and tend to mild to moderate and then severe.15 moreover, most infectious diseases re-occurred due to the multidrug resistance activity of associated microorganisms.16-18 in this case, the infection can be controlled only through region-specific epidemiology of pathogen identification and their drug susceptibility pattern for early diagnosis and therapeutic purposes. literature regarding individual head and neck infection sites is readily available as most studies aim to solve it independently concerning their expertise area. but this retrospective study covers almost all clinical profiles and other necessary information of patients suffering from any sites of hni attending the department of otorhinolaryngology, ims & sum hospital, bhubaneswar, odisha, india. materials and methods study subjects this hospital-based retrospective study was conducted with all age groups of head and neck infection patients who attended both the out-patient department (opd) and in-patients department (ipd) of otorhinolaryngology (ent) in this hospital from january 2018 to august 2022. patients only suspected of infection were included and associated with thyroid gland cysts, infection due to external cervical injury (traumatic or surgical), neoplastic pathology, tumor-associated cases, and clinical cases with insufficient information were excluded from this study. patients were categorized into four groups that were compared: pediatric (aged 1-14 years), young (aged 15-30 years), adult (aged 31-60 years), and seniors (aged 61 years above). a comparison of data from patients with different sites of infection and their associated factors was performed. sample collection and processing using stuart’s transport medium, swab samples were collected and transported from recurrent patients from infection sites. they were cultured using blood agar for bacterial growth and sabouraud dextrose agar for growing fungus. the culture was subjected to vitek 2 for accurately identifying and analyzing antibiotics’ minimum inhibitory concentration (mic) against individual microorganisms. statistical analysis the collected data were analyzed using the statistical package for the social sciences (spss, version 29.0.0.0). comparisons between groups of categorical variables were made using the chi-square test, and a multiple linear regression model was performed using graph pad prism 9 to predict or analyze other variables like sites of infection and annual distribution. the significance p value <0.05 was considered statistically significant. results demographic details of patients according to their clinical manifestation, 1080 head and neck infection patients were selected during the five years of the study period. out of the total head and neck infection registered patients, 771 (71.39%) were male, and 309 (28.61%) were female in a ratio of (247:301), where males predominated in all infected age groups. out of 1080 cases, 28 (2.59%) patients belonged to the pediatrics age group, 275 (25.46%) to the young age group, 674 (62.41%) to the adult age group, and 103 (9.54%) of senior citizens (figure 1) and the mean ±sd of all age group of patients are 41.18±15.04 (table 1). yearly, seasonal, and regional information the highest peak of head and neck infection patients was throughout the study period 309 (28.61%) in 2021 (figure 2). the distribution of patients with head and neck infection revealed seasonal variation: article figure 1. age distribution of patients. table 1. demographic, social status of patients suffering from head and neck infection. demographic social status gender number percentage mean±sd male 771 71.39 female 309 28.61 age pediatric (1-14) 28 2.59 6.64±4.75 young (15-30) 275 25.46 24.57±3.77 adult (31-60) 674 62.41 45.39±8.18 seniors (> 61) 103 9.54 67.15±6.15 locality urban 477 44.17 rural 603 55.83 figure 2. yearly distribution of patients diagnosed with head and neck infection. [healthcare in low-resource settings 2023; 11:11527] [page 67] non -co mmerc ial us e o nly 395 (36.57%) during summer > 303 (28.06%) during rainy > 277 (25.65%) in spring > and 105 (9.72 %) in winter (table 2). there 603 (55.74%) hni patients enrolled were from rural areas, and 477 (44.17%) were from the urban population of patients (table 3). detail evidence on sites and origins of infection for easier infection distribution, infection locations associated with hni were divided into compartments such as the ear, nasal, neck, and oral. but individual sites of infection were analyzed individually from the complete data set. neck abscess was the most prevalently diagnosed with 570 (52.78%) patients, followed by parotid abscess 233 (21.57%) and peritonsillar abscess 170 (15.74%). the location of hni varied among the different age groups. neck abscesses occurred in all age groups, but the average group of age mean±sd (41.38±14.71) suffered from neck abscesses which are near to the mean±sd of the overall age group 41.18±15.04. therefore, neck abscess was diagnosed higher times than other infection sites in all age groups (table 4). the predisposing cause of hni was determined that otological infection 38 (3.52%), sinus infection 188 (17.41%), and odontogenic infection 854 (79.07%) were the origin of initiation, where the odontogenic infection was the highest cause of origination of hni that includes dental infections and oropharyngeal infection as well (table 4). clinical manifestation, including all symptoms of hni, indicated infection at which the diagnosis process started. face swelling, ear pain, headache, jaw pain, neck pain, sore mouth, swollen neck, and throat pain were the common clinical characteristics with all populations where most of the patients were highly symptomatic with swollen neck 537 (49.72%), followed by face swelling 238 (22.04%) and throat pain 180 (16.67%) (table 3). in the sites of article table 3. clinical manifestation in accordance with internal and external symptoms. clinical manifestation number percentage internal symptoms airway blockage 2 0.19 fever 3 0.28 jaw pain 26 2.41 external jaw swelling 1 0.09 sore throat 4 0.37 throat pain 180 16.67 ear pain 32 2.96 headache 8 0.74 neck pain 29 2.69 external symptoms face swelling 238 22.04 jaw swelling 1 0.09 sore mouth 19 1.76 swollen neck 537 49.72 swollen throat 1 0.09 table 4. origin, complications, and diagnosis of infections. origin of infection number percentage otological infection 38 3.52 odontogenic infection 854 79.07 sinus infection 188 17.41 complication biofilm formation 276 25.56 mold formation 38 3.52 pus deposit 766 70.93 diagnosis number percentage hypopharyngeal abscess 2 0.19 laryngitis 4 0.37 neck abscess 570 52.78 oral cavity infection 26 2.41 otitis media 32 2.96 parapharyngeal abscess 1 0.09 parotid abscess 233 21.57 parotid gland infection 8 0.74 peritonsillar abscess 170 15.74 retropharyngeal abscess 6 0.56 sinusitis 10 0.93 submandibular gland infection 18 1.67 figure 3. frequency of microorganisms isolated from recurrence patients. table 2. seasonal and monthly distribution of patients. seasonal distribution monthly distribution number percentage spring jan 59 5.46 feb 77 7.13 mar 141 13.06 277 25.65 summer april 135 12.50 may 120 11.11 jun 140 12.96 395 36.57 rainy july 162 15.00 aug 97 8.98 sep 44 4.07 303 28.06 winter oct 40 3.70 nov 38 3.52 dec 27 2.50 105 9.72 [page 68] [healthcare in low-resource settings 2023; 11:11527] non -co mmerc ial us e o nly infection, complications like biofilm formation were 276 (25.56%), mold formation was 38 (3.52%), and pus deposit was 766 (70.93%; table 4). rate of severity, implementation of treatment, and recurrence the majority of populations, 695 (64.35%), had a moderate rate of infection in the same way 311 (28.80%) were a mild rate, and 74 (6.85%) had a severe rate of infection. hospitalization was needed by 650 (60.19%) patients having a severe and moderate rate of infections, and 430 (39.81%) were not hospitalized as some of them were treated with minor surgery, 142 (13.15%) and empirical antibiotic therapy 297 (27.50%). nearly all patients who underwent surgical drainage (59.35%) were hospitalized for a mean±sd, 14.03±3.23 period. recurrent hni was observed in 86 (7.96%) patients, 5 in the pediatric group, 19 in the young age group, 53 in the adult group, and 8 in the old age (senior) group (table 5). patients who underwent surgical treatment had a more significant number of days of hospitalization compared to minor surgery and those who were implicated by empirical antibiotics. there was a significant association (p<0.001) between sites of infection (compartments) and all treatment procedures. 7.96% of recurrences were noted after completion of treatment, whereas 6.11% of recurrences were patients with treated empirical antibiotics, and there was also a significant association (p<0.001) between treatment and recurrence. however, no significant difference in gender (p=0.5), local status (p=0.8), and age group (p=0.2) with recurrence. among 86 (7.96%) recurrence patients, 66 (6.11%) patients were implemented with empirical therapy, and 20 (1.85%) patients went through surgical drainage (both minor and major surgery). the microbiological investigation (through vitek 2) of recurrent patients revealed 12 different types of microorganisms (figure 3), including bacteria and fungus, and according to their drug susceptibility pattern, almost all antibiotics are resistant to most patients. article table 5. treatment and management details of hni patients. treatment and management number percentage procedure surgical drainage 641 59.35 minor surgery 142 13.15 empirical antibiotic 297 27.50 severity mild 311 28.80 moderate 695 64.35 severe 74 6.85 hospital stay yes 650 60.19 no 430 39.81 recurrence yes 86 7.96 no 994 92.04 observation period (1-5) 149 13.80 (5-10) 265 24.54 (11-15) 509 47.13 (16-20) 142 13.15 (21-25) 14 1.30 (26-30) 1 0.09 [healthcare in low-resource settings 2023; 11:11527] [page 69] table 6. details of all organisms isolated with antibiotic susceptibility pattern. sl.no. name of organisms frequency (n) percentage resistance to antibiotics/antifungals drugs in percentage 1 staphylococcus aureus 23 26.74 ben-pen -100; ox -100; gen -26.09; cip -82.61; le -86.96; e -91.3; cd -60.87; lz -17.39; dap -17.39; tei -13.04; va -4.35; te 21.74; tgc -0; nit -0; rif -21.74; tmp -65.22 2 klebsiella pneumoniae 20 23.26 amp -nd; amx -nd; ti -100; pi -100; cef -100; cefax -nd; cis -100; cfs -nd; cpm -100; etp –nd; imp -60; mrp -100; ak -85; gen -60; na -nd; cip –95; tgc -85; nit -nd; cl-20; tmp-90 3 pseudomonas aeruginosa 13 15.12 amp -nd; amx -nd; ti -100; pi -92.3; cef -100; cefax -nd; cis -92.3; cfs -nd; cpm -84.61; etp –nd; imp -92.3; mrp -92.3; ak -84.61; g en -84.61; na -nd; cip –84.61; tgc -100; nit -nd; cl-30.76; tmp-nd 4 acinetobacter baumannii 10 11.63 amp -nd; amx -nd; ti -100; pi -100; cef -100; cefax -nd; cis -100; cfs -nd; cpm -100; etp –nd; imp -100; mrp -100; ak -90; gen -100; na -nd; cip –100; tgc -0; nit -nd; cl-10; tmp-80 5 escherichia coli 8 9.30 amp -100; amx-100; ti -100; pi-100; cef-100; cefax -100; cis-100; cfs -100; cpm -100; etp – 100; imp-100; mrp-100; ak-100; gen-100; na-100; cip – 100; tgc -12.5; nit -37.5; cl-50; tr-75 6 candida albicans 4 4.65 kt -75; it100; flc-75; amp75; cot-100; mic100; ns-50 7 candida tropicalis 2 2.33 kt -100; it100; flc-100; amp100; cot-100; mic100; ns-100 8 candida glabrata 2 2.33 kt -100; it100; flc-0; amp100; cot-100; mic100; ns-100 9 candida krusei 1 1.16 kt -100; it100; flc-100; amp0; cot-0; mic100; ns-100 10 aspergillus fumigatus 1 1.16 kt -100; it100; flc-0; amp50; cot-100; mic100; ns-100 11 aspergillus flavus 1 1.16 kt -50; it100; flc-100; amp-100; cot-100; mic100; ns-100 12 aspergillus niger 1 1.16 kt -100; it100; flc0; amp-0 cot100; mic100; ns-100 antibiotics used: ak, amikacin, amp, ampicillin, amx, amoxicillin, ben-pbenzylpenicillin, cd, clindamycin, cef, cefuroxime, cef-ax, cefuroxime axetil, cfs, cefoperazone, cip, ciprofloxacin, cis, ceftriaxone, cl, colistin, cpm, cefepime, dap, daptomycin, e, erythromycin, etp, ertapenem, gen, gentamicin, imp, imipenem, le, levofloxacin, lz, linezolid, mrp, meropenem, na, nalidixic acid, nit, nitrofurantoin, ox, oxacillin, pi, piperacillin, rif, rifampicin, te, tetracycline, tei, teicoplanin, tgc, tigecycline, ti, ticarcillin, tmp, trimethoprim, va, vancomycin. antifungals used: amp, amphotericin b, cot, clotrimazole, flc, fluconazole, it, itraconazole, kt, ketoconazole, mic, miconazole, ns, nystatin. non -co mmerc ial us e o nly [page 70] [healthcare in low-resource settings 2023; 11:11527] investigation of microbial specimens collected from recurrent patients investigation of microbiologic specimens through the vitek 2 identification procedure gives five different genera and species of bacteria. only s. aureus was gram-positive, and the rest 4 were gramnegative. but the prevalence of s. aureus (n=23) was higher than other bacterial and fungal isolates (table 6). the prevalence of bacterial isolates was high compared to fungal isolates. only 12 (n=12) cases were identified with fungal cultures, which include candida spp.(n=7) and aspergillus spp. (n=5) (figure 3). a maximum number of antimicrobial agents were resistant to their respective bacteria/fungi. apart from colistin, almost all antibiotics were highly resistant against gram-negative bacteria, whereas in the case of s. aureus, benzylpenicillin, and oxacillin revealed 100% resistance, followed by erythromycin (91.3%), levofloxacin (86.96%) and ciprofloxacin (82.61%) (table 6). among 12 fungal isolates, there were 4 (n) c. albicans, and the rest of 3 (n) candida spp. were identified with single species such as c. tropicalis (n=1), c. glabrata (n=1), c. krusei (n=1). there were 5 (n) aspergillus spp. including a. fumigatus (n=2), a.flavus (n=2) and a. niger(n=1). all fungal isolates were resistant to most of the antifungals (ketoconazole, itraconazole) rather than some of the antifungals like fluconazole and amphotericin b were intermediate against two isolates of a. fumigatus, and one isolate of a. niger (table 6). discussion head and neck infections are an uncommon but severe problem in all age groups. although intravenous antimicrobial therapy might help reducing the incidence of primary and secondary hnis, life-threatening complications may arise if not diagnosed or treated promptly. at an early stage, it may have very subtle signs and symptoms, which demand a high index of suspicion and specific diagnostic examination, which may reduce the severity and significant complications. around 57% of the cases in the age group of 11 to 40 years were reported with hni by dudhe p et al., 2022,19 whereas a mean±sd of age 41.18±15.04 was reported in our closely relevant study. distribution of patients according to seasonal variation revealed a higher number in summer, but this can be different in a different climate. no significant differences were found in demographic distributions on the hni of our study with other studies. unlike our study, there was a high prevalence of male patients (55.26%) compared to females (44.74%) and primarily admitted from a rural background.20 it is reasonable that hnis may predominate in specific anatomic spaces according to the initiation of infection. as such, studies21,22 showed that odontogenic and otogenic etiological factors are responsible for spreading hni, and pain and swelling were the most common presenting features, followed by fever. this may not be the proportion in the present study, but the association was valid in all clinical presentations. previously reported that retropharyngeal infection and peritonsillar abscesses are frequently diagnosed in children and the young.23,24 due to potentially life-threatening complications, hospitalization is advised for patients at a severe stage. the duration of treatment should be individualized depending on the clinical response, like pus deposition, biofilm formation, or mold formation. empirical broad-spectrum antibiotic treatment should be started immediately to prevent the infection, and microbial diagnosis takes 24 to 72 hours, depending on the availability of the nearest laboratories. still, some cases might not respond as they would be at their moderate to severe stage of infection and need surgical drainage. it was supported by boscolorizzo et al., 201210 that only 61.9% of their patients responded to intravenous antimicrobial therapy, and 38.1% were gone for surgical drainage. here, 59.35% of our registered patients were treated with surgical drainage, which was closely relevant to the previous study. however, 27.50 % were treated with antimicrobial therapy, which needs to be considered as a future problem of the resistance mechanism of intravenous antimicrobials. following carbone et al., 2012,25 we found that those cases who underwent surgery had a greater length of hospitalization than those who did only medical treatment. along with clinico-demographic profiling, close follow-up is mandatory as some patients often show recurrence, which would be challenging for recent treatment procedures. in this study, 7.96% of recurrences occurred, and most of the patients treated with empirical antibiotics were under them, and there was found a significance (p<0.001) between treatment and recurrence. multiple infection sites have been previously associated with complicated clinical courses and to stated significant multiple space involvement (p<0.001).7 however, there was no statistically significant association between gender (p=0.5), local status (p=0.8), and age group (p=0.2) with recurrence to treatment. but, for those prescribed only antibiotics and those who underwent surgery concerning sites of infection, there was a significant association (p<0.001). unlike all spaces, brain abscess or infection also is part of hni,26 but no cases were found in the duration of this study regarding this. the previously reported mortality rate of hni was 0.3%,10 which was not recorded in our study. according to the present evaluation, the incidence of recurrence was n=86 (7.96%) among 1080 attended cases during the five years of retrospective study, which was undoubtedly an increasing point of recurrence compared to past studies.27-29 the disease and syndromes associated with the respective infection remain the same with the recurrency and their clinical, pathologic, and microbiologic features.30 in the present study, recurrent patients’ complications were more severe than in their last visit. according to yu et al., s. aureus has a prominent genetic cause of biofilm formation, contributing to virulence and immune evasion,31 and our study got the highest number of recurrent patients identified with s. aureus (table 6). almost all antibiotics and antifungals were resistant to all bacterial and fungal isolates. moreover, s. aureus, with the highest prevalence among recurrent patients, was 100% oxacillin-resistant, and methicillin/oxacillin-resistant s. aureus is a significant pathogen resulting in hospital-acquired infection.32-35 in this study, the antibiotic susceptibility pattern was analyzed through mic (minimum inhibitory concentration) of the vitek 2 system, as mic can report the breakpoint of antibiotic therapy. however, empirical therapy can only eradicate the infection in the initial stage of colonization with the patient’s immune response. despite their importance, the early recognition of infection still represents an unmet need in clinical microbiology. the present study was based entirely on patients’ clinico-demographic profile, and it seems worth underlining that the more severe the complication, the more difficult it may become to treat, but some exceptional cases needed to be considered either for their long-term hospitalization, delay in treatment, or recurrence. conclusions the present study exhibited that diagnosing and treating hni can sometimes be complicated and confusing. moreover, treating such infections has become an uphill task with the advent of mdr microorganisms. however, successful results can be achieved without significant complications if the infections are diag article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11527] [page 71] nosed sooner. it is evident from the study that the location and duration of infection vary in different age groups according to their immune response. minute symptoms like toothache and neck pain admission can be identified as possible predictors of complications. there should be a quick attempt at treatment in all age groups who present only fever, or oral or neck mass, even without more specific findings. intravenous antimicrobial treatment is still one of the most helpful treatment procedures. still, a quick step with microbial identification with their susceptibility pattern towards isolated microbes is a better way to combat drug resistance and failure of drug therapy. epidemiology of hni by their demographic and clinical history is essential to look forward to a bright step of diagnosis and treatment, supporting future research to eradicate any gap. references 1. duarte mj, ket al reinshagen k, knoll rm, abdullah kg, welling db, jung dh. otogenic brain abscesses a systematic review. laryngoscope investigative otolaryngol 2018;3:198208. 2. brożek-mądryz e, waniewskałęczycka m, robert b, krzeski a. head, and neck abscesses in complicated acute otitis media-pathways and classification. otolaryngol (sunnyvale) 2018;8:2. 3. pucci r, cassoni a, di carlo d, et al. odontogenic-related head, and neck infections: from abscess to mediastinitis: our experience, limits, and perspectives—a 5-year survey. int j environ res public health 2023;20: 3469. 4. fan x, peters ba, jacobs ej, et al. drinking alcohol is associated with variation in the human oral microbiome in a large study of 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oxacillin resistance in stealth methicillin-resistant staphylococcus aureus due to meca sequence instability. antimicrob agents chemother 2019;63:e00558-19. 33. kampf g, adena s, rüden h, weist k. inducibility and potential role of mecagene-positive oxacillin-susceptible staphylococcus aureus from colonized healthcare workers as a source for nosocomial infections. j hosp inf 2013;54: 124-9. 34. penn c, moddrell c, tickler ia, henthorne ma, kehrli m, goering rvet al. wound infections caused by inducible methicillin-resistant staphylococcus aureus strains. j glob antimicrob resist 2013;1:79-83. 35. bearman gm, rosato ae, assanasen s, et al. nasal carriage of inducible dormant and community-associated methicillin-resistant staphylococcus aureus in an ambulatory population of predominantly university students. int j infect dis 2010;14:e18-24.h article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11323 value of biochemical markers in predicting outcome of covid-19 infection in university hospital, alexandria, egypt neveen rashad mostafa,1 abeer ahmed mohamed ali,2 rehab moustafa ezzat,3 mostafa kamel bakry,4 roy rillera marzo5,6 1department of internal medicine; 2department of chemical pathology, medical research institute, alexandria university; 3department of pulmonology, alexandria student university hospital, alexandria university; 4department of ent, alexandria student university hospital, alexandria university, egypt; 5department of community medicine, international medical school, management and science university, shah alam; 6global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract this paper aims to examine the value of different biochemical markers in predicting the outcome of covid-19 infection. a total of 140 patients with confirmed covid-19 infection by polymerase chain reaction (pcr), different biochemical markers were tested, their relation to the outcome of the disease was monitored, and the most reliable tests were determined. the study found a significant correlation between all evaluated biochemical markers and severity of the disease, including c-reactive protein (crp), d-dimer, alanine aminotransferase (alt), aspartate aminotransferase (ast), prothrombin time (pt), activated partial thromboplastin time (aptt). in addition, ferritin, lactate dehydrogenase (ldh), procalcitonin (pct) and probrain natriuretic peptide (probnp) demonstrated highly sensitivity and specificity as well as significant prognostic performance. these markers were also independently significant in predicting mortality. early assessment of biochemical markers in patients with covid-19 can help clinicians in tailoring treatment and providing more intensive care to those with greater mortality risk. in particular, the assessment of ferritin, ldh, procalcitonin and probnp can independently predict mortality. introduction in late 2019, an outbreak of atypical pneumonia cases emerged in wuhan, hubei province, china, and sars-cov2 was identified as the causative organism. this atypical pneumonia was called corona virus disease 2019 (covid-19), with the primary target of the virus being the lung, although it can infect other organs that express angiotensin converting enzyme 2 receptors (ace2).1 sars-cov-2 is a single stranded rna virus, belonging to coronaviridae family, and has a characteristic corona when viewed under and electron microscope due to its spike like surface glycoproteins, which attach to target cell receptors in the host.1 the world health organization (who) has classified covid-19 patients into four categories: ordinary, mild, severe and critically ill types. patient may progress from one category to another within 7-10 days, particularly if the virus replicates rapidly and causes a cytokine storm.2 clinical presentation of covid-19 includes fever, cough, muscle pain and fatigue, with the patient may also show additional symptoms such as olfactory and gustatory dysfunction. progression to severe disease may be affected by comorbidities of the patient such as diabetes mellitus, dyslipidemia, pulmonary disease, and cardiovascular disorders; therefore, good history taking correspondence: neveen rashad mostafa, associate professodepartment of internal medicine, medical research institute, alexandria university, egypt. tel.: +20.01557709789. e-mail: doctor.aj.2000@gmail.com key wards: biochemical markers; covid-19; cytokines; mortality. contributions: nrm, conceptualize the idea, writing and editing the article; aa, running laboratory blood tests; rme, data collection and recruitment of cases; mb, data collection and recruitment and follow-up of cases. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethics committee of medical research institute approved this study (e/c.s/n.r2/2023). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 18 march 2023. accepted for publication: 2 may 2023. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):11323 doi:10.4081/hls.2023.11323 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s2):11323] [page 1] non -co mmerc ial us e o nly is mandatory in those patients.3 a hyper-inflammatory state has been identified during covid-19 infection, and several biochemical markers can differentiate between severe and non-severe outcomes. these markers can also predict the likelihood of complications and the course of disease, thus helping in clinical decisionmaking.4 to ensure early and effective management of the disease, various biochemical markers have been used to predict the course of the covid-19, differentiate between severe and non-severe cases, and determine the need for more advanced care.5 recent research has focused on identifying the most specific biochemical markers that are implicated in evolution of the disease. materials and methods this prospective cohort study was conducted on patients admitted to alexandria student university hospital, egypt from june 2021 to december 2021. the study was approved by the ethics committee of alexandria student university hospital in egypt and was carried in accordance with the helsinki declaration. written informed consent was obtained from all the participants. inclusion criteria a total of 140 adult patients with confirmed covid-19 infection by pcr throat swab testing6 were enrolled in the study. exclusion criteria bacterial pneumonia, bacterial sepsis, asymptomatic patients who tested positive for the infection but did not exhibit symptoms consistent with covid-19. clinical data included: i) demographic data: age and gender; ii) clinical data: time passed from the onset of symptoms till arriving to the hospital, clinical symptoms including cough, fever, headache, muscle aches, vomiting or diarrhea, with or without respiratory symptoms; iii) past medical history including any cardiac, renal, hepatic, or thyroid diseases, and presence of diabetes mellitus, hypertension or any autoimmune diseases. biochemical markers:7 i) routine blood tests were done including cbc, renal function, liver function tests, and electrolytes; ii) inflammatory markers including crp, ferritin, ldh, and procalcitonin; iii) coagulation markers including d-dimer, pt, aptt; iv) cardiovascular markers including pro-bnp. definition of clinical outcome in this study, clinical outcome was defined as discharge of the patient after recovery or death. discharge was considered when the patient was free of symptoms and had no fever for at least 3 days, and had two consecutive negative pcr test results.8 statistical analysis of the data data were entered into ibm spss software package version 20.0. (armonk, ny: ibm corp) and analyzed using appropriate statistical tests. categorical data were presented as numbers and percentages. chi-square test was applied to investigate the association between the categorical variables. alternatively, fisher exact correction test was applied when more than 20% of the cells have expected count less than 5. for continuous data, they were tested for normality by the kolmogorovsmirnov test and shapiro-wilk test. quantitative data were expressed mean, standard deviation, median and range (minimum and maximum). for normally distributed quantitative variables student t-test was used to compare two groups. on the other hand for not normally distributed quantitative variables mann whitney test was used to compare two groups. logistic regression was used to detect the most independent factor for affecting deceased patients. the obtained results were judged at the 5% level of significance. results according to the inclusion/exclusion criteria mentioned earlier, a total of 140 patients with confirmed covid-19 infection were involved in the study, out of these patients, 100 patients were discharged and 40 patients passed away. the mean age patients with covid019 was 65.2±15.3 years. the mean age of the discharged patients was 63.5±15.3 years, whereas the mean age of the deceased patients was 69.7±14.8 years. the age of the deceased patients was significantly higher than that of the discharged patients, p=0.031(table 1). male patients infected with covid-19 were 86 (61.4%) of the study sample, the discharged males were 57 (57.0%) patients, and the deceased males were 29 (72.5%) patients. females infected with covid-19 were 54 (38.6%) patients of the study sample, the discharged females were 43 (43.0%) patients, and the deceased females were 11 (27.5%) patients, no significant effect of gender on mortality in covid-19 infection, p=0.089. article table 1. comparison between the two studied groups according to demographic data and co-morbidity. total n=140 (%) discharged n=100 (%) deceased n=40 (%) test of sig. p age (years) mean±sd. 65.2±15.3 63.5±15.3 69.7±14.8 t= 2.179* 0.031* median (min.–max.) 65 (30–98) 64 (30–91) 73 (36–98) gender male 86 (61.4) 57 (57.0) 29 (72.5) χχ2= 2.897 0.089 female 54 (38.6) 43 (43.0) 11 (27.5) dm 63 (45.0) 44 (44.0) 19 (47.5) χ2=0.141 0.707 dyslipidemia 48 (34.3) 33 (33) 15 (37.5) χ2=0.257 0.612 htn 55 (39.3) 41 (41) 14 (35) χχ2=0.431 0.511 anemia 14 (10) 7 (7) 7 (17.5) χχ2=3.500 fep=0.114 ischemic heart disease 13 (9.3) 10 (10) 3 (7.5) χ2=0.212 fep=0.758 thyroid 13 (9.3) 9 (9) 4 (10) χ2=0.034 fep=1.000 sd, standard deviation; t, student t-test; χ2, chi square test; fe, fisher exact; p, p value for comparing between the studied groups. *statistically significant at p≤0.05. [page 2] [healthcare in low-resource settings 2023; 11(s2):11323] non -co mmerc ial us e o nly patients infected with covid-19 had multiple comorbidities, including dm in 63 (45.0%) patients, 44 (44.0%) patients were discharged and 19 (47.5%) patients were deceased, p=0.707. (table 1). dyslipidemia in 48 (34.3%) patients, 33 (33%) patients were discharged and 15 (37.5%) patients were deceased, p=0.612. htn in 55 (39.3%) patients, 41 (41%) patients were discharged and 14 (35%) patients were deceased, p=0.511. anemia in 14 (10%) patients, 7 (7%) patients were discharged and 7 (17.5%) patients were deceased, p=0.114. ischemic heart disease in 13 (9.3%) patients, 10 (10%) patients were discharged and 3 (7.5%) patients were deceased, p=0.758. thyroid disease in 13 (9.3%) patients, 9 (9%) patients were discharged and 4 (10%) patients were deceased, p=1.000. none of them significantly affects the outcome of the disease. many laboratory investigations were conducted and their relation to the outcome of the disease were recorded. crp showed mean value of 17.7±16.3 mg/l in all covid-19 infected patients, with a mean of 11.4±8.3 mg/l in discharged patients, and a mean of 33.4±20.4 mg/l in deceased patients. crp also showed high significant increase in deceased patients more than discharged patients, p<0.001 (table 2). ferritin showed mean value of 1308±2006 ng/ml in all covid-19 infected patients, with a mean of 715.8±1188.6 ng/ml in discharged patients, and a mean of 2788.8±2758.5 ng/ml in deceased patients, the increase in ferritin level was highly significant in deceased patients in comparison to discharged patients, p<0.001 (table 2, figure 1). ldh showed mean value of 585±590 iu/l in all covid-19 infected patients, with a mean of 380.7±246.7 iu/l in discharged patients, and a mean of 1095.9±843.5 iu/l in deceased patients, there was a high significant increase of ldh in deceased patients article table 2. comparison between the two studied groups according to laboratory investigations. total n=140 (%) discharged n=100 (%) deceased n=40 (%) u p crp (mg/l) mean±sd. 17.7±16.3 11.4±8.3 33.4±20.4 543.0* <0.001* median (min.–max.) 14.5 (0.3–71) 8.6 (0.3–36) 28 (10–71) ferritin (ng/ml) mean±sd. 1308±2006.1 715.8±1188.6 2788.8±2758.5 774.0* <0.001* median (min.–max.) 642.5 (14–10105) 354.5 (14–7006) 1588 (21–10105) ldh (iu/l) mean±sd. 585±590 380.7±246.7 1095.9±843.5 336.50* <0.001* median (min.–max.) 444 (134–3894) 290.5 (134–966) 874.5 (500–3894) d-dimer (ng/ml) mean±sd. 4442±4943.2 2902.5±2873.8 8290.8±6697.2 677.0* <0.001* median (min.–max.) 2427 (331–28809) 1581.8 (331–10177) 8524.5(1255–28809) alt (iu/l) mean±sd. 91.2±230.2 42.5±32.7 212.9±406 1258.50* 0.001* median (min.–max.) 41 (9–1577) 35.5 (9–148) 91 (11–1577) ast (iu/l) mean±sd. 129.5±276.2 54.2±51 318±462.9 727.0* <0.001* median (min.–max.) 45.5 (15–1692) 34 (15–284) 98.5 (30–1692) pt (seconds) mean±sd. 17.6±5.5 16.4±5.2 20.5±5.2 1042.0* <0.001* median (min.–max.) 16 (1–33) 15.7 (1–33) 18.1 (15–32) aptt mean±sd. 41.4±13.5 39.7±13.7 45.5±12.2 1376.50* 0.004* median (min.–max.) 37.4 (20–78) 35 (20–78) 43 (25–77) procalcitonin (ng/ml) mean±sd. 4.4±8.3 1.7±3.8 11.0±12.2 457.0* <0.001* median (min.–max.) 1.2 (0.03–45.0) 0.6 (0.03–23.0) 5.9 (0.2–45.0) pro-bnp (pg/ml) mean±sd. 4219.3±9446 1121.8±1601.1 11963.1±15013.3 486.50* <0.001* median (min.–max.) 784.5 (43–45908) 556.5 (43–8084) 6547.5 (300–45908) sd, standard deviation; u, mann whitney test; p, value for comparing between the studied groups. *statistically significant at p≤0.05. figure 1. error bar showing differences in three markers between discharged and deceased patients. [healthcare in low-resource settings 2023; 11(s2):11323] [page 3] non -co mmerc ial us e o nly more than discharged patients, p<0.001. d-dimer showed mean value of 4442±4943.2 ng/ml in all covid-19 infected patients, with a mean of 2902.5±2873.8 ng/ml in discharged patients, and a mean of 8290.8±6697.2 ng/ml in deceased patients, the increase in d-dimer was highly significant in deceased patients, p<0.001. alt showed mean value of 91.2±230.2 iu/l in all covid-19 infected patients, with a mean of 42.5±32.7 iu/l in discharged patients, and a mean of 212.9±406 iu/l in deceased patients, there was a significant increase of alt in deceased patients more than discharged patients, p=0.001. ast showed mean value of 129.5±276.2 iu/l in all covid19 infected patients, with a mean of 54.2±51 iu/l in discharged patients, and a mean of 318±462.9 iu/l in deceased patients, there was a significant increase of ast in deceased patients more than discharged patients, p<0.001. pt showed mean value of 17.6±5.5 seconds in all covid-19 infected patients, with a mean of 16.4±5.2 seconds in discharged patients, and a mean of 20.5±5.2 seconds in deceased patients, pt showed high significant increase in deceased patients more than discharged patients, p<0.001. aptt showed mean value of 41.4±13.5 seconds in all covid19 infected patients, with a mean of 39.7±13.7 seconds in discharged patients, and a mean of 45.5±12.2 seconds in deceased patients, aptt showed significant increase in deceased patients more than discharged patients, p<0.004. pct showed mean value of 4.4±8.3 ng/ml in all covid-19 infected patients, with a mean of 1.7±3.8 ng/ml in discharged patients, and a mean of 11.0±12.2 ng/ml in deceased patients, pct showed highly significant increase in deceased patients more than discharged patients, p<0.001. pro-bnp showed mean value of 4219.3±9446 pg/ml in all covid-19 infected patients, with a mean of 1121.8±1601.1 pg/ml in discharged patients, and a mean of 11963.1±15013.3 pg/ml in deceased patients, there was a high significant increase of pro-bnp in deceased patients more than discharged patients, p<0.001. to detect if the previous laboratory investigations were accurate in predicting mortality, we used the area under the curve (auc) and 95% ci of the receiver operator characteristic (roc) curve. we found that there was significant prognostic performance of crp, ferritin, ldh, d-dimer, pcct and pro-bnp with mortality, and the highest performance of variables were, ldh > pct > pro-bnp > crp, and the least was d-dimer and ferritin. the cut off value for ldh was > 500 iu/l, for pct was >2.09 ng/ml, for probnp was >1755 pg/ml, and for crp > 15.4 mg/l. (table 3, figure 2). univariate analysis showed that each one of the variables was associated with mortality after adjustment with alt, ast, pt, article table 3. prognostic performance for crp, ferritin, ldh, d. dimer, procalcitonin and pro-bnp to predict mortality (n=40) from discharged (n=100). auc p 95% c.i cut off sensitivity specificity ppv npv crp 0.864 <0.001* 0.803–0.926 >15.4 80.0 69.0 50.8 89.6 ferritin 0.807 <0.001* 0.718–0.895 >677# 87.50 70.0 53.8 93.3 ldh 0.916 <0.001* 0.872–0.960 >500 97.50 78.0 63.9 98.7 d. dimer 0.831 <0.001* 0.761–0.900 >2188# 92.50 63.0 50.0 95.5 procalcitonin 0.886 <0.001* 0.815–0.957 >2.09 90.0 79.0 63.2 95.2 pro-bnp 0.878 <0.001* 0.806–0.950 >1755# 85.0 84.0 68.0 93.3 auc, area under a curve; p value: probability value; ci, confidence intervals; npv, negative predictive value; ppv, positive predictive value. *statistically significant at p≤0.05. #cut off was choose according to youden index. table 4. univariate and multivariate logistic regression analysis for the parameters affecting deceased patients (n=40 vs. 100). univariate model 1 model 2 p or (95%c.i) (ll-ul) p or (95%c.i) (ll-ul) p or (95%c.i) (ll-ul) crp (>15.4) <0.001* 8.90 (3.68–21.53) <0.001* 11.41(3.11–41.86) 0.073 3.96 (0.88–17.79) ferritin (>677) <0.001* 16.33 (5.83–45.75) <0.001* 18.40 (4.60–73.72) 0.018* 10.95 (1.51–79.25) ldh (>500) <0.001* 138.3 (17.97–106) 0.005* 608(14.3–2588727) 0.003* 34.72 (3.23–373.7) d. dimer (>2188) <0.001* 21.0 (6.05–72.91) <0.001* 15.27(3.53–66.09) 0.573 2.64 (0.09–77.02) procalcitonin(>2.09) <0.001* 33.86 (10.83–105.8) <0.001* 27.12(6.95–105.9) 0.003* 11.82 (2.26–61.86) pro-bnp (>1755) <0.001* 29.75 (10.74–82.45) <0.001* 28.21 (7.07–112.6) 0.014* 7.73 (1.50–39.80) or, odd’s ratio; ci: confidence interval; ll, lower limit; ul, upper limit; model 1, each marker was adjusted by other significant variables (alt, ast, pt, appt and age); model 2, multivariate regression for the six markers. *statistically significant at p ≤ 0.05. [page 4] [healthcare in low-resource settings 2023; 11(s2):11323] figure 2. roc for crp, ferritin, ldh, d. dimer, pct and probnp to predict mortality. non -co mmerc ial us e o nly aptt, and age, model i showed that they were statistically significant, and after performing multivariate analysis (model ii) we found that ferritin > 677 ng/ml, ldh >500 iu/l, pct >2.09 ng/ml, and pro-bnp > 1755 pg/ml were still independently significant for predicting mortality (table 4, figure 3). discussion numerous studies have confirmed that increasing age and presence of chronic illness are significant risk factors in covid19 infection, leading to extended hospitalization periods and increase mortality. for instance, a retrospective study conducted on older patients infected with covid-19 at zhongnan hospital of wuhan university found that the mortality rate was significantly higher among patients aged over 65 years (34.5%) than in younger patients (4.7%).9 another study conducted in hyderabad, telangana, india revealed the impact of preexisting comorbidities on disease outcome, including diabetes mellitus, hypertension, coronary artery disease, and chronic kidney disease, either individually or in combination. the study found that preexisting comorbidities were significant contributing factor in increasing mortality, especially when diabetes mellitus and hypertension occurred together.10 moreover, a multivariate retrospective cohort conducted in bangladesh assessed the effect of sociodemographic factors, comorbidities, symptoms, charlson comorbidity index, and access to health facilities on disease outcomes. the study reported that increased age, the presence of more than 3 symptoms, and multiple comorbidities, were associated with higher morbidity and mortality in covid-19 patients.11 in our study, we also observed that the age had a significant impact on covid-19 mortality rates, with higher mortality rates observed in patients aged over 65 years. however, we did not observe any significant effect of other comorbidities on covid-19 mortality rates. one of the frequently studied aspects of covid-19 infection is its relation to patient sex, and its effect on the rate of infection and the outcome of the disease. according to data reported on 239,709 patients in italy, mortality is 17.7% in men and 10.8% in women, with 59% of total deaths were in males. even though the rate of infection was lower in males than in females, with 45.8% and 54.2% respectively, indicating that evolution of the disease may be affected by gender.12 in contrast, another study found higher infection risks among females than males at working ages, but the opposite trend was observed at older age, and across all age groups, mortality rate in males was double that in females.13 however, in our study, there was no significant effect of gender on mortality in covid-19 infection. laboratory investigations are crucial for the detection of covid-19 infection and monitoring evolution of the disease. crp is an acute-phase protein synthesized by the liver, and elevated in response to bacterial infection, which is usually used in the diagnosis of pneumonia.14 a retrospective study conducted in china involving 76 patients with confirmed covid-19 infection, found that crp ≥ 52.14mg/l was correlated with the severity of infection, and had prognostic value for mortality.15 additionally, another study conducted in china found that crp was strongly correlated with murray score which was originally used to determine the severity of lung injury in patients developing acute respiratory distress syndrome.3 in our study, crp showed high significant increase in deceased patients more than in discharged patients, and crp >15.4 mg/l had a significant prognostic performance with mortality, with sensitivity 80% and specificity 69% after adjustment with alt, ast, pt, aptt, and age. ferritin, although known primarily as an iron storage protein; has multiple functions, including serving as a signaling molecule and direct mediator of the immune system. its expression can be induced by cytokines, and it may also plays role in induction of proand anti-inflammatory cytokines.16 it was observed that hyperferritinemia in patients with severe covid-19 infection was between 1.5 and 5.3 times higher in patients with severe disease usually reaching >800 μg/l and less than theses values in patients with moderate disease.17 a study conducted in wuhan, china on patients survived the infection and patients died during their stay in the hospital found that ferritin levels on admission was around 1400 μg/l in non-survivors, which is between 3 and 4 times higher than that observed in survivors.18 in our study, ferritin showed significant increase in deceased patients more than discharged patients. ferritin levels above 677 ng/ml were significantly predictive of mortality, with a sensitivity of 87.5% and specificity 70% after adjusting for alt, ast, pt, aptt, and age. ferritin was also found to be independent significant predictor of mortality. ldh is a glycolytic enzyme that catalyzes the conversion between l-lactate and pyruvate and conversion between nadh and nad+. it is present in the cytoplasm of all tissues especially the heart, liver and skeletal muscles. in covid-19 infection, there is tissue injury and low oxygenation of the cells leading to up-regulation of glycolytic pathway and increased ldh levels especially in severe lung injury which leads to release of large amounts of ldh isoenzyme 3.19 a meta-analysis performed by martha j. showed that increased levels of ldh was associated with poor prognosis and high mortality rate, with a sensitivity of 74 % and specificity of 69%. positive likelihood ratio was 2.4, negative likelihood ratio was 0.38 and area under curve of 0.77, independently from age, male sex, hypertension and diabetes.20 another metaanalysis conducted including twenty eight study showed that high levels of ldh were observed in icu patients versus non-icu patients and in non-survivors compared with survivors and concluded that ldh is an important severity marker for covid-19 infection and can be used as a predictor of survival.21 in our study, ldh showed highly significant increase in deceased patients more than discharged patients, as ldh levels > 500 iu/l had a significant prognostic performance with mortality, with a sensitivity 97.5% and specificity of 78% after adjusting for alt, ast, pt, aptt, and age. ldh was also found to be independent significant article figure 3. graph showing odds ratio of different markers with 95% ci after a multivariate logistic regression for covid-19 mortality. [healthcare in low-resource settings 2023; 11(s2):11323] [page 5] non -co mmerc ial us e o nly predictor of mortality. d-dimers are fragments resulted from cleavage of fibrin to break down clots. therefore, any increase in production or degradation of fibrin will elevate plasma d-dimer levels. in severe covid-19 infection, proinflammatory and prothrombotic events are prominent leading to d-dimer production.22 studies also suggest that in sars-cov-2 infection there is dysregulation of the coagulation cascade with diffuse alveolar damage and infiltration with mononuclear inflammatory cells in the interstitium, this promotes prothrombotic activity. furthermore, proinflammatory cytokines cause endothelial injury, which enhances coagulation and inhibit fibrinolysis in those patients. these high levels of d-dimer that indicate increased hypercoagulability increase severity and contribute to mortality.23 reports from wuhan hospital showed that from the patients requiring icu admission, 26% had increased d-dimer levels. the main differences between non-survivors compared to survivors is markedly elevated d-dimer which progress on day 5 of infection, also lymphopenia, and renal dysfunction.24 in a multivariable logistic regression model of 171 patients in another wuhan hospital, an initial d-dimer level >1.0 μg/ml was associated with poor prognosis and high mortality with an odds ratio of 18.42 (2.64128.55; p=0.003).25 in our study, there was highly significant difference in ddimer level between deceased and discharged patients, as d-dimer levels > 2188 ng/ml had a significant prognostic performance with mortality, with sensitivity 92.5% and specificity 63% after adjustment with alt, ast, pt, aptt, and age. cytokine storm and hypoxia associated with covid-19 infection, may also contribute to liver injury in seriously ill patients, as shock and hypoxia leading to hypoperfusion of the liver, this inturn leads to hepatic dysfunction. moreover, liver damage may occur due the use of medications especially lopinavir and ritonavir.26 chen et al.27 evaluated 99 confirmed cases of covid-19 patients. he found that 43 patients presented with liver dysfunction, as alt and/or ast were elevated especially in severe cases. in a multicenter retrospective cohort study conducted in hubei province, liver injury indicators were evaluated and their relation to death risk was recorded. the study found that ast was elevated before alt and both were highly increased in severe group of patients, and that ast is in particular was associated with mortality risk.28 in our study, alt and ast were significantly elevated in deceased patients more than discharged patients. however, we did not find any significant prognostic performance with mortality. viral, bacterial, or fungal infection leads to activation of host defense mechanisms results in activation of coagulation pathways as a part of communication between humoral and cellular components of the immune response in what is called thromboinflammation or immunothrombosis.29 evidence of coagulopathy has been reported with appearance of covid-19 infection in china. reports of the first 99 patients hospitalized in wuhan demonstrated elevated aptt in 6% and elevated pt in 5%.27 another report from another wuhan hospital showed mild elevation in pt but normal aptt in the first 138 patients admitted to the hospital.24 in our study, pt and aptt were significantly elevated in deceased patients more than discharged patients. however, we did not find any significant prognostic performance with mortality. pct is a product of calcitonin-related gene, produced by epithelial cells during bacterial infection; it is considered as biomarker of blood infection, and usually used to monitor antibiotic therapy.30 in a recent study, elevated serum level of pct in covid-19 infected patients was associated with high mortality with high sensitivity, and reported that serum level of pct (≥ 0.10 ng/ml) was independent risk factor for mortality specially in old patients (age ≥ 60 y) and severe covid-19 infection.15 in our study, pct showed significant increase in deceased patients more than discharged patients, as pct levels > 2.09 ng/ml had a significant prognostic performance with mortality with, sensitivity 90% and specificity 79% after adjustment with alt, ast, pt, aptt, and age, it was independently significant for predicting mortality. cardiac complications during the covid-19 infection are predisposed by old age, prior cardiovascular disease and severe disease presentation. the pathogenic mechanisms include pro-inflammatory cytokines (il-6, il-7, il-22, cxcl10) which contribute to plaque rupture, activation of pro-coagulation factors; and hemodynamic changes leading to ischemia and thrombosis. these cardiac events lead to production of the n-terminal pro b type natriuretic peptide (nt-probnp) in those patients.29 a meta-analysis involving 4,189 patients enrolled in 28 studies reported that patients with severe covid-19 infection had significant high level nt-probnp, and its level rises progressively in non-survivors.5 in another study involving 138 patients, the average levels of nt-probnp (301.2 ng/l vs 2887.5 ng/l; p<0.01) were maximum in icu patients who stayed on mechanical ventilation, or extracorporeal membrane oxygenation or deceased patients.24 in our study, probnp showed significant increase in deceased patients more than discharged patients, as probnp levels > 1755 pg/ml had a significant prognostic performance with mortality, with sensitivity 85% and specificity 84% after adjustment with alt, ast, pt, aptt, and age, and it was independently significant for predicting mortality. after assessment of many biochemical markers during covid-19 infection, we found that there was significant prognostic performance of crp, ferritin, ldh, d-dimer, pct and pro-bnp with mortality, and the highest performance of variables were ldh > pct > pro-bnp > crp, and the least was d-dimer and ferritin. the cut off value for ldh was > 500 iu/l, for pct was >2.09 ng/ml, for pro-bnp was >1755 pg/ml, and for crp > 15.4 mg/l. univariat analysis showed that each one of the variables was associated with mortality after adjustment with alt, ast, pt, aptt, and age, multivariate analysis showed that ferritin > 677 ng/ml, ldh >500 iu/l, pct >2.09 ng/ml, and pro-bnp > 1755 pg/ml were still independently significant for predicting mortality. conclusions early assessment of biochemical markers in patients with covid-19 infection can assist clinicians in tailoring treatment and providing more intensive care to those at a greater risk of mortality. ferritin, ldh, pct and probnp are important markers to assess as they have demonstrated high sensitivity and specificity, prognostic performance, and independent significance in predicting mortality. by monitoring these markers, clinicians can better identify patients who may require more aggressive interventions or closer monitoring to improve outcomes references 1. lu r, zhao x, li j. genomic characterization and epidemiology of 2019 novel coronavirus: implication for virus origins and receptor binding. lancet 2020;395:565-74. 2. chen t, wu d, chen h, yan w, yang d. clinical characteristics of 113 deceased patients with coronavirus disease 2019: retrospective study. bmj.2020; 368: m1091. 3. hariyanto i and kurniawan a. thyroid disease is associated with severe corona disease 2019 (covid-19) infection. article [page 6] [healthcare in low-resource settings 2023; 11(s2):11323] non -co mmerc ial us e o nly diabetes metab syndr 2020;14:1429-30. 4. liu y, yang y, zhang c, et al. clinical and biochemical indexes from 2019-ncov infected patients linked to viral loads and lung injury. science china. life sciences 2020;63:364–74. 5. hariyanto t, japar k, kwenandar f, et al. inflammatory and hematologic markers as predictors of severe outcomes in covid-19 infection: a systematic review and meta-analysis. am j emerg med 2021;41:110–9. 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11. sharif n, opu r, ahmed s, et al. prevalence and impact of comorbidities on disease prognosis among patients with covid-19 in bangladesh: a nationwide study amid the second wave. diabetes metab syndr 2021;15:102148. 12. foresta c, rocca s, di nisio a. gender susceptibility to covid-19: a review of the putative role of sex hormones and x chromosome. j endocrinol invest 2021;44:951–6. 13. davies g, klepac p, liu y, et al. age-dependent effects in the transmission and control of covid-19 epidemics. nature med 2020;26:1205-11. 14. kalra l, smith c, hodsoll j, et al. elevated c-reactive protein increases diagnostic accuracy of algorithm-defined strokeassociated pneumonia in afebrile patients. int j stroke 2019;14:167-73. 15. xu j, xu c, zhang r, et al. associations of procalcitonin, creaction protein and neutrophil-to-lymphocyte ratio with mortality in hospitalized covid-19 patients in china. sci rep 2020;10:1-10. 16. rosário c, zandman-goddard g, meyron-holtz g, et al. the hyperferritinemic syndrome: macrophage activation syndrome, still’s disease, septic shock and catastrophic antiphospholipid syndrome. bmc med 2013;11:1-11. 17. ji d, zhang s, chen z, et al. clinical characteristics predicting progression of covid-19 (2/17/2020). available at ssrn 3539674. 18. hou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet 2020;395:1054–62. 19. henry m, aggarwal g, wong j, et al. lactate dehydrogenase levels predict coronavirus disease 2019 (covid-19) severity and mortality: a pooled analysis. am j emerg med 2020;38:1722–26. 20. martha w, wibowo a, pranata r. prognostic value of elevated lactate dehydrogenase in patients with covid-19: a systematic review and meta-analysis. postgrad med j 2022;98:422–7. 21. szarpak l, ruetzler k, safiejko k, et al. lactate dehydrogenase level as a covid-19 severity marker. am j emerg med 2021;45:638–9. 22. mikacenic c, hahn o, price l, et al. biomarkers of endothelial activation are associated with poor outcome in critical illness. plos one 2015;10:e0141251. 23. lippi g, favaloro e. d-dimer is associated with severity of coronavirus disease 2019: a pooled analysis. thrombosis haemostasis 2020;120:876–8. 24. wang d, hu b, hu c, et al. clinical characteristics of 138 hospitalized patients with 2019 novel coronavirus–infected pneumonia in wuhan, china. jama 2020;323:1061-9. 25. zhou f, yu t, du r, et al. clinical course and risk factors for mortality of adult inpatients with covid-19 in wuhan, china: a retrospective cohort study. lancet 2020;395:1054–62. 26. hui s, memish a, zumla a. severe acute respiratory syndrome vs. the middle east respiratory syndrome. curr opin pulm med 2014;20:233-41. 27. chen n, zhou m, dong x, et al. epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in wuhan, china: a descriptive study. lancet 2020;395:507–13. 28. lei f, liu m, zhou f, et al. longitudinal association between markers of liver injury and mortality in covid-19 in china. hepatology 2020;72:389–98. 29. jackson p, darbousset r, schoenwaelder m. thromboinflammation: challenges of therapeutically targeting coagulation and other host defense mechanisms. blood 2019;133:906–18. 30. mierzchała-pasierb m, lipińska-gediga m. sepsis diagnosis and monitoring procalcitonin as standard, but what next? anaesthesiol intensive ther 2019;51:299-305. article [healthcare in low-resource settings 2023; 11(s2):11323] [page 7] non -co mmerc ial us e o nly hrev_master [page 18] [healthcare in low-resource settings 2013; 1:e5] microbial contamination of pumice used in dental laboratories farzaneh firoozeh,1 mohammad zibaei,2 abolfazl zendedel,3 hushang rashidipour,4 aziz kamran5 1department of microbiology and immunology, school of medicine, kashan university of medical sciences, kashan; 2department of parasitology and mycology, school of medicine, lorestan university of medical sciences, khorram abad; 3department of internal medicine, school of medicine, lorestan university of medical sciences, khorram abad; 4department of endodontics, dental school, lorestan university of medical sciences, khorram abad; 5department of public health, isfahan university of medical sciences, isfahan, i.r. iran abstract dental appliances as well as sending and receiving prosthesis from laboratories are potential sources of cross-contamination for technicians, dentists, patients and can transmit different infectious agents as well. this study was conducted to determine the types of the microorganisms in pumice powder and pumice slurry used in dental laboratory in order to evaluate necessary disinfection control procedure in the dental settings. twenty-four active dental laboratories of khorram abad participated in our study. samples were randomly collected from prosthesis polishing containers in sterilized condition and were immediately sent to microbiology laboratory. specimens were cultured on selective bacterial and fungal media in order to determine the microorganisms. both oral and non-oral bacteria were recovered from pumice samples as follows: staphylococcus aureus (15.4%), streptococcus viridance (10.8%), bacillus cereus (18.7%), pseudomonas aeruginosa (12.8%), diphtheriods (7.3%), enterobacter cloace (4.3%), escherichia coli (13.1%), klebsiella pneumonia (5.4%), and acinetobacter spp. (12.2%). the isolated fungi included candida albicans (36.7%), other yeasts (17.3%), fusarium spp. (13.8%), aspergilus spp. (22.4%) and penicillium spp. (9.8%). this study showed that polishing pumices in the form of powder or slurry were contaminated with different oral and non-oral bacteria and also fungi. therefore, the chance of cross-contamination still severely exists, and measures should be conducted to prevent the contamination of predisposed people such as technicians, dentists and patients. introduction cross-contamination is a serious problem in dentistry and may occur among dental staff and patients.1 dental patients and dental personnel (dentists, dental laboratory technicians and assistants) can be exposed to a wide variety of pathogenic microorganisms in the blood and saliva, such as hepatitis b virus (hbv), hepatits c virus (hcv), hiv, pseudomonas, acinetobacter, diphteroids, lactobacilli, staphylococci, streptococci, mycobacterium and other microorganisms that colonize the oral cavity and respiratory tract. these organisms can be transmitted to dental settings through direct or indirect contact.2,3 most recent literature has focused on crosscontamination of dental prostheses in the dental laboratory.4,5 in dental laboratories, pumice is used in prostheses polishing. the pumice – as the last step of prosthesis finishing – has been reported to be the greatest source of contamination and also a transmission potential source for infection.6,7 during prosthesis polishing, contaminated aerosol particles spread and remain in the air for a long time causing high risks for both dental staff and patients. aspiration and inhalation of these aerosols for elderly immunocompromised patients, patients with endocarditis and respiratory disease is really hazardous.8,9 the bacteria, such as acinetobacter, pseudomonas and moraxella, which are not part of normal oral flora, can cause serious diseases if passed to patients whose dentures are polished with contaminated material and to the technician by exposure to contaminated aerosol.10 the prosthesis contaminated by potentially pathogenic microorganisms such as gram negative bacilli can cause serious diseases when it penetrates the oropharyngeal area and increases pneumonia incidence.7 despite rigorous need for sterilization and disinfection of dental instruments, prosthetic appliances do not receive adequate infection control.11 the sterilization has to be performed with suitable validated procedures so that the success of these procedures can be monitored and safety and health of patients, users, and other persons guaranteed.12 an earlier research from shiraz area (iran) reported the microorganisms isolated from pumice in dental laboratories.7 the aim of this research was to determine the bacterial and fungal contaminations present in pumice powder and slurry used in khorram abad dental laboratories to evaluate the role of pumice in cross-contamination of dental laboratories. materials and methods survey area khorram abad, the capital of lorestan province is located in the south-west iran, bordering with the provinces of markazi, hamedan, kermanshah, khuzestan, ilam, and isfahan. the estimated population of khorram abad is 540,000. the district covers an area of approximately 6233 km2. the study site (48°21’s, 30°43’w) is the largest city in lorestan province. sample collection this study was conducted between june and september 2012 in twenty-four dental laboratories in khorram abad. samples randomly collected were placed in sterile containers and immediately transferred to the microbiology laboratory for isolation of microorganisms. preparation, cultivation and identification initially, 1 g of pumice was aseptically weighed and a suspension in 9 ml sterile normal saline was prepared in a small test tube. healthcare in low-resource settings 2013; volume 1:e5 correspondence: mohammad zibaei, department of parasitology and mycology, school of medicine, lorestan university of medical sciences, khorram abad, iran. tel. +98.661.6200133 fax: +98.661.6200149. e-mail: zibaeim@sums.ac.ir key words: contamination, microbial, pumice, dental laboratory. contributions: ff, conception and design of the study, critical revision of the article for important intellectual content; mz, administrative, technical or logistical support, final approval of the study, guarantor of integrity of the entire study; az, obtaining funding for the study; hr, provision of study material or patients, collection; ak, analysis and interpretation of data. funding: the work was supported by the vice chancellor for research of lorestan university of medical sciences, khorram abad, iran. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 december 2012. revision received: 13 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright f. firoozeh et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e5 doi:10.4081/hls.2013.e5 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e5] [page 19] the tubes were mixed for 30 sec. afterwards, 1 ml of the suspension was cultured on blood agar [automatic tank dewater (atd); antec international ltd., sudbury, uk] with 5% defibrinated sheep blood cell for isolation of all bacteria, on mcconkey agar (merck kgaa, darmstadt, germany) for isolation of gram negative bacteria, on manitol salt agar (merck kgaa) for isolation of staphylococcus aureus, and on sabouroud dextrose agar (himedia laboratories ltd., mumbai, india) for detection of fungi. the cultured plates were incubated 24-48 h at 37°c for bacterial isolation and at 25°c for 2 weeks for fungi. the plates were checked daily for detection of microorganisms. morphologically different bacterial and fungal colonies were subcultured, and isolated colonies were identified to genus and species levels using microscopic and macroscopic characters.7 in addition, coagulase, catalase, sugar fermentation test, koh and hemolysis test were carried out according to the standard methods.13 to assure the sterility and reliability of the techniques, 24 nontreated pumices (with denture) for each dental laboratory were considered as the control group. results of the 72 samples collected from 24 dental laboratories, 16 (66.7%) dental laboratories were contaminated for microorganisms (table 1). the isolated microorganisms from cultures of pumice samples collected from dental laboratories in khorram abad are reported in figures 1 (gram positive bacteria) and 2 (gram negative bacteria). the results indicated that the highest rate belonged to bacillus cereus (18.7%) and the lowest one was enterobacter cloace (4.3%). candida albicans (36.7%) was the highest rate of isolated fungi and penicillium spp. (9.8%) was the lowest (figure 3). discussion pumice used as the last step in prosthesis polishing could be a potential source of contamination to dental laboratory technicians.10 it was shown that in patients with immune deficiency problems, dentures have higher levels of contamination,14,15 since most denture users are elderly people, so the risk of infection is even higher. in this study, we found a great part of bacterial species from pumices. most interestingly, this is consistent with report by verran et al.,16 although they also isolated micrococcus from pumice slurry. results obtained in the present study revealed a strong oral and non-oral contaminating source in polishing pumices. most of the fungi and bacteria isolated in our study were not pathogenic in healthy people, but some of them, such as staphylococcus aureus and streptococcus viridans, can be harmful both for the immunoicompromised and elderly patients as well as for healthy people. viridans streptococci are part of the oral cavity normal flora. the main significance of these bacteria relates to their ability to cause 30-40% of cases of subacute bacterial endocarditis.14 since the organisms are most abundant in the mouth, minor trauma may lead to their entry into the bloodstream and initiate of endocarditis especially in predisposed patients. witt et al.8 notified a similar situation. they found streptococcus viridians in cultures of pumice from laboratories. when prosthesis is polished with pumice, article table 1. microorganisms isolated from dental laboratories. no. lab.microorganisms s.vi. s.ae b.ce. p.ae dipht. e.co. e.cl. k.pn. acin. c.al. other fusa. aspe. peni. 1 + + + + 2 + + + + + + + + 3 + + + + + + + 4 + + + + + + + 5 + + + + + + + 6 + + + + + + + + + + 7 + + + + + + + + 8 + + + + + + + + 9 + + + + + 10 + + + + 11 + + + + 12 + + + + + 13 + + + + + 14 + + + 15 + + + + + + 16 + + + + 17 + + + + 18 + + + + 19 + + + + 20 + + + + 21 + + + + 22 + + + + + 23 + + + + 24 + + + + + + s.vi., streptococcus viridance; s.ae., staphylococcus aureus; b.ce., bacillus cereus; p.ae., pseudomonas aeruginosa; dipht., diphtheriods; e.co., escherichia coli; e.cl., enterobacter cloace; k.pn., klebsiella pneumonia; acin., acinetobacter species; c.al., candida albicans; other, other yeasts; fusa., fusarium species; aspe., aspergilus species; peni., penicillium species. non -co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2013; 1:e5] contaminated aerosol particles of microorganisms such as gram negative bacteria and fungi, are spread all around the laboratory. this could be a major source for different oral and non-oral infections. several studies have reported isolation of gram negative bacteria like pseudomonas, moraxella and acinetobacter from pumice which can be transferred to patients and dental laboratory staff by contaminated aerosols, and cause ocular and respiratory infection especially in persons with chronic respiratory disorders.16 the entry of gram negative bacteria such as escherichia coli, enterobacter and klebsiella into the blood of patients can cause a fatal infection especially gram negative septicemia in debilitated patients.17 isolation of gram negative bacteria in the current study is similar to that obtained by other studies.7 fungi recovered from used pumice samples in the current study included aspergillus, fusarium, penicillium and candida that increased risk of fungal infection especially in persons who work for a long period of time in dental laboratories and have been exposed to fungal spores.18 some reports support that candida albicans belong to the normal physiology flora of mouth. it is able to grow in pumice and cause infections in humans.19 besides, new studies have been conducted on viral infection transmission especially hbv and hiv in dental laboratories. occupational infection of the dental laboratory technicians with hbv has been reported. the studies suggest that all healthcare workers working in dental laboratories should be vaccinated against hepatitis b virus.20 there are many studies that provide some additional information regarding prosthesis disinfection. a previous study in brazil showed a transfer of microorganisms from patients prosthesis to sterile prosthesis and in most laboratories pumice was not changed or disinfected between polishing procedures.10 jagger et al.21 reported that about 6.1% of dental laboratories used disinfectants in the pumice and 92.9% did not disinfect the polishing instrument. a previous study has proven that pumice slurry freshly made up using disinfectants was reported to be free from most contaminations.8 unfortunately, in the present study most of the laboratories did not used a disinfectant while working with pumice, however, it will be good to use such disinfection protocol to minimize the chance of infection among the dental laboratories technicians and patients. it is recommended to disinfect old or used dentures before starting any action. the technician should use sterilized gloves, disinfected protecting glasses, oral masks, brushes and polishing tools to polish prosthesis. conclusions polishing pumices are potential source of infection in dental laboratories when considering the wide variety of microorganisms in the blood and saliva of patients. following our study results, low temperature sterilization, such as gas or plasma sterilization, would allow optimal reduction in the number of pathogenic bacteria. the use of sterile pumice or association of disinfectants with pumice for polishing the prosthesis, sterilization of containers after each use with adding of an appropriate disinfectant such as 0.2% chlorohexidine gluconate or 5% hypochlorite sodium to pumice could be effective and daily change of polishing paste is recommended to reduce the hazard of cross-contamination. however, no standard procedures actually exist. references 1. kugel g, perry rd, ferrari m, lalicata p. disinfection and communication practices: a survey of u.s. dental laboratories. j am dent assoc 2000;131:786-92. 2. al-saadi ak. bacterial cross-contamination between clinic & dental laboratory during polishing procedure of complete denture. mustansiria dental journal 2011;8:288-92. available from: http://www. iasj.net/iasj?func=issuetoc&isid=1872& uilanguage=en 3. al-kheraif aa, mobarak fa. infection control practice in private dental laboratories in riyadh. saudi dent j 2008;20:163-9. 4. debattista n, zarb m, portelli jm. bacterial cross-contamination between the dental clinic and laboratory during prosthetic treatment. malta med j 2010;22:17-9. 5. parisi e, glick m. immune suppression and considerations for dental care. dent clin n am 2003;47:709-31. 6. king ah, matis b. infection control of inoffice dental laboratories. dent clin n am 1991;35:415-26. 7. vojdani m, zibaei m. frequency of bacteria and fungi isolated from pumice in dental laboratories. j res health sci 2006;6:33-8. 8. witt s, hart p. cross infection hazards associated with the use of pumice in dental laboratories. j dent 1990;18:281-3. 9. chris h, miller c, john p. infection control and management of hazardous materials for the dental team. 2nd ed. london: mosby; 1998. 10. agostinho am, miyoshi pr, gnoatto n, et al. cross-contamination in dental laboratory through the polishing procedure of complete dentures. braz dent j 2004;15: 138-43. 11. williams dw, chamary n, lewis ma, et al. microbial contamination of removable prosthodontic appliance from laboratories and impact of clinical storage. brit dent j 2011;26:163-6. 12. smith pn, palenik cj, blanchard sb. microbial contamination and the sterilization/disinfection of surgical guides used in the placement of endosteal implants. int j oral max impl 2011;26:274-81. article figure 3. fungal species isolated from pumice samples. figure 1. frequency of gram positive bacteria isolated from pumice samples of dental laboratories. figure 2. frequency of gram negative bacteria isolated from pumice samples of dental laboratories. non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e5] [page 21] 13. washigton w jr, allen s, janda w, et al. color atlas and textbook of diagnostic microbiology. philadelphia, pa: lippincott williams & wilkins; 2006. 14. henderson cw, schwartz rs, herbold et, mayhew rb. evaluation of the barrier system, an infection control system for the dental laboratory. j prosthet dent 1987;58:517-21. 15. verran j, winder c, mccord jf, maryan cj. pumice slurry as a cross infection hazard in nonclinical (teaching) dental technology laboratories. int j prosthodont 1997;10: 283-6. 16. williams hn, falkler wa jr, hasler jf. acinetobacter contamination of laboratory dental pumice. j dent res 1983;62:1073-5. 17. schuoter gs. microbiology of the orofacial region in topazian, oral and maxillofacial infection. 4th ed. philadelphia, pa: wb saunders; 2002. 18. williams hn, falkler wa jr, smith ag, hasler jf. the isolation of fungi from laboratory dental pumice. j prosthet dent 1986;56:77-80. 19. de resende ma, souza lvnf, oliveira rcbw, et al. prevalence and antifungal susceptibility of yeasts obtained from the oral cavity of elderly individuals. mycopa thologia 2006;162:39-44. 20. al-dwarai zn. infection control procedures in commercial dental laboratories in jordan. j dent educ 2007;71:1223-7. 21. jagger dc, huggett r, harrison a. crossinfection control in dental laboratories. brit dent j 1995;179:93-6. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e16] [page 55] scrotal necrosis to total de-gloving injury of the male genitalia: an experience from sub-saharan africa christoph h. houben,1 chuks azubuike,2 okogbe ozoemena,2 bala saidu2 1department of surgery, prince of wales hospital, the chinese university of hong kong, china; 2yola specialist hospital, hospital road, yola, nigeria abstract two patients with very different aetiologies of their genital injuries are presented: one lost his scrotal skin as a result of fournier’s gangrene, the other experienced complete denudation of scrotal and penile skin plus the amputation of his glans penis through an agricultural machinery. the placement of denuded gonads in thigh pouches and delayed skin grafting provide safe treatment options in a low budget setting of a sub-saharan country. introduction we report our experience with two patients who sustained severe scrotal injuries in the low budget setting of a sub-saharan country. the injuries represent two ends of the spectrum of scrotal injuries: one patient lost his scrotum as the result of a severe infection to the perineum and scrotum (fournier’s gangrene), the other had a total de-gloving injury of his scrotum and penis plus avulsion of his glans penis through a mechanical devise. the management and treatment options of these very different aetiologies are outlined. case report #1 a seventy-year-old farmer was admitted to hospital for the first time in his life with generalised cardiac failure manifesting itself with shortness of breath and extensive oedema. he was commenced on diuretics and digitalized resulting in an improvement of his general condition, but during his hospitalisation he developed a sepsis causing fournier’s gangrene. broad-spectrum antibiotics were given to control the synergistic infection typical of fournier’s gangrene. aggressive debridement of the affected scrotal area was performed under general anaesthesia. this was followed by daily wound cleansing and dressing changes with vaseline gauze. there was a total loss of the scrotal skin with a significant absence of penile skin – the ventral defect being slightly larger than the dorsal defect. both testes appeared denuded but with intact blood supply. after around four weeks of daily dressing changes the wounds appeared clean for the reconstruction under general anaesthesia (figure 1). during the operation the two testicles were placed in medial thigh pouches on the right and left side respectively and anchored with non-absorbable 3-0 prolene® (ethicon, somerville, nj, usa) sutures (figures 2 and 3). the remaining scrotal skin was closed and the penile shaft defect sutured. a week later some of the suture lines had broken down requiring partial re-suturing. the patient enjoyed normal micturition following the removal of his catheter after completion of the wound healing two weeks later. case report #2 a thirty-year-old, previously healthy farmer accidentally entangled his clothes with the belt of a grinding machine. the trapping of his scrotum in the grinder resulted in the total loss of his scrotum, penile skin and glans penis. on arrival in the hospital the day after the injury, he had emergency surgery: on inspection there was a total loss of scrotal skin down to the perineum with the testicles exposed but viable, the penis was bleeding from its distal end as a result of complete loss of the glans penis in addition to the shaftand foreskin loss. after catheterization, the extensively bleeding wound was sutured at the penile shaft and both testicles were securely placed in medial upper thigh pouches. in addition, a urethral fistula was repaired with 4-0 monocryl® (ethicon). postoperatively antibiotics and painrelief were continued; the vaseline dressing was changed daily. twenty days following the accident a split skin graft was taken from his right thigh and the penile defect covered. approximately 80% of the raw surface took the initial graft. the catheter was removed two weeks later. the patient made a good recovery and was discharged home with control of his urinary function and no penile discomfort. at this stage his erectile function was unclear. discussion the mechanisms of scrotal injury range from incidents related to industrial and agricultural machinery, through animal attack to fournier’s gangrene.1 overall total de-gloving injuries of the penis and scrotum are exceedingly rare. large institutions manage only a handful of cases within a time span of a couple of decades.2 loss of scrotal skin as a result of severe sepsis (fournier’s gangrene) is seen a little more frequently.3 although fournier is credited with the first description of necrotizing fasciitis in the perineum and scrotal region, gangrene was reported a century earlier.4 fournier’s gangrene is treated with broadspectrum antibiotics in an attempt to overcome the synergistic infection of gram-negative and gram-positive anaerobes and aerobes. prompt debridement of the necrotic tissue as advocated initially by meleney in the 1920s has stood the test of time.5 scrotal skin – supplied by branches of the pudendal artery – is often lost to variable degrees; the testicles receiving their blood supply directly from the aorta are rarely affected, as in our case. however, they may hang, bereft of cover, like the clappers of a bell (figure 1).3 once the wound is considered clean, the testicles may be placed in thigh pouches and healthcare in low-resource settings 2013; volume 1:e16 correspondence: christoph heinrich houben, department of surgery, prince of wales hospital, the chinese university of hong kong, 7/f clinical sciences building, hong kong, china. tel. +86.852.26323936 fax: +86.852.26489384. e-mail: chhouben@web.de key words: fournier’s gangrene, genital trauma, de-gloving injury, sub-saharan africa. contributions: ch operated on the patients, conceived the report and drafted the article; oo assisted in the operations and contributed to the preand post-operative management of these patients; ca contributed to the preand postoperative management of the patients; and bs operated on one of the patients. conflict of interests: the authors declare no potential conflict of interests. acknowledgments: our patients have given permission to use their photographs in this article. juliane deubner, medical illustrator (saskatoon, canada) provided the graphics for figure 3. received for publication: 3 february 2013. revision received: 15 may 2013. accepted for publication: 20 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c.h. houben et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e16 doi:10.4081/hls.2013.e16 non -co mmerc ial us e o nly [page 56] [healthcare in low-resource settings 2013; 1:e16] the remaining wounds can be closed or if necessary covered with a split-skin-graft. at a later stage a new scrotum may be created using thigh pedicle flaps or meshed split-thickness grafts.1,6 following consultation our patient did not wish to have further surgery done apart from the high risk of infection from further reconstructive surgery in a setting with very limited resources. in patients with 50% or less loss of scrotal skin secondary to a mechanical injury, a direct reconstruction should be possible.7 total loss of the genital skin leaves the penile corpora most often intact;2,7,8 our case was complicated by the amputation of the glans penis as a result of the accident. in cases with total loss of genital skin secondary to trauma, one treatment option is to use thick-split-thickness or full-thickness grafts at the initial surgery with temporarily placement of the testes in thigh pouches. at a later stage, the creation of neo-scrotum is advocated. the alternative method is the direct reconstruction of the scrotum.1,2 if the avulsed scrotum is available, direct cover of the debrided wounds is naturally the preferred option.8 although we appreciate the psychological advantage of immediate skin grafting and creation of a neo-scrotum, we delayed the application of a thick-split-skin graft for 18 days after the emergency surgery. the penile shaft wound was bleeding heavily and the risk of infection was deemed too high; in subsaharan africa wound infection rates of more than 30% are reported for injuries to the male external genitalia.9 furthermore, we have currently no plans to create a new scrotum (e.g. tissue expansion) for the patient, because of the aforementioned risk of infection and the poor resources for equipment and materials in this low budget healthcare environment. whilst this may be acceptable for the first patient who presented at an advanced age, the younger man has certainly a risk of low fertility. there is evidence that placement of testes in thigh pockets or reconstruction with thick skin flaps may impinge fertility in the long term.8 conclusions despite our limited experience with de-gloving injuries of the scrotum in a low budget healthcare environment with a high infection risk – we had only two cases during a twelve months period – the following points can be made: i) preservation of denuded gonads is best achieved by creating thigh pouches; and ii) it is advocated to delay skin grafting of denuded penile areas. references 1. mcaninch jw. management of genital skin loss. urol clin n am 1989;16:387-97. 2. finical sj, arnold pg. care of the degloved penis and scrotum: a 25-year experience. plast reconstr surg 1999;104:2074-8. 3. eke n. fournier's gangrene: a review of 1726 cases. brit j surg 2000;87:718-28. 4. baurienne h. [sur une plaie contuse qui s’est terminee par le sphacele de la scrotum]. [article in french]. j med chir pharm 1764;20:251-6. 5. meleney fl. hemolytic streptococcus gangrene. arch surg chicago 1924;9:317-64. 6. chen sy, fu jp, chen tm, chen sg. reconstruction of scrotal and perineal defects in fournier’s gangrene. j plast reconstr aes 2011;64:528-34. 7. selvan ss, alagu gs, gunasekraran r. use of a hypogastric flap and split-thickness skin grafting for a degloving injury of the penis and scrotum: a different approach. indian j plast surg 2009;42:258-60. 8. wang d, zheng h, deng f. spermato genesis after scrotal reconstruction. brit j plast surg 2003;56:484-8. 9. ahmed a, mbibu nh. aetiology and management of injuries to male external genitalia in nigeria. injury 2008;39:128-33. brief report figure 1. scrotal and penile skin loss after fournier’s gangrene. figure 2. post reconstructive surgery for scrotal skin loss secondary to fournier’s gangrene. figure 3. graphic representation of the corrective surgery after scrotal loss due to fournier’s gangrene. non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:2116] [page 53] hepatitis b vaccine uptake assessment in india mohan bairwa centre for community medicine, all india institute of medical sciences, new delhi, india dear editor, hepatitis b (hep b) vaccine was introduced in the universal immunization program (uip) of 10 states of india in 2007-08. following hep b vaccine introduction, lahariya and colleagues conducted an assessment of hep b vaccine debut from august to december 2009 to i) ascertain the reasons for reported low coverage; ii) identify operational and programmatic challenges; and iii) derive lessons for further scale up of hep b and other newer vaccine introductions. two districts, one nearest and other farthermost to state headquarter were selected from five evaluation states [punjab (pb), madhya pradesh (mp), west bengal (wb), karnataka (ka) and tamil nadu (tn)].1 in the assessment, data were collected through a comprehensive desk review, 143 respondent interviews, a series of cold chain storage observations and immunization site observations of 36 sessions. lower coverage and higher drop outs were identified of three doses of hep b vaccine (hep b3) and three doses of diphtheria, tetanus, and poliomyelitis (dpt) vaccine (dpt3) during the study period. the main reasons behind this were shortage of vaccine, improper or incomplete data recording and reporting, lack of awareness amongst health workers, and not opening of vaccine vials to keep vaccine wastage low. birth dose administration has been documented in ka, tn and wb of the 5 states included in the assessment. other two states (pb and tn) concerned about vaccine wastage and adverse events following immunization. the incomplete recording and reporting of the birth dose, along with limited knowledge amongst health care providers about age for hep b birth dose, was an additional ground behind it. no proper reporting formats were in place to record hep b vaccine; therefore, it is assumed as equal to respective dpt doses coverage by field workers. amongst 36 session sites visited, the vaccine stocks and stores were replenished by push mechanism, leading to nil stock position commonly in 56% state and district levels as well as 60% primary health centre level stores. of the ten private sector paediatricians interviewed, three provided hep b birth dose and five provided coverage reports to the government. there is no provision to supply routine immunization vaccines to private practitioners by government, which was the reason behind non-reporting of vaccine coverage from private sector. the study documented major lessons were good central and state level oversights, clear policy communications and dissemination of guidelines, quality and timely trainings, effective monitoring and supervision prior and during early stage of introduction, and improvement in recording and reporting. while small sample size and purposive sampling were the limitations of the study, state selection according to geographic distribution considering wide geographic, cultural and socioeconomic differences, and comprehensive assessment at all levels from field workers to state program managers were the strengths of study. of the 25 million infants born every year in india, more than 4% live with the lifetime risk of developing chronic hep b infection. about 4% indian population were hbsag positive and over 100,000 indians die annually because of hep b-related illnesses.2 approximately 100 million hep b carriers live in the member countries of the who south-east asia region. despite availability of 95% effective hep b vaccine, it was not included in uip for nearly 2 decades till 2002-03 in selected districts.3 evaluation of newer health interventions plays a crucial role in improving implementation of health programs at field level, however, it is not commonly practiced in india.4 most of the program evaluations are neither properly documented nor published in india. the study at stake is a robust evaluation of new vaccine introduction among five major states. the authors report that findings were not only shared with national program managers for immediate corrective measures in early 2010 but also used for further scale up of hep b vaccine in all 35 states of india in 2011-12. two short reviews done in 2004 and 2007 provide assessments of pilot introduction of hep b vaccination in india; still, the reports were not widely disseminated. this article summarizes and analyses the findings of two previous assessments with the current one and provides comprehensive recommendations and lessons along with limitations of such assessment.1 india has a big private sector for immunization services delivery. however, private sector is assessed in very few program evaluations in india. the private pediatricians were included in the present assessment which is a refreshing approach and suggested consideration of their significant participation in health programs as well as program evaluations.the assessment outlined the findings and programmatic lessons including poor stock management, incomplete recording and reporting, perceived high cost and concern towards wastage of vaccine in multi-dose vial, lesser participation of private sector, and poor knowledge of hep b vaccination schedule amongst healthcare providers. these factors may have been contributed to comparatively low coverage of hep b vaccine. later on, the government of india corrected the majority of issues identified, showing that recommendations based upon robust methodology help in improving program performance. there is a number of vaccine introductions in india since adoption of hep b vaccine in 10 states of the country. measles second dose was introduced in 2010; hep b vaccination scaled up in the entire country in 2011-12, and haemophilus influenzae type b (hib) as pentavalent vaccine was introduced in 2 states in late 2011.5-7 pentavalent vaccine protects from hep b along with diphtheria, pertussis, tetanus, and hib. in kerala and tn, it has been launched in 2011.8 majority of lessons from this evaluation contributed to planning new vaccine introductions in india. the government of india issued welldefined guidelines, changed policy use of opened vials in subsequent immunization sessions, conducted quality trainings prior to the vaccine introduction, and increased supervision and monitoring in vaccine introductions.1 a post-introduction evaluation of pentavalent vaccine introduction in tamil nadu and kerala states documented major experience and noted that the challenges identified in the hep b vaccine introduction were not present in pentavalent vaccine introduction.9 the pentavalent vaccine has been further scaled up to gujarat, haryana, karnataka, goa, jammu, kashmir and puducherry in 2012-13 and there is plan for countrywide roll out in 2014.8 similarly, india has developed an indigenous rotavirus vaccine, which is likely to healthcare in low-resource settings 2014; volume 2:2116 correspondence: mohan bairwa, centre for community medicine, all india institute of medical sciences, new delhi 110029, india. tel: +91.97188.35447. e-mail: drmohanbairwa@gmail.com key words: hepatitis b vaccine, health program, newer health interventions. note: the opinions expressed by the author do not necessarily reflect the opinions of the all india institute of medical sciences, new delhi, india. received for publication: 25 december 2013. revision received: 12 august 2014. accepted for publication: 26 september 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m. bairwa, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:2116 doi:10.4081/hls.2014.2116 non co mmerc ial us e o nly [page 54] [healthcare in low-resource settings 2014; 2:2116] be considered for possible introduction in indian uip. a number of states in india plan to introduce the vaccine in their state immunization programs.10 thus, such evaluation may help in widely spreading programmatic benefits and improving program performance in india. vaccine introductions are not that different from the introduction of other health interventions. india aims to achieve millennium development goal 4 and national goals of reducing child mortality and a number of new initiatives are being already implemented and planned for improving child survival in india, under the national rural health mission (nrhm).11 the lessons from this evaluation are potential for being used for scale up of other health interventions. one of the major challenges in health programs in india is the limited focus on evaluations and correctives measures. however, the scenario is apparently changing now and numbers of evaluations are being conducted including common review missions in nrhm.12,13 the robust evaluation used for programmatic corrections is likely to benefit program implementation in the country and show health impact. references 1. lahariya c, subramanya bp, sosler s. an assessment of hepatitis b vaccine introduction in india: lessons for roll out and scale up of new vaccines in immunization programs. indian j public health 2013;57: 8-14. 2. verma r, khanna p, prinja s, et al. hepatitis b vaccine in national immunization schedule: a preventive step in india. hum vaccines 2011;7:1387-8. 3. government of india. operational guidelines for hepatitis b introduction in uip in india, 2009. new delhi: ministry of health and family welfare, government of india; 2009. 4. dandona l, raban mz, dandona r. analysis of evaluations of health system/policy interventions in india. natl med j india 2011;24:263-8. 5. gupta sk, sosler s, lahariya c. introduction of haemophilus influenzae type b as liquid pentavalent (dpt+hepb+hib) vaccine in 2 states of india. indian pediatr 2012;49:707-9. 6. verma r, khanna p, bairwa m, et al. introduction of a second dose of measles in national immunization program in india: a major step towards eradication. hum vaccines 2011;7:1109-11. 7. gupta sk, sosler s, haldar p, et al. introduction strategy of a second dose measles containing vaccine in india. indian pediatr 2011;48:379-82. 8. bairwa m, pilania m, rajput m, et al. pentavalent vaccine: a major breakthrough in india’s universal immunization programme. hum vaccines 2012;8:1314-6. 9. who. post introduction evaluation of pentavalent (dpt+hepb+hib) vaccine in tamil nadu and kerala, india, report 2012. new delhi: world health organization country office for india publ.; 2013. 10. government of india. press information bureau note on indigenous rotavirus vaccine in india. new delhi: government of india publ.; 2013. 11. government of india. national rural health mission. available from: www.nrhm.gov.in 12. government of india. sixth common review mission of nrhm. available from: http://nrhm.gov.in/monitoring/commonreview-mission/6th-common-review-mission-crm.html 13. lahariya c, dhawan j, pandey rm, et al. inter-district variations in child health status and health services utilization: lessons for health sector priority setting and planning from a cross-sectional survey in rural india. natl med j india 2012;25:137-41. letter to the editor non co mmerc ial us e o nly hrev_master the antiviral properties of edible medicinal plants: potential remedies against coronaviruses takele taye desta,1 kero jemal,2 rediet sitotaw,1 debissa lemessa,3 melesse maryo,1,4 alemtshay teka,5 tewodros mulugeta1 1department of biology, college of natural and computational science, kotebe university of education, addis ababa; 2aklilu lemma institute of pathobiology, addis ababa university, addis ababa; 3deparment of plant biology and biodiversity management, college of natural and computational sciences, addis ababa university, addis ababa; 4ethiopian biodiversity institute, addis ababa; 5endod and other medicinal plants research unit, aklilu lemma institute of pathobiology, addis ababa university, addis ababa, ethiopia abstract sars-cov-2 (severe acute respiratory syndrome coronavirus 2) is an unparalleled challenge for the international community. subsequently, an extraordinary effort has been made to contain sars-cov-2. however, this has been largely limited to behavioral changes and vaccination. to make the containment strategies effective, behavioral changes and vaccination need to be complemented with alternative prevention methods and curative treatments. this work reports the antiviral properties of some of the commonly known edible medicinal plants that can be used as potential remedies to suppress coronaviruses. a growing body of evidence substantiates that edible medicinal plants with antiviral properties that have been proven effective against sibling coronaviruses likely contain the spread of sars-cov-2, and they may also suppress the fatality of covid-19 (coronavirus disease 2019). the secondary metabolites found in herbal medicines do not cause pathogens to develop drug resistance, which is a common problem in conventional medicines. the use of edible medicinal plants is much safer and causes less panic, thereby avoiding the fear associated with the use of herbal medicines. right dosages and mixtures of edible medicinal plants need to be rigorously investigated to circumvent unanticipated side effects and chronic health risks. introduction infections that are caused by pandemic contagions such as coronaviruses are imposing unprecedented challenges to global health.1,2 for example, several coronaviruses have threatened public health; among these is sars-cov (severe acute respiratory syndrome coronavirus 2), which shares a significant portion of its genomic structure and etiology with sars-cov-2.3 sars-cov-2 is highly infectious,4 however, it is less fatal than sars-cov.5 sarscov-2 is rapidly transmitted through coughing, sneezing, respiratory droplets, or aerosols4 and contagiously via infectious secretions.6 hitherto, there is no effective treatment for covid-19.4,7 therefore, the most reliable containment strategies are behavioral changes8 – such as social distancing, enhancing hygiene, and the use of personal protection equipment. tremendous efforts have been made to develop vaccines5 and vaccination has commenced. however, vaccination needs to be supported by complementary preventive, suppressive, or curative treatments. moreover, based on the epidemiology of covid-19, sars-cov-2 may not last soon,9 and given the recent bunch of contagions we have faced novel coronaviruses could instantly emerge; therefore, prevention and treatment efforts need to be intensified and supported by alternative and complementary medications. although the impact of coronaviruses has been significantly decreased, worldometers data for april 26, 202310 (https://www.worldometers.info/coronavirus/) shows that there are ~687 million registered cases and ~6.9 million coronavirus-related deaths. still, a few new cases of coronavirus are registered daily in the worldometers database. all-inclusive efforts need to be made to avoid the devastating impact of the coronavirus. among the complementary strategies, the most environmentally friendly and safer one could be the use of edible medicinal plants. in the history of mankind, plants have been used as key ingredients for nourishment. paleontological evidence shows that the omnivorous modern-day human once in the course of his evolutionary history was herbivorous.11 consequently, plants make up the largest portion of the diet of modern humans. accordingly, the digestive system microflora have developed symbiosis to digest and absorb plant-derived compounds.12 this has made plants ubiquitously consumed healthy foods. some of these plants are not exclusively used as food but also as medicine. for example, an extensive list of medicinal plants with antiviral properties of which some are edible was reviewed by yasmin et al.13 moreover, a long list of edible medicinal plants was produced in the traditional chinese medicine systems pharmacology database,14-16 the encyclopedia of traditional chinese medicine,15 and symmap.16 several edible medicinal plants have been also used to treat diseases in india.17 interestingly, zhang et al.18 have screened insilco chinese medicinal plant databases and have proposed several traditional medicines (some of them might be edible) that can be used to contain sars-cov-2 or to treat covid19. to increase the prudent use of medicinal plants, it is essential to compile relevant literature on the most recent advancements in the treatment of coronaviruses and sibling respiratory syndromes with edible medicinal plants as well as the ongoing debates regarding the use of conventional medicines versus traditional medicinal plants. healthcare in low-resource settings 2023; volume 11:11205 takele taye desta, department of biology, college of natural and computational science, kotebe university of education, addis ababa, ethiopia. e-mail: takele_taye@yahoo.com key words: sars-cov-2, covid-19, edible medicinal plants, the antiviral properties of phytochemicals, docking effect. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. informed consent: not applicable. patient consent for publication: not applicable. received for publication: 24 january 2023. accepted for publication: 7 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11205 doi:10.4081/hls.2023.11205 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 22] [healthcare in low-resource settings 2023; 11:11205] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11205] [page 23] materials and methods while organizing this report, the pursued pieces of literature were looked through using google scholar, and the keywords “medicinal plants and coronavirus” were used as search items. as a result, the findings that identified medicinal plants that have been widely used for human consumption and have been used to treat coronaviruses and sibling respiratory syndromes were discussed in this report. results and discussions the unique importance of medicinal plants interestingly, medicinal plants have been validated and used for a long time to produce several drugs with potent antiviral properties.19 traditionally, plant substances have been used as medicine for more than 5000 years.20 this shows that there is an enriching pool of traditional knowledge and wisdom aligned with the utilization of medicinal plants. several studies have been conducted on the pharmacological properties of herbal medicines; however, the number of good quality clinical studies is limited (see for instance the review by eng et al.21 and the references listed in supplementary table 1),22-44 which constrains the broader use of edible medicinal plants. however, chinese and koreans have developed guidelines for traditional medicines, for example, to treat covid-19.7 medicinal plants possess several natural compounds with phytomedicinal properties, subsequently, they are usually broad-spectrum.9,17 therefore, they can be used to treat coinfections9 and comorbidities that aggravate the fatality of the disease in question. since the bioactive compounds of medicinal plants are readily absorbable, they can be used to prevent several infections affecting different parts of the body and related physiological functions. edible medicinal plants are safe to use besides affordability and being ubiquitous and highly diverse, edible medicinal plants with reasonable assumptions may not have side effects or long-lasting health risks, provided that the right dose and appropriate pharmacological procedures are adopted.45 edible medicinal plants could be wild and/or semi-domesticated types, commonly or rarely consumed. since edible medicinal plants are part of our daily meals,2,17 their basic characteristics are widely known by the general populace, which may then help to reduce the adverse impact of unforeseen effects. therefore, the use of edible medicinal plants lowers the fear and skepticism prevailing against herbal medicines. interestingly, medicinal plants are less susceptible to drug resistance usually developed by pathogens that are repeatedly exposed to a conventional drug17, and when there is inappropriate (indiscriminate), irregular, and irrational (improper) use of antibiotics.46,47 medicinal plants have a lot of secondary metabolites and phytochemicals, and these substances provide medicinal plants with several therapeutic roles.47 the activity of secondary metabolites (either in the intermediate or end-product form) found in the crude extracts of medicinal plants suppresses the development of drug resistance in the microbes.46 this special attribute of medicinal plants and the side effect of using synthetic drugs may have conferred medicinal plants with broadspectrum uses. medicinal plants are readily biodegradable; therefore, they do not cause environmental pollution. herbal medicines are widely used16, and their utilization is gaining importance.45 for example, 80 percent of the world’s population mainly relies on medicinal plants.48 interestingly, herbal medicines contain several active substances review figure 1. the mode of action of extracts of medicinal plants on viruses causing respiratory syndromes. medicinal plant extracts can inhibit the invasion of viruses into the animal’s cells, and the infected cells sensitize themselves against the entry of the virus (ifn-production) (1). medicinal plant extracts may have viral hemagglutinin or neuraminidase activity (2). medicinal plant extracts may inhibit the replication of viral rna (3). medicinal plant extracts may block the synthesis of viral proteins (4). medicinal plant extracts may inhibit the spread of the virus in the host (5). medicinal plant extracts may block the activity of viral proteins and enzymes (6, 7). medicinal plants' phytochemicals can be extracted using various methods (8). non -co mmerc ial us e o nly [page 24] [healthcare in low-resource settings 2023; 11:11205] with therapeutic roles.21-44 however, the interaction of these substances may sometimes produce undesirable consequences. therefore, understanding the pharmacological properties, interactions, side effects, and underlying molecular mechanisms (docking effect) of edible medicinal plants is inevitable to enhance their utilization.21 bioactive phytochemicals and their antiviral properties bioactive phytochemicals with antimicrobial properties possessed by edible medicinal plants are used to cure and/or induce/enhance/modulate the immune response.17,49 the preventive and curative capacity of edible medicinal plants inhibits, attenuates, docks, or suppresses the entry and cellular fusion, replication, infectivity, or fatality of the pathogens (figure 1).50 it is, therefore, vital to understand where and how phytochemicals specifically interact with or interrupt the life cycle of viruses, such as at the point of entry, replication, assembly, or release.45 however, the use of edible medicinal plants largely relies upon the knowledge and wisdom of traditional healers in the less developed world, and it is usually documented using the information retrieved from less rigorous field surveys and has not often been validated by clinical studies.51 this shows that carefully managed clinical studies should be carried out to avoid potential risks associated with the use of medicinal plants. conclusions this report suggests the cautious use of commonly available edible medicinal plants to acquire some level of immunity against sars-cov-2. however, it does not present an extensive list of medicinal plants and their mode of action. to enhance the safe use of edible medicinal plants extensive research needs to be conducted to unlock the active phytochemicals and secondary metabolites and their docking effect. moreover, an extensive review of the available literature needs to be conducted to identify the prevailing research gaps. references 1. desta tt. lifestyles and living standard disparities in the pandemicity of covid-19 in the global north versus the global south countries. geriatr care 2020;6:9025. 2. desta tt, mulugeta t. living with covid-19-triggered pseudoscience and conspiracies. int j public health 2020;65:713-4. 3. lu r, zhao x, li j, et al. genomic characterisation and epidemiology of 2019 novel coronavirus: implications for virus origins and receptor binding. lancet 2020;395:565-74. 4. shereen 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from natural polyphenols: an in silico strategy unveils a hope against corona. accessed on 26/1/2023. available from: https://www.preprints.org/manuscript/2 02003.0333/v1 40. jo s, kim s, shin dh, kim ms. inhibition of sars-cov 3cl protease by flavonoids. j enzyme inhib med chem 2020;35:145-51. 41. ho ty, wu sl, chen jc, et al. emodin blocks the sars coronavirus spike protein and angiotensin-converting enzyme 2 interaction. antiviral res 2007;74:92-101. 42. abouelela me, assaf hk, abdelhamid ra, et al. identification of potential sarscov-2 main protease and spike protein inhibitors from the genus aloe: an in silico study for drug development. molecules 2021;26: 1767. 43. cheng l, zheng w, li m, et al. citrus fruits are rich in flavonoids for immunoregulation and potential targeting ace2. accessed on 26/1/2023. available from: https://www. preprints. org/manuscript/202002.0313/v1 44. chen f, chan kh, jiang y, et al. in vitro susceptibility of 10 clinical isolates of sars coronavirus to selected antiviral compounds. j clin virol 2004;31:69-75. 45. ahmad a, rehman mu, alkharfy km. an alternative approach to minimize the risk of coronavirus (covid-19) and similar infections. eur rev med pharmacol sci 2020;24:4030-4. 46. gupta pd, birdi tj. development of botanicals to combat antibiotic resistance. j ayurveda integr med 2017;8: 266-75. 47. anand u, jacobo-herrera n, altemimi a, lakhssassi n. a comprehensive review on medicinal plants as antimicrobial therapeutics: potential avenues of biocompatible drug discovery. metabolites 2019;9:258. 48. world health organization. regional office for the western pacific. medicinal plants in the south pacific: information on 102 commonly used medicinal plants in the south pacific. 1998. available from: https://apps. who.int/iris/handle/10665/207584 49. fuzimoto ad, isidoro c. the antiviral and coronavirus-host protein pathways inhibiting properties of herbs and natural compounds-additional weapons in the fight against the covid-19 pandemic? j tradit complement med 2020;10:405-19. 50. huang f, li y, leung el, et al. a review of therapeutic agents and chinese herbal medicines against sars-cov-2 (covid-19). pharmacol res 2020;158:104929. 51. tuasha n, petros b, asfaw z. medicinal plants used by traditional healers to treat malignancies and other human ailments in dalle district, sidama zone, ethiopia. j ethnobiol ethnomedicine 2018;14:1-21. review online supplementary materials table 1. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11217 the implementation of code blue by nurses as first responders in outpatient and inpatient rooms at malang indonesia hospital tony suharsono,¹ sunarmi,1,2 nur ida,1,2 bella nove khirria,1,2 nazla asrin,1,2 ikhda ulya1 1nursing department, faculty of health sciences, universitas brawijaya, indonesia; 2bachelor nursing program, faculty of health sciences, universitas of brawijaya, indonesia abstract introduction: in-hospital cardiac arrest (ihca) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. nurses in public care rooms and outpatients are expected to be first responders to ihca until an activated hospital code blue team arrives. therefore, this study aims to analyze the implementation of code blue response by nurses in outpatient and hospital inpatient rooms in malang. design and methods: this is a quantitative study that uses observational methods with a cross-sectional approach comprising of 109 inpatient and outpatient care room nurses from 9 hospitals in malang. the implementation of code blue was measured by a simulated case of adult cardiac arrest in a hospital inpatient room. results: the nurses involved were 67.0% female, where the majority have a d3 education qualification (57.7%), with more than ten years working experience (45%). furthermore, 83.5% of nurses work in regular care rooms and 16.5% come from outpatient rooms. the results showed that the implementation of code blue by nurses in regular care and inpatient rooms was 66.7% and 65.9%, respectively in the insufficient categories. in addition, the mann-whitney u test obtained a p-value of 0.929. conclusions: in conclusion, there was no significant difference in the implementation of code blue that occurred in the inpatient and outpatient rooms. further studies were recommended to observe code blue events directly and take samples with balanced proportions. introduction cardiac arrest is a case that often occurs in the intensive care unit, the general ward, or the outpatient room.1 t is a sudden cessation of heart function in a person characterized by the absence of pulse and other signs of circulation.2 the survival rate following in-hospital cardiac arrests has been reported to be 7–26.7%. according to a study, cpr had survival rates of 14.7%, 16%, and 12% in the u.s., the u.k., and turkey, respectively. furthermore, reported that this rate after cpr varies in different countries and is generally low.3,4 cardiopulmonary resuscitation (cpr) is one of the most stressful events for nurses that require immediate action with a survival rate as low as 20% and their speed and performance affect survival after cpr.5,6 the study reported that the survival rate data for outpatients is 4.3% while inpatients have a much better survival, which is 14.88%.7 some of the factors that affect the survival of these patients include age, duration of cpr, delay in starting cpr, and speed of the team arriving at the scene.8 due to its critical life-saving role, the current study on cpr and ed nurses focused on improving performance for patient outcomes.9 lack of cpr skills of nurses and physicians contributes to the poor outcome of cardiac arrest victims,10-11 therefore, it is their professional responsibility to remain competent through regular updates.12,13 cardiac arrest is a leading cause of death in hospitals, therefore, special attention is required in its handling. some of the strategies developed by hospitals to prevent cardiac arrest deaths include implementing early warning systems, forming rapid response teams, and building a code blue system that provides a follow-up response.8,14 the code blue team aims to provide help quickly and appropriately to improve the survival rate of cardiac arrest victims in the hospital, through continued assistance and defibrillation.15 the nurses are responsible for initiating the cpr and performing basic life support until the team arrives; therefore, they need to be informed of and follow the cpr rules.16 design and methods this quantitative study uses observational methods with a cross-sectional approach and was conducted between 17-21 december 2020 on nurses working at certain hospitals in the malang region. the inclusion criteria of respondents in this study were nurses who worked in the general ward and nurses who worked in hospitals that had implemented the code blue system. the respondents comprises 109 inpatient and 91 outpatient nurses working in the general ward, outpatient care unit of 9 hospitals in malang region and were not part of a code blue team (table 1). the instrument used in this study was a questionnaire containing data on the characteristics of respondents and an overview of the implementation of code blue include the initial response of nurses in the treatment room and identification of the quality of cpr actions performed by nurses who responded early using the code blue implementation guide developed by american heart article significance for public health in-hospital cardiac arrest (ihca) is a frequent occurrence that necessitates prompt and appropriate assistance to improve survival rates. nurses in public care rooms and outpatients are expected to be first responders to ihca until an activated hospital code blue team arrives. the application of the code blue response by nurses in outpatient and hospital inpatient rooms in malang is documented in this study. [healthcare in low-resource settings 2023; 11(s1):11217] [page 169] non -co mmerc ial us e o nly association by measuring a simulated case of adult cardiac arrest in the hospital by asking when and how to call the code blue team, and what to do while waiting for their arrival. data were collected using a google form requiring the respondents’ id card that shows where they work and also fill out a statement indicating that they are not a member of the code blue team. the completely and validly filled data were presented and univariate analysis was conducted. the bivariate test was conducted using the mann-whitney u test because the data obtained is not normally distributed. the level of confidence used is 5%. furthermore, ethical clearance was obtained from the faculty of medicine, universitas brawijaya with no. 212/ec/kepk/12/2020. result and discussion the majority of respondents in the study were female and were in their early adult age range. also, nearly half of the patients are nurses with over 10s years of working experience and 98% of the respondents had participated in socialization and code blue simulations in their workplace hospital. about 93% of nurses did not consider advanced cardiac arrest and code blue system. the results showed that there was no significant difference in the implementation of code blue in inpatient and outpatient rooms (table 2 and 3). the majority of respondents had participated in socialization and code blue simulations organized by their workplace hospitals in the past year. this condition shows good understanding and acceptance by nurses when receiving materials and following simulations, ensuring that its implementation throughout the rooms in the hospital is relatively the same. the results are consistent with the reports of the study that code blue simulation can improve ability and confidence.17-20 furthermore, high-fidelity simulation has the potential to help hcps retain the necessary knowledge to perform cpr successfully.21 the nurses involved in this study have also participated in basic life support training, which includes basic relief in cardiac arrest patients. they were taught periodically how to recognize cardiac arrest conditions, activate code blue, perform pulmonary resuscitation, and use aed while waiting for further helpers. furthermore, there was a significant improvement in nurses’ knowledge and abilities after a brief training in bls, and some information and skills were retained after six months.22-24 they were also able to recognize cardiac arrest conditions and perform well-conscious examinations. meanwhile, the method of calling the team code blue in this study is to reach a call a specific number using a telephone. some hospitals use phones with special lines to activate code blue by calling the team through the emergency installation telephone number and then calling certain units to forward the information to all units. this is consistent with the reports of the study that some of the ways to activate the team include telephone calls and pressing the code blue button, however, no hospital has used gps to detect the location of the incident.25 the part of nurses’ role as the first helper of cardiac arrest that requires improvement is the effort to locate and use the aed that has been placed by the hospital to minimize delays in defibrillation of cardiac arrest patients. additionally, most nurses have performed well in their function of chest compression while waiting for the team’s arrival. based on the results, the factors that affect the outcome of cpr include delayed attendance of the team, inadequate skill, and deficient cpr equipment.26 three types of barriers were identified, namely procedural barrier, which is the time lost due to language and communication issues as well as telephone problems. the second and third barriers include cpr knowledge (skill deficits, perceived benefit), and personal factors.27 the study’s limitations include an imbalanced number of respondents and the lack of measurement of code blue application during the simulation procedure. furthermore, the number of inpatient and outpatient nurse respondents should be equal to compare and measure the implementation of code blue using direct simulation rather than surveys. conclusions the majority of code blue implementation by nurses as the first helper on cardiac arrest in the hospital is sufficient. furthermore, there is no significant difference between the implementation in article [page 170] [healthcare in low-resource settings 2023; 11(s1):11217] table 1. respondent characteristics. variable category n (%) sex male 36 33 female 73 67 total 109 100 low* <5 years 26 23.9 5-10 years 34 31.2 >10 years 49 45 total 109 100 work place walking clinic 18 16.5 general ward 91 83.5 total 109 100 *low: length of work . table 2. implementation of code blue by nurses in outpatient and inpatient rooms. variable category n (%) implementation of code blue less 36 33 fair 72 66.1 good 1 0.9 total 109 100 table 3. difference in implementation of code blue by nurses in the inpatient and outpatient room. implementation of code blue room less fair good p n % n % n % opr* 6 33.3% 12 66.7% 0 0% 0.929 ipr* 30 33.0% 60 65.9% 1 1.1% 36 33.0% 72 66.1% 1 0.9% *opr; outpatient room; ipr: inpatient room. non -co mmerc ial us e o nly the outpatient and inpatient room. hence, hospitals need to consistently socialize and simulate code blue to maintain nurses’ ability to help cardiac arrest victims in the hospital. references 1. ardiansyah f, nurachmah e, adam m. determining the quality of compression of pulmonary heart resuscitation by nurses. jurnal aisyiah medika 2019;3:123–137. 2. ismiroja r, mulyadi, kiling m. experience of nurses in handling cardiac arrest in the emergency department of the hospital prof. dr. r. d. kandou manado. jurnal keperawatan 2018;6(2). 3. amini s, moghadamnia mt, paryad e, et al. factors associated with survival rate after cardiopulmonary resuscitation. j holistic nurs midw 2017;27:1–7. 4. miranzadeh s, adib-hajbaghery m, hosseinpour n. a prospective study of survival after in-hospital cardiopulmonary resuscitation and its related factors. trauma mont 2016;21:e31796. 5. virani ss, alonso a, aparicio hj, et al. heart disease and stroke statistics—2021 update: a report from the american heart association. circulation 2021 feb 23;143:e254-e743. 6. dwyer t, mosel wi. nurses behavior regarding cpr and the theories of reasoned action and planned behavior. resuscitation 2002;52:85–90. 7. raffee la, samrah sm, al yousef hn, et al. incidence, characteristics, and survival trend of cardiopulmonary resuscitation following in-hospital compared to out-of-hospital cardiac arrest in northern jordan. indian j crit care med 2017;21:436–441. 8. yu sj, gang is. the oriental medicine hospital staff’s educational status, knowledge, attitudes, and self-confidence in performing cpr. korean j health serv manag 2014;8:109-119. 9. pasalli c, pantazopolous i, dontas i, et al. evaluation of nurses’ and doctors’ knowledge of basic & advanced life support resuscitation guidelines. nurse educ pract 2011;11:365-369. 10. perkin gd, boyle w, bridgestock h, et al. quality of cpr during advanced resuscitation training. resuscitation 2008;77:6974. 11. castle n, garton h, kenward g. confidence vs competence: basic life support skills of health professionals. br j nurs 2013;16:664-6. 12. niles d, sutton rm, donoghue a, et al. “rolling refreshers”: a novel approach to maintain cpr psychomotor skill competence. resuscitation 2009;80:909-912. 13. chan ps, krumholz, hm, nichol g, et al. delayed time to defibrillation after in-hospital cardiac arrest. n engl j med 2008;358:9–17. 14. sullivan nj, duval-arnould j, twilley m, et al. simulation exercise to improve retention of cardiopulmonary resuscitation priorities for in-hospital cardiac arrests: a randomized controlled trial. resuscitation 2015;86:6–13. 15. dame r, kumaat l, laihad m. overview of the level of knowledge of nurses about code blue system at rsup prof. dr. r. d. kandou manado. e-clini c 2018;6:162–168. 16. porter je, peck b, mcnabb tj, et al. a review of code blue activations in a single regional australian healthcare service: a retrospective descriptive study of riskman data. j clin nurs 2020;29:221–227. 17. eroglu se, onur o, urgan o, et al. blue code: is it a real emergency? world j emerg med 2014;5:20–23. 18. spehe j, march a, wilson c, et al. the effect of videoconferencing on code blue simulation training. clin simul nurs 2016;12:260-267. 19. everett-thomas r, turnbull-horton v, valdes b, et al. the influence of high fidelity simulation on first responders retention of cpr knowledge. appl nurs res 2016;30:94-7. 20. mpotos n, karel d, vincent vb, et al. automated testing combined with automated retraining to improve cpr skill level in emergency nurses. nurse educ pract 2015;15:12-21. 21. umuhoza c, chen l, unyuzumutima j, et al. impact of structured basic life-support course on nurses’ cardiopulmonary resuscitation knowledge and skills: experience of a pediatric department in a low-resource country. afr j emerg med 2021;11:366-371. 22. watanabe k, lopez-colon d, shuster jj, et al. efficacy and retention of basic life support education including automated external defibrillator usage during a physical education peri article [healthcare in low-resource settings 2023; 11(s1):11217] [page 171] correspondence: ikhda ulya, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: ikhda.fk@ub.ac.id key words: code blue, nurses, outpatient, inpatient. acknowledgment: the authors are grateful to the research development and community service agency of the medical faculty of brawijaya university for funding this study contributions: all authors contributed equally to this article. iu, s, ni, na conducted this study & ts served as chief of research project and reviewed the final article. conflict of interests: the author declares no conflict of interest. funding: this study was financially supported by the research development and community services agency of the medical faculty of brawijaya university. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. clinical trials: this study has been approved by health research ethics committee of faculty of medicine, university of brawijaya malang. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 6 december 2021. accepted for publication: 15 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11217 doi:10.4081/hls.2023.11217 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly od. prev med rep 2017;5:263–267. 23. madsen j, lauridsen k, lofgren b. in-hospital cardiac arrest call procedures and delays of the cardiac arrest team: a nationwide study. resuscitation plus 2021;5:100087. 24. janatolmakan m, nouri r, soroush a, et al. barriers to the success of cardiopulmonary resuscitation from the perspective of iranian nurses: a qualitative content analysis. int emerg nurs 2021;54:100954. 25. casea r, susie c, siedenburga j, et al. identifying barriers to the provision of bystander cardiopulmonary resuscitation (cpr) in high-risk regions: a qualitative review of emergency calls. resuscitation 2018;129:43-47. article [page 172] [healthcare in low-resource settings 2023; 11(s1):11217] non -co mmerc ial us e o nly hrev_master [page 34] [healthcare in low-resource settings 2015; 3:4946] impact of umbilical cord cleansing with 4% chlorhexidine on rate of omphalitis and separation time among newborns in khartoum state, sudan abdelmoneim e.m. kheir,1 amna m.a. mustafa,2 awatif a. osman2 1department of paediatrics and child health, faculty of medicine, university of khartoum; 2nursing school, university of medical sciences and technology, khartoum, sudan abstract infection of the umbilical cord remains high in developing countries with subsequent increase in neonatal mortality rates. this may be due to the practice of applying potentially harmful substances to the freshly cut cord. the aim of this study was to assess the impact of umbilical cord care with 4% chlorhexidine on the rate of omphalitis and separation time among newborns in khartoum state. this was a quasi-experimental research design that was carried out in the main maternity hospitals of khartoum state between february and august 2012. one hundred mothers and their respective babies were selected by convenience sampling and were divided equally into intervention and control groups. the tools used for data collection were a questionnaire and an observational checklist. the data were analyzed using statistical package for social sciences version 17 for descriptive and inferential statistics. umbilical cord training was effective in enhancing mothers’ knowledge and skills in the intervention group. the result showed that the omphalitis rate was reduced significantly in the intervention group; also the intervention group had a shorter separation time (mean=5.02) compared to the control group (mean=7.24). in conclusion, the application of 4% chlorhexidine on the freshly cut umbilical cord stump, significantly reduces omphalitis rate. this inexpensive and simple intervention can save a significant number of newborn lives in developing countries. introduction globally, there are approximately 3.3 million neonatal death each year, 98% of these occur in developing countries, more than half associated with home delivery, a third are due to infection.1,2 the umbilical cord stump constitutes a potential area for infection due to the presence of necrotic tissue that speeds up the colonization of organisms. about 2 to 7% of infants born in low resource countries develop omphalitis, 10% of these are severe with redness and discharge. of all neonates with omphalitis, 2 to 15% die of a systemic infection or neonatal sepsis.3 while umbilical cord infections can occur in all settings, they are more likely to occur in developing countries, where the majority of births take place at home and are not attended by a skilled person.4 the high mortality rate among neonates in developing countries as a result of omphalitis can be attributed to the practice of applying potentially harmful substances such as animal dung to the cord stump after it is cut.5,6 since 1998, the world health organization has recommended promotion of clean and dry cord care for newborn infants, while noting that topical antiseptics may be used where risk of infections is high.7 topical antiseptic agents were used widely over the past years, despite a lack of conclusive evidence that these agents can reduce infection rates.8 in the past, chlorhexidine (chx) was used widely in newborn intensive care units in western countries.3 chlorhexidine is an antiseptic agent that reduces the risk of acquiring infections in different health care settings. it has a high safety profile with little bacterial resistance, it reduces infection rates as well as bacterial colony counts.9,10 recently, three large community-based randomized trials have been conducted in nepal,11 pakistan12 and bangladesh13 to study the effectiveness of application of 4.0% chx to the umbilical cord after birth; all 3 south asian trials showed fairly similar, statistically significant protective effects against mortality with reduction rates ranging from 6% to 38%. the aim of this study is to i) assess the effect of umbilical cord cleansing with 4% chx on rate of omphalitis and separation time among newborns in khartoum state; ii) assess the existing knowledge scores of mothers towards umbilical cord care at pre-test; and iii) assess the existing skill scores of mothers towards umbilical cord care at post-test. materials and methods this was a quasi-experimental research design in which randomization is missing so it offers less tightness against bias. it was carried out in the main maternity hospitals of khartoum state between february and august 2012. one hundred mothers and their respective babies were selected by convenience sampling, which involves the selection of the most easily accessible members of the target population and were divided equally into intervention and control groups. in the intervention group the mothers were given health education about the importance of umbilical cord care and the risks of traditional practices on the umbilicus. the mothers were also told about the signs of omphalitis, on how to apply 4% chx and to make sure that their hands were carefully washed before and after dressing. mothers were told to apply chx by a clean cotton wool daily for seven days, and then followed up at home three times on day 2, 3, and 7. the newborns were observed for occurrence of omphalitis, and the cord separation time. the signs of omphalitis included odor, erythema, swelling, and discharge. omphalitis was graded into mild, moderate and severe depending on the number of signs present. the inclusion criteria applied included full term babies on the first day of life without any complications at birth and who were either delivered by normal delivery or caesarian section. preterm babies and those born outside hospital settings were excluded from the study. the tools used for data collection were a questionnaire (appendix) and an observation healthcare in low-resource settings 2015; volume 3:4946 correspondence: abdelmoneim e.m. kheir, department of paediatrics and child health, faculty of medicine, university of khartoum and soba university hospital, p.o. box 102, khartoum, sudan. tel.: +249.9.12313110 fax: +249.9.183776295. e-mail: moneimkheir62@hotmail.com acknowledgements: the authors express their sincere appreciation to the administration of all the hospital in khartoum for giving their approval and assistance in conducting this research. in addition, the authors are grateful to the mothers who participated willingly in this study. we dedicate this paper to professor awatif ahmed osman (co-author) who passed away recently. key words: umbilical cord; omphalitis; chlorhexidine; separation time; newborn. conflict of interest: the authors declare no potential conflict of interest. contributions: the authors contributed equally. received for publication: 10 january 2015. revision received: 13 may 2015. accepted for publication: 13 may 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.e.m. kheir et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4946 doi:10.4081/hls.2015.4946 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:4946] [page 35] al checklist. immediately after birth, a pre-test questionnaire was filled for both the intervention and the control groups. an immediate post training visit was carried out on day two to re-educate and observe the procedures, then on day three to check mothers’ skills, signs of omphalitis and separation time. on day seven the third checklist and the post questionnaire were conducted and data collected. home visits were extended up to 10 days for cord separation time. the main dependent variables were knowledge score, skill score, omphalitis rate and separation time. the main independent variable was training on use of chx, other independent variables were mother’s age, education, parity, occupation, weight and gender of neonates. the data were analyzed using statistical package for social sciences (spss) version 17 for descriptive and inferential statistics. chi square test was used to study the correlation between the dependent and the independent variables, an independent sample t-test was used to examine the differences in knowledge scores between the intervention and the control groups. p value was set on an alpha level at 0.05 and 95% confidence limit. ethical clearance and approval for conducting this study was obtained from the ethical committee of the university medical sciences and technology (irb00008867) and permission from the hospitals was received before conducting the study. prior informed consent was obtained from the mothers of the babies participating in this study after full explanation of the study. results a total of 100 mothers and their respective babies were included in the study; they were divided equally into intervention and control group. regarding mothers’ education in the control group, 5 (10%) were illiterate, 17 (34%) received primary education, 14 (28%) secondary education and 14 (28%) were university graduates. whereas in the intervention group, 8 (16%) were illiterate, 15 (30%) primary education, 13 (26%) secondary education and 14 (28%) were university graduates. in the control group 4 (8%) mothers were employed and 46 (92%) were unemployed, whereas in the intervention group 5 (10%) mothers were employed and 45 (49.5%) were unemployed. there were no significant differences between intervention and control group related to level of education, occupation, and parity at pre-test (p=0.75, 0.5, 0.59) respectively. regarding mothers’ age, the mean age in the control group was 26.32 (minimum 16 and maximum 43) and in the intervention group was 25.25 (minimum 16 and maximum 35). regarding baby’s characteristics there were 26 (52%) males and 24 (48%) females in the control group, however there were 28 (56%) males and 22 (44%) females in the intervention group. the mean weight for babies in the control group was 3.035 (minimum 2.690 and maximum 4.500) whereas in the intervention the mean weight was 3.128 (minimum 2.500 and maximum 5.000). concerning the gestational age in the control group, the mean was 38.48 (minimum 37 and maximum was 40) whereas in the intervention group the mean gestational age was 38.16 (minimum 37 and maximum 39). there were no significant differences between intervention and control group related to sex, weight or gestational age at pre-test. (p=0.6, 0.44, 0.5), respectively. the study demonstrated that there were no significant differences of knowledge scores at pre-test between intervention and control group (p=0.412). the result supported the hypothesis that mothers in the intervention group and in the control group have equal knowledge at pretest. the 95% confidence interval for the difference of mean was ranging from -1.978 to -0.818 (figure 1). the present study showed that there were significant differences of knowledge scores at post-test between intervention and control groups. the result was significant (p=0.001). the result supported the hypothesis that mothers in the intervention group have higher score compared to the control group. the 95% confidence interval for the differences of mean was ranging from -11.10 to -9.06 (figure 2). the results showed that there were signifi article figure 1. error bars (two standard deviations above and below the mean) for the pre-test knowledge score for intervention and control groups. figure 2. error bars (two standard deviations above and below the mean) for the post-test knowledge score for intervention and control groups. non co mmerc ial us e o nly [page 36] [healthcare in low-resource settings 2015; 3:4946] cant differences of skills scores at post-test between intervention and control groups. the result was significant (p=0.001). the result supported the hypothesis that mothers in the intervention group have higher score compared to the control group. the 95% confidence interval for the differences of mean ranged from -3.09 to -2.59 (figure 3). a two-way contingency table analysis was conducted to evaluate whether the omphalitis rate in neonates who received umbilical cord care using chx was lower compared to neonates without chx (routine) umbilical cord care. the two variables were omphalitis and groups. omphalitis with four categories (none, mild, moderate and severe), and the groups with two categories (intervention and control). the omphalitis rate in the control group was 64% calculated as: mild omphalitis 12%, moderate 34%, and severe 18%. while in the intervention group there was no omphalitis with significant difference between the two groups (p=0.001) (figure 4). an independent sample t-test was conducted to evaluate separation time between intervention and control groups. the result was significant [t (98)=10.47, p=0.001]. the result supported the hypothesis that neonates in the intervention group had shorter separation time (mean=5.02, standard deviation=0.74) compared to the control group (mean=7.24, standard deviation=1.30). the 95% confidence interval for the difference of mean was ranging from 1.80 to 2.64 (figure 5). discussion neonatal sepsis remains a major cause of neonatal mortality in the first two weeks of life.14 around the globe and depending on the cultural background people apply harmful substances to the freshly cut cord stump, such as animal dung, ash or mud. this and other unhygienic exposures to the fresh wound could well account for a significant proportion of newborn sepsis. in the present study an attempt has been made to study the effect of umbilical cord cleansing with 4% chx on rate of omphalitis and separation time among newborns in khartoum state. the study demonstrated that there were no statistically significant differences in demographic data between intervention and control groups. however, the knowledge score for both intervention and control group was low at pretest, which is different from a study done in kenya where 40% of the mothers had good knowledge regarding care of the newborn umbilical cord. this difference could be attributed to increased level of education, living in middle class areas and increased maternal age.15 our study showed that there were significant differences of skills scores at post-test between intervention and control groups, which supported the hypothesis that mothers in the intervention group have higher score as 99.7% of the mothers have good skills regarding hand washing and care of the umbilical cord. this is in contrast to a study done in rural egypt where 43% of the mothers did not wash article figure 3. error bars (two standard deviations above and below the mean) for the post-test skills score for intervention and control groups. figure 4. cluster bar chart of omphalitis rate in the intervention and control groups. figure 5. cluster bar chart of cord separation time for intervention and control groups. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:4946] [page 37] their hands before neonatal care and only 7% washed hands after diaper change.16 this difference is simply due to intervention as mothers in our study were well educated and visited many times at home. the present study showed that the application of chx to the umbilical cord of a newborn baby can significantly reduce the rate of omphalitis compared with routine care without chx. the omphalitis rate in the control group was 64% compared with none in the intervention group. similar results were obtained in a large cluster randomized study in nepal involving over 15,000 infants delivered at home which compared the use of 4% chx to the umbilical cord stump on 7 of the first 10 days of life with soap and water or dry cord care. they found a 75% reduction in severe omphalitis and a 24% reduction in neonatal mortality. another study done in pakistan involving 9741 infants, also delivered at home, used a factorial design to evaluate daily umbilical cord chx treatment over 14 days and hand washing. they found no impact of hand washing on either the incidence of omphalitis or neonatal mortality, but a substantial reduction in both omphalitis and neonatal mortality in the chx group.17 our study demonstrated that neonates who received umbilical cord care using chx had shorter separation time compared to neonates without chx (routine) umbilical cord care (mean=5.02) compared to the control group (mean=7.24) with significant difference between the two groups. this is in contrast to many studies in this area which showed that topical chx increased cord separation time by 25-50%, which led to dissatisfaction among the caretakers who still accepted the intervention.18,19 this difference may be explained by the much larger sample size used in the other studies. however, further studies are definitely needed in this area. conclusions omphalitis is an important cause of neonatal mortality and preventing this condition and its associated neonatal mortality is of high public health importance. the use of 4% chx on the freshly cut umbilical cord stump significantly reduces omphalitis rate. this inexpensive and simple intervention can save a significant number of newborn lives in developing countries. references 1. black re, cousens s, johnson hl, et al. child health epidemiology reference group of who and unicef. global, regional, and national causes of child mortality in 2008: a systematic analysis. lancet 2010;375:1969-87. 2. oestergaard mz, inoue m, yoshida s, et al. united nations inter-agency group for child mortality estimation and the child health epidemiology reference group. neonatal mortality levels for 193 countries in 2009 with trends since 1990: a systematic analysis of progress, projections, and priorities. plos med 2011;8:e1001080. 3. mullany lc, darmstadt gl, tielsch jm. role of antimicrobial applications to the umbilical cord in neonates to prevent bacterial colonization and infection: a review of the evidence. pediatr infect dis j 2003;22:996-1002. 4. mullany lc, darmstadt gl, katz j, et al. risk of mortality subsequent to umbilical cord infection among newborns of southern nepal: cord infection and mortality. pediatr infect dis j 2009;28:17-20. 5. agrawal pk, agrawal s, mullany lc, et al. clean cord care practices and neonatal mortality: evidence from rural uttar pradesh, india. j epidemiol commun h 2012;66:755-8. 6. darmstadt gl, hussein mh, winch pj, et al. practices of rural egyptian birth attendants during the antenatal, intrapartum and early neonatal periods. j health popul nutr 2008;26:36-45. 7. capurro h. topical umbilical cord care at birth: rhl practical aspects: rhl practical aspects. geneva, switzerland: world health organization; 2004. 8. zupan j, garner p, omari aaa. topical umbilical cord care at birth. cochrane db syst rev 2004;3:cd001057. 9. goldenberg rl, mcclure em, saleem s, et al. the use of vaginally administered chlorhexidine during labor to improve pregnancy outcomes: a systematic review. obstet gynecol 2006;107:1139-46. 10. mcclure em, goldenberg rl, brandes n, et al. the use of chlorhexidine to reduce maternal and neonatal mortality and morbidity in low-resource settings. int j gynecol obstet 2007;97:89-94. 11. mullany lc, darmstadt gl, khatry sk, et al. topical applications of chlorhexidine to the umbilical cord for prevention of omphalitis and neonatal mortality in southern nepal: a community-based, cluster-randomised trial. lancet 2006; 367:910-8. 12. soofi s, cousens s, imdad a, et al. topical application of chlorhexidine to neonatal umbilical cords for prevention of omphalitis and neonatal mortality in a rural district of pakistan: a community-based, cluster-randomised trial. lancet 2012; 379:1029-36. 13. arifeen se, mullany lc, shah r, et al. the effect of cord cleansing with chlorhexidine on neonatal mortality in rural bangladesh: a community-based, cluster-randomised trial. lancet 2012;379:1022-8. 14. liu l, johnson hl, cousens s, et al. global, regional, and national causes of child mortality: an updated systematic analysis for 2010 with time trends since 2000. lancet 2012;379:2151-61. 15. obimbo e, musoke rn, were f. knowledge, attitudes and practices of mothers and knowledge of health workers regarding care of the newborn umbilical cord. e afr med j 1999;76:425-9. 16. darmstadt gl, hussein mh, winch pj, et al. neonatal home care practices in rural egypt during the first week of life. trop med int health 2007;12:783-97. 17. goldenberg rl, mcclure em, saleem s. a review of studies with chlorhexidine applied directly to the umbilical cord. am j perinat 2013;30:699-701. 18. mullany lc, shah r, el arifeen s, et al. chlorhexidine cleansing of the umbilical cord and separation time: a cluster-randomized trial. pediatrics 2013;131:708-15. 19. mullany lc, darmstadt gl, khatry sk, et al. impact of umbilical cord cleansing with 4.0% chlorhexidine on time to cord separation among newborns in southern nepal: a cluster-randomized, community-based trial. pediatrics 2006;118:1864-71. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2017; 5:6108] [page 1] factors associated with schistosomiasis control measures in mwaluphamba location, kwale county, kenya ahmad juma,1 arthur k.s. ng’etich,1 violet naanyu,2 ann mwangi,2 ruth c. kirinyet1 1department of epidemiology & biostatistics, school of public health, moi university, eldoret; 2department of behavioral sciences-school of medicine, moi university, eldoret, kenya abstract the study set out to investigate the factors associated with schistosomiasis control measures in mwaluphamba location of kwale county. a descriptive cross-sectional study design was used. mwaluphamba location was purposely sampled and simple random sampling was used to select 338 respondents in villages in each location. structured questionnaires were used to collect data. a majority of the respondents were males (60%), muslim affiliated (85%), aged 41 years and over (39%) and most (56%) of them had achieved at least a primary level of education. results showed that 40% of the respondents were knowledgeable of health education as a service offered by health care providers to control schistosomiasis. male respondents and those of islamic affiliation were five times (or: 4.686) and three times (or: 3.13) more likely to seek health education in comparison to their female counterparts respectively. respondents’ who had achieved at least a primary level of education and those that earned an income of above one thousand shillings significantly utilized mass treatment. respondents with income levels below a thousand shillings were less likely to seek both health education and mass treatment compared to those with a higher income. in conclusion, there was a statistically significant association between respondents’ socio-demographic factors and control measures for the infection. there is need for equal implementation of all control measures to overcome the socio-demographic barriers and to ensure effective control of schistosomiasis infection. introduction schistosomiasis is considered one of the neglected tropical diseases (ntd) and it is second only to malaria as the most devastating parasitic disease. in kenya, schistosomiasis is endemic with an estimated prevalence of between 5% to 65 % affecting over six million people.1 both schistosoma mansoni and schistosoma haematobium exist and are unequally distributed in several parts of the country. schistosoma haemotobium is high in most parts of the coastal belt as well as the lake basin. it is prevalent in scattered foci and sometimes mixed with schistosoma mansoni in eastern, central and nyanza provinces with mixed infections existing on the shores of lake victoria. the vectors for schistosoma mansoni and schistosoma haemotobium in kenya belong to species of snails of the genus biomphalaria and bolinus respectively.2 schistosomiasis may not be a major cause of mortality but it ranks highly as a cause of morbidity as assessed in hospital attendances as well as research that has been carried out in different parts of kenya.2 the prevalence of infection is increasing as a result of the water development programmes such as agriculture and recreational activities which encourage the establishment of snail vectors exposing communities to infected water.3 while the socio-economic impact including poor school attendance and performance is known, schistosomiasis has not been given the attention it deserves and continues to be a health problem for many developing countries.2 treatment of schistosomiasis infection has been increasing from 12.4 million in 2006 to 33.5 million in 2010 depicting an upward trend in its prevalence since the year 2002 when universal declaration to control the disease was made.4 the universal control measure of using chemotherapy to treat school-aged children and populations at risk of the infection in endemic areas of kenya has not bore much fruits compared to other parts of the world. this is attributed to lack of consistent access to vulnerable populations, late detection of infections and inconsistent supply of the praziquantel drugs for consistent treatment.2 the coastal area of kenya is a schistosoma haemotobium endemic area causing urinary schistosomiasis which is a major public health problem in kwale county of the coastal region.4 kwale county had a prevalence rate of 70% amongst school-going children despite the tireless campaign efforts by kenyan government and other non governmental organizations (ngos) towards prevention and control of schistosomiasis.5 current research shows that urinary schistosomiasis has a prevalence rate of 45% in tsimba location and above 80% among school-aged children and an average prevalence of 18.2% among adults in mwaluphamba location of kwale county.3,6 kenya medical research institute (kemri) and the kenyan government through concerted efforts have been implementing a mass treatment programme to control schistosomiasis over a long period of time but the prevalence of the infection still remains high in kwale county. the programme is focused on treatment of school-going children who are diagnosed with schistosomiasis.3 it is probable that the programme has not been fully effective in achieving a significant reduction in the prevalence of the infection given lack of attention to the specific factors associated healthcare in low-resource settings 2017; volume 5:6108 correspondence: arthur kipkemoi saitabau ng’etich, moi university, p.o. box 747030100, eldoret, kenya. tel.: +254710 890 400. email: arthursaitabau@yahoo.com key words: schistosomiasis, control measures, kwale county. contributions: aj, research idea conception, study designing, data collection, analysis, and interpretation of data; aksn, drafting and revising the manuscript and final review and approval of final version of manuscript for publication; vn, study design, interpretation of manuscript, revising manuscript and final approval of version to be published; am, data analysis review, revising of manuscript and approval of the final version for publication; rck, references check, revising of manuscript and approval of the final version for publication conflict of interest: the authors declare no potential conflict of interest. acknowledgements: we would like to express our sincere appreciation to the entire moi university school of public health academic fraternity for their guidance and more importantly their extensive knowledge in this area of research which informed the study. a special thank you to the people of mwaluphamba location for their participation in the study. received for publication: 23 june 2016. revision received: 2 december 2016 accepted for publication: 21 december 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a. juma et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6108 doi:10.4081/hls.2017.6108 non co mmerc ial us e o nly with the control of urinary schistosomiasis hence resulting to infection and re-infection of the population from time to time in the region. recent studies have advocated for use of an integrated approach to control schistosomiasis infection since the mass chemotherapy approach has been implemented for several years and yet the disease continues to be of a public health concern to most health sectors in sub-saharan countries.7 the current study gives in-depth insight on the factors affecting the available control measures of schistosomiasis infection from the respondents’ point of view. in this respect, the study will trigger further research focused on effectiveness of control measures of schistosomiasis and encourage an integrated approach towards elimination of the disease in the region. materials and methods study population and design the study was conducted in mwaluphamba location, matuga subcounty in kwale county in the month of august, 2014. mwaluphamba location is made up of ten villages and 2,848 households with an estimated population of 17,559 people.8 the study respondents were drawn from all the ten villages in the area. a descriptive cross-sectional study design was used and the target population comprised of all household heads aged eighteen years and over. sample size and sampling techniques a sample size of three hundred and thirty eight respondents was determined in accordance with the fisher’s formula.9 kwale county and specifically mwaluphamba location was purposively selected as the study area given schistosomiasis high (80%) endemicity in the region. simple random sampling was used to recruit household heads in each village in the location using the formula described below. the sample size was then distributed amongst the ten villages as shown in table 1. the minimum calculated sample size for the study was three hundred and thirty eight respondents but up to three hundred and eighty four study respondents were included to cover for non-response. the heterogeneous sample size in each of the villages was as a result of the difference in the proportional distribution of the total number of households in the location. data collection instrument and study procedure respondents were interviewed using a structured questionnaire. the questionnaires were administered by the principal investigator and two other research assistants who were trained on administering the instrument. the questionnaires were in both english and kiswahili languages. the latter being the common language used in mwaluphamba location of kwale county, hence questions were translated to kiswahili to ease understanding for those respondents who could not comprehend in english. the first section of the questionnaire captured the socio-demographic data of the respondents such as their age, gender, educational level and religion status, while the second part inquired about the factors associated with the control measures for schistosomiasis in the region. house to house interviews were conducted in the selected households according to the list of the households sampled in each village. a random list of yes’s and no’s of the households was generated in each village and the number of yes’s corresponded to the sample size of the study. in each household, the head of the household was required to randomly pick a piece of paper marked yes or no. if the household head picked a paper marked yes, then an interview was conducted upon his/her consent. this was done until the desired sample size was reached. the questionnaire consisted of twenty questions and each of the respondents was interviewed for five minutes. the interviews were conducted with the heads of the household or a representative aged 18 years and above in the absence of the household head. data analysis data was coded and entered into the statistical package for social sciences (spss) software version 20. means and standard deviations were used for continuous variables, while frequency listings were used for categorical variables. associations between the variables were analyzed using chi-square tests of independence and multiple binary logistic regressions at 95% confidence interval. ethical consideration the researcher sought clearance from the relevant authorities including the institutional research and ethics committee of moi university and from the local authorities in the study area. a detailed explanation of the aim of the research was given to the study respondents before consenting to participate in the study and confidentiality of the data obtained from respondents was upheld. article table 1. proportionate distribution of respondents in mwaluphamba location. villages households (hhs) proportion of total no. of hhs distribution of sample size/village mtsangatamu 115 4% 14 burani 430 15% 51 mlafyeni 132 5% 16 tserezani 821 28% 98 maponda 508 18% 60 pande 134 5% 16 kirewe 163 6% 19 miatsani 197 7% 23 mirihini 323 11% 38 kajiweni 25 1% 3 total 2848 100% 338 [page 2] [healthcare in low-resource settings 2017; 5:6108] non co mmerc ial us e o nly results a socio-demographic summary of study respondents is presented in table 2. knowledge on control measures of schistosomiasis regarding respondents’ knowledge on the control measures of schistosomiasis infection, 154 (40 %) of the respondents reported to be aware of health education services as a measure of control, 16 (4.2%) had knowledge of clinical treatment of the infection, while 38 (9.9%), 13(3.4%), 17 (4.4%), 13 (3.4%) and 133 (34.6%) of the respondents reported having knowledge of mass chemotherapy, snail control, use of safe water for domestic use, proper sanitation and behavior change respectively as control measures of schistosomiasis infection. socio-demographic factors associated with schistosomiasis control measures as indicated in table 3, it was evident that gender, age, religious status, education level and income levels of the respondents were significantly (p < 0.05) associated with use of health education as a control measure of schistosomiasis infection. as indicated in table 4, respondents’ education and income levels were the only significant (p<0.05) variables associated with mass treatment as a control measure of schistosomiasis infection. multiple binary logistic regression indicated that controlling for respondents’ age, it was found that their religious status, income levels and gender were significant (p<0.05) predictors of seeking health education as a control measure for schistosomiasis infection (table 5). those of islamic affiliation were three times (or; 95 %: 3.313; ci 1.433-7.661) more likely to seek health education as a control method compared to their christian counterparts. while those with income levels of below ksh.1000 were less (85.7%) likely to use health education as a control method compared to those with income levels of ksh.5000 and above. male respondents were almost five times (or; 95%: 4.686; ci 2.655-8.269) more likely to use the method compared to the female respondents. on the other hand, controlling for respondents’ education level, their income levels was found to be a significant (p=0.001) predictor for use of mass treatment as a control measure for schistosomiasis infection. those with income levels of below ksh.1000 were less (or;95% ci: 0.461; 0.121-1.754) likely to use the mass treatment method compared to those with income levels of more than ksh.5000. discussion socio-demographic factors the study revealed that mwaluphamba location is majorly a muslim (85%) dominated region with only 14% of them being of christian faith and 1% comprising of traditionalists. in islamic culture one cannot undertake the obligatory prayers which are done five times a day without taking ablution using water.10 therefore, those of islamic faith come into contact with water more frequently exposing them to risks of schistosomiasis infection. the community in the region mostly practiced crop farming article table 2. socio-demographic characteristics of respondents. demographic characteristics of the respondents frequency( n=384) percentage (%) gender male 231 60 female 153 40 level of education primary 216 56 secondary 26 7 college 3 1 no formal education 139 36 religious status muslim 325 85 christian 56 14 traditional 3 1 age 18-24 51 13 25-30 73 19 31-35 49 13 36-41 62 16 over 41 149 39 occupation crop farming 169 44 livestock keeping 1 0.3 fishing 2 0.5 mixed farming 169 44 all the above 2 0.5 civil servant 9 2 others sources of income 32 8 income level in ksh.* <1,000 203 53 1,000-4,000 161 42 5,000-10,000 17 4 >10,000 3 1 *$1us dollar=ksh.101.09. [healthcare in low-resource settings 2017; 5:6108] [page 3] non co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2017; 5:6108] (44%) and mixed farming (44%) while a few others practiced fishing (0.5%). farming and fishing which solely depend on water, puts the community continuously in contact with water, therefore predisposing them to schistosomiasis infection. this was similar to findings in other studies which reported that the communities practicing water-related socio-economic activities are predisposed to the infection.11-14 mwaluphamba location was a low income region with a majority (53%) of the people earning less than a thousand shillings a month, therefore, falling below the poverty index category of earnings of less than usd $1 per person per day.15 respondents who had income levels of above ksh.10, 000 were a very infinitesimal proportion (1%) to have any significant influence in the community. with the high poverty levels in the region, those suffering from the schistosomiasis infection had difficulties accessing and affording the available health care services and sustaining good living conditions. this finding agreed with that of another study which found out that people with low incomes found it difficult accessing and affording health care services.16 the study also found that females (60.2%) were more at risk of schistosomiasis infection compared to their male (39.8%) counterparts consistent with other study findings.12,13,17 this was attributed to women being frequently in contact with water while undertaking their routine household roles, fetching water for domestic use and their involvement in farming activities. therefore, these activities increased their risk of contracting shistosomiasis in contrast to another reported study that found males were at increased risk.18 schistosomiasis control measures the study found that about 63.5% of the community disposes off their human excreta by use of latrine facilities. this is below the required national standard of 83% latrine coverage to create herd immunity.19 this meant that the water sources in the area were not safe for domestic use due to the probable contamination by human feacal matter predisposing the community not only to schistosomiasis infection but to other water borne diseases. this finding concurred with that of a study which reported poor sanitation as being a major cause of schistosomiasis infections.19 health education in itself was not an ultimate control measure of the infection because its success is influenced by peoples’ knowledge and perception of the infection, knowledge of disease transmission and symptoms presentation and the degree of disease burden. however, the current study found that a majority of people in the region were not knowledgeable of transmission of schistosomiasis, hence making health education less effective in controlling the infection. mass treatment being an effective control measure of reducing the endemicity of schistosomiasis according to a study done in tanzania,20 may not have been as effective in mwaluphamba location as the mass chemotherapy programme being implemented in the region only targets school-aged children leaving out other vulnerable groups such as the adults and pre-school aged children. the world health organization (who) recommends that where the level of transmission of schistosomiasis infection is above 50%, then treatment should be repeated every year until the prevalence decreases to 5%.21 however, this is not the case in mwaluphamba location where treatment is normally done once after several years which in essence may not be effective in controlling the infection and bringing down the disease prevalence. other control measures of schistosomiasis were less practiced by the people in the region such as proper water drainage of all stagnant water sources to destroy the breeding sites of the disease vectors. article table 3. socio-demographic factors associated with health education. variable health education chi-square p value no yes gender male 81(35.1%) 150(64.9%) 67.283 <0.001 female 119(77.8%) 34(22.2%) age 18-24 36(70.6%) 15(29.4%) 10.775 0.029 25-30 42(57.5%) 31(42.5%) 31-35 22(44.9%) 27(55.1%) 36-41 30(48.4%) 32(51.6%) over 41 70(47.0%) 79(53.0%) religious status muslim 154(47.4%) 171(52.6%) 19.455 <0.001 fisher exact christian 43(76.8%) 13(23.0%) traditional 3(99.9%) 0(0%) level of education primary 118(54.6%) 98(45.4%) 7.834 0.036 fisher exact secondary 17(65.4%) 9(34.6%) college 3(100%) 0(0%) no formal education 62(44.6%) 77(55.4%) income level in ksh.* <1,000 160(78.8%) 43(21.2%) 133.395 <0.001 fisher exact 1,000-4,000 33(20.5%) 128(79.5%) 5,000-10,000 5(29.4%) 12(70.6%) >10,000 2(66.7%) 1(33.3%) non co mmerc ial us e o nly association between respondents’ socio-demographic factors and schistosomiasis control measures the study found out that there was a statistically significant (p<0.05) association between respondents’ gender, religious status and income levels with the use of health education as a control measure of schistosomiasis infection. this could be because those of islamic affiliation tend to be in frequent contact with water as a routine practice before undertaking obligatory prayers as opposed to their christian counter parts. therefore, they were more likely to seek health education regarding water contact as a risk factor to water related diseases. this was similar to findings of a study done in egypt.22 male respondents on the other hand were found to be five times more likely to seek health education than the female respondents and this finding agreed with those of a similar study which reported men having attended more health education sessions than women.23 respondents’ income levels was also found to be significantly associated with health education as those earning less than a thousand shillings being less likely to seek health education as a control measure of schistosomiasis infection. this contradicted findings of a study done in western kenya where it was reported that those with low income levels suffered more from the infection and therefore sought health education as it was a free service offered to the community at no cost.19 conclusions the control measures for schistosomiasis infection exist in the region included: health education, snail control, case and mass treatment. there was a significant association between respondents’ gender, religious status and income levels with health education as a control measure article table 4. socio-demographic factors associated with mass treatment. variable mass treatment chi-square p value no yes gender male 191(82.7%) 40(17.3%) 2.803 0.094 female 136(88.9%) 17(11.1%) age 18-24 47(92.2%) 4(7.8%) 8.256 0.083 25-30 65(89%) 8(11.0%) 31-35 45(91.8%) 4(8.2%) 36-41 49(79%) 13(21.0%) over 41 121(81.2%) 28(18.8%) religious status muslim 272(83.7%) 53(16.3%) 3.259 0.171 christian 52(92.9%) 4(7.1%) traditional 3(100%) 0(0%) level of education primary 186(91.6%) 30(13.9%) 7.888 0.037 secondary 26(100%) 0(0%) college 3(100%) 0(0%) no formal education 121(80.6%) 27(19.4%) income level in ksh.* <1,000 186(91.6%) 17(8.4%) 16.478 0.001 1,000-4,000 124(77%) 37(23%) 5,000-10,000 15(88.2%) 2(11.8%) >10,000 2(66.7%) 1(33.3%) table 5. multiple binary logistic regression (health education). variable 95% ci for or p value regression coefficient (β) or age 0.499 18-24 -0.323 0.724 0.295-1.779 0.481 25-30 0.087 1.090 0.511-2.329 0.823 31-35 0.656 1.927 0.782-4.751 0.154 36-41 0.091 1.096 0.498-2.408 0.820 over 41 -0.323 0.724 0.295-1.779 0.499 religious status muslim 1.198 3.313 1.433-7.661 0.005 income level in ksh.* < 0.001 <1,000 -1.947 0.143 0.046-446 0.001 1,000-4,000 0.554 1.740 0.548-5.532 0.348 gender male 1.545 4.686 2.655-8.269 <0.001 [healthcare in low-resource settings 2017; 5:6108] [page 5] non co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2017; 5:6108] of the infection. the study also observed that there was a significant association between mass treatment in the community and the respondents’ income levels. in conclusion, it was clear that the differences in socio-demographic characteristics amongst the people of mwaluphamba location influenced use of the available measures towards control of schistosomiasis infection. we recommend that the ministry of health should formulate policies that ensure equal application of all the schistosomiasis control measures to complement each other for effective control of the infection in the region. the county government through the ministry of health should encourage other stakeholders in the county to conduct further research on the treatment seeking behavior of the community, effectiveness of snail control measures and on drug efficacy. future policy should design prevention campaigns to target places of worship for non-muslims and women’s groups and tailor health education to those identified as being at higher risk for disease. references 1. midzi n, mtapuri zinyowera s, mapingure m, et al. knowledge, attitudes and practices of grade three primary school children in relation to schistosomiasis, soil transmitted helminthiasis and malaria in zimbabwe. biomedical centralinfectious diseases 2011;11:169. 2. kenya medical research institute. neglected diseases. (kwale); 2010. 3. world health organization. weekly epidemiological record 30 april no.18.available at http://www.who.int/ wer.2010;85:157-164. 4. kenya medical research institute. preliminary report of the 8 selective mass-chemotherapy of urinary schistosomiasis in mwachinga community of kwale district, coast kenya. kemri; 2001. 5. kenya medical research institute. neglected diseases. kwale: kenya medical research institute; 1994. 6. njenga s, mwandawiro c, muniu e, et al. adult population as potential reservoir of ntd infections in rural villages of kwale district, coastal kenya: implications for preventive chemotherapy interventions policy. parasites vectors 2011;4:175. 7. mcmanus d, gray d, ross a, et al. schistosomiasis research in the dongting lake region and its impact on local and national treatment and control in china. negl tropl dis 2011;5:8. 8. kenya national bureau of statistics. national housing and population census 2009. nairobi: knbs; 2009. 9. mugenda o, mugenda a. research methods: quantitative and qualitative approaches. nairobi: african centre for technology studies (act); 2003. 10. al-farsy as. holy quran translation. nairobi: the islamic foundation; 1991. 11. aboagye i, edoh d. investigation of the risk of infection of urinary schistosomiasis at mahem and galilea communities in the greater accra region of ghana. west afr j appl ecol 2009;1:15. 12. ali h, abkar t, mohamed m. schistosomiasis and soil-transmitted helminthes among an adult population in a war affected area, southern kordofan state, sudan. parasites vectors 2012;5:133. 13. essa t, birhane y, mengistu e, et al. current status of mansoni infections and associated risk factors among students in gorgora town, north west ethiopia. isen infect dis 2013;2013:636103. 14. el katsha s, watts s. gender, behavior, and health: schistosomiasis transmission and control in rural egypt. new york and cairo: american university in cairo press; 2002. 15. world bank. world bank updates poverty estimates for the developing world. washington, dc: world bank group; 2005. 16. ugbomoiko s, okoye i, heukelbach j. factors associated with urinary schistosomiasis in two peri-urban communities in southern western nigeria. ann trop med parasitol 2010;104:409-19. 17. king c, muchiri e, ouma j. dynamics and control of schistosoma haematobium transmission in kenya: an overview of the msambweni project. am j trop med hyg 2000;55:127-34. 18. shati aa. factors affecting the prevalence of human schistosomiasis in aseer region, saudi arabia. j biol sci 2009;9:8. 19. mwinzi p, montgomery s, owapa c, et al. integrated community-directed intervention for schistosomiasis and soil transmitted helminthes in western kenya – a pilot study. parasites vectors 2012;5:182. 20. uneke cj. soil transmitted helminthes infections and schistosomiasis in school age children in sub-saharan africa: efficacy of chemotherapeutic intervention since world health assembly resolution. tanzania j health res 2009;12:1. 21. world health organization. prevention and control of schistosomiasis, and soil transmitted helmithiasis. geneva: who; 2002. 22. farroq m, nallah j. the behavioural pattern of social and religious watercontact activities in the egypt-49 bilharziasis project area. bull world health organ 1966;35:377-87. 23. schmitt i. schistosomiasis. the burden of disease and trends of intervention. international health practice; 2006. article non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11208 a societal adaptation model as a novel approach toward the recovery of people with schizophrenia retno lestari,1 ah yusuf,2 febri endra budi setyawan,3 ahsan ahsan,1 rachmat hargono4 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia; 3faculty of medicine, universitas muhammadiyah malang, malang, indonesia; 4faculty of public health, universitas airlangga, surabaya, indonesia article significance for public health many people with mental disorders serve as a catalyst for the community to rebuild and collaborate with the local government, related institutions, and stakeholders to expedite sufferers' recovery. through the adaptation model, society is expected to treat people with severe mental disorders as partners rather than just listeners or recipients of the information disseminated. once a problem phenomenon occurs in the surrounding environment, adaptive societies ought to respond well. this is viewed as a life challenge that needs to be overcome, not a threat. positive beliefs influence social support and good coping strategies, making people more adaptable while dealing with mental disorder sufferers. [healthcare in low-resource settings 2023; 11(s1):11208] [page 121] abstract introduction: people with severe mental disorders strain those involved, including families, societies, entire communities, and the government, due to decreased productivity. understanding the roles to be played in caring for such people necessitates a societal adaptation process. good adaptations boost societal resilience by caring for severe mental disorder sufferers. therefore, this study aimed to create a societal adaptation model that would increase societal resilience in the care of people with schizophrenia. design and methods:an observational analytic approach was applied with 205 society members living in the working area of the community integrated health center in malang, east java, indonesia. furthermore, several questionnaires were employed and analyzed using partial least squares–structural equation modeling (pls-sem). results: according to the results, social adaptation was a significant indicator of societal adaptation. it was discovered that coping strategies influenced adaptation (p=0.007), society problem appraisal influenced coping strategies (p=0.000), and social support (p=0.005), while societal adaptation influenced societal resilience (p=0.022). the novelty of this study is that the societal adaptation model increases societal resilience in caring for people with schizophrenia, leading to a more adaptive community by increasing social capital. conclusions: in conclusion, the adaptation model improves societal resilience by increasing social capital and stigma prevention, thereby promoting participation in the sufferers’ recovery process. introduction severe mental disorders strain all parties, including the government, families, and the community, because their productivity declines, leading to a significant financial burden for families and caregivers.1,2 the indonesian government has made several efforts to manage people with severe mental disorders, by spending on health services and removing shackles, which are both expensive. consequently, some society members prefer to use alternative medicine, such as herbs, massage, and other traditional treatment options.3 in indonesia, people with severe mental disorders are still mistreated and subjected to shackles. since the sufferers have a relapse, their family decides to do confinement because of the inability to help overcome this situation. furthermore, the family is embarrassed due to societies holding a negative stereotype of people with mental disorders.4,5 the associated stigmatization is commonly in form of demeaning, stereotyping, discriminating, insulting, blaming, isolating, avoiding, frustrating, and unhelpful behavior. this leads to negative social experiences such as isolation, rejection, marginalization, and discrimination. hence, stigma impacts the sufferers’ ability to improve medication adherence and access to appropriate and professional medical care.6,7 inappropriate treatment of the sufferers leads to symptoms exacerbation, which subsequently causes increased dependence, a worse response to treatment, and a higher burden on families, communities, and local governments. such people who relapse require the best possible care and close monitoring for their health progress to be tracked.8,9 a lack of community-owned resources, such as social capital, impacts how societies evaluate the occurring conditions. according to truelove et al.,10 the society appraisal process related to treating people with severe mental disorders can be described by the risk, coping, and social appraisal (rcsa) model. once there is a lack of resources in society, people help one another by sharing and assistance to meet their daily needs. in this case, the positive behavior displayed is influenced by the individual’s positive perception of society and prevailing norms. rcsa explains how the three stages of social appraisal affect adaptation but fails to detail the societal adaptation process. according to wong,11 a resource congruence model of effective coping states that the society achieves effective coping by using resources appropriately and suitably, however, insufficient resources lead to ineffectiveness. this model describes the coping strategies chosen by society, namely the usage of available resources. non -co mmerc ial us e o nly social capital is one of the resources in the community, employed in treating people with severe mental disorders, and can be used to gain specific knowledge and skills. 13 aldrich and meyer described this term as a resource formed from social relationships with other people.12 moreover, it is divided into three types, which are bonding, bridging, and linking social capital. the first type is a bond between emotionally close individuals, such as friends and family. it is important to note that more robust social ties provide social support and personal assistance in caring for people with mental disorders. the second is a bond formed within a particular social group due to differences in demographics and resources in society. this is specifically characterized by civic institutions and local government policies. meanwhile, the third is a network connection between community members and the local government.12,14,15 some components of social capital that are less optimal are the relationship between neighbors, tolerance towards people with mental disorders, and a proactive attitude. the interview results show a fear of community members to help neighbors who are mentally sick due to a feeling that the sufferers are not their relative or they are afraid of experiencing violent behavior. society is disrupted once several people living in the community with severe mental disorders relapse or worsen. parsons describes the economic, political, legal, and cultural subsystems associated with four community functions, namely adaptation, goal attainment, and integration, as well as maintenance and enforcement of community patterns plus structures (latent pattern maintenance). these four subsystems carry out their respective functions, but they are interconnected in realizing the social system as a whole.16,17 the adaptation model developed in this study is linked to social resources, specifically social capital and stigma factors, which influence people’s beliefs about the severity and vulnerability of sufferers. societies with high collective efficacy, response efficacy, community identity, and strong norms influence the chosen coping strategy. also, societies is capable of adapting become more resilient to assist people suffering from severe mental disorders. understanding the societies’ role in caring for the sick necessitates a societal adaptation process. good adaptations boost societal resilience by caring for people with severe mental illnesses. therefore, this study aimed to create a societal adaptation model meant to increase societal resilience in caring for people with schizophrenia. the hypotheses considered include hypothesis 1 (h1): social capital affects problem appraisal; h2: social capital affects social support; h3: social capital affects societal adaptation; h4: social capital affects societal resilience; h5: stigma affects problem appraisal; and h6: stigma affects societal resilience. furthermore, h7: problem appraisal affects coping strategy; h8: social support article [page 122] [healthcare in low-resource settings 2023; 11(s1):11208] table 1. indicators for reflective measurement model constructs. indicator definition social capital the society owns social resources x1.1 social participation participation of the society in the treatment of people suffering from severe mental disorders x1.2 social network a communication network is formed when people interact with one another to assist in caring for people suffering from severe mental disorders. x1.3 mutual help providing support for people with severe mental disorders. x1.4 trust society trust in the abilities of people with severe mental disorders x1.5 sense of belonging people with severe mental disorders are inextricably linked to the society stigma false society perceptions of people suffering from mental disorders x2.1. demeaning the society's attitude toward people with mental disorders does not respect their dignity x2.2. stereotype the incorrect society perception that people with mental disorders are dangerous and weak x2.3. discrimination people's attitudes toward people with mental disorders in their surroundings x2.4. insulting people's attitudes that denigrate the existence of people suffering from mental disorders x2.5. blame people's attitudes judge, complain, and accuse others of having mental illnesses x2.6. exclude people's attitudes that isolate people with mental illnesses in rural areas far from community settlements x2.7. dodging people's attitudes toward, and interactions with, people suffering from mental illnesses x2.8. frustrating people's attitudes that depress morale and make people with mental illnesses sad x2.9. unhelpful behavior people's attitude refuses to assist people with mental illnesses in carrying out daily tasks. problem appraisal society perceptions of problems in the treatment of people with severe mental illnesses y1.1 risk appraisal the society perception of the threat associated with the treatment of people with mental disorders, consist of perception of severity and perception of probability y1.2 coping appraisal the society perception on how to address issues in the treatment of people suffering from mental disorders, includes collective efficacy and response efficacy y1.3 social appraisal assessment of the society about social aspects in the care of people with mental disorders, includes society identification and perceived norms social support all efforts made by the society to accept, provide opportunities for, and motivate people with severe mental disorders to be productive y2.1 social integration giving people attention, opportunities, and time to do activities together so that they develop a sense of belonging y2.2 attachment giving people with severe mental disorders a sense of security, tranquility, and peace to foster emotional closeness y2.3 recognized by others recognizing and appreciating the abilities of people with severe mental disorders y2.4 guidance providing information, advice, or assistance needed to meet the needs of people suffering from severe mental disorders y2.5 rely on others helping people with severe mental disorders in the presence of other people when facing life's difficulties y2.6 opportunity to develop self making it possible for people with severe mental disorders to be productive and feel needed by others coping strategy the society problem-solving abilities assist with the day-to-day care of people with mental disorders y3.1 healthcare policy community-based policies for the treatment of people with mental disorders y3.2 social ties social bonds that form in the society non -co mmerc ial us e o nly affects coping strategy; h9: coping strategy affects societal adaptation; h10: social support affects societal adaptation; h11: coping strategy affects societal resilience; and h12: societal adaptation affects societal resilience. design and methods an observational analytic approach was employed with 205 society members living in the working area of the community integrated health center in malang, east java, indonesia. also, the sample size was determined using a saturated sampling of 55 leaders, 60 mental health cadres, and 90 neighbors who interact with 30 people suffering severe mental disorders. all respondents consented to participate in this study, and they had the right to refuse without penalty. in this study, the conceptual framework described the relationship between variables, namely social capital, stigma, problem appraisal, social support, coping strategies, societal adaptation, and societal resilience (figure 1). the theoretical examination combined rcsa models according to truelove et al. (2015),10 the resilience framework according to windle and bennett (2011)18 resource congruence model of effective coping (wong, 1993),11 and society-to-cells resilience framework according to szanton (2010).19 figure 2 shows how social capital in the form of social participation and networks, mutual help, trust, and sense of belonging, impacts problem appraisal, social support, adaptation, and resilience. stigma such as demeaning, stereotyping, discriminating, insulting, blaming, isolating, dodging, frustrating, and unhelpful behavior influences problem appraisal and societal resilience in caring for people with severe mental disorders. the societal adaptation process includes problem appraisal such as risk, coping, and social appraisal. perception of severity and probability is part of the risk appraisal, while collective and response efficacy is used to evaluate coping. the social appraisal process is mediated by society identification and perceived norms. problem appraisal influences the societies’ coping strategies during the adaptation process by involving care policies, social ties, mental health services, and the economy. social support including social integration, attachment, recognition, guidance, reliance on persons, and self-development opportunities, impacts coping strategies and societal adaptation. furthermore, coping strategies affect psychological and social societal adaptation as well as resilience. societal resilience in treating people with mental disorders is boosted by good adaptation. its components also include becoming stronger, reflecting and sharing learning, assisting other persons, and being socially organized, connected, locally interdependent, and reasonably profitable. moreover, several questionnaires were used and all instruments were valid and reliable based on pearson correlation analysis at a 5% significance level, while cronbach’s alpha coefficient was greater than 0.6. the definitions of all indicators for each variable can be seen in table 1. partial least squares–structural equation modeling (pls-sem) was used to analyse the theoretical model of this study. ethical approval was received from the ethics committee board of the faculty of medicine at universitas muhammadiyah malang (no. e.5.a/076/kepk-umm/iv/2019). results and discussions the current study aimed to determine the relationship between stigma, social capital and support, problem appraisal, societal adaptation and resilience, as well as coping strategies. additionally, the proposed model assumed that several factors article figure 1. the conceptual framework of societal adaptation. [healthcare in low-resource settings 2023; 11(s1):11208] [page 123] non -co mmerc ial us e o nly influence societal adaptation, including social capital and support, plus coping strategies. according to this model, societal adaptation affects societal resilience. measurement model evaluation smartpls 3.0 evaluates the relationships between observed variables, outer loadings for the measurement model, structural model, path coefficients, and r2 values. figure 3 shows the preliminary estimates of the pls-sem path model and several indicators on constructs with loading factors that were less than 0.6. in the subsequent analysis shown in figure 4, all the indicators were removed. besides, the values of average variance extracted (ave), composite reliability (cr), and cronbach’s alpha (ca) were used to assess the reflective measurement models’ reliability and validity. at the initial values, table 2 shows that cronbach’s alpha = < 0.6, ave = < 0.5, composite reliability = < 0.7, and ave = 0.5. after discarding the items with low loadings, all ave values were found to be > 0.5, the composite reliability value was > 0.7, and cronbach’s alpha was > 0.6. the constructs, in general, indicated the measures’ reliability and convergent validity as well as the relationship between constructs based on the research hypothesis. structural model evaluation figure 5 shows that all tcount values are greater than the ttable value (1.96), meaning figure 5 is the final path model. according to results, social adaptation is a significant indicator of societal adaptation. table 3 shows the structural path model coefficients’ results and their significance. coping strategies were found to influence adaptation (p=0.007), while society problem appraisal influences their coping strategies (p=0.000) and social support (p=0.005). furthermore, societal adaptation affects societal resilience (p=0.022). table 4 shows that problem appraisal and social support are the strongest influence on coping strategy (50.5%). in the social sciences, small r2 values tend to have a significant impact. studies that predict human behavior typically have an r-squared value of less than 50%.20 according to hypothesis1 (h1), social capital directly affects problem appraisal of 0.499 with a 0.000 p-value. this demonstrates that social capital improves problem appraisal in the societal adaptation model to increase societal resilience in caring for people with severe mental disorders. social networks, mutual help, and trust are essential indicators of social capital that influence problem appraisal. the community in this study has a high level of social capital, which impacts healthy living behaviors by forming social norms and disseminating more helpful health information. existing social networks are used to monitor and prevent adverse health behaviors as well as foster a sense of personal responsibility to maintain one’s health for other people’s sake. consequently, the sick receive social, emotional, and practical support for quick recovery and effective treatment. mutual trust and help, plus high participation, and social networks lead to improved self-esteem and psychological well-being.21 in agreement with h2, the results showed a direct positive effect of social capital on social support of 0.748 with a 0.000 pvalue. this means social capital increases social support in the adaptation model to promote societal resilience in caring for people with severe mental disorders. the existence of social networks, a helping attitude, and a strong sense of mutual trust indicate that the community’s social capital is outstanding in supporting sufferers’ recovery. the kinship attitude and trust found in rural area inhabitants promote the growth of good social networks once community members need help. also, social capital plays an essential role in growing social support. communities provide social support based on the understanding that they are not alone in helping the sufferers. social support is provided by friends, family, social networks, and the community using available resources.22 it is obtained from various forms of interpersonal relationships, through available bonding and bridging social capital. with bonding capital, the community obtains support based on similarities in character, both from friends and family. meanwhile, bridging social capital is from relationships between societal groups, and can be found in heterogeneity or differences in ethnicity, status, socioeconomic class, and others.23 h3 specifies that social capital had no direct effect on an adaptation of -0.314 with a 0.082 p-value. this means social capital does not directly increase adaptation in the adaptation model to promote societal resilience in the care of people with severe mental disorders. social capital indirectly improves adaptation in two ways, namely (a) problem appraisal and coping strategies, and (b) article figure 2. the theoretical path model of the study. figure 3. analysis pls-sem path model first results. [page 124] [healthcare in low-resource settings 2023; 11(s1):11208] non -co mmerc ial us e o nly social support and coping strategies. adaptation is also defined as a collective decision made by individuals, groups, or organizations in a community. collective adaptation is carried out on behalf of the community by the local government, sometimes to anticipate changes, but it cannot cancel individuals and groups’ expectations. hence, the adaptation process must incorporate the principle of interdependence among individuals, groups, and related institutions, for their available resources to be maximized.24 in accordance with h4, social capital has a direct positive effect on societal resilience of 0.478 with a 0.000 p-value. this demonstrates that social capital improves societal resilience in the adaptation model in caring for people with severe mental disorders. people with high social capital, defined by mutual trust, norms, participation, and extensive social networks, recover more quickly and easily from problems, particularly those related to their ability to assist in the care of mentally sick people. despite cultural and economic differences, societies that have higher social capital and community leadership are the most satisfied with the rapid recovery process. mutual trust and dependence raise awareness of volunteer opportunities and responsibilities, thereby supporting collective efficacy, recovery, and adaptation responses.25 according to h5, stigma does not affect problem appraisal of -0.290, with a 0.144 p-value. this indicates it does not affect the assessment of problems in the adaptation model as part of an effort to increase societal resilience. besides, public perception is dynamic, and changes once people’s awareness and level of knowledge shift. the main factors influencing people’s perceptions are their level of knowledge, social networks, and social media influence.26 in this study, h6 specifies that stigma did not affect societal resilience, with a 0.593 p-value. many factors influence community stigma, including the decision-making power of community leaders. subsequently, people’s resilience increases once offered adequate knowledge about mental disorders and how to assist sufferers’ daily care based on their respective roles. stigma is reduced as the knowledge gained is shared with other persons and they work collaboratively to care for one another. stigmatization of people with mental disorders reduces resilience which in turn reduces stigma. sufferers’ resilience is affected by a lack of access to the necessary treatment.27,28 according to h7, problem appraisal has a direct positive effect on coping strategies of 0.504 with a 0.000 p-value. this demonstrates that it improves coping strategies in the adaptation model. perceived severity, collective efficacy, society identification, and perceived norms are essential indicators in assessing problems for people with severe mental disorders. in social appraisal, society identification’s presence and a sense of belonging have positively impacted how individuals deal with stress. a previous study discovered that once employees identify themselves at work, they have more effective coping strategies. the availability of support from people’s surroundings influences how their identity and the coping strategies used are being recognized.29 in agreement with h8, social support has a direct positive effect on coping strategies of 0.298 with a 00.5 p-value. this implies it improves coping strategies in the adaptation model to increase societal resilience in the care of people with severe mental disorders. presenve of social integration, the ability to rely on others and an opportunity to perform self-development for the community while rendering patient care, are essential indicators in building social support to ensure people have better coping strategies. another study discovered a significant relationship between social support and coping strategies as well as overall mental health.30 according to h9, coping strategies affect an adaptation of 0.290 with a 0.007 p-value. this denotes it boosts adaptation to increase societal resilience in the care of people with severe mental disorders. community social and economic ties are essential indicators of coping strategies for adapting to mentally sick people. coping abilities influence adaptation, but anxiety, depression, and low self-esteem are all factors affecting adaptability.31 h10 states that social support has no direct effect on an adaptation of 0.147 with a 0.382 p-value. this demonstrates that social support does not directly increase adaptation to promote societal resilience in the care of people with severe mental disorders. through coping strategies, social support indirectly enhances adaptation. societal adaptation is influenced by sociodemographic characteristics, resources, facilities, and infrastructure, as well as institutional, political, socio-cultural, cognitive, and psychological factors. sociodemographic characteristics describe people’s backgrounds that their adaptation is easier. for example, older people tend to have much life experience and adapt better even though they still use conservative principles based on previously understood beliefs. the availability of sufficient resources also influ article figure 4. analysis pls-sem path model improved. figure 5. analysis pls-sem path final model. [healthcare in low-resource settings 2023; 11(s1):11208] [page 125] non -co mmerc ial us e o nly ences the community’s ability to make decisions. meanwhile, institutional and political factors explain how a community adapts, i.e. people follow once leaders set an excellent example of adaption. through habits and customs that the community believes in, socio-cultural factors influence their practices toward adaptation. cognitive and psychological factors describe how people believe in assessing a current challenge. therefore, once people perceive existing changes as a threat, the adaptation response displayed is more maladaptive.32 according to h11, coping strategies have no direct effect on societal resilience, with a p-value of 0.338. meaning that, in the adaptation model, coping strategies do not directly increase societal resilience in the care of people with severe mental disorders. this variable boosts societal resilience through adaptation, hence the process involved is critical for the community to complete to achieve resilience. identifying social capital factors that influence problem assessment, coping strategies, and existing social support is the first step in the adaptation process. people with adaptive ability have greater resilience while caring for sufferers of mental disorders. moreover, the quality of local government leadership and social capital are the most critical factors influencing societal resilience. this is specifically true for people living in poverty, where government regulations and policies are needed to achieve resilience. another determinant of resilience is a high level of social capital.33 h12 shows that adaptation has a direct positive effect on societal resilience with a 0.022 p-value. this implies it increases societal resilience in the care of people with severe mental disorders. social adaptation is an important indicator in influencing societal resilience. moreover, indicators of resilience include becoming stronger, reflecting and sharing learning, assisting other persons, and being socially organized while helping the sick. the novelty of this study is that the societal adaptation model increases societal resilience in caring for people with schizophrenia, leading to a more adaptive society by increasing social capital. the adaptation model promotes societal resilience in the treatment of mental dis article table 2. reflective measurement model results. variables ave composite reliability cronbach’s alpha initial improved initial improved initial improved social capital 0.383 0.584 0.722 0.807 0.657 0.651 stigma 0.227 0.955 0.191 0.977 0.756 0.954 problem appraisal 0.418 0.576 0.594 0.575 0.298 0.261 social support 0.489 0.805 0.773 0.924 0.622 0.880 coping strategy 0.399 0.652 0.450 0.789 0.212 0.467 societal adaptation 0.494 1.000 0.545 1.000 -0.093 1.000 societal resilience 0.383 0.672 0.719 0.889 0.576 0.833 table 3. results of the structural path model coefficients. paths path coefficients t sig. interpretation social capital (x1) → problem appraisal (y1) 0.499 4.423 0.000 significant social capital (x1) → social support (y2) 0.748 11.317 0.000 significant social capital (x1) → societal adaptation (y4) -0.314 1.747 0.082 not significant social capital (x1) → societal resilience (y5) 0.478 3.874 0.000 significant stigma (x2) → problem appraisal (y1) -0.290 1.465 0.144 not significant stigma (x2) → societal resilience (y5) -0.047 0.535 0.593 not significant problem appraisal (y1) → coping strategy (y3) 0.504 4.392 0.000 significant social support (y2) → coping strategy (y3) 0.298 2.851 0.005 significant coping strategy (y3) → societal adaptation (y4) 0.290 2.729 0.007 significant social support (y2) → societal adaptation (y4) 0.147 0.876 0.382 not significant coping strategy (y3) → societal resilience (y5) 0.117 0.960 0.338 not significant societal adaptation (y4) → societal resilience (y5) 0.221 2.300 0.022 significant table 4. explanation of variance. constructs r2 problem appraisal 0.297 social support 0.559 coping strategy 0.505 societal adaptation 0.142 societal resilience 0.288 [page 126] [healthcare in low-resource settings 2023; 11(s1):11208] non -co mmerc ial us e o nly order sufferers by increasing social capital and reducing stigma, therefore allowing people to participate in the recovery process. a key-person in the community is thought to be the backbone in all decision-making aspects. this critical figure is the most influential, serving as an example and protecting the community, health care officers, and religious leaders. the described statement is consistent with a previous study which found that the community leaders’ participation is required to improve the targeted goals. community leaders serve as role models for society members, motivating the people to increase social participation and contribute to development implementation.34,35 the process of societal adaptation in assisting mental disorder sufferers begins with identifying social capital factors that influence problem appraisal, coping strategies, and existing social support. people with adaptive ability have greater resilience while caring for those suffering from severe mental disorders. conclusions it is concluded that treatment of people with severe mental disorders in the community is more effective once social capital, bonds, and integration are optimized because these resources promote better functioning. therefore, sufferers, families, the community as a whole, and mental health service teams must be committed to providing support for mental health promotion. references 1. cohen r, kirzinger w. financial burden of medical care: a family perspective. nchs data brief 2014;142:1-8. 2. tan sc, yeoh al, choo ib, et al. burden and coping strategies experienced by caregivers of persons with schizophrenia in the community: caregiver’s burden and coping. j clin nursing 2012;21:2410–8. 3. human rights watch. indonesia: shackling reduced, but persists [internet]. human rights watch. 2018. accessed 2021 jan 19. available from: https://www.hrw.org/news/2018/10/02 /indonesia-shackling-reduced-persists. 4. hartini n, fardana na, ariana ad, et al. stigma toward people with mental health problems in indonesia. psychol res behav manag 2018;11:535–41. 5. rai ss, syurina ev, peters rmh, et al. assessing the prospect of a common health-related stigma reduction response: crossperspectives of people living with stigmatised health conditions in indonesia. global public health 2021;16:1856–69. 6. subu ma, wati df, netrida n, et al. types of stigma experienced by patients with mental illness and mental health nurses in indonesia: a qualitative content analysis. int j mental health systems 2021;15:77. 7. luo x, law sf, wang x, et al. effectiveness of an assertive community treatment program for people with severe schizophrenia in mainland china – a 12-month randomized controlled trial. psychol med 2019;49:969–79. 8. alphs l, nasrallah ha, bossie ca, et al. factors associated with relapse in schizophrenia despite adherence to long-acting injectable antipsychotic therapy. int clin psychopharmacol 2016;31:202–9. 9. xiao j, mi w, li l, et al. high relapse rate and poor medication adherence in the chinese population with schizophrenia: results from an observational survey in the people’s republic of china. neuropsychiatr dis treat 2015;11:1161–7. 10. truelove hb, carrico ar, thabrew l. a socio-psychological model for analyzing climate change adaptation: a case study of sri lankan paddy farmers. global environmental change 2015;31:85–97. 11. wong p, reker g, peacock ej. a resource-congruence model of coping and the development of the coping schemas inventory. in: handbook of multicultural perspectives on stress and coping. 2005. p. 223–83. 12. aldrich dp, meyer ma. social capital and societal resilience. am behav sci 2015;59:254–69. 13. areekul c, ratana-ubol a, kimpee p. model development for strengthening social capital for being a sustainable lifelong learning society. procedia social behav sci 2015;191:1613– 7. 14. poortinga w. societal resilience and health: the role of bond article correspondence: retno lestari, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: retno.lestari.fk@ub.ac.id key words: societal adaptation; recovery; people with schizophrenia; resilience acknowledgment: we would like to say thanks to department of nursing, faculty of health sciences, universitas brawijaya, malang who provided insight and expertise that greatly assisted the success of this study. contributions: all authors contributed equally to the development of conceptual model and structural model, performed the analytic calculations, and final version of the manuscript. conflict of interests: the authors disclosed no competing interests. funding: this study was financially supported by department of nursing, faculty of health sciences, universitas brawijaya. clinical trials: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 16 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11208 doi:10.4081/hls.2023.11208 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11208] [page 127] non -co mmerc ial us e o nly ing, bridging, and linking aspects of social capital. health place 2012;18:286–95. 15. chen h, meng t. bonding, bridging, and linking social capital and self-rated health among chinese adults: use of the anchoring vignettes technique. plos one 2015;10:e0142300. 16. segre s. talcott parsons: an introduction [internet]. upa; 2012. available from: https://books.google.co.id/books? id=lk0ikvieergc. 17. ormerod r. the history and ideas of sociological functionalism: talcott parsons, modern sociological theory, and the relevance for or. j operational res soc 2020;71:1873–99. 18. windle g, bennett km, noyes j. a methodological review of resilience measurement scales. health qual life outcomes 2011;9:8. 19. szanton sl, gill jm. facilitating resilience using a societyto-cells framework: a theory of nursing essentials applied to research and practice. adv nurs sci 2010;33:329–43. 20. frost j. how high does r-squared need to be? statistics by jim [internet]. 2018 [cited 2021 nov 2]. available from: https://statisticsbyjim.com/regression/how-high-r-squared/ 21. chen x, wang p, wegner r, et al. measuring social capital investment: scale development and examination of links to social capital and perceived stress. soc indic res 2015;120:669–87. 22. cirule i, prusis j. social capital and social support – perception by start-ups in riga city. in 2018 [cited 2021 oct 2]. p. 49–56. available from: http://llufb.llu.lv/conference/economic_science_rural/2018/latvia_esrd_47_2018-49-56.pdf. 23. nguyen-trung k, forbes-mewett h, arunachalam d. social support from bonding and bridging relationships in disaster recovery: findings from a slow-onset disaster. int j disaster risk reduct 2020;46:101501. 24. adger wn. social capital, collective action, and adaptation to climate change. in: voss m, editor. der klimawandel. wiesbaden: vs verlag für sozialwissenschaften; 2010 [cited 2021 oct 2]. p. 327–45. available from: http://link. springer.com/10.1007/978-3-531-92258-4_19. 25. aldrich dp, meyer ma. social capital and societal resilience. am behav sci 2015;59:254–69. 26. benti m, ebrahim j, awoke t, et al. community perception towards mental illness among residents of gimbi town, western ethiopia. psychiatry j 2016;2016:6740346. 27. crowe a, averett p, glass js. mental illness stigma, psychological resilience, and help seeking: what are the relationships? mental health and prevention 2016;4:63–8. 28. dibley l, norton c, mason-whitehead e. pwe-055 stigma in inflammatory bowel disease: building resilience. gut 2015;64:a235–6. 29. mckimmie bm, butler t, chan e, et al. reducing stress: social support and group identification. group processes intergroup rel 2020;23:241–61. 30. aflakseir a. the role of social support and coping strategies on mental health of a group of iranian disabled war veterans. iranian j psychiat 2010;5:102. 31. sopiah nn, krisnatuti d, simanjuntak m. kerentanan, strategi koping, dan penyesuaian anak di lembaga pembinaan khusus anak (lpka). jurnal ilmu keluarga & konsumen 2017;10:192–203. 32. dang hl, li e, nuberg i, et al. factors influencing the adaptation of farmers in response to climate change: a review. climate and development 2019;11:765–74. 33. kerr se. social capital as a determinant of resilience. in: resilience. elsevier; 2018 accessed 2021 feb 1. p. 267–75. available from: https://linkinghub.elsevier.com/retrieve/ pii/b9780128118917000220. 34. porawouw r. peran tokoh masyarakat dalam meningkatkan partisipasi pembangunan (studi di kelurahan duasudara kecamatan ranowulu kota bitung). [the role of community figures in increasing development participation (study in duasudara village, ranowulu district, bitung city).] politico: jurnal ilmu politik 2016;3:1154. 35. lestari r, yusuf a, hargono r, et al. adapting to people with schizophrenia: a phenomenological study on a rural society in indonesia. indian j psychol med 2021;43:31–7. article [page 128] [healthcare in low-resource settings 2023; 11(s1):11208] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e14] [page 53] application of emporiatrics in minimizing travelers’ health risks saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, emporiatrics or travel medicine deals with the prevention and management of health problems of international travelers.1 the number of people undertaking international travels is on the rise every year and with that, travelrelated risks to their health are increasing.2 travel on a global scale exposes many people to a range of health risks varying from exposure to different disease agents to changes in the physical/biological environment, all of which can lead to ill-health.2,3 however, many of these risks can be minimized by appropriate travel planning and precautionary measures.2,3 the need of maintaining the health of travelers has been realized in different studies.4,5 the mitigation measures should start right from the assessment of the determinants of the health risks to which travelers are exposed: e.g., health status before undertaking travel (viz. underlying chronic disease/low immunity); place of travel (viz. facility of accommodation/hygiene-sanitation/provision of medical services); purpose and duration of travel and travelers’ behavior.6 preventive strategies can be planned based on the risks to which travelers can be exposed. the travel must be planned well in advance and safeguard measures should be taken before, during and after travel. actions which the traveler must take prior to the commencement of the journey should be learning about the destination (ascertaining health risks prevalent in the area, climate, availability of health care facilities, etc.); medical consultation for necessary immunizations or for an ongoing health concern;7 obtaining special travelers health insurance for destinations where health risks are significant and medical care is expensive/not readily available; and carrying a medical/first-aid kit. during travel to the concerned destination, travelers should ensure an adequate sleep before leaving, wear loose and comfortable clothes, and have light meals and plenty of water. during their stay-period, they should be careful about food and water safety, practice safe sex, minimize injuries by wearing closedtoe shoes to prevent cuts/wounds/insect or snake bites/or infection from parasites, practice swimming only in pools filled with cleandisinfected water, abide by local traffic regulations to avoid road traffic accidents, and regularly use an insect repellent to prevent insect bites.2,3 the active measures should not be confined to the period of travel. rather, all travelers, after return, must undergo medical examination if they have spent more than three months in a developing country, they suffer from a chronic disease or the existing disease condition has worsened, they consider that they have been exposed to a serious infection during the travel, and they experience illnesses like fever, persistent diarrhea, jaundice, skin or genital infections, in the weeks following their return.2 in low-resource countries where there are constraints on availability of resources (viz. healthcare services), there is an immense need for advocacy by the policy makers and facilitation of travel medicine as a separate specialty by the government. clinicians and private medical practitioners should be made acquainted with the travel medicine/diseases which may occur in patients with a history of foreign travel so that they should be aware of the risks when treating them.8 to conclude, in order to avoid any deviation from healthy status, every traveler has to be proactive. emporiatrics will have an important role in future years not only in identifying new risks but also in establishing new methods of therapy and prophylaxis for the travelers’ benefit. references 1. burchard gd. travel medicine-the next 10 years. eur j med res 1999;4:399-402. 2. world health organization. international travel and health. geneva: who ed.; 2010. 3. park k. principles of epidemiology and epidemiologic methods. in: park k, ed. text book of preventive and social medicine. 21st ed. jabalpur: banarsidas bhanot publ.; 2011. p 116. 4. schlaudecker jd, moushey en, schlaudecker ep. keeping older patients healthy and safe as they travel. j fam practice 2013;62:16-23. 5. jensenius m, han pv, schlagenhauf p, et al. acute and potentially life-threatening tropical diseases in western travelers. a geo-sentinel multicenter study, 1996-2011. am j trop med hyg 2013;88:397-404. 6. zimmermann r, hattendorf j, blum j, et al. risk perception of travelers to tropical and subtropical countries visiting a swiss travel health center. j travel med 2013; 20:3-10. 7. hainsworth t. travel vaccines: a guide to appropriate use. nurs times 2002;98:40-2. 8. heywood ae, watkins re, iamsirithaworn s, et al. a cross-sectional study of pre-travel health-seeking practices among travelers departing sydney and bangkok airports. bmc public health 2012;12:321. healthcare in low-resource settings 2013; volume 1:e14 correspondence: saurabh r. shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: emporiatrics, vaccine, risk, travel medicine. received for publication: 19 march 2013. revision received: 26 march 2013. accepted for publication: 31 march 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e14 doi:10.4081/hls.2013.e14 non -co mmerc ial us e o nly hrev_master [page 56] [healthcare in low-resource settings 2022; 10:10694] non adherence to treatment and the associated factors in patients with epilepsy in southern ethiopia kebede abebe,1 birrie deresse,2 keneni gutema negeri3 1department of internal medicine, school of medicine, college of medicine and health sciences, arba minch university, arba minch; 2neurology unit, department of internal medicine, faculty of medical sciences, college of medicine and health sciences, hawassa university, hawassa; 3school of public health, health system management and policy unit, college of medicine and health sciences, hawassa university, hawassa, ethiopia abstract adherence to antiepileptic drug therapy in people with epilepsy is critical for seizure control. poor adherence to epilepsy treatment, on the other hand, is recognized as a worldwide problem, particularly in developing countries such as ethiopia. as a result, the current study seeks to ascertain patients’ adherence to antiepileptic medications and the factors that influence it at hawassa university comprehensive specialized hospital in southern ethiopia. from february 1 to october 15, 2017, 187 people with epilepsy who were on followup at hawassa university comprehensive specialized hospital underwent a hospitalbased retrospective medical review. adherence was measured using morisky medication scale-8. data was entered and analyzed using the soft ware statistical package for social sciences version 20. the results were summarized using cross-tabulations and frequency tables. while binary logistic regression was used to analyze factors associated with adherence to antiepileptic drug therapy, significance was declared at p<0.05. according to the findings of the current study, about nineteen percent of the study participants were nonadherent to their treatment. compared to patients with monthly income of less than 1000.00 etb, those who earn>3000.00 etb [aor=0.164, 95% ci (0.038: 0.702)] and those with monthly income between 2000 and 3000 etb [aor=0.110, 95%ci (0.026:0.461)] [aor=0.110, 95% ci (0.026:0.461)] are less likely associated with non-adherent to antiepileptic drugs (p<0.05). likewise, patients who perceived epilepsy as psychiatric disorder [aor= 0.250, 95%ci (0.087: 0.716)] compared to those who perceive it as neurologic, and those patients with seizure free period of less than one year [aor= 0.206, 95%ci(0.076:0.562)] compared to those with seizure free period of more than one year are found to be less non adherent (p<0.05). introduction epilepsy, one of the most common neurological diseases worldwide, is a chronic brain disorder that affects people of all ages. it affects approximately 50 million people worldwide, with approximately 80% of those affected living in lowand middleincome countries.1 adherence to antiepileptic drug therapy is necessary for effective seizure control and for ensuring that changes in patients treatment outcomes can be attributed to the recommended regimen.2 medication non-adherence continues to be a major source of concern for both health care providers and patients due to the negative effects it has on therapeutic outcomes.3 poor adherence to antiepileptic drug (aed) therapy has been reported to be as low as 20% and as high as 80%,4 which is associated with poor epilepsy control, with a reported prevalence of 21-45%.5 in patients with uncontrolled seizures due to poor adherence to aeds, non-adherence to medication regimen accounts for significant worsening of disease, death, increased health-care costs, and impaired productivity (e.g. missing school and work).6 because of the limited health-care system in developing countries, the magnitude and impact of poor adherence are expected to be greater than in industrialized countries.2 even with the best available treatment regimen, more than 30% of people with epilepsy (pwe) do not achieve complete seizure control. the failure of such a large proportion of pwe to have controlled seizures is attributed to poor adherence to medication(s).7 while non-adherence is a problem with many determinants, there is a scarcity of literature on the subject in ethiopia in general and hawassa comprehensive specialized hospital (hcsh) in particular. as a result, the purpose of this study is to examine nonadherence to treatment and the factors that contribute to it in patients with epilepsy at hcsh in southern ethiopia. materials and methods study area and period this study was conducted in hawassa university comprehensive specialized hospital of hawassa at southern ethiopia, healthcare in low-resource settings 2022; volume 10:10694 correspondence: keneni gutema negeri, school of public health, health system management and policy unit, college of medicine and health sciences, hawassa university, p.o.box. 1560 hawassa, ethiopia. tel.: 251911424467; fax: 046-2208755 email: kenenigut2000@yahoo.com key words: adherence; epilepsy; antiepileptic drug; seizure control. conflict of interest: the authors declare no conflict of interest. funding: there is no fund received from external source for this study availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the study was approved by the institutional review board (irb) of the college of medicine and health sciences of hawassa university. written informed consent was obtained from participants of the study after the objective of the study has been explined to them. additionally, each of the respondents were assured about the confidentiality of the information they provided as well as their right to withdraw at any time during participation. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 21 june 2022. revision received: 1 october 2022. accepted for publication: 1 october 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10694 doi:10.4081/hls.2022.10694 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly from february 01, to october 15, 2017 using a cross-sectional study design. data was explored from a retrospective patient chart review. the sample size was determined using a single population proportion formula with a 95% confidence interval as follows: n = (zα/2)2pq / d2 where n = sample size z α/2= 1.96 (z α/2 is the 95% confidence interval) p = estimated prevalence, 30% (taking the non-adherence rate from the study conducted in amanuel specialized mental hospital.8 q = 1-p and d = margin of error (5%) substituting all values the calculated sample size was resulted to be 322. however, the total number of pwe having follow up at hucsh was small (estimated from registration log-book is 400), finite population correction formula9 was used to calculate the exact sample size (nf) as follows: nf = n*n/n+n-1 where nf = adjusted estimated sample size n = population size substituting the values, the calculated sample size is 178. with consideration of 10% non-response rate, the final sample size was set to be 195. systematic random sampling method, set to be every other patient, was used to recruit the samples for the study in each day of the data collection process. the validated 8-item, mmas-8, a self reporting tool was used to assess the patient’s adherence level to aed therapy in this study. the mmas-8 is a generic selfreported, medication-taking behavior scale, validated for hypertension but used for a wide variety of medical conditions, which is the latest version of the scale, with a good internal consistency.10 it consists of eight items focusing on past medication use patterns. a higher score indicates high level of self-reported adherence. adherence level is to be categorized as high (score: 8), medium (score: 6 and 7) and low (score: <6). but for ease of analysis in the current study it was categorized in to non adherence (low score) and adherence (medium and higher score). a data abstraction form was prepared to extract pertinent information from patients’ chart. the form contained information on diagnosis, prescribed drugs, years of follow up and treatment, age at first seizure, seizure free period, adverse effects, and seizure control pattern. the questionnaire was pretested using 5% of the sample size by the investigators and necessary modifications were done. the collected data were crosschecked by the investigators and supervisors. data was collected by trained nurses who trained for two days on how to collect the necessary data from charts. the collected data were checked for completeness, cleaned prior to data entry and then entered using epi info™ version 3.1. data analysis was carried out using statistical package for social sciences program version 20. descriptive statistics like frequency and percentage were used to summarize characteristics and related information of the variables. the cross-tabular form of descriptive statistics was carried out to relate each variable to non-adherence and seizure control as a univariate. a chi-square (c2) test was used to see the significance of association of categorical variables to non-adherence. from the univariate analysis, the variables with a p-value of <0.20 were considered as candidate for further analysis using multivariable binary logistic regression method so that to assess the predictability of the independent variables of non-adherence. an estimate of odds ratios (or) with the corresponding 95% confidence intervals (ci) was used to determine the significant factors. and p-values. the association was declared significant at p<0.05. ethical clearance was approved by the institutional review board (irb) of the college of medicine and health sciences of hawassa university. a letter of support was asked from chief clinical director of hucsh. data was collected after permission was asked from the study subjects following a brief discussion with the people with epilepsy about the purpose and impor article table 1. scio-demographic characteristics of pwe having followup at hucsh, february 01-october 15, 2017. variables number % age in years 15-24 63 34 25-34 71 38 35-44 31 16 45-60 17 9 >60 5 2.5 sex male 98 52 female 89 48 marital status single 96 51 married 87 47 divorced 2 1 widowed 2 1 place of residence rural 45 24 urban 142 76 educational status no formal education 14 8 primary 51 27 secondary 62 32 tertiary 60 32 occupation student 44 24 goernment employed 43 23 merchant 27 14 farmer 19 10 house wife 18 10 day laborer 31 20 ethnicity sidama 82 44 amhara 25 13 oromo 28 15 wolayta 24 13 guraghe 13 7 others 15 8 religion protestant 105 56 orthodox 60 32 muslim 20 11 others 2 1 monthly income in etb 1000-1999 44 23.5 2000-2999 41 22 >3000 42 22.5 unknown 15 8 [healthcare in low-resource settings 2022; 10:10694] [page 57] non -co mmerc ial us e o nly tance of the study and was collected from those who were willing to participate. operational definition and definition of terms adherence to antiepileptic drugs: the extent to which the patient follows medication instructions. for this study; adherent: mmas-8 score of ≥6, non-adherent: mmas-8 score of <6 controlled seizure: seizure free for ≥1 year. results socio-demographic characteristics of the participants of the sought total sample size 187 epileptic patients card medical record was reviewed (96% response rate). of all participants, 98(52%) were male. the majority (38%) of them was in the age group between 25-34 years of age. fifty one percent of the participants reported to be unmarried; comparable with those who got married (47%). the urban dwellers comprised the large proportion (76%). the educational background of majority of the study participants was found to be secondary and tertiary schools, 32% for both. the majority of them reported to be students; with comparable proportion of those who responded to be employed, 24 and 23% respectively. financially, majority of them reported a monthly income of <1000 and 1000-1999, in etbs accounting for 24% and 22% respectively (table 1). clinical characteristics of the study subjects according to the current analysis, in 90 patients (58%) the onset of the first epileptic seizure occurred between the age of 16 to 30. the majority of them (57.5%) had >5 years of follow up duration at hucsh. duration of illness (epilepsy) was >10 years for 42% of them. the highest proportion of them (56%) had seizure free period of less than one year. in this study, non-adherence level by mmas-8 was found to 35 (18.5%) as detailed in table 2. patterns of antiepileptic drugs use on the bases of therapy with aed, monotherapy was found to be the most frequently prescribed treatment modality (84%), with phenobarbitone being prescribed for the majority of the participants (59%), followed by phenytoin (18%). among combination therapy, phenobarbitone with phenytoin was commonly prescribed (11%). duration of the use of aed was documented >5 years for majority of the study participants (63%; table 3). factors associated with non adherence to antiepileptic drugs in this study, of the potential factors identified by bivariate logistic regression analysis, participants monthly income, knowledge about epilepsy (neurologic, hereditary, psychiatric or evil spirit) and seizure control status were found to be significant factors associated with non-adherence to antiepileptic drugs (p<0.05). accordingly, patients with monthly income of >3000.00etb were about 16% less likely to be non adherent than those who earn <1000.00etb [aor=0.164, 95% ci (0.038, 0.702)]. likewise, patients who’s monthly income is between 2000 and 3000 etb were about 11% [aor=0.110, 95%ci (0.026:0.461)] less likely to be non adherent than patients with monthly income of <1000etb. patients who perceived epilepsy as psychiatric disorder were 25% less likely to be non adherent than those who perceive epilepsy as a neurologic disorder [aor= 0.250, 95%ci (0.087, 0.716)]. patients with seizure free period of less than one year are about 21% less likely [aor= 0.206,95%ci(0.076,0.562)] to be non adherent than those with seizure free period more than one year (table 4). discussion this study aimed to assess non adherence and the associated factors among pwe at hucsh in south ethiopia. the validated 8-item morisky medication adherence scale (mmas-8), a self reporting tool, was article table 2. clinical characteristics of people with epilepsy on follow-up at hucsh, february 01 to october 15, 2017. variables number % age at onset of first seizure (n=187) ≤5 years 15 10 6-15 years 57 30 16-30 years 90 58 >30 years 25 13 duration of follow up at hucsh (n=187) 1-2 years 21 11 3-5 years 59 32 >5 years 107 57.5 duration of illness (epilepsy) (n=187) ≤5 years 43 23 6-10 years 66 35 >10 years 78 42 seizure free period (n=187) <1 year 105 56 1-2 years 59 31 ≥3 years 23 13 co-morbidities (n=12) hypertension 6 3.2 hiv 2 1.1 hiv and stroke 1 0.5 stroke 3 1.6 adverse effect(s) (n=187) no 131 70 yes 56 30 adherence (by mmas-8) ≥6 152 81 <6 35 18.5 total 187 100 table 3. patterns of antiepileptic drugs use by peoples with epilepsy at hucsh, february 01-october 15, 2017. variables number % type of aed used phenobarbitone 110 59 phenytoin 34 18 carbamazepine 13 7 phenobarbitone and phenytoin 20 11 phenobarbitone and carbamazepine 4 2 phenytoin and carbamazepine 6 3 the no. of aed used one drug 157 84 two drugs 30 16 duration of aed use/treatment 1-2 years 27 14 3-5 years 43 23 >5 years 117 63 [page 58] [healthcare in low-resource settings 2022; 10:10694] non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10694] [page 59] used in this study which revealed a nonadherence rate of 18.5%. in contrast to this, higher percentage of non-adherence rate was documented in previous studies; like in yirgalem hospital, ethiopia 68%,5 northern nigeria 67.4%,11 ambo hospital, ethiopia 53.8%12 and dessie referral hospital (34.1%).13 the probable reason for the discrepancies could be due to the difference in sampling methods, and operational definitions for non-adherence to aeds in which the current study considered only low score (<6 mmas-8) excluding medium scores. besides, as one would expect, in self report non adherence measures, patients could overvalue their adherence and report low non adherence to aeds. patients with higher monthly incomes (>3000etb) were less likely to be nonadherent. this was consistent with the study in india.14 patients with better income might have better opportunity for education in turn awareness towards the adherence, in the current study patients who perceive epilepsy as a psychiatric disorder were less likely to be non-adherent. while such perception is reported in previous studies,15,16 the possible reason for being more adherent to the medication could be their better awareness on psychiatric disorders in which adherence is important to control the disease.17 patients with uncontrolled seizure (seizure free period of less than one year) are less likely to be non-adherent. this is not unexpected as most patients with epilepsy prefer adherence to aeds to reduce or even combat their seizure frequency effectively.18 like any other study, the current study is not without limitation. one obvious limitation is the use of self-reported mmas-8 method for adherence assessment that might have caused over estimation of adherence status. the cross-sectional nature of the study didn’t allow for follow up observation, an approach with better design to assess risk factors associated with nonadherence status, consequently, in the current study design, there is generally no evidence of a temporal relationship between non adherence and factors associated with it while such evidence is more stronger. however these limitations do not invalidate the findings. conclusions the non-adherence rate was discovered to be 18.5%. monthly income, knowledge of epilepsy, and seizure control status were found to have a statistically significant relationship with aed adherence. as a result, the hospital should devise strategies to improve current adherence levels. references 1. who. epilepsy [internet]. who 2019. accessed 13 august 2019. available from: https://www.who.int/newsroom/fact-sheets/detail/epilepsy 2. who. adherence to long-term therapies: evidence for action. 2003. available from: https://apps.who.int/iris/handle/10665/4 2682 3. munger ma, van tassell bw, lafleur j. medication nonadherence: an unrecognized cardiovascular risk factor. med gen med 2007;9:58. 4. buck d, jacoby a, baker g, chadwick d. factors influencing compliance with antiepileptic drug regimes. seizure 1997;6:87-93. 5. hasiso t, desse t. adherence to treatment and factors affecting adherence of epileptic patients at yirgalem general hospital, southern ethiopia: a prospective cross-sectional study. plos one 2016;11:e0163040. 6. getachew h, dekema n, awol s, et al. medication adherence in epilepsy and potential risk factors associated with non adherence in tertiary care teaching hospital in southwest ethiopia. gaziantep med j 2014;20:59. 7. sweileh w, ihbesheh m, jarar i, et al. self-reported medication adherence and treatment satisfaction in patients with epilepsy. epilepsy behav 2011;21:3015. 8. beyene m, engidawork e. adherence and treatment outcome among epileptic patients of follow-up at amanuel specialized mental hospital, ethiopia. ethiopian pharmaceut j 2018;33:53. 9. naing l, winn t, rusli bn. sample size calculator for prevalence studies. arch orofac sci 2006;1:9-14. 10. morisky d, ang a, krousel-wood m, ward h. predictive validity of a medication adherence measure in an outpatient setting. j clin hypert 2008;10: 348-54. 11. johnbull o, farounbi b, adeleye a, et al. evaluation of factors influencing medication adherence in patients with epilepsy in rural communities of kaduna state, nigeria. neurosci med 2011;02:299-305. 12. tefera g, woldehaimanot t, angamo m. poor treatment outcomes and associated factors among epileptic patients at ambo hospital, ethiopia. gaziantep article table 4. factors associated with non adherence to treatment in patients with epilepsy hucsh, february 01-october 15, 2017. adherence status to aed no (%) yes (%) cor (95% ci) aor(95%ci) monthly income <1000etb 3 (6.4) 44 (93.6) 1 1 1000-1999etb 5 (10.2) 44 (89.8) 0.600 0.135 2.665 0.761 .159 3.635 2000-3000etb 6 (34.8) 30 (65.2) 0.128 0.034 0.477** 0.110 0.026 0.461** >3000etb 11 (24.43) 34 (75.6) 0.211 0.054 0.815* 0.164 0.038 0.702* knowledge about epilepsy neurologic 7 (12.7) 48 (87.3) 1 1 hereditary (1) 3 (9.11) 30 (90.9) 1.458 0.350 6.078 1.404 0.304 6.490 psychiatric (2) 24 (25.5) 70 (74.5) 0.425 0.170 1.066 0.250 0.087 0.716* evil sprit (3) 1 (20.0) 4 (80.0) 0.583 0.057 5.998 0.605 0.048 7.704 whether epilepsy is yes 25(23.1) 83 (76.9) 0.481 0.216 1.071 0.630 0.251 1.580 controlled by no 10 (12.7) 69(87.3) 1 1 modern drug seizure control status controlled (seizure free period ≥1yr) 7 (8.5) 75 (91.5) 1 1 uncontrolled (seizure free period of <1yr) 28 (26.7) 77 (73.3) 0.257 0.106 0.623** 0.206 0.076 0.562** number of aeds used monotherapy 27 (17.2) 130 (82.8) 1 1 dual therapy 8 (26.7) 22(73.3) 0.571 0.230 1.418 0.747 0.252 2.213 note: * is statistically significant at p<0.05, ** is statistically significant at p<0.01. non -co mmerc ial us e o nly [page 60] [healthcare in low-resource settings 2022; 10:10694] med j 2015;21:9. 13. niriayo y, mamo a, gidey k, demoz g. medication belief and adherence among patients with epilepsy. behav neurol 2019;2019:1-7. 14. gurumurthy r, chanda k, sarma g. an evaluation of factors affecting adherence to antiepileptic drugs in patients with epilepsy: a cross-sectional study. singapore med j 2017;58:98-102. 15. henok a, lamaro t. knowledge about and attitude towards epilepsy among menit community, southwest ethiopia. ethiopian j health sci 2017;27:47. 16. kartal a. knowledge of, perceptions of, attitudes and practices regarding epilepsy among medical students in turkey. epilepsy behav 2016;58:115–8. 17. semahegn a, torpey k, manu a, et al. psychotropic medication non-adherence and associated factors among adult patients with major psychiatric disorders: a protocol for a systematic review. systematic rev 2018;7:10. 18. ernawati i, islamiyah wr, sumarno. how to improve clinical outcome of epileptic seizure control based on medication adherence? a literature review. open access macedonian j med sci 2018;6:1174-9. article non -co mmerc ial us e o nly hrev_master [page 48] [healthcare in low-resource settings 2023; 11:11204] compliant strategies to contain coronaviruses amidst the inconveniency of social distancing takele taye desta, tewodros mulugeta department of biology, college of natural and computational science, kotebe university of education, addis ababa, ethiopia abstract social distance is the most promising technique for containing respiratory disorders such as coronaviruses. however, social separation is impractical in some situations where physical proximity is unavoidable. this research proposes alternative and complementary preventive and suppressive social distancing measures. this study explored the literature, produced critical ideas, and synthesized personal insights to develop realistic respiratory syndrome containment measures. client-initiated congestion is common in enterprises and institutions that supply critical goods and services, according to experience. when overcrowding is unavoidable, containment methods such as using face masks, practicing proper cleanliness, improving the health of living and working environments, expanding access to critical supplies and services, and boosting social wellness must be implemented. additionally, using (locally available) antiseptics, avoiding risky behaviors such as aggression, loneliness, smoking, drug abuse, and excessive alcohol consumption, eating greens, getting enough rest, receiving psychological treatment, and forming social ties could all help to reduce the negative effects of respiratory syndromes. snipping hot liquids, preferably with honey, providing special attention to the elderly and individuals with comorbid diseases, seeing on-time healthcare workers and following their advise, and decreasing stress-inducing lifestyle factors all help to regulate respiratory syndromes. to control the transmission of contagions that cause respiratory syndromes, cost-effective and simple-to-implement measures should be used. ignoring impoverished and marginalized communities in pandemic cases allows contagions to flourish unchecked, increasing the recurrence and circulation of pathologically important respiratory disorders. introduction respiratory syndromes like the spanish flu and various lineages of coronaviruses that we have encountered recently have created unprecedented challenges for the global population and unparalleled challenges for the global healthcare system.1 especially following the devastating impact of the spanish flu and severe acute respiratory syndrome coronavirus 2 (sars-cov-2), millions of people across the world have lost their lives. as the name implies, contagions that cause respiratory syndromes infect the respiratory tracts of patients. people with upper respiratory tract infections can transmit contagions to healthy people that are in close contact through sneezing or coughing infectious droplets and aerosols, especially when their nose and mouth remain uncovered.2,3 moreover, contagions that can infect the respiratory tract can be spread while breathing, talking, and through respiratory secretions like mucus and saliva.4 although potent vaccination has been made possible against coronaviruses,5 no effective treatment methods have been invented to treat coronavirus disease 2019 (covid-19);6 consequently, the virus keeps circulating.7 still, the most reliable containment strategy is behavioral change.8 behavioral change among others, practically refers to social distancing or social isolation. social distancing is among the widely used mitigating strategies that halt the spread of coronaviruses. according to the u.s. centers for disease control and prevention,9 close contact is defined as being within an approximately 2-meter distance among individuals for a reasonably long period and/or being exposed to the infectious secretions of coronavirus patients. in some guidelines, physical distancing is, however, dragged down to 1.5 meters.10 however, coronavirus carriers may not be identified, for example, in the case of asymptomatic individuals, which crumbles the containment practices. close physical contact is inevitable under some circumstances and cultural settings, especially in developing countries. for example, when the frontier of physical space is limited, as in the case of companies producing and delivering essential products and services, refugee camps, overcrowded urban settings like shantytowns, congested marketing places, retail outlets, and prisons, social isolation is unbearable. likewise, in elderly care homes, among homeless individuals, on public transport, at airports, when several individuals are sharing a common living or working room, and in multigenerational homes11-13 most likely, it is dreadful to bear the guidelines of social distancing. moreover, people with disabilities and mental health problems likely face difficulties practicing social distancing.13 healthcare workers who spend a significant part of their time with coronavirus patients or carriers would not have a chance to maintain the recommended physical distance. children are less susceptible to coronaviruses compared to adults,14 however, they can serve as carriers of the contagion. during the coronavirus pandemic, parents and daycare workers were unable to keep their children at a safe distance. working from home through virtual platforms, distance learning, and online shopping is less practical in the less developed world where internet service is weak and unreliable,15,16 which then forces most people to communicate in person. large proportions of the residents of the less developed world use communal bathrooms healthcare in low-resource settings 2023; volume 11:11204 correspondence: takele taye desta, department of biology, college of natural and computational science, kotebe university of education, addis ababa, ethiopia. e-mail: takele_taye@yahoo.com key words: impracticality of social distancing, contagions, alternative and complementary containment, suppressive strategies, overcrowding, essential companies and institutions. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. patient consent for publication: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 24 january 2023. accepted for publication: 29 june 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11204 doi:10.4081/hls.2023.11204 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly and water taps; both lifestyles make them contact each other frequently. a significant proportion of the inhabitants in less developed nations earn their livings as street vendors and rely on a daily wage or work in the informal employment sector,17 all of which make them come into physical contact daily. people most likely do not abstain from sex where physical proximity is indispensable, perhaps the sex industry has subsisted on prostitution even during the worldwide lockdown. the incidence of sexual harassment has escalated across the globe following the coronavirus-induced lockdown.18 it might also be possible that people disproportionately capitalize on sex during the lockdown because the landscape of physical entertainment is virtually limited to the home. therefore, when social distancing is impractical, alternatives and/or complementary preventive or suppressive strategies should have to be devised. this study reports various strategies that can be adopted to contain respiratory syndromes when social isolation is impossible. materials and methods the study used a mixed approach to compile the report. accordingly, it consulted literature, elicited critical thoughts, and synthesized personal insights and experiences. a literature search was made using the general search engine of google and the keywords coronavirus and prevention and suppression methods. based on this information, the study proposed prevention and suppression strategies against coronaviruses in such a way that they especially addressed the context of the less developed world. it also highlighted plausible medication options. results and discussions the result and discussion section mainly deals with plausible preventive and suppressive strategies against coronaviruses and covid-19. prevention and suppression of contagions much has been learned about how to prevent and contain emerging contagions of respiratory syndromes like coronaviruses. indeed, much has been left to understand about the etiology of highly infectious contagions and the driving factors behind their outbreak and fatality. expansion and refinement of prevention, suppression, and treatment methods could save lives and resources and enhance and elaborate the efficacy of mitigation strategies. the central dogmas for major areas of intervention to mitigate the adverse impact of respiratory syndromes like coronaviruses are presented in figure 1 according to their decreasing order of importance but increasing level of complexity. regardless of this, all three strategies are intended to achieve a similar goal. although they may not represent an exhaustive list, core prevention, suppression, and treatment methods are summarized in figure 2. the lists show that the types of interventions decrease as we move from prevention to suppression and then treatment. it is worthwhile to opt for longlasting and affordable interventions like prevention and suppression to enhance the efficacy of containment strategies. however, the three main containment strategies are complementary to each other and interrelated (figure 3). the adoption of the proposed containment methods, however, needs to be context-dependent. prevention strategies when social distancing is impractical, wearing face masks and other personal protective equipment, frequent hand washing, disinfecting with antiseptics,10 and practicing proper hygiene19 have been recommended to reduce the spread of the coronavirus. however, in less developed countries, and at least in some areas of these nations, it is impractical to abide by the very basic preventive guidelines because the communities have limited access to even basic provisions such as water (especially in the case of dryland regions) and antiseptics.20 moreover, there is a tradition of communal living and the sharing of limited resources, and overcrowding is frequent in service-delivery centers and public spaces. under these circumstances, there is a sense of urgency to devise alternative and complementary preventive strategies for social distancing. otherwise, it takes a long time to eradicate respiratory syndromes once they have a foothold in the community. the following plausible alternative and complementary preventive strategies have been proposed to be implemented in line with the local context. the suggested strategies are grouped into clusters based on their practical application. short report figure 1. the linkage among the three core containment strategies of respiratory syndromes. figure 2. prevention, suppression, and treatment methods of coronaviruses and sibling respiratory syndromes. [healthcare in low-resource settings 2023; 11:11204] [page 49] non -co mmerc ial us e o nly personal protective equipment (ppe) and self-hygiene the strategies concerning the personal protective equipment (ppe) and selfhygiene are the following: i) enforcing the consistent use of readily accessible, durable, and reusable protective coverings such as face masks and gloves: ii) the use of natural soapberry plants with antimicrobial/antiseptic properties like phytolacca dodecandra and wood ash for cleaning clothes and handwashing; iii) avoiding garbage dumps — an excellent medium for the proliferation of pathogens. enhancing the condition of residential units and working quarters the strategies concerning living spaces are: i) artificially boosting the temperature of the living and working rooms, for example, using burning charcoal to create an inauspicious environment for the coronaviruses, especially during cold seasons. the anecdotal report shows that a family member living in addis ababa and infected by coronavirus was fumigated with kebericho (echinops kebericho mesfin) to the point of deadly sweating, which has made the coronavirus scramble. moreover, in ethiopia, there is a long-lasting tradition of smoking garbage in open spaces around homesteads on november 21st, i.e., the day dedicated to st. michael by the ethiopian orthodox church, perhaps to symbolize the taking away of the spanish flu that had severely affected ethiopia in november 1918; ii) allowing the free circulation of fresh air; iii) constructing low-cost shelters for the homeless; iv) freeing some of the prisoners who committed pardonable crimes to reduce overcrowding in the prisons; v) the use of green classrooms, such as green areas and wide canopy trees, reduces overcrowding in conventional classrooms; vi) the adoption of multiple shifts, perhaps combined with virtual classes, reduces the number of students attending a session. enriching supply units, marketplaces, and transportation services as far as infrastructure are concerned, the suggestions are: i) sustained provision of essential services and supplies; ii) restricting nonessential traffic among overcrowded settings and areas that have been infected by the coronaviruses; iii) shifting or splitting bus or taxi stations into wider and less congested, and in multiple places; iv) splitting big open-air markets into multiple locations to provide close access to the point within walking distance and to reduce overcrowding. moreover, cautions need to be made when disease outbreaks with the potential of being pandemics are expected and to become safe from avoidable infections, as presented in table 1. along with hygiene, healthcare management, and public awareness initiatives, efforts need to be made to enhance the wellbeing of the community. enhancing wellness (table 2) is vital to contain the spread of contagions and suppress their adverse impact. in some instances, contagions could escape prevention efforts. when prevention methods do not contain contagions, they will have the chance to infect the community. once infested, if the case is mild to moderate, suppression could work; if the case is severe, it likely requires treatment. suppressive strategies if any kind of strict prevention strategy could have been implemented, they may not have completely avoided coronavirus infection, as the battle is against the invisible and highly infectious orphan virus. infection by the coronavirus broadly produces asymptomatic, mild, moderate, and critically ill cases. in the latter three cases, effective treatment is required in line with their level of fatality. in this report, suggestions are made to treat mild to moderate cases of coronavirus infection: i) sipping hot drinks such as tea and coffee, preferably with honey, could suppress the multiplication of coronaviruses; ii) under normal or mild conditions, adopting the commonly used guidelines or using home-brewed cures and spicy foods that have been at least traditionally proven effective to treat the common cold and influenza; iii) feeding leafy green vegetables and citrus fruits may boost the immune response;23 iv) at any cost, avoiding dehydration. moistening the nasal cavity boosts the body’s defense mechanisms; v) regular sex may improve health conditions by activating the innate immune system;24 however, sex (especially unprotected) could expose them to sexually transmitted diseases; vi) avoid anxiety and frustration once you contract the coronavirus while taking all possible care; vii) confidence can be built using psychological treatments that have been commonly practiced by the communities of the less developed world, such as prayer, and swearing;25 viii) using and working with herbal medicines with robust antiviral activity. for example, bergner (1996)26 recommended the use of garlic in the form of a nose drop to suppress the common cold. moreover, desta et al.27 reviewed an extensive list of studies conducted on edible medicinal plants as potential remedies to treat coronaviruses; ix) limited and healthier intake of alcoholic drinks may suppress the negative impact of coronaviruses.28 for example, in ethiopia, a local drink made up of fractional distillation called katikela had high market demand during the coronavirus-induced lockdown period. trained phenotype even under worldwide coronavirus pandemics, immunity has been developed by a significantly large proportion of the world population through natural infection,29 which can be evidenced by the low fatality rate of sars-cov-2 cases in africa surviving with an underdeveloped healthcare system. this might be intriguing; however, the reality is that africans have experienced repeated exposure to circulating sibling viruses causing various types of respiratory syndromes; hence, they have developed a robustly trained phenotype with a broad short report figure 3. the cause and effect of repeated exposure to natural infections. [page 50] [healthcare in low-resource settings 2023; 11:11204] non -co mmerc ial us e o nly spectrum of fighting capacity. moreover, a large proportion of the african population lives scattered in rural areas, which reduces the spread of contagions. africans are also known to possess high genetic diversity30 and live in ecologically highly diverse tropics. this diversity creates an ideal environment for exposure to various contagions and enables them to develop high genetic polymorphism and diverse environmental conditions that induce expansive immune responses. repeated exposure to contagions makes the immune system develop robust immunity against various types of infections.31,32 treatments most conventional medicines are made from plants. enhancing the consumption of medicinal herbs, vegetables, fruits, and healthy diets could, to some extent, help treat non-critical cases. if there is no effective treatment for respiratory syndrome, the most plausible alternative is treating comorbidities and tirelessly working through international connections and the prevailing state-of-theart technology and expertise for the discovery of at least partially effective drugs. conclusions unless locally tailored alternative and complementary preventive strategies are developed and enforced as quickly as possible when an epidemic emerges, the international effort that has been made to contain contagions could fall apart. interventions that have been developed to combat the coronavirus pandemic need to be extensively documented and researched for their efficacy. traditional knowledge and wisdom need to be verified and form part of containment strategies. overlooking marginalized communities and disadvantaged groups amidst epidemiological crises could enable the contagion to circulate unchecked, which in turn serves as a recipe for the resurgence of the devastating contagion. references 1. dorn f, khailaie s, stoeckli m, et al. the common interests of health protection and the economy: evidence from scenario calculations of covid-19 containment policies. eur j health econ 2023;24:67-74. 2. wouk h. tuberculosis. marshall cavendish; 2010. 3. rai nk, ashok a, akondi br. consequences of chemical impact of disinfectants: safe preventive measures against covid-19. critical rev toxicol 2020;50:513-20. 4. stetzenbach ld. airborne infectious microorganisms. encyclopedia of microbiology, 2009:175. 5. schwarzinger m, watson v, arwidson p, et al. covid-19 vaccine hesitancy in a representative working-age population in france: a survey experiment based on vaccine characteristics. lancet public health 2021;6:e210-21. 6. tiwari n, joshi s, mahadik ss, et al. covid-19: prevention and control. gsc biological pharmaceutical sci 2023;23:287-92. 7. coccia m. preparedness of countries to face covid-19 pandemic crisis: strategic positioning and factors supporting effective strategies of prevention of pandemic threats. environ res 2022;203:111678. 8. eaton la, kalichman sc. social and behavioral health responses to covid19: lessons learned from four decades of an hiv pandemic. j behav med 2020;43:341-5. 9. centers for disease control and prevention. centers for disease control and prevention. interim us guidance for risk assessment and public health management of healthcare personnel with potential exposure in a healthcare setting to patients with coronavirus disease (covid-19). accessed 7 july 2020. available from. https://www. cdc. gov/coronavirus/201 9-ncov/hcp/guidance-risk-assesment-hcp.html 10. qian m, jiang j. covid-19 and social distancing. j public health (berl.) 2022;30:259-61. short report table 1. suggested preventive strategies for respiratory syndromes. category measures need to be taken hygienic measures avoid sharing personal belongings cover your mouth and nose while coughing or sneezing avoid touching the nose, mouth, hair, or eye with grubby hands safely dispose of and avoid direct contact with discarded materials wash hands frequently or use a sanitizer handle and prepare food safely clean and disinfect commonly used surfaces cough and sneeze into a tissue or a sleeve make the equipment and facilities of the healthcare system tidy safe disposal of body fluids and wastes cautiously approach pets and other domestic and wild animals health management stay home when feeling ill enhance wellness consistently and correctly wear a high-quality mask keep a physical distance and reduce the incidence of close contact contact tracing21 health risk assessment developing healthy eating and drinking habits immunize on time22 practice safe sex publicizing earnestly follow news developments mass education and training devising conspiracies and pseudo-science mitigating strategies table 2. enhancing wellness to contain the spread of respiratory syndromes. category itemized practices equity equitable access to (scarce) resources providing support for the elderly, low-earning people, and people with comorbidities reducing the normal working time but enhancing skillset and efficiency treating individuals with pre-existing health problems enforcement enforcing a rapid and decisive reaction against coronaviruses promoting solidarity among communities promoting mental well-being and having adequate rest engaging in regular physical exercise in safe places regular screening for temperature and general health status invent robot-assisted care for severely affected patients abiding by the advice of healthcare staff refrain from the politicization of coronaviruses [healthcare in low-resource settings 2023; 11:11204] [page 51] non -co mmerc ial us e o nly [page 52] [healthcare in low-resource settings 2023; 11:11204] 11. duffin e. average household size worldwide, by region 2019. accessed 6 may 2020. available from: https:// www.statista.com/statistics/1090668/av erage-household-size-worldwide-byregion/#statisticcontainer 12. tusting ls, bisanzio d, alabaster g, et al. mapping changes in housing in subsaharan africa from 2000 to 2015. nature 2019; 568:391–4. 13. ecdc (european centres for disease prevention and control). considerations relating to social distancing measures in response to covid-19 – second update. technical report – 23 march 2020. considerations relating to social distancing measures in response to covid-19 – second update (europa.eu). accessed on 10 july 2020. 14. ludvigsson jf. systematic review of covid-19 in children shows milder cases and a better prognosis than adults. acta paediatrica 2020;109:1088-95. 15. mulugeta t, tadesse e, shegute t, desta tt. covid-19: socio-economic impacts and challenges in the working group. heliyon 2021;7:e07307. 16. mulugeta t, tadesse e, shegute t, desta tt. the reaction of secondary school and university students toward covid-19-induced lockdown. j public health africa 2023;14:2123. 17. günther i b. why social distancing is a big challenge in many african countries. 20 april 2020 eth zurich. available from: https://phys.org/news/ 2020-04-social-distancing-big-africancountries.html. accessed 10 july 2020 18. caroline b-l. a double pandemic: domestic violence in the age of covid19. council on foreign relations – 13 may 2020. accessed 3 june 2020. available from: https://www.cfr.org/inbrief/double-pandemic-domestic-violence-age-covid-19 19. oosterhoff b, palmer ca. psychological correlates of news monitoring, social distancing, disinfecting, and hoarding behaviors among us adolescents during the covid-19 pandemic. accessed 10 july 2020. available from: https://psyarxiv.com/rpcy4/ 20. desta tt. lifestyles and living standard disparities in the pandemicity of covid-19 in the global north versus the global south countries. geriatric care 2020;6:9025. 21. benati i, coccia m. effective contact tracing system minimizes covid-19 related infections and deaths: policy lessons to reduce the impact of future pandemic diseases. j public admin govern 2022;12(3). 22. coccia m. optimal levels of vaccination to reduce covid-19 infected individuals and deaths: a global analysis. environ res 2022;204:112314. 23. thirumdas r, kothakota a, pandiselvam r, et al. role of food nutrients and supplementation in fighting against viral infections and boosting immunity: a review. trends food sci technol 2021;110:66-77. 24. haake p, krueger th, goebel mu, et al. effects of sexual arousal on lymphocyte subset circulation and cytokine production in man. neuroimmunomodulation. 2004;11:293-8. 25. desta tt, mulugeta t. living with covid-19-triggered pseudoscience and conspiracies. int j public health 2020;65:713-4. 26. bergner p. the healing power of garlic. prima publishing, 1996. 27. desta tt, jemal k, sitotaw r, et al. the antiviral properties of edible medicinal plants: potential remedies against coronaviruses. healthcare low-res sett 2023;11:11205. 28. foster rk, marriott he. alcohol consumption in the new millennium– weighing up the risks and benefits for our health. nutr bull 2006;31:286-331. 29. ioannidis jp. the end of the covid-19 pandemic. eur j clinical invest 2022; 52:e13782. 30. campbell mc, tishkoff sa. the evolution of human genetic and phenotypic variation in africa. current biol 2010;20:r166-73. 31. shah vk, firmal p, alam a, et al. overview of immune response during sars-cov-2 infection: lessons from the past. front immunol 2020;11:1949. 32. desta tt. selective vaccination could suffice to develop a robust herd immunity against sars-cov-2. j cell dev biol 2022;4:43-5. short report non -co mmerc ial us e o nly hrev_master [page 40] [healthcare in low-resource settings 2013; 1:e10] the cutting edge in the blunt space: an anthropological construct of auxiliary nurse midwives’ social world in the community avanish kumar,1 meerambika mahapatro2 1management development institute, gurgaon; 2national institute of health and family welfare, new delhi, india abstract auxiliary nurse midwives (anms) are the most peripheral health providers and manage the rural health sub-centre in a community. they mediate directly between the community and the health system for the management of maternal and child health programme in india. the purpose of this study was to find out the role of cultural factors, such as anms’ caste, age, marital status, being non-resident in the working village and other social factors regarding their acceptance in the community. the study is exploratory and qualitative. the area of study was a multi-caste remote village, mavaibhachan, in kanpur dehat district of uttar pradesh, india. data were collected through in-depth interviews and fieldwork notes taken during and immediately after the interviews with anms, and thematically analyzed. our results show that if anms belong to a different caste group, do not live in the working village and are relatively younger, they are socially insecure and stressed and the community hardly accepts them. despite direct interface with the community, their social status and lowest position in the health system is reflected in acceptability and recognition. the position of anms needs to be strengthened, within society and the health system. in order to make public health services effective and efficient the health system has to reduce stratification based on role and status. introduction auxiliary nurse midwives (anms) are the most peripheral health providers, and as a permanent functionary of health system, they manage the rural health sub-centre (sc) in a three-layered health system, interact directly with the community thus managing the maternal and child health programme in india.1 considering their status as front-line or cutting-edge, grass-root level health providers in the health organizational hierarchy, and the gamut of functions performed, their work is fundamental to the success of the health program.2 recent policy shifts in national rural health mission (nrhm) have made it clear how it is anms’ responsibility3 to manage all aspects of health and family welfare.4,5 other tasks include performing national health programmes and support the international classification of diseases (icd) and other outof-reach governmental services.6 consequent to the multiple functions performed by anms, they are expected to do home visits to meet the health needs of every household in the community, especially the poor and vulnerable sections of population in rural areas.7,8 they attempt to be on regular contact with their area population both individually and collectively and cover the area on foot, which often extends to socially and spatially excluded communities. with their active work and involvement in the community, they are expected to provide quality and timely health care. the limited time spent by workers in their jobs is a central factor in low levels of outreach effort.9-11 auxiliary nurse midwives are expected to live in the sc village and be available around the clock for providing their service.12,13 of the 20,521 scs in uttar pradesh, india (september 2005), 32% had anm quarters moslty inhabited by anms (5,183 out of 6,494). yet, given that two-thirds of the scs did not have staff quarters, it would be hardly surprising if anms rarely showed up for work.13,14 the role of anms has markedly changed over the past four decades,15 however, their training and infrastructure support remains stagnant. the efficiency and effectiveness of anms is more complex because their area of operation is embedded with social-political dimensions. a bigger problem lies in the increasing demand, diminishing resources and less attention paid to systemic operational problems that limit the functioning of services.8,12 this further gets accentuated because many anms have to face the consequence of such a mechanism of inefficiency allocation, chronically absence of human resources and doctors, and patients who are routinely charged for some services meant to be free.9,10 unlike hospitals or clinics, in villages, their gender, caste and even age, rather than disease and medicine, do influence consumers’ decision on health services.16 auxiliary nurse midwives work with the people confronted with illiteracy, poverty, unemployment, deep-rooted social customs and local caste-based politics. they have to provide services where people lack health culture.17 here, the clinical practice of medicine is not an idealized application of literacy and declarative system of knowledge learned in basic science courses, medical clerkships and practice, but like any other exchange, it is an arena for constructing new schemata by intuitively and systematic analogically modifying old domains of knowledge that interact with new experiences embedded in often mundane, emergent settings.18 the effect of these social factors in their routine work and acceptance in the village goes unnoticed.19 a prolonged non-response to emotional and interpersonal stressors on the job has an implication on inefficacy. it also depends on auxiliary nurse midwives’ experiences revolving around the quality of their relationship with the community, social status, their position in the occupational hierarchy of the health services, the nature and location of their health work, and their support mechanisms (professional, infrastructural, and personal). the present paper aims to find out how social factors like anms’ caste, age, marital status and being non-resident in the working village and other social factors contribute to their acceptance in the community, which in turn influences the quality of care rendered by anms. materials and methods the study design is exploratory and used a qualitative method. the participants’ observation was carried out by staying in the village for six months. the area of study was mavaibhachan, a multi-caste remote village in kanpur dehat district of uttar pradesh, india. during fieldwork, basic facilities such as electricity and toilets were far to be reached from the village. healthcare in low-resource settings 2013; volume 1:e10 correspondence: meerambika mahapatro, national institute of health and family welfare, baba ganganath marg, new delhi, india. tel. +91.011.2616.5959 fax: +91.011.2610.1623. e-mail: meerambika@rediffmail.com key words: auxiliary nurse midwife, community, community health worker. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 8 january 2013. revision received: 17 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. kumar and m. mahapatro, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e10 doi:10.4081/hls.2013.e10 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e10] [page 41] study design and setting the study design is exploratory and used a qualitative method to capture the worldview of the anms. the area of study was a village called mavaibhachan located in ghatampur block in kanpur dehat (rural) district of uttar pradesh, india. as the name suggests, kanpur dehat is one of the most backward districts of uttar pradesh. ghatampur block was purposively selected as one of the most social-economically backward block, having poor health indicators and a multi-caste village. the two dominant caste groups are the religious superior caste of brahmins and the politically and economically dominant caste of yadavs. the conflict between the two castes in local politics is reflected in their daily activities which further impact the health seeking behavior, as anms come from one dominant caste, i.e. brahmin. the sc was located in a house of a brahmin. being a widow, her regular visit to the village was question on her character by the other caste groups. during our stay in the village for six months, we interviewed and observed the work space of anms of different villages of ghatampur block, uttar pradesh. to triangulate our observations, we conducted indepth interviews of 20 fellow anms working in the district. sample size and frame twenty anms of ghatampur block were selected for in-depth interviews till data saturation. the method utilized was intensity sampling. data collection data were collected through in-depth interviews. quasi-non-participant observations were carried out to understand the interaction between community men and the anms. the questionnaire was open-ended and case narration was recorded. the narratives from questionnaire, field notes and diary were transcribed and thematically analyzed. some of the important questions asked were i) how anms’ caste influences the routine work schedule; ii) whether anms’ age and stage (marital status) affect their work; iii) anms as outsiders or non-resident in the village; iv) anms’ assistance delivery, sex of the child, support (professional and interpersonal) mechanisms; v) anms’ training; etc. informed consent was obtained from all participants: participation was entirely voluntary and confidentiality assured. health administration and community members were informed about the purpose of study. results in anms’ everyday life, their interactions with people and their social intercourse in relation to their environment, community, caste and gender as social actors interpret and give meaning to their professional world. the anms were young, inexperienced to this reallife work environment challenges because they joined the job just after the usual institute training. unlike controlled environment in hospitals, in the community the anms’ medical efficacy is confronted with social constraints. this is the more so because anms are women and work in a conservative patriarchal caste, and class and gender-based rigid social settings. our analysis focuses first on the social structure, anms’ caste, assistance delivery and sex of the child, their training as health providers, and their professional and interpersonal support within the healthcare system. subsequent sections examine the political quality of their facilities, deficiencies in anms’ performance and the targets. auxiliary nurse midwives’ caste in multi-caste villages of kanpur dehat – which have a patriarchal and caste-based social stratification system – anms are brahmin (the upper caste group) and this constitutes a problem. in mavaibhachan, intercaste rivalry existed between the yadavs (traditionally involved in dairy-related occupation and politically dominant in the region, though lower in the caste hierarchy) and the brahmins. as a consequence of political conflict, cases of murder, retaliatory looting and house burning took place, which is reflected in daily interaction. despite repeated efforts, anms are not able to overcome their caste barriers with their technical competence only. as a result, the efficiency of the system and the effectiveness of services get affected. since the sc of the public health system is located in a rented house within the village, anms get support to house sc in a brahmin’s family. auxiliary nurse midwives are categorized more as a brahmin rather than healthcare providers. auxiliary nurse midwives in the field have to face various social risks. the expectation of the community in terms of anms as an ideal womanhood puts them in question. this is more so, because they alone have to visit regularly to the sc that is in brahmins’ house. few villagers do raise their eyebrows before anms as they visit the sc located in other families’ house. in order to build their case against anms, yadav community maligns their character and credentials. similarly, an anm from a lower caste reported that she faced discrimination in a higher caste group where she was not allowed to touch people who sit in a chair and insulted her in various ways. auxiliary nurse midwives as a cutting-edge health professionals working in sc as a last mile health infrastructure lose their efficacy in a closely-stratified community. therefore, real-life clinic of anms is constantly mediated with cultural impediments and social infrastructure. the devolution of power and decentralization of public services have exposed anms to community politics and prejudices. another kind of harassment occurred when elected leaders – sarpanch – demanded special services at home in their village, but their requests were not met. thus, they complained against anms or rated their performance as poor in the appraisal dossier, or asked for transfer anms from the village. the problem gets worse because in the current policy, the sarpacnh (elected village head) is to sign the yearly progress and performance of anms. auxiliary nurse midwives’ assistance delivery and sex of the child the household level demand is destined to sons. anms and midwives reported that delivery of a female child fetched them less reward which was often expressed in less token money: approximately rs. 50/(around 1$) for a female child, while rs. 500 (10$) and dress as a gift for a male child. a repeated delivery of girl child by anms is often considered as bad hand or unlucky for the family. therefore, anms are not called for delivery anymore in the village. in another case, a man from the village brought a lady with whom he had extra-marital relation for forceful abortion. when the anm denied doing so, she was threatened with dire consequences. this forced her to abort the fetus without infrastructure and technical support leading to further complications due to abortion. sometimes, due to similar pressure, anms are forced to adopt illegal practices of sex selective abortion. auxiliary nurse midwives as outsiders or non-resident the notion of outsider for anms by the community exists in uttar pradesh. in kanpur dehat, anms being outsiders has a negative impact. auxiliary nurse midwives spent a large part of their service attempting to establish amicable relations with largely unfamiliar communities. they also try to establish a strong, credible presence in the community because they are seldom posted in their native villages. while building relations with strangers, they face sexual abuse, tease and harassment. an extended conversation with opposite sex is often quoted by the villagers as a default in the role model of anms: they are looked upon and tagged by the villagers as having extra-marital affairs. since anms’ work requires them to speak openly about contraceptives with men, they are viewed as women of loose morals. this negative social image and vulnerable status within the health system article non -co mmerc ial us e o nly [page 42] [healthcare in low-resource settings 2013; 1:e10] makes them an easy prey to sexual harassment. all the anms reported that most of the victims of molestation are the anms who are the outsiders from different districts. one block of kanpur dehat is infamous for criminality. once, an anm got molested and the news got printed in the hindi newspaper (state edition). her family got to know about it and the anm was forced to continue the job for her livelihood because her wage had a high impact on the economic stability of her households. over time, anms encounter numerous obstacles in their work but do not dare to contemplate a job switch. the fear is socialized in the anms community and has a direct impact on the health program. among the consequences, anms’ visits to their respective area become fewer, their staying in the block area rather than at the sc or in the village; even though they are on night duty and do not prefer to travel at night. auxiliary nurse midwives report that they have numerous reasons for preferring not to live in their scs as personal safety is a major concern, especially for unmarried women, who are most vulnerable to sexual harassment. auxiliary nurse midwives’ training most trained anms felt that too much information had been imparted in a too short time in a real-life clinic. they were trained on providing public services, but seldom they were trained in communication and negotiation skills at the village. this fails to build trainees’ confidence, a vital asset in an unassisted health workplace which requires independent decision making. moreover, their cloistered existence in the school does little to prepare them for work in unfamiliar, often uninviting, village communities. the threat of sexual harassment and abuse mars the careers of most anms, but trainees are not informed of their legal rights or channels of redress. in the end, anms learn their lessons of village-level health work not in training schools, but while negotiating the numerous hurdles they encounter in everyday real-life clinics. professional and interpersonal support auxiliary nurse midwives reported that they need professional support to help them carry out the tasks assigned to them particularly at a sub centre (sc) level where they are deprived of the re-assuring environment of a health site compared to the anm posted in the primary healthcare (phc). they also reported that, though transitory supportive supervision is given on technical guidance, they also need moral support and encouragement to handle the sc more confidently. the situation is highly unpalatable when anms visit the sc and its doors are locked. the scs were usually located at the village periphery or outside the protection of the main village cluster. they were often dark and dingy, sometimes located in rented rooms or government made structures with lack of electricity and drinking water facilities, i.e. they were not adequately or uniformly equipped and also lacked this basic amenity. their physical working conditions fall far short of that ideal with essential equipment and supplies. the vaccines and medicines are often supplied in respect to the requirements. as a result, community people asked to visit in the next session tikka nehi hai (unavailability of dose) in some of the phcs and scs. the sessions are organized weekly and, in some areas, children are already late for their scheduled vaccination. these inadequacies affected the ability of anms to work with any degree of confidence in the community. besides being overburdened, anms cited the inadequacy of facilities, equipment, and medicine stocks. they also complained about the lack of proper accommodation and inadequate transport facilities. discussion the outcomes of clinical encounters in the social world were influenced by various social circumstances. socio-demographic characteristic of patients, anms’ professional and social background, and the organization of practice settings appear to determine anms’ responses to patients’ complaints at least partially.14 the medical setting in the hospital creates conditions under which every modes of communication and thinking initially take precedence over formal concerns with production of objective medical knowledge.9, 20 nonetheless, in the social world of care and cure, anms and patients may have different health perspectives and therapeutic agendas.21 the representation of lower castes (chiefly scheduled castes) and upper castes, as evidenced by the caste variation among anms of different ages, has increased the acceptance. another important variable which is related to but not dependent upon geographical location is the resources of the practitioner’s disposal.22 in the course of anms’ life, their everyday interactions with people and social intercourse in relation to their environment, community, caste and gender as social actors, interpret and give meaning to their professional world.7 this is not to say that all actions are thought out, which would imply a highly rational view of behavior. it does, however suggest that all actions, even the most routine and automatic, are subject to interpretation and scrutiny in the local reality.23 young, unmarried or not having children anms were facing more problem in the working and getting accepted in the village. older age, personal characteristics, place and length of employment, and work schedule had an effect. this outcome of nonacceptance of anms may be a result of sociocultural differences that may be a reflection of difficulties in the work condition.24,25 negative conditions where the workload extensively exhaust individuals with little remuneration and reward can disrupt the quality and quantity of service26 by making it a blunt edge. rather than loading all desired activities on the anms under the pretext of integration, different types of health personnel should be provided for implementing a particular task. there is a need to separate functions and skills that can be integrated in one person and those that require different types of skills and appropriate training.27 improved infrastructure facilities available at the health centre can increase the mobility and social assistance/help by increasing the value of their work station.28 alternative systems may be arranged to meet socio-cultural adaptation for better acceptance of anms. decrease identity and social status gap between doctors and anms may increase acceptance of anms in the community very well and may be seen as a first step in the establishment of a quality framework. these concerns have to be adequately emphasized in india’s public health system. however, this will have to be backed up by uniformly available and accessible health institutions and practitioners. it became clear that it is not enough to confine integration to single programs. it must bring together programs with common strategies and resource requirements such as technological, organizational and administrative. finally, it must also build a shared evaluation and monitoring mechanisms of conceived linkages and objectives so that they may be revised if required.27,28 conclusions with the increasing devolution of public services, the role of anms has become much more complex and significant. the current epistemological characteristics of medical theory taught in the training centre cannot be manifested directly. the health system needs to build the capacity of anms of evolving medical specialization and social diagnostic practices. although the health program has been devolved upon a bottom-up approach, system and structure still remain top-down. despite direct interface with the community, anms’ lowest status in the health system gets reflected in their acceptability and recognition. one of the reason behind outplays of gender, age and caste identity is due to anm low status in the health system. the solution is provided by a system which is more flat in structure and can provide dignity and status for anms. the elevation in social status of anms and capacity to negotiate medical efficaarticle non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e10] [page 43] cy will overcome social barriers. along with these changes, social security of anms can be promoted through a deputing policy in their native districts. therefore, in order to provide services at the cutting-edge, the health system needs to constantly sharpen its edge with building skills of management and structure without stratification. references 1. barua a, kurz k. reproductive healthseeking by married adolescent girls in maharashtra, india. reprod health matter 2001;9:53-62. 2. jeffery p, das a, dasgupta j, jeffery r. maternal mortality and morbidity: is pregnancy getting safer for women? reprod health matter 2007;30:172-8. 3. grover d. reena s, kaishtha kc, et al. rch: the role of anm. available from: http://prcs-mohfw.nic.in/writereaddata/ research/222.pdf accessed: 25/12/2011. 4. karasek r, theorell t. healthy work: stress, productivity, and the reconstruction of working life. new york, ny: basic books; 1990. 5. government of india. national rural health mission. mission report 2005-2012. new delhi: ministry of health and family welfare, government of india; 2005. 6. malik g. role of auxiliary nurse midwives in national rural health mission. nurs j india 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econ polit weekly 2004;39:920-33. 15. iyer a, jesani a. barriers to the quality of care: the experience of auxiliary nursemidwives in rural maharashtra. in: koenig ma, khan me, eds. improving quality of care in india's family welfare programme. new delhi: population council; 1999. pp. 210-37. 16. mishra r. female health workers: problems and implications. econ polit weekly 1997;32:2791-3. 17. cicourel av. diagnostic reasoning in medicine: the role of clinical discourse and comprehension. actes rech sci soc1985;60: 79-89. 18. mccombie sc. the politics of immunization in public health. soc sci med 1989;28:843-9. 19. bonair a, rosenfield p, tengvald k. medical technologies in developing countries: issues of technology development, transfer, diffusion and use. soc sci med 1989;28:769-81. 20. dietsch e, mulimbalimba-masururu l. the experience of being a traditional midwife: living and working in relationship with women. j midwifery wom heal 2011;56: 1542-2011. 21. deodhar s. training of anms: an assessment. frch newsletter 1994;8:1-3. 22. ritchie j, dick d, lingham r. report of the committee of inquiry into the care of christopher clunis. london: mind/ cohse; 1994. 23. horobin g, mcintosh j. time, risk and routine in general practice. sociol health ill 1983;5:312-31. 24. cicourel av. doctor-patient discourse. in: van dijk ta, ed. handbook of discourse analysis. london: academic press; 1985. pp.193-202. 25. maslach c, schaufeli wb, leiter mp. job burnout. annu rev psychol 2001;52:397422. 26. srinivasan k, shekhar c, arokiasamy p. reviewing reproductive and child health programmes in india. econ polit weekly 2007;42:14-20. 27. qadeer i. health planning in india: some lessons from the past. soc sci 2008;36:5175. 28. mohan p, iyengar s, brahmawar s, et al. auxiliary nurse-midwife: what determines her place of residence? j health popul dev countries 2003;23:1-16. available from: http://www.longwoods.com/home.php?cat= 394 accessed: 23/12/2011. article non -co mmerc ial us e o nly hrev_master [page 4] [healthcare in low-resource settings 2014; 2:1390] multivariate regression analysis of prime variables affecting ophthalmic patients’ satisfaction in a resource limited economy emmanuel olu megbelayin,1 jacob sackey2 1department of ophthalmology, university of uyo teaching hospital, uyo; 2alache microfinance bank limited, ogoja, nigeria abstract the aim of the present study was to appraise prime dependent variables of ophthalmic patients’ satisfaction in a nigerian public eye care facility with a view to boosting service uptake. it was a cross sectional study conducted between march and may 2012 in our centre. consecutive clinic patients (n=251) that met study’s criteria were recruited. the patients filled interviewer-administered structured questionnaires. a total of 251 patients were analyzed comprising 139 males (55.4%) and 112 females (44.6%). male:female ratio=1:0.8. the ages of the patients studied ranged from 17 to 92 years with a mean of 37.2 years±15.57. bivariate analysis, validated by multiple logistic regression, showed p values of 0.021, 0.008, 0.036, 0.008 and 0.004 for privacy, comfort during eye exam, fairness (non-partiality), thoroughness of examination and expectation, respectively. satisfaction with overall quality of services was 80.1%. the services of any eye facility should be patient-driven to attain desired goals; therefore the identified areas of patients’ dissatisfaction should be addressed for effective service uptake. introduction one of the factors that influence patient satisfaction is efficiency of services. efficiency has a broad scope that embraces promptness of care, duration of consultation, quick response to emergencies, quick dispensation of drugs, fast and accurate laboratory tests, privacy, comfort during exam, fairness (non-partiality), thoroughness of examination and expectation.1 the extent to which the patients perceive these needs and expectations are met by the service provider determines satisfaction.2 with dwindling government earnings and health care becoming increasingly privatized and economically competitive, evidenced by privatization and commercialization of some of nigeria’s public institutions, there is urgent need for patient-centered health services. other reasons that have necessitated a shift towards business approach to healthcare delivery are intense competition, more patient awareness, increased purchasing power of patients, and availability of specialist care.3,4 public health systems in developing countries have failed to achieve adequate level of services. nigeria, for instance, satisfaction to public health care is considerably low.2 to improve public participation and effectiveness of health programs, one must understand the underlying factors that contribute to patients’ satisfaction. the success of any public institution should be consumer-driven to attain desired goals. interest has grown not only in the assessment of treatment interventions by patients, but in the systematic evaluation of the delivery of that care. this study attempted to define the level of ophthalmic health-care satisfaction in a cohort of nigerian patients, as well as to further explore its primary determinants. materials and methods setting our centre is a public tertiary referral centre in the heart of a state capital. the ophthal mology department is one of the oldest clinical units in the hospital that could be a window to the services rendered in this public institution. the hospital statutory activities include research, training of various cadres of health professional and clinical services to the state of location and not exclusively, 5 other neighbouring states in nigeria design of the study and sampling technique this was a cross sectional study. a total sampling of all consecutive patients who met the inclusion criteria and who presented within the study time frame were studied. population this study was conducted among adult patients attending eye clinic in our centre between march and may 2012. sample size to determine the sample size of this study, the following formula was used: (1) where n represents minimum sample size required, p stands for prevalence (from previous study)=83%, q=1-p/100, i.e. 1-83/100=10.83=0.17. z is standard normal deviation of 1.96 (which corresponds to 95% confidence interval), while z2=3.84. degree of accuracy desired (d) was 0.05 (d2=0.0025). substituting the above figures in the formula, we obtained: (2) thus the sample size calculated using the above formula was 217. in order to make an allowance for non-responders, an attrition rate of 10% of the calculated sample size was added to the 217 sample size to obtain a figure of 239. inclusion and exclusion criteria the inclusion criteria used in this study were as follows: i) age more than 16 years; ii) patients who were duly registered in the eye clinic and seen by a doctor at least once. conversely, the exclusion criteria were: i) age 16 years and below (unicef definition of a child is 16 years and below;5 children were deliberated excluded in this response-based healthcare in low-resource settings 2014; volume 2:1390 correspondence: emmanuel olu megbelayin, department of ophthalmology, university of uyo teaching hospital, abak road, uyo, nigeria. tel./fax: +234.8036.670920. e-mail: favouredolu@yahoo.com key words: multiple logistic regressions, satisfaction, patients, calabar, nigeria. acknowledgements: we would like to thank the medical students who assisted in data collection and the entire eye clinic staff for their overall support throughout the study. contributions: eom: concept and design, definition of intellectual content, literature search, acquisition of data, data analysis and interpretation, drafting of the article and final approval of the version to be published; js: concept and design, definition of intellectual content, literature search and final approval of the version to be published. conflict of interests: the authors declare no potential conflict of interests. received for publication: 19 february 2013. revision received: 21 june 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright e.o. megbelayin and j. sackey, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1390 doi:10.4081/hls.2014.1390 non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1390] [page 5] study to enhance reliability). adults’ appreciation of service provided is more likely to be objective; ii) non-eye patients of the hospital; iii) eye patients not yet seen by a doctor, whether registered or not. pilot study questionnaire was validated through pretest study that lasted one week conducted at the eye clinic of a peripheral health facility attached to our centre. this was to test research tools and to train data collectors in order to minimize inter and intra-observer variations. consents and ethical approval ethical approval was obtained from the ethics committee of our centre. written and oral informed consents were sought from every participant in accordance with the tenets of helsinki declaration. data collection proper the study was based on primary information collected through pretested questionnaire from consecutive patients of the eye clinic. only clinic patients were involved in the study to maintain homogeneity. structured questionnaires grossly divided into two parts was specifically developed for this study. the first part was on biodata to get basic information from patients including occupation and educational levels. the second part was a two-section, 10-items questionnaire to cover areas of research interest. all ratings were made on a modified 6-point likert-type scales. among others, questions contained in the questionnaire included socio-demographics characteristics, patient-provider relationship, issues on expectation, hospital appearance and adequacy of facilities in the eye clinic. questionnaires were filled by literate patients while medical students, specifically trained in the conduct of interviews assisted illiterate patients. communication among respondents was discouraged to check undue interferences. the items in the questionnaires were adapted from existing instruments used in previous patient satisfaction survey.6 options provided for patients to choose from included undecided or non-applicable to ensure patients were not forced to tick options which might not be relevant to them. patient indicated their level of satisfaction by the following options: agree, strongly agree, disagree and strongly disagree. those who chose disagree and strongly disagree were considered dissatisfied while those who selected agree and strongly agree were considered satisfied. focus group discussions (fgds) were held among the participants in batches during each clinic session. during the fgds, filled questionnaires with vague entries were clarified to douse ambiguity. one of the authors supervised data collection. data analysis the data from questionnaires were coded, entered and analyzed using spss (statistical package for social sciences) version 12 software in form of frequencies and percentages. multivariate regression analysis was used to control for confounders, with categorical variables compared by chi-square test. p values <5% (0.05) were considered statistically significant. results of the 267 filled questionnaires, only 251 were found suitable for research work, comprising 139 males (55.4%) and 112 females (44.6%). male:female ratio=1:0.8. the ages of the patients studied ranged from 17 to 92 years with a mean of 37.2 years±15.57. table 1 shows age and sex distribution of the patients studied. 17 to 40 years constituted the highest age group. the adoption of this age grouping was on the premise that they share similar ideologies and not on any statistical prejudice. table 2 shows the responses of the subjects. about 30% of patients were dissatisfied for not being attended to in the order they arrived at the clinic. majority of patients had pre-visit expectations meant in addition to being satisfied with patient-provider relationships, hospital appearance, manner of eye examination and level of privacy. the computed overall patient satisfaction with all services was 80.1%. p values were 0.021, 0.008, 0.036, 0.008 article table 1. age and sex distribution of the patients studied. age (years) male female total n. % n. % n. % 17-4 79 31.5 80 31.9 159 63.3 41-60 47 18.7 23 9.2 70 27.9 >60 13 5.2 9 3.6 22 8.8 chi-squared=6.127; p=0.047; degree of freedom= 2; 95% confidence interval=0.045-0.069. table 2. responses of subjects. question s (%) ns (%) u (%) na (%) nr (%) 1 confidentiality (privacy) 175 (69.7) 38 (15.1) 15 (6) 8 (3.2) 15 (6) 2 comfort of examinations 199 (79.3) 31 (12.4) 11 (4.4) 2 (0.8) 8 (3.2) 3 fairness (first come first serve was obeyed) 141 (56.2) 74 (29.5) 22 (8.8) 6 (2.4) 8 (3.2) 4 thoroughness of examination 204 (81.3) 8 (3.2) 23 (9.2) 5 (2) 11 (4.4) 5 my expectation was meant 188 (74.9) 11 (4.4) 37 (14.7) 6 (2.4) 9 (3.6) 6 pharmacists were courteous 157 (62.5) 24 (9.6) 28 (11.2) 38 (15.1) 4 (1.6) 7 lab scientists were courteous 122 (48.6) 18 (7.2) 46 (18.3) 60 (23.9) 5 (2) 8 other hospital staff were courteous 184 (73.3) 10 (4) 34 (13.5) 18 (7.2) 5 (2) 9 nurses were caring 203 (80.9) 24 (9.6) 16 (6.4) 2 (0.8) 6 (2.4) 10 doctor was willing to explain your eye condition 222 (88.4) 2 (0.8) 9 (3.6) 5 (2) 13 (5.2) 11 doctor was caring 225 (89.6) 6 (2.4) 12 (4.8) 4 (1.6) 4 (1.6) s, satisfied; ns, not satisfied; u, undecided; na, not applicable; nr, no response. source: compiled from questionnaires. non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2014; 2:1390] and 0.004 for patients’ privacy, comfort during eye exam, fairness (non-partiality) to patients, thoroughness of examination and patients’ expectation respectively. these key variables remained statistically significant after accounting for confounding factors such as literacy level, travels and socio-economic status. this is detailed in bivariate analysis in table 3 and validated by multiple logistic regressions in table 4. discussion the interpretation of this study must be understood against the backdrop of the pervasive limitations inherent in this kind of study. the spectrum of patients being questioned varied and so could have been their responses. a homogenous population could have obviated biases introduced by confounders such as literacy level, travels and socio-economic status. hospital-based studies have inherent selection biases to which this study could not be said to be immuned. the perception of satisfaction cannot be measured quantitatively while the qualitative alternative, being replete with subjectivity, is difficult to interpret. the age distribution of the patients showed that majority, 159 (63.3%) were between the ages of 17 and 40 years in conformity to a study in a similar institution in kano.2 the mean age of 37.2 years was comparable with the 38 years reported by umar et al. in sokoto, northern nigeria but significantly lower than 45 years obtained in karachi.7,8 there were more males than females in this study like another southern nigerian study on patients’ satisfaction.4 the finding of predominantly youthful male population taking advantage of public health facility might be because they are the working class and more likely to afford incurred expenses than their female counterparts who often depend on them, being from lower socioeconomic status in developing countries. there have been inconsistencies in the figures obtained from patient satisfaction surveys across nigeria in the order of 84, 83, 75 and 53%.2,9-11 though the overall satisfaction of 80.1% of this study falls comfortably within this range, the reasons for varied figures are multifactorial. these would include individual study’s methodology, setting and the target patients (population). others are patients’ expectation, socio-cultural differences and chequered political history and subsequent effects on public institutions in developing nations. the above studies cut across multiethno religious nigeria with variegated opinions and inequality in the distribution, most times stark inaccessibility to basic amenities. the diverse satisfaction figures reported are thus not unexpected. among the dependent variables considered in this study, patients’ privacy, comfort with examination, perception of equality of treatment, thoroughness of examination and patients’ pre-visit expectations were specifically isolated for discussion. this was because they remained statistically significant after accounting for such confounding variables as literacy and socio-economic factors. again, these variables are often not subjects of focus in many patients’ satisfaction surveys. reports of woodside et al. showed that overall satisfaction was related to specific services and there are certain service characteristics which are more important than others.12 on the contrary, it was found in the current study that substantial association existed among different variables. these divergent results may reflect different nature of service rendered in different settings. similar to the findings in this study, anderson, reported that patients’ comfort does affect satisfaction.13 yadav et al. and ogunfowokan et al. reported strong associations between patients’ expectations and comfort of examination and satisfaction.3,14 though linked with satisfaction in the current study, satisfying patients’ expectations does not translate to performance. in view of diversity of expectations against supposedly uniform services, patients’ perceptions of satisfaction are bound to be divergent. a system that tailors services to expectations seems likely to achieve higher levels of satisfaction despite a modest performance. thoroughness and comfort with medical exams were among the intangible variables that influenced patient’s satisfaction in this study. a similar association was reported by sharma et al.15 both examination parameters require that the examiners be gentle, empathic and not in a hurry. iliyasu et al. underscored the role of friendly staff attitude towards enhanced customer care.2 unfortunately, the large patient load and the conditions of the examination rooms in most developing countries cannot guarantee these all the time. dearth of basic amenities like electricity and water in health facilities were major sources of patient dissatisfaction in lagos and ibadan surveys.16,17 privacy during consultations and examinations, also reported by umar et al. and net et al. was a source of satisfaction or dissatisfaction.7,18 gender, religion, previous experiences and knowledge about presenting ailment are plausible confounders that determine patients’ privacy threshold. only about half of the subjects were satisfied with levels of fairness they experienced. some patients noted they received attention much later than they should. patients who came very late jump queues in connivance with their relations who work in the hospital resulting in dissatisfaction of punctual patients. conclusions based on the findings, this article concludes that to enhance satisfaction, it is important to give patient-centered care. this is health care that is responsive to patients’ wants, needs, and preferences. this is against the backdrop article table 3. bivariate analysis showing correlation between overall satisfaction and specific variables. variables p value pearson odds ratio 95% ci df chi-square privacy 19.502 0.021 11.630 0.019-0.084 9 comfort during examination 62.477 0.008 11.048 0.000-0.019 9 partiality 26.150 0.036 10.361 0.013-0.059 9 thoroughness of check-up 34.610 0.008 15.729 0.000-0.019 9 expectation 42.061 0.004 22.278 0.000-0.012 9 ci, confidence interval; df, degree of freedom. source: compiled from questionnaires. table 4. multivariate logistic regressions for overall satisfaction with quality of eye care. variables 95% ci p privacy (confidentiality intact) 0.650-1.656 <0.001 comfort during eye examination 0.939-1.738 <0.001 fairness (no partiality) 1.139-2.187 <0.001 thoroughness of examination 0.361-1.342 0.001 expectation was meant 0.564-1.659 <0.001 ci, confidence interval. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1390] [page 7] that the choice and eventual success of many treatment options are based on subjective patient-defined criteria. it is recommended that exit suggestion boxes should be strategically located at patients’ departure points to solicit suggestions on how services could be improved upon. providing grievances redressal system for aggrieved patients to access is a pragmatic step of showing genuine concern for improving patient satisfaction. periodic patient satisfaction survey should be institutionalized to provide feedback for continuous quality improvement. and most importantly, excellent health care can only be achieved when all the cadres of staff work as a team and as stakeholders. there should be routine stakeholders training workshops where health care workers are trained and re-trained on ways of improving quality of services. references 1. santillan d. uses of satisfaction data: report on improving patient care. soc sci med 2000;12:24-6. 2. iliyasu z, abubakar is, abubakar s, et al. patients' satisfaction with services obtained from aminu kano teaching hospital, kano, northern nigeria. niger j clin pract 2010;13:371-8. 3. yadav k. health services: the indian scene marketing of services-concept and applications. in: khurana r, kaushik m and yadav k, eds. new delhi: indira gandhi national open university; 1993. pp 141-9. 4. olawoye oo. patient satisfaction with cataract surgery and posterior chamber intraocular lens at university college hospital ibadan and st mary’s catholic hospital ago-iwoye, nigeria. ijanikin: national postgraduate medical college of nigeria; 2008. pp 9-10. 5. who. report of a who/iapb scientific meeting. preventing blindness in children. who/pbl/77. geneva: world health organization; 1999. 6. ware je, snyder mr, wright r. defining and measuring patient satisfaction with medical care. eval program plann 1993;6: 247-63. 7. umar i, oche mo, umar as. patient waiting time in a tertiary health institution in northern nigeria. j public health epidemiol 2011;3:78-82. 8. jawaid m, ahmed n, alam sn, et al. patients’ experiences and satisfaction from a surgical outpatient department of a tertiary care teaching hospital. pak j med sci 2009;25:439-42. 9. ofili an, ofovwe ce. patients’ assessment of efficiency services at a teaching hospital in a developing country. ann afr med 2005;4:150-3. 10. olusina ak, ohaeri ju, olatawura mo. patient and staff satisfaction with the quality of in-patient psychiatric care in a nigerian general hospital. soc psych psych epid 2004;37:283-88. 11. eze cu. survey of patient satisfaction with obstetric ultrasound at university of nigeria teaching hospital enugu, nigeria. niger j health biomed sci 2006;5:93-7. 12. woodside ag, frey ll, daly rt. linking service quality, patient satisfaction and behavioural intention. j health care mark 1989;7:61-8. 13. anderson d. the satisfied patient: service return behaviour in the hospital obstetrics market. j health care mark 1992;2:25-33. 14. ogunfowokan o, mora m. time, expectation and satisfaction: patients’ experience at national hospital abuja, nigeria. afr j prim health care fam med 2012;4:1-6. 15. sharma rd, hardeep c. a study of patient satisfaction in outdoor services of private health care facilities. accessed on 18/02/2013. available from: www.vikalpa. com/pdf/articles/1999/1999_oct_dec_079_ 076.pdf 16. oreniga oo, sofola oo, uti oo. patient satisfaction: a survey of dental outpatients at the lagos university teaching hospital, nigeria. nig q j hosp med 2009;19:47-52. 17. ajayi io, olumide ea, oyediran o. patient satisfaction with the services provided at a general outpatients' clinic, ibadan, oyo state, nigeria. afr j med med sci 2005;34: 33-40. 18. net n, chompikul j, sermsri s. patient satisfaction with health services in the out-patient department clinic of nangmamyen community hospital sakeao province, thailand. j public health dev 2007;5:33-42. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11748 antibacterial and antibiofilm effects of gold and silver nanoparticles against the uropathogenic escherichia coli by scanning electron microscopy (sem) analysis rini purbowati,1 vania mitha pratiwi,2 masfufatun masfufatun,3 putu oky ari tania,1 ali khumaeni4 1biomedical department and biomolecular research, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 2department of materials and metallurgical engineering faculty of industrial technology and systems engineering, institut teknologi sepuluh nopember, surabaya; 3department of biochemistry, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 4department of physics, faculty of science and mathematics, universitas diponegoro, semarang, indonesia abstract uropathogenic escherichia coli (upec) is a nosocomial pathogen associated with urinary tract infections and biofilm formation, which contributes to antibiotic resistance. discovering potent antibacterial agents is crucial. this study aimed to assess the antibacterial and antibiofilm effects of gold and silver nanoparticles on upec using scanning electron microscopy (sem). upec biofilms were cultivated on nitrocellulose membranes for 48 hours at 37°c, then treated with gold nanoparticles (50 ppm and 100 ppm) and silver nanoparticles (50 ppm and 100 ppm) for another 48 hours. antibacterial and antibiofilm activities were evaluated through cell density and sem analysis. sem revealed lower cell density, reduced biofilm formation, and altered cell morphology with rough, wrinkled surfaces after nanoparticle treatment. in conclusion, gold and silver nanoparticles exhibit antibacterial and antibiofilm properties, as observed in sem analysis. sem is a valuable tool for studying the antimicrobial effects of nano gold and silver on bacterial cell morphology and biofilm populations. introduction urinary tract infections (utis) affect approximately 150 million people annually worldwide, leading to significant healthcare expenditures. utis are the most prevalent bacterial infections and are considered a critical health issue, following respiratory and digestive tract infections.1,2 these infections are more common in women due to factors such as fecal flora contamination, the shorter female urethra, and pregnancy. utis affect individuals across various age groups, including neonates, young women, infants, children, and older men.3 escherichia coli (e. coli) is the predominant pathogen, causing over 80-90% of community-acquired utis and 30-50% of hospital-acquired utis.4,5 uropathogenic escherichia coli (upec) is a nosocomial pathogen associated with utis. upec utilizes various cellular appendages, including fimbriae and pili, to colonize and adhere to the bladder, forming biofilm-like bacterial communities. these biofilms play a crucial role in sustaining upec’s survival and evading the host’s immune response.6,7 the ability to adhere to epithelial cells, resist urine flow, and form biofilms are key factors that make upec the primary cause of utis in humans.8 biofilms are estimated to be responsible for about 65% of nosocomial infections and 80% of all microbial infections.9 these structured microbial communities, enveloped in an extracellular matrix (ecm), adhere to various surfaces. biofilm-associated cells exhibit distinct phenotypic characteristics compared to rini purbowati, biomedical department and biomolecular research, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia. e-mail: rini.purbowati@uwks.ac.id key word: upec; biofilm; antibiotic resistance; nanoparticles; sem analysis. contributions: rp, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; conceptualization, investigation, methodology, validation, writing – original draft, and review & editing; poat, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; methodology, visualization, writing – review & editing; ak, resources, investigation, and writing – review & editing; mm formal analysis, validation, writing – review & editing; resources, supervision, and writing – review & editing; vmp, resources, investigation, and writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the conducted research is not related to either human or animals use. funding: this research was supported by a research grant from direktorat jenderal penguatan riset dan pengembangan, kementerian riset, teknologi dan pendidikan tinggi with contract number 183/e5/pg.02.00.pl/2023. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to institute of tropical disease, airlangga university, surabaya for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 18 october 2023. early access: 26 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11748 doi:10.4081/hls.2023.11748 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11748] [page 83] non -co mmerc ial us e o nly planktonic or motile cells. notably, biofilms exhibit significantly higher resistance to antimicrobial agents, with microbial biofilms formed through the attachment of bacteria using a secreted polymer matrix. the primary constituents of this matrix include extracellular dna, proteins, and polysaccharides.10,11 biofilm-embedded cells generally display greater tolerance to antibiotics and the host’s immune system, with biofilm resistance to antibiotics being 100-1000 times higher than planktonic cells.12 the increasing prevalence of antibiotic-resistant bacteria is a global concern, as highlighted by the world health organization. moreover, the limited solubility, stability, and adverse side effects associated with current antibacterial therapies have prompted researchers to seek innovative strategies to combat these resilient microbes.13,14 this has led to a growing demand for new antibiotic delivery systems. nanotechnology, with its advantageous physicochemical properties, drug-targeting efficiency, enhanced absorption, and biodistribution, has gained significant attention.15 antibacterial research is a thriving field within nanomedicine, aimed at meeting drug delivery requirements, reducing antibiotic concentrations, and curbing drug resistance among pathogenic bacteria.16 numerous studies have demonstrated the antibacterial and antibiofilm activities of gold and silver nanoparticles against antibiotic-resistant bacteria. for instance, gold nanoparticles (aunps) have shown superior antibacterial potential compared to crude ethanol extracts of digera muricata against various drug-resistant bacteria, including vibrio cholera, staphylococcus pyrogen, klebsiella, citrobacter, and enterobacter.17,18 similarly, silver nanoparticles (agnps) derived from ferula ovina boiss (fob) extracts exhibited effective antibacterial activity against both grampositive (staphylococcus aureus and bacillus cereus) and gramnegative (salmonella typhimurium and escherichia coli) species using the disk diffusion method.19 ginger agnps demonstrated potent antibacterial and anti-adherent activity against biofilm-associated enterococcal isolates.20 furthermore, agnps exhibited significant dose-dependent antibiofilm activity, reducing biofilm formation at concentrations of 20 and 10 g/ml. when exposed to 20 g/ml of agnps, s. pseudintermedius displayed an uneven biofilm surface, indicating biofilm aggregation.21 regrettably, previous study did not investigate cellular morphology changes to explain alterations in cell surface structures and biofilm visualization. scanning electron microscopy (sem) is a valuable tool for visualizing biofilms and providing accurate descriptions of biofilm morphology. comparative analyses, such as evaluating the anti-biofilm effects of treatments, are highly useful because sem imaging results strongly correlate with findings from other analytical methods. sem micrographs have been employed to observe changes in the bacterial plasma membrane of drug-resistant s. aureus and p. aeruginosa cells following treatment with macropin, a novel antimicrobial agent.22 the aimed of this study was to evaluate the antibacterial and antibiofilm effects of gold and silver nanoparticles against upec through sem analysis. materials and methods bacterial isolates and nanoparticles (gold and silver) the upec strain used in this study was obtained from a previous isolation study.23,24 the research indicates that this particular upec strain is capable of forming biofilms, as determined by the microtiter plate method. the bacterial strains were cultured on eosin methylene blue (emb) agar at 37°c for two days. this specific strain was originally isolated from patients suffering from utis and subsequently processed at the gastroenteritis and salmonellosis laboratory, institute of tropical disease, airlangga university, surabaya, indonesia. the gold and silver nanoparticles used in this study were provided as finished products by the nanotechnology laboratory at diponegoro university.25 preparation of upec inoculum the upec strain was initially grown on nutrient agar (na) medium for 24 hours at 37°c. a subculture of the upec was then cultivated on luria bertani (lb) medium for an additional 24 hours at 37°c. following incubation, the culture was centrifuged at 5000 rpm for 5 minutes. the supernatant was subsequently resuspended in 0.9% nacl and adjusted to an optical density (od490) of 0.5, equivalent to approximately 108 cfu/ml. this prepared inoculum was used in each treatment. the gold and silver nanoparticles were sourced from the nanotechnology laboratory at diponegoro university. biofilm analysis of nitrocellulose membrane using sem as previously research finding described,26 the upec inoculum was applied to a nitrocellulose membrane and allowed to grow for 48 hours. the cultures were incubated at 37°c. following the biofilm formation, it was treated with gold nanoparticles (50 ppm and 100 ppm) and silver nanoparticles (50 ppm and 100 ppm), respectively, and incubated for an additional 48 hours at 37°c. the processed biofilm was then dried using an oven at a temperature of 36-37°c for 12 hours. dry membranes were dehydrated by immersion in ethanol with varying concentrations: 50% for 10 minutes, 70% for 10 minutes, and 96% for 20 minutes. the process was completed by coating the samples with gold, making them ready for analysis using a sem (fei inspect s50). antibacterial activity was assessed by evaluating cell density, while antibiofilm activity was analyzed descriptively by examining the appearance of the slime covering the cell population in sem images. results figure 1 displays a representative image of upec bacterial cells undergoing growth and biofilm formation on a nitrocellulose membrane (a-b) in the negative control, and with the addition of the antibiotic chloramphenicol (c-d) as a positive control after 24 hours of incubation. in figure 1a, the cell density is high, with cell colonies (lighter color) evenly covering the surface of the nitrocellulose membrane (darker color). the cells appear intact and maintain a smooth surface, indicating that the cell membranes are not contracted, and the cell morphology remains undistorted. the biofilm formation is evident as a slimy layer, reducing the visibility of elliptical cell shapes, causing bacterial cells to cluster. in figure 1b, the cell density is significantly lower, with cell colonies (lighter color) visible over a smaller portion of the nitrocellulose membrane (darker color). the biofilm formed is less pronounced, enabling the elliptical cell shapes to be more discernible, and the bacterial cells show a tendency to remain separate. figure 2 depicts a representative image of upec bacterial cells exposed to gold nanoparticles at concentrations of 50 ppm (b-c) and 100 ppm (e-f) after 24 hours of incubation. in figure 2b, the cell density is lower in comparison to the control (figure 2a). while the growth of cell colonies is still generally evenly distributed across the [page 84] [healthcare in low-resource settings 2023; 11:11748] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11748] [page 85] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. scanning electron microscopic analysis of biofilm structure. sem images of biofilm formed on nitrocellulose membrane after 24 h of incubation. (a) negative control in 10.000 x, (b) negative control in 20.000 x, (c) positive control in 10.000 x, (d) positive control in 20.000 x. figure 2. scanning electron microscopic analysis of biofilm structure. sem images of biofilm formed on nitrocellulose membrane treated with gold nanoparticle after 24 h of incubation. (a) negative control in 10.000 x; (b) treated with 50 ppm in 10.000 x; (c) treated with 50 ppm in 20.000 x; (d) treated with 100 ppm in 10.000 x; (e) treated with 100 ppm in 20.000 x; and (f) positive control in 10.000 x. non -co mmerc ial us e o nly membrane surface, the formed biofilm is still visible. however, noticeable alterations in morphology and cell surface are observed. the cells appear intact and maintain a rough and wrinkled surface, suggesting contracted cell membranes and distorted cell morphology (figure 2c). in figure 2d-e, the cell density is notably lower, and the biofilm formed is significantly reduced, causing bacterial cells to fragment. the cells remain intact and retain a rough and wrinkled surface, indicating membrane structure damage. figure 3, which presents results similar to those in figure 2, demonstrates the response of upec bacteria when exposed to silver nanoparticles at concentrations of 50 ppm (b-c) and 100 ppm (e-f) after 24 hours of incubation. in figure 3b, the cell density is lower compared to the control (figure 2a). the growth of cell colonies is still evenly distributed across the membrane surface. the biofilm is still apparent, yet noticeable alterations in morphology and cell surface are observed. cells maintain their integrity but exhibit a rough and wrinkled surface, indicative of contracted cell membranes and distorted cell morphology (figure 3c). in figure 3d-e, the cell density is considerably lower, and the biofilm formed is substantially reduced, causing bacterial cells to fragment. the cells appear intact with a rough and wrinkled surface, highlighting damage to the membrane structure. discussion nanotechnology has emerged as a significant and increasingly intriguing field of research over the last three decades. its applications span various sectors, with substantial focus on the medical field, encompassing diagnostics, therapeutic tools, and biomedical research. this amalgamation of nanotechnology with the realm of human health is referred to as nanomedicine.27 nanomaterials have demonstrated considerable potential in revitalizing the antibacterial activity of conventional antibiotics through mechanisms that include optimizing pharmacokinetics, enhancing antibiotic internalization, disrupting bacterial metabolism, increasing biofilm penetration, and modifying the biofilm microenvironment.28 the amalgamation of nanotechnology and antibiotics presents the most promising strategy for combating bacterial resistance to antibiotics.29 moreover, emerging antimicrobial nanomaterials are evolving into nanomedicines, wielding a wide-ranging impact on biomedical applications, encompassing targeting, imaging, therapy, and beyond.30 numerous studies have showcased the antibacterial efficacy of gold and silver nanoparticles against both gram-positive and gram-negative bacteria. for instance, gcl agnps exhibited a significant inhibition zone, with a diameter of 12.2 mm, against s. enterica, followed by an 11.8 mm diameter zone against p. aeruginosa.31 green-synthesized silver nanoparticles exhibited potent activity against foodborne pathogenic bacteria and displayed the potential to combat gram-negative and gram-positive bacteria.32 furthermore, the antibacterial potency of synthesized bv@agnps was examined against seven clinically isolated multidrug-resistant bacteria. the minimum inhibitory concentration (mic) values of berberis vulgaris (bv)@agnps against various bacteria were established, revealing their high antibacterial activity.33 the application of aunps extends to diverse fields, including therapy, medicine, and pharmaceutical.35 studies have also demonstrated the antibiofilm properties of [page 86] [healthcare in low-resource settings 2023; 11:11748] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 3. scanning electron microscopic analysis of biofilm structure. sem images of biofilm formed on nitrocellulose membrane treated with silver nanoparticle after 24 h of incubation. (a) negative control in 10.000 x; (b) treated with 50 ppm in 10.000 x; (c) treated with 50 ppm in 20.000 x; (d) treated with 100 ppm in 10.000 x ; (e) treated with 100 ppm in 20.000 x; and (f) positive control in 10.000 x. non -co mmerc ial us e o nly gold and silver nanoparticles against both gram-positive and gram-negative bacteria, shedding light on economical methods of agnp production with specific properties to target the growth modes of pathogenic c. albicans.36 these findings underscore the safety and effectiveness of agnps against mdr k. pneumoniae.37 the precise mechanisms underlying the antibacterial activity of nanoparticles are not yet fully understood, but it is believed to be attributed to one or a combination of mechanisms, such as the production of reactive oxygen species (ros), the release of toxic ions, and the direct interaction of deleterious particles with cell membranes.38 direct contact may induce stressful stimuli through electrostatic interactions between nanoparticles and bacterial cell surfaces, leading to ros production and bacterial cell demise.39 the disruption of the cell membrane, causing intracellular content leakage, is another facet of the antibacterial activity of nanoparticles. it’s worth noting that the antibacterial activity of nps varies based on the cell composition of specific bacteria; gram-positives are more susceptible to the antimicrobial action of zno due to differences in cell wall thickness and other components.16 the overall mechanical properties of bacteria are influenced by the characteristics of their cell envelope, including its integrity, and various factors like natural lytic elements. biochemical composition, conformational properties, and biomolecule density in the cell envelope play vital roles in determining bacterial elasticity, with the peptidoglycan layer prominently impacting cell elasticity.40 tc-aunps demonstrated a dose-dependent reduction in the ability of p. aeruginosa to form biofilms, as revealed by sem analysis. a higher concentration of nanoparticles was associated with a decreased number of biofilm-forming cells, indicating reduced adhesion and colonization on the surface. however, it is important to note the inherent limitations of sem analysis, such as challenges in detecting extracellular polymeric substances (eps) and reductions in total cell volume and architecture due to sem’s dehydration process.41 the biological impact of agnps relies on several mechanisms, including binding to the cell wall, which alters permeability. for example, in studies on gram-negative bacteria like e. coli and p. aeruginosa, agnps neutralized the bacterial surface charge, affecting membrane permeability. scanning and transmission electron microscopy demonstrated that agnps could create holes in the cell wall, leading to agnp accumulation.42 for a more comprehensive exploration of the antibacterial mechanism and bacterial morphology changes, sem was employed to visualize s. aureus and e. coli cells. the study yielded results consistent with previous findings.43 prior to treatment, bacterial cells exhibited smooth, intact membranes and normal morphology. after exposure to agnps, cells displayed deformities, disorganization, and surface cavities. the nps adhered to the cell surface due to electrostatic attraction between the bacterial cell surface and the nps. aggregation of nps was more pronounced and rapid in e. coli, potentially due to differences in cell wall composition between gram-positive and gram-negative bacteria. the outcome was the disruption of the outer membrane and deformities in cellular structures, leading to penetration into bacterial cells and interference with essential functions.44 biogenic agnps demonstrated the potential to inhibit the growth of pathogens, particularly well-structured bacterial biofilms like upec. the differences in biofilm structure among bacterial species and the physicochemical properties of agnps are significant factors affecting the efficacy of their antibiofilm activity. upec formed planktonic, preformed, and mature biofilms, suggesting that bacterial aggregation and physiology play pivotal roles in determining the mechanisms behind agnps’ antibacterial activity. these mechanisms may involve increased oxidative stress resulting from intracellular ag+ ion production, changes in membrane potential and respiratory chain function, and interactions with dna and regulatory proteins.44 biofilm formation is a multifaceted microbial process involving distinct developmental stages specific to different bacterial types.45 these biofilms are held together by extracellular polysaccharides, proteins, and nucleic acids, and biofilm development in e. coli serves a crucial role in disease causation and induction. biofilm formation is a complex process with a marked structure that aids in the storage of antimicrobial peptides, reducing corrosion. residual bacterial biofilms pose a significant health risk, characterized by their resilience to treatment and potential for nosocomial transmission. thus, the exploration of natural molecules to address these substantial challenges, and the ability of antibacterial agents to deter biofilm formation or destruction, remains an area of great importance.46 conclusions this study demonstrates the antibacterial and antibiofilm activities of gold and silver nanoparticles, as evident from the sem analysis. sem proves to be an invaluable tool for in-depth investigations into the antimicrobial properties of nano gold and silver on bacterial cell morphology and biofilm populations. sem can serve as an essential tool for assessing the efficacy of antibiotic and antibiofilm agents in microbial infections. future research may explore other analytical methods, including confocal laser scanning microscopy (clsm) and transmission electron microscopy (tem). references 1. sari yip, rohmah un, andini sa, luwao hp. summary of the prevention of catheter-associated urinary tract infection in an intensive care unit. jurnal ners 2019;14:103–7. 2. javed s, mirani za, pirzada za. phylogenetic group b2 expressed significant biofilm formation among drug resistant uropathogenic escherichia coli. libyan j med 2021;16:1845444. 3. issa om, bakir wae, abbas ma. laboratory diagnosis of urinary tract infections in patients with resistance genes towards antibiotics. bionatura 2022;7:46. 4. sjahriani t, wasito eb, tyasningsih w. isolation and identification of escherichia coli o157:h7 lytic bacteriophage from environment sewage. int j food sci 2021;2021:7383121. 5. katongole p, nalubega f, florence nc, et al. biofilm formation, antimicrobial susceptibility and virulence genes of uropathogenic escherichia coli isolated from clinical isolates in uganda. bmc infect dis 2020;20:1-6. 6. syaiful i, widodo adw, endraswari pd, et al. the association between biofilm formation abilitand antibiotic resistance phenotype in clinical isolates of gram-negative bacteria: a crosssectional study. bali med j 2023;12:1014-20. 7. boya br, lee jh, lee j. antibiofilm and antimicrobial activities of chloroindoles against uropathogenic escherichia coli. front microbiol 2022;13:872943. 8. magtoto r, poonsuk k, baum d, et al. evaluation of the serologic cross-reactivity between transmissible gastroenteritis coronavirus and porcine respiratory coronavirus using commercial blocking enzyme-linked [healthcare in low-resource settings 2023; 11:11748] [page 87] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly immunosorbent assay kits. msphere 2019;4:e00017-19. 9. bharadwaj kk, rabha b, choudhury bk, et al. current strategies in inhibiting biofilm formation for combating urinary tract infections: special focus on peptides, nano-particles and phytochemicals. biocatal agricult biotechnol 2021;38:102209. 10. yang ym, osawa k, kitagawa k, et al. differential effects of chromosome and plasmid blactx-m-15 genes on antibiotic susceptibilities in extended-spectrum beta-lactamase-producing escherichia coli isolates from patients with urinary tract infection. int j urol 2021;28:623-8. 11. sonawane jm, rai ak, sharma m, et al. microbial biofilms: recent advances and progress in environmental bioremediation. sci total environ 2022;824:153843. 12. olar r, badea m, chifiriuc mc. metal complexes-a promising approach to target biofilm associated infections. molecules 2022;27:758. 13. mhawesh a, khudair m, abbas on. major genetic determinants of extended-spectrum β-lactamase (esbl), carbapenemase, fosfomycin and colistin resistance in escherichia coli from intensive care units. bionatura. 2022;7:11. 14. waskito la, yamaoka y. the story of helicobacter pylori: depicting human migrations from the phylogeography. adv exp med biol 2019;1149:1-16. 15. eleraky ne, allam a, hassan sb, omar mm. nanomedicine fight against antibacterial resistance: an overview of the recent pharmaceutical innovations. pharmaceutics 2020;12:142. 16. zubair n, akhtar k. morphology controlled synthesis of zno nanoparticles for in-vitro evaluation of antibacterial activity. trans nonferrous metals soc china 2020;30:1605-14. 17. sathiyaraj s, suriyakala g, dhanesh gandhi a, et al. biosynthesis, characterization, and antibacterial activity of gold nanoparticles. j infect public health 2021;14:1842-7. 18. shah r, shah sa, shah s, faisal s, ullah af. green synthesis and antibacterial activity of gold nanoparticles of digera muricata. indian j pharmaceut sci 2020;82:374-8. 19. allafchian a, vahabi mr, jalali sah, et al. design of green silver nanoparticles mediated by ferula ovina boiss. extract with enhanced antibacterial effect. chem physics lett 2022;791:139392. 20. swidan ns, hashem ya, elkhatib wf, yassien ma. antibiofilm activity of green synthesized silver nanoparticles against biofilm associated enterococcal urinary pathogens. sci rep 2022;12:3869. 21. seo m, oh t, bae s. antibiofilm activity of silver nanoparticles against biofilm forming staphylococcus pseudintermedius isolated from dogs with otitis externa. vet med sci 2021;7:1551-7. 22. rusu d, stratul si, calniceanu h, et al. a qualitative and semiquantitative sem study of the morphology of the biofilm on root surfaces of human teeth with endodontic-periodontal lesions. experim therapeutic med 2020;20:201. 23. kitagawa k, shigemura k, yamamichi f, et al. international comparison of causative bacteria and antimicrobial susceptibilities of urinary tract infections between kobe, japan, and surabaya, indonesia. jpn j infect dis 2018;71:8-13. 24. purbowati r, sugiharto, listyawati af, et al. antibacterial and antibiofilm effect of silver and gold nanoparticles in uropathogenic escherichia coli. berkala penelitian hayati 2021;27(2 se-articles). 25. alhamid mz, hadi bs, khumaeni a. synthesis of silver nanoparticles using laser ablation method utilizing nd:yag laser. aip conf proceed 2019;2202:20013. 26. jailani a, ahmed b, lee jh, lee j. inhibition of agrobacterium tumefaciens growth and biofilm formation by tannic acid. biomedicines 2022;10:1619. 27. ibrahim h. nanotechnology and its applications to medicine: an over view. qjm int j med 2020;113:hcaa060.008. 28. mutalik c, lin ih, krisnawati di, et al. antibacterial pathways in transition metal-based nanocomposites: a mechanistic overview. int j nanomed 2022;17:6821-42. 29. wang s, gao y, jin q, ji j. emerging antibacterial nanomedicine for enhanced antibiotic therapy. biomat sci 2020;8(:6825-39. 30. garg p, attri p, sharma r, et al. advances and perspective on antimicrobial nanomaterials for biomedical applications. front nanotechnol 2022:4. 31. balachandar r, navaneethan r, biruntha m, et al. antibacterial activity of silver nanoparticles phytosynthesized from glochidion candolleanum leaves. materials letters 2022;311:131572. 32. alarjani km, huessien d, rasheed ra, kalaiyarasi m. green synthesis of silver nanoparticles by pisum sativum l. (pea) pod against multidrug resistant foodborne pathogens. j king saud university sci 2022;34:101897. 33. hashemi z, shirzadi-ahodashti m, mortazavi-derazkola s, ebrahimzadeh ma. sustainable biosynthesis of metallic silver nanoparticles using barberry phenolic extract: optimization and evaluation of photocatalytic, in vitro cytotoxicity, and antibacterial activities against multidrug-resistant bacteria. inorg chem comm 2022;139. 34. gouyau j, duval re, boudier a, lamouroux e. investigation of nanoparticle metallic core antibacterial activity: gold and silver nanoparticles against escherichia coli and staphylococcus aureus. int j mol sci 2021;22:1905. 35. mobed a, hasanzadeh m, shadjou n, et al. immobilization of ssdna on the surface of silver nanoparticles-graphene quantum dots modified by gold nanoparticles towards biosensing of microorganism. microchem j 2020;152:104286. 36. miškovská a, rabochová m, michailidu j, et al. antibiofilm activity of silver nanoparticles biosynthesized using viticultural waste. plos one 2022;17:e0272844. 37. siddique mh, aslam b, imran m, et al. effect of silver nanoparticles on biofilm formation and eps production of multidrug-resistant klebsiella pneumoniae. biomed res int 2020;2020:6398165. 38. kong as, maran s, yap ps, et al. antiand pro-oxidant properties of essential oils against antimicrobial resistance. antioxidants (basel) 2022;11:1819. 39. de silva c, nawawi nm, karim mma, et al. the mechanistic action of biosynthesised silver nanoparticles and its application in aquaculture and livestock industries. animals (basel) 2021;11:2097. 40. mathelié-guinlet m, asmar at, collet jf, dufrêne yf. lipoprotein lpp regulates the mechanical properties of the e. coli cell envelope. nature comm 2020;11:1789. 41. ali sg, ansari ma, alzohairy ma, et al. biogenic gold nanoparticles as potent antibacterial and antibiofilm nanoantibiotics against pseudomonas aeruginosa. antibiotics (basel) 2020;9:100. 42. gómez-núñez mf, castillo-lópez m, sevilla-castillo f, et al. nanoparticle-based devices in the control of antibiotic resistant bacteria. front microbiol 2020;11:563821. 43. ali s, perveen s, ali m, et al. bioinspired morphology-controlled silver nanoparticles for antimicrobial application. mat [page 88] [healthcare in low-resource settings 2023; 11:11748] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly sci engin c 2020;108:110421. 44. rodríguez-serrano c, guzmán-moreno j, ángeles-chávez c, et al. biosynthesis of silver nanoparticles by fusarium scirpi and its potential as antimicrobial agent against uropathogenic escherichia coli biofilms. plos one 2020;15:e0230275. 45. funari r, shen aq. detection and characterization of bacterial biofilms and biofilm-based sensors. acs sensors 2022;7:347-57. 46. algabar faa, baqer ba. detection of biofilm formation of (serratia and e.coli ) and determination of the inhibitory effect of quercus plant extract against these infectious pathogens. bionatura 2022;7:8. [healthcare in low-resource settings 2023; 11:11748] [page 89] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e22] [page 75] efficacy and safety of camosunate for the treatment of uncomplicated malaria in the university of benin teaching hospital, benin city, nigeria damien uyagu,1 augustine omoigberale,2 paul dienye3 1department of family medicine, university of benin teaching hospital, benin city; 2department of child health, university of benin teaching hospital, benin city; 3department of family medicine, university of port harcourt teaching hospital, port harcourt, nigeria abstract in nigeria, nearly 110 million clinical cases of malaria are diagnosed per year, thus being a major public health problem. the problems of resistance resulted in the introduction of the artemisinin based combinations (act) by the who. artesunate and amodiaquine (as+aq) is at present the world’s second most widely used act. this study is an assessment of the efficacy and safety of camosunate (a brand of as+aq; geneith pharmaceutical ltd., oshodi, lagos) in the treatment of uncomplicated malaria conducted at the university of benin teaching hospital (ubth). a cross-sectional assessment of the efficacy and safety of camosunate was conducted over a period of one year using 120 patients selected after stratification, by random sampling technique. all recruited patients had slide-proven uncomplicated malaria and were followed up for 28 days on commencement of camosunate. data was collected using a structured intervieweradministered questionnaire and was analysed using spss version 15. the overall efficacy of camosunate was found to be 95.8%. treatment was well tolerated as testified by the fact that there was no case withdrawal due to adverse drug reaction (adr) or treatment emergent signs and symptoms (tess). also no evidence of toxicity was recorded. camosunate is highly efficacious and well tolerated in this area of nigeria and justifies its use as a first line treatment for uncomplicated malaria. introduction in nigeria, nearly 110 million clinical cases of malaria are diagnosed per year, translating to about 50% of the adult population experiencing at least one malaria episode per year, while young children can have up to 2-4 attacks of malaria annually,1 accounting for 25% of under-five mortality, 30% of childhood mortality and 11% of maternal mortality. each year 70% of pregnant women suffer from malaria resulting in anaemia in pregnancy, abortions, stillbirths and low birth weight infants. the disease also accounts for 50-60% of outpatient consultations and 10-30% of overall hospital admissions in nigeria. in addition to the direct health impact of malaria on the nigerian population, the economic loss linked to the disease in this country is estimated to be about 132 billion naira (around 878 million us $) per year as treatment costs, loss of man-hour, to mention but a few.1,2 the disease is therefore a major public health problem in nigeria. antimalarial chemotherapy has been the primary option in the fight against this menace. national drug efficacy trials conducted in 2002 in nigeria demonstrated that the first line treatments then employed, chloroquine and sulphadoxine-pyrimethamine (sp) were no longer adequate.2 in 2005, the highly efficacious artemisinin-based combination therapy was adopted as first-line treatment for uncomplicated malaria.2 artemisinin-based combination therapy has since then remained the treatment of choice for uncomplicated plasmodium falciparum malaria in nigeria3 in line with global trend, following the recommendation of the world health organization (who) to that effect.4 starting from february 2009, more than 80 countries worldwide including nigeria have adopted act as firstline therapy.3 currently, five forms of act are recommended by the who, of which all are available in nigeria. these include: i) artemether and lumefantrine (al); ii) artesunate and amodiaquine (as+aq); iii) artesunate and mefloquine (as+mq); iv) artesunate and sulphadoxine-pyrimethamine (as+sp); v) dihydroartemisinin and piperaquine (dha+pqp). artemisinin compounds – when used in combination with longer acting antimalarial drugs – rapidly reduce parasite densities to low levels at a time when drug levels of the longer acting drug are still maximal, thereby reducing the likelihood of parasites being exposed to suboptimal levels of the longer acting drug and limiting the emergence of resistant strains.5,6 the choice of act for a country or a region depends on a number of considerations. a critical element is the level of underlying resistance to the longer-acting partner drug in the combination. this is particularly important for aq and sp in africa, where both drugs have been widely used as monotherapies. the who recommends that countries use acts, which are at least 90% effective, and introduce new forms of act that are at least 95% effective after discounting reinfections and that the day 28 efficacy of respective partner drugs alone should exceed 80%.7 concerns have been raised over act including amodiaquine meeting such criteria in areas where it has been widely used as monotherapy. the efficacy and tolerability of as+aq has been tested formally in several clinical trials in different epidemiological african settings.8-10 one of the as+aq brands in the country is camosunate by geneith pharmaceutical ltd. (lagos, oshodi). this study is an assessment of the efficacy and safety of camosunate in the treatment of uncomplicated malaria conducted at the university of benin teaching hospital (ubth). though similar studies have been conducted in other parts of africa including sub-saharan africa and democratic republic of congo,8-10 none has been conducted using the camosunate brand of act in south nigeria to the best of our knowledge. materials and methods the study was conducted on patients recruited from the departments of family healthcare in low-resource settings 2013; volume 1:e22 correspondence: paul dienye, department of family medicine, university of port harcourt teaching hospital, east-west road, 6173 port harcourt, nigeria. tel./fax: +234.8033.393806. e-mail: pdienye@yahoo.com key words: uncomplicated malaria, camosunate, efficacy, safety, nigeria. contributions: the authors contributed equally. funding: the drug samples used for this study were donated by geneith pharmaceutical ltd. (oshodi, lagos), which also funded the laboratory investigations. the company had no role in the study design, data collection and analysis, or preparation of this manuscript. acknowledgments: we are grateful to all the personnel of the departments of family medicine and child health of the university of benin teaching hospital who assisted the conduct of this study. we also wish to thank the haematologist, microbiologist and chemical pathologist who performed the laboratory analysis. received for publication: 28 march 2013. revision received: 14 may 2013. accepted for publication: 17 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright d. uyagu et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e22 doi:10.4081/hls.2013.e22 non -co mmerc ial us e o nly [page 76] [healthcare in low-resource settings 2013; 1:e22] medicine and child health of the ubth, benin city, nigeria. the ubth is a 700-bed tertiary institution made up of several clinical departments. the department of family medicine has a busy general outpatient unit with a daily attendance of about 400 patients of all age groups, and is open to patients all days of the week. the department of child health has consultant outpatient clinics, children’s emergency room and paediatric casualty as well as in-patient facilities for children. benin city has a population of about 2 million people and is the capital city of edo state, nigeria. it is located in the tropical rain forest of south nigeria where malaria is endemic, with high transmission rate throughout the year. chloroquine and sulphadoxine/pyrime thamine resistance is a known problem in benin city, like in other parts of nigeria.2,11 this was a cross-sectional study assessing the efficacy and safety of as+aq. it was conducted between september 2011-2012. malaria was diagnosed using the history of fever (axillary temperature ≥37.5°c) and by light microscopy of thick and thin blood smears stained with 3% giemsa for 30 min by trained microbiologists.12 malaria parasitemia in thick films was estimated by counting asexual or sexual parasites relative to 1000 leukocytes or 500 asexual or sexual forms, whichever occurred first. a smear was declared negative when the examination of 100 thick-film fields did not reveal the presence of malaria parasites.13 quality control checks were performed on a random 10% sample of blood films, examined at an independent site. four age strata, based on the formulations of camosunate by the manufacturers were identified prior to the study. the formulations were camosunate adult for patients ≥ 14 years, camosunate junior for patients 7-13 years, camosunate children for patients 1-6 years and camosunate paediatric for patients less than one year of age. the proportion of patients selected from each stratum was based on the knowledge of the total patient population as obtained from the outpatient record of the ubth. those who gave their written informed consent were recruited into the study using simple random sampling technique (lottery method) for each stratum until the required sample size was attained. a total of 120 patients of different age groups were recruited as follows: 20 patients aged ≥14 years; 30 patients aged 7-13 years; 60 patients aged 1-6 years; and 10 patients aged <1 year. the first two groups were recruited from the department of family medicine, and the others from the department of child health. inclusion criteria included: i) patients registered in ubth; ii) patients who gave written informed consent; iii) patients with history of fever (temperature ≥37.5°c) and with falciparum parasitaemia of 1000-200,000 parasites/µl; iv) patients who had not taken antimalarial drugs in the previous two weeks. exclusion criteria included: i) pregnant and breast feeding females because of possible toxicity to foetus and infant; ii) patients weighing less than 5 kg, since the dynamic developmental changes experienced by infants below this weight may affect the metabolism of ingested drugs;14 iii) patients who are unable to take oral drugs; iv) patients with signs and symptoms of severe p. falciparum malaria which include convulsion, coma, jaundice and severe anaemia as published previously;7 v) very ill patients who cannot withstand the stress of the research; vi) patients with known allergy to artesunate or amodiaquine. all recruited patients were treated with camosunate (tablets taken with water and powdered form taken after constituting into mixture with water), in the recommended dose by the manufacturers. each treatment was given under supervision by the researchers and the patient was observed during the first half hour. in case of vomiting, the complete dose was supplied again, and the 30min observation was repeated. any patient who vomited again was excluded from the study. the first dose was administered in the hospital (day 0), and patients were asked to report back on days 1, 2, 3, 7, 14, 21, and 28, or in between as needed. the second and third doses of the drug were administered on days 1 and 2 as they reported for follow up under the observation of the researchers. direct observation of patients by the researchers during drug intake assured that the drugs were taken, and ruled out losses due to vomiting. the four formulations and doses of camosunate included: i) camosunate adult (12 tablets), each tablet containing 300 mg amodiaquine base and 100 mg artesunate for patients aged 14 years and over. patients were administered 4 tablets once daily for 3 days; ii) camosunate junior (6 tablets), each tablet containing 300 mg amodiaquine base and 100 mg artesunate for patients aged 7-13 years. patients were administered 2 tablets once daily for 3 days; iii) camosunate children (2 sachets), each containing pleasantly flavored powder containing 150 mg amodiaquine and 50 mg artesunate respectively for patients aged 1-6 years. patients were administered whole contents of both sachets reconstituted in clean water once daily for 3 days; iv) camosunate paediatric (2 sachets), each containing pleasantly flavored powder containing 75 mg amodiaquine and 25 mg artesunate for patients aged under 1 year. patients were administered whole contents of both sachets reconstituted in clean water once daily for 3 days. patients who missed follow-up examination were traced by immediate active search or contacted using mobile phones. early treatment failure was defined as the development of danger signs or severe malaria on day 1, 2 or 3 and the presence of parasitaemia on or before day 3. late treatment failure was defined as the presence of danger signs or severe malaria in the presence of parasitaemia after day 3 or non-programmed return of the patient between days 4 to 28 due to a clinical deterioration in the presence of parasitaemia or parasitaemia on days 7, 14, 21, or 28. success was defined as parasite clearance that was sustained through day 28. adequate clinical-parasitological response was defined as the absence of either early or late failures. genotyping of parasites was not done to distinguish between recrudescences and re-infections due to non-availability of equipment. the end point for efficacy and safety was day 28. quinine was reserved for the rescue of parasitological failures. safety was assessed by: i) recording treatment emergent sign/symptom (events which were not present pre-treatment or worsened with treatment); ii) measuring liver [alanine (alt) and aspartic (ast) transaminases and bilirubin], renal functions (creatinine) and haematology [haematocrit, white blood cell (wbc) total counts]. thirty six patients (30%) of the study population had baseline and posttreatment measurements of these tests done (on day 0 and 28, respectively). instruction was placed on the patients’ records to report all cases of adverse drug reactions from the medications to the ethics and research committee of the ubth. data analysis data collected were entered into a personal computer and analyzed using statistical package for social sciences version 15. the results were presented as frequency tables, means, percentages and chi square using 95% confidence interval and p<0.05. ethical approval was obtained from the ethical committee of the ubth. results the study was conducted using 120 slideproven plasmodium-infected patients with uncomplicated malaria. none of the patients was lost to follow up. ten (8.3%) of the patients were <1 year and 60 (50%) were aged 1-6 years (figure 1). there were 65 (54.2%) females and 55 (45.8%) males with a ratio of 1.2:1. (figure 2). no malaria parasite (parasite clearance) was observed in the blood film of the study populations on or before day 3 of drug administration, indicating no early treatment failure (etf). late treatment failure (ltf) manifested as article non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e22] [page 77] recurrent parasitaemia during follow-up of five patients to day 28. the overall efficacy of camosunate was 95.8%. no patient was withdrawn due to treatment emergent signs/symptoms (tess) or adverse drug reaction (adr) (table 1). at presentation (day 0), all patients reported fever or had a measured fever in the clinic. other malaria associated signs/symptoms on presentation were weakness (55), headache (45), vomiting (39), diarrhea (32) and nausea (12). after treatment, eleven patients (9.2%) experienced at least one tess which was either not present pre-treatment or worsened post-treatment. nine patients had one tess and two had two, making a total of thirteen tess. four had vomiting, two vertigo, one asthenia, two abdominal pain, one diarrhoea, one pruritus without a rash, and two headache (table 2). the mean values for haematocrit, wbc, ast, alt, bilirubin and creatinine on days 0 and 28 are shown in table 3. there was no statistical difference between the mean values (p≥0.05) discussion following the reports and documentation of reduced efficacy of chloroquine and other commonly used mono-therapies in the treatment of uncomplicated malaria,15 the world health organization recommended the use of arteminisin-based combination therapy (act) for the treatment of uncomplicated p. falciparum malaria.4 this included artemisininamodiaquine combination, presenting in different brands. in this study which aims to assess the efficacy and safety of camosunate (a brand of as+aq) in the treatment of uncomplicated malaria, 83.3% of the subjects were below 13 years of age. this is in agreement with findings in other studies on efficacy and safety of acts in the management of malaria.8-10 it also article table 1. efficacy evaluation. age group etf ltf withdrawn mp -ve* total <1 year 10 10 1-6 years 2 58 60 7-13 year 1 29 30 >14 years 2 18 20 total 5 115 120 etf, early treatment failure; ltf, late treatment failure. *no malaria parasites were detected in blood film. table 2. treatment emergent signs and symptoms. symptoms age group <1 year 1-6 years 7-13 years >14 years abdominal pain 1 1 asthenia 1 diarrhoea 1 headache 1 1 nausea pruritus 1 vertigo 2 vomiting 1 2 1 total 2 3 3 5 table 3. clinical laboratory values on day 0 (pre-treatment) and 28 (study end-point). laboratory test day no. mean sd haematocrit (%) 0 36 39.1 5.6 28 36 38.8 4.8 wbc (x109/l) 0 36 6.420 1.050 28 36 6.887 0.985 ast (iu/l) 0 36 40.1 28.7 28 36 37.6 19 alt (iu/l) 0 36 21.2 9.3 28 36 18.8 8.7 bilirubin (mmol/l) 0 36 6.5 5.4 28 36 4.8 4.9 creatinine (mmol/l) 0 36 0.6 0.2 28 36 0.7 0.2 sd, standard deviation; wbc, white blood cell count; ast, aspartic transaminases; alt, alanine transaminases. figure 1. age distribution of the study population. figure 2. gender distribution of the study population. non -co mmerc ial us e o nly [page 78] [healthcare in low-resource settings 2013; 1:e22] underscores the fact that most of the morbidity and mortality of malaria is seen in children.2 the 100% parasite clearance observed in the blood film of the subjects by day 3 was an indication of the efficacy of the drug combination. the cure rate of 95.8% which was observed by day 28 of follow up corroborates a similar study in india in which 92.42% [real time polymerase chain reaction (pcr) corrected rate was 97.47%] was observed.18 the positive malaria parasite smears observed in five patients (4.2%) by day 28 could not be labeled as recrudescence or re-infection since genotyping of the parasites was not done due to non-availability of appropriate equipments. similar observation of late treatment failure was reported in ghana12 but higher than the 2.5% finding in india.16 treatment was well tolerated as testified by the fact that no case was withdrawn because of severe tess or adverse drug reaction. there were, however, thirteen tess experienced by eleven (9.2%) of the study group. this is higher than the finding in india in which 2.5% was reported.16 vomiting was the most common tess observed in this study. this may indicate gastric irritation caused by the study medication. the tolerability of this drug which was proven by no withdrawal from this study may have been due to the enlightenment of the subjects and their mothers or care givers on the known usual side effects of amodiaquine. amodiaquine-associated toxicities (hepatitis or severe leucopenia) have been reported in the past when it was used as prophylaxis in travelers.17 these and other toxic reactions were not observed among the patients in this study as manifested by the absence of statistically significant difference between the mean values of liver ast, alt and bilirubin, renal creatinine and haematology (haematocrit, wbc total count) on days 0 and 28. however, the number of closely monitored patients was too small to detect rare toxicities. the good compliance, resulting in good treatment outcome in this study could be attributed to the simple dose regimen as recommended by the manufacturers. it is generally accepted that making treatments easier to understand and use by patients or their care givers results in better compliance and that using fixed-dose combinations enhances this.17,18 limitations microscopy is the gold standard and mainstay for measuring parasitemia. however, it requires considerable expertise, has low sensitivity and is labour intensive. even with these disadvantages, microscopy was used to detect parasite clearance due to the non-availability of more modern equipments such as real time pcr and delta delta cycle threshold (ddct) calculation.19 this did not allow comparison of our results with others in which modern methods were used. another limitation imposed on the study was the paucity of drugs and reagents. this influenced the utilization of a sample size not based on power analysis in this pilot study. a larger sample size may have given better results. conclusions antimalarial medicines have an important role to play in reducing malaria transmission and curtailing the spread of drug resistant parasites. camosunate provided an efficacious treatment of falciparum malaria in nigerian patients. it was well tolerated and it exhibited no adverse drug reactions. references 1. federal republic of nigeria. national antimalarial treatment policy. abuja, nigeria: federal republic of nigeria, ministry of health national malaria and vector division ed.; 2005. available from: http://apps.who.int/medicinedocs/documents/s18401en/s18401en.pdf 2. federal republic of nigeria. strategic plan 2009-2013. a road map to malaria control in nigeria. abuja, nigeria: federal republic of nigeria, ministry of health, national malaria control program; 2009. 3. federal republic of nigeria. national antimalarial treatment policy. abuja, nigeria: federal republic of nigeria, ministry of health ed.; 2005. 4. who. antimalarial drug combination therapy: report of a who technical consultation. geneva: world health organisation ed.; 2001. 5. who. global antimalarial drug policy database, africa. available from: http://www.who.int/malaria/am_drug_policies_by_region_afro/en/ 6. white nj. delaying antimalarial drug resistance with combination chemotherapy. parassitologia 1999;44:301-8. 7. who. guidelines for the treatment of malaria. geneva: world health organisation ed.; 2010. available from: h t t p : / /whq l i bdoc .who . in t / pub l i ca tions/2010/9789241547925_eng.pdf 8. espié e, lima a, atua b, et al. efficacy of fixed-dose combination artesunate-amodiaquine versus artemether-lumefantrine for uncomplicated childhood plasmodium falciparum malaria in democratic republic of congo: a randomized non-inferiority trial. malaria j 2012;11:174. 9. zwang j, olliaro p, barennes h, et al. efficacy of artesunate-amodiaquine for treating uncomplicated malaria in subsaharan africa: a multi-centre analysis. malaria j 2009;8:203. 10. brasseur p, agnamey p, gaye o, et al. efficacy and safety of artesunate plus amodiaquine in routine use for the treatment of uncomplicated malaria in casamance, southern senegal. malaria j 2007;6:150. 11. ogungbamigbe to, ojurongbe o, ogunro ps, et al. chloroquine resistant plasmodium falciparum malaria in osogbo nigeria: efficacy of amodiaquine + sulfadoxine-pyrimethamine and chloroquine + chlorpheniramine for treatment. mem i oswaldo cruz 2008;103:78-84. 12. koram ka, quaye l, abuaku b. efficacy of amodiaquine/artesunate combination therapy for uncomplicated malaria in children under five years in ghana. ghana med j 2008;42:55-60. 13. gbotosho go, sowunmi a, okuboyejo tm, et al. therapeutic efficacy and effects of artemether-lumefantrine and artesunateamodiaquine coformulated or copackaged on malaria-associated anemia in children with uncomplicated plasmodium falciparum malaria in southwest nigeria. am j trop med hyg 2011;84:813-9. 14. kearns gl, abdel-rahman sm, alander sw, et al. developmental pharmacology: drug disposition, action, and therapy in infants and children. new engl j med 2003;349:1157-67. 15. sowunmi a, ayede ai, falade ag, et al. randomized comparison of chloroquine and amodiaquine in the treatment of acute, uncomplicated, plasmodium falciparum malaria in children. ann trop med parasit 2001;95:549-58. 16. anvikar ar, sharma b, shahi bh, et al. artesunate-amodiaquine fixed dose combination for the treatment of plasmodium falciparum malaria in india. malaria j 2012;11:97. 17. taylor wrj, white nj. antimalarial drug toxicity. a review. drug safety 2004;27:2561. 18. ratsimbasoa a, randrianarivelojosia m, millet p, et al. use of a pre-packadged chloroquine for the home management of presumed malaria in malagasy children. malaria j 2006;14:79. 19. beshir k, sutherland c. measuring the efficacy of anti-malarial drugs in vivo: quantitative pcr measurement of parasite clearance. malaria j 2010;9:312. article non -co mmerc ial us e o nly hrev_master [page 40] [healthcare in low-resource settings 2014; 2:4572] healthcare in low-resource settings: the individual perspective norman david goldstuck department of obstetrics and gynaecology, tygerberg hospital, cape town, south africa a health system which does not meet the accepted norms can be called a low resource setting (lrs) for healthcare. whose norms? whether it be the world health organisation (who) or any other quasi governmental organisation, how does this impact the individual who needs some type of healthcare which he or she can or cannot get? truly personal healthcare no longer exists except in exceptional circumstances. healthcare, like many other services in authoritarian left and right wing societies, in socialistic western societies, and even in capitalistic societies like the united states of america, is now under virtual total governmental control. this means that the individual does not ultimately decide whether he or she is in a lowresource setting, but the bureaucracy does. the central problem is that governments and organisations do not get sick (except perhaps in the metaphorical sense) and these bodies make decisions concerning those people receiving and supplying healthcare with whom they are not and will never be in direct contact. for this reason, it behoves us to look at healthcare resources from the perspective of the individual. healthcare resources can be grouped into the three broad categories of infrastructure, materials or supplies and human resources. while government can help bring about the first two, its ability to provide human resources (other than by way of financial inducements) is very limited. governments are also often confused when they see the results of providing the first two and yet healthcare seems inadequate. in terms of delivering healthcare and transforming a situation from a low-resource to an adequate health resource setting providing two out of three does not prove adequate. both government and the public at large also do not generally realise that the phrase build it and they will come may apply to patients but not necessarily to healthcare practitioners. this approach explains why patients in the us who become embroiled in the veterans administration or affordable healthcare act problems find themselves in a high resource country which is providing them with lowresource healthcare. the same thing happens to patients in the united kingdom, canada and other western countries when they have to face inordinately long waiting times for surgical and other care issues. what happens when infrastructure is poor and materials and supplies are not available but human resources (people), even relatively untrained, are? the simple answer is that no matter how low-resource the setting in terms of infrastructure and materials, concerned and compassionate human beings can always do something of value no matter how seemingly inadequate. the conclusion here seems to be that healthcare in low-resource settings is ultimately about people and that the most precious resource available in these circumstances is not surprisingly other people. that is not to say that infrastructure and material are not very important. it is just that we must emphasize that in whatever healthcare setting, and especially in lrs, it is people helping other people that is most vital. articles on epidemiology and resource management as applicable to healthcare in lowresource settings were originally a significant part of the mandate at the birth of this journal.1 articles on clinical methodology and practice in the broader definition of low-resource settings as outlined would also be of interest, whether it be in relation to diagnostic, procedural or psychological aspects of healthcare practice. particularly interesting would be how healthcare workers manage by necessarily cutting corners, i.e. omitting practises which are usually mandated by medical colleges and who and other guidelines but which in the circumstances become difficult or impossible to follow. many practice guidelines presume to be evidence based but in reality still reflect the prejudices of the drafters. in lrs situations these guidelines may not even be valid or appropriate. as the world’s population approaches 7 billion it will become almost impossible to provide everyone on the planet with what is deemed to be adequate medical care. paradoxically, as newer medications and procedures are becoming available all the time, the definition as to what constitutes adequate medical care of necessity changes. this then further changes the definition of what constitutes low-resource healthcare as high-resource healthcare becomes ever more complex and difficult. as the world’s population grows, the number of individuals dragged into low-resource healthcare settings both in the developed and underdeveloped world will increase. the solution to this problem, initially at least is to strengthen the one aspect of healthcare which can be brought into action almost immediately and that is the human resource factor. let us focus on what individual healthcare providers at all levels e.g. doctors, nurses, medical assistants, physiotherapists, paramedics and auxiliary healthcare personnel can do to help individuals in low-resource healthcare settings. reference 1. lahariya c. introducing healthcare in low-resource settings. health low resour settings 2013;1:e1. healthcare in low-resource settings 2014; volume 2:4572 correspondence: norman d. goldstuck, department of obstetrics and gynaecology, tygerberg hospital, green avenue, 8001 cape town, south africa. tel. +27.21.9384877 fax: +27.21.9316595. e-mail: nahumzh@yahoo.com key words: healthcare, low-resource settings, editorial. received for publication: 13 july 2014. accepted for publication: 13 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. goldstuck, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4572 doi:10.4081/hls.2014.4572 non -co mmerc ial materials or supplies and human resources. non -co mmerc ial materials or supplies and human resources. while government can help bring about the non -co mmerc ial while government can help bring about the first two, its ability to provide human non -co mmerc ial first two, its ability to provide human resources (other than by way of financial non -co mmerc ial resources (other than by way of financial inducements) is very limited. governmentsnon -co mmerc ial inducements) is very limited. governments are also often confused when they see thenon -co mmerc ial are also often confused when they see the are not very important. it is just that we must non -co mmerc ial are not very important. it is just that we must emphasize that in whatever healthcare setnon -co mmerc ial emphasize that in whatever healthcare setting, and especially in lrs, it is people helping non -co mmerc ial ting, and especially in lrs, it is people helping other people that is most vital. non -co mmerc ial other people that is most vital. articles on epidemiology and resource mannon -co mmerc ial articles on epidemiology and resource management as applicable to non -co mmerc ial agement as applicable to healthcare in lownon -co mmerc ial healthcare in lowresource settings non -co mmerc ial resource settings were originally a significant non -co mmerc ial were originally a significant part of the mandate at the birth of this journal. non -co mmerc ial part of the mandate at the birth of this journal. articles on clinical methodology and practice in non -co mmerc ial articles on clinical methodology and practice in the broader definition of low-resource settings non -co mmerc ial the broader definition of low-resource settings as outlined would also be of interest, whether it non -co mmerc ial as outlined would also be of interest, whether it be in relation to diagnostic, procedural or psynon -co mmerc ial be in relation to diagnostic, procedural or psychological aspects of healthcare practice. non -co mmerc ial chological aspects of healthcare practice. particularly interesting would be how healthnon -co mmerc ial particularly interesting would be how healthus e cious resource available in these circumus e cious resource available in these circumstances is not surprisingly other people. that us e stances is not surprisingly other people. that is not to say that infrastructure and materialus e is not to say that infrastructure and material are not very important. it is just that we mustus e are not very important. it is just that we must available all the time, the definition as to what us e available all the time, the definition as to what constitutes adequate medical care of necessity us e constitutes adequate medical care of necessity on lyone on the planet with what is deemed to be on lyone on the planet with what is deemed to be adequate medical care. paradoxically, as neweron ly adequate medical care. paradoxically, as newer medications and procedures are becomingon ly medications and procedures are becoming available all the time, the definition as to whaton ly available all the time, the definition as to whaton ly hrev_master [healthcare in low-resource settings 2016; 4:5584] [page 1] secondhand tobacco smoke exposure among adolescents in an ethiopian school sabit abazinab ababulgu,1 nebiyu dereje,2 abiot girma3 1jimma town administration health office, jimma; 2department of epidemiology, wachamo university, hosaina; 3department of epidemiology, jimma university, jimma, ethiopia abstract tobacco use is responsible for 6 million deaths globally per year, of which 600,000 deaths are due to secondhand smoke (shs) mainly among women and children. this study aims to determine the prevalence of shs exposure among school-going adolescents and highlights the essential determinants in developing successful strategies to prevent adverse health effects in ethiopia. the analysis is based on a school based cross sectional study where 1673 students with 98.2% of response rate from grade 9-12, aged 13-19 were included. data was collected by a self-administered questionnaire that is adapted from the global youth tobacco survey questionnaire. proportions and 95% confidence intervals were obtained as estimates of prevalence. bivariate and multivariate analyses were made using logistic regression on spss version 20.0 software in order to predict factors associated with shs exposure. about 17% of adolescents were exposed to tobacco smoke in their home, whereas more than half (60.8%) of adolescents were exposed to tobacco smoke in public places. in multivariate analysis, sex, parent smoking, peer smoking, and absence of discussion in the classroom about dangers of smoking were seen significantly associated with shs exposure. the prevalence of shs exposure among adolescents in ethiopia is highest. moreover, exposure to shs in public places is much higher than at home. introduction secondhand smoke (shs) consists of exhaled smoke as well as side-stream smoke that is released from the burning cigarette between inhalations and it has a very similar composition.1 it contains significant levels of nicotine and other toxic ingredients which are carcinogenic and are risk factors for different health problems and deaths.2,3 strong evidence links shs exposure to some diseases in adults and children. additionally, preliminary evidence suggests that shs contributes to other serious health effects. it can be particularly dangerous for women and children.4,5 tobacco-attributable mortality is increasing rapidly in developing countries, and by 2030 about 83% of the world’s tobacco deaths will occur in lowand middle-income countries.6,7 secondhand smokes was estimated to have caused 603,000 premature deaths globally. the largest number of estimated deaths attributable to shs exposure in adults was caused by ischemic heart disease, followed by lower respiratory infections in children, and asthma in adults.8 worldwide, 40% of children, 33% of male non-smokers, and 35% of female non-smokers were exposed to shs. the highest proportions exposed were estimated in europe, the western pacific, and south east asia, with more than 50% of population exposed. proportion of people exposed was lowest in africa.9 a study done in iraq among school adolescents and children showed that the prevalence of secondhand smoking was 34.2%, and that females were more exposed than males (18.7, 15.4%) respectively with statistically significant difference. this study also showed that indoor exposure to shs was significantly higher than outdoor public places exposure (24.6 and 9.2% respectively), and the main predictors of shs exposure were age, gender, place of exposure and, knowledge about health effects of shs.10 secondhand smoke exposure occurs either at home or in public places/outside home. for example a study done in 2006 in burkina faso found that 36% of youngsters live with a smoker, and 50% were exposed to shs outside their home. another cross-sectional study done in 2008 in south african school-going adolescents found that 26% of students were exposed to shs at home and 34% outside. further, this study showed how parental and close friends smoking status, allowing someone to smoke around you, and perception that passive smoking was harmful were significant determinants of adolescent’s exposure to both shs at home and outside.11 secondhand smoke affects the family, friends, and associates but also those who are employed in public settings, such as retail, transportation, and food service settings. these employees, who are often women, are exposed not only involuntarily, but also at high level.12 the world health assembly adopted the who framework convention on tobacco control (fctc) on 21 may 2003 and it entered into force on 27 february 2005. it has been ratified in many of the african countries; only eritrea, malawi, mozambique and zimbabwe are yet to ratify the convention.13,14 even if ethiopia ratified the convention in late january 2014, there is a need to commitment, strength, and urge by all health development partners to intensify their support for the speedy implementation of the who fctc and the placement of legislations to ensure that the public is protected from exposure to tobacco smoke. to do so, reliable evidences are important for ethiopian government; however the country lacks this evidence. therefore this paper can help magnificently different stakeholders and the government by revealing the magnitude of shs exposure and associated factors among the adolescents of ethiopia, who are the future of the country. materials and methods the school based cross sectional study was conducted from may 10 to 15, 2014 in school adolescents aged 13-19 years who were enrolled in grade 9-12 in the public and private schools of hawassa and jimma town in ethiopia. sample size was calculated by using single population proportion formula with the assumption of 50% proportion of tobacco use among adolescents, 5% margin of error, and 95% confidence interval. hence the sample size calculated was 1704 samples. multi stage sampling of students on grade 9-12 who were healthcare in low-resource settings 2016; volume 4:5584 correspondence: sabit abazinab ababulgu, jimma town administration health office, jimma, ethiopia. tel: +25.1913931747. e-mail: sabitabazinab@gmail.com key words: secondhand smoke; tobacco use; adolescent; ethiopia. contributions: saa, nd, data collecting and analyzing; saa, manuscript writing; ag, guiding overall work of the research. conflict of interest: the authors declared no potential conflict of interest. funding: the work was supported by ctca (center for tobacco control in africa) research grant no. 1st/2014. received for publication: 13 october 2015. revision received: 8 january 2016. accepted for publication: 11 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. abazinab ababulgu et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5584 doi:10.4081/hls.2016.5584 non co mmerc ial us e o nly [page 2] [healthcare in low-resource settings 2016; 4:5584] enrolled in the private and public schools of hawassa and jimma town were included in the sampling frame. at the first stage, three high schools from each town and each sector (total of 12 schools) in hawassa and jimma town were selected randomly. then at the second stage students from grade 9-12 were selected based on proportion to student size and included to the final study subjects by using simple random sampling from the registrar list of all students in their specific class until the desired sample size. global youth tobacco survey (gyts) questionnaire that were adapted to the ethiopian context were used to conduct the survey. this questionnaire is a self-administered type of questionnaire, which consisted of a core component and an optional component. all the questions were multiple choices and were translated to the official language, amharic. both the data collectors and supervisors were trained for three days on the objective and methodology of the research, and data collection approach. moreover, survey procedures were designed to protect the student’s privacy by allowing for anonymous and voluntary participation. secondhand tobacco smoke exposure was assessed using question: during the past 7 days (one week), how many days somebody smoked at your presence in your home or outside your home? data from 1673 students with 98.2% response rate were analyzed using spss version 20.0 software and proportions and 95% confidence intervals were obtained as estimates of prevalence. ethical clearance was obtained from the program coordinating parties and jimma university ethical review board. permission from the officials governing the town educational department and the respective schools were obtained, and then informed consent was obtained from the study participants after explaining the purpose of the study. results a total of 1673 students responded to our questionnaires, while 31 students refused to respond, i.e. we had a response rate of 98.2%, and data were analyzed. among them, 47.7% were males and 52.3% were females, and majority of them were in the age category of 16-17 years (60.2%) (figure 1). exposure to secondhand tobacco smoke about 17% [95% confidence interval (ci) 21.9-38.3] of adolescents who were non-smokers were exposed to tobacco smoke in their home (12.2% males and 4.8% females) (figure 2). on the other hand, 16.2% of total surveyed adolescents live with parents who were both smoker and one of them was smoker (figure 3). accordingly, 14% of them live with parents whose father only was smoker and 2.2% live with parents whose both father and mother article figure 1. proportion of study participants by sex. figure 2. secondhand tobacco smoke exposure at home by sex (n=1673). figure 3. proportion of respondents by sex whose family members smoke (n=1673). figure 4. secondhand tobacco smoke exposure outside respondents’ home/public places (n=1673). non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5584] [page 3] were smokers. more than half (60.8%, 95%ci 11.3-16.73) of adolescents who were non-smokers were exposed to tobacco smoke in public places in the past 7 days preceding the survey, among them 27% were males and the remaining (33.8%) females (figure 4). among those adolescents who were exposed to shs in public places, 19.4% have closest friends who were smokers. majority of the adolescents (84.6%) were thinking that smoke from others is harmful to them. moreover almost all the adolescents (95.7%) indicated that smoking should be banned from public places; among them, 47.3% were males and the remaining 52.7% were females (table 1). factors associated with secondhand smoke exposure those variables with p<0.25 in bivariate analysis were entered into multivariate analysis using multiple logistic regressions in order to predict factors associated with exposure to shs. according to multivariate analysis, sex, parent smoking, peer smoking, and not discussing about dangers of smoking and tobacco smoke in the class room were seen as significantly associated with shs exposure. female adolescents were 3.46 times more exposed to shs than male adolescents at home [adjusted odds ratio (aor)=3.46, 95% ci 2.624.57]. likewise, adolescents having either of their parents smoking were 3.3 times more likely to expose to shs than their counterpart adolescents (aor=3.34, 95% ci 2.37-5.03) and similarly adolescents having their closest friends smoking were more likely to expose to shs (shs) (aor=3.61, 95% ci 2.41-5.41) at their home. in public places adolescents who have peer smoker were 3.70 times more exposed to shs than those who do not have peer smokers (aor=3.76 95% ci 2.49-5.65). discussing danger health effects of shs and tobacco has also association with public places shs exposure. that is, those adolescents who were not informed on the danger health effects of tobacco smoke were 5.30 times more exposed to it (aor=5.32, 95% ci 4.13-6.81). discussion this study revealed that exposure of adolescents to shs is unacceptably very high, where over 6 in 10 were exposed to shs in public places. on the contrary, exposure to shs at their home was about 2 in 10 adolescents. this implies that exposure in public places was higher than at home. this finding contradicts with a study done in iraq which showed that shs exposure at home is higher than public places exposure.10 the gyts, assessing data from more than 130 countries and principalities, has found that: children and youths are widely exposed to shs.9 similarly, this study has evidenced increased prevalence of shs exposure among adolescents. this implies the need for effective strategy to prevent adolescents from shs exposure. public places exposure which was over 6 in 10 in the current study is much higher than the findings of the studies conducted in iraq, south africa and burkina faso.10,11 this difference could be due to high prevalence of tobacco use in the current study area and lack of tobacco control activities. moreover, the difference might be due to behavioral characteristics of study subject and difference of study areas. in public places male adolescents are more likely exposed to shs than female adolescents. likewise, adolescents who have peer who use tobacco are more likely exposed to shs smoke than those who do not have peer who use tobacco. those adolescents who were not discussed the danger health effects of tobacco smoke are more likely exposed to shs. moreover discussing the danger health effects of shs at school is protective factor of exposure to shs in public places. when we see exposure to shs at home which is about 2 in 10 adolescents were exposed it is almost consistent with percentage of adolescents whose family members use tobacco and lower than the study finding conducted in burkina faso and south africa.11,12 further the current study indicated that female adolescents are more likely exposed to shs at home than male adolescents are, which is consistent with reviewed study conducted in iraq.10 this might be explained by the cultural and traditional background of the country, at which females spend more of their life time at home and usually responsible for the activities inside their home. moreover adolescents whose parents and closest friends use tobacco are also more likely exposed to shs than adolescents whose parents and closest friends do not use tobacco at home. this finding is also consistent with the findings of study conducted in south africa.11 even though almost all the students were favoring law-prohibiting smoking in public places and agreed in banning, the finding of the current study is much higher from the study findings conducted in many countries. although some efforts are being made to protect non-smokers from shs by some service providers in ethiopia, there is a need to intensify and implement the law banning smoking in public places in order to protect non-smokers from shs, as it causes danger to the health of individuals. this study provides significant insight into prevalence of shs exposure among adolescents in ethiopia, an area relatively untouched to date. however, there has been number of limitations inherent in any cross sectional school survey where data collection is limited to a single time point, and shs exposure was assessed by self-report and therefore, some students may have under reported their exposure. the study sample was also school-based and therefore not entirely representative of all adolescents in ethiopia. conclusions from this study it possible to conclude that the prevalence of shs exposure among adolescents in ethiopia is highest. moreover, exposure to shs at public places is much higher than at home. since this study is a cross sectional survey made using gyts, it might not show cause-effect relationships. therefore, we recommend another study in order to establish article table 1. exposure to secondhand tobacco smoke and respondents’ intention towards banning smoking in public places (n=1673). variables frequency (%) smoke from other people’s cigarettes is harmful yes 84.6 no 15.4 exposed to smoke from others in their home yes 17.2 no 82.8 exposed to smoke from others in public places yes 60.8 no 39.2 smoking should be banned from public places yes 95.7 no 4.3 non co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2016; 4:5584] cause-effect relationships and attribution of the factors to shs exposure. references 1. who. framework convention on tobacco control. geneva, switzerland: who; 2003. 2. eriksen m, john m, ross h. the tobacco atlas. 4th ed. atlanta, ga: world lung foundation; 2012. 3. lopez ad, ezzati md, jamison dt, murray cj. global and regional burden of disease and risk factors, systemic analysis of population health data. lancet 2006;367:174757. 4. who. gender and the tobacco epidemic 2010. geneva, switzerland: who; 2010. 5. us office of surgeon general. how tobacco smoke causes disease: the biology and behavioral basis for smoking-attributable disease 2010. atlanta, ga: department of health and human services (us), centers for disease control and prevention (us), office on smoking and health; 2010. 6. who. tobacco free initiatives. why is tobacco a public health priority? geneva, switzerland: who; 2014. 7. mathers cd, lancer ds. projections of global mortality and barden of disease from tobacco. polim med 2006;3:442-5. 8. us office of surgeon general. the health consequences of involuntary exposure to tobacco smoke 2006. atlanta, ga: centers for disease control and prevention (us); 2006. 9. öberg m, jaakkola ms, woodward a, et al. worldwide burden of disease from exposure to second-hand smoke: a retrospective analysis of data from 192 countries. lancet 2010;377:139-46. 10. hamid yh, hussain dn. prevalence and some associated factors of passive smoking among iraqi adolescents and children. int j prev med 2015;1:1-5. 11. peltzer k. determinants of exposure to second-hand tobacco smoke among current non-smoking in-school adolescents (aged 11-18 years) in south africa. int j environ res 2011;8:3553-61. 12. schramm sc, scheffler j, aubriet f. analysis of mainstream and sidestream cigarette smoke particulate matter by laser desorption mass spectrometry. anal chem 2011;83:133-42. 13. cdc. global youth tobacco survey. ethiopian fact sheet. available from: http://nccd.cdc.gov/gtssdata/ancillary/data reports.aspx?caid=1 14. who. report on the global tobacco epidemic. geneva, switzerland: who; 2009. article non co mmerc ial us e o nly hrev_master [page 80] [healthcare in low-resource settings 2013; 1:e24] impact of a single educational session on oral hygiene practices among children of a primary school of meerut, india pawan parashar,1 sartaj ahmad,2 amir maroof khan,3 rupesh tiwari1 1department of community medicine, subharti medical college meerut, meerut; 2school of community medicine, swami vivekanand subharti university, meerut; 3department of community medicine, university college of medical sciences, new delhi, india abstract oral health promotion through schools is recommended by the world health organi zation (who) for improving knowledge, attitude, and behavior related to oral health and for prevention and control of dental diseases among school children. in low resource settings, it is important to develop evidence for health education methods in oral health behavioral practices. the objectives of this study were to assess both the baseline awareness and practices regarding oral hygiene and the impact of a single education session on the change in oral health behavior. a school based, cross-sectional study on 112 primary school children was conducted after obtaining the consent of the school authorities and parents. a pretested, structured proforma was used for baseline awareness and behavior regarding oral health. a 30 min educational session was imparted and after 1 month, and the oral health practices were reassessed to find out the impact of the education session. baseline survey revealed the following findings. self-reported dental problems were found in 48.22% of the children in the last 6 months. when asked about the risk factors for dental problems, 28.57% mentioned eating sweets followed by improper brushing, whereas 40.17% were not aware about any risk factor for dental problems. it was found that 28.57% of the children did not brush their teeth regularly, whereas 35.71% used a toothbrush for brushing their teeth. after the intervention, it was observed that there was a significant improvement in the proportion of children using a toothbrush for cleaning their teeth and of those who rinsed their mouth after meals. in conclusion, even a single education session was found to be effective in bringing about a change in the oral health behavior of primary school children. introduction oral health is an integral part of the general health and well-being of an individual. oral health promotion through schools is recommended by the world health organization (who) for improving knowledge, attitude, and behavior related to oral health and for prevention and control of dental diseases among school children.1 children tend to be more vulnerable to dental diseases due to social, economic and demographic factors like lack of awareness and transportation, limited access to professional dental care, lack of perceived need for dental care.2schools are a suitable place for imparting knowledge to the school children and school children also are receptive to the information given to them. school children can act as health change agents in the community.3 the national education policy of india also encourages linkages between education and health. studies conducted in india have focused mostly on adolescents4 or they have compared different methods of health education regarding dental hygiene practices.5 there are hardly any studies among primary school students where the impact of just one education session for oral hygiene practices have been seen.6 there exists a need to change the unhealthy practices regarding oral hygiene into healthy ones, and targeting school children is an important and effective strategy. hence, this study was designed with the following objectives: i) to assess the baseline awareness and practices regarding oral hygiene among children attending a primary school in meerut; ii) to assess the impact of a single educational session on the practices regarding oral hygiene among children attending a primary school in meerut. materials and methods the study was a cross-sectional, schoolbased interventional study. all children (n=112) aged 5-13 years who attended ishwarchandra vidhyasagar subharti primary school were included in the study. these children come from a peri-urban slum of meerut district of uttar pradesh, india. a written permission was obtained from the school authorities before the commencement of the study. informed consent was obtained from the parents of the children studied and verbal assent was taken from the children themselves. the knowledge, attitude and practices regarding oral hygiene of the children was assessed by using a pre-designed and a pre-tested questionnaire. using a mouth mirror and explorer, examination of oral cavity of the children was done by dental screening in broad day light, facing away from sunlight to detect clinically evident caries lesions and oral hygiene status. the examination of oral cavity of the children was conducted by a dentist. those who were having problems related to teeth were given treatment free of cost. an educational session of 30 min duration, comprising the lecture and demonstrations in local language (hindi), was carried out by the first and second author of the study in groups of 20-30 children. pictorial charts depicting the common oral health problems and techniques of maintaining a healthy oral hygiene was used. a model of an oral cavity was used to further enhance its understanding in three dimensions. finally a demonstration was conducted for proper brushing of teeth and a toothbrush was distributed free of cost to each student. re-assessment for the oral hygiene practices was done among the same group of children after a period of 1 month. data was entered in ms excel spreadsheet and analysed using epi info for windows. z test for proportions was used to test the difference in the proportions and p<0.05 was considered as statistically significant. results a total of 112 children aged 5-13 years of age were examined twice, once before the intervention and then after one month of intervention. of these, 72 (64.29%) were males and 40 (35.71%) were females. healthcare in low-resource settings 2013; volume 1:e24 correspondence: amir m. khan, department of community medicine, university college medical sciences, dilshad garden, 110095 new delhi, india. tel. +91.011.22582106 fax: +91.011.22582105. e-mail: khanamirmaroof@yahoo.com key words: health education, school children, oral health, dental hygiene. contributions: pp and sa conceived the idea of the manuscript and developed interview tools and data collection; pp, amk and sa prepared the manuscript; rt analyzed data. conflict of interests: the authors declare no potential conflict of interests. received for publication: 27 june 2013. revision received: 16 july 2013. accepted for publication: 28 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. parashar et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e24 doi:10.4081/hls.2013.e24 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e24] [page 81] pre-intervention findings self reported dental problems were found in 54 (48.22%) of the children in the last six months. out of these, 19 (35.19%) children had consulted the dental surgeon, 12 (22.22%) had consulted any doctor for consultation and 23 (42.59%) had used home based measures when they experienced any dental problem. the most common response (33.93%) for common oral health problems was mentioned as tooth decay. other oral health problems reported were bad smell (15.17%), cracked teeth (10.71%), toothache (7.14%) and gum diseases (4.46%), whereas 17.85% were not able to report any oral health problem. when asked about the risk factors for dental problems, majority (28.57%) mentioned eating sweets followed by improper brushing (17.85%). not rinsing the mouth was mentioned as a risk factor by only 8.73%, and 40.17% were not aware about any risk factor for dental problems. regarding the practices for maintaining oral hygiene, it was found that majority (35.71%) brushed their teeth with a toothbrush, whereas 22.32% used their finger for cleaning the teeth, 8.93% used other abrasive materials like coal etc., and 4.46% used neem’s or some other plant’s twig for cleaning their teeth, whereas 28.57% did not bush their teeth regularly and did not have any fixed method of cleaning their teeth. post-intervention findings there was a significant improvement – i.e. from 35.71% in the pre-intervention phase to 58.93% in the post-intervention phase – in the proportion of children using a toothbrush for cleaning their teeth (p<0.001). a significant increase in proportion of children who rinsed their mouth after meals also increased from 8.04 to 24.11% (p=0.001) after the intervention. the proportion of children using other things to clean their brush other than a tooth brush, like charcoal, plant’s twigs etc. declined significantly post intervention: from 35.71 to 23.21% (p=0.04). discussion in recent years, there is a growing emphasis on oral health and it is important to focus on the vulnerable groups of the society, especially children belonging to a lower socioeconomic status. nearly half (52.8%) of the respondents in a study by mehta and kaur7 have reported as having some dental problem in the last 12 months, which was nearly similar to the findings of the present study. another study by david et al.8 from kerala has observed that 23% of the school children, had self reported dental problems, which was lower than that in the present study. ayele et al.9 have reported from a community based study in ethiopia, that 67.3% of parents of the children having any dental problem were taken to any formal health care provider. this was higher than that reported in the present study. in a study by diwan et al.10 from meerut, 53.4 and 60.1% of the children studied suffered from gingivitis and dental caries, respectively, which was higher than in the present study, since in diwan and colleagues’ study the diagnosis was made by a physician, whereas in the present study self reported problems were recorded. joshi et al.11 has reported from a village in tamil nadu, that 61% of children between 6-12 years knew about tooth decay. this was higher than that reported in the present study. a study by sreebny using data on sugar supplied in various countries and data on caries prevalence obtained from who for 6-year-old children in 23 nations and 12-year olds in 47 nations, showed that the availability of <50 g of sugar per person per day in a country was always associated with decayed, missing, filled teeth (dmft) scores <3.12 similar findings were reported by winter and rule13 and shetty and tandon.14 in the present study, 35.71% children were using tooth brush and 22.32% of children were using fingers to clean their teeth. using a brush for cleaning the teeth has been reported as 62.96 and 71.4% among school going children by punitha and sriprakasam15 and mehta and kaur,7 respectively. these figures are higher than that reported in the present study. it may be due to the migrant labor population studied in the present study which cannot afford or do not give priority to oral hygiene due to lack of awareness. in a study by mehta and kaur, 17.3 and 4.1% of the children studied reported use of neem twigs and finger, respectively, for cleaning their teeth.7 in the present study, the proportion of children using neem twigs was lower but children using their fingers for cleaning their teeth was higher than in this study. another study from south india has also reported use of charcoal for brushing teeth among school going children.16 however, it should be noticed that children not using any fixed modality for cleaning their teeth was high (28.57%) in the present study. this highlights that these children are not seriously regarding oral hygiene. studies have shown that health education can improve the knowledge and to some extent the behavior regarding healthy oral hygiene practices.17 chaudhary et al. from delhi have reported an improvement in the knowledge regarding oral health after health education.18 however, this study did not assess the change in oral health behavior in the children studied. another study has revealed that dental health education given at 3-week-intervals was more effective than that at 6-week-intervals.19 as teachers already have other tasks to perform, they may not find much time to impart health education to children, which involves a considerable amount of time. hence, it is necessary to assess the impact of short duration education sessions on their oral health related practices. overall, the level of oral health knowledge among the surveyed children was low. results of this study suggest that oral health practices can be improved by even a single education session. limitations of the study the study was done in a single school and its results cannot be generalized. no control group was chosen in this study, but since this was a preliminary study, further studies need to be planned with a representative sample from the population and using a control group for comparison. another limitation was that this study did not measure the effectiveness of the intervention in the long term. conclusions inclusion of even a single education session on oral hygiene for school children can lead to a change in their behaviors and thus it can be promoted in schools even with resource poor settings. more studies need to be done to see the long term effect of such interventions. references 1. peterson pe. world health organization global policy for improvement of oral health. int dent j 2008;58:115-21. 2. grewal h, verma m. oral health status in rural child population: promotional and interventional strategies. a goi-who collaborative programme 2006-07. available from: ftp://203.90.70.117/searoftp/ wroind/whoindia/linkfiles/oral_health _oral_health_status_in_rural_child_pop ulation.pdf 3. mwanga jr, jensen bb, magnussen p, aagaard-hansen j. school children as health change agents in magu, tanzania: a feasibility study. health promot int 2008; 23:16-23. 4. shenoy rp, sequeira ps. effectiveness of a school dental education program in improving oral health knowledge and oral hygiene practices and status of 12to 13year-old school children. indian j dent res 2010;21:253-9. available from: http:// www.ijdr.in/text.asp?2010/21/2/253/66652 brief report non -co mmerc ial us e o nly [page 82] [healthcare in low-resource settings 2013; 1:e24] 5. hebbal m, ankola av, vadavi d, patel k. evaluation of knowledge and plaque scores in school children before and after health education. dent res j (isfahan) 2011;8: 189-96. 6. goel p, sehgal m, mittal r. evaluating the effectiveness of school-based dental health education program among children of different socioeconomic groups. j indian soc pedod prev dent 2005;23:131-3. 7. mehta a, kaur g. oral health-related knowledge, attitude, and practices among 12-year-old school children studying in rural areas of panchkula, india. indian j dent res 2012; 23:293. 8. david j, wang nj, astrom a, kuriakos s. dental caries and associated factors in 12year-old schoolchildren in thiruvanan thapuram, kerrala, india. int j paediatr dent 2005;15:420-8. 9. ayele fa, taye bw, ayele ta, gelaye ka. predictors of dental caries among children 7-14 years onld in northwest ethiopia: a community based cross-sectional study. bmc oral health 2013;13:7. 10. diwan s, saxena v, bansal s, et al. oral health: knowledge and practices in rural community. indian j community health 2013;22:29-31. available from: http://www. iapsmupuk.org/journal/index.php/ijch/art icle/view/398/pdf 11. joshi n, rajesh r, sunitha m. prevalence of dental caries among school children in kulasekharam village: a correlated prevalence survey. j indian soc pedod prev dent 2005;23:138-40. available from: http://www. jisppd.com/text.asp?2005/23/3/138/16887 12. sreebny lm. sugar availability, sugar consumption and dental caries. community dent oral 1982;10:1-7. 13. winter gb, rule dc. the prevalence of dental caries in pre-school children aged 1 to 4 years. brit dent j 1971;130:434. 14. shetty ns, tandon s. prevalence of dental caries as related to risk factors in school children of south kanara. j indian soc pedod prev dent 1988;6:30-7. 15. punitha vc, sriprakasam p. oral hygiene status, knowledge, attitude and practices or oral health among rural children of kanchipuram district. indian j multidisciplinary dentistry 2011;1:115-8. available from: http://www.ijmdent.com/ articles/volume1-issue2/original-researchoral-hygiene.pdf 16. mahesh kp, joseph t, varma rb, jayanthi m. oral health status of 5 years and 12 years school going children in chennai city. an epidemiological study. j indian soc pedod prev dent 2005;23:17-22. available online from: http://www.jisppd.com/ text. asp?2005/23/1/17/16021 17. kay e, locker d. a systematic review of the effectiveness of health promotion aimed at improving oral health. community dent hlth 1998;15:132-44. 18. chaudhary f, khayyam ku, siddiqui mj, et al. impact of teaching on dental knowledge in fifth standard of mcd primary school children of south delhi. journal applied pharm sci 2011;1:91-3. available from: http://www.japsonline.com/admin/php/uplo ads/179_pdf.pdf 19. shenoy rp, sequeira ps. effectiveness of school dental education program in improving oral health knowledge and oral hygiene practices and status of 1213-year old school children. indian j dent res 2010;21:253-9. available from: http://im sear.hellis.org/bitstream/123456789/139 858/1/ijdr2010v21n2p253.pdf brief report non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11194 a systematic review on telenursing as a solution in improving the treatment compliance of tuberculosis patients in the covid-19 pandemic ni nyoman elfiyunai,1 nursalam,2 tintin sukartini,2 ferry efendi2 1doctoral program of nursing, faculty of nursing, universitas airlangga, surabaya indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: the covid-19 pandemic had made patients scared of coming to clinics or hospitals, and this could affect the treatment of tb. therefore, one type of service that can be used by nurses to improve compliance to tb treatment is telenursing. this article aims to ascertain whether telenursing could be a solution in improving the compliance of tb patients to treatments in the covid-19 pandemic. design and method: this research was conducted using the randomised controlled trial design as well as prisma. furthermore, useful research articles were sourced from the database using the keywords, “message reminder and tuberculosis or medication adherence”. the databases used are scopus, science direct, pubmed, and sage, all in english text and from 2015 to 2021, with inclusion criteria. 277 articles were obtained, and then filtered to select 3 articles by reading the main focus of the write-up, with regard to the topic of study. result: telenursing can be a solution to reduce the spread of covid-19, and a substitute for remotely motivating individuals, as social support. furthermore, it could be used as a reminder to patients to be obedient in carrying out treatments, and as a means of educating and improving good relationships with providers. conclusions: telenursing is a fairly effective solution in helping tb patients improve treatment compliance, reduce drug dropout rates and missed doses, as well as, raise awareness about the importance of health in the covid-19 pandemic. introduction tuberculosis (tb) is one of the top 10 causes of death in the world.1 globally, about 10 million people were affected by the disease, with 1.4 million death in 2019.2 tb control efforts with direct observed treatment (dot) strategies have been implemented in many countries.3,4 however, patients are still unable to complete treatment thoroughly or be declared cured of the disease.5 many patients do not comply to the treatment because they feel bored, they miss taking their medication, and do not routinely seek treatment due to the length of time the process takes.6 usually about 6 to 8 months.7 prolonged transmission of the disease, failure of treatment, and risk of resistant variants are serious problems.3,8,9 furthermore, multidrug-resistance (mdr) can worsen the outcome of treatment, and lead to high morbidity and mortality.10,11 social support is needed.12 from friends, family, and health workers to improve patients’ trust and compliance in treatment.13 to support compliance, nurses play a role in providing education, communication, observation, and follow-up of patient treatment.14 during the covid-19 pandemic, many health programs and disease control to the public were discontinued.15 and this also impacted the treatment of cancer patients.16 the secondary effects of the pandemic include damage to the economy, the spread of diseases, the reduction of health workers, as well as patients being afraid to come to health care centers.17 the pandemic may also have increased the death of tb patients.18 mobile technology has been useful for all countries in overcoming obstacles in the provision of health services.19 strategies to end the epidemic of global tb disease by 2035 require electronic health plans.20 therefore, a global digital health task force team was set up by the world health organization (who) in 2015 to help prevent and improve tb treatment.21 support digital medicine can monitor and ensure the treatment of tb patients.22 furthermore, mobile-health networks (mhealth) can help tb programs and improve treatment and control compliance to health care centers.23 the use of cell phones is an alternative approach in providing support and reminding patients of their treatments.24 it could also be used in providing support and information to improve patient compliance in treatment.7,9,25 in the form of digital health, technology can help health workers monitor and support tb patients in terms of treatment adherence.26 previous research has cast doubt on the effectiveness of texting reminders in improving the treatment of tuberculosis patients.4,7 telenursing is very important to be used by health workers in pandemic times, to prevent the transmission of covid-19. it could also be used to help remind patients to take medication and conduct periodic checks in health care centers. therefore, the goal of this study was to ascertain whether telenursing is a solution in improving the treatment compliance of tb patients. review significance for public health telenursing is very helpful for improving the compliance of patients to tuberculosis treatment during the covid-19 pandemic. telenursing can be one of the options for the public to obtain information, as well as a form of support for patients in carrying out tb treatment and a reminder message to patients to take medication and visit health care facilities at times specified in the patient's mobile service. telenursing can alleviate the burden on family members' minds when reminding patients to take their tb medication. telenursing can reduce or eliminate the spread of tuberculosis (tb) to families, groups, or communities and prevent multi-drug resistance in patients and reduce tb mortality. therefore, this form of nursing is the topic of study in this article. it could be an alternative in overcoming obstacles in the delivery of health services. [healthcare in low-resource settings 2023; 11(s1):11194] [page 93] non -co mmerc ial us e o nly review [page 94] [healthcare in low-resource settings 2023; 11(s1):11194] table 1. summary of data description from the included studies. non -co mmerc ial us e o nly review [healthcare in low-resource settings 2023; 11(s1):11194] [page 95] table 1. summary of data description from the included studies. non -co mmerc ial us e o nly design and methods this study used the systematic review approach and was carried out following the preferred reporting items for systematic reviews and meta-analyses (prisma) method. the authors developed the research problem using pico with the criteria of a tb patient population, interventions with short message service reminder messages, or cell phone calls for tb treatment. furthermore, the authors studied patients who only received standard dots services, compliance, or improved treatment of tb patients, using a randomized, blinded, and controlled trial design. keywords that were used: “tuberculosis”, “reminder messages” and “tuberculosis” or “drug compliance”, dots treatment, compliance, tb intervention, adherence. additionally, articles in english published between 2015 and 2021 were obtained from scopus, sage, science direct, and pubmed. two hundred seventy-seven articles were found in the database, including 19 scopus articles, 24 pubmed articles, 141 sciencedirect articles, and 93 sage articles. the number of articles was reduced to 277 after identifying the articles thoroughly. furthermore, 116 articles were re-selected based on this inclusion criteria: lack of focus on tb treatment, patient messaging services were not adequately discussed, received only regular treatment from the directly observed treatment shortcourse (dots), and no evidence about tb treatment adherence. abstracts were also identified and filtered, reducing the number of articles to 161 and bringing the excluded articles to 70. following the screening process, ten complete articles were selected and used. data extraction from the selected articles was carried out with the distribution of extraction forms containing metadata such as the author’s name, year, title, research design, subject criteria, research location, intervention, length of follow-up, and results, as shown in table 1. results and discussions the results of the article selection are shown in figure 1 of the flowchart. the review’s findings yielded ten articles in the following categories: the respondents ranged from 15 to 80 years old, and the studies were conducted in northwest ethiopia,19 cameroon,4 china’s anchui province,27 pakistani karachi,7 malang, indonesia,9 heilongjiang, jiangsu, hunan, and chongqin provinces, china,28 british columbia kanda,29 district of sleman, indonesia,30 state of khartoun sudan,31 tb clinic khyber peshawar and teaching hospital nahaqi emergency satellite hospital, pakistan.32 a total of 8179 tb patients were studied in the overall study. the intervention group received mobile phone reminders and routine dot care, whereas the control group only received conventional therapy. previous study explained that through reminder messages sent every day from mobile phones about tb treatment in the form of text messages, there was an increase in treatment compliance, centered on good relationships between providers.19 text messaging effectively strengthens the level of complete treatment compliance in tb patients, as well as, reduces the possibility of missing medication schedules, and severed treatment. it also increases the awareness of patients to perform periodic checkups.27 medication monitors have also been shown to improve tb patient compliance, whereas receiving a reminder via text message does not affect medication adherence,28 even though text messages are sent in both directions every week.29 because resources are limited, sms reminders from mobile phones can help improve tb patient compliance.30 when compared to patients who do not receive short messages, health services with reminder messages can have a high cure rate.31 meanwhile, another study stated that there was no increase in treat review figure 1. literature search flow diagram. [page 96] [healthcare in low-resource settings 2023; 11(s1):11194] non -co mmerc ial us e o nly ment success from reminders given via sms. the low recovery of patients in the 6th month of treatment was estimated to be due to the condition of many school children dropping out of school between the 5th and 6th months of treatment.4 the discussion of the use of telenursing has been the focus in different research and applied in various disease conditions, as described in the 10 articles above. eight of the articles explained that there was an increase in treatment adherence and awareness of tb patients to conduct periodic examinations. meanwhile, between two article showed that texting reminders do not improve the success of tb treatment and the proportion of cures due to high dropout rates between the fifth and sixth months of tb treatment. to reduce the transmission of covid-19, many measures used by the government, ranges from the wearing of masks, restrictions on crowded places, the closure of public spaces and limiting the number of visits to political gathering every day.33 meanwhile, as stated by the who, this virus was first reported as a pandemic in wuhan china on december 8, 2019.34 since then, remote consultation by phone, such as telenursing, was introduced as it could be beneficial to patients during the pandemic.35,36 telenursing can provide social support especially when patients do not have someone to remind them about their treatment, or are far away from their social support. the patient feels the messages from sms can motivate them to comply to the treatment schedule regularly.24 telenursing via sms message can be a substitute in providing motivation to patients to take tb drugs.9 from research in india and south africa, patients undergoing tbhiv treatment expressed discomfort using cell phone via sms.23 the use of telenursing for diabetic patients can help improve their compliance to take medication. it could also serve as a reminder to exercise control when eating, and assist in the provision of health education in urban india.37 studies conducted in lesotho and mozambique on tb/hiv patients via telenursing reported a good relationship between patients and health care providers in the intervention group.38,39 indian research into tb control can effectively use telenursing as a major source of information.40 in north west ethiopia most participants were willing to use telenursing as a means of reminder to take their medication.41 similarly, in disasters, the use of this form of nursing is essential in helping to provide care.42 however, when the communication is made over the phone and the caller is unclear, there is the risk of the information received being wrong.43 with regards to postnatal situations, consultation via video is fun, but in such conditions, the communication is usually dominated by nurses with a focus on the weight of premature babies.44 telenursing is also beneficial in interpersonal skills and helps evaluate the competence of doctors in learning activities.45 in post-cataract surgery, telenursing can improve treatment adherence and can provide daily postoperative recovery information.46 it could also be used in the case of burn patients to help in providing education and improving quality of life during the rehabilitation phase.47 remote care using telenursing in the implementation of regulation and education is very effective, safe, and virtually relevant.48 it is also very beneficial in providing primary care, and could be developed and included in the law on the use of digital technology for nurses.49 finally, this form of nursing could be used in providing support on the provision of dot to improve tb patient compliance.50 it could also help improve adherence to treatment and healthy living in patients with a variety of chronic diseases.51,52 studies on the use of telenursing with sms may also assist patients in compliance with the release or replacement of endoscopic retrograde cholangiopancreatography (ercp).53 finally, in diabetic patients, this form of nursing could improve patient compliance.54 conclusions telenursing can be used during the covid-19 pandemic to reduce health workers’ contact with patients to limit the risk of transmission of the disease from officer to patient and vice versa. it is also a solution for assisting tb patients in improving their compliance to treatment, reducing drug dropout rates and missed doses, as well as raising awareness about the importance of health. finally, based on this study, the application of telenursing is enough to help improve the compliance to tb treatment in the covid-19 pandemic. references 1. world health organization. tuberculosis global report [internet]. world health organization. 2019; available from: review correspondence: ni nyoman elfiyunai, doctoral program of nursing, faculty of nursing, universitas indonesia, jl. dr. ir. h. soekarno, mulyorejo, surabaya, jawa timur 60115, indonesia, tel.:+62-31-5914042, fax:+62-031-5981841. e-mail: ni.nyoman.elfiyunai-2020@fkp.unair.ac.id. key words: telenursing; tuberculosis; medication; adherence; covid-19. acknowledgment: the author is grateful to the doctoral program of nursing, faculty of nursing, airlangga university, surabaya indonesia, for providing support and encouragement. contributions: all authors played a role in this article as nne searched for articles from the database and compiled them, while n and ts served as lecturers and reviewed the final articles. finally, the author is grateful to the fe lecturer for helping in improving the writing and authoring of this article. conflict of interests: the author declare no conflict of interest. funding: none. clinical trials: this systematic review study was conducted in accordance with the accepted practices. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 6 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11194 doi:10.4081/hls.2023.11194 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11194] [page 97] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11728 the effect of pregnant mother assistance on stunting prevention behavior nursyahid siregar, evy nurachma, siti raihanah department of midwifery, politeknik kesehatan kemenkes kalimantan timur, indonesia abstract stunting, a consequence of prolonged inadequate nutrition, often due to improper feeding practices, was a significant health issue. this study aimed to investigate the impact of maternal assistance on behaviors aimed at preventing stunting. the research employed a pre-experimental design with a one-group pre-test and post-test for 32 pregnant women attending a samarinda health center. data collection utilized structured questionnaires evaluating knowledge, attitudes, and actions. the result of the study revealed that most participants were aged 18-25, had a high level of education, and were housewives. a majority had an income exceeding 2,868,081 units, were primigravida, and lived in nuclear families. notably, maternal assistance significantly improved stunting prevention behaviors, as evidenced by a pvalue of 0.005. this study emphasizes the positive impact of providing comprehensive support, including education and counseling, to pregnant women. such assistance could enhance knowledge, attitudes, and actions related to stunting prevention. health professionals should prioritize this support to reduce the risk of stunting among children and promote maternal and child health. introduction stunting is a chronic malnutrition problem caused by prolonged insufficient nutritional intake, often resulting from inadequate feeding practices that do not align with nutritional needs.1,2 it’s worth noting that stunting can manifest from fetal development and becomes evident in children around the age of two.3,4 short stature in toddlers, commonly referred to as stunting, is a widespread nutritional issue affecting children worldwide.5 inadequate nutrition during pregnancy and the first year of life can have lasting effects on brain development. the prenatal period is marked by rapid brain development, which continues into early childhood.6 research reveals that newborns possess approximately one hundred billion brain cells, and the maturation and formation of neurological connections occur progressively from birth to early childhood. insufficient nutrition during this critical period can lead to neurological abnormalities, developmental disorders, and impact motor, cognitive, language, socio-emotional abilities, and even result in mental retardation.7 motor function decline in stunted children without congenital abnormalities is associated with the underdevelopment of the triceps surae muscle, hampering their motor abilities.8 in 2017, approximately 22.2% of the global toddler population, roughly 150.8 million children, experienced stunting. however, this figure represents an improvement compared to the stunting rate in 2000, which stood at 32.6%.8,9 indonesia, in particular, faces a high prevalence of stunted children, with national data from riskesdas in 2018 indicating a prevalence of 30.8%. this represents a decline from 37.2% in 2013 to 30.8% in 2018.10 while indonesia has made progress, the prevalence remains relatively high compared to the world health organization’s (who) benchmark of less than 20%, highlighting the need for continued attention.9 in east borneo, the prevalence of stunting, as per data from the east borneo health office in 2017, stands at 30.6% among toddlers. although this percentage is below the national correspondence: nursyahid siregar, department of midwifery, politeknik kesehatan kemenkes kalimantan timur, indonesia e-mail: siregarnursyahid@yahoo.co.id key words: assistance; pregnant; prevention; behavior; stunting contributions: ns, conceptualization, investigation, data curation, formal analysis, methodology, validation, writing – original draft, review & editing; en, conceptualization, methodology, validation, and writing – original draft, review & editing; sr, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing;. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kaltim, based on ethical certificate lb.02.01/7/ 2068/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from poltekeks kaltim with contract number pp.03.01/1.1/32997/2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to all parties involved in this research received: 9 september 2023. accepted: 11 october 2023. early access: 23 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11728 doi:10.4081/hls.2023.11728 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11728] [page 51] non -co mmerc ial us e o nly average, it still exceeds the who standard of 20%, making it a significant health concern.11 assistance for pregnant women encompasses activities such as education, nutrition guidance, and health counseling designed specifically for pregnant women.12 this support also extends to services and assistance, all aimed at preventing stunting through individual and group approaches.13 assistance involves various actions, including paying attention, delivering messages, encouragement, providing advice or solutions, offering services, referring, mobilizing, and collaborating to empower pregnant women. consequently, this research seeks to examine the impact of pregnant mother assistance on stunting prevention behavior within a health center in samarinda. previous studies offer valuable insights into the potential benefits of nutrition education and counseling for pregnant women. for instance, research in the west gojjam zone, ethiopia, demonstrated that pregnant women who received nutrition education were 2.02 times more likely to improve their dietary practices compared to those who did not receive such education.13 another study in katenga-kauda indicated that knowledge about nutrition and consumption of diverse foods increased in both study groups but was notably higher in the intervention group.14 furthermore, a study by yurni revealed that two weeks of balanced nutrition education in two sessions increased respondents’ practice of selecting a balanced menu by 7.7 percent.15 intensive nutritional counseling, employing leaflet media, has proven to be an effective method for enhancing pregnant mothers’ knowledge.16 this research aimed to assess the influence of pregnant mother assistance on stunting prevention behavior within a health center in samarinda. by building on previous studies and addressing the critical issue of stunting in toddlers, this research endeavors to contribute to the broader efforts aimed at improving maternal and child health outcomes. materials and methods design the research design employed in this study follows a preexperimental approach, specifically utilizing a one-group pre-test and post-test design. this design entails conducting an initial assessment (pre-test) before the intervention or treatment and then a follow-up assessment (post-test) after the intervention. sample the study employed consecutive sampling, selecting pregnant women in their first to third trimesters who met the criteria for normal pregnancies and completed all questionnaire items related to stunting prevention at both pre-test and post-test stages. a total of 32 participants comprised the study’s sample size. regarding the intervention procedure, pregnant women received assistance through direct education using visual aids such as flip sheets and informative leaflets during their visits to healthcare facilities. this educational and counseling approach aimed at stunting prevention involved two-way communication, fostering an interactive dialogue to enhance knowledge. this process served as the initial step in facilitating behavioral change towards stunting prevention. instruments the study utilized a questionnaire to assess the attitude and behaviour of pregnant women. in order to analyze the data descriptively, we established a measurement scale using attitude and behavioural instruments. attitudes participants responded to statements related to stunting during pregnancy, with 20 items in the questionnaire. half of these items (1, 5, 6, 7, 10, 11, 12, 17, and 18) were framed positively (+), while the remaining half (2, 3, 4, 8, 9, 13, 14, 15, 16, 19, and 20) were framed negatively (-). we employed a likert-scale rubric to assign scores, where for negative statements: extremely agree (ea) was scored as 0, agree (a) as 1, doubt (d) as 2, less agree (la) as 3, and extremely disagree (edis) as 4. conversely, for positive statements, the scoring was the opposite: extremely agree (ea) was scored as 4, agree (a) as 3, doubt (d) as 2, less agree (la) as 1, and extremely disagree (edis) as 0. all individual scores were then summed, and the total scores were classified as ‘good’ (>65) or ‘poor’ (<65). behavior behavior refers to actions taken by pregnant women both during and after childbirth related to stunting prevention. it was indicated by various factors such as pregnancy examination visits, balanced nutritional consumption, iron tablet intake, early breastfeeding initiation, and exclusive breastfeeding. each participant’s behavior was rated on a scale of 0 to 5 based on a combination of these five indicators. ‘good’ behavior was defined as scoring 2 or higher, representing adherence to at least four of these indicators, while ‘poor’ behavior was assigned to those scoring 1, indicating adherence to fewer than four indicators. analysis the paired t test was used to analyze the data. the level of significance used in this test is a p-value of  0.05 at 95% confidence. the variables measured are the knowledge, attitudes, and actions of pregnant women in preventing stunting. the measuring tool used is a questionnaire. measuring behavioral changes (knowledge, attitudes, and actions) in efforts to prevent stunting with questionnaires measurement results using ratio data. all questions have valid status because the value of r-count (corrected itemtotal correlation) is greater than table >0,468. ethical clearance ethical test at the poltekkes kaltim ethics committee with number lb.02.01/7/2068/2021. after obtaining prospective research respondents, the researcher first explained research information and ethics in research to the subject regarding the benefits and objectives of the research, time, and research procedures. the researcher also explained to the subjects who were willing to be respondents to sign the consent form; if they did not sign, they would not be used as research respondents. researchers also explained that the subject has the right to withdraw as a research subject and not be given any sanctions or treatment. results frequency distribution of demography characteristics of all variables. table 1 provides a comprehensive overview of the demographic characteristics of the pregnant women participating in this study. it reveals that a substantial proportion of the participants fell within the 18–25 age bracket, with 14 individuals (43.7%) belonging to [page 52] [healthcare in low-resource settings 2023; 11:11728] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly this age group. moreover, a notable percentage, consisting of 14 participants (43.8%), possessed a higher level of education, while a majority of 18 individuals (56.3%) identified as housewives. the economic profile of the participants was also noteworthy, with a significant 25 families (78.1%) reporting an income exceeding 2,868,081 rupiahs. additionally, 15 respondents (46.9%) were experiencing their first pregnancy (primigravida), and the family structure of 17 families (53.1%) adhered to a nuclear family arrangement. these demographic insights provide a valuable context for understanding the characteristics of the study’s participants and their potential influence on stunting prevention behaviors. table 2 provides a clear picture of the changes observed in pregnant women’s knowledge, attitudes, and actions before and after receiving assistance. prior to assistance, the mean knowledge score was 9.59±4.89, which increased significantly to 12.8±2.88 after assistance. similarly, the mean attitude score also showed a noteworthy improvement, rising from 7.91±2.84 before assistance to 10±0.00 after assistance. in terms of actions related to stunting prevention, the mean score before assistance was 7.84±2.61, and it slightly increased to 8.19 ± 2.38 after receiving assistance. to assess the impact of pregnant mother assistance on stunting prevention behavior, the paired t-test was employed with a significance level of 5% (0.05). the results revealed that for knowledge (p=0.00) and attitude (p=0.00), there was a highly significant effect of pregnant mother assistance. moreover, for stunting prevention actions, the p-value was 0.014, indicating a statistically significant influence of the assistance on these behaviors. this suggests that the provided assistance had a positive and statistically significant impact on enhancing knowledge, attitudes, and actions related to stunting prevention among pregnant women. discussion stunting prevention behavior prior to and following pregnancy assistance the result showed that knowledge, attitudes, and actions of pregnant women have shown significant improvement both before and after receiving assistance. in summary, pregnant mother knowledge, attitudes, and actions regarding stunting prevention have significantly enhanced. these findings align with research conducted in pulang pisau district, which indicates that pocketbook treatment is notably effective in improving pregnant women’s attitudes towards preventing stunting.17 similarly, the results of this study are consistent with the research conducted by wisma et al.,which demonstrates a significant difference (p<0.001) in healthy food consumption practices among pregnant women who received nutrition education in the intervention group compared to the control group.18 the mentoring intervention provided to pregnant women in this study successfully increased their average knowledge, indicating a solid knowledge base. the enhancement in pregnant women’s knowledge can be attributed to the educational and counseling assistance they received regarding stunting prevention. this two-way communication activity serves as the initial step in the process of behavior change for prevention.19 counseling plays a pivotal role in establishing productive cooperation and communication between counselors, creating a comfortable atmosphere. moreover, counseling and education aimed at stunting prevention in mothers correlate with reduced stunting prevalence and improved feeding practices during early childhood, as demonstrated in the research by mistry et al. counselors have the ability to gauge the extent of the counselee’s knowledge and build upon it. the repetition of information during counseling sessions also contributes to the enhancement of knowledge.20 [healthcare in low-resource settings 2023; 11:11728] [page 53] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. the frequency distribution of respondent characteristics. characteristics of respondents frequency percentage age < 18 years 1 3.1 18-25 years 14 43.7 26-30 years 6 18.8 >30 years 11 34.4 education primary education 5 15.6 secondary education 13 40.6 higher education 14 43.8 occupation housewife 18 56.3 self-employed 3 9.4 private employee 10 31.3 government employees 1 3 income < idr 2.868.081 7 21.9 > idr 2.868.081 25 78.1 number of children primigravida 15 46.9 secondary gravida 5 15.6 multi gravida 12 37.5 family structure nuclear family 17 53.1 extended family 15 46.9 non -co mmerc ial us e o nly the findings of waswa’s research in 2015 further substantiate the effectiveness of nutrition education in improving knowledge and practices related to complementary feeding, with significantly higher average nutritional knowledge observed in the intervention group.21 in summary, the results of this study underscore the effectiveness of assisting pregnant women in enhancing their knowledge, attitudes, and actions concerning stunting prevention during pregnancy. pregnant mother assistance has positively influenced the attitudes of pregnant women toward stunting prevention, as reflected in the increased average value. this highlights the capacity of pregnant mother assistance to instigate favorable changes in mothers’ attitudes and behaviors regarding stunting prevention. muluye’s research also supports this notion, demonstrating that nutrition education leads to improved practices and knowledge related to appropriate complementary foods.22 it is crucial to acknowledge that stunting is the result of multifaceted factors and not solely attributable to malnutrition experienced by pregnant women and children under the age of five. to effectively reduce the prevalence of stunting, interventions must focus on the first 1,000 days of life. changes in stunting prevention behavior before and after mentoring based on the statistical test results presented in table 2, it is evident that pregnant mother assistance has a significant impact on stunting prevention behavior. this signifies that pregnant mother assistance plays a crucial role in influencing stunting prevention behavior. according to the study’s findings, after pregnant women received assistance, their average knowledge, attitudes, and practices related to stunting prevention significantly improved. these results are consistent with research conducted in the west gojjam zone, ethiopia, which found that pregnant women who received nutrition education were 2.02 times more likely to enhance their dietary practices compared to those who did not receive such education. counseling based on the health belief model and the theory of planned behavior emerges as an effective approach to increasing the proportion of pregnant women who adopt appropriate dietary habits.23 likewise, the outcomes of this study align with the findings from katenga-kauda, where nutrition knowledge and diverse food consumption behaviors improved in both study groups but showed greater improvement in the intervention group. enhanced nutritional knowledge has a notable impact on improving nutritional perceptions and behaviors.14 stunting prevention primarily focuses on improving nutrition during the first thousand days of life, spanning from pregnancy until the child reaches two years of age. this approach can contribute to the optimal growth and development of millions of children, with far-reaching economic benefits in the long term.24 nutrition during the first 1000 days is recognized as pivotal, with significant implications for both maternal and offspring health. inadequate or inappropriate nutrition during this period elevates the risk of premature birth and low birth weight.25 conversely, pregnant women who experience excessive weight gain during pregnancy are at risk of giving birth to larger babies. the first 1000 days of life program highlights that changes in risk factors for obesity during pregnancy correlate with shifts in maternal behavior towards healthier food consumption.26 consequently, nutrition education aimed at fostering long-term healthy eating habits represents a strategic intervention. the assistance provided to pregnant women in this study demonstrates a substantial impact on behavior change regarding stunting prevention, moving in a positive direction. this is also corroborated by research in bangladesh, revealing that counseling mothers using the essential health care (ehc) framework can enhance knowledge and dietary practices related to child feeding, effectively reducing the prevalence of stunting.27,28 the study’s outcomes also align with monitz et al.’s, indicating that pregnant women who received preventive health promotion text messages displayed increased belief and expected behaviors. this suggests that text messages can effectively promote health during pregnancy.29 a mother’s knowledge profoundly influences her decision-making and behavior. mothers equipped with comprehensive knowledge about preventing stunting are more likely to implement effective prevention practices. this concept is further supported by the results of research by yurni and sinaga, demonstrating that a two-week balanced nutrition education program with two meetings led to a 7.7 percent increase in respondents’ practice of selecting a balanced menu.15 intensive nutrition counseling, utilizing leaflet media, emerges as an effective alternative for enhancing the knowledge of pregnant women.16 moreover, the observed behavioral changes in the subjects of this study can be attributed to an increase in knowledge regarding stunting. these findings collectively contribute to the growing body of evidence highlighting the positive impact of educating and counseling pregnant women during pregnancy on improving their knowledge, attitudes, and practices related to stunting prevention.30 this intervention can be efficiently administered through healthcare workers who possess a high potential to enhance maternal and child health, particularly in hard-to-reach rural areas.30,31 these studies underscore the scientific evidence that nutrition and reproductive health education during pregnancy enhance pregnant mother knowledge, attitudes, and practices, thereby contributing to improved maternal and infant health and reduced childhood stunting.18 mother’s level of nutritional knowledge significantly influences her nutritional status, as sound knowledge is closely linked to the selection of a balanced menu.32 knowledge is a pivotal factor predisposing individuals to adopt positive behaviors. by increasing knowledge, people’s behavior can be positively influenced to prevent stunting at an early age. while stunting may have genetic factors, it can also result from poor sanitation and inadequate nutritional intake during pregnancy. genetics or heredity accounts for 26% of the risk factors.33 the tendency to attribute a child’s short stature to genetics can sometimes lead to inaction, when in fact, the condition may be [page 54] [healthcare in low-resource settings 2023; 11:11728] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. the effect of pregnant mother assistance on stunting prevention behavior. behavioral domain mean ± sd p pre post knowledge 9.59 ± 4.89 12.8±2.88 0.00* attitude 7.91 ± 2.84 10±0.00 0.00* action 7.84±2.61 8.19±2.38 0.014* *p<0.05. non -co mmerc ial us e o nly stunting, which necessitates intensive medical intervention. early prevention of stunting, even during pregnancy, can be achieved by meeting nutritional needs from pregnancy until the child reaches two years old (the first 1000 days of life) while monitoring their growth. the maternal nutritional status during pregnancy directly affects the growth and development of the fetus, with food utilization, absorption, and utilization impacting the outcome.34,35 maternal nutrition is a critical factor during pregnancy, with healthy pregnant women who do not experience nutritional disorders before or during pregnancy giving birth to larger and healthier babies compared to those with nutritional disorders. chronic undernutrition contributes to the birth of stunted children.36 researcher asserts that providing assistance to pregnant women can indeed lead to changes in mothers’ behaviors regarding stunting prevention from pregnancy onwards. specific nutrition interventions, such as micronutrient supplementation and additional food for pregnant women, alongside counseling and education on regular pregnancy checks and the consumption of healthy and nutritious foods, represent effective strategies in this regard. conclusions in summary, this study underscores the significant impact of mentoring on pregnant women’s knowledge, attitudes, and actions in preventing stunting. it aligns with existing evidence highlighting the vital role of education, counseling, and support in promoting positive maternal behaviors related to stunting prevention, starting during pregnancy. in essence, this research illuminates a path toward healthier futures for both mothers and their children. recognizing the pivotal role of mentorship and targeted interventions, we can pave the way for improved maternal and infant health, reduced childhood stunting, and ultimately contribute to the overarching goal of fostering healthier communities and societies. references 1. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j global pharma technol 2020;12:815-25. 2. taqwin t, ramadhan k, hadriani h, et al. prevalence of stunting among 10-year old children in indonesia. j global pharma technol 2020;12:768-75. 3. erna. relationship of infant health status and the nutritional status of pregnants women toward incidence of stunted in children age 12-24 months in region puskesmas mersam in batanghari district 2015. scientia journal 2015;4:222-30. 4. kementerian kesehatan ri. data and information center of the ministry of health of the republic of indonesia: situation of short toddlers south jakarta; 2016; 2016. 5. nadhiroh sr, micheala f, tung seh, kustiawan tc. association between maternal anemia and stunting in infants and children aged 0-60 months: a systematic literature review. nutrition 2023;115. 6. abidanovanty fm, suryawan a, hendarto h. growth and development on infants aged 0-24 months with a history of low birth weight (lbw) in dr. soetomo general hospital surabaya. indonesian j public health 2023;18:230-41. 7. hanani r. differences in gross motor, fine motor, language and personal social development in stunted children. 2016; 8. das gracas paiva m, souza tol, canon f, et al. stunting delays maturation of triceps surae mechanical properties and motor performance in prepubertal children. eur j appl physiol 2012;112:4053-61. 9. kemenkes ri. the situation of short toddlers (stunting) in indonesia. 2018;1. 10. riskesdas. national basic health research report (2017 riskesdas). jakarta; 2018. 11. dinas kesehatan kaltim. 2017 health profile. samarinda; 2017. 12. nadhiroh sr, micheala f, tung seh, kustiawan tc. association between maternal anemia and stunting in infants and children aged 0-60 months: a systematic literature review. nutrition 2023;115:112094. 13. demilew ym, alene gd, belachew t. effects of guided counseling during pregnancy on birth weight of newborns in west gojjam zone, ethiopia: a cluster-randomized controlled trial. bmc pediatr 2020;20:1-13. 14. katenga-kaunda lz, kamudoni pr, holmboe-ottesen g, et al. enhancing nutrition knowledge and dietary diversity among rural pregnant women in malawi: a randomized controlled trial. bmc pregnancy childbirth 2021;21:1-11. 15. yurni af, sinaga t. the influence of nutrition education on the knowledge and practice of providing a balanced menu for elementary school children. media gizi indonesia 2018; 12:183. 16. daranga e, aminuddin, saidah. development and evaluation of an intensive nutrition counseling program to increase knowledge of pregnant women regarding quality nutrition intake. jurnal keperawatan muhammadiyah bengkulu, 2020;8:51. 17. oktaviani o, sulistyawati r. the effect of assistance for pregnant women on attitudes and behavior changes in stunting prevention. jurnal promosi kesehatan indonesia 2022;17:56-63. 18. diddana tz, kelkay gn, dola an, sadore aa. effect of nutrition education based on health belief model on nutritional knowledge and dietary practice of pregnant women in dessie town, northeast ethiopia: a cluster randomized control trial. j nutr metab 2018;2018. 19. persagi. nutrition counseling: communication process, management, and application of nutritional counseling on various diets. jakarta: penebar plus; 2013. 20. notoadmodjo soekidjo. health promotion and behavioral science. jakarta: rineka cipta; 2014. 21. waswa lm, jordan i, herrmann j, et al. community-based educational intervention improved the diversity of complementary diets in western kenya: results from a randomized controlled trial. public health nutr 2015;18:3406-19. 22. muluye sd, lemma tb, diddana tz. effects of nutrition education on improving knowledge and practice of complementary feeding of mothers with 6-to 23-month-old children in daycare centers in hawassa town, southern ethiopia: an institution-based randomized control trial. j nutr metab 2020;2020. 23. demilew ym, alene gd, belachew t. effect of guided counseling on dietary practices of pregnant women in west gojjam zone, ethiopia. plos one 2020;15:1-15. 24. kemenkes ri. buletin stunting. kementerian kesehatan ri 2020;301:1163-78. 25. pritasari dkk. gizi dalam daur kehidupan. jakarta: kementerian kesehatan ri; 2017. 26. simione m, moreno-galarraga l, perkins m, et al. effects of [healthcare in low-resource settings 2023; 11:11728] [page 55] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly the first 1000 days program, a systems-change intervention, on obesity risk factors during pregnancy. bmc pregnancy childbirth 2021;21:1-10. 27. sudrajad m, qomaruddin mb, nurmala i. influence of attitude toward behavior and subjective norms in predicting intention to provide healthy foods on child stunting under five years old. indian j public health res dev 2019;10:1834-8. 28. mistry sk, hossain mb, arora a. maternal nutrition counselling is associated with reduced stunting prevalence and improved feeding practices in early childhood: a post-program comparison study. nutr j 2019;18:1-10. 29. moniz mh, meyn la, beigi rh. text messaging to improve preventive health attitudes and behaviors during pregnancy: a prospective cohort analysis. j reprod med 2015;60:37882.  30. armini nka, hidayati n, kusumaningrum t. determinants of nutritional status among pregnant women: a transcultural nursing approach. jurnal ners 2020;15:214-21. 31. triharini m, mar’ah has em, nofita g. determinant factors of anemia in pregnancy based on health belief model: a correlational study. jurnal ners 2023;18:50-6. 32. olsa ea, sulastri dae. the relationship between mothers’ attitudes and knowledge of stunting incidents in children just entering elementary school in nanggalo district. jurnal kesehatan andalas 2017;63:523-529. 33. the national team for the acceleration of poverty reduction. 100 priority districts or cities for stunting child intervention. 2017. 34. helmyati s, wigati m, hariawan mh, et al. predictors of poor neonatal outcomes among pregnant women in indonesia: a systematic review and meta-analysis. nutrients 2022;14. 35. flora r, zulkarnain m, hasyim h, ermi n, jasmine ab, tanjung r, et al. effect of nutritional status and protein intake on levels of serum albumin in pregnant women in seluma district. southeast asian j trop med public health 2022;53:630-41. 36. soetjiningsih. child development. edisi 2. jakarta: egc; 2015. [page 56] [healthcare in low-resource settings 2023; 11:11728] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [page 38] [healthcare in low-resource settings 2015; 3:5217] world health organization calls for food safety and prevention of food-borne illnesses saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india introduction globally, food plays a crucial role in ensuring human survival and promotion of optimal health.1 in fact, owing to the consumption of unsafe food, millions of people fall sick and many die. thus, the world health organization (who) in the year 2000 adopted a resolution to acknowledge food safety as a public health priority.1,2 further, who, in collaboration with the food and agriculture organization (fao), monitors the functions of codex alimentarius commission (which formulates international standards for food safety) and of the international food safety authorities network (which provides timely information during food safety emergencies and assists nations in preventing similar incidents).2,3 in addition, who has also developed a global food-borne infections network to promote laboratorybased surveillance and encourage multi-sectoral collaboration.2 a public health concern: food safety the supply and consumption of safe food plays a significant role in not only maintaining health standards of the population but even in supporting the process of continuous development of the nations through supporting the national economy via encouraging trade and tourism activities.1,4 this is primarily because of the globalization and increasing population due to which the demand for a wide range of food items has increased eventually resulting in an increasingly complex and longer global food chain.1,5,6 furthermore, over a period of time due to the urbanization, changes in consumers’ habits and increase in travel, a greater number of people is buying and consuming food items which are prepared in public places.1,5 definitive evidence is available to suggest that consumption of unsafe food can propagate the vicious cycle of diarrhoea-malnutritiondiarrhoea, which can significantly affect the nutritional status of the population.4 it is very important to understand that although food contamination can occur at any level of food chain, the majority of the food-borne illnesses precipitate owing to the improper preparation/handling of the food items.4,5 in fact, results of the various epidemiological studies have concluded that a massive gap exists in the knowledge and practice of food handlers working in food establishments.7,8 food-borne illnesses globally, it has been identified that an excess of 200 diseases results because of consumption of contaminated food or water accounting for deaths of almost 2 million individuals on an annual basis.5,9 a large number of food-borne outbreaks has been reported across different parts of the world both in nondeveloped and developed nations, most recently being the german outbreak of escherichia coli attributed to the consumption of contaminated fenugreek sprouts.10 identified shortcomings although the policy makers and international agencies are aware of the after-effects of unsafe food, yet the stakeholders have failed to ensure food safety throughout the food chain.1,4 this has been attributed to the presence of multiple challenges, like the following. first, increasing internationalisation and complexity of the food supply chain. owing to the internationalization of trade/tourism and complex nature of food chain, the food contamination can occur at various different stages before it is actually consumed. second, emergence of resistance. due to the misuse (under/overuse) of antimicrobials in the fields of agriculture and animal husbandry, emergence of antimicrobial resistance has been observed across the globe. the problem gets further aggravated when humans consume animal foods enabling transmission of resistant bacteria to themselves and thus compromising their health standards. third, absence of integration with other national policies. even today, a major proportion of who member states have not prioritized integration of food safety with other programs to provide a smart solution to the problem of food-borne illnesses. in fact, even at administrative levels, varying extents of fragmentation have been observed among the food safety authorities. fourth, absence of multi-sectoral cooperation. in order to ensure food safety and prevent food-borne illnesses, it is a must that all the responsible sectors should work in an integrated manner. however, multiple lacunae and lack of coordination have been observed, which have significantly delayed the overall progress of ensuring universal food safety. fifth, lack of resources. in most of the settings, lack of resources (such as absence of a holistic surveillance mechanism to identify and notify cases of food-borne resources, limited financial support, minimum number of trained staffs or awareness campaigns, etc.) has also influenced the efforts of stakeholders. sixth, population growth. in view of the continuous rise in human population, food supply demand has progressively increased and thus serious concerns have emerged regarding food safety. seventh, climate changes. due to the deterioration of the climate over the last couple of decades, the practices of food production, storage and distribution have become quite demanding.1,4-6,9 suggested measures owing to the global impact of food safety and universal nature of food-borne illnesses, the need of the hour is that policy makers healthcare in low-resource settings 2015; volume 3:5217 correspondence: dr. saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com contributions: ss, conception and design, drafting of the article, review of the literature, guarantor; ps, drafting of the article, review of the literature, revising the paper critically for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interest: the authors declare no potential conflict of interest. key words: food safety; food-borne illnesses; world health organization. received for publication: 5 april 2015. revision received: 14 july 2015. accepted for publication: 18 july 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. r. shrivastava et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5217 doi:10.4081/hls.2015.5217 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5217] [page 39] should establish appropriate food systems and infrastructures to address any food safety risks along the complete food chain; encourage coordination between multiple sectors; and adopt strategies to enable integration of food safety with other food policies.1,5 further, all the parties involved in the food chain should adhere to their responsibility to maintain food safety.1,4 at the same time, food handlers/consumers should take efforts to get accustomed to the food they use so that they can make an informed food choice, and should handle food safely or grow fruits and vegetables all according to the recommendations made by the who.1,4,5 finally, strategies like empowering women through food safety education in senegal or sensitizing students in school regarding safe food as evidenced in haiti, can be implemented in various parts of the world to make food safe.11,12 support by the world health organization the world health organization (who) has called for both global prevention of food-borne illnesses, and establishment of an effective public health response to facilitate prompt detection of food-borne illnesses.1,5 in-fact, in order to show their commitment, who has adopted food safety: from farm to plate, make food safe as the theme for the year 2015.13 subsequently, the organization has devised five keys to safer food (viz. keep clean; separate raw and cooked; cook thoroughly; keep food at safe temperatures; and use safe water and raw materials) at home/hotels/markets, and five keys to growing safer fruits and vegetables (viz. practice good personal hygiene; protect fields from animal faecal contamination; use treated fecal waste; evaluate and manage risks from irrigation water; and keep harvest and storage equipment) for those who usually do not have access to food safety education, in order to promote health by decrease microbial contamination.14,15 by ensuring compliance with the above measures thousands of food handlers, including consumers, are empowered to prevent food-borne diseases and thus they can play an important role in safe food supply.14,15 moreover, who is assisting nations to ensure the prevention, detection and appropriate management of food-borne risks in accordance with the guidelines developed by the codex alimentarius.1,5 however, various nations have adopted these guidelines because of the law proposed by the world trade organization. in fact, there is a provision that nations can even adopt other standards provided they can justify these differences by means of a risk assessment. in addition, who has played a remarkable role in evaluating the safety of newer technologies employed in food production, in strengthening the national food systems and legal framework, and in obtaining the precise estimate of the global burden of food-borne diseases.1,5 conclusions to conclude, owing to the complex nature of food supply chain, it is high time that all the concerned stakeholders should work in coordination as proposed by the world health organization to ensure global food safety and thus prevent cases of food-borne illnesses. references 1. chan m. food safety must accompany food and nutrition security. lancet 2014;384:1910-1. 2. fukuda k. food safety in a globalized world. b world health organ 2015;93:212. 3. world health organization. infosan in action in the americas; 2014. available from: http://www.who.int/foodsafety/areas 0_work/infosan/en/#story-02 4. world health organization. 10 facts on food safety; 2015. available from: http://who.int/features/factfiles/food_safety/en/ 5. world health organization. food safety fact sheet n°399; 2014. available from: http://who.int/mediacentre/factsheets/fs39 9/en/ 6. anderson j, bogart n, clarke a, et al. food safety management in the global food supply chain. perspect public heal 2014;134:181. 7. brown lg, le b, wong mr, et al. restaurant manager and worker food safety certification and knowledge. foodborne pathog dis 2014;11:835-43. 8. bobhate ps, r shrivastava s, gupta p. profile of catering staff at a tertiary care hospital in mumbai. australas med j 2011;4:148-54. 9. world health organization. how safe is your food? 2015. available from: http://who.int/campaigns/world-healthday/2015/en/ 10. biliński p, kapka-skrzypczak l, posobkiewicz m, et al. public health hazards in poland posed by foodstuffs contaminated with e. coli o104:h4 bacterium from the recent european outbreak. ann agr env med 2012;19:3-10. 11. world health organization. empowering women through food safety education; 2015. available from: http://who.int/foodsafety/areas_work/food-hygiene/empowered-women/en/ 12. world health organization. haiti: safe food in rural schools; 2015. available from: http://www.who.int/features/2015/haitifood-safety/en/ 13. world health organization. world health day 2015: food safety; 2015. available from: http://who.int/foodsafety/en/#story02 14. world health organization. food safety. the five keys to safer food programme; 2015. available from: http://who.int/foodsafety/areas_work/food-hygiene/5keys/en/ 15. world health organization. five keys to growing safer fruits and vegetables: promoting health by decreasing microbial contamination. geneva: who press; 2012. editorial non co mmerc ial us e o nly hrev_master the magnitude of perinatal mortality rate and associated risk factors among deliveries at dilla university referral hospital, southern ethiopia: a case-control study kefale lelamo legu, alemu tamiso debiso, kaleb mayisso rodamo hawassa university college of medicine and health sciences, hawassa abstract the perinatal mortality rate is the sum of stillbirths and early neonatal deaths divided by the number of pregnancies of seven or more months’ duration. in ethiopia, the death rate was 33 deaths/1000 total births in 2016. we aimed to identify the perinatal mortality rate and associated risk factors among deliveries in dilla university referral hospital; january, 2016 december, 2018. a hospital based retrospective case-control study was conducted using subgroup binary logistic regression analysis including 138 cases and 296 control group. the proportion of hospital perinatal deaths was 30% with 90% of the deaths were occurred as a result of stillbirths and antepartum hemorrhage. adjusted odds ratios revealed that history of still birth, very low birth weight, short interval and nonuse of partograph found to be independent predictors of both stillbirths and early neonatal deaths besides to pregnancy induced hypertension and antepartum hemorrhage. the risk of perinatal mortality may be increased by not treating chronic illnesses, obstetrics complications and risk factors causing low birth weight as well as short birth intervals and not using partograph during labour. introduction the perinatal mortality rate is defined as the sum of the number of perinatal deaths (stillbirths and early neonatal deaths/ennd) divided by the number of pregnancies of seven or more months’ duration (all live births plus stillbirths). pmr is determined by the distinct features of antepartum, intra partum, and neonatal periods (a death in the first seven days of a child born alive). stillbirth is intrauterine death occurs either before onset of labour (antepartum death) or during labour (intra partum death) and classified as a fetal deaths ≥28 weeks gestation, weight of ≥1000 grams or a body length of ≥35 cm.1-3 annually 2.5 million neonatal deaths and 2.6 million stillbirths occur globally4,5 of which 1.3 million are intra partum stillbirths; and 41% of new-born deaths. 70% of stillbirths could be averted with an integrated cost effective antenatal and essential obstetric care.1,3,5 perinatal death assumed to be an important public health problem and key indicator of poor health status in low income settings where the death is maintained in very high rates. birth asphyxia, birth injury, preterm low birth weight, birth interval of <2 years, young maternal age at birth, low level education, poor maternal nutrition, absence of antenatal care (anc) and complications during labour were primary causes initiating the cascade of perinatal death.6,8 in ethiopia, the pmr was 33 deaths/1000 pregnancies of seven or more months’ duration (30 still births and 29 neonatal deaths), despite neonatal deaths shown a reduction of 17% over the past 5 years with significant disparities per 1,000 live births of 43 pmr in rural and 41 pmr in urban settings.9,10 in the southern region, threefold of the national figure was reported, with pregnancy induced hypertension (pih) being a single most important risk factor and obstructed labor accounted for 26 % of hospital deaths with 50% of still births and 2-5 folds of ennd.10,11 to the authors’ knowledge, data on the rate of perinatal deaths were very old and were obtained from urban residents rather than from remote population where the rate and the risk factors of perinatal deaths were poorly documented.12 hence, the study aimed to assess the rate and risk factors associated with perinatal mortality so as to fill the existing gap of data and knowledge using local epidemiological study findings of these kinds and to establish a foundation of knowledge and understanding. materials and methods study site a hospital based case-control study was conducted from april 1st-30th, 2019 at dilla university referral hospital (durh); a referral hospital for gedeo zone where the total population is estimated to be 1 million, as extrapolated from the 2007 national census. the hospital was selected based on availability of both delivery and neonatal intensive care units. study population all deliveries conducted from january healthcare in low-resource settings 2021; volume 9:9960 correspondence: kaleb mayisso rodamo, hawassa university college of medicine and health sciences, p.o box 1560, hawassa. tel.: +251.919532392 fax: +251.0462208755 e-mail: kalebmayisso@gmail.com key words: perinatal death; case-control study; ethiopia. acknowledgments: we are very grateful to the college of medicine and health sciences, hawassa university, for funding the research. contributions: kll contributed to conduct interviews, to the conception or design of the work; or the acquisition, analysis, or interpretation of data for the work, kmr contributed to drafting the work or revising it critically for important intellectual content; writing the manuscript, final approval of the version to be published and atd contributed as content expert and to manu-script editing, to ensure the accuracy or integrity of any part of the work are appropriately investi-gated and resolved. all authors read and approved the final manuscript. conflict of interests: the authors have no conflicts of interest to declare. further information: this work was supported by a budget for a student research of college of medicine and health sciences, hawassa university. availability of data: all data generated or analyzed during this study are included in this the arti-cle. ethics approval and consent to participate: ethical approval and clearance were obtained from institutional review board of hawassa university, college of medicine and health sciences. since this analysis used entirely registered data, there was no need of obtaining informed written consent. therefore, verbal informed consent was obtained from the mothers using telephone call to prove that discharged neonates were alive up to 7 completed days. the consent was incorporated with consideration of the right of volunteer participation and consent based subject’s best interest to participate in the research, both initially and during the course of the research based on helsinki’s declaration. moreover, the consent was approved by the institutional review board of hawassa university, college of medicine and health sciences. received for publication: 7 august 2021. revision received: 23 november 2021. accepted for publication: 29 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9960 doi:10.4081/hls.2021.9960 [healthcare in low-resource settings 2021; 9:9960] [page 39] 1st 2016 – december 30th 2018 were used as a source population. fetal deaths at 28 complete weeks of gestation and live newborns died in the first week of life were used as cases, while control group were newborn delivered alive who did not die before the age of first seven days of life. all medical charts with incomplete records and referred from others institution because of associated complications were excluded. the minimum required sample size was calculated using single proportion formula in a population as described in open epiinfo 2002, version 3, open source calculator.13 we assumed 54.3% frequency of the coexisting newborns low birth weight, one of the factors strongly associated with perinatal mortality from the study conducted in addis ababa public hospitals, with adjusted odds ratio (aor) of 16.45; 95% ci (9.57–28.26).12 the value of 95% confidence interval (ci), power of 80% (1b) and 5% margin of error; and a nonresponse rate of 15% and a control to case ratio of 2:1, an estimated sample size of 438 (138 cases and 300 control group) sufficient to determine associated factors. from 2016-2018 delivery reports, cases were traced systematically using delivery, operation and neonatology log books of the hospital. for each case, 2 other babies delivered in the same day as the cases, one before and one after each case, were selected and prepared based on inclusion criteria. for subgroup analysis, the matching of cases in the control group was changed from 1:2 in the total cases to control to 1:2.4 in stillbirth to control and to 1:20 in ennd to control group. variables outcome variables: this study selected the perinatal death as an outcome variable which is categorized as “yes” for who experienced still birth or ennd and “no” for did not experienced still birth or ennd. the independent variables selected for the purpose of analyses were: socio-demographic variables: age of the mother: the mother’s age at child birth and categorized as: i) less than 18 years, 18–34 years, and 35–49 years; ii) family size: based on the number of family members and dichotomized as small, medium and large family: iii) maternal education: categorized as: no education, elementary education, and higher education; iv) marital status of the mother, dichotomized as currently married and not married; v) house hold wealth: was dichotomized as low, medium and high wealth scores; vi) place of residence: was dichotomized as rural or urban residences; vii) maternal occupation: was categorized as: house wife, employed, daily laborer and farmer; and viii) the household’s religion was dichotomized as: protestant, orthodox or muslim. maternal obstetric conditions: obstetrics complications associated with pregnancy, labor and child birth were: i) aph, multiple pregnancy, premature rupture of membrane, prolonged and obstructed labor, cord accidents and pih; ii) parity of the mother: categorized as primiparous, multipara and grand multipara; iii) pregnancy intention: based on women’s self-reports of their desire to become pregnant right before the conception occurred was categorized as: intended, mistimed or unwanted. previous history of perinatal death: was categorized as: i) still birth, early neonatal death and no history of perinatal death; ii) history of abortion, both spontaneous and medically induced termination of pregnancy before the 28th week of gestation and dichotomized as yes (ever experienced)/no (never experienced); iii) fetal presentations: was trichotomized as vertex, breech and transverse; iv) mode of deliver: was trichotomized as spontaneous vaginal delivery, caesarean section and instrumental delivery; and v) antenatal follow up and use of partograph were dichotomized as yes/no. coexisting medical conditions of the mothers: i) history of chronic illnesses: diabetes mellitus, renal and cardiac diseases; ii) tuberculosis, hiv/aids and malaria were considered as common infectious diseases; and iii) maternal anemia: we trichotomized based on hemoglobin level of first, second and third trimester of pregnancy as severe anemia, moderate anemia, mild anemia and no anemia. fetal and newborn conditions: i) gestational age of the new born: was calculated from the last menstrual period and categorized as: preterm, term and post term neonates; ii) duration of the labor: was categorized based on the length for the stage of labor as: 12 hour-19 hour-normal first stage, >20 hour -prolonged first stage20 min-2 hours-second stage labor, and third stage5 hour-30 hour; iii) weight at birth: was categorized as smaller than average, average and larger than average; iv) newborn apgar score: was generally done at 1st and 5th minutes after birth and categorized based on the scores as: normal, fairly low and critically low; v) birth interval: was dichotomized as preceding interval < 2 years and preceding interval 2 or more years; vi) birth order, was trichotomized as: first/second-born, thirdborn, and fourth/higher order born; vii) neonatal sepsis: dichotomized based on the time of presentation after birth as earlyonset sepsis and late-onset sepsis; viii) birth asphyxia: dichotomized into two grades of severity, pale asphyxia and acute asphyxia; and ix) neonatal anemia: trichotomized based on hemoglobin level as severe anemia, moderate anemia, and mild anemia. data collection two midwives who were trained for 5 days collected the data so that mothers would be comfortable to discuss reproductive health matters that they may not be comfortable to discuss with men. a phone call was made to prove that the discharged neonates were alive up to 7 completed days after verbal informed consent was obtained. for a neonate discharged alive and died before seven completed days, the next alive neonate was taken as a control group. the mother was taken as a non-respondent if she didn’t respond to a phone call or if she was not available. social, demographic and economic data of the households were taken from admission register and medical log books. all data of fetal and neonatal conditions such as birth weight, gestational age of the neonate etc. and coexisting medical and obstetrics conditions were obtained from antenatal records, maternal admission register and log books, delivery and labor summary of the mother, ultrasonography records and medical records of neonates. data analysis the data were coded, checked and article table 1. distribution of perinatal deaths (cases) and control group by year of study, dilla univer-sity referral hospital, ethiopia, 2016-2018. year 2016 2017 2018 total total babies born 398 538 688 1624 cases 36 43 59 138 control group 74 98 128 300 pmr 90 86 86 85 stillbirths 35 38 50 123 ennd 4 5 6 15 sb to ennd ratio 9:1 8:1 8:1 8:1 pmr= perinatal mortality rate, ennd= early neonatal death, sb to ennd ratio= still birth to early neonatal death ratio. [page 40] [healthcare in low-resource settings 2021; 9:9960] entered using epi-info version 7 and exported into spss version 22.0 computer software programs for analysis. still-birth, perinatal and ennd death rates were calculated using descriptive statistics and cross tabulation. bivariate logistic regression analysis was conducted to measure the association between the dependent and independent variables and those variables associated with significance level of p value <0.05 were transferred into multivariate logistic regression model to identify the important determinants by controlling possible confounders, and the strength of association was measured using or with 95% ci of a p value <0.01. a total of 10 dichotomous household asset variables were involved to generate wealth index using principal component analysis. according to the index, households were divided in to quintiles ranging from the poorest 50% to the richest 2%. results in a period of three years, a total of 1624 deliveries of all types were registered with a perinatal deaths of 138 (123 stillbirths and 15 ennd); and overall pmr of 85 per 1,000 total pregnancies of 7 or more months’ duration (table 1). still-births accounted for more than two-third (67%) of the mothers admitted to the hospital due to fetal deaths. among the hospital admissions due to fetal deaths, thirty mothers were admitted with positive fetal heartbeats and reported as hospital stillbirths later on. the proportion of hospital deaths, the death of fetus recorded as “alive” on admission and later on reported as stillbirths plus ennd new borne babies died in the hospital before seven days of life were a quarter (33%) of a total perinatal deaths. antepartum hemorrhage (aph) contributed for about 44% of overall perinatal deaths, 40% of the hospital perinatal deaths and 53% of ennd (table 2). the majority (91%) of the mothers in the cases and 270 (90%) in the control groups were married and (96%) of the mothers in the cases and 57% in the control groups were rural dwellers with the literacy rate of 50% in both the groups. because of only 10 and 11% of the mothers in cases and in control group respectively were employed, 62% of them in the cases and 56% in the control group lied with in low wealth quintiles (table 3). the study demonstrated 22% of the mothers in the control group and 20% in the cases were primiparous and least (9%) of the mothers in cases had planned for the current pregnancy. more than three-fourth of the mothers in the control group had anc follow up and two-third used partograph during the labor. nearest to threefourth of the mothers in the cases had not anc follow up and more than three-fourth were not used partograph during the labor. the majority (96%) of the mothers in the control group and in the cases (82%) experienced vertex presentation and more than article table 2. the proportion of perinatal deaths before and after arriving at the hospital by type of ob-stetric complications, dilla university referral hospital, ethiopia, 2016-2018. obstetric complication total cases stillbirths before arrival hospital deaths (n) stillbirths ennd number % number % number % number % pih 61 44 41 44 12 40 8 53 aph 61 44 39 42 16 53 6 40 obstructed labor 6 4 4 4 2 7 0 0 prom 5 4 5 5 0 0 0 0 mal-presentation 2 1 1 1 0 0 1 7 cord accident 3 2 3 3 0 0 0 0 total 138 93 30 15 ennd=early neonatal death, aph=antepartum hemorrhage, pih= pregnancy induced hyperten-sion, prom=premature rapture of membrane. table 3. socio economic and demographic variables of the mothers, dilla university referral hospital, ethiopia, 20162018 (n=438). cases (n=138) control group (n=300) number percent number percent marital status currently married 125 91 270 90 currently single 13 9 30 10 occupation house wife 96 69 240 80 employed 12 9 34 11 daily labor 18 13 10 3 farmer 12 9 12 4 house wife 96 69 240 80 residences urban residents 15 11 128 43 rural residents 133 96 170 57 maternal education no education 72 52 157 52 primary education (1-6) 53 38 106 35 secondary education (7+) 13 10 37 12 wealth quintiles low wealth score 85 62 168 56 medium wealth score 35 25 90 30 high wealth score 18 13 42 14 family size small family (2-4) 8 6 15 5 medium family (5-10) 50 36 185 62 large family (>10 m) 80 58 100 33 [healthcare in low-resource settings 2021; 9:9960] [page 41] [page 42] [healthcare in low-resource settings 2021; 9:9960] three fourth in the cases delivered by spontaneous vaginal deliver (svd) and the remaining delivered with caesarean section and instrumental deliveries. 90% of the mothers in the control group and 84% in the cases had no previous history of abortion and 86% of them in cases and 98% in control group had no previous history of perinatal deaths (table 4). the mean age in the case of perinatal deaths was 26.5±6.3 and 27±5.8 years in the control group. among 132 (96%) of the cases of perinatal deaths who experienced single gestation, 76 (55%) had given birth to their first babies. close to 88% of the cases of perinatal deaths had smaller than average weight at birth and only two new borne were weighing 2500-3999 grams. more than two-third of the new borne in the control group had average birth weight and 10% weighted more than 4000 grams. more than three-fourth of the cases in perinatal deaths had delivered at an interval of less than two years of preceding birth while the majority (93%) in the control group had delivered at an interval of more than two years of preceding birth. gestational age at delivery in two-third of the cases was term and 7% were post-term; and three-fourth of the cases of the perinatal death had prolonged labor. gestational age at deliver in the majority (92%) of the control group were at term and 3% were post term; and only 3% of the control group had 25-48 hour’s median duration of labor. the majority (92%) of the cases in neonatal death had critically low apgar score during 1st minutes and 3% had seven and above apgar score during 1st.minutes. similarly, 94% of the cases in neonatal deaths had critically low apgar scores during 5th. minutes. threefourth of the cases in neonatal deaths had a hemoglobin level of <70 g/l whereas similar proportion of the control had a hemoglobin level of 110-90 g/l. seventy four (54%) of the cases in neonatal deaths had developed early onset neonatal sepsis and 8% had developed neither types of neonatal sepsis. three-fourth of the cases in neonatal deaths had developed severe asphyxia and the least (8%) had neither types of neonatal asphyxia (table 5). the majority 88% of the mothers of the cases of perinatal deaths had previous history of chronic medical illnesses and 12% had no previous history of the illnesses. majority of the mothers’ were negative of hiv/aids infection in the cases and in the control group whereas neither of the mothers in both the cases and in the control group was positive of hepatitis b virus infection. the least (16%) of the mothers in the cases were reactive for venereal disease research laboratory (vdrl). nearest to two-third of the mothers in the cases had not ever infected either with malaria or tuberculosis (table 6). the association of obstetric conditions and perinatal deaths as cases was tested in binary and multiple logistic regression analysis. those obstetrics conditions shown significant association in crude analysis with a p-value of <0.05 had been transferred to multivariate logistic regression model for adjusted analysis to rule out possible confounding factors. adjusted analysis showed that ennd was highest among mothers who had short birth interval (<2 years between births) (aor = 0.37, 95% ci: 0.17–0.82), a p value <0.01, than mothers who had birth interval of >2 years. very low birth weight newborns had 1.9 times increased risk of ennd (aor=0.19, 95% ci: 0.06-0.52), a p value <0.01, than normal weight newborns. babies born to women with history of chronic illness showed 0.2 times higher odds of still births (aor=0.13, 95% ci: 0.05-0.33), a p value <0.01 than babies born to women with no history of chronic illness. labor not followed up with pantographs had 0.1 times higher odds of still births (aor=0.10, 95% ci: 0.03– 0.26), a p value <0.00, as compared to labor followed up with pantographs. in subgroup analysis, aph (aor=0.03, 95% ci: 0.010.02), a p value <0.01 and pih (aor=0.02, 95% ci: 0.01-0.03), a p value<0.00 had higher risk of still births more than other obstetrics complications including obstructed labour, cord accident and premature rapture of membrane (table 7). article table 4. obstetrics characterstics of mothers, dilla university referral hospital, ethiopia, 20162018. obstetric variables cases (138) control group (300) no. % no. % age <18 years 16 12 23 8 18-34 years 98 71 232 77 35-49 years 24 17 45 15 pregnancy intended 12 9 260 87 mistimed 89 64 30 10 unwanted 37 27 10 3 anc follow up yes 37 27 231 77 no 101 73 69 23 partograph used yes 27 20 194 65 no 111 80 106 35 parity i 100 72 213 71 ii-iv 27 20 67 22 v+ 11 8 20 7 fetal presentation vertex 113 82 287 96 transvers 13 9 5 1 breech 12 9 8 3 mode of delivery svd 107 78 258 86 c/s 21 15 36 12 instrumental 10 7 6 2 history of abortion yes 22 16 31 10 no 116 84 269 90 history of perinatal deaths still births 4 3 6 2 ennd 15 11 0 0 no history 119 86 294 98 [healthcare in low-resource settings 2021; 9:9960] [page 43] article table 5. fetal and newborn characteristics, dilla university referral hospital, ethiopia, 2016-2018. variables cases (138) control group (300) no. % no. % number of gestation single 132 96 293 98 multiple 6 4 7 2 birth weight in grams 1000-1499 128 92.7 14 4 1500-2499 8 5.7 56 19 2500-3999 2 1.4 200 67 ≥4000 0 0 30 10 birth interval <2 years 128 92.7 21 7 >/=2 years 10 7.2 279 93 birth order first 76 55 126 42 second & third 32 23 137 46 fourth/higher 30 22 37 12 gestational age preterm 91 66 10 3 term 38 28 275 92 post term 9 6 15 5 duration of labor 12 -19 hours 8 6 250 83 >20 hours 23 17 42 14 25-48 hours 104 75 8 3 5-30 hours 3 2 0 0 apgar score at 1st minute 3 & below 127 92 0 15 4 to 6 7 5 44 65 7 & above 4 3 256 85 apgar score at 5th minute 3 & below 130 94 2 1 4 to 6 7 5 26 8 7 & above 1 1 272 91 neonatal anemia sever 103 75 10 3 moderate 22 16 68 23 mild 13 9 222 74 new born sepsis early onset 74 54 4 1.3 late onset 53 38 2 0.6 no sepsis 11 8 294 98 birth asphyxia sever asphyxia 104 75 0 0 acute asphyxia 22 16 5 2 no asphyxia 12 8 295 98 table 6. coexisting medical characteristics of the mothers, dilla university referral hospital, 2016-2018. variables cases (138) control group (300) no. % no. % *history of chronic illness yes 121 88 28 9 no 17 12 272 91 history of hepatitis b-virus positive 1 1 0 0 negative 137 99 300 100 vdrl status reactive 22 16 26 9 non-reactive 116 84 274 91 hiv/aids positive 11 8 13 4 negative 127 92 287 96 malaria infection yes 56 41 120 40 no 90 65 180 60 tuberculosis infection yes 45 23 14 5 no 93 67 286 95 maternal anemia severe 63 45 12 4 moderate 33 24 23 8 mild 30 22 102 34 no anemia 12 9 163 54 *chronic illness (diabetes mellitus, renal disease, cardiac disease). [page 44] [healthcare in low-resource settings 2021; 9:9960] discussion in this analysis of the hospital dataset, we found that perinatal deaths were adversely associated with a number of obstetric outcomes during perinatal period. we observed that the pmr was nearly three-fold of the national pmr estimated for 2016, ethiopia demographic and health survey (edhs).10 the possible explanations of the differences in the pmr were the variation in the scope of the studies and the level that the results were inferred for. however, the finding was almost comparable with the hospital-based studies conducted in different parts of ethiopia. the main reason for increased rate of perinatal mortality in both studies is probably because most of the mothers of the cases came very late and with serious obstetric complications and mechanical causes, mainly obstructed labor with or without uterine rupture. therefore, perinatal mortality is highly prone for overestimation in hospital based studies.11-14 but, the pmr in this study was found to be high as compared to population-based studies conducted in north and northwest ethiopia.15,16 we observed that birth interval of <2 years, low birth weight, nonuse of partograph and history of chronic illness found to had significant association with both still births and ennd. the findings were comparable with the findings from edhs, 2016 where the causes of stillbirths and early neonatal deaths were closely linked.9 however, predictive models analysis of population based prospective cohort study in low and middle income countries disagreed with the current findings: gestational age at enrollment, maternal age, birth order, parity hypertension, and severe pre-eclampsia, or eclampsia found to be important predictors of intra partum stillbirth in the prenatal and pre-delivery.17 our result suggested that birth interval <2 years had 0.037 times greater risk of perinatal deaths in comparison to birth interval of more than two years. this is in line with the finding of the longitudinal study conducted in northwest ethiopia.16 too many closely spaced pregnancies is a phenomena related to sibling competitions recognized as the maternal depletion syndrome,18 and associated with premature rupture of membranes and puerperal endometritis which can cause perinatal deaths.19 low birth weight was found to be 0.19 times at higher risk of neonatal death [aor 0.19; 95% ci (0.02-0.052)] in comparison to normal birth weight. this is consistent with retrospective study conducted in india,20 and predictive models analysis of population based prospective cohort study in low and middle income countries where birth weight was the most important variable for predicting the risk of neonatal mortality that provided the strongest evidence that the risk of mortality increased with decreasing in birth weight in both the delivery/day 1 and post-delivery/day 2 scenarios. aph in the predictive models analysis of population based prospective cohort study in low and middle income countries was the most important predictor of neonatal deaths. the finding is consistent with the current study in which aph had 0.03 times high risk of perinatal deaths [aor 0.03; 95% ci (0.01-0.023)].17 however, the finding of the current study was inconsistent with the findings of the study conducted in addis ababa public hospitals.10,11 the study demonstrated follow up of labor with pantographs had protective effect of 10% [aor 0.10; 95% ci (0.01-0.02)] against perinatal death than not followed up with pantographs. the finding is consistent with perinatal death audit carried out in semiurban hospital in kampala, uganda where updates on use of pantographs reduced a deaths rate by 5 per 1,000 total births after introduction of the audits compared to the death rate before the audit.21 the cases of perinatal deaths who were suffered from pih and having a history of chronic illness had 0.02/ 0.13 times higher risk of perinatal deaths [aor 0.02; 95% ci (0.01-0.033)] and [aor 0.13; 95% ci (0.05-0.33) than their counter parts respectively. the findings were consistent with the study conducted in odisha, india, which demonstrated ranges of fetal pregnancy outcomes: fetal deaths that were occurred as a result of fetal complications including a low birth weight, preterm birth and intra uterine growth retardation resulted in acidosis and less oxygen supply to fetus. in addition, some pre-eclamptic cases lead to severe preeclampsia associated with various maternal complications including the risk of stroke; kidney and liver dysfunction.22 conclusions low birth weight, birth interval <2 years, previous history of chronic illness, aph and pih were identified as increasing the risk of perinatal deaths. however, following labor with partograph was identified as decreasing the risk of perinatal deaths. birth interval of <2 years resulted from nonuse of modern contraceptive and poor quality of intra partum care reflected by nonuse of partograph for labor follow up article table 7. factors associated with perinatal mortality (still births and early neonatal deaths), dilla university referral hospital, ethiopia, 2016-2018. variables perinatal deaths (138) 95% ci for 95% ci for p-value still births (123, %) ennd (15, %) (cor) (aor) birth interval in years >2 5 (4.1) 5 (33.3) 1 1 <2 118 (95.9) 10 (66.6) 0.23(0.13-0.21) 0.037 (0.17-0.82)** 0.01 chronic illness yes 121 (98.4) 9 (60) 4.89(0.19-0.29) 0.13 (0.05-0.33)** 0.00 no 2 (1.6) 6(40) 1 1 birth weight in gram 1000-1499 121 (98.4) 12(80) 0.13(0.07-0.27) 0.19 (0.06-0.52)** 0.00 >2500 -3999 2 (1.6) 3(20) 1 1 use of parto-graph yes 2 (1.6) 1(6.7) 1 1 no 121(98.4) 14 (93.3) 0.08 (.04-.17) 0.10 (0.03-0.26)** 0.00 obstetric com-plications aph 55(45) 6(40) 0.07(0.02-1.23)* 0.03(0.01-0.023)** 0.02 mal-presentation 2(2) 0(53) 1 1 pih 53(43) 8(53) 0.09(0.01-1.33)* 0.02(0.01-0.033)** 0.00 mal-presentation 2(2) 0(20) 1 1 1: indicates the reference categories*: indicates significant association (p-value < 0.25. **: indicate highly significant association (p-value <0.05). [healthcare in low-resource settings 2021; 9:9960] [page 45] are the important determinant factors for perinatal loss. the study suggests that the risk of perinatal deaths could be improved by early investigation of pregnant mothers during anc follow up. appropriate monitoring of labor using partograph, immediate newborn care and interventions to prolong birth interval could be resulted in significant reductions of perinatal mortality. lots of ennd caused as a result of low birth weight and could be averted by optimizing immediate newborn care and neonatal resuscitation. limitations of the study the hospital record based data was utilized in addition to the participants driven information to overcome the possibilities of recall biases. intra partum and antepartum stillbirth differentiation can be associated with identification errors, but training of the data collectors, several quality checks and subgroup analyses were made to minimize this error. there is a possibility of potential confounders like individual health status and a wide range of sociocultural norms that were not captured. nonetheless, as the study results are based on a sufficient number of participants over 3 years, the potential impact of confounders on the study result should be low. although generalizability of the results could be questioned due to the limited scopes of the data, the results are likely to be pertinent to many of the hospitals similar to those of the study settings. references 1. allanson e, tunçalp ö, gardosi j, et al. classify the causes of perinatal death. world health organization 2016;94:79. available at https://www.researchgate.net/publication/292676625. 2. bradley sek, winfrey w, croft tn. contraceptive use and perinatal mortality in the dhs: an assessment of the quality and consistency of calendars and histories. dhs program, 2015. available from: www.dhsprogram.com/publications/publicationmr17-methodological-reports.cfm. 3. who, usaid, panamerican health organization, et al. latin american center for perinatology women and reproductive health. plan of action to accelerate the reduction of maternal mortality and severe maternal morbidity: monitoring and evaluation strategy. montevideo: clap/wr; 2012. (clap/wr. scientific publication; 1593-02). http://perinatal.bvsalud.org/. 4. unicef. levels and trends in child mortality. un inter-agency group for child mortality estimation. published 2018. accessed september 1, 2020. available from: h t t p s : / / d a t a . u n i c e f . o r g / w p conten t /up loads /2018/10/chi ldmortality-report-2018.pdf. 5. liu l, oza s, hogan d, et al. global, regional and national causes of child mortality in 2000-13, with projections to inform post-2015 priorities: an updated systematic analysis. lancet 2015;385:430-40. 6. richardus jh, graafmans wc, verloove sp, et al. the perinatal mortality rate as an indicator of quality of care in international comparison. medical care 1998;36:54-66. 7. world health organization. the global strategy for women’s, children’s and adolescents’ health (2016–2030): sustanable development goal report, every woman every child 2015. https://www.everywomaneverychild.or g/global-strategy. 8. little ga, keenan wj, niermeyer s, et al. neonatal nursing and helping babies breathe: an effective intervention to decrease global neonatal mortality. newborn and infant nursing reviews 2011;11:82-8. 9. central statistical agency (csa). ethiopia mini demographic and health survey 2014. addis ababa: central statistical agency [ethiopia]. available f r o m : http://www.healthdata.org/ethiopia 10. central statistical agency (csa) ethiopia and icf. the 2016 ethiopia demographic and health survey key findings. csa and icf, addis ababa, ethiopia, and rockville, maryland, usa, 2017. available from: https://dhsprogram.com/pubs/pdf/sr24 1/sr241.pdf. 11. bayou g, berhan y. perinatal mortality and associated factors: a case control study. ethiop j health sci 2012;22:15362. 12. getiye y, fantahun m. factors associated with perinatal mortality among public health deliveries in addis ababa, ethiopia, an unmatched case control study. bmc pregnancy childbirth 2017;17:245. 13. sullivan km, soe mm. sample size for cross-sectional & cohort studies & clinical trials. openepi, 2007. available f r o m : http://www.openepi.com/pdfdocs/ss cohortdoc.pdf. 14. asefa d, muleta g, araya f, et al. pattern of perinatal mortality among deliveries at jimma university teaching hospital, south-west ethiopia. j woman health issues 2016:5:1000252. 15. yirgu r, molla m, sibley l, gebremariam a. perinatal mortality magnitude, determinants and causes in west gojam: population-based nested case-control study. plos one 2016;11:e0159390. 16. andargie g, berhane y, worku a, et al. predictors of perinatal mortality in rural population of northwest ethiopia: a prospective longitudinal study. bmc public health 2013;13:168. 17. shukla vv, eggleston b, ambalavanan n, et al. predictive modeling for perinatal mortality in resource limited settings: original investigation. jama netw open 2020;3:e2026750. 18. david mckinney, melissa house , aimin chen,etal. the influence of interpregnancy interval on infant mortality.am j obstet gynecol 2017;216:316.e1-316.e9. 19. simetka o, michalec i, crkvenjas zn, et al. toxic epidermal necrolysis complicating antibi-otic treatment of puerperal endometritis: a case report. ginekol pol 2015;86:315-7. 20. shilpi srivastava, sanjaya sharma, sushila kharkwal, etal. a study of causes of perinatal mortality in tertiary center in bundelkhand region. int j reprod contracept obstet gynecol 2015;4:4346. 21. nakibuuka vk, okong p, waiswa p, et al. perinatal death audits in a peri-urban hospital in kampala, uganda. afr health sci 2012;12:435-42. 22. jena m, mishra s, jena s, et al. pregnancy induced hypertension & pre eclampsia: pathophysiology & recent management trends: a review. j pharmaceut res allied sci 2016;5:32634. article hrev_master [healthcare in low-resource settings 2013; 1:e7] [page 25] demand for healthcare in india brijesh c. purohit madras school of economics, kottur, india abstract in a developing country like india, allocation of scarce fiscal resources has to be based on a clear understanding of how investments in the heath sector are going to affect demand. three aspects like overall healthcare demand, consumer decisions to use public and/or private care and role of price/quality influencing poor/rich consumer’s decisions are critical to assessing the equity implications of alternative policies. our paper addresses these aspects through examining the pattern of healthcare demand in india. data from the national family health survey are used to model the healthcare choices that individuals make. we consider what these behavioral characteristics imply for public policy. this analysis aims to study disparities between rural and urban areas from all throughout india to five indian states representing three levels of per capita incomes (all-india average, rich and poor). results evidence that healthcare demand both in rural and urban areas is a commodity emerging as an essential need. choices between public or private provider are guided by income and quality variables mainly with regard to public healthcare denoting thus a situation of very limited alternatives in terms of availing private providers. these results emphasize that existing public healthcare facilities do not serve the objective of providing care to the poor in a satisfactory manner in rural areas. thus, any financing strategy to improve health system and reduce disparities across rich-poor states and rural-urban areas should also take into account not only overcoming inadequacy but also inefficiency in allocation and utilization of healthcare inputs. introduction public spending on healthcare has been one of the few uncontroversial issues of welfare. in the last decade, indian government has been under a dual internal and external pressure to reduce overall spending and simultaneously maintain adequate and efficient health services. to achieve the goals of health for all laid out by national health policy,1 the focus on primary care or marginally increasing public sector had to be re-assessed. however, it is less than obvious whether governments spend money in an appropriate fashion to raise access to healthcare services. in a developing country like india, allocation of scarce fiscal resources has to be based on a clear understanding of i) how investments in the heath sector affect demand; ii) how changes in the pricing of public services and investments in quality improvements affect consumer decisions; and iii) how poor vs nonpoor consumers make decisions about treatment relative to both pricing and quality. these three aspects – overall healthcare demand, consumer decisions to use public and/or private care and role of price/quality influencing poor/rich consumers’ decisions – are critical to assessing the equity implications of alternative policies. our paper addresses these aspects through examining the pattern of healthcare demand in india. we use data from the national family health survey (nfhs 3) to model the healthcare choices that individuals make when sick or injured. we then consider what these behavioral characteristics imply for public policy. first, we are interested in how changes in the availability of services will affect their use. a second important contribution of this paper is that it examines the impact of the quality of medical care on health demand. the call for improving quality is advocated by policy makers, action researches and international organizations. nonetheless, studies on the effect of quality when choosing a provider are scarce. besides, we also examine how a series of other characteristics of the household, and individuals, affect their healthcare choices. the role of education, age, etc. provides important insights into the potential opportunities and limitations of public policy to affect patterns of demand. this analysis aims to study disparities between rural and urban areas from all throughout india to five indian states representing three levels of per capita incomes (allindia average, rich and poor). the model used assumes that people have a limited number of healthcare options available, which is entirely plausible both for rural and urban areas by distinguishing each type of provider into public or private. materials and methods in the literature, basic approach to the demand for health2 is labeled as the human capital model because it draws heavily on human capital theory.3-6 this framework was used4,5 to develop models determining the optimal quantity of investment in human capital at any age. in addition, these models show how the optimal quantity varies over the life cycle of an individual and among individuals of the same age. according to human capital theory, increases in a person’s stock of knowledge or human capital raise his productivity in the market sector of the economy, where he produces money earnings, and in the non-market or household sector, where he produces commodities that enter his utility function. to realize potential gains in productivity, individuals have an incentive to invest in formal schooling and on-the-job training. the costs of these investments include direct outlays on market goods and the opportunity cost of the time that must be withdrawn from competing uses. grossman approach uses the household production function model of consumer behavior79 to account for the gap between health as an output and medical care as one of many inputs into its production. this model has also been further elaborated10-13 and, somewhat differently, also resembles proximate determinants model of health.14 this model draws a sharp distinction between fundamental objects of choice (commodities) that enter the utility function and market goods and services. consumers produce commodities with inputs of market goods and services and their own time. for example, they use sporting equipment and their own time to produce recreation, likewise they use medical care, nutrition, etc. to produce health. the concept of a household production function is perfectly analogous to a firm production function. each relates specific outputs to a set of inputs. since goods and services are inputs into the production of commodities, the demand for medical care and other health inputs is derived from the basic demand for health. there is an important link between the household production theory of consumer behavior and the theory of investment in human capital. consumers as investors in their human capital produce these investments with inputs of their own time. thus, some of the outputs of household production healthcare in low-resource settings 2013; volume 1:e7 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai-600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: healthcare, health policy, inequity, indian states. received for publication: 14 december 2012. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright b.c. purohit., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e7 doi:10.4081/hls.2013.e7 non -co mmerc ial us e o nly [page 26] [healthcare in low-resource settings 2013; 1:e7] directly enter the utility function, while other outputs determine earnings or wealth in a life cycle context. health, on the other hand, serves both the functions. according to the human capital model,2 consumers both demand and produce health. health is a choice variable because it is a source of utility (satisfaction) and determines income or wealth levels. health is demanded by consumers for two reasons: i) as a consumption commodity, it directly enters their preference functions; ii) as an investment commodity, it determines the total amount of time available for market and non-market activities. an increase in the stock of health reduces the amount of time lost from these activities, and the monetary value of this reduction is an index of the return to an investment in health. since health capital is a component of human capital, a person inherits an initial stock of health that depreciates with age, can be increased by investment, and falls below a certain level with death. the model originally proposes that individuals choose their length of life. gross investments are produced by household production functions that relate an output of health to such choice variables (or health inputs) as medical care utilization, diet, exercise, smoking, and alcohol consumption. in addition, the production function is affected by the efficiency or productivity of a given consumer as reflected by their personal characteristics. efficiency is defined as the amount of health obtained from a given amount of health inputs. as a fundamental law in economics is the law of the downward-sloping demand function, the quantity of health demanded should be negatively correlated with its shadow price. the shadow price of health is said to depend on many variables other than medical care price. shifts in these variables alter the optimal amount of health and the derived demand for gross investment and health inputs. the shadow price of health rises with age if the rate of depreciation on the stock of health rises over the life cycle and falls with education if more educated people are more efficient producers of health. the model stresses that, under certain conditions, an increase in the shadow price may simultaneously reduce the quantity of health demanded and increase the quantities of health inputs demanded. to develop empirically testable hypotheses, a model of the demand for health defined in terms of different indicators of mortality and diseases is specified. the model concentrates on the role of money and time prices, earned and non-earned income and health insurance. a number of socio-economic variables including religion, caste, education, assets are also used in empirical estimation. to simplify, the formal model is developed in terms of one provider of health only, but the implications for several providers can easily be drawn. if the inter-temporal utility function of a typical consumer is u=u(δtht, zt), t=0, 1, ... , n (1) where: ht is the stock of health at age/time period t, δt is the service flow per unit stock, ht=δtht is total consumption of health services, and zt is consumption of another commodity.the stock of health in the initial period (h0) is given, but the stock of health at any other age is endogenous. life length as of the planning date (n) also is endogenous. in particular, death takes place when ht δhmin. therefore, life length is determined by the quantities of health capital maximizing utility subject to production and resource constraints. if we write ht=δtht=m denoting medical services or any other commodity or characteristic leading to health, assume that two goods enter the individual’s utility function (medical services m, and a composite x) for all other goods and services, also presume a fixed proportions of money and time to consume m and x, and combine these with the full wealth assumption, the model can be represented as follows.15 maximize: u=u(m,x) – subject to (p + wt) m + (q + ws) x ≤y + wt=y (2) where: u=utility; m=medical services; x=all other goods and services; p=out-of-pocket money price per unit of medical services; t=own-time input per unit of medical services consumed; q=money price per unit of x; s=own-time input per unit of x; w=earnings per hour; y=total income; y=non-earned income; t=total amount of time available for market and own production of goods and services. here the consumption of m does not affect the amount of t. based on the optimization process, the reduced-form demand functions for medical care (mt) can be derived as: mt =m(p, q, w, v, h, e; et) (3) where: e is a vector of individual, family and community characteristics, v is the current annual household wealth income, and et is the unobserved initial endowment. most empirical studies use the reduced form approach and include both sets of variables denoting either demand and/or production function variables to analyze the determinants of healthcare. the conditional demand for curative care can be specified as: [mi|hi=1]=b1+b2pi+b3vi+b4ei+ei, i=1, 2... m sick persons (4) where: e is a vector of individual, household and community variables and m is the choice of health-care provider taking discrete values. m=0, if taking no treatment, or taking self treatment and other care (other than public and private) facilities; m=1, if public health facilities are used for treatment; m=2, if private healthcare is utilized. using the above basic consumption model formulation, and a reduced form equation, the effect of various parameters on health could be tested in a regression framework. literature from the health economics field mainly indicate five sets of factors that could be considered important to explore.16 these include socioeconomic status, access to health services, environment, nutrition and personal attributes, etc.17 the conditional demand for curative care (equation 4) is a discrete choice model involving three choices and hence estimated using appropriate logit method. generally, rural and urban populations tend to differ with respect to many health indicators. urban population is typically presumed to be better off. reality is depicted more vividly when a disaggregate scenario is analyzed using an acceptable measure of income categories. empirically, in some countries like colombia and peru, indicators suggest that the urban poor are worse off than their rural counterparts, and the health status of the urban population varies widely across countries, provinces and city sizes.18,19 in addition, urban populations are more susceptible due to degradation of physical environment. for instance, a study on são paolo, brazil, finds that an increase in airborne contamination (which is higher in cities) results in increased hospitalization due to respiratory illness and pneumonia.20 thus, that higher income is positively correlated with better health is another set of presumption, with the direction of causality clearly established from wealthier to healthier,21 urban poor can experience problems with their physical environment that are distinct from and have greater negative health impacts than those faced by their rural counterparts. moreover, personal hygiene, nutrition, choice of physical activities and employment can have an extremely important effect on health in terms of incidence of obesity, heart disease, cancer, sexually-transmitted diseases and similar kind of chronic lifestyle diseases. a notable trend across the globe is a steady increase in urban populace with nearly 1/3 of urban dwellers in slums. it is estimated that nearly 30% (about 300 million) indian people live in towns and cities and nearly 100 million of them live in slums characterized by overcrowding, poor hygiene, and absence of proper civic services.22 to conclude, we can reasonably presume that urban poor’s health is as worse as the rural population’s. by systematic planning since independence, health system in india focuses more on rural areas having an organizational structure from the basic to tertiary care managed by dedicatarticle non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e7] [page 27] ed staff.23 in contrast, such healthcare structure is highly deficient in urban areas. majority of healthcare in urban areas is served by the private sector, but its costing, distance and many other factors make it out of reach for most urban poor residents. in the last 45 years healthcare system in india has focused on increasing coverage in rural areas. urban health problems have been assumed to be fewer since health facilities and services highly concentrate in cities compared with rural areas. in fact, urban poors’ level of access to health facilities falls below the minimum equitable level, where primary healthcare facilities, their location, resources, quality and performance are often poor, their links to deprived communities inadequate and their utilization low.24 thus, a wide gap in the utilization pattern of health services and health improvement in urban areas exists.25 a priori, based on the formal model of demand for health services, time is expected to function as a normal price, demand for free care to be more sensitive to changes in time prices than demand for non-free care. the elasticity of demand for medical services with respect to non-earned income should be positive and the elasticity of demand with respect to earned income is indeterminate, but the price effect may dominate for free care (and thus reduce demand) and the income effect may dominate for non-free care (and thus increase demand). furthermore, without differences in taste for particular types of providers, more education may reduce care demand. if there are taste differentials (with the more educated preferring private care), there may be a negative elasticity with respect to education for public care and an elasticity biased upward (possibly positive) for private care. data source in order to carry out regression exercise we have made use of the third national family health survey (nfhs-3).26 nfhs-3 was conducted in 2005-2006 and provides information on fertility, mortality, family planning, hivrelated knowledge, and important aspects of nutrition, health, and healthcare. unlike earlier surveys, nfhs-3 interviewed men aged 1554, never married women aged 15-49, evermarried women, and included questions on several emerging issues. nfhs-3 collected information from a nationally representative sample of 109,041 households, 124,385 women, and 74,369 men. nfhs-3 sample covers 99% of indian population living in all 29 states. fieldwork for nfhs-3 was conducted in two phases from november 2005 to august 2006. a total of 515,507 individuals who stayed in the household the night before the interview were enumerated in the 109,041 nfhs-3 sample households. the age distribution of the population is typical of populations that have recently experienced fertility decline. under age 15 is 35% of the population, and only 5% is 65 and older. women represent the 14% of heads of households. over 2/3 (69%) of the population lives in rural areas. based on the religion of the household head, 82% of households is hindu, 13% muslim, 3% christian, 2% sikh and 1% buddhist/neo-buddhist. all other religions together account for <1% of households. nineteen percent of household heads belong to the scheduled castes, 8% to the scheduled tribes, and 40% to the other backward classes (obc). about 1/3 do not belong to any of these three groups. twenty-seven percent of households have a below poverty line (bpl) card. a separate analysis at the state level was also done using the same data source. we included five states: gujarat, maharashtra (both rich states), karnataka (an average income state), and madhya pradesh (mp) and rajasthan (both poorer states). these states are considered poor, middle income and rich depending upon their per capita state income being much below, nearer or much above allindia average per capita income. the dependent variables used are: i) respondent used any source of public healthcare (pubcare), ii) respondent used any private healthcare (pvtcare), and iii) respondent used any source of healthcare (anycare). among the explanatory variables we used reasons for not using a public or private source of care, namely, nonearby facility (nonfacty), facility timing not convenient (timenc), health personnel often absent (hpabst), waiting time too long (waittl) and poor quality of care as perceived by the respondents (pquac). these five variables are presumed to denote quality aspect of care. among socio-economic variables we used wealth index (wi), bpl card holding (bpl), female education (feedu), highest education level in the household (hedulh), religion (relgn), caste (caste), insurance coverage from any source (insany), source of water supply (watss), type of sanitation (santyp) and having electricity (electr). results and discussion all-india analysis: rural vs urban below we discuss results of our logit analysis which are presented in the appendix (tables as listed below). results of the rural all-india level indicate that all the variables are significant. among the explanatory variables, quality as represented by different variables indicates that utilization of governmental facilities is hampered by distance, inconvenient timing of facility, absence of health personnel, and poor perceived quality of care. the marginal impact of these variables is however small (table a1). the responsiveness (elasticity of) of these variables is particularly high in determining the utilization of governmental facilities. among the socio-economic variables, bpl card holding has a positive impact, but both the marginal effect and elasticity are low. likewise, asset ownership (as depicted by composite wealth index) has a negative impact with low elasticity. as expected, rural results indicate female education as leading to more utilization. however, the rural results depict a negative impact of sc/st belonging and sanitation facilities. other variables like religion and electricity have positive impact on public health facility utilization. in contrast to governmental facility utilization, private healthcare facility utilization has positive but low elasticity with respect to quality variables in rural areas (table a2). poverty hampers the utilization of private providers in the rural results. this is denoted by negative impact of bpl card holding. it is pertinent to note that income elasticity as denoted by wealth index has been low in rural areas relating to any type of care utilization (table a3). likewise, elasticity with respect to quality variables has been high only in the results of governmental facility but low in private or any type of care (tables a2 and a3). education elasticity has been low but negative in private or any type of care. low level of water sanitation facilities have a positive impact on any type of care, but elasticity coefficients are also low. most importantly, these results prove healthcare as necessity with low elasticities with respect to income and other socio-economic variables. nevertheless, the choice of a better provider (governmental vs private or no facility vs any facility) is seen through high responsiveness of rural respondents. a major difference between rural and urban results (tables a4a6) is in terms of impact of bpl status. in urban areas, bpl status has been a negative factor in the utilization of any type of healthcare facility. however, another factor, namely sc/st status, unlike rural areas, has a positive impact albeit with low magnitude. in the urban results, female education has been negatively influential in the utilization of private or any type of facilities but it did not emerge as significant for public facilities. there is no notable difference between rural-urban results in terms of water-sanitation impact which shows mixed results. in general, for all the three types of dependent variables, magnitude of income elasticity has been higher in urban areas relative to the rural counterparts, but the difference in magnitude is also low. in the case of individual state level results, among rich states, the results for gujarat indicate that for public healthcare facilities in rural areas variables representing bpl status, insurance, reliarticle non -co mmerc ial us e o nly [page 28] [healthcare in low-resource settings 2013; 1:e7] gion, education and water source have not emerged as statistically significant (table a7). these variables have even demonstrated to be insignificant for private facilities or any type of care (tables a8 and a9). pertinently, the results for rural gujarat indicate high negative elasticity with respect to quality variables impinging on utilization of public healthcare facilities. however, income elasticity for either facility has been low for rural areas (tables a8 and a9). an interesting observation is the high income elasticity as well as quality elasticity for public healthcare utilization in urban gujarat (table a10). by contrast, in this set of results, variables representing bpl status, insurance coverage, and amenities variables like sanitation and electricity have not emerged as significant. nor is the female education is found significant. thus it indicates that respondents in urban gujarat had most important criteria as income and quality to utilize public healthcare (table a10). however, the elasticity is much lower in magnitude for either private or any type of care in urban gujarat both with respect to quality and income. (tables a11 and a12) results for maharashtra indicate that some of the socio-economic variables like insurance, sc/st belonging, wealth index and religion have not emerged as significant for the rural results pertaining to public healthcare utilization (table a13). even among the quality variables only two of them, namely no nearby facility and poor quality, have emerged with high elasticity (table a13). however, elasticity coefficients have been low for all other results in rural maharashtra (tables a14 and a15). in line with public healthcare utilization, the results of private care and any type of care also denote some of the socio-economic variables like bpl, wealth index, female education, water and sanitation (in private care rural maharashtra; table a14) and sc/st belonging, female education, religion and sanitation (in any type of care rural maharashtra; table a15) are not significant. in line with other rich state, namely gujarat, the results of urban maharashtra also indicate high elasticity coefficients both with respect to quality and income variable in deciding utilization of public health facilities (table a16). in a similar manner, the results of private care utilization and any type of care do not depict high elasticity coefficients (tables a17 and a18). again, some of the socio-economic variables like bpl status, wealth index, religion and electricity (in public care utilization urban maharashtra; table a16), bpl status and electricity (in private care utilization in urban maharashtra; table a17) and sc/st status, sanitation, wealth index and electricity (in any type of care urban maharashtra; table a18) have not emerged as statistically significant. in line with the all-india rural results, the rural results for karnataka state (an average income state) also depict high elasticity with respect to quality and income variables only for public healthcare utilization (table a19). for other types, namely private care and any type of care, elasticity coefficients are low (table a19). some of the variables like religion, sc/st belonging, female education and water facility have not emerged statistically significant for rural results pertaining to public healthcare. likewise, for private care in rural karnataka, variables representing bpl status, sanitation type, religion, female education and electricity have not emerged as significant (table a20). in any type of care religion variable is found insignificant (table a21). even the results of urban karanataka also depict high elasticity coefficients with respect to quality and income variables in the results of public care utilization (table a22). however, the results for private care utilization in urban karanataka depict insignificance of religion, sc/st belonging, electricity, sanitation and wealth index (table a23). it seems that major determinant for private care utilization even among quality variables is availability, low waiting time and quality since other two quality variables namely vicinity of facility and timing are also insignificant (table a23). in urban karnataka the results for any type of care also depict insignificance of sc/st belonging, religion, female education and sanitation (table a24). results for rural mp depict overall significance of only few variables particularly in regard to utilization of public health facilities. the variables which emerged statistically significant include insurance coverage, type of sanitation and electricity. the impact of these variables and elasticities is low and generally depicts a lack of insurance coverage (negative sign), sanitation (positive sign) and electricity (positive sign) (table a25). the results of rural mp for private care utilization depict statistically significant coefficients for most of the variables except water and sanitation (table a26). however, elasticity coefficients are very low for all of them (table a26), thus again depicting healthcare as a necessity. in case of any type of care, some of the quality variables (timing and absence of personnel) are insignificant (table a27). however, other quality variables are significant and denote marginal impact as positive only for vicinity of facility and waiting time (table a27). likewise, other statistically significant variables include caste (positive sign), source of drinking water (positive sign), income (positive sign of wealth index) and presence of electricity (positive sign). however, both the marginal impact coefficients and elasticities are having low magnitudes (table a27). in contrast to rural results, urban mp results depict high impact and elasticities for most of the quality variables except absence of health personnel (table a28). however, high elasticity is indicated for public health facility (-3.35), inconvenient location of facility (-1.14), long waiting time (-2.42) and poor quality of care (3.72) (table a28). these depict that urban respondents had preference for private care due to lack of above quality factors at the government facilities. the results also indicate bpl card users with positive low elasticity for public healthcare facilities (.106), negative wealth index coefficient (-.748), religion (-.322) and female education (-.250) (table a28). in case of private care utilization, urban mp respondents did not depict high elasticity coefficients for any of the variables. however, the results indicated positive impact of all the quality variables, negative female education effect (elasticity as -.093) and positive elasticity for having electricity (.043) and source of drinking water (.012) (table a29). these results depict increasing likelihood of private care utilization due to better quality and inadequacy of water sanitation facilities leading to more private care utilization. in line with public care utilization, the results for urban mp depict low impact and elasticity coefficients for all the variables in utilization of any type of care, thus reinforcing the compulsive nature of healthcare (table a30). the rural results for another poor state, namely rajasthan, denote insignificance for public care utilization of all the quality variables (table a31). among other variables, only caste and religion have appeared with statistical significance. however, for private care utilization, most of the included variables depict significance (table a32). except for insurance coverage, sc/st belonging and electricity, others have emerged as significant but with low marginal impacts and low elasticity coefficients (table a32). in case of any type of care, in line with public facilities, many variables depicting, namely, quality, insurance coverage and source of drinking water are statistically insignificant (table a33). the variables like female education and income have the expected negative sign but low elasticity coefficients (table a33). unlike the results of urban mp, the results for public care utilization for urban rajasthan do not indicate high elasticity coefficients pertaining to any variables except for poor quality (-1.18) and wealth index (1.49) (table a34). however, other results for urban rajasthan do not depict high elasticity coefficients either for private care or any type of care utilization (tables a35 and a36). quality variables however have positive and low elasticity for private care (table a35). both the income and education variables have the expected negative elasticity (though low in magnitude) for private care utilization in rajasthan (table a35). the article non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e7] [page 29] results for any type of care depict mix of low impact and elasticity coefficients (table a36). a comparative view of elasticities is provided in tables a37-a39. both in rural and urban areas, respondents are responsive to quality variables pertaining to public care utilization. however, except for waiting time, the rural elasticities are higher for quality variables. in terms of income and education, the elasticity coefficients of urban areas are higher than their rural counterparts. a further analysis in terms of rural poor states and rural rich states indicate that the quality variables are not statistically significant (table a37). these coefficients are very small for poor states and rural areas. in rich states all quality variables in rural areas are significant for gujarat only. in terms of coefficient’s magnitudes, except for poor quality of care, the elasticity coefficients are higher for gujarat (table a37). in urban areas, a comparison of two poorer states depicts higher elasticity coefficients for mp for all the quality variables but for income rajasthan’s coefficients are higher and for female education mp’s elasticity coefficients are higher. in rich states, comparison of urban areas depict two quality variables namely facility timings and absence of health personnel as statistically insignificant for maharashtra (table a37). overall, there is a mixed nature of magnitudes between rich states (gujarat and maharashtra) pertaining to quality variables in urban areas. likewise, maharashtra has higher elasticity for income variables and gujarat has higher elasticity for female education (table a37). in contrast to public care utilization, the elasticity coefficients are generally low across all the categories (table a38). in general, urban areas have higher elasticities (with low magnitudes) both for quality and income-education variables (table a38). however, a comparative profile of two poor states in rural areas depicts magnitudes to be uniformly higher for those two sets (namely quality and income-education) for rajasthan. in rich states, a similar observation is broadly true for gujarat with higher magnitudes of elasticities for many of them (table a38). in urban areas, a comparison of two poor states depicts most of the magnitudes for elasticities to be higher for rajasthan than mp (table a38). in rich states, for urban areas, elasticity coefficients have in general higher magnitudes for maharashtra relative to gujarat (table a38). among the three sets of elasticities, the coefficients are lowest in the magnitudes for all variables pertaining to utilization of any type of care (table a39). in general, rural elasticities are lower relative to urban counterparts (table a39). in poor states, across rural areas, mp has generally higher magnitudes (table a39). in rich states, it is a mixed pattern across gujarat and maharashtra in rural areas (table a39). in urban areas, with a mixed pattern for quality variables, the income elasticity is higher for mp (table a39). in rich states’ urban areas, there is a mixed pattern for quality variables: the income elasticity is higher for gujarat and female education elasticity is higher for maharashtra (table a39). comparison with other studies our high income elasticity coefficients pertaining to public healthcare utilization are in general (except for urban poor states) in line with the results of other indian studies27 and developing countries like ghana.28 many other studies conducted in countries like kenya,29 indonesia,30 pakistan,31 china,32 and ivory coast,29 have not reported income or quality elasticities. conclusions results of the rural all-india level indicate that all the variables are significant. among the explanatory variables, broadly quality variables indicate that utilization of governmental facilities is hampered by distance, inconvenient timing of facility, absence of health personnel, and poor quality of care as perceived by respondents. the marginal impact of these variables is however small. the elasticity of these variables is particularly high in determining the utilization of governmental facilities. in contrast to governmental facility utilization, the private healthcare facility utilization has positive but low elasticity with respect to quality variables in rural areas. poverty hampers the utilization of private provider in the rural results. this is denoted by negative impact of bpl card holding. most importantly, these results prove healthcare to be a necessity with low elasticities with respect to income and other socioeconomic variables. nevertheless, choice of a better provider (governmental vs private or no facility vs any facility) is seen through the high responsiveness of rural respondents. a major difference between rural and urban results is in terms of impact of bpl status. in urban areas, bpl status has been a negative factor in utilizing any type of healthcare facility. there is no notable difference between rural-urban results in terms of water-sanitation impact which shows mixed results. in general, for all the three types of dependent variables, magnitude of income elasticity has been higher in urban areas relative to the rural counterparts, but the difference in magnitude is also low. in the case of individual state level results, among rich states, the results for gujarat indicate that high negative elasticity with respect to quality variables and this is impinging on the utilization of public healthcare facilities. it indicates that respondents in urban gujarat had most important criteria as income and quality to utilize public healthcare. in line with other rich state, namely gujarat, the results of urban maharashtra also indicate high elasticity coefficients both with respect to quality and income variable in deciding the utilization of public health facilities. in line with the allindia rural results, the rural results for karnataka state representing an average income state also depict high elasticity with respect to quality and income variables only for public healthcare utilization. among poor states, results for rural mp depict overall significance of only few variables particularly in regard to utilization of public health facilities. the variables which emerged statistically significant include insurance coverage, type of sanitation and electricity. the impact of these variables and elasticities are low and generally depict a lack of all these, namely insurance coverage (negative sign), sanitation (positive sign) and electricity (positive sign). the results of rural mp for private care utilization depict statistically significant coefficients for most of the variables except water and sanitation. however, elasticity coefficients are very low for all of them, thus again depicting healthcare as a necessity. in contrast to rural results, urban mp results depict high impact and elasticity coefficients for most of the quality variables except absence of health personnel. unlike the results of urban mp, the results for public care utilization for other poor states, namely rajasthan for urban areas, do not indicate high elasticity coefficients pertaining to any variables except for poor quality (-1.18) and wealth index (1.49). overall our results provide evidence that healthcare demand both in rural and urban areas is a commodity which emerges as an essential need. choices between public or private provider are guided by income and quality variables mainly in regard to public healthcare, thus denoting a situation of very limited alternatives in terms of availing private providers. these results emphasize that existing public healthcare facilities are not serving the avowed objective of providing care to the poor in a satisfactory manner even in rural areas. thus, any financing strategy to improve health system and reduce disparities across rich-poor states and rural-urban areas should take into account not only overcoming inadequacy but also inefficiency in allocation and utilization of healthcare inputs.33 references 1. national health policy 2002 (india). new article non -co mmerc ial us e o nly [page 30] [healthcare in low-resource settings 2013; 1:e7] delhi: government of india publ.; 2003. available from: www.mohfw.nic.in/nrhm/ .../national_health_policy_2002.pdf 2. grossman m. on the concept of health capital and the demand for health. j polit econ 1972;80:223-55. 3. becker gs. human capital. new york, ny: columbia university press; 1964. 4. becker gs. human capital and the personal distribution of income: an analytical approach. ann arbor, mi: university of michigan publ.; 1967. 5. ben-porath y. the production of human capital and the life cycle of earnings. j polit econ 1967;75:353-67. 6. mincer j. schooling, experience, and earnings. new york, ny: columbia university press; 1974. 7. becker gs. a theory of the allocation of time. econ j 1965;75:493-517. 8. lancaster kj. a new approach to consumer theory. j polit econ 1966;74:132-57. 9. michael rt. education in non-market production. j polit econ 1973;81:306-27. 10. rosenzweig mr, schultz tp. estimating a household production function: heterogeneity, the demand for health inputs and their effects on birth weight. j polit econ 1983;91:723-46. 11. schultz tp. studying the impact of household economic and community variables on child mortality. popul dev rev 1984;10:s25-45. 12. behrman jr, deolalikar ab. health and nutrition. in: chenery h, srinivasan tn, eds. handbook of development economics. amsterdam: north holland press; 1988. pp 631-771. 13. strauss j, thomas d. health, nutrition and economic development. j econ lit 1998;36: 766-817. 14. mosley wh, chen lc. an analytical framework for the study of child survival in developing countries. popul dev rev 1984;10: s25-45. 15. acton jp. demand for healthcare among the urban poor, with special emphasis on the role of time. washington, dc: the rand corporation ed.; 1973. 16. purohit bc. budgetary expenditure on health and human development in india. int j popul stud 2012;2012: id 914808. 17. world health organization. meeting the millennium development goals drinking water and sanitation targets: a mid-term assessment of progress. geneva: who ed.; 2004. 18. flores w. governance and health in an urban setting: key factors and challenges for latin american cities. in: tulchin js, varat dh, and ruble ba, eds. democratic governance and urban sustainability. washington, dc: woodrow wilson interna tional center for scholars publ.; 2000. pp 89-96. 19. ricardo b, giedion u, valenzuela r, monkkonen p. [la problemática de salud de las poblaciones urbanas pobres en américa latina]. [book in spanish]. washington, dc: world bank publ.; 2003. 20. gouveia n, fletcher t. respiratory diseases in children and outdoor air pollution in são paulo, brazil: a time series analysis. occup environ med 2000;57:477-83. 21. pritchett l, summers l. healthier is wealthier. journal of human resources 1996; 31:841-68. 22. kantharia sl. urban health issues in india need of the day. natl j comm med. 2010;1:1. 23. government of india. national commission on macroeconomics and health ministry of health and family welfare. new delhi: government of india publ.; 2005. 24. world health organization. the role of health centres in the development of urban health systems, report of the who study group on primary healthcare in urban areas. geneva: who ed.; 1992. 25. planning commission of india. high level expert group report on universal health coverage for india. new delhi: planning commission of india publ.; 2011. available from: http://planningcommission.nic.in/ reports/genrep/rep_uhc0812.pdf 26. international institute for population sciences. national family health survey (nfhs-3), india, 2005-06: state level reports. mumbai: iips ed.; 2008. 27. duraisamy p. health status and curative healthcare in rural india. new delhi: national council of applied economic research publ.; 2001. 28. gaddah m. progressivity of healthcare services and poverty in ghana. tokyo: national graduate institute for policy studies ed.; 2011. 29. gertler p, hammer j. strategies for pricing publicly provided health services. washington, dc: world bank publ.; 1997. 30. gertler p, molyneaux j. experimental evidence on the effect of raising user fees for publicly delivered healthcare services: utilization health outcomes, and private provider response. washington, dc: the rand corporation ed.; 1997. 31. alderman h, gertler p. family resources and gender differences in human capital investments: the demand for children's medical care in pakistan. in: haddad l, hoddinott j, alderman h, eds. intraho usehold resource allocation in developing countries: models, methods, and policy. baltimore: johns hopkins university press for the international food policy research institute ed.; 1997. 32. qian d, pong rw, yin a, et al. deter minants of healthcare demand in poor, rural china: the case of gansu province. health policy plann 2009;24:324-34. 33. purohit bc. healthcare system in india. new delhi: gayatri publ.; 2010. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11167 identification of new cases of tuberculosis during the covid-19 pandemic using model strategic management eppy setiyowati,1 umi hanik,1 ni njoman juliasih,2 priyo susilo3 1faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia; 2departement of public health, faculty of medicine, university ciputra surabaya, indonesia; 3staff of public health center at surabaya, indonesia abstract introduction: tuberculosis (tb) is a world health problem that causes the third-largest death after cardiovascular and respiratory diseases. one of the causes of transmission of environmental factors is controlling the mobilization of individuals suffering from tuberculosis. this research aims to develop a strategic model of finding new tb cases based on region. method: this descriptive research utilizes primary and secondary data. variables consist of geographical and demographic characteristics, resources, tuberculosis prevalence, and indicators of tuberculosis response processes. the tb management planning model document is based on the experiences of health centers perak timur, wonokromo, and siwalankerto in maximizing tb case detection. results: the management model outlines policies and procedures based on the variables. for example, the detection of new tb patients became a priority at the health center in perak timur. in contrast, the health center in wonokromo focused on developing cadres and private practice physicians. conclusions: this research provides an overview of the aspects that need attention and improvement by discovering different new cases in each region. introduction the struggle became a big challenge during the pandemic, particularly in eliminating tuberculosis (tb) disease. as a result, who declared the disease caused by mycobacterium tuberculosis (mtb) a global public health emergency since 1993.1 indonesia is one of the high burden countries with tb and ranks fifth after india, china, south africa, and nigeria.2,3 tb is a problem in surabaya since almost every health center gets more than ten patients.4,5 the neglect of tuberculosis during this pandemic has led to more complicated issues affecting health, social, economic, and mortality rates.6,7 in the tb countermeasures handbook, every health service is expected to make fundamental efforts to create and implement regional-based strategy management to identify new case discoveries. furthermore, they should create and implement regional-based tb strategy management to identify new case discoveries. however, none of the available health facilities has created or implemented this strategy.8,9 the discovery of lung tuberculosis cases was neglected because most activities focused on solving covid-19.10 however, this is not a reason to abandon the investigation of certain tb patients who seek treatment at the public health center.11,12 in this study, the discovery of lung tb cases was more on the family approach and the environment around people with pulmonary tb,13,14 which has not been carried out in research. a series of strategic management processes to identify new regional-based tb cases is needed to determine the direction and focus of tb prevention in its region. for this reason, specific needs can promote the successful prevention of tb disease in each region.15,16 based on some previous problems, a research needs to be conducted on the new regional-based tb case discovery strategy management model in surabaya. regional strategies are management made in an integrated and data-based or fact-based area by utilizing clinical information, epidemiological, administrative, and demographic facts.17,18 this research compiles a model management strategy and discovers new regional-based tb cases in surabaya. research methods this qualitative research with a case study approach was conducted in april-june 2021 at three health centers in surabaya, namely perak timur health center, wonokromo health center, and siwalankerto health center. these three locations are selected based on the characteristics of surabaya regions with a high average tb prevalence during the previous five years. the population was employees of perak timur, wonokromo, and siwalankerto health center. the sample is based on two criteria of core informants, namely officers involved in tb countermeasures program activities. in contrast, key informants are tb supervising representative of surabaya city health office and nurses who hold tb significance for public health the neglect of tuberculosis (tb) during the pandemic has led to more complicated issues affecting health, social, economic, and mortality rate. in the tb countermeasures handbook, every health service is expected to make fundamental efforts to create and implement regional-based strategy management to identify new case discoveries. furthermore, they should create and implement regional-based tb strategy management to identify new case discoveries. however, none of the available health facilities has created or implemented this strategy. article [page 26] [healthcare in low-resource settings 2023; 11(s1):11167] non -co mmerc ial us e o nly programs. the sample used was 10 informants; three from perak timur, three from wonokromo, three from siwalankerto, and one from tb supervising representative of surabaya city health office as a key informant. the research uses a system approach theory consisting of inputs, processes, and outputs through in-depth interviews. the contents of the questionnaire inputs include human resources, infrastructure facilities, budget, policy, sop (standard operational procedure). furthermore, the process includes planning a tb treatment program, structure, active discovery of tb patients, passive discovery of tb patients, supervision, and evaluation. the output includes the number of tb patients in three health centers for one year, namely in 2020. results and discussions the results of data analysis based on identification are displayed in the form of fish bones and through strategy theory, including process input and output arranged in the principles of strategic management. these processes include environment scanning, formulation strategy, implementation strategy, evaluation, and control. the initial stage of a strategic management process is to perform a situation analysis on three surabaya health centers, namely perak timur, wonokromo, and siwalankerto, and they have different lung tb sufferers in the high, moderate, and low categories.8 strategic steps are carried out to find new cases of lung tb sufferers through planning with several steps. first, the assessment process is carried out with staff in the pulmonary tb program at both health centers, involving village cadres who have conducted some coaching and training by the community health center. then, the source of the issue was described using fishbone diagrams. next, the reason for the selected problem was narrowed down to various problem-solving options. finally, the problem-solving alternatives were picked using the carl method, and the planning was compiled. each stage at each health facility is detailed in figure 1. the problem of the high prevalence of pulmonary tb in the working area of perak timur health center based on fishbone diagrams is caused by several factors, including the method of handling, human resources, and the environment. in terms of countermeasure methods, perak timur health center has continued to use passive case networking and tuberculosis health promotion, namely netting cases and conducting health promotion only on individuals accessing health services at the center. additionally, numerous organizations and agencies have established no partnerships related to tuberculosis countermeasures. in terms of human resources, perak timur health center has not met the minimum standard of human resources trained in tb management for the prm category. finally, judging from the environmental aspects of the working area of perak timur health center classified as a densely populated area, most of its people are in the category of common welfare. a problem solver selected in this region cannot discover tb cases using passive case-finding methods. therefore, alternatives developed from the causes of the selected problems. they produced problem-solving alternatives to increase community participation and support acf with tb screening campaigns through counseling, empowering midwives, and village health post nurses. furthermore, they establish cooperation with integrated service post cadres to net tb suspects in the working area of perak timur health center. the alternative to solving the problem using the crl method is to increase public knowledge about acf with a tb screening campaign through counseling during citizen meeting activities every month. however, the pandemic period of the meeting is conducted through zoom meetings, and counseling on tb disease is also achieved in conjunction with the meeting. strategy management model identifies new tb case discovery in article [healthcare in low-resource settings 2023; 11(s1):11167] [page 27] figure 1. strategic steps find new case of lung tb sufferers. non -co mmerc ial us e o nly wonokromo health center with moderate prevalence average (figure 2). wonokromo health center is an area with an average prevalence of 7 out of 14 over the past three years. an overview of the factors or causes of great tb problems illustrated in fishbone diagrams in terms of methods is that the health center applies tb case networking passively. meanwhile, partnerships with several organizations and agencies have not been established and has not met the minimum standard of trained tb management for the ps category. the working area is classified as a very densely populated area. the establishment of a partnership between the community health center and private practice doctors is the cause of selected problems in this region. alternatives developed from the underlying causes of the selected problem, resulting in problem-solving alternatives include providing tb countermeasures training under dots standards for dps, inviting dps to send patients suspected of tuberculosis and reporting to wonokromo health center, enacting regulations that tb patients accessing health services in the dps are guaranteed treatment until they are cured. selected troubleshooting possibilities from several attempts utilizing the carl is to establish and promote a ministry of private practice physicians responsible for referring patients to wonokromo health center. a series of steps led to the arrangement of model documents to manage the identification strategy for discovering new tb cases based on the region in the working area. as a result, the management program’s name for identifying new cases of tb in the region is “unyielding overcome tb (pamera kolaborasi tb)”. the purpose of the program is to pursue a partnership between the community health center and private practice doctors in the working area of wonokromo health center. these include several indicators of the success of activities, specifically in partnership cooperation with private practice doctors, composed mou pamera collaboration tb, the formation of the organization pamera collaboration tb and formed a work and follow-up plan pamera collaboration tb with sending the report of each tb patient to wonokromo health center. a summary of the factors/causes of significant tb issues at siwalankerto health center in terms of methodologies is shown in fishbone diagrams. siwalankerto health center has passively used tb case networking, specifically noting instances in persons seeking health services at health centers and establishing collaborations with several organizations and instancy (figure 3). however, it has not satisfied the minimal criteria for human resources educated in tb management for the ppm category. furthermore, the working area is classified as a region with a dense population. inadequate detection of tb patients using the passive case finding approach is the source of difficulties in the active area. this shows that other methods of resolving the issue were devised and adopted. these methods are educating positive bta tb patients to detect the possibility of tb suspects in their environment, conducting home visits to all bta positive tb patients to determine whether or not the transmission is occurring nearby, empowering midwives, nurses, and posyandu cadres to catch tb suspects in the region, and establishing cooperation with posyandu cadres to catch tb suspects in the siwalankerto health center’s working area. selected troubleshooting alternatives from multiple troubleshooting using the carl are to educate patients with positive bta tb to detect the possibility of tb suspects around the home environment. the sequence of actions culminated in creating a model document to manage the strategy of discovering new tb patients depend on the region in siwalankerto health center’s operational area. the name of the tb prevention program in the region is find and cure tb patients siwalankerto health center (tebus tb sito). the program aims to optimize the discovery of tb suspects by establishing tb care communitas in the siwalankerto region. there are several indicators of the main activities of this program, namely the formation of the tebus tb community in kutisari subdistrict, the existence of socialization and declaration of the tb tebus community, and the establishment of a follow-up plan with the existence of five main agenda activities of the tebus tb sito article figure 2. model management strategy of finding new tb cases wonokromo health center (wheelan and hunger 2008, modified). [page 28] [healthcare in low-resource settings 2023; 11(s1):11167] non -co mmerc ial us e o nly community. the management strategy model of finding new tb cases in perak timur health center with the highest average prevalence has a selected problem-solving alternative to increase public knowledge on acf with a tb screening campaign through counseling with meting zoom media. this is conducted considering that the situation is still in pandemic at data retrieval. for the asian region, there are three million undiagnosed tb sufferers, specifically in countries with a high tb burden, including indonesia. this occurs because the discovery of active tb suspects and information about screening is not widespread.1,19 interventions are undertaken to identify new cases of tb are reducing diagnostic delays. this can be achieved through active promotion and active discovery or active case finding, increasing the proportion of cases identified. as a result, the duration of transmission can be shortened since the model of management of tb new case discovery strategies for the working area of perak timur health center is similar to figure 1.20,21 the discovery of new cases of region-based tb was conducted through active promotion and counseling with meting zoom media. the implementation of these efforts certainly involves the active role of posyandu cadres, health extensionists, and tb management program holders.21,22 the problem-solving model for managing a novel tb case finding method in the wonokromo health center area was conducted with a high incidence of tb. this fosters a private practice physician partnership to send tb suspect patients to wonokromo health center. based on data from the tb prevalence survey, the ministry of health shows that tb sufferers use health services in the community health center and general practitioners.8,23 the decree of the minister of health no. 364 of 2009 also explained that private practice doctors are one element of health care efforts and centers. furthermore, tb cases should be reported to the health service to increase the number of recorded case findings.24,25 the strategy management model in figure 2 of lung tb case discovery strategies in the wonokromo region is produced according to existing theories and needs. the partnership of puskesmas with private practice doctors is one element of health care efforts and health centers. they should report tb cases or make patient referrals to the health center to increase the number of recorded case findings.24,26 the strategic management model of finding new tb cases in the wonokromo health center work area generates existing theories and needs. the partnership of community public health and private practice physicians is indispensable. wonokromo health center’s work area has the highest density among the other two regions. the region has 6 private practice doctors.25 planning to realize and foster the partnership is expected to embrace all private practice doctors to carry out several activities of tb sufferers such as in hospitals and pulmonary disease treatment centers.8,27 under certain conditions, private practice doctors can refer patients and specimens back to the health center for treatment and subsequent supervision.28,29 finding new cases of lung tb at wonokromo health center, where the incidence is lowest, has been made easier by using a management plan that promotes patients with positive bta tb tests to act out the prospect of encountering tb suspects in their immediate surroundings. the management model of lung tb case discovery strategy previously applied in the working area relies heavily on awareness of people’s behavior seeking health care. this is the weakness in most developing countries, including indonesia. the downside of this strategy is that when infectious patients do not arrive early or refuse to visit the health facility, they will remain a source of new cases among the public.15,30 the management model in figure 3 of the new lung tb case discovery strategy produced at siwalankerto health center focuses on finding cases among people closest to patients. who stated seven recommendations to prioritize risk groups for active tb screening. the recommendations are divided into two, namely strong and conditional. one of the groups that received strong recommendations for active tb screening was people in one house and those having close contact with sufferers. the main purpose of article [healthcare in low-resource settings 2023; 11(s1):11167] [page 29] figure 3. model management strategy of finding new tb cases siwalankerto health center (wheelen and hunger 2008, modified). non -co mmerc ial us e o nly screening in this group is to detect active tb as early as possible, contributing to the end goal. the ultimate goal is to reduce the risk of adverse treatment outcomes such as residual health symptoms.1,31 more aggressive case detection closer to the target will be more expensive than passive case.31,32 therefore, active detection involving former tb sufferers will certainly be good when applied by siwalankerto health center. conclusions this research resulted in a document management model for new case discovery identification strategies based on perak timur and siwalankerto health centers focused on optimizing tb case discovery in the working region using active case finding methods. in contrast, wonokromo health center is focused on fostering partnerships between the community health centers and private practice doctors in their work areas. references 1. who. systematic screening for active tuberculosis. geneva: who; 2015. 2. ministry of health republic of indonesia. basic health research data. jakarta: ministry of health republic of indonesia; 2018. 3. paradkar m, padmapriyadarsini c, jain d, et al. tuberculosis preventive treatment should be considered for all household contacts of pulmonary tuberculosis patients in india. plos one 2020;15:e0236743. 4. surabaya city health office. surabaya city profile 2018. surabaya: surabaya city health office; 2018. 5. gammon j, hunt j, williams s, et al. infection prevention control and organisational patient safety culture within the context of isolation: study protocol. bmc health serv res 2019;19:296. 6. shinan-altman s, levkovich i. covid-19 precautionary behavior: the israeli case in the initial stage of the outbreak. bmc public health 2020;20:1718. 7. almutairi km, al helih em, moussa m, et al. awareness, attitudes, and practices related to coronavirus pandemic among public in saudi arabia. fam community health 2015;38:332–40. 8. ministry of health republic of indonesia. pedoman nasional pengendalian tuberkulosis-keputusan menteri kesehatan republik indonesia nomor 364. jakarta: ministry of health republic of indonesia; 2011. 9. faronbi jo, adebowale o, faronbi go, et al. perception knowledge and attitude of nursing students towards the care of older patients. international journal of africa nursing sciences 2017;7:37–42. 10. kielmann k, karat as, zwama g, et al. tuberculosis infection prevention and control: why we need a whole systems approach. infectious diseases of poverty 2020;9:56. 11. adu pa, spiegel jm, yassi a. towards tb elimination: how are macro-level factors perceived and addressed in policy initiatives in a high burden country? globalization and health 2021;17:11. 12. altamimi a, abu-saris r, el-metwally a, et al. demographic variations of mers-cov infection among suspected and confirmed cases: an epidemiological analysis of laboratory-based data from riyadh regional laboratory. biomed res int 2020;2020:9629747. 13. setiyowati e, juliasih nn, sari rm. new normal behavior toward the covid-19 transmission. jnki (jurnal ners dan kebidanan indonesia) 2022;9:241–8. 14. tesema t, seyoum d, ejeta e, et al. determinants of tuberculosis treatment outcome under directly observed treatment short courses in adama city, ethiopia. plos one 2020;15:e0232468. 15. who. primary health care on the road to universal health coverage: 2019 monitoring report [internet]. 2019 [cited 2021 may 8]. available from: https://www.who.int/publicationsdetail-redirect/9789240029040 16. sabri a, quistrebert j, naji amrani h, et al. prevalence and risk factors for latent tuberculosis infection among healthcare workers in morocco. plos one 2019;14:e0221081. 17. a m. health systems and services. health for the millions [internet]. 1992 [cited 2021 may 8];18(1–2). available from: https://pubmed.ncbi.nlm.nih.gov/12343654/ 18. tamarack institute. tool the health planner’s toolkit [internet]. 2006 [cited 2022 may 28]. available from: https://www.tamarackcommunity.ca/library/the-health-plan article correspondence: eppy setiyowati , faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, jl smea no 57 surabaya jawa timur 60231, indonesia, tel.: +62318284508, fax: +62318284508. e-mail: eppy@unusa.ac.id key words: region, tuberculosis, new cases, model management strategies. acknowledgment: the author is grateful to the faculty of nursing and midwifery, universitas nahdlatul ulama surabaya indonesia, for the kind support and motivation during this research. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the ethics committee of universitas nahdlatul ulama surabaya approved this study (no 120/ec/kepk/unusa/2021). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all patients participating in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 10 december 2021. accepted for publication: 15 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11167 doi:10.4081/hls.2023.11167 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 30] [healthcare in low-resource settings 2023; 11(s1):1167] non -co mmerc ial us e o nly ners-toolkit 19. rolison jj, hanoch y. knowledge and risk perceptions of the ebola virus in the united states. preventive medicine reports 2015:262–4. 20. lepuen ap, bratajaya cna, rasmada s. tuberculosis case finding practice: the intention of cadres. jurnal keperawatan indonesia 2020;23:128–35. 21. brug j, aro ar, richardus jh. risk perceptions and behaviour: towards pandemic control of emerging infectious diseases. int j behav med 2009;16:3. 22. who. tb & covid-19 [internet]. 2020 [cited 2021 may 8]. available from: https://www.who.int/teams/global-tuberculosis-programme/covid-19 23. dc health. conserving the supply of personal protective equipment (ppe) in healthcare facilities – september 24, 2021 | doh [internet]. [cited 2021 may 8]. available from: https://dchealth.dc.gov/publication/conserving-supply-personal -protect ive-equipment-ppe-heal thcare-faci l i t ies%e2%80%93-september-24 24. ministry of health republic of indonesia. lokasi: keputusan menteri kesehatan republik indonesia nomor 364/menkes/sk/v/2009 tentang pedoman penanggulangan tuberkulosis (tb) [ peraturan ] [internet]. 2009 [cited 2021 may 8]. available from: https://www.onesearch. id/record/ios9.123456789-2096 25. li jb, yang a, dou k, et al. chinese public’s knowledge, perceived severity, and perceived controllability of covid-19 and their associations with emotional and behavioural reactions, social participation, and precautionary behaviour: a national survey. bmc public health 2020;20:1589. 26. asaad a, el-sokkary r, alzamanan m, et al. knowledge and attitudes towards middle east respiratory sydrome-coronavirus (mers-cov) among health care workers in south-western saudi arabia. east mediterr health j 2020;26:435–42. 27. al-raddadi rm, shabouni oi, alraddadi zm, aet al. burden of middle east respiratory syndrome coronavirus infection in saudi arabia. j infect public health 2020;13:692–6. 28. tasnim s, rahman a, hoque fma. patient’s knowledge and attitude towards tuberculosis in an urban setting. pulm med 2012;2012:e352850. 29. alqahtani fy, aleanizy fs, ali el hadi mohamed r, et al. prevalence of comorbidities in cases of middle east respiratory syndrome coronavirus: a retrospective study. epidemiol infect 2018;147:e35. 30. yu sh, guo am, zhang xj. effects of self-management education on quality of life of patients with chronic obstructive pulmonary disease. int j nursing sci 2014 [cited 2022 may 28];1(1). available from: https://cyberleninka. org/article/n/ 1005826 31. zachariah r, spielmann mp, harries ad, et al. passive versus active tuberculosis case finding and isoniazid preventive therapy among household contacts in a rural district of malawi. int j tuberc lung dis 2003;7:1033-9. 32. luba tr, tang s, liu q, et al. knowledge, attitude and associated factors towards tuberculosis in lesotho: a population based study. bmc infect dis 2019;19:96. article [healthcare in low-resource settings 2023; 11(s1):1167] [page 31] non -co mmerc ial us e o nly hrev_master [page 80] [healthcare in low-resource settings 2023; 11:11526] does satisfaction with the manual wheelchair have an impact on the quality of life in spinal cord injury? beenish mehmood paraplegic center, hayatabad, peshawar, pakistan abstract customized wheelchairs are an integral component of comprehensive rehabilitation and community integration for spinal cord injury (sci) survivors, while inappropriate wheelchairs negatively impact their functional independence, mobility and quality of life (qol). with this in mind, this study aimed to determine the effects of manual wheelchair users' satisfaction on qol in sci. this cross-sectional study, which included 112 sci, was conducted at the paraplegic centre, hayatabad, peshawar, over 6 months using "quebec user evaluation of satisfaction with assistive technology (quest)" and “world health organisation quality of life (whoqolbref)” as study tools. quest showed a significant positive correlation with physical health (rs=0.375; p< 0.001), social relationships (rs=0.234; p=0.013), and environmental health (rs=0.462; p<0.001) of qol except for psychological health, and similarly, overall health and overall qol was positively impacted. furthermore, overall health and environmental, social relationships, and physical domains of qol were statistically significantly impacted by the quest device and service aspects. a moderate level of satisfaction among participants for both devices and services was observed, which also impacts their physical, environmental, and social domains of qol. therefore, steps from the key stakeholders are required to provide satisfactory appropriate wheelchairs to patients so their qol can be improved. introduction mobility, one of the main rehabilitation goals for sci patients, impacts their quality of life (qol), maximum independence in activities of daily living (adl), and optimal community reintegration.1 sci leads to paralysis, which is the most common and evident manifestation,2 compelling sufferers to significantly rely on mobility aids,3 particularly wheelchairs, which serve as an essential and main source of mobility.4 manual wheelchairs (mws) are widely regarded as the most popular wheeled mobility aid among sci patients that enable their users’ independence in life, engage in social activities, access services, and improve qol.5 these mobility devices create opportunities for their users, and their appropriateness enables them to participate in desired activities, roles, and responsibilities. because of the injury and associated secondary complications, the qol of people with sci is comparatively lower than that of the general population.6,7 the benefits offered by a wheelchair, whether they pertain to a person’s mobility, community involvement, societal integration,8 qol,9 self-esteem, or functional independence, are only feasible when the equipment is satisfactory for its user.10 as it has ramifications for both the user and society as a whole, the appropriate wheelchair prescription, therefore, serves as the primary objective.11 earlier studies focused mainly on its design, price, delivery, and abandonment, with the least focus given to the fact that the device must be custom-made to the user’s satisfaction to attain its objectives to their maximum potential. therefore, quantification of a wheelchair user’s satisfaction and its impact on qol in sci is of utmost importance. low-income countries like pakistan struggle with quality wheelchairs, customization options, and rehabilitation services due to unique topography, socioeconomic imbalances, and inadequate infrastructure, making wheelchair acquisition and maintenance difficult.12 the current literature only contains a single study comparing manual and motorized wheelchairs, which is difficult to locate.13 taking this into account, this study aims to ascertain the effects of mw users’ satisfaction on qol in people with sci. materials and methods this cross-sectional study was conducted at the paraplegic centre, hayatabad, peshawar, pakistan. from july to december 2022, a total of 112 sci paraplegics (males and females), using customized manual wheelchairs (mws) for at least a month were included via convenience sampling. those with neurological problems other than sci and tetraplegics were not made part of the study. the sample size was calculated using the correlation sample size formula=[(zα + zβ)/c] 2 + 3. the study protocol was approved by the ethical review committee of the institute (ref: dir/kmu-eb/wu/000808, dated: 11/12/2020). informed consent was obtained from the study population, and the required information was recorded using a structured questionnaire where quest and whoqol-bref were used for satisfaction with mws and qol, respectively. healthcare in low-resource settings 2023; volume 11:11526 correspondence: beenish mehmood, paraplegic center, hayatabad, 25000 khyber pakhtunkhwa, pakistan. tel: +92.3468565641. e-mail: beenishmehmood7@gmail.com key words: spinal cord injury; wheelchair prescription; wheelchair satisfaction; manual wheelchair; quality of life; paraplegia. conflict of interest: the author declares no potential conflict of interest and confirms accuracy. ethics approval: the ethics committee approved this study (ref: dir/kmueb/wu/000808, dated: 11/12/2020). the study conforms with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: i would like to express my great appreciation to iftikhar ali (pharmacist and adjunct lecturer), college of physical medicine and rehabilitation sciences, paraplegic center, peshawar for his contribution, supervision, feedback and input. received for publication: 18 june 2023. accepted for publication: 29 september 2023. early access: 10 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11526 doi:10.4081/hls.2023.11526 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11526] [page 81] satisfaction levels between 1 to 2.33 were considered low while the scores 2.34 to 3.67 and 3.67 to 5 were considered moderate and high respectively.14 furthermore, occasional wheelchair users were considered the ones that tend to use their wheelchairs ‘less than once a month, 2 or 3 times a month,” while those with a frequency greater than that were considered regular users. for data analysis, spss (version 21®) was used. the shapiro-wilk test was used to determine data normality. descriptive statistics such as frequency and percentages were used for data and the mean along with standard deviation/ median with an interquartile range where appropriate were used for numerical data. the association between categorical variables was determined using the chi-square or fisher exact test. differences were calculated using student independent t-test or mannwhitney statistics, where applicable. similarly, one-way anova with post-hoc tukey test and kruskal-wallis tests were run for data with more than two categories. various correlations were determined using pearson and spearman rank correlations based on the data distribution. a p-value of <0.05 was considered significant. results the study includes participants with ages ranging between 17 and 65 years averaging at a mean of 31.14±10.94 years. more than half (n=61, 54.50%) of the participants were males. the majority of the participants had no formal education with 56 (50.30%) belonging to middle-income families with the thoracic spine injury being the most common site. the median time since the onset of sci was 36.00 (60.00) months. almost two-thirds (n=73, 65.18%) had sustained complete injury. background and spinal cord injury-related characteristics were compared across gender and the details are summarized in table 1. in general, the calculated mean for the quest subscales, namely device and services, was 3.24±0.50 and 3.25±0.59, respectively. additionally, the overall mean for satisfaction with the wheelchair was 3.24±0.68. approximately 75% of the participants expressed a moderate level of satisfaction with their wheelchairs, while 20% reported a high level of satisfaction. the whoqol-bref findings revealed that the mean scores were as follows: physical health (50.63±11.39), psychological health (51.47±7.42), social relationships (41.98±19.17), and environmental health (53.16±13.65). the association between outcome variables and background characteristics was determined. there was a significant mean difference between gender and the device subscale of quest (3.14±0.64 vs 3.38±0.5, p=0.029) and between socioeconomic status and satisfaction in the device domain (p=0.016) among participants. a post-hoc tukey test revealed that the upper class had a low score compared to the lower class. there was, however, no significant relationship between the age of participants and satisfaction with wheelchair use, as well as between device and service domains. similarly, there was a statistically significant difference in satisfaction with wheelchair service and usage of the wheelchair (p=0.038). however, there was no significant difference in satisfaction with wheelchair use across neurological levels or types of injuries. based on the data distribution, spearman rank correlation was used to determine the relationship between satisfaction and duration of injury and wheelchair usage. it was observed that the duration of sci and wheelchair usage were negatively correlated with the device subscale (p<0.05). moreover, in assessing the association between whoqolbref’s overall health, overall qol, and their domains with background characteristics, a statistically significant difference was observed between males and females in terms of overall qol (p=0.004). similarly, article table 1. sociodemographic and clinical characteristics association with gender. characteristics total gender p male, n=61 female, n=51 age, median(iqr) 28.00(12.75) 28.00(9.00) 29.00(19.00) 0.174¶ education, n (%) no formal education 46(41.07) 9 (14.75) 37(72.55) 0.000 primary 25(22.32) 19(31.15) 6(11.76) middle 20(17.86) 18(29.51) 2(3.92) higher 21(18.75) 15(24.59) 6(11.76) economic status, n (%) lower 52(46.43) 28(45.90) 24(47.06) 0. 173 middle 56(50.00) 29(47.54) 27(52.94) upper 4(3.57) 4(6.56) 0(0.00) duration of injury, median(iqr) 36.00(60.00) 48(72.00) 24(28.00) 0.004¶ neurological level, n (%) complete 73(65.18) 44(72.13) 29(56.86) 0.112 incomplete 39(34.82) 17(27.87) 22(43.14) type of injury, n (%) thoracic 80(71.43) 47(77.05) 33(64.71) 0.107 lumbar 32(28.57) 14(22.95) 18(35.29) wheelchair usage, n (%) regular 90(80.36) 50(81.97) 40(78.43) 0.643 occasional 22(19.64) 11(18.03) 11(21.57) comorbidities, n (%) present 30(26.79) 11(18.03) 19(37.25) 0.032 absent 82(73.21) 50(81.97) 32(62.75) duration of wheelchair use, median(iqr) 24.00(54.00) 36(60.00) 12(33.00) 0.004¶ ¶mann whitney statistics non -co mmerc ial us e o nly [page 82] [healthcare in low-resource settings 2023; 11:11526] the presence or absence of comorbidities was significantly associated with overall qol (p=0.015). with regards to quest’s items majority 53(47.32%) users in the category ‘dimensions’ reported being ‘more or less satisfied’ while for ‘effectiveness’ n=48, 41.96% and for ‘professionalism of service’ 16.96% reported being ‘quite satisfied’ and ‘very satisfied’ respectively. in the “repair and service” area, 29.46% of customers responded “not very satisfied,” while 14.29% in the ‘weight’ category gave a ‘not satisfied at all’ response as shown in figure 1. the correlation analysis showed that quest exhibited a significant positive correlation with physical health (rs=0.375; p<0.001), social relationships (rs=0.234; p=0.013), and environmental health (rs=0.462; p<0.001) of qol except for psychological health. similarly, overall health and overall qol were positively influenced. furthermore, the quest device and service aspects had a statistically significant impact on overall health, as well as the social relationships, physical, and environmental domains of qol. conversely, overall qol was impacted by device subscale only in the study sample (rs= 0.445; p<0.001) as depicted in correlogram figure 2. discussion sci patients heavily rely on wheelchairs for mobility, enabling daily activities and enduring companionship. the satisfaction found was moderate (3.24) for the wheelchair in this study, but in the swedish population, high satisfaction levels were reported by samuelsson et al.15 although, participants in both studies reported regular use of their wheelchairs, greater satisfaction (>80%) with the device could be attributed to factors such as effectiveness, durability and dimensions, with users being “quite” to “very satisfied,” while in this study, mw users for dimensions and comfort showed “more or less satisfaction (44.6%) similarly, a study conducted by de groot et al., found high levels of satisfaction with wheelchair-related aspects compared to services and a higher level of satisfaction with its dimensions. moreover, an active lifestyle was found in those with higher overall satisfaction. furthermore, the highest satisfaction 55.2% was found in effectiveness, 50.5% in simplicity of use and 45.3% in dimensions while in this study, comfort, dimensions and effectiveness were the identified components (>40%).14 furthermore, a study conducted by amosun on locally manufactured wheelchairs in tanzania reported high satisfaction with the features of the wheelchairs, where subjects expressed satisfaction with the durability (89%), and the professional services received (71%), compared to our study where customized wheelchairs were used, with overall satisfaction for both durability and professional services received was 45.60%.16 a study conducted in zimbabwe reported the highest dissatisfaction (>75) with durability, followed by weight then ease of adjustment.17 in the current study subjects were not dissatisfied, but the least dissatisfaction (<15%) that was documented was in follow-up, professional services and weight. in a regional study by sadiya et al. although it involved the most popular wheelchairs in india, i.e. “karma” and “artificial limbs manufacturing corporation of india” (alimco), still reported dissatisfaction, with 97% in follow-up, repairs and servicing and 94% in professional services.18 in this study, the mean score of the device subscale significantly differed between males and females as did the socioeconomic status. similarly, the duration of injury and wheelchair usage were significantly negatively correlated with the device subscale. contradictory results have been reported in the literature, a study conducted by de groot et al., found no variation in d-quest between gender, age and level of lesion.14 likewise, amosun reported no differences between males and females in wheelchair features and service delivery.16 lee et al. in south korea found high satisfaction for both genders in both categories article figure 1. quest item ratings. figure 2. correlation between quest and qol. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11526] [page 83] of quest.19 furthermore, participants in the current study reported comparatively high (3.26>3.18) satisfaction with the device. marchiori et al. studied not only the satisfaction scores of wheelchair users but their caregivers as well and found good satisfaction levels, with the majority like the current study being regular users. the author also reported no differences between the satisfaction scores of the occasional and regular wheelchair users similar to the age groups, sex or cause of mw use regarding global satisfaction scores and satisfaction with each parameter.20 geilen et al. found more or less satisfaction (3.8) for mws in bangalore with more satisfaction seen for devices than services. although gender, duration of the disability and a higher level of education (>0.05) were found related to satisfaction scores, females were reported to be more satisfied with the device than men (3.95>3.70). age however was negatively correlated with quest. the variation is, the inclusion of customized wheelchairs in our study while indians included children’s, 3-wheeled, hospitalstyle and rough terrain-style wheelchairs.21 a range of factors can be attributed to dissatisfaction including, appropriateness, provision and population characteristics both in terms of socioeconomic and sci characteristics. for instance, a study in brazil with a rigid frame wheelchair design reported high satisfaction (mean of 4.2).22 similarly, in india, where dissatisfaction with mws was reported, the level of injury might be the cause (tetraplegics).18 the level and severity of sci can impact wheelchair satisfaction. individuals with higher-level injuries (such as tetraplegia) typically face greater challenges in terms of independence and functional limitations.18, 23 age-related physical limitations and comorbidities impact wheelchair mobility satisfaction and overall satisfaction.21 similarly, gender differences could be due to differences in body mechanics, social roles, and expectations. the duration of wheelchair use can also have an influence.24 wheelchair users’ satisfaction can have a direct impact on overall qol. a wheelchair that meets functional independence and allows for increased mobility can positively influence qol. similarly, it has a significant impact on their psychological well-being, hence contributing to positive self-esteem, self-image, and mental wellbeing, which are essential components of overall qol.8,13 in this study, wheelchair satisfaction revealed positive impacts on environmental, physical and social domains of qol except the psychological domain. our findings are consistent with previously published study results. a study in tanzania reported improved qol as well as activity and participation with wheelchair satisfaction.16 similar results were also found with a low-cost wheelchair even in a multinational study where it improved qol and independence after one year of use.9 recently a study conducted in pakistan also found improvement in qol of sci paraplegics using both manual and motorized wheelchairs if they were satisfied with their device.13 a multinational study found that gen_2 wheelchair design was better than gen_1, however, overall health status and distance covered showed variation over time, and receiving one of two models appears to have a positive long-lasting effect on income and employment.24 similar to the current study olaleye et al. found wheelchair satisfaction to be associated with qol. furthermore, the author reported a significant relationship between the functioning, psychological situation and independence domains of sci-qol and satisfaction with wheelchair use among the participants. however, there was no significant relationship between the mood domain of hrqol and satisfaction with wheelchairs.8 on the other hand, some studies reported no significant results. de groot reported no association of quest with activity and participation.14 similarly, a study from china found no impact of wheelchair satisfaction on qol in sci. although satisfaction with devices was higher than satisfaction with services, this is similar to the current study. the correlation of the device (quest) with qol and with the psychological domain was weak but marginal but in our study significant relationship between the device subscale and overall qol, physical health, and social and environmental health was noted.25 a study by lee et al., reported that the parameters of device domain were associated with active lifestyle and participation.20 a moderate association was observed between the environmental and physical domain with quest but no association between services and qol which is contradictory to our study where the association between services and physical, social and environmental health(p<0.05) was observed.25 the greater the involvement of patients in the process of prescribing wheelchairs, the higher their satisfaction and their functional mobility, suggesting the significance of client involvement in prescription.26 further studies on this topic in different setups and other types of wheelchairs are required to validate these findings. there could be several justifications for these findings. psychological well-being is influenced by a multitude of factors beyond wheelchair users’ satisfaction. factors like social support, coping mechanisms, and personal resilience have a strong influence. additionally, other factors such as age, cultural background, prior psychological experiences, measurement limitations, contextual factors, timeframe considerations, body image and appearance which cannot be improved due to permanent body paralysis, may also impact the relationship between wheelchair satisfaction and psychological well-being.27 furthermore, this study not only included regular wheelchair users but also occasional wheelchair users. this inclusion aimed to gain insights from both categories of users regarding their satisfaction levels with wheelchairs and how it can impact their qol. limiting the study to only regular users would introduce bias into the results, as it would provide insights from a single category of users utilizing the same type of device (customized wheelchairs). previous studies have identified sources of occasional wheelchair usage, such as depression, social isolation, and wheelchair breakdowns. strength and limitations this study incorporated customized manual wheelchairs, recognized as potentially the most optimal assistive devices for individuals with sci when compared to standard wheelchairs. data collection was executed by a singular researcher, mitigating the potential for bias resulting from divergent interpretations of questionnaire items by different researchers. a noteworthy limitation of the study pertains to its design and the limited sample size. the exclusion of tetraplegics from the study cohort was predominantly influenced by their comparatively restricted ability to operate manual wheelchairs effectively. moreover, generalizability was also limited as it was conducted at a single center. conclusions customized mw (manual wheelchair) user satisfaction positively impacts the environmental, physical, and social domains of quality of life (qol). to achieve this goal, it is imperative to implement special measures that ensure the satisfaction of wheelchair users. it is worth noting that even minor improvements in the qol of wheelchair users can be immensely beneficial. therefore, it is crucial to prioritize the satisfaction of wheelchair users by taking appropriate measures to make the device more comfortable and efficient for them, especially at the policy level. this article non -co mmerc ial us e o nly [page 84] [healthcare in low-resource settings 2023; 11:11526] research addresses an important idea, customized wheelchairs, for which data is very scarce, especially in a country like pakistan. hence, it will add valuable data to the body of research and might provide material that can encourage future researchers to conduct studies on such an important topic. references 1. hamzat t. psychosocial impact of wheelchair usage on individuals with mobility disability in ibadan, nigeria. afr j med health sci 2015;44:89-94 2. harvey la. physiotherapy rehabilitation for people with spinal cord injuries. j physiother 2016;62:4-11. 3. florio j, arnet u, gemperli a, et al. need and use of assistive devices for personal mobility by individuals with spinal cord injury. j spinal cord med 2016;39:461-470. 4. sonenblum se, sprigle sh, martin js. everyday sitting behavior of full-time wheelchair users. j rehabil res dev 2016;53:585-598. 5. chen w-y, jang y, wang j-d, et al. wheelchair-related accidents: relationship with wheelchair-using behavior in active community wheelchair users. arch phys med rehabil 2011;92:892898. 6. adriaansen jj, ruijs le, van koppenhagen cf, et al. secondary health conditions and quality of life in persons living with spinal cord injury for at least ten years. j rehabil med 2016;48:853-860. 7. rivers cs, fallah n, noonan vk, et al. health conditions: effect on function, health-related quality of life, and life satisfaction after traumatic spinal cord injury. a prospective observational registry cohort study. arch phys med rehabil 2018;99:443-451. 8. olaleye oa, afolabi k, eds. satisfaction with wheelchair use and health-related quality of life among persons with spinal cord injury in southwest nigeria. proceedings of the resna annual conference; 2019; arlington. 9. shore s, juillerat s. the impact of a low cost wheelchair on the quality of life of the disabled in the developing world. med sci monit 2012;18:cr533– cr542. 10. borade ningle a, nagarkar a. lived experiences of people with mobilityrelated disability using assistive devices. disabil rehabil assist technol 2021;16:730-734. 11. greer nbrasure m, wilt tj. wheeled mobility (wheelchair) service delivery: scope of the evidence. ann intern med 2012;156:141-146. 12. ekman b, mishra s. sustainable and equitable provision of wheelchairs in lowand middle-income countries: an economic assessment of the models for wheelchair provision in tajikistan. disabil rehabil assist technol 2021; 16:865-870. 13. mehmood b, ali i, daud sa, et al. wheelchair user’s satisfaction and its impact on physical activity and quality of life in people with spinal cord injury. phys med rehab kuror 2022:18. 14. de groot s, post m, bongers-janssen h, et al. is manual wheelchair satisfaction related to active lifestyle and participation in people with a spinal cord injury? spinal cord 2011;49:560-565. 15. samuelsson k, wressle e. user satisfaction with mobility assistive devices: an important element in the rehabilitation process. disabil rehabil 2008;30:551-558. 16. amosun sndosi a, buchanan h. locally manufactured wheelchairs in tanzania–are users satisfied? afr health sci 2016;16:1174-1181. 17. visagie s, mlambo t, van der veen j, et al. impact of structured wheelchair services on satisfaction and function of wheelchair users in zimbabwe. afr j disabil 2016;5(1). 18. sadiya apattnaik m, mohanty p. exploring the impact of manual wheelchair design on user’s satisfaction and function in individuals with spinal chord injury’. asian j sci technol 2016;7:3464-3472 19. lee s-h. users’ satisfaction with assistive devices in south korea. j phys ther sci 2014;26:509-512. 20. marchiori c, bensmail d. manual wheelchair satisfaction among longterm users and caregivers: a french study. j rehabil res dev 2015;52:181192. 21. geilen bg, de witte l, norman g, et al. quality of wheelchair services as perceived by users in rural bangalore district, india: a cross-sectional survey. disabil rehabil assist technol 2020:1-9. 22. sugawara at, seigui oshiro m, yamanaka ei, et al. developing a rigid frame wheelchair in brazil. disabil rehabil assist technol 2019;16:538544. 23. shea jr, shay bl, leiter j, et al. energy expenditure as a function of activity level after spinal cord injury: the need for tetraplegia-specific energy balance guidelines. front physiol 2018;9:1286. 24. shore s. the long-term impact of wheelchair delivery on the lives of people with disabilities in three countries of the world. afr j disabil 2017;6:344. 25. chan sc, chan ap. user satisfaction, community participation and quality of life among chinese wheelchair users with spinal cord injury: a preliminary study. occup ther int 2007;14:123-143. 26. wolf n, maseko l, franzsen d, et al. wheelchair prescription after spinal cord injury: satisfaction and functional mobility. s afr j occup ther 2022;52: 68-77. 27. nas k, yazmalar l, şah v, et al. rehabilitation of spinal cord injuries. world j orthop 2015;6:8. article non -co mmerc ial us e o nly hrev_master [page 100] [healthcare in low-resource settings 2023; 11:11566] the prevalence and management of obstetric fistula among women of reproductive age in a low-resource setting olaniyi felix sanni,1 michael olugbamila dada,2 abimbola oluseyi ariyo,3 aisha oluwakemi salami,4 olaide lateef afelumo,4 oluwasola stephen ayosanmi,5 olaiya paul abiodun,4 elizabeth abike sanni1 1research and development department, fescosof data solutions, ogun state, nigeria; 2department of medical laboratory science babcock university, ogun state, nigeria; 3clinical services, aids prevention initiative, public health initiatives, abuja, nigeria; 4department of public health, texila america university, guyana (south america); 5department of pharmacy, university of saskatchewan, saskatoon, canada abstract obstetric fistula is one of the most significant obstetrical concerns and apparent indications of maternal morbidity in lowresource nations. therefore, the study assessed the prevalence and management of fistula among women of reproductive age (15-49) in low-resource settings. this population-based cross-sectional study was conducted in three local government areas (jere, konduga and maiduguri municipal city) in borno state. a structured questionnaire was used to collect data from 484 respondents, and the data were analysed using spss version 25.0. the overall prevalence of obstetric fistula was 10.7%. over 13% of women with seven or more vagina deliveries had a fistula. likewise, 19% of respondents knew about fistula prevention and treatment services available, and 13.7% of those did not participate in antenatal care services. furthermore, 48.1% of respondents with a fistula during labour were treated successfully. almost half (47.9%) who were aware of health facilities around them were successfully treated, same with 46.2% of those living within 1 to 2 km of a health facility, and almost half (49.0%) of those who got married within age 20. the study emphasizes the importance of effective community-level interventions to address obstetric fistula. to achieve this, a comprehensive action plan should be developed, ensuring pregnant women have access to necessary obstetric care services at all healthcare levels. the plan should include preventive measures, timely management of labour complications, and increased awareness of fistula prevention and treatment services. prioritizing maternal healthcare and empowering women with knowledge and access to services are essential in preventing and managing obstetric fistula. introduction one of the most apparent indications of maternal morbidity in low-resource nations is obstetric fistula (of), which remains a significant obstetrical concern.1 obstetric fistula is associated with prolonged and obstructed labour when emergency obstetric care is inadequate or inaccessible.2 those who survive an obstructed labour might suffer various physical and psychological injuries, as well as life-altering birth damage known as an obstetric fistula. a fistula occurs in a woman experiencing obstructed labour when the presenting foetal organ compresses the birth canal tissue, bladder base, urethra, or sometimes the rectum, producing ischemia and necrosis of the tissue.1 inadequate development of the pelvic bone structure increases the risk of obstructed labour and obstetric fistula. obstetric fistula is common in countries with a high prevalence of maternal mortality, which may be due to the aforementioned reasons.3,4 obstetric fistulas are generally ignored in low-resource and developing nations.4 it is more common among the poorest and most marginalised sections of society. furthermore, fistula is caused by various factors, including poverty, teenage pregnancy, early marriage, low socioeconomic level, and illiterate girls and women in rural areas, so it has remained a ‘hidden’ problem.5,6 data on obstetric fistula prevalence and burden are sparse. the most frequently cited prevalence estimate is two million cases worldwide and 50,000– 100,000 new cases yearly.1 although fistula is commonly found between the vagina and bladder (vesicovaginal), it can also form between the vagina and rectum (rectovaginal).7 consequently, fistula causes uncontrollable vaginal urine and/or faeces leakage and can cause infection.8 women with of have considerable psychological challenges, including loneliness, divorce, loss of social roles, loss of income, stigmatization, humiliation, and low self-esteem.9 many women who suffer from of also have to deal with the grief of a stillborn baby.10 of has been nearly eradicated in nations where emergency obstetric treatment is available and accessible. although it is avoidable and treatable, it remains widespread and harmful in many less-developed countries.5 surgical repair has been shown to have a success rate of about 90% for treating of. still, it can be difficult for women to access or pay in low-income countries due to a shortage of healthcare institutions offering surgical repair services and a lack of surgical training for fistula repair.4,11 however, successful of treatment necessitates the use healthcare in low-resource settings 2023; volume 11:11566 correspondence: olaniyi felix sanni, research and development department, fescosof data solutions, ogun state, nigeria. e-mail: fescosofanalysis@gmail.com key words: obstetric fistula; healthcare; women’s health; facilities to healthcare. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of national health research committee (nhrc) approved this study (nhrec/01/01/2007-7/03/2022). the study conforms with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 9 august 2023. accepted: 3 november 2023. early view: 10 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11566 doi:10.4081/hls.2023.11566 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly of specialized equipment, medications, infrastructure, and well-trained healthcare providers such as surgeons, anesthesiologists, nurses, physical therapists, and, in some cases, mental health counsellors. all of which are in short supply in many facilities.12 of is preventable via prompt and high-quality maternal health care services.12 because caesarean section or instrumental delivery is the most effective treatment for obstructed labour, making emergency obstetric care more widely available is essential to reducing the risk of both of and stillbirths.13 for nearly a decade, the united nations population fund (unfpa) and the us agency for international development (usaid) have worked to eliminate obstetric fistulas.14 quantifying development through trustworthy health measures, on the other hand, is challenging. based on a systematic analysis in 2013, over one million women in sub-saharan africa and south asia suffer from of, with 6,000 new cases occurring yearly.12 however, it was reported that of rates in lowand middle-income countries were 1 per 1,000 women of reproductive age and 1.57 per 1,000 women of reproductive age in sub-saharan africa and south asia alone.12 an additional thorough study is required to determine the global frequency of of and discover regional and national disparities. in nigeria, the frequency of obstetric fistula is 3.2 per 1000 births, and approximately 13,000 new cases are projected to rise each year, implying that the backlog of unrepaired cases will take about 83 years to resolve at the current pace of repair.15,16 according to the united nations international children’s emergency fund (unicef), nigerian women now live with of numbers between 400,000 and 800,000, and the country sees a further 50,000 to 100,000 new cases yearly.17 this study examines the prevalence and management of fistula among women of reproductive age in a low-resource setting. materials and methods study design a population-based cross-sectional study was conducted in three local government areas of low-resource settings in borno state, nigeria (jere, konduga and maiduguri municipal city (mmc) to evaluate the prevalence and management of obstetric fistula among women of reproductive age (15-49) years. the study population comprises women of reproductive age (1549) who have had at least one virginal delivery. the qualitative research method was used for this study. the quantitative method used structured questionnaires to collect data from the primary beneficiaries (women of reproductive age 15-49 years) regarding fistula repairs. the assessment also used a health facility assessment questionnaire by trained data collectors to collect quantitative data from all the existing health facilities in the three local government areas (lgas) in borno state. the study was conducted between march and august 2022. sample size findings from 2018 nigeria demographic health survey reports:21 where z = 1.96 p = prevalence of fistula among women of reproductive age in nigeria = 52% p = 0.16; 1-p = 1-0.16 = 0.48; d = marginal error = 0.05 = 383.5 = 384. the minimum sample size was calculated as 384. however, data were collected for 484 respondents to achieve a good representation of the population and to achieve good precision. sampling technique the study targeted females aged 10-49 years in three lgas. multi-stage cluster sampling was used to reach the respondents at the household level. the selection of reproductive age below 15 years was due to the early age of marriage in the northeast of nigeria, including borno state. in the first sampling stage, communities were categorized as urban or rural areas, and a list of villages/communities was obtained from lga offices. villages were then sampled proportionally based on their sizes. five communities/villages were selected in the catchment areas of health facilities (hfs) for interviews with females of reproductive age at the household level. during the survey, a housing unit was randomly selected at the centre of each village/community. subsequently, every third housing unit from the first randomly selected household was chosen for interviews. qualified respondents (females aged 15-49 years) were interviewed in each selected household. all hfs in the three lgas were surveyed.22,23 data collection method data was collected through a structured questionnaire from women of reproductive age 15-49 years in the three lgas of the state. the questionnaire is designed to collect important information about the respondents. the first section gathers background information, including the respondents’ gender, age, marital status, highest education completed, religion, and occupation. the second section assesses the respondents’ awareness of health facilities in their community, whether they have received medical treatment at these facilities, the type of treatment they received, and the type of health facility they visited. the third section delves into reproductive health, inquiring about marriage age, pregnancy history, current pregnancy status, and antenatal care services. the fourth section focuses on fistula history, asking about the number of vaginal and cesarean deliveries, any experience of fistula, and awareness of prevention and treatment services. data were also collected from all the existing health facilities’ assessment questionnaires by the trained data collectors in the three lgas of the state. additionally, the unfpa-approved trained data collectors used the fistula site assessment tool to collect data at the facility level. fieldworkers in each lga, the fieldworkers worked as a team. a consultant led a team of 5-7 data collectors in every local government area (lga). field personnel were recruited from borno and the northeastern geopolitical zone. this increased community participation and promoted resource efficiency. each data collector was assigned a minimum of six quantitative questionnaires each day when administering quantitative surveys. as a result, the data collectors collected fistula data from the health facilities in the lgas where they operated. training of field personnel and pre-test of instruments all field personnel were trained centrally in maiduguri metropolitan council (mmc). the exercise lasted three days and included a powerpoint presentation on survey methodology, logistics/fieldwork arrangement, role play, and field testing. after training, the evaluation instruments were pre-tested in neutral lgas in borno state for one day. the procedure necessitated data collection from a small number of households and two health facilities in the designated lga, where trained fieldwork article [healthcare in low-resource settings 2023; 11:11566] [page 101] non -co mmerc ial us e o nly ers administered the instruments. after the training, the findings were discussed. data analysis after data validation, all the data files were concatenated and exported to spss version 25.0, where data cleaning was done in preparation for the data analysis. the data analysis used descriptive statistics to summarize the demographic characteristics of women of reproductive age in a lowresource setting in a northern state in nigeria. logistic regression was employed to investigate the factors associated with fistula experiences and successful treatment. the odds ratios and 95% confidence intervals were calculated to assess the relationships between the presence of fistula experiences and various variables such as age category, marital status, education level, religion, occupation, age at marriage, number of vaginal deliveries, attendance of antenatal care, delivery in a health facility, and type of health facility attended. additionally, the study explored the characteristics of healthcare facilities providing fistula management services and assessed the availability of competent personnel for fistula surgeries and training in these facilities. ethical consideration the ethical approval for this study was obtained from the national health research committee (nhrc). results as shown in table 1, four hundred and eighty-four women from low-resource areas in a northern state in nigeria responded to this survey, of which 39.3% were within the age 20 to 29 years, 38.4% were within 30 to 39 years, 15.1% within 40 to 49 years and 7.2% were less than 20 years. most (84.9%) respondents were married, 5.6% were single, 6.0% were divorced, and 3.5% were widowed. more than half (52.7%) of the respondents had quranic education as the highest level; 18.2% completed secondary school, 15.7% finished primary school, 8.5% completed tertiary education, and 5.0% were illiterate. a significant proportion (93.4%) of the respondents were muslims, and the remaining 6.6% were christians. over two-thirds (71.5%) were into trading, 11.6% were professionals, 5.6% were in farming, and 11.4% earned through other employment means. table 2 presents the findings regarding the prevalence and factors associated with labour that resulted in a fistula among the respondents. of 484 participants, 52 (10.7%) experienced fistula during childbirth. the majority of women who had this experience were in the age category of 40 to 49 years (13.7%). being single was more common among respondents with a fistula (14.8%). similarly, those with a secondary education level accounted for the highest proportion (13.6%) of women who experienced fistula. many women identified as muslims (10.8%) and farmers (14.8%) also had this labour complication. women who married at or below 20 years constituted the majority (11.8%) of those who experienced fistula. seven or more vaginal deliveries were prevalent among women with fistula (13.5%). most of the women who experienced fistula were aware of prevention and treatment services (19.0%), and many did not know anyone in their community with a fistula (11.4%). not attending antenatal care (13.7%) and delivering outside a health facility (13.1%) were associated with a higher prevalence of fistula experiences. notably, attending secondary healthcare facilities (18.2%) was more common among respondents with labour that resulted in a fistula. the logistic regression analysis revealed that there was no statistically significant difference in the odds of having a labour that results in a fistula concerning age category, education, marital status, religion, occupation, age of marriage, vaginal delivery, a community member with fistula, attendance of antenatal care, and health facility attended (all p-values >0.05). however, two significant associations were observed. the odds of experiencing a fistula were 0.30 times higher and significantly different among those who knew about prevention and treatment services (95% ci: 0.17 – 0.54, p<0.05) compared to those who did not. similarly, the odds of having a labour that results in a fistula were 5.31 times higher and significantly different among women who did not give birth in a health facility (95% ci: 1.62 – 17.39, p<0.05) than those who did. table 3 presents the findings related to the successful fistula treatment among the respondents who experienced it during childbirth. out of the fifty-two participants with fistula, twenty-five (48.1%) had a successful treatment. among those who were aware of health facilities in their community, 23 (47.9%) received successful treatment for fistula. participants within 3 to 4 kilometres of health facilities had a higher proportion of successful treatment (55.6%), followed by those within 1 to 2 km (46.2%). nearly half (49.0%) of married respondents within 20 years and below had successful fistula treatment. the majority (63.6%) of women who had successfully treated fistula had experienced 3-4 vaginal deliveries. moreover, more than half (67.7%) of the women who knew about fistula prevention and treatment services received successful treatment. notably, a significant proportion (80.0%) of women who knew someone in their community who had a fistula also had successful treatment. almost half (48.3%) of women who did not attend antenatal care article table 1. characteristics of women of reproductive age in a low-resource setting. parameter frequency (n=484) percentage age category less than 20 35 7.2 20-29 years 190 39.3 30-39 years 186 38.4 40-49 years 73 15.1 marital status single 27 5.6 married 411 84.9 divorced 29 6.0 widowed 17 3.5 highest education none 24 5.0 quranic education 255 52.7 primary 76 15.7 secondary 88 18.2 tertiary 41 8.5 religion christianity 32 6.6 islam 452 93.4 occupation farming 27 5.6 trading 346 71.5 professional 56 11.6 others 55 11.4 [page 102] [healthcare in low-resource settings 2023; 11:11566] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11566] [page 103] received successful treatment, while 47.8% of those who attended antenatal care were treated successfully. additionally, more than half (57.1%) of women who were available for post-natal care had successful treatment for fistula, compared to 46.7% of those who were not available for post-natal care. a higher percentage (51.0%) of women who gave birth outside health facilities received successful treatment for fistula. furthermore, a higher proportion (64.3%) of women who had successfully treated fistula had attended secondary healthcare facilities. the logistic regression analysis revealed that there was no statistically significant difference in the odds of having successful treatment for fistula concerning awareness of health facilities in the community, distance of health facilities to residence, age of marriage, times of vaginal delivery, attendance of antenatal care, delivery in a health facility, and type of health facility attended (all p-values >0.05). however, two significant associations were observed. the odds of successful fistula treatment were 8.93 times higher and significantly different among respondents who were aware of available fistula prevention and treatment services (95% ci: 2.37 – article table 2. logistics regression of the respondents with labour that resulted in a fistula. parameter ever had a labour that resulted in fistula (n = 484) p no n (%) yes n (%) odds ratio (95% ci) overall 432 (89.3) 52 (10.7) age category less than 20 31 (88.6) 4 (11.4) ref 0.432 20-29 years 175 (92.1) 15 (7.9) 0.66 [0.21-2.13] 30-39 years 163 (87.6) 23 (12.4) 1.09 [0.35-3.38] 40-49 years 63 (86.3) 10 (13.7) 1.23 [0.36-4.24] marital status single 23 (85.2) 4 (14.8) ref 0.833 married 367 (89.3) 44 (10.7) 0.69 [0.23-2.09] divorced 26 (89.7) 3 (10.3) 0.66 [0.13-3.28] widowed 16 (94.1) 1 (5.9) 0.36 [0.04-3.52] highest education none 21 (87.5) 3 (12.5) 5.71 [0.56-58.38] 0.117 quranic education 222 (87.1) 33 (12.9) 5.95 [0.79-44.72] primary 73 (96.1) 3 (3.9) 1.64 [0.17-16.33] secondary 76 (86.4) 12 (13.6) 6.32 [0.79-50.33] tertiary 40 (97.6) 1 (2.4) ref religion christianity 29 (90.6) 3 (9.4) ref 0.796 islam 403 (89.2) 49 (10.8) 0.85 [0.25-2.90] occupation farming 23 (85.2) 4 (14.8) 2.22 [0.51-9.65] 0.369 trading 305 (88.2) 41 (11.8) 1.71 [0.59-4.99] professional 53 (94.6) 3 (5.4) 0.72 [0.15-3.39] others 51 (92.7) 4 (7.3) ref age at the time of marriage 20 years and below 382 (88.2) 51 (11.8) 6.68 [0.90-49.37] 0.063 above 20 years 50 (98.0) 1 (2.0) ref vaginal delivery 2 and below deliveries 118 (90.8) 12 (9.2) ref 0.683 3-4 108 (90.8) 11 (9.2) 1.00 [0.42-2.36] 5-6 81 (89.0) 10 (11.0) 1.21 [0.50-2.94] 7 deliveries and above 125 (86.8) 19 (13.2) 1.50 [0.70-3.21] awareness of the fistula prevention and treatment services available yes 132 (81.0) 31 (19.0) ref <0.001* no 300 (93.5) 21 (6.5) 0.30 [0.17-0.54] knowledge of anyone in the community who had a fistula yes 105 (91.3) 10 (8.7) ref 0.418 no 327 (88.6) 42 (11.4) 1.35 [0.65-2.78] attended anti-natal care yes 249 (91.5) 23 (8.5) ref 0.068 no 183 (86.3) 29 (13.7) 1.72 [0.96-3.06] delivered in a health facility yes 106 (97.2) 3 (2.8) ref 0.006* no 326 (86.9) 49 (13.1) 5.31 [1.62-17.39] type of health facility attended primary health care 306 (91.1) 30 (8.9) ref 0.128 secondary health care 18 (81.8) 4 (18.2) 1.62 [0.82-3.19] others 38 (82.6) 8 (17.4) 2.15 [0.92-5.02] non -co mmerc ial us e o nly [page 104] [healthcare in low-resource settings 2023; 11:11566] 33.55, p<0.05) than those who were unaware. likewise, the odds of having successful treatment for fistula were 5.88 times higher and significantly different among those who knew people with fistula in their community (95% ci: 1.11-31.17, p<0.037) than those who did not. treatment and management of fistula in the facilities as shown in table 4, thirty-three facilities were visited for this research work, of which 78.8% were primary healthcare, and the remaining 21.2% were secondary healthcare facilities. more than half (57.6%) of the facilities were private, and 42.4% were government-owned. the state government-financed 42.4% of the facilities, 27.3% were financed by private grants/donors, 21.2% got their funds from self-paying clients, 6.1% from charity, and the federal government funded 3.0% of the facilities. less than one-tenth (6.1%) of the facilities offer fistula clients counselling for prevention. similarly, 6.1% of the facilities provide fistula repair, 15.2% provide fistula treatment, 6.1% have a laboratory for all the main tests needed, and 30.3% offer fistula client referral. table 5 represents the staffing requirements for fistula surgery and the current availability of staff with specific competencies. “staff for fistula surgery” refers to the different categories of staff members required for performing fistula surgeries and training other surgeons. “needed (mean)” represents the ideal number of staff needed in each category to carry out fistula surgeries and training programs effectively. “present (mean)” indicates the current average number of staff members available in each category. “percentage present” shows the percentage of the required staff currently available in each category. in healthcare facilities, the ideal number of staff needed for competency in simple repair is 5, but only 2.5 staff members are available, resulting in a present availability of staff competent in simple fistula repair at 50% of the required number. similarly, the ideal number of staff needed for competency in moderate complexity repair is 5, and there are 3 staff members available, indicating a present availability of staff competent in moderately complex fistula repair at 60% of the required number. for competency in complicated surgery, the ideal number of staff needed is 5, with 2.5 staff available, resulting in a present availability of staff competent in complicated fistula surgeries at 50% of the required number. the ideal number of competent fistula surgeons needed is 5, but there are only 2.5 trainers available, article table 3. logistics regression of the respondents who had successful treatment on fistula. parameter successfully treated on fistula p no n (%) yes n (%) odds ratio (95% ci) overall 27 (51.9) 25 (48.1) aware of any health facility in your community no 2 (50.0) 2 (50.0) ref 0.936 yes 25 (52.1) 23 (47.9) 0.92 [0.12-7.08] distance of health facility to your residence 1-2 km 14 (53.8) 12 (46.2) ref 0.927 3-4 km 4 (44.4) 5 (55.6) 1.46 [0.32-6.70] 5-6 km 6 (60.0) 4 (40.0) 0.78 [0.18-3.42] 7-10 km 0 (0.0) 1 (100.0) - age at the time of marriage 20 years and below 26 (51.0) 25 (49.0) - above 20 years 1 (100.0) 0 (0.0) ref vaginal delivery 2 and under deliveries 6 (50.0) 6 (50.0) ref 0.513 3-4 4 (36.4) 7 (63.6) 1.75 [0.33-9.30] 5-6 7 (70.0) 3 (30.0) 0.43 [0.07-2.50] 7 deliveries and above 10 (52.6) 9 (47.4) 0.90 [0.21-3.82] aware of the fistula prevention and treatment services available no 17 (81.0) 4 (19.0) ref 0.001* yes 10 (32.3) 21 (67.7) 8.93 [2.37-33.55] knowledge anyone in the community who had a fistula no 25 (59.5) 17 (40.5) ref 0.037* yes 2 (20.0) 8 (80.0) 5.88 [1.11-31.17] attended anti-natal care no 15 (51.7) 14 (48.3) ref 0.974 yes 12 (52.2) 11 (47.8) 0.98 [0.33-2.94] attended post-natal care no 24 (53.3) 21 (46.7) ref 0.608 yes 3 (42.9) 4 (57.1) 1.52 {0.31-7.60} delivered in the health facility no 24 (49.0) 25 (51.0) ref yes 3 (100.0) 0 (0.0) - type of health facility attended primary health care 18 (60.0) 12 (40.0) ref 0.331 secondary health care 5 (35.7) 9 (64.3) 2.70 [0.73-10.06] others 4 (50.0) 4 (50.0) 1.50 [0.31-7.19] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11566] [page 105] making the present availability of trainers competent in training fistula surgeons at 50% of the required number. additionally, the ideal number of competent personnel to train the trainers is 5, with 3 trainers available, indicating a present availability of trainers competent in training other trainers at 60% of the required number. discussion obstetrical fistula is one of the primary health issues among women of childbearing age in low-income countries. perhaps women suffer one of the most unpleasant and demeaning conditions.24 obstetrical fistula is a health problem caused by the interplay of several physical elements and the woman’s social, cultural, and economic position. this interplay impacts the women’s social and economic standing, health, nutrition, fertility, behaviour, and vulnerability to obstetric fistula.25 inaccurate reporting and underreporting due to the stigma attached to obstetric fistula and the embarrassment felt by women who disclose their condition make it impossible to obtain reliable statistics on its prevalence.26 reaching rural women is challenging, and they are at increased risk for labour issues. nevertheless, most research is facilitybased, accounting solely for women who can access health care.27 in total, it is estimated that over one million women in subsaharan africa and south asia have a fistula, with over 6,000 new instances occurring each year in these two world regions. given the severe implications of fistula for women and their families, this is a huge burden.5 based on the result of this study, it was discovered that the overall prevalence of women who had a delivery that resulted in obstetric fistula was (10.7%). this study indicated that though the prevalence rate for obstetric fistula was low, it was more prevalent among women aged (30 to 39) years. studies conducted in india supported the low prevalence among women who had a delivery that resulted in obstetric fistula from this study.1 ethiopia28 and gambia29 also discovered a low prevalence rate among women who had a labour that resulted in an obstetric fistula. based on a study by wall,5 the possible reason for a low prevalence rate of obstetric fistula among women was the timely caesarean section performed on women admitted to the hospital, which may have prevented obstetric fistula from developing. however, several social, cultural, and healthcare issues, including a lack of emergency obstetric article table 4. characteristics of the sampled facilities. parameter frequency (n=33) percentage characteristics of health facilities type of facilities primary health care 26 78.8 secondary health care 7 21.2 ownership public 14 42.4 private 19 57.6 source of the fund to the facility state government 14 42.4 private grants/donors 9 27.3 self-paying clients 7 21.2 charity 2 6.1 federal government 1 3.0 fistula management services fistula client counselling for prevention yes 2 6.1 no 31 93.9 fistula client referral yes 10 30.3 no 23 69.7 fistula repair yes 2 6.1 no 31 93.9 fistula treatment yes 5 15.2 no 28 84.8 laboratory able to conduct all the main tests needed for fistula treatment yes 2 6.1 no 31 93.9 table 5. competent personnel for fistula surgery in the facility. staff for fistula surgery needed (mean) present (mean) percentage present competent in simple repair 5.0 2.5 50.0 competent in moderate complexity repair 5.0 3.0 60.0 competent in complicated surgery 5.0 2.5 50.0 competent trainer of fistula surgeons 5.0 2.5 50.0 competent as a trainer of trainers 5.0 3.0 60.0 non -co mmerc ial us e o nly [page 106] [healthcare in low-resource settings 2023; 11:11566] treatment, child marriage linked with early pregnancy, poverty, malnutrition, and poor healthcare facilities, all contribute to the increased incidence of obstetric fistula in low-income nations, including nigeria.30,31 commonly identified risk factors for obstetrical fistula include the place of birth and presence of a skilled birth attendant, labour duration, and early marriage.32,33 a study in india revealed that fistulae were associated with demographic variables such as education and high parity(number of deliveries).1 the study was similar to findings from other studies.32,34 these findings also correlated with the findings from this study in which women who had more than seven deliveries and women who were illiterate (with islamic education) had more cases of fistula. the low level of education could be due to poverty and inadequate investment in the education sector in the northeast and the high rate of insurgents, which has crippled most of their sources of income.35 it was also recorded in this study that the occurrence of fistula was more prevalent among women who were involved in early marriage. this report corresponds with a study conducted in yemen26 and ethiopia.36 the possible reason for this could result from forced marriage, particularly among muslims.37 this study discovered that many respondents did not attend antenatal care, supported by a study in yemen.26 this could result from the distance to health facilities or the cost of transportation to health care.38 women who did not receive antenatal care and gave birth at home have been shown to have a higher risk of having an obstetric fistula, as evidenced by this study.39 also, this study recorded a low prevalence rate of women who were aware of the prevention and treatment of fistula. this is consistent with a study conducted in china39 and india,1 which recorded participants’ low awareness of obstetric fistula. this could be because many women suffering from fistula do not know about it or are unaware that the condition is treatable.38 some might be misinformed. some women believe it is a punishment from god.40,41 furthermore, this study’s overall success rate for managing and treating fistula was (48.1%). this was significantly less than a study conducted in yemen, which recorded a high success rate for fistula treatment, consistent with the high success rate in some literature.42-44 moreover, this study recorded a substantial proportion of women who were aware of the prevention and treatment services available for obstetric fistula and were treated successfully. educating the local community about the social and physiological factors that increase the risk of obstetric fistula may be more effective in eradicating obstetric fistula in developing countries where women cannot access the health care system.45additionally, in this study, distance to healthcare centres greatly influenced the success rate of treatment of obstetric fistula as those who reside 1-2km close to health facilities had a higher successful treatment rate of obstetric fistula. this was supported by a study conducted in india1 and yemen.26 numerous countries in sub-saharan africa place a premium on establishing specialised fistula hospitals committed to treating women with fistula.5 in light of the rarity of the illness and the high degree of expertise and training required for fistulae surgery, the findings of this research imply that the vast majority of resources should always be better spent on prevention rather than cure. it is believed that strengthening maternal health services, creating favourable conditions for improved transportation and communication networks, and training local providers in the management of emergency complications, including those associated with caesarean sections, will have the additional effect of facilitating the provision of care for other causes of maternal and perinatal mortality and morbidity.3,5 fistula is exacerbated by various factors, including delays in getting caesarean operations, incorrect practices, and a scarcity of caesarean sections. as evidenced by the fact that fistula has nearly disappeared in high-income countries, it is reasonable to conclude that they are entirely preventable. efforts must be made to locate women suffering from fistula and treat them, given the seriousness of the condition. conclusions the study recorded a low obstetric fistula prevalence rate of 10.7% with a 48.1% (moderate) success rate in treatment. however, fistula cases and outcomes were not significantly influenced by factors such as age category, education, age of marriage, number of deliveries, awareness of treatment and prevention, antenatal care, delivery location, and distance to healthcare centres. however, knowledge of fistula prevention, treatment, and delivery in a health facility significantly influenced fistula cases. resolving fistula issues is crucial for maternal healthcare, and a community-level action plan is recommended to offer pregnant women necessary obstetric care at all healthcare levels, preventing obstructed and delayed labour, the main cause of fistula. addressing sociodemographic variables will help reduce fistula incidence, and welltrained community health workers should identify and refer cases promptly. references 1. swain d, parida sp, jena sk, das m, das h. prevalence and risk factors of obstetric fistula: implementation of a need-based preventive action plan in a south-eastern rural community of india. bmc womens health 2020;20:1-10. 2. yismaw l, alemu k, addis a, alene m. time to recovery from obstetric fistula and determinants in gondar university teaching and referral hospital, northwest ethiopia. bmc womens health 2019;19:5. 3. chauhan s, kulkarni r, agarwal d. prevalence & factors associated with chronic obstetric morbidities in nashik district, maharashtra, india. indian j med res 2015;142:479-88. 4. jungari s, govind chauhan b. obstetric fistula in assam, india: a neglected cause of maternal morbidities and mortality. healthc low-resource settings 2015;3:4663. 5. wall ll. obstetric vesicovaginal fistula as an international public-health problem. lancet 2006;368:1201-9. 6. mallick l, tripathi v. the association between female genital fistula symptoms and gender-based violence: a multicountry secondary analysis of household survey data. trop med int heal 2018;23:106-19. 7. adler aj. estimating the prevalence of obstetric fistula: a systematic review and meta-analysis. obstet gynecol surv 2013;13:246. 8. ramphal s. vesicovaginal fistula: obstetric causes. curr opin obs gynecol 2006;18147-51. 9. cowgill kd, bishop j, norgaard ak, et al. obstetric fistula in low-resource countries: an under-valued and understudied problem systematic review of its incidence, prevalence, and association with stillbirth. bmc pregnancy childbirth 2015;15:1-7. 10. roush km. social implications of obstetric fistula: an integrative review. j midwifery women’s heal 2009;54:e21-33. 11. creanga aa, ahmed s, genadry rr, stanton c. prevention and treatment of obstetric fistula: identifying research needs and public health priorities. int j gynecol obstet 2007;99:151-4. 12. kayla mcgowan. mhtf blog [part 1] obstetric fistula: a global maternal health challenge 2017;115. 13. wall ll. preventing obstetric fistulas in low-resource countries: insights from a haddon matrix. obstet gynecol surv 2012;67:111-21. 14. maheu-giroux m, filippi v, article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11566] [page 107] samadoulougou s, et al. prevalence of symptoms of vaginal fistula in 19 subsaharan africa countries: a meta-analysis of national household survey data. lancet glob heal 2015;3:e271-8. 15. bello oo, morhason-bello io, ojengbede oa. nigeria, a high burden state of obstetric fistula: a contextual analysis of key drivers. pan african med j 2020;36. 16. unfpa. national strategic framework for the elimination of obstetric fistula in nigeria 2019-2023. unfpa, new york 2019. 17. hodin s, initiative h. more women in nigeria are using maternal health services but gaps persist. but gaps persist 2018:1-7. 18. daniel mfonobong. borno state: list of local government areas & towns 2020:1-4. https://nigerianinfopedia. com.ng/borno-state-local-governmentareas-towns/ accessed december 21, 2021. 19. britannica. borno state, nigeria. britannica 2021:1-5. accessed december 16, 2021. available from: https://www.britannica.com/place/borno 20. city population. borno (state, nigeria) population statistics, charts, map and location 2020:1-3. accessed december 16, 2021. available from: https://www.citypopulation.de/php/nige ria-admin.php?adm1id=nga008 21. npc. nigeria demographic health survey 2018. natl popul comm [nigeria] icf 2019:748. 22. questionpro. multi-stage sampling definition, steps, applications, and advantages with example. questionpro 2021:1-4. accessed december 16, 2021. available from: https://www.questionpro.com/blog/mul tistage-sampling-advantages-and-application/ 23. brm. multi-stage sampling 2021:1-4. accessed december 16, 2021. available from: https://researchmethodology.net/sampling-in-primarydata-collection/multi-stage-sampling/ 24. naru t, rizi jh, talati j. surgical repair of genital fistulae. j obs gynaecol res 2004;30:293-6. hayet s, sujan km, mustari a, miah ma. hemato-biochemical profile of turkey birds selected from sherpur district of bangladesh. int j adv res biol sci 2021;8:1-5. 25. johnson k. incontinence in malawi: analysis of a proxy measure of vaginal fistula in a national survey. int j gynecol obstet 2007;99:s122-9. 26. muleta m, fantahun m, tafesse b, et al. obstetric fistula in rural ethiopia. east afr med j 2007;84:525-33. 27. walraven g, scherf c, west b, et al. the burden of reproductive-organ disease in rural women in the gambia, west africa. lancet 2001;357:1161-7. 28. kalilani-phiri lv, umar e, lazaro d, et al. prevalence of obstetric fistula in malawi. int j gynecol obstet 2010;109:204-8. 29. biadgilign s. a population-based survey in ethiopia using questionnaire as proxy to estimate obstetric fistula prevalence: results from demographic and health survey. reprod heal 2013;10:1-8. 30. cowgill kd, bishop j, norgaard ak, et al. obstetric fistula in low-resource countries: an under-valued and understudied problem systematic review of its incidence, prevalence, and association with stillbirth. bmc pregnancy childbirth 2015;15:193. 31. roka zg, akech m, wanzala p, et al. factors associated with obstetric fistulae occurrence among patients attending selected hospitals in kenya, 2010: a case-control study. bmc pregnancy childbirth 2013;13:56. 32. dolea c, abouzahr c. global burden of obstructed labour in the year 2000: evidence and information for policy (eip), world health organization, geneva. geneva world heal organ 2000:1-17. 33. amzat a. despite decades of funding, literacy level in the northern states remains low. the guardian nigeria news nigeria and world news 2017:1-4. accessed december 21, 2021. available from: https://guardian.ng/news/despitedecades-of-funding-literacy-level-inthe-northern-states-remains-low/ 34. muleta m, hamlin ec, fantahun m, kennedy rc, tafesse b. health and social problems encountered by treated and untreated obstetric fistula patients in rural ethiopia. j obstet gynaecol canada 2008;30:44-50. 35. itebiye bo. forced and early marriages: moral failures vs religious nuances. eur sci j 2016;12:305. 36. baker z, bellows b, bach r, warren c. barriers to obstetric fistula treatment in low-income countries: a systematic review. trop med int heal 2017;22:938-59. 37. wall ll, arrowsmith sd, briggs nd, browning a, lassey a. the obstetric vesicovaginal fistula in the developing world. obstet gynecol surv 2005;60:s3-s51. 38. dai y, zhou y, zhang x, xue m, sun p, leng j, et al. factors associated with deep infiltrating endometriosis versus ovarian endometrioma in china: a subgroup analysis from the feeling study. bmc womens health 2018;18:205. 39. muleta mm, fantahun b, tafesse ec. hamlin, r.c. kennedy. obstetric fistula in rural ethiopia. east african med j 2007;84:525-533. 40. kapoor r, ansari ms, singh p, et al. management of vesicovaginal fistula: an experience of 52 cases with a rationalized algorithm for choosing the transvaginal or transabdominal approach. indian j urol 2007;23:372-6. 41. biswas a. genital fistulaour experience. j indian med assoc 2007;105: 123-6. 42. khan rm, raza n, jehanzaib m, sultana r. vesicovaginal fistula: an experience of 30 cases at ayub teaching hospital abbottabad. j ayub med coll abbottabad 2005;17:48-50. 43. banke-thomas ao, wilton-waddell oe, kouraogo sf, mueller e. current evidence supporting obstetric fistula prevention strategies in sub-saharan africa: a systematic review of the literature. afr j reprod health 2014;18: 118-27. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11165 β-(1,3)-d-glucan from pleurotus ostreatus correlates with lower plasma il-6, il-1β, homa-ir, and higher pancreatic beta cell count in high-fat and high-fructose diet (hffd) rats alma maghfirotun innayah,1 elvira nur sa’idah hariani,2 husnul khotimah,1,3 inggita kusumastuty,2 ema pristi yunita,4,5 dian handayani2,5 1master program in biomedical sciences, faculty of medicine, universitas brawijaya, malang, indonesia; 2department of nutrition science, faculty of health sciences, universitas brawijaya, malang, indonesia; 3pharmacology department, faculty of medicine, universitas brawijaya, malang, indonesia; 4department of pharmacy, faculty of medicine, universitas brawijaya, malang, indonesia; 5research center of smart molecule of natural genetic resources (smonagenes), universitas brawijaya, malang, indonesia abstract introduction: the increasing consumption of high-fat and high-fructose foods contributes to the increasing prevalence of global obesity. low-grade chronic inflammation in obesity is a significant risk factor for insulin resistance and type 2 diabetes. therefore, this study aimed to determine the effect of β-(1,3)-dglucan from oyster mushroom (pleurotus ostreatus) extract on rats fed with a high-fat and high-fructose diet. design and methods: this experimental study was conducted on 35 male sprague-dawley rats aged eight weeks. the rats were divided into groups given a normal (n) diet, a high-fat and highfructose diet (hffd), d1 (hffd+125 mg/kg bw β-glucan), d2 (hffd+250 mg/kg bw β glucan), and d3 (hffd+375 mg/kg bw β-glucan) with an intervention of 14 weeks. il-6 and il-1β levels were measured by the elisa method, while homa-ir (homeostatic model assessment for insulin resistance) was calculated by the fasting insulin (ng/ml) x fasting blood glucose (mg/dl)/405 formula. pancreatic beta-cell counts were measured by hematoxylin and eosin (h&e) staining. results: the results showed no differences in il-6 and il-1β between the treatment groups. however, there were significant differences in homa-ir and pancreatic beta-cell counts between groups. there were negative correlations between the dose of βglucan and il-6, il-1β, and homa-ir levels. also, there was a positive correlation between the dose of β-glucan and the number of pancreatic beta cells. conclusions: administration of β-(1,3)-d-glucan from oyster mushroom (pleurotus ostreatus) extract prevented hyperglycemia and insulin resistance, also reduced inflammation in rats fed with hffd regardless of weight gain. introduction obesity is a significant global health issue that triggers insulin resistance, the beginning of non-communicable diseases such as type 2 diabetes mellitus.1,2 in indonesia, the prevalence of adult obesity increased from 10.5% in 2007 to 14.8% in 2013 and 21.8% in 2018. this condition was accompanied by an increase in diabetes mellitus based on the physician’s diagnosis, from 1.5% in 2013 to 2% in 2018. furthermore, diabetes mellitus diagnosis based on blood glucose testing increased from 6.9% in 2013 to 8.5% in 2018.3 changes in people’s consumption patterns to highfat and high-fructose foods and drinks increase the prevalence of obesity.4 fat tissue accumulation in overweight and obese conditions causes low-grade chronic inflammation by releasing cytokines such as tnf-α, il-6, and il-1β.5,6 low-grade chronic inflammation is a significant risk factor for insulin resistance and type-2 diabetes mellitus. in this case, elevated il-6 and il-1β increase insulin resistance and type 2 diabetes risk.2,7,8 prevention and treatment of metabolic syndrome is a strategy under development by developing functional food. an example is a well-known mushroom consumed for 3000 years and used in traditional chinese and east asian medicine.9,10 for their therapeutic effects, some of the best well-known mushrooms are ganoderma lucidum (lingzhi mushroom) and lentinula edodes (shiitake mushroom). a study showed that adding shiitake mushrooms into a high-fat diet mixture could reduce plasma triglyceride (tg) levels, inhibit weight gain, and reduce fat deposition in rats.11 in indonesia, one mushroom popularly cultivated is a white oyster mushroom (pleurotus ostreatus), consumed as an alternative for protein and a source of fiber.12 white oyster mushrooms have several bioactive components, such as β-glucan, a polysaccharide group composed of d-glucose molecules bound to β-(1,3)and (1,6)-d-glucan.13 β-glucan from oats have been explored earlier, which has been proven to improve insulin sensitivity and homa-ir and lowers blood glucose, hba1c levels, and body weight in mice fed with a high-fat diet.14,15 several species from the pleurotus genus have been explored, including pleurotus citrinopileatus, pleurotus sajor-caju, pleurotus tuber-regium, and pleurotus ostreatus, both in vitro and in vivo. they show positive effects on weight loss, prevent hyperarticle significance for public health changes in people's consumption patterns to high-fat and high-fructose food contribute to obesity and diabetes. white oyster mushroom has been widely consumed as alternative protein and dietary fiber. this in-vivo animal model study could be references for product development of β-glucan as nutraceuticals or white oyster mushrooms to prevent obesity and type 2 diabetes. [healthcare in low-resource settings 2023; 11(s1):1165] [page 13] non -co mmerc ial us e o nly glycemia and insulinemia, reduce gene expression of transcription factor il-6 and il-1β, and improve glucose tolerance.16–19 the increasing cultivation and consumption of oyster mushrooms in indonesia have not been studied based on their benefits. this has limited the data on the benefits of β-glucan bioactive compounds from oyster mushrooms to prevent and treat metabolic syndrome. therefore, this study aimed to investigate the effect of β-glucan from oyster mushroom (pleurotus ostreatus) extract on il-6, il1β, and homa-ir levels in rats fed with high-fat and highfructose diet (hffd). design and methods animals and diet our study was conducted using a post test only controlled group design. a sample of 35 male sprague-dawley (sd) rats aged five weeks were obtained from the animal resource center the national of drug and food control, jakarta-indonesia. they were given three weeks of acclimatization to their new environment, with ad libitum access to food and water. furthermore, all rats were fed a normal diet of modified ain-93m during the acclimatization period. they were divided into five groups based on the diet and the dose of β-glucan given, as shown in table 1. the normal and high-fat diet pellet was based on the ain-93m formula with modified ingredients amount.20 in this study, the normal diet contained 4.1 kcal/grams, with 7% fat, while the high-fat diet contained 5.46 kcal/grams, with 36.95% fat. fructose solution in 30% concentration was made by dissolving 300 grams fructose powder for each 1 l of water. the β-glucan from the oyster mushroom extract was produced based on the previous study.21 all experimental procedures have been approved by the research ethics committee of the faculty of medicine, universitas brawijaya, indonesia (136/ec/kepk/07/2020). food intake, body weight, and body composition animals were weighed weekly in the fourteen-week intervention period. food intake was measured by weighing the total food (g) provided to the rats and subtracting the remaining food (g) in the cage after 24 hours. after the intervention, the rats were sacrificed by ketamine + xylazine (0.1 ml/100 g bw) anesthetic agent after fasting for eight hours. anthropometric measurement was conducted by weighing, measuring the body (naso-anal) length, and abdominal circumference. the lee index was calculated by dividing the cubicle root of the weight (g) by the naso-anal length (mm) multiplied by 1000.22 sample collection and parameters analysis the plasma samples were prepared for parameters analysis by collecting blood through the heart using syringes. the samples were directly inserted into a vacutainer containing ethylene diamine tetraacetic acid (edta) anticoagulant. the blood samples were centrifuged for 10 minutes at 10,000 rpm. moreover, the plasma was aliquoted into several tubes using a micropipette. plasma il-6, il-1β, and insulin levels were performed by enzyme-linked immunosorbent assay (elisa) following the manufacturer’s protocol (elabscience rat il-6 cat no: e-el-r1005; bt-laboratory rat il-1β cat no: e0119ra; elabscience rat insulin cat no: eel-r3034). the pancreas was also obtained and preserved in 10% neutral buffered formaldehyde to examine pancreatic beta cell numbers. a histology examination was conducted by hematoxylin and eosin (h&e) staining and scanning with olympus dot slide microscope at x400 magnification. the number of the pancreatic beta-cell is a count from langerhans island in 10 visual fields, assisted by olyvia software.23 fasting blood glucose (fbg) was measured using a glucometer (autocheck).24 lastly, homair index was calculated according to the formula fasting insulin (ng/ml) x fasting blood glucose (mg/dl)/405.25 statistical analysis food intake, anthropometric parameters, homa-ir, plasma il-6, il-1β, and insulin levels were presented as mean and standard errors. statistical analysis was performed using spss software (spss inc version 25.0, chicago, ill, usa). moreover, body weight gain, abdominal circumference, lee index, an intake of total energy, protein and carbohydrate, fasting blood glucose, plasma il-6, and pancreatic beta-cell number were analyzed using a one-way anova test. this was followed by a post hoc tukey test for multiple comparisons. food and fat intake, plasma insulin, plasma il-1β, and homa-ir level were analyzed using the kruskal wallis test. it was followed by a post hoc mann-whitney u test to check different comparisons among the groups. the correlations between a dose of β-glucan given and fasting blood glucose, plasma insulin, plasma il-1β, homa-ir, and pancreatic beta-cell number were analyzed using spearman correlation test. the differences and correlations were considered significant when p-value <0.05. results and discussions after 14 weeks of intervention, the results showed a significant difference in weight gain between the normal and hffd groups. the lowest lee index scores were found in groups d1 and d3, and no significant difference in the rats’ abdominal circumference. the measurement of food intake showed significant differences in the intake of fat and carbohydrates, as shown in table 2. furthermore, there were no significant differences in groups’ plasma il-6 and il-1β levels. significant differences were found in fasting blood glucose levels (p = 0.000), insulin levels (p = 0.05), homa-ir (p = 0.005), and pancreatic beta-cell count (p = 0.000) between groups. the lowest blood glucose and homa-ir levels and the highest number of pancreatic beta cells were in group d2, as shown in figures 1 and 2. the spearman test results showed a negative correlation between β-glucan administration and levels of il-6 (p = 0.032; r = -0.406), il-1β (p = 0.018; r = -0.443), insulin (p = 0.025; r = 0.423), and homa-ir (p = 0.039; r = -0.392). however, a positive correlation was found between β-glucan administration and pan article [page 14] [healthcare in low-resource settings 2023; 11(s1):1165] table 1. animal grouping and treatment. group treatment normal normal diet hffd (high-fat and fructose diet) high-fat diet + 30% fructose solution (hffd) d1 hffd + 125 mg/kgbw β-glucan d2 hffd + 250 mg/kgbw β-glucan d3 hffd + 375 mg/kgbw β-glucan non -co mmerc ial us e o nly article table 2. anthropometric and food intake characteristics. parameter n hffd d1 d2 d3 p-value anthropometric body weight gain (g) 137.7 ± 52.5a 209.0 ± 16.8b 174.7 ± 23.9ab 188.4 ± 38.0ab 177.3 ± 53.2ab 0.034* abdominal circumference (cm) 18.6± 2.0 19.1 ± 0.9 19.3 ± 1.6 19.3 ± 1.1 19.0 ± 1.9 ns lee index 298.7± 7.6ab 291.3 ± 4.9a 288.8 ± 9.4a 308.2 ± 6.6b 288.1 ± 7.1a 0.000** food intake feed intake (g) 18.93± 3.1a 11.43 ± 0.8b 10.96 ± 1.1b 12.49 ± 2.1b 11.01 ± 1.9b 0.001** energy intake (kcal) 81.46 ± 9.4 94.77 ± 5.5 87.70 ± 7.7 92.35 ± 12.6 82.70 ± 12.6 ns protein intake (g) 2.80 ± 0.3 3.00 ± 0.2 2.46 ± 0.3 2.80 ± 0.5 2.47 ± 0.4 ns fat intake (g) 0.54 ± 0.1a 2.56 ± 0.2b 2.46 ± 0.3b 2.80 ± 0.5b 2.47 ± 0.4b 0.001** carbohydrate intake (g) 10.89 ± 1.3ab 12.03 ± 1.2b 10.77 ± 1.3ab 11.90 ± 1.4b 9.49 ± 1.4a 0.007* *one way anova test. *kruskal wallis test. ns: non-significant. a significant difference if p<0.05. post hoc test showed a significant difference between groups marked by different annotation (a,b,c). n: normal diet. hffd: high-fat diet + 30% fructose solution. d1: hffd + 125 mg/kgbw β-glucan. d2: hffd + 250 mg/kgbw β-glucan.. d3: hffd + 375 mg/kgbw β-glucan. figure 1. the comparison of levels of il-6, il-1β, fbg, insulin, homa-ir, and pancreatic beta cell count between groups. n: normal diet, hffd: high-fat diet + 30% fructose solution, d1: hffd + 125 mg/kgbw β-glucan, d2: hffd + 250 mg/kgbw β-glucan, d3: hffd + 375 mg/kgbw β-glucan post hoc test showed a significant difference between groups marked by different annotation (a,b,c). [healthcare in low-resource settings 2023; 11(s1):1165] [page 15] non -co mmerc ial us e o nly creatic beta cell count (p = 0.002; r = 0.558), as shown in figure 3. a positive correlation was also found between il-6 levels and plasma il-1β levels (p = 0.003; r = 0.533). the final anthropometric measurements showed no significant difference in the rats’ abdominal circumference between groups. the weight gain was inconsistent with the given dose, with group d2 having the highest weight gain. the results of the lee index in the group given the highest dose of β-glucan (375 mg/kg bw) showed the lowest value compared to other groups. these results are consistent with previous studies that showed no effect on weight changes in diabetic rats fed on a high-fat diet and stz induction fed with oat β-glucan, oat starch, or whole oats.26 however, the results contradict another study, which stated that administering pleurotus sajor-caju mushroom extract in rats fed with a high-fat diet could inhibit weight gain.19 in this study, the highest intake of carbohydrates, including fructose solution, was found in the hffd group, and the lowest was in the d3 group. previous studies showed that the fluid intake of rats given β-glucan was lower than the positive control group that experienced polydipsia.26 the group of rats fed with hffd experienced symptoms of polydipsia through increased intake of fructose solution, increasing carbohydrate intake than the rats given β-glucan. a decrease in carbohydrate intake lowers the food efficiency ratio and energy balance. the lower total carbohydrate intake is related to inhibiting the adipogenesis process. this indicates the group given the highest dose of β-glucan had the lowest lee index.19 however, there was no significant difference in energy intake between groups. these results contradict previous studies, which showed that administering β-glucan from oats and pleurotus sajorcaju extract could reduce energy intake.19,27 the energy density of normal feed and hffd used in this study has a small difference. the difference in intake is more influenced by feed composition and consumption of fructose solution. plasma il-6 and il-1β levels decreased in the group given βglucan from the oyster mushroom extract. the correlation test results showed a negative correlation between β-glucan dose and plasma il-6 and il-1β levels. these results support previous studies that concentrates from pleurotus ostreatus could suppress il-6 secretion in lps-exposed mice, while pleurotus tuber-regium extract could inhibit the release of il-6 in lps-induced cell lines.16,17 another study on β-glucan from oat sources stated that giving a β-glucan intervention to rats with a high-fat diet reduced plasma il-6 and il-1β levels.26 moreover, several in-vitro studies showed that β-glucan from sources such as pleurotus sajor-caju, ganoderma lucidum, and poria cocos could suppress the production of il-1β and tnf-α.28,29 this study found that β-glucan reduces pro-inflammatory cytokine levels, indicated by a significant negative correlation between the dose of β-glucan administered and plasma levels of il-6 and il-1β. the increase in proinflammatory cytokines in obesity and metabolic syndrome may occur by activating the transcription factor nf-kb. further increases in circulating cytokine levels increase the risk of insulin resistance and type 2 diabetes. the mechanism of β-glucan in activating the anti-inflammatory pathway is not fully understood. however, β-glucan molecules can be recognized as pathogen-associated molecular patterns (pamp) that bind to receptors such as dectin 1, complement receptor 3 (cr3), or toll-like receptors (tlrs).30 the interaction between β-glucan and tlr inhibits the activation of transcription factors nf-kb and ap-1, suppressing cytokine production and providing anti-inflammatory effects.16,31 this study did not determine the process that explains the anti-inflammatory mechanism of β-glucan from the oyster mushroom extract. this study showed significant differences between groups regarding fasting blood glucose, insulin, and homa-ir levels, and pancreatic beta-cell counts. administering β-glucan from oyster mushroom extract (pleurotus ostreatus) could reduce fasting blood glucose (fbg), insulin, and homa-ir levels and increase pancreatic beta cells. these results support previous studies, which stated that administering oyster mushroom powder and extract could reduce fbg levels and improve pancreatic beta cells in dia article figure 2. histological examination of pancreatic beta cells between groups. n: normal diet, hffd: high-fat diet + 30% fructose solution, d1: hffd + 125 mg/kgbw β-glucan, d2: hffd + 250 mg/kgbw β-glucan, d3: hffd + 375 mg/kgbw β-glucan. [page 16] [healthcare in low-resource settings 2023; 11(s1):1165] non -co mmerc ial us e o nly betic rats.32,33 another in-vivo study in mice and rats fed with a high-fat diet showed that administering pleurotus citrinopileatus and pleurotus tuber-regium extracts could reduce fasting blood glucose levels.19,34 administering β-glucan from sources such as oats and chitin reduces fbg and homa-ir levels insulin secretion and repairs pancreatic beta cells.15,26,35,36 furthermore, this study found that β-glucan improves glycemic control, insulin resistance, and pancreatic beta cells. this is seen by the negative correlation between β-glucan dose and insulin and homa-ir levels and a positive correlation between β-glucan dose and pancreatic beta-cell counts. several mechanisms concerning the effect of lowering glucose and insulin occur through the ability of soluble fiber (β-glucan) to form a viscous layer on the gastrointestinal tract. this slows gastric emptying, digestion, absorption and reduces nutrient transport to enterocytes.35,36 administering pleurotus ostreatus extract also increased p-ampk in muscle and adipose tissue. it leads to upregulation of the transcriptional regulator of the glut4 gene for increasing glucose uptake, providing an anti-hyperglycemic effect.33 moreover, β-glucan works as an antioxidant, protecting against pancreatic beta-cell apoptosis and increasing the production of hematopoietic stem cells (hscs). this indicates hscs could differentiate into special fibroblasts and liver, endothelial, and pancreatic cells. β-glucan becomes a potent molecule to improve glucose homeostasis in the body through hypoglycemic effects, improvement of insulin resistance, and decreased apoptosis of pancreatic cells.15,32,34 decreased pro article figure 3. spearman correlation test results between dose of β-glucan administration and levels of il-6, il-1β, insulin, homa-ir, and pancreatic beta-cell count. [healthcare in low-resource settings 2023; 11(s1):1165] [page 17] non -co mmerc ial us e o nly inflammatory cytokines also improved insulin resistance, where low il-6 and il-1β increased the expression and sensitivity of insulin receptor substrate, specifically irs-1. this resulted in increased insulin-mediated glucose uptake into cells.37,38 β-glucan has various structural and molecular weight variations, depending on its source and extraction procedure. the β-glucan extracted from the genus pleurotus has a high molecular weight. an example is pleurotus tuber-regium, which contains βglucan with a molecular weight of 5.76 x 104 77.4 x 104 g/mol, nearly similar with oat β-glucan, with a molecular weight of 15.6 x 104 68.7 x 104 g/mol.13,39 high molecular weight and viscosity β-glucans have hypocholesterolemic and hypoglycemic effects. in contrast, low molecular weight β-glucans have antioxidant and immunological effects.39 studies on the functionality of molecular weight show pros and cons influenced by the source of β-glucan, the amount of daily food intake, and the dose of β-glucan given.13,39,40 this study did not determine the molecular weight of β-glucan. therefore, further studies should analyze the molecular weight of pleurotus ostreatus β-glucan and its functionality. the βglucan structure is also associated with its functionality. it is composed of beta-d-glucose monomer units linked by glycosidic bonds at (1,3), (1,4), or (1,6), with or without branches.31 brown algae, oats, and barley contain β-(1,3/1,4)-d-glucan that modulate microbiota, lowering cholesterol and blood glucose levels. moreover, mushrooms and yeasts contain β-(1,3/1,6)-d-glucan that modulates the immune system and has antimicrobial and anticancer properties. agrobacterium contains branchless β-(1,3)-dglucan used as a thickening agent in food processing.31 the oyster mushroom extract used in this study had a β-(1,3)-d-glucan structure.21 the result supports another study on oyster mushroom (pleurotus ostreatus) using an alkaline extraction method, which stated that the compound found was β-(1,3)-d-glucan.41 the study of β-glucan from chitin sources stated that it contains β-(1,3)-dglucan, which improves blood glucose, triglyceride, and cholesterol levels and glucose tolerance in mice fed on a high-fat diet.36 regardless of the structural variation, biological activity is the β(1,3)-d-glucan core/backbone binding, which improves blood glucose control and dyslipidemic conditions. it also modulates immune responses and gut microbiota and improves obesity conditions.31 the findings concerning the correlation between differences in branch structure and functionality of β-glucans are still limited. therefore, further studies should examine the β-glucan structure with the desired therapeutic target. this study found that rats in the d2 group administered with 250 mg/kg bw β-glucan from oyster mushroom showed the best improvement effects in il-6, il-1β, homa-ir, and pancreatic beta-cell count. however, this mechanism was not elucidated in this study. previous studies on the toxicity of β -glucans are still limited, such as giving the β-(1,3/1-6)-d-glucan with doses of 500, 1000, and 2000 mg/kg bw sprague-dawley rats for 90 days without side effects on anthropometric and hematological blood parameters.42 another study administered β-(1,3/1-4)-d-glucan with doses of 0.7, 3.5, and 7% through a mixture of feed on wistar rats for 28 days. the results showed no side effects on growth, hematological abnormalities, and organ weight of rats.43 the levels of il-6 in the d3 group were +9.9% higher, il-1β -6.4% lower, homa-ir -3.3% higher. additionally, pancreatic beta cells were 0.7% lower than the normal group, with no significant difference. the β-glucan used in this study has a different β-(1,3)-d-glucan structure from the two previous studies, hence, it is necessary to explore the differences in structure and functionality. conclusions this study showed that administering β-glucan with the structure of β-(1,3)-d-glucan from oyster mushroom (pleurotus ostreatus) extract could reduce the levels of il-6 il-1β, fbg, homa-ir, and insulin. the administration could increase pancreatic beta-cell counts in hffd-treated rats, with the best effect reported in the dose of 250 mg/kg bw β-glucan. furthermore, the administration of β-glucans had a preventive effect on hyperglycemia and insulin resistance in inflammatory rats by inducing high-fat and fructose diets regardless of the weight gain. further studies should explore the influence of the structure and molecular weight of β-glucan as well as examine its mechanism as an anti-inflammatory, its prevention of hyperglycemia, and reduction of insulin resistance index. article correspondence: dian handayani, department of nutrition science, faculty of health sciences, universitas brawijaya, malang, indonesia, jl. veteran, malang, east java, indonesia 65145, tel.: +62341-569117, fax +62341-564755. e-mail: handayani_dian@ub.ac.id key words: β-(1,3)-d-glucan; homa-ir; il-6; il-1β; pancreatic beta cell. acknowledgment: the authors thank the faculty of medicine and institute of research and community services universitas brawijaya for their support and motivation during this study. contributions: dian handayani (dh), inggita kusumastuty (ik), and ema pristi yunita (ey) designed and coordinated the study. alma maghfirotun innayah (ai) and elvira nur sa’idah hariani (eh) conducted the experiments and biological assays. the first author and coauthors prepared and conducted the data analysis and wrote the manuscript. dian handayani (dh), husnul khotimah (hk), inggita kusumastuty (ik), and ema pristi yunita (ey) assisted in data interpretation and contributed to the final manuscript. dh is a corresponding author. conflict of interests: the authors have declared no conflict of interest. funding: this study was funded by the institute of research and community services universitas brawijaya (decree: 437.4/un10.c10/pn/2020). clinical trials: all procedures were approved by the research ethics committee of the faculty of medicine, universitas brawijaya, indonesia (ethics approval number: 136/ec/kepk/07/2020). availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11165 doi:10.4081/hls.2023.11165 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 18] [healthcare in low-resource settings 2023; 11(s1):1165] non -co mmerc ial us e o nly references 1. mcardle ma, finucane om, connaughton rm, et al. mechanisms of obesity-induced inflammation and insulin resistance: insights into the emerging role of nutritional strategies. front endocrinol (lausanne) 2013;4:52. 2. chen l, chen r, wang h, et al. mechanisms linking inflammation to insulin resistance. int j endocrinol 2015;2015:1–9. 3. kemenkes-ri. hasil utama riskesdas 2018. jakarta: balitbangkes kemenkes ri; 2018. 4. pereira rm, botezelli jd, da cruz rodrigues kc, et al. fructose consumption in the development of obesity and the effects of different protocols of physical exercise on the hepatic metabolism. nutrients 2017;9:405. 5. rodríguez-hernández h, simental-mendía le, rodríguezramírez g, et al. obesity and inflammation: epidemiology, risk factors, and markers of inflammation. int j endocrinol 2013;2013:1–11. 6. kern l, mittenbühler mj, vesting aj, et al. obesity-induced tnfα and il-6 signaling: the missing link between obesity and inflammation—driven liver and colorectal cancers. cancers (basel) 2019;11:24. 7. ballak db, stienstra r, tack cj, et al. il-1 family members in the pathogenesis and treatment of metabolic disease: focus on adipose tissue inflammation and insulin resistance. cytokine. 2015;75:280–90. 8. bao p, liu g, wei y. association between il-6 and related risk factors of metabolic syndrome and cardiovascular disease in young rats. int j clin exp med 2015;8:13491–9. 9. guillamón e, garcía-lafuente a, lozano m, et al. edible mushrooms: role in the prevention of cardiovascular diseases. fitoterapia 2010;81:715–23. 10. wasser s. medicinal mushroom science: current perspectives, advances, evidences, and challenges. biomed j 2014 sep 2;37. 11. handayani d, chen j, meyer bj, et al. dietary shiitake mushroom (lentinus edodes) prevents fat deposition and lowers triglyceride in rats fed a high-fat diet. j obes 2011;2011:1–8. 12. tjokrokusumo d. jamur tiram (pleurotus ostreatus) untuk meningkatkan ketahanan pangan dan rehabilitasi lingkungan. j rekayasa lingkung 2018;4:53–62. 13. golak-siwulska i, kałużewicz a, spiżewski t, et al. bioactive compounds and medicinal properties of oyster mushrooms (pleurotus sp.). folia hortic 2018;30:191–201. 14. zheng j, shen n, wang s, et al. oat beta-glucan ameliorates insulin resistance in mice fed on high-fat and high-fructose diet. food nutr res 2013;57:10.3402/fnr.v57i0.22754. 15. cheng y, zhang j, luo k, et al. oat bran β-glucan improves glucose homeostasis in mice fed on a high-fat diet. rsc adv 2017;7:54717–25. 16. jedinak a, dudhgaonkar s, wu q, et al. anti-inflammatory activity of edible oyster mushroom is mediated through the inhibition of nf-κb and ap-1 signaling. nutr j 2011;10:52. 17. liu y-w, mei h-c, su y-w, et al. inhibitory effects of pleurotus tuber-regium mycelia and bioactive constituents on lps-treated raw 264.7 cells. j funct foods 2014;7:662–70. 18. kanagasabapathy g, chua kh, malek sna, et al. amp-activated protein kinase mediates insulin-like and lipo-mobilising effects of β-glucan-rich polysaccharides isolated from pleurotus sajor-caju (fr.), singer mushroom, in 3t3-l1 cells. food chem 2014;145:198–204. 19. sheng y, zhao c, zheng s, et al. anti-obesity and hypolipidemic effect of water extract from pleurotus citrinopileatus in c57bl/6j mice. food sci nutr 2019;7:1295–301. 20. reeves pg. components of the ain-93 diets as improvements in the ain-76a diet. j nutr 1997;127:838s-841s. 21. yunita ep, yuniar am, kusumastuty i, et al. the effects of ßglucan extract from oyster mushroom (pleurotus ostreatus) on expression of serum malondialdehyde in sprague dawley rats induced by hfhf diet. j phys conf ser 2020;1665:12035. 22. malafaia ab, nassif pan, ribas capm, et al. obesity induction with high fat sucrose in rats. abcd arq bras cir dig (são paulo) 2013;26:17–21. 23. hariani ens. the effect of beta-glucan from oyster mushroom extract on pancreatic beta cell number in male sprague dawley rats given high-fat high fructose diet (unpublished undergraduate thesis). universitas brawijaya; 2021. 24. firdaus mf. the effect of beta-glucan from oyster mushroom extract on fasting blood glucose level in male sprague dawley rats given high-fat high fructose diet (unpublished undergraduate thesis). universitas brawijaya; 2021. 25. roza na v, possignolo lf, palanch ac, et al. effect of longterm high-fat diet intake on peripheral insulin sensibility, blood pressure, and renal function in female rats. food nutr res 2016;60:28536. 26. zhu y, dong l, huang l, et al. effects of oat β-glucan, oat resistant starch, and the whole oat flour on insulin resistance, inflammation, and gut microbiota in high-fat-diet-induced type 2 diabetic rats. j funct foods 2020;69:103939. 27. cheng hs, ton s, phang s, et al. increased susceptibility of post-weaning rats on high-fat diet to metabolic syndrome. j adv res 2017;8:743–52. 28 yoon h-m, jang k-j, han ms, et al. ganoderma lucidum ethanol extract inhibits the inflammatory response by suppressing the nf-κb and toll-like receptor pathways in lipopolysaccharide-stimulated bv2 microglial cells. exp ther med 2013;5:957–63. 29. jeong j-w, lee hh, han mh, et al. ethanol extract of poria cocos reduces the production of inflammatory mediators by suppressing the nf-kappab signaling pathway in lipopolysaccharide-stimulated raw 264.7 macrophages. bmc complement altern med 2014;14:101. 30. jager j, grémeaux t, cormont m, et al. interleukin-1betainduced insulin resistance in adipocytes through down-regulation of insulin receptor substrate-1 expression. endocrinology 2007;148:241–51. 31. murphy ej, rezoagli e, major i, et al. β-glucan metabolic and immunomodulatory properties and potential for clinical application. j fungi 2020;6:1–36. 32. purbowati, johan a, rmd rak. pengaruh jamur tiram putih ( pleurotus ostreatus ) terhadap kadar glukosa darah , profil lipid dan kadar mda pada tikus ( rattus norvegicus ) diabetes melitus. j gizi indones 2016;4:131–7. 33. asrafuzzaman m, rahman mm, mandal m, et al. oyster mushroom functions as an anti-hyperglycaemic through phosphorylation of ampk and increased expression of glut4 in type 2 diabetic model rats. j taibah univ med sci 2018;13:465–71. 34. huang h-y, korivi m, chaing y-y, et al. pleurotus tuberregium polysaccharides attenuate hyperglycemia and oxidative stress in experimental diabetic rats. evidence-based complement altern med 2012;2012:1–8. 35. el khoury d, cuda c, luhovyy bl, et al. beta glucan: health benefits in obesity and metabolic syndrome. j nutr metab 2012;2012:1–28. 36. delzenne nm, neyrinck am, cani pd. gut microbiota and metabolic disorders: how prebiotic can work? br j nutr article [healthcare in low-resource settings 2023; 11(s1):1165] [page 19] non -co mmerc ial us e o nly 2013;109:s81–5. 37. febbraio ma. role of interleukins in obesity: implications for metabolic disease. trends endocrinol metab [internet]. 2014;25:312–9. available from: https://doi.org/10.1016/ j.tem.2014.02.004 38. shi j, fan j, su q, et al. cytokines and abnormal glucose and lipid metabolism. front endocrinol (lausanne) 2019;10:703. 39. du b, meenu m, liu h, et al. a concise review on the molecular structure and function relationship of β-glucan. int j mol sci 2019;20:4032. 40. wang y, harding s v, eck p, et al. high-molecular-weight βglucan decreases serum cholesterol differentially based on the cyp7a1 rs3808607 polymorphism in mildly hypercholesterolemic adults. j nutr 2015;146:720–7. 41. baeva e, bleha r, lavrova e, et al. polysaccharides from basidiocarps of cultivating mushroom pleurotus ostreatus: isolation and structural characterization. molecules 2019;24:2740. 42. chen sn, nan fh, chen s, et al. safety assessment of mushroom β-glucan: subchronic toxicity in rodents and mutagenicity studies. food chem toxicol 2011;49:2890–8. 43. delaney b, carlson t, frazer s, et al. evaluation of the toxicity of concentrated barley β-glucan in a 28-day feeding study in wistar rats. food chem toxicol 2003;41:477–87. article [page 20] [healthcare in low-resource settings 2023; 11(s1):1165] non -co mmerc ial us e o nly hrev_master transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions time frame guide for emergency model of care and patient satisfaction in emergency facilities hidayatus sya'diyah,1 indra kurniawan saputra,2 ayu citra mayasari,2 sukma ayu candra kirana,2 diyan mutyah3 1program study profession of nursing, stikes hang tuah surabaya, surabaya; 2program study s1 of nursing, stikes hang tuah surabaya, surabaya; 3program study d3 of nursing, stikes hang tuah surabaya, surabaya, indonesia abstract patient satisfaction in the emergency department is crucial for assessing the quality of care provided. timely patient management enhances confidence in healthcare providers and the hospital. the time frame emergency model of care is instrumental in ensuring timely service delivery and reducing adverse effects associated with prolonged patient stays (los) and overcrowding. the purpose of this study was to investigate the relationship between the time frame guide emergency model of care and patient satisfaction in the emergency room. this quantitative cross-sectional study employed accidental sampling, involving 95 respondents aged over 18 years with triage 4 classification in the emergency department. questionnaires were used to collect data on the time frame emergency model of care and patient satisfaction. the chi-square test was utilised for data analysis. the findings revealed a high level of patient satisfaction in the emergency department. the chi-square test demonstrated a significant relationship between the time frame emergency model of care and patient satisfaction (p-value = 0.000, <0.05). moreover, the correlation coefficient of 0.582 indicated a strong relationship. in conclusion, this study established a significant relationship between the time frame emergency model of care and patient satisfaction at emergency room. these results emphasise the model’s role in enhancing patient satisfaction and reducing adverse outcomes associated with extended patient stays and overcrowding. introduction hospitals play a vital role within the social and healthcare framework by offering comprehensive services for disease prevention, cure, and community well-being.1 in particular, emergency departments (ed) and emergency room (er) aim to deliver prompt, accurate, and integrated healthcare services to minimise the risks of disability and fatality, emphasising the preservation of life and limb.2 a study conducted in california, united states revealed that among 995,379 er patients, overcrowded emergency rooms led to a 5% risk of death (95% ci).3 conversely, a study in kupang, indonesia reported that 89% of patients expressed satisfaction with the emergency department’s services.4 however, these findings suggest that the accuracy of patient management can decline in overcrowded emergency rooms. based on data collected from august to november 2022 at premier hospital surabaya’s emergency room, the treatment duration for non-emergency patients ranges from 3 to 4 hours. this duration slightly exceeds the target time frame for emergency care, which is set at 4 hours, indicating that premier surabaya hospital provides good patient care.5 correspondence: ayu citra mayasari, program study s1 of nursing, stikes hang tuah surabaya, surabaya, indonesia. e-mail: ayucitramayasari@stikeshangtuah-sby.ac.id key word: time guide emergency model of care; satisfaction; emergency department. contributions: hs conceptualization, data curation, formal analysis, methodology, validation, visualisation, writing – original draft, review & editing, supervision; iks conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; acm conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; dm methodology, visualization, writing – review & editing; sack resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, stikes hang tuah surabaya. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analysed during this study are included in this published article. acknowledgement: we would like to thankful to stikes hang tuah surabaya and premiere hospital surabaya for their valuable insights and contributions to this study. received: 10 september 2023. accepted: 6 november 2023. early access: 23 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11743 doi:10.4081/hls.2023.11743 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11743] [page 159] non -co mmerc ial us e o nly initial survey data from november 27, 2022, including interviews with five patient families visiting the er, revealed that three patient families were dissatisfied with the service. the diverse backgrounds of patients in the er, spanning socioeconomic, cultural, educational, and experiential differences, lead to varying patient and societal perceptions.6 patients tend to be satisfied with nursing services in the er when their expectations are met, which includes fast, responsive, courteous, friendly, and efficient service, as well as creating a comfortable atmosphere within the facility.7,8 however, some patients and the public perceive nurses as less independent and efficient in patient care in the er, often due to their limited understanding of the patient management procedures followed by nurses in this specific setting.9,10 the quality of hospital nursing services is shaped by several factors, encompassing input elements like medical personnel, funding, and facilities, as well as environmental factors such as management policies.11,12 patient satisfaction is also influenced by characteristics like age, gender, education level, and occupation.13 additionally, the quality of services relies on tangible, reliable, responsive, responsible, and considerate aspects.14 premier surabaya hospital is dedicated to improving service quality with the goal of achieving the highest levels of patient satisfaction, particularly within the emergency room (er). the time frame guide emergency model of care divides the 4-hour target for emergency patient care into three manageable time frames: 2 hours for er assessment and the initiation of clinical management, 1 hour for consultation and/or inpatient bed allocation, and 1 hour for patient transfer to inpatient care, another hospital, or discharge planning. given these considerations, this study aimed to investigate the relationship between the time frame guide emergency model of care and patient satisfaction in the emergency room. materials and methods this research employs a quantitative approach with a correlational design and a cross-sectional framework. the study was conducted among patients in the emergency room at premier surabaya hospital. ethical approval for this study was granted by the ethics committee of premier surabaya hospital in indonesia, and all procedures adhered to the principles outlined in the helsinki declaration. written informed consent was duly obtained from all participants. the study comprised 95 respondents, selected from patients aged >18 years who presented at the emergency room with a triage level of 4, employing accidental sampling at premier hospital surabaya. the study included emergency patients aged >18 years with a triage level of 4 presenting at the emergency room of premier hospital surabaya. patients who declined to participate and pediatric patients were excluded from the study. to measure the time guide for emergency care, a clock was used. in 2000, the united kingdom initiated the “four hour rule program” as part of a national health reform agreement. this policy sought to enhance access to emergency care by reducing overcrowding and access blockages and their associated adverse outcomes. it mandated that ed patients should, whenever clinically possible, receive treatment, referral, or discharge within four hours of arrival. on april 20, 2010, this policy was adopted by the australian government and termed the national emergency access target (neat). to improve patient throughput time in the emergency room and meet the four-hour target, the new south wales ministry of health introduced a guide/model of care known as the emergency model of care. this model was developed based on the ideal patient journey through the er. for the dependent variable of patient satisfaction, a questionnaire comprising 20 questions was administered to the respondents. the questionnaire underwent rigorous validity and reliability testing. each question’s validity was assessed by comparing the calculated correlation coefficient (r) results with the tabled correlation coefficient (r) for a given degree of freedom (df = n-2) at a 5% significance level. since the result (r table) (0.374) was less than the calculated correlation coefficient (r count) (0.517), the questionnaire was considered valid. moreover, the questionnaire demonstrated reliability, with a cronbach’s alpha value of (0.844), surpassing the recommended threshold of 0.60. data analysis was conducted using the spss 25 for windows software. given that all the research data are on a nominal scale, the statistical test employed was the chi-square test with significant value of 0.05 (5%). results the research results are categorised into general data and specific data. general data encompass variables such as gender, occupation, education, age, and insurance coverage. on the other hand, specific data pertains to response time and patient satisfaction within the emergency room at premier hospital surabaya. based on table 1, it is evident that the majority of respondents (patients), constituting 55 individuals (57.9%), were female. the results indicate that the highest proportion of respondents held a bachelor’s degree, with 75 individuals (78.9%). furthermore, the data reveals that the largest segment of respondents, numbering 70 individuals (73.7%), were employed in the private sector. in terms of insurance coverage, 65 respondents (68.4%) were registered under insurance plans. the average age of the respondents was calculated to be 50.11 years. the youngest respondent was 40 years old, while the oldest was 60 years old. table 2 presents the relationships between the time frame emergency model of care and patient satisfaction within the emergency room at premier hospital surabaya. among the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (patients) variable f(x) percentage (%) gender man 40 42.1 woman 55 57.9 education junior high school 5 5.3 senior high school 15 15.8 bachelor 75 78.9 work civil servants/tni 25 26.3 private 70 73.7 health insurance uninsured 30 31.6 insured 65 68.4 age min-max 40-60 mean 50.11 median 50 mode 43 [page 160] [healthcare in low-resource settings 2023; 11:11743] non -co mmerc ial us e o nly respondents, 13 (13.7%) expressed dissatisfaction, 2 (2.1%) reported satisfaction, and 16 (16.8%) were very satisfied with this care model. in cases of dissatisfaction, 1 respondent (1.1%) found the care sufficient, while 19 respondents (20.0%) expressed satisfaction, and 2 (2.1%) were very satisfied. interestingly, 1 respondent (1.1%) expressed dissatisfaction with patient satisfaction. the chi square statistical test results reveal a significant relationship between the time frame emergency model of care and patient satisfaction, with a ρ value of 0.00, which is less than the significance level α of 0.05. this indicates that there is indeed a connection between the two variables in the context of premier hospital surabaya’s emergency room. moreover, the correlation coefficient, with a value of 0.582, suggests a moderate-level relationship between these variables. discussion in the context of the time frame emergency model of care at the premier hospital surabaya’s emergency room, it is notable that 60.0% of respondents rated this model as good, whereas 23.2% found it adequate. however, 16.8% of respondents perceived it as poor. this observation aligns with asplin’s research, which emphasises the pivotal role of competent human resources in achieving efficient response times in the emergency room. the responsiveness of emergency room services to incoming patients significantly influences customer and patient satisfaction.15 the reliability of the medical staff, including both doctors and nurses at the premier hospital surabaya’s emergency room, underpins the effectiveness of this well-structured model of care. this can be attributed to various programs conducted periodically by the hospital, focusing on service development, excellence, and skill enhancement for nursing staff, including basic trauma and cardiac life support (btcls) training. mohtar’s research further supports the idea that training, particularly in basic life support theory, correlates with nurses’ improved understanding and response times to injured patients.11,16 research conducted in the united states points out that overcrowding issues in the emergency room typically arise due to unscheduled urgent care, safety net care, and emergency cases.15 this suggests that the factors affecting the time frame emergency model of care’s implementation may be linked to the growing demand for emergency room services, including increased patient visits and the severity of cases. however, these demands are not always matched by a proportional increase in medical personnel, leading to a primary focus on addressing emergency cases. additionally, the presence of a triage system, prioritising patients based on the severity of their condition, can lead to discrepancies in service times.17 consistent with qureshi’s research, nurses can play a critical role in enhancing the knowledge of patients categorised as “yellow label” about triage services. this proactive measure can help reduce anxiety and dissatisfaction among patients. improved patient understanding of the triage process, particularly for “yellow label” patients, is crucial to elevating their satisfaction levels while waiting in the emergency room. it is important to acknowledge that time in this context is closely associated with feelings of boredom and anxiety, given that patients perceive themselves to be in a dangerous and life-threatening condition, even when immediate treatment by healthcare professionals may not be warranted.18 the researchers’ observations regarding time frame 3 revealed several factors that influence processes within this time span. these factors encompass administrative procedures, ensuring the completeness of inpatient status, and the availability of necessary supporting tools. these findings emphasise the need for a wellstructured time frame emergency model of care in the emergency room, ensuring efficient and effective healthcare services for patients. addressing the factors affecting each time frame is essential for improving the quality and timeliness of emergency care services. upon analysing the patient satisfaction questionnaires from respondents in the emergency room of premier hospital surabaya, it is evident that the majority of respondents expressed satisfaction. specifically, 15.8% of respondents indicated dissatisfaction, while 55.8% expressed satisfaction, and 28.4% conveyed being very satisfied with their experience. this observation corresponds with earlier research, underscoring the significance of trust within the work organisation. trust is believed to be associated with an organisation’s capacity to deliver quality services that can be relied upon.19,20 reliability, in this context, refers to the ability to consistently provide dependable service. this entails that every employee possesses the requisite knowledge, expertise, independence, mastery, and a high degree of professional conduct to ensure that service provision is satisfactory.21,22 it is essential for the services delivered to leave no room for complaints or negative impressions among the public. the competence and skills of the staff in providing these services play a vital role in influencing patient satisfaction. when staff members excel in their roles and execute their tasks correctly, patients experience satisfaction and are unlikely to raise concerns about the care they receive in a hospital’s emergency room.23,24 the results suggest a significant relationship between a good time frame emergency model of care and patient satisfaction. these findings are consistent with a study conducted by zulfa, where respondents who reported a good time frame emergency model of care displayed very high satisfaction levels at 58.6%. another 17.6% of respondents expressed satisfaction, while 23.8% conveyed dissatisfaction with the hospital’s emergency room ser [healthcare in low-resource settings 2023; 11:11743] [page 161] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. cross tabulation of time frame emergency model of care and patient satisfaction. patient satisfaction variable not satisfied satisfied very satisfied total time frame emergency model of care n % n % n % n % poor 13 13.7 2 2.1 1 1.1 16 16.8 adequate 1 1.1 19 20.0 2 2.1 22 23.2 good 1 1.1 32 33.7 24 25.3 57 60.0 total 15 15,8 53 55.8 27 28.4 95 100.0 p=0.000≤0.05 non -co mmerc ial us e o nly vices. this variance in satisfaction levels is influenced by several aspects within the hospital’s emergency department concerning the time frame emergency model of care. these aspects significantly impact the quality of service delivered to incoming patients.25 conclusions based on our research, it’s clear that there’s a strong connection between how well the time frame emergency model of care works and how satisfied patients are in premier hospital surabaya’s emergency room. this means that when the time frame emergency model of care is effective, it makes patients happier. for the broader population, these findings have implications for healthcare facilities and patients in general. hospitals can consider adopting effective time management models like the one we studied to improve patient satisfaction. this approach isn’t just beneficial for premier hospital surabaya; it can be a valuable model for healthcare institutions worldwide to enhance the overall patient experience. patients, on the other hand, can be more informed about the importance of efficient care models, which can guide their choices and expectations when seeking medical care. ultimately, the focus on patient satisfaction can lead to improved healthcare experiences on a larger scale. references 1. uu-kesehatan-nomor-17-tahun-2023. 2. undang undang ri no. 44. sekertariat negara republik indonesia indonesia; 2009 p. 1-41. 3. sun bc, hsia ry, weiss re, zingmond d, liang lj, han w, et al. effect of emergency department crowding on outcomes of admitted patients. ann emerg med 2013;61:605 611.e6. 4. rochana n, djogotuga nn. kepuasan pasien stagnan di instalasi gawat darurat (igd) di kupang. journal of holistic nursing and health science [internet]. 2020;3:12-20. 5. premiere rs. laporan tahunan rumah sakit premiere 2021. surabaya; 2021. 6. laksono ad, wulandari rd, efendi f. determinants of hospital utilisation among urban poor societies in indonesia. int j innovat creat change 2020;12:375-87. 7. wulandari arc, rachmawaty r, ilkafah i, erfina e. patient satisfaction towards healthcare quality in indonesian public hospital. enferm clin 2021;31:s745-50. 8. ellina ad, kusnanto, adiutama nm, et al. evaluation of patient satisfaction and nurse caring behaviour: based on swanson’s theory. indian j public health res dev 2019;10:2698-702. 9. permarupan py, al mamun a, hayat n, et al. nursing management challenges: effect of quality of work life on depersonalisation. int j healthc manag 2021;14:1040-9. 10. mampuk v, karame v. hubungan respon time perawat dalam memberikan pelayanan dengan kepuasaan pelanggan di igd rsu pancaran kasih manado. j comm emerg 2019;7:278-88. 11. prakoeswa ac, arofiati f, hidayah n. the effect of basic trauma and cardiac life support training in increasing the competence of emergency room nurses. jurnal ners 2022;17:8-13. 12. pramundita b, mashudi a, chalidyanto d. nursing engagement relation with nurse performance at intensive care unit at surabaya hospital. indian j public health res dev 2019;10:2284-7. 13. yani rwe, khoiri a, bramantoro t. patient’s satisfaction in utilising public health center services during the covid-19 pandemic based on gender, age, education level, and occupation. asia pac j health manag 2022;17(2). 14. nurlina d, rifai a, jamaluddin j. faktor-faktor yang memengaruhi kepuasan pasien instalasi gawat darurat rumah sakit tni ad tk iv 02.07.04 bandar lampung tahun 2017. jurnal ilmu kesehatan masyarakat 2019;8:78-88. 15. asplin br, magid dj, rhodes kv, et al. a conceptual model of emergency department crowding. ann emerg med 2003;42:173-80. 16. mohtar ms. korelasi jenjang pendidikan dan kualifikasi terhadap pemahaman waktu tanggap perawat pada penanganan pasien cedera kepala di igd rsud ulin banjarmasin. dinamika kesehatan jurnal kebidanan dan keperawatan 2020;11:319-28. 17. kenny jf, chang bc, hemmert kc. factors affecting emergency department crowding. emerg med clin north am 2020;38:573-87. 18. qureshi a, smith a, wright f, et al. the impact of an acute care emergency surgical service on timely surgical decision-making and emergency department overcrowding. j am coll surg 2011;213:284-93. 19. anang pj. hubungan respon time dengan kepuasan pasien di igd rs tingkat iv madiun. [madiun]: stikes bhakti husada mulia; 2018. 20. hidayati l, ismail a, harmayetty, et al. understanding health service quality in emergency department through the length of stay and its determinants. j pak med assoc 2023;73:s30-3. 21. tjipto f. manajemen pelayanan jasa. yogyakarta: penerbit andi; 2011. 22. rahmaningtyas ri, supriyanto s. the effect of service quality on patients’ satisfaction in the maternity polyclinic of outpatient installation of surabaya haji public hospital. indon j public health 2019;14:80-92. 23. setyawan feb, supriyanto s, tunjungsari f, et al. medical staff services quality to patients satisfaction based on servqual dimensions. int j publ health sci 2019;8:51-7. 24. wahdatin a, sari dwp, abdurrouf m. the implementation of therapeutic communications with postoperative patient satisfaction in islamic hospital of sultan agung semarang. jurnal ners 2019;14:378-82. 25. kurniawan marta putra a, sholehah b, tri handoko y, et al. hubungan waktu tanggap (respon time) dengan kepuasan pelayanan kegawatdaruratan pada pasien asma di unit gawat darurat [internet]. available from: http://jurnal.globalhealthsciencegroup.com/index.php/jppp [page 162] [healthcare in low-resource settings 2023; 11:11743] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1): article significance for public health this study predicts the clinical conditions that affect foot comfort caused by t2dm in a community. furthermore, it provides a rationale whereby community nurses are capable of determining the choice of modality intervention therapy that affects the macrovascular and microvascular complications. comfort is an important aspect when providing care to t2dm patients experiencing complications of the feet when improving the quality of life of such patients. [healthcare in low-resource settings 2023; 11(s1):11173] [page 43] healthcare in low-resource settings 2023; volume 11(s1):11173 correlation of leg pain responses with ankle-brachial index and peripheral sensory responses in foot of type 2 diabetes mellitus heri kristianto,1 tina handayani nasution,1,3 endah panca lidya fatma,1 efris kartika sari,1 ahmad hasyim wibisono,1 haryadi kurniawan,1 firdausy ratna,1 ica cristiningtyas,1 endang listyowati2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2janti public health center, malang, indonesia; 3universitas lambung mangkurat, banjarmasin, indonesia abstract introduction: type 2 diabetes mellitus (t2dm) is associated with changes that occur in the peripheral circulation that affect foot functions. therefore, there is a need for a risk prediction test on foot abnormalities using the leg pain response parameters in t2dm patients with ankle-brachial index (abi) and peripheral sensory changes as a preventive effort to manage foot care. design and methods: this study employed a cross-sectional design in which 63 t2dm patients in a public health center (phc) in malang were investigated. the instruments used include visual analog scale (vas), monofilament, and foot doppler. results: the pearson correlation test showed no relationship between the responses to leg pain and the abi of the right and left feet (p-values = 0.217 and 0.692), but there was a significant relationship between the left foot abi and sensory status (p-value 0.002; left foot r = 0.383). meanwhile, the pearson’s correlation and linear regression test also showed a relationship between the right foot abi and sensory status (p-value = 0.007; r = 0.338). furthermore, a multiple linear regression test showed a relationship between the leg pain response and sensory perception of the right and left feet (p-value = 0.035; r = 0.325). conclusions: the relationship between the sensory status of the right and left feet and the response to leg pain in t2dm patients were moderate with a negative direction. it, therefore, implies that a decrease in the sensory responses increased the leg pain. meanwhile, the moderate relationship and positive direction between the abi and sensory status of the feet of t2dm patients indicates that a higher abi score led to an increase in the sensory status of the foot. introduction chronic hyperglycemia in t2dm is associated with long-term damage, impaired function, and failure of various organs, especially the eyes, kidneys, nerves, heart, and blood vessels. patients with diabetes mellitus may probably experience complications of the foot by 30% with a prevalence of 6.3%; this condition is more likely to occur in men with these characteristics, such as old age, low body mass index, longer duration of t2dm, hypertension, diabetic retinopathy, and those with a history of smoking.1-3 moreover, this condition is associated with changes in the macro and microcirculation which are present in the lower extremities. macrocirculatory complications are associated with stroke, cardiovascular, and peripheral arterial disease; whereas microcirculation complications are associated with retinopathy, nephropathy, and neuropathy. t2dm patients are at risk of developing peripheral vascular disease twice or three times as high as people without diabetes mellitus. subsequently, patients with peripheral vascular disorders will suffer from decreased pulses, intermittent claudication, and also sensory changes.4 this condition is associated with changes in the peripheral circulation that affect the foot functions of t2dm. furthermore, functional changes in the diabetic foot can lead to complications that may result in foot amputation. therefore, it is necessary to investigate the risk prediction for t2dm foot abnormalities with pain response parameters in patients with ankle-brachial index and sensory changes, as preventive measures to manage t2dm feet. this study is capable of providing an overview of the basic treatment methods used in detecting t2dm foot abnormalities that help prevent complications. furthermore, the results obtained may be implemented to enable nurses and doctors in monitoring the functions of t2dm feet. this explained phenomenon prompted the researchers to carry out an analysis on the relationship between leg pain response in t2dm with abi scores and peripheral sensory responses, as an effort to detect foot abnormalities. design and methods the subject used in this study was made up of 63 t2dm patients in phc, malang. they were selected using a purposive sampling technique. moreover, this study made use of a cross-sectional design. furthermore, the patients’ diabetic feet were examined by competent health staff with the aid of an equalization test of perceptions. the sample criteria include a patient that is more non -co mmerc ial us e o nly than 40 years of age, diagnosed with t2dm for more than 5 years, complains of tingling and pain in the legs, no paralysis and disability, and also no complications. the observations results were in the form of responses to leg pain, abi scores, and peripheral sensory levels, and the data obtained were analyzed using the correlation and regression test with spss 16. the dependent variable for this study was leg pain responses, while the independent variables were abi scores and sensory change levels. the instruments used in this study were visual analog scale (vas), monofilament, and foot doppler.5-7 permission was obtained to carry out this study from the ethics committee for health and medical research, faculty of medicine, university of brawijaya. results and discussion characteristics of respondents the characteristics of the study subjects were age, duration of suffering from t2dm, systolic and diastolic pressures, blood sugar levels, uric acid, cholesterol, leg pain responses, abi, sex, sensory responses, education, history of smoking, and exercise. these characteristics are presented in table 1. relationship of leg pain response between abi scores and sensory status the data normality test was first carried out before the bivariate test, where the correlation coefficient value was shown to be less than 30%. this finding concludes that the data were normally distributed. the results of the analysis are summarized in table 2. table 3 shows no relationship between the leg pain responses and abi of the right and left feet (p-values = 0.21 and 0.69), but there was a significant relationship between the leg pain responses and the right and left foot sensory (p-values = 0.012 and 0.043). this study also showed that the right and left foot abi was related to that of foot sensory (p-value = 0.010 and 0.003). furthermore, it also shows a leg pain response and abi modeling using the right and left foot sensory. the results obtained signified that the independent variable in the regression modeling was the right and left foot sensory. according to table 4, the coefficient of determination was 0.105, which means the regression model could explain 10.5% of the variation in the dependent variable. moreover, the p-value of 0.035, implies that the regression model matched the existing data. therefore, the relationship between the right and left foot sensory status and the leg pain responses in t2dm patients was moderate (r-value = 0.325). the abi and sensory status, in the foot of t2dm patients, had a moderate relationship (r-value of right foot = 0.338; r-value of left foot = 0.383) and a positive pattern. these findings denote that higher abi scores escalate the foot sensory status of t2dm patients where the coefficient of determination of the right foot was 0.114, and it indicates that the line equation is capable of explaining 11.4% of the sensory variation in the right foot. article [page 44] [healthcare in low-resource settings 2023; 11(s1):11173] table 1. characteristics of respondents. characteristics (n=63) mean (sd) minimal-maximal 95% ci age (years) 61.94 (7.62) 44-80 60.02-63.86 duration of t2dm (years) 9.01 (3.22) 6-17 8.20-9.83 systolic (mmhg) 137.46 (19.81) 100-175 132.47-142.45 diastolic (mmhg) 83.49 (9.44) 65-100 81.11-85.87 bmi (kg/m2) 24.25 (4.68) 13.78-34.65 23.07-25.43 blood glucose (mg/dl) 283.89 (73.84) 166-460 265.29-302.49 uric acid (mg/dl) 6.39 (1.58) 3.4-9.7 5.99-6.79 cholesterol (mg/dl) 204.16 (46.70) 100-300 192.40-215.92 leg pain 5.62 (1.71) 3-8 5.19-6.05 right foot abi 1.00 (0.15) 0.77-1.36 0.96-1.04 left foot abi 0.97 (0.17) 0.64-1.33 0.93-1.01 right foot sensory 5.84 (1.78) 2-9 5.39-6.29 left foot sensory 5.90 (1.56) 2-9 5.51-6.30 total % sex male 23 36 female 40 64 education elementary school 38 60 primary high school 9 14 secondary high school 12 19 college 4 7 smoking history smoker 14 22 non-smoker 49 78 exercises always 21 33 often 10 16 seldom 28 44 never 4 7 non -co mmerc ial us e o nly meanwhile, the coefficient of determination of the left foot was 0.147 which implies that the line equation is capable of explaining 14.7% of the sensory variation in the left foot. the statistical tests revealed a significant relationship between the abi scores and the sensory status of the right and left feet. the modeling results are illustrated in table 5. chronic neuropathy is characterized by an exaggerated response to painful stimuli (hyperalgesia).8, 9 while, the t2dm foot is characterized by spontaneous pain, hyperalgesia, and paranesthesia that has a complex mechanism. this pain is caused mainly by blocked blood vessels in the legs and it affects the changes in the abi scores. however, from this study, there was no relationship between leg pain responses and the abi scores of the right and left feet. changes in abi may not reflect the occurrence of atherosclerosis, which causes pain in the legs.10 furthermore, the pain responses in the dm foot were influenced by complex conditions that changed the abi score and this requires a longer process. the results, therefore, affirmed that the mean abi scores of the right and left feet were within normal limits with an average duration of 9.01 years. factors that influence abi include age, gender, smoking history, hypertension, duration of dm, and bmi.11 the sample characteristics used in this study include, the elderly, mainly women without a smoking history, mild hypertension, and excess bmi, and those affected by abi condition while, the respondents’ characteristics contributed to the occurrence of neuropathic pain.12, 13 furthermore, this study showed a negative direction and a moderate relationship between the sensory status of the right and left feet and the leg pain responses in patients with dmt2 and it also proposed a decrease in sensory responses with monofilament examination. the sensory status of diabetic feet was measured with a 10-g semmes-weinstein monofilament test.12,14,15 moreover, this condition verifies that microcirculation may improve the peripheral sensory status; thereby helping the patient to reduce their response to pain which impacted their comfort and also improve the quality of life.12 this study was used to develop a model that aids in leg comfort for patients with dm. therefore, further studies are needed to investigate the standard of treatment for diabetic neuropathic pain which may involve the combinations of therapy and drug that offers an opportunity to develop a nursing modality therapy to manage the pain of dm foot.16-18 modeling the sensory status of the right and left feet with pain response can guide practitioners to predict any emerging changes. the abi and sensory status in the feet of t2dm patients showed a moderate relationship and a positive pattern. these findings imply that a higher abi score increases the foot’s sensory status. the abi is a macrocirculation indicator, while the sensory status of the foot skin is a microcirculation indicator.19,20 the process of complications in diabetic foot periphery may be influenced by macrocirculation conditions. therefore, it is crucial to predict any emerging changes in macrocirculation conditions due to changes in microcirculation. from the results obtained in this study, an understanding of macro and microcirculation conditions in diabetic foot management must be considered as a means of improving treatment. this method may also be used as a future target for the management of macro and microcirculation foot conditions of dm patients.21 article [healthcare in low-resource settings 2023; 11(s1):11173] [page 45] table 2. normality test results. leg pain foot abi foot sensory right left right left sd 1.7 0.15 0.17 1.7 1.5 mean 5.6 1 0.97 5.8 5.9 covariance coefficient 30.35 15 17.52 29.31 25.42 table 3. correlation, means, and sd of variable models. variable mean (sd) p 1 2 3 4 5 1. leg pain 5.62 (1.71) 2. right foot abi 1.00 (0.15) 0.21 3. left foot abi 0.97 (0.17) 0.69 0.000* 4. right foot sensory 5.84 (1.78) 0.012* 0.010* 0.003* 5. left foot sensory 5.90 (1.56) 0.043* 0.000* 0.003* 0.000* * significantly different p-value < 0.05. table 4. correlation and regression analysis of right and left foot sensory status with leg pain responses in t2dm patients. variable r r2 equation p sensory status of right and left feet 0.325 0.105 leg pain = 7.66 -0.244 right foot sensory – 0.105 left foot sensory 0.035 table 5. analysis of abi correlation and regression with sensory status in the foot of t2dm patients. variable r r2 equation p right foot abi 0.338 0.114 right foot sensory = 1.76 + 4.16 right foot abi 0.007 left foot abi 0.383 0.147 left foot sensory = 2.23 + 3.89 left foot abi 0.002 non -co mmerc ial us e o nly this study showed that there was no relationship between leg pain responses and abi scores of the right and left feet in t2dm. therefore, it is known that the abi score reflects the macrocirculation conditions and the pain response because of the defects in microcirculation which is measured using tcpo2.22,23 this finding may be due to the presence of hyperglycemia that induces changes in the microvascular function, which increases the capillary pressure of the lower extremity and reduces the vasodilation response that occurs in diabetic neuropathy.24 however, there was a moderate relationship and a negative direction between the sensory status of the right and left feet and the leg pain responses. this finding, therefore, confirms that monofilament examination increases pain responses. moreover, there was a positive pattern and a moderate relationship between the abi and sensory status. according to the result, a higher abi score improves the sensory status of the feet of t2dm patients. therefore, it is important to understand the central pain mechanism and how it affects neuropathic diabetes. the central pain mechanism occurs due to cellular changes in response to the central and peripheral system in the form of excessive synaptic input, decreased neuronal activation threshold, increased response for the unlimited stimuli, and expansion of the receptor areas,9 which leads to a simulation in the neuropathic pain. in addition, the aberration in the transmission of a signal between the neurons and glia also contributes to the factors that trigger neuropathic pain. some hypotheses also suggest that microglia, loss of oligodendrocytes in the spinal cord and axons in the dorsal horn of the spine stimulate neuropathic pain.25,26 the mechanism of alteration in neuropathic pain is unclear, hence, several studies have suggested that the coexistence of pain may lead to a series of maladaptive neuroplastic changes involving the thalamus and other parts of the central projection of the somatosensory system.27 it is pivotal to conduct further studies with the use of large study subjects which will aid in achieving a clinical intervention for diabetic foot care. conclusions the relationship between the sensory status of the right and left feet and the leg pain responses in t2dm patients was moderate with a negative direction. it implies that a decrease in sensory responses led to an increase in leg pain. meanwhile, a moderate relationship and a positive direction between the abi and sensory status indicates that a higher abi score will lead to an increase in the sensory status of the t2dm foot. references 1. salvotelli l, stoico v, perrone f, et al. prevalence of neuropathy in type 2 diabetic patients and its association with other diabetes complications: the verona diabetic foot screening program. j of diabetes complicat 2015;29:1066-70. 2. yazdanpanah l, nasiri m, adarvishi s. literature review on the management of diabetic foot ulcer. world j diabetes 2015;6:37. 3. zhang p, lu j, jing y, et al. global epidemiology of diabetic foot ulceration: a systematic review and meta-analysis. ann med 2017;49:106-16. 4. crawford f, cezard g, chappell fm. the development and validation of a multivariable prognostic model to predict foot ulceration in diabetes using a systematic review and individual patient data meta-analyses. diabetic med 2018;35:1480-93. 5. shrestha s, gorhaly mp, bajracharya mr. diagnostic accuracy of monofilament test to detect diabetic neuropathy. j adv int med 2021;10:20-5. 6. hawker ga, mian s, kendzerska t, et al. measures of adult pain: visual analog scale for pain (vas pain), numeric rating scale for pain (nrs pain), mcgill pain questionnaire (mpq), short�form mcgill pain questionnaire (sf�mpq), chronic pain grade scale (cpgs), short form�36 bodily pain scale (sf�36 bps), and measure of intermittent and constant osteoarthritis pain (icoap). arthritis care res 2011;63:s240-s52. 7. kristianto h, waluyo a, gayatri d. relationship between diabetic foot ulcers profile and ankle brachial index score: a preliminary study. enfermería clínica 2021;31:s424-s7. 8. dobson j, mcmillan j, li l. benefits of exercise intervention in reducing neuropathic pain. front cellular neurosci article correspondence: heri kristianto, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62.341.5080686, fax: +62.341.5080686. e-mail: heri.kristianto@ub.ac.id key words: t2dm; abi; pain response; sensory status. acknowledgment: the authors are grateful to the department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia for their kind support and encouragement during this study. contributions: all authors contributed equally to this article. hks, hkw, fr, ic, el conducted this study; thn, epl, eks, ahw reviewed the final article. thanks to hks for being kind and thoughtful in managing this study. conflict of interests: the authors declare no conflict of interest. funding: this study was financially supported by the school of nursing, faculty of medicine, university of brawijaya malang. availability of data and materials: the complete dataset is available upon request. clinical trials: this study has been approved by the health research ethics committee of the faculty of medicine, university of brawijaya malang. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11173 doi:10.4081/hls.2023.11173 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 46] [healthcare in low-resource settings 2023; 11(s1):11173] non -co mmerc ial us e o nly 2014;8:1-9 9. jensen ts, finnerup nb. allodynia and hyperalgesia in neuropathic pain: clinical manifestations and mechanisms. lancet neurol 2014;13:924-35. 10. forbang ni, mcdermott mm, liao y, et al. associations of diabetes mellitus and other cardiovascular disease risk factors with decline in the ankle–brachial index. vascular medicine 2014;19:465-72. 11. salawu f, shadrach l, adenle t, et al. diabetic peripheral neuropathy and its risk factors in a nigerian population with type 2 diabetes mellitus. afr j diabetes med 2018;26:16-20 12. bouhassira d, letanoux m, hartemann a. chronic pain with neuropathic characteristics in diabetic patients: a french cross-sectional study. plos one 2013;8:e74195. 13. hébert hl, veluchamy a, torrance n, et al. risk factors for neuropathic pain in diabetes mellitus. pain 2017;158:560-8. 14. baraz s, zarea k, shahbazian hb, et al. comparison of the accuracy of monofilament testing at various points of feet in peripheral diabetic neuropathy screening. j diabetes metabolic disord 2014;13:19. 15. wang f, zhang j, yu j, et al. diagnostic accuracy of monofilament tests for detecting diabetic peripheral neuropathy: a systematic review and meta-analysis. j diabetes res 2017;2017:1-12 16. bakker k, apelqvist j, lipsky ba, et al. the 2015 iwgdf guidance documents on prevention and management of foot problems in diabetes: development of an evidence-based global consensus. diabetes/metabolism res rev 2016;32:2-6. 17. peltier a, goutman sa, callaghan bc. painful diabetic neuropathy. br med j 2014;348:1799. 18. volmer-thole m, lobmann r. neuropathy and diabetic foot syndrome. int j molecular sci 2016;17:917. 19. forsythe ro, hinchliffe rj. assessment of foot perfusion in patients with a diabetic foot ulcer. diabetes/metabolism res rev 2016;32:232-8. 20. stirban a. microvascular dysfunction in the context of diabetic neuropathy. curr diabetes rep 2014;14:541. 21. vouillarmet j, bourron o, gaudric j, et al. lower-extremity arterial revascularization: is there any evidence for diabetic foot ulcer-healing? diabetes metabolism 2016;42:4-15. 22. huang k, ma y, wang j, et al. the correlation between transcutaneous oxygen tension and microvascular complications in type 2 diabetic patients. j diabetes complicat 2017;31:886-90. 23. deng w, dong x, zhang y, et al. transcutaneous oxygen pressure (tcpo2): a novel diagnostic tool for peripheral neuropathy in type 2 diabetes patients. diabetes res clinical pract 2014;105:336-43. 24. eleftheriadou i, tentolouris a, grigoropoulou p, et al. the association of diabetic microvascular and macrovascular disease with cutaneous circulation in patients with type 2 diabetes mellitus. j diabetes complicat 2019;33:165-70. 25. gritsch s, lu j, thilemann s, et al. oligodendrocyte ablation triggers central pain independently of innate or adaptive immune responses in mice. nature comm 2014;5:5472. 26. sorge re, mapplebeck jc, rosen s, et al. different immune cells mediate mechanical pain hypersensitivity in male and female mice. nature neurosci 2015;18:1081. 27. feldman el, nave k-a, jensen ts, et al. new horizons in diabetic neuropathy: mechanisms, bioenergetics, and pain. neuron 2017;93:1296-313. article [healthcare in low-resource settings 2023; 11(s1):11173] [page 47] non -co mmerc ial us e o nly hrev_master [page 30] [healthcare in low-resource settings 2023; 11:11345] assessment of blood culture and tube agglutination serology test for the diagnosis of typhoid fever amongst malaria-negative patients: a one-year hospital-based study kirti nirmal,1 vikas saini,2 nadeem ahmad,1 narendra pal singh1 1department of microbiology, university college of medical sciences and guru tag bahadur hospital, delhi; 2department of microbiology, all india institute of medical sciences, ansari nagar, new delhi, india abstract salmonella serotypes, including salmonella typhi, s. paratyphi a, s. paratyphi b, and s. paratyphi c, are responsible for the systemic, protracted febrile sickness known as typhoid fever. various antibody-based tests are being used for diagnosing typhoid fever. this study was carried out to assess the performance of the widal test and blood culture for the diagnosis of typhoid fever among malaria-negative patients in a tertiary care hospital in east delhi, india. the study was conducted from july 2021 to june 2022 in the department of microbiology of a tertiary care hospital in delhi. patients, including the adult and pediatric population, were evaluated for typhoid fever and participated in an observational, prospective study on febrile patients that was malaria-negative. venous blood samples were obtained under strict aseptic conditions and further processed for widal serology and blood culture tests for typhoid fever. in our study, the prevalence of blood culture-positive salmonella species was 0.3% (30/10,000 = 0.3%) among antimicrobial susceptibility patterns, s. typhi revealed the highest resistance rates for ciprofloxacin (43.33%), azithromycin (36.66%), and third-generation cephalosporins. out of 30 blood culture-positive salmonella typhi of typhoid fever patients, 5 (17%) samples were negative for the widal test. among 30 samples, all were blood culture positive, but only 25 samples show widal titer above the baseline i.e. >1:64. although blood culture is the gold standard for the diagnosis of typhoid fever, the widal test does play a role in the diagnosis and management of typhoid fever, especially in suspected cases when blood culture is negative, especially in government tertiary care hospitals. introduction salmonella serotypes, including salmonella typhi, s. paratyphi a, s. paratyphi b, and s. paratyphi c, are responsible for the systemic, protracted febrile sickness known as typhoid fever. typhoid fever only affects humans as reservoir hosts, and in endemic places, the disease is spread through contact with fecescontaminated water and food, especially by carriers who handle food. typhoid fever is thought to cause over 21 million illnesses and more than 600,000 deaths annually, according to the world health organisation (who). in other words, in places with high population expansion, rising urbanization, and insufficient access to good water, infrastructure, and health systems, these instances are more likely to be seen in india, south and central america, and africa.1,2 typhoid fever must be accurately diagnosed at an early stage to determine the etiological agent as well as to locate possible carriers who may be to blame for acute enteric fever epidemics.3 clinical signs and symptoms, serological markers, bacterial culture, antigen detection, and dna amplification are all possible methods for diagnosing typhoid fever.4,5 the most accurate diagnostic approaches involve the culture of blood, bone marrow, and stool.6-8 blood culture is regarded as the gold standard for diagnosis and has a diagnostic yield of 70-75% during the first week of illness and declining 20-30% later in the course of the disease.9 the isolation from blood culture is more difficult due to the easy availability and widespread use of antibiotics in the community. alternate methods such as bone marrow cultures may be required, which are invasive and difficult to carry out.10 thus one has to rely on serological diagnosis, which is the mainstay of diagnosis of typhoid fever in most laboratories.11 various antibody-based tests are being used for diagnosing typhoid fever. the widal test is the most frequently used test for diagnosing enteric fever since it is generally less expensive, simple to apply, and requires less training and equipment.12,13 the efficacy of the widal test to diagnose enteric fever has been disputed for as long as it has been available, even though it has been in use for more than a century.14 it traditionally relies on the proof of an increasing antibody titer in paired samples taken 10 to 14 days apart. this study was carried out to assess the performance of the widal test and blood culture for the diagnosis of typhoid fever amongst malaria-negative patients in a tertiary care hospital in east delhi, india. healthcare in low-resource settings 2023; volume 11:11345 correspondence: vikas saini, department of microbiology, all india institute of medical sciences, ansari nagar, 110029 new delhi, india. tel.: 9953259572 e-mail: vikassaini287@gmail.com key words: blood culture, widal test, malarianegative typhoid fever. contributions: kn, vs, concepts and design; kn, vs, na, definition of intellectual contents; kn, vs, na, nps, content definition, investigation, manuscript writing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethical approval declaration: this study has been approved by the institutional ethical committee (iec no. gtbhec/apvl/ 2023/256-79). informed consent: we have not performed any extra tests apart from routine diagnostic methods (widal test and blood culture) for the diagnosis of typhoid fever from the sample. we have processed those samples only which came into our microbiology laboratory for routine testing of typhoid fever. however, verbal consent from the respective patient was taken for this study. patient consent for publication: the manuscript does not contain any person's data in any form. acknowledgment: i would like to acknowledge to blood seat senior technical staff mr. narender pal singh for processing of blood culture samples and mr. vinod for processing the widal test. received for publication: 31 march 2023. accepted for publication: 7 june 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11345 doi:10.4081/hls.2023.11345 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11345] [page 31] materials and methods the study was conducted from july 2021 to june 2022 in the department of microbiology under the bacteriology and serology laboratory of a tertiary care hospital, in delhi. patients including the adult and pediatric population were evaluated for typhoid fever and participated in an observational, prospective study on febrile patients which was malaria negative. the clinical symptom of typhoid fever, which is a fever that occurred two or more days before admission and was also accompanied by other clinical symptoms of typhoid fever, was checked on patients through a physician. the study comprised febrile patients whose presumptive clinical diagnosis was enteric fever and not started on antibiotics enrolled and their blood culture and serology sample was sent for a widal test in the laboratory. blood sample collection and inoculation venous blood samples of 8-10 ml from adults and 1-3 ml from children were obtained under strict aseptic conditions. each 8 to 10 ml blood sample was placed into a blood culture bottle with 50 ml of brain heart infusion broth for adults, and 30 ml of blood culture broth for pediatric patients. the blood culture sample will be delivered right away to the bacteriology laboratory, where it will spend the night being incubated at 37°c in an ambient atmosphere. following manual subculture onto 5% sheep blood agar and mac-conkey agar incubation for 24 hours, 48 hours, and a seventh day, the samples were processed. following the established process in our laboratory, the obtained growth was recognized using colony morphology, gram stain of the isolated colonies, common microbiological tests, and biochemical assays.15 all isolated blood culture salmonella species isolates from suspected cases of enteric fever were confirmed from salmonella antisera (salmonella sero-quick, ssi diagnostic) for grouping of serotype. widal test widal test also known as the tube agglutination serology test, was done by tube agglutination method using colored typhocheck reagent (tulip diagnostic pvt. ltd.). anti-salmonella antibodies in the patient’s blood react with the colored, smooth, typhocheck antigen solutions to produce agglutination when they are combined with the patient’s serum. the maximum dilution of serum that causes visible agglutination is determined by the antibody titer of the patient’s serum using typhocheck antigen suspensions. antimicrobial susceptibility testing of salmonella species isolates by using the kirby-bauer disc diffusion method on mueller-hinton agar plates, the antibiotic susceptibility pattern of the salmonella species salmonella typhi isolates, isolated from blood culture was assessed. the antibiotics disc including ampicillin (10 µg), ciprofloxacin (5 µg), azithromycin (15 µg), chloramphenicol (30 µg), ceftriaxone (30 µg), imipenem (10 µg) and trimethoprim-sulfamethoxazole (1.25/23.75 µg) was placed. the results were recorded according to the latest recommended clinical laboratory standard institute (clsi) guidelines.21 results in our study, the prevalence of salmonella species was 0.3% (30/10,000=0.3%) in clinically suspected cases of typhoid fever. among 30 blood culture-positive febrile patients, 21 (70%) and 9 (30%) were females and males respectively. the female: male ratio was (2:1). the age range of patients was 2–28 years with a mean of 9.8 and a median of 7 years of age. typhoid fever was more prevalent in the age group of 1-10 years (63.33%) and females (70%). moreover, in the present study, typhoid fever was more prevalent in pediatric intensive care unit (picu)patients (33.33%) than in other departments (table 1). amongst antimicrobial susceptibility patterns, s. typhi revealed the highest resistance rate for ciprofloxacin 13(43.33%) and azithromycin 11(36.66%) followed by tetracycline 4(13.33%), ceftriaxone 2(6.66%), cefotaxime 2 (6.66%), cotrimoxazole 2 (6.66%), and chloramphenicol 1 (3%). on the other hand, all s. typhi isolates were susceptible to meropenem and piperacillintazobactam. (figure 1) furthermore, 6 (20%) isolates of s. typhi were resistant to more than two different groups of class article table 1. socio-demographic characteristics and distribution of blood culture isolates of s. typhi in febrile patients. variables category number of positive blood culture isolates for s. typhi. n=30 (%) sex male 9 (30) female 21 (70) age (in years) 1-10 19 (63.33) >10 11 (36.66) departments picu 10 (33.33) medicine 9 (30) pediatrics 4 (13.33) surgery 3 (10) mch 2 (6.66) micu 2 (6.66) picu, pediatrics intensive care unit; micu, multidisciplinary adult intensive care unit; mch, maternity and child health. figure 1. antibiotic profile of s. typhi blood culture isolates among clinically suspected cases of typhoid fever in the study group (n=30). non -co mmerc ial us e o nly [page 32] [healthcare in low-resource settings 2023; 11:11345] drugs or multidrug resistance (mdr). (table 2) in the present study, tube agglutination serology test /widal test was carried out for all the clinically proven typhoid cases. the cut-off value of the widal test was considered as 1:64 for both to and th. out of 30 blood culture-positive cases of typhoid fever, 33.33% cases have shown an antibody titer of ≥ 128, 23.33% cases have shown an antibody titer of ≥ 64, 13.33% cases have showed an antibody titer of ≥ 256, 13.33% cases have shown an antibody titer of ≥ 512. out of 30 positive samples for blood culture; only 5 (17%) samples were negative for the widal test. amongst 5 negative widal tests the blood culture was positive for salmonella typhi. this was not statistically significant. (p<0.098, chisquare test) discussion in the present study, the prevalence of s. typhi among febrile illness patients at tertiary care government hospitals was 0.3%. this finding was much lower than the study conducted in shashemene ethiopia 5%,15 central ethiopia (4.1%),16 in indonesia (15.5%)17 and lalitpur 4.1%.18 similar findings were also reported in india 2.5%19 and nepal 1.2%.20 this difference might be due to the geographic setting of the study district, the disparity in the study population, time of the studies. moreover, the mode of the laboratory investigation technique disparity also affects the result. the finding of this study shows most of the isolates of s. typhi were sensitive to ceftriaxone. a similar finding was reported in a study done in bangladesh and lalitpur, nepal which shows 100% sensitivity to ceftriaxone.21,22 in this study s. typhi susceptible to chloramphenicol was observed in 29 (96.66%) cases. this finding was similar to a study done in india which shows 87.4% of s. typhi was sensitive to chloramphenicol.23 the widal test is still the widely used serological test for typhoid fever. here the antibody against antigens o and h are detected. in this study, a widal test was carried out for all the clinically proven typhoid cases. the cut-off value of the widal test was considered as 1:64 for both to and th antigens. present study about 33.33% of cases with a fever of more than a week showed an antibody titer of ≥128. a study done by shukla et al.,24 also found that 44.2% had to titter of ≥160 in a single sample collected from patients suspected to have typhoid in an endemic area of south india. second specimens are often not sent to the laboratory to verify the rising titter. it is possible that the widal test would have performed better if paired sera were tested to demonstrate the rising titers. patients rarely return for follow-up once treated so obtaining paired sera in a routine clinical setting is unlikely. clinicians cannot wait for results from two samples and hence widely rely on “positive” widal tests done on a single serum sample. typhoid fever diagnostic evaluations conducted on hospitalized patients provide little insight into the application of diagnostic tests in the community health care setting. however, it is the primary health care level where sensitive, specific, rapid, cheap, and user-friendly typhoid diagnostic kits are most required. it is in this context that highgrade fever is important: in areas of malaria and typhoid endemicity where malaria rapid diagnostic test (rdt) yields a negative result, there may be clinical signs and symptoms such as the severity of fever that can help determine the value of conducting a typhoid diagnostic test without negatively impacting patient outcome. although blood culture is the gold standard for diagnosis of typhoid fever, widal tests do play a role in the diagnosis and management of typhoid fever, especially in suspected cases when blood culture is negative. it is likely that the widal test will remain in use in tertiary government set-ups and many other low-income settings for the foreseeable future, despite its known limitations in such settings. references 1. willke a, ergonul o, bayar b: widal test in diagnosis of typhoid fever in turkey. clin diagn lab immunol 2002;9:938-41. 2. crump ja, luby sp, mintz ed: the global burden of typhoid fever. bull world health organ 2004;82:346-53. 3. gopalakrishnan v, sekhar wy, soo eh, et al. typhoid fever in kuala lumpur and a comparative evaluation of two commercial diagnostic kits for the detection of antibodies to salmonella typhi. singapore med j 2002;43:354-8. 4. nsutebu ef, martins p, adiogo d. prevalence of typhoid fever in febrile patients with symptoms clinically compatible with typhoid fever in cameroon. trop med int health 2003;8:575-8. 5. onyekewere ca. typhoid fever: misdiagnosis or over diagnosis. niger med pract 2007;51:76-9. 6. wain j, hosoglu s. the laboratory diagnosis of enteric fever. j infect dev ctries 2008;2:421-5. 7. parry cm, tuyet hnt, diep ts, et al. value of a single-tube widal test in diagnosis of typhoid fever in vietnam. j clin microbiol 1999;37:2882-6. 8. wain j, diep ts, be bay pv, et al. specimens and culture media for the laboratory diagnosis of typhoid fever. j infect dev ctries 2008;2:469-74. article table 2. multidrug resistance patterns among s. typhi isolated from clinically suspected cases of typhoid fever. antibiotics resistant resistance isolate of salmonella typhi n=6 (%) ctx+ctr+cip 2 cot+tet+cip 2 tet+cip+azt 2 ctx, cefotaxime, ctr, ceftriaxone, cip, ciprofloxacin, cot, cotrimoxazole, tet, tetracycline, azt, azithromycin. table 3. correlation between widal test and blood culture in typhoid fever patients (n=30). tests widal test (+) widal test (-) blood culture (+) 25 5 p<0.098 blood culture (-) 0 30 chi-square test not significant p<0.05 is statistically significant. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11345] [page 33] 9. krishna s, desai s, anjana vk, paranthaaman rg. typhidot (igm) as a reliable and rapid diagnostic test for typhoid fever. ann tropical med public health 2011;4:42. 10. olsen sj, pruckler j, bibb w, et al. evaluation of rapid diagnostic tests for typhoid fever. j clin microbiol 2004;42: 1885-9. 11. begum z, hossain ma, shamsuzzaman ak, et al. evaluation of typhidot (igm) for early diagnosis of typhoid fever. bangladesh j med microbiol 2009;3: 10-3. 12. ley b, mtove g, thriemer k, et al. evaluation of the widal tube agglutination test for the diagnosis of typhoid fever among children admitted to a rural hospital in tanzania and a comparison with previous studies. bmc infect dis 2010;10:180. 13. beyene g, asrat d, mengistu y, et al. typhoid fever in ethiopia. j infect dev ctries 2008;2:448-53. 14. olopoenia la, king al. widal agglutination test 100 years later: still plagued by controversy. postgrad med j 2000;76:80-4. 15. laxminarayan r, matsoso p, pant s, et al. access to effective antimicrobials: a worldwide challenge. lancet 2016;387:168-75. 16. murray ck, gasser ra, jr., magill aj, miller rs. update on rapid diagnostic testing for malaria. clinical microbiol rev 2008;21:97-110. 17. wongsrichanalai c, barcus mj, muth s, et al. a review of malaria diagnostic tools: microscopy and rapid diagnostic test (rdt). am soc trop med hygiene 2007;77:119-27. 18. bell d, peeling rw. evaluation of rapid diagnostic tests: malaria. nat rev microbiol 2006;4:s34-8. 19. who. report of a joint who/usaid informal consultation. new perspectives: malaria diagnosis. geneva, switzerland: world health organization; 1999. 20. banoo s, bell d, bossuyt p, et al. evaluation of diagnostic tests for infectious diseases: general principles. nat rev microbiol 2006;4:s20-2. 21. kalpana p, sharma vk, maharjan r. prevalence and antibiotic sensitivity test of salmonella serovars from enteric fever suspected patients visiting alka hospital, lalitpur. am j microbiol 2015;6:40-43. 22. globally td-ri. final report and recommendations. review on antimicrobial resistance report. 2016. 23. tewari r, jamal s, dudeja m. antimicrobial resistance pattern of salmonella enterica servars in southern delhi. int j community med public health 2015;2:254-8. 24. shukla s, patel b, chitnis ds. 100 years of widal test & its reappraisal in an endemic area. indian j med res 1997;105:53-7. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e23] [page 79] prevention of nosocomial infections in low resource countries saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, nosocomial infections are infections acquired during hospital care which are not present neither incubating at the time of admission. infections occurring more than 48 h after admission are usually considered nosocomial. in other words it is the cross-infection of one patient by another or by doctors, nurses and other hospital staff while in hospital.1 nosocomial infections have been observed worldwide affecting both developing nations with inadequate resources and developed nations.2 hospital-acquired infections add to functional disability, economic burden and emotional stress for the patient and his/her relatives that can reduce the quality of life.3,4 the most frequent nosocomial infections are infections of the surgical wounds, urinary tract infections and lower respiratory tract infections, with their highest incidence being observed in intensive care units and acute surgical/orthopedic wards. infection acquired in healthcare settings is one of the major cause of morbidity/mortality among hospitalized patients and is a direct indicator of quality of healthcare service delivered especially in low resource countries.1,2 many factors such as emergence of antimicrobial resistance, susceptibility of the patients (viz. age, immunocompromised state, underlying disease, invasive diagnostic and therapeutic interventionsparenteral nutrition, biopsies/endoscopic examinations/catheterization, etc.), a prolonged hospital stay, patient care practices, and hospital environment, have predominantly contributed to the rise in the occurrence of nosocomial infections.1,2,5 in order to prevent the occurrence of nosocomial infections, onus lies with all stakeholders’ i.e. all individuals providing health care services in the hospital, must work as a team to reduce the risk of infection to the patients and the staff. each hospital should design and implement a work plan to assess and promote good health care; advocate appropriate isolation/sterilization practices; and training and re-training of the hospital staff in a phase-wise manner.2 the above mentioned goals can be achieved by constituting a hospital infection control committee with representatives from different departments for multidisciplinary inputs and information sharing. this committee should devise mechanism for proper utilization of scarce resources and also ascertain the roles and responsibilities of different healthcare personnel (viz. hospital management/physician/microbiologist/pharmacist/nur sing staff/food handlers/central sterilization department/housekeeping department/laundry department, etc.) in the process of infection control in the hospital. hospital management must provide sufficient resources to support this program.1,2 on a global scale to prevent emergence of nosocomial infections, world health organization has launched an infection prevention and control in healthcare initiative to help low resource countries in reducing dissemination of infections associated with healthcare delivery, by assisting them in the assessment, planning, implementation and evaluation of national infection control policies. the ultimate goal is promotion of health care services which is safe for patients, health care workers, others in the healthcare setting, and to accomplish these goals in a cost-effective manner.6 surveillance of nosocomial infections has also been advocated as an important element to plan appropriate steps in different countries.7 to conclude, an increased awareness among the healthcare personnel, supplemented with proper implementation of a well-designed plan by active involvement of dedicated healthcare workers will substantially contribute in reducing the incidence of nosocomial infections in low resource countries. references 1. park k. epidemiology of communicable diseases. in: park k, ed. text book of preventive and social medicine. jabalpur: banarsidas bhanot publ.; 2011. pp 332335. 2. girard r, perraud m, pruss a, et al. epidemiology of nosocomial infections. in: ducel g, fabry j, nicolle l, eds. prevention of hospital-acquired infections: a practical guide. geneva: who ed.; 2002. pp 4-8. available from: http://www.who.int/ csr/resources/publications/drugresist/en/w hocdscsreph200212.pdf 3. herwaldt la, cullen jj, scholz d, et al. a prospective study of outcomes, healthcare resource utilization, and costs associated with postoperative nosocomial infections. infect cont hosp ep 2006;27:1291-8. 4. rosenthal vd, guzman s, migone o, safdar n. the attributable cost and length of hospital stay because of nosocomial pneumonia in intensive care units in 3 hospitals in argentina: a prospective, matched analysis. am j infect control 2005;33:157-61. 5. colombo al, matta dd, almeida lpd, rosas r. fluconazole susceptibility of brazilian candida isolates assessed by a disc diffusion method. braz j infect dis 2002;6:118-23. 6. who. infection prevention and control in health care. available from: http://www. who.int/csr/bioriskreduction/infection_co ntrol/en/index.html 7. lizan-garcia m, peyro r, cortina m, et al. nosocomial infection surveillance in a surgical intensive care unit in spain, 1996-2000: a time-trend analysis. infect cont hosp ep 2006;27:54-9. healthcare in low-resource settings 2013; volume 1:e23 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: nosocomial infections, prevention, antimicrobial resistance, healthcare. contributions: ss: conception and design, drafting of the article, review of literature, guarantor; ps: drafting of the article, review of literature, revising it critically for important intellectual content; jr: general supervision of the research, overall guidance in writing the manuscript. conflicts of interests: the authors declare no potential conflict of interests. received for publication: 7 may 2013. accepted for publication: 22 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e23 doi:10.4081/hls.2013.e23 non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:4659] [page 41] portrayal of smoking in nigerian online videos: a medium for tobacco advertising and promotion? adegoke oloruntoba adelufosi, olukayode abayomi department of psychiatry, lautech teaching hospital, ogbomoso, oyo state, nigeria abstract the nigerian home video industry, popularly known as nollywood is a booming industry, with increasing numbers of easily accessible online videos. the aim of this study was to analyse the contents of popular nigerian online videos to determine the prevalence of smoking imageries and their public health implications. using specific search terms, popular english language and indigenous yoruba language, nigerian home videos uploaded on youtube in 2013 were identified and sorted based on their view counts. data on smoking related scenes such as smoking incidents, context of tobacco use, depiction of cigarette brand, gender of smokers and film rating were collected. of the 60 online videos whose contents were assessed in this study, 26 (43.3%) had scenes with cigarrete smoking imageries. the mean (sd) smoking incident was 2.7 (1.6), giving an average of one smoking incident for every 26 to 27 min of film. more than half (53.8%) of the films with tobacco use had high smoking imageries. an average of 2 characters per film smoked, mostly in association with acts of criminality or prostitution (57.7%) and alcohol use (57.7%). there were scenes of the main protagonists smoking in 73.1% of the films with scenes of female protagonists smoking (78.9%) more than the male protagonists (21.1%). smoking imageries are common in popular nigerian online movies. given the wide reach of online videos, their potential to be viewed by people from different cultures and to negatively influence youngsters, it is important that smoking portrayals in online movies are controlled. introduction strict government legislations in many countries on overt advertising and promotion of tobacco products have forced many tobacco industries to look for new avenues to promote their products. the internet provides such an ideal forum for tobacco marketing because it is largely unregulated.1 because movies are powerful means of communication and strong tool for shaping social norms,2 the tobacco industry has exploited the increasing availability of movies, which may be censored at home, but freely available for viewing on the internet, to indirectly promote tobacco products especially to youths. tobacco imagery in movies is an important form of promotion still rarely considered by policy makers and smoking scenes still continue to permeate movies, including those rated as suitable for young people.2 according to the global adult tobacco survey, 5.6% of the nigerian population, totalling 4.5 million adults, currently use tobacco products.3 although the national tobacco control bill prohibits all forms of tobacco advertisements, sponsorships and sales promotions, many nigerian home videos now feature scenes of actors smoking and even depict cigarrete brand names. the nigerian home video industry, popularly known as nollywood is a booming industry, described as the 2nd biggest movie industry in the world after indian bollywood.4 in the last decade, accessibility to these home videos has significantly increased through their availability as online videos, freely available for viewing on the popular media website youtube. for example, in 2012 nigeria had the second highest youtube viewership growth in sub-saharan africa, increasing by 125% over that of 2011, while video upload increased by 50% over the same time.5 being a popular entertainment destination, there is a potential for anonymous exploitation of youtube by tobacco industries to reach a massive audience, particularly youngsters, by promoting and normalizing smoking.6 smoking imageries in films influence viewers’ perception and attitude towards smoking especially among youngsters and can negate effects of positive parental role modeling on smoking.7 in addition, previous studies have shown that there is a strong, direct association between seeing tobacco use in films and adolescent smoking initiation.8,9 however, there is a dearth of studies on the prevalence of cigarette smoking in online versions of popular nigerian home videos. the only available study which examined alcohol and substance use protrayals in video tapes found that tobacco was the second most portrayed substance, after alcohol.10 to our best knowledge, no study has examined the prevalence of cigarette smoking in online versions of nigerian home videos. the aim of this study was to analyze the contents of popular nigerian home videos uploaded on youtube for smoking imageries prevalence and their public health implications. materials and methods this study was conducted on 20 february 2014, using specific search terms to identify popular nigerian home videos uploaded on youtube in 2013. both english language and indigenous yoruba language movies were included in the search. to identify these movies, two separate search methods were used. first, we identified english speaking movies using search terms such as nollywood movies 2013 and nigerian movies 2013. indigenous yoruba language movies were also identified using search terms such as yoruba movies 2013, nollywood yoruba movies 2013 and yoruba magic 2013. the results from these searches were sorted using the site’s sort function: sort by view count. this enabled us to identify uploaded videos most viewed. on the assumption that few users would look at >60 videos, we selected 60 videos with the highest view counts, 38 from english home videos (using a cut off view count of ≥280,000) and 22 from indigenous yoruba language home videos (using a cut off view count of ≥153,000). data collected from the content analysis of the eligible home videos included: number of smoking incidents, total number of different individuals who smoked in the film, film length (in min), cigarette smoking by main protagonist(s) in the films, gender of protagonist(s), context of tobacco use, depiction of cigarette package and brand name or verbal mentioning of it, gender of cigarette smokers in the film, depiction of consequences of cigarette smoking and film rating. we calculated the number of tobacco incidents per minute of film, defined as total incidents of tobacco use (e.g. smoking or display of cigarettes, cigarette package, ashtrays) divided by the length of film in min.11 an incident is healthcare in low-resource settings 2014; volume 2:4569 correspondence: correspondence: adegoke oloruntoba adelufosi, department of psychiatry, lautech teaching hospital, 5000 ogbomoso, oyo state, nigeria. tel. +234.803.5988054. e-mail: ozotee@gmail.com conflict of interests: the authors declare no potential conflict of interests. key words: smoking, nollywood, tobacco advertising. received for publication: 11 july 2014 accepted for publication: 21 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.o. adelufosi and o. abayomi, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4569 doi:10.4081/hls.2014.4569 non co mmerc ial us e o nly [page 42] [healthcare in low-resource settings 2014; 2:4569] defined as tobacco use by an individual in a single scene, no matter the number of times the camera cuts back and forth between a smoker and a non-smoker in the scene. thus, a 52 min film with 6 incidents of smoking will have a smoking incident per minute of 0.12 or approximately one incident for every 8 to 9 min of film. home videos with tobacco use were further subdivided into those with low use (films with ≤2 smoking incidents) and those with high use (>2 smoking incidents). data were analysed using statistical package for social sciences (spss) version 16 (spss, chicago, il, usa) and presented using a frequency distribution table. results overall, the length included videos ranged from 38 to 104 min with view counts that ranged from 143,366 to 6,830,366. of the 60 online videos whose contents were assessed in this study, 26 (43.3%) had scenes with cigarrete smoking imageries. among films with smoking imageries, the mean (sd) film length was 72.35 (15.9) while the mean (sd) smoking incident was 2.7 (1.6), giving an average of one smoking incident for every 26 to 27 min of film. more than half (53.8%) of the films with tobacco use had high smoking imageries. an average of 2 characters per film smoked, mostly in scenes depicting criminality or prostitution (57.7%) and alcohol use (57.7%). there were scenes of the main protagonists smoking in 73.1% of the films with scenes of female protagonists smoking (78.9%) more than the male protagonists (21.1%) (table 1). discussion this study examined the prevalence and extent of tobacco portrayals in an online sample of nigerian english and indigenous yoruba speaking videos. the high proportion of movies, almost half of the total movies analyzed in this study, depicting tobacco imagery creates some concern. previous studies have demonstrated a direct relationship between frequency of exposures to smoking imageries in movies and the likelihood of initiating smoking.12 the public health risk of such imageries becomes obvious when one considers the potential wide reach of online videos as well as their long shelf life on the internet. the relationship between the entertainment and tobacco industries is mutually beneficial with the latter providing monetary or material support to film producers in exchange for using or depicting tobacco products in their films.13 while firm conclusions cannot be drawn based on the findings of this study alone, the high rate of tobacco imageries and even brand name depiction by many of the movies, raise the possibility of paid product advertisement by the tobacco industry. this subtle but powerful medium of advertisement reflects loopholes in existing legislation on tobacco advertisement in nigeria and represents at a global level, the unrelenting efforts by tobacco industries to promote the social acceptability and desirability of tobacco use.13 according to the definitions in article 1 of the world health organization framework convention on tobacco control (who fctc), a comprehensive ban on all tobacco advertising, promotion and sponsorship applies to all forms of commercial communication, recommendation or action and all forms of contribution to any event, activity or individual with the aim, effect or likely effect of promoting a tobacco product or tobacco use either directly or indirectly.14 this definition would imply that various forms of smoking imagery in movies would be included as part of the comprehensive ban called for by the who fctc, a bill which was also ratified by nigeria in 2005. a higher proportion of cigarette smokers in the movies examined were women compared to men. this could be a reflection of changes in cultural values and societal perception of the feminine role, resulting from an increasing influence of westernization and female empowerment.15 in the last few decades nigeria has witnessed an increasing struggle for gender equality in a society where the female gender is often at a disadvantage when compared to their male counterparts.16 adopting lifestyle habits such as smoking that are traditionally associated with males and once considered a social taboo among women, may be an indirect way of asserting gender equality. in addition, tobacco industries have increasingly targeted women specifically in their marketing, promoting smoking as a symbol of emancipation.17 smoking imageries in movies encourage youngsters to smoke and is a potent method for recruiting new smokers.8,18 the desire to smoke can further be reinforced when popular actors/actresses, whom youths look up to as role models for socialization, smoke in movies.19 in this study, popular actors, mostly females, were protagonists in the movies examined, and no negative consequences of their smoking habits were depicted by any of the movies. in addition, only 3 of the 27 movies depicting smoking sceneries were rated (for general viewers), indicating a need for closer monitoring by the appropriate regulatory body. in fact, 57.7% of movies depicting cigarette smoking showed its use along with alcohol, mostly in social settings and also in connection with social vices such as prostitution and other criminal behaviors. this finding is simi lar to that obtained in previous studies.20 none of the movies in this study depicted any negative consequences among characters who smoked cigarette, thereby giving a misleading impression that cigarette smoking is harmless. similar observations were made in a previous study in which 99.6% of film characters brief report table 1. smoking variables in online films. variable frequency n % smoking incidents category low 14 53.8 high 12 46.2 main protagonist smoking yes 19 73.1 no 7 26.9 gender of main protagonist* male 4 21.1 female 15 78.9 smoking context socializing/partying 11 42.3 criminality/prostitution 15 57.7 associated alcohol use yes 15 57.7 no 11 42.3 cigarette brand name depicted yes 13 50 no 13 50 gender of smokers males only 6 23.1 females only 12 46.2 both gender 8 30.8 smoking consequences depicted in film? yes 0 0 no 26 100 film rating indicated? yes 3 11.5 no 23 88.5 *nineteen of the 26 films examined had imageries of main protagonist(s) smoking. non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:4569] [page 43] who smoked on the screen suffered no life threatening consequences, making them seem invincible and belying tobacco’s role as a leading cause of preventable death.21 conclusions given the wide reach of online videos and their potential to be viewed by people from different cultures, it is important that tobacco advertisements be limited in online movies. some suggested recommendations by the world health organization include formulating policies that will motivate change in film industries’ behavior so that harmful contents are reduced and to encourage disclosures by film makers who received any form of support from tobacco industries.22 on a global level, youtube could be urged to adopt a rating system for smoking in videos, with those not meeting the recommended guidelines for a general audience subsequently banned from the site.6 there is need for a strong partnership between the nigerian movie industry regulators and the nigerian government, for an effective and comprehensive ban on all indirect forms of tobacco promotion and advertisement. references 1. elkin l, thomson g, wilson n. connecting world youth with tobacco brands: youtube and the internet policy vacuum on web 2.0. tob control 2010;19:361-6. 2. zolty b. smoke-free movies: an important component of a comprehensive ban on tobacco advertising, promotion and sponsorship. eur j public health 2012;22:168. 3. world health organization. the government of nigeria releases the first ever global adult tobacco survey (gats) report. geneva: world health organization ed.; 2013. available from: http://www.afro.who. int/en/nigeria/press-materials/item/5719the-government-of-nigeria-releases-thefirst-ever-global-adult-tobacco-surveygats-report-in-the-african-region.html 4. united nations. nigeria surpasses hollywood as world's second largest film producer. new york: united nations; 2009. available from: http://www.un.org/ apps/news/story.asp?newsid=30707#.u3b cakivdqo 5. this day live. nigeria records 2nd highest youtube figures in sub saharan africa in 2012. apapa: this day live ed.; 2012. available from: http://www.thisdaylive. com/articles/nigeria-records-2nd-highestyoutube-figures-in-sub-saharan-africa-in2012/140955/ 6. freeman b, chapman s. is “youtube” telling or sellingyou something? tobacco content on the youtube video-sharing website. tob control 2007;16:207-10. 7. sargent jd, dalton ma, beach ml, et al. viewing tobacco use in movies: does it shape attitudes that mediate adolescent smoking? am j prev med 2002;22:137-45. 8. sargent jd, beach ml, dalton ma. effect of seeing tobacco use in films on trying smoking among adolescents: cross sectional study. brit med j 2001;323:1-6. 9. charlesworth a, glantz sa. smoking in the movies increases adolescent smoking: a review. paediatrics 2005;116:1516-28. 10. aina of, olorunshola da. alcohol and substance use portrayals in nigerian video tapes: an analysis of 479 films and implications for public drug education. int q community health educ 2008;28:63-71. 11. mekemson c, glik d, titus k, et al. tobacco use in popular movies during the past decade. tob control 2004;13:400-2. 12. laugesen m, scragg r, wellman rj, difranza jr. r-rated film viewing and adolescent smoking. prev med 2007;45:454-9. 13. mekemson c, glantz sa. how the tobacco industry built its relationship with hollywood. tob control 2002;11(suppl.1): 81-91. 14. world health organization. guidelines for implementation of article 13 of the who framework convention on tobacco control (tobacco advertising, promotion and sponsorship). geneva: world health organization; 2011. available from: http://www.who. int/fctc/guidelines/article_13.pdf?ua=1 15. adesina os. the negative impact of globalization on nigeria. int j humanit soc sci 2012;2193-201. available from: http://www. ijhssnet.com/journals/vol_2_no_15_augu st_2012/24.pdf 16. oyekanmi fd. institutionalization of gender inequality in nigeria: implications for the advancement of women. population rev 2005;44:56-71. 17. amos a, haglund m. from social taboo to “torch of freedom”: the marketing of cigarettes to women. tob control 2000;9:3-8. 18. watson na, clarkson jp, donovan rj, giles-corti b. filthy or fashionable? young people’s perceptions of smoking in the media. health educ res 2003;18;5:554-67. 19. tickle j, sargent j, dalton m, et al. favourite movie stars, their tobacco use in contemporary movies, and its association with adolescent smoking. tob control 2001;10:16-22. 20. dalton ma, tickle jj, sargent jd, et al. the incidence and content of tobacco use in popular movies from 1988 to 1997. prev med 2002;34:516-23. 21. dozier dm, lauzen mm, day ca, et al. leaders and elites: portrayals of smoking in popular films. tob control 2005;14:7-9. 22. world health organization. smoke-free movies: from evidence to action. geneva: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011/9789241502399_eng.pdf?ua=1 brief report non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11177 a cross-sectional study of the knowledge, skills, and 6 rights on medication administration by nurses at emergency department linda wieke noviyanti,1 andri junianto,2 ahsan1 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2nursing practitioner, general hospital saiful anwar, malang, indonesia abstract introduction: medication errors occur when a patient is given the wrong drug or receives incorrect pharmacological therapy. incorrect drug administration can cause fatal errors resulting in the patient’s death. approximately 44,000-98,000 patients die each year due to medication errors and this condition is found often in the emergency room (er) due to the complexity. therefore, this study aims to analyze the relationship between nurses’ knowledge, skills, and 6 rights on medication at emergency department. design and methods: this is an analytical observational study involving 70 nurses randomly selected using consecutive sampling and working at the er department of saiful anwar hospital malang. data were collected through a questionnaire and analyzed descriptively to determine the knowledge and skills of nurses and the implementation of the correct principles of medication administration. results: the results showed that most of the emergency room nurses had good knowledge and skills in applying the correct principles of medicine. however, the majority could not calculate the drug dose accurately. the spearman rank results showed that there was a relationship between knowledge and the 6 correct drug principles (p<0.001, α= 0,05; r = 0.491) with a percentage of 44%. this indicates that a higher knowledge results in the correct implementation of the drug. similarly, there was a significant positive correlation between skills and proper medicine (p<0.001, α= 0,05; r = 0.378). conclusions: it can be inferred that a higher nurse’s knowledge and skill results in a better administration of medicine. introduction medication errors can be classified into dispensing, prescribing, and administration.1,2 these errors were detected in 85% of wrong doses with a prevalence rate of 32.1%.3 it is the third leading cause of death in the united states, such that one in every 4 hospitalized patients suffers from harm caused by medication errors.4 furthermore, more errors were detected during drug administration than in the preparation stage with the successive occurrence of 62.5% and 37.5%. overall, a total of 43 errors (14.3%) were found to be potentially severe with work conditions, transcription, and pharmacies accounting for 51.5%, 9.9%, and 1.2%, respectively.5 statistics showed that 38% of medication errors were related to nurses,6 and this is consistent with the reports of the study that the occurrence of errors was significantly associated with their experience and level of education.7 nurses have a low level of knowledge of the pharmaceuticals they use the most, which leads to a higher rate of medication errors in the icu.2 around 84% of nurses have poor knowledge of high alert medications (hams) administration.8 some factors that are significantly associated with medication administration errors include poor knowledge and communication, stress, as well as interruption during medication administration. 8,9 clinicians initially expressed negative attitudes towards existing medication management, citing their dissatisfaction with current policies and procedures, as well as their skepticism about the relevance and utility of potential changes to medication management.10 it is likely that nurses’ lack of information about the drugs, how it is administered, and the legal aspects of their actions will result in errors in drug administration error. in addition, nurses’ skills in carrying out action are important due to their impact on the patient’s condition. nurses with good knowledge will have better behavior (skills) in preventing medication errors. nurses play an important role in the implementation of drug administration, preventing medication errors, and administering safe drugs. therefore, before working in real-life care, nursing students should have adequate competencies regarding medication safety.2 they need to understand the indications, dosage, method of administration, and possible side effects to be able to administer drugs correctly and effectively because of lack of knowledge may result in adverse patient outcomes.8 nurses in giving drugs to patients have 6 rights on medication administration, these include correct patient, drug, dose, route, time, and documentation. according to several analysts, expanding nurses’ pharmaceutical information can be a critical technique for decreasing medication errors.11 a preliminary study conducted on 6 rights of medication administration at the er showed that the er receives approximately 70-100 patients a day for referrals and walk-ins. there is a article significance for public health medication administration contributes to the large literature on patient safety in healthcare settings. it is the complexity inherent in emergency services and the critical factors for enhancing teamwork and work procedures to avoid negligence or unrecorded mistakes. furthermore, medication safety is a drug control technique that is heavily reliant on good safety culture. it is therefore important to determine nurses’ knowledge and skill to develop and implement strategies for maintaining medication safety. this study describes the correlation between knowledge, skill, and 6 rights medication administration. [healthcare in low-resource settings 2023; 11(s1):11177] [page 57] non -co mmerc ial us e o nly high complexity of services and risk in the er due to the pressure of working quickly resulting in negligence or unrecorded errors. furthermore, the majority of the nurses in the er could not calculate the drug dose and the administration was not timely due to the long length of stay at work. the emergency department (ed) is a hospital setting that poses many patient safety challenges, including highly unpredictable conditions, and frequent use of high-risk medications, which increases the risk of error.12,13 this study contributes to the broad literature on medication management and safety in healthcare settings, especially the ed. it also emphasizes the complexity inherent in emergency services and the important points for improving teamwork and work procedures. in addition, the study evaluates the complexity of emergency services and the high risk of pressure to work quickly, which results in negligence or unrecorded errors. a study showed that the decision errors, crew resource management, inadequate supervision, and organizational climate contained more types of subfactors than other error factors in medication.14 furthermore, medication safety is both a process and the product of management that relies heavily on strong safety culture. building a safety culture involves creating an alignment between the individual, group, and institutional values, which impacts attitudes, perceptions, and generally the patterns of clinicians’ behaviour.15 therefore, the interest of most study is to examine the relationship between nurses’ knowledge and skills with the implementation of the 6 rights medicine principle. design and methods a quantitative, direct, observational study was conducted on the ed nursings, which treat approximately 100 patients a day. this study uses a cross-sectional, non-experimental design to identify the correlation between knowledge, skill, and 6 rights on medication administration. an information session was held to create awareness about the study, then the individual nurses were approached to solicit for their participation. after the informed consent, observers closely shadowed nursings for up to 3-hour intervals during day shifts. specifically, it was hypothesized that a nurses’ knowledge and skill are associated with good medication administration performance. the simple random sampling was used to draw a final sample size of 70 and data were collected using a validated structured pretested self-administered questionnaire that was adapted from previous studies. separate tools were used to collect data regarding the knowledge of nurses on medication administration. the result of construct validit index was between 0.595 – 0.895. cronbach’s alpha for knowledge instrument was 0.967 and skill instrument was 0.953, while reliability coeficient was 0.468. an observational checklist was developed and used to gather data by observing nurses while medicating patients to determine whether or not they followed the 6 rights of medication administration. furthermore, the spearman rank statistical test was adopted to determine the correlation between the two variables using spss for windows version 16 with a significance limit of p <0.05. results and discussions based on the data presented in table 1, the majority of nurses (38) were aged 20-35 years accounting for 54.28%. based on the gender of the respondents, it was discovered that there were 42 nurses (60%) and the majority (25 nurses) worked in hospitals for 1-5 years with a percentage of 35.71%. as shown in table 2, based on the p-value < 0.001, it can be inferred that there is a correlation between nurses’ knowledge and implementation of 6 rights medication administration. furthermore, there was a significant relationship between nurse skills and 6 rights medication administration by nurse (p < 0001, α= 0.05, r = 0.378). the nurse’s level of knowledge content analysis showed that the most errors include improper dosage, mistaken drug choice, knowledge-based mistakes, skillbased slips, and memory lapses.16 knowledge, often referred to as cognitive, is obtained from an individual’s or others’ experiences and it helps to determine the activities and obedience of a person. before individuals can have new behaviour or activities, they must have knowledge first. when the acceptance of this new behaviour is based on knowledge, awareness, and a positive attitude, then it will last long. on the contrary, a behavior that is not knowledgebased will not last long. the results showed that the education level of most ed nurses was diploma. education has a significant effect on the learning process because a higher level makes it easy for an individual to receive information. furthermore, it is needed to increase knowledge because an educational model must memorize formulas, def article table 1. demographics of respondents. characteristics n % 1. age group 20-35 years 38 54.28 36-50 years 26 37.14 > 51 years 6 8.57 2. education high school 3 4.28 diploma 45 64.27 bachelor 20 28.57 master 2 2.85 3. sex male 28 40 female 42 60% 4. work tenure 1-5 years 25 35.71 6-10 years 12 17.14 11-15 years 8 11.42 16-20 years 7 10.00 21-25 years 13 18.57 > 25 years 5 7.14 table 2. the relationship between knowledge, skill, and the implementation of 6 rights medication administration. correlations sig. value correlationcoefficient interpretation knowledge – implementation of 6 rights medication administration 0.000 0.491 moderate correlation skills implementation of 6 rights medication administration 0.001 0.378 weak correlation [page 58] [healthcare in low-resource settings 2023; 11(s1):11177] non -co mmerc ial us e o nly initions, and how to take action. it can be reached by simulation, which supports skill and improves medication administration knowledge of some concepts. the use of simulation helped to identify a consistent knowledge gap.17 ensuring that the drug is safe for the patient and monitoring the side effects of its administration is the duty of the nurse. consequently, nurses or health workers must be equipped with knowledge in carrying out their roles. in this case, education can be used as a parameter to determine a person’s level of knowledge about the implementation of the principle of 6 correct medicines, especially regarding steps towards patient safety and understanding of medication errors. in addition, follow-up should be carried out by increasing the manager’s or er director’s responsibility in providing training, seminars, and facilitating relevant activities in other hospital operations. based on the results, most ed nurses were aged 20-35 years old with a percentage of 54.28%, this is because the young adult stage is the peak development of the physical condition. in this stage, an individual has cognitive abilities and more complex moral judgments, they use their knowledge to achieve their goals, such as career and family. therefore, age plays a significant role in implementing the principle of 6 rights medicine. lack of knowledge may result in inadequate skills, consequently develops into a system failure because there is no sufficient education regarding drug administration. previous studies reported that there is a lack of education regarding pharmacology in the basic undergraduate program,18 especially in the field of knowledge.19 some of the common errors in drug administration include the wrong dose, followed by missed dose, and lack of prescription. furthermore, errors in administering reached the patients more often than prescribed due to shortcomings in knowledge, skills, and abilities, as well as workload. 20 therefore, it is important to improve nurses’ knowledge about the preparation and administration of intravenous medications.21 pharmacology knowledge acquisition and application, as well as lack of opportunities in practice to undertake medication administration roles and responsibilities, were major factors.22 nurse skill level the results showed that the majority of ed nurses have high skills to implement the 6 correct principles of medicine. skills can be acquired by performing repeated actions frequently to create a condition where skills become a work culture. furthermore, nurses could make errors due to a lack of adequate access to guidelines or unclear organizational routines.23 medication management is a complex process that involves prescribing, transcribing, preparation, checks, administering to patients, observation, documenting reactions and side effects, as well as reporting any deviations. nurses require good educational preparation including a full understanding of pharmacology to ensure safe medication and fulfill their roles efficiently.24 regardless of the strategies implemented, the formation of a culture that fosters the skills of reporting medication errors, and a systematic, nonpunitive approach to their elimination is where its prevention begins and ends.25 right patients have the lowest incidence rate with practically no error in the application of the correct principle of medicine. this is because the care system in the ed is divided based on the level of emergency and each level is held by several nurses, therefore, they memorize their patients’ names. the most common incident at ed is the right dose, which includes precise and accurate calculation. to ensure that the drug is given to the patient at the right dose, the nurse must be able to carry out the calculation accurately and also double-check. furthermore, the nurse must administer the appropriate amount of medication based on the calculation results to provide the patient with the right dose. the results of this study indicate that for the right dose component, only 25 people (35.71%) had a high application rate. the existing studies regarding calculating medications indicate that nursing students have poor mathematical and drug dose calculation skills.26 according to the results, strategies were recommended to be adopted for reducing or limiting medication errors, such as improving work conditions, and communication between healthcare workers.5 correlation between knowledge and the implementation of the 6 rights medication administration in this study, nurses’ knowledge of medication and the principles of drug administration to patients, such as the appropriate drug, right dose, time, patient, and route as well as documentation was examined. the results showed that some nurses in the ed had good knowledge about the implementation of the six rights medication administration. meanwhile, a small proportion has less knowledge about the implementation of the 6 principles of correct medicine. nurses’ pharmacological knowledge, inevitable errors, and complications were mentioned in a previous study.27 knowledge is needed to obtain new informations, such as things that support appropriate action in order to improve the patient’s quality of life. knowledge influences a person’s decisionmaking, motivating nurses to behave and participate in improving patient health by providing appropriate treatment measures. knowledge about medication administration is useful in clinical reasoning for safe medication and also as a precursor of error reporting.28 it is influenced by how much or at least the kind of information obtained by an individual. nurses who do not have access to information on medication administration and the implementation of the 6 rights will not have the knowledge to apply the principles correctly. meanwhile, knowledge-based results from prescribing and administration,13 dismissals of policies/procedures or guidelines, and human resources issues.29 increasing nurse’s knowledge could be through integrated educational interventions that allows nurses to assume a care provider role for patient. correlation between skill and the implementation of the 6 right medication administration as the largest group of healthcare providers, nurses play a significant role in the continuity of care by maintaining health at different levels of the system. it is therefore expected that the nurse provides the highest level of care based on scientific evidence and acquires the necessary skills and abilities to make clinical decisions through the service of control maintenance methods.30 according to a previous study, experienced nurses were more likely to practice beyond scope of practice to reduce error.23 furthermore, overhauling nurses’ information, particularly about unused medicines is an important factor in decreasing medication error.11 the majority of er nurses’ skills in implementing the principle of 6 correct medicine are still high because the behavior is carried out continuously, subsequently it becomes a culture or habit. the ability of nurses to implement these principles is also a moral responsibility for a profession that must fulfill its obligations. the results of the study showed that nurses’ work tenure significantly affects medication errors based on experience. statistically, good techniques eliminate the deficiencies in basic math knowledge, problem-solving skills, and correct dosage calculation.31 in the ed, there is a lot of skill mix that will contribute to the implementation of 6 rights medication administration. hospitals that increase the nursing skill mix and improve the work environment may achieve a reduction in the number of adverse events.32 article [healthcare in low-resource settings 2023; 11(s1):11177] [page 59] non -co mmerc ial us e o nly skill practice programmes like simulation in medication administration are important. according to a study, there was an improvement when the teaching programme was implemented and medication errors were reduced.33 furthermore, an understanding of the simulation program provides feedback to participants, thereby contributing to the reduction of medication errors.34 managers should focus on enhancing nursing practices by managing and organizing nurses’ work in a way that creates a feeling of supportiveness, motivation, and security.35 furthermore, in comparison to single profession education, in which individuals learn in isolation and only in their profession, interprofessional education helps to promote interprofessional collaboration and patient care by promoting multiple health professions to increase interprofessional collaboration. therefore, an interprofessional medication safety education program in icus can help to reduce errors and improve patient safety.36 limitation of the study include single institution, the short term of the observational. because this study uses cross sectional, results are not generalizable. therefore, more studies are needed to assess by increasing the number of observers and other hospital’s emergency department. conclusions based on the results, the conclusion drawn is that most of the ed nurses have a high level of knowledge and skill about 6 rights medication administration. the implication of this study for professional healthcare is to increase the ed nurses’ knowledge of the right medical principles, especially in calculating drug titration and a small part of the incorrect administration of drugs. therefore, the strategies recommended to be adopted for reducing or limiting medication errors include building a stronger pharmacology knowledge-base in nurses and nursing students, improving work conditions, and communication between healthcare workers.5 the result also showed that there is a significant relationship between information literacy and evidence-based nursing with the knowledge and attitude of nurses toward medication error.30 it was, therefore, suggested that learning by simulation will provide additional support in educational programs for healthcare professionals by increasing knowledge and skill of medication administration.34 references 1. shitu z, aung mmt, tuan kamauzaman th, et al. prevalence and characteristics of medication errors at an emergency department of a teaching hospital in malaysia. bmc health serv res 2020;20:1–8. 2. escrivá gracia j, brage serrano r, fernández garrido j. medication errors and drug knowledge gaps among criticalcare nurses: a mixed multi-method study. bmc health serv res 2019;19:1–10. 3. sutherland a, canobbio m, clarke j, et al. incidence and prevalence of intravenous medication errors in the uk: a systematic review. eur j hosp pharm 2020;27:3–8. 4. makary ma, daniel m. medical error-the third leading cause of death in the us. bmj 2016;353:1–5. 5. bagheri nesami m, esmaeili r, tajari m. intravenous medication administration errors and their causes in cardiac critical care units in iran. mater socio medica 2015;27:442. 6. al worafi ym. medication errors [internet]. vol. 48, nursing. new york: elsevier b.v.; 2020. 59–71 p. 7. basil jh, wong jn, zaihan af, et al. intravenous medication errors in selangor, malaysia: prevalence, contributing factors, and potential clinical outcomes. drugs ther perspect 2019;35:381–90. 8. salman m, mustafa zu, rao az, et al. serious inadequacies in high alert medication-related knowledge among pakistani nurses: findings of a large, multicenter, cross-sectional survey. front pharmacol 2020;11:1–7. 9. mekonen eg, gebrie mh, jemberie sm. the magnitude and associated factors of medication administration error among nurses working in amhara region referral hospitals, northwest ethiopia. j drug assess 2020;9:151–8. 10. bakhshi f, mitchell r, nikbakht nasrabadi a, et al. clinician attitude towards safety in medication management: a participatory action study in an emergency department. bmj open 2021;11:e047089. 11. rodziewicz tl, houseman b, hipskind je. medical error article correspondence: linda wieke noviyanti, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: linda.wieke@ub.ac.id key words: nurse, knowledge and skills, 6 rights medication. acknowledgment: the authors are grateful to all who contributed to this study, particularly the respondents, students of the bachelor program in nursing faculty of medicine universitas brawijaya, and universitas brawijaya. contribution: all the authors contributed equally to this study. lwn verified the method, the study design, and carried out the study. a served as supervisor. aj also carried out the study, analyzed and interpreted the data. all authors discussed the results and contributed to the final manuscript. conflict of interest: the author declares no conflict of interest. funding: this work was funded by the researcher. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. clinical trials: this study obtains ethical approval from the ethics committee of the general hospital dr. saiful anwar malang, (ethical clearance letter no. 400/245/k.3/302/2019). conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11177 doi:10.4081/hls.2023.11177 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its man[page 60] [healthcare in low-resource settings 2023; 11(s1):11177] non -co mmerc ial us e o nly reduction and prevention. [updated 2022 may 1]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2022 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk499956/ 12. westbrook ji, raban mz, walter sr, et al. task errors by emergency physicians are associated with interruptions, multitasking, fatigue, and working memory capacity: a prospective, direct observation study. bmj qual saf. 2018;27(8):655–63. 13. cabilan c, hughes j, shannon c. the use of a contextual, modal, and psychological classification of medication errors in the emergency department: a retrospective descriptive study. int j lab hematol 2016;38:42–9. 14. hsieh mc, chiang py, lee yc, et al. an investigation of human errors in medication adverse event improvement priority using a hybrid approach. healthcare (basel) 2021;9:442. 15. lee sh, phan ph, dorman t, et al. handoffs, safety culture, and practices: evidence from the hospital survey on patient safety culture. bmc health serv res 2016;16:1–8. 16. wolf zr, hughes rg. best practices to decrease infusionassociated medication errors. j infus nurs 2019;42:183–92. 17. myroniak k, elder s. improving safe medication administration in new rns using simulation. j contin educ nurs 2021;52:30–3. 18. sulosaari v, huupponen r, hupli m, et al. factors associated with nursing students’ medication competence at the beginning and end of their education. bmc med educ 2015;15:1–12. 19. di simone e, giannetta n, auddino f, et al. medication errors in the emergency department: knowledge, attitude, behavior, and training needs of nurses. indian j crit care med 2018;22:346–52. 20. cottell m, wätterbjörk i, hälleberg nyman m. medicationrelated incidents at 19 hospitals: a retrospective register study using incident reports. nurs open 2020;7:1526–35. 21. di simone e, tartaglini d, fiorini s, et al. medication errors in intensive care units: nurses’ training needs. emerg nurse 2016;24:24–9. 22. cleary-holdforth j, leufer t. senior nursing students’ perceptions of their readiness for oral medication administration prior to final year internship: a quantitative descriptive pilot study. dimens crit care nurs 2020;39:23– 32. 23. björkstén ks, bergqvist m, andersén-karlsson e, et al. medication errors as malpractice-a qualitative content analysis of 585 medication errors by nurses in sweden. bmc health serv res 2016;16:1–9. 24. høghaug g, skår r, tran tn, et al. three-month follow-up effects of a medication management program on nurses’ knowledge. nurse educ pract 2021;51:102979. 25. weant ka, bailey a, baker s. strategies for reducing medication errors in the emergency department. open access emerg med 2014;6;45-55. 26. guneş uy, baran l, yilmaz d (kara). mathematical and drug calculation skills of nursing students in turkey. int j caring sci 2016;9:220–7. 27. pazokian m, zagheri tafreshi m, rassouli m. iranian nurses’ perspectives on factors influencing medication errors. int nurs rev 2014;61:246–54. 28. kim ms, kim ch. canonical correlations between individual self-efficacy/organizational bottom-up approach and perceived barriers to reporting medication errors: a multicenter study. bmc health serv res 2019;19:1–10. 29. ramadaniati hu, hughes jd, lee yp, et al. simulated medication errors: a means of evaluating healthcare professionals’ knowledge and understanding of medication safety. int j risk saf med 2018;29:149–58. 30. azami m, sharifi h, alvandpur s. evaluating the relationship between information literacy and evidence�based nursing and their impact on knowledge and attitude of nurses working in hospitals affiliated to kerman university of medical sciences on medication errors. j fam med prim care 2020;9:4097–106. 31. özyazıcıoğlu n, aydın ai̇, sürenler s, et al. evaluation of students’ knowledge about paediatric dosage calculations. nurse educ pract 2018;28:34–9. 32. smith jg, plover cm, mcchesney mc, et al. rural hospital nursing skill mix and work environment associated with frequency of adverse events. sage open nurs 2019;5:1–13. 33. devi a, sembian n, kaur s. occurrence of medication errors and oral medication administration practices of staff nurses. res j pharm technol 2016;9:1145–52. 34. sarfati l, ranchon f, vantard n, et al. human-simulationbased learning to prevent medication error: a systematic review. j eval clin pract 2019;25:11–20. 35. nurmeksela a, mikkonen s, kinnunen j, et al. relationships between nurse managers’ work activities, nurses’ job satisfaction, patient satisfaction, and medication errors at the unit level: a correlational study. bmc health serv res 2021;21:1– 14. 36. irajpour a, farzi s, saghaei m, et al. effect of interprofessional education of medication safety program on the medication error of physicians and nurses in the intensive care units. j educ health promot 2019;8:1–5. article [healthcare in low-resource settings 2023; 11(s1):11177][ page 61] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11178 the efficacy of raspberry pi-based automatic voice message education on knowledge level and prevention behavior of high-risk population mifetika lukitasari,1,2 wahyu indah windarti,1 endah panca lydia fatma,1 tony suharsono,1 dwi adi nugroho2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2brawijaya cardiovascular research group, brawijaya university, indonesia abstract introduction: the number of confirmed covid-19 cases has increased in indonesia. preventive measures are believed to break the chain of transmission of covid-19. therefore, increasing knowledge through health education is essential to improve preventive behavior in the community. the study aims to determine the efficacy of implementing health education using raspberry pi based automatic voice massages in increasing high risk populations’ knowledge and prevention behavior. design and methods: this study was a quasi-interventional method with a pre-posttest research design and a non-equivalent control group, consisting of 30 respondents in each group. control group received health education through leaflet sharing, while intervention group received health education through raspberrypi based automatic voice massages. results: this study showed that there were no significant different in knowledge between control and intervention group after obtaining health education. meanwhile, the intervention group showed higher score in knowledge regarding covid-19. moreover, the prevention behavior was significantly improved in both groups after acquiring health education through leaflets and automatic voice messages. conclusions: health education using raspberry pi based automatic voice messages improved both knowledge and preventive behavior regarding covid 19 in high risk population. introduction the incidents of covid-19 cases is rapidly increasing as it spreads to several nations in a short period. furthermore, on september 30, 2020, the who reported up to 33.5 billion confirmed cases with 1.01 billion deaths worldwide.1 the ministry of health of the republic of indonesia reported 287,002 confirmed cases, with 10,729 deaths.1 based on data from the covid-19 task force in malang regency, 899 confirmed cases were reported as of september 29, 2020, with a death toll of 59. karangploso is the fourth-ranked sub-district based on reports on confirmed cases with 52 points and 4 deaths.2 the majority of deaths were caused by the deterioration of health in high-risk population groups with comorbidities. furthermore, the survey result showed that the death rate was 10%, 7.3%, 6.3%, 6%, 5.6% in patients with cardiovascular, diabetes, chronic respiratory, hypertension, cancer disease, respectively.3 even though the government has attempted various efforts, such as limiting outdoor activities to prevent the virus trnasmission, the number of confirmed cases continues to increase. this is due to the lack of awareness of the indonesian citizens towards the dangers of covid-19 transmission4 and the non-compliance with government recommendations.5 the knowledge and behavior of the community is a measure of the awareness level towards the dangers of virus transmission.6 consequently, it is essential to increase people’s knowledge and change their non-compliance behavior towards covid-19 prevention. in addition, knowledge plays an essential role in behavioral reflection. this fosters a sense of trust, which is then presented as the basis for the realization of decision making.7 promotive and preventive activities through health education improve people’s understanding of covid-19 behavior in kepuharjo village. health education is a process of improving one’s health status. as a result, a suitable method is needed for the proper dissemination of health information.8 computers and communication technologies, with technical advancements, are powerful channels for providing public information and education. according to dogba (2019), information and communication technology has great potential to improve education in rural areas.9 automatic voice message is one of the areas of information and communication technology applied in various healthcare education. the application of information technology in health education minimizes physical contact, thereby enabling educators to conduct their services without meeting faceto-face.10 therefore, this study aimed to investigate the efficacy of implementing health education using raspberry pi based automatic voice massages in increasing high risk populations’ knowledge and prevention behavior. design and methods this study was a quasi-interventional design with a pre-post test and a non-equivalent control group. furthermore, a design was used to determine the effect of health education using automatic voicemail media based on rasberry pi in kepuharjo village, significance for public health this study revealed that the usage of raspberry-pi based automatic voice message improved the high-risk population’s knowledge and preventive behavior in covid-19. this study provided a new perspective in educating the community during covid 19 pandemic era while they have to stay at home. article [page 62] [healthcare in low-resource settings 2023; 11(s1):11178] non -co mmerc ial us e o nly malang regency. furthermore, the intervention and control groups were given different treatments. the control group was educated through leaflets and automatic voice messages. the population is a high-risk community in kepuharjo village, karangploso district, malang regency. a purposive sampling technique obtained 60 respondents with details of 30 and 60 respondents in the intervention and control group, respectively. the data collected using the covid-19 knowledge questionnaire instrument consists of 18 questions on the etiology, symptoms, risk groups, transmission, and prevention of the virus11. furthermore, the second questionnaire is the pcibs (preventive covid-19 infection behavior scale), consisting of 6 question items on washing hands, avoiding touching eyes, nose, and mouth, coughing and sneezing etiquette, and keeping distance by staying at home.12 after the translation, the questionnaires were adapted to the study conditions and tested for validity and reliability, where r > 0.338. therefore, it was reliable, as seen from the cronbach’s alpha score > 0.6. furthermore, it is valid and reliable when the value of r > 0.443 and cronbach’s alpha > 0.6 in the pcis questionnaire. the data were analyzed by paired t-test and mann whitney test with p value <0,05 considered as significant result. results and discussions table 1 shows respondents’ characteristics based on gender, age, last education, and sickness history of the intervention and control groups. furthermore, most respondents were female, with 23 (76.6%) and 25 (83.3%) respondents in the control and intervention groups, respectively. most respondents are adults based on age, with 19 (63.3%) and 40 (70.0%) respondents in the control and intervention group, respectively. in addition, most of the respondents were graduated from elementary school, with 18 (69.0%) and 20 (66.7%) respondents in the control and intervention group, respectively. based on the medical history, hypertension was the most common health problem in the control and intervention group, with 19 (63.3%) in each group. table 2 showed that the average pre-test score of knowledge level is 13.83 lower than the average post-test score of 13.90 with a standard deviation of 1.704 knowledge level pre-test and 2.023 post-tests. meanwhile, the average pre-test score for preventative behavior was 16.13, higher than the average post-test score of 15.37, with a standard deviation of 1525 and 2,008 for behavioral pre-test and post-test. table 3 also showed the average pre-test score of knowledge level is 13.77 lower than the average post-test score of 14.20 with a standard deviation of 2.528 and 2.265 for pre-test and post-test, respectively. likewise, the average pre-test score of preventive behavior was 15.63, lower than the average post-test score of 16.10 with a standard deviation of 1.829 and 2.040 for pre-test and post-test, respectively. no difference in the level of knowledge of covid-19 between the pre-test and post-test in the control group (p = 0.826; = 0.05) was observed in this study. in contrast, the pre-test and post-test data analysis show a difference in preventive behavior between the pre-test and post-test (p = 0.001; = 0.05). moreover, no difference in the level of knowledge of covid-19 between the pre-test and post-test in the intervention group (p = 0.091; = 0.05) was observed. in contrast, the analysis of the pre-test and post-test data on preventive behavior shows a difference between the pre-test and post-test (p = 0.001; = 0.05) table 3 showed the result of the unpaired t-test on the improvement of covid-19 knowledge level between control and intervention groups. there was no significant difference in the level of article table 1. baseline characteristics. characteristics control groups (n=30) interventional group (n=30) total n % n % n % sex man 7 23.3% 5 16.7% 12 20.0% woman 23 76.6% 25 83.3% 48 80.0% age adulthood 19 63.3% 21 70.0% 40 66.7% elderly 11 36.7% 9 30.0% 20 33.3% education elementary 18 60.0% 20 66.7% 38 63.3% junior high school 4 13.3% 5 16.7% 9 15.0% senior high school 6 20.0% 4 13.3% 10 16.7% bachelor degree 2 6.7% 1 3.3% 3 5.0% medical history hypertension 19 63.3% 19 63.3% 38 63.4% diabetes melitus 6 20.0% 8 26.7% 14 23.3% hypertension and diabetes melitus 3 10.0% 2 6.7% 5 8.3% asthma 2 6.7% 1 3.3% 3 5.0% total 30 100% 30 100% 60 100% table 2. pre-test and posttest results in the control group. variable control group intervention group pre test post test p value pre test post test p value knowledge 13.83 ± 1.704 13.90 ± 2.023 0.862 13.77 ± 2.528 14.20 ± 2.265 0.091 attitude 16.13 ± 1.525 15.37 ± 2.008 0.001 15.63 ± 1.829 16.10 ± 2.040 0.001 [healthcare in low-resource settings 2023; 11(s1):11178] [page 63] non -co mmerc ial us e o nly covid-19 knowledge improvements between leaflets and automatic voice messages through rasberry pi groups (p< 0.423). moreover, improvement of prevention behavior in both control and intervention groups showed significant between the groups. the intervention group had a higher preventive behavior improvement compared to that of control group (p < 0.001). the result shows no significant difference in the level of knowledge about covid-19 between the pre-test and post-test after acquiring health education using leaflet media and automatic voicemail media. furthermore, most control and intervention group respondents were already informed on the etiology, symptoms, and transmission of covid-19. however, most respondents still do not understand the comorbidities issue as well as virus transmission. they believe the infection could not be worsen, except for the elderly population. previous study suggested that respondents do not know that the virus can penetrate the clothes and mask.13 meanwhile, 99% of indonesian people already have good knowledge about social distancing. however, these results are not in line with that of previous study that suggested 83% of the respondents in dki jakarta had a good knowledge regarding the prevention of covid-19.14 previous study explained that most of the acceptance of the cognitive component in the knowledge aspect is obtained from sensing the eyes and ears. in this research, the control group received health education through leaflet media, characterized by viewing.8 health education using leaflet media triggers respondents to view and repeat activities while imparting information.15 the decrease in knowledge is based on the respondent’s lack of interest in reading the educational material due to rewards and punishments. furthermore, the limitations in conducting observations also affect the increase in respondents’ level of knowledge because there is no control over the activities performed. health education was acquired in the intervention group through an automatic voice message based on raspberry pi, which is an outdoor audio educational medium. the information is conveyed systematically and repeatedly to the targeted respondents to change the intervention targets’ views. furthermore, individual stimulation is increased by using audio to promote learning, listening, and remembering of health education material.16 the lack of knowledge after health education was due to the majority of respondents’ previous high expertise and the large amount of information conveyed by the government through many educational media. additionally, the absence of activity restrictions from respondents also breaks concentration and affects the understanding of the proposed educational material. knowledge of covid-19 is also influenced by several factors, including the respondent’s age and education level, since most respondents were adults. also, age affects a respondent’s mindset and grasping power, which means that age is directly proportional to development and understanding. the study results show that most of the education level is elementary school or equivalent. previous study suggested that the level of education acquired is directly proportional to the knowledge of the receiver.8 however, there are many sources of information other than formal education, including television, newspapers, radio, and the internet.21-23 consequently, low education targets do not necessarily have common knowledge. environmental conditions such as noise and weather affect the transmission of information since health education media is performed outdoors.25-25 most respondents in the control and the intervention group were good at health protocols such as washing hands, avoiding touching eyes, nose, and mouth, staying at home when not feeling well, and using masks. however, some did not comply with the cough and sneeze etiquette protocol and the rules of social distancing. this study was supported by previous study that suggested 93% of respondents show good behavior in social distancing.13 the results are also in line with another study that showed 50.46% of respondents obeyed the rules of washing hands using soap, and 72.2% complied with the use of masks.17 preventive behavior is reviewed based on several components, including perceptions of vulnerability to disease, benefits for change, barriers and ability to change, motivation, environment, and knowledge.18 conclusions health education using raspberry pi based automatic voice messages improved both knowledge and preventive behavior regarding covid 19 in high-risk population. article correspondence: endah panca lydia fatma, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: endah.fk@ub.ac.id key words: covid-19, education, knowledge, behaviour, high-risk population. acknowledgment: the author thanks to faculty of medicine, brawijaya university, malang, and kepuh harjo regency, malang, indonesia contributions: the authors contributed equally to this article. edpl, ml, wiw, conceptualization, methodology; wiw, ts, formal analysis; dan, edpl, original draft preparation; ml, ts, manuscript review and editing. furthermore, they read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work conflict of interests: the author declares no conflict of interest. funding: this study was financially supported by brawijaya university through a non-competitive research scheme. clinical trials: approved by the ethics commission from the faculty of medicine, universitas brawijaya with no 122 / ec / kepk / 04/ 2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11178 doi:10.4081/hls.2023.11178 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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covid-19 di kota baubau: the effectiveness of providing online education through video and leaflet media on the knowledge level of covid-19 prevention at baubau city. jfg 2020;6:15253 article [healthcare in low-resource settings 2023; 11(s1):11178] [page 65] non -co mmerc ial us e o nly hrev_master [page 14] [healthcare in low-resource settings 2017; 5:6357] school health services in enugu east, nigeria: perspectives from a resourcepoor setting adaobi i. bisi-onyemaechi,1 afonne n. akani,2 anthony n. ikefuna,1 beckie n. tagbo,1 josephat m. chinawa,1 ugo n. chikani1 1department of paediatrics, college of medicine, university of nigeria enugu campus; 2department of paediatrics, university of port harcourt rivers state, port harcourt, nigeria abstract school health services (shs) have widespread impact on the health of a large number of children with implications on access to primary health care especially in developing countries. the aim of this study was to assess health services in primary schools in enugu east nigeria. thirty-three head teachers of primary schools in enugu east nigeria and officials of ministry of education were interviewed using a questionnaire adapted from school health evaluation scale. four private schools had health personnel. only six private schools had a health room. two public schools had a functional first aid box. there were no health records available in any of the schools. school lunch was given by only one private school. of a maximum of 45, public and private schools had a mean score of 10.3 and 12.7 respectively on the school health evaluation scale (p=0.01). three schools only attained the minimum acceptable score of 19. health services are at a minimal level in primary schools in enugu east nigeria. a state school health policy should be developed through inter-sectoral collaboration of the relevant stakeholders to use the platform provided by schools to ensure access to primary health care and also act as bridge for more formal medical care for school children. introduction schools have direct contact with as much as 95% of children aged 5-17 years1 and therefore are best situated to improve their health in addition to educating them. school health services (shs) are also necessary in order to keep the child in optimal health throughout his course of study, detect any departure from normal health and restore health as quickly as possible through immediate treatment in the school or appropriate referral.2 shs provide data for monitoring, evaluating and improving child survival. this is even more important in developing countries like nigeria where the school aged child is the survivor of high childhood mortality.3 effective implementation of school health services would ensure a substantial level of access to primary health care for children. it ensures early detection of diseases that can impede learning, improve access to care for non-emergent conditions, improve nutritional status and control of communicable diseases in the community. the health of young people and the adults they eventually become is critically linked to the health-related behaviour they adopt early in life4 and shs aims at inculcating healthy habits into the child which can be maintained through life by personal efforts.2 the realisation of these led to the launch of the national school health policy5 and implementation guidelines6 in nigeria in 2006 and 2007 respectively. this policy is yet to be appraised likely due to lack of continuity in government policies experienced in nigeria. it is also important to find out if these services exist in our schools, the level at which it operates where they exist and recommend ways of improving it. this study hopes to draw the attention of relevant stakeholders to the issue. the state also offers free primary and secondary education, a policy that has increased enrolment making more children accessible to education and health services. however, there is no data on health services in schools in this area that hosts such a large number of schools which can provide a good platform for improving child health statistics in the state. the researchers set out to appraise school health services in enugu east, to sensitize government on the need to step down the national school policy for the state and establish collaboration between the relevant stakeholders to ensure that schools act as a continuum of care for the child between the home and the community physician. materials and methods study setting: enugu is a mainland state covering 7,161, km2 in the south eastern nigeria with a population of 3.2 million.7,8 sampling: thirty three primary schools comprising 8 public and 25 private schools were selected from eight political wards in the local area using a systematic sampling method. ethical consent and approval: this was obtained from health research and ethics committee of the university of nigeria teaching hospital enugu. written consent was also obtained from the managing authorities of public and private schools in enugu. data collection: the school health program (shp) evaluation scale (health services) was used to assess the schools. the first shp evaluation scale was developed by anderson and cresswell, uk.4 this was modified by akani2 to suit the nigerian environment and level of economic development. it has three sections: school health services (used for this study), health instruction and healthful school environment. the subsections of shs and the maximum marks allotted to them are personnel (4), appraisals (5), treatment facilities (5), care of emergencies (5), control of communicable disease (10), record keeping (6), nutrition services (7), and guidance and coun healthcare in low-resource settings 2017; volume 5:6357 correspondence: adaobi i. bisi-onyemaechi, department of paediatrics, college of medicine, university of nigeria, enugu campus, nigeria. tel: +2348037082506 e-mail: adaobi.bisi-onyemaechi@unn.edu.ng key words: school health services; enugu; nigeria. contributions: aib-o conceptualized and designed the study, collected the data and analysed it, drafted the initial and final manuscript and approved the final manuscript as submitted; ana designed the data collection instrument, critically reviewed and revised the manuscript and approved of the final manuscript as submitted; ani contributed to the design, supervised the data collection and critically reviewed and revised the manuscript and approved of the final manuscript as submitted; bnt critically reviewed and revised the manuscript and approved of the final manuscript as submitted; jmc contributed to the design of the study, critically reviewed and revised the initial manuscript and approved of the final manuscript as submitted; unc critically reviewed and revised the manuscript and approved of the final manuscript as submitted. conflict of interest: the authors declare no potential conflict of interest. received for publication: 23 october 2016. revision received: 27 february 2017. accepted for publication: 26 april 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.i. bisi-onyemaechi et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6357 doi:10.4081/hls.2017.6357 non co mmerc ial us e o nly [healthcare in low-resource settings 2017; 5:6357] [page 15] selling (3). the scale has been used in shs evaluation in nigeria.9,10 the maximum score for school health services is 45 while the minimum acceptable score is 19. a questionnaire adapted from scale, reviewed by a panel of experts and pre-tested in two randomly schools in enugu north local government council was administered to the head teachers of selected primary schools in the area. scores were awarded to the responses given using the scale. some officials involved in school and health administration in the state were also interviewed to ascertain their disposition to school health services in the state. data analysis the data was analyzed using the statistical package for social sciences (spss) version 17. data presentation was done with tables. the difference in the mean scores of school health services in private and public schools was compared using the student ttest. the level of significance was set at a p value of less than `0.05 and confidence level at 95. results general eight public and twenty-five private schools were sampled. the schools had 304 teachers, 116 in the 8 public schools and 188 in the 25 private schools. the ages of the teachers ranged from 25 to 72 years. four head teachers had masters in education, twelve had bachelor’s degree in education, thirteen had national certificate of education, two, higher national diploma and two, bachelor of science. two of the schools were located in farm settlements. only eight of these head teachers had an idea of what school health services were but none of these could list its subcomponents. none of the administrators of schools in the state interviewed was aware of school health services and what it entails. twenty-seven (81.8%) of the schools have periodic meetings with the parents while four do not. one head teacher did not respond to this question while one school had stopped the parents teachers forum (ptf). personnel there were no health personnel in any of the public schools. four private schools had health personnel (2 nurses and 2 trained first aiders). the mean score for personnel for public schools was 0 while that of private schools was 0.24 out of a maximum of 4 (p= 0.97). health appraisal routine inspection was done by all the schools (public and private) while none of the schools sampled required pre-entry medical screening nor does periodic medical examination for the staff or students. ten (30 %), two public, eight private schools refer ill children to nearby health facility. seven schools (4 public, 3 private) had handicapped children who were given extra supervision but there were no screening test to detect handicaps. the mean scores for health appraisals were 1.44 and 1.75 for private and public school respectively, of a maximum of 5 (t=l.150, df= 31 p=0.26). treatment facilities within the school all but two of the schools (both public) had a first aid box, however, five of the boxes were empty as seen in 4 public and i private school. six schools (18%), all private, had a health room/sickbay. nine private schools only had a school bus. all but one public school had telephone services. the mean score for treatment facility within the public school was 2.63 while that of private was 3.52 of a maximum of 5. (t=-3.06, df=31, p=0.01). care of emergency illness twenty-four (72.7%) of the schools, two public and twenty-two private, gave first aid while none recorded the treatment given. twenty-seven (2 public, 25 private), 81.8%, notified parents immediately of any emergency illness while ten (2 public, 8 private), 30.3% would transport an ill child to a nearby health centre. one public school located in a farm settlement would take the child home after treatment is given. the mean score for the public schools was 1.00 while that of private was 2.40 of a maximum of 5 (t=-4.523, df=31, p=0.00). control of communicable diseases all the schools would send a child with a communicable disease home. twentyseven schools (8 public, 19 private), 81.8%, in addition, gave health talks to the children or the parents in the event of a communicable disease. two schools (1 private, 1 public), had the facility to quarantine/isolate a child with communicable disease during the school hours while immunization services was lacking in all the schools. mean scores for public and private schools were 2.13 and 2.04 respectively out of a maximum of 4. (t=0.860, df=31, p=0.40). record keeping the record of absenteeism was kept in all the schools but reasons for absence from school were not kept. thirteen (11 private and 2 public) schools had forms given to parents on admission to fill out the health history of the child but these were neither available nor transferable. there were no available records of medical events like outbreaks of communicable disease. the record of absenteeism was available to the researchers at only twenty-one schools (4 public, 17 private). the available records of absence were cumulative in only four private schools but none was transferable. the mean scores obtained for both public and private schools were 0.5 and 1.08 respectively out of a maximum of 3 (t=-2.137, df=31, p=0.04). nutrition services nine schools (5 private, 4 public), had school farms. nutrition demonstration was offered in only two schools (one public and one private) while only one private school offered school meals. none of the schools gave nutritional supplements. mean scores for public and private schools were 0.03 and 0.28 respectively out of a maximum of 7 marks. (t=1-316, df=31, p=0.20) (table 1). three schools (all private) attained the minimum score of 19 for school health services. the means for the public and private schools for school health services, out of a maximum of 45 is 10.36 and 12.76 respectively (p=0.01) (table 2). the mean of the schools for school health services (public and private) is 12.18 ± 2.46, of a minimum of 19. at a test value of 19, p=0.01. factors affecting school health services among the schools that do not request for medical report, nine (seven public, two private) said it was not in the curriculum, seven (one public, six private) said it was not necessary, six private schools thought it was expensive while four schools were not aware. the schools do not conduct periodic medical examination for the following reasons; not aware (19 schools), expensive (10 schools), not in the curriculum (9 schools), not necessary (3 schools), no appropriate personnel (one school), time wasting (1 school), new school (one school). school meals were not available in 32 schools for the following reasons; expensive (12), not necessary (8 schools), government not supportive (7 public schools), not in the curriculum (4 public and 1 private), against parents wish (4 private schools), no personnel (1 public and 1private). two private schools felt having ptf meetings was not necessary, one private school said it never achieved any good result and stopped it while 1 public school said caregivers and article non co mmerc ial us e o nly parents do not respond to call for ptf meetings. eighteen schools (3 public and 15 private) felt meeting with the host community was not necessary, five (1 public and 4 private) said it is expensive, three private school said it was a waste of time, three, not in the curriculum, one schools said it was new while one school gave no reason. five public schools gave no form of treatment in the school because they had neither materials nor personnel to do so while two public schools had their community health centers opposite and adjacent to them and quickly referred cases there. thirty-one head teachers thought school health services was beneficial, one was not sure while one did not respond. interactions with officials of both ministries of health and education showed that none of them (chairman ube, permanent secretary ube, director of schools – ministry of education, commissioner for education, director of clinical services and officer-in-charge of research and training, ministry of health) had heard of or was aware of school health services. none was also aware of the existence of a national school health policy. the plan on board for the maintenance of the health of the school population was to provide and re-equip the first aid boxes in the public schools. there are no plans to train the teachers on any health issues but government was willing to welcome any such training at no cost to it. there were no health personnel in public schools because ministry of education could not afford it and ministry of health does not have enough personnel for it. discussion there was non-uniformity in the qualification of the teachers and the explanation received was that tertiary education qualifies one to teach in primary school. this may also explain the poor awareness of school health services as some of them had no formal training in education. this has negative implications for child health because these teachers have the responsibilities of drawing attention to the child’s condition and follow up of care, educating and counseling parents, carrying out the physician’s requests and other activities to make the school more efficient. they are however ill-equipped to do these. this lack of awareness is in contrast to some other reports9-11 with awareness of up to 53% and 68%, but similar to another study by ofowe.12 it is not unexpected as the supervisors of these head teachers in the ministries are also not aware of shs. twenty three (70%) of the schools had a functional ptf while five schools (public) have what is known as a school based management committee (sbmc). this committee is made up of some prominent community leaders, some teachers and some parents who manage the affairs of the school. this sbmc found only in public schools was formed due to the non-chalance of parents to the welfare of the school and by extension, the school children, and also to increase the sense of belonging of the communities to the schools. the absence of health personnel in all the public schools and majority of the private schools is similar to previous reports.9,10,13 absence of health personnel was not perceived as a deficiency among the teachers. the head teachers would rather prefer training on basic elements of first aid and shs as this would reduce the fear of mistakes as reported in one school. the reason for this was inadequate personnel as explained by an official of the ministry of health, lack of resources to pay personnel on the part of ministry of education and an apparent lack of cohesion between the ministries of education and health in the state. this absence of health personnel in schools leaves health appraisals wholly in the hands of teachers whose competence may not be satisfactory. the result is that routine inspection of hair, teeth, nails and occasionally skin is the only form of appraisal done in all the schools. this is also similar to previous reports,10,14-16 though one report showed that as much as 45% of schools had routine medical examination of students.12 preentrance medical examination was not required by any of the schools. some schools issue forms to parents to fill out their child’s blood group, genotype etc. the parents fill these forms most times without a doctor’s endorsement. the government has not provided any framework for medical screening of children before admission to reduce to the barest minimum obstacles to enrollment. this was reported by an official of the ministry of education. pre-admission and periodic medical examination provides an opportunity to detect medical conditions that may prevent the child from benefiting maximally from this education and also to detect any underlying medical condition early before complications set in and this has not been uniformly implemented. the finding of only children with motor physical challenge in the schools is not surprising as there was no evidence to support the ability of schools to manage children with other challenges like visual or hearing impairment or programs specifically designed to do so. the finding of first aid boxes in 94% of schools is consistent with other reports.9,10,16,17 however, the schools that did not have first aid boxes were public and four of the five empty boxes were found in public schools. they were said to be empty because contents were not replenished nor replaced. first aid was also administered by untrained school teachers in most private schools and this may have serious consequences if unaddressed. the public schools were poorly equipped for emergencies as none of them had a health room or a school bus. however, two public schools in the rural area of the local government were located opposite and adjacent to article table 1. mean scores of components of school health services. service p value public private mean sd mean sd personnel 0 0 0.24 0.23 0.97 health appraisal 1.75 0.71 1.44 0.65 0.26 treatment facility 2.63 0.52 3.52 0.77 0.01 care of emergency 1.00 0.76 2.40 0.76 0.001 control of communicable disease 2.13 0.35 2.04 0.20 0.40 record keeping 0.50 0.53 1.08 0.70 0.04 nutrition services 0.03 0.01 0.28 0.15 0.20 table 2. mean scores of school health services of public and private schools. service t p value public private mean sd mean sd school health services (19-45) 10.36 2.39 12.76 2.22 -2.60 0.01 [page 16] [healthcare in low-resource settings 2017; 5:6357] non co mmerc ial us e o nly [healthcare in low-resource settings 2017; 5:6357] [page 17] the community health centre and referred all their medical cases there. majority of the schools (82%) found it more convenient to notify the parents immediately of any health challenge in their children for fear of mistakes and to reduce cost. the private schools that referred ill-children to health facilities had retainerships with them as had earlier been agreed with parents during ptf meetings. all the schools practiced sending home a child noticed to have a suspected communicable disease on arrival in the morning. even the two private schools with isolation rooms would be very unwilling to keep the child in school and would prevail on the parents to come and pick the child immediately. this is the practice as documented in other studies.9,10,16 the reasons attributed to this was fear of spread to other children and subsequent litigation. there are chances of sending the wrong child home or leaving a child incubating an infectious disease as the teachers may not have the expertise to differentiate an infectious from a non-infections disease. this strengthens the need for health personnel in the schools and training of school teachers on common communicable childhood illnesses. the poor recording of medical events noted here has also been reported in previous studies.9,15,16,18 the head teachers did not appreciate the need for such records and stated that there were no provisions for it by the supervising ministry. provision of school meals was available in one school where the cost was embedded in the school fees. this lack of school meals is also similar to the other reports.9,11,16,18 most of the public schools appreciated the importance of school meals but admitted that government was not committed to the provision of free school meals. this was also confirmed by top officials of the ministry of education who affirmed that government alone cannot sustain the school meal service. most of the private schools attributed lack of school lunches to the cost and objection of parents who would rather prepare meals eaten by their children. one public school had free school meal in the past before the collapse of the pilot phase of school meal service of the state government and an international organization. information gathered revealed that the program failed in the state because of the lack of counterpart funding by the government. in osun, south-west nigeria, the school feeding program currently provides midday meals for elementary one to four children numbering 254,000 at present. there has been an increase of about 25% in school enrollment following this and a reversal of the low academic performance of children in public schools. teachers also reported regular and punctual attendance to school, reduction in truancy and absenteeism, increase retention and participation in curricular activities.19 if sustained, this would contribute to achieving the sustainable development goals 1, 2,3,4,5 which address an end to hunger and poverty, improved nutrition, promotion of wellbeing at all ages, inclusive and quality education and measures to achieve gender equality and empowerment. parents would be more willing to send their female children to school because of the added benefits of feeding. malnutrition underlies more than 50% of all child mortality.20,21 school feeding program appears to be the most developed component in other countries. ghana initiated its school health policy in 1992 and school feeding in 2005 and currently feeds about 1.7 million school children (37% national coverage) and togo about 20,000 children.22,23 the involvement of government in school health services has only been the initial provision of first aid boxes in 12% of the public schools. the fundamental problem of lack of awareness of shs and its importance by the officials of the ministries of health and education may also explain the present state of school health services in the state. concerted enquiries revealed that as at present, enugu state is yet to have a school health policy. when these are in place, it is envisaged that school health services and child health by extension would improve dramatically in the state. conclusions school health services are at a minimal level in enugu east nigeria, but are comparatively better in the private schools than public schools. the public schools were ill equipped to handle emergencies. lack of awareness of school health services has contributed to the current state of health services in enugu schools. a state school health policy and a school health committee should be constituted in the state to aid and monitor the effective implementation of school health services. school districts should be created and nurses posted to such districts to visit specific schools on specific days. a transferable health card designed to keep information on the child’s medical history, health appraisals and other health events should be issued on admission to every child. references 1. center for disease control and prevention. guidelines for school and community health programmes; promoting lifelong healthy eating; and overview. atlanta, ga: cdc; 2001. 2. akani na, nkanginieme keo. the school health programme. in: azubuike jc, nkanginieme keo (eds.) pediatrics and child health in a tropical region. 2nd ed. owerri: african educational services; 2007. pp. 47-55. 3. akani na, nkanginieme keo, oruamabo rs. the school health programme: a situational revisit. nig j paediatr 2001;28:1-6. 4. anderson cl, cresswell eh. school health practice. st louis: the cv mosby company; 1980. 5. federal ministry of health, nigeria. national school health policy. abuja: federal ministry of health; 2006. 6. federal ministry of education, nigeria. implementation guidelines of national school health policy. abuja: federal ministry of health; 2006. 7. enugu state. available from: https://en.wikipedia.org/wiki/enugu_st ate 8. enugu state. available from: www.nigeriagalleria.com 9. ezeonu ct, akani na. evaluating school health appraisal scheme in primary schools within abakaliki metropolis, ebonyi state, nigeria. ebonyi med j 2010;9:71684. 10. mbaerie ia, ofovwe ge, ibadin mo. evaluation of the performance of primary schools in oredo lga of edo state in the shp. j commun med primary health care 2010;1:22-32. 11. akani na. the effect of a short term training of head teachers on the implementation of school health programme in primary schools in obio/akpor lga. a dissertation in part fulfillment of the part ii finals of the national postgraduate medical college of nigeria. 1997. 12. ofowe ge, ofili an. knowledge, attitude and practice of school health programme among head teachers of primary schools in egor lga, edo state nigeria. ann afr med 2007;6:99-103. 13. imogie ao. an evaluation of primary healthcare in secondary schools in oredo lga of bendel state. nig school health j 1987;7:99-104. 14. ejifugha au. awareness of school health services among primary school teachers in enugu state. nig school health j 1993;8:54-61. article non co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2017; 5:6357] 15. ojugo ai. status of health appraisal services for primary school children in edo state nigeria. int electr j health educ 2005;8:146-52. 16. alex-hart ba, akani na, nkanginieme keo. evaluation of the school health services in bonny lga of rivers state. nig j paediatrics 2008; 35:60-6. 17. ogaji ds, okokon eo. appraising the physical environment of secondary schools in calabar, nigeria. j environ sci toxicol food technol 2012;1:42-8. 18. oduntan so. the health of the nigerian children of school ages 6-15 years. md thesis. london: university of london; 1972. 19. akanmbi go, alayande e. home grown school feeding and health program in nigeria: an innovative approach to boosting enrolment in public primary schools. a study of osun state 2002-2010. african symp 2011;11:20-8 . 20. who media centre. children: reducing mortality. geneva: who; 2016. 21. katz j, lee ac, kozuki n, et al. mortality, risk in preterm and small-forgestational-age infants in low-income and middle-income countries 2013: a pooled analysis. lancet 2013;382:41725. 22. ghana business news. ghana launches national school feeding policy. available from: https://www. ghanabusinessnews.com/2016/07/23/gh ana-government-launches-nationalschool-feeding-policy/ 23. andrews c, galliano e, turk c, zampaglione g. social safety nets in fragile states: a community based school feeding program in togo. the world bank 2012. available from: https://openknowledge.worldbank.org/ bitstream/handle/10986/26829/646310 nwp011170box361542b00public0.pdf?sequence=1&isallowed=y article non co mmerc ial us e o nly hrev_master [page 44] [healthcare in low-resource settings 2013; 1:e11] acute care for stunned myocardium after lightning strike is life-saving: need for public awareness programs ahmed armin,1 azim afzal,1 singh narayan upendra,2 gurjar mohan1 1department of critical care medicine, sanjay gandhi postgraduate institute of medical sciences, lucknow; 2department of cardiology, sanjay gandhi postgraduate institute of medical sciences, lucknow, india abstract lightning injury is a global public health problem. it still exists as a major environmental threat in developing nations where majority of population lives in rural areas. the different mechanisms of lightning injury can result in a spectrum of injuries ranging from minor, through moderate to severe. the most common cause of death due to lightning strike is cardiopulmonary arrest. prognosis and outcome in moderate to severe lightning injury depends on timing of cardiopulmonary resuscitation and specialized care to prevent anoxic injury to vital organs. india lags behind in public education, awareness programs and health resources and has the biggest number of reported deaths due to lightning injuries. in this report, the authors highlight the importance of early cardiopulmonary support to a victim of direct lightning strike, which saved his life, and lay emphasis on the need to develop public awareness programs. introduction lightning injury is an under-reported phenomenon in many developing countries including india due to lack of provision for specific registration of deaths caused by lightning injuries. though there is no audit, even discharge records of hospitalized patients fail to mention lightning injury as a cause of death. therefore, although it is a public health problem, its incidence remains unknown.1,2 according to the national crime record bureau of india in the year 2001 there were 1507 deaths related to lightning injury. lightning injury can be fatal due to cardiac and neurological insult.3,4 acute care, resuscitation knowledge and awareness of bystanders can be life-saving because of the reversible nature of the injuries.5 we report a case of a victim of lightning injury who survived thanks to the availability of acute care facilities. to the best of our knowledge, there are currently no national programs to spread awareness regarding lightning injuries and resuscitation for general public. case report in the early hours of the morning, a thirty five year-old male with no comorbid illness was directly struck by lightning while he was going towards the farm. the patient immediately fell and became unconscious. he was rushed to private hospital by bystanders in around 30 min. on admission to hospital, he was tachypneic with a respiratory rate of 40/min, heart rate was 130/min sinus rhythm and he was sweating. there was also an entry wound near the epigastrium around 15 cm in diameter and involving superficial skin only. the exit wound was on the nape. the chest was full of bilateral crepts. electrocardiography (ecg) showed sinus tachycardia without signs of injury or ischemia. arterial blood gas showed ph -7.37, pao243 mmhg, paco2 33.8 mmhg, hco3 19.1, be -5.3, na135 meq/l (normal-135145meq/l), k2.77 meql (normal-3.54.5meq/l). the patient was intubated and started on mechanical ventilation. initial laboratory workup showed a raised total leukocyte count (tlc) 24,300/cu mm (normal 411,000/cu mm), hemoglobin (hb) 13 gm/dl (normal 12-15 gm/dl), platelet of 0.22 millions/cu mm (normal 0.15-0.45 millions/cu mm) with normal hepatic and renal function. chest x ray suggested the presence of pulmonary edema. echocardiography (echo) showed a dilated left ventricle and left atrium with global hypokinesia with ejection fraction (ef) of 20% (normal >55%). right ventricle showed normal size and contraction. the patient started a treatment of intravenous antibiotic piperacillin/tazobactum 4.5 g every 6 hours, injection furosemide 20 mg every 6 hours and dobutamine (2.5-7.5 µg/kg/min). over the next few hours, the patient developed hypotension, which required dopamine support, and was referred to our center for further management. at the time of admission, the patient was sedated with midazolam and paralyzed with vecuronium infusion. pupils were normal sized with normal reaction. his pulse was 98/min, blood pressure (bp) 120/70 mmhg with dopamine support of 5 µg/kg/min. bilateral air entry was equal with few basal crepts. his urine output was 1-2ml/kg/hour. electrocardiography showed a t wave inversion and st segment depression in all leads. cardiac enzymes were mildly elevated [creatine phosphokinase (cpk)-total 270 units/l (normal 40-120 units)], cpk-mb 18 ng/ml (normal value 0-3 ng/ml), troponin i 0.7 ng/ml [normal value <0.4 ng/ml]). supportive care in the form of enteral nutrition, deep vein thrombosis prophylaxis, and wound care was continued. within 24 h, he could open his eyes, follow commands and move his limbs. there was no neurological deficit. dobutamine was gradually tapered off in the next 48 h. serial ecgs showed non-specific t wave inversion and st segment depression in all leads. repeat echo on day 4 showed mildly dilated left ventricle with severe left ventricle dysfunction (ef 30%). a brief t piece trial was given and the patient was extubated. post-extubation patient was conscious, oriented, following commands, and hemodynamically stable with normal urine output. specific cardiac medications were added and included angiotensin-convertingenzyme (ace) inhibitors (ramipril 2.5 mg) and beta blocker (metoprolol 25 mg). the patient was discharged on day 7 and was kept on follow up. repeat echo was done on day 30 and showed improving cardiac parameters. serial echo findings are reported in table 1. the patient gave his informed consent. discussion there are three types of lightning injuries: direct, indirect and side splash.1 direct strike results in extensive injuries.1,2 though multiple systems can be involved, fatal injury mostly occurs due to myocardial and neurological insult.1,2 our patient suffered from direct cardiac injury, but did not suffer any neurological healthcare in low-resource settings 2013; volume 1:e11 correspondence: afzal azim, department of critical care medicine, sanjay gandhi postgraduate institute of medical sciences, raebareli road, 226014 lucknow, india. tel./fax: +91.0522.2668017. e-mail: afzala@sgpgi.ac.in/draazim2002@gmail. com key words: lightning, stunned myocardium, acute care, awareness program. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 12 december 2012. revision received: 15 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. armin et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e11 doi:10.4081/hls.2013.e11 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e11] [page 45] injury. indirect injury denotes contact of a person with a lightning struck object and side splash occurs when lightning jumps from its primary strike site to hit a nearby person or any other object in its path. lightning can lead to mechanical and/or electrical abnormalities in the myocardium.3 mortality rate is around 30% with severe cardiac injury due to primary ventricular fibrillation or asystole. therefore, emergency care – especially knowledge about basic life support (bls) regarding cardiopulmonary resuscitation (cpr) on the part of bystanders – can be life-saving.5 our patient fortunately did not need resuscitation at the time of injury or during the transport. moreover, none of the bystanders who transported the patient had any knowledge of cpr and they did not perform it. electrocardiography changes reported in the literature include sinus tachycardia, non-specific st-t changes, temporary prolongation of qt interval and broadening of t wave.6,7 generally, ecg abnormalities return to normal within one month. our patient’s ecg findings included non-specific st segment and t wave changes which reversed after 3 weeks. mechanical injury to heart includes myocardial stunning, infarction, pericarditis and takotsubo cardiomyopathy.7 pathophysiology behind myocardial stunning is unclear.8 some reports in the literature show takatsuboshaped hypokinesia. the mechanism proposed is high catecholaminergic surge with pathogenesis still remaining controversial. the recovery of myocardium stunned by lightning is similar to recoveries of myocardium stunned by other causes. there is a limited number of case reports in the literature discussing the recovery course of myocardium. the most comprehensive study is by lichtenberg et al. on 19 victims in 5 separate lightning strikes over a 2 month span.9 in their study, cardiac dysfunction recovered within two weeks even in patients with biventricular failure. our patient went into cardiogenic shock within few hours of injury requiring mechanical ventilation and inotropic support. serial echo suggested recovery of cardiac parameters at around four weeks. lightninginduced takotsubo-shaped left ventricular dysfunction is also reported to recover in 10 to 14 days.9-11 conclusions early aggressive respiratory and cardiac support (i.e. cpr) therapy can be life-saving in lightning injuries. the reversible nature of cardiac insults stresses the need to develop awareness and teaching programs related to cpr for the general public. references 1. holle rl. annual rates of lightning fatalities by country. preprints of the international lightning detection conference, 2008 apr 21-23, tucson, arizona. vantaa: vaisala publ.; 2008. pp 14. 2. ritenour ae, morton mj, mcmanus jg, et al. lightning injury: a review. burns 2008;34:585-94. 3. alyan o, ozdemir o, tufekcioglu o, et al. myocardial injury due to lightning strike. angiology 2006;57:219-23. 4. american heart association. american heart association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. part 10.9. electric shock and lightning strikes. circulation 2005;112:154-5. 5. palmer abd. lightning injury causing prolongation of the q-t interval. postgrad med j 1987;63:891-4. 6. mcintyre wf, simpson cs, redfearn dp, et al. the lightning heart: a case report and brief review of the cardiovascular complications of lightning injury. indian pacing electrophysiol j 2010;10:429-34. 7. bolli r, marbán e. molecular and cellular mechanisms of myocardial stunning. physiol rev 1999;79:609-34. 8. o'keefe gatewood m, zane rd. lightning injuries. emerg med clin n am 2004;22: 369-403. 9. lichtenberg r, dries d, ward k, et al. cardiovascular effects of lightning strikes. j am coll cardiol 1993;21:531-6. 10. rivera j, romero ka, gonzález-chon o, et al. severe stunned myocardium after lightning strike. crit care med 2007;35:280-5. 11. hayashi m, yamada h, agatsuma t, et al. a case of takotsubo-shaped hypokinesis of the left ventricle caused by lightning strike. int heart j 2005;46:933-8. case report table 1. serial echocardiography findings. days of injury ivs/pw edv(ml) esv(ml) ef (%) lvidd lvids (mm) (mm) day 4 11/11 103 69 30 53 40 day 7 11/10 94 54.5 42 50 37 day 30 9/9 81 36 56 44 29 ivs/pw, inter ventricular septum/posterior wall; edv, end diastolic volume; esv, end systolic volume; ef, ejection fraction; lvidd, left ventricle internal diameter diastole; lvids, left ventricle internal diameter systole. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11730 the effect of five activities daily living on improving cognitive function in ischemic stroke patients frana andrianur, dwi prihatin era, arifin hidayat, ismansyah ismansyah, diah setiani department of nursing, poltekkes kemenkes kalimantan timur, samarinda, indonesia abstract this study aimed to assess the effects of five activities of daily living (adl) interventions on improving cognitive function in patients with ischemic stroke. the study employed a quasi-experimental design with 16 ischemic stroke patients (n=8 per group) in an inpatient ward at a regional hospital in samarinda, indonesia. inclusion criteria were: i) confirmed ischemic stroke via medical records, ii) effective communication, iii) current inpatient status, and iv) hemiparesis. data collection used an adl activity instrument sheet, while cognitive function was assessed with the moca-ina screening (maximum score: 30 points). data analysis included the wilcoxon test and independent t-test, with significance set at p<0.05. after the intervention, the intervention group’s cognitive function significantly improved (from mean 20.25±2.60 to 25.13±1.81), while the control group changed from mean 17.13±2.10 to 20.50±2.00. the intervention group showed a significant cognitive improvement compared to the control group (p<0.05). in conclusion, adl interventions enhance cognitive function in ischemic stroke patients, aiding recovery and serving as an effective hospital nursing intervention. introduction stroke occurs due to insufficient oxygen supply, resulting in cell death. this damage often leads to hemiparesis, characterized by weakness in one part of the body, significantly impacting basic activities such as dressing, eating, and walking.1,2 interruption of cerebral blood flow for more than 24 hours can result in brain death and functional impairment, making it the third leading cause of death.3,4 based on data from the east kalimantan health office in 2019, mentioned that stroke ranked first, hypertension ranked second and diabetes mellitus ranked third all over indonesia. impaired cognitive function can be attributed to reduced blood flow caused by occlusions in specific brain regions, resulting in neurological deficits. these effects may occur due to neuroanatomical lesions in strategic areas such as the hippocampus or lesions in the white matter of the brain.5,6 persistent disruption of cerebral blood flow, lasting more than 24 hours, can lead to the death of brain cells – a condition that occurs in both ischemic and hemorrhagic strokes. in general, ischemic strokes account for approximately 87% of cases.3,7–9 patients who have experienced a stroke face a three-fold risk of decreased cognitive function.6,10 stroke often leads to memory and cognitive problems, where every minute of information processing and organization in the brain becomes crucial.11,12 various efforts have been made to prevent a decline in brain function, including involving families in supporting activities of daily living (adl) to enhance quality of life and promote patient recovery.6,13 research has emphasized the significance of physical activity in preventing cognitive decline.14 correspondence: frana andrianur, department of nursing, poltekkes kemenkes kalimantan timur, jalan wolter monginsidi no.38, samarinda east kalimantan 75123, indonesia. e.mail: franaandrianur@gmail.com key words: activity; cognitive function; hemiparesis; ischemic stroke; montreal cognitive assessment. contributions: fa, conceptualization; data curation; formal analysis; methodology; validation; visualization; writing – original draft; review & editing; final approval of the version to be published funding acquisition. dp, conceptualization; investigation; methodology; validation; and writing – original draft; review & editing. ah, conceptualization; methodology; formal analysis; validation, and writing – original draft; review & editing. ii, methodology; visualization; writing – review & editing. ds, resources; investigation; and writing –review & editing. conflict of interest: the authors declare no conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: the research has received ethical approval from ethics committee at the regional public hospital in samarinda, indonesia no 072/kepk-aws/v/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to be thankful to ferry efendi, ns., m.sc., phd and team for his suggestion on manuscript writing received: 9 september 2023. accepted: 2 october 2023. early access: 10 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11730 doi:10.4081/hls.2023.11730 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 26] [healthcare in low-resource settings 2023; 11:11730] non -co mmerc ial us e o nly intervention research focusing on adl is particularly important. these five activities include: i) teeth brushing, ii) dressing, iii) hair grooming, iv) telephone use, and v) eating and drinking. specifically, in the case of ischemic stroke patients, performing these daily activities is expected to stimulate and induce the neuroplasticity process, thereby potentially expediting patient recovery. recognizing the critical role of nurses in providing roundthe-clock care, both independently and collaboratively, is essential to preventing cognitive decline in ischemic stroke patients. studies have demonstrated an association between adl and the cognitive function of stroke patients.15 additionally, upper extremity disorders, particularly those affecting the hands and wrists, are linked to impaired cognitive function.16 thus, assessing cognitive function in hospitalized post-stroke patients becomes essential.15,16 while adl are often conducted in hospitals, they are typically limited to just one or two activities and may not follow a daily schedule. moreover, there is a tendency to focus on the stronger hand to assist the weaker upper extremity. this research, however, concentrates on five daily activities specifically designed for the weaker hand, particularly in patients experiencing hemiparesis in the upper extremity. patients will undergo gradual training, aiming to engage in stimulating activities using the hemiparetic upper extremity. this approach is anticipated to promote nerve cell recovery, with active participation in daily activities stimulating neuroplasticity, enabling the brain to reorganize and adapt. consequently, this can lead to improved cognitive function, memory, attention, and executive function. based on this rationale, the researchers have designed this study to investigate the impact of adl intervention on the cognitive function of ischemic stroke patients receiving treatment in the inpatient rooms of a regional public hospital in samarinda, indonesia. materials and methods a quasi-experimental research design was employed, utilizing a control group pretest-posttest approach, with measurements taken before and after the intervention for both the intervention and control groups. the study population consisted of all ischemic stroke patients in the stroke treatment unit at the regional public hospital in samarinda, indonesia. purposive sampling was employed, aligning with predefined outcome criteria. the sample size for this study comprised 16 patients, divided into two groups, all of whom were diagnosed with ischemic stroke. inclusion criteria included: i) confirmed ischemic stroke diagnosis based on medical records, ii) effective communication skills, iii) current hospitalization, iv) hemiparetic condition, and v) willingness to participate as respondents. exclusion criteria consisted of: i) patients who passed away during hospitalization, and ii) clinical conditions unrelated to stroke. the intervention involved five daily activities designed to stimulate and improve the condition of hemiparetic patients over a 7-day period, with sessions conducted twice a day. on the first day, while patients awaited stabilization, family members acting as caregivers were instructed in these five daily activities. guidelines were provided to facilitate the process. from the second to the seventh day, patients, with the assistance of their family caregivers, performed these activities in the morning and afternoon. the daily living activities included: i) tooth brushing, ii) dressing, iii) hair grooming, iv) telephone use, and v) eating and drinking. adl interventions for stroke patients were to be carried out daily by the patients themselves, targeting the upper extremities experiencing weakness. caregivers and nurses provided motivation and assistance, using a provided booklet as a reference for guidance in performing these five daily activities. the measurement instrument employed was the montreal cognitive assessment indonesia (moca-ina) screening, which comprises 30 points. this instrument underwent validation and reliability testing, yielding a validity coefficient of r=0.529 and p=0.046, as well as a reliability test result of p=0.027. the pearson correlation test yielded a value of r=0.963 and p=0.000.17 the indonesian version of the moca-ina is a 10-minute assessment that is easy to administer, consisting of 11 items: i) alternating trail making, ii) constructional visual abilities (cube), iii) constructional visual capabilities (wall clock), iv) naming, v) memory, vi) attention, vii) sentence repetition, viii) language fluency, ix) abstract ability, x) delayed memory, and xi) orientation ability. a total score of 26 or higher is considered within the normal range. the measurement was administered both before and after the intervention for both the intervention and control groups to assess changes in cognitive function scores among the patients. patients were provided with explanations regarding the research and provided informed consent by signing, with the option to decline or withdraw from participation at any point during the study. this study received ethical approval from the ethics committee at the regional public hospital in samarinda, indonesia, under approval no. 072/kepk-aws/v/2022. data collection took place from may to november 2022 in the stroke treatment unit at the regional public hospital in samarinda, indonesia. univariate data were analyzed using descriptive frequency distribution. all data were previously assessed for normality. data analysis included the wilcoxon signed test (p<0.05) to assess preand post-intervention differences, and the independent t-test (p<0.05) to compare cognitive function scores between the intervention and control groups of ischemic stroke patients. results an overview of the research results, including respondent characteristics, is presented in table 1. table 1 revealed that the control group predominantly consists of individuals aged over 65 years (62.5%), while the intervention group is evenly distributed between those aged 46-55 and 56-65 years, each comprising 25.0%. in both groups, the majority of respondents are female, with 62.5% in the control group and 75.0% in the intervention group. regarding education level, 50.0% of the intervention group had a high school/vocational school education, while 50.0% of the control group had only completed elementary or junior high school. table 2 describes the cognitive function of respondents in the intervention group before the adl intervention. all cognitive function scores were abnormal for 100% of the respondents. after the adl intervention, 31.3% of respondents scored normal cognitive function, while 100% of the control group respondents had abnormal cognitive function both before and after the intervention. table 3 displays the cognitive function scores in the intervention group before the adl intervention, with a median score of 20.00, ranging from 17 to 24, and a standard error (se) of 0.92. after the adl intervention, the median score increased to 25.13, with a range of 23 to 27 and an se of 0.64. in the control group, the initial score was 17.00, with a range of 14 to 20 and an se of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2023; 11:11730] [page 27] non -co mmerc ial us e o nly 0.74, while after the intervention, the median score was 20.00, with a range of 18 to 23 and an se of 0.71. table 4 presents pre-test and post-test p-values in the intervention group of 0.011 and in the control group of 0.017 (p<0.05). based on this data, it can be concluded that there were significant differences in cognitive function in both the intervention and control groups after the adl intervention. the pre-intervention p-value is 0.454 (p<0.05), and the post-intervention pvalue is 0.002 (p<0.05). based on this data, it can be concluded that there were significant differences in the cognitive function of respondents in the control and intervention groups before and after the adl intervention. discussion stroke is more prevalent among individuals aged 55 to 65 years, leading to vascular constriction and blockage, thus increasing the stroke risk. lower education levels are predictive of cognitive impairment, a condition often associated with strokes, making it challenging to retain information due to a lack of awareness about the importance of regular check-ups.18,19 the risk of impaired cognitive function and verbal memory is higher in women, primarily due to the influence of endogenous sexual hormones. stroke patients may experience decreased executive function and motor weakness, which require careful consideration.20 these issues can transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. cognitive function score of ischemic stroke patients (n=16). score of cognitive function median (min-max) se intervention before 20.00 17 24 0.92 after 25.13 23 27 0.64 control before 17.00 14 20 0.74 after 20.00 18 23 0.71 table 4. mean difference in cognitive function scores of ischemic stroke patients (n=16). variables n pre test n post test p mean±sd mean±sd cognitive level score intervention 8 20.25±2.60 8 25.13±1.81 0.011* control 8 17.13±2.10 8 20.50±2.00 0.017* p 0.454** 0.002** *wilcoxon signed test (p<0.05); **independent t-test (p<0.05). [page 28] [healthcare in low-resource settings 2023; 11:11730] table 1. distribution of respondent data (n=16). patient characteristics control group intervention group p f % f % age (years) < 46 1 12.5 2 25.0 0.631* 46-55 0 0 2 25.0 56-65 2 25.0 4 50.0 >65 5 62.5 0 0 gender male 3 37.5 2 25.0 1.000** female 5 62.5 6 75.0 education level elementary – junior high 5 62.5 4 50.0 0.596** senior high and above 3 37.5 4 50.0 *mann-whitney test; **fisher's exact test; statistically significant at p≤0.05. table 2. cognitive function of ischemic stroke patients (n=16). function cognitive intervention control before after before after f % f % f % f % normal 0 0 5 31.3 0 0 0 0 abnormal 8 100 3 18.8 8 100 8 100 non -co mmerc ial us e o nly be mitigated through methods that enhance neuronal plasticity to restore impaired function. neuromodulation interventions, aimed at regulating neural plasticity, play a significant role in facilitating faster recovery.21,22 the five adl intervention’s biological mechanism has been shown to optimize cognitive function in ischemic stroke patients by providing routine stimulation through activities such as dressing, eating, and cleaning. these activities can be carried out by nurses in the hospital or at home, leading to increased neural activity and improved brain tissue repair. adl interventions increase blood flow and oxygen supply to the brain, potentially enhancing neural plasticity, brain tissue recovery, reducing inflammation, and mitigating oxidative stress. these processes ultimately result in improved connectivity and recovery of brain tissue damaged by stroke. patients experiencing motor learning disabilities may undergo changes in cognitive function. adl interventions can yield positive outcomes, emphasizing the need to address motor processes. these interventions can also serve as a foundation for future stroke patient interventions.23,24 daily living activities, including upper extremity training, grip strength, and finger manipulation (e.g., dressing), have been proven beneficial in increasing motivation, active participation, and cognitive function.24,25 activities such as combing, especially upper extremity activities, must be taught to patients experiencing weakness or hemiparesis. these activities help patients indirectly establish brain patterns to relearn motor skills, increasing neuron connections, synapse activity, and cortical activity.26,27 adl, particularly for unilateral areas, differs from the concept of range of motion (rom) exercises. adl interventions aim to induce hemiparesis patients to perform daily activities, addressing the phenomenon of “learned non-use.” research supports interventions to improve post-stroke upper limb function, focusing on proximal arm non-use as a treatment target.28–30 brain rehabilitation, combined with cognitive training, has been shown to enhance cognitive function and daily activities in patients.31 adl encompass essential self-care tasks, including eating, drinking, mobility, and using personal equipment, which can be challenging for stroke patients. proper education on adl and healthcare information, such as routine care, medication schedules, and bed movement, is vital.32,33 assessing a person’s daily habits at home over several days can provide valuable insights into recovery, particularly in the upper extremities.34 addressing the impact of functional activity dysfunction, especially in the upper extremities following a stroke, is crucial for providing individuals with a meaningful life.35,36 the provided stimulation can be developed further, leading to increased brain plasticity and the potential for nerve bypass to aid in recovery. these aspects require further research.37 early mobilization, starting approximately 24 hours after a stroke, is crucial for reducing the risk of cognitive function decline. the family also plays a significant role in this process.6,38,39 upper limb effectiveness is more pronounced during the initial rehabilitation phase.40 the researchers argue that conducting exercises involving the upper extremities with weakness for seven days, utilizing five daily activity equipment, can facilitate the healing process. this activity serves as a stimulus that enhances brain plasticity in the nerves and should be initiated promptly to prevent a decline in cognitive function. daily activities, especially upper extremity functions, have therapeutic effects and can improve cognitive function in stroke patients.41,42 learning techniques, such as using a toothbrush, indirectly engage motor skills, resulting in a visceral response, such as reducing heart rate. this, in turn, enhances oxygen and nutrient delivery to the brain, optimizing brain function.43 stroke patients often struggle with basic activities, such as dressing and performing various tasks, which can lead to disability.44 the family’s role as caregivers and a support system is paramount in conducting adl to promote stroke patients’ independence. evidence supports physical training, including upper body strength training.45–47 researchers assume from the results of research supporting proven and appropriate improvement in cognitive function of ischemic stroke patients after being given stroke education interventions and information media can be used as guidelines that can be used for activity day living activities to help brain recovery to prevent extensive neuron damage due to stroke. notably, this study has certain limitations. first, the study’s results may not be generalizable due to the small number of respondents meeting the inclusion criteria. second, during the transitional period of the covid-19 pandemic, access to the hospital for direct observation of daily activities was limited. third, the study did not examine all potential risk factors. future research should explore the impact of extended stimulation and brain rehabilitation on stroke patients. despite these limitations, this study provides valuable insights into the potential benefits of adl interventions for improving cognitive function in ischemic stroke patients. these findings can serve as a foundation for future research in this area. conclusions the five adl have demonstrated their effectiveness in improving the cognitive function of ischemic stroke patients. by engaging in these activities twice a day over a seven-day period, and with an emphasis on comprehension, repetition, and prompt action, cognitive function enhancement is accelerated. the establishment of guidelines for implementing these five daily activities holds the potential to facilitate brain recovery and mitigate extensive neuron damage resulting from stroke. references 1. american stroke association. hemiparesis [internet]. american stroke association. 2019. available from: https://www.stroke.org/en/about-stroke/effects-of-stroke/physicaleffects-of-stroke/physical-impact/hemiparesis#:~:text= hemiparesis is weakness or the,loss of balance 2. arfianti l, rochman f, hidayati hb, subadi i. the addition of mirror therapy improved upper limb motor recovery and level of independence after stroke: a randomized controlled trial. brazilian j occup ther 2022;30. 3. who. health topics: stroke, cerebrovascular accident. world health organization. 2019. 4. huttami vt, hidajah ac. the utilization of golden period of ischemic stroke in patients in productive ages. indones j public heal 2020;15:258-65. 5. rajahthurai sd, farrukh mj, makmor-bakry m, tan hj, fatokun o, mohd saffian s, et al. use of complementary and alternative medicine and adherence to medication therapy among stroke patients: a meta-analysis and systematic review. front pharmacol 2022;13. 6. nurani rrs, martini s, marzela f. risk factors of cognitive impairment post ischemic stroke. kemas j kesehat masy [healthcare in low-resource settings 2023; 11:11730] [page 29] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 2019;15:295-302. 7. black, j. m., & hawks jh. keperawatan medikal bedah: manajemen klinis untuk hasil yang diharapkan. – buku 3. edisi 8. singapore: elsevier; 2014. 8. cdc. stroke facts [internet]. centers for disease control and prevention. 2023 [cited 2023 feb 20]. available from: https://www.cdc.gov/stroke/facts.htm 9. feigin vl, stark ba, johnson co, et al. global, regional, and national burden of stroke and its risk factors, 1990-2019: a systematic analysis for the global burden of disease study 2019. lancet neurol 2021;20:1-26. 10. hamdan m, wisnujono r, haryono y, et al. correlation between hyperglycemia stress and short-term memory function in thrombotic stroke patients. indian j forensic med toxicol 2020;14:1777-81. 11. heltty h, zahalim z. resilience after stroke and its correlation with functional independence. j ners 2023;18:57-63. 12. stroke association. problems with memory and thinking (cognitive problems). stroke association. 2023. 13. sullivan ab, miller d. who is taking care of the caregiver? j patient exp 2015;2:7-12. 14. bherer l. cognitive plasticity in older adults: effects of cognitive training and physical exercise. ann n y acad sci 2015;1337:1-6. 15. prakoso k, vitriana, ong a. correlation between cognitive functions and activity of daily living among post-stroke patients. althea med j 2016;3:329-33. 16. uwa-agbonikhena if, gryb va, gerasymchuk vr. associations between the upper extremity function and cognition in poststroke patients. wiad lek 2021;74:1917-20. 17. panentu d, irfan m. uji validitas dan reliabilitas butir pemeriksaan dengan moteral cognitive assessment versi indonesia ( mocaina ) pada insan pasca stroke fase recovery. j fisioter 2013;13:55-67. 18. o’donnell m, hankey gj, rangarajan s, et al. variations in knowledge, awareness and treatment of hypertension and stroke risk by country income level. heart 2021;107:282-9. 19. hanas m, lestari e, asni ek. gambaran fungsi kognitif pada pasien pasca stroke di poliklinik rsud arifin achmad provinsi riau. j online mhs fak kedokt 2016;3:1-12. 20. israfil i, yusuf a, efendi f. effect of cognitive behavioral therapy on the behavior of patients with cardiovascular disease: a systematic review. gac med caracas 2023;131:s478-88. 21. ting wk chun, fadul fa rahaman, fecteau s, ethier c. neurostimulation for stroke rehabilitation 2021;15:1-11. 22. whitiana gd, cahyani a. level of activity daily living in post stroke patients. althea med j 2017;4:261-6. 23. ryan s, brady o. cognitive stimulation and activities of daily living for individuals with mild-to-moderate dementia: a scoping review. br j occup ther 2023;86:540-59. 24. an hs, kim dj. effects of activities of daily living-based dual-task training on upper extremity function, cognitive function, and quality of life in stroke patients. osong public health res perspect 2021;12:304-13. 25. prasetyo bt, kurniawan rg, rilianto b, et al. clinical prediction score for prolonged length of hospital stay in aneurysmal subarachnoid hemorrhage. bmc neurol 2023;23:1-10. 26. alison a, hunter sm. optimising rehabilitation potential after stroke: a 24-hour interdisciplinary approach. br j neurosci nurs 2015;10:242-6. 27. kennedy nc. the role of neuroplasticity in stroke nursing. br j neurosci nurs 2021;17:s20-5. 28. pollock a, farmer se, brady mc, et al. cochrane overview: interventions for improving upper limb function after stroke. stroke 2015;46:e57-8. 29. pollock a, farmer se, brady mc, et al. interventions for improving upper limb function after stroke. cochrane database syst rev 2014;2014:cd010820. 30. bakhti kka, mottet d, schweighofer n, et al. proximal arm nonuse when reaching after a stroke. neurosci lett 2017;657:91-6. 31. hu y, zhong w, cen y, et al. prediction of epidemiological characteristics of vascular cognitive impairment using sir mathematical model and effect of brain rehabilitation and health measurement system on cognitive function of patients. results phys 2021;25:104331. 32. maher c. activities of daily living after stroke: how to regain your independence. flint rehab 2022; available from: https://www.flintrehab.com/activities-of-daily-living-after-stroke/ 33. ninds. post-stroke rehabilitation fact sheet. national institute of neurological disorders and stroke. 2022. 34. bhatnagar k, bever ct, tian j, et al. comparing home upper extremity activity with clinical evaluations of arm function in chronic stroke. arch rehabil res clin transl 2020;2:100048. 35. yamanie n, lamuri a, felistia y, et al. importance of social support for indonesian stroke patients with depression. f1000research. 2022;11. 36. purton j, sim j, hunter sm. the experience of upper-limb dysfunction after stroke: a phenomenological study. disabil rehabil 2021;43:3377-86. 37. genzor s, prasko j, mizera j, et al. sex transition from female to male as a risk factor for sleep-disordered breathing. sleep med 2023;102:180-5. 38. ding r, zhang h. efficacy of very early mobilization in patients with acute stroke: a systematic review and meta-analysis. ann palliat med 2021;10:11776-84. 39. pruski a. stroke recovery timeline. the johns hopkins hospital. 2021. 40. dehem s, gilliaux m, stoquart g, et al. effectiveness of upper-limb robotic-assisted therapy in the early rehabilitation phase after stroke: a single-blind, randomised, controlled trial. ann phys rehabil med 2019;62:313-20. 41. song cs, lee on, woo hs. cognitive strategy on upper extremity function for stroke: a randomized controlled trials. restor neurol neurosci 2019;37:61-70. 42. widiyawati w, yusuf a, devy sr. developing a vocational social rehabilitation model to increase the independence of the instrumental activity of daily living (adl) among people with severe mental illness. j public health res 2021;10:2263. 43. alonso mb, stienstra j, dijkstra r. brush and learn: transforming tooth brushing behavior through interactive materiality, a design exploration. tei 2014 8th int conf tangible, embed embodied interact proc. 2014;113-20. 44. lee ph, yeh tt, yen hy, et al. impacts of stroke and cognitive impairment on activities of daily living in the taiwan longitudinal study on aging. sci rep 2021;11:1-9. 45. andrianur f. dukungan keluarga sebagai caregiver pada aktivitas hidup seharihari (adl) pasien stroke: literatur riview. in: seminar nasional & call for papers “ inovasi pelayanan penyakit tidak menular .” samarinda: politeknik kesehatan kementerian kesehatan kalimantan timur; 2019. p. 66-71. 46. andrianur f, era dp. level of patient dependence in stroke patients in fulfilling daily activities ( adl ). in: post covid-19 pandemic the future of health care (opportunities and challenges). surabaya: poltekkes kemenkes surabaya; 2022. p. 36-42. 47. diener hc, hankey gj. primary and secondary prevention of ischemic stroke and cerebral hemorrhage: jacc focus [page 30] [healthcare in low-resource settings 2023; 11:11730] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2022; 10:9994] [page 37] breast self–examination practice and the associated factors among bule hora university students, oromia regional state, ethiopia. an institution based cross sectional study tamrat alemu tegegn, kaleb mayisso rodamo, keneni gutama negeri hawassa university college of medicine and health sciences, hawassa, ethiopia abstract regular breast self-examination in women is one of the practicable ways to screen, to detect earlier and to seek prompt medical attention of breast cancer in lowincome countries. the study aimed to assess breast self-examination practice and associated factors among female students of bule hora university from februaryjune 2019. a cross-sectional study was conducted using pretested, self-administered and structured data collection tools from regular and undergraduate class female students. data were entered using epi info. version 7.2; and analyzed by spss version 20. only 30 (14.78%) of the students were found to practice breast self-examination regularly. being urban resident [(aor= 2.757: 95% ci (1.471, 5.167)], perceived susceptibility to breast cancer [aor =2.910, 95% ci (1.537, 5.508)] and having family history of the practice [aor= 2.047: 95% ci (1.040, 4.028)] had shown a significant association with the practice of breast self -examination. discussion about breast cancer and practicing breast self-examination among the students is very low. the students who came from rural communities did not yet perceive the susceptibility and; therefore, health education pertaining to the subject is recommended. introduction incidence and the death rate due to of cancer is growing rapidly world-wide.1 the female breast cancer is the second most frequently diagnostic cause of death and accounts for about 2.1 million newly diagnosed cause for cancer deaths.2,3 cancer is an emerging public health problem in africa with estimates of 715 000 new cases and 542 000 deaths secondary chronic infection of its origin being a cause for a majority of the deaths. in africa, there was projected that the incidence and mortality due to cancer will be as double to 1.28 million new cases and 970 000 deaths per year by 20304,5 with the incidences of breast cancer grown to unaccepted rate even though many cases remain undetected in the continent.6 aging and rising population together with the adoption of lifestyle habits such as smoking, physical inactivity and unhealthy and high-calorie western diets are key risk factors.4 hiv epidemics and race-being white could be accountable risks for breast cancer.7,8 besides to that the female’s reluctance and embarrassing nature to meet physicians in person to discuss their intimate body parts all contribute to the rise of cancer burden worldwide.9 in ethiopia, cancer accounts for about 5.8% of total national mortality. as it was projected from population based data from addis ababa, the annual incidence and the mortality due to cancer was around 60,960 cases and over 44,000 deaths respectively with about 34% of the deaths were contributed by female breast cancer. for people below the age of 75 years, the probability of being diagnosed with cancer is only 11.3% and the risk of dying from the disease is 9.4%.10-12 regular breast self-examination (bse) in women is one practicable ways of screening breast cancer. this is important especially in low income countries like ethiopia where it plays a major role in early detection of breast cancer and helps to seek prompt medical attention.13,14 since most healthcare facilities do not have advanced laboratory investigations for breast cancer denoting, bse practice should be promoted to reduce the related morbidities and mortalities. however, little is known of awareness creation on breast self-examination practice to detect abnormality and treat early before reach the advanced stage in the country in general and female students at higher education institutions of ethiopia in particular.15 even less is known of awareness creation on breast self-examination practice in female students at bule hora university (bhu). therefore, the current study aims to assess bse practice and associated factors among female students of bhu in southern ethiopia. materials and methods study site this a cross-sectional study was conducted in bhu among regular under graduate class female students of 2016-2019 class years from february 1-june 30, 2019. bhu is one of third generation universities in ethiopia, which is located at a distance of 455 km south of addis ababa. the university consists of 9 colleges and 53 depart healthcare in low-resource settings 2022; volume 10:9994 correspondence: kaleb mayisso rodamo, hawassa university college of medicine and health sciences, p.o box: 1560, hawassa, ethiopia. tel.: +251.919532392, fax: +2510462208755 e-mail: kalebmayisso@gmail.com, key words: female student; cancer screening practice; breast self-examination. acknowledgements: our gratitude goes to hawassa university college of medicine and health science for giving the opportunity of conducting the research. we are indebted to all the students who took part in the study. we are grateful for bule hora university staff for facilitating all necessary activities during data collection. further, our appreciation goes to the study subjects for their willingly participation in the study. contributions: tat conceived the title and prepared the draft manuscript. kmr and kgn participated in design of the study, statistical analyses and revised of the manuscript. all authors read and approved the final version of the manuscript. conflict of interests: the authors have no conflicts of interest to declare further information: this work was supported by a budget for a student research of college of medicine and health sciences, hawassa university. availability of data: all data and materials of this study are available and can be accessed with a reasonable request from the corresponding author. ethics and consent: ethical approval was obtained from institutional review board of hawassa university college of medicine and health science. written informed consent was obtained from participants after a detailed explanation of the objective of the study before the individual data collection, and also each of the respondents were assured about the confidentiality of the information they provided as well as their right to withdraw at any time during participation. received for publication: 21 july 2021. revision received: 25 march 2022. accepted for publication: 25 march 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:9994 doi:10.4081/hls.2022.9994 non commercial use only [page 38] [healthcare in low-resource settings 2022; 10:9994] ments; and expected to offer undergraduate degree programs in different fields of study. in 2019, the total number of regular students estimated to be 9583, of which female students account for 3233 (33.7%). study population the source population was all bhu regular under graduate from third year and above class female students of all faculties and of 2017 and above years of enrollment. all randomly selected regular, under graduate class female students of third year and above were considered as study subjects. the sample size was determined by 30.25% proportion of the students who had good knowledge and practices on breast self-examination from the study conducted in debre birhane university16 using single population proportion formula at 95% confidence interval (ci): n=z(α/2)2 ×p (1-p)/ d2 = =324 where n is the required sample size, zα/2 (z alpha over two) = 1.96 at 95% ci, p is the proportion of the students who had good knowledge and practices on breast selfexamination, q = 1 − p and d is the assumed marginal error (5%). since the source population was less than 10,000, correction factor was applied to estimate the final sample size required in the study using correction formula: nf= = (324/1+ (324/3233)) adjusted sample (nf) estimated to be ≈ 270. where, nf= adjusted sample size, no = calculated sample size and n=source population. in addition, including with 10% nonresponse rate and a design effect of 1.5 [270+ (270 × 0.1) and 297* 1.5], the final sample size calculated to be 446. data collection to allocate the number of participants from selected departments, a third and above year students’ records was assessed and the trend showed 3233 female students. based on this, sample size distribution was done as follows: for instance, 24 students [(166/3233) ×446] from natural science department, and so on from all twenty four selected departments were expected to be included in the study. finally, students were selected using systematic random sampling technique from these departments for the study. socio-demographic and others relevant clinical information of the study subjects were collected using pre tested and self-administered structured data collection tools. study variables while level of bse practice among the female students was considered as dependent variable, the independent variables included; socio demographic factors like age, place of residence, educational status of parents, family occupation and average monthly income of house-hold. data analysis data was entered and cleaned using epi info. version 7.2 and exported to statistical package for social science (spss) version 20 for analysis.17 descriptive statistics was used to see frequency, and percentages of the characteristics. binary logistic regression analysis was used to calculate odds ratios (or) with 95% confidence intervals (ci) to estimate the association between the dependent and independent variables. to identify the relative effects of explanatory variables, variables having a p-value of less than 0.25 during bivariate analysis were transferred into multivariate analysis. multivariate analysis was also used to control confounding effect of explanatory variables and to determine the adjusted odds ratio (aor). the result of the final model was expressed in terms of the aor with the corresponding 95% ci and statistical significance was declared at p-value less than 0.05. results out of the total 466 sampled study subjects, 454 female students with the age range from 20 to 26 years were participated, yielding 97% response rate. age between 24 and 26 years was the dominant group account for 51% of a total study participant. about a half, 240 (52.86%) of the respondents were urban residents. concerning year of university study, 181 (39.86%) of participants were from third year and above while 132 (29%) of them were in their first year of study as detailed in the table 1 below. in the study, two hundred and four (44.9%) of the participants ever performed breast self-examination during the past 12 months. of these, majority 104(22.9%) performed irregularly at any time. only 30(6.6%) of the participants perform regularly on monthly bases. on the other hand, during bse 81(17.8%) of them palpate with their three middle finger pads. consequently, 27(5.9%) of the respondents said they perform bse after menstruation within 7-10 days. of those who do not perform bse, as a reason, 145(31.9%) said that they don’t have any problem on their breast (table 2). factors associated with practice of breast self-examination were assessed using bivariate and multivariate logistic regression (table 3). in bivariate logistic regression analysis, explanatory variables having article table 1. socio-demographic characteristics of the study participants in bule hora university in june, 2019 (n=454). variables category no. % age in year 20 23 years 222 48.9 24 26 years 232 51.1 previous place of residence urban 240 52.9 rural 214 47.1 years of study first year 132 29.1 second year 141 31.1 third year and above 181 39.9 department of study engineering 60 13.2 health science 44 9.7 social science 77 17.0 natural science 70 15.4 law 20 4.4 agriculture 61 13.4 faculty of business education 43 9.5 education 36 7.9 automotive 43 9.5 non commercial use only a p-value of <0.25, as a candidate for multivariable, were respondents original residence, or 2.180 at 95% ci (1.232, 3.858), family history of breast self – examination, cor 3.491 at 95% ci (1.984, 6.142) and perceived susceptibility towards breast cancer with cor 3.865 at 95% ci (2.172, 6.876). considering these variables as candidate for multivariate analysis at p<0.05, and to rule out confounders the analysis was conducted. in multivariate analysis, respondents residing in urban were 2.76 times more likely practice bse than who reside in rural areas [aor 2.757 at 95% ci (1.471, 5.167)]. respondents having family history of bse practice perform bse 2 times more likely than who don’t have family history of bse practice [aor 2.047 at 95% ci (1.040, 4.028)]. in addition, participants having perceived susceptibility of breast cancer were about 3 times more likely perform bse than who did not have perceived susceptibility [aor 2.910 at 95% ci (1.537, 5.508). for the details see table 3. discussion despite the advent of modern screening methods, more than 90% of cases of cancers of the breast are identified by women themselves which still implies on the importance of breast self – examination.15 most healthcare facilities in ethiopia do not have advanced laboratory investigations for diagnosing breast cancer. thus, like any resource limited countries, in ethiopia, practice of breast self-examination should be promoted.18,19 in this institution based cross sectional study, we tried to identify practice of breast self-examination and factors determining it in bhu. according to response from participants, only, 12.8% are had performed breast self-examination regularly. this finding is in line with the result of the study conducted among undergraduate students in ambo university, western ethiopia.20 however, compared to a study conducted in buea university of cameroon in which 3% had performed bse regularly, our finding is higher.21 possible reason for the differences might be the differences in number of study participants and study settings. contrary to this, the finding in this study is smaller than a study conducted in jimma university, ethiopia15 in which 21% of the study participants had performed bse regularly. so also, it is smaller than the study conducted on nursing students in article table 2. prior practice of t respondents on breast self examination in bule hora university in june, 2019. variables responses frequency % ever practiced breast self -examination during the past 12 months no 250 55.1 yes 204 44.9 how often do you perform breast self-examination yearly base 66 32.4 any time 104 62.9 regularly on monthly base 30 14.7 skill how to practicing breast self -examination palpating with three middle fingers pads 81 39.7 palpating with the whole fingers 52 25.5 palpating with one or two fingers 42 20.6 others ways than fingers 29 14.2 when you perform breast self -examination in relation to your menstrual cycle any time 58 28.4 during menstruation 49 23.0 the date before start of menstruation 39 18.6 after menstruation 1-6days 31 15.2 after menstruation 7-10days 27 13.2 reason why not performing breast self -examination don’t have any problem and symptom on their breast 145 58.0 don’t know how to perform breast self -examination 53 21.2 don’t think it is important 44 17.6 it is not comfortable 8 3.2 table 3. factors associated with practice of breast self -examination among bule hora university female students, 2019. variables bse practice cor (95% ci) aor (95% ci) p-value yes no no. (%) no. (%) age in year 17 21 years 24(10.8) 198(89.2) 1 1 22 26 years 34(14.7) 198(85.3) 1.417(0.810, 2.476) 1.264(0.695, 2.300) 0.442 residence rural 21(8.8) 219(91.3) 1 1 urban 37(17.3) 177(82.7) 2.180(1.232, 3.858) 2.757(1.471, 5.167) 0.002* family history of bse no 28(8.5) 303(91.5) 1 1 yes 30(24.4) 93(75.6) 3.491(1.984, 6.142) 2.047(1.040, 4.028) 0.038* perceived susceptibility no 21(7.2) 272(92.8) 1 1 yes 37(23.0) 124(77.0) 3.865(2.172, 6.876) 2.910(1.537, 5.508) 0.001* *statistically significant p-value < 0.05. [healthcare in low-resource settings 2022; 10:9994] [page 39] non commercial use only [page 40] [healthcare in low-resource settings 2022; 10:9994] amino kano teaching hospital, kano, nigeria.22 possible reasons for these gaps may be due to the difference in students’ educational back ground given that study participants in both jimma university of ethiopia and kano university of nigeria were health science students who have better health related information as one would expect. according to the current study, bse practice is significantly association with their family knowledge and practice. this is in line with the finding of the studies conducted on nurses in university hospitals in addis ababa and on health extension workers in west gojjam zone, northwest ethiopia.23,24 our study revealed that perceived susceptibility to breast cancer has significant association with practicing of breast selfexamination. this is consistent with the result of the study conducted at adwa town among women aged 20–70 years attending public health institutions.21 compared to students who join the university from rural areas, urban based residents were more likely to perform bse regularly. this is not unexpected as student urban residents are more accessible for health related information from the very beginning if not during their university stay.25 conclusions in conclusion, the study revealed that the respondents’ bse practice was low. not experiencing breast selfexamination among mothers of the respondents, not discussing about the breast cancer and the importance of breast self-examination among the students, not perceiving of susceptibility of the disease and coming from rural communities were independently associated with both knowledge and experience towards breast self-examination. thus, it is recommended that health care providers at all level should advocate breast selfexamination regularly, and also display bse posters in all examination rooms in health centers and hospitals. operational definition breast self-examination: physical and visual self-checkup of breast by female students to examine any change or abnormality on their breast through palpation and inspection. level of breast self-examination practice: the frequency of performing one’s own breast self-examination both physically with palpating and visually with inspecting at a regular time on monthly base after 7-10 days of menstrual cycle. practicing: one is performing bse every month at ideal time (7-10 days) after menstrual cycle. the ideal time of bse practice: when bse is performed on monthly base after 710 days of menstrual cycle.26 limitation of the study since the study is cross-sectional by its design, causal conclusions cannot be drawn. since this study has been done among female undergraduate students, the findings cannot be generalized to the other universities in the country and also for the whole population in ethiopia. references 1. thorat ma, cuzick j. preventing invasive breast cancer using endocrine therapy. breast 2017;34:s47-s54. 2. bray f, ferlay j, soerjomataram i, et al. global cancer statistics 2018: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin 2018;68:394-424. 3. cardoso f, spence d, mertz s, et al. global analysis of advanced/metastatic breast cancer: decade report (20052015). breast 2018;39:131-8. 4. ekortarl a, ndom p, sacks a. a study of patients who appear with far advanced cancer at yaounde general hospital, cameroon, africa. psycho-oncology 2008;16:255-7. 5. tsoka-gwegwenia jm, cumber sn, nchanji kn. breast cancer among women in sub-saharan africa: prevalence and a situational analysis. southern afr j gynaecol oncol 2017;9:28-30. 6. cumber sn, nchanji kn, tsokagwegweni jm. breast cancer among women in sub-saharan africa: prevalence and a situational analysis. southern afr j gynaecol oncol 2017;9:35-37. 7. reddy p, ebrahim b, singh b, et al. breast cancer and hiv: a south african perspective and a critical review of the literature. sajs 2017;55:10–15. 8. omaka-amari ln, ilo ci, nwimo io, et al. demographic differences in the knowledge of breast cancer among women in ebonyi state, nigeria. ijnmh 2015;1:18–27. 9. khana r, mahinderjit singh m, damanhoori f, etal. breast selfexamination system using multifaceted trustworthiness: observational study. jmir med inform 2020;8:e21584. 10. birhane n, mamo a, girma e, etal. predictors of breast self examination among female teachers in ethiopia using health belief model. archives of public health = archives belges de sante publique 2015;73:39. 11. abay m, tuke g, zewdie e, etal. breast self-examination practice and associated factors among women aged 20-70 years attending public health institutions of adwa town, north ethiopia. bmc 2018;11:622. 12. woldeamanuel yw, girma b, teklu am. cancer in ethiopia. lancet oncol 2013;14:289-90. 13. aker s, öz h, tunçel ek. practice of breast cancer early diagnosis methods among women living in samsun, and factors associated with this practice. j breast health 2015;11:115-22. 14. hailu t, berhe h, hailu d, et al. knowledge of breast cancer and its early detection measures. clinical medicine 2014;3:57-64. 15. desta f, workicho a, atomsa a, et al. knowledge, practice and associated factors of breast self examination among female students of the college of public health and medical science, jimma university, ethiopia. am j health res 2018;6:44-50. 16. kalayu b, miskir a, belayneh a, et al. practices of breast self-examination and associated factors among female debre berhan university students. int j breast cancer 2017;8026297. 17. sullivan km, soe mm. sample size for cross-sectional & cohort studies & clinical trials. 2007. available from: http://www.openepi.com/pdfdocs/ss cohortdoc.pdf 18. birhane k, alemayehu m, anawte b, et al. practices of breast self-examination and associated factors among female debre berhan university students. int j breast cancer 2017;2017:8026297. 19. getu ma, kassaw mw, tlaye kg, et al. assessment of breast self-examination practice and its associated factors among female undergraduate students in addis ababa university, addis ababa, ethiopia, 2016. breast cancer 2019;11:21-8. 20. natae sf, health dop. assessment of knowledge, attitude and practice of breast selfexamination among ambo university undergraduate regular female students; 2015. physiology and biophysics 2015;32. 21. nde fp, assob jc, kwenti te, etal. knowledge, attitude and practice of breast self-examination among female undergraduate students in the university of buea. bmc 2015;8:43. article non commercial use only [healthcare in low-resource settings 2022; 10:9994] [page 41] 22. okolie uv. breast self examination among female undergraduates in enugu, southeast nigeria. int j nursing midwifery 2012;4. 23. azage m, abeje g, mekonnen a. assessment of factors associated with breast self-examination among health extension workers in west gojjam zone, northwest ethiopia. int j breast cancer 2013;814395. 24. zeru y, sena l, shaweno t. knowledge, attitude and practice; and associated factors of breast cancer self-examination among urban health extension workers in addis ababa, central ethiopia. j midwifery reproduct health 2019:1-11. 25. janni l, mckenzie s, martin j, et al. longitudinal patterns of breast cancer screening: mammography, clinical, and breast self-examinations in a rural and urban setting. womens health issues 2014;24:e139-46. 26. gale encyclopedia of medicine. breast self-examination. 2008. accessed: october 20 2021. available from: https://medical-dictionary.thefreedictionary.com/breast+self-examination article non commercial use only hrev_master [healthcare in low-resource settings 2014; 2:727] [page 19] anaesthesia for acute abdomen in developing countries yvonne o. buowari department of anaesthesiology, university of port harcourt teaching hospital, nigeria abstract acute abdomen is an emergency that requires immediate surgical intervention. in developing and low-income countries, there is limited modern drugs and medical equipment and personnel. general anaesthesia is administered for emergency abdominal surgeries. ketamine is used in hospitals without trained personnel in the administration of anaesthesia. in other hospitals in developing countries with anaesthetist, ketamine is used for induction of anaesthesia and muscle relaxant administered to facilitate endotracheal intubation and maintain anaesthesia with inhalational agents to avoid awareness under anaesthesia. introduction the term acute abdomen denotes an episode of severe abdominal disorder, which requires urgent intervention usually best treated by surgery, and encompasses a spectrum of surgical, medical, and gynaecological conditions ranging from trivial to life threatening conditions.1-4 the incidence of acute abdomen during pregnancy is 1 in 500-635 pregnancies.3 many medical and gynaecological diseases manifest as acute abdomen, therefore it is sometimes difficult to differentiate them.1 acute abdomen usually manifests by pain, emanating from the perineum, hollow intestinal viscera, mesentery, or pelvic organs and may be caused by inflammation or by a mechanical process such as obstruction, acute distension, or vascular disturbances. patients presenting with abdominal emergencies often come to hospitals in africa very late especially if payment for treatment is required. they have often been sick for some days with a perforated or obstructed bowel. it is due to high environmental temperature and third space loss (fluid in the body, which is not available to the circulation for example oedema, ascites or other collections). the possibility of drug or herb ingestion should be considered by asking about visit to the local healer or ingestion of local or traditional medications.5 resuscitation and preoperative optimization are likely to improve outcome. if prolonged, this develops into hypovolaemia, hypokalaemia, hypochloraemia, and metabolic alkalosis.4 the outcome and survival of the patient depends on the surgical disease, extent of the surgery, urgency, degree of preparation and anaesthetic technique. anaesthetic considerations all emergencies are considered as full stomach and usually the preoperative fasting guidelines are not feasible with the risk of regurgitation and vomiting. the patient may have underlying poorly controlled medical illness. there may not be adequate time for detailed history taking. the patient may be dehydrated, hypovolaemic from bleeding or vomiting with electrolyte derangement. every patient with an acute abdomen is severely dehydrated unless proven otherwise.5 hypotension and tachycardia will follow as the vascular volume decrease in relation to the size of the vascular bed.6 abdominal distension occurs from intestinal obstruction or other causes of acute abdomen; it splints the diaphragm and decreases respiratory reserves.7 if the abdominal distension is long standing, a chest infection may have developed.7 preoperative assessment preoperative diagnosis of acute abdomen is crucial to minimise the morbidity and mortality especially where the diagnostic facilities are limited.4,8 the main purpose of the preoperative treatment is to optimize the patients’ condition and maximise their chance of survival.5 effective preoperative assessment requires accurate identification of pare-existing problems, risk assessment, preoperative preparation, plan of anaesthetic technique and anticipation of difficulties that might result during or after anaesthesia.7 resuscitation and optimization treatment depends on the cause.9 through appropriate planning, the patients’ preoperative condition can then be optimized.7 the first step in the resuscitation process is to obtain reliable venous access with large bore intravenous cannulae in a peripheral vein. optimization of the patient is done as far as possible to allow surgical intervention with minimal risk to the patient. nasogastric tube should be connected for gastric decompression to remove fluid and air from the stomach to lessen the likelihood of aspiration of gastric contents into the tracheobronchial tree during the induction of anaesthesia.2,4,6,7,10 the nasogastric tube should be connected to a reservoir that the effluent can be measured and allowed to drain freely.11 in some developing countries like nigeria, an uribag is connected to the nasogastric tube. in some very poor settings, latex disposal gloves are used. resuscitation may run concurrently with surgery. fluid and electrolyte disturbances as well as the metabolic imbalances should be corrected prior to the theatre.7,12 timely decision to carry out surgery when reasonable correction of electrolyte and fluid deficiencies has been achieved should be made.12 the goals of preoperative fluid management are to restore vascular and intestinal volumes, to correct electrolyte and acid-base balance, normalise systemic vascular resistance and optimise oxygen delivery. whole blood or packed cells may be used to restore circulating red blood cells.6 urine output is a good indication of renal and tissue perfusion and should be monitored. choice of anaesthesia in an abdominal emergency, it is always assumed that the stomach is full and that an emergency rapid sequence crash induction technique with cricoid pressure and intubation of the trachea is carried out.4,11-14 the endotracheal intubation is to prevent aspiration.15 rapid sequence induction also balances the risk of losing control of the airway against risk of aspiration. the report of the investigation results should be known prior to induction of anaesthesia especially haemoglobin estimahealthcare in low-resource settings 2014; volume 2:727 correspondence: yvonne omiepirisa buowari, department of anaesthesiology, university of port harcourt teaching hospital, 11 ihediohanma street, mile 2 diobu, port harcourt, rivers state, nigeria. tel./fax: +234.803732440. e-mail: dabotabuowari@yahoo.com key words: acute abdomen, anaesthesia, ketamine, developing countries. received for publication: 13 december 2013. revision received: 28 august 2013. accepted for publication: 1 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright y.o. buowari, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:727 doi:10.4081/hls.2014.727 non -co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2014; 2:727] tion, urinalysis, serum electrolyte, urea, and creatinine. cardio stable drugs will be used. because the vital organs of the body such as liver and kidney can be damaged by electrolyte imbalances and dehydration, lower doses of intravenous anaesthetic drugs should be used. technique of anaesthesia induction rapid sequence induction with the application of cricoid pressure will be used at the induction of anaesthesia. drugs with little or no depressant properties on the cardiovascular and respiratory system will be used. the majority of patients requiring laparatomy will present an aspiration risk and therefore, require intermittent positive pressure ventilation. the nasogastric tube is aspirated and removed. the patient is preoxygenated with 100% oxygen by facemask for five minutes ketamine is used as the induction agent which is readily available in developing countries as has good cardiovascular and respiratory stability and a potent analgesic. a major feature that distinguishes ketamine from other intravenous anaesthetics is stimulation of the cardiovascular system.16 ketamine increases the sympathetic nervous system and circulatory levels of adrenalin and adrenaline consequently leading to heart rate, cardiac output, blood pressure, and central venous pressure.17,18 the respiratory rate may be increased and the laryngeal reflexes relatively preserved.18 ketamine is an effective agent in poor risk patients and those with a tendency to hypotension example relative hypovolaemia and shock.19 salivation is increased requiring therefore antisialogue premedication is recommended prior to the use of ketamine.14,20,21 it is difficult to detect the patient when sleep commences, as the patient appear to gaze into space and not close their eyes for several minutes. there is no loss of eyelash and corneal reflexes.14 loss of verbal response in conscious patients can be used to determine when the patient starts sleeping. there is dissociation from the surroundings.12 ketamine causes vivid and unpleasant dreams, hallucinations, and delirium following its use14 which often are frightening20 which may be reduced by the concurrent use of benzodiazepines.16,18,20 intubation is facilitated by the administration of suxamethonium, a depolarizing muscle relaxant. the greatest danger during the induction of anaesthesia is vomiting or regurgitation of gastric contents into the pharynx and into the tracheobronchial tree.6 to aid and prevent this complication, an assistant is required at induction of anaesthesia to apply cricoid pressure once consciousness is lost after administration of the induction agent. fasciculations may increase intraabdominal pressure and induce regurgitation.6 once the trachea is intubated by direct laryngoscopy, it is connected to the breathing circuit and intermittent positive pressure ventilation commenced. confirmation of correct placement of the endotracheal tube is done by the absence of cyanosis, auscultation for breath sounds, equal chest movement with positive pressure ventilation and fill of the reservoir bag. in patients with pre-existing tachycardia or hyperthermia, atropine or glycopyrrolate is omitted.6 the nasogastric tube is put in place after anaesthesia has been induced and the patient intubated. maintenance atracurium of pancurium may be used for muscle relaxation. atracurium has minimal cardiovascular effects and it releases histamine.21 to prevent awareness under anaesthesia, an inhalational agent is administered. the depth of anaesthesia is hard to assess when using ketamine infusion for maintenance of anaesthesia. two disadvantages that may be encountered with technique are hypertension and hallucinations. if the patient is moribund, ventilation is done with 100% oxygen and a small dose of ketamine. shocked patients need small doses of drugs but a higher concentration of oxygen.14 the most important monitoring of the patient is clinical including pulse, blood pressure, color, respiration, pupil size, lacrimation in addition to monitoring the surgical field, blood loss, urine output, and fluid input.13 reversal and recovery the end of surgery is the beginning of the next challenging period13 and requires planning to ensure that the sequence of timing of cessation of the inhalation agent, reversal of muscle relaxant with atropine and neostigmine return of spontaneous ventilation, suction of the mouth and pharynx and extubation of the patient occur smoothly. the assistant must be ready to start suction and tilt the table if required.13 there has to be some return of neuromuscular function before patients can be reversed with neostigmine and atropine.14 extubation is done only return of airway reflexes. the patient is extubated until the protective reflexes have returned, as the risk of regurgitation is present.22 in the absence of a nerve stimulator, the presence of adequate neuromuscular function at the end of anaesthesia may be crudely determined by grip strength, the patient being able to lift their head off the pillow for at least five seconds and the ability to generate a tidal volume between 15 and 20 ml/kg.23 the patient in recovery should continue oxygen, have continuous monitoring of the airway, breathing and circulation and be given analgesia as required. postoperative care in the recovery ward, the patient should be given oxygen and vital signs monitored and analgesics given.12 the postoperative respiratory problems are those related to hypoventilation. although the intestinal obstruction has been relieved, there may still be significant abdominal distension that will inhibit diaphragmatic motion and the patient may develop hypoxia and hypercapnia. as the patient gradually regains respiratory adequacy, ventilation returns to normal and the patients can be extubated.6 if a drain site was put in place in the course of surgery, effluent from it should be noted and documented such as color, smell, amount and presence or absence of blood. in some developing countries, uribag is used as it does not soil the beddings, is transparent and graded. where there is no recovery room/ward as in rural hospitals, the patient should be monitored closely. the patient must be transported on a trolley with supporting sides and which easily tips into the head down position with facilities for oxygen delivery. intravenous fluid, antibiotics, and analgesics should continue. blood transfusion is given when necessary. the required level of postoperative care will be influenced by the patients’ general condition.4 prognosis the prognosis of the patient with acute abdomen depends on the time of presentation, presence, or absence of peritonitis, onset, and progression of symptoms, age of patient, aetiological factor, level of care, preoperative optimization, and resuscitation and the premormid condition of the patient. conclusions acute abdomen is an emergency and a diagnostic dilemma. it is regarded as a full stomach and associated with shock, sepsis, electrolytes and fluid deficits and losses, compromised respiration, acid/base balance. treatment depends on the cause but the patient must be resuscitated by the administration of intravenous fluid, nasogastric aspiration, close monitoring of pulse and blood pressure. in hypotension and patients in shock, ketamine is the better induction agent. the patient must be intubated to prevent aspiration and regurgitation. the principles of the management of intestinal obstruction are provision of analgesia, intestinal decompression, intravenous fluid therapy and if appropriate surgery. the care of the patient review non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:727] [page 21] includes routine observations, airways, state of the cardiovascular and respiratory system, oxygen therapy, analgesia, urine output, and early ambulation postoperatively to prevent deep venous thrombosis. the postoperative management of the acute abdomen patient includes postoperative pain relieve and monitoring postoperative pain management is essential for improved mobility, patient comfort, enhanced breathing and prevention of gut immobility. other aspects of the treatment include administration of antibiotics and sometimes intensive care admission. good understanding of how to handle emergencies helps reduce morbidity and mortality. proper evaluation, resuscitation and optimization is paramount in urgent interventions as it reduces the incident of morbidity and mortality. references 1. chhetri rk, shrestha ml. a comparative study of pre-operative with operative diagnosis of acute abdomen. kathmandu univ med j 2005;3:107-10. 2. smith gcs, paterson-brown s. the acute abdomen and intestinal obstruction. in. garden oj, bradbury aw, forsythe j, eds. principles and practice of surgery. london; churchill livingstone: 2002. pp 198-220. 3. augustin g, majerovic m. non-obstetrical acute abdomen during pregnancy. eur j obstet gyn r b 2007;131:4-12. 4. gemmell lw, rincon c. anaesthetic management of intestinal obstruction. brit j anaesth 2001;1:138-41. 5. bojarska a. fluid management for emergency laparotomy in rural hospitals. update in anaesthesia 2005;20:7-11. 6. yao ff, artusio jf. anaesthesiology problem oriented patient management. philadelphia, pa: lippincott 1998. pp 30311. 7. foulkes ma, crabbe djo, badoe ea. pre, peri and postoperative care. in: badoe ea, archampong eq, da rocha-afodu jt, eds. principles and practice of surgery including pathology in the tropics. accra: university of ghana medical school; 2000. pp 189-220. 8. famewo ce. lectures in anaesthesia and intensive care for medical students and practitioners. ibadan: lovemost printers limited; 2004. pp 6-149. 9. naadar sb. the acute abdomen. in. badoe ea, archampong eq, da rocha-afodu jt, eds. principles and practice of surgery including pathology in the tropics. accra: university of ghana medical school; 2000. pp 503-4. 10. cephas m. anaesthesia for the patient with a full stomach. update in anaesthesia 1994;4:1. 11. doods c, kumar cm, servin f. anaesthesia for the elderly patient. oxford: oxford university press; 2007. p 81. 12. elegbe eo. oduntan and oduro’s handbook of anaesthesia for medical students and general medical practitioners. ibadan: hebn publishers plc.; 2007. pp 8-77. 13. phillips g, aigeeleng h, didei g. anaesthesia for the patient requiring emergency abdominal surgery. update in anaesthesia 2002;15:17. 14. cavill g, kerr k. pre-operative management. in: pinnock c, lin t, smith t, eds. fundamentals of anaesthesia. cambridge: cambridge university press; 2003. pp 3-24. 15. bryson g, kitts jb. preoperative evaluation and risk assessment. in: sullivan p, ed. anaesthesia for medical students. ottawa: department of anaesthesia ottawa civic hospital; 1999. pp 9-20. 16. reich dl, silvay g. ketamine: an update on the first twenty-five years of clinical experience. can j anaesth 1989;36:186-97. review non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e4] [page 11] willingness and professional motivations of medical students to work in rural areas: a study in alexandria, egypt aida m. mohamed community medicine department, faculty of medicine, alexandria university, egypt abstract retaining health workers in rural areas is challenging for a number of reasons, e.g. personal preferences, difficult work conditions and low remuneration. our aim was to determine the effect of motivational factors on willingness to accept postings to rural underserved areas in alexandria, egypt and to identify perceived attributes of rural service.,a cross-sectional survey involving 302 4th-year medical students was conducted in march-july 2012. logistic regression analysis was used to assess the association between students’ willingness to accept rural postings and their professional motivations, rural exposure and family parental professional and educational status (ppes). perceived attributes to rural service were also assessed. over 85% students were born in urban areas and 41.4% came from affluent backgrounds. more than half students reported strong intrinsic motivation to study medicine. after controlling for demographic characteristics and rural exposure, motivational factors significantly influenced willingness to practice in rural areas. high-family ppes was consistently associated with lower willingness to work in rural areas. a sizable portion of medical students are motivated to study and practice medicine in rural areas. efforts should be made to build on motivation during medical training and designing rural postings, as well as favor lower ppes students for admission and improving organizational and contextual issues of rural service. introduction the world health organization (who) estimates that more than 4 million health workers are needed to fill the health workforce gap globally.1 this includes 2.4 million physicians, nurses and midwives. fifty-seven countries are defined as having a critical shortage of health staff; of these, 36 are in sub-saharan africa. medical services in egypt greatly suffer shortage of healthcare workers; however, statistics from egypt concerning this is lacking. africa has only 3% of the the total world’s health work force (59.2 million people), in spite of having 25% of the global burden of disease.1,2 the shortage of health staff cripples the health delivery system. it is also a threat to provision of essential, life-saving interventions such as childhood immunizations, provision of safe water, safe pregnancy and childbirth services for mothers as well as access to treatment for aids, tuberculosis and malaria. health workers are critical to the global preparedness for and response to threats posed by emerging and epidemic-prone diseases. different interventions have been tried to address these shortages. four main downstream interventions have been implemented by developed and developing countries: financial incentives, provision of education opportunities, interventions supporting the work of health professionals and regulatory mechanisms, such as compulsory services in underserved areas.2 health worker shortages in rural areas have been identified as one of the biggest challenges to the health sector and a barrier to reaching the country’s health-related millennium development goal targets.3 while the public sector has made considerable efforts to place doctors (and a variety of other health workers) in rural areas, issues like absenteeism, ghost doctors, and dual practice have compromized the effectiveness of this effort. retaining health staff in rural areas has proven extremely difficult as young professionals increasingly prefer urban postings and health systems do not reward rural service.4 qualitative research has also shown the importance of healthcare providers’ personal characteristics and value systems, such as religious beliefs and socio-political convictions, to their motivation towards rural practice. emigration of skilled professionals to highincome countries is another barrier to adequate staffing of health facilities.5 a study in ghana in 2006 on trainee physicians and nurses revealed that the majority had considered emigrating. more physicians (68%) than nurses (57%) considered emigration.6 these findings imply that achieving improvements in the health status of people living in low-income countries, and particularly, in rural areas, will be extremely difficult.7 this highly uneven distribution between urban and rural areas is rooted in the fact that cities offer better incomes (e.g. the potential for private practice), more opportunities for career progression, better infrastructure and more social amenities than rural areas.8 while previous research has looked at incentives and working conditions to promote uptake of rural posts, few studies have focused on motivation crowding and its effect on willingness to accept postings to rural area. motivation crowding is the conflict between external factors (extrinsic), such as monetary incentives or punishments, and the underlying desire or willingness to work (intrinsic) in areas needed most. students may have a mix of extrinsic and intrinsic motivations for studying medicine.9 relatively little research has been conducted on effective strategies to promote rural practice, particularly in low-income countries.10 to tackle the uneven distribution of human resources for health, understanding the factors that motivate medical students to study and practice medicine and their willingness to accept postings to rural underserved area is essential. this study was conducted to determine the effect of motivational factors on stated willingness to accept postings to rural underserved areas in alexandria, egypt and to identify perceived attributes of rural service. materials and methods study design, setting and target population this descriptive cross-sectional survey was conducted between march and july 2012 in the alexandria faculty of medicine. medical education consists of three years of basic sciences (bsc), and three years of clinical training at a healthcare in low-resource settings 2013; volume 1:e4 correspondence: aida m. mohamed, community medicine department, faculty of medicine, alexandria university, al-khartom square, alexandria, egypt. tel./fax: +203.12792.9039. e-mail: aida_mohey@yahoo.com key words: health manpower, motivation, rural health services, egypt. acknowledgments: i am greatly indebted and grateful to alexandria medical students who made this study possible. they devoted some of their precious time in helping me to collect the data. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 12 december 2012. revision received: 10 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.m. mohamed., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e4 doi:10.4081/hls.2013.e4 non -co mmerc ial us e o nly [page 12] [healthcare in low-resource settings 2013; 1:e4] teaching hospital in rotating housemanship. a stratified random sample of medical students was invited to participate in the study. stratification is based on the clinical round rotations (4 groups in 4 clinical rounds of different departments). fourth-year medical students were selected because they had completed the bsc, and had also been exposed to field work, but had not yet made their final decisions about rural or urban practice. the total number of fourth year students was 960. sex distribution reflects that males (n=576) outnumbered females (n=384) (faculty registration year: 2012). with the assumption that students’ willingness to work in rural areas was 30% and using a significant level of 0.05, a sample size of 355 fourth-year alexandria medical school was selected with equal proportionate to clinical round size (n=120), a sample of approximately 45 students from each clinical round (n=8) was randomly enrolled. data collection data collection was preceded by approvals from the heads of the involved departments, who were informed of the content of the questionnaire and provided access to the student population. the data collection instruments were developed after three-focus group discussions of 6-8 participants facilitated by the trained investigator. the themes for the focus group discussion were motivation, willingness to work in deprived areas, and the influence of background characteristics on willingness to work in deprived areas. the survey instrument – which included structured questions – was then pre-tested and finalized for the study. the questionnaires were administered to the students in their clinical departments at the faculty of medicine. the survey format took 30 min to be filled on average. the questionnaires covered the following domains. i) students were asked to rate how likely they were to work in a deprived area (at any time in their careers) on a scale from 1-4, where 1 represented i will definitely not work in a deprived area; 2 i am unlikely to work in a deprived area; 3 i am likely to work in a deprived area; and 4 i will definitely work in a deprived area. this response set was collapsed to a dichotomous willing (groups 3 or 4) vs unwilling (groups 1 or 2) to practice in a deprived area. deprived area was defined as a rural area that is distant from the big cities with few social amenities such as schools, roads, pipe-borne water, etc.2 ii) students were also asked to identify any of the 12 factors (identified as important by the focus group discussions) that motivated them to study and practice medicine. the five intrinsic motivations included: desire to help others, desire to give back to their home community or country, interest in medicine as a subject matter, inspiration by a role model, and loss of a loved one. the seven extrinsic motivation factors included: income of physicians, job security and lifestyle, social status/prestige, proposed by parents, opportunities to travel and work internationally, ability to use new cutting-edge technologies, and research opportunities. motivation factors were coded as no=0 and yes=1. respondents were coded as having strong intrinsic or extrinsic motivation if total score was ≥3. thus, strong intrinsic and extrinsic motivation groups were mutually exclusive. iii) socio-demographic factors included: sex, age, marital status and parental professional and educational status (ppes). high ppes was defined as having a mother and/or father who is a university-trained professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.) and low ppes was defined as having neither mother nor father as a universitytrained professional. iv) rural (an area with a population less than 5000) exposure factors included: birth location (urban vs rural), having ever lived in rural area (from the age of 5 onwards), and exposure to rural service in medical training (for a minimum of 6 months). v) the students were also asked to indicate the strength of a set of important organizational and contextual attributes and conditions for rural practice. these identified through a literature review and discussions with physicians from the ministry of health and practicing physicians. ethical considerations the study received ethics approval from the ethical review committee at the alexandria faculty of medicine. all respondents voluntarily participated after the intent and design of the study were explained to them and signing informed consent forms. the study participants were assured of anonymity and confidentiality, in responding to the questions. confidentiality of the data was maintained throughout the study. statistical analysis the study used spss version 18.0 for data entry and statistical analyses. descriptive statistics such as frequency, percentage, mean and standard deviation (sd) were conducted to describe socio-demographic characteristics and rural exposure as well as perceived attributes to rural service. bivariate associations and 95% confidence intervals (cis) were estimated using multivariate logistic regression analysis. the main outcome of interest was the willingness to work in a deprived area after graduation. predictors of interest included motivation (intrinsic and extrinsic), demographic characteristics, and rural exposure variables. significance was set at 0.05 level. results socio-demographic characteristics and rural exposure of the 355 eligible medical students, 302 participated in the survey (85.0% response rate). the socio-demographic characteristics of respondents are presented in table 1. of the 302 respondents recruited for the study, the majority were male (60.6%), with a mean age of 20.9 (sd 1.4). only 5.6% of them were married or engaged. most respondents were born in or around urban areas (87.4%) and had never lived in rural underserved area (75.8%). in terms of socio-economic status, more than half of students (58.6%) came from low ppes families and the rest (41.4%) came from affluent backgrounds. about one fifth of the respondents (20.2%) were exposed to rural service (rural outreach or service during medical studies). professional motivation and likelihood of working in an underserved area willingness to work in underserved area according to the intensities of current motivational factors is presented in table 2 and figure article table 1. socio-demographic characteristics and rural exposure of alexandria medical students (n=302). variable frequency (n) % sex male 183 60.6 female 119 39.4 age mean (sd) 20.9 (1.40) family ppes low° 177 58.6 high# 125 41.4 marital status married or engaged 17 5.6 not in a relationship 285 94.4 birth area urban§ 264 87.4 rural^ 38 12.6 ever lived in rural area$ yes 73 24.2 no 229 75.8 exposed to rural service°° yes 61 20.2 no 241 79.8 sd, standard deviation; ppes, parental professional and educational status. °low-family ppes, neither mother nor father is a universitygraduated professional; #high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.); §urban area defined as a place with more than 5000 residents; ^rural area defined as a place with less than 5000 residents; $from age five onwards; °°participated in outreach or service in a deprived area during medical studies. non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e4] [page 13] 1. overall, 158 (52.3%) students stated that they were likely to or definitely would work in an underserved area. more than half of students (181, 59.9%) had strong intrinsic motivation to study medicine. a significantly higher proportion of respondents who had strong intrinsic motivation (61.3%) indicated willingness to work in a rural area, compared to those with weak intrinsic motivation (38.8%) (χ2=7.952, p=0.008). significantly higher proportions of those motivated to study medicine by the desire to give back to their home community or country (64.0%) were willing to work in an underserved area as compared to 36.0% who would not like to work in rural area (p=0.007). more than two-thirds of students (203, 67.2%) had strong extrinsic motivation to study medicine. the results were reversed for those with strong extrinsic motivation. a significantly lower proportion of respondents who had strong extrinsic motivation (35.0%) indicated willingness to work in a rural area, compared to those with weak extrinsic motivation (87.9%) (χ2=8.121, p=0.003). article table 2. willingness and current motivations of alexandria medical students (n=302) to work in an underserved area according to factors that motivated them to study and practice medicine. factors motivating alexandria medical total (n) willingness to work in an underserved area χ2 test students to study and practice medicine° (p value) unlikely likely domain items n % n % intrinsic motivation desire to help others 284 135 47.5 149 52.5 3.764 (0.836) desire to give back to their 114 41 36.0 73 64.0 7.942 home community or country (0.007)* interest in medicine as a subject matter 118 62 52.5 56 47.5 3.968 (0.802) inspiration by a role model 84 60 71.4 24 28.6 8.032 (0.003)* loss of a loved one 13 12 92.3 1 7.7 fe(0.000)* weak motivation# 121 74 61.2 47 38.8 7.952 (0.008)* strong motivation§ 181 70 38.7 111 61.3 7.952 (0.008)* extrinsic motivation income of physicians 216 174 80.6 42 19.4 7.523 (0.009)* job security and lifestyle 119 76 63.9 43 36.1 6.236 (0.028)* social status/prestige 212 192 90.6 20 9.4 9.612 (0.000)* proposed by parents 59 32 54.2 27 45.8 2.754 (0.814) opportunities to travel and work internationally 181 112 61.9 69 38.1 6.034 (0.033)* ability to use new cutting-edge technologies 109 100 91.7 9 8.3 8.632 (0.002)* research opportunities 23 22 95.7 1 4.3 fe(0.000)* weak motivation# 99 12 12.1 87 87.9 8.121 (0.003)* strong motivation§ 203 132 65.0 71 35.0 total 302 144 47.7 158 52.3 fe, p value of fisher exact test; * significant at 0.05 level. categories are not mutually exclusive. °motivation factors were scored as 0=no, 1=yes. maximum possible score for intrinsic factors=5 and that for extrinsic factors=7; #score<3 ; §score ≥3. figure 1. willingness of alexandria medical students (n=302) to work in an underserved area according to strength of factors that motivated them to study medicine. non -co mmerc ial us e o nly [page 14] [healthcare in low-resource settings 2013; 1:e4] multivariate analysis of motivations and the willingness to accept postings in a rural underserved area after graduation multivariate logistic regression results for strength of intrinsic motivation and willingness to work in a rural underserved area after graduation are presented in table 3. variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. in the final adjusted model, having a strong intrinsic motivation increased the odds of being willing to accept a job in an underserved area [adjusted odds ratio (aor)=2.6, 95% ci 1.3-8.2]. in the model adjusting for demographics, high ppes were associated with reduced willingness to practice in underserved areas (aor=0.4, 95% ci 0.2-0.8). while a higher age was associated with greater willingness to practice in a rural area (aor=3.1, 95% ci 1.8-7.5). living in a rural area was significantly associated with greater willingness to practice in a rural area (aor=3.2, 95% ci 1.8-7.4). these variables constituted 80% of factors influencing the willing to work in a deprived area (r2=0.798) with an overall model (likelihood ratio χ2=33.48, p=0.000). table 4 shows the multivariate logistic regression results for the strength of extrinsic motivation and willingness to work in a rural underserved area after graduation. variables included in the model were those significantly associated with willingness to work in a deprived area by bivariate analysis. in the final adjusted model, a strong extrinsic motivation reduced the odds of being willing to accept a job in an underserved area (aor=0.5, 95% ci 0.3-0.9). demographic factors, female gender (aor=0.4, 95% ci 0.3-0.8), and high ppes (aor=0.4, 95% ci 0.2-0.7) were associated with reduced willingness to practice in a deprived area while a higher age was associated with greater willingness to practice in a rural area (aor=3.8, 95% ci 1.9-8.4). living in a rural area was significantly associated with greater willingness to practice in a rural area (aor=3.4, 95% ci 1.7-7.0). these variables constituted 83% of factors influencing the willing to work in a deprived area (r2=0.826) with an overall model (likelihood ratio χ2=31.33, p=0.000). perceived attributes of rural service table 5 shows students’ perceived organizational and contextual factors pertaining to living in a rural area. organizational factors financial attributes the vast majority of students (96.7%) felt that a substantially higher salary is a strong attribute if they are to take up a rural job. facilities one of the strong issues that medical students have with working in a rural area is the availability of infrastructure (staff, drugs, equipment, diagnostics, and physical structure of the health center) to treat patients: this was felt by 69.5% of students. moreover, a good physical work environment (e.g. clean surroundings, good furniture) and having mentors were perceived to be important attributes by 65.6% and 62.9% of students, respectively. organizational culture, policies and management many students expressed their need for having clarity in the process for taking leave (60.3%), and transfer policies (59.6%). career growth opportunities the vast majority of medical students (93.7%) aspire to further specialize. lower proportions felt that following graduation they were inadequately learned or trained to treat patients. the need for learning opportunities was perceived by 66.2% and for training opportunities by 65.6%. contextual factors expectedly living facilities (housing, electricity, water, access to the market, hygiene) are felt as a strong attribute by almost the entire number of students except two (99.3%). moreover, a lower proportion (71.9%) felt the need for security (physical security, legal protection against political interference). article table 3. multivariate logistic regression analysis of strength of intrinsic motivation and the willingness of alexandria medical students (n=302) to accept postings to rural underserved area after graduation. independent variables willingness to accept postings to rural underserved area after graduation or ci p value strong intrinsic motivation to study medicine 2.6 1.3-8.2 0.001* socio-demographics female 0.5 0.3-1.09 0.634 age (years) 3.1 1.8-7.5 0.000* high-family ppes° 0.4 0.2-0.8 0.011* married or in a relationship 0.9 0.5-1.7 0.621 rural exposure born in a rural area 1.4 0.5-4.3 0.321 lived in a rural area 3.2 1.8-7.4 0.009* exposed to rural service 1.5 0.8-2.8 0.467 r2 0.798 likelihood ratio χ2, p 33.48, p=0.000* or, odds ratio; ci, confidence interval; ppes, parental professional and educational status. °high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). table 4. multivariate logistic regression analysis of strength of extrinsic motivation and the willingness of alexandria medical students (n=302) to accept postings to rural underserved area after graduation. independent variables willingness to accept postings to rural underserved area after graduation or ci p value strong extrinsic motivation to study medicine 0.5 0.3-0.9 0.001* socio-demographics female 0.4 0.3-0.8 0.016* age (years) 3.8 1.9-8.4 0.000* high-family ppes° 0.4 0.2-0.7 0.012* married or in a relationship 0.9 0.5-1.7 0.583 rural exposure born in a rural area 1.4 0.5-4.3 0.264 lived in a rural area 3.4 1.7-7.0 0.012* exposed to rural service 1.5 0.8-2.8 0.531 r2 0.826 likelihood ratio χ2, p 31.33, p=0.000* or, odds ratio; ci, confidence interval; ppes, parental professional and educational status. °high-family ppes, mother and/or father is a university-graduated professional (e.g. doctor, lawyer, engineer, accountant, technical, etc.). non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e4] [page 15] connectivity (transport availability, no sense of isolation) is expressed by 69.9% of students. discussion the present study found that more students reported strong intrinsic motivation compared to high extrinsic motivation to study medicine. this may reflect the underlying altruistic motivation for many students entering a profession focused on serving others.6,7 moreover, despite the fact that study participants were assured of anonymity and confidentiality in responding to the questions, there may also be an element of social desirability bias in the students’ responses as intrinsic motivation may be thought to be more socially acceptable than extrinsic motivation. for this reason, a measure of high intrinsic and extrinsic motivation was selected for use in the regression models. research comparing students stated intentions with their actual career choices during internship is urgently needed as few studies on matched follow-ups are available. in addition, most students participating in the study were young and had not yet tasted the rigors of working in a rural area, which may have affected their job preferences. thus, the findings of this study may not be applicable to practicing physicians. from the work of serneels11 and hanson,12 it appears that these two groups may differ in their preferences for rural practice. in this study, a strong extrinsic motivation was associated with reduced reported willing for rural practice and the reverse was true for high intrinsic motivation. similar results were reported in other studies.13,14 interestingly, this association remained statistically significant at the 95% ci in models with demographic and rural exposure confounders. studies conducted outside egypt have found rural origin to be an important motivator for rural practice.15-17 in contrast to this, the present study found that rural origin did not influence students’ willingness to work in rural areas after controlling for intrinsic/extrinsic motivation and demographic characteristics. the difference could be due to the socio-cultural differences between different locations. this study highlights the importance of locallyrelevant data for decision making. high socio-economic status, measured using parental education and profession, was consistently associated with lack of willingness to work in rural areas. this finding suggests that admission policies favoring well-todo applicants may reduce the pool of students willing to consider rural practice. female gender was also strongly associated with reduced interest in rural practice for women even after controlling for extrinsic motivation and rural exposure variables. this is consistent with similar studies which revealed that women are less likely to accept positions in remote areas due to varying family reasons; they would like to live where their husbands’ jobs are, have difficulties convincing their husbands to follow them to rural areas and want their children to have better education in urban areas.18-20 the studies further explained that female doctors rarely live in the same village as their assigned post and have higher overall absentee rates in rural practice.20,21 with increasing representation of female healthcare professionals,18 it is likely that the supply of health staff to rural underserved areas will remain a major setback if professional motivations are designed to attract more female students to rural practice. more research is urgently needed to determine how female healthcare professionals’ motivations towards rural practice can be better engaged by policy-makers. the present study examined the perceived factors that encourage graduates to work in a article table 5. perceived attributes of rural service by alexandria medical students (n=302). attributes student perception weak attribute strong attribute n % n % organizational factors financial attributes increase in salary 10 3.3 292 96.7 facilities good clinic infrastructure 92 30.5 210 69.5 good physical work environment 104 34.4 198 65.6 availability of monitoring staff 112 37.1 190 62.9 availability of support staff 140 46.4 162 53.6 adequate workload 142 46.0 160 53.0 organizational culture, policies and management regulatory policies 152 50.3 150 49.7 policies on leave 120 39.7 182 60.3 transfer policies 122 40.4 180 59.6 job security 241 79.8 61 20.2 management 132 43.7 170 56.3 career growth opportunities learning opportunities on the job 102 33.8 200 66.2 training opportunities 104 34.4 198 65.6 research opportunities 212 70.2 90 29.8 post-graduation opportunities 19 6.3 283 93.7 contextual factors living facilities 2 0.7 300 99.3 proximity to family 123 40.7 179 59.3 children development (education) 258 85.4 44 14.6 family well-being and comfort 190 62.9 112 37.1 security 85 28.1 217 71.9 connectivity (transport) 91 30.1 211 69.9 social life 164 54.3 138 45.7 community type 202 66.9 100 33.1 categories are mutually exclusive. non -co mmerc ial us e o nly [page 16] [healthcare in low-resource settings 2013; 1:e4] rural area. it was found that the students valued rural job attributes with appropriate salary, that enabled them to perform well clinically (improved infrastructure, physical work environment and monitoring staff), to grow professionally (career growth opportunities, especially for post-graduation), and that provided adequate living facilities, security and connectivity. this is consistent with what has emerged from focus group discussions with ghana students, who expressed doubts about being able to apply their clinical skills to help patients in poorly equipped rural hospitals where basic inputs such as electricity and supply of medicines were unreliable.22 these findings are consistent with the results of studies in ghana23 and ethiopia12 in which housing facilities and security were scored as the most important determinants for accepting postings to rural areas. moreover, in several case studies in middleand low-income countries, supportive supervision has been noted to improve motivation among health workers to rural practice and quality of care.24-26 in uganda, kaye et al. found that a community based training experience of graduates significantly influenced their choice to work in a rural and underserved area, compared with their counterparts from the traditional curriculum.27 an interesting experiment is under way in zambia, where the government, with support from development partners, has instituted several measures to recruit and retain physicians in rural areas. interventions included the refurbishment of government housing, school fees, car loans, improved hospital equipment and assistance with placement for post-graduate training at the end of a 3-year contract.28 this study has certain implications. first, the majority of students have high intrinsic motivation for rural service. more research is needed to determine the potency of this motivation source in real-life decision making and how to best engage it in health policy. it is possible that emphasizing the community service aspect of medical practice and elevating the status of rural primary care in under-graduate and post-graduate training may help narrow the gap between motivation and eventual career choice in favor of rural areas. in addition, well-supervised and supported rural placements in which students experience the rewards of rural practice may help to persuade students who are largely unfamiliar with rural life. however, the success of these rural rotations is likely to depend heavily on having adequate local infrastructure and mentorship.17 second, the current results suggest that effective strategies to promote and support rural practice after graduation should be implemented and evaluated. it was suggested that students may be willing to commit to short-term placements of 2 years or less in rural areas.29 the ministry of health may want to consider the possibility of short contracts that rotate physicians in and out of difficult staff rural areas. conclusions a sizable portion of students reported high intrinsic motivation and therefore it is important to appeal and build on this in medical school curricula and in designing rural postings. however, extrinsic motivation and, perhaps most importantly, gender and socio-economic status, will likely continue to be important factors in deciding on job postings. the present research also suggests that increasing efforts to recruit medical students from low socio-economic backgrounds may be the most effective current pathway to increasing the yield of physicians willing to practice in underserved areas. financial incentives from central or local governments would attract health workers to rural areas. well planned strategies can help identify effective and efficient human and non-human resources for meeting the health needs of underserved rural populations in alexandria. references 1. world health organization. the world health report 2006: working together for health. geneva: world health organization ed.; 2006. 2. grobler l, marais bj, mabunda sa, et al. interventions for increasing the proportion of health professionals practicing in rural and other underserved areas. cochrane db syst rev 2009;1:cd005314. 3. asante ad, zwi ab. factors influencing resource allocation decisions and equity in the health system of ghana. public health 2009;123:371-7. 4. nadeem n, muhammed a. brain drain: causes and implications. karachi: dawn; 2004. 5. garbarino s, lievens t, quartey p, serneels p. ghana qualitative health worker study: draft report of preliminary descriptive findings. accra: oxford policy management publ.; 2007. 6. united nations development programme. country fact sheets: ghana. geneva: undp ed.; 2009. 7. anarfi jk. migration expectations of trainee health professionals in ghana. accra: institute of statistical, social and economic research and the university of ghana publ.; 2006. 8. dussault g, franceschini mc. not enough there, too many here: understanding geographical imbalances in the distribution of the health workforce. hum resour health 2006;4:12. 9. frey bs, reto j. motivation crowding theory: a survey of empirical evidence. j econ surv 2001;15:589-611. 10. wilson nw, couper id, de vries e, et al. a critical review of interventions to redress the inequitable distribution of healthcare professionals to rural and remote areas. rural remote health 2009;9:1060. 11. serneels p, lindelow m, montalvo jg, barr a. for public service or money: understanding geographical imbalances in the health workforce. health policy plann 2007;22:128-38. 12. hanson k, jack w. health worker preferences for job attributes in ethiopia: results from a discrete choice experiment (working paper). washington, dc: georgetown university publ.; 2008. 13. munga m, mbilinyi d. non-financial incentives and retention of health workers in tanzania. dar es salaam: national institute for medical research ed.; 2008. 14. kuehn bm. global shortage of health workers, brain drain stress developing countries. jama-j am med assoc 2007;298: 1853-5. 15. dovlo d. the brain drain and retention of health professionals in africa. accra: medact ed.; 2003. 16. akerlof ga. labor contracts as partial gift exchange. q j econ 1982;97:543-69. 17. ghana ministry of health. the ghana health sector 2009 programme of work: change for better results: improving maternal and neonatal health. accra: ministry of health publ.; 2009. 18. fritzen sa. strategic management of the health workforce in developing countries: what have we learned? hum resour health 2007;5:4. 19. kletke pr, marder wd, silberger ab. the growing proportion of female physicians: implications for us physician supply. am j public health 1990;80:300-4. 20. knaul f, frenk j, aguilar a. the gender composition of the medical profession in mexico: implications for employment patterns and physician labor supply. j am med women assoc 2000;55:32-5. 21. white cd, willet k, mitchell c, constantine s. making a difference: education and training retains and supports rural and remote doctors in queensland. rural remote health 2007;7:700. 22. kruk me, johnson jc, gyakobo m, et al. rural practice preferences among medical students in ghana: a discrete choice experiment. b world health organ 2010; 88:333-41. 23. snow r, asabir k, mutumba m, et al. policy talk: how ghanaian doctors would improve article non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e4] [page 17] retention in rural service. in: proceedings of the ghana health summit 2010: from strategy to action, 2009 apr 26-30, accra, ghana. 24. hole ar. modelling heterogeneity in patients’ preferences for the attributes of a general practitioner appointment. j health econ 2008;27:1078-94. 25. loevinsohn bp, guerrero et, gregorio sp. improving primary health care through systematic supervision: a controlled field trial. health policy plann 1995;10:144-53. 26. bosch-capblanch x, garner p. primary health care supervision in developing countries. trop med int health 2008;13:369-83. 27. douglas m. supervision of rural health centres in papua new guinea: consolidation of the delivery of health services. papua new guinea med 1991;34:144-8. 28. kaye dk, mwanika a, sewankambo n. influence of the training experience of makerere university medical and nursing graduates on willingness and competence to work in rural health facilities. rural remote health 2010;10:1372. 29. koot j, martineau t. mid term review. zambian health workers retention scheme (zhwrs) 2003-2004. lusaka: ministry of health publ.; 2005. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2021; 9:9799] [page 23] health service delivery for type 1 diabetes during the lockdown in uganda following the coronavirus disease 2019 pandemic silver bahendeka,1 thereza piloya,2 jasper onono,3 ronald wesonga,4 gerald mutungi,5 wenceslaus sseguya,6 denis mubangizi6 1department of internal medicine, mother kevin post graduate medical school, uganda martyrs university, kampala; 2department of paediatrics, makerere university college of health sciences, kampala; 3it department, diabetes unit, st. francis hospital, nsambya; 4school of statistics and planning, makerere university, kampala; 5ncd department, uganda, ministry of health; 6diabetes centre, st. francis hospital, nsambya, kampala, uganda abstract lockdown measures to reduce the spread of coronavirus disease 2019 (covid-19), may adversely impact on diabetes supplies and metabolic control, especially in type 1 diabetes in low-resource countries. to address this, we conceptualized a service delivery model that incorporated a digitized tool. the digitized tool (ut1d-himas) maintained electronic health records, monitored clinic supplies, patient clinic visits and admissions, and sent automated sms messages. delivery of supplies was by motor vehicles, motorcycles, bicycles or patients/caregivers walking to clinics. metabolic control was assessed by glycated haemoglobin (hba1c). monitoring of clinic supplies including emergency restocking, patient clinic visits and admissions, and sending automated sms by ut1d-himas were successfully achieved. a fall in clinic visits, reaching a nadir (67.9%) in may 2020 was observed. hba1c (mean ± sd mmol/mol) significantly (p= 0.040) worsened from 79.1 ± 26.8 to 94.9 ± 39.2 and (p=0.002) from 67.1 ± 22.7 to 84.8 ± 39.4 in the rural and urban clinic respectively. the digitized health information system exhibited high practicability in tracking stocks, clinic visits and hospitalisation but failed to improve metabolic control. introduction severe acute respiratory syndrome coronavirus 2 (sars-cov-2), the aetiologic agent of coronavirus disease 2019 (covid-19) is highly contagious.1 sarscov-2 infection was first reported in wuhan, hubei province, china, in december 2019; and in a few short months the disease had spread globally, prompting the world health organization (who) to declare it a public health emergency of international concern on january 30th 2020.2 on march 22nd 2020, the first case of sars-cov-2 infection in uganda was confirmed, prompting the uganda government on the march 25th 2020 to enforce a lockdown and a nationwide curfew from 19:00 to 05:30 hours in order to curb the rapid spread of the disease.3,4 this lockdown lasted over two months in most parts of the country. during this period, motor vehicle transportation for the greater public community was largely restricted to those persons charged with providing essential services. the sick in the community and those accessing chronic care services required prior government travel authorization in order to access care. therefore, there was an urgent need to review the country’s health service delivery for type 1 diabetes (t1d) in the light of the restrictive lockdown measures. significant concerns surrounded the likelihood of interruption of insulin and other essential supplies; inability of the health system to respond to acute metabolic emergencies; and poor outcomes associated with sars-cov-2 infection in patients with diabetes. the later was a serious concern, as recent studies in our t1d patients had shown an overall poor metabolic control.5 in march 2020, a t1d health care team composed of paediatric and adult endocrinologists, representatives of ministry of health and program managers for t1d met and conceptualized a context-driven health service delivery model to address health service delivery during the covid-19 pandemic lockdown. the model included a digitized health information system with two main functionalities: i) an application for electronic health care records (ehr) and ii) an administrative system for monitoring supplies and sending automated short messaging services (sms). figure 1 shows a schematic diagram of the conceptualized health service delivery model to respond to covid-19 lockdown. we describe the performance of the health service delivery model in monitoring clinic supplies including emergency restocking, patient clinic visits and admissions, and send healthcare in low-resource settings 2021; volume 9:9799 correspondence: silver bahendeka, department of internal medicine, mother kevin post graduate medical school, uganda martyrs university, ground floor, doctors plaza building, plot 1470, nsambya-gaba road, p.o box 32297, kampala, uganda. e-mail: silverbahendeka@gmail.com key words: type 1 diabetes; covid-19; sars-cov-2; lockdown; e-health. acknowledgements: we wish to thank the novo nordisk changing diabetes in children (cdic®), denmark and life for a child (lfac) sydney for providing support to the t1d program in uganda. we further would like to appreciate the contributions of sonia nabeta foundation (snf), which provided funds for boda-boda in distributing the insulin. contributions: skb, tp and rw designed the study; skb and rw analysed the data; skb drafted the manuscript and all authors contributed critically to its final form and agreed on the journal for publication. conflict of interest: the authors declare no conflict of interest. funding: there was no funding for this study; novo nordisk supports the program of improving care for t1d in uganda. novo nordisk had no role in the design and conduct of the study, collection, management, analysis, and interpretation availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the study was approved by the st. francis hospital review and ethics committee (ugrec-020) and uganda national council of science and technology (hs519es) and was conducted in line with good clinical practice (gcp). all patients participating in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 4 april 2021. revision received: 3 november 2021. accepted for publication: 11 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9799 doi:10.4081/hls.2021.9799 non -co mmerc ial us e o nly ing automated sms; and the impact of lockdown on the metabolic control as assessed by glycaeted haemoglobin (hba1c). subjects participants were all patients with t1d (n=1473 in the registry) attending specialized t1d clinics (n=40) in uganda. the geographical distribution of the clinics is given in the supplemental material (figure s1). there are 40 specialized t1d clinics and all, except one which receives support from life for a child (lfac) programme, are supported by changing diabetes in children (cdic®) programme. both the lfac and cdic® have provided free, comprehensive outpatient service to underprivileged children and adolescents with diabetes since 2009. all participants gave informed consent: participants above the age of 18 years consented and parents/guardian consented for children below the age of 18 years (8-18 years of age, in addition to parent/guardian consent, assented). because of logistics during lockdown, two clinics were conveniently selected for assessment of metabolic control: virika hospital, in fort portal district, a rural clinic and st. francis hospital, in kampala district, an urban tertiary teaching hospital. the participants in these two clinics were required to have been residents of the respective districts. all patients attending virika hospital (n=24) and a random sample of 42 patients [selected using the electronic health records (ehr) registry as the sampling frame] from st. francis hospital, nsambya (total patients attending this clinic =180) had hba1c measured as an assessment of metabolic control. materials and methods the management response to the lockdown included the provision of electronic health records (ehr), combined with an administrative digital tool [uganda type 1 diabetes health information and administrative system (ut1d-himas)] that extended geographic access of t1d health service delivery to 40 health units; provided health provider communication to patients; allowed individual patient-level data collection; and had a functionality for clinic stock and inventory. clinics stocks monitored included insulin, syringes, lancets, strips and glucose meters for patients to carry out self-monitoring of blood glucose (smbg), log-books for recording results of smbg. selected centres which had the hemocue® hba1c 510 analyser monitoring included stocks of cartridges used in the analyser. health care workers were supplied with tecno® android smart phones devices (165.60 x 73.30 x 9.10 cm) to connect with ut1dhimas at the health facility. to enhance the program administrator’s monitoring of clinic activity, the following features were incorporated into the ut1d-himas: i) an administrator’s notification centre to show notifications on upcoming stock outs for all clinics and patients; ii) a general notification centre (this mirrors the administrator’s notification centre, but is related to the logged-in clinic and the clinic patients only). additionally, it has notifications dispatched by the administrator to healthcare workers; iii) a general notification centre (which mirrors the administrator's notification centre, but is related to the logged-in clinic and the patients patients and, additionally, it has notifications dispatched by the administrator to the healthcare workers; iv) patients’ timeline: stock supplies, laboratory records, clinic records and admissions; v) mobile application (cdic app) for data entry, with the option of working offline, should internet connectivity be absent. the following steps were put in place so to achieve a nationwide coordinated response: i) step 1: all the 40 t1d clinics were immediately (march 2020) re-stocked with supplies and instructed to give extra insulin supplies and syringes patients. the supplies included insulin, syringes, lancets, strips and glucose meters for patients to carry out self-monitoring of blood glucose (smbg), log-books for recording results of article figure 1. schematic representation of the conceptualized healthcare delivery response for type 1 diabetes patients during covid-19 pandemic in uganda. [page 24] [healthcare in low-resource settings 2021; 9:9799] non -co mmerc ial us e o nly smbg. selected centres which had the hemocue® hba1c 510 analyser monitoring included stocks of cartridges used in the analyser; ii) step 2: healthcare workers were sent information on the management of acute respiratory infections with particular emphasis on sars-cov-2 infection and reminded of traditional measures to avoid diabetic ketoacidosis (dka) and further advised on prompt data reporting especially on ehr and diabetes supplies; ii) step 3: program administrators were to closely follow up clinic stocks and supplies using the administrator’s notification centre of ut1d-himas and where required to make a telephone call and discuss with the health workers. the administrators would contact consultant endocrinologists by phone, should there be a clinical problem lower cadres could not solve or the health workers were unable to contact the consultant endocrinologists directly; iv) step 4: automated sms in english format were to be sent to all t1d patients regarding clinic services and diabetes management. the system would use telephone numbers recorded at the time of index registration into chronic care. glycated haemoglobin (hba1c) was measured by hemocue® hba1c 510 system. good glycaemic control was regarded as optimal if below 53 mmol/mol. impact of lockdown on metabolic control was assessed by comparing the most recent hba1c before lockdown (performed in february 2020 or march 2020) with that of three months into the lockdown (performed in june 2020) in two sites: one rural – virika hospital, fort-portal, situated 250 km from kampala city and one urban – st. francis hospital, nsambya, a tertiary teaching facility located 3 km from the centre of kampala city. data was entered into ut1d-himas and later exported into excel and into stata version 15 (1985 – 2017 statacorp llc, 4905 lakeway drive, college station, texas 77845 usa) for analysis. a p value < 0.05 was considered statistically significant. the study was approved by the st. francis hospital review and ethics committee (ug-rec-020) and the uganda national council of science and technology (hs519es) and was conducted in line with good clinical practice (gcp). results the uganda type 1diabetes health information management administration system (ut1d-himas) the ut1d-himas digital tool was article table 1. clinic status 14 weeks before and 14 weeks after sars-cov-2 infection was confirmed in uganda. description period 14 weeks before lockdown period 14 weeks into lockdown number of t1d clinics 40 40 total number t1d registered at end of period in ehr 1408 1483 patients enrolled into chronic care during period 41 75 t1d attending clinic but not previously captured in ehr 10 known t1d enrolled into specialized clinics but previously attending the elsewhere 59 t1d presenting with hyperglycaemia; bg > 15 mmol/l (new-onset diabetes) 17 (7) 20 (6) deaths 0 0 note: the uganda government enforced the lockdown restrictive measures on 25 march 2020 and began to relax them for majority of the population at the end of june 2020. abbreviations: bg, blood glucose; ehr, electronic healthcare records; t1d, type 1 diabetes. table 2. characteristics of patients presenting with hyperglycaemia (blood glucose > 15 mmol/l) before and after the lockdown. clinics routinely attended approximate before lockdown during lockdown distance newly detected previously enrolled newly detected previously (km) enrolled from kampala1 n m/f age (yrs) n m/f age (yrs) n m/f age (yrs) n m/f age (yrs) arua rrh 500 2 1m/1f 9.2;14.6 virika hospital 310 2 2f 14.5;11.9 holy innocent hospital 270 1 1m 13.7 jinja rrh 80 4 2m/2f 13.3;26.3; 14 6m/8m amean 19.7;22.8 kiboga hospital 120 1 1m 16 kisoro hospital 470 1 1m 12.6 masaka rrh 130 1 1m 14.5 1 1m 14.7 mbale rrh 225 1 1f 8.9 mulago nrh within city 2 2m 6.5; 7.8 st. francis hospital within city 1 1f 11.6 1 1m 17.2 uganda martyrs hospital within city 1 1f 15.3 4 3m/1f 14.8;3; 0.1;15.8 total 7 4m/3f 10 6m/4f 6 4m/2f 14 6m/8f note: the number of patients who enrolled into chronic care with the type 1 diabetes clinics and had been under care in other health facilities was highest in jinja hospital and are here given as mean ± sd. abbreviations: f, female m, male; nrh, national referral hospital. rrh, regional referral hospital; sd, standard deviation yrs, years; 1kampala is the capital city of uganda. 2mean ± sd 14.2 ± 5.6 years; range 2.8 – 26.3 years. [healthcare in low-resource settings 2021; 9:9799] [page 25] non -co mmerc ial us e o nly operationalized in march 2020 and enabled electronic collection, storage, management and sharing of patient’s electronic health records for purposes of patient care, research and quality management. figure 2 shows a computer screen caption of a typical administrator dashboard in ut1dhimas clinic activity in june 2020. thirty-one (77.5%) clinics responded to all sms and telephone calls from the administrator during the lockdown period. the system automatically sent sms notification reminders to all t1d patients with active telephone numbers [1310 (88.9%)] for any upcoming clinic planned visits and reminders if the patient did not fulfil the appointment. reminders on missed appointments averaged 60% per month during the lockdown period. the system did not have the functionality to note received sms. type 1 diabetes clinics during the lockdown period, a further 75 patients were captured into ehr; 10 of who were already attending the clinics but data not entered into ehr; 6 had newly detected diabetes and the rest 59 had been attending other health facilities. a total of 20 patients presented with hyperglycaemia (glucose above 15 mmol/l); 19 were managed on outpatient basis while one patient with malaria required admission. there was no reported case of sars-cov-2 infection in t1d; and no deaths. table 1 shows the status of the clinics 14 weeks before and 14 weeks after sars-cov-2 infection was confirmed in uganda. table 2 shows the characteristics of patients who presented with hyperglycaemia during the period before and period during the lockdown. clinic attendance fell during the lockdown period, and began to pick up in june 2020. the average clinic attendance in january and february 2020 (before lockdown) was 1,304, and fell by 9.6% in march (total attendance 1,179); by 17.8% in april (total attendance 1,072); by 67.9% in may (total attendance 419) and by 24.4% in june (total attendance 991). figure 3 shows a histogram of clinic visits before and during the period of lockdown in uganda. emergency diabetes supplies in may 2020, all the 40 clinics centres were restocked with diabetes supplies. patients or their contact neighbours or peers were contacted by sms or phone calls and supplies sent on motorcycles or bicycles in line with the conceptualized intervention. there was no reported case of a complete day’s out of stock of insulin and no clinic reported insulin stock outs. however, we noted that prior to the lockdown, there was a shortage of strips for self-monitoring of blood glucose (smbg) in 36 (90%) clinics. blood glucose monitoring strips arrived in the country in may 2020 and restocking of the clinics was done with other diabetes supplies. glycaemic control table 3 summarises hba1c before and during the lockdown in two selected clinics: virika and st. francis hospitals. prior to the lockdown, the mean hba1c in st. francis article figure 2. a caption of a typical administrator’s dashboard screen view showing clinic visits in the month of june 2020. purple curves represent repeat visits and green curves represent index clinic visits. four clinics were offline. [page 26] [healthcare in low-resource settings 2021; 9:9799] non -co mmerc ial us e o nly hospital was 67.2 mmol/mol significantly (p = 0.05) lower than the mean hba1c of 79.2 mmol/mol in virika hospital. there was worsening of hba1c in both clinics with the lockdown; mean hba1c three months into the lockdown (june 2020) was significantly (p=0.002) higher at 84.7 mmol/mol in st. francis hospital and similarly significantly (p=0.04) higher at 94.5 mmol/mol in virika hospital. the previous gradient observed between virika hospital (a rural clinic) and st. francis hospital (an urban teaching facility) narrowed; 31.0% patients had hba1c below 53 mmol/mol in st. francis hospital versus 16.7% in virika hospital before the lockdown, dropping down to 23.8% and 12.5% during lock down in st. francis hospital and virika hospital respectively. discussion the t1d health care team in uganda conceptualized a national response that included ehr combined with an information and administrative digitized tool and guidelines for healthcare workers to address adverse effects of lockdown restrictive measures on diabetes supplies and metabolic control among t1d patients. the conceptualized response to the lockdown successfully avoided severe shortages of diabetes supplies but unfortunately failed to improve glycaemic control. the success achieved in avoiding insulin and other essential diabetes supplies stock outs is attributed to the rapid inflow of information enabled by the digital health services that comprised of appropriately and promptly entering clinic and patient data by health care workers into the application of the digital tool, the program administrators utilising a digital tool to monitor the stocks and supplies backed by the use of phone calls and sms. for this exercise to be completed, there was need to utilise all locally available means of delivering and collecting supplies: motor vehicles, motorcycles (boda boda), and in some cases, patients and/or their care givers walking to and from the t1d specialized clinics to collect the diabetes supplies. while the later may have imposed some hardships on the patients and/or their care givers, it should be seen as an important component of developing telehealth in low resource countries, as it entailed a culture change among providers and institutions, provided early contextually driven engagement of institutional stakeholders in the development of a formal telehealth onboarding process for patients and/or care givers, providers and staff. clinical operations using the digital tool were limited to ehr and sms for patient reminders about clinic visits and other general clinic information. this was because the technological requirements of more elaborate clinical operations that would promote patient-driven, patient-centred diabetes care with individualized content and timing was not available and would not be article table 3. a summary of glycated haemoglobin (hba1c) for patients attending virika hospital, fort portal and st. francis hospital, nsambya, kampala before and during the lockdown. characteristic virika hospital, st. francis hospital, p value fort portal (rural) kampala (urban) distance of clinic from kampala (km) 250 3 patients registered in clinic (m/f) 66 (37/29) 257 (121/136) patients enrolled for hba1c (m/f) 24 (6/18) 42 (24/18) participants mean age in years (range) 17 (4 – 23) 22 (9 – 32) aggregated hba1c (mmol/mol) before lockdown (decemberfebruary 2020) 79.1 ± 26.8 67.1 ± 22.7 0.05 % hba1c < 53 mmol/mol 16.7 30.9 %hba1c 53 -64 mmol/mol 12.5 21.4 %hba1c 65-75 mmol/mol 25.0 11.9 % hba1c >75 mmol/mol 45.8 35.7 aggregated hba1c (mmol/mol) during lockdown (march– june 2020) 94.9 ± 39.2 84.8 ± 39.4 0.31 % hba1c < 53 mmol/mol 12.5 23.8 %hba1c 53 -64 mmol/mol 8.3 16.7 %hba1c 65-75 mmol/mol 16.7 2.4 % hba1c >75 mmol/mol 62.5 57.1 hba1c change before and three months after lockdown: p value 0.040 0.002 [healthcare in low-resource settings 2021; 9:9799] [page 27] figure 3. a histogram showing clinic visits before and during the period of lockdown in uganda. the bar of january february 2020 represents the average attendance just prior to the lockdown restrictive measures enforced in march 2020. the rest of the bars represent actual visits as recorded at the clinic during the months of march to june. non -co mmerc ial us e o nly [page 28] [healthcare in low-resource settings 2021; 9:9799] supported by the existing infrastructure. the proportion of ugandan households with at least one telephone is 10.8% (10.6% rural; 11.1% urban) while only 5.9% of all households have access to a computer at home. only 15.8% of the individuals who own a mobile phone, owns a smart phone; however, 98.7% of the households agree to share a phone. sms was therefore a good option for keeping in touch with patients and a positive step towards building a more elaborate diabetes telehealth.7,8 in our ugandan t1d patients, the conceptualized response to the lockdown failed to improve the metabolic control. we suggest this could have been due to multiple factors. first, diabetes self-management education (dsme), a major factor underlying poor metabolic control among t1d patients in uganda5,9,10 could not be addressed by the tool. secondly, the lockdown prevented adequate clinic visits and consequently patients had very little support from healthcare workers, whether or not it was a rural or an urban setting. thirdly, other factors that we did not address, like excessive consumption of juices and other sugars during lockdown, reduction in exercise activity, change in dietary patterns, reduced monitoring for fear of running out of supplies may have been contributing factors to the observed metabolic dysregulation.11-13 recent studies from the high-income countries suggest that patients of all ages with t1d did not experience a deterioration in their glucose control through the lockdown.14 the use of telemedicine was reported as the leading factor in the improvement of metabolic control during the lockdown of the covid-19 pandemic.14 this option was not possible as the infrastructure in uganda cannot support telemedicine. as of february 18, 2021, uganda was still in a very fortunate position of having moderate spread of sars-cov-2 infection.15 no case of sars-cov-2 infection had been reported among patients with t1d. study limitations sms were given in the english format. some t1d or their care givers may not have understood the sms as some may not have been fluent in the english language. uganda has over 45 officially recognised local languages.16 at enrolment into chronic care patients are required to register a mobile phone that may be used to reach him/her. when the t1d patient or his family/caregiver did not own a phone, they gave the neighbour’s or local leader’s phone contact, which is what was used for sms. it is envisaged that in such cases some sms were not delivered or delivered late. few patients or their neighbours had smart phones, hence the sms had to be very basic and therefore no significant dsme could be incorporated. calls and sms to the healthcare workers were not tollfree, which may have acted as a barrier to patients calling for assistance during lockdown. monitoring was emphasised, but strips were not available until may 2020. because of logistical problems, only two clinics were conveniently chosen for the assessment of metabolic control during the lockdown. therefore, caution needs to be exercised in conclusions drawn from these clinics, rural and urban, as they may not be generalised to all the clinics. the strength of this study is the inclusion of all specialized t1d clinics from uganda for the monitoring of diabetes supplies and stock-outs (only two clinics were included to evaluate metabolic control), a significant achievement in overcoming geographic barriers to accessing care. conclusions the conceptualized response to the lockdown that utilised a digitized health information system based on a context-driven health service delivery model exhibited a high practicability and efficiency in tracking stocks and delivery of diabetes supplies, but failed to mitigate worsening of glycaemic control. references 1. yesudhas d, srivastava a, gromiha mm. covid-19 outbreak: history, mechanism, transmission, structural studies and therapeutics. infection 2021;49:199-213. 2. world health organization. (2020). who director-general's opening remarks at the media briefing on covid-19 11 march 2020. accessed on 15 august 2020. avalable from: https://www.who.int/dg/speeches/detail /who-director-general-s-openingremarks-at-the-media-briefing-oncovid-19---11-march-2020 3. federica m, pattnaik a, jordanwood t, et al. (2020). case study: the initial covid-19 response in uganda. washington, dc: thinkwell and ministry of health uganda. accessed on 23 october 2021. available from: h t t p s : / / t h i n k w e l l . g l o b a l / w p content/uploads/2020/09/ugandacovid-19-case-study-_18-sept20201.pdf 4. migisha r, kwesiga b, mirembe bb, et al. early cases of sars-cov-2 infection in uganda: epidemiology and lessons learned from risk-based testing approaches march-april 2020. global health 2020;16:114. 5. bahendeka s, mutungi g, tugumisirize f, et al. healthcare delivery for paediatric and adolescent diabetes in low resource settings: type 1 diabetes clinics in uganda. global public health 2019. doi: 10.1080/17441692.2019.1611897 6. collaboration on international ict policy for east and southern africa (cipesa). (2018) national information technology survey 2017/18 report. accessed 03 march 2020. available from: https://www.nita.go.ug/sites/ default/files/publications/national%20i t%20survey%20april%2010th.pdf 7. hartmann-boyce j, morris e, goyder c, et al. managing diabetes during the covid-19 pandemic2020. accessed on 06 february 2021. available from: https://www.cebm.net/covid-19/managing-diabetes-during-the-covid-19-pandemic/ 8. kompala t, neinstein ab. telehealth in type 1 diabetes. curr opin endocrinol diabetes obes 2021;28:21-9. 9. kyokunzire c, matovu n. factors associated with adherence to diabetes care recommendations among children and adolescents with type 1 diabetes: a facility-based study in two urban diabetes clinics in uganda. diabet metabol syndr obes targets ther 2018;11:93104. 10. mbanya jc, naidoo p, kolawole ba, et al. management of adult patients with type 1 diabetes mellitus in africa: a post-hoc cohort analysis of 12 african countries participating in the international diabetes management practices study (wave 7). medicine (baltimore) 2020;99:e20553. 11. tenywa g. covid-19: foods you must eat to boost your immunity. new vision, 2020. accessed on 31st march 2020. available from: https://www.newvision.co.ug/news/151 7308/covid-19-foods-eat-boost-immunity 12. kasozi ki, macleod e, ssempijja f, et al. misconceptions on covid-19 risk among ugandan men: results from a rapid exploratory survey, april 2020. front public health 2020;8:416. 13. usman im, ssempijja f, ssebuufu r, et al. community drivers affecting adherence to who guidelines against article non -co mmerc ial us e o nly [healthcare in low-resource settings 2021; 9:9799] [page 29] covid-19 amongst rural ugandan market vendors. front public health 2020;8:340. 14. trevisani i, bruzzi p, madeo sf, et al. covid-19 and type 1 diabetes: concerns and challenges. acta biomed 2020;91:e2020033. 15. ministry of health uganda government. uganda government, ministry of health, coronavirus (pandemic) covid-19, 2020: accessed on 28 june 2020. available from: https://www.health.go.ug/covid/ 16. igloos consultancy: francis. (2019). how many languages uganda has? accessed on 10 october 2020. available from: https://igloosconsultancyservices.com/how-many-languagesuganda-has/ article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:10575] [page 7] analysis of the potential reasons for repeated radiography: a study in a major hospital in south eastern iran hamid dahmarde, marzieh abiri, sharareh sanei sistani deparment of radiology, zahedan university of medical sciences, zahedan, iran abstract rejecting, removing and repeating the process of taking diagnostic x-ray images could lead to professional and moral challenges in the case of radiologic imaging. the aim of this study was to investigate the common causes of repetitive imaging and the types of images mostly repeated. radiographs taken in our medical center form january 1st 2021 to july 1st 2021 were evaluated. after gathering information and importing form-related data into the statistical software spss ver. 26. in this study, a total of 4916 were evaluated. among 398 repeated radiographs, 94 repetitions (23.62%) were due to inappropriate positioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inadequate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. in this study, the rate of repeated radiographs taken in a tertiary hospital was estimated at 8.10%, with the most common cause for repetitions being inappropriate positioning. considering the fact that repeated radiography mostly depends on operator-related factors, it is recommended to repeat the study after educating staff in order to compare the rate and reason of repetition. introduction rejecting, removing and repeating the process of taking diagnostic radiographic images could lead to professional and moral challenges in the case of radiologic imaging. rejection analysis is one of the important parts of qualification assurance programs in medical imaging departments.1 the analysis is a basis for determining the reason behind the rejection of images and maybe beneficial in radiography-related education, improving quality of work in the radiology department, and finally reducing patients’ exposure to radiation.2 the radiographic examination is mostly done in at least two planes in order to gain diagnostic images to help diagnose disorders or damages.3 a rejected image is one considered to have inadequate quality by a radiologist. the radiologist decides that the image does not hold technical standards for a certain diagnosis process and consequently rejects the image demanding another one.4 this recurrent imaging process increases the patient’s exposure to radiation and thus violates the concept of keeping ionizing radiation exposure at a fair minimum. moreover, rejected images reduce the efficiency of the department and patients’ consent which accordingly increases institutional costs.5 evaluating the rate of repeated images is a part of the rejection analysis process, which is an acceptable standard to assure the quality in general radiology. observing repeated radiographs can help evaluating the quality of diagnostic images, improving examination protocols, educating staff, and assessing patients’ radiation exposure.6,7 for a diagnostic radiology department to be able to provide images of high quality with the minimum exposure of patients and staff to the radiation, a program of quality assurance needs to be set and accomplished.8,9 the reasons for the rejection of images correspond with technical alternated advances. the most common reason to reject images in conventional filmscreen radiology was reported to be exposure errors (that is, too much or too little exposure).10,11 currently, this issue is a position error in computed radiography (cr) and digital radiology. the accuracy of results achieved by rejection analysis depends on radiologists’ obligation to categorize their rejected images appropriately. also, the ability of the imaging department to reduce the rate of rejected images depends on the application of findings acquired by rejection analysis using a feedback and education system.12-15 this study reports the repetition rate in an imaging department in iran. the aim of this study was to investigate the causes for repetitive imaging and to evaluate the types of images mostly repeated. materials and methods this study was approved by the ethical committee of zahedan university of medical sciences. the radiographic images taken in radiology department of ali ibn-eabi talib hospital, zahedan, iran form january 1st 2021 to july 1st 2021 were included. first, a radiology technician was asked not to delete any repetitive images for different reasons and to save them just the same. at the end of each week, repetitive images were referred to the researcher to analyze the frequency of repetitive radiographs and the causes. there was a form that the specialist should fill if they want to ask for a repeated imaging where they were provided with 6 options: i) inadequate radiation (too much or too little amount of radiation), ii) inappropriate positioning, iii) patient’s movements, iv) inadequate processing, v) inadequate preparation of the healthcare in low-resource settings 2023; volume 11:10575 correspondence: marzieh abiri, deparment of radiology, zahedan university of medical sciences, zahedan, iran e-mail: 30stana@gmail.com key words: repeated radiography; rejecting; x-ray images. conflict of interest: the authors declares no conflict of interest. ethics approval and consent to participate: the ethics committee of zahedan university of medical sciences approved this study (ir.zaums.rec.1399.314). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 25 april 2022. accepted for publication: 21 april 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10575 doi:10.4081/hls.2023.10575 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly patient, vi) other reasons. these filled forms were reviewed by a radiologist and in cases where the radiologist was not consistent with the specialist, the issue was discussed with a second radiologist who was experience in that specific field and the final decision was made by him/her. inadequate processing includes items such as lack of marking or false marking, false crop, the false record of names and other features of radiographic. other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable images, errors regarding the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. repeated images were also differentiated based on anatomic areas, including skull, spine, chest, abdomen, hips, and limbs, and the frequency of repetition was analyzed in each as well as their causes (table 1). it is necessary to mention that radiographs taken of knee, femur, ankle, and foot were all subgroups of lower limbs, while radiographs taken of the elbow, shoulder, wrist, hand, radius, ulna, and humerus were subgroups of upper limbs. statistical analysis after gathering information and importing form-related data into the statistical software spss ver. 26. statistical indexes regarding descriptive statistics such as frequency and percentage were first calculated. the results were then represented as charts and tables. results in this study, a total of 4916 radiographs were included. radiographs were categorized and assessed in 7 anatomic groups including chest, hips, abdomen, upper limbs, lower limbs, skull and spine. most of the radiographs among the data obtained were chest images (cxr), of which there were a number of 3060 (62.25%), secondly abdomen (718 images accounting for 14.61%), and thirdly lower limb (472 images accounting for 9.60%). the numbers and percentages of radiographs taken of each body area are represented in table 1. most frequent repetitions were seen in radiographs of the skull and upper limbs (respectively 8 images accounting for 13.33% and 30 images accounting for 10.34%) while the fewest repetitions occurred in abdominal radiographs (8 images accounting for 1.11%). the numbers and percentages of radiographs taken of different body areas are represented in table 1. reasons of repetition included inadequate radiation (too much or too little amount of radiation), inappropriate positioning, patient’s movements, inadequate processing, inadequate preparation of the patient, and other reasons. it is necessary to say inadequate processing includes items such as lack of marking or false marking, false crop, the false record of names and other features of radiographic, etc. other reasons consist of items such as dysfunction of radiology device, cassette size-related problems in portable images, errors regarding the type of radiography which was asked for, presence of artifacts, and other items leading to repetition. among 398 repetitive radiographs, 94 repetitions (23.62%) were due to inappropriate positioning, 92 repetitions (23.12%) were due to patient’s movements, 56 repetitions (14.07%) were due to inadequate radiation, 51 repetitions (12.81%) were due to inadequate processing, 46 repetitions (11.56%) were due to inadequate preparation of the patient, and 59 repetitions (14.82 %) were due to other reasons. the number and percentage of each radiographic repetition factor are represented in table 2. discussion repeated radiographic imaging made up 398 images (8.10%) of 4916 radiographic images totally taken in our study. this amount has been 16.85% in zewdu et al.’s study13 and 14.1% in owsue et al.’s study.15 meanwhile, yurt et al.’s reported a repeated frequency of 1.2%,14 which is lower compared to the current study. when evaluating the repeated images based on the anatomical area in our study along with other studies (table 3) showed that the repeat rate is higher than the other parts. pelvis (ranging from 4% to 31.1%) and spinal cord (ranging from 4.6% to 20%) radiographic images seem more likely to be repeated based on previous studies.12-22 meanwhile our study found the highest rate of repetition in skull radiographic images (13.3%), which was consistent with the previous studies in terms of frequency.13,19,21 this might indicate the need for more training specifically regarding these areas.21 in fintelmann’s12 study, in which only chest radiographs were assessed, repetitions accounted for 13.3% of the images, while in article table 1. the number and frequency of evaluated radiographs and the repeats. radiograph number (%) number of repeat (%) skull 60 (1.2) 8 (13.33) upper limb 290 (5.9) 30 (10.34) chest 3060 (62.5) 304 (9.93) lower limb 472 (9.6) 32 (6.78) spinal cord 328 (4.64) 14 (6.14) pelvis 88 (1.79) 2 (2.27) abdomen 718 (14.61) 8 (1.11) overall 4916 (100) 398 (8.1) table 2. different reasons of repeated radiography. characteristic the reason for repeated radiography overall positioning patient exposure inappropriate inappropriate image patient other error movement error processing preparation radiographs (4916) skull (60) 2(25) 2(25) 4(50) 0(0) 0(0) 0(0) 8 upper limb (290) 8(26.67) 6(20) 2(6.67) 0(0) 0(0) 6(20) 30 chest (3060) 74(24.34) 72(23.68) 34(11.18) 35(11.51) 40(13.16) 49(16.12) 304 lower limb (472) 4(12.5) 8(25) 10(31.25) 4(12.5) 2(6.25) 4(12.5) 32 spinal cord (228) 4(28.57) 2(14.29) 4(28.57) 2(14.29) 2(14.29) 0(0) 14 pelvis (88) 0(0) 0(0) 2(100) 0(0) 0(0) 0(0) 2 abdomen (718) 2(25) 2(25) 0(0) 2(25) 2(25) 0(0) 8 [page 8] [healthcare in low-resource settings 2023; 11:10575] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:10575] [page 9] our study repetitions accounted for 9.93%. this rate was different from 5.7% to 24% in the previous studies (table 4).12-22 it is essential to consider that in different hospitals, the number of repetitions in each anatomic area might be affected by existing specialties, the professionalism of the radiology department assistants.21 evaluating the causes of image repetition is a very crucial part of studying the imaging repetition. the most common cause of repetition in our study was inappropriate positioning which was in line with most of the previous studies.12,13,20,21 earlier studies which evaluated film-based radiography reported exposure errors as the most common error for leading to repetition.16,20 by reviewing similar papers (table 2), it can be seen that in most studies, the most prevalent reasons behind repetitive radiographs have been related to positioning or inappropriate radiation, which depend on the radiology staff, the hospital being educational, lack of experience for students or new staff, not using tables and radiation factor controllers, the large number of patients, lack of accuracy, inadequate knowledge and experience, application.20,22 these factors are mostly manageable and can be partially corrected by educating staff. in addition, some studies reflect a variation in the reasons for repeated radiographs in different regions of a city or different hospitals.16,20 in each region, reasons for repetitions in hospitals differed according to substructures, equipment, staff, the load of work, different departments, and specialties, and thus different percentages have occurred regarding various factors.16,20 conclusions in this study, the rate of repeated radiographs taken in a tertiary hospital was 8.10%, with the most common reason for repetitions being inappropriate positioning. considering the fact that repetitive radiography mostly depends on operator-related factors, it is recommended to repeat the study after educating staff in order to compare the rate and reason of repetition. references 1. hofmann b, rosanowsky tb, jensen c, wah khc. image rejects in general direct digital radiography. acta radiol 2015;4:1–6. 2. taylor n. the art of rejection: comparative analysis between computed radiography (cr) and digital radiography (dr) workstations in the accident & emergency and general radiology departments at a district general hospital using customized and standardized reject criteria over a three year period. radiography 2015;21:236–41. 3. atkinson s, neep m, starkey d. reject rate analysis in digital radiography: an australian emergency imaging department case study. j med radiat sci 2020;67:72-9. 4. jones ak, polman r, willis ce, shepard sj. one year’s results from a server-based system for performing reject analysis and exposure analysis in computed radiography. j digit imaging 2011;24:243–55. 5. lin cs, chan pc, huang kh, et al. guidelines for reducing image retakes of general digital radiography. adv mech eng 2016;8:1–6. 6. dunn ma, rogers at. x-ray film analysis as a quality indicator. radiography 1998;4:3. 7. whaley js, pressman bd, wilson jr, et al. investigation of the variability in the assessment of digital chest x-ray image quality. j digit imaging 2013;26:217– 26. 8. alashban y, shubayr n, alghamdi aa, et al. an assessment of image reject rates for digital radiography in saudi arabia: a cross-sectional study. j radiation res appl sci 2022;15:21923. 9. alyousef ka, alkahtani s, alessa r, alruweili h. radiograph reject analysis in a large tertiary care hospital in article table 3. the frequency of repeated radiographs in different studies. radiograph fintelmann zewdu yurt owusu-banahene haghparast mahmoodi jadidi asgharzadeh atkinson alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) skull n/a 13.9 3 n/a 11 n/a 13.7 7 14 4.5 upper limb n/a n/a 8 n/a 3.8 n/a 9.9 4 8 6.7 chest 13.3 13.7 24 12.5 6.7 n/a 14.6 5.7 7 8.9 lower limb n/a 15.57 15 12.5 3.7 n/a 11.1 4.3 11 3.8 spinal cord n/a 20 1 25% 9.3 n/a 17.1 4.6 17.6 10 pelvis n/a 31.11 9 9 n/a 4 7 23 20 abdomen n/a 13.2 8 n/a 7 n/a 19.4 2.6 12 13.9 overall n/a 16.85 1.2 14.1 6 8.7 7.98 4.9 9 9.5 table 4. the causes of repeated radiographs in different studies. reasons fintelmann zewdu yurt owusu-banahene haghparast mahmoodi jadidi asgharzadeh atkinson alashban (%) (%) (%) (%) (%) (%) (%) (%) (%) (%) positioning error 84.8 n/a 36.11 n/a 24.1 9.3 29.3 n/a 49 41.3 patient movement 4.6 n/a 16.67 n/a 1.5 14.1 n/a 5.6 5 14.5 exposure error n/a n/a 1.01 n/a 55.2 6 12.6 49 5 4.4 inappropriate 1.5 n/a 5.56 n/a 0.4 3.1 2 9.4 1 n/a image processing inappropriate n/a n/a 15.66 n/a n/a 5.3 n/a n/a n/a n/a patient preparation non -co mmerc ial us e o nly [page 10] [healthcare in low-resource settings 2023; 11:10575] riyadh, saudi arabia. global j qual safety healthc 2019;2:30-3. 10. nol j, isouard g, mirecki j. digital repeat analysis; setup and operation. j digit imaging 2006;19:159–66. 11. zhang m, chu c. optimization of the radiological protection of patients undergoing digital radiography. j digit imaging 2012;25:196-200. 12. fintelmann f, pulli b, abedi-tari f, et al. repeat rates in digital chest radiography and strategies for improvement. j thoracic imag 2012;27:148-51. 13. zewdu m, kadir e, berhane m. analysis and economic implication of x-ray film reject in diagnostic radiology department of jimma university specialized hospital, southwest ethiopia. ethiopian j health sci 2017; 27:421-6 14. yurt a. reject analysis in digital radiography: a prospective study. int j anat radiol surg 2018;7:4. 15. owusu-banahene j, darko eo, hasford f, et al. film reject analysis and image quality in diagnostic radiology department of a teaching hospital in ghana. j radiation res appl sci 2014; 7:589-94. 16. haghparast m, hosseini tashnizi s, golverdi yazdi m, et al. investigating the causes of repetition of radiographic images in radiology centers of bandar abbas teaching hospitals. med j hormozgan univ 2013;17:74-167 (in persian) 17. fallah mohammadi g, samiei z, mirshafiei f. digital radiography repeat rate and associated factors in referral hospitals, sari, iran 2017. j mazandaran univ med sci 2018;28:130-4. 18. gourabi h, sharafi a. evaluation of repeated or abandonment of radiolgraphy in diagnostic radiology. partou journal 2003;1:12-14. [persian] 19. jadidi m. quality assessment of the radiography films. razi j med sci 2002;9:317-326. [persian] 20. asgharzadeh aa, mohseni m. evaluation of repeated radiographic film and its causes in kashan hospitals in 2003. feyz journal 2005;33:50-56. [persian] 21. atkinson s, neep m, starkey d. reject rate analysis in digital radiography: an australian emergency imaging department case study. j med radiat sci 2020;67:72-9. 22. alashban y, shubayr n, alghamdi aa, et al. an assessment of image reject rates for digital radiography in saudi arabia: a cross-sectional study. j radiat res appl sci 2022;15:219-23. article non -co mmerc ial us e o nly hrev_master [page 40] [healthcare in low-resource settings 2015; 3:5278] the effect of skills training on attitudes, knowledge and clinical uptake of postplacental intra-uterine device use christine els,1 johannes l. van der merwe,1 justin harvey,2 petrus steyn1,3 1department of obstetrics and gynaecology, stellenbosch university and tygerberg hospital, tygerberg; 2centre for statistical consultation, stellenbosch university, tygerberg, south africa; 3department of reproductive health and research, world health organization, geneva, switzerland abstract the objective of the present study is to investigate the effect of skills training on knowledge and attitudes of post-placental intra-uterine device (ppiud) use, including the uptake thereof, and suggest training proposals. in-service skills training, alongside departmental protocol implementation, on ppiud insertions were offered to healthcare professionals at tygerberg hospital, south africa. training was based on the postpartum intrauterine device. a training course for service providers, participant handbook from engenderhealth (new york, ny, usa). participants completed a questionnaire at enrolment and after 6 months to assess their knowledge and attitude towards ppiud use. most participants reported having the necessary skills to fulfil their family planning responsibilities (p<0.01), defined by their own perceived ability, and also reported that they could apply what they learnt (p<0.01). most health care providers recommended iuds to post-partum women (p=0.03), especially those who desire no more children (p=0.05), resulting in more participants providing iuds (p=0.03) that could be attributed to the increased availability of reference material, i.e. training materials (p=0.02) and protocols (p=0.02). in conclusion, in-service ppiud skills training guided by local protocol implementation resulted in an improvement of self-reported competency, counselling and ppiud insertion. repeated training with adequate supervision is imperative. introduction the intra-uterine device (iud) is the second most prevalent contraceptive method worldwide (13.6% among women of reproductive age, married or in union), second only to sterilisation.1 effective post-partum contraception is an absolute necessity especially since many young women commence sexual activity by 6 weeks post-partum,2 thus making the optimal time available for initiating an effective, long acting contraceptive method limited. the safety and efficacy of post-partum iuds has been proven with large studies and well composed systematic reviews.3,4 immediate post-placental iud (ppiud) insertion (within 10 min after placental delivery) has the benefit of instant peace of mind against unplanned pregnancies while being safe5 with a low infection rate6 favorable side effect profile,5 no effect on breastfeeding7 and is also cost effective for the health care system.8 yet many health care workers are still misinformed9 and most women are not offered the option of having a ppiud inserted, even though many would have chosen the option. in a local survey tshivula and steyn reported that only 5.9% of pregnant women were counselled on iuds and only 1.3% of post-partum women were prescribed an iud.10 furthermore, a qualitative study in post-partum adolescents noted that a major barrier to iud uptake in service-level obstacles were the lack of provider training.11 the study aim was to investigate the effect of skills training on the knowledge and attitudes of health care providers, secondly to review the uptake of ppiud and propose a model for future training. materials and methods a prospective cohort intervention study was performed at tygerberg hospital, a regional referral and academic teaching center in the western cape province, south africa, providing care to roughly 1.2 million women. the study population consisted of the health care providers of the department of obstetrics and gynaecology involved with antenatal and peripartum care, as they are responsible for reviewing and counselling pregnant women on their future contraceptive need, specifically medical officers (general medical practitioners), registrars (postgraduate obstetric and gynaecology specialists in training), consultants (qualified obstetricians and gynaecologists), and advanced midwives. after enrolment, a self-administered, anonymous staff performance and attitude towards post-partum family planning questionnaire comprising of multiple-choice questions [based on engenderhealth’s (new york, ny, usa) the acquire project]12 was completed. this questionnaire served a dual function of evaluating their knowledge and attitude as well as assessing their needs for providing post-partum family planning. thereafter, they attended a half-day course on post-partum iud insertion and use based on engenderhealth the acquire project,13 which was used with their permission. they were given access to the handbook and a departmental protocol was introduced regarding ppiud insertion. participants had to insert the first five iuds under the supervision of two master trainers. after a six-month period the questionnaire was administered a second time. answers from the questionnaires were then entered into a tabulated database with summative scores. mothers attending the high-risk antenatal clinic received counselling on post-partum contraception and their choice was documented in their maternity case record. those requesting ppiud were re-counselled and reviewed for eligibility when they presented in labour. the copper t380a intrauterine device was used. primary outcomes were the health care providers’ self reported attitude and knowledge on post-partum iud use. secondary outcomes included: i) percentage of participants who provide clients with information about all family planning methods; ii) percentage of participants who provide clients with information about post-partum iud use; iii) percentage of participants who were able to healthcare in low-resource settings 2015; volume 3:5278 correspondence: johannes l. van der merwe, department of obstetrics and gynaecology, stellenbosch university and tygerberg hospital, 19081 tygerberg, south africa. tel: +27.219385173. e-mail: hvdm@sun.ac.za key words: post-placental iud; post-partum; skills training. acknowledgements: the authors would like to acknowledge engenderhealth (new york, ny, usa) for the course material used. contributions: ce and jlvdm conceived the study; all authors participated in the study design. data collection done by ce and jlvdm, and analysis was done by jh. all authors read, edited, and approved the final manuscript. conflict of interest: the authors declare no potential conflict of interest. received for publication: 21 may 2015. revision received: 26 july 2015. accepted for publication: 26 july 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c. els et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5278 doi:10.4081/hls.2015.5278 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5278] [page 41] provide post-partum iud use; and iv) number of iuds inserted post placental. statistical analyses were done comparing the combined first to the second questionnaire results using statistica version 11 from statsoft.com (statsoft, tulsa, ok, usa). data were expressed as medians (ranges), means (sd) or n (%) as appropriate. categorical data was analysed using the chi-square test. where an expected cell value was less than 5, the fischer exact test was used. continuous data was analyzed with student’s t test for parametric and the mann-whitney u test for nonparametric data. a p value of <0.05 was regarded as significant. the study was approved and registered by the human research and ethics committee of stellenbosch university (s11/11/031). a review of the literature was performed on training and attitudes of ppiud insertion of all original articles published before august 1, 2014, by incorporating the following terms in a medline/pubmed database search: intra-uterine device, iud, post-partum, post-placental and training. all articles (n=419), including their references, titles and abstracts were screened for relevance. this identified 111 articles, of which the full text was reviewed. this search strategy yielded a total of 4 original research articles on ppiud insertion training. results the study (from 17 february 2012 to 10 january 2013) enrolled fifty participants who completed the first questionnaire (q1) while 42 completed the second questionnaire (q2). participants consisted of consultants (n=15, 30%) and registrars (n=18, 36%), medical officers (n=7, 14%) and midwives (n=10, 20%). eight participants did not complete the second questionnaire (three did not participate in training, two changed employment, two were unavailable and one declined to complete the second questionnaire). there were no differences between the characteristics of the first and second questionnaires participants with regards to respective position (p=0.37), number of months in position (p=0.28) or in the number of months within the facility (p=0.12). table 1 depicts their expectations, knowledge and skills on family planning. most indicated that they understood their role in family planning (q1 86% and q2 83%; p=0.72) this was mainly due to the training they received (q1 50% and q2 45%; p=0.65). however only 28% received training specifically in family planning or reproductive health in the last 2 years. more participants indicated that they had access to reference material to assist them in their family planning responsibilities such as training materials (q1 14% and q2 29%; p=0.02) and protocols (q1 12% and q2 31%; p=0.02) in the second questionnaire. table 2 depicts the attitudes and practices towards post-partum family planning. the methods most discussed with clients include injectable contraceptives (q1 98% and q2 86%; p=0.04), the iud (q1 90% and q2 95%; p=0.35) and female sterilization (q1 88% and q2 78%; p=0.22) synchronously most provided injectable contraceptives (q1 66% and q2 66%; p=0.95) and female sterilization, (q1 58% and q2 64%; p=0.54) in the last three months. while more provided iuds to clients after training (q1 50% and q2 71%; p=0.03). for clients specifically wanting to space their next birth most recommended iuds (q1 90% and q2 92%, p=0.62), injectable (q1 62% and q2 61%; p=0.99) and oral contraceptives (q1 50% and q2 45%; p=0.65), whereas most recommended female sterilization (q1 100% and q2 100%; p=1.0), vasectomy (q1 88% and q2 88%; p=0.99) and iuds (q1 62% and q2 80%; p=0.05) to women who desire no more children. the methods recommend within the first 48 h post-partum were iuds (q1 76% and q2 article table 1. study participants’ job expectations, general knowledge and skills. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) providing family planning services, n (%) 45 (90) 40 (95) understood their roles/tasks in family planning, n (%) 43 (86) 35 (83) job expectations participants who had access to norms/procedures, flowcharts or protocols assisting them in family planning tasks, n (%) 18 (36) 21 (50) knowledge and skills participants who could apply what they learned in these courses, n (%) 6 (12) 18 (43) <0.01 participants who felt they had the skills necessary to fulfil their family planning responsibilities, n (%) 31 (62) 37 (88) <0.01 table 2. study participants’ attitudes and practices towards post-partum family planning. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) counselled/provided information to pregnant women on contraceptives in the last three months, n (%) 49 (98) 40 (95) methods agreed to be used post-partum (0-48 h), n (%) lam 27 (54) 22 (54) pill 9 (18) 15 (36) 0.05 injectable 33 (66) 29 (69) condom 28 (56) 18 (43) iud 38 (76) 38 (92) 0.04 female sterilization 36 (72) 31 (75) vasectomy 22 (44) 20 (48) participants who have heard about post-partum insertion of an intrauterine contraceptive device, n (%) 44 (88) 38 (93) participants who provide information and counselling on stis and hiv to post-partum women, n (%) 50 (100) 40 (97)° participants who would be willing to provide family planning services to an hiv positive client, n (%) 50 (100) 40 (97)° participants who would be willing to provide family planning services to a person living with aids, n (%) 50 (100) 40 (97)° lam, lactational amenorrhoea method; iud, intrauterine device; stis, sexually transmitted infections; hiv, human immunodeficiency virus; aids, acquired immunodeficiency syndrome. °one participant did not provide clinical care to post-partum women. non co mmerc ial us e o nly [page 42] [healthcare in low-resource settings 2015; 3:5278] 92%; p=0.03), female sterilization (q1 72% and q2 75%; p=0.69) and injectable contraceptives (q1 66% and q2 69%; p=0.76). most indicated that all methods of family planning could be used while breastfeeding with injectable contraceptives (q1 86% and q2 90%; p=0.54), iuds (q1 82% and q2 87%; p=0.45) and condoms (q1 72% and q2 82%; p=0.21) most frequently endorsed. most would never recommend lactational amenorrhoea method (lam) to anyone (q1 66% and q2 66%; p=0.95). table 3 depicts their specific knowledge on ppiud insertion and use. most specified that iud insertion is associated with side effects and minor complications, specifically cramping (q1 78% and q2 83%; p=0.52) and bleeding (q1 80% and q2 88%; p=0.29), but after training more indicated that intermenstrual spotting can be expected (q1 50% and q2 71%; p=0.04) and fewer noted that iud insertion is associated with infections (q1 70% and q2 50%; p=0.05). moreover, most indicated that clients should return to the clinic if they experienced increased bleeding (q1 74% and q2 76%; p=0.81) and signs of infection (q1 88% and q2 83%; p=0.52). whilst most indicated that clients should return within three to six weeks after the insertion (q1 76% and q2 85%; p=0.24), some uncertainty remained as nearly 20% indicated that they should return only after the first normal period (q1 20% and q2 16%; p=0.68). the questionnaire’s final section enquired about the participants perceptions concerning environmental and equipment needs for postpartum iud insertion. most felt that although there were sufficient space (q1 76% and q2 76%; p=0.96) and clean/aseptic work place (q1 58% and q2 71%; p=0.18), there was a lack of privacy (q1 65% and q2 75%; p=0.29). the majority indicated that they had the equipment and instruments, including supplies, for postpartum iud insertion (q1 66% and q2 78%; p=0.18) however nearly half of the participants did not to have enough time to offer a practical and manageable post-partum iud service (q1 56% and q2 45%; p=0.30). during the year preceding the study 15 ppiuds were inserted, while in the 6 months of the study intervention 67 ppiuds were inserted. there were 7576 deliveries during 2012 at this facility. discussion across the world the use of long acting reversible contraceptive methods, especially ppiuds, is being promoted in the puerperium. this study highlighted the importance of inservice training with significant more participants reporting that they had the necessary skills to fulfil their family planning responsibilities (p<0.01) and could apply what they learnt (p<0.01). furthermore, more recommended iuds to post-partum women (p=0.03), especially those who desire no more children (p=0.05). this resulted in more participants providing iuds overall (p=0.03). the effect could be attributed to the increased availability of reference material to assist them in their family planning responsibilities such as training materials (p=0.02) and protocols (p=0.02). although few participants (28%) had any recent training in family planning prior to the study, most had good basic knowledge about ppiud use. expectedly their knowledge improved especially in terms of timing of placement [within 10 minutes after placental expulsion (p<0.01)], side effects (as bleeding/menstrual irregularities are common) and infections rates (a rare event with ppiud), potentially leading to better counselling skills. encouraging breast-feeding could be a valuable addition in counselling, as breast-feeding patients experience fewer side effects.14 thiery and colleagues noted a significant difference between skilled and unskilled ppiud inserters especially in terms of expulsion-, pregnancyand removal rates.15 in the index study less than 5% had inserted more than 10 in their career, and almost half had never inserted any ppiud. banharnsupawat and rosenfield16 reported that expulsion rates decreased as medical staff gained experience, underlining the importance of continuous training and review. additionally the importance of correct ppiud insertion technique cannot be overemphasized, as proper technique is another important factor in reducing expulsion rates. the insertion technique which employs a ring forceps was advocated in this study due to reported higher expulsion article table 3. study participants’ specific knowledge on post-placental intrauterine device use. questionnaire 1 questionnaire 2 p value (tot=50) (tot=42) the specific times that iuds can be inserted, n (%) any time that the client is not pregnant 42 (84) 34 (82) any time during the menstrual cycle 24 (48) 24 (58) immediate post-placental (<10 min) 36 (72) 39 (95) <0.01 within 48 hours of delivery 24 (48) 11 (26) 0.04 after six week post-partum 44 (88) 36 (87) immediately after abortion or miscarriage 30 (60) 30 (73) the longest time delay participants would allow before 10 seconds 2 (4) 0 (0) inserting a post-partum iud, n (%) 10 minutes 17 (34) 27 (65) <0.01 12 hours 8 (16) 2 (4) 24 hours 16 (32) 10 (24) the iuds can fall out, n (%) 45 (90) 40 (97) the chance of falling pregnant with an iud is, n (%) no chance 2 (4) 0 (0) very high 1 (2) 0 (0) the same as sterilization 46 (92) 40 (97) the same as using a condom 1 (2) 0 (0) the iud does offer protection against stis and hiv infection, n (%) 0 (0) 3 (7) 0.08 the participants that would insert an iud in an hiv positive client, n (%) 39 (78) 38 (92.6) 0.05 the number of iud devices participants inserted, n (%) 0 24 (48) 17 (41) 1-10 21 (42) 21 (51) 11-25 1 (2) 2 (4) >25 2 (4) 0 (0) would recommend an iud to their wife, sister, daughter or even use it themselves 48 (96) 41 (100) iud, intrauterine device; stis, sexually transmitted infections; hiv, human immunodeficiency virus. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5278] [page 43] rates with hand insertion17 although this finding was not validated in systematic reviews.3 irrespective of the technique used, emphasis should be put on high fundal placement. ppiud insertions can be performed safely and effectively within a training program, but the safety profile, complication and side effect rates are dependant on the level of training and supervision.18 intensive training (over a nine day period) with supervised insertions19 or repeated training (6 weekly) aided by ultrasound-guided insertions18 resulted in a more effective service. the incorporation of ultrasound assessment post insertion could also be a valuable tool to further improve clinical care but this would come at the cost of additional equipment, training and time per insertion. accumulative expulsion and missing strings rate of 10 and 11% respectively were seen in larger programs.20 the fact that only theoretical training and protocol implementation with supervision but no model training was done could be criticised as model training was beneficial in the training program of prager and colleagues.19 the participants in the index study consisted mostly of doctors and this raises the question whether the emphasis should have been placed on training midwives, as they are better positioned for a ppiud service. this high doctor ratio possibly contributed to the majority of ppiuds being cited during caesarean deliveries. insertions during caesarean sections are well recognized to have lower expulsion rates3 (than after vaginal deliveries) and were not as dependent on provider experience.14 however, discontinuation rates after caesarean ppiud can be as high as 40% at 1 year follow up and the frequent side effect of missing strings have been well documented.5,21 furthermore the low vaginal insertion rate can be explained by the lack of having a master trainer available at all times in the labour ward (as the master trainers also had other responsibilities), and it is easier to arrange supervision during a planned or urgent caesarean delivery than within the 10 min after a vaginal delivery. this possibly discouraged participants to prepare for vaginal insertion. the lack of time available for setup and counselling during routine vaginal deliveries could also have played a role as nearly half of the participants felt that they did not have the time to offer a post placental iucd service (q1 56% and q2 45%; p=0.30). training more master trainers, utilising a family planning counsellor as well as having vaginal delivery packs that include the necessary equipment specifically for ppiud could make the program more efficient. ppiud integration into an existing family planning program have also been reported from the african continent,22 yet the a lack of knowledge, low iud prevalence and cultural factors such as husband disapproval still lead to low overall ppiud uptake as this could further explain the low vaginal insertion rate seen in the index study.23 a largely neglected strategy to avert motherto-child hiv transmission is pregnancy prevention by voluntary use of contraception in hivpositive women. most women irrespective of their hiv status still had poor knowledge of long acting methods and 60% still reported that their last pregnancy was unplanned.24 in the index study there was a significant increase in the number of participants that would insert an iud in an hiv positive patient (p=0.05). evidence regarding the safety of intrauterine contraceptive use among women with hiv remains limited, but is generally reassuring regarding adverse health effects, disease transmission to uninfected partners, and disease progression.25 the study method utilised in the index study could be a unique approach to improve postpartum contraceptive awareness and clinical uptake. furthermore the high participant completion rate (84%) is an indication that most health care providers saw this an area of need and essential training. a major limitation was the subjective nature of this study, without an objective assessment of the health care workers to validate their responses. also this study did not reflect on the clinical outcomes of the ppiud insertions, highlighting the need for further research to investigate the clinical significance of self reported ppiud skills (a study in progress). a previous systematic review noted that the clinical benefit of small studies like this might be short lived and that bigger high-quality studies with supply-side approaches (vs demand side) using integrated programs have long-term impacts.26 conclusions this study was done in answer to the shortcoming of in-service training of permanent staff, as well as the lack of long-term post-partum contraceptive choices. it demonstrated that healthcare workers could have a better self-reported understanding and skill acquisition with in-service training and supervision, in this case specifically in ppiud. the challenge will be to facilitate a continuous training platform on post-partum family planning with focus on all health care staff (especially midwives) utilising model insertions. the incorporation of family planning counsellors and ppiud ready delivery packs could further enable the service. references 1. d’arcangues c. worldwide use of intrauterine devices for contraception. contraception 2007;75:s2-7. 2. lewis ln, doherty da, hickey m, skinner sr. implanon as a contraceptive choice for teenage mothers: a comparison of contraceptive choices, acceptability and repeat pregnancy. contraception 2010;81:421-6. 3. grimes da, lopez lm, schulz kf, et al. immediate post-partum insertion of intrauterine devices. cochrane db syst rev 2010;5:cd003036. 4. kapp n, curtis km. intrauterine device insertion during the postpartum period: a systematic review. contraception 2009;80: 327-36. 5. kittur s, kabadi ym. enhancing contraceptive usage by post-placental intrauterine contraceptive devices (ppiucd) insertion with evaluation of safety, efficacy, and expulsion. int j reprod contracept obstet gynecol 2012;1:26-32. 6. welkovic s, costa lo, faundes a, et al. post-partum bleeding and infection after post-placental iud insertion. contraception 2001;63:155-8. 7. goldstuck nd, steyn ps. intrauterine contraception after cesarean section and during lactation: a systematic review. int j womens health 2013;5:811-8. 8. rodriguez mi, evans m, espey e. advocating for immediate postpartum larc: increasing access, improving outcomes, and decreasing cost. contraception 2014;90:468-71. 9. madden t, allsworth je, hladky kj, et al. intrauterine contraception in saint louis: a survey of obstetrician and gynecologists' knowledge and attitudes. contraception 2010;81:112-6. 10. tshivula f, steyn ps. the knowledge and attitudes of antenatal patients towards intra-uterine contraceptive devices. specialist forum 2007;6:10-8. 11. weston mr, martin sl, neustadt ab, gilliam ml. factors influencing uptake of intrauterine devices among postpartum adolescents: a qualitative study. am j obstet gynecol 2012;206:e1-7. 12. the acquire project. improving the use of long-term and permanent methods of contraception in guinea: a performance needs assessment. new york, ny: the acquire project/engenderhealth; 2005. 13. the acquire project. the postpartum intrauterine device: a training course for service providers. trainer’s manual. new york, ny: engenderhealth; 2008. 14. chi ic. postpartum iud insertion: timing, route, lactation, and uterine perforation. article non co mmerc ial us e o nly [page 44] [healthcare in low-resource settings 2015; 3:5278] in: bardin cw, mishell dr jr, eds. proceedings from the fourth international conference on iuds, boston, ma, usa. london: butterworth-heinemann;1994. pp 219-27. 15. thiery m, van kets h, van der pas h. immediate postplacental iud insertion: the expulsion problem. contraception 1985;31:331-49. 16. banharnsupawat l, rosenfield ag. immediate postpartum iud insertion. obstet gynecol 1971;38:276-85. 17. apelo ra, waszak cs. postpartum iud insertions in manila, philippines. adv contracept 1985;1:319-28. 18. jatlaoui tc, marcus m, jamieson dj, et al. postplacental intrauterine device insertion at a teaching hospital. contraception 2014;89:528-33. 19. prager s, gupta p, chilambwe j, et al. feasibility of training zambian nurse-midwives to perform postplacental and postpartum insertions of intrauterine devices. int j gynecol obstet 2012;117:243-7. 20. shukla m, qureshi s, chandrawati. postplacental intrauterine device insertion: a five year experience at a tertiary care centre in north india. indian j med res 2012;136:432-5. 21. eroğlu k, akkuzu g, vural g, et al. comparison of efficacy and complications of iud insertion in immediate postplacental/early postpartum period with interval period: 1 year follow-up. contraception 2006;74:376-81. 22. morrison c, waszak c, katz k, et al. clinical outcomes of two early postpartum iud insertion programs in africa. contraception 1996;53:17-21. 23. bryant ag, kamanga g, stuart gs, et al. immediate postpartum versus 6-week postpartum intrauterine device insertion a feasibility study of a randomized controlled trial. afr j reprod health 2013; 17:72-9. 24. credé s, hoke t, constant d, et al. factors impacting knowledge and use of long acting and permanent contraceptive methods by postpartum hiv positive and negative women in cape town, south africa: a cross-sectional study. bmc public health 2012;12:197. 25. curtis km, nanda k, kapp n. safety of hormonal and intrauterine methods of contraception for women with hiv/aids: a systematic review. aids 2009;23:s55-67. 26. mwaikambo l, speizer is, schurmann a, et al. what works in family planning interventions: a systematic review. stud fam plann 2011;42:67-82. article non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11193 knowledge and peer support for increase menstrual hygiene management (mhm) in adolescents ni ketut alit armini,1 arik setyani,2 aria aulia nastiti,1 mira triharini3 1basic nursing department, faculty of nursing, universitas airlangga, surabaya, indonesia; 2nursing profession, faculty of nursing, universitas airlangga, surabaya, indonesia; 3advance nursing department, faculty of nursing, universitas airlangga, surabaya, indonesia abstract introduction: during the transitional period of reproductive function development, adolescents require special attention, one of which is menstrual hygiene management (mhm). teenagers dealing with menstruation have little information and understanding due to the taboo assumption of being more comfortable communicating with peers. therefore, this study aims to explain the relationship between knowledge and peer support with mhm in adolescent girls. design and methods: this study adopted a correlational descriptive design with a cross-sectional approach and 122 students in a public junior high school in east java were selected using proportional simple random sampling. furthermore, the questionnaire was adopted as the study instrument to measure the variables of knowledge level, peer support, and mhm. data were then analyzed using spearman rho test with a significance level of p<0.005. results: the results showed that there is a significant relationship between the level of knowledge (p = 0.000 r = 0.619 and peer support (p = 0.000 r = 0.534) with mhm in adolescent girls. conclusions: adolescent girls with adequate knowledge and peer support have better mhm. therefore, information and education about mhm are recommended for adolescents. introduction menstruation is the process of shedding the uterine lining and bleeding that occurs every month. considering the insufficient knowledge of teenagers, special attention is required for the maintenance of genital organ cleanliness during this period.1 the practice of proper menstrual hygiene management (mhm) plays a vital role in determining health status, specifically to avoid reproductive tract infections (rti).2 furthermore, adolescent reproductive organs reach the stage of maturity and are commonly referred to as puberty and according to a 2017 ministry of health report, many girls in indonesia do not have the proper understanding that menstruation is a normal biological process.3 girls are new to menstruation at menarche and they often have difficulty buying or getting sanitary napkins when needed, causing minimal mhm in indonesia.4 mhm is most likely influenced by the level of knowledge about reproductive health,5 and adolescents mainly prefer to tell stories and share information with their peers rather than their parents. this is because peers can provide sources of information and comparisons about things outside the family, hence, teenagers are more comfortable communicating with their friends.6 moreover, teenagers feel comfortable talking about menstrual hygiene with their age group, hence, they can explore questions more and discuss it without embarrassment.7 a study conducted in ethiopia from july 2015 to june 2016 found a total of 1,421 cases of sexually transmitted infections (stis) with sti symptoms, mainly vaginal discharge (52.2%), followed by urethral (25.3%), and lower abdominal pain, below (13.3%), and genital ulcers (7.4%), and a total of 968 cases (68.1%) were women.8 according to the data from national development planning agency (bkkbn), over 63 million adolescents in indonesia are at risk of not maintaining the cleanliness of their reproductive organs during menstruation.9 furthermore, based on the indonesian health demographic survey (idhs) in 2017, the behaviour of adolescent girls in maintaining hygiene during menstruation is still poor (63.9%), due to a lack of knowledge and information about mhm. the rural youth have low, inaccurate, or incomplete knowledge about menstruation and the women do not have access to sanitary products, lack knowledge about their types and methods of use or are too expensive. they mostly rely on reusable cloth sanitary napkins, which they wash and reuse, specifically among adolescents in rural areas and public schools.10 according to the indonesian demographic and health survey (idhs) in 2018, the sources of information for adolescents concerning menstruation were peers (38%), mothers (29%), fathers (1%), siblings (9%), teachers (10%), and 14% understand independently. proper mhm actions significantly affect the cleanliness and health of women’s organs during menstruation.11 the benefits of mhm are to avoid vaginal infections, keep the area around the vulva clean, and provide a sense of comfort in the genital area. germs can easily penetrate the genital and causes disease in the reproductive tracts and symptoms, hence, the cleanliness of these area needs to be maintained.12 therefore, this study aims to explain the relationship between knowledge and peer support with mhm in adolescents. significance for public health adolescents experience physical and psychological changes including menstruation, which is a sign of the maturity of the female reproductive organs and often considered a dangerous disease. furthermore, menstrual hygiene management (mhm) practices play an important role in avoiding reproductive tract infections (isr), which have a significant effect on health status. therefore, it is important to analyze the relationship between the level of knowledge and peer support with mhm in adolescents. article [page 88] [healthcare in low-resource settings 2023; 11(s1):11193] non -co mmerc ial us e o nly design and methods this study uses a descriptive correlational design with a crosssectional approach and data were collected from march to april 2021 at a junior high school in east java. the sample size of 122 adolescents was selected using proportional simple random sampling and its criteria include the age of 11-14 years, menarche, and no reproductive organ disease. the dependent and independent variables mhm and the knowledge and peer support, respectively. the instruments used included a demographic questionnaire, level of knowledge, peer support, and mhm. furthermore, the demographic questionnaire includes information such as age, menarche, length of menstruation, menstrual cycle, and menstrual complaints. the 15 multiple choice questions in the knowledge level questionnaire include the definition and purpose of menstrual hygiene, how to clean the vulva, use of underwear, correct sanitary napkins, and the impact of the use of poor mhm. each question has a choice of answers a, b, and c, a score of 1 denote “accurate” and 0 for “wrong”, with categories such as poor 55%, moderate 5675%, and good 76-100%. the peer support questionnaire consists of 12 questions structured on a 4-point likert scale as 1 for “never”, 2 for “rarely”, 3 for “often”, and 4 for “always”. each question has a rating of 1-4, hence, the total score ranges from 1248 with a low and high category of 65% and >65%, respectively. furthermore, mhm was measured using the menstrual practices questionnaire (mpq), which includes 19 questions on a likert scale. it includes using menstrual materials, changing sanitary napkins, hand and genitalia washing, storage and disposal of sanitary napkins, washing and drying of underwear, and toilet practices during menstruation. each question has a rating of 1-4, hence the total score ranges from 19-76 and the results were categorized as poor 55%, moderate 56-75%, good 76-100%. the validity test of 3 variable instruments on 15 female students as a whole was declared valid because the r count was in the range of 0.527-0.880 for the physical activity variable; 0.550-0.917 for the anxiety variable; and 0.552-0.877 for the premenstrual syndrome variable, so that the 3 instrument variables have r arithmetic greater than r table 0.514. the results of the reliability test showed that the alpha cronbach value of the physical activity instrument was 0.875; the anxiety of 0.944; and the premenstrual syndrome of 0.863. obtained r alpha > r table (r table = 0.514), then the instrument is declared reliable both the descriptive and inferential statistics were adopted for data analysis and the relationship between variables was tested using the spearman rho with a significance level of p<0.05. results and discussions based on demographic data in table 1, there were 122 female students with the majority (55) aged 13 years old with a percentage of 45.1%. the majority of respondents (43) had their menarche at the age of 12 years accounting for 35.2%. the length of menstruation for the majority of respondents (43) is 6-7 days accounting for 35.6% and the most menstrual cycles were 28 days (44.7%). furthermore, 77 female adolescents accounting for 63.1% did not experience any complaints during menstruation. the spearman rho correlation test results (table 2) showed the variable level of knowledge is p = 0.000 r = 0.62. this indicated that there is a significant relationship between the level of knowl article [healthcare in low-resource settings 2023; 11(s1):11193] [page 89] table 2. knowledge level, peer support, and menstrual hygiene management (mhm). variable category menstrual hygiene management (mhm)totalspearmen rho poor moderate good n % n % n % n % p r knowledge level poor 39 60 15 23.1 11 16.9 65 53.3 0.000 062 moderate 5 14.3 7 20.0 23 65.7 35 28.7 good 0 0 3 13.6 19 86.4 22 18 peer support low 39 50.6 21 27.3 17 22.1 77 63.1 0.000 0.53 high 5 11.1 4 8.9 36 80.0 45 36.9 table 1. characteristics of respondents. no characteristics indicator n % mean sd 1. age (years) 11 1 0.8 13.15 0746 12 23 18.9 13 55 45.1 14 43 35.2 2. age of menarche (years) 9 7 5.7 11.4 1.149 10 22 18 11 28 23 12 43 35.2 13 22 18 3. menstruation length (days) 4-5 19 15.6 5.6-6.44 1.013 5-6 30 24.6 6-7 43 35.2 >7 30 24.6 4 menstrual cycle 14 days 13 10.6 26 0.932 21 days 19 15.4 28 days 55 44.7 >30 days 35 28.5 5 complaints during menstruation yes 45 36.9 0.489 no 77 63.1 non -co mmerc ial us e o nly edge and mhm. it further implies that a better level of knowledge in adolescents results in a proper mhm. the result also showed a significant relationship (p=0.000 r=0.53) between peer support mhm. this indicates that higher peer support results in proper mhm. based on the results, only 43.3% of adolescents had good mhm, moderate (20.5%), and many were rated as poor (36.1%). mhm includes the use of clean, sanitary napkins to absorb or collect blood during the menstrual period, soap and water to wash genitals, and access to facilities for disposing of menstrual waste.13 these practices are influenced by individuals’ water, sanitation, and hygiene facilities.14 mhm is also influenced by the level of knowledge about reproductive health.5 this is because a lack of knowledge about menstrual hygiene will result in worse mhm. in addition, inadequate mhm practices lead to various reproductive health problems for adolescents, such as itching, vaginal discharge, reproductive tract infections, and cervical cancer.15 this is consistent with the previous report which shows a significant relationship between the level of knowledge and menstrual hygiene behaviour with a p-value of 0.000.16 adolescent characteristics such as age, menarche, length of menstruation, menstrual cycle, and complaints during menstruation affect the practice of mhm.17 furthermore, as a person’s age increases, the knowledge and way of thinking will improve, specifically about mhm. human beings’ capacity differs, some have a lesser level of ability, hence, they experience difficulty in learning. the age of menarche in each teenager is also different, some are quick, while others are slow.18 adolescents who experience menarche in their early teens tend to have less knowledge about menstruation, leading to a lack of awareness about the importance of mhm practice. meanwhile, those who experience menarche at an older age and have received knowledge and information about menstrual hygiene have better mhm practices.19 the length of menstruation, menstrual cycles, and complaints during menstruation significantly affect the practice of mhm in adolescents. when the length of menstruation and the menstrual cycle is regular, it does not interfere with mhm practice and menstrual complaints. similarly, mhm practices are not affected when there are no complaints.20 the practice mhm is influenced by factors such as the level of knowledge, peer support, parental support, information exposure, use of mass media, and the completeness of existing infrastructure suggestions.19 based on the results of this study, the majority of respondents have low knowledge about menstrual hygiene, low peer support, and good mhm practice. there is a strong and positive relationship between the level of knowledge with mhm in adolescent girls. this result indicates that the higher level of knowledge possessed by adolescents results in proper mhm. adolescents mostly have a low level of knowledge about menstrual hygiene accounting for 53.3% of the total respondents. however, some have a sufficient and good level of knowledge with a percentage of 28.7% and 18%, respectively. a person’s knowledge is influenced by extrinsic and intrinsic factors. the intrinsic factors include age, age of menarche, ability and will or willingness, and the extrinsic include education and information obtained from other parties such as mothers, peers, and relatives.21 furthermore, adolescent knowledge about reproductive organ hygiene is an essential domain in determining the individual’s hygiene behaviour. suppose the level of knowledge about reproductive organ hygiene was high, then there will be a better level of behaviour. the lack of knowledge of adolescents related to menstrual hygiene is consistent with the previous report that most respondents have poor knowledge about menstrual hygiene, and only 23 accounts for 46% have good knowledge.22,23 furthermore, the theory of self-determination states that a major aspect of a person’s basic needs is influenced by knowledge and competence to behave well.24 there is a moderate and positive relationship between peer support and mhm in adolescents. this indicated that the higher peer support obtained by adolescent girls, the better mhm in adolescents and otherwise. based on the results, the reward support has the highest value. respondents have good appreciation from their peers because they are always willing to listen to all menstrual-related complaints. they also reported that their peers support healthy lifestyle behaviour while menstruating. this condition is consistent with the study which shows that adolescent girls receive appreciation in the form of praise while carrying out proper menstrual hygiene practices and good information support from peers concerning mhm.25 in addition, adolescent girls assume that they can freely talk to their friends of the same age group about all problems related to reproduction without feeling awkward in expressing their experiences, including hygiene in their reproductive organs.26 it is important to note that messages by close friends do not necessarily have the ultimate truth. however, students do not want to clarify and invite discussions from both parents at home or teachers at school.27 based on the responses of the respondent that their peers rarely care about their menstrual hygiene, it can be concluded that the lowest type of peer support is emotional. peers rarely motivate to clean genitals during menstruation. this is also consistent with the previous results which shows that the support and responses from friends of teenage girls related to menstrual hygiene were still lacking.28 it may be attributed to the introverted and shy nature of women experiencing growth while talking about menstruation. meanwhile, social support is better both psychologically and materially and it comes from family, friends, or the religious community.29 the data from peer support questionnaire is categorized into two, namely high and low. the data showed that most adolescents have low peer support (63.1%), while some already have high (36.9%). low support concerning menstrual hygiene in adolescents results in poor mhm. adolescents spend more time telling stories and sharing experiences with peers to provide adequate information and support. furthermore, there is a relationship between peer support and menstrual hygiene practices in adolescent girls.29 this is contrary to the study which states that there is no relationship between peer support and menstrual hygiene.30 the theory of self-determination suggests that some aspects of basic human needs are influenced by relatedness including personal social relations in interacting with other individuals in a community, one of which is peers. adolescents who receive reproductive health information from sources other than their parents are also influenced by their peers because they spend more time with their friends. this study was conducted online with a form such that the respondents were not accompanied directly due to the pandemic situation of online data collection. researchers have emphasized respondents fill out the questionnaire honestly. in addition, the mhm instrument did not thoroughly measure the activity of adolescents during menstruation because it is subjective from the answers submitted by respondents. measurement of mhm in future studies needs to be done during the adolescent menstrual cycle. conclusions conclusively, there are only a few adolescents that practice mhm in the “excellent” category, while a large number falls in “good and less”. furthermore, adolescents who have a good level of knowledge and high peer support have better mhm. future article [page 90] [healthcare in low-resource settings 2023; 11(s1):11193] non -co mmerc ial us e o nly studies are expected to analyze adolescent girls’ psychosocial and cultural aspects with mhm. references 1. phillips howard pa, caruso b, torondel b, et al. menstrual hygiene management among adolescent schoolgirls in lowand middle-income countries: research priorities. glob health action 2016;9:1–8. 2. kambala c, chinangwa a, chipeta e, et al. acceptability of menstrual products interventions for menstrual hygiene management among women and girls in malawi. reprod health 2020;17:1–13. 3. lutfiya i. analisis kesiapan siswi sekolah dasar dalam menghadapi menarche. [analysis of readiness of elementary school students in facing menarche] j biometrika dan kependud 2017;5:135. 4. kemenkes ri. manajemen kebersihan menstruasi perlu dipahami. [management of menstrual hygiene needs to be understood]. internet. 2017 [cited 2020 dec 22]. available from: kemkes.go.id/article/view/17052700001/manajemenkebersihan-menstruasi-perlu-dipahami-.html 5. mishra sk, dasgupta d, ray s. a study on the relationship of sociocultural characteristics, menstrual hygiene practices and gynaecological problems among adolescent girls in eastern india. int j adolesc med health 2016;29:/j/ijamh.2017. 29.issue-5/ijamh-2015-0111/ijamh-2015-0111.xml. 6. akasyah w, margono hm, effendi f. peran dukungan sosial teman sebaya terhadap ketahanan psikologis remaja yang mengalami konflik. [the role of peer social support on the psychological resilience of adolescents experiencing conflict.] encephale 2020;53:59–65. 7. lestari dp, armini nka, mariyanti h, et al. the correlation between knowledge and menstrual hygiene practices in children with early menarche. int j psychosoc rehabil 2020;24:4172–80. 8. mandal r, sarkar a, ghorai s. a study on premenstrual syndrome among adolescent girl students in an urban area of west bengal. int j reprod contraceptio obstet gynecol 2015;4:1012–5. 9. bkkbn. survey kesehatan reproduksi remaja indonesia. [indonesian adolescent reproductive health survey.] jakarta: ministry of health; 2016. 10. kaur r, kaur k, kaur r. menstrual hygiene, management, and waste disposal: practices and challenges faced by girls/women of developing countries. j environ public health 2018;2018. 11. agiwahyuanto f. gambaran tingkat pengetahuan praktik vulva hygiene saat menstruasi pada siswa kelas viii smp negeri 25 semarang tahun pelajaran 2017-2018. [description of the knowledge level of vulva hygiene practices during menstruation in class viii students of smp negeri 25 semarang academic year 2017-2018.] j visikes 2018;17:127– 35. 12. davis j, macintyre a, odagiri m, et al. menstrual hygiene management and school absenteeism among adolescent students in indonesia: evidence from a cross-sectional schoolbased survey. trop med int heal 2018;23:1350–63. 13. ademas a, adane m, sisay t, et al. does menstrual hygiene management and water, sanitation, and hygiene predict reproductive tract infections among reproductive women in urban areas in ethiopia? plos one 2020;15:1–15. 14. torondel b, sinha s, mohanty jr, et al. association between unhygienic menstrual management practices and prevalence of lower reproductive tract infections: a hospital-based cross-sectional study in odisha, india. bmc infect dis 2018;18:1–13. 15. sychareun v, chaleunvong k, essink dr, et al. menstruation practice among school and out-of-school adolescent girls, lao pdr. glob health action 2020;13:1785170. 16. maidartati m, hayati s. hubungan pengetahuan dengan perilaku vulva hygiene pada saat menstruasi remaja putri. [relationship between knowledge and vulva hygiene behavior during menstruation for young women.] jurnal article [healthcare in low-resource settings 2023; 11(s1):11193] [page 91] correspondence: ni ketut alit armini, faculty of nursing, universitas airlangga, jl. ir soekarno, surabaya, east java 60115, indonesia. tel.:+62315913754, fax +62315913257, e-mail: nk.alita@fkp.unair.ac.id key words: reproductive health; adolescent; menstrual hygiene. acknowledgment: the authors are grateful to the faculty of nursing, universitas airlangga, for supporting the study and publication. the authors are also grateful to the adolescent girls who were willing to become respondents, the parents who allowed their daughters’ participation, and the teachers who assisted in conducting the study. contribution: the authors contributed equally to this study. nka prepares the study design, interpreted data, provides manuscripts. as collected and analyzed data. aan and mt interpreted data and review manuscripts. conflict of interests: the authors declare no conflict of interests. funding: this study was financially supported by airlangga university. clinical trials: this study has been reviewed and approved by the health research ethics commission, faculty of nursing, airlangga university with record no. 2184-kekp. conference presentation: a part of this study was presented at the 2nd international nursing and health sciences symposium, 2021 october 28-30 at brawijaya university, east java, indonesia. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11193 doi:10.4081/hls.2023.11193 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly keperawatan bsi 2016;4(1). 17. sinaga e. manejemen kesehatan menstruasi. [menstrual health management.] jakarta: iwwash; 2017. 18. andani pr. correlation between knowledge and attitude toward personal menstrual hygiene practice among adolescents. jph recode 2021;4:88-98. 19. dolang mw, rahma, ikhsan m. faktor yang berhubungan dengan praktik hygiene menstruasi pada siswi sma negeri 1 sesean kabupaten toraja utara factors related to menstrual hygiene practices of sma negeri 1 sesean students , north toraja regency. [factors related to menstrual hygiene practices of sesean 1 public high school students, north toraja regency factors related to menstrual hygiene practices of sesean 1 public high school students, north toraja regency.] j mkmi. 2017;36–44. 20. das p, baker kk, dutta a, et al. menstrual hygiene practices, wash access and the risk of urogenital infection in women from odisha, india. plos one 2015;10:1–16. 21. hubaedah a. hubungan pengetahuan dan perilaku vulva hygiene saat menstruasi dengan kejadian pruritus vulvae pada remaja putri kelas vii di smp negeri 1 sepulu bangkalan. [relationship between knowledge and behavior of vulva hygiene during menstruation with pruritus vulvae incidence in class vii young girls at smp negeri 1 sepulu bangkalan.] embrio 2019;11:30–40. 22. gultie t, hailu d, workineh y. age of menarche and knowledge about menstrual hygiene management among adolescent school girls in amhara province, ethiopia: implication to health care workers & school teachers. plos one 2016;9:1– 10. 23. ilmiawati h, kuntoro k. pengetahuan personal hygiene remaja putri pada kasus keputihan. [personal hygiene knowledge of young women in cases of leucorrhoea.] j biometrika dan kependud 2017;5:43. 24. deci el, olafsen ah, ryan rm. self-determination theory in work organizations: the state of a science. annu rev organ psychol organ behav 2017;4:19–43. 25. phytagoras kc. personal hygiene remaja putri ketika menstruasi. j promkesthe indones j heal promot heal educ 2016;5:12–24. 26. sommer m, kjellén m, pensulo c. girls’ and women’s unmet needs for menstrual hygiene management (mhm): the interactions between mhm and sanitation systems in low-income countries. j water sanit hyg dev 2017;3:283–97. 27. nursalam n, oktaviani dwd, armini nka, et al. analysis of the stressor and coping strategies of adolescents with dysmenorrhoea. indian j public heal res dev 2018;9:381–6. 28. pemiliana pd. perilaku remaja putri dengan personal hygiene saat menstruasi di sma etidlandia medan tahun 2018. gaster 2019;17:62. 29. hennegan j, dolan c, steinfield l, et al. a qualitative understanding of the effects of reusable sanitary pads and puberty education: implications for future research and practice. reprod health 2017;14:1–13. 30. solehati t, ermiati e, trisyani m, et al. hubungan sumber informasi dan usia remaja puteri dengan perilaku perawatan diri saat menstruasi. [relationship of information sources and age of young girls with self-care behavior during menstruation.] j keperawatan padjadjara 2017;5:145–54. article [page 92] [healthcare in low-resource settings 2023; 11(s1):11193] non -co mmerc ial us e o nly hrev_master mosquito net as an environmental aid in the management of pemphigus ghazal ahmed department of dermatology, venereology, and leprosy, all india institute of medical sciences, raipur, india dear editor pemphigus is often difficult to manage disease, which involves, apart from the pharmacological management, maintaining the environmental temperature and humidity within a narrow range as the loss of skin easily result in thermal and hydration imbalance.1 while this might be easy to do this in a well-equipped hospital with airconditioning, but turns out to be difficult in a low resource set-up. in this context, mosquito nets may play an adjunctive role. using a mosquito net with appropriate coverage on the sides, keeping the upper surface open can help create a personal niche for the patient. it keeps the micro-environment around the patient warm and comfortable and can even possibly prevent fluid loss from extensive erosions as it is well-known for attenuating the airflow.2 very often, patients with extensive erosions need open dressing with minimal clothing for faster healing. nevertheless, the privacy of the patient should be regarded as right and respected.3 the mosquito net-based set-up provides a private space for the patient to avoid unnecessary anxiety of nakedness. while there might be some alternative to the mosquito net, we have used the net considering the wide availability, cheap, and even customizable. there is limited or no data available on the ideal micro-environment for pemphigus treatment. the pemphigus resembles burn patients in terms of skin loss and evaporative loss. the recommended temperature of 32-35 degrees celsius with a relative humidity of 50% for burn patient management to reduce the evaporative loss4 might be applied to the pemphigus management. airflow around the burn patient is also advocated in burn patients in the exposure method. however, mosquito net mesh size is found to be inversely related to airflow. to overcome this problem, we have covered the sides of the net with cloths and kept the top uncovered. the mosquito net can also be stitched in a customized way using smaller mesh sides but having a more oversized mesh top. a ceiling fan can be placed just above the net. temperature is also another critical factor,5 and in the winter or colder places will need attention. we have used a 100–200-watt tungsten filament bulb on the open side if needed to add heat. however, other external heating sources can also be used. nevertheless, we will require clinical studies to evaluate the system objectively and in the clinical outcome context. references 1. kar pk. recent trends in the management of pemphigus vulgaris. med j armed forces india 1998;54:243-6. 2. von seidlein l, ikonomidis k, bruun r, et al. airflow attenuation and bed net utilization: observations from africa and asia. malar j 2012;11:200. 3. lindsay e, renyi r, wilkie p, et al. patient-centred care: a call to action for wound management. j wound care 2017;26:662-77. 4. martin cj, ferguson jc, rayner c. environmental conditions for treatment of burned patients by the exposure method. burns 1992;18:273-82. 5. alonso fernández jm, lópez pablo c. body temperature and heating temperature in the care of large burn patients. global nursing 2021;20:466–88. healthcare in low-resource settings 2022; volume 10:9828 correspondence: ghazal ahmed, department of dermatology, venereology, and leprosy, block-d, first floor, all india institute of medical sciences, pin 492099, raipur, india. tel.: +91.9835521686. e-mail: ghazal.ahmed4u@gmail.com key words: bullous disease; pemphigus; body temperature regulation; moisture. conflict of interests: the author declares no conflict of interest. availability of data and materials: all data underlying the findings are fully available. received for publication: 24 april 2021. revision received: 24 august 2021. accepted for publication: 13 december 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:9828 doi:10.4081/hls.2022.9828 figure 1. showing a patient inside a mosquito net with bedsheets hanging from sides and an incandescent bulb. in this picture, bedsheets were folded up to show the set-up. [healthcare in low-resource settings 2022; 10:9828] [page 13] non commercial use only hrev_master [healthcare in low-resource settings 2018; 6:6468] [page 11] healthcare in low-resource settings 2018; volume 6:6468 increased waist circumference as an independent predictor of hypercholesterolemia in community-dwelling older people claudineia matos de araujo,1-3 marcos henrique fernandes,1,2 josé ailton oliveira carneiro,1,2 raildo da silva coqueiro,2 rafael pereira1-3 1postgraduate program in nursing & health; 2center for studies in aging epidemiology (nepe); 3research group in neuromuscular physiology, department of biological sciences, state university of southwest bahia (uesb), jequié, brazil abstract hypercholesterolemia is a worldwide public health problem, contributing to cerebrovascular and ischemic heart diseases as one of the major cardiovascular risk factors, and associated with approximately 4.4 million deaths each year worldwide. this study aimed to evaluate the association and predictive value of increased waist circumference (wc) to identify hypercholesterolemia in community-dwelling elderly people. in a cross-sectional, home-based epidemiological survey, 296 community-dwelling old adults consented to capillary blood collection and anthropometric evaluation. total cholesterol was quantified, and the population was stratified as normal or high (≥200 mg/dl). wc was used to stratify the population into normal or elevated values (men: ≥90 cm; women: ≥80 cm). the association was investigated using logistic regression. increased wc was associated with a greater probability of hypercholesterolemia (or=2.82, 95%ci 1.68 to 4.74). thus, the widely used wc cutoff was demonstrated to be significantly associated with hypercholesterolemia in community-dwelling elderly people and could serve as a useful screening tool for hypercholesterolemia in older adults. introduction elevated total cholesterol (i.e., hypercholesterolemia) is a worldwide public health problem contributing to cerebrovascular and ischemic heart diseases.1 in brazil, as well as in other developing countries, cardiovascular diseases account for one third of all deaths and are the main source of healthcare expenditure. the hypercholesterolemia is one of the major cardiovascular risk factors and estimatives have associated hypercholesterolemia with approximately 4.4 million deaths each year worldwide.2 additionally, it is estimated that, in 2025, the number of deaths/year attributed to hypercholesterolemia will increase to 25 million.3 it is known that the aging enhances the probability to develop cardiovascular and metabolic complications, including hypercholesterolemia.4 notwithstanding, the body composition changes associated to aging process lead to an increased fat deposition with consequent cardiovascular and metabolic disorders, including insulin resistance, hyperlipidemia, hypertension, coronary artery disease.5 in this context, rezende et al. (2006) observed that, in adults and older people, the abdominal or central obesity is correlated with many cardiovascular risk factors, including the hypercholesterolemia. the excessive body fat may be identified by anthropometric measurements, including body mass index (bmi), an indicator of overall obesity, and waist circumference (wc), an indicator of central or visceral obesity.6-8 anthropometric measurements are easy-to-apply and low-cost when compared to more precise methods for body composition assessing, allowing its use in population-based studies to assess changes in body composition, as well as in clinical situations where access to technology is limited,5 which is especially important to developing countries. thus, they should be used in household surveys, epidemiological population-based studies, clinical practice and primary health care in many scenarios.9 although ldl cholesterol, total cholesterol/hdl ratio, and specific apolipoproteins can be better cardiovascular risk indicators, the analysis of total cholesterol alone is suitable for population studies, since the analysis of serum lipoproteins and apolipoproteins are not available for all population in many countries.2 thus, this study aimed to evaluate the association and predictor value of increased waist circumference to identify hypercholesterolemia in community-dwelling older people. materials and methods this is a descriptive study with crosssectional design, which analyzed data from a home-based epidemiological survey called “nutritional status, risk behaviors and health conditions of older people from lafaiete coutinho, bahia.” the study was developed in lafaiete coutinho, bahia, which had, registered in the family health strategy (fhs), 3,901 inhabitants the urban area at the collection period.10 the study population consisted of all individuals aged ≥ 60 years, of both sex, not institutionalized and residing in the urban area and registered in the fhs. from all residents in urban areas and aged ≥ 60 years (n = 355), 316 (89.0% participated in the survey, it were registered 17 refusals (4.8%) and 22 (6.2%) subjects were not located after three home visits in different days, then, it were considered as losses. the research procedures were approved by the local ethics committee (no 064/2010). participation was voluntary, and individuals signed and informed consent, according to the ethical standards required by resolution no 196/96 of the national health council. correspondence: rafael pereira, department of biological sciences, state university of southwest bahia, rua josé moreira sobrinho s/n, jequiezinho, jequie 45210-506, ba, brazil. e-mail: rafaelpereira@uesb.edu.br key words: anthropometry; aging; cholesterol. acknowledgements: the authors thank the municipal secretariat of health of lafaiete coutinho-ba and the elderly who participated in the study. contributions: cma, mhf, rsc, jaoc, data collecting and analyzing; cma, rsc, jaoc, manuscript writing; mhf, funds collection; rp, mhf guiding overall work of the research. conflict of interest: the authors declare no potential conflict of interest. funding: this work was supported by the state university of southwest bahia (uesb) (grant numbers uesb 117/2009 and 011/2010) and foundation for research support of the state of bahia (fapesb) (grant number ppp0070/2011). received for publication: 13 december 2016. revision received: 23 june 2018, accepted for publication: 25 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright c.m. de araujoet al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6468 doi:10.4081/hls.2018.6468 non -co mmerc ial us e o nly data collection the data were collected in january 2011 by the interviewers with the support of community workers in each area of the fhs. data were collected in two stages: the first stage consisted of home interviews with a previously validated questionnaire,11 which involved socio-demographic, lifestyle and cognitive evaluation. the second stage involved blood sampling, cardiorespiratory tests, anthropometric measurements and motor performance tests. total cholesterol and hypercholesterolemia (dependent variable) after 12 hours of fasting the total cholesterol (tc) was quantified from capillary blood samples with the accutrend plus® system (roche diagnostics, germany), a previously validated analyzer.12 after 5 minutes of rest in a sitting position, capillary blood samples were collected through transcutaneous puncture on the medial side of the middle finger tip using a disposable hypodermic lancet. the study population was stratified into normal or hypercholesterolemia according the recommended values (tc ≥ 200 mg/dl) in the vi brazilian guidelines on hypertension13 and v brazilian guidelines on dyslipidemia and prevention of atherosclerosis.14 increased waist circumference (predictor variable) the measurement of waist circumference (wc) was obtained with inelastic tape (graduated in centimeters), positioned over the umbilicus, with the patient standing. the international diabetes federation (idf) in 2005 proposed a cutoff point for wc that differs between ethnic groups, being used in this study the cutoff ≥ 90 cm for men and ≥ 80 cm for women, as recommended by idf for the ethnic group from central and south americans.15 statistical procedure descriptive analysis was conducted with frequencies, means and standard deviations of the population characteristics. initially, the chi-square test was applied to verify the association between waist circumference and the dependent variable hypercholesterolemia, which was confirmed (p <0.001). thus, the data were submitted to logistic regression analysis to verify the association strength between variables. from the logistic regression parameters, the odd ratio was calculated with respective 95% confidence intervals (95% ci). data were analyzed in spss statistics software for windows (spss 21.0, 2012, armonk, ny: ibm corp.) and the significance level was 5% (α = 0.05). results from the 316 older people included in the study, 296 (74.2 ± 9.7 [60 to 105] years old) had total cholesterol and wc data collected. in this population, the prevalence of hypercholesterolemia was 51.4% (152 subjects), which was higher in women (106 women, corresponding to 69.7% of all cases of hypercholesterolemia). two hundred and seven (69.9%) subjects presented wc above to the used cutoff values (≥ 90 cm for men and ≥ 80 cm for women), of whom 144 (69.6%) were women. the results from the logistic regression showed a strong association between wc (categorized) and hypercholesterolemia (p < 0.001). table 1 shows the results of logistic regression, allowing to verify that a waist circumference measure above the established cutoff values (≥ 90 cm for men and ≥ 80 cm for women, respectively) impacts in greater chance of presenting hypercholesterolemia (or = 2.82, 95% ci 1.68 to 4.74). discussion this study aimed to investigate the association strength of wc and hypercholesterolemia in community-dwelling older people. the results showed that the increased wc was strongly associated to hypercholesterolemia in the studied population. the aging process is associated to significant changes fat, muscle and bone mass, with an increase of fat mass and decrease in muscle and bone mass. the accumulation of intra-abdominal fat (i.e., visceral fat) is a major risk factor for several diseases, and have attracted special attention when compared to other forms of body fat distribution,16 which is justified by the fact that visceral fat have different metabolic characteristics of subcutaneous fat that favor the installation of metabolic alterations that culminate in increased cardiovascular risk.17,18 the wc measurement does not allow inferring directly the amount of visceral fat, distinguishing from the subcutaneous fat in the abdominal section. however, ross (2003),19 suggest that subcutaneous and visceral fat are highly correlated in the abdominal section. additionally, ribeiro filho et al. (2006)18 and rothberg et al. (2015),17 highlight that, among the available anthropometric methods to analyze the central distribution of body fat, the wc is the most widely used method for assessing visceral adiposity, because it is easy to collect and involves a single measure, being less subject to the measurement variability. zahorska-markiewicz (2006)20 states that the wc is the best predictor to the development of cardiometabolic diseases. rezende et al. (2006),6 studying a population with a wide age range (21-76 years) reported that the wc, as stratified here, is better associated to cardiometabolic risk factors, than the body mass index. our results corroborate zahorska-markiewicz (2006)20 and rezende et al. (2006),6 and strengthen the understanding that the association between wc and hypercholesterolemia, an important cardiometabolic risk factor, is applies to the older people, since we found a greater association between hypercholesterolemia and increased wc (or = 2.82, 95% ci 1.68 to 4.74) in older people, independently of sex. nevertheless, nagatsuyu et al. (2009)21 did not identify a significant association between waist circumference (measured at the umbilicus) and total cholesterol values. the form of analysis of the variable as continuous data, besides the fact that the cited study involved a smaller number of elderly people (only 98 older people), can justify the divergence from our results. it is noteworthy that the accumulation of visceral fat also indicates a greater reserve of nutrients in the lipids form, so that the establishment of a cause-effect relationship between hypercholesterolemia and the visceral fat accumulation, as measured by wc, is complex. our finds should encourage the use of anthropometric indicators of easy application and interpretation for clinical purposes and epidemiological research in order to prevent, maintain or improve monitoring of blood total cholesterol in the elderly of both sexes. article table 1. regression coefficient, odds ratio (or) with its 95% confidence interval (ci) obtained in the logistic regression. lafaiete coutinho, bahia, brazil, in 2011. variable rc standard error of rc or 95% ci of or waist circumference 1.038 0.265 2.82 1.68 4.74 constant -0.6763 0.224 rc, regression coefficient. [page 12] [healthcare in low-resource settings 2018; 6:6468] non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:6468] [page 13] conclusions the results of this study showed that the wc is significantly associated to hypercholesterolemia in the older population, suggesting that the wc measure, categorized in ≥ 90 cm for men and ≥ 80 cm for women, could be used as a tool for health surveillance when the goal is to identify older people more prone to hypercholesterolemia. references 1. ncep expert panel. third report of national cholesterol education program (ncer) expert panel on detection, evaluation, and treatment of high blood cholesterol in adults (adult treatment panel iii). final report. circulation 2002;106:3143–421. 2. farzadfar f, finucane mm, danaei g, et al. national, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3·0 million participants. lancet 2011;377:578–86. 3. raposo l. hipercolesterolemia familiar e doença coronária prematura. rev factores risco 2010;18:28–34. 4. trapani l, pallottini v, trapani l, pallottini v. age-related hyperchole sterolemia and hmg-coa reductase dysregulation: sex does matter (a gender perspective). curr gerontol geriatr res 2010;2010:1–7. 5. hughes va, roubenoff r, wood m, et al. anthropometric assessment of 10-y changes in body composition in the elderly. am j clin nutr 2004;80:475–82. 6. rezende fac, rosado lefpl, ribeiro r de cl, et al. body mass index and waist circumference: association with cardiovascular risk factors. arq bras cardiol 2006;87:728–34. 7. karaouzene n, merzouk h, aribi m, et al. effects of the association of aging and obesity on lipids, lipoproteins and oxidative stress biomarkers: a comparison of older with young men. nutr metab cardiovasc dis 2011;21:792–9. 8. lee hh, lee hj, cho ji, et al. overall and abdominal adiposity and hypertriglyceridemia among korean adults: the korea national health and nutrition examination survey 2007–2008. eur j clin nutr 2013;67:83–90. 9. who. obesity: preventing and managing the global epidemic. report of a who consultation. world health organ tech rep ser 2000;894:1–253. 10. ibge ib de g e e. síntese de indicadores sociais: uma análise das condições de vida. rio de janeiro: instituto brasileiro de geografia e estatística; 2010. 11. albala c, lebrão ml, león díaz em, et al. encuesta salud, bienestar y envejecimiento (sabe): metodología de la encuesta y perfil de la población estudiada. rev panam salud pública 2005;17:307–22. 12. coqueiro r da s, santos mc, neto j de sl, et al. validity of a portable glucose, total cholesterol, and triglycerides multi-analyzer in adults. biol res nurs 2014;16:288–94. 13. sbc sb de c. vi diretrizes brasileiras de hipertensão arterial. rev hipertens 2010;13:i–iii. 14. xavier ht, izar mc, faria neto jr, et al. v diretriz brasileira de dislipidemias e prevenção da aterosclerose. arq bras cardiol 2013;101:01–22. 15. abeso ab para o e da o e da sm. diretrizes brasileiras de obesidade 2009/2010. itapevi: associação brasileira para o estudo da obesidade e da síndrome metabólica; 2009. 16. vasques acj, priore se, rosado lefp de l, franceschini s do cc. utilização de medidas antropométricas para a avaliação do acúmulo de gordura visceral. rev nutr 2010;23:107–18. 17. rothberg ae, halter jb. obesity and diabetes in an aging population. clin geriatr med 2015;31:1–15. 18. ribeiro filho ff, mariosa ls, ferreira srg, zanella mt. gordura visceral e síndrome metabólica: mais que uma simples associação. arq bras endocrinol metabol 2006;50:230–8. 19. ross r. advances in the application of imaging methods in applied and clinical physiology. acta diabetol 2003;40:s45-50. 20. zahorska-markiewicz b. metabolic effects associated with adipose tissue distribution. adv med sci 2006;51:111–4. 21. nagatsuyu dt, moriguti eku, pfrimer k, et al. o impacto da obesidade abdominal sobre os níveis plasmáticos de lípides nos idosos. medicina 2009;42:157. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11739 integration in nursing curriculum for building islamic nurses’ character in indonesia: a descriptive qualitative approach dwi setiowati,1 waras budi utomo,1 marisca agustina2 1department of nursing, faculty of health sciences, universitas islam negeri syarif hidayatullah; 2department of nursing, faculty of health sciences, universitas indonesia maju, indonesia abstract the integration of a curriculum that combines islam and science has become a necessity and a demand in higher education, including nursing study programs in indonesia. this study aimed to explore the perceptions of nursing school heads, lecturers, and students regarding the integration of character-building islamic values into nursing education. the research design was a qualitative descriptive approach. the sample collected using a purposive sampling technique, focusing on lecturers and students involved in integration, resulting in a total of twenty-six participants. data was collected by conducting online interviews, posing questions to individuals from five islamic higher education nursing schools, including nursing school principals and lecturers. the research reveals six key themes: perception of the integration of islam and science, its application, the sources of power in the integration, the barriers faced, the evaluation process, and potential solutions for achieving successful integration. it is essential to consistently monitor and evaluate the integration process through a comprehensive review of the curriculum, including semester learning plans at the beginning, during, and at the end of the study, in the form of outputs and outcomes. furthermore, it is crucial to optimize collaboration between nursing lecturers and islamic expert lecturers. introduction indonesia is a country that has a majority muslim population which was 220 million residents in 2018 when the total population of indonesia was 265 million.1,2 this fact means that indonesia possesses a substantial pool of human resources, particularly in the field of health. this potential can be leveraged to develop a halal-based industry, allowing indonesia to compete effectively in the global halal market. however, achieving this goal is not without its challenges, there are several obstacles that must be faced by indonesia.3,4 the challenges of the halal industry are important for indonesia with advantages in islamic human resources including sharia hospitals to become a halal lifestyle in the world including halal pharmacies, halal nutrition, and health workers including nurses.3,5–7 as of december 2016, nurses constituted the largest portion of the healthcare workforce in indonesia, accounting for 29.66% of all health workers.4 one of the health challenges in indonesia is palliative care where in 2015 indonesia was ranked 53rd (33.6% achievement) out of 80 countries that made palliative care efforts.3,8 nurses must involve the patient’s awareness, faith and belief (spiritual) in providing palliative care to the patient.9–11 islam has guided providing patients with comprehensive, bio, psycho, sociocultural, and spiritual care. islam is created as the universe’s and nature’s grace, service care nursing. nurses must correspondence: dwi setiowati, department of nursing, faculty of health sciences, universitas islam negeri syarif hidayatullah, indonesia. e-mail: dwi.setiowati@uinjkt.ac.id key words: curriculum; islamic nursing school; nursing. contributions: ds, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; wbu, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ma, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: ethical clearance was carried out and approved by the research ethics committee of the faculty of health sciences at uin syarif hidayatullah with number was un.01/f.10/kp.01.1/ke.sp/08.08.011/2022. participants were free to participate in time data collection and offer informed consent. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. funding: this research was supported by a research grant in 2022 from the research and publishing center (puslitpen) uin syarif hidayatullah jakarta. availability of data and materials: all data analyzed during this study are included in this published article. acknowledgement: the researcher would like to thank the research and publishing center (puslitpen) uin syarif hidayatullah jakarta for the support in the form of research grants in 2022. received: 9 september 2023. accepted: 18 october 2023. early access: 6 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11739 doi:10.4081/hls.2023.11739 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11739] [page 57] non -co mmerc ial us e o nly tackle patient problems from an interpersonal, faith-based, wellinformed, and charitable perspective. this thing demand nurse have islamic spiritual competence, and interpersonal, and intellectual ability to preach amar ma’ruf nahi munkar (enjoin what is known [to be good] and forbid what is rejected [or evil]).8 one factor that shapes islamic caring for students nursing based on studies qualitative is continuous application when students are studying nursing academic.9,10 previous study also added the character of islam and the environment such as education as factors in islamic caring shaper student nursing.12,13 this is becoming a challenge for education in indonesia in particular institutions of education islamic nursing for build profile nurses with islamic values. islam is a grace for the natural makes islamic nursing values universally acceptable, allowing it to provide services for more than just islam in indonesia. islamic nursing develops its character by imbuing students with the values of islam through education. nursing integration that integrates islam and nursing is still not yet many do. curriculum becomes important as guidelines are based on shaping the character of islamic nursing through the educational process. integration of islam and nursing based on planting islamic values in monotheism and sharia as well as morals.14,15 curriculum-based integration must undergo significant conceptual and practical transformation. teachers have a significant role in creating designs each semester, teaching the learning process, and producing learning outcomes that demonstrate integration.16 there is a positive and significant relationship between learning models integration knowledge and the formation of the islamic character of students in college with high levels of islam in indonesia and malaysia.17 students in the student center engaged in learning in the curriculum process to see how far is the application curriculum.18 every institution of education in islamic nursing must use a vision and mission based on islam in the learning process. researchers as lecturers at islamic universities in indonesia also apply the integration of islam and nursing as the vision mission of universities, faculties, and study programs since the curriculum was based on indonesian national framework and the association indonesian ners education center (ainec) in 2017 with the integration of islam and nursing. but then, it revises into the curriculum integration of islam and nursing year 2021. data regarding the not optimal output of students in the integrated curriculum, including clinical students at syarif hidayatullah state islamic university jakarta and alaudin makasar state islamic university, performed islamic nursing care well at 52%.19 this is also a gap according to early research stated that there is no difference in perceptions of spiritual care for general nursing students based on the islamic religion.20 literature on spiritual care is also unclear in the application of nursing care, especially education.21 evaluation of clinical learning in the form of input from the hospital during curriculum workshops at islamic nursing university found data that students were not confident and had not optimally performed spiritual care for patients. given that the school has provided various courses on islam and integrated them into the nursing curriculum as well as the output profile of graduates, this is a gap in the program’s curriculum. it is problematic for researchers to use this title for their research. the purpose of this study was exploring the perceptions of nursing school leaders, lecturers, students in implementing the integration of islam and nursing in forming the character of islamic nurses. materials and methods the research used qualitative design. qualitative research was descriptive data in the form of words written or verbal and behavioral in detail based on real conditions.22 research time started from the preparation of proposals until the preparation of publications conducted in january-august 2022. studies were conducted in nursing programs at various islamic universities in indonesia. a total of 26 samples were collected using a technical non-random sampling technique with purposive sampling. the participants were 8 the head of the nursing schools, 8 lecturers and 10 nursing students. informant criteria such as the lecturer who focuses on integrating islam and nursing (exposed to islamic integration), undergraduate students who are in semester 6, and student nurses whose undergraduate thesis are about integrating islam or providing spiritual islamic care. collecting data using online interviews by asking 10-11 questions with online interviews. participants were free to participate in time data collection and offer informed consent. ethical clearance done with the number was un.01/f.10/kp.01.1/ke.sp/08.08.011/2022. stages of qualitative data analysis were do a transcript from guidelines interview: analyze statements important in accordance with topics research; classify to in theme or units of meaning based on what happened participant and description researcher based on experience, reflection self, opinion, feelings, and hopes; then combine meaning in group theme.23,24 the credibility of data on research this use method was triangulation source. results table 1 describes the characteristics of the informants consisting of head nursing school, lecturers, and nursing students at several islamic-based universities in indonesia. analysis results get six themes including perception, application, source power, barriers, evaluation, and solutions in integration. key themes and subthemes are presented in table 2. theme 1: perception of integration islam and science participants a total of 26 originating from the five institutions that have base islam state that integration of islam and science in knowledge nursing of course required. participants in the study have different views on the integration of islam and science in nursing among them. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. informant demography data. no. informants information 1 head of nursing school there were 5 women and 3 men with an age range of 35-50 years, with master's and doctoral degrees in nursing 2 lecturers there were 5 women and 3 men with an age range of 30-45 years, with master's degrees in nursing 3 nursing student there were 8 women and 2 men with an age range of 23-25 years, who are still studying nursing at the academic and clinical stages [page 58] [healthcare in low-resource settings 2023; 11:11739] non -co mmerc ial us e o nly learning quality integration of islam and science in knowledge nursing was already found in the curriculum education nursing from quality learning education integrated and involved values islam. “according to me, integration islam important applied in knowledge nursing so that nurse operate his job in accordance with rule islam” p22 scientific fundamentals importance score islam in the learning process was considered as a base knowledge that can sustainable with the care process nursing to patient: “islamic integration is needed to equip students not only to do care nursing based on knowledge nursing just but how to include religion (islam) in the nursing process” p6 identity institution the application of islam in institutions was also related to characteristics possessed by the institution. “must be implemented integration science and islamic, as marker university based islam, and implemented field” p1 holistic approach care nursing needed an approach of thorough (holistic) good fulfillment of biological, psychological, social, and spiritual in gift care nursing. “... integrating among islam and nursing means fulfill patient’s spiritual needs as well as undergo all aspects and actions in nursing based on islamic …” p19 theme 2: application to integration of islam and science period application every institution started to apply the integration of islam and science in nursing at different times from the beginning standing, 3-6 years. “6 years” p2 “more from 3 years” p8 “maybe already implemented since beginning to stand“ p4 learning program integration of islam and science in knowledge nursing created by a teacher in the learning process with material and practicum delivered in lectures. “...material lectures and learning use related verses and hadiths with each topic” p13 “adding the lectures and practicum within in each college” p1 planning application integration islam needed preparation for learning delivered with good and looks already planned carefully. “according to me, institutions and lecturers are already excellent in terms of studying and there is supposed to be more explanation about islam from the perspective of the college. the institution should bring a lecturer who has science in the field of islamic…” p19 “it is necessary to continue moving through research, development, and curricular integration with islamic” p2 “it was only a trial because we are unsure of its accuracy as of yet with the emphasis on affective, cognitive, and behavioral/psychomotor elements,” p10 participant readiness participants in education must first complete the essential prework completed in accordance with islam. before the study start, participants were required to educate themselves and prepare themselves by independently finding relevant information or practicing islam. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. themes of research results. no. themes subthemes 1 perception of integration 1. quality of learning 2. scientific fundamentals 3. identity institution 4. approach holistic 2 application in integration 1. period application 2. learning program 3. readiness planning 4. readiness participant (students) 3 source power in integration 1. participation mentor 2. participation institution 4 barriers in integration 1. information factors 2. teacher factors 3. students factors 4. course factors 5 evaluation in integration 1. assessment participant (students) 2. review of learning process 3. students feedback 6 solutions in integration 1. improving lecturers competencies for integration 2. improve student quality learning 3. multiply source learning healthcare in low-resource settings 2023; 11:11739] [page 59] non -co mmerc ial us e o nly “... for the lecturer, they expected for give design learning maximum one day before lectures, so that students get the picture and get prepare by their selves to explore more theory from other references” p18 theme 3: source power in integration islam and science application integration of islam and science no could be done without existence cooperation from various parties in the field of education. implemented learning needs existence support from the teacher, resource information, and support from the institution for the learning process. participation supervisor (lecturer) implementing the fusion of islam and science in nursing knowledge is not free from the need for lecture assistance during the teaching process. “cooperate in the process of teaching/mentoring” p12 the involvement of the lecturer in this life-filled activity is crucial to the formation of learning. the teacher’s involvement in research, discussion-related learning, and socialization is done through numerous chances. “holding a drafting workshop, curriculum, integration workshop islamic together” p2 “it is necessary to conduct scientific discussions with islamic experts (seminars, workshops, fgds, etc.)…” p3 “come along becomes a key person at plenary or dk facility, osce examiner” p9 participation institution participation institution becomes a great support big in the implementation of the learning process. institutions could give support related with facilitate teachers so that could increase the competence of teachers in facilitating training well in terms of funds, regulations, and facilities. “institution support with existence chess dharma (education, research, and service society), then the university also included aik as an achievement of iks study program” p4 “in form policy and determination of curriculum decrees. integration, and support for workshops and seminars” p1 theme 4: obstacles in the integration of islam and science source factor information islam and science must be integrated, and source-supportive knowledge must be used as guidelines or a source of reference. teachers, however, experience difficulty due to the little source information that is currently available. “... islam is still not widely used in nursing, especially according to research done in indonesia…” p15 “when faced with a duty-related occasion, the individual must hunt for a reliable source and read sources that are directly relevant to nursing and islam” p19 lecturer factor the competence of the teacher has an impact on the learning process in a study. few lecturers have yet to incorporate islam into theory lectures and knowledge nursing. “the problem is expertise from the lecturer who can link (verses and hadiths) in every theme lectures and other lessons” p13 “muslim worked as a clinical lab nurse at the hospital in makassar. most large nurses do not understand nursing islam, which is one of the issues caused by our pupils’ lack of access to accompanying moments. nursing-based islam should be implemented at the hospital.” p20 participant factor participants in the initial learning process have an impact on learning. for educated participants, the application integration of islam and science in nursing is still difficult to understand. “i still not enough qualified in islamic knowledge…” p25 teaching factor islam and science integration could not be implemented across all educational curricula. “because there several courses that have not been integrated with islamic” p6 theme 5: evaluation in islamic integration and science participant evaluation evaluation concerning implementation is required for the application of learning programs. some activities might be conducted in the implementation assessment process up until outside participants produced an effective education in terms of affective, cognitive, or psychomotor skills. “adjusting to the kbm that is being carried out. for example with the mcq evaluation which contains questions related to islam and blocks themes, evaluation in soft skills during practical exams (example: islamic adab, praying, and greetings)” p13 “so far, it has not been measured systematically, for example: making it in the form of exam questions, assessing practicum. while other aspects have not” p10 study program review making learning programs has a curriculum in which there are lesson plans, assignments, to the final assessment of students. the continuity between islamic integration in learning is reflected in the lesson plan. this can be seen as a form of evaluation related to the implementation of learning in accordance with the plans that have been made and the final results to be achieved. “evaluated in the learning process” p6 “learning preparation meetings and workshops, to see the extent of islamic and scientific implementation” p4 students’ feedback the implementation of the integration of islam and science in nursing received positive feedback from the student. students feel [page 60] [healthcare in low-resource settings 2023; 11:11739] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly that they have gained broader insights regarding islamic principles that can be applied in nursing and are interested in the learning process. “very good, student enthusiastic and more interested in the themes of knowledge and islam” p13 “gain a broader learning experience and new competencies through several learning activities based on islamic and scientific nursing “ p24 theme 6: solutions in the integration of islam and science increase the competency of educators several things can be done to continue to solve the problems that exist in the application of the integration of islam and science in nursing. activities that can be carried out are by participating in workshops, working with islamic religious education teachers, and increasing qualified knowledge in delivering theoretical lectures. “for abilities that must be possessed 1. basic knowledge obtained in education that has been pursued 2. experience in islamic organizations that have been attended 3. field practice regarding experience in applying theory” p25 “invite lecturers for the subject to take part in workshops related to islamic integration in both rps and module workshops “ p11 increase the quality of students quality student reflects success in learning. there are barriers consisting of internal and external factors that influence the experience of the study process among students. “changing outlook on life, changing laziness to be active, keep the spirit in seeking knowledge “ p24 “the shape of the character can set a good example that reflects religious ethics. teach how to be polite, and moral, an islamic nurse in providing nursing services to patients. “ p15 “providing assistance, habituation and strengthening islamic understanding and behavior to students during the nursing profession, namely a hermitage so that each student can realize the character and competence of islamic nurses “ p14 various sources of learning achievements in establishing a nursing program require support from various sources. the integration of islam and science in the field of nursing still lacks the required information. this causes the need for increasing sources of information to support achievement outside of learning. “doing a workshop with inviting an expert in islam which lecturer of al islam” p14 “looking for ma references related to the qur’an, book, and al-hadith conducting research assigning students to conduct literature studies from various studies related to islam and nursing as well as carry out a synthesis analysis of the literature obtained “ p15. discussion the first theme that we found is perception in integration. the most important goal of the integrated curriculum is to produce alumni who have personality and capable of showing the figure of the ‘ulama’ (or judge) in wider understanding, like represented by prominent muslim scientists in islamic history. the curriculum character is comprehensive, competitive, flexible, and adaptive in adapting progress knowledge and technology that demonstrates the integration with principles of prosecution knowledge in islam.25–27 islamic universities have the responsibility to produce individuals who are not only highly knowledgeable but also possess noble character, guided by virtuous values. these individuals are called upon to work diligently for their own betterment and the greater good of humanity at large.28,29 the competency-based curriculum (kbk) and the indonesian national qualifications framework (kkni) encompass three key aspects: formulating graduate learning outcomes, designing courses, and preparing relevant documentation.29 given that nursing is an applied field, and nursing graduates are expected to adapt dynamically to diverse environments, the curriculum must remain flexible and responsive to the evolving needs of society.30 the characteristics of islamic nurses, as revealed in the research findings, align with those from previous studies. these include the development of student personalities with the ulul albab character, which comprises traits of individual and social piety cultivated through reflection and devotion.17 the character of islamic nurses integrates monotheism and good morals, enabling students to apply these principles in their provision of islamic nursing services.31 the second theme that researcher found is application in integration. nursing students exhibit a range of islamic values, including piety, sincerity, hospitality, kindness, responsibility, gratitude, adherence to halal food, and observance of tayyib principles, which are instilled across several courses.32 a prior study established that nursing students at yogyakarta university identify as muslim nurses, adhering to islamic law, internalizing islamic values, delivering islamic nursing care, and adhering to nursing regulations as muslim nurses.33 another study suggests that islamicbased nursing education and curricula offer a solution to healthrelated challenges among muslim populations.14 this approach is rooted in the islamic paradigm and integrates principles of safety, professional ethics, and effective communication. the characteristics of islamic nurses are faith, integrity, innovation, professionalism, sincerity, educative, communication, and capability according to amar ma’ruf nahi munkar.34 the foundation for educational success lies in a curriculum comprising objectives, outcomes, standards, philosophy, and subject content that students will engage with. a high-quality curriculum plays a pivotal role in shaping both the present and future of the healthcare system.35 enhancing the quality of state islamic religious colleges (ptkin) is contingent upon the implementation of the iqf-based curriculum, influenced by three primary factors: the availability of educational resources, encompassing the quality of teaching staff, financial resources, and learning facilities; the quality of the teaching and learning process, which fosters effective student learning; and the quality of the educational outcomes, encompassing knowledge, skills, and attitudes.36 the third theme is source power in integration. lecturers play an important role in the preparation of lesson plans. lecturers are at the forefront of knowledge integration, and lecturers must be able to become pioneers of knowledge integration. as pioneers of knowledge integration, lecturers at least have a complete concept [healthcare in low-resource settings 2023; 11:11739] [page 61] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly of knowledge integration. in addition, lecturers also have qualified abilities to carry out the integration. lecturers with non-religious fields of knowledge can obtain islamic knowledge through formal and non-formal channels (training). lecturers can also use team teaching by involving islamic lecturers in the form of teaching discussions, research, and community service.25 making textbooks with a scientific integration approach is one of the main supporting forces in socializing the running of the knowledge integration program. textbooks can be in the form of integration in the order of epistemology, philosophy of science as well as integrative learning topics that combine the approaches of two studies between religion and non-religion. each tertiary institution usually has books on epistemology that serve as the basis and guidelines for developing the integration of science, but at the lecturer level, there are not many books on the integration of science according to the fields of science being taught. students will gain insight and easily integrate knowledge if they have a reference book containing the integration of knowledge by their lecturers.25 the fourth theme is barriers in integration. there is a need to establish a core courses designed with a philosophical framework to provide basic knowledge about the traditions and treasures of islamic science. in this context, several courses can be determined that can be used as core courses that have clear and stable epistemological and ontological foundations. as an example, courses can be offered: “introduction to islamic history,” “history of science and civilization in islam,” and “epistemology and classification of science in islam”.25 this is in accordance with the inclusion of islamic nursing courses in nursing study programs. islamic nursing care is included in all parts of nursing competence such as islamic nursing care in medical-surgical nursing and community nursing. the forms of the contribution made by the science integration learning model with student islamic character included in the learning model is still limited to the cognitive domain and has not touched other domains, namely the affective and psychomotor domains17. moreover, in this study also educators or lecturers still do it only by presenting naqli arguments without any research or experiments that can strengthen these arguments. the fifth theme is evaluation in integration. the ministry of religion (2019) formulated the integration of knowledge as “the unification of islamic religious knowledge with other sciences, so that these sciences do not contradict each other and are dichotomous”.37 this formulation formally became the official formulation of uin syarif hidayatullah jakarta as stated in rector’s decree 864 of 2017 concerning guidelines for knowledge integration. the possibility of integrating islamic sciences with other sciences in the philosophical, substantive, applicative, or implementation domains is also the possibility of integration of both in the realm of research and researchers, as well as in the process of reconstruction of the core sciences and supporting sciences. this was welcomed by the formulation of guidelines for the integration of islam and health sciences, faculty of health sciences uin jakarta in 2022. evaluation in the integration of islam and science in reviewing learning programs/semester learning plans (rps), student feedback is an important part and a challenge for the islamic and nursing integration curriculum. even though the curriculum and lesson plans have been prepared, monitoring and evaluation of processes and results are needed. the results are not only outputs but outcomes that become input for reviewing the lesson plans in the following semester. the researcher assumes that if this is done in a structured and consistent manner, then the graduates with the character of islamic nurses will be achieved. the curriculum is the basis for the integration of islam and nursing (theme 6). the need for stabilization and monitoring of input processes (lecturers, education staff, students, facilities, and infrastructure), processes with learning methods, outputs, and outcomes in the teaching and learning process both at the nursing undergraduate stage and as the ners. it is necessary to formulate graduate achievements in the cognitive, affective, and psychomotor domains in each subject which is of course different at the undergraduate and ners stages. preparation of rps with collaboration between islamic and nursing lecturers which discusses in more detail learning methods, learning outcomes, and evaluation of outcomes which provide input in the process of reviewing and developing rps so that the integrated curriculum is even better and the quality of graduates who has the character of an islamic nurse is achieved. conclusions islamic-based nursing education institutions should establish mechanisms to monitor and evaluate the integration of islamic principles and nursing in their bachelor of nursing and clinical nursing school programs. the six themes are perceptions of the integration, the implementation of the integration, learning programs, the strength of the resources, the constraints of the integration, and evaluation of the integration of islam and science. the findings of this study indicate the need for monitoring each subject through the semester learning plan (rps) at the beginning of lectures, during (process/method), and at the end of learning in the form of outputs and outcomes. references 1. brackery r. the largest muslim country is not in the middle east. imb. 2018. 2. bramantoro t, karimah n, sosiawan a, setijanto rd, berniyanti t, palupi r, et al. miswak users’ behavior model based on the theory of planned behavior in the country with the largest muslim population. clin cosmet investig dent 2018;10:141-8. 3. sa’adah l, soedarman m, falah yh al. pengaruh current ratio, debt to asset ratio, dan net profit margin terhadap pertumbuhan laba. j anal akunt dan perpajak 2022;6:14-21. 4. kemenkes ri. situasi tenaga keperawatan di indonesia. pusat data dan informasi kesehatan kemenkes ri. 2017. 5. sukesi, akbar hidayat wgp. managing the halal industry and the purchase intention of indonesian muslims the case of wardah cosmetics. j indones islam 2019;13:200-29. 6. jaswir i, sari dp, haji che daud mr, sukmana r. motives for participation in halal food standard implementation: an empirical study in malaysian halal food industry. int j islam middle east financ manag. 2023. 7. maison d, marchlewska m, syarifah d, et al. explicit versus implicit “halal” information: influence of the halal label and the country-of-origin information on product perceptions in indonesia. front psychol 2018;9. 8. rahmat r. implementasi keperawatan islami perawat pelaksana terhadap patient safety di rumah sakit muhammadiyah bandung tahun 2017. j ilmu kesehatan bhakti husada (health science journal). 2018;9(1). 9. wardaningsih s, zikri ah. pembentukan perilaku caring islami pada mahasiswa keperawatan 2019;4(1). proceeding of [page 62] healthcare in low-resource settings 2023; 11:11739] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly the konferensi nasional (konas) xvi keperawatan kesehatan jiwa, 2019. oct 17-19: bandar lampung, indonesia. 10. khamida, yusuf a, budury s, karein ap. the relationship of religiosity and social support with students adaptation in the islamic boarding school. bali med j 2022;11:729-33. 11. bakar a, nursalam, adriani m, et al. the development of islamic caring model to improve psycho-spiritual comfort of coronary disease patients. indian j public heal res dev 2018;9:312-7. 12. widya a, ana fn, ainul yq. the analysis of islamic characters in forming caring behavior of nursing student. j keperawatan respati yogyakarta 2021;8(2). 13. kørup ak, søndergaard j, christensen rp, et al. religious values in clinical practice are here to stay. j relig health 2020;59:188-94. 14. nurumal ms, jamaludin tss, ahmad n, et al. integration of islamic values in undergraduate nursing program: an expository analysis. int j care sch 2019;2(2). 15. abdurrouf m, nursalam n, purwaningsih p. islamic caring model on increase patient satisfaction. j ners 2013;8:153-64. 16. baron ka. changing to concept-based curricula: the process for nurse educators. open nurs j 2017;11:277-87. 17. nurbaiti, suparta, taufik as. integrasi ilmu dan kontribusinya terhadap pembentukan karakter islami mahasiswa. tangerang: cv qolbun salim; 2020. 18. john j. empowering students as active participants in curriculum design and implementation. eric, december 2010 (cited 20 january2023). available from: https://files.eric.ed.gov/fulltext/ed514196.pdf. 19. dwi s, peggy rks, rasdiyanah r the application of islamic spiritual methods in nursing program curriculum at uin syarif hidayatullah jakarta and uin alauddin makasar. islam transformatif j islamic studies 2021;5(2). 20. frida a, novieastari e, nuraini t. perception on spiritual care: comparation of the nursing students of public university and religious-based university. wbfer clin 2019;29:59-64. 21. o’brien me. spirituality in nursing. burlington. ma jones bartlett learn. 2017. 22. taylor sj, bogdan r, devault m. introduction to qualitative research methods: a guidebook and resource. iv. hoboken: nj: john wiley & sons inc; 2016. 23. colaizzi pf. psychological research as the phenomenologist views it. 1978. 24. creswell jw. research design, pendekatan metode kualitatif, kuantitatif, dan campuran. 4th ed. yogyakarta: pustaka belajar; 2016. 25. kementerian agama republik indonesia. pedoman implementasi integrasi ilmu di perguruan tinggi keagamaan islam (ptki). kementerian agama republik indonesia; 2019. 26. dawood h, al zadjali df, al rawahi m, karim ds, hazik dm. business trends and challenges in islamic fintech: a systematic literature review. f1000research. 2022;11. 27. amin h, suhartanto d, ali m, ghazali mf, hamid r, abdul razak d. determinants of choice behaviour of islamic investment products in malaysia. j islam mark 2022. available from: https://eprints.ums.edu.my/id/eprint/33672/ 28. direktorat pendidikan tinggi keagamaan islam direktorat jenderal pendidikan islam kementerian agama republik indonesia. pedoman implementasi integrasi ilmu di perguruan tinggi keagamaan islam (ptki) 2019;73. 29. liliana s. alternatif penyusunan kurikulum mengacu pada kkni. paper on the lldikti region 12 website.tim dikti 2013. 2013;1-49. 30. parvaneh a, elham n, fatemeh b. comparative study of nursing curriculum in nursing faculties of canada, turkey, and iran according to spices model. j educ heal promot 2019;8. 31. saputra c, arif y, yeni f. andra’s nursing informatic system application (annisa) dalam upaya meningkatkan pengetahuan perawat tentang dokumentasi keperawatan. j keperawatan silampari 2020;4:20-30. 32. nina a. integrasi nilai nilai islam dalam kurikulum ilmu keperawatan. j kesehat budi luhur 2020;13(2). 33. noviani w, musharyanti l, pratama rpa. “i internalize islamic values”: bachelor nursing students’ perception and experience of professional identity in indonesia. j med sci 2021;9:158-66. 34. syaifullah a. critical thinking: pemecah problema pendidikan islam di era covid-19. proceeding the 3rd icdis (international conference on data intelligence and security) 2021;2(1). 35. samireh a, hesamaddin kt, sadigheh a. assessing nursing curriculum: graduate nurse viewpoint. can j nurs informatics 2011;6(3). 36. khairiah. pengaruh implementasi kurikulum berbasis kkni terhadap peningkatan mutu pendidikan ptain. nuansa: j kemasyarakatan dan studi islam 2015;8(2). 37. mohamad am. sinergi atau konflik hukum? (perbandingan kompilasi hukum ekonomi syariah (khes) dengan fatwa dewan syariah nasional (dsn). al-‘adalah j 2015;12(2). healthcare in low-resource settings 2023; 11:11739] [page 63] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e1] [page 1] introducing healthcare in low-resource settings chandrakant lahariya public health specialist, new delhi, india healthcare resources are often referred to as the means available in a health system to deliver services to the population. healthcare or health resources, like any other system, can be grouped into three broad categories of infrastructure, material or supplies or consumable, and human resources. health outcome or status of a population is interplay of all 3 categories of resources, working in tandem to deliver services. there are population-based global norms for resources in a functioning health system. a health system which does not meet the accepted norms can be called as low-resource setting (lrs) for healthcare. the resources for health are allocated by national governments and the economic condition of the country is a major determinant in health budget allocation. political instability, public unrest, war, conflicts and natural calamities, all play a major role in the determining the resources for health system. as a rule of thumb, low and middle income countries (lmics) have at least some form of imbalance in either health infrastructure or supply or in human resources. thus, lmics not always but generally equates with lowresource healthcare settings. the historically low resource allocation for healthcare in lmics leads to increased disease burden and health service requirement, worsening the situation. healthcare in lrss is different from other countries in many aspects: lower investments by the governments, poor infrastructure, limited equipments and medicines, scarce human resources with high turn-over, limited service provision, and large out-of-pocket expenditure. the situation becomes even more complex when discussion moves from simple inputs (infrastructure, materials and human resources) to distribution of health services, fragmentation of services (rural-urban, preventive-curative, major city-small town, motherchild, young-old) in-equities and also on service provision for various health issues, etc. low resource settings are the reality and have the highest all-cause mortality, including child and maternal mortalities, thus hampering the overall achievement of millennium development goals. the quantity and quality of healthcare services in lrs is not supposed to be different than any other situation; however, till the resources are increased, the available resources should be effectively and efficiently utilized. the solutions of the local challenges need to be found by research, which is often not conducted due to the low resources/funding. the emic health data is needed rather than the widely available etic data. though, both of these approaches could be complementary. the view often presented by external observers (in etic) is often colored by the experience in their own settings and has less acceptability by the country program managers. there is emerging need for emic data from lrss to bring transformational health changes. the sufficient etic data exist and the time for emic to supplement this information is ripe. low-resource settings need additional attention as there are higher expectations from these to perform and deliver. the cultural context needs to be understood and addressed and the political leadership in these settings need to be brought on the board. people often get overwhelmed by the absolute number of challenges and the efforts become non-starter because of failure to identify a point to start with. people in lrss need as good services as in any other settings and they cannot wait indefinitely. the challenges should be addressed immediately and can probably be solved by recognizing healthcare in low-resource settings (hls) as a separate field of work: that is what this journal aims at. i have written in the past that scientific journals have a bigger role to play in healthcare delivery. a reputed and well-focused journal can draw a lot of attention on the part of all stakeholders to bring right changes and become a societal catalyst.1 this trend has become increasingly common where journals publish research theme issues, start discussion and debates among stakeholders and changes happen. the lack of availability of local evidence is often cited as a major hurdle in improving health status and introducing new interventions in lrss.2 the gap in knowledge translation and in policy to implementation has been reported often. the 10/90 gap – where there is 10% investment on the problems of 90% – is also often highlighted.3 the limited in-country research capacity, scarce funding and poor quality data results that very little evidence (for action) is generated from lrs. the research work conducted in these settings fails to find a place in reputed journals due to lack of methodological rigour and poor quality data. this has a domino effect and when it comes to decision making, the sufficient local pieces of evidence are not available. the limited resources make it necessary to optimally utilize the available resources. at a program manager level, this could be achieved by improving focus on efficiency and effectiveness; designing service provision as per the local epidemiology and needs; ensuring equitable distribution; and making health system responsive to the need of people. additionally, the cost analyses (cost effectiveness, cost benefit and accounting, etc.) are other sub-optimally utilized tools in these settings. the publication of healthcare in lowresource settings would provide a platform to researchers and policy makers alike. the journal aims to publish editorials, commentaries, policy analysis, review articles, original research work and would often have discussions and debates on important health issues with focus on hls. opinion articles and viewpoints on topical issues and both qualitative and quantitative research would find place in the journal. free access to the research published in hls is likely to benefit the cause of researchers in lrss. healthcare in lowresource settings would publish series to build capacity of researchers in lrs in research methodology, cost analyses and epidemiological principles. healthcare in low-resource settings is an idea converted into a journal to provide a common platform for information sharing and dissemination. it will welcome authors to document best practices and compare health situations in low resources with those in other settings. it is expected that with the time, the pieces of evidence published in this journal assist in cross-learning to find solutions to common health challenges. i sincerely hope that a few years down the line, the journal would have accumulated some path-breaking research evidences to guide the health system in such settings, when it becomes a common platform used by researchers in all countries. the growth and improvement in healthcare will benefit from research evidences in hls. this is my sincere thought and wish, and all of you are welcome to join this exciting journey. i really feel privileged to introduce this healthcare in low-resource settings 2013; volume 1:e1 correspondence: chandrakant lahariya, b7/24/2, first floor, safdarjung enclave main, safda-rjung enclave main, new delhi-110029, india. tel. +91.98101.60665. e-mail: c.lahariya@gmail.com conflict of interests: the author declares no potential conflict of interests. received for publication: 2 january 2013. accepted for publication: 13 january 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright c. lahariya., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e1 doi:10.4081/hls.2013.e1 non -co mmerc ial us e o nly [page 2] [healthcare in low-resource settings 2013; 1:e1] journal to you. the journal aims to bring path-breaking changes in health service delivery and healthcare provision in lrss. it requires your regular contributions and inputs. the journey would be satisfying only if it could improve the health of people in the settings where they need it the most. references 1. lahariya c. journals have a bigger role to play in the healthcare delivery. indian j community med 2006;31:120. 2. sidiqui k, newell jn. putting evidence into practices in low-resource settings. b world health organ 2005;83:882. 3. currat lj, de francisco a, nchinda tc. the 10/90 report on health research 2000. geneva: global forum for health research publ.;2000. editorial non -co mmerc ial us e o nly hrev_master [page 48] [healthcare in low-resource settings 2015; 3:5411] psychosocial stressors and support needs of survivors of ebola virus disease, bombali district, sierra leone, 2015 waheed ariyo bakare,1 olayinka stephen ilesanmi,2 edmund presiror nabena,3 temitope famuyide4 1nigeria center for disease control, abuja; 2department of community health, federal medical centre, owo; 3braithwaite memorial specialist hospital, port harcourt, nigeria; 4african union support ebola in west africa, addis ababa, ethiopia abstract ebola virus disease (evd) survivors are increasing. there is a need to document their psychosocial stressors and support needs to enable appropriate interventions. the aim of this study was to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone, in 2015. qualitative and quantitative methods were used. a cross-sectional study design (questionnaire) was used for quantitative data collection from 299 survivors, while in-depth interview was done for 6 survivors. parental losses, poor economic situation, joblessness, lack of food were among the problems reported. the median age of survivors was 24 years (range 189 years). orphans were 66 (22.1%), widows were 59 (19.7%), while widowers were 19 (6.4%). food was needed by 291 (97.3%) of the survivors, 196 (65.6%) reported they needed clothing. shelter was the need of 20 (6.7%) survivors, while 246 (82.3%) wanted financial support. in all, 4 (1.4%) survivors were rejected by their families’ members, while community members rejected another 4 (1.3%). ebola survivors are champions and they should be projected in that light within their family and community. governments need to establish strategic partnership with non-governmental bodies to ensure the needs of the survivors are met. introduction the outbreak of ebola virus disease (evd) in 2014 remained by far the largest and longest outbreak of viral hemorrhagic fever ever in the world.1 the spread of evd is due to traditional, socio-cultural attitudes (funeral rites), economic and political issues and the insufficient supply of disposable infection, prevention and control (ipc) materials in the communities and hospitals.2 ebola virus can be transmitted by close contact with body fluids of an infected person (who is symptomatic) or an infected corpse. sierra leone has recorded more than 50% of confirmed cases (over 12,000) in this outbreak and more than 3000 deaths.3 in august 2014, ebola was reported in sierra leone during farming activities, and this rendered many farmers – including some ebola survivors – inactive by restricting their movement and enclosing them in quarantine homes and communities. these resulted in damaged farm produce and food shortage. there was no opportunity to harvest or store farm produce. after the rain there was nothing to sell because the majority harvested nothing. since the beginning of the 2014 evd outbreak, more than 400 ebola survivors have been recorded in sierra leone’s bombali district.4 there are few explanations to why patients go through psychosocial stresses after being discharged from ebola treatment center (etc). these factors include mental and physical health issues, how much they could count on others for support, personal and family history of mental health problems, cultural background, traditional practices, and age.5 either one or a combination of these factors influenced the medical and mental responses of survivors to ebola. these factors are also unique in the sense that each survivor bears varying degrees of how much he/she could withstand the impact of any of the factors. one major factor that assists any survivor in going through the psychological after-effects of ebola is the availability of sustainable psychosocial support systems within the immediate family and the broader community they are integrated with.6 the most common psychological challenges faced by ebola survivors include: sadness, fear, depression, frequent anxiety, panic, insomnia and nightmares, confusion, emotional numbness, embarrassment, low morale, lack of confidence, frustration, helplessness.2 these psychological effects are expressed in the outward disposition and display of survivors such as being of few words, low voice when they speak, withdrawn from people, conversation delays, over thinking, display of disregard to others, appearing lost and self-isolation and loss of hope. and there are explanations to these psychological experiences; when examined, it is realized that coming out of the etc is a single stressor producing experience. others include, family reaction when tested positive to the disease, bad experiences in holding centres, bad experiences with ambulances, excessive isolation in the red zone of the etc and the shocking news of family members who have died unknown to them while they were undergoing treatment in the etc. some studies have examined the general health needs of evd survivors.7-9 there is a need to document psychosocial stressors and support needs of evd survivors to enable appropriate interventions. this study aimed to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone. materials and methods the study was conducted at bombali district of sierra leone. bombali is the second largest district in sierra leone based on geographical land mass (after koinadugu district) and the second most populous district in the north, after port loko district. before ebola in 2014, the population of sierra leone was over 6 million.10 agricultural sector (food and tree crops, fishery, livestock and forestry) is the backbone of the economy in the country. the raining season is between may and october. a mixed method comprising of qualitative and quantitative methods was used for this study. a cross-sectional study design was used for quantitative data collection, while in-depth interview was used for the qualitative aspect. survivors in bombali district were invited to a survivor’s conference organized by the district health management team (dhmt) bombali district, african union, who, unicef and other partners. in all, 310 survivors attended the conference out of which 299 participated fully by responding to interviewer adminis healthcare in low-resource settings 2015; volume 3:5411 correspondence: olayinka stephen ilesanmi, department of community health, federal medical centre, owo, ondo state, nigeria. tel:+234.8032121868. e-mail: ileolasteve@yahoo.co.uk key words: ebola virus; psychosocial stressors; sierra leone; welfare. acknowledgements: volunteers of africa union support to ebola outbreak in west africa (aseowa), district health management team (dhmt), and staff of the world health organization (who) bombali district, sierra leone are thanked. received for publication: 2 july 2015. revision received: 31 august 2015. accepted for publication: 31 august 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright w.a. bakare et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5411 doi:10.4081/hls.2015.5411 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5411] [page 49] tered questionnaire used for data collection. the survivors’ conference was held in kamaranka village to favor those outside the city and in makeni city in february 2015. qualitative aspect this study was conducted among evd survivors. a survivor is a person who had suffered ebola as confirmed by a positive ebola polymerase chain reaction (pcr) or serology tests, went through the ebola disease management and survived the disease. the survivor status is confirmed when the patient tests negative to an ebola pcr test after evd management. saturation of ideas was achieved after interviewing 6 survivors. in-depth responses about the psychosocial experiences were obtained. few verbatim quotations were included. procedure invitation was given to the participants during a meeting. participation of survivors was voluntary. all participants were advised that they could withdraw from the study at any time. no one refused to participate and nonwithdrew their participation from this study. questions were asked about the psychosocial needs of the survivors. questions were unstructured and designed to promote openended responses. interview was between 15-20 minutes. an observer who could write fast wrote the responses. this assured complete capturing of responses. the study participants were informed that their responses would help in improving the psychosocial health of evd survivors. the psychosocial needs identified in the qualitative data collection complemented the quantitative data. the data was collected in february 2015. quantitative aspect informed consent was sought and obtained from the survivors. clinically oriented psychosocial welfare officers interviewed the respondents individually using a standardized questionnaire written in english. the questionnaire has two parts, the first part comprised of sociodemographic characteristics while the second was on their psychosocial needs. identical questions were asked from all survivors irrespective of tribe, religion or etc where they were managed. interpreters were used to aid the understanding of those who could not speak english. data management questionnaires were checked for omissions and errors. corrections were made where necessary to the questionnaires. data was analyzed with microsoft excel. only descriptive statistics was done. ethical considerations this study was based on data collected during surveillance and response activities for evd in sierra leone. all information collected on individual survivors was anonymous to improve their state of health. results qualitative results with regard to family stress, the first interviewee said that her husband had 3 wives with 14 children while her husband’s younger brother had two wives with eight children. there were 22 children in the family. the whole family comprising of adults and children (29 in all) were together in the same compound before evd affected them. only the woman and nine children were left behind as survivors. they depended on well-wishers for their daily needs, she added. the post ebola economic challenge was huge. the country’s economic situation was unfavorable to many. free movements, inter-trade between towns and cities and normal market conditions ceased following the ebola outbreak. this situation has been linked to extreme poverty, unemployment and food shortage in the country. a 12-year-old girl narrated her experiences. she and her two younger brothers were orphaned by evd. they reside in robuyya village, bombali district. the first brother was 3 years, while the second was 7 months. she solicited for food from the community for 6 months (since october 2014) to take care of her brothers. how she was able to care for a 7-month-old brother from age 2 months was surprising. another respondent lost 12 persons out of her family members to ebola. she would be 19 years in november 2015. this girl who was an orphan was also a student in one of the secondary schools in bo. the mother who got the evd from her elderly son infected her with the disease before the rest of the family contracted it. she was the only survivor among her family members. due to lack of financial support she could not join her colleagues when schools reopened. a 35-year-old man who was admitted on the 6th november 2014 at the hastings etc in freetown got the ebola virus during his rescue mission to help his people in november 2014. he is knowledgeable about the use of ppe and also trained others, but this did not prevent him from contracting the virus. i tried my best but it has been destined that i would get it. i saved many lives but i lost many of my family members to this deadly disease. i reported myself early but still, my 2 brothers, 3 children and wife died. my remaining 3 children survived but no money to take care of them, he added. a 19-year-old survivor orphaned by evd a resident of masongbo village also narrated her story. me papa, me mama die in october. my problem now be me eye. me eye no see and i no get nothing. ar no get money, ar no get job. e for better make ar die. she spoke in krio language. she was a secondary school student who was infected in january, 2015 by her survivor boyfriend that was discharged from the etc in december 2014. she was treated and discharged in january from mateneh etc. when school reopened she could not resume due to both financial issues and stigma. a nurse was also interviewed. he was the only survivor in a family of 10. his wife, 5 children, his 2 younger brothers and mother died. he started crying during the interview and he said i don’t even know where to start. he was reassured, offered some relief materials and the interview was terminated. a young man was discharged on 11th december, 2014. he collected survivors’ package from the etc, which comprises of a bag of rice, some condiments, mattress, bucket and a sac bag which contained condoms, flip-flops, blanket and some clothes. the clothes he was giving were feminine; he could not use any of it. he added that before he arrived home from the etc where he was treated all his belongings were burnt by the decontamination team. quantitative results among the 299 respondents who participated in this study, male were 117 (39.1%). the median age of survivors was 24 years (range 189 years). respondents aged 18 years and above were 204 (60.2%). orphans were 66 (22.1%), widows were 59 (19.7%) while widowers were 19 (6.4%) (table 1). table 2 shows the support needs of evd survivors in bombali district sierra leone. food was needed by 291 (97.3%) of the survivors, 196 (65.6%) reported they needed clothing. shelter was the need of 20 (6.7%), while 246 (82.3%) wanted financial support. about 144 (48.2%) were willing to learn new vocations. table 3 shows the psychological stressors encountered by evd survivors in bombali district. inability to access property was reported by 10 (3.3%) survivors. they were not privileged to go back to their property such as houses and farm after they survived and returned home. in all, 4 (1.4%) survivors were rejected by their families’ members, while community members rejected another 4 (1.3%). since the time the survivors were discharged from the etc, 106 (35.4%) were not able to return to their job or do their businesses. discussion this study aimed to document psychosocial stressors and support needs of evd survivors in bombali district, sierra leone, using quali article non co mmerc ial us e o nly tative and quantitative (mixed) methods. more than half of the studied population are female and also adults. every one out of five was an orphan and also every one in five was a widow. economic problem was common to orphans after the deaths of parents; orphans were faced with loss of household income. the problem of how to pay treatment costs was reported by those who developed post ebola health issues. most of these orphans were seen with dirty, faded and/or old cloth. orphans were easily dispossessed of their inheritance when the parents died this increased the economic problems that were already established on them.11 the severity of the economic or financial challenges facing survivors determined all other problem. there was variance in the way survivors were coping with life after ebola. some of these could be traced to how evd was communicated in their local community and the level of their own understanding of the disease. it did not help when ebola is surrounded by mythological beliefs such as the virus is a weapon of witch craft, giving an impression that anyone infected must have offended the gods. ebola was portrayed as a self-induced punishment for a wrongdoing an individual had committed. feeling of guilt conscience, indifference to getting treatment from an etc or delay in doing so and lack of any form of hope in chances of surviving the disease might be a contributory factor for not reporting early. ebola affected all the socio-economic activities in the affected countries. this added to the problems of survivors. the opportunity to trade was not available with lock down of movements here and there. kudos to government of sierra leone and also the ministry of social welfare, gender and children affairs for making sure that survivors got what was called survivors package at the point of their exit from the etcs. the packages vary though based on the treatment centre but the fact was that the government and some partners were there to give the survivors some essential emergency needed including money following discharge from the etc. the social challenges facing ebola survivors were numerous and these generally fell within food, shelter, finance, education and health services. these needs also vary based on the classes of survivors such as orphans, widows/widowers, divorced, aged and children. conclusions discussions are on to know the issues facing the survivors after discharge from the etc. there is need for haste in converting these discussions into tangible interventions. a comprehensive approach must include proper integration of survivors into the community. we have heard of survivors rejected by their communities on the grounds that they were witches. it is unacceptable for a person to survive a disease as deadly as ebola only to die from poverty, frustration from hunger or lack of job. therefore, the government in conjunction with implementing partners must help these survivors to restart their lives. a holistic approach for addressing psychological challenges of survivors should include a focused psychological first aid to help survivors article table 1. sociodemographic characteristics of survivors of ebola virus disease, bombali district, sierra leone, 2015. sociodemographic characteristics frequency percent sex male 117 39.1 female 182 60.9 age group (years) <18 95 31.8 ≥18 204 60.2 marital status single/married 155 51.8 widows 59 19.7 widowers 19 6.4 orphans 66 22.1 table 2. support needs of survivors of ebola virus disease, bombali district, sierra leone, 2015. support needs frequency percent food yes 291 97.3 no 8 2.7 clothing yes 196 65.6 no 103 34.4 shelter yes 20 6.7 no 279 93.3 financial support yes 246 82.3 no 53 17.7 vocational needs yes 144 48.2 no 155 51.8 table 3. psychological stressors encountered by survivors of ebola virus disease, bombali district, sierra leone, 2015. stressors frequency percent inability to access property yes 10 3.3 no 289 96.7 family rejection yes 4 1.3 no 295 98.7 community rejection yes 4 1.3 no 295 98.7 job loss yes 106 35.4 no 193 64.6 [page 50] [healthcare in low-resource settings 2015; 3:5411] non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5411] [page 51] understanding their conditions and reverse negative assumptions they probably hold in mind. an aggressive community behavioral change communication must be put in place to inform and guide communities and family members on the significance of surviving ebola and the peculiar psychological support they require to help rebuild their lives to normality, particularly addressing the issues of stigmatization.12,13 ebola survivors are champions and they should be projected in that light within the family and community. effective health education/communication would help to identify the needs of the survivors.6 governments need to establish more strategic partnership with non-governmental bodies in the area of treatment, research and welfare. references 1. centers for disease control and prevention. 2014 ebola outbreak in west africa. available from: http://www.cdc.gov/vhf/ebola/outbreaks/20 14-west-africa/ 2. umeora o, emma-echiegu n, umeora mna. ebola viral disease in nigeria: the panic and cultural threat. afr j med health sci 2014;13:1-5. 3. saeidi m, moghadam ht, kiani ma, et al. a short overview of ebola outbreak. int j pediatrics 2014;2:287-94. 4. national ebola response centre. nerc 2015. available from: http://nerc.sl/ 5. the world bank. the socio economic impact of ebola in sierra leone 2015. available from: http://www.worldbank.org /en/topic/poverty/publication/socio-economic-impacts-ebola-sierra-leone 6. davtyan m, brown b, folayan m. addressing ebola-related stigma: lessons learned from hiv/aids. global health action 2014;7:26058. 7. bausch dg. sequelae after ebola virus disease: even when it’s over it’s not over. lancet infect dis 2015;15:865-6. 8. medical xpress. study examines long-term adverse health effects of ebola survivors 2015. available from: http://medicalxpress.com/news/2015-04-long-termadverse-health-effects-ebola.html 9. clark dv, kibuuka h, millard m, et al. long-term sequelae after ebola virus disease in bundibugyo, uganda: a retrospective cohort study. lancet infect dis 2015;15:905-12. 10. countrymeters. sierra leone population 2015. available from: http://countrymeters.info/en/sierra_leone 11. steinberg m, johnson s, schierhout g, ndegwa d. hitting home: how households cope with the impact of the hiv/aids epidemic: a survey of households affected by hiv/aids in south africa. menlo park, ca: kaiser family foundation; 2002. available from: http://www.ceped.org/cgi /wwwisis. cgi/%5bin=../cdrom/orphelins_sida_2006/ en/biblio/direct.in%5d/?t2000=124x/%285 %29 12. mcleroy kr, norton bl, kegler mc, et al. community-based interventions. american j of public health 2003;93:52933. 13. start fund. is sensitisation effective in changing behaviour to prevent ebola transmission? available from: http://www. start-network.org/wp-content/uploads/ 2014/09/start-fund-sle-case-study.pdf article non co mmerc ial us e o nly hrev_master [page 38] [healthcare in low-resource settings 2014; 2:1897] disinfection: an indispensable tool in controlling outbreaks in low-resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, previously, infection control authorities believed that the environment played little or no role in the transmission of infectious disease; in fact, the role of the inanimate environment in disease transmission has been reexplored. the centers for disease control and prevention stated that contact transmission (viz. direct from body surface or indirect transmission via contaminated inanimate objects) is one of the main routes of microorganism transmission.1 disinfection is defined as the process that eliminates many or all pathogenic microorganisms, except bacterial spores and inanimate objects.2 considering the global threats of emergence and re-emergence of old diseases, especially in low-resource settings disinfection of soiled articles at appropriate time can be of paramount importance in preventing and controlling outbreaks/epidemics of communicable diseases.3 the process of disinfection can be either carried out concurrently (viz. disinfection of the patient himself, of his excreta and discharges and of all articles used by him or likely to have been contaminated during the course of his illness, including hands and clothing of attendants) or terminally (viz. disinfection of the room or premises and their contents after the patient has recovered, died or has been removed elsewhere).2 the principles of disinfection have been found to be of immense help not only in preventing but also in controlling disease outbreaks in different practical settings (viz. tuberculosis control);4 chicken-pox outbreak in a medical college;5 in preventing rotavirus and norovirus associated gastroenteritis outbreaks;6 and in intensive care units, to minimize transmission of infections.7 although the incidence of most of the communicable diseases has decreased in developed nations, the advantages of appropriate disinfection measures cannot be neglected in averting transmission of infectious diseases to health care providers.8 in order to minimize nosocomial infections, planning of an effective cleaning and disinfection program is the foremost requirement. there are several important areas which should be addressed in developing an effective disinfection action plan, starting with promoting regular hand washing followed by assessment of the prevalent infectious agents (viz. identifying and evaluating the infectious agent suspected with the help of laboratory tests, its mode of transmission, potential areas affected and selection of the proper disinfectant), cleaning, washing, disinfection, and ultimately evaluation to verify that the disease agent(s) have been destroyed. once a disinfection plan is devised, all employees should be trained and re-trained about the absolute implementation of the disinfection protocol. in order to extend the benefits of disinfection in rural/tribal areas, grass-root level workers should be trained about proper disinfection measures of sputum, feces and soiled articles.3 to conclude, the proper implementation of environmental disinfection in low-resource settings reduces the incidence of infection, creating a public health benefit for the patients, community and health care workers by reducing the number of pathogenic microorganisms on surfaces. references 1. garner js. guidelines for isolation precautions in hospitals, 1996. infect control hosp epidemiol 1996;1:53-80. 2. rutala wa, weber dj, healthcare infection control practices advisory committee (hicpac). guideline for disinfection and sterilization in healthcare facilities, 2008. available from: http://www.cdc.gov/hicpac/pdf/guidelines/disinfection_nov_2008 .pdf 3. jones ke, patel ng, levy ma, et al. global trends in emerging infectious diseases. nature 2008;451:990-3. 4. ziegler r, just hm, castell s, et al. tuberculosis infection control: recommendations of the dzk. gesundheitswesen 2012;74:337-50. 5. shrivastava sr, shrivastava ps, ramasamy j. epidemiological investigation of a case of chickenpox in a medical college in kancheepuram, india. germs 2013;3:18-20. 6. protano c, vitali m, raitano a, et al. is there still space for the implementation of antisepsis and disinfection to prevent rotavirus and norovirus gastroenteritis outbreaks? j prev med hyg 2008;49:55-60. 7. kossow a, schaber s, kipp f. surface disinfection in the context of infection prevention in intensive care units. med klin 2013;108:113-8. 8. araujo mw, andreana s. risk and prevention of transmission of infectious diseases in dentistry. quintessence int 2002;33: 376-82. healthcare in low-resource settings 2014; volume 2:1897 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: disinfection, outbreak, gastroenteritis, hand washing, low-resource settings. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting the article, review of literature, critical revision of the article for important intellectual content; jr, general supervision of research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 28 august 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1897 doi:10.4081/hls.2014.1897 non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:4471] [page 19] do district health systems perform differently because of their managers? preliminary insights from indonesia augustine asante,1 sandi iljanto,2 john rule,1 jennifer doyle1 1school of public health and community medicine, unsw australia, sydney, australia 2faculty of public health, centre for health administration, management and policy, university of indonesia, jakarta, indonesia abstract district health systems (dhs) are central to the global efforts to improve health outcomes but many remain ineffective. in many lowresource settings, despite the generally weak dhs there is evidence that some districts consistently perform well against the odds, and this is often attributed to the calibre of managers leading such districts and their management and leadership (m&l) skills. this paper examines the m&l practices of district health managers in high and low performing districts in indonesia in an attempt to understand whether the differences in the performance of dhs can be explained, at least in part, by the differences in the performance of their health managers. we employed a mixed methods case study design focusing on two purposefully selected districts. data were collected in 2011 using questionnaires and in-depth interviews. the preliminary results suggest that m&l practices of managers in the high and low performing districts are similar and provide little explanation for the differences in the performance of the two dhs. contextual and health system factors offered a much better explanation for the variations in dhs performance. introduction district health systems (dhs) are pivotal to the delivery of basic health services and achievement of the health millennium development goals (mdgs). in lowand middleincome countries (lmics) dhs are usually comprised of community health centres, networks of local facilities delivering primary health care (phc) and outreach services, and district hospitals that receive referrals from health centres.1 efforts to strengthen dhs globally date back many years and have had varying degrees of success. in countries such as thailand, the local health system functions relatively well through an established system of financing and network of providers.2 in other southeast asian countries including the philippines and indonesia, efforts to strengthen dhs are linked to a radical policy of decentralization of healthcare systems with the devolution of health services to local governments.3 such restructuring may affect the performance and equity of health systems.4 within countries there may be variations in the performance of dhs. in south africa the district health barometer 2010/11 shows significant differences in the performance of dhs across a wide range of health indicators.5 it is widely believed that the calibre of health managers who lead the dhs, particularly their management and leadership skills, has much to do with the differences in the performance of dhs.6,7 in 2007, the world health organization (who) sponsored international consultations on management and leadership (m&l) in lowincome countries concluded that weak m&l capacity is a barrier to effective health systems including dhs.7 strengthening m&l capacity has been an integral part of the global efforts to improve the effectiveness of health systems including the dhs. despite this, m&l capacity is generally weak in many low-resource settings and the need to identify effective interventions for improving the capacity and performance remains urgent.6,7 indonesia is a middle-income country and the largest economy in southeast asia. the government of indonesia has prioritised phc, committed to implementing universal health coverage, and to reducing maternal mortality.8 the effectiveness of the dhs and the performance of its managers are crucial to achieving these goals. as part of the efforts to strengthen dhs, the indonesian ministry of health (moh) assesses and ranks districts by performance using a health development index created by its national institute of health research and development (nihrd) and some districts perform relatively better than others.9 in this study, two groups of health service managers selected from a high and a low performing district were examined in an attempt to understand why some dhs perform relatively better than others and the role m&l practices play in improving dhs performance. as an exploratory study, the objective was not to attribute effective m&l practices to improved dhs performance at this stage but to use the findings as a basis for a follow up study that will assess more comprehensively the link between m&l practices and dhs performance. the study was part of a broader collaborative project between the university of new south wales (human resources for health knowledge hub), the centre for health service management, universitas gadjah mada (ugm) and researchers from university of indonesia. ethics approval was obtained from the ugm ethics committee with permission from provincial health authorities. materials and methods design this investigation employs a mixed methods case study design focusing on two purposefully selected districts in the west java province – one relatively high performing (district a) and one low performing (district b). the definition of high and low performing districts was based on the 2008 nihrd ranking of health districts.9 two sets of indicators comprising 10 generic measures in each set healthcare in low-resource settings 2015; volume 3:4471 correspondence: augustine asante, school of public health and community medicine, faculty of medicine, unsw australia, sydney nsw 2052, australia. tel: +61.2.93858683 fax: +61.2.93136185. e-mail: a.asante@unsw.edu.au acknowledgements: we acknowledge the input of dr. graham roberts and other staff of the human resources for health knowledge hub, unsw australia. contributions: aa conceived and designed the study; he oversaw the data analysis and drafting of the manuscript. si oversaw the data collection and contributed to the data analysis and drafting of the manuscript. jr and jd contributed to data analysis and drafting of the manuscript. all authors reviewed the final draft of the manuscript. conflict of interest: the authors declare no potential conflict interest. funding: this study was carried out as part of the activities of the human resources for health knowledge hub which was funded by the australian aid. the views and opinions expressed therein are those of the authors and do not necessarily reflect those of the australian aid. key words: district health systems; health managers; indonesia; management and leadership; performance. received for publication: 28 june 2014. revision received: 28 august 2014. accepted for publication: 26 september 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. asante et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4471 doi:10.4081/hls.2015.4471 non co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2015; 3:4471] were used to assess the m&l practices of health managers in the two districts (table 1). the indicators covered some of the basic moh functions of district health managers and were put together in consultation with the provincial health authority and after reviewing the published and grey international and local literature. the leadership indicators were used to assess the leadership practices of the head of the dho as the designated manager. data collection data were collected in 2011 from three levels of the health system provincial, dho and facility. at the provincial level two in-depth interviews were conducted with senior officials of the provincial health office (pho) exploring issues around i) m&l practices of the dho managers and ii) the differences in performance of the various dhs in the province. this information was used to triangulate data obtained from district managers. at the dho level we used researcher-administered questionnaires and in-depth interviews to gather data on a range of issues including supervision, performance evaluation and personnel administration from five officials with managerial responsibilities including the head of the dho. finally, at the facility level we used semi-structured interviews to elicit views on m&l practices of the dho manager and general information about health delivery in the district. we used snowball sampling approach to recruit participants. verbal permission was obtained from heads of various levels who recommended other managers whom we could approach and invite to take part in the study. consent was obtained from each participant. in total, we conducted 20 interviews in the two districts: ten at the dho level (five in each district), eight at the health centre level (four in each district) and two at the provincial level (figure 1). data analysis we developed a simple scoring system to analyze the data. for the quantitative questions that explored whether a management activity (denoted by an indicator) was carried out by the district team, we assigned a score of 0 to a negative (no) response and 1 to a positive (yes) response. a further score of 0, 0.5, or 1 was assigned if the qualitative account of the respondent suggested that the activity was rarely, partially or routinely carried out. where possible, we triangulated the information obtained at the dho level with data from the provincial and health centre levels to ensure reliability. the total score of each of the 10 indicators were aggregated to get the final district score. for the leadership indicators the questions were on a likert scale and were scored from 0 (strongly disagree) to 4 (strongly agree). a maximum score of 16 per indicator was derived from the four respondents in each district. this was scaled down to 10 to give a total score of 100 for all the ten indicators. results characteristics of managers all 10 respondents from the two dhos were aged between 47 and 54 years and seven were female. eight of the 10 were eligible to retire within the next five years in compliance with the official indonesian civil service retirement age of 55 years for staff in structural (managerial) positions. the primary professional qualifications were predominantly medicine and dentistry (two gps and two dentists from each district). all respondents had worked in the health service for over 15 years with most of them working their way up from the sub-district level. nearly all reported spending 100% of their time on management issues, contradicting the general assumption that health managers often perform dual roles as managers and clinicians. the majority of respondents indicated, however, that they practice privately as clinicians or dentists after office hours. formal training in management was limited; six of the 10 respondents had no management qualification. however, all 10 had attended a short training program in leadership and health administration conducted for structural staff in the public sector by the regional civil service agency (badan ketenagaan daerah – bkd). management and leadership practices knowledge of responsibilities and use of manuals management roles and functions were performed to a similar degree in the two districts. all respondents indicated that they were fully aware of their management responsibilities and that detailed written job descriptions including responsibilities and authority had been provided with their appointment letters. they also confirmed that there were standard operating manuals and guidelines for all pro article table 1. indicators for assessing management and leadership practices of managers. management indicators leadership indicators know responsibilities as manager listen to staff have and use procedural manuals understand the needs of staff undertake routine staff assessment treat staff as individuals provide timely feedback on staff assessment set good work examples worth emulating handle staff disciplinary matters effectively motivate and encourages staff request drugs and supplies on time handle staff matters fairly and consistently undertake regular staff supervisory visits acknowledge jobs well done have regular technical meetings handle disciplinary matters without any bias use health data for decision making show concern for staff career advancement collaborate with the non-government sectors generally enjoy the respect of staff figure 1. number and location of interviews. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:4471] [page 21] grams, which were adjusted as required for local conditions. however, it should be noted that interview data from both districts suggest that the manuals were mainly technical manuals guiding program implementation and not for personal administration purposes (table 2). overall, there appeared to be a strong culture of referring to formal, written guidelines with the majority of respondents stating that they must always adhere to the rules and regulations or steps that are described in the technical guidelines. the use of manuals appeared more strongly observed in district a than b (table 2). performance assessment and feedback the data from the dho level indicate that some form of staff performance assessment was carried out although there was no consensus on the frequency of such assessment; reported frequency ranged from once every three months to once a year. respondents explained that the performance assessment process was hierarchically arranged with the dho head being evaluated by the head of the district (bupati), then he/she evaluates the other managers (unit heads) at the dho who in turn evaluate their subordinates in the subdistricts. they further explained that a standard civil servant performance evaluation form known as assessment of working performance (daftar penilaian pelaksanaan pekerjaan or dp3) was used for assessment with the results used mainly for staff promotion purposes. some respondents expressed dissatisfaction with the dp3-based assessment, indicating it does not assist them to improve upon their performance: it (dp3-based assessment) is not helpful because it is just normative; sometimes i don’t understand how... it should be filled out differently for each person, right? but it is not... to me, it is better not to use the dp3. i mean if we are assessing performance, it must be different between staff; some are diligent; some are not but still good in other areas. for example, i often perform tasks that are not listed in my tupoksi (job description) but are very important, dp3 won’t consider that (district a dho level respondent). there was no agreement among the respondents at the dho level as to whether written feedback on performance (other than the duplicate copy of the completed dp3) was given to staff. however, data from the health centre level in both districts clearly suggest that no written feedback on performance (aside the dp3 duplicate copy) was given. staff supervision and disciplinary matters supervision of health centres was regarded by respondents in both dhos as an integral part of the dhs monitoring and evaluation process. the district b dho appeared to have a well-structured system of supervision involving assigning specific facilities and geographic areas to individual managers. participants also reported that they undertook emergency supervisory visits to health centres if the situation on the ground warranted it. there were inconsistencies in the data from district a regarding the frequency of supervision with some respondents indicating that supervision of health centres was done several times in a month while others stated it was done annually. regardless, respondents from both districts described supervision as being facilitative and program-based; in other words it was used to monitor program implementation and provide technical assistance to those implementing the programs. no differences were found between the two districts in relation to staff disciplinary matters. in both districts there were formal procedures for managing disciplinary issues, which all respondents reported they followed. government regulation no. 53 year 2010 outlines the course of actions to be taken against civil servants who contravene civil service rules and regulations. respondents from both districts observed that depending on the nature of violation, disciplinary action could consist of a light, medium or severe reprimand for the staff involved. an absence from work for 16-30 working days without permission, for example, could lead to a delayed salary increase of up to one year, a postponement of promotion for a year, or a demotion to a lower level for a year. technical meetings and request for supplies technical meetings were held regularly in both districts according to the dho level data. meetings occurred at least once in a month or more if the situation on the ground required it. these meetings included participants from health centre level, usually the health centre heads. in both districts, specific programs held their own technical meetings to plan or review implementation progress. a record of minutes of larger technical meetings indicating issues discussed and proposed actions to be taken were kept at the dho and reviewed in following meetings. respondents from both districts thought technical meetings were effective and useful. respondents from all the three levels where data were collected indicated that drugs and other essential supplies were requested on time following an established process for requesting materials. the overall availability of drugs in both districts was reported as satisfactory with only occasional shortages especially during disease outbreaks and other emergency situations. leadership similar to management practices, there was little difference overall in leadership behaviour between dho heads, except perhaps in the areas of personal initiative to get things done and fair and consistent dealing with staff disciplinary issues. in these two areas the head of district a dho scored slightly better than district b (table 2). several respondents believed the personal initiative of the district a dho head had played a role in getting the local government to support district health activities such as the implementation of free medical care for people suffering from dengue and mobiliza article table 2. performance of management and leadership roles by district. indicators district a district b score score management know responsibilities as manager 10.0 10.0 have and use procedural manuals 9.0 5.0 undertake routine staff performance assessment 7.5 7.5 provide timely feedback on performance 7.5 7.7 handle staff disciplinary matters effectively 10.0 10.0 request drugs and supplies on time 10.0 9.4 undertake regular staff supervision 7.0 7.5 hold regular technical meetings 10.0 10.0 use health data for decision making 8.0 9.1 collaborate with the non-government sectors 8.0 6.5 leadership listen to staff 10.0 10.0 understand the needs of staff 6.5 6.9 treat staff as individuals 5.6 6.3 set good work examples worth emulating 8.8 8.1 personal initiative to get things done 9.5 7.0 diligent in handling personnel matters 7.5 6.9 acknowledge jobs well done 8.1 7.5 fair and consistent in dealing with staff disciplinary issues 10.0 7.5 show concern for staff career advancement 7.5 7.5 generally respected by staff 9.4 8.8 non co mmerc ial us e o nly [page 22] [healthcare in low-resource settings 2015; 3:4471] tion of local resources to support high-risk mothers in need of medical care. these initiatives were deemed to have reduced financial and other barriers to accessing health care in the district for these groups. overall, both dho heads appeared to enjoy considerable respect from the health staff in their districts, although there was some reluctance on the part of health centre participants from both districts to say things about the dho heads that could be perceived as unpleasant. it was also clear that some of the health centre staff had not been in their positions long enough to have a personal view about the head of the dhos. organizational and contextual factors there were differences between the two districts in terms of key health system organizational factors including number of health workers, authority over staff, funding adequacy and timely disbursements, and access to transport. however, the differences were not all in favour of district a (the high performing district) as one would expect. although scores for health workforce numbers and authority over staff were better in district a, timely disbursement of funds from dho to sub-districts and access to transport favoured district b (table 3). in both districts respondents generally felt that funding for the dhs was inadequate, and in district a the majority indicated that disbursement was often delayed. some respondents attributed the problem to a range of issues including unfavorable budget cycle, politics at the regional level, and weakness of the dho finance office. they all acknowledged, however, that the finance and budgeting system had improved and that on the whole funding and disbursement processes were getting better. workforce numbers were inadequate in both districts but more so in district b than a. respondents from the two districts indicated that the growing need to provide services previously not provided such as methadone treatment and aged care services, especially in district a, has contributed to the inadequacy. existing staff had to perform additional roles sometimes in areas they were not trained to cope with the shortage. there were differences between the two districts in terms of the context in which the health system functioned. district a is a municipality located just some 25 kilometres away from central jakarta it is largely one of its suburbs. it also has a smaller population of around 1.5 million that is spread across a 200 square kilometre stretch of land. the proportion of the population living in poverty is relatively low about 2.4 percent, and the literacy rate is 100 percent. district a also has more private hospitals and limited presence of nongovernment providers. the district’s fiscal outlook as illustrated by the ministry of finance’s fiscal capacity index of 1.2508 (table 3) is among the best in the west java province. district b, by contrast, has nearly three times the population of district a (4.3 million) and more than 10 times the landmass. the district’s location could not be described as remote since the district capital is only 55 km away from jakarta. however, several of the sub-districts are not easily accessed and poverty appears more widespread than in district a. there is also a substantial presence of nonprofit health providers – a further indication of high-unmet health needs. discussion the similarities in m&l practices of managers in the two districts raises several issues regarding the contributions of district health managers to the overall performance of dhs and the extent of influence of contextual and other factors. arguably, because of the common legislative framework (government decree no 41/2007) underpinning the appointment and work of heads of local government departments in indonesia, including dho heads, there is bound to be some similarities in characteristics of managers and their m&l practices. the issue of ageing of managers in both districts, for example, may be attributed to the regulations governing the appointment of dho managers. the district health manager position is a structural position that by law must be occupied by a senior staff member (echelon ii for dho head and iii for unit head). this requirement makes it difficult to appoint a younger person who has not served for many years in the health system irrespective of the district in which they serve. it is therefore not unexpected that most managers were approaching retirement. the legislation also outlines the functions of dho heads as local government officials, which include policy development and implementation as well as development of guidelines for implementation.10 a review of the written job descriptions of dho managers from the two districts confirmed that these managers have similar duties and responsibilities. their main task is to coordinate the implementation of government health policy within the district including coordinate health planning, organise health service delivery, monitor program implementa article table 3. organizational and contextual factors relating to the health systems. indicators district a district b organizational factors adequate and timely disbursement of funds 5.0 7.0 (score) adequate number of health workers 7.0 5.0 established functional system of procurement and supply 10.0 10.0 functional health management information system 7.0 7.0 access to transport 6.0 7.0 established system of incentives 7.0 7.0 authority over staff 7.0 5.0 authority over finance 10.0 10.0 context district population (n) 1,500,000 4,300,000 area (land size in km2) 200 2371 fiscal capacity of district 1.2508 0.2588 remoteness of district (distance in km) 25 55 proportion of poor population 2008 (below national poverty line %) 2.4 13.1 education (literacy rate %) 100 97.6 size of non-government support for health limited substantial size of private for-profit sector (private hospitals) 15 10 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:4471] [page 23] tion and assess service performance. other district health management teams (dhmt) members have similar roles and responsibilities relating specifically to their units or divisions. this may explain why only minor differences exist in the m&l practices of the managers in the two dhos. the law, however, provides for local government heads (bupati) to add to the scope of work of dho heads based on the needs of the district. where the needs of individual districts differ, one would expect that the nature and scope of work would also differ to some extent. the lack of any significant differences in m&l practices in the study districts, despite the differences in health needs, may be interpreted as the district heads (bupati) not exercising their right of adding to the scope of work of dho heads where necessary. effects of context and organizational factors the differences in contextual and organizational factors between the two districts provide some explanations for the performance differences. district b (the low-performing district), is relatively disadvantaged in terms of population size, landmass and access to health personnel. with nearly 3 times the population of district a, 10 times the landmass and many rural and remote communities, district b has the more daunting task regarding the delivery of health care. at the very least a significant amount of resources, particularly human resources are required to accomplish efficient and effective health care provision. disparities in socio-economic conditions between the two districts also shed light on variations in dhs performance. as a municipality, district a (the high performing district) has a relatively well-developed infrastructure and easy access to health facilities including hospitals in jakarta. only 2.4% of the district population live below the national poverty line (compared to over 13% in district b) and nearly 87% of district a households have access to proper sanitation (compared to less that 50% of households in district b).9 the relationship between socio-economic status and health in developing countries has been well-documented.11 there is ample evidence that poor people suffer worse health. in zimbabwe, for example, woelk and chikuse12 found that stunting, underweight and diarrhoea episodes varied by socioeconomic status with children the lowest socioeconomic group having increased risk of being underweight. overall, district b’s low socioeconomic status may have played a significant role in the relatively low performance of its dhs. conclusions while no major differences in m&l practices were found between the two study districts, this should not lead to the conclusion that m&l practices of district health managers do not affect the overall performance of dhs. it must be emphasized that although the aim of the study was to understand why some dhs perform relatively better than others, it was an exploratory study to test the feasibility of a more comprehensive study, potentially with a nationally representative sample of highand low-performing districts. to that end, valuable lessons have been learned from the selection of cases and administration of the research instruments. it was clear, however, that context and health system organizational factors crucially influence dhs performance and deserve careful analysis in order to establish the degree of such influence. references 1. segall m. district health systems in a neoliberal world: a review of five key policy areas. int j health plan m 2003;18(s1):s5s26. 2. hisro. thailand’s universal coverage scheme: achievements and challenges. an independent assessment of the first 10 years (2001-2010). nonthaburi, thailand: health insurance system research office ed.; 2012. 3. chongsuvivatwong v, phua kh, yap mt, et al. health and health-care systems in southeast asia: diversity and transitions. lancet 2011;377:429-37. 4. heywood p, choi y. health system performance at the district level in indonesia after decentralization. bmc int health hum rights 2010;10:3. 5. day c, barron p, massyn n, et al. district health barometer 2010/11. durban: health systems trust; 2012. 6. msh. an urgent call to professionalise leadership and management in health care worldwide. cambridge, ma: management sciences for health; 2006. 7. who. towards better leadership and management in health: report on an international consultation on strengthening leadership and management in low-income countries. available from: www.who.int/management/ working_paper_10_en_opt.pdf 8. rokx c, schieber g, harimurti p, et al. health financing in indonesia: a reform road map. washington dc: the world bank; 2009. 9. nihrd-moh. health indicators in indonesian jakarta. jakarta, indonesia: national institute of health research and development, ministry of health; 2009. 10. indonesian national government. government regulation no. 41/2007 on regional structure of organization. jakarta, indonesia: indonesian national government; 2007. 11. gwatkin dr. health inequalities and the health of the poor: what do we know? what can we do? b world health organ 2000;78: 3-18. 12. woelk g, chikuse p. using demographic and health surveys (dhs) data to describe intra country inequalities in health status: zimbabwe. mid-rand, south africa: equinet; 2000. available from: http://www. equinetafrica.org/bibl/docs/pol09equity.pdf article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:10658] [page 1] a descriptive study on nursing practice environment among public sector nurses in lahore zunira amir,1 shama maroof,2 shahbaz haider3 1assistant nursing instructor, lady aitchison hospital, lahore, pakistan; 2superior college of nursing, lahore, pakistan; 3superior university, lahore, pakistan abstract pakistan is a country where the nursing profession still has to get a good working environment as it is directly related to improved patient care. the nursing practice environment is a key factor that contributes to retention. bearing in mind the importance of the issue the present study is designed to know the current state of the nursing practice environment. the data were collected from the nurses working in the medical wards and critical care units in the pakistan institute of neurosciences, lahore. convenience sampling was used to select the respondents and collect the data. a total of 150 questionnaires were distributed among the nurses and 110 questionnaires were used for the data analysis in statistical package for social sciences. frequency, descriptive statistics, reliability, and validity analyses were performed. as per the results of the study, the questionnaire used in the study was reliable and valid. additionally, the results of the study established that the nursing practice environment is poor asking for concrete steps to make it better for improved patient care delivery. nurse leaders can dedicate their efforts to the improvement of the nursing practice environment to improve the nurse job outcomes. further, they can also arrange the trainings for the professional development of the nurses to ensure the better healthcare services delivery. the perceptions of the good nursing practice environment can be fostered among the nurses by having their active participation in the hospital matters and decision making because they are also the key staff in the hospital environment. introduction environment exerts influence on the nurses, patients and organizational outcomes as well where healthcare services are provided to the patients. the authorized nurses in the hospital tend to increase a sense of responsibility among them. the resources availability in the hospital environment is necessary to deliver the patient care and address their needs related to the care provided. additionally, the effective communication can be maintained in a good working environment in hospitals.1 continuing on environment it is worthy to mention that the nursing practice environment is a key factor that contributes to the retention and recruitment of nurses, at the same time it has a significant impact on nurse missed nursing care and directly or indirectly influences the quality of nursing care.2 shift work among nurses may reduce their well-being3 quality of sleep that causing medication errors in nurses. besides the shift work, previous research indicated that the conflict between nurses and physicians in the ward reduces the impact of quality of care and leads to negative patient outcomes.4 a study was conducted to find out the relationship between adequate staff and resources’ impact on patient satisfaction. the study finding reveals that increased workloads, inadequate nurse-patient ratios, long time for work, and increased documentation cause stress, fatigue, and disappointment in nurses and their levels of care. an adequate number of staff nurses and the availability of proper resources positively affect nurse performance and the quality of patient care.5 accordingly, global shortages of nurses are the main reason for role overload, job dissatisfaction, and poor nursing practice environment among nurses. moreover, wilson enlightened the fact that inadequate availability of health care professionals has been recognized as a global issue. rivaz et al.5 suggested that an adequate number of staff nurses and the availability of proper resources positively affect nurses’ performance and quality of patient care. wang et al.6 concluded that the negative perceptions of nursing practice environments were also significantly associated with intentions to leave their jobs. bawakid et al.7 suggested that patients will satisfy and cure early if they patient is happy with the health services provided by health care providers. rivaz et al.5 studied that due to poor management, work overload, lack of time, and improper hospital strategies impact proper care delivery on the other hand adequate number of staff nurses and proper availability of resources positively affect nurse performance and quality of patient care. nurse performance will be optimal in a better environment that contributes to giving proper care to the patient which ultimately leads to patient satisfaction and nurse job satisfaction.6 the collaborative teamwork of nurses and physicians leads to proper patient care and a work environment that results in positive organizational outcomes.7 during the patient’s stay in the hospital nurse’s polite behavior, attitude, timely healthcare in low-resource settings 2023; volume 11:10658 correspondence: shahbaz haider, superior university, lahore, pakistan. tel.: +923086149902 e-mail: shahbazhaider199@gmail.com key words: nursing practice environment; staffing adequacy; nurse leader; nurse training and development; nurse-physician collegial relationship. acknowledgment: we acknowledge all the nurses who participated in the study voluntarily. contributions: all the authors have equally contributed. conflict of interest: the authors declare no conflict of interest. funding: this research study is not funded by any institute/agency. clinical trial registration: this does not apply to the present study as it is not an experimental study or clinical trial. availability of data and materials: data is available from the corresponding author on request. ethics approval: the research study is approved by the research committee of superior college of nursing, lahore (ref. # scn/rc/2021-rn08) informed consent: this does not apply to the present study as data were not collected from the patients. permission to reproduce material from other sources: all the materials have been cited and permissions obtained if necessary. received for publication: 7 june 2022. revision received: 8 january 2023. accepted for publication: 12 january 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:10658 doi:10.4081/hls.2023.10658 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly solving of the patient’s problem, and empathy toward the patient can build up trust in health care providers to improve the patient’s condition, and patient satisfaction.8 nurse managers improve the clinical practice environment by proper balancing of resources, bed allocation, positive attitude towards subordinates and teamwork leads to a positive practice environment which leads to the positive patient, nurse, and organizational outcomes. nurse behavior toward patients is the key to positive patient outcomes and nurses will lead to compassion satisfaction.9 therefore, the study has the objective to assess the state of nursing practice environment in the public sector hospital in lahore, pakistan. the significance of this study lies in the fact that it has considered the nursing practice environment comprising of many factors including staff adequacy, resources, nurse-physician collegial relationship, quality of care, and nurse perception that results in positive organizational outcomes such as quality of care. the study is also significant since it measures the perceptions of the nursing practice environment of nurses. it is argued that the nursing practice environment denotes the surroundings in which a nurse works and influences the control of quality to deliver nursing care. it is also important for nurses to develop an awareness about their perception of the working environment that has a positive impact on their performance and enhances the patients’ satisfaction.1 accordingly, it becomes necessary to know the current state of perceptions of the nurses regarding their nursing practice environment so that the administration may take necessary steps for its improvement ultimately aiming for a higher quality of patient care. materials and methods the study aims to assess the current state of the nursing practice environment. the current section describes the research methods adopted to complete the study. population and sample size the current study is quantitative and follows the deductive approach. in this regard, the study was designed in the tertiary care hospital of lahore. all the nurses in the medical and critical care departments were the population of the study. accordingly, nurses were selected from medical care and critical care departments as a sample to represent the population of the study. questionnaire and measurement data were collected by using the previously validated questionnaire of the nursing practice environment. there are different questionnaires for the assessment of the nursing practice environment, for instance, the korean general unit-nursing work index,10 revised nursing work index,11 and nursing practice environment.12 it is worthy to note that the nursing practice environment is one of the widely used scales and the present study adapted it for data collection. it has been previously used by different studies in pakistani nursing context as well.13 lake13 developed a scale to measure the nursing practice environment containing the five dimensions. the nurse participation in hospital affairs was measured by five items (i.e., staff nurses are not involved in the internal governance of the hospital). the nursing foundation for quality of care was measured by adapting five items (i.e., nursing care is not based on a nursing, rather a medical, model in this hospital). nurse manager ability, leadership, and support of nurses were measured by adapting eight items (i.e., supervisors do not use mistakes as learning opportunities, rather as criticism). staffing and resource adequacy was measured by adapting five items (i.e., there is not enough time and opportunity to discuss patient care problems with other nurses), finally, three items were used to measure the collegial nurse-physician relations (i.e., there is less functional collaboration, that is, joint practice, between nurses and physicians). after preparing the questionnaire it was then sent to the academicians and practicing nurses to ensure the face validity of the questionnaire. after the review, necessary minor adjustments were made before distribution of the questionnaire for data collection. data collection data were collected by using the questionnaire. a total of 150 questionnaires were distributed among the nurses working in public hospital in lahore. all the nurses voluntarily participated in the data collection. a total of 110 valid questionnaires were used for data analysis. the participants were selected by using convenience sampling for data collection. every nurse that was readily available in the ward was approached and informed. the participants were all able to converse, read, write and speak english so the questionnaire was not translated into the urdu language. the sample size was sufficient for the study as it resulted in 73% response rate approximately. the study adopted the questionnaire for data collection and previously studies reported that the response rate of the nurses as follows for the questionnaire mailed, emailed and handed out the response rate of nurses was 58%, 57.4% and 71.8% respectively.14 ethical considerations for the study, a structured questionnaire was distributed to collect data. prior permissions for conducting the study were obtained from the superior college of nursing. participation in the study was voluntary and no nurse was forced to participate in the data collection procedure. no personal information was requested and respondents were made assured that their data would only be used for the academic study purpose with complete secrecy. results first of all, the frequency analysis was performed to know the distribution of the different attributes of the respondents of the study. as per the findings reported in the table majority of the respondents belonged to the age group with having higher post rn bsn qualifications. additionally, the majority of the respondents were found to be working night shifts (table 1). data normality once the attributes of the respondents (nurses) were assessed then the descriptive statistics were performed to assess the data normality. in this regard, the skewness and kurtosis are reported in the following table 2. the values of the skewness and kurtosis for all the measuring instrument items fall between the ranges of -2 to +2 indicating the data normality. additionally, table 3 shows the overall data normality for the computed variables. reliability and validity cronbach’s alpha was assessed to know the reliability of the data. as per the standard, the value of cronbach’s alpha should be greater than 0.7. as per the findings reported in table 4 all the values of cronbach’s alpha are greater than 0.7 indicating the reliability. additionally, table 4 shows the validity of the constructs. kmo bartlett’s test was performed. as per the parameters, the values of kmo for all the variables are greater than 0.5 and all the values are significant. hence, both reliability and validity are established. state of nursing practice environment since all the data collected is valid and reliable so the assessment of the nursing article [page 2] [healthcare in low-resource settings 2023; 11:10658] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:10658] [page 3] article table 1. profile of respondents (nurses). demographic variables categories frequency percentage age 21 to 30 39 35.5 31 to 40 45 40.9 41 to 50 25 22.7 51 to 60 1 .9 qualification diploma in midwifery 21 19.1 diploma in general nursing 34 30.9 post rn bsn 45 40.9 bsn generic 10 9.1 shift morning 30 27.3 evening 53 48.2 night 27 24.5 experience 1 to 3 year 19 17.3 4 to 6 year 29 26.4 7 to 9 year 35 31.8 10 t0 12 year 17 15.5 12+ year 10 9.1 department medical ward 63 57.3 critical care 47 42.7 table 2. descriptive statistics (individual items of constructs). n std. skewness kurtosis deviation statistic statistic statistic std. error statistic std. error a nurse manager or immediate supervisor who is a good manager and leader 110 1.23505 0.158 0.230 -0.873 0.457 a nurse manager who backs up the nursing staff in decision making, even if a conflict is with a doctor 110 1.03145 0.292 0.230 -0.530 0.457 a senior nursing administrator who is highly visible and accessible to staff 110 1.05780 0.463 0.230 -0.715 0.457 supervisors use mistakes as learning opportunities, not criticism 110 1.06897 0.055 0.230 -0.589 0.457 a supervisory staff that is supportive of the nurses 110 0.87291 -0.179 0.230 -0.409 0.457 administration to listens and responds to employee concerns 110 1.02223 0.361 0.230 -0.593 0.457 praise and recognition for a job well done 110 0.95154 0.352 0.230 -0.115 0.457 nursing administrators consult with staff on daily problems and procedures 110 1.06428 0.147 0.230 -0.337 0.457 career development/clinical ladder opportunity 110 1.08964 -0.016 0.230 -0.646 0.457 opportunities for advancement 110 1.05040 -0.021 0.230 -0.528 0.457 nurses have the opportunity to serve on hospital and nursing committees 110 0.98703 -0.084 0.230 -0.203 0.457 opportunity for nurses to participate in policy decisions 110 0.85065 0.030 0.230 -0.328 0.457 a senior nursing administration equal in power and authority to other top level hospital executives 110 1.07609 0.057 0.230 -0.628 0.457 enough staff to get work done 110 0.91799 0.000 0.230 -0.037 0.457 enough registered nurses on staff to provide quality patient/client/resident care 110 1.02902 0.251 0.230 -0.587 0.457 adequate support services allow me to spend time with my patients 110 1.01712 0.186 0.230 -0.514 0.457 enough time and opportunity to discuss patient/client/resident care problems with other nurses 110 1.13217 -0.039 0.230 -0.856 0.457 working with nurses who are clinically competent 110 1.12059 0.361 0.230 -0.616 0.457 written, up to date nursing care plans for all patients/clients/residents 110 1.06381 -0.104 0.230 -0.777 0.457 high standards of nursing care are expected by the administration 110 1.14361 0.169 0.230 -0.788 0.457 valid n (listwise) 110 patients/clients/residents care assignments that foster continuity of care 110 1.12300 0.197 0.230 -0.685 0.457 nursing care is based on a nursing model, rather than a medical model 110 1.13878 0.385 0.230 -0.677 0.457 an active quality improvement program 110 1.21380 0.301 0.230 -0.937 0.457 doctors and nurses have good working relationships 110 1.04670 0.269 0.230 -0.623 0.457 a lot of team work between nurses and doctors 110 1.10609 0.341 0.230 -0.600 0.457 collaboration between nurses and doctors 110 1.07454 0.397 0.230 -0.501 0.457 non -co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2023; 11:10658] practice environment was done by categorizing it as poor, average, and good. as per the findings reported in table 5, only 30% of nurses reported having a good nursing practice environment as compared to 70% of nurses who did not report having a good nursing practice environment. additionally, cross-tabulation was performed to know the state of the nursing practice environment concerning the attributes of the respondents. as per table 6, only a minor number of respondents regarded the nursing practice environment as good in both the medical wards (17) and critical care units (16). on the other hand, the majority of the nurses working the evening shift regarded the nursing practice as good as compared to the majority of the nurses working morning and night shifts who regarded the nursing practice environment as average. there was a mixed response regarding the nursing practice environment when it comes to the experience and only nurses having aged between 31 to 40 years reported it as a good. discussion the purpose of the study was to examine the current state of the nursing practice environment. in this regard, data were collected from the nurses working in the medical wards and critical care units. data were subjected to the spss for data analysis. the results of the study revealed that the overall nurses do not consider the nursing practice environment in which they are working as good. these findings are similar to the previous studies which have also reported the nursing working environment as poor. the results of the study revealed that nurses have less participation in decision-making. nurses with poor engagement tend to have poor experiences at work 15. previously a study contended that nurses must participate in hospital activities to improve nurses’ practices and reduce the mistakes and improve nurses quality of care. nurses discuss daily problems with leaders to improve clinical practices. good nurse practices improve patient satisfaction.1 on the other hand, the nursing foundation for quality of care, nurse manager ability, leadership, and support of nurses; staffing, and resource adequacy; and collegial nurse-physician relations were found to be poor as well. the results can be interpreted that the nurses are not satisfied with their nursing practice environment. for instance, the report does not have an appropriate system for their development to ensure the quality of care. they reported not having an appropriate system for learning and improving practices related to patient care. previously a study reported that hospital staffing and resource adequacy is perceived by nurse respondents as unsatisfactory. severe shortages in resources and staffing in the public sector hospitals of pakistan critically undermine the efforts of medical practitioners to ensure patient safety 13. overall, the findings of the study revealed the perceptions of the nurses at the pakistan institute of neurosciences (pins). the present study carries several practical implications for a better working environment at hospitals. first, the grievances article table 3. descriptive statistics (computed variables). n std. skewness kurtosis deviation statistic statistic statistic std. error statistic std. error nurse manager support 110 0.71188 0.064 0.230 -0.267 0.457 nurse participation 110 0.70616 0.199 0.230 -0.118 0.457 staffing resource adequacy 110 0.74914 0.235 0.230 -0.069 0.457 nurse foundation care 110 0.85846 0.217 0.230 -0.462 0.457 collegial nurse physician relationship 110 0.90063 0.545 0.230 0.021 0.457 valid n (listwise) 110 table 4. reliability and validity. reliability validity constructs cronbach’s alpha number of items kmo significance nmls 0.836 8 0.783 0.000 np 0.734 5 0.718 0.000 sra 0.762 5 0.683 0.000 nfqc 0.811 5 0.751 0.000 cnpr 0.786 3 0.665 0.000 table 5. state of nursing practice environment. rating frequency percent valid percent cumulative percent poor 36 32.7 32.7 32.7 average 41 37.3 37.3 70.0 good 33 30.0 30.0 100.0 total 110 100.0 100.0 non -co mmerc ial us e o nly of the nurses can be reduced by getting them engaged in the decision-making. by doing so they will feel like a part of the larger hospital environment where their suggestions are taken up to the table as they spend maximum time with the patients. secondly, there should be appropriate training for the nurses so they can get hands-on experience for better patient care. to have better nursing outcomes, a proper quality foundation should be established. therefore, it is suggested that concerned government departments and hospital management should work toward ensuring a suitable and safe working environment for nurses by improving the accountability system. authorities need to provide suitable opportunities for the professional development of the nurses to improve their competency. thirdly, the literature identifies that most nurses are not satisfied with their nurse managers either he/she do not listen to them or are not able to take decisions in a critical situation. the nurse manager may lack the leadership ability and can’t raise the voice of nurses at the hospital. therefore, it is suggested that nurse managers should be trained enough in their leadership roles. leadership development programs should be implemented to address the poor leadership concerns among the nurses. fourthly, the study also identified the nursing shortage as a serious concern so it is required that higher nursing authorities such as pakistan nursing council should address this issue and find a possible solution. based on the results of the study it is recommended that new nursing colleges should be established to boost the availability of the new workforce for this sector to curb the pressure on the healthcare delivery services. there is dire need to address the issues highlighted in the study for the betterment of the nursing practice environment so that the healthcare services delivery can be improved and patient satisfaction can be increased as well. conclusions the descriptive research of the present study concluded that a better work environment can be beneficial for nurses, patients, and organizations. and it is necessary to provide all resources that lead to a productive work environment. the negative impact of the nursing practice environment can lead to patient death. so better nurse work environment leads to better patient care. it is worthy to note that a poor environment caused harmful effects on nurses and patients. therefore, an organization must provide a productive environment for the betterment of patients and nurses as well as the institute. the environment is a key factor for patient quality of care and enhancing the professional quality of life. poor nurse job outcomes are attributed to poor practice environments and high patient-to-nurse ratios. leaders can focus their efforts on modifying these organizational factors to improve job outcomes and increase nurse retention. future directions the present study is descriptive and provided the results about the perceptions of nurses regarding the nursing practice environment. it is suggested that future studies may use the larger sample sizes from the multiple hospitals to have a comparative analysis of the state of the nursing practice environment at both the private and public hospitals. additionally, future studies are suggested to include the outcomes of the nursing practice environment that will enhance the understanding of the topic. references 1. hameed s, hussain m. nurses perception of practical environment relationship with patient satisfaction in government hospital lahore. int j soc sci manag 2019;6:75-81. 2. zeleníková r, jarošová d, plevová i, janíková e. nurses’ perceptions of professional practice environment and its relation to missed nursing care and nurse satisfaction. int j environ res public health 2020;17:3805. 3. algahtani fd, hassan s-u-n, alsaif b, zrieq r. assessment of the quality of life during covid-19 pandemic: a cross-sectional survey from the kingdom of saudi arabia. int j environ res public health 2021;18:847. 4. bloomer mj, clarke ab, morphet j. nurses’ prioritization of enteral nutrition in intensive care units: a national survey. nursing crit care 2018;23:1528. 5. rivaz m, momennasab m, yektatalab s, ebadi a. adequate resources as essential component in the nursing practice environment: a qualitative study. j clin diagnostic res 2017;11: ic01. 6. bawakid k, rashid oa, mandoura n, et al. patients’ satisfaction regarding family physician’s consultation in primary healthcare centers of ministry of article table 6. state of nursing practice environment (demographics). poor average good department medical ward 22 24 17 critical care 14 17 16 total 36 41 33 shift morning 7 16 7 evening 20 16 17 night 9 9 9 total 36 41 33 experience 1 to 3 years 7 6 6 4 to 6 years 5 13 11 7 to 9 years 15 10 10 10 t0 12 years 4 9 4 12+ years 5 3 2 total 36 41 33 age 21 to 30 11 20 8 31 to 40 11 15 19 41 to 50 14 5 6 51 to 60 0 1 0 total 36 41 33 qualification diploma in midwifery 10 6 5 diploma in general nursing 6 13 15 bscn 14 19 12 generic 6 3 1 total 36 41 33 [healthcare in low-resource settings 2023; 11:10658] [page 5] non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2023; 11:10658] health, jeddah. j fam med primary care 2017;6:819. 7. al-hamdan z, banerjee t, manojlovich m. communication with physicians as a mediator in the relationship between the nursing work environment and select nurse outcomes in jordan. j nursing scholarship 2018;50:714-21. 8. al-hussami m, al-momani m, hammad s, et al. patients’ perception of the quality of nursing care and related hospital services. health primary care 2017;1:1-6. 9. kellogg mb, knight m, dowling js, crawford sl. secondary traumatic stress in pediatric nurses. j pediatr nursing. 2018;43:97-103. 10. kim c-w, lee s-y, kang j-h, et al. application of revised nursing work index to hospital nurses of south korea. asian nursing res 2013;7:128-35. 11. aiken lh, patrician pa. measuring organizational traits of hospitals: the revised nursing work index. nursing res 2000;49:146-53. 12. lake et. the nursing practice environment. medical care res rev 2007;64:104s-22s. 13. jafree sr, zakar r, zakar mz, fischer f. nurse perceptions of organizational culture and its association with the culture of error reporting: a case of public sector hospitals in pakistan. bmc health serv res 2015;16:1-13. 14. corner b, lemonde m. survey techniques for nursing studies. canadian oncology nursing j 2019;29:58-60. 15. park sh, hanchett m, ma cjjons. practice environment characteristics associated with missed nursing care. j nurs scholarsh. 2018;50:722-730. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e21] [page 71] qualitative c-reactive protein as a marker of neonatal sepsis in a tertiary neonatal unit in sudan abdelmoneim e. kheir,1 ghada a. jobara,2 kamal m. elhag,3 mohamed z. karar2 1department of pediatrics, university of khartoum, khartoum; 2department of neonatology, soba university hospital, khartoum; 3microbiology department, soba university hospital, khartoum, sudan abstract sepsis is one of the most common causes of morbidity and mortality in newborns. diagnosis of neonatal sepsis may be difficult because clinical presentations are often non-specific. the aim of this study was to evaluate the role of qualitative c-reactive protein in the diagnosis of neonatal sepsis, and examine the correlation between c-reactive protein, blood culture and risk factors for sepsis. this was a prospective study, conducted in the neonatal intensive care unit at soba university hospital, sudan. a total of seventy babies with a clinical diagnosis of sepsis were included. chi square test was used to determine the association between c-reactive protein and risk factors for sepsis and also the association between c-reactive protein and blood culture. blood culture was positive in 41.4% of babies, and c-reactive protein was positive in 58% of babies with positive blood culture. there was significant association between c-reactive protein results and blood culture (p=0.00). in conclusion, we can assume that creactive protein is a reliable diagnostic marker of neonatal sepsis, especially in developing communities with poor resources. introduction neonatal sepsis is a clinical syndrome of bacteraemia characterized by systemic signs and symptoms of infection in the first month of life. it encompasses systemic infection of newborn including septicemia, meningitis, pneumonia, arthritis, osteomyelitis and urinary tract infection.1 the diagnosis of infection in neonates is difficult, because of the non-specific clinical presentation and the lack of reliable diagnostic tests. as a result of this uncertainty, antimicrobial chemotherapy is often commenced on the slightest clinical suspicion of infection. recently there has been great interest in the potential diagnostic value of a range of hematological and immunological surrogate markers of infection.2,3 although a positive blood culture remains the standard for diagnosing neonatal sepsis, many investigators have assessed measuring the host response as an adjunct to culturebased diagnosis. the goal of serum biomarker research is to identify a means by which an infected child can be identified rapidly, before the onset of life-threatening symptoms.4 c-reactive protein (crp), the most commonly used biomarker, is synthesized within 6 h of exposure to an infectious process and usually becomes abnormal within 24 h. because crp takes up to 24 h after the onset of an infection to become abnormal, it has little utility in assisting the early detection of sepsis. creactive protein is also limited in that other processes in addition to infection can result in elevation, including trauma and ischemia.5 the most rapid quantitative method for determining crp concentration is by nephelometry. alternative positive crp latex agglutination test of undiluted sample corresponds to plasma crp concentration of 0.6-1 mg/dl. normalization of crp elevation appears to be helpful in determining the response to antimicrobial therapy and duration of treatment.6 neonatal septicemia continues to be a major cause of morbidity and mortality in sudan. it is one of the major causes of neonatal mortality in developing countries contributing to 26% of all neonatal deaths.7 in developing countries there is need for a test that is cheap and easily performed with quick availability of results. an ideal diagnostic test for neonatal sepsis should have maximum sensitivity and specificity. in recent years, various investigators have evaluated some highly sensitive and specific inflammatory markers (e.g. elisa methods, haptoglobins, interleukins and procalcitonin) to diagnose neonatal sepsis.8 although, these markers are sensitive and specific, they are expensive, thus not practical for developing countries. for this reason, there have been many attempts to develop screening tests to identify infected neonates and guide the duration of treatment. the aim of this study is to i) evaluate the role of qualitative crp in the diagnosis of neonatal sepsis, ii) determine the relationship between crp and risk factors for sepsis and iii) examine the correlation between crp and blood culture. to our knowledge this is the first study done in sudan to examine the correlation between crp and blood culture. materials and methods this was a prospective hospital-based, case finding study, conducted in the neonatal intensive care unit (nicu) at soba university hospital in khartoum, sudan, february to august 2011. all newborn babies (0-28 days) admitted to nicu at soba university hospital during the study period with clinical suspicion of sepsis or having risk factors for sepsis were included in the study. specific risk factors that were used in the study are duration of membrane rupture >18 h, mode and place of delivery, whether labor was prolonged or precipitate, intrapartum fever, antibiotic usage during labor, history of vaginal discharge, previous sibling with neonatal sepsis in addition to the gestational age, and weight of the baby. pediatricians usually look for specific symptoms and signs of sepsis, i.e. symptoms like refusal of feeds, lethargy, irritability, poor cry, vomiting, diarrhea and fever. specific signs like cyanosis, tachpnoea, apnoea, seizures, temperature instability, abdominal distension and purpura are also taken into account. neonates with major congenital malformation or with birth weight less than 1000 g were excluded. a total of 70 babies were included in the study. data were collected using a precoded and pretested specifically designed questionnaire (appendix). at the time of admission, a complete septic screen was done, which included complete blood count, crp, blood culhealthcare in low-resource settings 2013; volume 1:e21 correspondence: abdelmoneim elamin kheir, department of pediatrics, university of khartoum, almc namr street, 11115 khartoum, sudan. tel. +249.912313110 fax: +249.183776295. e-mail: moneimkheir62@hotmail.com key words: neonatal sepsis, c-reactive protein, blood culture, sudan. conflict of interests: the authors declare no potential conflict of interests. contributions: the authors contributed equally. acknowledgements: the authors express their sincere appreciation to the administration of soba university hospital for giving their approval and assistance in conducting the research. in addition, the authors are grateful to the staff of the microbiology department and neonatal unit of the same hospital for their great help. received for publication: 18 february 2013. revision received: 4 may 2013 accepted for publication: 7 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.e. kheir et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e21 doi:10.4081/hls.2013.e21 non -co mmerc ial us e o nly [page 72] [healthcare in low-resource settings 2013; 1:e21] ture, chest x-ray, cerebrospinal fluid (if applicable). c-reactive protein values were estimated qualitatively by the latex agglutination method, with a detection limit of 6 mg/l. the average cost of complete blood count is 60 sudanese pound (10 us $), blood culture is 60 sudanese pounds (10 us $) and qualitative crp is 15 sudanese pounds (2.5 us $). newborn babies were classified as having sepsis if they had signs suggestive of sepsis and a positive blood culture. probable sepsis was diagnosed if they had a negative blood culture with signs suggestive of sepsis and no sepsis if there were no clinical features of sepsis with a negative blood culture. positive blood culture was considered the gold standard against which crp result was compared. the following values were considered indicative of sepsis: white blood count (wbc) ≤5000 or ≥25,000 mm3; absolute neutrophil count (anc) ≤1800 or ≥5000; and crp 6 mg/l or more. the sensitivity, specificity, positive (ppv) and negative predictive values (npv) were calculated by the following equations: sensitivity=number of true positive/number of true positive+number of false negative (1) specificity=number of true negative/ number of true negative+number of false positive (2) ppv=number of true positive/numberof true positive+number of false positive (3) npv=number of true negative/number of true negative+number of false negative (4) data were analyzed using statistical package for social sciences (spss) version 17; chi square test was used to determine the association between crp and risk factors for sepsis and also the association between crp and blood culture. p value was set on an alpha level at 0.05 and 95% confidence limit. ethical clearance and approval for conducting this study was obtained from the ethical committee of soba university hospital. prior informed consent was obtained from the parents of the babies participating in this study after full explanation of the study. results a total of 70 babies with sepsis were admitted, males were 43 (62.1%), females were 27 (37.9%). twenty-nine babies (41.4%) were proven sepsis (positive blood culture plus signs of sepsis) and 41 babies (58.6%) were probable sepsis (negative blood culture plus signs of sepsis). c-reactive protein was positive in 17 babies with proven sepsis and in only 6 babies with probable sepsis. there was a significant association between crp result and blood culture (p=0.00). in our study klebseilla pneumonae was the commonest bacteria isolated followed by staphylococcus aureus and escherichia coli. figure 1 shows the percentage of babies infected with various organisms. lethargy and fever were the common presenting symptoms (22.9 and 15.7%, respectively) followed by refusal of feed (8.6%), vomiting (5.7%) and poor cry (4.3%). we found that jaundice, abdominal distension, tachypnea and temperature instability were the common clinical signs (27.1, 25.7, 22.9, 22.9%, respectively) followed by seizures (8.6%), purpura (5.7%), skin mottling (1.4%), and cyanosis (1.4%). of the symptomatic babies, 42.9% were crp positive, whereas only 17.9% of the asymptomatic babies were crp positive. there was a significant association between symptoms of sepsis and crp results (p=0.029). higher proportion of babies with late onset sepsis were crp positive (45.5%), compared with those with early onset sepsis (21.6%), and there was a significant association between onset of sepsis and crp results (p<0.034). in most of the neonates with positive crp, their mother had regular antenatal care. there was no significant association between crp level and antenatal care follow up (p=0.216). table 1 shows the correlation between crp and antenatal care follow up. out of the 70 babies, 44 were delivered by caesarian section; of these, 15 (34.1%) were crp positive. our study showed that there was no significant association between crp level and mode of delivery (p=0.775). table 2 shows the correlation between crp and duration of membrane rupture: there was no significant association between crp and duration of membrane rupture (p=0.137). there was prolonged labor in 12 (17.14%) out of the 70 babies, whereas labor was precipitate in 3 (4.28%). there was no significant association between crp and history of labor (p=0.438). interestingly enough, when taking intraarticle table 1. correlation between c-reactive protein and regular antenatal care (p=0.216). regular antenatal care crp total negative positive yes n 44 23 67 % 65.70 34.30 100.00 no n 3 0 3 % 100.00 0.00 100.00 total n 47 23 70 % 67.10 32.90 100.00 crp, c-reactive protein. table 2. correlation between c-reactive protein and duration of membrane rupture (p=0.137). duration of membrane rupture crp total negative positive normal n 33 21 54 % 61.10 38.90 100.00 <18 h n 1 0 1 % 100.00 0.00 100.00 >18 h n 13 2 15 % 86.70 13.30 100.00 total n 47 23 70 % 67.10 32.90 100.00 crp, c-reactive protein. figure 1. babies infected with various organisms (values expressed as percentage; p=0.028). non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e21] [page 73] partum fever as a risk factor for sepsis, our study showed that there was no significant association between crp and intrapartum fever (p=0.615), again crp level was not affected by intrapartum antibiotic usage (p=0.19). regarding the gestational age, our study showed that 31.1% of the preterm babies were crp positive, whereas 37.5% of the term babies were crp positive. there was no significant association between crp and gestational age (p=0.675). the correlation between crp and birth weight was not significant (p=0.236). most of the babies with sepsis had their weight ranging between 1000 and 1500 g. table 3 shows the correlation between crp and total white blood cell (twbc) count. there was no significant correlation between crp and twbc (p=0.074). again, there was no significant correlation between crp and anc (p=0.557). the diagnostic value of sepsis screen parameter showed that crp had good specificity and negative predictive value (npv). table 4 shows the comparative analysis of the tests used in this study. discussion neonatal sepsis with its high mortality rate still remains a diagnostic and treatment challenge for the neonatal health care providers. an early diagnosis of neonatal septicemia helps the clinician in instituting antibiotic therapy at the earliest, thereby reducing the mortality rates in the neonates. there is no single reliable test for the early definite diagnosis of neonatal sepsis, and therefore, there is a continuing search for a new infection marker. the c�reactive protein has been the most analyzed parameter for the detection of bacterial infections for years.9,10 severe neonatal infections are one of the most significant causes of pediatric mortality, resulting in more than 500,000 deaths each year.11 ninety-nine percent of these deaths occur in low resource settings.12 identifying neonates with severe infections is difficult in high resource settings, and limited laboratory capability in low resource settings makes diagnosis even more challenging. clinical criteria for the diagnosis of neonatal sepsis have been developed and are included in the who integrated management of childhood illness (imci) program.13 in the present study an attempt has been made to evaluate the usefulness of qualitative crp as a predictor of sepsis, and also to study the correlation between crp, blood culture and risk factors for sepsis. this is because it is simple and cost effective. in our study, 29 babies (41.4%) were proven to have bacterial sepsis based on positive blood culture results. this is different from a study done in egypt where it was found that 70% of the neonates had positive blood cultures. in the same study, the identified bacteria included gram positive cocci, staphylococcus epidermidis, staphylococcus aureus, and streptococci agalacti as the commonest organisms and this is in contrast to our study where klebseilla pneumonae was the commonest bacteria isolated followed by staphylococcus aureus and escherichia coli.14 in a study conducted in poland where 48 babies with a clinical diagnosis of sepsis were recruited, it was found that 18 (58%) out of 31 babies with positive blood culture had increased crp, which is similar to what obtained in our study where 17 (58%) out of 29 babies with proven sepsis had positive crp.15 in a study done by dollner et al. in norway, 6 inflammatory mediators including crp were compared as early diagnostic tests for neonatal sepsis and the possible benefit of combining parameters was studied. c-reactive protein performed best as a diagnostic test for neonatal sepsis. diagnostic accuracy was further improved by combining crp and interleukin-6, whereas the other parameters added no further diagnostic information.16 in this study, crp had sensitivity, specificity, ppv, npv of 63, 85.36, 73.9, 73.9%, respectively, at a cut-off value of 6 mg/l. these results are comparable to those reported by abdollahi et al., i.e. lower sensitivity and higher specificity of crp in detecting sepsis among their study group.17 nuntnarumit et al. in bangkok (thailand), reported the highest sensitivity, specificity, ppvs and npvs. this is probably due to the quantitative sampling method which they used as compared to the qualitative method used in the present study.18 when we studied the hematological parameters for sepsis, we found that the wbc had high specificity and npv, while the anc showed unsatisfactory results. however, the specificities were better if combined together and can have a good npv. this is in agreement with a study done by varsha et al., who found that the use of multiple hematological parameters is a good diagnostic aid for both early and late neonatal sepsis.19 conclusions neonatal sepsis remains a major cause of neonatal mortality and morbidity and early diagnosis and prompt treatment determine good outcome. qualitative crp has strong correlation with blood culture and can reliably be used as an indicator of sepsis. high cost of other inflammatory markers preclude their clinical and routine application in low resource settings. therefore, crp being easily measurable and more affordable, can be conveniently used as a good marker for the diagnosis of neonatal sepsis especially in developing communities with limited resources. references 1. aggarwal r, sarkar n, deorari a, paul v. sepsis in the newborn. indian j pediatr 2001;68:1143-7. article table 3. correlation between c-reactive protein and total white blood cell count (p=0.074). twbc crp total negative positive normal (5000-25,000 mm3) n 41 16 57 % 71.90 28.10 100.00 abnormal (≤5000 or ≥25,000 mm3) n 6 7 13 % 46.20 53.80 100.00 total n 47 23 70 % 67.10 32.90 100.00 twbc, total white blood cell; anc, absolute neutrophil count; crp, c-reactive protein. table 4. comparative analysis of tests used in study. test(%) sensitivity specificity ppv npv crp 63 85.36 73.9 74.4 twbc 27.60 87.80 80.77 81.82 anc 62.69 44.00 44.00 62.69 ppv, positive predictive value; npv, negative predictive value; crp, c-reactive protein; twbc, total white blood cell; anc, absolute neutrophil count. non -co mmerc ial us e o nly [page 74] [healthcare in low-resource settings 2013; 1:e21] 2. ng pc. diagnostic markers of infection in neonates. arch dis child-fetal 2004;89: f229-35. 3. lam hs, ng pc. biochemical markers of neonatal sepsis. pathology 2008;40:141-8. 4. bhatti m, chu a, hageman j, et al. future directions in the evaluation and management of neonatal sepsis. neoreviews 2012; 13:e103. 5. hawk m. c-reactive protein in neonatal sepsis. neonatal netw 2008;27:117-20. 6. philip ag, mills pc. use of c-reactive protein in minimizing antibiotic exposure. pediatrics 2000;106:e4. 7. chacko b, sohi i. early onset neonatal sepsis. indian j pediatr 2005;72:23-6. 8. mehr s, doyle lw. cytokines as markers of bacterial sepsis in newborn infants: a review. pediatr infect dis j 2000;19:87987. 9. manneret g, labaune jm, isaac c, et al. procalcitonin and c-reactive protein levels in neonatal infections. acta paediatr 1997;86:209-12. 10. chiesa c, signore f, assumma m, et al. serial measurements of the c-reactive protein and interleukin 6 in the immediate postnatal period: the reference intervals and the analysis of the maternal and the perinatal confounders. clin chem 2001;47:1016-22. 11. black re, cousens s, johnson hl, et al. global, regional, and national causes of child mortality in 2008: a systematic analysis. lancet 2010;375:1969-87. 12. thaver d, zaidi ak. burden of neonatal infections in developing countries: a review of evidence from community-based studies. pediatr infect dis j 2009;28:3-9. 13. gove s. integrated management of childhood illness by outpatient health workers: technical basis and overview. the who working group on guidelines for integrated management of the sick child. bull world health organ 1997;75(suppl.1):724. 14. boraey n, sheneef a, mohamed ma, yousef lm. procalcitonin and c-reactive protein as diagnostic markers of neonatal sepsis. aust j basic appl sci 2012;6:108-14. 15. kawczynski p, piotrowski a. procalcitonin and c-reactive protein as markers of neonatal sepsis. ginekol pol 2004;75:43944. 16. dollner h, austgulen r, vatten l. early diagnostic markers for neonatal sepsis. j clin epidemiol 2001;54:1251-7. 17. abdollahi a, shoar s, nayyeri f, shariat m. diagnostic value of simultaneous measurement of procalcitonin, interleukin-6 and hs-crp in prediction of early-onset neonatal sepsis. mediterr j hematol infect dis 2012;4:e2012028. 18. nuntnarumit p, pinkaew o, kitiwan wanich s. predictive values of serial creactive protein in neonatal sepsis. j med assoc thai 2002;85:1151-8. 19. varsha, rusia u, sikka m, et al. validity of hematologic parameters in identification of early and late onset neonatal infection. indian j pathol micr 2003;46:565-8. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11172 the three month's dietary brown rice intervention has not significantly decreased levels of crp, tnf-α, and il6 of type 2 diabetes mellitus patients fajar ari nugroho, inggita kusumastuty, anggun rindang cempaka, atifa nafia hasantie latif, dian handayani department of nutrition, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: the increased quantities of inflammatory biomarkers such as c-reactive proteins (crp), tumour necrosis factor-α (tnf-α), and interleukin-6 (il-6) have been reported to be associated with an increased risk of metabolic syndrome including type 2 diabetes mellitus (t2dm). however, brown rice is an alternative dietary food source that is known to have many health benefits including high fibre content. in addition to fibre, brown rice is also reported to have moderate amounts of proteins, unsaturated lipids, several minerals, and a lot of bioactive substances that are highly beneficial to health. this study aims to prove the role of brown rice dietary intervention in the reduction of inflammatory biomarkers in type 2 diabetes mellitus patients. design and methods: this was a cross-sectional study with a post-test conducted on 18 patients with type 2 diabetes mellitus. in the intervention phase i, all type 2 diabetes mellitus patients were given brown rice diet for 3 months and followed by a phase ii intervention, in which white rice diet was given to the other group of type 2 diabetes mellitus patients for 3 months. serum was collected at the end of each intervention stage and then serum for tumour necrosis factor-α, interleukin-6 and c-reactive proteins were analysed by the elisa method. statistical analysis of the ttest was conducted in order to determine the differences between the two groups allocated in the study. results: at the end of the study, it was found that the levels of c-reactive protein, tumour necrosis factor-α, and interleukin-6 after the brown rice intervention was given to type 2 diabetes mellitus patients, it showed a decreasing trend compared to the white rice intervention although not significantly different (p = 0.6, p = 0.63, p = 0.59, respectively). conclusions: this study concluded that the administration of brown rice dietary intervention to patients with type 2 diabetes mellitus for 3 months was able to reduce tumour necrosis factorα, c-reactive proteins, and interleukin-6 however, the reduction was not significant to influence policy change. introduction currently, studies on how inflammatory biomarkers have contributed negatively to the health outcomes of patients with type 2 diabetes mellitus are being explored.1 the increased quantities of inflammatory biomarkers such as c-reactive protein,2 tumour necrosis factor-α, and interleukin-6 have been reported to be associated with an increased risk of metabolic syndrome including type 2 diabetes mellitus and cardiovascular diseases (cvds).3 type 2 diabetes mellitus is a type of metabolic syndrome that is commonly associated with high c-reactive proteins values. according to a recent cohort study, high c-reactive protein values, especially in subjects with obesity and hypertension were associated with the risk of developing type 2 diabetes mellitus even after the adjustments were made (p trend = 0.02).4 similarly, other studies have also indicated that high c-reactive protein was associated with high risk of developing type 2 diabetes mellitus (or = 1,204 95%ci 1,058-1,371, p = 0.005), also with hypertriglyceridemia (or = 1,157 95%ci 1,040-1,287, p = 0.007), and metabolic syndrome (or 1,128 95%ci 1.112-1,375, p < 0.001).5 furthermore, another inflammatory indicator known as tumour necrosis factor (tnf-) also significantly contributes to the development of type 2 diabetes mellitus. similarly, a crosssectional study reported that increased levels of tumour necrosis factor in the obese group of type 2 diabetes mellitus patients were strongly associated with hba1c (r = 0.361, p = 0.003) and homa-ir (r = 0.2296, p = 0.017).6 these results are in support of another study that reported an association between increased tumour necrosis factor and insulin resistance in type 2 diabetes mellitus patients (all p = 0.008).7 meanwhile, interleukin-6 inflammatory biomarker has also been shown to be associated with the risk of developing type 2 diabetes mellitus. according to a recent study on clients who were likely to develop type 2 diabetes mellitus, it was observed that patients showed an increase in interleukin-6 levels accompanied article significance for public health diabetes mellitus is recognized globally as a major public health threat. rice as a staple food for indonesia, is considered to be the main source of carbohydrate and might be an important part of diabetes mellitus nutrition management. additionally, current study indicates that brown rice contains bioactive ingredients and could be beneficial to be part of the diet for diabetes mellitus patients. therefore, this clinical study explores the potential advantages of eating brown rice, particularly in relation to its anti-inflammation properties that are necessary in the fight against diabetes mellitus. [healthcare in low-resource settings 2023; 11(s1):11172] [page 39] non -co mmerc ial us e o nly by an increase in insulin resistance.8 it was further reported that an increase in interleukin-6 in type 2 diabetes mellitus patients could trigger the emergence of diabetic retinopathy (p = 0.005).9 scientists have observed that brown rice is an alternative dietary food source that has many health benefits including high fibre content which could be beneficial in the fight against type 2 diabetes mellitus in communities. additionally, brown rice is also reported to have moderate amounts of protein, unsaturated lipids, several minerals, and bioactive substances that are also beneficial to health. in addition, this staple food is also affordable and readily available across the globe hence, could be considered as a potential and reliable alternative food source.10 however, the contribution of brown rice in controlling inflammation is currently still low but further study in similar field is encouraged. additionally, an experimental animal study reported that the administration of fermented brown rice was able to reduce the mrna expression of several indicators of inflammation.11 meanwhile, an in vitro study, reported that the special protein content in brown rice was able to provide an inflammatory-reducing effect as well as the effect of selenium.12 further studies are needed to truly optimize the health benefits of eating brown rice especially by patients with type 2 diabetes mellitus. therefore, this current study was conducted in order to provide the scientific evidence on the contributions of brown rice in improving inflammatory biomarkers in type 2 diabetes mellitus patients. design and methods this was a cross-sectional study with a post-test that was conducted on 18 type 2 diabetes mellitus patients. the phase i intervention was giving brown rice dietary intervention to type 2 diabetes mellitus patients for 3 months and followed by a wash-out period for 2 weeks before phase ii intervention was carried out. the study was continued to phase ii intervention in which white rice dietary intervention was administered to another group of type 2 diabetes mellitus patients for 3 months. the inclusion criteria for participants were females aged 40-60 years, post-menopausal, nutritional status in the range of bmi = 23-27 kg/m2, used 1 or a combination of oral anti-diabetes drugs (oad), willing to be the subject of the study and also willing to sign the informed consent forms. the exclusion criteria in this study were respondents who had heart, kidney, liver, and malignancy disorders. in addition, those respondents who had a history of gastrointestinal disorders requiring long-term medical therapy, were smokers, history of allergies and took antibiotics in the last three months were excluded from participating in this study. brown rice dietary intervention was given to type 2 diabetes mellitus patients after conducting balanced nutritional calculations. participants in stage 1 were given brown rice while those in stage ii received white rice. in addition, energy requirements were calculated individually using the harris-benedict formula. the energy needs of the current study respondents ranged from 1300 to 1500 kcal/day with the provision of brown rice/white rice around 250-300 grams/day which they were given for 3 consecutive months. furthermore, the analysis of serum levels of c-reactive proteins, tumour necrosis factor-alpha, and interleukin-6 was performed at the end of each administration of the brown rice and white rice intervention using the elisa method. statistical analysis of different tests using t-test was carried-out with the stata version 16 program and the results were declared significant if the p-value < 0.05 was recorded. results and discussions the characteristics of the type 2 diabetes mellitus patients involved in the current study included the age range from 40-60 years with the majority being housewives (72.2%), suffering from type 2 diabetes mellitus for less than 5 years (55.6%) and had never received nutrition education (66.7%). studies have shown that the prevalence of type 2 diabetes mellitus increase with age with peaks recorded at the age range of 55-64 years however, it decreases when an individual is above 64 years. furthermore, the results of the indonesian baseline health research, 2013 and 2018 study indicated that as the age increases, the risk of a person developing type 2 diabetes mellitus also increases.13 additionally, the increase in the prevalence of metabolic diseases such as type 2 diabetes mellitus in the elderly individuals was not only directly related to age but also indirectly related to several risk factors such as central obesity, mitochondrial dysfunction, lipid metabolism disorders, inflammation, cell dysfunction, insulin resistance and metabolism syndrome.14 shou (2020), further reported that the ageing process of skeletal muscle can cause insulin resistance through mitochondrial dysfunction, accumulation of intra myo cellular lipid (imcl), inflammation, oxidative article table 1. distribution of respondents characteristics kusumastuty et al.16 characteristics n % age 40-49 years old 3 16,7 50-60 years 15 83,3 work housewife 13 72,2 government employees 2 11,1 private employees 1 5,6 entrepreneur 2 11,1 long suffering dm <5 years 10 55,6 5-10 years 8 44,4 history of receiving nutrition education once 6 33,3 never 12 66,7 table 2. comparison of respondents' intake data. parameter brown rice white rice p-value mean ± sd mean ± sd (t-test) energy intake (kcal) 1508.15 ± 104.40 1486.78 ± 121.25 0.356 carbohydrate intake 48.82 ± 2.72 49.60 ± 2.34 0.109 (% energy) table 3. inflammatory profile data crp, tnf-α, il-6. parameter brown rice white rice p-value mean ± sd mean ± sd (t-test) crp (mg/l) 112.1 ± 151.2 142.9 ± 186.8 0.59 tnf-α (ng/l) 194.6 ± 133.2 219.1 ± 144.4 0.60 il-6 (ng/l) 0.9 ± 0.9 1.1 ± 1.1 0.63 [page 40] [healthcare in low-resource settings 2023; 11(s1):11172] non -co mmerc ial us e o nly stress, expression of protein tyrosine phosphatase 1b (ptp1b), endoplasmic reticulum stress, decreased autophagy, sarcopenia, and overactive renin-angiotensin system (ras). again, intra myo cellular lipid accumulation induce oxidative stress and endoplasmic reticulum stress resulting in inflammation that can lead to insulin resistance.15 based on the history of type 2 diabetes mellitus who never received nutrition education which was at 66.7%, the current study suggests that increasing type 2 diabetes mellitus awareness through nutrition education and self-management would greatly help the affected individuals in controlling their respective conditions. a preliminary study, showed that increased nutrition education interventions in the elderly individuals with type 2 diabetes mellitus were not only able to improve their behaviour, knowledge, and attitudes but also increased the glucose control index during the three months of undergoing through the intervention.17 furthermore, another study that investigated the clinical benefits of implementing diabetes self-management education (dsme), reported an improvement in glucose control and thereby reducing the progression and development of microvascular and macrovascular complications in type 2 diabetes mellitus patients.18 in this current study, all respondents were given nutrition dietary interventions according to the needs of each individual. in the intervention stages i and ii, there was no significant difference in the amount of energy supplied but the only minor difference that was observed was those participants in stage i received brown rice while those in stage ii were given white rice. the actual dietary intake data that was recorded indicated that there was no significant difference in the amount of energy and carbohydrate intake from the two intervention stages and did not significantly affect the measured results of inflammatory biomarkers (table 2). furthermore, the results of the measured inflammatory biomarkers such as c-reactive proteins, tumour necrosis factorα and interleukin-6 showed decreased quantities in the brown rice dietary group and lower inflammatory biomarker values although, the results were not statistically significantly different to influence policy practice (table 3). although brown rice has a higher bioactive content than white rice such as fibre (5 times), magnesium (7.7 times), potassium (5.7 times), and manganese (1.59 times),19 however, it did not significantly reduce the inflammatory profile. this inability may be related to the type 2 diabetes mellitus patient’s body mass index (bmi) profile which was considered to be overweight and ranged between 23-27 kg/m2 and total body fat of 83.3% of the total patients body weight.20 it is known that adipose tissues can act as an endocrine organs and be able to secrete adipokines, leptin hormones21 and chemokines (mcp-1, il-10, tnf-α, and il-6).22 in addition, interleukin-6 has been reported as a cytokine with pleiotropic effects on inflammation,23 immune response and haematopoiesis.24 furthermore, interleukin-6 can also stimulate the production of several acute phase reactants such as c-reactive protein and stimulate hepatic lipogenesis associated with obesity25 and insulin resistance.26 however, the limitation of this study is that it was extremely difficult to properly the arrange the eating schedules for both groups of the type 2 diabetes mellitus patients hence, this could have affected the outcomes of the research findings. in addition, some patients from both groups also had the desire to consume unhealthy foods that were not recommended in this study. these findings showed that the best strategy to keep diet adherence is laying on consistency and willingness from each individual. conclusions this study concluded that the administration of brown rice dietary intervention for 3 consecutive months had a reduction trend of inflammatory biomarkers such as c-reactive proteins, tumour necrosis factor-α, and interleukin-6 in type 2 diabetes mellitus patients however, the difference in the studied groups were not statistically significant to influence change in practice. therefore, further studies are needed to ascertain the potential and significant effects of brown rice dietary intake on reducing inflammatory indicators in type 2 diabetes mellitus patients. article correspondence: fajar ari nugroho, department of nutrition, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62.341.5080686, fax: +62.341.5080686. e-mail: fajar_arinugroho.fk@ub.ac.id key words: brown rice; type 2 diabetes mellitus; tnf-α; crp; il-6. acknowledgement: the author would like to thank the department of nutrition, faculty of medicine, university of brawijaya contributions: all authors contribute equally to this article. fan, ik, arc, anhl, and dh designed and coordinated this study. fan, ik, and dh analyse the biological essays. arc and anhl analyse nutritional intake data. fan, ik, arc, anhl, and dh managed the manuscript together. conflict of interest: the authors declare no conflict of interest. funding: this study has been funded by faculty of medicine, university of brawijaya no. dipa-023 17.2.67751212021 availability of data and materials: all data generated or analyzed during this study are included in this published article. clinical trials: this study obtained research ethics permit from the health research ethics commission, faculty of medicine, university of brawijaya no. 143/ec/kepk/07/2020 informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: this manuscript was presented in the 2nd international nursing and health sciences symposium 28-30 october 2021, university of brawijaya malang, indonesia. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 17 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11172 doi:10.4081/hls.2023.11172 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11172] [page 41] non -co mmerc ial us e o nly references 1. hebert jr, shivappa n, wirth md, et al. perspective: the dietary inflammatory index (dii)-lessons learned, improvements made, and future directions. adv nutr 2019;10:185-95. 2. na w, kim m, sohn c. dietary inflammatory index and its relationship with high-sensitivity c-reactive protein in korean: data from the health examinee cohort. j clin biochem nutr 2018;62:83-8. 3. tangvarasittichai s, pongthaisong s, tangvarasittichai o. tumor necrosis factor-alpha, interleukin-6, c-reactive protein levels and insulin resistance associated with type 2 diabetes in abdominal obesity women. indian j clin biochem 2016;31:68-74. 4. kanmani s, kwon m, shin mk, et al. association of creactive protein with risk of developing type 2 diabetes mellitus, and role of obesity and hypertension: a large population-based korean cohort study. sci rep 2019;9:4573. 5. jeong h, baek sy, kim sw, et al. c reactive protein level as a marker for dyslipidaemia, diabetes and metabolic syndrome: results from the korea national health and nutrition examination survey. bmj open 2019;9:e029861. 6. alzamil h. elevated serum tnf-alpha is related to obesity in type 2 diabetes mellitus and is associated with glycemic control and insulin resistance. j obes 2020;2020:5076858. 7. hossain m, faruque mo, kabir g, et al. association of serum tnf-œ± and il-6 with insulin secretion and insulin resistance in ifg and igt subjects in a bangladeshi population. int j diabetes mellitus 2010;2:165-8. 8. hossain m, faruque mo, kabir g, et al. association of serum tnf-œ± and il-6 with insulin secretion and insulin resistance in ifg and igt subjects in a bangladeshi population. int j diabetes mellitus 2010;2:165-8. 9. yasa iwps, wande in, susila nkn, et al. kadar il-6 plasma pasien diabetes melitus dengan dan tanpa pengidap retinopati diabetika. indonesian j clin pathol med laborat 2010;20:1-4. 10. lee js, sreenivasulu n, hamilton rs, et al. brown rice, a diet rich in health promoting properties. j nutr sci vitaminol 2019;65:26-8. 11. umeyama l, kasahara s, sugawara m, et al. anti-inflammatory effect of fermented brown rice and rice bran with aspergillus oryzae on mice. traditional kampo medicine 2020;8:60-5. 12. feng m, wang x, xiong h, et al. anti-inflammatory effects of three selenium-enriched brown rice protein hydrolysates in lps-induced raw264.7 macrophages via nf-œ∫b/mapks signaling pathways. j funct foods 2021;76:1-9. 13. ministry of health republic of indonesia. tetap produktif, cegah dan atasi diabetes mellitus. [stay productive, prevent and overcome diabetes mellitus.] jakarta: republic of indonesia; 2020. 14. suastika k, dwipayana p, semadi ms, et al. age is an important risk factor for type 2 diabetes mellitus and cardiovascular diseases. in: chackrewarthy s, editor. glucose tolerance. uk: intechopen book series; 2012. p. 1-5. 15. shou j, chen pj, xiao wh. mechanism of increased risk of insulin resistance in aging skeletal muscle. diabetol metabol syndr 2020;12:1-10. 16. kusumastuty i, handayani d, attamimi n, et al. kepatuhan diet berbasis beras coklat terhadap kadar glukosa darah dan lemak tubuh pada pasien diabetes mellitus. [brown ricebased diet on blood glucose and body fat levels in diabetes mellitus patients.] indonesia j human nutrition 2021;8:18294. 17. ahmadzadeh tn. effect of basnef-based nutrition education on nutritional behaviors among elderly people and mini nutritional assessment on nutritional status in elderly with diabetes with type 2 diabetes (a clinical trial intervention). j educ health promotion 2019;8:94. 18. chrvala ca, sherr d, lipman rd. diabetes self-management education for adults with type 2 diabetes mellitus: a systematic review of the effect on glycemic control. patient educ counsel 2016;99:926-43. 19. sulistyowati e, rudijanto a, suharto s, et al. the identification of characteristic macroand micronutrients and the bioactive components of indonesian local brown rice as a functional feed in obesity nutrition therapy. curr nutrition food sci 2019;16:494-500. 20. kusumastuty i, handayani d, attamimi n, et al. kepatuhan diet berbasis beras coklat terhadap kadar glukosa darah dan lemak tubuh pada pasien diabetes mellitus. indonesia j human nutrition 2021;8:182-94. 21. martinez-sanchez n. there and back again: leptin actions in white adipose tissue. int j mol sci 2020;21(17). 22. zhang dm, jiao rq, kong ld. high dietary fructose: direct or indirect dangerous factors disturbing tissue and organ functions. nutrients 2017;9:1-25. 23. hernandez hr, mendia les, ramirez gr, et al. obesity and inflammation: epidemiology, risk factors, and markers of inflammation. int j endocrinol 2013;2013:1-11. 24. tanaka t, narazaki m, kishimoto t. il-6 in inflammation, immunity, and disease. cold spring harbor perspect biol 2014;6:1-16. 25. mahwati y, nurrika d. obesity indicators and c-reactive protein in indonesian adults (‚â• 40 years): the indonesian family life survey-5 2014-2015. kesmas: national public health journal 2020;15(3). 26. hadizadeh f, elham fpa. nonalcoholic fatty liver disease: diagnostic biomarkers. world j gastrointest pathophysiol 2017;8:11-26. article [page 42] [healthcare in low-resource settings 2023; 11(s1):11172] non -co mmerc ial us e o nly hrev_master [page 18] [healthcare in low-resource settings 2021; 9:10057] covid-19 pandemic and management on hospital length of stay: a review fatemeh abdollahi,1 seilan ghanyan,1 farkhondeh asadi2 1department of technology and management, shahid beheshti university of medical science, tehran; 2health information technology and management department, shahid beheshti university of medical science, tehran, iran abstract covid-19 virus is a serious threat to public health everywhere on the planet. the world health organization (who) declared the disease epidemic in december 2019 because of its rapid prevalence around the world. the disease is transferred by inhalation or contact with contaminated droplets, and the incubation period varies from 2 to 14 days. covid-19 has led to unprecedented pressures as demand for healthcare in hospitals and intensive care units around the world increases. as the epidemic intensifies, determining the resulting needs for health care resources (beds, staff, equipment) has become a priority for many countries. predicting future demand requires estimating how long covid-19 patients must have access to different levels of hospital care. the length of hospitalization for these patients is one of the management priorities. it is possible to pass through the crisis only with careful planning and comprehensive cooperation. introduction in 2019, the 2019-ncov or acute respiratory syndrome (sars-cov-2) spread from wuhan, china, to other parts of the world.1 the virus was uncontrollable and caused the deaths of many people around the world. preliminary data show that the elderly and those with weakened immune systems are more prone to the disease, while children are less likely to get sick. preventive measures are the best way to control this disease.2 risk factors of sarscov-2 activation are relevant to the immune system suppressor, such as aging, being a man, diseases such as diabetes, cardiovascular problems, weight gain, and preexisting viral diseases. infectious viruses may remain hidden in the body, and they appear at the same time as other active viruses. sars-cov-2 may allow the activation of these sub-viruses.3,4 the epidemic covid-19 makes proper management and isolation essential to prevent further outbreaks in the world.5 less current symptoms at covid-19, such as nausea, vomiting, diarrhea, are transmitted by person-to-person.6 patients with symptoms like fever, dry cough, and metabolic process distress should refer to the hospital.7 also, people who have more severe symptoms of the disease should be hospitalized to continue the treatment. hospital systems have been challenged by the influx of patients.8 hospital care such as patient monitoring, sample testing, infection control in health centers, maintenance of necessary resources, pathways, beds, staff, and equipment required in the hospital, can affect the length of hospital stay.9 many countries have failed despite having well-equipped sanitation systems and beds in hospitals.10 the increasing demand for hospital beds, as well as staff and related equipment, provides basic evidence indicating the need for careful decision-making and planning. los, long normal, and weibull estimation models can be used to predict the number of beds needed by hospitalized patients.11 obviously, taking such measures is reflected in the hospital admissions and health information technology (hit), supposed to be key restrictive parameters for hospitalized patients.12 the relative shortage of hospital beds and the high incidence of the disease, the increase in the risk of mortality, and the delay by physicians in the discharge of patients until full recovery, may make it difficult to identify the appropriate level of health care.13 the study aims to raise awareness of the efforts made by health policymakers and hospital managers to better predict the needs of hospitalized patients while protecting them during the covid-19 epidemic.14 covid-19 as a pandemic in hospitals the disease brought by coronavirus is of the most recent crises in human society, which spread worldwide and was declared as an epidemic by who on march, 11, 2020. in italy, which had the highest number of patients after china, almost twothirds of all hospital beds were filled with covid-19 patients whitin 10 days.15 thus, hospitals were placed at the forefront of the healthcare system and crisis response.16 health managers and policymakers now control and manage the situation in a different context. identifying the challenges in hospitals, along with the implementation of effective strategies in the face of biological crises, can play an important role in crisis management planning.17.it is also possible to extend these programs to other countries.18,19 at the start of the covid-19 pandemic, hospital managers could use the total capacity of hospital beds,18 trying to discharge patients with lower priority and concentrate on more critical conditions.20 then, separate clinical centers were allocated to covid-19 suspected patients to manage hospital patient flow.21 restrictions were also imposed on visits for the wards designated to these patients.22 in addition to the restrictions and hospitalization of many patients, there were healthcare in low-resource settings 2021; volume9:10057 correspondence: fatemeh abdollahi, department of technology and management, shahid beheshti university of medical science, tehran university of medical sciences, tehran, iran. e-mail: f.abdollahii92@gmail.com acknowledgements: this study was supported by mrs. samira hosseini from tabriz university of medical sciences. conflict of interest: the authors declare no conflict of interest. key words: covid-19; length of stay; quality health care; sars-cov-2; hospitalization. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the ethics committee of shahid beheshti university of medical science, tehran approved this study (ir.sbmu.vcr. rec.1398.395). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all patients participating in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 23 august 2021. revision received: 22 september 2021. accepted for publication: 4 october 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:10057 doi:10.4081/hls.2021.10057 non commercial use only several efforts to use the simplest accessible resources and facilities in the best way.23 accordingly, crisis management specialists coordinated closely with alternative hospitals.24 hospital support measures associated with the covid-19 in the early phase of the pandemic, information on the disease was still evolving; thus, case definitions and hospital pointers were most often modified.25 hospitals became scenes of super-spreading events throughout the disease and mers epidemic.26 outpatients and emergency groups were supposed to be at a higher risk.27 all facilities were mobilized to establish elaborate strategies aimed at safe testing and effective quarantine of suspects.28 otherwise, uncertainties of those on the forefront and the increasing number of patients would turn such locations into hospital-related epidemics.29 the allocation of a unit to assess medical services by an associate in nurse staffing requirements may act as a security barrier to the construction.30 sorting can be a clinical strategy to deal with patients who have acute metabolism illnesses.31 for example, as in the case of associate in nurse staffing, initial testing, treating the disease, and managing different cases can be performed with voluntary home quarantine.32 then, if it does not respond, covid-19 visits and examinations can be performed at intervals of 5 to 9 days.33 the use of telemedicine or telecommunications is usually supposed to reduce the need to travel to outpatients.34 hospitals got to establish potential programs for general wards and treatment units.35 caring for patients with covid-19 requires an associate degree and large rooms and areas to quarantine mobile contaminants, which means exceeding the available capacities.36 the adjustment of air conditioning systems is also a useful solution to deal with the crisis worldwide.37 heating, ventilation, and air conditioning (hvac), along with waste management and handling, have been at the center of attention in public departments to manage patients with covid-19.38 pharmacies and private offices face particular challenges due to the lack of capabilities for quarantine and testing.39 an efficient flow of patient testing and referrals is very important, and the cooperation of competent public health professionals with society is required to support healthcare foundations effectively.40 communications and management of patients, visitors, and staff at the early phase of virus prevalence, hospital guidelines often underwent revisions.41 now, strict measures of isolation and protection are the main priorities to deal with this disease.42 nurses are provided with online training on how to protect against and prevent coronavirus infection in their hospitals to increase staff awareness and communication 43 (figure 1). coordination between all employees is also necessary.44 all staff should report their respiratory symptoms and body temperature before and after exposure to patients with covid-19 while avoiding entrance into unnecessary wards.45 the staff must carry out all programs according to the instructions given by the hospital manager.46 patient management managers focused on discharging patients who had better conditions through international agencies or taking their admission to completely different hospitals or clinics so that they could take advantage of the hospital’s full capacity.47 the closure of the operation rooms and rejection of elective patients aimed at prevent patient flow to the hospitals.48 also, covid-19 suspected patients were assigned distinct clinical centers providing visits and administrative procedures.49 a follow-up center was also established for those patients who received care, but their administrative unit did not institutionalize the reception process.50 patients admitted at home had access to routine contacts and residential care nursing groups when required.51 the red crescent society and other volunteers helped in the establishment of patient centers.52 visits of the wards in which covid-19 patients were hospitalized were also restricted or prohibited (figure 2).53 patient position: must be manufactured to isolate patients with doubtful or established covid-19.54 article figure 1. proposals for hospital. figure 2. theoretical topics of research in the hospital. [healthcare in low-resource settings 2021; 9:10057] [page 19] non commercial use only [page 20] [healthcare in low-resource settings 2021; 9:10057] patient education: napkins should be prepared and patiently instructed to cover the nose and mouth.55 management of items and facilities considering the constraints, together with higher chances of hospitalization within the next phases of the pandemic, the attempt was made to use the available resources and equipment effectively.56 accordingly, in addition to the effective use of the resources and provisions, the consultants in crisis management coordinated with alternative hospitals to arrange donations and fund facilities such as personal protection kits, masks, gloves, and disinfectants.57 also, because of the lack of resources and facilities to treat infected individuals, specialized hospitals such as medicine or medical specialty centers need exclusion from the cycle of the fight against the pandemic.58 as the patient variety increases, coordination with alternative establishments is necessary to create field hospitals.59 conclusions nowadays, the diffusion of up to date on the latest information on covid-19 is an important method that can into the performance of self-care guidance. control of this disease requires society’s involvement and presentation information about covid-19 to the society has a key role in managing critical conditions60 the prevalence of the novel virus has challenged the infrastructure of many countries in the world, affecting the lives of all humans.61 moreover, we need to consider the behavioral variations of covid-19, and its longterm effects in the human body.62 emergency and disaster readiness is an important and global issue.63 most hospitals are unable to maintain their normal operations for a week due to a lack of disasterrelated resources.64 however, it is possible to overcome the epidemic with the necessary preparations and the coordination and cooperation of all hospital departments, including staff, doctors, and nurses.65 in this review study, the hospital system monitored staff performance to detect significant changes and take appropriate measures for patients admitted to covid-19 wards.66 to change the patients’ length of stay in the hospital, it is important to use hospital management techniques and coordinate with health centers in the community.67 adherence to protocols, health and care guidelines, and social distancing between people can decrease virus infection cases.68 compliance with the principles of health and self-care make it possible to prevent acute cases of the disease and hospitalization.69 references 1. rinaldi f, trink a, pinto d. efficacy of postbiotics in a prp-like cosmetic product for the treatment of alopecia area celsi: a randomized doubleblinded parallel-group study. dermatol ther (heidelb) 2020;10:483493. 2. pfefferbaum b, north cs. mental health and the covid-19 pandemic. n engl j med 2020;383:510-2. 3. mehraeen e, seyed 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anesth analg 2020;131:31-6. 25. hao f, tam w, hu x, tet al. a quantitative and qualitative study on the neuropsychiatric sequelae of acutely ill covid-19 inpatients in isolation facilities. transl psychiatry 2020;10:355. 26. peeri nc, shrestha n, rahman ms, et al. the sars, mers and novel coronavirus (covid-19) epidemics, the newest and biggest global health threats: what lessons have we learned? int j epidemiol 2020;49:717-26. 27. zhao j, li h, kung d, et al. impact of the covid-19 epidemic on stroke care and potential solutions. stroke 2020;51:1996-2001. 28. liu y, wang h, chen j, et al. emergency management of nursing human resources and supplies to respond to coronavirus disease 2019 epidemic. int j nurs sci 2020;7:135-8. 29. yu h, sun x, solvang wd, zhao x. reverse logistics network design for effective management of medical waste in epidemic outbreaks: insights from the coronavirus disease 2019 (covid-19) outbreak in wuhan (china). int j environ res public health 2020;17:1770. 30. basu s. non-communicable disease management in vulnerable patients during covid-19. indian j med ethics 2020;v:103-5. 31. peiffer-smadja n, lucet jc, bendjelloul g, et al. challenges and issues about organizing a hospital to respond to the covid-19 outbreak: experience from a french reference centre. clin microbiol infect 2020;26:669-72. 32. chew nws, lee gkh, tan byq, et al. a multinational, multicentre study on the psychological outcomes and associated physical symptoms amongst healthcare workers during covid-19 outbreak. brain behav immun 2020;88:559-565. 33. zhang j, litvinova m, wang w, et al. evolving epidemiology and transmission dynamics of coronavirus disease 2019 outside hubei province, china: a descriptive and modelling study. lancet infect dis 2020;20:793-802. 34. giacomelli a, ridolfo al, milazzo l, et al. 30-day mortality in patients hospitalized with covid-19 during the first wave of the italian epidemic: a prospective cohort study. pharmacol res 2020;158:104931. 35. song z, hu y, zheng s, et al. hospital pharmacists' pharmaceutical care for hospitalized patients with covid-19: recommendations and guidance from clinical experience. res social adm pharm 2021;17:2027-31. 36. aguwa ut, aguwa cj, repka m, et al.teleophthalmology in the era of covid-19: characteristics of early adopters at a large academic institution. telemed e-health 2020;27:0372. 37. cheng y, wei w, zhong y, zhang l. the empowering role of hospitable telemedicine experience in reducing isolation and anxiety: evidence from the covid-19 pandemic. internat j contem hospitality manag 2021;33:851–72. 38. berger g, horowitz na, shachormeyouhas y, et al. hospital solution for covid-19 isolation facility. am j disaster med 2021;16:35-41. 39. goff da, ashiru-oredope d, cairns ka, et al. global contributions of pharmacists during the covid-19 pandemic. j am coll clin pharm 2020:10.1002/jac5.1329. 40. greenhalgh t, knight m, a'court c, et al. management of post-acute covid-19 in primary care. bmj 2020;370:m3026. 41. hoernke k, djellouli n, andrews l, et al. frontline healthcare workers' experiences with personal protective equipment during the covid-19 pandemic in the uk: a rapid qualitative appraisal. bmj open 2021;11:e046199. 42. xu c, jin j, song j, et al. application of refined management in prevention and control of the coronavirus disease 2019 epidemic in non-isolated areas of a general hospital. int j nurs sci 2020;7:1437. 43. alharthy a, faqihi f, mhawish h, et al. configuring a hospital in the covid19 era by integrating crisis management logistics. infect control hosp epidemiol 2021;42:911-3. 44. grange es, neil ej, stoffel m, et al. responding to covid-19: the uw medicine information technology services experience. appl clin inform 2020;11:265-75. 45. htun hl, lim dw, kyaw wm, et al. responding to the covid-19 outbreak in singapore: staff protection and staff temperature and sickness surveillance systems. clin infect dis 2020;71:194752. 46. adams jg, walls rm. supporting the health care workforce during the covid-19 global epidemic. jama 2020;323:1439-40. 47. jing zc, zhu hd, yan xw, et al. recommendations from the peking union medical college hospital for the management of acute myocardial infarction during the covid-19 outbreak. eur heart j 2020;41:1791-4. 48. janbabai g, razavi s, dabbagh a. how to manage perioperative patient flow during covid-19 pandemic: a narrative review. j cell molecular anesth 2020;5:47-56. 49. lee i, wang c, lin m, et al. effective strategies to prevent coronavirus disease-2019 (covid-19) outbreak in hospital. j hospital infect 2020;105:102. 50. fond g, pauly v, leone m, et al. disparities in intensive care unit admission and mortality among patients with schizophrenia and covid-19: a national cohort study. schizophr bull 2021;47:624-34. 51. abuhammad, s, manar, a, mukattash, t. the perception of nurses towards their roles during the covid-19 pandemic. int j clin pract 2021;75:e13919. 52. abed alah m, ali k, abdeen s, et al. the psychological impact of covid19 on health care workers working in a unique environment under the umbrella of qatar red crescent society. heliyon 2021;7:e07236. 53. chang cm, tan tw, ho tc, et al. covid-19: taiwan's epidemiological characteristics and public and hospital responses. peerj 2020;8:e9360. 54. krishnamurthy s. the future of business education: a commentary in the shadow of the covid-19 pandemic. j bus res 2020;117:1-5. 55. tabatabai s. covid-19 impact and virtual medical education. j adv med educ prof 2020;8:140-3. 56. eftekhar ardebili m, naserbakht m, bernstein c, alazmani-noodeh f, hakimi h, ranjbar h. healthcare providers experience of working during the covid-19 pandemic: a qualitative study. am j infect control 2021;49:547-54. 57. kliger as, silberzweig j. mitigating risk of covid-19 in dialysis facilities. clin j am soc nephrol 2020;15:707-9. 58. mohammadi f, farjam m, gholampour y, et al. health professionals' perception of psychological safety in patients with coronavirus (covid-19). risk manag healthc policy 2020;13:785-94. 59. reeves jj, hollandsworth hm, torriani fj, et al. rapid response to covid-19: health informatics support for outbreak article non commercial use only [page 22] [healthcare in low-resource settings 2021; 9:1057] management in an academic health system. j am med inform assoc 2020;27:853-9. 60. mehraeen e, hayati b, saeidi s, et al. self-care instructions for people not requiring hospitalization for coronavirus disease 2019 (covid19), arch clin infect dis 2020;15:e102978. 61. yang p, wang x. covid-19: a new challenge for human beings. cell mol immunol 2020;17:555-7. 62. seyedalinaghi s, afsahi am, mohssenipour m, et al. late complications of covid-19; a systematic review of current evidence. arch acad emerg med 2021;9:e14. 63. matias t, dominski fh, marks df. human needs in covid-19 isolation. sage publications sage uk: london, england, 2020. 64. huang l, lin g, tang l, et al. special attention to nurses’ protection during the covid-19 epidemic. crit care 2020;24:120. 65. humam am, loh tc, foo hl, et al. dietary supplementation of postbiotics mitigates adverse impacts of heat stress on antioxidant enzyme activity, total antioxidant, lipid peroxidation, physiological stress indicators, lipid profile and meat quality in broilers. animals (basel) 2020;10:982. 66. bambi s, iozzo p, lucchini a. new issues in nursing management during the covid-19 pandemic in italy. am j crit care 2020;29:e92-e93. 67. brindle me, gawande a. managing covid-19 in surgical systems. ann surg 2020;272:e1-e2. 68. chen q, liang m, li y, et al. mental health care for medical staff in china during the covid-19 outbreak. lancet psychiatry 2020;7:e15-e16. 69. mauffrey c, trompeter a. lead the way or leave the way: leading a department of orthopedics through the covid-19 pandemic. eur j orthop surg traumatol 2020;30:555-7. article non commercial use only hrev_master [page 68] [healthcare in low-resource settings 2013; 1:e19] contraception and poverty: a lost battle nisrine n. makarem department of family medicine, american university of beirut, beirut, lebanon dear editor, as part of my residency program at the department of family medicine at the american university of beirut, i was sent to an outreach clinic located in the poorest suburbs of beirut and serving one of the most underprivileged communities in lebanon. besides the difficulties of practicing medicine in such settings, one of the greatest challenges of the clinic was the high fertility rates and the very low use of contraceptive methods that were available for free. the clinic is full of children, every woman walks in with 3-4 children clinging on to her, so closely spaced that you would not know their order of age. sometimes she herself would stop and think before giving you names or ages. you may wonder why. why do the poor have so many children? could the answer be evolutionary? could it be that like all other mammals, humans also tend to follow a fast evolutionary track when they live in harsh environments? lebanon has a contraceptive-use rate of 58% for any method and a value for fertility rate of 1.76 in 2013, a minimum since 1960.1,2 despite such encouraging figures, contraceptive use is rare among women in this community. from what women tell us, it seems that men in this community are the ones who demand many children. women, as they are raised up to be, are obedient to their men’s wishes. some tell us that since they got married right after menarche, or in extreme cases had their menarche while married, rarely get their menses. as one woman recalls, last time i saw blood was ten years ago! since her marriage, she was either pregnant with one of her 7 children or was breastfeeding. in this community, men take pride in the number of offspring they have; it is a manifestation of how manly and potent they are. nevertheless, women are also part of the dilemma. conceiving makes them feel productive and that they are living up to the expectations of their husbands and communities. as another woman explains it: this is what i know to do best. furthermore, boredom, lack of electricity, and lack of ordinary life pleasures could be a contributing factor. one of the women joked about it saying that if we had electricity maybe we would spend the night watching television instead of conceiving! as bitter and trivial as this may sound, it could unfortunately be a contributing factor. the final knock-out to the use of contraception in this community is the endless number of myths surrounding it. many think that oral contraceptive pills are addictive, while others believe that their effects are irreversible and conceiving after stopping them is almost impossible. the unrealistic fear from irreversible infertility applies to progestin injections whereby the women believe that these work by killing their eggs. among the most bizarre beliefs about intrauterine devices is that the husband’s penis might get tangled to the thread. you try to challenge these myths, but your medical degree, your years of experience, and your scientific proofs all falter and fall when facing these poor powerless women. you realize at this point how poverty has its own culture, how this culture in itself can perpetuate poverty and how these combined can hinder the delivery of proper healthcare in such settings. what is said above attempts to explain the behavior of underprivileged communities at times of peace, but what happens at times of war? do the same factors still hold true? hay el gharbeh has become shelter to hundreds of syrian refugees in the past 2 years. an interesting observation is that 9 out of the 10 women who come for weekly fetal ultrasounds are syrian. they are pregnant despite being refugees. many do not know where and how they are going to deliver. most cannot afford the delivery charges of most lebanese hospitals; back home their deliveries were at negligible amounts. and then the one million dollar question pops up: but why did you get pregnant? we have lost so many martyrs during this war, we want to make up for that is the almost unanimous answer. you then understand that wars can be fought in so many different ways not necessarily with guns and cannons. the reasons are many, for lebanese and syrians, for peace and war, but the outcome is one: an increased burden on this already strained community for the story does not end when the baby is born, it is just when the misery begins. references 1. population council. lebanon 1996: results from the lebanon maternal and child health survey. stud family plann 2001;32:175-80. 2. central intelligence agency. the world factbook: lebanon. washington, dc: central intelligence agency ed.; 2013. available from: https://www.cia.gov/library/ publications/the-world-factbook/geos/le. html healthcare in low-resource settings 2013; volume 1:e19 correspondence: department of family medicine, american university of beirut, riad el solh 11-0236, 1107 2020 beirut, lebanon. tel. +961.3164180 fax: +961.1483115. e-mail: nisrinemakarem@hotmail.com key words: poverty, contraception, lebanon, syrian refugees. conflict of interests: the author declares no potential conflict of interests. received for publication: 1 march 2013. revision received: 22 april 2013. accepted for publication: 23 april 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.n. makarem, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e19 doi:10.4081/hls.2013.e19 non -co mmerc ial us e o nly hrev_master [page 46] [healthcare in low-resource settings 2013; 1:e12] risk factors for pre-eclampsia among women at antenatal booking in kano, northern nigeria ibrahim a. yakasai,1 imran o. morhason-bello2 1department of obstetrics and gynaecology, bayero university kano/aminu kano teaching hospital, kano; 2department of obstetrics and gynaecology, university college hospital, ibadan, nigeria abstract pre-eclampsia (pe) is an important cause of maternal mortality. there have been several studies on risk factors assessment with conflicting reports across the globe on this disease; however, rigorous recent evaluation of these factors is uncommon in this region. the aim of the present study was to determine the risks factors in the early-onset pe in aminu kano teaching hospital (akth), kano (northern nigeria). we conducted a case-control study in nigeria between april 2009 and january 2010 to identify the risk factors associated with the early-onset pe in women attending antenatal clinic in akth. information on socio-cultural characteristics, medical history, previous obstetrics history, level of stress at home, and type of family were obtained and recorded in a proforma designed for the study. multiple logistic regression analysis was used to determine the risk factors for pe at 95% confidence level. pregnant women with early-onset pe (150 in each case and control group). risk factors associated with increased risk of early-onset pe were: history of pre-eclampsia/eclampsia (pe/e) in a previous pregnancy [adjusted odds ratio (aor) 2.09]; exposure to passive smoking (aor 1.34); inadequate antenatal supervision (aor 15.21); family history of hypertension in one or more 1st-degree relative (aor 8.92); living in a joint family (aor 6.93); overweight (120% to 150% of pre-pregnancy ideal body weight, aor 4.65). risk factors among women in northern nigeria are similar to those reported from other studies. good antenatal cares, early detection, reduction of stressful conditions at home are the most important preventive measures of early-onset severe pe among these women. introduction pre-eclampsia (pe) is a major cause of maternal and fetal mortality and morbidity. in general, the incidence of pe ranges between 2 and 10% worldwide.1 in an average uk population, the incidence of pe is less than 1 in 20 women.2 according to the national institute of clinical excellence (nice) antenatal guidelines, a woman’s level of risk for pe in a given pregnancy should be assessed at the first antenatal visit by identifying the presence of one or more predisposing historical risk factors, and they should be supervised more vigilantly and managed at centers with facilities for specialized neonatal and maternal intensive care.1 in the guidelines, some of the risk factors for the development of pe are: first pregnancy; previous pe; >10 years since last baby; age >40 years; body mass index (bmi) >35; family history of pe; booking diastolic blood pressure (bp) 80 mmhg; proteinuria at booking of +1 on more than one occasion or 300 mg/24 h; multiple pregnancy; and underlying medical conditions. different populations and ethno-geographical groups may have different risk factors.2 it is important to establish the individual contribution of the various risk factors for the development of pe, most relevant to the particular population. such studies in african women are limited. the incidence of pe in nigeria is not known. it has never been evaluated on a large randomized trial to give a true national incidence. beside the study by anorlu and colleagues there is none available to the best of our knowledge that attempts to estimate the incidence of pe in lagos state. most studies from nigeria dealt with the incidence on eclampsia, and these vary in different geographical areas. it is as low as 0.3%/100 delivery in calabar (southern nigeria) to as high as 5-9%/100 in kano (northern nigeria). rates are generally higher in the north than the south. several other studies have been carried out on eclampsia.3-5 in general, the diagnostic criteria for pe are hypertension (ht) and significant proteinuria. the degree of these criteria is a major determinant to the progression of the disease. women who have had a pregnancy complicated by pe and endured significant maternal or perinatal morbidity require specific counseling regarding recurrence (range 0-5% and up to 47%) in order to make decisions about future reproduction. the screening tests to predict pe are also available and they are biophysical and biochemical. the most promising biophysical test is uterine artery doppler scan. though inexpensive in the western world, it is rarely performed in developing countries due to cost and manpower.6 therefore, identification of clinical, laboratory and historical risk factors for the development of pe in a particular population group will guide the healthcare providers during counseling of such women and possibly reduce the recurrence risk of pe if some modifiable risk factors (like obesity and insulinresistance) are present. the present study is proposed to identify the clinical and historical risk factors in women with early-onset pe (defined as having symptoms of pe before 34 weeks’ pregnancy)7 attending a tertiary care hospital in north nigeria, and compare these risk factors with those in women in a control group without ht. materials and methods this case-control study was conducted between april 2009 and january 2010 in the department of obstetrics and gynaecology of aminu kano teaching hospital (akth) kano, nigeria. in this study pe is defined as a rise blood pressure of 140/90mmhg and 300 mg of protein in a 24-hour urine sample in the second half of pregnancy. severe pe is defined as a bp over 160/110 with or without additional symptoms. the study group was comprised of 150 women seen at the clinic and admitted with early-onset (34 weeks) pe with a systolic bp of 160 mmhg or a diastolic of 110 mmhg after 20 weeks’ gestation, plus proteinuria of 2.0 g/24 h (or 2+ on qualitative examination), according to the national guidelines and the departmental protocol.1,8 the control group was comprised of 150 women admitted without ht and a bp less than 140/90 obtained on two occasions at least 6 h apart, for first time during pregnancy healthcare in low-resource settings 2013; volume 1:e12 correspondence: ibrahim yakasai, department of obstetrics and gynaecology, aminu kano teaching hospital, hospital road, pmb 3452, kano, nigeria. tel./fax: +234.802.751.3292. e-mail: ibrahimyakasai57@hotmail.com key words: hypertension, pre-eclampsia, risk factors, nigeria. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 december 2012. revision received: 9 febraury 2013. accepted for publication: 16 febraury 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright i.a. yakasai and i. mohassan bello, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e12 doi:10.4081/hls.2013.e12 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e12] [page 47] after 34 weeks’ gestation and no proteinuria, which delivered during the same period. the control groups were normotensive women matched with the study group in terms of gestational age, parity and age. women with uncertain gestational age, poor compliance for follow-up, whose data did not contain platelet count, renal and liver functions, were excluded. all women gave written informed consent and the study was approved by the research ethics committee of the institute. the researchers took the medical history and fill the proformas: data was collected by the principal investigator and research assistant, using a pre-tested interviewer-administered questionnaire. a detailed history, including past, personal and family history, pregnancy outcome, including delivery details and perinatal outcome and available investigations were recorded. if bp records in the 1st trimester were not available, the women were examined after 12 weeks of delivery to note the presence of high bp. though pe and ht may have different pathology, patients with existing ht were included, in order to determine those who develop superimposed pe and the role if any and influence of pre-existing ht in women who go on to develop pe. data also exist showing that, pre-eclamptic women were more likely to have a family history of ht.9,10 the stress at work was calculated by a fivelevel activity score, based on the distance and transportation from home to workplace, type and physical intensity of work and weekly working hours adapted from a study by anorlu et al.11 the nature of work among the employed women in the present study was classified into sedentary, moderate and intense physical activity.12 anorlu et al. had calculated the stress at home in terms of lack of home help, number of young children, stress from husband and number of extended family members living with the patient. they assess factors regarding stress at home and its role as a risk factor in pe. no particular score was given to these factors, but found stress from lack of home help to be the most important factor. the score is not validated but useful in assessing risk factors in pe among pregnant nigerian women. we therefore chose to use it in this study. these factors were modified to be suitable for the population enrolled in the present study and included availability of home help, resting hours and family type. the minimum sample size was calculated to be 138 using this validated formula:13 n = z2p(1-p)/d2 (1) where n=minimum sample required; z=standard normal deviation=1.96 (at 95% confidence level); d=sample error=5%=0.05; p=incidence of women with pe (obtained from other studies) 10%.1 therefore: n=(1.96)2(0.10)(1-0.10)/(0.05)2 n=3.84x0.10x0.90/0.0025 n=0.3456/0.0025 n=345/2.5 n=138.2 to account for failed or incomplete response, the minimum sample size was increased to 150. consecutive sampling method was used to recruit study participants data were analyzed using software spss version 11 for windows. analysis was done to check for range and consistency of data to determine the risk factors associated with severe pe. odds ratio (or) and 95% confidence interval (ci) was calculated for each risk factor. a p value <0.05 was considered significant. results during the study period, there was a total of 2920 deliveries, of which 250 women had high diastolic bp (mild pe 38, 15.2%; severe pe 120, 48%; eclampsia 78, 31.2%; chronic ht 14, 5.6%). among the 150 study patients, 110 women had early-onset severe pe, 30 had eclampsia and 10 had superimposed pe on the underlying ht. all the women in the control group had normal bp at 6 weeks’ postpartum. the mean age of cases and controls were 26.03 and 26.46 years, respectively. the sociodemographic characteristics of patients are shown in table 1. the study group had significantly more multigravid women as compared with the control group [crude odds ratio (cor) 1.92; 95% ci 1.05-3.52]. the socio-economic status was categorized into five classes according to olusanya’s classification.14 in the study group, 81% of women belong to the lower and lower-middle classes as compared with only 43% in the control group, which is statistically significant. table 2 shows the medical and obstetric characteristics of patients. in the present study, the mean gestation at which women developed severe pe/e was 34 weeks, while none among the control developed it. the perinatal mortality in the study group was 42% as compared with none in the control group. the study group women had severe disease, as 70% had bp 4180/120; 68% had urine albumin 3+; 35% had hellp syndrome; 17% had deranged renal functions and 25% had eclampsia. the frequencies of antenatal visits are categorized into adequate, intermediate and inadequate, according to kessner index criteria.15 the mean weight of cases and controls were 68.03 + 5.61 kg (range 50-81 kg) and 66.58 + 8.48 kg (range 44-95 kg), respectively. since there are no nomograms of bmi during pregnancy, and the pre-pregnancy weight is not always recorded, these women were categorized into four groups on the basis of the current pregnancy weight expressed as a percentage of the pre-pregnancy ideal body weight.16 two women in the study group had gestational diabetes mellitus (gdm) controlled on diet and four had frank diabetes (type 1). a history of previous pe/e was associated with more than 18 times increased risk of developing pe (cor 18.86; 95% ci 2.55389.25). as smoking has been found to be a factor that reduces the risk of pe/e, we considered exposure to passive smoking to represent this factor, since none of the participants in the study group gave a history of smoking. exposure to passive smoking is defined as the involuntary exposure to a combined but diluted cigarette side-stream smoke and the exhaled smoke from the smokers.17 the level of stress at home and at work is shown in table 3. resting hours were defined as the availability of resting time for 2 h in the day and 7 h at night. a monogamous family consists of the married couple and their dependent children occupying the same dwelling place. the polygamous consists of a number of wives married to one man living with their children; other members of the family related may also be living in the same compound. pre-pregnancy ht was taken as a significant risk factor for the development of early-onset severe pe on the basis of a highly significant p value (p<0.0003). article table 1. demographic data of women in study and control groups. variables cases (n=150) controls (n=150) or 95% ci p value n % n % age (years) <20 10 6.67 14 9.33 0.69 0.28-1.73 0.5 20-34 122 81.33 126 84 0.83 0.44-1.57 0.65 ≥35 18 12 10 6.67 1.91 0.80-4.63 0.16 gravidity primigravidae 66 44 75 50 0.6 0.37-0.97 0.04 multigravidae 84 56 75 50 1.27 0.79-2.06 0.35 or, odds ratio; ci, confidence interval. non -co mmerc ial us e o nly [page 48] [healthcare in low-resource settings 2013; 1:e12] discussion in this study the finding revealed that a history of pe, pre-existing diabetes, multiple pregnancies, and family history, a raised bmi greater than 35 at booking, maternal age greater than 35 years, underlying renal disease, ht, more than 5 years since last pregnancy, and raised bp at booking all increased the risk of women developing pe. the study further shows that exposure to passive smoking is a significant risk factor for the early-onset severe pe. however, other studies have reported that cigarette smoking during pregnancy was associated with a 32% and 35% reduction in the risk of pe.9,18 the biologic mechanism by which cigarette smoking during pregnancy may reduce the risk of pe is not clear. it may be possible that smoking leads to the earlier termination of pregnancies – miscarriage, preterm delivery, or abruption – which would otherwise be destined to manifest as pe.17 family history of pe was reported to be a risk factor and nearly triples the risk for pe.17 however, in another study, it did not emerge as a significant risk factor.19 history of pre-pregnancy ht was a significant risk factor associated with early-onset severe pe in univariate analysis (rr 2.14), which is in agreement with other studies. brown and colleagues20 found that the prevalence of chronic ht was higher in women who develop pe than women who do not (12.1% vs 0.3%). the results of the present study regarding the stress-related factors shows that women of lower socio-economic status and living in a joint family have an increased risk of severe early-onset pe. it is likely that these women may have increased household work due to more family members in a joint family leading to increased physical and mental stress, which may predispose them to develop severe earlyonset pe. chronic autoimmune disease like hypothyroidism in this study remained a significant risk factor in the development of pe. in a matched case-controlled study wolfberg et al.21 found that women who develop pe were more likely to have an autoimmune disease. in the present study, of the 150 women with severe pe, 4/8 women with hypothyroidism had chronic ht as compared to 26/92 euthyroid women (50 vs 28%). the final verdict as to whether hypothyroidism per se is a significant risk factor for pe or whether it is a contributory factor due to its association with chronic ht will be clarified by larger studies. risk factors may be specific to the mother or the pregnancy. some such as primigravidity or past history of pe are well known. primigravidae are 15 times more likely to develop protienuric pe than parous women,21 which is similar to the present study where nulliparity almost triples the risk for pe. however, sibai et al.22 showed that hdp are more frequent in multigravidae suggesting that multigravidae are more likely to have early-onset and severe disease. in the present study, only a few women were employed during pregnancy in both the study (6%) and the control (15%) groups; and being unemployed appeared to be a risk factor for early-onset severe pe in univariate analysis (cor 2.76). on the other hand, some authors have reported that employment during pregnancy is a significant risk factor for developing pe.12,23 this difference may be due to a lesser number of employed women in both groups. the present population of northern nigeria women represents a group, among which most women are not formally employed, but may be working much harder in large joint families, which was a significant risk factor for severe early-onset pe (aor 6.93). article table 2. medical and obstetric characteristics of women in study and control groups. variables cases (n) controls (n) or 95% ci p value kessner index criteria adequate 28 101 0.11 0.06-0.2 <0.0001 intermediate 43 49 0.83 0.49-4.28 0.5 inadequate 69 44 2.05 1.24-3.4 0.004 antenatal complications multiple pregnancy (twins) 12 8 1.54 0.57-4.28 gestational diabetes 9 20 0.41 0.17-1.00 abruptio placenta 25 0 placenta praevia 4 0 prom 7 4 1.79 0.46-7.44 bmi/pregnancy weight categories normal weight (80-120%) 39 76 0.34 0.2-0.57 <0.0001 overweight (>120-150%) 105 66 0.92 0.6-1.42 0.77 obese (>150%) 6 8 0.74 0.22-2.42 0.78 medical disorders pre-pregnancy ht 24 0 <0.0001 diabetes mellitus 4 0 0.06 renal disease 5 0 0.03 hypothyroidism 2 0 2.01 0.14-56.69 0.5 previous obstetric outcome abortions 38 40 0.93 0.54-1.61 0.9 pe/e 32 2 20.1 4.56-123.7 <0.0001 gestational ht 12 3 4.26 1.09-19.45 0.03 family history of medical disorders ht 84 36 4.03 2.39-6.82 <0.0001 diabetes mellitus 38 42 0.87 0.5 -1.50 0.7 pe/e 12 6 2.09 0.7-6.44 0.22 smoking yes 4 3 1.34 0.25-7.7 0.5 no 146 147 or, odds ratio; ci, confidence interval; kessner index criteria, adequacy of prenatal care; prom, prelabor rupture of membranes; bmi/pregnancy weight categories, current weight expressed as a percentage of ideal pre-pregnancy weight; bmi, body-mass index; ht, hypertension; pe/e, pre-elcampsia/eclampsia. table 3. level of stress at home and at work of women in study and control groups. variables cases (n) controls (n) or 95% ci p value employment during pregnancy yes 25 34 0.68 0.37-1.26 0.25 no 125 116 availability of home help (housemaid/relations) yes 60 111 0.23 0.14-0.39 <0.0001 no 90 39 family type monogamous 68 67 1.03 0.64-1.66 0.1 polygamous 82 83 0.97 0.6-1.57 0.1 or, odds ratio; ci, confidence interval. non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e12] [page 49] there have been conflicting reports on the impact of maternal age on pe. we did not find age to be a significant risk factor, which is consistent with a similar study by eskenazi et al. who conducted their study in north california (usa) among black pregnant women attending antenatal clinic.24 however, a nationwide us data suggest that the risk of pe increases by 30% for every additional year of age after 34 years.25 this may be probably due to the fact that the majority of our study participants concluded their childbearing by the age of 30. furthermore, multiple pregnancy as a significant risk factor was also observed in this study. several studies have shown that when a woman is pregnant with twins her risk of pe nearly triples, neither the chronicity nor zygosity alter this increased risk.11,26,27 in summary, factors which emerged to be significant in the multivariate analysis were: history of pe/e in a previous pregnancy (aor 71.40); exposure to passive smoking (aor 16.40); inadequate antenatal supervision (aor 15.21); family history of ht in one or more 1st-degree relatives (aor 8.92); living in a joint family (aor 6.93); overweight (4120150% of pre-pregnancy ideal body weight, aor 4.65) and lower socio-economic class (olusanya’s class iii-v) (aor 3.00). the results of the present study are in agreement with other studies.10,19,24,28 a history of previous pe/e was associated with more than 18 times increased risk of developing pe, while pre-pregnancy ideal body weight found to be least associated with pe. conclusions based on the presence of risk factors identified in the present study, women may be counseled prior to or during pregnancy and advised to have adequate antenatal supervision in a hospital with appropriate facilities for caring of women with severe pe and pre-term neonates. this may help to constitute a risk model as practice in other units, thereby reducing the attendant maternal and perinatal complications. references 1. national institute for health and care excellence. nice guidelines cg6 antenatal care-routine care for the healthy pregnant woman. london: nice publ.; 2003. 2. milne f, redman c, walker j, et al. the pre-eclampsia community guideline (precog): how to screen for and detect onset of pre-eclampsia in the community. brit med j 2005;330:576-80. 3. adamu ym, salihu hm, sarthiakumar n, alexandra r. maternal mortality in northern nigeria: a population based study. eur j obstet gyn r b 2003;109:1539. 4. yakasai ia, gaya sa. maternal and fetal outcome in patients with eclampsia at murtala muhammad specialist hospital kano, nigeria. ann afr med 2011;10:305-9. 5. itam ih. sociodemographic determinants of eclampsia in calabar: a 10 year review. mery slessor. j med 2003;3:72-4. 6. lawoyin to, ani f. epidemiological aspect of pre-eclampsia in saudi arabia. e afr med j 1996;73:404-6. 7. oettle c, hall d, roux a, grove d. early onset severe preeclampsia: expectant management at a secondary hospital in close association with a tertiary institution. brit j obstet gynaec 2005;112:84-8. 8. duckitt k, harrington d. risk factors for pre-eclampsia at antenatal booking: systematic review of controlled studies. brit med j 2005;2:1-7. 9. conde-agudelo a, belizan jm. risk factors for pre-eclampsia in a large cohort of latin american and caribbean women. brit j obstet gynaec 2000;107:75-83. 10. cincotta rb, brennecke sp. family history of pre-eclampsia as a predictor for preeclampsia in primigravidas. int j gynecol obstet 1998;60:23-7. 11. anorlu ri, iwuala nc, odum cu. risk factors for preeclampsia in lagos, nigeria. aust nz j obstet gyn 2005;45:278-82. 12. spinillo a, capuzzo e, colonna l, piazzi g, nicola s, baltaro f. the effect of work activity in pregnancy on the risk of severe pre-eclampsia. aust nz j obstet gyn 1995;35:380-5. 13. lwanga sk, lemeshow s. sample size determination in health studies: a practical manual. geneva: world health organization ed.; 1991. 14. olusanya o, okpere e, ezimokhai m. the importance of social class in voluntary fertility control in developing country. west afr j med 1985;4:205-12. 15. kessner d. infant death: an analysis by maternal risk and health care. 1. washington, dc: national academy of sciences ed.; 1973. 16. devader sr, neeley hl, myles td, leet tl. evaluation of gestational weight gain guidelines for women with normal prepregnancy body mass index. obstet gynecol 2007;110:745-51. 17. salafia c, shiverick k. cigarette smoking and pregnancy ii: vascular effects. placenta 1999;20:273-9. 18. mostello d, kallogjeri d, tungsiripat r, leet t. recurrence of preeclampsia: effects of gestational age at delivery of the first pregnancy, body mass index, paternity, and interval between births. am j obstet gynecol 2008;199:1-7. 19. nanjundan p, bagga r, kalra jk, et al. risk factors for early onset pre-eclampsia and eclampsia among north indian women. j obstet gynaecol 2011;31:384-9. 20. brown ma, davis gk, mchugh l. the prevalence and clinical significance of nocturnal hypertension in pregnancy. j hypertens 2001;19:1437-44. 21. wolfberg aj, lee-parritz a, peller aj, lieberman es. obstetric and neonatal outcomes associated with maternal hypothyroid disease. j matern-fetal neo m 2005; 17:35-8. 22. sibai bm, gordon t, thom e, et al. risk factors for pre-eclampsia in a healthy parous women: a prospective multicenter study. am j obstet gynecol 1995;172:642-8. 23. lee cj, hsieh tt, chiu th, et al. risk factors for pre-eclampsia in an asian population. int j gynecol obstet 2000;70:327-33. 24. eskenazi b, fenster l, sidney s. a multivariate analysis of risk factors for preeclampsia. j amer med assoc 1991;266: 237-41. 25. redman cwg. hypertension. in: de sweit m, ed. medical disorders in obstetrics practice. 4th ed. oxford: blackwell scientific publications; 2002. pp 159-197. 26. campbell dm, macgillivray i. preeclam psia in twin pregnancies: incidence and outcome. hypertens pregnancy 1999;18: 197-207. 27. stone jl, lockwood cj, berkowitz gs, et al. risk factors for severe pre-eclampsia. obstet gynecol 1994;83:357-81. 28. odegard ra, vatten lj, nielsen st, et al. risk factors and clinical manifestation of pre-eclampsia. brit j obstet gynaec 2000;107:1410-6. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5482] [page 29] occupational hazards correlates of ocular disorders in ghanaian fisheries samuel kyei,1 andrew owusu-ansah,1,2 samuel bert boadi-kusi,1 dennis nii abbey,1 emmanuel kwasi abu1 1department of optometry, school of allied health sciences, college of health and allied sciences, university of cape coast, cape coast, ghana; 2department of ophthalmology, the second xiangya hospital of central south university, changsha, hunan, china abstract the study examined the ocular health of agricultural workers in the fisheries sub sector with the aim of establishing a possible correlation between the work place hazards and their ocular health. a multi-stage random sampling (involving 683 subjects, 358 fishmongers and 325 fishers) was employed. ocular hazards encountered at the work place included seawater, sand or dust, heat, sunrays and smoke. exposure to these hazards were found to be associated with ocular irritation (p<0.001), tearing (p<0.001), red eye (p<0.001), gritty sensation (p<0.001), blurred distant vision (p=0.001) and blurred near vision (p=0.001). the development of pterygium was associated with the exposure to sunrays (p=0.042) and heat (p=0.001) among fishmongers. further analysis using multivariate logistic regression indicated exposure to heat as the most important predictive factor for pterygium (or=1.951, p=0.003). exposure to seawater was found to be associated with the development of cataract (p=0.022) among fishermen/fishers. cataract among fishmongers was rather associated with exposure to heat (p=0.005), sunrays (p=0.035) and sand/dust (p=0.002). exposure to work place hazards is associated with ocular disorders in the fishing industry of ghana. introduction comparative statistical records on fatalities in fisheries around the globe put fishing as one of the most dangerous jobs ahead of driving, fire fighting, policing and others who ply their work on land and remains history’s most dangerous occupation.1 globally, it is estimated that 24,000 fatalities occur in the fisheries industry annually. in coastal countries of west africa, artisanal canoe fatality rates range from 300 to 1000 per 100,000 fishermen. in nordic countries where there is evidence of best practices regarding accident prevention, survival training, search and rescue services, fatality rates still persist between 90 and 150 per 100,000 people. this underscores the likelihood of under estimation of fisheries fatalities in countries where there are no data.2,3 reports of non fatal injuries are rather too common in spite of evidence of under reporting attributable to paucity of and unsatisfactory documentation from several countries of the world.4,5 apart from the vast evidence of fatalities and injuries among workers in the fisheries industry, ocular injuries, most of which are sight threatening, have been specifically cited.6-8 these injuries are commonly associated with the hazardous working environment in most fisheries which include the use of fishing hooks, lures, weights, biofuels and excessive reflection of extraneous sun rays.6,7 the specificity and diversity of hazards, depending considerably on geographical-climate and cultural factors, make the differentiation of problems and solutions important in different zones of fishing. ghana has a marine coastline of 550 km, which extends from aflao in the east to half assini in the west; the fishing industry serves as a source of livelihood for some 10% of ghanaians.9 the sector has seen a decline in its contribution to the nation’s gross domestic product (gdp) over the past decade. it is estimated to contribute some 1.5% of the agriculture gdp (gss, 2013 budget).10 most fish consumed in ghana comes from the marine fishing industry and it remains the favorite and cheapest source of animal protein with about 75 per cent of total annual production being consumed domestically.11,12 an average of 500,000 fishermen, fish processors, traders and boat builders are employed in the fishing industry.13 a canoe census conducted for the marine fisheries estimated the number of artisanal fishermen at 124,000.14 artisanal fishing involves the use of dugout canoes propelled by outboard motors. ghana’s coastline stretches along the atlantic ocean providing rich grounds for artisanal marine fishing.3 the central region has long been noted as a fishing hub.15 historical records trace the subsistence of the fishing industry in the central region as early as 1471,15 operating in household-based entities and utilizing small vessels. notwithstanding the importance of the fishing industry to the overall economy and nutritional needs of the country, players within the industry are exposed to several workplace hazards with long term consequence for their health especially their eye health. recent data from the international labor organization (ilo) and the world health organization (who) indicate that overall occupational accident and disease rates are slowly declining in most industrialized countries,16 but are on level or increasing in developing countries. generally, there are several hazards associated with the fishing industry but those that directly pose threats to the eye as outlined in the literature include dust/sand, plants, chemicals, decomposing leaves, micro-organisms in the fishing environment, smoke, radiations and heat, equipments and machines with sharp and pointed edges.17 it has been noted that there is a dearth of information on the potential effect of such exposures on the eyes of workers of the fishing industry mainly fishermen and fishmongers. we therefore sought to evaluate the correlations between these hazards and ocular disorder in the fishing industry of ghana. healthcare in low-resource settings 2016; volume 4:5482 correspondence: samuel kyei, department of optometry, school of allied health sciences, college of health and allied sciences, university of cape coast, cape coast, ghana. tel: +233243309718. e-mail: skyei@ucc.edu.gh; samdollar2@yahoo.com key words: cataract; artisanal fishing; fishmongers; atlantic ocean; pterygium. contributions: sk conceived the idea and designed the study. aoa and sbb were also involved in the design of the study. dna and eka wrote the protocol, managed the literature searches and collected data. sk and dna wrote the first draft of the manuscript. sk, dna, sbb and aoa managed the analyses and interpretation of the data. sk, aoa, eka critically revised the content. all authors read and approved the final manuscript. conflict of interest: the authors declare no potential conflict of interest. acknowledgements: the authors are grateful to mrs esther kyei, mrs alice abu, mrs mary boadikusi and mrs jennifer owusu-ansah for their immense support and encouragement. received for publication: 9 august 2015. revision received: 29 may 2016. accepted for publication: 19 october 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. kyei et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5482 doi:10.4081/hls.2016.5482 non co mmerc ial us e o nly materials and methods study area the central region of ghana has the widest continental shelf and the longest coastline of 150km spanning eight (8) coastal districts18 (figure 1). there are 43 coastal towns and villages from gomoa nyanyano in the east to kafodzidzi in the west with a total of 103 landing sites. the two main types of marine fishing are; artisanal or canoe fisheries and inshore fisheries. there are 46,513 artisanal fishermen working with 4675 canoes as against 1500 inshore fishermen operating over 100 inshore motor fishing vessels. the fishermen in the region dock about 36% of the nation’s fish production.19 these include some exportable species of marketable value such as: lobsters, squids and octopuses, shrimps, soles, sea breams, mackerels, groupers, skipjack tunas, yellow fin tunas, round and flat sardinellas and sailfish.19 sampling technique multi-stage random sampling was employed. four out of the eight coastal districts were randomly selected of which a fishing town or villages each was also randomly selected (figure 1). in each of the four fishing towns or villages, two landing sites were randomly selected. a register of fishers /fishermen and fishmongers for each chosen landing site was then obtained from the chief fishermen and the queen fishmongers as per their records. a total of 683 (involving 358 fishmongers and 325 fishers) people within these four major communities were sampled. the minimum sample size for the survey was determined as quoted by glenn using the formula developed by cochran (1963).20 the minimum sample size computed was 374. however, the sample size was adjusted to 683 to include 358 fishmongers and 325 fishers to reduce the incidence of reporting false positive responses. subject selection/data collection procedure the subjects were systematically selected (every nth person) based on the number of participants needed for that area for interview using a pretested interview-based questionnaire and subsequent routine ophthalmic examination (external and internal eye exams) by four experienced optometrists, ods. inclusion/exclusion criteria the study participants included fishers/fishermen and fishmongers who had been engaged in the fishing industry not less than 3 years and were aged 18 years and older at the time of the study. all fishers/fishermen or fishmongers who had other part time engagements outside of the fishing industry were excluded. data analysis procedure data collected was analyzed using spss version 19 (statistical package for social sciences) and reported as frequency tables, percentage tables, bar charts and cross tabulation. goodness of fit-test was calculated to compare the frequency levels between fishmongers and fishermen. chi-square model was performed to measure the association between categorical variables. multivariate logistic regression was also conducted to measure the predictive ability of the independent variable (hazards) to the dependent variables (prevalent ocular diseases and symptoms). the alpha level was set at p=0.05, thus association existed between categorical variables when p≤0.05. ethical consideration the research was done according to the helsinki declaration on research regarding human subjects. a detailed rationale for the study was given to respondents, after which respondents signed a consent form or verbal consent depending on their educational background. confidentiality was ensured and a forum was organized to educate participants on basic safety measures regarding their workplace. those with ocular disorders were treated and some referred to eye clinics for further attention. results socio-demographic characteristics a total of 683 participants comprising 325 fishers and 358 fishmongers were interviewed and examined in this study. all the participating fishers/fishermen were males while 354females and 4 males were fishmongers. majority of the fishmongers (181, 51.0%) and fishermen (158, 48.8%) were in the age range of 36-59 years (adult). those aged between 18 and 35 (youth) were 102 (28.7%) for fishmongers and 126 (38.9%) for fishermen and those aged 60 and older were 72 (20.3%) for fishmongers and 40 (12.3%) for fishermen. goodness of fit test showed no significant difference (p=0.236) between the total participants of fishers/fishermen and fishmongers. the results indicated that the majority of the fishermen and fishmongers had no form of formal education and only one person each among the fishermen and fishmongers had had tertiary education. the most frequent income range for both fishermen and fishmongers was gh� 1000-1999 (us$ 350-699) and the least number of the respondents had an income range of gh� 4000-4999 (us$ 14001749) (table 1). ocular hazards there were 623 and 717 responses (due to multiple responses) to ocular hazards identified at the workplace by fishermen and fishmongers respectively. sun rays was the main ocular hazard reported among the fishermen (299, 36.8%). the fishmongers on the other hand, reported smoke 357 (49.8%) as the main article figure 1. a map of the central region showing the study districts and communities. [page 30] [healthcare in low-resource settings 2016; 4:5482] non co mmerc ial us e o nly ocular hazard (table 2). ocular symptoms after exposure to hazards ocular symptoms after exposure to hazards during smoking of fish by fishmongers indicated 1126 responses (due to multiple responses) with irritation of the eyes being the highest and redness being the least. the most prevalent symptom among fishmongers included photophobia, 222 (62.2%), 217 (60.8%) complaints of burry distance vision, 201 (56.3%) complaints of tearing, 154 (43.1%) complaints of ocular pain, 143 (51.3%) complaints of burning sensation. ocular symptoms after exposure to hazards during fishing by fishermen indicated 997 responses with blurry distance vision being the highest 273 (72.70%). the others were irritation 138 (61.1%), gritty sensations 232 (71.2%), ocular pains 162 (49.7%), photophobia 211 (64.7%) and tearing 225 (78.2%) (table 3). players within the fishing industry were more prone to suffer ocular irritation (p<0.001) than burning sensation. there was significant association between ocular irritation and some identified workplace hazards such as smoke (p=0.001), heat (p=0.002), dust/sand (p=0.047) and seawater (p=0.016). complaints of ocular pain were found to be associated with workplace hazards such as sunrays (p=0.001), heat (p<0.001) and smoke (p=0.047), gritty sensation, tearing and photophobia were associated with sunrays (p≤0.001, 0.015, 0.000). photophobia was also associated with seawater (p=0.000). anterior segment eye examination anterior segment eye examination using a handheld slitlamp revealed pterygium was the most prevalent ocular surface disorder and trichiasis the least prevalent. the total number of cases (abnormalities detected) was 396 among the fishermen but 501 among the fishmongers (figure 2). there was association between some workplace hazards experienced by fishmongers such as sunrays (p=0.042) and heat (p=0.001) and pterygium but there was no such association between hazards and pterygium among fishermen. multivariate logistic regression between workplace hazards indicated that exposure to heat was a very significant factor associated pterygium among fishmongers (table 4). internal eye examination direct ophthalmoscopic examination revealed 169 posterior segment disorders among the fishermen, 66 (39.1%) were glaucoma suspects, 53 (31.4%) had cataract, 32 (18.9%) had other posterior segment diseases like retinal degeneration, retinal scars and other retinal disorders, 8 (4.7%) had article table 1. distribution of educational levels and annual income. level of education/annual income fishermen, n (%) fishmongers, n (%) level of education no formal education 123 (37.8) 170 (47.5) elementary/primary 110 (33.8) 83 (23.2) middle/junior 87 (26.8) 94 (26.3) secondary/technical 4 (1.2) 10 (2.8) tertiary 1 (0.3) 1 (0.3) annual income° less than ghȼ1000 57 (17.5) 81 (22.6) ghȼ1000-ghȼ1999 87 (26.8) 111 (31.0) ghȼ2000-ghȼ2999 82 (25.2 90 (25.1) ghȼ3000-ghȼ3999 39 (12.0 49 (13.7) ghȼ4000-ghȼ4999 25 (7.7) 14 (3.9) greater than ghȼ5000 35 (10.8) 13 (3.6) total 325 (100.0) 358 (100.0) °the exchange rate as time of the study was us$ 1:ghȼ 2.86 table 2. ocular hazards reported among fishermen and fishmongers. hazard type of occupation total fishermen fishmongers n=623 (%) n=717 (%) n smoke 7 (1.1) 357 (49.8) 364 heat 10 (1.6) 153 (21.3) 163 sunrays 229 (36.8) 118 (16.5) 347 dust/sand 161 (25.8) 87 (12) 248 sea water 216 (34.7) 2 (0.2) 218 [healthcare in low-resource settings 2016; 4:5482] [page 31] figure 2. prevalence of anterior segment disorder as detected upon slit lamp examination in fishermen (a) and fishmongers (b). non co mmerc ial us e o nly [page 32] [healthcare in low-resource settings 2016; 4:5482] retinopathies, 5 (3.0%) had toxoplasmosis scar, 3 (1.8%) had optic atrophy and 2 (1.2%) had maculopathies. fishmongers on the other hand had 213 posterior segment disorders. ninety-nine (46.5%) had cataract, 49 (23.0%) were glaucoma suspects, 48 (22.5%) had other posterior segment diseases like retinal degeneration, retinal scar and other retinal disorders, 5 (2.3%) had retinopathies, 4 (1.9%) had maculopathies and toxoplasmosis scar, 2 (0.9%) had optic atrophy and posterior uveitis. no association was found between any of the workplace hazards and suspicion of glaucoma among fishermen and fishmongers, nevertheless, exposure to seawater was found to be associated with the development of cataract (p=0.022) among fishermen. cataract among fishmongers was associated with exposure to heat (p=0.005), sunrays (p=0.035) and dust (p=0.002). discussion the study employed multi-stage random sampling which was most suitable since the communities studied were diverse (8 coastal districts with 43 coastal towns and villages and a total of 103 landing sites) in a bid to ensure representativeness.21 the male dominance in fishing has long been documented as it is deemed as a risk prone and adventurous task reserved for the males while females are more often than not discouraged and excluded.22 however, fish mongering is an agricultural processing activity known to involve both males and females.23 in africa, market systems are customarily seen as compatible with the female gender’s role as housekeepers and caregivers hence the few men (1.2%) involved in these post-harvesting activities of the fishing industry.24 a greater proportion of fisher folks were illiterates with nearly half of the fishmongers (47.5%) having no formal education at all. recent studies have highlighted this high proportion of illiteracy among fishing communities in africa with females being the most affected. this phenomenon is attributable to the remote locations, marginalization and mobility of most fishing communities affecting access to education and even health.25-31 their reported income levels, though only one of the various indices for the determination of socioeconomic status,32,33 were generally low especially among fishmongers who were predominantly females. it is common knowledge that poverty is prevalent among artisanal fisheries of which ghana is no exception.34 the adult population dominating the fishing industry presupposes that they are in their active age and need to earn to keep their homes. the arduous nature of the work also favors the active working population. due to the ubiquity of hazards in the fishing industry, fishing has been tagged as one of the most dangerous occupations in the world.35-37 at the same time, those involved in the processing of the fish are also not spared. the top three most common hazards among the fishermen were sunlight, seawater and dust/sand. these have been reported as major eye health risks among fishermen.38,39 half of the reports from the fishmongers identified exposure to smoke as the single most important ocular hazard at their workplace due the use of biofuel (i.e. fire wood).40 excessive heat was also found to be a worrisome hazard among fishmongers. the most prevalent complaint of ocular irritation was found to be associated with exposure to hazards such as smoke, heat, dust/sand and seawater.39-41 other ocular com article table 4. multivariate logistic regression between workplace hazards and pterygium. hazards exp (b) p 95% ci for exp (b) lower upper smoke 1431268.01 0.999 0.0 heat 1.951 0.003* 1.252 3.038 sun rays 1.356 0.203 0.848 2.166 constant 0.00 0.99 ci, confidence interval. table 3. ocular symptoms among fishmongers and fishermen. symptoms type of occupation total p fishermen fishmongers n (%) n (%) n irritation no 188 (41.1) 269 (58.9) 457 0.000* yes 138 (61.1) 88 (38.9) 226 burning sensation no 190 (47.0) 214 (53.0) 404 0.659 yes 136 (48.7) 143 (51.3) 279 ocular pains no 164 (50.3) 203 (56.9) 367 0.086 yes 162 (49.7) 154 (43.1) 316 blurred distance vision no 89 (27.3) 140 (39.2) 229 0.001* yes 273 (72.7) 217 (60.8) 490 blurred near vision no 12 (3.7) 36 (10.1) 48 0.001* yes 314 (96.3) 321 (89.9) 635 foreign body sensation no 44 (13.5) 65 (18.2) 109 0.096 yes 282 (86.5) 292 (81.8) 574 redness no 32 (9.8) 14 (3.9) 46 0.002* yes 294 (90.2) 343 (96.1) 637 gritty sensation no 94 (28.8) 205 (57.4) 299 0.000* yes 232 (71.2) 152 (42.6) 384 photophobia no 115 (35.3) 135 (37.8) 250 0.491 yes 211 (64.7) 222 (62.2) 433 tearing no 71 (21.8) 156 (43.7) 227 0.000* yes 255 (78.2) 201 (56.3) 456 *significant values at the 0.05 alpha level. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5482] [page 33] plaints associated with workplace hazards were ocular pain, gritty sensation, photophobia and tearing which are mostly symptoms of conjunctivitis.42 conjunctivitis was the second most prevalent ocular surface disease after pterygium. pterygium was the most prevalent ocular surface disorder and was found to be associated with exposure to smoke and heat which are the two most common hazards encountered by fishmongers relative to fishermen. fishmongers, most of whom are predominantly women, are frequently exposed to biofuels, mainly firewood and charcoal, which have been implicated in adverse consequences to the human eye.40,43 the continuous use of biofuel in poor communities such as fishing communities has been observed despite its decline in use on the global scene.44,45 multivariate logistic regression indicated heat as the single most important predictor of developing pterygium (p=0.003). other studies elsewhere have indicated a high prevalence of pterygium among agricultural workers due to exposure to heat. the linkage between heat and the pathogenesis of pterygium has been predicted previously.40,46 the association between cataract and some workplace hazards in the fisheries sector was implied but has been difficult to establish. epidemiologists were unable to establish a simple realistic causal model for cataract because each risk factor could be a component cause.47 the multiple risk factors of the workplace environment including heat, sunrays, and dust/sand may wholly or partly be involved in the pathogenesis of age-related cataract commonly found among fishmongers.41,48 the seawater is said to be a good reflector of sunlight and may be indirectly involved in causing cataract among fishermen.38 this study highlights the fact that the continuous engagement in fishing and post harvest activities as an occupation exposes workers to potential risks which have implications for their eye health.49 it is worthy to note that several of these risk factors are manageable through the use of protective eye wears, photoprotective lenses, and re-orientation of fishers and fishmongers on modern fish processing methods. it is therefore recommended that these fishers and fishmongers be educated on safety practices and provision of first aid kits and adequate training be implemented by stakeholders in the fisheries industry. conclusions in conclusion, this study found some association between workplace environments and ocular disorders in the fishing industry of ghana. these associations are of worthy note in the context of public health intervention. references 1. symile ma. perilous catch: the history of commercial fishing. dublin: the history press ireland; 2015. 2. fao. the state of the world fisheries and aquaculture. rome: food and agriculture organization; 2000. 3. eliasen s, sverdrup-jensen s, holm p, johnsen jp. nordic experience of fisheries management seen in relation to the reform of the eu common fisheries policy. temanord 2009;2009:579. 4. el-saadawy me, soliman ne, el-tayeb im, hammouda ma. some occupational health hazards among fishermen in alexandria city. gaziantep med j 2014; 20:71-8. 5. kaerlev l, jensen a, nielsen ps, et al f. hospital contacts for injuries and musculoskeletal diseases among seamen and fishermen: a population-based cohort study. bmc musc dis 2008;9:8. 6. endresen ne. injuries and diseases among commercial fishermen in the northeast atlantic and barents sea. data from the royal norwegian coast guard. int arch occ environ health 2002;76:241-5. 7. alfaro dv, jablon ep, rodriguez fm, et al. fishing-related ocular trauma. am j ophthalmol 2005;139:488-92. 8. meltzoff sk, lipuma es. a japanese fishing joint venture: worker experience and national development in the solomon islands. manila: international centre for living aquatic resource management; 1983. 9. bank of ghana. the fishing sub sector and ghana’s economy, 2008. available from: www.bog.gov.gh 10. ghana statistical service. provisional gross domestic product 2013. available from: www.statsghana.gov.gh 11. britwum ao. the gendered dynamics of production relations in ghanaian coastal fishing. ferminist africa 2009;12:69-85. 12. ministry of food and agriculture. fisheries 2013. available at http://www.fao.org/fishery/facp/gha/en 13. armah ak, nunoo fke, koranteng ka. critical issues that make reconciling fisheries with conservation an uphill task in the coastal zone of ghana. bethesda, md: american fisheries society symposium; 2007. 14. amador k, bannerman p, quartey r, ashong r. ghana canoe frame survey. marine fisheries research division. accra: ministry of fisheries; 2006. 15. odotei i. the artisanal marine fishing industry in ghana: a historical overview. legon: institute of african studies, university of ghana; 2002. 16. ilo. ilo standards-related activities in the area of occupational safety and health. report vi, international labour conference, 91st session, 2003a. available from: http://www.ilo.org/public/ english/protection/safework/integrap/survi ndex.htm 17. greenberg mi, hamilton rj, philips ds, mcclouskey gj. occupational, industrial and environmental toxicology. 2nd ed. maryland heights: mosby; 2003. 18. ghana statistical service. 2010 population and housing census (phc), 2012. accra: ghana statistical service; 2012. 19. ministry of food and agriculture. fisheries subsector cr, 2012. accra: ministry of food and agriculture; 2012. 20. glenn d. determining sample size. sampling the evidence of extension program impact, peod-5, 1992. available from: http://www.edis.ifas.ufl.edu/pd006 21. hardon a, hodgkin c, fresle d. how to investigate the use of medicines by consumers. amsterdam: university of amsterdam; 2004. 22. fao, worldfish center and world bank. small-scale capture fisheries. a global overview with emphasis on developing countries: a preliminary report of the big numbers project. rome & penang: fao and worldfish center; 2008. 23. duncan ba. women in agriculture in ghana. 2nd ed. bonn: friedrich ebert foundation; 2004. 24. walker ble. sisterhood and seine-nets: engendering development and conservation in ghana’s marine fishery. prof geogr 2001;53:160-77. 25. allison eh. linking national fisheries policy to livelihoods on the shores of lake kyoga, uganda. norwich: overseas development group (odg), university of east anglia; 2003. 26. grellier r, tanzarn n, lamberts d, howard c. the impact of hiv/aids on fishing communities in uganda. london: marine resources assessment group (m rag) and options; 2004. 27. keizire bb. policy and planning processes for responding to hiv/aids in fishing communities in uganda. in: responding to hiv and aids in the fishery sector in africa. proceedings of the international workshop held in lusaka, zambia, cairo: worldfish centre 2006:34-40. 28. meinert l. sweet and bitter places: the politics of school children’s orientation in rural uganda. in: kf olwig and e gulløv (eds.) children’s places: cross cultural perspectives. london: routledge; 2003. 29. ray r. the determinants of child labour and child schooling in ghana. j afr econ 2003;11:561-90. article non co mmerc ial us e o nly [page 34] [healthcare in low-resource settings 2016; 4:5482] 30. ansell n. children, youth and development. abingdon and new york: routledge; 2005. 31. lewin km. improving access, equity and transitions in education. creating a research agenda. create pathways to access. research monograph 1. brighton: university of sussex; 2007. 32. bene c, friend rm. water, poverty and inland fisheries: lessons from africa and asia. water int 2009:34:47-61. 33. bene c, friend rm. poverty in small-scale fisheries: old issue, new analysis. prog dev stud 2011;11:119-44. 34. asiedu b, nunoo fke, ofori-danson pk, et al. poverty measurements in small-scale fisheries of ghana: a step towards poverty eradication. curr res j soc sci 2013;5:7590. 35. el-saadawy m, soliman n, el-tayeb imm, hammouda ma. some occupational health hazards among fishermen in alexandria city. gaziantep med j 2014;20:71-8. 36. rodrigues de, kiran u. a pilot study on knowledge & practice regarding prevention of occupational hazards and attitude towards utilisation of safety measures among fishermen working at a selected harbor. nujhs 2013;3:3. 37. le bouar g, chauvin c. an analysis of the risk in the french sea fishing industry. example of the dockside accident risk. int marit health 2006;57:103-13. 38. national institute for occupational safety and health. surveillance and prevention of occupational injuries in alaska: a decade of progress 1990-1999, 2002. available from: http://www.cdc.gov/niosh/docs/2002115/pdfs/2002-115.pdf 39. burke wa, griffith dc, scott cm, howell er. skin problems related to the occupation of commercial fishing in north carolina. n c med j 2006;67:260-5. 40. saha a, kulkarni pk, shah a, et al. ocular morbidity and fuel use: an experience from india. occup environ med 2005;62:66-9. 41. oriowo om, chou br, cullen ap. eye exposure to optical radiation in the glassblowing industry: an investigation in southern ontario. can j public health 2000;91:4714. 42. american optometric association. conjunctivitis. st. louis, mo: american optometric association; 2014. 43. bruce n, perez-padilla r, albalak r. indoor air pollution in developing countries: a major environmental and public health challenge. b world health organ 2000;78:9. 44. world resources institute, unep, undp, world bank. 1998-99 world resources: a guide to the global environment. oxford: oxford university press; 1998. 45. world health organization. health and environment in sustainable development, who/ehg/97.8. geneva: world health organization; 1997. 46. rohatgi s. pterygium: an epidemological study in india. int j healthcare biomed res 2013;4:297-301. 47. rothman kj. causes. am j epidemiol 1976;104:587-92. 48. gritz dc. can cataracts be prevented? b world health organ 2001;79:260-1. 49. olaoye jo, odebiyi oc, abimbola ot. occupational hazards and injuries associated with fish processing in nigeria. j aquat sci 2015;3:1-5. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2018; 6:7276] [page 19] training interventions on helping babies breathe among health workers in tertiary hospital of the republic of south sudan: a non-randomized quasi-experimental study christopher vunni draiko,1 khemika yamarat,1 alessio panza,1 judith draleru,2 martin taban,3 joseph onyango,3 regina akur,2 rose aliru omega4 1college of public health sciences, chulalongkorn university, bangkok, thailand; 2juba college of nursing and midwifery, juba teaching hospital, juba, south sudan; 3real medicine foundation, kampala, uganda; 4united nation population fund, juba, south sudan abstract this study aimed to examine the effects of the helping babies breathe (hbb) training interventions program on the knowledge, psychomotor skills, and competency of health workers in managing birth asphyxia and reducing mortality of newborns experiencing asphyxia within 24 hours. this study used preand post-test design (quasi experimental study). purposive sampling was employed, and a computer-generated number was used to select the participants. health workers from juba teaching hospital comprised the intervention group. they were evaluated before and after the training from february to june 2017. a post training skill and competency evaluation was performed using a neonatalie newborn simulator and was repeated after three months of implementation for intervention and control group. seventy health workers were enrolled; 40 were in the intervention group and 30 in the control group. early newborn mortality due to asphyxia within 24 hours in intervention and control measure at pre and post implementation showed a significant reduction within the intervention than the control. knowledge, psychomotor and competency of health care workers improved immediately after training and early newborn mortality reduced by half at the end of three months. it is recommended that training of health workers on hbb should be scaled up in most of the health facilities in south sudan. introduction south sudan has a high number newborn mortality. the neonatal mortality was estimated at 35 per 1,000 live births with infant mortality of 67 per 1,000 live births.1 in 2015, 4.5 million (75%) of all underfive deaths occurred within the first year of life. the risk of a child dying before completing the first year of age was highest in the african region (55 per 1000 live births) and over five times higher than that in the developed region (10 per 1000 live births). although, there is reported decreased in the number of infant mortality birth worldwide, more newborn deaths are reported in low and poor developing countries where access to health care for the vulnerable (women and newborn) was difficult and sometimes nonexistent.2 according to the world health organization3 an estimated 136 million infants are born each year, and this figure is expected to rise globally to nearly 137 million births yearly by 2016. in the entire human life cycle, the riskiest period is the day of birth4 previous studies reported that 136 of the one million of newborn births each year will not survive their first day of life.5 based on the global total of one million deaths each year, efforts must be aimed at reducing the high number of newborn deaths. the main causes of newborn deaths have remained unchanged for the last decade and are usually infection-related complications (26%), intrapartum complications (24%) including birth asphyxia, preterm delivery (34%) with breathing problems contributing to mortality and morbidity, and congenital abnormalities (9%).6 the real cause of newborn deaths is difficult and most challenging to determine for the health professionals. nurses, midwives, clinical officers, medical officers, maternal health workers, and community health workers attending births must have the essential knowledge and skills to assess the neonates’ breathing status and effectively respond as needed. majority of the health workers/staff often failed to recognize breathing difficulties early and, most of the times, could not assess and take immediate action to resuscitate non-breathing babies at the time of delivery. priority has often been given to the mother’s needs. the neonates often remained unattended for several minutes with little attention. this problem could be partly attributed to not having a staff member present dedicated to the newborns. despite the burden of newborn death being high in the low and poor countries, the coverage of skilled birth attendance is very scarce in these countries.7 similarly, more than one million preterm neonates die from complications of preterm delivery, including respiratory distress syndrome, as majority of the preterm newborns require assistance to initiate breathing at birth.4 having known that prematurity and intrapartum hypoxic are the main causes of early neonate mortality in majority of the neonates, global, regional, and local training of health workers in basic neonatal resuscitation will help improve the newborn survival and will save hundreds of thousands of newborn infants yearly.4 despite the benefits of the health workers’ training on neonatal resuscitation in averting newborn deaths, the coverage of neonatal resuscitation remains very low in settings with a high burden of neonatal deaths. currently, various neonatal resuscitation training courses are being promoted and implemented in many countries in order to build the capacity and competence of the health workers to become better qualified in managing sick newborns or children in the emergency setting. healthcare in low-resource settings 2018; volume 6:7276 correspondence: christopher vunni draiko, college of public health sciences, chulalongkorn university, bangkok, thailand. e-mail: chrissvunni@gmail.com key words: asphyxia, babies breath; resuscitation; neonatal mortality; psychomotor skills. acknowledgements: the authors want to thank all the health workers who diligently participated in the study, ministry of health and the staff of juba and wau teaching hospital. their sincere thank goes to the staff of juba college of nursing and midwifery providing room for the training and the united nations midwives who supported the training. contributions: cvd designed the study, interpreted data and wrote the report. ky, ap, jd, mt, jo, ra, rao supported the study, reviewed the manuscript and proofread the article before submission. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 13 january 2018. accepted for publication: 25 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright c.v. draiko et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7276 doi:10.4081/hls.2018.7276 non -co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2018; 6:7276] a number of guidelines and algorithms exist, and most of these can be found online. however, most of the guidelines and algorithms are reported to have been based on the consensus of the pediatricians’ expertise rather than the evidence-based training module.8 newborn life support, neonatal resuscitation program, the who’s essential newborn care, and pediatric life support are the courses used in teaching neonatal resuscitation. a review conducted by opiyo and english9 found inadequate evidence to prove that the in-service training in neonatal resuscitation had improved the skill and performance of the health workers in caring for critically ill newborn baby. however, there is still some evidence to show the benefits of training of health workers in newborn resuscitation. among the most effective strategies available for low-resource setting is the helping babies breathe (hbb) program, a neonatal resuscitation training program aimed to increase the knowledge and skills of skilled birth attendants (sba)10 the hbb is a life support program developed by the american academy of pediatrics in collaboration with other organizations.11 with the objective of achieving a sustainable development goal of ending preventable neonatal and under-five child deaths through increasing the coverage of sba and improving the quality of maternal and newborn care, the training intervention on helping babies breath in hospitals and health centers is essential. the “hbb-plus” training intervention is believed to increase the knowledge, skill, and competency of the health workers on newborn resuscitation that will contribute to reducing asphyxia-related newborn mortalities in south sudan. neonatal resuscitation is not new in the south; however, the simplified version of resuscitation packaged as helping babies breathe is a new idea that has not been explored and implemented in the public health facilities in south sudan on large scale. the training was adapted from the helping babies breathe program developed by the american academy of pediatricians for low-resourced countries. this study aims to evaluate the immediate and longterm effects of the hbb training on the knowledge and skills of health professionals about neonatal resuscitation and the reduction of neonatal mortality due to asphyxia. materials and methods the protocol for this non-randomized clinical trial and supporting trend statement checklist are available as supporting information respectively and the registration was registered retrospectively. reason for late registration: the study was initially measuring the increase in the knowledge, skill, and competency, and the distal portion of the impact on newborn resuscitation and survival was added later. the study population and design the pre and post study was conducted two tertiary hospital of juba and wau in south sudan. after obtaining ethical clearance from the south sudan ethical review board, ministry of health, and administrator of both juba and wau teaching hospital, a total of 70 health workers (40 from the intervention group and 30 from the control group) comprising midwives, clinical officers, nurses, community maternal health workers, and intern doctors were selected. the 40 health workers from juba teaching hospital were trained on simplified helping babies breathe for two days. purposive sampling was used in selecting the participants of the study. the implementation period lasted for three months from march to june 2017, and the three months evaluation took place in june. blinding of the participants was unachievable based on the nature of the intervention. health workers in the control group never received any hbb training and continued to provide routine care to the newborn, whereas those in the intervention group received two days, 6 hours training based on the hbb protocol. participant’s recruitment health workers who consented to participate in the study were randomly selected. forty participants were selected from juba teaching hospital (intervention) and thirty from wau teaching hospital (control). all health worker selected to participate in the study had no received any training on helping babies breathe protocol for the past one year. training for the health workers in the intervention lasted for two day six hours each. procedures and intervention hbb facilitators and participants training of hbb was conducted by experienced facilitator who were trained midwives and received training as research assistants. training session of the health workers were divided into two phases to allow a ratio of one trainer to 6 participant’s trainee and adequate time for supervision. training covered main area of preparation for birth, newborn routine care, the golden minute and ventilation of the newborn. the participant were introduced to each section of the hbb protocol followed by demonstration and return demonstration by the participants. the trainers and the trainees reviewed the training and practical sessions related to newborn asphyxia, routine care, ventilation. the health workers practiced on neonatalie new born simulator. health workers trained were provided with the basic equipment’s for the practice of hbb neonatal resuscitation during and after the training. participants were asked to evaluate the training session using likert scale of one to five and majority agreed that the training enhanced their psychomotor skills and competency in newborn resuscitation. hbb knowledge and psychomotor skills and competency evaluation health workers were tested using multiple choice questionnaire pre and post intervention for both groups lasting for twenty minutes. psychomotor skill and competency for the intervention and control group were conducted in simulated environment using bag and mask checklist for psychomotor skill and oscea &b for competency. health workers in the intervention group were assessed at pre, post and 3 months period while those in the control group were assessed at posttest and 3 months follow up. health were scored for each of the steps and action in the checklist. the correctly performed action was awarded a score of one whole incorrect steps or answer was given zero marks. to qualify to have adequate knowledge psychomotor skill and competency for newborn resuscitation, health workers must score 80% or above and this was also considered successful completion of the course. study outcomes the primary objective was that hbb training will improve the knowledge and practical skill of the participants. this was determined tests conducted to evaluate changes before training, post training and 3 months follow up. the secondary was reduction in early neonatal deaths within 24 hours and the observed outcome was tested by pearson chi square for newborn deaths due to asphyxia within 24 hours. data management and analysis data from the answer sheets and evaluation checklists were entered into spss version 20 software, where the results of the preand post-test as well as the three-month follow up was analyzed and presented. to get the result desired, all the files containing the different measurements were merged at one point in time before conducting the complete analysis. the mean scores in knowledge, psychomotor skills, and compe article non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:7276] [page 21] tency from the preand post-test within the intervention and within control groups was tested using repeated measure anova for within intervention and control group. the unpaired sample t-test was used to test the mean difference in knowledge, psychomotor skills, and competency between the intervention and control group. the result analyzed and obtained was presented and reported as mean of the correctly passing scores _+ standard deviation. the study was considered significant at p value < 0.05. ethical clearance the study was approved by chulalongkorn university college of public health, bangkok, thailand in december 2016. the ethical clearance for study was approved by the ethical review board, ministry of health, and south sudan in february 2017, and the ethics review committees of juba and wau hospital. informed consent both written and verbal was obtained from the participants before the training intervention. verbal approval was sought from the mothers with newborn with asphyxia by the health worker. results a total of 70 health care workers enrolled in this study of which 40 received simplified hbb training and completed (100%) the preand post-test course assessment. approximately 30 participants in the control group took the post-test simultaneously with those of the intervention group. because the health workers at the control group were unable to receive the training due to insecurity, their pre-training assessment (baseline) for the practical skill was conducted at the time of the post-test administered among the intervention group; it was then considered as the immediate post intervention assessment to evaluate the knowledge, skills, and competency of these health workers. at three months, two of the participants in the intervention group and one from control group were lost to follow up. therefore, only (67) 96% of the health workers completed the assessment at threemonth follow up (figure 1). socio demographic and professional characteristics majority of the health workers were aged between 25 years to 35 years. nurses and midwives were the majority in intervention and control group and were predominantly female (82.5%) in intervention and 80%) providing newborn care (table 1). most of the health workers were working in maternity labor room) 23 (57.5%) and 19(63.3%), children ward 16 (40%) and 7(23.3%) and operating theater 1(2.5%) and 4(13.3%) respectively. majority of the health workers self-reported to be registered nurses and midwives with tertiary and college education (77.5% of the intervention versus 73.3% in control). the level of income in the middle income bracket of 10012,000 ssp varies between intervention and control group with control group slightly receiving higher income compared to intervention. the difference however is not significant. the duration of practice among the health workers ranged from less than one year to over five years with most having practiced over five years (32.5%) intervention and versus (36.7%) in control group and there was insignificant difference between intervention and control group (table 1). health workers hbb knowledge examining the test mean score of the participants within the intervention and within the control at pretest, posttest intervention and three months of study period tested by repeated measures anova, in intervention, there was significant increase in terms of knowledge between the pretest and immediate post intervention (mean difference increase of 55.2 (50.9-59.6) p<0.05) and this decreased slightly between the immediate post intervention and three months follow up with mean difference of 13.3(-17.7-8.87), p<0.05). this mean decrease between the immediate post intervention and 3 months follow was insignificant. in the control group, there was slight increase in knowledge between pretest and immediate post (mean difference of 3.1(3.0-9.4) p> 0.05) and this increased further at 3 months follow up (mean difference of 0.3(-0.1-6.0) p>0.05) which was insignificant. in terms of outcome between the intervention and control group, there was no significant difference in knowledge at baseline (p>0.05). however, this significantly increased in intervention at posttest and 3 months (p>0.05) (table 2). health workers hbb psychomotor skills repeated measures anova was used to test for the psychomotor skill for the intervention and control group at baseline, article figure 1. flow chart for recruitment and allocation health workers. non -co mmerc ial us e o nly [page 22] [healthcare in low-resource settings 2018; 6:7276] immediate post intervention and 3 months follow up (table 2). when compared from baseline to 3 months follow up, the intervention had significant increase between base line and immediate post intervention with mean difference of 69.2(62.8-75.7) p<0.05 and this increased at 3 months follow up (mean difference 0.1(-0.3-0.8), p<0.05). in the control group, the baseline was not tested and only the immediate post intervention and 3 months follow-up was tested. from the outcome, there was no significant increase in psychomotor skill in the control (mean difference -3.4 (-11.0-4.10, p>0.05.). between the intervention and control group at immediate post intervention and 3 months follow up, there was significant increase in psychomotor skill in the intervention compared with the control group (p<0.05). health worker competency for simple resuscitation measured through osce a in table 2 below, health workers competency for simple resuscitation in the intervention and control group tested by repeated measures anova at baseline, immediate post intervention and 3 months follow showed that within the intervention group, there was significant increase of competency for simple neonatal resuscitation from baseline and immediate post intervention (mean difference of 61.2(57.0-66.5 p<0.05) and deceased slightly at 3 months follow up (mean difference 0.3.1(-4.6-5.32). however, the mean difference between the immediate post intervention and 3 months was not statically significant (p>0.05). health workers in control group were not tested at baseline for simple resuscitation but tested at immediate post intervention and 3 months. result showed that there was no significant increase in competency of health workers between immediate post intervention and 3 months follow-up (p>0.05). health worker competency complex neonatal resuscitation measured through osce b when compared from baseline to 3 months of follow up, the intervention group had significant increase between baseline and immediate post intervention (p<0.05) and this decreased at 3 months follow up (mean difference 2.74(-6.71-1.22) but the changes remained insignificant (p>0.05) in the control group, the health worker were tested at immediate post intervention and 3 months follow up and there was no sig article table 1. sociodemographic and professional characteristics (age, gender, and educational level). intervention control demographic characteristics freq. (%) freq. (%) pvalue statistical test (n=40) (n=30) age in years 25-35 25 62.5 20 66.7 0.130 0.719 chi-square 36 above 15 37.5 10 33.3 gender male 7 17.5 6 20.0 0.071 0.790 chi-square female 33 82.5 24 80.0 education level primary eight 6 15.0 4 13.3 0.748 0.781 fisher exact secondary 3 7.5 4 13.3 college/ tertiary 31 77.5 22 73.3 diploma in midwifery 1 2.5 0 0 community h.w training 1 2.5 0 0 professional qualification nurse 12 30.0 10 33.3 5.690 0.623 fisher exact midwives 17 42.5 11 36.7 maternal child health officer 3 7.5 1 3.3 nurse practitioner 1 2.5 0 0 clinical officer 2 5.0 2 6.7 fisher exact community health workers 4 10.0 2 6.7 skilled birth attendants 1 2.5 1 3.3 intern doctor 3 10.0 primary area newborn care 11 27.5 8 26.7 5.987 0.097 sick children ward 4 10.0 1 3.3 maternal and newborn care 25 62.5 17 56.7 obstetrics/obstetrician 4 13.3 current place of work maternity ward 23 57.5 19 63.3 4.135 0.129 fisher exact children ward 16 40.0 7 23.3 operating theater (ot) 1 2.5 4 13.3 monthly income 3001000 ssp 18 45.0 8 26.7 2.896 0.235 chi-square 10012,000 ssp 14 35.0 16 53.3 2,001 ssp and above 8 20.0 6 20.0 duration of practice ≤ 1 year 12 30.0 6 20.0 0.980 0.806 two – three years 10 25.0 8 26.7 four – five years 5 12.5 5 16.7 over five years 13 32.5 11 36.7 knowledge baseline 17 42.5 48 0.6 unpaired test psychomotor skill baseline (pretest) 10 26 * * simple competency baseline (pretest ) 10 26.9 * * complex competency baseline (pretest) 7 17.5 * * significant level at 0.05. the 25-35 years in case of age is based on the fact that it represents the youthful age group. fishers exact test have been used for cell counts less than 5. *psychomotor skill and competency for simple and complex neonatal resuscitation at baseline cannot be compared due to lack of assessment for control at baseline. non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:7276] [page 23] nificant change in the competency for complex neonatal resuscitation (p>0.05). between the intervention and control group, health workers in intervention group showed significant increase in competency compared to control group (p<0.05) (table 2). early neonatal mortality a total of 4981 live births were recorded in the hospital registry; 2127 live births registered before implementation from november 2016 to february 2017, and 2062 after implementation from march to june 2017. all births were attended by the health workers in the study during implementation (figure 2). early newborn death within 24 hours table 3 is the composite summary of early newborn mortality due to asphyxia within 24 hours in intervention and control. when compared at pre and post implementation, there was significant reduction in the intervention than the control group in term of newborn mortality within 24 hours. newborn mortality reduced from 51.9% pre implementation to 23.5% post implementation. the percentage decreased in the control group remained insignificant (48.1% to 48.1% both pre and post implementation). the reduction and changes within the pre intervention and post implementation article table 2. hbb health worker’s knowledge, psychomotor skills, competency for simple and complex neonatal resuscitation of the health workers at pretest immediate intervention and 3 moths follow up. intervention p-valuea control p-value mean mean df. (ci) mean mean df. (ci) knowledge pretest 42.5± 17.3 48.0±13.9 immediate post intervention 97.8±3.4 55.2(50.9-59.6) <0.001 51.2±11.2 3.1(-3.0-9.4) 0.9 3 months follow-up 84.7±7.7 -13.3(-17.7-8.87) <0.001 50.9±15.7 -0.3(-0.1-6.0 0.9 psychomotor skills pre-test 26.1±19.9 -* immediate post test 94.4±8.5 69.2(62.8-75.7) <0.001 43.8±16.7 3 months follow-up 95.4±6.8 0.1(-03-08) <0.001 40.9±18.9 3.4(11.0-4.10) 0.37 competency for simple neonatal resuscitation pretest 26.9±14.6 -* intermediate 88.8±8.5 61.2(57.0-66.7) <0.001 38.9±8.5 3 months follow-up 89.3±8.1 03.1(-4.6-532) 0.9 41.3±14.4 2.65(-8.42-3.1) 0.36 competency for complex neonatal resuscitation pre test 17.5±8.9 -** intermediate 90.9±7.1 73.47(69.5-77.36) <0.001 36.5±13.0 3 months follow-up 88.3±10.8 -274(6.71-1.22 0.17 33.1±8.7 -3.63(-8.2-0.93) 0.12 data are expressed as mean difference. *significant level at 0.005 post intervention and 3 months follow up. pa-value within intervention group tested by repeated anova ,0.001 and 0.001 between immediate post intervention and 3 months follow up. **no baseline conducted for control group for bag and mask, osce a and b due to logistical problems, and time. figure 2. flow chart for birth registry pre and post implementation. non -co mmerc ial us e o nly [page 24] [healthcare in low-resource settings 2018; 6:7276] period on reduction of among the intervention and control group was tested using person chi squared. within the intervention group, there was significant change ratio of early newborn mortality compared to the control group within the 24 hours after conducting resuscitation (p<0.05). discussion the professional background of the health workers in the intervention group who attended the hbb training in juba teaching hospital had similar characteristics, and the working environment of the control group (wau teaching hospital) was situated 100 kilometers away from the intervention site. both the intervention and control hospitals are teaching hospital with a similar setup and are supported by the government of south sudan. this generalized the findings on the evaluation made in other health care settings and public hospitals in the country as well other low-income developing countries with a similar setting. during our study, we administered the osce a and b to the intervention group pre-test, post-test, and at the three-month follow-up, and at post-test and three-month follow-up in the control group because of the insecurity which was not safe for the trainers and the participants to undertake the assessment. frequently, the osce a and b were considered too difficult to be administered to the participants during the pre-training period. administering the osce a and b pre training helped us establish the health workers’ skills and competency pre training and aided the design of the educational instruction approach. based on the pre-assessment of the practical skill and competency of health workers in the intervention group, we tailored support to each of the participant’s ability and understanding of the training, and that facilitated the good result at post training. our study introduced and implemented a quality improvement cycle as a means of improving the knowledge, skills, and competency of the health workers in the long term. the hbb training implementation contributed to the improvement of the knowledge of the health workers from intervention hospital after a two-day training. however, the level of knowledge attained at post-training declined at the end of implementation period. meanwhile there was no significant increase in knowledge among the health worker in the control site. the study on hbb training in south sudan has shown that the hbb knowledge mcq written scores improved by 55.3% from 42.5% at pre-training to 97.8% immediately after post training (pre-test) (table 2). this result concurred with a similar study in kenya which has showed that, passing rate of the knowledge mcq-based test increased from 75% to 95% after a similar training intervention. the use of the simulated-based environment for teaching and learning had greatly improved the health workers hbb knowledge and skill in neonatal resuscitation; however, this knowledge was not retained at three months. among the points of interest is that the practical psychomotor skill and competency of the health workers improved greatly and were retained after three months. surprisingly, the health workers retained the skill and competency at three months despite the similar major studies about retention of practical skills and competency conducted in rwanda and kenya that indicated that it was mostly difficult to retain the skill and competency at three to six months after the helping babies training intervention. the persistence of the practical skill and competency among the trainees could be attributed to the implementation of quality improvement cycle during our study with a focus on the practical application of the hbb steps and problem solving. many studies on hbb reported a decline in the knowledge and practical skill within three to six months of receiving the neonatal resuscitation training.12 similarly, it was reported that the practical skill and competency fades faster than the knowledge.13 our study finding confirmed that the hbb is a practical course that requires actions with periodic reinforcement of the skill through review and problem solving and self-assessment of retention and skill learned. furthermore, an evaluation study conducted in ghana on the retention of knowledge and practical skills and the competency of health workers at 9-12 months after training on modified neonatal resuscitation program indicated that the knowledge and skill remained stable within the period of 9-12 months post training. this mostly concurs with the retention of practical skill and competency found among the health workers from the juba teaching hospital. article table 3. early newborn mortality. variable before intervention after intervention intervention/control frequency percent (%) frequency percent (%) p value total live births intervention 1116 52.40 1112 53.9 control 1011 47.50 950 46 total 2127 99.9 2,062 99.9 newborn birth asphyxia intervention 88 55.7 125 57.1 0.18 control 70 44.3 94 42.9 total 158 219 newborn resuscitated using hbb intervention 0 00 124 98.4 0.001* control 0 00 2 1.6 0.114 total 0 126 asphyxia deaths intervention 26 50.9 4 30.7 0.001* control 25 49 9 69.2 0.110 total 51 13 death within 24 hours intervention 14 51.9 4 23.5 0.001* control 13 48.1 13 48.1 0.110 total 27 17 death after 24 hours intervention 12 50.0 9 33.3 0.000* control 12 50.0 18 66.7 0.112 total 24 37 *significant level at 0.05. rounded at 1 decimal place tested by pearson chi square test 2x2 sided significance for birth asphyxia, newborn death within and after 24 hours before and after implementation. non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:7276] [page 25] many of the researchers who conducted a similar study advocated for the means of retention of knowledge, skill, and competencies among the trainees and suggested refresher training courses between the post training and implementation period.14 during the study evaluation of the hbb training, we found out that 5.2% failed the written test at post training, and this further increased to 19% at the end of three months. similarly, 11.9% failed the practical skills at post-test and 18.3% at three months and the passing scores were not met (table 2). our failure rate in the study among the health workers was similar to other studies conducted by singhal at al indicating that health workers skills and competency for neonatal intubation and ventilation remained very limited after training our results of the failure rate among the health workers was demonstrated by other studies reporting the limited skills and competency in neonatal intubation and ventilation.15 the training intervention revealed a potential benefit of not only improving the knowledge, skills, and competency of the health workers but has also impacted on the newborn outcomes. a remarkable decline in the newborn mortality ratio due to asphyxia was noted among the intervention hospital. the early newborn infant deaths within 24 hours due to asphyxia reduced from 51.9% to 233.5%. the association between knowledge and neonatal reduction at the same period was not explored in this study. on the global context, a few studies have demonstrated the long term of effects of the hbb training of health workers in the early neonatal outcomes. similarly, a large before-and-after design study conducted in tanzania showed that training in and the targeted implementation of the hbb program was associated with a significant reduction in the primary outcome of the early neonatal mortality (within 24 hours) and the rate of fresh stillbirths and early perinatal mortality.16 there was no significant increase in the ratio of early newborn mortality in the control site (48.1% to 48.1% both pre and post implementation). although, there was notably decreased in the ratio of early newborn deaths at intervention site, the three months period for baseline and implementation was not enough make the interpretation of the result conclusive and generalized the strengths of our study was the use of the research instruments that was previously validated, standardized, and adapted from the american academy of pediatrics and was used to evaluate the hbb knowledge, skills, and competency of the health workers in the similar setting in low-income countries like kenya, rwanda, and uganda.17 despite the study being extensive, there were many limitations to it: some due to the inherent issues with the study design used and some due to the conflict, time, and finances that had direct and indirect effects on the study result. first, the study’s ability to evaluate resuscitation practices was limited by the small number of infants who required active resuscitation; however, the authors were able to demonstrate improvements in preparation for the resuscitation. second, the preand post-test design of the study with the introduction of the quality improvement cycle limited the researchers’ ability to determine the effects of the hbb training alone. it also hindered them from experiencing the changes in the knowledge, skills, and competency during the implementation let alone the significant reduction of the early neonatal mortality. however, no ongoing similar intervention was performed at the hospital during our implementation. third: our study did not assess the control group for the psychomotor sill and competency attributed to the prevailing security and this affected our comparison of intervention and control group at baseline. the study strongly recommends that since the hbb training had an positive impact on the knowledge, skill, and competency of health workers in the hospital setting and in the reduction of early neonatal mortality, training must be provided by the ministry of health and other supporting organizations in the country particularly in rural setting where this protocol has put emphasis. the training must be conducted and an in-phased approach must be used when training the first pool of facilitators and health workers where neonatal mortality indicators are highest. it is recommended that similar research on hbb should consider assessing both groups (intervention and control) at baseline for knowledge, psychomotor skills and competency. conclusions the study has demonstrated that the health workers from juba teaching hospital in south sudan significantly improved their knowledge, practical and competency on neonatal resuscitation after participating in a two-day training course. with the ongoing conflict, it was expected that training of health workers in hbb might not have the hypothesized impact, but this was proven to be wrong; however, the knowledge was found to decline during the three-month follow-up. interestingly, the practical skill and competency of the health workers remained intact over the three-month period and even continued to increase strongly among the health workers evaluated. additionally, the training and implementation had a positive effect on the survival rate of neonates evaluated in the teaching hospitals. overall, a significant reduction in early newborn mortality rates due to asphyxia-related illness was noted after the implementation. this may prove directly replicable in other similar settings, not only in south sudan, but also in other low-income countries. references 1. countdown coverage writing group. countdown to 2015 for maternal, newborn, and child survival. lancet 2008;371:1274-8. 2. goldenberg rl, mcclure em, bann cm. the relationship of intrapartum and antepartum stillbirth rates to measures of obstetric care in developed and developing countries. acta obstet gynecol scand 2007;86;1303-9. 3. world health organization. making pregnancy safer: the critical role of the skilled attendant. a joint statement by who, icm and figo. geneva: world health organization; 2005. 4. lawn j, kerber k, enweronu-laryea c, cousens s. 3.6 million neonatal deaths--what is progressing and what is not? sem perinatol 2010;34:371-86. 5. save the children. ending newborn deaths. london, uk; 2014. 6. unicef. committing to child survival: a promise renewed – progress report 2013. new york: unicef; 2013. 7. world health organization. world health statistics. who; 2010. 8. lawn je, lee ac, kinney m, et al. two million intrapartum-related stillbirths and neonatal deaths: where, why, and what can be done? int j gynecol obstet 2009;107:s5-18,19. 9. opiyo n, english m. in-service training for health professionals to improve seriously ill newborn or child in low and middle-income countries (review). cochrane database syst rev 2010;4. 10. singhal n, lockyer j, fidler h, et al. helping babies breathe: global neonatal resuscitation program development and formative educational evaluation. resuscitation 2012;83:90-6. 11. american academy of pediatrics helping babies breathe: 2014. available from http://www.helpingbabiesbreathe.org/implementationguide.ht ml 12. trevisanuto d, ferrarese p, cavicchioli p, et al. knowledge gained by pediatric article non -co mmerc ial us e o nly [page 26] [healthcare in low-resource settings 2018; 6:7276] residents after neonatal resuscitation program courses. paediatr anaesth 2005;15:944-7. 13. carlo wa, wright ll, chomba e, et al. educational impact of the neonatal resuscitation program in low-risk delivery centers in a developing country. j pediatr 2009;154:504-8e5. 14. kaczorowski j, levitt c, hammond m, et al. retention of neonatal resuscitation skills and knowledge: a randomized controlled trial. fam med 1998;30:70511. 15. singhal n, lockyer j, fidler h, et al. helping babies breathe: global neonatal resuscitation program development and formative educational evaluation. resuscitation 2012;83:90-6. 16. georgina m, augustine m, donan m, et al. newborn mortality and fresh stillbirth rates in tanzania after helping babies training. pediatrics 2013;131:2. 17. korioth t. helping babies breathe: new global program to boost newborn survival rates. aap news 2010;31. available from: http:// aapnews.aappublications.org/content/31/8/1.1.full.p df+html. accessed: june 24, 2017. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2018; 6:6239] [page 7] perception of rural communities in akoko north west local government area of ondo state, nigeria, towards the ikaram millennium village project olayinka ilesanmi, adesola kareem department of community health, federal medical centre, owo, ondo state, nigeria abstract the millennium village project (mvp) is designed to harness the progress of the time-bound millennium development goals. this study aimed to assess the perception of the ikaram millennium village project by the residents of akoko north west local government area of ondo state. a descriptive cross-sectional study of 496 residents of five of the seven communities that make up the ikaram mvp was done. the perception of the respondents were rated poor or good by scoring their responses to 8 validated questions. chi square test was used to assess significant association. the mean age of the respondents were 42.20±17.1 years. half were female (50.4%), 311 (62.7%) were married. the majority of the respondents (82.1%) reported a poor perception of the mvp. among the yorubas only 79 (17.1%) had good perception compared to 7 (46.7%) from other ethnic groups (p=0.003). contributory factors to poor perception about the ikaram mvp were the far location of the health facility from the community, lack of communication and community ownership of the project. for community orientated health projects to be successful community participation is important. introduction the millennium development goals (mdgs) were introduced at the millennium summit in 2000 with the aim of addressing the problems impeding growth especially in developing countries by 2015.1 the millennium village project (mvp) was established in 2005 reaching nearly 500,000 people in rural villages across 10 countries in subsaharan africa, through collaboration between undp, millennium promise, the earth institute at colombia university and the japanese government to relieve poverty and improve health in developing countries thereby aiding the timed accomplishment of the mdg’s goal.1-3 the mvp was designed to integrate community participation and leadership; science-based innovations and local knowledge with a cost conscious national action plan for reaching the time-bounded and targeted objectives of the mdgs.4 several interventions are pursued simultaneously in a millennium village project encompassing sectors like agriculture, health, education, infrastructure (including water and sanitation), and business development. the intervention package which is given priority is primarily community specific.1 in nigeria, the mvp is located at two sites: pampaida (kaduna state) and ikaram (ondo state).1 the ikaram mvp has a research village called mv1 and a secondary cluster of villages called mv2. they are made up of 7 villages located in the akoko north-west local government area of ondo state in south-western part of nigeria. the second phase was established in may 16, 2006 (what was the first phase?).1,5 the project received its overall management from united nations development programme (undp) and was supported by the ondo state government. the federal medical centre, owo became formally involved in the project in the second phase.6,7 the ikaram mvp has functioned for the past 8 years without adequate knowledge of community perceptions in the akoko north-west local government area. when a similar mvp in ghana was evaluated, positive perception and high level of participation were reported.8 in order to improve the ikaram mvp, there is a need to review the perception of the communities towards it. this study aimed to assess the perception of the ikaram millennium village project by the residents of akoko north–west local government area of ondo state. materials and methods the study area comprised of rural communities that are beneficiaries of the ikaram millennium village project. a descriptive, cross sectional study was done. the study population comprised adult residents of the communities, who have resided in akoko north-west lga for at least one year. the required sample size was calculated by using the leslie kish formula. prevalence of good perception towards the mvp was assumed to be 50% in the absence of any previous study. the minimum sample size calculated was 423. however, 496 respondents were studied in all the selected wards. data was collected using a semi structured interviewer administered questionnaire. a 3 stage sampling technique was used. in stage 1,ffive communities were selected using simple random sampling out of the seven communities in the ikaram mvp. in stage 2, a ward was selected from each community using simple random sampling. in stage 3, one adult per household was selected as respondent from all the households in each of the five selected wards. in a household with more than one qualified respondent, one was selected by ballot. a semi-structured, interviewer administered questionnaire was used. questionnaires were checked for omissions and errors after collection and corrections were made where necessary. the questionnaires were pilot tested among a similar patient population utilizing the out-patient clinic of the federal medical centre, owo, ondo state prior to final adminsitration. administration was done in yoruba or the local pidgin english. data was analysed with spss version 21.0. descriptive statistics was performed using mean to calculate the age of the respondents and chi square test was used for the assessment of significant associations between the sociodemographic status of the respondents and their perception about the ikaram millennium village project. the perception of the respondents healthcare in low-resource settings 2018; volume 6:6239 correspondence: olayinka stephen ilesanmi, department of community health, federal medical centre, owo, ondo state, nigeria. tel.: +2348032121868. e-mail: ileolasteve@yahoo.co.uk key words: millennium village project; rural communities; perception; health facilities; community participation. acknowledgements: the authors acknowledge all the health workers who have been part of the ikaram millennium village project. contributions: the authors contributed equally. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 24 august 2016. revision received: 12 december 2017. accepted for publication: 23 february 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright o.ilesanmi and a. kareem, 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6239 doi:10.4081/hls.2018.6239 non -co mmerc ial us e o nly [page 8] [healthcare in low-resource settings 2018; 6:6239] were determined using a likert scale with 8 validated questions and responses ranging from ‘strongly agree’, ‘agree’, ‘undecided’, ‘disagree’, ‘strongly disagree’ with the positive response to the appropriate question score of 5 and the negative response to positive inclined response scored 1. the total score excluding respondents who had not assessed the ikaram millennium village project health facilities ranged from <32 to 40, score of <32 was taken as a poor perception and 32-40 was rated as a good perception. a p value of <0.05 was used as statistical significance. informed consent (written and verbal) was obtained from the respondents, who were made to understand that participation is voluntary and there will be no consequences for non-participation. ethical clearance was obtained from federal medical centre ethical, research review committee, owo. results the mean age of respondents was 42.20 ± 17.1 years while 250 (50.4%) out of the 496 respondents were females. more than half of the respondents were married 311 (62.7%). more than half of the respondents (65.8%) have completed secondary school education and the major ethnic group represented (97%) were yoruba. almost a quarter of respondents were traders 119 (24%), following closely by farming at 118 (23.8%). out of the 5 villages studied, ikaram had the highest number of respondents 255 (51.4%). the socio-demographic characteristic of the respondents are summarised in table 1. the majority of the respondents were aware and had utilized services rendered in ikaram mvp especially the outpatient service 422 (85.1%) as shown in table 2. the frequency of participation of the community in the mvp were displayed in table 3. it showed that 340 (79.1%) of the participants were not involved in the mvp. among those who were not involved 170 (50%) felt the program does not belong to them while 100 (29.4%) said the location is far from them (figures 1 and 2). factors associated with the perception of the ikaram mvp are as shown in table 4. among those who live in ikaram 74 (29.8%) had good perception compared to only 4 (2.9%) respondents living in erusu (p<0.001). among the yorubas only 79(17.1%) had good perception compared to 7(46.7%) from other tribes, p=0.003. discussion and conclusions this study on perception of ikaram millennium village project among rural communities in the akoko north west lgas was done to evaluate the perception of the residents in the communities. the level of awareness of respondents were high though level of utilization of services rendered in ikaram mvp was low. the level of community participation in the programme was also low. the cause was the primary location of the ikaram mvp in ikaram community. the location of the health facility was far from residential areas in the community. closer proximity to the mvp resulted in greater utilizing of services and a better perception of it. the access barrier due to cost of transportation and the belief that “it doesn’t belong to us” affected other communities.9 some community members felt only selected few people in the community were involved in the operation of the health centre. the latter finding could impede the aim of the millennium village project which is targeted towards self-sustainment development.2 it is of note that the respondent’s community significantly affected their perception of ikaram mvp. this is associated with the level of awareness of the community and the belief system of the respondents. in a study carried article table 1. sociodemographic data of respondents. variables frequency percentage age <45 296 59.7 45-64 129 26.0 ≥65 71 14.3 sex male 246 49.6 female 250 50.4 educational status no formal 60 12.1 primary 161 32.5 secondary 165 33.3 tertiary 110 22.2 marital status single 97 19.6 married 311 62.7 separated 23 4.6 divorced 10 2.0 widow/widower 55 11.1 tribe yoruba 481 97.0 others 15 3.0 occupation civil servant 77 15.5 farming 118 23.8 artisan 89 17.9 student 93 18.8 trading 119 24.0 name of community erusu 140 28.2 gedegede 49 9.9 ibaram 27 5.4 ikaram 255 51.4 iyani 25 5.0 number of years lived in the community <10 years 135 27.2 ≥10 years 361 72.8 figure 1. the respondents who have heard about the ikaram millennium village project (mvp) and those who have accessed the services. figure 2. the community members accessing health care services ikaram millennium village project. non -co mmerc ial us e o nly article table 2. awareness and utilization of services available in ikaram health centre. services respondents awareness of services available respondents utilising the services n(%) n(%) out-patient 422(85.1) 365(73.6) natal services 390(78.6) 17(3.4) immunization 444(89.5) 71(14.3) surgical 167(33.7) 17(3.4) table 3. frequency of community participation in ikaram-ibaram millennium village project. variable frequency percentage involvement in ikaram millennium village project yes 90 20.9 no 340 79.1 awareness of members involvement in ikaram millennium village project yes 256 53.8 no 220 46.2 table 4. factors associated with perception of ikaram. variables good perception poor perception chi-square p-value n (%) n (%) age (years) <45 55(19.6) 225(80.4) 0.229 0.319 45-64 17(13.6) 108(86.4) ≥65 14(19.7) 57(80.3) sex male 40(17.0) 195(83.0) 0.343 0.558 female 46(19.1) 195(80.9) educational status no formal education 11(18.3) 49(81.7) 0.239 0.496 primary 26(16.6) 131(83.4) secondary 34(21.7) 123(78.3) tertiary 15(14.7) 87(85.3) marital status single 13(14.6) 76(85.3) 0.277 0.597 married 58(19.3) 243(80.7) separated 6(26.1) 17(73.9) divorced 1(10.0) 9(90.0) widow/widower 8(15.1) 45(84.9) tribe yoruba 79(17.1) 382(82.9) 0.856 0.003 others 7(46.7) 8(53.3) occupation civil servant 11(15.3) 61(84.7) 0.351 0.477 farming 23(19.8) 93(80.2) artisan 20(23.5) 65(76.5) student 16(17.8) 74(82.2) trading 16(14.2) 97(85.8) name of community erusu 4(2.9) 135(97.1) 0.513 <0.001 gedegede 6(12.8) 41(87.2) ibaram 0(0) 18(100.0) karam 74(29.8) 174(70.2) iyani 2(8.3) 22(91.7) years stayed in the community <10 years 17(13.9) 105(86.1) 0.189 0.169 ≥10 years 69(19.5) 285(80.5) [healthcare in low-resource settings 2018; 6:6239] [page 9] non -co mmerc ial us e o nly [page 10] [healthcare in low-resource settings 2018; 6:6239] out in maiduguri, community awareness of the community-based medical education has been shown to be beneficial to the community.10 other tribes’ aside yoruba had better perception of the ikaram mvp. the proximity of the other ethnic groups and positive health seeking behaviour could have made them to have a better perception. it has been reported that perceptions of modern medicine also negatively affected the outcome of the project in another study done in senegal.11 the perception of ikaram mvp and the occupation of the respondents were not significantly related in this study. the absence of professionals and respondents doing white collar jobs could be responsible. in the study done in potou, it was observed that despite the increase in the agricultural practises thereby increasing their food production, the level of malnutrition among the children was high.11 this could be as a result of the primary location of the ikaram mvp which is in ikaram and far from other communities. in a study done in senegal on the monitoring and evaluation of mvp, a before-and-after method was used to assess the project with its shortcoming.11 also of importance is the valuation of the ikaram mvp which is the measurement of the impact of the programme on the community residents’ well-being which was not part of this study because of the lack of access to the baseline records of the ikaram mvp. the study done in potou, also had difficulty in using baseline data, though they were available baseline records but cannot be trusted.11-15 the poor perception of the communities about the ikaram mvp and its location contributed to the low level of utilization. this is a cause of the slow progress towards achieving millennium development goals. for community orientated health projects to be successful community participation is important. references 1. the millennium villages project: the next five years: 2011-2015. available from: www.millenniumvillages. org/reports/the-millenium-villages-project-the-next-five-years-2011-2015. 2. kanter as, negin j, olayo b, et al. sachs millennium global village-net: bringing together millennium villages throughout sub-saharan africa. int j med inform 2009;78:802-7. 3. kinda o. the monitoring and evaluation system of the millennium villages project-potou/senegal: close look at the mid-term evaluation report. consilience: j sustain develop 2012;9:33-46. 4. the millennium villages project: an overview. the earth institute, millennium promise & undp 2007;1. 5. the mdg centre west and central africa, earth institute/columbia university. available from: http://www. mdgwca.org/en/clutter.php?mv=ikaram %20(nigeria)&phpsessid=fb2d4006 5601c63e9dd80eeaf861572. 6. millennium villages. available from: www.m i l l e n n i umv i l l a g e s . o r g . accessed: 10/06/15. 7. the millennium villages project: progress report november 2006. available from: www.undp.org.sn/new /mv/newsletter 8. minkah oa. millennium village project and poverty reduction: a case study of bonsaaso cluster in the amansie west district: a dissertation sumitted to the department of geography and rural development, college of art and social science, faculty of social sciences. kumasi: kwame nkrumah university of science and technology; 2013. 9. xu k, evans db, carrin g, et al. protecting households from catastrophic health expenditures. health affairs 2007;6:972-83. 10. omotara ba, yahya sj, shehu u, et al. communities’ awareness, perception and participation in the communitybased medical education of the university of maiduguri. educ health (abingdon) 2006;19:147-54. 11. kinda o. the monitoring and evaluation system of the millennium villages project-potou/senegal: close look at the mid-term evaluation report. j sustain develop 2012;9:3346. 12. mashego ta, peltzer k. community perception of quality of (primary) health care services in a rural area of limpopo province, south africa: a qualitative study. curationis 2005;28:13-21. 13. united nations undp. handbook on planning, monitoring and evaluating for development results. united nations; 2009. 14. millennium villages project. study protocol, integrating the delivery of health and development interventions: assessing the impact on child survival in sub-saharan africa; 2009. available from: https://ciesin.columbia. edu/.../mvp+ accessed: 10/06/2015. 15. gertler pj, martinez s, premand p, et al. impact evaluation in practice. washington dc: world bank group; 2011. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:11304] [page 75] fracture of the mandible treatment in a child: a simplified technique christoph h. houben, lundy campbell, chuol chiok s. khuol msf hospital idp camp, bentiu (unity state), south sudan abstract after being hit by a motorcycle, a seven-year-old boy presented with a displaced fracture of the body of the right mandible [type iii]. in the absence of orthodontic internal fixation or ligature wire equipment, suture material was used to provide approximation and stabilization of the fracture. the non-absorbable suture was fed through a cannula which was pierced through the bone on either side of the fracture. we present this simplified technique as a suitable alternative for the fixation of mandible fractures in settings with very limited resources. introduction mandibular fractures were first reported in ancient egypt in 1650 bc, albeit the author did not recommend a therapy because of the advanced soft tissue infection surrounding the fracture site.1 currently, in african countries mandibular fractures are mostly the result of motor vehicle accidents and interpersonal violence.2,3 assault dominates the cause of mandibular fractures in urban centers of the usa.4 falls and sports accidents are also major contributors to mandibular fractures in children.5 pediatric maxillofacial fractures are seen in less than 15% of facial fractures as a result of anatomical and developmental factors.6 its incidence is rare below the age of ten years.7,8 boys are more often affected by this type of fracture; one representative study quotes a male-tofemale ratio of 2.5 to 1.9 we present the case of a patient who received a simplified treatment for his mandible fracture due to a lack of resources. case report a seven-year-old alert and orientated boy was admitted via the emergency room after being hit by a motorcycle on the right side of his body. he sustained multiple abrasions mainly on the right buttock and occipital area together with a forehead and back of the head wound. in the absence of a working x-ray machine, the fractures were diagnosed clinically. a closed right upper humerus fracture, a right-sided non-displaced mid-shaft tibia fracture, and a right displaced body of the mandible fracture [type iii] were identified.10 he underwent general anesthesia for wound suturing, debridement of his abrasions, placement of an above-the-knee plaster cast for his right tibia fracture, manipulation of the humerus fracture and an initial assessment of his displaced mandibular bone fracture at the level of the premolars. the following day we proceeded with general endotracheal anesthesia and through a one-inch submandibular incision on the right side we gained access to the fracture ends. the fracture was aligned manually with the help of a small retractor. at the lower border of the mandible, we placed a sterican hypodermic needle (1.10´30 mm; b braun melsungen, germany) through the buccal and lingual cortex on either side of the fracture (figure 1). a 1 nylon suture (ethicon, new jersey, united states) was passed through the needle lumen followed by a second suture which was placed bi-cortically just below the dental growth area again approximately 3-4 mm from the fracture side as illustrated by the artist impression (figure 2). the sutures allowed for a good approximation of the fractured mandible (figure 3). the wound was closed in two layers with a penrose drain left in for 48 hours. postoperatively, granulation tissue formed at the wound site most likely as a result of a foreign body reaction to the drain. the tissue was excised without further disturbance of the wound healing; the sutures were removed at 10 days. in the early post-operative phase, the patient was only allowed a liquid diet. at around 3 weeks post fixation of his jaw fracture his mother confirmed he had regained his ability to chew. at four weeks post-surgery he received his third anesthesia to remove his plaster cast from his right leg and assess the stability of his healed fractures. the right jaw bone was found to be sound as were the two other previous fracture sites. the suture material was not obviously palpable and was left in situ as it caused him no problems. at a review seven months after his trauma, the patient was in good spirits with no sign of any disability related to his former fractures. in particular, the lower jaw alignment felt normal on palpation. discussion maxillofacial fractures are less frequent in small children as a result of the elasticity of young bone and flexible suture lines; fur healthcare in low-resource settings 2023; volume 11:11304 correspondence: christoph h. houben, msf hospital idp camp, bentiu (unity state), south sudan; available at duffenterstr 89 a, 52222 stolberg, germany. tel.: +49.24026322. e-mail: chhouben@web.de key words: pediatric mandibular fracture; simplified technique. contributions: chh, operated on the patient, conceived the report, and drafted the article; lc, anesthetized the patient; ccsk, (nursing officer) conceived the novel idea to treat the fracture, and assisted in the operations; lc, ccsk, contributed to the preand post-operative management. all the authors approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: no ethical committee approval was required for this case report by the department, because this article does not contain any studies with human participants or animals. informed consent was obtained from the patient included in this study. patient consent for publication: the patient’s guardian gave their written consent to use the patient’s personal data for the publication of this case report and any accompanying images. availability of data and materials: all data underlying the findings are fully available. acknowledgment: dr. deubner kindly contributed to the drawing. received for publication: 11 march 2023. accepted for publication: 30 august 2023. early access: 11 september 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11304 doi:10.4081/hls.2023.11304 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [page 76] [healthcare in low-resource settings 2023; 11:11304] thermore, children have a higher cancellous to cortical bone proportion and thicker overlying soft tissue/fat in comparison to adults.11,12 finally, the large head of a child protects the face, e.g., the cranium-to-face ratio is 4 to 1 in a five-year-old decreasing to 2.5 to 1 in an adult.6 whilst concerns for the developing mandible and the odontogenesis favor a conservative approach to the management of mandibular fractures, we had to resort to an open reduction because of the displaced nature of the fracture of the mandibular body [type iii].11 in the absence of intermaxillary fixation devices and equipment (plates) for an open reduction internal fixation lacking, we chose to fix the fracture with sutures in these limited resources setting. the non-absorbable sutures were placed at the inferior border of the mandibular body and below the developing tooth germs in the hope of avoiding dentition problems in the future (figure 2). this suture technique has been used before in a premature neonate with a symphysis fracture [type iii] after a forceps-assisted delivery for breech presentation.13 another investigator fixed the angle of mandible fracture [type ii] in two cases with an absorbable polyglycolic acid suture and secured the arrangement with intraoral arch bars.14 we were satisfied having achieved bony union and normal occlusion for this young boy and hope to have avoided impediments to the growth of the mandible and the budding teeth. conclusions while undisplaced fractures of the mandible may well be treated with conservative means; the above outlined technique may serve as a valuable strategy in dealing with displaced bodies of the mandible fractures in a setting deprived of basic resources (figure 3). there is justified hope in achieving restoration of normal form and function with this minimalist approach. references 1. breasted jh. a fracture of the mandible – case 24. the edwin smith surgical papyrus. university of chicago press, chicago; 1930;301-3. available from: https://isac.uchicago.edu/sites/default/fi les/uploads/shared/docs/oip3.pdf 2. el-rouby ma, el-salam aa, el-sherif af. metaanalysis of outcomes of treatment of mandibular fractures. j plast reconstr surg 2019;43:361-4. 3. adeyemo wl, iwegbu io, bello sa, et al. management of mandibular fractures in a developing country: a review of 314 cases from two urban centers. nigeria world j surg 2008;32:2631-5. 4. ogundare bo, bonnick a, bayley n. pattern of mandibular fractures in an urban major trauma center. j oral maxillofac surg 2003;61:1251-5. 5. dodson tb. mandibular fractures in children. oms knowledge update 1995;1:95-107. 6. sharma a, patidar dc, gandhi g, et al. mandibular fracture in children: a new approach for management and review of literature. int j clin pediatr dent 2019;12:356-9. 7. lin f-y, wu c-i, cheng h-t. mandibular fracture patterns at a medical center in central taiwan: a 3-year epidemiological review. medicine 2017;96:51. 8. wolfswinkel em, weathers wm, wirthlin jo, et al. management of paediatric mandible fractures. otolaryngol clin n am 2013;46:791-806. 9. kao r, rabbani cc, patel jm, et al. management of mandible fractures in 150 children across 7 years in a us tertiary care hospital. jama facial plast surg 2019;21:414-8. 10. brown js, khan a, wareing s, schache ag. a new classification of mandibular fracture. int j oral maxillofac surg 2022;51:78-90. 11. aizenbud d, hazan-molina h, emodi o, rachmiel a. the management of mandibular body fractures in young children. dental traumatol 2009;25: 565-70. 12. standring s. skull and mandible chap 27. gray’s anatomy 39th ed. elsevier churchill livingstone, edinburgh, 2005:455-91. 13. bhatt n, khachi g, yu j. resorbable suture fixation of neonatal mandibular fractures: a novel technique. plastic and reconstructive surgery 2010;126:258e260e. 14. roed-petersen b. absorbable synthetic suture material for internal fixation of fracture of the mandible. int j oral surg 1974;3:133-6. short report figure 1. sterican hypodermic needle, b braun melsungen, germany. figure 2. drawing of the technique. figure 3. fracture site after fixation. non -co mmerc ial us e o nly hrev_master [page 34] [healthcare in low-resource settings 2013; 1:e9] readiness of health facilities to deliver safe male circumcision services in tanzania: a descriptive study frank mosha, mwita wambura, joseph r. mwanga, jacklin f. mosha, gerry mshana, john changalucha national institute for medical research, mwanza, tanzania abstract assessing the readiness of health facilities to deliver safe male circumcision services is more important in sub-saharan africa because of the inadequacy state of health facilities in many ways. the world health organization recommends that only facilities equipped with available trained staff, capable to perform at least minor surgery, able to offer minimum mc package and appropriate equipment for resuscitation, and compliant with requirements for sterilization and infection control should be allowed to deliver safe circumcision services. a cross-sectional study using quantitative data collection technique was conducted to assess the readiness of the health facilities to deliver safe circumcision services in selected districts of tanzania. all hospitals, health centres and 30% of all dispensaries in these districts were selected to participate in the study. face-toface questionnaires were administered to the heads of the health facilities and to health practitioners. overall, 49/69 (59%) of the facilities visited provided circumcision services and only 46/203 (24%) of the health practitioners performed circumcision procedures. these were mainly assistant medical officers and clinical officers. the vast majority – 190/203 (95%) – of the health practitioners require additional training prior to providing circumcision services. most facilities – 63/69 (91%) – had all basic supplies (gloves, basin, chlorine and waste disposal) necessary for infection prevention, 44/69 (65%) provided condoms, hiv counselling and testing, and sexuallytransmitted infections services, while 62/69 (90%) had the capability to perform at least minor surgery. however, only 25/69 (36%) and 15/69 (22%) of the facilities had functioning sterilization equipment and appropriate resuscitation equipment, respectively. there is readiness for roll out of circumcision services; however, more practitioners need to be trained on circumcision procedures, demand forecasting. sterilization equipment for infection prevention and resuscitation equipment should also be made available. introduction male circumcision (mc) has been shown to considerably reduce the risk of sexually acquired hiv infection.1,2 randomized controlled trials have shown that circumcision reduces the risk of hiv acquisition by 60%.3-5 a sub-analysis of 10 african observational studies found a 71% reduction in hiv acquisition among higher-risk men in 2000.2 similar findings were observed after controlling for potential confounding factors in a 2002 update in which the results of 28 studies plus the 10 studies were considered.6 circumcision has also been shown to have other benefits. these include: a decreased risk of urinary tract infections in children;7 a reduced risk of some sexually transmitted infections (stis) in men (especially ulcerative diseases like chancroid and syphilis);8,9 furthermore, randomized controlled trials have shown that mc reduces the risk of hiv transmission from women to men;3,10 protection against penile cancer, if the circumcision is done in the neonatal period;11,12 and a reduced risk of cervical cancer in female sex partners.13 modelling studies suggest that universal mc in sub-saharan africa (ssa) could prevent 5.7 million new cases of hiv infection and 3 million deaths over 20 years.14 therefore, the world health organization (who) recommends mc as an additional intervention against hiv infection for countries with high prevalence of hiv infection and lower levels of mc. many countries in ssa have either introduced or are in now rolling out mc programs.15 prior to rolling out mc programs, it is important for countries to assess the capacity/readiness of health facilities in provision of safe circumcision services. this assessment is crucial for ssa countries because of the weakness of the health systems:16 for instance, most facilities lack surgical equipment and other necessary equipment, space (minor theatre, rooms), and so forth. in addition, if mc is not done properly, it can result into adverse events. for example, in a kenyan study it was observed that bleeding and infection were the most common adverse effects. this study also showed that practitioners lacked appropriate knowledge, training, instruments and supplies.16 this paper reports findings from the assessment of the readiness of health facilities to provide safe mc in selected regions in tanzania and it provides the literature with some empirical evidence on the issues that may adversely affect the scale-up of mc for countries considering mc roll-out. materials and methods this study was conducted as part of the situation analysis study in ileje, tarime and bukoba rural districts of mbeya, mara and kagera regions of tanzania, respectively. to assess the readiness of facilities in a traditionally circumcizing population to provide safe medical mc, tarime district was selected randomly to participate into the study. likewise, ileje and bukoba rural were selected to learn the capacity of facilities in traditionally noncircumcizing area to provide safe medical mcs. the study aimed to assess the availability and acceptability of circumcision services in health facilities, the procedures for medical circumcision (any pre-operative care, surgical healthcare in low-resource settings 2013; volume 1:e9 correspondence: frank mosha, national institute for medical research, p.o. box 1462, mwanza, tanzania. tel. +255.28.2500399 fax: +255.28.2500654. e-mail: fmosha2002@yahoo.co.uk key words: male circumcision, hiv infection, health facilities, tanzania, africa. acknowledgments: we would like to thank the government of tanzania which funded this work through the ministry of health and social welfare and the national aids control programme. we are profoundly grateful to the regional authorities of mara, kagera and mbeya and the district authorities of tarime, bukoba rural and ileje for their support. we are also grateful to the national institute for medical research for allowing us to publish the study findings. we wish to extend our gratitude to all study participants from the three districts for their valuable information and time. finally, we thank the fieldworkers, who ensured that the work was carried out to the highest standard, and our data managers, jonas aswile and baltazar mtenga, who, were instrumental in processing the data for analysis. contributions: mw, jfm, jrm, jc, design of the study; gm, fm, mw, jrm, jfm collection and analysis of quantitative and qualitative data; jc, editorial input. all authors read and approved the final manuscript. conflict of interests: the authors declare no potential conflict of interests. funding: the work was supported by the ministry of health and social welfare and the national aids control programme (government of tanzania). received for publication: 10 january 2013. revision received: 30 january 2013. accepted for publication: 2 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright f. mosha et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e9 doi:10.4081/hls.2013.e9 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e9] [page 35] procedures, and post-operative care) in clinical set-up, the barriers for medical mc (costs of the procedure, competency of health practitioners, availability of equipment, supplies and consumables for safe circumcision), and the training needs. the detailed methodology has been explained elsewhere.17 in summary, a list of all facilities in the study district was generated stratified by residence (urban, roadside centre, and rural). from the list, all hospitals and health centres and 30% of the dispensaries in each strata were included in the study. for each facility in the study, a performance checklist and two questionnaires were used to collect information. one questionnaire was administered to the person in-charge of the health facilities to collect information on the number of circumcisions carried out by the health facility per year, age at circumcision, availability of working equipment, supplies and skills required for the operation, cost of the service, and the ability to recoup costs and to meet an increased demand for services. the second questionnaire was administrated to healthcare workers who collected information on the healthcare workers’ knowledge and opinions about circumcision practices at the local health facility. health service providers’ number, skills level and abilities to perform circumcision were measured using a performance checklist which included, among others: infection prevention (use of sterile disposable equipment and protective gears for providers), preand post-operative counselling/care, pain management, and optimal circumcision techniques. sample size the study intended to survey 60 health facilities in three districts of tanzania. in each facility, we aimed to interview the head of the facility, up to 5 of the rare professional cadres (ratio of 1 health practitioner to 50,000 people using national data) and up to 3 of the remaining cadres. the selection of the health practitioners was done randomly. rare professional cadres included physicians, assistant medical officers (amos), clinical officers (cos), counsellors and anaesthetists. professional experience and aims of the study guided the decision making process of the number of health practitioners to be interviewed per cadre. the number of healthcare workers at the selected health facilities was unknown and varied with the level of health facility. data processing and analysis the questionnaires were double entered by two independent data entry clerks using article table 1. description of the health facilities surveyed. factor bukoba rural ileje tarime c2(p value) (total n=22) (total n=20) (total n=27) � n % n % n % type of health facility hospital 1 4.5 2 10.0 1 3.7 5.15 (0.19) health centre 6 27.3 1 5.0 8 29.6 dispensary 15 68.2 17 85.0 18 66.7 ownership of health facility government 16 72.7 17 85.0 13 48.2 13.5 (0.029) faith-based 4 18.2 3 15.0 7 25.9 ngo 1 4.5 0 0 private 1 4.5 0 7 25.9 population of service area <10,000 15 68.2 18 90.0 16 59.3 5.4 (0.06) ≥10,000 7 31.8 2 10.0 11 40.7 ngo, non-governmental organization. figure 1. circumcision providers (doctors, assistant medical officers, clinical officers, nurses) in the districts under study. figure 2. percentage of health practitioners providing circumcision for the past 12 months arranged by designation (medical officers, clinical officers, nurses, medical attendants, others) and district. non -co mmerc ial us e o nly [page 36] [healthcare in low-resource settings 2013; 1:e9] census and surveys processing system,18 cleaned and validated. a descriptive analysis of the data was done using the stata data analysis software.19 chi square tests were done to compare the similarity of the study districts with respect to type of health facility in the district, ownership, population of the service area, capacity of the district to deliver safe circumcision services and complications reported to the health facilities. the chi-square statistics with its p value is reported where appropriate; when numbers were small, fisher’s exact test was used. ethical considerations the ethical clearance for the study was obtained from the medical research coordination committee (mrcc) of the national institute for medical research, tanzania. all participants were asked to give written informed consent prior to enrolment. results sixty nine of 93 (74.2%) facilities were visited in 3 districts. of these, 4/69 (6%) were hospitals, 15/69 (22%) were health centres, and 50/69 (73%) dispensaries. most of the facilities visited served a population of <10,000. overall, two-thirds of the facilities were owned by the government of tanzania. in tarime district, government of tanzania significantly owned less facilities than in bukoba rural and ileje districts (c2=13.5, p=0.029) and similarly, facilities in tarime district significantly served more people than those in ileje and bukoba rural districts. however, the type of facilities in the three districts did not differ significantly (table 1). these facilities had a total of 714 health practitioners (199 males, 515 females). of these, 5 (4 males, 1 female) were doctors, 23 (17 males, 6 females) were amos, 88 (68 males, 20 females) were cos, 6 were anesthetists (5 males, 1 female), 80 were counsellors (24 males, 56 females) and 54 were nursing officers (15 males, 39 females). others were 157 enrolled nurses (21 males, 136 females) and 301 medical attendants (45 males, 256 females). the four hospitals had 3 doctors, 16 amos and 29 cos, while the 15 health centres had 1 doctor, 3 amos and 17 cos. the 50 dispensaries had 1 doctor, 4 amos and 42 cos. on average a doctor, amo or co, served 8 people per day if they worked in a hospital, 38 people per day if they worked in a health centre and 25 people per day if they worked in a dispensary. however, it is worthy to mention that this is not related to the number of mc procedures they performed in a day. current capacities of the health facilities the three districts did not differ significantly with respect to the available basic surgical facilities (table 2). overall, only 6/69 (9%) had an operating main theatre, 44/69 (64%) had an operating outpatient minor theatre, 63/69 (91%) had operating essential surgical equipment and 15/69 (22%) had functioning emergency equipment. in all three districts, nearly half or less than half of all facilities had reliable water or reliable electricity. reliable water and electricity did not differ significantly across the three districts. the main source of electricity was the national grid, though in bukoba rural district, solar energy supplied electrical power to one-fifth of the health facilities surveyed. running water was mainly provided by a captive source and, to a lesser extent, from water authorities. generally, most facilities surveyed in all the three districts did not use autoclave sterilizing article table 2. current capacity of the facilities surveyed. factor bukoba rural ileje tarime (total n=22) (total n=20) (total n=27)� n % n % n % facilities with basic surgical facilities° main operating theatres 2 9.1 2 10.0 2 7.4 outpatient minor theatre 15 68.2 9 45.0 20 74.1 essential surgical equipment 21 95.4 18 90.0 24 88.9 essential emergency equipment 7 31.8 2 10.5 6 22.2 facilities with reliable power 9 40.9 7 35.0 10 37.0 facilities with adequate water supply 11 50.0 9 47.4 13 48.2 sti services sti services dedicated 0 2 10.0 2 7.4 sti services integrated 22 100.0 16 80.0 24 88.9 counselling and testing for hiv dedicated hiv counselling and testing 9 40.9 11 55.0 11 42.3 intergraded hiv counselling and testing 13 59.1 8 40.0 23 88.5 rch services° anc 22 100.0 18 90.0 27 100.0 under-five services 20 90.9 19 95.0 24 88.9 family planning services 22 100.0 18 90.0 23 85.2 post-natal services 22 100.0 18 90.0 20 95.2 functioning sterilizing equipment autoclave 4 18.2 2 10.0 4 14.8 pressure cooker 3 13.6 1 5.0 11 40.7 supplies for basic infection prevention (12 months) chlorine or appropriate decontaminant 21 91.5 19 95.0 23 85.2 plastic bucket for decontamination 22 100.0 19 95.0 25 92.6 gloves (surgical, examination, cleaning) 22 100.0 20 100.0 27 100.0 waste disposal 22 100.0 18 90.0 26 96.3 facilities providing condoms to public 20 90.9 20 100 22 84.6 sti, sexually-transmitted infection; rch, reproductive and child health; anc, ante-natal care. °people in-charge of health facilities selected more than one response. non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e9] [page 37] equipment. however, facilities in tarime district significantly reported the use of pressure cooker as sterilizing equipment more than facilities in bukoba rural and ileje districts (c2=9.87, p=0.011). sexually-transmitted infections (stis) and voluntary counselling and testing (vct) services were available in almost all the health facilities surveyed. these services were integrated into the outpatient department. reproductive and child health (rch) services such as ante-natal clinic care [67/69 (97%)], family planning [63/69 (91%)], post-natal services [60/69 (87%)] and services to children aged less than 5 [63/69 (91%)] were common services offered in almost all facilities. about 37/46 (80%) of the government-owned facilities visited had all four essential supplies required for basic infection prevention, i.e. gloves, basin, chlorine and waste disposal. twenty nine out of forty six (64%) government facilities visited provided condoms, hiv counselling and testing, and sti services to the community. there was no correlation between the number of skilled staff available and the number of surgeries done in the last 12 months (correlation between staff and surgeries, 49%). approximately, 13/14 (90%) of the faith-based facilities visited had all four essential supplies (gloves, basin, chlorine and waste disposal) for infection prevention. two-thirds (8/14) of all the faith-based facilities visited did not provide condoms to the community. while additional 4/14 (30%) health facilities were providing sti, hiv counselling and testing services, and condoms. for faith-based health facilities, there was a strong correlation between the number of skilled staff available and the number of surgeries done in the last 12 months (correlation between staff and surgeries, 92%). facilities providing circumcision services about 41/69 (59%) of the health facilities surveyed were providing mc services. significantly, more facilities 22/27 (82%) in tarime district were providing mc services compared to facilities in bukoba rural 8/22 (36%) and ileje 11/20 (55%) districts (c2=10.46, p=0.005). overall, fewer facilities had records on circumcision procedures done: 3/11 (27.3%) in ileje, 6/22 (27.3%) in tarime, and 2/8 (25.0%) in bukoba rural districts. most of the circumcisions were conducted by cos and were done either in outpatient minor theatre or elsewhere. in tarime district nurses performed circumcision procedures in addition to amos and doctors (figure 1). in tanzania, cos are high school graduate who have undergone a diploma course in clinical training, while amos are cos who have received 3 years of additional clinical training after their clinical diploma. these two medical cadres form the bulk of clinical health practitioners in most hospitals, health centres and dispensaries. overall, 63/69 (91%) of the health facilities felt that they would be capable of providing circumcision services if it was promoted in their area. similarly, 66/69 (96%) of the health facilities reported that they would be able to increase the number of circumcisions performed if they had additional equipment and instruments and more staff trained on how to perform mc. to improve circumcision services, facilities were recommended to have: reliable electrical power, medicines, recruitment and training of staff, surgical protective gear, and availability of a procedure room. other requirements were sterilizer, surgical bed and adequate water supply. most of the health facilities – 58/69 (84%) – suggested that circumcision should be included into the national health insurance fund cover. competence of the providers two hundred and three health practitioners (53 males, 150 females) were interviewed from the 3 study districts. of these, 113/203 (56%) were from tarime, 50/203 (24.6%) and 40/203 (19.7%) were from bukoba rural and ileje districts, respectively. the majority of the respondents [130/203 (64%)] was composed by nurses. of those interviewed, 163/203 (80%) had performed circumcision procedure for more than 5 years. providers in ileje and bukoba had practiced medicine significantly longer than those in tarime (c2=12.9, p=0.045). conversely, practitioners in tarime had significantly performed more circumcisions than those in ileje and bukoba rural (c2=29.11, p<0.001). in bukoba rural, circumcision was mainly done by nurses, while in ileje it was mainly done by medical officers, amos and cos. in tarime, circumcision was done by all health practitioners including medical attendants, lab technicians and anesthetists, most of whom had no formal training but learned through observation (figure 2). complications of male circumcision complications observed by health practitioners were excessive bleeding, infections, disfigurement and erectile dysfunction. the three districts differed significantly in terms of magnitude and type of complications observed (c2=57.22, p<0.001). most complications were reported by practitioners from tarime. this could be attributed to traditional circumcision practices (table 3). complications were also reported in clinical-based circumcision, though at a lesser magnitude compared to traditional circumcisions. in ileje district, there were no reported article table 3. complications of circumcision. factor tarime bukoba rural ileje c2(p value) (total n=107) (total n=49) (total n=39) � n % n % n % complication arising elsewhere not from clinical settings° excessive bleeding 77 69.4 20 40.8 0 57.2 (<0.001) infections 73 69.4 23 46.9 4 10.3 41.2 (<0.001) disfigurement 75 67.6 22 44.9 4 10.3 38.8 (<0.001) impotence 73 65.8 23 46.9 4 10.3 35.9 (<0.001) other 35 31.5 2 4.1 2 5.1 22.7 (<0.001) complication arising from clinical settings° excessive bleeding 7 6.3 4 8.2 0 3.1 (0.216) infections 5 4.5 4 8.2 0 3.6 (0.187) disfigurement 5 4.5 1 2.0 0 2.2 (0.331) impotence 5 4.5 4 8.2 0 3.4 (0.187) other 4 3.6 1 2.0 0 1.6 (0.452) °health practitioners selected more than one response. non -co mmerc ial us e o nly [page 38] [healthcare in low-resource settings 2013; 1:e9] cases of complication arising from circumcisions done in clinical setting. this may be because all circumcision procedures were done by medical officers or cos only, unlike what reported in tarime and bukoba rural districts. male circumcision training and challenges only 50 (25%) of the 203 respondents reported to have received training on mc and 41/50 (82%) of those were from tarime district. of those reporting to have been trained, 22/50 (44%) were trained in college and 28/50 (56%) received on-job training. overall, 190/203 (94%) of the practitioners interviewed said they will benefit from additional circumcision training. the major challenges reported by respondents in providing circumcision services to a large number of males in health facilities were lack of equipment [97/190 (51%)], lack of enough trained practitioners [89/190 (47%)], and inadequate space for circumcision procedures [5/190 (2%)]. the majority of the untrained health practitioners did not perform circumcision. only 12/46 (26%) of practitioners who reported to have never received any mc training reported to perform mc services. discussion our study relied heavily on reported information and what we could observe at the time of the survey. for example, the method we used to assess complications was based on what respondents could remember and therefore, it could be affected by recall biases. competence of the health providers was reported rather than observed, as there were no circumcision procedure going on at the time of the survey. the best method would be for a doctor to observe mc procedures and follow-up patients to assess healing and complications like the study conducted in bungoma, kenya.16 eighty percent of the government health facilities and 90% of the faith-based organizations (fbos) had all four essential supplies required for basic infection prevention, i.e. gloves, basin, chlorine and waste disposal, which are important as part of mc scale up. forty three percent of health practitioners reported to be performing the mc procedure; half of these providers have never been formally trained on mc. when this study was conducted, there were neither guidelines nor policy document guiding mc practices. findings from this study led to the development of a national strategy for scaling up mc for hiv prevention. in the new guidelines, nurses are allowed to provide circumcision services. a similar situation where practitioners lacked knowledge and training, proper instruments and supplies at most health facilities was reported in a study carried out in bungoma district, kenya.16 therefore, it is important that the policy in tanzania defined the minimum quality of care to be provided in mc. service providers will need to be assessed for competency, and facilities will be required to meet specific criteria as set by the medical council.20 in this study, some facilities visited had sterilization equipment and basic infection prevention facilities, and most facilities had basic surgical equipments. this suggests that the roll-out of circumcision services is almost ready. however, more practitioners need to be trained and facilities provided with the required equipment. lack of equipment and inadequate training of health practitioners has also been reported in other countries.16 moreover, there was a strong correlation between the number of surgeries done in the last 12 months and the number of staff available in facilities owned by fbos, unlike what reported in government-owned facilities. this lack of correlation may either be due to lack of staff motivation or inaccurate documentation of surgeries done. healthcare workers were over, some of the health facilities did not have clinicians and were run by nurses and others had alarming understaffing. our finding is consistent with that from the bureau of statistics survey of 2006 where in most parts of tanzania one doctor served 10,000 people.21 this area still remains a major challenge despite the efforts to recruit and train healthcare workers. therefore, where appropriate, we recommend tasks to be delegated to less specialized health workers (task shifting) or to be shared with these less specialized workers.20 the successful use of less specialized health workers (e.g. nurses and cos) to perform more complex clinical and surgical procedures is well-documented in various countries.15 there are many examples of this type of delegation for delivering a range of health services, including those for hiv.22 in a number of highincome countries, such as australia, uk, and the usa, the role of nurses has been extended in some settings to include the prescription of routine medication, and people living with hiv/aids have been empowered to participate in the management of their own chronic condition and to support others as part of expert patient programs.22-26 task-shifting of various kinds is also currently being implemented in some resource-constrained countries as a response to acute shortages of human resources for health and particularly for generalized hiv epidemics. in malawi and uganda, the basic care package for people living with hiv/aids has been designed to be delivered by non-specialist doctors or nurses supported by community health workers and people living with hiv/aids. similarly, ethiopia has implemented a plan to hire community health workers to expand the current workforce delivering hiv services. experience has also shown that appropriately trained non-physician providers can safely conduct surgical procedures under local anaesthesia.15 specifically, it has been successfully demonstrated that well-trained staff (including cos) can be used to perform circumcision.4 thus, in order to scale up the availability of mc services, it is recommended that tanzania should identify non-physician providers (like cos and nurses) who can be trained to perform this procedure.20 conclusions in this study, we found that a large proportion of facilities visited had sterilization equipment and basic infection prevention facilities, staff was willing to be trained and most facilities had basic surgical equipments, suggesting that there is capacity to scale up mc in tanzania. however, in order to meet the increased demand for mc services as a result of roll out, more practitioners need to be trained and facilities will need more supplies and medication for circumcision services. references 1. siegfried n, muller m, deeks j, et al. hiv and male circumcision a systematic review with assessment of the quality of studies. lancet infect dis 2005;5:165-73. 2. weiss ha, quigley ma, hayes rj. male circumcision and risk of hiv infection in subsaharan africa: a systematic review and meta-analysis. aids 2000;14:2361-70. 3. auvert b, taljaard d, lagarde e, et al. randomized, controlled intervention trial of male circumcision for reduction of hiv infection risk: the anrs 1265 trial. plos med 2005;2:e298. 4. bailey r, moses cs, parker cb, et al. male circumcision for hiv prevention in young men in kisumu, kenya: a randomised controlled trial. lancet 2007;369:643-56. 5. gray rh, kigozi g, serwadda d, et al. male circumcision for hiv prevention in men in rakai, uganda: a randomised trial. lancet 2007;369:657-66. 6. clark s, gerber w, fua i. male circumcision: current epidemiological and field evidence. program and policy implications of article non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e9] [page 39] male circumcision for hiv prevention and reproductive health. conference report, 2002 sept 18-19, washington, usa. washington, dc: us agency for international development and aidsmark; 2003. pp 1-35. 7. wiswell te, hachey we. urinary tract infections and the uncircumcised state: an update. clin pediatr 1993;32:130-4. 8. cook ls, koutsky la, holmes kk. circumcision and sexually transmitted diseases. am j public health 1994;84:197201. 9. nasio jm, nagelkerke nj, mwatha a, et al. genital ulcer disease among std clinic attenders in nairobi: association with hiv1 and circumcision status. int j std aids 1996;7:410-4. 10. barclay l. circumcision significantly reduces risk of hiv transmission. medscape 2006. available from: http:// www.medscape.com/viewarticle/549547 11. american academy of pediatrics. report of the task force on circumcision. pediatrics 1989;84:761. 12. dodge og, kaviti jn. male circumcision among the peoples of east africa and the incidence of genital cancer. e afr med j 1965;42:98-105. 13. agarwal ss, sehgal a, sardana s, et al. role of male behaviour in cervical carcinogenesis among women with one lifetime sexual partner. cancer 1993;72:1666-9. 14. williams bg, lloyd-smith jo, gouws e, et al. the potential impact of male circumcision on hiv in sub-saharan africa. plos med 2006;3:e262. 15. who, unaids. new data on male circumcision and hiv prevention: policy and programme implications. in: proceedings of the who/unaids technical consultation on male circumcision and hiv prevention: research implications for policy and programming, 2007 march 6-8, montreux, france. geneva: who ed.; 2007. available from: http://www.who.int/hiv/pub/malecircumcision/research_implications/en/inde x.html 16. robert cb, omar e, stephanie r. male circumcision for hiv prevention: a prospective study of complications in clinical and traditional settings in bungoma, kenya. b world health organ 2008;86:669-77. 17. wambura m, mwanga jr, mosha jf, et al. acceptability of medical male circumcision in traditionally circumcising communities in northern tanzania. bmc public health 2011;11:373. 18. united states census bureau. census and survey processing system (cspro). washington, dc: us census bureau ed.; 2012. available from: http://www.census. gov/population/international/software/cspr o/ accessed: 22/01/2013. 19. stata corp. stata statistical software: release 8. college station, tx: statacorp lp ed.; 2003. available from: http://www. joplink.net/prev/200901/ref/08-013.html accessed: 22/01/2013. 20. who, unaids. progress in male circumcision scale-up. country implementations update. geneva: who ed.; 2009. available from: www.malecircumcision.org/publications/documents/country_experiences_in _scale-up_in_eastern_and_southern_ africa_06.09.09.pdf. accessed 01/03/2011. 21. nbs and macro international inc. tanzania service provision assessment survey 2006. key findings on hiv/aids. dar es salaam: national bureau of statistics and macro international inc. ed.; 2007. 22. samb b, celletti f, holloway j, et al. task shifting: an emergency response to the health workforce crisis in the era of hiv. lessons from the past, current practice and thinking. new engl j med 2007;357: 2510-4. 23. laurant m, reeves d, hermens r, et al. substitution of doctors by nurses in primary care. cochrane db syst rev 2005;2: cd001271. 24. hongoro c, mcpake b. how to bridge the gap in human resources for health. lancet 2004;364:1451-6. 25. lewis ce, miramontes h. nurse practitioners in rural california and aids. j of assoc nurse aids c1999;10:39-42. 26. kober k, van damme w. expert patients and aids care. a literature review on expert patient programmes in highincome countries, and an exploration of their relevance for hiv/aids care in lowincome countries with severe human resource shortages. antwerp: institute of tropical medicine ed.; 2006. article non -co mmerc ial us e o nly hrev_master antioxidation and anti-inflammatory activities of blended essential oil suriya chaiwong, kunthasaya akkarasiritharattana, khemjira jarmkom, punyanut amorndoljai faculty of integrative medicine, rajamangala univesity of technology thanyaburi prathumthani, thailand abstract the mixtures of essential oils are increasing popularly in holistic medicine. the different ratios of oil components in the preparation can result in different health benefits. therefore, this study aimed to develop a mixture of essential oil formulation having promising bioactivities for pharmaceutical and cosmetic applications. the five popular essential oils including vetiver oil, lavender oil, eucalyptus oil, lemongrass oil, and phlai oil were selected for blended formulation. the selected oils were mixed in a suitable ratio and their antioxidant and anti-inflammatory activities were evaluated using 2,2-diphenyl-1-picrylhydrazyl radical scavenging and nitric oxide (no) radical scavenging, respectively. the prepared blended essential oil formulation had clear yellow-pale color and good smell. the blended oil showed good antioxidative activity by acting as a hydrogen donator. however, the blended oil presents mild antiinflammatory activity via no quenching action. the results of this study exposed that the developed blended essential oil formulation has promising properties to be used as a natural antioxidant as well as an anti-inflammatory agent in cosmetic and pharmaceutical applications. introduction inflammation is an adaptatively physiological condition triggered by tissue injury, stress, or infection to recover tissue homeostasis. in the inflammatory process, nitric oxide (no) produced from activated macrophages plays the role of inflammatory mediator.1,2 no can further react with superoxide radicals to form reactive radical peroxynitrite and directly damage the cellular components which can lead to cellular dysfunction. thus, the overproduction of no causes cellular oxidative stress and conducts a higher severity level of inflammation as well as may further induce carcinogenesis.3 although inflammation is a recovery process of the body, self-damage caused by inflammation is unavoidable. eventually, prolonged inflammation can lead to pathological conditions.2 moreover, at the site of inflammation, an increase in cell and tissue oxidative stress was found. reactive oxygen species (ros) are wellknown as molecular intermediates for oxidative stress. moreover, ros can also cause the severity of inflammation.4 thus, the direct elimination of no and ros could be considered as potential targets for inflammation remedies. essential oil is one of the interesting natural products that have been used for health promotion for a long time.5 essential oils have earned great favor in the food, cosmetic, as well as pharmaceutical industries owing to their biological activities such as analgesic, anti-inflammatory, antioxidant, antibacterial, antiviral, and antifungal.6,7 recently, the use of essential oil in the form of a mixture is increasing particularly in holistic care because we can select the desired benefit of each essential oil into the mixture. the combination of essential oils may provide more efficacy than sole use. for example, the mixtures of essential oils produced various effects on antioxidant activity due to their free radical scavenging ability. this activity supports their use in food preservation and for the management of many ailments such as cancers, and neurodegenerative, cardiovascular, and immune system diseases.8 based on holistic medicine principles, essential oils that have healthy balance property is often selected for blended essential oil preparations.9 popular essential oils that have been used in holistic care such as vetiver oil (vetiveria zizanioides), lavender oil (lavandula angustifolia), eucalyptus oil (eucalyptus globulus), lemongrass oil (cymbopogon citratus), and phlai oil (zingiber montanum). these essential oils and their active constituents have previously been reported as anti-inflammatory agents and antioxidants.2 however, the preparation of blended essential oil formulations by using these in different ratios can result in different health benefits. therefore, this study aimed to develop a blended essential oil preparation for inflammation management. in addition, the bioactivities of prepared essential oil formulation including antioxidation and anti-inflammatory activities were also evaluated. the obtained formulation can be applied in cosmetic or pharmaceutical applications. healthcare in low-resource settings 2023; volume 11:11548 correspondence: punyanut amorndoljai, faculty of integrative medicine, rajamangala univesity of technology thanyaburi prathumthani, 12130 thailand. tel.: 0899864839 fax: 025921999. e-mail: punyanut_a@rmutt.ac.th key words: antioxidant; anti-inflammation; essential oil; holistic medicine. contributions: sc, conceptualization; methodology; investigation; formal analysis; data curation; visualization; writing-original draft; writing-review and editing; final approval of the version to be published funding acquisition; ka and kj, conceptualization; final approval of the version to be published, funding acquisition. pa, conceptualization; methodology; investigation; formal analysis; data curation; writing-original draft; writing-review and editing; final approval of the version to be published; visualization; project administration; funding acquisition. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: there is no necessary ethical issue to be approved in this study. informed consent: there are no patients participated in this study. patient consent for publication: there are no patients participated in this study. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this project was financial supported by the program management unit for areabased development (pmu-a) (fund no a1 3f650059). acknowledgments: we are grateful to assoc. prof. dr. prasart nuangchalerm for his suggestion on manuscript writing. received for publication: 27 june 2023. accepted for publication: 23 august 2023. early access: 11 september 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11548 doi:10.4081/hls.2023.11548 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11548] [page 77] non -co mmerc ial us e o nly materials and methods chemicals the essential oils including vetiver oil (vetiveria zizanioides), lavender oil (lavandula angustifolia), eucalyptus oil (eucalyptus globulus), lemongrass oil (cymbopogon citratus), and phlai oil (zingiber montanum) were purchased from royal lotus. dpph and gallic acid were obtained from sigma aldrich. ascorbic acid was from chem-supply. sodium nitroprusside and naphthyl ethylene diamine were bought from himedia and loba chemie, respectively. preparation of blended essential oil the blended essential oil formulations were prepared by using popular essential oils that have been used in holistic medicine. the selected essential oils were vetiver oil (vetiveria zizanioides), lavender oil (lavandula angustifolia), eucalyptus oil (eucalyptus globulus), lemongrass oil (cymbopogon citratus), and phlai oil (zingiber montanum). the mixtures of selected oils in various ratios (by weight) were developed. briefly, the largest amount of essential oil was pipetted into the vial first, followed by adding the minor components into the same vial. the blended oil was then homogenized and stored at 4°c prior to use. the physical characteristics of suitable obtained oil formulation such as color and odor were observed. evaluation of bioactivities 2,2-diphenyl-1-picrylhydrazyl radical scavenging assay the 2,2-diphenyl-1-picrylhydrazyl (dpph) radical quenching ability of blended essential oil was tested following a previous report.10 the fresh dpph solution was prepared by dissolving dpph in methanol to obtain an absorbance unit of 1.1±0.02 at 515 nm. the sample was diluted with methanol into various concentrations (20-200 µg/ml). the sample solutions (80 µl) and dpph solution (80 µl) were added to 96-well plates and incubated in the dark condition at room temperature for 30 minutes. then the absorbance of reactions was measured at 515 nm with a microplate reader. ascorbic acid was used as a positive control. the experiment was done in triplicate. the % inhibition was achieved by using the following equation: %inhibition = [(odcontrol-odsample)/odcontrol]×100. in vitro nitric oxide radical scavenging assay the no radical scavenging test was employed to assess the anti-inflammatory activity of blended essential oil based on a previously reported method10. the 20 mm snp solution was mixed with the blended essential oil solution (5-50 mg/ml) and incubated at ambient temperature for 180 min. then the mixture was reacted with griess reagent. the absorbance was read at 546 nm using a microplate reader. gallic acid (1-20 mg/ml) was used as a positive control. the test was performed in triplicates. the % inhibition was achieved by using the following equation: %inhibition = [(odcontrol-odsample)/odcontrol]×100. statistical analysis results were presented as mean±standard deviation. the data were analyzed using the microsoft excel program. results and discussion blended essential oil formulation the blended essential oil formulation was prepared by mixing five essential oils. the mixing ratios are presented in table 1. the physical characteristic of the obtained oil was the clear yellow-pale color. this ratio was the suitable smell from the proportions of the top note, middle note, and base note. 2,2-diphenyl-1-picrylhydrazyl radical scavenging activity the antioxidant potency of blended essential oil was evaluated using dpph proton radical scavenging. the result found that tested oil and ascorbic acid exhibited dpph radical scavenging activity in a dosedependent manner. the highest tested concentration of oil (300 mg/ml) and ascorbic acid (10 mg/ml) presented similar scavenging activity up to 82.34±0.58 and 82.47±0.72 % dpph radical scavenging (figure 1). this suggested that blended essential oil carried a lower antioxidant potency of 30 times than ascorbic acid when compared with the highest tested concentrations. the dpph radical scavenging test was based on the reduction of dpph, a hydrogen acceptor, in the presence of a hydrogen donator.11 thus, the antioxidant activity of blended essential oil is due to its hydrogen-donating properties. nitric oxide radical scavenging activity no is an important inflammatory mediator. no is over-released from activated article table 1. mixing ratios of blended essential oil. essential oil ratio (by weight) vetiver 2 lavender 2 eucalyptus 1.5 lemongrass 1.5 figure 1. 2,2-diphenyl-1-picrylhydrazyl radical scavenging activity of blended essential oil and ascorbic acid. dpph, 2,2-diphenyl-1-picrylhydrazyl. figure 2. nitric oxide radical scavenging activity of blended essential oil and gallic acid. [page 78] [healthcare in low-resource settings 2023; 11:11548] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11548] [page 79] macrophages during inflammation.12 thus, no scavenging is one of the mechanisms of anti-inflammatory agents. the anti-inflammation potency of blended essential oil was evaluated using inflammatory mediator no radical scavenging. the result found that tested oil and gallic acid presented dosedependent no radical scavenging capacity (figure 2). however, no radical quenching at the highest tested concentration of essential oil (27.41±0.87%) was approximately 2.1 folds lower than the scavenging efficacy of gallic acid (56.17±1.47%) at the highest tested dosage. this finding revealed that blended essential oil possessed mind antiinflammatory activity. the increase in the used dosage may improve the anti-inflammatory potency of this essential oil. conclusions the present study has developed a blended essential oil formulation from the popular essential oils used in holistic medicine to use for pharmaceutical and cosmetic applications. the biological activities of prepared oil were evaluated and showed that the oil has a promising potential as an antioxidant by acting as a proton radical scavenger. in addition, the anti-inflammatory property of the oil was expanded via inflammatory mediator no scavenging. references 1. guzik t, korbut r, adamek-guzik t. nitric oxide and superoxide in inflammation. j physiol pharmacol 2003;54: 469-87. 2. rawat a, rawat m, prakash om, et al. comparative study on eucalyptol and camphor rich essential oils from rhizomes of hedychium spicatum sm. and their pharmacological, antioxidant, and antifungal activities. anais da academia brasileira de ciências, 2022;94. 3. knowles rg, moncada s. nitric oxide synthases in mammals. biochem j 1994;298:249-58. 4. mittal m, siddiqui mr, tran k, et al. reactive oxygen species in inflammation and tissue injury. antiox redox signal 2014;20:1126-67. 5. sadgrove nj, padilla-gonzález gf, phumthum m. fundamental chemistry of essential oils and volatile organic compounds, methods of analysis and authentication. plants 2022;11:789. 6. ni zj, wang x, shen y, et al. recent updates on the chemistry, bioactivities, mode of action, and industrial applications of plant essential oils. trends food sci technol 2021;110:78-89. 7. turek c, stintzing fc. stability of essential oil: a review. compr rev food sci food saf 2013;12:40-53. 8. horvathova e, navarova j, galova e, et al. assessment of antioxidative, chelating, and dna-protective effects of selected essential oil components (eugenol, carvacrol, thymol, borneol, eucalyptol) of plants and intact rosmarinus officinalis oil. j agric food chem 2014;62;6632-9. 9. halm ma. essential oils for management of symptoms in critically ill patients. ame j crit care 2008;17:1603. 10. chaiwong s, puttarak p, sretrirutchai s, kaewsuwan s. in vitro anti-inflammatory and antioxidative activities of isolated interruptins from cyclosorus terminans. lat ame j pharma 2019;38: 1677-82. 11. kadhum aah, al-amiery aa, musa ay, mohamad ab. the antioxidant activity of new coumarin derivatives. int j mol sci 2011;12:5747-61. 12. muntané j, de la mata m. nitric oxide and cancer. world j hepatol 2010;2: 337-44. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11196 the effectiveness of self-care management in treating heart failure: a scoping review alfrina hany,1 ratih arum vatmasari2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2school of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: heart failure is a common chronic disease associated with increased mortality and rehospitalization rates. selfcare management provided in various ways is one approach to avoiding the need for rehospitalization by lowering recurrence rates. therefore, this study aims to determine the most effective self-care management interventions for heart failure patients. design and methods: the databases science direct, google scholar, and pubmed were used to conduct literature reviews over ten years. in september 2021, a full-text article search was conducted using the keywords “self-care,” “self-management,” “intervention,” “heart failure patients,” and “randomized control trial” in pubmed sciencedirect and google scholar databases. the inclusion and exclusion criteria were determined using the picos technique. after the screening, 39 articles met the criteria. results: self-care management is provided through education programs, training programs, and the utilization of apps and websites to improve its self-care abilities. conclusions: therefore, one way to provide self-care management during the covid-19 pandemic was through the program’s website, which is viewed “remotely” and used to track patient progress. introduction heart failure has become the most common chronic disease over the past 20 years, accounting for half of all deaths in developing countries, and it reduces labor productivity, causing disability and economic damage.1 heart failure has become a serious concern worldwide, with a significant increase in morbidity and death2 to increase the use of healthcare facilities, decrease the quality of life for patients and their families, and a greater economic burden on individuals and society due to the required and frequent hospitalizations of heart failure patients.3 patients with complex chronic diseases, such as heart failure, need to follow a comprehensive treatment plan that includes diet and medications, monitoring symptoms, assessment of health changes signs, and coordination with care professionals to access prior care in emergency cases.4 the symptoms of heart failure were linked to self-care activities, while lower self-care levels were associated with worsening heart failure symptoms.5 self-care is essential in heart failure patients and multidisciplinary heart failure management programs globally. also, it is considered effective for reducing mortality, rehospitalization, and improving quality of life.6 nurses play an essential role in patient interaction, including providing information about self-care before their discharge from the hospital.7 furthermore, the information about the management of heart failure and the variables that influence self-care are used to design culturally acceptable and successful disease maintenance and management methods.8 the heart failure education provided by nurses has been shown to enhance knowledge and selfcare practices.9 this information is provided in the form of educational interventions through booklets, training programs, applications, and websites.10–13 therefore, the use of digital health communication technology enhances the efficiency and quality of selfcare management in heart failure patients.14 the covid-19 epidemic has presented nurses with new problems of providing direct education in hospitals.15 furthermore, web-based education programs effectively allow nurses to carefully view their feelings and emotions and the emotional and cultural factors that influence their decision-making.16 these new technologies offer “remotely” opportunities to provide patients with constant education, the incentive to take action in their treatment, and aid in frequent monitoring, hence the world health organization is focused on providing them with leverage to change healthcare.17 technology provides new ways to improve people’s self-care by measuring their progress and cost-effectively enhancing patient empowerment.18 the web-based interventions promote the involvement of heart failure patients in self-care, however web-based self-care interventions for heart failure patients are still uncommon.19 therefore, this study aims to determine the most effective self-care management interventions for heart failure patients. significance for public health the self-care management methods are widely used in patients with heart failure. furthermore, the development of its strategies is facilitated by advances in technology. according to the conclusion of this study, website usage is one of the self-care management measures of patients with heart failure study. it improves the effectiveness of self-care by lowering rehospitalization rates and enhancing the quality of life. review [page 106] [healthcare in low-resource settings 2023; 11(s1):11196] non -co mmerc ial us e o nly design and method according to the pris-ma guidelines, a data-driven literature search was performed in september 2021, selecting credible publications. the studies, being limited to those published between 2011 and 2021, were carefully evaluated to collect empirical data on the effectiveness of self-care management treatments in heart failure patients through the use of search engines such as sciencedirect, pubmed, and google scholar. this was accomplished by combining the terms “self-care,” self-management,” “intervention,” “heart failure patients,” and “randomized control trial” with boolean search methods like “and,” “or” and “not” to discover relevant study that matches the review’s objectives. table 1 shows how inclusion and exclusion criteria were determined using the picos (population, intervention, comparators, outcomes, and study design) technique, which was adjusted to the review’s aims (table 1). the results, including publications from three databases, showed that 2997 items matched the keywords selected. figure 1 shows the selection results in a flowchart using the pris-ma method, and 288 articles with identical material were deleted after a duplication check, leaving 2709 items. furthermore, 631 papers were admitted after additional filtering by title and abstract. after which, they were filtered by complete text, resulting in correlated articles. the eligibility assessment of the 631 articles was based on the overall text and conformity with the criteria. as a result, 592 articles were considered inappropriate, while 39 were used in this study. result and discussion the current guidelines emphasize the joint provision of heart failure management education to patients and family caregivers and the significance of knowledge sharing between patient and caregiver.54 the self-care management interventions are performed through education and self-management programs, motivational interviewing, applications, websites, and follow-up via telemonitoring (supplementary table s1). 13,23,24,26,30,34 educational programs educational programs on heart failure are made available using booklets, board games, or multimedia.10,22,26,32 furthermore, the booklets are created based on the theory of heart failure self-care and should include daily follow-up charts in which their weight, edema status, blood pressure, pulse, additional drugs taken such as diuretics, and other daily notes are recorded.10 game board educational programs increase the knowledge of patients on heart failure and self-care behavior compared to traditional educational approaches.22 these various educational programs can improve knowledge, performance, self-care behavior, and quality of life.10,22,26 however, this educational program does not have a significant impact on self-care confidence and failed to identify the effect of rehospitalization.22,32 self-management programs patient-centered self-management programs were more effective than traditional care education in achieving certain self-management outcomes.24 several approaches are employed in the selfmanagement program, which include the follow-up strategy.24,29 certain aspects of self-management competence (self-monitoring and insight) and the incidence of repeated treatments were significantly influenced.24,29 however, there was no significant effect on self-efficacy and knowledge or understanding of subjective behavior.24,29 motivational interviewing (mi) furthermore, motivational interviewing is used in a new behavioral intervention led by nurses to help patients with heart failure improve their self-care.35 it enhances self-care maintenance (primary endpoint), management, and behavior after three months of enrolment.25,40 lack of motivational interviewing intervention in heart failure patients does not promote self-efficacy.40 the loss of participants to follow-up was also a key drawback of motivational interviewing. this nurse-led intervention included one home visit and three to four follow-up calls over 90 days.35 application this study used android application in the self-care management of heart failure patients.12,34,43 the application offers different review [healthcare in low-resource settings 2023; 11(s1):11196] [page 107] figure 1. flowchart of scoping review with selection process using pris-ma. table 1. inclusion and exclusion criteria. criteria inclusion exclusion p (population) studies that focus on heart failure patients oother than patients with heart failure, such as nurses i (intervention) studies that addressed the self-care management intervention studies that do not address the self-care management intervention c (comparison) studies with control or comparison intervention they were no exclusion criteria o (outcomes) studies explain the effectiveness of self-care management they were no exclusion criteria interventions in heart failure patients s (study design) randomized control trial nonrandomized control trial, systematic review, meta-analysis review non -co mmerc ial us e o nly features, including daily weighing, symptom assessment, responding to customized alerts, monitoring vital signs, heart failure education, and performing breathing and walking exercises.12 on the other hand, the content of the avatar app is based on the booklet “living well with heart failure” by the heart foundation of australia.34 the use of apps to implement self-care management help patients understand more and improve symptom control and self-care scores.12,34,43 heartapp needs an update in integrating wrist-worn bluetooth devices for vital sign monitoring12 and the avatar application is not available for free download.34 website interventions the covid-19 pandemic has posed major challenges for healthcare organizations to address public information demands.55 patients believe there are gaps in information and knowledge on testing and therapy. however, the experiences of other heart failure patients are considered essential in providing support, which is bridged by the website.56 the web-based interventions enhance self-care, clinical results, and the required number of treatments.57 it is used by patients to provide accurate self-care information from the comfort of their own home, make an educated choice about how to best manage their symptoms, and determine when to see their doctor.58 based on the previous study, it appears that webbased, interactive interventions improve self-determination and physical activity in patients with various chronic diseases.59 this website facilitated the follow-up of patients in remote monitoring programs, thereby improving clinical outcomes and reducing rehospitalization rates.51 therefore, web-based programs are effective and accessible to nurses and patients for learning; even when nurses work different shifts, they can participate without restrictions on time or place of learning because of the development of web-based educational programs.13 most of these rct articles included follow-up activities separated into several periods, such as 1 month, 3 months, 4 months, 6 months, and 12 months.28,35,48,50 this follow-up activity may be conducted by telephone or by home visits28,35. the intervalsa have a major impact on heart failure patients because they enable them to take better care of themselves and improve their quality of life.10,40 meanwhile, a follow-up period is required for the longterm progress of the intervention, especially in terms of outcomes such as readmission, mortality, and quality of life.21 the website program is being used for follow-up in cancer patients, and it is a method of managing patients with a low risk of recurrence.60 the limitation of this review is that the follow-up program did not explain the frequency of follow-up and the duration of the follow-up. the development of web-based self-care interventions is currently uncommon, it is suggested that web-based self-care interventions for heart failure patients be developed in the future. conclusions a variety of self-care management strategies have been developed in patients with heart failure. these interventions aim to increase patient awareness, improve self-care management abilities, reduce hospitalizations, and improve quality of life. therefore, web-based self-care management is one of the strategies used during the covid-19 pandemic. furthermore, it is considered useful to improve the self-care management of heart failure patients by increasing their knowledge and abilities. also, it is used to monitor the effectiveness of prior interventions offered to patients. references 1. rahimi kordshooli k, rakhshan m, ghanbari a. the effect of family-centered empowerment model on the illness perception in heart failure patients: a randomized controlled clinical trial. j caring sci 2018;7:189-195. 2. tavakoly sany sb, peyman n, zadehahmad z, et al. effect of educational interventions on health literacy in patients with heart failure. int j heal promot educ 2018;57:23–36. 3. jaarsma t, cameron j, riegel b, et al. factors related to selfcare in heart failure patients according to the middle-range theory of self-care of chronic illness: a literature update. curr hear fail rep 2017;14:71–7. 4. riegel b, dickson vv, garcia le, et al. mechanisms of change in self-care in adults with heart failure receiving a tailored, motivational interviewing intervention. patient educ couns 2017;100:283–8. 5. auld 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conflicts of interest. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 17 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11196 doi:10.4081/hls.2023.11196 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article 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clinical trial. rev da esc enferm 2020;54:1–8. 31. chen c, li x, sun l, et al. post-discharge short message service improves short-term clinical outcome and self-care behaviour in chronic heart failure. esc hear fail 2019;6:164– 73. 32. boyde m, peters r, new n. self-care educational intervention to reduce hospitalisations in heart failure: a randomised controlled trial. eur j cardiovasc nurs 2018;17:178–85. 33. van spall hgc, lee sf, xie f, et al. effect of patient-centered transitional care services on clinical outcomes in patients hospitalized for heart failure: the pact-hf randomized clinical trial. jama 2019;321:762–72. 34. wonggom p, nolan p, clark ra, et al. effectiveness of an avatar educational application for improving heart failure patients’ knowledge and self-care behaviors: a pragmatic randomized controlled trial. j adv nurs 2020;76:2401–15. 35. creber rm, patey m, lee cs, et al. motivational interviewing to improve self-care for patients with chronic heart failure: miti-hf randomized controlled trial. patient educ couns 2017;99:256–64. 36. hale tm, jethwani k, kandola ms, et al. a remote medication monitoring system for chronic heart failure patients to reduce readmissions: a two-arm randomized pilot study. j med res 2016;18. 37. ding h, jayasena r, chen sh, et al. the effects of telemonitoring on patient compliance with self-management recommendations and outcomes of the innovative telemonitoring enhanced care program for chronic heart failure: randomized controlled trial. j med res 2020;22:1–12. 38. young l, hertzog m, barnason s. effects of a home-based activation intervention on self-management adherence and readmission in rural heart failure patients: the patch randomized controlled trial. bmc cardiovasc disord 2016;16:1– 11. 39. dionne-odom jn, ejem db, wells r, et al. effects of a telehealth early palliative care intervention for family caregivers of persons with advanced heart failure: the enable chf-pc randomized clinical trial. jama netw open 2020;3:e202583. review [healthcare in low-resource settings 2023; 11(s1):11196] [page 109] non -co mmerc ial us e o nly 40. vellone e, rebora p, ausili d, et al. motivational interviewing to improve self-care in heart failure patients (motivatehf): a randomized controlled trial. esc hear fail 2020;7:1309–18. 41. jurgens cy, lee cs, reitano jm, et al. heart failure symptom monitoring and response training. hear lung j acute crit care 2013;42:273–80. 42. chew hsj, sim kld, choi kc, et al. effectiveness of a nurseled temporal self-regulation theory-based program on heart failure self-care: a randomized controlled trial. int j nurs stud 2021;115:103872. 43. jiang y, koh kwl, ramachandran hj, et al. the effectiveness of a nurse-led home-based heart failure self-management programme (the hom-hemp) for patients with chronic heart failure: a three-arm stratified randomized controlled trial. int j nurs stud 2021;122:104026. 44. hwang b, pelter mm, moser dk, et al. effects of an educational intervention on heart failure knowledge, self-care behaviors, and health-related quality of life of patients with heart failure: exploring the role of depression. patient educ couns 2020;103:1201–8. 45. cajanding rjm. the effectiveness of a nurse-led cognitive– behavioral therapy on the quality of life, self-esteem and mood among filipino patients living with heart failure: a randomized controlled trial. appl nurs res 2016;31:86–93. 46. sahlin d, rezanezad b, edvinsson ml, et al. self-care management intervention in heart failure (smart-hf): a multicenter randomized controlled trial. j card fail 2021;00:1–9. 47. koehler f, winkler s, schieber m, et al. impact of remote telemedical management on mortality and hospitalizations in ambulatory patients with chronic heart failure: the telemedical interventional monitoring in heart failure study. circulation 2011;123:1873–80. 48. brännström m, boman k. effects of person-centred and integrated chronic heart failure and palliative home care (prefer): a randomized controlled study. eur j heart fail 2014;16:1142–51. 49. ong mk, romano ps, edgington s, et al. effectiveness of remote patient monitoring after discharge of hospitalized patients with heart failure the better effectiveness after transition-heart failure (beat-hf) randomized clinical trial. jama intern med 2016;176:310–8. 50. rogers jg, patel cb, mentz rj, et al. palliative care in heart failure: the pal-hf randomized, controlled clinical trial. j am coll cardiol 2017;70:331–41. 51. zan s, agboola s, moore sa, et al. patient engagement with a mobile web-based telemonitoring system for heart failure selfmanagement: a pilot study. jmir mhealth uhealth 2015;3:e33. 52. seto e, leonard kj, cafazzo ja, et al. mobile phone-based telemonitoring for heart failure management: a randomized controlled trial. j med res 2012;14:1–14. 53. hindricks g, taborsky m, glikson m, et al. implant-based multiparameter telemonitoring of patients with heart failure (in-time): a randomised controlled trial. lancet 2014;384:583–90. 54. bidwell jt, higgins mk, reilly cm, et al. shared heart failure knowledge and self-care outcomes in patient-caregiver dyads. hear lung 2018;47:32–9. 55. higashi rt, sweetenham jw, israel ad, et al. covid-19 communication from seven health care institutions in north texas for englishand spanish-speaking cancer patients: mixed method website study. jmir cancer 2021;7:e30492. 56. kristiansen am, svanholm jr, schjødt i, et al. patients with heart failure as co-designers of an educational website: implications for medical education. int j med educ 2017;8:47–58. 57. bashi n, windsor c, douglas c. evaluating a web-based selfmanagement intervention in heart failure patients: a pilot study. jmir res protoc 2016;5:e116. 58. little p, stuart b, andreou p, et al. primary care randomised controlled trial of a 38.8% tailored interactive website for the self-management of respiratory infections (internet doctor). bmj open 2016;6:1–11. 59. kuijpers w, groen wg, aaronson nk, et al. a systematic review of web-based interventions for patient empowerment and physical activity in chronic diseases: relevance for cancer survivors. j med res 2013;15:e37. 60. bartlett yk, selby dl, newsham a, et al. developing a useful, user-friendly website for cancer patient follow-up: users’ perspectives on ease of access and usefulness. eur j cancer care (engl) 2012;21:747–57. review [page 110] [healthcare in low-resource settings 2023; 11(s1):11196] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2022; 10:10800] [page 61] covid-19 and neurological complications: a review feryal dabagh-gorjani,1 mohammad-ali fatehchehr2 1department of immunology, school of medicine, shiraz university of medical sciences, shiraz; 2department of computer engineering, amirkabir university of technology, tehran, iran abstract infections with viruses have detrimental effects on neurological functions, and even cause severe neurological damage. there is mounting evidence that coronaviruses (cov) as well as sars-cov-2 exhibit neurotropic abilities and might cause neurological problems. neuroinvasive viruses are not fully understood, which makes it important to investigate their impact on the nervous system. in this paper, we review research into neurological complications associated with cov. introduction on march 11th, 2020, coronavirus disease 2019 (covid-19) was affirmed by the world health organization as a pandemic. it was reported at the time as an epidemic disease in wuhan, hubei province, china in december 2019 . the cause of the severe acute respiratory syndrome that became known as covid-19 was a novel coronavirus, sars-cov-2.1 there are seven members in the cov family and sars-cov-2 is one of them which can infect humans,2 and it belongs to the equal lineage of covs, which reasons sars; however, this novel virus is genetically distinct. the emergence of covid-19 is a serious threat to global public health.3 evidence shows these viruses can affect different human systems such as the respiratory, nervous, hepatic, and gastrointestinal systems.4 neurological manifestations are the second most common symptom after respiratory symptoms5 and it can be seen in both severe form and early stage of disease.6 headache, confusion, dizziness, mild cognitive impairment, altered taste, loss of smell, blurred vision, as well as muscle and nerve pain are the most common manifestations in covid-19 patients.7 covid-19 can develop neurological complications either by direct effect on the nervous system during the acute phase or indirectly by immune-mediated infection, which may appear even after months following the acute phase.8,9 in this review, we summarized the studies that have shown neurological manifestations of covid-19 in patients. pathophysiology sars-cov-2 has a large envelope with spiked proteins on its surface. through these surface proteins, sars-cov-2 binds to the human angiotensin-converting-enzyme receptor 2 (ace2) on human cells. therefore, the presence of ace2 in humans plays a key role in the entrancing of virus. ace2 is expressed in many tissues like the lung, kidney, pancreas, small intestine, testicles and vascular epithelial, cns, including neurons and glial cells.10 after binding to ace2, the enzyme tmprss2 helps to virion entry and the virion releases its rna. rna is translated to proteins which are necessary for the virion and finally the rna is assembled into a new virion and exits the cell.11 routes and mechanism of cns invasion as mentioned above, evidence suggests that sars-cov-2 is a neuroinvasive, neurotropic, and neurovirulent virus to both humans and animals.12 because ace2 exists in different human organs such as central nervous system (cns) and the endothelial cells, interaction between sars-cov-2 and ace2 receptors leads to invasion into the cns through different ways, including the olfactory route, the trans-synaptic route, the leukocytic route and the haematogenic route.13 sars-cov-2 infects olfactory epithelium and reaches the cns via the olfactory neurons. the high expression of ace2 and tmprss2 on the olfactory epithelium has a significant role in transferring the virus into the cns through olfactory neurons.14,15 the second rout occurs when sars-cov-2 infects peripheral nerves and the virus uses the axonal transport machinery (retrograde transport) to access the cns.16 the third route is about the role of leukocytes. coronavirus can spread to the cns via infected immune cells, such as monocytes, neutrophils and t cells.17 some evidence shows immune cells can express the binding receptors of coronaviruses. so they serve as the reservoirs for virus particles.17,18 about the fourth route is assumed, coronaviruses can attack ace2 receptors on the endothelial cells of brain vessels that cause disruption in bbb and viruses spread into the cns.19 the most important injuries in cov hypoxia many problems such as hemorrhagic problems or infections can lead to brain hypoxia. proliferation of virus in lung cells is accompanied by alveolar gas exchange disorders, which cause hypoxia in the brain via enhancing anaerobic metabolism in the brain cells’ mitochondria.20 hypoxia in the brain subsequently causes edema in brain cells, cerebral vasodilation, cerebral blood healthcare in low-resource settings 2022; volume 10:10800 correspondence: feryal dabagh-gorjani, department of immunology, school of medicine, shiraz university of medical sciences, shiraz, iran. tel:: +989126306762 e-mail: dabaghferyal@gmail.com key words: covid-19; inflammation; neurodegeneration; immune system; cytokine storm. contributions: fdg carried out the design, literature survey, writing and revision of the manuscript; maf collected the data and articles and provided critical feedback on the manuscript. conflict of interest: the authors declare no conflict of interest. funding: none. availability of data and materials: the authors confirm that the data supporting the findings of this study are available within the article. ethics approval and consent to participate: not applicable. informed consent: not applicable. received for publication: 13 august 2022. revision received: 14 november 2022. accepted for publication: 14 november 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10800 doi:10.4081/hls.2022.10800 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.non -co mmerc ial us e o nly [page 62] [healthcare in low-resource settings 2022; 10:10800] flow impediment and headache. if hypoxia continues, brain function will be reduced and drowsiness, bulbar conjunctival edema and more complex problems like coma can be observed.20 hypoxia may also cause acute cerebrovascular disease such as acute ischemic stroke in a patient. as patients with covid-19 often suffer from severe hypoxia,21 this may lead to subsequent nervous system damage. immune injury high levels of il-1β, il-2, il-6, il-7, il-8, il-10, il-17, inf-γ, mcp1, g-csf, tnfα, and macrophages inflammatory protein 1α were seen in patient with covid19.22 on the other hand, neurotropic viruses can lead to brain damage and chronic inflammation via the activation of glial cells. glial cells, by producing high levels of inflammatory factors, such as cytokines, chemokines, and other inflammation signals, enhance brain damage. cytokine storms cause disruption to the integrity of bbb, which provokes the neuro inflammatory process.23 additionally, studies showed there is a positive correlation between il-6 and the severity of covid-2019 symptoms.24 activation of immune cells in the brain will cause chronic inflammation and brain damage. cognition impairment clinical and preclinical studies suggest that bacterial, viral, and toxic inflammation can activate toll-like receptors in microglia and astrocytes, and finally cause neuro inflammation that may lead to neuronal death and cognitive impairments.25 neuro inflammation induced by prolonged hypoxia and systemic inflammation lead to damage in brain regions responsible for cognitive functions and behavioral alterations, such as the hippocampus and cortex.26 delirium as functional brain damage is commonly activated by peripheral infection associated with systemic inflammation and is accompanied by an elevated level of serum pro-interleukins and s100b (as an index for bbb disruption) in elderly patients.27 neuro inflammation has been implied as an important factor in neurodegenerative disorders28 and psychiatric pathologies, including acute psychosis, schizophrenia, and autism spectrum disorder.29 some evidence showed that anxiety and depression increased in patients with covid-19.30 therefore, covid-19 can affect the brain and leads to neurocognitive impairments. conclusions according to the fact that receptors, which are for virus entry, exist on many tissues such as the cns, the adverse effects of the virus will not be limited to the lungs. as the studies showed, viruses, via altering blood brain barrier (bbb) permeability access to the cns and leads to different neuronal injuries. evidence suggests that inflammatory pathways and cytokine storms induce neuronal damage. effects of cytokine storms are documented in some neurodegenerative diseases and neuropsychiatric complications. in addition, clinical findings in covid-19 patients showed not only pulmonary problems but also neuronal complications such as epilepsy, intracranial infections, encephalitis, meningitis, dizziness, depression, parkinsonism, confusion, headache, insomnia, stroke, myelitis, etc. although these documents are at preliminary stages and we need more information about the virus, special attention must be given to patients with covid-19 for preventing neurological damage in the future until a specific treatment is available. references 1. chaplin s. covid-19: a brief history and treatments in development. prescriber 2020;31:23-8. 2. zhu n, zhang d, wang w, et al. a novel coronavirus from patients with pneumonia in china, 2019. n engl j med 2020;382:727-33. 3. deng s-q, peng h-j. characteristics of and public health responses to the coronavirus disease 2019 outbreak in china. j clin med 2020;9:575. 4. hassan sa, sheikh fn, jamal s, et al. coronavirus (covid-19): a review of clinical features, diagnosis, and treatment. cureus 2020;12:e7355. 5. kanwar d, imran m, wasay m. neurological involvement in coid-19 infections; pathophysiology, presentation and outcome. pakistan j neurol sci 2020;15:52-8. 6. carod-artal fj. neurological complications of coronavirus and covid-19. revista de neurologia 2020;70:311-22. 7. zhou y, li w, wang d, et al. clinical time course of covid-19, its neurological manifestation and some thoughts on its management. stroke vasc neurol 2020;5:177-179. 8. ellul ma, benjamin l, singh b, et al. neurological associations of covid19. lancet neurol 2020;19:767-783. 9. baker d, amor s, kang as, et al. the underpinning biology relating to multiple sclerosis disease modifying treatments during the covid-19 pandemic. mult scler relat disord 2020;43:102174. 10. venkatesan a, tunkel ar, bloch kc, et al. case definitions, diagnostic algorithms, and priorities in encephalitis: consensus statement of the international encephalitis consortium. clin infect di 2013;57:1114-28. 11. fehr ar, perlman s. coronaviruses: an overview of their replication and pathogenesis. methods mol biol 2015; 1282:1-23. 12. lima m, siokas v, aloizou a-m, et al. unraveling the possible routes of sars-cov-2 invasion into the central nervous system. curr treat options neurol 2020;22:37 13. dewanjee s, vallamkondu j, kalra rs, et al. emerging covid-19 neurological manifestations: present outlook and potential neurological challenges in covid-19 pandemic. mol neurobiol 2021;58:4694-4715. 14. li yc, bai wz, hashikawa t. the neuroinvasive potential of sars�cov2 may play a role in the respiratory failure of covid-19 patients. j med virol 2020;92:552-5. 15. bilinska k, jakubowska p, von bartheld cs, butowt r. expression of the sars-cov-2 entry proteins, ace2 and tmprss2, in cells of the olfactory epithelium: identification of cell types and trends with age. acs chem neurosci 2020;11:1555-62. 16. yavarpour-bali h, ghasemi-kasman m. update on neurological manifestations of covid-19. life sci 2020;257:118063. 17. iadecola c, anrather j, kamel h. effects of covid-19 on the nervous system. cell. 2020;183:16-27.e1. 18. lodigiani c, iapichino g, carenzo l, et al. venous and arterial thromboembolic complications in covid-19 patients admitted to an academic hospital in milan, italy. thromb res 2020;191:914. 19. hamming i, timens w, bulthuis m, et al. tissue distribution of ace2 protein, the functional receptor for sars coronavirus. a first step in understanding sars pathogenesis. j pathol 2004;203: 631-7. 20. abdennour l, zeghal c, dème m, puybasset l, eds. interaction cerveaupoumon. annales francaises d’anesthesie et de reanimation; 2012: elsevier. 21. guo y-r, cao q-d, hong z-s, et al. the origin, transmission and clinical therapies on coronavirus disease 2019 (covid-19) outbreak–an update on the status. military med res 2020;7:1-10. 22. huang c, wang y, li x, ren l, zhao j, review non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:] [page 63] et al. clinical features of patients infected with 2019 novel coronavirus in wuhan, china. the lancet 2020;395:497-506. 23. wang q, zhang y, wu l, et al. structural and functional basis of sars-cov-2 entry by using human ace2. cell 2020;181:894-904. e9. 24. wan s, yi q, fan s, lv j, et al. characteristics of lymphocyte subsets and cytokines in peripheral blood of 123 hospitalized patients with 2019 novel coronavirus pneumonia (ncp). medrxiv. 2020. 25. sankowski r, mader s, valdés-ferrer si. systemic inflammation and the brain: novel roles of genetic, molecular, and environmental cues as drivers of neurodegeneration. front cellular neurosci 2015;9:28. 26. sasannejad c, ely ew, lahiri s. longterm cognitive impairment after acute respiratory distress syndrome: a review of clinical impact and pathophysiological mechanisms. critical care 2019;23:1-12. 27. mcneil jb, hughes cg, girard t, et al. plasma biomarkers of inflammation, coagulation, and brain injury as predictors of delirium duration in older hospitalized patients. plos one 2019;14:e0226412. 28. heneka mt, carson mj, el khoury j, et al. neuroinflammation in alzheimer’s disease. lancet neurol 2015;14:388405. 29. pape k, tamouza r, leboyer m, zipp f. immunoneuropsychiatry—novel perspectives on brain disorders. nature revi neurol 2019;15:317-28. 30. rogers jp, chesney e, oliver d, et al. psychiatric and neuropsychiatric presentations associated with severe coronavirus infections: a systematic review and meta-analysis with comparison to the covid-19 pandemic. lancet psychiat 2020;7:611-27. article non -co mmerc ial us e o nly hrev_master [page 90] [healthcare in low-resource settings 2023; 11:11332] six-minute step test performance in asymptomatic adults riya kalra,1 kanu goyal,1 manu goyal,1 hina vaish2 1maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana, india; 2department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india abstract the objectives of this study were i) to measure a six-minute step test (6mst) in asymptomatic adults; ii) to determine the applicability of arcuri et al.’s reference equation to indian adults; iii) to develop a prediction equation for indian adults. 110 adult males and females aged 18-40 years were recruited for this prospective crosssectional study conducted in india. participants underwent 6mst. applicability was assessed by comparing the findings of the 6mst with the values derived from arcuri et al.’s predicted equations using the bland-altman plot. a multiple regression analysis was used to develop the prediction equation. the mean±sd six-minute step count was 159.42±17.60 steps and 150.78±14.39 steps in males and females respectively. the 6mst for males can be determined by males (steps)=204.3711.521×age(years) and females (steps)=179.567-1.06×age (years). arcuri et al.’s equation cannot be used to predict 6mst in indian adults. region-specific equations are useful to assess the values. introduction the ability to exercise plays an important role in determining quality of life and prognosis. despite the fact that assessing exercise capacity can provide valuable information about a population’s health, it is rarely employed in primary care.1 the step climbing activity necessary in daily life is used to assess exercise ability. step test has been used to assess functional capability for a long time, particularly in healthy people. six-minute step test is a quick, easy, inexpensive method of measuring exercise tolerance. also, it requires the least amount of space.1 the six-minute step test (6mst) is extensively used in field testing and is linked to disease prediction, estimated oxygen use, and the identification of functional limitations.2 the six-minute step is more commonly used for pulmonary pathologies like chronic obstructive pulmonary disease, interstitial lung disease, etc. if there is a lack of space and the six-minute walking test (6mwt) cannot be conducted. the 6mst is found to be valid and reliable when compared with 6mwt.3,4 the 6mst is valid and reproducible, producing greater cardiovascular stress than the 6mwt in cardiac pathologies.5 the 6mst has also been characterized as a submaximal test for the assessment of exercise tolerance in individuals with obstructive sleep apnea treated with continuous positive airway pressure.6 one of the earliest equations for the prediction of 6mst is that of arcuri et al.1 prediction equations that predict the expected value in the absence of pathology allow the magnitude of an individual’s functional limitation to be quantified. ethnic and geographic variations have been reported as some of the factors responsible for the discrepancies in physical test scores.7 the present study therefore aimed to measure 6mst in indian adults, to check the applicability of arcuri et al.’s reference equation to this group and, to develop a prediction equation. materials and methods the sample size was calculated by using the equation, n>50+8k,8 where k represents the number of independent variables. seven variables [age, height, weight, body mass index (bmi), waist circumference, hip circumference, and waist-hip ratio] were used, resulting in at least 106 participants. 110 participants were recruited by purposive sampling for this prospective cross-sectional study. the study was approved by the institutional ethical committee, project no. iec-11f. participants were volunteers recruited over a period of eight months from among the students and staff of the institute, relatives of the patients, and nearby community dwellings. participants were included if they were asymptomatic males and females aged 18-40 years with stable vitals, nonsmokers, absence of any disease in the 6 weeks preceding the study, and were able to step up and down without using any external support. exclusion criteria included resting heart rate (hr) > 100bpm; systolic blood pressure (bp) >139 mmhg, diastolic bp >89 mmhg; any documented health problem or use of medication such as impaired sensation or cognition, metabolic, cardiac, neurologic, or orthopedic disease; use of walking aids; pregnant females and lactating mothers. all the participants provided written informed consent regarding the study. the body weight (kg) was mea healthcare in low-resource settings 2023; volume 11:11332 correspondence: hina vaish, department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india. tel.: +91.9450124758. e-mail: hina22vaish@gmail.com key words: aerobic fitness; cardiovascular endurance; exercise; functional capacity; health. contribution: rk, kg, mg, hv designed the experiments; rk, collected the data; rk, kg; mg wrote the manuscript; kg, mg, data synthesis; kg, mg, hv, data analysis, and critical intellectual content. all the authors approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethical approval and consent to participate: the study was approved by the institutional ethical committee, project no. iec-11f. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we greatly acknowledge the support from all participants and sincerely thank all the subjects for taking part in the study. received for publication: 23 march 2023. accepted for publication: 23 august 2023. early access: 11 september 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11332 doi:10.4081/hls.2023.11332 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11332] [page 91] sured with a beam balance scale. body height (m) was measured using a height scale and bmi [weight/height2 (kg/m2)] was calculated. using a non-elastic, flexible measuring tape, the circumference of the hips and waist were measured, and the waist-hip ratio was calculated. the 6mst was performed according to the guidelines of the american thoracic society for conducting the six-minute step test,9 the 6mst was carried out on a portable 20-cm-high step with a non-slip rubber surface, physiotherapist counting the steps. participants were told to sit at rest for five minutes before the test while the physiotherapist explained the exam to them.10 participants were given six minutes to climb up and down as many times as they could while maintaining their own rhythm. participants were motivated using phrases like “you’re doing well” and “keep it up”.10,11 when the timer was less than 15 seconds away from finishing the test, the participants were informed. the level of exertion was quantified using the modified borg scale. for each participant, maximum hr was estimated using hrmax=220-age in years, and submaximal hr was defined as 85 percent of maximal hr.the participants might also choose to take a break from the test to rest, but the timer was not halted in either scenario. the test score was recorded at the end and the total number of steps taken in the time limit of 6 minutes.9 statistical analyses a statistical package for the social sciences ibm version 26 statistical software (ibm, armonk, 97 ny, usa) was used to analyze the data. correlations were estimated using pearson’s coefficient of correlation. comparisons between males’ and females’ step count included an independent t-test. bland-altman comparison was performed between the measured and predicted 6mst, based on arcuri et al.’s reference equation: male 6mst= 209-[1.05 × age (years)], female 6mst=174[1.05 × age] (years)].1 limits of agreement, calculated as mean difference between measured and predicted 6mst±1.96 standard deviation (sd), were used for comparison. comparisons between measured and predicted 6mst also included paired t-test. comparison of pre and post-test heart rate and oxyhemoglobin saturation were assessed through paired t-test. stepwise multiple regression analysis was used to develop the gender-specific reference equation for 6mst. p<0.05 was considered significant. results all the enrolled participants (n=110) completed the test, and there were no dropouts. the baseline characteristics of the study population and results of the sixminute step test along with correlations are summarized in table 1. the mean±sd sixminute step count was 159.42±17.60 steps and 150.78±14.39 steps in males and females respectively. the 6mst reference values determined in the study were found to overestimate the step count in indian males by 24.84±15.75 steps and underestimate in females by 4.73±13.93 steps. there was a significant difference between the 6mst count between males and females (p=0.032). there was a significant difference between preand post-6mst heart rate (p<0.0001). also, there was a significant difference between preand post-6mst oxyhemoglobin saturation (p<0.0001). figures 1 and 2 show the bland-altman comparison between the measured and predicted 6mst between males and females. there was a systematic bias between measured and predicted 6mst with arcuri et al.’s reference equation. the 6mst reference value determined in the study was found to be substantially different from previously reported values.1 hence new prediction equations were developed. based on the results of the regression analysis, the 6mst for males can be determined by 6mst (steps) males =204.3711.521×age (years), r2=0.38 and 6mst (steps) females =179.567-1.065×age (years), r2=0.23. discussion the present study established normative values for the number of steps climbed during the 6mst in adult participants from india. males climbed more steps than women. this study also provided genderspecific reference equation for the 6mst. the 6mst reference value determined in the study was found to be substantially different from previously reported values.1 short report table 1. baseline characteristics of the participants and results of the six-minute step test. total (n=110) males (n=54) females(n=56) variables mean±standard deviation mean±standard deviation mean±standard deviation age (years) 28.26±6.928** 29.56±7.19** 27.02±6.48** height (cm) 1.65±.057 1.68±.06 1.62±.045 weight (kg) 63.68±9.56 66.82±8.78 60.64±9.36 body mass index (kg/m2) 23.35±3.10 23.74±2.68 22.98±3.45 waist circumference (cm) 90.04±7.70 90.61±6.89 89.50±8.43 hip circumference (cm) 96.67±7.027 96.17±6.48 97.16±7.54 waist hip ratio .93±.04 .94±.03 .92±.045 rate of perceived exertion 4.14±.97 4.33±1.05 3.96±.87 resting heart rate (beats per minute) 79.09±7.04 79.87±7.52 78.34±6.53 post-test heart rate (beats per minute) 126.25±16.47 123.50±16.15 128.91±16.47 pre spo2 (%) 99.00±.62 98.90±.59 99.09±.64 post-test spo2 (%) 98.42±.83 98.42±.77* 98.43±.89 hr max 191.74±6.93** 190.44±7.19** 192.98±6.48** six-minute step count 155.03±16.55 159.42±17.60 150.78±14.39 predicted six-minute step count‡ 184.27±8.50 146.07±8.05 6mst, six-minute step test; hr, heart rate; spo2, oxy-haemoglobin saturation. *p<0.05; **p<0.001; ‡ using arcuri et al.’s equations: male 6mst= 209-[1.05 × age (years)], female 6mst=174[1.05 × age] (years)]. non -co mmerc ial us e o nly the 6mst reference values determined in the study were found to overestimate the step count in indian males by 24.84+15.75 steps and underestimate in females by 4.73+13.93 steps. the discrepancies may have been due to geographic and ethnic variability as ethnicity influences physical fitness test performance.12 anthropometric characteristics of participants may also differ, as asians have a higher body fat percentage for the same age, gender, and bmi when compared to the european white population.13 also, the participants included in the present study were non-obese and adults of 18-40 years. we did not want to dilute the sample by merging young adults and older adults due to physiological alterations with advancing age. age and gender were found to have an association with 6mst.14 there was a significant negative association of 6mst count with age in the total population, males as well as females in agreement with the previous study.15 age was the predominant variable in the regression equation as well. the 6mst values decreased in a linear fashion with respect to the increase in age. this may probably be due to the reduced lower limb muscle strength. although we included normal individuals in our study, this could be attributed to normal age-related changes in the musculoskeletal systems. other age-related anthropometric and physiological changes, such as increased passive tissue stiffness, aerobic and anaerobic capacity, due to reduced cardiovascular function and alterations in oxidative capacity, also, skeletal muscle structure and function may contribute to the decline in test performance.16,17 there was a significant difference in the 6mst values between males and females. the participants, both men and women, in our study were independent. certain physiological variances between the genders, such as body composition, cardiovascular, and lung function, may affect performance.18 the participants in the present study reached an average of 65.84% of their hr max% predicted. on the contrary, there was no correlation of 6mst with weight, waist and hip circumference, bmi as all our participants were non obese and healthy.10 thirty-eight percent and 23% of variance was explained in males and females respectively for 6mst, this put forth the need for future large multicenter studies with the inclusion of varied age, weight, and other anthropometric data categories. limitations this study was limited by several factors. we had a nonrandom sampling method but stringent selection criteria to prevent the risk of bias. finally, we did not evaluate additional probable variables such as peripheral muscle strength, or body fat composition. also, the prospective validity of the developed equation was not checked. conclusions this study brings an important contribution as region-specific reference values are needed for use in clinical settings. arcuri et al.’s equation cannot be used to predict the 6mst in indian adults. the region-specific values will provide a better interpretability for clinicians to use for assessment and rehabilitation purposes. the new gender-specific regression equations are expected to prove useful for assessment and rehabilitation in indian adults. references 1. arcuri jf, borghi-silva a, labadessa ig, et al. validity and reliability of the 6-minute step test in healthy individuals: a cross-sectional study. clin j sport med 2016;26:69-75. 2. grosbois jm, riquier c, chehere b, et al. six-minute stepper test: a valid clinical exercise tolerance test for copd patients. int j copd 2016;11:657-63. 3. dourado im, santos pb, goulart cl, et al. is the six-minute step test able to reflect the severity and symptoms based on cat score? heart lung 2023;58:2833. 4. patel s, jones se, walsh ja, et al. the six-minute step test as an exercise outcome in chronic obstructive pulmonary disease. ann am thorac soc 2023;20:476-9. short report figure 1. the bland-altman representation of measured and predicted six-minute step test using arcuri et al.’s equation 6mst (steps) females = female 6mst=174[1.05 × age] (years)]. 6mst= six-minute step test. figure 2. the bland-altman representation of measured and predicted six-minute step test using arcuri et al.’s equation 6mst (steps) males =209-[1.05 × age (years). 6mst= six-minute step test. [page 92] [healthcare in low-resource settings 2023; 11:11332] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11332] [page 93] 5. marinho rs, jürgensen sp, arcuri jf, et al. reliability and validity of six-minute step test in patients with heart failure. braz j med biol res 2021;54:e10514. 6. magalhães mgs, teixeira jb, santos amb, et al. construct validity and reproducibility of the six-minute step test in subjects with obstructive sleep apnea treated with continuous positive airway pressure. j bras pneumol 2020;46:e20180422. 7. ritt lef, darzé es, feitosa gf, et al. the six-minute step test as a predictor of functional capacity according to peak vo2 in cardiac patients. arq bras cardiol 2021;116:889-95. 8. green sb. how many subjects does it takes to do a regression analysis. multivariate beahvioral research 1991:26(3):499-510. 9. 6 minute step test. ats. available from: htps://www.thoracic.org/members/asse mblies/assemblies/pr/videos/6-minutestep-test.php 10. de oliveira tmd, oliveira cc, albuquerque vs, et al. performance, metabolic, hemodynamic, and perceived exertion in the six-minute step test at different heights in a healthy population of different age groups. motriz rev educ fis 2021;27. 11. singh sj, puhan ma, andrianopoulos v, et al. an official systematic review of the european respiratory society/american thoracic society: measurement properties of field walking tests in chronic respiratory disease. eur respir j 2014;44:1447-78. 12. vaish h, chorsiya v. influence of parity on six-minute walk test in indian females. health care women int. 2023;44(6):753-763 13. clemente fm, manuel f, martins l, nikolaidis pt. association between physical activity patterns and anthropometric characteristics of adults: an issue of public health? 2017;9:124-32. 14. muhammed g, kibria a. using asian and world health organization cutoffs among adults in nepal: analysis of the demographic and health survey 2016. obes res clin pract 2019;1-8. 15. albuquerque vs, dal corso s, amaral dp, et al. normative values and reference equation for six-minute step test to evaluate functional exercise capacity: a multicenter study. j bras pneumol 2022;48:e20210511. 16. hawkins s, wiswell r. rate and mechanism of maximal oxygen consumption decline with aging: implications for exercise training. sports med 2003;33:877-88. 17. wanderley fa, silva g, marques e, et al. associations between objectively assessed physical activity levels and fitness and self-reported health-related quality of life in community-dwelling older adults. qual life res 2011;20:1371-8. 18. harms ca, cooper d, tanaka h. exercise physiology of normal development, sex differences, and aging. compr physiol 2011;1:1649-78. short report non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2018; 6:6361] [page 1] assessment of nutritional status and its associated factors among people affected by human immune deficiency virus on antiretroviral therapy: a cross sectional study in siltie zone, south ethiopia mewuba shamil saliya,1 telake azale,2 atinkut alamirrew,2 dawit jember tesfaye3 1maternal and child health core process, south nation, nationalities and people regional state health bureau, hawassa; 2institute of public health, college of medicine and health sciences, university of gondar, gondar; 3department of epidemiology, school of public health, college of medicine and health sciences, hawassa university, hawassa, ethiopia abstract ethiopia is among the countries most affected by malnutrition and nutrition-related complications remain a challenging issue for human immunodeficiency virus (hiv)infected patients and those involved in their care. the aim of this study was to assess nutritional status among hiv positive adults in south ethiopia and assess risk factors for malnutrition in this population. institution based cross sectional study was conducted among 428 hiv positive adults who are taking art at 12 health centers, silte zone, ethiopia. convenience sampling technique was used to select the study participants. structured questionnaire and anthropometric measurements were used to collect data. data were analyzed using spss version 20.0 software. bivariate and multivariate analyses were used to identify predictors of malnutrition. p-value less than 0.05 were used as cut of point to declare statistical significance. prevalence of chronic energy deficiency was 24.1%. food insecurity [aor= 0.35, 95% ci (0.21, 0.62)], feeding ≤ 2 meals/day [aor= 0.29, 95% ci (0.29, 0.13)], ambulatory functional status [aor= 3.4, 95% ci (1.67, 6.98)] and absence of dietary counseling [aor= 1.7, 95% ci (1.05, 2.78)] were found to be independent predictors of chronic energy deficiency among hiv positive adults. prevalence of malnutrition was high among hiv infected adults who are on art in the study area. regular nutritional assessment of the patients and dietary counseling should be integrated with routine care for hiv/aids patients. hiv/aids prevention and control programs need to involve nutritionists or trained health care provider to integrate nutritional care services. introduction the emergence of human immunodeficiency virus (hiv) epidemic is one of the biggest public health challenges the world has seen in recent history.1 in the last three decades hiv has spread rapidly and affected all sectors of ethiopian society. recently, although the global incidence of hiv infection has stabilized and begun to decline in many countries with generalized epidemics, it varies widely between regions. not all regions and countries fit the overall trends. furthermore, the annual number of people newly infected with hiv has risen in the middle east and north africa from 43 000 in 2001 to 59 000 in 2010. countries in the sub saharan africa (ssa) are home to the majority of all people living with hiv in the world.1,2 in many developing countries, especially in ssa; hiv/aids and malnutrition are both prevalent than other parts of the world.3 a significant proportion of patients who require art are malnourished because of low energy intake combined with increased energy demands due to hiv and other related infections, which is associated with increased resting energy expenditure. food insecurity can lead to macronutrient and micronutrient deficiencies, which can affect both vertical and horizontal transmission of hiv, and contribute to immunologic decline; poor treatment outcome and increased morbidity and mortality among those already infected with the disease.3-6 ethiopia is the second most populous country in africa with an estimated population of 83 million, of which over a third (32.7%) live below the absolute poverty line and largely affected population by malnutrition and hiv/aids. although the rate of new infections shows more than a 25% decline, it is still high and possibly expanding to newer population groups and geographic areas. ethiopian demographic and health survey 2011 data shows an overall prevalence of 1.5% among the general population and an estimate show as nearly 800,000 are living with hiv; more are orphaned.7,8 there is no single defining pathophysiology to aids wasting. however, protein metabolism is abnormal in hiv-infected individuals and there are situations such as severe rapid weight loss, failure to respond to nutrition support and inability to achieve adequate energy intake, in which combined use of anabolic agents may be indicated. micronutrient deficiencies, body weight loss, and wasting in advanced hiv disease are caused by a similar combination of decreased food intake or chronic food insecurity, catabolic state induced by opportunistic infections (oi) or malignancy, prolonged fever and depressive syndrome. acute wasting tends to be associated with secondary infections (oi) and chronic wasting is associated with gastrointestinal disease. a decrease in the rate of hiv infection–related wasting has been reported in the era of highly active antiretroviral therapy.6,9,10 adequate nutrition increases resistance to infection and disease, improves energy, and thus makes a person stronger and more productive and is also necessary to treat malnourished hiv patients. people who are infected with hiv require more healthcare in low-resource settings 2018; volume 6:6361 correspondence: dawit jember tesfaye, school of public health, college of medicine and health sciences, hawassa university, p.o. box 1560, hawassa, ethiopia. tel.: +251.912.17.31.29. e-mail: devanhijember@gmail.com key words: nutritional status; chronic energy deficiency; hiv positive; antiretroviral therapy. acknowledgements: university of gondor gave ethical clearance for the study. the authors appreciate the study participants for their cooperation in providing the necessary information. the authors acknowledge the local administrators and the community for their strong support during the study. conflict of interest: the authors declare that they have no competing interest. contributions: ms conceived the study and was involved in the design, coordination, field supervision and report writing. ta and aa were involved in providing advice during proposal preparation, report writing and reviewed the draft manuscript. dj participated in data analysis and drafted the manuscript. all authors read and approved the manuscript. funding: none. received for publication: 25 october 2016. revision received: 2 february 2017. accepted for publication: 26 april 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.s. saliya et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:6361 doi:10.4081/hls.2018.6361 non -co mmerc ial us e o nly nutrients to compensate for poor absorption, adverse drug effects, frequent diarrhea, nausea and recurrent opportunistic infections.11-13 despite implementing different programs to control and prevent hiv/aids, new hiv infection is still widespread with subsequent progression to aids and death. nutrition-related complications remain a challenging issue for hiv-infected patients and for those involved in their care.10,14,15 to improve the nutritional status of hiv positive individuals, designing and implementing proper intervention is vital. this requires sufficient evidence and context specific knowledge. in ethiopia, however, there is little evidence regarding nutritional status of hiv positives. in addition, factors associated with malnutrition mainly food security status and dietary pattern and habit among peoples’ living with hiv/aids receiving art in the study area is far from complete. therefore, this study aimed to assess the nutritional status and associated factors among hiv positive adults who are taking antiretroviral therapy at silte zone, south ethiopia. materials and methods study design and setting institution based cross sectional study was conducted from september to october 2015 in 12 health centers of siltie zone. the zone has 34 health centers and 1067 health workers, and providing health services for the total of 873,854 populations. out of the total public health facilities, only 12 health centers are providing services for 1116 patients on pre art and 653 patients on art. nutrition intervention activities include, 131 outpatient therapeutic feeding programs, 13 stabilization centers (sc) to manage severely malnourished children including hiv infected children and 127 community based nutrition kebeles (smallest administrative unit) for early detection and prevention of malnutrition among children. selection of study participants the study population comprised of hiv positive adults attending art clinic for follow up visit at the health centers of siltie zone. single population proportion formula was used to calculate the sample size with the assumption of 25.5 % prevalence of under nutrition among hiv infected adults,16 with 95% confidence level and 4 % tolerable error. the sample size yield was 456. the calculated sample size was allocated to twelve health centers using probability proportional to size. convenience sampling technique was used to select the study participants. hiv positive adults’ ≥ 18 years of age and had base line or recent cd4 counts during the data collection period were included in the study. patients who were seriously ill and unable to talk were excluded from the study. data collection procedure data were collected using structured questionnaire adapted from different literatures,16-23 and weight and height measurements. medical records were reviewed for who clinical stage, cd4 count and opportunistic infections. the questionnaire contained sociodemographic and economic characteristics, hiv and nutritional history, medical and psychological condition, dietary habit and household food security status questions. the questionnaires was prepared in english and translated into amharic language and back translated into english to check its consistency. the amharic version was used for data collection. measurements participant height was measured by using standio-meter. the subjects were asked to remove their shoes, stand erect and look straight in horizontal plan. the shoulder blades, buttocks and the heel touch the standing measuring board. height was recorded to the nearest 0.1cm. weight was measured by using beam balance. the scale was checked at zero before each measurement. the subjects were asked to remove heavy clothes and weight measurement was recorded to the nearest 0.1kg. five health officers and 12 nurses collected the data and three senior staffs supervised the data collection process. respondent nutritional status was classified as normal if the bmi was between 18.5 24.99 kg/m2. participants with severely low bmi (<16.00 kg/m2), moderately low bmi (16.00 16.99 kg/m2) and mildly low bmi 16.00 16.99 kg/m2) were categorized as malnourished. food security was assessed by using 6-item module during the last 30 days and the sum of affirmative responses to the six questions. the questions includes whether they did not have money to get food; afford to eat balanced meals; ever cut the size of meals or skip meals and how many days did this hap article table 1. socio demographic characteristics and chronic energy deficiency status of hiv positive adults who are on art, siltie zone, south ethiopia, 2015. chronic energy deficiency yes n (%) no n (%) total n (%) age (years) 18-24 4 (3.9) 9 (2.8) 13 (3.0) 25-34 44 (42.7) 123 (37.8) 167 (39.0) 35-54 52 (50.5) 185 (56.9) 237 (55.4) 55+ 3 (2.9) 8 (2.5) 11 (2.6) sex male 40 (38.8) 116 (35.7) 156 (36.4) female 63 (61.2) 209 (64.3) 272 (63.6) residence urban 27 (26.2) 72 (22.2) 99 (23.1) rural 76 (73.8) 253 (77.8) 329 (76.9) marital status married 59 (57.3) 202 (62.2) 261 (61.0) never married 4 (3.9) 18 (5.5) 22 (5.1) divorced/widowed 40 (38.8) 105 (32.3) 145 (33.9) ethnic group siltie 83 (80.6) 270 (83.1) 353 (82.5) guraghe 17 (16.5) 37 (11.4) 54 (12.6) others 3 (2.9) 18 (5.5) 21 (4.9) occupation unemployed 51 (49.5) 145 (44.6) 196 (45.8) farmer 36 (35.0) 111 (34.2) 147 (34.3) self employed 9 (8.7) 55 (16.9) 64 (15.0) others 7 (6.8) 14 (4.3) 21 (4.9) education no education 60 (58.3) 191 (58.8) 251 (58.6) primary 39 (37.9) 120 (36.9) 159 (37.1) secondary+ 4 (3.9) 14 (4.3) 18 (4.2) [page 2] [healthcare in low-resource settings 2018; 6:6361] non -co mmerc ial us e o nly pen; ever eat less than they felt because there wasn’t enough money for food; every hungry but didn’t eat. the food security status of respondents with raw score 0-1 is coded as food secure and the two categories “low food security” (raw score 2-4) and “very low food security” (raw score 5-6) in combination are classified as food insecure.17 wealth index is a composite measure of household’s cumulative living standard. it is particularly important in countries that lack reliable data on income and expenditures.18 respondents were ranked in to five wealth quintiles based on eight wealth indicator variables (electricity, ownership of agricultural land, ownership of electronics (tv, mobile, frig.), ownership of house and housing condition and toilet facilities. lowest quintile was classified as poorest, second quintile as poor. third quintile was defined as middle economic class. fourth and fifth quintile were classified as high and highest economic classification respectively. data quality control and management the data collectors and supervisors were trained for two days on the objective, basic data collection skills and how to take anthropometric measurements. pretesting of the instrument was made before the commencement of the actual data collection. the data collectors were supervised on daily basis for completeness and consistency of the filled questionnaire. the weight scale was checked against zero reading before weighing every participant. data processing and analysis data were entered to epi info version 3.5.1 and exported to spss version 16 for statistical analysis. descriptive and summary statistics were used to reduce and present the data. bivariate analysis was used primarily to assess association between dependent variable (malnutrition) and the independent variables (age, sex, residence, marital status, ethnic group, occupation, who clinical stage, cd4 count, opportunistic infection, functional status, hiv status disclosure to family, nutritional counseling, food security status, dietary frequency and wealth index). then variables found to have p-value of ≤ 0.2 were fitted in to multivariate logistic regression model to control the possible effect of confounders. finally the variables which have significant association were identified on the basis of odd ratio (or) with 95% confidence interval (95% ci) at p value < 0.05. ethical consideration ethical clearance was granted by institutional review board of institute of public health, college of medicine and health science, university of gondar and official letters was submitted to the snnpr regional health bureau. the regional health bureau ethical review board approved the study and formally notified zonal health departments. supervisors and data collectors were trained on confidentiality. the purpose and importance of the study was explained to the study participants and verbal informed consent was obtained from all participants before starting the interviews or taking body measurements and also they were informed about the freedom to withdraw their participation at any time of data collection. confidentiality of the data were assured and kept anonymously; code number was assigned to the study participants without mentioning the name, the information that was collected during the study was kept in a file and locked with key. participants identified as malnourished were given nutritional advice and support through comprehensive chronic care clinic. results socio demographic characteristics four hundred twenty eight clients participated in the study, making the response rate 93.8%. the mean age of the respondents was 35.7 (sd±8) years. the majority 272 (63.6%) of the participants were female and more than two-third 329 (76.9%) were living in rural areas. three hundred fifty three (82.5%) of the respondents belonged to siltie ethnic group and 359 (83.9%) of the respondents were muslims. housewives accounted for 196 (45.8%) of the respondents. more than half 251 (58.7%) of the participants were without formal education (table 1). medical and psychological conditions of participants two hundred thirty five (54.9%) of the respondents were graded to be at who hiv clinical stage i. concerning cd4 count of the respondents 57(13.3%) had< 200 cells/ul. one hundred and nine (25.5%) of the respondents had opportunistic infection, of which tuberculosis was the leading ill article table 2. past and present medical and psychological history of hiv infected adults who are on art at the health centers of siltie zone, south ethiopia. number % who clinical stage one 235 54.9 two 91 21.3 three 96 22.4 four 6 1.4 cd4 count ≤200 57 13.3 201-350 124 29 351-500 110 25.7 >500 137 32 opportunistic infections yes 109 25.5 no 319 74.5 types of oi tuberculosis 34 31.2 chronic diarrhea 29 26.6 chronic cough 14 12.8 oral/esophageal thrush 11 10.1 prolonged fever 10 9.2 others 11 10.1 functional status working 388 90.6 ambulatory 40 9.4 depressed yes 29 6.8 no 399 93.2 chew chat yes 49 11.4 no 374 88.6 [healthcare in low-resource settings 2018; 6:6361] [page 3] non -co mmerc ial us e o nly ness which accounts for 34 (31.2%) followed by chronic diarrhea 29 (26.6%) and chronic cough 14 (12.8%). twenty nine (6.8%) of the respondent had depression and 49 (11.4%) of the respondents had history of chat chewing. majority 400 (93.5%) of the participants had disclosed their hiv status to their partner or family member (table 2). nutritional status and dietary habit of the respondents the prevalence of chronic energy deficiency (bmi <18.518.5 kg/m2) was 24.1% [95% ci (20%, 28.1%)]. the mean (± sd) bmi of the respondents was 20.27 (± 2.5). out of the total respondents, 325 (76%) had normal nutritional status. severe, moderate, and mild chronic energy deficiency (ced) were detected on 10 (2%), 24 (6%) and 69 (16%) respectively. age group 35-54 (50.5%), female (61.1%), rural by residence (73.7%), unemployed (49.5%), married (57.3%) and with no educational status (58.2%) are the most affected groups (table 1). among the participants with normal bmi, 218 (50.9 %) had a habit eating kocho (false banana) ≥ once/day, 99 (96.1%) and 98 (95.2%) of the respondents had a habit to take meat and fruits ≤ once / week respectively (table 3). factors associated with nutritional status of hiv positive adults food secured hiv positive adults were less likely to be malnourished than patient with food insecurity [aor= 0.35, 95% ci (0.21, 0.62)]. there was statistically significant association between malnutrition and frequency of feeding per day. patient who ate ≥ 3 meals /day were less likely to be malnourished when compared to those who ate ≤ 2 meals /day [aor= 0.29, 95%ci (0.29, 0.13)]. patient who didn’t get dietary counseling were 1.7 times more likely to develop malnutrition than who got the counseling [aor= 1.7, 95% ci (1.05, 2.78)]. patients with ambulatory functional status were 3.4 times more likely to be malnourished than patients with working functional status [aor= 3.4, 95% ci (1.67, 6.98)] (table 4). discussion in many developing countries, especially in ssa; hiv/aids and malnutrition are both highly prevalent than other parts of the world. food insecurity can lead to macronutrient and micronutrient deficiencies and contribute to immunologic decline, increased morbidity and mortality among those already infected with the disease.5 hiv/aids is associated with biological and social factors that affect the individual’s ability to consume, utilize, and acquire food.19 wasting in advanced hiv disease is caused by a similar combination of decreased food intake or chronic food insecurity, catabolic state induced by opportunistic infections or malignancy and functional status of the patient.20,21 in this study, high prevalence of chronic energy deficiency was observed among hiv positive adults receiving art. this prevalence was in line with the study conducted at felege hiwot hospital 25.5%16 and gondar university hospital 27.8%.22 in contrary, the finding of this study was higher than the result reported from meta-analysis (10.3%) conducted by pooling preva article table 3. dietary habit and nutritional status of hiv positive adults who are on art, siltie zone, south ethiopia, 2015. presence of malnutrition yes n (%) no n (%) total n (%) staples (injera with wet) ≤ once /week 68 (66.0) 228 (70.2) 296 (69.2) twice /week 12 (11.7) 31 (9.5) 43 (10.0) ≥ once/day 23 (22.3) 66 (20.3) 89 (20.8) false banana (kocho) ≤ once /week 38 (36.9) 99 (30.5) 137 (32.0) twice /week 1 (1.0) 8 (2.5) 9 (2.1) ≥ once/day 64 (62.1) 218 (67.1) 282 (65.9) whole milk ≤ once /week 84 (81.6) 240 (73.8) 324 (75.7) twice /week 10 (9.7) 45 (13.8) 55 (12.9) ≥ once/day 9 (8.7) 40 (12.3) 49 (11.4) meat ( fish, beef/chicken) ≤ once /week 99 (96.1) 299 (92.0) 398 (93.0) twice /week 4 (3.9) 17 (5.2) 21 (4.9) ≥ once/day 0 (0.0) 9 (2.8) 9 (2.1) grains (peas & beans) ≤ once /week 40 (38.8) 106 (32.6) 146 (34.1) twice /week 18 (17.5) 64 (19.7) 82 (19.2) ≥ once/day 45 (43.7) 155 (47.7) 200 (46.7) fruits /fruit juice ≤ once /week 98 (95.1) 316 (97.2) 414 (96.7) twice /week 3 (2.9) 4 (1.2) 7 (1.6) ≥ once/day 2 (1.9) 5 (1.5) 7 (1.6) vegetables ≤ once /week 41 (39.8) 110 (33.8) 151 (35.3) twice /week 5 (4.9) 26 (8.0) 31 (7.2) ≥ once/day 57 (55.3) 189 (58.2) 246 (57.5) table 4. factors associated with malnutrition among hiv positive adults who are on art, siltie zone, south ethiopia, 2015. presence of malnutrition predictors yes n(%) no n(%) cor, 95%ci aor, 95%ci food security food secured 21 (12.9) 142 (87.1) 0.33 (0.19, 0.56) 0.35 (0.21, 0.62) food insecure 82 (30.9) 183 (69.1) 1 1 dietary counseling yes 57 (19.9) 230 (80.1) 1 1 no 46 (32.6) 95 (63.4) 1.9 (1.24, 3.10) 1.7 (1.05, 2.78) functional status working 85 (31.3) 303 ( ) 1 1 ambulatory 18 ( ) 22 ( ) 2.9 (1.45, 5.69) 3.4 (1.67, 6.98) meal frequency ≤ 2/day 95 (26.5) 263 (73.5) 1 1 ≥ 3/day 8 (11.4) 62 (88.6) 0.36 (0.16, 0.77) 0.29(0.20, 0.82) [page 4] [healthcare in low-resource settings 2018; 6:6361] non -co mmerc ial us e o nly lence estimate of 11 sub-saharan african countries between 2003 and 2006.23 this difference could be in the meta-analysis hiv infected women who are not on art were included which could be undermining the prevalence since they are at lower risk of developing wasting than who are on art. in a study done at botswana, the prevalence of malnutrition among hiv infected adults was reported 30% which is higher than the finding of this study. study from miami, florida.24 reported lower prevalence of ced (17.6%) than the current study. this might be due to the difference in the general living condition and socio cultural characteristics of the countries. hiv associated wasting has a strong association with food insecurity which can lead to decreased food intake. this study revealed that, food security status was associated with lower risk of malnutrition. in line with this, lower risk of malnutrition was observed among hiv positives with high meal frequency. these findings are consistent with the study conducted in sub saharan africa which have shown malnutrition among hiv infected adult is common among population with food insecurity and hiv positive experience low diet quality and quantity.5,6 functional status of a patient is a proxy indicator of the underlying medical condition in which patients with deteriorated functional status could have a compromised health status which may result in increased losses of nutrient, decreased productivity and food intake which farther compromise the nutritional status of the patients.21,25 the finding of this study showed positive association between ambulatory functional status and chronically energy deficiency. this finding was inline with the study finding from south india where hiv infection affect the individual’s ability to consume adequate quality and quantity of meals and thus can decrease the working capacity of hiv positive individuals.26 hiv positive adults especially those who are on art are at higher risk of developing drug side effects and drug-food and nutrient interaction which can affects the individual’s ability to consume and utilize the required nutrients. nutrition counseling is necessary to decrease the effect of these problems on infected individuals.11-13 in this study, hiv positive adults who didn’t get dietary counseling were 1.7 times more likely to develop malnutrition than those who got the dietary counseling. this finding is supported by the study conducted in south india which has shown macronutrient supplementation alone did not result in significantly increased weight gain without counselling.26 in the present study, opportunistic infection, who clinical stage, sex and income of the participants were not associated with ced. this could be attributed to the difference in study setting; patient who present at referral hospital level are at advanced clinical stage and with low cd4 counts which makes the individuals more susceptible to hiv associated infections. study findings from felege hiwot and gondar university hospitals, north ethiopia16,22 showed that as there are 85.8% and 74% of the respondents were at clinical stage iii and iv respectively. conclusions the prevalence of chronic energy deficiency was high in the study area. hiv positive adults with food insecurity, ambulatory functional status, who feed ≤ 2 meals /day and didn’t get dietary counseling were more likely to be malnourished. regular nutritional assessment of the patients and dietary counseling should be integrated with routine care for hiv/aids patients. hiv/aids prevention and control program need to involve nutritionist or trained health care providers to integrate nutritional care services. hiv related symptoms and other medical conditions should be treated as soon as possible to improve the functional status of patients. developing income generating activities and other sectorial programs are required to improve and ensure food security and adequate meals intake of hiv positives. further longitudinal study to understand the effect of cd4, who clinical staging disclosure status of patient and, depression on nutritional status of hiv positive adults is forwarded. references 1. united nations program on hiv/aids. report on the global aids epidemic, unaids; 2010. 2. world health organization. global hiv/aids response: epidemic update and health sector progress towards universal access: progress report; 2011. 3. world health organization. nutrient requirements for people living with hiv/aids: report of a technical consultation. geneva: world health organization; 2003 4. lisa k. energy expenditure in hiv infection. am j clin nutr 2011;94: 1677s-82s. 5. john r, douglas c. nutritional aspects of hiv-associated wasting in subsaharan africa. am j clin nutr 2010;91:1138s-42s. 6. weiser s, bangsberg d, kegeles s, et al. food insecurity among homeless and marginally housed individuals living with hiv/aids. aids behav 2009;13:841-8. 7. federal democratic republic of ethiopia. country progress report; 2012. 8. international central statistical agency and ethiopia demographic and health survey. cent. stat. agency, addis ababa, ethiopa. calverton, maryland, usa: icf international; 2011. 9. derek c. clinical trials for the treatment of secondary wasting and cachexia. j nutr 1999;129:238s-42s. 10. wanke c. nutrition and hiv in the international setting. nutrition clin care 2005;8:44-8. 11. de pee s, semba r. role of nutrition in hiv infection: review of evidence for more effective programming in resource-limited settings. food & nutr bull 2010;31:313s-44s. 12. laurence a, chantal u, helena h, et al. nutrition outcomes of hiv-infected malnourished adults treated with readyto-use therapeutic food in sub saharan africa. food & nutr bull 2010;31:287s-364s. 13. federal democratic republic of ethiopia, federal hiv/aids prevention and control office. report on progress towards implementation of the un declaration of commitment on hiv/aids; 2010. 14. louise c, kimberly a, kenneth a, et al. hiv/aids, under nutrition, and food insecurity. oxford j med clin infect dis 2009;49:1096-102. 15. mangili a, murman d, zampini a, et al. nutrition and hiv infection: review of weight loss and wasting in the era of highly active antiretroviral therapy. clin infect dis 2006;42:83642. 16. daniel m, mazengia f, birhan d. nutritional status and associated factors among adult hiv/aids clients in felege hiwot referral hospital, bhir dar, ethiopia. sci j public health 2013;1:24-31. 17. stephen j, karil b, william l, ronette r. the effectiveness of a short form of the household food security scale . am j public health 1999;89:1231-4. 18. rutstein s, kiersten j. the dhs wealth index. dhs comparative reports no. 6. calverton, maryland, usa: orc macro; 2004. 19. shalini d, tulsi d, ashish k. hiv and malnutrition: effects on immune system. clin development immunol article [healthcare in low-resource settings 2018; 6:6361] [page 5] non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2018; 6:6361] 2012;784740. 20. world health organization. executive summary of a scientific review: an update, who regional consultation on nutrition and hiv/aids. who; 2007. 21. spiegelman d, drain p, mwiru r, et al. predictors of weight loss after haart initiation among hiv-infected adults. aids 2012;26:577-85. 22. wasie b, kebede y, yibrie a. nutritional status of adult living with hiv/aids at the university of gondar referral hospital, north west ethiopia. etiop j health biomed sci 2010;3:3-14. 23. olalekan a. prevalence and pattern of hiv-related malnutrition among women in sub-saharan africa: a metaanalysis of demographic health surveys. bmc public health 2008;8:226. 24. adriana c, yang z, shenghan l, et al. hiv-related wasting in hiv-infected drug users in the era of highly active antiretroviral therapy. clin infect dis 2005;41:1179-85. 25. desta k. the pattern of immunologic and virologic responses to highly active antiretroviral treatment (haart): does success bring further challenges? ethiop j health dev 2011;25:61-70. 26. swaminathan s, padmapriyadarsini c, yoojin l, et al. nutritional supplementation in hiv-infected individuals. clin infect dis 2010;51:517. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:5067] [page 5] a minimalist technique for insertion of intrauterine devices norman david goldstuck department of obstetrics and gynaecology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, south africa abstract the world’s population is approaching 7 billion. as a general rule, the countries with the highest population have the least available healthcare resources, the most notable exception being the united states of america (usa). most of these countries have an urgent need to reduce their populations. the intrauterine device (iud) is used by the largest number of contraceptives world-wide and it has a proven record in reducing unwanted pregnancies. its efficacy rate as a long-acting reversible contraceptive is matched only by subdermal implants which are not as cost effective. although the rates of pelvic infection are elevated in many countries with low-resource health care systems, we now know that pelvic infection rates are independent of iud usage. this is therefore no longer a contraindication for using iuds on a large scale in family planning programs. the technique of iud insertion as described in most textbooks and journals is unnecessarily complex and based on ritual rather than good clinical evidence. this is particularly interesting in that at a time where we prefer evidence based medicine there are still so many clinical practice sacred cows. this article advocates a simplification of the technique for inserting iuds. the scientific rationale for simplifying the technique is presented, as well as evidence that it is as safe if not safer than the currently suggested methods, if used for the correct type of iud acceptors. introduction the instruments which are used for inserting iuds are historically those used for gynaecological procedures. during these procedures the subject is usually anaesthetised or provided with analgesia. this is not usually the case with iud insertion, especially in low resource settings. thus, an allis forceps1-4 may be preferable to using a sharp toothed tenaculum as it prevents the iud provider from attempting the insertion too forcefully as it will lose grip if more than 6 n of force are applied while it is attached to the cervix.5 it thus acts as a safety-valve to the use of excessive force, and causes less pain than a conventional single toothed tenaculum. the correct time for inserting an iud is there and then.6 there is no time during the menstrual cycle that an iud cannot be placed in a suitable candidate, and some compelling reasons why insertions at times other than during the menstrual period may be preferable.6 technical note other than the iud itself, the minimalist technique requires only 3 pieces of equipment: i) a sterilised or disposable speculum, ii) an allis forceps (preferably) or a sharp toothed tenaculum, also sterilised and iii) a scissors (preferably long and curved in that it does not come into contact with body tissue at any stage so that it only needs to be surgically clean). additionally, some disinfectant solution, e.g. povidone-iodine and cotton ball swabs are required. these are shown in figure 1. discussion this technique is designed to ensure the fastest, most comfortable, and quickest way to ensure an intrauterine device is placed. it is assumed that at least a perfunctory history has been taken this may take only 2-3 minutes. a detailed pelvic examination for screening for general gynaecological examination is not performed. the assumption is made that it has either recently been completed or that resources are so limited that the necessary testing, e.g. pap smears, bacteriology etc. is not available and only resources for family planning are. this technique is applicable for interval insertion (insertion at least 8 weeks post-partum or post-abortion only). it should be used with great caution in women who are lactating or have been on injectable contraception for over 12 months since these women are known to be more susceptible to uterine perforation.7 the only equipment which is needed is shown in figure 1. either a disposable or a sterilised speculum can be used, as well as the remainder of the instruments as previously described. a rapid pelvic examination will exclude pelvic infection, gross uterine or adnexal abnormalities and give an indication of the position of the uterus. the next steps are as follows. first, insert the speculum and view the cervix. the position of the cervix will very often confirm if the uterus is anteverted or retroverted. second, using the allis forceps hold the back of a cotton-ball swab and dip it into a povidine-iodine disinfectant solution, or equivalent. swab the cervix. third, withdraw the marker on the iud stem (the one that is usually set to uterine length) and insert the iud until the fundus is felt, in the same way one would do when using a uterine sound. release the device into the cavity using the mechanism appropriate for the device. fourth, cut the threads to the appropriate length and remove the speculum. this technique omits the sounding of the uterus which is considered a quintessential procedure before iud insertion for which there is no one established piece of evidence.8 there are no controlled studies with or without the use of a uterine sound before iud insertion. here are some reasons why sounding is not advisable. first, it is possible to perforate the uterus in vitro with a metal sound with 20 n of force. second, it is not possible to perforate the uterus in vitro with most types of iud as they will bow.8 the degree of bowing is however unknown for the mirena®. third, uterine sounding for establishing total uterine axial length is an inherently geometrically useless operation.9 it is the attempt to make a one dimensional assessment of a three dimensional organ (the uterus), before inserting a two dimensional product (the iud). fourth, a simple understanding of geometry and topology will make obvious that in this situation, uterine sounding is more a ritual than a scientific procedure. uterine sounding may however be of some limited value prior to insertion of the gyne fix iud, because it is a one dimensional device. sounding with metal sounds has been shown to be inaccurate.9 this inaccuracy may lead to an inaccurate placement of the iud so that it is not placed at the uterine fundus which makes it more likely that the device will be expelled, or if its position in the uterine cre healthcare in low-resource settings 2015; volume 3:5067 correspondence: norman david goldstuck, department of obstetrics and gynaecology, faculty of medicine and health sciences, stellenbosch university and tygerberg hospital, cape town, western cape 7505, south africa. tel: +27.823418200. e-mail: nahumzh@yahoo.com key words: intrauterine device; insertion; gynaecology. received for publication: 24 january 2015. accepted for publication: 24 january 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright n.d. goldstuck, 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5067 doi:10.4081/hls.2015.5067 non co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2015; 3:5067] ates sufficient asymmetrical uterine muscle forces than embedment, partial or complete perforation may be the result.7 conclusions this technique can be used by all iud providers with confidence in women who have had children. while the intrauterine device has been shown to be appropriate for nulliparous women, this technique should only be used by very experienced providers in the nulliparous group. by using this method and inserting iuds with lifetimes of 10 years and more large numbers of women in low resource countries could receive adequate contraception at minimal cost as it is possible to get the tcu 380a from some manufacturers for as little as $10 for bulk purchases. a minimal amount of mainly re-useable instruments has only ongoing costs related to re-processing. there is a minimal cost of consumables. finally, the ability to perform insertions this way very rapidly produces staff cost savings. references 1. department of economic and social affairs, population division of the united nations. world contraceptive use 2007. available from: http://www.un.org/esa/population/publications/contraceptive2007/co ntraceptive2007.htm 2. winner b, peipert jf, zhao qiuhony z, et al. effectiveness of long-acting reversible contraception. new engl j med 2012;36:1 998-2007. 3. farley tm, rosenberg mj, rowe pj, et al. intrauterine devices and pelvic inflammatory disease: an international perspective. lancet 1992;339:785-8. 4. goldstuck nd. insertion of intrauterine devices: some technical considerations. practitioner 1979;223:647-51. 5. goldstuck nd. insertion forces with intrauterine devices: implications for uterine perforation. eur j obstet gyn r b 1987;25:315-23. 6. whiteman mk, tyler cp, folger sg, et al. when can a woman have an intrauterine device inserted? a systematic review. contraception 2013;87:66-73. 7. goldstuck nd, wildermeersch d. role of uterine forces in intrauterine device embedment, perforation and expulsion. int j womens health 2014;6:735-44. 8. goldstuck nd. ‘bowing’ forces with iud insertions in vitro: reference to difficult iud insertions. clinical rep fertil 1987;5:173-6. 9. goldstuck nd. the mark 7 sound an accurate determinant of uterine axial length. contraception 1979;20:359-65. technical note figure 1. layout of all the instruments and appliances needed for minimalist intrauterine device insertion. non co mmerc ial us e o nly hrev_master [page 12] [healthcare in low-resource settings 2017; 5:5932] building resilient and responsive health systems for geriatric care in india sandul yasobant,1 kranti vora,2 deepak saxena2 1center for development research (zef), university of bonn, germany; 2indian instititue of public health, gandhinagar, india dear editor, currently, more than 12% of the world’s elderly population lives in india. the demographic trends suggest that between the years 2000-2050, the indian population in their 60s and above will increase by 326%, while those in the age group of 80+ will increase by 700% – the fastest growing group.1 with this demographic transition, very soon india might become a grey nation. as a consequence, the proportion of disease burden contributed by cancers, cardiovascular conditions, diabetes, musculoskeletal disorders and neurological disorders such as dementia, hearing and vision loss, is expected to increase.2 therefore, we aimed to do a situational analysis and identify opportunities to build resilient health system for better geriatric care in india. overview of the indian health system indian health system is presently struggling with rapidly changing demographics and disease burden. underfinancing, shortage of skilled human resource for health are one of the greatest challenges to respond to changing priorities.3 currently, we are passing through a stage of epidemiological mosaic with an unfinished agenda of infectious diseases and maternal, child health problems with an added burden of noncommunicable diseases due to aging population. indian health system has responded to these changes, but in addition to limited public health infrastructure there are also issues such as geographical vastness, sociocultural diversity and rural-urban differences throughout the nation.4 in addition to infrastructure issues dogging public sector there is a vast private sector in india that caters to more than two thirds of health services. a mixed health care market of public and private providers is a reality as india is an under-resourced country with respect to human resources for health.5 because of limited access in public sector, formal and informal private providers remain the main source for primary health care services in india.6 current geriatric care system in india geriatrics health care in india is in its nascent stage. indian government has focused on rural healthcare since independence and developed a three tier healthcare delivery system to improve access in remote areas by providing primary care at the village level, secondary care at the subdistrict and district levels, and tertiary care at the regional level. medical colleges are developed as apex institutes with specialties. neither infrastructure wise nor by skilled training of human resources, these three tier system healthcare services are geared for geriatrics care except in few apex institutes. to improve public sector capacity for health services targeted for elderly, the govt. of india has implemented a national level health program called national programme for the health care for the elderly (nphce) in 2011.7 nphce program focused on development of regional geriatric centers (rgc), specific geriatric ward, training of health personnel in geriatric healthcare and conducting research including postgraduate degree in geriatric medicine in the rgcs.8 opportunities to build a resilient geriatric care system in india currently, indian health system has a mixed market and there are ample opportunities if private providers are included into the current strategies of planning for universal health care. unfortunately, for the geriatrics care in reference to nphce, there is no concept of public-private mix. we propose that public-private mix could be a potential strategy to improve access to geriatric care with available resources and it could lead to building a responsive health system. we use relevant resilient health system criteria9 to propose strategies to build the same for geriatric care in india. first, systems awareness: developing an up-to-date map of resources available including private sector and not limiting to rgcs. mapping would help identify resource gaps in human, physical, and information and help in efficient planning and monitoring. second, system diversity: geriatric care services should address a broad range of health services needs starting from curative to preventive services in a comprehensive package for each tier. third, systems integration: geriatric care should be integrated with allied sectors like old-age homes, education department etc. as geriatric care requires multidisciplinary team, integration with other sectors is vital for holistic and culturally appropriate care. fourth, system adaptation: as the current system does not have geriatric care as a focus area, once that has been achieved, system should be able to adapt to any shocks. health system resilience has been well understood only after the ebola out-break,10 similarly it is important to build such system for geriatric care in india. improved system would be able to withstand any upcoming challenges. in the current health system scenario of india and given the magnitude of the service provision in this country of billions, it is important to take baby steps towards building responsive and resilient system for the elderly. it seems a daunting task but indian health system has adapted in the past and can continue to do so in its endeavor to provide universal health care. references 1. verma r, khanna p. national program of health-care for the elderly in india: a hope for healthy ageing. int j prev med 2013;4:1103–7. 2. thakur r, banerjee a, nikumb v. health problems among the elderly: a cross-sectional study. ann med health sci res 2013;3:19–25. 3. kumar jr. role of public health systems in the present health scenario: key challenges. indian j publ health 2013;57:133–7. healthcare in low-resource settings 2017; volume 5:5932 correspondence: sandul yasobant, center for development research (zef), walter flex str.3, 53113 bonn, germany. tel: +49-162-161-0570. email: dryasobant@gmail.com key words: resilient health systems; responsive health systems; geriatric care; india. contributions: sy, kv, ds equally contributed to the manuscript. conflict of interest: the authors declare no potential conflict of interest. received for publication: 13 april 2016. revision received: 28 february 2017. accepted for publication: 17 march 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s. yasobant et al., 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:5932 doi:10.4081/hls.2017.5932 non co mmerc ial us e o nly [healthcare in low-resource settings 2017; 5:5932] [page 13] 4. engelgau mm, el-saharty s, kudesia p, et al. capitalizing on the demographic transition: tackling noncommunicable diseases in south asia. washington, dc: world bank; 2011. 5. srinivisan r. health care in indiavision 2020: issues & prospects. new delhi, india: government of india, planning commission of india; 2010. 6. alok m. public-private partnership in the health sector in india. public-private partnerships. 2000. available from: uhrc.in/uhgateway/documents/1073.pdf 7. indian ministry of health and family welfare. national programme for the health care of the elderly (nphce): an approach towards active and healthy ageing. new dehli: directorate general of health services, ministry of health and family welfare, government of india; 2011. 8. indian ministry of health and family welfare. national programme for the health care of the elderly. operational guidelines. new dehli: ministry of health and family welfare, governement india; 2011. 9. maresso a, wismar m, greer s, palm w. what makes healthsystems resilient & innovative? voices from europe. eurohealth obs 2013;19:3–6. 10. kruk me, myers m, varpilah st, dahn bt. what is a resilient health system? lessons from ebola. lancet 2015;385:1910–2. letter to the editor non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5447] [page 17] family factors associated with immunization uptake in children aged between twelve and fifty-nine months: a household survey in kakamega central district, western kenya joram l. sunguti,1 penny e. neave,1 steve taylor2 1department of public health; 2department of biostatistics and epidemiology, school of public health and psychosocial studies, auckland university of technology, new zealand abstract in this study, we assessed immunization uptake and identified family factors associated with immunization in children aged between 12 and 59 months in kakamega central, western kenya. a cross sectional study was conducted in 13 sub-locations between june and july 2013. data on 577 children were collected from their respective caregivers, by trained research assistants. the proportion of fully immunized children was 80.9% (95% confidence interval 76.9-85.3%). immunization coverage was higher among caregivers who had completed secondary school (88%), those who had attended antenatal care clinics (81%) and children born in a health facility (85%). some evidence was seen of increasing coverage with increasing socio-economic status. no evidence for a gender difference in coverage was seen. in the logistic regression model, the risk factors for incomplete immunization were: low educational level of the caregiver [adjusted odd ratio (aor)=0.25; p<0.005], never attending any antenatal care (anc) (aor=0.14; p<0.05) and delivery outside of health facilities (aor=0.40; p<0.005). further inquiry is required into this area to fully comprehend the inextricable linkage between factors affecting immunization. introduction in 1974, the world health organization (who) launched the expanded program on immunization (epi) initiative. its aim was to ensure that children aged below 5 years in all countries benefited from vaccination against diphtheria, pertussis, tetanus (dpt), poliomyelitis, measles and tuberculosis. in some countries, more vaccines have now been added to the schedule including hepatitis b, haemophilus influenza type b and yellow fever.1 despite this, in 2013, an estimated 14% of the infants (mostly from low income countries) failed to access three of these vaccines (dpt) during their first year of life.2 in kenya, the ministry of health is charged with the delivery of efficient immunization services, through the division of immunization (dvi) department. within one year of birth, each child should receive one dose of bacillus calmette-guérin (bcg) as protection against tuberculosis, three doses of vaccination against dpt, four doses of oral polio vaccine (opv), three doses of hepatitis b vaccine (hbv), three doses of haemophilus influenza type b vaccine (hib), three doses of pneumococcal conjugate vaccine and one dose of measles vaccine. the dpt, hepatitis b and haemophilus influenza type b vaccines are administered as a pentavalent vaccine.3 despite the aim to vaccinate all children, vaccine-preventable disease outbreaks have been recorded,4 indicating that this is not being achieved. the most recent official estimates support this, with the national coverage being approximated as: bcg 79%; dpt-3 76%; opv 82%; hbv 83%; hib 83%; and measles 79%.5 variations in immunization uptake have been documented in different areas of kenya, with the highest rates being in nandi county (93.9%) and the lowest in mandera (27.7%).6 however, it is acknowledged that there are limitations to the accuracy of all official estimates with possible variations between 8% and 16%.5 a number of factors have been associated with immunization uptake. these include maternal education or literacy,7-9 maternal age at birth,10,11 paternal education level12 and antenatal care utilization during pregnancy.13 children born in a health facility have been found to be more likely to be immunized than those born at home,14,15 but there is no strong evidence that a child’s sex is associated with vaccination uptake.16,17 household characteristics that have been documented to correlate with immunization include socioeconomic status,18 proximity to a health facility19 and whether the household is located in a rural or urban area.20 despite studies showing association between socio-demographic factors and immunization uptake, this relationship is not conclusive. a study in ethiopia failed to show any significant association between immunization and socioeconomic status, maternal age, total number of children, age of the father, education level of the father and sex of the child.13 in kenya, the following factors were not associated with immunization; maternal age, socioeconomic status, partner’s education level, sex of the child and place of delivery.9,19,21,22 this highlights the need for further studies to understand these associations. kakamega county is in a predominately rural area of kenya. the district consists of 13 administrative units, called sub-locations. the average population in each sub-location is 13,000. the main language is luhya followed by swahili and english. the majority of the population is subsistence farmers with a small number of business people working in an urban center. like the other 47 counties, kakamega county has a devolved governance system. each county draws revenue from the central government allocation and levies taxes at the county level. immunization uptake in kakamega county is estimated to be 62.2%.6 however, as is the case with national vaccination uptake estimates, these may not be accurate. clearly, there is a need to gather accurate estimates of complete immunization and the factors associated with this. understanding factors associated with immunization are important in informing stakeholders to implement key healthcare in low-resource settings 2016; volume 4:5447 correspondence: joram luke sunguti, department of public health, school of public health and psychosocial studies, auckland university of technology, 55 wellesley street east, auckland central, new zealand. tel: +64.9.9219779. email: jsunguti@yahoo.com acknowledgements: we acknowledge the participants from kakamega who took time to take part in this study. we also acknowledge the district medical officer of health, the public health officer and all the research assistants from kakamega central for their invaluable support during the research period. we are grateful to the new zealand aid foundation for their funding support. key words: immunization; vaccination; factors; kenya. contributions: jls, study conception, data acquisition and drafting of manuscript; st, design, data analysis and interpretation; pen, critical revision and final approval. conflict of interest: the authors declare no potential conflict of interest. funding: this work was supported by new zealand aid foundation. received for publication: 16 july 2015. revision received: 7 february 2016. accepted for publication: 8 february 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright j.l. sunguti et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5447 doi:10.4081/hls.2016.5447 non co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2016; 4:5447] interventions aimed at improving immunization uptake. the purpose of this study therefore was to measure completeness of immunization uptake and the factors associated with this in children aged between 12 and 59 months living in kakamega county, western kenya. materials and methods a cross-sectional study design was used, specifically a stratified survey of households. it was determined that a sample size of 520 children (40 per sub-location or stratum) was required, based on the recommended single proportion formula for immunization, with a 95% confidence level, 5% margin of error and assuming 80% immunization coverage rate.23 a 5% non-response rate and a design effect of two were considered. inclusion criteria were: a caregiver to a child aged between 12 and 59 months who had lived in the caregiver’s home in kakamega central district for at least six months. in households with two or more children qualifying for inclusion, the youngest was selected. in houses where twins lived, the tossing of a coin determined for which child the information should be collected. all those not meeting the inclusion criteria were excluded from participation. three weeks before data collection began, six research assistants from the district public health office were trained by the principal investigator on the rationale for the study, ethical issues, inclusion and exclusion criteria, the study method and how to record and return the information gathered. five research assistants were public health officers while the other was a health records and information officer. all had attained tertiary level training (diploma and/or degree). two weeks before the study, chiefs, village elders and research assistants made announcements about the study in local schools, churches and market places and encouraged participation. the selection of participants was done through stratified sampling followed by simple random sampling of households within strata. kakamega central district consists of 13 administrative units, called sub-locations. each sub-location constituted a stratum from which households were drawn for the survey. the first household to be visited within each sub-location was selected randomly from a sampling frame listing all households available from the ministry of provincial administration. the person who answered the door was informed about the study and asked if a child in the household met the inclusion criteria. the next house to be visited was the nearest household, which met the inclusion criteria. for those who met the inclusion criteria, one caregiver was interviewed with a short structured questionnaire. information was collected on: caregiver’s relationship to the child; mother’s age at delivery of the child; age and level of education of the principal caregiver and partner; the number of antenatal visits made; place of delivery; the birth order and sex of the child and the number of immunizations for the child. socio-economic status was measured using a principal component analysis used in other household surveys in kenya.23,24 in addition to responding to the questionnaire, all study participants were asked to produce the child’s vaccination card, national identification cards of the caregiver, birth certificates and academic certificates. these were used to corroborate the information given by the care article figure 1. baseline characteristics of the survey. table 1. summary of the survey data per stratum. strata population distribution sample distribution survey results weights n* % n* % p̂� i var (p̂� i) emukaya 1235 3.3 33 5.7 0.818 0.00465 0.57 lurambi 1130 2.9 45 7.8 0.844 0.00299 0.38 eshisiru 989 2.6 48 8.3 0.896 0.00198 0.32 indangalasia 1566 4.2 44 7.6 0.432 0.00571 0.54 shibuli 2417 6.4 38 6.6 0.868 0.00310 0.97 shirakalu 1173 3.1 46 8.0 0.935 0.00135 0.39 shiyunzu 1919 5.1 45 7.8 0.956 0.00096 0.65 sichilayi 10,475 27.8 48 8.3 0.771 0.00376 3.34 shirere 7738 20.5 46 8.0 0.870 0.00251 2.58 township 2691 7.2 39 6.8 0.846 0.00343 1.06 matioli 1387 3.7 49 8.5 0.673 0.00458 0.43 murumba 2104 5.6 48 8.3 0.646 0.00487 0.67 mahiakalo 2865 7.6 48 8.3 0.896 0.00198 0.91 total 37,689 100 577 100 *n refers to number of households from which respondents were picked. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5447] [page 19] giver. respondents’ information was coded by the primary researcher into numerical responses and double-entered in excel before being exported to spss (ibm corp. released 2011. ibm spss statistics for windows, version 20.0. armonk, ny, usa). statistical analysis was conducted using the software spss v20 for windows, with an alpha value of 0.05 used to indicate significance. data were initially checked for consistency and outliers through use of tables, histograms and box plots. mean, median and standard deviations were used to describe continuous data, while frequencies were used for categorical data. a multiple logistic regression model was used to estimate associations and check for potential confounders among variables. to ensure accurate estimation of immunization in kakamega central district, each sample proportion (with the respective 95% confidence intervals) was weighted (table 1). the sample weights, wi were derived from the formula: ethical approval for the study was obtained from auckland university of technology ethics committee. permission to proceed with the study was also obtained from the kenyan ministry of health. results baseline characteristics after visiting 649 households (oversampling was done due to availability of more household for interviews), caregivers from 577 households were interviewed, translating to a response rate of 90.1% (figure 1). the mean age of the caregivers was 27.6 years, whilst that of the children was 24.8 months, with slightly more than half being boys (53.2%). table 2 summarizes the sample characteristics. immunization coverage among the households visited, the proportion of completely immunized children was 80.2%. adjusting for the stratified design, the estimated coverage for the district was 80.9%. every child had received at least one form of vaccine against the diseases in the kenyan immunization schedule. the vaccination coverage rates for bcg, the third polio dose (opv3), pentavalent 3 and measles were 99.5, 85.1, 94.5 and 90.8% respectively. bivariate analyses the coverage was higher (88%) among caregivers who had completed secondary school than among those who had not (74%), p<0.001. a similar result was seen for the education level of the partners. although there were relatively few caregivers who did not attend any antenatal care (anc) visits, there was evidence of a significantly lower coverage (54%) for them, compared to those who had attended anc (81%), p<0.001. no evidence for a gender difference in coverage was seen, p=0.74. children born in a health facility had greater coverage (85%) than those who were not (71%), p<0.001. some evidence was seen of increasing coverage with increasing socioeconomic status. coverage decreased for children born into larger families, down to 69% for children with a birth order of six or more (table 3). logistic regression analysis complex samples logistic regression was performed to assess the impact of the factors measured on the likelihood that children would be fully immunized. prior to interpretation of regression coefficients, the model was tested to determine its fitness. the hosmerlemeshow goodness of fit test indicated that the logistic regression model was fit to test the association between socio-demographic variables and immunization uptake. after backward stepwise elimination, the final model contained three explanatory vari article table 2. sample characteristics (n=577). variable n % caregiver’s relationship to the child mother 547 94.8 father 13 2.3 other 17 2.9 marital status of the caregiver married 483 83.7 single 70 12.1 divorced 12 2.1 widowed 12 2.1 caregiver’s age (years) ≤20 71 12.3 21-30 357 61.9 31-40 123 21.3 40+ 26 4.5 caregiver’s higher school level <secondary 322 55.8 ≥secondary 255 44.2 parther’s higher school level <secondary 266 47.0 ≥secondary 300 53.0 sex of the child male 307 53.2 female 270 46.8 child’s place of delivery health facility 377 65.3 home or other place 200 34.7 age of the child (months) ≤20 243 42.1 21-30 173 30.0 31-40 140 24.3 41-50 17 2.9 51+ 4 0.7 vaccine coverage bcg 574 99.5 polio birth dose 568 98.4 opv-1 565 97.9 opv-2 549 95.1 opv-3 491 85.1 pentavalent 1 565 97.9 pentavalent 2 561 97.2 pentavalent 3 545 94.5 measles 524 90.8 bcg, bacillus calmette-guérin; opv, oral polio vaccine. non co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2016; 4:5447] ables, all of which were statistically significant. the model as a whole correctly classified 83.5% of cases. the risk factors for incomplete immunization identified by the final model (table 4) were: low educational level of the caregiver [adjusted odd ratio (aor)=0.25; p<0.005], never attending any anc (aor=0.14; p<0.05) and delivery outside of health facilities (aor=0.40; p<0.005). discussion in kenya the aim is for 100% uptake of bcg, opv birth dose, measles, and pentavalent vaccination (a combination of dpt, opv and haemophilus influenza type b). full delivery of these vaccinations ensures compliance with the aims of the epi initiative and ensures that all children are protected from the vaccine-preventable diseases. in the research reported here, it was found that although the estimated completed immunization was higher than the 62.2% reported in official estimates,6 and all children had received at least one vaccination, only 80.2% received full vaccination. understanding the reasons why immunization is not complete is important to focus future interventions appropriately. in this study, maternal education level, antenatal clinic attendance and place of delivery were found to be significant according to the multivariate analysis. this is similar to previous studies.79,13-15 in this study, educated mothers were more likely to take their children for immunization. this could be due to the fact that educated mothers have more knowledge about good medical practices (perhaps through courses undertaken within learning institutions) and are thus aware of the benefits of medical care. also, educated mothers are likely to be more active and assertive within their households and the public arena. such women are more likely to advocate for better healthcare for their children. in the research reported here, 17% of women who had been educated to at least secondary level did not have their children immunized, suggesting that although maternal education is valuable, other factors need to be in place to ensure full coverage. the second factor shown to be strongly associated with full vaccination coverage was attendance of antenatal clinics. the who recommends that pregnant mothers attend at least four antenatal classes during which mothers are taught about the importance of immunization to their children.25 interestingly, in the study reported here, only 3% of care givers reported they had not attended antenatal classes and it is surprising that this did not result in higher immunization, with nearly 100 women who attended these classes not having fully immunized their children. children delivered within a health facility were more likely to be immunized than those delivered at home. the children of kenyan mothers delivering at health facilities are given the polio birth dose and bcg and advised when to return for the next set of vaccines. children born from home only access the first set of vaccines on first contact with their health care provider, often when they are brought to hospital for other reasons such as sickness. home-based vaccination programs are not in place for routine immunization and children are only vaccinated from home during campaigns to control outbreaks such as measles and polio. despite the advantage for those children who are born in a health facility being given at least some protection, this did not result in complete immunization. strengthening messages about the importance of the child receiving all vaccinations should be considered. whilst these findings are in line with those of other studies, the results presented here show that despite these three factors being significant, none determines full coverage. other factors must also play a part. variations in the uptake of different vaccines revealed missed opportunities especially for vaccines administered concurrently. for article table 3. factors associated with immunization (n=577). variable and category total fully immunized crude or p n % caregiver’s highest school level ≥secondary 255 224 88 3.68 <0.001 <secondary 322 239 74 1.00 partner’s highest school level ≥secondary 300 249 83 1.42 0.104 <secondary 266 205 77 1.00 mother ever attended anc clinic yes 553 450 81 3.70 <0.001 no 24 13 54 1.00 sex of the child male 307 250 81 1.07 0.739 female 270 213 79 1.00 place of delivery health facility 377 321 85 3.96 <0.001 home or other place 200 142 71 1.00 socioeconomic status (quintiles) first 113 82 73 1.00 second 118 87 74 1.06 0.841 third 115 92 80 1.51 0.187 fourth 115 101 88 2.73 0.004 fifth 116 101 87 2.54 0.006 birth order of the child 1-2 332 273 82 2.06 <0.001 3-5 219 172 79 1.63 0.920 6+ 26 18 69 1.00 age of the caregiver yes no mean age (years) 27.3 29.1 0.034 or, odds ratio; anc, antenatal care. table 4. multivariable analysis of determinants of complete immunization. variable aor 95% ci caregiver’s highest school level ≥secondary 3.40 1.28, 9.01* <secondary 1.00 ever attended anc visit yes 2.43 1.51, 3.95° no 1.00 place of delivery health facility 2.58 1.61, 4.15* home 1.00 aor, adjusted odd ratio; ci, confidence interval; anc, antenatal care. *p<0.005; °p<0.05. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5447] [page 21] instance, there was a discrepancy between the coverage of the opv-3 and the third dose of the pentavalent vaccine. these vaccines are administered together and could be expected to have similar coverage rates. other factors impacting on incomplete coverage may be contextual and/or difficult to quantify using survey designs. one possible next step would be to carry out some qualitative research to explore these issues from the perspective of all stakeholders and a review of logistical factors relating to vaccination. strength of the study was that all research assistants were trained before data collection commenced, which ensured that the method of data collection was standardized. household selection was randomized, with all households having an equal chance of being asked to participate in the study. the number of participants exceeded the estimated required sample size. the response rate was high, and recall bias were minimized by the verification of the information provided by the majority of participants. one possible limitation of the study was that it was carried out in only one area of kenya and as such, the results could not be extrapolated to other areas of this country. the study focused on the knowledge and behaviors of caregivers but did not investigate structural and other factors which might impact on immunization uptake. this was outside the scope of the study, and further work needs to be undertaken to investigate this. in this study, immunization uptake was generally good. however uptake of some vaccines was better than others. factors associated with immunization uptake among children within the study area were identified. the main consumers of study findings include caregivers and their partners, healthcare workers, nongovernmental organizations and the government of kenya. study findings highlight the importance of demand creation for immunization services through health education during immunization, outreach sessions and through the media. this would in turn improve the knowledge, attitude and practice of all the stakeholders hence increase immunization uptake. health workers would use the study findings to encourage mothers to start antenatal clinics early and ensure that mothers attend more than four antenatal visits during their pregnancy. conclusions this study explored the immunization uptake in an area of kenya with relatively good health care facilities and the factors, which might nonetheless impact on incomplete immunization coverage. the vaccination coverage was found to differ from previous official estimates. the study also contributed to our understanding of the factors associated with full coverage. despite factors significantly associated with greater coverage, it is demonstrated that a multi-faceted approach to vaccination coverage is essential as no single factor results in full coverage. further detailed exploration of the complexity and interaction of factors affecting decision-making around vaccination uptake, and the logistics of vaccination provision would be worthwhile to enable the goal of complete vaccination coverage to be attained. references 1. world health organization. who recommendations for routine immunization summary tables. available from: http://www.who.int/immunization/policy/im munization_tables/en/ 2. world health organization. immunization coverage. available from: http://www.who. int/mediacentre/factsheets/fs378/en/ 3. world health organization. who vaccinepreventable diseases: monitoring system. 2015 global summary. available from: http://apps.who.int/immunization_monitoring/globalsummary/schedules 4. ministry of public health and sanitation. weekly epidemiological bulletin. provincial & national surveillance indicators for week 47. nairobi, kenya: ministry of public health and sanitation; 2012. 5. who, unicef. estimates of national immunization coverage 2014. geneva, switzerland: who-unicef; 2014. 6. knbs-icf macro. kenya demographic and health survey 2014. nairobi, kenya-fairfax, va, usa: kenya national bureau of statistics-icf macro; 2015. 7. kamau n, esamai f. determinants of immunization coverage among children in mathare valley, nairobi. east afr med j 2001;78:590-4. 8. kumar d, aggarwal a, gomber s. immunization status of children admitted to a tertiary-care hospital of north india: reasons for partial immunization or non-immunization. j health popul nutr 2010;28:300-4. 9. abuya b, onsomu e, kimani j, moore d. influence of maternal education on child immunization and stunting in kenya. matern child health j 2011;15:1389-99. 10. jani jv, de schacht c, jani iv, bjune g. risk factors for incomplete vaccination and missed opportunity for immunization in rural mozambique. bmc public health 2008;8:161. 11. luman et, mccauley mm, shefer a, chu sy. maternal characteristics associated with vaccination of young children. pediatrics 2003;111:1215-8. 12. salmon da, smith pj, pan wk, et al. disparities in preschool immunization coverage associated with maternal age. hum vaccin 2009;5:557-61. 13. phimmasane m, douangmala s, koffi p, et al. factors affecting compliance with measles vaccination in lao pdr. vaccine 2010;28:6723-9. 14. sullivan mc, tegegn a, tessema f, et al. minding the immunization gap: family characteristics associated with completion rates in rural ethiopia. j community health 2010; 35:53-9. 15. chhabra p, nair p, gupta a, et al. immunization in urbanized villages of delhi. indian j pediatr 2007;74:131-4. 16. phukan rk, barman mp, mahanta j. factors associated with immunization coverage of children in assam, india: over the first year of life. j trop pediatr 2009;55: 249-52. 17. pande rp. selective gender differences in childhood nutrition and immunization in rural india: the role of siblings.demography 2003;40:395-418. 18. parashar s. moving beyond the motherchild dyad: women’s education, child immunization, and the importance of context in rural india. soc sci med 2005;61:989-1000. 19. babalola s. maternal reasons for non�immunisation and partial immunisation in northern nigeria. j pediatr child health 2011;47: 276-81. 20. ndiritu m, cowgill kd, ismail a, et al. immunization coverage and risk factors for failure to immunize within the expanded programme on immunization in kenya after introduction of new haemophilus influenzae type b and hepatitis b virus antigens. bmc public health 2006;6:132. 21. rahman m, obaida ns. factors affecting acceptance of complete immunization coverage of children under five years in rural bangladesh. salud publica mex 2010;52: 134-40. 22. owino l, irimu g, olenja j, meme j. factors influencing immunisation coverage in mathare valley, nairobi. east afr med j 2009;86:7-10. 23. mutua mk, kimani-murage e, ettarh, rr. childhood vaccination in informal urban settlements in nairobi, kenya: who gets vaccinated? bmc public health 2011;11:6. 24. world health organization. immunization coverage cluster survey reference manual. geneva, switzerland: world health organization; 2005. 25. who pregnancy, childbirth, postpartum and new born care: a guide for essential practice. geneva, switzerland: world health organization; 2009. article non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11197 physical activity, exercise habits, and body mass index of adults ratna candra dewi,1,2 bambang wirjatmadi3 1doctoral program of public health faculty, universitas airlangga, surabaya, indonesia; 2faculty of sport science, universitas negeri surabaya, surabaya, indonesia; 3faculty of public health, universitas airlangga, surabaya, indonesia abstract introduction: the risk of degenerative diseases begins to appear in adulthood. physical activity and exercise habits prevent the incidence of obesity which is a risk factor for degenerative diseases’ emergence. therefore, this study aims to examine the relationship between physical activity, exercise habits, body mass index, and fat mass percentage. design and methods: this study used an analytic observational cross-sectional design and 32 office workers in surabaya aged 28-56 years were selected by simple random sampling technique. the data collected included measurements of physical activity, exercise habits, anthropometry, and body composition, which were analyzed using spearman’s rank correlation test. results: the results showed that 46.9% of participants had moderate activity, 43.8% exercised 1-2x a week, 56.3% exercised for 20-60 minutes, 56.30% had a low exercise intensity, 62.50% had an overweight body mass index, and 71.9% had overfat mass percentage. spearman’s rank test showed a significant relationship between energy intake, physical activity, exercise frequency, duration and intensity, and body mass index as well as between energy intake, physical activity, exercise intensity, and body fat percentage. conclusions: increased physical activity and exercise habits were associated with decreased bmi and body fat percentage. introduction physical activity (pa) and exercise habits help to prevent and manage chronic disease, due to their beneficial effects on clinical endpoints in various diseases.1 high levels of pa show a relationship with better health and life quality.2,3 in contrast, low pa is associated with negative health outcomes, including obesity, type 2 diabetes mellitus, and death.4 physical activity, exercise, and nutrition work together to maintain body weight at the desired level.2 although diet contributes more to short-term weight loss, exercise appears to be important in maintaining the desired body weight.3 decreased pa due to lifestyle changes initiates obesity, while light pa performed during leisure time such as sitting relaxed, watching television, and playing computer, decreases bodily-produced energy, causing an imbalance between energy generated from food and the amount expended for physical activity. this leads to fatty tissue accumulation that increases the risk of obesity, especially in adulthood.5 obesity in adulthood (26-45 years) which has the highest level of productivity compared to other age groups, directly increases the economic burden. hence, elevation in medical expenses and absenteeism at work due to diseases caused by obesity is used to measure a country’s productivity decline. obese employees require more time to complete tasks and have limited ability to work physically. their counterparts with a normal body weight lack or only have a few related health disorders.6 physical activity that prevents obesity can be conducted with moderate intensity for at least 150-250 minutes per day. additionally, there is a need to limit excess food, rest sufficiently (6-8 hours in adults) and reduce stress.7 moderate-intensity pa done regularly maintains a balance of expended and consumed energy.8 pa in adulthood includes sports or planned exercises, as well as leisure activities (such as walking, dancing, gardening, swimming), household chores (such as washing, cooking, sweeping), on-site work, and play which are carried out routinely. body mass index (bmi) is a method that uses height and weight data to determine whether a person is healthy, overweight, or obese, but its disadvantage is the inability to provide accurate information about body composition. this aspect led some authors to define “the obesity paradox” as a situation in which obese individuals do not appear to be at a higher risk for hypertension, dyslipidemia, type ii diabetes, or cardiovascular disease compared to their lean counterparts.2 a recent study on total body fat shows that adiposity is a significant risk marker for evaluating unhealthy weight. furthermore, body fat is a more accurate indicator than bmi for predicting obesity.3 there is ample evidence regarding the importance of physical activity in weight loss programs to maintain a healthy weight and prevent long-term weight gain. increased pa has also been reported to provide comprehensive health benefits and reduce mortality associated with any cause, regardless of bmi. specifically, this study aims to analyze the relationship between physical activity, exercise habits, body mass index, and body fat percentage. article significance for public health an unbalanced diet and lack of physical activity increase the risk of non-communicable diseases. meanwhile physical activity has several benefits including reducing the risk of coronary heart disease, stroke, diabetes, hypertension, colon cancer, breast cancer, and depression. it is also the key to energy expenditure which balances energy and controls body weight to facilitate a normal bmi and body fat percentage. [healthcare in low-resource settings 2023; 11(s1):11197] [page 111] non -co mmerc ial us e o nly design and methods an analytic observational cross-sectional design was used, while the population selected by simple random sampling technique were 32 office workers in surabaya aged 25-55 years. anthropometric measurements included the assessment of height using a microtoise. bodyweight, body fat percentage, and bmi were measured by bioimpedance using a tanitamulti frequency analyzer (tanita corporation, tokyo, japan). furthermore, consumption intake was determined with a 2x24 hour recall method and analyzed using nutrisurveysoftware, while the gpaq (global physical activity questionnaire) method was used for pa. in this study, exercise habits were divided into frequency, duration, and intensity of exercise. all data were analyzed with spss version 22 and descriptive statistics were calculated to determine consumption intake percentage, body fat percentage, bmi, physical activity, and exercise habits. rank spearman correlation test was used to analyze relationships between variables, where α (two-sided) = 0.05 and power of study = 95%. before data collection, all participants were provided with information about the study and the right to withdraw at any time, then they filled out informed consent. results and discussions characteristics of participants table 1 shows that most of the participants were male (78.1%), 46.9% had an energy intake of 2500-2999 kcal, 46.9% did a moderate physical activity, 62.5% had overweight bmi, 71.9% had excess body fat percentage, 43.8% exercised at a frequency of 1-2 times/week, 56.3% had an exercise duration of 20-60 minutes, and 56.3% did low-intensity exercise. table 2 shows a significant relationship (<0.05) between energy intake, physical activity, exercise frequency, duration and intensity, and bmi, as well as between energy intake, physical activity, exercise intensity, and body fat percentage. the energy intake coefficient is positive, meaning a greater coefficient value tends to increase bmi and body fat percentage. on the other hand, the coefficients of exercise frequency, duration and intensity, and physical activity are negative, meaning a greater value reduces bmi and body fat percentage. this study aimed to analyze the relationship between energy intake, physical activity, exercise frequency, duration and intensity, bmi, and percentage body fat in adults aged 28-56 years. bodyweight and composition are the sums of many factors that regulate and influence the “intake” and “output” sides of the energy balance equation.1 in weight management and obesity prevention, the role of diet and pa is not simply ‘eat less’ or ‘exercise more’, but understanding the synergies and interrelated nature of both factors.9 diet influences energy balance and health more than just providing energy. for example, daily energy expenditure is affected by total energy intake (e.g., kcal or kj consumed), plus food macronutrient composition (percentage of energy from protein, fat, carbohydrates, and alcohol),4,10 its energy density (kcal or kj per g of food),10,11 and timing of intake.12 these dietary factors also change the food’s thermic effect and the type of substrate stored or used for fuel during pa.13-15 physical activity and exercise affect the balance of energy more than just its expenditure. the energy amount expended and article table 1. variables of the participant’s characteristics. characteristics n % sex male 25 78.1 female 7 21.9 energy intake 2000 – 2499 kcal 4 12.5 2500 – 2999 kcal 15 46.9 3000 – 3499 kcal 10 31.2 >3500 3 9.4 minimum: 2000 maximum: 3500 mean: 2787.50 sd: 421.02 physical activity low (< 600 met-minutes a day) 13 40.6 moderate (600 <1500 met-minutes a day) 15 46.9 high (1500 <3000 met-minutes a day) 4 12.5 body mass index underweight (bmi ≤ 18.4) 1 3.1 normal (bmi 18.5-25) 11 34.4 overweight (bmi ≥ 25.1) 32 62.5 body fat percentage lean 0 0 optimal 9 28.1 overfat 23 71.9 exercise frequency no exercise 5 15.6 1-2x/week 14 43.8 3-5x/week 8 25.0 >5x/week 5 15.6 exercise duration <20 minutes 7 21.9 20-60 minutes 18 56.3 >60 minutes 7 21.9 exercise intensity low 18 56.3 moderate 13 40.6 high 1 3.1 remark: met= metabolic equivalents; bmi= body mass index. table 2. the relationship between explanatory variables, body mass index, and body fat percentage. variables bmi body fat percentage r sig. r sig. energy intake 0.522 0.002 0.479 0.006 physical activity -0.415 0.018 -0.418 0.017 exercise frequency -0.396 0.025 -0.255 0.159 exercise duration -0.375 0.034 -0.315 0.079 exercise intensity -0.628 0.000 -0.528 0.002 [page 112] [healthcare in low-resource settings 2023; 11(s1):11197] non -co mmerc ial us e o nly the fuel used are affected by the type, intensity, and duration of pa. for example, 30 minutes of running consumes more energy than walking at that same time. pa also alters appetite and its-regulating hormones by promoting appetite suppression or hunger, which in turn changes total energy intake.16-19 this in addition to regular and frequent exercise jointly increases energy flux, namely energy conversion rate after absorption from food into body tissues for use in metabolism or the conversion into energy stores.20 higher energy flux levels augment the body’s ability to match energy intake with expenditure thereby making weight management easier.20,21 pa and proper exercise increase muscle mass and strength,22,23 as well as elevate or maintain bone mass.23 these factors improve body composition and health as well as increase an individual’s ability to maintain an active lifestyle and reduce the risk of obesity and chronic disease.11,24 according to shook et al., the group with low activity levels had high body weight and bmi. they also discovered that weight differences were entirely attributable to differences in fat mass, with the low pa group having the highest fat mass (30.9 kg or 68 lb) versus the greatest pa group (14.2 kg or 32 lb).25 one year later, another study reported that the two lowest pa groups had a 1.82 to 3.80 times greater risk of gaining >3% body fat than the group participating in medium or higher pa, meaning a low pa level is a risk factor for weight gain. physical activity reduces energy intake by changing appetite, and its effect on appetite is influenced by pa type and intensity, environmental temperature, and characteristics of the exerciser. pa tends to create a negative energy balance, depending not only on its direct effect on the ability to increase expenditure but also indirectly on the potential to modulate appetite and/or energy intake. based on a study, the type and intensity of exercise or pa affect changes in appetite. high-intensity exercise has a greater propensity to suppress hunger or food intake after being performed than moderate or light exercise.26,27 appetite is suppressed for 15-60 minutes after exercise and potentially delays the next meal. the type of exercise also affects appetite suppression. another study shows that running, rope jumping, or high-intensity exercise interval workouts tend to suppress appetite than swimming and walking which rather stimulate appetite and/or food intake. additionally, running has a stronger effect on appetite suppression than strength training.28-33 the environmental temperature during or after exercise also affects appetite. increased hunger and/or food intake can be caused by a cold environment while hunger is suppressed by hotness. it was reported that exercising for 45 minutes in 20◦c water elevates food intake by an average of 44% more after 1 hour of exercise compared to 32◦c.(34,35) differences in environmental or body temperature show that swimming increases hunger compared to other types of exercise.35 the limitations of this study are related to body composition measurements that only bmi and body fat percentage. there need to be other measurements such as muscle mass and bone mass. this is to determine the role of physical activity, exercise habits and diet on body composition. conclusions based on the results, increased physical activity and exercise habits were associated with decreased bmi and body fat percentage. regular physical activity and exercise, as well as a healthy and balanced diet will create a healthy body composition. references 1. sparling pb, franklin ba, hill jo. energy balance: the key to a unified message on diet and physical activity. j cardiopulm rehabil prev 2013;33:12–5. 2. hall kd, heymsfield sb, kemnitz et al. energy balance and its components: implications for body weight regulation 1-3. am j clin nutr 2012;95:989–94. 3. shook rp, hand ga, blair sn. top 10 research questions related to energy balance. res q exerc sport 2014;85:49–58. 4. galgani j, ravussin e. review energy metabolism, fuel selection and body weight regulation. int j obes 2008;32:109– 19. 5. elder bl, ammar em, pile d. sleep duration, activity levels, and measures of obesity in adults. public health nurs 2016;33:200–5. 6. sanchez bustillos a, gregory vargas iii k, gomero-cuadra r. journal of epidemiology and global health work productivity among adults with varied body mass index: results from a canadian population-based survey work productivity among adults with varied body mass index: results from a canadian article correspondence: ratna candra dewi, faculty of public health, universitas airlangga, jl. dr. ir. h. soekarno, mulyorejo, surabaya, indonesia 60115, tel.: +62315920948, fax: +62315924618, e-mail: ratna.can.dewi-2017@fkm.unair.ac.id key words: physical activity, exercise habits, body mass index, body fat percentage acknowledgment: the authors are grateful to the faculty of public health universitas airlangga for the support and encouragement provided during this study. contributions: all authors read and approved the final manuscript. conflict of interest: the authors declare no conflict of interest. funding: this study was funded by the faculty of public health, universitas airlangga. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11197 doi:10.4081/hls.2023.11197 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11197] [page 113] non -co mmerc ial us e o nly population-based survey. j epidemiol glob health 20155:191– 9. 7. hruby a, hu fb. the epidemiology of obesity: a big picture. pharmacoeconomics 2015;33:673–89. 8. swift dl, johannsen nm, lavie et al. the role of exercise and physical activity in weight loss and maintenance. prog cardiovasc dis 2014;56:441–7. 9. flatt jp. issues and misconceptions about obesity. obesity (silver spring) 2011;19:676–86. 10. ledikwe jh, rolls bj, smiciklas-wright, et al. reductions in dietary energy density are associated with weight loss in overweight and obese participants in the premier trial 14. am j clin nutr 2007;85:4754403 11. madjd a, taylor ma, delavari a et al. beneficial effects of replacing diet beverages with water on type 2 diabetic obese women following a hypo-energetic diet: a randomized, 24week clinical trial. diabetes, obes metab 2017;19:125–32. 12. hawley ja, burke lm, phillips sm, et al. nutritional modulation of training-induced skeletal muscle adaptations [internet]. j appl physiol 1985;110:34–45. 13. hawley ja, burke lm. carbohydrate availability and training adaptation: effects on cell metabolism. exerc sport sci rev 2010;38:152–60. 14. manore m, meyer nl, thompson j. sport nutrition for health and performance. human kinetics; 2009. available from: https://books.google.vg/books?id=uawjvhhtm2qc. 15. stensel d. exercise, appetite and appetite-regulating hormones: implications for food intake and weight control. ann nutr metab 2011;57:36–42. 16. hagobian ta, braun b. physical activity and hormonal regulation of appetite: sex differences and weight control. exercise and sport sciences reviews. exerc sport sci rev 2010;38:25– 30. 17. king ja, garnham jo, jackson ap, al e. appetite-regulatory hormone responses on the day following a prolonged bout of moderate-intensity exercise. physiol behav 2015;141:23–31. 18. thackray ae, deighton k, king ja, stensel dj. exercise, appetite and weight control: are there differences between men and women? nutrients 2016;8:583. 19. hill jo, wyatt hr, peters jc. energy balance and obesity. circulation 2012;126:126–32. 20. melby cl, paris hl, foright rm, peth j. attenuating the biologic drive for weight regain following weight loss: must what goes down always go back up? nutrients. 2017;9:468. 21. ramírez-vélez r, correa-bautista je, lobelo f, et al. high muscular fitness has a powerful protective cardiometabolic effect in adults: influence of weight status. bmc public health 2016;16:1012. 22. kohrt wm, bloomfield sa, little kd et al. physical activity and bone health. med sci sports exerc 2004;36:1985–96. 23. hupin d, roche f, gremeaux v, et al. even a low-dose of moderate-to-vigorous physical activity reduces mortality by 22% in adults aged ≥60 years: a systematic review and metaanalysis. br j sports med 2015;49:1262-7. 24. shook rp, hand ga, drenowatz c, et al. low levels of physical activity are associated with dysregulation of energy intake and fat mass gain over 1 year 1,2. am j clin nutr 2015;102:1332–40. 25. ueda s-y, yoshikawa t, katsura y et al. comparable effects of moderate intensity exercise on changes in anorectic gut hormone levels and energy intake to high intensity exercise. j endocrinol 2009;203:357–64. 26. imbeault p, saint-pierre s, and na et al. acute effects of exercise on energy intake and feeding behaviour. br j ofnufrifion 2021;77:51–2. 27. deighton k, karra e, batterham et al. appetite, energy intake, and pyy3-36 responses to energy-matched continuous exercise and submaximal high-intensity exercise. appl physiol nutr metab 2013;38:947–52. 28. larson-meyer de, palm s, bansal a, austin kj, hart am, alexander bm. clinical study influence of running and walking on hormonal regulators of appetite in women. j obes 2012;2012:15. 29. kawano h, mineta m, asaka m et al. effects of different modes of exercise on appetite and appetite-regulating hormones. appetite 2013;66:26–33. 30. king ja, wasse lk, stensel dj. the acute effects of swimming on appetite, food intake, and plasma acylated ghrelin. j obes 2011;2011. 31. verger p, lanteaume mt, louis-sylvestre j. human intake and choice of foods at intervals after exercise. appetite 1992;18:93–9. 32. broom dr, batterham rl, king ja et al. influence of resistance and aerobic exercise on hunger, circulating levels of acylated ghrelin, and peptide yy in healthy males. am j physiol integr comp physiol 2009;296:r29–35. 33. crabtree, daniel r.blannin ak. effects of exercise in the cold on ghrelin, pyy, and food intake in overweight adults. med sci sport exerc 2015;47:49–57. 34. white lj, dressendorfer rh, holland e et al. increased caloric intake soon after exercise in cold water. int j sport nutr exerc metab 2005;15:38–47. 35. halse re, wallmann ke, guelfi kj. postexercise water immersion increases short-term food intake in trained men. med sci sport exerc 2011;43:632–8. article [page 114] [healthcare in low-resource settings 2023; 11(s1):11197] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11215 the effectiveness of nursing psychoeducation toward family burden and quality life on caregiver of people with schizophrenia in the community suharsono,1 noor faidah,2 moh hanafi1 1health polytechnic semarang, central java, indonesia; 2institute of technology and health cendekia utama kudus, central java, indonesia abstract introduction: the caregivers of people with schizophrenia have problems that include high family, burden and low quality of life at home. therefore, this study aims to determine the effectiveness of nursing psychoeducation on family, burdens and quality of life in caregivers of schizophrenia patients in the community. design and methods: this study used a pre-test and post-test group control design and repeated measurement with a total of 100 respondents. the treatment group was given weekly nursing psychoeducation for seven sessions. also, the general linear model (glm) was used to analyze the result. results: this study showed that before the intervention of nursing psychoeducation, the average family burden was 49,02 and 46.28 in the treatment and control groups, respectively. this decreased to 38.24 and 37.56 in the first and fourth weeks of post treatment. meanwhile, the control group was 44.86 in the first week and 45.62 in the fourth. the psychoeducation had an effect on decreasing the family burden with a p value < 0.001. moreover, this study showed that before the intervention of nursing psychoeducation, the average caregiver quality of life was 75,72 and 74.24 in the treatment. after treatment, it increased to 91.22 in the first week after intervention and 92.54 in the fourth week of post-intervention. therefore, the intervention effectively improved the caregiver quality of life with p < 0.001 conclusions: nursing psychoeducation can effectively reduce family burdens and improve the quality of life for caregivers. introduction schizophrenia is a chronic mental disorder that requires longterm care and treatment. the prevalence of this disease in the indonesian population is 6.7‰ and the provinces with the highest cases include bali with 11.1‰, followed by yogyakarta special region with 10.4‰, west nusa tenggara with 9.6‰, south sulawesi 8.8‰, west sumatra 9.1‰, central java and aceh 8.7‰.1 patients with schizophrenia who have been discharged from the hospital and live with their families often relapse with behavioral and emotional disturbances caused by low medication adherence, lack of family support or interpersonal relationships, and stressful life events.2 a study stated that 52% of patients experienced a relapse once a year after being discharged from the hospital.3 the factors that contributed to this relapse include an unsupportive family environment, feelings of inferiority and worthlessness, side effects of drugs that patients often experience and joblessness. therefore, the family as a caregiver is important in order to get a clear understanding of caring for these patients at home. mental disorders need continuous services because the impact is not only felt by people with this condition but also by their families.3 these disorders cause susceptibility to psychosocial problems caregivers, including feelings of worry and guilt. in addition, the psychological burden experienced by the family and the stigma in society often make them vulnerable to mental disorders.4 the family is the center of nursing services because it is a source of fulfillment for individual needs. all dysfunctions that occur in the family will have an impact on one or more members or the whole.4 the family is also a system, therefore, a disturbance in one of its members will definitely affect the whole system. the paradigm shift in mental health services that focuses on the community (deinstitutionalization) has resulted in the family playing an important role in providing the care that patients need at home.5 in addition, there has been a change in the focus of management from biological symptoms and their pathological implications to specific interventions addressing the spectrum of sequelae, biological, psychological, social, and cultural consequences of severe mental disorders.6 the success of hospital care might be less than optimal when it is not followed up with nursing home care because it can result in the patient being hospitalized again (relapse). families play an important role in handling and preventing the recurrence of mental patients.7 they are also very important in dealing with mental disorders in the community. this is because health workers are limited and patients live with their families, therefore, it is easier for them to be independent. furthermore, the sources of support are more, varied as the costs are cheaper, and significance for public health patients with schizophrenia who are discharged from the hospital and live with their families often relapse with behavioral and emotional disturbances. this situation is caused by low medication adherence, lack of family support or interpersonal relationships, and stressful life events. families as caregivers for schizophrenic patients are at the risk of having a lower quality of life due to mental and physical health problems, as well as high family burdens. therefore, this condition needs modalities therapy to improve the knowledge and skill of these individuals. one of the treatments is nursing psychoeducation. nurses in the community play an important role in psychoeducational, program because they have frequent contact with caregivers who care for schizophrenic patients. this study showed the effectiveness of nursing psychoeducation on family, burdens and quality of life among caregivers of schizophrenia patients in the community. article [page 162] [healthcare in low-resource settings 2023; 11(s1):11215] non -co mmerc ial us e o nly patients are easier to adapt and require long treatment to overcome psychological symptoms.4 this condition requires the participation of the community and family in improving mental health efforts. however, the families face challenges while caring for patients at home. this is due to the condition and behavior of patients, which can be a burden. the concept of burden describes the negative impact of mental illness/disorder on the family. the burden in caring for schizophrenic patients can be divided into objective and subjective, where the former include practical problems and those related to having relatives with patients, such as loss of income and disruption of routine household activities. meanwhile, subjective burdens include psychological and emotional impacts such as feelings of sadness and worries about relatives.8 based on previous studies, families with relatives suffering from schizophrenia experienced a very high burden as a consequence of treatment, hence, it can negatively affect all areas of their lives.9 it was also revealed that schizophrenia is a severe mental illness, which places a heavy burden on the family as caregiver.10 in addition, caregivers experience much physical, emotional and financial stress due to the patient’s abnormal behavior, as well as social and occupational dysfunction. this burden is mainly felt by the closest relatives, such as the family as caregivers who live together, interact regularly, and assist patients with daily activities. 11 caregiver burden as a psychological condition that arises is a combination of physical work, emotions, social pressures, and financial restrictions which are consequences of caring for patients. 9 a study showed that family members who lived with patients or spent many time with sick relatives felt more burdened and the level is usually associated with dysfunction or disability, the severity of negative and positive symptoms, and the duration of schizophrenia, the frequency of visits to the hospital, as well as the distance to the hospital from home.12 a study explained that caregiver burden is used to describe the severe consequences of mental disorders for families as caregivers.13 the family burden is not only the burden of care but others such as physical, psychological, social, and financial problems.14 the shift in the mental health care system from hospital-based to community-based care has caused families to take a greater role in caring for patients.14 the family as a caregiver is at the forefront of caring for relatives with schizophrenia.15 changes in roles and responsibilities, high treatment costs, inappropriate behavior, shame, and negative stigma towards patients and their families can cause changes in family dynamics. this condition also affects health and become a burden on the family as a caregiver.16 the schizophrenia symptoms cause the family to experience stress, frustration, and ineffective coping. therefore, a coping strategy is needed to reduce the. coping strategy is one of the factors that affect the caregivers’ quality of life. the caregivers with effective coping strategies have a higher level of commitment in caring for schizophrenic patients and are able to reduce their psychological morbidity.17 families as caregivers for these patients are at the risk of having a lower quality of life due to mental and physical health problems, as well as high burdens.18 several studies showed that these families have a lower quality of life compared to caregivers of patients with other psychiatric diagnoses or the general population.19 the caregiver’s quality of life has a direct impact on the patient’s symptoms and indirectly on their quality of life. in addition, quality of life has been shown to be a predictor in the functional recovery of schizophrenic patients. therefore, the quality of life for families as caregivers should be an important issue for health professionals and policy makers in considering or providing interventions to caregivers. 20 psychoeducation is one of the therapeutic modalities in mental health nursing that provide ways to overcome psychosocial problems and offer skills to care for clients which are given by the therapist through family meeting sessions.21 this intervention does not only provide training but also emotional reinforcement, psychological and social support to reduce feelings of anxiety. this is certainly very helpful in reducing the subjective and objective burden of the family.22 psychoeducation is an effective therapy and it saves costs when the intervention is carried out in groups, because in this way the therapist can work with various families at the same time.22 a study was conducted to assess the efficacy of family psychoeducation programs in changing behavior and health perceptions in families with schizophrenia. it was further stated that family psychoeducation could change the relative’s negative behavior towards schizophrenic patient. in addition, the study was conducted to assess the efficacy of the interventions on caregivers’ quality of life. the results indicated that most caregivers experienced a significant increase in the overall quality of life scores as observed in the experimental group compared to the control. the study aims to test the efficacy of the psychoeducational intervention program (pip) compared to standard care to reduce caregiver burden at post-intervention (4 months), and at follow-up (8 months). the results showed a change in scores since there was baseline on the zarit burden interview (zbi) and involvement evaluation questionnaire (ieq).23 nurses play an important role in psychoeducational programs, because they have frequent contact with caregivers. the increasing involvement of mental nurses with the programs was demonstrated through the literature.24. therefore, they need to provide accurate information and skill to caregiver in order to enhance their knowledge and high skill in dealing with schizophrenic patient at home. generally, this study aims investigate the effect of nursing psychoeducation on family burden, coping skills, and caregiver’s quality of life of people with schizophrenia. design and methods this is an experimental study with a pre-test and post-test control group design with repeated measurement. the population is a family with a schizophrenic patient in the mental health alert village area, the public health center, magelang regency. this study classified the respondents into the experimental and control groups, while an informed consent was signed. a paired simple randomization was applied, and the intervention group received the psychoeducational nursing intervention for 7 sessions per week while the control did not receive the intervention. this study was conducted at the public health center in the working area of magelang regency, which has a community mental health program and developed a mental health alert village since january 2020. the data collection procedure was carried out through primary data which were obtained by filling in the provided instruments, including i) personal data questionnaire, ii) family burden with zarit burden interview (zbi), iii) quality of life with whoqol-bref. the secondary data were obtained from the results of the patient’s medical records and the results of family interviews. the data collection procedure was follows: i) patient data were recorded and traced by the mental health coordinator nurse to ensure the eligibility of the caregivers. this is in line with the criteria, and the doctor or person in charge of mental health at the puskesmas provided a letter of willingness when they agreed to be participants; ii) caregivers who meet the requirements to become the participants were given an explanation of the objectives, and their willingness to participate in the entire process was confirmed; iii) after obtaining informed consent, an invitation was article [healthcare in low-resource settings 2023; 11(s1):11215] [page 163] non -co mmerc ial us e o nly given to come to the nearest public health center at a predetermined time where the data collection process and implementation of all nursing psychoeducation sessions according to the schedule will be completed; iv) the filling of the informed consent and instruments was carried out by the subjects themselves; v) personal data questionnaires and instruments to measure family burden and quality of life were completed and collected back by the study team to check the completeness; vi) caregivers who completely filled out the instruments were given a transport fee of rp. 50,000 as an expression of gratitude. each session was divided into 4 stages, namely, pre-interaction, orientation, work, and termination. the topics in the seven session nursing psychoeducation were i) identification of family problems, ii) definition, response ranges and causes of schizophrenia, iii) symptoms and effects of schizophrenia, iv) how to care for the patient, v) management of relapse, vi) stress management, and vii) family burden management and family empowerment. the obtained data were analyzed and univariate analysis was carried out by descriptive analysis to observe the characteristics of each variable studied. furthermore, the general linear model statistical test was used to determine the effectiveness of nursing psychoeducation on family burden and quality of life. results and discussions the results indicated that majority of the caregiver’s age group was more than 35 years while the gender was dominated by female in both treatment and control groups. table 1 shows the educational level of most respondents was college graduates, with 21 people (42%) each in the treatment group and 24 (48%) in the control. furthermore, high school education levels were 19 (38%) in the treatment group and 17 (34%) in the control. this result indicated that most of the caregivers were married with as many as 40 people (80%) and 39 (78%) in the treatment and control groups, respectively. meanwhile, the caregiver’s job as a trader was 17 (34%) and 15 (30%) in the treatment and control groups, respectively. majority of the respondents in the treatment group were life partners (husband/wife) as many as 21 (42%), while the control group was majorly parents with 23 people (46%). the duration of caring for family members was mostly more than 5 years by 26 (52%) and 33 (66%) in the treatment and control groups, respectively. this study showed that there was a significant difference in mean before and after giving nursing psychoeducation. in the first week after intervention, there was a difference in the average burden of the family as a caregiver in the treatment and control groups with -6.62. likewise, in the post test’s 4th week, there was a decrease in the family burden score with a difference of -8.06 between the treatment and control groups. the results indicated that nursing psychoeducation had statistically and clinically significant effect in reducing the burden on families as caregivers for people with schizophrenia (p value <0.001). furthermore, before the intervention, majority of the respondents from both treatment and control groups experienced a fairly high family burden in caring for their relatives suffering from schizophrenia. the control group had a mean family burden score of 46.1, while the treatment group had average score of 46.02. this occurs since schizophrenia is a severe mental disorder that causes a decrease in social function and has the potential to cause a longterm burden for the family as caregiver. the burden experienced by the caregivers includes meeting daily needs, finances, and loss of jobs. 25,26 this also occurs in indonesian society where besides meeting the needs of relatives suffering from schizophrenia, families also feel subjective burdens such as shame, anxiety, guilt and stigma. the burden of families with schizophrenic patients has a high level of distress and difficulty, specifically during the early phase. the results are in accordance with previous studies which identified that the family burdens experienced by caregivers were both objective and subjective.27 the objective burden includes the article table 1. the caregiver characteristics. variables experimental group (n=50) control group (n=50) f % f % age (year) <35 10 20 16 32 >35 40 80 34 68 sex male 23 46 21 42 female 27 54 29 58 educational level no formal education 1 2 elementary school 6 12 7 14 junior high school 3 6 2 4 senior high school 19 38 17 34 university 21 42 24 48 marital status married 40 80 39 78 unmarried 6 12 9 18 widow 4 8 2 4 occupation no job 4 8 2 4 civil servant 15 30 12 24 police 2 4 1 2 trader 17 34 15 30 farmer 9 18 11 22 labor 3 6 9 18 relationship with the patient parent 15 30 23 46 couple 21 42 12 24 sibling 3 6 10 20 child 11 22 5 10 caring duration < 5 years 24 48 17 34 >5 years 26 52 33 66 [page 164] [healthcare in low-resource settings 2023; 11(s1):11215] non -co mmerc ial us e o nly cost of care, housing, food and transportation. this was also experienced by caregivers in this study who had to take patients to a health facility, prepare daily needs, control medication as well as monitor their behavior and emotions at home. while the subjective burden include worrying when patients experience a relapse and stigma from the community. most of the respondents cared for the patients at home for more than five years with 52% and 66% in the treatment and control groups, respectively. the results of the regression test showed there was no relationship between duration of care and family burden. this is contrary to a study which stated that there was a relationship between the duration of caring for clients with family burdens. 27 this difference could be as a result of indonesian culture, the longer duration of caring for patients do not cause the perceived psychological burden or pressure to be greater. the family already has a close relationship or an attitude of helping and tends to be able to adapt.27 this study showed the burden on the family as a caregiver was not influenced by age. this is contrary to a literature which stated that family burden had a positive correlation with caregiver’s age. it was stated that the older the age, the more the burden due to reduced physical abilities and concerns about who will be responsible for the patient after death. the difference in this study could be caused by indonesian culture of helping each other, as families believe it is their responsibility when a member is sick.27 studies in india and chile on outpatient schizophrenic caregivers in hospitals stated that length of illness, levels of psychopathology and disability, frequency of relapse, positive symptoms and lack of social support were predictors of family care burden.28 this burden was not only influenced by the condition of patients and the characteristics of the caregiver, but also by differences in mental health services in the health care system. the caregiver characteristics that affected the family burden were symptoms, male gender, joblessness, marital status, coping abilities, contact with patients and sufferers’ parents. therefore, sociocultural and ethnic characters have an important role in the perception of the family care burden. schizophrenia management in the community should not only be conducted for sufferers but should also focus on families as caregivers.29. it can increase understanding in caring for patients at home, reduce the stress, improve coping and the quality of family life as caregivers. caregivers need to access health services which are part of the schizophrenic management in the community setting. the results were supported by previous study conducted in japan to provide psychoeducation for caregivers with schizophrenia in the community by visiting nurses.30 the results showed that there was a significant reduction in family burden after home visits and psychoeducation. although psychoeducation effectively increased knowledge and positive coping with the patient’s family, it was less useful in reducing psychological morbidity, care burden or emotional expression. psychoeducation conducted in this study in the form of groups where participants could exchange experiences, increase knowledge and skills facilitated by health workers this is in accordance with a previous study which stated that psychoeducation can increase caregiver’s knowledge about psychosis31. psychoeducation was recommended to be carried out as early as possible from the first contact of caregivers with severe mental disorders to health workers and on an ongoing basis.5 this intervention could reduce the burden of family care because it could improve the life quality of patients and caregivers, and reduce the severity of symptoms.32 in this study, psychoeducation was carried out in the form of groups for caregivers to interact with each other among participants or health workers and gain knowledge or skills regarding the definition, causes, symptoms, signs, care and treatment management, stress and family burden management, family empowerment as well as preventing recurrence. families as caregivers need support for community-based mental health services. this is because patients living with their families need to get longterm care which will increase the burden of family life as caregivers, such as financial burdens, time devoted to caregiving, resulting in loss of job opportunities and reduced income. it takes a long time to manage stress while caring for patients, and the stress increases when families experience a relapse. in addition, caregivers are worried about the future of people with schizophrenia when the family as caregiver dies. the majority experienced a burden as a result of the deteriorating condition of patients who require long-term care and decreased ability to interact with other people. caregiver burden results in physical and mental health, social relationships, financial condition, psychological morbidity, less free time, workload, and caregiver burnout. in addition, their emotional problems, such as feelings of frustration, anger, shame, fear, sadness, and stress increases due to the patient’s behavior, and the negative attitudes towards the patient. this study is in accordance with previous ones which article table 2. the effect of nursing psychoeducation on family burden. family burden control group (n=50)mean (s.d.) experimental group (n=50) mean (s.d.) mean difference ci 95% p value before nursing 46.28 (9.40) 49.02 (12.16) 2.74 45.22 <0.001 psychoeducation post test 1st week 44.86 (6.20) 38.24 (9.88) -6.62 post test 4th week 45.62 (7.33) 37.56 (8.62) -8.06 table 3. the effect of nursing psychoeducation on quality of life. family burden control group (n=50)mean (s.d.) experimental group (n=50) mean (s.d.) mean difference ci 95% p value before nursing 74.24 (9.59) 75.72 (2.53) 1.48 -1.30 – 4.26 <0.001 psychoeducation post test 1st week 79.44 (2.58) 91.22 (2.50) 11.78 10.77 – 12.79 post test 4th week 74.00 (2.05) 92.54 (3.08) 18.54 17.50 -19.58 [healthcare in low-resource settings 2023; 11(s1):11215] [page 165] non -co mmerc ial us e o nly showed that there was a decrease in the family burden for the group receiving psychoeducation treatment compared to the control group.33 this consistency occurs because psychoeducation serves to inform about illness and how to deal with it, provide emotional support to caregivers and implement coping strategies or stress management.34 the family burden is very important and needs attention as it is the result of a chronic disease condition and considering that the patients live with their families. this burden occurs due to emotional reaction to illness suffered by relatives, the family’s ability to cope with psychological problems of caring for people with schizophrenia, the stigma that arises as well as social withdrawal and family economic problems. the caregiver’s burden is caused by the distress they experienced, disrupted routine activities as they need to care for and fulfill their daily integrity. 25 nursing psychoeducation carried out in this study was a comprehensive technique which is a combination of a model that focuses on providing information to families about the disease and its management (information model), a model that focuses on skills in order to be treated effectively by the relatives (skill training model), and a model that involves families sharing feelings in a support group. 21 this intervention was carried out in groups for caregivers to interact with themselves and gain knowledge and skills in defining causes, response ranges, signs and symptoms, management of care for relatives at home, stress and family burden management as well as prevention of recurrence and empowerment of families as caregivers. this study showed that there was a significant difference in mean before and after giving nursing psychoeducation. in the first week after the intervention, there was a difference in the average quality of family life as caregivers in the treatment and the control groups with 11.78. likewise, in the post test’s 4th week, there was an increase in the quality of life score with a difference of 18.54 between the treatment and the control groups. the results showed a p value of <0.001, which indicated that nursing psychoeducation had a significant effect in improving the life quality of caregiver for people with schizophrenia (table 2). it was also revealed that prior to the implementation of the intervention, majority of the respondents, both the treatment and control groups, had poor quality of life in all areas including physical, psychological, social relationships, and environmental domains. the mean for quality of life in the treatment and control groups was 75.72 and 74.24, respectively. this could be due to socioeconomic conditions and caregiver’s level of knowledge. this is in accordance with the study which stated that caregivers with lower economic status were associated with lower quality of life.18 individuals with better financial conditions could meet basic physical and psychosocial needs such as higher self-esteem in order to improve their quality of life. the results indicated that age and relationship with the patient affect the caregiver’s quality of life. the results are in accordance with the study that caregivers who were older had a significantly lower quality of life in the social and environmental domains. 35 furthermore, elderly caregivers often have illnesses and declining physical health which could affect the physical domain on their quality of life.36 several studies in western countries showed that the life quality of caregivers increases with age, while it decreases with age in asian countries. these results are consistent with a study which stated that parents a lower quality of life compared to other family members. this was contrary to a study which stated that age was not significantly related to the caregiver’s quality of life.12 this difference was possible due to cultural factors. older caregivers could accept the patients with their condition.37 in addition, the results were a small proportion of respondents who did not work (8%) in the treatment group and 4% in the control group and there was no relationship between family work and caregiver’s quality of life. these are consistent with a study that therewas no significant relationship between work status and caregiver’s quality of life.12 however, in contrast to the results, several studies showed a relationship between the variables.35 caregivers who work will have better financial conditions to meet basic physical and psychosocial needs like higher self-esteem. in addition to having an income, caregivers can temporarily switch from caregiving tasks while working outside. having a job will indirectly expand the social support network that plays an important role in reducing the burden on the caregivers. this difference could be caused by the culture of mutual assistance that is still developing in indonesia. the study discovered that there was no decrease in the life quality of family caregivers of schizophrenia patients in indonesia, even though they did not have a job. it is a common habit in the extended family and the surrounding environment to support each other, even financially. in addition, caregivers who are not working did not have to make adjustments between their work life and caring for their family members.18 this study showed that after the nursing psychoeducation was carried out, caregivers experienced an increase in the average quality of life score in the treatment group from 75.72 in the initial data to 91.22 in the 1st -week of post-measurement and 92.54 in the 4th week of post-nursing psychoeducational implementation. therefore, there is a significant effect of the intervention on improving the quality of life with a p value of < 0.001 (table 3). this is in accordance with a study which assessed the efficacy of family psychoeducational interventions on the schizophrenic patients and the caregiver’s quality of life.35 most of the respondents are over 40 years, married, and male. the results showed family psychoeducation significantly improved the overall quality of life observed in the treatment group caregivers compared to those in the control. the similarity between these results could be due to nursing psychoeducation increasing knowledge and skills in caring for patients with schizophrenia at home, therefore, caregivers are able to use effective coping which can improve quality of life. this study also showed that the quality of life in the physical domain experienced an increase after the intervention with a mean difference between the control and treatment groups of 3.72 in the first week after treatment and 4.46 in the fourth week. study identifying the life quality of families who care for schizophrenic patients showed that the highest average whoqol-bref score was recorded in the physical health domain.35 this means the quality of life was higher in the physical health domain compared to others. these results were consistent with this study.35 this is because caregivers tend to ignore physical limitations or complaints of pain, and feel that they get more physical strength when caring for relatives suffering from the disease. conclusions there was a decrease in the mean score of caregiver burden in the group that received nursing psychoeducation compared to those who did not. this showed the effectiveness of the intervention towards family caregiver burden. furthermore, there was an increase in the average quality of life score in the group that received the intervention compared to those who did not. therefore, this study showed the effectiveness of nursing psychoeducation towards family quality of life. article [page 166] [healthcare in low-resource settings 2023; 11(s1):11215] non 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11(s1):11215] [page 167] correspondence: suharsono, health polytechnic semarang, central java, indonesia. tel.: +6293365185. e-mail: suharsono.disi@gmail.com key words: psychoeducation, family burdens, quality of life, caregiver. acknowledgment: the authors are grateful to the head of the public health center, nurses, and doctors who were participated as well as the following team members for their contributions to the success of this study. contributions: all authors contributed equally, namely sh conducted this study, nf and mh served as supervisors and reviewed the final article. conflict of interests: the author declares no conflict of interest. funding: this study wasfinancially supported by board for development and empowerment human resources of health. minister of health indonesia clinical trials: this study was approved the ethical committee of the faculty of medicine, public health and nursing, gadjah mada university – dr sardjito hospital yogyakarta with the number: ke/fk/016/ec/2020) dated january 22, 2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11215 doi:10.4081/hls.2023.11215 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.non -co mmerc ial us e o nly pract 2012;13:42. 23. martín-carrasco m, fernández-catalina p, domínguezpanchón ai, et al. a randomized trial to assess the efficacy of a psychoeducational intervention on caregiver burden in schizophrenia. eur psychiatry 2016;33:9–17. 24. matsuda m, kohno a. effects of the nursing psychoeducation program on the acceptance of medication and conditionspecific knowledge of patients with schizophrenia. arch psychiatr nurs 2016;30:581–6. 25. zhou y, ning y, rosenheck r, et al. effect of living with patients on caregiver burden of individual with schizophrenia in china. psychiatry res 2016;245:230–7. 26. suharsono, marchira cr, rahmat i, subandi. the relationship between family burden and coping strategies in the caregiver of patient with schizophrenia in community. int j psychosoc rehabil 2020;24:2593–9. 27. ozlu a, yildiz m, aker t. burden and burden-related features in caregivers of schizophrenia patients. düşünen adam: j psychiatr neurol sci 2015;28:147–53. 28. jagannathan a, thirthalli j, hamza a, et al. predictors of family caregiver burden in schizophrenia: study from an in-patient tertiary care hospital in india. asian j psychiatr 2014;8:94–8. 29. öksüz e, karaca s, özaltın g, et al. the effects of psychoeducation on the expressed emotion and family functioning of the family members in first-episode schizophrenia. community ment health j 2017;53:464–73. 30. yasuma n, sato s, yamaguchi s, et al. effects of brief family psychoeducation for caregivers of people with schizophrenia in japan provided by visiting nurses: protocol for a cluster randomised controlled trial. bmj open 2020;10:e034425 31. marchira cr, supriyanto i, subandi s, et al. brief interactive psychoeducation for caregivers of patients with early phase psychosis in yogyakarta, indonesia. early interv psychiatr 2017;13:469–76. 32. navidian a, kermansaravi f, rigi sn. the effectiveness of a group psycho-educational program on family caregiver burden of patients with mental disorders. bmc res notes 2012;5:399. 33. shiraishi n, watanabe n, katsuki f, et al. effectiveness of the japanese standard family psychoeducation on the mental health of caregivers of young adults with schizophrenia: a randomised controlled trial. bmc psychiatry 2019;19:1–12. 34. tabeleão v, tomasi e, de avila quevedo l. a randomized, controlled trial of the effectiveness of a psychoeducational intervention on family caregivers of patients with mental disorders. community ment health j 2018;54:211–7. 35. ribé jm, salamero m, pérez-testor c, mercadal j, aguilera c, cleris m. quality of life in family caregivers of schizophrenia patients in spain: caregiver characteristics, caregiving burden, family functioning, and social and professional support. int j psychiatry clin pract 2018;22:25-33. 36. zamzam r, midin m, hooi ls, et al. schizophrenia in malaysian families: a study on factors associated with quality of life of primary family caregivers. int j ment health syst. 2011;5:16. 37. yazici e, karabulut u, yildiz m, et al. burden on caregivers of patients with schizophrenia and related factors. noro psikiyatr ars. 2016;53:96–101. article [page 168] [healthcare in low-resource settings 2023; 11(s1):11215] non -co mmerc ial us e o nly hrev_master abstract nutritional status and health are crucial factors in maintaining a healthy pregnancy, especially during the covid-19 pandemic. this study aimed to analyze the relationship between cgol (chlorophyll, ginger, orange, and lemongrass) consumption and confirmed covid-19 cases in pregnant women. the research, conducted in east java with 250 purposively sampled respondents, employed a correlational cross-sectional design. data were collected through questionnaires, likert scales, and documentation. analysis of research data using descriptive analysis and spearmanrho analyses. the study revealed that cgol consumption in pregnant women was 28% less than optimal, 21.2% moderate and 50.8% optimal. confirmed covid-19 cases in pregnant women are 10%, and 90% are not confirmed. there was a significant relationship between cgol consumption and confirmation of covid-19 in pregnant women (p=0.0001). these findings emphasize the importance of integrating cgol-based nutritional guidelines into prenatal care programs, particularly during pandemics, to enhance pregnant women’s and their babies’ health. introduction pregnancy is a significant event for both pregnant women and their partners,1 representing a period of maturation amidst potential crises.2 physiological changes during pregnancy lead to a decrease in immunity,3 necessitating various measures to safeguard the health of expectant mothers.4,5 the global occurrence of covid19, including indonesia, has presented a critical issue, as there is currently no specific cure for this virus.6 thus, it is imperative to adopt preventive measures against covid-19 exposure and infection.7 these preventive measures include physical distancing,8 frequent handwashing,9 optimizing nutrition through a balanced diet,10 and the supplementation of essential nutrients to enhance immunity,11,12 based on health service data from confirmed covid-19 cases, it is evident that certain demographics, such as the elderly, toddlers, individuals with comorbidities, and pregnant women, are at a higher risk for adverse outcomes.13 certain nutrients are believed to have immunity-boosting properties, such as foods rich in chlorophyll,14 essential ingredients from spices like ginger and lemongrass,13,15 as well as fruits abundant in vitamin c, such as oranges.11,16 however, no studies have investigated whether the consumption of these ingredients effectively enhances immunity in pregnant women, particularly in preventing covid-19 exposure. indonesia reported its first two positive cases of covid-19 on march 2, 2020. by april 15, 2020, the virus had spread to all 34 provinces.17 jember regency in east java, which reported one of the highest maternal mortality rates (mmr) in the province and ranked second in infant mortality rate (imr), was significantly affected.18 in 2020, there were 645 reported cases of covid-19 in pregnant women in indonesia by september 11, 2020.19 given these circumstances, it is essential to optimize promotive and preventive actions to mitigate the risk of covid-19 healthcare in low-resource settings 2023; volume 11:11749 relationship between cgol (chlorophyll, ginger, orange, and lemongrass) consumption and confirmed covid-19 cases on pregnant women diyan indriyani,1,2 esti yunitasari,3 ferry efendi3 1doctoral nursing program, faculty of nursing, universitas airlangga, surabaya; 2faculty of health sciences, universitas muhammadiyah jember, jember; 3faculty of nursing, universitas airlangga, surabaya, indonesia correspondence: diyan indriyani, doctoral nursing program, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: diyanindriyani@unmuhjember.ac.id key words: cgol; covid-19; pregnant woman. contributions: di conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ey conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; fe conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing, resources, supervision, and writing investigation. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the ethical standards of the university of muhammadiyah jember (ethic number: 0075/kepk/fikes/i/2021). during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 11 september 2023. accepted: 9 october 2023. early access: 13 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11749 doi:10.4081/hls.2023.11749 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 16] [healthcare in low-resource settings 2023; 11:11749] non -co mmerc ial us e o nly complications during pregnancy. while previous research has investigated the nutritional content of chlorophyll,14 ginger, oranges,13 and lemongrass,11 no studies have explored whether the consumption of these nutrients, particularly among pregnant women, can effectively prevent covid-19 exposure. the aim of this study was to analyzing relationship between cgol consumption and confirmed covid-19 cases on pregnant women. materials and methods research design a correlational design with a cross-sectional, retrospective study approach was employed, with the research aim of analyzing relationship between cgol consumption and confirmed covid19 cases on pregnant women. study participants the study population consisted of pregnant women who received antenatal care at the hospital in east java in 2020, there were five hospitals as research locations located in east java province. researchers determined the sample size 250 samples using purposive sampling techniques from january to july 2021. the inclusion criteria comprised pregnant women who received antenatal care at an east java hospital, who were willing to participate as respondents, and who did not have comorbidities. pregnant women with malnutrition and anemia were excluded. demographics key demographic characteristics of the pregnant women included maternal and paternal age (categorized as < 20 years, 2035 years, and > 35 years), maternal and paternal education (categorized as elementary-junior high, senior high, and bachelor’s degree), maternal and paternal occupation (categorized as private employees, entrepreneurs, and civil servants), parity status (categorized as primigravida, multigravida, and grandemultigravida), antenatal care visits (categorized as non-routine and routine), family monthly income (categorized as <2,000,000 idr, 2,000,0005,000,000 idr, > 5,000,000-7,000,000 idr, and > 7,000,000 idr), and the role of health workers and family (categorized as less optimal and optimal). research instrument data on the characteristics of pregnant women were collected using a questionnaire that included information on maternal age, paternal age, parity, maternal education, paternal education, maternal employment, paternal employment, family monthly income, and antenatal care visits. the role of health workers was assessed using 20 questions, family roles with 20 questions and cgol consumption with 20 questions. the likert scale was employed to measure responses, offering four choices: always, often, rarely, and never. covid-19 confirmation data were obtained from patient medical records at both hospitals. statistical analysis statistical analysis encompassed univariate and bivariate techniques. univariate analysis was used to describe the categorical characteristics of respondents by providing frequency distributions. bivariate analysis aimed to explore the relationship between cgol consumption and confirmed covid-19 cases on pregnant women with spearman rho analyses were utilized with a significance level set at 5% (0.05). results the characteristics of pregnant women can be found in table 1, which includes a total of 250 respondents. it can be inferred that the majority of mothers are aged 20-35 years, with a total of 160 respondents (64%). most fathers are aged 20-40 years, with a total of 147 respondents (58.8%). the majority of parity status is multiparous, with a total of 166 respondents (66.4%). for mothers’ education, most have completed senior high school, with 132 respondents (52.8%), and fathers’ education also predominantly falls under the senior high school category, with 168 respondents (67.2%). regarding occupation, the majority of mothers were housewife with 110 respondents (44%), and the smallest category is civil servants, with only 25 respondents (10%). fathers mostly work as entrepreneurs, with 153 respondents (61.2%). the highest family income within a month falls between idr 2,000,000 idr 5,000,000 or equal to 130.55 usd 326.37 usd, with 115 respondents (46%). antenatal care visits, as seen in table 1, are mostly done routine, with 187 respondents (74.8%), and non-routine by 63 respondents (25.2%). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of general characteristics of pregnant women (n = 250). variable quantity percentage mothers’ age <20 years old 35 14.0 20-35 years old 160 64.0 >35 years old 55 22.0 fathers’ age <20 years old 8 3.2 20-40 years old 147 58.8 >40 years old 95 38.0 parity status primigravida 75 30.0 multigravida 166 66.4 grandemultigravida 9 3.6 mothers’ education elementary-junior high school 88 35.2 senior high school 132 52.8 university level 30 12.0 fathers’ education elementary-junior high school 43 17.2 senior high school 168 67.2 university level 39 15.6 mothers’ occupation housewife 110 44.0 private employees 57 22.8 entrepreneur 58 23.2 civil servants 25 10.0 fathers’ cccupation private employees 70 28.0 entrepreneur 153 61.2 civil servants 27 10.8 family income within a month (idr/ usd) < 2.000.000 / > 130.55 75 30.0 2.000.000-5.000.000 / 130.55-326.37 115 46.0 > 5.000.000-7.500.000 / >326.37-489.56 35 14.0 > 7.500.000/ > 489.56 25 10.0 antenatal care visit non-routine 63 25.2 routine 187 74.8 [healthcare in low-resource settings 2023; 11:11749] [page 17] non -co mmerc ial us e o nly data on the role of health workers, family, cgol consumption and confirmed cases of covid-19 on pregnant woman are shown in table 2. the role of health workers and family in pregnant women are mostly optimal, with 175 respondents (70%) and 162 respondents (64.8%), respectively. the majority of cgol consumption is optimal, with 127 respondents (50.8%). most pregnant women have never been confirmed positive for covid-19, with 225 respondents (90%). bivariate analysis was carried out using spearman rho as shown in table 3. there is a relationship between cgol consumption and confirmed covid-19 cases with a p value of 0.0001, with a correlation coefficient of 0.647, which means there is a strong relationship. discussion one of the key strategies for maintaining the health of pregnant women is optimizing their nutrition. the nutritional needs of pregnant women, both for the mother and the fetus, are critical.12,20 previous research has suggested that the consumption of foods rich in certain ingredients, such as green vegetables, vitamin c-rich oranges, ginger, and lemongrass, can effectively boost immunity.21,22 our results indicate that the roles of health workers and families in preventing covid-19 and illnesses in pregnant women were largely optimal. families play a crucial role in providing essential support to pregnant women during the perinatal period, which includes pregnancy, childbirth, and the postpartum period. their active involvement is facilitated by daily interactions and a strong sense of responsibility for the well-being of pregnant women.20,23 this family support is vital for preparing pregnant women mentally and emotionally to adapt to the challenges of pregnancy.3,24 additionally, our findings suggest that the role of health workers was predominantly optimal, with a focus on education and health promotion, often provided during antenatal care visits. timely initiation of antenatal care is influenced by various factors, including maternal age, education level, and socioeconomic status.1 non-routine attendance, often related to delayed first visits, can pose risks to maternal and fetal health.2 also stated that both rural and suburban women had a high percentage of a late first anc visit.2 these findings align with the impact of the covid-19 pandemic on the mental health of pregnant women, as it has added stress and uncertainty to an already challenging period.25,26 in terms of nutritional behavior, the majority of pregnant women exhibited optimal consumption of cgol-rich foods. this suggests that many pregnant women include cgol in their diets, which can be considered a safe and healthy practice.27 these foods, such as green vegetables with chlorophyll, ginger with its numerous health benefits,15,28,29 vitamin c-rich oranges, and lemongrass containing essential oils and other nutrients, contribute to overall well-being.16,21,22 the antioxidant and anti-inflammatory properties of gingerol compounds in ginger, for example, can positively impact health.30,31,32 regarding specific health variables, 90% of the respondents tested negative for covid-19, while 10% confirmed positive cases. this highlights the susceptibility of pregnant women to respiratory infections, including covid-19, due to physiological changes and weakened immunity during pregnancy.4,6 however, it is important to address the stress and mental health challenges that pregnant women face during the pandemic to protect their wellbeing. factors such as maternal age, education level, and socioeconomic status can influence health behaviors and outcomes. additionally, maintaining optimal health behaviors during pregnancy positively impacts overall health, especially during the pandemic.31,33,34,35 a study indicated that pregnant women are more susceptible to contracting covid-19 due to potential weakening of their immune systems.9 covid-19 is characterized by immunerelated factors such as reduced lymphocyte levels and elevated proinflammatory cytokines.36 pregnant women and their fetuses represent a high-risk population during infectious disease outbreaks.36 furthermore, pregnancies complicated by sars-cov-2 infection are associated with an increased likelihood of cesarean delivery and preterm birth.10 the emergence of new mutations in the coronavirus presents unique challenges to the medical community, as the optimal treatment approach has not yet been determined and often relies on institutional guidelines.37 several previous studies have explored the relationship between the consumption of nutrients containing cgol and preventive efforts against covid-19 in pregnant women. these studies have emphasized the importance of a balanced diet or nutritional therapy as a powerful strategy to combat covid-19.14 research findings have indicated that around 10.5% of the population, equivalent to approximately 4.6 million adults in south korea, falls into the high-risk category, with about 20% of them having inadequate intakes of vitamins a, b1, b2, b3, and c.11 while good nutrition, in general, is crucial for recovery from covid-19 and other serious infections, specific nutrients can be particularly beneficial.13 other studies have suggested that better nutrition and supplementation with various nutrients, such as omega-3 fatty acids, amino acids, zinc, and vitamins c and e, may be helpful in preventing and treating covid-19 and other serious infections.16 in line with the aforementioned explanations, vitamin c plays a crucial role in enhancing the body’s immunity, which includes protection against covid-19.22 oranges are an excellent example of a fruit rich in vitamin c. furthermore, the consumption of nutri transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. frequency distribution of the role of health workers and family, cgol consumption, and case of covid-19 on pregnant women (n=250). variable quantity percentage the role of health workers less optimal 75 30.0 optimal 175 70.0 the role of family less optimal 88 35.2 optimal 162 64.8 cgol consumption less optimal 70 28.0 average 53 21.2 optimal 127 50.8 confirmed covid-19 cases confirmed 25 10.0 not confirmed 225 90.0 table 3. bivariate analysis of the relationship between cgol consumption and confirmed covid-19 cases on pregnant women (n=250). variable correlation coeficient p-value cgol consumption confirmed covid-19 case 0.647** 0.0001 (**) strong relationship. [page 18] [healthcare in low-resource settings 2023; 11:11749] non -co mmerc ial us e o nly ents containing chlorophyll, ginger, and lemongrass is equally important in boosting immunity.31,32 conclusions cgol consumption is associated with the prevention of covid-19 cases on pregnant women. nurses can play a pivotal role in educating pregnant women about the importance of incorporating cgol into their daily nutritional intake. furthermore, integrating cgol-based nutritional guidelines into prenatal care programs, especially during pandemics, can be a proactive approach to enhancing the health and immunity of pregnant women. references 1. manyeh ak, amu a, williams j, gyapong m. factors associated with the timing of antenatal clinic attendance among firsttime mothers in rural southern ghana. bmc pregnancy childbirth 2020;20:1-7. 2. ebonwu j, mumbauer a, uys m, et al. determinants of late antenatal care presentation in rural and peri-urban communities in south africa: a cross-sectional study. plos one 2018;13:1-16. 3. hawkins m, misra d, zhang l, et al. family involvement in pregnancy and psychological health among pregnant black women. arch psychiatr nurs 2021;35:42-8. 4. khoury je, atkinson l, bennett t, et al. covid-19 and mental health during pregnancy: the importance of cognitive appraisal and social support. j affect disord 2021;282:1161-9. 5. efendi f, israfil i, ramadhan k, et al. factors associated with receiving iron supplements during pregnancy among women in indonesia. electron j gen med 2023;20(5). 6. salma u. relationship of covid-19 with pregnancy. taiwan j obstet gynecol 2021;60:405-11. 7. efendi f, haryanto j, has emm, et al. determinants of mortality risk among indonesian patients with covid-19. f1000research 2023;11:814. 8. moore km, suthar ms. comprehensive analysis of covid19 during pregnancy. biochem biophys res commun 2021;538:180-6. 9. phoswa wn, khaliq op. is pregnancy a risk factor of covid19? eur j obstet gynecol reprod biol 2020;252:605-9. 10. joseph nt, rasmussen sa, jamieson dj. the effects of covid-19 on pregnancy and implications for reproductive medicine. fertil steril 2021;115:824-30. 11. baik i. region-specific covid-19 risk scores and nutritional status of a high-risk population based on individual vulnerability assessment in the national survey data. clin nutr 2022;41:3100-5. 12. armini nka, hidayati n, kusumaningrum t. determinants of nutritional status among pregnant women: a transcultural nursing approach. j ners 2020;15:214-21. 13. curtis l. good nutrition critical to prevent covid 19 mortality. hear lung 2021;50:441. 14. alam s, bhuiyan fr, emon th, hasan m. prospects of nutritional interventions in the care of covid-19 patients. heliyon 2021;7:e06285. 15. abdullahi a, khairulmazmi a, yasmeen s, et al. phytochemical profiling and antimicrobial activity of ginger (zingiber officinale) essential oils against important phytopathogens. arab j chem 2020;13:8012-25. 16. richa r, kohli d, vishwakarma d, et al. citrus fruit: classification, value addition, nutritional and medicinal values, and relation with pandemic and hidden hunger. j agric food res 2023;14:100718. 17. kementerian kesehatan republik indonesia. pedoman pelayanan antenatal, persalinan, nifas, dan bayi baru lahir di era adaptasi kebiasaan baru. kementerian kesehatan republik indonesia dirjen kesehatan masyarakat; 2020. 18. dinas kesehatan kabupaten jember. survei data kesehatan aki dan akb di kabupaten jember. 2018. 19. dinas kesehatan kabupaten jember. survei data kesehatan di kabupaten jember. 2020. 20. yani ly, merbawani r, munfadlila aw. empowering health cadres on nutrition education for pregnant women in industrial areas during the pandemic. j ners 2021;16:177-82. 21. sánchez-martínez jd, cifuentes a, valdés a. omics approaches to investigate the neuroprotective capacity of a citrus sinensis (sweet orange) extract in a caenorhabditis elegans alzheimer’s model. food res int 2023;172. 22. almuhayawi ms, al jaouni sk, almuhayawi sm, et al. elevated co2 improves the nutritive value, antibacterial, antiinflammatory, antioxidant and hypocholestecolemic activities of lemongrass sprouts. food chem 2021;357:129730. 23. triharini m, sulistyono a, adriani m, devy sr. the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and self-determination theory. j ners 2019;14:92-100. 24. liang h, acharya g. novel corona virus disease (covid�19) in pregnancy: what clinical recommendations to follow? acta obstet gynecol scand 2020;99:439-42. 25. ibragimov u, beane s, friedman sr, et al. evidence for hiv transmission across key populations: a longitudinal analysis of hiv and aids rates among black people who inject drugs and black heterosexuals in 84 large u.s. metropolitan areas, 20082016. ann epidemiol 2021;55:69-77.e5. 26. hall s, white a, ballas j, et al. education in trauma-informed care in maternity settings can promote mental health during the covid-19 pandemic. j obstet gynecol neonatal nurs 2021;50:340-51. 27. swain ss, paidesetty sk, padhy rn, hussain t. nano-technology platforms to increase the antibacterial drug suitability of essential oils: a drug prospective assessment. opennano 2023;9:100115. 28. kim j, kim h, beuchat lr, ryu jh. synergistic antimicrobial activities of plant essential oils against listeria monocytogenes in organic tomato juice. food control 2021;125:108000. 29. spence c. ginger: the pungent spice. int j gastron food sci 2023;33:100793. 30. owusu-ansah p, alhassan ar, ayamgama aa, et al. phytochemical analysis, enumeration, isolation, and antimicrobial activity of lemongrass and moringa leaves extracts. j agric food res 2023;12:100579. 31. balakrishnan b, paramasivam s, arulkumar a. evaluation of the lemongrass plant (cymbopogon citratus) extracted in different solvents for antioxidant and antibacterial activity against human pathogens. asian pacific j trop dis. 2014;4:134-9. 32. martins w da s, de araújo jsf, feitosa bf, et al. lemongrass (cymbopogon citratus dc. stapf) essential oil microparticles: development, characterization, and antioxidant potential. food chem 2021;355. [healthcare in low-resource settings 2023; 11:11749] [page 19] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 33. ryan lm, mahmood dma, laurence pco. incidence of concomitant illnesses in pregnancy in indonesia: estimates from 1990-2019, with projections to 2030. lancet reg heal west pacific 2021;10:100139. 34. dawood fs, kittikraisak w, patel a, et al. incidence of influenza during pregnancy and association with pregnancy and perinatal outcomes in three middle-income countries: a multisite prospective longitudinal cohort study. lancet infect dis 2021;21:97-106. 35. chilaka vn, konje jc. viral hepatitis in pregnancy. eur j obstet gynecol reprod biol 2021;256:287-96. 36. dashraath p, wong jlj, lim mxk, et al. coronavirus disease 2019 (covid-19) pandemic and pregnancy. am j obstet gynecol 2020;222:521-31. 37. syeda s, baptiste c, breslin n, et al the clinical course of covid in pregnancy. semin perinatol 2020;44:151284. [page 20] [healthcare in low-resource settings 2023; 11:11749] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11340 the effect of vitamin d deficiency on glycemic control in patients with type 2 diabetes mellitus neveen rashad mostafa,1 abeer ahmed mohamed ali,2 roy rillera marzo3,4 1department of internal medicine; 2department of chemical pathology, medical research institute, alexandria university, egypt; 3department of community medicine, international medical school, management and science university, shah alam; 4global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract multiple factors are involved in the development of type 2 diabetes mellitus (t2dm), but an imbalance between free radical formation and antioxidant removal is the main cause of diabetic complications. micronutrients with antioxidant properties may have a role in the development of diabetes mellitus (dm) and its complications. vitamin d has recently been found to have membrane antioxidant effect and a relationship to the development of t2dm, as it can modify its risk. whether vitamin d deficiency has an effect on hyperglycemia in diabetic patients or not need further study. our aim was to examine the effect of vitamin d deficiency on glycemic control in t2dm. we examined the vitamin d levels of 100 patients with t2dm and correlated them with fasting blood sugar and glycated hemoglobin a1c (hba1c) levels. high levels of fasting blood sugar and hba1c levels were significantly associated with vitamin d deficiency. vitamin d deficiency negatively affects glycemic control in patients with t2dm. introduction type 2 diabetes mellitus (t2dm) is highly prevalent worldwide, especially in developing countries. it is caused by pancreatic β-cell dysfunction and insulin resistance, it places a burden on health care institutions due to its many macrovascular and microvascular complications, which lead to high morbidity and mortality.1 some humoral substances, such as adipokines increase incidence of diabetic complications. one of these adipokines is pasma omentin -1, which has an anti-diabetogenic effect and its level is reduced in diabetic patients with high insulin resistance, as it is found that plasma level of omentin -1 is much lower in diabetic patients with complications than in diabetic patients without complications.2 another adipokine is neuregulin-4, which has an important role in regulating energy balance, and metabolism of glucose and lipid. it also helps in chronic inflammation down-regulation and it is a good predictor of microvascular complications in diabetic patients.3 t2dm is associated with chronic low grade of inflammation, and many inflammatory markers are produced. these lead to free radical formation that needs removal by antioxidant. one new cytokine produced in dm is cardiothrophin-1 (ct-1), which is composed of 201 amino acid, and has protective effects against apoptosis. aktas et al., found that there are increased levels of ct1 in diabetic patients independently of hypertension and heart failure. the cause of elevation of ct-1 in type 2 diabetes is that pancreatic beta cell volume and function progressively dimensioned and ct-1 protect pancreatic beta cells from apoptosis. however, the elevated levels lead to left ventricular failure as they cause structural modification of myocytes.4 another set of markers of inflammation derived from hemogram in diabetic patients are neutrophil/lymphocyte ratio and mean platelet volume/lymphocyte ratio (mpvlr). they are found to be associated with frailty in diabetes and are considered to be independent predictors of gestational diabetes.5,6 another novel marker of inflammation increased in diabetes, especially correspondence: neveen rashad mostafa, department of internal medicine, medical research institute, alexandria university, egypt. e-mail: nevomos@gmail.com key words: vitamin d; diabetes mellitus type 2; glycemic control, inflammation. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethics committee of medical research institute approved this study (e/c.s/n.r6/2022). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 27 march 2023. accepted for publication: 3 may 2023. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):111340 doi:10.4081/hls.2023.11340 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 8] [healthcare in low-resource settings 2023; 11(s2):11340] non -co mmerc ial us e o nly those with diabetic nephropathy, is crp to albumin ratio. this marker is found to be elevated in those patients (according to the roc curve, a level higher than 0.82% presents the best sensitivity and specificity in the association with diabetic nephropathy).7 many predictors of diabetic control have emerged to help in differentiating well from poorly controlled diabetes. one of them is uric acid/hdl cholesterol ratio, which has a strong association with fasting blood sugar and hba1c.8 vitamin d is a fat soluble vitamin that is produced through the effect of ultraviolet b radiation on the epidermis of the skin. it is also found in food substances like fish oil and egg yolk. to become active, it needs two hydroxylation processes, one in the liver that produce 25-hydroxyvitamin d, and the other in the kidney that produce 1, 25-hydroxyvitamin d.9 vitamin d receptors are present in the pancreatic βcells as vitamin d is involved in regulation of insulin secretion, that’s why some hypothesis postulated that vitamin d is involved in the pathogenesis of diabetes mellitus.10 many studies have been conducted to determine the relation between vitamin d deficiency and progression of diabetes, especially its macrovascular complications. vitamin d deficiency is associated with high inflammatory burden, and many inflammatory markers have been found to be elevated in vitamin d deficiency patients.11 other studies have found a significant effect of vitamin d supplementation on improving fasting blood sugar and glycated hemoglobin a1c.12 however, more studies are needed to determine the relationship between vitamin d deficiency and glycemic control in diabetic patients and whether vitamin d supplement is going to help in controlling the disease progression. materials and methods study design this study was a prospective randomized clinical trial conducted on 100t2dm patients. the participants ‘vitamin d level, fasting blood sugar and hba1c were measured, all patients were treated with oral hypoglycemic medications. the study was conducted at medical research institute, alexandria university, between june 2021 to september 2021. patients enrolled in the study were selected from diabetic population routinely attending the outpatient clinic or admitted to the inpatient wards for follow up and treatment of their diabetes. all patients provided written informed consent, and the study was approved by the ethics committee of the institute. patients type 2 diabetic patients were randomly selected from those who were registered at our outpatient clinic or admitted to our inpatient wards. during selection, diabetes was diagnosed and confirmed according to the diagnostic criteria established by the american diabetes association at the time of the study,13 with no change in their diabetes treatment protocol during the study. inclusion criteria t2dm patients above 18 years of age, non-obese with 18.5>bmi <25 kg/m2 according to who criteria.14 exclusion criteria individuals with any of the following were excluded: type 1 dm, gestational dm, chronic kidney disease, chronic liver disease, article figure 1. relation between vitamin-d level and parameters of glycemic control. table 1. distribution of the studied cases according to demographic data and vitamin d level (n=100). variable no. (%) gender male 40 (40) female 60 (60) age (years) mean ± sd. 56.7±12.9 median (min. – max.) 60.5 (25–75) vitamin-d (ng/ml) deficient (<30) 60 (60) normal (30 – 100) 40 (40) mean ± sd. 27.5±15.4 median (min. – max.) 23.5 (8.1–63.3) sd, standard deviation. table 2. relation between vitamin-d and demographic data (n= 100). vitamin-d (ng/ml) p deficient normal (<30) (30 – 100) test of sig. (n = 60) (n = 40) gender male 28 (46.7%) 12 (30%) χ2= 2.788 0.096 female 32 (53.3%) 28 (70%) age (years) mean ± sd 56.37±14.24 57.3± 0.6 t=0.355 0.723 median (min. – max.)61 (25–75) 60.5 (27–74) sd, standard deviation; t, student t-test, χ2, chi square test; *statistically significant at p≤0.05. table 3. relation between vitamin-d level and parameters of glycemic control (n=100). vitamin-d (ng/ml) u p mean ± sd. median (min.–max.) fasting blood sugar controlled (≤130) 32.4±14.7 31.7 (11.6–57.5) 774.0* 0.003* uncontrolled (>130) 24.3±15.1 18.7 (8.1–63.3) hba1c (%) controlled (≤7) 31.6±15.3 31.7 (10.4–57.5) 838.0* 0.005* uncontrolled (>7) 23.2±14.4 18.7 (8.1–63.3) sd, standard deviation; u, mann whitney test; *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11340] [page 9] non -co mmerc ial us e o nly and hypoparathyroidism: i) thorough clinical examination including weight and height; ii) routine laboratory investigations including: liver function tests, renal function tests, electrolytes, complete blood picture, and lipid profile;14,15 iii) glycemic control was assessed by fasting blood sugar and hba1c;13 iv) vitamin d assessment by high performance liquid chromatography.16 statistical analysis data were fed to the computer and analyzed using ibm spss software package version 20.0. (armonk, ny: ibm corp). the kolmogorovsmirnov test was used to verify the normality of distribution of variables. paired t-test was assessed for comparison between two periods for normally distributed quantitative variables, while wilcoxon signed ranks test was assessed for comparison between two periods for abnormally distributed quantitative variables. significance of the obtained results was judged at value <0.05. results according to the inclusion and exclusion criteria, 100 type 2 diabetic patients were involved in the study. vitamin d was deficient in 60 (60%) of cases, and normal in 40 (40%; table 1). the demographic data of diabetic patients at baseline were: 40 (40%) males, 28 (46.7%) had vitamin d deficiency and 12 (30%) had normal vitamin d level. 60 (60%) females, 32 (53.3%) had vitamin d deficiency and 28 (70%) had normal vitamin d level, p= 0.096 (tables 1, 2). the mean age of diabetic patients with vitamin d deficiency was 56.7 ± 12.9 years, and mean age of diabetic patient with normal vitamin d level was 57.3 ± 10.6 years, p=0.723 (table 2). mean vitamin d level in diabetic patients with controlled fasting blood sugar was 32.4±14.7ng/ml, while the mean vitamin d level in diabetic patients with uncontrolled fasting blood sugar was 24.3±15.1ng/ml, p= 0.003*(table 3, figure 1). the mean vitamin d level in diabetic patients with controlled hba1c level was 31.6±15.3ng/ml, while the mean vitamin d level in diabetic patients with uncontrolled hba1c level was 23.2±14.4ng/ml, p=0.005* (table 3, figure 1). discussion vitamin d deficiency is a common finding in diabetic patients, and prevalence varying between regions. for instance, a study conducted in a referral hospital in kenya reported lower prevalence rates of vitamin d deficiency and insufficiency among diabetic patients (38.4% and 21.9% respectively), compared to other countries in asia, europe, and north america.17 however, in a study conducted in saudi arabia found higher rates of prevalence of vitamin d deficiency (59.8%) and insufficiency (38.6%) among diabetic patients, which is similar to our findings where 60% of diabetic patients were vitamin d deficient.18 gender may also play a role in the prevalence of vitamin d deficiency among diabetic patients, as recent research has shown that female diabetic patients are more deficient in vitamin d than male diabetic patients.19 in our study, we found that 53.3% of female diabetic patients were vitamin d deficient, while 46.7% of the male diabetic patients were deficient, but this was not statistically significant. the difference may be attributed to factors such as poor sun exposure, poor dietary vitamin d, obesity and sedentary life in middle east females. in addition, elderly people, including diabetic patients, are more susceptible to vitamin d deficiency, especially in european countries with low sun exposure, decreased synthesis, absorption, and metabolism because of aging.17 however, in our study, there was no significant difference in the mean age between diabetic patients with or without vitamin d deficiency, probably because the study population had mean age of 56.7 years, and diabetes is more common in old age group. as diabetes continues to pose a major health problem, researchers have explored other pathogenic mechanisms that contribute to its development and progression, such as the relationship between vitamin d deficiency and progression of diabetes. this is due to the presence of vitamin d receptors in pancreatic b cells and other tissues such as liver and muscle tissue, suggesting that vitamin d may be involved in glucose homeostasis.20 studies have shown that optimum level of vitamin d in serum reduces insulin resistance, and hba1c level and leading to more control of hyperglycemia.21 in another case control study, hba1c found to be higher in the group with vitamin d deficiency than the group with no vitamin d deficiency.22 a recent study done by erkus e, et al. involved a controlled group of diabetic patients and uncontrolled group, assessing vitamin d levels in both controlled and uncontrolled groups. they found that vitamin d levels were much lower in the uncontrolled group of patients and suggested that vitamin d could be used as a treatment modality for diabetes in the future.23 another interventional study used a vitamin d supplement 4500 iu/day for 2 months and assessed fasting blood sugar and hba1c at baseline and after giving the supplement was given. they found a reduction in fasting blood sugar from a mean of 133 mg/dl to mean of 127 mg/dl and reduction of mean hba1c from 7.7% to 7.2%.24 in a double-blind, placebocontrolled study conducted by lemieux et al.,25 on 96 subjects at risk to develop diabetes or with early diabetes, they found a significant increase in peripheral insulin sensitivity and b cell function after administrating 5000 iu vitamin d daily for 6 months. however, some authors, such as kumar et al.26 in a retrospective case-control study, did not find any relation between vitamin d deficiency and glycemic control. they evaluate 78 cases and 69 controls for vitamin d and hba1c levels and found no significant correlation between them. in our study, we found that the mean vitamin d level was 32.4ng/ml in patients with controlled fasting blood sugar, while it was 24.3ng/ml in patients with uncontrolled fasting blood sugar levels. regarding hba1c, the mean vitamin level was 31.6ng/ml in patients with values ≤ 7 and 23.2ng/ml in patients with hba1c values >7. these results suggest that vitamin d deficiency is associated with higher levels of fasting blood sugar and hba1c. these results may be attributed to the postulated role of vitamin d in glycemic control where it reduces systemic inflammation by modulating the immune response and decreasing insulin resistance at the peripheral tissue.27 moreover, vitamin d increases insulin secretion via direct mechanism in which it increases intracellular calcium through calcium channel leading to increase insulin secretion or indirectly through mediating bcell calcium – dependent activation which enhance conversion of pro insulin to insulin.28 these results lead us to consider evaluation of vitamin d in diabetic patients and to correct the deficiency if present, together with optimizing diet, exercise and medications for better glycemic control. article [page 10] [healthcare in low-resource settings 2023; 11(s2):11340] non -co mmerc ial us e o nly conclusions in conclusion, higher levels of fasting blood glucose, and hba1c levels were associated with vitamin d deficiency that may affect glycemic control in type 2 diabetic patients. this may call for correction of vitamin d deficiency in patients with uncontrolled dm. references 1. ogurtsova k, rocha j, fernandes d, et al. idf diabetes atlas: global estimates for the prevalence of diabetes for 2015 and 2040. diabetes res clinical pract 2017;128:40-50. 2. latif a, anwar s, gautham k, et al. association of plasma omentin-1 levels with diabetes and its complications. cureus 2021;13:e18203. 3. kocak z, aktas g, atak b, et al. is neuregulin-4 a predictive marker of microvascular complications in type 2 diabetes mellitus? eur j clin invest 2020;50:e13206. 4. aktas g, alcelk a, tosun m, et al. diabetes mellitus increases plasma cardiothrophin-1 levels independently of heart failure and hypertension. acta med mediterr 2013;29:78. 5. liu w, lou x, zhang z, et al. association of neutrophil to lymphocyte ratio, platelet to lymphocyte ratio, mean platelet volume with the risk of gestational diabetes mellitus. gynacol endocrinol 2021;37:105-7. 6. bilgin s, aktaş g, kahveci g, et al. does mean platelet volume/lymphocyte count ratio associate with frailty in type 2 diabetes mellitus? bratisl lek listy 2021;122:116-9. 7. bilgin s, kurtkulagi o, atak b, et al. does c-reactive protein to serum albumin ratio correlate with diabetic nephropathy in patients with type 2 diabetes mellitus? the care time study. primary care diab 2021;15:1071-4. 8. aktas g, kocak m, bilgin s, et al. uric acid to hdl cholesterol ratio is a strong predictor of diabetic control in men with type 2 diabetes mellitus. aging male 2020;23:1098-102. 9. pasquali m, tartaglione l, rotondi s, et al. calcitriol/calcifediol ratio: an indicator of vitamin d hydroxylation efficiency? bba clin 2015;3:251-6. 10. zatalia r, sanusi h. the role of antioxidants in the pathophysiology, complications, and management of diabetes mellitus. acta med indones 2013;45:141–7. 11. erkus e, aktas g, atak b, et al. haemogram parameters in vitamin d deficiency. j college phys surg pak 2018;28:77982. 12. vujosevic s, borozan s, radojevic n, et al. relationship between 25-hydroxyvitamin d and newly diagnosed type 2 diabetes mellitus in postmenopausal women with osteoporosis. med princ pract 2014;23:229–33. 13. american diabetes association. classification and diagnosis of diabetes: standards of medical care in diabetes 2018. diabetes care 2018;41:s13–s27. 14. peterkova va, vasyukova ov. about the new classification of obesity in the children and adolescents. problems endocrinol 2015;61:39-44. 15. doust j, glasziou p. monitoring in clinical biochemistry. clin biochem rev 2013;34:85-92. 16. shan i, aktar m, hisaindee s, et al. clinical diagnostic tools for vitamin d assessment. j steroid biochem mol biol 2018;180:105-17. 17. karau p, kima b, amayo e, et al. the prevalence of vitamin d deficiency among patients with type 2 diabetes seen at a referral hospital in kenya. pan afr med j 2019;34:8. 18. al-humaidi m, agha a, dewish m. vitamin d deficiency in patients with type 2 diabetes mellitus in southern region of saudi arabia. maedica 2013;8:231-6. 19. a-zaharani m. the prevalence of vitamin d deficiency in type 2 diabetic patients. majmaah j health sci 2013;1:18-22. 20. zhao h, zhen y, wang z, et al. the relationship between vitamin d deficiency and glycated hemoglobin levels in patients with type 2 diabetes mellitus. diabetes metab syndr obes 2020;13:3899-907. 21. szymczak-pajor i, sliwinska a. analysis of association between vitamin d deficiency and insulin resistance. nutrient 2019;11:794. 22. al quaiz a, al rasheed a, kazi a, et al. is hydroxyvitamin d associated with glycosylated hemoglobin in patients with type 2 diabetes mellitus in saudi arabia? a population based study. int j environ res puplic health 2021;18:2805. 23. erkus e, aktas g, kocak mz, et al. diabetic regulation of subjects with type 2 diabetes mellitus is associated with serum vitamin d levels. rev assoc med bras (1992) 2019;65:51-55. 24. mohamed i, elsherbeny e, bekhet m. the effect of vitamin d supplementation on glycemic control and lipid profile in patients with type 2 diabetes mellitus. j am collnutr 2016;35:399-404. 25. lemieux p, weisnagel j, caron z, et al. effect of 6 months vitamin d supplementation on insulin sensitivity and secretion in a randomized placebocontrolled trial. eur j endocrinol 2019;181:287-99. 26. kumar a, nada k, bharathy n, et al. evaluation of vitamin d status and its correlation with glycated hemoglobin in type 2 diabetes mellitus. biomed res 2017;28:66-70. 27. li x, liu y, zheng y, et al. the effect of vitamin d supplementation on glycemic control in type 2 diabetic patients: a systemic review and meta-analysis. nutrients 2018;10:375. 28. valdes-ramos r, lopez ana laura g, elina m, donaji b. vitamins and type 2 diabetes mellitus. endocr metab immne disord drug targets 2015;15:54-63. article [healthcare in low-resource settings 2023; 11(s2):11340] [page 11] non -co mmerc ial us e o nly hrev_master [page 22] [healthcare in low-resource settings 2014; 2:1831] residents need focused teaching during pediatric emergency medicine rotation to optimize their educational objectives mohammed alomar,1 narges daliri,1 awatif alamer,1 abdolmoneim eldali2 1emergency department, king faisal specialist hospital and research centre, riyadh; 2biostatistics department, king faisal specialist hospital and research centre, riyadh, saudi arabia abstract pediatric emergency medicine (pem) rotation provides a unique training environment for rotating residents. we aim to assess the impact of pem rotation on the scientific knowledge of residents from different specialties and training centers by comparing the preand post-rotation knowledge. pem departments of three major tertiary care training centers were selected. rotating pediatric and emergency medicine residents were given pre-test with twenty multiple-choice type questions related to the scientific knowledge of pem and then re-tested with the same questions towards the end of their rotation. the t-test was used to compare mean scores. further comparison based on specialty and training center was also done. seventy-three residents were approached and enrolled, 48 from pediatrics and 25 from emergency medicine. the mean preand post-scores for all residents were 15.9/20 and 15.5/20, respectively. all residents’ score was less on the post-rotation compared to the pre-rotation in all centers. pediatric residents at one center scored higher, but they were not statistically significant. there were no statistically significant differences in resident specialty. we found a statistical difference between the residents of two centers compared to the third with p=0.04 and 0.02 respectively. after one month of rotation in pem, we observed a decrease in the post-rotation test scores as compared to the pre-rotation scores. since the reasons for the lower scores could not be identified by this study, educational deficiencies should be identified and perhaps a focused teaching and allotted study time to optimize the residents educational objective could be advised. introduction the pediatric emergency medicine (pem) rotation provides a unique training to a significant number of rotating residents by offering them access to patients with undifferentiated medical issues. they are afforded continuous supervision by attending physicians.1-4 over the past two decades, the knowledge about pem subspecialty has grown through fellowship programs, formation of pem sections in professional organizations and research.5-10 pediatric and emergency medicine residents rotating in pem are exposed to specific curriculum which has been developed by the residency training committees.11-14 saudi commission for health specialties (scfhs) in saudi arabia oversees all the training programs including pediatrics, emergency medicine (em) and has recognized and endorsed pem subspecialty fellowship training program since january, 2005.15 currently as per scfhs guidelines, pediatric residents spend five months [2 months in first post-graduate year (pgy), 1 month on third and 2 months on the fourth pgy] in pem; while em residents have to spend 4 months (2 months on the second and 2 months on the fourth pgy).16 all residents are expected to participate and attend the didactic and practical training sessions and do at least eighteen clinical shifts per month during their rotation in pem. we aim to assess the impact of pem rotation on the scientific knowledge basis of residents from different specialties and centers by comparing their preand post-rotation knowledge. materials and methods a prospective, observational, and educational study of the impact of one month training in pem at three different major tertiary care hospitals in riyadh, saudi arabia on the residents’ scientific knowledge was assessed by their performance on preand post-rotation written examinations. study setting and population the study was conducted in the pem departments of three major tertiary care centers: king faisal specialist hospital and research center (hospital a), king abdulaziz medical city (hospital b), and king fahad medical city (hospital c). these hospitals were chosen due to their reputable established pediatric residency and pem fellowship training programs and the presence of a relatively high number of trainees. program directors were notified by the authors. residents at pgy 1 to 4 in the training programs for pediatric and emergency medicine that rotated in pem as an elective or part of their integral program were selected. inclusion and exclusion criteria all rotating residents from pediatric and emergency medicine training programs were included during the study period. there were no exclusions. we developed twenty multiplechoice type questions based on clinical case scenarios that cover resuscitation, emergent airway management, trauma care, toxicological and environmental emergencies with single best answer (table 1). the questions were initially formulated by the principal investigator and subsequently approved by professionals in our institution interested in the field and the subject. the co-investigators and a few other pem physicians were consulted to review, test the questions and suggest any modifications prior to final approval. the questions were distributed to all rotating residents in the three major hospitals at the commencement of their first shift and collected at the end of the same shift by the principal or co-investigators. all participants received the same 20written questions in a paper format. after completion of the rotation participants again completed the same written examination. the residents were refrained from discussing the questions and urged to complete the test during the same shift. the participants were not given the correct answers or critical elements to the written test before, during, or after the rotation. measurement and timetable the scores were given based on the correct responses out of 20. the study was conducted healthcare in low-resource settings 2014; volume 2:1831 correspondence: mohammed alomar, emergency department, king faisal specialist hospital and research centre, p.o. box 3354 mbc 84, takhassusi street, 11211 riyadh, saudi arabia. tel. +966.1.4424425 fax: +966.1.4423429. e-mail: momar@kfshrc.edu.sa key words: residents, education, pediatric, emergency. conflict of interests: the authors declare no potential conflict of interests. contributions: ma and nd, proposal writing; aa, data collections; ae, data analysis; ma and nd, manuscript writing. received for publication: 17 july 2013. revision received: 11 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m. alomar et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1831 doi:10.4081/hls.2014.1831 non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1831] [page 23] over ten months from november 2011-july 2012. hypothesis and outcomes the hypothesis is that residents shall show improvement in their score by the end of their rotation. primary outcome is: change in the scientific knowledge of the residents by the end of their rotation. secondary outcome is: any difference from one center or specialty compare to the other. sample size and statistical analysis to our knowledge, based on literature search this is the first pilot study done in saudi arabia with participation of residents of different training programs rotating in pem. we estimated that a meaningful difference in test performance would be at least 10% improvement in the score delta (post-test minus pretest). for detection of statistical significance, with two-tailed mean comparison test with 90% power and alpha of 0.05, a sample size of at least 22 persons in each group was needed. this assumed a standard deviation (sd) of mean score delta to be 10%. the student’s ttest was used to compare mean test scores. completed answers were entered in an excel spreadsheet and spss version 10 statistical packages were used. descriptive data used in form of frequency tables, which were generated for each resident in the test. further comparison based on specialty and the training center was also done. a p<0.05 was considered statistically significant. ethics a verbal consent was taken from all participants and they were assured that the results of the tests would be kept confidential and have no bearing on their official evaluation or future performance in pem. office of research affairs’ approval of hospital a (base hospital of the investigators) approved the study before enrollment of subjects. results all approached seventy-three residents from three centers were enrolled, 48 pem and 25 em. the exact number of residents enrolled from each center is indicated (table 2). all residents completed the study during the enrollment period. the mean pre and post score for all residents were (15.9/20 and 15.5/20) respectively. none of the residents achieved full mark (20) in the preor post-rotation score. all residents scored less on post-rotation test compared to the pre-rotation except pediatric residents at hospital b which was statistically not significant. there were no statistical differences in the means by residents’ level within the centers. there were no statistically significant differences in resident specialty between the groups (p>0.05) (table 3). as for the centers, there were a statistical difference among all residents at both hospital c and hospital a compared to hospital b with a p value of 0.04 and 0.02 respectively (table 4). discussion riyadh tertiary care hospitals are often thought to be ideal sites for pem rotations because of high acuity and a diverse spectrum of patients. the clinical experience is somearticle table 1. contents and distribution of the test questions. contents number of questions dehydration 2 metabolic disorders 2 upper airway emergencies 2 acute neurologic emergencies 2 simple laceration 1 management of mammalian bite wound 1 orthopedic emergencies 1 injury prevention advice 1 lower respiratory tract infection 1 immunocompromised with fever 1 management of soft tissue infection 1 sickle cell disease 1 acid-base imbalance 1 common congenital heart diseases 1 differential diagnosis of common 1 pediatric rashes management of common 1 toxic ingestion table 2. exact number of residents enrolled from each center with their preand post-rotation scores. hospital specialty pgy level score number mean score/20 sd min. max. p 1 2 3 4 a em 2 pre-rotation 2 16.5 0.7 16 17 0.20 post-rotation 2 15 1.4 14 16 pediatrics 3 5 pre-rotation 8 16.8 1.5 14 19 0.08 post-rotation 8 15.9 1.4 14 18 b em 4 3 11 2 pre-rotation 20 16.3 1.4 14 18 0.15 post-rotation 20 15.6 2 12 19 pediatrics 8 14 6 3 pre-rotation 31 15.4 2.4 10 19 0.72 post-rotation 31 15.6 2.1 10 19 c em 1 2 pre-rotation 3 17.7 1.2 17 19 0.18 post-rotation 3 16.3 102 15 17 pediatrics 4 4 1 pre-rotation 9 15.2 2.2 10 18 0.18 post-rotation 9 14.3 2.2 11 17 pgy, post-graduate year; sd, standard deviation; em, emergency medicine. table 3. residents’ preand post-rotation scores according to the specialty. specialty score number mean/20 sd min. max. p em pre-rotation 25 16.5 1.4 14 19 0.03 post-rotation 25 15.6 1.8 12 19 pediatrics pre-rotation 48 15.6 2.2 10 19 0.51 post-rotation 48 15.4 2 10 19 sd, standard deviation; em, emergency medicine. non co mmerc ial us e o nly [page 24] [healthcare in low-resource settings 2014; 2:1831] what similar in all three hospitals. a tertiary hospital is a center which caters to patients with complex disorders such as hematology, oncology, metabolic, immunodeficiency syndrome, neurologic disorders, congenital heart diseases, trauma and many general pediatric diseases. even though our study may suggest residents’ scientific knowledge did not improve after one month of rotation in pem and attendance at four didactic academic sessions, we certainly cannot ignore the need for further evaluation of our training programs. training requirements have to be periodically revised as educational weaknesses are identified, mainly by cross-sectional surveys of program directors. these surveys may be limited by recall bias and do not focus on measures of quality, such as quantifying clinical and procedural skills.17-19 quantitative information such as number of patients seen, resuscitations and procedures performed enables program directors to identify training/trainee deficits, provide real-time feedback to the residents, and make real time changes. if important skills and knowledge cannot be attained during the rotation, then simulated resuscitations and standardized patient encounters may be used to supplement this experience. monitoring the types of resident clinical encounters allows the program director to further tailor the didactic and interactive components of the curriculum to fill in the gaps. for example, simulation is useful for teaching high-acuity, low-frequency situations such as pediatric resuscitation. while many centers may already be using simulation to teach resuscitation and other highacuity events, this study suggests an important need for interactive educational experiences to teach additional skills or concepts that have low or no frequency during training.20-22 the efficacy of an online didactic curriculum in improving knowledge acquisition among non em, em rotating residents and medical students during their em rotations was established. after exposure to an online didactic curriculum, rotating residents demonstrated a significant increase in em knowledge and reported a high level of satisfaction with the didactic program.23,24 a recent survey data show that 58% of rotating residents in academic eds currently attend em resident conferences,25 and only 7% would prefer attending the standard em residency core conferences.26 it is difficult to predict didactic topics desired by rotating residents based solely on their respective medical specialties.27 a learner centered approach,28 allowing the resident to pick from a selection of didactic subjects, may be an appropriate solution. the community hospital provides the residents with exposure to the private practice environment, and its large children’s emergency department (ed) provides pediatric em experience. for those programs that use multiple training hospitals, identifying the types of patient encounters in each hospital may also help direct the residency curriculum. according to international data, 30-40% of ed patients present with semi urgent or nonurgent conditions,29 the care of less acute complaints is a cornerstone of pem practice.30 assuming that our training model is similar to others, an alarm should be raised because the care of lower-acuity conditions may be a training deficit. as the use of urgent care centers and triage physicians in eds increases; resident exposure to lower-acuity patients likely will decreases. residents must also be afforded the opportunity to supervise and collaborate with midlevel providers.31-33 ensuring adequate exposure to low-acuity conditions should be a priority for program directors and should affect the staffing plans for eds with pem residency programs. there is a strong need for continued research in the educational needs of residents and evaluation of educational experiences in pem training programs. further studies, possibly incorporating simulation or actual patient encounters, should be performed to determine whether this improved knowledge results in better patient care outcomes. limitations we aimed to evaluate the improvement in knowledge acquisition as measured by scores on a multiple-choice test. we acknowledge that the goal of any curriculum is to achieve true competency among learners, only a facet of which is test-taking ability and medical knowledge. furthermore, our results might differ if residents had been assessed by other means like objectively structured clinical examination. finally, these results represent the experience of only these institutions. the conclusions may not be generalizable to other centers. the pretest was performed at the start and the same questions repeated at the end of the rotation. some residents could have studied these questions checking for the correct answer, though none of them score the full marks on the post test. thus, the majority of interactions between the educational supervisors in the ed and the study participants likely occurred without confounding knowledge transmission. while there was no way to standardize clinical teaching, shift schedules for all participants were made based on routine scheduling requirements by a consultant who was not involved in the study. shift schedules for pem faculty were made by a faculty member who had no knowledge of the study or study participant shift schedule. therefore, there is no reason to suspect that residents had any significant differences in clinical teaching or patient care experiences. we therefore feel that the educational experience of residents was an accurate representation of learning by clinical practice and teaching alone. future studies should include a larger sample size and multiple institutions. conclusions after one month of rotation in pem, we observed a decrease in the post-rotation test scores as compared to the pre-rotation scores. since the reasons for the lower scores could not be identified by this study, educational deficiencies should be identified and perhaps a focused teaching and allotted study time to optimize the residents educational objective could be advised. references 1. sanders ab, kobernick me. educating internists in emergency medicine. west j med 1984;141:534-7. article table 4. residents preand post-rotation scores according to centers. hospital annual pem visits (n) pem consultants (n) score number mean/20 sd min. max. p a 15,000 12 pre-rotation 10 16.7 1.3 14 19 0.02 post-rotation 10 15.7 1.3 14 18 b 100,000 20 pre-rotation 51 15.8 2.1 10 19 0.59 post-rotation 51 15.6 2 10 19 c 65,000 8 pre-rotation 12 15.8 2.2 10 19 0.04 post-rotation 12 14.8 2.2 11 17 pem, pediatric emergency medicine; sd, standard deviation. non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1831] [page 25] 2. branzetti jb, aldeen az, courtney dm. educational orphans: a survey of emergency medicine residency directors on didactics for rotating residents in the emergency department. acad emerg med 2009;16:48. 3. kessler cs, marcolini eg, schmitz g, et al. off-service resident education in the emergency department: outline of a national standardized curriculum. acad emerg med 2009;16:1325-30. 4. rodenberg h. education in accident and emergency medicine for senior house officers: review and recommendations. j accid emerg med 1996;13:238-42. 5. pena me, snyder bl. pediatric emergency medicine. the history of a growing discipline. emerg med clin n am 1995;13:23553. 6. barkin rm. pediatric emergency medicine comes of age. acad emerg med 1994;1:12930. 7. abramo tj. pediatric emergency medicine fellowship programs. pediatr emerg care 1997;13:169-77. 8. izsak e. pediatric emergency medicine fellowship programs. pediatr emerg care 1994;10:121-6. 9. jaffe dm. research in emergency medical services for children. pediatrics 1995; 96:191-4. 10. cook rt jr. the institute of medicine report on emergency medical services for children: thoughts for emergency medical technicians, paramedics, and emergency physicians. pediatrics 1995;96:199-206. 11. asch sm, weigand jv. a pediatric curriculum for emergency medicine training programs. ann emerg med 1986;15:19-27. 12. singer ji, hamilton gc. objectives to direct the training of emergency medicine residents in pediatric emergency medicine. j emerg med 1993;11:211-8. 13. boyle mf, eilers ma, hunt rl, et al. objectives to direct the training of emergency medicine residents on off-service rotations: emergency medical services. j emerg med 1990;8:791-5. 14. asch sm, weigand jv. a pediatric curriculum for emergency medicine training programs. ann emerg med 1986;15:19-27. 15. saudi commission for health specialties, fellowships. available from: http://www.scfhs.org.sa/en/education/train ingandrecognition/higheduprogs/fellows hipprograms/pages/default.aspx 16. saudi specialty certificate of pediatrics and emergency medicine training programs. available from: http://www.kfshrc.edu.sa/ata/trainingpro grams.pdf 17. accreditation council for graduate medical education. 2007 residency review committee program, requirements for emergency medicine. available from: http://www.acgme.org/acgmeweb/ tabid/131/programandinstitutionalaccredi ta t ion /hosp i ta l -basedspec ia l t i es / emergencymedicine.aspx 18. accreditation council for graduate medical education. 2007 residency review committee program, requirements for pediatrics. available from: http://www.acgme.org/acgmeweb/tabid/143 /programandinstitutionalaccreditation/me dicalspecialties/pediatrics.aspx 19. chen s, shofer f, baren j. emergency medicine resident rotation in pediatric emergency medicine: what kind of experience are we providing? acad emerg med 2004;11:771-3. 20. ludwig s, fleisher g, henretig f, ruddy r. pediatric training in emergency medicine residency programs. ann emerg med 1982;11:170-3. 21. ros sp, cetta f, ludwig s. pediatric education in emergency medicine residency programs-10 years later. pediatr emerg care 1993;9:143-5. 22. biese kj, moro-sutherland d, furberg rd, et al. using screen-based simulation to improve performance during pediatric resuscitation. acad emerg med 2009;16 (suppl 2):s71-5. 23. american board of emergency medicine. qualifying examination description and content specifications. available from: https://www.abem.org/public/emergencymedicine-%28em%29-initial-certification/qualifying-examination/qualifyingexamination-description-and-contentspecificiations 24. tintinalli j, shofer f, biese k, phipps j. toward a new paradigm: goal-based residency training. acad emerg med 2011; 18:71-8. 25. burnette k, ramundo m, stevenson m, beeson ms. evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students. acad emerg med 2009;16 (suppl 2):s46-50. 26. branzetti jb, aldeen az, foster aw, courtney dm. a novel online didactic curriculum helps improve knowledge acquisition among non-emergency medicine rotating residents. acad emerg med 2011; 18:53-9. 27. tenn-lyn na, leblanc vr, bandiera gw. can we predict what objectives off-service residents have for their emergency medicine rotations. ann emerg med 2008;51: 516 (abstract). 28. carter aj, mccauley wa. off-service residents in the emergency department: the need for learner centredness. cjem 2003;5:400-5. 29. niska r, bhuiya f, xu j. national hospital ambulatory medical care survey: 2007 emergency department summary. natl health stat rep 2010;26:1-32. 30. perina dg, beeson ms, char dm, et al. the 2007 model of the clinical practice of emergency medicine: the 2009 update. acad emerg med 2011;18:e8-26. 31. crane m, guglielmo w. nps and pas. what’s the malpractice risk? med econ 2000;77:205-8. 32. henry g. mid-levels: the staffing solution of the future? available from: http://www.epmonthly.com/departments/co lumns/oh-henry/mid-levels-the-staffingsolution-of-the-future/ 33. henry g. mid-level question calls for highlevel discourse. emerg physicians mon 2011;18:39. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e8] [page 31] cost of treatment as a barrier to access and continuity of healthcare for patients with mental ill-health in lagos, nigeria olufemi b. olugbile,1 ayodele o. coker,2 mathew p. zachariah2 1department of psychiatry, lagos state university teaching hospital, ikeja; 2department of behavioural medicine, lagos state university college of medicine, ikeja, nigeria abstract in nigeria, there are several barriers to access to effective mental healthcare, e.g. cost, distance to the mental health facility, social stigma, cultural beliefs, attitudes and taboos. this study aimed at i) determining the cost of treatment of a random sample of psychiatric patients and to compare the sample with a matched group of patients from the internal medical department clinics; ii) assessing the impact of cost on access to care and maintenance treatment for the study group in the context of their exclusion from the lagos state free health services and the national health insurance scheme. medical records of 100 patients currently attending the outpatients’ clinic of the department of psychiatry of the lagos state university teaching hospital (ikeja, nigeria) were randomly selected and audited. a similar exercise was also conducted for patients attending the medical outpatients’ clinic in the same hospital. the monthly costs of prescribed medications were computed and compared. the monthly cost of treatment of patients from the department of psychiatry compared to patients with physical ailments from the medical outpatients’ clinic was found to be significant vis à vis the average income of average nigerians. contrary to expectations, the mean cost of drug treatment borne by medical outpatients was much higher (n=2549.07 vs n=1904.5) (p<0.05) than that of patients attending the psychiatric outpatients’ clinic. however, the expensive cost for the psychiatric patients far exceeded the expensive costs for the medical patients. the findings from this study showed that the average monthly cost of treatment of patients attending the psychiatric clinic was lower than patients from the medical outpatients’ clinic. however, the most expensive cost for psychiatric patients far exceeded the most expensive cost for medical patients. this study also revealed that there is no free health program covering psychiatric treatment anywhere in nigeria and mental health drugs are funded from personal and family expenses. it is thereby suggested that policy makers should change policy regarding the coverage of nigerians with mental illness. in doing so, the major barrier to assess and the treatment gap can be reduced. introduction recent evidence showed that mental illnesses are among the most disabling illnesses globally. these reports also showed that more than half of all people with serious mental disorders are not receiving treatment and the situation is even worse in low and middle-income countries (lamics).1,2 the reviewed literature also indicated that the prevalence of mental disorders varied from 26.4% in usa, 17.6% in uk, 31% in colombia and 12.1% in nigeria.3,4 in the same vein, evidence derived from past studies indicated that in lamic mental health disorders are highly prevalent and disabling and sufferers of mental health disorders are not likely to patronize the few available mental health hospitals for assistance.4,5 many studies have also demonstrated that among the several major impediments to the provision of quality mental health in lamics are the lack of adequate mental health facilities, insufficient human resources and poor funding for increasing mental health services.1,6,7 in nigeria, there is little acknowledgement of mental illness at the primary health care level, which is run by the local government. local studies have shown that doctors at primary care levels show little interest or aptitude for diagnosing mental disorder or carrying out interventions.4,8-11 other identified factors preventing access to mental health care by patients in lamics include cultural perception about the nature and origin of mental disorder, social stigma attached to mental illness and the logistics of travelling long distances to the few general hospitals with psychiatric facilities or specialist psychiatric hospitals.1,4,6,8,9 however, the most reported important barrier to mental health care is finance.1,4,6,8,9 in a country such as nigeria and many other subsaharan countries, evidence shows that about 45% to 60% of the population lives below the poverty line.12 therefore, it stands to reason that if individuals suffering from mental disorders in lamics cannot relatively afford quality mental health care, it is expected that governments from these countries should provide free mental health care services or subsidize the cost of mental health care. previous studies from other parts of the world show that patients with mental health conditions receive special consideration to relieve the cost burden of their care.13,14 that may not be the case in nigeria, where the national health insurance scheme (nhis) does not provide coverage for people with mental health disorders. this means that the cost of mental health treatment by patients is from personal or family expenses. the explanation for this may not be far-fetched. mental health disorders, especially the severe forms, are regarded as problems for the society.11,15 studies focusing on the issue of cost and access to mental health care were mostly carried out in the developed countries of the world. manual and electronic searches of the literature showed that very little work has been carried out in sub-saharan countries. a study on this important topic in nigeria cannot be over-emphasised. this study, therefore, was aimed at: i) determining the cost of treatment of a random sample of psychiatric patients and compare them with a matched group of general patients from the medical department; ii) assessing the impact of cost on access to care and maintenance treatment for the study group in the context of their exclusion from the lagos state free health services and the nhis. materials and methods the study was a cross-sectional descriptive and comparative survey carried out at the department of psychiatry and medicine of the lagos state university teaching hospital (lasuth) (ikeja, nigeria) from april to june 2010. the lasuth is a tertiary health instituhealthcare in low-resource settings 2013; volume 1:e8 correspondence: ayodele o. coker, department of behavioural medicine, lagos state university college of medicine, p.m.b. 21266, ikeja, nigeria. tel./fax: +234.8033267544. e-mail: cokerrotimi@gmail.com key words: cost of treatment, barrier to access, continuity of healthcare, nigeria. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 20 december 2012. revision received: 4 february 2013. accepted for publication: 16 february 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright o.b. olugbile et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e8 doi:10.4081/hls.2013.e8 [page 32] [healthcare in low-resource settings 2013; 1:e8] tion situated in ikeja, local government area of lagos state. it was formerly known as ikeja general hospital. it is a multi-disciplinary tertiary hospital and it has a total bed space of 520 beds. it has many specialists’ clinics; it runs 24 hour-accident and emergency services and inpatient care services. the hospital also provides clinical services in internal medicine, general surgery, obstetrics and gynecology, community health, family medicine, radiology, clinical pathology, hematology and blood transfusion, pediatrics, psychiatry, dentistry, and orthopedics and trauma, among others. although the hospital is a tertiary centre, it also serves as a primary, secondary and tertiary centre. for this reason, its services are affordable because consultation and other services are rendered free of charge and only prescription medicine and laboratory investigations are paid for by the patients. however, children under the age of 12 and adults above the age of 60 are not supposed to pay for their prescribed medications. permission to carry out the study was sought from the research and ethics committee of the hospital. likewise, written informed consent was sought from every participant that took part in this study. one hundred participants attending the lasuth outpatients’ psychiatric clinic were randomly selected. the cost of prescription medication procured and used for one month was also quantified for each patient. all the recruited participants paid for their medication prescription from their personal or family expenditures. a matched group of 100 patients was also randomly selected from the internal medicine outpatients’ clinic. their prescription costs over the same period were also computed and analyzed. participants with multiple medical or mental conditions were excluded from the study. the average national minimum monthly income in nigeria is 18,000 naira (n), an equivalent of $110 us dollars per month. the currency used in the study is the nigerian naira. it has an equivalent of n160 naira to $1. statistical analysis the data collected was analyzed with the aid of statistical package for social sciences (spss; version 14 windows). p<0.05 was considered significant. results one hundred psychiatric patients attending the outpatients’ clinic of the lasuth psychiatric department formed the study group, while another 100 patients from the internal medicine outpatients’ clinic of the same hospital formed the comparison group. the findings showed that the mean cost of drug treatment borne by patients attending the medical outpatients was much higher [n=2549.07 ($15.9) vs n=1904.5 ($11.9)] than that of patients attending the psychiatric outpatients’ clinic. however, the standard deviation (sd) for the psychiatric patients was very wide (3991.3) compared to the medical patients (1904.5) as reflected in table 1. table 2 shows the t test significance of difference between the means and it shows that there is no significant difference between the means. one observed factor was that, despite the fact that most of the psychiatric patients appeared to receive treatment at somewhat cheaper cost than the medical patients, the most expensive cost for the psychiatric patients far exceeded the most expensive costs for the medical patients. discussion this study sought out to determine the cost of monthly treatment of a sample of psychiatric patients from lasuth, to compare them with a matched group of patients from the internal medicine outpatients’ clinic, and to assess the impact of cost on access to care and maintenance treatment for the psychiatric patients. the findings from this study did not detect a significantly higher cost for psychiatric treatment over treatment for patients with medical conditions. however, the top costs for a small minority of the mentally ill were observed to be much higher. the explanation for this findings could probably be due to the observed best practice within the mainstream of psychiatry which now requires that atypical antipsychotics and new generation antidepressants such as the selective serotonin reuptake inhibitors (ssris) are prescribed as first line medications for newly diagnosed cases of conditions such as schizophrenia, mania or severe depression.16-18 again, the results of this study also showed that all the patients surveyed who attended the psychiatric outpatients’ clinic, virtually paid for their psychiatric medications from personal and family expenditures. in nigeria, where the poverty rate is high, access to quality mental health care is achieved by travelling long distances, which could also be disincentive to treatment. due to the nature of mental disorders that run a long course, individual with chronic mental disorders may find it relatively difficult to continue to pay for the costs of their medications. in lagos state and perhaps in the whole nigeria, psychiatric patients may possibly not be getting the best possible treatment for their psychiatric illnesses and this should be evaluated by future studies. unfortunately, this situation may remain the same until the barrier to access to good care is removed either through a comprehensive national health insurance scheme or through some direct policy specifically aimed at reducing the cost of medications of people who suffer from mental illness. however, the literature has demonstrated that changes are going on globally with regard to the funding of mental health care.1,4,19,20 the increasing emphasis on community mental health care is putting an increasing cost of burden on the healthcare provider, even in those countries with comprehensive nhis, such as the uk.21 nonetheless, health policy planners have the twin challenges of keeping cost to the state or managed care provider down, and ensuring that the cost issue even with the most expensive drugs does not become a major barrier to access or maintenance for patient.22-24 for example, after persistent complaints from different sectors about the marginalization of the mentally ill in the managed care system in the usa, there has recently been a lot of attention focused on how to include patients with mental health disorders without being exorbitant about cost of drug.25 the limitation of this study includes its small size. it was also carried out only in one teaching hospital in nigeria, thus its generalarticle table 1. mean cost of drug treatment borne by psychiatric and medical outpatients. group no. mean sd min max psychiatry 100 1796.0 3991.3 150 35210 medicine 100 2549.07 1904.5 60 9080 sd, standard deviation; significance=p<0.05. table 2. means between the cost of medications of the two departments group no. mean sd df mean significance 2-tail difference psychiatry 100 1796.0 3991.3 198 -752.47 .09 medicine 100 2549.07 1904.5 sd, standard deviation; df, degree of freedom; significance=p<0.05. [healthcare in low-resource settings 2013; 1:e8] [page 33] ization may be difficult. however, the provision of mental health services and the supply of psychotropics to patients in all teaching hospitals in nigeria are quite similar and if there are differences, they may be insignificant. nonetheless, in light of these findings, it is desirable that future studies on cost of care and other barriers to mental healthcare should involve a larger multi-centred random sample. conclusions this study provided evidence that the cost of care of psychiatric patients as compared to medical patients might not be significant. findings of this study also showed that patients suffering from mental health disorders in lagos state and nigeria pay out-of-pocket for their medications which may eventually affect long-term compliance to their drug intake. psychiatrists and mental health policy makers in lagos state and nigeria must formulate a policy that will take into consideration prescribing affordable drugregime in managing patients with psychiatric disorders which should also be determined substantially by the clinician’s assessment of patients’ financial ability to bear the costs of medications. references 1. eaton j, mccay l, semrau m, et al. scale up of services for mental health in lowincome and middle-income countries. lancet 2011;378:1592-603. 2. world health organization. who world mental health surveys find mental disorders are widespread, disabling and often go untreated. geneva: who ed.; 2012. available from: http://www.who.int/mediacentre/news/notes/2004/np14/en/index.ht ml 3. saraceno b, dua t. global mental health: the role of psychiatry. eur arch psy clin n 2009;259(suppl 2):109-17. 4. gureje o, lasebikan vo, kola l, makanjuola v. lifetime and 12-month prevalence of mental disorders in the nigerian survey of mental health and wellbeing. b j psychol-gen sect 2006;188:46571. 5. jibril o, abdulmalik o, shehu s. pathways to psychiatric care for children and adolescents at a tertiary facility in northern nigeria. j public health africa 2012;3:15-7. 6. patel v. mental health in lowand middleincome countries. brit med bull 2007;81:81-96. 7. saraceno b, van ommeren m, batniji r, et al. barriers to improvement of mental health services in low-income and middleincome countries. lancet 2007;370:116474. 8. maguen s, litz bt. predictors of barriers to mental health treatment for kosovo and bosnia peacekeepers: a preliminary report. mil med 2006;171:454-8. 9. olugbile ob, zachariah mp, coker ao, et al. provisions of mental health services in nigeria. int psychiatry 2008;2:27-31. 10. lasebikan v, ejidokun a, coker ao. prevalence of mental disorders and profile of disablement among primary health care service users in lagos island. epidemiol res int 2012;2012:1-6. available from: http://www.hindawi.com/journals/eri/2012/ 357348/ 11. coker ao, lasebikan v, olugbile ob, eaton j. psychiatric psychosocial rehabilitation in nigeria; what needs to be done. nigerian j psychiatry 2011;9:2-9. 12. crick lund c, breen a, flisher aj, et al. poverty and common mental disorders in low and middle income countries: a systematic review. soc sci med 2010;71:51728. 13. eaton j. ensuring access to psychotropic medication in sub-saharan africa. afr j psychiatry 2008;191:179-81. 14. jenkins r, baingana f, ahmad r, et al. health system challenges and solutions to improving mental health outcomes. ment health fam med 2011;8:119-27. 15. olugbile ob, zachariah mp, coker ao, et al. yoruba world view as the nature of psychotic illness. afr j psychiatry 2009;12:149-56. 16. stahl sm, grady tm. high cost of use of second generation antipsychotics under california’s medicaid program. psychiat serv 2006;57:127-9. 17. rodríguez-antona c, gurwitz d, de leon j, et al. cyp2d6 genotyping for psychiatric patients treated with risperidone: considerations for cost-effectiveness studies. pharmacogenomics 2009;10:685-99. 18. kendrick t, simons, l. cost effectiveness of referral for generic care or problemsolving treatment from community mental health nurses, compared with use of general practitioner care for common mental disorders: a randomized controlled trial. brit j psychiat 2006;189:50-9. 19. world health organization. mental health atlas 2011. geneva: who ed.; 2012. available from http://www.who.int/mental_health/publications/mental_health_atl as_2011/en/index.html 20. institute of global mental health. the global burden of mental health disorders, 2010. london: institute of global mental health publ.; 2012. available from: http://www.ucl.ac.uk/news/news-articles/1005/10052803 21. belling r, whittock m, mclaren s, et al. achieving continuity of care: facilitators and barriers in community mental health teams. implement sci 2011;6:2-7. 22. vazquez-polo fj, negrin m. an analysis of the costs of treating schizophrenia in spain: a hierarchical bayesian approach. j ment health policy econ 2005;8:153-6. 23. hickie ib, davenport ta, luscombe gm. mental health expenditure in australia: time for affirmative action. aust nz j publ heal 2006;30:119-22. 24. chisholm d, gureje o, saldivia s, et al. schizophrenia treatment in the developing world: an interregional and multinational cost-effectiveness analysis. b world health organ 2008;86:542-51. 25. sundararaman r. the us mental health delivery system infrastructure: a primer. collingdale, pa: diane publ.; 2009. article hrev_master [page 6] [healthcare in low-resource settings 2013; 1:e3] implementation of public health practices in tribal populations of india: challenges and remedies saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college & research institute, ammapettai, india abstract large inequities in health exist between indigenous and non-indigenous populations worldwide. this health divide has also been demonstrated in india, where indigenous groups are officially classified as scheduled tribes (sts). india has one of the largest tribal populations in the world. tribal communities in general and primitive tribal groups in particular are highly disease prone and their misery is compounded by poverty, illiteracy, ignorance of causes of diseases, hostile environment, poor sanitation, lack of safe drinking water, blind beliefs, etc. as per the estimates of national family health survey-3 (nfhs-3), the likelihood of having received care from a doctor is lowest for st mothers (only 32.8% compared to india of 50.2%). while many strategies have been attempted over the years to discuss some of the economic, social, and physical factors preventing tribal population to get access to healthcare services, the ultimate outcome has remained far less than the expectations. considering that these st groups are culturally and economically heterogeneous, the methods to tackle their health problems should not only be integrated and multi-fold, but also specific to the individual groups as feasibly as possible. measures like strengthening of the existing human resources, bringing health services within the reach of remote populations, promotion of health awareness, facilitation of community participation using innovative strategies, bringing about a change in the behavior of health care providers, implementation of measures for the empowerment of ethnic groups by carrying out administrative reforms and finally by ensuring the sustainability of all above recommended measures. introduction large inequities in health exist between indigenous and non-indigenous populations worldwide.1 this health divide has also been demonstrated in india,2 where indigenous groups are officially classified as scheduled tribes (sts). scheduled tribes are groups of historically disadvantaged people who are descendents of the tribal communities. this group of people did not agree to caste system. instead, they prefer to dwell deep inside forests as well as mountainous areas of india, far away from the chief part of the society. india has one of the largest tribal populations in the world. the government of india defined a tribal region based on certain characte ristics,3 which include (and are not limited to) economically backward communities living in a primitive condition, having a distinct culture, primitive traits, socio-economic backwardness and usually away from the mainstream. the tribal population of the country, as per the 2001 census, is 84.3 million, constituting 8.2% of the total population with 91.7% of them living in rural areas and 8.3% in urban areas.4 tribal communities in general and primitive tribal groups in particular are highly disease prone. the st groups who were even more isolated from the wider community and who maintained a distinctive cultural identity have been categorized as primitive tribal groups. these have been identified as less acculturated ethnic groups among the tribal population groups and are in need of special programs for their sustainable development and they do not have required access to basic health facilities. they are most exploited, neglected, and highly vulnerable to diseases with high degree of malnutrition, morbidity and mortality.5 their misery is compounded by poverty, illiteracy, ignorance of causes of diseases, hostile environment, poor sanitation, lack of safe drinking water, and blind beliefs, etc. although st are accorded special status under the fifth/sixth schedules of the indian constitution, their status on the whole, especially their health, remains unsatisfactory. this paper explores the problems in delivering public health services to the tribal population, and suggests possible recommended measures about the same. indian scheduled tribes demography the total population of sts according to the 2001 census is 84.3 million and has increased from 67.8 million in 1991, showing a decadal growth rate of 24.3%. this rate of growth remains higher than the national average of 21.3%.2 scheduled tribes are distributed throughout the nation except pondicherry, haryana, punjab, chandigarh, and delhi. almost 25% of the indian tribal live in madhya pradesh and chattisgarh.6 out of the 75 districts with more than 50% of their population being composed of sts, 41 districts are from north-east states.6 the sex ratio of tribal is more favorable to women than the general population (972/1000 men vs 927/1000). however, there is a wide variation among the different groups and states (1002 in orissa to 889 in goa).4 the dependency ratio among tribes is 83.9% and in the general population is 69%.4 literacy is increasing (47% in 2001 from 29.6% in 1991) but still lower than the general population (65%) and the gap between the literacy rates of sts and the general population has continued almost at the same level of 17-18% for the last three decades. almost 65% women are illiterate against the national figure of 46%.4 dropout rates of tribal students of standard (oneten) have gradually decreased from 85% in 1990-1991 to 76.8% in 2007-2008.7 around 91% of the tribal population still lives in rural area as against 72% for the nation.4 the percentage of tribal living below poverty line is 47.3% in rural and 33.3% in urban areas, which is higher than the corresponding national figures of 28.3% and 25.7%, respectively.8,9 the average tribal household size is 5.2 and is comparable to the national average of 5.3.4 healthcare in low-resource settings 2013; volume 1:e3 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college & research institute, thiruporur-guduvancherry main road, ammapettai, 603108 kancheepuram, india. tel. +91.9884227224 fax: .91.044.27440138. email: drshrishri2008@gmail.com key words: tribal, public health, community participation. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critically revising of the article for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 19 december 2012. revision received: 14 january 2013. accepted for publication: 14 january 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e doi:10.4081/hls.2013.e non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e3] [page 7] maternal and child health parameters there are vast differences in the health status of mothers and children between tribal and non-tribal populations. table 1 shows the indicators comparing the maternal and child health, highlighting the under-achievements among the tribes.9,10 in a hospital-based, retrospective, reproductive-age mortality study (ramos) of tribal women of bastar region, chhattisgarh, maternal mortality percentage among tribal women was 85.7% and was 100% in the year 2009-2010 and 20102011 which is higher than the national estimates.11 compared to the national family health survey-2 (nfhs-2) survey,9 the infant mortality, under-five mortality, and neonatal mortality have decreased:10 the proportion of home deliveries is at a standstill. in a retrospective cohort study done in maharashtra, percentage of still-births in tribal areas (1.96%) was higher than non-tribal areas (1.47%).12 the total fertility rate (table 1) had shown a slight increase compared to the nfhs-2 survey. though obstetrics care from a trained provider during delivery is recognized as critical for the reduction of maternal and neonatal mortality, only 17.1% of births to st women was assisted by a doctor, compared with 47.4% of births to women, who do not belong to a scheduled caste, st, or other backward class group (others).10 as per the estimates of nfhs-3, the likelihood of having received care from a doctor is lowest for st mothers (only 32.8% compared to india of 50.2%). the percentage of st women consuming iron folic acid (ifa) for at least 90 days and who took a drug for intestinal parasites during their pregnancy was only 17.6 and 3.7, respectively.10 in a study done in yeotmal district of maharashtra, it was concluded that reach of contraceptive services of copper-t (cu-t) needs to be improved in tribal areas.13 among st children who suffered from diarrhoea in the two weeks preceding the survey, only 29.3% of them did not receive any treatment at all. based on information obtained from a vaccination card or reported by the mother (either source), only 31.3% of st children were found to be fully vaccinated as compared to 53.8% belonging to others. among st children, 49.9% received services at an anganwadi centre.10 other public health problems among tribes compared to national averages, sts have higher mortality rates,14 and experience a greater prevalence of tuberculosis,15 leprosy,16 under-nutrition,10,17 visual impairment from avoidable causes of blindness including the outcome of surgeries,18,19 and high anaemia levels.20-,21,22 these groups are also exposed to higher risks of inadequate food intake,23 poor hygiene,24 and tobacco and alcohol consumption,25,26 as well as lower access to health care.27-30 in a community-based cross-sectional study carried out in the tribal population of randomly selected villages of jabalpur district, it was observed that though 88% of the respondents felt modern medicine was the best remedy for sexually transmitted infections (sti), only a few of them actually used medical treatment while suffering from an sti.31 northeast india is known for the demographic heterogeneity of its tribal population, and it has a very high prevalence of hepatitis c virus infection and their associated risk factors.32 high sero-prevalence of certain bacterial and viral infections has been observed among irula and kolli hills tribes of tamil nadu.33,34 intestinal helminthiasis and skin infections such as tinea and scabies are widely prevalent among tribal children.35 sickle cell trait prevalence varies from 0.5 to 45%, and disease prevalence is around 10%.36 public health infrastructure accessibility is one of the principles of health for all stated in alma ata declaration on primary health care but still, due lack of universal access, equality in health status cannot be assured. moreover, because there are other important social determinants of population health and its distribution, even with the increasing catchment of tertiary health care facilities, use of primary health care is low due to costs, attitude of health provider as well as place of facilities, etc. tribal development strategies need to be more human-centred with health at its centre. the conventional, bureaucratic approach of looking at health issues for tribal in a sectoral, compartmentalized way can have little impact on achieving health goals. while many strategies have attempted to address some of the economic, social, physical factors and barriers contributing to poor maternal health outcomes, women’s use of maternal health services is often influenced by perceived socio-cultural, economic, and health system factors operating at the community, household, and individual level as well as within the larger social and political environments and health care infrastructure. these include inequitable distribution of facilities and/or infrastructure for primary healthcare and maternal healthcare services, inadequate referral services and overburdened healthcare facilities.37,38 although in tribal areas the population norms for establishment of primary health centers and sub-centers is for every 20,000 and 3000 population respectively, health care is not available to the majority of the tribal.39 this is due to multiple factors, namey lack of accessibility to health facilities;40 non-availability of health staff in the health centers; poor quality of services offered (non-availability of essential drugs and equipments, lack of proper building facilities); lack of transport and communication facilities; traditional practices and superstitions (local beliefs, customs, and practices); poverty and financial constraints (the majority of healthcare services is theoretically free of cost, but indirect and informal payments, such as travel cost to and from the government facility, leaving work to seek care, and paying for prescribed medicines, exist); logistics barriers from the healthcare providers side; waiting time at the health center and timings of the facilities. all these factors in multiple ways have obstructed accessibility of healthcare services.40-42 review table 1. maternal and child health indicators among tribes and others.9,10 indicators st others nfhs-2 nfhs-3 nfhs-3 median age at marriage (years) 15.8 16.3 18.1 awareness of legal age for marriage (%) 7.5 22 total fertility rate 3.06 3.12 2.68 median age at first childbirth (years) 18.8 19.1 20.6 proportion of pregnancies with no antenatal checkups (%) 43.1 37.8 22.8 home deliveries (%) 81.8 82.3 49 infant mortality rate/1000 live births 84.2 62.1 57 exclusive breast-feeding (median) (months) 2.9 3.1 1.9 completion of primary immunization (%) 26 31.3 53.8 no. vaccination (%) 11.5 4.3 st, scheduled tribes; nfhs-2, national family health survey-2; nfhs-3, national family health survey-3. non -co mmerc ial us e o nly [page 8] [healthcare in low-resource settings 2013; 1:e3] recommended measures as discussed earlier, sts in india are demographically, culturally and economically heterogeneous, varying widely in terms of their population size, language, and the nature of their interactions with the rest of society.43,44 hence, the methods to tackle their health problems should not only be integrated and multi-fold, but also specific to the individual groups as feasibly as possible. in the following, elements and strategies which should be considered as an essential element of the comprehensive approach for the wellbeing of tribal populations are discussed. strengthening of the existing human resources one of the major problems in delivering health care to the tribal is shortage of staff. doctors and paramedical workers from the general population are reluctant to work in backward tribal areas. furthermore, medical staff hailing from the tribal communities, who has a better understanding about the needs of their people and who may be more willing to work in such areas is not enough. as for march 2010, undue delays in recruitment resulted in vacancies even in available posts at health centers. over 34% of male health workers, 38% of radiographers, 16% of laboratory technicians, 31% of specialists, 20% of pharmacists and 20.7% of the sanctioned posts of doctors were lying vacant.45,46 though there is a statutory provision of 7.5% reservation for tribal in medical education, apparently either the enforcement of this policy is not strictly done or takers from the tribal for these seats are not enough. it is proposed that the proportion of distribution of all these reserved seats should be worked out according to the proportion of the individual clans of tribal. the situation is worse among other cadres of health workers. on the one hand, as such, the number of available paramedic education institutions is very small compared to the needs of the country. only 13,000 auxiliary nurse midwives (anms) are graduating every year.47 a phenomenal increase is required in this area, which is the purview of general policy. within this area, a parallel sponsorship with educational opportunities has to be developed to cater for the needs of the tribal population. to tackle the acute shortage of medical doctors, indian government has planned to make its undergraduate bachelor of medicine and bachelor of surgery (mbbs) course sixand-a-half years long, instead of the present five-and-a-half years that would make a oneyear rural posting compulsory for all mbbs students before they can become doctors.46 also, with a purpose to churn out more doctors, the union health ministry has increased postgraduate seats by 85% and undergraduate seats by 35% in various medical colleges of the country over the last three years.48 in addition, the medical council of india (mci) has also cleared a three-and-a-half-year long medical course (bachelor of science in community health) which will be open to anybody after class 12.49 bringing health services to remote populations while medical camps have often been conducted in the past, different stakeholders have stressed on the need for either state-sponsored or non-governmental organizations (ngos), sponsored mobile medical camps to reach remote tribal populations. outsourcing of these services to ngos and medical colleges may prove to be an efficient option if availability of drugs, diagnostic facilities and vehicles remains assured and consistent. population can be drawn to these camps through door-todoor canvassing by accredited social health activists (asha) and anm, as well as loudspeaker announcements, banners and pamphlets. provision of emergency transportation to take tribal pregnant women to health facilities for obstetrical care should be ensured. while not all hamlets have access to tarred roads, the emergency ambulance services should reach the nearest motorable point to pick up patients in all tribal regions. janani suraksha yojana is a safe motherhood intervention being implemented with the goal of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. to encourage institutional deliveries among tribal groups, stringent enforcement and implementation of janani suraksha yojana should be done.50 promotion of awareness about health issues promotion of awareness about health-related issues is the first step towards improving health outcomes. however, while public health programs have often conducted information, education and communication (iec) campaigns – such as stressing the importance of hand washing, regular antenatal check-ups, institutional deliveries, immunization, etc. – they have had little impact. in order to have a significant impact on tribal masses, all the messages should be culturally appropriate and professionally crafted to markedly improve the content and quality of health messages and pre-tested for greatest impact at specific tribal groups. in rajasthan, health messages were most commonly disseminated using live performances by drummers, dancers, folk musicians, magicians, puppeteers, etc. to appeal to tribal populations. similarly, in tamil nadu, in addition to posters, hoardings, bus boards, and personalized letters of communication for the literate members of a family, radio jingles and video broadcasts featuring popular film stars were found to be effective means for disseminating health messages to the state’s tribal people. even in developed nations culturally appropriate technology was employed for targeting the native youth of tribal populations.51 community-based participatory research (cbpr) which is conducted as an equal partnership between traditionally trained experts and members of a community has been hailed as an alternative approach which emphasizes co-sharing, mutual benefit, and community capacity building.52 facilitating tribal community participation women from the tribal localities can be recruited as anms and then trained to bring health care closer to tribal settlements. also, as tribal populations find it difficult to navigate through the complexities of medical facilities, government in collaboration with local ngos can arrange for counselors who are from tribal communities themselves and then can be placed at district hospitals to guide patients, explain doctors’ prescriptions, help patients take advantage of welfare schemes and counsel them on preventive and promotive health behaviors. these counselors can also pay weekly visits to tribal hamlets to raise awareness about health issues and promote healthy behaviors. in karnataka, citizens helpdesks have been established to offer round-the-clock assistance to tribal and other vulnerable groups in selected district and taluk level hospitals. these helpdesks also address complaints by mediating between consumers and service providers.53 changing the behavior of health care providers to help tribal people at medical facilities, the obligation is to change their insensitive and discriminatory behavior towards poor and disreview non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e3] [page 9] advantaged groups. this change in behavior is desired not only from paramedic and lower staff but also from the doctors. this can be achieved by organizing campaign to instill patientfriendly behavior among health care providers. simultaneously, there should be a mechanism to get feedback from tribal people based on which corrective measures should be taken. empowerment of the tribal population nutrition and education are basic accessories needed for the progress of any community. a closely knit public distribution system (pds) as witnessed in anthyodaya anna scheme has to be developed nationwide, covering every interior pocket of the tribal areas, with a well-supported supply network. under this scheme, the poorest of the poor were supported by providing them with 35 kg of rice and wheat at rs.2 per kg.54 in the same vein, schooling and education have to be developed fully utilizing the help of anthropologists and non-governmental organizations to inculcate the habit of universal education at the primary, middle, and higher secondary levels. initiatives to distribute educational and related items free of cost along with supplementary nutrition have also been found successful in states like tamil nadu. to recognize the achievements of the tribal population, the ministry of tribal affairs instituted the national tribal awards from the year 2008 for the best janjatiya achiever. such awards and monetary benefits should be extended in future for the best performing grass-root level health workers which will serve as a source of continuous motivation. provision of health insurance should be extended to the sts for prompt use of healthcare services by them without undue debt.55 tribal cooperative marketing and development federation of india ltd. (trifed) is a welcome sign as it provides marketing help and remunerative prices to sts for collection of minor forest production and surplus agricultural production to protect them from exploitative private traders and middlemen.56 administrative reforms approach the utilization of any social services, including health services, has never been equitably distributed throughout society. people with access to the facilities are generally found to make greater use of them than people who have neither knowledge nor access to the facilities. though health is a state subject, the centre has been given the authority of giving directions to the state governments [article 339(2) of the fifth schedule in the interest of the tribal population], which should be used to direct the state governments to ensure provision of separate tribal sub-plans based on the percentage of tribal as recommended by the ministry of tribal affairs. in a cohort of births examined in gujarat, it was concluded that for sustaining the momentum of reduced neonatal mortality there is a need of long-term policy intervention to promote better living standards and better reproductive health.57 racial and ethnic approaches to community health (reach) is an initiative promoted by the centers for disease control and prevention’s (cdc), which strives to eliminate racial and ethnic disparities in health. it is a communitybased, participatory approach to identify, develop and disseminate effective strategies for addressing health disparities across a wide range of health priority areas such as cardiovascular disease, diabetes, breast and cervical cancer, infant mortality, asthma, immunization, and obesity.58 similar strategies/programs customized to the local tribal population can be devised to eliminate caste-based disparities in health. while most innovations have included the provision of free medical services to poor tribal populations, a few pilots have sought to ease the financial burden of inpatient care on these groups as well. in tamil nadu, bed grant scheme was implemented under financial assistance of world bank, in partnership with ngos for the provision of free inpatient care to tribal populations. all costs pertaining to minor ailments and surgeries are reimbursed by the project. ensuring sustainability in authors’ opinion, though many of the above suggested methods are not entirely new ones and have been tried with success in vast sections of non-tribal areas, the administrative skills and organizational capabilities need to be tuned up according to the tribal needs. politically-sustained and administrative commitment is what we currently need to have a long-term and comprehensive impact on the health status of tribal populations. references 1. cunningham c. health of indigenous peoples. brit med j 2010;340:1840. 2. subramanian sv, smith gd, subramanyam m. indigenous health and socioeconomic status in india. plos med 2006;3:1794-804. 3. angra sk, murthy gv, gupta sk, angra v. cataract related blindness in india and its social implications. indian j med res 1997;106:312-24. 4. registrar general of india. census of india, 2001. new dehli: registrar general of india ed.; 2001. 5. balgir rs. dimensions of rural tribal health, nutritional status of kondh tribe and tribal welfare in orissa: a biotechnological approach. in: bn bandodkar college of science, ed. proceedings of the ugc sponsored national conference on human health and nutrition: a biotechnological approach, 2004 dec 1213, thane, india. thane: bn bandodkar college of science ed.; 2004. pp 47-57. 6. draft national policy on tribals, 2005. new delhi: ministry of tribal affairs, government of india ed.; 2005. 7. tables of statistics for school education; 2007-2008. available from: http://www.educationforallinindia.com/selected-education-statistics-2007-08-mhrd.pdf 8. planning commission, government of india. eleventh five year plan. new delhi: planning commission, government of india ed.; 2008. 9. 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and standard of living across the life course. am j public health 2006;96:818-25. 15. kaulagekar a, radkar a. social status makes a difference: tuberculosis scenario during national family health survey-2. indian j tuberc 2007;54:17-23. review non -co mmerc ial us e o nly [page 10] [healthcare in low-resource settings 2013; 1:e3] 16. kumar as, kumar s, abraham s, rao ps. leprosy among tribal population of chhattisgarh state, india. indian j lepr 2011;83:23-9. 17. bawdekar m, ladusingh l. contextual correlates of child malnutrition in rural maharashtra. j biosoc sci 2008;40:771-86. 18. dhake pv, dole k, khandekar r, deshpande m. prevalence and causes of avoidable blindness and severe visual impairment in a tribal district of maharashtra, india. oman j ophthalmol 2011;4:129-34. 19. khanna rc, pallerla sr, eeda ss, et al. population based outcomes of cataract surgery in three tribal areas of andhra pradesh, india: risk factors for poor outcomes. plos one 2012;7:e35701. 20. bharati p, som s, chakrabarty s, et al. prevalence of anemia and its determinants among non pregnant and pregnant women in india. asia pac j public health 2008;20:347-59. 21. nayar kr. social exclusion, caste & health: a review based on the social determinants framework. indian j med res 2007;126:355-63. 22. de m, halder a, chakraborty t, et al. incidence of anemia and effect of nutritional supplementation on women in rural and tribal populations of eastern and northeastern india. hematology 2011;16:190-2. 23. ghosh r, bharati p. women’s status and health of two ethnic groups inhabiting a peri-urban habitat of kolkata city, india: a micro-level study. health care women in 2005;26:194-211. 24. basu sk. a health profile of tribal india. health millions 1994;2:12-4. 25. neufeld kj, peters dh, rani m, et al. regular use of alcohol and tobacco in india and its association with age, gender, and poverty. drug alcohol depen 2005;77:28391. 26. mohindra ks, narayana d, anushreedha ss, haddad s. alcohol use and its consequences in south india: views from a marginalised tribal population. drug alcohol depen 2011;117:70-3. 27. nanda s, tripathy m. reproductive morbidity, treatment seeking behaviour and fertility: a study of scheduled caste and tribe women. j hum ecol 2005;18:77-83. 28. meher r. livelihood, poverty and morbidity: a study on health and socio-economic status of the tribal population in orissa. j health manag 2007;9:343-67. 29. dolla ck, meshram p, verma a, et al. health and morbidity profile of bharias a primitive tribe of madhya pradesh. j hum ecol 2006;19:139-41. 30. ray sk, basu ss, basu ak. an assessment of rural health care delivery system in some areas of west bengal-an overview. indian j public health 2011;55:70-80. 31. rao vg, saha kb, bhat j, et al. exploring knowledge and health seeking behaviour related to sexually transmitted infections among the tribal population of madhya pradesh, central india. j biosoc sci 2012;44:625-9. 32. medhi s, goswami b, das ak, et al. new insights into hepatitis c virus infection in the tribal-dominant part of northeast india. arch virol 2012;157:2083-93. 33. gnanasekaran a, paramasivam r, mohan k, et al. seroprevalence of certain bacterial and viral infections among the irula tribal population of marakkanam, tamil nadu state, india. prim health care res dev 2012:1-7. 34. kalaivani v, rajendran p, thyagarajan sp, et al. the seroprevalence of hepatitis b and c viruses and the associated risk factors in the kolli hills tribal population of tamil nadu. biomedicine 2001;21:7-13. 35. chhotray gp. health status of primitive tribes of orissa. icmr bull 2003;33:1-6. 36. sahu t, sahani nc, das s, sahu sk. sickle cell anemia in tribal children of gajapati district in orissa. indian j community med 2003;28:180-3. 37. griffiths p, stephenson r. understanding users’ perspectives of barriers to maternal health care in maharashtra, india. j biosoc sci 2001;33:339-59. 38. ram f, singh a. is antenatal care effective in improving maternal health in rural uttar pradesh? evidence from a district level household survey. j biosoc sci 2006;38:433-48. 39. indian public health standards (iphs) guidelines for primary health centers. new dehli: directorate general of health services, ministry of health and family welfare, government of india ed.; 2012. available from: http://mohfw.nic.in/ nrhm/iphs_revised_guidlenes_2012/pri may_health_centres.pdf 40. saha pk. the status of family welfare services in tribal areas: highlights of the evaluation process. indian j community med 2003;28:141-4. 41. levesque jf, haddad s, narayana d, fournier p. outpatient care utilization in urban kerala, india. health policy plann 2006;21:289-301. 42. levesque jf, haddad s, narayana d, fournier p. affording what’s free and paying for choice: comparing the cost of public and private hospitalizations in urban kerala. int j health plan m 2007;22:159-74. 43. xaxa v. protective discrimination: why scheduled tribes lag behind scheduled castes. econ polit weekly 2001;21:2765-72. 44. kakkoth s. the primitive tribal groups of kerala: a situational appraisal. stud tribes tribals 2005;3:47-55. 45. rural health statistics in india; 2010. available from: http://nrhm-mis.nic.in/ ui/rhs/rhs%202010/rural%20health%20 statistics%202010.htm 46. times news network. govt mulls six-anda-half year mbbs with one-year rural stint. in: the times of india, section times nation (col. 1), 06/02/2012. 47. ministry of health and family welfare. national rural health mission. strengthening of public health infrastructure. new dehli: mohfw ed.; 2005. 48. times news network. norms relaxed to increase medical seats. in: the times of india, section times city (col. 2), 29/09/ 2012. 49. kounteya sinha. mci clears 3-and-a-halfyr med course. in: the times of india, section times nation (col. 3), 24/09/2012. 50. janani suraksha yojana. guidelines for implementation; 2006. available from: http://www.mohfw.nic.in/nrhm/rch/guid elines/jsy_guidelines_09_06.pdf 51. rushing cs, stephens d. tribal recommendations for designing culturally appropriate technology based sexual health interventions targeting native youth in the pacific northwest. am indian alaska nat 2012;19:76-101. 52. wallerstein n, duran b. community-based participatory research contributions to intervention research: the intersection of science and practice to improve health equity. am j public health 2010;100:s40-6. 53. karnataka health system development and reform project national rural health mission. operational guidelines for citizen help desk under public private partnership; 2009. available from: http://stg2. kar.nic.in/healthnew/kshrdp/pdf/ppp/o perational%20guidelines%20for%20citize n%20help%20desk.pdf 54. antyodaya anna yojana; 2000. available from: http://www.karmayog.org/publicdistributionsystem/publicdistributionsystem_2619.htm 55. friedsam d, haug g, rust m, lake a. tribal benefits counseling program: expanding health care opportunities for tribal members. am j public health 2003;93:1634-6. 56. tribal cooperative marketing development federation of india limited, 2004. available from: http://tribal.gov.in/ index1.asp?linkid =359&langid=1 57. kutty rv, shah p, modi d, et al. reducing neonatal mortality in jhagadia block, gujarat: we need to go beyond promoting hospital deliveries. j trop pediatrics [in press]. 58. racial and ethnic approaches to community health (reach). atlanta: centers for disease control and prevention ed.; 2012. available from: http://www.cdc.gov/reach/ review non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:4677] [page 31] typhoid ileal perforation: a 13-year experience poras chaudhary, rajeev kumar, chandrakant munjewar, utsav bhadana, gyan ranjan, shailesh gupta, sanjay kumar, mohinder p. arora lady hardinge medical college and associated dr ram manohar lohia hospital, new dehli, india abstract typhoid fever is endemic in many developing countries with a high rate of complications. aim of this study is to analyse epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. records of total number of 646 patients, who presented with perforation peritonitis due to enteric fever in the surgical emergency unit of dr ram manohar lohia hospital, new delhi between january 2001 and december 2013, were reviewed retrospectively. descriptive statistics was used to analyze the data. out of 646 patients, 62 (9.59%) presented in shock. stomal, peristomal, local and systemic complications were high in these patients. primary closure was done in 212 (33.12) patients, primary ileostomy was created in 410 (64.06) patients, and resection and anastomosis was done in 24 (3.75) patients. thirteen patients (2.01%) died of typhoid intestinal perforation. to prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. awareness and education about the disease, its nature and complications will also be of great help. introduction enteric fever is a systemic disease caused by salmonella typhi and salmonella paratyphi and it is characterized by fever, abdominal pain, relative bradycardia with involvement of the lymphoid tissues. the serotypes a, b and c cause enteric fever and they have no known hosts other than humans.1 the term enteric fever includes both typhoid and paratyphoid fevers. worldwide, there are an estimated 22 million cases of enteric fever with 200,000 deaths annually.2 typhoid fever is endemic in india. reported data for the year 2011 shows 1.06 million cases and 346 deaths the prevalence rate of typhoid in india is 88 cases/lac population and death rate due to typhoid is 0.029/lac population.3 a high incidence of enteric fever correlates with poor sanitation and lack of access to clean drinking water. the enteric fever has high socio-economic impact because survivors may take several months to recover and resume work. incubation period is usually 10-14 days but the range may be from 3-56 days depending upon the dose of the bacilli ingested.1 fever is documented at presentation in more than 75% of the cases and abdominal pain is reported in only 30-40%. serious complications occur in up to 10% of patients which depends on host factors like immunosuppression, antacid therapy and vaccination, and strain virulence and inoculum. life threatening complications, intestinal perforation (1-3%), gastrointestinal bleeding (10-20%) and circulatory collapse most commonly occur during third week of illness. in treated cases, the fatality rates of enteric fever range from 1-4% and in untreated cases, the fatality rates may rise to 10-20%.1 the most common surgical complication of enteric fever in india is intestinal perforation, which carries a high morbidity and mortality. this is a retrospective study on our experiences with enteric perforation peritonitis in the past 13 years. the aim of this retrospective study was to analyze epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis diagnosed and treated in our hospital. materials and methods records of a total number of 646 patients, who presented with perforation peritonitis due enteric fever in the surgical emergency unit of dr ram manohar lohia hospital, new delhi between january 2001 and december 2013, were reviewed retrospectively. patients with associated malignancy and hiv were excluded from the study. records of these patients were then reviewed in detail to analyze epidemiological features, clinical presentations, complications and therapeutic outcomes of enteric perforation peritonitis. the parameters including age, gender, socioeconomic status, complete blood count, liver and kidney function test, serum electrolytes at presentation and after surgery, diagnostic procedures, duration of hospital stay, post-operative morbidity, mortality, medical/surgical treatment and socioeconomic impact were evaluated. blood culture was done in all of these patients which confirmed enteric fever. descriptive statistics was used to summarize the data. results there were 435 male and 211 female patients. their mean age was 29 (range 14-76) (table 1). total leucocyte count was found to be high in 598 patients with a mean of 16,500/cu.mm. and less than 4000/cu.mm. in 48 patients only. renal function tests were deranged in 621 patients and electrolyte imbalance was found in 612 patients. out of these 646 patients 62 presented in shock. exploratory laparotomy was possible in 56 patients after resuscitation and drain insertion and 6 patients died before surgery only due septic shock. out of these 56 patients, 3 patients died after surgery and out of 584 patients without shock at presentation, 8 patients died after surgery due to septic shock and multiple organ dysfunction syndrome. stomal, peristomal, local and systemic complications were high in these patients (table 2). primary closure was done in 212 patients, primary ileostomy was created in 410 patients and resection and anastomosis was done in 24 patients (table 3). reperforations requiring surgery were observed in 43 patients. these perforations occurred proximal to previous perforation site in 39 cases while distal to the first perforation in 4 cases. in all of these cases perforation site was brought out as ileostomy during first surgery. discussion typhoid fever occurs in all parts of the world where water supplies and sanitation are substandard. the incidence is highest in southcentral and south-east asia. though it is easy to diagnose and cure enteric fever, the complication rate is still very high in developing countries including india. ileal perforation is the most common surgical complication of enteric fever in india.4 one reason is obvious, healthcare in low-resource settings 2015; volume 3:4677 correspondence: poras chaudhary, lady hardinge medical college and associated dr ram manohar lohia hospital, 189 deoli road, 110062 new dehli, india. tel.: +91.9891.4473.358. e-mail: drporaschaudhary@yahoo.com key words: typhoid fever; intestinal perforation; high morbidity; awareness and education. received for publication: 23 august 2014. revision received: 6 april 2015. accepted for publication: 7 april 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright p. chaudhary et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4677 doi:10.4081/hls.2015.4677 [page 32] [healthcare in low-resource settings 2015; 3:4677] i.e. sub-standard water supplies and sanitation. other reasons include persistence of quackery in almost every part of the country including metropolitan cities. typhoid fever is more common in low socioeconomic group, though it occurs in upper and middle class as well, but incidence is comparatively less and complication rate is almost negligible in upper and middle class. this difference of incidence of typhoid fever and its complication is due to the two reasons mentioned previously. people in low socio-economic groups almost always first go to quacks and they misdiagnose and misguide patients, which results in increased complication rates. out of 646 patients, 412 article table 1. patients’ characteristics. patients characterictics (n=646) value age (year) 29 (range 14-76) sex (m:f) 435:211 low socioeconomic status (n) 528 duration of symptoms before seeking medical advice (days) 9 patients presented in shock (n) 62 operative time (min) 50 (range 45-90) icu care yes immediate after surgery 92 later during post-op period 43 no 511 patients requiring antibiotics other than iv ceftriaxone (n) 146 hospital stay (days) 15 patients presented to quacks initially before coming to government centres (n) 412 mortality (n) 13 icu, intensive care unit. table 2. complications of typhoid enteric perforation after surgery. complications patients (n=633) n % stomal and peristomal skin excoriation 408 64.45 high output 53 8.37 retraction 13 2.05 prolapse 87 13.74 parastomal hernia 9 1.42 systemic acute renal failure 16 2.52 ards 18 2.84 pneumonitis 76 12.01 atelectasis 68 10.74 secondary to primary surgery anastomotic or primary closure site leak 48 7.58 intra-abdominal collections 65 10.26 wound dehiscence superficial 512 80.88 deep 84 13.27 prolonged ileus 92 14.53 severe electrolyte imbalance 77 12.16 adhesive intestinal obstruction 32 5.05 incisional hernia 31 4.89 ards, acute respiratory distress syndrome. table 3. operative procedures done for typhoid enteric perforation. type of surgery patients n % perforation site brought out as stoma (n=640) 410 64.06 primary closure (n=640) 212 33.12 resection and anastomosis (n=640) 24 3.75 reperforation after stoma creation (n=410) 43 10.48 resurgery for leak after primary closure (n=212) 32 15.09 leak after r&a (n=24) 16 66.66 r&a, resection and anastomosis. [healthcare in low-resource settings 2015; 3:4677] [page 33] (63.77) initially went to quacks for management of fever for which they received empirical treatment. patients attend government tertiary care centers after complications arise. government tertiary care centers are very well equipped and provide free services to all the patients. poor patients who seek early advice during the course of illness in tertiary care centers almost never develop complications like perforation peritonitis and intestinal haemorrhage. ileal perforation peritonitis is the most common surgical complication encountered in our institute. six hundred forty six patients presented with perforation of ileum in surgical emergency. the authors have studied only those patients who presented in surgical unit 6, so actual burden of these complications is much more. out of these 646 patients, 62 presented in shock. aggressive resuscitation and insertion of abdominal drain before taking up patients for definitive surgery were helpful in saving life. exploratory laparotomy was possible in 56 patients after resuscitation and drain insertion. kouame and colleagues5 also recommended the importance of aggressive resuscitation before surgery. stomal, peristomal and systemic complications are more with enteric perforations as compared to perforation secondary to other causes.4 wound dehiscence, and post-operative intra-abdominal collections including abscess were the most common complications requiring resurgery. reperforations requiring surgery were observed in 43 patients. these perforations occurred proximal to previous perforation site in 39 cases while distal to the first perforation in 4 cases. in all of these cases perforation site was brought out as ileostomy during first surgery. during resurgery, new perforation site was then brought out as ileostomy and distal part was resected. three patients developed perforations after second surgery proximal to previous perforation site and during third surgery stoma was refashioned. reperforations were possibly due to presence of multiple ulcers resulting in perforation at these ulcer sites. patients who were not diagnosed properly initially and did not receive any treatment for enteric fever resulted in progression of pathology in the form of multiple ulcers and perforation at different times. primary closure was done in 212 patients, out of which leak was observed in 32 patients and a stoma was created in these 32 patients during resurgery. resection and anastomosis was done in 24 patients and leak from anastomotic site was observed in 16 patients and during resurgery double barrel ileostomy was created in 6 patients and in 10 patients, end ileostomy with closure of distal ascending colon loop was done. zida and colleagues6 recommended creation of ileostomy as primary therapy for ileal perforation peritonitis as it reduces morbidity and mortality while pal and colleagues7 recommended primary closure and side to side ileotransverse for better results. surgical site infection (ssi) is one of the major complications in these patients. superficial incisional surgical site infections, involving only skin and subcutaneous tissue, occurred in 512 patients while deep incisional surgical site infections were seen in 84 patients. all the patients who presented in shock in emergency and then underwent surgery after resuscitation and broad spectrum antibiotic coverage developed deep incisional ssis. out of these 84 patients, 69 underwent resurgery. surgical site infections are more common in patients with shock because shock results in reduction of local perfusion which enhances susceptibility to infection and a little load of organisms is required to produce infection in presence of shock.8 fluid and electrolyte imbalance was seen in all the patients and persisted for a varying period of length after surgery. fluid and electrolyte imbalance results in inadequate perfusion of gastrointestinal tract and increases chances of ssi. surgical site infection resulted in impaired mobility, increased hospitalization, delayed rehabilitation and incisional hernia. mortality due to complication of this benign disease was high. out of 62 patients who presented with shock, 6 died even before surgery. rest of the 56 patients underwent surgery after aggressive resuscitation and drain insertion under local anaesthesia. after surgery, 3 of these patients died due to septic shock and multiple organ dysfunction syndrome. out of 584 patients, 8 died due to septic shock. the total number of deaths in present study was 13 (2.01%), while mogasale and colleagues9 reported 706 deaths out of 4626 patients. atamanalp and colleagues10 stressed upon the role of early and appropriate surgical intervention to decrease morbidity and mortality. conclusions to conclude, treatment of cases, contacts and carriers is important to prevent complications. typhoid fever and its complications are never a major problem where there is clean water supply and very well established modern public health and these are accomplished fact in most of the developed countries. to prevent complications of typhoid fever, in addition to control sanitation, it is also important to control quackery and malpractices. awareness and education about the disease, its nature and complications, and about the potential hazards of using contaminated food and water will also be of great help. moreover, vaccines are available for typhoid, though typhoid vaccination is presently not part of the national immunization programme. still, vaccination alone cannot control typhoid fever and its complications. this awareness can be spread through national programmes which are still lacking in india. references 1. ananthnarayanan r, paniker ckj. enterobacteriaceae iii: salmonella textbook of medical microbiology. 8th ed. hyderabad; universities press; 2009. pp 288-300. 2. park k. epidemiology of communicable diseases. park’s textbook of preventive and social medicine. 21st ed. bhanot; jabalpur: 2011. pp 213-6. 3. government of india. national health profile 2011. new delhi; ministry of health and family welfare: 2012. 4. chaudhary p, nabi i, ranjan g, et al. prospective analysis of indications and early complications of emergency temporary loop ileostomies for perforation peritonitis. ann gastroent hepato 2014;27:1-6. 5. kouame j, kouadio l, turguin ht. typhoid ileal perforation: surgical experience of 64 cases. acta chir belg 2004;104:445-7. 6. zida m, ouedraogo t, bandre e, et al. primary ileostomy for typhoid-related ileal perforation: a 62-case series in ouagadougou, barkina faso. med trop (mars) 2010;70:267-8. 7. pal dk. evaluation of best surgical procedures in typhoid perforation: an experience of 60 cases. trop doct 1998;28:16-8. 8. meakins jl, masterson bj. acs surgery: principles and practice. in: souba ww, fink mp, jurkowich gj, kaiser lr, pearce wh, pemberton jh, soper nj, eds. american college of surgeons. new york, ny: webmd; 2007. p 27. 9. mogasale v, desai sn, mogasale vv, et al. case fatality rate and length of hospital stay among patients with typhoid intestinal perforation in developing countries: a systematic literature review. plos one 2014;17:e93784. 10. atamanalp ss, avdinli b, ozturk g, et al. typhoid intestinal perforation: twenty-six year experience. world j surg 2007;31: 1883-8. article hrev_master [page 34] [healthcare in low-resource settings 2021; 9:10056] computed tomography severity scoring of covid 19 infected young patients: is the second wave affecting the young lungs more than the first wave in india? omair shah, shadab maqsood, tahleel shera, mudasir bhat, naseer choh, aamir shah, feroze shaheen, tariq gojwari department of radiology, sheri kashmir institute of medical sciences soura, j&k, srinagar, india abstract we evaluated the high resolution computed tomography (hrct) findings in young patients (< 40 years) infected with the covid 19 virus and tried to find out any difference in the severity of lung involvement between the first and second wave of the pandemic and whether the notion of young population being more severely affected by the second wave holds true.two-hundred (200) young patients (<40 years) with rt pcr documented covid infections undergoing hrct chest at our institute were included. group a included young patients infected in the first wave (up to 28 february 2021) while group b included patients beyond this date. demographic and clinical data was obtained from the medical records department. hrct scans were retrieved from the archive and were assessed by two radiologists or ct severity scoring. the mean severity scores were calculated and any statistical difference between group a and b was sought. ct scans of four fully vaccinated patients were also evaluated.the age and gender distribution among the two groups was comparable. a greater number of patients in group b required hospital admission compared to group a (74% vs 53%). in group a, the mean severity score was 10.1±2.1 with 34 patients (34%) in mild category, 46 patients (46%) in moderate group and 20 patients (20%) in the severe group. in group b, the mean ct severity score was 12.6±2.3 with 20 patients (20%) in mild category, 42 patients (42%) in moderate group and 38 patients (38%) in the severe group.lung involvement in young patients in the second wave is more severe requiring more hospital admissions. vaccinated population may well have a milder form of the disease. introduction a new virus with extra ordinary contagious nature was first detected in the chinese city of wuhan in december 2019.1this virus was found to belong to the coronavirus family which is a positive sense rna virus and was namedsevere acute respiratory syndrome coronavirus 2 (sarscov-2). this virus is highly contagious and has spread to all parts of the world making it a pandemic.2the clinical picture of infected persons has been evolving since the time of its inception but predominantly involves the respiratory system. patients usually present with fever, cough, dyspnea, myalgias, anosmia and loss of taste.3,4 the diagnosis is usually based on rt-pcr (reverse transcription polymerase chain reaction) of the nasopharyngeal or oropharyngeal swab. this method although quite accurate can have significant false negative results.5,6 a high resolution computed tomography (hrct) of the chest has emerged as a reasonable diagnostic modality which can not only help identify patients infected with the virus but also give an overview of the severity of the lung involvement.7 hrct findings including the morphology and extent of lung involvement has been found to correlate with clinical findings and the degree of inflammatory process.8-10 the age of the patient is an important determinant of the severity of the disease including the need for hospitalization and even ventilation. while the first wave of the covid-19 obeyed this general rule of age, the second wave with new emerging variants seems to defy this generalization with young patients being affected more with increased mortality and morbidity. our study aims at investigating the sudden drift in the age of involvement of covid-19 infected patients in term of their lung involvement on hrct chest images. the objective lung involvement on chest ct can perhaps help make the population at large and young adults in particular understand the severity of this second wave and perhaps push them towards vaccination and covid specific protocols. materials and methods our study was a retrospective study performed at sheri kashmir institute of medical sciences including patients with covid-19 infection undergoing hrct chest at our institute. the inclusion criteria were patients with age ≤40 years with rt pcr documented infection with no known co morbidity and whose images were available in our archive. the patients over 40 years of age, with known co morbidities, hrct features of pleural effusion/superimposed bacterial infection and fully vaccinated individuals were excluded. a total of 200 patients were included in the study and were divided into two time frames, group a including covid positive patients who underwent a hrct in the time period from the start of the pandemic up to 28thfebraury 2021 and group b including patients beyond 1st march 2021. the cut off date was selected based on the input of start of the second wave in our region. all the scans were obtained from the archive and were transferred to the work station for evaluation. ct technique hrct scans were done in a separate time slot for covid positive patients to avoid cross infections. all scans were done on ct 64 somatom scanner with the patient in supine position. scans were obtained in inspiration with the following parameters: tube voltage (80-120 kv), tube current (80-500 ma), slice collimation (64 x 0.625 mm), width (0.625 x 0.625 mm), pitch (1), and rotation time (0.5 s). the reconstruction was done with following parameters: slice thickness1mm, interslice gap0.9 mm, kernelb 90 sharp. the images were transferred and stored in the archive. healthcare in low-resource settings 2021; volume9:10056 correspondence: omair shah, department of radiology, sheri kashmir institute of medical sciences soura, j&k, 167 nursingh garh, karanagar, srinagar, india. e-mail: shahomair133@gmail.com key words: hrct; covid 19; rt pcr. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethicsapproval and consent to participate: not required by the institution. informed consent: not required by the institution. received for publication: 23 august 2021. revision received: 22 november 2021. accepted for publication: 22 november 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:10056 doi:10.4081/hls.2021.10056 non commercial use only image evaluation all images were retrieved from the archive and transferred to a dedicated workstation. the images were separately interpreted by two radiologists with over 5 years of experience. the clinical profile of the patients was kept blinded. the ct of each patient was scored according to 25 point ct severity scoring and the patients were placed in three groups according to the mean score: mild 0-7, moderate 8-15 and severe 16-25. the scoring was done based on the visual assessment of the five lobes (3 lobes of the right lung and 2 lobes of the left lung). each lobe was given a score of 0-5 based on the percentage involvement of that lobe with ground glass opacities or consolidation typical for covid pneumonia: 0no involvement, 1-1-5%, 2-5-25%, 3-26-49%, 4-50-75% and 5->75%. the total severity score was the summation of the score of all 5 lobes. in cases where the two radiologists gave a differing score, the mean of the two scores was taken as the final score. statistical analysis the data was compiled and the patients in the two groups were divided into mild, moderate and severe covid groups based on the ct severity scores. the ct severity scores between the two groups (group a and group b) were compared for any significant differences. the data was collected and evaluated using spss 21.0. descriptive data was analyzed by frequencies and categorical data by percentages and continuous variables by means and standard deviations. continuous variables were compared using student’s t test. for all comparisons, pvalue of <0.05 was considered statistically significant. results our retrospective study was conducted over a period of 14 months and included a total of 200 patients who underwent hrct chest at our institute and were covid rtpcr positive. patient profile we divided the patients into two main groups based on their presentation to our institute before or after 1st march 2021group a before and group b after this date. we had 100 patients in each group. the mean age of patients in group a was 33.1 ± 5.9 years and included 63 males and 37 females. the mean age of the patients in group b was 33.2 ± 5.6 years and included 64 males and 36 females. clinical profile all these young adults were otherwise healthy with no underlying co-morbidity. most of the patients presented with usual symptoms of covid including fever, dyspnea, anosmia, altered taste and cough. although the clinical findings were blinded, we found that patients in group b were clinically worse as compared to patients in group a evidenced by increased number of hospital admissions in group b patients (n=74 74%) as compared to group a patients (n=53 53%). computed tomography the hrct images were evaluated and a ct severity score was assigned to each patient and the patients in each group categorized into mild, moderate or severe disease. in group a, the mean severity score was 10.1 ± 2.1 and it included 34 patients (34%) in mild category, 46 patients (46%) in moderate group and 20 patients (20%) in the severe group. in group b, the mean ct severity score was 12.6 ± 2.3 and it included 20 patients (20%) in mild category, 42 patients (42%) in moderate group and 38 patients (38%) in the severe group (tables 1 and 2). we also had 4 patients, all medical professionals, who were fully vaccinated and had contracted the virus. in all these patients the ct severity was mild with a mean score 5 and none required hospital admission. discussion we conducted our study using data in our archive with the aim of establishing the vicious nature of the second wave of covid in our part of the world with special focus on young population below the age of 40 years. although the clinical features of the patients were not taken into account, the extent of lung involvement on hrct chest can serve as an indicator of the severity of the disease.11-13 we found that the majority of the patients in our part of the world were males approximately in the ratio of 2:1(m:f). this male predominance has been previously documented in many studies including those of jinet al.14and li q et al.15 the male predominance can be explained by the fact that most females in our part of the world are homemakers with less chances of exposure to the virus. also the severity of the disease in the males can be explained by the increased number of ace-2 receptors in males, which is believed to be the target for covid virus.15 age has also been previously studied as an important factor affecting the severity of covid infection in the population with increasing severity associated with increasing age. this is probably secondary to increased co-morbidities like diabetes, cardiovascular disease, and obstructive airway article table 1. mean ct severity scores and hospital admissions among the two groups. ct severitycategory group a (n=100) group b (n=100) mild (0-7) 34 20 moderate (8-15) 46 42 severe (15-25) 20 38 mean ct severity score 10.1 ± 2.1 12.6 ± 2.3 need for hospital admission 53 74 table 2. the results of students t test applied to ascertain the statistical difference between the ct severity scores among the two groups. t-test: two-sample assuming unequal variances ct score new ct score old mean 12.55 10.18 variance 23.62 19.83 observations 100 100 hypothesized mean difference 0.00 degrees of freedom 197 t stat 3.59 p(t<=t) one-tail 0.00 t critical one-tail 1.65 p(t<=t) two-tail 0.00 [healthcare in low-resource settings 2021; 9:10056] [page 35] non commercial use only diseases being more common in the elderly. the severity of involvement in the younger age group with no associated co-morbidity has been mild with few exceptions. however as indicated in our study, the new wave with its new variants has seen greater involvement of young people. we found in our study that more young patients required hospital admission in the new wave (n=74, 74%) in comparison to the previous wave (n=53, 53%). the increased number of admissions in the first wave was probably due to the initial national guidelines which required even asymptomatic and mild disease patients were admitted to the hospital. with the onset of the new wave (after march 2021), the national guidelines had already been changed and admissions were recommended only for patients with moderate to severe disease. therefore the increased admissions during the new wave were in view of the increased severity of the disease rather than asymptomatic and mild cases being admitted during the first wave. this clearly indicates that the new wave of covid 19 is more severe even in young patients with no significant co-morbidities and most of these patients required hospital admission and oxygen administration. the severity of covid 19 infection has been graded in terms of clinical features, lab parameters as well as ct severity scoring. although clinical staging is the standard, ct severity scoring has been found to correlate with clinical features in many studies.8-10we identified in our study that the ct severity score in young patients was significantly less as compared to the older counterparts. however a trend that has been seen with the second wave of the virus is the more severe involvement of even the younger patients with no co-morbidities. we found that the mean ct severity score in group a was 10.1 ± 2.1 while that in group b patients was 12.6 ± 2.3 having a statistically significant difference (p< 0.001; tables 1 and 2). the findings in group a were mainly in the form of patchy ground glass opacities and consolidations in the sub-pleural locations (figures 1 and 2). the patients in group b in addition of having more severe ct scores also had more confluent consolidations and ground glass opacities in the sub-pleural locations (figures 3, 4 and 5). the increased severity, especially the confluent lung involvement in the group b patients can be attributed to new variants that have emerged probably secondary to the known phenomenon of genetic drifts and shifts. we also had four patients in our study who were fully vaccinated health care workers and were infected in the second wave. however all these patients had no or only mild lung involvement in their hrct scans. we therefore believe that the new variants of the covid article figure 1. 31 year old health care worker with covid 19 showing mild disease in the form of multifocal patchy ground glass opacities (a,b) and sub pleural linear bands in the right lower lobe (c). ct severity score was 5. figure 2. upper (a), mid (b) and lower level (c) hrct axial scans in a 30 year young male showing patchy multifocal lung involvement post covid 19 infection. total ct severity score was 8. figure 3. 25 year old female with moderate ct severity score of 14. hrct scans at upper, mid and lower levels (a,b,c) showing multifocal confluent subpleural consolidations and ground glass opacities diffusely involving both lung fields. [page 36] [healthcare in low-resource settings 2021; 9:10056] non commercial use only virus are emerging that can infect and adversely affect the young patients in contrast to the earlier notion of elderly population being most commonly involved. this further emphasizes the role of prevention in the form of covid standard operating procedures (masks, hand washing, good hygiene) in curbing this pandemic, not only for the elderly but also for young people irrespective of any co-morbidity. the ct severity scores in the four fully vaccinated patients, although a small number indicates the role of vaccination in bringing down the severity of the disease in the infected population. however a larger study may be required to establish this fact. to the best of our knowledge no similar study has been conducted in our region whereby the ct severity scores have been compared between the first and the second wave of the covid 19 infection. the limitations of our study obviously include the lack of clinical data in the form of oxygen requirements and the lab findings in these young patients. also there is no follow up ct scans available which can give us an idea about the chronic effects of this viral infection on the lungs in the form of any fibrosis. conclusions the second wave of covid 19 infection is definitely affecting the young patients more than in the previous wave. the lung involvement in the form of ct severity score is more severe with the new wave with increased need for hospital admissions. vaccination can act as the answer to reducing the severity of the disease in covid infected patients. references 1. gorbalenya ae, baker sc, baric rs, et al. severe acute respiratory syndrome related coronavirus: the species and its viruses – a statement of the coronavirus study group. biorxiv 2020;https:// www.biorxiv.org/content/10.1101/2020 .02.07.937862v1 2. chan jf, yuan s, kok kh, et al. a familial cluster of pneumonia associated with the 2019 novel coronavirus indicating person-to-person transmission:a study of a family cluster. lancet 2020;395:514–523. 3. lee n, hui d, wu a, et al. a major outbreak of severe acute respiratory syndrome in hong kong. n engl j med 2003;348:1986–94. 4. assiri a, al-tawfiq ja, al-rabeeah aa, et al. epidemiological, demographic, and clinical characteristics of 47 cases of middle east respiratory syndrome coronavirus disease from saudi arabia: a descriptive study. lancet infect dis 2013;13:752–61. 5. corman vm, landt o, kaiser m, et al. detection of 2019 novel coronavirus (2019-ncov) by real-time rt-pcr. eurosurveillance 2020;25. 6. bustin sa,nolan t. pitfalls of quantitative real-time reverse-transcription polymerase chain reaction. jbiomoltechn2004;15:155–66. 7. liu j, yu h,zhang s. the indispensable role of chest ct in the detection of coronavirus disease 2019 (covid-19). eur jnuclear medmolec imaging2020:47:1638-9. 8. colombi d, bodini fc, petrini m, et al. well-aerated lung on admitting chest ct to predict adverse outcome in covid-19 pneumonia. radiology 2020;295:715–21. 9. zhang n, xu x, zhou ly, et al. clinical characteristics and chest ct imaging features of critically ill covid-19 patients. eurradiol2020;30:1–10. 10. saeed ga, gaba w, shah a, et al. correlation between chest ct severity scores and the clinical parameters of adult patients with covid-19 pneumonia. radiol res pract 2021;2021: 6697677. 11. turcato g, panebianco l, zaboli a, et al. correlation between arterial blood gas and ct volumetry in patients with sars-cov-2 in the emergency department. int j inf dis 2020;97:233–5. 12. shang y, xu c, jiang f, et al. clinical characteristics and changes of chest ct features in 307 patients with common covid-19 pneumonia infected sarscov-2: a multicenter study in jiangsu, article figure 4. hrct axial images at different levels (a,b,c) in a 20 year old male rt pcr positive covid 19 patient showing extensive confluent subpleural consolidations and ground glass opacities. ct severity score in this patient was 16. figure 5. 27 year old covid positive female. hrct axial scans at upper(a), middle(b) and lower lobe (c) levels showimg extensive confluent consolidations predominantly involving lower lobes with a total ct severity score 15. [healthcare in low-resource settings 2021; 9:10056] [page 37] non commercial use only [page 38] [healthcare in low-resource settings 2021; 9:10056] china. int j inf dis 1996;96:157–162. 13. attia nm, othman mhm. chest ct imaging features of covid-19 and its correlation with the pao2/fio2 ratio: a multicenter study in upper egypt. egypt j radiolnucl med 2020;51;252. 14. jin j-m, bai p, he w, et al. gender differences in patients with covid19: focus on severity and mortality. front public health 2020;8:152. 15. li q, guan x, wu p, et al. early transmission dynamics in wuhan, china, of novel coronavirus-infected pneumonia. n engl j med 2020;382:1199–207. article non commercial use only hrev_master [page 10] [healthcare in low-resource settings 2016; 4:5757] motivation for studying medicine: assessing the similarities between uk and ghanaian medical students benjamin clayton plymouth university peninsula schools of medicine and dentistry, plymouth, uk abstract countries around the world experience challenges in ensuring equal distribution of health workers. for countries faced with this problem, there are many benefits to international co-operation. before this can occur, however, there needs to be an understanding of the homogeneity of medical students between countries. this paper assesses the similarities in motivation to study medicine between medical students from the united kingdom (uk) and ghana. a survey previously performed on fourth-year ghanaian students was reproduced with medical students in the uk. students were asked to record their motivation for studying medicine, opinions on future career [general practice (gp) for uk students and a rural position for ghanaian students] and basic demographics. the results were compared between the two cohorts using fisher’s exact test. of medical students, 302 from ghana and 78 from uk completed the survey. of students, 63.5 and 75.0% were classified as intrinsically motivated in ghana and the uk, respectively. apart from parental education status, student demographics were broadly similar. within the uk cohort, 30.1% of students considered it likely that they would work in gp in their future careers. medical students are similarly motivated between the two countries. this suggests that greater co-operation may be possible when tackling difficulties in human resources for health. this is especially relevant for the uk, as the level of students predicting a career in gp in this study remains well below the national target. introduction unequal distribution of health workers affects the health of populations around the world.1 globally, there is a disproportionate number of doctors working in urban as opposed to rural settings. around 50% of the world’s population lives in rural areas yet they are served by only 25% of available physicians.2 this imbalance occurs in high, middle and low income countries3 and also affects the uptake within specialities, with fields such as primary care4 and psychiatry5 often being neglected. the resulting lack of health workers leads to direct health consequences for affected populations.6-8 in an increasingly globalized world, international and domestic migration appear closely interconnected. as health workers continue to move in large numbers from areas of low health worker coverage to high, it is the poorest places with the greatest need that are disproportionally affected.9-12 the united kingdom (uk) is not exempt from these problems. as well as receiving and losing health workers internationally, it also experiences difficulty in ensuring an even distribution of doctors in certain geographical areas and specialties.13 general practice (gp), for instance, has been struggling to fill its training places, and a significant proportion of current practitioners are set to retire in the next 5 years.14 this deficit is felt most acutely in rural areas.15 the need for central planning in these situations is apparent due to the current failure of market forces. forcing doctors to work in specific areas has generally failed when it has been attempted previously.1,16 ensuring compliance with job allocation is often impossible and can result in unmotivated doctors who fail to provide adequate care.1,9,17,18 incentivizing doctors to actively choose to work in an underfilled area would eliminate many of these difficulties.2,6 accordingly, countries around the world have researched and introduced a variety of strategies that have attempted to influence medical students’ career choices.18,19 for countries with a need to redistribute health workers, such as the uk, learning from previous international attempts could highlight areas of good practice as well as identifying mistakes to be avoided. however, for knowledge to be transferable there must be an understanding of the similarity of medical students between countries. this information would also prove beneficial in managing international health worker migration. for instance, identifying medical students’ homogeneity would be helpful in the setup of bilateral strategies appropriate to both cohorts. appreciation of comparison’s importance has led the world health organization (who) to call for more international comparative research.1 one area that would benefit from comparison is medical students’ motivation. in high, middle and low income countries around the world, various studies have demonstrated the importance of motivation in a range of factors, including in influencing decisions about future careers and specialities.20-26 one method of classifying motivation is as either intrinsic or extrinsic.27 kusurkar28 describes intrinsic motivation as the drive to perform an activity for personal interest or enjoyment. extrinsic motivation, on the other hand, is the desire to execute a task for a separable outcome such as obtaining a reward or avoiding a loss. vaglum and colleagues,29 in a study on norwegian medical students, showed that the balance between extrinsic and intrinsic motivation in medical students has a strong influence on their future career choices. similar findings have occurred in a diverse range of countries such as switzerland,21 the west indies,30 netherlands,22 hungary,31 ghana,32 and egypt.33 as the royal college of general practitioners currently embarks upon a campaign to persuade uk medical students to choose gp as a career,14 understanding the impact of underlying motivation would allow for better targeted interventions.33 however, within the uk there is little literature studying the effect of motivation on student’s future career choice. it is therefore beneficial to examine how similar uk medical students are to those in other countries. this knowledge would provide a greater understanding of the extent to which conclusions reached from foreign studies are transferrable, and thus could help compensate for the current dearth of uk research. in addition, if students are found to be similar, the uk could be more confident in learning from previous international attempts to influence career choices. there has been very little direct comparison healthcare in low-resource settings 2016; volume 4: 5757 correspondence: benjamin clayton, plymouth university peninsula schools of medicine and dentistry, john bull building, tamar science park, research way, plymouth, devon pl6 8bu, uk. tel: +44.07510.195790. e-mail: claytonben@hotmail.co.uk key words: cross-cultural study; motivation; human resources for health. acknowledgements: the author would like to thank simon thornton (university of bristol) for his much appreciated advice and support and simon collin (university of bristol) for his statistical guidance. finally, the author is grateful to the students of university of bristol medical school for taking the time to participate in the survey. conflict of interest: the author declares no potential conflict of interest. received for publication: 19 january 2016. accepted for publication: 19 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright b. clayton, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5757 doi:10.4081/hls.2016.5757 non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 11] of motivation between medical students. one study examined motivation to study medicine between uk and spanish medical students and determined some similarities between the two cohorts.34 however, both spain and the uk are high income, european countries. it would be helpful to expand upon this work by comparing medical students in very different situations. to achieve this, this study has replicated a previous survey performed by agyei-baffour and colleagues32 on ghanaian medical students, applying it to uk students. within ghana, policy makers have struggled with high rates of domestic and international health worker migration that have deeply impacted upon the health of the population.23 in their work, agyei-baffour and colleagues32 used a questionnaire to analyze student’s motivation to study medicine and its influence on their decision to work in a deprived area. in this study, uk medical students at a similar point in their studies were provided with the same questions. in terms of development, disease burden and healthcare, ghana is dramatically different to the uk.35 by comparing the results from both cohorts, this study hopes to assess how homogenous motivation is between medical students from these two vastly different countries. materials and methods study site the ghanaian data was taken from results published by agyei-baffour and colleagues32 their research was performed on 4th year medical students studying at two universities in ghana. medical students in ghana undertake 3 years of basic science teaching followed by three years of clinical training and a two-year rotating housemanship. the present study gathered its uk data from the university of bristol medical school (ubms) between april and may 2015. ubms is based in bristol, a city with an estimated population of 430,000 people situated in the south-west of england.36 medical students in ubms undertake two years of preclinical teaching followed by three years of clinical placements before graduation. two further years follow as a junior doctor before a decision can be made to enter specialist training. attempts were made to survey all 3rd year medical students. this year group was chosen as, having completed their pre-clinical training and just starting their clinical experience, they closely matched the professional experience of the ghanaian cohort. data from the world bank clearly demonstrates the difference between the two countries. the uk in 2013 had an estimated population of 64 million with a gross national income (gni) per capita of 41,680 usd.37 in comparison, ghana has an estimated population of 26 million, with a gni per capita of 1770 usd.38 in 2014, the uk was placed 14th on the human development index whilst ghana was 138th.39 in terms of health worker density, in 2013 the uk had 2.8 physicians per 1000 population, roughly 20 times the 2008 ghanaian figure of 0.11.40 ethical approval ethical approval was received from the university of bristol ethical review committee. all respondents voluntarily participated after having the purpose of the study explained to them. consent was implied by filling out the questionnaire. all results were anonymous and confidential. data collection the use of questionnaires is a well-established method to compare medical students from different cohorts.41-43 paper questionnaires were handed out to all 3rd year ubms students attending a compulsory workshop on future career choices. the questionnaire was compiled using the methodology reported by agyei-baffour and colleagues.32 attempts were made to keep questions as similar as possible to the published methodology, however some minor adjustments were required. details of the questionnaire are given below, with any necessary changes highlighted. participants were first asked to choose the statement that most accurately represented their current position with regards to their future career. they could choose between i) definitely work in gp; ii) likely to work in gp; iii) unlikely to work in gp; and iv) definitely not work in gp. for analysis these were grouped into dichotomous positions of likely to be a gp (statements 1&2) and unlikely to be a gp (statements 3&4). this question differs from the ghanaian study, which assessed students’ willingness to work in a deprived area, and reflects the different health worker imbalances found in the two countries. to assess motivation, students were presented with twelve factors and asked to pick the top three that motivated them to study medicine. five intrinsic motivations were included: inspiration by a role model; desire to help others; interest in medicine as a subject matter; desire to give back to home community and loss of a loved one. seven extrinsic motivations were included: job security and lifestyle; social status/prestige; income of physician; proposed by parents; opportunity to travel and work internationally; research opportunities and ability to use cutting edge technology. participants were judged to have strong intrinsic motivation if they chose two or more intrinsic factors and strong extrinsic motivation if they chose two or more extrinsic factors. the two states were thus mutually exclusive. the demographics assessed included sex, age, partnership status (married/in a relationship vs single) and parental education status (pes). a high pes was assigned if one or more parents had received a university degree. instead of ethnicity, which was assessed in the ghanaian study, uk students were asked whether they were a domestic or international student. rural exposure was assessed by asking about birth location, location of secondary school and whether they had lived in a rural area at any point since the age of 5. in this questionnaire, rural was defined in line with the uk government definition as an area no bigger than a small town i.e. population less than 10,000.42 this is slightly different from the definition used by agyei-baffour and colleagues32 who described rural as an area with a population less than 5000. this change was necessary as the uk is more densely populated than ghana, and thus definitions of the term rural vary accordingly. statistical analysis results were analyzed using graphpad prism version 6.00 for windows (graphpad software; microsoft corporation, redmond, wa, usa). main outcome of interest was comparison of motivation and demographics between uk and ghanaian students. bivariate associations and 95% confidence intervals (cis) were calculated using fisher’s exact test. results demographics of the 244 ubms medical students in 3rd year, 168 (69%) attended the lecture. of these, 78 (46%) responded to the survey. the sociodemographic characteristics of respondents are shown in table 1. a small majority of the participants were female (52.6%) with an average age of 22.0 years [standard deviation (sd)=1.77]. most respondents were domestic students (83.3%) and were not in a relationship (57.9%). 61 (78.2%) respondents had a parent who had achieved a university degree. in terms of rural experience, half of the respondents (50.0%) had not lived in a rural area from the age of 5 and the majority had been born in an urban area (64.1%) and had gone to secondary school in an urban area (67.9%). motivation two students did not report their motivation to study medicine or their current views of gp as a career and were therefore excluded from the analysis. when motivational factors were grouped, just over three quarters of respon article non co mmerc ial us e o nly [page 12] [healthcare in low-resource settings 2016; 4:5757] dents were categorized as having an intrinsic motivation to study medicine (n=55 or 75.3%). only 30.1% (n=22) of all participants stated that they definitely or likely work in gp in their future career. the relationship between motivation and future career opinions is shown in table 2. a higher percentage of students who reported intrinsic motivation thought they were likely to work in gp compared to those who were extrinsically motivated (32.7 vs 22.2%, respectively). however, this does not reach significance when using fisher’s exact test (p=0.56). comparison with ghanaian students a comparison of uk and ghanaian students’ motivation for studying medicine can be found in figure 1. of uk students, 75.0% were categorized as intrinsically motivated compared to 63.5% of ghanaian students. this difference does not reach a level of significance [odds ratio (or) 1.64, 95% ci 0.92 to 2.91]. demographic characteristics have been compared in figure 2 and table 3. ethnicity was incomparable and the ghanaian study did not report on the students’ school location so both categories were excluded from comparison. both sets of students are similar in age (uk 22.0 sd=1.77 vs ghana 22.9, sd=1.40). there is a smaller proportion of males in the uk than in ghana (or 0.55, 95% ci 0.33 to 0.91). uk students are less likely to be in relationships (or 0.59, 95% ci 0.32 to 0.98) and substantially more likely to have a parent who is university trained (or 3.04, 95% ci 1.63 to 5.70). with regards to rural experience, uk students were far more likely to report being born in a rural area (or 4.14, 95% ci 2.28 to 7.53) and having lived in a rural area since the age of 5 (or 3.02, 95% ci 1.79 to 5.09) than their ghanaian counterparts. discussion comparison of students’ motivation the results clearly demonstrate that the majority of both ghanaian and uk students are intrinsically motivated, numbering 63.5 and 75.0%, respectively. although uk students may be more likely to report intrinsic motivation, the results between the two cohorts are broadly similar. this homogeneity occurs despite living and training in areas with vastly different cultures, healthcare systems and living standards. this suggests that some level of transferability may be possible between both countries in the use of strategies that target underlying motivation of medical students. however, this result must be treated with caution. adjusting motivation into two binary article table 1. socio-demographic characteristics and rural exposure of uk students. variable frequency % (n=78) gender male 35 44.9 female 41 52.6 na/prefer not to answer 2 2.6 mean age (sd) 22.0 (1.77) student status domestic 65 83.3 international 10 12.8 na/prefer not to answer 3 3.8 relationship status married/in a relationship 20 25.6 single 53 67.9 na/prefer not to answer 5 6.4 pes high* 61 78.2 low 14 17.9 na/prefer not to answer 3 3.8 lived in a rural area° yes 37 47.4 no 39 50.0 na/prefer not to answer 2 2.6 birthplace rural# 26 33.3 urban 50 64.1 na/prefer not to answer 2 2.6 secondary school rural 23 29.5 urban 53 67.9 na/prefer not to answer 2 2.6 na, not available; sd, standard deviation; pes, parental education status. *high pes is one or more parents achieved a university degree; °from age five on; #rural is an area with population<10,000. table 2. comparison of intrinsic and extrinsic student motivation versus likelihood of entering general practice in future career. likely unlikely total* (n) n % n % intrinsic° 18 32.7 37 67.3 55 extrinsic# 4 22.2 14 77.8 18 total 22 30.1 51 69.9 73 *two students failed to answer the question and were thus excluded. °intrinsic motivation is defined as factors chosen from: inspiration by a role model, desire to help others, interest in medicine as a subject matter, desire to give back to home community and loss of a loved one. #extrinsic motivation is defined as factors chosen from: job security and life style, social status/prestige, income of physician, proposed by parents, opportunity to travel and work internationally, research opportunities and ability to use cutting-edge technology. figure 1. comparison of reported motivation between uk and ghanaian medical students (%). non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 13] categories (intrinsic or extrinsic) is a crude method that provides little detail. determining which factor is intrinsic or extrinsic is open to interpretation and may be overly arbitrary. there is no weighting possible between the different motivational factors and the importance of each may differ widely between participants. in addition, it may be that context affects the practical implications of the underlying motivational factors. for instance, a desire for good job security and lifestyle may mean entirely different things between ghanaian and uk students. yet, despite this study’s limited ability to capture nuances or high levels of detail, it does succeed in a direct comparison between two highly divergent populations. it is also important not to draw overly specific conclusions from this result. although underlying motivation has been shown in many contexts to influence career choice,20-26 the relationship between the two is complicated and may differ greatly between the two cohorts. additionally, the students were surveyed at the beginning of their clinical experience, and most would not yet have experienced at first-hand the realities of being a doctor. as they progress through their career, perception of both underlying motivation and career preferences may change.44 thus although midlevel medical students may be similar in both ghana and the uk, by the time they are in a position to make career decisions they may have diverged significantly. further research is therefore needed to compare junior doctors’ motivations and decision-making processes between the two countries. however, the results of this study remain important. they suggest that it is reasonable for countries such as the uk to look internationally and learn from others when attempting to manage difficulties in human resources for health. this presents a valuable opportunity to increase the movement of information between countries, regardless of income level. the increased transfer of information both ways between high-income countries, where the majority of research has taken place, and low-income countries, which have been disproportionately affected by imbalances in health worker distribution, would be beneficial for all. in addition, the global nature of migration ensures that the crisis in human resources for health cannot be tackled by one country alone.1,45 in its world health report in 2006, the who recommends co-operation between countries in both research and practice to ensure effective solutions are found and implemented.1 considering a popular destination for ghanaian health worker migrants is the uk,46 understanding similarities between the workforces presents a useful starting point that should encourage both countries to work together in this area. demographic differences between ghanaian and uk students at first view, it would appear that uk students have far greater exposure to rural life than their ghanaian counterparts. however, the definition of rural exposure differs, with the uk’s definition (population<10,000)47 being twice the size of ghana’s (population<5000).48 in addition, the practical implications of rural life vary greatly between the two countries. for instance, the world bank estimated that in 2010 around 62% of the rural population in ghana did not have access to electricity and 19% did not have access to an improved water source.38 even in the most rural areas within the uk, conditions are generally vastly improved on this.37 thus a direct comparison is inappropriate. the ghanaian study found that high pes was associated with a low desire to work in rural areas. the influence of family background in medical career decisions has been identified in other studies20,33 although it is not a consistent finding.25 the influence of pes is article figure 2. comparison of demographics between uk and ghanaian medical students (%). pes=parental education status. non co mmerc ial us e o nly [page 14] [healthcare in low-resource settings 2016; 4:5757] important, as uk students are much more likely to have a parent who is a university-trained professional than their ghanaian counterparts (or 3.04, 95% ci 1.63 to 5.70). little is known about the effect of pes on uk students and this study is too low powered to determine if any association exists. two uk studies that have examined this topic indirectly found no obvious relationship.49,50 however, the influence of pes on career decisions was only a minor consideration in both of these and more work is needed to fully explore this area. until this occurs, the difference in the rate of high pes between the two cohorts presents an unknown variable when attempting to compare ghanaian and uk medical students’ career decisions. underlying motivation of uk students as far as the author is aware, this is the first study to directly examine the effect of uk medical students’ motivation for studying medicine on their speciality preferences. the observed differences between intrinsically and extrinsically motivated students were not statistically significant. however, other studies performed around the world have found an association between high intrinsic motivation and a tendency for primary care.25 additionally, much research has explored the link between motivation and certain demographic factors, specifically gender.4,20,21,29,49 preliminary logistical regression performed within this present study suggests that gender may be a confounding factor within the bristol cohort. however, numbers are too low to produce meaningful results. despite not revealing an association between motivation and career choice, the result of the present study demonstrates that a large majority of uk students report themselves as being intrinsically motivated. underfilled areas and specialities should therefore consider appealing to this intrinsic motivation in order to attract the highest proportion of medical students possible. further qualitative and longditudinal research is needed to identify the specific actions that could achieve this. number of uk students likely to work in general practice a worrying finding of the present study is that only 30.1% of respondents thought they were likely or definitely going to work in gp during their future career. this supports previous studies that suggest the number of students interested in gp is low 13,51-54 and is below the department of health target of 50% recruitment of medical graduates to gp.14 the students surveyed were in their 3rd year of study, and much can change before graduation and eventual career choices, and numbers interested in gp has been shown to increase as time goes on.55 however, the low numbers interested at this stage of training is concerning, as early career intentions have been shown to be predictive of future career.53 this study’s findings suggest that efforts to increase recruitment for gp may need to start before the start of clinical years. limitations this study has several limitations. as previously mentioned, the dividing of motivation into two categories lowers the level of detail gained and risks inappropriately grouping different motivational factors. however, the limitations are consistent between both groups of students. thus this study’s primary goal of accurately comparing the results of two different cohorts remains valid. there is also a danger that the results do not accurately represent the respective populations. social desirability may have biased the results despite efforts to limit this by making the questionnaires anonymous and confidential. the study also attempted to sample an accurate representation of bristol medical students by distributing the questionnaire at a compulsory event. however, those who chose not to fill in the survey or attend the event may differ in some way from the respondents. finally, bristol medical students may not necessarily be representative of uk medical students overall. to build upon this study, further qualitative research could develop a deeper understanding of the motivational factors present in medical students and the effect they have on career choices. conducting focus groups from each cohort would allow for a more detailed exploration of themes and perspectives. this would create further awareness of potential differences and similarities in motivational factors, their practical implications and their importance in the career decision-making process. conclusions this study contributes to current understanding by demonstrating that despite the vast differences between their countries, uk and ghanaian medical students have similar motivations to study medicine. this provides evidence that should support countries to cooperate and learn from each other when tackling problems relating to human resources for health. in the current global situation, collaboration and transfer of information is key to ensure that countries are both well informed and can act effectively. on this background, the importance of continuing to assess the similarities of workforces between countries is clear. this study also has important implications article table 3. a comparison of medical students’ demographics between the uk and ghana. variable uk (%) ghana (%) or (95% ci) gender male 44.9 60.6 0.55 (0.33 to 0.91) female 52.6 39.1 na/prefer not to answer 2.6 0.3 mean age (sd) 22.0 (1.77) 22.9 (1.4) relationship status married/in a relationship 25.6 39.4 0.59 (0.32 to 0.98) single 67.9 58.3 na/prefer not to answer 6.4 2.3 pes high* 78.2 57.3 3.04 (1.63 to 5.70) low 17.9 40.1 na/prefer not to answer 3.8 2.7 lived in a rural area° yes 47, .4 23.8 3.02 (2.28 to 7.53) no 50.0 75.8 na/prefer not to answer 2.6 0.3 birthplace rural 33.3 10.9 4.14 (2.28 to 7.53) urban 64.1 87.4 na/prefer not to answer 2.6 1.7 or, odds ratio; ci, confidence interval; sd, standard deviation; na, not available; pes, parental education status. *high pes is one or more parents achieved a university degree; °from age five on. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5757] [page 15] for the uk as it begins to formulate its own strategies to increase the proportion of its students choosing gp. the results demonstrate the importance of intrinsic motivation for ubms medical students. as motivation plays a role in determining future career choice, any future strategies must maintain awareness of this. references 1. world health organization. the world health report 2006: working together for health. geneva: world health organization; 2006. 2. world health organization. increasing access to health workers in remote and rural areas through improved retention: policy recommendations. geneva: world health organization; 2010. 3. 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http://data.worldbank.org/country/united-kingdom 38. the world bank. country profile: ghana. available from: http://data.worldbank.org/ country/ghana. 2015. accessed 22/05/2015 39. united nations development programme. 2014 human development report. new york 2014. available from: http://hdr. undp.org/en/content/human-development article non co mmerc ial us e o nly [page 16] [healthcare in low-resource settings 2016; 4:5757] report-2014 40. world health organization. global health observatory data repository. 2015. available from: http://apps.who.int/gho/ data/node.main.a1444 41. crossley ml, mubarik a. a comparative investigation of dental and medical student’s motivation towards career choice. br dent j 2002;193:471-3. 42. kelly jc, o’briain de, kumar t, et al. orthophobia and orthophilia: the attitude of medical students and doctors to orthopaedics, an international comparison. irish j med sci 2010;179:s151-s. 43. o’sullivan e, ryan ca. an international comparison of professional 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55. henderson e, berlin a, fuller j. attitude of medical students towards general practice and general practitioners. br j gen pract 2002;52:359-63. article non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11176 the ethical principles and caring behavior of indonesian nurses ilkafah ilkafah,1 anestasia pangestu mei tyas,1 rini rachmawaty2 1nursing study program, faculty of vocational studies, universitas airlangga, surabaya, indonesia;2faculty of nursing, universitas hasanuddin, makassar, indonesia abstract introduction: the caring behavior of nurses affects their working performance and the health care quality received by patients. the adherence to ethical principles by nurses is also known to increase this factor. however, no previous studies have been conducted on how ethical principles affect the caring behaviors of nurses. hence, this study aims to investigate the association between nursing ethics and other demographic characteristics and their caring behavior in indonesian hospitals. design and methods: a cross-sectional descriptive-analytical study was conducted with 389 nurses working in indonesian hospitals. furthermore, data were collected using questionnaires, which included demographic characteristics, ethical principlesbased attitudes, and caring behavior. the analysis of the data was performed using descriptive (m, sd) and inferential statistics (chi-square, spearman’s rank correlation, fisher’s exact test, and multiple logistic regression) with α= 0.05. results: according to this study, the caring behavior of nurses was associated with gender (p=0.030) and nursing ethical principles, such as veracity (p=0.025), non-maleficence (p=0.007), beneficence (p<0.000), and fidelity (p<0.000). fidelity was also revealed as the most influential ethical principle on nurses’ caring behavior, with a value of exp(b)= 3.446. this indicates that nurses, who had demonstrated good fidelity, cared three times more than those who lacked this quality. conclusions: nurses with good ethical principles deliver suitable caring behavior. hence, applying the right ethics to a patient would result in a great caring attitude, as the principle of ethical behavior is compassion and respectful conduct towards patients. introduction a caring attitude is an essential function that nurses must perform, as this approach aids in their development into more professional individuals, who prioritize patients’ interests and their families.1,2 however, limited studies have been conducted on caring behavior among indonesian nurses, with some reports showing a lack of this quality.3–6 a previous study also revealed that having a caring nurse while implementing a treatment or therapy plan was beneficial to patients. this approach helped patients adapt to their health problems, independently fulfilled their basic needs, prevented suffering from diseases, and improved their health, as well as body function.7 the caring attitude of nurses also increases their job satisfaction and quality of care.8 although several nurses may have a compassionate nature from childhood, this behavior must be learned and developed through education.9 caring is a nurse’s attitude towards patients’ needs, which is provided with sincerity and affection, either through communication, support, or direct care. the ethics of this approach is essential and involves caring for both humans and nurses. furthermore, this quality is related to the ontological basis of humanity, where an individual’s identity is defined by a set of relationships with other humans. this is also a universal attribute that is ethically fundamental to people. therefore, it can be concluded that the application of ethical behavior by every human will result in the possession of a wellcaring attitude.10 in indonesia, limited studies have been conducted to examine the correlation between nurses’ ethical and caring behavior. the majority of these studies only analyzed caring from a communication, personality, emotional intelligence, and organizational aspect.3,11 also, previous studies using qualitative methods were typically focused on patients’ perception towards nurses’ caring,12 and only a few examined nurses’ perceptions of their caring behavior.13,14 in addition to caring behavior, professional nurses must be able to apply ethical principles to all patients.15 particularly, nurses who apply beneficence do the best for their patients by showing respect for their autonomy, which automatically confirms that a well-caring behavior has been demonstrated.16 other studies discovered the attitude of nurses influences their ethical behavior while implementing care.17 in watson’s caring theory, there are 10 carative factors,9 of which are nearly identical to the seven ethical principles. therefore, this study aimed at examining the association between nurses’ ethical and their caring behavior. design and methods this study used a correlational with a cross-sectional descriptive-analytical design.18 also, stratified random sampling was persignificance for public health nurses are required to have caring behavior, which is essential in the interaction with humans and other nurses. this attitude may also assist nurses in becoming more professional while providing patient care. in addition, professional nurses are obligated to apply ethical principles in delivering care to all patients. in watson's caring theory, there are 10 carative factors, and the core of these characteristics is nearly identical to the seven ethical principles. therefore, this study describes the association between the ethical behavior and other demographic characteristics of nurses and their caring behavior towards hospitalized patients in indonesian hospitals. article [page 52] [healthcare in low-resource settings 2023; 11(s1):11176] non -co mmerc ial us e o nly article [healthcare in low-resource settings 2023; 11(s1):11176] [page 53] formed by selecting patients from all inpatient units in the hospital, based on the inclusion criteria to maintain the representativeness of the sample. the respondents included 389 nurses, who had been working for at least 2 years, in the inpatient room, the maximum age is 55 years, not in the period of study assignment or study permit, and is willing to be a respondent and interviewed if something is lacking in filling out the questionnaire. an ethical, demographic, and watson’s 10 carative factors-based questionnaires were used.9,19 the latter instrument was developed based on the 2019 code of ethics guidelines from the new zealand nurses organization20 and the ethical recommendations from the indonesian national nurses association. in addition, the cronbach alpha value on tests 1 and 2 were 0.89 and 0.91, and pearson’s correlation coefficient between the first and second surveys was =0.901 and 0.93. hence, the questionnaire was valid and reliable. univariate analysis was presented in the form of a table containing frequency (n), percentage (%), mean (m), and standard deviation (sd). statistical tests, such as chi-square, spearman’s rank correlation, and fisher’s exact were used to investigate the association between the respondents’ characteristics, ethical, and caring behavior. bivariate analysis was also used as a multivariate test selection with a p-value<0.25. multivariate logistic regression was selected to examine which independent variables (numeric or categorical) had the greater influence on the dependent (categorical).18 the ethical clearance of this study was obtained from the ethics committee of the faculty of nursing, universitas airlangga, surabaya, indonesia (number 2063-kepk). results and discussions table 1 shows that there is no relationship between gender and caring behavior (p > 0.135). a majority (59.7%) of the male nurses have good caring behavior, while the (51.2%) females were less table 1. the characteristic of respondents in three hospitals in indonesia. no variable caring behavior total p-value less (n=192) good (n=197) (n=389) n % n % n % 1 gender male 27 40.3 40 59.7 67 100 0.135a* female 165 51.2 157 48.8 322 100 2 marital status single 60 45.8 71 54.2 131 100 0.372a married 132 51.2 126 48.8 258 100 3 education diploma nurses 76 49.7 77 50.3 153 100 0.053b* undergraduate nurses 116 50.4 114 49.6 230 100 post-graduate nurses 0 0 6 100 6 100 4 role in the wards associate nurse 160 48.5 170 51.5 330 100 0.501a primary nurse 32 54.2 27 45.8 59 100 5 career level pre-clinical nurse 9 37.5 15 62.5 24 100 0.636b clinical nurse i 107 49.1 111 50.9 218 100 clinical nurse ii 63 52.1 58 47.9 121 100 clinical nurse iii 12 48 13 52 25 100 clinical nurse iv 1 100 0 0 1 100 6 autonomy less 116 68.6 53 31.4 169 100 0.000a* good 76 34.5 144 65.5 220 100 7 non-maleficence less 132 68.4 61 31.6 193 100 0.000a* good 60 30.6 136 69.4 196 100 8 beneficence less 126 72.4 48 27.6 174 100 0.000a* good 66 30.7 149 69.3 215 100 9 justice 0.000a* less 115 75.2 38 24.8 153 100 good 77 32.6 159 67.4 236 100 10 veracity less 117 76.5 36 23.5 153 100 0.000a* good 75 31.8 161 68.2 236 100 11 fidelity less 125 77.6 36 22.4 161 100 0.000a* good 67 29.4 161 70.6 228 100 12 age (mean ± sd) 31.57 ± 5.74 31.17 ± 5.71 389 100 0.240c* 13 length of work (mean ± sd) 7.35 ± 5.71 6.79 ± 5.33 389 100 0.252c a ) chi-square test. a*) chi-square test and candidate mlr (p<0,25). b )fisher’s exact test. c ) spearman test . c*) spearman test and candidate mlr (p<0,25). non -co mmerc ial us e o nly compassionate. no relationship was observed with marital status (p > 0.372), with most (54.2%) unmarried nurses depicting this attitude, while their (51.2%) married counterparts were less caring. however, there was no relationship with education (p > 0.053). the majority of (100%) nurses with post-graduate degrees had better caring behavior than those (50.4%) with undergraduate, and (50.3%) diploma degrees. this study also shows that diploma nurses cared 0.7% better than the undergraduates, due to their lengthier period of stay in the hospital. several other studies illustrated that length of work experience has a positive impact on nurse’s caring behavior and quality of care.21,22 there is no relationship between nurses’ role in the wards and their caring behavior (p > 0.501). a majority of (51.5%) associate nurses were seen to care more than most of their counterparts in the primary level (p > 0.636). the entire (100%) clinical nurses iv were less compassionate than most (62.5%) of those in the preclinical stage. according to previous studies, managers had lower scores than clinical nurse 1 in “assurance of human presence” and “respectful difference of others”. additionally, they had lower scores on four dimensions of caring behavior than clinical nurses 2 and 3 in “respectful difference of others”.23 the workload of nurses also increased with their career levels, with managers taking on more assignments. this phenomenon was stated as the cause of stress, which affects their interactions with other people. humanistic behavior has been established to fade over time, affecting the nursing practice. consequently, patients are faced with poor caring attitudes and behaviors.24 there was also no relationship with age (p > 0.240). however, nurses aged 32 years and above were reported to have less caring behavior while those who were less than 31 years displayed more of this character. no relationship was observed between the length of work and the caring behavior of nurses, where those with an average working experience of 7.4 years cared less while individuals with 6.8 years were more compassionate. the demographics of nurses had no effect on caring behavior, hence, this variable is unique. personality, emotional and organizational factors in nurse’s workplace can affect this behavior.11,25 this study shows that a caring nature may be acquired from birth or learned in school. furthermore, length of work does not affect caring, indicating that the study of this behavior prior to employment is essential. respect and care for others can be formed in the family.26,27 some people are easy to empathize with and care for others because their personalities easily empathize with others.28 especially during the study period, students need to educate regarding caring behavior to become nurses who behave caring.29 caring for students is also a topic that is discussed frequently because early education is very effective in creating nurses who are ready to work in the field and have good behavior.30,31 the respondent’s characteristics may not affect caring behavior because nurses with inadequate knowledge on this matter do not understand how to behave in compassionate situations. therefore, education and training on caring should begin at an early age, through its implementation in nursing schools and workplaces.30,32 when taking a degree as a nurse, caring for nurses must be given a separate and more specific topic and teachers have to know student personally.29,33 these educational institutions may also assist in the development of caring abilities, skills, social involvement, and emotional intelligence.34 according to the multiple logistic regression (mlr) analysis in table 2, there is a correlation between gender and caring behavior (p=0.030). consequently, a majority of male nurses were seen to be more compassionate than females. this was reinforced by another study, where male nurses were more caring in terms of knowledge, skills, and assurance of human presence. also, the presence of male nurses results in a greater diversity as concerns this behavior.23 in indonesia, despite experiencing several obstacles, this set of nurses had higher self-efficacy levels and were usually just as caring as their female counterparts or even better.21,35 an imbalanced number was observed between the male and female respondents, with the females being higher. due to the high level of studies in an east java district and the culture of respect for patients and families, men were seen to be just as caring as women. furthermore, culture is known to greatly influence the nursing practice, not only the customs of the patient but also that of the nurse.36 based on the mlr test in table 2, veracity (p=0.025), nonmaleficence (p=0.007), beneficence (p =0.000), and fidelity (p=0.000) were discovered to be significant. nurses with good non-maleficence and veracity principles were two times more caring compared to the less ethical individuals. meanwhile, good beneficence was nearly three times more. the most influential principle was fidelity with a value of exp(b) = 3.446, hence, nurses who have this character were three times more caring than those lacking. furthermore, fidelity creates an environment for achieving goals of care and services.37 the principle of fidelity that many nurses do in this study is keeping promises when educating patients, providing information about the patient’s condition to other health workers, and involving patients in developing nursing plans. this principle requires nurses to treat all patients with respect, which is not always easy, specifically when patients are disagreeable, uncooperative, or rude.38 the notion of non-maleficence was performed to prevent physical and psychological harm or injury to patients. therefore, nurses must always provide services with the intent of helping their patients overcome health problems. a caring behavior, specifically humanistic altruisticvalue and providing a supportive and protective environment prevents physical, psychological, or social harm to patients.9 the presence of beneficence and fidelity is more likely to facilitate a caring behavior. the principle of beneficence that many nurses do in this study is to provide nursing interventions that make patients comfortable, assist patients’ basic needs, and always article table 2. analysis multivariate logistic regression (n=389). no variable b sig. exp(b) 95% ci lower upper 1 gender (1) -0.732 0.030 0.481 0.248 0.933 2 non-maleficence (1) 0.726 0.007 2.067 1.225 3.486 3 beneficence (1) 1.035 0.000 2.816 1.648 4.812 4 veracity (1) 0.682 0.025 1.978 1.090 3.588 5 fidelity (1) 1.237 0.000 3.446 1.989 5.969 6 constant -1.476 0.000 0.229 [page 54] [healthcare in low-resource settings 2023; 11(s1):11176] non -co mmerc ial us e o nly re-assessments to identify nursing diagnoses that can arise. beneficence is nurse’s obligation to defend the rights of others, prevent harm that may be experienced by patients,39 and provide beneficial care. this behavior also protects patients from anything that threatens their health or life. nurse’s job is to provide education concerning the care offered to patients, assist in the decisionmaking process, and provide freedom for patients’ decisions.40 fidelity is defined as the obligation to remain faithful to one’s commitments, particularly when information is given in confidence. honoring commitments and providing a rationale for decisions also promotes this principle.20 moreover, nurses and other health providers who make agreements with patients must respect and be committed to others,34 as these principles are part of caring behavior.9 caring is also directly related to moral sensitivity and emotional intelligence.25 hence, nurses who apply moral and ethical principles will automatically behave in a caring manner. applying these variables in all matters is also essential, specifically in providing care to patients in order to improve the quality of nursing services.8,39,41 because of the covid-19 epidemic, interviews for the questionnaire were completed over the phone. further research should look into the barriers to nurses’ strengths in implementing ethical concepts to patients. conclusions the essence of nursing is caring behavior. this is an inherent characteristic seen in nurses, which is influenced by their behavior through upholding ethical principles properly and correctly. generally, caring and ethical behavior cannot be separated and will always be aligned to improve the quality of nursing and health services. references 1. karlsson m, pennbrant s. ideas of caring in nursing practice. nurs philos 2020;21:1-5. 2. ozan yd, okumuş h, lash aa. implementation of watson’s theory of human caring: a case study. int j caring sci 2015;8:25-35. 3. karo m, baua e. caring behavior of indonesian nurses towards an enhanced nursing practice indonesia year 2018. int j pharm res 2019;11:367-84. 4. shields l, hartati le. nursing and health care in indonesia. j adv nurs 2003;44:209-16. 5. permana b, putri nn, lindyani l. the views of registered nurses’ for caring characteristics: a cross-sectional survey from hospital and public health services in bandung. int j caring sci 2019;12:359-65. 6. fitri g. machmud r, priscilla v. pengaruh pelatihan komprehensif caring terhadap perilaku caring perawat. j ilm stikes kendal 2020;10:509-20. 7. watson j. assessing and measuring caring in nursing and health sciences. 3rd edición. berlin, heidelberg, dordrecht, new york: springer publishing company; 2019. 8. gede i, gunawan y. a concept analysis of quality nursing care. j korean acad nurs 2021;51:430-41. 9. watson j. watson’s theory of human caring and subjective living experiences: carative factors/caritas processes as a disciplinary guide to the professional nursing practice. texto context enferm 2007;16:129-35. 10. woods m. an ethic of care in nursing: past, present and future considerations. ethics soc welf 2011;5:266-76. 11. hidayati l, rifai f, ni’mah l. emotional intelligence and caring behavior among muslim nurse: a study in religiousbased hospital in surabaya-indonesia. adv heal sci res 2017;3:2-5. 12. amalina sf, rachmawaty r, ilkafah i, et al. patient experiences of nurse caring behaviors based on swanson’s theory in indonesian hospital. enfermería clínica 2020;30:332-6. 13. peng x, liu y, zeng q. caring behaviour perceptions from nurses of their first-line nurse managers. scand j caring sci 2015;29:708-15. 14. ogugu e, odero t, ong’any a, et al. nurses’ and patients’ perceptions on the importance of nurse-caring behaviors: a study at the surgical wards of kenyatta national hospital, nairobi. int j hum caring 2015;19:55-61. article correspondence: ilkafah ilkafah, faculty of vocational studies, universitas airlangga, jl. dharmawangsa dalam selatan no. 28-30, surabaya, east java, indonesia, tel.: +62315033869, fax: +623199005114. e-mail: ilkafah@vokasi.unair.ac.id key words: caring behavior, ethical principles, indonesian nurses, principle of ethics, quality of care. acknowledgment: the authors are grateful to the faculty of vocational studies, universitas airlangga, surabaya, indonesia, for their kind support and promotion during this study. contributions: the authors contributed equally to this study. conflict of interests: the authors declared no conflict of interests. funding: this study was financially supported by the faculty of vocational studies, universitas airlangga, surabaya. clinical trials: ethical approval was obtained from the health research ethics committee of the faculty of nursing, universitas airlangga, surabaya (number 2063-kepk). availability of data and materials: the complete data are avaiable upon request. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11176 doi:10.4081/hls.2023.11176 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11176] [page 55] non -co mmerc ial us e o nly 15. mcdermott-levy r, leffers j, mayaka j. ethical principles and guidelines of global health nursing practice. nurs outlook 2018;66:473-81. 16. woodward vm. caring, patient autonomy and the stigma of paternalism. j adv nurs 1998;28:1046-52. 17. ilkafah i, tyas apm, haryanto j. factors related to implementation of nursing care ethical principles in indonesia. j public health res 2021;10(2211). 18. maltby j, williams ga, mcgarry j, day l. research methods for nursing and healthcare. london: routledge; 2013. 19. qasim mm, ahmad m, omar m, et al. a process for developing an instrument to measure the persuasion perspectives of parents using pmcom app. aip conference proceedings. 2018;2016:020119. 20. new zealand nurses organisation. guideline – code of ethics. new zealand: new zealand nurses organisation; 2019. 21. handiyani h, kusumawati as, karmila r, et al. nurses’ selfefficacy in indonesia. enferm clin 2019;29:252-6. 22. surbakti s, novieastari e, nuraini t. caring efficacy to improve nurses’ caring behavior. enferm clin. 2019;29:698702. 23. inocian ep, cruz jp, saeed alshehry a, et al. professional quality of life and caring behaviours among clinical nurses during the covid-19 pandemic. j clin nurs 2021;0:1-13. 24. delmas p, o’reilly l, cara c, et al. effects on nurses’ quality of working life and on patients’ quality of life of an educational intervention to strengthen humanistic practice among hemodialysis nurses in switzerland: a protocol for a mixed-methods cluster randomized controlled trial. bmc nurs 2018;17:1-11. 25. taylan s, özkan i̇, şahin g. caring behaviors, moral sensitivity, and emotional intelligence in intensive care nurses: a descriptive study. perspect psychiatr care 2021;57:734-46. 26. abdullah sh, salim rma. parenting style and empathy in children: the mediating role of family communication patterns. humanit indones psychol j 2020;17:34. 27. sapungan gm, sapungan rm. parental involvement in child’s education: importan ce, barriers and benefits. asian j manag sci educ 2014;3:42-8. 28. handayani et, kuntarti k. nurses’ caring behavior based on personality in indonesia: a pilot study for better-humanized healthcare services. j public health res 2021;11:2741. 29. nadelson sg, zigmond t, nadelson l, et al. fostering caring in undergraduate nursing students: an integrative review. j nurs educ pract. 2016;6(11). 30. pourteimour s, nobahar m, raiesdana n. moral intelligence, clinical placement experience and professional behaviors among iranian undergraduate nursing students in a baccalaureate nursing program: a descriptive correlational study. nurse educ pract 2021;55:103146. 31. özkan i̇, taylan s, adıbelli d, et al. investigation of the relationship between nursing students’ disgust sensitivity and caring behaviours. nurse educ pract 2021;54(may). 32. mathe tl, downing c, kearns i. south african student nurses’ experiences of professional nurses’ role-modelling of caring. j prof nurs 2021;37:533. garza r, alejandro ea, blythe t, et al. caring for students: what teachers have to say. isrn educ 2014;2014:1-7. 34. honkavuo l. educating nursing students emotional intelligence and the didactics of caring science. int j caring sci 2019;12:1-10. 35. maryunani a, hariyati rts, novieastari e. phenomenological study on the experience of male nurses in caring for female patients. j keperawatan indones 2021;24:32-41, 36. coffman mj. cultural caring in nursing practice: a meta-synthesis of qualitative research. j cult divers 2004;11:100-9. 37. corcoran bc, brandt l, fleming da, et al. fidelity to the healing relationship: a medical student’s challenge to contemporary bioethics and prescription for medical practice. j med ethics 2016;42:224-8. 38. mayfield e, highfield mef, mendelson s. meaning of courtesy and respect: nurse and patient experiences. j nurs care qua 2020;35:177-81. 39. varkey b. principles of clinical ethics and their application to practice. med princ pract 2021;30:17-28. 40. skår r. the meaning of autonomy in nursing practice. j clin nurs 2010;19:2226-34. 41. macias-konstantopoulos wl. caring for the trafficked patient: ethical challenges and recommendations for health care professionals. ama j ethics 2017;19:80-90. article [page 56] [healthcare in low-resource settings 2023; 11(s1):1176] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11729 efficacy of turmeric (curcuma longa linn) decoction to reduce pain in patients with gastritis ismansyah ismansyah,1 frana andrianur,1 rini ernawati2 1health polytechnic, ministry of health, east kalimantan, samarinda; 2faculty of nursing, muhammadiyah university of east kalimantan, samarinda, indonesia abstract turmeric (curcuma longa linn) has been used by indonesian people for a long time to treat pain in digestive disorders. the purpose of this study was to determine the efficacy of turmeric decoction on pain in gastritis patients. this study employed a quasiexperimental design with a one-group preand post test approach. the consecutive sampling method was employed to recruit 100 participants in samarinda, indonesia. after assessing baseline pain levels (pretest), participants were administered the intervention, which involved the consumption of turmeric decoction for 14 consecutive days, with a regimen of 2×150 ml daily, specifically 15 minutes before breakfast and dinner. post-test measurements were recorded on days 5, 10, and 14. pain scores were evaluated using the numeric rating scale, data analysis utilized the paired t-test to determine differences in mean gastritis pain levels before and after the intervention. the findings revealed a significant reduction in gastritis pain scores between the pretest measurements is 3.8 and the post-test on day 5 (1.34), day 10 (0.62), and day 14 (0.31). the statistical analysis yielded a p-value of 0.000. the study demonstrated the efficacy of turmeric decoction in alleviating pain among gastritis patients, with notable improvements observed as early as day 5 of the treatment regimen. consequently, we recommend the incorporation of turmeric decoction as a complementary and non-pharmacological therapeutic approach for the effective management of gastritis symptoms. introduction gastritis is a digestive tract disorder with the most frequent causes are the use of nonsteroidal anti-inflammatory drugs (nsaids), corticosteroids, lifestyles with high levels of stress,1,2 helicobacter,3,4 consumption of alcohol, coffee, and smoking and the attitude of gastritis sufferers who pay less attention to the food consumed every day.3,5–7 the complication of this disease is gastric bleeding which causes the patient to die.3 gastritis in indonesia amounted to 40.8% in 2018 with almost the same variation in every region in indonesia.8,9 data from the samarinda city health office, gastritis is included in the top 10 visits at the public health center in 2022 10. acute gastritis has symptoms of nausea and pain such as burning or discomfort in the epigastrium.11,12among the non-pharmacological measures that can overcome pain is to use herbal medicine or traditional medicine, namely turmeric.11,13 the curcuminoid content in turmeric functions as an herbal medicine to relieve pain in the injured gastric mucosa and can reduce stomach acid levels.11,14 turmeric is an herbal therapy that has long been known to the indonesian people as a health drink and is used to treat gastritis pain complaints as a complementary approach or non-pharmacological therapy.15 turmeric (curcuma longa linn) is a safe and non-toxic ingredient that is safe for consumption.16,17 turmeric is an herbal therapy ingredient and is used as traditional medicine.18 turmeric (c. longa l.) is a type of tropical plant from the zingiberaceae family.19 the content of turmeric rhizome, especially curcumin, is known to have many pharmacological effects and correspondence: ismansyah ismansyah, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: ismanamin18@gmail.com key words: turmeric decoction; gastritis; pain reduction. contributions: ism, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing initial draft, review & editing; fa, conceptualization, investigation, methodology, validation, and writing initial draft, review & editing; re, resources, investigation, supervision and writing review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission of the health polytechnic of the east kalimantan ministry of health based on ethical certificate no. dp.04.03/7.1/07746/2023. during the research, researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research received no external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 9 september 2023. accepted: 9 october 2023. early access: 16 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11729 doi:10.4081/hls.2023.11729 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11729] [page 31] non -co mmerc ial us e o nly has been shown to exhibit high antibacterial,20 anticarcinogenic, anti-inflammatory,21,22 and antioxidant properties and has immunosuppressive activity.23,24 the anti-inflammatory mechanism of curcumin is by inhibiting prostaglandins and proinflammatory cytokines, cox-2, inos, nf-kb, ap-1 and also mmp.25 empirically, the researcher’s experience while working in the community, found that for generations, people have used turmeric decoction to treat various complaints they experience, including complaints of indigestion. people consume turmeric to reduce pain, but research on the benefits of turmeric, especially to reduce gastritis pain, is still lacking. this study aims to determine the effectiveness of turmeric decoction to treat pain in gastritis patients in samarinda, indonesia. materials and methods research design this type of research is a pseudo-experiment, to determine the efficacy of turmeric decoction on gastritis patient pain with a one group pre and post test design approach. the study was conducted for 2 months from april 01 to may 30, 2023, at the community health center in samarinda, indonesia. researchers met participants at the community health center and then continued with home visits. participants were given a turmeric decoction which was consumed for 14 days without a break. the rules for consuming 2×150 ml are 15 minutes before breakfast and dinner. the first day a pre-test was conducted, then turmeric decoction was given, day 5 post test i, day 10 post test ii and day 14 post test iii. post test measurements were taken 3 times to determine differences in the effect of curcuma longa linn decoction on pain. the schedule for consuming turmeric decoction was controlled through text messages to participants to ensure the intervention was carried out according to schedule. research participants the participants of this study were gastritis patients, totaling 100 participants, obtained by consecutive sampling method. participants who met the criteria and were willing to participate were sampled, conducted a pre-test and continued to provide interventions with home visits. participants were aged between 17 years and 45 years, diagnosed with gastritis, experiencing mild pain and not taking analgesic drugs. variables, instruments and data collection the dependent variable measured was gastritis pain, measured pretest and 3 times post test measurements, namely on day 5, day 10 and day 14. the instrument used was the numeric rating scale (score 0-10).1 data analysis the data analysis used is the dependent t test through data processing software. the pre-test measurement results were compared with post test 1 (day 5), post test 2 (day 10) and post test 3 (day 14). the degree of confidence was set at 95% (α=0.05). ethical clearance this study has received a certificate of ethical clearance from the ethical review commission of the east kalimantan health polytechnic, according to the ethical review certificate no. dp.04.03/7.1/07746/2023. during the research, the researchers paid full attention to the fulfillment of ethical principles, implementing informed consent, respect for human rights, confidentiality, beneficience and non-maleficience. results based on table 1, it was found that the characteristics of participants based on gender were 89 participants (89%) female and the remaining 11 participants (11%) were male, the age of participants 51 (51%) participants were between 17-25 years old, 27 (27%) were 36-45 years old and 22 (22%) were between 26-35 years old. while the participants’ education level, 64 (64%) high school, 19 (19%) junior high school, 14 (14%) higher education and the remaining 3 (3%) elementary school. 70 (70%) did not have a job, 27 (27%) worked in the private / self-employed sector and 3 (3%) as civil servants, based on the length of time suffering from gastritis were participants who suffered from gastritis for 1 month as many as 35 participants (35%), for 2 months as many as 40 participants (40%), and for 3 months as many as 25 participants (25%). based on table 2, it is known that the pain score experienced by participants (gastritis patients), the highest in the pre-test was 6.00, the lowest pain score was 3.00, mean 3.83, median 4.00, mode 4.00, and standard deviation value 0.68. the highest pain score in post test 1 (day 5) was 3.00 and the lowest pain score was 1.00, mean 1.34, median 1.00, mode 1.00 and standard deviation transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of participants by gender, age, education, occupation. in samarinda, indonesia (n=100). indicator n % gender female 89 89 male 11 11 age 17-25 51 51 26-35 22 22 36-45 27 27 education elementary school 3 3 junior high school 19 19 high school 64 64 higher education 14 14 job not working 70 70 civil servant 3 3 private/self-employed 27 27 duration of gastritis 1 month 35 35 2 months 40 40 ≥ 3 months 25 25 table 2. results of pre and post test pain score measurements. pain pre post test 1 post test 2 post test 3 test (day 5) (day 10) (day 14) mean 3.83 1.34 0.62 0.31 median 4.00 1.00 1.00 0.00 mode 4 1 1 0 standard deviation 0.68 0.536 0.546 0.465 min-max 3-6 1-3 0-2 0-1 [page 32] [healthcare in low-resource settings 2023; 11:11729] non -co mmerc ial us e o nly value 0.536, post test 2 (day 10) the highest pain score was 2.00 and the lowest pain score was 0.00, mean 0.546, median 1.00, mode 1.00 and standard deviation value 0.546, and post test 3 (day 14) the highest pain score was 1.00 and the lowest pain score was 0.00, mean 0.31, median 0.00, mode 0.00 and standard deviation value 0.465. based on table 3, the results of the paired t test of pain scores between pretest, post test 1 (day 5), post test 2 (day 10) and post test 3 (day 14), obtained p=0.000<α=0.05. the difference in pain scores between pretest and post test 1=2.49 pain scale scores. the difference in pain scores between post test 1 (day 5) and post test 2 (day 10) was 0.72 and the difference in pain scores between post test 2 (day 10) and post test 3 (day 14) was 0.31. discussion the results of this study prove the efficacy of turmeric decoction against gastritis pain which is characterized by a decrease in pain scores after being given turmeric decoction. after 5 days of consuming turmeric decoction, there was a significant decrease, from an average pain of 3.86 down to 1.34 (a difference of 2.49), on day 10 the pain decreased from 1.34 to 0.62 (a decrease of 0.72), on day 14 there was a decrease in pain score to 0.31 (a decrease of 0.31). statistically there is still a decrease in the pain scale in the 2nd and 3rd measurements, but clinically there is no significant difference because it is in the mild category of pain. curcumin found in turmeric is a potential agent for controlling pain due to irritation of the gastric mucosal epithelium due to inflammation in gastritis, including gastritis caused by helicobacter pylori.26,27 a common result of inflammation is pain.11,27 if allowed to continue, it can cause progressive damage to tissues and organs, especially the gastric mucosal epithelium. traditional communities in indonesia have been using non-pharmacological approaches, namely turmeric as a natural remedy to treat epigastric pain and other digestive disorders.28 turmeric, is a plant that is often used as a traditional medicine that can empirically reduce pain due to inflammation in the body. one of the active substances of curcuma longa linn is curcumin.18,23,27 a number of studies have reported that curcumin has various biological activities including antimicrobial, anti-oxidant, anti-tumor and antiinflammatory effects.18,29 in addition, curcumin has some immunosuppressive activity, increasing the phagocytic activity of macrophages, including the expression of cytokines such as il-1 and tnf-α.28,30 curcuminoids are components that give yellow color which are antioxidants and have properties such as hypocholesteromic, cholagogue, choleretic, bacteriostatic, spasmolytic, antihepatotoxic, and anti-inflammatory.4,13,30 curcuminoids are components that give yellow color which are antioxidants and have properties such as hypocholesteromic, cholagogue, choleretic, bacteriostatic, spasmolytic, antihepatotoxic, and anti-inflammatory.18,29 curcumin is reported to have multicellular activity because it can ward off and reduce the risk of various diseases including antiproliferation and antioxidant by inhibiting 97.3% of cellular lipid peroxidation activity, binding to various types of cell proteins and inhibiting enzyme kinase activity, regulating cellular transcription factor activity, expression of inflammatory enzymes, cytokines, molecular adhesion, decreasing cyclin d1, cyclin e and increasing gene expression mechanism of p21, p27 and p53 in the process of carcinogenesis.23,27 the physical properties of curcumin which is a flavonoid compound insoluble in water but soluble in ethanol, dimethylsulfoxid, and acetone. curcumin has a boiling point of 183°c.30 efficacy of turmeric decoction (curcuma longa linn) against gastritis pain a total of 100 gastritis participants experienced an average pretest pain score of 3.83, gradually decreasing to 1.34 on day 5, and 0.62 on day 10, on day 14 down to 0.31. a significant decrease in pain scores occurred in post test 1 (day 5). the difference in pain scores between pre test and post test 1 (day 5) was 2.49. the results showed that the administration of turmeric decoction was effective in reducing pain scores because turmeric decoction is an herbal plant containing curcumin which can reduce stomach acid levels and prevent gastric infections that cause pain in the stomach. curcumin compounds contained in the rhizome of c. longa l. have anti-inflammatory effects on gastritis.4,14,16 in addition to working as an analgesic, the anti-inflammatory effect of curcumin longa linn helps reduce pain and accelerate the healing process in gastritis patients. curcumin contained in turmeric can inhibit the occurrence of cyclooxygenase (cox) reactions so that it can inhibit and reduce inflammation and inhibit and reduce pain and have an effect as an analgesic.31-33 the efficacy of curcumin to reduce pain is also shown in cases of osteomyelitis.17 turmeric decoction is proven to reduce pain in gastritis sufferers and long-term use can cure gastritis.22,27 the content of turmeric (curcumin) can accelerate reepithelialization, cell proliferation and act as an antioxidant.22,24 turmeric can inhibit histamine h2 (rh2) receptors directly and inhibit gastrin receptors so that gastric acid secretion decreases.21 through this mechanism, gastritis pain can decrease because gastric mucosal epithelial irritation is prevented or inhibited.21,26 another benefit of turmeric is that it can protect the gastric mucosa by increasing mucus secretion and has a vasodilator effect so it is very useful for increasing the resistance of the gastric mucosa and coating the epithelial surface of the gastric mucosa from ulcers.24,25 studies show that turmeric and its major curcumin compounds are effective as gastroprotective agents.13,16 in various models of gastric ulceration such as in pyloric ligation, indomethacin, reserpine, and hypothermic restraint stress. in vitro studies have shown that curcumin is effective on helicobacter pylori bacterial infection.11 conclusions the efficacy of turmeric decoction in reducing pain was observed in gastritis patients, with significant improvements noted to occur from day 5 of treatment. based on these results, the researchers recommend the use of turmeric decoction as a complementary and non-pharmacological therapeutic approach in the effective management of gastritis symptoms. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. test of differences in mean pain scores between pretest, post test 1, post test 2 and post test 3. test average pain score sd n p pre 3,83 0,68 100 0,000 post test 1 (day 5) 1,34 0,536 100 0,000 post test 2 (day 10) 0,62 0,546 100 0,000 post test 3 (day 14) 0,31 0,465 100 0,000 [healthcare in low-resource settings 2023; 11:11729] [page 33] non -co mmerc ial us e o nly references 1. krebs ee, carey ts, weinberger m. accuracy of the pain numeric rating scale as a screening test in primary care. j gen intern med 2007;22:1453-8. 2. andreas. hubungan pola makan dengan kejadian gastritis di puskesmas marina permai no title. j surya med 2020;08: 159-65. 3. sepdianto tc, abiddin ah, kurnia t. asuhan keperawatan pada pasien gastritis di rsud wonolangan probolinggo: sebuah studi kasus. j ilm kesehat sandi husada 2022;11:220-5. 4. foryst-ludwig a, neumann m, schneider-brachert w, naumann m. curcumin blocks nf-kappab and the motogenic response in helicobacter pylori-infected epithelial cells. biochem biophys res commun 2004;316:1065-72. 5. bela. hubungan konsumsi lemak hewani, makanan pedas, dan minuman tinggi kafein dengan kejadian gastritis pada mahasiswa poltekkes kemenkes malang. j gizi 2022;1:21-8. 6. zainurridha y. stres dan pola makan terhadap kejadian gastritis pada mahasiswa keperawatan stikes bhakti alqodiri. j keperawatan dan kebidanan 2021;6:69. 7. hastari nk, putri th. hubungan kecemasan dan pola makan dengan kejadian gastritis pada masa pandemi covid-19. keperawatan jiwa 2023;11:215-24. 8. wardani p. gambaran karakteristik gastritis kronis di poli penyakit dalam rumah sakit haji medan tahun 2020. j kedokt stm 2020;6:366. 9. ri kementerian k. laporan hasil riset kesehatan dasar. 2023. available from: https://www.badankebijakan.kemkes.go. id/laporan-hasil-survei/ 10. samarinda dkk. data puskesmas dengan 10 besar penyakit gastritis di samarinda. 2022. 11. fajriyah n, dermawan d. penatalaksanaan manajemen nyeri: relaksasi autogenik dan pemberian air kunyit dengan masalah keperawatan nyeri pada pasien gastritis di desa nguter. 2022;1:34. 12. silaban ly. karakteristik pasien gastritis di rumah sakit santa elisabeth medan tahun 2018. j kedokt stm 2022;6. available from: https://repository.stikeselisabethmedan.ac.id/wp-content/uploads/2022/01/devi-pardede.pdf 13. kapoor s. curcumin and its emerging role in pain modulation and pain management. korean j pain 2012;25:202-3. 14. ari dnm. gambaran penggunaan jamu ekstrak kunyit pada penderita gastritis kronis di desa sibang gede kecamatan abiansemal kabupaten badung. 2022. 15. ni kd rintan listiani ekayanti. pemanfaatan tanaman herbal dalam pengobatan nyeri berdasarkan kearifan lokal bali usada tiwang. pros work dan semin nas farm 2023;1:396405. 16. yashavanth hs, haniadka r, rao s, et al. turmeric and its principal polyphenol curcumin as a nontoxic gastroprotective agent: recent update. polyphenols prev treat hum dis 2018;319-25. 17. vahid soleimani as. turmeric (curcuma longa) and its major constituent (curcumin) as nontoxic and safe substances: reviewno title. j ilm kesehat promot 2021;53. 18. jayakar dbb. turmeric: a herbal and traditional medicine. 2008. available from: file:///c:/users/asus/downloads/ turmeric_a_herbal_and_traditional_medicine (1).pdf 19. thejaswini s, pattan dn. composition and health benefits of turmeric (curcuma longa). int j res appl sci eng technol 2022;10:658-70. 20. mohammadi a, khanbabaei h, zandi f, et al. curcumin: a therapeutic strategy for targeting the helicobacter pylori-related diseases. microb pathog 2022;166. 21. kim dc, kim sh, choi bh, et al. curcuma longa extract protects against gastric ulcers by blocking h2 histamine receptors. biol pharm bull 2005;28:2220-4. 22. santos am, lopes t, oleastro m, et al. curcumin inhibits gastric inflammation induced by helicobacter pylori infection in a mouse model. nutrients 2015;7:306-20. 23. nugraha mia, erna harfiani ap. systematic review: potensi kurkumin dalam rimpang kunyit (curcuma longa linn) sebagai anti-inflamasi pada gastritis akibat infeksi helicobacter pylori. med j 2022;3:2069. 24. nasser ga. kunyit sebagai agen anti inflamasi. wellness heal mag 2022;2. available from: file:///c:/users/asus/downloads/79-230-1-pb.pdf 25. rudrappa gh, chakravarthi pt, benny ir. efficacy of highdissolution turmeric-sesame formulation for pain relief in adult subjects with acute musculoskeletal pain compared to acetaminophen: a randomized controlled study. medicine (baltimore) 2020;99:e20373. 26. kessaratikoon p, ninsalai k, ruthairat boonkrongcheep nc. measurement and analysis of specific activities of natural and anthropogenic radionuclides in fresh turmeric (curcuma longa l.) from lan khoi sub-district, pa phayom district. phatthalung. 2022;22. 27. yang tc, lee k-y, gul k, et al. phenolics and antioxidant activity of aqueous turmeric extracts as affected by heating temperature and time. lwt 2019;105:149-155. 28. santos am, lopes t, oleastro m, et al. curcumin inhibits gastric inflammation induced by helicobacter pylori infection in a mouse model. nutrients 2015;7:306-20. 29. razavi bm, ghasemzadeh rahbardar m, hosseinzadeh h. a review of therapeutic potentials of turmeric (curcuma longa) and its active constituent, curcumin, on inflammatory disorders, pain, and their related patents. phytother res 2021;35: 6489-6513. 30. zebib b, mouloungui z, noirot v. stabilization of curcumin by complexation with divalent cations in glycerol/water system. bioinorg chem appl. 2010;2010:292760. 31. ratnasari bd, aini dm. pengaruh suhu dekoksi terhadap kadar kurkumin dan aktivitas antioksidan pada rimpang temulawak (curcuma zanthorrhiza). j pharm heal res 2023; 4:40-5. 32. valentina d. no hubungan pola makan dengan kejadian gastritis di kabupaten tana toraja tahun 2021. j ilm kesehat promot 2021;6:53. 33. koosirirat c, linpisarn s, changsom d, et al. investigation of the anti-inflammatory effect of curcuma longa in helicobacter pylori-infected patients. int immunopharmacol 2010;10:815-8. [page 34] [healthcare in low-resource settings 2023; 11:11729] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:11359] [page 73] projected shortfall of 10 million healthcare workers by 2030: implications for lowand middle-income countries and the way forward bashar haruna gulumbe,1 nazeef idris usman2 1department of microbiology, faculty of science, federal university birnin-kebbi, kebbi state; 2department of microbiology, bauchi state university, gadau, bauchi state, nigeria dear editor, the global healthcare landscape is facing an impending crisis, with a projected shortfall of 10 million healthcare workers by 2030 worldwide.1 this alarming forecast, declared by the world health organization (who)’s director-general during the 5th global forum on human resources for health on 3 april 2023,1 poses a significant challenge to lowand middle-income countries (lmics), where the impact of this deficit is expected to be disproportionately severe. notably, this projection represents an increase compared to the who’s estimate of a 7 million deficit made a exactly decade earlier,2 further underscoring the urgency and magnitude of the issue at hand. according to a study conducted by naicker et al.2 in 2016, the degree of shortage of medical personnel in 47 sub-saharan african countries, for example, is striking with the shortfall of doctors and nurses amounting to 2.4 million. similarly, in a recent study, ikhurionan et al.3 reported that with a deficit of 6.9 million and 4.2 million, respectively, south-east asia and africa have the largest shortfall of healthcare workers. this situation is particularly dire in remote communities where some villages have no access to trained healthcare professionals. the shortage is driven by a complex interplay of factors, including rapid population growth, ageing societies, insufficient investment in health workforce development, inadequate working conditions, and the migration of skilled health professionals to high-income countries.2–4 the increasing shortage of healthcare workers lmics is poised to have profound and far-reaching consequences. one such implication is the increased burden on existing healthcare professionals.3,5 as the number of available healthcare workers dwindles, the workload and pressure on those remaining in the field will escalate, potentially leading to burnout and a consequent decline in the quality of care provided.6 furthermore, the shortages are likely to disproportionately impact rural and remote regions, exacerbating existing inequalities in access to healthcare services and further widening the gap between urban and rural areas.3,6 the ripple effects of this crisis extend beyond the immediate healthcare sector, with significant implications for health outcomes and economic development. a reduced capacity to deliver healthcare services due to workforce shortages may contribute to increased morbidity and mortality rates in lmics, as patients experience delays or gaps in treatment.3,6 additionally, the shortage of healthcare workers could have severe economic consequences, as a healthy workforce is indispensable for sustainable growth and prosperity. in light of these challenges, it is crucial to address the healthcare worker crisis through comprehensive, collaborative strategies that emphasize innovation, technological advancements, and global cooperation. the convergence of emerging technologies and scientific advancements presents a promising array of solutions to address the healthcare worker shortage in lmics. telemedicine and remote monitoring solutions, such as video consultations and remote diagnostic tools, can bridge the gap in healthcare accessibility, particularly in rural and remote areas.7 stakeholders can help develop cuttingedge healthcare technologies and approaches that address the particular problems encountered by lmics by implementing these techniques, ensuring that new solutions are usable, affordable, and scalable. artificial intelligence and machine learning applications in healthcare can enhance the efficiency of healthcare delivery and alleviate the workload of healthcare professionals. furthermore, digital health training and education can expand the reach and accessibility of healthcare education, providing opportunities for individuals in lmics to enter the profession and address workforce shortages. similarly, to effectively tackle the healthcare worker shortage, a comprehensive, global approach is essential. this approach should encompass strengthening public-private partnerships, promoting international collaboration, integrating technology into health systems, fostering a culture of innovation, and monitoring and evaluating implemented solutions. with this multifaceted strategy, it is possible to stimulate the creation of creative answers to the workforce crisis, thereby enhancing healthcare delivery and results in lmics. in conclusion, the projected healthcare worker shortage for 2030 poses a formidable challenge, especially for lmics where the effects are expected to be the worst. a comprehensive, internationally coordinated strategy that makes use of new technology, encourages innovation, and develops cooperation between the public and private sectors as well as international organizations is needed to address this challenge. stakeholders may improve health outcomes and promote sustainable development in lmics by embracing these ideas and working together to create resilient health systems and guarantee equitable access to healthcare. references 1. who director-general’s opening remarks at 5th global forum on human resources for health – 3 april 2023. 2023. available from: https://www.who.int/director-general/ speeches/detail/who-director-general-sopening-remarks-at-5th-global-forumon-human-resources-for-health---3april-2023 2. naicker s, eastwood jb, plange-rhule j, tutt rc. shortage of healthcare workers in sub-saharan africa: a healthcare in low-resource settings 2023; volume 11:11359 correspondence: bashar haruna gulumbe, department of microbiology, faculty of science, federal university birnin-kebbi, kebbi state, nigeria. e-mail: bashar.haruna@fubk.edu.ng key words: healthcare workers deficit; lowand middle-income countries; rural and remote regions. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. received for publication: 5 april 2023. accepted for publication: 4 august 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11359 doi:10.4081/hls.2023.11359 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [page 74] [healthcare in low-resource settings 2023; 11:11359] nephrological perspective. clin nephrol 2010;74:s129-33. 3. ikhurionan p, kwarshak yk, agho et, et al. understanding the trends, and drivers of emigration, migration intention and non-migration of health workers from low-income and middleincome countries: protocol for a systematic review. bmj open 2022;12:e068522. 4. yakubu k, blacklock c, adebayo ko, et al. social networks and skilled health worker migration in nigeria: an ego network analysis. int j health plann manage 2023;38:457-472. 5. darzi a, evans t. the global shortage of health workers—an opportunity to transform care. lancet 2016;388:2576– 2577. 6. tsolekile lp, abrahams-gessel s, puoane t. healthcare professional shortage and task-shifting to prevent cardiovascular disease: implications for lowand middle-income countries. curr cardiol rep 2015;17:115. 7. kannampallil t, ma j. digital translucence: adapting telemedicine delivery post-covid-19. telemed j e health 2020;26:1120-22. letter non -co mmerc ial us e o nly hrev_master [page 50] [healthcare in low-resource settings 2022; 10:10499] effects of home-based exercise program on physical functioning of hemodialysis patients: a randomized controlled trial nahrat kumar,1 suman sheraz,1 felicianus anthony pereira,2 aisha razzaq,1 christina angela,3 syed muhammad saad4 1riphah international university, islamabad; 2dow university of health sciences, karachi; 3united medical & dental college, karachi; 4memon medical institute, karachi, pakistan abstract chronic kidney disease is one of the leading causes of death, which is often neglected due to lack of knowledge and resources. the objective of this study was to determine the effects of home-based exercise on physical functioning, quality of life and fatigue assessment for patients on hemodialysis. a randomized control trial was conducted, with participants divided into two groups. twenty-six (26) participants were enrolled, and were assigned equally to each group. the control group received hospital-based care, and the intervention group received a home exercise program. both groups received three sessions per week, for six weeks. outcome measures included six-minute walk test, standing balance, 4-metre gait speed, chair stand, fatigue assessment scale and quality of life. significant improvement in sixminute walk test, fatigue assessment scale, 4 meter gait speed, chair stand test and standing balance was noted in the intervention group as compared with control group. this study concluded that aerobic and resistance exercises are more effective in improving the functional outcomes of patients on hemodialysis as compared to routine physical therapy. introduction chronic kidney disease (ckd) occurs when kidneys are not able to purify blood, due to damage in kidneys over a longer period of time. this causes fluid retention in the body, which contributes to poor sleep and muscular weakness.1 this disruption in kidney function leads to the clinical symptoms and signs of renal failure.2 at the age of 30 years, both gfr and renal plasma flow (rpf) decreases with increasing age.3 in stages 3 to 5 there is irreversible decrease in nephrons quantity.3,4 ckd is associated with decline in age-related renal function while there is an increase in high blood pressure, diabetic mellitus, and other disorders.5 ckd has various levels of urgency; if it left untreated, it may cause failure of kidney, heart related disease, or even death.6 the burden of ckd was high in general and high-risk populations from underprivileged and middle-class countries.7 in the united states, the rise of ckd prevalence reached a record high in the mid2000s. the european studies on ckd burden were scrutinized, which concluded that the results had shown a high prevalence of ckd, similar to the united states.8 the prevalence of ckd-was found to be 70% in pakistan.9 the evaluated prevalence of ckd, in five ethnic groups, was found to have highest prevalence among sindhis; meanwhile, the lowest prevalence was among baloch and pashtuns.10 the typical signs and symptoms of ckd are: decreased urine output, tiredness, or shortness of breath. in late phases, subsequent changes in renal function, pruritus, anorexia, weight loss, nausea, and vomiting may occur. deep respiration (kussmaul breathing) due to profound metabolic acidosis may also occur in some patients.11 declining concentration of urine hinders the capacity to excrete excess phosphate, acid, and potassium from the urine.12 ckd results in increase of blood pressure and also immune system related disorder.13 conservative treatment approaches are progressively undertaken as an appropriate treatment, for patients with ckd, who are unlikely to benefit from dialysis, or who choose non-dialysis care.14 most appropriate management of ckd are by reduction of cardiovascular risks, and adjustments to drug dosing.15 ckd patients clinically are treated by injecting intravenous iron administration, which promotes oxidative damage to peripheral blood lymphocyte dna, lipid peroxidation, and protein oxidations.16 hemodialysis (hd) is a treatment to filter out wastes and balance electrolytes and water from the blood. hd also helps in controlling blood pressure and balances important minerals in blood. hd is not a complete treatment for kidney failure.17 the physiotherapeutic exercise program during hd improves the quality of life (qol) of chronic renal patients, in physical, social, environmental and psychological aspects. on a regular basis, physiotherapy intervention is provided to lower the frequency of edema and muscle cramps, and to reduce the intensity of pain.18 in 2019, a study reported that aerobic, as well as strength training proved to have favorable short and long-term effects, on the physical performance and the functional balance in patients, on maintenance renal hd.19 a randomized controlled trial concluded that physiotherapeutic programs (resistance and healthcare in low-resource settings 2022; volume 10:10499 correspondence: felicianus anthony pereira, dow university of health sciences, karachi, pakistan. tel.: +92.331.2333569 e-mail: f.pereira93@hotmail.com key words: chronic kidney disease; home care services; kidney failure; resistance training. contributions: nk: methodology and manuscript writing; ss: methodology and manuscript writing; fp: manuscript writing and overview; ar: data collection and data analysis; ca: manuscript writing; ss: manuscript writing. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the riphah international university institutional review board approved this study (riphah/rcrs/rec/letter-00703; clinicaltrials.gov identifier: nct04674930). the study conforms with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. all participsnts in this study signed a written informed consent form for participating in this study. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received for publication: 6 april 2022. revision received: 6 june 2022. accepted for publication: 6 june 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10: doi:10.4081/hls.2022.10499 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly home based) can improve aerobic capacity, health related qol, and nutritional and metabolic parameters without any adverse effects in dialysis patients.20 as exercise has been shown to have benefits, when used in conjunction with hd, this study formed an exercise protocol to determine its effects on the qol in patients with ckd. the aim of this study was to determine the effects of home-based exercise therapy on physical functioning, qol and fatigue assessment for chronic kidney disease patients on hd. materials and methods it was a single-blinded randomized controlled trial. this study followed the consolidated standards of reporting trials 2010 guidelines for reporting parallel group randomized trials and reports the required information accordingly. after obtaining written consent, participants were randomly assigned to homebased exercise therapy group, and control group. measures included: six-minute walk test (6mwt), short physical performance battery, standing balance assessed in different positions (feet together, semi-tandem, and tandem) for 10 seconds without support, 4-meter gait speed, chair stand test, fatigue assessment scale. qol was also evaluated by kd-qol – 36. each tool was assessed at the start of the study, and upon completion of study duration. patients were recruited from the pakistan institute of medical sciences (pims), islamabad. a total of 26 patients participated in the study, and 13 patients were assigned to each group. the inclusion criteria were as follows: either gender with the range between 30–65 years; stage 5; kidney failure (gfr <15) and who were on hd thrice a week and also undertaking sessions for last 3 months. individuals who were hemodynamically stable and stable clinical and functional state for at least 4 weeks were also included. the exclusion criteria were as follows: any hospitalization within past 4 weeks (with dialysis or nondialysis reasons), patients with acute illness or infection, recent surgery, or vascular intervention, uncontrolled hypertension, patients with difficulty walking, without a walking aid owing to orthopedic problems, patients with neurological, musculoskeletal, cardiac and pulmonary disease and physical impairment. this study was approved by the riphah international university institutional review board. all procedures on human subjects were performed in accordance with the helsinki declaration. all participants provided written informed consent to participate. figure 1 depicts the consolidated standards of reporting trials study flow diagram. non-probability purposive sampling technique and randomization was done through sealed envelope method. participants were randomly allocated into two groups.a session recorded list was provided to the participants by one allocated outcome assessor. intervention home based exercise therapy group patients in this exercise group were asked to perform unsupervised walk, thrice a week for 6 weeks. physiotherapy exercise were taught to the caregivers, and also performed once by the participant, to ensure the proper follow up at home. aerobic training the target training zone was set at 40%–60% of the peak heart rate, as determined in the baseline 6mwt. the target walking speed was kept the same, as speed two levels below the maximum speed in the 6mwt, and the patients were trained to walk at the target speed, under the supervision of the physical therapist, for 50m or more at the baseline examination. patients started the program at 20 minutes per session, and progressed to 30 minutes per session, with an increased pace according to the compliance of patient. resistance training was prescribed at 70% of one repetition maximum (rm). one rm is the maximum amount of weight an individual can lift once, and the target training weight was almost the same, as the weight an individual can lift or press 10 times. patients were instructed to train a variety of upper and lower body muscle groups (e.g., latissimus, deltoid, biceps, quadriceps, and gastrocnemius muscles), using thera-band for 1 set of 10 repetitions twice a week. one rm reassessed monthly, and the program was tailored accordingly. control group treatment was given as per criteria of the hospital (metaxalone for muscular pain and hand grip used for fistula as well as conservative treatment). checklist was provided to monitor their adherence to both aerobic exercise (including the duration of each walking session) and resistance training. the number of sessions performed in 6 weeks was calculated as a percentage of the total possible sessions. six-minute walk test this is the sub-maximal exercise test that is used to assess the aerobic capacity as well functional capacity. the length cov article figure 1. consolidated standards of reporting trials study flow. [healthcare in low-resource settings 2022; 10:10499] [page 51] non -co mmerc ial us e o nly ered in 6 minutes, performed in a gallery having a distance of 20rn in length, in a straight line, is used as the outcome, by which to compare the changes in performance capacity, this is used to evaluate the physical performance of the participant which provides valuable findings in terms of all the systems during physical performance which includes pulmonary and cardiovascular systems, movement of blood, neuromuscular units, body metabolism, and peripheral circulation.21 zero (0) value shows absolute dependence to 100 value being independence;22 1 autonomous 100; 2 light dependence >60; 3 moderate dependence 55–40; 4 severe dependence 35–20; 5 depend total: <20.23 short physical performance battery this examines three subcomponents of the lower extremity’s function, these are standing balance, 4-metre gait speed, and chair stand these are of essential tasks for independent living among ckd patients on hd.24 this is an objective assessment tool which is used to measure lower extremity function. tests will be performed by following the sequence: i) standing balance test, ii) 4-metre gait speed, and iii) chair stand test (5 repetitions). fatigue assessment scale fatigue assessing scale and its correlations can help in assessing fatigue, and in carry out of interventions to alleviate fatigue.25 the fas is based on 10-item, which is used to evaluate symptoms of chronic fatigue.26 this is the self-reported questionnaire, measured by a notebook and pen, the time required to fulfill the selfassessment form is to take approximately 2 minutes.27 kidney disease quality of life — sf36 (kdqol-sf 36) the national forum of the quality conducted the qol in adult patients with ckd for outcome.28 this questionnaire asks about how the patient feels about his/her qol, health, and other areas of life. the kdqol-36 is a self-administered, and surrogates’ responders will require paperandpencil measure, which took approximately 5 minutes. statistical analyses data was analyzed by spss version 22. the normal value of variables was checked by applying normality test. within group analysis, friedman test was used. from baseline to 3rd and 6th week of trial, wilcoxon signed rank test was used. for qol, both within and intergroup analysis was used, wilcoxon and mann-whitney test. results there were a total of 26 participants with ckd on hd included in the study and randomly allocated into control group and interventional group as shown in table 1. the mean height, weight, body mass index, article table 1. demographic data of hemodialysis patients. variables study group (%) control group (%) gender male 11 (73.3) 11 (73.3) female 4 (26.7) 4 (26.7) employed 13 (100) 11 (84.6) diabetic 5 (38.4) 4 (30.7) hypertensive 9 (69.2) 13 (100) age (years) 46.13 ±10.57 43.60 ±11.15 weight in kilogram (kg) 61.70±5.83 60.26±8.43 height in inches (inches) 64.60±3.62 64.00±2.75 body mass index (kg/m2) 22.05±1.18 22.27±1.85 duration of diagnosis (years and months) 3.08±2.58 4.73±3.92 duration of hemodialysis (years and months) 3.26±2.69 5.83±3.86 spo2 (mg/l) 96.26±1.94 95.66±1.49 pulse rate (beats per minute) 79.53±12.76 78.33±9.33 respiratory rate breaths per minute) 18.33±2.05 19.93±2.81 systolic (mmhg) 142.20±16.87 154.40±19.08 diastolic (mmhg) 75.86±12.76 84.66±9.34 table 2. results of wilcoxon test and friedman test of assessment tools. assessment group baseline median week 3 wilcoxon/ week 6 wilcoxon friedman (iqr)/mean±s.d median indepe p-value median (iqr) p-value p-value (iqr)/mean±s.d six minute walk test 1 410 (20) 400 (19) 0.460 398 (20) 0.064 0.247 2 411 (13) 422 (8) 0.002 427 (15) <0.001 <0.001 fatigue assessment scale 1 30.20 ±60.47 27.93± 4.58 0.255 29.20± 5.63 0.564 0.386 2 31.80 ±40.64 24.46 ±6.08 0.04 19.53 ±2.94 0.030 <0.001 standing balance 1 4 (1) 4 (3) 0.655 4 (3) 0.2851 0.717 2 4 (0) 4 (0) 1.00 4 (0) 0.180 0.273 4-metre gait speed 1 2 (1) 2 (1) 0.564 2 (1) 0.317 0.584 2 2 (0) 3 (1) 0.005 3 (0) 0.001 < .001 chair stand test 1 1 (0) 1(0) 0.157 1 (1) 0.564 0.472 2 1(0) 1(1) 0.034 2 (0) 0.001 < .001 [page 52] [healthcare in low-resource settings 2022; 10:10499] non -co mmerc ial us e o nly duration of diagnosis, duration of hd, oxygen saturation, pulse rate, respiratory rate, systolic, diastolic are shown in table 1. there were 13 (100%) participants who had a history of smoking, and in study group there was only one smoker. most of the participants were hypertensive in the control group. wilcoxon, and mann-whitney u test results are highlighted in tables 2 and 3, respectively. the values of kdqol-sf 36 for both the groups were taken at preand post-treatment durations of 0 week and 6th week respectively. the findings of inter group comparison between the subcomponent of kdqol-sf 36 scores of two respective groups showed no significance difference in physical functioning pre, role limitation due to physical health pre, emotional wellbeing pre, social functioning pre, pain pre, general health pre, health change pre and health change post difference p=0.950, p=0.494, p=0.226, p=0.763, p=0.116, p=0.261, p=0.966 and p=0.780 respectively. these subcomponents shown significant difference in physical functioning post (p<0.001), role limitations due to physical health post and (p=0.007), role limitations due to emotional problems pre (p=0.048), role limitations due to emotional problems post (p=0.011), energy/fatigue pre (p=0.005), energy/fatigue post (p<0.001), emotional well-being post (p<0.001), social functioning post (p< 0.001), pain post (p<0.001) and general health change post (p<0.001), with the median (iqr) values physical functioning pre 25 (15), physical functioning post 25 (30), role limitation due to physical health post 75 (25), role limitation due to emotional problem post 66.7 (66.7), energy fatigue post 55 (5), emotional wellbeing post 80 (8), social functioning post 100 (25), pain post 80 (22.5), general health post 35 (10), of subcomponent of kdqol sf-36 being higher for interventional group compared to control group. furthermore, in terms of preand post-treatment comparison for both the groups, as all variables were not normally distributed; thus, wilcoxon test was applied and a significant difference was observed in the interventional group (p<0.05). significant differences were noted in the variables measured. the home-based group demonstrated improvements in 6mwt (p<0.001), fas (p=0.03), 4 meter gait speed (p=0.001), and chair stand test (p=0.001). neither the control group, or the intervention group showed any improvement in standing balance (p=0.28 in the control group, and p=0.18 in the intervention group). discussion this present study was performed to assess the benefits of home exercise program compared with hospital-based treatment, on the physical functioning, and the qol in patients with ckd on hd. the results of this study showed that there were significant differences between groups in the qol. a study was conducted to determine the effects of home-based exercise on physical functioning which compares with hospital based physical therapy (control group) in the management of patients with ckd on dialysis. in the current study, the patients were given six weeks treatment and the outcomes were evaluated at follow up intervals of three weeks and six weeks, while kdqol –sf36 questionnaire was assessed on 6th week follow up only. the finding of current study represents 20minute walk and using thera-band for 1 set of 10 repetitions which is significantly effective (p<0.001) in terms of better outcome measure of 6mwt, standing balance, 4-metre gait speed and chair stand test and some sub component of kdqol-sf 36 test questionnaire score. a randomized control trial which was conducted by kiyotaka et al. in 2018 on the effects of aerobic exercise and resistance training in the management of physical functioning, outcome measures contained used in the study were incremental shuttle walk test, hand grip strength and quadriceps strength and health related qol.29 the finding of the study showed that aerobic and resistance training to be effective with regards to improved general strength of the body and qol while the doses of analgesics and calcium channel blockers were reduced. flisinski et al. aimed to analyze overall outcome measures, they also tried to represent deleted data values, with the average value being noted.30 a nurse led exercise training program at home-based for hd patients showed between group effects of normal gait speed is significantly improved in study group than control group (p=0.038). however, patients in the study group reported significant improvement on the parameter of 10 sit to stand test is reduced from 19.78 to 14.03 (p<0.001) seconds when recorded from baseline to week 12th.31 in current study, findings are in parallel with previous studies on the same test, it was p <0.001 at the 6th week, whereas at 3rd week it was p=0.487. another reason that highlights the importance of exercise adherence in the ckd population is the increased prevalence of sarcopenia. maintaining an active lifestyle can help in reducing the detrimental effects that sarcopenia has on this population.32 the present study shows that people with ckd who are receiving hd, and are unable to attend in-person rehabilitation sessions, can benefit from a home-based exercise program. benefits received include and increase in physical, and mental, functioning. article table 3. mann-whittney test for sf-36 within the group. variable p-value physical functioning pre 0.950 physical functioning post <0.001 role limitations due to physical health pre 0.494 role limitations due to physical health post 0.007 role limitations due to emotional problems pre 0.048 role limitations due to emotional problems post 0.011 energy/fatigue pre 0.005 energy/fatigue post <0.001 emotional well-being pre 0.226 emotional well-being post <0.001 social functioning pre 0.763 social functioning post <0.001 pain pre 0.116 pain post <0.001 general health pre 0.261 general health post <0.001 health change pre 0.966 health change post 0.780 [healthcare in low-resource settings 2022; 10:10499] [page 53] non -co mmerc ial us e o nly [page 54] [healthcare in low-resource settings 2022; 10:10499] limitations and future directions all of the patients in control group were smokers and also majority of patients were hypertensive which may have confounded the results. the sample size of his study was small, thus affecting generalizability. it is recommended that further studies should be carried out for physical therapeutic intervention during dialysis or after dialysis with increased follow-up to assess long term effects of physical therapy interventions. conclusions a home-based, exercise program is effective in improving cardiorespiratory fitness, decreasing fatigue, and improving qol in patients on dialysis, as compared with hospital-based rehabilitation. this will provide benefits to patients who are unable to attend in-person physical therapy sessions, while maintaining, and eventually improving, their physical conditioning, thus providing them a cost-effective method of maintaining the long-term conditioning of their disorder. references 1. national kidney foundation. k/doqi clinical practice guidelines for chronic kidney disease: evaluation, classification, and stratification. am j kidney dis 2002;39:s1. 2. gansevoort rt, correa-rotter r, hemmelgarn br, et al. chronic kidney disease and cardiovascular risk: epidemiology, mechanisms, and prevention. lancet 2013;382:339-52. 3. bikbov b, purcell ca, levey as, et al. global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the global burden of disease study 2017. lancet 2020;395:709-33. 4. rehman iu, munib s, ramadas a, khan tm. prevalence of chronic kidney disease-associated pruritus, and association with sleep quality among hemodialysis patients in pakistan. plos one 2018;13:e0207758. 5. ralston sh, penman id, strachan mwj, hobson r. davidson’s principles and practice of medicine. elsevier health sciences, 23rd ed.; 2018. 6. ren j, dai c. pathophysiology of chronic kidney disease. in: yang j, he w (eds). chronic kidney disease. springer, singapore; 2020. 7. colledge nr, walker br, ralston s, davidson s. davidson’s principles and practice of medicine. edinburgh, churchill livingstone/elsevier; 2010. 8. pinelli nr, moore cl, tomasello s. incretin-based therapy in chronic kidney disease. adv chronic kidney dis 2010;17:439-49. 9. davison sn, tupala b, wasylynuk ba, et al. recommendations for the care of patients receiving conservative kidney management: focus on management of ckd and symptoms. clin j am soc nephrol 2019;14:626-34. 10. koncicki hm, brennan f, vinen k, davison sn. an approach to pain management in end stage renal disease: considerations for general management and intradialytic symptoms. sem dialysis 2015;28:384-91. 11. chen tk, knicely dh, grams me. chronic kidney disease diagnosis and management: a review. jama 2019;322:1294-304. 12. joshi s, hashmi s, shah s, kalantarzadeh k. plant-based diets for prevention and management of chronic kidney disease. curr opin nephrol hyperten 2020;29:16-21. 13. hall yn, larive b, painter p, et al. effects of six versus three times per week hemodialysis on physical performance, health, and functioning: frequent hemodialysis network (fhn) randomized trials. clin j am soc nephrol 2012;7:782–94. 14. neto jr, e castro lm, de oliveira fs, et al. comparison between two physiotherapy protocols for patients with chronic kidney disease on dialysis. j phys ther sci 2016;28:1644-50. 15. zhang f, bai y, zhao x, et al. the impact of exercise intervention for patients undergoing hemodialysis on fatigue and quality of life: a protocol for systematic review and meta-analysis. medicine (baltimore) 2020;99:e21394. 16. gravina ep, pinheiro bv, da silva jesus la, et al. effects of long-term aerobic training and detraining on functional capacity and quality of life in hemodialysis patients: a pilot study. int j artific organs 2020;43:411-5. 17. cid-ruzafa j, damian-moreno j. assessment of physical disability: barthel index rev. esp. health public 1997;71:127-37. 18. bessa b, moraes c, barros a, et al. effects of intradialytic resistance trainning on functional capacity, strengh and body composition in hemodialysis patients. kidney res clin pract 2012;31:a59. 19. anees m, ibrahim m, imtiaz m, et al. translation, validation and reliability of the kidney diseases quality of life-short form (kdqol-sf form) tool in urdu. j coll physicians surg pak 2016;26:651-4. 20. soares v. influence of inspiratory muscle training on respiratory function and quality of life in patients with chronic kidney disease on hemodialysis and the relationship with body composition and aerobic capacity. 2014. available at: https://repositorio.bc.ufg.br/tede/handle/tede/3987 21. matsuzawa r, matsunaga a, wang g, et al. habitual physical activity measured by accelerometer and survival in maintenance hemodialysis patients. clin j am soc nephrol 2012;7:2010– 16. 22. donoghue oa, savva gm, cronin h, et al. using timed up and go and usual gait speed to predict incident disability in daily activities among communitydwelling adults aged 65 and older. arch phys med rehabil 2014;95:1954–61. 23. caner c, ozlem s, yavuz y, et al. the effects of exercise during hemodialysis on adequacy. hemodialysis int 2005;9:77. 24. roxo r, bertoni xavier v, miorin la, et al. impact of neuromuscular electrical stimulation on functional capacity of patients with chronic kidney disease on hemodialysis. j bras nefrol 2016;38:344-50. 25. koufaki p, mercer th, naish pf. effects of exercise training on aerobic and functional capacity of end-stage renal disease patients. clin physiol funct imaging 2002;22:115–24. 26. de buyser sl, petrovic m, taes ye, et al. physical function measurements predict mortality in ambulatory older men. eur j clin invest 2013;43:379– 86. 27. twisk j, de vente w. attrition in longitudinal studies. how to deal with missing data. j clin epidemiol 2002;55:329–37. 28. martins mr, cestarino cb. qualidade de vida de pessoas com doença renal crônica em tratamento hemodialítico. [quality of life of people with chronic kidney disease on hemodialysis treatment.] [article in portuguese] erev latinoam enferm 2005;13:670–6. 29. uchiyama k, washida n, muraoka k, et al. exercise capacity and association with quality of life in peritoneal dialysis patients. peritoneal dialysis int 2019;39:66-73. 30. flisinski m, brymora a, elminowskawenda g, et al. morphometric analysis of muscle fibre types in rat locomotor article non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10499] [page 55] and postural skeletal muscles in different stages of chronic kidney disease. j physiol pharmacol 2014;65:567–576. 31. stolić rv, mihailović b, matijašević ir, jakšić md. effects of physiotherapy in patients treated with chronic hemodialysis. biomedicinska istraživanja 2018;9:103-11. 32. moorthi rn, avin kg. clinical relevance of sarcopenia in chronic kidney disease. curr opin nephrol hyperten 2017;26:219. article non -co mmerc ial us e o nly hrev_master [page 28] [healthcare in low-resource settings 2016; 4:6396] healthcare in low-resource settings: the long view for healthcare abiola fasina henry jackson foundation/u.s. military hiv research program, bethesda, md, usa it is with great pleasure and gratitude that i commence my two-year appointment as editorin-chief for healthcare in low resource settings (hls). recent events have demonstrated the interconnectedness of our world. a patient with ebola from west africa ended up in new york city after riding the subway. information is dispersed within minutes through the internet and social media. the brexit vote affected global financial markets. this era calls for a wily adaptability in healthcare as we try to understand and synthesize disparate streams of information and integrate them into practice. it also affords the opportunity to harness technology in new ways to solve age-old health problems. in such changing times, how can hls prove to be relevant? i submit that the way forward is to attend to our initial mandate with renewed vigor. currently, no forum successfully blends the voices and experience of researchers from both developing and developed worlds in an equitable way. the current nature of academic publishing favors increased productivity from those based in high-resource countries by virtue of improved access to robust institutional support for research and better funding. that this journal is open access increases its reach in low-resource settings but more must be done to understand all viewpoints in order to develop effective outcomes. it is vitally important that those who live and work in lowresource settings are instrumental in the proposal and development of their own solutions. barriers to hearing their voices need to be actively overcome by collective will. our journal will focus on the following strategic targets over the next two years: increased publication of work resulting from multi-disciplinary collaboration between researchers in high and low-resource settings; adaption of our current format to improve access for those in low bandwidth low-resource countries where large streaming content is difficult to view; a review of the editorial board with greater inclusion of researchers from lowresource settings, if they are currently underrepresented; increased efforts to highlight the work of early and mid-career professionals in both settings with an interest in issues pertinent to low-resource settings; a renewed focus on ethics and policy around work in lowresource settings; highlighting and publishing research focused on innovative and disruptive technology that can be harnessed towards lowresource settings for more effective healthcare outcomes. these ideas are not new but i believe they represent a subtle recalibration in the way in which knowledge is solicited and disseminated with respect to low-resource settings. in today’s world, information flows in so many directions that the two-way street idiom is obsolete. we have much to learn from each when there is a forum to communicate and hls intends to play a key role in that discussion. healthcare in low-resource settings 2016; volume 4:6396 correspondence: abiola fasina, henry jackson foundation/u.s. military hiv research program, 6720a rockledge drive, suite 400, 20817 bethesda, md, usa. tel: +1.301.500.3600 fax: +1.301.500.3666. e-mail: abiola.fasina@gmail.com key words: healthcare in low-resource settings; multi-disciplinarity; technology; pagepress. received for publication: 17 november 2016. accepted for publication: 27 november 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a. fasina, 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:6396 doi:10.4081/hls.2016.6396 non co mmerc ial us e o nly hrev_master [page 56] [healthcare in low-resource settings 2014; 2:4772] color coding: a tool to enhance the quality of health care in low resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india abstract color coding in health sector refers to the systematic process of displaying information using different colors for providing assistance in classification and identification. in the public health sector, where the aim is to improve the health indicators of the general population as a whole, application of color coding not only enables diagnosis of important health condition but even serves as a rationale to start an appropriate line of management. multiple applications of color-coding have been identified in the health sector. however, the colorcoded approach is not fool-proof and has its shortcomings. moreover, most of these concerns can be resolved by proper sensitization of health professionals and adoption of a standardized color-coding approach universally. in conclusion, color coding in health care has the immense scope to ensure delivery of quality assured services, especially in low resource settings. nevertheless, there is a crucial need to implement this approach universally to expand its range of benefits to both patients and healthcare professionals. introduction color coding in health sector refers to the systematic process of displaying information using different colors for providing assistance in classification and identification.1 although, color coding finds utility in multiple sectors (electronics, navigation, military, etc.), in health care it is employed in different fields of medicine (both diagnostic and therapeutic) to ensure better differentiation, improvement in quality, systematic classification, thereby preventing medication errors and hence ensuring health promotion and augmenting patient safety.1,2 acknowledging the enormous scarcity in the number of trained healthcare professionals (number of doctors/nurses per thousand population), especially in developing countries and in low-resource settings, color coding remains an important tool to promote the extension of quality assured health care services in remote areas through the outreach workers.1 in the public health sector, where the aim is to improve the health indicators of the general population as a whole, application of color coding not only enables diagnosis of important health condition but even serves as a rationale to start an appropriate line of management.1,2 furthermore, color coding has been used to minimize common diagnostic or therapeutic errors and even enhances parental understanding about different attributes related to health.3,4 the world health organization and even the program managers from different nations have advocated for the employment of color coded growth charts in detecting malnutrition and grading the same in under-five year children.1,4 these growth charts not only assist medical practitioners in the diagnosis and follow-up, but even serve as an important educational tool to involve mother (both literate and illiterate) in the rehabilitation program of the child.1,4 in addition, to screen large population of children with malnutrition, shakir’s tricolored tape has been utilized for measuring the mid-upper arm circumference. the red color on the tape (which fell in the less than 12.5 cm zone) marked danger, yellow or white color (12.5-14 cm) marked caution, and green color (more than 14.0 cm) is considered as normal. children thus screened, can be subjected to further anthropometric measurements and other (clinical/biochemical) tests for specific nutritional deficiencies.5 the biggest advantage of using the mid-upper arm circumference is that it is easy to conduct and can be used easily even by a village health worker.5 in order to extend appropriate and adequate management of common childhood ailments (dehydration, acute respiratory infections, etc.), under the integrated management of neonatal and childhood illness program, principles of color coding have been employed.1,6 thus, the health professionals have been trained to adhere to a standardized protocol and depending upon the clinical findings (history/clinical evaluation), children are categorized as pink (i.e. require urgent referral to higher center for admission and management); yellow (i.e. indicate initiation of treatment at the outpatient health facility); and green (i.e. home management).1,6 to ensure appropriate handling and management of victims when the quantity and severity of injuries exceed the operative capacity of health facilities, the triage approach has been employed.1 triage is a color coded approach under which patients are rapidly classified based on the severity of their injuries and the likelihood of their survival with prompt medical interventions.7 it enables health professionals to take the best possible decision for the individual victim, within the available resources at times of disaster.1,7 it generally employs four color codes, namely red tag (for critical patients demanding immediate action), yellow tag (for patients between critical and minor categories requiring urgent action), green tag (for ambulatory patients who need minor care), and black tag (refers to dead persons).1,7 color coding in the arena of family welfare, cycle-beads (string of color-coded beads that represent each day of the woman’s menstrual cycle) have been introduced as a temporary contraceptive measure, and is based on the standard days method.8 this cycle-bead consists of four color beads, namely red color beads – signifies the first day of menstrual cycle; blue/brown color beads – refers to days when women is not likely to get pregnant even with unprotected sex; white color bead – most likely days on which women can get pregnant and thus should not have unprotected sex; and dark brown color beads – to indicate if the women menstrual cycle is shorter than 26 days.8 it is an extremely useful tool especially for illiterate women, requires no medical supervision, and has no local or systemic side effects unlike other con healthcare in low-resource settings 2014; volume 2:4772 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: color-coding, health care, growth chart, cycle-beads. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 october 2014. revision received: 8 november 2014. accepted for publication: 8 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4772 doi:10.4081/hls.2014.4772 non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:4772] [page 57] traceptive measures.8 among the multiple interventions implemented under the national aids control program, one of the key interventions is to supply pre-packed color coded kits for the management of sexually/reproductive tract infections (sti/rtis).9 the rationale behind these color-coded kits is to allow syndromic management of sti/rtis, especially in primary health care centers with an absence of specialist doctors, and at the same time it reduces unnecessary referrals. seven kits have been proposed, namely kit 1 (grey color – for urethral or anorectal discharge and cervicitis), kit 2 (green – vaginitis), kit 3 (white) and kit 4 (blue) for non-herpetic genital ulcerative disease; kit 5 (red – genital herpetic ulcer), kit 6 (yellow – lower abdominal pain), and kit 7 (black – scrotal swellings).9 the diagnosis for these conditions is established by the trained medical officer posted in the respective peripheral health centre.9 the principles of patientwise color coded box have also been employed in the treatment of tuberculosis under the revised national tuberculosis control program in india. in adults, red color box (category i for newly diagnosed tuberculosis patients), and blue color box (category ii for previously treated patients) has been recommended for the treatment.10 in addition, colorcoded box is available for even pediatric tb (for weight band 6-10 kg yellow color box, for weight band 11-17 kgs – orange color box, and pink and grey color box as prolongation pouch).10 in fact, even for the treatment of leprosy, color coded monthly strips are available depending upon the type of leprosy (paucibacillary – green color or multibacillary – pink color).1 these color-coded treatment regimens allows untrained community worker/patients themselves to administer treatment (after the diagnosis of the disease has been established by trained laboratory technicians), without the need for daily supervision.1,10 the ministry of environment and forests has recommended the use of color-coded bags to ensure safe management and handling of biomedical waste and thus prevent hazards to both man and the environment.1,11 four colorcoded bags are in use to allow safe disposal of the waste, namely yellow bag (for human anatomical waste, animal waste, microbiological waste, and solid wastes); red bags (for microbiological waste and solid waste – tubes/blood or fluid soaked wastes); blue bag for sharp wastes; and black bin is for discarded drugs, incineration ash, and solid chemical waste.1,11 the principles of color-coding have also been employed to assess the potency of the vaccines and whether they can be used during an immunization session.12 as maintenance of cold-chain is a key component in the immunization program, to enable health workers to check the potency of vaccines at the site of immunization, most of the vaccines contain a vaccine-vial monitor (vvm).12 the vvm consists of an inner square and an outer circle (viz. inner square is light in color than the outer circle).1 thus, as long as inner square color remains lighter than the outer circle, vaccine can be used. however, if either the color becomes similar or the inner square is darker than the outer circle, then the vaccine should not be used.12 in addition, color-coding has been used in different ways in heterogeneous settings, such as to assess the efficacy of antenatal care;13 color-coded stratification for ordering radiological tests to bring about a reduction in the number of tests (red, amber, and green test can be authorized by a consultant, registrar/consultant, and by interns/residents respectively);14 uniform hospital color codes for conveying different emergency situations to hospital staffs without panicking the patients;15 to improve the safety of multiple infants;16 color coded anesthetic drugs for preventing accidental syringe swapping;17 intravenous color coded cannula;17 gas cylinders;18 color coded wrist bands for identification of specific alerts like allergies;19 periodontal instruments;20 asthma inhalers;21 drug packaging;22 for sensitization sessions on electrocardiograms;23 to monitor the use of medicines beyond their expiry date;24 radiological scans and other dye-based investigations;25 etc. however, the color-coded approach is not fool-proof and has its shortcomings like presence of limited number of identifiable colors in contrast to the numerous pharmaceutical products available; inaccurate color coding; untrained health professionals; and association of certain colors with specific meaning like red for warning, black or white for death, and therefore it should be used cautiously to avoid confusion.18,26,27 moreover, most of these concerns can be resolved by proper sensitization of health professionals and adoption of standardized color-coding approach universally.23,26 conclusions in conclusion, color coding in health care has the immense scope to ensure delivery of quality assured services, especially in lowresource settings. nevertheless, there is a crucial need to implement this approach universally to expand its range of benefits to both patients and healthcare professionals. references 1. park k. preventive medicine in obstetrics, paediatrics and geriatrics. in: park k, eds. textbook of preventive and social medicine. 20th ed. jabalpur: banarsidas bhanot; 2009. pp 468-71, 495-6, 698-702. 2. apa. apa statement on the use of color coding. washington, dc: american psychological association ed.; 2008. 3. deboer s, seaver m, broselow j. color coding to reduce errors. am j nurs 2005;105:68-71. 4. oettinger md, finkle jp, esserman d, et al. color-coding improves parental understanding of body mass index charting. acad pediatr 2009;9:330-8. 5. chaturvedi m, nandan d, gupta sc. rapid assessment of nutritional status of children in agra district. indian j prev soc med 2006;37:165-9. 6. who. integrated management of childhood illness (imci). geneva, switzerland: world health organization; 2013. available from: http://www.who.int/maternal_ child_adolescent/topics/child/imci/en/ 7. ramesh ac, kumar s. triage, monitoring, and treatment of mass casualty events involving chemical, biological, radiological, or nuclear agents. j pharm bioallied sci 2010;2:239-47. 8. family planning services. cycle beads for fertility awareness: a method of natural family planning; 2013. available from: http://www.familyplanningservices.org/fps websitehealthinfotopicssheets/pdf/natural _family_planning.pdf 9. government of india. national guideline on prevention, management and control of reproductive tract infections including sexually transmitted infections. mumbai: ministry of health and family welfare, government of india publ. 2007. 10. tbc india. managing the rntcp in your area. a training course (modules 1-4); 2011. available from: http://tbcindia.nic.in /documents.html 11. jindal ak, gupta a, grewal vs, mahen a. biomedical waste disposal: a systems analysis. med j armed forces india 2013;69:351-6. 12. turner n, laws a, roberts l. assessing the effectiveness of cold chain management for childhood vaccines. j prim health care 2011;3:278-82. 13. ravindran j, shamsuddin k, selvaraju s. did we do it right? an evaluation of the colour coding system for antenatal care in malaysia. med j malaysia 2003;58:37-53. 14. phan td, lau kk, de campo j. stratification of radiological test ordering: its usefulness in reducing unnecessary tests with consequential reduction in costs. australas radiol 2006;50:335-8. 15. doughman d, fitzpatrick t. hospital preparedness and the terrorism alert system. j healthc prot manage 2003;19:47-54. 16. salera-vieira j, tanner j. color coding for brief report non co mmerc ial us e o nly [page 58] [healthcare in low-resource settings 2014; 2:4772] multiples: a multidisciplinary initiative to improve the safety of infant multiples. nurs womens health 2009;13:83-4. 17. hyland s. does color coded labeling reduce the risk of medication errors? the con side. can j hosp pharm 2009;62:155-6. 18. taylor nj, davison m. inaccurate colour coding of medical gas cylinders. anaesthesia 2009;64:690. 19. fabbian f, melandri r, borsetti g, et al. color-coding triage and allergic reactions in an italian ed. am j emerg med 2012;30:826-9. 20. zohn hk. color coding periodontal instruments. quintessence int 2010;41:591-4. 21. jayakrishnan b, al-rawas oa. asthma inhalers and colour coding: universal dots. brit j gen pract 2010;60:690-1. 22. van hamel c, sant p. colour-coding of drug packaging. anaesthesia 2013;68:649. 23. blakeway e, jabbour rj, baksi j, et al. ecgs: colour-coding for initial training. resuscitation 2012;83:e115-6. 24. hattoy s, kozakiewicz j, seo t. color-coding process for monitoring medication beyond-use dates. am j health-syst ph 2010;67:1591. 25. struffert t, deuerling-zheng y, engelhorn t, et al. monitoring of balloon test occlusion of the internal carotid artery by parametric color coding and perfusion imaging within the angio suite: first results. clin neuroradiol 2013;23:285-92. 26. webster cs, merry af. colour coding, drug administration error and the systems approach to safety. eur j anaesth 2007;24: 385-6. 27. fong js. color coding complications. hosp health network 2007;81:8. brief report non co mmerc ial us e o nly hrev_master [page 24] [healthcare in low-resource settings 2015; 3:5258] the public health and economic consequences of unintended pregnancies in south africa hoa h. le,1 mark p. connolly,1,2 jingbo yu,3 yacob pinchevsky,4 petrus s. steyn5 1department of pharmacy, university of groningen, the netherlands; 2global market access solutions, mooresville, nc, usa; 3merck & co., whitehouse station, nj, usa; 4msd (pty) ltd., south africa; 5department of obstetrics and gynaecology, university of cape town, south africa abstract unintended pregnancy (uip) poses considerable humanistic and economic burden in both developed and developing countries. in the analysis described here, we evaluate the costs of unintended pregnancies based on estimates in south africa. to estimate the burden of uip, a decision-analytic model was developed using probabilities for pregnancy related outcomes related to uips in a single year, which included miscarriage, ectopic pregnancy, abortion and live birth. costs to the public health system were estimated for each birth outcome. we estimated 636,040 annual unintended pregnancies. the annual maternal deaths were estimated to be 1134 of which 219 (19.3%) are attributed to abortions and 915 (80.7%) attributed to complications from miscarriages, ectopic pregnancies and deliveries. the costs attributed to uip birth outcomes accounted for 3.42 billion rand annually. annual costs of uip live births were estimated to be 82.8% of the total costs with abortion and miscarriage accountable for 8.3% and 8.4% of costs, respectively. in conclusion, despite weaknesses of modelling approaches in healthcare, we believe that our findings here will support further preventative initiatives in south africa and more broadly to improve access to affordable and effective contraception. introduction the concept of unintended pregnancies is multifactorial and broadly encompasses pregnancies that are either unwanted or mistimed.1 obtaining specific estimates on unintended pregnancies is difficult due to data limitations and differences in classifying and reporting of pregnancies. global estimates suggest there were 86 million unintended pregnancies in 2008 with 74 million (86%) occurring in less developed countries.2 in many instances unintended pregnancies are likely to end by induced abortion where worldwide estimates suggest 50% will be voluntarily terminated.3 in 2008 it was estimated that 43.8 million abortions occurred worldwide of which 86% occurred in developing economies.4 furthermore, between 2003 and 2008 the number of induced abortions was found to decrease in developed economies, but increased in developing economies.4 during this same period of time, the proportion of unsafe abortions increased and unsafe abortions were believed to account for 13% of maternal deaths, with the majority of them concentrated in countries with restrictive laws on abortion. 5 the effects of unintended pregnancy can influence many facets of life and society. these can include impacts on physical and mental health status and reductions in quality of life.6,7 children born from unintended pregnancies are also at risk of being born with low birth weight and premature birth compared with planned pregnancies.8,9 furthermore, women with unintended pregnancies are thought to be at increased risk of physical abuse.10 the problem of unintended pregnancies can be additive as children born from an unintended pregnancy are also likely to perpetuate unintended pregnancies when they are adults.11,12 many countries with abortion restrictions pose considerable personal harm and economic consequences to those that pursue illegal and unsafe abortions. previous estimates suggest an average cost of treating post abortion complications range from $86 $111 (2006).13 in latin america and africa alone the total health costs combined were $159 million to $333 million per year which represents a significant cost for these health services. 13 south africa faces a quadruple burden of disease.14 these include the colliding hiv and tuberculosis epidemics, a high burden of chronic illness, mental health disorders, injury and violence-related deaths, as well as a silent epidemic of maternal, neonatal, and child mortality. at present, the health system in south africa has a predominantly curative focus which places less emphasis on disease prevention and health promotion.15 south africa’s per capita health burden is the highest of any middle-income country (8.7% of its gdp) in the world.14 a comprehensive national department of health (doh) strategic plan 2010/20112012/13 was developed reflecting interventions to improve health service delivery and improve health outcome for all south africans.15 the objectives of this study were to evaluate the likely costs of uip in south africa using a deterministic modeling approach. as with all modelling approaches there are inherent weaknesses attributed to changing treatment practices, data limitations and evolving cultural norms. despite these weaknesses, we believe a model to measure the economic impact of uips would support the new initiatives of prevention.15 materials and methods model description a deterministic decision tree model was developed to estimate the humanistic and healthcare in low-resource settings 2015; volume 3:5258 correspondence: mark connolly, unit of pharmacoeconomics and pharmacoepidemiology, department of pharmacy, university of groningen, antonius deusinglaan 1, 9713 av groningen, the netherlands. e-mail: m.connolly@rug.nl key words: unintended pregnancy; economic impact; south africa. contributions: hhl, model development, literature review, results generation, manuscript development; mpc, review model design, input identification, critical review of results, manuscript development; jy, critical review model design, model input identification, manuscript review; yp, critical review model design, model input identification, manuscript review; pss, critical review model design, clinical input identification, clinical interpretation, policy impact, manuscript development. conflict of interest: the research conducted by dr. mark connolly was funded by an unrestricted grant from merck (whitehouse station, nj, usa). dr. jingbo yu and mr. yacob pinchevsky are employees of merck. professor petrus steyn, dr. hoa le and dr. mark connolly declare no conflict of interest regarding the publication of this article, and specifically no financial interests in the commercial operations of merck. acknowledgements: we would like to thank princess makhosazane majola for her inputs and assistance in data collection. received for publication: 29 april 2015. revision received: 15 may 2015. accepted for publication: 16 may 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright h.h. le et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5258 doi:10.4081/hls.2015.5258 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 25] economic burden of unintended pregnancies in south africa. the timeframe for the analysis was one year. however, outcomes of unintended pregnancies within the year were allowed to take their course. all pregnancies among women on contraception were assumed to be unintended pregnancies. the annual cases of unintended pregnancies among women of reproductive age in south africa were estimated using distribution of contraceptive use across methods and the associated failure rates. conversely, pregnancies from women not using contraceptives were assumed to be wanted pregnancies and were not considered in the current analysis which likely leads to an underestimate of uips as many women not using contraceptives can experience an uip. the major outcomes of unintended pregnancies evaluated in the model were induced abortion, miscarriage, ectopic pregnancy, and live birth (figure 1). maternal mortality and related costs were assessed for each of these outcomes. while the legalization of abortion through the choice on termination of pregnancy act in 1996 permitted more choices for women and couples, the proportion of unsafe abortion, as defined by who, remains high in south africa.4 because of differences in maternal health and associated costs, abortions were further characterized as safe or unsafe abortions. birth outcomes were also separated between deliveries taking palace within and outside of health facilities. additionally, a distinction was made between vaginal and cesarean deliveries. outcomes and resulting costs for infants were also followed. these included stillbirths and infant survival and complications from term and pre-term deliveries. complications included admission to neonatal care, hospitalization during the first year, and cerebral palsy. data source and analysis unintended pregnancies the number of unintended pregnancies was estimated by applying the distribution of contraceptive use and associated failure rates to the population of reproductive age women in south africa (table 1). the model evaluates contraceptive methods that are currently in use in south africa. these include male and female condoms, oral contraceptive pills, hormonal injections (e.g., depot medroxyprogesterone acetate and nur-isterate), copper intrauterine device (iud), and female and male sterilization. we assumed that women on these contraceptive methods represent the total population of contraceptive users in south africa. the number of women on each contraceptive method was estimated using market share data from the doh applied to the total population of reproductive age women (15-49 years old) in south africa in 2011.16 unintended pregnancies for each method were calculated by multiplying the number of women using the contraceptive with the failure rate associated with typical use.17 although the failure rates were obtained from the united states, there is a lack of published data on contraceptive failures in south africa and these figures are accepted in the contraception guidelines in south africa.18 contraceptive failure rates represent unintended pregnancies per 100 women per year. outcomes of unintended pregnancies the model evaluated four pregnancy outcomes. we assumed that 14.4% of all unintended pregnancies ended in induced abortion. this figure was derived from estimates of abortions (6.8%) and unintended pregnancies (47.3%) as percentages of all pregnancies.19,20 for miscarriage and ectopic pregnancies, article figure 1. model framework for assessing maternal and child burden and costs attributed to unintended pregnancies. non co mmerc ial us e o nly [page 26] [healthcare in low-resource settings 2015; 3:5258] 16.0% and 1.1% were used, respectively.21,22 continuation to birth was assumed for the remainder of the unintended pregnancies. we used data on unsafe abortion for southern africa as a proxy for south africa. because of the liberal laws on abortion in south africa, the percentage of unsafe abortion in this region has dramatically decreased from 100% in 1995 to 58% in 2008.4 for the model, we assumed 58% unsafe and 42% safe abortion and mortality rates associated with each were 370 and 59 per 100,000 abortions, respectively.5,23 maternal mortality rates that were used for miscarriage, ectopic pregnancy, and birth were 6.73, 2.72, and 176.22 per 100,000 live births, respectively. the vast majority (90.1%) of deliveries were performed in a health facility of which 22.7% were cesarean deliveries.24,25 all deliveries outside of a health facility were assumed to be vaginal deliveries. maternal mortality rate (mmr) of 176.22 per 100,000 deliveries was applied.26 the percentages of term, preterm, and stillbirths were 80.1%, 17.5%,26 and 2.4%,27 respectively, and were assumed to be independent of the place and type of deliveries. these infant outcomes and data on infant mortality and complications such as neonatal care admission, re-hospitalization, and cerebral palsy are summarized in table 2. cost of outcomes of unintended pregnancies costs of subsequent outcomes of unintended pregnancies were only followed for abortion, miscarriage, ectopic pregnancies, and birth. these estimates represent the average cost for each outcome. miscarriage and ectopic pregnancies were assumed to incur the same cost. itemized costing elements for each are provided in table 3. the costs of contraceptive use prior to experiencing an uip have been excluded, as these costs would not be incurred during the pregnancy period. productivity loss due to unintended pregnancies an employment rate of 50% was used to estimate the number of women who were employed and had an unintended pregnancy.33 based on statutory maternity leave benefits of 16 weeks, we estimated the broader economic consequences of uip based on an average weekly salary for women of rand (r) 643.34 article table 1. distribution of contraceptive use and failure rates for estimating unintended pregnancy. contraceptives population of women contraceptives women on failure per 100 uips (age 15-49 years) (%) contraceptives (n) women per year (%) (n) condoms 13,866,489 8.1 1,125,437 18.00 202,579 oral contraceptives 13,866,489 12.2 1,695,101 9.00 152,559 depot medroxyprogesterone acetate 13,866,489 19.0 2,634,633 6.00 158,078 nur-isterate 13,866,489 13.8 1,913,575 6.00 114,815 iud device 13,866,489 0.8 111,155 0.80 889 sterilization female 13,866,489 10.1 1,403,322 0.50 7017 sterilization male 13,866,489 0.5 69,472 0.15 104 total 64.6 8,952,695 636,040 uip, unintended pregnancy; iud, intrauterine. table 2. infant mortality and complications.28-32 vaginal deliveries p term delivery* infant mortality 0.0427 neonatal care admission° 0.10 cerebral palsy 0.0002 intrapartum-related birth asphyxia 0.0048 preterm delivery infant mortality 0.1000 neonatal care admission° 1 cerebral palsy 0.0002 intrapartum-related birth asphyxia 0.0048 stillbirth 0.0240 cesarean deliveries p term delivery* infant mortality 0.0427 neonatal care admission° 0.10 cerebral palsy 0.0018 intrapartum-related birth asphyxia 0.0048 preterm delivery infant mortality 0.1000 neonatal care admission° 1 cerebral palsy 0.0018 intrapartum-related birth asphyxia 0.0048 stillbirth 0.0240 *derived from residual of preterm births. °information was obtained from staff working at the neonatal intensive care unit at tygerberg hospital in stellenbosch university. probabilities of term delivery and preterm delivery were in both cases 0.8010 and 0.1750, respectively. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 27] article table 3. itemized costs of abortion, miscarriage, ectopic pregnancies, and birth in public hospitals. cost (rand) abortion patient transport service facility fee 286.00 emergency consultation nursing practitioner 65.00 emergency consultation nursing practitioner facility fee 136.00 emergency consultation general medical practitioner 113.00 emergency consultation general medical practitioner facility fee 136.00 pregnancy test 0.68 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward specialist medical practitioner (x3 days) 294.00 inpatient general ward specialist medical practitioner (x3 days) facility fee 819.00 minor procedure cat c -general medical practitioner 258.00 minor procedure cat c -general medical practitioner facility fee 319.00 radiology, cat c general medical practitioner 88.20 radiology, cat c general medical practitioner facility fee 137.40 ultrasound gel 3.57 mortuary – facility fee 138.00 cremation certificate – facility fee 138.00 total 3093.69 miscarriage and patient transport service -facility fee 286.00 ectopic pregnancy emergency consultation nursing practitioner 65.00 emergency consultation nursing practitioner facility fee 136.00 emergency consultation general medical practitioner 113.00 emergency consultation general medical practitioner facility fee 136.00 pregnancy test 0.68 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward specialist medical practitioner (x3 days) 294.00 inpatient general ward specialist medical practitioner (x3 days) facility fee 819.00 minor procedure cat c -general medical practitioner 258.00 minor procedure cat c -general medical practitioner facility fee 319.00 radiology, cat c general medical practitioner 88.20 radiology, cat c general medical practitioner facility fee 137.40 ultrasound gel 3.57 total 2817.69 birth outpatient consultation nursing practitioner 43.00 outpatient consultation nursing practitioner facility fee 67.00 urine dipstick pregnancy 3.40 urine dipstick glucose, protein, nitrates etc. 17.00 full blood count 50.25 hiv test rapid screen test 38.21 if hiv test is positive cd4 helper t cell marker 19.28 hiv western blot 68.17 viral load 36.19 inpatient general ward medical practitioner 98.00 inpatient general ward medical practitioner facility fee 273.00 minor procedure cat b -general medical practitioner 163.00 minor procedure cat b -general medical practitioner facility fee 319.00 nurse practitioner in ward 37.00 nurse practitioner in ward facility fee 273.00 natural birth – nursing practitioner 1944.00 neonatal care facility fee 2963.00 paracetamol box of 10 to take home 0.76 folic acid + ferrous sulphite (vitaforce ferovit) 76.95 vaccination neonate bcg r1.77 + oral polio 4.07 total 6494.27 non co mmerc ial us e o nly [page 28] [healthcare in low-resource settings 2015; 3:5258] results based on reported annual births and probabilities for unintended pregnancies, miscarriage and induced abortion rates we estimated 636,040 annual unintended pregnancies. the annual maternal deaths were estimated to be 1134 of which 219 (19.3%) were attributed to abortions and 915 (80.6%) attributed to complications from miscarriages, ectopic pregnancies and deliveries (table 4). the number of infant deaths attributed to unplanned pregnancies within 12-months following birth was estimated at 30,754. we estimated 76,272 preterm deliveries attributed to unintended pregnancies. the estimated number of neonatal admissions associated with unintended pregnancies was estimated to be 100,175 that included all preterm deliveries and 7.6% of term deliveries. based on the estimated number of annual uips, we estimate annual cost to the public health system of r3.42 million. the majority of costs within the health service were attributed to live births from uips at cost of r2.83 million. the estimated costs of miscarriage and abortion for a single year were r287 million and r282 million, respectively. the estimated annual cost per uip case based on each potential outcome is described in table 5. of the predicted number of unintended pregnancies, we anticipated 45,720 and 217,919 employed women to be impacted from abortions and births, respectively. based on the statutory maternity leave allowance for women, the costs were estimated to be r2.24 billion per annum. discussion in many cases unintended pregnancies are partly due to lack of service provision and not meeting women’s contraceptive needs. however, a large proportion of these pregnancies also occur due to lack of knowledge and myths regarding contraception, failure and discontinuation of short-term hormonal contraception.35 contraceptive effectiveness is determined by several factors: efficacy (theoretical ability to prevent pregnancy), compliance, continuation, fecundity (ability to conceive) and timing of coitus.36 combined oral contraceptives and barrier contraception are popular methods of contraception. however, their effectiveness is dependent on compliance and correct use.36,37 efficacy can also be impaired because women commonly switch methods, often with a period of delay before starting the new method rendering them susceptible to unintended pregnancies. in this context, long acting reversible contraceptive (larc) methods combine reversibility with high effectiveness and do not depend so much on compliance or correct use. the larcs [except for depo medroxyprogesterone acetate (dmpa)] have higher continuation rates than other contraceptives such as the oral contraceptives and condoms.38 the results described here estimate an annual cost of r3.42 billion attributed to uips. from the total costs, uips that resulted in live birth represented 82.8% (r2.83 billion) of the total costs with abortion and miscarriage accountable for 8.3% (r283 million) and 8.4% (r287 million), respectively. these costs are likely to represent an underestimate, as we have not accounted for the costs attributed to neonatal admissions costs. furthermore, preterm births are at risk of increased hospitalization in the early year of life, which would further increase the cost estimates described here.39 expert opinion and supporting clinical guidelines indicated that the most effective approach to prevent unintended pregnancies is through education and contraceptive use, of which long-acting contraceptive methods are believed to be the most effective intervention.40-42 in particular, amongst adolescents, prevailing evidence suggests that education and contraception are the main interventions for reducing unintended pregnancies.42 furthermore, previous economics analysis of providing reproductive services and contraception has been shown to be cost-saving compared with no contraception. a study in the united states estimated annual cost savings of $19.2 billion attributed to pregnancies averted.43 these costs are likely to be an underestimate as they do not consider long-term complications attributed to uips. previous studies have estimated the scale of unintended pregnancies in sub-saharan africa of approximately 42 million unintended births over a 5-year time horizon.35 it was also estimated that approximately 44% of unintended births occurred in women under the age of 25. the disproportionate amount of unintended births that occur in younger ages suggests our estimates of the indirect costs for maternity leave coverage are overestimated. in the absence of age-specific unintended pregnancies, we assumed a constant rate of uips, which may underestimate pregnancies in the younger ages. several policy options are available for reducing the burden of unintended pregnancies. because of the high failure rates of oral article table 4. maternal and child outcomes attributed to unintended pregnancies. pregnancy (n) 636,040 abortions (n) 91,439 ectopic pregnancies (n) 6996 miscarriages (n) 101,766 births (n) 435,838 maternal deaths (n) abortion 219 miscarriage 7 ectopic pregnancy 140 birth 768 total 1134 preterm births (n) 76,272 neonatal admissions° (n) 100,175 cerebral palsy cases (n) 749 infant deaths within the first year (n) 32,754 °it contains proportion of term births admitted. table 5. annual costs and cost per case for different birth outcomes attributed to unintended pregnancies in south africa. annual cost (rand) cost (%) cost per case (rand) birth 2830 million 82.8 6494 miscarriage 287 million 8.4 2818 ectopic pregnancy° 20 million 0.6 2818 abortion 283 million 8.3 3094 total costs 3420 million 100 5377 °costs for ectopic pregnancy are based on treatment practice for miscarriage. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5258] [page 29] and injectable contraceptives, investigations have estimated the impact of switching to implants for those currently treated with alternative contraceptive methods. it was estimated that switching 1% of current contraceptive users to implants could avoid 18,600 uips per annum. a switch of 5% current contraceptive use to implants could further reduce uips by 92,800 births annually, and the greater number switching to implants offered further reductions in uips.35 the inability to reliably estimate pregnancy intention is a weakness of the analysis described here. in the analysis described here, we attempted to evaluate unintended pregnancies based on contraceptive use and known failure rates for each method. consequently, we assumed that any pregnancy that occurred while on contraceptives was an unintended pregnancy, which may not be the case with some pregnancies. furthermore, by using contraceptive failure as a proxy for unintended pregnancy this does not account for women not using contraceptives that have unintended pregnancies. because pregnancy intention cannot be assessed at the point of conception, and is often discussed post-conception, we believe that our estimates for unintended pregnancy are conservative. an additional weaknesses of the analysis described here relates to the inclusion of mistimed pregnancies in the definition of unintended pregnancy. by definition, mistimed pregnancies are those that would likely have occurred at some point in the future. in this context the direct costs described here may overestimate costs in the short-term. however, mistimed pregnancies carry significant social and economic consequences that should not be accounted for in this analysis. these included reduced educational attainment for parents and a trend towards reduced education attainment of the impending child,44 and increased exposure to physical violence compared with intended pregnancies.45 furthermore, mothers of mistimed pregnancies are less likely to consume prenatal care and consequently expose mother and child to preventable risks that will have cost implications at the time of delivery and beyond.45,46 to complicate matters there is considerable variation in the duration of mistimed pregnancies which could likely influence the negative consequences attributed to mistimed pregnancies that occur in older aged women.47 the synthesis of treatment outcomes and costs in economic models for health condition can help fill a void in the available evidence to inform future contraception policy. whilst every effort is attempted to find precise cost estimates for each event, in many developing countries published cost estimates are not available on which to estimate treatment costs. in many instances it is necessary to apply estimates based on comparable resource items as we have done here. without a reasonable estimate for ectopic pregnancy costs we have applied the cost of miscarriage to the ectopic pregnancy outcomes. recognizing that ectopic pregnancies are likely more costly than miscarriages, this assumption likely underestimates the true costs. furthermore, the authors acknowledge that in many instances data used for constructing the model was not current. this is a potential weakness, however considering there have been no major policy changes or introduction of new products during the years investigated. on this basis we believe that treatment practices have not changed substantially enough to undermine the model described here. conclusions the analysis described here provides annual estimates for mortality and health service costs attributed to uips in south africa. despite weaknesses of modelling approaches in healthcare, we believe the findings here will support preventative initiatives in south africa to improve access to affordable and effective contraception. in particular, initiatives that improve access to long-acting reversible contraceptives which have low failure rates and have been shown to be cost-effective.17,37 references 1. santelli j, rochat r, hatfield-timajchy k, et al. the measurement and meaning of unintended pregnancy. perspect sex repro h 2003;35:94-101. 2. singh s, sedgh g, hussain r. unintended pregnancy: worldwide levels, trends, and outcomes. stud family plann 2010;41: 241-50. 3. gipson jd, koenig ma, hindin mj. the effects of unintended pregnancy on infant, child, and parental health: a review of the literature. stud family plann 2008;39:18-38. 4. sedgh g, singh s, shah ih, et al. induced abortion: incidence and trends worldwide from 1995 to 2008. lancet 2012;379:625-32. 5. world health organization. unsafe abortion incidence and mortality. global and regional levels in 2008 and trends during 1990-2008. geneva, switzeralnd: world health organization; 2012 http://apps.who. int/iris/bitstream/10665/75173/1/who_rh r_12.01_eng.pdf 6. khajehpour m, simbar m, jannesari s, et al. health status of 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intergenerational pattern of adolescent pregnancy in brazil. perspect sex repro h 2009;35:139-46. 13. vlassoff m, walker d, shearer j, et al. estimates of health care system costs of unsafe abortion in africa and latin america. int perspect sex reprod health 2009;35:114-21. 14. kleinert s, horton r. south africa’s health: departing for a better future? lancet 2009;374:759-60. 15. national department of health. national department of health strategic plan. pretoria, south africa: national department of health; 2010. available from: http://www.mm3admin.co.za/documents/docmanager/2d5ed792-878c-43719575-8281a96bbb26/00023294.pdf 16. statistics south africa. mid-year population estimates 2011. pretoria, south africa: statistics south africa; 2011. available from: http://www.statssa.gov.za/ publications/p0302/p03022011.pdf 17. trussell j. contraceptive failure in the united states. contraception 2011;83: 397-404. 18. department of health, republic of south africa. national contraception clinical guidelines. pretoria, south africa: department of health; 2012. 19. johnston’s archive. historical abortion statistics, south africa, 2010. available from: http://www.johnstonsarchive.net/ policy/abortion/ab-southafrica.html 20. south africa demographic and health survey 2003. available from: http://www.mrc. ac.za//bod/sadhs2003part2.pdf 21. grobler f. contraception, theory and practice. 4th ed. preotria, south africa: van schaik; 2003. 22. amoko dh, buga ga. clinical presentation article non co mmerc ial us e o nly [page 30] [healthcare in low-resource settings 2015; 3:5258] of ectopic pregnancy in transkei, south africa. east afr med j 1995;72:770-3. 23. benson j, andersen k, samandari g. reductions in abortion-related mortality following policy reform: evidence from romania, south africa and bangladesh. reprod health 2011;8:39. 24. health systems trust. delivery rate in facility. available from: http://indicators. hst.org.za/healthstats/229/data 25. health systems trust. caesarean section rate. available from: http://indicators. hst.org.za/healthstats/76/data 26. department of health, national committee for confidential enquiry into maternal deaths. saving mothers 2008-2010. fifth report on the confidential enquiries into maternal deaths in south africa. 2012. available from: http://www.hst.org.za/publications/saving-mothers-2008-2010-fifthreport-confidential-enquiries-maternaldeaths-south-afri 27. beck s, wojdyla d, say l, et al. the worldwide incidence of preterm birth: a systematic review of maternal mortality and morbidity. bull world health organ 2010; 88:31-8. 28. national perinatal mortality and morbidity committee. triennial report (2008-2010). pretoria, south africa: national perinatal mortality and morbidity committee; 2011. 29. index mundi. infant mortality rate in south africa 2012. available from: http://www. indexmundi.com/g/g.aspx?c=sf&v=29 30. drumbill d. fit pregnancy. available from: http://www.birthoptions.co.za/dumbrill.html 31. buchmann ej, pattinson rc, nyathikazi n. intrapartum-related birth asphyxia in south africa--lessons from the first national perinatal care survey. s afr med j 2002;92:897-901. 32. health 24. preterm birth an african killer. available from: http://www.health24.com/ news/child_safety/1-943,77936.asp 33. klaveren m, tijdens k, hughie-williams m, martin nr. an overview of women’s work and employment in south africa. amsterdam, the netherlands: university of amsterdam; 2009. available from: http : / /www.uva-aias .net /uploaded_ files/publications/wp79-klaveren,tijdens, hughie-williams,ramos-southafrica.pdf 34. statistics south africa. monthly earnings of south africans. pretoria, south africa: statistics south africa; 2010. available from: http://www.statssa.gov.za/publications/p02112/p021122010.pdf 35. hubacher d, mavranezouli i, mcginn e. unintended pregnancy in sub-saharan africa: magnitude of the problem and potential role of contraceptive implants to alleviate it. contraception 2008;78:73-8. 36. grimes da. commentary: forgettable contraception. contraception 2009;80:497-99. 37. national institute for health and clinical excellence. long-acting reversible contraception. clinical guideline 30. london: nice; 2005. available from: www.nice.org .uk/nicemedia/pdf/cg030niceguideline.pdf 38. trussell j. contraceptive efficacy. in: hatcher ra, trussell j, nelson al, cates jr w, stewart f, kowal d, eds. contraceptive technology. 19th ed. new york, ny: ardent media inc.; 2007. pp 747-826. 39. petrou s. the economic consequences of preterm birth during the first 10 years of life. brit j obstet gynaec 2005;112 (suppl.1):10-5. 40. american college of obstetricians and gynecologists, committee on adolescent health care long-acting reversible contraception working group. committee opinion no. 539: adolescents and long-acting reversible contraception: implants and intrauterine devices. obstet gynecol 2012;120:983-8. 41. winner b, peipert jf, zhao o, et al. effectiveness of long-acting reversible contraception. new engl j med 2012;366: 1998-2007. 42. oringanje c, meremikwu mm, eko h, et al. interventions for preventing unintended pregnancies among adolescents. cochrane db syst rev 2009;4:cd005215. 43. trussell j. the cost of unintended pregnancy in the united states. contraception 2007;75:168-70. 44. myhrman a, olsén p, rantakallio p, läärä e. does the wantedness of a pregnancy predict a child's educational attainment? fam plann perspect 1995;27:116-9. 45. gazmararian ja, adams mm, saltzman le, et al. the relationship between pregnancy intendedness and physical violence in mothers of newborns. obstet gynecol 1995;85:1031-8. 46. cheng d, schwarz eb, douglas e, horon i. unintended pregnancy and associated maternal preconception, prenatal and postpartum behaviors. contraception 2009; 79:194-8. 47. pulley l, klerman lv, tang h, baker ba. the extent of pregnancy mistiming and its association with maternal characteristics and behaviors and pregnancy outcomes. perspect sex repro h 2002;34:206-11. article non co mmerc ial us e o nly hrev_master [page 14] [healthcare in low-resource settings 2015; 3:3260] a tool to guide the process of integrating health system responses to public health problems tilahun nigatu haregu,1 geoffrey setswe,2 jullian elliott,3 brian oldenburg4 1african population and health research center, nairobi, kenya; 2human sciences research council, pretoria, south africa; 3burnet institute, melbourne; 4university of melbourne, australia abstract an integrated model of health system responses to public health problems is considered to be the most preferable approach. accordingly, there are several models that stipulate what an integrated architecture should look like. however, tools that can guide the overall process of integration are lacking. this tool is designed to guide the entire process of integration of health system responses to major public health problems. it is developed by taking into account the contexts of health systems of developing countries and the emergence of double-burden of chronic diseases in these settings. chronic diseases – hiv/aids and ncds – represented the evidence base for the development of the model. system level horizontal integration of health system responses were considered in the development of this tool. introduction the tool presented here is based on the analysis – synthesis – action continuum. it considers integration as a spiral rather than a linear process. the potential users of this tool are health policy makers, health care managers and health policy and systems researchers. these users may use this tool out of sequence based on their contexts and needs. as this tool is generic in its nature, users should adapt it to their own health system context, public health problems, and responses considered for integration. this tool was developed based on an action model of integration presented elsewhere.1-5 it builds upon the best available evidence and it combines theoretical, empirical and practical evidence. it is worth noting that there are several other models that address the different components of this tool.6-10 this tool presents a unique consolidation of the translation of these models in a form of a guiding tool along with essential new elements. the contents of this tool are conceptually validated and were enriched using inputs from expert consultations. this tool is divided into five major sections: i) analysing the connections between problems; ii) examining similarities between responses; iii) scanning the environment for integration; iv) repackaging evidence for communication; v) managing integration. analysing the connections between the problems convergence between the problems understanding population level (epidemiological) overlap between the distributions of two public health problems is important to inform overall policy approaches that address the problems. considering the socio-ecological model, epidemiological overlap between two diseases has three dimensions: population groups (segments of the population based on different factors), geographic settings (different places within a certain county/region), and time (a point or a period of time of interest).11 to assess overlap between two problems in terms of the population groups, one needs to use a 3x3 table and assign different population groups/segments into the cells. to assess overlap between two problems in terms of the geographic settings, one needs to use a 3x3 table and assign different geographic settings into the cells. to assess concurrence between the two problems in terms of their magnitude (at a defined population and place) at a point in time, one needs to use a 3x3 tool and assign the magnitude of the problems into the cells. the average/medium magnitude to be used for comparison could be national prevalence (for sub-national considerations) or global prevalence (for national considerations). when both problem a and problem b have high magnitude, the need for integrated response is more likely to be higher. this is exemplified in table 1. to assess epidemiological overlap between two problems in terms of their trend (of magnitude) across time (at a defined population and place), one needs to use a 3x3 matrix and assign the trends in the magnitude of the problems into the cells (table 2). a trend-line would be important to assess the presence of overlapping trends. when both problems have an increasing trend, the need for integrated response becomes more likely. the time period for the trend needs to be set based on relevance and availability of data. trends without a defined pattern may be treated in a different way. correlational analysis could also be used in such cases. linkage between the problems information about the inter-relationships between problems is important to inform the content of interventions packages.12 the linkage between two problems takes two forms: risk and severity. risk is when the presence of problem a affects the probability of occurrence of problem b and/or vice versa. severity is when the presence of problem a affects the severity of problem b and/or vice versa. to assess the linkage between two problems in terms of risk and severity, one needs to compare the risk and severity in the sub-populations with that of the general population. tool presented in table 3 summarizes the risk and severity of a problem in the sub-populations, along with a three-point scale, as compared to that of the general population. when data are available, it would be preferable to use quantitative measures of risk and severity to demonstrate actual levels. the greater the risk and severity of the problems in the sub-populations (as compared to the general population), the higher is the need for integrated response. co-occurrence of the problems evidence about the magnitude of co-occurrence of two problems in an individual is useful to inform planning and resource allocation.13 co-occurrence of two diseases can be expressed in two forms: co-morbidity (when there is an index disease) and multimorbidity (when there is no index disease).14 to explore the magnitude of co-occurrence of two problems, one needs to compare the prevalence of each problem among those having the other with that of the general population (for comorbidity); and the prevalence of both diseases in the population to prevalence that would otherwise occur by chance. tool described in table 4 summarizes these meas healthcare in low-resource settings 2015; volume 3: 3260 correspondence: tilahun nigatu haregu, african population and health research center, manga close, off kirawa road, 10787-00100 nairobi, kenya. tel: +254.20.400.1000 fax: + 254.20.400.1101. e-mail: tilahunigatu@gmail.com key words: healthcare system; public health problems; integration. received for publication: 15 march 2014. revision received: 22 july 2014. accepted for publication: 22 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyrigh t.n. haregu et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:3260 doi:10.4081/hls.2015.3260 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:3260] [page 15] ures. in situations where actual prevalence values are available, they can be used for the comparison. the greater the prevalence of comorbidity and multimorbidity, the higher the need for integrated response. examining similarities between responses define response a health system response to a public health problem contains several components at different levels. at upstream (macro) level are strategic functions including policy making, leadership and governance. at mid-stream (meso) level are management functions like planning, coordination, resource mobilization etc. at down-stream (micro) level are operational functions such as service provision, data collection etc. within each of the elements of the response, several functions and structures are involved.15 an effort of integration may involve all or some of these functions/structures. some processes may require a stronger integration than others. one possible method to establish this is by analysing the similarities between parallel processes (e.g. treatment of a and treatment of b). this is based on the assumption that a higher level of similarity predicts a stronger need for integration. analysis of similarities between the responses to problem a and problem b starts with defining the functions of interest that constitutes a response. depending on the intended focus and type of integration, identify and describe the elements of the response that could be the possible candidates for integration. the scale of the details of these functions would vary based on the level of the health system. an example of list of core functions and their description is presented in table 5. identify comparators once the response functions, the possible candidates for integration, are defined, the next step will be to assess the similarities between the parallel functions. assessment of similarity between two functions requires comparators – parameters that are used to compare two functions. to identify parameters/attributes of the functions that could be used to compare two processes in order to identify similarities and differences, a list of possible parameters is given in table 6. rate degree of similarity the degree of (relational) similarity is the extent to which a pair of parallel response functions (e.g. prevention of a and prevention of b) shares common parameters/attributes. short communciation table 1. a 3x3 matrix for convergence between the problems. magnitude of problem b high average low magnitude of problem a high medium/average low cut-off points that differentiate between high, medium and low (in task 1 and 2) are relative and highly dependent on local contexts. thus, these are left to the users of this tool. groups/settings assigned to high-high will be the most likely focus of integration. cluster analysis could be used if actual values are available. table 2. a 3x3 matrix for relating time-trends of two problems. time-trend of problem b increasing stabilized decreasing time-trend of problem a increasing stabilized decreasing table 3. matrix for rating linkage between two problems. greater similar lower risk of problem b among a+ as compared to general population risk of problem a among b+ as compared to general population severity of problem b among a+ compared to general population severity of problem a among b+ compared to general population table 4. matrix of classifying levels of co-occurrence of two problems. greater similar lower prevalence of a among b+ as compared to prevalence of a (pa) prevalence of b among a+ as compared to prevalence of b (pb) prevalence of ab in general population as compared to (pa*pb) table 5. list of major functions that constitute response to health problems. categories functions description of the functions policy leadership high level political commitment policy advising providing inputs for policy making policy making formulation/approval of policies governance overseeing policy implementation processes program prevention measures taken to prevent disease treatment services provided to control/treat disease care and support services provided to improve quality of life system strengthening interventions that improve system capacity management planning strategic and annual planning implementation overseeing implementation of programs resource mobilization securing resources needed for programs multisectoral coordination coordination of multiple actors/sectors strategic information patient monitoring monitoring the progress of patients disease monitoring monitoring of disease/epidemic patterns program m&e monitoring and evaluation of programs dissemination communication of findings of m&e non co mmerc ial us e o nly [page 16] [healthcare in low-resource settings 2015; 3:3260] the most appropriate and applicable set of parameters should be used for the rating. the rating scale may vary from dichotomous scale to a higher point likert scales. using a selected set of parameters, one should rate the degree/strength of similarities between a pair of parallel functions. a sample template for rating the similarity between program related functions of problem a and problem b is given in table 7. determine importance of similarities in addition to the degree of similarity, the relative importance of similarity is also essential. the importance of the similarities between a pair of parallel functions can be viewed from four major perspectives: policy – the strategic importance of the similarity for policy purpose; managerial – the importance of the similarity for decision making; economic – the importance of the similarity in efficient use of resources; and practical – the importance of the similarity for program implementation. to determine the relative importance of the similarities between a pair of parallel functions by considering the policy, management, economical, and practice perspectives one should follow table 8. scanning the environment for integration after establishing the need for integration (section i) and identifying candidate functions/structures for integration (section ii), the third phase is assessing whether the environment is enabling/conducive for integration. this is conducted using environmental scanning. in principle, three components of the environment need to be considered: internal (staffs, managers, organizational set up), task-related (patients, competitors i.e. other actors, partners, donors, pressure groups), and external (political, economic, socio-cultural and technological factors). from the perspective of integration, the following themes are important. motivation for integration interest among managers and staffs (of unit a and unit b) to integrate the relevant functions/structures and operate in an integrated approach. to assess whether policy makers, managers and staffs of unit a and unit b are interested to integrate the respective functions and thereby operate in an integrated approach one should follow table 9. capacity for integration capacity to integrate (for managers) and capacity to operate in an integrated approach short communication table 6. list of potential parameters that may be used to assess similarity. parameters descriptions operational characteristics nature and technical complexity timing of the functions time and frequency (when and how often) actors/performers the skills/expertise/speciality required methods/tools models and approaches used targets/users the characteristics of the customers/users results/outputs the attributes of the end products input requirements monetary and non-monetary requirements levels in the system levels of health system where the functions happen lines of accountability command and communication chains monitoring modalities monitoring requirements (formats, schedules, etc.) priority and interests accorded priorities and vested interests table 7. matrix for rating degree of similarity of parallel functions. pairs of parallel functions degree of similarity (these are examples only, add more to this list) low medium high prevention (of a and b) treatment (of a and b) care & support (of a and b) health system strengthening (of a and b) table 8. matrix for rating relative importance of similarity between parallel functions. similarity between relative importance (these are examples only) low medium high prevention (of a and b) treatment (of a and b) care and support (of a and b) health system strengthening (of a and b) at the end of this section, an initial short-list of possible candidates (for integration) of response functions would be reached. though higher degrees of similarity and higher relative importance of the similarity could be the mainstay of the selection, this will also depend on judgement by the responsible body. table 9. matrix for rating levels of motivation towards and capacity for integration. levels of motivation low medium high policy makers managers practitioners levels of capacity managerial capacity technical capacity institutional capacity table 10. matrix for rating levels of acceptability of integration by end users. end users levels of acceptability low medium high service users/customers (e.g. patients) funding agencies (donors) governing bodies (including government) non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:3260] [page 17] (for staffs and institution/infrastructure). to assess the capacity (managerial, technical and institutional) to integrate the functions and operate in an integrated approach one should refer to table 9. acceptability of integration the extent to which the integrated approach is acceptable to the end users (patients, donors, governments) of the processes or the arrangements. to assess whether an integrate approach is acceptable to end users of the functions one should follow table 10. influences on integration the effects (reactions) of important stakeholders and their activities on integration process. influences may be negative, neutral or positive. to assess the possible reactions of other important stakeholders towards the integrated approach one should refer to table 11. implications of integration the possible effects (impacts) of the integration on important stakeholders and their business. this may also be positive, neutral or negative. assessing how the integration of the functions/structures might affect other important stakeholders is described in table 11. repackaging evidence for integration all the preceding sections of this tool were designed for generating important evidence about the need for integration, identifying the appropriate candidate functions/units for integration and assessing the conduciveness of health system environment for integration. the evidence generated needs to be repackaged in a form that can better inform decisions related to integration. a matrix of four major elements of evidence communication should include: purpose, audience, content/message, method. the audience (who) integration may mean different things for different people. policy makers, managers, healthcare providers, patients, and researchers have different views about integration. repackaging evidence of integration needs to take into account these views and interests. the task of this section is to clearly state the target audience, their views, and their interests in relation to integration. the purpose (why) repackaging of integration related evidence should be targeted towards achieving a clearly defined purpose. the purpose is usually instrumental – for practical applications. in some instances, however, it may be symbolic – to confirm decisions, policies and practices. the task of this section is to clearly state the purpose(s) of the communication of evidence about integration. the content (what) what needs to be included in the communication package depends on the purpose and the audience of the communication. the task of this section is to prepare the content of communication product – the knowledge/evidence that is going to be communicated. the method (how) the method of communication may be selected based on knowledge about the interests of the audience. it may be in the form of printed materials, electronic materials, audiovisuals, conference presentations, etc. the task of this section is to decide on the method of communication and appropriate communication product. managing integration once the evidence about integration is effectively communicated, responsible bodies are expected to make decision about the integration. the translation of that decision in to action should be systematic, with steps involving planning, implementation, monitoring and evaluation. short communication table 11. matrix for classifying anticipated reactions of stakeholders and impacts of integration on them. important stakeholders anticipated reactions negative neutral positive stakeholder 1 stakeholder 2 (add rows for more stakeholders) anticipated impacts stakeholder 1 stakeholder 2 (add rows for more stakeholders) table 13. major constructs for evaluation of integration. indicators for before integration after integration change level of integration systems’ performance cost performance units objectives of integration goals of health system table 12. the ten levels of integration. levels communication consultation coherence consensus coordination cooperation collaboration co-location coalition combination of integration baseline level target level non co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2015; 3:3260] planning integration integration should be a well-planned process. integration planning needs to consider the parts and the parties that are going to be integrated. depending on its extent, integration planning may address a range of tasks: i) select the foci of integration (units/functions that are going to be integrated), which may include functions/structures relevant to policy, institutional arrangement, management, program, and information; ii) formulate the goals/objective of the integration; iii) determine baseline (the existing) and the target (the desired level) of integration for each foci of integration (table 12); iv) identify strategies/mechanisms to be used to achieve objective of the integration; v) estimate the cost/resources required for implementing the strategies; vi) weigh the benefits and risks that might be associated with the integration. once this is done, one should define the key elements of integration plan and prepare the plan. implementing integration this step is about the application of the integration plan in to action. it involves operationalization of integration plan in to implementation plan and carrying out activities as per the implementation plan. the implementation of integration plan, therefore, involves: i) operationalization (i.e. deciding who will do what and when); ii) implementation (i.e. translating the implementation plan in to action); iii) coordination (i.e. synchronizing activities and actors); iv) supervision (i.e. supervising and taking corrective action); v) monitoring (i.e. measuring progress and comparing against the plan). evaluating integration as any other performance improvement initiative, integration should be evaluated (table 13). the key constructs that are usually important in the evaluation of integration are: configuration (whose objective is to describe the alignment of the processes before and after integration and explain the differences in the integration architecture); synergy [aimed at measuring performance of the integrated architecture (after integration) and compare it with the sum of performance of the units (before integration)]; efficiency (which calculates the unit cost per performance units before and after the integration and describe the differences); effectiveness [whose aim is to determine the level of achievement of the stated objectives of the integration (as stated in the integration plan)]; impact (aimed at determining the difference between the level of achievements of the objectives of the health system before and after the integration). conclusions the proposed generic tool is developed based on the existing evidence relevant to the integration of responses to major public health problems. it has laid out the basic processes and sub-processes that need to be undertaken in the process of integrating system level responses in a systematic manner. it provides guidance for a comprehensive, evidence-based and step-wise approach to integration. as it includes the generation, synthesis, and utilization of evidence in its steps, it can suit situations where evidence relevant to integration is yet to be generated. however, this tool has undergone only conceptual and content validation. further studies are needed to evaluate how the tool can be best streamlined into various health systems. references 1. suter e, oelke nd, adair ce, armitage gd. ten key principles for successful health systems integration. healthcare q 2009;13:16-23. 2. shigayeva a, atun r, mckee m, coker r. health systems, communicable diseases and integration. health policy plann 2010;25(suppl.1):4-20. 3. miranda jj, kinra s, casas jp, et al. noncommunicable diseases in lowand middle-income countries: context, determinants and health policy. trop med int health 2008;13:1225-34. 4. armitage gd, suter e, oelke nd, adair ce. health systems integration: state of the evidence. int j integr care 2009;9:e82. 5. haregu tn, setswe g, elliott j, oldenburg b. developing an action model for integration of health system response to hiv/aids and noncommunicable diseases (ncds) in developing countries. glob j health sci 2013;6:9-22. 6. budetti pp, shortell sm, waters tm, et al. physician and health system integration. health affair 2002;21:203-10. 7. russell e, johnson b, larsen h, et al. health systems in context: a systematic review of the integration of the social determinants of health within health systems frameworks. rev panam salud publ 2013;34:461-7. 8. jackson sf, birn ae, fawcett sb, et al. synergy for health equity: integrating health promotion and social determinants of health approaches in and beyond the americas. rev panam salud publ 2013;34:473-80. 9. evans jm. health systems integration: competing or shared mental models? int j of integr care 2014;14:e028. 10. tsasis p, evans jm, forrest d, jones rk. outcome mapping for health system integration. j multidisc healthc 2013;6:99-107. 11. sword w. a socio-ecological approach to understanding barriers to prenatal care for women of low income. j adv nurs 1999;29:1170-7. 12. govindasamy d, kranzer k, van schaik n, et al. linkage to hiv, tb and non-communicable disease care from a mobile testing unit in cape town, south africa. plos one 2013;8:e80017. 13. shwartz m, iezzoni li, moskowitz ma, et al. the importance of comorbidities in explaining differences in patient costs. med care 1996;34:767-82. 14. valderas jm, starfield b, sibbald b, et al. defining comorbidity: implications for understanding health and health services. ann fam med 2009;7:357-63. 15. murray cj, frenk j. a framework for assessing the performance of health systems. b world health organ 2000;78:71731. short communication non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11626 healthcare seeking behavior for acute illnesses among adult aborigine communities (orang asli) in cameron highlands, malaysia: a house-to-house survey ganesan danaletchumy,1,2 sumaira hussain,2 chandrashekhar t. sreeramareddy2 1school of postgraduate studies, international medical university, kuala lumpur; 2division of community medicine, international medical university, kuala lumpur, malaysia abstract indigenous people often have poor health due to a lack of access to health care. we studied healthcare-seeking behaviors and associated factors of orang asli populations living in remote hilly areas of peninsular malaysia. a house-to-house survey was done in 11 of 28 randomly selected villages. a sample of 225 adults aged 18 years and above were interviewed about healthcare-seeking behavior for an episode of illness 30 days before the survey date. factors associated with appropriate healthcare-seeking behavior as determined by binary logistic regression analyses. more than a third of the orang asli adults (88/225) did not consult any healthcare provider (39%) for which “illness does not need treatment” or “not sick enough” (22%) and no transportation (12%) were the main reasons. being of older age (aor 0.95, 95%ci 0.9, 0.98), income higher than 500 malaysian ringgits per month (aor 2.35, 95%ci 1.04, 5.39), perception of illness as “severe” (aor 54.79 95% ci 12.61, 239.9), and closer distance of health facility (aor 0.86 95% ci 0.81, 0.93) were associated with appropriate healthcare-seeking behavior. health promotion campaigns are needed to improve awareness about common illnesses and improve care-seeking behavior. introduction wide gaps exist in the health status of indigenous compared to non-indigenous populations.1 disparities in health are often due to the lower education and economic status of the indigenous population. nevertheless, the indigenous populations are reportedly undergoing a socioeconomic development and they are even facing a non-communicable disease burden.2,3 the indigenous people of peninsular malaysia known as orang asli (oa), account for about 0.6% of the total malaysian population. an estimated 200,000 oa population living in malaysia have about 18 subgroups. oa people speak unique dialects and have diverse cultures and belief systems. however, oa people from each settlement speak the same dialect. oa people are marginalized and lack access to education, social services, and healthcare.4 however, in recent years the malaysian government has taken initiatives led by jabatan kemajuan orang asli (jakoa) to bring about the socioeconomic development of oa populations. despite such initiatives, the health indicators of the oa population are still poorer than the national population. oa people have lower child survival, life expectancy, and a higher undernutrition and communicable diseases burden than the national population.5 the ministry of health malaysia is the main healthcare provider in malaysia and has implemented special services such as setting up dedicated hospitals and clinics, catering for transit and treatment, mobile teams, and landing zones in remote areas where oa people usually reside. the national health and morbidity survey has reported that government facilities are the preferred choice by oa.6 survey studies among different oa settlements in malaysia have also shown that government healthcare facilities are the preferred choice for seeking healthcare.7, 8 correspondence: chandrashekhar t. sreeramareddy, division of community medicine, international medical university, jalan jalil perkasa 19 bukit jalil, kuala lumpur, 57000 malaysia. tel.: +601139868114 fax: +6003-8656 7228 e-mail: chandrashekharats@yahoo.com chandrashekhar t. sreeramareddy is currently affilaited at institute of research development and innovation, mu university, kuala lumpur, malaysia key words: health utilization, aboriginal, acute illness, knowledge, treatment. contributions: dg, sh, and cts were involved in the conception of the study. dg collected the data dg, sh and cts performed the data analysis and interpretation of data. dh, sh, and cts were involved in drafting, editing, and revising the manuscripts. all authors approved the final version. ethics approval and consent to participate: ethical approval was obtained from the medical research ethics committee of malaysia (nmrr id: nmrr id-21-02244-nfo (iir)) and international medical university joint committee on research and ethics and medical research (msph i/2021(03)) followed current regulations on the protection of personal data. the participant information sheet provided assurance about anonymity and confidentiality. informed consent was obtained from all survey participants. the study methodology followed the ethical guidelines in accordance with relevant guidelines and regulations. availability of data and materials: the data collected for this study are available from the corresponding author upon reasonable request. conflict of interest: all the authors declare that there no competing interest to declare. acknowledgments: the authors would like to extend their appreciation to the district health office cameroon highland) for their support in conducting this study. the authors would also like to thank the director general of health of malaysia for his kind permission to publish this article. received: 31 july 2023. accepted: 21 november 2023. early access: 18 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11626 doi:10.4081/hls.2024.111626 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11626] [page 253] non -co mmerc ial us e o nly however, the choice of healthcare provider may be affected by geographic barriers, health beliefs, and preference for traditional and spiritual ways of healing by the oa people.9 oa settlements of malaysia vary in their dialects, beliefs, and culture. these settlements are in geographically diverse locations, such as hills, and coastal areas with differential access to modern healthcare facilities.4 studying the morbidity profile and healthcare-seeking behavior during illness is important information needed to improve illness management. it helps policymakers address demand-side factors and barriers in accessing healthcare facilities aimed to improve appropriate hsb.10 few studies have reported hsb among other settlements of oa in malaysia.7,8,9 we studied those oa populations in deep forest areas of cameroon highlands in pahang state. we aimed to study the type of healthcare provider consulted during an illness 30 days before the survey and the reasons for not consulting a healthcare provider. materials and methods study design a cross-sectional, house-to-house health interview survey. study setting the survey was conducted in the oa settlements (villages) in cameron highlands, pahang state, peninsular malaysia. there are 28 villages scattered in the remote forests along the hills of cameron highlands.therefore, trading forest products, hunting, and farming is their main source of income. study participants all the adults aged 18 years and above and are permanent residents of the household were eligible. sample size calculation sample size was estimated for a finite population using the lynch formula (n = 2𝑐 2𝑁 ρ(1−ρ)/(a*𝑁) +(𝑐 ρ[1−ρ]). ]). the total estimated sample of oa living in the cameron highlands was 2626.4 there were no prior surveys that estimated the proportion of individuals who sought appropriate healthcare. we anticipated that 20% would be seeking appropriate healthcare for their most recent episode of an acute illness (p). for a 95% confidence level (c) and a 5% allowable error (a), the minimum sample required (n) was 225 adults who had experienced an acute illness during the last 30 days. sampling method a two-stage sampling method was followed. in the first stage, from the list of 28 villages (sampling frame) having an estimated population each village ranging from 300 to 700, 11 villages were randomly chosen by a lottery method. in the second stage, in each selected village, the households (primary sampling unit) were selected by moving in a randomly chosen direction starting from the center of the village. the random direction was chosen by rotating a bottle. the researcher moved in the direction the mouth of the bottle was facing. since the informal settlements did not have any street or house numbers this was the only feasible method to select the households. all the consecutive households in the selected direction were selected for the survey all eligible adults. households were sampled until about 20-25 adults were interviewed in each village. if the sample of eligible was not reached in a chosen direction, a different direction was chosen from the village center. questionnaire a structured questionnaire was adapted from the national health and morbidity survey 2019, malaysia.6 it consisted of three sections namely i) sociodemographic factors, ii) self-rated health status and illness during the past 30 days, and iii) health-seeking behaviors such as the type of healthcare provider consulted for the illness and the reasons for not seeking healthcare if any healthcare provider was not consulted. operational definition the main outcome variable appropriate hsb appropriate hsb was consultation with a qualified medical professional in either the public or private sector. consultation with a traditional healer and purchase of over-the-counter medications using home remedies or self-medication were considered inappropriate hsb. we adopted the above operational definition to suit our study context. predictor variables demographic variables such as age, sex, marital status, education, monthly household income, distance from the nearest health facility (in kilometers), self-rated health status (excellent, good, fair, poor, and very poor), and perceived severity of illness (mild, moderate and severe). data collection procedure a house-to-house survey was carried out in the selected villages during september and october 2022. in each selected house all the adults were listed and were asked if any episode(s) of illness. for ease of recall, they were asked to report the symptoms experienced during a period of 30 days before the day of the survey. in each household, only one adult member who reported any illness was invited for an interview about hsb. in the event of multiple illnesses reported data was collected for the most recent illness. informed consent was taken from the head of the household and each participant after reading out the participant information sheet. for consenting participants, a face-to-face interview was done in bahasa malaysia by the principal researcher. when necessary, a community health volunteer was used as an interpreter. each interview took around 15 to 20 min. data analyses data were analyzed using statistical package for social sciences version 24.0. descriptive statistics of absolute numbers and proportions were calculated. bivariate comparisons of appropriate hsb with sociodemographic, illness-related factors were made. appropriate hsb was the dependent variable whereas sociodemographic, and illness-related factors were the independent variables univariate analyses followed by multivariable analyses were done to identify the factors associated with appropriate hsb. factors significant in univariate analyses were entered into the binary logistic regression analyses by enter method. adjusted odds ratios and their 95% ci were estimated. a p-value less than 0.05 was considered significant. results sociodemographic and morbidity profile a total of 412 households were surveyed in a random sample of 11 villages and 225 eligible adults were identified all of them article [page 254] [healthcare in low-resource settings 2024;12:11626] non -co mmerc ial us e o nly agreed to participate in the interview. the mean age of the respondents was 41 years (sd 14.3) and about 70% of them were aged between 20-60 years, and 60% were women. about 70% were employed and 72% were living with a partner, and most earned <1000 ringgit malaysian per month. the median number of members in the household was 6 (iqr 4-7, range 1-12), whereas the median distance of the household from the nearest health facility was 5 (iqr 3-5, range 3-40). the top five morbidities reported by the respondents were cough fever (17.3%), joint pain(14.2), wheezing(12.0%), and heartburn (7.6%). health-seeking behavior and reasons for not seeking healthcare we assessed the type of healthcare provider consulted by 225 survey respondents for their illness during the last 30 days. appropriate hsb was shown by 132 (58.7%) respondents. of these 52% had consulted a medical doctor including a specialist. about 39% of the respondents did not seek any consultation at all. the main reasons cited by 88 respondents for not consulting any hcp during the illness were “illness does not need treatment” (32%), “no transportation (31%), and not sick enough (23%) (figure 1). factors associated with appropriate hsb a significantly higher proportion of the younger respondents, women, educated up to secondary school and had a monthly household income higher than rm 500 reported an appropriate hsb during an episode of illness in the past 30 days. similarly, respondents who were nearer to the health facility and reported their self-rated health as poor and perceived their illness as severe showed a significantly higher proportion of appropriate hsb. bivariate and multivariate analyses i.e. binary logistic regression association with hsb with sociodemographic, health, and illnessrelated factors was done. by binary logistic regression analyses, the age of the respondents, self-rated health as “fair”, monthly family income of rm 500 and more, distance from the health facility, and perception of illness as “severe” were associated with appropriate hsb. for a unit increase in respondent”s age, the odds of appropriate hsb decrease by a factor 0.95 aor 0.95 (95% ci 0.9, 0.98). as compared to the respondents who rated their health as good/excellent, respondents who rated their health fair had 71% lower odds of appropriate hsb. respondents from households with a family income higher than rm 5oo had 1.5 times higher odds of appropriate hsb than their counterparts with household income ≤rm500. for a unit increase in distance of a household from a health facility the odds of appropriate hsb decreased by a factor 0.86, aor 0.86 95%ci 0.81, 0.93). finally, respondents who perceived their illness as severe had 54 times higher odds of appropriate hsb than those who perceived their illness as not severe. discussion main findings a house-to-house survey in remote oa settlements revealed most of the oa people had appropriate hsb, with over half of them consulting medical doctors. yet more than a third of them did not seek any consultation. perceptions that “illness either does not need treatment”, “not sick enough”, and “lack of transportation” were reported as the main reasons for not consulting an hcp. younger age, farther distance from health facilities, and perception of their health as “fair” were associated with inappropriate hsb, whereas higher income and perceived severity were associated with appropriate hsb. comparison with existing literature the oa population is specific to peninsular malaysia and has been identified as one of malaysia”s most socio-economically disadvantaged populations. they also have poor health and nutritional status,5 while several studies have highlighted the various health issues,5 very few have studied various aspects of healthcare utilization by the oa population.7,8,9 these studies were done in different settlements that are close to urban regions and studied hsb and perceptions about health services,8 health, socioeconomic status,9 and use of goods and services.7 the socio-economic status of the respondents in our is comparable to those from other settlements of peninsular malaysia.7,8,9,11 in studies from other settlements oa had mainly sought healthcare from governmental hospitals and clinics.8,9 the findings are suggestive that oa is aware of the modern healthcare facilities available to them.12 however, a notable proportion of them had used local traditional healers and self-treatment with roots and shoots from the forest9 similar findings were reported among the tribal populations in india.13-15 in our survey as well as comparable proportions had not sought any consultation from any hcp, it is likely that these respondents had used some indigenous treatments as in tribal populations of india.13,14 the initiatives are taken by the ministry to improve the health services to the oa are being utilized, nevertheless, there appears to a considerable proportion who either do not consult any modern hcp or use herbal medicine or consult a traditional healer. lack of transport was one of the reasons for not seeking any consultation. by multivariate analyses, a lesser distance of health facility was associated with appropriate hsb. other main reasons were “illness does not need treatment, and “not sick enough” are supported by the association of appropriate hsb with self-rated health status and perceived severity of health. studies from other oa settlements have not reported any transport-related barriers to appropriate hsb.7-9 these study sites were much closer to an urban community, where health facilities are located compared to the remote settlements in cameroon highlands where the median distance to the nearest hcp as reported by the respondents was five kilometers. hsb studies among the tribal populations of india, article figure 1. reasons for not seeking consultation from any type of provider during an episode of illness during the last 30 days by an adult orang asli. [healthcare in low-resource settings 2024;12:11626] [page 255] non -co mmerc ial us e o nly bangladesh, and brazil have also identified ease of access or lack of transportation as barriers to seeking consultation from an hcp.13,14,16,17 in all studies including ours, oa usually consulted a doctor or a nurse when they were ill. a mixed-methods study supports these findings as it reported positive attitudes of oa towards hcp and their acceptance of government health facilities,8 but they highlighted the lack of family support is also a barrier to seeking modern healthcare.9 policy implications though there are transitory treatment services and mobile clinics about of third of adults did not consult any hcp during an episode of acute illness and most of them perceived the disease as mild to moderate. health education campaigns are needed in the oa settlement to improve the hsb. as the settlements are in hilly areas not easily accessible, satellite health centers and mobile clinics should be made available within a more accessible distance from the settlements. continued efforts are needed to tackle the existing burden of ill health among the oa population.18 limitations our findings should be interpreted considering some limitations of the survey. though we sampled settlements of oa documented by the jakoa, smaller settlements may have been missed due to the remoteness of this hilly region. as the oa people can understand the malay language, they were interviewed in the malay language, in the presence of a local community representative. however, some participants may not have correctly understood a few questions. the self-reported hsb may be affected by social desirability bias as the interviewer was hcp. finally, reasons for not seeking consultation were explored using a questionnaire that may not truly represent actual barriers to hsb. as hsb is a complex decision process that is best studied using qualitative research methods. conclusions oa adults mostly consulted doctors, nurses, and medical assistants during episodes of acute illness. a substantial proportion did not consult any hcp or self-treated or consulted an alternative hcp. lack of transport and non-perception of illness as “severe” were the main reasons for any healthcare. health promotion campaigns and improved geographic accessibility are needed in the oa settlements of cameron highlands, malaysia. references 1. anderson i, robson b, connolly m, et al. indigenous and tribal peoples” health (the lowitja institute global collaboration): a population study. lancet 2016;388:131-57. 2. baldoni nr, aquino ja, alves gcs, et al. prevalence of overweight and obesity in the adult indigenous population in brazil: a systematic review with meta-analysis. diabetes metab syndr 2019;13:1705-15. 3. prince sa, mcdonnell la, turek ma, et al. the state of affairs for cardiovascular health research in indigenous women in canada: a scoping review. can j cardiol 2018;34:437-49. 4. jabatan kemajuan orang asli. data terbuka sektor awam laman web rasmi jabatan kemajuan orang asli. 2021. accessed 1 apr 2021. available from: https://www. jakoa.gov.my/data-terbuka-sektor-awam/. 5. khor gl, shariff zm. do not neglect the indigenous peoples when reporting health and nutrition issues of the socio-economically disadvantaged populations in malaysia. bmc public health 2019;19:1-5. 6. institute for public health. national health and morbidity survey 2015 vol iii: healthcare demand. kuala lumpur: ministry of health malaysia, 2015. 7. rosnon mr, gill ss, badari saz, et al. petunjuk pembangunan komuniti orang asli: suatu analisis penggunaan barangan dan perkhidmatan. geografia malays j soc space 2019; 15:132-46. 8. ithnin m, juliana n, effendy nm, rani md. health seeking behaviour among adult orang asli (indigenous peoples) from rural negeri sembilan, malaysia: a mixed-methods study. malaysian j public health med 2021;28:348-58. 9. cheng yx, chong cp, kiew cf, bahari mb. an assessment of health and social-economic status among lanoh ethnic subgroup of orang asli (indigenous peoples) in air bah i village, state of perak, malaysia. j appl pharmaceut sci 2014;30:0327. 10. mackian s. a review of health seeking behaviour: problems and prospects. health systems development programme. 2003. 11. shah nm, rus rc, mustapha r, et al. the orang asli profile in peninsular malaysia: background & challenges. int j acad res business soc sci 2018;8:1157-64. 12. yew vw, sia mk, lam kc, et al. education and awareness of modern health care amongst aboriginal people: the case of the jakuns of peninsular malaysia. gmjss 2015;11:79-85. 13. gandhi s, verma vr, dash u. health seeking behaviour among particularly vulnerable tribal groups: a case study of nilgiris. j public health epidemiol 2017;30:74-83. 14. podder d, dasgupta a, dobe m, et al. health care seeking behavior in a scheduled tribe community in india: a mixed methods research using the framework of andersen”s behavioral model. asia pac j public health 2021;33:369-77. 15. venkatramana p, latheef sa. health-seeking behavior among tribes of india. studies of tribes and tribals 2019;17:1-7. 16. bussalleu a, pizango p, king n, et al. kaniuwatewara (when we get sick): understanding health-seeking behaviours among the shawi of the peruvian amazon. bmc public health 2021;21:1-3. 17. shaikh bt. understanding social determinants of health seeking behaviours, providing a rational framework for health policy and systems development. j pak med assoc 2008;58:33. 18. mahmud mh, baharudin um, md isa z. diseases among orang asli community in malaysia: a systematic review. bmc public health 2022;22:2090. article [page 256] [healthcare in low-resource settings 2024;12:11626] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2017; 5:6401] [page 7] c-reactive protein as a marker of infection in children with severe acute malnutrition in khartoum state, sudan abdelmoneim e.m. kheir, balla g. gebreel department of paediatrics and child health, university of khartoum and soba university hospital, khartoum, sudan abstract severe acute malnutrition and acute systemic infection are often synergistic in children and lead to considerable mortality. the main aim of this research was to determine whether children with severe acute malnutrition can mount an acute phase reactant response measured by c-reactive protein. this was a descriptive, cross-sectional, hospital-based study that was carried out in the five main children hospitals in khartoum state, from november 1st, 2012 to march 1st, 2013. 132 children with severe acute malnutrition were included in the study. data collection included history, examination and c-reactive protein measurement. the data were analyzed using statistical package for social sciences (spss) for descriptive and inferential statistics. the main results revealed that 93(70.5%) children between 12-23 months of age and most of them had marasmus. diarrhoea was the commonest presenting symptoms in 86.4%, followed by fever and vomiting. most of the children (82.6%) had positive c-reactive protein with variable levels. in conclusion malnourished children are able to synthesize c-reactive protein in response to an infectious process and the magnitude of this response is increased in those with severe infections. introduction malnutrition remains one of the most common causes of morbidity and mortality among children throughout the world. it is estimated that, in developing countries, more than one-quarter of all children younger than 5 years of age are malnourished.1 malnutrition diminishes immune function and prevents the host from mounting an adequate protective response to infectious agents. in turn, infections alter nutrient status and can create a deficiency state. thus, malnutrition and infection often act synergistically to increase morbidity and mortality, particularly among infants and children.2 several studies on the effect of malnutrition at the immunological level have been carried out with humans and experimental animals. these studies indicate that malnutrition decreases t-cell function, cytokine production, and the ability of lymphocytes to respond appropriately to cytokines.3 the usual signs of infection are absent or nonspecific in children with acute severe malnutrition (sam), furthermore, laboratory diagnostic capacity is often limited in regions with the highest burdens of malnutrition. consequently, treatment is empirical.4,5 malnourished patients maintain the capacity to release inflammatory markers such as crp & il-6 which can be considered favorable for combating infections.6 there are very few studies that have investigated the role of c reactive protein (crp) as a diagnostic tool of infection in african children where infection profiles are different.7,8 this is further complicated by the fact that sam, particularly edematous malnutrition, can be associated with reduced levels of acute phase proteins. 9 the main objectives of this study were to determine whether children with sam can mount an acute phase reactant response namely crp and to evaluate the usefulness of quantitative crp as a predictor of severe infections in children with sam. materials and methods this was a prospective, cross-sectional, hospital-based study that was carried out in the five main children hospitals in khartoum state, during the period 1.11.2012 to 1.3 2013 (change this date format). all children aged 6-59 months who were admitted with the diagnosis of sam during their first three days of admission were included in the study. 132 children with sam were recruited to participate in the study. the diagnosis of sam was made using the recent who criteria measuring weight for length/height and mid-upper arm circumference (muac) and the presence of bilateral pitting oedema and severe wasting. two forms of sam exist in children: nonoedematous malnutrition, also known as marasmus, characterized by severe wasting and currently defined by weight for length/height z score < -3 of the who growth standard, or muac <11.5 cm; and oedematous malnutrition defined by bilateral pitting oedema also known as kwashiorkor.10 the term marasmic kwashiorkor, has been used to describe children with both wasting and oedema.11 children with malnutrition secondary to serious underlying conditions including congenital anomalies, inborn errors of metabolism, malignancies, inherited autosomal disorders like cystic fibrosis, chronic diarrheal diseases like caeliac disease, congenital cardiac diseases, chronic kidney disease were excluded from the study. all children underwent detailed history and clinical examination by a senior member of the staff (registrar, consultant), personal details were recorded like age, sex, residence, symptoms and signs of sepsis, bilateral pitting oedema and visible severe wasting. anthropometric measurements were taken namely weight, length or height and muac. all those who were enrolled in this study, underwent blood sampling: (two milliliters of blood were drawn from a peripheral vein under aseptic condition after cleaning the skin with 70% alcohol), then the serum was separated and sent for crp measurement, using the latex agglutination test and patients were put into 5 groups according to crp level:12,13 level less than 10 mg/l, regarded as normal; level from healthcare in low-resource settings 2017; volume 5:6401 correspondence: abdelmoneim e.m. kheir, department of paediatrics and child health, faculty of medicine, university of khartoum and soba university hospital, p.o. box 102, khartoum, sudan. tel: +249 9 12313110 fax +249 183776295. e-mail: moneimkheir62@hotmail.com acknowledgements: the authors express their sincere gratitude to the administrations of the five hospitals in khartoum state for giving their permission to conduct this research. thanks are also extended to the caregivers of the children who participated willingly. key words: malnutrition; marasmus; kwashiorkor c-reactive protein; infection. conflict of interest: the authors declare no potential conflict of interest. contributions: the authors contributed equally, all authors read and approved the final manuscript. funding: there was no research grant for this study. received for publication: 21 november 2016. accepted for publication: 2 february 2017. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.e.m. kheir and b.g. gebreel, 2017 licensee pagepress, italy healthcare in low-resource settings 2017; 5:6401 doi:10.4081/hls.2017.6401 non co mmerc ial us e o nly [page 8] [healthcare in low-resource settings 2017; 5:6401] 10-20 mg/l, regarded as elevated; level from 20-50 mg/l, may rule out serious bacterial infections; level from 50-100 mg/l, suggests bacterial infections; level exceeding 100 mg/l, suggests serious bacterial infections. other routine investigations were also done like stool analysis, urinalysis, random blood sugar, complete blood count, renal function test and electrolytes. cxr was done where applicable. blood culture was done on few patients because it is not always available. the data was analyzed using the statistical package for social sciences (spss) version 20 for descriptive and inferential statistics. chi-square test was used to test for significant association between sam and the following independent variables (age, sex, residence, muac, weight for height). also, the association of crp level and serious infections was studied. p value of less than 0.05 was considered significant. ethical clearance and approval for conducting this research was obtained from the ethical committee of the sudan medical specialization board. prior informed consent was obtained from the caregivers of the individual subjects. results a total of 132 children with sam were included in this study. there were 76 (57.6%) males and 56 (42.4%) females, the male: female ratio was 1.36:1. the study revealed that 93(70.5%) children were 1223 months of age , 34(25.8%) between 2436 months and only 5(3.7%) between 36-59 months. most of the children had marasmus and were lying between the age group 1223 months with significant association between age and type of sam (p = 0.006) (table 1). with regards to place of residence, 39(29.5%) were living in urban areas where as 93(70.5%) live in periurban areas with no significant association between place of residence and type of sam (p= 0.072) (table 2). 70 (53%) of the total participants had marasmus, 39 (29.5%) had kwashiorkor and 23 (17.4%) had marasmic-kwashiorkor. regarding the presenting symptoms of the study population, 89 (67.4%) children had fever, 71(53.8%) had poor appetite, 114 (86.4%) had diarrhea, 83 (62.9%) had vomiting, 100 (75.8%) had weight loss, 48 (36.4%) had cough, 4 (3.0%) had sore throat, 3 (2.3%) had ear discharge, 18 (13.6%) had skin lesions. 2 (1.5%) had burning micturition, 96 (72.7%) had pallor, 62 (47.0%) had oedema, and 3 (2.3%) had convulsions. therefore diarrhea was the article table 1. distribution of the study population according to age and type of severe acute malnutrition. age in months disease total m mk k 12 up to 23 count 41 18 34 93 % within age 44.1 19.4 36.6 100.0 % within disease 58.6 78.3 87.2 70.5 % of total 31.1 13.6 25.8 70.5 24 up to 36 count 27 3 4 34 % within age 79.4 8.8 11.8 100.0 % within disease 38.6 13.0 10.3 25.8 % of total 20.5 2.3 3.0 25.8 36 up to 59 count 2 2 1 5 % within age 40.0 40.0 20.0 100.0 % within disease 2.9 8.7 2.6 3.7 % of total 1.5 1.5 .8 3.7 total count 70 23 39 132 % within age 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 2. distribution of study population according to residence and type of severe acute malnutrition. age in months disease total m mk k residence urban count 20 11 8 39 % within residence 51.3 28.2 20.5 100.0 % within disease 28.6 47.8 20.5 29.5 % of total 15.2 8.3 6.1 29.5 peri urban count 50 12 31 93 % within residence 53.8 12.9 33.3 100.0 % within disease 71.4 52.2 79.5 70.5 % of total 37.9 9.1 23.5 70.5 total count 70 23 39 132 % within residence 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 3. relation between mid-upper arm circumference and type of severe acute malnutrition. muac disease total m mk k < 11.5 cm count 44 11 28 83 % within muac 53.0 13.3 33.7 100.0 % within disease 62.9 47.8 71.8 62.9 % of total 33.3 8.3 21.2 62.9 11.5 12.5 cm count 24 11 9 44 % within muac 54.5 25.0 20.5 100.0 % within disease 34.3 47.8 23.1 33.3 % of total 18.2 8.3 6.8 33.3 > 12.5 cm count 2 1 2 5 % within muac 40.0 20.0 40.0 100.0 % within disease 2.9 4.3 5.1 3.8 % of total 1.5 .8 1.5 3.8 total count 70 23 39 132 % within muac 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 muac, mid-upper arm circumference; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. non co mmerc ial us e o nly [healthcare in low-resource settings 2017; 5:6401] [page 9] most common presenting symptom (86.4%), while burning micturition was the least common (1.5%). the study showed that in 83 (62.9%) children muac was below 11.5 cm, out of these 44 (33.3%) had marasmus, 11(8.3%) marasmic-kwashiorkor and 28 (21.2%) had kwashiorkor, with no significant association between muac and type of sam (p= 0.356) (table 3). when considering weight for length/height, 86 cases (65.2%) had their weight for length/height less than -3sd, of whom 69 cases (52%) were marasmic, and 17 (12.9%) marasmic-kwashiorkor, and there was significant association between weight for length/height and sam(p=0.00) (table 4). all participants were subjected to quantitative crp measurement. 45 (34.1%) cases had crp less than 10 mg/l, 32 (24.2%) cases had crp level between 1020 mg/l, 22 (16.7%) cases had crp level between 21-50 mg/l, 15 (11.4%) cases had crp level between 51-100 mg/l and 18 cases (13.6%) had crp level more than 100 mg/l, of whom 11 cases (8.3%) marasmus, 5 (3.8%) kwashiorkor and 2 (1.5%) marasmic-kwashiorkor. the study revealed no significant association between crp level and type of sam (p=0.341) (table 5). out of these 18 cases with crp more than 100mg/l, 3 (2.3%) cases had extensive infected skin lesions, 4 (3%)cases had pneumonia based on x-ray. 4(3%) had gastroenteritis, 2 (1.5%)cases had severe sepsis, both had blood cultures taken, in one sample the result was contaminated and the parents refused a repeat sample. in the second sample klebsiella species was isolated. 1 case had urinary tract infection. 2 cases out of the 18 refused to continue after the result of crp, while the remaining 2 discharged themselves against medical advice. there was significant association between crp level and serious infections (table 6) (p=0.000). discussion severe malnutrition and acute systemic infection are often synergistic in children.14 in the present study an attempt has been made to see whether children with sam can mount an acute phase reactant response, namely crp and to evaluate the usefulness of quantitative crp as a predictor of severe infections in children with sam. our data indicated that most of the children (70.5%) were less than two years of age which is quite compatible with other reports from developing countries.15,16 our study showed that diarrhoea was the commonest presenting symptoms in 86.4%, followed by fever and vomiting which is quite similar to the statistics of african and asian countries though our figure is slightly higher.17 it is stated that most children with severe protein–energy malnutrition have asymptomatic infections because their immune system fails to respond with chemotaxis, opsonization and phagocytosis of bacteria, viruses or fungi, however this is not the finding in our study.18 our data indicated that most of the children with sam (82.6%) had positive crp with variable levels and most of them were marasmus or marasmic-kwashiorkor, this article table 4. relation between weight for height/length and type of severe acute malnutrition. weight for height/length disease total m mk k 1 to -2 sd count 0 1 7 8 % within wt.for.height 0.0 12.5 87.5 100.0 % within disease 0.0 4.3 17.9 6.1 % of total 0.0 0.8 5.3 6.1 -2 to -3 sd count 1 5 32 38 % within wt.for.height 2.6 13.2 84.2 100.0 % within disease 1.4 21.7 82.1 28.8 % of total 0.8 3.8 24.2 28.8 < 3 sd count 69 17 0 86 % within wt.for.height 80.2 19.8 0.0 100.0 % within disease 98.6 73.9 0.0 65.2 % of total 52.3 12.9 0.0 65.2 total count 70 23 39 132 % within wt.for.height 53.0 17.4 29.5 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 17.4 29.5 100.0 sd, standard deviation; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. table 5. relation of c-reactive protein with type of severe acute malnutrition. crp disease total m mk k -< 10 mg/l count 27 14 4 45 % within crp 60.0 31.1 8.9 100.0 % within disease 38.6 35.9 17.4 34.1 % of total 20.5 10.6 3.0 34.1 10-20 mg/l count 12 12 8 32 % within crp 37.5 37.5 25.0 100.0 % within disease 17.1 30.8 34.8 24.2 % of total 9.1 9.1 6.1 24.2 20-50 mg/l count 13 6 3 22 % within crp 59.1 27.3 13.6 100.0 % within disease 18.6 15.4 13.0 16.7 % of total 9.8 4.5 2.3 16.7 50-100 mg/l count 7 2 6 15 % within crp 46.7 13.3 40.0 100.0 % within disease 10.0 5.1 26.1 11.4 % of total 5.3 1.5 4.5 11.4 > 100 mg/l count 11 5 2 18 % within crp 61.1 27.8 11.1 100.0 % within disease 15.7 12.8 8.7 13.6 % of total 8.3 3.8 1.5 13.6 total count 70 39 23 132 % within crp 53.0 29.5 17.4 100.0 % within disease 100.0 100.0 100.0 100.0 % of total 53.0 29.5 17.4 100.0 p=0.135 crp, c-reactive protein; m, marasmus; k, kwashiorkor; mk, marasmic-kwashiorkor. non co mmerc ial us e o nly [page 10] [healthcare in low-resource settings 2017; 5:6401] indicates that children with sam are able to synthesize crp in response to infections and the magnitude is more (>100 mg/l) in those with severe infections, our finding is quite consistent with other similar studies which agreed that severely malnourished infected children are capable of increasing concentrations of crp in response to infectious diseases.19,20 18 cases in our series had crp level more than 100 mg/l, of whom 11 cases had marasmus. amesty-valbuena et al. reported a similar finding as they found high crp levels in children with marasmus.20 the weaker response in the edematous group is not surprising and can be explained by the fact that children with kwashiorkor, however, differ from those with marasmus in having slower rates of whole-body protein breakdown, which may reduce the availability of endogenous amino acids for crp synthesis.19 it is interesting that there is one study which found that crp levels in response to infection are lower in malnourished than in well-nourished children.21 conclusions these results showed that malnourished children are able to synthesize crp in response to an infectious process and the magnitude of this response is more in those with severe infections. high cost of other inflammatory markers precludes their clinical and routine application in low resource settings. therefore, crp being easily measurable and more affordable can be conveniently used as a good marker for the diagnosis of infection in children with sam. references 1. united nations administrative committee on coordination. 2000. fourth report on the world nutrition situation. united nations administrative committee on coordination/subcommittee on nutrition, geneva, s w i t z e r l a n d . www.unscn.org/layout/modules/resourc es/files/rwns4.pdf 2. calder pc, jackson aa, undernutrition, infection and immune function. nutr res rev 2000;13:3-29. 3. rodríguez l, gonzález c, flores l, et al. assessment by flow cytometry of cytokine production in malnourished children. clin diagn lab immunol 2005;12:502-7. 4. chisti mj, tebruegge m, la vincente s, et al. pneumonia in severely malnourished children in developing countries—mortality risk, aetiology and validity of who clinical signs: a systematic review. trop med int health 2009;14:1173-89. 5. page al, de rekeneire n, sayadi s, et al. infections in children admitted with complicated severe acute malnutrition in niger. plos one 2013;8:e68699. 6. delgado af, okay ts, leone c, et al. hospital malnutrition and inflammatory response in critically ill children and adolescents admitted to a tertiary intensive care unit. clinics (sao paulo) article table 6. relation of c-reactive protein matching the level of serious infections with diagnosis. based on total none clinical chest stool blood diagnosis x-ray analysis & culture culture urinalysis infected skin lesions count 0 3 0 0 0 0 3 % within diagnosis 0.0 100.0 0.0 0.0 0.0 0.0 100.0 % within bass on 0.0 100.0 0.0 0.0 0.0 0.0 16.7 % of total 0.0 16.7 0.0 0.0 0.0 0.0 16.7 pneumonia count 0 0 4 0 0 0 4 % within diagnosis 0.0 0.0 100.0 0.0 0.0 0.0 100.0 % within bass on 0.0 0.0 100.0 0.0 0.0 0.0 22.2 % of total 0.0 0.0 22.2 0.0 0.0 0.0 22.2 gastroenteritis count 0 0 0 4 0 0 4 % within diagnosis 0.0 0.0 0.0 100.0 0.0 0.0 100.0 % within bass on 0.0 0.0 0.0 100.0 0.0 0.0 22.2 % of total 0.0 0.0 0.0 22.2 0.0 0.0 22.2 sepsis count 0 0 0 0 2 0 2 % within diagnosis 0.0 0.0 0.0 0.0 100.0 0.0 100.0 % within bass on 0.0 0.0 0.0 0.0 100.0 0.0 11.1 % of total 0.0 0.0 0.0 0.0 11.1 0.0 11.1 u.t.i count 0 0 0 0 0 1 1 % within diagnosis 0.0 0.0 0.0 0.0 0.0 100.0 100.0 % within bass on 0.0 0.0 0.0 0.0 0.0 100.0 5.6 % of total 0.0 0.0 0.0 0.0 0.0 5.6 5.6 dama count 2 0 0 0 0 0 2 % within diagnosis 100.0 0.0 0.0 0.0 0.0 0.0 100.0 % within bass on 50.0 0.0 0.0 0.0 0.0 0.0 11.1 % of total 11.1 0.0 0.0 0.0 0.0 0.0 11.1 refused to continue count 2 0 0 0 0 0 2 % within diagnosis 100.0 0.0 0.0 0.0 0.0 0.0 100.0 % within bass on 50.0 0.0 0.0 0.0 0.0 0.0 11.1 % of total 11.1 0.0 0.0 0.0 0.0 0.0 11.1 total count 4 3 4 4 2 1 18 % within diagnosis 22.2 16.7 22.2 22.2 11.1 5.6 100.0 % within bass on 100.0 100.0 100.0 100.0 100.0 100.0 100.0 % of total 22.2 16.7 22.2 22.2 11.1 5.6 100.0 uti, urinary tract infection; dama, discharged against medical advice. non co mmerc ial us e o nly [healthcare in low-resource settings 2017; 5:6401] [page 11] 2008;63:357-62. 7. carrol ed, mankhambo la, jeffers g, et al. the diagnostic and prognostic accuracy of five markers of serious bacterial infection in malawian children with signs of severe infection. plos one 2009;4:e6621. 8. díez-padrisa n, bassat q, morais l, et al. procalcitonin and c-reactive protein as predictors of blood culture positivity among hospitalised children with severe pneumonia in mozambique. trop med int health. 2012;17:1100-7. 9. jahoor f, badaloo a, reid m, forrester t. protein metabolism in severe childhood malnutrition. ann trop paediatr 2008;28:87-101. 10. world health organization, united nations children’s fund (2009). who child growth standards and the identification of severe acute malnutrition in infants and children. a joint statement. available from: http://www.who. int/maternal_child_adolescent/documents/9789241598163/en/ 11. wellcome trust working party. classification of infantile malnutrition. lancet 1970;8:302-3. 12. melbye h, stocks n. point of care testing for creactive protein, a new path for australian gps ? aust fam physician 2006;35:523-6. 13. gabay g, kushner i. acute phase proteins and other systemic responses to inflammation. n eng j med 1999;340: 448-54. 14. scrimshaw ns, sangiovanni j. synergism of nutrition, infection and immunity: an overview. am j clin nutr 1997;66:464s-77s. 15. mahgoub hm, adam i. morbidity and mortality of severe malnutrition among sudanese children in new halfa hospital, eastern sudan. trans r soc trop med hyg 20121;06:66-8. 16. muller o, krawinkel m. malnutrition and death in developing countries. cmaj 2005;173:279-86. 17. bernal c, velásquez c, alcaraz g, botero j. treatment of severe malnutrition in children: experience in implementing the world health organization guidelines in turbo, colombia. j pediatr gastroenter nutr 2008;46:3228. 18. bhan mk, bhandari n, bahl r. management of the severely malnourished child: perspective from developing countries. bmj 2003;326:146-51. 19. manary mj, broadhead rl, yaresheski ke. whole-body protein kinetics in marasmus and kwashiorkor during acute infection. am j clin nutr 1998; 67:1205-9. 20. amesty-valbuena a, pereira n, castillo j, et al. mediadores de inflamación (proteina c reactiva) en el niño con desnutrición proteico-energética y en el niño eutrófico. invest clin 2004;45:5362. 21. manary mj, yarasheski ke, berger r, et al. wholebody leucine kinetics and the acute phase response during acute infection in marasmic malawian children. pediatr res 2004;55:940-6. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2021; 9:9731] [page 7] menisco-ligamentous injuries of knee joint: can ultrasonography serve as an effective screening modality? farooq mir,1 zahoor raina,2 omair shah,2 tariq gojwari,2 irfan robbani,2 tahleel shera2 1department of radiology, skims medical college bemina, j&k; 2department of radiology, skims soura, j&k, india abstract the aim is to calculate sensitivity, specificity and diagnostic accuracy of ultrasonography (usg) as a screening modality in evaluation of meniscoligamentous injuries of knee joint with magnetic resonance imaging (mri)as gold standard for comparison.patients with clinically suspected menisco-ligamentous injurieswere evaluated by usg initially followed by mri on the same day. a total of 60 patients (50 males, 10 females) underwent usg and mri. usg was done using high frequency probe (9-14 hz) and all the injuries noted. usg of the normal knee was done for comparison. mri with trauma protocol sequences was done on the same day. the accuracy of usg and mri in diagnosis of menisco-ligamentous injuries was compared.majority of the patients (50%) belonged to age group of 21-40 years. most common injuries seen were medial meniscal tear followed by medial collateral ligament injury. the strength of agreement between usg and mri was good with diagnostic accuracy of usg ranging from 83.3% to 95% for different meniscal/ligamentous injuries.usg is an effective imaging modality with high accuracy in diagnosing menisco-ligamentous injuries. usg can act as an effective screening modality in closed knee trauma for evaluation of menisco-ligamentous injuries especially in resource constrained regions owing to its easy availability, portability and lower cost. mri can be reserved for patients with suspicious usg and clinical findings. introduction the knee joint is a compound synovial joint that consists of hyaline cartilage articulations between femur, tibia and patella. the major stabilizers of the knee joint include its ligamentous structures andinjury to these supporting structures is quite common.knee injuries are commonly sports related.1 the knee joint is stabilized by a number of ligaments. medially, the medial collateral ligament extends from medial femoral condyle to the tibia in the coronal plane. the lateral or fibular collateral ligament originates from lateral femur and extends over the popliteus tendon to insert on the lateral aspect of fibula with the biceps femoris tendon. the anterior and posterior cruciate ligaments within the intercondylar notch extend from femur to the proximal tibia as intra-capsular but extra-synovial structures.the menisci are c-shaped fibrocartilagenous structures present between femur and tibia acting as shock absorbers.2 clinical evaluation and localization of knee injuries is quite difficult. imaging plays a pivotal role in management of knee injuries. while radiographs are limited to bony injuries, usg and mri have been widely used in the past for assessing ligaments, menisci and soft tissue injuries. mri provides multiplanar imaging capabilities, is non-invasive and lacks radiation. it provides a wide range of information in cases of knee injury ranging from ligamentous injuries to bone and meniscal injury. the disadvantage, if any, is lack of availability, cost of the study and few contraindications like claustrophobia and metallic plates common in trauma patients.3,4arthroscopy is considered as the gold standard and has the advantage of being both diagnostic and therapeutic. however it is invasive and associated with complications like deep vein thrombosis, pulmonary embolism and infections.5-7 high resolution ultrasound (usg) has emerged in the recent decade as an easily available modality for evaluation of knee trauma. although the sensitivity and specificity might not be better than mri, but usg has shown to be comparable to mri in diagnosing certain injuries including joint effusion, muscle and tendon injury and meniscal injuries. nerves and vessels around knee joint can also be reliably assessed. the advantages of usg include its availability, possibility of bedside use and use in patients with contraindications to mri. comparison of the injured knee with the normal side is also possible.8 the role of usg therefore needs to be evaluated vis-a-vis knee injuries. our study aims at assessing hrusg as an initial screening modality in patients with menisco-ligimentous injuries of knee and along with clinical examination decide whether further evaluation in the form of mri and/or arthroscopy is required or not. materials and methods the prospective study was conducted at sher-i-kashmir institute of medical sciences, srinagar over a period of two years (2018-2020). sixty patients clinically suspected of having knee ligamentous or meniscal injuries were included in the study. patients with poly trauma with hemodynamic instability, open wounds around the knee and those in whom fractures had been fixated were excluded from the study. all the patients underwent usg of the injured knee as well as normal knee using healthcare in low-resource settings 2021; volume 9:9731 correspondence: omair shah, department of radiology, skims soura, srinagar j&k, 190010 india. tel.: 91.7006560813 e-mail: shahomair133@gmail.com keywords: magnetic resonance imaging; ultrasonography; menisco-ligamentous injuries; knee joint. acknowledgement: department of orthopaedics, skims medical college bemina, j&k, india. contributions: mf, study design, data collection, statistical analysis, data interpretation, manuscript preparation, literature search; rz.study design, data collection, data interpretation, literature search; so. study design, data interpretation, manuscript, preparation; gt. data collection, statistical analysis, manuscript preparation; ri, study design, statistical analysis, data interpretation; st, data collection, data interpretation, manuscript preparation. conflict of interest: the authors have no conflict of interest to declare. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article received for publication: 7 march 2021. revision received: 8 june 2021. accepted for publication: 15 july 2021 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9731 doi:10.4081/hls.2021.9731 non -co mmerc ial us e o nly ge logic p5 high resolution usg machine and mr of the injured knee on the same day. image interpretations were done by radiologists with more than 5 years experience in musculoskeletal radiology. the findings of usg and mri were kept mutually blinded for the radiologists. all the patients were clinically examined by an orthopaedic with more than 15 years of experience and a clinical diagnosis was made based on various clinical signs which again were not revealed to the radiologist. ultrasound technique all usg9,10 examinations were performed using logic ge p5 machine equipped with high frequency linear probe (7-15 hz). menisci were examined in partially flexed knee along lateral and medial aspects. normal meniscus was described as a triangular shaped hyperechoic structure located at the joint space while meniscal tears were suggested byappearance of hypoechoic or anechoic clefts within the structure. pcl was evaluated in prone position from popliteal fossa with the knee fully extended. normal pcl appeared homogenously hypoechoic with a well defined posterior border, while torn pcl is heterogeneously hypoechoic with increased antero-posterior diameter and/or indistinct or wavy posterior margins.direct visualization of acl being extremely difficult, acl injuries were indirectly diagnosed by haemarthrosisseen as a fluid collection in intercondylar space when knee is examined in full flexion together with anterior translation of knee on dynamic usg. mcl and lcl are examined in semi-flexed (30-50 degrees) position of knee along medial and lateral aspects respectively. the torn mcl was diagnosed in the form of thickening and heterogeneously hypoechoic change of the ligament on sonogram.lcl is usually depicted as a hypoechoic thin band like structure; however its oblique orientation makes assessment difficult owing to anisotropic effect (figure 1). mri technique and protocol a careful trace of the ligament from its distal insertion in the fibular head to the proximal femoral insertion was done for complete evaluation. note was made of any additional feature including effusion, tendon or muscle injury and patellar fracture.mri was carried out using 1.5t mr system (magnetom avanto, siemens medical systems, erlangen, germany) using the set protocol in our institution (table 1). meniscal tears on mri were diagnosed by abnormal meniscal morphology and intra-substance high signal intensity on t2w and pd images. ligament tears were seen as high signal intensity on t2w and pd images and interruption or disruption of fibres. statistical analysis collected data was evaluated using spss 22.0. continuous variables were expressed as mean±sd and categorical variables were summarized as frequencies and percentages.sensitivity, specificity and diagnostic accuracy of usg was calculated keeping mri as standard for comparison. the sensitivity and specificity were calculated using formulas (sensitivity = true positive / true positive + false negative) and (specificity = true negative / false positive + true negative) respectively with mri acting as gold standard. accuracy of usg was obtained by using the formula (accuracy = true positive + true negative article table 1. mri protocol for knee trauma at our institution. sequence tr te fov read fov phase slice thickness flip angle t1coronal 3650 42 160 90.6 3.5mm 150 t1 -tirmcoronal 527 12 160 100 3.0mm 150 pdfsaxial 3320 24 150 100 3.0mm 150 pd-fscoronal 3320 24 150 100 3.0mm 150 pd -fs -sagittal 3320 24 150 100 3.0mm 150 t2-medic-axial 623 16 150 100 3.0mm 30 pd: proton density, fs: fat saturated, tirm: turbo inversion recovery magnitude, medic: multiple echo data image combination. figure 1. normal morphology of menisco-ligamentous component of knee joint on usg. a) medial meniscus; b) posterior cruciate ligament; c) medial collateral ligament; d) anterior cruciate ligament. [page 8] [healthcare in low-resource settings 2021; 9:9731] non -co mmerc ial us e o nly / true positive + true negative + false positive + false negative). results patient profile we studied 60 patients suspected of having menisco-ligamentous injuries of knee joint with a meanage of 35±8 years (range 17-59 years), majoritybelonging to the age group of 21 to 30 years (n=37, 62%). male to female ratio was 4:1and right knee (n=45, 75%) was more commonly involved than left knee (n=15, 25%). sports related injuries (n=38,63%) followed by road traffic accidents (n=17, 28%) were the main causes of knee joint injuries. evaluation of acl out of 60 cases, 11 (18%)cases were positive by usg and clinical examination. only 09 of these were proved to be positive on mri, thusresulting in 09 true positives and 02 false positives. out of 60 cases, 49 cases were negative on usg and 46 proved to be negative on mri resulting in 46 true negatives and 03 false negatives. the clinical examination was negative in 40 cases only thereby over diagnosing acl tear. evaluation of pcl pcl injury was diagnosed on usg in 15 (25%) cases. mri in these cases was suggestive of pcl injury in 7 cases resulting in 7 true positives and 8 false positives. out of 60 cases, 45 cases were negative on usg and 43 proved to be negative on mri resulting in 43 true negatives and 02 false negatives. evaluation of menisci for medial meniscal tear, usg was consistent with mri in 53 (88%) patients consisting of 20 true positives, 33 true negatives, 3 false positives and 4 false negatives. for lateral meniscal tear, usg was consistent with mri in 50 (83%) patients consisting of 5 true positives, 45 true negatives, 06 false positives and 04 false negatives. all meniscal tears(n=25) that were detected by usg were high grade tears (grade 2 and 3) on mri (figure 2)and meniscal tears(n=8) which were missed by usg belonged to grade 1 category on mri. evaluation of collateral ligaments mcl injury was seen in 15 (25%) patients on usg. all of these cases were positive on mri also resulting in 15 true positives. out of 45 patients who were negative on usg, only 41patients were negative on mri resulting in 41 true negatives and 04 false negatives. lcl injury was seen in 7 (12%) patients on usg, all of which were positive on mri resulting in 07 true positives. however out of 53 patients who were negative on usg, 50 patients were negative on mri resulting in 50 true negatives and 03 false negatives. discussion usg in menisco-ligamentous knee injuries has remained an enigma over many decades. with variable results in many previous studies its role remains ambiguous. our study aimed at setting out clear guidelines vis-a-vis use of usg in knee ligaments and meniscus injuries. we included a total of 60 patients with a mean age of 35.7 years with male predominance (83%). the results we obtained were are quite similar to those of nasir et al.11 indicating the increased incidence of knee injuries in young males owing to more participation in contact sports and outdoor work compared to females in our part of the world. we assessed the accuracy of usg in regards to closed knee injuries with clinical suspicion of menisco-ligamentous injuries taking mri as the gold standard. we found usg to be consistent with mri in 55 (91.67%) out of 60 patients. sensitivity, specificity and accuracy of ultrasound in detecting acl injury was 75%, 95.8% and 91.67% respectively. our results were concordant with the studies done by friedlet al.12(sensitivity 70% and specificity 98%), ptaszniket al.13(sensitivity 91% and specificity 100%) and monem et al.14(sensitivity article figure 2. 25 year old male presenting with sports related injury to right knee. a) usg image depicts hypoechoic cleft in medial meniscus (arrow), suggestive of tear; b) pd sagittal image shows linear hyperintense signal in posterior horn of medial meniscus which was reaching up to the articular surface suggestive of a tear; c) arthroscopic image showing horizontal medial meniscal tear(arrow) which was treated with meniscectomy. [healthcare in low-resource settings 2021; 9:9731] [page 9] non -co mmerc ial us e o nly 81% and specificity 84%) showing comparable statistics. the lower sensitivity of usg in diagnosing acl injuries is probably because of dependence on indirect signs for diagnosis and lack of direct visualization. however, indirect signs of acl tear on usg together with clinical suspicion of acl injury should serve as an indication for mri of the injured knee (figure 3). for posterior cruciate ligament tears (figure 4), ultrasound was consistent with mri in 50 (83.3%) out of 60 patients having a sensitivity, specificity and accuracy of 77.7%, 84.3% and 83.3% respectively. the diagnostic accuracy of our study vis-a-vis pcl tears was comparable to previous studies conducted by wang et al.15 (sensitivity83.3%, specificity 87.0% and an accuracy of 85.7%) and bhanupriya et al.16(sensitivity 75%, specificity 93% and accuracy 92%).the overall diagnostic accuracy of usg in cruciate ligament injury can be regarded as acceptable and in resource constrained regions like ours, usg together with clinical examination can help guide mri examinations. also the injuries which remained elusive on usg were mostly grade 1 and 2 injuries which are otherwise also managed conservatively. the menisci are important components of knee joint function. tears of menisci can be assessed on hrusg and appears in the form of hypoechoic area within the meniscus substance. usg in our study helped in the diagnosis of medial meniscal tears with a sensitivity, specificity and accuracy of 83.3%, 91.67% and 88.3% respectively. lateral meniscal tears on the other hand had a sensitivity, specificity and accuracy of 55.5%, 88.23% and 88.33% respectively. the results match those described by monem et al.,14 bhanupriyaet al.16 and attya.17 bhanupriya et al.16 demonstrated sensitivity, specificity and accuracy of 83.8%, 89.4% and 86% for medial meniscal tears and 40%, 91% and 78.3% for lateral meniscal tears. the diagnostic accuracy for lateral and medial meniscal tear assessment by usg in the study by monem et al.14 was 83% and 76% while that of attya.17 was 88% and 73% respectively. majority of the meniscal tears detected by usg in our study were high grade tears on mri and all located in peripheral red zone or red-white zone of the meniscus. the other associated finding we observed were para-meniscal cysts seen in 10(30%) of our patients with meniscal tear (n=33). the disadvantages were lack of classification of meniscal tears and inability to identify displaced meniscal fragments as well as variants like discoid meniscus, which can be a predisposing factor for tears. the classification of meniscal tears was well established on the mri with 17(52%) horizontal type, 10 (30%) radial tears, 4(12%) bucket handle type and 2(6%) flap type article figure 3. 38 year old female with history of injury to left knee.a) longitudinal usg imagedepicts disruption of anterior fibres (arrow) of acl; b)pd sagittal imageshowing hyperintense signal involving acl with disruption of fibres. some fibres are seen posteriorly suggesting a near total tear; c) arthroscopic imageshowing partial acl tear (arrow) which was repaired with an acl graft. figure 4. 40 year old male with injury to left knee. a) usg image depicts thickened hypoechoic pcl suggestive of pcl injury. fibre continuity could not be assessed; b) pd sagittal image depicts hyperintense signal with associated fibre disruption suggestive of a complete pcl tear. joint effusion is also noted. [page 10] [healthcare in low-resource settings 2021; 9:9731] non -co mmerc ial us e o nly tears. the predominance of medial meniscus tears is probably due to more sports related injuries in our study especially the twist injuries owing to the bad quality grounds in our part of the world. the role of usg in meniscal tears can be termed as an initial imaging modality owing to its easy availability and ready use in any environment. also meniscal tears detected on usg tend to be major tears in nature and hence arthroscopy can be directly advised to confirm the diagnosis and therapeutic intervention in the same go. however in usg negative cases with strong suspicion of meniscal tear, a mri should be the answer. the collateral ligaments are well visualized on usg owing to their superficial location and are lateral stabilizers of the knee joint (figure 1). in our study, the sensitivity, specificity and accuracy of ultrasound for detection of mcl injury was 78.9%, 100% and 93.3% and for lcl injury was 70%, 100% and 95% respectively. our results are corroborated by the study done by amandeep et al.18 who observed a sensitivity, specificity and accuracy of 84.6%, 100% and 96.6% for mcl injury and 84.6%, 97.8% and 95% for lcl injury. bhanupriya et al.16 recorded diagnostic accuracies of 96% and 94% for mcl and lcl respectively. the high specificity and diagnostic accuracy makes usg a potent imaging modality as far as collateral ligament injury is concerned (figure 5). the increased number of mcl tears (n=15) in comparison to lcl (n=7) again goes with increased sports related injuries in our study group as a part of the unhappy triad (medial meniscus tear + medial collateral ligament tear + acl tear). therefore a mcl injury on usg should prompt the radiologist to look for other injuries and thereby guide management. the limitations of the study included the lesser number of patients probably owing to the current covid-19 pandemic. a larger study is warranted to obtain further statistical correlations. arthroscopy was not done in all patients and hence confirmation of mri and usg findings were not possible. however, considering high diagnostic accuracy of mri, role of usg can be assessed based on mri findings as standard. conclusions usg is an effective screening modality for menisco-ligamentous injuries of the knee. collateral ligament injuries can be completely assessed by usg. major meniscal and cruciate ligament tears can be diagnosed on usg, however grades 1 and 2 injuries, deep injuries and classification is not possible.indirect signs like haemarthosis, parameniscal cysts and muscle/tendon tears together with clinical suspicion can serve as guides for further imaging in the form of mri. a wide availability, lower cost and fair reliability makes usg a modality of first choice for evaluation of knee injuries in resource constrained countries with mri being reserved for patients with suspicious usg results. references 1. kapur s, wissman rd, robertson m, et al. acute knee dislocation: revive of an elusive entity. curr probl diagn radiol 2009;38:237-50. 2. abulhasan jf, grey mj. anatomy and physiology of knee stability. j funct morphol kinesiol 2017;2:34. 3. yaqoob j, alam ms, khalid n. diagnostic accuracy of magnetic resonance imaging in assessment of meniscal and acl tear: correlation with arthroscopy. pak j med sci 2015;31:263-8. 4. navali am, bazavar m, mohseni ma, et al. arthroscopicevaluation of the accuracy of clinicalexamination versus mri in diagnosingmeniscustears and cruciate ligamentruptures. arch iran med 2013;16:229-32. 5. ward bd, lubowitz jh. basic knee arthroscopy part 3: diagnostic arthroscopy. arthrosc tech 2013;2:5035. 6. friberger pajalic k, turkiewicz a, englund m. update on the risks of complications after knee arthroscopy. bmc musculoskelet disord 2018;19:179. 7. salzler mj, lin a, miller cd, et al. complications after arthroscopic knee surgery. am j sports med 2014;42:2926. 8. jacobson ja. knee ultrasound. in: jacobson ja, ed. fundamentals of musculoskeletal ultrasound, 2nd edition. philadelphia, pa: elsevier saunders; 2013: 212-56. 9. patil p, dasgupta b. role of diagnostic ultrasound in the assessment of musculoskeletal diseases. ther adv musculoskelet dis 2012;4:341–55. 10. bianchi s, martinoli c, bianchi s. knee. in: baert al, ed. ultrasound of the musculoskeletal system. berlin heidelberg: springer-verlag; 2007: 637–744. 11. nasir ai.the role of magnetic resonance imaging in the knee joint injuries. int res j medical sci2013;1:1-7. 12. friedl w, glaser f. dynamicsonography in the diagnosis of ligament and meniscal injuries of knee.arch orthop trauma surg 1991;110:132-8. 13. ptasznik r, feller j,bartlett j, et al.the value of sonography in the diagnosis of traumatic rupture of the anterior cruciate ligament of the knee. am j roentgenol 1995;164:1461-3. 14. monem sae, enaba mm. comparative study between high resolution ultrasound (hrus) and mri in the diagnosis of meniscal and cruciate ligament injury of the knee. med j cairo article figure 5. 22 year old male with injury to right knee. a) longitudinal usg image showing mildly bulky hypochoic mcl (yellow arrow) with no frank disruption of fibers suggestive of mcl sprain; b) pd coronal image depicts hyperintensesignal in the bulky mcl with maintained fiber continuity (cursor). contusions involving the medial femoral and tibial condyles are also noted. [healthcare in low-resource settings 2021; 9:9731] [page 11] non -co mmerc ial us e o nly [page 12] [healthcare in low-resource settings 2021; 9:9731] univ2012; 233-42. 15. wang c, shih t, wang h, chiu y, wang t. the accuracy of ultrasonographic examination of injured posterior cruciate ligament. j med ultrasound 2009;17:187-92. 16. bhanupriya s, khushal n, suhas sg, et al. evaluationof knee joint by usg and mri. iosr-jdms 2016;15:122-31. 17. attya msa. evaluation of role of non ionized radiology tools in knee soft tissue injuries. al-azhar assiut med j 2015;13:52-9. 18. amandeep s, indermeet m, thukral cl, et al. diagnostic accuracy of usg in evaluation of knee injuries with mri correlation. ijars 2018;7:ro50-5. article non -co mmerc ial us e o nly hrev_master [page 44] [healthcare in low-resource settings 2014; 2:1978] post-polio eradication: vaccination strategies and options for india jayakrishnan thayyil,1 thejus jayakrishnan2 1department of community medicine, government medical college, calicut, india; 2department of surgical oncology, medical college of wisconsin, milwaukee, wi, usa abstract in 1988, the world health organization (who) resolved to eradicate poliomyelitis globally. since then, the initiative has reported dramatic progress in decreasing the incidence of poliomyelitis and limiting the geographical extent of transmission. 2013 is recorded as the second consecutive year not reporting wild poliovirus (wpv) from india. if the country can retain this position for one more year india will be declared as polio eradicated. what should be the future vaccination strategies? we searched and reviewed the full text of the available published literature on polio eradication via pubmed and examined internet sources and websites of major international health agencies. the oral polio vaccine (opv) has been the main tool in the polio eradication program. once wpv transmission is interrupted, the poliomyelitis will be caused only by opv. india could expect 1 vaccine-associated paralytic polio per 4.2-4.6 million doses of opv. considering the threat of vaccine-derived viruses to polio eradication, who urged to develop a strategy to safely discontinue opv after certification. the ultimate aim is to stop opv safely and effectively, and eventually substitute with inactivated polio vaccine (ipv). the argument against the use of ipv is its cost. from india, field based data were available on the efficacy of ipv, which was better than opv. ipv given intradermally resulted in seroconversion rates similar to full-dose intramuscular vaccine. the incremental cost of adopting ipv to replace opv is relatively low, about us $1 per child per year, and most countries should be able to afford this additional cost. introduction 2013 is recorded as the second consecutive year of not reporting wild poliovirus (wpv) from india.1 operationally, eradication of polio is currently defined as the absence of a single indigenous case of acute flaccid paralysis (afp) attributable to wpv in a defined geographical area for a period of three consecutive years.2 hence, if this position can be retained for one more year, india will be declared polio-eradicated. the implicit promise of any eradication program is to end the intervention once the causative agent for the disease has been eradicated and apply the financial savings to other priority interventions.3 how do we prepare for posteradication of polio? what should be our vaccination strategies? we searched and reviewed the full text of the available published literature on polio eradication via pubmed and examined internet sources and the websites of major international health agencies. current status of wild poliovirus transmission: world in 1988, the world health organization resolved to eradicate poliomyelitis globally. since then, the polio eradication initiative has reported dramatic progress in decreasing the incidence of poliomyelitis and limiting the geographical extent of transmission.1-3 the world health organization (who) region of the americas (1994), the western pacific region (2000) and european region (2002) have been certified as polio-free.4 the number of polio-endemic countries decreased from over 125 in 1988 to 7 in 2002 and 4 in 2008.3 until 2011, the wild polio endemic countries were confined to four afroasian countries referred to as pain (pakistan, afghanistan, india and nigeria). india was removed from the list since january 2011.5 during 2010-2011, environmental surveillance of wpv transmission was accomplished through testing of sewage samples in 21 countries without active poliovirus transmission.4 in 2009 twelve countries had circulating viruses and in 2010 four countries in the european region (kazakhstan, tajikistan, turkmenistan and the russian federation) experienced wpv outbreaks. during 2010-2011, 21 countries in the african, eastern mediterranean and south-east asian regions experienced wpv transmission. re-established transmission continued in the previously polio-free countries of angola, chad and the democratic republic of the congo, and wpv outbreaks occurred in 13 african countries and nepal during 2010-2011.4 twenty six countries have circulating wpv.4 in january 2012, polio eradication was declared a programmatic emergency for global public health by the executive board of who.4 current status of wild poliovirus transmission: india along with all 192 member nations of the who, the government of india in 1988 committed the nation to the goal of global polio eradication. since 1995, the ministry of health and family welfare, government of india has been conducting intensive immunization and surveillance activities aimed at the complete elimination of poliovirus and paralytic polio.1,6 in india polio cases decreased from 24,257 in 1988 to 4793 in 1994 with the help of routine immunization, well before the eradication program.7 the country has spent more than rs 120 billion (us $ 2.5 billion, us $ 1=rs 50) on polio eradication after the program started in 1994, and rs 1000 crore/year since 2000.5,8 india witnessed a surge of poliomyelitis type 1 in 2006. india is among the world’s large reservoirs (63%) of wpv, with 874 confirmed cases of poliomyelitis (wild virus) being reported in 2007 with 83 type 1 and 792 type 3 cases.6 during the following years the reported wild polio cases were 559 (2008), 741 (2009), 42 (2010), 1 (2011), 0 (2012).1 historically, wpv transmission in india has mainly occurred in bihar and uttar pradesh, two states with low coverage of routine immunization, migrant and remote subpopulations, and a lower relative effectiveness of oral poliovirus vaccine (opv) compared with other areas.9 combined with sensitive afp surveillance, environmental surveillance has provided additional evidence to monitor the absence of wpv transmission in india. sewage sampling was expanded from 10 sites in 2 states in 2010 to 15 sites in 4 states in 2011.4 the last detected wpv from sewage testing in india was in november 2010 proving that there were no environmental transmissions.3 keeping the country free of polio for two years was a feat that is a tribute to the government of india and its 2.3 million vaccinators, who visited over 200 million households to ensure that the nearly 170 million children (under five years in age) were repeatedly immunised with opv.5 now polio eradication in india is at a cross healthcare in low-resource settings 2014; volume 2:1978 correspondence: jayakrishnan thayyil, depart ment of community medicine, government medical college, 673008 calicut, india. e-mail: jayanjeeja@yahoo.co.in key words: wild poliovirus eradication, oral polio vaccine, inactivated polio vaccine, vaccinederived virus, vaccine-associated paralytic polio. received for publication: 12 october 2013. accepted for publication: 23 july 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. thayyil and t. jayakrishnan, 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1978 doi:10.4081/hls.2014.1978 non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1978] [page 45] road. we achieved this with the precious resources, enthusiasm of millions of health workers, commitment of governments and faith of hundreds of polio experts all over the globe.10 the absence of polio is both a measure of and means of development.8 so, the sustainability of this achievement is important. problems after eradication with the use of oral poliovirus vaccine the live attenuated strains used in the opv have been the main tool in the who polio eradication program.11 like other developing countries in the national program we used opv. however, these strains replicate in the human gut and are excreted for several weeks after immunisation. during this period, the attenuating mutations in the vaccine strains can rapidly revert.11 once wpv transmission has been interrupted, poliomyelitis due to poliovirus will be caused only by opv.12 poliovirus isolates originating from opv are, by definition, vaccine-derived polioviruses (vdpvs).3 they can cause vaccine-associated paralytic polio (vapp) among recipients of vaccines, or their contacts, which can be subdivided into three: i) immunodeficient related excretors (ivdpvs) isolated from patients with congenital immunodeficiency syndrome who become chronically infected after exposure to opv; ii) circulating vdpvs (cvdpvs) that arise and circulate in communities with low population immunity; and iii) ambiguous/other (avdpvs) detected from healthy children or from environmental samples.3 continued use of the opv would, rarely, lead to prolonged excretion (>6 months) of ivdpv from a person with a severe primary immunodeficiency syndrome.2 in 40 years of opv use, 28 ivdpvs were documented by the end of 2004.2 in a hospital-based study among patients with primary immunodeficiency disorders in sreelanka, it has been found that 10.2% of patients excreted poliovirus.13 reports of cvpdps were available from polio-eradicated countries. during 2000-2002, three outbreaks of cvdpvs were reported from hispaniola, madagascar, and the philippines.1416 the attack rate and severity of disease associated with the recent cvdpv identified in nigeria, a polio endemic country, were similar to those associated with wpv:17 they are genetically unstable sabin-strain viruses that revert toward the genotypic and phenotypic profile of the virulent parent strain.18 an international review reported re-emergence of wpv in 21 previously polio-free countries.19 within the last two year period, angola, chad, the democratic republic of congo and sudan have had year-long outbreaks.5 hence, international planning for the management of the risk of wpv, after eradication, must include scenarios in which equally virulent and pathogenic cvdpvs could emerge. this should also be applicable to india. outbreaks of poliomyelitis caused by vdpv have recently occurred in communities with long-term incomplete immunisation coverage.11 these chances are high in india where overall coverage of universal immunization program (uip) was about 50%, with low performing states like bihar, and uttar pradesh below this level. as long as opv is used, cvdpv and ivdpv pose a risk of causing poliomyelitis in unprotected individuals and threaten the goal of poliovirus eradication.11 in the case of reemergence of cvdpv similar to wpv with a potential of outbreak after opv use, experts warn about the fragility of achievement of eradication with the current vaccination strategy and force us to accept the reality that we are fighting fire with fire.18 this paradox provides a major incentive for eventually stopping polio immunization or replacing opv, but it also introduces complexity into the process of identifying safe and scientifically sound strategies for doing so. the core posteradication immunization issues include the risk/benefits of continued opv use, the extent of opv replacement with inactivated poliovirus vaccine (ipv), possible strategies for discontinuing opv, and the potential for development and licensure of a safe and effective replacement for opv.12 in the framework for national policy makers for opv using countries, world experts prepared a timetable for opv cessation in 2005 which can be divided into three distinct periods correlating with the evolution of the major polio risks and risk management strategies. the three distinct periods are as follows:2 phase 1, opv cessation preparatory phase: this is for three years following the last case of polio by wpv. the risk during the phase is undetected wild transmission assured by optimal afp surveillance. india is now passing through this phase from 2012-2014. phase 2, opv cessation verification stage: this phase will begin with the simultaneous cessation of opv and will continue for at least three years thereafter, until verification of the disappearance of sabin poliovirus strains, absence of cvdpvs. during this phase the any incidence of cvdpvs have to be controlled by type specific monovalent opv (mopv). phase 3, post-opv era: this period will begin with the verification of the disappearance of sabin-strain polioviruses, as well as the absence of cvdpvs, and will continue indefinitely. major risks during this period would be the re-introduction of a wild, vaccine derived or sabin-strain poliovirus. routine immunization and surveillance should be continued during this period. post-eradication strategies resolution 45.17 of the world health organization assembly mandates that only newer vaccines that are cost-effective can be integrated into the national immunization programs of member countries.7 in literature, two choices are available, each with four possible scenarios that can be constructed for potential routine vaccination policies. both the choices and and the possible scenarios are discussed below.3,20 choice i: i) stop all polio vaccination; ii) continue with current vaccination policies (opv, ipv, or sequential schedule); iii) discontinue opv, but continue ipv universally; and iv) discontinue opv, with some countries electing to continue the use ipv.3 choice ii: i) continue opv vaccination; ii) coordinate discontinuation of opv with or without ipv, depending on national decisions; iii) replace opv with ipv in all countries before final cessation of polio immunization; and iv) develop new live vaccines that would not cause vapp and would not be transmissible.21 even after eradication, vaccination can not be stopped abruptly as in choice i.i, since there are chances of poliovirus transmission both as wpv and vdpv, as currently reported from non-endemic countries. continued use of opv as in choice ii.i will jeopardize the whole world’s efforts in polio eradication. at the international level, the global polio control program has used opv exclusively. while this strategy has succeeded in ending the transmission of wpv, it is being challenged by the fact that, after the global eradication of polio, all cases of paralytic poliomyelitis will be vapp-associated with the use of opv. because live-attenuated poliovirus would be used, it is likely that at any time and anywhere, the conditions may be suitable for vdpvs to acquire the neurovirulence and transmission characteristics of wpv and cause outbreaks.3 as explained in the above scenarios, the formulation of a routine vaccination policy for the post-certification era requires that two critical decisions are made: to continue or discontinue vaccination with live attenuated opv; and, if opv is discontinued, whether vaccination with ipv is needed.3,20 choice i.ii, sequential use of opv and ipv: sequential schedule was based on the theory that the development of vapp was high among non-immune children who received first dose of vaccine. the primary doses are with ipv followed by opv boosters. but sequential schedule can also result in vapp, as experienced by the us. after eradication, us tried this option. in january 1997, the advisory committee on immunization practice recommended the adoption of a sequential ipv/opv vaccination review non co mmerc ial us e o nly [page 46] [healthcare in low-resource settings 2014; 2:1978] schedule (ipv at 2 and 4 months of age, followed by opv at 12 to 18 months and again at 4 to 6 years).20 due to occurrence of vapp on 1 january 2000, the sequential schedule was stopped and changed to the ipv-only schedule.20 both choices i.iii and ii.iii suggest discontinuation of opv, with universal ipv use. the major advantages of scenario iii) are the following: first, it is not associated with vapp, or the threat of cvdpv or immunodeficient excretors; second, it could maximize a high population immunity. choice ii.iv suggests the development of new live vaccines that would not cause vapp and would not be transmissible. this is on the experimental stage. a sabin-ipv development collaboration among the netherlands vaccine institute, japan poliomyelitis research institute, and bio farma was established in 2005. sabin-ipv is being developed independently for licensure by the japan poliomyelitis research institute, by panacea biotec of india, and by the kunming vaccine institute in china.21 in india we could expect 1 vapp per 4.2 to 4.6 million doses of opv.20 considering the threat of vdpvs to polio eradication, the informal who meeting urged who to develop a strategy to safely discontinue opv after certification of global eradication.22,23 the meeting of the advisory committee on polio eradication after estimating the probabilities of vapps following the use of opv after eradication in different countries, led to the decision of stopping the routine use of opv.23,24 the ultimate aim for the post-certification era is to stop opv safely and effectively, and eventually substitute it with ipv. further research is urgently needed to answer key scientific and programmatic questions. factors against oral poliovirus vaccine use after eradication poliovirus will be eradicated only when opv use is discontinued and any reintroduction of the virus in the community after eradication will be from continuing use of opv.12 who reported that children who have been vaccinated with opv and are serologically immune can still excrete wpv, and this might contribute to continued transmission despite the high coverage of opv.9 it is a known factor that in tropical countries like india immune responses to opv are quite unpredictable and erratic, and the vaccine virus take rate is lower in developing countries. a latest published study from india found that after three doses of opv, the sero conversion rate was only 65 and 63% for types i and iii, respectively, and 96% for type ii. according to most recent estimates from uttar pradesh, this would come to a mere 39%.25 in the existing epidemiological situation the gut immunity provided by opv which prevents infection is now undergoing scrutiny. a recent study from india reported that opv vaccine take is less than expectation, highly seasonal and results in intestinal mucosal immunity that appears to wane significantly within a year of vaccination.24 thus, in areas where faecal oral transmission is high, gut infection with wpv cannot be ruled out. we are having vdpv incidence by type 2 virus reported from various parts of countries even after 14 years of its extinction (1999). this is solely attributed to the use of topv which contains type 2 virus. in 2011 india reported seven cases of vdpvs, one of them in a child with congenital immune deficiency in dhamtari district in chhattisgarh, and the others in areas with low routine immunization coverage [udaipur (rajasthan), ghaziabad and badaun (uttar pradesh), barnala (punjab), vidisha (madhya pradesh) and jajpur (orissa)].1 similar incidence may happen in the future after eradication if we continue to use opv with live virus. hence, the infection may be reintroduced and may cross the borders. in order to avoid cross border reinfection, all countries using opv should stop opv use simultaneously in a coordinated manner.17,18 factors favoring the use of inactivated polio vaccine many experts committees associated with who advice and policy makers agreed to stop immediately and switch over to use ipv after eradication.19,22,24-27 in 2007, the acpe added to the list of prerequisites the requirement for an affordable ipv that would be appropriate for use in developing countries. the inclusion of ipv in eradication programs requires immediate consideration and the world will need to rely on ipv indefinitely to maintain immunity.18 from india field based data were available on the efficacy of ipv better than opv. in 1985, two im doses of ipv given to indian children at the age of 6 weeks at 2-week-interval or at the age of 8 weeks at 4-week-interval were having adequate sero-conversion rate against all 3 types of wpv.2 in a recently conducted community based randomized controlled trial (rct) performed at moradabad, india among infants, the adequate antibodies were reported among 29% who took mopv1, 56% who took intradermal (id) ipv and 85% among intramuscular (im) ipv after 28 days of vaccination.26 the only argument raised against the use of ipv was its cost. considering the priority, resources in terms of man power, money, material, we have to keep the eradication status at any cost to ensure that it will never return in the future.8 the current (2010) weighted average purchase prices per dose of vaccine, when purchased by the united nations children’s fund (unicef), are $ 0.15 for the trivalent opv vaccine and approximately us $3 for the ipv vaccine.23 in order to fully immunize a child of age 5 against polio, the child needs minimum five routine doses of opv along with five annual doses during national immunization days, a total 10 doses. by substituting with ipv the doses can be reduced to 3. in an economic evaluation of polio eradication program, experts from the centre all india institute of medical sciences comment that the direct costs for an intensive pulse polio immunization round was rs 24.4 per child. in terms of finances and human resources required for pulse polio immunization, we have reached a threshold where new direction and approach is needed to control polio.6 the cost of ipv can be reduced by giving fractional doses through id route. it was an approved scientific fact that the antigens given through id route are more potent, effective and economic. there is a theoretical advantage of using the dermis as the site of vaccination, including the high density of dendritic cells in the skin compared with the muscle. intradermal immunization could minimize the inhibitory effect of the passively acquired maternal antibody and thus lead to higher seroconversion rates.21 in 1998 nirmal et al. reported that among indian new borns aged 6-8 weeks 2 doses of id ipv at 4and 8-week-interval produce 90, 80, 98% and 90, 70, 97% seroconvertion for type i, ii, iii, respectively.27 in studies conducted in india, fractional-dose ipv given intradermally resulted in seroconversion rates that were similar to those achieved with the full-dose vaccine.28,29 a recently published rct conducted in a tropical country like oman showed that fractional doses of ipv vaccine administered intradermally at 2, 4, and 6 months, as compared with full doses of ipv vaccine given intramuscularly on the same schedule, induce similar levels of seroconversion.23 a study from cuba reported less seroconversion with id ipv with doses at 6, 10, 14 weeks. authors commented that this may be due to genetic variation from india. half life of maternal derived antibodies range from 29 to 36 days. so, the schedule may be reconsidered according to the local situation.21 the cost per infant vaccinated with ipv would be less than $ 3 with the fractional-id dose vaccine, as compared with $ 9 for the fulldose im vaccine, a saving of $ 6 per vaccinated infant.23 antigen-sparing techniques such as id administration could reduce ipv costs significantly, making it more affordable for lowincome countries.18 various ongoing studies by the global polio eradication initiative on how to make ipv affordable in low income group countries is an ample proof of inevitability of review non co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1978] [page 47] its use in later stages of program where there are increase chances for virus transmission.30 to reduce the cost along with dose and schedule reduction, other strategies like the use of adjuvants, resulting in a decreased need for antigen, optimization of production processes i.e., increasing cell densities, creating new cell lines, using alternative inactivation agents, can be tried.23 the development of an ipv produced from sabin strains that would be appropriate for production in developing countries can be tried in the future as well.21 the asian country singapore have got eradication certificate in year 2000.31 given the risk of vaccine-associated paralytic poliomyelitis and circulating vaccine-derived, expert committees advice policy makers to timely consider the replacement of opv with ipv in national immunisation programs.31 an economic study on global polio eradication estimated the costs and made the following comments.32 the current cost of routine and intensive opv immunisation is about us $ 2143 million in the 148 opv-using countries. routine use of ipv in these countries should cost us $ 1246 million. if the current costs of routine and intensive polio immunisation are considered, adopting ipv to replace opv will not increase the total global cost. even if the cost of intensive polio immunisation is ignored, cost-effectiveness ratio of adopting ipv remains less than the average gross national income per capita of opv-using countries. the incremental cost of adopting ipv to replace opv is relatively low, about us $ 1 per child per year, and most countries should be able to afford this additional cost,32 which is applicable to india. suitable inactivated polio vaccine schedule on the schedule of ipv, the indian association of pediatrics committee gave two suggestions.33 first, sequential as l primary doses of ipv at 6, 10 and 14 weeks, followed by two doses of opv at 6 and 9 months, another dose (booster) of ipv at 15-18 months, and opv at 5 years. due to the risks of vapp and more number of doses and costs, this sequential dose is not acceptable. alternatively, two doses of ipv can be used for primary series at 8 and 16 weeks, though this schedule is immunologically superior to epi schedule and the number of ipv doses is reduced.33 as per our stated health policy of self sufficiency of uip vaccines, with future vision an attempt was made in the 1980s for indigenous manufacture of ipv at public sector. indian vaccines corporation limited was constituted by indian petrochemicals corporation ltd and department of biotechnology (government of india) with joint venture of pasteur merieuxserium and vaccines, france in 1989. the main objective of the company was to manufacture ipv to be incorporated in the immunizations program of the government of india. however, ipv was not approved by who, subsequently pasteur merieuxserium and vaccines left the joint venture. in 2008, the entire infrastructure of the company was given on a 30 year lease to m/s reliance life sciences pvt ltd, for the establishment of a life science research and development centre at the project site.34,35 thus, the indigenous availability of ipv is now remote in india. conclusions though ipv is the appropriate option for india for polio eradication, the forse cercavi: ministry of health and family welfare has not made any plan or attempt to get enough ipv or mopvs stock/supply for the future due to a prejudice against the cost of ipv and a bias towards opv. india urgently needs to ensure that adequate supplies of vaccines are available for children, so that this eradication adventure does not transform itself into an epidemic disaster.5 we need to show urgency and must reject ambiguity, dogmas and prejudices to take some unprecedented decisions.10 references 1. government of india. surveillance, at the heart of india’s polio success story. available from: http://www.searo.who.int/ india/topics/poliomyelitis/surveillance/en/ 2. who. cessation of routine oral polio vaccine (opv) use after global polio eradication. geneva, switzerland: world health organization; 2005. 3. sutter rw, cáceres vm, mas lago p. the role of routine polio immunization in the post-certification era. b world health organ 2004;82:31-9. 4. who. tracking progress towards global polio eradication, 2010-2011. geneva, switzerland: world health organization; 2012. 5. vashisht n, puliyel j. polio programme: let us declare victory and move on. indian j med ethics 2012;9:114-7. 6. yadav k, rai sk, vidushi a, pandav cs. intensified pulse polio immunization: time spent and cost incurred at a primary healthcare centre. natl med j india 2009;22:13-7. 7. puliyel jm, gupta ma, mathew jl. polio eradication and the future for other programmes: situation analysis for strategic planning in india. indian j med res 2007;125:1-4. 8. the hindu daily. two years without polio. available from: http://www.thehindu.com/ todays-paper/tp-opinion/two-years-without-polio/article4305845.ece 9. who. progress towards eradicating poliomyelitis in india, january 2009october 2010. geneva, switzerland: world health organization; 2010. 10. agarwal rk. polio eradication in india: a tale of science, ethics, dogmas and strategy. indian j pediatr 2008;45:349-51. 11. minor p. vaccine-derived poliovirus (vdpv): impact on poliomyelitis eradication. vaccine 2009;27:2649-52. 12. dowdle wr, de gourville e, kew om, et al. polio eradication: the opv paradox. rev med virol 2003;13:277-91. 13. de silva r, gunasena s, ratnayake d, et al. prevalence of prolonged and chronic poliovirus excretion among persons with primary immune deficiency disorders in sri lanka. vaccine 2012;30:7561-5. 14. kew om, morris-glasgow v, landeverde m, et al. outbreak of poliomyelitis in hispaniola associated with circulating type 1 vaccine-derived poliovirus. science 2002;296:356-9. 15. who. paralytic poliomyelitis in madagascar, 2002. geneva, switzerland: world health organization; 2002. 16. centers for disease control and prevention. acute flaccid paralysis associated with circulating vaccine-derived poliovirus: philippines. mmwr morb mortal wkly rep 2001;50:874-5. 17. jenkins he, aylward b, gasasira a, et al. implications of a circulating vaccinederived poliovirus in nigeria. new engl j med 2010;362:2360-9. 18. modlin jf. the bumpy road to polio eradication. new engl j med 2010;25:2346-9. 19. lahariya c. global eradication of polio: the case for “finishing the job”. available from: http://www.who.int/bulletin/volumes/ 85/6/06-037457/en/index.html 20. xingzhu l, levin a, makinen m, day j. opv vs ipv: past and future choice of vaccine in the global polio eradication program. bethesda, md, usa: the partners for health reformplus project-u.s. agency for international development ed.; 2003. 21. resik s, tejeda a, mas lago p, et al. randomized controlled clinical trial of fractional doses of inactivated poliovirus vaccine administered intradermally by needle-free device in cuba. j infect dis 2010;201:1344-52. 22. who. final report of the who informal consultation on identification and management of vaccine-derived polioviruses, geneva, 3-5 september 2003. geneva, switzerland: world health organization; 2003. 23. mohammed aj, alawaidy s, bawikar s, et review non co mmerc ial us e o nly [page 48] [healthcare in low-resource settings 2014; 2:1978] al. fractional doses of inactivated poliovirus vaccine in oman. new engl j med 2010;362:2351-9. 24. grassly nc, jafari h, bahl s, et al. waning intestinal immunity after vaccination with oral poliovirus vaccines in india. j infect dis 2012;205:1554-61. 25. paul y. ipv for opv primed children. indian j pediatr 2012;49:423-4. 26. estívariz cf, jafari h, sutter rw, et al. immunogenicity of supplemental doses of poliovirus vaccine for children aged 6-9 months in moradabad, india: a community-based, randomised controlled trial. lancet infect dis 2012;12:128-35. 27. nirmal s, cherian t, samuel bu, et al. immune response of infants to fractional doses of intradermally administered inactivated poliovirus vaccine. vaccine 1998;16:928-31. 28. samuel bu, cherian md, sridharan g, et al. immune response to intradermally injected inactivated poliovirus vaccine. lancet 1991;338:343-4. 29. samuel bu, cherian md, rajasingh j, et al. immune response of infants to inactivated poliovirus vaccine injected intradermally. vaccine 1992;10:135. 30. butcher j. polio eradication nears the end game. lancet neurol 2008;7:292-3. 31. lee hc, tay j, kwok cy, et al. certification of poliomyelitis eradication in singapore and the challenges ahead. ann acad med singap 2012;41:518-28. 32. khan mm. economics of polio vaccination in the post-eradication era: should opvusing countries adopt ipv? vaccine 2008;26:2034-40. 33. indian academy of pediatrics. indian academy of pediatrics committee on immunization (iapcoi). consensus recommendations on immunization and iap immunization timetable 2012. indian j pediatr 2012;49:549-64. 34. indian department of public enterprises. public enterprises survey 2010-2011: vol-ii. finance service. vaccine corporation ltd. manesar, gurgaon, haryana. available from: dpe.nic.in/sites/upload_files/dpe /files/survey1011/survey01/volume2/362.pdf 35. the economic times. reliance life science to buy indian vaccine. available from: http://articles.economictimes.indiatimes.c om/2002-07-29/news/27332216_1_ivcolindian-vaccine-corporation-bharat-biotech review non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11174 the use of web-based digital media to enhance admission orientation for patients in the hospital ike nesdia rahmawati,1 imeldha monitasari,2 debby hamsa putri,2 delfira arizda,2 febry pricila,2 fitri rosyidawati,2 bagus lanang sejati2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2student of school of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: newly hospitalized patients often face some situations that have not been recognized or faced previously. meanwhile, admission orientation can help inpatients to adapt and reduce their anxiety, but it has not been carried out optimally in some hospitals in indonesia. therefore, innovative media is needed to improve the efficiency and increase the willingness of nurses in carrying out admission orientation. objective: this study aims to identify the effect of implementing website-based digital media about admission orientation on nurses’ compliance with the procedure for new patient admissions. design and method: this is a quantitative study with a preexperimental one-group pretest-posttest design. the sample population consists of nurses in the inpatient ward, and a total of 21 samples were then selected using the total sampling method. subsequently, statistical analysis was carried out on the data obtained using the paired t-test. results:the results showed that the p-value was 0.001 (< 0.05), indicating there was a significant difference between the nurse compliance level before and after implementing the webbased digital media. furthermore, the average pretest score was 90, while the average posttest score was 94.6. conclusions: based on the results, there was an increase in the level of nurse compliance after the intervention. introduction patients that are hospitalized for the first time usually experience anxiety because the hospital is different from their regular environment.1,2 they can also experience stress-inducing situations during treatment.3 furthermore, a survey by the agency for health research and quality (ahrq) on 100 new patients reported that 75% experienced acute stress in the first 24-48 hours of hospitalization, while 25% adapted to the condition.1 inpatient often face many unknown and complicated procedures, which causes mild level to severe anxiety and fear.3 it was then assumed that these problems occurred due to a lack of proper orientation by the nurses.4 admission orientation has not been optimally carried out in some hospitals in indonesia. moreover, a study conducted at a hospital in the bandung regency, indonesia reported that 54.11% of the respondents conducted patient orientation, which did not meet the standard operational procedure (sop).5 another study conducted at a hospital in riau province, indonesia also stated that 21.4% of nurses did not orient the patient on how to use the bell, and more than 50% did not perform orientation about the rules, facilities, rights, and obligations.6 furthermore, the interviews with the head of the ward, where this study was conducted revealed that they already have a standard procedure for new patient admissions. however, the implementation is not optimal because many nurses do not follow the procedure completely. this causes an information gap with the patients because they did not receive the complete information7. lack of proper orientation causes various problems, such as lack of knowledge about the nurses in charge,8 and the function of the ward facilities.9 it also causes a slow adjustment to new conditions and the patient’s family/friends can interfere with their safety5 and health care service process.5,10 media can be used to simplify, explain in detail, and shorten the time for orientation by nurses.11 therefore, this study aims to identify the effect of implementing website-based digital orientation media on nurse compliance with the sop for new patient admissions. design and methods this is a quantitative study with a pre-experimental one-group pretest-posttest design, which was conducted for approximately 1 month in july 2021 at panti waluya sawahan hospital, malang city, east java, indonesia. the sample population consists of nurses in the inpatient ward of the placida pavilion ward. furthermore, a total of 21 respondents were selected using the total sampling technique. the orientation of patient admission was usually performed using the verbal method without the media, but this study used a website-based method. at the beginning of the intervention, respondents were socialized about the procedure for implementing the orisignificance for public health inpatients often experience acute stress in the first 24-48 hours of hospitalization. meanwhile, admission orientation has not been optimally carried out in some hospitals. a lack of proper orientation causes various problems, such as a lack of knowledge about the healthcare workers and the function of ward facilities. it also causes a slow adjustment by the patient to the new conditions, which affects their comfort and environmental safety. the loitering of family members also interferes with the health service process. therefore, the web-based digital media for patient admission orientation was studied in this research. the result showed that it can simplify, explain in detail, and shorten the nurses' orientation time. article [page 48] [healthcare in low-resource settings 2023; 11(s1):11174] non -co mmerc ial us e o nly entation using digital media. subsequently, when there is a new admission, the nurse provides a website link to the patient and family, which they can access with their smartphone or the hospital property accompanied by a worker. the nurse then orients the patient and family about the healthcare workers, facilities, services, and rules. the nurses’ pretest and posttest compliance level was obtained with a questionnaire, which was adapted from previous study and has been modified in accordance with the applicable sop at the study hospitals. furthermore, the questionnaire had a validity test score of 0.93 and a reliability score of 0.76. it was then measured using a likert scale with answer option that always have a score of 5, often with a score of 4, sometimes with a score of 3, rarely with a score of 2, and never with a score of 1. subsequently, the total score was converted to a value of 1-100 and then interpreted into three levels, namely good compliance level when the value is 76-100, the moderate category when the value is 51-75, and the category is less when the value is less than 50. results and discussion measurement of demographic data showed that 95.2% of the respondents were female, and 61.9% were 20-30 years old. furthermore, a total of 19 respondents (90.5%) had the latest diploma of nursing education, while 38.1% had worked in hospitals for >10 years. table 1 shows the demographic data of the respondents. the results revealed that there were 18 respondents (85.8%) with a good pretest compliance level, while 3 respondents (14.2%) had a moderate level. however, the posttest compliance level of all nurses (100%) increased after the intervention, as shown in table 2. the analysis results using the paired t-test showed a p-value of 0.001 (< 0.05), which indicates that there was a significant difference in the compliance level after the web-based digital media was implemented (table 3 and 4). furthermore, it shows that the average pretest score was 90, which increased to a post-test score of 94.6. the results showed that there was an increase in nurse compliance in orienting new patients after intervention in all aspects, namely orientation of the inpatients about places, facilities, and rules. these results are consistent with another study that reported a 76.2% article table 1. patient admission orientation instrument. always often sometimes rarely never 5 4 3 2 1 orientation of persons 1 implementation of orientation regarding the doctor in charge o �o �o �o o 2 implementation of orientation regarding the nurse in charge � � � � � 3 implementation of orientation regarding other health workers in charge o �o �o �o �o orientation of places 4 implementation of orientation regarding the location of the nurse station o �o �o �o o 5 implementation of orientation regarding the room map o �o �o �o o 6 implementation of orientation regarding the use of bells, air conditioners or fans, o �o �o �o o televisions, bathrooms, and water � � � � � 7 implementation of orientation regarding evacuation directions in the event of a disaster o �o �o �o o orientation of facilities 8 implementation of orientation regarding the unit's daily activities o �o �o �o o (controlling nurse, administering medication, monitoring vital sign, eating, bathing, wound care, etc.) � � � � � 9 implementation of orientation regarding procedures for filing complaints, o �o �o �o o doctor visiting hours, and how to meet doctors to inquire about the latest medical conditions � � � � � 10 implementation of orientation regarding information on treatment costs, o �o �o �o o costs of supporting examinations, drug costs, operating costs, etc � � � � � orientation of rules and education 11 implementation of orientation regarding the visiting hours o �o �o �o o (not being allowed to receive patient visitors during the pandemic) � � � � � 12 implementation of orientation regarding the number of patient companion o �o �o �o o (the antigen swab result must be negative during the pandemic and it is mandatory to wear a mask) � � � � 13 implementation of orientation regarding not being allowed to roll out mats, o �o �o �o o carrying pillows, and not being allowed to sit on the patient's bed � � � � � 14 implementation of orientation regarding not being allowed to make noise and smoking o �o �o �o o 15 implementation of orientation regarding to look after luggage o �o �o �o o (the loss of patient's personal belongings is not the responsibility of the hospital) � � � � � 16 implementation of orientation on how to dispose of medical and non-medical waste o �o �o �o o 17 implementation of orientation regarding hand washing using 6 steps o �o �o �o o 18 implementation of orientation regarding fall risk prevention o �o �o �o o 19 implementation of orientation on pain management o �o �o �o o 20 implementation of orientation regarding effective cough o �o �o �o o [healthcare in low-resource settings 2023; 11(s1):11174] [page 49] non -co mmerc ial us e o nly increase in compliance.6 furthermore, providing information about the use of facilities, procedures, and health workers are useful because most of the patients lack the knowledge.12–14 procedures for using facilities, such as the bell can also increase the response time of nurses in providing direct care to the patients.15,16 orientation of discipline is also important because medical activities in hospitals are regulated by different rules.17,18 the responsibilities of both the hospital management, personnel, doctors, nurses as well as other matters related to health services have specific guidelines.19 therefore, it is important to inform visitors about the orientation of places, facilities, and rules to ensure their knowledge and compliance, which helps to maintain a comfortable hospital environment. the demographic data results showed that 19 nurses (90.5%) had the latest d3 nursing education while the other 2 (9.5%) had the last education and 38.1% had worked in hospitals for >10 years. furthermore, the post-test result revealed that most of the respondents had a diploma education. it also showed that there was a 100% increase in compliance level with an average post-test score of 94.62. this finding is in line with a study by tutik at purbalingga hospital where the majority of nurses have a diploma education and there was a 74% increase in adherence to sops.20 another sudy also reported that 66.9% of the respondents carried out facility orientation properly.21 meanwhile, notoatmodjo stated that the factors affecting compliance and knowledge include the level of education, experience, environment, and the mass media.22 bloom also believes that behavior based on knowledge lasts longer than that without knowledge.23 the nurses’ knowledge positively correlated with their compliance, which indicates the higher the nurses’ knowledge, the higher the level of compliance.24 this is consistent with a statement that the ability to carry out services in accordance with standards, adequate knowledge, abilities, and skills are needed.25 additionally, the level of knowledge affects the attitudes and behavior toward participation.26 the higher the level of knowledge, the higher the awareness to participate. the limitation of this study is that this study used a limited sample and was only applied to one ward in the hospital. it is hoped that further research can be carried out on a wider scope so that more generalizable research results can be obtained. conclusions the nurses’ post-test level of compliance in carrying out the orientation of new patients after the web-based digital media intervention was higher than that of the pretest. therefore, inpatients must be oriented after admission about the healthcare workers, places, facilities, and rules. the analysis result using the paired t-test obtained a significant value, which indicates that there was an increase in the compliance level after the intervention. article table 2. characteristics of respondants. characteristics of respondant (n=21) n % sex male 1 4.8% female 20 95.2% age 20-30 13 61.9% 31-40 6 28.6% 40-50 2 9.5% education background bachelor in nursing 2 9.5% diploma 19 90.5% work experience < 5 years 7 33.3% 5-10 years 6 28.6% >10 years 8 38.1% table 3. pretest and posttest score of the nurse compliance level in the procedure of admission orientation. (n=21) poor n (%) moderate n (%) good n (%) pretest 0 (0%) 3 (14.2%) 18 (85.8%) posttest 0 (0%) 0 (0%) 21 (100%) table 4. the differences of the nurse compliance level in the procedure of admission orientation. (n=21) mean p value pretest 90 0.001 posttest 94.6 correspondence: ike nesdia rahmawati, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62.341.5080686, fax: +62.341.5080686. e-mail: nesdia@ub.ac.id key words: patient admission, patient orientation, nursing management, nursing informatics. acknowledgment: the authors are grateful to universitas brawijaya and all participants for their commitment to this study. contribution: conceptualization was carried out by i.n.r and i.m. the methodology was designed by i.nr, and i.m. i.m., d.h.p., d.a., and f.p. carried out the analysis, i.m., d.h.p., d.a., and f.p. performed the investigation, while i.n.r wrote the original draft preparation. all authors wrote, reviewed, and edited the study. all authors met the authorship criteria and no other criteria were omitted. conflict of interest: the authors declare no conflict of interest. funding: funds were provided by the department of nursing, faculty of health, universitas brawijaya ethics approval and consent to participate: this study was approved by the health research ethics committee of the faculty of medicine, universitas brawijaya, malang, indonesia. all participants signed a written informed consent to participate in the study. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11174 doi:10.4081/hls.2023.11174 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 50] [healthcare in low-resource settings 2023; 11(s1):11174] non -co mmerc ial us e o nly references 1. rodiyah sp. the provison of orientation to the anxiety levels of the new patient at the ponek (obgyn) general hospital jombang. indones nurs j educ clin 2015;2:88-91. 2. tiedeman me. anxiety responses of parents during and after the hospitalization of their 5-to 11-year-old children. j pediatr nurs 1997;12:110-119. 3. kusnanto, guntarlin s, arisandi dn. admission orientation reduces the level stress of early hospitalized patients. j ners. 2007;2:141-146. 4. rahman, yusuf m, darti, et al. pengaruh orientasi terhadap tingkat kecemasan pasien yang dirawat di ruang rawat bedah rumah sakit umum daerah kota makassar. j media keperawatan 2018;9:138-144. 5. asmirajanti m. gambaran pelaksanaan tindakan keperawatan menerima pasien baru, orientasi pasien baru, pemenuhan nutrisi melalui ngt dan memberikan obat melalui nebulizer di ruang lukmanul hakim rumah sakit al ihsan bandung. indones j nurs heal sci 2016;1:33-37. 6. lestari j, lita, anggreny y. pelaksanaan orientasi pasien baru di rsud petala bumi pekanbaru provinsi riau. j nurs sci 2020;9:122-132. 7. dahm mf, wadensten b. nurses’ experiences of and opinions about using standardised care plans in electronic health records – a questionnaire study. j clin nurs 2008;17:2137-2145. 8. lotfi m, zamanzadeh v, valizadeh l, et al. assessment of nurse–patient communication and patient satisfaction from nursing care. nurs open 2019;6:1189-1196. 9. sofaer s, crofton c, goldstein e, et al. what do consumers want to know about the quality of care in hospitals? health serv res 2005;40:2018-2036. 10. akici a, kalaça s, uǧurlu mü, et al. patient knowledge about drugs prescribed at primary healthcare facilities. pharmacoepidemiol drug saf 2004;13:871-876. 11. vanzetta m, vellone e, dal molin a, et al. communication with the public in the health-care system: a descriptive study of the use of social media in local health authorities and public hospitals in italy. ann ist super sanita 2014;50:163–70. 12. kieft ramm, de brouwer bbjm, francke al, et al. how nurses and their work environment affect patient experiences of the quality of care: a qualitative study. bmc health serv res 2014;14:1-10. 13. naidu a. factors affecting patient satisfaction and healthcare quality. int j health care qual assur 2009;22:366-381. 14. reiling j. safe design of healthcare facilities. bmj qual saf 2006;15:i34-i40. 15. roszell s, jones cb, lynn mr. call bell requests, call bell response time, and patient satisfaction. j nurs care qual 2009;24:69-75. 16. digby r, bloomer m, howard t. improving call bell response times. nurs older people 2011;23:22-27. 17. loveday hp, wilson ja, pratt rj, et al. epic3: national evidence-based guidelines for preventing healthcareassociated infections in nhs hospitals in england. j hosp infect 2014;86:s1-s70. 18. chen c, savva n. unintended consequences of hospital regulation: the case of the hospital readmissions reduction program [internet]. [cited 2021 may 8]. available from: https://www.researchgate.net/publication/327413909_uninten ded_consequences_of_hospital_regulation_the_case_of_th e_hospital_readmissions_reduction_program 19. fiabane e, giorgi i, sguazzin c, et al. work engagement and occupational stress in nurses and other healthcare workers: the role of organisational and personal factors. j clin nurs 2013;22:2614-2624. 20. pamuji t, asrin, kamaludin r. hubungan pengetahuan perawat tentang standar prosedur operasional (spo) dengan kepatuhan perawat terhadap pelaksanaan spo profesi pelayanan keperawatan di instalasi rawat inap rsud purbalingga. j keperawatan soedirman 2008;3:1-9. 21. sari ei, rofii m. gambaran perawat dalam melakukan orientasi pasien baru di instalasi rawat inap rsud hj. anna lasmanah banjarnegara [thesis on the internet]. semarang (indonesia): faculty of medicine, universitas diponegoro; 2017 [cited 2021 oct 10]. available from: http://eprints.undip.ac.id/55073/ 22. notoatmodjo s. pendidikan dan perilaku kesehatan. jakarta: rineka cipta; 2004 23. adams ne. bloom’s taxonomy of cognitive learning objectives. j med libr assoc 2015;103:152. 24. dwi rianita a, suryani d. factors influencing nurses’ compliance level in the application of hand hygiene in inpatient wards of muntilan general hospital. j medicoeticolegal dan manaj rumah sakit 2019;8:40-47. 25. cimatti b. definition, development, assessment of soft skills and their role for the quality of organizations and enterprises. int j qual res 2016;10:97-130. 26. fabrigar lr, petty re, smith sm, et al. understanding knowledge effects on attitude-behavior consistency: the role of relevance, complexity, and amount of knowledge. j pers soc psychol 2006;90:556-577. article [healthcare in low-resource settings 2023; 11(s1):11174] [page 51] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11179 patient’s knowledge, gender, and physical activity level as the predictors of self-care in heart failure patients mifetika lukitasari,1,2 ulfia fitriani nafista3 1department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia; 2brawijaya cardiovascular research center, universitas brawijaya, malang, indonesia; 3nursing faculty, university of indonesia, depok, indonesia abstract introduction: self-care management is the fundamental approach for heart failure (hf) management and is influenced by patient ability in preventing rehospitalization, mortality, and morbidity. therefore, this study aims to investigate the predictors of a patient’s ability in hf self-care management. design and methods: a cross-sectional study was carried out on 96 patients with hf. the data were collected through interviews using questionnaires on demographic characteristics, physical activity (ipaq), knowledge (dutch heart failure knowledge score), and self-care management (self care heart failure index). subsequently, the data were analyzed using logistic regression analysis, and the best fit model for predicting self-care management in hf patients was generated. results: the proportion of samples was 56.3% female, with mostly primary school (50%) as their education level. furthermore, the proportion of patients with adequate hf self-care management was only 21% of the total participant. based on the results, the patient’s physical activity level, hf knowledge, and gender were verified as a predictor of self-care management. conclusions: the hf knowledge level, physical activity level, and gender were the predictors of hf self-care management. introduction heart failure (hf) is the major cause of death and disability that has affected approximately 26 million people worldwide due to non-communicable diseases.1 it was responsible for more than 10% of the total health expenditure for cardiovascular disease in the usa.2 in 2017, approximately 5.7 million people in the us suffered from hf with a projection of more than 8 million hf patients in 2030.3 previous data showed that despite considerable improvement after 60-90 days of hospitalization, patients suffered from high mortality and frequent rehospitalization due to an episode of acute decompensation.4 meanwhile, frequently rehospitalized hf patients are more susceptible to a reduced quality of life. hf patients need to deal with the complexity of care leading to a lack of self-care behaviors. self-care in hf is focused on treatment adherence, lifestyle modifications, disease symptoms monitoring, and response to hf exacerbations. this makes adequate self-care behavior to be important for successful hf management and ideal quality of life, reduced rehospitalization, as well as mortality rate.5–7 several factors that contribute to self-care behavior include patients’ sociodemographic factors, knowledge of hf, and physical activity levels.8–10 a previous study suggested that depression, cognitive function, and patients’ cognitive function are the predictors of self-care behavior.11 the identification of these predictors is essential to support the formulation of effective educational strategies to meet individuals’ needs. therefore, this study aims to investigate the predictors of a patient’s ability in hf self-care management. design and methods a cross-sectional study was carried out on 96 hf patients in rsd dr. soebandi jember from october 2019 to march 2020. adult hf patients with the stable condition, without cognitive limitation, and no paralysis were also included. however, hf patients with nyha level iv and congenital heart disease were excluded. the data were collected using a structured questionnaire with a face-to-face interview, while purposive sampling was used to select respondents. the instrument used included european heart failure self-care behaviour scale (schfi) for self-care level assessment,12 ipaq questionnaire for physical activity measurement,13 dutch heart failure knowledge scale for hf knowledge assessment,14 and sociodemographic questionnaire. the data were analyzed using logistic regression to identify the predictors of self-care behavior. results and discussions socio-demographic and clinical characteristics showed that out of 96 participants, the proportion of women was 56,3% (table 1). the proportion of nyha class was similar between adequate and inadequate self-care management group, their marital status, and physical activity level. meanwhile, a significant difference between adequate and inadequate self-care management groups was also observed in the mean for respondents’ age, level of edusignificance for public health self-care is the most essential part of heart failure (hf) management in the community. it improvement needs to consider related factors to ameliorate patient outcomes, prevent mortality, and morbidity in hf. this study suggested that women with higher physical activity levels and a good knowledge of hf had better self-care management in the community. article [page 66] [healthcare in low-resource settings 2023; 11(s1):11179] non -co mmerc ial us e o nly cation, and knowledge on hf. the result showed that most hf patients had inadequate selfcare management, where people with adequate self-care were 22%, while the rest were inadequate (table 2). based on the activity level measured using ipaq score and analyzed with regression logistic to determine a correlation with self-care, it shows an adequate correlation of p = 0.042. based on the predictors of self-care management as shown in table 3, gender played a significant role in patient self-care level. the results showed that women have better self-care compared to men with an odds ratio of 6.527, 95%ci (1.680-25.352). furthermore, hf patients’ knowledge also contributed to management adequacy with an odds ratio of 39.694, 95%ci (6.923227.583). a high physical activity level was discovered as the predictor of adequate self-care management compared to a low physical activity level with an odds ratio of 6.572, 95%ci (1.41030.640). this model was considered fit based on the result of the hosmer lemeshow test, which showed a significance of 0.571. meanwhile, the pseudo-r-square score showed that the adequacy of self-care management is explained by women’s gender, high physical activity, and good knowledge on hf by 45.2%. participants who had adequate self care management were women patients, high physical activity level, and adequate knowledge on hf. this study also showed that most patients with hf in the community had inadequate self-care management. therefore, self-care promotion needs to be enhanced from the primary level as prevention to follow-up programs for patients after hospitalization. this makes it necessary to promote their self-care on hf management, improve cardiovascular health level, and personal management.15 there is also a need for continuous training to educate patients on their chronic condition and maintain life quality.16 knowledge on hf was a strong predictor of hf patients’ selfcare management in the community.17 a previous study showed that the higher the knowledge the better their self-care level, even 9 months after being discharged from the hospital.18,19 this is because knowledge is closely related to education received by patients from a health care professional. this plays a critical role in patient self-care regiment, form an understanding of weight management, daily intake, lowering alcohol level, smoking reduction, daily physical exercise, medication, and adhering to health care professional.20 an introduction to patient self-care should continue to be carried out as periodic education in the community for patients to improve their quality of life. therefore, multidisciplinary education strategies are considered an effective method in improving self-care management. sociodemographic factors such as gender, level of education, income, and age were considered as the predictors of self-care management in hf patients.21 this study suggested that among all these factors, only gender significantly contributed to self-care behavior while the others did not show any significance. a previous study showed that a higher level of education, living alone, and a new york heart association (nyha) functional classification article table 1. table of socio demography and clinical characteristic. characteristics adequate self-care (n=21) inadequate self-care (n=75) p value age 64.10±11.55 57.76±12.64 0.041 educational level 0.000 not attended school 1 (4.8) 5 (6.7) primary school 5 (23.8) 43 (57.3) junior high school 3 (14.3) 14 (18.7) senior high school 4 (19) 11 (14.7) higher education 8 (38.1) 2 (2.7) gender 0.017 male 14 (66.7) 28 (37.3) female 7 (33.3) 47 (62.7) marital status 0.440 married 19 (90.5) 73 (97.3) unmarried 2 (9.5) 2 (2.7) nyha class 0.987 class i 3 (14.3) 10 (13.3) class ii 13 (61.9) 46 (61.3) class iii 5 (23.8) 19 (25.3) physical activity level 0.591 low 2 (9.5) 8 (10.7) moderate 11 (52.4) 30 (40) high 8 (38.1) 37 (49.3) knowledge on hf 0.000 good 10 (47.6) 3 (4.0) poor 11 (52.4) 72 (96) table 2. multivariate logistic regression for self-care level and indpendent variable. variables sig b exp (b) 95% ci for exp (b) lower upper physical activity level (high) 0,017 1.883 6.572 1.410 30.640 knowledge on hf 0.000 3.681 39.694 6,923 227,583 gender 0,007 1.876 6.527 1.680 25.352 [healthcare in low-resource settings 2023; 11(s1):11179] [page 67] non -co mmerc ial us e o nly were associated with better self-care maintenance, management, and confidence.22 a detailed study on gender differences also showed that 37% of married women were less likely to report adequate self-care maintenance compared to unmarried women.23 several studies showed that gender was not the predictor of selfcare management in hf patients.20,24 meanwhile, it affected the outcome as suggested in a previous study which stated that there are different outcomes between men and women based on mortality and rehospitalization after practicing self-care management.8 this indicated that self-care needs to be implemented based on gender differences to improve patients’ prognoses. hf condition will significantly affect a patient’s tolerability to daily activities as shown in the nyha classification. it was also shown that continuous exercise will improve patients’ physical activity level, which contributed to hf patients’ self-care adequacy. meanwhile, providing an understanding of patient output such as activity related to their part for personal self-care is the key for patients and families to maintain a quality life. this makes it necessary for patients with activities limitations to create a certain modification and acceptance related to the change for a better selfcare.25 the health care professional motivation and supervision will improve patients’ daily exercise to ameliorate patients’ physical activity level and self-care adequacy. therefore, in clinical practice, patients’ confidence and self-efficacy in practicing regular physical exercise should be supported to improve their physical activity level and self-care management. although self-care itself is highly associated with clinical symptoms, there is a need for intervention and targeted self-cate to reduce the number of clinical event.26 the level of patient’s nyha showed no contributions on patient’s self-care in this study, therefore, further report on clinical level is recommended. another reason that contributed to patient level of self-care is the duration of hf diagnosis because those who has been diagnosed with hf more than 1 year usually is 1.8 times better for self-care.20 therefore, comprehensive assessment on self-care and its determinants is essential in hf patient care to achieve better outcome.27 conclusions the results showed that continuous education on activity restriction and their treatment regimens are important to promote adequate self-care in hf patients. although a woman can have adequate self-care, there is a need to study and promote self-care in both males and females. therefore, further study is recommended to investigate the other factors related to the level of self-care in hf patients to reduce the number of rehospitalization and mortality. references 1. ponikowski p, anker sd, alhabib kf, et al. heart failure: preventing disease and death worldwide. esc heart failure 2014;1:4–25. 2. mozaffarian d, benjamin ej, go as, et al. heart disease and stroke statistics—2016 update: a report from the american heart association. circulation 2016;133(4). 3. savarese g, lund lh. global public health burden of heart failure. card fail rev 2017;3:7–11. 4. rockwell jm, riegel b. predictors of self-care in persons with heart failure. heart & lung 2001;30:18–25. 5. asadi p, ahmadi s, abdi a, et al. relationship between selfcare behaviors and quality of life in patients with heart failure. heliyon 2019;5:e02493. 6. calero-molina e, hidalgo e, rosenfeld l, et al. the relationship between self-care, long-term mortality, and heart failure hospitalization: insights from a real-world cohort study. eur j cardiovasc nurs 2022;21:116–26. 7. kessing d, denollet j, widdershoven j, et al. self-care and allcause mortality in patients with chronic heart failure. jacc: heart failure 2016;4:176–183. 8. abe r, sakata y, nochioka k, et al. gender differences in prognostic relevance of self-care behaviors on mortality and hospitalization in patients with heart failure – a report from the chart-2 study. j cardiol 2019;73:370–378. 9. chriss pm, sheposh j, carlson b, et al. predictors of successful heart failure self-care maintenance in the first three months after hospitalization. heart & lung 2004;33:345–353. 10. bagheri –saweh mi, lotfi a, salawati ghasemi s. self-care behaviors and related factors in chronic heart failure patients. int j biomed public health 2018;1:42–47. article correspondence: mifetika lukitasari , department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: mifetika.fk@ub.ac.id key words: self-care, heart failure, heart failure knowledge, heart failure physical activity. acknowledgment: the author is grateful to brawijaya university, malang, for the funding, support, and motivation during this study. contributions: all authors contributed equally, namely ufn conducted this study and ml served as supervisors and reviewed the final article. conflict of interests: the author declares no conflict of interest. funding: this study was financially supported by brawijaya university through the hibah peneliti pemula scheme. clinical trials: this study has been approved by the health research ethics committee of saiful anwar hospital. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 11 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11179 doi:10.4081/hls.2023.11179 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 68] [healthcare in low-resource settings 2023; 11(s1):11179] non -co mmerc ial us e o nly 11. cameron j, worrall-carter l, riegel b, et al. testing a model of patient characteristics, psychologic status, and cognitive function as predictors of self-care in persons with chronic heart failure. heart & lung 2009;38:410–418. 12. riegel b, lee cs, dickson vv, et al. an update on the selfcare of heart failure index. j cardiovasc nurs 2009;24:485– 497. 13. maddison r, mhurchu c, jiang y, et al. international physical activity questionnaire (ipaq) and new zealand physical activity questionnaire (nzpaq). int j behavioral nutrition physical activity 2007;4:62. 14. van der wal mhl, jaarsma t, moser dk, et al. development and testing of the dutch heart failure knowledge scale. eur j cardiovasc nurs 2005;4:273–277. 15. prihatiningsih d, widaryati w. self-care behavior in heart failure patients: impact on cardiovascular health profile. jurnal keperawatan 2021;12:23–32. 16. bagheri –saweh mi, lotfi a, salawati ghasemi s. self-care behaviors and related factors in chronic heart failure patients. international journal of biomedicine and public health 2018;1:42–47. 17. lee ks, moser dk, dracup k. relationship between self-care and comprehensive understanding of heart failure and its signs and symptoms. eur j cardiovascular nurs 2018;17:496–504. 18. meng x, wang y, tang x, et al. self-management on heart failure: a meta-analysis. diabetes & metabolic syndrome: clinical research & reviews 2021;15:102176. 19. róin t, á lakjuni k, kyhl k, et al. knowledge about heart failure and self-care persists following outpatient programmea prospective cohort study from the faroe islands. int j circumpolar health 2019;78:1653139. 20. fetensa g, fekadu g, turi e, et al. self-care behaviour and associated factors among chronic heart failure clients on follow up at selected hospitals of wollega zones, ethiopia. int j afr nurs sci 2021;15:100355. 21. vellone e, fida r, ghezzi v, et al. patterns of self-care in adults with heart failure and their associations with sociodemographic and clinical characteristics, quality of life, and hospitalizations: a cluster analysis. j cardiovasc nurs 2017;32:180–189. 22. koirala b, dennison himmelfarb cr, budhathoki c, davidson pm. heart failure self-care, factors influencing selfcare and the relationship with health-related quality of life: a cross-sectional observational study. heliyon 2020;6:e03412. 23. lee cs, riegel b, driscoll a, et al. gender differences in heart failure self-care: a multinational cross-sectional study. int j nurs studies 2009;46:1485–1495. 24. delgado b, lopes i, mendes t, et al. self-care in heart failure inpatients: what is the role of gender and pathophysiological characteristics? a cross-sectional multicentre study. healthcare (basel) 2021;9:434. 25. nursita h, pratiwi a. peningkatan kualitas hidup pada pasien gagal jantung: a narrative review article (improved quality of life in heart failure patients: a narrative review article). jurnal berita ilmu keperawatan 2020;13:10–21. 26. lee cs, bidwell jt, paturzo m, et al. patterns of self-care and clinical events in a cohort of adults with heart failure: 1 year follow-up. heart lung: j acute critical care 2018;47:40–46. 27. meng x, wang y, tang x, et al. self-management on heart failure: a meta-analysis. diabetes metabol syndr 2021;15: 102176. article [healthcare in low-resource settings 2023; 11(s1):11179] [page 69] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11209 mother’s knowledge as a dominant factor for the success of exclusive breastfeeding in indonesia rinik eko kapti1,3 yuni sufyanti arief,2 nurona azizah3 1doctoral degree programs, faculty of nursing, universitas airlangga, surabaya, indonesia; 2faculty of nursing, universitas airlangga, surabaya, indonesia; 3faculty of health sciences, university of brawijaya, malang, indonesia abstract introduction: exclusive breastfeeding is one of the important indicators in achieving nutritional problems in children. unfortunately, only 1 in 2 babies are exclusively breastfed in indonesia. therefore, this study aims to examine the factors associated with exclusive breastfeeding in the country. design and methods: data were obtained from the indonesian family life survey (ifls), by using a cross-sectional design involving a total of 2,217 mothers. the independent variables include weaning food, knowledge, labor difficulties, postpartum visits, number of children, marital status, sex of children, and low birth weight (lbw), while the dependent variable include exclusive breastfeeding. subsequently, chi-square test and logistic regression were used to examine the relationship between exclusive breastfeeding and the related factors. results: the prevalence of exclusive breastfeeding in indonesia was 36.5%. bivariate analysis showed that the variables associated with exclusive breastfeeding were weaning feeding, knowledge, low birth weight, and difficulty in labor with p-values of 0.005, 0.000, 0.040, and 0.005, respectively. the most dominant variable for exclusive breastfeeding behavior is knowledge with a value of or = 1.85. conclusions: there is a significant relationship between knowledge of mothers, weaning food, and low birth weight with exclusive breastfeeding behavior. meanwhile, the main determinant among the variables is mother’s knowledge. therefore, health workers and community service cadres need to provide counseling about health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. introduction globally, only 36% of infants under six months of age are exclusively breastfed.1 in indonesia, only 1 in 2 infants under the age of 6 months are exclusively breastfed, meaning that almost half of all the country’s children do not get the food they need during the first two years of their life. another study showed that over 40% of infants are introduced to weaning foods before reaching 6 months, which often do not meet their nutritional needs.2 the percentage of infants aged less than 6 months who received exclusive breastfeeding in 2018 was 44.36%.3 in the first crucial months, breastfed children were six times more likely to survive than non-breastfed children. failure to exclusively breastfeed by six months of age and to initiate breastfeeding within the first hour contributed to the deaths of 800,000 children under the age of five.1 the risk of mortality from all causes was lower in infants who were exclusively breastfed for 0–5 months, than in those who were not. children aged 6–11 and 12– 23 months who were not breastfed had a 1.8 and 2.0-fold increased risk of death, respectively. the risk of dying from an infection is higher in non-breastfed infants aged 0–5 months than in breastfed ones and the risk is twice as high.4 exclusive breastfeeding reduces the prevalence of respiratory and digestive problems in infancy.2,5 also, it is associated with the incidence of pneumonia in toddlers (hidayah nurul 2017; wulandari 2018). for example, it has an effect of 34.70% on the incidence of pneumonia under the age of five.6,7 infants who are not exclusively breastfed have a higher risk of dying from diarrhea than those who are exclusively breastfed for 0-5 months.8 increasing breastfeeding rates globally were able to save the lives of over 820,000 children under 5 years of age each year and also prevent an additional 20,000 cases of breast cancer in women yearly.2 who recommends mothers around the world to exclusively breastfeed their babies for the first six months to achieve optimal growth, development, and health. exclusive breastfeeding provides benefits in the form of faster maternal weight loss after delivery, and delays in the return of menstrual periods. currently, no adverse effects on growth have been documented with exclusive breastfeeding for six months.9,10 exclusive breastfeeding is one of the indicators for achieving child nutrition problems which is part of the sustainable development goals (sdgs).11 the who has also set global targets to improve maternal, infant, and young child nutrition as well as monitoring the progress. one of the targets is to increase the rate of exclusive breastfeeding to at least 50% during the first 6 months.12 the findings revealed that the baby’s age, birth order, mother’s education, income, place of residence, and antenatal treatment frequently significantly impact the practice of exclusive breastfeeding. we identified similarities and differences in the components related to exclusive breastfeeding and demonstrated the significance of these factors in exclusive breastfeeding.13,14 article significance for public health mother's knowledge, weaning food, and low birth weight have a relationship with exclusive breastfeeding behavior in indonesia. among the listed variables, the main determinant is mother's knowledge. therefore, it is important for health workers to provide information that will motivate mothers to exclusively breastfeed. this paper describes the relationship between mother's knowledge, weaning food, low birth weight, and exclusive breastfeeding behavior in the country. [healthcare in low-resource settings 2023; 11(s1):11209] [page 129] non -co mmerc ial us e o nly meanwhile, research on exclusive breastfeeding in indonesia has been limited. policymakers must consider the findings to discover the reasons for the rise in exclusive breastfeeding. meanwhile, research on exclusive breastfeeding in indonesia is lacking. policymakers must study the results to find the causes linked to the growth in exclusive breastfeeding in indonesia. design and methods the design used was cross sectional and the data was obtained from the fifth indonesian family life survey (ifls) in 2014 which is open access on rand.org. ifls is a longitudinal survey conducted by research and development (rand) corporation in collaboration with research institutions such as survey meter, the demographic institute of universitas indonesia, and center for population and policy studies at gadjah mada university. the population were mothers who participated in ifls 5 in 2014 with a total of 50,148 respondents covering 13 provinces in indonesia, namely north sumatra, west sumatra, south sumatra, lampung, jakarta, west java, central java, special region of yogyakarta, east java, bali, west nusa tenggara, south kalimantan, and south sulawesi as well as west sulawesi, conducted from 2014 to 2015. the total population of children aged 060 months known as toddlers was 5,095 living in the country in 2014. after the number of samples was processed, only 2,217 children met the requirements. the dependent variable was exclusive breastfeeding which is based on the length of time the baby is breastfed, while the independent entails 8 variables, as follows: i) weaning food given for less than six months or more than six months; ii) knowledge, namely good and poor categories; iii) postpartum visits, which are divided into receiving postnatal visits or not; iv) infant birth weight, with categories of less than 2.7 or more than 2.7; v) difficulty in labor, namely categories of experiencing difficulties or not; vi) gender, which is divided into male or female; vii) the number of children with total of below 3 and above, or equal to 3; viii) the marital status of the mother, namely married or unmarried. the data obtained from ifls 5 were checked for completeness for each variable by using the stata 16 program, and data were cleaned up by analyzing the frequency of all variables. when missing data are found, they will be treated according to the inclusion criteria. women aged 15–49 years with newborns under oneyear-old and a history of having a baby with low birth weight (lbw) were included as inclusion criteria. when all data has been collected and the missing ones has been processed and cleaned, data coding is carried out according to the operational definition and objective criteria. for data collection, we used survey methods and documented observation. data analysis was performed using chi-square for univariate and bivariate, while logistic regression was used for multivariate analysis to see differences in each group of variables and assess the strength of the relationship (por and 95% ci). in order to see the effect of each covariate variable on the relationship between the independent and dependent variables, a stratification analysis was performed, which was also able to see the confounding variables and the modifying effect of the homogeneity test results. results and discussions a total of 809, representing 36.5% of 2,217 children under 5 years, were exclusively breastfed. these children were divided into boys and girls with the respective percentages of 48.5% and 51.5%. subsequently, 7.63% had a history of lbw and those who did not are 92.37%. infants with inappropriate weaning food were 60.67%, while 39.33% were adequate. of the mothers who took part in this survey, 30.99% had knowledge about exclusive breastfeeding and 69.01% had less knowledge. the majority of respondents who are married with more than 2 children represent 63.51%. 36.81% of mothers had a history of difficult delivery and 38.79% received postpartum visits. further details on the descriptive characteristics of the respondents are presented in table 1. in the bivariate analysis, most variables were significantly associated with exclusive breastfeeding. variables that have a relationship are weaning food, knowledge, lbw, and labor difficulties. while the other four including postpartum visits, gender, number of children and maternal status, were not associated with exclusive breastfeeding. the details of the bivariate analysis are presented in table 2. in the multivariate analysis, multiple logistic regression was used to analyze the dependent and independent variables as shown in table 3. the most dominant variables for exclusive breastfeeding behavior were knowledge followed by weaning foods and birth weight with a p value of 0.015 and 0.013, respectively. respondents with less knowledge had 1.8 times risk of exhibiting non-exclusive breastfeeding behavior after controlling through weaning food with a value of or = 1.25 and birth weight with or = 0.66. in the general population, 95% of people believe that knowledge is a factor that determines exclusive breastfeeding behavior with an interval ranging from 1.54 to 2.23. this study aims to analyze the determinants of exclusive breastfeeding in infants in indonesia. overall, only 36.49% of 2,217 respondents were exclusively breastfed. according to bps data from 2018, exclusive breastfeeding coverage in the country article table 1. socio-demographic characteristics of study participants (n = 2.217). variables n % breastfeeding exclusive 809 36.49 non exclusive 1408 3.51 weaning food appropritate 872 39.33 not appropriate 1345 0.67 knowledge good 687 30.99 poor 1530 69.01 low birth weight yes 169 7.62 no 2048 92.38 difficulty of labor yes 816 6.81 no 1401 63.19 postpartum visit yes 860 38.79 no 1357 1.21 gender female 1142 1.51 male 1075 8.49 number of children ≤2 612 27.60 >2 1605 2.40 marital status married 2176 98.15 unmarried 41 1.85 [page 130] [healthcare in low-resource settings 2023; 11(s1):11209] non -co mmerc ial us e o nly has increased, but it is still low at 44.36%.3 this result is consistent with the one conducted in ethiopia which showed that exclusive breastfeeding coverage was 44.2% and 56.1% in nigeria.15,16 although the who and unicef have recommended exclusive breastfeeding for the first 6 months, the rate of exclusive breastfeeding is still low. many factors influence exclusive breastfeeding, including a lack of knowledge, breastfeeding problems, poor families and social support, social norms, work, and health services.17 this study showed that mothers who have less knowledge about breastfeeding will have the opportunity to provide up to 1.85 to exclusive breastfeeding. unicef stated that every woman has the right to receive full information about breastfeeding to ensure the right decision is made for the babies (unicef, 2017). this helps to balance mothers’ perceptions of the benefits of breastfeeding with their practice.16 this is also supported by the results of previous studies which showed that knowledge is the most important determining factor in exclusive breastfeeding.18,19 karcz’s study also explained that knowledge is the main determinant of breastfeeding duration, while rapingah’s stated that knowledge and age are dominant factors in the practice of exclusive breastfeeding.20,21 furthermore, tambuanan’s 2021 survey of knowledge and exclusive breastfeeding in a hospital found that mothers with little knowledge were given the opportunity to exclusively breastfeed 2,556 times.18 knowledge is an influential factor in the success of exclusive breastfeeding. therefore, nurses need to develop and improve health promotion to increase mothers’ knowledge. the health promotion of exclusive breastfeeding behavior is very important and should be taught not only in the prenatal period but also in the postnatal period up to the second year of delivery.18 health promotion is expected to include a maternal support system based on the results of the study which found that father’s knowledge of exclusive breastfeeding (ebf) enhances mother’s knowledge by sharing information and offering the support mothers need.22 in indonesia, health workers need to develop and improve child health promotion facilities through discharge planning, to raise mothers’ awareness of exclusive breastfeeding and to develop infant program and cadres in posyandu. similarly, program activities and cadres need to be optimized as an important support and media to identify mothers who are struggling to exclusively breastfeed at home. mothers and babies need to be monitored through regular assessments by cadres and health workers during posyandu activities, and provide mothers with proper health education to enable them provide exclusive breastfeed. in this study, lbw was associated with exclusive breastfeed article table 2. socio-demographic characteristics of study participants (n = 2.217). variables exclusive breastfeeding x2 yes no n % n % weaning food 0.005 appropritate 349 15.74 523 23.59 not appropritate 460 20.75 885 39.92 knowledge 0.000 good 319 14.39 368 16.60 poor 490 22.10 1040 46.91 low birth weight 0.040 yes 74 3.34 95 4.29 no 735 33.15 1313 59.22 difficulty of labor 0.005 yes 268 12.09 548 24.72 no 541 24.40 860 38.79 postpartum visit 0.798 yes 311 14.03 549 24.76 no 498 22.46 859 38.75 gender 0.613 female 411 18.54 731 32.97 male 398 17.95 677 30.54 number of children 0.189 ≤2 210 9.47 402 18.13 >2 599 27.02 1006 45.38 marital status 0.718 married 300 13.53 875 39.47 unmarried 509 22.96 533 24.04 [healthcare in low-resource settings 2023; 11(s1):11209] [page 131] tabel 3. multivariate analysis of factors associated with exclusive breastfeeding among children in indonesia. variables odds ratio p>|z| [95% conf. interval] minimum maximum weaning food 1.25 0.015 1.04 1.49 knowledge 1.85 0.000 1.54 2.23 low birth weight 0.66 0.013 0.48 0.92 non -co mmerc ial us e o nly ing. additional findings from this study are that mothers with lbw babies have the option of exclusively breastfeeding up to 0.6. this result is not in line with the study of pineda (2011), stating that the baby factors including birth weight and gestational age, were not related to the mother’s breastfeeding behavior.23 however, the results showed that only 52% of low birth weight infants were effectively breastfed after discharge from the hospital and four weeks after lbw infants were home, 40% were still exclusively breastfed but 19% were replaced with formula milk.24 mothers who give early weaning food have an opportunity to give exclusive breastfeeding up to 1.25. lessa et al. indicated that the early introduction of solid foods was likely to shorten breastfeeding duration thus suggesting to delay solid foods until 6 months of age because it is important to support breastfeeding.25 based on paramita and purnomo (2015), one of the factors influencing exclusive breastfeeding is the introduction of weaning foods before the age of 6 months.26 interestingly, exclusive breastfeeding is also the most powerful indicator to check for the early introduction of solid foods.27 the who and unicef recommend an early start of breastfeeding within 1 hour after birth, exclusive breastfeeding for the first 6 months of life, and the introduction of solid foods that are nutritionally adequate and safe at the age of 6 months along with continued breastfeeding up to age 2 years or older. however, many babies and children are not optimally nourished. for example, in 2015–2020, only about 44% of infants aged 0–6 months worldwide were exclusively breastfed.28 exclusive breastfeeding has a positive effect on both mother and baby. mothers who do not exclusively breastfeed are 7.58 times more likely to experience postpartum depression (ppd) than mothers who exclusively breastfeed. this ppd is significantly higher in mothers with impaired exclusive breastfeeding and even get worse when there is increased stress and restricted social support.29 exclusive breastfeeding for 6 months is recommended for infants because it can protect against diarrhea and respiratory tract infections, reduce hospital admissions, and achieve growth.30 this study provides new information using secondary data from indonesia’s demographic year 2017 and health survey (idhs). it’s only that this study has limitations, such as still focusing on the mother’s understanding. family center care must be prioritized to improve children’s health. it is necessary to study the mother’s information and knowledge from the father’s side. so, for future research, focusing on the father’s side of expertise will bring new and essential information on whether it influences the effectiveness of exclusive breastfeeding in indonesia. conclusions mother’s knowledge, weaning food, and low birth weight has a significant relationship with exclusive breastfeeding behavior in indonesia. meanwhile, the most important determinant among the variables was the mother’s knowledge. therefore health workers and community service cadres need to provide counseling about the health, assistance, and motivation to mothers, thereby they will be able to properly provide exclusive breastfeeding. the result also motivates educational institutions and nursing students to further increase their creativity in the development of mother-friendly health promotion. further study is needed to identify the optimal factors for exclusive breastfeeding behavior by adding aspects from husband support. references 1. shetty p. indonesia’s breastfeeding challenge is echoed the world over. bull world health organ 2014;92:234–5. 2. who. world breastfeeding week: unicef and who call on the government and employers to support breastfeeding mothers in indonesia during covid-19. 2020. available from: https://www.who.int/indonesia/news/detail/03-08-2020world-breastfeeding-week-unicef-and-who-call-on-the-government-and-employers-to-support-breastfeeding-mothers-inindonesia-during-covid-19 3. bps. persentase bayi usia kurang dari 6 bulan yang mendapatkan asi eksklusif menurut provinsi (persen), 2018 article [page 132] [healthcare in low-resource settings 2023; 11(s1):11209] correspondence: rinik eko kapti, doctoral degree programs, faculty of nursing, universitas airlangga, jl. mulyorejo campus c unair, surabaya indonesia, 60115, e-mail: rinik.eko.kapti-2020@fkp.unair.ac.id key words: knowledge, exclusive breastfeeding, mother acknowledgments: the authors are grateful for the data provided by the indonesian family life survey (ifls) which helps to know about the important issues that occur regarding mother’s knowledge as a determinant of exclusive breastfeeding in indonesia. contributions: rek and ysa understand the ideas presented, and contributed to the study design, analysis of the results, and writing of the manuscript. all authors read and approved the final manuscript. conflict of interest: the author declares no conflict of interest. funding: this study did not receive a specific grant from any funding agency in the public, commercial, or not-for-profit sector. clinical trials: the ifls data used is publicly available, while the surveys and procedures were reviewed and approved by the institutional review board (irb) at rand corporation in the us and universitas gadjah mada (ugm) in indonesia. written informed consent was obtained from all participants before data collection began. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 18 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11209 doi:10.4081/hls.2023.11209 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly 2020. [percentage of infants age less than 6 months getting exclusive breastfeeding by province (percent), 2018-2020.] 2021. available from: https://www.bps.go.id/ indicator/30/1340/1/persentase-bayi-usia-kurang-dari-6-bulan-yangmendapatkan-asi-eksklusif-menurut-provinsi.html 4. sankar mj, sinha b, chowdhury r, et al. optimal breastfeeding practices and infant and child mortality: a systematic review and meta-analysis. acta paediatr int j paediatr 2015;104:3–13. 5. fisk cm, crozier sr, inskip hm, et al. breastfeeding and reported morbidity during infancy: findings from the southampton women’s survey. matern child nutr 2011;7:61– 70. 6. wulandari ra. the influence of exclusive breastfeeding toward the occurrence of childhood pneumonia in east java. j berk epidemiol 2018;6:236. 7. hidayah nurul. the correlation of sex and exclusive breastfeeding status with acute respiratory infection (ari) incidence among under-five children at the cempaka public health center banjarmasin. din kesehat 2017;8:330–5. 8. mazumder s, taneja s, dube b, et al. effect of community-initiated kangaroo mother care on survival of infants with low birthweight: a randomised controlled trial. lancet 2019;394:1724–36. 9. who. exclusive breastfeeding for six months best for babies everywhere. 2011. available from: https://apps.who.int/mediacentre/news/statements/2011/breastfeeding_20110115/en/inde x.html 10. ho c. optimal duration of exclusive breastfeeding. int j evid based healthc 2013;11:140–1. 11. unicef, bappenas. achieving the sdgs for children in indonesia: emerging findings for reaching the targets. indones minist natl dev plan united nations child fund 2019;288. 12. who. global targets 2025. 2021. available from: h t t p s : / / a p p s . w h o . i n t / n u t r i t i o n / g l o b a l t a r g e t 2025/en/index.html 13. rahman ma, khan mn, akter s, et al. determinants of exclusive breastfeeding practice in bangladesh: evidence from nationally representative survey data. plos one 2020;15:1– 14. 14. um s, chan yzc, tol b, et al. determinants of exclusive breastfeeding of infants under six months among cambodian mothers. j pregnancy 2020;2020. 15. elyas l, mekasha a, admasie a, et al. exclusive breastfeeding practice and associated factors among mothers attending private pediatric and child clinics, addis ababa, ethiopia: a cross-sectional study. int j pediatr 2017;2017:1– 9. 16. sholeye oo, abosede oa, salako aa. exclusive breastfeeding and its associated factors among mothers in sagamu, southwest nigeria. j heal sci 2015;5:25–31. 17. el-houfey aa, saad k. factors that exclusive breastfeeding. int nursing, midwife heal related cases 2018;4:16–28. 18. tambunan at, tanggulungan f, poppy r, et al. relationship between mothers’ knowledge and exclusive breastfeeding behavior in one private hospital in west indonesia. int j nurs heal serv 2021;4:1–8. 19. rosyid zn, sumarmi s. hubungan antara pengetahuan ibu dan imd dengan praktik asi eksklusif. [the relationship between mother’s knowledge and imd with exclusive breastfeeding practices.] amerta nutr 2017;1:406. 20. karcz k, lehman i, królak-olejnik b. the link between knowledge of the maternal diet and breastfeeding practices in mothers and health workers in poland. int breastfeed j 2021;1–15. 21. rapingah s, muhani n, besral, et al. determinants of exclusive breastfeeding practices of female healthcare workers in jakarta, indonesia. kesmas 2021;16:59–65. 22. ouyang yq, nasrin l. father’s knowledge, attitude and support to mother’s exclusive breastfeeding practices in bangladesh: a multi-group structural equations model analysis. healthcare 2021;9:276. 23. pineda rg. predictors of breastfeeding and breastmilk feeding among very low birth weight infants. breastfeed med 2011;6:15–9. 24. hill pd, ledbetter rj, kavanaugh kl. breastfeeding patterns of low-birth-weight infants after hospital discharge. j obstet gynecol neonatal nurs 1997;26:189–97. 25. lessa a, garcia al, emmett p, et al. does early introduction of solid feeding lead to early cessation of breastfeeding? matern child nutr 2020;16:1–9. 26. paramita a, pramono ms. the pattern and factor analysis of the breastfeeding duration in 2013. j ekol kesehat 2015;14:157–70. 27. kronborg h, foverskov e, væth m. predictors for early introduction of solid food among danish mothers and infants: an observational study. bmc pediatr 2014;14:1–10. 28. who. infant and young child feeding [internet]. 2021. available from: https://www.who.int/news-room/factsheets/detail/infant-and-young-child-feeding 29. islami mj, broidy l, baird k, et al. early exclusive breastfeeding cessation and postpartum depression: assessing the mediating and moderating role of maternal stress and social support. plos one 2021;16:1–19. 30. agrasada gv, ewald u, kylberg e, gustafsson j. exclusive breastfeeding of low birth weight infants for the first six months: infant morbidity and maternal and infant anthropometry. asia pac j clin nutr 2011;20:62–8. article [healthcare in low-resource settings 2023; 11(s1):11209] [page 133] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2022; 10:9829] [page 35] oxygen therapy using bain’s circuit as an alternate option for moderate covid-19 patients in resource-limited set-ups habib md reazaul karim department of anaesthesiology and critical care, all india institute of medical sciences raipur, india dear editor, coronavirus disease of 2019 (covid19) has been slowly engulfing society since december 2019. many parts of the world are facing the second and third waves of the pandemic. the virus is rapidly getting mutated, posing a significant challenge. oxygen therapy is required in most symptomatic patients, and most mild-to-moderate cases are managed by supportive therapy using a face mask. non-rebreathing facemask (nrbm) is frequently used as it can provide a higher fraction of inspired oxygen (fio2). however, it cannot deliver a positive endexpiratory pressure (peep). even the positive pressure generated inside the mask is nearly zero. on the other hand, covid-19 patients’ lung shows atelectasis and pathophysiology somewhat like acute respiratory distress syndrome (ards), yet with better lung compliances.1 the ability of peep to improve oxygenation in ards is well known. covid19 patients are also likely to be benefitted, and even relatively lower peep might be helpful from pathophysiological viewpoints. nrbm cannot produce peep. it can be solved to some extent by using bain’s circuit in place of nrbm. if connected with noninvasive ventilation (niv) mask, it can provide high fio2, peep, and minimal positive pressure during inspiration, mimicking continuous positive airway pressure (cpap) device. the expired gas outlet can also be connected to a viral filter to reduce the environmental contamination with the virus. the l-connector connecting the circuit with the mask (niv mask with harness) can also have a port for end-tidal carbon-di-oxide sampling when the monitoring facility is available. the arrangement is shown in schematic figure 1a. the proposed assembly will require a bain’s circuit, an niv mask with a harness, and a bacterio-viral filter. if end-tidal carbon dioxide (etco2) monitoring is planned, an ‘l’ connector with an etco2 sampling port or monitoring device can be connected between the patient end of the bain’s circuit and niv mask as shown in figure 1a and 1b. it is preferable to have a bain’s circuit whose adjustable peep valve has markings for the amount of pressure exerted. the filter needs to be connected to the gas exit outlet of the bain’s circuit. flow inflating devices like bain’s circuit are effective as indigenous cpap and have also been used to provide cpap.2,3 the fresh oxygen flow rate required to minimize the rebreathing in bain’s circuit is 10-15l/min (150-200ml/kg) for a 70kg person, which is similar to the requirement for nrbm to keep the bag inflated.4,5 the authors have also used the proposed device for managing postoperative respiratory failure in covid-19 recovered patients,9 as well as for transferring patients from covid-19 icu to step down facilities. the assembled device will also create a positive pressure zone outside and around the nasal cavity, which can mimic the favorable pressure niche created by a high-flow nasal cannula (hfnc) in the pharynx. the requirement of fresh gas flow in hfnc is also very high. it is imperative when many countries are facing acute crises for medical oxygen during this pandemic. the cost of hfnc is also reasonably higher, especially in the context of mass requirements. besides, the viral filter attachment is also not possible in hfnc. therefore, bain’s circuit can be a crucial armamentarium in supportive oxygen therapy for covid-19 patients in low resource set-ups. the device, however, has limitations. if the length of the circuit is increased, it can increase resistance and work of breathing to a minimal extent.5 additionally, this set of devices will be slightly costlier than nrbm. if the niv mask interface leaks, the fresh oxygen entering from the bedside-side outlet or cylinder might be inadequate to keep the bag inflated. further, accidental complete closure of the peep valve in the face of the air-tight interface might cause barotrauma. healthcare in low-resource settings 2022; volume 10:9829 correspondence: habib md reazaul karim, department of anaesthesiology and critical care, faculty room a001, block-a, ground floor, all india institute of medical sciences, raipur, ge road, tatibandh, 492099 india. tel.: +91.9835521686. e-mail: drhabibkarim@gmail.com key words: breathing circuit; oxygenation; covid-19; facemask. conflicts of interest: the author declare no conflicts of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: consent for publication of the patients' image is taken from the patient. no other informed consent is applicable for this manuscript. received for publication: 25 april 2021. revision received: 14 november 2021. accepted for publication: 10 march 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:9829 doi:10.4081/hls.2022.9829 figure 1. schematic representation of bain’s circuit arrangement to be used for covid19 patients and 1b showing the attachment connected to a postoperative patient with respiratory failure. non -co mmerc ial us e o nly [page 36] [healthcare in low-resource settings 2022; 10:9829] references 1. grasselli g, tonetti t, protti a, et al. pathophysiology of covid-19-associated acute respiratory distress syndrome: a multicentre prospective observational study. lancet respir med 2020;8:1201-8. 2. anitha gf, velmurugan l, sangareddi s, et al. effectiveness of flow inflating device in providing continuous positive airway pressure critically ill children in limited-resource settings: a prospective observational study. indian j crit care med 2016;20:441-7. 3. scheller ms, varvel jr. cpap oxygenation during one-lung ventilation using a bain circuit. anesthesiology 1987;66:708-9. 4. conway cm. anaesthetic breathing systems. br j anaesth 1985;57:649-57. 5. kaul tk, mittal g. mapleson's breathing systems. indian j anaesth 2013;57:507-15. 6. kumari s, karim hmr, arora p, nadirsha a. bain’s circuit as continuous positive airway pressure device in a postoperative covid-19 associated mucormycosis patient with type-1 respiratory failure: a case report. discoveries reports 2021;4:e22. letter non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2018; 6:7464] [page 27] impoverishing effect of household healthcare expenditure in semi-rural communities in yenagoa, nigeria adedotun daniel adesina, daprim samuel ogaji department of preventive and social medicine, university of port harcourt, nigeria abstract inequity in the payment mechanism for healthcare systematically affects poorer households more than the rich. this article examines the impoverishing effect of healthcare expenditure on households in yenagoa. data was obtained from a crosssectional survey of households in 2 communities in yenagoa selected by simple random sampling. a pretested, structured, interviewer-administered questionnaire was used to obtain information on household (hh) income, general expenditures and financing for healthcare. two international poverty lines designed by world bank were employed to classify households as poor, extremely poor and to determine the impoverishing effects of households’ healthcare expenditures. responses were received from 525 hhs with 9.2% of hhs falling below poverty line, another 9% pushed deeper into poverty after healthcare spending. a 12.3% and 16% increase in the poverty and extreme poverty gaps respectively were attributable to health payment. a significant percentage of households who were non-poor were pushed into poverty after healthcare spending. there is need for increased public spending and implementation of innovative pre-payment mechanisms and social insurance that assures financialrisk protection and equity in health financing in yenagoa. introduction inequities in health financing systematically place households (hhs), especially the poor ones, who are already socially disadvantaged at further disadvantage with respect to their health. hence, health financing options which ensure achievement of the core objectives of ‘goodness’ and ‘fairness’ of health systems should be the focus of policy makers and stakeholders in developing equitable distribution of qualitative healthcare goods and services. however, many health systems especially in developing countries are mainly financed privately through out-of-pocket payments for healthcare at the point of access.1 the direct out-of-pocket (oop) payment for health services is an inequitable way to finance a health system as it places great financial burden on households,1 excludes financial solidarity2 and could compel many households to forgo basic needs such as education, food, and housing in order to pay for healthcare.2-4 the usual consequence is that they suffer financial catastrophe or even impoverishment while seeking healthcare. they may also totally avoid or delay to seek necessary healthcare where the cost is perceived to exceed their ability to pay.3-5 nigeria, like many lower middle-income countries (lmic), relies on oop payments for financing health services. fund from private sources is responsible for 75% of total expenditure on health (the) and 90% of this is oop payments.6,7 this payment modality prevent people from seeking or continuing care, while some who do seek care incur catastrophic financial burdens that push them into poverty.8 the ensuing vicious cycle of poverty further magnifies the need for healthcare while shrinking the capacity of household to pay for it.9 household spending on health in settings like nigeria, can also disrupt their budget, making it impossible to meet some essential expenditure in the home.10-16 catastrophic health expenditure which occurs when healthcare expenditures exceed pre-defined proportions of household income and/or non-food expenditure does not completely demonstrate the extent of hardship bore by household after such expenses.11-13,17,18 the concept of impoverishment after healthcare spending paints a clearer picture of this financial burden as it demonstrates how expenditure on healthcare could push households into poverty or further down the poverty line.19 a study done in kenya reported that 3.5% of households and 4% of households were impoverished by health spending in 2003 and 2007 respectively. outside the continent of africa, study done in brazil also revealed an increasing trend like in kenya as poverty headcount increased from 6.8% in 2002/2003 to 11.6% in 2008/2009.15 though a multifaceted social menace, poverty can be measured by the poverty line which defines a monetary threshold below which it becomes difficult for individuals or households to afford basic needs. poverty lines are commonly defined in relation to average household subsistence spending or ‘food share’20 and household per capita income. the world bank had developed the international poverty lines using per capita income of households, adjusted for purchasing power parity. the most recent thresholds are us$1.9 per capita per day and us$3.1 per capita per day for extreme poverty and poverty respectively.9,11,15 a non-poor household that becomes poor after paying for healthcare is said to be impoverished by such health expenditures with reference to any of the defined poverty lines.1215,20 there is a paucity of studies that quantified the impoverishing effect of health spending on households in this setting. this study aims to bridge this gap by investigat healthcare in low-resource settings 2018; volume 6:7464 correspondence: adedotun daniel adesina, department of preventive and social medicine, university of port harcourt, nigerian law school, yenagoa campus, pmb 60, yenagoa, bayelsa state, nigeria. tel.: +234.8034469945 e-mail: adeshinadedotun@yahoo.com key words: out-of-pocket; impoverishing effect; poverty line; healthcare financing; yenagoa. acknowledgements: the authors are grateful to johnson igoniderigha and ipusi ikiobho staff of bayelsa geographic information system who assisted them in identifying the geographical zones of yenagoa and assisted in data collection in conjunction with ibarakumo sokare and amani samuel. they are also grateful to the study communities for agreeing to participate in the study. finally, they thank adesina ileola, emudiaga-ohwerhi, mabel, and diete-spiff kaine for their contributions to the project design and overall management of the study. contributions: daa was involved in the conceptualization and design of the study, supervised data collection, data processing and analysis and the initial write up of the manuscript; dso was involved in the conceptualization and design of the study and the study instrument; he reviewed the data processing and analysis and finally reviewed the manuscript. both authors approved the final manuscript for publication. conflict of interest: the authors declare no potential conflict of interest. funding: none. received for publication: 5 april 2018. revision received: 8 july 2018. accepted for publication: 30 july 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright a.d. adesina and d.s. ogaji, 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7464 doi:10.4081/hls.2018.7464 non -co mmerc ial us e o nly ing the incidence and depth of poverty due to healthcare spending among households in yenagoa where oop mechanism of payment is the predominant payment method for healthcare. materials and methods study setting the study was conducted in yenagoa, one of the traditional homes of the ijaw people and the capital of bayelsa state. it is located on the banks of epie and ekole creeks, major tributaries of the nun river between 4o 47’ 15” and 5o 11’ 55” north of the equator and long. 6o 07’ 35” and 6o 24’ 00” east of the greenwich meridian.21,22 yenagoa is a semi-rural settlement made up of 21 communities linearly arranged along both sides of the mbiamayenagoa road22 inhabited by people who engage in fishing, farming, palm oil production, palm wine tapping, local gin making, lumbering, craving and weaving. communities in yenagoa are organized as compounds with representative family heads.23 yenagoa has at least one primary health care centre in each of its ward and major communities. it is also served by two tertiary health institutions, a number of private hospitals/clinics, patent medicine dealers, and a wide range of non-formal healthcare providers (including traditional medicine practitioners). study design the study is a cross-sectional survey of households in two randomly selected communities in yenagoa (akenfa and kpansia). sampling the 2 study communities were selected from the existing 21 communities by simple random sampling. households were recruitment with the help of the bayelsa geographic information system (bgis). the three geographical zones of these 2 communities were demarcated and zones 2 and 3 in kpansia and akenfa communities respectively were chosen for the study. all roads in the 2 selected zones were identified as clusters from which houses were chosen by systematic random sampling, using the new bgis numbering system. the interviews were conducted in households selected by simple random sampling (balloting) from the chosen houses. the number of households needed for this study was calculated using the estimation formula for calculating the required sample size for household survey (nh)which is suitable for international use given by the department of economic and social affairs, statistics division, united nations:24 eq. 1 where nh is the parameter to be calculated and is the sample size in terms of number of households to be selected; z is the statistic that defines the level of confidence desired; r is an estimate of a key indicator to be measured by the survey; f is the sample design effect, deff, assumed to be 2.0 (default value); k is a multiplier to account for the anticipated rate of non-response; p is the proportion of the total population accounted for by the target population and upon which the parameter, r, is based; n is the average household size (number of persons per household); e is the margin of error to be allowed. data collection data was collected by trained data collectors over a period of 5 weeks in july and august 2017 using an extensive questionnaire adapted from previous studies.7,12,25,26 the questionnaire investigated household sociodemographic profile, household income, total consumption expenditure, healthcare expenditure and household assets. the study considered: household income included all earnings, welfare package or financial benefits accruing to the household from all members of the household not just the income of household head. household total consumption expenditure to include spending on health, food and non-food items like rents, transportation, school fees, cable television and mobile phone subscription bills, fuel for generator, clothing, religious contributions and expenses at social events. household healthcare expenditure includes expenditures on drug and medicines, consultation fees, hospital bed charges, transport charges to the treatment facilities and daily living cost, including food and lodging for the purpose of caring for the ailing household member. it also included expenditure made on self-medication for minor illnesses and other services sought from alternative/traditional medical practitioners (e.g. tbas, tbss and spiritual healing homes). the study explicitly explored healthcare payments during episodes of chronic illnesses, hospitalizations, childbirths in the preceding 12-month period (july 2016 – june 2017) and minor illnesses over 4-week period. chronic illness was defined as a condition that is long-lasting (e.g., more than 6 weeks), in many cases lifelong, which needs to be managed on a long-term basis.27 minor illnesses were considered as nonsevere health conditions of less than 6-week duration for which affected household members were treated on outpatient basis. hospitalization care were similarly considered as in-patient care received by household members either in the formal health sector or with the alternative/traditional health practitioner.26 the study instrument was pre-tested among 30 households in yenegwe, a small community on the outskirt of yenagoa. the results obtained were used to improve the different aspects of the questionnaire. the pattern of some of the questions, the arrangement of the sections and the coding of some responses were revised after the pre-test. data analysis data generated from the field was directly entered into ibm spss 22.0 version which was also used for the analysis. analyses were done to uncover the demographics, earnings and expenditures of the households. data was presented as frequency distribution tables and descriptive statistics like means, standard deviation and range were calculated. a principal component analysis was done to group household into different socioeconomic groups. we estimated household impoverishment by calculating poverty estimates using international poverty and extreme poverty lines of n1,095 (us$3) and n730 (us$2) per person per day respectively before and after households made healthcare payments.14 the calculated estimates are the poverty headcount, poverty gap and the normalized poverty gap before and after households made health expenditures. these poverty estimates were operationalised as follows: the poverty headcount represented the percentage of households living below the defined poverty lines.2,5,12,15 the poverty gap represented the mean deficit from the poverty line among the study population. it is the average amount by which resources fall short of the defined poverty line.2,5,15 the normalized poverty gap was computed by dividing the estimated poverty gap by the defined poverty line. this is useful for international comparisons.2,5,15 all financial estimates were made in naira which is the nigerian currency (conversion: us$1 = 365 naira). article [page 28] [healthcare in low-resource settings 2018; 6:7464] non -co mmerc ial us e o nly the difference between the poverty estimates before and after healthcare expenditure represented the impoverishing effect of health payment.28 thus the differences in poverty headcounts, poverty gaps and normalized poverty gaps before and after health payment represents the impoverishment attributable to health spending. ethics and permission ethical approval was obtained from the university of port harcourt research ethics committee. the standard protocol for community entrance was applied and data was obtained from respondents only after the study objectives were explained and a written consent obtained from them. results sociodemographic profile of household responses were received from 525 households of which majority were headed by males (77%), had married/cohabiting partners (70.7%) and over 90% of household heads had post-primary education (table 1). in total, two thousand five and twentyeight (2,528) persons were studied in the five hundred and twenty-five (525) households with a median household size of 5. about 17% of households made health expenditures related to childbirth while others did same when they sought care for long-term health condition (16.2%) and hospitalization (13%) (table 2). household income, total consumption expenditure and health expenditure table 3 shows that the household mean monthly income from all sources is n160, 785 with a high level of variability (sd n148, 871). the mean total expenditure on consumption in the study was almost n150, 000 (sd n128, 087) while healthcare gulped on the average n19,520 monthly from the households’ income, this corresponds to a mean percentage of 15.9% of household income spent on health. impoverishing effect of healthcare payment the mean household income per capita per day was estimated as n1, 220 (sd = 1,073; se = 47). this estimate reduced to n1, 038 after health spending was discounted from household total income. the proportion of households (poverty headcount) whose members live on less than the poverty line of n1,095 (us$3) per day was 58.7% and 67.9% before and after discounting household income by household health expenditure respectively, increasing the prevalence of poverty by 9.2% (table 4). the results also show that 9% of poor households were further pushed deeper into extreme poverty by health payment. other impoverishing impact attributable to health spending are presented in table 4. discussion the study demonstrated the impoverishing effect of healthcare expenditure on households in yenagoa. it showed that a substantial proportion of households are living on the margin of poverty. almost 10% of households who were hitherto non-poor were pushed below the poverty line and another 9% who were poor were further pushed deeper into extreme poverty by healthcare expenditure. a 12.3% increase in the poverty gap and 16% increase in the extreme poverty gap were attributable to health payment. the average per capita deficit of n480 suffered by households without healthcare spending increased to approximately n540 after accounting for health spending. studies done in india, kenya and brazil, reported 3.3%, 2.7% and 2.6% increase in poverty headcount respectively article table 1. sociodemographic of household heads. characteristics frequency (n =525) percentage (%) sex male 404 77.0 female 121 23.0 age of household heads (in years) 18 24 9 1.7 25 34 98 18.7 35 44 197 37.5 45 54 120 22.9 55 64 48 9.1 65 and above 53 10.1 marital status single 77 14.6 married 371 70.7 divorced/separated 51 9.7 widowed 26 5.0 educational status no formal education 9 1.7 primary education 35 6.7 secondary education 158 30.1 post-secondary education 323 61.5 occupation unemployed 14 2.7 student/apprentice 18 3.4 farming/fishing 27 5.1 company worker/artisan 97 18.5 civil servants 181 34.5 business owner/ contractor 127 24.2 professionals 32 6.1 pensioner 29 5.5 socioeconomic status (n = 475) q1 (poor) 150 31.6 q2 (middle) 273 57.5 q3 (wealthy) 40 8.4 q4 (wealthiest) 12 2.5 household assets (ownership) radio 300 57.3 television 508 96.9 fridge 449 85.7 car 173 33.0 phone 519 99.0 house 213 40.7 stocks/equities 40 7.6 [healthcare in low-resource settings 2018; 6:7464] [page 29] non -co mmerc ial us e o nly after health expenditures.15,29,30 the analysis of household income and expenditure from 11 countries in asia showed an increase of 3.8% and 3.6% in extreme poverty and poverty headcounts respectively after household health spending deductions in bangladesh which had the most significant proportional variation in the study.4 our finding shows an increase of approximately 9% in both extreme poverty and poverty headcounts which is higher than these quoted percentages from india, kenya, brazil and bangladesh. however, a direct comparison of the estimates from different studies and countries can be misleading because the different methods that might have been employed in constituting health expenditure and the cutoff to define poverty vary in time and place. nonetheless, all these studies showed that healthcare spending especially through oop mechanism have an impoverishing effect on households. the high proportion of households impoverished in yenagoa, bayelsa state due to healthcare spending provides additional support for the recently established bayelsa health insurance scheme (bhis). it is expected that stakeholders would galvanize efforts towards the success of this mandatory social health insurance scheme in the state. however, there are other important considerations which the operators would need to consider. notable among these are the provisions for funding premiums for the poor, near poor and other vulnerable groups as contributory mechanisms alone will not ensure universal health coverage in situations where the population is largely poor and/or in the informal sector.14,31 it is pertinent to note that from the multi-country study involving 11 asian countries, indonesia had the lowest incidence of impoverished households attributable to healthcare payments.4 this arose from the country’s ability to protect poor households from high healthcare cost through targeted exemptions with the use of a health card.2 even in developed setting like the uk where hospital services are free at the point of access to all, similar exemptions from co-payment exist for prescribed drugs, dental treatment and eyesight examination for vulnerable population including those with long-term conditions.32 indeed, there are further lessons to learn from the scenario in the uk32 as 16% and 13% of households in yenagoa had at least a member living with at least one long-term condition or hospitalized in the last one year respectively. the enormous financial burden associated with these events can be article table 4. impoverishment estimates before and after health expenditure. before discounting after discounting difference (absolute) difference health payment (1) health payment (2) (3)= (2) – (1) (relative)[(3)/(1)*100] assessment using the $3.00 (1,095 naira) capita/day poverty line poverty headcount (%) 58.7 67.9 9.2 15.7 poverty gap (naira) 482.4 541.6 59.2 12.3 normalized poverty gap (%) 44.1 49.5 5.4 12.2 assessment using the $2.00 (730 naira) capita/day extreme poverty line poverty headcount (%) 37.8 46.8 9.0 23.8 poverty gap (naira) 280.2 324.9 44.7 16.0 normalized poverty gap (%) 38.4 44.5 6.1 15.9 table 2. morbidity pattern of households. characteristics frequency percent (%) morbidity pattern in households (n = 525) hhs with members having long term health condition 85 16.2 hhs with members hospitalized 68 13.0 hhs with members that had minor illness 265 50.5 hhs with childbirth 87 16.6 hhs with nonspecific medical conditions 169 32.2 hhs without health expenditure in last 1 year 115 22.0 table 3. household income, total consumption expenditure and healthcare expenditure. variable mean value (in naira) standard deviation (in naira) range hh mean monthly income primary income 150,970 140,079 (10,000 – 750,000) collective income (all sources) 160,785 148,871 (10,000 – 1,010,000) hh mean monthly expenditure total consumption expenditure 149,597 128,087 (12,000 – 771,925) food expenditure 60,900 32,625 (7,000 – 195,300) non-food expenditure 73,729 80,391 (3,450 – 550,000) total healthcare expenditure 19,510 44,899 (0 – 683,330) breakdown of hh mean health care expenditure long-term medical condition 4,515 15, 475 (0 – 200,000) minor illness 8,940 3,709 (0 – 35,000) childbirth 3,150 6,980 (0 – 46,000) hospitalization 6,770 28,630 (0 – 333,330) non-specific health payments 3,065 7,278 (0 – 86,000) [page 30] [healthcare in low-resource settings 2018; 6:7464] non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:7464] [page 31] ameliorated with expanded funding options for public health services that can guarantee improved access to hospital care for all and exemption of poorer households from all co-payments as part of a broader social security system. although the relative increase of 15.7% and 12.3% in the headcount and depth of poverty respectively are worrisome, this may still represent an underestimation of the impoverishing effect of healthcare cost on households in yenagoa as indirect costs and lost earnings by households with sick members were not accounted for in this study. like the kenyan study,18 underestimation could also arise from the 22% of households that reported zero spending on healthcare in the one-year recall period. the zero spending may reflect non-recall or denial of past illness episodes which are often given negative connotations or because they had completely forgone care due to lack of resources, not necessarily because they do not need healthcare. interestingly, while impoverishment as a result of health expenditures occurs in all countries irrespective of income levels, its prevalence is higher in countries which depend predominantly on oop payment mechanisms like nigeria.6,33,34 a quick recommendation would be urging all leaders in africa to increase public spending on health to at least achieve the target of 15% endorsed at the abuja declaration.35 this would appear difficult in view of other formidable challenges, dwindling public revenue and lack of political will in these countries. however, widening the sources of funding may just well be the way out. in this regard, a range of innovative prepayment methods including the national health insurance scheme (nhis) should be introduced, strengthened and expanded to achieve national coverage. although this community-based study quantified and deduced the impoverishing effect of healthcare expenditure, its limitations arise from the fact that only the total oop expenditures was reported without categorizing them into healthcare expenditure subheads like fees for drug, consultation, investigation, transportation, accommodation as was done in similar studies.33-34 this categorization would have helped identified the specific spending that influenced household impoverishment the most in our setting. furthermore, applying a longitudinal approach is more apt and reliable in studying expenditures and their impact on household impoverishment. the paucity of longitudinal data on the subject may not be unrelated to the difficulties in implementing such research protocols, hence researchers often resort to cross sectional designs.2,11,13,15,18,33-34,36,37 despite these limitations, findings from this study would be a useful guide in the on-going implementation of the state-wide health financing model that would minimize systematic disparities while ensuring the achievement of universal health coverage for the population. conclusions a significant percentage of households who are marginally non-poor were pushed into poverty because of healthcare expenditure. there is need for increased public spending on healthcare, implementation of innovative and progressive pre-payment mechanisms as well as exemption from payment by vulnerable households that would assure financial risk protection, guarantee equity in health financing and universal coverage for households in yenagoa, bayelsa state. references 1. world health organization. the world health report 2000: health systems: improving performance. world health organization; 2000. 2. kimani dn, mugo mg, kioko um. catastrophic health expenditures and impoverishment in kenya. esj. 2016;12:434-52. 3. baeza c, packard t. beyond survival: protecting households from health shocks in latin america. stanford university press; 2006. 4. van doorslaer e, o'donnell o, rannaneliya rp, et al. effect of payments for health care on poverty estimates in 11 countries in asia: an analysis of household survey data. lancet 2006;368:1357-64. 5. wagstaff a, doorslaer ev. catastrophe and impoverishment in paying for health care: with applications to vietnam 1993–1998. health econ 2003;12:921-33. 6. world health organization. world health statistics 2015. world health organization; 2015. 7. onwujekwe oe, uzochukwu bs, obikeze en, et al. investigating determinants of out-of-pocket spending and strategies for coping with payments for healthcare in southeast nigeria. bmc health serv res 2010;10:67. 8. xu k, evans db, carrin g, et al. protecting households from catastrophic health spending. health affairs 2007;26:972-83. 9. world bank group. world development report-a better investment climate for everyone; 2005. available from: siteresources.worldbank.org/intwdr 2005/resources/complete_report.pdf 10. su tt, kouyaté b, flessa s. catastrophic household expenditure for health care in a low-income society: a study from nouna district, burkina faso. bull world health org 2006;84:21-7. 11. rashad as, sharaf mf. catastrophic economic consequences of healthcare payments: effects on poverty estimates in egypt, jordan, and palestine. economies 2015;3:216-34. 12. xu k, evans db, kawabata k, et al. household catastrophic health expenditure: a multicountry analysis. lancet 2003;362:111-7. 13. mchenga m, chirwa gc, chiwaula ls. impoverishing effects of catastrophic health expenditures in malawi. int j equity health 2017;16:25. 14. hoang vm, oh j, tran ta, et al. patterns of health expenditures and financial protections in vietnam 19922012. j korean med sci 2015;30:s1348. 15. boing ac, bertoldi ad, posenato lg, peres kg. the influence of health expenditures on household impoverishment in brazil. rev saude publ 2014;48:797-807. 16. elgazzar h, raad f, arfa c, et al. who pays? out-of-pocket health spending and equity implications in the middle east and north africa. 2010 health, nutrition and population (hnp) discussion paper. washington dc: the world bank; 2010. 17. kusi a, hansen ks, asante fa, enemark u. does the national health insurance scheme provide financial protection to households in ghana? bmc health serv res 2015;15:331. 18. buigut s, ettarh r, amendah dd. catastrophic health expenditure and its determinants in kenya slum communities. int j equity health 2015;14:46. 19. wagstaff a. measuring financial protection in health. world bank, washington, dc; development research group. policy research working paper# wps 2008;4554. 20. xu k, world health organization. distribution of health payments and catastrophic expenditures methodology. discussion paper no. 2. hsf, world health organization; 2005. 21. koinyan aa, nwankwoala ho, eludoyin os. water resources utiliza article non -co mmerc ial us e o nly [page 32] [healthcare in low-resource settings 2018; 6:7464] tion in yenagoa, central niger delta: environmental and health implications. int j water res environ engin 2013;5:177-86. 22. iyorakpo j. impact of rapid urbanization on environmental quality in yenagoa metropolis, bayelsa statenigeria. esj 2015;11:255-68. 23. national population commission abuja, nigeria. 2006 housing population census: population on distribution by age and sex: state and local government area, priority table. national population commission 2010;4:54-8. 24. department of economic and social affairs, statistics division, united nations. designing household survey samples: practical guidelines. studies in methods series f no.98 new york, 2005. pp 44-46. 25. musoke d, boynton p, butler c, musoke mb. health seeking behaviour and challenges in utilising health facilities in wakiso district, uganda. afr health sci 2014;14:1046-55. 26. mondal s, kanjilal b, peters dh, lucas h. catastrophic out-of-pocket payment for health care and its impact on households: experience from west bengal, india. future health syst innov equity 2010. available from: http://www.chronicpoverty.org/uploads /publication_files/mondal_et_al_health. pdf 27. choi jw, choi jw, kim jh, et al. association between chronic disease and catastrophic health expenditure in korea. bmc health serv res 2015;15:26. 28. berki se. a look at catastrophic medical expenses and the poor. health affairs 1986;5:138-45. 29. garg cc, karan ak. reducing out-ofpocket expenditures to reduce poverty: a disaggregated analysis at rural-urban and state level in india. health policy plann 2008;24:116-28. 30. chuma j, maina t. catastrophic health care spending and impoverishment in kenya. bmc health serv res 2012;12:413. 31. somanathan a, tandon a, dao hl, et al. moving toward universal coverage of social health insurance in vietnam: assessment and options. world bank; 2014. 32. world health organization. world health report, 2010: health systems financing the path to universal coverage. world health organization; 2010. 33. ogaji ds, nwi-ue lb, agalah hn, et al. impact and contributors to cost of managing long term conditions in a university hospital in nigeria. j commun med primary health care 2015;27:3040. 34. ogaji ds, mark oc, oghenetega ep, et al. cost burden for accessing paediatric emergency services at a tertiary health facility. niger health j 2015;15:10310. 35. birch s. health care charges: lessons from the uk. health policy 1989;13:145-57. 36. barasa ew, maina t, ravishankar n. assessing the impoverishing effects, and factors associated with the incidence of catastrophic health care payments in kenya. int j equity health 2017;16:31. 37. levie a, xu k. coping with out-ofpocket health payments: empirical evidence from 15 african countries. bull world health org 2008;86:849-56c. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11747 the influence of religious well-being on the resilience of family spirituality during the covid-19 pandemic yoyok bekti prasetyo,1 faridi faridi,2 nur lailatul masruroh,1 nur melizza,1 sita afkarina mutmainnah3 1department of community health nursing, faculty of health science, universitas muhammadiyah malang, malang; 2department of islamic religion, faculty of islamic religion, universitas muhammadiyah malang, malang; 3student of nursing science, faculty of health science, universitas muhammadiyah malang, malang, indonesia abstract religious or spiritual well-being has a significant influence on family resilience, particularly in the spiritual aspect when dealing with changes or crises. the covid-19 pandemic represents a significant change and crisis that can potentially impact religiosity and affect family resilience in spirituality. this study aimed to analyze the impact of religious well-being on family resilience in terms of family spirituality during the covid-19 pandemic. this was a descriptive study, utilizing a cross-sectional survey approach. a total of 243 respondents were recruited for this research using accidental sampling technique. data collection was conducted through questionnaires. data analysis involved binary logistic regression and multivariate logistic regression, with a 95% degree of freedom and a standard error of 0.05. the main finding of this study indicates that religious well-being (p=0.000) significantly influences family resilience in family spirituality. families with sufficient religious well-being are four times more likely to exhibit resilience in family spirituality compared to families with inadequate religious well-being (or: 3.807; 95% ci: 2.2306.498). the family resilience in family spirituality is strongly influenced by the factor of religious well-being. strengthening the community with a religious approach is essential to bolster the family’s ability to cope with the challenges posed by the pandemic. introduction the high transmission and rapid spread of the covid-19 disease pose a significant threat to communities, affecting people’s health indiscriminately.1–3 in september 2021, there were 230,326,827 new cases reported worldwide, resulting in 4,722,924 deaths due to covid-19. unsurprisingly, the fear of covid-19 has a profound impact on people’s well-being.4 this fear can significantly affect mental health and overall wellbeing.5–8 previous research has revealed alarming statistics, indicating that during the pandemic, the prevalence of depression was at 26.1%, anxiety at 33.2%, and stress at 5.8%.9–12 furthermore, the implementation of social distancing and self-isolation regulations in many countries worldwide has led to significant societal changes and has given rise to various mental health issues, including anxiety, fear, sadness, feelings of worry, impulsive behavior, and difficulty in concentration. however, a previous study has suggested that spiritual beliefs can help reduce fear and anxiety, providing individuals with a sense of security.13 religious well-being represents a spiritual expression through which an individual connects with themselves, god, society, and the environment. it is typically measured within the dimensions of existential and religious well-being.14–16 this form of well-being has a notable impact on family resilience, particularly in the spircorrespondence: nur melizza, department of community health nursing, faculty of health science, universitas muhammadiyah malang, malang, indonesia. e-mail: melizza@umm.ac.id key words: covid-19; family spirituality; resilience; religious wellbeing. contributions: ybp, conceptual, study design, analysis, data interpretation, and overall guidance; ff, consultant in the field of religious and conceptual research frameworks; nlm, supervision from research conception to final approval of the proposed version; nm, compilation of articles, overall guidance, and facilitation in article revision for content accuracy, sam, data collection, article writing under the supervision of all authors. conflict of interest: no potential conflict of interest was reported by the authors. ethics approval and consent to participate: this study received ethical approval from the health research ethics commission of the university of muhammadiyah malang with protocol number e.5.a/007/kepkumm/i/2022. participants provided written consent for participation before data collection. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from productive innovative research funding/riset inovatif produktif (rispro) from the ministry of finance's education fund management institute with contract number 166/e4.1/ ak.04.ra/2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: the authors would like to thank the indonesian ministry of education, culture, research and technology which has provided funding for this research. the researcher also thanks the directorate of research and community service, the universitas muhammadiyah malang, which has provided administrative and policy assistance in this study. received: 11 september 2023. accepted: 18 october 2023. early access: 9 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11747 doi:10.4081/hls.2023.11747 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11747] [page 77] non -co mmerc ial us e o nly itual aspect, enabling families to cope with changes and crises effectively.17 the advent of the covid-19 pandemic presented a significant crisis, potentially challenging religiosity and influencing family resilience in the spiritual domain.18 family resilience, in essence, signifies the strength to endure and recover from adversity, necessitating constructive adaptation.19 the covid-19 pandemic, marked by elevated levels of fear and anxiety, has prompted significant lifestyle changes, including alterations in religious beliefs and behaviors.20 resilience during a pandemic can reduce anxiety levels.21 the results of a study conducted in italy indicated that participants perceived lower levels of spiritual well-being and mental health than in pre-pandemic situations with significant gender differences.22 a low level of spirituality will result in psychological impacts such as mental disorders (adjustment disorder or stress reactions that result in depression) (80.2%) and the remaining 19.8% only have a low impact.22 besides that, world health organization (who) also explains practical considerations and recommendations for religious leaders that increase spirituality and apply it in daily life during the co-19 pandemic to provide greater resilience to families and society in general.23 furthermore, a low level of spiritual well-being is related to a decreased life satisfaction level and a disturbing sense of meaning and purpose in life experienced by the community due to the covid-19 pandemic.24,25 this can be overcome by strengthening spiritual resilience.26–28 spiritual resilience is different from other forms of resilience, spiritual resilience can strengthen and empower resilience that is manifested in other bio-psychosocial emotional forms.26 spirituality is an effective factor for dealing with stress and anxiety related to covid-19.19,20,29 spirituality is a source of social support that creates a sense of meaning to overcome confusion and increases a sense of indirect control over an event.30–32 in addition, previous research shows that according to indicators of family resilience, 95% of participants believe that this pandemic is a test from god almighty and makes participants aware of the importance of family, this shows that spiritual values can be a good coping in the family.33 spiritual health is created when a person voluntarily strengthens his spiritual strength through prayer, relaxation, and associating with like-minded people, as well as learning from spiritual guides and reading books on religion.34 prior research regarding the impact of spirituality on the resilience of patients with chronic illnesses has indicated that spirituality plays a significant role in enhancing an individual’s ability to withstand adversity, resulting in increased resilience35. furthermore, spirituality fosters cognitive flexibility and resilience by encouraging individuals to accept and reconcile with challenging circumstances. patients with higher levels of spiritual wellbeing demonstrate more effective coping and adaptation to challenging conditions, leading to heightened levels of resilience and improved stress management. positive religious coping and regular spiritual experiences have been linked to positive influences and higher life satisfaction. conversely, religious coping is negatively associated with negative affect and psychological distress. nevertheless, it’s noteworthy that there has been no previous research specifically investigating the influence of religious wellbeing on the resilience of family spirituality. in overcoming the impact of declining spiritual resilience, religious well-being or spiritual well-being can be used as a protector in psychological and mental health as well as physical health.22 the purpose of the current study was to analyze the influence of religious well-being on family spirituality resilience during the covid-19 pandemic. this study also stated that addressing psychosocial and spiritual needs can improve the quality of life and individual well-being, especially in the current pandemic conditions. materials and methods design and participants the study was descriptive study, utilizing a cross-sectional survey approach. the study was conducted in 2022 with data collection carried out in january-february 2022. the study’s population consisted of all indonesian citizens residing in malang, east java province. for eligibility, the sample was defined as adults capable of reading and completing the questionnaire. the sample size, determined using g power version 3.1, with a z-test, logistic regression, odds ratio of 1.5, a power of 80%, and a probability error of 0.05, resulted in a sample size of 243 respondents. sampling was conducted through accidental sampling technique. in this study, the inclusion criteria encompassed village residents aged 17 years and older who were literate and willing to participate in the research, while the exclusion criteria included individuals who met the inclusion criteria but were ill and unable to complete the distributed questionnaire. procedure the data obtained by an online survey using google forms. before the research begins, respondents were recruited based on written criteria. after finding suitable respondents, the respondents join the whatsapp group that has been created. then the researcher gathered the respondents in the hall, the researcher explained filling in the link, gave informed consent, and then asked the respondent to access the questionnaire link that the researcher distributed via the whatsapp application. overall, it took 30 minutes to complete the questionnaire. meanwhile, for respondents who had not yet come to the hall, data collection was carried out by gathering respondents at one of the respondents’ houses closest to them. to increase and maintain research contribution provisions, incentives are given to respondents after completing the questionnaire. instruments the main independent variable was religious well-being, which was assessed through a questionnaire consisting of 10 items with a score range of 1-6 (1=often used, 6=never used). sample questions from this questionnaire include: “i don’t feel satisfaction when i pray to god personally” and “i don’t know who i am, where i am from, or where i am going.” the total scores for this questionnaire can range from 10 to 60. subsequently, these scores were categorized into two groups: poor (above the median) and good (below the median). additionally, there were several other independent variables under consideration, such as age, education, family type, income, and occupation. age is classified into six categories: 17-25 years (late adolescence); 26-35 years (early adulthood); 36-45 years (late adulthood); 46-55 years (early elderly); 56-65 years (late old age); and over 65 years (old age). education levels include no schooling, elementary school, junior high school, senior high school, or college. family types are categorized as nuclear family, extended family, or single-parent. income is divided into two groups: less than 3 million and more than 3 million. occupation is categorized as having a job or being jobless. the dependent variable was family resilience in the context of family spirituality, which was assessed through four question items related to worshiping in places of worship, seeking advice from religious figures, belief in god, and participating in worship activities. respondents provide their answers on a likert scale ranging from 1 (disagree) to 4 (strongly agree). the composite scores for this variable fall within the range of 4 to 108 and are subsequently categorized as either adequate (above the median) or inadequate (below the median). [page 78] [healthcare in low-resource settings 2023; 11:11747] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly data analysis all data were analyzed using statistical package for social science (spss) version 21 software (ibm usa). descriptive analysis was used to identify religious coping, age, education, family type, income, occupation, and family resilience with frequency and percentage. logistic binary analysis was used to select candidate variables. variables with p<0.25) were included in the modeling. multivariate analysis was used to analyze the effect of candidate variables on family resilience in communicating and solving problems during the covid-19 pandemic. the degree of freedom used is 95% with a standard error of 0.05. ethical considerations this study received ethical approval from the health research ethics commission of the university of muhammadiyah malang with protocol number e.5.a/007/kepk-umm/i/2022. participants provided written consent for participation before data collection. results univariate analysis among all demographic data was presented in table 1. most of the ages ranged from 46 to 55 years as much as 30.9%, with a high school education level (47.7%). the most common type of family was the nuclear family (66.7%). most of the residents’ income was less than 3 million rupiahs (90.5%). moreover, the data was also dominated by 162 residents, or 66,7% of people who lost a job during the pandemic, nevertheless, there were 51% of respondents have good religious well-being and adequate family resilience in family spirituality 53.5% (table 1). from figure 1, it can be seen that the practice and faith of family resilience in family spirituality are indicated by activities in the form of maintaining their belief in the power of the almighty (god) is 91.4%, there were 61,7% of respondents who participate in religious activities and 56 % who worshiping in places of worship, and consulting with religious leaders as much as 53.1%. one factor that influences family resilience in family spirituality is religious well-being. families with adequate religious wellbeing were 4 times more likely to have resilience in family spirituality than families with inadequate religious well-being (or: 3,807; 95% ci: 2,230 6,498) (table 2). the selection of candidates who entered the model was religious well-being, while the variables were not included in the model because they had a p>0.25 value, namely age (p= 0.288), family type (p=0.268), occupation (p=0.552), income (p=0.321). discussion the study’s findings indicated that religious well-being or spiritual well-being significantly impacts family resilience in the context of family spirituality. religious well-being encompasses the sense of satisfaction and inner peace experienced by individuals in the practice of their religion or spirituality. on the other hand, spiritual resilience within a family can be understood as the family’s capacity to uphold their faith and spiritual values in the face of pressure and challenging circumstances. this resilience can also transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. the final multivariate logistic regression model of family resilience in family spirituality. variable b se wald p or 95% ci for exp (b) lower upper religious well-being 1.337 .273 24.016 0.000 3.807 2.230 6.498 constant -1.822 .419 18,936 0.000 0.162 figure 1. family resilience questionnaire item scores in family spirituality during the covid-19 pandemic. table 1. demographic characteristics of respondents (n=243). characteristics n percentage age 17-25 19 7.8% 26-35 57 23.5% 36-45 56 23.0% 46-55 75 30.9% 56-65 27 11.1% >65 9 3.7% education no formal education 1 0.4% elementary school 46 19% junior high school 55 22.6% senior high school 116 47.7% college 25 10.3% family type nuclear family 162 66.7% extended family 60 24.7% single parent 21 8.6% income <3 million 220 90.5% >3 million 23 9.5% occupation (during the pandemic) have a job 81 33.3% jobless 162 66.7% religious well-being poor 119 49% good 124 51% family spirituality resilience inadequate 113 46.5% adequate 130 53.5% total 243 100% [healthcare in low-resource settings 2023; 11:11747] [page 79] non -co mmerc ial us e o nly assist individuals in coping with stress, anxiety, and life’s trials. as a result, an increase in the family’s religious well-being is likely to contribute to the enhancement of their spiritual resilience. this is in line with previous research that mentions that the relationship with god contributes to the welfare of life.36 families affected by covid-19 sometimes experience loneliness, religious well-being or spiritual well-being can reduce the loneliness they feel.37 spiritual well-being also has a role in overcoming stress that occurs, this is because there is a relationship between spiritual well-being, peace, faith, and psychological adjustment to the stress that occurs.38,39 spiritual well-being along with hope and resilience can be good predictors of stress.40 the ongoing pandemic has brought about significant changes in family routines, which, in turn, can serve as triggers for family problems and health issues.41 in response, families are increasingly relying on mutual support, including spiritual support, as spirituality can be a valuable source of strength42. it has become increasingly recognized as a significant contributor to overall health and well-being, and its benefits should not be underestimated.43 a systematic review has demonstrated that various aspects of spirituality and religiosity, such as attendance at places of worship and the significance of religious beliefs, possess a modest yet consistent ability to predict levels of mental health problems over time.44 religious well-being or spiritual well-being is widely regarded as a stabilizing factor in life, fostering a sense of spiritual peace.45 several studies have demonstrated that enhancing the spiritual dimension in one’s life can enhance adaptability to changing circumstances,46 promote the maintenance of mental health,47 and improve social functioning.48 additionally, spirituality contributes to increased cognitive flexibility and individual resilience when faced with challenging situations.49 the increasing family resilience is associated with higher degrees of spiritual well-being religious well-being and existential well-being.50 the results of this study also found that age, family type, family income, and education level did not affect family spirituality resilience. the age factor is a direct factor related to a person’s maturity to perceive something. so age does not affect spiritual resilience.51 this is also in line with previous research that age has a significant impact on a person’s perception of spiritual wellbeing. family type and family income do not affect spiritual resilience. high family income does not guarantee good spiritual resilience, and low family income does not rule out the possibility of the family having good spiritual resilience.52 this depends on how grateful the family is for everything that happens, revealing the importance of creating gratitude practices every day to build family welfare and family resilience.53 the high and low level of education does not guarantee the strength of spiritual resilience in the family. since spiritual resilience arises from self-belief and awareness of the existence of a supreme being (god), it is in line with research which states that spirituality refers to experiences and deep inner feelings and beliefs that arise from awareness of the existence of the holy one which can increase the meaning of life’s purpose and inner peace.54 the level of education does not find a significant relationship with the level of spiritual resilience.51 this study shows that work does not affect family spirituality resilience. during this pandemic, the unemployment rate has increased, as well as changes to working regulations to reduce exposure to covid-19. this is in line with the statement which mentions the development of a global pandemic causing mass unemployment, and an increase in remote work.55 there is a positive impact from working remotely, where families will have more time to be closer to other family members. previous research stated that apart from the negative impact of the pandemic that can disrupt family relationships, the pandemic also has a positive impact on families, where families have a lot of quality time and can be spent together.56 this research was conducted on respondents who are muslim, so it has not been able to generalize to other religions. questionnaires can be developed for other religions. this study has several limitations. this research was only conducted on muslim populations, so the spiritual level data focused on only one religion. recommendations for further research are that similar research can be carried out with various types of religions so that the data obtained is more diverse. by making diverse religions, it is hoped that future research can represent the entire population without distinguishing between religions. conclusions family resilience in spirituality is heavily influenced by factors of religious well-being. strengthening the community through a religious approach is essential to bolster the family’s defense against the challenges of this pandemic. the findings from this study can serve as a foundation for delivering spiritual support therapy to families in distress. exploring the application of such spiritual support, especially to distressed families, is a compelling topic for subsequent research. this study can aid in enhancing nursing interventions, particularly those centered on spiritualitybased family nursing, taking into account the factors discussed above. references 1. polizzi c, lynn 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18:6828. 56. luttik mla, mahrer-imhof r, garcía-vivar c, et al. the covid-19 pandemic: a family affair. vol. 26, journal of family nursing. sage publications sage ca: los angeles, ca; 2020. p. 87-9. [page 82] [healthcare in low-resource settings 2023; 11:11747] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [page 26] [healthcare in low-resource settings 2023; 11:11229] prevalence of mlsb phenotypes of staphylococcus aureus isolates in a tertiary care hospital of delhi malika grover, nisha goyal, seema gangar, narendra pal singh department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi, india abstract against the backdrop of the ever-changing staphylococcal resistance pattern, clindamycin remains a viable therapeutic alternative variation of clindamycin drug resistance patterns with geographic area make inducible clindamycin resistance testing imperative for all staphylococcal isolates to avoid therapeutic failure. this was a prospective study conducted over a period of 1.5 years from january 2021 until june 2022. prevalence of different mlsb phenotypes of staphylococcus aureus isolates was determined by standard disc diffusion method as per clsi guidelines. pyogenic samples received in the microbiology lab that yielded staphylococcus aureus were further tested for the presence of clindamycin resistance by disc diffusion method. out of 6586 total pyogenic and respiratory specimens received in the lab, staphylococcus aureus was yielded in 752 samples. on further testing for the mlsb phenotypes, 16.3% isolates were found to be imlsb, 19.28% were cmlsb, 43.1% were of msb type. icr screening will reduce the unessential subjection of the patient to the antibiotic, and would prevent unnecessary adverse effects in the patients. introduction staphylococcus aureus (s. aureus) is a potential pathogen as well as a colonizer of the humans owing to the arsenal of virulence factors including toxins such as tsst-1 (toxic shock syndrome toxin), exfoliative toxins (eta and etb), heat stable enterotoxins etc. manifestation of staphylococcal infections ranges from local (folliculitis, carbuncles, furuncles, impetigo, wound infections) to systemic (endocarditis, pneumonia, sepsis, osteomyelitis, arthritis). localised s. aureus infections have the potential to become invasive and cause bacteremia at any stage of the infection. the mainstay of treatment for these infections include cell wall inhibitors such as β-lactams, glycopeptides, dna gyraseinhibiting quinolones, and ribosomal inhibitors such as macrolides, lincosamides and streptogramins (mlsb). mlsb drugs are a good alternative in treating infections, especially in current times of increasing resistance. clindamycin in particular is an important antibiotic for skin and soft tissue infections caused by s. aureus (especially mrsa i.e., methicillin resistant staphylococcus aureus) due to its ease of administration (available as oral/parenteral) and its property to neutralise toxins. it switches off production of toxins like tsst responsible for toxic shock syndrome,1 alpha toxin which is a pore forming cytotoxin leading to infections such as dermonecrosis, keratoconjuctivitis and pneumonia2 and pvl (panton-valentine leukocidin), which is associated with manifestations like necrotising pneumonia, purpura fulminans and skin sepsis.3 the three antimicrobial classes of mlsb act by binding to the 50s ribosomal subunit, thus inhibiting protein synthesis in the bacteria.4 resistance amongst these can be conferred mainly by three mechanisms – target site modification, antimicrobial inactivation and efflux. the enzyme erythromycin ribosome methylases plays the most significant role in the resistance, by attaching the adenine residue of 23s rrna to methyl groups, thus decreasing affinity for mlsb antibiotics. it is encoded by the erm (erythromycin ribosome methylation) gene which is of three main types i.e., erm (a), erm (b) and erm (c); also, genes erm (f) and erm (y) may be responsible. the other mechanisms that contribute to the cross resistance of these mlsb phenotypes include drug inactivation mediated by lun gene and active efflux mechanisms that pumps out antimicrobials from the bacteria, mediated by msr gene.5 mlsb drugs can exist as different phenotypes – constitutive, inducible, or msb (figure 1): i) constitutive mlsb (cmlsb) – defined as those isolates which are clindamycin and erythromycin resistant; ii) inducible mlsb (imlsb) – defined as isolates which are clindamycin susceptible and erythromycin resistant. however, a dshaped zone of inhibition is seen around clindamycin, with flattening towards the erythromycin disc; iii) msb – is defined as those isolates which are clindamycin susceptible and erythromycin resistant with a circular zone of inhibition around the two. clinical and laboratory standards institute (clsi) states two methods for detecting inducible clindamycin resistance (icr), i.e., by disc diffusion and broth microdilution. detection of inducible clindamycin resistance in particular holds significance in clinical scenarios, wherein the s. aureus isolates exhibiting in vitro clindamycin susceptibility will not show in vivo response on administration of the drug. this leads to unnecessary overuse of the drug in the patient, thus enhancing the risk of emergence of resistant strains of bacteria and putting the patient at increased risk of side effects of the drug. improper treatment during the initial phase can also put the patient at risk for metastasis of the disease. our current study aims at identifying the distribution of mlsb phenotypes of s. aureus isolates for better understanding of healthcare in low-resource settings 2023; volume 11:11229 correspondence:nisha goyal, department of microbiology, university college of medical sciences & guru teg bahadur hospital, 110095 delhi, india. tel.: +91.8447444427. e-mail: drnishagoyalucms@gmail.com key words: staphylococcus aureus, inducible clindamycin resistance, constitutive clindamycin resistance, msb phenotype. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. this study used only the samples received in the lab for routine susceptibility testing and no other sample was collected for the purpose of this study. patients were not identified or visited at any point of time. informed consent: not applicable patient consent for publication: not applicable availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 31 january 2023. accepted for publication: 7 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11229 doi:10.4081/hls.2023.11229 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.non -co mmerc ial us e o nly resistance patterns to crucial antibiotic of clindamycin in the management of infections caused by s. aureus. material and methods this was a prospective study carried out over a period of one and a half year spanning from january 2021 to june 2022 in our tertiary care hospital of delhi. a total of 6586 samples, including pus aspirates, peritoneal fluid, pleural fluid, synovial fluid, respiratory samples, and genital secretions were received in the microbiology lab of our hospital. the samples were cultured on blood agar, macconkey agar and chocolate agar using standard laboratory protocols. bacterial identification of the growth was done by conventional methods, using biochemical reactions (catalase, slide and tube coagulase, mannitol salt agar). the samples that yielded growth of s. aureus on culture were further subjected to antimicrobial susceptibility testing (ast) by kirby bauer disk diffusion method, according to latest clsi guidelines.6 for ast 0.5 mcfarland of the strain was lawn cultured on muller hinton agar, followed by placement of the antimicrobial discs at a distance of 15-20 mm edge to edge from each other and incubation at 35°c±2°, ambient air. isolates were classified as methicillin susceptible or resistant on the basis of zone of inhibition diameters of cefoxitin. while, presence of clindamycin resistance (constitutive, inducible and msb) was determined by performing disk diffusion method, placing erythromycin (15µg) and clindamycin (2µg) at a distance of 15-26mm from each other. zone cut-offs for the antibiotics have been descried in the table 1. isolates with intermediate zone diameters were considered as resistant for icr analysis. presence of d-zone i.e., flattening of the zone of inhibition adjacent to the erythromycin disc was interpreted as inducible clindamycin resistance, as shown in figure 1a. results out of the total 6586 pyogenic and respiratory samples received, s. aureus was isolated from 11.4% (752/6586) samples. majority of these samples were received from the patients admitted in surgical wards. the organism was isolated more commonly from the male population (54.9%) as compared to the females (45.07%). isolation of s. aureus was more common from adult patient population (71.8%) in comparison to the paediatric population (28.9%). of the total s. aureus isolates 335 (44.54%) were mssa (methicillin sensitive staphylococcus aureus), while 417 (55.45%) were mrsa (methicillin resistant staphylococcus aureus. all the strains of this gram-positive organism were tested for different mlsb phenotypes i.e., inducible, constitutive and msb. inducible clindamycin resistance was found in 16.35% of the isolates; constitutive clindamycin resistance was observed in 19.28% of the observed isolates, while msb phenotypes were observed in 43.08%. percentage distribution of various mlsb phenotypes has been described in table 2. distribution of mssa and mrsa were also observed among the mlsb phenotypes (table 3). on application of fischer’s exact test, no significant association was observed between methicillin susceptibility of the isolates and the constitutive and msb phe article table 1. antimicrobial susceptibility break points (clsi 2022). antibiotic susceptible intermediate resistant erythromycin (15 µg) ≥23 mm 14-22 mm ≤13 mm clindamycin (2 µg) ≥21 mm 15-20 mm ≤14 mm cefoxitin (30 µg) ≥22 mm ≤21 mm table 2. distribution of various mlsb phenotypes among staphylococcal aureus isolates from clinical samples (n=752). erythromycin clindamycin d test phenotype no. of isolates percentage susceptibility susceptibility susceptible susceptible negative 160 21.27 resistant resistant negative cmlsb 145 19.28 resistant susceptible positive imlsb 123 16.35 resistant susceptible negative msb 324 43.08 figure 1. identification of various mlsb phenotypes of staphylococcal aureus isolates from clinical samples (n=752): a) inducible mlsb (imlsb); b) constitutive mlsb (cmlsb). [healthcare in low-resource settings 2023; 11:11229] [page 27] non -co mmerc ial us e o nly notypes, as the p value was found to be 0.0556. association of methicillin susceptibility was established in the isolates displaying inducible clindamycin resistance. of the total 123 isolates showing inducible clindamycin resistance, 29.2% were methicillin susceptible while the rest 71% were found to be methicillin resistant (figure 2). no significant association was observed between icr phenotype and methicillin susceptibility (p≥0.05). discussion s. aureus is the most common aetiological agent of pyogenic infections. drugs such as trimethoprim-sulfamethoxazole, tetracyclines (minocycline and doxycycline) and clindamycin have gained importance in present scenario of increasing drug resistance in staphylococcal isolates.7 clindamycin, belongs to the lincosamide group of antibiotics and possesses activity against gram-positive as well as anaerobic bacteria. its properties such as good tissue penetration, cost, spectrum and, oral bioavailability make clindamycin conducive to treating infections. it is thus, used for skin and soft tissue infections, with particular significance in cases of ca-mrsa infections, wherein an oral treatment regimen can suffice for the patient. this lincosamide antibiotic is also effective in treating conditions such as pleural empyema, osteomyelitis and septic arthritis. though clindamycin has several properties to its advantage, there are a few challenges that a clinician faces while using the drug. pseudomembranous colitis due to clostridioides difficile is observed in 0.110% of the patients using clindamycin persistently1 and likelihood of failure if the strain possesses erm gene are the two main disadvantage to clindamycin use. clindamycin resistance can either be induced or can be rendered constitutively based on the phenotype. in our study, constitutive resistance to the mlsb drugs was found to be more (19.3%) in comparison to the inducible phenotype. icr rates were found to be 16.35%, which were considerably higher in mrsa isolates (70.8%) than the mssa strains. not many studies have commented upon the reason justifying the higher prevalence of icr in mrsa, but one possible explanation is more positivity rate for erma in mrsa than mssa.8 this is indicative of increased chances of treatment failure with clindamycin in resistant infections. table 4 compares the distribution of mlsb phenotypes in various geographical regions of our country and beyond. the presence of msb phenotype in our study was higher in comparison to the other two variants. similar finding was observed in the other areas of delhi.10 therefore, clindamycin can be used empirically by clinicians for indicated infections with lesser chances of it turning out to be ineffective. table 4 shows the geographical distribution of mlsb phenotypes in various geographical regions. in our study higher prevalence of cmlsb than that of imlsb was observed, which was found to be in concordance with other studies conducted in the regions of kolkata, shimla and nepal.4,6,7 conversely higher prevalence of imlsb than cmlsb was observed in other regions of delhi and wardha.5,8 the varying article table 4. geographical distribution of mlsb phenotypes in various geographical regions. study year region no. of isolates (n) imlsb (%) cmlsb (%) msb (%) kumar et al.9 2010 kolkata, india 195 16.9 23.1 16.9 lall and sahni et al.10 2014 delhi, india 305 43.1 21.4 54.3 mokta et al.11 2015 shimla, india 350 13.71 17.14 8.28 deotale et al.12 2017 wardha, india 247 14.5 3.6 14.17 adhikari et al.13 2017 nepal 147 21 53.4 25.17 our study 2022 east delhi, india 752 16.35 19.28 43.08 figure 2. distribution of mssa and mrsa among staphylococcus aureus isolates exhibiting inducible clindamycin resistance (n=752). table 3. mssa & mrsa distribution amongst the constitutive and msb phenotypes. mlsb phenotype mssa (%) mrsa (%) constitutive 59 (40.7) 86 (59.4) msb 171 (52.8) 153 (47.2) [page 28] [healthcare in low-resource settings 2023; 11:11229] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11229] [page 29] geographical prevalence of different resistance patterns emphasizes upon the importance of clindamycin testing in all isolates. it was observed that the prevalence of clindamycin resistance (both cmlsb and imlsb) was more in mrsa isolates in comparison to the mssa isolates that was consistent with the findings of other studies.11,14,15 against the backdrop of the ever-changing staphylococcal resistance pattern, clindamycin remains a viable therapeutic alternative. our study may prove useful in better understanding of varying distribution of different mlsb phenotypes of s.aureus in recent times. variation of clindamycin drug resistance patterns with methicillin susceptibility, geographic area and even intercity16 differences make icr testing imperative for all staphylococcal isolates to avoid therapeutic failure. references 1. clindamycin: an overview uptodate. accessed 2023 may 11. available from: https://www.uptodate.com/contents/clin damycin-an-overview?search=clindamycin%20in%20staphylococcal%20i nfections&source=search_result&select edtitle=3~150&usage_type=default&d isplay_rank=3#h12 2. alpha toxin – an overview | sciencedirect topics. accessed 2023 may 11. available from: https://www. sciencedirect.com/topics/medicine-anddentistry/alpha-toxin 3. morgan m. staphylococcus aureus, panton-valentine leukocidin, and necrotising pneumonia. bmj 2005; 331:793-4. 4. saribas z, tunckanat f, pinar a. prevalence of erm genes encoding macrolide-lincosamide-streptogramin (mls) resistance among clinical isolates of staphylococcus aureus in a turkish university hospital. clin microbiol infect 2006;12:797-9. 5. ghanbari f, ghajavand h, havaei r, et al. distribution of erm genes among staphylococcus aureus isolates with inducible resistance to clindamycin in isfahan, iran. adv biomed res 2016;5:62. 6. clsi-31-2021.pdf. accessed 2022 oct 9. available from: https://www.treata. academy/wp-content/uploads/2021/ 03/clsi-31-2021.pdf 7. moellering, jr. rc. current treatment options for community-acquired methicillin-resistant staphylococcus aureus infection. clin infect dis 2008;46: 1032-7. 8. nahar l, hagiya h, nada t, et al. prevalence of inducible macrolide, lincosamide, and streptogramin b (inducible mlsb) resistance in clindamycin-susceptible staphylococcus aureus at okayama university hospital. acta med okayama 2023;77. 9. kumar s, bandyopadhyay m, bhattacharya k, et al. inducible clindamycin resistance in staphylococcus isolates from a tertiary care hospital in eastern india. ann trop med public health 2012;5:468. 10. lall m, sahni ak. prevalence of inducible clindamycin resistance in staphylococcus aureus isolated from clinical samples. med j armed forces india 2014;70:43-7. 11. mokta kk, verma s, chauhan d, et al. inducible clindamycin resistance among clinical isolates of staphylococcus aureus from sub himalayan region of india. j clin diagn res jcdr 2015;9:dc20-3. 12. deotale v, mendiratta d, raut u, narang p. inducible clindamycin resistance in staphylococcus aureus isolated from clinical samples. indian j med microbiol 2010;28:124-6. 13. adhikari rp, shrestha s, barakoti a, amatya r. inducible clindamycin and methicillin resistant staphylococcus aureus in a tertiary care hospital, kathmandu, nepal. bmc infect dis 2017;17:483. 14. supriyarajvi, gupta a, tina g, sharma bp. detection of inducible clindamycin resistance among staphylococcal isolates from various clinical specimens in a tertiary care institute in north west region of rajasthan, india. int j curr microbiol appl sci 2015;4:741-9. 15. molecular characterisation of methicillin-resistant staphylococcus aureus isolated from patients at a tertiary care hospital in hyderabad, south india. indian j med microbiol 2020;38:183-92. 16. schreckenberger pc, ilendo e, ristow kl. incidence of constitutive and inducible clindamycin resistance in staphylococcus aureus and coagulasenegative staphylococci in a community and a tertiary care hospital. j clin microbiol 2004;42:2777-9. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:3786] [page 7] article integration of mental healthcare into primary healthcare in lagos, nigeria: the way forward ayodele o. coker,1 olufemi b. olugbile,2 olufemi oluwatayo3 1department of behavioural medicine, lagos state university, college of medicine, ikeja; 2lagos state ministry of health, ikeja, lagos, nigeria; 3wells road centre, nottinghamshire healthcare nhs trust, nottingham, uk abstract the lagos state ministry of health recently launched its mental health policy aimed at addressing the mental health needs the residents of the state. the policy also aimed at reducing the mental disorders treatment gap in the state by integrating mental healthcare into the primary healthcare in order to make mental healthcare services closer and accessible for residents of the state. this paper therefore critically reviews the rationale for the integration, magnitude of problems in lagos state with regards to mental healthcare services, available resources, challenges in providing mental healthcare services, recommendations for successful integration, the necessary advocacy needed to implement the integration and benefits of the integration. introduction mental and substance use disorders have been severally reported to be common, they tend to become chronic and require long-term commitment to treatment.1,2 they were found to constitute the leading cause of disability adjusted life years worldwide accounting for 37% of healthy life years lost from non-communicable diseases.3,4 previous published reports showed that neuropsychiatric disorders account for 13% of the global burden of disease and more than 75% of this burden was found in the low and middle-income countries.3,4 despite many published evidence on the negative impact of mental disorders, only a minority of people with mental disorders receive treatment, and even fewer receive high-quality treatment from mental health experts in the low and middle-income countries.5,6 in the light of this, studies showed that between 76 and 84% of individuals with serious mental illhealth did not receive treatment for their mental health disorders representing a very high treatment gap.5,6 the world health organization (who) declared that to reduce the global mental health treatment gap, a possible solution is to integrate mental healthcare services into the primary healthcare (phc) centers. for this reason, the who introduced the mental health gap action programme, with the specific aim of scaling up services for mental, substance use and neurological disorders.7-9 lagos state is the formal capital city of nigeria and it has a population of 18 million people. the state government recently mentioned that the city of lagos was the fasted growing mega city in the world.10 the lagos state government also claimed that lagos state was passing through a phase of transformation characterized by rapid population growth and overcrowding with its attendant physical and mental health issues.10 the whoaims report on mental health aspects of nigeria and other published documents from the lagos state showed that mental healthcare services have been neglected in nigeria.11-16 nonetheless, the lagos state government took the initiative of launching its mental health policy.15 however, for the policy to be effective, the state must be proactive by looking into the mental health needs of the 18 million residents of the state. this paper therefore discusses the rationale for the integration, magnitude of mental health problems with regards mental healthcare services in the state, available resources, challenges in providing mental healthcare services, recommendations for successful integration, the necessary advocacy needed to implement the integration and the benefits of the integration. the rationale for integrating mental healthcare services to primary healthcare primary healthcare is the provision of basic essential healthcare made universally accessible to individuals and families in the community as near as possible to where people live and work.7 for effective mental healthcare services at the phc settings, certain issues need to be carried out. the phc workers are the frontline formal health professionals who are the first level of contact with individuals (and relative families) with physical or mental health disorders within the community. therefore, medical officers and other medical allied phc workers need to be trained to acquire the clinical skills of identifying, diagnosing, and managing patients with mental disorders.7 when these workers are adequately trained, phc will reduce the observed negative implications of those living with severe mental disorders in the lagos city. the integration will further improve access to mental healthcare within the city, increase acceptability, reduce associated social stigma and human rights abuse, prevent chronicity and physical health comorbidity will likely to be detected early and managed. all specialist and teaching hospitals that offer specialist mental healthcare services are located in downtown lagos state. however, 80% of lagos state dwellers live in rural areas where mental healthcare services are not available. the integration of mental healthcare services in lagos state will make them available also to those living in rural areas, thus reducing the burden of traveling to the city center to receive treatment in specialist and teaching hospitals which are often associated with labeling and stigmatization. available mental healthcare resources lagos state through the ministry of health runs a three-tier health system of healthcare: primary (health centers), secondary (general hospitals), and tertiary (teaching) hospital. the state has 51 phc centers, 21 general hospitals and 1 teaching hospital. currently, there are no mental healthcare services in any of the primary care centers. there are only seven consultant psychiatrists working for the lagos state government. three consultant psychiatrists work at the level of the secondary care in three different general hospitals, while the remaining four consultant psychiatrists work at the state’s teaching hospital. other allied mental healthcare personnel in the state include 30 psychiatric nurses and 2 clinical psychologists. the number of psychiatric healthcare in low-resource settings 2015; volume 3:3786 correspondence: ayodele o. coker, department of behavioural medicine, lagos state university, college of medicine, p.m.b. 21266, ikeja, nigeria. tel./fax: +234.8033267544. e-mail: cokerrotimi@gmail.com key words: integration; mental healthcare; primary healthcare; lagos, nigeria. received for publication: 15 april 2014. accepted for publication: 7 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.o. coker et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:3786 doi:10.4081/hls.2015.3786 non co mmerc ial us e o nly [page 8] [healthcare in low-resource settings 2015; 3:3786] social workers is quite low and the state cannot boast of any professional occupational therapist. the lagos state government has only 12 beds at the department of psychiatry of teaching hospital meant solely for academic and didactic purposes. the inadequacy of mental health personnel in lagos state is another important reason to integrate mental healthcare services into phc centers. the integration will further bridge the mental illness treatment gap in the state and provide a wider coverage to a large population of lagosians, especially those living in rural communities. the lagos state ministry of health in 2011 launched its mental health initiative to comprehensively address the state’s mental health needs.15 nonetheless, there are few specific mental health programs, such as the one being carried out by a research team from the state’s teaching hospital funded by a canadian grant in which the mental health treatment gap work book is being used to train phc workers in just one local government area of the state. it is however worthy of note that the federal government through the federal ministry of health runs parallel mental healthcare services through the presence of a 476-bed-specialist psychiatric hospital which has 12 consultant psychiatrists; one academic psychiatric department in the university of lagos teaching hospital which has 6 consultant psychiatrists; and a small psychiatric unit in the military hospital which has one consultant psychiatrist. the mental healthcare services provided by these federal institutions are meant to augment those being provided by the lagos state government and are all located at the center of lagos state. the activities of these federallyfunded hospitals are totally independent from the activities of the lagos state government and they do not in any way provide mental healthcare services at the primary care centres. the expected challenges in integrating mental healthcare services into primary healthcare services the medical personnel at the various phc centers in lagos state include medical officers, registered nurses, community health officers, community health extended workers, and social workers. in order to integrate mental healthcare services to phc centers, there are likely to be some implementation challenges and they need to be anticipated in order to address them. the expected challenges include: training of the phc staff who have limited skills in identifying, diagnosing and managing individuals with common mental disorders; reluctance of phc workers to manage people with mental health disorders because of the cultural and traditional aetiological beliefs of mental illness. other challenges include inadequate personnel at the phcs which must be addressed, the probability of increased work load. there must be regular supervision by consultant psychiatrists who must be ready and available to advice and guide the phc workers on management of patients with mental disorders and who they can refer to in cases of seriously disturbed patients. likewise, different types of psychotropic medications must always be made available.7,12,1-19 recommendations for a successful integration the lagos state ministry of health has 51 phc centers, and 21 general hospitals. in order to start the integration, the ministry should be able to strengthen existing networks of primary and secondary medical services. the integration process must provide adequate funds for recruitment of additional staff and for continuous capacity building of the phc staff. generic basic psychotropic medications can be purchased from local pharmaceutical organizations to make them available and affordable for patients. the consultant psychiatrists working at the general hospitals or the state’s teaching hospital close to any of the phc centers should be motivated to closely monitor and supervise the phc workers and also discuss difficulties encountered in the management of mental disorders at the phcs. the lagos state ministry of health must also encourage a two-way referral system between the phcs and secondary and tertiary levels of care. the ministry must reach out to other non-health sectors for inter-sectorial collaborations. the relevant sectors include the ministries of social welfare, education, justice, prison and police. likewise, active collaboration and partnering with religious leaders and non-governmental organisations providing mental healthcare must be encouraged. psycho-social solutions must also be put in place to assist rehabilitated patients that may require services such as employment, housing and other social services that may alleviate the mental health conditions of patients. there must be regular evaluation and monitoring especially with regards to data collection. data on patients must be integrated in the general health information system of the state to be used for service improvement. advocacy in order to provide a successful mental healthcare service to the citizens of lagos state, the state government needs to carry out needs-assessment studies in different local government areas of the state. the prevalence of specific mental health and neurological disorders – including alcohol and substance abuse – must be known for effective planning and integration. thereafter, mental health advocacy and awareness programs should be designed to sensitise the residents of the state on preventive and rehabilitative aspects of mental health disorders. the speciallydesigned advocacy programs should include series of interactive and participatory lectures, symposia, seminars, workshops and outreach mental health programs to bring to awareness signs and symptoms of common mental health disorders at inception, their causes and what needs to be done with regards to help-seeking. in the same vein, the electronic and print media should be involved in the advocacy programs. there should be regular weekly radio and television programs on mental disorders where listeners should be encouraged to phone the mental health specialist on air for further clarifications. the advocacy and awareness programs should also include the making and free distributions of flyers and posters on relevant and concise information on the prevention of mental ill-health.2,7,18 the expected benefits of integrating mental healthcare services to primary healthcare services the benefits of integrating mental healthcare into primary healthcare have been documented to be enormous. previously published studies have enumerated the benefits of such integration to include social benefits, understanding and support from nuclear and extended families and from significant members of the community.5,7,8,18-20 with regards to cultural benefits, there will be more tolerance for those living with severe and chronic mental disorders.5,18 the economic benefits include reduced cost traveling far distance to receive care, and a cost-effective, evidenced-based mental healthcare therapeutic delivery system.5,7,18 the psychological benefits include reduction of social stigma, human rights abuse and negative attitudes towards individual living with psychotic condition in the community which may increase self-esteem of such individuals.20,21 the spatial benefits were noted to include proximity of care to patients, and review non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:3786] [page 9] increased access to care. the treatment of comorbid physical conditions such as tuberculosis, hypertension and diabetes can also be co-managed which can also lead to better health outcome of patients.5,7,18 thus, prevention and early detection of mental disorders at the primary care level can also reduce chronicity. the integration will prevent individuals with mental illness in the community from being admitted and abused by charlatans, faith-based religious and traditional healers.7,21,22 lastly, capacity building of allied medical professionals at the primary care settings will increase the number of those that can manage mental health disorders within the community.7 conclusions the lagos state government through its ministry of health intends to integrate mental healthcare to phc centers. the rationale, magnitude of the problems, available resources, and expected challenges benefits were discussed and suggestions preferred. when mental healthcare services are integrated to primary care centers, such services will be taken closer to people in communities within the state. this will encourage those with mental health disorders to seek for help early, and it can lead to reduction of social stigma and human rights violation. it is believed that the effective integration of mental healthcare services into phcs within the state will eventually reduce the incidence and prevalence of mental health disorders in the state. the advocacy and awareness programs should provide sensitised residents with addresses of various phcs where mental healthcare services can be received. the phcs that will provide mental healthcare services must always have adequate and affordable psychotropic medications available at all times. the consultant psychiatrists working for the lagos state government must be motivated to monitor and attend to difficult psychiatric cases at the phcs and assist in admitting cases of acutely-disturbed individuals with mental health conditions to their hospitals. references 1. who. integrating mental health services into primary healthcare. geneva, switzerland: world health organization; 2013. available from: hhp://www.who.int/mental/policy/services/en/index.html 2. saxena s, skeen s. no health without mental health: challenges and opportunities in global mental health. afri j psychiatry 2012;15:397-400. 3. whiteford h, degenhardt l, rehm j, et al. global burden of disease attributable to mental and substance use disorders: findings from the global burden of disease study 2010. lancet 2013;282:1575-86. 4. kessler rc, aguilar-gaxiola s, alonso j, et al. the global burden of mental disorders: an update from the world mental health (wmh) surveys. epidemiol psychiat s 2009;18:23-33. 5. lund c, tomlison m, de silva m, et al. prime: a programme to reduce the treatment gap for mental disorders in five low and middle-income countries. plos one 2012;9:e1001359. 6. who. mental health systems in low and middle income countries: a cross national analysis of 42 countries using who-aims data. geneva, switzerland: world health organization; 2009. 7. who. the who mind project: mental improvement for nations development. geneva, switzerland: department of mental health and drug abuse, world health organization; 2008. 8. who. mental health gap action programme (mhgap): scaling up care for mental, neurological and substance use disorders. geneva, switzerland: world health organization; 2007. 9. who. mental health gap action programme (mhgap) newsletter, june 2011. geneva, switzerland: world health organization; 2011. available from: http://www.who.int/mental_health/publications/mhgap_newsletters/en/ 10. lagos state government. available from: http://www.lsmoh.com/ 11. gureje o, saxena s. who-aims report on mental health system in nigeria. ibadan, nigeria: world health organization and ministry of health publ.; 2006. 12. olugbile ob, zachariah mp, coker ao, et al. provisions of mental health services in nigeria. int psychiatry 2008;2:27-31. 13. coker ao, olugbile ob, eaton j, lasebikan vo. psychiatric psychosocial rehabilitation in nigeria; what needs to be done. nigerian j psychiatry 2011;9:2-9. 14. lasebikan vo, ejidokun a, coker ao. prevalence of mental disorders and profile of disablement among primary healthcare service users in lagos island. epidemiol res intern 2012;2012:357348. 15. oluwatayo o, olugbile o, coker ao. addressing the mental health needs of a rapidly growing megacity: the new lagos mental health initiative. int psychiatry 2014;11:20-2. 16. gureje o, lasebikan vo. use of mental health services in a developing country. results from the nigerian survey of mental health and well-being. soc psych psych epid 2006;41:44-9. 17. who. declaration of alma-ata. geneva, switzerland: world health organization; 1978. available from: www.who.int/publications/almaata_declaration_en.pdf 18. erinoso l. community psychiatry in nigeria: retrospection, challenges, and future prospects. in: proc. annual conf. association of psychiatrists in nigeria, 2010, enugu, enugu state, nigeria. 19. saraceno b, vanommeren m, batniji r, et al. barriers to improvement of mental health source in low income and middle income countries. lancet 2007;370:116474. 20. patel vh, kirkwood br, pednekar s, et al. improving the outcomes of primary care attenders with common mental disorders in developing countries: a cluster randomized controlled trial of a collaborative stepped care intervention in goa, india. trials 2008;9:4. 21. eaton j, agomoh ao. developing mental health services in nigeria: the impact of a community-based mental health awareness programme. soc psych psych epid 2008;43:522-8. 22. adewuya a, makanjuola r. preferred treatment for mental illness among southwestern nigerians. psychiat serv 2009;60: 121-4. review non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:1559] [page 1] public health and research funding for childhood neurodevelopmental disorders in sub-saharan africa: a time to balance priorities muideen o. bakare,1 kerim m. munir,2 mashudat a. bello-mojeed3 1child and adolescent unit, federal neuropsychiatric hospital, enugu, nigeria; 2division of developmental medicine, boston children’s hospital, boston, ma, usa; 3child and adolescent unit, federal neuropsychiatric hospital, lagos, nigeria abstract sub-saharan african (ssa) population consists of about 45% children, while in europe and north america children population is 1015%. lately, attention has been directed at mitigating childhood infectious and communicable diseases to reduce under-five mortality. as the under-five mortality index in sub-saharan africa has relatively improved over the last two decades, more sub-saharan african children are surviving beyond the age of five and, apparently, a sizeable percentage of this population would be living with one or more childhood neurodevelopmental disorders (ndd). the distribution of child mental health service resources across the world is unequal. this manifests in the treatment gap of major childhood onset mental health problems in ssa, with the gap being more pronounced for childhood ndd. it is important to balance the public health focus and research funding priorities in sub-saharan africa. we urgently need to define the burden of childhood ndd in the region for healthcare planning and policy formulation. introduction public health and research funding in subsaharan africa (ssa) has largely focused on communicable diseases, with less attention being paid to non-communicable diseases among the latter category ndd in children have a special place as they affect a major segment of the population.1 this linkage in disproportionate increase in developmental delays and intellectual disabilities was once termed as new morbidity and was one of the impetuses for the emergence of the special needs movement in the us.2 many of these children are showing declines in cognitive functioning, delays in language skills, as well as poor motor and social skills. there is a need for urgent research to identify nodal points for early intervention.2 one possible explanation for the current lack of public health attention to childhood ndd in ssa may be due to lack of human resource capacities for evaluation and interventions for children with complex ndd. capacity building in terms of public health and clinical services as well as provision of research funding in this area are of paramount importance at the present time. neurodevelopmental disorders (ndd) are group of disorders arising from impairments in the developing brain and/or the central nervous system. they are considered neurodevelopmental in that by definition they originate during the developmental period, that is, during the prenatal, ante-natal, post-natal, infancy and early childhood periods. the disorders have varying degrees of associated burden on children, their families and their communities and almost always require multi-faceted services to address special educational, health care, social inclusion and rehabilitation needs. the ndd include intellectual developmental disorders with known genetic or metabolic etiologies, traumatic or congenital brain injuries including conditions such as cerebral palsy, as well as such prenatal exposures such as fetal alcohol syndrome, and disorders of social relatedness such as autism spectrum disorders (asd). among the ndd of childhood, in particular, asd has received great deal of attention in the us and europe in the past decade. asd comprise a group of complex, lifelong, disorders that are now usually identifiable prior to 3 years of age. asd is characterized by qualitative impairments in reciprocal social interaction, impairments in verbal and non-verbal communication skills and a restricted pattern of interest or behavior (who, 1992; apa, 1994).3,4 in ssa, children under the age of 15 years on average consist about 36.5% (ghana) to 50% (uganda) of the overall population depending on country concerned.5 these figures contrast with under 15-year child population distribution in ireland (21%), united states (20%), uk (17.3%), netherlands (17%), sweden (15.4%), greece (14.2%), and germany (13.3%). europe and north america comprise about 15 to 20 percent of the total population (figure 1).5 in ssa, the number of children that will go on to lead productive lives will therefore have an important impact not only in term of the quality of life of their own and their families, but will be of critical importance for sustaining the economic and political development of the region. in view of the differences in health care priorities globally, public health and research funding policies in ssa had, to date, focused overwhelmingly on childhood communicable infectious diseases (e.g. pneumonia, diarrhea, malaria, hiv/aids) targeted towards reducing the rate of under-five mortality in the region in keeping with the millennium development goals (mdg).6 declining under-five mortality in sub-saharan africa over the last decades in ssa, efforts had been directed through multiplex public health and research policies to curtail the communicable diseases that contributed greatly to under-five morbidity and mortality. these efforts are yielding important fruits based on the present indicators of under-five mortality over the past two decades in the region.7 the efforts had been moving the ssa region closer to achieving reduction in child mortality rate as part of the mdg 4 (figure 2). ssa region had achieved on the average about 30 percent reduction in under-five mortality rate between the period of 1990 and 2010, it had also achieved double in its average rate of reduction from 1.2 percent a year between the period of 1990 and 2000 compared to 2.4 percent a year between the period of 2000 and 2010 (figure 3).7 in absolute terms, healthcare in low-resource settings 2014; volume 2:1559 correspondence: muideen o. bakare, child and adolescent unit, federal neuropsychiatric hospital, chime avenue, enugu, nigeria. tel./fax: +234.703.097.0079. e-mail: mobakare2000@yahoo.com key words: public health, childhood neurodevelopmental disorders, sub-saharan africa. acknowledgements: this work was partly supported by fogarty international center/nih grants tw005807 and tw009248 (kmm). contributions: all authors contributed to the conception of the idea behind this article and were involved in revising the manuscript. mob wrote the initial draft of the manuscript. all authors read and approved the final draft of the manuscript. received for publication: 10 april 2013. revision received: 4 july 2013. accepted for publication: 14 july 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright m.o. bakare et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1559 doi:10.4081/hls.2014.1559 non -co mmerc ial us e o nly [page 2] [healthcare in low-resource settings 2014; 2:1559] four countries in ssa region had achieved the greatest reduction world-wide with up to 60 percent reduction in under five mortality rate over the last two decades and more than 4.5 percent yearly rate reduction on the average between the period of 1990 and 2010. these ssa countries included malawi, liberia, niger and sierra leone.7 relative neglect of childhood neurodevelopmental disorders within the sub-saharan africa public health framework while understandably communicable diseases and the attendant under-five mortality rate might have been great challenge to ssa region, current evidence suggests that there are ongoing substantial improvements in these indices.7 going by the earlier observation that onset of symptoms of asd and other ndd often coincide with the period of underfive morbidity and mortality in ssa children,8,9 it is logical to think that with the improvement in under-five mortality index in the region, the prevalence of asd and other childhood ndd will be on the increase and deserve a greater level of public health significance. ironically however, asd and other childhood ndd have not been given adequate attention in the ssa region in terms of public health focus and research funding.10,11 likewise, the who mhgap has not emphasized the importance of the childhood ndd, focusing on adulthood disorders such as depression, national policies and rights of people with mental health conditions (where childhood ndd has a minor part, despite the disproportionate population numbers). to date, there has been no large scale epidemiological study of children to define the magnitude of the problem of asd and other childhood ndd in the ssa region, which can be used for the purpose of planning and policy formulation in the region.10-13 autism spectrum disorders and other neurodevelopmental disorders in africa it is well established that symptoms of asd occur among african children contrary to earlier notions.14 despite worldwide reports of increase prevalence of asd, there is no large scale community based epidemiological data on asd in africa. a recent study on asd among african children with intellectual and ndd suggests an increase in prevalence of asd in africa.13 there is a need for community based epidemiological study of asd in africa to confirm this trend. the onset of asd symptoms among african children coincide with the period of less than five (and often 3) years of age that is characterized by vulnerabilities of african children to physical illness and infectious diseases associated with neurological consequences.15 there is an over-representation of non-verbal cases of asd among african children presenting to orthodox medical facilities.16 the lack of or limited expressive language ability could be related to late interventions, resulting from late presentation and identification of asd among african children.16 in africa, it has been observed that asd is rarely diagnosed exclusively of intellectual disabilities and there is a wide gap between age of onset of symptoms and diagnosis of asd in africa.10 therefore identification and diagnosis of asd has been observed to be late among african children.12 possible factors identified from the literature that are associated with late identification of asd in africa include: poor knowledge and awareness about asd; cultural beliefs and practices; tortuous pathway to care/ help-seeking behavior; inadequate number of trained personnel; inadequate healthcare facilities.16 there is scarcity of intervention programs for children with asd and other ndd in africa. the few available services are very expensive with huge unaffordable cost to most of the parents of affected children.12 the changing paradigm in a review of pattern of funding for health in africa between the year 2000 and 2002, communicable diseases have received the majority of funding, 52%. this is followed by nutrition and food security that has ranked second in funding, 28%. child and adolescent health and survival, and women’s health and rights collectively received just about 3% of funding for this period.17 the present pattern of public health funding in africa may need to be reviewed because of the changing paradigm outlined in this report. we need to move to at least an equal emphasis on non-communicable disorders affecting children that now survive well beyond 5 years of age and likely to suffer lifespan effects with ensuing long term economic and societal gains. as noted earlier, the onset of asd symptoms among african children coincide with the period of less than five years that is characterized by vulnerabilities of african children to physical illness as well as infectious diseases associated with neurological consequences that effect brain development10 recent evidence suggests that with improvement in the index of under-five mortality in ssa and gradual progress being made towards achieving mdg 4, more children would be surviving beyond the age of five years and sizeable percentage of this population would be experiencing the burden of living with one or more ndd.10,18 the pertinent question is is the ssa region getting braze-up for this challenges? the answer at this time is a resounding no. the way forward there is unequal distribution of mental health service resources across the world, which has manifested in a mental health treatment gap (mhgap) which itself shows a specific imbalance for identification and treatment of major childhood mental disorders in ssa.19,20 the unequal distribution of child menbrief report figure 1. contrast in west africa and western europe population pyramids showing children population distribution. figure 3. many regions globally have reduced the under-five mortality rates by at least 50 percent between 1990 and 2010, with sub-saharan africa achieving an average of 30% reduction. figure 2. though slowly, sub-saharan africa is making progress towards reduction in under-five mortality and achieving the millennium development goal 4. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1559] [page 3] tal health service resources as it affects countries in ssa is more pronounced for childhood ndd.21 in line with mdg 6 which aims at achieving the objective of combating hiv/aids, malaria, and other diseases, research in the area of childhood ndd in ssa region is highly justified. furthermore, despite a disproportionately lower percentage of children in the general population the research on childhood ndd, and in particular, research on asd, in europe and north america has seen a remarkable surge. this also needs to be justified as an urgent policy perspective in ssa. there is a distributive ethical need to redress the imbalance that is reflected by the much larger population of children in ssa compared to that in europe and north america.22 conclusions the right time is now to conduct large scale epidemiological studies on asd and other childhood ndd among ssa children. this is justified for the purpose of planning and policy formulation in the region that is urgently needed to address the burden of the problem on children that are surviving well beyond age 5 and to reduce the stigma upon families and communities at large. these objectives cannot be achieved without reviewing the present public health and research funding policies in the region. finally, there is a need for major international ngos to emphasize research in childhood ndd in the ssa context. such a prioritization needs also to be reflected in the policies of the who mental health and substance abuse department, as well as early childhood development policies of unicef, among others, to begin to understand the complex neurodevelopmental conditions affecting children’s cognitive and social development. this needs to be achieved within a mental health paradigm, rather than a fantasy that somehow mental health does not exist and public health is all about prenatal care, maternal support, nutrition, immunization and prevention of communicable diseases. in order to effect lasting influences across the lifespan we need to prepare earlier on in the lifecycle for the identification of complex ndd and to provide cost effective early educational and behavioral interventions, as well as parent and teacher training strategies, social inclusion, and community empowerment. this is the time to balance priorities in public health and research funding, emphasizing childhood ndd in ssa. references 1. maher d, ford n, uwin n. priorities for developing countries in the global response to non-communicable diseases. global health 2012;8:8-14. 2. borkowski jg, whitman tl, passino aw, et al. unraveling the “new morbidity”: adolescent parenting and developmental delays. int rev res ment ret 1992;18:15996. 3. who. international classification of diseases. 10th ed. geneva: world health organization ed.; 1992. 4. apa. diagnostic and statistical manual of mental disorders. 4th ed. washington dc: american psychiatric association ed.; 1994. 5. undp. world development report. united nations development programme ed; 2004. available from: http://hdr.undp.org/ en/media/hdr04_complete.pdf 6. baingana fk, bos er. changing pattern of diseases and mortality in sub-saharan africa: an overview. in: jamison dt, feachem rg, makogba mw, eds. disease and mortality in sub-saharan africa. 2nd ed. washington dc: world bank ed.; 2006. 7. you d, wardlaw t. united nations interagency group for child mortality estimation (2011 report): levels and trends in child mortality. available from: http://resourcecentre.savethechildren.se/c ontent/library/documents/levels-trendschild-mortality-2011-report 8. lotter v. cross cultural perspectives on childhood autism. j trop pediatrics 1980; 26:131-3. 9. mankoski re, collins m, ndosi nk, et al. etiologies of autism in a case-series from tanzania. j autism dev disord 2006; 36:1039-51. 10. kauchali s, davidson ll. commentary: the epidemiology of neurodevelopmental disorders in sub-saharan africa: moving forward to understand the health and psychosocial needs of children, families, and communities. int j epidemiol 2006;35:68990. 11. idro r, newton c, kiguli s, kakoozamwesige a. child neurology practice and neurological disorders in east africa. j child neurol 2010;25:518-24. 12. bakare mo, munir km. autism spectrum disorders in africa. in: mohammad-reza m, ed. a comprehensive book on autism spectrum disorders. intech, 2011. rijeka: intech; 2011. pp 183-95. available from: http://www.intechopen.com/books/a-comprehensive-book-on-autism-spectrum-disorders/autism-spectrum-disorders-inafrica 13. fuentes j, bakare m, munir k, et al. autism spectrum disorders. in: rey jm, ed. iacapap e-textbook of child and adolescent mental health. geneva: international association for child and adolescent psychiatry and allied professions; 2012. pp c.2 1-27. available from: http://iacapap.org/wp-content/uploads/c.2autism-spectrum-072012.pdf 14. sanua vd. is infantile autism a universal phenomenon? an open question. int j soc psychiatr 1984;30:163-77. 15. bakare mo, ebigbo po, ubochi vn. prevalence of autism spectrum disorders among nigerian children with intellectual disability: a stopgap assessment. j health care poor u 2012:23:513-8. 16. bakare mo, munir km. excess of non-verbal cases of autism spectrum disorders presenting to orthodox practice in africa: a trend possibly resulting from late diagnosis and intervention. sajp-s afr j psychi 2011:17:118-20. 17. africa grantmakers’ affinity group. funding for health in africa: mapping the u.s foundation landscape 2000-2002. washington, dc: the tides center/africa grantmakers’ affinity group ed.; 2004. available from: http://www.africagrantmakers.org/pdf/hia.pdf 18. mung’ala-odera v, meehan r, njuguna p, et al. prevalence and risk factors of neurological disability and impairment in children living in rural kenya. int j epidemiol 2006;35:683-8. 19. saraceno b, dua t. global mental health: the role of psychiatry. eur arch psy clin n 2009;259(suppl.2):s109-17. 20. omigbodun o. developing child mental health services in resource poor countries. int rev psychiatr 2008;20:225-35. 21. njenga f. autism in africa: a challenge in the management of an important disorder. paper presented at the 13th iassid world congress cape town, south africa, august 2008. 22. yan eg, munir k. regulatory and ethical principles in research involving children and individuals with developmental disabilities. ethics behav 2004;14:31-49. brief report non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11750 evaluating the effect of dental explosion boxes on oral health awareness in preschoolers dewi sodja laela, indah fauziah, ulfah utami, megananda hiranya putri, yonan heriyanto, neneng nurjanah, irwan supriyanto, deru marah laut, nurul fatikhah, devy octaviana ministry of health bandung health polytechnic, bandung, indonesia abstract many children experienced anxiety during their initial dental visits, often fearing medical equipment and the procedures they would undergo. the dental explosion box served as an alternative approach to enhance oral health awareness and functioned as an educational tool integrated with a game. this study aimed to assess the effectiveness of the dental explosion box in introducing oral health concepts to early childhood. this research employed a pre-experimental design featuring a one-group pretest and post-test approach. sampling relied on the purposive sampling technique, with the sample size determined using the isaac and michael formula, resulting in a cohort of 25 preschool students. variables examined in this study encompassed the dental explosion box and oral health awareness. oral health awareness in preschool children was measured using a checklist of questions. the dental explosion box had undergone rigorous testing and had been endorsed by media and material experts. the study’s hypotheses were tested using the wilcoxon sign rank test. the average pre-intervention oral health introduction score was 6.68, while the post-intervention score increased to 11.00. analysis through the wilcoxon sign rank test revealed a significant difference (p-value of 0.000, <0.05) between the level of oral health awareness in early childhood before and after receiving intervention with the dental explosion box. the findings from this study highlighted the effectiveness of the dental explosion box in introducing oral health concepts to early childhood. it enhanced children’s familiarity with oral health and motivated them to regularly visit the dentist. introduction early recognition and dental care are highly important, especially considering the substantial number of children with a relatively high def-t index, many of whom have not received proper treatment. it has been reported that the global prevalence of caries in children ranges from 23.8% to 57.3% among all children aged 0-6 years worldwide. research in mexico indicates that dental caries affects 20-70% of children under 6 years of age. similarly, in developed countries like england, the prevalence of dental caries among 5-year-old children is approximately 40-60%.1 research by the basic health research (2018) indicates a very high prevalence of caries in early childhood (90.1%), with only 9.9% of children being free from dental problems such as cavities.2 according to the indonesia basic health survey (2013), there was a 28.9% increase in dental and oral health problems among children aged 5-9 years and a 25.2% increase among those correspondence: dewi sodja laela, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: lalawardiyo@gmail.com key word: oral health; awareness; dental explosion boxes. contributions: dsl, if, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ut conceptualization, methodology, formal analysis; mph visualization, writing – review and editing; yh resources, investigation, and writing –review and editing; nn validation, writing – review and editing; is resources, supervision, and writing –review and editing; dml resources, investigation, and writing –review and editing; nf resources, investigation, and writing –review and editing; do resources, investigation, and writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, team of the bandung health polytechnic, based on ethical certificate no.39/kepk/ec/iii/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 11 september 2023. accepted: 6 november 2023. early access: 16 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11750 doi:10.4081/hls.2023.11750 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11750] [page 119] non -co mmerc ial us e o nly aged 10-14 years. efforts to maintain oral health should commence early, particularly during elementary school, which is an ideal time for practicing motor skills in children.3 efforts to maintain the overall health of children, including factors related to dental and oral health, are of paramount importance in supporting the growth and development of children. oral health can effect the well-being, abilities, and competence of a child, and it can also affect the child’s overall physical health.4–6 therefore, it is essential to begin preventive measures for dental cavities early on. one of the prevalent oral health issues in indonesia today is tooth loss. several treatments can be undertaken to address these problems, particularly to restore the function of missing teeth, including mastication, speech function, and aesthetic improvement.7 the american dental association and the american academy of pediatrics mention that regular check-ups with a dentist every 6 months are highly recommended to detect dental and oral problems as early as possible. children should be taken to a doctor or dental clinic before they reach one year of age or before their first baby teeth emerge.8 in ismau’s study (2019), an overview of routine oral health checks for school-age children was provided. out of 150 samples, only 41 students, or approximately 27.33%, regularly checked their teeth with a dentist, while 109 students, or about 72.66%, did not undergo routine dental check-up.9 the fear experienced by children can influence their behavior and, in turn, may determine the success of their visit to the dentist. introduction to the world of dental health can begin during a visit to the dentist at the age of 18 months, with treatment being carried out at the age of 23 years. during the visit, the child is introduced to dentists, dental nurses, the examination room’s facilities and infrastructure, as well as the situations that may occur during dental treatment.10–14 one of the efforts to introduce the concept of dental health can be achieved through the use of educational media. learning media utilized in early childhood education should be capable of enhancing children’s enthusiasm, such as interactive toys. the dental explosion box comprises various educational sections combined with games to make learning engaging for children. the components of the dental explosion box can serve as a creative and innovative knowledge medium for introducing oral health to children.15–17 the advantages of using the explosion box as supplementary media in dental education include its ability to make students enthusiastic and eager to interact, as well as its capacity to facilitate students’ comprehension of the learning material. research results from sari et al. (2020) indicated differences in learning outcomes when using the explosion magic box, with an average pre-test score of 61.06 increasing to 85.95.18 santoso et al. (2021) suggest that a media promotion model, the teeth box explosion, is effective in bringing about changes in tooth brushing behavior in elementary school students.19 based on research by syarief et al. (2021), it can be observed that there is a change in the level of knowledge regarding vegetables and fruit when using the explosion box media. students’ memory is more focused on visual objects and images as compared to written content and images in powerpoint or slides.20 the difference in this research lies in the fact that the respondents were at a very young age, and the type of explosion book was more specific, focusing on the world of dental health. the research aimed to analyze the effectiveness of the dental explosion box as a medium for introducing the concept of oral health to young children, which can serve as study material to encourage young children to undergo regular check-ups at oral health service facilities. materials and methods research design this research is a pre-experimental study with a one-group pre-test and post-test design. the research sample consisted of dental toddler boarding school students in march 2023. study participants the sample size was determined using the formula developed by isaac and michael, with a 5% error rate.21 the inclusion criteria encompass children aged 4 to 6 years who are registered as preschool students, while the exclusion criteria pertain to preschool children with special conditions that may influence the results. the sample calculations yielded a total of 25 preschool students. variable, instrument and data collection primary data were obtained through research instruments in the form of checklists and the dental explosion box (figure 1). the measurement of students’ awareness of oral health was conducted using a checklist of questions. the data collection process was assisted by the toddlers’ teacher to ensure that the language used was easier for the students to understand. the assessment of the level of recognition before and after the intervention involved assigning a numerical code to the checklist sheet: correct answers were given a value of 1, while incorrect answers were given a value of 0. the assessment results were grouped into three categories: i) high awareness = 12-18, ii) moderate awareness = 6-12, and iii) low awareness = 0-6. the dental explosion box consists of five components. the first component introduces oral health workers in clinics. the second component provides an introduction to dental clinic infrastructure. the third component introduces dental examination tools. the fourth component includes tools for examining and maintaining oral health. the fifth component models good and bad oral habits.regarding the media and materials used in the dental explosion box, the materials have undergone feasibility testing by media and material experts, utilizing the media and material feasibility test presentation formula. the eligibility categories are based on the following criteria: i) < 21% = very unsuitable, ii) 21-40% = not feasible, iii) 41-60% = somewhat feasible, iv) 61-80% = feasible, and v) 81-100% = very suitable. the assessment of the diligence results by three material experts and three media experts in this study obtained a score of 87%, indicating that it was highly suitable for use. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. dental explosion box introduction to the oral health. [page 120] [healthcare in low-resource settings 2023; 11:11750] non -co mmerc ial us e o nly data analysis the data in this study were analyzed using the wilcoxon sign rank test, with a significance level of p < 0.05. if the probability value is < 0.05, the hypothesis is accepted, indicating that the dental explosion box can increase preschool children’s awareness of oral health. ethical clearance the research has received ethical approval from the health research ethics commission, a team at the bandung health polytechnic, based on ethical certificate no. 39/kepk/ec/iii/ 2023. during the research, the researcher adhered to ethical principles, including obtaining informed consent, respecting human rights, and ensuring beneficence and non-maleficence. results this study analyzes the effectiveness of the dental explosion box in introducing oral health to preschool children. the research was conducted with 25 early preschool children in one of the preschool areas. table 1 displays the characteristics of the respondents based on age and gender. the most common age is 6 years, with a total of 11 people (44%), and the predominant gender is female, with a total of 15 people (60%). table 2 presents the level of awareness of oral health before using the dental explosion box, with boys having a recognition level of 20.0% and girls at 6.6%. after receiving counseling on oral health using the dental explosion box, both boys and girls achieved a 100% recognition level. the recognition scores of early childhood related to oral health using the dental explosion box are provided in the form of descriptive statistical data values, with the measurement results as follows. table 3 displays a total of 25 samples of children’s recognition scores related to oral health. the recognition scores prior to receiving treatment varied between a minimum of 4 and a maximum of 9. the pre-introduction score data had an average of 6.6800 and a standard deviation of 1.2819. following treatment using the dental explosion box, recognition scores ranged from a minimum of 9 to a maximum of 12. post-treatment recognition score data had an average of 11.000 and a standard deviation of 0.7071. the smaller standard deviation values in both data sets indicate that the measurements are consistent, with no data deviating significantly from the average. the wilcoxon sign rank test was used to analyze the effectiveness of introducing the dental explosion box to oral health. table 4 displays the p-value (0.000) < 0.05, leading to the conclusion that there are differences in preand post-scores for the introduction to the world of oral health. the data scores indicate an improvement in the introduction of oral health to preschool children. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. level of awareness of the oral health based on gender of preschool childrens before and after intervention using dental explosion box.categorical frequency percentage (%) awareness level not awareness (%) enough awareness (%) awareness (%) pre post pre post pre post gender male 2 (20) 0 (0) 8 (80) 0 (0) 0 (0) 10 (100) female 1 (6.6) 0 (0) 12 (80) 0 (0)2 (13.4) 15 (100) total 3 0 20 0 2 25 table 3. results of the average the oral health recognition score. n minimum maximum mean std. deviation score pre-test 25 4.00 9.00 6.6800 1.2819 score post-test 25 9.00 12.00 11.000 0.7071 table 4. effectiveness dental explosion box introducing the oral health. n mean std. deviation z p remarks score pre-test 25 6.680000 1.281926 -4.413912 0.000 significant test (significant) score post-test 25 11.000000 0.707107 table 1. the characteristics of the respondents include the age and sex of the child. categorical frequency percentage (%) age 4 years 7 28 5 years 7 28 6 years 11 44 gender male 10 40 female 15 60 total 25 100 [healthcare in low-resource settings 2023; 11:11750] [page 121] non -co mmerc ial us e o nly discussion oral health care for children from an early age is important because children are in a period of growth and development. dental health is closely related to the physical and psychological development of children. maintaining awareness of dental and oral health can help prevent issues and provide treatment as needed.22 tooth decay is the most common issue in children compared to other dental and oral diseases. one way to address this is by taking children to dental health care facilities, with the hope that regular dental checkups will help children become accustomed to them, reducing anxiety and fear related to dental and oral care.23–25 the child’s first visit to the dentist is crucial for motivating them to continue with dental treatment. during this initial visit, it’s best to introduce your child to the dental examination process and demonstrate that it can be a pleasant experience.26–28 dental health workers typically aim to establish a connection with children before examining their teeth. this bond is essential to ensure the child’s cooperation during treatment.29 the results of this study indicate the level of introduction to oral health in preschool children before and after intervention using the dental explosion box. it shows that girls gain awareness of oral health more quickly (table 1). according to their perception, female students tend to have greater motivation in recognizing an object than male students. this is because boys often prefer unstructured outdoor activities, and they are more dependent on physical space rather than time. boys design their games, and during play, they rely more on visual skills than verbal ones, with language use primarily limited to task completion. this research on the dental explosion box is designed to provide an overview of dental and oral health. dioramas and interior models within the dental explosion box consist of representations of a healthcare team, dental health service settings, dental tools, dental treatment processes, and methods for maintaining oral health. the dental explosion box includes various educational sections integrated with games to make it engaging for children. the instructional dental explosion box offers a variety of learning activities to prevent boredom and encourages students to participate in activities beyond simply listening to the teacher, including observing, doing, and presenting. according to the results of daniati et al.’s research in 2020, the game component within the explosion box media serves as a creative and innovative knowledge medium.17 according to wijayanti et al. (2020), the explosion box learning media is created with the aim of helping students understand the material in a more enjoyable way.30 the research results in table 3 show that the use of dental explosion media can increase preschool children’s awareness of oral health. the selection of the dental explosion box as a method to introduce oral health makes it easier for students to learn about the dental care process, including how to maintain oral health behaviors. the results of this study align with the research conducted by santoso et al. in 2021, which demonstrates that the dental explosion box is an effective medium for promoting oral health and changing tooth brushing behavior in school-age children, as compared to flashcards.19 the dental explosion box offers the benefit of enhancing the maintenance of oral health in children, increasing their self-awareness, making children more conscious of how to properly and correctly care for their teeth, providing a high-quality and creative play experience for children, and developing children’s fine motor skills to remember how to brush their teeth correctly and effectively.31 the dental explosion box can enhance logical thinking abilities in preschool children, making it a suitable medium for early childhood education. an interactive and effective dental explosion can have a positive effect on children, leading to changes in their knowledge, attitudes, and behaviors in a positive direction. using an interactive and efficient dental explosion box is highly appropriate for delivering lessons. interactive engagement with the dental explosion box can stimulate a child’s curiosity and promote the development of logical thinking skills. when teaching early childhood, methods that provide holistic situations and relate them to oral health models should present materials that are relevant to the characteristics and needs of children. learning that mirrors real-life situations will pique children’s curiosity, and incorporating play activities in an engaging and colorful manner is essential. the results of this study are supported by the research conducted by fitriana & chandrawati in 2016, which demonstrated the effective use of games in the field of dental health as a learning tool for early childhood dental health, including an introduction to dental caries.32 additionally, research conducted by humaira et al. in 2023 regarding the development of the smart dental box media illustrates an improvement in the maintenance of dental and oral health in children aged 5-6 years after receiving an interventiontion.33 the dental explosion box provides variations in learning activities to prevent boredom and encourages students to engage in activities beyond just listening to the teacher, such as observing, participating, and presenting. the dental explosion box can assist the dental health team in educating children about oral health. in addition to being a learning tool, the dental explosion box also clarifies the meaning of the subject matter through visuals. health workers and parents have a role in efforts to introduce oral health to children.34 insufficient knowledge and understanding of oral health among less supportive parents can result in poor dental and oral health maintenance behaviors in six-year-old children (golden age).35,36 providing educational stimulation aims to support the growth and development of children, both physically and spiritually, so that they are prepared for further education. early childhood learning should focus on imparting meaningful basic concepts to children through real experiences, allowing them to engage in activities and curiosity optimally.37 early childhood can easily absorb experiences about of oral health through concrete (real) objects. introduction to the world of oral health using the dental explosion book is the most effective way to develop children’s abilities optimally. when facilitated optimally, indoor play activities with the dental explosion book are important for the holistic development of children, encompassing physical, emotional, mental, intellectual, creative, and social aspects. the limitation of this research is that when explaining the contents of the explosion box, preschool children’s concentration can be easily distracted. therefore, it is necessary to provide assistance from the teacher in explaining it in a way that children can understand. conclusions dental explosion boxes can be an effective tool in increasing preschool children’s understanding of the importance of oral health care. children become more familiar with of oral health, and they are motivated to routinely visit the dentist. [page 122] [healthcare in low-resource settings 2023; 11:11750] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly references 1. who. global oral health status report: towards universal health coverage for oral health by 2030. world health organization. 22ad. 2. kementerian kesehatan ri. laporan nasional riskesdas 2018. balitbangkes. 2019. p. hal 156. 3. aufa alma’as nabila m, firdaus r, fitriyani in, et al. effectivity difference with of powerpoint and pop-up education media in dental knowledge and habit in elementary school students. int j pharm res 2020;12:2099-103. 4. pratamawari dnp, atikasari d, bramantoro t. the effect of parents’ socioeconomic factors on their willingness to take care of their children’s oral health in early childhood. j int dent med res 2022;15:845-9. 5. gussy mg, waters eb, riggs em, et al. parental knowledge, beliefs and behaviours for oral health of toddlers residing in rural victoria. aust dent j 2008;53:52-60. 6. mahmoud n, kowash m, hussein i, hassan a, al halabi m. oral health knowledge, attitude, and practices of sharjah mothers of preschool children, united arab emirates. j int soc prev community dent 2017;7:308. 7. berniyanti t, palupi r, alkadasi ba, et al. oral health-related quality of life (ohrqol) analysis in partially edentulous patients with and without denture therapy. clin cosmet investig dent 2023;15:89-98 8. george a, sousa ms, kong ac, et al. effectiveness of preventive dental programs offered to mothers by non-dental professionals to control early childhood dental caries: a review. bmc oral health 2019;19:1-9. 9. ismau ai, ngadilah c, obi al, fankari f. pengetahuan dan tindakan orang tua dalam perawatan gigi susu. dent ther j 2019;1:66-73. 10. veale m, ajwani s, johnson m, et al. the early childhood oral health program: a qualitative study of the perceptions of child and family health nurses in south western sydney, australia. bmc oral health 2016;16:2-10. 11. sumangando ff, mintjelungan cn, pangemanan dhc. level of parental knowledge about maintenance of dental and oral hygiene in early childhood. e-gigi 2022;10:197. 12. zhou n, wong hm, mcgrath c. oral health and associated factors among preschool children with special healthcare needs. oral dis 2019;25:1221-8. 13. alai-towfigh h, schroth rj, hu r, et al. canadian dentists’ views on the first dental visit for children. front oral heal 2022;3. 14. hamid t, kuntari s. mothers’ role in dental health behaviors of their children in the low-income community, blitar rural area. j int dent med res 2022;15:218-22. 15. schroth rj, kyoon-achan g, levesque j, et al. a mixed methods approach to obtaining health care provider feedback for the development of a canadian pediatric dental caries risk assessment tool for children <6 years. front oral heal 2023;4:1-10. 16. camargo mbj, barros ajd, frazão p, et al. predictors of dental visits for routine check-ups and for the resolution of problems among preschool children. rev saude publica 2012;46:87-97. 17. daniati n, hendaningrum m, kusmana a. dental explosion box 3d on knowledge of dental and oral health student’s incisor. indonesian j care’s oral heal 2022;6:303-13. 18. sari eni, chaidaroh u, sirojudin d. efektivitas media explosion magic box untuk meningkatkan hasil belajar siswa kelas xi pada mata pelajaran fikih di ma alihsan kalikejambon. j educ manag stud 2020;3:31-8. 19. santoso b, marludia ma, djamil m, et al. explosion teeth box promotion media model against changes in teeth brushing behavior in school students. j appl heal manag technol 2021;3:53-8. 20. syarief o, handayani f, widartika w, et al. pendidikan gizi menggunakan media exploding box terhadap pengetahuan tentang sayur dan buah pada anak sekolah dasar. j ris kesehat poltekkes depkes bandung 2021;13:1-11. 21. sugiyono. metode penelitian pendidikan (pendekatan kuantitatif, kualitatif, dan r&d). bandung: alfabeta; 2013. 458 p. 22. ramadhan nt, sari af, prakoso mrt, et al. the level of knowledge about health and dental care in non-dental medicine students. syst rev pharm 2020;11:864-7. 23. cheng j, cheng j. empirical analysis of early childhood enlightenment education using neural network. comput intell neurosci 2022;2022. 24. ahn e, kim sm. the costeffectiveness of early dental visit in infants and toddlers focused on regional deprivation in south korea: a retrospective cohort study. plos one 2022;17:1-11. 25. elfarisi rn, susilawati s, suwargiani aa, et al. kesehatan gigi dan mulut terkait kualitas hidup anak usia 4-5 tahun di desa cilayung oral health related to the quality of life of children aged 4 5-years-old in cilayung village. j kedokt gigi univ padjadjaran 2018;30:85-94. 26. qu x, houser sh, tian m, et al. effects of early preventive dental visits and its associations with dental caries experience: a crosssectional study. bmc oral health 2022;22:1-9. 27. hung m, licari fw, lipsky ms, et al. early preventive dental visits: do they reduce future operative treatments? dent j 2022;10:53. 28. john jr, mannan h, nargundkar s, et al. predictors of dental visits among primary school children in the rural australian community of lithgow. bmc health serv res 2017;17:1-10. 29. luo h, i. garcia r, moss me, et al. trends of children being given advice for dental checkups and having a dental visit in the united states: 2001-2016. j public health dent 2020;80:123-31. 30. wijayanti1 fd, lestariningrum a, sari atr. pengembangan media pembelajaran explosion box pada anak usia 5-6 tahun guna meningkatkan kemampuan kognitif berpikir logis. j early child incl educ 2022;6:40-5. 31. ulfah m, nurhayati e, abyati h. pengembangan media box of number berbasis tematik untuk pembelajaran matematika permulaan anak usia 4-5 tahun. al-athfal j pendidik anak 2019;5:151-68. 32. fitriana dn, chandrawati b. the world of “gigi” game. sisforma 2016;3:63-9. 33. humaira s, satria d, riau u, et al. pengembangan media smart dental box terhadap pemeliharaan kesehatan gigi anak usia 56 tahun di tk as-shofa kecamatan tembilahan hulu. j educ 2023;5:7563-673. 34. pristina n, arief ys, armini nka. family parenting on the incidence of dental caries in children: a systematic review. malaysian j med heal sci 2023;19:135-44. 35. hariyani n, setyowati d, listl s, nair r. effect of socioeconomic status on teeth and dental care evidence from a populationbased study in indonesia. oral heal prev dent 2023;21:77-82. 36. feldens ca, fortuna mj, kramer pf, ardenghi tm, vítolo mr, chaffee bw. family health strategy associated with increased dental visitation among preschool children in brazil. int j paediatr dent 2018;28:624-32. 37. hashim r, thomson wm, ayers kms, et al. dental caries experience and use of dental services among preschool children in ajman, uae. int j paediatr dent 2006;16:257-62. [healthcare in low-resource settings 2023; 11:11750] [page 123] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s2):11379 helicobacter pylori infection and non-alcoholic fatty liver disease. is there a relationship? neveen rashad mostafa,1 abeer a.m. ali,2 mona gamalludin alkaphoury,3 roy rillera marzo4,5 1department of experimental and clinical internal medicine, medical research institute, alexandria university, egypt; 2department of chemical pathology, medical research institute, alexandria university, egypt; 3department of diagnostic radiology, ain shams university, egypt; 4department of community medicine, international medical school, management and science university, shah alam, malaysia; 5global public health, jeffrey cheah school of medicine and health sciences, monash university malaysia, kuala lumpur, malaysia abstract the most prevalent infection that causes chronic gastritis, gastric ulcers, and gastric cancer is helicobacter pylori infection. recent research has implicated h. pylori in the pathogenesis of non-gastrointestinal diseases such as cardiovascular, autoimmune, and metabolic disorders. in addition, since h. pylori is believed to be implicated in insulin resistance, numerous studies have been conducted to determine the relationship between h. pylori infection and nonalcoholic fatty liver diseases (nafld), but the results have been contested. the purpose of this study is to determine the relationship between h. pylori infection and nonalcoholic fatty liver diseases. one hundred patients were examined via urea breath test for the presence of h. pylori infection and vibration-controlled transient elastography for the diagnosis of non-alcoholic fatty liver disease. after adjusting for other variables, age, body mass index (bmi), and h. pylori infection were associated with elastography 248db/m. infection with h. pylori contributes to the development of nafld, and its eradication may influence prognosis. introduction helicobacter pylori infection is a prevalent condition worldwide, particularly in developing countries. it is considered the most common cause of gastric mucosa causing chronic gastritis, gastric ulcers, and gastric cancer.1 recently, h. pylori was found to be involved in the pathogenesis of other non-gastric diseases, and involved in the pathogenesis of insulin resistance and several metabolic and autoimmune diseases that affects the liver.2 nonalcoholic fatty liver disease (nafld) is a group of metabolic diseases caused mainly by insulin resistance with hereditary susceptibility. it is considered a manifestation of metabolic syndrome in the liver, in the absence of alcohol consumption, and includes nonalcoholic fatty liver, nonalcoholic steatohepatitis, liver fibrosis, and cirrhosis.3 nafld is a common disease condition affecting 25% of the population worldwide, with higher prevalence rates observed in the middle east (32%), and in latin america (31%).4 hepatic lipid homeostasis is controlled by signaling/transcriptional pathways mediated by hormones, transcription factors, and nuclear receptors. triglyceride accumulation mostly is considered the first step in the development of nafld and results from a disturbed balance between tg production and utilization and unregulated insulin signaling at the level of the adipose tissue.5 in obese and diabetic patients with insulin resistance there is increased lipolysis with increased formation of nonesterified fatty acids directed to the liver where they are taken up by hepatocytes.6 cd36 also facilitates their uptake and accumulation in other cell types (macrophages, adipocytes, enterocytes, and myocytes). cd36 has been shown to rise in animal models with hepatic steatosis. in humans, morbidly obese patients with nafld showed a correlation between messenger rna levels of cd36 and liver fat content.7 it has been shown that there are other two factors contributing to fat accumulation in the liver, these factors are dietary fat and de novo lipogenesis. two enzymes catalyze hepatic correspondence: neveen rashad mostafa, department of experimental and clinical internal medicine, medical research institute, alexandria university, egypt. e-mail: doctor.aj.2000@gmail.com key words: helicobacter pylori, lipid, non-alcoholic fatty liver. contributions: nrm, data collection, manuscript drafting and statistical analysis; aama, biochemical assay; mgak, elastography; rrm, manuscript editing, language revision. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: the study was approved by the medical research institute hospital’s local ethics committee, which follows the helsinki declaration terms. informed consent was taken from all participants. consent for publication: the manuscript does not contain any individual person’s data in any form. availability of data and materials: data sharing is not applicable as no dataset was generated or analyzed during the current study. received for publication: 11 april 2023. accepted for publication: 10 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):11379 doi:10.4081/hls.2023.11379 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 12] [healthcare in low-resource settings 2023; 11(s2):11379] non -co mmerc ial us e o nly fatty acid synthesis which is acetyl-coa carboxylase and fatty acid synthase and are controlled by insulin and by glucose through liver x receptors which directly induce acetyl-coa carboxylase and fatty acid synthase. de novo lipogenesis is markedly increased in nafld mainly due to the coexistent hyperinsulinemia and increased intake of simple sugars.6 the mechanism claimed to be involved in the development of nafld is the “second hit hypothesis” which is the oxidative stress, as the “first hit” usually is the fat accumulation in hepatocytes, and the “second hit” is the oxidation that causes hepatic injury.8 recently, the “multiple hits” hypothesis is more reliable and accepted, as proposed by takaki et al.,9 and buzzetti et al.,10 they found that multiple factors work together on genetically predisposed subjects that lead to the development of nafld; these factors include insulin resistance, adipose tissue hormones, nutrition, and gut microbiota. khosravi et al.,11 found that h. pylori infection was related to gut microbiota by using germ-free and specific pathogen-free mice and found that there is a strong relation between normal gut microbiota and infection with h. pylori which alters the metabolism and induce gut inflammation considering h. pylori as one of the mechanisms that cause nafld through gut microbiota dysbiosis. this was confirmed by sumida et al.,12 as they found that invasion of h. pylori into intestinal mucosa may increase gut permeability and alter gut microbiota and subsequently increase the passage of bacterial endotoxin through the portal vein to the liver and initiate inflammation and considered as one of the multiple hits causing nafld. in this study, we are aiming at finding the relationship between h. pylori infection and the development of nafld. materials and methods study design and population this study was conducted on 100 patients, 50 of whom were diagnosed with h. pylori infection while the other 50 were not. the patients were examined for the presence of fatty liver in the absence of alcohol consumption. they were selected from either outpatient clinics or inpatient wards of the medical research institute for any medical reason during the period from june 2022 to december 2022, in alexandria, egypt. participants with dm, hypertension, alcohol consumption, and chronic liver disease were excluded from the study. informed consent was obtained from all patients in a case-control study and approved by the medical research institute ethics committee. clinical data the clinical data collected included: i) thorough clinical examination including weight and height; ii) routine laboratory investigations include liver function tests, renal function tests, lipid profiles, electrolytes, complete blood pictures, and fasting blood sugar;13 iii) the urea breath test was done for the diagnosis of h. pylori infection;14 iv) nfld was diagnosed using vibration-controlled transient elastography, the cut-off for steatosis is >248 db/m.15 statistical analysis data were fed to the computer and analyzed using ibm spss software package version 20.0. (armonk, ny: ibm corp). categorical data were represented as numbers and percentages. the chi-square test was applied to investigate the association between the categorical variables. for continuous data, they were tested for normality by the shapiro-wilk test. quantitative data were expressed as a range (minimum and maximum), mean, standard deviation, and median. student t-test was used to compare two groups for normally distributed quantitative variables. on the other hand, the mann-whitney test was used to compare two groups for not normally distributed quantitative variables. and receiver operating characteristic curve (roc) was used to determine the diagnostic performance of the markers, an area of more than 50% gives an acceptable performance, and an area of about 100% is the best performance for the test. the significance of the obtained results was judged at the 5% level. results the effect of demographic data on nafld was tested, and we found that fatty liver is more common in females but not statistically significant. p=0.680, while age was significantly related to fatty liver where the mean age in patients with steatosis was 52.5±12.4 years, and the mean age of patients without steatosis was 38.2±14.3 (p<0.001). bmi also was a risk factor for steatosis, where the mean bmi in patients with nafld was 32±3.9 kg/m2, and in patients without nafld was 28.8±4.3kg/m2, p<0.001 (table 1). various biochemical markers were evaluated for their relationship to nafld, including liver enzymes such as alanine aminotransferase (alt), aspartate aminotransferase (ast), total cholesterol (tc), low-density lipoprotein (ldl), high-density lipoprotein (hdl), and triglyceride level (tg). however, none of these markers showed a significant relationship with nafld (table 2). article table 1. relation between elastography and demographic data. total n = 100 elastography test of sig. p ≤248 db/m >248 db/m gender male (%) 38 (38.0) 18 (36.0) 20 (40.0 χ2= 0.170 0.680 female (%) 62 (62.0) 32 (64.0) 30 (60.0) age (years) mean±sd 45.4±15.1 38.2±14.3 52.5±12.4 u=566.0* <0.001* median (min-max) 46 (19-68) 35 (19-66) 57 (29-68) bmi (kg/m2) mean±sd 30.4±4.37 28.8±4.3 32±3.9 t=3.963* <0.001* median (min-max) 30.5 (18.5-38) 29.0 (18.5-37.0) 32 (26-38) sd, standard deviation; χ2, chi-square test; t, student t-test; u, mann-whitney test. *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11379] [page 13] non -co mmerc ial us e o nly the relation between nafld and h. pylori infection was examined, revealing a prevalence of h. pylori infection in patients with nafld was 68% and in patients without nafld 32%. additionally, we found that the mean elastography value in h. pylori +ve patients was 250.4±33.59 db/m, while the mean in h. pylori-ve patients was 229.3±33.83 db/m, p=0.002 (table 3). furthermore, h. pylori was found to have a significant prognostic performance of h. pylori infection with elastography values ≥248 db/m, (95% ci 0.582-0.794, p=0.001, sensitivity 68% and specificity 68%; table 4, figure 1). assessment of various biochemical markers, demographic data, and h. pylori infection in patients with and without nafld in a univariate analysis showed that age, bmi, and h. pylori infection were associated with elastography ≥ 248 db/m after adjustment with other variables. multivariate analysis showed that these factors were independent risk factors for nafld (table 5). discussion non-alcoholic fatty liver disease is a common metabolic health problem that has become a public health concern. the peak of fatty liver incidence is between 40-50 years of age in males and 60-69 years in females, with minimal reduction in older (>70 yrs) cohorts.16 in a retrospective cohort study conducted on 351 patients with nafld diagnosed by biopsy, the patients were divided into (≥60 yrs), (≥50 to <60 yrs), and a younger (<50 yrs) group. the study found that nafld was more prevalent in the middle-aged and the elderly.17 in our study, we found that the mean age of patients with nafld was 52.5±12.4 years and in patients without nafld it was 38.2±14.3 years. hence, confirming that the incidence increases with age and it is an independent risk factor for nafld. this is probably due to an increase in all risk factors for fatty liver in older age groups such as hypertension, diabetes, hyperlipidemia, and obesity. according to previous longitudinal studies, nafld is more common in males as compared to females.18 however, a study specifically investigating nafld in females found that the incidence is higher in menopausal females (7.5%) and postmenopausal females (6.1%) than in premenopausal females (3.5%). the study also reported that postmenopausal women had an increased risk of nafld at univariate but not at multivariate analysis after adjustment for age, metabolic syndrome, and bmi.19 in our study, we found that the incidence of nafld is more common in females but was not statistically significant, this may be due to the increased age of patients with nafld in our study, and the fact that most of the females studied were postmenopausal. female sex hormones are known to protect against dysmetabolism and promote the division of fatty acids into ketone bodies rather than into very low-density lipoprotein-triacylglycerol. the senescence of the article table 2. relation between elastography and different parameters. total n=100 elastography test of sig. p ≤248 db/m >248 db/m alt mean±sd 28.7±23.1 24.2±12.8 33.3±29.6 u=1014.0 0.103 median (min-max) 23 (10-153) 20 (11-72) 23 (10-153) ast mean±sd 25.6±16.5 22.9±8.49 28.3±21.5 u=1046.0 0.159 median (min-max) 22 (11-125) 22 (13-49) 26 (11-125) total cholesterol mean±sd. 183.7±30 181.6±26.0 185.8±33.6 t 0.692 0.490 median (min.-max.) 181 (105-254) 180 (137-245) 182 (105-254) ldl mean±sd 100.7±22.5 98.5±22 102.9±23.1 t=0.985 0.327 median (min-max) 95 (59-157) 93 (68-155) 100 (59-157) hdl mean±sd 49.96±8.80 50.5±8.84 49.4±8.83 t=0.589 0.557 median (min-max) 49 (29-74) 53 (29-67) 46 (38-74) triglyceride mean±sd 114.8±46.49 112.4±44.52 117.2±48.72 u=1250.0 1.000 median (min-max) 96.5 (51-246) 98 (51-246) 94 (60-225) h. pylori (%) 50 16 34 χ2=12.96* <0.001* sd, standard deviation; t, student t-test; u, mann-whitney test; χ2, chi-square test. *statistically significant at p≤0.05 figure 1. roc curve for elastography to prognoses positive h. pylori patients. [page 14] [healthcare in low-resource settings 2023; 11(s2):11379] non -co mmerc ial us e o nly ovaries also increases the formation of hepatic steatosis and progression to fibrosis.20 obesity has been linked to fatty liver disease in all stages, starting from simple steatosis to steatohepatitis and fibrosis. obesity causes the accumulation of fat inside liver cells through increasing insulin resistance and leads to progression to non-alcoholic steatohepatitis and its related cirrhosis.21 in a cross-sectional study conducted on 3202 individuals to investigate the association of bmi with fatty liver found that a dose-response analysis with adjustment of other factors like age, gender, hypertension, total cholesterol, triglycerides, glucose, high-density lipoprotein, low-density lipoprotein, uric acid, homocysteine, creatinine, aspartate aminotransferase, and alanine transaminase showed that overweight and obesity were significantly related to fatty liver risk (p=0.004 or lower). they reported that high bmi (overweight/obesity) is an independent, dose-dependent risk factor for fatty liver.22 in a study conducted on the sudanese population to assess the risk factors for non-alcoholic fatty liver disease, they found that increasing age and obesity were the most prominent predisposing factors in developing nafld23 in our study, we found that the mean bmi in patients with nafld was 32±3.9 kg/m2, and in patients without nfld it was 28.8±4.3 kg/m2, and increased bmi was highly significantly related to fatty liver p<0.001 and was an independent risk factor for nafld p≤0.009 nafld occurs when there is an imbalance between the rate of uptake of fatty acids and triglycerides from circulation, increased lipogenesis, and a decreased ability to oxidize fatty acids and export very low-density lipoprotein-tg. therefore, changes in liver and serum lipid parameters can be a predictor of disease development.24 kantartzis et al.25 in their study on 16 patients with fatty liver and 24 control subjects found that fatty liver was associated with decreased levels of high-density lipoprotein 2 (hdl2) which is potent antiatherogenic. moreover, in patients with nafld, abnormal serum alt and ast are usually present when the disease progress to steatohepatitis or hepatic fibrosis.26 however, in a study done by ma et al.27 they found the prevalence of normal alt in patients with nafld reached over 90%. in our study, we found that in patients with nafld, total cholesterol, ldl, and tg, as well as alt and ast were higher than in patients without nafld. however, none of these were statistically significant. this may be attributed to the low number of patients with dyslipidemia involved in the study and the early stage of nafld in those patients. several studies have been conducted to demonstrate the relationship between h. pylori infection and nafld. this is because the main pathogenic mechanism in nafld is insulin resistance which makes hepatocytes more susceptible to oxidative stress and lipid peroxidation. at the same time, h. pylori was implicated in the development of insulin resistance through increasing proinflammatory cytokines and reactive oxygen species production. numerous studies aimed to find out whether there is a relationship between them or not.28 in a study done by polyzos et al.29 on 28 patients with biopsy-proven nafld and 25 healthy controls, they article table 3. relation between h. pylori and elastography. total n=100 h. pylori test of sig. p negative (n=50) positive (n=50) mean±sd 239.8±35.18 229.3±33.83 250.4±33.59 3.133* 0.002* median (min-max) 248.5 (150-296) 230 (150-296) 259 (170-294) sd, standard deviation; t, student t-test; u. *statistically significant at p≤0.05. table 4. prognostic performance for elastography to prognoses positive h. pylori patients (n = 50) from negative h. pylori patients (n = 50). auc p 95% c.i cut off sensitivity specificity ppv npv elastography 0.688 0.001* 0.582-0.794 >248 68.0 68.0 68.0 68.0 auc, area under a curve; ci, confidence intervals; npv, negative predictive value; ppv, positive predictive value. *statistically significant at p≤0.05. table 5. univariate and multivariate logistic regression analysis for the parameters affecting elastography >248db/m. univariate multivariate p or (ll–ul 95%c.i) p or (ll–ul 95%c.i) male 0.680 1.185 (0.528-2.660) age (years) <0.001* 1.075 (1.041-1.110) <0.001* 1.082 (1.039-1.127) bmi (kg/m2) 0.001* 1.227 (1.091-1.380) 0.009* 1.225 (1.052-1.427) alt 0.077 1.023 (0.998-1.049) ast 0.151 1.028 (0.990-1.067) total cholesterol 0.487 1.005 (0.991-1.018) ldl 0.324 1.009 (0.991-1.027) hdl 0.553 0.986 (0.943-1.032) triglyceride 0.607 1.002 (0.994-1.011) h. pylori <0.001* 4.516 (1.949-10.463) 0.001* 5.632 (1.967-16.130) or, odd’s ratio; ci, confidence interval; ll, lower limit; ul, upper limit. *statistically significant at p≤0.05. [healthcare in low-resource settings 2023; 11(s2):11379] [page 15] non -co mmerc ial us e o nly found that h. pylori diagnosed by serology were found in 82% of nafld patients and 56% of healthy controls. meta-analysis of data from cross-sectional and case-control studies involving 91,958 individuals concluded that h. pylori infection was also associated with increased nafld incidence.30 in addition, another study found a remarkable effect of h. pylori infection on nafld after ruling out many confounding factors like age, dyslipidemia, diabetes, hypertension, and liver enzymes, h. pylori infection was found to be an independent risk factor for nafld (95% ci 1.021.79, or 1.35, p=0.036).31 yan et al.32 conducted a wide-scale study on 1185 patients. abdominal color doppler ultrasound was used to assess nonalcoholic fatty liver disease and13 c-urea breath test was used to diagnose h. pylori infection, nafld was found in 44.6% (n=529), distributed in 362 males and 167 females. the study concluded that h. pylori is a significant and independent risk factor for nafld (95% ci 1.02-1.79, p=0.036, or=1.35). on the other hand, a similar study was conducted using abdominal color doppler ultrasonography as well as transient elastography, fat attenuation parameter, and liver stiffness for diagnosis of nafld,13 c-urea breath was the method for diagnosis of h. pylori infection. the study found no association between h. pylori infection and nafld or elevated liver steatosis, but it could be a risk of increased liver stiffness in males.33 other studies intended to demonstrate the effect of h. pylori eradication on hepatic fat contents. one of these studies performed by jamali et al.34 on 100 patients diagnosed h. pylori positive and given slandered treatment and re-tested again to confirm eradication, found no effect of eradication on hepatic fat content checked by nafld liver fat score. in our study, h. pylori infection was significantly associated with nafld, where it existed in 68% of patients with elastography > 248 db/m (95% ci 0.582-0.794, p=0.001, sensitivity 68% and specificity 68%). univariate analysis showed that age, bmi, and h. pylori infection were associated with nafld after adjustment with alt, ast, total cholesterol, ldl, hdl, and tg, multivariate analysis showed that they were still independent risk factors for nafld. conclusions increasing age, weight, and h. pylori infection are independent risk factors for the development of nafld. therefore, weight reduction and treatment of h. pylori infection may help to reduce the incidence of fatty liver. references 1. narayanan m, reddy k, marsicano e. peptic ulcer disease and helicobacter pylori infection. mo med 2018;115:219-24. 2. waluga m, kukla m, zorniak m. from the stomach to other organs: helicobacter pylori and the liver. world j hepatol 2015;18:2136-46. 3. kim d, kim wr. non-obese. clin gastroenterol hepatol 2017;15:474-85. 4. younossi z, anstee m, marietti m. global burden of nafld and nash: trends, predictions, risk factors and prevention. nat rev gastroenterol hepatol 2018;15:11-20. 5. anstee m, targher g, day p. progression of nafld to diabetes mellitus, cardiovascular disease or cirrhosis. nat rev gastroenterol hepatol 2013;10:330-44. 6. arab p, arrrese m, trauner m. recent insight into pathogenesis of nonalcoholic fatty liver disease. annu rev pathol 2018;13:321-50. 7. berlanga a, guiu-jurado e, porras a, auguet t. molecular pathways in non-alcoholic fatty liver disease. clin.exp. gastroenterol 2014;7:221-39. 8. basaranoglu m, basaranoglu g, senturk h. from fatty liver to fibrosis: a tale of "second hit." world j gastroenterol 2013;19:1158-65. 9. takaki a, kawai d, yamamoto k. multiple hits including oxidative stress, as pathogenesis and treatment target in nonalcoholic steatohepatitis (nash). int j mol sci 2013;14: 20704-28. 10. buzzetti e, pinzani m, tsochatzis a. the multiplehit pathogenesis of non-alcoholic fatty liver (nafld). metabolism 2016;65:1038-48. 11. khosravi y, seow s, moyo a, et al. helicobacter pylori infection can affect energy modulating hormones and body weight in germ free mice. sci rep 2015;5:8731. 12. sumida y, kanemasa k, imai s, et al. helicobacter pylori infection might have a potential role in hepatocyte ballooning in nonalcoholic fatty liver disease. j gastroenterol 2016;50: 996-1004. 13. doust j, glasziou p. monitoring in clinical biochemistry. clin biochem rev 2013;34:85-92. 14. sabbagh p, mohammadnia-afrouzi m, javanian m, et al. diagnostic methods for helicobacter pylori infection: ideals, options, and limitations. eur j clin microbiol infect dis 2019; 38:55-66. 15. tapper eb, loomba r. noninvasive imaging biomarker assessment of liver fibrosis by elastography in nafld. nat rev gastroenterol hepatol 2018;15:274-82. 16. allen a, therneau t, larson j, et al. nonalcoholic fatty liver disease incidence and impact on metabolic burden and death: a 20 yearcommunity study. hepatology 2018;67:1726-36. 17. alqahtani schattenberg j. nafld in the elderly. clin interv aging 2021;16:1633-49. 18. ballestri s, nascimbeni f, baldelli e, et al. nafld as a sexual dimorphic disease: role of gender and reproductive status in the development and progression of nonalcoholic fatty liver disease and inherent cardiovascular risk. adv ther 2017;34: 1291-326. 19. hamaguchi m, kojima t, ohbora a. aging is a risk factor of nonalcoholic fatty liver disease in premenopausal women. world j gastroenterol 2012;18:237-43. 20. wang z, xu m, hu z. prevalence of nonalcoholic fatty liver disease and its metabolic risk factors in women of different ages and body mass index. menopause 2015;22:667-73. 21. polyzos s, kountouras j, mantzoros c. adipose tissue, obesity and non-alcoholic fatty liver disease. minerva endocrinologica 2017;42:92-108. 22. fan wang j, du j. association between body mass index and fatty liver risk: a dose-response analysis. sci rep 2018;8:15273. 23. almobarak a, barakat s, kalifa m, et al. non-alcoholic fatty liver disease (nafld) in a sudanese population: what is the prevalence and risk factors. arab j gastroenterol 2014;15:125. 24. mato j, alons c, noureddin m, lu sc. biomarkers and subtypes of deranged lipid metabolism in non-alcoholic fatty liver disease. world j gastroenterol 2019;25:3009-20. 25. kantartzis k, stefan n. cardiovascular disease in patients with non-alcoholic fatty liver disease. ann gastroenterol article [page 16] [healthcare in low-resource settings 2023; 11(s2):11379] non -co mmerc ial us e o nly 2012;25:276. 26. sookoian s, castano c, scian r, et al. serum aminotransferases in nonalcoholic fatty liver disease are a signature of liver metabolic perturbatins at the amino acid and krebs cycle level. am j clin nutr 2016;103:422-34. 27. ma x, liu s, zhang j, et al. proportion of nafld patients with normal alt value in overall nafld patients: a systematic review and meta-analysis. bmc gastroenterol 2020; 14:10. 28. santos c, de brito b, da silva f, et al. helicobacter pylori infection: beyond gastric manifestations. world j gastroenterol 2020;26:4076-93. 29. polyzos a, kountouras j, paptheodorou a, et al. helicobacter pylori infection in patients with nonalcoholic fatty liver disease. metabolism 2013;62:121-6. 30. wei l, guo ding h. relationship between helicobacter pylori infection and nonalcoholic fatty liver disease: what should we expect from a meta-analysis? medicine (baltimore) 2021;100:e26706. 31. liu r, liu q, he y, et al. association between helicobacter pylori infection and nonalcoholic fatty liver: a meta-analysis. medicine (baltimore) 2019;98:e17781. 32. yan p, yu b, li m, zhao w. association between nonalcoholic fatty liver disease and helicobacter pylori infection in dali city, china. saudi med j 2021;42:735-41. 33. liu y, li d, li y, shuai p. association between helicobacter pylori infection and non-alcoholic fatty liver disease, hepatic adipose deposition and stiffness in southwest china. front med (lausanne) 2021;8:764472. 34. jamali r, mofid vahedi farzaneh r, dowlatshahi s. the effect of helicobacter pylori eradication on liver fat content in subjects with non-alcoholic fatty liver disease: a randomized open-label clinical trial. hepatol 2013;13:e14679. article [healthcare in low-resource settings 2023; 11(s2):11379] [page 17] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2022; 10:10298] [page 29] are we adequately prepared to handle the anticipated 3rd peak of covid-19: a kap survey among hcws narendra pal singh,1 nisha goyal,1 vikas saini,1 abhilasha kapoor,2 seema gangar1 1department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi; 2department of community medicine, university college of medical sciences & guru teg bahadur hospital, delhi, india abstract experts in the field are predicting a third covid-19 peak very soon in coming times, it is important to assess recent knowledge, attitude in view of prolonged exhaustion and adherence to preventive practices of hcws. this cross-sectional study involved 168 hcws (42 doctors, 42 nurses, 42 paramedical staff and 42 anms). data was collected through online survey tool google forms in july and august 2021. first section included sociodemographic information and infection with sars-cov2, section 2 assessed recent knowledge, section 3 practices of covid-19 appropriate behavior and section 4 assessed attitude of hcws. shapiro wilk test was used to determine normality of distribution of variables. kruskal-wallis and mann-whitney u tests were used to determine the association between two variables. pairwise comparison was done following a significant kruskal-wallis test using bonferroni’s correction. 42.9% of the hcws and family members of 44.6% hcws were infected with sars-cov-2. 54.1% of infected hcws were infected during the marchmay 2021 peak. 85.1% hcws had taken covid-19 vaccine. mean knowledge, attitude, practice scores were 7.88±3.03(maximum score: 12), 20.35±3.2 (maximum score: 25), 69.89±9.39 (maximum score: 85) respectively. only 48.8% hcws had good knowledge about more recent covid-19 information. a significant association was observed between profession and knowledge scores (p<0.001). over 85% hcws had good scores for attitude towards covid-19 and 88.7% hcws scored good in covid-19 appropriate behavior practices. our hcws need to be better equipped with the more recently available knowledge about covid-19 to improve our preparedness for the next anticipated peak. introduction covid-19 originated from wuhan, china in the end of 2019 and has now rapidly spread over the world, reaching even the faraway places.1 world health organization (who) declared this novel coronavirus outbreak as a public health emergency of international concern on january 30, 2020.2 sars-cov-2 being an rna virus, is more susceptible to genetic variation than the dna viruses.3,4 the genome of sars-cov2 is constantly evolving & mutating, the resultant variants have become a regular occurrence. the genomic sequencing of sars-cov-2 shows a nucleotide substitution rate of roughly 1×10-3 substitutions per annum.5 who has classified these variants under two categories, variant of concern (voc) and variant of interest (voi).6 there are four variants (alpha, beta, gamma, delta) under the category of voc and another four (eta, iota, kappa, lambda) under the category of voi.7 certain variants appear to have an enhanced capability to spread, contributing to a rapid increase in number of covid-19 cases.7,8 the delta variant for which the earliest samples were documented from india in october 2020, has spread to over 60 countries.7,9 delta variant reportedly has a higher secondary attack rate10 and growth rate11 than the alpha variant for which the earliest samples were documented from united kingdom (uk) in september 2020.7 this explains the rapid rise and displacement of alpha variant in the uk. in india, covid-19 cases dramatically started increasing in late march 2021. due to the higher transmissibility as well as immune evasive nature of the delta variant, 17 million cases of covid-19 were reported between march – may 2021 that was about twice the number reported during the previous 14 months.12 india, particularly the national capital, has witnessed the unprecedented extent of morbidity and mortality during this surge of covid-19 cases. this new variant spared very few, even the hcws were affected in the most extensive and distressing manner. the healthcare infrastructure was stretched beyond its limits and hcws lived the worst nightmare of modern times. the decline of second wave was largely credited to non-pharmaceutical interventions, covid-19 appropriate behavior and less favorable weather conditions during march–may, rather than to high population immunity despite the large previous covid-19 peaks and mass-vaccination rollout. despite the rollout of mass-vaccination in india, only approximately 13% of the population had received at least a single dose of covid-19 vaccine by the end of may 2021.12 vaccination is often conferred as the only hope for back to ‘normal life’. covid-19 vaccines have a protective role against severe disease.13,14 the preliminary data also suggests that vaccination reduces the transmission of sars-cov-2.15 if vaccination is done slowly, virus gets more time to mutate and find ways to evade or deceive antibodies.16 this further emphasizes the importance of sensitization to the need of covid-19 vaccination at a faster pace. hcws have not yet recovered fully from the physical and mental impact of last surge of covid-19 cases and experts in the field are predicting a third covid-19 peak very soon in coming times.16 covid19 appropriate behavior and vaccination are the only means we have to contain or delay this anticipated next covid-19 peak. it is of paramount importance to assess knowledge about the recent information about the covid-19, attitude in view of prolonged exhaustion and level of adherence to preventive practices by hcws in the current scenario as it would play a crucial role in the adequate handling of next covid-19 healthcare in low-resource settings 2022; volume 10:10298 correspondence: nisha goyal, department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi, india. e-mail: drnishagoyalucms@gmail.com conflict of interest: the authors declare no conflict of interest. key words: covid-19; kap study; practices against covid-19; knowledge of covid-19; attitude. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: participants gave their informed consent when they agreed to taking part to the survey. received for publication: 24 november 2021. revision received: 22 february 2022. accepted for publication: 22 february 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10298 doi:10.4081/hls.2022.10298 non -co mmerc ial us e o nly peak if it comes. therefore, in the present kap study we have tried to assess if we are adequately prepared to handle the next anticipated peak. materials and methods the present cross-sectional study was conducted by the department of microbiology of a tertiary care hospital in national capital of india. this study included hcws as the study subjects and data was collected through the online survey tool google forms in the months of july and august 2021. the questionnaire link was shared through extensively used social media platform of whatsapp account. the information was anonymous and no personal identifier was used in the questionnaire. considering the variability of 1.32, 0.93, 0.79 in knowledge, attitude, practices with reference17 to estimate the relative difference of 10% on either side of mean score at alpha=5%, a sample of 30 subjects was required. but due to availability of time and resources, we included 168 hcws in the present study. in order to better understand the distribution of knowledge, practices and attitudes within hcws, 42 each of doctors, nurses, technical staff and auxiliary nursing midwifery (anm) were included. the google form questionnaire had four sections. first section included questions about the socio-demographic profile, past infection of sars-cov-2 in self or family members, probable source of infection in positive cases, number of family members infected with sars-cov-2 till date, severity of disease in self and family members, covid-19 vaccination history. section 2 assessed the knowledge of hcws about the recent available information about covid-19 that may affect the adequate handing of the anticipated next peak of covid-19 cases. this section had 12 questions. one mark was given for each correct answer in this knowledge assessment section. section 3 assessed the practices of covid-19 appropriate behavior among hcws. this section had 3 questions out of 8 questions that assessed the variation in practicing covid-19 appropriate behavior over a period of 4 months from april to july 2021. in this section, hcws had to score themselves in each question ranging from 1 to 5, with score 5 implying the best covid-19 appropriate practices. section 3 carried the maximum score of 85. section 4 consisted of 5 questions that assessed the attitude of hcws. a five-point likert-type scale was used to ascertain the level of agreement or disagreement. this section carried the maximum score of 25. statistical analysis data was entered in ms excel and was analyzed using spss version 20.0 (statistical package for the social sciences). descriptive statistics included mean ± standard deviation (sd) for the scores of knowledge, attitude and practices. frequencies and proportions were calculated for the qualitative variables. hcws with scores ≥70% for knowledge, practices or attitude were regarded as having good knowledge, practices or attitude and those with scores below 70% were considered to have poor knowledge, practices or attitude. the shapiro wilk test was used to determine the normality of distribution of the variables. for variables which were not normally distributed like the scores of knowledge, practices and attitude, non-parametric tests were used. kruskal-wallis test and mann-whitney u test were used to determine the association between two variables, kap scores and other variables. pairwise comparison was done following a significant kruskal-wallis test using bonferroni’s correction. associations with p-value <0.05 at 95% confidence level were taken as statistically significant. results the male to female ratio for present study was 1.07. the age wise distribution of hcws is shown in figure 1. the highest educational qualification for majority of hcws was graduation (57.7%), followed by postgraduation (26.8%), 12th class (14.3%) and 10th class (1.2%). in present study, 42.9% of the hcws were infected with sars-cov-2 at least once since the beginning of covid-19 pandemic. among hcws who tested positive for covid-19, 54.1% were infected during the march-may 2021 peak, 29.2% during may-august 2020 and 16.7% during the september-december 2020. colleagues were suspected to be the source of covid-19 in 34.7% cases, followed by friends (26.4%), relatives (11.1%). in 23.6% of the cases, the probable source of infection was not known. frequency distribution of severity of covid-19 disease among infected hcws is depicted in figure 2. the family members of 44.6% hcws developed covid-19 since the beginning of this pandemic. 64% hcws shared the same household with the covid-19 positive family member. in 70.7% of instances, more than one family members of the respondent hcw were tested positive for covid-19. parents were the first to get involved in majority (37.3%), followed by siblings (22.7%) and spouse (17.3%). the source of infection was not known in 42.6% instances of positive family members. 16% suspected friends, 14.7% colleagues, 10.7% relatives, 9.3% market places, 2.7% neighbors, 1.3% suspected their domestic help and 4% others (not covered in the list) as probable source of sars-cov-2 infection for their family members. majority (77.3%) of affected family members experienced only mild covid-19 illness. 21.3% of affected family members developed moderate illness needing oxygen support, 12% of such cases were managed at home. majority (85.1%) of hcws had taken covid-19 vaccine. among the vaccinated hcws, 76.9% had taken both the doses of covid-19 vaccines. majority (93%) of hcws had taken the covishield vaccine, followed by covaxin (2.8%). 14.9% hcws had not taken even a single dose of covid article figure 1. age wise distribution of hcws (n=168). [page 30] [healthcare in low-resource settings 2022; 10:10298] non -co mmerc ial us e o nly 19 vaccine. 20% unvaccinated hcws didn’t think vaccine has any protective role and same percentage of hcws had no specific reason for being unvaccinated till date, 16% could not find time for vaccination and similar percentage reported nonavailability of vaccine as their reason behind being unvaccinated and (12%) feared adverse effects. recent knowledge about covid-19 table 1 shows the distribution of means and standard deviations (sd) for knowledge among different groups of hcws. mean overall knowledge score in present study was 7.88±3.03 (maximum score: 12). figure 3 depicts the distribution of good (≥70%) knowledge scores among different groups of hcws. only 48.8% hcws had good knowledge about more recent covid-19 information. over 85% doctors included in this study had good knowledge scores. among various groups of hcws, doctors group also had the highest mean value for more recent covid-19 related knowledge. age group of the study participants and gender had no significant association with their knowledge scores. the participants with highest education and those who had infection with covid-19 were more likely to have higher knowledge scores and the association was statistically significant (p=0.008 & p=0.001, respectively). on applying pairwise comparison, those who have postgraduation were more likely to have higher knowledge scores as compared to those who were graduates (p=0.027). a significant association was also observed between the profession of study participants and the knowledge scores (p<0.001). doctors were more likely to have higher knowledge scores as compared to nurses (p<0.001), technical staff (p<0.001) and anms (p<0.001). over 94.6% of hcws were aware about the variants of sarscov-2 virus. 49.4% hcws knew that alpha variant was first detected in united kingdom. majority (80.4%) rightly identified delta variant as the most transmissible variant till date. nearly 64% hcws had knowledge that the delta variant was responsible for the devastating 2nd peak (may-june 2021) in delhi. two-third (75%) hcws correctly identified the delta plus variant as the emerging variant in india with reportedly high transmissibility and potency to reduce monoclonal antibody response. nearly 60% hcws possessed knowledge that being a rna virus, sars-cov-2 virus is more susceptible to mutations. 51.2% respondents had knowledge that gene sequencing technique is used to identify the newer emerging variants of sars-cov-2. however, over a quarter (30.9%) believed that rt-pcr was used for the same. the majority (66.7%) was aware that symptomatic relief is the main stay of management in mild covid-19 cases. a large proportion (85.7%) of respondent hcws rightly answered that to stop/delay the 3rd wave of covid-19, we need the collaboration of all three factors of covid-19 appropriate behavior, vaccination and enhanced surveillance for newer emerging variants. 61.3% hcws had knowledge that children are at higher risk in coming times as they are still not vaccinated. 18.4% hcws incorrectly answered about the eligibility of pregnant or lactating mothers for covid-19 vaccine. only 17.8% had knowledge that the available vaccines in india are about 60-65% efficient against newer emerging variants of concern. covid-19 appropriate behavior including vaccination practices distribution of means and sd for covid-19 appropriate behavior practices among different groups of hcws is shown in table 1. mean score for practice in present study was 69.89±9.39 (maximum score: 85). figure 3 illustrates the distribution of good (above mean) covid-19 appropriate practices scores among various groups of hcws. overall, 88.7% hcws had good scores for covid-19 appropriate behavior practices. over 80% hcws in each of four groups included in this study had good practice scores. among various groups of hcws, doctors’ group had the highest mean value for covid-19 appropriate behavior practices. there was no statistically significant association between practice scores and age group, sex or highest education of the study participants. a significant difference was seen in the practice scores among hcws infected with covid-19 as compared to those who were not infected (p=0.011). distribution of covid-19 appropriate behavior practices among hcws on the basis of self-assessment score ranging from 1 to 5 during the months of april to july, 2021 is depicted in figure 4. highest frequency of best (score 5) preventive practices including avoidance of visits to markets or malls, avoidance of gatherings for tea or lunch with colleagues/friends, use of facemask was observed during the month of april and a consistent decline in score 5 was observed in the following months. nearly 90% hcws had not taken any unnecessary trip in last four months. majority (67.3%) hcws had attended or were planning to attend a session for covid-19 preparedness. figure 5 shows the distribution of covid-19 vaccination practices among hcws. over 85% hcws had taken at least single dose of covid-19 vaccine and all the eligible family members of hcws were vaccinated in 44% instances. spouse and parents had received at least a single jab of covid-19 vaccine in 60.7% cases. article figure 2. frequency distribution of severity of covid-19 disease among infected hcws (n=72). table 1. distribution of knowledge, practice & attitude scores among various groups of hcws (n=168). s.no category knowledge practices attitude (mean±sd) (mean±sd) (mean±sd) 1 overall 7.88±3.03 69.89±9.39 20.35±3.15 2 doctors 10.19±1.73 71.98±5.51 21.61±2.81 3 nurses 7.64±1.96 69.69±8.95 20.26±3.80 4 technical staff 6.33±3.30 68.81±12.37 19.60±3.02 5 anms 7.36±3.38 69.10±9.43 19.93±2.58 [healthcare in low-resource settings 2022; 10:10298] [page 31] non -co mmerc ial us e o nly attitude of hcws regarding covid-19 table 1 shows the distribution of means and sd for attitude scores among different groups of hcws regarding covid-19. this study observed a mean attitude score of 20.35±3.2 (maximum score: 25). over 85% hcws had good scores for attitude towards covid-19. table 2 depicts the attitude of hcws regarding covid-19. a positive attitude was observed among majority of hcws towards covid-19. only 64.9% hcws had a positive attitude that we will be able to manage the next wave of covid-19 if it comes. however, nearly 90% hcws agreed that they have to stay ready to play a bigger role in this ongoing covid-19 pandemic if situation arises. there was no statistically significant association between attitude scores and age group, sex, or highest education of the study participants. a statistically significant association was observed between profession and attitudes score (p=0.001). on pairwise comparison, attitude scores were more likely to be seen among doctors as compared to technical staff and anms, and the difference was also found to be statistically significant (p=0.002 & p=0.003, respectively). discussion in present study, 31-40 years constituted the most predominant (42.9%) age group, marginally falling behind (42.2%) was 21-30 years age group. however, in another study involving the hcws 20-30 years was the most predominant (60.9%) age group, followed by 31-40 years (18.9%) age group.18 in our study, 51.8% participants were males. similarly, in a study by verma et al., 53.0% of study participants were males.18 this ongoing pandemic of covid-19 has affected the hcws at the personal front, besides enhancing the professional stress to humongous levels. the present study shows that over 40% hcws were infected with sars-cov-2 during this pandemic and over half of them were infected during the devastating covid-19 peak that hit the national capital during march-may 2021. nearly 45% hcws reported that their family members tested positive for covid-19 and in the majority of instances, more than one family member got infected with sars-cov-2. the scale and impact of sars-cov-2 particularly the delta variant was unprecedented. our hcws have fought this battle against covid-19 at multiple article table 2. attitude of hcws regarding covid-19 (n=168). strongly disagree neutral agree strongly disagree n(%) n(%) n(%) n(%) agree n(%) 1. do you think we will be able to manage the 3rd wave of 5(3) 5(3) 49(29.2) 92(54.8) 17(10.1) covid-19 if it comes? 2. do you think covid appropriate behavior is important in 5(3) 3(1.8) 28(16.7) 73(43.5) 59(35.1) prevention/ delay of 3rd covid-19 wave? 3. maximum coverage of vaccination against covid-19 is key to 5(3) 1(0.6) 21(12.5) 91(54.2) 50(29.8) limit the spread of covid-19. 4. one should avoid all unnecessary travel of any kind during these times. 3(1.8) 0 20(11.9) 81(48.2) 64(38.1) 5. being the healthcare professionals, we have to stay ready to play a bigger 2(1.2) 1(0.6) 14(8.3) 70(41.7) 81(48.2) role if situation arises. [page 32] [healthcare in low-resource settings 2022; 10:10298] figure 3. distribution of good knowledge, practice and attitude scores among different groups of hcws (n=168). figure 4. distribution of covid-19 appropriate behavior practices among hcws on the basis of self-assessment score (1-5) during the months of april to july, 2021 (n=168). non -co mmerc ial us e o nly fronts at the same time. in present study, over two thirds of the hcws developed a mild covid-19 disease. our findings are in line with another study that assessed the characteristics of hcws infected with covid-19.19 covid-19 vaccine plays a critical role in the mitigation and control of current pandemic. the government of india had prioritized hcws along with other frontline workers for covid-19 vaccination at the availability of covid-19 vaccines. over 85% hcws were vaccinated and over two third of hcws had taken both the jabs of covid-19 vaccine. our findings are in agreement with another study that reported 84.1% acceptance of covid-19 vaccines among respondent hcws.20 in present study, less than 50% hcws had good knowledge scores. however, almohammed oa, et al., in their study have reported an adequate knowledge in 67.8% hcw participants about covid-19.21 in a study by kamacooko et al., 84.5% of the participants scored ≥80% on knowledge assessment parameters.22 this could be due to the fact that present study has assessed more recent information about covid-19 like variant of sars-cov-2 responsible for recent peak, technique to detect emerging variants, efficiency of available vaccines in india against newer emerging variants of concern, eligibility of pregnant mothers for covid-19 vaccine, reason for children being proposed at higher risk of covid-19 infection in coming times. for the first time, knowledge of hcws was assessed on the basis of information that became available very shortly and extended beyond the basic information about covid-19 that became available in early six months of year 2020. furthermore, in present study, four different groups of hcws were included in equal numbers. highest proportion of participants from doctors’ group had good knowledge scores in present study, followed by nurses’ group. similarly, other study has also reported highest percentage of doctors to have good knowledge regarding covid19, followed by nurse participants.18 though nearly 90% participant hcws had good scores for practices involving covid-19 appropriate behavior, we observed a consistent decline in best practices against covid-19 from april to july 2021. another study has also reported a decline in preventive practices over months. however, this previous study assessed the preventive practices from the beginning of lockdown in india (25th march, 2020) till october 2020.23 the initial months involved in present study coincided with the catastrophic peak of covid-19 cases in the region that also warranted the observation of extreme preventive measures by hcws to ensure the safety of self and family members. in present study, over 85% hcws had good attitude scores. however, another indian study has reported 95.7% of participant hcws having good attitude.18 this could be explained on the basis that in present study, obtaining ≥70% was considered as good score, whereas another study has considered scores above mean value as good scores. only 65% hcws were confident that we will be able to manage the next peak of covid-19 in present study. another study from national capital has reported a positive attitude regarding the same in 89% hcws.23 this was probably because the present study was carried out after the ravaging second peak of covid19. the magnitude and impact of last peak was unforeseen and hcws being at the forefront have witnessed the worst. though more hcws had reservations about being too optimistic about the next wave, nearly 90% agreed that being healthcare professionals, they had to stay ready to play a bigger role if situation arises. the present study had a limitation that it might lack the accurate representativeness due to its online mode. however, there is no reason to believe that the included groups of hcws would have been significantly different if this study would have been conducted in offline face-to-face mode. our study suffered the limitation that for collection of data, standardized tools were not used. the findings of our study should be validated with more extensive multicentric studies involving larger sample sizes. conclusions sars-cov-2 is constantly evolving and mutating. the dynamics of covid-19 is continuously changing and it is more important than ever that we don’t lag behind in our knowledge about this invisible enemy. this study has helped us in knowing our weaker areas better. now we know that our hcws need to be better equipped with the more recently available knowledge about covid-19 to improve our preparedness for the next anticipated peak. this study has shown that our hcws are observing good practices against covid-19 and despite the hardships of last peak, the attitude is positive among hcws. references 1. wang c, horby pw, hayden fg, gao gf. a novel coronavirus outbreak of global health concern. lancet 2020;395:470-3. 2. world health organization. statement on the second meeting of the international health regulations (2005) emergency committee regarding the outbreak of novel coronavirus (2019ncov). accessed on: 17.09.2021. available from: https://www.who.int/news/item/30-012020-statement-on-the-second-meeting-of-the-international-health-regulations-(2005)-emergency-committeeregarding-the-outbreak-of-novel-coronavirus-(2019-ncov) 3. khan w, shrungaram rv, broor s, parveen s. glycosylation studies of gprotein of ba genotype of group b human respiratory syncytial virus in mammalian cells. europ resp j article figure 5. distribution of covid-19 vaccination practices among hcws (n=168). [healthcare in low-resource settings 2022; 10:10298] [page 33] non -co mmerc ial us e o nly [page 34] [healthcare in low-resource settings 2022; 10:10298] 2015;46:pa2673. 4. haider ms, khan wh, deeba f, et al. ba9 lineage of respiratory syncytial virus from across the globe and its evolutionary dynamics. plos one 2018;13:e0193525. 5. duchene s, featherstone l, haritopoulou-sinanidou m, et al. temporal signal and the phylodynamic threshold of sars-cov-2. virus evol 2020;6:veaa061. 6. davidson ad, williamson mk, lewis s, et al. characterisation of the transcriptome and proteome of sars-cov2 reveals a cell passage induced inframe deletion of the furin-like cleavage site from the spike glycoprotein. genome med 2020;12:1-5. 7. world health organization. tracking sars-cov-2 variants. 2021. accessed:20.07.2021. available from: https://www.who. int/en/activities/ tracking-sars-cov-2-variants/ 8. toyoshima y, nemoto k, matsumoto s, et al. sars-cov-2 genomic variations associated with mortality rate of covid-19. j human gen 2020;65: 1075-82. 9. a global initiative on sharing avian flu data (gisaid). hcov-19 tracking of variants (see menu option gr/501y.v3(p.1). accessed:20.07. 2021. available from: https://www. gisaid.org/hcov19-variants/ 10. public health england (phe). sarscov-2 variants of concern and variants under investigation in england. technical briefing 14. london: phs. accessed: 03.06.2021. available from: https://assets.publishing.service.gov.uk/ government/uploads/system/uploads/att achment_data/file/991343/variants_of_ concern_voc_technical_briefing_14. pdf 11. challen r, dyson l, overton ce, et al. early epidemiological signatures of novel sars-cov-2 variants: establishment of b. 1.617. 2 in england. medrxiv 2021. 12. yang w, shaman j. covid-19 pandemic dynamics in india and impact of the sars-cov-2 delta (b. 1.617. 2) variant. medrxiv 2021. 13. voysey m, clemens sa, madhi sa, et al. safety and efficacy of the chadox1 ncov-19 vaccine (azd1222) against sars-cov-2: an interim analysis of four randomised controlled trials in brazil, south africa, and the uk. lancet 2021;397:99-111. 14. baden lr, el sahly hm, essink b, et al. efficacy and safety of the mrna1273 sars-cov-2 vaccine. new england j med 2021;384:403-16. 15. levine-tiefenbrun m, yelin i, katz r, et al. decreased sars-cov-2 viral load following vaccination. nature medicine. nat med 2021;27:790–792. 16. zeyaullah m, alshahrani am, muzammil k, et al. covid-19 and sars-cov-2 variants: current challenges and health concern. front gen 2021;12. 17. verma sk, chandan n, narayanmurthy mr. knowledge, attitude, and practices towards covid-19 among ayurvedic practitioners of karnataka, india: a cross-sectional survey. int j community med public health 2020;7:4056-62. 18. verma sk, kumar ds, khanum rs, et al. knowledge, attitude and practices towards covid-19 among healthcare workers of karnataka, india: a crosssectional survey. int j community med public health 2020;7:4889-94. 19. al maskari z, al blushi a, khamis f, et al. characteristics of healthcare workers infected with covid-19: a cross-sectional observational study. int j infect dis 2021;102:32-36. 20. mehta k, dhaliwal bk, zodpey s, et al. covid-19 vaccine acceptance among healthcare workers in india: results from a cross-sectional survey. medrxiv 2021. 21. almohammed oa, aldwihi la, alragas am, et al. knowledge, attitude, and practices associated with covid19 among healthcare workers in hospitals: a cross-sectional study in saudi arabia. front public health 2021;9:643053. 22. kamacooko o, kitonsa j, bahemuka um, et al. knowledge, attitudes, and practices regarding covid-19 among healthcare workers in uganda: a crosssectional survey. int j environ res public health 2021;18:7004. 23. goyal n, loomba p, sharma a, et al. are we growing tired of being cautious in this apparently endless covid-19 pandemic: a kap study in hcws of a tertiary care center to determine the answer. indian j health sci care 2021;8:19-28. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11744 the impact of sleep toward executive functions among rapidly rotating shift nurses of emergency departments in indonesia lilis setyowati,1 hsiao-yean chiu,2 anggraini dwi kurnia,1 nur aini,3 erma wahyu mashfufa,3 ollyvia freeska dwi marta3 1departement of nursing, faculty of vocational, universitas muhammadiyah malang, malang, indonesia; 2college of nursing, taipei medical university, taipei, taiwan; 3department of nursing, faculty of health science, universitas muhammadiyah malang, malang, indonesia abstract sleep problems are significant and are closely related to attention issues, impacting executive function disorders, especially among healthcare professionals, including nurses. in contemporary times, shift work has emerged as a new challenge for healthcare professionals, affecting their health, wellbeing, and cognitive functions. this study aimed to investigate the relationship between sleep and executive function among staff working in the emergency department (ed). the research was a cross-sectional study conducted on emergency nurses (en) from four hospitals in malang, indonesia. sleep quantity parameters, including total sleep time (tst), sleep onset latency (sol), wake after sleep onset (waso), and sleep efficiency (se), were collected based on 7-day sleep diaries. sleep quality was measured using the pittsburgh sleep quality index (psqi). executive function was assessed using a trail making test (tmt). data analysis was carried out using one-sample t-tests and multiple linear regression with a stepwise model. around 82% of er have poor sleep quality (psqi > 5). other findings waso, tst, and se reported a shorter duration compared to the healthcare population, while the duration of sol was twice as long. the sources of executive function tmt-a, tmt-b, and tmt b-a were longer, and tmt b/a was shorter than the normal population. tst was negatively related to simple (tmt-a), alternating (tmt-b), and performance difference (tmt b-a) p values =0.000. this study concludes that fastrotating shift ed nurses experienced poor sleep and executive function. the most significant factors influencing executive function were tst and bmi. introduction the critical relationship between sleep and cognitive processing has been confirmed in normal and abnormal populations over the past decade. sleep is controlled by the suprachiasmatic nucleus (scn) of the hypothalamus. the circadian rhythm regulates melatonin production, which induces sleep.1–4 sleep promotes several cognitive functions, including decision-making, language learning, categorization, memory, and executive functions.5,6 most work focuses on the effects of sleep on various types of mind, especially work that uses work shifts, especially among medical professionals.7–9 shift work is widely recognized for its substantial impact on desynchronizing the circadian rhythm, with a notable focus on the disruption caused by night-shift work on regular circadian physiology. sleep deprivation has adverse effects on the functioning of specific areas of the brain, resulting in a decline in cognitive performance. after completing a night shift, nurses demonstrated reduced prefrontal brain activity and diminished cognitive abilicorrespondence: lilis setyowati, departement of nursing, directorate of vocational education, universitas muhammadiyah malang, malang, indonesia. e-mail: lilis@umm.ac.id key words: emergency department; executive function; nurses; rotating shift; sleep. contributions: ls, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; hyc conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; adk conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; na, methodology, visualization, writing – review & editing; ewm, resources, investigation, and writing –review & editing; ofdm, formal analysis, validation, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethical number clearance from the universitas muhammadiyah malang was e.5.a/122/kepk-umm/viii/2018. patient consent for publication (in indonesia version): written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the author would like to thank the emergency nurses of malang city regional hospital, especially universitas muhammadiyah malang hospital, dr. soepraoen, saiful anwar hospital, wava husada hospital kepanjen, east java, indonesia, for their participation. this research was fully supported by the universitas muhammadiyah malang (umm). the author would like to thank umm for its support in implementing this research. received: 10 september 2023. accepted: 13 october 2023. early access: 31 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11744 doi:10.4081/hls.2023.11744 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11744] [page 71] non -co mmerc ial us e o nly ties.10–12 a correlation is observed between shift work among en and a decline in performance on neuropsychological testing.13,14 cognitive domains such as visual attention, processing speed, hand-eye coordination, task-switching, and executive function experience a deterioration when individuals engage in night-shift work.15 poor sleep has implications for the quality of patient treatment, as it is associated with increased rates of errors and personal safety concerns, particularly in driving following shift work.10 executive function (fe) is a top-down mental process needed when you have to concentrate and pay attention when it runs automatically.16,17 executive function (ef) refers to a top-down mental process required when you need to concentrate and pay attention consciously, as opposed to automatic processes.18 ef involves an effort to engage in an activity with the intention of minimizing deviations and making decisions that require careful consideration before taking further actions. at its core, ef encompasses inhibition (inhibitory control, which includes self-control in terms of behavior and the management of impulses), working memory (wm), and cognitive flexibility (also known as set-shifting, mental flexibility, or shifting mental sets, closely associated with creativity). ef skills are crucial for mental and physical health, success in academics and life, as well as cognitive, social, and psychological development.18,19 in general, sleep problems are of considerable significance related to attention problems. sleep problems that impact the disruption of executive functions are very prone to occur in health professions, especially nurses. nurses have a high potential to suffer mental stress, especially in treating patients. clinical nurses must stay on guard throughout the night.10 this mode of work makes their sleep time irregular. the problem of nurse sleep quality has become a prominent social focus.20 previous studies have shown that sleep disorders in nurses affect not only their health but also the nursing quality and even psychological health and patient care processes.16 in contemporary medical settings, the issue of overcrowding in the emergency department (ed) has risen to critical concern. impaired cognitive functions can heighten the risk of medical errors, thereby jeopardizing patient safety and potentially leading to adverse outcomes. however, no prior studies have specifically examined executive function, which represents the subset of cognitive functions responsible for task monitoring, response inhibition, error detection, and compensatory behavior. therefore, the primary objective of this study was to investigate both the qualitative and quantitative aspects of sleep in ed nurses and to explore the potential association between sleep and executive function. materials and methods design, setting, and sample in this study, a cross-sectional design was employed, and a multi-stage sampling technique was used to recruit participants. data was collected from 115 ed nurses in four hospitals in malang city, indonesia, in 2018. participants had to meet the following inclusion criteria: i) nurses who had worked in the ed for more than three months, ii) those working on a consecutive seven-day duty schedule with one day off during the study period, and iii) participants needed to have the ability to complete cognitive tasks on the last day of their duty. excluded from this study were individuals who were pregnant and those with a diagnosed sleep disorder. the first step in the research involved obtaining informed consent from participants in four hospitals: saiful anwar hospital malang, wava husada kepanjen, muhamaddiyah university malang, and dr. soepraoen military malang. the participants in this study were emergency nurses. before signing the informed consent, the researcher provided a detailed explanation of the research topic, objectives, benefits, and the research plan. after obtaining written consent, participants were provided with a sleep diary to fill out for seven days. each morning, participants recorded their sleep data, including trail making test (tmt), wake after sleep onset (waso), sleep efficiency (se), and sleep latency (sl), as well as their work shift for that day. the pittsburgh sleep quality index (psqi) and tmt evaluations took place during the morning service attendance over the course of seven days. the total time required for completing the psqi and tmt questionnaires was approximately 60 minutes. this sampling method was chosen due to the numerous hospitals in the east java area, with only education and high-accreditation hospitals included in this study. instrument and data collection data were collected by questionnaires, which were translated into the indonesian language. a self-administered questionnaire has been completed: the questionnaires, seven-day sleep diary was used to assess the sleep quantity the present, including tst, se, sol and waso,22 and this instrument was validated.23 other questionnaires of sleep quality in version indonesia24 and executive function by trail making test (tmt).25-26 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. number and percentage of demographic characteristics of participants (n=115) characteristics of respondent n (%) age, mean (sd) 32.2 (8.8) 20-29 60 (52.2) 30-39 32 (27.8) ≥ 40 23 (20) gender male 52 (45.2) female 63 (54.8) bmi, mean (sd) 23.6 (3.0) marital status single and divorced 44 (38.3) married 71 (61,7) education level licensed practical nurse (lpn) 91 (79.1) registered nurse (rn) 24 (20.9) working experience (year), mean (sd) 9 (8.5) < 4 years 45 (39.1) ≥ 5 years 70 (60.9) personal income a month < $ 250 59 (51.3) ≥ $ 250 56 (48.7) coffee intake every day no 55 (47.8) yes 60 (52.2) tea intake every day no 40 (34.8) yes 75 (65.2) exercise habit every week no 57 (49.6) yes 58 (50.4) total 115 100 [page 72] [healthcare in low-resource settings 2023; 11:11744] non -co mmerc ial us e o nly a seven-day sleep diary assesses the sleep quantity present, including total sleep time (tst), which is the time filling in sleep last night and the time of getting up this morning. sleep efficiency (se) is a proportion of the whole sleep time and the entire time in bed multiplied by 100%. sleep onset latency (sol) is the time calculated from lying down to sleep onset after the light is off. wake after sleep onset (waso) is a wake-up time to attend sleep onset. psqi for measuring sleep over the past month.27 the partners or roommates answer an additional five items, which are not counted for analysis. the 19 items generate seven components, including subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep deficiency, frequent use of sleeping medication, and daytime dysfunction — each item measured by the four-point likert scale (0-3). the global score is between 0 and 21. individuals with a global score of psqi of > 5 are considered poor sleepers. the trail making test (tmt) was generated from the correct number of connections minus the wrong amount. the results of the validity of the trail making test are evident, suggesting that performance simple tmt-a represented visual, conceptual tracking, psychomotor processing speed, and attention. alternating tmt-b assesses visual, conceptual tracking, and psychomotor processing speed. difference performing tmt b-a considers the set-switching task required in part b. performance b/a ratio represents more reliable executive control task-switching. data analysis all data analyses were conducted using the statistical package for the social sciences 23 (ibm corp., armonk, ny, usa). descriptive analyses were employed to estimate sociodemographic data, sleep parameters, and tmt scores. continuous variables were presented as mean ± standard deviation, while categorical variables were expressed as case numbers and percentages. a onesample t-test was used to assess differences between sleep parameters and norm data, as well as between tmt scores and norm data. the selected variables were then included in a multivariable linear regression stepwise model to investigate the associations between sleep and executive functions in ed nurses. the selected variables were then entered into a multivariable linear regression stepwise model to examine associations between sleep and executive functions in ed nurses. the significant level is set as 0.5. ethical permission the ethical number clearance from from the universitas muhammadiyah malang was e.5.a/122/kepkumm/viii/2018. results the results presented as follows: descriptive analysis included demographic characteristics of the participants (age, gender, bmi, material status, education, working experience, income, and habitually); distributions of self-reported sleep parameters, distributions of tmt scores of the study, and factors predicting tmt. table 1 showed the results of sociodemographic characteristics. regarding the consequence of score bdi and hypnotic use, no one in the study has symptoms of depression and does not use any medication for sleep disorders. the mean age of the respondents was 32.24 years (sd = 8.77). approximately half of the participants were female (54.8%). the mean bmi was 23.59 (sd = 3.02). furthermore, the mean of working experience was nine years. around 60.9% of participants worked in the ed for over five years (n =70). half of the participants’ monthly personal income was < $ 250; with education level, more than half percent of the participants were licensed practical nurses (lpn) or graduated from a diploma-3 nurse (79%). there were 52.2% and 65.2% of participants having habits of consuming coffee and tea, and more than half of participants (n = 58) regularly exercise every week. results of sleep parameters are shown in table 2, including waso, tst, sol, se, and the global score of psqi presented in table 3. the ed nurses were more likely to have prolonged sol, shorter tst, poorer se, and a higher global score of psqi than the published norm (all the p 0.000). it should be noted that the value of waso in our participants was much lower than data from the health population (p 0.000). in table 3, tmt was used to test the performances in the speed of processing, cognitive flexibility, sequence alternation, visual search, and executive function. the distribution of simple tmt a, alternating tmt b, the difference tmt b-a, and the ratio tmt b/a are presented in table 4. the values of tmt a, tmt b-a, and tmt b were higher in ed nurses than those of norm data p value < 0.001), reflecting that our participants needed more time to complete the task than the healthy population. besides, more participants produced lower scores than tmt b / a compared to the norm (p<0.001). tmt b / a performance proves that participants do not experience interference in the process of executive control functions and task-switching ability. multilinear regression analysis was conducted to examine the significant associations between sleep and executive function variables. after reviewing the assumption of the linear regression, the independent variables include waso, tst, sol, se, psqi, age, gender, bmi, material status, education level, working experience, personal income, habits (drinking coffee, tea, and exercise) interred in the stepwise multiple regression model. the stepwise regression model revealed that sleep parameters, including the effect of tst, se, and bmi, were significantly related to executive function among ed nurses in malang, east java, indonesia. table 4 shows that the effect of tst and bmi combined accounted for 89.8% of the variants representing visual, conceptutransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. distributions of self-reported sleep parameters (n=115). variable norm means participants mean sd p waso (minutes) 15 8.7 5.5 0.000 tst (minutes) 420 327.7 66.59 0.000 sol (minutes) 12 29.89 20.49 0.000 se (%) 92 88 6 0.000 psqi 5 7.68 2.73 0.000 < 5 (n, %) 21 18.3 >5 (n, %) 94 81.7 waso, wake after sleep onset; tst, total sleep time; sol, sleep onset latency; se, sleep efficiency; psqi, pittsburgh sleep quality index. table 3. distributions of tmt scores of the study (n=115). variable norm means participants mean sd p tmt a 25.4 34.92 15.22 0,000 tmt b 59.3 67.87 22.86 0,000 tmt b – a 27.69 32.95 9.35 0,000 tmt b/a 2.41 1.99 0.19 0,000 [healthcare in low-resource settings 2023; 11:11744] [page 73] non -co mmerc ial us e o nly al tracking, psychomotor processing speed, and attention. the effect of tst and bmi significantly correlated to 96.2% of the variants representing visual, conceptual tracking, and psychomotor processing speed. besides, we found that tst and se were associated with variants that indicated tmt b-a function (r2 = 0.770). se and bmi were significantly associated with tmt b / a of 22.7% of reliable variants of executive control and task shifting. the strongest association of tmt b-a executive functions is tst (beta= 0.874) followed by t.st with tmt-b correlation (beta= 0.631). the equation for the executive function of the tmt b-a, se association gives the lowest significance (beta=0.133). discussion on average, the 115 participants slept only five hours, which is notably less than the seven to eight hours of sleep typically observed in the normal population.28 other sleep parameter results, including waso, tst, and se, were likely shorter than usual but have a prolonged sol22. psqi analysis showed that the majority of respondents have poor sleep quality. the participants’ lack of sleep was due to the many patients coming to the er and the severity of the treated cases.29 apart from that, lack of staff is also one of the causes of work overload.30 on the other hand, the impact of burnout is a sleep problem.31,32 sleep disorders that occur in nurses, especially in the ed, will impact patient care, the occurrence of medication errors, and the most fatal effect is death.33 the previous research that supports nurses experiencing decreased cognitive function associated with lack of sleep.28,34,35 our findings suggest that ed nurses working fast rotating shifts have poor executive function. sleep disturbances and rapid shift changes can have consequences; however, our study could not confirm the possible effects or mechanisms of sleep and shift work on executive function.10,36-37 further investigation should examine this issue. another important finding was that only tst was negatively related to executive function. a possible explanation is that our participants may have experienced light sleep compared to deep sleep, as we found that they had greater waso than their counterparts. executive function is associated with non-rem sleep and rem sleep stages.34 the most significant decrease in brain activity during slow-wave sleep occurs in the frontal lobes.38 multiple findings support the benefits of slow-wave sleep for cognition. the highest delta activity during slow-wave sleep is associated with cognitive performance.39,40 another important finding was that only tst was substantially associated with executive function. our results found lower tst scores compared with the healthy population. most participants spent about five hours daily in bed, followed by a shorter waso. previous meta-analyses suggest that short sleep can impact cognitive performance.35 in line with this statement, sleep duration is correlated with cognition. executive function is associated with non-rem sleep stages for rem cycles when a person has lower sleep time.41 lower sleep can prevent people from progressing generally through sleep stages and limit the time spent in slowwave sleep.42 the most significant decrease in brain activity during slow-wave sleep occurs in the frontal lobe; multiple findings support the benefits of slow-wave sleep for cognition. results indicated that participants took longer to complete the tmt (a, b, b-a) portion. only tmt b/a had a completion time shorter than the norm. the results indicated a correlation between findings, demonstrating an increase in the duration of wake after sleep onset (waso), sleep efficiency (se), and completion time for tmt-a, b, and ba. these results suggest that participants who experience longer sleep and tmt completion times often report visual disturbances, sluggishness in taking action due to fatigue, and increased susceptibility to distraction when faced with fast-paced tasks.43,44 on the other hand, tmt b-a results are shorter than usual. participants could still do it correctly when they simultaneously received the doctor’s advice, but it took longer to concentrate fully. b-a tmt performance predictions influence the consideration of set-switching tasks.44 this study has certain limitations, including the utilization of cross-sectional data and self-report measures. while there are theoretically valid reasons to believe that the mentioned factors can influence nurses’ sleep quality, it is important to note that causal relationships cannot be definitively established from the data collected in this cross-sectional study. the generalizability of these findings to all clinical nurses in indonesia is constrained by the inclusion of only one level of hospital nurses in this study. furthermore, this study solely incorporated quality-of-life measures and did not consider other factors that may contribute to sleep disturbances, thereby limiting the analysis of the relationship between mental health and sleep disturbances. a further limitation is the lack of exploration into the quantitative interactions between psychological, quality-of-life, work-related, and personal factors. future research should explore the interplay between these intermediary factors to construct comprehensive models of sleep disturbances among clinical nurses. conclusions the study emphasized that emergency room (er) nurses with rapidly rotating shifts experienced poor sleep quality, longer sleep latency, lower sleep efficiency, shorter sleep duration, and higher wake after sleep onset (waso) compared to healthy populations. the study also found a negative relationship between sleep duration and participants’ executive function, which could result in reduced responsiveness due to quick fatigue and increased susceptibility to task-related distractions. these findings provide valuable evidence for the development of health promotion initiatives and strategic programs aimed at enhancing the wellbeing of ed nurses, particularly in the context of managing rotating shift work that can influence the health and safety of both nurses and patients. by addressing these issues, the aim is to minimize the occurrence of medical errors during 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[page 76] [healthcare in low-resource settings 2023; 11:11744] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [page 10] [healthcare in low-resource settings 2015; 3:5011] incremental detection of pulmonary tuberculosis among presumptive patients by genexpert mtb/rif® over fluorescent microscopy in mwanza, tanzania: an operational study jeremiah seni,1 benson r. kidenya,1 mercy anga,1 anthony kapesa,1 john r. meda,2 richard mutakyawa,3,4 zahra h. mkomwa,4 fidelis marcel,3 john m. changalucha,5 stephen e. mshana1 1department of microbiology and immunology, catholic university of health and allied sciences bugando, mwanza 2department of internal medicine, university of dodoma 3sekou toure regional referral hospital, mwanza 4path tanzania, dar es salaam 5national institute for medical research, mwanza medical research centre, tanzania abstract laboratory confirmation among presumptive tuberculosis (ptb) patients is pivotal in ensuring prompt management. limited information exists in tanzania regarding the performance of genexpert mtb/rif® in comparison with conventional methods. an operational study was conducted involving 806 ptb patients at sekou toure hospital in mwanza, tanzania from june to november 2013. patients’ information was obtained and their respective sputum samples analyzed by lightemitting diode fluorescent microscopy (led fm) and genexpert mtb/rif®. the mean age of study participants was 39.6±16.0 years, with males accounting for 50.5%. the majority of patients (97.5%) were new cases. the proportions of ptb patients confirmed by led fm and genexpert mtb/rif® were 14.1% (114/806) and 23.7% (191/806) respectively, resulting into a 9.6% incremental detection rate by genexpert mtb/rif® over led fm. the detection rate among hiv positive individuals was also higher [23.6% (63/267) vs 14.2% (38/267), respectively], with an incremental detection of 9.4%. the incremental detection of ptb by genexpert mtb/rif® over led fm calls for expansion of its use to increase detection of smear negative ptb among people living with hiv. introduction the escalating burden of tuberculosis (tb) in tanzania in the midst of high prevalence of hiv/aids poses a negative social and economic impact in this developing country which is ranked 22nd among countries accounting for 80% of the global burden of tb.1-3 to avert continuous transmission, morbidity and mortality attributable to tb, laboratory confirmation among presumptive pulmonary tuberculosis (ptb) patients is pivotal in ensuring prompt management.2,4 ziehl-neelsen (zn)-based light microscopy which is the main stay and universally available diagnostic technique in tanzania and other developing countries has long been shown to have low performance.5,6 in the light of this, the world health organization (who) has recommended scaling up the use of light-emitting diode fluorescent microscopy (led fm) which is on average 10% more sensitive in detection of tb compared to the conventional zn-based light microscopy using culture as a gold standard.5,7,8 this notwithstanding, led fm coverage is still low in developing countries.2 to address the low performance of microscopy-based detection methods for tb, a number of molecular based diagnostic methods have been validated by who to increase coverage and enhance timely detection of ptb patients,8-10 but their utility is unevenly appreciated across countries mainly due to the installation and running costs as well as lack of expertize.10,11 recently, who endorsed a new rapid molecular test called genexpert mtb/rif® (cepheid, sunnyvale, ca, usa).9 the dual function of the machine in simultaneously diagnosing tb and identifying resistance to one of the core first line anti-tb drug, rifampicin along with its high sensitivity and specificity, has revolutionized the diagnosis of tb globally.9,12-15 the performance of genexpert mtb/rif® has been shown to be better compared to led fm in both smear positive and negative people living with hiv (plwh), though variability exists depending on the population involved.16-18 the rifampin resistance has been shown to vary in different countries from 0% in mbeya (tanzania), 10% in harare (zimbabwe) to as high as 35.1% in moldova.16,19 in response to who call to scale up the utilization of this new diagnostic, the ministry of health in the united republic of tanzania, through the national tuberculosis and leprosy control program (ntlp)3,9 and other developmental partners, has cordially rolled out the genexpert mtb/rif® machines to various regions. apparently the target groups are smear negative plwh, ptb patient who recently contacted multidrug resistant tuberculosis (mdr) patient and children.3 in tanzania, mwanza region is second to dar es salaam in terms of tb case notification rates emphasizing the need to have reliable diagnostic methods in place.3 despite this, limited information exists in this region regarding the performance of the recently introduced genexpert mtb/rif® in comparison with led fm for the diagnosis of tb. furthermore, the magnitude of rifampicin (rif) resistance remains to be explored in this setting. therefore, the present study aimed at determining the incremental detection of tb among ptb patients by genexpert mtb/rif® and led fm at sekou toure regional referral hospital (srrh) in mwanza, tanzania so as to offer baseline information crucial for future assessment of the diagnostic performance of the facility as well as the utility of the new technique in this local setting. healthcare in low-resource settings 2015; volume 3:5011 correspondence: jeremiah seni, department of microbiology and immunology, catholic university of health and allied sciences, p.o. box 1464, bugando, mwanza, tanzania. tel: +255.78.4593000 fax: +255.28.2502678. e-mail: senijj80@gmail.com key words: tuberculosis detection; genexpert mtb/rif®; mwanza; tanzania. contributions: js, brk, ma and sem conceived and designed the study; ma and fm carried out the laboratory procedures; js, brk, ma, ak and jrm analyzed data; js wrote the first draft of the manuscript; ak, jrm, rm, zhm, jc and sem critically reviewed the manuscript. all authors have read and approved the final draft of the manuscript. conflict of interest: the authors declare no potential conflict of interest. acknowledgements: the authors are sincerely thankful to the patients who participated in the study, srrh administration for allowing conduction of this study. mr. othman sade and other laboratory staffs working in the tb section at srrh for their technical support. the genexpert mtb/rif® was generously donated and is being maintained path tanzania under usaid tb to 2015 funds. part of this work was presented at the 6th cuhas scientific graduation symposium: abstract book, november 2014, mwanza. tanzania. received for publication: 17 january 2015. revision received: 21 march 2015. accepted for publication: 26 march 2015. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. seni et al., 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:5011 doi:10.4081/hls.2015.5011 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5011] [page 11] materials and methods study design and area this was an operational prospective laboratory based study carried out at srrh in mwanza, tanzania from june 2013 to november 2013 involving 1946 ptb patients submitting their sputum for analysis at srrh. of these, 806 (41.4%) had dual results (i.e. led fm and genexpert mtb/rif® results) fulfilling the inclusion criteria, and 1140 (58.6%) patients were excluded for various reasons (figure 1). sample collection, processing and data analysis sputum samples were collected from ptb patients following the ntlp guidelines,1 and analyzed based on the standard operating procedures by led fm and genexpert mtb/rif®.8,9,15,20 for comparison purposes of the two diagnostic techniques, one sputum sample per patient was used. in case the sample was negative requiring the second sputum sample as per ntlp guideline,1 the latter was analyzed to guide patient’s management but not used for the index study. patients’ information was obtained from laboratory request forms and the tb registry book. analysis was done using stata software version 11 (college station, tx, usa) according to the objectives of the study. continuous variables were described as mean (±standard deviation). categorical variables were described as proportions (percentages) and were analyzed to compare the distribution of ptb positive and negative patients with variables. study clearance and ethical considerations the study was approved by the joint bugando medical centre and catholic university of health and allied sciences institutional review board. permission to conduct the study was obtained from srrh medical officer in charge, tb coordinator and laboratory manager. all patients’ information was kept confidential and anonymous using study codes. presumptive patients found to have ptb were treated in their respective treatment units basing on the ntlp guidelines1 and those with rif resistance were referred to kibong’oto national tuberculosis hospital for confirmation and further expertize management. results we involved 806 ptb patients in this study with the mean age (±standard deviation) of 39.6±16.0 years (age range 1-96 years); males accounted for 50.5% (407/806). majority of patients (97.5%) were new cases and were residing within mwanza city, 81.7% (658/806). the proportion of ptb patients confirmed to have ptb disease by either fm or genexpert mtb/rif® was 24.8% (200/806) (table 1). of these, 14.1% (114/806) and 23.7% (191/806) were detected by fm and genexpert mtb/rif® respectively. this resulted into 9.6% incremental detection rate by genexpert mtb/rif® over led fm (figure 1 and table 1). the detection rate of genexpert mtb/rif® was higher compared to led fm in both children (≤17 years) [8.3% (6/72) vs 4.2% (4/72)] and adults [25.2% (185/734) vs 15.1% (111/734)] respectively resulting into the incremental detections of 4.1% and 10.1% for children and adults respectively. the detection rate among hiv positive individuals was also higher using genexpert mtb/rif® compared to fm [23.6% (63/267) vs 14.2% (38/267) respectively], with an incremental detection of 9.4%. moreover, the genexpert mtb/rif® detected 12.4% (86/692) and 12.2% (28/229) among all smear negative irrespective of hiv serostatus and smear negative hiv positive ptb patients were respectively. the rif resistance was found in 2 (1.1%) patients, 5 (2.6%) had indeterminate resistance, whereas in 184 (96.3%) there was no rifampin resistance detected. of 200 ptb positive patients, majority were found to be in the age group of more than 18 years (96.5%), males (60%), residents of mwanza city (69.4%), new cases (94.5%) and hiv positive (86.8%) (table 2). discussion the low performance of sputum smear microscopy in developing countries with high article table 1. diagnostic performance of genexpert mtb/rif® vs light emitting diode fluorescent microscopy. led fm genexpert mtb/rif® total mtb detected mtb not detected afb detected 105 9 114 afb not detected 86 606 692 total 191 615 806 led fm, light emitting diode fluorescent microscopy; mtb, mycobacterium tuberculosis; rif, rifampicin; afb, acid fast bacilli. figure 1. flow chart showing series of events in the recruitment procedures and results. led fm, light emitting diode fluorescent microscopy; ptb, pulmonary tuberculosis; mtb, mycobacterium tuberculosis; rif, rifampicin; srrh, sekou toure regional referral hospital. non co mmerc ial us e o nly [page 12] [healthcare in low-resource settings 2015; 3:5011] tb burden has been widely documented and if unchecked, it can result into uninterrupted transmission of this deadly infectious disease.2,5,6 despite a number of new technological advancement on the diagnosis of tb, the local evaluations of their performance remain a challenge in most developing countries.10,11,13,21 the incremental detection of 9.6% among ptb patients at srrh by genexpert mtb/rif® over led fm in the present study along with the 23% from a review involving 8880 participants in 21 studies,12 8.0% among children in uganda,17 and 9.7% in a recent multicenter, randomized controlled trial involving south africa, zimbabwe, zambia and tanzania,16 emphasizes the utility of genexpert mtb/rif® over microscopy in the diagnosis of tb patients. but the cost-related challenges for the universal introduction of genexpert mtb/rif® in many health facilities in developing countries reiterate the need to continue strengthening the pre-existing microscopy-based tb diagnostic methods, so that the newer technique remains reserved to risky groups like smear negative plwh, ptb patients who recently contacted mdr, and children.3 the incremental detection of tb among smear negative plwh in this and other studies17,18,21,22 further justifies its utility in this risky group as recommended by the new ntlp guidelines.3 the use of genexpert mtb/rif® to detect rif resistance as a surrogate marker of mdr has been suggested in many studies, with concordance ranging from 88 to 100%.14,23,24 in the light of these, rif resistance in the present study (2.2%) is higher than 0.86 (4/464) and 0.17% (2/1167) from a study in mwanza and national survey in tanzania respectively25,26 but lower than 3.5 to 7.3% in different african countries.19 interestingly, no rif resistance has been detected in three studies from mbeya, tanzania.16,21,27 the finding of rif resistance in mwanza region which is second to dar es salaam in terms of tb case notification calls for strengthening of surveillance system in this region to enable timely detection of patients with rif resistant and mdr tb, thereby interrupting further transmission by provision of prompt management. based on the nature of works and likelihood of exposure, the preponderance of males and city dwelling residents to be infected with ptb in this study is also similar to other reports.3,28 the high proportion of ptb patients to be co-infected with hiv in the present study relates to another study.17 these findings are also supported by other studies which have shown association of development of active tb with hiv/aids, smoking, co-morbidity such as diabetes mellitus, indoor air pollution and young age.2,29 limitations the culture method which is a gold standard for laboratory diagnosis of tb is not done at srrh. thus, this operational study did not compare the performance of genexpert mtb/rif® and led fm with culture. also, the impact of other predictor variables on diagnostic performance such as cd4+ count was not evaluated. conclusions there is an approximately 10% incremental detection of tb among ptb patients by genexpert mtb/rif® compared to led fm, with more detection also among smear negative plwh who are apparently targeted by ntlp to be among beneficiaries of this new technology. therefore, we recommend the expansion of its use to increase detection of ptb among smear negative plwh at srrh and other settings in the lake victoria zone. evaluation of genexpert mtb/rif® performance among people with extra pulmonary tb and the impact of various predictor variables on this diagnostic assay will be of interest to further delineate its utility in this setting. references 1. ministry of health and social welfare, united republic of tanzania. manual of the national tuberculosis and leprosy programme in tanzania. dar es salaam, tanzania: ministry of health and social welfare; 2006. 2. who. global tuberculosis control: who report 2011. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011 /9789241564380_eng.pdf 3. ministry of health and social welfare, united republic of tanzania. manual for the management of tuberculosis and leprosy. national tuberculosis and leprosy programme. dar es salaam, tanzania: ministry of health and social welfare; 2013. 4. zumla a, raviglione m, hafner r, von reyn cf. tuberculosis. new engl j med 2013;368:745-55. 5. steingart kr, henry m, ng v, et al. fluorescence. conventional sputum smear microscopy for tuberculosis: a systematic review. lancet infect dis 2006;6:570-81. 6. seni j, kidenya br, obassy e, et al. low sputum smear positive tuberculosis among pulmonary tuberculosis suspects in a tertiary hospital in mwanza, tanzania. tanzania j health res 2012;14:1-9. 7. cattamanchi a, davis jl, worodria w, et al. sensitivity and specificity of fluorescence microscopy for diagnosing pulmonary tuberculosis in a high hiv prevalence setting. int j tuberc lung d 2009; 13:1130-6. 8. who. fluorescent light-emitting diode (led) microscopy for diagnosis of tuberculosis: policy statement. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who. article table 2. distribution of pulmonary tuberculosis positive and negative patients with variables. variables ptb patients (total=806) positive (total=200)*n (%) negative (total=606) n (%) mean age (years) 39.4±14.0° 39.7±16.7° age groups (years) ≤8 4 (2.0) 17 (2.8) 9-17 3 (1.5) 48 (7.9) ≥18 193 (96.5) 541 (89.3) sex female 80 (40.0) 319 (52.6) males 120 (60.0) 287 (47.4) residence mwanza city 138 (69.4) 520 (85.8) outside mwanza city 61 (30.6) 86 (14.2) treatment category new cases 189 (94.5) 597 (98.5) follow up 11 (5.5) 9 (1.5) hiv serostatus# positive 66 (86.8) 201 (87.0) negative 10 (13.2) 30 (13.0) ptb, presumptive tuberculosis. *diagnosed by either led fm or genexpert mtb/rif®; °continuous variable; #only 307 patients knew hiv serostatus. non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:5011] [page 13] int/publications/2011/9789241501613_eng .pdf 9. who. policy statement: automated realtime nucleic acid amplification technology for rapid and simultaneous detection of tuberculosis and rifampicin resistance: xpert mtb/rif system. geneva, switzerland: world health organization; 2011. available from: http://whqlibdoc.who.int/publications/2011 /9789241501545_eng.pdf 10. parsons lm, somoskovi a, gutierrez c, et al. laboratory diagnosis of tuberculosis in resource-poor countries: challenges and opportunities. clin microbiol rev 2011;24:314-50. 11. pantoja a, fitzpatrick c, vassall a, et al. xpert mtb/rif for diagnosis of tuberculosis and drug-resistant tuberculosis: a cost and affordability analysis. eur respir j 2011;42:708-20. 12. steingart kr, schiller i, horne dj, et al. xpert(r) mtb/rif assay for pulmonary tuberculosis and rifampicin resistance in adults. cochrane db syst rev 2014:cd009593. 13. lawn sd, nicol mp. xpert(r) mtb/rif assay: development, evaluation and implementation of a new rapid molecular diagnostic for tuberculosis and rifampicin resistance. future microbiol 2011;6:106782. 14. boehme cc, nabeta p, hillemann d, et al. rapid molecular detection of tuberculosis and rifampin resistance. new engl j med 2010;363:1005-15. 15. helb d, jones m, story e, et al. rapid detection of mycobacterium tuberculosis and rifampin resistance by use of ondemand, near-patient technology. j clin microbiol 2010;48:229-37. 16. theron g, zijenah l, chanda d, et al. feasibility, accuracy, and clinical effect of point-of-care xpert mtb/rif testing for tuberculosis in primary-care settings in africa: a multicentre, randomised, controlled trial. lancet 2014;383:424-35. 17. sekadde mp, wobudeya e, joloba ml, et al. evaluation of the xpert mtb/rif test for the diagnosis of childhood pulmonary tuberculosis in uganda: a cross-sectional diagnostic study. bmc infect dis 2013;13:133. 18. ssengooba w, nakiyingi l, armstrong dt, et al. clinical utility of a novel molecular assay in various combination strategies with existing methods for diagnosis of hiv-related tuberculosis in uganda. plos one 2014;9:e107595. 19. creswell j, codlin aj, andre e, et al. results from early programmatic implementation of xpert mtb/rif testing in nine countries. bmc infect dis 2014;14:2. 20. lumb r, van deun a, bastlan i, fitz-gerald m. laboratory diagnosis of tuberculosis by sputum microscopy. adelaide, australia: sa pathology; 2010. available from: http://www.who.int/tb/laboratory/tb-sputum-microscopy-handbook.pdf 21. rachow a, zumla a, heinrich n, et al. rapid and accurate detection of mycobacterium tuberculosis in sputum samples by cepheid xpert mtb/rif assay: a clinical validation study. plos one 2011;6:e20458. 22. lawn sd, brooks sv, kranzer k, et al. screening for hiv-associated tuberculosis and rifampicin resistance before antiretroviral therapy using the xpert mtb/rif assay: a prospective study. plos med 2011;8:e1001067. 23. kidenya br, webster le, behan s, et al. epidemiology and genetic diversity of multidrug-resistant tuberculosis in east africa. tuberculosis 2014;94:1-7. 24. blakemore r, story e, helb d, et al. evaluation of the analytical performance of the xpert mtb/rif assay. j clin microbiol 2011;48:2495-501. 25. range n, friis h, mfaume s, et al. antituberculosis drug resistance pattern among pulmonary tuberculosis patients with or without hiv infection in mwanza, tanzania. tanzania j health res 2012;14:1-9. 26. chonde tm, basra d, mfinanga sg, et al. national anti-tuberculosis drug resistance study in tanzania. int j tuberc lung d 2010;14:967-72. 27. ntinginya en, squire sb, millington ka, et al. performance of the xpert(r) mtb/rif assay in an active case-finding strategy: a pilot study from tanzania. int j tuberc lung d 2012;16:1468-70. 28. austin jf, dick jm, zwarenstein m. gender disparity amongst tb suspects and new tb patients according to data recorded at the south african institute of medical research laboratory for the western cape region of south africa. int j tuberc lung d 2004;8:435-9. 29. narasimhan p, wood j, macintyre cr, mathai d. risk factors for tuberculosis. pulm med 2013; 2013:828939. article non co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2015; 3:4663] [page 1] obstetric fistula in assam, india: a neglected cause of maternal morbidities and mortality suresh jungari, bal govind chauhan international institute for population sciences, mumbai, maharashtra, india abstract each year between 50,000 to 100,000 women worldwide are affected by obstetric fistula, a hole in the birth canal. obstetric fistula is one of the major cause for maternal morbidities and mortality and it has been successfully eradicated in developed nations. women who experience obstetric fistula suffer constant incontinence, shame, and social segregation. obstetric fistula is prevalent in african and asian countries, including india. in india, data has been collected in a large scale survey of district level household survey regarding obstetric fistula and its causes. in this study, efforts are endeavoured to understand the prevalence and causes of obstetric fistula in assam state, india, where prevalence of obstetric fistula is very high (4.5%). chi-square test was applied to determine the affecting factors of obstetric fistula. results showing the socioeconomic status, education, place of residence and age group are important determinants in variation of fistula prevalence among women. introduction obstetric fistula is a hole or tear in the tissue wall between the vagina and the bladder or rectum, or a hole between them both that results in incontinence of urine. obstetric fistula is the most devastating of all pregnancyrelated disabilities. it is an injury of childbirth that has been relatively neglected, and is usually caused by several days of obstructed labour. it is estimated that more than 2 million young women live with untreated obstetric fistula in asia and sub-saharan africa.1 obstetric fistula cases are prevented by taking adequate care during pregnancy.2 commonest fistulas are genitourinary, rectovaginal and both genitourinary and rectovaginal.3 obstetric fistula problems are still prevalent in the underdeveloped world, but developed nations do not have fistula cases because of the availability of high quality emergency obstetric services. prolonged obstructed labour during pregnancy and lacking availability of healthcare services on time are major causes for obstetric fistula formation. in obstructed labour the soft tissues of the pregnant woman’s vagina, bladder, and rectum are compressed between the fetal head and the maternal pelvic bones by the contractions of the uterus. as the fetal head is forced tighter and tighter into the pelvis, the blood supply to the mother’s soft tissues is progressively constricted, and ultimately it is completely shut off.4 in almost all cases of fistula, the baby dies. an obstetric fistula leads to high rates of infant, child and maternal mortality. sexual assault, including rape and forced insertion of objects into a woman’s vagina leads to fistula. a fistula resulting from sexual violence is one example of a traumatic gynaecologic fistula.5,6 traumatic fistulas are rare compared to obstetric fistulas. fistulas indirectly related to sexual violence are likely to be more common than those directly related7 and sexual violence can lead to more pregnancy complication and fistulas in india.8 obstetric fistula is one of the neglected causes of maternal mortality in the developing world, including india. it has several health consequences on women reproductive health and it is considered as a major public health threat.9 maternal morbidity affects women, their families, communities and societies and country at large.10 moreover, untreated obstetric fistula can lead to secondary infertility. poverty, illiteracy, traditional practices during childbirth and pregnancy in young ages are the major social causes of obstetric fistula in developing countries including india. the social consequence of obstetric fistula is pathetic: women are blamed, they are excluded from mainstream and under the isolation they may not receive treatment in time lives with longer duration. due to continue urine leaking women feel ashamed, and in some cases they receive violence from intimate partner. more than 50% of obstetric fistula affected women are divorced by husbands in india.11,12 another social consequence of obstetric fistula is the suicide of affected women: a study in bangladesh and ethiopia found that 97% of women with obstetric fistula were screened positive for potential mental health dysfunction. this shows how women with obstetric fistula are at high risk of mental health problems,13,14 and are predisposed to high levels of depression and suicidal ideations.15 data on obstetric fistula is scarce: any population-based data for prevalence of obstetric fistulas is not available and research on causes and consequences of obstetric fistula is needed for further exploring the issue. reliable data and research on this maternal morbidity burden is lacking16-18 due to the stigma related to this condition. fistula untreated cases may not be reported and underestimation of fistula cases is another issue of concern. research in india found that small obstetric fistulas can be repaired and cured with layered closure and complicated fistulas can be repaired with tissue interposition or tissue graft,19 but one of the complication after the repair of the obstetric fistula is that 10-30% of women is still left with urinary incontinence even if the fistula is closed.20,21 the majority of the studies are undertaken in a hospital set or are trial-controlled studies and focus on medical aspects; very few studies are attempted to understand the sociological consequences of obstetric fistula. maternal health situation in assam, india assam state belongs to the empowered action group states, selected by the government on the basis of socio-economic indicators. demographic and health indicators reveal that assam state is poorer than other states. according to the sample registration system report 2011, the maternal mortality ratio is 390, which is higher than total indian 212 (2007-09). despite government efforts to reduce maternal mortality burden through national rural health mission schemes, e.g. janani surksha yojan, no real improvement has been observed. utilization of maternal health services in the state is minimal as compared to other states and india. any antenatal care is 57%, which is considered to be very poor: its utilization is much important because possible pregnancy complications can be ascertained in early stage of pregnancy and it can be useful in avoiding obstetric emergences. institutional deliveries of the state represent only 23% and in rural areas they are reduced to 18%, which is a great area of concern to avoid pregnancy-related complications.22 according to the district level healthcare in low-resource settings 2015; volume 3:4663 correspondence: suresh jungari, international institute for population sciences, govandi station road, mumbai, 400088 maharashtra, india. tel: +91.22.2556.3489. e-mail: sureshjungariiips@gmail.com key words: obstetric fistula, maternal mortality, district level household survey, institutional delivery. received for publication: 5 august 2014. accepted for publication: 19 august 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s. jungari and b. govind chauhan, 2015 licensee pagepress, italy healthcare in low-resource settings 2015; 3:4663 doi:10.4081/hls.2015.4663 non co mmerc ial us e o nly [page 2] [healthcare in low-resource settings 2015; 3:4663] household survey (dlhs)-3,23 prevalence of obstetric fistulas in assam is unacceptably high (4.5%) compared to all other states, and national prevalence of obstetric fistula is 1.2%, which is another bad indicator for higher maternal mortality and morbidities. dlhs-3 represents the very first time nationwide data on the prevalence of obstetric fistula and its determinants has been collected. all this considered, this study intends to understand the prevalence and the determinants of higher percentage obstetric fistulas in assam state, india. materials and methods data source this study used data from most recent dlhs, i.e. dlhs-3 (2007-08),23 which is one of the largest demographic and health surveys ever carried out in india, with a sample size of about 700,000 households covering all the districts of the country. in 1997, the ministry of health and family welfare, government of india, started to provide district level estimates on health indicators to assist policy makers and program administrators in decentralized planning, monitoring and evaluation. the present dlhs is the third in the series preceded by dlhs-1 in 1998-99 and dlhs-2 in 200204. dlhs-3 interviewed ever-married women (age 15-49) and never married women (age 15-24). dlhs-3 adopts a multi-stage stratified probability proportional to size sampling design. in dlhs-3, a separate module of obstetric fistula consisting of five questions was canvassed to all ever-married women to gather information on fistula status. methods information about women reproductive morbidities has been collected through questionnaires to understand the fistula prevalence. women who said yes to the question do you have a problem of urine incontinence were considered as fistula cases. following this, one more question was asked, i.e. when the problem started?, to understand the causes of obstetric fistula, which are, hospital delivery, pelvic surgery, sexual violence or other. cross tabulation and chi-square test were applied to understand fistula prevalence and causes. study variables current age of mothers, education, place of residence, parity, birth order, religion, caste, wealth quintile, induced abortion were the study variables. obstetric fistula has been considered as an outcome variable in the study. table 2. chi-square analysis of obstetric fistula prevalence in assam state, india. background characteristics n % current age of respondent (years) (4.580) <20 1454 3.5 20-24 4674 4.8 25-29 6449 4.6 30-34 5717 4.3 35-49 11,946 4.5 parity (0.402) 1 3679 4.8 2-3 4147 4.7 ≥4 2145 4.5 place of residence (18.485)*** rural 26,626 4.7 urban 3615 3.1 educational level (years) (9.535)** non literate 30 3.3 <5 4202 4.6 5-9 10,621 4.4 ≥10 5179 3.5 religion (20.819)*** hindu 20,746 4.7 muslim 8137 3.6 other 1357 5.7 cast/tribe (9.415)*** schedule cast 3290 3.7 schedule tribe 7316 5.0 other 19,635 4.4 wealth index (20.270)*** poor 11,846 4.9 middle 8617 4.7 rich 9776 3.7 induced abortion (51.051)*** no 28,366 4.3 yes 1871 7.8 total 30,241 4.5 values in brackets represent chi-square test at 0.05 level of significance. table 1. obstetric fistula prevalence in indian states. states obstetric fistula n % jammu and kashmir 15,161 3.0 himachal pradesh 10,015 1.5 punjab 20,889 0.0 chandigarh 848 0.0 uttarakhand 12,636 3.1 haryana 21,411 0.2 delhi 8096 0.8 rajasthan 40,222 0.4 uttar pradesh 86,029 1.6 bihar 45,800 1.5 sikkim 4399 1.5 arunachal pradesh 15,074 0.4 manipur 9263 1.4 mizoram 7846 0.3 tripura 4166 0.2 meghalaya 6941 0.7 assam 30,241 4.5 west bengal 21,863 0.8 jharkhand 26,828 2.5 orissa 27,842 0.5 chhattisgarh 18,128 0.3 madhya pradesh 46,148 3.4 gujarat 24,162 2.7 daman and diu 1943 1.3 dadra and nagarhaveli 921 4.1 maharashtra 34,900 1.5 andhra pradesh 21,716 1.8 karnataka 27,779 1.0 goa 1452 2.1 lakshadweep 1363 0.4 kerala 12,359 0.6 tamil nadu 26,669 0.3 pondicherry 3849 0.8 andaman and nicobar 1823 1.9 islands india (total) 638,782 1.5 non co mmerc ial us e o nly [healthcare in low-resource settings 2015; 3:4663] [page 3] results table 1 shows the prevalence of obstetric fistula among all states in india. assam state has higher percent of fistula (4.5%), followed by madya pradesh (3.4%) and uttarakhand (3.2%). those states lacking behind in maternal health indicators have higher percent of obstetric fistula prevalence. kerla, tamilnadu, hariyana, and punjab have the least prevalence of obstetric fistula cases. table 2 shows the weighted percentage of women who experienced obstetric fistula by selecting their background characteristics. overall, 4.5% of women experienced obstetric fistula. of <20year-old women, 3.5% experienced any type of symptom of obstetric fistula, while older women (20-24-year-old) with obstetric fistula were 4.8%. the percentage of obstetric fistula was 4.8, 4.7 and 4.5 respectively, with parity 1, 2-3 and ≥4, respectively. of ever married women living in rural areas, 4.7% experienced obstetric fistula compared to city dwellers (3.1%). the percentage of obstetric fistula was 3.3 among women with no education, and 3.5 for those with 10 or more years of education. muslim women experiencing obstetric fistula were 3.6%, while those belonging to other religious groups and experiencing the disease were 5.7%. women belonging to schedule tribes, living in a poor economic status, and experiencing induced abortion more likely experienced obstetric fistula (5.0, 4.9, and 7.8%, respectively). women who ever experienced obstetric fistula were asked about the causes of their diesase. there seem to be four main causes (table 3): about 75.2% of women have experience of obstetric fistula after hospital delivery, 7.2% after surgery, 14.4% as a result of sexual violence (considered as a traumatic gynaecologic fistula), and only 3.3% due to other causes. discussion reducing child mortality and improving maternal health represent the fourth and fifth millennium developmental goals, respectively. to achieve these goals, all levels of improvement in maternal health situation are required and in india improvements in maternal indicators in the so-called empowered action group states is crucial. obstetric fistula is one of the major causes of maternal morbidities and mortality. the present study used the most recent data of dlhs-3 (2007-8) which is the first of its kind to collect information on obstetric fistula. study results clearly show the alarming picture of assam state in india. the consequences of higher prevalence are long lasting. both medical and social consequences of obstetric fistula are vast, fistula-affected women often face the isolation and frustration which can lead to further psychological disorders. in india many husbands obtain divorce from fistula-affected women. the study found daunting results: 14.4% of fistula cases are due to sexual violence by husbands (traumatic gynaecologic fistula) and many similar cases are not yet reported nor documented. morevoer, a number of barriers delay women’s access to traumatic fistula services, like higher financial costs and lack of awareness about available services. prevention of fistula is important to reduce the burden of maternal morbidities and mortality and it could be attained by providing appropriate maternal health services and emergency obstetric care. to overcome the burden of fistula, programmatic approaches integrated with other maternal health services are urgently needed. limitations of the study information has been collected on the basis of symptoms of obstetric fistula, therefore it does not provide small details. the study results may be then considered only as tentatively providing the prevalence of the disease. conclusions higher and unacceptable prevalence of obstetric fistulas in assam state is disturbing news for healthcare providers, health system managers, policy makers and especially for those who are pregnant and exposed to any form of violence. the major reasons for fistula are obstetric labour during child birth and sexual violence by husbands. women in rural areas are at greater risk to be affected by fistula, as the availability of emergency obstetric care in rural areas is very minimal. also, illiterate women are more likely to affect fistula than educated ones. international to local efforts are needed to solve this problem, overall by informing women on available antenatal services and identifying possible pregnancy complications. references 1. who. mental health aspects of women’s reproductive health: a global review of the literature. geneva, switzerland: world health organization; 2009. 2. mccord c, premkumar r, arole s, arole r. efficient and effective emergency obstetric care in a rural indian community where most deliveries are at home. int j gynaecol obstet 2001;75:297-307. 3. singh s, chandhiok n, dhillon bs. obstetric fistula in india: current scenario. int urogynecol j 2009;20:1403-5. 4. wall ll. obstetric vesicovaginal fistula as an international public-health problem. lancet 2006;368:1201-9. 5. arrowsmith sd, ruminjo j, landry eg. current practices in treatment of female genital fistula: a cross sectional study. bmc pregnancy childbirth 2010;10:73. 6. acquire project. traumatic gynaecological fistula: a consequence of sexual violence in conflict settings. a report of a meeting held in addis ababa, ethiopia. new york, ny: acquire project/engender health; 2006. 7. onsrud m, sjøveian s, luhiriri r, mukwege d. sexual violence-related fistulas in the democratic republic of congo. int j gynaecol obstet 2008;103:265-9. 8. who. understanding and addressing violence against women: health consequences. geneva, switzerland: world health organization; 2012. 9. medina m, roedee g, decosas j, et al. thematic evaluation of the national programmes and unfpa experience in the campaign to end fistula: assessment of national programmes. final synthesis report. new york, ny: unfpa; 2010. 10. national research council. the consequences of maternal morbidity and maternal mortality: report of a workshop. washington, dc: national academy press; 2000. 11. wall ll, arrowsmith sd, briggs nd, et al. urinary incontinence in the developing world: the obstetric fistula. j obstet gynaecol 2003;23:439-40. 12. ahmed s, holtz sa. social and economic consequences of obstetric fistula: life changed forever? int j gynaecol obstet 2007;99:10-5. 13. goh jt, sloane km, krause hg, et al. mental health screening in women with genital tract fistulae. int j gynaecol obstet 2005;112:1328-30. 14. browning a, fentahun w, goh jtw. the impact of surgical treatment on the mental health of women with obstetric fistula. int j gynaecol obstet 2007;114:1439-41. 15. weston k, mutiso s, mwangi jw, et al. article table 3. causes of obstetric fistula in assam, india. causes n % hospital delivery 1016 75.2 pelvic surgery 97 7.2 sexual assault 194 14.4 other 44 3.3 total 1351 100.0 non co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2015; 2:4663] depression among women with obstetric fistula in kenya. int j gynaecol obstet 2011;115:31-3. 16. zheng ax, anderson fw. obstetric fistula in low-income countries. int j gynaecol obstet 2009;104:85-9. 17. hardee k, gay j, blanc ak. maternal morbidity: neglected dimension of safe motherhood in the developing world. global public health 2012;7:603-17. 18. stanton c, holtz sa, ahmed s. challenges in measuring obstetric fistula. int j gynaecol obstet 2007;99:4-9. 19. goyal nk, dwivedi us, vyas n, et al. a decade’s experience with vesicovaginal fistula in india. int urogynecol j 2007;18:39-42. 20. kelly mj, kwast be. epidemiologic study of vesicovaginal fistulas in ethiopia. int urogynecol j 1993;4:278-81. 21. browning a. prevention of residual urinary incontinence following successful repair of obstetric vesico‐vaginal fistula using a fibro‐muscular sling. int j gynaecol obstet 2004;111:357-61. 22. iips. national family health survey (nfhs), 2005-06. mumbai, india: international institute for population sciences; 2007. 23. iips. district level household and facility survey (dlhs-3), 2007-08. mumbai, india: international institute for population sciences; 2010. non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:11108 health information use and the associated factors among public health facilities of the sidama zone, southern ethiopia: a facility-based cross-sectional study melaku getahun,1 keneni gutema2 1jsi/hmis scaling up project, hawassa; 2health systems and policy unit, school of public health, hawassa university college of medicine and health science hawassa, ethiopia abstract a strong health information system (his) is a foundation for evidence-based decision making in health care management. however, there is a dearth of literature with respect to health information use practice, particularly in public health facilities of sidama zone, southern ethiopia. a cross-sectional, facility-based quantitative study was conducted from 15 february to 5th of march 2018. quantitative data was collected using a structured questionnaire and checklists from a sample of 48 health facilities and 213 health workers, and analyzed using binary logistic regression. to complement the quantitative findings, qualitative data was collected using key informant interviews. the level of information use based on standard observation checklists was 58%. health information system’s specific supportive supervision (adjusted odd ratio, aor, 3.070; 95% confidence interval, ci, 1.206, 7.816), staff’s perception of data use practice (aor=3.732, 95%ci 1.383, 10.068), and staff’s experience of root cause analysis (aor=3.782, 95%ci 1.456, 9.819) were significant factors associated with the information use. health information use among public health facilities was low. strengthening supportive supervision, awareness creation on the use of available data, and improving the skill of root cause analysis of the problem is recommended. introduction health information systems (his) are among the six building blocks of health system strengthening.1 sound and reliable his enables the best use of health information by ensuring health information data quality, hence assisting decision makers and stakeholders manage and plan resources at every level of health care delivery systems.2 his can positively impact health outcomes if strengthened and negatively impact them if not. for instance, a robust his can reduce health data errors, provide quick access to patient histories, improve the accuracy of diagnoses, and result in cost-effective service provision. moreover, his facilitates evidence-based decisions, helping health policymakers and planners create the right policies and plans to improve the health outcomes of the population.3 according to the health metrics networks (hmn) framework, there is a wide variety of his data that could be categorized at healthcare facilities as individual-level health status data, health services, and administrative records.4 information use is a paramount improvement effort of any healthcare delivery system at all levels. consequently, the data management system should be improved to generate the appropriate information for decision-making activities, without which progressive change doesn’t exist.5 correspondence: keneni gutema, health systems management and policy unit, school of public health, college of medicine and health sciences, hawassa university, p.o. box 1560, hawassa, ethiopia. tel. 251911424467. fax. 046-2208755. e-mail: kenenigut2000@yahoo.com key words: information use, health management information system, public health facilities. conflict of interest: the authors declare no potential conflict of interest. funding: jsi/hmis scaling up project has fully supported the study financially by covering the stationary and data collection costs. contributions: mg was involved in conceptualization, data collection, formal data analysis, interpreted data, and drafted the manuscript. kg participated in the study design supervision and analysis, interpreted data, and reviewed the manuscript for publication. both authors read and approved the final manuscript, and agreed to be held accountable for all aspects of the work. ethics approval and consent to participate: ethical approval was granted by the institutional review board of hawassa university (ref. no.irb/066/10) on 11/01/ 2018. then a permission letter was obtained from hawassa university school of public health, sidama zonal health department, and woreda health offices sequentially. finally, the health facilities were communicated using letters received from higher officials. during data collection, professional and social ethics were maintained, and the names of the facilities and personnel involved in the study were not stated on the data collection tools. the participants were asked to sign a consent form to confirm their willingness to take part in the study. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to thank hawassa university for facilitating the study. we are also grateful to sidama zone health facilities for providing us with all the necessary data. the authors would also like to thank all data collectors and supervisors, particularly solomon haile and zewetir azeze. last but not least our acknowledgment goes to jsi/hmis scaling up project for financial support. received: 20 december 2023. accepted: 2 august 2024. early access: 5 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:11108 doi:10.4081/hls.2024.11108 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:11108] [page 1] it is well recognized that the ultimate goal of his is ensuring data quality and information use for more assertive informed decisions that determine the efficiency and effectiveness of identifying performance gaps, defining priorities, proposing solutions, and allocating resources for improved health outcomes.6 information use culture is determined by the accessibility of well-designed and documented information sources, monitoring and evaluation structures, availability of guidelines, finance, and skilled staff. these factors can be categorized into three general categories: the attitudes and actions of a multitude who produce or use information, the technical facet of data process and tools, and the organizational context that living or inhibits data processes.7,8 the need for quality data and information used for evidencebased decisions in the health care delivery systems is becoming a priority area of concern. in response, the federal ministry of health (fmoh) in ethiopia has commenced a widespread reform and redesign of the national his. in view of that, his was considered as one of the four health transformation agendas labeled as information revolution with the objective of maximizing the availability, accessibility, quality, and use of health information for evidence-based decision-making processes at all levels of health care delivery systems.8,9 however, ensuring the information used for policy and advocacy, planning and priority setting, resource allocation, implementation, and action remains critical and challenging, especially at lower levels in spite of some improvements that have been observed as a result of remarkable efforts made to develop the culture of information use.8,10 many pieces of evidence from developing countries show that there is enormous data generated through the routine health management information system. however, utilization of the generated information for planning and programming is low.11 for instance, according to one study in pakistan, situation analysis and planning are hardly ever undertaken through health management information system (hmis) generated data.12 another study conducted by nyamtema, on bridging the gaps in the hmis in the context of a changing health sector in 2008 revealed that 42% of the respondents had not ever used the hmisgenerated data at the health facility level for planning, budget allocation, and evaluation of service delivery.13 a similar study in ethiopia indicated that 95% of health facilities could maintain source documents for the indicators; 77% and 68 of health facilities maintain the report completeness and timeliness rate within the agreed national standard respectively. similarly, the discussion and decisions based on hmis data occurred in 37% of the facilities.14 one similar study conducted in ethiopia by tsedeke on hmis performance and factors associated with its implementation in the health facilities of wolaita zone showed that the data recording was 100%, report completeness 94%, data accuracy 11%, data processing 86%, data display 86%, the discussion made 74%, the decisions made 32% and the follow up actions taken 26%.15 the study conducted by mebrhatu mahtsentu on hmis implementation in eastern part of ethiopia revealed that only 22.2% of respondents use information. the same study reported that 33.3% utilize the information for planning and decision-making, 36.7% to observe the trends in service delivery, and 28.3% to seek financial assistance. a similar study stated that the documentation of hmis data was 94%. regarding timeliness, completeness, and consistency, they were of 51.1%, 38.1%, and 50.7% respectively.16 another study conducted by dubale, in ethiopia on the electronic record system to ascertain user satisfaction with using the system and its associated factors revealed a moderate (53.10%) degree of satisfaction among healthcare professionals working at private hospitals in addis ababa, ethiopia.17 one study conducted by sultan on the use of his at the district level in jimma zone, oromia regional state, ethiopia, in 2009 showed the average information use in the study area was only 32.9.18 an assessment conducted by ermias a. on the use of hmis and associated factors in hadiya zone, snnpr, ethiopia, in 2014 indicated that the utilization of health management information system was 69.3% in all the study units. it is also noted that the presence of a listed set of indicators with charts and tables, complete information in the formats, and consistency between registers, tallies, and reports have improved the utilization of health information.19 a study conducted on the implementation of hmis in bahir dar in 2011 also revealed that information used for decision-making was less than 45.6%. regarding the purpose of data use among the study participants, 35.3% use data for future reference, 42.4% to observe the trends, and, 42.9% are to pass report data to health office.20 another study conducted by teklegiorgis et al. on the factors associated with low levels of health information utilization in resource-limited settings, in eastern ethiopia, in 2014 also showed that the use of health information for decision-making was found to be 65.3%.21 similarly, according to a study conducted by asemahagn in west amahara of ethiopia, only 38.4% of study participants used facility health information for two or more purposes regularly, few more than half (52%) use the information for developing plans, merely 24% and 18% for feedback and patient management respectively. the study also disclosed that only 6% of the study participants used the information for conducting research.22 the practical use of health information that is how often and how effectively data is used or not used is determined by the availability of well-designed and documented data sources, monitoring and evaluation structures, availability of guidelines, finance, and skilled staff. these factors can be categorized into three general categories: the attitudes and actions of people who produce or use information, the technical aspects of data processes and tools, and the organizational context that supports or inhibits data processes.23 in this context of factors associated with low utilization of health information, one study from malawi reported; that absence of accountability and guidance, resource constraints, lack of holistic/vision approach, lack of management skills and personality, punitive environment, lack of incentives, inadequate dissemination of information, organizational and behavior and absence of change strategies, donor-driven interventions that focused on specific subsystems.24 in the sidama zone of southern ethiopia, studies in health information use and or practice of health systems are very limited if not none. therefore, this study aims to measure the level of health management information system’s information use and explore the associated factors in the public health facilities of the sidama zone, in southern ethiopia. materials and methods study area the study was conducted in the sidama zone, southern ethiopia, from february 15 to march 5, 2018. the sidama zone is one of the fifteen zones and four special woredas in snnpr state which is situated about 275 kilometers away from addis ababa. article [page 2] [healthcare in low-resource settings 2025;13:11108] the zone has a total area of 6981.8 square kilometers. it has 19 districts and 4 town administrations with a total of 576 kebeles (lowest administrative units) of which 524 of them are rural and 52 are urban. based on the ethiopian population census report 2007 projections, the total population of the zone in 2017 reached 3,804,551. out of the total population, 5.7% are urban and 94.3% rural residents.25 the sidama zonal administration has a total of 4063 health professionals of different disciplines and 524 health posts, 127 health centers (hcs), 1 general and 12 district hospitals owned by the government; additionally there are 21 private, 3 nongovernment owned (ngo) clinics, and 65 private rural drug vendors. the overall potential health service coverage of the zone by public health facilities is 90.3%. study design and period the study employed a facility based quantitative cross-sectional descriptive study design because this study design is relatively quick, inexpensive to conduct and also advantageous in identifying the associated factors. the quantitative part was complemented with a qualitative study to assess the level of hmis data quality in public health facilities and the associated factors from february 15 to march 5, 2018. study population and sampling procedure (sampling and sample size determination) there are 13 hospitals, 125 health centers, and 524 rural health posts in the zone. health centers were selected using the lot quality assurance sampling (lqas) method to determine the sample size. the preference of lqas over conventional sampling methods is it allows low sample size needs (n=19 in most cases) that yield reliable decisions on the performance of locally relevant results for small or large supervisory areas.26 sample size determination all 10 hospitals that implemented his a year before the data collection period were included in the assessment. sixteen his performance indicators were measured at the facility level with an upper threshold of 90% and a lower threshold of 60%. a decision value (d) of 6 health centers and an acceptable alpha value of 0.06 were set. on the basis of this information, sample size (n) was estimated using lqas sampling approach. a plan with a sample size of nineteen (n=19) was used; this single-stage sampling plan accepts an alpha error of <10%. accordingly, 19 hcs and one health post (hp) attached to each sampled health center were chosen randomly for the health post-level assessment. overall 19 hps, 19 hcs, and 10 hospitals were included (table 1). for the purpose of assessing factors affecting data use, all the 213 healthcare provider staff with the responsibility of health care data management were included as a sample for the study since the size is manageable. these comprised of facility in charge, his focal persons/m&e team members, 3 case team coordinators, and phcu linkage focal persons, a total of 6 health facility staff members were included. for hospitals, ceos, ccos, his coordinator, opd coordinator, 3 ipd coordinators (internal medicine, surgery, and gynecological), and emergency coordinator, a total of 8 health workers were included to fill the questionnaire (table 1). for the health post level, one health extension worker with the role of reporting and coordinating activities was selected to fill out the questionnaire (table 1). data collection tools and techniques quantitative data was collected through key informant interviews and observation checklists, and a self-administered questionnaire that was adapted from prism framework version 3.1,25 then the qualitative method was used to further explore the result found from the quantitative study through a semi-structured key informant interview guide. key informant interviews were conducted and documented using an audio tape recorder and backup notes were taken. participant behavioral and contextual aspects were observed and documented as part of the interview. the questionnaire was pretested outside of the study site in one hospital, two hcs, and two hps representing 10 % of the total study sample size. six health workers with detailed knowledge of reformed his were selected to collect data and trained for two days. a supervisor with previous experience in data collection and supervision was recruited to check the research data quality and to oversee the overall procedure of data collection on a daily basis. the principal investigator also followed the overall procedure of data collection closely. data processing and analysis the collected data was checked for completeness, then coded, entered, and cleaned using epi info. version 7 and exported to statistical package for social sciences (spss) version 21 for analysis. both descriptive and inferential statistics were used for the analysis of the quantitative part of the study. in the descriptive statistics, frequency percentages were computed and for inferential statistics, a binary logistic regression model was used. the degree of association between independent and dependent variables was assessed using odds ratio, 95% confidence interval, and p-value <0.05 was considered as significant. variables that are significant at 0.25 on the bivariate level were fitted to multivariate to control the confounding effect and the model fitness was checked using the hosmor-lemshow model. for the qualitative part, the transcriptions were completed within 24 hours of the interview completion. analysis was initiated when the data collection reached halfway through the interview. the categories were coded manually and collected to respective themes. themes were identified and organized through attentive reading and re-reading of data. finally, the data was summarized based on the objectives of the study. article [healthcare in low-resource settings 2025;13:11108] [page 3] table 1. sample size of health institutions included in the study. s.n. health facility sample health facility sample per facility total staff 1 health center 19 6 114 2 health post 19 1 19 3 hospital 10 8 80 4 total 48* 213** * number of health facilities assessed using facility checklist. ** number of health workers involved in the study. data quality assurance the data collectors and supervisors were provided with a twoday training that focused on the objectives of the study and how to complete the questionnaire. the supervisors were given special training on how to supervise the data collection processes. during data collection, the supervisors and the principal investigators closely supervised the data collection process on a daily basis for its correctness and completeness. furthermore, we conducted a pretest on facilities that possesses similarities with sampled facilities to check the data collection tools for their consistencies and any ambiguous items, and necessary amendments were made. operational definitions information is processed data useful for decision-making. the information system is a system that provides information support for the decision-making at each level of an organization. hmis is a system that allows a routine collection, storage, compilation, transmission, analysis and usage of health data that assist decision makers and stakeholders manage and plan resources at every level of health service. lqas is a methodological approach that helps to explore information from program planning and management. it substantially uses small sample sizes to classify health or administrative geographical areas, to inform if these areas have achieved or not a pre-determined target for a given indicator. thus, using rigorous sampling theory it helps to identify where the successes and challenges are located. information use is a process of collecting, aggregating, analyzing, using information for problem identification, prioritizing solutions and deciding actions based on evidence from routine data. in this study, information use practice is determined by at least 3 (50%) of the following 6 practices exercised by the health facilities: calculating the service coverage of their catchment area, display the updated information based on the key indicators, documented evidence for discussions based on the performance, evidence of decisions made based on discussions, evidence of actions taken, and feedback provided by the supervisor during the last visit. results background of study participants in this study, all the 48 sampled health facilities in table 1 were participated. of these, 19(39.6%), 19(39.6%) and 10(19%) were hcs, hps and hospitals respectively. out of the total sample of 213, two hundred eight (97.6%) health workers participated. of the total participants, 152 (73.1%) were males, 29(14%) were health facility in charge (heads of health centers and chief executive officers from hospitals), 84(40.4%) were case team leaders, 27(13%) were hmis focal persons and 50(24%) are health care workers who are facility performance monitoring team (pmt) members (table 2). regarding the level of education, 98 (47.1%) were all-type diploma nurses, 22(10.6 %) bsc nurses, 23 (11.1%) health officers, 17 (8.2 %) medical doctors, and 45 (23.3 %) were other health professionals (table 2). information use practice data regarding information use practice was gathered using two approaches. first, we collected from study participants’ perceptions of information use using the preset criterion. accordingly, 137 (66%) perceived that the information use was at least good and the rest did not feel it as good (figure 1). second, we complement article table 2. description of study participants in health facilities of sidama, april 2018. study participants (health workers) number percent sex of study participants male 152 73.1 female 56 26.9 total 208 100 responsibility of study participants facility in charge 29 13.9 health care provider 50 24.0 case team leaders 84 40.4 hmis focal 27 13.0 hews 18 8.7 total 208 100.0 qualification of the study participants diploma nurse (all type) 98 47.1 bsc nurse 22 10.6 health officers 23 11.1 medical doctor 17 8.2 other health professionals 47 23.0 total 208 100.0 [page 4] [healthcare in low-resource settings 2025;13:11108] figure 1. level of information use, in public health facilities of sidama, april 2018. ed the participants’ perception of information use level by observation checklist using the same preset criterion and summarized below. practice of data analysis for information use health information needs to be summarized and ready for evidence-based decision-making at the level of data collection and in all hierarchies of the health system. in this study, out of all 48 health facilities, 89.6% calculate indicators, 68.8% compare the performance with the target, and 35.4% compare with service type and 58.3% compare the trend of performance over time. the summary of the above indicators results with the overall level of data analysis/processing among the health facilities was 63% (figure 2). discussions, decisions, and actions a regular pmt meeting usually termed a performance review team (prt) is an opportunity to take action based on the data collected from the hmis. the presence of pmt meetings was verified by observation of pmt minute books. the majority of health facilities, 42 (87.5%) had maintained pmt minutes in the last 3 months. it was also observed that about 21 (43.8%) health facilities had discussions on hmis data quality. however, the remaining 56.2% did not have evidence of discussions made on data quality. only 21 (43.8%) health facilities had decided different actions based on hmis findings. regarding the actions taken based on the decision made, only 5 (10.5%) health facilities took action and the remaining majority (89.6%) did not take any actions based on the decisions (figure 3). generally, the overall level of information use practice among health facilities was computed based on the set criteria. moreover, based on the set criteria, the overall proportion of health facilities using hmis information for decision-making and actions was found to be 28 (58%). however, in considering information used for decision-making between the health facilities; out of the 19 total hcs it was 15 (79%), that of the 10 hospitals was 5 (50%) and for the 19 hps, this was 8 (42%) (figure 4). factors associated with information use practice according to the analysis results, in the health facilities where health workers received hmis-specific supportive supervision, health information use was about 3.07 times more likely than in health facilities where health workers did not get any hmis-specific supervisory (aor=3.070, 95% ci 1.206, 7.816). article figure 2. the proportion of health facilities’ health management information system (hmis) data, sidama, april 2018. figure 3. the proportion of health facilities’ discuss and decide actions in the sidama zone snnpr, april 2018. [healthcare in low-resource settings 2025;13:11108] [page 5] in the facilities where health workers document hmis data regularly, health information use was about 3.73 times more likely than those who do not document data regularly (aor=3.732, 95% ci 1.383, 10.068). in the health facilities where the staff feel that the root cause analysis of the problems is helpful, health information use was about 3.78 times more likely than in the facilities where the staff do not feel the root cause analysis was not helpful (aor=3.782,95% ci 1.456, 9.819; table 3). qualitative findings the key informant interview was conducted among 12 respondents; 3 hospital hmis focal persons, 3 health center heads, 3woreda health offices monitoring and evaluation coordinators, and 3 health extension workers from health posts. practice of information use for evidence-based decision making each of the interview participants was asked how they explain the practice of information use in their respective health care facilities and whether there are factors that they think hinder the use of health information. accordingly, the majority of the participants stated that there is a database system where data is collected monthly, reviewed and utilized, and this facilitates the health information use in their health facilities. however, the participants also stated that there are factors that can negatively affect the practice of information use. a male m&e coordinator from woreda said ‘’at the sector level the reports received from health facilities were entered into the database and reviewed by prt. according to the review, the gaps were identified and the feedback was sent to health facilities, and corrective measures were undertaken accordingly. moreover, charts are used for data presentation in the selected core processes like maternal and child health, disease prevention and health promotion, and curative”. another female health extension worker said “… we review the activities every week, and summarize it at the end of every month. once the compiled data is reviewed, it will be sent to the next level and they eventually display data on charts and tables”. article [page 6] [healthcare in low-resource settings 2025;13:11108] figure 4. level of information use (%) based on the categories of health facility in the sidama zone, april 2018. table 3. factors associated with information use practice as perceived by the study participants, sidama zone, snnpr, april 2018. variables in information use cor with aor with yes no 95% ci 95% ci exposure to formal hmis trainings yes 70 48 2.205(.981, 4.957) 2.129(.958, 4.727) no 67 23 1.00 1.00 received hmis specific supervision yes 68 32 3.464 (1.325, 9.055) 3.070 (1.206, 7.816)* no 69 39 1.00 1.00 availability of adequate hmis tools favorable 96 38 2.816(1.064, 7.450) 2.287 (.907, 5.764) no 41 33 1.00 1.00 staff feel that the document of hmis data is for facility management yes 112 46 4.066(1.493,11.068) 3.732(1.38, 10.068)* no 25 25 1.000 1.000 root cause analysis of the problem is helpful yes 109 39 3.494(1.335, 9.142) 3.782(1.456, 9819)* complex 28 32 1.000 1.000 simplicity of hmis reporting formats simple 111 48 2.681(.940, 7.646) 2.549(.910, 7.141) unfavorable 26 23 1.000 1.000 *p<0.05. ci, confidence interval; cor, crude odds ratio; aor, adjusted odds ratio; hmis, health management information system. one male respondent working as a head of a health center said “we have good practice in using hmis information for decisionmaking. primarily we review data for data quality findings with prt and health extension workers. all play their active roles. secondly, the hmis focal person compiles the report and all members of prt discuss based on the findings of hmis data and take different actions. once the report is sent to the woreda, there is a trend of feedback. but we always try to provide feedback for health posts before the woreda feedback is at hand”. factors that can affect the health information use most of the respondents asked for organizational factors that could affect information use practice. they stated these as; not having training in the area, lack of regular supportive supervision, culture of information use, and language barrier within each of their facilities. one health center head said “… some case team members do not use charts for data presentation because of low awareness of hmis information use”. pertaining to supportive supervision, the participant said “integrated supportive supervisions were done once in the last quarter and program-specific supervision has been done on a monthly basis. however, hmisspecific supervision was not done regularly, but, during integrated supportive supervision, hmis program implementation is monitored. he also added “good knowledge and skill on hmis tool, a good commitment by the staff and managers are factors that facilitate use and implementation of hmis”. among the participants, some raised language of the reporting and recording formats as a barrier to information use practice. one health extension female respondent from hp said “… community health information data recording tools including monthly formats are prepared in english, this gives you another challenge to understand and fill it properly”. discussion health information transformation is one priority area of ethiopia’s ministry of health. information use and data quality were among the focus areas of the transformation.10 the aim of this study was to assess the level of hmis information use practice at health facilities of the sidama zone in southern ethiopia based on the performance of routine information systems management (prism) framework.25 the study also tried to explore possible factors that affect the use of health information. based on the observed checklist, the overall information use practice in the studied healthcare facilities was found to be 58%. however, the level of health information use practice was different when seen by facility types. while about two-thirds of health centers were found to practice health information use; only half of hospitals and only 42 of health posts were found to practice information use. this difference could be attributed to the frequency of supervision provided by their supervisors. the overall information use finding was higher when compared to other studies conducted in different parts of ethiopia; harar, jimma, and bahirdar, where the level of his utilization was 22.9 %, 32.9%, and 45.6% respectively.18,20,27 the difference might be due to differences in infrastructures and supplies, since the zone has multiple partners who support the his. the availability of hmis personnel who can handle the data for utilization at their level and other higher levels for evidence-based decision-making might have also contributed to the difference.20 however, it was lower when compared to studies conducted in the hadiya zone, and eastern ethiopia reported 69.3% and 65.3% respectively.19,21 the variation in this study may be due to healthcare workers’ attitudes toward routine health information utilization in the aforementioned study areas.20 in this study, factors associated with information use were analyzed based on the participants’ perceptions of information use and the related factors. accordingly, the odds of health information use among those who had his-specific supervision were about three times more than those of their counterparts. this is not surprising, as one would expect, supervision plays an important role in improving the performance of the health workers by feeling the identified gaps during the supervision. in the current study, participants who reported that staff feel the documentation of hmis data for facility management were about four times more likely to use information than those who did not report this feeling. this may imply, that if the staff keeps data documentation appropriately with the awareness that it will serve a purpose beyond routine use, the likelihood of utilizing that information for facility management and beyond increases. similarly, health information use was about four times higher among the participants who felt that root cause analysis of the problem was more helpful than their counterparts. this can be explained by the fact that in facilities where participants feel that root cause analysis of the problem is carried out the performance, including information use, is higher because the staff looks at the problem from its source and seeks solution specific to the identified problem.30 in this study, although the explored qualitative findings generally complement the quantitative findings, language used in the reporting formats and recording registries emerged as the unique reported factors hindering the information. among the health post participants, there were health extension workers who found it difficult to understand the english language used in the recording and reporting formats which challenge them to keep the data and use it accordingly. while the language barrier has a negative implication on health care quality that includes health information utilization from individual patient safety side31 the lower grass root level health workers, particularly health extensions’ language challenge should not be overlooked. at last, while the mixed method employed in the current study could be seen as strength, individual-level participants’ attributes weren’t included exhaustively which might have its own limitation in the identification of the information use associated factors. conclusions the information use practice in this study was found to be 58.3%. however, there is variation among health facility types; hcs, hospitals, and hps. hmis-specific supportive supervision, having an understanding of hmis data documentation for facility management, and practice of root cause analysis have an association with information use practice. recommendations based on these findings, health information system-specific supportive supervision should be maximized particularly in health posts and hospitals. optimizing awareness of health workers in documenting the health information data for information use should be considered. language barriers that the health extension workers who work at the grass root level should be addressed. article [healthcare in low-resource settings 2025;13:11108] [page 7] references 1. measure evaluation. health management information system (hmis): facilitator’s guide for training of trainers. 2010. available from: https://www.measureevaluation.org/ resources/publications/ms-13-74/at_download/document 2. tadesse k, gebeye e, tadesse g. assessment of health management information system implementation in ayder referral hospital, mekelle, ethiopia. int j intelligent information systems 2014;3:34-9. 3. hincapie a, warholak t. the impact of health information exchange on health outcomes. appl clin inform 2011;2:499507. 4. health metrics network. strengthening country health information systems: assessment and monitoring tool. 2007. available from: https://www.measureevaluation.org/hisstrengthening-resource-center/resources/hmn_ assessment _tool_guide_ver2.pdf 5. world health organization (who). quality improvement in primary health care: a practical guide. 2004. available from: https://iris.who.int/bitstream/handle/10665/119694/dsa231.pdf 6. kerr k, norris t, stockdale r. data quality information and decision making: a healthcare case study. 2007. available from: https://aisel.aisnet.org/acis2007/98/ 7. measure evaluation. tools for data demand and use in the health sector. 2008. available from: https://www.measureevaluation.org/resources/publications/ms-11-46/at_download/document 8. us agency for international development (usaid). ethiopia’s information revolution. 2016. available from: https://www. usaid.gov/sites/default/files/2022-05/ethiopia_ information_revolution_practice_spotlight_final_508_co mpliant.pdf 9. us agency for international development (usaid). health management information system (hmis) / monitoring and evaluation (m&e). 2008. available from: https://www. cmpethiopia.org/content/download/478/2765/file/health%20 managment%20information%20system%20(hmis).pdf 10. measure evaluation. national health information system strategy. 2012. available from: https://it.scribd.com/document/542609066/national-health-information-systemstrategic-plan 11. ebongue mbondji p, kebede d, soumbey-alley ew, et al. health information systems in africa: descriptive analysis of data sources, information products and health statistics. j r soc med 2014;107:34-45. 12. suleman qazi m, ali m. health management information system utilization in pakistan: challenges, pitfalls and the way forward. bioscience trends 2011;5:245-54. 13. nyamtema as. bridging the gaps in the health management information system in the context of a changing health sector. bmc medical informatics and decision making 2010;10:36. 14. mesfin g, tesfaye h, worku n, et al. data quality and information use: a systematic review to improve evidence, ethiopia. afr health monitor 2010;2010:53-60. 15. komibamo t, berhane y, astatkie a. hmis performance and factors associated with its implementation. lap lambert academic publishing; london, uk; 2014. 64 pp. 16. jsi. harari region’s experience implementing an electronic community health information system (echis). 2022. available from: https://www.jsi.com/ethiopia-electronic-community-health-information-system/ 17. dubale at, mengestie nd, tilahun b, walle ad. user satisfaction of using electronic medical record system and its associated factors among healthcare professionals in ethiopia: a cross-sectional study. biomed res int 2023;2023:4148211. 18. abajebel s, jira c, beyene w. utilization of health information system at district level in jimma zone oromia regional state, south west ethiopia. ethiopia j health s 2011;21:65-76. 19. abera e, daniel k, letta t, tsegaw d. utilization of health management information system and associated factors in hadiya zone health centers, southern, ethiopia. res health sci 2016;1:98-109. 20. chanyalew ma, yitayal m, atnafu a, tilahun b. routine health information system utilization for evidence-based decision making in amhara national regional state, northwest ethiopia: a multi-level analysis. bmc med inform decis mak 2021;21:28. 21. teklegiorgis k, tadesse k, mirutse g, terefe w. factors associated with low level of health information utilization in resources limited setting, eastern ethiopia. int j intelligent information systems 2014;3:69-75. 22. asemahagn ma. determinants of routine health information utilization at primary healthcare facilities in western amhara, ethiopia. cogent medicine 2017;4:1-11. 23. measure evaluation. tools for data demand and use in the health sector. 2011. available from: https://www.measureevaluation.org/resources/publications/ms-11-46. 24. chaulagai cn, moyo cm, koot j, et al. design and implementation of a health management information system in malawi: issues, innovations and results. health policy planning 2005;20:375-84. 25. united nations international children’s emergency fund (unicef). health sector annual performance report. 2017. available from: https://www.unicef.org/ethiopia/ media/2151/ file/health%20budget%20brief%20.pdf 26. core group. a participant’s manual and workbook using lqas for baseline surveys and regular monitoring. 2002. available from: https://coregroup.org/wp-content/uploads/ 2020/03/assessing-community-health-programs_aparticipants-manual-and-workbook.pdf 27. shama at, roba hs, abaerei aa, et al. assessment of quality of routine health information system data and associated factors among departments in public health facilities of harari region, ethiopia. bmc med inform decis mak 2021;21:287. article [page 8] [healthcare in low-resource settings 2025;13:11108] hrev_master healthcare in low-resource settings 2023; volume 11(s1):11212 the correlation between family support and health status in patients with diabetes mellitus setyoadi,1 ah yusuf,2 niko dima kristianingrum,3 yati sri hayati,3 linda wieke noviyanti,3 nurmalia filda syafiky3 1nursing doctor student universitas airlangga mulyorejo, surabaya, indonesia; 2lecture faculty of nursing universitas airlangga mulyorejo, surabaya, indonesia; 3department of nursing, faculty of health sciences, universitas brawijaya malang, indonesia abstract introduction: the health status of a patient is strongly influenced by the family members because they play an important role during the health care process, and in healthy living. this implies that they must be involved in decision-making and therapeutic actions at every stage of the treatment. therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in malang. design and methods: this study used a descriptive correlational design with a cross-sectional approach, which was carried out by filling questionnaires to determine the relationship between family support and the health status of diabetes mellitus patients. the sample population consists of 327 diabetes mellitus patients and 327 family caregivers of patients with the disease. meanwhile, the respondents were selected through a cluster random sampling technique. results: the results showed that 62.7% of the caregivers provided a good family support, while 90.8% of the patients have a good health status. this indicates that there is a positive correlation between family support and the health status of people with the disease (p-value= 0,000, α<0.05, r= 0,400). conclusions: further studies are advised to explore the use of nursing interventions as an effort to maintain and improve the ability of families in providing long-term care for members with diabetes mellitus. introduction diabetes mellitus (dm) is a long-lasting metabolic disorder caused by the inadequate production of insulin by the pancreas or the body’s inability to effectively use it. insulin is a hormone that regulates blood sugar levels, thereby preventing high glucose levels in the body (hyperglycemia).1 furthermore, the disease is characterized by hyperglycemia due to defects in insulin function and/or secretion abnormalities.2 in 2014, the world health organization (who) discovered that there were 422 million overweight or obese adults with diabetes mellitus globally. the disease accounted for over 1.5 million deaths among people less than the age of 70. based on doctors’ diagnosis, the 2018 riskesdas result showed that its prevalence increased to 2% among people in indonesia aged> 15 years. furthermore, in east java province, there was a 0.5% increase in its rate between 2013 and 2018, when a prevalence of 2.6% was recorded5. malang city has the eleventh highest rate of 2.3% among the 38 cities in east java.6 the health profile data about the city revealed that dm was ranked 4th out of the 10 common diseases, and various public health data revealed that its prevalence is expected to continue increasing over the next couple of years.7 data from the malang city health office in 2017 showed that approximately 22,206 people had diabetes in the 16 primary health centers with an average of 1,850 cases per month.8 furthermore, lower numbers were obtained in 2018, where 18,817 cases were recorded with an average of 1,568 per month.9 in 2019, a total of 12,509 cases were reported between january and july with an average of 1,787 people per month.10 diabetes mellitus is a non-communicable disease and is a serious threat to world health. it is caused by abnormal blood sugar levels, and the patients usually express clear physical symptoms. meanwhile, the condition or state of health of a person is known as health status, and it is influenced by the ability of the patients to understand and optimize their condition. it is also influenced by their ability to reach their physical and mental potentials optimally as well as to prevent risk factors that can occur due to illness.11 the american diabetes association stated that there is a need to develop a medical intervention using a multifactorial risk reduction strategy that is beyond glycemic control.12 the management of dm is guided by the 4 pillars of diabetes management, which consists of knowledge about the condition, a regulated diet, adequate amount of physical activity, and medication adherence.13 furthermore, the management of the disease can be divided into two category, where the first management is short-term, which involves controlling blood sugar and preventing constant illness in the patients.14 families are expected to participate in the treatment from the beginning because they play an important role in the recovery program.15 family support is defined as an act of acceptance by the families of patients with certain health problems. furthermore, it can be divided into 4 types, namely informational, reward, instrumental, and emotional support.16 motivation and article significance for public health family is the main source of support for people with chronic diabetes mellitus. furthermore, their support is easier to obtain because they are closely related, hence, they can help to improve knowledge, attitudes, and compliance during the treatment process. the health status of the patients is strongly influenced by the form of support provided by the family. therefore, this paper describes the correlation between family support and the health status of diabetes mellitus patients. [healthcare in low-resource settings 2023; 11(s1):11212] [page 145] non -co mmerc ial us e o nly support from families are needed in the management of diabetes.17 the health status of patients is strongly influenced by their family members because they play a role during the treatment.16 therefore, they need to participate in decision-making and therapeutic action at every stage to achieve successful disease management.18 a challenge that often occurs during dm treatment is the patient’s disobedience during the process. support from family is an important element in improving their health because they can promote the patient to live healthily.19 therefore, this study aims to determine the relationship between family support and the health status of diabetes mellitus patients in malang city. design and methods this study used an analytical correlational design with a crosssectional approach, which involves the concurrent measurement and observation of data to determine the relationship between family support and health status of diabetes mellitus patients. a quantitative data analysis method was used by recording the data obtained in the form of numbers for analysis. the inclusion criteria for the study were dm patients who were members of the prolanis program at every public health center, had health insurance, and were willing to be respondents. furthermore, a total of 327 diabetes patients and 327 family caregivers of patients with the disease were obtained using slovin’s formula in malang city. a cluster random sampling technique was used to select the respondents from the 16 public health centers in the city. data collection was carried out by visiting each selected public health center by first calculating the proportion, then we took it randomly based on the attendance list at the time of the prolanis activity (health program activities for managing chronic diseases). instrument using family support scale (fss) and health status using short form 12 (sf-12). the results of the validity and reliability test have an r arithmetic value of 0.48 – 0.79 (> 0.44) and a cronbach alpha coefficient of 0.932 > 0.600, and have an r arithmetic of 0.466 – 0.721 (> 0.44) and a cronbach alpha coefficient of 0.909 > 0.600. data analysis was then carried out using the pearson product moment spss because the data is a numerical scale, test with a 95% confidence level (ci; 5%). results and discussions table 1 shows the characteristic of respondents and the majority of the caregivers were <45 years (48.3%), and this finding is consistent with damayanti where most of the family respondents were in the same age range with this study.20 furthermore, this range is known as productive age and has sufficient experience to care for members that are suffering from a disease.21 friedman reported that the level of maturity affected the support received by the respondents, hence, age is an important factor that affects the role of caregivers in family nursing.16 the level of education influences the knowledge on environmental factors that affect health requirements as well as the amount of knowledge and information received.22 158 caregivers (48.6%) had the latest high school or equivalent education, and this is in line with chusmeywati that obtained a total of 29 respondents (55.8%) with the same level of education.23 the insight about caring for family members with disease conditions is influenced by education level. almost all of the caregivers used in this study were muslims, and this finding is consistent with chusmeywati where all respondents practiced the religion.23 friedman’s theory states that god, prayer, and faith are needed to overcome any disease.16 furthermore, susanti reported that the spiritual factor, which is a guidance in daily living affects the rate of socialization with the surrounding environment and the ability to achieve life’s desires.24 the majority of the family respondents were male (51.4%), and this is inconsistent with jessica where 57.6% (19 caregivers) were female.25 furthermore, 57.5% of the caregivers (188) have a private or self-employed job, and this finding is in line with alfiaturrohmah.21 good financial ability to support life can be obtained when the respondent has a job.21 chusmeywati reported that 40.4% of the caregivers (21 respondents) were children, and a similar result of 47.1% (154 respondents) was obtained in this study.23 the elementary school was the most recent education in 169 patients (51.7%), while cleonara reported that 14 respondents (45.2%) have an elementary school education.26 a low educational level makes it difficult to receive information due to limited knowledge. furthermore, inappropriate food selection and uncontrolled diet are factors that can increase the risk of diabetes mellitus.27 table 2 reveals that 285 respondents (96%) received good emotional support, while 290 (97.6%) received appraisal support. the diabetic patients in the working area of the public health centre in malang city received good family support, and this is in line with damayanti that it influences the implementation of selfmanagement.20 friedman stated that there are 4 types of family support, namely instrumental, informational, emotional, and appreciation supports.16 the highest type of support received by the patients was reward support, followed by emotional, informational, and instrumental supports. furthermore, 92% of the patients received reward support, which is the feedback received for their action, and this is inconsistent with setyoadi where it was the lowest type of support. this type of support can be given in the form of praise or appreciation, providing motivation, and asking for their opinion while solving problems.26 emotional support was the second-highest type of support received with a total of 296 respondents (90.5%). this finding is in line with setyoadi, which reported that approximately 89.47% of the respondents received this type of support.26 examples of emotional support are attention, affection, and sympathy.16 furthermore, it can be provided in the form of psychosocial protection by listening to their complaints, keeping their feelings private, comforting the patients when they are sad as well as expressing affection with actions and words. 87.5% of the patients received good informational support, which is not in line with setyoadi where it was the most widely received by 51 respondents (89.47%).26 this type of support can be in the form of providing solutions to problems, advice, and information needed in the healing process. informational support can easily be received because information about a disease can easily be accessed from various media.27 202 respondents (61.8%) received good instrumental support because the families have good health care and economic function. providing food, clothing, shelter, and assisting patients in taking medication are health care functions that can be provided. meanwhile, providing adequate finance for care and medication is an economic function in the family.28 based on these results, family support is an important aspect that is needed during the treatment process. the health status of diabetic patients tends to deteriorate when the support received is less. furthermore, several factors affect the level of support, namely age, education, occupation, gender, and relationship with the patient. good family support gives the patient a sense of calmness and comfort.29 it can also decrease mortality rate and increase the recovery rate, consequently, friedman concluded that family support is very beneficial because it has a major effect on health and article [page 146] [healthcare in low-resource settings 2023; 11(s1):11212] non -co mmerc ial us e o nly well-being.16 most of the respondents have a better health status (table 3), and this is in line with amigo that good health status was obtained in 123 respondents (75.5%) out of 163.11 furthermore, most of the patients are between the age of 45-65 years (63.3%). a similar result was obtained by trisnawati where 47.5% of the respondents were within the age range of 45-52 years.9 the risk of developing diabetes increases along with age because glucose intolerance begins at the age of 45-65 due to decrease in the activities of the pancreatic β cells. 80.4% of the respondents were females because they have a greater chance of developing a high bmi. fats are easily accumulated in their body due to hormonal processes, such as premenstrual syndrome and post-menopause, article table 1. distribution of respondents. demographic aspects caregivers patients f % f % age (years) <45 158 48.3 7 2.1 45-65 123 37. 207 63.3 >65 46 14.1% 113 34.6 religion islam 317 96.9 317 96.9 christian 7 2.1 7 2.1 catholic 3 0.9 3 0.9 gender male 168 51.4 64 19. female 159 48.6 263 80.4 last education uneducated 1 0.3 2 0.6 elementary school 71 21.7 169 51.7 middle school 54 16.5 76 23.2 high school 159 48.6 65 19.9 college 42 12.8 15 4.6 profession does not work 120 36.7 225 68.8 labor 9 2.8 3 0.9 farmers 1 0.3 0 0 civil servants 7 2.1 3 0.9 tni/polri 2 0. 1 0.3 entrepreneur 188 57.5% 95 29.1 relationship with patients husband 102 31.2 wife 51 15.6 child 154 47.1 mother 1 0.3 grandchild 9 2.8 sister 6 1.8 niece 1 0.3 son/daughter in law 5 0.9 older suffer (years) <1 36 1 1-5 159 48.6 >5 132 40.4 the last result of gd (mg/dl) 80-109 9 2.8 110-125 34 10.4 >125 284 86.9 table 2. distribution of family support and type of support. family support not good good frequency (f) percentage (%) frequency (f) percentage (%) whole support 122 37. 205 62.7 emotional support 31 9.5% 296 90.5 appraisal support 26 8 301 92 instrumental support 125 38.2 202 61.8 informational support 41 12.5% 286 87.5 [healthcare in low-resource settings 2023; 11(s1):11212] [page 147] non -co mmerc ial us e o nly hence, they have a high risk of developing diabetes mellitus.30 damayanti reported that 60.3% of the respondent used were female, while 39.7% were males.20 based on the results, the most recent blood sugar level was 125 mg/dl, which was obtained in 284 respondents (86.9%). this result is consistent with cleonara where all respondents had sugar levels of 126 mg/dl, which has been previously categorized as an uncontrolled level.31 uncontrolled eating patterns combined with decreased physical activity make it difficult for diabetic patients to control blood sugar.32 table 4 shows that 197 patients with good health status (66.3%) received good family support, while 100 patients with good health status (33.7%) were not supported by their families. furthermore, a total of 195 patients (65.7%) received instrumental support, while 277 (93.7%) received informational support and they all have a good health status. table 5 shows the analysis results, which revealed that there is a significant relationship between family support and health status (p <0.001; α = 0.05; r = 0.400). the higher the family support, the higher the health status of the patients. previous study also confirmed the positive correlation in type 2 diabetes mellitus patients, where 38.30% of the respondents that received family support were healthier. therefore, the higher the support from the family, the better the health status.33 good appreciation support with good health status has the highest percentage in this study, which accounted for 97.6% of the respondents (290). this finding is in line with yusra that there is a relationship between the dimensions of appreciation and the quality of life of diabetic patients.34 these results are also consistent with friedman’s theory that reward support is a form of effective family function, which improves the mental health of sick members.16 patients receive recognition for their abilities and skills with the support of appraisals, and they help to improve their psychosocial status, motivation, enthusiasm, and self-esteem, which also improve their health status. good emotional support with good health status had the second-highest percentage of 96% (285 respondents). a similar study reported that the easiest type of support to obtain was emotional support, which can be in the form of acceptance by the family.35 this support makes the patients more alert and able to manage the complications as well as their physical disorders.36 this finding is in line with nuraisyah that support has a relationship with the quality of life.37 health can be improved through family support, which helps to reduce the incidence of stress in diabetic patients. medical and paramedics are expected to always advise families to be closer to the patient. they can assist in arranging a routine blood sugar check schedule, which serves as a motivation to improve their article table 4. cross tabulation results between family support, types of family support and health status. health status not good % good % family support less 22 73.3 100 33.7 good 8 26.7 197 66.3 types of family support emotional support less 19 63.3 12 4 good 11 36.7 285 96 appraisal support less 19 63.3 7 2.4 good 11 36.7 290 97.6 instrumental support less 23 76.7 102 34.3 good 7 23.3 195 65.7 informational support less 21 70 20 6.7 good 9 30 277 93.7 table 5. results of analysis of the relationship between family support and health status using the pearson product moment test. variable correlation coeff. p-value family support with health status in diabetes mellitus patients 0.400** 0,000 [page 148] [healthcare in low-resource settings 2023; 11(s1):11212] table 3. distribution of health status domain. health status domain not good good frequency (f) percentage (%) frequency (f) percentage (%) general health 145 44.3 182 55.7 physical function 17 5.2 310 94.8 physical role 48 14.7 279 85.3 discomfort 31 9.5 296 90.5 the role of emotions 26 8 301 92 mental health 4 1.2 323 98.8 vitality 97 29.7 230 70.3 social function 6 1.8 321 98.2 non -co mmerc ial us e o nly health status.36 this motivation can also be provided through informational support, and in this study, 277 respondents (93%) that received it had a good health status. instrumental support has the lowest percentage of 65.7% where 195 respondents that received it had a good health status. this kind of support can be provided through diet monitoring, medication adherence, exercise, as well as a routine control of blood sugar levels. furthermore, a similar study stated that it can provided by increasing the level of medication adherence and blood sugar stability.37 the health status of patients with the support was better compared to others without it, and this result is consistent with friedman’s theory, which states that the instrumental dimension involves supporting each respondent’s efforts to exercise, care efforts, paying for treatment, and providing food based on the required diet.16 active instrumental support from the family affects the adherence to diabetes mellitus treatment.38 previous studies showed that health increases along with the level of support provided by the family. they provide motivation to sick members and also work together to provide treatment. this study’s findings are in accordance with friedman that a good family support decreases the incidence of death and facilitates the recovery of intellectual function, physical, and emotional health.16 the limitations of the results of the study only looked at one external factor, namely family support, there was also a health service support factor, and family values. health status is also largely determined by internal factors such as self-efficacy, demographic characteristics, and level of independence. it is suggested for the next research to involve more other variables that affect the health status of dm patients to get more comprehensive results. conclusions based on the results, 62.7% of the family caregivers in the working area of malang city public health center provided good family support for their member, while 90.8% of the diabetic patients had a good health status. this finding indicates that there is a positive correlation between family support and health status (p <0.001; α = 0.05; r = 0, 400). references 1. ministry of health of the republic of indonesia. infodatin, diabetes situation and analysis. jakarta: data and information center of the ministry of health of the republic of indonesia; 2014. 2. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care 2010;33:s62–9. 3. perkeni. konsensus pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia 2015. [consensus on management and prevention of type 2 diabetes mellitus in indonesia 2015.] jakarta: perkeni; 2015. 4. who. global report on diabetes. 2016. accessed 2021 may 2. available from: https://www.who.int/publications-detail-redirect/9789241565257 5. ministry of health republic of indonesia. basic health research data 2017. jakarta: ministry of health republic of indonesia; 2018. 6. dini cy, sabila m, habibie iy, et al. asupan vitamin c dan e tidak mempengaruhi kadar gula darah puasa pasien dm tipe 2. [intake of vitamins c and e does not affect fasting blood sugar levels in type 2 dm patients.] indonesian j human nutrition 2017;4:65–78. 7. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva 2017. malang: malang city health office; 2017. 8. malang city health office. malang city health profile 2016. malang: malang city health office; 2017. 9. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva january-december 2018. malang: malang city health office; 2018. 10. malang city health office. search data for ptm noncommunicable disease spm, keswa, iva january-july 2019. malang: malang city health office; 2019. 11. amigo tae. hubungan karakteristik dan pelaksanaan tugas perawatan kesehatan keluarga dengan status kesehatan pada aggregate lansia dengan hipertensi di kecamatan jetis yogyakarta. [correlation between characteristics and implementation of family health care tasks with health article correspondence: setyoadi, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: setyoadi@ub.ac.id key words: family support, health status, diabetes mellitus. acknowledgment: the authors are grateful to the faculty of health sciences, universitas brawijaya malang, indonesia for their kind support and encouragements during this study. contributions: all authors contributed equally to this article. conflict of interests: the author declares no conflict of interest. funding: this study was funded by the faculty of medicine, university of brawijaya, malang. clinical trials: this study was approved by the health research ethics committee of the faculty of medicine, university of brawijaya, malang. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 7 december 2021. accepted for publication: 12 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11212 doi:10.4081/hls.2023.11212 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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[eg textbook of family nursing-research, theory & practice. indonesian translation.] jakarta: egc; 2010. 17. bistara dn. hubungan pola makan dengan kadar gula darah pada penderita diabetes melitus. [the relationship between diet and blood sugar levels in patients with diabetes mellitus.] jurnal kesehatan vokasional 2018;3:29–34. 18. kurniawan i, ratnasaria tb. gambaran pelaksanaan tugas kesehatan keluarga pada keluarga yang memiliki lansia hipertensi di desa glagahwero kecamatan panti kabupaten jember. [description of implementation of family health tasks for families with elderly hypertension in glagahwero village, panti district, jember regency.] indonesian j health sci 2018;1:194–204. 19. nurleli. dukungan keluarga dengan kepatuhan pasien diabetes melitus dalam menjalani pengobatan di blud rsuza banda aceh. idea nursing journal 2016;vii:47–54. 20. damayanti s, et al. dukungan keluarga pada pasien diabetes melitus tipe 2 dalam menjalankan self-management diabetes. [family support for patients with type 2 diabetes mellitus in implementing diabetes self-management.] jurnal keperawatan padjadjaran 2014;2:56-66. 21. alfiaturrohmah sn, anggraeni r, jati rp. hubungan peran family caregiver terhadap pemenuhan personal hygiene lansia. [the relationship between the role of family caregivers and the fulfillment of elderly personal hygiene.] jurnal keperawatan 2018;10:147–52. 22. lamb ke, crawford d, thornton le, et al. educational differences in diabetes and diabetes self-management behaviours in who sage countries. bmc public health 2021;21:2108. 23. chusmeywati v. hubungan dukungan keluarga terhadap kualitas hidup penderita diabetes melitus di rs pku muhammadiyah yogyakarta unit ii. [the relationship between family support and quality of life for patients with diabetes mellitus at pku muhammadiyah yogyakarta unit ii hospital.] yogyakarta: universitas muhammadiyah yogyakarta; 2016. 24. susanti ml, sulistyarini t. dukungan keluarga meningkatkan pasien diabetes melitus di ruang rawat inap rs. baptis kediri. [family support increases diabetes mellitus patients in hospital inpatient rooms. kediri baptist.] jurnal stikes 2013;6:1-9 25. dunne jl, maizel jl, posgai al, et al. the women’s leadership gap in diabetes: a call for equity and excellence. diabetes care 2021;44:1734–43. 26. dini cy, sabila m, habibie iy, nugroho fa. asupan vitamin c dan e tidak mempengaruhi kadar gula darah puasa pasien dm tipe 2. [intake of vitamins c and e does not affect fasting blood sugar levels in type 2 dm patients.] indonesian j human nutrition 2017;4:65–78. 27. misdarina m. pengetahuan diabetes melitus dengan kadar gula darah pada pasien dm tipe 2. [knowledge of diabetes mellitus with blood sugar levels in type 2 dm patients.] jurnal keperawatan klinis 2012;2:194. 28. setyoadi, nasution th, kardinasari a. family support in improving independence of stroke patients. jurnal ilmu keperawatan 2018;6:96–107. 29. notoatmodjo s. promosi kesehatan dan ilmu perilaku. [health promotion and behavioral sciences.] jakarta: rineka cipta; 2007. 30. papatheodorou k, banach m, bekiari e, et al. complications of diabetes 2017. journal of diabetes research 2018;2018:e3086167. 31. suardana ik, rasdini igaa, kusmarjathi nk. hubungan dukungan sosial keluarga dengan kualitas hidup pasien diabetes melitus tipe 2 di puskesmas iv denpasar bali. [relationship between family social support and quality of life for patients with type 2 diabetes mellitus at puskesmas iv denpasar bali.] jurnal skala husada 2020;12:96-102 32. trisnawati sk, setyorogo s. faktor risiko kejadian diabetes melitus tipe ii di puskesmas kecamatan cengkareng jakarta barat tahun 2012. [risk factors for type ii diabetes mellitus at the cengkareng district health center, west jakarta in 2012.] jurnal ilmiah kesehatan 2013;5:6–11. 33. ramadhan n, marissa n. karakteristik penderita diabetes mellitus tipe 2 berdasarkan kadar hba1c di puskesmas jayabaru kota banda aceh. [characteristics of type 2 diabetes mellitus patients based on hba1c levels at the jayabaru health center, banda aceh city.] sel jurnal penelitian kesehatan 2015;2:49-56. 34. kusumappraisalani sa. hubungan pengetahuan, dukungan keluarga dan kepatuhan berobat dengan status kesehatan pasien diabetes melitus tipe 2. [relationship between knowledge, family support and medication compliance with the health status of type 2 diabetes mellitus patients.] surakarta: universitas sebelas maret; 2014. 35. yusra a. hubungan antara dukungan keluarga dengan kualitas hidup pasien diabetes melitus tipe 2 di poliklinik penyakit dalam rumah sakit umum pusat fatmawati jakarta. [relationship between family support and quality of life for patients with type 2 diabetes mellitus at the internal medicine polyclinic, fatmawati general hospital, jakarta.] depok: universitas indonesia; 2011. 36. chesla ca, fisher l, mullan jt, et al. family and disease management in african-american patients with type 2 diabetes. diabetes care 2004;27:2850–5. 37. meidikayanti w, wahyuni cu. hubungan dukungan keluarga dengan kualitas hidup diabetes melitus tipe 2 di puskesmas pademawu. [the relationship between family support and quality of life for type 2 diabetes mellitus at the pademawu health center.] jurnal berkala epidemiologi 2017;5:240-25 38. nuraisyah f, kusnanto h, rahayujati tb. dukungan keluarga dan kualitas hidup pasien diabetes mellitus. [family support and quality of life of diabetes mellitus patients.] bkm j com med public health 2017;33:25. article [page 150] [healthcare in low-resource settings 2023; 11(s1):11212] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11166 the effect of community of practice in improving the role of clinical instructor in patient safety implementation by prelicensure nursing students dyah wiji puspita sari,1,2 hanny handiyani,3 kuntarti,3 yuni sufyanti arief1 1doctoral program of nursing science, faculty of nursing, universitas airlangga, surabaya, indonesia; 2faculty of nursing, universitas islam sultan agung, semarang, indonesia; 3faculty of nursing, universitas indonesia, jakarta, indonesia abstract introduction: patient safety problems caused by students leads to different adverse event, hence clinical instructor plays a role in guiding them in the implementation of patient safety programs. furthermore, the community of practice is considered to improve the role of clinical instructors in patient safety problems. this study is then conducted to measure the impact of community of practice toward the role of clinical instructors in patient safety problems. design and methods: this is a pre-experimental design for one group and a pre-post test design without a control group. in addition, the sample includes 36 prelicensure nursing students. result: the results showed that the score of clinical instructors’ role before and after intervention with community of practice implementation was 58 (34-67) and 79.33 with sd of 10,960, respectively, with a significant increase of 24.27. also, the statistic analysis depicted that the role had a significant effect after implementation, with a p-value of < 0,000. conclusions: based on the results, the community of practice had a significant impact in increasing the role of clinical instructors in the implementation of patient safety problems by prelicensure nursing students. introduction a nursing student is a prospective nurse that participates in giving nursing care, hence being equipped with patient care capabilities as early as possible is necessary to prevent errors that can lead to patient safety incidents. the students need to implement patient safety in the clinical learning process conducted on patients nd they also influence the quality of care and patient safety.1,2 this condition results in various negative adverse effects for patients, thereby promoting educational institutions to include patient safety programs in the clinical practice learning process.3,4 the results showed that students who obtain remarkable safety training improved patient safety incidents.5 patient safety competence has not been maximally achieved by prelicensure nursing students.6 the achievement of competencies that have not been maximized is one of them influenced by the clinical education model used.7 furthermore, about 44.7% of 889 nursing students in the last year indicated that the knowledge about the patient safety domain was competent, hence more than half or about 55.3% were incompetent.8 the students who attended clinical education for a short period have low patient safety competence and limited clinical experience, subsequently they are at risk of making mistakes in giving treatment to patients.9,10 additionally, almost 60% of 829 students have average knowledge about patient safety in the medium and poor categories.11 the results showed that the nursing students made 113 reports of medication errors made and 40% were not reported due to hiding errors, hampering the learning process.12 the nursing professional students’ achievement of competence in the implementation of the six patient safety goals also reveals that majority are in the moderate or not yet good category.13 the factors affecting the student achievement of patient safety competence include the curriculum, number of credits, and learning strategies. also, nursing education does not discuss patient safety in detail, necessitating the integration of theory and practice into clinical nursing education. the clinical instructor plays an optimal role in achieving competence in the clinical education process.14-16 clinical education in nursing is a complex phenomenon that requires an optimal role from the instructors in developing the knowledge, skills, and behavior of nursing students. the clinical instructors’ role includes a mentor, facilitator, resource person, evaluator, support provider, and observer. furthermore, they help students overcome obstacles and difficulties that are potentially confusing, and an effective clinical instructor will achieve the optimal role.17-20 the clinical instructor role determines the achievement of learning competencies, especially those related to patient safety. article significance for public health patient safety is an important element to improve the quality of health services. the implementation of patient safety is a form of competency of the health workers including the clinical instructor and students. therefore, health care organizations must build systems that ensure a safer patient care process, including the implemented clinical education system, to achieve patient safety. also, clinical education in hospitals can be improved by increasing the role of clinical instructors, hence they can educate students to prevent patient safety incidents, and this can be achieved through the community of practice. this study aims to describe the effectiveness of community of practice in improving the role of clinical instructors in patient safety implementation by prelicensure nursing students. [healthcare in low-resource settings 2023; 11(s1):11166] [page 21] non -co mmerc ial us e o nly clinical instructors with good knowledge and skills help the students gain knowledge and skills. the instructors contribute to the student’s clinical learning activities to achieve learning goals.21,22 increasing the role of an effective clinical instructor requires a community practice of clinical instructor, which is an approach to situated learning theory. the community of practice (cop) is a learning environment where nursing students develop their attitudes toward the nursing profession. furthermore, it improves knowledge, expertise, skills, and create innovation by providing solutions in a specific area of knowledge or competence. community of practice streamlines knowledge flow within the organization and promote the development of quality learning human resources ready to respond to circumstances and changes accurately, resulting in a knowledge-based organization. this practice is a systematic and structured strategy to overcome problems related to students’ guidance process in patient safety clinical practice and increase the role of clinical instructors.23-25 design and methods this is a quantitative study with a pre-experimental design in one group and a pre-post test design without a control group. furthermore, data were collected before and after the intervention was carried out in the experimental group. the first observation (pre-test) was conducted to test the changes that occurred after the intervention. a total of 36 prelicensure nursing students were collected using total sampling. the reeve’s instrument was used to assess the role of clinical instructor taken and modified, consisting of 20 statements. the instrument was used and modified to identify clinical instructor role in the implementation of patient safety. furthermore, the instrument is valid and reliable with cronbach’s alpha value of 0.943 and a coefficient clinical instructor value above 0.8, indicating reliability. the data analysis carried out was univariate and bivariate analysis, where the univariate analysis included the characteristics of respondents such as age, gender, and length of professional practice. furthermore, numerical data is displayed from the results of the calculation of the mean, median, sd, and min–max of age, length of practice for the nurse profession, the role of clinical instructor before and after the implementation of the community of practice with an interval coefficient (ci) of 95%. this data is a description of the object of study before proceeding to the bivariate analysis. meanwhile, bivariate analysis was conducted to differentiate the role of clinical instructors in the implementation of patient safety by prelicensure nursing students before and after the implementation of the community of practice. the wilcoxon test was used to conduct this analysis due to abnormal data, namely pre-test data. the study was conducted after being approved by the research ethics committee from faculty of nursing in islam sultan agung university. the plan and objectives were informed to the respondents, who were given full rights to agree or refuse to participate by signing an informed consent or a letter of approval. research intervention procedure the implementation procedure includes the preparation, pretest, implementation, and post-test stages. furthermore, the study was carried out at the preparation stage by obtaining a permit at the site in a teaching hospital, then selecting a clinical instructor who became a member of the clinical instructor practice community based on the inclusion criteria. the nursing students were used as respondents based on the number of students, the distribution of practice rooms, and the length of professional practice. furthermore, a pre-test needs to be conducted to assess the role of clinical instructors. additionally, before participating in the community of practice, the respondents completed questionnaires a and b containing demographic data and assessment of clinical instructors’ roles, respectively. at the implementation stage, clinical instructors who met the inclusion criteria were selected to explain the aims and objectives of the study. the process of conducting the study and the community of practice model was explained to the selected respondents, who signed the application form for informed consent and to become respondents. subsequently, the researchers form a community of clinical instructor practice with respondents who have signed informed consent, until all functions of the community are formed. a pre-test on the role of clinical instructors and patient safety goals to clinical instructors was performed to ensure that the instructors understood the role and goals. the results showed that 90% of the instructors understood the role of clinical instructors and patient safety goals. meanwhile, instructors who did not understand were given a briefing on the role of clinical instructors and patient safety goals. the next stage is the formation of a structured and organized community of clinical instructor practice. this organizational structure includes champions, sponsors, resource persons, administrators, and members, and cop is held periodically with a meeting duration of 90 minutes. generally, the community of clinical instructor practice is established until the accommodative, informative, collaborative, and innovative functions are achieved. the result of the community of practice indicated the existence of innovations by clinical instructors to teach students patient safety goals in the implementation of clinical practice, which is documented in the practice community minutes by the administrator. after the functions of the practice community were established, it was carried out to strengthen the innovation results at the previous meeting, including efforts to teach students about patient safety goals in the implementation of clinical practice. the aim was to show that the instructors are capable of implementing the community of practice and the results that must be followed up. furthermore, the community of practice was carried out without assistance with the evaluation of the instructor’s role in the implementation of patient safety as the topic of discussion, after the implementation of the previous community of practice. this meeting generated ideas, experiences, commitments, methods, strategies, or innovations for clinical instructors to optimize their role in the patient safety implementation by nursing professional students based on the clinical instructor practice room. a post-test was conducted at the end of the study to assess the role of clinical instructors in the implementation of patient safety after the formation and integration of a community of practice. the test was conducted for each respondent, namely students who followed the pre-test stage. students distributed questionnaires and assessed questionnaires a and b, as they executed in the pre-test after the community clinical advisory practice was completed. results and discussions based on table 1 the results on gender showed that about 23 students (63.9%) were female and 13 students (36.1%) were male. based on table 2 the results on age of students is 23 years (sd: 0.543). furthermore, at the 95% confidence level, the average age of students is 22.96-23.32 years. however, the average length of a article [page 22] [healthcare in low-resource settings 2023; 11(s1):11166] non -co mmerc ial us e o nly student’s profession is 5 months (sd: 2,966), while at the 95% confidence level, the average length of a student’s profession is 6.33-8.34 months. the role of clinical instructors before obtaining a community of practice was 58 (sd: 9,971). also, the results of the interval estimation indicated that at the 95% confidence level, the average score of the clinical instructor role before being given to the clinical instructor practice community ranges from 51.68 to 58.43 (table 3). the results indicated that the clinical instructors’ role was in a moderate category before being involved in the community of practice. furthermore, a clinical instructor role that is not implemented will be less professional due to several factors. the results showed that this condition was due to an out-of-date skill in performing its role as a clinical instructor. meanwhile, training increases the need for new knowledge, individual, and system performance.26,27 the role of clinical instructors is the main focus in the implementation of nursing students’ practice in the hospital. this role is significant to make the implementation of clinical practice effective. additionally, there is a relationship between the clinical instructor and nursing students’ performance in clinical practice. the clinical instructor develops the knowledge, skills, and behavior of nursing students. subsequently, students with effective and continuous guidance from a clinical instructor perform better during education compared to others.28-30 the clinical instructors’ role in the implementation of patient safety by the students after joining the community of practice was in the good category under different conditions. this shows that the community of practice has a significant effect in improving the role of clinical instructors in implementing patient safety. however, a study stated that the improvement of clinical nursing practice is achieved by regular interaction among the community of practice members.31 the result of the study (table 4) showed a significant difference in clinical instructors’ role in the implementation of patient safety before and after treatment (p< 0,001). furthermore, the mean score of clinical instructors after involving the community of practice activity was higher than before being treated (md: 24,27). the result of this study indicates that the community of practice has a significant impact on clinical instructors’ roles. in addition, the clinical instructor’s community of practice influences nursing students in developing an attitude toward the profession. the promotion and fostering of a community of practice in healthcare settings are related to the students’ experience in achieving professional competencies and clinical skills. also, the community of practice unifies the boundaries between education and clinical practice nursing students, and college students have the opportunity to form and practice to be professional and increase productivity. the implementation of practice community motivates employee’s performance to share knowledge, hence improving employee performance, work-related problems, and increasing organizational performance.32-34 knowledge management through the community of practice clinical instructors is an innovative effort that requires professional management. the community of practice has several functions including a forum for sharing ideas, knowledge, views, ideas on a problem, a vehicle for finding solutions to problems faced by groups in their field, a means of fostering innovations from community members, and as a forum exchange and interpretation of information. this promotes the improvement of clinical instructors’ role when guiding students in the implementation of patient safety.35 the community of practice is the right place to practice within the organization. furthermore, the functions consist of accommodating, informative, collaborative, and innovative among fellow clinical instructors. this practice explores the knowledge potential that exists in each member of the organization, hence it builds organizational knowledge.36 according to the study, the clinical instructors’ role is enhanced by the practice community by sharing information between clinical instructors based on the problems faced while carrying out their duties and solutions to problems that occur. in addition, various innovations have emerged to address the problem of students implementation of patient safety. the process of knowledge transfer in the informative function by clinical instructors makes an indispensable contribution to the role of clinical mentors. furthermore, the community of practice turns the clinical instructors’ knowledge into a source of intellectual property for an organization.36 the clinical instructor requires preparation to carry out its role optimally in guiding the implementation of patient safety conducted by the students. also, the clinical instructor provides proper preparation and guidance to students during clinical practice. furthermore, the nursing student’s hospital experiences do not harm or injure patients. the guidance process for the implementation of patient safety to nursing students is integrated into clinical practice when giving nursing care to patients. this is conducted to ensure that the safety aspect is in line with the nursing care, and it does not require a particular time, place, and condition to be implemented. the application of patient safety by the students provides benefits to improve safety culture, service quality, positive image of the hospital, public confidence, and decrease injured patients. article table 1. frequency and percentage distribution of students according to gender. variable frequency (n) percentage (%) gender male 13 36.1 female 23 63.9 table 2. frequency and percentage distribution of students according to age and lengthy of practice. variable m min-max 95% ci age (year) 23 23-26 22.96-23.32 lengthy of practice (months) 5 5-11 6.33-8.34 table 3. the mean score of clinical instructor role in the implementation patient safety by preliscencure nursing students. clinical instructor role m sd min-max 95% clinical instructor before 58* 9.971 34-67 51.68-58.43 after 79.33 10.960 53-98 75.63-83.04 table 4. the diference analysis of clinical instructor role preand post intervention. clinical instructor rolem sd md p before 58 9.971 24.27 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[the role of clinical supervisors and the implementation of patient safety by nurse profession students] unissula nursing conference call for paper & national conference 2018;1:138–44. 29. vaismoradi m, salsali m, marck p. patient safety: nursing students’ perspectives and the role of nursing education to provide safe care. int nurs rev 2011;58:434–42. 30. dahlke s, baumbusch j, affleck f, et al. the clinical instructor role in nursing education: a structured literature review. j nurs educ 2012;51:692–6. 31. lave j. legitimate peripheral participation in communities of practice. in: strategic learning in a knowledge economy [internet]. elsevier; 2000 [cited 2021 may 9]. p. 167–82. available from: https://linkinghub.elsevier.com/retrieve/pii/b97807506722385 00101 32. ranmuthugala g, cunningham fc, plumb jj, et al. a realist evaluation of the role of communities of practice in changing healthcare practice. implement sci 2011;6:1–6. 33. portoghese i, galletta m, sardu c, et al. community of practice in healthcare: an investigation on nursing students’ perceived respect. nurse educ pract 2014;14:417–21. 34. kai loon c. the emerging dynamic social learning theory of a learning community of practice. ontario: trent university; 2019. 35. davis b, coryell je. relationships, participation, and characteristics of a community of practice in short-term adult study abroad. adult learn 2020;31:17–26. 36. jiang rs, chou cc, tsai pl. preceptor-guided clinical practica and the learning experiences of nursing students. j nurs res 2012;20:152–7. article [healthcare in low-resource settings 2023; 11(s1):11166] [page 25] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11182 relationship between postural stability and fall risk in young adult after lower limb muscle fatigue mohd khairuddin mohd safee,1,2 noor azuan abu osman1 1department of biomedical engineering, faculty of engineering, university of malaya, kuala lumpur, malaysia; 2department of science rehabilitation, faculty of health sciences, university sultan zainal abidin, kuala nerus, terengganu, malaysia abstract introduction: muscle fatigue can reduce body balance and activity of daily living tasks. therefore, this study aims to identify the correlation between postural stability and fall risk due to muscle fatigue. the components in postural stability include overall stability index (osi), anterior-posterior stability index (apsi), and mediolateral stability index (mlsi). design and methods: a total of seven healthy adults aged 31.1±7.4 years were recruited in this study. the sit-to-stand (sts) protocol was used to induce lower limb muscle fatigue, while postural stability and fall risk were assessed using the biodex balance system (bbs) before and after muscle fatigue. result: the result showed a significant increase in postural stability index after fatigue only for osi with p<0.05, while no significant difference was found on apsi and mlsi with p=0.157 and p=0.109 respectively. however, the mean score for the postural stability index showed an increase in percentage with 47.8% in osi, 26.3% in apsi and 46.8% in mlsi. furthermore, fall risk showed no significant differences with p=0.149, but the mean score data increased by 16.7% after fatigue. the correlation between fall risk and osi was significant with p<0.05, while mlsi had a significant negative correlation with apsi (p<0.05). conclusions: based on the results, the young adults had reduced overall postural stability but were less affected by fall risk after muscle fatigue. the positive correlation between osi and fall risk indicated that their overall postural stability can induce the fall risk after muscle fatigue. therefore, young adults need to be aware of their fatigue symptoms during prolonged exercise that can increase fall risk potential. introduction fatigue can be defined as lack of energy, exhaustion, an overwhelming sense of tiredness, and difficulties in performing a voluntary activity.1 enoka and duchateau2 define fatigue as “a disabling symptom in which physical and cognitive function is limited by interactions between performance and perceived fatigability”. muscle fatigue can affect balance, proprioception, coordination, and reduce contractile muscle ability.3 there are several possibilities for people experiencing muscle fatigue, such as prolonged maintenance of the muscle force,4 incline walking,5 prolonged isometric tasks, and repetitive movements.6 standing up and sitting down is an everyday activity often performed spontaneously by healthy subjects.7 however, repetitive sts activity will produce fatigue and decrease postural stability.8 prolonged voluntary contractions of lower limb muscles during the sts also affect motor control and body balance.9 although fatigue reduces postural stability, a therapist provides rehabilitation programs for the patients to increase their ability to maintain good postural stability in daily living activities and complex tasks.10 in rehabilitation, physical actions such as exercises and repetitive movement also increase patients’ ability to perform activities of daily living and recover their physical performance.11 however, fatigue due to prolonged physical activity negatively affects balance control and increases the risk of falling even after the cessation of exercise.12 previous studies showed that elevation in the risk of falls and increasing postural instability are caused by insufficient attention, memory, and executive functions.13 arjunan et al.,4 mentioned that localized muscle fatigue might be a risk factor in causing slip-induced falls. other studies also reported that fatigue can negatively affect muscle force-generating capacity,14 balance,15 and increase the asymmetry between the lower limbs during standing.16 in recent years, a few studies have investigated the relationship between postural stability during standing and muscle fatigue.3,7 however, none examined the relationship between postural stability and fall risk due to muscle fatigue. therefore, this preliminary study was conducted to identify the relationship between postural stability and fall risk among healthy young adults before and after lower limb muscle fatigue. the results will be beneficial to the young adult in performing an exercise, and therapists in identifying the effect of fatigue due to prolonged muscle activity on the patients. in addition, the results are expected to help young adults plan their prolonged activities and therapists in planning better treatments to increase postural stability and reduce fall risk. article significance for public health understanding the relationship between postural stability and fall risk enables therapists to handle and rehabilitate patients who have a deficit in one of these areas with greater care. this is because postural stability and fall risk showed a significant association in this study, which suggests that a deficiency in one of these aspects might be related to the other. the data in this study can be utilized to educate young adults about the importance of maintaining postural stability to avoid falling. it is recommended that young adults monitor their muscle exhaustion levels throughout a repetitive activity and take a break when fatigue sets in. [healthcare in low-resource settings 2023; 11(s1):11182] [page 83] non -co mmerc ial us e o nly design and methods this was a preliminary study conducted to identify the correlation between postural stability and fall risk due to muscle fatigue. the data were collected from 2019 and stopped in 2020 due to the covid-19 pandemic and the targeted population was healthy adults between the ages of 20 and 40 years. a total of seven participants aged 31.1±7.4 years participated in this study. participants were excluded when they have any medical history regarding muscular or neurological disorders, lower limb injury, or balance disorders. before the experiment commenced, the subjects read and signed a consent form after explaining the experimental protocols verbally. institutional review board from university medical committee approved the test procedure (mec 895.7). in addition, this study was registered in a who-compliant trial registry (thai clinical trials registry: tctr20210805001). all subjects performed fatigue protocol with repeated sts, the standard chair used in this protocol was a bench without armrests, 44 cm in-depth, 440 cm in width, 46cm in height. sts was performed with patients standing straight, knees completely extended, feet at the same distance apart as the hips, and upper limbs crossed in the anterior region. subjects’ feet were barefoot and shoulderwidth apart, the heels and toes were marked on the floor at the same level to guarantee that the feet remained stationary throughout the procedure. the subjects were asked to stand and then sit repeatedly to the metronome’s beat until they are unable to complete the procedure. the fatigue protocol was terminated when one of the following conditions were met: i) voluntary exhaustion occurred, ii) repeated sts movement remained below 35 beats/min, or iii) a 30-minute cut-off time was reached.3 the subjects’ postural stability and fall risk were assessed using biodex balance system sd inc., shirley, ny (bbs), a computerized screening test. the bbs is a round platform that can move freely and is used to assess an individual’s ability to maintain either static or dynamic postural stability as well as the anteroposterior and mediolateral axes. patients were asked to look at a screen in the front to ensure the markers were in the midpoint of the targeted position. the vertical projection was kept with their center of gravity on the platform, then the anterior-posterior stability index (apsi), medial-lateral stability index (mlsi), and overall stability index (osi) were used to calculate the bbs postural stability score. for the fall risk measurement, the test began with an initial platform setting of 6 and ends with a setting of 2. the bss was used to measure the degree of tilt in each axis, providing an average sway score and calculated in the bbs’s software to identify the fall risk index. all the balance tests required that the subjects stand on the bbs without footwear. the bbs was used to assess the body displacement of sagittal and frontal plane motion, the x-direction represents the horizontal displacements along medial-lateral (ml) axes, while the y-direction represents vertical along anterior-posterior (ap) axes. furthermore, the bipedal stance test to measure the postural stability score under the static level, and the fall risk under the dynamic level was accomplished using bbs. the subjects were asked to maintain a static standing position for 20s during the postural stability test which was performed five times with 10s between each, and all the data were averaged. the subjects were told to maintain their foot’s placement on the platform throughout the balance test. all data were entered into a database and were verified before the analysis. subsequently, the data were summarized in means as well as standard deviations or percentages forms. the normality of the variables’ distribution was tested using shapiro–wilk test due to the small number of subjects, while the wilcoxon signed-rank test was used in identifying the significant difference before and after fatigue on postural stability and fall risk. furthermore, spearman’s rho correlation coefficient was used to examine the relationship between the study variables as all variables were not normally distributed. all statistical analysis was performed using the statistical software spss26.0 (version26, ibmcorp., armonk, ny). results and discussions all the participants were recruited before the covid-19 pandemic started, the age ranged between 20 and 40 years with a mean of 31.1±7.4 years. on average, the mean scores of body mass index ranges (bmi) were normal namely 23.1±1.8. all subjects were instructed to perform experimental protocols and the results were recorded as shown in table 1. article table 1. subject’s demographic data (mean ± sd). subjects (n=7) age (years) 31.1±7.4 height (cm) 168.6±2.7 weight (kg) 65.9±5.3 bmi (kg/cm2) 23.1±1.8 figure 1. mean of the postural stability before and after muscle fatigue. figure 2. mean of the fall risk before and after muscle fatigue. [page 84] [healthcare in low-resource settings 2023; 11(s1):11182] non -co mmerc ial us e o nly the results showed an increase in postural stability index scores after fatigue with osi 47.8 %, apsi 26.3%, and mlsi 46.8 %. figure 1 shows the histogram of the three postural stability indexes scores before and after muscle fatigue. based on the result, significant differences before and after fatigue were found only on the osi (p<0.05) but not on apsi (p=0.157) and mlsi (p=0.109). the statistical analyses for this result are summarized in table 2. the fall risk analysis results presented in figure 2 showed that the mean score increased after fatigue, but the increase was not significant as demonstrated by p=0.149. furthermore, the scoring percentage (%) was determined by normalizing the data to the prefatigue score and calculating the increasing value in each subject. the histogram showed a 16.7% increase in fall risk after fatigue indicating that fatigue has the potential to increase fall risk. table 3 presents the statistical analysis for the fall risk test, while figure 3 shows the biodex score for postural stability and fall risk. spearman’s rho correlation coefficient was used to assess the relationship between postural stability and fall risk. the results showed that there was a significant correlation between fall risk and osi with r= .81, p = 0.028, n=7) but not with apsl p=0.843 and mlsi p=0.640. however, the apsi and mlsi showed a significant negative correlation with each other as indicated by r= .81, p=0.028, n=7. this shows that the score in apsi and mlsi correlated, table 4 presents the statistical analysis for the correlations. one of the objectives of this study was to investigate the effect of muscle fatigue on postural stability pre and post fatigue. the results showed that the subjects demonstrated an increase in postural stability but only osi showed a significant increase after fatigue compared to apsl and mlsi. however, all mean postural stability indexes showed an increase after fatigue. the osi indicated that fatigue has a significant effect on increasing postural stability. this result aligns with previous studies that showed a relationship between fatigue and postural sway,8,17 specifically with the anterior-posterior and medio-lateral center pressure.8 this is presumably due to the effect of the sensorimotor process that can also affect the proprioceptive system and force-generating capacity.18 based on the results, the young adult subjects were considered to have good proprioception given that their apsi and mlsi showed no significant increase in postural stability. the subjects in this study have an excellent vestibular system that includes the proprioception, inner ear, and vision which send the sensory information used for balance.19 other factors that contribute to postural stability were minimized by filtering the subjects, hence, individuals on medication, have musculoskeletal conditions, or neurological deficits were not recruited to avoid potential confounding factors affecting balance and falls.13,20 horak21 mentioned that a few components might affect postural stability, such as control of dynamics, biomechanical constraints, cognitive processing, sensory and movement article table 3. fall risk score pre and post fatigue. median interquartile range sd p fall risk pre fatigue 1.80 1.20 0.81 0.149 post fatigue 2.50 1.10 0.94 *p<0.05. table 4. correlations between fall risk and postural stability index (osi, apsi, mlsi). fall risk osi apsi mlsi spearman's rho fall risk correlation coefficient 1.000 .809* .093 .217 p . .028 .843 .640 n 7 7 7 7 osi correlation coefficient .809* 1.000 .000 .490 p .028 . 1.000 .264 n 7 7 7 7 apsi correlation coefficient .093 .000 1.000 -.808* p .843 1.000 . .028 n 7 7 7 7 mlsi correlation coefficient .217 .490 -.808* 1.000 p .640 .264 .028 . n 7 7 7 7 *p<0.05 table 2. postural stability index result pre and post fatigue. median interquartile range sd p osi pre fatigue 0.30 0.20 0.11 0.026 post fatigue 0.50 0.01 0.09 apsi pre fatigue 0.20 0.20 0.13 0.157 post fatigue 0.30 0.30 0.13 mlsi pre fatigue 0.20 0.10 0.08 0.109 post fatigue 0.20 0.30 0.17 p<0.05. [healthcare in low-resource settings 2023; 11(s1):11182] [page 85] non -co mmerc ial us e o nly strategies, as well as orientation in space. humans can maintain posture by restoring balance, but this requires a great ability to control the center of mass (com) above an area of equilibrium,22 maintain the center of pressures (cop) to the base of support,23 and control balance strategy during perturbation.24 furthermore, the sensory strategy for balance control also demonstrated the important role of integrated visual, vestibular, and proprioception aspects in quiet standing.19 the fall risk assessment for the young adult subjects indicated that the mean score percentage increased after fatigue but was not significant. this indicates that young adults have the potential to maintain their fall risk without other factors. however, the result showed a significant correlation between overall postural stability and fall risk after fatigue. in general, postural sway can induce an increase in fall risk after muscle fatigue for young adults. previous studies that showed increased fall risk and decreased postural control in young adults mentioned the contribution of both physical and cognitive fatigue.17,25 in contrast, this study only provided 30 minutes cut-off time for the fatigue protocol which did not significantly increase fall risk among young adults. the limited-time in this study might not be sufficient to show the severity of fatigue. this aligns with kamitani et al.26 which reported a positive association between fatigue severity and fall frequency. the positive relationship between fall risk and overall stability indicates that increasing postural sway can indirectly increase the fall risk. however, further studies with a more extended period of fatigue protocol are needed. these results are consistent with previous studies which also reported that fatigue can increase the fall risk.8,15,20,27–29 a few factors related to fatigue were mentioned including lower limb amputee, pain, diseases, and repetitive movements. in other studies, most of the risk factors associated with falls were primarily elderly patient cohorts and not young adults.5,30–33 furthermore, a higher rate of falls was detected in older adults with more severe fatigue than in those who reported milder fatigue,26 but the cohort population in this study is younger compared to that of previous studies, with an age range of 20 to 40 years old. the results did not show a significant increase in fall risk in younger subjects, but the mean scores indicated a rise in fall risk by 16.7%. nevertheless, this minimum risk needs to be considered as a potential of increasing falling. this implies that the age factor can be one of the components in identifying the fall risk. considering that this is a preliminary study, it has several limitations, first, only seven participants were recruited due to the covid-10 pandemic and only focused on healthy young adults. therefore, it is suggested that further studies be conducted on a larger amount of subjects with different age populations. second, this assessment needs to be carried out for different levels of body mass index, as well as gender and condition of patients. it can also be a pilot study to identify the correlation between muscle fatigue and fall risk in different conditions and situations. this study protocol can be used for lower-limb amputees to analyze their adaptation during muscle fatigue and develop a rehabilitation program. conclusions fatigue of the lower limb muscles can impair overall postural stability of the body. therefore, understanding the relationship between postural stability and fall risk enables therapists to handle and rehabilitate patients who have a deficit in one of these areas with greater care. this is because postural stability and fall risk showed a significant association in this study, which suggests that a deficiency in one of these aspects might be related to the other. by using a therapy method to improve one of these aspects, the other characteristics can also be improved concurrently. therefore, the results have significant implications for monitoring fall risk and postural stability due to acute muscular exhaustion caused by recurrent multi-joint exercises and repetitive activities, mainly in the lower limb muscles. additionally, the data can be utilized to educate young adults about the importance of maintaining postural stability to avoid falling. it is recommended that young adults monitor their muscle exhaustion levels throughout a repetitive activity and take a break when fatigue sets in. references 1. gruet m, temesi j, rupp t, et al. stimulation of the motor cortex and corticospinal tract to assess human muscle fatigue. neuroscience 2019;231:384–99. article [page 86] [healthcare in low-resource settings 2023; 11(s1):11182] correspondence: mohd khairuddin mohd safee, science rehabilitation department, faculty of health sciences, university sultan zainal abidin, 21300 kuala nerus, terengganu, malaysia. e-mail: mohdkhairuddin@unisza.edu.my key words: posture stability; muscle fatigue; fall risk; young adult. acknowledgment: the author thanks to faculty of engineering, university of malaya, kuala lumpur, malaysia for their support and encouragemnets during this study. contributions: all authors contributed to this study and were fully committed to the process of data collection, editing, and writing manuscripts. all authors have read and approved the final manuscript. conflict of interests: the author declares no conflict of interest. funding: this study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. clinical trials: this study has registered in a who-compliant trial registry (thai clinical trials registry: tctr20210805001). availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 12 december 2021. accepted for publication: 20 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11182 doi:10.4081/hls.2023.11182 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly 2. enoka rm, duchateau j. translating fatigue to human performance. med sci sports exercise 2021;48:2228–38. 3. barbieri fa, dos santos pcr, vitório r, et al. effect of muscle fatigue and physical activity level in motor control of the gait of young adults. gait posture 2019;38:702–7. 4. arjunan sp, kumar dk, naik g. computation and evaluation of features of surface electromyogram to identify the force of muscle contraction and muscle fatigue. biomed research international 2021;2014. 5. morrison s, colberg sr, parson hk, et al. walking-induced fatigue leads to increased falls risk in older adults. j am med directors assoc 2016;17:402–9. 6. soto-leon v, alonso-bonilla c, peinado-palomino d, et al. effects of fatigue induced by repetitive movements and isometric tasks on reaction time. human movement sci 73:102679. 7. bohannon rw. daily sit-to-stands performed by adults: a systematic review. j physical ther sci 2021;27:939. 8. bryanton ma, bilodeau m. postural stability with exhaustive repetitive sit-to-stand exercise in young adults. human movement sci 2021;49:47–53. 9. paillard t. effects of general and local fatigue on postural control: a review [internet]. vol. 36, neurosci biobehav rev 2012;36:162-76. 10. haddad jm, rietdyk s, claxton lj, et al. task-dependent postural control throughout the lifespan. exercise sport sci rev 2021;41:123. 11. crowther f, sealey r, crowe m, et al. influence of recovery strategies upon performance and perceptions following fatiguing exercise: a randomized controlled trial. bmc sports sci med rehab 2017;9:25. 12. chaubet v, paillard t. effects of unilateral knee extensor muscle fatigue induced by stimulated and voluntary contractions on postural control during bipedal stance. neurophysiol clinique/clinical neurophysiol 2012;42:377-83. 13. nascimento m de m. fall in older adults: considerations on balance regulation, postural strategies, and physical exercise. geriatrics gerontol aging 2021;13:103–10. 14. oksa j, rintamäki h, takatalo k, et al. firefighters muscular recovery after a heavy work bout in the heat. appl physiol nutrition metabol 2017;38:292–9. 15. abutaleb ee, mohamed ah. effect of induced fatigue on dynamic postural balance in healthy young adults. bulletin faculty physical ther 2015;20:161–7. 16. penedo t, polastri pf, rodrigues st, et al. motor strategy during postural control is not muscle fatigue joint-dependent, but muscle fatigue increases postural asymmetry. plos one 2021;16:e0247395. 17. beurskens r, haeger m, kliegl r, et al. postural control in dual-task situations: does whole-body fatigue matter? plos one 2021;11:e0147392. 18. mezaour m, yiou e, le bozec s. effect of lower limb muscle fatigue on anticipatory postural adjustments associated with bilateral-forward reach in the unipedal dominant and non-dominant stance. eur j appl physiol 2021;110:1187–97. 19. wiesmeier ik, dalin d, wehrle a, et al. balance training enhances vestibular function and reduces overactive proprioceptive feedback in elderly. front aging neurosci 2017;9:273 20. verma sk, willetts jl, corns hl, et al. falls and fall-related injuries among community-dwelling adults in the united states. plos one 2021;11:e0150939. 21. horak fb. postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls? age and ageing 2006, p. ii7–11. 22. ws e. center of mass of the human body helps in analysis of balance and movement. moj app bio biomech 2018;2:144– 148 23. ruhe a, fejer r, walker b. the test-retest reliability of centre of pressure measures in bipedal static task conditions a systematic review of the literature. gait posture 2010;32:436-45. 24. blenkinsop gm, pain mtg, hiley mj. balance control strategies during perturbed and unperturbed balance in standing and handstand. royal society open sci 2021;4:161018. 25. el-khoury f, cassou b, latouche a, et al. effectiveness of two year balance training programme on prevention of fall induced injuries in at risk women aged 75-85 living in community: ossébo randomised controlled trial. bmj 2015;351:h3830. 26. kamitani t, yamamoto y, kurita n, et al. longitudinal association between subjective fatigue and future falls in community-dwelling older adults: the locomotive syndrome and health outcomes in the aizu cohort study (lohas). j aging health 2021;31:67–84. 27. granacher u, wolf i, wehrle a, et al. effects of muscle fatigue on gait characteristics under single and dual-task conditions in young and older adults. j neuroeng rehabil 2010;7:56. 28. parijat p, lockhart te. effects of quadriceps fatigue on the biomechanics of gait and slip propensity. gait posture 2008;28:568-73. 29. wong ck evi., chen cc, blackwell wm, et al. balance ability measured with the berg balance scale: a determinant of fall history in community-dwelling adults with leg amputation. j rehabil med 2015;47:80-86. 30. halvarsson a, roaldsen ks, nilsen p, et al. staybalanced: implementation of evidence-based fall prevention balance training for older adults—cluster randomized controlled and hybrid type 3 trial. trials 2021;22:1–9. 31. renner sw, group of in m (mros) s, cauley ja, et al. higher fatigue prospectively increases the risk of falls in older men. innovation in aging 2021;5:1–8. 32. stanmore ek, mavroeidi a, jong ld de, et al. the effectiveness and cost-effectiveness of strength and balance exergames to reduce falls risk for people aged 55 years and older in uk assisted living facilities: a multi-centre, cluster randomised controlled trial. bmc medicine 2021;17:1–14. 33. morrison s, colberg sr, parson hk, et al. walking-induced fatigue leads to increased falls risk in older adults. j am med directors assoc 2021;17:402–9. article [healthcare in low-resource settings 2023; 11(s1):11182] [page 87] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11736 family support and coping strategies among female inmates: a cross-sectional study in penitentiaries akhmad yanuar fahmi pamungkas,1 yulifah salistia budi,1 woro nurul seftianingtyas,2 pipih salanti,2 tria eni rafika devi,3 muninggar muninggar,2 miftahul hakiki,1 muhammad al amin,1 arni nur rahmawati,4 prita adisty handayani,5 rudiyanto rudiyanto1 1institute of health science banyuwangi, banyuwangi; 2institute of health science bhakti pertiwi indonesia, south jakarta; 3institute of health science rustida, banyuwangi; 4universitas harapan bangsa, indonesia, banyumas; 5institute of health science telogorejo semarang, semarang, indonesia abstract family is one of the closest people in helping individuals solve problems and serve as the foundation for developing coping strategies. several factors influence coping strategies, including problem-solving skills and family support. this study aimed to explore the correlation between family support and coping strategies among female prisoners. the research employed a quantitative correlation design using a cross-sectional approach and a total sampling technique, with a sample of 33 female prisoners. the study included two variables: family support as the dependent variable and coping strategy as the independent variable. the chisquare test was used for data analysis. the results revealed that a majority of female prisoners received good family support (51.5%), and most of them used emotion-focused coping strategies (63.6%). the results indicate a significant correlation between family support and coping strategies for female prisoners, with a p-value of 0.004. it highlights the importance of family support for prisoners in developing effective coping strategies. the findings emphasize that family support plays a crucial role in enhancing coping strategies for inmates, ultimately contributing to an improved quality of life. introduction prisoners are individuals who have violated the law, their independence is temporarily revoked to serve prison sentences in detention centers for committing crimes.1 crime is a form of behavior that violates social rules applied by legal entities.2 crime can be committed by anyone, male or female. the involvement of women in criminal matters in the life of the general public is indeed an odd thing to see from the inherent nature of women themselves and can occur among children, adolescents, adults, and even the elderly. the psychological factor of a man usually has a high emotional level, however, that does not mean that a woman does not have the potential to commit crimes. we can see that crimes committed by women are usually caused by economic factors and social factors. individuals who violate the law will receive punishment, both to society and justice. part of the justice system is the penitentiary (prison law no. 12). penitentiarys make individuals who originally had freedom become individuals who are limited in many ways. these restrictions involve rules that must be followed, loss of privacy, and separation from the outside world, such as family and friends.1 being a prisoner is a difficult and unpleasant thing because they have to live in a penitentiary to serve their sentence and are required to be able to adjust to life in [healthcare in low-resource settings 2024;12:11736] [page 1] correspondence: akhmad yanuar fahmi pamungkas, institute of health science banyuwangi, banyuwangi, indonesia. e-mail: yanuarfahmi20@gmail.com key words: coping strategy; family support; prisoners. contributions: ayfp conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ysb conceptualization, investigation, methodology, validation, and writing, original draft, review and editing; wns resources, investigation, and writing, review and editing; ps formal analysis, validation, writing, review and editing; terd resources, supervision, and writing, review and editing; mm resources, investigation, and writing – review and editing; mh formal analysis, validation, writing, review and editing; maa resources, supervision, and writing –review and editing; anr resources, investigation, and writing, review and editing; pah conceptualization, and writing, original draft, review and editing; rr resources, investigation, and writing, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has been declared to have passed the ethical test with ethical no. 114/01/kepkstikesbwi/v/2022 by kepk health research ethics committee sekolah tinggi ilmu kesehatan banyuwangi. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. in this research, the data collection process was carried out by directly distributing questionnaires to respondents which began with an informed consent process to obtain approval from the respondents. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. all supporting data was obtained from the prison in banyuwangi, the results of this research will be continued for intervention by the research site acknowledgement: we would like to thank various parties who have helped realize this research: head of sekolah tinggi ilmu kesehatan banyuwangi, research assistant officer at banyuwangi penitentiary. received: 9 september 2023. accepted: 17 november 2023. early access: 5 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11736 doi:10.4081/hls.2023.11736 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly a penitentiary. when imprisoned, female prisoners are isolated from the outside world, separated from their loved ones, lose privacy, and subject to prison rules, which can cause psychological distress to prisoners due to the new situation.3,4 several countries in east and southeast asia have the highest number of female prisoners. in general, southeast asia is at the highest level, namely, thailand is ranked 5th, the philippines is ranked 7th, vietnam is ranked 8th, indonesia is ranked 9th followed by myanmar at ranked 11th5. data in indonesia showing the largest number of prisoners in 2018 are in the regional offices of north sumatra, east java, west java, dki jakarta, and the central java regional office ranks 5th in indonesia with a total of 9,493 prisoners, and class ii brebes penitentiary occupies the top 15 in central java, this figure shows a high number and is a stressor for prisoners. the situation experienced by prisoners becomes a stressor that causes stress for most prisoners. stressor situations include prison time, friendships in prison, environment, and family support but a crucial impact on prisoners is family support because positive psychological support from the family can improve psychological well-being. the impact of stress on prisoners who are serving criminal sentences in prison always has physical and psychological impacts.6,7 there are 898 female prisoners in the penitentiary (prison) area in east java. many factors influence coping strategies, including physical health, a positive view of the problems faced, problem-solving skills, materials, and family support from within, such as emotional factors dealing with stress as well as spiritual aspects. handling stress is very dependent on a person’s coping, the majority of female prisoners have positive and negative coping.8–10 female prisoners in penitentiary need motivation and support from family or closest people to avoid anxiety and emotional problems. since they are apart from family support, to avoid anxiety and emotional problems, female prisoners can do positive coping strategies that can provide benefits to female prisoners how to relax, pray to get closer to each other’s beliefs, support friends in prison, listen to music, joke, or try to think of good things, express feelings by sharing with friends in prison, and help others.11–13 coping is related to the form of effort made by individuals to protect against psychological pressures, due to social experiences. hence, psychologically, good coping is able to provide strength effects (feelings about self-concept and life), emotional reactions, reduce levels of depression or anxiety, and balance between negative and positive feelings.14,15 coping strategies used by prisoners will help them cope with the responsibility and pressure that comes with certain behaviors. the behavior that appears can be in the form of negative action responses, but can also be in the form of positive action responses through family support. family support can come from parents, spouses or lovers, siblings, or even from loyal pets. with high family support, they have low-stress levels, are more successful at coping, and experience positive things in life more positively.16,17 based on this explanation, the purpose of this study was to determine the correlation between family support and coping strategies for women prisoners at the banyuwangi penitentiary. materials and methods the study was a quantitative correlation design using a crosssectional. the sampling method employed was total sampling, encompassing the entire population, resulting in a sample size of 33 participants. the study comprised two variables: family support as the dependent variable and coping strategies as the independent variable. for data collection, the family support scale (fss) by carl j. dunst was used to measure family support. the fss demonstrated good validity (alpha > 0.8) and reliability (cronbach’s alpha = 0.725) with 20 valid items falling into categories of good (74-100), sufficient (47-73), and low (0-46). the coping strategy variable utilized the way of coping questionnaire by folkman and lazarus (1986), which demonstrated validity (alpha > 0.7) and reliability (cronbach’s alpha = 0.725) with 36 valid items. scoring in this instrument categorized problemfocused coping (37.5-75) and emotion-focused coping (76-100), both of which were filled out by all respondents. participants were categorized based on their detainee type and length of detention to investigate potential correlations with coping strategies. data collection involved distributing questionnaires directly to respondents after obtaining informed consent. the questionnaire results were then analyzed using the chi-square statistical test, with a p<0.05 signifying a significant correlation and a p>0.05 indicating a lack of significant correlation. researchers ensured ethical considerations by informing participants about the research, obtaining informed consent, and providing the option to decline participation. the study received ethical approval (ethical no. 114/01/kepk-stikesbwi/v/2022) from the health research ethics committee sekolah tinggi ilmu kesehatan banyuwangi. results based on table 1, it is explained that most of the characteristics of the respondents by age show that there were 18 people (54.5%) aged 20-35 years with an education level of almost half being high school as many as 16 people (48.5%). a total of 17 people (51.5%) of the prisoners’ marital status were widows and almost half of the prisoners had lived in the penitentiary for 0-9 months as many as 16 people (48.5%) and a number of 32 people (97%), almost all of the respondents were muslim. the activities carried out by almost half of the prisoners in penitentiary were worship, 14 people 42.4%, and most of the cases involving respondents were criminal acts of drug abuse 19 people (57.6%). regarding the result from 33 respondents, table 2 showed that the correlation between family support and coping strategies for female-assisted residents was obtained from 17 people using family support in a good category. there were 21 people (63.6%) female-assisted residents who used emotional-focused coping, while 16 female-assisted residents experienced adequate family support and 12 people (36.4%) used problem-focused coping. this showed that most respondents have good family support as many as 17 people and most respondents used emotional focus coping strategies which was 21 people (63.6%). the results of the chisquare statistical test on the correlation between family support and coping strategies among inmates obtained a significant pvalue, namely 0.004 (p<0.05). this shows that there is a correlation between family support and coping strategies among inmates at the banyuwangi prison institution in 2022. discussion the results indicate that a majority of female prisoners received family support categorized as good. family support, characterized as a form of family therapy, assists families in addressing transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 2] [healthcare in low-resource settings 2024;12:11736] non -co mmerc ial us e o nly multiple health issues simultaneously. this support is typically provided by family members who have experience with the relevant issues in their social environment, offering emotional support and influencing acceptance behavior.18 family visits to female prisoners in prison play a crucial role in affirming their existence and status within the family, fostering a positive outlook. during these visits, families demonstrate continued respect, love, and enthusiasm for the female prisoners.19 family support can manifest in various forms, including internal family support from spouses, siblings, and other close relatives, as well as external family support. the factors influencing family support can be categorized into internal and external factors. internal factors encompass stages of development, education, knowledge level, and economic, emotional, and spiritual factors. external factors include family background, socioeconomic status, and cultural influences. these factors collectively contribute to the dynamics of family support for female prisoners.20 effective family support can be influenced by factors such as age, marital status, and the duration of time female prisoners have spent in prison. analysis of the age of female prisoners in prison reveals that the majority fall within the productive age range. this finding aligns with prior research suggesting that individuals in their productive age may encounter challenges related to desires and capabilities, potentially leading to criminal activities.21 by this age, individuals often possess mature attitudes and are receptive to advice from their families. considering marital status, the majority of female prisoners are widows, emphasizing the continued need for robust family support in prison. this aligns with previous research, indicating that widows, having experienced married life, may face prolonged stress in the absence of family support.22 support from parents, children, and close relatives becomes crucial for these individuals. families of female prisoners frequently visit the prison, particularly during the initial months of incarceration, as over half of new respondents had lived in correctional institutions for 0 to 9 months. research suggests that the duration of prison time is linked to an individual’s resilience in coping with problems, underscoring the importance of family support during incarceration.23 family support is evident in the proactive efforts of female prisoners’ families, who take the time to visit and demonstrate care. this involvement helps female prisoners feel valued and cherished, as families pay attention to their well-being and inquire about both the health of the detainees and their families. these supportive actions contribute significantly to the overall well-being and adjustment of female prisoners within the prison environment. the study’s findings revealed that the majority of female prisoners in banyuwangi penitentiary employed emotion-focused coping strategies, with 21 individuals (63.6%) utilizing this approach. the ability of an individual to cope is influenced by various elements, encompassing physical health, constructive attitudes or beliefs, problem-solving abilities, social skills, social support, and material resources. coping strategies are methods employed to modify the environment or situation, or to resolve perceived or encountered difficulties.24 these influencing factors play a vital role in determining a person’s success in managing stress or anxiety, as coping strategies encompass not only problem-oriented but also emotionally oriented approaches. the aim of coping strategies is to navigate situations and demands perceived as pressing, challenging, burdensome, or surpassing available resources.25 in this study, a notable emphasis is placed on emotion-focused coping, which centers on addressing the emotions arising from the challenges faced. emotion-focused coping entails prioritizing efforts to transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. respondents’ characteristics (n=33). characteristic frequency percentage (%) age 20-35 years old 18 54.5 36-45 years old 8 24.2 46-65 years old 7 21.3 education elementary school 4 12.1 junior high school 9 27.3 senior high school 16 48.5 higher education 4 12.1 marital status single 3 9.1 married 13 39.4 widow 17 51.5 religion islam 32 97 christian 1 3 duration of occupies prison 0-9 months 16 48,5 10-24 months 11 33.3 25-36 months 4 12.1 > 36 months 2 6.1 activity in prison physical exercise 7 21.2 worship 14 42.4 coaching 7 21.2 other activitiwa (related) 5 15.2 reasons to enter prison drug abuse 19 57.6 tax 1 3 embezzlement 7 21.2 fraud 5 15.2 child protection 1 3 family support good 17 51.5 enough 16 48.5 coping strategy problem-focused coping 12 36.4 emotion-focused coping 21 63.6 table 2. correlation between family support and coping strategies for women prisoners (n=33). coping strategy p problem focus coping emotional focus coping support family f % f % f % good 2 11.8 15 88.2 17 100 0.004 enough 10 62.5 6 37.5 16 100 [healthcare in low-resource settings 2024;12:11736] [page 3] non -co mmerc ial us e o nly alleviate the negative emotions experienced when confronting problems. this approach significantly impacts the success of female prisoners in managing stress and controlling anxiety in the face of threatening situations. several factors contribute to shaping coping strategies, including physical health, positive perspectives on encountered problems, problem-solving skills, and the support provided by family and material resources. recognizing and understanding these influencing factors are crucial for comprehending the coping mechanisms adopted by female prisoners and can inform interventions aimed at enhancing their overall wellbeing in correctional settings.26 the age distribution of female prisoners in the prison predominantly falls within the productive age range, characterized by a capacity for effective problem-solving. furthermore, nearly half of the respondents have an educational background at the high school level, indicating a reasonable ability to analyze problems. female prisoners, as individuals employing emotion-focused coping, often find solace in surrendering themselves through religious practices, with worship to god being a prevalent coping mechanism. this coping mechanism is further exemplified by statements from assisted residents, revealing that they frequently turn to their closest friends for support when facing problems. seeking meaning in each problem, approaching god through prayer, avoiding procrastination of problems, assuming self-responsibility, discomfort with solitude, and actively seeking solutions are key aspects of the coping strategies adopted. the study establishes a significant correlation between family support and coping strategies for female prisoners at the banyuwangi penitentiary. family support, considered a form of family therapy, proves instrumental in addressing various health problems within the family unit.18 this support can manifest as internal family support from spouses and siblings, as well as external family support. influencing factors for family support encompass both internal and external aspects, with internal factors including stages of development, education, knowledge levels, economic, emotional, and spiritual factors. external factors encompass family, socio-economic status, and cultural background. recognizing these factors provides valuable insights for understanding the dynamics of family support and its impact on coping strategies employed by female prisoners in correctional settings.20 in this study, 48.5% of respondents possessed a high school education level, indicating a reasonable understanding of the family’s role in managing individuals. consequently, respondents actively sought maximum family support, as evidenced by 51.5% reporting good family support. the spiritual activities of respondents during their incarceration indicated that 42.4% engaged in worship. the study’s findings revealed that a majority of respondents, specifically 63.6%, employed coping mechanisms primarily focused on emotions. emotion-focused coping strategies entail an individual’s efforts to manage emotional responses in highly stressful conditions.27 coping strategies, in general, involve ways to modify the environment or situation, addressing problems being felt or faced. these strategies are influenced by several factors, including physical health, positive beliefs or perspectives, problem-solving skills, social skills, and social and material support. the success of coping strategies is contingent on factors such as physical health, positive perspectives on encountered problems, problem-solving skills, and the support provided by family and material resources.24 these factors collectively influence an individual’s ability to effectively control stress or anxiety in the face of threatening situations.26 understanding these dynamics is crucial for comprehending how individuals, in this case, female prisoners, navigate and cope with the challenges presented during their time in correctional facilities.28 conclusion in conclusion, this study reveals that a majority of female prisoners receive good family support, and the predominant coping strategy employed by them is emotion-focused. the analysis indicates a significant correlation between family support and coping strategies among female inmates at the banyuwangi penitentiary. this underscores the crucial role of family support in influencing and shaping the coping mechanisms utilized by female prisoners in the correctional setting. the findings emphasize the importance of understanding and addressing the emotional aspects of coping strategies, highlighting the need for continued support systems to enhance the well-being of female inmates during their incarceration. references 1. rahmah s. sistem pembinaan warga binaan di cabang rumah tahanan negara lhoknga kabupaten aceh besar. 2018. 2. sugiharti l, purwono r, esquivias ma, rohmawati h. the nexus between crime rates, poverty, and income inequality: a case study of indonesia. economies 2023;11(2). 3. santi a, asrina a, nurlinda a. problem focus coping pada narapidana seumur hidup di lembaga pemasyarakatan kelas i makassar. j aafiyah heal res 2020;1:38-47. 4. yousefi f, talib ma. predictors of personality disorders in prisoners. j med life 2022;15:454-61. 5. walmsley r. world female imprisonment list: fourth edition, women and girls in penal institutions, including pre-trial detainees/remand prisoners. world prison br 2017;1-13. 6. fijianto d, rejeki h, aryati dp. hubungan tingkat pendidikan dengan strategi koping warga binaan pemasyarakatan di lapas kelas ii b brebes. j keperawatan muhammadiyah 2021;6:31-6. 7. rahmah cd, fitryasari r, pradanie r. analysis factors related to prisoner’s resiliency in rutan perempuan kelas iia surabaya. j ners 2022;17:190-5. 8. fahmi ay. hubungan dukungan sosial dengan tingkat stres pada warga binaan pemasyarakatan perempuan di lembaga pemasyarakatan. holist nurs heal sci 2019;2:42-7. 9. tonapa si, lin wt, kuo fl, lee bo. mediating effects of coping strategies on quality of life following extremity injury. nurs res 2022;71:200-8. 10. maisyarah u. an overview of psychlogical perception, psychological distress, and coping strategy of yppm almuttaqien teachers in balikpapan against covid-19 pandemic. indones j public heal 2023;18:130-41. 11. pardede ja, sinaga tr, sinuhaji n. dukungan keluarga dengan tingkat stres narapidana di lembaga pemasyarakatan. j kesehat 2021;4:98-108. 12. lestari r, yusuf a. developing community resilience as a supporting system in the care of people with mental health problems in indonesia. indian j public heal res dev 2018;9:168791. 13. iqbal bhatti m, saud m, ahmad a, khalid mahmood q. religiosity, social support and meaning in life as predictors of resilience among victims of natural disaster in pakistan. minerva psychiatry 2022;63:263-71. 14. hasan n, rufaidah er. hubungan antara dukungan sosial dengan strategi koping pada penderita pasca stroke. talent psikol 2013;ii:41-63. 15. elsayed m, schönfeldt-lecuona c, welte xa, dardeer kt, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 4] [healthcare in low-resource settings 2024;12:11736] non -co mmerc ial us e o nly kamal ma, abdelnaby r, et al. psychological distress, fear and coping strategies during the second and third waves of the covid-19 pandemic in southern germany. front psychiatry 2022;13:860683. 16. ediati a. hubungan antara dukungan sosial dengan resiliensi pada narapidana di lembaga pemasyarakatan kelas iia wanita semarang. j empati 2016;5:537-42. 17. nordin nm, dahamat azam n, rosnon mr, abu talib m. job stress and depression among malaysian anti-drug professionals: the moderating role of job-related coping strategies. front psychiatry 2022;13:1020947. 18. hariadi e, aryani f, buston e. hubungan dukungan keluarga dengan kualitas hidup penderita tbc di kecamatan selebar kota bengkulu tahun 2018. j nurs public heal 2019;7:46-51. 19. utomo rw. hubungan dukungan keluarga terhadap tingkat. stres tahanan di rumah tahanan negara kelas 1 bandung. politeknik ilmu permasyarakatan; 2020. 20. nursyamsiah st. pengaruh dukungan sosial keluarga terhadap implementasi pendidikan anak pranatal perspektif islam di dusun turen rt 5 rw 2, sardonoharjo, ngaglik, sleman, yogyakarta. uii; 2016. 21. liu l, chui wh. social support and chinese female offenders’ prison adjustment. prison j 2014;94:30-51. 22. chen ys, lai yl, lin cy. the impact of prison adjustment among women offenders: a taiwanese perspective. prison j 2014;94:7-29. 23. genders e, player e. long sentenced women prisoners: rights, risks and rehabilitation. punishm soc 2022;24:3-25. 24. rasmun r. stres, koping dan adaptasi teori dan pohon masalah keperawatan. jakarta: sagung seto; 2019. 25. maryam s. strategi coping: teori dan sumberdayanya. j konseling andi matappa 2017;1:101-7. 26. fauziah n. hubungan penggunaan strategi coping dengan prestasi akademik pada siswa kelas xi. j bimbing konseling 2015;4:1-11. 27. folkman s, moskowitz jt. coping: pitfalls and promise. annu rev psychol 2013;55:745-74. 28. budi ys. strategi koping mahasiswa program studi d-iii keperawatan menghadapi ujian skill laboratorium yulifah salistia budi program studi s-1 keperawatan. 2018;38-43. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11736] [page 5] non -co mmerc ial us e o nly hrev_master [page 62] [healthcare in low-resource settings 2013; 1:e18] factors affecting immunization coverage in urban slums of odisha, india: implications on urban health policy santosh k. prusty,1 bhuputra panda,2 abhimanyu s. chauhan,2 jayanta k. das3 1department of health and family welfare, government of odisha, bhubaneswar; 2indian institute of public health, public health foundation of india, bhubaneswar; 3national institute of health and family welfare, new delhi, india abstract infectious diseases are major causes of morbidity and mortality among children. one of the most cost-effective interventions for improved child survival is immunization, which has significant urban-rural divides. slum dwellers constitute about one-third of indian population, and most children still remain incompletely immunized. the main purpose of this study was to understand the factors behind partial or non-immunization of children aged 12-23 months in slum areas of cuttack district, india. session-based audit and a population-based survey were conducted in the urban slums of cuttack city, april-june 2012. total 79 children were assessed and their mothers were interviewed about the nature and quality of immunization services provided. children fully immunized were 64.6%. antigen-wise immunization coverage was highest for bacillus calmette-guérin (bcg) (96.2%) and lowest for measles (65.8%), which indicates high instances of late drop-out. frequent illnesses of the child, lack of information about the scheduled date of immunization, frequent displacement of the family and lack of knowledge regarding the benefits of immunization were cited as the main factors behind coverage of immunization services. the study showed that there is an urgent need to revise the immunization strategy, especially for urban slums. district and sub-district officials should reduce instances of early and late dropouts and, in turn, improve complete immunization coverage. community participation, inter-sectoral co-ordination and local decision making along with supportive supervision could be critical in addressing issues of drop-outs, supply logistics and community mobilization. introduction infectious diseases are major causes of morbidity and mortality among children. one of the most cost effective and easy methods for child survival is immunization. childhood immunization is a proven strategy for prevention of many infectious diseases.1 worldwide, about 2.5 million deaths of under-5 children are averted annually by immunization against diphtheria, tetanus, pertussis, and measles.2 in india, vaccine preventable diseases (vpds) are still responsible for over 0.5 million deaths annually. in may 1974 the world health organization (who) officially launched a global immunization programme known as extended programme of immunization (epi) to protect all children against six vpds by 2000. the epi was launched in india in january 1978 and subsequently in 1985 was renamed as universal immunization programme (uip). it covered nine vpds, namely tuberculosis, diphtheria, whooping cough (pertusis), tetanus, polio, measles, mumps, rubella and hepatitis-b. the national population policy (npp) (2000) highlighted the need for immunizing all children against six common childhood diseases (tuberculosis, tetanus, pertussis, diphtheria, measles and polio). there are wide coverage disparities between the rich and the poor and between urban and rural children.3 there is wide interdistrict, intra-district, urban-rural and richpoor difference with respect to immunization coverage. for instance, as compared to the rest of india, the coverage is poor in empowered action group (eag) states which constitutes more than 40% of the total population.4 complete immunization coverage in urban areas of odisha was 49% as compared to 84 and 73% in tamil nadu and kerala, respectively.5 one of the recent studies indicate that about 60% children in aged 12-23 months are fully immunized in odisha, the same for poor children is a dismal 43%.6 this variation indicates a service coverage gap and reinforces the fact that those who need these services the most are the ones who are also neglected the most. despite a steady rise in overall immunization coverage, children living in large numbers of slum dwellers remain incompletely immunized.7 government of odisha defines a slum as a compact settlement of at least 20 households with a collection of poorly built tenements, mostly of temporary nature, crowded together usually with inadequate sanitary and drinking water facilities in unhygienic conditions.8 emerging evidences indicate immunization coverage has been steadily increasing but the average level remains far less than desired. only 44% of infants in india are fully immunized – much less than the desired goal of achieving a 85% coverage. even though the coverage in urban areas is relatively better than in rural areas, studies found more than 50% of poor children are underweight and almost 60% miss total immunization before completing one year.9 we aimed to understand the current status of immunization of children aged 12-23 months and the factors affecting coverage of immunization in a slum set-up. we also studied the perception of mothers about the nature and quality of immunization services provided in the public health system. materials and methods study setting cuttack city, india, has 257 identified urban slums10 with a population of about 0.6 million and a density of 4382.23/km2. male population constitutes about 52 and female 48%. the average literacy rate of the city is 77% with a remarkable gender difference (male 86 and female 67%). cuttack municipal corporation (cmc) runs health centres and provides immunization services through the fixed day outreach service delivery approach. as per 2009 slum survey, the city had 223,000 urban slums dwellers. we selected five slum settlements at random, spread across two wards (35 and 36) of the cmc. the total population of all five urban slums together is estimated to be about 5220.11 sampling all mothers of children aged 12-23 months residing in the above mentioned five urban healthcare in low-resource settings 2013; volume 1:e18 correspondence: bhuputra panda, indian institute of public health, public health foundation of india, e1/1 infocity road, 751024 bhubaneswar, india. tel. +91.674.6655601 fax: +91.674.6655614. e-mail: bhuputra.panda@iiphb.org key words: vaccination coverage, slum dwellers, factors of immunization, perception of quality, immunization strategy. conflict of interests: the authors declare no potential conflict of interests. received for publication: 17 may 2013. revision received: 12 june 2013. accepted for publication: 15 june 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.k. prusty et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e18 doi:10.4081/hls.2013.e18 non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e18] [page 63] slums constituted our primary respondents. all children registered in the respective anganwadi centres (awc) in the age group of 12 to 23 months were enlisted. total 79 mothers of children aged 12-23 months were available for the study against expected 105 mothers (calculated with crude birth rate of 20 per 1000 population). thus, 79 children were assessed for immunization status. on further enquiry, it was found that about 26 eligible mothers had gone to their native places because of summer season and thus were excluded from the study. data collection and analysis we used session-based audit and population-based survey as the methods for data collection. a semi-structured in-depth interview schedule was developed, field-tested and translated into local language. it contained ten questions in a five point likert scale pertaining to immunization status, behavior of service providers, waiting time, satisfaction level and economic loss due to immunization, etc. it also contained questions related to studying perception of mothers on factors related to immunizing their children. data collection was done during april-june 2012. both quantitative and qualitative techniques were used for data collection. quantitative analysis was done through spss version 16.0. descriptive statistics was used to show the characteristics of the participants in the study and the extent of coverage against antigens. a bivariate analysis was undertaken for all covariates to identify the factors associated with vaccination coverage. qualitative data was used for free-listing and content analysis. study variables we used the who guideline for defining full vaccination status. a child who had received one dose of bacillus calmetteguérin (bcg), three doses of oral polio vaccine (opv) (excluding polio 0), three injections of diphtheria-pertussis-tetanus (dpt), and one dose of measles before first birthday was considered fully immunized and who had not received even a single dose was considered as non-immunized. both early and late drop-outs were calculated using government of india definition. to cross-verify the immunization status, the interviewer verified the date of each received vaccination. if the mother could not show the vaccination card, she was asked if the child had received bcg, dpt, polio and measles. while bcg was examined in terms of the scar on the child’s arms, information about dpt and polio was obtained on the basis of the mother’s response in terms of number of actual doses of immunization the child had received. results results are reflected in sample characteristic measures, status of vaccination against antigens and bivariate analysis for factors affecting vaccination. the study found that majority of the people residing there were daily labourers, mechanics, rickshaw-pullers, auto drivers and small shop owners. out of the total 79 children examined, 56% were males and 44% females. among hindus (n=45), 80% were schedule caste and 20% of general caste. in terms of literacy level of respondents, 20% were illiterates, 28% had up to primary education and 42% up to secondary level education. eighty-seven percent mothers were housewives, 9% were daily labourers and 4% were into miscellaneous profession. it was found that 65% of children were completely immunized, 33% were partially immunized and 2% were not immunized at all (figure 1). ninety five percent respondents considered vaccination as important for their children (table 1). when asked about the basic reason behind the importance they attach to vaccination, 81% respondents attributed this to selfbelief, followed by influence of electronic media and communication of health workers (22.8%, each). with respect to immunization coverage by antigens, bcg coverage was the highest 96% whereas measles was 65%. dropout rate between bcg-measles, dpt3measles and dpt1-dpt3 was found to be 30, 27 and 3.94%, respectively. with regard to the distance factor from the service delivery site, it was found that 63% respondents lived within a distance of one km from the nearest health centre, while 35% lived within 1-2 kms and rest 2% were living at a distance of beyond 2 kms. eighty-five percent respondents attended article table 1. importance and reasons of immunization status. attributes frequency n % vaccination considered as important for child survival yes 75 94.9 no 1 1.3 cannot say 3 3.8 basic reasons behind laying importance* self-belief 64 81 influence of neighbors 5 6.3 health workers’ communication 18 22.8 message aired in electronic media 18 22.8 *multiple responses were ticked. categories are mutually not exclusive. figure 1. immunization status. table 2. perception on key indicators of immunization services. perception on health services yes no cannot say (%) (%) (%) has it ever happened that you had come for vaccination 4 (5.1%) 74 (93.7%) 0 and found the service not available? would you come back to same facility for vaccinating 76 (96.2%) 3 (3.8%) 0 your child again? would you come back for vaccinating your child again 77 (97.5%) 2 (2.5%) 0 if you have option to get the same services from some other public health facility? would you come back for vaccinating your child again 6 (7.6%) 70 (88.6%) 3 (3.8%) if you have option to get the same services from other private health facility? do you think not getting vaccine on a prescheduled 69 (87.3%) 0 10 (12.7%) date is bad for your child’s vaccination continuity? do you know any of your neighbors who after having 1 73 5 similar experience did not visit the health facility (1.2%) (92.4%) (6.4%) for further vaccination of his/her children? non -co mmerc ial us e o nly [page 64] [healthcare in low-resource settings 2013; 1:e18] health centres by walking and 15% travelled with their personal vehicles. 93.7% respondents said that services were available when they visited public health facility (table 2). ninety-five percent respondents preferred to take services from public health facility. however, about 7.6% respondents had also visited private health facilities, and 87.3% considered getting immunization at right time was important for their child. as table 3 indicates, interestingly we found that 75% respondents’ children had adverse events following immunization (aefi). however, when asked to enumerate the symptoms most respondents mentioned mild fever, loose motion, crying and sleeplessness. with respect to the amount of time they had to spend to avail the services, 77% mothers waited for less than an hour to immunize their children. when asked as to whether the child was taken for immunization during illness, about 60% mothers responded negatively. on the other hand, more than 60% respondents also mentioned that their children were denied immunization services by providers due to illnesses. among illiterate mothers (n=16), seven children (43.75%) were completely immunized, while amongst mothers having education level ranging from class one to graduation (n=63), 44 children (70%) were fully immunized. on a likert’s five-point scale to rank the importance of immunization services, where 5 meant very important and 1 meant not at all important, we found that behavior of providers, aefi, regular session, distance, health education by auxiliary nurse midwives, waiting time and loss of wages were ranked as most important in descending order (table 4). however, interestingly, more than 90% mothers were satisfied with the services provided at the public health facility. this could be indicative of low-level of expectation among slum-dwellers from public health delivery system and lower level of understanding about quality of services. mothers during in-depth interview cited frequent illnesses (figure 2) of the child, lack of information regarding the immunization schedule, frequent displacement of families for economic reasons, poor importance to the impeding diseases, insufficient family members to take the child to immunization site, service providers not attending even mild illnesses, poor knowledge regarding the benefit of immunization and limited but prominent aefi as the main factors behind late dropouts. an attempt was made to analyze at what stage the children dropped out and did not get all vaccines. the bcg to measles dropout rate was found to be the highest (30%) in our study, followed by dpt3 to measles (27%). thus, in order to achieve universal immunization goals it is important to track all chilarticle table 3. perceived factors of immunization coverage. attributes frequency n % aefi yes 60 75.9 no 16 20.3 cannot say 1 1.3 no response 2 2.5 time taken for the child to get immunized (h) <1 61 77.2 1-2 15 19.0 no response 3 3.8 had you ever taken your child for immunization when he/she was not well (sick)? yes 31 39.2 no 47 59.5 no response 1 1.3 did your child receive immunization during that illness episode* (n=31)? yes 12 38.7 no 19 61.3 aefi, adverse events following immunization. *only for those respondents who had answered yes to the previous question. table 4. ranking of factors for quality immunization services. attributes scores* mean score 5 4 3 2 1 behavior of providers 36 40 1 0 0 4.45 adverse effects of immunization 12 59 4 0 0 4.10 regular outreach sessions 13 58 5 0 1 4.06 distance of session site 2 67 4 1 1 4.04 health education by health worker 6 66 4 0 1 3.98 availability of vaccines all the time 9 47 21 0 0 3.88 waiting time 5 45 7 19 0 3.47 health education by doctor 3 14 56 1 0 3.28 loss of daily wages 4 6 10 51 5 2.38 *5, very important; 4, important; 3, cannot say; 2, not important; 1, not at all important. figure 2. reasons behind partial or non-immunization (multiple responses were allowed; values are expressed as percentage). non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e18] [page 65] dren on regular basis. the study also revealed that about 2.5% children did not receive even a single antigen and were completely left out of the uip. comparable figure as reported by coverage evaluation survey (ces) 2009 reported it at 5.2%. we cross-analyzed immunization status with level of education of mothers, and found that though there was no linear association between these two, the coverage of immunization varied according to the educational status of the mother. discussion rapid urbanization also is accompanied by proportionate growth of urban slums.12 studies of early 20th century mainly focused on exploring the link between poverty and ill health.13-15 subsequent studies found poor environmental conditions and high population density in urban areas act as precipitating factors behind frequent outbreaks of vpds. despite the supposed proximity of the urban poor to health facilities, their access to healthcare is significantly curtailed. this is on account of inadequate public health delivery system, ineffective outreach and weak referral system. the social exclusion and lack of information and assistance at the secondary and tertiary hospitals makes slum dwellers unfamiliar to the modern environment of hospitals and restricts their access. on the other hand, limited purchasing power deters them from accessing private facilities. lack of benchmark for the health delivery system, when contrasted with the rural network, makes the urban poor even more vulnerable and worse off than his rural counterpart.16-18 demographic projections indicate by 2021 the urban population of the country will increase to 432 million and of slum population to more than 85 million.19,20 undoubtedly, it will exert tiresome strain on the health infrastructure, especially of larger towns and cities that already have serious deficiencies. lack of preparation to foresee this will limit the options to town planners, public health departments and policy makers, then. until late 1990s the urban health centers were grossly inadequate with only one uhp per 145,854 population.21 though the india population project-viii (ipp-viii, 1993 to 2002) created and upgraded more than one thousand facilities in karnataka, delhi, west bengal and andhra pradesh,22 it did not include smaller cities and towns across the country. secondly, there is complete disproportionate staffing for areas against the growth.23 and low staff motivation owing to lack of supportive supervision, poor transport facilities often result in weak outreach.24 the relatively new indian public health standards has recommended minimum standards for facilities at various levels, but compliance is far from satisfactory. various reasons may explain the lower levels of full immunization coverage in urban slums in india. there are several challenges that are unique to areas, such as, rapid population growth particularly in slum populations, array of types of service providers in both private and public sectors, over-crowding, poor environmental conditions and deterioration of family fabrics. these would need creative strategies to reach the marginal sub-populations.25-27 studies in nigeria, india and pakistan indentified factors, such as lack of confidence of health workers in administering vaccines, irregular supply of vaccines, unwillingness of health workers to open vaccine vials until many clients appear at the immunization site, and long interval between sessions as the main reasons for low immunization coverage in urban areas and slum areas.28-33 some of these studies also revealed the extent of missed opportunities for vaccination in the slum settlements.31,33 the national complete immunization estimation is 62.5% for urban areas and 50% for rural areas. the immunization coverage in odisha among 12-24 months aged group children is estimated at 94.2, 73.9, 78.6 and 81% for bcg, dpt3, opv3 and measles, respectively, while complete/full immunization is estimated at 62.3 against 54% for india district level household and facility survey-3 (dlhs3). there is no national level or state-specific survey data to assess the urban-rural divide or within urban areas, slum-non-slum divide. our study found complete immunization at 64.6% in the slum area of cuttack. furthermore, antigen-wise coverage for bcg (96.2%), dpt3 (92.4%), opv3 (92.4%) and measles (65.8%) reflects high instances of late dropouts. our findings on early and late drop-outs are similar to other studies conducted.27-29 the higher coverage of dpt3 and opv3 could be mainly due to the recent improvement in immunization strategy during 2007-2012 which focused on micro-planning, capacity building, community mobilization and incentivized supervision. however the low coverage of measles vaccine continues to pose serious challenges to the national immunization goals which must be remedied urgently.33 other studies have shown that maternal education, attendance for antenatal and postnatal care, and parity are associated with full vaccination among children.34 in rural areas, efficient tracking mechanisms are being followed mainly because of existence of a definite health care delivery system and availability of trained and devoted female health workers. the addition of a volunteering cadre named accredited social health activists into the health system under national rural health mission has given the impetus to immunization programme for rural residents. on the contrary, for urban areas, particularly for slum dwellers, there are no link workers to track the partially immunized or unimmunized children. co-ordination among the multitude of providers, timely and regular outreach, effective monitoring and quality services are critical for improving utilization of immunization services in urban set-ups which have the inherent characteristic of heterogeneity. the concept of urban advantage seemingly has lost its significance for the poor. the who puts it thus: whenever and wherever infrastructure and services are lacking, urban settlements are amongst the world’s most life threatening environments.35 disintegration of social fabric in urban areas in general and urban slums in particular has led to erosion of confidence and interpersonal communication among slum dwellers.36 from demand side, it is already well established that working mothers do not get adequate family support to attend to child’s health needs, as they remain engaged in earning livelihood. from supply side, improper microplanning, underestimated indenting and consequent insufficient supply of vaccines continue to pose challenges to quality immunization for slum areas.37,38 furthermore, the harm caused by poor injection safety and waste disposal outweighs the benefits of vaccination.39,40 some recommendations on how to bridge the gap between the community and the urban health care delivery system are here provided: i) strengthen the health system: a separate cadre of health functionaries may be created for urban areas, focusing on urban slums. the initiatives under national urban health mission may be expedited to cover the high risk urban pockets on top priority. unique tracking system can and should be developed to address the issue of frequent displacement of families. ii) develop local ownership: renewed interest should be developed both in local health functionaries and beneficiaries to accelerate the optimization of immunization services. the role of local municipality may be clearly defined to address the multi-factorial causes of non-immunization or partial immunization. iii) expand the basket of services: the basket of immunization services may be broadened, such as, family planning counselling, iron, folic acid and vitamin-a supplementation, and provision of iodized salt, to attract and retain parents’ attention during the contact period between dpt3 and measles vaccinations. it could also improve the health status of both the mother and the child under life cycle approach. iv) revisit the urban immunization strategy: the reproductive and child health (rch) program for immunization should revise its strategy and focus on bottlenecks by reducing the late dropout and improving coverage of measles. improvement of interpersonal communication with the community would article non -co mmerc ial us e o nly [page 66] [healthcare in low-resource settings 2013; 1:e18] increase awareness about sessions and ensure their involvement in service provision for its long-term sustenance. improved vigilance at session site and supportive supervision by higher officials could improve the level of motivation of service providers. all missed opportunities must be overcome with adequate training, periodic sensitization and regular review. it is high time that we create a dedicated work force for urban areas. slum volunteering scheme (svs) or urban social health activist (usha) may be introduced on priority which would provide the much needed connection in the chain of events for successful immunization of all children. v) capitalize on the opportunities: municipality health department, civil society organizations, icds workers and panchyat raj institution (pri) members have critical roles to play in counselling, mobilizing, monitoring and linkage establishing activities, respectively. slum dwellers and health provider linkage must also be strengthened. a multistakeholder co-ordination approach may be adopted as had been done successfully in early 1990s (universal immunization campaign in kolkata).41 vi) generate more evidence: urban slums are high risk areas leading to high rate of disease transmission.42,43 maternal and child health indicators among slum people show that their health is two to three times worse than non-slum areas. thus, further studies focusing on the effect of on-site corrective measures and mobilization strategies may be undertaken on time-bound manner. conclusions improve access to and utilization of immunization services is low in the urban slums owing to its unique inherent characteristics of urban slums, such as, floating population, overcrowding, poor sanitation and personal hygiene. urban slums do have more morbidity withholding vaccinations by paramedics; there were also many instances of non-immunization of children because there was no one in the family to take the child to the health centre for vaccination. the traditional temporary migration of pregnant women for delivery, and the consequent non-availability of their records, results in missing out on services at either of the residences. this highlights the need and importance of ensuring immunization for all vulnerable poor. these findings could be helpful to the people in charge of immunization at local level. anganwadi workers are responsible for identifying and tracking all eligible children for immunization along with the female health workers. thus, co-ordination between the icds under the department of women and child development and the department of health and family welfare at all levels will be crucial in bridging the gap between the community and the urban health care delivery system. the national uip goals pose stiff challenges and require to address weak primary health infrastructure, hidden urban poor population, poor social access, inadequate demand for services, week monitoring and policy revision issues. needless to say then, that there is an urgent need for formulating and implementing a comprehensive urban health policy, focusing on immunization services. if health in all policies is the destination, healthy public policy could be a good beginning. references 1. anderson rm. the concept of herd immunity and the design of immunity-based immunization programmes. vaccine 1992;10:928-35. 2. who. global immunization data. geneva: world health organization ed.; 2008. available from: www.who.int/immunization/newsroom/global_immunization_dat a.pdf 3. government of india. national commission on population. national population policy. new delhi: government of india ed.; 2000. 4. banthia j. final population totals, agglomerations and towns. new delhi: census of india ed.; 2001. 5. ehp-usaid. standard of living index based reanalysis of national family health survey (nfhs-2), india and state reports 1998-1999, international institute for population sciences (iips) and orcmacro (2001). mumbai: ehp-usaid ed.; 2003. 6. government of india. coverage evaluation survey 2009. new delhi: government of india, ministry of health and family welfare ed.; 2009. 7. who/unicef. review of national immunization coverage 1980-2002 (india). new delhi: who/unicef; 2003. 8. government of odisha. the orissa gazette. available from: http://orissa. gov.in/govtpress/pdf/2011/442.pdf 9. government of india. national family health survey, india. new delhi: government of india, international institute of population sciences ed.; 2007. available from: http://www.rchiips.org/ nfhs/chapters.shtml 10. cuttack municipal corporation. available from: http://www.cmccuttack.gov.in/ (s(h0gr0mb5yizl2feoe0ttgs3l))/vision.htm l 11. government of odisha. records of icds, office of district social welfare officer, cuttack. bhubaneswar: government of odisha, department of women and child development, ed.; 2012. 12. madhiwalla n. healthcare in urban slums in india. natl med j india 2007;20:113-4. 13. chandavarkar r. the origins of industrial capitalism in india. business strategies and the working class in bombay, 19001940. cambridge: cambridge university press; 1994. 14. jhirad j. report on an investigation into the causes of maternal mortality in the city of bombay. new delhi: government of india press; 1941. 15. women’s medical service organization. summary of the findings of investigations into the causes of maternal mortality in india. new delhi, women’s medical service organization ed.; 1947. 16. agarwal s, bhanot a, goindi g. understanding and addressing childhood immunization coverage in urban slums. indian pediatr 2005;42:653-63. 17. lodha r, dash n, kapil a, kabra s. diphtheria in urban slums in north india. lancet 2000;355:204. 18. loening w, coovadia h. age specific occurrence rates of measles in peri-urban, and rural environment: implications for time of vaccination. lancet 1983;2:324-6. 19. government of india. provisional population tables. registrar general and census commissioner. new delhi: ministry of home affairs, government of india ed.; 2011. 20. government of india. report of the committee on slum statistics/census 2010. new delhi: ministry of housing and urban poverty allevation, government of india ed.; 2010. available from: http://mhupa.gov.in/w_new/slum_report_ nbo.pdf 21. government of india. annual report on special schemes, 1999-2000. new delhi: government of india, ministry of health and family welfare ed.; 2000. 22. institute for research in medical statistics. india population project-viii. end-line survey, 2003. new delhi: institute for research in medical statistics ed.; 2003. 23. lal s, vashisht bm. innovative approaches to universalize immunization in rural areas. indian j community med 2003;28: 51-6. 24. darshana v, ramesh k. immunization promotion in ahmedabad. paper presented at the health consultation organized by environment health project and ministry of health and family welfare, 2003 june 30-july 1, bangalore, india. new delhi: ministry of health and family welfare, government of india ed.; 2003. 25. atkinson sj, cheyne j. immunization in article non -co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e18] [page 67] urban areas: issues and strategies. b world health organ 1994,72:183-94. 26. mutua mk, kimani-murage e, ettarh rr. childhood vaccination in informal urban settlements in nairobi, kenya: who gets vaccinated? bmc public health 2011;11:6. 27. sharma r, desai vk, kavishvar a. assessment of immunization status in the urban slums of surat by 15 clusters multi indicators cluster survey technique. indian j community med 2009;34:152-5. 28. odusanya o, alufohai e, meurice f, ahonkhai v. determinants of vaccination coverage in rural nigeria. bmc pubic health 2008;8:381. 29. chhabra p, nair p, gupta a, et al. immunization in urbanized villages of delhi. indian j pediatr 2007;74:131-4. 30. torun s, bakirci n. vaccination coverage and reasons for non-vaccination in a district of istanbul. bmc public health 2006;6:125. 31. agarwal s, bhanot a, goindi g. understanding and addressing childhood immunization coverage in urban slums. indian pediatr 2005;42:653-63. 32. odiit a, amuge b. comparison of vaccination status of children born in health units of those born at home. e afr med j 2003;80:3-6. 33. nath b, singh j, awasthi s, et al. a study on determinants of immunization coverage among 12-23 months old children in urban slums of lucknow district, india. indian j med sci 2007;61:598-606. 34. rahman m, obaida-nasrin s. factors affecting acceptance of complete immunization coverage of children under five years in rural bangladesh. salud publica mex 2010;52:134-40. 35. satterthwaite d. the earthscan reader on sustainable cities. london: earthscan publ.; 1999. 36. egolf b, lasker j, wolf s, potvin l. the roseto effect: a 50-year comparison of mortality rates. am j public health 1992;82:1089-109. 37. kaur m, reddaiah v, kant s. primary immunization status of children in slum areas of south delhi: the challenge of reaching the urban poor. indian j community med 2001;26:151-4. 38. hutchins s, jansen h, robertson s, et al. studies of missed opportunities for immunization in developing and industrialized countries. b world health organ 1993;71:549-60. 39. brown p. india: an environmentally sustainable solution in a crowded country. geneva: gavi ed.; 2002. 40. hunt c. child waste pickers in india: the occupation and its health risks. environ urban 1996;8:111-8. 41. chaudhuri er. universal immunization in urban areas: calcutta's success story. indian j public health 1990;34:227-34. 42. government of india. draft final report of the task force to advise the national rural health mission on “strategies for health care”. new delhi: ministry of health and family welfare, government of india ed.; 2006. 43. government of india. guidelines for developing city level health projects. new delhi: ministry of health and family welfare, government of india ed.; 2004. article non -co mmerc ial us e o nly hrev_master [page 14] [healthcare in low-resource settings 2018; 6:7106] awareness and reporting of notifiable diseases among private laboratory scientists in lagos, southwest nigeria magbagbeola d. dairo,1,2 salewa leye-adebayo,1 abimbola f. olatule1 1department of epidemiology & medical statistics, faculty of public health, college of medicine, university of ibadan; 2nigeria field epidemiology and laboratory training programme, abuja, nigeria abstract the availability of accurate, up-to-date, reliable and relevant health information on disease notification by medical laboratory practitioners is essential to detecting and responding to epidemic outbreaks. however, information on notification practices of private laboratory scientists are not well documented. this study was conducted to assess the level of awareness and knowledge of integrated diseases surveillance and response (idsr), as well as its practice by private laboratory scientists in lagos state, nigeria. in a cross-sectional study, 190 respondents from 14 chapters of the association of medical laboratory scientists in lagos state were interviewed using a pretested self-administered semistructured questionnaire to collect information on socio-demographic characteristics, awareness of idsr and its policy, knowledge of notifiable diseases, practice of idsr and constraints to reporting notifiable diseases. data was analyzed using descriptive statistics, chi-square test and logistic regression at p = 0.05. the mean age of the respondents was 34.0 years with a standard deviation (sd) of ±8.5 years and 65.3% were males. half (50.0%) of them have ≤5 years of working experience with a mean of 7.5±5.8 years. about 8.9% had ever heard of idsr. about 9.5% had ever seen a disease notification form and 51.1% had good knowledge of idsr guidelines for the country. most (86.3%) had never reported a notifiable disease. lack of knowledge on how to report (56.8%) and inefficiency of the health department (44.7%) were the major reasons given for not reporting. a significant predictor of disease notification was awareness of idsr (or= 5.7, ci=1.9-16.7). private medical laboratory practitioner’s awareness and practice of disease notification is poor. a range of interventions including awareness campaign, idsr training, feedback and logistic support for reporting is recommended to improve reporting practices by private medical laboratory scientists. introduction disease surveillance, notification and reporting have been defined as effective strategies in the scrutiny of the occurrence of diseases and health related events to enable intervention for the prevention and control of diseases.1 effective communicable disease control relies on effective response systems, which in turn depend on effective disease surveillance.2 in developing countries, notifiable diseases surveillance systems rely on mandatory reporting of cases by physicians and laboratories. in sub-saharan africa, infectious diseases remain the most common cause of morbidity, hence, the need for surveillance and control.3 in nigeria, all 36 states in the federation, including the federal capital territory are currently implementing idsr.4 this system seeks to ensure that effective and functional systems are available at each level of the health system, from health facilities to local government areas (lgas), states and on to the national level. idsr focuses on the lga level where information is generated to other levels.5 in nigeria, the current status of disease surveillance system is deplorable, characterized by a lack of intra and inter-sectorial collaboration. this leads to verticalization of programs and multiplicity of disease reporting formats and as a result compromises efficiency and quality of data6. integrated disease surveillance and response (idsr) is part of national health management information system (hmis) in nigeria and was adopted to tackle the problem of multiplicity and duplicity of reporting formats in the country. however, one of the challenges encountered in the implementation of the idsr programme is the issue of reporting which is often incomplete and untimely, a problem traceable to the level of awareness, knowledge and practice of personnel towards the programme.6 a laboratory network is an important component of a disease surveillance system; it serves as collection points from which samples are transported to regional or national reference laboratories for isolation and identification of pathogens. trained laboratory workers in wellequipped primary level laboratories can carry out simple diagnostic test for many suspected disease conditions and should be required to notify the medical officer of health (moh) of any notifiable disease he/she identifies. private medical laboratory scientists are becoming more important in the delivery of health care in nigeria consequent to the infrastructural challenges occasioned by the downturn in the economy which had led to reduced public sector spending on upgrading laboratory services. the private medical laboratory services provide diagnostic support to both the public sector hospitals and private sector hospitals in nigeria. these laboratory scientists can become an important link in the reporting of diseases and are therefore a key stakeholder in surveillance of diseases in nigeria. engagement of these personnel in reporting and surveillance activities will strengthen the disease control activities in the nation. this study therefore aims to determine the level of awareness of and compliance with idsr policies, and identify barriers against reporting of notifiable diseases among private laboratory scientists in lagos, an urban metropolis south west, nigeria. healthcare in low-resource settings 2018; volume 6:7106 correspondence: magbagbeola david dairo, department of epidemiology & medical statistics, faculty of public health, college of medicine, university of ibadan, nigeria. e-mail: drdairo@yahoo.com key words: disease surveillance and notification; notifiable diseases; private laboratory scientists. acknowledgements: the authors wish to acknowledge the members of the association of medical laboratory scientists, lagos state and ibadan, for their cooperation on this project. contributions: mdd and ofa designed the study; ofa collected the data and did the analysis. mdd and sla wrote the draft manuscript. all authors approved of the final manuscript before submission. conflict of interest: the authors declare no potential conflict of interest. received for publication: 29 september 2017. revision received: 27 february 2018. accepted for publication: 29 june 2018. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.d. dairo et al., 2018 licensee pagepress, italy healthcare in low-resource settings 2018; 6:7106 doi:10.4081/hls.2018.7106 non -co mmerc ial us e o nly materials and methods study setting and study population the study site was lagos state, nigeria. the state is divided into administrative divisions called lgas. one lga is an equivalent of a county. the 2006 national population census of nigeria credited the metropolitan area with a population of 9, 019, 534. with a population projection at growth rate 3.2%, the population now approaches 17 million inhabitants, which is almost one tenth of the population of nigeria.7 study population comprised medical laboratory scientists working in private medical facilities in the state. there are 22 chapters of the association of medical laboratory scientists (amlsn) in the state, of which 14 are chapters of medical laboratory scientists working within private health facilities at the lga level. study design the study was a descriptive cross sectional study. the sample size of 190 was obtained using the formula for the estimation of single proportion (n = z2 pq/d2) in which p is the proportion of health workers reporting notifiable diseases in benin city, edo state, nigeria.8 the percentage point of the normal distribution z is a constant set at a value 1.96 for 95% confidence interval, while q is (1-p) and d, the precision estimate is set at a value of 0.05. the sample size calculated was adjusted for 10% non-response rate. a systematic sampling technique was used to select 190 respondents out of the total 710 laboratory scientists in all the chapters, using a sampling interval of 4, derived by dividing the total population of the laboratory scientists by the calculated sample size (nt/ns = 710/ 190). ethical approval to conduct the study was obtained from university of ibadan/university college hospital ethical review committee (imrat) and amlsn lagos state before the commencement of the study. the data collection instrument was survey questionnaire, developed from review of the technical guidelines for idsr in the african region and literature on previous surveys on awareness and knowledge of notifiable diseases and its challenges of disease notification.9-12 the questionnaire contains information such as socio-demographic characteristics; awareness of idsr and its policy; knowledge of notifiable diseases, practices of idsr and challenges of diseases notifications. the semi structured questionnaire consists of both openand closed-ended questions and was pretested among private laboratory scientist in ibadan, oyo state. the self-administered questionnaire was distributed by the principal investigator with the help of two research assistants. the two research assistants were trained on the process of creating rapport with potential respondent and obtaining consent for the study from each participant. the questionnaires were coded for confidentiality and respondents were not required to give their names. in the field, research assistants were required to give a brief introduction of themselves and the survey request respondents to give a written consent assuring them that the survey will in no way be harmful to them. respondents were also informed that ethical approval has been obtained from university of ibadan/imrat and amlsn lagos state. the interview was conducted in an enclosed space for privacy. the interviewers review each questionnaire for missing/incomplete data since they were self-administered by respondents. at the end of each day questionnaires were checked for completed data, feedback on the data collection process was obtained and problems faced were resolved. the knowledge of notifiable diseases was scored based on respondents’ understanding of 61 idsr guidelines on notification of notifiable diseases as done in previous studies.8,12 these includes knowledge of reportable diseases and where to report them, priority diseases for idsr and time frame for reporting diseases. this was adopted from the technical guidelines for idsr in the african region.9 each correct response was awarded one mark. respondents with score >30 were regarded as those with good knowledge of idsr guidelines. data was analyzed using statistical package for social sciences (spss) version 20. descriptive statistics such as frequencies, percentages, chi-square and logistic regression were used. the level of statistical significance in tests of hypothesis was set at a p-value below 0.05. results a total of one hundred and ninety private laboratory scientists were interviewed. about a third [124, 65.3%) were males. the majority [140, 73.7%] were christians and 136, 71.6% were of the yoruba ethnic group. half [95, 50.0%] of them had ≤5 years of working experience (table 1). level of awareness and knowledge of idsr polices among respondents less than one-tenth [17, 8.9%] had ever heard of idsr and 24 (12.6%) are aware of the idsr policies in the country. only 9.5% had ever seen a disease notification form (table 2). about half [97, 51.1%) had good knowledge of idsr guidelines in the country while almost half [93, 48.9%] had poor article table 1. socio-demographic characteristics and years of experience of respondents in lagos. variables frequency n=190 percentage (%) age (years) 20-24 19 10.0 25-29 49 25.8 30-34 41 21.6 35-39 29 15.3 40-44 33 17.4 ≥45 19 10.0 gender male 124 65.3 female 66 34.7 religion christian 140 73.7 islam 50 26.3 tribe yoruba 136 71.6 igbo 42 22.1 hausa 2 1.1 others 10 5.3 years of experience since graduation <5 95 50.0 5-9 34 17.9 10-14 30 15.8 15-19 23 12.1 ≥20 8 4.2 [healthcare in low-resource settings 2018; 6:7106] [page 15] non -co mmerc ial us e o nly knowledge (table 2). a low proportion 6 (3.2%) of them knew that the form 003 is used for monthly reporting of diseases while 8 (4.2%) knew that the idsr form 001 is used for immediate reportable diseases and the 8 (4.2%) knew the idsr 002 is used for weekly reportable diseases. prevalence of ever reported notifiable diseases among private laboratory scientists about 13.7% of the respondents have ever reported a notifiable disease while 86.3% never reported a notifiable disease. about one third [31.1%] report to the local government health office, which is the ideal section to report cases (table 3). about three quarters of out of the 13.7% have ever reported a disease using only forms. about one third of the 13.7% reported the diseases to the local government health office, which is the ideal place while almost half [46.2%] reported diseases to the epidemiological unit of the state ministry of health directly (table 3). in the bivariate analysis, majority of those that have never heard of idsr have never reported a diseases compared to those that have heard of it [89% versus 58.8%, p=0.001]. also more of those that are not aware of idsr policy in the country have never reported a disease compared to those aware [88.6% versus 70.8%, p=0.018]. more of those that have not seen the disease notification form before have never reported a disease compared to those that have seen it before [93.0% versus 22.0%, p=<0.001] (table 4). logistic regression associations between ever report a notification disease and awareness of idsr the significant predictors of reporting a notifiable disease among the respondents were awareness of idsr and its policy, and seeing the notification forms. those that have heard of idsr were almost 6 times more likely to report a notifiable disease compared to those that have not ever heard (or= 5.7, 95% ci= 1.9-16.7). those that were not aware of idsr policy were about 3 times more likely not to report a notifiable disease compared to those that were aware (or= 3.2, 95% ci= 1.2 -8.7). those that have not seen a notification form before were more likely not to report a disease compared to those that have seen it before (or= 46.7, 95% ci= 13.3 – 164.0) (table 5). reasons for not reporting diseases among respondents in lagos reasons the respondents gave for not reporting the notifiable diseases include: not knowing how to report a disease [56.8%], inefficiency of the local government area health department [44.7%], lack of feedback i.e. reporting may not make a difference [30%] (figure 1). discussion less than one-tenth of the respondents in this study have ever seen diseases notification forms and significant proportion of them that had never sighted these forms were more likely not to have reported a notifiable disease compared to those that have sighted them. the low level of awareness in this study is comparable to the report by oyegbile in southwest nigeria13. it differs from the findings of a study in northern nigeria, which revealed that a higher proportion (38.2%) of health-care personnel studied were aware of the disease surveillance and notification system in nigeria (dsn) system and that in the eastern nigeria in which most (89.8%) of the respondents were aware of the existence of the dsn system.11,12 the findings of this study conform to those of other studies, which showed persisting poor awareness of health-care personnel on the system of reporting of infectious diseases and notifiable conditions.8,11,12 in this study, although the awareness of the dsn policies was generally low, knowledge of the dsn system was significantly high among those who were aware of the idsr policies. about half of the respondents were knowledgeable about the dsn system in the country. however detailed knowledge about the reporting forms was poor. for instance, on the knowledge of the respondents about the respective forms; only 4.2% each knew the form 001 and 002 are used for immediate and weekly reporting of diseases while 3.2% of them knew form 003 used for monthly reporting. in a different report in anambra state, more than a quarter of health-care personnel in the state were aware of the idsr form 001, 002 article table 2. respondent’s awareness of idsr, notification forms and where to report notifiable diseases in the country. variables frequency n=190 percentage (%) ever heard of idrs before yes 17 8.9 no 173 91.1 awareness of idsr policy in the country yes 24 12.6 no 166 87.4 ever seen a diseases notification forms before yes 18 9.5 no 172 90.5 where to report diseases lg health office is an ideal section to report diseases 59 31.1 state ministry of health (epidemiological unit) 64 33.7 federal ministry of health (epidemiological unit) 61 32.1 don’t know 6 3.2 respondents category of idsr knowledge good 93 48.9 poor 97 51.1 table 3. practice of reporting diseases according to the idsr among respondents in lagos. variables frequency n=190 percentage (%) ever reported a notifiable disease yes 26 13.7 no 164 86.3 how do you report the diseases (n=26) phone only 3 11.5 forms only 20 76.9 phone, forms and electronically 3 11.5 where do you report to (n=26) local government health office 9 34.6 state ministry of health (epidemiological unit) 12 46.2 federal ministry of health (epidemiological unit) 5 19.2 [page 16] [healthcare in low-resource settings 2018; 6:7106] non -co mmerc ial us e o nly [healthcare in low-resource settings 2018; 6:7106] [page 17] and 003 for immediate/case-based reporting, weekly notification of epidemic-prone diseases and monthly notification of diseases of public health-care importance.11 this underscores the need of intervention to improve awareness and knowledge among the health personnel. the major reasons given by the respondents for not reporting notifiable diseases are lack of knowledge of how to report, inefficiency of the health department and for those who had reported before, lack of feedback on diseases they have reported. similar to this study, previous authors have reported lack of knowledge of how or to whom to report and inadequate feedback as common reasons for not reporting notifiable disease.12-14 feedback had been reported as a major component of a surveillance system.15 studies showed that 33% and 40% of health-care workers at primary health care in nigeria and germany respectively received feedback on their surveillance data.11,16 in our study these observations reflect a lack of emphasis by public health departments and health authorities on surveillance support activities. this lack of article table 4. associations between awareness, knowledge of idsr and ever reported a diseases. variables ever reported a disease (n%) total chi-square p-value yes no ever heard of idsr yes 7 (41.2) 10 (58.8) 17 12.0 0.001 no 19 (11.0) 154 (89.0) 173 aware of idsr policy yes 7 (29.2) 17 (70.8) 24 5.6 0.018 no 19 (11.4) 147 (88.6) 166 ever seen the diseases notification form yes 14 (77.8) 4 (22.2) 18 69.2 <0.001 no 12 (7.0) 160 (93.0) 172 knowledge of idsr good 14 (14.4) 83 (85.6) 97 0.1 0.760 poor 12 (12.9) 81 (87.1) 93 where did you report to lg health office 9 (100.0) 0 (0.0) 9 4.3 0.113 smh epidemiological unit 12 (100.0) 0 (0.0) 12 fmoh epidemiological unit 4 (80.0) 1 (20.0) 5 figure 1. reasons for not reporting a disease among the respondents in lagos. table 5. logistic regression relationship between ever report a notifiable disease and awareness of idsr. 95% confidence interval variables odd ratio lower upper p-value ever heard of idsr no 5.7 1.9 16.7 0.002 *yes aware of idsr policy no 3.2 1.2 8.7 0.023 *yes ever seen a notification form before no 46.7 13.3 164.0 <0.001 *yes *reference group; variables significant at p<0.2 on the bivariate analysis was included in the model. non -co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2018; 6:7106] emphasis might arise from a mistaken perception that such activities are not vital for a successful surveillance programme, or from a lack of adequate resources, human and otherwise, at the central level. conclusions the level of knowledge of the idsr was average and the prevalence of those that had ever reported a notifiable disease was low which might had resulted to low rate of reporting for some of the notifiable diseases encountered by the respondents. ignorance of reporting requirements and absence of feedback are identified as factors militating against efficient reporting among private medical laboratory service providers. recommendation regular information, education and communication programs concerning the idsr programme and its importance to the public, is recommended for health-care facility workers generally but particularly for the laboratory scientists. for data collection to be effective, the forms for reporting of disease should be readily available. furthermore, there should be regular provision of copies of the standard case definitions guides, transportation, as well as other necessary logistics to the health care facility by the local and state governments. laboratory staff particularly those in gateway cities needs to be conscious of the surveillance guidelines and comply with its provisions to prevent importation of exotic diseases. thus regular training of laboratory staff on idsr is necessary and beneficial to public health service in the state. however, beyond awareness of surveillance guidelines, strengthening laboratory capacity to provide services for identification and confirmation of microbial agents has become imperative. laboratories are required to aid diagnosis, differentiate between similar syndromes and illnesses and therefore ensure the accuracy of diagnosis. early diagnosis of the infectious agent responsible for an outbreak could aid speedy intervention in epidemic conditions. public health laboratory capacity thus needs to be strengthened to respond to outbreak of diseases and provide strong support to its control throughout the federation. while reference laboratories are often established to provide confirmatory services for cases of diseases from different parts of the nation strong peripheral laboratories will ensure that common microbial agents often implicated in outbreaks are rapidly isolated and thus preventive services commenced to mitigate the impact of an outbreak. references 1. dairo md, bamidele jo, adebimpe wo. disease surveillance and reporting in two southwestern states in nigeria: logistic challenges and prospects. jphe 2010;2:125-9. 2. abubakar aa, sambo mn, idris sh, et al. assessment of integrated disease surveillance and response strategy implementation in selected local government areas of kaduna state. ann nigeria med 2013;7:14-9. 3. adefuye bo, dairo md, adedokun bo. knowledge, attitude and practice of infectious disease surveillance/notification among doctors in a tertiary institution in sagamu, nigeria. am j respir crit care 2009;179:1a519710.1164. 4. federal ministry of health. national policy on integrated disease surveillance and response. idsr policy 2014:1-7. 5. world health organization. guide for the use of core idsr indicators in the african region. world health organization; 2005. pp 8-10. 6. world health organization. world health organization afro region. afr/rc 48/r2. integrated disease surveillance in the african region: a regional strategy for communicable diseases 1999-2003. who/afro; 2014; available from: http://www.google.com.disease surveillance accessed: 2014 october 25. 7. national population commission: nigeria population census; 2006. 8. ofili an, ugwu en, ziregbe a, et al. knowledge of disease notification among doctors in government hospitals in benin city, edo state, nigeria. public health 2003;117:214–7. 9. world health organization. who report on global surveillance of epidemic-prone infectious diseases– introduction; 2014. available from: http://www.who.int/csr/resources/publications/ introduction/en/index4.html. accessed: november 18, 2014. 10. tan h, yeh c, chang h, et al. private doctors' practices, knowledge, and attitude to reporting of communicable diseases: a national survey in taiwan. biomed central infect dis 2009;9:1-8. 11. nnebue cc, onwasigwe cn, adogu po, et al. awareness and knowledge of disease surveillance and notification by health-care workers and availability of facility records in anambra state, nigeria. niger med j 2012;53:220–5. 12. bawa sb, olumide ea, umar us. the knowledge, attitude and practices of reporting of notifiable diseases among health workers in yobe state, nigeria. afr j med sci 2003;32:49–53. 13. oyegbile ks. health data in nigeria; review of existing situation, form and format. abuja, nigeria: proceedings of the conference on national health management information system; 1992. pp 42-44. 14. harvey i. infectious disease notification – a neglected legal requirement. health trends 1991;23:73-4. 15. nazzal za, said h, horeesh na, alattal s. measles surveillance in qatar, 2008: physicians’ knowledge and practices and support received. east mediterr health j 2011;17:818-24. 16. krause g, ropers g, stark k. notifiable disease surveillance and practicing physicians. centre dis control emerg infect dis 2005;11:442– 5. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:1839] [page 9] did capitation payment reform make a difference in chinese rural primary health care? jing sun,1 jun kang,2 qian qu,3 weibin zhang,3 yongqian tan,4 wenxian xiang4 1national institute of hospital administration, national health and family planning commission, beijing; 2chongqing medical university, chongqing; 3chongqing health bureau, chongqing; 4qianjiang health bureau, qianjiang, china abstract this paper evaluated the effect of capitation payment reform in new rural cooperative medical scheme designating primary facilities in qianjiang 2007-2009. retrospective administrative claims were analyzed. intercepts changes of cost per visit in facilities started the reform in different stages and of overall qianjiang were compared. referral rate, prescribing indicators, hospitalization rate, income of facility and individuals were compared preand postthe reform. growth rate of cost per visit in health centers was contained in 2008, kept unchanged in 2009. cost containment effect on village clinics was observed in each starting stage of reforms, but vanished later on. except for the fact the proportion of essential medicines used in health centers significantly increased (c2 test, p<0.05), prescription indicators were not improved significantly in all facilities. after a slight increase in 2007, the hospitalization rate continuously dropped. the monthly income and outpatient revenue continuously increased in 2006-2009. cost containment objective of the capitation reform was achieved immediately following the reform, but was not sustainable. provider behaviors were partially improved with limited effects on prescriptions behaviors. the reform brought no financial loss to both the facilities and individuals. introduction new rural cooperative medical scheme (nrcms) has been providing basic health security for rural residents in china since 2003. the longtime constrained medical needs of farmers have been thus greatly alleviated.1 efforts have been made to improve benefit package, which include covering outpatient services in addition to inpatient services, and reducing co-payment of enrollees. there has been an increasing cost containment pressure on the local governments.2 fee for service (ffs) is the key payment method of nrcms. intermixed with other complicated factors, ffs has been creating perverse incentives in chinese health system, driving the preference of expensive medicines and over prescribing, and intensifying the surging medical costs.3,4 there has been a consensus in qianjiang that, the nrcms should shift its payment to designated facilities from resource exhausted ffs to pre-paid method. the capitation payment reform in qianjiang expected to remove the perverse incentives for expensive medicines and over prescribing, thereby to rationalize provider behavior, and to contain the surging medical cost.5 the reform in qianjiang targeted nrcms designated outpatient services of health centers and village clinics, started in july 2007 in 2 village clinics. another 49 village clinics followed in january 2008. all other village clinics and 4 health centers joint in october 2008. by january 2009, all health centers and village clinics fully implemented the reform. annual payment limits were calculated for health centers and village clinics respectively. the limits were calculated based on a set of comprehensive indicators, which included number of population covered and density, scale and equipment of facilities, annual number of outpatient visit, total cost per visit, reimbursement ratio, coefficient to adjust the geographic differences, administrative cost, and satisfaction of enrollees. former reimbursement and inflation factors were considered. in parallel with the capitation payment reform since 2007, maximum expenditure per prescription was set and adjusted for each year, referral and hospitalization criteria were clearly defined and circulated to all nrcms designated facilities in qianjiang.5,6 a comprehensive performance assessment system was established to conduct quarterly and year-end evaluations on each individual facility. irregular and spot checks were also organized to examine every aspect of performance, including management (weighted 31%), quality of care (weighted 63%), and patients’ satisfaction (weighted 6%). payment was made monthly with 80% of the budgeted expenditure and settled with the other 20% at the year end. the final 20% payment could be the full or 20% cut down, based on the results of various assessment results during the year, and was kept within the budget expenditure. there was no compensation to the overruns, and balance could be kept by individual facilities.6 this study evaluated whether the capitation payment reform helped in achieving the primary objectives of cost containment, and provider behavior rationalization (reduction of antibiotics, steroids and infusions). the study also assessed if such a payment reform induced higher referral and hospitalization rates. considering that the payment reform might affect the interests of primary health workers, the study also explored if it resulted the facilities and health workers to lose income. materials and methods to measure the effect of the reforms piloted in 4 phases, we targeted all 2 village clinics which piloted the reform in phase i, and sampled a number of village clinics and health centers from the facilities which piloted the reforms in phase ii and iii respectively.7 considering that only a very limited number (4) of health centers out of the total 30 piloted the reform in advance of others in phase iii, we healthcare in low-resource settings 2014; volume 2:1839 correspondence: jing sun, national institute of hospital administration, national health and family planning commission, 38 xueyuan road, haidian district, 100191 beijing, china. tel. +86.10.62026607 fax: +86.10.82311837. e-mail: sunjingx@yahoo.com key words: payment, physician’s behavior, cost containment. acknowledgements: this work was supported by the world health organization [11.001.wp01.chn01,11.5]. we thank the qianjiang district health bureau for its support to the field survey and data collection. we also thank chongqing health bureau for sharing necessary nrcms data, providing strong support for the implementation of the study, and allowing us to publish relevant data of qianjiang. contributions: js and jk were the key designers of the study: jk led the data collection and preliminary analysis, js provided input into the data analysis and interpretation, wrote the first draft of the manuscript, and made critical revisions of the manuscript. qq and wz coordinated the data collection. yt and wx contributed to the data collection, analysis and interpretation. conflict of interests: the authors declare no potential conflict of interests. funding: the paper was supported by a world health organization grant: 11.001.wp01. chn01,11.5. received for publication: 25 july 2013. revision received: 15 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j. sun et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1839 doi:10.4081/hls.2014.1839 non -co mmerc ial us e o nly [page 10] [healthcare in low-resource settings 2014; 2:1839] targeted 3 of 4. the sample size of village clinics was determined to have 10% of 51 village clinics which piloted the reform in phase i and ii. 2 village clinics (locates in different towns) who firstly implement the reform in july 2007 were automatically selected. the corresponding 2 health centers were targeted accordingly. the other one township/community health center was randomly selected from the other towns which reformed in phase iii. followed the principle of 2 village clinics under each selected township/community health center, and excluded 2 village clinics automatically included, 4 village clinics were randomly selected from the village clinics which reform in phase ii and were under 3 selected health centers. there were a total of 6 village clinics (2 reformed in phase i, 4 reformed in phase ii) and 3 health centers (reformed in phase iii) targeted as sample facilities. the study assessed the effect of the reform by measuring changes of total cost per visit, quality of care and income of facility and individual. these changes of 3 groups of sample facilities were compared before and after the reform, compared with overall qianjiang, and with the maximum expenditure per prescription during 2006-2009 (major components of outpatient service cost are for medicines). prescribing indicators were used to assess the quality of care, included proportion of essential medicines prescribed, and proportion of prescriptions with antibiotics, steroids and infusions. referral rate helped to assess if patient selection occurred. hospitalization rate reflected if patients were shifted from outpatient to inpatient care. annual average total costs per visit of each group of sample facilities and overall qianjiang were calculated based on the data directly extracted from qianjiang nrcms management database. it was compared before and after the reform during 2006-2009, and compared with overall qianjiang and the maximum expenditure per prescription. health centers and village clinics were compared separately. quality of care and income data was obtained from surveys in sample facilities. under the support of qianjiang health bureau, sample facilities were required to track prescriptions, and reported income and revenue. referral and hospitalization rates were regular data collected annually, which were extracted from the qianjiang nrcms management database. results cost per visit health centers in 2007, no health centers started the reform. the annual average total cost per visit of three sample health centers was cny 16.71, higher than that of overall qianjiang health centers (cny 15.4). both were above the maximum expenditure per prescription (cny 15). reform in health centers started in four centers in october 2008, three months before the end of 2008. the annual average total cost per visit of three sample health centers reached cny 17.6, and the overall qianjaing health centers reached cny 16.85. both got increased, and were under the maximum expenditure per prescription (cny 18). the intercept of three sample health centers was smaller than that of overall health centers 2007-2008: hsample 07-08(0.89)< hoverall 07-08(1.45). assumed that the contribution of any changes of three sample facilities (brought by the reform started in october 2008) to 30 overall facilities in 2008 could be neglected. although reform only implemented three months in 2008, it still gained cost containment effect, as its growth rate got smaller. the other 26 township health centers joint the reform in january 2009. the annual average total cost per visit of three sample health centers (cny19.73) and overall qianjaing health centers (cny19.34) both further increased and faster in 2009, and the latter increased faster than the former. both went below the maximum expenditure per prescription (cny 20). the intercepts of three sample and overall health centers 2008-2009 were: hoverall 08-09=2.45; hsample 08-09=2.13.hoverall 0809>hsample 08-09>hoverall 07-08> hsample 07-08. this implied that: i) cost containment effect of reform in three sample health centers in 2008 did not continue in 2009. the increasing rate of three sample health centers in 2009 was faster than that of overall health centers in 2008; ii) no cost containment effect was observed on the 2nd group of health centers which joint the reform in january 2009, its cost increasing speed was faster than the 1st group (who joined the reform in october 2008) in 2009 (figure 1). village clinics cost per visit of sample village clinics in 2006 was not available. assumed that there was no significant difference between the sample village clinics and the others before the reform, and contribution brought by two sample village clinics to 158 overall village clinics in 2007 could be neglected. the cost per visit of village clinics in 2006 overall qianjiang village clinics (cny 11.56) was regarded as the baseline of the sample village clinics, which represented the 1st group village clinics pioneered the reform in july 2007, and the 2nd group joined the reform in january 2008. the annual average total cost per visit of two sample village clinics (cny 11.29) got a bit lower than that of the overall village clinics (cny 11.35) in 2007. both decreased and were above the maximum expenditure per prescription (cny 10). larger intercept of two sample village clinics 2006-2007 (h2 06-07=-0.27) than that of overall village clinics (hoverall 06-07=-0.21) was observed in the negative part of y-axis, which implied slight cost containment effect of reform in 2007 on two pioneer village clinics. in january 2008, another 49 village clinics jointed the reform. both two (cny 10.75) and four sample village clinics (cny 10.97) got decreased annual average total cost per visit, and both were lower than the maximum expenditure per prescription (cny 12). on the contrary, that of overall village clinics continuously increased to cny 12.34. this indicated cost containment effect in july 2007 continued, and there was also positive cost containment effect on the 2nd group of village clinics which started the reform in january 2008. the intercepts of two and four sample village clinarticle figure 1. annual average total cost per visit of health centers 2007-2009. source: new rural cooperative medical scheme management database of qianjiang health bureau. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1839] [page 11] ics 2007-2008 were: h2 07-08=-0.54, h4 07-08=-0.16. h2 07-08-h2 06-07=h2 06-07<h4 07-08 indicated that, cost containment effect on 1st group village clinics in 2008 kept same as it was in 2007, and was stronger than that on the 2nd group village clinics who started the reform in january 2008. in january 2009, all 158 village clinics fully implemented the reform. the annual average total cost per visit of overall village clinics shifted from upward to downward, and decreased to cny 11.97. on the contrary, that of two and four sample village clinics increased to cny 11.01 and 11.54. this indicated strong cost containment effect of the reform started in january 2009 on the 3rd group of village clinics (figure 2). quality of care during 2007-2009, referral rates of sample health centers ranged between 37.16-36.24%; proportion of essential medicines used in health centers and village clinics increased from 95 and 98 to 100%; proportion of prescriptions with steroids, antibiotics and infusions continuously went down, from 3.58 to 2.59% for steroids, from 24.11 to 16.57% for antibiotics, and from 13.69 to 11.90% for infusions respectively. prescription information of village clinics was not analyzed, due to the absence of data. statistic analysis showed that, these changes between 2007 and 2009 were not significant (c2 test, p>0.05), except that of proportion of essential medicines used in health centers (c2 test, p<0.05) (table 1). prescribing with essential medicines was significantly improved in health centers following the reform, but did not have significant change in village clinics. the other prescription behaviors of health centers did not statistically change as well. these enabled us to conclude that the overall effect of the reform on changing prescription behaviors was not significant. steroids, antibiotics and infusions prescriptions in village clinics were not assessed due to absence of data. there was no significant change of referral rate following the reform, which implied that reform did not bring unexpected effect, like patient selection. when there was only two village clinics piloted the reform, and no health centers started the reform in 2007, hospitalization rate of qianjiang nrcms enrollees increased from 7.1% in 2006 to 7.81% in 2007. following an expansion of reform in 2008 in another 49 village clinics in january 2008 and four health centers in october 2008, hospitalization rate of qianjiang nrcms enrollees dropped to 6.68% in 2008. when all village clinics and health centers joint the reform, hospitalization rate of qianjiang nrcms enrollees further dropped to 3.65% in 2009 (figure 3). income the monthly income of health workers in qianjiang kept growing during 2007-2009, increased from cny 1683 to 2575 in health centers and cny 1220 to 1975 in village clinics. the increasing government subsidies to primary care during this period might contribute to the income growth the most. for example, article figure 2. annual average total cost per visit of village clinics 2006-2009. source: new rural cooperative medical scheme management database of chongqing health bureau. figure 3. hospitalization rate of qianjiang new rural cooperative medical scheme enrollees 2006-2009. source: qianjiang health bureau. table 1. quality of care in sample facilities 2007-2009. source: qianjiang health bureau. 2007 2008 2009 χ2 p referral rate in health centers (%) 37.16 36.45 36.24 0.018 0.8928 essential medicines (%) health centers 95 100 100 7.6017 0.0058 village clinics 98 100 100 3.0101 0.0827 prescriptions with steroids in health centers (%) 3.58 3.19 2.59 0.1616 0.6877 prescriptions with antibiotics in health centers (%) 24.11 19.93 16.57 1.7573 0.185 prescriptions with infusions in health centers (%) 13.69 12.92 11.90 0.1427 0.7056 non -co mmerc ial us e o nly [page 12] [healthcare in low-resource settings 2014; 2:1839] the secured government subsidy to village doctors increased from cny 500 per year in 2007 to cny 1400 per year in 2009. the outpatient revenue of all the sample facilities kept growing during 2007-2009. there were no overruns in all sample facilities in qianjiang (table 2). discussion cost containment owing to the aging population and the strengthened benefict package of the nrcms, like most of the other rural areas in china, total cost per visit in qianjiang has been continuously growing. the capitation payment reform in qianjiang did not decrease the cost, but contained its growth rate, and achieved the maximum expenditure per prescription target. the reform was implemented in four stages, which did have cost containment effect on both village clinics and health centers during the initial period in each stage (two pioneer village clinics which reformed in july 2007, 2nd group of village clinics which started to reform in january 2008, 3rd group of village clinics which started to reform in october 2008, three pioneer health centers started in october 2008, 2nd group of health centers started in january 2009). except 2 pioneer village clinics, which continued the cost containment effect in its second period of reform implementation in 2008, all other facilities were observed with an inconsistent cost containment effect of reform in 2009. such a phenomenon was caused by a shift of nrcms management function from health bureau to the insurance bureau in 2009. management and supervision were slacked in that year. quality of care overall prescription behaviors were observed with no significant changes, except of a significant increase of using essential medicines in health centers. prescription behaviors are complex and are affected by multiple perverse incentives like pricing system and others, single capitation payment reform approach might not be able to make a complete change of it. changing prescription behaviors will need more comprehensive interventions with multiple approaches. unchanged referral rate implied that, under the capitation payment reform, prescribers did not simply reduce services, or select patients with minor illness to avoid comprehensive treatment. the unexpected effects of capitation payment8,9 were successfully averted. comprehensive performance assessment system valued workload and controlled revisit rate for the same symposium within 72 h. a set of specific and comprehensive indicators with considerable weights to secure the quality of care greatly contributed to this success. linking the capitation payment with comprehensive performance assessment system secured the quality of care under cost containment pressure. hospitalization rate a systematic review of hospitalization rate in china10 conducted a merger analysis with the 3rd national health service survey (nhss) data it found that hospitalization rate of rural china was 3.82% before 2008. the 3rd and 4th nhss gave the age-standardized hospitalization rate in rural china in 2003 and 2008,11 which ranged between 3-3.7% for rural areas with high to low annual net income per capita in 2003, and 5.9-7.2% for 2008. 2008 hospitalization rate was almost twice of that in 2003. qianjiang falls into the low income category. comparing the hospitalization rate of qianjiang nrcms enrollees in 2006 (4.06%) with the systematic review data before 2008 (3.82%), we found that they were around the same level. if there were no effective interventions, we assumed that the significant growth of rural hospitalization rate at national level during 2003-2008 should happen in qianjiang during 2006-2009 as well. the increasing trend during 2006-2007 in qianjing was in line with this assumption, when the capitation payment reform was yet implemented in most of the facilities in qianjiang (except two pioneer village clinics). qianjiang was at the national level in 2007 (4.73%), it dropped to 2.87% in 2008, which was far below the rural national level (3.7%, low income category). this implied that, expanded reform in all village clinics and four pioneer health centers in qianjiang between january and october 2008 had a strong effect on reducing hospitalization rate of nrcms enrollees. the following increasing trend had it reached to 4.57% in 2009, which was still below the rural national level (low income category). rebounded hospitalization rate was also in line with the cost changes in 2009, which was due to the same fact that, nrcms management function shifted from health bureau to the insurance bureau in 2009, management and supervision were slacked in that year. to explain a comparatively low hospitalization rate of qianjiang nrcms enrollees, we should not forget that, in parallel with the capitation payment reform, qianjiang developed supporting policies which imposed strict admission standard and strengthened supervision on inpatient services of nrcms designated facilities in 2007. hospitalization criteria were clearly defined and circulated to all nrcms designated facilities. these were important contributors for controlling unnecessary hospitalizations under the outpatient capitation payment reform in qianjiang. income the no overruns result and the continuously increased staff salary of health centers and village clinics in qianjiang showed that, maximum expenditure per prescription, insurance payment budget limit, and relevant supporting policies in inpatient services in qianjiang secured a steady implementation of the capitation payment reform, and had no negative impact on the operation of the facilities and the income of the health workers. conclusions cost containment objective of the capitation reform was achieved but were not sustainable in qianjiang. provider behaviors were partially improved but with limited effect on prescriptions behaviors. careful development of comprehensive performance assessment system article table 2. salary, outpatient revenue and surplus of new rural cooperative medical scheme fund in sample facilities 2007-2009 (cny). source: qianjiang health bureau. 2007 2008 2009 monthly outpatient nrcms monthly outpatient nrcms monthly outpatient nrcms income revenue outpatient income revenue outpatient income revenue outpatient fund surplus fund surplus fund surplus health centers 1683 896,295 38,000 1897 972,968 29,833 2575 1,248,445 35,000 village clinics 1220 39,763 615 1712 40,442 554 1975 43,517 2395 nrcms, new rural cooperative medical scheme. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1839] [page 13] and supporting policies were crucial to address the unexpected effects of capitation payment, like patient selection and unnecessary hospitalization. the reform brought no financial loss to both the facilities and the individuals. limitations availability of data in order to relief data collection workload, the study heavily relied on administrative data of qianjiang health bureaus. data was collected annually as an average, quarterly or monthly data was not available. the assessment was then a rough trend analysis rather than a strict interrupted time series analysis. quality of data data were obtained from qianjiang health bureaus, and were reported by individual facilities. although chongqing and qianjiang health bureaus organized regular trainings for lower level health bureaus and facilities, helped them in conducting appropriate data collection and reporting, possible quality problems may still exist. we assumed that the reported data is true and correct. sampling reform started in two village clinics in july 2007, and expanded to all primary facilities of qianjiang until january 2009. it was implemented step by step in four stages within one and half year. it was difficult to design a good sampling model for concise measurement and accurate revelation of the changes. annual average data for qianjiang covered facilities which reformed in different time period, which was affected by the reforms different groups of facilities. although the contributors were only a small number of facilities comparing with overall qianjiang, its contribution was weak and could be neglected, 2007 and 2008 annual average data of overall qianjiang village clinics was not a perfect controller for two pioneer village clinics and four sample village clinics. this was the same case that, 2008 annual average data of overall qianjiang health centers was not a perfect controller for four pioneer health centers. mixed policy effect although the payment reform was the most important reform in qianjiang during 20062009, there were tremendous policy changes under the overall health system reform framework during the same period. other policy changes might not directly link with the nrcms payment, but might indirectly contribute to the effects either positively or negatively. the evaluation drew mixed effects of all those policy changes, among which the payment reform contributed the most. comparison among different groups of facilities which reformed in different stages helped to control confounding policies effects. patient care and facility indicator consultation time, dispensing time, patients’ satisfaction, patients’ perception on medicines use, and availability of key essential medicines are important indicators for comprehensive assessment on quality of care. however, they were not regularly collected and recorded in qianjiang. this study did not include these patient care and facility indicators, instead of focusing on prescribing indicators and referral rate. the aim was to focus analysis on prescribing behavior changes. references 1. ministry of health of china. the new rural cooperative medical scheme (nrcms) in china. beijing: ministry of health ed.; 2008. 2. zhang l, liu yg. a case study of rural health policy and management reform in qianjiang, chongqing. beijing: china financial and economic publ.; 2007. 3. wang yf. practice and research on the payment reform of medical insurance. china medicine bulletin 2004;4:28-30. 4. gosden t, forland f, kristiansen i, et al. capitation, salary, fee-for-service and mixed systems of payment: effects on the behavior of primary care physicians. chinese journal of evidence-based medicine 2008;8:416-7. 5. nrcms committee. announcement to pilot the capitation payment reform in the outpatient of primary facilities. no.11. qianjiang: qianjiang health bureau ed.; 2007. 6. nrcms committee. announcement to strengthen hospitalization service in nrcms designated health facilities. no. 2. qianjiang: qianjiang health bureau ed.; 2007. 7. wang j. clinical epidemiology-design, measurement and evaluation of clinical study. shanghai: science and technology publ.; 2009. 8. yang w, xuan l, shen rh, gu zl. policy effect analysis of the capitation payment to the outpatient free medical care program. chinese health economics 1999;18:57-9. 9. meng qy. cost containment impact analysis of the payment method of medical insurance. health economics research 2002;9:18-21. 10. lei hc, wang j, liu xl. study of national hospitalization rate in china second-hand data. a systematic review approach. chin j hosp admin 2008;24:649-52. 11. ministry of health of china. an analysis report of national health service survey in china, 2008. beijing: china medical union university publ.; 2008. available: http://www.moh.gov.cn/cmsresources/moh wsbwstjxxzx/cmsrsdocument/doc9911.pdf article non -co mmerc ial us e o nly hrev_master the impact of c-reactive protein testing on treatmentseeking behavior and patients’ attitudes toward their care in myanmar and thailand rachel c. greer,1,2 thomas althaus,3,4 sabine dittrich,2,5,6 christopher c. butler,7 phaik yeong cheah,1,2,8 tri wangrangsimakul,1,2 frank m. smithuis,2,9,10 nicolas p.j. day,1,2 yoel lubell1,2 1mahidol oxford tropical medicine research unit, faculty of tropical medicine, mahidol university, bangkok, thailand; 2centre for tropical medicine and global health, nuffield department of medicine, university of oxford, oxford, uk; 3the department of health action, monaco, monaco; 4monaco scientific centre, monaco, monaco; 5find, global alliance for diagnostic, geneva, switzerland; 6deggendorf institute of technology, europeancampus rottal inn, pfarrkirchen, germany; 7clinical trials unit, nuffield department of primary care health sciences, university of oxford, oxford, uk; 8the ethox centre, nuffield department of population health, university of oxford, oxford, uk; 9myanmar oxford clinical research unit, yangon, myanmar; 10medical action myanmar, yangon, myanmar abstract c-reactive protein (crp) point-of-care testing can reduce antibiotic prescribing in primary care patients with febrile and respiratory illness, yet little is known about its effects on treatment-seeking behavior. if patients go on to source antibiotics elsewhere, the impact of crp testing will be limited. a randomized controlled trial assessed the impact of crp testing on antibiotic prescriptions in myanmar and thai primary care patients with a febrile illness. here we report patients’ treatmentseeking behavior before and during the twoweek study period. self-reported antibiotic use is compared against urine antibacterial activity. patients’ opinions towards crp testing were evaluated. antibiotic use before study enrolment was reported by 5.4% while antimicrobial activity was detected in 20.8% of samples tested. during the study period, 14.8% of the patients sought additional healthcare, and 4.3% sourced their own antibiotics. neither were affected by crp testing. overall, patients’ satisfaction with their care and crp testing was high. crp testing did not affect patients’ treatment-seeking behavior during the study period whilst modestly reducing antibiotic prescriptions. crp testing appears to be acceptable to patients and their caregivers. introduction c-reactive protein (crp) point of care (poc) testing can improve antibiotic prescribing by reducing initial antibiotic prescriptions for adults and children attending primary care with respiratory tract infections (rtis).1,2 the majority of rtis are viral and do not benefit from antibiotics, but despite this, rtis remain a common reason for an antibiotic prescription. high levels of antibiotic prescribing have been reported in southeast asia; situational analyses of public primary care facilities in myanmar revealed that antibiotics were prescribed to 87% (range 73-96%) of patients with upper respiratory tract infections (urtis), while in thailand, 43% (20-52%) were prescribed antibiotics during 2014 and 2015.3 thailand has been active in developing antimicrobial stewardship policies and plans, and this appears to be reducing antibiotic prescriptions for urtis.3-5 optimal use of antibiotics is key to reducing the burden of antimicrobial resistance. in 2019, an estimated 254,000 deaths were attributable to bacterial resistance in southeast asia.6 crp is an acute-phase protein that is raised in infection and inflammation. it can be measured at the poc using a finger prick blood test. qualitative studies suggest that the majority of patients view the crp poc test favorably.7-9 less is known about its effect on treatment-seeking behavior after the initial consultation and whether patients comply with the recommendation to take or more likely not to take antibiotics. researchers and healthcare workers have suggested that patients will go on to seek healthcare or antibiotics from other sources if they are unsatisfied with consultations using crp poc tests.8 whilst in research settings consultation at study sites has been largely unaffected by crp interventions, there is a paucity of data on crp testing’s effect on seeking healthcare and antibiotics from alternative sources.4,10-14 trial participants report conflicting views about crp testing’s impact on future care-seeking; some report that they will re-attend to receive another test (medicalizing a selflimiting illness) while others will delay seeking care as antibiotics were not healthcare in low-resource settings 2023; volume 11:11278 correspondence: rachel c. greer, mahidol oxford tropical medicine research unit, faculty of tropical medicine, mahidol university, 3rd floor, 60th anniversary chalermprakiat building, 420/6 ratchawithi rd., ratchathewi district, bangkok 10400, thailand. tel.: +66.2.2036333 fax: +66.2.354 9169 e-mail: rachel@tropmedres.ac key words: c reactive protein, antibiotics, amr, point of care testing, healthcare-seeking behaviour. contributions: yl, sd, funding acquisition; rcg, ta, sd, tw, fms, npjd, yl, study design; rcg, ta, yl, data analysis; yl, npjd, pyc, ccb, supervision; rcg, yl, first draft of the paper. all authors reviewed and edited the paper. ethics approval: ethical approval was received from the oxford tropical research ethics committee, the mahidol university faculty of tropical medicine ethics committee, the myanmar department of medical research, and the chiangrai provincial public health office research ethics committees. all participants gave their written informed consent, or assent and parental consent to join the trial. availability of data and material: data access will be granted upon reasonable request from the mahidol oxford tropical medicine research unit’s data access committee. instructions and the data application form are available from: https://www.tropmedres.ac/units/moru-bangkok/ bioethics-engagement/data-sharing. conflict of interests: sd was employed by find the global alliance for diagnostics during the study period. the other authors declare no conflict of interest; all authors confirm accuracy. funding: this trial was funded by the wellcome trust institutional strategic support fund grant (105605/z/14/z) and foundation for innovative new diagnostics (find) funding from the australian government. this research was funded in part, by the wellcome trust [220211]. the funders and sponsor had no role in the study design; in the collection, analysis, and interpretation of data; in the writing of the report; and in the decision to submit the article for publication. for the purpose of open access, the author has applied a cc by public copyright licence to any author accepted manuscript version arising from this submission. acknowledgments: we would like to thank all the trial participants, their caregivers, and the healthcare workers involved in this study. we would like to acknowledge the hard work of all the research nurses, clinicians, and clinical trial support groups at mahidol oxford tropical medicine research unit. we thank dr. daranee intralawan and dr. supalert nedsuwan from the chiang rai regional hospital for facilitating the study in the primary care units. received for publication: 27 february 2023. accepted for publication: 24 june 2023. this work is licensed under a creative commons attribution 3.0 license (by 3.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11278 doi:10.4081/hls.2023.11278 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 42] [healthcare in low-resource settings 2023; 11:11278] needed.7,12 patient-reported antibiotic use can be difficult to assess and validate due to a lack of awareness or understanding of antibiotics and other medications being taken, as well as poor adherence to treatment and recall times. measuring urine antibacterial activity is one way to verify whether antibiotics are being taken currently.10,15-17 we conducted a randomized controlled trial (rct) to evaluate crp-guided antibiotic prescribing for patients attending primary care with an acute febrile illness. the primary outcomes have been reported previously.4 in summary, a modest reduction (39% vs. 34%) in antibiotic prescribing was seen in the intervention arm using a crp cut-off of 40mg/l compared with the control arm (aor 0.80, 95% ci 0.65-0.98). patients with a high crp level were more likely to receive an antibiotic and those with a low crp were less likely to receive an antibiotic in the intervention arms compared to the control arm. clinical outcomes were not affected.4 in this paper, we describe the secondary outcomes of patients’ treatment-seeking behavior (healthcare and antibiotics) before and during the two-week study period and compare self-reported antibiotic use against urine antibacterial activity. we explore patients’ and their caregivers’ views toward crp poc testing. materials and methods we conducted a multicentre, open–label rct in myanmar and thailand. the trial design details have been reported previously.4 in brief, we recruited patients aged 1 year or older attending primary care with a documented fever (>37.5°c) or history of fever in the last 2 weeks. patients were individually randomized 1:1:1 into intervention arm a (crp cut-off of 20mg/l), intervention arm b (crp cut-off of 40mg/l), or the control arm (standard care). these crp cutoffs were based on reported crp levels in southeast asian febrile patients and recent rcts on poc crp testing in primary care. prior antibiotic use did not prevent participation.4 healthcare workers were advised that patients with a low crp result (defined by the intervention arm’s threshold) were unlikely to benefit from antibiotics while those with a high crp were more likely to benefit from antibiotics. all patients were followed up on days 5 and 14. urine samples were collected on day 0 and day 5. opinions towards their care and crp testing were ascertained by the researcher using close-ended questions on day 14. study sites the study sites in myanmar included three not-for-profit clinics which provide primary healthcare for marginalized people and one government outpatient department. all patients were treated for free by doctors. the thai study sites were six governmentrun primary care units that provide universal health care and medication to thai citizens for a nominal fee. they are usually staffed by nurses and public health officers. in both myanmar and thailand, antibiotics are also available from multiple sources, such as pharmacies and village shops without a prescription. laboratory procedures urine antibacterial activity was tested at the mahidol oxford tropical medicine research unit (moru) laboratory in bangkok, thailand. the reference organism, bacillus stearothermophilus (atcc 7953) was plated on mueller hinton agar. urine samples were thawed and then 3 μl samples were pipetted onto a blank filter paper noting the disc position. plates were incubated aerobically at 56°c for 18 to 24 hours. if an inhibitory zone was seen around the urine sample then antibacterial activity was declared.16 samples were tested in duplicate and divergent results were repeated. all urine samples collected on day 5 were tested for antibacterial activity but only a subset of day 0 urine samples (409/2,292, 17.8%) were tested due to resource constraints. crp levels were assessed using the nycocard ii reader, axis-shield, oslo, norway. capillary blood samples were tested at point-of-care for intervention patients whereas for control patients venous samples were retrospectively tested in moru’s local laboratories.18 statistical analysis categorical data were summarised using counts and percentages, and compared using χ2 tests. mann-whitney u tests were used to compare scores without normal distribution. logistic regression models were used to evaluate indicators of treatment-seeking behavior during the study, with the study sites fitted as random effects. univariate analyses of the potential indicators of treatment-seeking behavior were performed and significant variables (p<0.05) were added to multivariable analyses. agreement between patient-reported antibiotic use and urine antibacterial activity was assessed using the kappa statistic. patients’ consultation experience scores were created using the sum of responses to questions 2, 3, 4, 8, and 9 (table 1). responses were recoded so that positive answers received 1 point, neutral answers 0 points, and negative responses -1 point.18 results health-seeking and antibiotic use before enrolment the rct enrolled 2,410 patients with an acute fever or history of fever presenting to primary care in myanmar and thailand between 2016 and 2017.4 over half of the patients (1,372/2,408, 57%) had sought healthcare in the two weeks before study enrolment, most frequently from pharmacies (53.8%) and clinics (22.1%). prior care was more likely to have been sought by patients in the myanmar facilities, as compared with those in the thai facilities (74.9% vs 38.4%, p<0.001), and when the patient was an adult as compared with children (61.5% vs 52.4%, p<0.001). new medication had been taken by 1,732/2,409 (71.9%) of the patients in the 2 weeks before study enrolment; of these, 367 (21.2%) had taken at least one unknown medication. antibiotics had been knowingly taken by 130/2,409 (5.4%). sources of antibiotics include clinics (81/126, 62.3%), pharmacies (30, 23.1%), hospitals (6, 4.6%), natural healers (5, 3.9%), household supplies (3, 2.3%), street vendors (1, 0.8%) and unknown (4, 3.1%). a minority of those who had sought healthcare reported taking antibiotics (127/1,372, 9.3%). prior antibiotic use did not vary between myanmar and thai patients or adults and children (p=0.347 and 0.223, respectively). antibacterial activity was found in 85/409 (20.8%) of the urine samples tested at enrolment. the agreement between reported antibiotic use and urine antibacterial activity was 81.2% (kappa = 0.21). of the 409 patients, 22 reported antibiotic use in the 48 hours before the test, of whom 15 were positive and 7 were negative for antibacterial activity, while 70/85 (82.4%) of the patients with urine antibacterial activity did not report antibiotic use (figure 1). in those who were taking an unknown medication, 29/61 (47.5%) of the urine samples were positive for antibacterial activity.18 health-seeking and antibiotic use after enrolment antibiotics were prescribed at enrolment to 515/1,593 (32.3%) of the patients in the crp intervention arms compared to 297/799 (37.2%, p=0.018) in the control arm. this reduction in prescribing was primarily due to a reduction in myanmar adults.4 during the study period, healthcare was sought by 339/2,294 (14.8%) of the article [healthcare in low-resource settings 2023; 11:11178] [page 43] patients (from any source or facility other than the study follow-up visits). there was no difference between those in the crp intervention arms and the control arm (p=0.552, supplementary table 1). in the multivariable analysis, significantly less care was sought during the study by thai patients and those who had received an antibiotic at enrolment. significantly more care was sought by those who had sought care before the study, presented with a documented fever, higher self-reported symptom severity, higher crp results, and those diagnosed with an unspecified acute viral or dual infection compared to those with rtis (table 2). antibiotics were prescribed to 110/2,311 (4.8%) of the patients on day 5 and 15/2,317 (0.7%) on day 14. in addition, 95/2,206 (4.3%) of the patients sourced their antibiotics, approximately a third of the 254 patients seeking care elsewhere; an additional 79 patients received an unknown medication. there was no difference between those seeking antibiotics in the crp intervention or control arms. the only significant variable in the univariate analyses for seeking antibiotics during the study was having a higher crp result at enrolment, p=0.002 (supplementary table 1). on day 5, urine antibacterial activity was found in 521/2,065 (25.2%) of the samples (figure 1). the overall agreement between patient-reported antibiotic use and urine antibacterial activity was 77.4% (kappa=0.46). in the preceding 48 hours, 641/2,065 (31.0%) patients reported antibiotic use; 352 (54.9%) samples were positive and 289 (45.1%) were negative. in those with urine antibacterial activity, 352/521 (67.6%) patients had reported antibiotic use, while 155 (29.8%) reported no antibiotic use. most (77.6%) patients reported knowing whether they had been prescribed an antibiotic at enrolment; the rest were unsure when asked on day 14. adherence to antibiotic courses was reported by 687/829 (86.7%) of the patients.18 patients’ and caregivers’ opinions and attitudes toward the consultation and crp testing on day 14, all patients were asked about their care, and those in the intervention arms were asked additional questions about crp testing. half of the patients answered these questions themselves while the other half were answered by their parents or guardians. overall satisfaction with the care received was very high (table 1). there were no differences between the intervention and control arms in terms of consultation scores (p=0.980), an adequate explanation of the treatment (p=0.966), or agreement with the treatment (p=0.864). thai patients rated each of these higher than myanmar patients (p<0.001). patients who sought further healthcare during the study scored lower for their consultation experience (p<0.001), an adequate explanation of the treatment (p=0.007), and agreement with their treatment (p=0.006) than those who did not. patients who sourced antibiotics during the study had similar consultation scores (p=0.313) and an adequate explanation of the treatment (p=0.847) but reported less agreement with treatment (p=0.001). agreement with the treatment was also lower in those not prescribed an antibiotic at enrolment compared to those who were (p=0.033), however over 80% agreed with the antibiotic prescribing decision. in total, 67.3% of the patients reported receiving enough explanation to understand their treatment. while in the intervention arms, 61.1% felt the objective of the crp test was clear and 56.6% reported that the test results were explained in a way that they understood. the majority of intervention patients wanted the crp test to be used again, felt more confident whether antibiotics were needed, and that it improved their quality of care.18 discussion following a modest reduction in prescribing after the first presentation, crp poc testing did not affect patients’ treatment-seeking behavior during the two-week study period. patients expressed positive opinions towards crp testing and its use in future consultations. studies from asia and europe have reported no difference in reattendances between patients in crp and control arms.4,10-14,19 our study goes further by showing no difference in the numbers of patients seeking additional healthcare or antibiotics in the two weeks following first attendance at the study facility. it is encouraging that despite the relatively low antibiotic prescribing in the control and intervention arms, less than 5% of the patients went on to source their antibiotics. taken together with the reported high adherence to antibiotic courses this should encourage healthcare workers and policymakers that most patients will comply with antibiotic treatment plans, even when antibiotics can be sought from other sources. patients reported high levels of satisfaction with their care. this is consistent with other studies on crp poc testing.10-12 our study raises concerns about unknown medication use. a fifth of those taking a new medication before enrolment did not know what they were taking. even within the context of a trial focusing on antibiotic use a quarter did not know if they were prescribed an antibiotic as part of the study. some of this uncertainty about antibiotic use may be explained by the multiple terms used for antibiotics in thailand and the lack of a formal word for antibiotics in myanmar.20,21 this uncertainty is likely to be reflected in the differences between reported antibiotic use and urine antibacterial activity and is consistent with other studies that found lower levels of reported antibiotic use compared to urine antibacterial activity.15,16,22 another reason for this discrepancy may be environmental exposure to antibiotics, foods or chemicals with antibacterial activity.16,23 false-negative results may have been caused by non-adherence to antibiotics, extra-renal antibiotic excretion, reduced test sensitivity due to one reference organism being used, and the freezing and thawing of urine samples.15-18,22 moving forward patients need to be aware of their antibiotic use if they are to be involved in strategies to optimize antibiotic use. patients’ understanding of the crp test could be improved and may help to article figure 1. venn diagrams to show day 0 and day 5 urine antibacterial activity and reported antibiotic use. adapted from greer 2022.18 [page 44] [healthcare in low-resource settings 2023; 11:11278] article table 1. patients’ and caregivers' opinions and attitudes towards the consultation and crp poc testing, by country and intervention. adapted from greer 2022.18 patients’ and caregivers’ opinions & attitudes agree neutral disagree n (%) n (%) n (%) i think that the healthcare worker’s decision to prescribe or not to prescribe an antibiotic for my treatment was correct (q 2) intervention arms (n = 1,377) 1,113 (80.8) 241 (17.5) 23 (1.7) control arm (n = 691) 556 (80.5) 125 (18.1) 10 (1.5) thailand (n = 1,172) 1,107 (94.5) 49 (4.2) 16 (1.4) myanmar (n = 896) 562 (62.7) 317 (35.4) 17 (1.9) i did not get enough explanation to understand the treatment (q 3) intervention arms (n = 1,448) 79 (5.5) 394 (27.2) 975 (67.3) control arm (n = 725) 37 (5.1) 200 (27.6) 488 (67.3) thailand (n = 1,173) 54 (4.6) 269 (22.9) 850 (72.5) myanmar (n = 1,000) 62 (6.2) 325 (32.5) 613 (61.3) i felt that the consultation was too fast (q 4) intervention arms (n = 1,451) 335 (23.1) 254 (17.5) 862 (59.4) control arm (n = 726) 155 (21.4) 123 (16.9) 448 (61.7) thailand (n = 1,174) 394 (33.6) 36 (3.1) 744 (63.4) myanmar (n =1,003) 96 (9.6) 341 (34.0) 566 (56.4) i fully understood the instructions for taking the prescribed antibiotic (including when, how much, how often, and how long i have to take the medication) (q 5) intervention arms (n = 407) 388 (95.3) 15 (3.7) 4 (1.0) control arm (n = 211) 195 (92.4) 14 (6.6) 2 (1.0) thailand (n = 353) 343 (97.2) 8 (2.3) 2 (0.6) myanmar (n = 265) 240 (90.6) 21 (7.9) 4 (1.5) it is too much effort to come to the health center for the treatment that i received (q 8) intervention arms (n = 1,461) 107 (7.3) 212 (14.5) 1,142 (78.2) control arm (n = 732) 58 (7.9) 101 (13.8) 573 (78.3) thailand (n = 1,173) 32 (2.7) 30 (2.6) 1,111 (94.7) myanmar (n = 1,020) 133 (13.0) 283 (27.8) 604 (59.2) overall, i am satisfied with my care (q 9) intervention arms (n = 1,464) 1,429 (97.6) 33 (2.3) 2 (0.1) control arm (n = 730) 709 (97.1) 19 (2.6) 2 (0.3) thailand (n = 1,173) 1,155 (98.5) 16 (1.4) 2 (0.2) myanmar (n = 1,021) 983 (96.3) 36 (3.5) 2 (0.2) intervention arms only the objective of the finger-prick crp test is not clear to me (q 6) all (n = 1,453) 64 (4.4) 502 (34.6) 887 (61.1) thailand (n = 776) 31 (4.0) 292 (37.6) 453 (58.4) myanmar (n = 677) 33 (4.9) 210 (31.0) 434 (64.1) the finger-prick test for crp is painless (q 7) all (n = 1,450) 998 (68.8) 222 (15.3) 230 (15.9) thailand (n = 777) 672 (86.5) 36 (4.6) 69 (8.9) myanmar (n = 673) 326 (48.4) 186 (27.6) 161 (23.9) yes do not know no did the health worker explain the finger-prick test results to you in a way that you understood? (q 10) all (n = 1,450) 821 (56.6) 299 (20.6) 330 (22.8) thailand (n = 774) 435 (56.2) 194 (25.1) 145 (18.7) myanmar (n = 676) 386 (57.1) 105 (15.5) 185 (27.4) would you like the health worker to use the finger-prick test for crp again the next time you have an illness? (q 14) all (n = 1,461) 1,329 (91.0) 103 (7.1) 29 (2.0) thailand (n = 778) 763 (98.1) 12 (1.5) 3 (0.4) myanmar (n = 683) 566 (82.9) 91 (13.3) 26 (3.8) did the health worker seem to base his/her treatment decision on the test results? (q 12) all (n = 1,443) 782 (54.2) 557 (38.6) 104 (7.2) thailand (n = 774) 492 (63.6) 273 (35.3) 9 (1.2) myanmar (n = 669) 290 (43.4) 284 (42.5) 95 (14.2) continued on the next page. [healthcare in low-resource settings 2023; 11:11278] [page 45] increase the impact of crp testing and patients’ agreement with their antibiotic treatment. the patients who did seek additional healthcare during the study had lower consultation experience scores, less adequate explanation, and less agreement with their treatment. further work is required to explore how these areas could be addressed in future interventions. special focus needs to be given to patients who are not prescribed an antibiotic, especially when antibiotics are expected and this is the prescribing norm. this manuscript adds detailed treatment-seeking behavior to the results of our crp poc rct. combined with the urine antibacterial activity data and patient’s opinions towards crp poc testing this provides a more holistic review of the patient’s acceptance of crp poc testing, in the context of two low-and-middle-income countries. there are, however, several limitations to our study; the effect of crp testing on treatment-seeking behavior may have differed if the intervention had had a larger impact on antibiotic prescribing. patients’ satisfaction with their care may have been influenced by the study design, including the follow-up visits. opinions towards crp testing were assessed using close-ended questions which cannot give as detailed or nuanced answers as qualitative methods. however, as part of our wider work patients’ views were explored using semistructured interviews and their opinions were widely positive.8 due to resource constraints we were unable to test all the enrolment urine samples for antibacterial activity and were only able to use one reference organism; this may have led to an underestimation of urine antibacterial activity. our study sites were limited to government and not-for-profit-run primary care clinics so the results may not be generalizable to other facilities. article table 1. continued from previous page. patients’ and caregivers’ opinions & attitudes too much enough/ adequately not enough if so: do you think the health worker relied too much, enough, or not enough on the test results when he/she made the treatment decision? (q 12a) all (n = 778) 192 (24.7) 580 (74.6) 6 (0.8) thailand (n = 491) 181 (36.9) 309 (62.9) 1 (0.2) myanmar (n = 287) 11 (3.8) 271 (94.4) 5 (1.7) more neither more less confident nor less confident confident did the finger-prick test make you feel more or less confident that antibiotics are needed / not needed for your illness? (q 11) all (n = 1,432) 1,201 (83.9) 225 (15.7) 6 (0.4) thailand (n = 776) 738 (95.1) 37 (4.8) 1 (0.1) myanmar (n =656) 463 (70.6) 188 (28.7) 5 (0.8) improves no difference, unsure worsens do you feel that the finger-prick test for crp improves or worsens the quality of the care you receive? (q 13) all (n = 1,446) 1,281 (88.6) 165 (11.4) 0 thailand (n = 778) 753 (96.8) 25 (3.2) 0 myanmar (n = 668) 528 (79.0) 140 (21.0) 0 table 2. multivariable logistic regression of variables associated with seeking healthcare during the rct. adapted from greer 2022.18 variable additional healthcare sought during the study period aor* (95% ci) p value country myanmar patients reference thai patients 0.43 (0.23 to 0.81) 0.008 sought healthcare before enrolment 1.47 (1.07 to 2.01) 0.016 documented fever at enrolment 1.75 (1.31 to 2.35) <0.001 self-reported symptom severity score (1 point increase) 1.81 (1.33 to 2.46) <0.001 diagnosis at enrolment# rtis reference other infections 1.22 (0.70 to 2.12) 0.480 acute viral infections (unspecified) 1.71 (1.12 to 2.63) 0.014 dual infection 1.82 (1.04 to 3.18) 0.037 crp level at enrolment (1 mg/l increase) 1.01 (1.00 to 1.01) 0.001 antibiotics prescribed at enrolment 0.52 (0.37 to 0.73) <0.001 *the study site was added as a random effect. #other infections include all non-rtis affecting other systems such as gastrointestinal and skin infections. acute viral infection was a common diagnosis made in myanmar alongside rtis, common symptoms included cough and runny nose but some patients had fever as the sole symptom. dual infections include a diagnosis from two of the diagnosis categories. [page 46] [healthcare in low-resource settings 2023; 11:11278] [healthcare in low-resource settings 2023; 11:11278] [page 47] conclusions the use of crp poc testing has been shown to improve healthcare workers’ antibiotic prescribing practices. here it was shown that crp testing was widely acceptable to primary care patients in myanmar and thailand, without affecting subsequent treatment-seeking behavior. encouragingly, the vast majority of antibiotics obtained outside the study facilities came from formal sources, such as pharmacies and clinics, even though in myanmar and thailand antibiotics are widely available from informal providers, such as natural healers or street vendors. these formal providers could be easier sites to target antimicrobial stewardship interventions. healthcare workers should communicate to patients when they are prescribing antibiotics and if they are not the reasons why antibiotics are not required. references 1. verbakel jy, lee jj, goyder c, et al. impact of point-of-care c reactive protein in ambulatory care: a systematic review and meta-analysis. bmj open 2019;9:e025036-e36. 2. smedemark sa, aabenhus r, llor c, et al. biomarkers as point-of-care tests to guide the prescription of antibiotics in people with acute respiratory infections in primary care. cochrane database syst rev 2022;10:cd010130. 3. holloway ka, kotwani a, batmanabane g, et al. antibiotic use in south east asia and policies to promote appropriate use: reports from country situational analyses. bmj 2017;358:j2291. 4. althaus t, greer rc, swe mmm, et al. effect of point-of-care c-reactive protein testing on antibiotic prescription in febrile patients attending primary care in thailand and myanmar: an openlabel, randomised, controlled trial. lancet glob health 2019;7:e119-e31. 5. thai ministry of public health. hdc service report on the service plan for rational drug use 2020. accessed 17/07/2020 2020. available from: https://hdcservice.moph.go.th/hdc/repo rts/report.php?source=pformated/format1.php&cat_id=03b912ab9ccb4c072 80a89bf05e5900e&id=d1ccec314e928 75acb5142769eb479a2 6. murray cjl, ikuta ks, sharara f, et al. global burden of bacterial antimicrobial resistance in 2019: a systematic analysis. lancet 2022;399:629-55. 7. tonkin-crine s, anthierens s, francis na, et al. exploring patients’ views of primary care consultations with contrasting interventions for acute cough: a six-country european qualitative study. npj prim care respir med 2014;24:1 4026. 8. haenssgen mj, charoenboon n, althaus t, et al. the social role of creactive protein point-of-care testing to guide antibiotic prescription in northern thailand. soc sci med 2018;202:1-12. 9. van den bruel a, jones c, thompson m, et al. c-reactive protein point-ofcare testing in acutely ill children: a mixed methods study in primary care. arch dis child 2016;101:382. 10. do nt, ta nt, tran nt, et al. point-ofcare c-reactive protein testing to reduce inappropriate use of antibiotics for nonsevere acute respiratory infections in vietnamese primary health care: a randomised controlled trial. lancet glob health 2016;4:e633-41. 11. cals j, butler c, hopstaken r, et al. effect of point of care testing for c reactive protein and training in communication skills on antibiotic use in lower respiratory tract infections: cluster randomised trial. bmj 2009;338:1374. 12. cals jwl, schot mjc, de jong sam, et al. point-of-care c-reactive protein testing and antibiotic prescribing for respiratory tract infections: a randomized controlled trial. ann fam med 2010;8:124-33. 13. little p, stuart b, francis n, et al. effects of internet-based training on antibiotic prescribing rates for acute respiratory-tract infections: a multinational, cluster, randomised, factorial, controlled trial. lancet 2013;382:117582. 14. schot mj, van den bruel a, broekhuizen bd, et al. point-of-care creactive protein to assist in primary care management of children with suspected non-serious lower respiratory tract infection: a randomised controlled trial. bjgp open 2018;2:bjgpopen 18x101 600-bjgpopen18x00. 15. emary kr, carter mj, pol s, et al. urinary antibiotic activity in paediatric patients attending an outpatient department in north-western cambodia. trop med int health 2015;20:24-8. 16. khennavong m, davone v, vongsouvath m, et al. urine antibiotic activity in patients presenting to hospitals in laos: implications for worsening antibiotic resistance. am j trop med hyg 2011;85:295-302. 17. liu y-c, huang w-k, huang t-s, et al. detection of antimicrobial activity in urine for epidemiologic studies of antibiotic use. j clin epidemiol 1999; 52:539-45. 18. greer rc. evaluation of c-reactive protein point of care testing, and associated research challenges, to improve the quality of antibiotic prescribing in the community in northern thailand. phd thesis the open university, 2022. 19. andreeva e, melbye h. usefulness of c-reactive protein testing in acute cough/respiratory tract infection: an open cluster-randomized clinical trial with c-reactive protein testing in the intervention group. bmc fam pract 2014;15:80. 20. haenssgen mj, charoenboon n, zanello g, et al. antibiotic knowledge, attitudes and practices: new insights from cross-sectional rural health behaviour surveys in low-income and middleincome south-east asia. bmj open 2019;9:e028224. 21. miyano s, htoon tt, nozaki i, et al. public knowledge, practices, and awareness of antibiotics and antibiotic resistance in myanmar: the first national mobile phone panel survey. plos one 2022;17:e0273380. 22. liu y-c, huang w-k, huang t-s, et al. extent of antibiotic use in taiwan shown by antimicrobial activity in urine. lancet 1999;354:1360. 23. wang h, wang b, zhao q, et al. antibiotic body burden of chinese school children: a multisite biomonitoring-based study. environ sci technol 2015;49:5070-9. article online supplementary materials table s1. univariate analyses of variables for seeking healthcare and antibiotics during the rct study period. hrev_master healthcare in low-resource settings 2024; volume 12:11355 marburg virus in tanzania: examining emergence, consequences, and mitigation approaches bashar haruna gulumbe,1 innocent h. p. uggh,2 aminu shehu,3 ernest winchislaus4 1department of microbiology, federal university birnin kebbi, nigeria; 2tanzania better health, tanzania; 3department of microbiology, bayero university kano, nigeria; 4bugando medical centre, mwanza, tanzania abstract the first-ever marburg virus disease (mvd) outbreak in tanzania serves as a stark warning of the vulnerability of the entire world to newly emerging infectious diseases. this article looks at the causes of tanzania’s susceptibility to mvd, containment efforts, and strategies to stop further outbreaks. the analysis emphasizes the significance of addressing socio-economic variables, environmental issues, and community participation in addition to healthcare infrastructure and surveillance systems for longterm health security. it highlights the requirement for a concerted effort on the part of governments, international organizations, and local communities, as well as ongoing financial support for public health infrastructure. the analysis also urges regional collaboration and coordination, as well as the adoption of a learning attitude to incorporate lessons from this and other outbreaks for enhancing and perfecting public health policies. we can contribute to global efforts to prevent and limit future infectious disease outbreaks and protect the health of communities around the world by adopting a thorough, proactive, and evidence-based strategy. introduction marburg virus disease (mvd) is a highly virulent and often fatal infectious disease caused by the marburg virus, a member of the filoviridae family that also includes the ebola virus.1 in march 2023, the united republic of tanzania reported its firstever mvd outbreak, with eight cases and five deaths (case fatality ratio [cfr]: 62.5%) in two villages in the bukoba district, kagera region.2,3 the outbreak has since been officially declared over on june 2, 2023. tanzania’s vulnerability to marburg virus outbreaks is multifaceted. ecological factors, including zoonotic transmission from reservoir hosts such as rousettus bats, contribute to this vulnerability. additionally, challenges within the healthcare system, such as delays in case identification and nosocomial transmission, exacerbated the risk.2 the need to understand and address these vulnerability factors and implement effective response measures is of paramount importance in managing future outbreaks. the kagera region, where the outbreak originated, is characterized by porous borders, increased cross-border movement, regional trade, and economic activities around lake victoria. these factors, coupled with limited healthcare infrastructure, population density, urbanization, and socioeconomic challenges, contribute to the potential spread of the disease and other infectious diseases.2 the emergence of the marburg virus in tanzania underscores the need for a proactive and comprehensive approach to outbreak prevention and containment. in response to the outbreak, the tanzanian government has deployed rapid response teams to investigate and implement interventions in the affected areas, including contact tracing and risk communication activities.4 collaboration with international organizations, such as the world health organization (who), africa centre for disease control (africa cdc), and other global partners, is essential for sharing information, and best practices, and providing support during this critical time.2 as the country grappled with its first mvd outbreak, the successes and challenges of containment efforts offer valuable insights and lessons for future preparedness and response measures. this commentary aims to provide a comprehensive analysis of the 2023 marburg virus outbreak in tanzania, discussing the factors that rendered the country vulnerable to such outbreaks and the measures deployed in place to contain the virus. additionally, the commentary will explore strategies for preventing future outbreaks, emphasizing the importance of strengthening healthcare infrastructure, enhancing surveillance and early warning systems, fostering community engagement and resilience, and addressing broader socioeconomic and environmental factors. as researchers not directly involved in managing the outbreak but with a keen interest in global public health and disease outbreaks, our ultimate goal is to highlight the significorrespondence: bashar haruna gulumbe, department of microbiology, federal university birnin kebbi, nigeria. e-mail: bashar.haruna@fubk.edu.ng key words: marburg, tanzania, outbreaks, pandemics, epidemics, public health infrastructure. contributions: all authors contributed equally to conception, writing, and revision. all authors approved the final copy of the manuscript. conflict of interest: the authors have no competing interests to declare funding: not applicable. ethics approval: not applicable. availability of data and material: not applicable. received: 4 april 2023. accepted: 14 february 2024. early access: 23 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11355 doi:10.4081/hls.2024.11355 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 284] [healthcare in low-resource settings 2024;12:11355] non -co mmerc ial us e o nly cance of a proactive and comprehensive approach to outbreak prevention and containment and to call for collective action and continued investment in tanzania’s public health infrastructure. why is tanzania more vulnerable? tanzania’s susceptibility to marburg virus outbreaks stemmed from a complex interplay of ecological, healthcare, and population factors. the recent outbreak highlighted the significance of zoonotic transmission, particularly from the widespread rousettus bats, which served as carriers of the virus.5 this direct or indirect transmission highlighted the pivotal role of ecological factors in disease emergence, exacerbated by human activities that increased contact with these reservoir hosts. following the initial human infection, the transmission of the virus escalated through human-to-human contact, necessitating robust public health measures to prevent and contain outbreaks.6 however, the emphasis on ecological and environmental factors provided a more accurate framework for understanding the risk factors associated with marburg virus outbreaks in tanzania. as such, focusing on human-wildlife interactions and reservoir species, public health strategies could be tailored to address the root causes of zoonotic disease emergence and spread. yet, the presence of a low-resource healthcare setting significantly impacted the epidemiological landscape of marburg virus outbreaks.7 challenges such as low clinical suspicion and limited infection control measures contributed to delays in case identification and nosocomial transmission, amplifying outbreak dynamics. despite these challenges, it was essential to recognize that the inherent limitations of low-resource healthcare systems did not directly initiate outbreaks. rather, they rendered countries more vulnerable to experiencing larger outbreaks once the virus gained a foothold. therefore, strengthening healthcare infrastructure and investing in research were crucial components of a comprehensive approach to disease prevention and control.8 tanzania’s experience with the marburg virus outbreak highlighted the critical need for a multifaceted public health strategy that not only addresses immediate healthcare challenges but also takes into account the broader ecological and environmental determinants of disease. the outbreak has served as a poignant reminder of the interconnectedness of human, animal, and environmental health, reinforcing the importance of the one health approach. public health interventions in response to the marburg virus outbreak in tanzania, the government has launched a series of coordinated initiatives aimed at containing the spread of the disease while minimizing its impact on affected communities.1,9 to promptly identify and manage potential cases of marburg virus disease (mvd), the tanzanian government has bolstered its surveillance and early detection capabilities. rapid response teams have been dispatched to affected areas to investigate and implement targeted interventions. these teams work closely with local health officials to enhance contact tracing efforts, monitor individuals exhibiting symptoms, and actively seek out new cases in both community settings and healthcare facilities.2 similarly, to curb the spread of mvd, the government has implemented quarantine measures for individuals who have been in close contact with confirmed cases. these measures involved isolating and monitoring contacts for 21 days, allowing for early detection and treatment of potential cases.2 additionally, travel restrictions have been imposed in affected areas to minimize the risk of mvd transmission to other regions of tanzania or neighboring countries. the tanzanian government has initiated risk communication activities to raise public awareness about mvd, its transmission pathways, and the protective measures individuals can adopt to reduce exposure to the virus.2 these campaigns emphasize the importance of personal hygiene, safe burial practices, and prompt reporting of suspected cases to healthcare facilities. by empowering communities with accurate information and practical guidance, the government aims to foster a proactive and collaborative approach to outbreak containment. recognizing the value of global partnerships in addressing public health crises, tanzania has sought the assistance and expertise of international organizations to strengthen its response to the mvd outbreak.2 the world health organization (who) is working closely with the tanzanian ministry of health to provide technical assistance, resources, and expertise in managing the mvd outbreak. this support includes guidance on surveillance, case management, infection prevention and control, laboratory testing, and risk communication. other global partners, such as non-governmental organizations and donor agencies, have also contributed to the response efforts by providing financial and logistical support. in the spirit of international cooperation, tanzania has engaged in the exchange of information and best practices with other countries that have experienced mvd outbreaks.2 this collaboration fosters a collective learning process, enabling tanzania to build on the successes and lessons learned from previous mvd response efforts and adapt its strategies accordingly. successes and challenges in containing the outbreak the successful containment of the mvd outbreak in tanzania’s kagera region declared on march 16, 2023, and officially ended by june 2, 2023,4 stands as a testament to effective public health response. under the leadership of president dr. samia suluhu hassan, prime minister kassim majaliwa, and health minister ummy mwalimu, tanzania, in collaboration with the africa cdc and partners like who, msf, us cdc, and others, rapidly mobilized to address the outbreak.4 this swift action resulted in the containment of the virus within 78 days, limiting it to nine confirmed cases and six deaths. key to this success was the integration of existing health programs, robust multi-sectoral partnerships, regular strategic coordination, and a motivated health workforce.4 the approach emphasized transparency, accountability, and international cooperation, demonstrating the efficacy of a coordinated, multi-faceted response strategy in managing and overcoming public health emergencies, providing valuable insights for future outbreak management. however, challenges such as low-resource healthcare infrastructure, cross-border movements, and public awareness gaps highlight the need for continued investment in public health preparedness and resilience. these challenges further illuminate the necessity for enhanced transparency in public health efforts—a measure that cannot be overstated. additionally, they emphasize the critical reliance on partnerships, showcasing the indispensable role of collaborative efforts in bolstering health systems and ensuring effective response mechanisms are in place. debate article [healthcare in low-resource settings 2024;12:11355] [page 285] non -co mmerc ial us e o nly preventing future outbreaks a robust and well-funded healthcare infrastructure is crucial to prevent future marburg virus outbreaks.7 this requires significant investment in building and maintaining hospitals, clinics, and laboratories, ensuring that they are equipped with the necessary resources and technology to effectively diagnose, treat, and contain infectious diseases. in addition to investing in healthcare facilities, it is essential to prioritize the training and retention of healthcare professionals and those who are in pre-service training. by providing education, training, and ongoing support, the healthcare workforce can be better prepared to identify and manage cases of the marburg virus disease and other infectious diseases, thereby preventing the escalation of future outbreaks. utilizing technology and data-driven approaches can significantly improve the effectiveness of surveillance and early warning systems. integrating real-time data collection and analysis, advanced diagnostics, and predictive modeling can help identify potential outbreaks early, allowing for rapid response and containment efforts.10 enhanced regional cooperation and coordination among neighboring countries are essential for the timely sharing of information and resources in the event of an outbreak.11 by establishing strong networks and communication channels, countries can work together to monitor and respond to potential outbreaks, thus preventing their spread across borders.11 empowering communities through education and awareness campaigns is critical to preventing future marburg virus outbreaks. by providing accurate and accessible information on the virus, its transmission, and the necessary precautions, individuals can be better equipped to protect themselves and their communities. implementing community-based interventions and establishing support networks can help build resilience and encourage local ownership of disease prevention and control measures. these initiatives may include targeted programs for at-risk populations, engagement with local leaders and the private sector, and the establishment of community health worker networks to dispel misinformation and promote disease awareness and prevention strategies. addressing the root causes of vulnerability to infectious diseases requires tackling broader socioeconomic challenges, such as poverty and limited access to essential services. implementing poverty reduction and social welfare programs can help improve living conditions and promote overall health and well-being, thereby reducing the risk of disease transmission. climate change and environmental factors can contribute to the emergence and spread of infectious diseases like the marburg virus disease. by adopting and implementing climate change adaptation and mitigation strategies, countries can reduce the impact of environmental factors on disease dynamics and improve overall public health outcomes.12,13 these strategies may include promoting sustainable land use, preserving ecosystems, and investing in early warning systems for climate-sensitive diseases. conclusions the marburg virus disease outbreak in tanzania highlights the critical importance of proactively addressing public health threats and the interconnected nature of various factors that contribute to vulnerability. the outbreak serves as a stark reminder that emerging infectious diseases are an ongoing challenge, requiring constant vigilance, adaptability, and collaboration across multiple sectors and disciplines. the key takeaways from the analysis of the outbreak and response measures emphasize the need to enhance tanzania’s public health infrastructure and regional cooperation to prevent future outbreaks. furthermore, addressing the root causes of vulnerability, including poverty, climate change, and disparities in access to healthcare, is vital for fostering long-term resilience and equity. as we move forward, stakeholders must adopt a learning mindset, integrating the lessons from this outbreak and others to continuously refine and optimize public health strategies. by embracing a comprehensive, proactive, and evidence-based approach, we can contribute to global efforts to prevent and contain future infectious disease outbreaks and safeguard the wellbeing of populations worldwide. references 1. manno d. developing a vaccine against marburg virus disease. the lancet 2023;401:251–3. 2. who. marburg virus disease – united republic of tanzania [internet]. 2023 [cited 2023 mar 31]. available from: https:/ /www.who.int/emergencies/disease-outbreaknews/item/2023-don451 3. who. who | regional office for africa. 2023 [cited 2023 mar 31]. tanzania confirms first-ever outbreak of marburg virus disease. available from: https://www.afro.who.int/countries/united-republic-of-tanzania/news/tanzania-confirms-first-ever-outbreak-marburg-virus-disease 4. africa cdc. lessons learnt from the marburg virus disease (mvd) outbreak in tanzania [internet]. africa cdc. 2023 [cited 2024 feb 9]. available from: https://africacdc.org/newsitem/lessons-learnt-from-the-marburg-virus-disease-mvd-outbreak-in-tanzania/ 5. okesanya oj, manirambona e, olaleke no, et al. rise of marburg virus in africa: a call for global preparedness. ann med surg 2023;85:5285–90. 6. bulimbe db, masunga ds, paul ik, et al. marburg virus disease outbreak in tanzania: current efforts and recommendations – a short communication. ann med surg 2023;85:4190–3. 7. eneh sc, okonji oc, chiburoma ag, et al. marburg virus disease amid covid-19 in west africa: an emerging and re-emerging zoonotic epidemic threat, future implications and way forward. ther adv infect dis 2023;10:2049936123116 8520. 8. gulumbe bh, lawan ka, bagwai ma. healthcare facilities recovering from the covid-19 pandemic now struggling to contain the spread of infectious diseases in africa. bull natl res cent 2023;47:109. 9. africa cdc. republic of tanzania declares marburg virus disease (mvd) outbreak [internet]. africa cdc. 2023 [cited 2023 mar 31]. available from: https://africacdc.org/newsitem/republic-of-tanzania-declares-marburg-virus-disease-mvdoutbreak/ 10. macintyre cr, chen x, kunasekaran m, et al. artificial intelligence in public health: the potential of epidemic early warning systems. j int med res 2023;51:030006052311593. 11. rashmi br. bimstec: disaster management as a tool for regional cooperation. in: bimstec. routledge india; 2022. 12. arikan a, cakir n. climate change and future infectious diseases: a growing threat. new microbes new infect 2023;52:101088. 13. rawson t, doohan p, hauck k, murray ka, ferguson n. climate change and communicable diseases in the gulf cooperation council (gcc) countries. epidemics. 2023;42:100667. debate article [page 286] [healthcare in low-resource settings 2024;12:11355] non -co mmerc ial us e o nly hrev_master [page 35] [healthcare in low-resource settings 2023; 11:11302] pityriasis versicolor: host susceptibility in relation to il-10 and ifn g cytokine gene polymorphism charu jain,1 shukla das,1 vishnampettai g. ramachandran,1 rumpa saha,1 sambit nath bhattacharyak,2 sajad ahmad dar,1 nikita birhman,1 narendra pal singh1 1department of microbiology, ucms & gtb hospital; 2department of dermatology and venerology, ucms & gtb hospital, india abstract pityriasis versicolor is a skin condition caused by the commensal yeast malassezia. little is known about the pathogenesis of why a commensal only causes symptoms in a subset of infected individuals. understanding the susceptibility of the host to these commensal-associated diseases may be facilitated by knowledge of genetic polymorphism. the purpose was to investigate the relationship between single nucleotide polymorphism in the il10 and ifn genes of the host and susceptibility to malassezia infection. there were 38 cases of pityriasis versicolor (pv) and 38 healthy controls in the sample. blood samples were extracted for genomic dna from all study participants. amplification refractory mutations systempolymerase chain reaction (arms-pcr) with sequence-specific primers was used to genotype cytokines. in all patients and healthy controls, three snps (il10-1082a/g; il10-819/592c/t; ifn+874a/t) in two cytokine loci were analyzed. in the pv group, we observed significant differences in allele or genotype distribution for the il10-819/592c/t and ifn+874a/t gene polymorphisms. in the present investigation, cytokine gene polymorphism revealed that the host was susceptible to malassezia infection. introduction malassezia is part of cutaneous commensal flora and is associated with certain superficial cutaneous disorders like pityriasis versicolor (pv), atopic dermatitis (ad), and seborrheic dermatitis (sd), etc.1 malassezia demonstrates two distinct phenotypes: one stimulates the immune system, significantly activating several immunological pathways, while the other greatly restricts immune stimulation, possibly allowing it to coexist as a commensal in the majority of people.1-3 the immunomodulatory ability of malassezia has been shown to downregulate the production of proinflammatory cytokines which is in marked contrast to the effect of many other organisms.1 pityriasis versicolor (pv) is a mild, chronic superficial cutaneous condition characterized by hypo or hyper-pigmented plaques that are covered by fine scales, sometimes associated with mild pruritus.4 pv is mostly distributed in the sebum-rich areas of the skin such as the back, chest, and neck.4 there is a significant fungal load on the skin but no inflammatory alterations are observed. the excellent adaptive mechanism is attributed to the presence of various metabolites produced by the yeast.5 cytokine gene polymorphism (single nucleotide polymorphism) governing the cytokine production could determine the susceptibility of the host to the disease.6 the occasional polymorphisms that occur in the normal healthy population are compatible with normal immune function. but when present with certain other susceptibility genes they may contribute to the disease. cytokine secretion profiles can be considered as promoting cell-mediated immunity or humoral immunity. il10 shifts the balance by down-regulating th1 response and by suppressing proinflammatory cytokine ifn γ secretion. il10 is a th2 anti-inflammatory cytokine and inter-individual variations in il10 production are genetically determined by polymorphism within the il10 promoter region -1082 g/a, -819 c/t, and -592 c/a. the polymorphism at -810 c/t and -592 c/a are in linkage disequilibrium with each other.7 ifn γ is a th1 proinflammatory cytokine that can augment the immune response. the functional single nucleotide polymorphism (snp) +874 t/a is located at the 5’ end of a ca repeat at the first intron of the human ifn γ gene. the t allele of ifn γ at +874 provides the binding site for the transcription factor, kb (nf-kb), which in turn leads to high ifn γ production.8 the goal of the current study is to compare the genetic susceptibility of the host to infections by relating the polymorphism of the cytokine gene to any inherited susceptibility and comparing the polymorphism between the study and control groups. pityriasis versicolor aetiologically related to malassezia was chosen to explore this immunological tenet. materials and methods the study is an observational prospective laboratory-based study and included 38 consecutive untreated clinically diagnosed cases of pv irrespective of age and sex recruited from the outpatient department of dermatology of a tertiary care hospital, delhi over a year, january 2012-january 2013. an equal number of healthy volunteers were also included as controls. a clearance from the college ethical committee was obtained as per the institu healthcare in low-resource settings 2023; volume 11:11302 correspondence: shukla das, department of microbiology, room no. 312, university college of medical sciences, gtb hospital, dilshad garden, 110095 new delhi, india. e-mail: cjain@ucms.ac.in key words: cytokine, polymorphism, pityriasis versicolor, snp. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: university college of medical sciences ethical committee approval was taken as per the institutional guidelines before recruiting patients. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. acknowledgments: the authors are grateful for the financial support rendered by university grant commission and intramural research grant. received for publication: 9 march 2023. accepted for publication: 7 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11302 doi:10.4081/hls.2023.11302 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11302] [page 36] tional guidelines before recruiting patients. informed consent was obtained from the patients. three ml venous blood sample in an edta vial was collected aseptically from all patients and healthy controls for dna extraction and subsequent study for single nucleotide polymorphism the diagnosis is based on clinical suspicion, woods lamp (365 nm) examination showing reddish or yellowish green fluorescence and the so-called evoked scale sign.9.10 direct microscopic examinations with 10% koh were done for numerous budding yeast cells and short hyphae characteristic of the ‘spaghetti and meatball’ appearance. blood samples were kept at 40°c till further use. genomic dna extraction genomic dna was extracted from blood samples of all study subjects for determining three snps in two cytokine genes through amplification refractory mutation system-polymerase chain reaction using sequence-specific primers.11 genomic dna was extracted from edta anticoagulated peripheral blood using a hipuratm blood genomic dna extraction kit (himedia laboratories, mumbai, india) following the manufacturer’s instructions. 200µl blood sample was collected in a 2.0ml collection tube, and 20 µl of the reconstituted proteinase k solution (20 mg/ml) was added. the sample was vortexed for 10-15 seconds to ensure thorough mixing. to extract rna-free genomic dna, 20 µl of rnase a solution (20 mg/ml) was added, and the mixture vortexed again for 10-15 seconds. the sample was then incubated for 2 minutes at room temperature (15-250°c). following this, 200 µl of the lysis solution (c1) was added to the sample and vortexed thoroughly for a few seconds to obtain a homogenous mixture. the sample was incubated at 550°c for 10 minutes in a water bath. the lysate for binding to the spin column was prepared as follows; 200 µl ethanol (96-100%) was added to the lysate obtained from the above step and mixed thoroughly by gentle pipetting. lysate was transferred into the spin column provided with the kit and centrifuged at 10,000 rpm for 1 minute. the flow-through liquid was discarded and the column was placed in a new 2.0 ml collection tube; 500µl of diluted pre-wash solution was added to the column and centrifuged at 10,000 rpm for 1 minute. after discarding the flow-through liquid, 500 µl of diluted wash solution was added to the column and centrifuged at 13,00016,000 rpm for 3 minutes to dry the column. flow-through liquid was discarded and a dry spin was given at the same speed to remove the residual ethanol, if any. the column was put in a new 2.0ml collection tube and 200 µl elution buffer was added without spilling to the sides. the column was incubated at room temperature for 5 minutes for a high yield of dna and then centrifuged at 10,000 rpm for 1 minute to elute the dna. the samples were stored at -200c until used. dna samples were subjected to specific pcr reactions in cytokine genotyping. cytokine genotyping by amplification refractory mutations systempolymerase chain reaction (armspcr) amplification refractory mutations system-polymerase chain reaction (armspcr) with sequence-specific primers was used to genotype cytokines from genomic dna (sigma aldrich, banglore, india).7,8 all of the patients and healthy controls were tested for three snps (il10-1082a/g, il10819/592c/t, and ifn +874a/t) in two cytokine genes. the pcr products were loaded onto a 1 percent agarose gel in a specific order for electrophoresis and run at 150 volts for 20-25 minutes for separating the dna. ethidium bromide-stained gel was taken and examined for distinct amplification patterns following electrophoresis. a control band was confirmed to be present in each lane (globulin, 100 bp). the bands in the wells used to detect the cytokines il101082 and il10-819/592 were 258 bp and 233 bp, respectively.7 wells identified the ifnγ +874 cytokines contained a band of 261bp.12 the primer sequence is as follows: il-10 -1082g/a common primer: 5’ – cagtgccaactgagaatttgg – 3’ g allele: 5’ – ctactaaggcttctttgggag – 3’ a allele: 5’ – actactaaggcttctttgggaa – 3’ il-10 -819c/t / -592c/a common primer : 5’ – aggatgtgttccaggctcct – 3’ c allele: 5’ – cccttgtacaggtgatgtaac – 3’ t allele: 5’ – acccttgtacaggtgatgtaat – 3’ ifn-γ +874t/a common primer: 5’ – tcaacaaagctgatactcca – 3’ a allele: 5’ – ttcttacaacacaaaatcaaatca – 3’ t allele: 5’ – ttcttacaacacaaaatcaaatct – 3’ β-globulin (internal control) forward: 5’ acacaactgtgttcactagc – 3’ reverse: 5’ – caacttcatccacgttcacc – 3’ statistical analysis cytokine polymorphisms and genotype frequencies were evaluated by gene counts. the observed and expected genotype frequencies data was analyzed using chi square test. as multiple comparisons were made, bonferroni’s correction was applied to significant p values (p<0.02) that were multiplied for the number of genotypes detected.13 but, as p<0.05 is also considered statistically significant in a small study group, our discussion included all variables considering p<0.05 as significant. results clinically diagnosed patients with pv (n=38; 23 males, 15 females) were included in the study. healthy controls (n=38; 21 males and 17 females) were unrelated individuals without a clinical history of any skin disease were also included. three snps in 2 cytokine genes were investigated in all the subjects by cytokine genotyping using sequence-specific primers. in the case-control study, significant differences in allele, or genotype distribution were observed in il10-819/592c/t (rs1800871: rs1800872) and ifnγ+874t/a (rs2430561) gene polymorphisms (table 1). il10-1082 g/a (rs1800896) genotype and allele frequency was not found to be significant. the distribution of ifn γ+874t/a (p=0.012) and il10-819/592c/t (p=0.036) alleles were significantly different between patients and healthy control. pv patients were more likely to carry the il10-819/592 t allele (p=0.036) and it was significantly associated with the disease (or=0.476, 95% ci 0.236-0.959). ifn γ+874 allele was significantly associated with pv (or=0.424, 95% ci 0.216-0.833). in pv patients, the il10 -819/592 ct genotype frequency was found to be lower (or 0.260, 95% ci 0.0990.683; p=0.005). the cc genotype frequency was found to be higher (p=0.05) in pv patients as compared to healthy controls. similarly, the ifn γ+874 aa genotype frequency was found to be higher (p=0.037) in pv patients than in controls. discussion yeasts of the genus malassezia are part of the normal cutaneous commensal microflora and also an etiologic agent of certain diseases.1 colonization occurs in infancy and reaches its highest concentration after puberty and in early adulthood. malassezia yeast is found in 75 to 78 percent of healthy adults as normal flora of the skin.4,14 malassezia’s pathogenic and commensal stages are not easily distinguished from one another.1 the transition from commensal to pathogenic state is probably a continuum and not an on/off condition. malassezia-associated skin conditions span the whole spectrum between overt inflammatory response (seborrheic dermatitis) and a distinct absence of inflammation article non -co mmerc ial us e o nly (pv). the annual incidence of pv has been reported to range from 5.2 percent to 8.3 percent.15 composition of the cell wall lipids and various metabolites produced by malassezia are known to be responsible for altering the host immunological response and thus preventing the killing of the yeast.3,16 the role of the host immune system in disease manifestation and severity is critical. hence, polymorphism in the genes responsible for cytokine production can influence the susceptibility of the host to develop and manifest the disease. association between specific cytokine gene polymorphism and clinical outcome if found to be significant can determine whether an individual will develop the disorder if he/she carries the particular allele in comparison to the individual without the allele.6 it is important to determine the allelic frequency of both th1 and th2 representative genes as the disease outcome is influenced by their mutual antagonism and therefore individual association may be non-informative.6 so far, immunological studies on the association with pv have been scarce. the interaction of malassezia with the dendritic cells, keratinocytes, and pbmc has led to varied results in different human and animal studies.17,21 il10, a th2 pleiotropic anti-inflammatory cytokine, acts on monocytes and macrophages and downregulates the expression of mhc class ii antigens on antigenpresenting cells. il10 also suppresses the production of nitric oxide and other metabolites responsible for killing pathogens. they also suppress the production of inflammatory mediators e.g. il1, il6, il8, etc. ifn γ is the signature th1 proinflammatory cytokines, responsible for acute flare-up inflammatory responses. along with other cytokines of the th1 subset, it dampens the th2 response. in our study, polymorphism in the gene ifn γ at position +874 t/a in the first intron was identified in pv. ifn γ+874 aa genotype frequency was found to be higher in pv than in controls and the t allele was significantly associated with the disease. this finding is in parallel with other studies suggesting that pv patients may produce a lower level of ifn γ.17-21 we postulate that the time of production and concentration of proinflammatory cytokines during the inflammation process may be critical but a dampened t-cell response was observed due to allelic polymorphisms. the c/t allele of il10-819 was significantly associated with pv. in pv patients compared to healthy controls, the frequency of the il10 -819/592 ct genotype was found to be lower and the frequency of the cc genotype to be higher. the reason for the underlying inflammatory response in pv in the presence of gene polymorphism (il10819/592 cc) which is associated with high production of il-10 in our study, is probably suggestive of th17-induced production of inflammation and hence also explains the neutrophilic infiltration in the pv lesions as documented in studies.5 increased il10 levels have been demonstrated in pbmc challenge studies with malassezia antigens in different patient groups and also in keratinocyte stimulation studies using different species of malassezia.22 the finding also suggests the involvement of the regulatory t cell subset in the pathogenesis of the disease since elevated il10 production as suggested by the genotypic result has been known to be implicated in limiting the development of the inflammatory response towards invading pathogens and allowing its persistence. thus, the development of the disease in the host could be explained, in part, by the th1/ th2 balance. however, a larger number of subjects need to be studied to understand the development of the disease better. the determination of the genetic profile of the host might allow assessing the susceptibility towards the disease and also explain the differential association of a known commensal to cause symptoms in a selected group of population. the association of certain polymorphisms with a disease phenotype needs to be assessed on a larger scale taking into consideration the role of other cytokine mediators to further expand our knowledge regarding the pathogenesis of infectious diseases. these studies on the host factors could pave the way for determining the changing trend of individual-based diagnosis and future treatment.23 the understanding of the disease pathogenesis of pv has been a topic of debate as the malassezia yeasts, a known commensal, is responsible to cause symptoms in only a subset of the population who are colonized with it. our study was able to provide an understanding of the susceptibility of this subset of the population by comparing their genetic profile with the normal population through a study of the cytokine gene polymorphism in the il10 and ifn γ snps. the results reflected a significant level of polymorphism in all the snps. the genotype responsible for higher production of il10 was found to be significantly higher in the patient group as compared to the healthy. and also the proinflammatory response mediated by the ifn γ, determined by the snp in its promoter was found to be in favor of a decreased th1 outcome. in conclusion, the above findings suggest a genetic level of susceptibility in the host toward the development of disease, with the immune response of the host as an important determinant in the hostpathogens’ interaction. article table 1. allele and genotype frequencies of cytokine polymorphisms in pityriasis versicolor patients and healthy controls. cytokine polymorphism pv, n=38 (%) hc, n=38 (%) p value odds ratio 95% ci il10-1082 alleles a 48(63.2) 45(59.2) 0.739 1.181 0.615-2.269 g 28(36.8) 31(40.8) 0.618 0.847 0.441-1.627 genotypes aa 10(26.3) 7(18.4) 0.409 1.582 0.530-4.717 ag 28(73.7) 31(81.6) 0.409 0.632 0.212-1.886 gg 0(0.0) 0(0.0) il10-819/592 alleles c 58(76.3) 46(63.2) 0.036* 2.101 1.043-4.235 t 18(23.763.2) 30(63.2) 0.036* 0.476 0.236-0.959 genotypes cc 21(55.3) 9(23.7) 0.05* 3.980 1.488-10.648 ct 16(42.1) 28(72.7) 0.005*# 0.260 0.099-0.683 tt 1(2.6) 1(2.6) 1.000 1.000 0.060-16.594 ifn g +874 alleles a 55(72.4) 40(52.6) 0.012*# 2.357 1.200-4.629 t 21(27.6) 36(47.4) 0.012*# 0.424 0.216-0.833 genotypes aa 21(55.3) 12(31.6) 0.037* 2.676 1.049-6.827 at 13(34.2) 16(42.1) 0.479 0.715 0..282-1.811 tt 4(10.5) 10(26.3) 0.076 0.329 0.093-1.165 pv, pityriasis versicolor; hc, healthy control; ci, confidence interval; n, number of subjects. *significant according to (p<0.05); #significant according to bonferroni correction (p<0.02). [page 37] [healthcare in low-resource settings 2023; 11:11302] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11302] [page 38] conclusions cytokine gene polymorphism data demonstrated the susceptibility of the host to malassezia infections in our study. data could help to find out who is disease prone, i.e., risk prediction which might influence the use of prophylactic measures, avoid risk factors. this helps in understanding particular pathways used in host resistance to infection and augmenting those using scientific approaches and also devising therapeutic modalities via exogenously supplementing cytokines to balance out the immune response. vaccines targeting specific genes can be developed to resolve cases of chronic and recurrent lesions. detailed further studies might direct individual-based treatment depending on the genetic makeup of the patient. references 1. ashbee hr, evans eg. immunology of diseases associated with malassezia species. clin microbiol rev 2002;15: 21-57. 2. thomas ds, ingham e, bojar ra, holland kt. in vitro modulation of human keratinocyte proand antiinflammatory cytokine production by the capsule of malassezia species. fems immunol med microbiol 2008; 54:203-14. 3. cafarchia c, otranto d. association between phospholipase production by malassezia pachydermatis and skin lesions. j clin microbiol 2004;42:4868-9. 4. choe yb, jang sj, yim sm, ahn kj.the quantitative study on the distribution of malasseziayeasts on the normal skin of the young adults. korean j med mycol 2004;9:174-81. 5. forke r, jäger a, knölker hj. first total synthesis of clausine l and pityriazole, a metabolite of the human pathogenic yeast malassezia furfur. org biomol chem 2008;21:2481-3. 6. carvalho a, cunha c, pasqualotto ac, et al. genetic variability of innate immunity impacts human susceptibility to fungal diseases. int j infect dis, 2010; 14:460-8. 7. afzal ms, tahir s, salman a, et al. analysis of interleukin-10 gene polymorphisms and hepatitis c susceptibility in pakistan. j infect dev ctries 2011;5:473-9. 8. ansari a, hasan z, dawood g, hussain r. differential combination of cytokine and interferon-γ +874 t/a polymorphisms determines disease severity in pulmonary tuberculosis. plos one 2011;6:27848. 9. han a, calcara da, stoecker wv, daly j, siegel dm, shell a. evoked scale sign of tinea versicolor. arch dermatol 2009;145:1078. 10. shi vs, lio pa. diagnosis of pityriasis versicolor in paediatrics: the evoked scale sign. arch dis child 2011;96:392–3. 11. little, s. amplification-refractory mutation system (arms) analysis of point mutations. curr protoc hum genet 2001;9:9.8. 12. manne m, gunde s, kondreddy rk, et al. association of ifn-g+874(t/a) polymorphism with female patients of agerelated cataracts. j ophthalmol 2012;5: 32-6. 13. armstrong ra. when to use the bonferroni correction. ophthalmic physiol opt 2014;34:502-8. 14. ahn, kj. taxonomy of the genus malassezia. korean j med mycol 1998;3:81-8. 15. el-hefnawi h, el-gothamy z, refai m. studies on pityriasis versicolor in egypt. i incidence mykosen 1971;14:225–31. 16. mayser p, gaitanis g. physiology and biochemistry. in: malassezia and the skin. science and clinical practice. 2010th edition. boekhout t, guého e, mayser p, velegraki a, eds. springer, berlin, germany, 2010; p. 121–38. 17. rezaee ma, motaharinia y, hosseini w, et al. natural oils enhance il-10 & ifn gamma production by human pbmcs cultured with malassezia furfur. iran j immunol 2012;9:100-19. 18. buentke e, zargari a, heffler lc, et al. update on the genus malassezia furfur & its allergenic components by human immature cd1a+ dendritic cells. clin exp allergy 2000;30:1759-70. 19. valli jl, williamson a, sharif s, et al. in vitro cytokine responses of peripheral blood mononuclear cells from healthy dogs to distemper virus, malassezia & toxocara. vet immunol immunopathol 2010;134:218-29. 20. akaza n, akamatsu h, takeoka s, et al. increased hydrophobicity in malassezia species correlates with increase proinflammatory cytokine expression in human kertatinocytes. med mycol 2012;50:802-10. 21. buentke e, heffler lc, wallin rp, et al. the allergenic yeast malassezia furfur induces maturation of human dendritic cells. clin exp allergy 2001;31:158393. 22. neuber k, kroger s, gruseck e, et al. effects of pityrosporum ovale on proliferation, immunoglobulin (iga, g, m) synthesis and cytokine (il-2, il-10, ifn gamma) production of peripheral blood mononuclear cells from patients with seborrhoeic dermatitis. arch dermatol res 1996;288:532–6. 23. balestri r, rech g, piraccini b, et al. pityriasis versicolor during anti tnf alpha monoclonal antibody therapy: therapeutic consideration. mycoses 2012;55:444-6. article non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:4800] [page 59] fight against ebola disease: strengthening laboratory framework in low resource settings saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india the 2014 outbreak of ebola disease has uncovered bitter facts about the prevalent health indicators pertaining to people living in low resource settings.1 although, the enemy – ebola virus – was not new, public health authorities have failed miserably in all the affected regions (guinea, sierra leone, liberia, nigeria, and senegal).1,2 despite the fact that health professionals were able to successfully contain the disease in the last twenty of its emergences in different settings, the current outbreak has proved to be way beyond the coping abilities of the public health care delivery systems.2,3 furthermore, the caseload continued to increase at an exponential rate, with a fatality rate of almost 90%, and the virus did not spare health professionals like doctors and paramedical personnel (who are supposed to be well-equipped in comparison with the common men), and all this happened despite the extension of support from international welfare agencies.4,5 although multiple determinants (poverty, weak public health care delivery system, lack of preparedness, failure to involve the community, no isolation wards/dedicated treatment centers/ vaccine, logistics constraints, etc.) played their part, the inability of the stakeholders to ensure prompt detection of confirmed cases (no designated laboratory), remained the crucial element in allowing the disease to progress to epidemic proportions.1,6,7 the current outbreak is caused by the zaire species of the genus ebola virus,8 and its existence in humans is essentially confirmed by laboratory investigations [viz. detection of viral rna by reverse transcriptase polymerase chain reaction (rt-pcr), and/or by detection of ebola antigen by a specific antigen detection test, and/or by detection of immunoglobulin m (igm) antibodies directed against ebola].8,9 establishment of diagnosis carries a lot of importance, as failure to detect even a single case can start a new chain of transmission anywhere around the world, and at the same time can produce an extremely high case fatality rate associated with the disease.3,4 by acknowledging the threat associated with the disease, multiple interventions such as exhaustive case and contact finding (viz. establishing the diagnosis in all suspect/probable cases), effective response to patients and the community (viz. isolation of patients and symptomatic contacts, appropriate and adequate treatment, contact tracing and monitoring each contact for 21 days after exposure, use of personal protective equipments, and maintenance of hand hygiene), and preventive interventions (viz. infection control in health care settings, community education, and avoiding contact with reservoir species), have been proposed to interrupt the chain of transmission and thus the progression of the disease.3,4,6,7,10 exhaustive case and contact finding remains the most crucial step in reducing the incidence of ebola virus disease (evd) cases, and thus ensuring availability of easily accessible diagnostic services in low-resource setting remains the major cause of public health concern.11 in fact, the world health organization has strictly advocated for all the unaffected nations to designate laboratories and build a team of trained personnel to perform laboratory activities efficiently.12 these designated laboratories are bio-safety level (bsl)4/bsl3 facilities, in which competent medical staff are employed to safely collect the appropriate specimens from the patients or ensure safe handling of dead bodies or human remains for post-mortem examination.9,13 however, the success of case finding indirectly depends on the strategy of contact tracing (which assist in prompt identification of symptomatic contacts) in the community, during which if any contact develops symptoms, is immediately referred to the diagnostic laboratories for confirmation of diagnosis of evd, so that subsequent measures can be initiated.13,14 the role of laboratories is not only limited to diagnostic purposes, but it also assists in estimation of the caseload in the catchment area and helps in notification of cases to higher authorities to ensure rational allocation of scarce resources depending on caseload. moreover, it enables clinicians to discharge patients (on obtaining two negative rt-pcr results done at least 48 hours apart) from hospital (shortage of bed in low resource settings).3,9,10 however, amidst all the above mentioned responsibilities, the laboratory personnel should take appropriate preventive measures (e.g. use of personal protective equipments and personal hygiene, etc.) to avoid contracting the illness themselves.9 in conclusion, designating laboratories for ebola virus related work and supporting the same through a team of trained personnel can play an indispensable role in reducing the magnitude of the evd in low resource settings as well as across the globe. references 1. chan m. ebola virus disease in west africa no early end to the outbreak. new engl j med 2014;371:1183-5. 2. cdc. outbreaks chronology: ebola virus disease. atlanta, ga, usa: centers for disease control and prevention; 2014. available from: http://www.cdc.gov /vhf/ebola/outbreaks/history/chronology.ht ml 3. frieden tr, damon i, bell bp, et al. ebola 2014: new challenges, new global response and responsibility. new engl j med 2014; 371:1177-80. 4. who. ebola in west africa: heading for catastrophe? geneva, switzerland: world health organization; 2014. available from: http://www.who.int/csr/disease/ebola/ebola -6-months/west-africa/en/ 5. lefebvre a, fiet c, belpois-duchamp c, et al. case fatality rates of ebola virus diseases: a meta-analysis of world health organization data. med maladies infect 2014;44:412-6. 6. who. ebola virus disease. fact sheet n°103. geneva, switzerland: world health organization; 2014. available from: http://www.who.int/mediacentre/factsheets/fs103/en/ 7. cheng y, li y, yu hj. ebola virus disease: general characteristics, thoughts, and per healthcare in low-resource settings 2014; volume 2:4800 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: ebola virus, laboratories, low-resource settings, public health. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 28 october 2014. accepted for publication: 3 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4800 doi:10.4081/hls.2014.4800 non co mmerc ial us e o nly [page 60] [healthcare in low-resource settings 2014; 2:4800] spectives. biomed environ sci 2014;27:651-3. 8. baize s, pannetier d, oestereich l, et al. emergence of zaire ebola virus disease in guinea. new engl j med 2014;371:1418-25. 9. who. laboratory guidance for the diagnosis of ebola virus disease. interim recommendations. geneva, switzerland: world health organization; 2014. 10. who. who response to the ebola virus disease outbreak: update by the who regional director for africa. geneva, switzerland: world health organization; 2014. 11. briand s, bertherat e, cox p, et al. the international ebola emergency. new engl j med 2014;371:1180-3. 12. hwang es. preparedness for prevention of ebola virus disease. j korean med sci 2014;29:1185. 13. okeke in, manning rs, pfeiffer t. diagnostic schemes for reducing epidemic size of african viral hemorrhagic fever outbreaks. j infect dev ctries 2014;8:114859. 14. kelly jd. make diagnostic centres a priority for ebola crisis. nature 2014;513:145. editorial non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12546 stem cells of the maternal milk allow a better development of lactating newborns gavino faa,1,2 giuseppina pichiri,1 monica piras,1 pierpaolo coni,1 vassilios fanos3 1department of medical sciences and public health, aou cagliari, university of cagliari, italy; 2department of biology, college of science and technology, temple university, philadelphia, united states; 3department of surgical sciences, neonatal intensive care unit, university of cagliari, italy abstract recent findings of stem/progenitor cells in maternal milk and their ability to cross the intestinal barrier of lactating newborns and integrate into neonatal organs to promote optimal child development present a new challenge in perinatal medicine. these findings emphasize the need for all mothers to breastfeed their babies for a long time. according to recent research, breastfeeding protects the lactating newborn from multiple infectious agents that can cause severe and fatal early infancy diseases. the second benefit is that maternal stem cells accelerate the development of several organs, including the brain, protecting lactating infants from severe childhood and adult diseases. the success and diffusion of exclusive breastfeeding, especially in low-resource settings, depends on mothers’ knowledge of the many benefits for their child, including recent discoveries on breastfeeding’s powerful benefits. every mother may need simple booklets to learn about the unique benefits of maternal breastfeeding, including the nutrients and multiple cell types that protect the newborn from infections and accelerate neonatal organ development. social media should also be encouraged to spread news about breastfeeding and maternal stem cells’ impact on lactating infants’ health. health belief model interventions may boost breastfeeding. in conclusion, the discovery of massive amounts of cells in maternal milk and the identification of stem/progenitors with previously unknown potential in newborn development after birth should be considered a new valuable tool for exclusive breastfeeding advocates. data here suggests that every action to spread this message and educate mothers and families about breastfeeding’s irreplaceable role is mandatory. introduction the mammary gland is the only human organ to derive its name from the mother, and this happens in multiple languages including english (mammary gland), greek (mastikós) and italian (mammella) languages. the human milk, produced by mammary glands, has been for a long time considered important for the perinatal development of any newborn, due to its peculiar nutrients, differing in composition from the milk of other mammals. due to this knowledge, breastfeeding has been indicated by the medical community as the preferred method of infant feeding for the first year of life.1 exclusive breastfeeding is considered, even nowadays, the healthiest and simplest method for feeding newborns and for preventing malnutrition.2 more recent studies evidenced a dynamic quality of human milk, with a high interindividual and intraindividual variability regarding the levels of vitamins, minerals, macroand micro-nutrients.3 the human milk stem cells in recent years, some studies have changed completely the debate regarding the role of maternal milk in neonatal development.4 the report that maternal stem cells are present in breast human milk, a finding so unexpected that it was defined “a mystery to be unraveled”.5 these findings encouraged new studies focused on the composition of human breast milk and, particularly, on the cell types detectable in the human milk. first reports from an indian group evidenced that the human milk is a rich source of multipotent mesenchymal stem cells: colostrum was found to contain about 5 million cells per ml, and a breast-fed neonate has been reported to ingest about 108 milk cells per day.6 a modern view of the human breast milk was prospected in further studies. accordingly, the human milk was defined as a dynamic fluid, with all necessary nutrients and growth factors useful for the optimal development of the newborn, but also containing huge amounts of maternal live cells.7 the mix of all constituents was considered fundamental for the optimal growth of the neonate. in following studies, the lactating mammary gland revealed its inticorrespondence: prof. gavino faa, department of medical sciences and public health, aou cagliari, university of cagliari, italy e-mail: gavinofaa@gmail.com key words: stem cells, maternal milk, lactating newborns. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and informed consent: not applicalble. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 5 april 2024. accepted: 12 april 2024. early access: 30 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12546 doi:10.4081/hls.2024.12546 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 376] [healthcare in low-resource settings 2024;12:12546] non -co mmerc ial us e o nly mate nature: to represent a source of a heterogeneous population of breast-derived cells, including exfoliated luminal epithelial cells, immune cells, mesenchymal stem cells and embryonic stem cells, giving rise to a peculiar stem/progenitor cell pool.8 further studies carried out on cells freshly isolated from the human breast milk evidenced a heterogeneous expression of stemness markers in milk staminal cells.9 the recent discovery that a subset of human milk cells may express the transcription factor isl1, a stem cell factor with relevant roles in human development, reinforced the hypothesis on a major role of milk stem cells in the development and growth of lactating neonates.10 at this time, a question emerged from the scientists and clinicians involved in the study of maternal milk:11 which are the potential benefits of the multiple cells detectable in the breast milk for the lactating newborn? an answer to this question was given by a greek researcher, foteini hassiotou, who tried to explain the role of the maternal milk cells in the development of lactating infants. analyzing the milk stem cells, multiple questions arose: are breast milk stem cells heterogeneous? can milk stem cells migrate through the intestinal barrier into the newborn organism? and can maternal stem cells integrate into the organs of the lactating infant and differentiate towards multiple cell types?12 according with this author, breast milk cells should be subdivided into two main groups: immune cells and plastic stem cells. the former may give an immunological support to the newborn, protecting the breast-fed infant from infections, with the production of immunoglobulins, cytokines, lysozyme and lactoferrin. in this vision, immune cells might play a major role in the present of the newborn life, protecting him/her from the infectious agents encountered after delivery, allowing their survival. the second pool of breast milk cells, the stem/progenitor cells, might play a major role in the developmental training of the nursing infant, with shortand long-term positive influences on the infant growth.13 regarding the heterogeneity of milk stem cells, a study by kaanta et al. revealed the existence of different subpopulations inside the milk stem cell pool and identified their immunophenotype. the first group to be identified was that of mesenchymal stem cells, characterized by the following phenotype: cd44+, cd29+, sca-1+, nestin+, vimentin+. the second group included the luminal progenitor cells, characterized by the expression of cd61. the third group included the basal progenitors, with the following immunophenotype: oct4+, sox2+, nanog+. the progenitor cells of the last group were also defined “pregnancy-specific progenitors”.14 as for the ability of stem cells to migrate into the neonatal organism, initially it was claimed that milk stem cells could not survive in the newborn stomach, due to the low ph. this hypothesis was abandoned. old analyses had evidenced that the newborn stomach is characterized by a neutral ph which, associated with the buffering capacity of the milk, may allow the survival of milk stem cells during their passage in the gastrointestinal tract.15 the most important open question on the role of maternal milk stem cells regarded their putative ability to integrate into the organ of the lactating newborn. a brilliant and elegant experimental study carried out by dr. hassiotou gave an answer to this critical question. given that mice may express or not the antigen tdtomato (tdt) on the surface of their cells, tdt-negative newborn mice were breast-fed by a tdt-positive mother. when tdt-negative lactating mice were sacrified, tdt+ cells were found in their stomach, thymus, liver and brain16 of the originally tdt-negative newborns. these findings taken together allowed to state that the milk-derived maternal tdt+ stem cells might cross the stomach wall, reach the portal vein, find homing in the liver and thymus and reach the brain, differentiating into neural stem/progenitors and neurons.16 these data taken together revealed that breast milk stem cells may transfer from the maternal milk to neonatal organs through lactation, and that maternal stem cells can migrate across the intestinal barrier, differentiate towards different cell types, assimilate and integrate with newborn tissues, accelerating their post-natal development. these experimental data had the power of changing completely the debate on the utility of breast-feeding in the postnatal development of any newborn. before the discovery of the huge amounts of cells, particularly of stem/progenitor cells, present in the breast milk, the relevance of breast feeding for the optimal development of newborns was mainly due to the peculiar association of nutrients typical of the human breast milk. the studies demonstrating the ability of maternal stem cells to integrate into the organs of the lactating infant reinforced very much the value of maternal milk for survival and development of lactating newborns. the immune cells of the human milk may assure a big advantage to breast-fed infants against infections, allowing their survival, in spite of the immaturity of their immune system. moreover, the milk pool of stem/progenitor cells may accelerate the development of single organs of the newborn, allowing the acquisition of a proper number of differentiated cells, reinforcing the burden of specialized cells which will represent an important tool against the insurgence of chronic diseases later in life. the ability of maternal milk progenitors to differentiate into metanephric stem cells in the kidney will allow the persistence of nephrogenesis, ending with the evolution of new glomeruli in the renal cortex of the newborns.17 this aid will transform an oligonephronic kidney into a kidney with a burden of glomeruli within the normal range and will transform an individual susceptible to develop renal insufficiency later in life into an individual resistant to the insurgence of chronic kidney disease.18 the ability of maternal milk progenitor cells to differentiate into neurons and glial cells will allow a better development of the brain with relevant positive consequences on the newborn life.19 maternal progenitors which integrate in the brain cortex might increase the number of post-mitotic neurons and glial cells of the cortex, transforming an individual susceptible for neurodegenerative disorders, such ad alzheimer disease, into a resistant subject, due to the increased burden of cortical neurons.20 maternal progenitors integrating into the dopaminergic neurons of the substantia nigra, would increase the burden of neurons able to synthesize dopamine, ending with the resistance of breast-fed infants to develop parkinson disease later in life.21 similar protective actions exerted by maternal milk stem cells may be hypothesized regarding other organs, with relevant positive consequences on the development of multiple chronic diseases of adulthood, including atherosclerosis,22 diabetes,23 infectious diseases like covid-19,24 metabolic syndrome,25 and cancer.26 concluding remarks the recent findings regarding the presence of stem/progenitor cells in the maternal milk, and their ability to cross the intestinal barrier of lactating newborns and integrate into the neonatal organs, contributing to the optimal development of children represents a new challenge in perinatal medicine. these findings reinforce significantly the message on the absolute necessity for all mothers to utilize breastfeeding of their infants for a long period. breastfeeding is characterized, at the best of the more recent knowledge, by two main advantages: it assures an immunological protection of the lactating newborn towards the multiple infectious agents, which may be responsible for severe and lethal diseases of article [healthcare in low-resource settings 2024;12:12546] [page 377] non -co mmerc ial us e o nly early infancy. the second advantage regards the ability of maternal stem cells to accelerate the neonatal development of several organs, including brain, protecting the lactating infants from multiple severe diseases insurging in childhood and in the adult life. mother’s knowledge of the multiple advantages for their little daughter/son, related to the more recent discoveries on the powerful positive effects of breastfeeding, represents a key factor for the success and diffusion of exclusive breastfeeding, particularly in low-resource settings.27 to improve the knowledge of the peculiar value of maternal breastfeeding regarding the nutrients and the multiple cell types able to protect the newborn from infections and able to accelerate the development of the neonatal organs, may need the distribution of simple booklets to every mother, in order to improve their knowledge regarding the gift they are giving to their lactating infant.2 moreover, even the use of social media should be encouraged for a better diffusion of all the news regarding the key role of breastfeeding, adding news regarding the relevant role played by the maternal stem cells for the actual and the future health of lactating infants.28 health belief model interventions may also enhance the breastfeeding success.29 in conclusion, the discovery of the presence of huge amounts of cells in the maternal milk and the identification among them of stem/progenitors with a previously unknown potential in the newborn development after birth, should be considered a new precious tool for people involved in the diffusion of exclusive breastfeeding. every action aimed to diffuse this message, enhancing mothers and family knowledge regarding the irreplaceable role of breastfeeding, appears, on the basis of data here reported, mandatory.20 references 1. picciano mf. nutrient composition of human milk. pediatr clin north am 2001;48:53-67. 2. katmavanti s, paramita f, kurniawan a, et al. the effects of exclusive breastfeeding booklets on mothers’ knowledge in providing exclusive breastfeeding in mataram city, indonesia. healthc low-resour sett 2023;11:11211. 3. samuel tm, zhou q, giuffrida f, et al. nutritional and non-nutritional composition of human milk is modulated by maternal, infant, and methodological factors. front nutr 2020;7:576133. 4. bardanzellu f, peroni dg, fanos v. human breast milk: bioactive components, from stem cells to health outcomes. current nutrition reports 2020;9:1-13. 5. fan y, chong ys, choolani ma, et al. unravelling the mystery of stem/progenitor cells in human breast milk. plosone 2010;5:e14421. 6. patki s, kadam s, chandra v, bhonde r. human breast milk is a rich source of multipotent mesenchymal stem cells. human cell 2010;23:35-40. 7. patki s et al. cytology of the human milk in the first postpartum week – a clinical prospective. j cytol histol 2014;s4:2. 8. sani m, hosseini sm. origins of the breast milk-derived cells: an endeavor to find the cell source. cell biol int 2015;39:611.618.b 9. coni p, piras m, piludu m, et al. exploring cell surface markers and cell-cell interactions of human breast milk stem cells. j public health res 2023;12:22799036221150332. 10. piras m, coni p, piludu m, et al. human breast milk cells are positive for the pioneer transcription factor isl1. eur rev med pharmacol sci 2023;27:8842-9. 11. faa g, fanos v, puddu m, et al. breast milk stem cells: four questions looking for an answer. jpnim 2016;5:050203. 12. hassiotou f. cells in human milk: state of the science. j hum lact 2013;29:171-82. 13. hassiotou f, geddes dt. immune cell-mediated protection of the mammary gland aid the infant during breastfeeding. adv nutr 2015;6:267-275. 14. kaanta as et al. evidence for a multipotent mammary progenitor with pregnancy-specific activity. breast cancer res 2013;15:r65. 15. malcom g, ellwood d, devonald k, beilby r, henderson-smart d. absent or reversed and diastolic flow velocity in the umbilical artery and necrotizing enterocolitis. arch dis childs 1991;66:805807. 16. hassiotou f. differentiation of breast milk stem cells to neural stem cells and neurons. faseb journal 2014;28:216.4 17. faa g, gerosa c, fanni d, et al. morphogenesis and molecular mechanisms involved in human kidney development. cell physiol 2011;227:1257-68. 18. faa g, fanni d, gerosa c, et al. kidney development and susceptibility to develop kidney disease in adulthood. jpn j med 2018;1:217-21. 19. faa g, marcialis ma, ravarino a, et al. fetal programming of the human brain: is there a link with insurgence of neurodegenerative disorders in adulthood? curr med chem 2014;21:3854-76. 20. faa g, manchia m, pintus r, et al. fetal programming of neuropsychiatric disorders. birth defects res (part c) 2016;108:20723. 21. piras m, fanos v, ravarino a, et al. fetal programming of parkinson’s and alzheimer’s diseases: the role of epigenetic factors. j pediatr neonatal individ med 2014;3:e030270. 22. gerosa c, faa g, fanni d, et al. fetal programming of atherosclerosis: may the barker hypothesis explain the susceptibility of a subset of patients to develop stroke or cardiac infarct? eur rev med pharmacol 2021;25:6633-41. 23. yajnik cs. fetal programming of diabetes. still so much to learn. diabetes care 2010;33:1146-8. 24. gerosa c, faa g, fanni d, et al. fetal programming of covid19: may the barker hypothesis explain the susceptibility of a subset of young adults to develop a severe disease? eur rev med pharmacol 2021;25:5876-84. 25. marciniak a, patro-malysza j, kimber-trojnar z, et al. fetal programming of the metabolic syndrome. taiwanese j obstetr gynecol 2007;56:133-8. 26. coghe f, fanni d, gerosa c, et al. the role of fetal programming in human carcinogenesis. may the barker hypothesis explain interindividual variability in susceptibility to cancer insurgence and progression? eur rev med pharmacol sci 2022;26:35853592. 27. kapti re, arief ys, azizah n. mother’s knowledge as a dominant factor for the success of exclusive breastfeeding in indonesia. healthc low-resour sett 2023;11:11209. 28. deswani d, rahmawati de, mulyanti y, et al. social media utilization and knowledge levels in exclusive breastfeeding among mothers in indonesia. healthc low-resour sett 2023;11:11765. 29. safaah n, yunitasari e, prasetyo b, et al enhancing maternal role achievement and breastfeeding success through health belief model intervention. healthc low-resour sett 2024; doi.org/10.4081/hls.2024.11941. 30. kamsatun k. the effect of family empowerment through education and mentoring on increasing knowledge of exclusive breastfeeding. healthcare in low-resource settings 2023;11:11793. article [page 378] [healthcare in low-resource settings 2024;12:12546] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11968 effectiveness of pineapple and papaya leaf combination for dysmenorrhea pain relief in mice (mus musculus) heriza syam,1 siti masitoh,1 ukhradiya magharaniq safira purwanto,1 hasnah muzakkiyah,1 redhalfi fadhila,1 siska mulyani2 1politeknik kesehatan kemenkes jakarta iii, jakarta; 2tinggi ilmu kesehatan payung negeri, pekanbaru, indonesia abstract dysmenorrhea is a common gynecological condition in women, often attributed to excessive prostaglandin production, significantly impacting daily activities. papaya leaves, known for their medicinal properties, are a chosen herbal remedy, albeit with a bitter taste, necessitating combination with pineapple fruit. this study aimed to assess the effectiveness of a combination of papaya leaf extract and pineapple fruit as an alternative treatment for primary dysmenorrhea. in an experimental research design employing the posttest-only control group, 32 male mice were divided into seven groups, injected with acetic acid as a pain inducer, and their writhing responses were recorded for 45 minutes at 15minute intervals. data analysis using the anova test revealed significant differences in the number of writhing responses in mice (p<0.05) compared to the positive control group, followed by the duncan test. the percentage of analgesic protection was as follows: mefenamic acid (61.01%), pineapple fruit extract (62.78%), papaya leaf extract (63.39%), a combination of pineapple and papaya leaf extracts with a dose ratio of 3:1 (73.21%), 2:2 (47.32%), and 1:3 (37.78%). in conclusion, the combination of pineapple extract and papaya leaves in a dose ratio of 3:1 demonstrated the most effective pain reduction. introduction dysmenorrhea is the term for pain and cramps in the pelvis experienced by women during menstruation.1 the pain is caused by contractions of the uterine wall due to the high production of uterine prostaglandins (pgf2α and pgf2).2 in general, dysmenorrhea is more common in young women of reproductive age, with the highest occurrence in adolescents, and has a prevalence variation between 60% to 90%.3,4 according to ju et al. (2014),5 several developed countries have a fairly large prevalence of dysmenorrhea women, such as australia with a number of dysmenorrhea women at 71.7%, while japan has a presentation of dysmenorrhea women at 76.1%. in indonesia, there is uncertainty regarding the prevalence of dysmenorrhea. a previous epidemiological study noted that out of 240 women in central jakarta aged 11-22 years, 87.5% of the respondents had primary dysmenorrhea with details of mild symptoms (20.48%), moderate symptoms (64.76%), and severe symptoms (14.76%). although not considered a life-threatening disorder, dysmenorrhea can affect the quality of life and social relationships of women who have it.6 not only is the number of incidents quite high, but dysmenorrhea is also a gynecological condition that greatly interferes with women’s daily activities.7 severe symptoms experienced by women have been described as characteristically sharp and intermittent, felt in the suprapubic area, which worsens in the first few hours of menstruation and culminates with maximum blood flow.8 moreover, severe symptoms are accompanied by systemic symptoms such as nausea, vomiting, diarrhea, fatigue, fever, and insomnia. due to these severe symptoms, some women (3-33%) require 1-3 days of complete rest every menstrual cycle, leading to absenteeism from school or work. according to world health organization (who) data in indonesia, 15% of individuals with dysmenorrhea complain of limited activities due to the discomfort correspondence: heriza syam, politeknik kesehatan kemenkes jakarta iii, jakarta, indonesia. e-mail: heriza@poltekkesjakarta3.ac.id key words: papaya leaves, pineapple fruit, primary dysmenorrhea, reducing pain. contributions: hs conceptualization, collected the data, formal analysis, methodology, visualization, writing – original draft, review and editing; sm investigation, methodology, validation; umsp conceptualization, methodology, writing – original draft. hm conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rm conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; smu data curation, formal analysis, methodology, validation, visualization, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: all ethical procedures used in this study follow the national institute of health guidelines for the case and use of laboratory animals (nrc 1996) and have been approved by the ethics committee of the pharmacology department of faculty medicine, university of north sumatera with no. 0859 / kephfmipa/2021 patient consent for publication: this research was conducted on experimental animals. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 1 october 2023. accepted: 23 january 2024. early access: 23 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11968 doi:10.4081/hls.2024.11968 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11968] [page 403] non -co mmerc ial us e o nly of this gynecological condition. there is even data indicating that almost 10% of female students are absent each month due to illness, whether related to dysmenorrhea or other causes.9 there are several ways to relieve the symptoms of dysmenorrhea, including reducing physical activity, taking pain relievers, and using herbs.7,8,10 the main cause of dysmenorrhea is the overproduction of pain precursors, namely prostaglandins; thus, the pain relievers and herbs consumed aim to reduce prostaglandin production.8 non-steroidal anti-inflammatory drugs (nsaids) such as ibuprofen are commonly used to relieve pain, but they come with side effects such as headache, dizziness, dysuria, drowsiness, loss of appetite, nausea, acne, acute increase in asthma, vomiting, and gastrointestinal bleeding.11 consequently, many phytotherapeutic treatments have been developed to minimize side effects in addressing dysmenorrhea. herbal medicine can serve as an alternative to nsaids, effectively reducing menstrual pain.10 research conducted by abidah in 2017 demonstrated that papaya leaf extract reduced menstrual pain levels and prostaglandin levels in primary dysmenorrhea.12 while papaya leaves have been studied for their ability to alleviate dysmenorrhea symptoms,13 their very bitter taste necessitates the addition of a flavoring agent to maintain the essence without compromising palatability. the inclusion of organic acids from fruits, known to mask the bitter taste of papaya leaves, is a viable option.14 pineapple fruit, with its organic acids, can be an alternative to mitigate the bitter taste. additionally, the bromelain enzyme content in pineapple has analgesic activity, supporting the analgesic effects of papaya leaf extract.15 the combination formulation is expected to have a potentiating effect without causing contraindicated effects. several studies have explored the treatment of primary dysmenorrhea using papaya leaves and pineapple fruit in the form of juice or extract, but research on the combination of pineapple fruit extract and papaya leaves has not been undertaken before. therefore, researchers are interested in understanding the analgesic activity of a combination of papaya leaf extract and pineapple fruit as a treatment for primary dysmenorrhea. this study was conducted to determine the effectiveness and optimal combination of papaya leaf extract and pineapple fruit in treating symptoms of primary dysmenorrhea using animal models. materials and methods research design this study was an experimental study with a posttest-only control group design, aiming to test the effectiveness of the combination of papaya leaves and pineapple fruit as a treatment for primary dysmenorrhea. plant materials the papaya leaves used in this study came from the bekasi area, weighing approximately 5 kg. the leaves were selected based on age, ensuring they were neither too old nor too young, and were fresh, green in color, and not wilted or diseased. for this study, bogor honey pineapple weighing approximately 2.8 kg was used. the selected pineapple was a young pineapple with a pale-yellow color and a slightly hard texture. preparation of extract papaya leaves were cleaned and cut into several pieces, then dried in an oven at 50°c for approximately 3 days. the dried papaya leaves were then mashed into a powder. the extraction method used was maceration, with a sample and solvent ratio of 1:5. maceration was repeated three times. the obtained macerate was filtered, collected, and then evaporated with a vacuum evaporator at 40°c.16 pineapple fruit was washed, cut into small pieces, and then blended with ice cubes and phosphate buffer at ph 7. the blended pineapple fruit was filtered three times. the filter results were centrifuged at 3000 rpm at 4°c for 20 minutes. the supernatant obtained was separated from the pellet and stored in the freezer. furthermore, the centrifuged filtrate underwent the freeze-drying method at 40°c to obtain the crude extract of pineapple fruit.17 determination of total flavonoids the total flavonoid assay was conducted using the aluminium chloride-based method.18 this quantitative method measures total flavonoids based on a standard curve equivalent to quercetin. quercetin standards were prepared with a concentration series of 1, 5, 10, 15, and 20 mg/ml, respectively, with ethanol as the solvent. subsequently, 0.5 ml of the standard solution was pipetted separately into a test tube, and then 0.1 ml of 10% alcl3, 1.5 ml of ethanol, 0.1 ml of sodium acetate, and 2.8 ml of water were added. the solution was shaken, allowed to stand for 30 minutes, and then measured at an absorbance of approximately 425 nm using uv-vis spectrophotometry. samples were prepared at a concentration of 3000 ppm, reacted, and measured according to standards. the total flavonoid concentration of the sample was determined from the calibration curve. the percentage of total flavonoids as quercetin in the extract, using the standard curve, is calculated using the following formula:19 information: cp = flavonoid content of the extract v = volume of test solution before dilution f = dilution factor of the test solution w = weight of test material protein level test measurement of the protein content of pineapple extract was conducted based on the bradford test method (1976). bovine serum albumin (bsa) was used as a standard with concentrations of 0, 0.0625, 0.125, 0.25, and 0.5 mg/ml, each with a volume of 10 ml. to perform the test, 25 µl of each bsa concentration was pipetted into a new test tube, and 1.25 ml of bradford reagent was added. the solution was homogenized with a vortex and then incubated for 5 minutes. after incubation, the absorbance of the solution was measured at a wavelength of 595 nm. the concentration and absorbance data of the standards were expressed as x and y, respectively, and connected to form the graph of the linear regression equation. for the measurement of the protein content of pineapple extract, 25 µl of the extract was pipetted into a test tube, and 1.25 ml of bradford reagent was added. the solution was homogenized with a vortex and then incubated for 5 minutes. after incubation, the absorbance of the solution was measured at a wavelength of 595 nm, and this process was repeated three times. the absorbance data (y) of the sample were entered into the standard regression equation to determine the protein content of the pineapple extract. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 404] [healthcare in low-resource settings 2024;12:11968] non -co mmerc ial us e o nly preparation of mice the experimental subjects consisted of healthy male mice (mus musculus) aged 2-3 months, weighing between 20-30 grams. the sample size, determined using the federer formula with a 20% dropout addition, totaled 28 mice. before treatment, the mice underwent a 2-week to 1-month adaptation period, during which they were provided ad libitum access to water and cp 552 type pellet feed for approximately 8-12 hours daily. the mice were housed in stainless steel cages measuring 30 x 20 x 20 cm, featuring a cage bottom covered by 1 cm thick husks replaced every three days. the cages were situated in a well-ventilated room with indirect sunlight, and cleanliness was maintained by cleaning drums and feeding areas at least three times a week. to ensure randomization, the samples were divided into 7 groups using the simple random sampling method, where each mouse was assigned a number and then randomly selected by the researchers. analgesic assay (in vivo test) the test for the analgesic effect of the extract is conducted following the procedure outlined in reference.16 the analgesic power test was conducted on male mice (m. musculus) using the chemical excitatory method with a 1% acetic acid solution as the pain inducer. the papaya leaf and pineapple fruit extract were prepared as a stock solution of 20 ml, then administered to mice in a quantity of 1 ml. after a 30-minute interval following the extract administration, mice in each treatment group were injected with 1% acetic acid, also in a volume of 1 ml, using an aqueous solvent. mice subjected to the acetic acid-inducing solution exhibited pain endurance by wriggling on the abdomen and retracting their legs. the observed and calculated amount of writhing was monitored over a 45-minute period at 15-minute intervals. determination of analgesic protection the evaluation of analgesic activity using the acetic acid induction method involves assessing the percent protection and percent effectiveness of the analgesic. the percentage protection against acetic acid is determined by comparing the number of stretches in each group to the control and calculating the percentage reduction in stretching. the formula for calculating analgesic protection is as follows:20 analgesic protection here, nc represents the number of stretches in the negative control, and nt represents the number of stretches in the test animals from each treatment group. the percent analgesic can be determined from the difference in the amount of stretching, nc nt. experimental design the combination dose was prepared at 500 mg/kg body weight. considering the average weight of mice is 20 g, the dose variation was 10 mg per 20 g body weight. oral administration to mice is restricted to a maximum volume of 1 ml. therefore, a stock of 20 ml is created, containing 200 mg of extract, ensuring that each ml contains 10 mg of extract. the mice were divided into seven groups, each with four repetitions, based on the treatment, as outlined in the following table 1. statistical analysis spss 2.5 software was used to analyze data on mice’s wriggling results. all data are presented in the form of an average value and standard deviation. the data were analyzed using one-way analysis of variance (anova), followed by duncan’s test. data with a p value <0.05 are considered significant. ethical considerations all mice used were obtained from the laboratory of the department of pharmacology, faculty of medicine, university of north sumatra in indonesia. the mice were housed in stainlesssteel cages measuring 30 x 20 cm and were fed cp 552 type pellets during the treatment period. all ethical procedures used in this study adhere to the national institute of health guidelines for the care and use of laboratory animals (nrc 1996) and have been approved by the ethics committee of the pharmacology department of fk usu with no. 0859/keph-fmipa/2021. results quantitative phytochemical of papaya leaf and pineapple extract based on table 2, the results of the total flavonoid test showed that papaya leaf extract with a concentration of 3,000 µg/ml had a flavonoid content of 12.034 mg ek/g extract or 1.2034%. the protein content test of pineapple extract was carried out using the bradford method, where the protein content was obtained from the linear regression equation of the bovine serum albumin (bsa) cal transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. single extract dose and combination administration in mice groups. group treatment pineapple fruit extract papaya leaf extract (dose mg/kg bw) (dose mg/kg bw) 1 positive control mefenamic acid 0.13 ml/20 g bw (k+) 2 negative control na-cmc 0.5% 20 ml (k-) 3 pineapple fruit extract 500 4 papaya leaf extract 500 5 combination of pineapple fruit extract and papaya leaves in a 3:1 dosage ratio 375125 6 combination of pineapple fruit extract and papaya leaves in a 2:2 dosage ratio 250250 7 combination of pineapple fruit extract and papaya leaves in a 1:3 dosage ratio 125375 bw, body weight. [healthcare in low-resource settings 2024;12:11968] [page 405] non -co mmerc ial us e o nly ibration curve. the results of the protein content test showed that pineapple fruit extract contained a relatively high amount of protein. effectiveness of combination papaya leaf and pineapple extract in mice data on the number of mice writhing are presented in figure 1. stretching symptoms that arise are observed for 45 minutes with an interval of 15 minutes. the writhing response is in the form of the legs and stomach being pulled back due to the pain caused by acetic acid induction. mice injected with 50% na-cmc had the highest number of stretches. this indicates that the 50% na-cmc solution has no effect on relieving pain because it has no active substance and does not cause bias. of all the sample extracts tested, both single extracts and a combination of extracts from papaya leaves and pineapple fruit were able to reduce the amount of stretching. the amount of writhing that decreased with time intervals indicated that the combination of extracts was able to relieve pain caused by acetic acid induction. based on the anova analysis at the 5% test level, the number of ticks in the mice showed significantly different results (p <0.05) compared to the positive control group, so duncan’s further test was carried out. of the 7 test groups, it can be seen that the combination of pineapple and papaya leaf extracts with a ratio of 3:1 is the combination that produces the least wriggling of mice with an average of 22.5 writhing and with a decrease in the amount of writhing as the test time increases (table 3). these results were better when compared with the positive control mefenamic acid. from duncan’s test, it can be concluded that the mice injected with the negative control had the highest number of stretches. mefenamic acid injection as a positive control showed analgesic protection of 61.01%. meanwhile, each single extract of papaya leaf and pineapple fruit produced analgesic protection of 63.39% and 62.78%, respectively. the highest analgesic protection was produced by the test sample that resulted in the least amount of writhing, namely the combination of extracts of pineapple and papaya leaf in a ratio of 3:1, with an analgesic protection of 73.21%. discussion this study assessed the analgesic potential of a papaya or carica papaya leaves extract (cpe) and pineapple or ananas comosus extract (ace) combination for alleviating primary dysmenorrhea pain, a condition characterized by lower abdominal pain before and during menstruation without pelvic damage.7,21 the pain’s onset involves complex pathways, including hormonal changes, anti-inflammatory responses, and immune system activity. prostaglandin overproduction, particularly prostaglandins f2α and e2, is considered a primary cause of dysmenorrhea,2,22 linked to hormonal changes such as decreased progesterone levels due to factors like stress and diet.23,24 the prolonged presence of arachidonic acid, coupled with menstruation-related intracellular damage, contributes to excessive prostaglandin production.2,25 this overproduction can result in uterine hypercontraction, vasoconstriction, ischemia, hypoxia, and inflammatory responses, releasing pro-inflammatory molecules like cytokines, bradykinins, and prostaglandins.22,26 these molecules activate receptors on nociceptor neurons, increasing sensitivity and triggering pain perception. additionally, prostaglandins act as sensitizing agents, lowering the nociceptive activation threshold and potentially leading to hyperalgesia, allodynia, and increased pain perception.27,28 the combination of cpe and ace, administered in mice using the acetic-acid writhing test, demonstrated significant analgesic activity by reducing writhing and increasing percent protection. this aligns with prior research, which established the analgesic properties of cpe and ace.29 cpe acts as a peripheral analgesic, blocking pain transmission to the peripheral or central nervous system. ace exhibits antinociceptive activity, reducing pain in the acetic-acid writhing test model.30 other studies also mention that pineapple juice and papaya leaves can reduce menstrual pain levels and prostaglandin levels in individuals with dysmenorrhea.12,31 the combined cpe and ace in this study effectively reduced pain in acetic acid-induced mouse models, attributed to flavonoids. cpe’s flavonoids inhibit prostaglandin production by blocking cox-1, cox-2, and 5-lipoxygenase active sites, and suppressing cox-2 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. flavonoids and protein levels in papaya leaf and pineapple extracts. phytochemistry extract qualitative quantitative flavonoids + 12.034 mg ek/g extract proteins + 0.275 mg/ml table 3. treatment group writhing time (45 minutes). group the amount of stretching average ± sd 1 2 3 4 negative control (na-cmc) 98 88 82 68 84±12.54 positive control (mefenamic acid) 39 30 34 28 32.75±4.85abc pineapple extract 30 31 30 34 31.25±1.89ab papaya leaf extract 38 32 29 24 30.75±5.85ab combination of pineapple extract and papaya leaf 3:1 30 26 22 12 22.5±7.72a combination of pineapple extract and papaya leaf 2:2 39 38 31 69 44.25±16.88bc a combination of pineapple and papaya extracts 1:3 55 54 53 47 52.25±3.59c *a, b, c, d different letters indicate a significant difference between samples at the 5% level of significance (duncan's test). *sd, standard deviation. [page 406] [healthcare in low-resource settings 2024;12:11968] non -co mmerc ial us e o nly gene expression.32,33 ace is known to contain the enzyme bromelain, which can serve as an alternative to nsaids in the treatment of pain due to its analgesic and anti-inflammatory activity.34 numerous studies have highlighted the anti-inflammatory and analgesic properties of bromelain, elucidating various mechanisms and pathways. among these, the most prominent is bromelain’s ability to reduce bradykinin levels, a pain mediator.35 the reduction in bradykinin levels occurs through the inhibition of bradykinin synthesis at the inflammation site, achieved by depleting plasma kallikrein and inhibiting plasma exudation with bromelain.36 in addition to its impact on the bradykinin pathway, bromelain has been reported to induce a decrease in prostaglandin e2 concentrations by inhibiting cox-2 and reducing glutamate concentrations, a neurotransmitter involved in pain perception.37,38 the analgesic activity of the ace and cpe combination was assessed using an intraperitoneal acetic acid-induced writhing model, a common method to evaluate peripheral analgesic activity.39 acetic acid injection induces visceral pain by releasing endogenous pro-inflammatory mediators, including prostaglandins, serotonin, and bradykinin, stimulating peripheral nociceptive neurons and causing pain and stretching responses.26,30,40 the local inflammatory response involves the release of arachidonic acid via cox-1 and cox-2, impacting the biosynthesis of prostaglandins e2 and f2 (pge2, pgf2).41 nociception from acetic acid injection is linked to cytokine release from mast cells and resident macrophages, including interleukin (il-1β, il-8) and tumor necrosis factor-alpha (tnf-α).42 the tested compounds’ analgesic activity was determined by reduced total nociceptive score and writhing frequency, along with an increased protection percentage, manifesting as back arching, abdominal muscle contraction, and hind limb stretching.43 the ace and cpe combination significantly exhibited analgesic activity, suggesting potential intervention in the prostaglandin pathway. further research, including testing prostaglandin levels and evaluating the combination’s impact on pro-inflammatory mediators like il-1β, il-8, tnf-α, and cox-2 expression, is warranted to understand its mechanisms in primary dysmenorrhea intervention.44,45 while the acetic acid injection stretch model is recognized for simplicity and sensitivity in assessing analgesic activity, it may yield false-positive results due to its lack of selectivity. therefore, additional testing methods, such as the formalin test, which mimics acute and chronic pain through neurogenic and central nociceptive mechanisms, should be employed to confirm the analgesic activity of the ace and cpe combination.46 furthermore, an oxytocininduced writhing test is recommended to assess pain inhibition of uterine hypercontraction in cases of primary dysmenorrhea.26 in conclusion, the analgesic effects of the ace and cpe combination were demonstrated in the acetic acid-induced writhing model, suggesting a potential intervention in the prostaglandin pathway. however, further research, including the assessment of prostaglandin levels and the impact on pro-inflammatory mediators, is needed to fully understand the mechanisms involved in the combination’s role in primary dysmenorrhea. additionally, employing more selective testing methods will enhance the validity of the findings. conclusions administration of papaya leaf extract and pineapple fruit, either as a single dose or in various combinations, exhibits analgesic activity in mice induced with acetic acid. among the five extract groups, the combination of pineapple extract and papaya leaves in a 3:1 ratio demonstrates the most effective pain relief. this combination proves to be comparable to mefenamic acid, the positive control. further research is warranted, such as geliat tests with formalin and oxytocin, along with assessments of prostaglandin levels, il-1β, il-8, tnf-α, and cox-2 expression levels. these investigations aim to elucidate the mechanisms underlying the impact of the combined extract of pineapple fruit and papaya leaves on primary dysmenorrhea pain. additionally, this study should extend its scope to include research on adolescents with primary dysmenorrhea, subjecting them to acute, chronic, and sub-chronic toxicity tests involving the combination of pineapple fruit extract and papaya leaves. references 1 nursalam n, oktaviani dwdwd, armini nkaka, efendi f. analysis of the stressor and coping strategies of adolescents with dysmenorrhoea. indian j public heal res dev 2018;9:381–6. 2 iacovides s, avidon i, baker fc. what we know about primary dysmenorrhea today: a critical review. hum reprod update 2015;21:762–78. 3 sumaryani s, puspita sari pi. ar rahman-based dysmenorrhea gymnastic to reduce pain. j ners 2015; 10:360–5. 4 noor s, norfitri r. the changes of premenstrual symptoms after aerobic exercise intervention. j ners 2015;10:38–47. 5 ju h, jones m, mishra g. the prevalence and risk factors of dysmenorrhea. epidemiol rev 2014;36:104–13. 6 najafi n, khalkhali h, moghaddam tabrizi f, zarrin r. major dietary patterns in relation to menstrual pain: a nested case control study. bmc womens health 2018;18:69. 7 kusumaningrum t, nastiti aa, dewi lc, lutfiani a. the correlation between physical activity and primary dysmenorrhea in female adolescents. indian j public heal res dev 2019;10:2559–63. 8 handayani sg, ayubi n, komaini a, et al. n-3 polyunsaturated fatty acids (pufas) and physical exercise have the potential to reduce pain intensity in women with primary dysmenorrhea: transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. graph of the percentage of analgesic protection for each test group. (ma: mefenamic acid; ace: ananas comosus extract; cpe: carica papaya leaves extract; 3ace:1cpe: combination of ananas comasus (pineapple) extract and papaya leaf 3:1 etc). [healthcare in low-resource settings 2024;12:11968] [page 407] non -co mmerc ial us e o nly systematic review. retos 2023;48:106–12. 9 yuliani p, estu n. hubungan antara dismenorea dengan aktivitas belajar siswa smp n 4 boyolali. j kebidanan 2011;20–6. 10 imandiri a, faizah r, rakhmawati. acupuncture and papaya leaf powder (carica papaya l) to treat dysmenorrhea. malaysian j med heal sci 2019;15:37–9. 11 ogunfowokan aa, babatunde oa. management of primary dysmenorrhea by school adolescents in ile-ife, nigeria. j sch nurs 2010;26:131–6. 12 abidah sn, hadisaputro s, runjati r, et al. effect of carica papaya l leaf on menstrual pain and prostaglandin level in adolescent with primary dysmenorrhea: a true experiment. belitung nurs j 2017;3:198–204. 13 octavianus s, lolo wa. uji efek analgetik ekstrak etanol daun pepaya (carica papaya l) pada mencit putih jantan (mus mucculus). pharmacon 2014;3:87–92. 14 sudarwati tpl, kusumo gg, hanny ferry fernanda ma, et al. bioautography of ethanol extract from carica papaya leaves for antimicrobial activity against staphylococcus aureus, e. coli and bacillus subtillis. ecol environ conserv 2021;27:917–20. 15 goel b, maurya nk. overview on: herbs use in treatment of primary dysmenorrhea (menstrual cramps). adv zool bot 2019;7:47–52. 16 amran n. efek analgetik kombinasi ekstrak buah belimbing wuluh (averrhoa bilimbi l) dan ekstrak daun pepaya (carica papaya l.) pada mencit (mus musculus). as-syifaa j farm 2018;10:213–20. 17 amalia f, abrori c, sutejo ir, kalimantan j. efektivitas analgesik kombinasi parasetamol dan ekstrak kasar nanas terhadap refleks geliat mencit yang diinduksi asam asetat. 2017;5:6. 18 courtney a, ed. formularies. pocket handbook of nonhuman primate clinical medicine, taylor and francis, boca raton, 2012; p. 213–8. 19 yusuf h, husna f, gani ba, garrido g. the chemical composition of the ethanolic extract from chromolaena odorata leaves correlates with the cytotoxicity exhibited against colorectal and breast cancer cell lines. j pharm pharmacogn res. 2021;9(3):344–56. 20 gupta ak, parasar d, sagar a, et al. analgesic and antiinflammatory properties of gelsolin in acetic acid induced writhing, tail immersion and carrageenan induced paw edema in mice. plos one 2015;10:e0135558. 21 dawood my. dysmenorrhoea and prostaglandins: pharmacological and therapeutic considerations. curr ther (seaforth) 1982;23:71–83. 22 barcikowska z, rajkowska-labon e, grzybowska me, et al. inflammatory markers in dysmenorrhea and therapeutic options. int j environ res public health 2020;17:1191. 23 masruroh l, muniroh l. the correlation between nutritional status and calcium adequace level on the incidence of premenstrual syndrome (pms) in female students at the faculty of public health universitas airlangga. indones j public heal 2021;16:426–36. 24 armini nka, zahriya an, hidayati l, dewi ki. physical activity and anxiety with complaints of pms in adolescents during the covid-19 pandemic. int j public heal sci 2022;11:601–6. 25 itani r, soubra l, karout s, et al. primary dysmenorrhea: pathophysiology, diagnosis, and treatment updates. korean j fam med 2022;43:101–8. 26 wong j, chiang yf, shih yh, et al. salvia sclarea l. essential oil extract and its antioxidative phytochemical sclareol inhibit oxytocin-induced uterine hypercontraction dysmenorrhea model by inhibiting the ca2+–mlck–mlc20 signaling cascade: an ex vivo and in vivo study. antioxidants 2020;9:1–16. 27 kidd bl, urban la. mechanisms of inflammatory pain. br j anaesth 2001;87:3–11. 28 yam mf, loh yc, tan cs, et al. general pathways of pain sensation and the major neurotransmitters involved in pain regulation. int j mol sci 2018;19:2164. 29 anaga ao, onehi e v. antinociceptive and anti-inflammatory effects of the methanol seed extract of carica papaya in mice and rats. african j pharm pharmacol 2010;4:140–4. 30 ajayi am, coker ai, oyebanjo ot, et al. ananas comosus (l) merrill (pineapple) fruit peel extract demonstrates antimalarial, anti-nociceptive and anti-inflammatory activities in experimental models. j ethnopharmacol 2022;282:114576. 31 wrisnijati d, wiboworini b, sugiarto s. effects of pineapple juice and ginger drink for relieving primary dysmenorrhea pain among adolescents. indones j med 2019;4:96–104. 32 verri wa, vicentini ftmc, baracat mm, et al. flavonoids as anti-inflammatory and analgesic drugs: mechanisms of action and perspectives in the development of pharmaceutical forms. 1st ed. vol. 36, studies in natural products chemistry. elsevier b.v., 2012; 297–330 p. 33 ferraz cr, carvalho tt, manchope mf, artero na, rasqueloliveira fs, fattori v, et al. therapeutic potential of flavonoids in pain and inflammation: mechanisms of action, pre-clinical and clinical data, and pharmaceutical development. molecules 2020;25:1–35. 34 pavan r, jain s, shraddha, kumar a. properties and therapeutic application of bromelain: a review. biotechnol res int 2012;2012:1–6. 35 brien s, lewith g, walker a, et al. bromelain as a treatment for osteoarthritis: a review of clinical studies. evidencebased complement altern med 2004;1:251–7. 36 kumakura s, yamashita m, tsurufuji s. effect of bromelain on kaolin-induced inflammation in rats. eur j pharmacol 1988;150:295–301. 37 helmy sa, el-bedaiwy hm, el-masry sm. effect of pineapple juice on the pharmacokinetics of celecoxib and montelukast in humans. ther deliv 2020;11:301–11. 38 bakare ao, owoyele bv. bromelain reduced pro-inflammatory mediators as a common pathway that mediate antinociceptive and anti-anxiety effects in sciatic nerve ligated wistar rats. sci rep 2021;11:1–13. 39 ma h, su s, duan j, et al. evaluation of the analgesic activities of the crude aqueous extract and fractions of shao fu zhu yu decoction. pharm biol 2011;49:137–45. 40 zendehdel m, torabi z, hassanpour s. antinociceptive mechanisms of bunium persicum essential oil in the mouse writhing test: role of opioidergic and histaminergic systems. vet med (praha) 2015;60:63–70. 41 uddin mj, reza asma, abdullah-al-mamun m, et al. antinociceptive and anxiolytic and sedative effects of methanol extract of anisomeles indica: an experimental assessment in mice and computer aided models. front pharmacol 2018;9:1–16. 42 ribeiro ra, vale ml, thomazzi sm, et al. involvement of resident macrophages and mast cells in the writhing nociceptive response induced by zymosan and acetic acid in mice. eur j pharmacol 2000;387:111–8. 43 gawade sp. acetic acid induced painful endogenous infliction transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 408] [healthcare in low-resource settings 2024;12:11968] non -co mmerc ial us e o nly in writhing test on mice. j pharmacol pharmacother 2012;3:348. 44 jahan h, siddiqui nn, iqbal s, et al. suppression of cox2/pge2 levels by carbazole-linked triazoles via modulating methylglyoxal-ages and glucose-ages – induced ros/nfκb signaling in monocytes. cell signal 2022;97. 45 aminuddin m, sargowo d, sardjono tw, widjiati w. curcuma longa supplementation reduces mda, tnf-α, and il-6 levels in a rat model exposed to soot particulates. open vet j 2023;13:11–9. 46 henneh it, armah fa, ameyaw eo, et al. analgesic effect of ziziphus abyssinica involves inhibition of inflammatory mediators and modulation of katp channels, opioidergic and nitrergic pathways. front pharmacol 2021;12:1–15. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11968] [page 409] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11969 the relationship between clinical education and nursing students’ patient safety competencies dyah wiji puspita sari,1,2 yuni sufyanti arief,3 ahsan ahsan4 1doctoral program in nursing, department of nursing management, faculty of nursing, universitas airlangga, surabaya; 2department of nursing management, faculty of nursing, universitas islam sultan agung, semarang; 3department of pediatric nursing, faculty of nursing, universitas airlangga, surabaya; 4department of nursing management, faculty of nursing, universitas brawijaya, malang, indonesia abstract students play a crucial role in contributing to patient safety issues, a contribution that is significantly influenced by the implementation of clinical education. this study aimed to investigate the impact of clinical education on the achievement of patient safety goal competencies among nursing students. a cross-sectional study was conducted among 125 students in a nursing professional program at sultan agung hospital in semarang, central java, indonesia. a total sampling technique was employed for sample recruitment. data for the dependent variable were collected using an observation sheet, while data for the independent variable were collected using a structured questionnaire. bivariate data analysis was performed using the chi-square test. the bivariate analysis revealed a significant relationship between the implementation of clinical education and the achievement of patient safety goal competencies, with a p-value of 0.000 (p < 0.05) and a correlation coefficient of 0.609. the achievement of patient safety goal competencies can be facilitated through the implementation of optimal clinical education. therefore, the implementation of clinical education must include a clinical education model based on the community of practice, making it easier for students to implement patient safety goals. introduction patient safety incidents remain a prominent global concern in the delivery of healthcare services.1 students contribute to patient safety issues, which can have various impacts on patients.2 previous research results indicate that students’ knowledge of patient safety concepts, including infection prevention and control, as well as medication safety, is still inadequate.3 dauphinee’s research results show that this low level of knowledge results in students’ limited ability to apply patient safety skills, thereby increasing the risk of patient safety incidents occurring.4 as many as 44.7% of a total of 889 final-year nursing students showed that their level of knowledge regarding the patient safety domain was declared competent, which means that more than half or 55.3% were not competent.3 in addition, almost 60% of 829 students had an average level of knowledge about patient safety in the moderate and poor categories.1 the research results showed that there were 113 reports of medication errors made by nursing students, and 40% were not correspondence: yuni sufyanti arief, department of pediatric nursing, faculty of nursing, universitas airlangga, surabaya, 60115 indonesia. tel.: +62.8123106365. e-mail: yuni_sa@fkp.unair.ac.id key words: clinical education, health care quality, learning outcomes, nursing students, patient safety. contributions: dwps, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ysa, conceptualization, formal analysis, investigation, methodology, validation, and writing – original draft, review & editing; aa, conceptualization, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this study was approved by the ethics research committee of sultan agung islamic hospital, semarang, indonesia (no sk: no 85/kepk-rsisa/viii/2022). prior to the study, written informed consent was signed by all respondents after they were given an explanation regarding the procedures, rights, and obligations during the research. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: the indonesian ministry of education, culture, research, and technology has provided funding for this study under the research grant number: 1004/un3/2022 and agreement/contract number: 085/e5/pg.02.00.pt/2022 and 976/un3.15/pt/2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors would like to express their gratitude to the respondents of this study for their valuable support and to the indonesian ministry of education, culture, research, and technology for providing funding for this research. received: 13 october 2023. accepted: 11 december 2023. early access: 22 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11969 doi:10.4081/hls.2024.11969 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 166] [healthcare in low-resource settings 2024;12:11969] non -co mmerc ial us e o nly reported because they hid the errors, thus hindering the learning process.2 postgraduate students’ competence in implementing patient safety protection in six domains is at a score below 55%.5 this condition encourages educational institutions and students to play a role in reducing patient safety incidents through a good clinical education process.2 clinical education allows students to directly practice the provision of professional and comprehensive nursing care services.6 clinical education teaches students to apply skills and standard operational procedures with patients directly. the clinical education process prioritizes the integration of knowledge-based and skill-based learning, as well as the reorganization of existing knowledge to solve clinical problems effectively.7 in indonesia, the educational curriculum does not provide special emphasis on clinical education for the implementation of patient safety; instead, it focuses more on theory and practicum, so that it is less than optimal in achieving patient safety goal competency in nursing students.8 the research results showed that as many as 32.10% of professional students stated that patient safety education was provided in a small portion of the educational curriculum.1 however, the current application of clinical education does not make it easy for students to understand the application of patient safety.9 research results found that clinical education does not discuss patient safety in-depth, so there is a need for the integration of theory and practice into clinical care education.10 research results show that most students prefer learning strategies through real examples in the field of clinical education and problem-based learning approaches because they are easier to understand.1 the research results show that several strategies have been used to achieve patient safety competency targets in nursing students, such as training,11 increasing the role of clinical educators, and developing a patient safety model based on socialization, externalization, and combination knowledge management internalization (seci).12 the current situation highlights a gap between the quality of the implementation of the clinical education process and the efforts to increase the achievement of patient safety goal competencies by nursing students. therefore, this study aimed to determine the relationship between the implementation of clinical education and the achievement of patient safety goal competencies by nursing students. materials and methods design this study employed an explanatory research design with a cross-sectional approach. during this stage, data were collected from the population samples simultaneously at one time without any intervention. after acquiring the data, an analysis was conducted to elucidate the relationship between the studied variables. this stage utilized a quantitative research method, involving the presentation of numbers, data collection, data discovery, and the presentation of research findings to establish the relationship between the prevalence of a phenomenon and its potential causes. population, sample, sampling data were collected from february to april 2023 from nursing professional students engaged in clinical practice at sultan agung hospital in semarang, central java, indonesia. the study population and sample size included 125 nursing students. the inclusion criteria encompassed nursing students who had completed the undergraduate program, passed the patient safety management course, and engaged in clinical practice at sultan agung hospital. excluded students were those with prior work experience at the hospital or who had dropped out. this study employed a non-probability sampling method with total sampling. variable in this research, there are two variables. the independent variable is the implementation of clinical education, and the dependent variable is the achievement of patient safety goals competencies among nursing students. the indicators in clinical education consist of guidelines, regulations, application of methods, case management, and evaluation. the indicators of the achievement of patient safety goals competencies consist of: i) identifying patients correctly; ii) improving effective communication; iii) improving the safety of high-alert medication; iv) ensuring the correct site, correct procedures, and correct patient surgery; v) reducing the risk of healthcare-associated infection, and vi) reducing the risk of patient harm resulting from falls. instrument this study used two instruments: a clinical education questionnaire and an observation sheet for assessing the achievement of patient safety goal competencies. the instruments were adapted from previous research 11. the observation sheet consists of 22 items assessing skills in implementing six patient safety goals, namely: i) identifying patients correctly; ii) improving effective communication; iii) improving the safety of high-alert medication; iv) ensuring the correct site, correct procedures, and correct patients’ surgery; and v) reducing the risk of healthcare-associated infection, and vi) reducing the risk of patient harm resulting from falls. the observation sheet employs a guttman scale with “yes” and “no” answer choices. based on their answers, respondents are classified into competent and incompetent individuals. respondents are deemed competent if they score over 75% in performing patient safety goal skills. the clinical education questionnaire instrument consists of 24 statements, including five clinical education indicators. the indicators in the clinical education questionnaire include guidelines, regulations, application of methods, case management, and evaluation. the observation sheet employs a guttman scale with “yes” and “no” answer choices. the validity of this instrument was tested using pearson product-moment correlation with a p-value <0.05. the reliability test result of this instrument, using cronbach’s alpha, ranged between 0.743 and 0.877. the results of the validity and reliability tests for this instrument indicate its validity and reliability. data collection process data collection was conducted by the researchers, who provided the respondents with an information sheet explaining the benefits and objectives of the research. subsequently, the researchers explained the procedure for filling out the instruments to the respondents. prospective respondents willing to participate signed an informed consent form as proof of their agreement. after completing the instruments, the researchers rechecked the data for completeness. all collected data were processed and analyzed. for the assessment of the achievement of patient safety goal competencies by nursing students, data collection was done using an observation sheet. researchers observed respondents during their clinical education at the teaching hospital to evaluate their achievement of patient safety goal competencies. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11969] [page 167] non -co mmerc ial us e o nly analysis in this study, data for the dependent variable were collected using an observation sheet, while data for the independent variable were collected using a structured questionnaire. the data collection period spanned from december 2022 to march 2023. to ensure anonymity, no names were included in the questionnaire and observation sheet. the collected data were tabulated and analyzed using the ibm statistical package for social sciences (spss) version 21.0. bivariate analysis was conducted using the spearman correlation test. the spearman correlation test was employed to determine the level of relationship between the implementation of clinical education and the achievement of patient safety goals competencies since each variable to which the data is linked is in ordinal form. ethical clearance this study received approval from the research ethics committee of the university hospital in semarang city, indonesia (reference number: 85/kepk-rsisa/viii/2022). before participating in the study, all respondents provided written informed consent after receiving an explanation regarding the procedures, rights, and obligations during the research. research ethics in this study adhered to the principles of justice, beneficence, confidentiality, anonymity, privacy, self-determination, and respect for individuals. results respondents’ characteristics table 1 displays the characteristics of the respondents, including their demographic data. the majority of students were female, accounting for 114 students (91.3%), and all students were in the 21-25 years age group (100%). additionally, all 125 students (100%) had completed hospital orientation and had exposure to patient safety. univariate analysis description of clinical education variable table 2 describes the clinical education variable. the majority of respondents demonstrated “good” performance in the indicators of orientation, regulation, case management, application of the method, and evaluation. based on the category in the operational definition, the score in this variable is 24-48, which is categorized into 24-31 in the bad category, 32-40 in the fair category, and 41-48 in the good category. based on this category, in the clinical education category, most of the respondents were categorized as “good.” description of patient safety goal competency achievements table 3 presents a description of the achievement of patient safety goal competencies. most of the respondents demonstrated competence in patient identification, effective communication, safe use of high-vigilance drugs, correctness of the procedure, surgical sites, and patients to be operated on, prevention of infection risks, and prevention of patient falls. the score in this variable is 22-44, which is categorized into 22-32 in the incompetent category, and 33-44 in the competent category. based on this category, in the competency achievement category for patient safety goals, most respondents were in the competent category. bivariate analysis table 4 displays the relationship between clinical education and the achievement of patient safety goal competencies. in the crosstab, it can be seen that the majority of respondents with “incompetent” patient safety goal competency achievement had “sufficient” clinical education. almost all respondents with “competent” patient safety goal competency achievement had “good” clinical education. the spearman correlation test resulted in a significance value of 0.000, which is less than 0.05, indicating a significant relationship between clinical education and the achievement of patient safety goal competencies. the positive coefficient value suggests that better clinical education is more likely to increase the achievement of patient safety goal competencies. a coefficient value of 0.609 indicates a strong relationship between clinical education and the achievement of patient safety goal competencies. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondents’ characteristics based on gender at a sultan agung hospital in semarang (n=125). variable frequency percentage (f) (%) gender male 11 8.7 female 114 91.3 age 21-25 125 100 25-30 0 0 hospital orientation yes 125 100 no 0 0 exposure to patient safety yes 125 100 no 0 0 table 2. the description of the clinical education variable (n=125). indicator category frequency percentage (f) (%) orientation poor 6 4.8 sufficient 14 11.2 good 105 84.0 regulation poor 14 11.2 sufficient 25 20.0 good 86 68.8 case management poor 6 4.8 sufficient 14 11.2 good 105 84.0 application of the method poor 4 3.2 sufficient 12 9.6 good 109 87.2 evaluation poor 5 4.0 sufficient 15 12.0 good 105 84.0 clinical education poor 3 2.4 sufficient 17 13.6 good 105 84.0 [page 168] [healthcare in low-resource settings 2024;12:11969] non -co mmerc ial us e o nly discussion the process of implementing clinical education influences the achievement of competency goals for patient safety. this is in line with research results which state that clinical education allows students to practice directly in implementing patient safety targets.13 the research results found that the more direct exposure students have to clinical settings during clinical education, the more skilled they become in applying clinical skills.14 clinical practice facilitates students in providing direct nursing care services.6 this research shows that one of the factors for increasing competency in patient safety targets by nursing students can be achieved through the implementation of clinical education. optimizing the implementation of clinical education can be done in various ways, including through the development of learning strategies. one innovation in learning could involve a problembased learning approach in a real-life clinical education setting or developing a clinical education model for patient safety in hospitals.1 the results of this research are in line with findings that show that patient safety based on seci knowledge management can increase patient safety target competency in nursing students.15 other research results indicate that the development of a clinical education model can be used as an effort to improve competency outcomes.16 the research results show that the implementation of clinical education can be used as an effort to increase student competence.16 carrying out appropriate clinical education can enhance students’ achievement of clinical practice competency.17 this competency includes patient safety target competencies that must be possessed by students undergoing clinical education.18 basic knowledge, skills, behavior, and attitudes that are relevant to the scientific field of patient safety need to be innovated in the educational process to equip students with competent skills.3 knowledge, skills, behavior, and attitudes are factors that influence the implementation of patient safety.19 ultimately, students will be able to maintain patient safety when undergoing clinical practice and avoid being the cause of patient safety incidents. this research shows that nursing education institutions must be able to improve the quality of clinical education. nursing educational institutions must equip nursing students with patient safety competencies while undergoing clinical education.20 the nursing education association in indonesia issued a policy to provide learning credit units for patient safety clinical practice and develop clinical education models.13 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. the achievement of patient safety goal competencies. indicator category frequency percentage (f) (%) correctly identifying patients not competent 11 8.8 competent 114 91.2 effective communication not competent 56 44.8 competent 69 55.2 increasing the safety of using drugs that require high vigilance not competent 23 18.4 competent 102 81.6 ensuring the correctness of procedures, operating sites, and patients to be operated not competent 32 25.6 competent 93 74.4 prevents the risk of infection not competent 22 17.6 competent 103 82.4 prevents the risk of patient falls not competent 9 7.2 competent 116 92.8 achievement of patient safety goal competencies not competent 14 11.2 competent 111 88.8 table 4. the relationship between clinical education and achievement of patient safety goal competencies. variable achievement of patient safety goal competencies correlation coefficient p not competent competent clinical education poor count 2 1 0.609 0.000 % 14.3% 0.9% sufficient count 9 8 % 64.3% 7.2% good count 3 102 % 21.4% 91.9% [healthcare in low-resource settings 2024;12:11969] [page 169] non -co mmerc ial us e o nly conclusions the implementation of clinical education has proven to be effective in increasing the achievement of competency goals for patient safety in nursing students. therefore, to improve the ability to implement patient safety goals, nursing education institutions and education hospitals need to collaborate to create a clinical education model that can support the achievement of patient safety target competencies by nursing students. one of these clinical education models is a clinical education model based on the community of practice. community of practice-based clinical education is a learning strategy in the area of clinical practice that involves students sharing solutions about a particular area of knowledge or competency, such as patient safety goals, and learning together to deepen their knowledge, expertise, skills, and create innovations regarding the implementation of patient safety goals. references 1. solomon a, gudayu t. students’ assessment on the patient safety education: the case of college of medicine and health sciences, university of gondar. iran j nurs midwifery res 2020;25:296–303. 2. teal t, emory j, patton s. analysis of medication errors and near misses made by nursing students. int j nurs educ scholarsh 2019;16:1–9. 3. levett-jones t, andersen p, bogossian f, cooper s, guinea s, hopmans r, et al. a cross-sectional survey of nursing students’ patient safety knowledge. nurse educ today 2020;88:104372. 4. dauphinee wd. educators must consider patient outcomes when assessing the impact of clinical training. med educ 2012;46:13-20. 5. alquwez n, cruz jp, alshammari f, felemban em, almazan ju, tumala rb, et al. a multi-university assessment of patient safety competence during clinical training among baccalaureate nursing students: a cross-sectional study. j clin nurs 2019;28:1771-81. 6. zhang y, wei l, li h, et al. the psychological change process of frontline nurses caring for patients with covid-19 during its outbreak. issues ment health nurs 2020;41:1-6. 7. jessee ma. pursuing improvement in clinical reasoning: the integrated clinical education theory. j nurs educ 2018;57:713. 8. tonapa si, mulyadi m, ho khm, efendi f. effectiveness of using high-fidelity simulation on learning outcomes in undergraduate nursing education: systematic review and meta-analysis. eur rev med pharmacol sci 2023;27:444-58. 9. mulyadi m, tonapa si, rompas ssj, et al. effects of simulation technology-based learning on nursing students’ learning outcomes: a systematic review and meta-analysis of experimental studies. nurse educ today 2021;107. 10. torkaman m, sabzi a, farokhzadian j. the effect of patient safety education on undergraduate nursing students’ patient safety competencies. community heal equity res policy 2022;42:219-24. 11. taylor i, bing-jonsson p, wangensteen s, et al. the selfassessment of clinical competence and the need for further training: a cross-sectional survey of advanced practice nursing students. j clin nurs 2020;29:545-55. 12. fadhillah h, nursalam, hadi m, et al. international patients safety goals (ipsg) based on knowledge management of seci (socialization, externalization, combination and internalization) on adverse events at jakarta islamic hospital. indian j public heal res dev 2018;9:462-8. 13. sari dwp, handiyani h, kuntarti, arief ys. the effect of community of practice in improving the role of clinical instructor in patient safety implementation by prelicensure nursing students. healthc low-resource settings 2023;11:21-5. 14. suryani l, handiyani h, hastono sp. peningkatan pelaksanaan keselamatan pasien oleh mahasiswa melalui peran pembimbing klinik. j keperawatan indones 2015;18: 115-22. 15. harianto jw, nursalam n, dewi ys. patient safety based knowledge management seci to improve nusrsing students competency. j ners 2015;10:324-31. 16. gemuhay hm, kalolo a, mirisho r, et al. factors affecting performance in clinical practice among preservice diploma nursing students in northern tanzania. nurs res pract 2019;2019:1-9. 17. leonardsen acl. the impact of clinical experience in advanced practice nursing education—a cross-sectional study of norwegian advanced practice nurses’ perspectives. nurs reports 2023;13:1304-17. 18. komisi akreditasi rumah sakit. standar nasional akreditasi rumah sakit edisi 1.1. jakarta: jakarta: komisi akreditasi rumah sakit; 2019. 19. nihayati he, gunawan g, wahyuni edd, purwanza sw, arifin h. attitude of nurses related to the implementation of patient safety in the intensive care unit. j ners 2020;14:345. 20. jang h, lee nj. patient safety competency and educational needs of nursing educators in south korea. plos one 2017;12:1-19. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 170] [healthcare in low-resource settings 2024;12:11969] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11814 effect of gamelan and progressive muscle relaxation on blood pressure in hypertensive patients ira rahmawati,1 firda ayu magfiroh,2 budiono budiono,1 sulastyawati sulastyawati1 1department of nursing, politeknik kesehatan kemenkes malang, malang, indonesia; 2prima husada hospital, malang, indonesia abstract chronically elevated blood pressure was a prominent risk factor for cardiovascular diseases. the management of hypertension, especially in community settings, should combine pharmacological and non-pharmacological interventions. this study aimed to evaluate whether music-assisted progressive muscle relaxation (pmr) using gamelan, javanese classical music, could reduce blood pressure more effectively in hypertensive elderly individuals in malang, indonesia, than pmr alone. this study employed a pre-test and post-test study design with a control group. fiftyeight respondents were randomly assigned to the intervention group (n=31) and the control group (n=27). three respondents in the control group did not complete the study; thus, they were excluded from the analysis. the intervention group was trained and guided to perform pmr while listening to gamelan. meanwhile, the control group only received pmr. the intervention was conducted twice a week for 20 minutes for eight weeks. dependent variables in this study were systolic and diastolic blood pressure, which were measured using an aneroid sphygmomanometer. data were analyzed using descriptive statistics, paired t-tests, independent t-tests, and mann-whitney test. we found a significant decrease in systolic and diastolic blood pressure in both groups. a mann-whitney test showed that there was a significant difference in the reduction of systolic blood pressure in the intervention group compared to the control group (p=0.000). meanwhile, the independent t-test showed that the diastolic blood pressure in the intervention group reduced more significantly than that in the control group. the efficacy of gamelan-assisted pmr in significantly reducing both systolic and diastolic blood pressure showcases the potential of such combined interventions in managing hypertension. we recommend gamelan-assisted pmr as a complementary therapy for the elderly with primary hypertension. introduction elevated blood pressure is a significant risk factor for critical diseases, including heart, kidney, and cerebral diseases, as well as many other serious conditions.1 the incidence of hypertension is consistent with trends related to increasing age span and life expectancy.2 recent studies have found that hypertension increases the risk of poor outcomes in patients with covid-19. globally, hypertension affects 1.13 billion people, with two-thirds of them residing in underdeveloped and developing countries.3 globally, hypertension affects 1.13 billion people, with two-thirds of them residing in underdeveloped and developing countries.4 in 2018, approximately 34.1% of indonesians aged over 18 years had hypertension, and only 54.4% of them had adequately controlled blood pressure.5 although hypertension is commonly asymptomatic, it can cause complications that account for about eight million deaths each year, 88% of which occur in underdeveloped and developing countries.6 hypertension is generally asymptomatic and goes unnoticed, but sometimes patients report dizziness, headaches, nosebleeds, chest pain, and palpitations.7 behavioral risk factors for hypertension are well-studied. these factors include physical inactivity, regular alcohol consumption, tobacco use, caffeine intake, and stress.8–11 in older people, physiological changes in the blood vessels increase the risk of primary hypertension, especially in individuals who lack physical activity.7 the management of hypertension, especially in commucorrespondence: ira rahmawati, department of nursing, politeknik kesehatan kemenkes malang, malang, indonesia. e-mail: irarahmawati.polkesma@gmail.com key word: progressive muscle relaxation; javanese classical music; gamelan; hypertension; music-assisted pmr. contributions: ir, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; fa, conceptualization, investigation, and writing – original draft, review and editing; bd, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; sl, methodology, visualization, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the research ethics commission, politeknik kesehatan kementerian kesehatan malang (state polytechnic of health) malang based on ethical certificate number 546/kepk-polkesma. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 15 september 2023. accepted: 22 november 2023. early access: 14 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11814 doi:10.4081/hls.2023.11814 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11814] [page 41] non -co mmerc ial us e o nly nity settings, should encompass both pharmacological and nonpharmacological interventions.12 in general, hypertension treatment involves the use of a class of drugs that block the angiotensin-converting enzyme, calcium channel blockers, diuretics, beta-blockers, alpha-blockers, and angiotensin ii receptor antagonists.13 it has been proven that non-pharmacological interventions can effectively control blood pressure, so these interventions should be considered a complement to pharmacological therapies.14 in addition, the use of antihypertensive drugs to manage hypertension has not proven to be efficacious due to the long-term side effects of these drugs. a study has revealed that the use of angiotensin-converting enzyme (ace) inhibitors, which are commonly prescribed antihypertensive drugs for the elderly with hypertension, can significantly increase the risk of new-onset osteoporotic fractures (nof)15. studies have also found that the incidence of new-onset osteoporotic fractures (nof) and osteoporosis had increased in patients with hypertension and chronic heart failure (chf) who used loop diuretics.16,17 due to the various adverse effects of drugs and the presence of drug-resistant hypertensive patients, non-pharmacological therapies should be widely implemented as adjuvants to classical therapies. progressive muscle relaxation (pmr) is one of the oldest non-pharmacological interventions for reducing blood pressure in hypertensive patients. however, this exercise has not been routinely implemented in community health care as part of the management of patients with hypertension. pmr decreases muscle tension, blood pressure, and anxiety in both patients and healthy individuals by reducing sympathetic nervous system activity. studies have suggested that a combination of two or more non-pharmacological methods is more effective in achieving goals than individual therapy.18,19 studies have found that music can have beneficial effects on blood pressure.20–22 however, most studies included a broad range of ages and exclusively used mozart classical music.23 only a few studies have been conducted to analyze the effect of music on blood pressure in the pre-elderly and elderly population, especially in indonesian settings. therefore, research is needed to understand music preferences among pre-elderly and elderly individuals in indonesia and whether it could help control blood pressure among hypertensive elderly patients. gamelan is one of indonesia’s traditional music forms that is famous and appreciated, especially among javanese older people. in this study, we aim to investigate whether a combination of pmr and gamelan music has more positive effects on blood pressure and therapy adherence in hypertensive elderly patients compared to pmr alone. materials and methods this experimental study employed a pre-test and post-test study design and was conducted in krajan village, malang district, from july to november 2022. elderly individuals with primary hypertension who met the inclusion criteria and willingly participated in this research were recruited. all the respondents were regular members of the integrated development post program, known as posbindu in indonesia, a facility that provides community health services for the elderly in krajan village. the inclusion criteria in this study include people aged above 45 years old, diagnosed with primary hypertension, fully conscious, and able to communicate. elderly individuals with significant health problems such as heart diseases and chronic kidney diseases were excluded from this study. initially, a total of 58 respondents participated in this study and were randomly assigned to the intervention and control groups. the intervention group comprised 31 respondents were initially assigned to the intervention and control groups, with the intervention group comprising 31 individuals who received a combination of progressive muscle relaxation and gamelan javanese music, while 27 in the control group received only progressive muscle relaxation therapy. three respondents in the control group did not complete the intervention, so they were excluded from the statistical analysis. the control group received only progressive muscle relaxation therapy. the instruments used in this study included mp3 players and headphones for listening to gamelan music, an aneroid sphygmomanometer and stethoscope for measuring blood pressure, and scoring sheets for recording blood pressure measurements. each respondent in the intervention group was trained and guided to perform progressive muscle relaxation while listening to gamelan, javanese classical music, twice a week for 20 minutes over eight weeks. meanwhile, the control group was trained and guided with the same technique but without gamelan music. each intervention session lasted about 30 minutes. in addition, respondents were instructed to independently perform pmr and musical therapy every day for eight weeks on their own. the independent variables in this study were pmr and gamelan music, while the dependent variable was blood pressure. blood pressure was measured before and after the interventions by a registered nurse using an aneroid sphygmomanometer and a stethoscope. ethical approvals were obtained from politeknik kesehatan kementerian kesehatan malang (state polytechnic of health) in malang with ethical certificate number 546/kepkpolkesma. all participants signed a consent form to participate in this study. data were analyzed using ibm spss statistics 25. demographic data were analyzed descriptively. a paired-sample ttest was conducted to compare systolic and diastolic blood pressure before and after interventions in each group. a mann-whitney test was used to compare the reduction in systolic blood pressure between the intervention group and the control group. meanwhile, an independent t-test was performed to determine whether the reduction in diastolic blood pressure in the two groups was statistically significant (p<0.05; figure 1). results characteristics of the respondents the majority of the respondents in the intervention group were female (77%), aged above 55 years old (74.2%), and had a family history of hypertension (83.9%), but only 19.4% of the respondents were active smokers. similar to the intervention group, most of the respondents in the control group were female (79.1%), aged above 55 years old (83.3%), had a family history of hypertension (79.1%), and were non-smokers (83.3%). all of the respondents in the intervention group completed the interventions for eight weeks with zero dropout rates. meanwhile, three respondents in the control group did not complete the study for eight weeks, resulting in an 11% dropout rate. the demographic data of the respondents are shown in table 1. table 2 reveals a noteworthy reduction in both systolic and diastolic blood pressures within the intervention group, registering substantial declines of 18.87 and 14.44, respectively, following an eight-week intervention period. in contrast, the control group exhibited more modest decreases, with systolic and diastolic blood pressures diminishing by 6.56 and 4.06, respectively, over the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 42] [healthcare in low-resource settings 2024;12:11814] non -co mmerc ial us e o nly same eight-week treatment period. a comprehensive overview of these findings is presented in table 3 for clarity and comparison. mann-whitney test was conducted to compare the difference in the reduction of systolic blood pressure between the intervention and control groups. the results of this test are presented in table 3. the difference in the reduction of diastolic blood pressure between the intervention and control groups was tested with the independent t-test. the results of this test are presented in table 4. asymp. sig. (2-tailed) of 0.000<0.05 indicates a significant difference in diastolic blood pressure reduction between the intervention and control groups (p<0.05). discussion this study showed that blood pressure reduced by 18.871 mmhg (systolic) and 14.452 mmhg (diastolic) among respondents who received pmr while listening to gamelan music. meanwhile, in the group who only received pmr, the systolic blood pressure dropped by 6.583 mmhg, and diastolic blood pressure dropped by 5. mmhg. similar studies have revealed that progressive muscle relaxation reduced blood pressure in hypertensive respondents by 5.1 mmhg (systolic) and 3.6 mmhg (diastolic) after a four-week intervention of daily 30 minutes pmr18,24 and 24.54 mmhg (systolic) and 16.54 mmhg (diastolic) after seven days of daily pmr25. in the latter, the respondents were also taking daily antihypertensive drugs. progressive muscle relaxation is a well-known nonpharmacological intervention for reducing stress, anxiety, and excessive tension in the body. progressive muscle relaxation is total relaxation that achieved by contracting and relaxing various muscles in the body.26 these activities may lower blood pressure transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of the respondents. characteristics intervention group control group (n = 31) (n=24) no % no % sex male 7 22.6 5 20.8 female 24 77.4 19 79.1 age 45-55 8 25.8 4 16.6 56-60 13 41.9 9 37.5 61-65 10 32.3 11 45.8 currently smoking yes 6 19.4 4 16.6 no 25 80.6 20 83.3 family history of hypertension yes 26 83.9 19 79.1 no 5 16.1 5 20.8 table 2. comparison of mean blood pressure before and after interventions in the intervention and control groups. groups variables pre-intervention post intervention mean sig mean sd mean sd difference (2tailed) intervention group systolic blood pressure 163.71 12.039 144.84 10.605 18.871 0 diastolic blood pressure 96.71 5.599 82.26 6.434 14.452 0 control group systolic blood pressure 151.25 6.456 144.67 7.631 6.583 0.001 diastolic blood pressure 92.21 4.818 86.71 4.506 5.500 0.004 figure 1. flow of the intervention. [healthcare in low-resource settings 2024;12:11814] [page 43] non -co mmerc ial us e o nly by reducing sympathetic nervous activity in response to a decrease in the secretion of corticotropin-releasing hormone (crh) and adrenocorticotrophic hormone (acth) by the hypothalamus. this results in a reduced heart rate, vasodilated blood vessels, decreased respiration and metabolic rate, and lower blood pressure.24,27,28 systolic and diastolic blood pressure significantly reduce when progressive muscle relaxation is combined with another relaxation technique, such as musical therapies. a study that combined the effects of pmr and musical therapy using a piece of instrumental music, showed that systolic blood pressure reduced by as much as 29.2 mmhg, and diastolic blood pressure was lowered by 16.2 mmhg.18 however, in this study, the dropout rate was high (20.6%). in our study, we combined pmr with gamelan, which is one of the famous traditional music forms in indonesia. the dropout rate in our study was zero, which could be influenced by the type of music we chose. all the respondents in this study were javanese older adults, who might be more familiar with and prefer gamelan over other types of relaxing music. listening to their preferred musical instrument brings greater benefits to the respondents and improves their hemodynamic status.29,30 studies have shown that music therapy has beneficial effects on patients’ physical and psychological outcomes in various clinical settings.22,31,32 however, not all types of music can effectively improve the hemodynamic and psychological status of the respondents.33 several studies have shown no statistical difference in the reduction of blood pressure between respondents who receive music therapy and those who only rest.33,34 music that might positively affect cardiovascular parameters includes classical music because it is associated with calm and relaxation. musical pieces chosen by or more familiar to respondents are often more effective and can lead to positive hemodynamic changes.35,36 to produce positive changes, music therapy should be played in a quiet environment for a minimum of 20-25 minutes for at least four weeks.37 listening to music activates the hypothalamus and nucleus accumbens (nac), which are two of the main brain areas involved in processing rewarding and pleasure-evoking stimuli, resulting in increased pleasure response and changes in heart rate and respiration rate.38 music therapy might also decrease the activity of the sympathetic nervous system and stimulate endorphin release.39 furthermore, a study investigating the effect of music on blood pressure found that exposure to classical music increased serum calcium levels and brain dopamine synthesis, which reduced blood pressure.40,41 indeed, music therapy is one of the non-pharmacological interventions that can be used to help reduce blood pressure with low cost and minimal side effects.42 our study found a statistical difference in the reduction of systolic and diastolic blood pressure between the respondents who received a combination of pmr with musical therapy using gamelan compared to the control group who only received pmr (tables 3 and 4). several studies have suggested that combining pmr with other non-pharmacological therapies has better effects on the respondents’ outcomes, such as decreasing stress, enhancing academic performance, reducing chronic pain and fatigue, and improving coping styles.19,43,44 this study shows that gamelanassisted pmr can effectively reduce the blood pressure of hypertensive elderly individuals. this result is similar to that of another study which combines pmr with classical music therapy.18 musicassisted pmr should be regularly provided to the respondents to help maintain their blood pressure within the normal range. additionally, the choice of instrumental music used should be relaxing and familiar to the respondents. this study has several limitations. we employed a relatively small sample size, which may limit the generalizability of the study. further studies with a large sample size and multi locations are needed to ensure the quality of the study. conclusions this study was the first to investigate the effect of musicassisted progressive muscle relaxation using javanese classical music to reduce the blood pressure of javanese elderly individuals. we discovered that respondents receiving gamelan-assisted pmr had better outcomes in blood pressure than those only receiving pmr. based on the result of this study, it is recommended that health workers or other medical personnel can apply music gamelan therapy regularly as adjuvant therapy in managing hypertensive older patients, especially in community settings. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. difference of systolic blood pressure reduction between the two groups. statistics testa systolic blood pressure mann-whitney u 65.500 wilcoxon w 561.500 z -5.209 asymp. sig. (2-tailed) 0 agrouping variable: group. asymp. sig. (2-tailed) of 0<0.05 illustrates a significant difference in systolic blood pressure reduction between the intervention and control groups (p<0.05). table 4. difference of diastolic blood pressure reduction between the two groups. independent sample test levene's test for t-test for equality sig. (2-tailed) mean std. error 95% confidence interval equality of variances of means difference difference of the difference f sig. t df lower upper diastolic equal 0.938 0.337 -9.140 53 0.000 -8.952 0.979 -10.916 -6.987 blood variances pressure assumed equal -9.278 51.904 0.000 -8.952 0.965 -10.888 -7.015 variances not assumed [page 44] [healthcare in low-resource settings 2024;12:11814] non -co mmerc ial us e o nly references 1. israfil i, yusuf a, efendi f, lutfa i, sriwahyuningsih i. factors associated with behavior in the prevention of cardiovascular complications in hypertensive patients in indonesia: a systematic review. in: the 22 international conference of public health sciences. 2022. p. 1. 2. makhfudli, susanto j, sairozi a, ubudiyah m. determinants of hypertension in outpatients in east java, indonesia. j pak med assoc 2023;73:s113-7. 3. world health organization. hypertension and covid-19: scientific brief [internet]. 17 june 2021. 2021 [cited 2021 jun 26]. p. 2-7. available 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factors for undiagnosed and known hypertension among malaysians. malaysian j med sci 2019;26:98-112. 10. tiruneh sa, bukayaw ya, yigizaw st, angaw da. prevalence of hypertension and its determinants in ethiopia: a systematic review and meta-analysis. plos one 2020;15(12 12). 11. agho ke, osuagwu ul, ezeh ok, et al. gender differences in factors associated with prehypertension and hypertension in nepal: a nationwide survey. plos one 2018;13:1-18. 12. wijaya in, athiyah u, fasich, et al. the association between drug therapy problems and blood pressure control of patients with hypertension in public health center setting. j public health afr 2023;14:137-40. 13. pristianty l, hingis es, priyandani y, rahem a. relationship between knowledge and adherence to hypertension treatment. j public health afr 2023;14:2502. 14. verma n, rastogi s, chia yc, siddique s, turana y, cheng h min, et al. non-pharmacological management of hypertension. j clin hypertens 2021;23:1275-83. 15. chen hy, ma ky, hsieh pl, et al. long-term effects of antihypertensive drug use and new-onset osteoporotic fracture in elderly patients: a population-based longitudinal cohort study. chin med j (engl) 2016;129:2907-12. 16. katano s, yano t, tsukada t, et al. clinical risk factors and prognostic impact of osteoporosis in patients with chronic heart failure. circulation j 2020;84:2224-34. 17. wang j, su k, sang w, et al. thiazide diuretics and the incidence of osteoporotic fracture: a systematic review and metaanalysis of cohort studies. front pharmacol 2019;10:1-11. 18. astuti nf, rekawati e, wati dnk. decreased blood pressure among community dwelling older adults following progressive muscle relaxation and music therapy (resik). bmc nurs 2019;18:1-5. 19. ozgundondu b, gok metin z. effects of progressive muscle relaxation combined with music on stress, fatigue, and coping styles among intensive care nurses. intensive crit care nurs 2019;54:54-63. 20. li j, yang z, zhang c, et al. chinese classical music lowers blood pressure and improves left ventricular hypertrophy in spontaneously hypertensive rats. front pharmacol 2022;13:1-12. 21. kulinski j, ofori ek, visotcky a, et al. effects of music on the cardiovascular system. trends cardiovasc med 2022;32:3908. 22. mir ia, chowdhury m, islam rm, et al. relaxing music reduces blood pressure and heart rate among pre-hypertensive young adults: a randomized control trial. j clin hypertens 2021;23:317-22. 23. tandirerung rj, irwanto, krisna aan. the effect of mozart’s classical music on blood pressure in wistar white rats (rattus norvegicus). bali med j 2023;12:2055-7. 24. sheu s, irvin bl, lin hs, mar cl. effects of progressive muscle relaxation on blood pressure and psychosocial status for clients with essential hypertension in taiwan. holist nurs pract 2003;17:41-7. 25. rosdiana i, cahyati y. effect of progressive muscle relaxation (pmr) on blood pressure among patients with hypertension. int j adv life sci res 2019;2:28-35. 26. li y, wang r, tang j, et al. progressive muscle relaxation improves anxiety and depression of pulmonary arterial hypertension patients. evidence-based complement altern med 2015;2015. 27. kato k, vogt t, kanosue k. brain activity underlying muscle relaxation. front physiol 2019;10(december). 28. hadi as, lefi a, pikir bs, et al. the association of depression and central obesity on hypertension in indonesian provinces: a path analysis of the indonesian baseline health research 2018 data. blood press 2022;31:187-93. 29. wakim jh, smith s, guinn c. the efficacy of music therapy. j perianesthesia nursing 2010;25:226-32. 30. kavak akelma f, altınsoy s, arslan mt, ergil j. effect of favorite music on postoperative anxiety and pain. anaesthesist 2020;69:198-204. 31. aalami m, jafarnejad f, modarresgharavi m. the effects of progressive muscular relaxation and breathing control technique on blood pressure during pregnancy. iran j nurs midwifery res 2016;21:331-6. 32. lorber m, divjak s. music therapy as an intervention to reduce blood pressure and anxiety levels in older adults with hypertension a randomized controlled trial. res gerontol nurs 2022;15:85-92. 33. bekiroǧlu t, ovayolu n, ergün y, ekerbiçer hç. effect of turkish classical music on blood pressure: a randomized controlled trial in hypertensive elderly patients. complement ther med 2013;21:147-54. 34. zarurati m, pishgooie sah, farsi z, karbaschi k. the effect of music therapy on comfort level and some vital signs of patients undergoing hemodialysismodialysis. military caring sci 2017;3:221-32. 35. bernatzky g, presch m, anderson m, panksepp j. emotional foundations of music as a non-pharmacological pain management tool in modern medicine. neurosci biobehav rev transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11814] [page 45] non -co mmerc ial us e o nly 2011;35:1989-99. 36. rolvsjord r. what clients do to make music therapy work: a qualitative multiple case study in adult mental health care. nord j music ther 2015;24:296-321. 37. do amaral mas, neto mg, de queiroz jg, et al. effect of music therapy on blood pressure of individuals with hypertension: a systematic review and meta-analysis. int j cardiol 2016;214:461-4. 38. quintin em. music-evoked reward and emotion: relative strengths and response to intervention of people with asd. front neural circuits 2019;13:1-8. 39. bradt j, dileo c, potvin n. music for stress and anxiety reduction in coronary heart disease patients. cochrane database syst rev 2013;2013(12). 40. laksmidewi aaap, mahadewi npap, adnyana imo, widyadharma ipe. instrumental balinese flute music therapy improves cognitive function and serum dopamine level in the elderly population of west denpasar primary health care center. open access maced j med sci 2019;7:553-8. 41. darki c, riley j, dadabhoy dp, et al. the effect of classical music on heart rate, blood pressure, and mood. cureus 2022;14:1-6. 42. nurjanah da, harmayetty, mishbahatul e. relaxing melody from flute combined with a foot massage can reduce systolic and diastolic blood pressure in elders. medico-legal update 2019;19:398-403. 43. kunikullaya ku, goturu j, muradi v, et al. music versus lifestyle on the autonomic nervous system of prehypertensives and hypertensives-a randomized control trial. complement ther med 2015;23:733-40. 44. gallego-gómez ji, balanza s, leal-llopis j, et al. effectiveness of music therapy and progressive muscle relaxation in reducing stress before exams and improving academic performance in nursing students: a randomized trial. nurse educ today 2020;84:104217. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 46] [healthcare in low-resource settings 2024;12:11814] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2021; 9:9307] [page 1] economic contestation over user fees in low-resourced healthcare systems: a literature review vincent pagiwa okavango research institute, university of botswana, maun, botswana abstract this paper reviewed the literature on economic theory and assumptions that provide the rationale for using a price system to finance health care services in developing countries. the primary case in favor of a system of user fees for financing healthcare in these countries lies in allocative efficiency results to be achieved through a price system. the assumption being that, the price system signals to consumers what they must pay for health care services hence giving them an incentive to utilize those services well. however, this assumes perfect markets, where prices reflect the true marginal benefits of consuming healthcare goods and the marginal cost of their production. all equity concerns being addressed through price discrimination, a system of user fees can then allocate health care resources efficiently. although the application of user fees in the health sector is justified by the perfect markets, there are concerns that a perfect market is less likely to be the case in health sector. therefore, it will not be a viable way to rely on the price system to allocate resources to the population when markets of any healthcare goods and services are not available or are imperfect. information asymmetry and uncertainty are the major obstacles to a proper function of a price system in healthcare service provision. due to the inelastic nature of the demand for healthcare, charging fees for healthcare services can pose hard financial catastrophes to poor and lead into poverty. this suggests the need to establish healthfinancing policies that would facilitate the creation of new markets or which can improve the performance of existing ones in developing countries. introduction in the early 1980s, governments in most developing countries were struggling to contain national debt, by lowering spending and increasing revenues.1 in most developing countries, where governments were unable to finance running costs in the health sector, one of the options was to introduce or raise charges for public healthcare services in response to this macro-economic stress.2 in sub-saharan african countries there were also concerns with technical and allocative efficiency in publicly funded health service provision. in many countries tertiary hospitals were providing primary healthcare, which caused overcrowding at tertiary hospitals and difficulty in resource allocation and managing referral systems.3,4 in 1987, the principle of cost recovery through user fees was recommended by the world bank. the 1987 world bank policy report entitled financing health services in developing countries advocated cost sharing for the health care users in public health facilities and the need for governments to recover 15 to 20 percent of general expenditure in health from user charges. this was part of the reforms directed at the health sector in developing countries.3 by early 1990s, cost recovery in the form of user fees was commonly approved and used by many governments as a tool of health funding policy.5,6,7 to date, most developing countries still maintained the price system to finance health care and out-of-pocket expenditure accounted for 37% of current health expenditure (che) in developing countries.8 the theoretical and empirical literature documenting the arguments for and against a price system for health care in developing countries has been growing to date, and includes several views varying in scope and focus. most literature focused on arguments for and against user fees based on the benefits of user fees as outlined by the world bank in 1987, i.e. the net benefits on efficiency and utilization of health services, equity and quality in healthcare delivery as well as resource mobilization and cost recovery in health services. this paper aims to critically analyze economic contestation over user fees specifically presenting the price system as the theoretical basis for user fees in healthcare in a market economy and the argument for and against the price mechanism of user fees in low-resourced healthcare settings. the findings of this study are relevant to advice policy makers, especially in developing countries where a price system in healthcare is in operation or about to be introduced. search strategy and process the analysis of this study was based on a survey of the scientific literature (systematic review). systematic reviews are helpful in summarising the most robust data to explore differences among studies on the same question under study.9,10,11 conducting a systematic review involves a scientific process of assembling, critical appraisal and synthesis of relevant evidence that address the question under study, in a way that limit bias and random errors.9 the review process in this study was well developed and planned to reduce biases and eliminate inclusion of irrelevant and low-quality studies. the steps of analysis followed a process of implementing a systematic review which included “(i) correctly formulating the research question to answer, (ii) developing a protocol (inclusion and exclusion criteria), (iii) performing a detailed and broad literature search and (iv) screening the abstracts of the studies identified in the search and subsequently of the selected complete texts.”11 in order to maximise chances of identifying all relevant articles, several databases relevant to the study were searched, including pubmed, the cochrane library, science direct, web of science and oxford academic. the search terms were only in healthcare in low-resource settings 2021; volume 9:9307 correspondence: vincent pagiwa, okavango research institute, university of botswana, shorobe road, sexaxa, private bag 285, maun, botswana. tel.: +267.6817204 fax: +267.6817204. e-mail: vpagiwa@ub.ac.bw key words: user fees; price system; lowresource settings; healthcare systems. acknowledgement: the literature review was conducted during the author’s phd thesis write up. therefore, the author would like to acknowledge la trobe university for the scholarship to study for phd and production of this literature review. conflict of interest: the author has no conflict of interest to declare. ethics approval: not applicable. disclaimer: the views and opinions expressed in this article are those of the author and do not necessarily reflect the official or position of any affiliated agency of the author. received for publication: 13 august 2020. revision received: 5 february 2021. accepted for publication: 12 february 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2021 licensee pagepress, italy healthcare in low-resource settings 2021; 9:9307 doi:10.4081/hls.2021.9307 non -co mmerc ial us e o nly english. the key words searched were user fees, user charges, co-payment, cost recovery, hospital charges. i developed a search strategy by combining one of the key words with the following terms: developing countries, sub-saharan africa, africa, asia, international, primary healthcare, politics, economics, world bank, who, benefits, effects, theories, market price, demand and supply and revenue. in addition to this database search, the references of included articles and other reviews on similar and related subjects were hand searched to identify additional relevant empirical studies. an article was only retained if it dealt with the economics of healthcare user fees at all levels of care; reported original empirical data, a textbook, a report or commentary; involved developing countries; mentioned arguments for and against user fees in developing countries; was published in a peer-reviewed journal or monograph; was published between 1982 and 2016 inclusively; and was in english. studies that qualified and used both qualitative, quantitative and mixed method designs were included. this study examined the content of articles selected to identify the economic arguments for and against user fees in developing countries particularly on the price system in the healthcare market economy. findings my research approach gathered 28 articles (table 1) specific to developing countries or with an international perspective. the studies were either discussing only positive (n=12), negative (n=12) or both positive and negative effects (n=4) of price system in healthcare in developing countries. arguments in favor of price system in healthcare efficiency results of the price system in healthcare in addition to the possibility of reducing review table 1. overview of the articles. positive and negative effects of price author study site study design system in healthcare positive effects 1. charges as an efficiency signal tool to regulate araoyinbo & ataguba13 africa an essay demand and utilization of public health services arkin, birdsall & de ferranti3 developing countries world bank report baicker, mullainathan & schwartzstein24 theoretical (general) working paper bajari, dalton, hong & khwaja25 theoretical (general) a semiparametric analysis dupas16 developing countries a review madore17 developing countries report mwabu12 developing countries a review schokkaert & de voorde18 developing countries book 2. ability to generate revenue when healthcare arkin, birdsall & de ferranti3 developing countries world bank report demand is price inelastic john37 sub-saharan africa critical analysis of evidence ellis, martins & zhou33 international empirical study fox & edmiston34 africa working paper mcpake, normand & smith29 international book mwabu12 developing countries a review pendzialek, simic& stock30 international systematic review ringel, hosek, vollaard & manhovski32 international a literature review shaw & ainsworth36 africa discussion paper zhou et al.31 rural china empirical study negative effects 1. market failure and inefficiency as a result of arrow40 international a review uncertainty; asymmetry of information; chen and toxvaerd44 international empirical study and externalities donaldson & gerard41 international textbook dupas16 developing countries a review england et al.45 developing countries who report glied & smith14 international textbook mwabu12 developing countries a review nguyen42 vietnam empirical study novotny & zhao43 international empirical study 2. inequalities in the provision of healthcare arrow40 international a review services & charges creating a regressive dupas16 developing countries a review system in the provision of health services ellis, martins & zhou33 international empirical study gilson46 africa empirical study gilson, russell &buse49 developing countries empirical study munge & briggs47 kenya empirical study onarheim et al.35 ethiopia empirical study schokkaert& de voorde18 developing countries book steinhardt et al.48 afghanistan empirical study [page 2] [healthcare in low-resource settings 2021; 9:9307] non -co mmerc ial us e o nly [healthcare in low-resource settings 2021; 9:9307] [page 3] reliance on government sources of revenue, the principal argument in favor of user fees in healthcare is one related to efficiency driven by neoclassical economic theory. this regards health care as no different from any other good or service and assumes that potential users of health care can make rational decisions about the number and nature of the health services they need. this assumption underpins the idea that the allocation of all goods and services in an economy, including health care, should be based on market prices. this market-based allocation of goods and services is pareto-efficient at competitive equilibrium.12 meaning that under certain conditions, the allocation of resources is such that one person’s situation cannot be made better without making another person’s situation worse off. the pareto-efficient equilibrium can be achieved by using the price mechanism and in this case market prices will coordinate economic activities so that, demand and supply of commodities are simultaneously equal at every market.12 based on this neoclassical economic theory, user fees in the health sector can be justified only when the value of public health services financed through user fees exceeds the value of health services that users could otherwise obtain from a private health service provider.13 this simply means that user fees are suitable only where the marginal benefit of every additional dollar of user fees on public health services exceeds the marginal benefit of every additional dollar in private health services. under a perfectly competitive market, equilibrium prices reflect both the marginal benefit of consuming healthcare goods and the marginal cost of their production.12 this means that the prices households are willing to pay for health services convey a message to service providers of the kind of services consumers want and at what quantity. the prices that service providers charge for health services would inform households of the costs of the health services the households are willing to consume.12,14,15 in the end, the decision of the consumers of health services whether or not to seek healthcare and what kind of healthcare will depend on the price they face. in such a perfect competitive market, a consumer knows all there is to know about the products they wish to consume, and it will be very difficult for the provider to influence the demand for such services.16 households will not purchase health care services if the costs attached to those services exceed the benefit expected. for example, a person suffering from a simple cold may decide not to seek medical attention if the cost of treatment and travel time are high. but for a person affected by severe malaria the benefits of medical treatment are likely to exceed the costs, even if the costs are high. the healthcare market just like many markets, constitute the economy and requires scarce resources to produce.12,16,17 therefore, a price mechanism for allocating healthcare services such as user fees signals the scarcity of health care resources and promotes efficiency in their provision and consumption. to consumers of healthcare services, user fees, whilst not the same as market prices, provide an incentive to utilise healthcare resources well. this incentive was a result of budget constraints faced by households, in such that they would not spend part of this constrained budget on unnecessary health services depriving themselves benefits from consuming other important goods and services.18 implementing user fees for health services creates an efficiency enhancing effect as budget constraints by household will provoke a rational response to the use of health services, hence reducing unnecessary demand for healthcare.3,12 therefore, charging fees should make the users of public health services more sensible in their demand for services. if the fees reflect the relative cost of services, then charging higher fees at hospitals than at clinics for same service would encourage proper referral practices and discourage patients from seeking those services at the hospitals. the potential psychological effects of price in healthcare although not widely researched in the health sector, price may also have important psychological effects beyond the rational comparison of cost and benefit. the effectiveness of some healthcare goods is dependent upon the behavior and compliance by the healthcare user. user fees can enhance allocative efficiency by the psychological effects of prices mainly through the sunk-cost fallacy and price-placebo effect. thaler’s sunk-cost effect theory,19 suggests that paying for the right to a good and services increases the chance it will be used to its full potential. this idea operates when a consumer uses the product to avoid a feeling that they would have wasted their money if they do not make use of the good or service they paid for.20,21,22 this idea is common in other markets such as the entertainment industry,16 but it can also be applicable to health products, such that when a consumer pays for a health service, they will comply with treatment. preventive services such as the use of mosquito nets will be used to full potential as the consumers would feel the need to use the net considering they paid for it. the placeboprice effect theory depicts that when a consumer pays a higher price for a good or service, it increases their psychological investment in the good or service, thus boosting its perceived impact.19 implementing user fees for public health services may have a placebo-price effect on the consumers if they perceive price to be an indicator of quality or effectiveness. prices and moral hazard implementing user fees for health services could improve efficiency by discouraging ex-ante moral hazard (the behavioural change of patient before the illness),23-26 such that when health services are costly people are more motivated to stay healthy.16 when curative services are costly, people will be motivated to invest in preventive services, for example, if the cost of injury is high, people will avoid drinking and driving to avoid road traffic accidents. contrary to that,16 argues that user fees could reduce preventive and primary healthcare investments leading to higher costs of curative services in the future. this implied that charging fees for primary healthcare services could delay seeking of preventative and primary healthcare leading to complications requiring higher and expensive services. the world bank27 argued that the first point of contact in a healthcare system ought to be primary healthcare either at a clinic or health post where health services are usually less costly than at hospital level. this means that health care users will make a choice to utilize the affordable services at those facilities rather subvert the referral system and seek the more expensive service in hospitals. in a health system where there are no fees or fees are uniform across all levels of care, clients may not consider the cost of health care services,28 rather they will opt to utilize services at higher levels of care for minor health problems which are offered at the clinics. price inelastic demand and revenue generation effect of user fees elasticity measures how responsive or the rate at which demand/quantity of a good or service change with change in price, income or prices of substitute or complement goods.29,30 when analysing user fees in healthcare, it is important to know about how healthcare demand responds to changes in price, known as price elasticity of demand. price theory suggests that if the price of a good or service rises then the demand of that good or services will fall and vice versa.31,32 when the demand for health care services is said to be inelastic, consumers will not be very responsive to changes in price32,33 and there will be only a slight drop in demand for healthcare ser review non -co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2021; 9:9307] vices, but expenditure will increase.12,34 therefore, a system of user fees will raise revenue for public health facilities when health care demand is highly inelastic. the demand for many curative health services is expected to be relatively inelastic, in large part because there are few close substitutes for medical services.32 this means that there will only be a small effect in demand from raising fees for health services. this inelastic price effect means that a modest fee on curative services would increase revenue without a negative effect on their utilization. for example, severe health problems like cardiac attack and cancers, are considered to be ‘in-elastic’ of demand of the people. in such a case, people will sell their properties like cattle, land, etc. to meet the high prices of health care services. this is obviously of importance when governments in developing countries consider policy objectives; is it to raise revenue or to deter use of low-value services? proponents of the price system argued that user fees could not only encourage efficiency, but also consumers might opt for cheaper and alternative treatments that are as effective and safe as public health facilities.12,30,31an additional argument made by the world bank,3 was that revenue generated from user fees could allow for expansion of underfunded essential health services, which in turn helps governments rectify problems with allocation of basic health services. user fees were seen to be increasing financial resources in the health sector3,35,36 which could ease budgets for healthcare in developing countries.37 introducing user fees would lessen the economic burden on government in trying to fund healthcare, by shifting part of the costs of healthcare to the users.3 the increased revenue from user fees in developing countries was expected to support public health in general and most importantly areas of public health importance such as preventive services and immunizations.3,36 this means that revenue generated through user fees should be reinvested and be allocated to cost-effective services that improve the health of the poor. arguments against price system in healthcare there are also counterarguments against relying on user fees as a model for financing and allocating healthcare services, particularly in developing countries. one argument challenges the neoclassical assumption of perfect markets, suggesting instead that health care markets are unable to yield a pareto-efficient outcome because of what is known as “market failure.”12,38,39 market failure and inefficiency of price system healthcare markets fail to ensure efficiency because of the combined effects of three characteristics: uncertainty; asymmetry of information; and externalities.40 a person’s demand for health care is characterized by uncertainty. people do not know when they will get sick or will need a particular health care service, they can be unsure of the consequences of illness and cannot easily work out the price of health care or what treatment will cost them.34,41 a particular medical need might arise at a time where the patient’s income is not sufficient to meet the treatment expenses. despite the fact that the patient may have sufficient income to cover medical costs, paying for health services may adversely affect the household budget, pushing families into poverty. therefore, the uncertainty about health care is that the cost of future treatment carries the risk of inability to pay for the required treatment or may be too expensive even if treatment can be afforded.12 in the face of uncertainty, there are benefits to be gained from insurance, which pools risk and helps spread the costs of health care.16 however, insurance insulates people from price, deliberately so in order to reduce uncertainty, and this undermines reliance in user charges and the price mechanism (a problem that health economists refer to as moral hazard). price theory also assumes that users are well informed about their need for and the quality of any health services being traded.12 it is questionable whether this assumption applies in relation to health care, especially for complex or rare conditions. patients are unlikely to know all there is to know about health care services such as the diagnosis of their illness and treatment they will need, and they rely instead on service providers to decide what treatment is required (an issue of information asymmetry). in short, it is the service provider who typically shapes a patient’s demand for health care services. the patient enters into an agency relationship with the service provider,12 whereby the market yields a pareto optimum outcome only if the health care service provider acts in the best interest of the patient.12,42 in that case, there is a possibility that the provider may be influenced by self-interest when treating the patient, even if only sub-consciously. a system of user fees must be accompanied by strong policies by the government that makes it difficult for the violation of efficiency conditions, such that the necessary information is passed to patients regarding their health and health provider behavior is regulated.14 the third cause of market failure is externalities. these are examples of costs incurred or benefits that are enjoyed by people other than the one consuming the good in question. externalities in health care include the adverse health consequences of environmental tobacco smoke43 and the benefits of herd immunity enjoyed by families who do not have their child vaccinated.44 free markets tend to under-provide goods where there are beneficial externalities, (such as vaccination) and over-provide goods where there are harmful externalities such as tobacco use. one needs to be careful therefore that any reliance on user-fees does not deter the use of services where there are substantial positive externalities. this often means recommendations to keep actions to prevent or treat infectious disease outside of any user-fee system.45 inequitable access to healthcare services a second argument against user fees relates to their differential impact, especially in relation to rich and poor. user fees will likely lead to proportionately greater reduction in use of health care services among the poor than the rich.16,18 this implies that even if user fees are set below the average cost but are high enough to reduce the demand for health care services more among the poor than the rich, then public health spending will be regressive as benefits will accrue to the rich. although user fees do not reduce demand for health care services by the poor, they will have negative redistributive effects because in paying more for their health services the poor will be left with less money for other essential services than the rich will do.16 frivolous use of public health services is already deterred because travel and time costs to reach health services are usually high.35,46 this means that charging user fees for primary health care services may cause delays in seeking care by the poor who are price sensitive. these delays will give rise to complications requiring expensive curative services hence jeopardizing efficiency in the health system. the rich will enjoy more subsidized free services than the poor even when services were made available in the same area for equal access. this is because the rich have more wealth, which enables them to meet the cost of time and traveling to obtain care. therefore, a system of price discrimination by charging fees only to those who are able to pay, would make it easier for governments to scale up services to underserviced population through the revenues generated, and this will also remove unfair inherent subsidy review non -co mmerc ial us e o nly [healthcare in low-resource settings 2021; 9:9307] [page 5] through free care.47,48 a more equitable health financing system is the one which will charge those who can afford to pay to subsidize the poor, thereby reducing frivolous use of benefits by rich and reducing high costs of providing services to the poor.49 conclusions this paper has reviewed the economic theories and assumptions that provide the rationale for using a price system to finance health care services in developing countries. it was every government’s responsibility to intervene in raising sufficient revenue for health in response to the macro-economic stress in most sub-saharan african countries. although insurance consideration is an important factor when it comes to risk sharing mechanisms (through a health insurance or progressive taxation), user fees became an option to financing of public health care services in those countries. the option to institute user fees was based on the neo-classical economic theory and the principle that suggests efficiency can be improved through a pricing strategy. all equity concerns being addressed through price discrimination, a system of user fees would allocate health care resources efficiently. the assumption being that the price system would signal to consumers what they must pay for health care services hence giving them an incentive to utilise those services well. also contentious is the assumption of perfect markets, where prices would reflect true marginal benefits of consuming healthcare goods and marginal cost of their production. in addition, user fees could be a useful way to increase additional funding for health when demand for healthcare is highly inelastic. however, opponents of user fees arguments indicated that the health care market is imperfect, that is, the perfect market theoretical implications cannot be applicable to the health market simply because demand for health care is not independent of supply as it the case in a perfect market. available evidence has put forward argument in either favour of or against a system of user fees in the health sector especially in developing countries. the literature reviewed yields robust insights to these arguments’ empirical relevance and the reassuring linkage between the findings in different developing countries. although the application of user fees in the health sector is justified by the perfect market theory, there are concerns that in the health sector a perfect market does not exist. therefore, it will not be a viable way to rely on the price system to allocate resources to the population when markets of many health care goods and services are not available or are imperfect. this suggests that need to create institutions that would facilitate creation of new markets or which can improve the performance of existing ones in developing countries. for example, enforcing insurance laws could help in creation of progressive mandatory insurances and private health insurances as supplementary to attract the wealthier population. references 1. nolan b, turbat v. cost recovery in public health services in sub-saharan africa. the world bank; 1995: p.114. 2. dercon s, ruttens c. cost recovery in health care in africa: a review of the principles and the effects on the poor. word bank institute resources 1998 bvo/98.2 3. akin j, birdsall n, de ferranti d. financing health services in developing countries. world bank publications; 1987: p. 99. 4. schieber gj. innovations in health care financing. world bank publications; 1997: p. 266. 5. shaw rp, griffin,cc. cost sharing: towards sustainable health care in sub-saharan africa. africa region findings & good practice infobriefs; no. 63. washington, dc: world bank; 1996. 6. ridde v, morestin f. a scoping review of the literature on the abolition of user fees in health care services in africa. health policy plan 2011;26:1–11. 7. opwora a, waweru e, toda m, et al. implementation of patient charges at primary care facilities in kenya: implications of low adherence to user fee policy for users and facility revenue. health policy plan 2015;30:508–17. 8. global health observatory. out-ofpocket expenditure as percentage of current health expenditure (che) (%) data by world bank income group. world health organization; 2020. 9. cook dj, mulrow cd, haynes rb. systematic reviews: synthesis of best evidence for clinical decisions. ann intern med 1997;126:376–80. 10. mcgrath j, saha s, welham j, et al. a systematic review of the incidence of schizophrenia: the distribution of rates and the influence of sex, urbanicity, migrant status and methodology. bmc med 2004;2:13. 11. linares-espinós e, hernández v, domínguez-escrig jl, et al. methodology of a systematic review. actas urol esp 2018;42:499–506. 12. mwabu g. user charges for health care: a review of the underlying theory and assumptions. 1997. unu: 5218. 13. araoyinbo i, ataguba j. user fees in africa: from theory and evidence, what next? an essay submitted to the african health economics and policy association. alliance for health policy and system research 2008. available form: https://www.who.int/alliancehpsr/araoyinbo_ataguba_userfeesafr ica.pdf 14. glied s, smith pc. the oxford handbook of health economics. oxford university press; 2011. 15. kolstad jt, chernew me. quality and consumer decision making in the market for health insurance and health care services. med care res rev 2009;66:28s-52s. 16. dupas p. global health systems: pricing and user fees. prepared for the elsevier encyclopedia of health economics, 2012. accessed 17.3.2013. 17. madore o. the health care system in canada: effectiveness and efficiency. ottawa: library of parliament, research branch; 1993: p. 15. 18. schokkaert e, de voorde cv. user charges. the oxford handbook of health economics. oxford publishers; 2011. 19. thaler r. toward a positive theory of consumer choice. j econ behavior organization 1980;1:39–60. 20. roth s, robbert t, straus l. on the sunk-cost effect in economic decisionmaking: a meta-analytic review. bus res 2015;8:99–138. 21. arkes hr, blumer c. the psychology of sunk cost. organizational behavior and human decision processes 1985; 35:124–40. 22. cunha mc, caldieraro f. sunk-cost effects on purely behavioral investments. cognitive sci 2009;33: 105–13. 23. aron-dine a, einav l, finkelstein a, cullen m. moral hazard in health insurance: do dynamic incentives matter? the review of economics and statistics 2015;97:725–41. 24. baicker k, mullainathan s, schwartzstein j. behavioral hazard in health insurance. q j econ 2015;130: 1623–67. 25. bajari p, dalton c, hong h, khwaja a. moral hazard, adverse selection, and health expenditures: a semiparametric analysis. the rand j econ 2014;45: 747–63. review non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2021; 9:9307] 26. geyman jp. moral hazard and consumer-driven health care: a fundamentally flawed concept. int j health serv 2007;37:333–51. 27. world bank. world development report 1993:investing in health, volume 1. world bank publications; 1993: p. 346. 28. griffin cc. user charges for health care in principle and practice. international bank for reconstruction and development, world bank; 1988. 29. mcpake b, normand c, smith s, nolan a. health economics: an international perspective. routledge; 2020 30. pendzialek jb, simic d, stock s. differences in price elasticities of demand for health insurance: a systematic review. eur j health econ 2016;17:5–21. 31. zhou z, su y, gao j, et al. new estimates of elasticity of demand for healthcare in rural china. health policy 2011;103:255–65. 32. ringel js, hosek sd, vollaard ba, mahnovski s. the elasticity of demand for health care: a review of the literature and its application to the military health system. rand corporation; 2002. no. mr-1355-osd. 33. ellis rp, martins b, zhu w. health care demand elasticities by type of service. j health econ 2017;55:232–43. 34. fox w, edmiston k. user charge financing of urban public services in africa. international center for public policy, andrew young school of policy studies, georgia state university; 2000. report no.: paper0004. 35. onarheim kh, sisay mm, gizaw m, et al. selling my sheep to pay for medicines – household priorities and coping strategies in a setting without universal health coverage. bmc health serv res 2018;18:153. 36. shaw rp, ainsworth m. financing health services through user fees and insurance. world bank publications (world bank discussion papers); 1996: p. 254. 37. john eu. the impacts of user fees on health services in sub-saharan african countries: a critical analysis of the evidence. am j public health res 2013;1:196–202. 38. roberts j. primary care: core values primary care in an imperfect market. bmj 1998;317:186–9. 39. vaithianathan r. health insurance and imperfect competition in the health care market. j health econ 2006;25:1193– 202. 40. arrow kj. uncertainty and the welfare economics of medical care. 1963. bull world health organ 2004;82:141–9. 41. donaldson c, gerard k. market failure in health care. in: donaldson c, gerard k, editors. economics of health care financing: the visible hand. london: macmillan education uk; 1993. p. 26–48. 42. nguyen h. the principal-agent problems in health care: evidence from prescribing patterns of private providers in vietnam. health policy plan 2011;26:i53–62. 43. novotny te, zhao f. consumption and production waste: another externality of tobacco use. tob control 1999;8:75–80. 44. chen f, toxvaerd f. the economics of vaccination. j theor biol 2014;363: 105–17. 45. england s, kaddar m, nigam a, pinto m, organization wh. practice and policies on user fees for immunization in developing countries who. 2001. available from: https://apps.who. int/iris/handle/10665/66712 46. gilson l. the lessons of user fee experience in africa. health policy plan 1997;12:273–85. 47. munge k, briggs ah. the progressivity of health-care financing in kenya. health policy plan 2014;29:912–20. 48. steinhardt lc, aman i, pakzad i, kumar b, singh lp, peters dh. removing user fees for basic health services: a pilot study and national rollout in afghanistan. health policy plan 2011;26:ii92–103. 49. gilson l, russell s, buse k. the political economy of user fees with targeting: developing equitable health financing policy. j int devel 1995;7:3 69–401. review non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11793 the effect of family empowerment through education and mentoring on increasing knowledge of exclusive breastfeeding kamsatun kamsatun departement of nursing, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract providing appropriate education to breastfeeding mothers and their families is essential to ensure a high level of breastfeeding implementation. the purpose of this study was to analyze the effect of education and mentoring on increasing knowledge about exclusive breastfeeding. this study employed a quasi-experimental design with two groups, one before and one after testing. the research was conducted in one village during march and april 2023, using purposive sampling techniques. data were collected through questionnaires. family empowerment interventions in the form of education and mentoring were administered twice with one-week intervals. data analysis was performed using an independent t-test with p<0.05. the study revealed significant differences in respondents’ knowledge after they received educational interventions and guidance. the results showed a p-value of 0.006, which is less than 0.05, indicating a significant difference in respondents’ knowledge before and after the intervention. education and instruction had a positive impact on respondents’ knowledge of exclusive breastfeeding. both the intervention and control groups showed efficacy. notably, the intervention group displayed a highly significant increase, as evidenced by the significant difference values. in conclusion, family empowerment through education and assistance has a positive effect on increasing knowledge about exclusive breastfeeding. enhancing family knowledge, skills, and social support can lead to improved optimal breastfeeding practices, enhanced infant health, and reduced infant mortality. introduction the ministry of health of indonesia reports that diarrhea and pneumonia were the most common causes of post neonatal death in 2021.1 early initiation of breastfeeding is a practice associated with the promotion of exclusive breastfeeding.2,3 it is crucial to maintain the baby’s life as it likely reduces the incidence of hypothermia. a systematic review reported that initiation of breastfeeding within 24 hours of birth was significantly associated with a reduction in all causes of neonatal mortality.4 during the corona virus disease 2019 (covid-19) pandemic, exclusive breastfeeding rates in indonesia have declined.5 this decline can be attributed to limited access to health support, increased stress, uncertainty, a lack of social support, and difficulties in consulting with health workers. riskesdas data for 2021 reveals that only 52.5 percent of babies aged less than six months are exclusively breastfed. according to a joint national survey conducted with the ministry of health of indonesia, fewer than 50 percent of mothers and caregivers of children under two years of age received breastfeeding counseling services during the pandemic.6 according to regulation number 25 of 2014 from the minister of health, which pertains to health services for infants, toddlers, and preschoolers, article 21 states that one of the health services for infants and toddlers is provided through exclusive breastfeeding until the age of 6 months. exclusive breastfeeding offers extraordinary benefits for optimizing the growth, development, and resilience of low birth weight (lbw) infants.7 the prevalence of malnutrition, including stunting, was lower in children who were exclusively breastfed compared to those who were not exclusively breastfed.8 exclusive breastfeeding is beneficial for the children, for their nutrition and development. exclusive breastfeeding is a protective force against several infectious diseases, and it also increases their intelligence.9 based on a previous study in jeneponto district, the determinants of exclusive breastfeeding in infants aged 0-6 months included giving colostrum, the mother’s employment status, family income, the mother’s educacorrespondence:kamsatun kamsatun, departement of nursing, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: kamsatun70@gmail.com key word: breast feeding; empowerment; health education; maternal health. contributions: kk, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 september 2023. accepted: 6 november 2023. early access: 16 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11793 doi:10.4081/hls.2023.11793 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11793] [page 143] non -co mmerc ial us e o nly tion, and her knowledge about the benefits of exclusive breastfeeding.10 the government of indonesia has made various efforts to increase exclusive breastfeeding in the community such as education and campaigns to increase awareness of the benefits of exclusive breastfeeding. in addition, policies and regulations that support exclusive breastfeeding, such as prohibiting formula milk advertisements and protecting mothers’ rights to breastfeed at work.11 previous research show that several obstacles that are often faced in providing exclusive breastfeeding are lack of knowledge and support.12 helina’s research results show that lack of support and accurate information can make mothers feel insecure or find it difficult to provide exclusive breastfeeding.13 some mothers experience difficulties in prioritizing time to provide exclusive breastfeeding, especially if they are working, lack of support at work such as lack of breastfeeding facilities or inadequate time for breastfeeding or expressing breast milk can be an obstacle in exclusive breastfeeding. some health conditions such as maternal health problems, infections or disorders of breast milk production or baby health problems such as premature birth, difficulty breastfeeding, can become obstacles in exclusive breastfeeding. factors that influence exclusive breastfeeding are the limited number of health workers. the provision of education about exclusive breastfeeding is not maximal yet, the lack of availability of facilities and infrastructure public and the lack of optimal family support.14 lactation education and breastfeeding support can increase the satisfaction of breastfeeding mothers in giving exclusive breastfeeding.13 exclusive breastfeeding mentoring for the self-confidence of breastfeeding mothers and families is very important because it will affect the success of carrying out exclusive breastfeeding practices.15 mother’s milk is an ideal nutrient for babies because it contains nutrients most suitable for the baby’s needs and some substances protect against various diseases.16 exclusively breastfed babies have a lower risk of developing gastrointestinal diseases and allergies.17 by giving breast milk, it is three times less likely to be treated with respiratory tract disease compared to formula milk. about 16.7 times less common pneumonia. about 47% less often suffer from diarrhea.18 through education and mentoring can overcome this obstacle and enable mothers to provide exclusive breastfeeding successfully and encourage optimal breastfeeding practices for the health of babies and breastfeeding mothers. materials and methods the research design used was quasi-experimental with a pretest-posttest control group approach, where measurements were taken before and after the intervention in both the intervention and control groups. the research population consisted of all breastfeeding mothers in gajah mekar village, bandung regency, west java, indonesia. sampling uses objectives, aligning with predetermined result criteria. the sample size for this study consisted of 60 respondents divided into two groups of breastfeeding mothers. inclusion criteria include: i) being able to read and write, ii) willingness to participate as a respondent. exclusion criteria consist of: i) breastfeeding mothers who have a history of complications such as bleeding, infection. this intervention is carried out twice with a span of one week. each intervention was carried out for 30 minutes. researchers provide education and assistance using modules. the media used is a booklet. the measurement instrument used is a questionnaire in the form of questions related to knowledge consisting of 20 questions. data analysis used the independent t test. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. the research did not use an ethical review due to limited resources, finances and people results the study results included characteristics of respondents and knowledge means in breastfeeding mothers table 1 shows that most respondents are between the ages of 20-35. the education of most respondents was secondary (high school) in both the intervention and control groups. most respondents (63.33%) already have one or more children.  table 2 reveals that the analysis of the average difference in knowledge indicates no significant disparity in the pre-test, with a p-value of 0.8677. a p-value greater than 0.05 suggests equal variances (equality). with an alpha level set at 5%, there was no significant difference in knowledge before the intervention between the intervention group and the control group. this demonstrates transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of the respondents. characteristics intervention control f % f % age 20-35 15 50 22 73.33 >35 15 50 8 26.66 parity status primipara 15 50 11 36.66 multipara 15 50 19 63.33 education primary (elementary school junior high school) 6 20 8 26.67 secondary (high school) 21 70 22 73.33 tertiary (college) 3 10 0 0 table 2. distribution of respondents' average knowledge before education and mentoring by group. groups mean sd se p n intervention 52.67 7.849 1.433 0.867* 30 control 53.00 7.497 1.369 30 *independent t test (p>0.05). [page 144] [healthcare in low-resource settings 2023; 11:11793] non -co mmerc ial us e o nly that the two groups were equal before the intervention, and there was no distinction between the intervention group and the control group. table 3 analyzes the difference in mean knowledge and demonstrates a significant disparity in the posttests, with a p-value of 0.000. when p-values are less than 0.05, it indicates unequal variances. a p-value less than alpha (0.000), where alpha is set at 5%, can lead to significant variations in mean knowledge between the intervention and control groups following the implementation of the intervention. this suggests that there are substantial differences in respondents’ knowledge after they have received educational interventions and guidance.”  table 4 indicates that the intervention group had a mean knowledge level of 52.67 before the test and a knowledge level of 66.00 after the test. we can see that the average difference between pretest and posttest is 13.33. from this, we can conclude that education and instruction influence respondents’ knowledge (p<α (0.05)). therefore, statistically, respondents’ knowledge of exclusive breastfeeding has educational and instructional effects. both groups showed efficacy in both intervention and control groups. there is a very significant increase in the intervention group, which is very large (significantly significant) in the intervention group as can be seen from the difference values.  discussion the results of this study demonstrate that family empowerment has a positive influence on increasing the knowledge of breastfeeding mothers. family empowerment, achieved through education and support, enhances knowledge about exclusive breastfeeding. this empowerment can be facilitated through various community education programs and activities that actively involve the family in the learning and development process.19 families also receive emotional support and access to adequate health facilities to bolster exclusive breastfeeding practices. with this assistance, it is expected that mothers and families will gain greater confidence and the ability to overcome various obstacles in adhering to exclusive breastfeeding. therefore, education and support can serve as effective strategies for promoting exclusive breastfeeding within the community. education and mentoring can enhance families’ capacity to address challenges in exclusive breastfeeding and make informed decisions when issues arise. according to friedman (2003), one of the family’s functions is to provide emotional support for its members, assist nursing mothers in forming their identities, and help them navigate problems while preventing them stress.20 family empowerment is expected to nurture independent families capable of managing and finding solutions to problems. empowered families exhibit creativity in enhancing the well-being of their members. family support can enhance comprehension of techniques and ways to address breastfeeding issues, thus improving the practice of exclusive breastfeeding. family empowerment is an endeavor or process aimed at fostering family awareness, willingness, and ability to recognize, overcome, maintain, protect, and enhance their own well-being. several studies have shown that family empowerment can enhance family coping and change the behavior of family members.21 the study results indicate that involving fathers in the breastfeeding process increases mothers’ confidence.22 offer support and motivation to encourage mothers to continue exclusive breastfeeding for their babies, which includes emotional and practical assistance, such as tips for increasing milk production and strategies for coping with stress. the exclusive breastfeeding program, through family empowerment, aims to elevate the rate of exclusive breastfeeding for newborns by delivering information and education about the advantages of exclusive breastfeeding while empowering families to act as advocates for exclusive breastfeeding. some programs that can be implemented to achieve this objective involve training for pregnant women and expectant mothers on the benefits of exclusive breastfeeding, correct breastfeeding techniques, and addressing potential issues that may arise during breastfeeding. through a system of family support and motivation, mothers can gain increased confidence in providing exclusive breastfeeding to their babies. this, in turn, can help enhance the baby’s health and strengthen the bond between the mother and the baby within the family. fathers contribute by providing physical, emotional, and financial support to promote exclusive breastfeeding.23 to minimize issues for breastfeeding mothers, counseling regarding lactation management should be provided during pregnancy. this way, mothers can approach childbirth without panic.24 family empowerment is expected to foster independent families capable of managing and finding solutions to problems. empowered families demonstrate creativity in enhancing the welfare of their members. with family empowerment, mothers will feel more confident and motivated to provide exclusive breastfeeding for their babies. this will help improve the baby’s health and create a harmonious and healthy family environment.25 by aiding and offering psychological and emotional support to mothers during breastfeeding, which includes counseling services as well as support from the family and the surrounding community.26 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. distribution of respondents' average knowledge before education and mentoring by group. groups mean sd se p n intervention 66.00 7.240 1.322 0* 30 control 55.33 6.814 1.244 30 *independent t test (p>0.05). table 4. changes in average knowledge value, before and after intervention. variable intervention (n=30) control (n= 30) pretest post test diff p pretest post test diff p knowledge 52.67 66 13.33 0 53 55.33 2.33 0.006 [healthcare in low-resource settings 2023; 11:11793] [page 145] non -co mmerc ial us e o nly the knowledge and information component pertains to a breastfeeding mother’s understanding of the benefits of exclusive breastfeeding, as well as her knowledge of appropriate breastfeeding techniques and how to address potential issues that may arise during breastfeeding.27 political and environmental factors encompass government and community support, which may involve the availability of breastfeeding rooms in public places and corporate policies to facilitate breastfeeding for mothers.28 education is a widely used intervention to promote mothers’ participation in improving the early initiation breastfeeding rate. additionally, maternal, and infant health conditions, as well as traditional practices, can serve as barriers to early initiation of breastfeeding.29 other research findings demonstrate that family reinforcement programs involving family members, including husbands and inlaws, can enhance breastfeeding behaviors and increase the success rate of exclusive breastfeeding programs.30 many mothers may not fully understand that babies require breast milk. some parents mistakenly believe that their baby is not getting enough milk and is hungry and crying, leading them to use a pacifier to feed formula. to address this, lactation management counseling should be offered during pregnancy to help prevent mothers from panicking during labor.31 family support for breastfeeding mothers enables families to participate in decision-making, problem-solving, and skills development. counselors assist families in gathering information, expanding knowledge, and understanding, and developing the skills needed to overcome challenges and achieve their own goals. this approach fosters independence and empowers families to take control of their lives. support and encouragement are provided to mothers to continue providing exclusive breastfeeding for their babies, including emotional and practical support such as tips on increasing milk production and stress coping strategies. family psychoeducation significantly enhances cognitive and psychomotor skills. badiah’s research results in 2022 demonstrate that psychoeducational family therapy can improve cognitive skills. this treatment includes elements that increase knowledge and equip family members with techniques that can contribute to family support.32 according to the world health organization (who), exclusive breastfeeding for the first six months of life provides babies with optimal nutrition and protection, leading to long-term positive effects on their health and development.33 family education and support can help enhance mothers’ knowledge and understanding of the benefits of exclusive breastfeeding, correct breastfeeding techniques, and how to overcome challenges that may arise during the breastfeeding process. a family support approach to improving naming practices is crucial for equipping families with the information, skills, and support needed to actively engage in naming-related decisions and actions. family support for exclusive breastfeeding is of utmost importance as it provides the emotional, social, and informational support that mothers require for breastfeeding. family education and support can assist mothers in feeling secure and motivated to breastfeed exclusively, overcoming any obstacles that arise, and maintaining their motivation over the long term. strengthening the family through support can also raise awareness and offer mothers the necessary assistance in coping with the stress and uncertainty that may accompany exclusive breastfeeding 34. family support allows mothers to feel heard, understood, and encouraged in their pursuit of exclusive breastfeeding, thereby enhancing the success and sustainability of breastfeeding practices.35 conclusions family empowerment through education and support has a positive effect on increasing knowledge about exclusive breastfeeding. active family involvement is crucial for enhancing breastfeeding. while breastfeeding mothers and families can obtain information from various sources, the application of assistance is essential as it can boost the motivation of breastfeeding mothers. family factors, in the form of family support, are necessary for breastfeeding mothers to maintain the continuation of the exclusive breastfeeding process. references 1. kemenkes. berbagai penyebab diare pada bayi. jakarta: kemenkes; 2023. 2. pujiastuti n. grandmother’s role as a personal reference toward exclusive breastfeeding behavior. media karya kesehatan 2021;4(1). 3. sebayang skksk, dibley mjjmj, astutik e, t al. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16(1). 4. shofiya d, sumarmi s, sulistyono a, suyanto b. determinants of successful exclusive breastfeeding in primiparas 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health 2022;5:532-6. 29. hadisuyatmana s, has emm, sebayang sk, efendi f, astutik e, kuswanto h, et al. women’s empowerment and determinants of early initiation of breastfeeding: a scoping review. j pediatr nurs 2021;56:e77-92. 30. djamilus f, wahyuni s, mulyati s, astuti m, studi p, bogor k, et al. pengaruh rekayasa model pemberdayaan masyarakat terhadap pola pemberian asi. jurnal riset kesehatan poltekkes depkes bandung 2022;14:114-21. 31. widaryanti r (rahayu). assistance for breastfeeding mothers during the covid-19 pandemic to maintain family resilience. pancanaka 2021;2:517645. 32. badi’ah a, mendri nk, palestin b, et al. family empowerment psychoeducation on family support caring of children diarrhea. maced j med sci 2021;9:137-41. 33. world health organization. global nutrition targets 2025: breastfeeding policy brief [internet]. jenewa: world health organization. 2014 [cited 2023 oct 25]. available from: https://www.who.int/publications/i/item/who-nmh-nhd14.7 34. duncan r, coleman j, herring s, et al. breastfeeding awareness and empowerment (bae): a black women-led approach to promoting a multigenerational culture of health. societies (basel) 2022;12(1). 35. nurhayatia ma, alit armini nk, kusumaningrum t. analysis of breastfeeding factors: the sunrise model approach. medicolegal update 2020;20:334-9. [healthcare in low-resource settings 2023; 11:11793] [page 147] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11929 reducing gadget use intensity in preschool-aged children through storytelling and coloring therapy umi kalsum,1 andi lis arming gandini,1 sutrisno sutrisno,1 emmy putri wahyuni,1,2 rosalin ariefah putri,3 nyimas heny purwati2 1department of nursing, poltekkes kemenkes kalimantan timur, samarinda; 2faculty of nursing, universitas muhammadiyah jakarta, jakarta; 3department of midwifery, poltekkes kemenkes kalimantan timur, samarinda, indonesia abstract the use of gadgets in the current era of globalization has become a concerning trend, especially among preschool children, leading to addiction and detrimental effects on their physical, psychological, and emotional health. it has also resulted in increased social isolation and hindered development. the impact of this trend is significantly influenced by the roles of parents, family, and the surrounding environment. this study aimed to determine the effectiveness of health education using modules on the benefits of storytelling and coloring therapy in enhancing parents’ knowledge, attitudes, and behaviors regarding prudent gadget use in preschool children. the research design was a pre-post quasiexperiment without a control group. the population comprised parents with preschool children attending 11 public kindergartens in samarinda city. a total sampling method was utilized, resulting in 303 respondents. health education intervention occurred after the pre-test, followed by one month of assistance and a subsequent post-test. the research instrument was a questionnaire adapted from the theory of planned behavior, assessing parents’ knowledge, attitudes, and behaviors related to providing gadgets to children. data analysis included univariate and bivariate analyses using the wilcoxon test. the results indicate a significant influence of health education using modules on the benefits of storytelling and coloring therapy on parents’ wise gadget use in preschool children (p-value < 0.005). thus, health education for parents on prudent gadget use in preschoolers is highly recommended, particularly during parent meetings at school. introduction children are at a stage of rapid growth and development, necessitating proper nutrition, stimulation, a conducive environment, and access to health services.1,2 among these, toddlers and preschoolers are particularly vulnerable to health issues.3 during the preschool years, children are in the initiative versus guilt phase, characterized by burgeoning curiosity and imagination, leading them to ask numerous questions about their surroundings that they don’t yet understand.4 in this golden age, children absorb information quickly, becoming adept imitators and laying the groundwork for their character, personality, and cognitive abilities.5 while technology has become indispensable in contemporary life, its rapid advancement has significantly impacted various spheres, including education.6 gadgets, in particular, have gained immense popularity, with both adults and children utilizing them. many gadget manufacturers target children as their primary market, resulting in children becoming active consumers of such devices.7 studies indicate that approximately one-third of preschoolers globally have access to digital devices, with a majority exceeding recommended screen time.8-10 nathan, muthupalaniappen, and muhammad (2022) found that the prevalence of digital device use among preschoolers was 95.9%, primarily smartphones (94.2%). despite this high usage, most chilcorrespondence: umi kalsum, department of nursing, poltekkes kemenkes kalimantan timur, wolter monginsidi street no. 38, samarinda ulu sub-district, samarinda city, indonesia. e-mail: umi2508@gmail.com key word: coloring; family empowerment; gadget addiction; preschoolers; storytelling. contributions: uk, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; alag, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ss, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; epw, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; rap, methodology, visualization, writing – review and editing; ss resources, investigation, and writing –review and editing; nhp formal analysis, validation, writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes kalimantan timur, based on ethical certificate dl.02.03/4.3/10432/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from [dipa poltekkes kemenkes kalimantan timur] with contract number [lb.02.01/4.3/01573/2022]”. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 8 october 2023. accepted: 14 march 2024. early access: 12 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11929 doi:10.4081/hls.2024.11929 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 448] [healthcare in low-resource settings 2024;12:11929] non -co mmerc ial us e o nly dren (95%) did not own the devices, and usage was supervised (95.7%) to prevent exposure to inappropriate content (70.5%). notably, digital devices were mainly used for educational (37.4%) and entertainment purposes (36%), primarily through videos (30.9%) and games (30.2%). alarmingly, a significant portion of children (21.5% on weekdays and 50.3% on weekends) spent more than 1-2 hours on digital devices.9 in indonesia, a substantial proportion (79.5%) of children and adolescents are gadget users, primarily for information retrieval, entertainment, and online communication.11 moreover, a survey by indonesia hottest insight in 2013 revealed that about 40% of indonesian children are active internet users.12 despite parents’ awareness of the detrimental effects of excessive screen time, including poor posture, sleep disturbances, eye strain, reduced physical activity, exposure to inappropriate content, addiction, and diminished parent-child interaction, adherence to screen time guidelines remains low.13 one of the adverse consequences of excessive gadget use is dependency and addiction, leading to developmental issues in children.6 additionally, limited communication and interaction between parents and children due to gadget use can hinder speech development in toddlers.14 it’s crucial to acknowledge that the ages of 1-5 years represent the most sensitive period of child development, underscoring the importance of cautious gadget use during early childhood.15 parents play a pivotal role in fostering effective communication and continuously anticipating and addressing their children’s negative habits.16 research has consistently demonstrated the negative impacts of gadget use on preschoolers, including speech delays, attention deficits, learning difficulties, anxiety, mental health problems, and character assassination.17,18 conversely, activities like coloring and storytelling have been shown to enhance imagination, fine motor skills, and knowledge in preschoolers.19,20 thus, encouraging parents to engage in storytelling and coloring activities with their children can help mitigate the negative effects of excessive gadget use. parental involvement is paramount in regulating children’s gadget usage. this study aimed to assess the impact of health education, focusing on the benefits of storytelling and coloring therapy, on parents’ behavior regarding gadget use in preschoolers. by promoting alternative activities and empowering parents with knowledge, attitudes, and behaviors conducive to prudent gadget use, this research endeavors to steer children away from excessive gadget dependency and toward healthier developmental pathways. materials and methods the research design employed in this study was quantitative, utilizing a quasi-experimental design, specifically a pre-post test non-equivalent group without a control group. study participants the study population consisted of parents with preschool children. samples were drawn from all parents with preschool-aged children at 11 kindergartens in samarinda city who met the inclusion criteria. these included parents of preschool children aged 37 years whose children were capable of using gadgets and who themselves owned gadgets. the exclusion criteria were preschool children unable to monitor gadget use. the sampling used the total sampling method, resulting in 303 respondents selected from 11 public kindergartens in samarinda city, indonesia. variable, instrument and data collection independent variables comprised the effect of health education using modules on the benefits of storytelling and coloring therapy. dependent variables encompassed parents’ knowledge, attitudes, and behaviors regarding prudent gadget use with children. a questionnaire was utilized to assess knowledge about preventing and managing gadget use in preschoolers (consisting of 8 questions), parents’ attitudes toward gadget use in children (12 questions), and parental and child behavioral practices in gadget use (5 questions). the instrument was adapted from lani’s (2019) research, with validity and reliability tests yielding satisfactory results (knowledge questionnaire: r=0.540-0.933, attitude questionnaire: r=0.643-0.780, behavior questionnaire: r=0.519-0.740), indicating validity and reliability. the cronbach alpha value exceeded 0.6, indicating instrument reliability.21 data analysis univariate and bivariate analyses were conducted using the ibm spss statistics 26 computer program. bivariate analysis utilized the wilcoxon test due to non-normally distributed data, with a significance level set at 95%. ethical clearance ethical approval for the research was obtained from the health research ethics commission, poltekkes kemenkes kalimantan timur, under ethical certificate dl.02.03/4.3/10432/2022. throughout the research process, adherence to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence, was observed, with the study subjects being parents with preschool children. results table 1 presents data on the characteristics of parents. the majority of mothers (51.2%) have graduated from high school, while a similar proportion of fathers (51.8%) have attained the same level of education. furthermore, a significant portion of mothers (74.6%) are not employed, whereas a considerable pro transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents indicator mom father f % f % education not in school 2 0.7 4 1.3 elementary school 18 5.9 13 4.3 junior high school 34 11.2 31 10.2 senior high school 155 51.2 157 51.8 higher education 94 31.0 98 32.3 work doesn't work 226 74.6 0 0.0 employee 32 10.6 147 48.5 civil servant 13 4.3 27 8.9 self-employed 32 10.6 107 35.3 laborer/farmer/fisherman 0 0.0 22 7.3 family income < idr 1,500,000 23 7.6 idr 1,500,000-3,000,000 114 37.6 idr 3,000,000-5,000,000 99 32.7 > idr 5,000,000 65 21.5 [healthcare in low-resource settings 2024;12:11929] [page 449] non -co mmerc ial us e o nly portion of fathers work in the private sector. additionally, approximately 37.6% of respondents reported incomes ranging between idr 1,500,000 and 3,000,000. based on table 2, the data regarding children’s dependence on gadget use reveals that the majority of children (57.4%) exhibit a dependency on gadgets, while nearly half of the children (42.6%) do not show such dependence. regarding the types of gadget use activities among children, the data indicates that playing games is predominantly observed (57.4%), while listening to songs is mostly not observed (71.3%). moreover, the data suggests that watching cartoons is nearly universal (85.1%), indicating that children primarily engage in watching cartoons when using gadgets. based on the results of the wilcoxon test presented in table 3, it is evident that there is a significant difference in knowledge, attitude, and behavior before and after the intervention with health education, focusing on the benefits of storytelling and coloring therapy for children. discussion level of gadget dependency gadgets are small devices or tools widely utilized by various age groups, offering numerous benefits and often regarded as innovative items. they cater to diverse needs, serving users ranging from adults to children. while adults typically use gadgets for 1 to 4 hours per session, often multiple times a day, preschool children have specific time limits and usage patterns distinct from adults.22 consequently, negative effects such as gadget addiction can manifest quickly due to prolonged use.23 increased gadget usage can lead to heightened levels of gadget addiction, which, in turn, heightens the risk of attention deficit disorder and hyperactivity. gadget addiction disrupts the normal release of dopamine, a neurotransmitter associated with the brain’s reward system, emotions, motivation, and perception of rewards. excessive gadget usage triggers excessive dopamine release, fostering a cycle of addiction where users continually seek gratification through gadget activities.24,25 the consequences of gadget addiction can adversely affect brain development, particularly the maturity of the pre frontal cortex (pfc), responsible for executive functions like impulse control, decision-making, and concentration.26 studies indicate that excessive gadget use, particularly at a young age, can impede the pfc’s normal development, leading to diminished impulse control and concentration skills.27 therefore, it’s crucial to recognize the potential risks of gadget addiction and prudently limit gadget usage, especially in children. effective supervision and scheduling are vital to ensuring gadget use remains moderate and doesn’t interfere with healthy brain development. moreover, offering alternative, stimulating activities such as sports, outdoor play, reading, and social interaction can foster balanced brain development and mitigate the risk of gadget addiction.24,28 this study corroborates nurfitri rahmawati’s research (2020), which highlights that daily gadget usage often indicates high dependency levels, with many children experiencing negative impacts associated with gadgets.29 excessive screen time among young children has been linked to various harmful consequences, including screen dependency, as evidenced by research indicating a troubling prevalence of media-related dependency among adolescents and preschoolers.30 types of gadget use activities in children in reality, when children become excessively engrossed in their gadget world, they often overlook fundamental needs such as learning and proper socialization in life.31 many children derive great enjoyment from using smartphones in their daily activities at home, school, and during playtime, leading some to develop a sense of coolness associated with gadget use. some children even prioritize their gadgets over obeying parental instructions and may react negatively when asked to disengage. this behavior exemplifies a form of gadget addiction among children. providing gadgets to children without adult supervision or guidance can indeed lead to various negative impacts.32 the study highlights some of the adverse effects of excessive gadget use on children’s physical and mental health. from vision impairments to severe mental disorders, the consequences can be significant. moreover, if children are left unsupervised while using gadgets, their condition may deteriorate further. while engaging in play is acceptable, it’s crucial to ensure that children don’t become excessively immersed in gaming to the point where it adversely affects their well-being. parents’ knowledge in preventing gadget use having good knowledge forms a solid foundation for making informed decisions and taking appropriate actions regarding gadget use in children.33,34 parents’ attitudes towards gadget usage vary. some parents are comfortable with their children using gadgets for over an hour a day, viewing them as suitable play tools for preschool-age children. additionally, many parents see gadgets as an engaging entertainment medium for their children. some parents even support their children’s gaming skills by downloading specific applications. however, a minority of parents permit gad transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. dependence and types activities of gadget use in children. indicator f % gadget use dependency 174 57.4 not dependent 129 42.6 playing games yes 174 57.4 not 129 42.6 listening to songs yes 87 28.7 not 216 71.3 watching cartoons yes 258 85.1 not 45 14.9 table 3. results of bivariate analysis using the wilcoxon test before and after intervention. indicator f min-max p knowledge 0.001 before 303 1-8 after 303 2-7 attitude 0.010 before 303 27-44 after 303 26-44 behavior 0.001 before 303 9-20 after 303 10-20 [page 450] [healthcare in low-resource settings 2024;12:11929] non -co mmerc ial us e o nly get use at the dinner table, believing it enhances their children’s appetite while eating. furthermore, parents may resort to giving gadgets to their children when they are occupied with work.21 parrents’ attitude in preventing gadget use parents, as the primary caregivers spending considerable time with their children at home, bear the responsibility of regulating and supervising their children’s gadget usage. this entails selecting appropriate content for their children, ensuring it aligns with their age and is free from harmful elements such as pornography or violence, and enforcing time limits on gadget use. each parent employs distinct parenting styles and approaches, collectively termed as parenting.35,36 the role of parents holds immense significance in shaping the future quality and contribution of children to the nation and society.37,38 therefore, parents must exert optimal efforts in educating and nurturing their children, guaranteeing their rights are fulfilled both physically and mentally.39 parental involvement during children’s gadget use forms part of digital parenting strategies aimed at preventing gadget addiction.40 parental methods of assisting children with gadget usage vary, including supervising their internet access, providing guidance on responsible gadget use, and diverting their attention from gadgets by allocating dedicated time for interactive play.41 parents’ behavior in preventing gadget use parents often hold the belief that providing gadgets to their children will keep them entertained indoors, favoring gadget use over outdoor play with friends.42,43 however, this mindset may indicate a lack of awareness regarding age-appropriate child development. allowing children unrestricted access to gadgets can be perceived as a convenient solution for keeping them occupied. nevertheless, without proper supervision and limitations, excessive gadget use can impede children’s social and physical growth.21 researchers suggest that imposing time limits is an effective strategy to curb gadget dependency. while initially challenging, children gradually adapt to new rules within a week. implementing such restrictions aims not to inconvenience children but rather to encourage engagement in alternative activities and outdoor pursuits. by regulating gadget usage duration, children are more inclined to explore other beneficial activities such as playing with peers, participating in sports, engaging in artistic endeavors, or reading books.44 moreover, time constraints facilitate improved time management skills, mitigate gadget addiction, and minimize the adverse effects of excessive technology exposure. conclusions considering the evidence, targeted health education interventions are demonstrably effective in shaping parental attitudes and practices regarding gadget use in preschoolers. consequently, educational institutions must place emphasis on incorporating modules that extol the benefits of storytelling and coloring therapy into the curriculum of parent meetings at schools. such an initiative would ensure that schools are at the forefront of equipping parents with essential knowledge and strategies to guide gadget use amongst their children. this measure is pivotal for cultivating a more conducive digital environment that supports the well-being and development of preschool-aged children. references 1. hasinuddin m, noviana u, fitriah f. family support system as an effort to optimize coping mechanism of preschool children during hospitalization. j ners 2019;14:199–204. 2. khasanah u, efendi f, has emm, et al. healthcare-seeking behavior for children aged 0–59 months: evidence from 2002– 2017 indonesia demographic and health surveys. plos one 2023;18:e0281543. 3. junaidi es, jalaludin j, tualeka ar. a review on the exposure to benzene among 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dampak negatif gadget melalui pendekatakan komunikasi dan psikologi. ijip indones j islam psychol 2020;2:267–89. 17. sundus m. the impact of using gadgets on children. j depress anxiety 2017;07:1–3. 18. setianingsih s, ardani aw, khayati fn. dampak penggunaan gadget pada anak usia prasekolah dapat meningkatan resiko gangguan pemusatan perhatian dan hiperaktivitas. gaster 2018;16:191. 19. rahma r, rizki s. efforts for children’s fine motor development through coloring schedule media in group b children at tkn permata hati. early child res j 2023;5:24–8. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11929] [page 451] non -co mmerc ial us e o nly 20. strouse ga, ganea pa. the effect of object similarity and alignment of examples on children’s learning and transfer from picture books. j exp child psychol 2021;203:105041. 21. lani t. perilaku orang tua terhadap penggunaan gawai anak prasekolah serta dampak pada tajam penglihatan anak. airlangga university; 2019. 22. mahmudiono t, rachmah q, indriani d, et al. gadget use, pocket money, and snacking habits of children with and without overweight/obesity problem in surabaya, indonesia. syst rev pharm 2020;11:1087–90. 23. hidayati t. minimalisir penggunaan gadget pada anak pra sekolah. community dev j 2020;4(1). 24. hikmaturrahmah h. dampak penggunaan gadget pada anak usia dini. musawa j gend stud 2020;10:191–218. 25. juárez olguín h, calderón guzmán d, hernández garcía e, barragán mejía g. the role of dopamine and its dysfunction as a consequence of oxidative stress. oxid med cell longev 2016;2016:9730467. 26. dewi rk, efendi f, has emm, gunawan j. adolescents’ smartphone use at night, sleep disturbance and depressive symptoms. int j adolesc med health 2021;33(2). 27. dresp-langley b. children’s health in the digital age. int j environ res public health 2020;17(9). 28. thesia p. the impact of gadget use on early 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playing gadget and mental emotional state of elementary school students. open access maced j med sci 2019;7:148–51. 35. lanjekar pd, joshi sh, lanjekar pd, wagh v. the effect of parenting and the parent-child relationship on a child’s cognitive development: a literature review. cureus 2022;14:e30574. 36. kong c, yasmin f. impact of parenting style on early childhood learning: mediating role of parental self-efficacy. front psychol 2022;13:1–11. 37. abidin ds, irwanto. correlation between types of parenting with the development of children aged 1-5 years. indian j public heal res dev 2019;10:1661–5. 38. dewi rk, sumarni s. parenting style and family empowerment for children’s growth and development: a systematic review. j public health africa 2023;14(s2). 39. gadsden vl, ford m, breiner h. parenting matters: supporting parents of children ages 0-8. parenting matters: supporting parents of children ages 0-8. 2016. 1–506 p. 40. hidaayah n, yunitasari e, nihayati he, et al. parenting stress against symptoms of gadget addiction in elementary school age during the covid-19 pandemic. bali med j 2022;11:1189–94. 41. tri rizki m, kustiono k, utanto y. parent assistance in the use of gadgets for early childhood learning process. innov j curric educ technol 2021;10:132–9. 42. unicef. the art of parenting training guide. unicef. 2013;41(2):93–100. 43. larseman dela v, munandar a, amri k, et al. the role of parents in assisting the use of gadgets in preschool children. kne soc sci 2023;2023:667–72. 44. skharninda r, setyowati we. the effect of storytelling on ability to control violence behavior in early childhood. j ners 2020;15:574–7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 452] [healthcare in low-resource settings 2024;12:11929] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11762 the relationship between knowledge and social support with sexual behavior in adolescents puji hastuti, alesya putri jayanti, astrida budiarti, iis fatimawati hang tuah surabaya college of health sciences, surabaya, indonesia abstract adolescents often undergo a tumultuous phase of sexual maturation, leading to increased dating activity due to a lack of adequate knowledge and support. this study aimed to investigate the relationship between knowledge, social support, and sexual behavior among adolescents. the research adopted a cross-sectional design with 100 respondents from manukan kulon. simple random sampling was used to select the respondents. knowledge and social support served as independent variables, assessed through questionnaires, while sexual behavior was the dependent variable, evaluated with a separate questionnaire. ordinal data analysis, specifically the spearman rho test (ρ<0.05), was employed. results indicated that 57% of adolescents in manukan kulon had low knowledge, 46% lacked social support, and 60% engaged in unsafe sexual behavior. the spearman rho test revealed significant relationships between knowledge and sexual behavior (ρ = 0.000) and between social support and sexual behavior (ρ = 0.000). in conclusion, improved knowledge can lead to safer sexual behavior among adolescents, while strong social support, particularly from parents and teachers, plays a vital role in providing information and promoting safe sexual behavior. introduction adolescents are individuals experiencing a transitional phase of sexual and biological maturation, which can lead to excessive dating behavior, including unhealthy reproductive behaviors like premarital sex.1 premarital sexual behavior is sexual behavior carried out without going through an official marriage process according to the law or according to their respective religions and beliefs. one of the factors of sexual behavior is social support and lack of knowledge.2,3 little knowledge of sex in adolescents makes adolescent behavior worrying, such as things that should not be done but in this day and age teenagers consider holding hands, hugging kissing with the opposite sex is common.4 this perception often stems from the absence of correct and comprehensive sexual education1. in addition to insufficient knowledge, social support plays a significant role in adolescent sexual behavior. parents, as a primary influence within the family environment, exert considerable impact by providing social support.5,6 families, particularly parents, have a pivotal role in shaping adolescent sexual behavior by imparting knowledge and understanding of the consequences of premarital and free sex.7,8 however, adolescents tend not to disclose their premarital sexual activities to their parents or family.3 they often place more trust in their peers, believing that friends can maintain confidentiality and offer solutions to their problems.9 according to data from the adolescent reproductive health survey (skrr) in 2017, 45% of women and 44% of men started dating between the ages of 15 and 17. regarding sexual behavior, correspondence: puji hastuti, hang tuah surabaya college of health sciences, surabaya, indonesia. e-mail: pujihastuti@stikeshangtuah-sby.ac.id key words: knowledge; social support; sexual behavior; adolescent. contributions: ph conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; apj conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ab conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; if visualization, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, stikes hnag tuah surabaya, based on ethical certificate pe/20/vi/2022/kep/sht. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. research consent was obtained from adolescents and parents by signing their willingness to become research respondents. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to head of rw 3 manukan kulon, for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 3 october 2023. early access: 16 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11762 doi:10.4081/hls.2023.11762 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11762] [page 1] non -co mmerc ial us e o nly most women and men reported activities such as holding hands (64% of women and 75% of men), hugging (17% of women and 33% of men), kissing on the lips (30% of women and 50% of men), and touching/groping (5% of women and 22% of men) while dating. the survey also indicated that 8% of men and 2% of women reported engaging in premarital sexual intercourse. reasons cited for engaging in premarital sex included love (47%), curiosity (30%), chance (16%), coercion (3%), and influence from friends (9%).10 in a preliminary study involving 10 adolescents from manukan kulon, findings revealed that 70% had limited sexual knowledge, while 30% possessed a higher level of knowledge. regarding social support, 60% received support from peers, 20% from family, and 20% from special individuals like partners. in terms of sexual behavior, 70% had girlfriends, four held hands with the opposite sex, and three hugged individuals of the opposite sex. furthermore, 30% did not have girlfriends, but two of them engaged in holding and hugging with the opposite sex, while one abstained from any such interactions. notably, three teenage girls experienced unwanted pregnancies, highlighting the consequences of risky sexual behavior. observations in manukan kulon indicated that adolescents lacked information about premarital sexual behavior and its consequences. limited parental support, such as allowing latenight dating, pushed adolescents to rely on peers and special individuals for emotional support during highs and lows. this combination of insufficient knowledge and inadequate social support may contribute to high-risk sexual behavior among adolescents in manukan kulon. adolescent knowledge about sex remains deficient, often influenced by incorrect sources of information, such as pornographic videos, pornographic websites on the internet, and other sources, which can lead to misconceptions and incorrect perceptions about sex.11,12 these misconceptions can lead to inappropriate attitudes and subsequent sexual behaviors.13 additionally, adolescents may believe that engaging in sex is a way to express love, leading them to engage in sexual activity before marriage.14 lack of knowledge can result in sexual activity, and the worst consequences can include sexually transmitted diseases (stds) like hiv/aids.15 inadequate social support, including support from parents, peers, and special individuals, is another contributing factor to adolescent sexual behavior. adolescents naturally seek independence from their parents and form bonds with peers, and peer associations significantly influence their sexual behavior, as they spend more time with friends.16,17 adolescents often rely more on friends than their parents and develop strong emotional connections within their peer groups. this strong solidarity among peers can influence adolescents’ sexual behavior.18 the consequences of insufficient and incorrect social support can lead to sexual behaviors that result in unwanted pregnancies, abortions, stds like hiv/aids, and psychological impacts such as anxiety, depression, shame, and fear.15 the support provided by families, peers, and special individuals is a crucial factor influencing premarital sexual behavior in adolescents. insufficient social support can lead to limited knowledge, which is essential for preventing sexual behavior.15 early sex education, provided by parents or teachers, is necessary to help adolescents make informed decisions about their behavior and avoid accepting incorrect information. parents should maintain open communication with their children to explain what is acceptable and what is not. the primary objective of this research was to examine the relationship between knowledge, social support, and adolescent sexual behavior. materials and methods research design this study employed a quantitative research approach with an observational analytical design using a cross-sectional approach. the research was conducted in a specific area of west surabaya, namely manukan kulon. study respondents the population for this study comprised adolescents residing in manukan kulon, with a total of 133 potential respondents. the sample size selected for this study consisted of 100 respondents. the sampling method involved collecting data from teenagers at a single location during a specific time frame, and those who were present during that time were included as research respondents. the inclusion criteria for this study included adolescents who were living in the area, willing to participate by completing the distributed questionnaires, aged between 15 and 21 years, and not married. exclusion criteria encompassed adolescents who did not attend the research site as respondents and adolescents with disabilities. variable, instrument and data collection the independent variables in this study were knowledge and social support, while the dependent variable was sexual behavior. the questionnaire used to gather demographic data from respondents included initial name, gender, age, age at first menstruation (only for women), age at first wet dream (for men only), individuals respected by the respondent, presence of close friends, number of close friends, presence of friends, the number of friends, sources of friendship, sources of information related to sexuality, existence of a romantic relationship, and parental restrictions on relationships. the knowledge measurement instrument employed in this study used a knowledge questionnaire comprising 15 guttmann scale questions adapted from prior research,9 with two optional answers. knowledge was categorized as low if the score was < 75% (true < 11) and high if the score was ≥ 75% (correct ≥ 11). the social support questionnaire in this study consisted of 12 likert scale questions adapted from lakey and cohen,18 with four optional answers: very suitable (4), suitable (3), not suitable (2), very inappropriate (1). social support was categorized as low (1223), medium (24-35), and high (36-48). the sexual behavior questionnaire in this study consisted of 15 likert scale questions adapted from muflich’s research,19 with two optional answers: never=0 and ever=1. sexual behavior was categorized as safe (if all answers were “never”), less safe (if the respondent answered “ever” for one of the indicators: touching, kissing, and masturbation), and unsafe (if the respondent answered “ever” for one of the indicators: deep kissing, oral sex, petting, and sexual intercourse). validity and reliability tests were conducted on 30 respondents, and the results indicated that all the questions were valid. the cronbach alpha results for the knowledge questionnaire were 0.760, and for the sexual behavior questionnaire, they were 0.764, demonstrating the reliability of both questionnaires. data analysis statistical analysis was performed using spearman’s rho (α<0.05). mentioning data normality and characteristics is essential. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 2] [healthcare in low-resource settings 2023; 11:11762] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly results the study’s respondents, as described in table 1, primarily consisted of 58% males and 42% females. the majority fell into the 15-year-old age category (31%). most females experienced menarche at age 12 (15%). among males, wet dreams commonly occurred at ages 12 and 13 (15%). regarding respected individuals, 71% of respondents respected their parents. the majority had 1-5 close friends (66%), who primarily came from the home environment (38%) or school (34%). information about sexuality was mainly obtained from multiple sources (33%). in terms of relationships with the opposite sex, 63% of respondents reported not having such relationships. parental restrictions on relationships were mostly not imposed (62%). table 2 illustrates that a significant majority of adolescents, specifically 60.0%, exhibit low knowledge and engage in unsafe sexual behavior. in contrast, a smaller percentage, 21.1%, display low knowledge but practice safe sexual behavior. additionally, 40.0% of adolescents with high knowledge engage in unsafe sexual behavior, while 78.9% of those with high knowledge practice safe sexual behavior. only 19.0% of adolescents with high knowledge engage in unsafe sexual behavior. the spearman rho test results (ρ = 0.000) with a value of r = -0.378 indicate a significant negative relationship between adolescent knowledge and sexual behavior in rw 3 manukan kulon. this suggests that the hypothesis, which posits a low-nature relationship, is accepted, affirming the association between knowledge and sexual behavior among these adolescents. table 3 provides insights into the relationship between adolescent social support and their sexual behavior in rw 3 manukan transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutionstransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic data characteristics of youth in rw 3 manukan kulon 18-19 june 2022 (n=100). characteristics frequency (f) percentage (%) gender male 58 58 female 42 42 age middle adolescent (14-17year old) 56 56 last adolescent (18-21 year old) 44 age of puberty (menarche/wet dream) 8 year old 1 1 10 year old 6 6 11 year old 14 14 12 year old 30 30 13 year old 24 24 14 year old 12 12 15 year old 7 7 16 year old 6 6 respected person parent 71 71 teacher 3 3 parent and teacher 19 19 special other 6 6 nothing 1 1 number of close friend nothing 5 5 1-5 people 66 66 6-10 people 25 25 11-15 people 4 4 neighborhood origins of close friends household 38 38 school 34 34 household and school 23 23 nothing 5 5 information about sexual behavior comes from social media 25 25 school 27 27 parent 1 1 friend 14 14 choose more 1 33 33 relationship status (have boy/girlfriend) yes 37 37 no 63 63 parent limitation of relationship yes 38 38 no 62 62 [healthcare in low-resource settings 2023; 11:11762] [page 3] non -co mmerc ial us e o nly kulon. notably, 48.3% of adolescents with low social support tend to engage in unsafe sexual behavior, while a smaller proportion (66.7%) with similarly low support also exhibit unsafe sexual behavior. however, a modest 15.8% of adolescents with low social support practice safe sexual behavior. on the other hand, 30.0% of adolescents with high social support engage in unsafe sexual behavior, while a significant majority (73.7%) with high support follow safe sexual practices. moderate social support corresponds to diverse outcomes: 21.7% of adolescents with moderate support exhibit unsafe sexual behavior, while 9.5% with the same level of support engage in unsafe sexual practices. additionally, 10.5% of adolescents with moderate social support opt for safe sexual behavior. the spearman rho test results (ρ = 0.000) with a correlation coefficient (r) of -0.344 signify a significant negative relationship between adolescent social support and their sexual behavior in rw 3 manukan kulon. this supports the hypothesis of a low-nature relationship, underlining the meaningful connection between social support and adolescent sexual behavior in this context. discussion factors related to adolescent sexual behavior include knowledge and social support. knowledge can shape a person’s attitudes and behavior. it also enables adolescents to have awareness and act in accordance with their knowledge. behavior based on knowledge tends to be more enduring than behavior without a knowledge foundation. the results of this study are consistent with kumalasari’s research19 which suggests that students with limited knowledge are more likely to engage in premarital sexual behavior. conversely, adolescents with higher knowledge levels are less likely to engage in premarital sexual behavior.12,20,21 this study’s findings align with a survey conducted by kumalasari19 in various countries, demonstrating that access to accurate information can reduce reproductive issues in adolescents.22,23thus, it can be inferred that a higher level of knowledge among adolescents correlates with more responsible behavior. cognitive knowledge is a vital domain for shaping an individual’s actions (i.e., behavior).24,25 interestingly, there were 19% of respondents with high knowledge who engaged in unsafe sexual behavior. researchers speculate that these adolescents may have understood the definition and consequences of sexual behavior, leading them to take more risks. access to abundant information on reproductive health through various media sources, such as websites, videos, television, books, and magazines, might influence this behavior.26,25,27 the results highlight that well-informed respondents can still engage in risky sexual behavior, possibly because the information they receive is not always accurate or complete, encouraging experimentation despite their knowledge.27,28 low social support among adolescents was associated with less safe sexual behavior. behavior can be influenced by the support provided by individuals in one’s social circle, which encompasses emotional support, information, rewards, and tools that enhance responsible behavior.29 various factors, including predisposition, support, and driving factors, can shape an individual’s actions. peer social support is a driving factor that should significantly influence behavior, as strong peer support can deter premarital sexual behavior. however, family support is another factor that may directly affect behavior.9,22,30 interestingly, some respondents received high social support but still engaged in unsafe sexual behavior (23.8%). it’s possible that respondents perceived the support they received as granting them the freedom to do as they pleased, as the surrounding support allowed them to act without fear, including engaging in negative behaviors. this finding aligns with previous research31 which established a connection between parental support and adolescent risky sexual behavior. this support sometimes takes the form of permissive-indulgent parenting, where parents prioritize their children’s happiness, granting them more freedom and complying with their wishes. consequently, this approach can lead to more aggressive, independent, and socially unaware adolescents who may engage in risky sexual behavior.7,28,30,32 one limitation of this study is that the measurement of social support does not provide detailed data on the sources of support received by adolescents. [page 4] [healthcare in low-resource settings 2023; 11:11762] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. the relationship between knowledge and sexual behavior in adolescents in rw 3 manukan kulon on 18-19 june 2022 (n=100). knowledge sexual behavior total unsafe less of safe safe f % f % f % n % low 17 81.0 36 60.0 4 21.1 57 57 high 4 19.0 24 40.0 15 78.9 43 43 total 21 100 60 100 19 100 100 100 result of spearman’s rho analysis (α = 0.05) > (ρ = 0.000) (r = -0.378). table 3. the relationship between social support and sexual behavior in adolescents in rw 3 manukan kulon on 18-19 june 2022 (n=100)knowledge sexual behavior total knowledge sexual behavior total unsafe less of safe safe f % f % f % n % low 14 66.7 29 48.3 3 15.8 46 46 middle 2 9.5 13 21.7 2 10.5 17 17 high 5 23.8 18 30.0 14 73.7 37 37 total 21 100 60 100 21 100 100 100 result of spearman’s rho analysis (ρ = 0.000)<(α = 0.05) (r = -0.344) non -co mmerc ial us e o nly conclusions the knowledge and social support possessed by adolescents are related to their sexual behavior. providing appropriate information that aligns with the needs of adolescents is one of the key factors in helping them avoid risky sexual behavior. efforts to prevent premarital sexual behavior should focus on increasing knowledge and social support, particularly from those who are closest to adolescents, including parents, teachers, and peers. this approach aims to create an environment conducive to the healthy development of adolescents as they navigate their developmental tasks. references 1. wulandari s. hubungan pengetahuan dengan perilaku seksual remaja pada siswa/i di smk n 1 tandun kabupaten rokan hulu. j martenity neonatal 2020;3:36-45. 2. berliana sm, utami ed, efendi f, kurniati a. premarital sex initiation and the time interval to first marriage among indonesians. bull indones econ stud 2018;54. 3. berliana sm, kristinadewi pan, rachmawati pd, fauziningtyas r, efendi f, bushy a. determinants of early marriage among female adolescent in indonesia. int j adolesc med health 2021;33:1-6. 0 4. ortiningsih r, kasiati k, handayani s. premarital counseling affects primigravidas’ knowledge and attitude on reproductive and sexual health. j ners 2021;16:49-53. 5. zubaidah z, maria i, rusdiana r. the relationship between parenting style and sexual behavior before marriage in teenagers. j ners 2020;15:553-6. 6. panewaty df, indrawati es. hubungan antara dukungan sosial orangtua dengan penyesuaian sosial pada siswa dalam asuhan nenek di smp negeri 1 ngraho kabupaten bojonegoro. empati 2018;7:145-54. 7. krisnana i, rachmawati pd, kurnia id, rummy nsj. parental interactions associated with adolescent health risk behavior: premarital sexual and aggressive behavior. j ners 2021;16:106-10. 8. mohan sbvr, dhanapal s, govindasamy v, pillay ksp. psychological impact of parent-adolescent communication: a critical analysis. int j public heal sci 2022;11:1210-22. 9. chasanah m. hubungan antara kontrol diri dan dukungan sosial teman sebaya dengan perilaku seksual pranikah pada remaja akhir. 2020. 10. bkkbn. survei demografi dan kesehatan : kesehatan reproduksi remaja 2017. badan kependud dan kel berencana nas 2017;1-606. 11. tan ess, chin safx, sathapan msp, dewi ad, amini f, bustami na, et al. mental health and the covid-19 pandemic: observational evidence from malaysia. int j environ res public health 2023;20:4046. 12. santoso s, siswantara p. adolescents’ knowledge and attitude before and after exposure to media of youth sexual behavior in indonesia. indian j forensic med toxicol 2020;14:2338-42. 13. fevriasanty fi, suyanto b, soedirham o, et al. effects of social media exposure on adolescent sexual attitudes and behavior: a systematic review. int j public heal sci 2021;10:272-80. 14. alfiyah n, solehati t, sutini t. gambaran faktor-faktor yang berhubungan dengan perilaku seksual pranikah pada remaja smp. j pendidik keperawatan indones 2018;4:131-9. 15. hervina. hubungan dukungan teman sebaya dan religiusitas dengan perilaku seks pra nikah. 2018; 16. hartini n. complete family and teenager’s well-being. j adv res dyn control syst 2019;11:1302-7. 17. suharmanto, suyanto b, purnomo w, set al. organized activities in peer groups improve mental and social well-being in adolescents: a qualitative study. indian j public heal res dev 2019;10:1239-44. 18. santy e, sari usc, hikmah k. assessing factors influencing free sexual behavior among teenagers. j vokasi kesehat 2020;6:22-7. 19. kumalasari d. hubungan pengetahuan dan sikap dengan perilaku seksual pada siswa smk. j aisyah j ilmu kesehat 2017;1(1). 20. susanti e. women’s knowledge and the role of local female leaders in ending the practice of the early marriage of girls in rural communities of indonesia. j int womens stud 2019;20:13-28. 21. muthmainnah m, devi yp, khoiriyah ie, et al. determinants of adolescent sexual behaviour in indonesia during the covid-19 pandemic: a scoping review. niger postgrad med j 2023;30:87-95. 22. pradanie r, yunitasari e, wibawati ar, abigail w. analysis of factors related to behaviours to prevent sexual assault of teenage girls. j pak med assoc 2023;73:s126-9. 23. chotimah k, suza de, efendi f, et al. determinants of adolescent first births in indonesia. syst rev pharm 2020;11:241-5. 26294 24. nurmala i, ahiyanasari ce, muthmainnah, et al. emerging premarital sexual behavior among adolescent in indonesia: the impact of knowledge, experience, and media use to attitudes. indian j forensic med toxicol 2020;14:2864-70. 25. kurnia id, krisnana i, yulianti fn. increasing prevention knowledge of sexual violence and emotional maturity on children through the mini-movie media. j keperawatan padjadjaran 2020;8:242-52. 26. wahyuni pa, winarti y. hubungan pengetahuan dengan perilaku seksual pranikah berisiko kehamilan tidak diinginkan (ktd) pada mahasiswa prodi s1 kesehatan masyarakat. borneo student res 2020;2:383-9. 27. hastutii p, salsabila r, budiarti a, yunitasari e. the correlation between social media use, peer influence, and sexual behaviour among adolescents. j pak med assoc 2023;73:s3941. 28. permatasari e, kuntoro, devy sr, hendriani w. parental knowledge on the perpetrators and the impacts of child sexual abuse towards parental protection efforts to prevent children from being the victims of sexual abuse. indian j public heal res dev 2019;10:1823-7. 29. idawati i, salim la, devy sr, et al. literature review: the relationship between the role of parents as educators on the behavior of preventing early marriage in adolescents. j public health africa 2023;14:2554. 30. permatasari e, kuntoro, devy sr, hendriani w. parental responsiveness of mindest-based nursing on early sexual education to prevent child sexual abuse. indian j public heal res dev. 2019;10:885-90. 31. ungsianik t, yuliati t. pola asuh orang tua berhubungan dengan perilaku seksual berisiko pada remaja binaan rumah singgah. j keperawatan indones 2017;20:168-75. 32. kohno a, dahlui m, nik farid nd, et al. why girls get married early in sarawak, malaysia an exploratory qualitative study. bmc womens health 2020;20:46. [healthcare in low-resource settings 2023; 11:11762] [page 5] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master evaluation of the static and dynamic balance in single and dual tasks among active smokers and non-smokers yuvraj rana,1 hina vaish2 1maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana; 2department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india abstract chronic smoking may lead to postural imbalance and there is the risk of injuries due to instability. balance is needed to maintain posture. literature is scarce regarding static and dynamic balance in smokers. hence, the study aimed to evaluate the static and dynamic balance in single and dual tasks among active smokers and age-matched non-smokers.100 smokers and 100 non-smokers aged 20-50 years were selected by purposive sampling. static balance was assessed by a single-leg stance (sls) test. dynamic balance was assessed by performing the time up and go (tug) test, and 10m walk test. all the tests were performed in single and dual tasks in both smokers and age-matched non-smokers. kolmogorov-smirnov test was used for assessing normality. mann-whitney u test was used to compare the two groups. pvalue ≤ 0.05 was considered significant. there was a significant difference in the sls test, 10m walk test, and tug test in single as well as dual tasks. the static and dynamic balance is impaired in chronic smokers in comparison to age-matched non-smokers and seeks further exploration in larger samples. introduction cigarette smoking is a well-known source of various chronic diseases.1 globally in 2019, smoking tobacco use accounted for 7·69 million deaths and was the leading risk factor for death among males (20·2% of male deaths).2 in this era of modernization, factors that promote the excess use of smoking are curiosity, fashion, social approval, high socioeconomic status, flavored aromatic tobacco (in hookah), the need for diversion, misperception of health hazards, and most important peer pressure among teenagers and adults.3 the physical fitness and mental health components are affected by these habits of smoking.4 from the previous reports it was accounted that smokers occupy more medical expenditure than nonsmokers.5 cigarette smoking delivers a drug named nicotine which sustains tobacco addiction. this drug has adverse effects and affects motor, sensory, cognitive, and attention abilities.6 there is evidence, that static postural stability is decreased in chronic smokers.7 chronic smoking lowers muscle strength, flexibility, and aerobic exercise level and therefore, it promotes the change in the body’s organic functions.4 chronic smoking can cause dizziness, unsteadiness, nausea, and some other problems and can also increase postural sway.8 factors controlling the body’s balance and orientation consist of the vestibular, visual, somatosensory system, and motor responses.9,10 these factors are required to maintain postural control in both static and dynamic conditions. dynamic postural control plays a vital role in maintaining dynamic balance because individuals perform many different tasks in daily living in a dynamic state.11 increased risks of falls are related to balance which leads to injuries. the injuries comprise some shortand long-term effects i.e. functional declination, dependent care, limitation in mobility, demotion in quality of life, and risk of early death.12 there is a 7.3% of reduction in bone mineral density of the lumbar spine, poorer and weak balance, a decrease in neuromuscular and physical functions, and surging bone fragility due to which there are more chances of falls and injuries in postmenopausal smokers.13 nicotine affects muscles that are responsible for the instability of upright posture, also decreases the blood flow of the inner ear, and reduces the accuracy of the peripheral vestibular system.14 cigarette smoking may increase the risk of postural instability during the walking and standing phase. it is essential to maintain postural control in static and dynamic conditions. the ability of the brain to organize multi-task interactions is an important component of motor control and balance.15 during the dual task, there is a concurrent performance of a motor-motor or motorcognitive task that is performed independently and it is tested by measuring the interference of one or both tasks in one another.16 maintenance of balance in dual-task is a complex outcome of trunk stability and healthcare in low-resource settings 2023; volume 11:11159 correspondence: hina vaish, department of physiotherapy, school of health sciences, csjm university, kanpur, uttar pradesh, india. tel.: +91.9450124758. e-mail: hina22vaish@gmail.com key words: balance, cognition, muscle strength, smoking. contributions: yr, experiments design, data collection, and manuscript writing; hv, experiment design, data analysis, contribution with critical intellectual content, and manuscript writing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. availability of data and materials: the data set associated with this study is available here: yuvraj r, vaish h. evaluation of static and dynamic balance in single and dual tasks among active smokers and non-smokers. mendeley data, v1, 2021. doi: 10.17632/9wg 4t87kgg.1. ethics approval: the study was approved by the student project committee of the maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana, india. informed consent: all the participants to this study signed a written informed consent form for participating in this study. consent for publication: written informed consent was obtained from a legally authorized reppatient information to be published in this article. funding: this research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. acknowledgments: we greatly acknowledge the support from all participants and sincerely thank all the individuals for taking part in the study. received for publication: 16 january 2023. accepted for publication: 25 june 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11159 doi:10.4081/hls.2023.11159 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 38] [healthcare in low-resource settings 2023; 11:11159] non -co mmerc ial us e o nly the sensory-motor and/or automatic central function.15 hence, performing two tasks simultaneously strains a higher degree of attention, balancing skills, and executive function than a single-task performance. 15 poor attention and cognitive skills result in impaired motor-motor or motor-sensory tasks, such as maintaining static or dynamic balance.17 nicotine binds to nicotinic acetylcholine receptors (nachrs), which are pentameric ligand-gated ion channels composed of α and β subunits (α1–7, 9–10; β1– 4); nachrs are extensively distributed throughout the brain and periphery and are critical in the processes of the neuromuscular junction, neurotransmitter release, brain maturation, reward processing, and cognition.18 to the best of our knowledge, literature is scarce regarding the static and dynamic balance during single and dual tasks in smokers. so, the study aimed to evaluate the static and dynamic balance in single and dual tasks among active smokers and to compare it with age-matched nonsmokers. material and methods the study was approved by the student project committee of the maharishi markandeshwar institute of physiotherapy and rehabilitation, maharishi markandeshwar (deemed to be university), mullana-ambala, haryana, india, and was conducted in accordance with the declaration of helsinki (revised 2013) and national ethical guidelines for biomedical and health research involving human participants’ guidelines laid by the indian council of medical research (2017). written informed consent was taken from the participants. for this observational study, 200 participants (100 smokers and 100 aged-matched non-smokers) were recruited through a purposive sampling method from among the university employees, students, visitors, and people residing in the nearby community. asymptomatic individuals aged between 20-50 years of males were included. smokers with a smoking history of ≥3 years and consumption of ≥10 cigarettes/day were included and agematched lifetime non-smokers were also included. the individuals were excluded if they had any acute illness or hospitalization 6 weeks preceding the study, any documented use of medications, metabolic disorders, cardiovascular, musculoskeletal, sensory, vestibular dysfunction, etc. that may affect the outcome of the study, bmi ≥ 25 kg/m2, systolic bp <100 mmhg or >139 mmhg, diastolic bp <60 mmhg or >89 mmhg and resting heart rate ≤ 60bpm or ≥ 100bpm participants meeting the exclusion and inclusion criteria were selected for the study. a detailed description was given to all the participants about the study. written consent was obtained from participants before the conduct of the study. after screening the participants’ demographic data was collected. weight and height were measured and then bmi was calculated. smoking history was recorded for smokers. we instructed the participants not to consume any heavy meal or cigarettes two hours before the test conduction and all the test was conducted between 9 am – 1 pm to avoid any intra-day variability. single leg stance (sls) test was performed for the evaluation of static balance. 10m walk test and tug (time up and go test) were performed for the evaluation of dynamic balance. to perform the sls test, individuals were directed to stand on a single leg (dominant leg) and maintain balance.19 to execute the 10m walk test, the 14 m track was marked and measured on the plane surface by indicating cones on both starting and ending points of the track. a 2 m distance was excluded from both sides for the acceleration and de-acceleration phase and time was recorded for a 10m distance.20 all the participants were instructed to walk on track and time was recorded for the 10m using the stopwatch. to execute the tug test, a chair was placed at one point and a 5m distance was marked with an indicating cone on the other side as a barrier. participants were instructed to stand from the chair and walk 5 meters and turn around and walk back to the chair until seated.11 all the tests were performed in 3 different conditions i.e., single task (performance of the task alone), dual manual task (performance of the task while holding a cup of water), and cognitive task (performing test while counting in decrement of 3). in between each test, 5 minutes of rest was given. for better accuracy and final analysis, each test was conducted 3 times, and an average of 3 readings was considered for analysis. statistical analysis the normality of data was assessed by using the kolmogorov-smirnov test (n>50) and the data was found to be not normality distributed. mann-whitney u test was used to compare the difference between smokers and non-smokers. all analysis was done by statistical software spss 16.0 version. a pvalue of less than 0.05 was considered statistically significant. results all the participants performed all the tests completely and there were no dropouts. the demographic characteristics of the participants are described in table 1. the smokers recruited had a smoking history ranging from 4 years to 27 years. the smoking history of the participants is described in table 2. there was a significant difference in static balance in single as well as dual (motor and cognitive) tasks (table 3); dynamic balance in single as well as dual (motor and cognitive) tasks (table 4). article table 1. demographic characteristics of the participants. demographic details total population (n=200) smoker (n=100) non-smoker (n=100) median (range) median (range) median (range) age (years) 34.5 (21.0, 50.0) 34.0 (22.0-50.0) 33.0 (21.0-50.0) height (m) 1.70 (1.53, 1.87) 1.70 (1.55-1.85) 1.70 (1.53-1.85) weight (kg) 66.50 (42.0, 86.0) 67.0 (45.0-86.0) 66.0 (42.0-86.0) bmi (kg/m²) 22.41 (17.71, 24.98) 22.41 (17.7-24.98) 22.53 (17.98-24.98) systolic (mmhg) 130.0 (120.0, 138.0) 130.0 (120.0-138,0) 130.0 (120.0-138,0) diastolic (mmhg) 84.0 (78.0, 89.0) 84.0 (78.0, 89.0) 84.0 (78.0, 89.0) n, number of participants. [healthcare in low-resource settings 2023; 11:11159] [page 39] non -co mmerc ial us e o nly discussion in the present study, the author evaluated the balance between active smokers and lifetime non-smokers by performing an sls test for static balance. for dynamic balance, a 10m walk, and tug test were performed. all the instructions were commanded to the participants verbally. all the tests were performed 3 times for better accuracy and in between each test 5-minute rest was given. all the tests were performed according to the standardized guidelines. in the present study, the authors found that there was a significant difference in the sls test, 10m walk test, and timed up-andgo test in single as well as dual (motor and cognitive) tasks. authors from previous studies reported that chronic smoking is related to postural instability as nicotine causes a lack of neuromuscular control and vestibular dysfunction.7,14,21 cigarette smoking contains a substance called nicotine, which leads to adverse effects on the neuromuscular junction, sensory nerve endings, ganglia, central nervous system, and adrenal medulla which affect the motor, sensory, cognitive, and attentional functions.6 nicotine when interacts with acetylcholine receptors, it mimics acetylcholine (neurotransmitter), which has greater affinity to the acetylcholine receptor. nicotine also interferes with the coagulation process as it increases the activity of platelets which leads to increased microvascular trauma caused due to atherosclerosis of the endothelial wall which causes impaired blood flow to the spinal cord and the brain.22 impaired blood flow to the brain leads to motor and cognitive deficits because the neuromuscular junction and frontal cerebral cortex were also affected by impaired blood flow in the brain. these factors lead to the initiation of a chain of oxidative injuries and activation of pro-inflammatory response that causes cellular disruption in blood brain barrier (bbb) which acts as a consequence of impairment in motor and cognitive function.22 in the present study, we found that the time to stand on the dominant leg in smokers was significantly different from that of nonsmokers under single and dual tasks. a previous study conducted by takeshi santo et al. reported that there is a relationship between balance and cigarette smoking. they reported that balance on one leg is considerably reduced in smokers as compared to nonsmokers while closing their eyes.4 however, in the present study the single-leg stance task was performed with eyes open. this indicates that smokers’ balance is affected more because of musculoskeletal involvement. there are several pieces of literature available indicating that muscle force-generating capability and muscle mass are reduced in smokers in comparison to non-smokers.23,24 a lower muscle force-generating capability has been reported in smokers by several studies. authors from previous studies have observed that there are 25% smaller fiber cross-sectional area in the vastus lateralis muscle; “lean body mass is also lower in smokers as compared to non-smokers”.25 in the present study, we found that there was a significant difference in the 10m and tug tests (functional balance test) in smokers when compared to non-smokers. 10m walk test is used to assess the gait speed, coordination, and functional balance of an individual.26 the tug test is used for assessing participants moving ability and strength during dynamic as well as static balance by evaluating the time taken from standing from the chair, walking 5m, turning back from the barrier, and sitting back to the chair. these test findings could be related to gait variability and parameters. smoking is related to impaired gait parameters and gait velocity.27 lower gait velocity is linked with more pack-years of smoking. more pack year of smoking is related to decreased speed and rhythm. smoking components like nicotine is having adverse effects on the nervous system, cardiovascular system, and musculoskeletal system. this correlation shows that smoking may associate with gait parameters which are comprised of slow pace, velocity, and rhythm.27 lamoth et al. stated that while performing cognitive task gait variables and trunk coordination is diminished.28 in the present study, we found that there is a difference during attention-demanding tasks in smokers and age-matched nonsmokers. these findings suggest that the maintenance of static balance requires attention. in the present study, we noticed that the time to stand with difficulty in the secondary task was comparatively different in smokers. a previous study showed that smokers have impaired cognitive function and there is a decrease in psychomotor speed in smokers.29 these impairments may cause imbalance and make it difficult to maintain stability and perform tasks.30 the study had few limitations. we could not enroll female participants. the study was singly cantered with participants from the same geographical location. the sample was small and was collected by nonprobability method though strict inclusion and exclusion criteria were followed. we did not record the level of physical activity and dietary patterns of the participants subjectively. we did not record the time when the last cigarette was smoked. article table 2. smoking history of participants. variables median (range) no. of cigarette smoking per day 11.5 (10.0, 18.0) no. of years the participant is smoking 10.0 (4.0, 27.0) table 3. comparison of static balance in smokers and non-smokers. test smoker non-smoker z value p-value (median) (median) sls in single task 26.5 30 -5.226 0.0001* sls in the dual cognitive task 25 30 -6.350 0.0001* sls in dual manual task 25 30 -6.476 0.0001* sls, single leg stance; *p<0.05 was considered significant. table 4. comparison of dynamic balance in smokers and non-smokers. test smoker non-smoker z value p-value (median) (median) 10-meter walk test in single task 6.5 6 -4.968 0.0001* 10-meter walk test in the dual cognitive task 7.1 6.8 -5.092 0.0001* 10-meter walk test in dual manual task 7.2 6.7 -4.121 0.0001* tug test in single task 7 6.5 -4.088 0.0001* tug test in the dual cognitive task 7.5 7 -4.112 0.0001* tug test in dual manual task 7.5 7.15 -3.778 0.0001* tug, time up and go; *p<0.05 was considered significant. [page 40] [healthcare in low-resource settings 2023; 11:11159] non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11159] [page 41] conclusions the present study concluded that static and dynamic balance is impaired in chronic male smokers as compared to non-smokers and seeks further exploration in larger samples. hence, it is reasonable to promote the prohibition of smoking and develop exercise habits focusing on muscle strengthening and balance measures. references 1. wang r, jiang y, yao c, et al. prevalence of tobacco-related chronic diseases and their role in smoking cessation among smokers in a rural area of shanghai, china: a cross-sectional study. bmc public health 2019;19:753. 2. gbd 2019 tobacco collaborators. spatial, temporal, and demographic patterns in the prevalence of smoking tobacco use and attributable disease burden in 204 countries and territories, 1990-2019: a systematic analysis from the global burden of disease study 2019. lancet 2021;397:2337-60. correction in lancet 2021;397:2336. 3. qasim h, alarabi ab, alzoubi kh, et al. the effects of hookah/waterpipe smoking on general health and the cardiovascular system. environ health prev med 2019;24:58. 4. saito t, miyatake n, nishii k. relationship between cigarette smoking and one leg with eyes closed balance in japanese men. environ health prev med 2015;20:388-91. 5. hayashida k, murakami g, takahashi y, et al. nihon eiseigaku zassh 2012;67:50-5. 6. heishman sj, taylor rc, henningfield je. nicotine and smoking: a review of effects on human performance. exp clin psychopharmacol 1994;2:345–95. 7. schmidt tp, pennington dl, durazzo tc, meyerhoff dj. postural stability in cigarette smokers and during abstinence from alcohol. alcohol clin exp res 2014;38:1753-1760. 8. pereira cb, strupp m, holzleitner t, brandt t. smoking and balance: correlation of nicotine-induced nystagmus and postural body sway. neuroreport 2001;12:1223-1226. 9. toprak cş, duruöz mt, gündüz oh. static and dynamic balance disorders in patients with rheumatoid arthritis and relationships with lower extremity function and deformities: a prospective controlled study. arch rheumatol 2018;33: 328-34. 10. bressel e, yonker jc, kras j, heath em. comparison of static and dynamic balance in female collegiate soccer, basketball, and gymnastics athletes. j athl train 2007;42:42-6. 11. hemmati l, rojhani-shirazi z, malekhoseini h, mobaraki i. evaluation of static and dynamic balance tests in single and dual task conditions in participants with nonspecific chronic low back pain. j chiropr med 2017;16:189–94. 12. lesinski m, hortobágyi t, muehlbauer t, et al. effects of balance training on balance performance in healthy older adults: a systematic review and metaanalysis. sports med 2016;46:457. 13. wong pk, christie jj, wark jd. the effects of smoking on bone health. clin sci 2007;113:233-41. 14. iki m, ishizaki h, aalto h, et al. smoking habits and postural stability. am j otolaryngol 1994;15(2):124-8. 15. plummer p, eskes g, wallace s, et al. cognitive-motor interference during functional mobility after stroke: state of the science and implications for future research. arch phys med rehabil 2013;94:2565-74.e6. 16. fritz ne, basso dm. dual-task training for balance and mobility in a person with severe traumatic brain injury: a case study. j neurol phys ther 2013;37: 37-43. 17. leland a, tavakol k, scholten j, et al. the role of dual tasking in the assessment of gait, cognition and community reintegration of veterans with mild traumatic brain injury. mater sociomed 2017;29:251-6. 18. ren m, lotfipour s. nicotine gateway effects on adolescent substance use. west j emerg med 2019;20:696-709. 19. perez-cruzado d, gonzález-sánchez m, cuesta-vargas ai. parameterization and reliability of single-leg balance test assessed with inertial sensors in stroke survivors: a cross-sectional study. biomed eng online 2014;13:127. 20. scivoletto g, tamburella f, laurenza l, et al. validity and reliability of the 10-m walk test and the 6-min walk test in spinal cord injury patients. spinal cord 2011;49:736-40. 21. chomiak t, pereira fv, hu b. the single-leg-stance test in parkinson's disease. j clin med res 2015;7:182-5. 22. mazzone p, tierney w, hossain m, et al. pathophysiological impact of cigarette smoke exposure on the cerebrovascular system with a focus on the bloodbrain barrier: expanding the awareness of smoking toxicity in an underappreciated area. int j environ res public health 2010;7:4111-26. 23. seymour jm, spruit ma, hopkinson ns, et al. the prevalence of quadriceps weakness in copd and the relationship with disease severity. eur respir j 2010;36:81-88. 24. degens h, gayan-ramirez g, van hees hw. smoking-induced skeletal muscle dysfunction: from evidence to mechanisms. am j respir crit care med 2015;191:620-5. 25. montes de oca m, loeb e, torres sh, et al. peripheral muscle alterations in non-copd smokers. chest 2008;133: 13-8. 26. peters dm, fritz sl, krotish de. assessing the reliability and validity of a shorter walk test compared with the 10-meter walk test for measurements of gait speed in healthy, older adults. j geriatr phys ther 2013;36:24-30. 27. verlinden vj, maksimovic a, mirza ss, et al. the associations of alcohol, coffee and tobacco consumption with gait in a community-dwelling population. eur j clin nutr 2016;70:116-22. 28. lamoth cj, stins jf, pont m, et al. effects of attention on the control of locomotion in individuals with chronic low back pain. j neuroeng rehabil 2008;5:13. 29. pushpa k, kanchana r. effect of cigarette smoking on cognitive performance in young adult smokers. natl j physiol pharm pharmacol 2019;9:562-5. 30. demi̇r t, balal m, demi̇rki̇ran m. the effect of cognitive task on postural stability in cervical dystonia. arq neuropsiquiatr 2020;78:549-55. article non -co mmerc ial us e o nly hrev_master [page 42] [healthcare in low-resource settings 2022; 10:10094] large cervical leiomyoma: an experience from sudan christoph h. houben, joseph y. erishlo cap anamur hospital, lwere, nuba mountains, sudan abstract cervical leiomyomas even small ones are extremely uncommon. two consecutive cases of very large cervical leiomyomas in young women came to our attention during the summer 2018 in sudan. both women presented with symptoms of heaviness/discomfort in the lower abdominal region and signs of anemia. their management and surgical therapy are outlined. introduction matthew baillie is credited with the first description of uterine myomas back in 1793.1,2 since leiomyoma of the uterus has been identified as the most common benign neoplasm of the female reproductive organs. the incidence of symptomatic leiomyomas is 20-25% in women of reproductive age group, rising to 40% at the onset of the menopause.3,4 this can increase to a detection rate of more than 75% for leiomyomas in general once meticulous histology studies are undertaken on hysterectomy specimen.5 leiomyomas in the cervical region are considered extremely uncommon.6 we present two cases of very large cervical leiomyoma identified during the summer 2018 at the lwere cap anamur hospital in the nuba mountains of sudan. materials and methods the surgery is done through a lower midline incision from the umbilicus superiorly to the pubis inferiorly. invariably the small uterus is sitting on top of the much larger polypoid cervical leiomyoma embedded in the pelvis. the appearance has been dubbed ‘lantern on top of st. paul’.7 initially the subverted anatomy is analyzed to identify the pressure effects of the pelvine leiomyoma on the surrounding structures. after separating and protecting the bladder and other structures first by anatomical dissection the smallish uterus is mobilized according to a standard practice.8 following the ligation of the uterine vessels and the upper part of the cardinal ligament a retrograde hysterectomy is performed, because the large size of the cervical leiomyoma prevents identification of the border between the cervix and the vagina.9 a longitudinal incision is made from the anterior wall of the cervix/polypoid mass to the vagina to open the vaginal cavity thereby avoiding a vaginal shortening. the procedure progresses through the opening of the anterior vaginal wall, the ligation and cutting of the bilateral vesicouterine and sacrouterine ligaments respectively and finally the incision of the posterior vaginal wall. at this stage the polypoid mass attached to the small uterus can be retrieved from the pelvic cavity while rocking it back and forth and side to side. the bilateral ends of the vagina are knotted, the longitudinal incision is sutured and the vaginal cuff is closed with interrupted mattress sutures. a pelvic drain is kept for 48-72 hours postoperatively to allow for the drainage of serous fluids as the vagina vault was closed. the abdomen is closed through a continuous mass suture followed by the separate closure of the subcutaneous layer and the skin. an indwelling urinary catheter remains for 7-10 days to aid the recovery of the immobile patient with difficult access to the wash room. results case #1 in june 2018 a 29-year old mother of one boy (kk) came to our attention with a significant anemia (hb 4.3 g%) and a lengthy history of abdominal discomfort and menorrhagia. a vague pelvic mass was palpable associated with a cervical mass replacing the cervical opening on speculum examination. the ultrasound examination showed a tumor of mixed echogenicity associated with a smallish uterus without adherence to the pelvic wall. whilst consenting for surgery the patient and her partner were made aware of the possibility of the need for a potentially curative hysterectomy. at laparotomy a small uterus atop a pelvic mass was identified. in conjunction with a blood transfusion after ligation of the main vessels a retrograde hysterectomy and mobilization of the bulk of the leiomyoma was done. the postoperative recovery was uneventful, the urinary catheter was removed after ten days. post discharge she was asked to continue her iron supplement to aid her recovery from the anemia. the histological work up of the tumor revealed findings consistent with an intra-cervical leiomyoma replacing the cervix. she is doing well 3.5 years after her surgery. case #2 a 28-year old nulliparous woman (fu) complained of a longstanding history of abdominal discomfort and irregular vaginal bleeding attended the outpatient department in july 2018. she was found to have a mild healthcare in low-resource settings 2022; volume 10:10094 correspondence: christoph h. houben, cap anamur hospital, lwere, nuba mountains, sudan. tel.: +4924026322 e-mail: chhouben@web.de key words: myoma; large cervical leiomyoma; hysterectomy. acknowledgements: the authors would like to thank professor dr r. knuechel-clarke department of pathology, university clinics aachen, germany, who kindly provided the histological analysis of the specimen in case #1. contributions: chh operated on the patients, conceived the report and drafted the article. jye assisted in the operations and contributed to the preand post-operative management. conflict of interests: the authors declare no potential conflict of interests availability of data and materials: all data underlying the findings are fully available. ethics approval and consent to participate: no ethical committee approval was required for this case report by the department, because this article does not contain any studies with human participants or animals. informed consent was obtained from the patient included in this study. consent for publication: the patients gave their written consent to use their personal data for the publication of this case reports and any accompanying images. received for publication: 9 september 2021. revision received: 28 march 2021. accepted for publication: 8 april 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10094 doi:10.4081/hls.2022.10094 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non commercial use only [healthcare in low-resource settings 2022; 10:10094] [page 43] anemia. during the gynecological examination a smooth large mass was identified within the vagina having replaced the cervix but not infiltrated the sidewalls of the pelvis. the ultrasound confirmed the mixed echogenicity of this polypoid mass connected to the uterus. her operation was planned with her and her caretaker on the understanding she might lose her reproductive ability. so far she had not conceived. at the laparotomy the small uterus was situated between a pedunculated subserosal myoma originating from the fundus of the uterus and the large central cervical myoma occupying the pelvis (figure 1). following identification of the structures of the urinary tract a retrograde hysterectomy and removal of the pelvic leiomyoma was done. the postoperative recovery was smooth, the urinary catheter was kept in place for seven days. she continued her iron supplementation after her discharge form the hospital. the patient is doing fine 3.5 years after her hysterectomy. discussion a large if not the only study on cervical myomas undertaken by tiltman on the mainly black population of south african women identified only 4 cervical myomas in 661 hysterectomy specimen (0.6%); of which two cases (0.3%) were clinically significant.6 one was a 6 cm submucosal leiomyoma within the endocervical canal the other replaced the cervix by an interstitial leiomyoma protruding into the upper vagina.6 in our cohort both leiomyomas originated in the central portion of the cervix replacing the cervical opening and occupying the pelvis through a circumferential expansion whereby distorting the pelvic anatomy in the process (see figure 1). it is accepted that black women are more at risk of developing uterine myomas than caucasian women; epidemiological studies conclude the risk at 2-3 times higher in black women.3,10,11 we have no explanation for the development of such large cervical leiomyomas in young african women. numerous case reports highlight the difficulties tackling a large in some publications even called a ‘giant’ cervical myoma and present the various surgical techniques adopted to achieve its removal.4,7,12-14 invariably these reports present postmenopausal women. 4,7,12-14 in our cohort both patients were only in their late twenties when they required surgical intervention. attempts are being made to preserve the reproductive function for women in the premenopausal age group through resection of a myoma arising from the wall of the cervical lip.15,16 others use the option of trachelectomy.17 both of our patients had a complete replacement of their cervix by the leiomyoma rendering a trachelectomy not suitable. case reports on ‘giant’ cervical leiomyomas implying a uterus weight of more than 500g secondary to the tumor highlight modifications or new techniques for the hysterectomy ranging from laparoscopic hysterectomy to hybrid procedures.12,14 experience with uterine artery embolisation is limited to smaller and mostly extracervical leiomyomas.18 whilst affluent economies have the means to initiate and experiment with new treatments like the aforementioned variations, a hysterectomy through an open procedure as first described by keith in 1887 is the most valuable option for the low resource setting of hospitals in northeastern africa.19 it appears to be by far the safest option. having the choice between a pfannenstiel-kerr incision and a lower midline approach to the pelvis, we opted for the incision through the linea alba in order to minimize blood loss.18,20 it is acknowledged that the difficulties arising through the distortion of the pelvic anatomy by the large myoma leads to a prolonged operating time.18,20 some practitioner leave the vaginal vault ‘open’; whilst we recognize the rationale we opted to close the vaginal opening and placed a temporary drain within the pelvic cavity in the hope to avoid an ascending pelvic infection.20 conclusions two women in this cohort were of reproductive age, of which one was nulliparous and the other had one child. it is disappointing for these women to lose their fertility at such an early age within a society that places a significant emphasis on having large families. there was no option even with techniques available in affluent societies to preserve/restore their fertility in view of the extent of the disease process. the cervical opening was occluded through the interstitial growth of the leiomyoma effectively replacing the cervix (see figure 1). references 1. baillie m. the morbid anatomy of some of the most important parts of the human body. london, f johnson & g nicol; 1793. 2. baillie m. a series of engravings accompanied with explanations which are intended to illustrate the morbid anatomy of some of the most important parts of the human body. london, w bulmer & co; 1799. 3. sparic r, mirkovic l, malvasi a, tinelli a. epidemiology of uterine myomas: a review. int j fertil steril 2016;9:424-35. 4. singh s, chaudhary p. central cervical fibroid mimicking as chronic uterine inversion: a case report. int j reprod contracept obstet gynecol 2013;2:6878. case report figure 1. hysterectomy specimen of a 28-years old woman with a small myoma attached to the fundus of the uterus (left) and a much larger leiomyoma distal to the small uterine body replacing the cervix (right) non commercial use only [page 44] [healthcare in low-resource settings 2022; 10:10094] 5. cramer sf, patel a the frequency of uterine leiomyomas. am j clin path 1990;94:435-8. 6. tiltman aj. leiomyomas of the uterine cervix: a study of frequency. int j gyn path 1998;17:231-4. 7. kavitha b, jyothi r, devi ar, madhuri k et al. a rare case of central cervical fibroid with characteristic „lantern on top of st. paul“ appearance int j res dev health 2014;2:45-7. 8. hiramatsu y. hysterectomy for cervical and intraligamental fibroids surg j 2020;6:s2-s10. 9. de barros lopes a, spirtos nm, hilton p, monaghan jm. operations on the uterus chap 11 in: de barros lopes a, spirtos nm, hilton p, monaghan jm, editors. bonney’s gynaecological surgery 12th ed. john wiley &sons ltd; 2018 p.107-25. 10. marshall lm, spiegelman d, barbieri rl, et al. variations in the incidence of uterine leiomyoma among premenopausal women by age and race. obstet gyn 1997;90:967-73. 11. stewart ea, cookson cl, gnadolfo ra, schulze-rath r. epidemiology of uterine fibroids: a systematic review. br j obstet gynecol 2017;124:1501-12. 12. chopra k, dutta d, jain k. management of giant cervical fibroid by “hybrid technique”. obstet gynecol res 2018;1:65-7. 13. sharma s, pathak n, goraya sps, et al. large cervical fibroid mimicking an ovarian tumour. sri lanka j obstet gynaecol 2011;33:26-7. 14. nakayama k, tsukao m, ishikawa m, et al. total laparoscopic hysterectomy for large uterine cervical myoma. mol clin oncol 2017; 6: 6555-60. 15. kamra ht, dantkale ss, birla k, et al. myxoid leiomyoma of cervix. j clin diag res 2013;7:2956-7. 16. keriakos r, maher m. management of cervical fibroid during the reproductive period. case rep obstet gynecol 2013;2013:984030. 17. wong j, tan ghc, nadarajah r, teo m. novel management of a giant cervical myoma in a premenopausal patient. bmj case rep 2017;2017:bcr2017221408. 18. ferrari f, forte s, valenti g, et al. current treatment options for cervical leiomyomas: a systemic review of literature. medicina (kaunas, lithuania) 2021;57:92. 19. keith t. results of supravaginal hysterectomy with remarks on the old ways and the new of treating uterine fibroids. bmj 1887;2:1257-8. 20. de barros lopes a, spirtos nm, hilton p, monaghan jm. uterine fibroids chap 12 in: de barros lopes a, spirtos nm, hilton p, monaghan jm, editors. bonney’s gynaecological surgery 12th ed. john wiley & sons ltd; 2018 p.12733. case report non commercial use only hrev_master [page 14] [healthcare in low-resource settings 2022; 10:10256] a retrospective analysis of emergency department usage in rural and semi-urban indigenous guatemalan populations emma l. svenson,1 amber sheth,1 jessica schmidt,2 rafael tun,3 james e. svenson2 1university of wisconsin-madison school of medicine and public health, madison, wisconsin; 2department of emergency medicine, university of wisconsin-madison school of medicine and public health, madison, wisconsin, usa; 3hospital parroquial de san lucas tolimán, san lucas tolimán, guatemala abstract functioning healthcare systems provide emergency medical care. disparities exist in accessibility and availability of emergency care in lowand middle-income countries. we present a descriptive epidemiologic analysis of emergency department (ed) usage in a rural, indigenous guatemalan population. san lucas tolimán is situated in central guatemala. hospital parroquial de san lucas offers emergency care to san lucas tolimán and surrounding villages. all ed visits between january 1st, 2016 and december 31st 2018 were recorded and analyzed. during the study period, 12,229 patient encounters occurred. almost all patients identified as indigenous. children comprised 43% of visits. medical issues represented a majority (83%) of complaints. respiratory (40%) and gastrointestinal disease (26%) were frequent presenting complaints. almost all visits (83%) occurred during the day and evening hours. trauma/surgical complaints were slightly more frequent at night. 93% of patients were discharged, while the rest were admitted or transferred. these data contribute to understanding of disease burden and emergency care needs and capacity in rural areas of lowand middle-income countries. this information may be used to inform local policy decisions, identify research priorities, and create training topics for local health care providers in guatemala and other countries in this region. introduction the provision of emergency medical care is a crucial component of successful healthcare systems.1 emergency care is a primary response to time-sensitive medical conditions such as trauma, obstetric complications, or ischemic cardiovascular disease, and prevents significant morbidity and mortality associated with these acute conditions. emergency care also represents an entry point for access to additional specialized care, providing crucial preventive health services at a population level.2–4 in nations where a significant portion of people are uninsured or underinsured, and lack access to primary care providers, emergency departments are even becoming point of care for non-urgent medical conditions.5,6 a lack of emergency care infrastructure is thus linked to poorer health outcomes, and ensuring access to emergency medical care is being prioritized as a mechanism to improve overall population health on a global scale.1,3,4,7 while emergency medical systems are often robust in high-income countries, significant obstacles exist to developing, delivering and accessing emergency care in lowand middle-income countries.8,9 lack of transportation to medical facilities, affordability of services, poor facility infrastructure, decreased availability of medical supplies and medications, and a paucity of skilled emergency providers and emergency training programs are all frequently cited barriers to providing effective acute care in these settings.2,10–15 yet lowerand middleincome countries (lmic) frequently shoulder a significant burden of critical acute illness.13 for example, recent estimates suggest that ninety percent of trauma related deaths occur in lmic.13,16 in addition to the burden of infectious diseases, the acute health sequelae associated with non-communicable diseases, including diabetes and heart disease, are also on the rise in these areas.2,13,17–20 based on the rising burden of acute illness in lmic, there is a growing impetus to understand emergency care needs and strengthen capacity.20–25 little is known about access to, and availability of, emergency care in central and south america.9,11 guatemala is the most populous nation in central america. since 1999, the guatemalan ministry of health has undertaken initiatives to develop pre-hospital and in-hospital emergency care, and advanced disaster preparedness on a national level.12 however, hospital emergency departments are typically staffed by rotating physicians and medical students without formal emergency medical training. it is only recently that international partnerships have led to the establishment of guatemala’s sole emergency medicine residency at the universidad de san carlos de guatemala, with the first matriculated class of residents entering the program in 2019.12,26,27 although there is increasing access to emergency medical care in urban areas, provision of emergency services to rural areas is not widespread.12 strikingly, up to fifty-five percent of guatemala’s population inhabit geographically isolated rural regions, the majority of which is indigenous mayan.28 indigenous populations often face unique challenges to accessing emergency medical care.28–34 although guatemala ranks as a middle-income country based on gross domestic product (gdp), extreme healthcare in low-resource settings 2022; volume 10:10256 correspondence: emma l. svenson, university of wisconsin-madison school of medicine and public health, madison, wisconsin. tel.: 608.216.5396 e-mail: svenson@wisc.edu key words: acute care; underserved populations; guatemala. contributions: els: study design, data analysis, and original write-up of manuscript; as: study design, data collection, editing manuscript; js: study design, editing manuscript; rt: role: study design, data collection, editing manuscript; jes: study design, data analysis, editing manuscript. conflict of interest: the authors have no conflict of interest to declare. conference presentation: svenson el, sheth am, schmidt jn, tun r, svenson je. a retrospective analysis of emergency department usage in rural and semi-urban indigenous guatemalan populations. poster presentation. international conference of emergency medicine (virtual). abu dhabi, june 2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the institutional review board of the university of wisconsin-madison determined this study to be exempt, and this study was also reviewed and approved by the medical board of the friends of san lucas mission. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. received for publication: 29 december 2021. accepted for publication: 13 january 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10256 doi:10.4081/hls.2022.10256 non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10256] [page 15] income inequality endures, with 79% of guatemala’s indigenous population living in poverty.28,35 routine preventive care and medications can be obtained free of charge at government run health centers (centros de salud) throughout guatemala; however, poor staffing, long wait-times and lack of medical supplies at these free, governmentsponsored public hospitals drives rural residents to seek care both routine and emergency care at private hospitals, where the high out-of-pocket cost of medical care can act as a deterrent to seeking treatment. furthermore, widespread discrimination at biomedical institutions, including both physical and mental abuse, remains a common experience for indigenous patients.28,36– 40 these barriers can be compounded by different cultural understanding of what constitutes a medical emergency, particularly in the case of obstetric emergencies.41–43 to our knowledge, there have been limited studies examining emergency medical services in guatemala, with few specifically examining acute care needs and emergency medical service utilization in rural and semi-urban indigenous populations. the scope of these articles is narrowly focused on emergency training program development, pre-hospital care, and pediatric case management. 12,44–47 therefore, the goal of this study is to provide a basic descriptive analysis of an emergency department (ed) located in rural guatemala, to better define acute disease burden and emergency care needs in a representative rural guatemalan community. materials and methods san lucas tolimán is located on the southeast shores of lake atitlán and is considered part of the guatemalan highlands. san lucas tolimán is home to a population of 17,000 people living in a semi-urban central village, with an additional 14,000 people living in 19 surrounding rural communities. a majority of its population identifies as indigenous mayan.48,49 the impact of recent civil war and genocide is substantial and persistent in these mountain communities, with substantial cultural and socioeconomic barriers limiting access to education, basic sanitation, and healthcare.50,51 the average yearly income in the san lucas tolimán area is less than 1,000 u.s. dollars (usd), or the equivalent of $3 usd per day.49,52,53 multiple healthcare practices are present in the san lucas area. for example, government run health centers (centros de salud) provide free primary care services to san lucas and surrounding communities. residents have identified poor staffing and supply shortages as deterrents to seeking care at these institutions.52 an igss (instituto guatemalteco de seguridad social) is located in the town proper, and also provides free, routine health services to certain patients and employers who pay into the igss system. as of 1995, only 16% of guatemala’s total population was covered through the igss, indicating that this service is not accessible to many guatemalans.54–57 several private clinics are also present in the town proper.53 emergency care is available to residents of san lucas tolimán at hospitals in neighboring municipalities, such as the hospitalito atitlán or hospital nacional de sololá. emergency care is also available closer to home at the hospital parroquial de san lucas tolimán (hospital monseñor gregorio schaffer), and this hospital is the focus of this study.35,58 a nonprofit organization, the friends of san lucas, in association with the san lucas mission, provides social services based on community needs, and helped establish a low-cost private hospital in san lucas tolimán in the late 1990’s, hospital parroquial de san lucas tolimán (hospital monseñor gregorio schaffer). this hospital regularly employs one physician (on call 24 hours/day), along with several nurse practitioners, who help staff the emergency department after normal business hours. the hospital partners with an established health promoter program and volunteer international healthcare providers to offer basic medical care and health education onsite to neighboring communities and within san lucas’s town proper. the hospital also coordinates with internationally based physicians to offer advanced surgical, ophthalmologic, and dental care, among other specialties. a daily clinic is offered on a first come-first serve basis by the hospital’s regularly employed physician. emergency care is also available twenty-four hours a day at the hospital, a fact that is well-known in the community, and that is advertised on the hospital’s website and social media sites, among other media sources. the emergency department includes an ambulance available for emergency transport. referrals to other hospitals are made as necessary.48,49,59–61 over a three-year period between january 1st, 2016 and december 31st, 2018, all ed visits to hospital parroquial de san lucas tolimán were collected and entered into an excel database by hospital staff at time of visit. the information gathered for each patient encounter included age, gender, whether or not an individual was indigenous, municipality/department/country of origin, date and time of service, chief complaint, category of chief complaint, if medical or surgical treatments were recommended, and if follow-up care was required. categories of chief complaint were designated by hospital staff included abdominal, auditory, cardiovascular, dermatologic, diarrheal/parasitic, gynecologic, hematologic, infectious, neurologic, nutritional, ophthalmologic, dental, post-operation, surgical, renal/urinary, respiratory, rheumatic/ endocrine, traumatic, premature, not diagnosed, or other. all analyses were performed using sas v 9.4 (sas corporation, cary, nc). groups were compared using student’s t-test for continuous variables, or with fisher’s exact or mantel haenzel chi square test for categorical variables. variations between multiple variables were carried out with logistic regression for dichotomous variables, or generalized linear models for categorical variables with multiple outcomes. this study was determined to be exempt by the institutional review board at the university of wisconsin-madison, as defined by the federal regulations for protection of human research subjects. this study was also reviewed and approved by the medical board of the friends of san lucas mission prior to accessing and analyzing data, which includes both local hospital staff and international partners. it was conducted with the full support of the hospital parroquial de san lucas tolimán, the friends of san lucas, and the san lucas mission. results demographic information between january 1st 2016 and december 31st 2018, a total of 12,229 patient encounters were recorded, 46.15 (n=5644) male and 53.85% (n=6585) female. the average age was 24.0±23.8 years for males and 29.0 ± 24.0 years for females (p<0.01). the age distributions of patients presenting to the ed were similar for both sexes as shown below in figure 1, although a slightly greater proportion of patients were male in each age category below 18 years, whereas a greater proportion of patients were female in each age category over 18 years. children < 18 years old represented 43% of all patient visits to the ed, shown in figure 2. almost all patients presenting to the ed were indigenous (92.1%, n=11248). female patients comprised the bulk of both indigenous and non-indigenous patient vis article non -co mmerc ial us e o nly its to the ed, 53.23% and 61.06% respectively. non-indigenous patients tended to be older, with an average age of 34.61±26.18 compared to 26.0±23.71 (p=0.001). patient origin guatemala is divided into 22 departments, and further subdivided into 331 administrative districts called municipalities.51,62 during the time period of our study, almost all patients presenting to the ed reported primary residence in sololá (n=11,430, 93.5%), the department in which hospital parroquial de san lucas tolimán is located. the remaining patients were from 14 other departments scattered throughout guatemala, 6.06% (n=741), or from foreign countries, 0.46% (n=58). guatemalan departments represented at the ed included alta verapaz, jutiapa, petén, retalhuleu, totonicapán, suchitepéquez, santa rosa, san marcos, quiche, quetzaltenango, huehuetenango, escuintla, chimaltenango and la ciudad de guatemala. patients from foreign countries included residents of england, germany, belize, el salvador, spain and the united states. the department of sololá was examined at a more granular level. within this department, the municipality of san lucas tolimán was the primary residence for most patients presenting to the ed, 90.09% (n=9803). nine other municipalities in sololá were represented, although a bulk of patients came from municipalities bordering san lucas tolimán, including san antonio palopó (5.11%, n=556) and santiago atitlán (4.34%, n=472). as mentioned previously, the municipality of san lucas tolimán includes the semi-urban town of san lucas tolimán, with numerous rural communities surrounding the town proper. of the 9,803 residents residing in san lucas tolimán, 88.92% (n=8,717) lived in the town proper, and 11.08% (n=1,086) lived in surrounding rural communities. temporal and seasonal variability over a three-year span, a slight increasing trend in annual presentations was observed. of the 12,229 total patient encounters recorded, 29.98% (n=3,666) occurred in 2016, 32.43% (n=3,966) occurred in 2017, and 37.59% (n=4,597) occurred in 2018. this trend was significant (p<0.001). in guatemala, the rainy season lasts from may through october, while the dry season lasts from november to april. a total of 6,070 patient encounters (49.64%) occurred during the rainy season. a total of 6,159 patient encounters (50.36%) occurred during the dry season. there was no statistically significant change in number of ed visits across seasons (p=0.42). visits were also evenly distributed across individual months, shown in figure 3. the bulk of ed visits (n=10,453, 85.3%) occurred during the day (7 am – 3 pm) and evening (3 pm – 11 pm) hours. relatively fewer visits occurred during night hours from 11 pm – 7 am (n=1,796, 14.69%). this trend was significant (p <0.0001). chief complaint and disposition presenting complaint was recorded for all patients, and these were categorized into one of 21 categories by the hospital. these were further stratified as medical or surgical complaints. medical complaints accounted for most of the visits to the ed (83.1%). there was a statistically significant difference in the proportion of males presenting with a surgical complaint (12.59%) compared to females (21.90%). a slight temporal variability was also observed, with a greater proportion of surgical complaints occurring during day and evening hours (19.50% and 16.73% respectively). within the municipality of san lucas tolimán, rural residents presented more frequently with surgical complaints (19.98%) than did their semi-urban counterparts (16.28%). type of complaint did not appear to be significantly correlated with season, ethnicity or outcome. these results are shown in table 1. overall, a majority of patients were discharged to home from the ed 93.02% (n=11,298). 814 patients (6.7%) were either admitted to the hospital or referred to another hospital for care, such as the hospital universidad del valle de guatemala or the hospital nacional de sololá. thirty patients, 0.25%, did not survive to discharge. medical visits were categorized into respiratory illnesses, cardiovascular disease (cv), gastrointestinal (gi) disease, neurological disease (neuro), and other. the majority of these medical visits were either respiratory (n=4,110, 40.4%) or gi article figure 1. distribution of patient age based on sex over a three-year period. figure 2. age distribution of all patients presenting to the ed over a three-year period by age group <1, 1-5, 5-18, 18-65 and > 65 years old. [page 16] [healthcare in low-resource settings 2022; 10:10256] non -co mmerc ial us e o nly (n=2694, 26.5%). while the pattern of medical complaints was similar between indigenous and non-indigenous patients, indigenous patients presented more frequently with respiratory complaints and non-indigenous patients present more frequently with cardiovascular issues. during the dry season, presentation for gi complaints was slightly more common, but there was no significant difference in complaint distribution between the two seasons. these results are shown in table 2. presenting complaint for medical cases varied significantly by age (figure 4). while respiratory complaints were the most frequent in most age groups, for adults aged 18-65 years, gi complaints were the most frequent complaint. for older adults >65 years, cardiovascular problems were almost as common as respiratory complaints. traumatic complaints made up 43.2% of all surgical presentations to the ed. the average age of patients presenting with trauma was 31.9 years. most trauma cases occurred during day or evening hours, and only 39.33% of surgical cases presenting to the ed during late-night hours were traumas. there were no significant seasonal trends in the distribution of surgical complaints. female patients presented more frequently with trauma compared to male patients. in general, a greater proportion of trauma cases were admitted to the hospital or referred to another institution for follow up care (54.48%), compared to other surgical complaints. these results are shown in table 3. a greater proportion of patients presenting to the ed with a traumatic surgical complaint were referred (8%) compared to admitted (1.03%), whereas an equal proportion of patients presenting to the ed with nontraumatic surgical complaints were article table 1. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for medical or surgical complaints over a three-year period. medical complaint (%, n=10,164) surgical complaint (%, n=2,065) p* average age (years) 25.9 30.28 <0.0001 location rural 80.02 19.98 0.001 semi-urban 83.72 16.28 season rainy 83.05 16.95 0.4914 dry 83.18 16.82 time 7 am – 3 pm 80.50 19.50 <0.0001 3 pm – 11 pm 83.27 16.73 11 pm – 7 am 90.09 9.91 indigenous yes 83.21 16.79 0.5743 no 82.04 17.96 sex male 78.10 21.90 <0.0001 female 87.41 12.59 outcome discharge 83.31 16.69 0.4248 admit/ refer 82.19 17.81 * p-value of regression model containing all variables. figure 3. distribution of monthly patient encounters from january 1st, 2016 to december 31st, 2018. rainy season is depicted in blue, and dry season is depicted in red. figure 4. frequency of medical complaints across age categories, <1, 1 – 5, 5 – 18, 18-65, and >65 years old. [healthcare in low-resource settings 2022; 10:10256] [page 17] non -co mmerc ial us e o nly referred (2.84%) compared to admitted (2.84%). discussion emergency medical care has a demonstrable impact on healthcare system functions, yet scant data exist to describe emergency department availability, access and utilization in lowand middle-income countries.9,20,63 data from south and central america are especially scarce.9,11,63 this study represents the first attempt to describe the functioning of an emergency department in a rural and semi-urban setting in guatemala. although a vast majority of emergency departments worldwide still rely on paper-based records, electronic documentation of patient presentation to hospital parroquial de san lucas tolimán allowed for nearly full capture of acute care during the time period studied.64 while presentations to the ed were fairly consistent between months and seasons, time of patient presentation over the course of a day followed a clear distribution. a majority of patient encounters occurred during day and evening hours (7 am – 11 pm). relatively fewer patients presented to the ed during late evening or early morning hours (11 pm – 7 am). this finding is consistent with other studies of emergency department utilization in lmic.65–67 for example, a tertiary care institution in northern india found that peak patient encounters occurred during day and evening hours and concluded that a lack of readily available transportation may be responsible for this temporal distribution, given that an ambulance was not available, public transportation shuts down at 21:00, and personal vehicles are difficult to arrange.66 another study of trauma systems in kenya also found that transportation at night was a barrier to accessing care, given the risk of being hijacked or shot.67 in remote rural areas of guatemala, many families live without access to motor vehicles, and there is poor public transportation infrastructure.68 for people living in mountain hamlets and rural areas, traversing roads on foot may take several hours, and may be impassable depending on weather conditions, or generally unsafe at night.69 thus, the temporal distribution of patient presentation at this hospital underscores that transportation, distance and road infrastructure may still be significant barriers to accessing acute care in the predominantly indigenous article table 3. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for surgical complaints over a three-year period. trauma (%, n=892) other (%, n=1,173) p* average age (years) 31.9 29.0 location rural 43.78 56.22 0.6025 semi-urban 42 58 season rainy 41.21 58.79 0.227 dry 45.17 54.83 time 7 am – 3 pm 45.84 54.16 0.2761 3 pm – 11 pm 41.01 58.99 0.5640 11 pm – 7 am 39.33 60.67 indigenous yes 42.20 57.60 0.0566 no 52.60 47.40 sex male 39.97 60.03 0.010 female 51.99 48.01 outcome discharge 41.99 58.01 0.0005 admit/ refer 54.48 45.52 * p-value of regression model containing all variables. table 2. demographic characteristics, seasonal/ temporal characteristics, and disposition associated with patients presenting for medical complaints over a three-year period. respiratory cardiovascular gastrointestinal neurological other p* (%, n=4,110) (%, n=676) (%, n=2,694) (%, n=957) (%, n=1,727) average age (years) 55.2 25.9 35.9 32.4 16.0 <0.0001 location rural 33.26 4.14 30.49 11.85 20.25 0.0001 semi-urban 42.89 7.07 25.61 8.77 15.66 season rainy 40.71 6.41 25.03 9.92 17.93 0.4797 dry 40.17 6.89 27.95 8.92 16.06 time 7 am – 3 pm 39.94 5.86 25.70 8.84 19.66 <0.0001 3 pm – 11 pm 41.58 7.58 24.79 10.02 16.03 11 pm – 7 am 38.57 6.12 33.25 9.21 12.86 indigenous yes 41.18 6.06 26.48 9.53 16.75 <0.0001 no 31.52 13.54 26.84 8.23 19.87 sex male 44.90 5.24 25.25 6.74 17.88 <0.0001 female 37.02 7.73 27.47 11.47 16.31 outcome discharge 41.25 6.65 25.86 9.75 16.49 0.6091 admit/ refer 31.24 5.23 33.93 4.78 24.81 * p-value of regression model containing all variables [page 18] [healthcare in low-resource settings 2022; 10:10256] non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10256] [page 19] population studied. interestingly, children and adolescents represented nearly half of all ed visits (43.2%). elderly patients over 65 years old were seen less frequently. presumably younger patients are free of the chronic conditions that typically burden the increasing volume of elderly patients seen in high-income country emergency departments.9 however, other studies have identified higher mortality for younger patients in lowand middle-income countries. thus, timely access to quality emergency care with relatively simple interventions may significantly reduce morbidity and mortality for younger subsets of patients.9,70–73 for example, implementing emergency triage and treatment (etat) guidelines may improve pediatric care. at a hospital in malawi, etat was responsible for halving mortality rate for pediatric inpatients.73–75 this system has already been used in select referral hospitals and primary health centers in guatemala to successfully train health providers in acute pediatric care, and could be implemented at other rural health centers across the country, including the hospital parroquial de san lucas tolimán.46,76 respiratory infections remain a top global cause of morbidity and mortality.63 our study corroborated this finding, with 40.4% of all medical complaints to the ed attributable to respiratory illness. this is particularly concerning in the era of covid-19. although covid-19 patients are unlikely to have co-existent viral and bacterial respiratory infections, there may be significant overlap in patient presentation and comorbidities.77 a surge in patients needing diagnosis and treatment of respiratory illness may overwhelm already overburdened health systems, and result in delays in diagnosis and treatment of respiratory cases requiring timely intervention, such as tuberculosis, which remains a major burden of infectious disease in guatemala.78–80 there is evidence that there may be dual risk posed by co-infection with tuberculosis and covid-19, advancing disease severity and progression for both diseases, and leading to dramatic differences in health services utilization that can affect tuberculosis disease management.81–84 it is difficult to quantify the true impact of covid-19 on this particular hospital and emergency department at this time; however, given the aforementioned issues, it is unlikely that hospital functions will remain unaffected by this evolving pandemic. indeed, excess mortality due to the pandemic has been documented in guatemala on a nation-wide level.85 traumatic complaints made up 43.2% of all surgical presentations to the ed. notably, 51.99% of all females presenting with a surgical complaint were classified as having a traumatic injury. only 39.97% of males presenting with a surgical complaint, on the other hand, were classified as having a traumatic injury. this is in contrast to a body of existing literature that demonstrates males are generally more likely than females to present to emergency departments for traumatic injury.86–95 detailed etiologies of traumatic surgical complaints were not available in hospital records; however, understanding the nature of trauma may represent a potential future area of study, and an important point of intervention for female patients presenting to the ed with trauma. while we are unable to conclude what is causing the observed phenomena in our study population, we are concerned that previous studies have demonstrated that women may suffer a greater proportion of sexual violence and assault injuries compared to male counterparts.93,96 domestic violence against women is well documented in guatemala, and may be one factor that has contributed to the trend observed in our study.97–99 future research should explore this potential in a culturally sensitive manner. furthermore, the substantial burden of traumatic surgical complaints that were identified on presentation to this ed, and the higher percentage of those referred to another institution compared to admitted to the hospital may underscore the need for improved organization and planning for trauma care services regardless of genderbased differences. low cost initiatives to streamline trauma care have been evaluated in mexico, and include the design of specific trauma registries, uniform training for hospital staff involved in the management of trauma cases, and strengthening prehospital services, among others.100–102 similar low-cost efforts could be developed in this setting depending on local interest and resources. for example, an effective prehospital emergency trauma care curriculum was recently developed for lay first responders in the departments of chimaltenango, escuintla and sacatepéquez, and could be modified for use in the san lucas tolimán setting.44 long-term capacity building could also include more in-depth analyses of the types of surgical traumas presenting to the ed, and staff concerns regarding the hospital’s ability to manage these cases on-site. identifying any deficits that exist at this hospital could suggest site-specific interventions. limitations our descriptive epidemiologic study may have been subject to a few different sources of bias, limiting the interpretation of our results. first, there may be crosslevel confounding by individual level covariates, including individual income.103 presentation to the ed may have been influenced by socioeconomic status and/or educational attainment, leading to significant selection bias. more financially stable individuals, with easy access to transportation, may choose to seek care at larger urban centers rather than at a local rural hospital. given that a higher proportion of indigenous individuals are socioeconomically disadvantaged, this could have led to an overrepresentation of the indigenous population at hospital parroquial de san lucas tolimán, and not accurately reflected emergency department usage in non-indigenous populations. for this reason, patient outcome may also be somewhat misleading. individuals may choose to recover at home given the high cost of referred medical care and hospitalization, despite advice to seek additional treatment. thus, socioeconomic status could be a confounding variable not readily apparent based on the information contained in this dataset. migration across groups may also be a problem.103,104 in guatemala, seasonal labor on agricultural plantations (fincas), including coffee and sugarcane plantations, is a primary source of employment for many individuals.105,106 the availability of temporary labor on plantations may cause substantial migration into, and out of, our study population based on season. there may be differences in health risks for temporary workers on plantations compared to permanent residents, given extant labor conditions.106,107 for example, labor exploitation and abuses that occur on guatemalan coffee farms include child labor, the utilization of dangerous forms of transportation, exposure to pesticides/chemicals without adequate personal protective equipment, food and shelter deprivation, and poor living conditions.107 this in turn may lead to an increase in ed encounters among groups of seasonal laborers. we may therefore have observed an overrepresentation of laborers whose primary residence is not san lucas tolimán or the immediate surrounding rural area. finally, non-differential misclassification/measurement error may be a problem.108,109 although hospital staff coded presenting complaint according to a specified system, individuals may have been misclassified if there were multiple presenting complaints or an ambiguous presenting complaint, or if untrained hospital staff filled out the electronic medical record. while we do not expect that this was a significant source of error in this study, in many ecological studies, this type of mis article non -co mmerc ial us e o nly [page 20] [healthcare in low-resource settings 2022; 10:10256] classification can bias results away from null hypotheses.109 conclusions despite limitations, this study generates epidemiologic data that will contribute to the understanding of acute care disease burden and emergency care needs and capacity in a middle-income country, with specific focus on an underserved indigenous population. this information adds to general knowledge of emergency care in this region, and may be used to inform local policy decisions, identify research priorities, create training topics for local health care providers, and perhaps introduce new protocols at rural ed’s in guatemala. references 1. coyle rm, harrison hl. emergency care capacity in freetown, sierra leone: a service evaluation. bmc emerg med 2015;15:2. 2. burke tf, hines r, ahn r, et al. emergency and urgent care 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innovative inter-institutional model for scientific capacitybuilding, healthcare education, and public health. front public health 2017;5:70. 27. universidad de san carlos de guatemala, guatemala city, guatemala. roshreview.com. accessed december 5, 2020. available from: https://www.roshreview. com/global-foundation/profile/universidad-de-san-carlos-de-guatemalaguatemala-city-guatemala/ 28. chary a, flood d, austad k, et al. accompanying indigenous maya patients with complex medical needs: a patient navigation system in rural guatemala. healthc (amst) 2018;6:144-9. 29. browne aj, smye vl, rodney p, et al. access to primary care from the perspective of aboriginal patients at an urban emergency department. qual health res 2011;21:333-48. 30. thomas dp, anderson ip. use of emergency departments by aboriginal and torres strait islander people. emerg med australasia 2006;18:68-76. 31. arnaert a, schaack g. cultural awareness of inuit patients’ experiences with emergency nursing care. accident emerg nursing 2006;14:97-103. 32. dell em, firestone m, smylie j, vaillancourt s. cultural safety and providing care to aboriginal patients in the emergency department. can j emerg med 2016;18:301-5. 33. berg k, mclane p, eshkakogan n, et al. perspectives on indigenous cultural competency and safety in canadian hospital emergency departments: a scoping review. int emerg nursing 2019;43:133-40. article non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10256] [page 21] 34. johnston�leek m, sprivulis p, stella j, palmer d. emergency department triage of indigenous and non-indigenous patients in tropical australia. emerg med 2001;13:333-7. 35. green t, green h, scandlyn j, kestler a. perceptions of short-term medical volunteer work: a qualitative study in guatemala. global health 2009;5:4. 36. berry ns. who’s judging the quality of care? indigenous maya and the problem of “not being attended.” med anthropol 2008;27:164-89. 37. cerón a, ruano al, sánchez s, et al. abuse and discrimination towards indigenous people in public health care facilities: experiences from rural guatemala. int j equity health 2016;15:77. 38. ruano al, sánchez s, jerez fj, flores w. making the post-mdg global health goals relevant for highly inequitable societies: findings from a consultation with marginalized populations in guatemala. int j equity health 2014;13:57. 39. lindblade ka, johnson aj, arvelo w, et al. low usage of government healthcare facilities for acute respiratory infections in guatemala: implications for influenza surveillance. bmc public health 2011;11:885. 40. van der stuyft p, delgado e, sorensen sc. utilisation rates and expenditure for public and private, curative-care services in semi-urban guatemala. ann tropical med parasitol 1997;91:20916. 41. berry ns. kaqchikel midwives, home births, and emergency obstetric referrals in guatemala: contextualizing the choice to stay at home. soc sci med 2006;62:1958-69. 42. becker s, fonseca-becker f, schenckyglesias c. husbands’ and wives’ reports of women’s decision-making power in western guatemala and their effects on preventive health behaviors. soc sci med 2006;62:2313-26. 43. rööst m, johnsdotter s, liljestrand j, essén b. a qualitative study of conceptions and attitudes regarding maternal mortality among traditional birth attendants in rural guatemala. bjog 2004;111:1372-7. 44. delaney pg, figueroa ja, eisner zj, et al. designing and implementing a practical prehospital emergency trauma care curriculum for lay first responders in guatemala. trauma surg acute care open 2020;5:e000409. 45. walker dm, holme f, zelek st, et al. a process evaluation of pronto simulation training for obstetric and neonatal emergency response teams in guatemala. bmc med educ 2015;15:117. 46. crouse hl, torres f, vaides h, et al. impact of an emergency triage assessment and treatment (etat)based triage process in the paediatric emergency department of a guatemalan public hospital. paed int child health 2016;36:219-24. 47. bose s, bream k, barg f, band r. willingness to pay for emergency referral transport in a developing setting: a geographically randomized study. acad emerg med 2012;19:793800. 48. evanson ta, zust bl. the meaning of participation in an international service experience among baccalaureate nursing students. int j nurs educ scholarship 2004;1:1070 49. andrews cm, wyne k, svenson je. the use of traditional and complementary medicine for diabetes in rural guatemala. j health care poor underserved 2018;29:1188-208. 50. chickering wh. a guide for visiting clinicians to guatemala: common presenting symptoms and treatment. j transcult nurs 2006;17:190-7. 51. chamarbagwala r, morán he. the human capital consequences of civil war: evidence from guatemala. j devel econ 2011;94:41-61. 52. svenson el, tun r, conway jh, et al. a one health approach to compare selfprescribed antibiotic use across rural and semi-urban populations in san lucas tolimán, guatemala. j health care poor underserved 2021;32:1798817. 53. sperling j. the influence of poverty and violence on the therapeutic landscapes of the kaqchikel. published online 2006. accessed december 26, 2021. available from: https://uwspace.uwaterloo.ca/handle/1 0012/982 54. ao t, mccracken jp, lopez mr, et al. hospitalization and death among patients with influenza, guatemala, 2008–2012. bmc public health 2019;19:463. 55. gragnolati m, marini a. health and poverty in guatemala. soc sci res network 2003. accessed december 22, 2021. available from: https://papers.ssrn.com/abstract=6363 28 56. bowser dm, mahal a. guatemala: the economic burden of illness and health system implications. health policy 2011;100:159-66. 57. becerril-montekio v. sistema de salud de guatemala. salud pública de méxico 2011;53:12. 58. peltan id. disaster relief and recovery after a landslide at a small, rural hospital in guatemala. prehosp disaster med 2009;24:542-8. 59. duffy s, norton d, kelly m, et al. using community health workers and a smartphone application to improve diabetes control in rural guatemala. glob health sci pract 2020;8:699-720. 60. inicio. hospital gregorio schaffer. accessed december 22, 2021. http://hospitalgregorioschaffer.org/ 61. healthcare – friends of san lucas. accessed december 26, 2021. https:/ /sanlucasmission.org/programs/healthcare/ 62. lópez-carr d, davis j, jankowska mm, et al. space versus place in complex human–natural systems: spatial and multi-level models of tropical land use and cover change (lucc) in guatemala. ecological modelling 2012;229:64-75. 63. chang cy, abujaber s, reynolds ta, et al. burden of emergency conditions and emergency care utilization: new estimates from 40 countries. emerg med j 2016;33:794-800. 64. mowafi h, dworkis d, bisanzo m, et al. making recording and analysis of chief complaint a priority for global emergency care research in lowincome countries. acad emerg med 2013;20:1241-5. 65. kironji ag, hodkinson p, de ramirez ss, et al. identifying barriers for out of hospital emergency care in low and low-middle income countries: a systematic review. bmc health serv res 2018;18:291. 66. tiwari y, goel s, singh a. arrival time pattern and waiting time distribution of patients in the emergency outpatient department of a tertiary level health care institution of north india. j emerg trauma shock 2014;7:160-5. 67. wesson hkh, stevens ka, bachani am, et al. trauma systems in kenya: a qualitative analysis at the district level. qualitative health research 2015;25: 589-99. 68. chomat am, kring b, bekker lp. approaching maternal health from a decolonized, systemic, and culturally safe approach: case study of the mayan-indigenous populations of guatemala. in: schwartz da, ed. maternal death and pregnancy-related morbidity among indigenous women of mexico and central america: an anthropological, epidemiological, and biomedical approach. global maternal article non -co mmerc ial us e o nly [page 22] [healthcare in low-resource settings 2022; 10:10256] and child health. springer international publishing; 2018:483511. 69. lindstrom dp, muñoz-franco e. migration and maternal health services utilization in rural guatemala. soc sci med 2006;63:706-21. 70. razzak j, usmani mf, bhutta za. global, regional and national burden of emergency medical diseases using specific emergency disease indicators: analysis of the 2015 global burden of disease study. bmj global health 2019;4:e000733. 71. salomon ja, wang h, freeman mk, et al. healthy life expectancy for 187 countries, 1990–2010: a systematic analysis for the global burden disease study 2010. lancet 2012;380:2144-62. 72. viner rm, coffey c, mathers c, et al. 50-year mortality trends in children and young people: a study of 50 lowincome, middle-income, and highincome countries. lancet 2011;377:1162-74. 73. baker t. pediatric emergency and critical care in low-income countries. pediatric anesthesia 2009;19:23-7. 74. molyneux e, ahmad s, robertson a. improved triage and 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and hiv on health services in subsaharan africa. int j infect dis 2021;113:s16-s21. 85. martinez-folgar k, alburez-gutierrez d, paniagua-avila a, et al. excess mortality during the covid-19 pandemic in guatemala. am j public health 2021;111:1839-46. 86. mehmood a, razzak ja, kabir s, et al. development and pilot implementation of a locally developed trauma registry: lessons learnt in a lowincome country. bmc emerg med 2013;13:4. 87. casey er, muro f, thielman nm, et al. analysis of traumatic injuries presenting to a referral hospital emergency department in moshi, tanzania. int j emerg med 2012;5:28. 88. ladha ks, young jh, ng dk, et al. factors affecting the likelihood of presentation to the emergency department of trauma patients after discharge. ann emerg med 2011;58:431-437. 89. gaw ce, zonfrillo mr. emergency department visits for head trauma in the united states. bmc emerg med 2016;16:5. 90. clark k, rao a, chen v, et al. we need to target trauma: a prospective observational study in eastern cape province, south africa. samj 2020;110:38-43. 91. blom l, klingberg a, laflamme l, et al. gender differences in burns: a study from emergency centres in the western cape, south africa. burns 2016;42:1600-8. 92. hode l, madougou s, fatigba ho, et al. the direct cost of treatment of traumatic brain injury in a sub-saharan african country (benin). world neurosurg 2017;99:210-3. 93. sanyang e, peek-asa c, bass p, et al. injury factors associated with discharge status from emergency room at two major trauma hospitals in the gambia, africa. injury 2017;48:14518. 94. maegele m, lefering r, sakowitz o, et al. the incidence and management of moderate to severe head injury. dtsch arztebl int 2019;116:167-73. 95. arslan ed, solakoglu ag, komut e, et al. assessment of maxillofacial trauma in emergency department. world j emerg surg 2014;9:13. 96. tennakoon l, hakes na, knowlton lm, spain da. traumatic injuries due to interpersonal and domestic violence in the united states. j surg res 2020;254:206-16. 97. johri m, morales re, boivin jf, et al. increased risk of miscarriage among women experiencing physical or sexual intimate partner violence during pregnancy in guatemala city, guatemala: cross-sectional study. bmc pregnancy childbirth 2011;11:49. 98. ogrodnik c, borzutzky s. women under attack: violence and poverty in guatemala. j int women’s studies 2011;12. 99. halvorsen r. women caught in a culture of violence in guatemala. nurs women’s health 2014;18:425-8. 100. arreola-risa c, mock c, vega rivera f, et al. evaluating trauma care capabilities in mexico with the world health organization’s guidelines for essential trauma care publication. rev panam salud publica 2006;19:94103. 101. mock c, joshipura m, quansah r, arreola-risa c. advancing injury prevention and trauma care in north america and globally. surg clin north am 2007;87:1-19. 102. arreola-risa c, vargas j, contreras i, mock c. effect of emergency medical technician certification for all prehospital personnel in a latin american city. j trauma 2007;63:914-9. 103. morgenstern h. ecologic studies in epidemiology: concepts, principles, and methods. ann review public health 1995;16:61-81. 104. tong s. migration bias in ecologic studies. eur j epidemiol 2000;16:3659. article non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10256] [page 23] 105. fischer ef, victor b. high-end coffee and smallholding growers in guatemala. latin am res rev 2014;49:155-77. 106. butler-dawson j, krisher l, asensio c, et al. risk factors for declines in kidney function in sugarcane workers in guatemala. j occup environ med 2018;60:548-58. 107. verité, united states department of labor. research on indicators of forced labor in the supply chain of coffee in guatemala. united states department of labor. accessed december 10, 2020. https://www.verite.org/wp-content/uploads/2016/11/research-onindicators-of-forced-labor-in-theguatemala-coffee-sector__9.16.pdf 108. greenland s, brenner h. correcting for non-differential misclassification in ecologic analyses. j royal statistical soc series c (applied statistics) 1993;42:117-26. 109. guthrie ka, sheppard l. overcoming biases and misconceptions in ecological studies. j royal statistical society: series a (statistics in society) 2001;164:141-54. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11876 comparison of the effect of patient-centred and family-centred education through smartphones on the quality of life of patients with type 2 diabetes: a quasi-experimental study danial mohammadi-avizi,1 mohammadreza firouzkouhi,2 abdolghani abdollahimohammad,2 mahin naderifar3 1student research committee, faculty of nursing and midwifery, zabol university of medical sciences, zabol; 2department of medical surgery, faculty of nursing and midwifery, zabol university of medical sciences, zabol; 3department of pediatrics, faculty of nursing and midwifery, zabol university of medical sciences, zabol, iran abstract diabetes is one of the most common non-communicable metabolic diseases with debilitating complications that affect the quality of life of patients. therefore, the present study aimed to determine the effect of patient-centred and family-centred education via smartphone on the quality of life of type 2 diabetic patients. this is a quasi-experimental study with a three-group design (patient-centred education, family-centred education and patient-family-centred education) that was conducted on patients with type 2 diabetes and their families in 2022. research subjects were selected by the purposive sampling method. the collected data were analyzed using spss ver. 21. the results showed no significant difference between the three groups in terms of age, sex, marital status, educational level and duration of diabetes. there was a significant difference between the three groups in terms of the mean total quality of life (qol) score before and after the intervention (p <0.05). in other words, in addition to having a better score than the previous intervention in the three groups after the intervention, the total qol score was better in the patient-family-centred education group. the results of the present study showed that patient-family-centred education has a greater impact on qol scores. therefore, healthcare providers and policymakers should pay more attention to this issue. introduction diabetes is one of the health challenges and its incidence rate is on the rise worldwide. it is predicted to be one of the most important causes of death and disability in the world over the next 25 years.1 diabetes causes major changes in most systems of the body and causes the immediate or late onset of the disease, which can eventually lead to death, disability, and high medical costs.2 according to the reports, healthcare expenditures for diabetic patients are 4 times higher than that of non-diabetic individuals.3 the quality of life (qol) issue and its various aspects in chronic diseases, especially due to their duration and severity, undergo many changes in physical, psychological, social and economic dimensions. according to studies, chronic diseases have had negative effects on health and qol.4 considering the nature of the disease and the long-term complications of diabetes, one of the ways to control the disease is to emphasize self-care behaviours.5 the increasing trend of mobile phone use in human societies has introduced this device as a new remote care tool to establish communication between patients and health care providers.6 one of the key empowerment components that have been considered by health educators is the participation of people to help improve their qol.7 the patient’s family plays different roles. one of the roles is to be a caregiver.8 empowerment refers to opportunities given by a professional team to the patient and family members to increase the ability and skills of family members to meet the needs of patients.9 correspondence: mohammadreza firouzkouhi, department of medical surgery, faculty of nursing and midwifery, ferdowsi st, zabol university of medical sciences, zabol, iran fax: +98.5435223101. e-mail hdah9467@gmail.com key words: family-centred education, patient-centred education, diabetic patients, type 2 diabetes. contributions: dma, design, data collection, writing; mrf, design, edit, writing; aam, design, data analysis. funding: this study has not received any external funding. conflict of interest: the authors declare that there are no conflicts of interest. ethics approval: the study was approved by the medical ethics committee of zabol university of medical science. (ethical approval code: ir.zbmu.rec.1399.161.). informed consent: written & oral informed consent was obtained from all individual participants included in the study. additional informed consent was obtained from all individual participants for whom identifying information is included in this manuscript. data materials availability: all data associated with this study will be available based on the reasonable request to the corresponding author. acknowledgements: this work was obtained from a master thesis. we would like to thank from research deputy of zabol university of medical science. we thank the participants who all contributed samples to the study. received: 26 september 2023. accepted: 28 december 2023. early access: 8 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11876 doi:10.4081/hls.2024.11876 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11876] [page 287] non -co mmerc ial us e o nly self-care education and empowerment of patients and their families leads to an increase in client satisfaction, improvement of qol level, reduction in patient anxiety, as well as reduces the disease-related complications, increased participation in healthcare programs, increased client independence in the implementation of daily programs and increased family health.10 the results of research on health promotion indicate that the family plays an essential and pivotal role in the prevention and treatment of diseases. in his study, agrawal used the active presence of the family as a good social base to improve dietary adherence.11 larson et al. conducted a study titled “investigating the effect of nurses’ educational and supportive programs on stroke patients and their spouses”. the results of the study showed a significant difference between the two groups in terms of overall qol score over time.12 therefore, qol monitoring is the best tool to assess the health status of patients with chronic diseases and the response of these patients to treatment and care methods. since the prevalence of this chronic disease is high in iran and is associated with several complications, so, it is necessary to take measures to empower this group of patients and their families.13 as the results of previous studies show, the caring behaviours of the patient and the family affect qol; however, patients will face various disease-related problems without education for different reasons. the families, as people who help to care for the patient, are also effective in the patient’s self-care behaviours due to ignorance of the disease and its complications. education can be an effective approach to eliminating these factors that affect the patient and the family and help solve these problems. it also seems that the combination of patientand family-centred education, which has not been addressed so far, is more effective than the individual patient or family education, which needs further relevant studies. therefore, the present study aimed to determine the effect of patient-centred and family-centred education through smartphones on the qol of patients with type 2 diabetes. materials and methods design and participants this is a quasi-experimental study that was performed on type 2 diabetes patients and their families who were referred to in zabol diabetes clinic in 2022. the study samples were selected using the purposive sampling method and randomly divided into three groups: 1, 2, and 3 interventions based on a random numbers table. inclusion criteria included reading and writing literacy, patients aged 35-60 years old, confirmed type 2 diabetes, suffering from diabetes for six months after diagnosis, the ability to use mobile phones, tendency to participate in studying and absence of mental illnesses. exclusion criteria also included hospitalization during the study period, being absent from training sessions and unwillingness to participate in the study. the sample size was determined 45 people (n=15 per group) by considering a confidence interval of 95%, test power=90% and using the sample size formula, based on the mean difference: n = 2c x (√sd12 + sd22) / (m1 m2)) 2 (22).13 instruments the data collection instrument was a two-part questionnaire. the first part contains demographic characteristics and individual characteristics and disease as well as (age, sex, marital status, level of education, type of disease, drug use, and duration of the disease). the second part is the 12-item short-form health survey (sf-12). sf-12 is the moderated form of sf-36 that consists of 8 dimensions and is divided into two physical and psychological scales. physical scales include four dimensions of general health (gh), physical functioning (pf), role physical (rp), and bodily pain (bp). the psychological scale consists of four dimensions of role limitations due to emotional problems, role emotional (re), vitality (vt), mental health (mh), and social functioning (sf). the possible score range for each dimension and the total qol is between 0 and 100, with scores 100 and 0 indicating the best and the worst qol scores, respectively. the validity and reliability of article table 1.absolute frequency distribution and frequency percentage and mean and standard deviation of demographic variables of subjects in three groups. variable group patient-centred mean family-centred patient and family-centred (standard deviation) (standard deviation) mean (standard deviation) frequency (%) frequency (%) frequency (%) age mean (standard deviation) 55.07(6.67) 56.47(7.73) 55.33(7.35) sex male 4(26.7) 8(53.3) 6(40) female 11(73.3) 7(46.7) 9(60) marital status married 13(86.7) 15(100) 15(100) single 0 2(13.3) 0 0 education level reading and writing 6(40) 5(33.3) 3(20) diploma 6(40) 7(46.7) 8(53.3) bachelor and higher 3(20) 3(20) 4(26.7) history of disease (year) mean (standard deviation) 5.93(1.75) 5.60(2.58) 5.60(1.95) [page 288] [healthcare in low-resource settings 2024;12:11876] non -co mmerc ial us e o nly the above questionnaire were measured by montazeri et al. (2009), its reliability for the physical and psychological components was 0.73 and 0.72, respectively.14 data collection after obtaining the relevant permissions from the university ethics committee and obtaining the informed consent for participation of the research subjects based on the inclusion criteria, they were selected through the purposive sampling method and were divided into three groups; i.e. family-centred and patient-centred and patient-family-centred groups. the study was performed on patients with an active family member (family member who was the main caregiver of the patient at home and hospital and spent the highest time with the patient). the researcher then held a briefing to introduce himself to patients and their families (parents or children or spouses), explain the study objective and obtain their written consent and contact number to send educational content to them. sf-12 was completed by the studied subjects in person before training. afterwards, educational materials on diet, exercise, and medicine were sent to patients and their families in person and via sms (smartphones) due to the covid-19 epidemic. the educational materials were also sent in the form of pamphlets; educational videos, or cds depending on the facilities available for patients. then, for two months, through mobile sms, the educational materials were sent to patients and their families and the training process was followed up by telephone, email or referring to patients and patients’ questions were answered. the study groups included family-centred patient-centred and patient-familycentred groups. at the end of the two-month follow-up, when patients were referred to the centre for treatment follow-up, they completed sf-12. the educational content was sent three times a week using smartphones to the intervention group. at the end of each session, the patient’s questions regarding the educational content were answered. the educational content included: i) exercise, type, and duration of daily activity, ii) training the drug complications and use; iii) familiarity with diet, type, amount and frequency of diet in these patients.15. data analysis the collected data were first coded and then analyzed using spss ver. 22. first, the normality of variables was initially investigated using the shapiro-wilk test. demographic information was described by determining the absolute frequency and frequency percentage, mean and standard deviation. to perform the intergroup comparison, chi-square, one-way anova and paired t-test tests were used. the confidence coefficient of the study was 95% and p<0.05 was considered as the significant level. ethical consideration this study was approved by the ethics committee of zabol university of medical sciences and the ethics committee of the article table 2.absolute frequency distribution and frequency percentage and mean and standard deviation of demographic variables of subjects in three groups. variable group patient-centred mean family-centred patient and family-centred (standard deviation) (standard deviation) mean (standard deviation) frequency (%) frequency (%) frequency (%) total quality of life score before intervention 36.02(5.31) 36.19(4.71) 36.10(4.38) after intervention 54.04(5.68) 51.85(2.89) 57.85(6.31) [healthcare in low-resource settings 2024;12:11876] [page 289] figure 1. gender of participants. figure 2. marital status of participants. figure 3. quality of life of participants before and after intervention in three groups. non -co mmerc ial us e o nly place where the research was conducted (ethic code: ir.zbmu.rec.1399.161). results the results of the demographic data analysis of the present study showed that the age range of the samples was between 35-56 years. females made up most participants in the three groups. the chi-square test showed no statistically significant difference between the three groups in terms of sex, education level, marital status, or history of the disease (p>0.05) (table 1; figure 1 and 2) regarding the results of investigating qol, the one-way anova test showed no significant difference between the three groups in terms of the total qol score before and after intervention (p>0.05) (table 2; figure 3) also, a paired t-test showed a significant difference between the patient-centred, family-centred and patient and family-centred groups in terms of the mean total qol score before and after the study (p<0.05). the quality of life in the patient and the familycentred group was better than in other groups. (p<0.05). discussion the present study aimed to determine the effect of patientbased and family-centred education and a combination of patientbased and family-centred education through smartphones on the quality of life of patients with type 2 diabetes. data analysis showed no significant difference between the three groups in terms of age, sex, marital status, education and duration of diabetes. the mean age of patients in the three groups was nearly 55 years and the duration of diabetes in the three groups was also nearly 5.5 years. data analysis indicated that the mean total qol score in the patient-centred education group was significantly different from before and after the study (p<0.05). in other words, patients in the patient-centred education group had a better score in the post-intervention phase. in this regard, in their meta-analysis and systematic review, aminuddin et al. showed that smartphone-based self-care and self-management interventions lead to improved self-efficacy, and self-care activities, thus improving the qol of patients,16 which is consistent with the results of the present study. in the present study, educational content included exercise, type and duration of daily activity, training on drug programs, the drug complication and use and familiarity with diet, type, rate and frequency of diet in these patients. in other words, educational content was designed to promote self-care and self-management capabilities. therefore, similar to the study by aminuddin et al., the present study revealed that smartphone-based education on self-care activities and self-management promotes qol of patients by increasing the empowerment and awareness of patients about self-care. studies show that education-based promotion of self-care activities can improve the qol of patients with type 2 diabetes. on the other hand, improvement of qol increases the empowerment of patients in self-care activities.17 therefore, there is a reciprocal relationship between qol and patient education. in the present study, the type of educational method including in-person and telephone was used. in a clinical trial, rossi et al. investigated the effect of smartphone education on qol, weight control and treatment satisfaction in patients with type 1 diabetes during the 6-month follow-up. they reported significantly lower glycosylated haemoglobin levels in the experimental group than in the control group. they also reported a significantly lower risk of hypoglycemia (86%) in the experimental group, and in general, the qol of patients in the experimental group was significantly better after six months.18 this study is consistent with the findings of the present study that suggests improved qol after smartphone-based education. smartphone-based education led to increased awareness and empowerment of patients in blood glucose control at its normal level; therefore, patients suffer from hyperglycemia-related morbidity and complications less frequently. there are also fewer cases of recurrent hypoglycemia, which occurs due to a lack of knowledge and proper insulin administration. reducing the incidence of diabetes-related morbidity and complications can lead to increasing and promoting qol of patients and treatment satisfaction. in a quasi-experimental study, sabzevari et al. also investigated the effect of the implementation of a nurse’s follow-up program on qol of patients with type 2 diabetes in kerman. they showed a significant difference between control and intervention groups in terms of the total qol scores (overall score). in general, the experimental group had a better qol score than the control group.19 the results of this study are consistent with the findings of the present study. thus, based on the results of these two studies, the telephone follow-up program has been able to improve the qol of the studied clients. the results of the present study also showed a significant increase in the mean total qol score of the family-centred group after the intervention (p<0.05). in this regard, garcia et al. investigated the effect of family-centred education through telephone follow-up on the glucose levels of patients with diabetes. they showed that patients had a better qol after the intervention. there was also a significant decrease in glycosylated haemoglobin levels and an improvement in the knowledge and self-efficacy of patients.20 the results of this study are consistent with the present study. hu et al. also reported an improvement in the qol of diabetes patients after smartphone-family-centred education.21 the results of this study are also consistent with the results of the present study. according to the results of these studies, it can be concluded that family education and family members’ involvement can be used as an effective patient education strategy because, family members, in addition to supporting and encouraging patients, can act as caregivers for patients by increasing their awareness. fewer studies have investigated the effect of familycentred education on qol as well as the effect of smartphone training on improving the qol of diabetic patients, such as self-efficacy and self-care. katebi et al. showed that the total qol score of the family-centred education group is significantly higher after intervention,22 which is consistent with the results of the present study so that qol scores increased in patients undergoing family-centred education in both studies. family-centred education can effectively improve the qol of diabetic patients, so, the patient’s family members should be used as members of the treatment team to maintain and improve the qol of diabetic patients. in another study, ebrahimi et al. investigated the effect of family-centred education on qol of patients with type 2 diabetes. in this clinical trial, 12week training was performed on patients’ families. the results showed that the total qol score of patients was significantly higher in the post-training phase.23 the results of the above study are also consistent with the findings of the present study which showed better qol scores in patients undergoing family-centred education. also, the results of comparing the patient-centred education with the combination of patient and family-centred education showed no significant difference in the mean total qol scores of the study samples before the study. however, there was a signif article [page 290] [healthcare in low-resource settings 2024;12:11876] non -co mmerc ial us e o nly icant difference in the total qol scores of study samples after the intervention. there was no study comparing patient-centred education and patient-family-centred education. fine et al. referred to patient-family-centred education as the best educational method.24 besides, various studies provide simultaneous education to patients and their families as an effective method and strategy in patient education.25 however, the present study showed no significant difference between patient-centred education and patientfamily-centred education, which may be due to the small sample size. also, results of comparing family-centred education with patient-family-centred education showed a significant difference between the family-centred and the patient-family-centred education group in terms of the total qol scores. that is, qol scores were higher in the patient and family-centred group than the family-centred group. there was no significant difference between the family-centred group and the patient and family-centred group in terms of the total qol scores. in other words, patients in the patient-centred and family-centred groups had a better total qol score than the family-centred group. this difference reveals that patient-family-centred education is a more effective strategy for education. there was no study comparing simultaneous patient and family education with family training alone. it seems that patients and family-centred education seem to be a more effective patient education strategy. it is recommended to carry out further studies in this regard. conclusions patient, family and patient-family-centred education affected the quality of life. therefore, nurses, physicians, patients and their families recommend that if patients and families are taking care of patients, use this method as one of the non-pharmacological methods to strengthen the quality of life of patients. because patients follow up treatment more successfully when they experience a better quality of life. considering the chronicity of diabetes and longterm patient involvement, it causes fatigue and a negative impact on their lives, thus the results of the current study can help improve the quality of life of these patients. to ensure better generalization, it is recommended to conduct the present study on a larger sample of patients and their families because family-patient-centred education is a more effective method in increasing the quality of life of patients. references 1. beran d, besançon s, ewen m, et al. diabetes and the who model list of essential medicines. he lancet diabetes endocrinol 2022;10:17-18. 2. reichert kp, castro mfv, assmann ce, et al. diabetes and hypertension: pivotal involvement of purinergic signaling. biomed pharmacother 2021;137:111273. 3. association ad. 4. comprehensive medical evaluation and assessment of comorbidities: standards of medical care in diabetes-2021. diabetes care 2021;44:s40–s52. 4. abdelghani m, hamed mg, said a, fouad e. evaluation of perceived fears of covid-19 virus infection and its relationship to health-related quality of life among patients with diabetes mellitus in egypt during pandemic: a developing country single-center study. diabetol int 2021;13:108-16. 5. schmitt a, mcsharry j, speight j, et al. symptoms of depression and anxiety in adults with type 1 diabetes: associations with self-care behaviour, glycaemia and incident complications over four years–results from diabetes miles–australia. j affect disord 2021;282:803-11. 6. abd-alrazaq aa, suleiman n, baagar k, et al. patients and healthcare workers experience with a mobile application for self-management of diabetes in qatar: a qualitative study. computer methods and programs in biomedicine update 2021:100002. 7. ernawati u, wihastuti ta, utami yw. effectiveness of diabetes self-management education (dsme) in type 2 diabetes mellitus (t2dm) patients: systematic literature review. j public health res 2021;10:2240. 8. bennich bb, munch l, overgaard d, et al. experience of family function, family involvement, and self-management in adult patients with type 2 diabetes: a thematic analysis. j adv nurs 2020;76:621-31. 9. khani jeihooni a, kashfi sm, hazavehei smm. effects of the basnef model-based educational programs on blood sugar control,(type 2 diabetes). health education and health promotion 2013:33. 10. kooshyar h, shoorvazi m, dalir z, hosseini m. health literacy and its relationship with medical adherence and healthrelated quality of life in diabetic community-residing elderly. j mazandaran university med sci 2014:134. 11. aggarwal b, liao m, allegrante jp, mosca l. low social support level is associated with non-adherence to diet at 1 year in the family intervention trial for heart health (fit heart). j nutr educ behav 2010;42:380-8. 12. wang w, cheng mtm, leong fl, et al. the development and testing of a nurse-led smartphone-based self-management programme for diabetes patients with poor glycaemic control. j adv nurs 2020;76:3179-89. 13. mohalli f, mahmoudirad gh, alhani f, et al. the effect of family-centered empowerment model on the indicators of the ability of patients with hypertension. ijnr 2019:8. 14. montazeri a, vahdaninia m, mousavi sj, omidvari s. the iranian version of 12-item short form health survey (sf-12): factor structure, internal consistency and construct validity. bmc public health 2009;9:341. 15. ghavidel a, farokhnezhad-afshar p, bakhshandeh h, ghorbanpour f. effect of family-centered education on the quality of life patients after coronary artery bypass graft surgery. iranian j cardiovascular nursing 2015:6. 16. aminuddin hb, jiao n, jiang y, hong j, wang w. effectiveness of smartphone-based self-management interventions on self-efficacy, self-care activities, health-related quality of life and clinical outcomes in patients with type 2 diabetes: a systematic review and meta-analysis. int j nurs stud 2021;116:103286. 17. rosiek a, kornatowski t, frąckowiak-maciejewska n, rosiek-kryszewska a, wyżgowski p, leksowski k. health behaviors of patients diagnosed with type 2 diabetes mellitus and their influence on the patients’ satisfaction with life. ther clin risk manag 2016;12:1783-92. 18. rossi mc, nicolucci a, lucisano g, et al. impact of the “diabetes interactive diary” telemedicine system on metabolic control, risk of hypoglycemia, and quality of life: a randomized clinical trial in type 1 diabetes. diabetes technol therapeut 2013:670. 19. sabzevari s, lashkari t, borhani f, abbaszadeh a. effect of phone follow-up on quality of life in type ii diabetic patients. med surg j 2014. article [healthcare in low-resource settings 2024;12:11876] [page 291] non -co mmerc ial us e o nly 20. garcía aa, brown sa, horner sd, et al. home-based diabetes symptom self-management education for mexican americans with type 2 diabetes. health educ res 2015;30:484-96. 21. hu j, wallace dc, mccoy tp, amirehsani ka. a family-based diabetes intervention for hispanic adults and their family members. diabetes educ 2014;40:48-59. 22. katebi ms, moudi a, dehghan f, ghalenoei m. comparing the effects of family-center education with person-center on the quality of life in patient with type 2 of diabete. j sabzevar university med sci 2020:755. 23. ebrahimi h, ashrafi z, rudsari dm, parsayekta z, haghani h. effect of family-based education on the quality of life of persons with type 2 diabetes: a randomized clinical trial. j nurs res 2018;26:97-103. 24. hannon ts, yazel-smith lg, hatton as, et al. advancing diabetes management in adolescents: comparative effectiveness of mobile self-monitoring blood glucose technology and family-centered goal setting. pediatr diabetes 2018;19:776-81. 25. donegan d, gowan t, gruber r, et al. the need for patientcentered education among patients newly diagnosed with a pituitary tumor. j endocr soc 2021;5:bvab061. article [page 292] [healthcare in low-resource settings 2024;12:11876] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11211 abstract introduction: exclusive breastfeeding is the simplest and healthiest infant feeding method that, directly or by extraction, uses only breast milk with the exception to drops or syrups containing vitamins, mineral supplements or medicines. this practice help prevents malnutrition among toddlers and provide essential dietary values for subsequent growth and development, especially in the first 6 months. however, mataram has the lowest coverage of exclusive breastfeeding in west nusa tenggara province in 2018. this exposure increased by 70.30% from 2017-2018, but has not achieved the 80% national target. the low coverage was caused by mothers’ inadequate knowledge. therefore, the present research aims to demonstrate the effectiveness of booklets as a promotional medium for exclusive breastfeeding towards increasing the knowledge of breastfeeding mothers. design and methods: the research method involved the conduction of preand post tests (before and after the booklet was distributed) on 50 respondents by voluntary sampling. this sampling refers to a probability technique that provides equal opportunities for each population element selected as a member of the sample, while the participants were chosen using consecutive sampling technique results: the results showed the average values of the preand posttests at 72 and 77, respectively. conclusions: therefore, it is concluded that the booklet is effective in increasing mothers’ knowledge on exclusive breastfeeding. introduction currently, undernutrition is the leading cause of death in underdeveloped nations, accounting for over half of all deaths among children mal the age of five. in developing countries, 52 million children are underweight and 155 million are stunted due to malnutrition.1 the world bank and nutrition report in 2019 emphasized that the problem of undernutrition is one of the world’s most serious challenges but has been least tackled.2 the existence of a significant relationship between infant feeding practices makes the exclusive breastfeeding promotion program an early and appropriate way of overcoming undernutrition.3 this is in line with the sustainable development goals (sdgs) or the 2030 sustainable development goals which state that breastfeeding is one of the first steps for a human being to have a healthy and prosperous life.4 but unfortunately there are still many mothers who do not give exclusive breastfeeding practices to their babies. in underdeveloped nations, such as indonesia, dedicated programs to combat undernutrition are already in place, one of which is a program to promote exclusive breastfeeding. exclusive breastfeeding is given to toddlers from the age of 6 months, without adding and or replacing them with other foods or drinks (except tablets, nutrients, and minerals). colostrum is an important substance in breast milk which is rich in antibodies because it contains high amounts of protein for immunity and germ killer so that special breastfeeding can reduce the danger of death in infants. in addition, breast milk contains absorbent materials in the form of enzymes that do not interfere with other enzymes in the intestine. whereas in formula milk, the process of absorption of food will depend on the ability of the child’s intestines to digest. in addition, breast milk also plays a major role in optimal physical and cognitive growth and development in infants.1 breastfeeding is a staple food for toddlers, rich in nutrients essential for growth and development . exclusive breastfeeding for 0-6 months is a strategy intensified to prevent malnutrition. several methods have been used in indonesia to increase exclusive breastfeeding coverage.5 several methods have been used in indonesia to increase the coverage of exclusive breastfeeding. this method is usually in the form of health eduaction. education has been an essential component of action to promote health and article significance for public health breastfeeding coverage in indonesia, particularly in mataram, east nusa tenggara, has not achieved the set target. this situation poses a problem that needs crucial resolution. furthermore, the effectiveness of promotional media, in terms of exclusive breastfeeding, has not generated optimal results. therefore, a new breakthrough that provides sufficient knowledge and positive attitudes to the people of mataram concerning exclusive breastfeeding appears very necessary. this approach possibly leads to significant changes in good behavior towards exclusive breastfeeding practices. [healthcare in low-resource settings 2023; 11(s1):11211] [page 139] h the effects of exclusive breastfeeding booklets on mothers’ knowledge in providing exclusive breastfeeding in mataram city, indonesia septa katmawanti,1 farah paramita,1 agung kurniawan,1 siti khuzaimah a sharoni,2 rosuzeita fauzi,2 intan gumilang pratiwi,3 dea aflah samah,1 yassinda thasia audina,1 oktavia sri wahyuni,1 meyralda dara adisa,1 alinda rahmani1 1departement of public health, faculty of sport science, universitas negeri malang, malang, indonesia; 2centre for nursing studies, faculty of health sciences, universiti teknologi mara, selangor, puncak alam, malaysia; 3department of midwifery, politeknik kesehatan negeri mataram, mataram, indonesia non -co mmerc ial us e o nly prevent disease throughout this century. in developing countries, health education directed towards these goals remains a fundamental tool in the promotion of health and prevention of disease.6 health education can be done with a variety of media. media in health education can be interpreted as a tool for health promotion to facilitate communication and dissemination of information. there are various forms of promotional media such as audio, video, or text.7 the implementation of the exclusive breastfeeding promotion program has not given satisfactory results. one of the factors that mothers do not give exclusive breastfeeding is because knowledge about exclusive breastfeeding is low. knowledge will directly affect the attitudes and behavior of a mother to give exclusive breastfeeding or not.8 according to who, breastfeeding is the most ideal feeding process for newborns up to 6 months for their development and growth, and for 2 years or more with the addition of complementary feeding.9 research conducted by girish et al in 2015 said that mothers did not have complete knowledge about exclusive breastfeeding, although in terms of their attitude they were quite good at doing it because they were assisted by health workers and their families.10 according to seema in 2019, 35% of people globally still fail to do exclusive breastfeeding even though exclusive breastfeeding promotion programs have been carried out.11 in indonesia alone, the coverage of exclusive breastfeeding in 2018 was 37.3%.12 however, mataram showed the lowest exclusive breastfeeding coverage in west nusa tenggara in 2018. this occurrence increased from 2017 to attain 70.30% in 2018, but did not meet the 80% national target.13 in addition, the poor coverage was mainly due to insufficient knowledge of mothers, which is also related to individual educational levels, and beliefs in existing myths.14,15 therefore, promotional efforts in enhancing the awareness of breastfeeding mothers include literacy, lectures or discussions. this research method incorporated literacy with the use of booklets as promotional media to convey information on exclusive breastfeeding proper procedures, the nutrition, benefits and related myths. therefore, the booklet, as a literacy media, is expected to provide effective improvement on exclusive breastfeeding among nursing mothers. design and methods the present research involved the conduction of preand posttests (before and after booklet distribution) on 50 respondents by voluntary sampling. these analyses used a questionnaire with a total of 25 questions based on the literature. respondents’ answers were assessed manually with a maximum of 100 points. in addition, the probability sampling was used to provide equal opportunities for each population element as a selected member of the sample, while the participants were chosen by consecutive sampling technique. mothers with toddlers between 0-2 that are willing to be respondents, as well as demonstrate the ability to read and write served as the inclusion criteria. the research sample size comprised of 50 third trimester pregnant women that do not exclusively breastfeed. furthermore, the respondents were provided with a consent form to confirm their willingness from the antenatal period at the health center, to post-birth stage, with the need for home visits to ascertain subsequent performances. this study also involved 1 research assistant (midwife) and 8 cadres for home visits under the supervision of ampenan and sandubaya health centers in mataram city. respondents also completed a pre-test knowledge questionnaire during antenatal at both clinics, before obtaining the booklet. subsequently, the nursing mothers were assigned 8 cadres after birth to observe the breastfeeding skills and also complete the post-test knowledge questionnaire at their homes. the data collection process commenced from 22-23rd june 2021, with the pre-test conducted on the first day. this was followed by the distribution of booklets, and within 24 hours, the post-test was arranged. the data capture and analysis were performed using wilcoxon signed rank test with ibm computer software, spss 22. more importantly, the present research is known to comply with the research code of ethics under the auspices of the research ethics committee of the bhakti wiyata kediri institute of health sciences with ethics number 421/pp2mkei/ii/2021. results and discussions pre-test results table 1 shows that before booklet distribution, 16 (39%) breastfeeding mothers that did not provide exclusive breastfeeding had good knowledge, 19 (46.3%) had sufficient knowledge, and 6 (14.6%) had less knowledge. post-test results table 2 indicates that after booklet distribution, 33 (70.2%) breastfeeding mothers that did not give exclusive breastfeeding had good knowledge, 19 (25.5%) had sufficient knowledge, and 6 (4.3%) had less knowledge. data analysis the wilcoxon signed rank test is required to test the resulting data and also determine if the values increased between the preand post-tests. table 3 outlines the analysis results, while the average of the preand post-tests were estimated at 72 and 77, respectively. also, the asymp value. sig (2-tailed) occurred at 0.000, indicating <0.05. furthermore, the booklet appeared very effective in enhancing the awareness on exclusive breastfeeding. article table 1. pretest results. category frequency percentage(%) good (76-100) 16 39 sufficient (56-75) 19 46.3 less (≤55) 6 14.6 total 50 100 table 2. posttest results. category frequency percentage(%) good (76-100) 33 70.2 sufficient (56-75) 12 25.5 less (≤55) 2 4.3 total 50 100 table 3. wilcoxon signed-rank test. pretest posttest mean 72 77 asymp. sig (2-tailed) 0,000 [page 140] [healthcare in low-resource settings 2023; 11(s1):11211] non -co mmerc ial us e o nly discussion based on the test results, the average maternal knowledge on exclusive breastfeeding occurred prior to the pre-test process (72). this suggests a reasonably good experience despite no practical application, although is not always followed by positive behavioral changes. the outcome matched several research theories in mataram, where a high awareness level does not guarantee absolute exclusive breastfeeding.16,17 similar research stated that 20% of the 74 mothers with good knowledge, do not engage in exclusive breastfeeding due to several factors, including inadequate family support or physiological disorders.18,19 the post-test results showed an increase in the average mothers’ knowledge (77) after reading the booklet. based on the material, one of the reason mothers do not employ exclusive breastfeeding is due to the non-smooth release of the breast milk. this discovery was supported by the statistical analysis results of the preand post-test data using the wilcoxon signed-rank test with the ibm spss 22 computer software. in addition, the asymp results sig (2-tailed) of 0.000 and the significance value below 0.05 (0.000 <0.05) was also applied. therefore, the use of the booklet was known to influence the increase in exclusive breastfeeding. this conclusion matched the research by septa katmawanti,20 where breastfeeding booklets tend to improve maternal knowledge at posyandu sisir, kota batu. another study by lestari (2021) reported that the use of the material as educational support for pregnant women significantly impacted on the maternal knowledge about self-efficacy in breastfeeding at several public health centers in semarang, indonesia. similar report s were also confirmed at sungai ulin health center, banjarbaru and integrated healthcare center in sisir batu city.20 furthermore, the combination of booklet media with an interactive lecture method impacted the increase in exclusive breastfeeding awareness.22 according to the research by mulye in india, a booklet containing adequate feeding techniques appears very effective in fostering the breastfeeding experience.23 however, in identifying the factors affecting the implementation of exclusive breastfeeding in ethiopia, mothers that do not receive counseling after giving birth are less probable to perform exclusive breastfeeding. this statement further confirmed the knowledge or education factor as very influential.24 knowledge is the result of humans’ feeling or understanding of an object with the five senses, mostly by hearing and sight.25 several factors influence knowledge levels, including education, occupation, age and environment. the research on the use of mch books in integrated healthcare center, bekasi regency, showed a high curiosity in majority of the mothers with low education, and therefore were known to adopt regular reading.26 conversely, sugiarti (2020) stated that higher education breeds easier comprehension and improve the knowledge on mch books,27 while lindawati (2019) reported that the proportion of exclusive breastfeeding appears more frequent in mothers with higher education, including high school (sma) or college graduates. furthermore, adequate education helps process information on the benefits of exclusive breastfeeding from various sources, leading to an increased awareness.28 in principle, occupation provides experience and also influences knowledge. working mothers exhibit broader knowledge, compared to the stay-at-home counterparts, due to a wide range of relationships and opportunities in acquiring extensive information.29 research in pekanbaru, riau, found that the majority of working mothers with the convenience to breastfeed were approximately 67.6%. the stay-at-home category also showed a high rate of implementing exclusive breastfeeding (54.8%). this practice is therefore possible for both working and non-working mothers.30 furthermore, different results were reported by sihombing (2018), where a significant relationship (p-value = 0.005 < 0.05) occurred between a mother’s occupation and exclusive breastfeeding around hinai kiri health center’s business area. in addition, the research stated that the time-off for working mothers also influences exclusive breastfeeding. in most cases, formula milk serves as an alternative, due to poor breastfeeding awareness.31 poor coverage of exclusive breastfeeding triggers a high rate of vulnerable adolescent mothers with inadequate physical, mental and information readiness regarding birth and breastfeeding.32 age is also known to influence maternal knowledge, motivation and activities, as the period between 20-35 years is commonly attributed to a healthy reproduction stage. this is because the reproductive organs are physically ready, and the psychological condition has an impact on the readiness to accept pregnancy. subsequently, it is generally believed that older mothers show more breastfeeding experience, compared to the younger counterparts.33 this result is also in line with a previous research where majority of mothers between the age range of 20-35 years have exclusively breastfed.34 however, according to hanifah (2015), mothers that do not offer exclusive breastfeeding in cikeruh village were mostly between 20-35 years (80.6%), due to poor motivation.33 self-motivation occurs internally, but is possibly influenced by several factors across different individuals. in principle, people with a high sense of motivation tend to realize their desires. this theory was proven in an earlier research where the effect of selfmotivation on dietary compliance was examined among diabetes mellitus patients. respondents with good self-motivation tend to be more obedient to the expected diet, due to the confidence in performing certain tasks or actions.35 in the practice of exclusive breastfeeding, research in bali city showed a significant relationship between the motivation of nursing mothers and the success of exclusive breastfeeding in the commercial area of ubud i public health engineering implementation unit, gianyar regency, with a strong relationship. this means that higher motivation enhances the success in exclusive breastfeeding.36 meanwhile, nandini’s analysis results (2018) showed that motivation, perception and knowledge of mothers about breastfeeding did not show any significant relationship. this is possibly caused by several factors, including the husband, family, and health workers support, employment status, as well as others with either direct or indirect effects.37 apart from education, occupation, age and motivation, knowledge is also influenced by other factors, including the facilities or availability of information resources. hipri (2020) results on the provision of mp-asi (complimentary food of breastfeeding) showed that out of the 85 respondents that received information, 43 correctly provided mp-asi (50.6%). meanwhile, out of the 31 respondents that did not receive any information, 29 did not offer precise mp-asi (93.5%).38 mothers exposed to information sources are known to obtain 9.64 times the opportunity to offer exclusive breastfeeding, compared to the counterparts without any media experience.39 furthermore, exposure to sources from general communication media, interpersonal awareness, health facilities related services during pregnancy, childbirth and postpartum are possible influencing factors of exclusive breastfeeding. subsequently, the analysis on breastfeeding workers at pt. globalindo intimates klaten revealed that the existence of a polyclinic facility and a lactation room with a doctor and nurse help generated information for knowledge expansion.40 in addition to the availability of information sources, breastfeeding hoaxes need to also be restrained. several related myths appear more widespread in indonesia’s remote communities, including the article [healthcare in low-resource settings 2023; 11(s1):11211] [page 141] non -co mmerc ial us e o nly deception that colostrum is not suitable for babies, as special tea or other liquids are needed before feeding.41,42 these rumors also occur in mataram, east nusa tenggara. educational efforts remain an important measure in promoting exclusive breastfeeding, although the increase in knowledge is not always directly proportional to individual behaviorial changes. in this research, health education appears very crucial,43,44 but in order to achieve effective education and reach the right target, appropriate methods and media are required. various techniques have already been employed to improve exclusive breastfeeding practice, ranging from the use of social media, multi-level promotional systems and counseling.45-48 in addition, print, electronic and outdoor channels occur among the frequently applied health education media.49 in the present research, media is used as a promotional medium or an information source, mainly in the form of an exclusive breastfeeding booklet. this material also serves as a communication medium that is promotional or recommended to the public and contains interesting summaries and pictures intended for easier comprehension.50 the advantages of the booklet include the relatively low production cost and sufficient printed durability, compared to audio and audio-visual media. in addition, the literature comes in an a5 size of 16 pages, with a short language and background that contrasts with the writing for easier understanding. for example, a black text on a white background result in a neat and attractive layout. this neatness translates to the frame on all pages, with clearer boundaries. in contrast, the image selection is expected to match the color theme that is attractive, contrast, and facilitates the easier understanding of the contents. in general, the research booklet has fulfilled the criteria for a suitable literature material.51 this exclusive breastfeeding booklet serves as one of the best media in health promotion efforts towards increasing the awareness of exclusive breastfeeding among mothers that do not practice exclusive breastfeeding at integrated healthcare center in the commercial area of mataram city. furthermore, multiple research by li tang et al., yasya et al., masruroh et al., and souza et al. found that conveying knowledge through audio-visual is more successful than traditional media such as booklets.52-55 conclusions the provision of booklets as suitable promotional media for exclusive breastfeeding are very significant to nursing mothers. information in these materials are also effective in enhancing knowledge. therefore, the coverage of exclusive breastfeeding in mataram has the capacity to gradually meet the national target and subsequently reduce the high occurrence of malnutrition among infants. other than traditional media, such as booklets, further research on the impact of other media is needed. references 1. suffian sh, rumianti f, sumbayak e. pengaruh air susu ibu eksklusif terhadap perkembangan kognitif dan perilaku anak usia 6-24 bulan di puskesmas kecamatan grogol petamburan pada tahun 2016. [the effect of exclusive mother’s milk on the cognitive development and behavior of children aged 624 months at the grogol petamburan district health center in 2016.] j kedokt med univ kristen krida wacana 2016;23:15– 21. 2. the world bank. the world bank and nutrition. worldbank.org. 2019. accessed 2022 feb 16. available from: https://www.worldbank.org/en/topic/nutrition/overview#1 3. unicef (united nations children’s fund). global nutrition report 2020: action on equity to end malnutrition. unicef.org. 2020. accessed 2021 jan 14. available from: https://data.unicef.org/resources/global-nutrition-report-2020/ 4. united nations. sustainable development goals | united nations development programme. 2017. accessed 2021 nov 28. available from: https://www.undp.org/sustainable-development-goals 5. safitri a, puspitasari da. upaya peningkatan pemberian asi eksklusif dan kebijakannya di indonesia. penelit gizi dan makanan. [efforts to increase exclusive breastfeeding and its policy in indonesia. nutrition and food researcher.] j nutr food res 2019;41:13–20. article correspondence: septa katmawanti, departement of public health, faculty of sport science, universitas negeri malang, malang, indonesia; e-mail: septakatma.fik@um.ac.id key words: booklets, breastfeeding, mataram city, indonesia acknowledgment: the authors are grateful to the lembaga penelitian dan pengabdian masyarakat (lp2m), universitas negeri malang, indonesia, for the kind support and encouragements during this study. contribution: all authors contributed equally to this article. sk, fp, ak, da, yt, os, mda, ar, ig conducted this study. skas and rf, on the other hand, is a researcher and lecturer from uitm malaysia serving as a research partner and always providing input during the research and manuscript preparation. conflict of interest: the authors declare no conflict of interest. funding: this study was financially supported by lembaga penelitian dan pengabdian masyarakat (lp2m) from pnbp funding, universitas negeri malang. clinical trials: this study has been approved by the health research ethics committee of institut ilmu kesehatan bhakti wiyata kediri. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 7 december 2021. accepted for publication: 12 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11211 doi:10.4081/hls.2023.11211 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 142] [healthcare in low-resource settings 2023; 11(s1):11211] non -co mmerc ial us e o nly 6. nutbeam d. health literacy as a public health goal: a challenge for contemporary health education and communication strategies into the 21st century. health promot int 2000;15:259–67. 7. listyarini ad, fatmawati y. edukasi gizi ibu hamil dengan media booklet tentang perilaku pencegahan balita stunting di wilayah puskesmas undaan kabupaten kudus. 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[factors that cause low exclusive breastfeeding in pejeruk village, ampenan district, mataram city.] mataram: mataram ministry of health health polytechnic;2010. 18. bernard a, musa f, peter d. knowledge, practices and factors affecting exclusive breastfeeding among lactating mothers with babies aged 6 months to 1 year attending magomeni reproductive and child health clinic, kinondoni, dar es salaam: descriptive cross sectional study. 2021. 19. katmawanti s, firdausi r, aflah samah d. the effectiveness of emo-demo in increasing the knowledge and attitudes in mother who do not provide exclusive breastfeeding in the working area of cisadae public health center in malang. kls 2021 mar 25. accessed 2021 may 2. available from: h t t p s : / / k n e p u b l i s h i n g . c o m / i n d e x . p h p / k n e life/article/view/8871 20. katmawanti s, eko wardani h, fauzi r, et al. effectiveness of booklet on exclusive breastfeeding in improving the knowledge and attitudes of mother who do not exclusively breastfeed in the work area of posyandu sisir batu city, east java, indonesia. kls 2021 mar 25. accessed 2021 may 2]; available from: https://knepublishing.com/index.php/knelife/article/view/8894 21. lestari kp, kinasih d, jauhar m. the use of booklet media in improving breastfeeding selfefficacy among pregnant women in a primary health care services. 2021;(august). 22. arifin s, salsabela n, suhartono e, et al. the effect of booklet media with interactive lecture method on mother’s knowledge and intention in giving exclusive breastfeeding in the sungai ulin public health center working area. int j res publications 2019. available from: http://eprints.ulm. ac.id/6162/ 23.nag a, chaturvedi a, kumari r. effectiveness of an information booklet on knowledge regarding breastfeeding among mothers of under two-years children. int j contemp pediatr 2021;8:1387. 24. hunegnaw mt, gezie ld, teferra as. exclusive breastfeeding and associated factors among mothers in gozamin district , northwest ethiopia : a community based cross-sectional study. int breastfeed j 2017;1–8. 25. notoadmojo s. metode penelitian kesehatan. jakarta: rineka cipta; 2007. 26. karminingsih, latifah, saputri fa. gambaran pengetahuan ibu tentang pemanfaatan buku kesehatan ibu dan. [description of mother’s knowledge about utilization of maternal health books and.] j kesmas prima indones 2021;3:1–6. 27. sugiarti s, kurniawati hf. pengetahuan dan sikap pemanfaatan buku kesehatan ibu dan anak (kia) pada ibu hamil mengenai tanda bahaya kehamilan. [knowledge and attitudes on the use of maternal and child health (kia) books in pregnant women regarding the danger signs of pregnancy.] proceeding of the urecol 2020;39:214–20. 28. lindawati r. hubungan pengetahuan, pendidikan dan dukungan keluarga dengan pemberian asi eksklusif. [relationship between knowledge, education and family support with exclusive breastfeeding.] faletehan heal j 2019;6:30–6. 29. ramli r. hubungan pengetahuan dan status pekerjaan ibu dengan pemberian asi eksklusif di kelurahan sidotopo. [correlation of mothers ’ knowledge and employment status with exclusive breastfeeding in sidotopo.] j promosi kesehat 2020;8:36–46. 30. bahriyah f, putri m, jaelani ak, indragiri ak. hubungan pekerjaan ibu terhadap pemberian asi eksklusif pada bayi. [the relationship between mother’s work and exclusive breastfeeding in infants.] j edurance 2017;2:113–8. 31. sihombing s. hubungan pekerjaan dan pendidikan ibu dengan pemberian asi ekslusif di wilayah kerja puskesmas hinai kiri tahun 2017. [relationship of mother’s work and education with exclusive breastfeeding in the work area of hinai kiri health center in 2017.] jurnal bidan 2018 jan;iv(1). 32. fau sy, nasution z, hadi aj. faktor predisposisi ibu usia remaja terhadap pemberian asi eksklusif pada bayi di kecamatan luahagundre maniamolo kabupaten nias selatan. [predisposing factors for adolescent mothers to exclusive breastfeeding for babies in luahagundre maniamolo district, south nias regency] media publikasi promosi kesehatan article [healthcare in low-resource settings 2023; 11(s1):11211] [page 143] non -co mmerc ial us e o nly indonesia (mppki) 2019;2:165–73. 33. hanifah sa, astuti s, susanti ai. gambaran karakteristik ibu menyusui tidak memberikan asi eksklusif di desa cikeruh kecamatan jatinangor kabupaten sumedang tahun 2015. [description of the characteristics of breastfeeding mothers not giving exclusive breastfeeding in cikeruh village, jatinangor district, sumedang regency in 2015.] jurnal sistem kesehatan 2017;3:13960. 34. rahma s, wenny d, agustina a, et al. hubungan pengetahuan dan karakteristik ibu baduta dengan pemberian asi eksklusif di wilayah kelurahan meruya utara tahun 2020. [the relationship between knowledge and characteristics of baduta mothers and exclusive breastfeeding in the north meruya village area in 2020.] jurnal ilmiah kesehatan masyarakat media komunikasi komunitas kesehatan masyarakat 2021;13:133–40. 35. risti kn, isnaeni fn. hubungan motivasi diri dan pengetahuan gizi terhadap kepatuhan diet dm pada pasien diabetes mellitus tipe ii rawat jalan di rsud karanganyar. [the correlation of self-motivation and nutritional knowledge to diet compliance dm in type ii diabetes mellitus patients outpatient at karanganyar hospital.] j kesehat 2017;10:94–103. 36. ririn m, wulandari s, suartha in, et al. the correlation between motivation of breastfeeding mothers and exclusive breastfeeding successful. j cent res publ midwifery nurs 2020;4:33–9. 37. nandini n. hubungan motivasi, persepsi, dan pengetahuan ibu pada masa kehamilan dan pemberian air susu ibu. [relationship of motivation, perception, and mother’s knowledge during pregnancy and breastfeeding.] med technol public heal j 2018;2(1). 38. hipri, indah qn, dhewi s. informasi dan dukungan keluarga ibu dengan ketepatan pemberian mp-asi pada bayi di wilayah kerja. [information and support from the mother’s family with the accuracy of giving mp-asi to babies in the work area.] kalimantan: univ islam kalimantan. 2020. 39. astuti i. determinan pemberian asi eksklusif pada ibu menyusui. [determinants of exclusive breastfeeding in breastfeeding mothers.] heal qual 2013;4:1–76. 40. listyaningrum tu, vidayanti v. tingkat pengetahuan dan motivasi ibu berhubungan dengan pemberian asi eksklusif pada ibu bekerja. [level of mother’s knowledge and motivation related to exclusive breastfeeding to working mothers.] jurnal ners dan kebidanan indonesia 2016;4:55–62. 41. maulida s, kartika i. hubungan antara mitos dengan ketidakberhasilan pemberian asi ekslusif di bpm kecamatan batujajar kabupaten bandung barat. [the relationship between myth and the unsuccess of exclusive breastfeeding at bpm, batujajar district, west bandung regency.] jurnal sehat masada 2018 j;12:36–9. 42. rosida l, sari df. faktor mitos dan budaya terhadap keberhasilan asi eksklusif pada suku jawa. [myth and cultural factors on the success of exclusive breastfeeding in the javanese.] j ilm keperawatan stikes hang tuah surabaya 2020;15:151–61. 43. jayanti kd, khalim rfn. peningkatan pengetahuan ibu melalui penyuluhan tentang pentingnya asi eksklusif di desa kedak kabupaten kediri. [increasing mother’s knowledge through counseling about the importance of exclusive breastfeeding in kedak village, kediri regency.] prosiding (senias) seminar pengabdian masyarakat 2017;0:38. 44. laila nn, shofwati i. hubungan status gizi dengan status menarche pada remaja (usia 10-15 tahun) di indonesia tahun 2010. [the relationship between nutrition status and menarche status in adolescents (10-15 years old) in indonesia, 2010.] j kesehat reproduksi 2013;4(1). 45. wilson jc. using social media for breastfeeding support. nurs womens health 2020;24:332-343. 46. alianmoghaddam n, phibbs s, benn c. “i did a lot of googling”: a qualitative study of exclusive breastfeeding support through social media. woman and birth 2019;32:147-156. 47. susiloretni ka, krisnamurni s, yosef s, et al. the effectiveness of multilevel promotion of exclusive breastfeeding in rural indonesia. sci lifestyle chang 2013;28:44–56. 48. nababan s, yikwa e, widjanarko b. health promotion media to behavior change on exclusive breastfeeding mothers. j promkes indones j heal promot ad heal educ 2019;7:233–9. 49. notoadmojo s. promosi kesehatan: teori dan aplikasi. [health promotion: theory and applications.] jakarta: rineka cipta; 2010. 50. gustaning g. pengembangan media booklet menggambar macam-macam celana pada kompetensi dasar menggambar celana siswa smkn 1 jenar. [development of booklet media drawing various pants on the basic competencies of drawing pants for students of smkn 1 jenar.] universitas negeri yogyakarta. yogyakarta: universitas negeri yogyakarta; 2014. 51. landreansyah. pengembangan booklet sebagai media kehidupan di muka bumi kelas x di sma negeri 12 semarang tahun 2015. [booklet development as a media for life on earth class x at sma negeri 12 semarang in 2015.] semarang; universitas negeri semarang; 2015. 52. tang l, lee ah, binns cw, et al. wechat-based intervention to support breastfeeding for chinese mothers: protocol of a randomised controlled trial. bmc med infor decision making 2020;20:300. 53. yasya w, hardinsyah h, muljono p, et al. online social support communication of breastfeeding mothers on facebook group. prosiding 1st borobudur international symposium on humanities, economics and social sciences (bis-hess 2019)]. 2020. accessed may 2. available from: https://www.researchgate.net/publication/341360236_online_ social_support_communication_of_breastfeeding_mothers_ on_facebook_group 54. mukhoirotin, masruroh s. health education: audio visual media for improving mother’s knowledge, attitude, and psychomotor of breastfeeding techniques. jurnal kebidanan midwiferia 2022;8:9–21. 55. souza to de, morais te do v, martins c da c, et al. effect of an educational intervention on the breastfeeding technique on the prevalence of exclusive breastfeeding. revista brasileira de saúde materno infantil. 2020;20:297–304. article [page 144] [healthcare in low-resource settings 2023; 11(s1):11211] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11820 parenting style, family support, and relapse among schizophrenia patients: a literature review av sri suhardiningsih,1 dya sustrami,1 mundakir mundakir2 1college of health science, sekolah tinggi ilmu kesehatan hang tuah, surabaya; 2faculty of health science, universitas muhammadiyah surabaya, indonesia abstract schizophrenia is a mental health problem that is quite widespread in indonesia. relapse among patients with schizophrenia is related to parenting style and family support. this study aimed to present a literature review that address parenting style, family support, and relapse among schizophrenia patients. three databases were used in this study, proquest, google scholar, and pubmed. the keywords were used according to the medical subject heading (mesh): parenting and families support or emotional support and family functioning and relapse and schizophrenia. we limited the articles from 2020-2022 and in english. we obtained 434 articles which divided into google scholar 214 articles, proquest 134 articles, and pubmed 86 articles. in the end, we obtained six articles. the methodology of articles was evaluated using jbi critical checklist. scores less than 50% were excluded from the study to ensure the quality of the articles. the review results showed that parenting style and family support are risk factors contributing to relapse among schizophrenia patients. however, there was one article showed that there was no correlation between family cohesion and relapse among schizophrenia patients. parenting style and family support has a function in preventing relapse among schizophrenia patients. so, parenting style and family support management are needed to address intervention for preventing relapse among schizophrenia patients. introduction globally, the prevalence of mental health problems is escalating. in 2019, approximately one in eight individuals, totaling 970 million people worldwide, were reported to have a mental condition.1 mental health issues now contribute to one in every five years of disability. surprisingly, 20% of the world’s children and adolescents are grappling with a mental health disorder, and suicide ranks as the second leading cause of death among those aged 15 to 29, making it a critical concern.2–4 schizophrenia stands out as a prominent global mental disorder affecting numerous countries and is recognized as one of the top fifteen causes of disability worldwide.5 the impact of schizophrenia extends to adding 13.4 million years of disabled life to the global disease burden.6 in indonesia, schizophrenia is a widespread mental health problem, evidenced by an increase in reported cases by 7 per thousand individuals.7 specifically, menur mental health hospital in indonesia recorded 9,994 outpatients with schizophrenia.8 relapse is a significant focus in schizophrenia, causing adverse outcomes among individuals with the condition.9 over a one-year period, 59 out of 323 (18.3%) patients experienced a recurrence.10 research has established a correlation between relapse among patients with schizophrenia and their parenting style as well as family support.11 specifically, an overprotective parenting style has been found to impact schizophrenia,12 while a lack of support contributes to relapse among schizophrenia patients.13,14 the influence of parenting style on the growth and development of children is well-documented.15,16 previous studies have categorized parenting styles into four types: authoritative, democratic, permissive, and neglectful.17 notably, authoritarian and permissive parenting styles have been associated with harm to individuals with schizophrenia.18 schizophrenia patients also face stigma from the community and their families.19 stigma has been linked to relapse among schizophrenia patients,20 underscoring the importance of a robust correspondence: dya sustrami, college of health science, sekolah tinggi ilmu kesehatan hang tuah, surabaya, indonesia. e-mail: dyastaufan@gmail.com key words: family; mental disease; parenting; relapse; schizophrenia; support. contributions: ass, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ds, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; mm, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: none. acknowledgements: the authors would like to thank hang tuah surabaya, college of health science, surabaya, indonesia for their valuable support. received: 15 september 2023. accepted: 19 december 2023. early access: 30 january 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11820 doi:10.4081/hls.2024.11820 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11820] [page 181] non -co mmerc ial us e o nly support system from their families.21 paradoxically, families of individuals with schizophrenia may themselves exhibit discriminatory behaviors, including isolating patients and restricting their mobility, reflecting internalized stigma.21,22 family support encompasses various forms, such as emotional support, informational support, instrumental support, and appraisal support,23 all of which are crucial for individuals with schizophrenia.24 these forms of support have been shown to alleviate symptoms in schizophrenia patients and contribute to preventing relapses. based on this background, this study aimed to present a review that address parenting style, family support, and relapse among schizophrenia patients. to the best of our knowledge, there are only a few studies related to family intervention25 and none specifically addressing parenting style. therefore, this study is essential to identify relevant articles concerning parenting style and support from the family to mitigate relapses among schizophrenia patients. materials and methods research design this study employed a literature review that addressed parenting style, family support, and relapse among schizophrenia patients.26 the inclusion criteria for this study were limited to original articles in english, with the study population consisting of schizophrenia patients. the study specifically concentrated on exploring the relationships among parenting style, family support, and relapse in schizophrenia patients. the primary outcome of interest was relapse among schizophrenia patients. articles were excluded if they did not involve human subjects, were not master’s or dissertation papers, or were not full-length articles. search strategy and sources this study utilized three databases: proquest, google scholar, and pubmed. the search was limited to articles published between 2020 and 2022. the review was conducted from july 21 to october 25, 2021. the keywords were selected based on the medical subject heading (mesh) terms and included: parenting and family support or emotional support and family functioning and relapse and schizophrenia. tables were created to present the results of the study. risk of bias the methodologies of the articles were evaluated using the joanna briggs institute (jbi) critical appraisal checklist.27 articles with scores less than 50% were excluded from the study to ensure the quality of the included articles. results records identified through databases yielded 434 articles (figure 1). figure 1 outlines the article selection procedure and extraction process. the original articles included in the review were 214 articles from google scholar, 134 articles from proquest, and 86 articles from pubmed. duplicate articles were removed, and two researchers independently screened titles and abstracts. articles had to meet eligibility criteria based on population, study type, and outcome. as a result, only six articles were included in the final record. table 1 presents a study on the relationship between parenting style and relapse among schizophrenia patients. parenting styles transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 182] [healthcare in low-resource settings 2024;12:11820] table 1. relationship between parenting style and relapse among schizophrenia patients. author year study country total age outcome family conclusion design sample support or parenting style khoshgoftar 2022 descriptive iran 15 > 18 age schizophrenia early mother-child early mother-child et al., 2022 study years old symptoms relationship in patients with schizophrenia was associated with schizophrenia. ishii et al., 2020 prospective 89 40.1 recovery and parental bonding overprotective parent was 2020 research non-recovery instrument (pbi) associated with group to assess parental non-recovery in patients care and overprotection with schizophrenia. abbaspour et al., 2021 cross iran 130 30.51 psychiatric disorder parental bonding most of the patients with 2021 sectional support psychiatric disorders were affected by ineffective parenting styles. figure 1. flow chart of the study selection.non -co mmerc ial us e o nly examined in the articles included early mother-child, parental care, and parental bonding.28–30 the outcomes assessed in the articles were the symptoms of schizophrenia, recovery, and psychiatric disorders. all studies indicated that parenting style was related to the study outcomes (table 1). table 2 displays a study on the relationship between family support and relapse among schizophrenia patients. family support in the articles encompassed relationship with family, multifamily psychoeducation, and family support. the outcomes considered in the articles were the recurrence of schizophrenia, relapse rate, and adaptation mechanisms. all studies demonstrated that family support was related to the study’s outcomes (table 2). discussion schizophrenia poses a severe mental health challenge with the risk of lifelong relapse for affected patients.31 ineffective parenting styles impact individuals with schizophrenia, where parenting involves interactions between parents, children, and the family.32 parenting is closely tied to parental attitudes and behaviors, shaped by factors such as maintenance, care, support, and punishment.33 previous research has classified parenting styles into four categories: authoritative, democratic, permissive, and neglectful.17 the study titled “associations between parental bonding during childhood and functional recovery in patients with schizophrenia”29 demonstrated that parental bonding during childhood influences the onset of schizophrenia. an overprotective parental style was linked to relapses among schizophrenia patients. ineffective parenting could result in children becoming overly dependent on others. the family’s role is crucial in shaping parenting, ultimately influencing the development of children. the conclusion drawn was that schizophrenic patients benefit from positive parenting, leading to improved socialization skills and preventing relapses. the parenting styles provided by families to schizophrenia patients encompass attitudes, behavior, care, patience, perseverance, and affection. the study “parental bonding styles in schizophrenia, depressive and bipolar patients: a comparative study”30 suggested that parenting patterns could serve as predictors for children’s mental disorders. ineffective parenting styles were prevalent among patients with psychiatric disorders, with the mother’s role being particularly critical. the study “analysis of the early mother-child relationship in schizophrenic patients”28 also emphasized the crucial role mothers play in a child’s behavior, development, and language. the early association between mothers and children in schizophrenia patients was characterized by emotions, ranging from hatred to love. lack of attention from mothers was identified as a contributing factor to emotional problems among children. one of the family’s functions is to care for its members.34,35 family support is anticipated to enhance the potential recovery of schizophrenia patients and aid in their adaptation to symptoms.36 patients lacking support from their families are more prone to relapse. family support includes emotional, informational, instrumental, and appraisal support.23 the study “correlation between family cohesion and recurrence in schizophrenics at the dr. soetomo hospital psychiatric clinic”37 aimed to assess the correlation between family cohesion and relapse among schizophrenia patients. however, this study showed no correlation between these two variables, deviating from other studies. the study “the effectiveness of relapse prevention intervention on the ability of patients and their families to prevent psychotic symptoms of relapse among patients with schizophrenia: systematic literature review”26 demonstrated that family support, especially through family-focused therapy and family psychoeducation programs, could prevent relapses among schizophrenia patients. the study “family support and adaptation mechanisms of adults outpatients with schizophrenia”38 explained that emotional support from the family could enhance coping mechanisms for patients with schizophrenia. emotional support comprises affection, trust, attention, listening, and being listened to.9 information support involves advice to improve health and motivation among patients.39 instrumental support encompasses providing shelter, food, and transportation, reflecting the family’s economic and healthcare functions.40,41 thus, the family plays a crucial role in preventing relapses among schizophrenia patients. several limitations of this study should be considered. this study conducted a review and has not yet measured the quantitative effect of parenting style on relapse among schizophrenia patients and family support on schizophrenia patients. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. relationship between family support and relapse among schizophrenia patients. author year study country total age outcome family conclusion design sample support or parenting style texaga and rejeki, 2022 cross indonesia 40 16-40 recurrences of brief family there is no significant 2022 sectional schizophrenia patients relationship scale relationship between family (times per year) cohesion and the recurrence of schizophrenia. abu sabra and 2021 systematic 12 relapse rate multifamily the relapse prevention hamdan-mansour, review psychoeducation intervention increases 2021 for patients and their families to minimize and prevent psychotic symptoms. widiyawati 2020 cross indonesia 101 15-75 adaptation mechanism family support the positive influence et al., 2020 -sectional to the symptom of of family support on schizophrenia the adaptability of schizophrenia outpatients [healthcare in low-resource settings 2024;12:11820] [page 183] non -co mmerc ial us e o nly conclusions the review findings suggest that parenting style and family support have been identified as significant risk factors contributing to relapse among schizophrenia patients. to address this issue, it is crucial to incorporate family support management as part of the treatment approach to effectively prevent relapse in individuals with schizophrenia, such as by enhancing family relationships and providing psychoeducation. engaging the family, including aspects like parental bonding and early mother-child relationships, in the intervention process can enhance support systems and create a conducive environment for the patient’s overall well-being and relapse prevention. references 1. who. mental disorders. 2022. available from: https://www. who.int/news-room/fact-sheets/detail/mental-disorders 2. haining k, karagiorgou o, gajwani r, et al. prevalence and predictors of suicidality and non-suicidal self-harm among individuals at clinical high-risk for psychosis: results from a community-recruited sample. early interv psychiatry. 2020; available from: https://www.scopus.com/inward/record.uri?eid=2-s2.085098155248&doi=10.1111%2feip.13075&partnerid=40&m d5=85a564472c5028aeac8384ca1ff6c6bb 3. who. the who special initiative for mental health (20192023): universal health coverage for mental health. geneva pp geneva, switzerland: world health organization; 2019. available from: https://www.who.int/publications/i/item/special-initiative-for-mental-health-(2019-2023) 4. who. world mental health report: transforming mental health for all. world health organisation. geneva; 2022. available from: https://www.who.int/publications/i/item/9789240049338 5. vos t, abajobir aa, abate kh, et al. global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990&#x2013;2016: a systematic analysis for the global burden of disease study 2016. lancet 2017;390:1211-59. 6. charlson fj, ferrari aj, santomauro df, et al. global epidemiology and burden of schizophrenia: findings from the global burden of disease study 2016. schizophr bull 2018;44:1195-203. 7. kementrian kesehatan republik indonesia. laporan nasional riskesdas 2018 [national report on basic health data research]. badan penelitian dan pengembangan kesehatan 2019. p. 223-5. 8. sustrami d, yusuf a, fitriyasari r, suhardiningsih as. family burdens in patients with schizophrenia. j ilm keperawatan 2022;17:30-7. 9. sustrami d, yusuf a, fitryasari r, et al. relationship bet ween social support and family caregiver burden in schizophrenia patients. j pak med assoc 2023;73:s42-5. 10. alphs l, nasrallah ha, bossie ca, et al. factors associated with relapse in schizophrenia despite adherence to long-acting injectable antipsychotic therapy. int clin psychopharmacol 2016;31:202-9. 11. febriana b, susanto w, rochmawati dh, setiawati we. family support is the key to compliance with the treatment of relapsing schizophrenia patients. j ners 2020;15:457-61. 12. arifuzzaman m, acharjee p. parenting style in a schizophrenic patient: a case report. bangladesh j psychiatry 2020;32:22-3. 13. maramis mm, sofyan almahdy m, atika a, et al. the biopsychosocial-spiritual factors influencing relapse of patients with schizophrenia. int j soc psychiatry 2022;68:1824-33. 14. pothimas n, tungpunkom p, chanprasit c, kitsumban v. a cross-sectional study of factors predicting relapse in people with schizophrenia. pacific rim int j nurs res 2020;24:44859. 15. garcia of, serra e. raising children with poor school performance: parenting styles and shortand long-term consequences for adolescent and adult development. int j environ res public health 2019;16. 16. sangawi h, adams j, reissland n. the impact of parenting styles on children developmental outcome: the role of academic self-concept as a mediator. int j psychol 2018;53:37987. 17. maccoby ee, martin ja. socialization in the context of the family: parent-child interaction. in: mussen ph, hetherington em, editors. handbook of child psychology: vol 4 socialization, personality, and social development. new york, usa: wiley; 1983. p. 1-101. 18. ali q, chaudhry da. an anthropological study of parenting style on the behavior of schizophrenic patients. eur acad res 2014;2:6076-88. 19. krupchanka d, chrtková d, vítková m, et al. experience of stigma and discrimination in families of persons with schizophrenia in the czech republic. soc sci med 2018;212:129-35. 20. da silva ag, baldaçara l, cavalcante da, et al. the impact of mental illness stigma on psychiatric emergencies. front psychiatry 2020;11:573. 21. pribadi t, lin ecl, chen p-s, et al. factors associated with internalized stigma for indonesian individuals diagnosed with schizophrenia in a community setting. j psychiatr ment health nurs 2020;27:584-94. 22. tristiana rd, triantoro b, nihayati he, et al. relationship between caregivers’ burden of schizophrenia patient with their quality of life in indonesia. j psychosoc rehabil ment heal 2019;6:141-8. 23. friedman rm. restructuring of systems to emphasize prevention and family support. j clin child psychol 1994;23:40-7. 24. karmila k, lestari dr, herawati h. dukungan keluarga dengan kepatuhan minum obat pada pasien gangguan jiwa di wilayah kerja puskesmas banjarbaru [family support with medication compliance in patients with mental disorders in the work area of the banjarbaru health center]. dunia keperawatan 2017;4:88. 25. mcfarlane wr. family interventions for schizophrenia and the psychoses: a review. fam process 2016;55:460-82. 26. a. abu sabra m, hamdan-mansour am. the effectiveness of relapse prevention intervention on the ability of patients and their families to prevent psychotic symptoms of relapse among patients with schizophrenia: systematic literature review. med leg updat 2021;21:392-402. 27. tufanaru c, munn z, aromataris e, et al. systematic reviews of effectiveness. in: aromataris e, munn z, editors. jbi manual for evidence synthesis. jbi; 2020. 28. khoshgoftar m, khodabakhshi-koolaee a, sheikhi mr. analysis of the early mother-child relationship in schizophrenic patients. int j soc psychiatry 2022;68:548-54. 29. ishii j, kodaka f, miyata h, et al. associations between parental bonding during childhood and functional recovery in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 184] [healthcare in low-resource settings 2024;12:11820] non -co mmerc ial us e o nly patients with schizophrenia. plos one 2020;15:e0240504. 30. abbaspour a, bahreini m, akaberian s, mirzaei k. parental bonding styles in schizophrenia, depressive and bipolar patients: a comparative study. bmc psychiatry 2021;21:169. 31. al-nema m, gaurav a. schizophrenia: the ambiguous mechanism behind the disorder. jordan j pharm sci 2022;15:239-57. 32. belsky j. the determinants of parenting: a process model. child dev 1984;55:83-96. 33. power tg. parenting dimensions and styles: a brief history and recommendations for future research. child obes 2013;9:s1421. 34. berger lm, font sa. the role of the family and familycentered programs and policies. futur child 2015;25:155-76. 35. lekoadi rg, temane ma, poggenpoel m, myburgh c. lived experiences of family members caring for individuals living with bipolar disorder. afr j nurs midwifery 2023;21. 36. seshadri k, sivakumar t, jagannathan a. the family support movement and schizophrenia in india. curr psychiatry rep 2019;21:95. 37. texaga dr, khairina, purwo sri rejeki. correlation between family cohesion and recurrence in schizophrenics at the dr. soetomo hospital psychiatric clinic. j psikiatri surabaya 2022;11:41-6. 38. widiyawati w, yusuf a, devy sr, widayanti dm. family support and adaptation mechanisms of adults outpatients with schizophrenia. j public health res 2020;9:219-22. 39. cham cq, ibrahim n, siau cs, et al. caregiver burden among caregivers of patients with mental illness: a systematic review and meta-analysis. healthc 2022;10. 40. yusuf a, hartanto ae, mundakir, agustina n. the family role model in self-care at schizophrenic patients. opcion 2019;35:1544-57. 41. chronister j, fitzgerald s, chou c-c. the meaning of social support for persons with serious mental illness: a family member perspective. rehabil psychol 2021;66:87-101. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11820] [page 185] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11210 brassica oleracea var. italica extract reducing free radicals and inflammation initiated by an exposure to cigarette smoke rivan virlando suryadinata, dwi martha nur aditya, viera permatasari wiana, diana rahman faculty of medicine, universitas surabaya (ubaya), surabaya, indonesia abstract introduction: herbal extracts are often administered to cigarette smokers to prevent excessive free radicals. these include brassica oleracea var. italica, known to contain high antioxidant flavonoids and selenium micronutrients. therefore, this study aims to determine the efficacy of brassica oleracea var extract. italica in reducing the free radicals and inflammation present in experimental animals exposed to cigarette smoke. design and methods: this research was conducted based on an experimental method using a randomized controlled trial (rct) for 21 days. the animals used were divided into six groups (negative control, positive control, and four treatments). particularly, the positive control and treatment groups were exposed to cigarette smoke for 2 minutes, twice a day, at 50 ppm co levels. the treatment groups were administered the extract at different doses (0.5 ml; 0.75 ml; 1 ml; 1.25 ml), before assessing the blood level of malondialdehyde and c-reactive protein. result: the results showed the tendency for exposure to smoke to increase the number of free radicals and stimulate inflammation responses in the body (p<0,05). in addition, a strong correlation between variables was established (p=0.000; r=0.713). conclusions: broccoli extracts (brassica oleracea l. var. italica) administration has the potential to cause a decline in the two aspects, including free radicals and inflammation responses resulting from exposure to cigarette smoke. introduction tobacco cigarette is one of the products consumed through smoking. in addition, there has been an increase in popularity despite the negative health effects. numerous countries have explored various means to stop the use,1 but these efforts have not yielded significant results. based on previous reports, one of the serious potential problems of every smoker is the elevated risk of disease infections, which is implicated in around 6 million deaths, worldwide. despite the practice of abstinence for several years, smokers are known to have a sustained higher risk of infection with earlier onset than non-smokers. these are strongly associated with 10 years of shorter life expectancy.2 the total number of smokers worldwide is estimated to have reached 1 billion people and consist predominantly of men.3 in addition, the prevalence in developed countries, including america is relatively high, at about 15% of the total population, and consists more of people in the productive age groups.4 the number in developing countries, including armenia, laos and indonesia, is comparably more, reaching over 50% of the total population.5 the increased mortality rate of smokers is evidence of the dangerous effects. previous studies showed the development of various diseases, including lung cancer, respiratory tract, heart problems, and problems during pregnancy. furthermore, about 40% of the total smoking population are known to die prematurely.6 the increase in complications from diseases have been attributed to the free radicals present in cigarette smoke and are known to directly stimulate the body’s inflammatory response.7 further exposure potentially instigates a decline in antioxidant levels and propagates immunosuppression.8 previous studies also highlighted the tendency for cigarettes to initiate endothelial dysfunction as a result of excessive free radicals and inflammation.9 physiologically, free radicals play an important role in cellular functions related to the enzymatic defence system assumed to prevent further accumulation. the presence of excessive radicals causes cellular changes, and consequently oxidative stress.10,11 the production of reactive oxygen species, including superoxide (o2 • -), peroxynitrite (onoo • -), and hydroxyl (oh) is possible during metabolism.12 the enzymatic antioxidants, in form of superoxide dismutase (sod), glutathione peroxidase (gsh-px), and catalase (cat) function to neutralize these free radicals.13 other variants are possibly derived from food intake, including nonenzymatic antioxidants.14 in addition, inflammation is another expression of the body’s natural defence mechanism, which occurs in response to the entry of various foreign objects, including bacteria, viruses, allergens, toxic chemicals, and cigarettes. pathogens or other hazardous substances continuously perpetuates chronic oxidative stress and consequently trigger protein oxidation, which releases pro-inflammatory cytokines and stimulates inflammatory responses all over the body.15 the intake of non-enzyme antioxidants is necessary to reduce excessive free radicals. these include polyphenols, a natural compound obtained from numerous fruits and vegetables, including broccoli. this constituent serves as a defence system from ultravisignificance for public health the increasing number of active smokers is expected to cause serious health problems. this habit has been implicated in the increase in free radicals entering the respiratory tract, which stimulate an inflammatory process in the body. this process triggers cell damage and death, eventually causing health problems. moreover, brassica oleracea var. italica is known to contain high antioxidants, hence, there is a postulation of potential capacity to neutralize free radicals and reduce body inflammations. article [page 134] [healthcare in low-resource settings 2023; 11(s1):11210] non -co mmerc ial us e o nly olet radiation as well as various pathogens and also has antiinflammatory properties with the potential to confer cellular protection against oxidative stress.16 the broccoli plant (brassica oleracea var. italica) is known to contain one of the polyphenol types termed flavonoids and considered to have higher amounts compared to other vegetables.17,18 therefore, this research aims to determine the effectiveness of broccoli in reducing free radicals and inflammation resulting from exposure to cigarette smoke. design and methods this is an experimental research with a post-test control group design. this involved the use of male wistar rats (rattus novergicus) as samples during a 21 days experiment (no:139/ke/x/2021). the animals were subdivided into 6 groups (one negative control group, one positive control group, and four treatment groups). in addition, basic maintenance and care were provided with reference to the 3r principle (replacement, reduction, and refinement). kretek cigarettes, predominantly consumed by indonesians, was used in this study, and is characterized by 2.4 mg nicotine and 38 mg tar. the smoke exposure was carried out two times daily for 21 days (each for 2 minutes with 50 ppm carbon monoxide levels measured using a carbon monoxide meter device). the broccoli was extracted through a maceration process using 96% ethanol as the solvent. furthermore, the preparations were obtained by evaporating the extracts with a vacuum rotary evaporator. based on laurence and bacharach’s framework, a flavonoid present in broccoli extract (18 mg/ml) was measured and evaluated by comparing it with the adequacy daily rate of (8 mg/day). hence, a dose of 0.5 ml; 0.75 ml; 1 ml; 1.25 ml were derived and used for the experiment. the negative control (group i) consisted of experimental animals administered a daily intake, while the positive control (ii) were only exposed to cigarette smoke. in addition, each of the four treatment groups (group iii, iv, v, vi) comprised of experimental animals exposed to cigarette smoke and the different doses of broccoli extracts (0.5 ml; 0.75 ml; 1 ml; 1.25 ml). therefore, the ratio data of malondialdehyde and c-reactive protein for each group were obtained and analysed to ascertain the possible differences and relationships. results and discussions the results showed the mean levels of malondialdehyde in each group. table 1 highlights the highest values (11.23 ± 1.45) in group ii, while the lowest (3.36 ± 0.74) were demonstrated in i. furthermore, all data obtained were subjected to a normality test (p > 0.05) to ensure a well-modelled dataset is used, based on a normal distribution. the homogeneity test (p = 0.018) identified the dataset as non-homogeneous (p < 0.05). therefore, differences in both results were calculated using the t-test. table 2 showed differences in level within each group, although no significant differences were observed between ii and iii (p = 0.898) as well as between group i and v (p = 0.465). the free radicals contained in cigarette smoke are assumed to instigate tissue damage through various mechanical processes, and consequently trigger the peroxidation of lipids, proteins, and dna. this damage reportedly reduces the antioxidant defence system and stimulates the release of pro-inflammatory cytokines.19 in addition, an increase in the predominance of cellular damage from exposure to cigarette smoke that enters the respiratory tract directly elevates malondialdehyde levels in the blood. this compound is not considered a free radical, but the end product of lipid peroxidation.20 the intrinsic characteristics include relatively strong stability and potential for use as an indicator of oxidative stress or body radical content.21,22 table 3 shows the highest levels of c-reactive protein (6.58 ± 0.58) in group ii, while i had the lowest values (4.44 ± 0.74). therefore, a normality test (p> 0.05) was performed on all the data obtained to determine if the dataset was well-modelled by a normal distribution. the homogeneity test (p = 0.831) showed the samples as homogeneous (p >0.05). the differences in both results for each group were then calculated using the anova test, followed by the least significance different (lsd) assessment. in addition, free radicals entering the body potentially stimulate the phagocytosis process of the body’s immune system. this article table 1. means of malondialdehyde between all groups. groups means ± sd normality homogeneity i a group only given daily intake 3.36 ± 0.74 0.754 0.018 ii a group only exposed to cigarette smoke 11.23 ± 1.45 0.367 iii a group given daily intake, cigarette smoke, and 0.5 ml of brassica oleracea var. italica extract 11.14 ± 1.62 0.580 iv a group given daily intake, cigarette smoke, and 0.75 ml of brassica oleracea var. italica extract 5.60 ± 0.94 0.237 v a group given daily intake, cigarette smoke, and 1 ml of brassica oleracea var. italica extract 3.87 ± 0.83 0.640 vi a group given daily intake, cigarette smoke, and 1.25 ml of brassica oleracea var. italica extract 1.90 ± 0.70 0.552 table 2. the results of t-test on malondialdehyde levels between all groups. groups i ii iii iv v vi i ii 0.000 iii 0.000 0.898 iv 0.003 0.000 0.000 v 0.465 0.000 0.000 0.019 vi 0.038 0.000 0.000 0.000 0.006 [healthcare in low-resource settings 2023; 11(s1):11210] [page 135] non -co mmerc ial us e o nly process stimulates the secretion of pro-inflammatory cytokines, including interleukin-1, interleukin-6, and tumour necrosis factoralpha (tnf-α), known to be responsible for inflammatory responses.23,24,25 the reaction serves as a defence mechanism against various microorganisms or foreign objects, and there is a need to control this effect to avoid attacks by autoimmune diseases.26 furthermore, a gradual change in the cells surrounding the site is observed during chronic attacks, and potentially results in permanent damage.27 these conditions are also possibly created after chronic cigarette exposure, which initiates a plaque build-up in the artery. this formation is consequently implicated in atherosclerosis, which leads to serious diseases, including cardiovascular and stroke.28 the increase in free radicals is signalled by an elevation in malondialdehyde levels, which directly triggers inflammatory responses with negative health impacts. the anova analysis results showed differences in the levels of c-reactive protein in each group. these were further evaluated using the least significance different (lsd) test. table 4 showed a significant difference (p < 0.05) in group i compared to others, while ii demonstrated no substantial variation in contrast with iii (p = 0.917) and group iv (p = 0.152). however, no significant difference were observed between group iv and iii (p = 0.182), as well as v (p = 0.139) and vi (p = 0.085). the results also indicate no substantial variations between group v and vi (p = 0.794). table 5 depicts the relationship between increased malondialdehyde and c-reactive protein levels. this was ascertained using the pearson test, and the results showed a strong correlation between both parameters (r = 0.713). the external antioxidants or exogen antioxidants obtained from food possess different action mechanisms compared to enzymatic antioxidants, despite the intrinsic neutralizing capacity. these compounds are known to reduce free radicals in various ways, including through the protection of cells from lipid peroxidation (vitamin e), as strong reducing agents to be potentially rereduced by enzymes and glutathione (vitamin c). previous reports showed proficiency in boosting the immune system (β carotene) and polyphenol groups, known to act as both antioxidant and antiinflammatory agents.29,30,31 in addition, non-enzymatic antioxidants reportedly reduce muscle pain and physical strain resulting from oxidative stress reactions.32 broccoli (brassica oleracea var. italica) contains various types of non-enzymatic antioxidants and high polyphenol, including flavonoids, which is estimated to reduce free radicals and inflammation caused by cigarette smoke exposure.33,34 this vegetable also contains selenium, and is known to potentially increase various enzymatic antioxidants, including superoxide dismutase (sod) and glutathione peroxidase (gshpx).35 conclusions the conclusion of this study is exposure to cigarette smoke increases free radicals and stimulates an inflammatory response in the body. broccoli (brassica oleracea var. italica) extracts plays an intrinsic role in reducing these negative impacts, and the effect is dose-dependent. article table 3. means of c-reactive protein levels between all groups. groups means ± sd normality homogeneity p i a group only given daily intake 4.44 ± 0.74 0.530 0.831 0.000 ii a group only exposed to cigarette smoke 6.58 ± 0.58 0.642 iii a group given daily intake, cigarette smoke, and 0.5 ml of brassica oleracea var. italica extract 6.54 ± 0.50 0.384 iv a group given daily intake, cigarette smoke, and 0.75 ml of brassica oleracea var. italica extract 6.02 ± 0.52 0.758 v a group given daily intake, cigarette smoke, and 1 ml of brassica oleracea var. italica extract 5.44 ± 0.45 0.074 vi a group given daily intake, cigarette smoke, and 1.25 ml of brassica oleracea var. italica extract 5.34 ± 0.74 0.248 table 4. the results of the least significance different (lsd) test between all groups. groups i ii iii iv v vi i ii 0.000 iii 0.000 0.917 iv 0.000 0.152 0.182 v 0.014 0.006 0.008 0.139 vi 0.026 0.003 0.004 0.085 0.794 table 5. the results of the pearson test between all groups. groups p pearson test malondialdehyde 0.000 0.713 c-reactive protein [page 136] [healthcare in low-resource settings 2023; 11(s1):11210] non -co mmerc ial us e o nly references 1. lorensia a, muntu cm, suryadinata rv, et al. effect of lung function disorders and physical activity on smoking and nonsmoking students. j prev med hygiene 2021;62:e89-e96. 2. west r. tobacco smoking: health impact, prevalence, correlates and interventions. psychol health 2017;32:1018–36. 3. drope j, schluger n, cahn z, et al. the tobacco atlas. atlanta: american cancer society and vital strategies. am cancer soc 2018;26 p. 4. jamal a, king ba, neff lj, et al. current cigarette smoking among adults — united states, 2005–2015. mmwr morb mortal wkly rep 2016;65:1205–1211. 5. saleheen d, zhao w, rasheed a. epidemiology and public health policy of tobacco use and cardiovascular disorders in lowand middle-income countries. arterioscler thromb vasc biol 2014;34:1811–9. 6. national center for chronic disease prevention and health promotion (us) office on smoking and health. the health consequences of smoking—50 years of progress: a report of the surgeon general. atlanta (ga): centers for disease control and prevention (us); 2014. pmid: 24455788. 7. suryadinata rv, wirjatmadi b. selenium linked to increased antioxidant levels and decreased free radicals in lung tissue of wistar rats exposed to e-cigarette smoke. j global pharma technol 2020;12:32-39. 8. khanna a, guo m, mehra m, et al. inflammation and oxidative stress induced by cigarette smoke in lewis rat brains. j neuroimmunol 2013;254:69–75. 9. winkelmann br, von holt k, unverdorben m. smoking and atherosclerotic cardiovascular disease: part i: atherosclerotic disease process. biomarkers in medicine 2009;3:411-428. 10. suryadinata rv, wirjatmadi b, adriani m, et al. effects of knowledge of vitamin d on attitudes toward sun exposure among middle-aged and elderly indonesian adults. indian j public health res develop 2018;9:11-15. 11. bardaweel sk, gul m, alzweiri m, et al. reactive oxygen species: the dual role in physiological and pathological conditions of the human body. eurasian j med 2018;50:193– 201. 12. weng m, xie x, liu c, et al. the sources of reactive oxygen species and its possible role in the pathogenesis of parkinson’s disease. parkinsons dis 2018;9163040. 13. wang y, chun o, song w. plasma and dietary antioxidant status as cardiovascular disease risk factors: a review of human studies. nutrients 2013;5:2969-3004. 14. suryadinata rv, wirjatmadi b, adriani m. efektivitas penurunan malondialdehyde dengan kombinasi suplemen antioksidan superoxide dismutase melon dengan gliadin akibat paparan asap rokok. global medical and health communication 2017;5:79-83 15. biswas s, das r, banerjee er. role of free radicals in human inflammatory diseases. aims biophysics 2017;4:596-614. 16. hussain t, tan b, yin y, et al. oxidative stress and inflammation: what polyphenols can do for us?. oxidative medicine and cellular longevity 2016;1-9. 17. sami fj, rahimah s. uji aktivitas antioksidan ekstrak metanol bunga brokoli (brassica oleracea l. var. italica) dengan metode dpph (2,2 diphenyl-1-picrylhydrazyl) dan metode abts (2,2 azinobis (3-etilbenzotiazolin)-6-asam sulfonat). [test di attività antiossidante dell’estratto metanolo di fiori di broccoli (brassica oleracea l. var. italica) utilizzando i metodi dpph (2,2 difenil-1-picrylhydrazyl) e abts (2,2 azinobis (3etilbenzotiazolina)-6-solfonico)) .] jurnal fitofarmaka indonesia 2015;2:107-110. 18. suryadinata rv, sukarno da, sardjono sc, et al. antioxidant activity in red mulberries on sperm development exposed by cigarette smoke. bali med j 2021;10:583-586. 19. suryadinata rv, wirjatmadi b. the molecular pathways of lung damage by e-cigarette in experimental mice. sultan qaboos university med j 2021;1(1). 20. cherian da, peter t, narayanan a, et al. malondialdehyde as a marker of oxidative stress in periodontitis patients. j pharm bioallied sci 2019;11: s297–s300. 21. cui x, gang j, han h, et al. relationship between free and total malondialdehyde, a well-established marker of oxidative stress, in various types of human biospecimens. j thorac dis 2018;10:3088–3097. 22. ito f, sono y, ito t. measurement and clinical significance of lipid peroxidation as a biomarker of oxidative stress: article [healthcare in low-resource settings 2023; 11(s1):11210] [page 137] correspondence: rivan virlando suryadinata, faculty of medicine,universitas surabaya (ubaya), surabaya, jl. tenggilis mejoyo, kalirungkut, kec. rungkut, kota sby, jawa timur 60293, indonesia. tel.: +62.31.2981000. e-mail: rivan.virlando.s@staff.ubaya.ac.id key words: brassica oleracea; c-reactive protein; free radical; inflammation; malondialdehyde. acknowledgement: the authors are sincerely grateful to the staff at the faculty of medicine, universitas surabaya (ubaya) for the assistance rendered during this research. contributions: all authors contributed equally to this research. conflict of interest: the author declare no conflicts of interest. funding: this research uses independent funds from all research members. clinical trials: this research was approved by the health research ethics committee of the university of surabaya. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11210 doi:10.4081/hls.2023.11210 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly healthcare in low-resource settings 2023; volume 11(s1):11211 oxidative stress in diabetes, atherosclerosis, and chronic inflammation. antioxidants 2019;8:72. 23. mantovani a, dinarello c, molgora m, et al. interleukin-1 and related cytokines in the regulation of inflammation and immunity. immunity 2019;50:778-795. 24. borsini a, benedetto m, giacobbe j, et al. proand antiinflammatory properties of interleukin in vitro: relevance for major depression and human hippocampal neurogenesis. int j neuropsychopharmacol 2020;23:738-750. 25. phaniendra a, jestadi db. free radicals: properties, sources, targets, and their implication in various diseases. ind j clin biochem 2015;30:11–26. 26. chen l, deng h, cui h, et al. inflammatory responses and inflammation-associated diseases in organs. oncotarget 2018;9:7204–7218. 27. takeuchi o, akira s. pattern recognition receptors and inflammation. cell 2010;140:805-20. 28. jee y, jung kj, lee s, et al. smoking and atherosclerotic cardiovascular disease risk in young men: the korean life course health study. bmj open 2019;9: e024453. 29. azlina mfn, qodriyah ms, kamisah y. tocopherol and tocotrienol: therapeutic potential in animal models of stress. curr drug targets 2018;19:1456-1462. 30. peternelj tt, coombes js. antioxidant supplementation during exercise training: beneficial or detrimental? sports med 2011;41:1043-69. 31. lohan sb, vitt k, scholz p, et al. ros production and glutathione response in keratinocytes after application of βcarotene and vis/nir irradiation. chem biol interact 2018;280:1-7. 32. simioni c, zauli g, martelli am, et al. oxidative stress: role of physical exercise and antioxidant nutraceuticals in adulthood and aging. oncotarget 2018;9:17181–17198. 33. teixeira j, chavarria d, borges f, et al. dietary polyphenols and mitochondrial function: role in health and disease. curr med chem 2019;26:3376-3406. 34. suryadinata rv, lorensia a, sefania k. effectiveness of lime peel extract (citrus aurantifolia swingle) against c-reactive protein levels in alloxan-induced wistar rats. global medical and health communication 2021;9:23-28. 35. suryadinata rv, wirjatmadi g, lorensia a. the time pattern of selenomethionine administration in preventing free radicals due to exposure to electric cigarette smoke. j public health res 2021;10:2232. article [page 138] [healthcare in low-resource settings 2023; 11(s1):11210] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11870 nurse caring with the swanson theory approach and patient satisfaction in class 3 inpatient room tita rohita, dedeng nurkholik faculty of health sciences, universitas galuh, ciamis, indonesia abstract patient satisfaction is crucial in nursing services and could be influenced by nurses’ caring behavior. this study aimed to discover the relationship between swanson’s caring nurse approach and patient satisfaction in the 3rd-grade inpatient room. this quantitative descriptive research employed an explanatory survey with a cross-sectional approach. purposive sampling is the sampling technique used in this research, with a total of 73 participants. data analysis was conducted using the chi-square test, and data were collected using an instrument. the results indicated that 47 responders (64.4%) perceived that nurses’ caring behavior was not good. specific indicators revealed that “maintaining belief” was not good for 39 respondents (53%), “knowing” for 53 (73%), “being with” for 45 respondents (62%), “doing for” for 48 respondents (66%), and “enabling” for 49 respondents (67%). regarding patient satisfaction, 43 people (58.9%) expressed being quite satisfied. bivariate analysis demonstrated a significant relationship between caring nurses and patient satisfaction, with a p-value of 0.000 or p<0.05. it was recommended that nurses in the inpatient room incorporate improvements in caring behavior into nursing planning and goals. policies related to the obligation of providing caring actions should be established to enhance patient satisfaction. nurses were encouraged to consistently apply caring principles, including “maintaining belief”, “knowing”, “being with”, “doing for”, and “enabling”, to ensure patients were satisfied with their care experience. introduction patient satisfaction is one of the most important factors for evaluating the quality of nursing services among nurses in hospitals.1 nurses’ caring behavior is an important factor in nursing services because caring behavior is closely related to human relationships and greatly influences the quality of service and patient satisfaction.2-4 caring behavior, empathy, compassion, and gentle communication will create a therapeutic relationship between nurses and clients. this way, patients will feel comfortable, so stress will be reduced and patient satisfaction will increase; in reality, the caring behavior of nurses is still not optimal, so it has a negative impact on patient satisfaction.5,6 caring is the main point in nursing action; this refers to several things such as discipline, knowledge, and professional practice.7 nursing scholars expressed the opinion that nursing practice must be based on caring. the theory is accepted that caring is the core of a nurse’s role. furthermore, it has been defined that caring is the absolute identity of nursing.8 it is appropriate for a nurse in carrying out nursing practice duties to view caring as their role and identity.9 however, some studies report that nurses have not implemented caring behavior well. a study conducted in hospitals nationwide showed that 35.1% of nurses do not provide health information to patients.10 a study shows that about 10-30% of general hospital nurses rate the quality of care in hospitals as low and up to 50% feel that the quality of patient care has deteriorated.11 the results of research related to patient satisfaction found that some patients (50.0%) expressed dissatisfaction with nursing services.12 based on the results of several studies, 32% of patients are still dissatisfied with the caring behavior of nurses in ethiopia,2 while research in indonesia as many as 66.7% said they were dissatisfied correspondence: tita rohita, faculty of health sciences, universitas galuh, ciamis, indonesia. e-mail: rohitatita@gmail.com key words: caring, patient satisfaction, nurse. contributions: tr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing original draft, review and editing; dn conceptualization, investigation, methodology, validation, and writing original draft, review and editing. conflict of interest: the authors declare no potential conflict of interest. funding: this research received funding from universitas galuh. ethics approval and consent to participate: ethical approval has been obtained from the ethics committee under reference number no.012.02/e.01/kepk-bth/iii/2023. during research, researchers apply the principles of research ethics, namely information to consent, beneficence, respect for human rights, and non-maleficence. before the research begins, the researcher provides an informed consent sheet and the respondent signs an agreement to participate in the research. patient’s consent for publication: patient s' informed consent was obtained in written form for anonymized patient information to be published. availability of data and materials: all data research results and data that have been analyzed are included in this published article. acknowledgments: special thanks to universitas galuh, ciamis indonesia, for supporting this research. received: 24 september 2023. accepted: 23 january 2024. early access: 1 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:18870 doi:10.4081/hls.2024.11870 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11870] [page 393] non -co mmerc ial us e o nly with nurses’ caring behavior.13 caring is a form of nurse concern for clients as a form of attention, appreciation, and being able to meet their needs.14,15 proper nurse caring behavior allows nurses to demonstrate their professional competence to patients. other studies show factors influencing nurse caring behavior are care environment, low staffing, and support for nurses in the work environment.2,16 when nurses and patients interact in nursing actions and care, caring behavior occurs. for better outcomes nurses have a professional responsibility to provide high quality nursing interventions to patients. nurses’ caring behavior will influence the quality of service and also impact patient satisfaction; if patients are satisfied with the quality of service, they will come back to the hospital again.2,17 caring behavior, empathy, compassion and gentle communication will form harmonious interpersonal relationships between patients and nurses.18,19 caring is a fundamental aspect of various nursing theories. caring behavior, according to swanson, can be seen from the five dimensions of caring, namely “maintaining confidence” (maintaining confidence in events or transitions and seeing them full of wisdom), “knowing” (trying hard to understand the meaning of events in other people’s lives), “being with” (showing feelings of empathy for others), “doing for” (working/doing something for others such as for themselves) and enabling (facilitating others in transition).20 according to swanson’s theory caring is holistic nursing which is useful for supporting the client’s healing process and a way of establishing a caring relationship with the client and taking responsibility for the client’s condition.21 the caring behavior of nurses in class 3 rooms tends to be less than optimal because the number of patients is not balanced with the number of nurses. so, nurses’ caring behavior is closely related to patient satisfaction. therefore, this study aimed to discover the relationship between swanson’s approach to nurses’ caring behavior with patient satisfaction in the class 3 inpatient room. materials and methods research design the research design employed in this study was a descriptive correlational design, utilizing a cross-sectional approach. study participants the study employed purposive random sampling to select a total of 73 respondents who were privately hospitalized in one of the hospitals located in the west java region. purposive sampling is carried out by selecting samples based on certain criteria that are appropriate to the research topic. the inclusion criteria pertain to patients who received treatment in the inpatient setting, were age ≥18 years, compos mentis level of consciousness, could read and write, could hear and see well, and patients who were not in critical condition and had many opportunistic infections. the calculation of the sample size is derived from the slovin formula. this research has limitations, namely the sample is relatively small due to time constraints and this research uses primary data, namely collected data directly from the field by distributing questionnaires to respondents. variable, instrument, and data collection the independent variables consisted of nurse caring behaviors according to swanson’s approach. swanson’s approach to nurse caring behavior includes five indicators: “knowing”, “being with”, “doing for”, “enabling”, and “maintaining belief”. the dependent variable was patient satisfaction, defined as the patient’s feelings towards the performance of health services, with indicators including responsiveness, reliability, assurance, empathy, and tangibles. instruments to measure the variables were adapted from existing ones. the research used a questionnaire that had been previously tested for validity and reliability and was found to be valid and reliable. the results of the validity test for nurse caring behavior showed that all questions were valid, with calculated r-values ranging from 0.541 to 0.894, which were greater than the r table value of 0.444. for the patient satisfaction questionnaire, all questions were deemed valid, with r-values ranging from 0.470 to 1.000. a 4-point likert scale was employed in the instrument, with the following scoring for the agreed responses: for caring nurse 1 never, 2 sometimes, 3 often, 4 always; for patient satisfaction, 1 very dissatisfied, 2 not satisfied, 3 quite satisfied, 4 satisfied, and 5 very satisfied. data collection was conducted by distributing questionnaires to the respondents. the respondents were asked to fill out the questionnaires by themselves after they had given their consent to participate in the research through agreeing to informed consent. data analysis descriptive analysis is employed to provide a comprehensive depiction of the frequency distribution of nurse caring behavior and patient satisfaction levels. the chi-square test was employed to examine the association between the nurse’s caring behavior and patient satisfaction (p<0.05). ethical clearance the present study is grounded in the fundamental tenets of ethical research, including self-determination, privacy and dignity, protection from discomfort and harm, and beneficence. to maintain confidentiality, researchers do not include names, and respondents are only given a code. the consent form contains an explanation of the research carried out, research objectives, research procedures, benefits obtained from respondents, and the risks that may occur. only respondents who are willing to fill out and agree to the consent form voluntarily are included in the study. it received approval from the ethics committee under reference number no.012.02/e.01/kepk-bth/iii/2023. results based on table 1, 47 respondents (64.4%) thought that the general picture of nurses’ caring behavior was not good. nurses’ “maintaining belief” behavior was not good for 39 respondents (53%). nurses’ “knowing” behavior was good for 53 respondents (73%). nurses’ “being with” behavior was not good for 45 respondents (62%). nurses’ “doing for” behavior was not good for 48 respondents (66%). nurses’ “enabling” behavior was not good for 49 respondents (67%). while, as for the results of the study for patient satisfaction, 43 respondents (58.9%) said they were quite satisfied. based on the data processing in table 2, the results of the bivariate analysis showed a significant relationship between caring nurses and patient satisfaction, evidenced by p=0.000, or p<0.05. discussion the research results confirmed our hypothesis that nurses’ caring behavior significantly influences patient satisfaction. caring behavior of nurses is closely related to patient satisfaction, which transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 394] [healthcare in low-resource settings 2024;12:11870] non -co mmerc ial us e o nly is one indicator of the quality of service in a hospital. patient satisfaction is related to the quality of services provided by nurses to patients while hospitalized.18 treating patients carefully, keeping patient information confidential and providing timely care and treatment is critical, along with a sense of security during hospitalization and satisfaction with nursing services.22 nursing care is a multidimensional concept, which describes attitudes and behavior that demonstrate interest and respect for the patient’s psychological, social and spiritual values. caring behavior is a key element of the interaction between nurses and patients in nursing care. implementing a nurse-patient interaction model based on caring behavior in the health system can improve the quality of good services, providing higher levels of satisfaction to nurses and patients.23,24 patient satisfaction with nursing care proves that patients at the time of discharge from the hospital experience a positive relationship between confidentiality of information, treatment, timely administration of drugs, safety during hospitalization, and satisfaction with nursing care.25 swanson’s theory of caring is a theory structured around five caring principles (“maintaining belief”, “knowing”, “being with”, “doing for”, and “enabling”). when applied to nursing practice, each of these five stages stimulates the nurse’s attitude, which in turn improves the overall well-being of the patient.26 some differences of opinion and agreement are found between patients regarding good nursing care. while “enabling,” such as providing information, coaching, and guidance, is more emphasized by patients, “being with” is more emphasized by nurses. “doing for,” especially improving physical comfort, is the attribute most often mentioned in good nursing care by patients.27 researchers assume that the services carried out by nurses must be felt and have a positive impact on patients as recipients of health services in hospitals where the better the caring behavior of nurses in the hospital, the more the patients will feel satisfied and vice versa; if the nurse’s caring behavior is not good, the patient will feel dissatisfied and will be reluctant to use these health services. nurses who are concerned with providing nursing care to patients in hospitals are nurses who have a caring attitude (“maintaining belief”, “knowing”, “being with”, “doing for”, and “enabling”). care, empathy, gentle communication, and nurse affection for patients will form a harmonious interpersonal relationship between clients, and can help meet client needs to provide satisfaction to clients. caring nurses can improve patient recovery because patients feel their physical, emotional, and spiritual needs are met.28 a nurse must have caring behavior in giving service to patients because the relationship between service providers and patient health is a factor that influences the satisfaction process of patients regarding the services provided and cures the patient’s illness.29 the findings in this study have several important implications, namely improving nurses’ caring behavior to increase patient satisfaction. nurses in inpatient rooms can incorporate increased caring behavior into nursing plans and goals and create policies regarding the obligation to carry out care with attention to increase patient satisfaction. this research has limitations, namely the sample is relatively small due to time constraints and this research uses primary data, namely collected data directly from the field by distributing questionnaires to respondents. conclusions patient satisfaction is a very important factor to evaluate the quality of nursing services and nurses’ caring behavior was one aspect related to nursing services because caring includes human relationships and affects patient satisfaction. nurses who are concerned with providing nursing care to patients in hospitals are nurses who have a caring attitude (maintaining belief, knowing, being with, doing for, and enabling). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. caring behavior of nurses with swanson theory approach and patient satisfaction (n=73). variable n (%) caring behavior of nurses good 26 35,6 not good 47 64,4 nurses’ caring behavior indicators maintaining belief good 34 47 not good 39 53 knowing good 53 73 not good 20 27 being with good 28 38 not good 45 62 doing for good 25 34 not good 48 66 enabling good 24 33 not good 49 67 patient satisfaction very satisfied 7 9,6 satisfied 23 31,5 quite satisfied 43 58,9 not satisfied 0 0 very dissatisfied 0 0 total 73 100 table 2. relationship of nurse caring behavior with patient satisfaction in class 3 inpatient room. caring nurse patient satisfaction sum p x2 calculate very satisfied satisfied quite satisfied not satisfied very dissatisfied f % f % f % f % f % f % 0 19.576 good 7 9,6 0 0.0 8 11 0 0 0 0 15 20.5 not good 11 15.1 12 16.4 35 47.9 0 0 0 0 58 79.5 total 18 24.7 12 16.4 43 58.9 0 0 0 0 73 100 [healthcare in low-resource settings 2024;12:11870] [page 395] non -co mmerc ial us e o nly references 1. bakar a, nursalam, adriani m, et al. the development of islamic caring model to improve psycho-spiritual comfort of coronary disease patients. indian j public heal res dev 2018;9:312-7. 2. oluma a, abadiga m. caring behavior and associated factors among nurses working in jimma university specialized hospital, oromia, southwest ethiopia, 2019. bmc nurs 2020;19:17. 3. setyawan feb, supriyanto s, ernawaty e, lestari r. organizational commitment, patient satisfaction and loyalty in the first-level health facilities. int j public heal sci 2022;11:1046-57. 4. mariana e, apriyani w, supriyanto s. analysis of perceived health care quality on patient satisfaction. eurasian j biosci 2020;14:2703-8. 5. asikin m, nasir m, podding it. caring behavior of nurses increase level of client’s satisfaction in clinical area’. am j biomed sci res 2020;10:408-17. 6. fadhillah h, nursalam n, mustikasari m. development of nurse performance model based on knowledge management: seci with caring approach to quality of nursing services in hospital. syst rev pharm 2020;11:1090-4. 7. kurniawati nd, karamy e, pradanie r, yuswanto tja. factors affecting patient’s perception on nurse’s carative-caring behaviour. enferm clin 2020;30:31-4. 8. watson j. unitary caring science-universals of human caring and global micro practices of caritas. nsc nursing 2018;4:1-7. 9. enns cl, sawatzky ja v. emergency nurses’ perspectives: factors affecting caring. j emerg nurs 2016;42:240-5. 10. lake et, germack hd, viscardi mk. missed nursing care is linked to patient satisfaction: a cross-sectional study of us hospitals. bmj qual saf 2016;25:535-43. 11. chana n, kennedy p, chessell zj. nursing staffs’ emotional well-being and caring behaviours. j clin nurs 2015;24:283548. 12. sasmita fn, dwiana d, parera g. hubungan perilaku asertif perawat dalam memberikan pelayanan keperawatan dengan tingkat kepuasan pasien di ruang seruni rsud dr. m. yunus bengkulu. prepotif j kesehat masy 2020;4:121-30. 13. sera ts, triyoso t, furqoni pd. hubungan perilaku caring perawat dengan kepuasan keluarga pasien jiwa di irj rsjd provinsi lampung tahun 2014. holistik j kesehat 2014;8. 14. noprianty c, karana i. perilaku caring perawat berdasarkan teori jean watson di ruang rawat inap. j kesehat vokasional 2019;4:33-48. 15. lisnadiyanti, nursalam, zuriati. patient satisfaction increases towards nurses who have a caring attitude in the inpatient room of a hospital in jakarta. j pharm negat results 2022;13:1874-8. 16. bakar a, qomariah sn, iswati i. effect of caring behaviour approach to improve nurses’ caring character in medical-surgical wards. j ners 2022;17:110-4. 17. fradelos e, alexandropoulou ca, kontopoulou l, et al. factors affecting greek nurses’ caring behaviors: the 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setting. j psychosoc nurs ment health serv 2019;57:29-38. 23. blasdell nd. the meaning of caring in nursing practice. int j nurs clin pr. 2017;4:2. 24. fortuno af, oco db, clores ma. influential components of caring nurse-patient interaction (cnpi) in a tertiary hospital in the philippines: towards improving health outcomes of patients. int j nurs sci 2017;7:84-90. 25. kol e, arıkan f, i̇laslan e, akıncı ma, kocak mc. a quality indicator for the evaluation of nursing care: determination of patient satisfaction and related factors at a university hospital in the mediterranean region in turkey. collegian 2018;25:516. 26. swanson km. nursing as informed caring for the well-being of others. image j nurs scholarsh 1993;25:352-7. 27. lee k, kim sh. patients’ and nurses’ perceptions of what constitutes good nursing care: an integrative review. res theory nurs pract 2020;34:144-69. 28. purwaningsih df. perilaku caring perawat pelaksana di ruang rawat inap. j ilm kesehat 2018;9:61-7. 29. hafriska c, kamil h. perilaku caring perawat dengan pendekatan teori swanson di ruang rawat inap. j ilm mhs fak keperawatan 2017;2:1-6. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 396] [healthcare in low-resource settings 2024;12:11870] non -co mmerc ial us e o nly hrev_master [page 54] [healthcare in low-resource settings 2013; 1:e15] the diverse issues of healthcare in low-resource settings asfandyar khan niazi college of medicine, dentistry and nursing, university of dundee, uk this first issue of the healthcare in lowresource settings (hls) includes several papers on diverse topics. among the many interesting papers published in this issue, some are briefly summarized here. the paper by jargin discusses the barriers to the import of medical products to russia, problems resulting thereof and presents forth some possible solutions.1 the author highlights the consequences of widespread red-tape and corrupt practices in the current russian import systems and argues that such practices have led to an isolation of russia from the rest of the medical world. shrivastava et al. in their paper2 describe the inadequate healthcare services for the indigenous tribes of india and the inequitable distribution of healthcare resources between the indigenous and non-indigenous population. the authors present several practical and implementable ways to improve the health status of the indigenous tribes. purohit used a mathematical model to evaluate the differences in the healthcare behaviors between rural and urban, and private and public healthcare providers in india.3 by using the data from the national family health survery – 3 of india, the author found significant disparities between rural and urban areas, with important public health policy implications. olugbile et al. used a retrospective chart review to study the cost of treatment of patients with psychiatric diseases in the nigerian population.4 on the basis of the records of 100 psychiatric patients, the researchers found that the cost of treatment of medical patients was much higher than psychiatric patients (nigerian naira 2549.07 vs 1904.5, p<0.05). however the researchers found that nigeria does not have any free psychiatric health program. they, therefore, identified the absence of free mental healthcare as a barrier to psychiatric healthcare utilization. mosha et al. used a cross-sectional study based on face to face questionnaires to assess the adequacy of healthcare facilities offering male circumcision in tanzania.5 they compared the standards currently being followed in tanzania with the standards recommended by the world health organization. the researchers found a shortage of sterilization and research equipment in the healthcare centers offering male circumcision. in another report from india, kumar and mahapatro performed a qualitative study using interviews with the auxillary nurse midwives.6 the researchers evaluated the role of sociocultural factors on the acceptance of midwives, as reported by the midwives, working in the rural community of india. several sociocultural factors were identified by the researchers that impede the acceptance of these midwives in the villages which points towards the need to strengthen their position in their work places. a cross-sectional study from egypt conducted by mohamed assessed the factors motivating healthcare workers to work in rural areas.7 the researchers conducted interviews of 302 medical students and found that a high parental professional and educational status was associated with a lower willingness to work in rural areas. however a significant portion of the study participants were interested in working in the rural areas. the issue also includes several other interesting articles that we invite you to read. references 1. jargin sv. barriers to the importation of medical products to russia: in search of solutions. healthcare in low-resource settings 2013;1:e13. 2. shrivastava sr, shrivastava ps, ramasamy j. implementation of public health practices in tribal populations of india: challenges and remedies. healthcare in low-resource settings 2013;1:e3. 3. purohit bc. demand for healthcare in india. healthcare in low-resource settings 2013;1:e7. 4. olugbile ob, coker ao, zachariah mp. cost of treatment as a barrier to access and continuity of healthcare for patients with mental ill-health in lagos, nigeria. healthcare in low-resource settings 2013; 1:e8. 5. mosha ff, wambura m, mwanga jr, et al. readiness of health facilities to deliver safe male circumcision services in tanzania: a descriptive study. healthcare in low-resource settings 2013;1:e9. 6. kumar a, mahapatro m. the cutting edge in the blunt space: an anthropological construct of auxiliary nurse midwives’ social world in the community. healthcare in low-resource settings 2013;1:e10. 7. mohamed am. willingness and professional motivations of medical students to work in rural areas: a study in alexandria, egypt. healthcare in low-resource settings 2013;1:e4. healthcare in low-resource settings 2013; volume 1:e15 correspondence: asfandyar khan niazi, college of medicine, dentistry and nursing, university of dundee, george pirie way, dundee, uk. tel./fax: +44.1382.381600. e-mail: editor@hlsjournal.org key words: healthcare, low-resource settings, editorial. conflict of interests: the author declares no potential conflict of interests. received for publication: 1 august 2013. accepted for publication: 1 august 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a.k. niazi, 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e15 doi:10.4081/hls.2013.e15 hrev_master healthcare in low-resource settings 2024; volume 12:12008 exploring the correlation of social networks, family support, health worker assistance, and health education using the precede-proceed model: impact on emotional responses in diabetes mellitus patients umdatus soleha, siti nurjanah, umi hanik faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia abstract diabetes mellitus is a chronic disease that has the potential to cause stress due to uncertainty about the course of the disease, treatment, and complications. the aim of this research was to analyze the relationship between the support of health workers, family support, social networks, and health education through the precede-proceed model approach to emotional responses. the type of research is a cross-sectional study. the research was conducted at the simo mulyo health center in surabaya, with data collected from june to july 2023. the independent variables, namely the support of health workers, family support, social networks, and health education, were measured using a questionnaire, while the dependent variable, emotional response, was measured using a questionnaire. the population in this study comprised all people with diabetes mellitus registered at the simo mulyo health center in surabaya. the inclusion criteria for this study were as follows: patients with unstable blood sugar regulation, aged between 26 and 65 years, capable of reading, and willing to be respondents. the sample size in this study was 112 respondents, and the sampling technique used was simple random sampling. data analysis utilized the spearman rho correlation test with a significance level of α=0.05. the findings indicate that social network support and emotional response, with a p-value of 0.000 (p<0.005) and r=0.879. health education is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.585. health worker support is correlated with dealing with emotional responses, with a p-value of 0.000 (p<0.005) and r=0.786. family support is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.738. social network support, health education, family support, and health worker support correlate with the emotional response of people with diabetes mellitus. therefore, health workers, families, and social networks can enhance support to improve the quality of the patient’s emotional response, promoting patient enthusiasm for adhering to treatment and minimizing complications due to diabetes mellitus. introduction diabetes mellitus (dm) is classified as one of the noncommunicable diseases (ncds).1 it is a chronic condition that has the potential to induce stress, stemming from uncertainty regarding the disease’s progression, treatment, and complications due to insufficient insulin production by the pancreas.2 the ability to respond positively to stressors and manage emotions is crucial in the treatment of this disease. the prolonged duration of treatment can lead sufferers to experience feelings of hopelessness, fear, anxiety, and depression.3 in 2021, the international diabetes federation (idf) recorded 537 million people living with diabetes.4 indonesia ranks seventh globally in the number of people with diabetes mellitus (dm), totaling 19.47 million people, indicating a prevalence of 10.6%. the 2018 riskesdas results reveal that the prevalence of dm with a doctor’s diagnosis has increased by 2% from the original 2013 prevalence of 1.5%.5 dm is the primary chronic disease associated with severe psychosocial problems.6 riskesdas data from 2018 indicates that the prevalence of emotional disorders in individuals aged 15 years and over increased from 6% to 9.8%, with the prevalence of depression sufferers reaching 6.1%.7 factors influencing the psychological adjustment in individuals with dm, according to the precedence-procedure theory, include predisposcorrespondence: umdatus soleha, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia. e-mail: umdatus@unusa.ac.id key words: diabetes mellitus, emotional response, family support, health education, health worker support, social network. contributions: us conceptualization, formal analysis, methodology,writing – original draft; sn validation, visualization; uh review and editing; fe data curation, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the brahmanda lentera chakra institute no. 094/010/vii/ec/kep/lcbl/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from universitas nahdlatul ulama surabaya with contact https://lppm. unusa.ac.id/ availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 20 october 2023. accepted: 21 december 2023. early access: 8 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12008 doi:10.4081/hls.2024.12008 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12008] [page 249] non -co mmerc ial us e o nly ing factors such as age, education, employment status, and knowledge. enabling factors encompass the distance of residence and family income, while reinforcing factors involve peer support, health workers, and family.8 individuals with diabetes are at a high risk of decreased psychological well-being, with over 40% experiencing emotional aspects.9 this is attributed to changes in treatment and health well-being since diagnosis. people with diabetes often report difficulty accepting a diagnosis of a long-term condition that necessitates constant self-management.10 this difficulty leads to various psychological reactions, including rejection and avoidance, resulting in poor glycemic control. reinforcing factors from the environment, in the form of support from health workers, family, and friends, significantly contribute to enhancing the optimism of individuals with chronic diseases, thereby reducing psychological burdens.11 other research indicates that individuals with diabetes generally experience greater anxiety compared to patients with other diseases.12 increased support serves as reinforcement and is essential to reduce fear, anxiety, and depression, fostering positive emotional responses. the aim of this research was to analyze the relationship between the support of health workers, family support, social networks, and health education using the precedeproceed model approach to understand emotional responses. materials and methods this research was meticulously crafted as a cross-sectional study, homing in on individuals grappling with diabetes mellitus at simo mulyo health center in surabaya. a carefully curated group of 180 respondents actively participated, meeting stringent inclusion criteria that encompassed patients contending with unstable blood sugar regulation, individuals aged between 26 and 65 years, those possessing reading capabilities, and a willingness to be respondents. to guarantee the representativeness of the sample, a methodical approach employing simple random sampling was undertaken. the study delved into diverse independent variables, including the examination of health worker support, family dynamics, social networks, and health education. the focal point of investigation revolved around the emotional response of the participants, serving as the dependent variable. methodologically, data collection was executed using a meticulously designed questionnaire, rigorously validated, and tested for reliability. this meticulous approach aimed to ensure the robustness and accuracy of the results. the subsequent analysis employed the spearman rho correlation test, with a predetermined significance level set at α=0.05. moreover, ethical considerations played a pivotal role throughout the research process. the study garnered ethical clearance from the chakra brahmanda lentera institute under the reference number 094/010/vii/ec/kep/ lcbl/2023, thereby attesting to its unwavering commitment to upholding ethical standards and guidelines. results table 1 presents the demographic data of the respondents. in this study, most respondents were classified as late elderly (37.5%), with a significant portion employed in the private sector (74.1%). furthermore, a predominant percentage of respondents had attained primary education as their highest educational level (60.7%). regarding the duration of suffering from diabetes mellitus, the majority reported a duration of 6 months to 1 year (78.6%), and a significant proportion had never been treated in a hospital for their condition (61.6%). table 2 illustrates the social network support among respondents, with the majority reporting transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic characteristics of the respondent. characteristics frequency (n) percentage (%) age (year) 26-35 12 13.4 36-45 10 8.9 46-55 26 23.2 56-65 42 37.5 >65 19 17 total 112 100 work government employees 12 10.7 private sector employees 83 74.1 pension 6 5.4 trader 8 7.1 doesn't work 3 2.7 total 112 100 education primary education 68 60.7 secondary education 31 27.7 high education 13 11.6 total 112 100 long suffered 6 month 1 year 88 78.6 2 year 5 year 24 21.4 total 112 100 hospital experience been in hospital 43 38.4 never been in hospital 69 61.6 total 112 100 table 2. variable characteristics. characteristics frequency (n) percentage (%) social network good 14 12.5 enough 57 50.9 not enough 41 36.6 total 112 100 health education good 83 74.1 enough 17 15.2 not enough 12 10.7 total 112 100 family support good 20 74.1 enough 77 15.2 not enough 15 10.7 total 112 100 health worker support good 32 28.6 enough 70 62.5 not enough 10 8.9 total 112 100 emotional response good 26 23.2 enough 41 36.6 not enough 45 40.2 total 112 100 [page 250] [healthcare in low-resource settings 2024;12:12008] non -co mmerc ial us e o nly sufficient support (50.9%). the health education received by respondents was predominantly deemed good (74.1%), while family support was largely considered sufficient (68.8%). additionally, a substantial proportion of respondents indicated receiving adequate support from health workers (62.5%), and the emotional response of the respondents was largely characterized as sufficient (40.2%). table 3 show the correlation between social network support and emotional response, with a p-value of 0.000 (p<0.005) and r=0.879. health education is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.585. health worker support is correlated with dealing with emotional responses, with a p-value of 0.000 (p<0.005) and r=0.786. family support is correlated with emotional response, with a p-value of 0.000 (p<0.005) and r=0.738. discussion the results indicate that the social network has an effect on the patient’s emotional response, implying that the better the patient’s social network, the better their emotional response to their illness. this finding aligns with research conducted by moulaei et al. (2022). social networking refers to the connection of people with diabetes mellitus to others, including friends, both individually and organizationally, physically, and through social media. in this study, indicators include social activities, roles and interaction intensity outside the home, friendships, and frequency of interaction.13 a strong social network assists sufferers in developing their emotional responses and helps them avoid fear, anxiety, and depression. this is consistent with the findings of the schram et al. (2021) study, which asserts that robust social networks for people with diabetes mellitus can enhance emotional relationships. sufferers receive more attention, affection, and care from those around them, enabling them to manage emotional symptoms arising from diabetes mellitus, such as increased anxiety, irritability, and frequent discomfort.14 the results indicate that family support has an effect on the emotional response of sufferers, signifying that good support from the family can improve the emotional response of individuals in coping with their illness. this finding aligns with the research conducted by wulandari et al. (2021), which emphasizes the essential role of family support for the elderly in the treatment process. physical limitations experienced by elderly sufferers necessitate support from the family in various forms, including informational, instrumental, emotional, and appreciation support.15 the family can serve as a potent motivator for individuals with diabetes mellitus in terms of glycemic control, particularly when they consistently offer companionship to the elderly during health facility visits and actively engage in problem-solving with them.16 another study conducted by mphasha et al. (2022) stated that family support plays a crucial role in therapy, especially when provided to elderly patients. it is a vital aspect in empowering the elderly for engaging in activities and fostering a desire to explore and adopt new things or novel concepts.17 various forms of family support encompass emotional, instrumental, informational, and evaluative support in responding to illness.18 according to the researchers’ assumptions, the family can serve as a source of information, offer emotional support, accompany sufferers to health services, and provide feedback on efforts made to treat their illness. sufficient family support can assist sufferers in managing emotional responses. for instance, the assumption is that robust family support can alter a person’s perception of an illness, thereby reducing the potential for stress.19 family support has the potential to bring inner peace and positivity to the elderly, influencing them to think and engage in positive activities, consequently reducing the incidence of depression in this demographic.18 the results indicate that the support of health workers influences the emotional response of sufferers. the attention provided by health workers in the form of information and feedback serves as effective assistance for sufferers in achieving proper care. this finding aligns with the study conducted by kalra et al. (2018), which highlights that good support from health workers leads to positive emotional responses, improving the coping mechanisms of sufferers. this positive coping, in turn, fosters adherence to both pharmacological and non-pharmacological medication therapy.19 health workers’ support is considered integral to the success of patients in avoiding depression.20 various forms of support from health workers, including emotional support, information, instruments, and assessments, are consistently required to motivate individuals with diabetes mellitus to undergo treatment. health education also plays a role in affecting the emotional response of sufferers, aligning with the responsibilities of health workers as health promoters. health workers are tasked with providing preventive, promotive, curative, and rehabilitative services. in line with chawla et al.’s (2019) perspective, effective prevention efforts involve health workers, who are respected individuals within the community. when people with diabetes mellitus receive advice from health workers, they gradually adhere to the guidance provided. therefore, the substance of advice material and education is crucial to achieving overall well-being.21 another perspective asserts that information provided by health workers inspires sufferers to think more constructively, leading to favorable emotional responses.22 once individuals receive information about the possibility of a disease through various channels, according to problem-solving theory, they become motivated to return to a state of normality free from problems. this process involves giving meaning to the problem.23 based on the theory of the precede-proceed model, reinforcing factors are crucial in shaping the behavior of individuals with dm. the quality of support from social networks, health education, and health workers significantly influences the level of activity in sufferers. this, in turn, helps them avoid feelings of despair during treatment, enabling them to persevere without complaint and fatigue, and maintain good glycemic control. conclusions social network support, health education, family support, and health worker support are correlated with the emotional response of individuals with dm. continuous efforts are required to build and enhance support, aiming to improve the quality of the patient’s emotional response. this is crucial for individuals with dm to be free from fear, anxiety, and depression. a positive emotional transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. correlation test. variable coefficient p correlation social network support and emotional response 0.879 0.000 health education and emotional response 0.585 0.000 health worker support and emotional response 0.786 0.000 family support and emotional response 0.738 0.000 [healthcare in low-resource settings 2024;12:12008] [page 251] non -co mmerc ial us e o nly response significantly influences the patient’s coping mechanisms, fostering adherence to the ongoing treatment, thereby minimizing complications associated with dm. references 1. akoit ee, efendi f, dewi ys. impact of diabetes self-management education in middle-aged patients with type 2 diabetes mellitus: a systematic review. gac med caracas 2022;130:s1183–95. 2. zairina e, nugraheni g, sulistyarini a, et al. factors related to barriers and medication adherence in patients with type 2 diabetes mellitus: a cross-sectional study. j diabetes metab disord 2022;21:219-28. 3. aldossari kk, shubair mm, al-ghamdi sh, et al. psychological wellbeing of diabetic individuals, prediabetics, and non-diabetics: a population-based study in saudi arabia. front psychol 2022;13:863861. 4. international diabetes federation. idf diabetes atlas 2021. international diabetes federation; 2021. 5. kementerian kesehatan republik indonesia. laporan nasional riset kesehatan dasar. kementrian kesehat. 2018; ri 1–582. 6. gbd 2019 indonesia subnational collaborators. the state of health in indonesia’s provinces, 1990-2019: a systematic analysis for the global burden of disease study 2019. lancet glob health 2022;10:e1632-45. 7. laporan provinsi jawa timur riskesdas 2018. 2019;1532p. 8. green lw. modifying and developing health behavior. annu rev public health 1984;5:215–36. 9. widakdo g, besral b. effects of chronic illness to the mental emotional disorders. kesmas natl. public heal j 2013;7:309. 10. woon ls, sidi hb, ravindran a, et al. depression, anxiety, and associated factors in patients with diabetes: evidence from the anxiety, depression, and personality traits in diabetes mellitus (adapt-dm) study. bmc psychiatry 2020;20:227. 11. aktar r, satu f. perceived stress, coping strategies and psychological well-being of people with diabetes and people without diabetes in bangladesh: a comparative study. 2017. 12. delaney al, basinger ed. uncertainty and support-seeking in us-based online diabetes forums. j appl commun res 20214;9:305–24. 13. moulaei k, dinari z, dinari f, et al. the role of social networks in diabetes self�care: a cross�sectional study. heal. sci. reports 2022;5. 14. schram mt, assendelft wjj, van tilburg tg, dukers-muijrers nhtm. social networks and type 2 diabetes: a narrative review. diabetologia 2021;64:1905–16. 15. wulandari i, kusnanto k, wibisono s, haryani a. family support in caring for diabetes mellitus patient: patient’s perspective. open access maced j med sci 2021;9:199–205. 16. bao h. relationship among family support, mental resilience and diabetic distress in patients with type 2 diabetic mellitus during covid-19. iran j public health 2021;50:1648. 17. mphasha mh, mothiba tm, skaal l. family support in the management of diabetes patients’ perspectives from limpopo province in south africa. bmc public health 2022;22:1–8. 18. sari cwm, hilmi dr, purnama d. support of family for type 2 diabetes mellitus patients in primary health center during the covid-19 pandemic. j nurs sci updat 2023;11:100–8. 19. kalra s, jena bn, yeravdekar r. emotional and psychological needs of people with diabetes. indian j endocrinol metab 2018;22:696–704. 20. egbujie ba, delobelle pa, levitt n, et al. role of community health workers in type 2 diabetes mellitus self-management: a scoping review. plos one 2018;13:e0198424. 21. chawla sps, kaur s, bharti a, et al. impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. j family med prim care 2019;8:2618. 22. slaven a, hsu j, schelling jr, et al. social support in older adults with ckd: a report from the cric (chronic renal insufficiency cohort) study. kidney med 2021;3:776-784.e1. 23. ogden j. health psichology: a textbook. p. 489; 2007. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 252] [healthcare in low-resource settings 2024;12:12008] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11734 increasing young women's knowledge of early marriage issues through audiovisual media intervention ega ersya urnia, dini indo virawati, cristinawati b.r. haloho midwifery department, health polytechnic, ministry of health, east kalimantan, samarinda, indonesia abstract each year, approximately 12 million girls worldwide enter into marriage before reaching the age of 18. in east kalimantan province, data from the 2020 national socio-economic survey revealed that 11.54% of women aged 20-24 had experienced early marriage, surpassing indonesia’s average. this study aimed to assess the efficacy of audiovisual and printed health education media in enhancing the knowledge of young women about early marriage. a quasi-experimental approach was adopted, involving 32 young women aged 15-18 from a public high school in borneo. the study measured the knowledge change in young women and their parents through questionnaires. data analysis consisted of descriptive and inferential procedures, including normality tests, homogeneity tests, paired t tests, and analysis of variance tests. the findings demonstrated that audiovisual media significantly improved young women’s awareness of early marriage (p<0.005). the study encourages midwives and healthcare professionals to employ effective health education media, particularly audiovisual tools, in educational settings to combat early marriage practices. introduction the united nations children’s fund (unicef) reports that every year, as many as 12 million girls worldwide marry before the age of 18. this alarming statistic breaks down to 23 girls marrying every minute, with nearly 1 girl marrying every 3 seconds. shockingly, approximately 650 million women currently alive became brides before the age of 18, with some even getting married before the age of 10. globally, 1 in 5 girls is married before reaching the age of 18.1 in the indonesian child profile data from 2020, it was revealed that 1 out of 9 girls was married in 2018. it’s estimated that in 2018, 1,220,900 women aged 20-24 were married before the age of 18 in indonesia, ranking the country among the top 10 with the highest number of child marriages globally.2 the national socio-economic survey in 2020 highlighted that the east kalimantan province still had a concerning percentage of women aged 20-24 who experienced their first marriage before the age of 18, standing at 11.54%. this figure surpasses the national average for early marriages in indonesia, which is 11.21%.1 early marriage leads to early pregnancy and childbirth, resulting in elevated mortality rates and adverse conditions for both the child and mother due to the girl’s body not being fully mature for childbirth.3 they have less voice in household decisions and are less able to advocate for themselves or their children. they are also less able to earn income and contribute financially to the family. these things can increase the poverty rate. marriage at a young age burdens girls with the responsibilities of being a wife, sex partner, and mother, roles that should be played by adults, for which girls are not ready to take on. this marriage also creates a correspondence: ega ersya urnia, midwifery department, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: egaersya@gmail.com key words: health media; audiovisual; leaflet; knowledge; young women. contributions: eeu, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; div, resources, investigation, and writing – review & editing; cbh, formal analysis, validation, writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, the ethical number no.dp.04.03/7.1/07745/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to airlangga university for their valuable insights and contributions to this study. received: 9 september 2023 accepted: 25 october 2023. early access: 10 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11734 doi:10.4081/hls.2023.11734 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11734] [page 109] non -co mmerc ial us e o nly great psychological and emotional burden for them.1 studies by hotchkiss et al. (2016)4 identified risk factors contributing to early marriages, including the place of residence (urban or rural), religion, economic status, education level, age at first marriage, and tolerance for domestic violence. other research by windiarti and besral (2018)5 explored various determinants of early marriage in indonesia, such as unwanted pregnancies, peer influence, parental roles, education level, reproductive health knowledge, family economic status, culture, media exposure, rural residence, religion, and ethnicity.6,7 according to unicef in 2015,1 the determinants of child marriage in indonesia are influenced by individual, household, and community factors. unicef highlighted a positive correlation between child marriage and internet use via mobile phones, the age of the head of the household, and the number of children in the family attending primary school. the research revealed that adolescents who understood the potential for pregnancy during sexual intercourse were 0.9 times less likely to engage in premarital sexual behavior.8 knowledge can be enhanced through health education, which is a dynamic process of behavioral change. this transformation is not merely a matter of transferring information or theory from one person to another, but it occurs when individuals, groups, and society become more aware of certain issues.9,10 health education relies on media to maximize the information delivered to the recipients. media has the capacity to convey messages and stimulate individuals’ thoughts, feelings, and abilities, thereby fostering the learning process. creative media can help audiences learn more effectively and enhance their performance in line with their objectives.11,12 among various media types, audiovisual media stands out. it combines sound and visual elements, making it particularly effective in conveying information. audiovisual media serves as a tool for learning, assisting in the transmission of knowledge, attitudes, and ideas through both auditory (hearing) and visual (seeing) channels.13,14 for instance, audiovisual tools, such as film information shows, can effectively convey information about understanding early marriage.15 research conducted by nanlohy, asrina, and kurnaesih in 202116 has shown that audiovisual or video media has a significant impact on increasing adolescents’ knowledge about the risks of early marriage. similarly, research by dewi et al. in 201717 has demonstrated that print media, such as leaflets, effectively enhances knowledge about early marriage before and after providing treatment through printed materials. given this background, it is evident that a research gap exists, as some studies suggest that health education using audiovisual and print methods may have limited effects on adolescent knowledge. therefore, researchers intend to determine which health education methods are most suitable for increasing adolescent knowledge. the purpose of this research is to analyze the effectiveness of health education media, including audiovisual and print components, in enhancing young women’s knowledge about early marriage. materials and methods this research employed a quasi-experimental design with a time series approach, utilizing pretests and posttests to measure knowledge before and after providing health education through audio-visual media and print media (leaflets). the study was conducted in june 2022. the sampling technique used was purposive sampling, giving every individual in the population an equal chance to be selected. the study population consisted of 121 girls aged 15 to 18 in a public high school in borneo. following the inclusion criteria and taking into account the population size, 32 girls were selected and divided into two groups. inclusion criteria encompassed physically and mentally healthy respondents, young women aged 15-18, and those willing to participate. exclusion criteria included physical or mental illness and unwillingness to participate. the dependent variable measured was the knowledge of young women, and the independent variable was the health education media, which included audiovisuals and leaflets. a questionnaire was used to assess changes in knowledge, and the questionnaire underwent validity and reliability tests. data were processed using descriptive and inferential analysis techniques, such as normality test, homogeneity test, paired t-test, and analysis of variance test. ethical approval was granted by the ethics committee at politeknik kesehatan kementerian kesehatan kalimantan timur, with the reference number no. dp.04.03/7.1/07745/2022. results this research, conducted in june 2022 at a public high school in borneo, aimed to assess the effectiveness of health education using audiovisual and print media in enhancing knowledge among young women. a total of 32 research samples were included in the study. based on table 1, it is evident that in the group of young women who received health education through audiovisual media, the majority were aged 14-16 years (68.75%), their parents’ education was primarily at the high school level (50%), and their parents were mainly self-employed (81.25%). in the group of young women who received health education through print media, most were aged 14-16 years (62.5%), their parents’ education was large transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of young women (n=32). characteristics characteristics of respondents audiovisual media print media frequency (%) frequency (%) age (years) middle adolescence (14-16 years) 11 68.75 10 62.5 late adolescence (17 years) 5 31.25 6 37.5 parent education elementary school 1 6.25 1 6.25 junior high school 5 31.25 6 37.5 senior high school 8 50 7 43.75 college 1 6.25 1 6.25 no school 1 6.25 1 6.25 parent job government employees 2 12.5 1 6.25 private employees 1 6.25 14 87.5 self employed 13 81.25 1 6.25 [page 110] [healthcare in low-resource settings 2023; 11:11734] non -co mmerc ial us e o nly ly at the high school level (43.75%), and their parents were predominantly private employees (87.5%). from the results of the data analysis in table 2, it is evident that providing audiovisual health education had a significant effect on adolescent knowledge, with a p-value of 0.0000. additionally, providing health education through print media also had an effect on adolescent knowledge, with a p-value of 0.0130. the results from data analysis in table 3 reveal a significant effect of providing audiovisual health education, compared to leaflets, on adolescent knowledge, with a p-value of 0.0000. discussion audiovisual health education media proves to be more effective in increasing young women’s knowledge about early marriages compared to print media. knowledge is closely related to education, where higher education often results in a broader knowledge base.18 adolescents who choose to marry at an early age often lack awareness of the negative consequences of early marriage due to ineffective information dissemination.6,19 the effectiveness of conveying information is greatly influenced by the choice of media. to engage and educate teenagers effectively, it’s crucial to use media that captures their attention and provides an engaging learning atmosphere.20 media is instrumental in helping the educational process reach all five senses, as the more senses involved, the clearer the knowledge imparted. media can be either visual or audiovisual, and multiple studies have demonstrated the effectiveness of audiovisual media in facilitating learning.21 audiovisual media combines sound and visuals, making it highly effective due to its dual auditory and visual elements. it serves as a valuable instructional tool, aiding in the delivery of written and spoken information to transmit knowledge, attitudes, and ideas.22 audiovisuals attract attention, enhance motor skills, enable direct observation of phenomena, facilitate interaction analysis, issue resolution, and problem-solving. they can be repeatedly shown, shape attitudes, and foster appreciation.21 the advantage of using audiovisual media in educational activities extends beyond being a mere tool; it serves as a conduit for information and messages. when applied to the topic of early marriage, audiovisual media can vividly illustrate the abstract concept of why it’s crucial for teenagers to postpone marriage, allowing respondents to both hear and see the negative impacts of early marriage clearly.23 this approach aligns with the learning concept known as the “pyramid of experience,” as proposed by edgar dale, which asserts that people learn over 50% from what they see and hear.23,24 research conducted by lestari & sundayani (2018)16 indicated that counseling, whether with or without video media, influences adolescents’ knowledge regarding the risks of early marriage. similarly, another study found significant differences in knowledge levels about early marriage before and after screening a film, demonstrating the impact of audiovisual media. in various community service initiatives, audiovisual media is frequently used. according to a study by rohmawati, hidayah, and marwan (2020),25 60 out of 68 participants experienced knowledge improvements regarding early marriage through health counseling involving audiovisual media. information media and various factors play pivotal roles in influencing knowledge and consequent changes in adolescent behavior, which then impact their reproductive health.26 health education using print media (leaflets) aims to raise awareness among young women regarding the consequences of early marriage for adolescents. leaflets are fundamentally effective in enhancing knowledge, as both health education and the leaflet method are one-way, active methods where the target audience is passive.27 nevertheless, leaflet media has certain drawbacks, including the time required for printing, limitations in displaying movement on the page, and the potential to reduce readers’ interest if containing excessive or overly lengthy information. adolescents need to receive comprehensive information about the perils of early marriage to make informed decisions and comprehend the associated risks.28 inadequate knowledge can lead to risky sexual behavior among adolescents.29 one’s level of knowledge significantly influences psychosocial maturity and thinking capabilities. higher knowledge levels facilitate rational thinking, problem description, problem-solving, and decision-making.28 researchers assume that the availability of various health education media for adolescents will bolster their knowledge about early marriage. one limitation of this study is the limited use of leaflet media for transferring knowledge to young women. young women often prefer listening to explanations presented through audiovisual media. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. the effectiveness of audiovisual media on young women's knowledge of early marriage. knowledge of young women regarding early marriage on post test p well enough not enough audiovisual media 12.3% 12.3% 7.9% 0.000* print media 4.4% 4.4% 4.4% 0.013 table 3. comparison of the effectiveness of audiovisual media and print media on young women's knowledge of early marriage on post test. knowledge of young women regarding early marriage mean differences std. error sig. audiovisual media good knowledge 12.3000 1.2583 0.000 enough knowledge 12.3000 1.2583 0.000 less knowledge 7.9000 1.2583 0.000 print media good knowledge 4.4000 1.2583 0.013 enough knowledge 4.4000 1.2583 0.013 less knowledge 4.4000 1.2583 0.013 [healthcare in low-resource settings 2023; 11:11734] [page 111] non -co mmerc ial us e o nly conclusions this study conclusively demonstrates the potency of audiovisual media in enhancing young women’s understanding of early marriage issues. it strongly recommends the integration of audiovisual media into health education, emphasizing its use not only within healthcare facilities but also as part of school curricula. by doing so, we can contribute significantly to reducing early marriages and empowering young women to make informed choices. young women have responded enthusiastically to audiovisual media, making it a powerful educational tool. however, further research could explore the effectiveness of other methods, ensuring a comprehensive approach to addressing early marriages. references 1. united nations children’s fund. the state of children in indonesia – trends, opportunities and challenges for realizing children’s rights. jakarta; 2020. 2. sitaresmi mn, indraswari bw, rozanti nm, sabilatuttaqiyya z, wahab a. health-related quality of life profile of indonesian children and its determinants: a community-based study. bmc pediatr 2022;22:103. 3. sanjaya a, narendra mb, irwanto, suryawan a, irmawati m, efendi f. early marriage and its relationship with child development. indian j public heal res dev 2018;9:193-8. 4. hotchkiss dr, godha d, gage aj, cappa c. risk factors associated with the practice of child marriage among roma girls in serbia. bmc int health hum rights 2016;16:6. 5. windiarti s, besral b. determinants of early marriage in indonesia: a systematic review. in: the international conference on applied science and health. yayasan aliansi cendekiawan indonesia thailand; 2018. p. 287-93. 6. berliana sm, kristinadewi pan, rachmawati pd, et al. determinants of early marriage among female adolescent in indonesia. int j adolesc med health 2021;33:1-6. 7. mohan sbvr, dhanapal s, govindasamy v, pillay ksp. psychological impact of parent-adolescent communication: a critical analysis. int j public heal sci 2022;11:1210-22. 8. berliana sm, utami ed, efendi f, kurniati a. premarital sex initiation and the time interval to first marriage among indonesians. bull indones econ stud 2018 may 4;54:215-32. 9. topping kj. peer education and peer counselling for health and well-being: a review of reviews. int j environ res public health 2022;19(10). 10. harini r, rahmat i, nisman wa. improving counselling skills about reproductive health among students by using peer counselor training. j ners 2016;9:173-82. 11. urnia ee, noor ms, hartoyo e, et al. meta analysis: the influence of health education about early marriage to knowledge on teenagers (review of caution using motion picture, booklet and leaflet). j adv heal med sci 2020;6:7-13. 12. jalaludin fw, abdul rahim f, tai lc, cham th. spreading faster than the virus: social media in spreading panic among young adults in malaysia. m. ae, k. s, m.a. as, editors. vol. 550 lnns, international conference on information systems and intelligent applications, icisia 2022. faculty of accountancy and management, universiti tunku abdul rahman, selangor, kajang, malaysia: springer science and business media deutschland gmbh; 2023. p. 163-74. 13. barik al, purwaningtyas ra, astuti d. the effectiveness of traditional media (leaflet and poster) to promote health in a community setting in the digital era: a systematic review. j ners 2019;14:76-80. 14. yunitasari e, sa’adah k, wahyuni sd, harmayetty h. the effect of health education with “numbered head together” and demonstration methods on menstrual hygiene behavior in adolescent islamic boarding school. int j pharm res 2020;12: 1677-84. 15. rasul s, bukhsh q, batool s. a study to analyze the effectiveness of audio visual aids in teaching learning process at uvniversity level. procedia soc behav sci 2011;28:78-81. 16. nanlohy w, andi asrina, een kurnaesih. the effect of video and leaflets for health promotion on adolescents knowledge about early marriage in rural area indonesia. j aafiyah heal res 2021;2:33-42. 17. dewi rk, adhisty y, ariningtyas n, pratiwi f. efektifitas leaflet dan ceramah terhadaptingkat pengetahuan tentang resiko pernikahan dini di sma negeri i baturetno wonogiri tahun 2017 [the effectiveness of leaflets and lectures on increasing knowledge about the risks of early marriage in public high s. j kesehat masy 2017;10(2). 18. naghizadeh s, mirghafourvand m, mohammadi a, azizi m, taghizadeh-milani s, ganbari h. knowledge and viewpoint of adolescent girls regarding child marriage, its causes and consequences. bmc womens health 2021;21:351. 19. susanti e. women’s knowledge and the role of local female leaders in ending the practice of the early marriage of girls in rural communities of indonesia. j int womens stud 2019;20:13-28. 20. nurmala i, ahiyanasari ce, muthmainnah, wulandari a, devi yp, pathak r, et al. emerging premarital sexual behavior among adolescent in indonesia: the impact of knowledge, experience, and media use to attitudes. indian j forensic med toxicol 2020;14:2864-70. 21. putri im, rosida l. peningkatan pengetahuan program pendewasaan usia perkawinan di karang taruna angkatan muda salakan bantul yogyakarta [improvement of knowledge on the marriage age maturity program in karang taruna youth generation of salakan, bantul, yogyakarta]. j pengabdi masy kebidanan 2019;1:5-11. 22. intan s, yusuf sb, sari df. a review on the use of audiovisual as media in improving listening skills among junior high school students. english educ j. 2022;13:303-16. 23. bouman m, lubjuhn s, hollemans h. entertainmenteducation and child marriage. a scoping study for girls not brides: the global partnership to end child marriage. center for media & health; 2017. 24. yulianti y. online psychoeducation about the dangers of early marriage against the high incidence of divorce during the pandemic. indones j heal sci 2022;6:61-5. 25. rohmawati d, hidayah n, marwan m. pelatihan konselor teman sebaya dalam upaya peningkatan gizi dan reproduksi pada remaja [training peer counselors in efforts to improve nutrition and reproductive health in adolescents]. j community engagem heal 2020 sep;3(2 se-articles). 26. djanah n, muaslimah m, ayuningtyas rw. pengabdian pada masyarakat dalam upaya promotif berupa peningkatan kemampuan remaja putri tentang program pendewasaan usia perkawinan (pup) di desa banguntapan bantul [community engagement in promotive efforts to enhance the skills of adolescent girls reg. j kesehat pengabdi masy 2020;1:19–25. 27. dewi rk, adhisty y, ariningtyas n, pratiwi f. efektifitas [page 112] [healthcare in low-resource settings 2023; 11:11734] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly leaflet dan ceramah terhadaptingkat pengetahuan tentang resiko pernikahan dini di sma negeri i baturetno wonogiri tahun 2017 [the effectiveness of leaflets and lectures on increasing knowledge about the risks of early marriage in state high sc. j kesehat masy 2017;10(2). 28. elba f, wijaya m. pengaruh pembekalan materi kesehatan reproduksi tentang bahaya pernikahan dini untuk remaja putri [the influence of reproductive health education on the dangers of early marriage for adolescent girls]. dharmakarya 2019;8(1). 29. oktavia er, agustin fr, magai nm, widyawati sa, cahyati wh. pengetahuan risiko pernikahan dini pada remaja umur 13-19 tahun [knowledge of the risks of early marriage among adolescents aged 13-19 years]. higeia journal public heal res dev 2018;2:239-248. [healthcare in low-resource settings 2023; 11:11734] [page 113] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12343 characteristics of nurses with musculoskeletal disorders from dr soedarso regional hospital, pontianak wuriani wuriani,1 annisa rahmawati,1 ardi wahyudi,2 sunandar syahlewangi,2 dian saputri,2 jaka pradika,1 almumtahanah almumtahanah,1 ridha mardiyani,1 uji kawuryan,1 suriadi jais3 1department diploma of nursing, institut teknologi dan kesehatan muhammamdiyah kalbar, pontianak; 2soedarso national hospital, kalbar, pontianak; 3postgraduate nursing programme, institut teknologi dan kesehatan muhammadiyah, kalbar, pontianak, indonesia abstract musculoskeletal disorders (msds) can have a significant negative impact on quality of life, resulting in reduced ability to work, absenteeism, and possibly switching occupations. the purpose of this study was to investigate the relationship between the prevalence and severity of msds and the nurse characteristics (ncs) of nurses working in the dr soedarso regional hospital (dsrh) inpatient department. an analytical and descriptive cross-sectional methodology was used to examine 134 nurses from inpatient wards a and b. total sampling was used to select the respondents. the level of exposure to the conditions investigated by the quick exposure check (qec), namely, static and dynamic movements in the back, shoulders/arms, neck, and work-related stress, was significantly correlated with gender and neck (0.050), a history of education-related physical strain, such as back mobility (0.021), years of work-related strain on the neck (0.040), and work-related stress (0.033). there were no significant correlations found between age and static and dynamic movements of the back, shoulders/arms, and neck. gender, education level, and employment duration all have a strong correlation with msds among dsrh inpatient nurses. introduction nurses have highlighted that work-related musculoskeletal disorders (msds) significantly affect quality of life. based on a study conducted by the bureau of labour statistics1 in xinjiang, the prevalent ailments among nursing professionals included msds of the lower back (54%), neck (41%), shoulders (34%), and wrists (26%). the global incidence of msds among nurses ranges from 33.0 to 88.0%. research on nurses in estonia and taiwan reported msds in 84.0% and 76.2% of the respondents, respectively. the most common msd grievance among nurses was chronic pain in the lumbar region, followed by discomfort in the shoulders, neck, hands, and feet. research on nurses in brazil and italy has identified lower back, neck, and knees as the most common msd. in turkey, the prevalence of msd among nurses is 79.5%.2 asian nurses have a higher prevalence of msds, ranging from 40 to 95%, in at least one body region. the lower back, neck, and shoulders are the most commonly affected areas in western populations, with prevalence rates of 29%–64% for the lower back, 34%–63% for the neck, and 17%–75% for the shoulders. furthermore, an examination of scholarly articles regarding msds in female nurses in the 2021 revealed that the knee, ankle, and foot were the most common msd regions. msds in the knee vary from 7.5 to 77% and from 3.2 to 100% in the ankle.3 nurses working in inpatient rooms are prone to developing msds because of their jobs. the patient care activities performed by nurses and their frequent contact with the environment pose a significant msd risk.4 the work duties that frequently lead to msds include maintaining an upright posture (48.8%), bending (42.3%), twisting the body (40.6%), exerting force with the hands or fingers (37.3%), sitting (36.6%), and performing repeated arm motions correspondence: suriadi jais, postgraduate nursing programme, institut teknologi dan kesehatan muhamamdiyah kalbar, jalan sei raya dalam gg ceria v no 19 kubu raya, kalbar, pontianak, indonesia. e-mail: suriadif@yahoo.com.au key words: musculoskeletal disorders, nurse, characteristics. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of institution approved this study (no. 45/rsud/kepk/v/2022 ). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors express their gratitude to the institute of technology and health’s centre for research and community service for their invaluable help in facilitating the successful execution of this research. received: 1 february 2024. accepted: 16 march 2024. early access: 17 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12343 doi:10.4081/hls.2024.12343 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12343] [page 321] non -co mmerc ial us e o nly (34.3%).5 nurses delivering nursing care in inpatient rooms experience effects like diminished concentration, physical exertion when transferring patients from wheelchairs and beds or vice versa, assisting patients with daily tasks such as bathing, aiding patients with defecation, and challenges due to limited room size, leading to extended working hours. according to putri et al.,4 it may be inferred that nurses suffering from msds may lose productivity and work efficiency. musculoskeletal disorders (msds) can significantly impair quality of life and lead to work limitations, increased absenteeism, or a desire to switch occupations.2 yan et al.1 identified many characteristics that are considered risk factors for msds in the workplace. these variables include age, work status, sex, race, education level, health conditions, shifts, and weekly working hours. dr. soedarso regional hospital (dsrh), a national referral hospital, has an inpatient facility comprising 11 rooms for inpatient care, ranging from class iii to class i. the 2020 hospital occupational safety and health (k3rs) report of the dsrh revealed that 16 healthcare professionals received outpatient physiotherapy for msds or hernia nucleus pulposus (hnp [unpublished data]). hnp is the sixth most prevalent disease affecting healthcare professionals worldwide. however, the prevalence of msds among healthcare professionals in hospitals remains unknown. hence, the present study aimed to assess nurse characteristics (ncs) and msd prevalence among nurses working in the inpatient wards of the drsh. materials and methods this study used a quantitative design based on analytical and descriptive statistics, following a cross-sectional approach. the study population comprised 194 nurses working in inpatient wards a and b of the drsh. this study used total sampling, which included all nurses in the inpatient wards who met the inclusion criteria. the sample included public servant (pns) and non-public servant (ppt) employees working there for at least one year, not on work leave at the time of the study, and willing to provide informed consent. the sample size was determined based on the slovin formula as follows:6 where n is the population size and e is the margin of error. the calculations indicated a minimum sample size of 131 participants. questionnaires were used to collect instrument-based data. questionnaire a was used to collect data regarding ncs, such as age, gender, education level, and service duration, as well as the quick exposure check (qec) score checklist.7-9 the qec checklist was not tested as it uses a standard format. the qec assessment considers several aspects that represent musculoskeletal risk factors: position in both static and dynamic back movements, shoulders/arms, wrists/hands, neck, work pace, vibrations, and work-related stress.10,11 muscles can function in a static (postural) or dynamic (rhythmic) manner. static refers to the maintenance of a stance or pose with minimal movement. dynamic movements consist of repeated motions that actively involve several muscles and joints over their full range of motion.10,11 this study was approved by the review board and ethics committee of the ministry of health of drsh (no. 45/rsud/kepk/v/2022). data analyses were performed using stata/mp version 17 (statacorp, usa) and medcalc statistical software version 15.8 (medcalc, ostend, belgium); p<0.05 was considered statistically significant. results as seen in table 1, most participants were aged 36 to 45 (53.7%), female (81.3%), employed for equal to or more than five years (89.6%), and possessing an 82.8% nursing diploma. table 2 shows that most nurses had msds in static lower back mobility, with 50.0% falling in the moderate category. additionally, 97.8% experienced mild msds in dynamic back mobility, 40.3% in article [page 322] [healthcare in low-resource settings 2024;12:12343] table 1. the nurse characteristics (ncs) of the participants (n=134). ncs frequency percentage (%) age 26-35 32 23.9 36-45 72 53.7 more than 45 30 22.4 gender male 25 18.7 female 109 81.3 service duration (years) less than 5 14 10.4 equal or more than 5 120 89.6 education level diploma iii 111 82.8 nursing 23 17.2 table 2. the distribution of musculoskeletal disorder (msd) severity among the examined nurses (n=134).ncs variable mild moderate high extreme n % n % n % n % back (static) 61 45.5 67 50.0 6 4.5 0 0 back (dynamic) 131 97.8 3 2.2 0 0 0 0 shoulders/arms 54 40.3 44 32.8 18 13.4 18 13.4 wrists/hands 67 50.0 44 32.8 21 15.7 2 1.5 neck 63 47.0 30 22.4 28 20.9 13 9.7 work pace 13 9.7 116 86.6 5 3.7 0 0 vibrations 17 12.7 60 44.8 49 36.6 8 6.0 work-related stress 17 12.7 60 44.8 49 36.6 8 6.0 non -co mmerc ial us e o nly shoulders/arms, 50.0% in wrists/hands, 47.0% in the neck, 86.6% at a moderate work pace, and 44.8% in moderate vibrations and work-related stress. table 3 shows the ncs that exhibited a significant correlation with the extent of qec exposure. spearman’s correlation analysis revealed a relationship between ncs and msds. there were significant msd and nc relationships: work pace influenced by education level, work pace, and vibrations influenced by sex, neck condition, and work-related stress influenced by service duration (p<0.05, table 3). there was no significant correlation between age and any of the qec components in the static and dynamic movements of the back, shoulders, arms, wrists/hands, neck, vibrations, work pace, or work-related stress (p>0.05). discussion rahmawati’s12 study indicated that musculoskeletal disorders (msds) often manifest at 35 years of age. this shows that individuals in their productive age comprise the majority of ncs, which raises the risk of msd. widodo’s13 study indicated that most people suffering from msds were ≥ 30 years old. our study indicated a higher proportion of individuals aged 36-45 years; however, the statistical analysis did not reveal any significant findings. workers aged 35 years often experience musculoskeletal issues that tend to increase with age. muscular complaints arise due to a decline in muscular strength and endurance, leading to an increased likelihood of experiencing muscle issues.14 school-aged children frequently experience musculoskeletal diseases due to factors such as improper sitting posture while studying, carrying school bags over 10% of body weight, and lack of daily muscular stretching or warm-up before activities.15 msds are not influenced by age but rather by factors such as physical load, bmi, sitting posture, and daily activities. regardless of age, individuals are at risk of developing msds if they do not maintain spinal balance as well as muscle and bone flexibility.16 the findings of this study were consistent with habibie’s17 findings that the majority of nurses are women, as nursing tends to value maternal instincts over other vocations. according to soylar and ozer,2 nurses’ age and sex affect the prevalence of msds, with age increasing the likelihood of msd symptoms. beginning at approximately 40 years of age, muscle mass, capacity, and intervertebral disk potency decrease, reducing strength and mobility. additionally, the majority of respondents had served for ≥ five years. habibie17 found that 52.6% of nurses had served for ≥ five years, supporting the study’s conclusions. rahmawati11 found that those who had served for > five years were more likely to develop msds. the disc space narrows permanently and degenerates because of the long-term spinal strain. most respondents in this study had a nursing diploma. diploma iii nursing education is vocational and most hospital workers are graduates, in line with indonesian nursing law no. 38.18 yazid and situmorang19 stated that more formal education makes it simpler to absorb knowledge, particularly health information, and increases awareness of healthy living behaviors. human behavior is heavily influenced by cognitive knowledge. the study showed that most nurses had msds in the static and dynamic back, shoulders/arms, wrists/hands, and neck. work-related stress and pace were moderate. the complaints were mostly mild-to-moderate for every component of the qec. rudyarti and dewi18 found that 60% reported at least two complaints and 36% reported three complaints in the past six months. lower back symptoms were the most frequent msds among the nurses (69.6%). neck problems outnumbered shoulder complaints (45.7% and 54.3%, respectively). shoulder issues were less prevalent than neck complaints (45.7% vs 54.3%, respectively). 28.3% of nurses reported experiencing both lower back and neck issues, whereas 34.8% reported lower back and shoulder complaints, and 23.9% reported neck and shoulder complaints.20 nurnaningtyas and martiana21 also reported that many inpatient nurses’ work requires uncommon postures such as bending, standing, and sitting. nurses complained of back, waist, calf, and foot pain due to an abnormal working posture. soylar and ozer2 also believe that pulling and pushing beds, lifting patients, repeated motions, excessive flexion, bending, twisting, and rapid movements affect nurses’ health in hospitals. rudyarti and dewi20 also linked work-related physical demands to neck, shoulder, and back msd symptoms. the results of this study indicated that sex is associated with msd symptoms, specifically neck issues, among nurses in the inpatient wards of dsrh. another study found a correlation between gender msd prevalence (p<0.05).22 this condition reveals women’s natural tendency to care for patients and the dual duty of a female nurse as a housewife, mother, and family supporter. according to fathonah et al.,23 married female nurses may experience harmful work-family conflicts. besides fulfilling their duties and responsibilities as nurses, to perform well according to article table 3. musculoskeletal disorders (msds) and nurse characteristics (ncs) affect qec scores for static and dynamic back movements, shoulders/arms, wrists/hands, neck, vibrations, work pace, and work-related stress (n=134).ncs nc msd p correlation coefficient age back (static) 0.969 0.003 back (dynamic) 0.346 -0.088 shoulders/arms 0.627 0.042 wrists/hands 0.592 0.047 neck 0.728 -0.030 work pace 0.682 -0.036 vibrations 0.703 -0.033 work-related stress 0.781 0.024 education back (static) 0.570 0.050 back (dynamic) 0.188 0.115 shoulders/arms 0.329 0.085 wrists/hands 0.456 0.065 neck 0.251 0.110 work pace 0.877 -0.013 vibrations 0.016* 0.207 work-related stress 0.109 -0.138 gender back (static) 0.778 0.025 back (dynamic) 0.396 0.074 shoulders/arms 0.406 0.072 wrists/hands 0.068 0.159 neck 0.316 0.087 work pace 0.004* 0.247 vibrations 0.036* 0.181 work-related stress 0.571 0.049 service duration back (static) movement 0.181 -0.116 back (dynamic) movement 0.418 -0.071 shoulders/arms 0.857 0.016 wrists/hands 0.111 -0.139 neck 0.048* 0.171 work pace 0.589 0.047 vibrations 0.385 0.075 work-related stress 0.033* 0.183 * p 0.05). [healthcare in low-resource settings 2024;12:12343] [page 323] non -co mmerc ial us e o nly organizational standards, they must also care for and foster their families, which can cause musculoskeletal issues. indonesian nursing law no. 3818 states that nurses at home and abroad graduating with a higher education in nursing, specifically those with a diploma, the most basic higher education level, provide care to sick or healthy individuals, families, groups, or communities. studies have indicated that nursing education is linked to msds, particularly back pain. most nurses hold a diploma iii in nursing, with a focus on physical nursing. during the 8.5-hour morning shift, nurses perform guard duties, evaluations, diagnoses, nursing, and assessments, which require sitting, standing, bending, and walking. distance from the supporting examination areas, including the laboratory, radiology, and surgery rooms, exacerbates msds in nurses. nuryaningtyas and martiana recommended 10 min for each patient for bending exercises such as lifting.21 actions like this are performed daily without stretching or resting. working time increases the risk of msds, especially in physically demanding jobs.18 this study found a link between service duration and neck and work-related stress-based musculoskeletal symptoms. nuryaningtyas and martiana21 found a link between service duration and msds. according to soylar and ozer,2 nurses’ work hours affect msd complaints. adriansyah et al.24 found a link between service duration and msds (p = 0.002). muscle diseases, especially neck disorders, can manifest because of unsuitable working circumstances and postures such as placing an intravenous (iv) drip while bending inappropriately, which nurses repeatedly perform during long work hours. proper work posture requires a 20-60° bend. msds are more likely to arise because of these circumstances.19 nurses may avoid msds by learning to lift weights, maintain proper posture, and stay healthy. fitness may be improved by stretching before or after work. william’s flexion stretching exercises reduce lower back discomfort.25 wuriani et al.26 found that static stretching and appropriate work posture reduce musculoskeletal discomfort. among all qec aspects presented in our study, age does not affect the prevalence of msd among nurses working in the inpatient wards of the dsrh. the implications for healthcare systems recognizing musculoskeletal grievances is fundamental to ensuring comfort in the workplace. nurses with msd knowledge can contribute to the early prevention of occupational disorders, such as hnp, which can disrupt their daily lives. the findings of this study may offer perspectives and emphasize the need for training healthcare professionals, particularly in the field of ergonomics. it is crucial for hospitals to prioritize and support nurses, particularly concerning safety, protection, and comfort for both nurses and other hospital staff. this attempts to enhance spinal stability and function in workers with lower back pain and stabilize the pelvic muscles. limitations of the study the sole instrument utilized in this study was the qec, which is one of the many techniques used to identify musculoskeletal grievances. furthermore, not every employee can be simultaneously diagnosed with msds. conclusions musculoskeletal disorders (msds) among inpatient nurses at the dsrh were primarily moderate for static back and mild for back dynamics, shoulders/arms, neck, vibrations, work pace, and work-related stress. nurses’ sex, education, and service duration in dsrh inpatient wards affect the prevalence of msds. among the nurses working in dsrh inpatient wards, age did not affect back mobility-related msds. references 1. yan p, li f, zhang l, et al. prevalence of work-related musculoskeletal disorders in the nurses working in hospitals of xinjiang uygur autonomous region. pain res manag 2017;2017:5757108. 2. soylar p, ozer a. evaluation of the prevalence of musculoskeletal disorders in nurses: a systematic review. med sci 2018;7:479-85. 3. krishnan ks, raju g, shawkataly o. prevalence of workrelated musculoskeletal disorders: psychological and physical risk factors. int j environ res public health 2021;18:9361. 4. putri zm, murni d, maisa ea, et al. dampak gangguan muskoloskeletal akibat pekerjaan pada perawat di rsi siti rahmah padang tahun 2019. proc. semin kesehat perintis 2019;2:133-7. 5. ribeiro t, serranheira f, loureiro h. work related musculoskeletal disorders in primary health care nurses. appl nurs res 2017;33:72-7. 6. adhikari gp. calculating the sample size in quantitative studies. scholars' j 2021;4:14-29. 7. hossain md, aftab a, al imam mh, et al. prevalence of work related musculoskeletal disorders (wmsds) and ergonomic risk assessment among readymade garment workers of bangladesh: a cross sectional study. plos one 2018;13:e0200122. 8. lavery la, higgins kr, lanctot dr, et al. preventing diabetic foot ulcer recurrence in high-risk patients: use of temperature monitoring as a self-assessment tool. diabetes care 2007;30:14-20. 9. david g, woods v, li g, buckle p. the development of the quick exposure check (qec) for assessing exposure to risk factors for work-related musculoskeletal disorders. appl ergon 2008;39:57-69. 10. ispășoiu a, milosan i, ispasoiu a, meita c. study on the application of the bowtie methodology for the assessment of ergonomic risks in the industrial field. recent j 2021;22:12836. 11. tahernejad s, choobineh a, razeghi m, et al. investigation of office workers’ sitting behaviors in an ergonomically adjusted workstation. int j occup saf ergon 2022;28:2346-54. 12. rahmawati u. faktor-faktor yang berhubungan dengan keluhan muskuloskeletal disorders pekerja pengangkut barang di pasar panorama kota bengkulu. j kesehat lingkung 2020;17:49-56. 13. widodo yw. hubungan karakteristik perawat dan aktivitas memindahkan pasien dari atas meja operasi ke atas brankar dengan keluhan musculoskeletal disorders (msds) pada perawat kamar operasi rsupn dr. cipto mangunkusumo jakarta. phd dissertation, dept. perpustakaan. jakarta, indonesia: universidad muhammadiyah; 2013. 14. tarwaka. ergonomi industri dasar-dasar pengetahuan ergonomi dan aplikasi di tempat kerja. surakarta: harapan press; 2015. 15. grimes p, legg s. musculoskeletal disorders (msd) in school students as a risk factor for adult msd: a review of the multi article [page 324] [healthcare in low-resource settings 2024;12:12343] non -co mmerc ial us e o nly ple factors affecting posture, comfort and health in classroom environments. j hum environ syst 2004;7:1-9. 16. hendi om, alturkistani lh, bajaber as, et al. prevalence of musculoskeletal disorder and its relation to stress among medical student at taif university, saudi arabia. int j prev med 2021;12:98. 17. habibie h, diani n, hafifah i. hubungan umur, jenis kelamin, masa kerja, dan kebiasaan olahraga dengan keluhan musculoskeletas disorders (msds) pada perawat. caring nurs 2019;3:23-30. 18. keperawatan u-u. republik indonesia no. 38 tahun 2014 tentang keperawatan. jakarta; 2014. 19. yazid b, situmorang h. hubungan aktivitas fisik dengan gangguan muskuloskeletal pada perawat di rsu sundari medan. j kel sehat sejah 2021;19:38-47. 20. rudyarti e, dewi pr. analisis risiko keluhan muskuloskeletal pada perawat di rumah sakit sentra medika cikarang. j ilm kesehat inst med drg suherman 2019;1:1-9. 21. nuryaningtyas bm, martiana t. analisis tingkat risiko muskuloskeletal disorders (msds) dengan the rapid upper limbs assessment (rula) dan karakteristik individu terhadap keluhan msds. indones j occup saf heal 2014;3:160-9. 22. gu r. hubungan faktor individu dan faktor pekerjaan dengan keluhan musculoskeletal disorder (msds) pada perawat (studi observasional pada perawat instalasi rawat inap rsd idaman banjarbaru tahun 2017. phd dissertation, perpustakaan. banjarbaru, south kalimantan, indonesia: universidad lambung mangkurat; 2017. 23. fathonah d, syahran s, andriansyah a. pengaruh peran gender dan stres kerja terhadap kinerja perawat di rumah sakit umum daerah tarakan provinsi kalimantan utara. coop j ilm manaj 2020;11:117-24. 24. adriansyah m, mallapiang f, ibrahim h. faktor yang berhubungan dengan keluhan msds pada penenun lipa’ sa’be mandar di desa karama kecamatan tinambung kabupaten polewali mandar. hig j kesehat lingkung 2019;2:79-84. 25. khasanah fr. pengaruh latihan stretching fleksi william terhadap tingkat nyeri punggung bawah di wilayah kerja puskesmas geger. thesis. prodi keperawatan, stikes bhakti husada mulia madiun, east java, indonesia; 2018. 26. wuriani w, rosa em, afandi m. pengaruh perbaikan postur kerja terhadap nyeri muskuloskeletal pada perawat di klinik kitamura pontianak. mutiara j kedok kesehat 2017;17:22-8. article [healthcare in low-resource settings 2024;12:12343] [page 325] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s2):12005 urban and rural disparities: evaluating happiness levels in indonesian women sri idaiani, ika saptarini research center for preclinical and clinical medicine, national research and innovation agency, indonesia abstract grasping the underlying determinants of happiness has significant implications for societal growth and individual wellbeing. to this end, our investigation delved deep into the factors enhancing happiness among indonesian women, with a spotlight on the disparities evident in urban versus rural settings. from a robust sample size of 38,144 women, we employed logistic regression analysis (using a significance threshold of 0.05) and took advantage of stata 17’s spmap command to meticulously outline happiness averages across provinces. our analyses revealed a compelling trend: urban women consistently reported more elevated happiness scores (71.51; 95%ci 71.40-71.62) compared to their rural peers (70.19; 95%ci 70.08-70.29), with a significant p-value of 0.001. parsing this data further, we recognized that across urban and rural landscapes, the nexus between higher education levels, younger age, and augmented household income remained a strong predictor of happiness elevation. intriguingly, though, densely populated urban hubs did not always translate to heightened contentment. as a directive, policymakers should amplify efforts towards enriching educational and economic landscapes for women in high-density zones. moreover, the study suggests a pivotal need to explore the idiosyncratic attributes of distant provinces, aiming to translate those lessons to enrich urban living conditions. introduction the intricate relationship between happiness, prosperity, and health is well-established, yet it’s important to note that economic factors alone do not guarantee happiness. this is because happiness is a multifaceted construct influenced by a plethora of variables.1,2 such determinants encompass genetics, education, socio-economic conditions, time management, activities, stress exposure, marital status, and intrinsic personality traits. furthermore, elements like spirituality, religiosity, social support, as well as physical and mental health, have been observed to be closely tied to one’s happiness.3–7 residency, whether urban or rural, plays a pivotal role in determining happiness. generally, urban inhabitants report higher happiness levels, likely due to enhanced facilities in cityscapes. however, there are exceptions.8,9 notably, in certain locales, rural populations have shown higher happiness scores than their urban counterparts.8 it’s essential to highlight that the determinants of happiness vary across demographic segments. for instance, factors contributing to the well-being of adolescorrespondence: sri idaiani, research center for preclinical and clinical medicine, national research and innovation agency,cibinong science center jalan raya jakarta-bogor km. 46, kecamatan. cibinong, kabupaten bogor, jawa barat 16915, indonesia. e-mail: sri.idaiani@brin.go.id key words: indonesian women; urban-rural divide; happiness determinants; societal well-being; provincial happiness levels. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of the national research and innovation agency (brin) adjudged this study as exempt from requiring an ethical clearance, as evidenced by letter number 129/ke.01/sk/7/2022. availability of data and materials: this study used data from the central bureau statistics (cbs) with permission from the director of statistic dissemination. data will be made available upon request at silastik@bps.go.id conference presentation: part of this article was presented in global public health conference, february 23 rd 2023. funding: the authors received no funding for the work reported in this article. acknowledgements: the authors appreciate dr. harimat hendarwan as the head of the research centre for preclinical and clinical medicine and the head of center for data and information national research and innovation agency for facilitating the data request to cbs. received: 19 october 2023. accepted: 19 november 2023. early access: 28 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s2):12005 doi:10.4081/hls.2023.12005 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 18] [healthcare in low-resource settings 2023; 11(s2):12005] non -co mmerc ial us e o nly cents, adults, or the elderly differ.10–12 similarly, professionals or students might experience varied happiness sources, warranting diverse measurement tools aligned with specific influencing factors.3,13–15 to cater to these varied segments, a myriad of happiness measurement instruments have been formulated. these tools, customized for distinct demographics like workers, caregivers, adolescents, or even cultural backgrounds, ensure nuanced assessments.3,16–18 furthermore, these assessments often incorporate unique factors tailored for specific populations, such as living arrangements or registrations.19,20 for urban youth, for instance, career progression prospects emerge as significant happiness determinants.21 turning our gaze to indonesia, the nation employs an extensive happiness assessment, anchored by the central bureau of statistics. this evaluation, based on international standards, adopts frameworks delineated by the new economic foundation (nef) and the organization for economic co-operation and development (oecd), mirroring indonesia’s unique socio-cultural landscape.22 given the global economic ramifications triggered by the covid-19 pandemic, evaluating happiness levels concerning urban versus rural residency gains paramount importance.8,23–25 the factors influencing happiness evidently diverge across urban and rural landscapes. this disparity is pronounced in indonesia, where 56% of the populace resides in the relatively advanced regions of java and bali.22 yet, the characteristics delineating happiness across these settings remain underexplored. recognizing these distinct attributes could empower individuals to align their residence with their happiness determinants, thereby elevating their well-being. women have a specialty, namely that based on the results of the 2021 happiness survey, their index is lower than men.22 unlike men, women have hormonal influences, for example menopause, which causes discomfort. besides that, the factors of living in urban or rural areas, work, social activities are different between women and men therefore it is better to explain happiness for each gender, in this case for women.15,26 thus, this research primarily seeks to discern characteristics fostering happiness among indonesian women. simultaneously, it delves into contrasting happiness determinants across urban and rural settings. materials and methods design and setting this study employed a survey-based design conducted in period 1 july to 27 august 2021 by the central bureau of statistics (cbs) across 34 provinces. while aiming for a sample size of 75,000 respondents, the survey yielded data from 74,684 participants, reflecting a response rate of 99.5% with adequate provincial representation. the sampling unit is household. the survey employed a two-stage one-phase sampling strategy, namely the first stage was selecting census blocks. the second stage was household selection. census blocks were selected by means of urban-rural stratification. in the first stage, it selected 7500 census blocks from 30,000 census blocks in probability proportional to size using urban rural stratification. in the second stage, it selected 10 households from 20 households in each selected census by taking into account implicit stratification, including house floor variables, lighting, drinking water, education and so on. that selection was using systematic random sampling. data collection data collection was carried out by cbs enumerators using questionnaires. the criteria for a household were an ordinary household, namely a group of people who live in one or part of a census building and eat from the same kitchen. special households, for example dormitories, were not included in the survey. the sampling unit is a household selected by cbs randomly. the primary respondent was the household head. in instances where the household head was unavailable, their spouse served as the representative respondent.22 exclusion criteria were they refused, were not present until the specified time limit or they moved to different census block. enumerators may not replace households that were not found. for the purposes of this analysis, we narrowed our focus to female respondents, resulting in a final sample size of 38,144. it is noteworthy that this survey was conducted amidst the covid-19 pandemic. questionnaire the happiness level survey was initiated by cbs in 2012 and underwent a national-level pilot in 2014. it was crafted around the new economic foundation nef framework. in 2017, it was augmented to incorporate elements from the organization for economic co-operation and development oecd framework. the methodology adopted is in line with the standardized gallup world pool method, which also serves as the foundation for the world happiness index. this consistency ensures that the derived data is compatible with other international happiness datasets. the happiness index encompasses 19 defining factors spread across three primary dimensions: life satisfaction, affect, and eudaimonia. the life satisfaction dimension probes into areas such as education, primary activities or employment, housing amenities, household income, health, familial harmony, availability of leisure time, neighborhood social interactions, environmental quality, and safety measures. the affective domain delves into feelings of happiness/contentment/joy, serenity versus anxiety, and cheerfulness versus despondency. lastly, eudaimonia addresses facets like autonomy, environmental mastery, personal growth, cultivating positive relationships, life’s purpose, and self-appreciation.22 a comprehensive list of these 19 questions is provided in appendix 1. responses are calibrated on a scale ranging from 0 (indicating deep dissatisfaction) to 10 (indicating supreme satisfaction, table 1). data analysis the cbs-sourced data was subjected to a multiple logistic regression analysis employing the enter method. this analytical method was selected owing to the non-normal distribution of the happiness dependent variable. a significance benchmark was established at 0.05. variations in characteristics were evaluated using independent sample t-tests and chi-square tests. all analytical procedures were conducted on stata software (version 17). moreover, an illustrative representation of average provincial happiness levels was generated using stata’s spmap command. ethical considerations given our reliance on cbs’s secondary data, we sought an ethical review from the ethics committee of the national research and innovation agency (brin). the committee adjudged this study as exempt from requiring an ethical clearance, as evidenced by letter number 129/ke.01/sk/7/2022. article [healthcare in low-resource settings 2023; 11(s2):12005] [page 19] non -co mmerc ial us e o nly results sample analyses were conducted on data from 38,144 respondents, with their demographic and other pertinent characteristics presented in table 2. notably, urban areas reported a higher average happiness score compared to their rural counterparts (71.51 vs. 70.19), with this disparity being statistically significant. intriguingly, the mean age of respondents remains consistent across both urban and rural settings, and this consistency is statistically significant. additionally, the proportion of participants possessing higher education, positioned at the pinnacle economic bracket (level 1), and identifying as single, is notably lower than other categorized groups. in table 4, both the crude and adjusted odds ratio (or) calculations, a persistent theme emerges: tertiary education wields the most substantial influence over happiness levels in both urban and rural populations. conversely, females who are either divorced, widowed, of advancing age, and situated in a lower economic stratum, depict an inverse relationship with happiness. after adjusting for age, marital status, and family income variables, the or for respondents with higher education (minimum college graduates) registers at 3.409 (95% confidence interval (ci) = 3.026-3.839, p = 0.001) for urban regions, and 3.494 (95% ci = 3.013-4.051, p = 0.001) for rural localities. while household income certainly influences happiness levels, it’s the lowest income cohort (earning below idr 1.7 million monthly) that manifests the most significant negative correlation. in the rural backdrop, this group’s or is tabulated at 0.397 (95% ci = 0.342-0.462, p = 0.001). in stark contrast, their urban counterparts have an or measured at 0.279 (95% ci = 0.245-0.319, p = 0.001). the average happiness metrics, segregated based on urban and rural demarcations per province, are elaborated in table 3. these averages serve as a foundation for the graphical representations in figures 1 and 2. gleaning insights from these maps, one observes that provinces like central kalimantan, central sulawesi, gorontalo, north maluku, and maluku consistently report elevated happiness levels, irrespective of urban or rural classification. a similar homogeneity in happiness scores, straddling urban and rural divides, is evident in provinces such as aceh, west sumatra, lampung, east java, east nusa tenggara, east kalimantan, and papua. diverging from this trend, provinces like jambi, south sumatra, north kalimantan, and north sulawesi exhibit a pronounced urban bias, with city dwellers article [page 20] [healthcare in low-resource settings 2023; 11(s2):12005] table 2. characteristic respondents. variables urban (n=17873) % rural (n=20271) % p happiness (mean) 71.51; 95%ci 71.40-71.62 70.19; 95%ci 70.08-70.29 0.001* age (mean) 46.22; 95%ci 46.02-46.41 46.21; 95%ci 46.02-46.41 0.483* education no school-primary s 6370 35.64 12238 60.37 0.001** junior hs-senior hs 8851 49.52 6844 33.76 diploma-university 2652 14.84 1189 5.87 marital status unmarried 469 2.62 213 1.05 0.001** married 13238 74.07 14986 73.93 divorce/widowed 4166 23.31 5072 25.02 household income level1 2141 11.98 975 4.81 0.001** level2 2540 14.21 1531 7.55 level3 3952 22.11 3375 16.65 level4 5068 28.36 6895 34.01 level5 4172 23.34 7495 36.97 *independent sample t test ** chi square. table 1. variables. variables variable descriptions 1 happiness consisting of 19 questions. each question is a selfreported measure of how satisfied the individual is with his/her health, all things considered, where 0 = very unsatisfied and 10 = very satisfied. 1. less happy (< mean score) 2. happy (≥ mean score) 2 age 1.< 30 years; 2. 30-59 years; 3. ≥ 60 years. 3 marital status 1. unmarried, 2. married, 3. divorced/widowed 4 education 1. no school-primary finished, 2. secondary-high school, 3. d1-university 5 living 1. urban, 2. rural 6 household income level 1 (> 7.2 million/month), level 2 (> 4.8 -7.2 million/month), level 3 (> 3.0-4.8 million/month), level 4 (> 1-1.8-3.0 million/month), level 5 (< 1.8 million/month) non -co mmerc ial us e o nly article table 3. the mean of urban and rural happiness level by province.variables urban rural no province mean no province mean no province mean no province mean 1 aceh 72.50 20 west 72.35 1 aceh 70.10 20 west 70.25 kalimantan kalimantan 2 north sumatera 70.71 21 central kalimantan 73.43 2 north sumatera 68.47 21 central kalimantan 71.44 3 west sumatera 71.13 22 south kalimantan 72.52 3 west sumatera 69.69 22 south kalimantan 68.73 4 riau 70.77 23 east kalimantan 73.08 4 riau 71,16 23 east kalimantan 70.78 5 jambi 73.96 24 north kalimantan 74.10 5 jambi 69,54 24 north kalimantan 70.85 6 south sumatera 71.91 25 north sulawesi 75.55 6 south sumatera 70,06 25 north sulawesi 75,07 7 bengkulu 70.36 26 central sulawesi 75.20 7 bengkulu 67.28 26 central sulawesi 73.56 8 lampung 71.91 27 south sulawesi 72.35 8 lampung 69.70 27 south sulawesi 70.07 9 babel 71.37 28 south east sulawesi 72.45 9 babel 70.52 28 south east sulawesi 72.04 10 riau island 72.50 29 gorontalo 73.74 10 riau island 71.14 29 gorontalo 73.54 11 spec region jakarta 71.18 30 west sulawesi 72.51 11 spec region jakarta 30 west sulawesi 72.59 12 west java 70.71 31 maluku 75.26 12 west java 68.54 31 maluku 75.15 13 central java 69.81 32 north maluku 78.33 13 central java 69.40 32 north maluku 74.83 14 spec region jogjakarta 33 spec region jogjakarta 70.51 papua barat 72.98 14 67.73 33 papua barat 72.46 15 east java 71.04 34 papua 73.04 15 east java 69.74 34 papua 69.79 16 banten 69.29 35 indonesia 71.51 16 banten 68.28 35 indonesia 70.19 17 bali 70.23 17 bali 67.57 18 west nusa tenggara 70.66 18 west nusa tenggara 69.19 19 east nusa tenggara 72.15 19 east nusa tenggara 69.27 [healthcare in low-resource settings 2023; 11(s2):12005] [page 21] table 4. logistic regression model characteristics influenced to happiness. non -co mmerc ial us e o nly article figure 1. urban happiness. figure 1. rural happiness. [page 22] [healthcare in low-resource settings 2023; 11(s2):12005] non -co mmerc ial us e o nly expressing heightened happiness. in stark contrast, provinces like central java, west sulawesi, south east sulawesi, and west papua spotlight rural regions as happiness hotspots. a concluding observation is the comparatively depressed happiness scores in provinces like north sumatra, riau, bengkulu, banten, west java, bali, and west nusa tenggara, spanning both urban and rural sectors. discussion our findings indicate a notable trend: on average, urbanites in indonesia revel in greater happiness compared to their rural counterparts. these findings resonate with similar investigations across the globe, suggesting a pervasive urban-rural happiness divide.8,24 however, it’s pivotal to acknowledge the deviations seen in some developed nations where rural inhabitants, empowered by a plethora of amenities, often report enhanced happiness levels.24 a remarkable highlight from our analysis was the preeminent role of education in governing happiness across urban and rural landscapes. nonetheless, contrasting literature suggests that the real elixirs of joy might be well-paying jobs and robust income streams, rather than educational milestones.27 gender emerges as another pivotal determinant, particularly pronounced in rural settings. rural men seem to grapple with happiness more than their urban peers.15 and while gender’s influence on happiness appears fairly balanced across urban and rural arenas, life events such as menopause can usher in profound psychological perturbations for women.26 hence, urban locales, brimming with a plethora of engagements ranging from academia to politics, might appeal more to this demographic.28 age undeniably modulates happiness. while youth often radiates exuberance, the multifaceted ingredients of happiness morph across the age spectrum. older demographics often report an inverse relationship between age and happiness, with familial bonds and interactions with kin playing a cardinal role in their emotional well-being.11,12,19 socio-economic stature, underlined by family income, remains a stalwart indicator of happiness. such factors consistently sculpt the happiness landscape across urban and rural arenas. however, post-factorial adjustments spotlight the pronounced weight of socio-economic influences in rural settings compared to urban ones.2,22 this is intriguing, especially when contemplating the broader, macro-economic perspectives and their interplay with individual happiness. our spatial analysis, via comprehensive maps, unveils consistent happiness zeniths across provinces like central kalimantan and central sulawesi. conversely, stark urban-rural happiness disparities are evident in provinces like jambi and central java. alarmingly, traditionally dense and developmentally advanced provinces such as java and bali manifest suboptimal happiness metrics across both urban and rural domains. the results of this study show that indonesia is not yet like developed countries, for example denmark, where the level of happiness is higher for those living in rural areas.8 the fact that urban areas on the island of java are densely populated turns out to provide less happiness for its residents. this needs to be researched more deeply socioculturally to find out what actually happens to residents in densely populated areas in relation to their happiness. yet, our study isn’t devoid of limitations. notably absent is the inclusion of professional vocations, largely due to data unavailability. also, our respondent demographic, primarily household heads or their surrogates, might induce certain sampling biases, possibly skewing happiness insights towards mature adults. this age restricting could be possible overgeneralizing happiness among indonesian women. another limitation are that self-reported happiness measurements have the potential for subjectivity. the social support, cultural factors, access to healthcare and other variable might contribute to happiness were not available as well.29 the temporal context of our research, conducted amidst the 2021 covid-19 pandemic, cannot be overlooked. this global health crisis, with its far-reaching psychological reverberations, undeniably imprinted upon our findings.30 a commendable strength of our study lies in its vast, nationally representative sampling. bolstered by a standardized happiness assessment tool, our results are ripe for juxtaposition with global studies. however, a potential limitation arises from the singular respondent model, restricting the age profile of our respondents and possibly overgeneralizing happiness insights among indonesian women. our findings beckon attention from policy architects, healthcare professionals, and local authorities. intriguingly, densely populated and economically advanced provinces register lackluster happiness metrics, in stark contrast to fledgling provinces like maluku, which bask in contentment across urban and rural spectrums. in conclusion, the trinity of higher education, robust income, and youthfulness seems instrumental in paving pathways to happiness, irrespective of urban or rural habitats. the implication of the results of this research for the future is that to increase happiness evenly, it is necessary to increase education and income. increased income will also be in line with the increased availability of living facilities. in this way, it is hoped that there will be no disparity in the happiness of residents whether they live in the city or in the village. conclusions factors contributing to heightened happiness among women include advanced education, youth, and high household income. surprisingly, in densely populated and developed provinces, happiness levels remain lower. in contrast, in provinces distant from the capital—both in urban and rural settings—happiness levels are notably higher. governments and policymakers should prioritize investments in education and economic opportunities for women, particularly in densely populated areas. additionally, studying the unique attributes of newer provinces distant from the capital could provide insights for improving well-being in more developed regions. amplify efforts towards enriching educational and economic landscapes for women in high-density zones. moreover, the study suggests a pivotal need to explore the idiosyncratic attributes of distant provinces, aiming to translate those lessons to enrich urban living conditions. references 1. halbreich u. pursuit of happiness, prosperity and health (phph). int j soc psychiatry 2018;64:307–308. 2. sasaki y, shobugawa y, nozaki i, et al. association between happiness and economic status among older adults in two myanmar regions. int j environ res public health 2022;19:3216. 3. jun wh, jo mj. factor affecting happiness among nursing stu article [healthcare in low-resource settings 2023; 11(s2):12005] [page 23] non -co mmerc ial us e o nly dents in south korea. j psychiatr ment health nurs 2016;23:419–426. 4. wang w, sun y, chen y, et al. health effects of happiness in china. int j environ res public health 2022;19:6686. 5. steptoe a. happiness and health. annu rev public health 2019;40:339–359. 6. nugroho tw, hanani n, toiba h, et al. promoting subjective well-being among rural and urban residents in indonesia: does social capital matter? sustainability 2022;14:2375. 7. susanti s, pierewan ac, kismiantini k, et al. what makes indonesians satisfied with their health? a multilevel analysis. sage open 2022;12:21582440221121720. 8. sørensen jfl. the rural happiness paradox in developed countries. soc sci res 2021;98:102581. 9. haghdoost aa, momeni m, bahraminejad f, et al. levels and predictors of happiness in the south of the islamic republic of iran. east mediterr health j 2020;26:779–786. 10. mohd hashim ih, mohd zaharim n. happiness among malaysian adolescents: the role of sociodemographic factors and everyday events. sage open 2020;10:2158244020940695. 11. mahmoodi z, yazdkhasti m, rostami m, et al. factors affecting mental health and happiness in the elderly: a structural equation model by gender differences. brain behav 2022;12:e2549. 12. giray yakut s, bacaksız ne, camkıran c. socio-demographic determinants of happiness in turkey. business manag studies 2021;9:561–578. 13. bencsik a. measuring organisational well-being and happiness based on gnh logic. econ sociol 2022;15:268– 285. 14. park kh, kim h, park s. leisure factors predicting the happiness of self-employed workers in south korea. int j environ res public health 2021;18:9852. 15. wang c, liu j, pu r, et al. determinants of subjective health, happiness, and life satisfaction among young adults (18-24 years) in guyana. biomed res int 2020;2020:9063808. 16. alquwez n, cruz jp, alotaibi ns, et al. validity and reliability of the subjective happiness scale arabic version among saudi working women. j taibah univ med sci 2021;16:835–842. 17. fitriana n, hutagalung fd, awang z, et al. happiness at work: a cross-cultural validation of happiness at work scale. plos one 2022;17:e0261617. 18. gardiner g, lee d, baranski e, et al. happiness around the world: a combined etic-emic approach across 63 countries. plos one 2020;15:e0242718. 19. hwang ej, sim io. association of living arrangements with happiness attributes among older adults. bmc geriatr 2021;21:100. 20. liu xh, han lm, yuan b. does the conversion of household registration actually improve the happiness of migrant workers in china? int j environ res public health 2020;17:2661. 21. shen f, zou j, huang x, et al. career development, institutional factors, social factors and urban young returnees’ happiness in the context of healthy china. int j environ res public health 2022;19:9379. 22. bps. indeks kebahagiaan 2021, https://www.bps.go.id/publication.html?publikasi%5btahunjudul%5d=2021&publikasi% 5bkatakunci%5d=sptk&publikasi%5bcekjudul%5d=0&y t0=tampilkan 23. easterlin ra, angelescu l, zweig js. the impact of modern economic growth on urban-rural differences in subjective wellbeing. world development 2011;39:2187–2198. 24. requena f. rural–urban living and level of economic development as factors in subjective well-being. soc indic res 2016;128:693–708. 25. mofijur m, fattah imr, alam ma, et al. impact of covid-19 on the social, economic, environmental and energy domains: lessons learnt from a global pandemic. sustain prod consum 2021;26:343–359. 26. shin hj, kim ji. development and validation of the happiness scale for middle-aged women based on existence, relation, and growth theory. asian nurs res (korean soc nurs sci) 2021;15:96–104. 27. van aardt cj, de clercq b, meiring j. the stochastic determinants of happiness in south africa: a micro-economic modelling approach. j econ financial sci 2019;12:1–15. 28. he l, wang k, liu t, et al. does political participation help improve the life satisfaction of urban residents: empirical evidence from china. plos one 2022;17:1–24. 29. şahin f, sahin altun ö. concept of happiness in schozophrenic. psikiyatride guncel yaklasimlar current approaches in psychiatry 2022;14:291–298. 30. lin x, lin y, hu z, et al. practice of new normal lifestyles, economic and social disruption, and level of happiness among general public in china in the post-covid-19 era. risk manag healthc policy 2021;14:3383–3393. article [page 24] [healthcare in low-resource settings 2023; 11(s2):12005] online supplementary materials appendix. questions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e20] [page 69] the importance of a patient’s background in formulating a management approach anil ojha, pawan shrestha, david a. green kathmandu medical college teaching hospital, kathmandu, nepal abstract peptic ulcer disease is uncommon in childhood, with non-specific clinical features. a tendency to late diagnosis makes it more likely for a patient to present with complications. here we discuss a child with low socio-economic status from a developing country who presented with severe anemia secondary to a bleeding duodenal ulcer. the case highlights the importance of the patient’s background in the formulation of a management approach. in some cases this may be intuitive to an experienced physician. however, we demonstrate this with a simple mathematical diagnostic model using disease prevalences which are tied to our individual patient’s circumstances. the model shows how the negative predictive value of a test can change according to the patient’s background. we also suggest that the best treatment option will be influenced by the patient’s circumstances. our patient comes from nepal, but the principles involved are universally applicable. case report a 12-year-old nepali boy presented with a 2day history of black tarry stools, a similar episode 6 months previously, and 6 months of recurrent upper abdominal pain, worse after meals, increasing pallor, palpitations and dyspnea on exertion. there was no drug use, nor contact with tuberculosis. positive findings were pallor, tachycardia, tachypnea, epigastric tenderness, soft systolic murmur, hemoglobin of 2.3 gm/dl, microcytic, hypochromic erythrocytes, and stool positive for blood. relevant negative findings were absence of rash, jaundice, lymphadenopathy, organomegaly, malnutrition, and hookworm in stool. platelet and white cell counts were normal. endoscopy (after transfusion) showed a large, solitary ulcer in the first part of the duodenum, with exudates over the base, surrounding edema and slight oozing of blood. subsequent histopathology showed chronic inflammatory changes, with no histological evidence of metaplasia, atrophy or helicobacter pylori (hp) infection. he remained well on triple therapy [2 weeks of proton pump inhibitor (ppi), amoxicillin and clarithromycin], followed by oral iron and an additional three weeks of ppi. he was counseled not to smoke or use non steroidal antiinflammatory drugs (nsaid). at 4 weeks follow up he returned to his normal activities. examination was normal, he had no occult blood in his stool and his hemoglobin level increased satisfactorily. at 6 months follow up, he remained well, examination was normal and his hemoglobin was 13.4 gm/dl. discussion we elected to give short term triple therapy despite no evidence of hp infection, and presented this to highlight the importance of a patient’s background in formulating a management approach. the prevalence of hp is lower in bleeding than non-bleeding peptic ulcers, but similar if the comparison is limited to patients not taking nsaids.1 furthermore, detection of hp can be elusive in acutely bleeding cases. delayed testing (≥4 weeks after bleeding) and testing in younger patients, give a prevalence of hp approaching that seen in non-bleeding ulcers.2 early reviews showed hp infection rates of 80 to 95% in duodenal ulcer (du) patients3 in developed countries. rates are now dropping there, but remain high in developing countries. if we assume a prevalence of 90% in patients like ours, then in table 1 cell e=90 and cell f=10. in the presence of a recently bleeding du, the sensitivity and specificity of histology testing for hp is 70 and 90%, respectively.4 thus: cell a=0.7 x 90=63; cell c=27; cell d=0.9 x 10=9; cell b=1. the negative predictive value (npv) of the histology for hp in our patient is 9/36=0.25. thus, even in the face of a negative test, a patient like ours is likely to have an hp infection. this contrasts with the same scenario in a developed country. in a study of 144 nonnsaid using du patients in new york, hp prevalence was 61%.5 if we use this prevalence in the model (e=61) with the same sensitivity and specificity estimates, then npv=0.66. thus, a patient is probably not infected. in the western literature the general consensus is for long-term antisecretory therapy after hp eradication in bleeding du cases.6 however, liu et al. found that after successful eradication with short-term ppi, ongoing therapy made no difference to ulcer recurrence or hp re-infection on long term follow up.7 in our case the local context was dominated by a high prevalence of enteral infections (favouring preservation of an effective acid gastric barrier), and concern about ongoing treatment costs: we therefore opted against long term acid suppression. conclusions most of the medical literature comes from the developed world, and colleagues in the developing world by necessity use this body of evidence to inform their clinical practice. however, patients’ backgrounds are very different in these two worlds, and we offer this healthcare in low-resource settings 2013; volume 1:e20 correspondence: david anthony green, kathmandu medical college teaching hospital, 184 baburam acharya sadak, 44600 kathmandu, nepal. tel. +977.661.447472857 fax: +977.661.89516976. e-mail: david.green@nt.gov.au key words: helicobacter pylori, negative predictive value, management approach. contributions: the authors contributed equally. conflict of interests: the authors declare no potential conflict of interests. received for publication: 11 february 2013. revision received: 3 may 2013. accepted for publication: 4 may 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright a. ojha et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e20 doi:10.4081/hls.2013.e20 table 1. one hundred hypothetical patients with bleeding duodenal ulcer in a developing country. truly hp + truly hp – total histology + for hp a=63 b=1 64 histology – for hp c=27 d=9 36 total e=90 f=10 100 hp, helicobacter pylori; +, positive; –, negative. non -co mmerc ial us e o nly [page 70] [healthcare in low-resource settings 2013; 1:e20] case as a reminder of the importance of a patient’s background in the formulation a management approach. references 1. gisbert jp, gonzalez l, de pedro a, et al. helicobacter pylori and bleeding duodenal ulcer: prevalence of the infection and role of non-steroidal anti-inflammatory drugs. scand j gastroentero 2001;36:717-24. 2. sánchez-delgado j, gené e, suárez d, et al. has h. pylori prevalence in bleeding peptic ulcer been underestimated? a metaregression. am j gastroenterol 2011;106: 398-405. 3. barody tj, george ll, brandl s, et al. helicobacter pylori-negative duodenal ulcer. am j gastroenterol 1991;86:1154. 4. gisbert, jp, abraira, v. accuracy of helicobacter pylori diagnostic tests in patients with bleeding peptic ulcer: a systematic review and meta-analysis. am j gastroenterol 2006;101:848. 5. jyotheeswaran s, shah an, jin ho, et al. prevalence of helicobacter pylori in peptic ulcer patients in greater rochester, ny: is empirical triple therapy justified? am j gastroenterol 1998;93:574-8. 6. national institutes of health. nih consensus conference. helicobacter pylori in peptic ulcer disease. nih consensus development panel on helicobacter pylori in peptic ulcer disease. jama-j am med assoc 1994;272:65. 7. liu cc, lee cl, chan cc, et al. maintenance treatment is not necessary after helicobacter pylori eradication and healing of bleeding peptic ulcer: a 5-year prospective, randomized, controlled study. arch intern med 2003;163:2020-4. case report non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12831 innovations in cancer diagnosis and treatment: prospects and challenges katarzyna wisniewska,1 ervin marku,2 martina vidova ugurbas,3 ilona hartmane,4 malika shukurova5 1faculty of health sciences, radom higher school, radom, poland; 2faculty of technical medical sciences, tirana medical university, tirana, albania; 3department of plastic, reconstructive and aesthetic surgery, pavol jozef šafárik university in kosice, kosice, slovakia; 4department of dermatology and venereology, riga stradins university, riga, latvia; 5department of development of children’s cancer registry, scientific practical medical center for pediatric hematology, oncology and clinical immunology, tashkent, uzbekistan abstract the research relevance of cancer diagnostics and treatment is determined by its widespread occurrence and the lack of adequate modern diagnostic methods. the study aims to characterise new diagnostic methods, namely screenings in detecting cancer at early stages of development. to achieve this goal, the bibliosemantic and bibliographic methods were used. cancer is the leading cause of morbidity and mortality after cardiovascular diseases and injuries in many countries around the world. various diagnostic and treatment methods are used to combat this problem, including computed tomography, magnetic resonance imaging and positron emission tomography. in addition, modern diagnostic methods such as polymerase chain reaction, mass spectrometry and genomic sequencing play an important role in determining the types of cancer cells and their sensitivity to treatment. these advanced methods can be used to diagnose cancer more accurately and efficiently and choose the most appropriate treatment strategies for each patient. the practical significance of this topic is to ensure appropriate care for patients with cancer: providing high-quality, efficient, fast and minimally invasive diagnostics using the latest methods, as well as implementing a screening system. introduction cancer remains one of the most common and dangerous medical problems in the world today. the speed of diagnosis, the success of treatment, and the prognosis of the disease leave much to be desired. for this reason, new approaches and innovations in the field of cancer diagnostics are constantly being sought.1 according to siegel et al.,2 the number of cancer cases is expected to increase every year. for example, in the united states, despite technological advances in medicine, 609,820 cancer deaths were recorded. the topic presented is extremely relevant and needs to be studied in connection with the rapid spread of cancer incidence of various origins and locations. the problem occurs in several cancers that remain without visible early symptoms for a long time, or such symptoms are often missed and diagnosed at later stages. another reason is the diversity and heterogeneity of tumours, and most importantly, the lack of a perfect screening system for early cancer diagnosis. for instance, merkuri et al.3 addressed the imperfection of cervical cancer diagnosis in albania. this pathology is the second most common among women aged 14-44, and screenings have been established at the state level for primary examinations. however, complicated cases of the disease have become increasingly common around the world. dimitrova et al.4 state that many countries, such as albania, macedonia, and bosnia and herzegovina, already have decent standards of early cancer detection. however, despite significant progress, such screenings remain imperfect and require further improvement, as complicated forms of cancer are overlooked due to the lack of diagnostic accuracy. xhemalaj et al.5 point out that the prevalence of cancer among the population of albania, including even the capital tirana, is quite high, which endangers the healthcare system. moreover, in albania, malignant tumours cause 13 to 18% of deaths. the author notes that lung cancer is the first among morbidity and mortality, and this number is more than 15%. given the widespread prevalence of cancer, it is important to introduce not only new diagnostic methods but also therapeutic ones. to put the results in perspective, it would be more instructive to compare the lung cancer rates and treatments in albania correspondence: katarzyna wisniewska, faculty of health sciences, radom higher school, radom, poland. e-mail: wisniewska.kater@gmail.com key words: cancer, disease detection, tumour, benignity, screening. contributions: kw and em, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; mvu, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ih and ms, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: not applicable. funding: none. acknowledgements: none. received: 22 july 2024. accepted: 22 august 2024. early view: 22 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12831 doi:10.4081/hls.2024.12831 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12831] [page 95] non -co mmerc ial us e o nly with those of other nations in the area or the world. thus, filaj et al.6 described the use of lasers in the treatment of cancer. this method is widely used to correct benign tumours – haemangiomas – and vascular anomalies. in addition, this method should be considered as an innovative approach to tumours of other origins. although a comparison with other treatment modalities would provide a more comprehensive view of haemangioma management. modern sources focus on the latest trends in cancer diagnostics. one of them is diagnostic markers based on rna and dna. wang et al.7 believe that such methods are promising in addressing mrna, non-coding rna, circular rna, and microrna. the author notes that these types of rna are the most sensitive in the diagnosis of cancer. song et al.8 describe another promising method shortly: the determination of cell-free dna in the patient’s plasma. it is believed that part of the tumour dna enters the bloodstream and can be considered a biomarker of a particular tumour, and this fact may be useful in treatment in the future. however, at the same time, the collection and determination of this dna can be inconvenient and inaccurate, so this method still needs to be developed. a similar study on the structure of dna was highlighted by dolatkhah et al.9 the scientists tested the effectiveness and reliability of dna detection in the early diagnosis of colorectal cancer. however, colonoscopy has proven to be a more accurate and effective method, although it is not a new method. in turn, molecular screenings leave more questions than answers, which means that these areas are innovative and promising but still poorly understood. additionally, it’s important to keep in mind that diverse populations and healthcare systems may respond differently to screening techniques. by offering a thorough and current examination of advancements in cancer detection and therapy, this study seeks to advance previous findings in the field. as opposed to earlier research, which frequently concentrated on particular cancer types or diagnostic techniques, this research adopts a more comprehensive strategy, looking at a wide range of cutting-edge technology and procedures across diverse cancer types. it offers a comprehensive picture of the state of oncology today by combining, for the first time, a review of both diagnostic and therapy breakthroughs. the authors also highlight how these new technologies should be integrated into the current healthcare systems, discussing alternative answers and real-world implementation issues. furthermore, the authors looked at how artificial intelligence (ai) and machine learning can improve cancer diagnosis and treatment planning. the study aims to describe the main aspects of the latest methods of diagnosing cancer, which can be useful for the timely detection of cancer pathology. materials and methods bibliographic and bibliosemantic methods were used in the study of literature, which has significantly improved the quality and depth of the research. the approach to the use of scientometric databases such as scopus, web of science, pubmed, and google scholar, as well as other archives, including research gate, demonstrates a broad analysis of the current professional literature on the problem under study. the choice of searching by title rather than by topic allowed us to accurately identify relevant research topics, which contributes to the accuracy and relevance of the information obtained. the absence of language restrictions makes it possible to cover a wide range of scientific literature and consider different points of view and approaches to the problem under study. a number of terms, concepts, phrases and keywords were used to search for scientific information: “cancer,” “oncology,” “pre-cancerous conditions,” “screening,” “diagnosis,” “treatment,” “therapy,” “examination,” “biopsy,” “cervical cancer,” “colorectal cancer,” “treatment effectiveness,” “tumour markers,” “biomarkers,” “dna analysis,” “rna analysis,” “genetic engineering,” “gene mutations,” “gene expression,” “non-coding genes,” “gene alleles,” “lung cancer,” “biomolecular condensates,” “molecular analysis,” “circular rna,” “gene regulators,” “incidence,” “population,” “risk group,” “smokers,” “teratogenic factor,” “bad habits,” “mortality,” “prognosis,” “risks,” “research perspectives,” “standardisation of diagnostics,” “ultrasound diagnostics,” “computed tomography,” “regional spread of the tumour,” “regional lymph nodes,” “pancosta syndrome,” “low-dose tomography,” “health insurance,” “diagnostic limitations,” “clinical manifestations,” “peripheral tumour growth,” “paraneoplastic syndromes,” “positron emission tomography,” “scintigraphy,” “gun biopsy,” “navigation biopsy,” “fibre optic biopsy.” in general, the approach to the problem involves the use of various methods of analysis, synthesis, generalisation, and classification, which contributes to a more complete and deeper understanding of the topic under study. the method of analysis, which includes collecting information and breaking down the main statement into theses, made it possible to systematise the data and highlight key aspects of the problem. literary analysis, based on the collection and processing of scientific literature, provides access to relevant and authoritative sources, which contributes to qualitative analysis and conclusions. the hermeneutic method used to interpret the texts and identify the main concepts and provisions determined the semantic depth and meaning of key terms in the context of the problem under study. this action is especially important when researching such a serious problem as the oncology of various localisations and studying modern methods of cancer diagnosis with their advantages and disadvantages. this integrated approach to analysing and processing information allowed us to gain a comprehensive understanding of the problem and formulate informed recommendations and conclusions. the classification method provided information on the clinical division by location of different types of cancer. in addition, benign neoplasms of various organs were also considered to select the optimal diagnostic method. the integration of statistical data from various countries, such as albania, korea, europe, the united states, canada, australia, and japan, has provided a more complete picture of the prevalence and characteristics of the problem on a global scale. the statistics provide an opportunity to analyse the probable causes of the sharp rise in cancer incidence in different countries, regardless of where they live, and to analyse both standard and advanced diagnostic methods to ensure timely detection of the tumour process. meta-analysis, as a type of statistical method, is important when analysing large amounts of data from various sources on the topic of oncology diagnostics. this method was used to combine the results of multiple studies to obtain a more generalised and reliable assessment of the effectiveness of diagnostic methods, as well as to assess the degree of consistency of results between different studies. despite the potential for bias in opinion or data, meta-analysis still provides valuable information to form an average assessment or opinion about the purpose and problem of oncology diagnosis. social and political factors affecting public health [page 96] [healthcare in low-resource settings 2024;12(s2):12831] non -co mmerc ial us e o nly results and discussion cancer is a disease with different genetic characteristics the results by wang et al.10 showed that effective interventions can prevent 30-50% of cancer cases. early diagnosis is substantial in improving the prognosis and survival of patients with cancer. the development of new molecular biomarkers for tumours that are highly sensitive and specific and have a low false-positive rate is becoming particularly important.11 the use of these biomarkers can help detect cancer progression over time. modern methods of oncology diagnostics include a wide range of technologies, from molecular to imaging. technologies that play an important role in improving the accuracy and speed of diagnosis: i) radiomics; ii) machine learning; iii) rare biopsies; iv) immunodiagnostics; v) genomic and proteomic diagnostics; vi) blood immunology testing; vii) mass spectrometry. one of the most promising areas in oncology diagnostics is a personalised approach. this includes analysing the patient’s genetic makeup, the molecular characteristics of the tumour and other factors to select the most effective diagnostic and treatment methods for each individual. there are large differences in how innovative cancer diagnostic technologies are implemented in various nations and healthcare systems. while developed countries like the us, japan, and many european countries are leading the way in implementing cutting-edge methods like genomic profiling, aiassisted imaging, and liquid biopsies, many developing nations find it difficult to obtain these advancements because of infrastructure and resource limitations.12 for example, pet/ct scans are rarely available in lowand middle-income countries, despite being widely used for cancer staging in high-income countries. in a similar vein, the use of genomic testing-based precision medicine techniques is expanding quickly in certain areas but is still out of reach for a large portion of the world’s population. these differences in the availability of state-of-the-art diagnostics underscore the necessity of international collaboration and policies aimed at closing the worldwide disparity in cancer care. adapting and deploying affordable versions of these technologies in areas with limited resources is essential to guaranteeing more equitable access to modern cancer diagnostics globally. the importance of rna in cancer diagnosis following cervena et al.,13 long non-coding rnas (lncrnas) are substantial in tumour formation and development, regulating the malignant biological activity of tumour cells at the levels of transcription, post-transcription, and gene epigenetics. their influence on transcription processes organises and coordinates gene expression, which affects various biological functions of the cell, including growth, division, and metastasis. at the post-transcriptional level, lncrnas can interact with rna molecules and proteins, regulating mrna processing and stabilisation and affecting gene transfer mechanisms in cancer. these long, non-coding rnas can affect the epigenetic landscape of a cell by altering chromatin availability and interactions with regulatory elements. this is of great importance for controlling gene expression and tumour development. for instance, high expression of snhg3 can promote tumour cell proliferation and migration by activating signalling pathways such as tgf-β and il-6/jak2/stat3. this, in turn, leads to an increase in the growth rate of tumour cells and inhibition of apoptosis by inhibiting the expression of klf2 and p21 genes. recent studies have confirmed that snhg3 affects cancer progression by regulating its interaction with micrornas, in particular mir-384, mir-182-5p, and mir-139-5p.14, 15 this interaction increases, which leads to a decrease in the effectiveness of control over cellular balance and contributes to the acceleration of cancer progression. biopsy is a basic method of cancer screening following park et al.16 and shende et al.,17 the number of cancer cases in korea has decreased over the past few years, which can be explained by modern early diagnosis. however, when studying the issue of lung cancer, the study determined that the proportion of patients among men is decreasing, while among women it is increasing. the reason is that more and more men are quitting smoking, and women are smoking more and more often. the author focuses on the problems of early diagnosis of peripheral lung cancer. one of the most promising diagnostic methods is a biopsy from the pathological focus, but this procedure has several advantages and disadvantages in its use (table 1). an important statistic is the fact that more than 85% of ovarian cancer cases occur in women without an increased hereditary risk.18 since the ovarian cancer screening procedure requires social and political factors affecting public health table 1. characteristics of different types of biopsies type of biopsy advantages disadvantages fibre optic bronchoscopy the diagnostic efficiency of detecting the efficiency of diagnosis of non-endobronchial central and endobronchial lesions has been and peripheral lesions is low significantly improved. ultrasound-guided endobronchial real-time ultrasound imaging facilitates the detection assessment of peripheral lung and other lymph node transbronchial needle aspiration of central lung lesions and some lymph nodes located involvement may be limited in the mediastinal, paratracheal, subcarinal, hilar, and interlobular regions. also provides the ability to collect cells and lung tissue fragments for further analysis. endobronchial transbronchial real-time ultrasound imaging provides improved the high cost of professorship and the need for ultrasound-guided needle aspiration access to more peripheral lesions. specialist skills with a special guiding sheath also provides the ability to collect cells and lung tissue fragments for further analysis. bronchoscopy with navigation capability the purchase of a reconstructed and virtual roadmap high requirements of the navigation system helps to improve access to more peripheral lesions. and highcost also helps collect cells and lung tissue fragments. pistol biopsy the diagnostic efficiency of biopsy needles is high. pneumothorax and pulmonary bleeding are ensure that sufficient lung tissue is collected for analysis. common complications source: compiled by the authors based on16. [healthcare in low-resource settings 2024;12(s2):12831] [page 97] non -co mmerc ial us e o nly surgery, it is recommended that the positive predictive value should be at least 10%.19 this is to ensure that the benefits of screening are balanced against the potential harm of unnecessary procedures. this approach maximises the benefits of screening for women by reducing the likelihood of unnecessary medical interventions. various methods are used to detect ovarian cancer at an early stage, with ultrasound imaging and blood tests, such as ca125, being among the main ones. transabdominal and, more recently, transvaginal sonography has also been investigated in several large scientific studies. nebgen et al.18 described that 90% of patients with stage iii-iv ovarian cancer can have elevated levels of ca125 in the blood. however, in stages i-ii, the sensitivity of this marker decreases, and only 50-60% of patients may have elevated ca125 levels. this means that ca125 cannot always be used effectively to detect early stages of ovarian cancer, and other diagnostic methods such as ultrasound and transvaginal sonography may also be required to fully assess the patient’s condition. the same opinion is shared by budny et al.20 in a description of ovarian and breast cancer. in addition, the authors addressed the heredity and medical history of patients and emphasised the importance of ultrasound, biopsy, and tumour marker testing. a high percentage of ovarian cancer cases are observed in women with genetically determined factors, such as mutations in the brca1 and brca2 genes, as well as the li-fraumeni, cowden, and peitzjeghers syndromes. women with genetic mutations or syndromes have a significantly increased risk of developing ovarian cancer compared to the general population.21, 22 following connal et al.23 and xu et al.,24 surgery is an effective cancer treatment that provides the best chance of a complete cure and is reported to have fewer side effects than chemotherapy and radiotherapy. early diagnosis of cancer not only saves lives but also significantly reduces treatment costs. however, current clinical tests lack sensitivity and specificity in the early stages of cancer. many cancers can be asymptomatic in the early stages, making them difficult to detect. the liquid biopsy test can open new opportunities to improve screening and triage at an early stage, increasing the proportion of patients with abnormalities who need further investigation. this improvement in the efficiency of the diagnostic process can help reduce delays in diagnosis and lower healthcare costs. an effective liquid biopsy triage test should be affordable so that it can be used by large populations of patients with nonspecific symptoms. this will allow for regular screening and early detection of pathological changes in liquid biopsy without unnecessary costs and efforts.25, 26 the use of such a test can also reduce unnecessary diagnostic procedures, overtreatment, and patient anxiety. as a result, it is possible to expect a reduction in healthcare costs and an improvement in the quality of patient care. pandey et al.27 and bradshaw et al.28 addressed the diagnostic capabilities of molecular methods in the detection of gastric cancer. the development and progression of gastric cancer are associated with various molecular biomarkers that play an important role in the diagnosis, prognosis, and selection of treatment methods for this disease. the her2 protein (the so-called human epidermal growth factor 2) is one of the key biomarkers of gastric cancer. increased her2 expression is associated with a more aggressive course of gastric cancer and a poorer prognosis. assessing the level of her2 expression is important in selecting the appropriate therapy, as some patients may benefit from targeted anti-her2 therapy, such as trastuzumab. the tyrosine kinase receptor of the epidermal growth factor receptor (egfr) family also plays a significant role in the development and progression of gastric cancer. egfr expression is often associated with more aggressive forms of gastric cancer and may affect prognosis and treatment options. targeted therapy against egfr may be effective in subgroups of patients with high levels of egfr expression. thus, the assessment of her2 and egfr expression levels is of great clinical importance in the management of gastric cancer, and the use of targeted therapies against these molecules may be an effective approach in the treatment of certain subtypes of this disease. instrumental diagnostic methods in solving the problem of cancer screening following liu et al.29 and brito et al.,30 computed tomography (ct) is widely used to detect and stage primary lesions in patients with unknown primary lesions, particularly those with a particular sensitivity to primary lesions in the lung, pancreas, or kidney, and is useful for detecting metastatic lesions in the liver, lung, and bone. however, it is worth noting that in some cases, ct may miss smaller or inconspicuous lesions without abnormal morphological or vascular changes. this can occur, for example, in cases where the lesions are very small or in areas that are difficult to visualise with ct. positron emission tomography/computed tomography (pet/ct) is a powerful diagnostic tool that combines functional and structural information to social and political factors affecting public health [page 98] [healthcare in low-resource settings 2024;12(s2):12831] table 2. comparison of imaging techniques in cancer diagnostics imaging strength limitations main applications in cancer diagnostics technique ct high resolution for bone and lung tissue limited soft tissue contrast detecting and staging primary lesions quick scan time radiation exposure identifying metastases in liver, lung, and bone widely available may miss smaller lesions mri excellent soft tissue contrast long scan times detailed assessment of soft tissue tumours no radiation exposure expensive brain and spinal cord imaging multiplanar imaging not suitable for patients with certain evaluating tumour invasion into surrounding structures metal implants pet/ct combines functional and anatomical information lower spatial resolution than ct or mri alone detecting primary tumours of unknown origin high sensitivity for metabolically active tumours expensive assessing treatment response whole-body imaging limited availability identifying distant metastases ultrasound real-time imaging operator-dependent guiding biopsies no radiation exposure limited depth penetration evaluating superficial masses portable and relatively inexpensive not effective for imaging bone or air-filled organs assessing blood flow in tumours source: compiled by the authors. non -co mmerc ial us e o nly study pathological changes in the body in detail. in the case of gastric cancer and other cancers, pet/ct can be used to determine the extent of tumour spread, detect metastases to other organs, and assess the effectiveness of treatment. this method can be used to visualise areas of increased metabolism, which often correspond to cancer cells, and to accurately localise the tumour. pet/ct is a powerful diagnostic tool that combines functional and structural information, providing accurate localisation and characterisation of bodily damage. these two methods complement each other, making pet/ct particularly valuable in clinical practice. pet/ct uses a radioactive tracer, usually 18f-fluorodeoxyglucose (18f-fdg), which is similar to glucose.31 after intravenous injection of 18f-fdg, it is phosphorylated by hexokinase and accumulates in tissues with increased glucose metabolism, such as tumours. 18f-fdg is not further metabolised and remains in the cells, which allows visualisation of active tumour foci on the scan. 18f-fdg in pet/ct can be used to detect and evaluate tumour activity, as increased glucose metabolism is typical for most malignant tumours. thus, pet/ct with 18f-fdg becomes a molecular probe for the diagnosis of cancer processes, which makes it an important tool for assessing the extent of cancer spread, monitoring the effectiveness of treatment, and making decisions on further treatment. this method provides more detailed information about the volume, size, and activity of tumours, which helps in making treatment decisions and determining prognosis.32 studies confirm that the concentration of 18f-fluorodeoxyglucose (18f-fdg) used in pet/ct can effectively distinguish malignant lesions from benign ones. 18f-fdg is an analogue of glucose and accumulates in tissues with increased glucose metabolism, which is typical for tumour cells. therefore, on a pet/ct scan, areas with increased glucose metabolism activity may indicate the presence of cancer or other malignant processes. the high diagnostic accuracy provided by pet/ct can be used to determine the stage of the disease, assess its spread in the body, and determine the effectiveness of treatment. this is especially important for planning the optimal treatment strategy and monitoring the dynamics of the disease. the use of 18f-fdg pet/ct imaging allows the detection of primary tumour lesions with high diagnostic value. the results by gharehzadehshirazi et al.33 have shown a decrease in the incidence of unknown primary lesions among head and neck cancers from 2-9 to 1-2% after the introduction of pet/ct. in addition, pet/ct can simultaneously detect other metastatic sites and assess their extent, which has a significant impact on determining the stage of the tumour, its recurrence, and the choice of treatment methods. consequently, pet/ct plays a key role in the diagnosis of cup, providing a more accurate and comprehensive assessment of patients with unknown primary lesions. magnetic resonance imaging (mri) can also be used to diagnose stomach cancer, especially if the tumour is suspected to have invaded neighbouring structures or metastasised. mri provides higher image resolution and contrast, especially in soft tissues, making it a useful tool for detailed assessment of the tumour process.34 table 2 provides a comparative overview of various imaging techniques mentioned before that are used in cancer diagnostics, highlighting their strengths, limitations, and primary applications. although the diagnosis of cancer can be much improved with these cutting-edge imaging methods, there are a number of obstacles to overcome in their use. many healthcare facilities may find the expensive cost of equipment, particularly for pet/ct and mri, to be unaffordable, especially in environments with low resources. furthermore, these technologies frequently call for specific training for both use and interpretation, which can result in a staffing shortage. these sophisticated procedures typically offer more precision and detail when compared to more conventional techniques like x-rays.35 for example, pet/ct might identify metabolically active tumours that traditional ct alone might miss, which could result in an earlier diagnosis and better patient outcomes. but the price of each exam goes up with this greater precision. it is also important to carefully consider the diagnostic benefits of ct and pet/ct radiation exposure vs. radiation exposure, particularly in situations when repeat imaging is necessary. despite these difficulties, the enhanced diagnostic powers of these sophisticated procedures can result in more accurate staging, better treatment planning, and possibly better patient outcomes compared to more conventional approaches. for instance, mri is very useful for tracking treatment response over time since it may give comprehensive soft tissue imaging without exposing the patient to radiation. a key difficulty in enhancing overall cancer care is striking the correct balance between introducing these cutting-edge technologies and guaranteeing universal access to fundamental diagnostic tools as healthcare systems continue to change.36 the development of nanotechnology opens broad prospects for the diagnosis and treatment of cancer. according to jin et al.37 and gupta et al.,38 nanotechnology is a promising area of research that can significantly improve the diagnosis, treatment, and monitoring of cancer. nanoparticles and nano vectors can be used to deliver drugs directly to tumour cells, which increases the effectiveness of treatment and reduces side effects. nanoparticles can be used to deliver gene constructs to tumour cells, which modulate their function and regulate growth and division. various nanomaterials, such as gold nanoparticles and quantum dots, can be used in these applications due to their unique physical and chemical properties. the use of nanotechnology in oncology opens new opportunities to improve the diagnosis and treatment of cancer, and research in this area may lead to the development of new innovative methods of combating this disease.39 these materials can work at the molecular level, which can be used for accurate cancer diagnosis and visualisation of pathological processes. for instance, nanoparticles can be loaded with drugs and delivered directly to the tumour, providing precise and targeted treatment. nanotechnologies are also used to develop nanosensors for detecting cancer biomarkers with high sensitivity and specificity.40 all these advances in nanotechnology open new opportunities for early diagnosis and effective treatment of cancer, which will significantly improve the prognosis and quality of life of patients. thakur et al.41 described the possibility of predicting the occurrence of cancer in their research. as determined, the known gene signature can be successfully used for histopathological classification of non-small cell lung cancer. ji and cui,42 bahrami and ferns43 presented one method of cancer prognosis based on gene expression. the main purpose of this classifier is to predict earlystage recurrence of the disease in patients with colorectal cancer. this gene expression-based classifier identifies patients at increased risk of colorectal cancer recurrence and prescribes additional treatment or monitoring promptly. this method can improve treatment results and reduce the likelihood of recurrence. such studies open new opportunities for an individualised approach to cancer treatment and improve the efficiency of predicting treatment outcomes based on genetic data. recent years have brought significant advances in genomic and transcriptomic engineering based on the crispr system. the crispr-cas13 rna-targeting system is a unique tool with potential for cancer diagnosis, therapy, and research. cas13, as part of this system, has several biochemical properties that make it a promising tool in the fight against cancer. cas13-based diagnostic social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12831] [page 99] non -co mmerc ial us e o nly methods offer early detection and monitoring of cancer markers from liquid biopsy samples such as blood or urine without the need for sophisticated devices. this can simplify the diagnostic process and improve the results of disease treatment, as it will allow the detection of cancer at early stages when treatment is more effective.44 in addition, cas13 can be used for targeted cancer therapy by degrading and manipulating cancer-associated transcripts. this method has high efficiency and specificity, which makes it promising for use in the treatment of cancer. thus, the rna-targeted crispr-cas13 system opens new opportunities in cancer diagnostics, therapy, and research, which can significantly affect the practice of clinical oncology and improve patient outcomes. this, in turn, opens new opportunities for the development of innovative treatments aimed at precisely targeting cancer cells with minimal side effects. in cancer therapy, the crispr-cas13 system can be used for targeted editing of the tumour cell genome, which allows for the inactivation of oncogenes or enhancing the activity of tumour suppressor genes. this fact opens up prospects for the development of innovative cancer treatment methods with high efficiency and safety. in cancer research, the crispr-cas13 system plays an important role in identifying new molecular mechanisms of tumour development, investigating mechanisms of drug resistance, and finding new therapeutic targets. this contributes to the development of more effective methods of cancer diagnosis and treatment. these new technologies allow researchers to better understand the mechanisms of cancer development, identify genes that may be responsible for drug resistance, and discover new molecular markers that can be used as therapeutic targets.45,46 in addition, the crispr-cas13 system is applicable for precise rna editing, which opens new opportunities for the development of personalised cancer treatments. researchers actively using crisprcas13 technologies can develop new next-generation cancer diagnostic and treatment strategies that can be effective and safe for patients. psa and acpp are just two examples of protein biomarkers found in areas of high concentration in tissues, and many others are being studied. in addition to selective gene expression, the expression of tissue-specific proteins can result from mechanisms such as differential splicing, which generates tissue-specific variants.47,48 while new technologies have the potential to revolutionise cancer diagnosis, a lot of them use ai, which also raises significant ethical concerns. the possibility of bias in ai algorithms, which might result in differences in diagnosis and treatment is one of the main problems. ai systems may generate biassed results and disadvantage some groups based on factors such as ethnicity, gender, or socioeconomic position if they are trained on datasets that are not representative of varied communities. furthermore, maintaining confidence in ai decision-making processes depends on their transparency. clear explanations and accountability systems are necessary for patients and healthcare professionals to be able to comprehend and critically examine the reasoning behind ai-driven decisions. the use of ai in cancer diagnosis could worsen alreadyexisting healthcare disparities and erode patient confidence in new technologies if these ethical issues are not resolved. post-translational processing and modification of proteins are important aspects of their functional regulation. in the human body, proteins can undergo various types of post-translational modifications, such as phosphorylation, glycosylation, acetylation, methylation, and others, which can significantly affect their structure, function, and interaction with other molecules. the proteome is the set of all proteins synthesised in a cell or organism, and it represents a more complex level of organisation of biological systems than the genome. as estimated by yadav et al.,49 in general, many different proteoforms can exist in the human body due to various types of post-translational modifications and alternative splicing. one example of a protein modification used as a biomarker for malignant diseases, as mentioned, is ca19-9. ca19-9 is a glycoprotein, and its levels may be elevated in the blood of patients with certain types of cancer, such as pancreatic and gastric cancer. changes in ca19-9 glycosylation can be used as a disease marker and in the diagnosis of cancer. thus, the understanding of posttranslational modifications of proteins and their role in pathology contributes to the development of new methods of diagnosis and therapy of various diseases, including cancer. although oncofoetal antigens may be considered an unexpected source of tumour-specific markers, tumours seem to regularly express tumour-specific modified proteins or neoantigens resulting from mutations. these neoantigens are of interest because they can stimulate the body’s immune response to fight tumours. in addition, they can serve as targets for diagnostic or therapeutic applications.49 thus, the study of neoantigens opens new prospects for the development of effective methods of cancer diagnosis and treatment. recent advances in immune-oncology therapy targeting pd-1, pd-l1, and ctla4 proteins are opening new perspectives in cancer treatment. studies show that many tumours stimulate specific immune responses. however, progressive tumours can develop mechanisms to avoid the immune response, which necessitates the improvement of treatment methods.50 one of the key aspects of this research is the identification of new molecular mechanisms underlying the interaction between tumours and the immune system.51 this describes why some tumours become resistant to immunotherapy, while others respond effectively to this therapy. one of these mechanisms is the tumour’s ability to neutralise the immune response through molecular mechanisms, such as pd-l1 expression or the production of immunomodulators. this makes them less vulnerable to immune system attacks. however, given the ongoing research, it is possible to develop new treatments that can overcome these mechanisms. studies also show those immune responses can be directed to specific targets in the tumour.52,53 this opens the possibility of developing individualised immunotherapy that addresses the molecular characteristics of each patient’s specific tumour. rna plays an important role in many aspects of oncology, including diagnosis, prognosis, disease progression, therapy selection, and monitoring of treatment efficacy. some micrornas may be associated with cancer and serve as biomarkers for diagnosis or prognosis. for example, fusion rnas: in some cases of cancer, genes can be rearranged or fused, leading to the formation of fusion proteins.54 the detection of fusion rnas can indicate specific mutations that are targeted for drug therapy. these circulating rnas can serve as non-invasive biomarkers for the diagnosis, prognosis, and monitoring of cancer. rna sequencing: modern rna sequencing methods can be used to analyse gene expression on a large scale and identify new changes in the genome that may be associated with cancer. the role of dna in cancer diagnosis dna is also important in oncology and is used to diagnose, predict, and treat cancer. genetic mutations: changes in dna can lead to the development of cancer. some genetic mutations can be inherited, while others can be caused by external factors, such as ultraviolet radiation or chemical carcinogens. dna analysis can identify these mutations and establish their association with specific types of cancer. genetic tests can identify individuals at high risk of developing cancer as a result of specific genetic variants. social and political factors affecting public health [page 100] [healthcare in low-resource settings 2024;12(s2):12831] non -co mmerc ial us e o nly this can help in the detection and prevention of the disease. determination of microsatellite instability can be used to diagnose hereditary forms of cancer and select treatments, such as immunotherapy.55 all of these aspects demonstrate the importance of dna analysis in oncology for the diagnosis, prognosis, and treatment of cancer. modern methods of molecular analysis of cancer used in diagnosis and treatment are often expensive and require sophisticated equipment. for example, genetic tests, dna sequencing, and other molecular techniques can be costly and require specialised equipment and qualified personnel to perform them.56 in addition, targeted therapeutic agents such as monoclonal antibodies and small molecule drugs may have off-target effects and are available only for a limited range of cancer-causing targets.57 this limits their effectiveness and use in a wide range of cancers. in this regard, there is a constant need to develop universal, effective, and accurate tools for the diagnosis and treatment of cancer. these tools may include new molecular analysis technologies that are more affordable and easier to use, as well as innovative treatments that provide targeted effects on cancer cells with minimal side effects. such developments can significantly improve the efficiency and results of the fight against cancer. conclusions thus, modern technologies play a key role in the development of cancer diagnostic methods. they ensure not only early detection of cancer but also the accuracy and objectivity of the diagnosis. immunohistochemical methods, molecular genetic research, and medical image processing have become essential tools in modern oncological diagnostics. diagnosing cancer remains an important but also challenging problem in medical practice. ways to address this problem include the development of new technologies, improved screening methods, and increased health literacy among the population. significant progress in the diagnosis and treatment of cancer can only be achieved through joint efforts. the overall progress in oncology diagnostics has resulted in a significant improvement in the ability to detect and treat cancer. innovative methods, together with personalised approaches, are opening new prospects for improving the effectiveness of the fight against this disease. future research in oncology diagnostics may include the development of new technologies, such as nanotechnology and molecular sensors, as well as the search for new biomarkers and other disease markers. an important component is the ability to closely monitor patients during treatment, which helps to detect any changes in the course of therapy in time and adjust it if necessary. this approach to the diagnosis and monitoring of patients with central and endobronchial lesions helps to increase the effectiveness of treatment and improve prognosis. the growing interest in health and regular medical check-ups, together with ongoing research and development of new treatments, has led to a significant increase in demand for the purchase of instruments for routine diagnostics as well as for companion diagnostics. this demand is growing, as accurate and rapid diagnostics play a critical role in the detection and treatment of various diseases. innovative treatments require accurate and reliable diagnostic results, which makes molecular and tissue science very important in modern medicine. cancer screening tests play an important role in the early detection of the disease in asymptomatic patients to reduce mortality and morbidity. early detection of cancer can start treatment at earlier stages when the disease has not yet reached an advanced level, which increases the chances of a complete cure or increases the patient’s life expectancy and quality of life. the second goal of cancer screening tests is to reduce the incidence of cancer by detecting and treating its precursors or pre-cancerous conditions. this helps to prevent the development of cancer in the future and reduce the overall number of cases. such screening tests play a key role in preventing and controlling cancer, as they allow the detection and treatment of cancerous precursors, which can significantly reduce the risk of developing cancer and help maintain health. prospects for further research in this area include a thorough study of instrumental diagnostic methods as well as further indepth research into genetic, modulatory, and chemical components that can help diagnose cancer at an early stage. references 1. latka k, kołodziej w, rajski r, et al. outpatient spine surgery in poland: a survey on popularity, challenges, and future perspectives. risk manag healthc policy 2023;16:1839-48. 2. siegel rl, miller kd, wagle ns, jemal a. cancer statistics, 2023. ca cancer j clin 2023;73:17-48. 3. merkuri l, kamberi f, qorri e, shapo l. assessment of the albanian university female students’ knowledge, attitudes, and practices on cervical cancer. j infect dev ctries 2023;17:534-41. 4. dimitrova m, lakic d, petrova g, et al. 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2016. changing trends in the surgical approach to hysterectomy. ginekol pol 2018;89:529-35. 20. budny a, starosławska e, budny b, et al. epidemiology and diagnosis of breast cancer. pol med mercurius 2019;46:195204. 21. basta a, bidzinski m, bienkiewicz a, et al. recommendation of the polish society of oncological gynaecology on the diagnosis and treatment of epithelial ovarian cancer. oncol clin pract 2015;11:233-43. 22. svyatova g, berezina g, urazbayeva g, murtazaliyeva a. frequencies of diagnostically significant polymorphisms of hereditary breast cancer forms in brca1 and brca2 genes in the kazakh population. asian pac j cancer prev 2023;24:3899-907. 23. connal s, cameron jm, sala a, et al. liquid biopsies: the future of cancer early detection. j transl med 2023;21:118. 24. xu m, ergin i, beyaz s. advances in diagnostic procedures and their applications in the era of cancer immunotherapy. adv exp med biol 2020;1244:37-50. 25. van der strate i, kazemzadeh f, nagtegaal id, et al. international consensus on the initial diagnostic workup of cancer of unknown primary. crit rev oncol hematol 2023;181:103868. 26. nasir a, khan a, li j, et al. nanotechnology, a tool for diagnostics and treatment of cancer. curr top med chem 2021;21:1360-76. 27. pandey i, misra v, pandey at, et al. artificial intelligence technologies empowering identification of novel diagnostic molecular markers in gastric cancer. indian j pathol microbiol 2021;64:s63-8. 28. bradshaw ra, hondermarck h, rodriguez h. cancer proteomics and the elusive diagnostic biomarkers. proteomics 2019;19:e1800445. 29. liu x, jiang h, wang x. advances in cancer research: current and future diagnostic and therapeutic strategies. biosensors 2024;14:100. 30. brito b, price tw, gallo j, et al. smart magnetic resonance imaging-based theranostics for cancer. theranostics 2021;11:8706-37. 31. gaya a, crook t, plowman n, et al. evaluation of circulating tumor cell clusters for pan-cancer noninvasive diagnostic triaging. cancer cytopathol 2021;129:226-38. 32. wiley c, wise cf, breen m. novel noninvasive diagnostics. vet clin north am small anim pract 2019;49:781-91. 33. gharehzadehshirazi a, zarejousheghani m, falahi s, et al. biomarkers and corresponding biosensors for childhood cancer diagnostics. sensors 2023;23:1482. 34. latka k, kolodziej w, pawlak k, et al. fully endoscopic spine separation surgery in metastatic disease – case series, technical notes, and preliminary findings. medicina (kaunas) 2023;59:993. 35. postic sd. x-ray diffraction technique in the analysis of phases of hydroxylapatite and calcium phosphate in a human jaw. int j biomed 2014;4:109-13. 36. slivkina n, abduldayeva a, tardjibayeva s, et al. the health of the population, according to prenosological diagnostics. georgian med news 2020;303:188-93. 37. jin c, wang k, oppong-gyebi a, hu j. application of nanotechnology in cancer diagnosis and therapy – a mini-review. int j med sci 2020;17:2964-73. 38. gupta d, roy p, sharma r, et al. recent nanotheranostic approaches in cancer research. clin exp med 2024;24:8. 39. bhushan s, mittal a, beg mf, agarwal a. missed gall bladder malignancy: a result of ignoring predisposing factors. int j med med res 2023;9:6-14. 40. parker j. uncovering cancer’s secrets: could liquid biopsies and artificial intelligence hold the answers? future oncol 2023;19:1231-3. 41. thakur t, batra i, luthra m, et al. gene expression-assisted cancer prediction techniques. j healthc eng 2021;2021:4242646. 42. ji x, cui q. ancient genes can be served as pan-cancer diagnostic and prognostic biomarkers. j cell mol med 2020;24:6908-15. 43. bahrami a, ferns ga. diagnostic, prognostic, and therapeutic value of mir-148b in human cancers. curr mol med 2022;22:860-9. 44. palaz f, kalkan ak, can z, et al. crispr-cas13 system as a promising and versatile tool for cancer diagnosis, therapy, and research. acs synth biol 2021;10:1245-67. 45. rai a, noor s, ahmad si, et al. recent advances and implication of bioengineered nanomaterials in cancer theranostics. medicine 2021;57:91. 46. animesh s, singh yd. a comprehensive study on aptasensors for cancer diagnosis. curr pharm biotechnol 2021;22:106984. 47. landegren u, hammond m. cancer diagnostics based on plasma protein biomarkers: hard times but great expectations. mol oncol 2021;15:1715-26. 48. makler a, asghar w. exosomal biomarkers for cancer diagnosis and patient monitoring. expert rev mol diagn 2020;20:387-400. 49. yadav s, vadivelu r, ahmed m, et al. stretching cells – an approach for early cancer diagnosis. exp cell res 2019;378:191-7. 50. polatova dsh, madaminov ayu, savkin av, et al. pd-l1 and p53 expression in squamous cell carcinoma of the oropharynx depending on human papilloma virus status. head neck tumors 2023;13:44-56. 51. pal m, muinao t, boruah hpd, mahindroo n. current advances in prognostic and diagnostic biomarkers for solid cancers: detection techniques and future challenges. biomed pharmacother 2022;146:112488. 52. wang xq, goytain a, dickson bc, nielsen to. advances in sarcoma molecular diagnostics. genes chromosomes cancer 2022;6:332-45. 53. kim dh, kim y, kim sw, hwang sh. use of narrowband social and political factors affecting public health [page 102] [healthcare in low-resource settings 2024;12(s2):12831] non -co mmerc ial us e o nly imaging for the diagnosis and screening of laryngeal cancer: a systematic review and meta-analysis. head neck 2020;42:2635-43. 54. mueller cg, gaiddon c, venkatasamy a. current clinical and pre-clinical imaging approaches to study the cancer-associated immune system. front immunol 2021;12:716860. 55. wong pk, chan in, yan hm, et al. deep learning based radiomics for gastrointestinal cancer diagnosis and treatment: a minireview. world j gastroenterol 2022;28:6363-79. 56. lavasanifar a, sharp cn, korte ea, et al. long interspersed nuclear element-1 mobilization as a target in cancer diagnostics, prognostics and therapeutics. clin chim acta. int j clin chem 2019;493:52-62. 57. ivashko m, burmei s, yusko l, et al. microbiological diagnostics: from traditional to molecular genetic methods: a literature review. bull med biol res 2023;5:34-41. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12831] [page 103] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2013; 1:e17] [page 57] sex differences in long-term outcomes of patients with percutaneous coronary intervention: the armenian experience yeva sahakyan,1,2 michael e. thompson,1,3 lusine abrahamyan1,4 1college of health sciences, american university of armenia, yerevan; 2department of therapy, yerevan state medical university, yerevan, armenia; 3department of public health sciences, the university of north carolina at charlotte, nc, usa; 4toronto health economics and technology assessment (theta) collaborative, university of toronto, ontario, canada abstract the present study aimed at assessing sex differences in perioperative characteristics and 3-year event-free survival from major adverse cardiac and cerebrovascular events (macce) in patients with percutaneous coronary intervention (pci) in armenia. the study utilized an observational, retrospective cohort design enrolling patients who underwent pci from 2006 to 2008 at a single center in yerevan, armenia. major adverse cardiac and cerebrovascular events included all-cause mortality, myocardial infarction (mi), repeat revascularization, or stroke/transient ischemic attack. among 485 participants included in the analysis, 419 (86%) were men. women were older, more hypertensive, more obese, and had significantly higher rates of diabetes. at the end of follow-up, the incidence of macce was 37% for men and 33% for women (p=0.9). based on the results from the adjusted cox proportional hazards model, the independent predictors of macce included acute mi [hazard ratio (hr)=1.43, 95% confidence interval (ci): 1.02-2.00], arrhythmia (hr=1.64, 95% ci: 1.07-2.50), sex (hr=2.46, 95% ci: 1.085.61), diabetes (hr=5.65, 95% ci: 2.14-14.95), and the interaction between sex and diabetes (hr=0.16; 95% ci: 0.05-0.47). among diabetic patients, men had better event-free survival from macce (hr=0.40, 95% ci: 0.19-0.85) than women, whereas in patients without diabetes men had worse outcomes than women (95% ci: 1.08-5.62). in armenia, the baseline profile of women undergoing pci differed considerably from that of men. in patients with diabetes, women had worse outcomes at longterm follow-up, while the opposite was noted in patients without diabetes. introduction coronary artery disease (cad) is the leading cause of morbidity and mortality among both men and women worldwide.1 although historically considered a man’s disease because of its earlier manifestation in a man’s life, recent studies have indicated that more females die from cad than males.2,3 nonetheless, women are referred less frequently for invasive interventions such as percutaneous coronary intervention (pci), comprising only one-third of all pcis performed in the us.4 such a discrepancy may be explained by the belief that women do not benefit from invasive strategies as much as men do.2 studies have documented that women have worse clinical outcomes such as myocardial infarction (mi), stroke, and vascular complication after pci than men.2,5 poor outcomes can be attributed to a higher prevalence of risk factors and comorbidities such as older age, obesity, hypertension, diabetes mellitus, and congestive heart failure in women than in men at the time of the intervention.2,5,6 after adjustment for these factors, several studies reported a persistent survival disadvantage for women.2,4 several other studies, however, reported that the sex differences disappeared after adjustments5-9 or that women had better outcomes.10-12 armenia, located in the caucasus, has a population of approximately 3 million people.13 the burden of cad in armenia is significant. according to armenia’s ministry of health, in 2009 cad morbidity was 1967/100,000 and mortality was 247/100,000 population.14 given the conflicting evidence on gender differences and the paucity of information on cad in armenia, this study assessed sex differences in the long-term clinical outcomes of pci patients in armenia treated at the nork marash medical center (nmmc) in yerevan. the nork marash medical center is the largest tertiary cardiac surgery center in armenia and boasts outcomes comparable to those observed in other international cardiac centers.15 in this study we evaluated sex differences in average patient-reported 3-year event-free survival from the composite major adverse cardiac and cerebrovascular events (macce) in patients with cad who had pci at nmmc. materials and methods the study utilized an observational, retrospective cohort design. the sample included all patients with cad who had undergone pci at nmmc from 1 january 2006 to 31 december 2008. patients with missing contact information, missing medical records, residing outside of armenia at the time of the study, or who did not speak armenian were excluded. patient contact information was abstracted from the nmmc pci dataset. telephone surveys were conducted from february to april 2011 to evaluate patients’ long-term outcomes and to obtain consent to review patients’ medical records for perioperative information. the study protocol was approved by the institutional review board at the american university of armenia and by the nmmc administrative board. the main outcome of interest was the 3-year average survival rate from the composite macce that included all-cause mortality, mi, repeat revascularization, or stroke/transient ischemic attack (tia) established by patient self-reports. all patient-reported repeat hospitalizations to nmmc were verified using the nmmc database. we also assessed patients’ hospital length of stay, prescription of discharge medications, and in-hospital and early operative complications and mortality. a repeat revascularization was defined as a repeat surgical (coronary artery bypass grafting) or percutaneous coronary intervention (target or new vessel). operative complications were defined as all major events occurring within 30 days after the pci. healthcare in low-resource settings 2013; volume 1:e17 correspondence: lusine abrahamyan, toronto health economics and technology assessment (theta) collaborative, university of toronto, 144 college street, on m5s 2s2 toronto, ontario, canada. tel. +1.416.946.3718 fax: +1.416.946.3719. e-mail: lusine.abrahamyan@utoronto.ca key words: percutaneous coronary intervention, diabetes, long-term outcomes, armenia. contributions: ys developed the project proposal, acquired data, performed data analysis and wrote the draft paper; la and met provided guidance to project proposal, data analysis and interpretation, and critically revised the manuscript. conflict of interests: the authors declare no potential conflict of interests. funding: this study was made possible by the internal student support funds provided by the college of health sciences and the center for health services research and development of the american university of armenia. received for publication: 15 february 2013. revision received: 14 april 2013. accepted for publication: 15 april 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright y. sahakyan et al., 2013 licensee pagepress, italy healthcare in low-resource settings 2013; 1:e17 doi:10.4081/hls.2013.e17 non co mmerc ial us e o nly [page 58] [healthcare in low-resource settings 2013; 1:e17] statistical analysis continuous variables are presented as means and standard deviations and compared between groups using student’s t-test; categorical variables are presented as counts and percentages and compared using a chi-square test or fisher’s exact test. the event-free survival rate from macce was estimated by the kaplan-meier product-limit method. cox proportional hazard models were used to estimate unadjusted and adjusted hazard ratios (hr) of macce at the end of follow-up. backward stepwise elimination was used for the multivariable cox proportional hazards model. all variables found significant in univariate analyses (p<0.05) and those found predictive from past studies were entered together into the model at once and eliminated using the likelihood ratio test. the final model was checked for effect modifiers and for conformity with the proportionality assumption. all statistical analyses were performed using the stata10 software package (stata statistical software, college station, tx, usa). results overall, 894 patients underwent pci from 2006 to 2008 at nmmc. of these, 839 were residents of armenia. we could not reach 315 patients for various reasons (i.e. phone number not provided, wrong number/number changed, patient was out of the country at the time of contact, no response to call). in total, 524 patients were contacted for the phone interview. of these, 23 refused to participate, 3 were found to be ineligible, and, after the interviews, medical records were not available for 13 patients. if the patient was reported as dead (n=38) at the time of the interview, information about the macce and consent to access the medical records was obtained from an immediate family member. the final total sample included 485 patients. patient baseline and procedural characteristics the study sample (n=485) included 419 (86%) men and 66 women. patients’ baseline characteristics stratified by sex are presented in table 1. women were on average 5 years older than men and had a higher prevalence of hypertension, obesity, and diabetes and more often presented with stable angina. a significantly higher proportion of men smoked and at admission presented with acute mi more frequently than women. no differences were observed in the number of diseased vessels and the number and types of stents implanted (table 1). in men and women, the most frequently stented vessel was the left anterior descending (lad) artery. no statistically significant differences were seen between women and men in discharge medication, except for a higher rate of angiotensinconverting enzyme inhibitors (acei)/ angiotensin receptor blockers (arb) prescribed to women. acute in-hospital and 30-day operative outcomes thirty-day operative complications were observed in 3 women (4.5%) and in 23 men (5.5%, p=0.7). overall, the following complications were observed: ventricular tachycardia/ ventricular fibrillation (n=4); complete atrioventricular block (n=2); hematoma at the intervention site (n=1); coronary artery dissection (n=1); reperfusion syndrome (n=1); stent thrombosis (n=2); tia (n=1); acute renal failure (n=1); acute heart failure (n=1); lad occlusion during coronary angiography (n=1); recurrent mi (n=2); and repeat revascularization (n=4). in-hospital deaths occurred in 2 men. death within 30 days after pci occurred in 1 woman and 3 men. the hospital length of stay did not differ between sexes and was on average 4.5±3.6 days for the total sample. article table 1. baseline patients’ characteristics. patients’ characteristics° men (n=419) women (n=66) p risk factors and comorbidities age (years, mean±sd) 54.7±9.5 59.9±8.6 <0.01 family history of cad (%) 210 (53.4) 41 (65.1) 0.09 current smoker (%) 258 (63.9) 4 (6.2) <0.01 diabetes (%) 58 (13.9) 24 (36.3) <0.01 hypertension (%) 292 (69.6) 57 (86.4) <0.01 bmi (kg/m2, mean±sd) 28.6±4.1 30.4±5.3 <0.01 stroke/tia (%) 33 (7.9) 8 (12.1) 0.26 renal failure (%) 3 (0.7) 0 (0.0) 0.49 cardiac status (%) acute mi 148 (35.3) 16 (24.2) 0.08 prior mi 155 (37.2) 19 (28.7) 0.19 unstable angina 183 (43.7) 32 (48.5) 0.46 stable angina 56 (13.4) 17 (25.7) 0.01 previous pci 10 (2.4) 0 (0.0) 0.20 previous cabg 24 (5.7) 2 (3.0) 0.36 arrhythmia 59 (14.2) 11 (16.7) 0.59 angiographic profile ef (%, mean±sd) 45.1±7.1 47.2±6.9 0.03 number of diseased vessels (%) single vessel 123 (30.2) 20 (31.8) 0.40 double vessel 161 (39.6) 20 (31.8) triple vessel 123 (30.2) 23 (36.5) number of stents implanted (%) one 303 (72.3) 41 (62.1) 0.21 two 101 (24.1) 21 (31.8) three 15 (3.6) 4 (6.1) type of stented vessel (%) lcx 130 (31.2) 19 (28.8) 0.45 lad 221 (53.0) 45 (68.0) 0.02 rca 125 (29.9) 18 (27.3) 0.65 stent type (%) des 339 (81.9) 58 (87.9) 0.48 bms 67 (16.2) 7 (10.6) both 8 (1.9) 1 (1.5) discharge medications (%) aspirin 384 (97.5) 63 (100.0) 0.20 tienopiridine derivatives 382 (96.9) 62 (98.4) 0.50 beta blockers 330 (83.7) 56 (88.9) 0.30 acei/arb 259 (65.7) 50 (79.3) 0.03 statins 340 (86.0) 52 (82.0) 0.40 cad, coronary artery disease; bmi, body mass index; tia, transient ischemic attack; mi, myocardial infarction; pci, percutaneous coronary intervention; cabg, coronary artery bypass graft; ef, ejection fraction; lcx, left circumflex; lad, left anterior descending; rca, right coronary artery; des, drug eluting stent; bms, bare metal stent; acei/arb, angiotensin converting enzyme inhibitors/angiotensin receptor blockers. °results are presented as frequencies and percentages, unless specified otherwise. all percentages were calculated after excluding missing values. non co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e17] [page 59] event-free survival rates at long-term follow-up the median follow-up of the total sample was 1148 days, ranging from 3 to 1917. the mean follow-up was 1267±321 days for women and 1232±321 days for men (p=0.4). during the follow-up period, the total number of macce (n=180) did not significantly differ between men and women (37.0 vs 33.3%, p=0.9) (table 2). the most frequently observed macce in both groups was repeat revascularization. the event-free survival from macce at the median follow-up was 0.79 (95% ci: 0.66-0.87) for women and 0.74 (95% ci: 0.69-0.78) for men (p>0.05). the unadjusted predictors of long-term survival (macce) were identified using univariate cox proportional hazard models. significant predictors (p<0.05) of event-free survival were acute mi at admission, arrhythmia, left ventricular ejection fraction, number of diseased vessels, and stent type. the final, multivariable model included sex (hr=2.46, 95% ci: 1.08-5.61), diabetes (hr=5.65, 95% ci: 2.14-14.95), arrhythmia (hr=1.64, 95% ci: 1.07-2.50), acute mi at admission (hr=1.43, 95% ci: 1.02-2.00), and the interaction between sex and diabetes (hr=0.16; 95% ci: 0.05-0.47) (table 3). in patients without diabetes, after adjusting for arrhythmia and acute mi at admission, men had worse event-free survival from macce (hr=2.46, 95% ci: 1.08-5.62) than women (table 4, figure 1a). after adjusting for arrhythmia and acute mi at admission, in patients with diabetes, men had better eventfree survival from macce (hr=0.40, 95% ci: 0.19-0.85) than women (table 4, figure 1b). discussion this observational study sought to evaluate sex differences in 3-year event-free survival from macce in patients with cad who had pci in a single center in armenia. we observed significant differences in several baseline factors between men and women. for example, women on average were older than men, more hypertensive, more obese, and had a significantly higher rate of diabetes. in contrast, men were more likely to be smokers. similar differences were observed in several past studies.2,5,11,16,17 for example, a recent observational study conducted by duvernoy et al. found that women were more obese (47.9 vs 43.1%) and more often had diabetes mellitus (38.5 vs 29.2%) and hypertension (82.5 vs 71.0%), and that men were more likely to smoke (27.3 vs 21.7%).2 in the current analysis, the unadjusted event-free survival at the end of follow-up was article table 2. distribution of major adverse cardiac and cerebrovascular events between sexes. events, n (%) total sample men women p (n=485) (n=419) (n=66) mi 31 (6.4) 26 (6.2) 5 (7.6) 0.8 rr 102 (21.0) 92 (22.0) 10 (15.2) 0.3 pci 71 (14.6) 64 (15.3) 7 (10.6) cabg 32 (6.6) 29 (6.9) 3 (4.5) death 38 (7.8) 31 (7.4) 7 (10.6) 0.4 stroke/tia 9 (1.9) 9 (2.2) 0 (0.0) 0.4 total macce 180 (37.1) 158 (37.7) 22 (33.3) 0.9 mi, myocardial infarction; rr, repeat revascularization; pci, percutaneous coronary intervention; cabg, coronary artery bypass graft; tia, transient ischemic attack; macce, major adverse cardiac and cerebrovascular events. table 3. unadjusted and adjusted cox proportional hazard models of survival from major adverse cardiac and cerebrovascular events. unadjusted adjusted predictors hazard ratio 95% ci p hazard ratio 95% ci p sex 1.12 0.69-1.81 0.652 2.46 1.08-5.61 0.032 diabetes 1.28 0.85-1.94 0.241 5.65 2.14-14.95 0.000 acute mi 1.51 1.09-2.10 0.014 1.43 1.02-2.00 0.036 arrhythmia 1.66 1.09-2.53 0.018 1.64 1.07-2.50 0.022 sex*diabetes 0.16 0.05-0.47 0.001 ci, confidence interval; mi, myocardial infarction; sex*diabetes, interaction between sex and diabetes. table 4. interaction between sex and diabetes in survival from major adverse cardiac and cerebrovascular events after controlling for acute myocardial infarction and arrhythmia. patients (n) macce (n) hazard ratio (95% ci) p diabetes male 58 15 0.40 (0.19-0.85) 0.02 female 24 15 1.0 (reference) no diabetes male 361 143 2.46 (1.08-5.61) 0.03 female 42 7 1.0 (reference) macce, major adverse cardiac and cerebrovascular events; ci, confidence interval. figure 1. survivor functions by sex, adjusted for acute myocardial infarction and arrhythmia. non co mmerc ial us e o nly [page 60] [healthcare in low-resource settings 2013; 1:e17] similar between sexes, despite the differences in baseline profiles. these results agree with past studies that also had a retrospective design, followed patients 3 years or longer, and similarly enrolled patients with stable and unstable angina and acute mi.7,9,18 however, these studies demonstrated that after the adjustment for baseline differences the rates of major adverse cardiac events (mace) were no longer different between the sexes. overall, compared to studies in the early 1990s, recent studies have mostly shown that with improved care and technologies, the gap between men and women in complication rates and rates of mace at long-term follow-up is disappearing.19 the evidence of the impact of diabetes status on sex differences in pci outcomes is still contradictory. in our sample of patients, the prevalence of diabetes was almost 2.5 times higher among women than men (36 and 14%, respectively). after adjusting for acute mi and arrhythmia, we found that women with diabetes had a higher risk of macce than men. in contrast, a recent study that enrolled only patients with diabetes in japan found that at 4year follow-up after pci, the cumulative incidence of mace was similar between the sexes, despite the fact that women had a worse baseline profile.20 similar to our study, a significant interaction was observed by mehilli et al., who evaluated the impact of sex on mortality after pci in a cohort of patients with stable and unstable angina.12 they reported that diabetic women had almost twice the mortality hazard in comparison to diabetic men, whereas no significant difference was observed in mortality among the non-diabetic population. further analysis of our data revealed that among men, diabetes status did not significantly affect the risk of developing macce. among women, diabetes was a significant predictor of macce after adjusting for acute mi and arrhythmia (data not shown). our finding is supported by a recent meta-analysis of 37 studies that evaluated the risk of fatal coronary events among a diabetic population.21 it demonstrated that the rate of adverse outcomes was higher among diabetic than nondiabetic patients, but the difference was more pronounced among women than men. the study concluded that the relative risk for fatal cad associated with diabetes is overall 50% higher in women than in men, most likely due to differences in baseline risk profiles and disparities in treatment approaches. in our study, we did not evaluate the severity of diabetes (insulin dependent or not; effectively managed or not) that might explain the observed variability in the impact of diabetes on the outcomes by sex. a study that evaluated the effectiveness of drug-eluting stents in acute coronary syndrome patients with diabetes reported a higher prevalence of insulindependent diabetes among women compared to men.22 the sex differences in our study may also be explained by unequal access to or utilization of health care services in armenia. the 2005 armenian demographic and health survey found that although a higher proportion of women reported having health problems than men (13.8 vs 11.2%), men had overall higher hospitalization rates than women (2.6 vs 2.3%).13 the limitations of the study merit discussion. in the studied sample, the male female ratio was almost six to one (419 to 66), thus limiting the number of independent predictors that could have been studied and potentially their precision. another important limitation of our study was that the follow-up data about macce were collected retrospectively through telephone interviews, which could introduce recall and report biases. to minimize that bias, we verified self-reported outcomes with the nmmc medical records where possible. another source of potential bias came from inaccuracies in medical records where, for example, heart failure status and blood lipid levels were not consistently reported and were excluded from the analyses. about one-third of the patients from the original sample were unreachable, either because of inaccurate contact information or absence from the country. the comparison of these non-responders with the final study population using nmmc patient registry information indicated that nonresponders were on average 2 years younger (p<0.05) than the enrolled patients, and the difference was mainly attributed to the difference among the male population. thus, the non-response bias suggests that our detected differences would probably be of a larger magnitude if the total sample had been included. conclusions in conclusion, we found that in armenia, women with cad differed from men in several baseline risk factors and comorbidities. women were older than men and had higher prevalence of hypertension, obesity, and diabetes. a significantly higher proportion of men smoked. the differences in the long-term outcomes of pci between men and women were dependent on the diabetes status. future studies should investigate the nature, extent, and causal mechanism of the excess risk of diabetes on pci outcomes, and targeted strategies should be developed to decrease this risk and improve patient outcomes. references 1. roger vl, go as, lloyd-jones dm, et al. heart disease and stroke statistics-2011 update: a report from the american heart association. circulation 2011;123:e18-e209. 2. duvernoy cs, smith de, manohar p, et al. gender differences in adverse outcomes after contemporary percutaneous coronary intervention: an analysis from the blue cross blue shield of michigan cardiovascular consortium (bmc2) percutaneous coronary intervention registry. am heart j 2010159:677-83. 3. shu w, lei w, peng s. recent development of ischaemic heart disease in sex difference. postgrad med j 2007;83:240-3. 4. lansky aj, hochman js, ward pa, et al. percutaneous coronary intervention and adjunctive pharmacotherapy in women: a statement for healthcare professionals from the american heart association. circulation 2005;111:940-53. 5. blomkalns al, chen ay, hochman js, et al. gender disparities in the diagnosis and treatment of non-st-segment elevation acute coronary syndromes: large-scale observations from the crusade (can rapid risk stratification of unstable angina patients suppress adverse outcomes with early implementation of the american college of cardiology/ american heart association guidelines) national quality improvement initiative. j am coll cardiol 2005;45:832-7. 6. kovacic jc, mehran r, karajgikar r, et al. female gender and mortality after percutaneous coronary intervention: results from a large registry. catheter cardio inte 2011;80:514-21. 7. onuma y, kukreja n, daemen j, et al. impact of sex on 3-year outcome after percutaneous coronary intervention using bare-metal and drug-eluting stents in previously untreated coronary artery disease: insights from the research (rapamycineluting stent evaluated at rotterdam cardiology hospital) and t-search (taxus-stent evaluated at rotterdam cardiology hospital) registries. jacc cardiovasc interv 2009;2:603-10. 8. solinas e, nikolsky e, lansky aj, et al. gender-specific outcomes after sirolimuseluting stent implantation. j am coll cardiol 2007;50:2111-6. 9. singh m, rihal cs, gersh bj, et al. mortality differences between men and women after percutaneous coronary interventions. a 25year, single-center experience. j am coll cardiol 2008;51:2313-20. 10. alfredsson j, stenestrand u, wallentin l, et al. gender differences in management and outcome in non-st-elevation acute coronary syndrome. heart 2007;93:1357-62. 11. berger js, sanborn ta, sherman w, et al. influence of sex on in-hospital outcomes and long-term survival after contemporary article non co mmerc ial us e o nly [healthcare in low-resource settings 2013; 1:e17] [page 61] percutaneous coronary intervention. am heart j 2006;151:1026-31. 12. mehilli j, kastrati a, bollwein h, et al. gender and restenosis after coronary artery stenting. eur heart j 2003;24:1523-30. 13. national statistical service, armenia. armenia demographic and health survey 2005. yerevan: national statistical service of armenia ed.; 2006. available from: http://www.measuredhs.com/pubs/pdf/fr18 4/fr184.pdf 14. republic of armenia, ministry of health. health and health care of armenia 2009. official annual statistical report. yerevan: republic of armenia, ministry of health ed.: 2010. 15. abrahamyan l, demirchyan a, thompson me, et al. determinants of morbidity and intensive care unit stay after coronary surgery. asian cardiovasc thorac ann 2006;14:114-8. 16. akhter n, milford-beland s, roe mt, et al. gender differences among patients with acute coronary syndromes undergoing percutaneous coronary intervention in the american college of cardiology-national cardiovascular data registry (acc-ncdr). am heart j 2009;157:141-8. 17. el-menyar a, zubaid m, rashed w, et al. comparison of men and women with acute coronary syndrome in six middle eastern countries. am j cardiol 2009;104:1018-22. 18. d’ascenzo f, gonella a, quadri g, et al. comparison of mortality rates in women versus men presenting with st-segment elevation myocardial infarction. am j cardiol 2011;107:651-4. 19. ge jb. gender difference in patients with acute myocardial infarction treated by primary percutaneous coronary intervention in drug-eluting stent era. chinese med jpeking 2010;123:776-7. 20. ogita m, miyauchi k, dohi t, et al. genderbased outcomes among patients with diabetes mellitus after percutaneous coronary intervention in the drug-eluting stent era. int heart j 2011;52:348-52. 21. huxley r, barzi f, woodward m. excess risk of fatal coronary heart disease associated with diabetes in men and women: metaanalysis of 37 prospective cohort studies. brit med j 2006;332:73-8. 22. longo g, gonella a, d’ascenzo f, et al. percutaneous drug-eluting stent implantation in diabetic patients: short and long term outcomes from an observational study. minerva cardioangiol 2011;59:1-7. article non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11214 the application of the public health model in pregnancy coaching for preventing high-risk pregnancy sri wahyuni,1,2 apriliani yulianti wuriningsih,2 nursalam,3 yuni sufyanti arief3 1doctoral program of the faculty of nursing, airlangga university, surabaya, indonesia; 2lecturer of the faculty of nursing, universitas islam sultan agung, semarang, indonesia; 3lecturer of the faculty of nursing, airlangga university, indonesia abstract introduction: primary health care which is part of the public health model can be applied through pregnancy coaching to prevent high-risk pregnancies. design and methods: this study was conducted using the literature review and meta-analysis (prisma) method. results: a total of 152 articles were obtained from different databases consisting of scopus 7, pro-quest 24, science direct 39, pub med 25, ebsco 57 and were analyzed by excluding articles using picos. the data collection was restricted to pregnancy, pregnancy coaching, research-relevant interventions, outcomes, and article that are not systematic reviews, hence, the analysis obtained 20 relevant articles. conclusion: primary health care which is part of the public health model aimed at reducing new cases is applicable to pregnant women in preventing high-risk pregnancy by optimizing health cadres. introduction a high-risk pregnancy is a dangerous condition for both mother and fetus as it triggers an increase in maternal and fetal mortality. data from the world health organization (who) shows that the number of pregnant and childbirth women who die daily is 810 and 75% is due to the various complications experienced.1 several disorders can occur due to high-risk pregnancies that affect maternal problems in the perinatal period such as the occurrence of premature labor, as well as the birth of babies with low weight which has the potential to increase morbidity and mortality, hence, a high-risk pregnancy needs more attention.2 various examinations are generally carried out at least 6 times in a normal pregnancy period, but in pregnancies with risks referral is necessary.3 the usual practice by the community generally is to visit health care facilities for a pregnancy check-up at least 4 times every month in one pregnancy period.4 the waiting period for antenatal checkups needs to be monitored regularly to ensure that the health conditions of the mother and baby are in a good state to reduce associated risks.5 monitoring can be optimized through mentoring from the closest people who can always remind and increase the mother’s motivation to reduce anxiety and prevent risks associated with pregnancy.6 furthermore, mentoring carried out by an individual with special skills can prevent the occurrence of risks in pregnancy. meanwhile, the primary prevention model in the public health model developed by degreeld caplan (2001) mentioned that primary prevention can be performed by special identification of high-risk groups through health promotion targeted at building an adaptation process by optimizing supporting resources and community social potential. optimizing community potential resources in the form of companions for pregnant women can reduce the risk of pregnancy.7 assistance can be provided through pregnancy coaching, a method of mentoring for pregnant women performed by health workers. the assistance provided can increase the knowledge of pregnant women and improve self efficacy.8 assistance to pregnant women can reduce complications as well as maternal and infant mortality per annum.9 assistance by the closest person who understands health and care efforts in high-risk pregnancies helps the mother to scale through pregnancy safely and comfortably.10 the education provided by the pregnancy companion instills a deep awareness and enables the mother to be independent in recognizing the health problems, this is known as self-efficacy. achieving independence and optimizing self-potential to prevent high-risk pregnancy can be carried out through the care for pregnant women. efforts by service providers include the provision of antenatal care which increases the self-efficacy during pregnancy.11 antenatal care services provide various kinds of health checks for the mother and fetus as well as health consultations. a previous study showed that the mother’s health condition can be optimized through regular antenatal care.12 design and methods this study used is a literature review and meta-analysis (prisma) checklist as a formulation in the systematic review methodology. it focused on topics or variables using results that review significance for public health primary health care which is part of the public health model aimed at reducing new cases can be applied to pregnant women in preventing high-risk pregnancy by optimizing health cadres. meanwhile, pregnancy coaching consisting of trained health cadres can be an extension of the primary health care to provide assistance. the coach is the closest person to pregnant women and is given the responsibility to monitor, provide education, and ensure the maintenance of their health and the fetus. the existence of pregnancy coaching contributes positively to government programs as one of the efforts to achieve sustainable development goals (sdgs), namely the third goal of good health and welfare. pregnancy coach participates in ensuring a healthy life and well-being for all pregnant women. [healthcare in low-resource settings 2023; 11(s1):11214] [page 157] non -co mmerc ial us e o nly have been published in international journals on databases such as scopus, proquest, science direct, pubmed, and ebsco with the keywords: pregnancy coaching, pregnancy, public health model, primary care, self-efficacy. the inclusion criteria of this systematic review include international journals related to the study variables from various databases, as well as studies focused on pregnancy coaching interventions, effects or impacts of giving pregnancy coaching, qualitative, pre-experimental and systematic/literature reviews, articles published from 2017 to 2021, english language journal, full-text, and focused on the implementation of the public health model through pregnancy coaching as an effort to prevent highrisk pregnancy. the prisma (preferred reporting items for systematic reviews and meta analysis) method was used after data collection to find articles that are consistent with the inclusion criteria as demonstrated in figure 1. literature review began with searching for the most relevant journals, reading abstracts, and recording important points of quotation or information that is systematically arranged to easily retrieve the sources.13 each journal selected based on the inclusion criteria is identified in the form of a summary table. results and discussions table 1 describes the literature review performed to obtain data on the public health model through pregnancy coaching as an effort to prevent high-risk pregnancy. the analysis results of 20 literature showed that both ha or the alternative hypothesis were accepted, which signifies that pregnancy coaching effectively prevents high-risk pregnancies. the results were categorized into 4 groups with a breakdown of 4 journals focused on pregnancy educator, 6 on prenatal care, 6 on virtual pregnancy coaching, and 4 on public health or peer coach. public health model the public health model (phm) basedn on gerald caplan is related to prevention interventions developed in basic services in the community, mental health services, basic treatment, prevention, and care that requires social support to overcome crises through three levels of prevention, namely primary prevention, secondary, and tertiary.14,15 primary prevention in public health in the form of actions to promote health such as the education that focuses on the entire population, while secondary prevention aims to reduce disturbances in the community with a focus on the population at risk, and tertiary prevention is an effort that emphasizes review figure 1. prisma chart search flow. [page 158] [healthcare in low-resource settings 2023; 11(s1):11214] non -co mmerc ial us e o nly the population suffering from a disease with the goal of reducing damage through rehabilitation to increase productivity.15 the three preventive measures in pregnancy are prioritized using a primary prevention approach as a form of vigilance to reduce the incidence of risky pregnancies.16 primary prevention which aims to reduce new cases, as well as community education using available resources, and strengthening individual abilities are important components of the mentoring method.17 prenatal care pregnancy is a maturational crisis in women that stimulates physical and psychological changes.18 hormonal changes also have the potential to trigger a high risk of various disorders that accompany pregnancy.19 these risks have dangerous impacts and lead to complications, including maternal and fetal death.1 therefore, intensive monitoring and care of pregnancy are needed as a form of vigilance to prevent the occurrence of complications. awareness of high-risk prevention can be achieved by increasing knowledge through various pregnancy classes.20 antenatal care is usually scheduled for a minimum number of 6 visits during pregnancy.21 through periodic antenatal care, the health condition of the mother and fetus will be monitored continuously for early detection of possible hazards to pregnancy.22 considering the contribution of antenatal check-ups to the prevention of high-risk pregnancies, there is a need for public awareness and special assistance on health conditions during pregnancy. the new thing from this study is optimize the closest community to pregnant women who have been given special training to become a pregnancy coaching. pregnancy coaching pregnancy coaching is an antenatal care program offered to mothers as part of prenatal care to provide education and monitor their health status.17 assistance is very necessary considering that pregnancy stimulates physical, psychological, and behavioral changes that affect the health condition.23 furthermore, the ministry of health of indonesia in 2020 stipulates that antenatal checks be carried out at least 6 times during pregnancy.3 this is because regular antenatal care enables early detection of possible health problems in pregnancy.24 the waiting period for the antenatal care schedule can be optimized with pregnancy coaching . pregnancy coaching is a companion for pregnant women who have been given training beforehand so that they have the skills to provide education and provide motivation to always maintain a healthy pregnancy, carry out routine checks and be aware of risks in pregnancy. the waiting period for the antenatal care schedule can be optimized with pregnancy coaching through education and counseling that can increase motivation, confidence, and independence in making decisions on health issues.25 pregnant women who undergo a mentoring period tend to have self-confidence and increased self-efficacy. this is consistent with a previous study which stated that the education provided during pregnancy significantly increased self-efficacy in both mothers accompanied by their husbands and those unaccompanied.26 self maternal confidence is the mother’s confidence in her ability to provide care and be able to meet all the needs of herself and her baby. self-efficacy is a perception and belief in one’s abilities, it influences a person’s ability to motivate themselves in taking an action to overcome obstacles, problems, and stressors.27-29 for pregnant women, self-efficacy provides confidence in overcoming problems during the pregnancy period and preparing for childbirth as well as the associated new role. furthermore, good self-efficacy will reduce individual stress and improve the quality of maternal health during pregnancy. self-efficacy is related to maternal success in the perinatal period. increased self-efficacy is also positively correlated with successful pregnancy and average vaginal delivery.30-31 self-efficacy can be formed by four main sources, namely performance achievement, experience, verbal persuasion, and the source of information. self-confidence is formed when each component can be optimized to increase the confidence and motivation of pregnant women. low self-efficacy has an impact on maternal anxiety. this is consistent with a previous study which stated that anxiety occurs due to the new roles in primigravida.32-33 self efficacy can be improved by increasing the knowledge of pregnant women specifically through mentoring or pregnancy coaching. a previous study found an increase in the efficacy and parenting ability in caring for babies among mothers who marry at an early age with pregnancy coaching. moreover, understanding the health conditions during pregnancy will reduce individual stressors on the health of mothers and their fetuses. it was also reported that high self-efficacy in pregnant women improves healthy behavior and compliance with health worker recommendations which lead to better perinatal conditions and prevent the emergence of high risks in pregnancy.34-35 review correspondence: sri wahyuni, faculty of nursing, sultan agung islamic university jl. kaligawe raya street km.4. semarang. central java. 50112, indonesia, e-mail: wahyuni@unissula.ac.id key words: public health model, pregnancy coaching, high-risk pregnancy. acknowledgment: the authors are grateful to the faculty of nursing, sultan agung islamic university for their support during the implementation of this study. contributions: all authors contributed equally to this article. conflict of interests: the authors declare no conflict of interest. funding: this study was financially supported by sultan agung islamic university. clinical trials: this study has been approved by the health research ethics committee, faculty of nursing, sultan agung islamic university. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 11 december 2021. accepted for publication: 22 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11214 doi:10.4081/hls.2023.11214 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11214] [page 159] non -co mmerc ial us e o nly conclusions primary health care which is part of the public health model aimed at reducing new cases is applicable to pregnant women in preventing high-risk pregnancies. furthermore, education efforts are carried out by optimizing community resources as companions or pregnancy coaching. pregnancy coaching provides education and monitoring continuously for pregnant women to ensure that the health condition of the mother and fetus is monitored properly. this can be carried out optimally by involving health cadres given that they are the community resources closest to pregnant women. references 1. who. maternal mortality: level and trends 2000 to 2017. sexual and reproductive health. 2019. 12 p. available from: https://www.who.int/reproductivehealth/publications/maternal-mortality-2000-2017/en/ 2. irwinda r, surya r, nembo lf. impact of pregnancy-induced hypertension on fetal growth. med j indones 2016;25:104–11. 3. ministry of health of the republic of indonesia. guidelines for antenatal care, childbirth, postpartum and newborns in the era of adaptation to new habits. jakarta: ministry of health of the republic of indonesia; 2020. 4. central java provincial health office. central java province health profile 2017. central java: central java provincial health office; 2017. 5. who. who recommendations on antenatal care for a positive pregnancy experience : summary highlights and key messages from the world health organization ’ s 2016 global recommendations for routine antenatal care. matern child surviv progr 2018;10:1–10. 6. onchonga d. sexual & reproductive healthcare prenatal fear of childbirth among pregnant women and their spouses in kenya. sex reprod healthc. 2021;27:100593. 7. jombang health office. jombang health office | socialization of assistance for high risk pregnant women for the 2021 fiscal year. 2021. accessed 2021 may 29. available from: https://dinkes.jombangkab.go.id/sosialisasi-pendampinganibu-hamil-risiko-tinggi-tahun-anggaran-2021.koer 8. wahyuni s, rahayu t, nursalam. self efficacy of pregnant women in areas affected by covid 19. enfermería clínica 2021;31:601–4. 9. ratnaningsih t, joebagio h, murti b. mentoring of pregnant women at high risk program (gerdaristi) to reduce maternal and infant mortality in nganjuk, east java. j matern child heal 2016;01:268–76. 10. vidayanti v, pratiwi daa. the role of social support in reducing anxiety among high risk pregnant women in third trimester. int respati heal conf 2019;1:610–5. 11. gökçe i̇sbir g, i̇nci f, önal h, et al. the effects of antenatal education on fear of childbirth, maternal self-efficacy and posttraumatic stress disorder (ptsd) symptoms following childbirth: an experimental study. appl nurs res 2016;32:227–32. 12. mekonnen t, dune t, perz j, et al. trends and determinants of antenatal care service use in ethiopia between 2000 and 2016. int j environ res public health 2019;16:748. 13. nursalam. metodologi penelitian ilmu keperawatan. [nursing science research methodology.] 5th ed. jakarta: salemba madika; 2020. 14. carrey nj. gerald caplan, then and now: public mental health applications to the current psychological challenges of the pandemic. cmaj 2021;193:e1635. 15. erchul wp. consultation in community, school, and organizational practice: gerald caplan’s contributions to professional psychology. 2015. 16. aryawati w. pengembangan model pencegahan resiko tinggi kehamilan dan persalinan yang terencana dan antisipatif (regita). [development of regita model for planned and anticipatory high risk pregnancy and childbirth prevention. j kebijak kesehat indones 2016;86:86–93. 17. rissel c, khanal s, raymond j, et al. piloting a telephone based health coaching program for pregnant women: a mixed methods study. matern child health j 2019;23:307– 15. 18. nayak sk, poddar r, jahan m. psychological problems during advance stage of pregnancy. int j indian psychol 2015;2:103– 13. 19. vaghela n. study of pregnancy outcome in various high-risk pregnancies in tertiary care hospital. int j med biomed stud 2019;3:38–42. 20. downer t, young j, mcmurray a. are we still woman-centred? changing ideologies, a history of antenatal education in australia. collegian 2020;27:634–41. 21. ministry of health of the republic of indonesia. mch teaching materials. jakarta: center for education and training of health workers for rights; 2015. 22. who. who recomendations on antenatal care for a positive pregnancy experience. world heal organ. 2016;1– 172. 23. zinsser la, stoll k, wieber f, et al. changing behaviour in pregnant women: a scoping review. midwifery 2020;85:102680. 24. fadilah dr, devy sr. antenatal care visits and early detection of pre-eclampsia among pregnant women. int j public heal sci 2018;7:248. 25. seward mw, simon d, richardson m, et al. supporting healthful lifestyles during pregnancy: a health coach intervention pilot study. bmc pregnancy childbirth 2018;18:1–12. 26. jaqin n, syafar m, suryani a, et al. increasing of pregnancy education on the self efficacy of pregnant women in groups accompanied by their husbands and groups unaccompanied husband in gowa regency. int j sci basic appl res 2019;44:33–42. 27. shafaie fs, mirghafourvand m, bagherinia m. the association between maternal self-confidence and functional status in primiparous women during postpartum period, 2015-2016. int j women’s heal reprod sci 2017;5:200–4. 28. ministry of health of the republic of indonesia. psychiatric nursing. jakarta: ministry of health of the republic of indonesia; 2016. 29. flores fj, mayorga-vega d, blanco jr, et al. perceived selfefficacy in problem solving and scientific communication in university students. a gender study. psychology 2014;05:358–64. 30. ellen l. tilden, aaron b. et al. the effect of childbirth selfefficacy on perinatal outcomes ellen. j obs gynecol neonatal nurs 2016;45:456–80. 31. mohammadi f, kohan s, farzi s, et al. the effect of pregnancy training classes based on bandura self-efficacy theory on postpartum depression and anxiety and type of delivery. j educ health promot 2021;10:273. 32. van der bijl j, shortridge-baggett l. the theory and measurement of the self-efficacy construct. scholar inquiry nurs pract 2001;15:189–207. 33. tosson mm, atwa m, mahmoud ma. anxiety and fear level review [page 160] [healthcare in low-resource settings 2023; 11(s1):11214] non -co mmerc ial us e o nly toward childbirth among primigravida versus multigravida. iosr jnhs 2019;8(2). 34. yosefina nelista pnf. the effect of peer coaching as health coaching support on parenting self efficacy to infant care in early marriage mother in the waipare public health center working area. j injec 2018;3:101–7. 35. barker m, angelo sd, ntani g, et al. the relationship between maternal self-efficacy, compliance and outcome in a trial of vitamin d supplementation in pregnancy. osteoporos int 2017;28:77–84. review [healthcare in low-resource settings 2023; 11(s1):11214] [page 161] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:xxx healthcare in low-resource settings 2024; volume 12:11815 perception of burnout syndrome among nurses providing nursing care in the emergency room at a hospital in riau province raja fitrina lastari, gusvita sari, siska mayang sari, susi erianti, rajunitrigo rajunitrigo bachelor of nursing program, faculty of health, universitas hang tuah pekanbaru, indonesia abstract the demands to nurses in the emergency room (er) can lead to stress, potentially causing burnout syndrome. this may diminish the effectiveness of the nursing care provided to patients. this study aimed to explore the experience of burnout syndrome among nurses in the er using a descriptive qualitative research design. ten nurses from the er participated in the study. all participants provided consistent answers, leading researchers to conclude data saturation through purposive sampling. in-depth interviews with a semistructured format were conducted for data collection, and the collaizi technique was employed for analysis. findings revealed that nurses exhibited signs of burnout syndrome, such as physical, emotional, and mental exhaustion, while providing patient care, attributing this to the substantial workload. introduction a hospital serves as a comprehensive healthcare facility, offering a full range of individualized health services, including inpatient, outpatient, and emergency care.1,2 the emergency department serves as the primary point of entry for patients seeking treatment in both urgent and non-urgent medical situations.3-5 within a hospital, nurses play an indispensable role as they are often the first and longest point of contact with patients.6 their responsibilities encompass the entire spectrum of nursing care, including the assessment process, nursing diagnosis, intervention, implementation, and the evaluation of care outcomes.7 it is worth noting that nursing is among the healthcare sectors with the highest prevalence of occupational stress.8,9 improper management of this workload can lead to workplace stress,10-12 and prolonged stress can ultimately result in feelings of ennui or the development of burnout syndrome.13,14 burnout syndrome can be defined as a condition characterized by an overwhelming sense of exhaustion, encompassing physical, mental, and emotional fatigue, leading to significant personal distress and a decline in individual achievements.15,16 one of the indicators of burnout syndrome in nurses is reflected in their behavior, including responding negatively to patients, experiencing delays in tasks, reacting irritably to simple questions from colleagues or patients, expressing feelings of quick fatigue and dizziness, and, at its worst, displaying apathy towards their work and surroundings.17 this syndrome is typically delineated by three key dimensions: firstly, emotional exhaustion; secondly, depersonalization; and thirdly, a decline in personal accomplishment.18 the impact of burnout syndrome on nursing care can be attributed to several factors. first, there is a delay in the data collection process, resulting in extended periods for acquiring necessary information. second, in the diagnosis phase, nurses often experience decreased concentration, leading to a failure in accurately determining the patient’s diagnosis. nurses may mistakenly believe that the diagnosis provided by the doctor is sufficient. third, when it comes to nursing intervention, it is uncommon to find nurses who openly acknowledge their difficulties in determining appropriate interventions. fourth, the emergence of burnout syndrome can lead to various adverse effects, subsequently diminishing job performance and job satisfaction. lastly, during the evaluation phase, nurses may encounter challenges. the nursing evaluation is a mandatory task to assess the effectiveness of the provided care for each patient.19 according to the world health organization (who), burnout syndrome has been included in the 11th revision of the correspondence: raja fitrina lastari, bachelor of nursing program, faculty of health, universitas hang tuah pekanbaru, indonesia. e-mail: rajafitrinalestari@htp.ac.id key words: burnout syndrome, emergency room, nurse, nursing care. contributions: rfl, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; gs, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; sms, methodology, visualization, writing – review and editing; se, resources, investigation, and writing –review and editing; rr, formal analysis, validation, writing – review and editing. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas hang tuah pekanbaru, based on ethical certificate 068/kepk/uhtp/v/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. consent for publication: written informed consent was obtained for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 15 september 2023. accepted: 1 february 2024. early access: 7 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11818 doi:10.4081/hls.2024.11815 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11815] [page 421] non -co mmerc ial us e o nly international classification of diseases (icd-11) as a manifestation of work-related fatigue, without being classified as a medical condition. the prevalence of burnout syndrome among nurses has been extensively researched internationally. in spain, for instance, approximately 80% of nurses exhibit a high level of burnout syndrome. in iran, a study reported that 72% of nurses experienced burnout syndrome to varying degrees, while in greece, around 44% of nurses expressed dissatisfaction with their work. the association for occupational health highlights that stress and burnout syndrome among nurses are among the top 40 causes of stress among workers.20 in one hospital in the tulungungung area, emergency room (er) nurses were found to experience severe burnout syndrome, with 58% exhibiting symptoms such as easy fatigue, tiredness, physical discomfort upon completing tasks, difficulty in establishing a relaxed atmosphere with patients, and a lack of enthusiasm when interacting with patients. additionally, the ministry of health data from 2019 indicates that a significant proportion (74%) of nurses in the bontang er experienced heavy workloads, which subsequently led to reduced levels of patient satisfaction.21 based on previous research, it was found that nurses experienced a moderate workload with a percentage of 93.3% and a high category of 6.7%, characterized by nurses complaining of fatigue because a lot of work had to be done quickly and right.10 burnout syndrome in the workplace is a situation that cannot be avoided. nursing work has several characteristics that can create high and stressful work demands.22 these characteristics include a tight work schedule and having to be ready to work at any time. and there are even some service settings that employ nurses with excessive workloads. sometimes in one shift, one nurse must serve as many as 8-10 patients.22 the nurse’s role was to prioritize triage for incoming patients, which sometimes led to feeling overwhelmed. typically, in the er, nursing care is administered following triage, unless there is a lower patient volume and an adequate nursing staff to permit direct intervention. from the various phenomena and theories that have been explained, this study aimed to analyze burnout syndrome in nurses in carrying out nursing care in the er materials and methods research design this study was conducted through a qualitative technique, within the framework of a descriptive research approach. study setting and participants in this study, participants were chosen through a purposive sampling method, adhering to specific inclusion criteria: individuals working as nurses in the er, with a minimum of one year of experience, aged 25 years or older, and a willingness to participate. the study included a total of 10 participants, comprising 8 executive nurses as the primary subjects and 2 nurse team leaders in a supporting role. research findings in this research, the researcher explains the aims and objectives of the research, the letter of availability to become a participant, the rights obtained when becoming a participant, and the identity of the participant is disguised in the results of the interview data obtained (credibility). researchers can obtain consistent research results or data, namely by carrying out a structured data analysis and trying to interpret the results of the study correctly so that readers can make the same conclusions using raw data, perspectives and analysis documents of the study being carried out and in this research, confirmability is obtained by processing the interview results and showing them to the participants with the aim that the interview results have been clarified and confirmed by the participants who have been interviewed. data collection this descriptive qualitative study pertains to nurses working in the er of provincial hospital in riau. these variables encompass characteristics such as age, gender, marital status, highest educational attainment, employment status, and years of work experience. data collection in this qualitative research focuses on the type of data and procedures that will be carried out to collect data. the type of data collected by qualitative researchers was collected by observation and interviews. the data collection process in qualitative research was carried out simultaneously with the data analysis process. the data collection method will be carried out in three stages, namely: orientation stage, implementation stage, and termination stage. data analysis data collection was accomplished by conducting comprehensive interviews using a semi-structured format, followed by an analysis employing the collaizi technique. in this process, the researcher assumes the role of a data collection instrument, attentively listening to participants’ descriptions during interviews. subsequently, these descriptions were meticulously examined, transcribed, and subjected to repeated review for analysis. ethical clearance this research has obtained ethical approval from the health research ethics commission (kepk) of hang tuah university pekanbaru under the reference number 068/kepk/uhtp/v/2023. results this research effectively identified five primary themes, which encompass nurses’ viewpoints regarding burnout syndrome, their encounters with this syndrome, the underlying factors contributing to burnout, the impact of burnout syndrome on nurses, and strategies for its management. the viewpoints of nurses regarding burnout syndrome the definition of burnout syndrome can be categorized into two distinct categories: physical exhaustion and psychological exhaustion. participants in the study provided insights into the definition of falling under physical exhaustion, which encompasses feelings of fatigue, weariness, and a decline in work quality. on the other hand, the definition falling into the category of psychological exhaustion involves feelings of monotony, overwhelm, boredom, anxiety, and work-related stress. “it can also be categorized as physical or mental; if it’s physical, it means experiencing fatigue. when we are excessively tired, our immune system weakens, especially when our physical health is compromised. this can lead to illnesses, and our work performance in caring for patients may also decline” (p6) transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 422] healthcare in low-resource settings 2024;12:11815] non -co mmerc ial us e o nly “this is when we experience stress while working, like that... it means that during our work, we may not handle things smoothly, perhaps we experience anxiety, and we keep performing actions like that... maybe due to the workload or long-term service, we start to feel a sense of monotony, right?” (p2). the firsthand encounters of nurses with burnout syndrome the indications and manifestations of burnout syndrome encompass three distinct categories, specifically physical fatigue, emotional depletion, and mental exhaustion. within the physical fatigue category, individuals who are experiencing signs and symptoms of burnout have reported sensations such as lightheadedness, drowsiness, bodily aches, and a sense of weakness. “i often find myself unable to concentrate due to a combination of fatigue and sleepiness. there are moments when i acknowledge that my efficiency is compromised, but this typically occurs intermittently” (p3). additionally, individuals grappling with burnout syndrome have encountered various signs and symptoms in the emotional exhaustion category, including feelings of boredom, confusion, a sense of being burdened, difficulty focusing, weariness, strained interpersonal relationships with colleagues, heightened emotional responses, a negative mood, and occasional panic. “fatigue often intensifies our emotional reactions, and it can lead to discomfort even in our interactions with friends. for example, when we are swamped and fatigued while our friends are still engrossed in their smartphones. it’s likely because of our exhaustion, which affects our mood and mental state” (p2). “i’m finding it difficult to muster the energy, and i’m losing interest in my job or even coming to work. my mindset is shifting towards ‘it doesn’t matter, i’m just too exhausted.’ essentially, i’ve become disinterested in my work, and my enthusiasm for socializing has waned as well, and that seems acceptable to me” (p4). factors contributing to the development of burnout syndrome the factors leading to burnout syndrome among participants encompass both internal and external elements. participants disclosed internal factors contributing to burnout syndrome, including aspects such as age and tenure in their roles. “prolonged working hours could also contribute, as well as the repetitiveness of daily tasks. age-related health issues might also play a role; the longer you work here, the more you encounter individuals who have been here for two years, and their routines remain largely unchanged” (p4) “the potential causative factor, perhaps, stems from the demanding nature of the emergency room where patients keep coming in. it could be attributed to factors originating from external sources, like this continuous influx of patient complaints, which can lead to stress. it’s an unending cycle; one issue hasn’t been resolved, and another one arises, which leaves me feeling fatigued. it’s more about the sheer volume of patients from the external environment, well, the workload” (p2). the impact of burnout syndrome on nurses the impact of burnout syndrome on participants can be categorized into its effects on the individual and its effects on the delivery of nursing care. participants highlighted the influence of burnout syndrome on individuals, including its impact on themselves and on others, such as family members and patients. “for instance, when there is a persistent shortage of healthcare staff or an overwhelming number of patients, it can significantly affect our mood. we might end up feeling similar to the patients, or at the very least, we become so fatigued that we lose the desire to engage with our colleagues at work” (p4). “regarding my family, well, if i’m extremely tired from work, there are times when i don’t engage in much conversation when i get home. for instance, i may prefer to rest first and request some time to recharge” (p6). furthermore, participants also conveyed that the impact of burnout syndrome on the execution of nursing care could be observed in two distinct categories: its effect on the quality of nursing care and its influence on the various stages involved in providing nursing care. “no, we find ourselves not fully engaged, and as a result, our actions may not be as effective or efficient. this happens because we become disinterested, and it affects our ability to fully attend to the needs of the patients. serving patients becomes somewhat compromised” (p2) “when we are under stress, our focus can waver. for instance, when we are entering patient data into the computer’s electronic health records (imr), we may inadvertently mix up details. for example, if a patient initially complained of stomach pain during the initial assessment, we might accidentally record it as lower back pain. so, it becomes a state of confusion, necessitating follow-up questions to the patient for clarification. this primarily impacts the assessment and evaluation process within the soap” (p2) management of burnout syndrome the management of burnout syndrome among participants involves three main components: individual efforts, organizational initiatives, and hospital policies. participants highlighted that individual effort management, which includes practicing self-care, can effectively mitigate the occurrence of burnout syndrome. “how to address it, well, it’s like taking a breather first, finding alternative activities, you know, not just constantly scrolling through your phone or looking at your phone” (p2) “yes, when we return home, prioritizing sleep, relaxation, and ensuring we eat and hydrate. regardless of the challenges we face with our patients, taking care of ourselves by maintaining our nourishment and well-being is essential” (p4) discussion participants provided various definitions of burnout syndrome, including feeling exhausted, fatigued, reduced work quality, boredom, a sense of being burdened, disinterest, panic, and workplace stress. among these descriptions, sensations of exhaustion, fatigue, and boredom were the most prominent in participants’ responses. the statements offered by the participants align with the definition of burnout syndrome. according to her, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions healthcare in low-resource settings 2024;12:11815] [page 423] non -co mmerc ial us e o nly burnout syndrome encompasses both physical and mental fatigue, leading to the development of a negative self-concept, diminished concentration, and negative work-related behaviors. additionally, burnout syndrome can be characterized as a form of work-related fatigue or a psychological condition resulting from extreme fatigue, whether it is physical, mental, or emotional, leading to personal disturbance and reduced personal achievement.15 nurses’ encounters with burnout syndrome are identifiable through the signs and symptoms they manifest. burnout syndrome exhibits itself through physical, emotional, and mental exhaustion. in the research findings, many participants shared their experiences regarding the signs and symptoms of burnout syndrome encountered while working in the er. interestingly, during interviews, one participant initially claimed to have never experienced burnout syndrome. however, as they were probed with questions about the signs and symptoms of burnout syndrome, participants came to recognize these indicators accurately. this suggests that nurses often go through burnout syndrome without realizing that these are indeed signs and symptoms of the condition. burnout syndrome entails physical, emotional, and mental exhaustion stemming from enduring emotionally taxing situations.19 physical fatigue can manifest as headaches, insomnia, bodily pain, aches, gastrointestinal disturbances, and persistent weariness. emotional exhaustion leads to negative emotions such as emptiness, ennui, fatigue, feelings of inadequacy, helplessness, diminished selfesteem, anxiety, disorientation, loss of values and hope, alterations in self-perception, difficulties in concentration, lowered tolerance, and heightened irritability. on the other hand, mental fatigue can be identified by avoidance behaviors, an inability to enjoy a relaxed life, engagement in high-risk activities, reduced personal performance, and a lack of organization.23 the factors contributing to the development of burnout syndrome can be categorized into internal factors, such as age and length of service, and external factors, including role ambiguity, workload, social support, organizational culture, recognition support, and human resources-related aspects. the research findings indicate that a significant portion of burnout syndrome factors can be attributed to workload. nurses working in the er experience substantial workload due to the demanding nature of their work environment. this includes the need for heightened vigilance in providing comprehensive care to patients with various levels of emergency and diverse medical conditions. additionally, nurses often encounter anxious patient families who frequently seek updates on their loved ones’ conditions. furthermore, there is a constant demand for swift decision-making in emergency and critical situations to prevent more severe complications. the workload encompasses a large patient volume, pressures from patients and their families, ongoing work tasks, and limited break opportunities, all of which contribute to workplace fatigue and stress.24,25 previous research highlighted the relationship between nurses’ high workload and the development of burnout syndrome. to mitigate this, hospitals should adjust their nurse staffing levels to match the workload they face. the multitude of responsibilities and job demands can potentially lead to stress for nurses. when this stress becomes chronic and the individual is unable to adapt, it can result in a collection of symptoms known as burnout syndrome.26 the repercussions of burnout syndrome on nurses can manifest in two forms: affecting the individual and influencing the execution of nursing care. burnout syndrome can exert adverse effects on various levels, including the individual, organizational, and service levels. on an individual level, burnout syndrome can lead to a range of negative physical and mental health issues. at the organizational level, it can result in reduced organizational commitment and job satisfaction. additionally, at the service level, research indicates that burnout syndrome can lead to a decline in the quality of care and services provided to patients.19 the impact of burnout syndrome on individuals includes symptoms such as confusion, sleep disturbances, mood swings, and a lack of focus while at work. this is consistent with previous findings, which involved interviews with several non-pns (civil servants) employees. the study revealed that during their work duties, these employees frequently experienced headaches, drowsiness, dizziness, and reduced concentration, especially after serving in the emergency department. they also reported feelings of irritability, a negative mood, boredom, and a decline in self-confidence.27 the impact of burnout syndrome on other individuals includes emotional changes and reduced communication with colleagues and family members. the influence of burnout syndrome experienced by individuals on others is primarily perceived by the recipients of the service and their families.19 additionally, burnout syndrome can disrupt the various stages of nursing care implementation, leading to errors in the assessment, implementation, and evaluation processes. several nurses frequently expressed concerns about this issue, acknowledging that comprehensive assessments were infrequently conducted due to physical exhaustion, causing them to focus solely on data related to the patient’s complaints. the management of burnout syndrome can be approached through individual efforts, organizational initiatives, and hospital policies. burnout syndrome should not be regarded as normal because if left untreated, it can have severe consequences on individuals, both physically and mentally. consequently, there are several methods and expectations from participants for addressing the issue of burnout syndrome, encompassing self-management strategies and anticipations related to hospital policies. self-care constitutes a means for individuals to attend to their physical, emotional, social, and spiritual needs. dedication of time to fulfilling these basic requirements empowers nurses to reduce stress levels, relax their bodies and minds, and sustain a positive mood.28 research indicates that support from supervisors plays a pivotal role in helping employees combat work-related dysfunction and the effects of stress on their performance and overall well-being. such support involves displaying genuine concern for employees.29 this aligns with findings which underscored the crucial role of managers employing a caring approach toward nurses in mitigating burnout syndrome. furthermore, managerial care for nurses constitutes a strategy that can cultivate a healthy work environment, enhancing nurses’ self-efficacy and reducing emotional exhaustion and depersonalization among them.30 conclusions in the context of nursing care within the er, nurses exhibit vulnerability to experiencing burnout syndrome. they display signs and symptoms associated with burnout syndrome, yet often remain unaware of their condition. the presence of burnout syndrome among nurses significantly impacts the execution of nursing care, leading to errors in actions that, in turn, affect the quality of care delivered to patients. nurses hold expectations for hospital policies designed to address burnout syndrome, with a focus on managerial support. this support encompasses measures such as increasing staffing levels, providing training opportunities, facilitating educational counseling activities that involve interactions with room heads and team leaders, conducting employee fol transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 424] healthcare in low-resource settings 2024;12:11815] non -co mmerc ial us e o nly low-ups, and offering rewards such as performance incentives, rejuvenation programs, additional time off, and family gatherings. references 1. kepmenkes ri. standar instalasi gawat darurat (igd) rumah sakit. 2009. available from: https://sardjito.co.id/wpcontent/uploads/2015/12/kepmenkes-856-thn-2009-standarigd.pdf 2. dewi ys, wahyuni ed, arifin h, et al. health literacy of icu patients’ family: a review. malaysian j med heal sci 2022;18:302-6. 3. kepmenkes ri. riset kesehatan dasar riskesdas 2013. available from: https://repository.badankebijakan.kemkes. go.id/id/eprint/4467/1/laporan_riskesdas_2013_final.pdf 4. asmoro cp, hariyati ts, ayuningtyas d, et al. researching nurses’ adherence to patient safety guidelines in emergency departments. emerg nurse 2022;30. 5. hidayati l, ismail a, harmayetty, et al. understanding health service quality in emergency department through the length of stay and its determinants. j pak med assoc 2023;73:s30-3. 6. kurniati a, rosskam e, efendi f. hospital nurses’ perceptions of distributive justice under the national health insurance scheme in indonesia. collegian 2021;28:506-14. 7. jainurakhma j, rukmi dk, gultom ab, et al. proses berpikir kritis dalam keperawatan. 2023. available from: https://kitamenulis.id/2023/02/15/proses-berpikir-kritis-dalam-keperawatan/ 8. shodiqurrahman nr, martini nm, kep m, et al. keperawatan kegawatdaruratan dan keperawatan kritis. 2022. available from: https://elibrary.uwn.ac.id/index.php? p=show_detail&id= 3849&keywords= 9. rohita t, nursalam n, hadi m, et al. relationship quality of nursing work life and burnout among nurses: a systematic review. gac med caracas 2022;130:s1205-14. 10. yudi d, tangka jw, wowiling f. hubungan beban kerja fisik dan mental perawat dengan penerapan patient safety di igd dan icu rsu gmim pancaran kasih manado. j keperawatan 2019;7. 11. paskarini i, dwiyanti e, syaiful da, syanindita d. burnout among nurses: examining psychosocial work environment causes. j public health res 2023;12. 12. sandianto s, tualeka ar, indriani d. the effect of workload on the job stress of nurses in outpatient care unit of public hospital surabaya, indonesia. indian j public heal res dev 2018;9:80-4. 13. astiti iw. pengaruh burnout terhadap kinerja perawat di instalasi intensive care rsud kardinah tegal. 2020. available from: https://journal.um-surabaya.ac.id/jkm/article/view/ 5576 14. purnawati y, martiana t, hargono r, rahman fs. the analysis of workload and safety communication against burnout syndrome in inpatient nurses. indian j forensic med toxicol 2020;14:2244-8. 15. alam r. kelelahan kerja (burnout), teori, perilaku organisasi, psikologi, aplikasi dan penelitian. 2022. available from: https://repository.umi.ac.id/1256/1/kelelahan%20kerja%20% 28burnout%29%20-%20dr.%20roslina%20alam%2 c%20s.e.%2c%20m.si.pdf 16. tri ardiansyah r, negeo putra f, soebagiyo h, yosepfus weu b. factors affecting burnout syndrome among nurses: a systematic review. j ners 2019;14:272-6. 17. tampubolon lf. burnout syndrome pada perawat di ruangan rawat inap rumah sakit santa elisabeth medan. j keperawatan prior 2018;1. 18. mulawarman m, antika er. mind-skills konsep dan aplikasinya dalam praktik konseling. prenada media; jakarta, indonesia. 2020. 120 pp. 19. wijaya cp. pengaruh burnout syndrome terhadap proses asuhan keperawatan (studi pada perawat rumah sakit medika utama blitar). revital j ilmu manaj 2019;5:23-36. 20. world health organization (who). burn-out an “occupational phenomenon”: international classification of diseases. available from: https://www.who.int/news/item/28-05-2019burn-out-an-occupational-phenomenon-international-classification-of-diseases 21. presiden republik indonesia. undang-undang republik indonesia nomor 44 tahun 2009 tentang rumah sakit. 2009. available from: https://peraturan.bpk.go.id/details/38789/uuno-44-tahun-2009 22. subiyono k, susanti ih, hanum f. hubungan burnout dengan kepuasan kerja perawat diruang rawat inap rsu wh. sentri j ris ilm 2022;1:215-22. 23. wati nmn. penerapan metode gayatri mantra emotional freedom technique (geft) pada aspek psikologis. 2021. available from: https://repository.stikeswiramedika.ac.id/358/ 24. shoja e, aghamohammadi v, bazyar h, et al. covid-19 effects on the workload and mental health of iranian healthcare workers. bmc public health 2020;20:1-7. 25. al ma’mari q, sharour la, al omari o. fatigue, burnout, work environment, workload and perceived patient safety culture among critical care nurses. br j nurs 2020;29:28-34. 26. ezdha aua, hamid a. analisa hubungan burnout dan beban kerja perawat di rumah sakit pekanbaru medical center. j kesehat saelmakers perdana 2020;3:301-8. 27. azzahroh p, kurniati d, reksaningtyas a. faktor-faktor yang berhubungan dengan burnout syndrome pada tenaga kesehatan igd selama pandemi covid-19 di rsal dr. mintohardjo. j penelit kesehatan” suara forikes”(journal heal res forikes voice”) 2022;13:453-7. 28. adhiatma w, christianto lp. suara psikologi: untuk insan indonesia. 2019. available from: https://edeposit. perpusnas.go.id/collection/suara-psikologi-untuk-insanindonesia-sumber-elektronis/9307 29. andarini e. analisis faktor penyebab burnout syndrome dan job satisfaction perawat di rumah sakit petrokimia gresik. 2019. available from: https://repository.unair.ac.id/77964/ 30. putra kr, sutadi h, setyowati s, hariyati rts. the impact of nurse manager caring behaviors and work environment on burnout syndrome among nurses. kontakt-journal nurs soc sci relat to heal illn 2021;23. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11815] [page 425] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:11486] [page 85] post-spinal hypotension management for cesarean section in low resource settings: efficiency and safety of two very low-dose boluses of norepinephrine, a randomized double-blinded controlled trial feryel benamor, ines elbekri, sofiene benmarzouk, bochra fouzai, takwa hkiri, hayene maghrebi department of anesthesiology and intensive care, maternity and neonatology center of tunis, faculty of medicine, university of tunis el manar, tunis, tunisia abstract spinal anesthesia is the gold standard anesthetic technique for cesarean section. however, its major complication is hypotension. norepinephrine has recently been described as an efficient and safe alternative to phenylephrine. the aim of this study was to determine the effective target bolus of norepinephrine to prevent and treat postspinal anesthesia hypotension. we conducted a prospective controlled randomized study including 126 parturients scheduled for cesarean delivery under spinal anesthesia. we compared two groups that received a prophylactic bolus of either 1 μg/kg or 0.5 μg/kg of norepinephrine without fluid loading. the rescue intravenous bolus of norepinephrine was half the dose of the prophylactic bolus. the main outcomes were the percentage of decrease in systolic and mean blood pressure. the secondary outcomes included the timing of the first hypotension, duration of hypotension, number of rescue boluses, total norepinephrine consumption, incidence of hypotension and maternal adverse effects and fetal outcomes. our primary outcome has shown similarities between groups; delta systolic blood pressure before delivery was 19.4% in group 1 µg/kg versus 20.5% in group 0.5 µg/kg. both groups were similar for all secondary outcomes, except that the higher dose of norepinephrine resulted in more hypertension. fetal outcomes were similar in both groups. bolus of 0.5 μg/kg followed by rescue doses of 0.25 μg/kg of norepinephrine was efficient in preventing and treating spinal anesthesia-induced hypotension. these doses may be recommended for routine use in healthy parturients. introduction caesarean section is a frequent surgery that is most often performed under spinal anesthesia which is considered the anesthetic technique of choice. the major problem with this technique remains arterial hypotension resulting from the extensive sympathetic block with a decrease in cardiac output and uteroplacental output with a consequent decrease in fetal oxygenation with acidosis and bradycardia if hypotension is prolonged beyond 4 minutes.1-3 ephedrine has long been considered the favorite vasopressor for the management of hypotension in obstetrics. in fact, it preserves uteroplacental flow due to its lack of vasoconstrictive effect in this territory. however, because of its placental passage, ephedrine, at high doses, is responsible for neonatal acidosis and maternal tachycardia limiting its prophylactic use.4 currently, phenylephrine is the vasopressor of choice for the prevention and treatment of spinalinduced arterial hypotension in parturients.5 as phenylephrine is a potent alpha-adrenergic receptor agonist, its use is often associated with a dose-dependent slowing of heart rate and a fall in maternal cardiac output. a low dose of norepinephrine or noradrenaline (nad) has been proposed as an effective alternative to phenylephrine with less bradycardia and less drop in cardiac output.6,7 norepinephrine appears to be a promising vasopressor in obstetric anesthesia. it is also an interesting molecule in limited resource settings because of its availability and low cost. most studies have investigated the use of noradrenaline as a continuous infusion; however, bolus administration has not been sufficiently studied. therefore, bolus administration of norepinephrine for the prevention and treatment of arterial hypotension after spinal anesthesia during caesarean section is based on a low level of evidence, and there is currently no recommendation for its use in this setting. the aim of our study was to compare the efficiency of two bolus doses of norepinephrine in preventing and treating hypotension induced by spinal anesthesia. materials and methods this is a prospective randomized controlled study, in a double-blind, which took place in the department of anesthesia and intensive care of the maternity and neonatology center of tunis in 2018 and lasted over a period of 4 months. we included pregnant women aged between 18 and 45 years, classified as asa 2 (pregnant women with no notable pathological history or major dysgravidia), with a full-term progressive mono-fetal pregnancy with a gestational age over 36 sa, proposed for a pro healthcare in low-resource settings 2023; volume 11:11486 correspondence: feryel benamor, maternity and neonatology center of tunis, rue djebel lakhdher la rabta, tunis, tunisia. tel.: +216.29402122 e-mail: ferielbenamor@gmail.com key words: norepinephrine; cesarean section; hypotension; spinal anesthesia; vasopressor. contributions: fb, article writing; ie, case collection and application of the study protocol; sb, the concept of work and supervision; hm, team leader. all the authors approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. ethical approval and consent to participate: our work was previously approved and registered in clinicaltrials.gov with this nct public number: 03706755. in cases where we could not obtain written consent, we clearly explained the study protocol to the patient, and oral consent was requested from participants before including them in the study. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and material: data and materials are available by the authors. acknowledgments: i would like to thank all those who took part in this study, the patients who agreed to be part of it, and my seniors who supervised and directed this work. received for publication: 24 may 2023. accepted for publication: 25 august 2023. early access: 21 september 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11486 doi:10.4081/hls.2023.11486 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly grammed or semi-urgent caesarean section with an extraction time over 15 minutes (this implies that there is not life-threatening acute fetal distress exposing the fetus to acidosis), under spinal anesthesia. we did not include parturients with asa class >2, body mass index <18.5 kg/m2 or >35 kg/m2, major dysgravidia, women taking serotonin reuptake inhibitors, with a history of multiple pregnancies, abnormal placental insertion, fetal pathologies (hydrops fetalis, intrauterine growth retardation), chorioamnionitis or with contraindications to spinal anesthesia. patients who refused to participate in the study were not included. exclusion criteria for the study were the failure of spinal anesthesia, the extension of anesthetic block requiring tracheal intubation and mechanical ventilation, the occurrence of an allergic reaction to any of the anesthetics used, the occurrence of an intraoperative complication requiring additional surgery and conversion to general anesthesia for any reason. the preparation and labeling of the product were carried out by an operator who was aware of the outcome of the randomization and who was different from the second operator who conducted the anesthesia, carried out the protocol, and collected data. the parturient was also unaware of which product she had received. randomization was carried out immediately on arrival of the parturients in the operating room by drawing lots in order to produce a balanced series of 10 patients. the parturients were randomized into two groups: group a, in which patients received a preventive bolus of slow intravenous diluted nad over 15 seconds immediately after spinal anesthesia at a dose of 1 μg /kg; group b in which women received a preventive bolus of 0.5μg/kg over 15 seconds immediately after spinal anesthesia. these preventive doses were administered in order to prevent the occurrence of a sympathetic block after spinal anesthesia to maintain systolic blood pressure between 80 and 100% of its baseline value, and in all cases >100 mm hg, given that both groups did not receive fluid loading either before or during spinal anesthesia. the sham of administration was exactly the same for both groups, they only differ in doses. then, to achieve this objective throughout the caesarean section, curative boluses at half the dose of the preventive boluses of nad (0.5μg /kg for group a; and 0.25μg /kg for group b) were administered systematically and as much as necessary whenever the systolic blood pressure (sbp) drops by 20% of its initial reference value or was simply below100 mm hg; and this with a article figure 1. the variation in systolic blood pressure throughout the caesarean section was comparable between groups except at few points of time: (25-27, 30-32, 34, 35, and at 38 min) knowing that the average duration of the caesarean section was 36 min. the systolic blood pressure time curves were nearly superimposable. figure 2. the variation in mean blood pressure throughout the caesarean section was comparable between groups except at few points of time: (32 and 35 min) knowing that the average duration of the caesarean section was 36 min. the mean blood pressure time curves were nearly superimposable. figure 3. mean total norepinephrine consumption was significantly greater in group a than in group b during the whole caesarean section (225±183 µg and 126±100 µg respectively; p<10-3) and before fetal extraction (57±46 µg in group a versus 30±30 µg in group b; p<10-3). [page 86] [healthcare in low-resource settings 2023; 11:11486] non -co mmerc ial us e o nly minimum delay of 02 minutes between rescue boluses. blood pressure (bp) was measured every minute. no other vasopressors were used during the study. in the case of hypertension (bp>120% of baseline), the course of action was to withhold treatment. for bradycardia under 40 bpm without hypotension, atropine (1 mg) was administered. our primary outcome was the depth of hypotension which was estimated by: i) percentage decrease in sbp (δ sbp/reference sbp) before delivery (δ sbpd) and throughout the caesarean section (δ sbp: defined as the difference between reference sbp and min sbp (the minimum value of sbp measured during the caesarean section); ii) percentage drop in mean blood pressure (mbp) (δ mbp/baseline mbp) before delivery (δ mbpd) and throughout the caesarean section. secondary endpoints were time to first hypotensive episode, duration of the first hypotensive episode and the number of rescue boluses, total nad consumption during caesarean section and before delivery (including preventive bolus), the incidence of hypotension during caesarean section and before delivery, incidence of severe hypotension (drop in sbp below 60% of baseline), the total dose of atropine, maternal outcome (incidence of bradycardia (hr<50), incidence of heart rhythm disturbance, incidence of reactive hypertension and intraoperative nausea/vomiting) and finally the neonatal impact [apgar score (at 1st and 5th min) and fetal ph (fetal acidosis defined as fetal ph from umbilical cord blood below 7.2)]. the data were processed by spss® software in its 22nd edition. the number of parturients required in each group was calculated using the online software biosta tgv. the risk of error of the first kind α was fixed at 0.05 and a power 1-β at 80% in a two-sided test, to detect a difference of 5% between the two groups, the number of necessary subjects calculated was fixed at 126 patients or 63 in each group. categorical variables were expressed as percentages and medians and compared by pearson’s and fisher’s chi-square tests. quantitative variables were expressed as means±standard deviation with extremes if necessary. comparisons of means were made by student’s t-test. a p-value less than 0.05 was considered statistically significant. the anonymity and security of patients’ personal data were respected. in cases where we could not obtain written consent, we clearly explained the study protocol to the patient, and oral consent was requested from participants before including them in the study. participation was voluntary and patients did not receive any financial reward in return. we did previously obtain the written agreement of the ethics committee and our work was previously approved and registered in clinicaltrials.gov with this nct public number: 03706755. results demographic, anthropometric, and obstetric data were comparable between the groups. in our study, we collected 126 parturients, 63 in each group. two parturients were excluded, the first one from group a because of a placenta accreta with bleeding, and the second one from group b because of an aorto-caval syndrome requiring the use of fluid and ephedrine before spinal anesthesia. finally, 124 patients were included. until fetal extraction ,the results were comparable between groups .in fact, the sbp decreased by 19.4±11.5% in group a versus 20.5±10.6%; (p=0.57) and the mbp decreased by 24.5±15.5% in group a versus 27.5±12.5% in group b; (p=0.22). regarding the variation in sbp and mbp throughout the caesarean section, the sbp has fallen by 24.7±9.1% in group a versus 27.6±9.4% in group b (p=0.08) throughout the caesarean section, the mbp has fallen by 36.7±9.5% in group a versus 39.3±10.5% in group b (p=0.15) (table 1). these results were comparable between groups except at a few points of time: (2527, 30-32, 34, and 35 and at 38 min for sbp, 32 and 35 min for mbp) knowing that the average duration of the caesarean section was 36 min. the sbp and mbp time curves were nearly superimposable (figures 1, 2). the first hypotension episode occurred at 6.3±3.3 min in group a versus 7.9±6 min in group b; (p=0.07), these results were comparable between groups. both groups were similar regarding post-spinal hypotension incidence during cesarean section (p=0.54) and before delivery (80.6% in group a and 67.8% in group b; p=0.07), duration of hypotension (1.6±1 min in group a versus 2±1.2 min in group b; p=0.08) and cumulative rescue boluses (with a median of 5 during the whole caesarean section, 1 before delivery for both groups). however, mean total norepinephrine consumption was significantly greater in group a than in group b during the whole caesarean section (225±183 µg and 126±100 µg respectively; p<10-3) and before fetal extraction (57±46 µg in group a versus 30±30 µg in group b; p<10-3) (figure 3). no significant difference was found in the incidence of bradycardia, arrhythmia, nausea, and vomiting with the mother. however, the higher dose of norepinephrine resulted in more hypertension (40%) than the lower dose (18%); p<0.001. fetal outcomes (apgar score and fetal ph) were similar in both groups. in fact, at one minute of life, 35% of newborns had an apgar score of 7-8 in group a versus 29% in group b; the apgar score was 9 in 65% of cases in group a versus 71% in group b; p=0.76. at 5 minutes, 26.7% of newborns had an apgar score of 8-9 in group a versus 27.4% in group b; the apgar score was 9 in 73.3% of cases in group a versus 72.6% in group b; p=0.99. fetal ph was 7.33±0.08 in group a versus 7.33±0.09 in group b; p=0.8 (the incidence of fetal acidosis was negligible: 2 newborns presented a ph<7.2 in group a versus 4 in group b; p=0.28). discussion the aim of our study was to determine the effective target bolus of norepinephrine article table 1. percentage drop and lowest systolic blood pressure and mean blood pressure values. group a group b p delta sbp* 24.7±9.1 27.6±9.4 0.08 delta sbpd* 19.4±11.5 20.5±10.6 0.57 delta mbp* 36.7±9.5 39.3±10.5 0.15 delta mbpd* 24.5± 15.5 27.5±12.5 0.22 lowest sbp** 87.4±11.3 85.2±11 0.27 lowest sbpd** 93.8±14.9 93.8±12.8 0.99 lowest mbp** 52.2±7.6 52.1±8.3 0.96 lowest mbpd** 62.3±12.7 62.2±10.1 0.98 *percentage drop (%); **mean±standard deviation (mm hg); sbp, systolic blood pressure; mbp, mean blood pressure; sbpd, percentage decrease in sbp (δ sbp/reference sbp),[δ sbp: defined as the difference between reference sbp and min sbp (the minimum value of sbp measured during the caesarean section)]; mbpd, percentage decrease in mean blood pressure (δ mbp/baseline mbp). [healthcare in low-resource settings 2023; 11:11486] [page 87] non -co mmerc ial us e o nly [page 88] [healthcare in low-resource settings 2023; 11:11486] to prevent and treat post-spinal anesthesia hypotension during caesarean delivery. our primary outcome has shown similarities between groups regarding the percentage decrease in sbp before delivery and throughout the caesarean section, as well as for the percentage drop in mbp. the secondary outcomes found that both doses were similar regarding post-spinal hypotension incidence, timing to the onset of the first hypotension episode, duration of hypotension, and cumulative rescue boluses. the incidence of maternal hypotension after spinal anesthesia for caesarean section is still high.8,9 the literature review shows that several preventive measures have been deployed and have proven insufficient, namely the use of mechanical means such as left lateral decubitus,10 compression of the lower limbs (by bandages or compression stockings),11 and leg raising as well as vascular fluid loading to increase venous return. indeed, it has recently been shown that post-spinal anesthesia hypotension is essentially the result of a drop in systemic vascular resistance due mainly to arteriolar vasodilation and to a lesser degree to venous vasodilation.12,13 this explains why vasopressors currently play a major role in maintaining blood pressure after spinal anesthesia. these vasoconstrictor agents, by restoring vascular tone, have become the mainstay of treatment for spinal anesthesiainduced hypotension.14 for a long time, ephedrine was the vasopressor of choice for hypotension in the parturient after spinal anesthesia, as it preserves uteroplacental perfusion and is easy to use. however, its prophylactic use is limited by a slow onset and duration of action which can lead to tachycardia, reactive hypertension, and fetal acidosis when large doses are used.15 currently, phenylephrine has become the gold standard in obstetric anesthesia.16 it is a direct-acting α-adrenergic agonist that produces less fetal acidosis and nausea and vomiting compared to ephedrine.17 nevertheless, phenylephrine, especially at high doses, induces reflex bradycardia with a drop in cardiac output that can be harmful to the mother and her fetus.18 this has led to research into other alternatives such as nad.19 indeed, nad is a sympathomimetic amine with a very powerful direct action on α-adrenergic receptors and a more moderate action on β-adrenergic receptors. this mild beta-adrenergic agonist activity makes nad more suitable for the physiology of hypotension induced by spinal anesthesia in the parturient. this positive inotropic effect is in addition to the potent vasoconstrictor effect, resulting in a smaller decrease in heart rate and output compared to phenylephrine.19 in addition, for fetal safety, nad does not cross the placenta.20 the in vitro maternal-fetal transfer in the perfused human placenta was 11.6±0.6%;21 the fetoplacental microcirculation was not compromised after nad administration as reported in the study by minzter et al.22 although continuous infusion of the vasopressor offers better hemodynamic stability with fewer fluctuations in blood pressure and fewer interventions by the anesthetist,23 this mode of infusion may not be common practice in limited-resource countries given the high cost of continuous infusion (due to the use of pumps). the studies concerning nad bolus are recent, some have chosen a fixed preventive bolus just before starting the nad infusion,24 while others have compared boluses of nad alone,25 with ephedrine or phenylephrine.20,26 the efficacy and safety of bolus nad as an alternative to phenylephrine for blood pressure maintenance after spinal anesthesia for caesarean section has been proven in many international studies,21 but also by our team in previous work.27 low-dose intermittent bolus nad has proven to be effective and even superior to phenylephrine in a recent study published in 2019.28 other studies have compared nad to ephedrine for prophylaxis either as a bolus or continuous infusion where nad has proven to be effective with less effect on maternal heart rate and fetal well-being.26 the efficacy of nad has often been studied by comparing it with equivalent doses of phenylephrine or ephedrine.26,29 this stage of the literature has established the concept of prevention with nad. however, the ideal dose of nad must be sought by comparing different doses of this molecule with the purpose of determining the more effective and safer bolus dose for the management of hypotension after spinal anesthesia for caesarean section, and at the same time for both mother and fetus. this was done in the study by onwochei published in 2017 in which a preventive and/or curative efficacy was demonstrated without major adverse effects on either the mother or the fetus.25 these results were comparable to those found in our study in which we compared two boluses of norepinephrine to determine the optimal dose per weight to prevent and treat hypotension induced by spinal anesthesia for caesarean section without any vascular filling. however, we found in our study that the incidence and depth of arterial hypotension after spinal anesthesia were comparable between groups as well as a similarity in hemodynamic status throughout the procedure between the two groups, and we can therefore infer that the 0.5μg/kg dose of nad combined with half-dose rescue boluses is sufficient to maintain intraoperative hemodynamic stability comparably to that of the 1μg/kg. the fact that a comparable number of rescue boluses were found between the two groups meant that the need to maintain the hemodynamic state would lie not in the injected dose but in the time interval between injections, which is in perfect agreement with the short half-life of nad. in fact, the usefulness of the preventive bolus is to anticipate arterial hypotension before it occurs, and the short half-life of nad makes it necessary to use rescue injections to maintain blood pressure. in summary, a preventive bolus of 0.5μg/kg followed by rescue boluses of 0.25μg/kg at a regular time interval of at least 2 min is sufficient to maintain a stable hemodynamic state intraoperatively. this same result can be achieved with the preventive dose of 1μg/kg and rescue boluses of 0.5μg/kg at minimum 2 min time intervals although it is associated with a higher incidence of hypertension. according to our study, nad at the dose of 0.5μg/kg as a preventive bolus and rescue doses of 0.25μg/kg can be used safely for the prevention and treatment of arterial hypotension induced by spinal anesthesia during caesarean section, especially as this strategy can be adopted in limitedresource settings thanks to the low cost of nad. on the other hand, apgar scores at 1 and 5 minutes of life and cord blood ph were comparable between the groups, with a negligible incidence of fetal acidosis, suggesting that even in case of fetal distress, the administration of norepinephrine to the mother will probably not cause or worsen potential fetal acidosis. in addition, reestablishing blood pressure will certainly improve perfusion and oxygen supply to the mother and fetus which usually results in a better ph value. conclusions bolus of 0.5μg/kg with rescue doses of 0.25 μg/kg of norepinephrine was respectively efficient in preventing and treating spinal anesthesia-induced hypotension. these doses may be recommended for routine use in healthy parturients. article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11486] [page 89] references 1. mueller md, brühwiler h, schüpfer gk, lüscher kp. higher rate of fetal acidemia after regional anesthesia for elective cesarean delivery. obstet gynecol 1997;90:131-4. 2. ebner h, barcohana j, bartoshuk ak. influence of postspinal hypotension on the fetal electrocardiogram. am j obstet gynecol 1960;80:569-72. 3. corke bc, datta s, ostheimer gw, et al. spinal anaesthesia for caesarean section. the influence of hypotension on neonatal outcome. anaesthesia 1982;37:658�62. 4. le gouez a, martel jacob s, dermoch f, mercier fj. vasopresseurs pour césarienne urgente et programmée. mapar. 2011. 5. heesen m, stewart a, fernando r. vasopressors for the treatment of maternal hypotension following spinal anaesthesia for elective caesarean section: past, present and future. anaesthesia 2015;70:252�7. 6. carvalho b, dyer ra. norepinephrine for spinal hypotension during cesarean delivery: another paradigm shift? anesthesiology 2015;122:728�30. 7. mets b. should norepinephrine, rather than phenylephrine, be considered the primary vasopressor in anesthetic practice? anesth analg 2016;122:1707�14. 8. mercier fj, bonnet mp, de la dorie a, et al. spinal anaesthesia for caesarean section: fluid loading, vasopressors and hypotension. ann fr anesth reanim 2007;26:68893. 9. klöhr s, roth r, hofmann t, et al. definitions of hypotension after spinal anaesthesia for caesarean section: literature search and application to parturients. acta anaesthesiol scand 2010;54:909�21. 10. cluver c, novikova n, hofmeyr gj, hall dr. maternal position during caesarean section for preventing maternal and neonatal complications. cochrane database syst rev 2013;3:cd007623. 11. morgan pj, halpern sh, tarshis j. the effects of an increase of central blood volume before spinal anesthesia for cesarean delivery: a qualitative systematic review. anesth analg 2001;92:997�1005. 12. sharwood smith g, drummond gb. hypotension in obstetric spinal anaesthesia: a lesson from pre-eclampsia. br j anaesth 2009;102:291-4. 13. langesæter e, dyer ra. maternal haemodynamic changes during spinal anaesthesia for caesarean section. curr opin anaesthesiol 2011;24:242-8. 14. chooi c, cox jj, lumb rs, et al. techniques for preventing hypotension during spinal anaesthesia for caesarean section. cochrane database syst rev 2017;8:cd002251. 15. ngan kee wd, khaw ks, lee bb, et al. a dose-response study of prophylactic intravenous ephedrine for the prevention of hypotension during spinal anesthesia for cesarean delivery. anesth analg 2000;90:1390-5. 16. butwick aj, columb mo, carvalho b. preventing spinal hypotension during caesarean delivery: what is the latest? br j anaesth 2015;114:183-6. 17. xu c, liu s, huang y, et al. phenylephrine vs ephedrine in cesarean delivery under spinal anesthesia: a systematic literature review and meta-analysis. int j surg 2018;60:48-59. 18. mon w, stewart a, fernando r, et al. cardiac output changes with phenylephrine and ephedrine infusions during spinal anesthesia for cesarean section: a randomized, double-blind trial. j clin anesth 2017;37: 43-8. 19. ngan kee wd, lee sy, ng ff, et al. randomized double-blinded comparison of norepinephrine and phenylephrine for maintenance of blood pressure during spinal anesthesia for cesarean delivery. anesthesiology 2015;122:736-45. 20. puolakka j, kauppila a, tuimala r, et al. the effect of parturition on umbilical blood plasma levels of norepinephrine. obstet gynecol 1983;61:19-21. 21. sodha rj, proegler m, schneider h. transfer and metabolim of norepinephrine studied from maternal-to-fetal and fetal-tomaternal sides in the in vitro perfused human placental lobe. am j obstet gynecol 1984;148:474-81. 22. minzter bh, johnson rf, paschall rl, et al. the diverse effects of vasopressors on the fetoplacental circulation of the dual perfused human placenta. anesth analg 2010;110:857-62. 23. kinsella sm, carvalho b, dyer ra, et al. international consensus statement on the management of hypotension with vasopressors during caesarean section under spinal anaesthesia. anaesthesia 2018;73:71-92. 24. hasanin am, amin sm, agiza na, et al. norepinephrine infusion for preventing postspinal anesthesia hypotension during cesarean delivery: a randomized dose-finding trial. anesthesiology 2019;130:55-62. 25. onwochei dn, ngan kee wd, fung l, et al. norepinephrine intermittent intravenous boluses to prevent hypotension during spinal anesthesia for cesarean delivery: a sequential allocation dose-finding study. anesth analg 2017;125:212-8. 26. elnabtity am, selim mf. norepinephrine versus ephedrine to maintain arterial blood pressure during spinal anesthesia for cesarean delivery: a prospective double-blinded trial. anesth essays res2018;12:92-7. 27. el gheribi m. prévention de l’hypotension induite par la rachianesthésie pour césarienne: éphédrine versus noradrénaline en perfusion continue [thèse]. médecine: tunis; 2018. 66p. 28. puthenveettil n, sivachalam sn, rajan s, et al. comparison of norepinephrine and phenylephrine boluses for the treatment of hypotension during spinal anaesthesia for caesarean section a randomised controlled trial. indian j anaesth 2019;63:995-1000. 29.ngan kee wd. a random-allocation graded dose-response study of norepinephrine and phenylephrine for treating hypotension during spinal anesthesia for cesarean delivery. anesthesiology 2017;127:934-41. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11795 factors affecting individual beliefs associated with the quality of life of traditional divers in the coastal area dhian satya rachmawati, nur chabibah, muh. zul azhri rustam sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia abstract traditional divers in surabaya’s coastal area face challenges despite the abundance of marine resources. this study aims to explore the factors that related to the quality of life among these divers. the research followed an observational analytic approach with a cross-sectional design. the study involved 31 traditional divers from kedung cowek village in surabaya, randomly selected based on specific criteria. the research utilised the health belief model theory to assess individual beliefs and the whoqol-bref tool to measure their quality of life. the individual beliefs were categorised into five indicators: perceived vulnerability, perceived severity, perceived obstacles, perceived benefits, and self-efficacy. out of these factors, two had a significant influence on the quality of life of traditional divers: perceived benefits (p = 0.009) and self-efficacy (p = 0.020). the study concludes that the quality of life for traditional divers in the surabaya coastal area is primarily influenced by perceived benefits and self-efficacy. it suggests that nearby healthcare facilities could offer health education to traditional divers, focusing on specific protective measures to reduce the risks associated with diving, such as barotrauma and decompression sickness. introduction indonesia possesses vast marine and coastal resource potential.1 however, this potential is not paralleled by the quality of life of traditional divers in coastal regions. a significant portion of coastal residents engage in traditional diving as their primary livelihood.2–4 traditional divers are men who use rudimentary equipment and breath-hold diving or surface-supplied air via compressors to search for marine resources in the sea.5 unfortunately, the quality of life for traditional divers is often subpar.6 the government has been striving to enhance the welfare of traditional divers, with a particular focus on the health sector. these efforts include promoting preventative measures, such as ensuring work safety, improving nutrition, enhancing basic sanitation, providing clean water, addressing maternal and child health, and managing infectious and noninfectious diseases, in addition to empowering traditional divers.7 welfare is gauged by the overall quality of human life.8 while a significant number of traditional divers has the potential to sustainably manage marine resources, low quality of life could diminish the resource management potential of traditional divers9. the decline in the quality of life of traditional divers also hampers the achievement of sustainable development goals (sdgs), particularly goal 1 (no poverty) and goal 3 (good health and well-being).10 in fact, the indonesian government aims to eradicate extreme poverty, targeting a reduction to zero percent by 2024, as outlined by the president of the republic of indonesia on march 4th, 2020.11 the actual extent of poverty affects society in both urban and rural areas,12 with a particular impact on coastal regions.13 the government’s programs have shown promising results, with poverty rates dropping to below double digits, standing at 9.66% or approximately 25.7 million people as of september 2018, marking a decrease of 1.78 million individuals or 1.14%.14 despite these advances, the quality of life of traditional divers still remains at a low level, approximately 73.3%.6 correspondence: nur chabibah, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia. e-mail: nhbienajah@gmail.com key words: individual belief; quality of life; traditional divers; coastal area. contributions: dsr, conceptualization, methodology, validation, visualization, resources, writing – original draft; nc, resources, methodology, writing – original draft, visualisation, review & editing, supervision; mzar, methodology, data curation, formal analysis, validation. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of the sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia based on the ethical certificate number pe/119/viii/2023/kep/sht. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analysed during this study are included in this published article. acknowledgement: this research was supported by a sekolah tinggi ilmu kesehatan hang tuah surabaya indonesia. received: 13 september 2023. accepted: 6 november 2023. early access: 17 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11795 doi:10.4081/hls.2023.11795 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 146] [healthcare in low-resource settings 2023; 11:11795] non -co mmerc ial us e o nly efforts to elevate the quality of life of traditional divers demand considerable attention.15,16 boosting the motivation of traditional divers can be a key strategy to fulfill their basic needs.13 one approach to increasing the motivation of traditional divers is the application of the health action process approach (hapa).17 hapa is anticipated to improve the quality of life of traditional divers, potentially serving as an intervention to empower traditional divers in achieving a higher quality of life.18 the application of the hapa model posits that the adoption, initiation, and maintenance of health behavior must be understood as a process comprising a motivational phase and a volitional phase, further divided into planning, action, and maintenance phases, with self-efficacy being a critical condition at all stages along with other cognitive elements.19 for instance, risk perception primarily facilitates the early stages of the motivational phase but no further. similarly, outcome expectations are particularly influential in the motivational phase when individuals weigh the pros and cons of behavioral consequences, but their predictive power wanes after personal decisions are made.20 ultimately, if an individual lacks confidence in their ability to perform a desired action, they may fail to adopt, initiate, and maintain it.21 given this background, the objective of this study was to analyse the individual belief factors associated with the quality of life of traditional divers in the surabaya coastal area. materials and methods research design this study employed a cross-sectional approach. the sample was selected through simple random sampling, applying predefined inclusion and exclusion criteria. the inclusion criteria included active traditional divers who were willing to participate, residing in kedung cowek village, indonesia, and engaged in traditional diving. traditional divers were defined as individuals actively hunting at sea without modern equipment, using breathhold diving or air supply provided through surface compressors. they operated boats measuring 5 meters in length, 1 meter in width, and 0.5 meters in height, with a maximum passenger capacity of 2 individuals, powered by an outboard engine with a capacity of 5.5 paarden kracht (p.k.). data collection was conducted by the researchers, and the collected data was analysed using a linear regression test. study participants the participants in this study were traditional fishermen, specifically traditional divers, from kedung cowek village in surabaya, indonesia. the study population consisted of all traditional divers between the ages of 20 and 80 residing in kedung cowek village, surabaya. the sample included 31 traditional divers randomly selected from a total population of 34, based on predefined inclusion and exclusion criteria. variable, instrument, and data collection this study examined the individual beliefs of traditional divers and their quality of life. additionally, demographic factors, including age, gender, education, occupation, religion, economic status, and marital status, were assessed. the research employed a questionnaire to measure the individual beliefs and quality of life of traditional divers. the individual beliefs questionnaire was adapted from the health-belief model theory developed by victoria et al. (2008)22 and transformed into a questionnaire format. these individual beliefs encompassed five indicators: perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and self-efficacy. the validity and reliability of the questionnaire for individual beliefs were assessed before data collection, confirming their validity. the reliability testing resulted in correlation coefficients ranging from 0.679 to 0.971. the instrument used to measure the quality of life was the whoqol-bref. this standardised instrument, acquired from kiling et al. (2019),23 did not require validity or reliability testing. data were collected in the first and second weeks of july 2023, and participants provided their responses by filling out the questionnaires. data analysis the collected data were analysed using a linear regression test, assuming the data met the normal distribution requirement. the linear regression aimed to investigate the factors associated with the quality of life of traditional divers in the surabaya coastal area. quality of life was measured using the whoqol-bref instrument. the analysis involved assessing the significance of the t-test. the significance value of the t-test was compared with a predefined threshold value of 5%. if the obtained significance value of the t-test was smaller than the threshold value, it indicated a significant influence between individual beliefs and the quality of life of traditional divers. ethical clearance this research received ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia, granted under ethical certificate number pe/119/viii/2023/kep/sht. throughout the research process, ethical principles, such as informed consent, respect for human rights, beneficence, and non-maleficence, were observed. results distribution of demographic characteristics in traditional divers based on table 1, the demographic data of traditional divers on the coast of surabaya are presented. the results indicate that over half of the traditional divers fall within the age range of 23-45 years (58.1%). all divers in the study are male, with 38.7% having received no formal education. the majority of these divers have been engaged in traditional diving to catch fish and shellfish for over four years (93.5%), and their average monthly income is below the regional minimum wage (74.2%). furthermore, 93.5% of them are married, with 61.3% serving as the primary breadwinners. the average household consists of two individuals, making up 51.6% of the sample. this study presents descriptive statistics to characterise the research variables, encompassing the lowest and highest values, the mean, and the standard deviation. the summary of the descriptive statistics for the research variables influencing individual beliefs on quality of life is presented in table 2. table 2 displays the individual belief factors in traditional divers, involving 31 participants. the average score for these factors is 88.71, considering the maximum quality of life score, with a standard deviation of 10.7%. specifically, the average score for perceived susceptibility to the quality of life among traditional [healthcare in low-resource settings 2023; 11:11795] [page 147] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly divers is 15.90 out of a maximum of 22.00, indicating a relatively high perception of susceptibility. the perception of severity, which also affects the quality of life, has an average score of 16.26 out of a maximum of 22.00, signifying a relatively high perception of severity compared to susceptibility. in the context of barriers affecting quality of life, an average score of 12.35 is achieved from a maximum score of 17.00, with a standard deviation of 3.4%. in contrast, perceived benefits yield an average score of 9.13 from a maximum score of 14.00, while self-efficacy results in an average score of 7.68 out of a total of 13.00, accompanied by a standard deviation of 2.5%. these findings suggest that both perception and self-efficacy have a noteworthy impact on changing the quality of life for traditional divers. individual belief analysis of quality of life in traditional divers table 3 reveals that the significance values for perceived benefits and self-efficacy are 0.009 and 0.020, respectively. these values are smaller than the tolerance limit of 5%, indicating that both perceived benefits and self-efficacy have a significant influence on quality of life. on the other hand, the anova test results in a significance value of 0.071, suggesting that there is no significant influence when considering perceptions of susceptibility, severity, barriers, benefits, and self-efficacy simultaneously on the quality of life of traditional divers. furthermore, the r-squared value is 0.319, signifying that the impact of individual beliefs, which encompass perceptions of severity, susceptibility, barriers, benefits, and selfefficacy, on the quality of life of traditional divers amounts to 31.9%. the remaining factors contribute to the remaining variance. discussion factor individual beliefs associated with traditional divers in the surabaya coastal area individual beliefs are essentials particularly in shaping their attitudes and behaviours. in this research, individual beliefs pertain to the traditional divers’ beliefs regarding their own health and how these beliefs affect their attitude towards their well-being. this study measures five factors within individual beliefs: perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and self-efficacy. according to table 2, the perception of benefits and self-efficacy significantly impacts the quality of life of traditional divers. traditional divers are confident that their work benefits not only themselves but also their families and the environment. they provide marine products to the community, which leads to economic success, aligning with the findings of ghani et al. (2017)24 which suggests that the more traditional divers catch, the more they can provide for the community and their families.24 furthermore, self-efficacy also influences the quality of life of traditional divers, as their educational status affects their job opportunities. those with lower levels of education may find it challenging to secure better job opportunities. this aligns with the assumption that the level of education significantly influences [page 148] [healthcare in low-resource settings 2023; 11:11795] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of demographic characteristics in traditional divers (n=31). characteristic demographic frequency (f) percentage (%) p age 23-45 years 18 58.1 46-77 years 13 41.9 gender male 31 100 female 0 0 graduation not finished elementary school 12 38.7 elementary school 11 35.5 junior high school 5 16.1 senior high school 3 9.7 bachelor 0 0 timer working as traditional divers 1-3 years 2 6.5 > 4 years 29 93.5 marital status married 29 93.5 not married 2 6.5 income (monthly) < the regional’s minimum salary 23 74.2 > the regional’s minimum salary 8 25.8 is there a family member other than the respondent who is working? yes 12 38.7 no 19 61.3 number of family members in a household 1 8 25.8 2 16 51.6 3 7 22.6 non -co mmerc ial us e o nly human resources. traditional divers are often reluctant to attempt new activities unless they believe they are capable of doing them. they believe in the benefits of these new behaviors but may not have the confidence to try them. in many cases, the younger generation of traditional divers is compelled to support their families economically.25 quality of life of traditional divers there are various definitions of the quality of life. in this research, the quality of life pertains to that of traditional divers and based on five perception factors: perception of susceptibility, perception of severity, perception of barriers, perception of benefits, and self-efficacy. these results indicate no simultaneous influence of perceptions of susceptibility, severity, barriers, benefits, and self-efficacy on the quality of life of traditional divers.24 quality of life can be measured through various influencing factors, including education, health, and economic status. low quality of life often results from deficiencies in human resources, health, and the economy.6 the researcher’s assumption is that the level of education can significantly influence the quality of life of traditional divers. a low level of education tends to result in diminished human resources, which, in turn, leads to a lack of skills and an inability to perceive and adopt behaviors that support a good quality of life. our finding highlights that two factors influence the quality of life of traditional divers. specifically, perceived benefits and selfefficacy are linked to the low educational levels of traditional divers, which in turn affect family income and economic factors. traditional divers often encourage their children to assist in increasing family income and alleviating family burdens. many traditional divers appreciate the benefits of their work and feel grateful for their improved lives, partly due to increased government and social institution attention to traditional fishermen, especially traditional divers. this perspective aligns with previous research that considers the concept of quality of life as an amalgamation of opportunities, human needs, and welfare.26,27 quality of life pertains to the extent to which human needs are met and can be evaluated objectively and subjectively. essential human needs include safety, self-sufficiency, and reproduction.28 moreover, selfefficacy factors significantly impact the quality of life of traditional divers. these divers are particularly susceptible to illnesses such as decompression sickness and barotrauma, and some of them mistakenly believe that these illnesses will naturally heal. they have confidence that their families will continue to support them through such hardships.24 the impact of self-efficacy on the quality of life of traditional divers aligns with previous studies. for instance, traditional divers who engage in extended dives, exceeding 10.5 hours per week, and have over 2.6 years of diving experience are at higher risk of decompression sickness.29 the accumulation of nitrogen in the body over longer dives is a contributing factor, and this condition necessitates treatment as it does not resolve spontaneously.30 research conducted in the west coast region of malaysia further supports the idea that the quality of life of traditional divers can be improved with special attention from the government, including the adoption of effective technology in marine fishing activities.24,26,27 [healthcare in low-resource settings 2023; 11:11795] [page 149] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. descriptive data analysis on traditional divers. variable n min. max. mean deviation std. quality of life 31 71 105 88.71 10.759 perceived severity 31 9 22 16.26 2.792 perceived susceptibility 31 9 22 15.90 2.914 perceived barrier 31 0 17 12.35 3.382 perceived benefit 31 4 14 9.13 2.566 self-efficacy 31 4 12 7.68 2.508 table 3. the result of analysis the infuence of individual beliefs on quality of life in traditional divers. variable unstandardised coefficients standardised t sig.*) b std. error coefficients beta (constant) 92.062 14.319 6.430 0.000 perceived susceptibility 0.160 0.752 0.043 0.212 0.834 perceived severity -0.441 0.769 -0.114 -0.574 0.571 perceived barrier -0.306 0.567 -0.096 -0.539 0.595 perceived benefit 2.113 0.745 0.504 2.838 0.009 self-efficacy -1.855 0.744 -0.432 -2.494 0.020 sig.**) 0.071 normalitas test ***) 0.525 r square 0.319 *linier regression tes; **anova test; ***shapiro-wilk test. non -co mmerc ial us e o nly conclusions in this research, individual beliefs encompass five factors: perceived susceptibility, perceived severity, perceived barriers, perceived benefits, and self-efficacy. among these factors, two significantly impact the quality of life of traditional divers: perceived benefits and self-efficacy. to comprehensively understand the factors influencing the quality of life of traditional divers in the coastal areas of surabaya city, further research is needed to identify and explore additional contributing factors. the research implies that the nearest health facilities should offer health education programs tailored to traditional divers. these programs should provide specific protective measures to mitigate the risks associated with diving activities, such as barotrauma, decompression sickness, and other related health concerns. references 1. suryadi am, sufi s. strategi pemberdayaan masyarakat nelayan dalam peningkatan kesejahteraan nelayan (studi di kantor camat muara batu kabupaten aceh utara). negot j ilmu adm bisnis 2019;2:118. 2. goso goso, anwar sm. poverty of traditional fisherman as well as the influence toward dirty village. in: natural and social science (iconss) 2017. p. 81-9. 3. zain ma, suhaimi j, dahlui m, et al. what are the outcomes of marine site protection on poverty of coastal communities in southeast asia? a systematic review protocol. environ evid 2022;11(1). 4. sudarso, keban pe, mas’udah s. poverty, lack of awareness of gender education, and patriarchy among javanese coastal women. opcion 2019;35:2899-921. 5. prasetyo at, soemantri jb, lukmantya l. pengaruh kedalaman dan lama menyelam terhadap ambang-dengar penyelam tradisional dengan barotrauma telinga. oto rhino laryngol indones 2012;42:69-76. 6. trijayanti e, mutaali l. kualitas hidup nelayan desa kemadang, kecamatan tanjungsari, kabupaten gunungkidul. j bumi indones 2017;6:1-9. 7. latif i. analisis deskriptif masalah kesehatan masyarakat pesisir desa karangsong indramayu. j kesehat indra husada 2017;4:29-36. 8. laratmase aj. pengembangan alat ukur kualitas hidup nelayan. j ilm pendidik lingkung dan pembang 2016;17:34-41. 9. paskarini i, alwi mnm, martiana t, mahmudah, arini sy, dwiyanti e. the decrease in the quality life of fishermen due to covid-19 widespread. malaysian j med heal sci 2022;18:79-85. 10. tain a. penyebab kemiskinan rumah tangga nelayan di wilayah tangkap lebih jawa timur [causes of household poverty among fishermen in the east java fishing grounds]. humanity 2011;7:110. 11. tnp2k. penentuan wilayah prioritas kemiskinan ekstrem 2021-2024. 2022;1-20. 12. laksono ad, wulandari rd, efendi f. determinants of hospital utilisation among urban poor societies in indonesia. int j innov creat chang 2020;12:375-87. 13. tamboto hj., manongko aac. model pengentasan kemiskinan masyarakat pesisir. 2019. 157 p. 14. bps 2020. statistik indonesia 2020. stat indones 2020. 2020;1101001:790. 15. saroinsong rp. peran pemerintah desa dalam penanggulangan kemiskinan nelayan di desa lantung kecamatan wori kabupaten minahasa utara. acta diurna komun 2014;3:1-12. 16. alayyannur pa, haqi dn, zahroh f, munib ta, alhakim mm, ningrum dp. relationship between individual characteristics and the risk of exposure to heat stress in indonesian fishermen. pharmacogn j 2023;15:294-7. 17. malik k, amir n, kusumawardhani aaaa, lukman pr, karnovinanda r, melisa l, et al. health action process approach (hapa) as a framework to understand compliance issues with health protocols among people undergoing isolation at emergency hospital for covid-19 wisma atlet kemayoran and rscm kiara ultimate jakarta indonesia. front psychiatry 2022;13:1-15. 18. widyastuti sr, hadisaputro s, munasik m. berbagai faktor yang berpengaruh terhadap kualitas hidup penyelam tradisional penderita penyakit dekompresi. j epidemiol kesehat komunitas 2019;4:45. 19. el-soud faa, alhoraim sa, alammar ba, alotaibi rs. quality of life, self-rated health and social support among older adult in the saudi community. malaysian j nurs 2020;11:1325. 20. abbas a, ekowati d, suhariadi f, fenitra rm. health implications, leaders societies, and climate change: a global review. springer climate. department of economics and business, jawa timur, surabaya, indonesia. springer science and business media b.v.; 2022. p. 653-75. 21. manab a. memahami regulasi diri: sebuah tinjauan konseptual. psychol humanit 2016;7-11. 22. champion vl, skinner cs. the health belief model. in: glanz k, rimer bk, viswanath k, editors. health behavior and health education: theory, research, and practice. 4th ed. san francisco, ca, us: jossey-bass; 2008. p. 45-65. 23. kiling iy, kiling-bunga bn. pengukuran dan faktor kualitas hidup pada orang usia lanjut. j heal behav sci 2019;1:14965. 24. ghani na, raub ma, adam f, abdullah b, afgani@eusoff y, ali puteh dahm. quality of life (qol) of fishermen in the west coast states of peninsular malaysia. int j acad res bus soc sci 2017;7(4). 25. gai am, soewarni i. the characteristics and poverty level of people in sukolilo fisherman village surabaya based on sustainable livelihood approach. j econ sustain dev 2017;8(20). 26. dahlui m, azzeri a, zain ma, et al. health status, healthcare utilisation, and quality of life among the coastal communities in sabah: protocol of a population-based survey. medicine (baltimore) 2020;99:e22067. 27. putra mm, sari npwp. model theory of planned behavior to improve adherence to treatment and the quality of life in tuberculosis patients. j ners 2020;15(2). 28. zain rm, kamarudin mka, saad mhm. assessment of quality of life on fishermen community in kuala terengganu, malaysia: a review. int j acad res bus soc sci 2018;8:640-50. 29. chabibah n, mayasari ac, rachmawati ds, said fbm. the impact of frequency and duration of diving activities on the occurrence of decompressive sickness. malaysian j nurs 2022;14:75-81. 30. widyastuti sr, hadisaputro s, munasik m. berbagai faktor yang berpengaruh terhadap kualitas hidup penyelam tradisional penderita penyakit dekompresi. j epidemiol kesehat komunitas 2019;4:45-54. [page 150] [healthcare in low-resource settings 2023; 11:11795] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11981 the effectiveness of booklets on family knowledge of diabetes mellitus patients about the management of hypoglycaemia romalina romalina, meisa daniati, rima novia putri, asmarita jasda tanjungpinang ministry of health health polytechnic, tanjungpinang, indonesia abstract the three main acute complications of diabetes mellitus related to an imbalance in glucose levels that lasted in the short term were hypoglycemia, diabetic ketoacidosis (dka), and hyperglycemic hyperosmolar nonketotic syndrome. the family, as the people closest to and always interacting with the patient, played a significant role in preventing complications. a booklet served as one medium to increase knowledge for families. this study aimed to determine the effectiveness of the booklet on the knowledge of families of dm patients regarding the management of hypoglycemia. a quantitative method with a quasiexperimental design approach involving pre-test and post-test designs was employed. the population in this study comprised families of diabetes mellitus patients who were at puskesmas (public health centre) batu x and puskesmas mekarbaru, indonesia. the research sample consisted of 70 respondents selected through purposive sampling. the research variables included demographic factors, family knowledge before and after the intervention in the intervention and control groups, and bivariate analysis. the research instrument employed a questionnaire and a booklet regarding the management of hypoglycemia. independent t-test analysis was conducted (α=0.05). the booklet proved effective in improving the knowledge of families of diabetes mellitus patients regarding the management of hypoglycemia, with a p-value of 0.028. the booklet can enhance family knowledge about the management of hypoglycemia. therefore, every internal medicine clinic or health centre should provide booklets as an educational medium. introduction data from the international diabetes federation (idf) indicates that 463 million people had diabetes (dm) in 2019, which rose to 573 million people in 2021. it is estimated that this figure will reach 700 million people by 2045. dm is often referred to as a silent killer because it can affect other organs, including the heart, kidneys, nerves, blood vessels, and eyes.1 based on the blood test, the percentage of people aged greater than or equal to 15 years with diabetes (dm) was 6.9% in 2013 and increased to 10.9% in 2018.2 based on data from the tanjungpinang city health office, in 2019, there were 6,419 cases of diabetes mellitus patients. in 2020, the number decreased to 4,690 cases, and from january to november 2021, there were 3,089 cases of dm. the three major acute complications of diabetes mellitus related to short-term imbalances in glucose levels are hypoglycemia, diabetic ketoacidosis (dka), and hyperglycemic hyperosmolar nonketotic syndrome. hypoglycemia has a serious impact on morbidity, mortality, and quality of life. the diabetes control and complications trial (dcct) reported a threefold increase in severe hypoglycemia and coma in intensively managed patients compared to conventionally treated patients.3,4 hypoglycemia can lead to brain disorders and, in some cases, even patient fatalities. approximately 66.7% of diabetes mellitus patients who visited the emergency room had hypoglycemia.5 the previous study correspondence: romalina romalina, tanjungpinang ministry of health health polytechnic, tanjungpinang, indonesia. e-mail: romlin17@gmail.com key words: booklet, diabetes management, empowerment and family education, hypoglycemia. contributions: rr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; md, conceptualization, methodology, validation, and writing – original draft, review and editing; hh methodology, visualization, writing – review and editing; rm, methodology, formal analysis, validation; aj, methodology, validation, visualization. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from stikes bani saleh ethics committee with number ec.237/kepk/stkbs/vi/2023 on june 1 2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from dipa poltekkes kemenkes tanjungpinang with contract number dp.04.03/ iv/0905/2023. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 14 october 2023. accepted: 17 november 2023. early access: 7 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11981 doi:10.4081/hls.2023.11981 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 78] [healthcare in low-resource settings 2024;12:11981] non -co mmerc ial us e o nly found that poor glycemic control was associated with being female, being younger in age, receiving a combination of oral hypoglycemic agents and insulin, not taking biguanides, and having the presence of hyperglycemia and comorbid diseases.6 according to research, out of 109 diabetes mellitus patients, 33.9% experienced hypoglycemia.7 another study found that there are several risk factors for hospitalization among hypoglycemia patients, namely epidemiology, pathophysiology, impact, and prevention strategies.8 families are expected to participate in the treatment from the beginning as they play an important role in the recovery program.9 meanwhile, additional research indicates that family knowledge about hypoglycemia in patients with diabetes mellitus is categorized as follows: poor knowledge (60%), good knowledge (10%), and sufficient knowledge (30%). in another study, it was found that nurses’ roles were classified as “good” in 54.90% of cases.10 next, it indicates that family involvement is suboptimal, especially among younger family members. meanwhile, an alternative solution to address this issue is through home visits, but this presents a challenge for health workers at the puskesmas due to the numerous routine tasks that they must perform.11 moreover, continuous education for families through wechat can enhance the health of patients with type 2 diabetes.12 recognizing this issue calls for a health education program designed for patients and the families of those affected by hypoglycemia. according to research, there is a need to develop an evidence-based education program focused on hypoglycemia prevention for patients and their families.13 the subsequent study discovered that patient and family education through the use of booklets led to improvements in diabetes mellitus self-care knowledge.14 from this description, it is evident that effective education is necessary to enhance family knowledge about hypoglycemia management as an effort to prevent hypoglycemia and associated fatalities. therefore, the aim of this study was to assess the effectiveness of booklets in improving the knowledge of families with dm patients regarding hypoglycemia management. materials and methods research design this study uses a quantitative method with a quasiexperimental design approach with a pre test and post test design. study participants the population for this study consisted of 82 people (based on the number of visits in the last 3 months). the sample for this study included the families of diabetes mellitus patients in the working areas of puskesmas batu x and puskesmas mekarbaru, totaling 70 respondents (determined using the slovin formula) – 35 in the intervention group and 35 in the control group. the sampling method employed was purposive sampling. the criteria for selecting participants for the study were as follows: adults, capable of reading and writing, participation in the entire study, and having a family member with dm. during the study, two respondents refused to complete the questionnaire at the end of the intervention, so they were replaced. variable, instrument and data collection the independent variables include demographic factors such as age, gender, education, ethnicity, occupation, relationship with the patient, and the duration of suffering from dm. the dependent variable is the family’s knowledge about hypoglycemia management. the research instrument employed a questionnaire that had been previously tested for validity and reliability, and it was confirmed to be valid and reliable. the instruments used in this study included questionnaires and booklets on hypoglycemia management. the questionnaire consists of questions related to demographic data and 12 statements about hypoglycemia and hypoglycemia management, which were modified from previous research by sunaryo.15 data analysis the analysis was conducted using spss. for bivariate analysis, the unpaired t-test was employed with a significance level set at p=0.05, and for univariate analysis, central tendency measures were utilized. ethical clearance the research has received ethical approval from stikes bani saleh, under ethical approval number ec.237/kepk/ stkbs/vi/2023 issued on june 1, 2023. throughout the research, the researcher adheres to ethical principles including informed consent, respect for human rights, beneficence, and nonmaleficence. results respondent characteristics the characteristics of respondents in the intervention group were as follows (table 1): 24 people (69%) were elderly, with 25 people (71%) being female. the highest level of education among the respondents was high school, which accounted for 18 people (52%). the majority of the respondents belonged to the javanese ethnic group, totaling 13 people (37%). most respondents worked as housewives, with 19 people (54%), and 24 people (69%) had a relationship with dm patients as wives. the majority of patients had been suffering from dm for more than 5 years, amounting to 23 people (66%). as for the characteristics of respondents in the control group: 18 people (51%) were elderly, with 24 people (69%) being female. the highest level of education that respondents had attained was high school, which was the case for 23 people (65%). the most common ethnic group among the respondents was malay, with 14 people (40%). most respondents worked in the private sector, which applied to 14 people (40%), and they had a relationship with the patient as a child in 16 cases (46%). the majority of patients had been suffering from dm for more than 5 years, totaling 26 people (74%). family knowledge the results regarding knowledge about hypoglycemia in the control group and intervention group were different, but both groups showed an improvement (table 2). in the intervention transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11981] [page 79] non -co mmerc ial us e o nly group, the average increased from 58.8 at pretest to 77.2, while in the control group, the average increased from 57.46 to 83.46. bivariate analysis the bivariate test results in table 3 demonstrate the effectiveness of the booklet in improving the knowledge of families with diabetes mellitus patients regarding hypoglycemia management, with a p-value of 0.028 discussion hypoglycemia is an emergency condition that requires immediate treatment because its complications can lead to reduced consciousness, seizures, and permanent brain damage. both type 1 and type 2 diabetes mellitus patients can experience hypoglycemia. therefore, knowledge about hypoglycemia, including prevention, treatment, and monitoring, is essential.16 based on the results of the research conducted by the researchers, it is evident that booklets transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents in the intervention group (n=35). intervention group control group no age amount percentage (%) age amount percentage (%) 1 mature 11 31 mature 17 49 2 elderly 24 69 elderly 18 51 no gender amount percentage (%) gender amount percentage (%) 1 man 10 29 man 11 31 2 woman 25 71 woman 24 69 no education amount percentage (%) education amount percentage (%) 1 not attending school 3 9 not attending school 0 0 2 elementary school 4 11 elementary school 3 9 3 junior high school 4 11 junior high school 3 9 4 senior high school 18 52 senior high school 23 65 5 pt 6 17 pt 6 17 no ethnic group amount percentage (%) ethnic group amount percentage (%) 1 java 13 37 java 11 31 2 malay 10 28 malay 14 40 3 batak 3 9 batak 5 14 4 buton 1 3 buton 0 0 5 minang 5 14 minang 3 9 6 sunda 2 6 sunda 0 0 7 chinese 1 3 chinese 2 6 no work amount percentage (%) work amount percentage (%) 1 doesn't work 4 11 doesn't work 2 6 2 housewife 19 54 housewife 9 26 3 household assistant 1 3 state civil apparatus 3 8 4 state civil apparatus 3 9 private 14 40 5 laborer 3 9 student 4 11 6 private 4 11 retired 3 9 7 financial staff 1 3 financial staff 0 0 no relationship with patients amount percentage (%) relationship with patients amount percentage (%) 1 wife 24 69 wife 14 40 2 husband 2 6 child 16 46 3 father 3 8 father 2 6 4 mother 4 11 husband 2 6 5 grandma 1 3 mother 1 2 6 older brother 1 3 older brother 0 0 no suffering from amount percentage (%) suffering from amount percentage (%) dm for a long time dm for a long time 1 <5 years 12 34 <5 years 9 26 2 ≥5 years 23 66 ≥5 years 26 74 [page 80] [healthcare in low-resource settings 2024;12:11981] non -co mmerc ial us e o nly have proven to be effective in improving the knowledge of families with diabetes mellitus patients about hypoglycemia management. several studies have shown a correlation between age, education, and occupation with the level of knowledge, where age is the dominant factor influencing knowledge17 other studies have shown that age, education level, and knowledge are positively correlated with hypertension self-management. as age increases, the ability to self-manage hypertension decreases, while higher education and better knowledge enhance hypertension selfmanagement.18 additional studies have indicated that the quality of type 2 diabetes self-management is influenced by factors such as age, gender, level of education, duration of type 2 diabetes, knowledge, self-efficacy, stress, and family support.19 good adherence to a medication regimen is a crucial aspect of healthcare quality.20 knowledge about diabetes helped the patient to control the disease and to reduce the risk of disability.21 additional evidence suggests that a relationship exists between the duration of illness and the knowledge of foot and skin care in patients with type 2 diabetes mellitus at the mamplam room of rsud dr. zaenoel abidin banda aceh. booklets and leaflets have an impact on increasing knowledge, but booklet media is more effective than leaflet media in enhancing adolescents’ understanding of the consequences of teenage pregnancy, as observed at pertiwi high school in jambi city22 another study reported a difference in the average knowledge level before and after maternal parenting education through booklet media. booklet media is an effective tool for health education as it can improve the knowledge and attitudes of mothers with stunted toddlers. furthermore, booklet media is practical, allowing for easy portability and on-the-go reading.23 the results indicated that self-care supportive education with booklets had a positive effect on the ability to detect early hypoglycemia and hyperglycemia. this was characterized by a better ability to detect early hypoglycemia and hyperglycemia in the treatment group compared to the control group.24 the study demonstrated a significant difference in knowledge and compliance levels before and after providing booklets to the intervention group. however, there was no significant difference in knowledge and compliance levels in the control group. therefore, it can be concluded that booklet media can enhance knowledge and compliance in patients with diabetes mellitus25 research also underscores the importance of patient and family education through booklets, which leads to improvements in diabetes mellitus self-care knowledge. this emphasizes the significant role of the family in recognizing the health status and changes experienced by their family members.14 conclusions booklets and flipcharts are educational media that can enhance knowledge, but booklets have been proven to be more effective in increasing the knowledge of families with diabetes mellitus patients regarding hypoglycemia management. the implication of this research for nursing services is to provide information and insights to nursing practitioners about managing hypoglycemia. hypoglycemia management booklets should be made readily available in hospital and health center clinics. references 1. badan pusat statistik. kajian indikator sustainable development goals (sdgs ). kajian indikator lintas sektor. 2014. 2. bestari il. characteristics of patients with type 2 diabetes mellitus at surabaya haji general hospital. indon j public health 2020;15:286-94. 3. perhimpunan dokter spesialis penyakit dalam indonesia. eimed papdi : kegawatdaruratan penyakit dalam buku i. vol. 1. jakarta pusat : interna publishing; 2016. 4. dinas kesehatan kota tanjungpinang. data diabetes melitus tipe ii tahun 2019-2021. tanjungpinang; 2020. 5. bakar a, qomariah sn, santoso ch, et al. factors the incidence of hypoglycemia in diabetes mellitus patients: a pilot study in the emergency room. enferm clin 2020;30:46-9. 6. suprapti b, izzah z, giriayu a, et al. prevalence of medication adherence and glycemic control among patients with type 2 diabetes and influencing factors : a cross-sectional study. glob epidemiol 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of family knowledge. no group pretest post test 1 intervention mean = 58.8 mean = 77.2 median = 58 median = 75 highest score= 83 highest score= 100 lowest score 42 lowest value = 50 2 control mean = 57.46 mean = 83.46 median = 58 median = 83 highest score= 83 highest score= 100 lowest value = 33 lowest value = 42 table 3. unpaired t test results. n mean ±sb mean difference (ci 95%) p control 35 3,232 0.688-11.826 0.028 intervention 35 3,232 0.688-11.826 0.028 [healthcare in low-resource settings 2024;12:11981] [page 81] non -co mmerc ial us e o nly to health reform in china. hum resour health 2017;15:50. 12. mao l, lu j, zhang q, et al. family-based intervention for patients with type 2 diabetes via wechat in china: protocol for a randomized controlled trial. bmc public health 2019;19:381. 13. whittemore r, watts sa, meulstee m. development of an educational program on prevention of hypoglycemic events among elderly veterans with type 2 diabetes. diabetes educ 2015;41:690 -7. 14. pranata l, indaryati s, daeli ne. perangkat edukasi pasien dan keluarga dengan media booklet (studi kasus self-care diabetes melitus). jurnal keperawatan silampari 2020;4:10211. 15. sunaryo t. faktor-faktor yang berhubungan dengan kemampuan pasien diabetes mellitus dalam melakukan deteksi episode hipoglikemia dalam konteks asuhan keperawatan di rsud karanganyar. [jakarta]: fik ui; 2008. 16. rusdi ms. hipoglikemia pada pasien diabetes mellitus [internet]. 2020. available from: http://ejurnal.ung.ac.id/ index.php/jsscr 17. suwaryo paw, yuwono p. faktor-faktor yang mempengaruhi tingkat pengetahuan masyarakat dalam mitigasi bencana alam tanah longsor. the 6th university research colloquium 2017 universitas muhammadiyah magelang, 2017. 18. sakinah s, ratu jm, weraman p. hubungan antara karakteristik demografi dan pengetahuan dengan self management hipertensi pada masyarakat suku timor: penelitian cross sectional. jurnal penelitian kesehatan ‘suara forikes’ (journal of health research ‘forikes voice’) 2020;11:245. 19. samudera ws, efendi f, indarwati r. effect of community and peer support based healthy lifestyle program (cp-help) on self care behavior and fasting blood glucose in patient with type 2 diabetes mellitus. j diabetes metab disord 2021; 20:193-9. 20. zairina e, nugraheni g, sulistyarini a, et al. factors related to barriers and medication adherence in patients with type 2 diabetes mellitus: a cross-sectional study. j diabetes metab disord 2022;21:219-28. 21. rondhianto, kusnanto, melaniani s. the effect of diabetes self-management education, based on the health belief model, on the psychosocial outcome of type 2 diabetic patients in indonesia. indian j public health res dev 2018;9:1718-23. 22. sidiq r, nurleli n. relationship with knowledge of older suffering disease and feet on skin care patients type 2 diabetes mellitus in mamplam room general hospital of dr. zaenoel abidin banda aceh. idea nursing journal 2015;vi(2). 23. sari la. efektivitas media booklet dan leaflet terhadap pengetahuan remaja putri tentang dampak kehamilan remaja. jambura j health sci res 2019;1(2). 24. inung sylvia e, azizah i, manuntung a, datak g. peningkatan pengetahuan pasien diabetes melitus melalui edukasi tentang katarak dengan media booklet. jurnal ilmiah permas: jurnal ilmiah stikes kendal 2019;9:353-8. 25. raodah, sitti nur djannah, lina hadayani. efektivitas media edukasi booklet terhadap pengetahuan dan sikap ibu balita stunting aceh. media publikasi promosi kesehatan indonesia (mppki). 2023;6(5). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 82] [healthcare in low-resource settings 2024;12:11981] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11834 the journey of indonesian nurse migration: a scoping review rifky octavia pradipta,1 ferry efendi,1 abdullah saleh alruwaili,2,3,4 mohammad rizal diansya,1 anna kurniati5 1faculty of nursing, universitas airlangga, surabaya, indonesia; 2emergency medical services program, college of applied medical sciences, king saud bin abdulaziz university for health sciences, al ahsa, saudi arabia; 3king abdullah international medical research center, al ahsa, saudi arabia; 4school of health, faculty of medicine and health, university of new england, armidale, new south wales, australia; 5directorate general of health workforce, ministry of health, jakarta, indonesia abstract the migration of nurses from indonesia to other foreign countries is an inevitable part of the global mobility of the nurse profession. this phenomenon requires investigation to understand the current trajectories of indonesian nurses in the global market. this scoping review aimed to investigate the indonesian nurses’ mobility to the international healthcare market. a scoping review of primary research addressing indonesian nurses migration journey overseas. a range of databases were searched, including scopus, web of science clarivate analytics, cumulative index to nursing and allied health literature (cinahl), and pubmed. a systematic process was performed guided by the work of arksey and o’malley. four databases were searched, and 68 articles were retrieved. after screening articles and abstracts, 19 full texts were assessed for eligibility, and finally, 17 studies were further analysed and synthesized. eight qualitative studies, five quantitative studies and four literature review studies met inclusion criteria, emphasizing the three phases of migration: pre-migration, migration and post-migration. the destination countries of indonesian nurses including japan, kuwait, saudi arabia and taiwan. at the pre-migration stage there are several aspects that must be considered, there were: language, understanding of the job position, reason to work and comprehensive understanding of the destination countries. migration stage include issues language, deskilling, mental health, unclear career path, cultural adaptation, lack of religious services and homesickness. at the post-migration stage includes deskilling, brain waste and re-integration with brain circulation platform. the comprehensive approach of indonesian nurses migration from pre-migration, migration and post-migration has shown us the trajectory of indonesian nurses in international migration. understanding the bottle neck of each stage with improve policy support is needed to create safe and sound migration channel for indonesian nurses. this review highlighted to the need for future research in key areas such as the impact of nurse migration on indonesia’s health systems. introduction the migration of nurses to more developed countries has been a longstanding practice, driven by the pursuit of better career prospects and income to support family members in their home countries. this trend carries significant consequences for the countries of origin, which require robust healthcare systems and access to nursing care for their citizens.1 therefore, it is imperative for destination countries that rely on migrant nurses to adhere to the who code of ethical recruitment to uphold their responsibility towards all stakeholders involved.2 the migration of nurses offers various benefits, including opportunities for personal and professional growth, improved family income, and support for the new communities they serve.3 as a result, a supportive and ethical framework is necessary to engage migrant nurses in the development of policies that affect their future and decision to migrate, in line with the inevitable globalization of the nursing profession.4 the migration of nurses is a global phenomenon, and correspondence: rifky octavia pradipta, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: rifky-op@fkp.unair.ac.id key word: indonesian nurses; international migration; migration policy; nurse migration. contributions: fe, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rop, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; asa conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; mrd, methodology, visualization, writing – review & editing; ak, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: not applicable. patient consent for publication: not applicable. funding: this research did not receive external funding availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 18 september 2023. accepted: 20 october 2023. early access: 7 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11834 doi:10.4081/hls.2023.11834 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 100] [healthcare in low-resource settings 2023; 11:11834] non -co mmerc ial us e o nly indonesia is no exception.5 over the past few decades, the migration of indonesian nurses has become increasingly prevalent due to several factors, including economic instability, limited career opportunities, and inadequate working conditions in the country.6,7 as a result, many indonesian nurses are seeking employment opportunities in foreign countries, particularly in developed nations such as japan, kuwait, and others.8 global nurse migration is a complex issue that presents both benefits and challenges.1 the latest data from the international centre of nurse migration showed that the world needs 18 million health workers by 2030.4 out of this number, the world need 13 million of nurses in which the number worsen by the global pandemic of covid-19.4 while the world need nurses, indonesia reported having high graduation of nursing students. every year, estimated around 26,304 nursing graduates who pass the national examination.9 having great number of nurses graduates, indonesia has an opportunity to deploy nursing human resources in the global market. the aimed of this scoping review was to explore the journey of indonesian nurses migration and to provide an overview of the existing literature on this topic. the review examines the premigration, migration and post-migration experience of indonesian nurses abroad. materials and methods this scoping review was conducted following the scoping review guidelines developed by arksey and o’malley (2005)10 and levac, colquhoun, and o’brien (2010).11 a scoping review makes it possible to examine all relevant evidence on a particular issue without considering individual study designs while ensuring a systematic and rigorous process. this is important for the issue of nurse migration because of the potential for several studies investigating the experiences of migrants returning to their country of origin after working abroad. step one: research question the review was guided by the following research question: “what are the experiences of indonesian nurse migrants in premigration, migration and post-migration stages?” step two: identification of relevant studies this study employed a three-step search strategy, according to joanna briggs institute (jbi) scoping review guidelines.12 the initial step was a limited search in cinahl, web of science (wos), pubmed and scopus conducted in march 2023. we then analyzed text for words contained in titles and abstracts of retrieved papers to specify appropriate key terms. several relevant terms (e.g., “indonesian nurse*”, “pre-migration”, “indonesian nurse migrant”, “migration”, “immigration”, “immigrant”, “emigration”, “return migration”, “migrant”, and “mobility”) were identified accordingly. in the subsequent phase, an initial search was conducted in march 2023 utilizing four distinct databases: cinahl via ebsco, web of science, pubmed, and scopus. this search incorporated combinations and variations from the preliminary search terms along with specialized search strings. there were no restrictions based on the publication year of the articles, and only literature written in english was included. in the final stage, the bibliographies of all identified articles and reports were manually reviewed to locate further relevant studies. the methodology for this search process was devised by the research team and executed by the authors, who also analysed the search outcomes and extracted relevant data. step three: selection of studies and data management process at this step, the researcher selects literature obtained from various search engines that have been mentioned previously based on predetermined keywords. the literature obtained will be selected according to the inclusion and exclusion categories of the study. papers were included based on the following criteria: studies focused on indonesian nurse migrants at pre-migration, migration and post-migration stages. we defined nurse migrants as including the mobility of indonesian nurse after working as health professionals in other countries from pre-migration, migration or placement until post-migration or return to the home country. papers were excluded from consideration if they met one or more of the following conditions: i) the language of publication was not english; ii) the work was not research-based and had not undergone peer review, examples of which include editorial comments, viewpoints, letters to the editor, book critiques, summaries of conference proceedings, analyses of pre-existing data, instructional guides, or policy papers. a total of 68 articles were retrieved from four databases: cinahl (18 articles), web of science (24 articles), scopus (12 articles) and pubmed (14 articles). following removal of 26 duplicates, titles and abstracts of 22 studies were scrutinized to discard irrelevant papers. as a result, 48 studies were excluded, leaving 20 for full-text review (figure 1). out of these, 3 studies were excluded. step four: charting the data at this phase, we compiled data from the seventeen selected studies into a tabular format that includes the following headings: author, country of origin, target country, research objective, research methodology, participant demographics and sample size, principal outcomes, and constraints. this step is crucial for organizing the data types and drawing out the relevant information. step five: collating, summarizing and reporting results at this phase, we employ microsoft excel to arrange the gathered data and assist in categorizing it into various themes. we utilize thematic analysis to recognize, scrutinize, and describe developing patterns. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. prisma diagram. [healthcare in low-resource settings 2023; 11:11834] [page 101] non -co mmerc ial us e o nly results a total of 8 qualitative research pieces, five quantitative analyses, and four reviews study met the criteria for inclusion, focusing on the three key phases of migration: pre-migration, the migration process itself, and post-migration. these studies originated from four worker-receiving countries: japan, taiwan, kuwait, and saudi arabia. in terms of the economic status of the destination countries, most were high-income nations. the findings across all papers charted the migration trajectory of indonesian nurses through these migration phases, as outlined in supplementary material table 1, with key themes delineated in table 2. amount, distribution, and types of evidence the geographic distribution of the 17 records reveals majority from japan, followed by saudi arabia, kuwait, and indonesia and taiwan. records were published between 2013 and 2022, with the largest number issued in 2016, 2017, 2019 and 2022. the common methods were qualitative methods (n=8) and review (n=4), followed by quantitative methods (n=5). pre-migration language prior to joining the workforce, applicants must fulfill the language prerequisites stipulated by the country they are moving to. specifically, proficiency in the japanese language was a requirement.13 those who arrived in 2008 had to undergo a six-month training program in both the japanese language and culture before commencing their employment. this training duration can be lengthened if the acquired skills are deemed inadequate. the language education is coordinated and funded by the employing organization, and is conducted either directly or through external educational entities such as language schools or universities.14 they have the opportunity to be employed for a duration of three years as they get ready for the domestic assessments. success in these exams allows them to acquire extendable residency and keep working in japan. however, if they are unsuccessful, they are obligated to go back to their home country, although they have the option to return using a short-term visa for further employment.15 understanding of the job position initial confusion among migrating nurses was mainly about their position in a job. many nurses misunderstand the job of being a nurse, because of the different responsibilities given. based on their previous knowledge and experience, they assume that the job is care workers. nurses perceive job descriptions as working as a nurse at home or a geriatric nurse working in a nursing home like in indonesia where caring for the elderly is a nurse’s job. they were taken aback when they discovered that both care workers and nurses are employed at the healthcare facility where they work.16 candidates work as temporary assistants until they pass a japanese language test. while they’re expected to take on more complex tasks with experience and language skills, this often doesn’t happen. unaware of job progression expectations, they worry about skill loss and mostly handle basic tasks like feeding, bathing, and cleaning.14 reason to work abroad nurses articulated diverse rationales for their decision to seek employment as care workers in japan. while financial incentives were frequently cited, the primary motivations for many were to acquire work experience and specialize in geriatric care. if their aspirations to advance their skills in caring for older people are not completely realized, they begin to reconcile with the actual circumstances and reconsider their initial reasons for going overseas.16 the other reason nurses go abroad is to gain recognition as professional nurses internationally by passing the nurse licensure exam. they believed that obtaining a nursing license was a prestigious achievement that could have a significant impact on their future professional paths. as a result, they remained motivated as they worked towards passing the national licensure exam.5 in a different research investigation, it was found that the primary incentives for nurses relocating to taiwan included the pursuit of financial opportunities and the desire to acquire additional professional experience. the majority of these nurses cited financial gain as their main driving force for seeking employment in taiwan.17 enhanced opportunities in their careers, reflecting both economic and social incentives, were experienced by nurses who migrated to kuwait. these incentives serve as the underlying reasons for nurses’ migration, encompassing the aspiration for a better income and improved living conditions. meanwhile, the primary factors motivating nurses to seek employment overseas are their family’s financial circumstances and the comparatively low salaries in their home countries. this aligns with research that highlights economic factors as the primary catalyst for nurse migration.7,8,17 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. themes identified. themes detailed aspect sources pre-migration language ford et al., 2013; ford et al., 2016; anwar rp, 2019 understanding of the job position ford et al., 2013; efendi et al., 2022 reason to work abroad efendi et al., 2016; efendi et al., 2022; haryanto et al., 2022; nursalam et al., 2020; efendi et al., 2020; comprehensive understanding of the destination countries efendi et al., 2016; kurniati et al., 2017; efendi et al., 2022; migration language efendi et al., 2016; efendi, 2021 deskilling kurniati et al., 2017; nursalam et al., 2020 mental health nugraha et al., 2016; sato et al., 2016; nugraha et al., 2017; zaghloul et al., 2019; efendi et al., 2020 unclear career path efendi et al., 2016; nugraha et al., 2016; kurniati et al., 2017; efendi et al., 2019; nursalam et al., 2020; haryanto et al., 2022; efendi et al., 2022 cultural adaptation efendi et al., 2016; efendi et al., 2020; anwar rp, 2019 lack of religious services nugraha et al., 2017; efendi et al., 2020; efendi et al., 2022 homesickness efendi et al., 2020; efendi et al., 2022 post-migration deskilling kurniati et al., 2017; efendi et al., 2019; efendi et al., 2021 work in non-health sector (brain waste) kurniati et al., 2017; nursalam et al., 2020; efendi et al., 2022 re-integration and brain circulation platform efendi, 2017; efendi et al., 2021 [page 102] [healthcare in low-resource settings 2023; 11:11834] non -co mmerc ial us e o nly comprehensive understanding of the destination countries nurses who relocated to japan recounted their experiences in adjusting to the culture of excellence prevalent in the country. they highlighted the rigorous cleanliness standards, the demanding workload, and the level of professionalism expected from care providers.16 in japan, nurses are expected to maintain a structured and highly professional work environment, necessitating their constant mental alertness and diligence.7 the exemplary conduct of japanese individuals has left a lasting impact on both their personal and professional lives. the nurses acknowledged that, irrespective of one’s religious beliefs, there are valuable lessons to be learned from the japanese about cultivating kindness, helpfulness, respect, and honesty. as a result, these nurses embraced positive attitudes to inform their roles, whether in nursing or as family caregivers.18 migration language communication is a challenge for nurses who migrate to foreign countries, such as a nurse who migrates to japan. in japan, cultural differences and the lack of language skills of migrant nurses are the major non-financial barriers in the workplace and daily life. even after receiving a year of japanese language instruction, they continued to encounter challenges in communication because of their limited grasp of the language and the presence of regional dialects. communication barriers are especially experienced in the early days as a care worker.7 language barrier is the dominant problem experienced by migrant nurses when entering a new world of work abroad. language is an important element in communicating with patients and colleagues.6 deskilling deskilling is often experienced by caregivers from the first day of work, and the lack of understanding of caregiver jobs in the care unit can often discourage them from working there. this situation is beyond the migrants’ expectations, as their duties as caregivers are only feeding, bathing, and taking patients for walks. before leaving for japan, the migrant caregivers were given an explanation about caregiving work, and the participants thought it was not much different from the work of nurses in indonesia. but in reality, this is not the case.18 this situation is also experienced by nurses working in taiwan. they also believed that their skills deteriorated during their time in nursing homes and ltc facilities, as they were prohibited from actively applying their professional expertise. they felt compelled to set aside these abilities and perceived no prospects for advancing their careers.17 however, in the alternate scenario, nearly all indonesian nurses employed in taiwan come to the understanding that transferring their credentials and practicing as professional nurses in taiwan is unattainable, as the taiwanese system does not permit foreign nurses to work in such roles.17 mental health mental health cannot be separated from the daily patterns of individual living. this can be happened to anyone, including nurses who migrate to other countries with different daily and social life patterns. competence in sociocultural adaptation is an important element that must be possessed by economic partnership agreement (epa) candidates because it will be related to their lives in the next few years. the situation away from family is a challenge for migrant nurses by finding adequate sources of social support.19 the lack of economic conditions in the pre-migration period also affects the mental health of nurses migrants. this is linked to the expensive living expenses in japan and the sensation of being weighed down by the responsibilities of the family left at home.20 in a different research investigation, some individuals faced potential mental health challenges as a result of their gender transition and their citizenship status and qualifications acquisition.21 in other studies in islamic-majority countries such as saudi arabia and kuwait, the lowest mental health burden was experienced by nurses from the philippines and indonesia. they felt fortunate and appreciative of their work in kuwait since it’s a muslim nation, which made it easier for them to observe their religious customs without encountering any hardships.8,22 unclear career path most nurses who choose to work in japan aspire to advance their nursing careers and immerse themselves in the local culture. when they sense their professional growth has reached a plateau in indonesia, they are inclined to seize the chance for further career development. their primary goal when going to japan is to acquire the fundamental knowledge and skills necessary for delivering essential or hands-on care. conversely, they also find solace in the legal protection afforded to registered nurses, which ensures their safety while providing nursing services.7,19 they believe that holding a nursing license is a prestigious achievement with the potential to shape their future professional path. consequently, they maintain their motivation while grappling with the challenges of preparing for the national licensure examination and striving to succeed.5 another aspect that nurse migrant candidates must take into account is that various healthcare facilities have distinct employment guidelines for international caregivers. not all organizations provide chances for failed applicants to extend their contracts. consequently, if a candidate doesn’t pass the exam, there is a potential risk that they may be repatriated unexpectedly to their home country.18 nurses who migrate often encounter ambiguous career trajectories or stagnant career advancement, a situation frequently observed.23 nurses who came back to the field shared their disappointment that their prior work experience didn’t enhance their prospects for securing appropriate employment. the combination of a shortage of jobs and diminished nursing skills leaves returning nurse migrants with limited alternatives.18 another crucial concern for migrant nurses overseas was the restricted career prospects they encountered in taiwan. they disclosed that this factor has a substantial influence on their future aspirations.17 nurses’ concern about their current and future careers is due to their work as care workers which restricts them from performing the actions of professional nurses. the deskilling process experienced, the skills that are not trained and the expertise of professional nurses that do not increase is a concern for migrating nurses.16 cultural adaptation cultural differences are a common occurrence when migrating to other regions and even between countries. geographical distance does not eliminate the possibility of differences in culture and lifestyle of the community. the impacts of this are not only experienced by the general public, but also by nurses. most nurses employed in japan concur that japanese individuals exhibit a strong work ethic and punctuality at their jobs. furthermore, there are notable cultural distinctions in the roles family members assume in the care of ill patients or family members. in indonesia, the majority of family members remain in the care unit around the clock and alternate in providing care, even beyond designated visiting hours. conversely, in japan, family members tend to be less present around the patient, leading to limited family involvement [healthcare in low-resource settings 2023; 11:11834] [page 103] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly in the care of unwell family members.7 cultural adaptation involves fully engaging with the customs and traditions of a specific locale. it’s clear that nurses working abroad encounter varying cultural norms, necessitating a heightened awareness and the potential for culture shock. to integrate into the surroundings in kuwait, female nurses must navigate cultural aspects such as the restriction on women travelling independently and the requirement to cover their entire body, including their face and hands, when in public spaces. despite the dominant islamic influence, religious practices are observed with great intensity in this region.8 lack of religious services migrant nurses reveal their life struggles while working in japan. they mentioned facing difficulties as a result of residing in rural facilities. residing in a rural location restricts nurses’ ability to reach religious establishments like mosques and churches. they also encounter challenges related to the demands of strenuous and repetitive tasks, language barriers involving japanese and local dialects, and the emotional hardship of being separated from their families, which leads to feelings of loneliness 16. various studies on migration show that social adjustment during the migration process is related to mental health status, which can be influenced by various sociodemographic factors (gender, age, economic background) and sociocultural adaptations which include language barriers, social support, acceptance by the host countries and working conditions 20. during their time in kuwait, female nurses must conform to the local customs, which include restrictions on women travelling alone and the requirement to cover their entire bodies, including their face and hands, when in public spaces. despite the fact that islam is the predominant religion in the country, these religious and cultural practices are observed more rigorously, whether in the workplace or elsewhere 8. homesickness residing in a foreign country requires nurses to be ready to distance themselves from their loved ones in indonesia. homesickness frequently affects nurses who move abroad, as they are compelled to be separated from their families for an extended period, occasionally reuniting only after approximately a year. nurses assert that adapting to this circumstance necessitates some effort. they mention various strategies, such as staying connected with their families back home, bolstering their mental resilience, and actively participating in social activities, as effective ways to manage homesickness.8 loneliness and sadness often come to nurses who migrate and are away from their families. the eid moment becomes a sad experience when they cannot return to their home countries due to work or other obstacles. when caring for patients, migrant nurses sometimes remember their families at home and when the holiday comes, they are confused about what to do.16 post-migration deskilling the process of deskilling frequently commences on a caregiver’s very first day of work, as they may find it surprising that their responsibilities mainly revolve around tasks such as providing meals, assisting with bathing, and accompanying patients on walks. they thought that the caregiver’s duties were the same as gerontic nurses in indonesia, but it turns out that the caregiver’s duties there are different. their main task is to help provide basic human needs, so their nursing skills very limited use in the job because there are no medical or nursing interventions allowed.18 although they received professional caregiver training, their abilities dwindled as their time in japan extended. their diminishing nursing skills led to feelings of inadequacy. they came to understand the challenges of transitioning from caregivers to nurses. this sense of stagnation in their nursing abilities over years in japan also eroded their self-assurance.18 nurse migrants coming back lack the ability to effectively convey the skills and knowledge they acquired overseas.23 those who experienced brain waste abroad may feel a loss of professional knowledge and competence. for instance, a migrant nurse employed in a caregiving role might have restrictions that limit them to carrying out tasks associated with the patient’s fundamental requirements on a daily basis.18 although nurses may possess clinical competence in their home country, their inability to secure certification as professional nurses in the destination country, along with variations in job opportunities, restricts them from applying their nursing expertise. this hindrance in utilizing their nursing skills can result in a decline in confidence as healthcare practitioners when these nurses eventually return to their home country.18,24 work in non-health sector (brain waste) the process of deskilling can have short-term and long-term impacts on a nurse’s career. brain drain is often felt due to neglected caregiver skills and loss of skills and confidence as a caregiver.18 migrant healthcare professionals who encounter underutilization of their skills in foreign countries may perceive a loss of their professional expertise and capabilities due to their qualifications from their home country not being recognized for use in their current location. they are prohibited from honing their professional abilities, leading them to abandon the use of these skills and perceive no prospects for their careers.17 the phenomenon of brain drain and brain waste is unavoidable, although migrant health workers have high expectations of practicing their profession in the destination country. in truth, numerous healthcare professionals face underutilization of their skills when they work in positions below their qualifications. therefore, it is imperative to have stringent regulations in place to ensure that their nursing abilities can be refined and put to good use upon their return to indonesia.16 re-integration and brain circulation platform in a study conducted by efendi et al. (2017), they noted that the implementation of circular migration or policies that promote “brain circulation” could offer a potential solution to mitigate the problems associated with deskilling and underutilization of intellectual talent.25 one suitable approach for creating a mutually advantageous migration program within the framework of the indonesia japan economic partnership agreement (ijepa), aligning with indonesia’s strategic plan, involves establishing provisions for circular migration or the return of migrants. after health professionals have worked for several years in their destination country, both private and government recruiters should assume responsibility for aiding their return and integrating their expertise and training into the local healthcare system. this can be facilitated through formal partnerships and mechanisms, supported and funded by fees generated through the ijepa. enacting these policy reforms will not only assist indonesia in retaining a crucial healthcare workforce but will also transform nurse migration into a sustainable international training strategy and a source of income for candidates.25 contrary to this widespread belief, the dynamics of brain circulation are intricate, with many healthcare professionals not anticipating a return home once they secure employment in a more developed nation.25 migrant nurses who go back to their native [page 104] [healthcare in low-resource settings 2023; 11:11834] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly countries aspire to receive government support. in indonesia, the ministry of health (moh) promotes cooperative agreements for the supervision of healthcare professionals’ placements overseas. the ministry of health (moh) also promotes the adoption of the idea of brain circulation in the enhancement of health worker migration. this approach aims to strengthen healthcare professionals who come back to indonesia, thereby enriching the healthcare system with the enhanced expertise and skills they have acquired through their international work experience.26 returning indonesian nurses who participated in the ijepa program hope to gain an advantage in becoming civil servants as part of the brain circulation program. however, this aspiration is unlikely to materialize due to the government’s civil service policy of no expansion and equal employment opportunities. to address this, returning ijepa nurses view job fairs organized by the ministry of health as a practical method to expedite their reemployment and secure quality nursing positions.6 discussion this scoping review aimed to gain insight into the experiences of nurses who migrate to foreign countries, with a specific focus on highlighting the three stages of their migration process, namely pre-migration, migration and post-migration. a three-cycle migration approach is used to facilitate understanding of the migration nurse’s experience. in the pre-migration stage, it discusses the preparations required by a nurse before going to the destination country. this includes language competence, an understanding of the job and a comprehensive understanding of the destination country, reason to work abroad and comprehensive understanding of the destination countries. language competency is an important aspect before going abroad, as communication is a major challenge for nurses migrating abroad.7 this barrier becomes more severe when they communicate with patients or coworkers who use local dialects.27,28 language is also an important aspect for nurses who want to work abroad such as in japan there is a competency qualification exam for international nurses in order to work there and the exam uses japanese language.5 understanding the job description or description and authority of nurses there must be clarified to avoid misinformation about the roles and tasks of nurses at work. the healthcare system and structural setup in indonesia varies from that found in japan. indonesia recognized nursing as a profession during its colonial history.29 conversely, “care worker” is a recently emerged occupation created in response to the rising demand for caregiving in more advanced nations. the nature of care work is perceived differently depending on the specific circumstances.30,31 international applicants are also impacted by the pronounced differentiation within the japanese system between healthcare and elderly care.15 in japan, medical care and elderly care are generally seen as separate domains, and there are often different regulations, systems and funding streams for each. for example, medical care is usually provided by hospitals and clinics, while geriatric care is provided by long-term care facilities such as nursing homes.32 the variances between the two stances need to be emphasized, not just for aspiring candidates but also for the nursing community in indonesia. this perspective is in accordance with the findings of previous studies by alam and wulansari (2010), which discovered that people with nursing backgrounds aiming to become kaigofukushishi frequently face challenges in their current jobs because their expectations are not met.33 according to an earlier examination conducted by hirano-ohara, ogawa, and ohno (2012), approximately 98% of aspiring indonesian certified care workers opt to migrate to japan through the epa program to enhance their career prospects.34 the inability to work as nurses, which consequently hinders their ability to enhance their clinical skills and competencies, presents a significant challenge for them in their current work environment, resulting in a considerable psychological burden.35 the second theme found in this study is the migration cycle, which consists of language, deskilling, mental health, an unclear career path, cultural adaptation, lack of religious services, and homesickness. migration involves a significant change in a person’s life, which could lead to leaving their homeland. this situation may trigger feelings of anxiety, potentially leading to the onset of depression and other mental health issues.4,15 additionally, there are studies examining the migration of nurses to countries like canada or england, which have significantly colder climates.36 alternatively, an individual contemplating migration may experience adverse mental health symptoms as a result of their existing socioeconomic circumstances, which have compelled them to seek employment opportunities overseas due to state-imposed conditions. this speculation highlights the necessity for additional investigation concerning the social, psychological, and economic circumstances during the pre-migration phase.26 alternatively, there are numerous potential advantages associated with relocating to a different country in terms of future prospects. the destination country may provide enhanced opportunities and experiences compared to an individual’s country of origin, potentially leading to a more favourable perception.30 this is consistent with previous studies in the field. exploring the factors that intending migrants are waiting for, aside from their concerns, can provide further insights into the potential positive impact of migration on health and welfare.25 our study found that individuals who expressed an reason to migrate experienced higher levels of stress when it came to acquiring a comprehensive understanding of the destination country. for instance, the process of seeking and ensuring employment opportunities in foreign countries, navigating the bureaucratic procedures involved in obtaining necessary documentation and approval for migration, making arrangements for the care of one’s family during extended periods of absence, and acquiring the necessary financial resources, among other factors, can all contribute to increased levels of stress.14 numerous studies have posited the concept of pre-acculturative stress within the framework of migration. the assertion is made that voluntary migrants initiate the process of psychological and behavioural adaptation to their new life in the destination country, as well as engage in preparatory measures prior to undertaking the actual act of migration.35 based on various sources of pre-migration information, such as interactions with previous migrants via social networks, voluntary migrants develop expectations regarding their experiences after migration, including their ability to adapt and cope with potential discrimination.6 these expectations can potentially induce stress. the results of our study regarding perceived stress align with the concept of pre-acculturative stress, which merits further investigation in future research endeavors. this review highlights that working situation in the workplace affect the well-being of migrant nurses, especially those from ethnic and racial minority backgrounds, particularly impacting their mental health. other studies have shown a noteworthy link between racism and poorer health results, with a more pronounced connection found in terms of mental health and a less pronounced one in relation to physical health.7 provided evidence supporting the presence of prejudicial behaviors against migrant nurses and [healthcare in low-resource settings 2023; 11:11834] [page 105] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly clarified the potential outcomes of this bias, which may encompass reduced job performance and increased stress levels. migrant nurses who encounter instances of discrimination and racism often refrain from reporting such occurrences due to concerns of potential social isolation and retaliatory actions.3 the state of the workplace and the absence of rest and vacation opportunities have a significant impact on the employees’ mental well-being.36 the research elucidates that the career trajectory lacks clarity. this occurrence took place in both japan and taiwan. the establishment of a well-defined career trajectory for international nurses is a crucial factor to consider in maintaining the ongoing migration cycle within the nursing industry.37 nevertheless, the divergent strategies employed by taiwan and indonesia have proven ineffective in tackling this matter. the republic of indonesia’s official authorities recognize nursing as an officially acknowledged profession that involves specific responsibilities and requirements to be met by individuals who hold the necessary certification.38 conversely, the healthcare system in taiwan restricts foreign nurses from practicing at their certified qualification level. the results of this study emphasize the necessity of implementing transparent, knowledgeable, and comprehensive contractual agreements for indonesian nurses who express interest in pursuing employment as care workers in taiwan. there is a need for clarification of the term “careworker” in order to alleviate confusion among nurses who are seeking employment in long-term care (ltc) facilities in taiwan.17 in the context of this study, if indonesian nurses are assigned to foreign countries might have faced the absence of religious support for these individuals. however, some muslim nurses and doctors who migrate seek employment in saudi arabia easily to practice their faith.39 culture shock is a phenomenon primarily encountered by individuals who travel abroad, particularly those who reside or spend an extended duration in a foreign country. nurses relocating to japan need to successfully acclimate themselves to japan’s work culture, which emphasizes perfectionism. this entails adhering to rigorous hygiene standards, handling a substantial workload, and maintaining a high level of professionalism in their performance.16 a well-structured professional work environment necessitates nurses to be prepared and possess a strong work ethic. in japan, placing service as the foremost concern and prioritizing patients is paramount. this principle holds true not only in japan but also in all nations where patient well-being takes precedence in healthcare services.6 migrant nurses must be able to adjust to the work system and social life there. even though it has a high workload, a positive attitude and good lifestyle can be a lesson for nurses who migration there.7,18 the desire to enhance the financial well-being of one’s family is certainly met through well-paying jobs overseas. few express dissatisfaction with their earnings, yet these wages do not guarantee that migrant nurses will be free from hardship.17 this stress can be started from their departure which is motivated by insufficient economic problems so that they go abroad in the hope of improving the family economy.21 sources of stress for migrating nurses are host acceptance of foreign nurses, sociocultural differences, and feelings of being away from family (homesickness).8,16 the last theme on this study is post-migration which consists of deskilling, brain waste and brain circulation platform. deskilling usually starts at the beginning of employment and continues until she returns to her home country. deskilling occurs because competencies and skills are never practiced there because of differences in work positions and qualification status as professional nurses there.18 this then results in brain waste and loss of confidence of migrant nurses. the long-term impact of this situation is that nurses can lose their career paths due to decreased competence and career choices that will be undertaken as a result of post-migration deskilling.23 in a research undertaken by efendi and colleagues in 2017, they proposed that implementing a policy known as “brain circulation” could serve as a viable solution to tackle issues associated with deskilling and underutilization of talent.25 the circular migration system might entail nurses who have migrated temporarily to another country returning after gaining a few years of work experience there. it is the duty of recruiters, whether they are from the private or government sector, to help facilitate the return of these nurses and seamlessly incorporate their expertise and training back into the local healthcare system.16 the inevitability of brain drain and brain underutilization is a recognized phenomenon. despite the hopeful anticipation of migrant healthcare professionals to practice their profession in host countries, the truth is that a significant number of them experience cognitive decline as a result of working in roles that demand strict adherence to regulations and involve less complexity. in order to perfect their nursing skills and facilitate the exchange of knowledge upon their return to indonesia, it is very important for individuals to be given the opportunity to improve their skills in nursing. the government facilitation through brain circulation platform needs to be developed and implemented and strengthened by reintegration in all sectors. this aligns with earlier research carried out in the caribbean and indonesia. canada, the united kingdom (uk), and the united states (us) are widely acknowledged as the primary choices for caribbean nurses looking to immigrate. scholars argue that these countries are responsible for a phenomenon known as “brain drain” in talent-providing countries.5 in addition, the phenomenon of brain drain poses immediate and lasting challenges, including depleting economic investment and emerging health care deficits in terms of human resources for countries that provide skilled individuals.40 while it is widely recognized that the migration of caribbean nurses has negative consequences, it is important to recognize that there are also advantages, especially when it comes to remittances.20 issues of global concern remain, with limited solutions available for regions such as indonesia. in a study carried out in the caribbean, an alternative approach was identified in relation to brain waste prevention. the caribbean government implemented a comprehensive international nurse migration management strategy, which not only deals with the circumstances before nurses leave for another country and during their time there, but also after they have migrated 6. certainly, this necessitates government involvement and the participation of pertinent stakeholders to formulate policies that can be advantageous for both nations in question.6,40 limitations this scoping review exclusively comprised published studies, and it specifically focused on studies conducted in the english language. the publications found by researchers only cover the migration of indonesian nurses to several countries, including japan, taiwan, kuwait, and saudi arabia. the migration of nurses to other countries has not yet been identified. conclusions establishing regulations, resources, and additional skills for indonesian nurses during the pre-migration phase is a valuable way to facilitate their entry into the global nursing job market. additionally, investing in language preparation that aligns with the [page 106] [healthcare in low-resource settings 2023; 11:11834] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly requirements of receiving countries is inevitable. it’s crucial to ensure holistic policies for nurse migrants to advance their careers and maintain their motivation in the face of global competition. as a gesture of appreciation for returning nurse migrants, efforts should be made to retain and enhance their nursing skills, prevent skill degradation, and provide a platform for brain circulation. references 1. buchan j, catton h, shaffer f. sustain and retain in 2022 and beyond: the global nursing workforce and the covid-19 pandemic. int counc nurses. 2022;71:1-71. 2. who. the who global code of practice on the 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springer; 2018. 31. ogawa r. the state and the market: acceptance of migrant care workers through multiple channels [internet]. jakarta: eria; 2022. available from: https://policycommons.net/artifacts/2642716/agents-of-care-technology-transfer/3665475/ 32. yamada m, arai h. long-term care system in japan. vol. 24, annals of geriatric medicine and research. korean geriatrics society; 2020. p. 174-80. 33. alam b, wulansari sa, alam, wulansari. creative friction: some preliminary considerations on the socio-cultural issues encountered by indonesian nurses in japan. bull kyushu univ asia cent. 2010;5(2010-06):183-96. 34. ohara�hirano y. the mental health status of indonesian candidates leaving for japan under the japan-indonesia economic partnership agreement: after the great east japan earthquake. int j japanese sociol. 2012;21(1):37-45. 35. walton-roberts m. intermediaries and transnational regimes of skill: nursing skills and competencies in the context of international migration. j ethn migr stud. 2021 jul;47(10):232340. 36. de castro ab, gee g, fujishiro k, rue t. examining premigration health among filipino nurses. j immigr minor heal [internet]. 2014;17(6):1670-8. available from: https://www.scopus.com/inward/record.uri?eid=2-s2.084946480745&doi=10.1007%2fs10903-014-0131-7&partner id=40&md5=6265b49582e7d35c8bdaebb131fde1d3 37. kurniati a, chen c-m, efendi f, ogawa r. a deskilling and challenging journey: the lived experience of indonesian nurse returnees. int nurs rev [internet]. 2017;64(4):494-501. available from: https://www.scopus.com/inward/ record.uri?eid=2-s2.0-85013041892&doi=10.1111%2 finr.12352&partnerid=40&md5=cbda400e68fc2fbe4e9f7123 369d56a7 38. mlinarić m. juliane klein, transferring professional knowledge and skills: the case of central and eastern european migrant physicians in german hospitals. int sociol. 2019 sep;34(5):597-600. 39. kaveri q, ben k, nasar m, sarah h. submission of evidence on the disproportionate impact of covid 19, and the uk government response, on ethnic minorities and women in the uk. 2020;(april):1-10. 40. efendi f, aurizki ge, auwalin i, kurniati a, astari ld, puspitasari it, et al. the paradox of surplus and shortage: a policy analysis of nursing labor markets in indonesia. j multidiscip healthc [internet]. 2022;15(march):627-39. available from: https://www.scopus.com/inward/ record.uri?eid=2-s2.0-85127743920&doi=10.2147% 2fjmdh.s354400&partnerid=40&md5=15504b233d6bc476 ba7c69e016954102 [page 108] [healthcare in low-resource settings 2023; 11:11834] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions online supplementary material: table 1. summary of included studies. non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2020; 8:9320] [page 1] patient perceived quality of nursing care in hemodialysis: a meta-synthesis abbas balouchi,1 abbas ebadi,2,3 soroor parvizy,4 hamid sharif nia5 1student research committee, faculty of nursing and midwifery, iran university of medical sciences, tehran; 2behavioral sciences research center, life style institute, baqiyatallah university of medical sciences, tehran; 3nursing faculty, baqiyatallah university of medical sciences, tehran; 4department of nursing, iran university of medical sciences; 5school of nursing and midwifery amol, mazandaran university of medical sciences, sari, iran abstract this study was done with the purpose of clarifying the concept of patient perceived quality of nursing care in hemodialysis. in this meta-synthesis study, qualitative studies was searched in the four interntional databases from january 1st, 2000 to december 30th, 2019. the keywords used were: nursing care quality, and hemodialysis. studies which had been done with the purpose of understanding the patient perceived quality of nursing care concept aomg hemodialysis patients were included. two researchers were evaluate the quality of included studies separately using jbi tool, required information were extracted using the designed table. the main themes in the structure dimension include sufficient human resource, quality of equipment, financial support from patient and quality of the patient care environment. process dimension consisted of continuous monitoring of the syndromes, effective patient education, efficient care, effective therapeutic relationship, and patient’s empowerment and participation in the process, and in the outcome dimension included high dialysis adequecy, patient burnout reduction, and increased patient satisfaction from services. the results of the study indicated a comprehensive, deep and interactive dimensions about the concept of nursing quality of care. introduction today, chronic diseases including chronic kidney disease (ckd) consider as one of the most important health challenges. the prevalence of ckd in the world and iran is 13.4%1 and 15.6%,2 respectively. of the 500 million people with ckd, about 80 percent of them live in less developed countries.3 asia, which have 60 percent of the world’s population, has the highest prevalence statistics of infected with ckd.4 in over 90% of ckd patients, hemodialysis is the only treatment option.5 in iran, the number of patients with ckd is about 84,000, of which more than 82,000 (89%) are undergoing hemodialysis.6 using hemodialysis while saving millions of lives, is accompanied with various physical complications (vascular access complications, cardiac complications, gastrointestinal bleeding, cancer, bones metabolism disorder, ineffective dialysis adequecy, skin problems, anemia, loss of appetite, muscle cramps and psychological complications (sleep disorder, depression, fatigue, reduce the quality of life and anxiety).7 on the other hand, better care in hemodialysis patients causes improving therapeutic indicators in patients.8 health policy-makers around the world face to challenge of quality of cares provided for chronic diseases, because more than 50% of the burden of diseases belongs to chronic non-contagious diseases such as ckd.9 nursing care quality has also been changed in to a central principle in the health cares of patients with ckd. various definitions have been presented by organizations and experts about the concept of care quality. according to the definition of american medicine institute, “quality of care (or care quality) is a degree of providing health cares to individuals and populations that maximizes desired health outcomes and is consistent with current professional knowledge.”10 quality of care is defined by the world health organization as: to what extent services provided to individuals and patients would reach them to mentioned health outcomes. that to reach this goal, the cares must be safe, effective, efficient, timely, fair and people-oriented.11 experts also provided different definitions on quality of care. donabedian considers the quality of care as performing all necessary measures to help the patient which reflects the present values and goals of the individual and the care system.12 having agreement on a correct and clear definition of the nursing care quality can promote the health, support, and correct education of patients.13 today, the perceived care quality from the perspective of the patient is raised as one of the main components of care in the health system.14 paying attention to the patient’s perspective leads to increase quality of life, safety level, private satisfaction associated with disease progression, and knowledge. the outcome for the system can also be reduction of new beds rate (readmission), optimal use of resources, and providing more service with more cost-effective.15 on the other hand, various studies show a positive relationship between attending to patients’ perspectives and increasing the nursing care quality of patients and increasing their satisfaction.16 although the concept of nursing care quality has been clarified to some extent from the perspective of organizations11 and experts 17 and nurses,18,19 the reviewing literatures indicate that this concept has been less evaluated by patients under hemodialysis who have different conditions in terms of complications, symptoms, severity of illness, concomitant healthcare in low-resource settings 2020; volume 8:9320 correspondence: soroor parvizy, full professor, department of pediatric nursing, school of nursing and midwifery, iran university of medical sciences (iums). rashid yasmi st, valiasr blvd, tehran, iran. e.mail: jahant1992@gmail.com key words: patient satisfaction; syndrome; renal dialysis; nurse-patient relations; patient care; workforce. acknowledgments: this study is part of a ph.d. thesis in nursing. i would like to thank the research assistant of the faculty of nursing and midwifery. contributions: all the authors contributed equally. conflict of interest: the authors declare no conflict of interest. funding: iran university of medical sciences ethics approval and consent to participate: this study was approved by the ethics committee of iran university of medical sciences (ethic code: ir.iums.rec. 1398.673). consent for publication: not aplicable. availability of data and materials: the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. received for publication: 21 august 2020. revision received: 10 september 2020. accepted for publication: 11 september 2020. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2020 licensee pagepress, italy healthcare in low-resource settings 2020; 8:9320 doi:10.4081/hls.2021.9320 non -co mmerc ial us e o nly illnesses, and required care and have main contribution in the care chain. it is also very essential to pay attention to patients ‘opinions through understanding the various psychological, emotional, physical, social dimensions of patients and, as a result, a deep understanding of patients’ needs for doing holistic care. this study was done with the aim of clarifying the concept of patient perceived quality of nursing care from the perspective of patients undergoing hemodialysis based on existing studies. materials and methods design and eligibility criteria in this meta-synthesis study, qualitative studies related to the experiences of hemodialysis patients on the quality of nursing care was evaluated using a systematic review approach. inclusion criteria in this study include: known patients undergoing hemodialysis who had passed at least 6 months from their first dialysis session. the included studies were qualitative and were published in english. exclusion criteria: review studies, quantitative studies (crosssectional, rct, case control, case report, case series, and letter to editor) were excluded. search strategy four international electronic databases inlclude: web of sciecne, pubmed, scopus and embase searched from january 1st, 2000 to 30 december 30th, 2019. the articles were searched in three stages. first, a targeted and centered search in pubmed and scopus was conducted with the purpose of finding the most relevant articles using related keywords. then, a comprehensive search was performed in all selected databases. the search strategy was written by two researchers (ab, ae) with the advice of a librarian expert. in the third step after searching the databases, the sources of related articles were also evaluated to find more articles. screening the studies the studies searched in the various databases were included indenot. duplicate studies were initially removed. in this way that firstly duplicate studies were evaluated based on title and duplicate studies were excluded, then the remaining studies were reviewed and excluded based on their abstract. in the final step, the full-text version of the articles was evaluated based on the inclination criteria and the irrelevant items were excluded. screening the studies were performed separately by two researchers (ab, sp). the disagreement between the two persons was discussed and resolved by a third party. evaluation of studies quality and data extraction the jbi tool for qualitative studies was used to evaluate the quality of the included studies.20 this tool was consisted of 10 items which assessed the methodology and how to report qualitative studies. two researchers individually performed the evaluation of the studies quality. disagreement cases between two persons were being resolved by a third party. data extraction was performed using data extraction tables in excel and word. the extracted data included: article number, author, year of publication, country, title, purpose of study, number of participants, method of work, data collection, analysis method and main results and themes. data analysis thematic approach of analysis was used for data analysis. in this approach, the codes were systematically classified and the descriptive and analytical themes were clarified and analyzed. first, the results of the included studies were studied line-by-line, and then the cases related to the purpose of the study were clarified as free codes and in the following similar and different codes were identified through constant comparison. similar codes were then named as descriptive themes, and in the final step, the themes were identified analytically and abstractly, and together were formed the definition of concept of perceived nursing care quality from the perspective of the patient.21 results select the studies the 4,386 searched records in various databases have been included in indenot. 3474 non-duplicated studies were evaluated on the basis of title and abstract, of which 24 records entered the final stage. out of 24 included studies, 6 studies were included in meta-synthetic and 18 studies were excluded [review (n=2), non-english (n=10), no quality (n=1), no full text (n=5)] (figure 1). characteristics of included studies out of the six included studies, 4 studies were conducted using the content analysis approach and 2 studies were conducted through focus group on 189 participants. data were collected through semi-structured interviews in all studies. in most stud review figure 1. studies selection process. [page 2] [healthcare in low-resource settings 2020; 8:9320] non -co mmerc ial us e o nly ies (n=5), data were analyzed using content analysis method (table 1). main results the most well-known model used to classify care quality components is the donabedian model, which classifies the quality of cares provided into three parts: structure, process, and outcome (25). the perceived nursing care quality from the patients’ perspective was consisted of three main themes: structure, process, and outcome (figure 2). the structure of perceived quality of nursing care proper structure of perceived nursing care quality from the perspective of patients was composed of four different sub-themes including: sufficient suman resource, quality of equipments, financial support from patient and adequacy of the patient care environment. sufficient human resource sufficient human resource is one of the main components of quality care from the patients’ point of view. sufficient human resource means appropriate number of nurse, kidney specialist, nutritionist, social review table 1. characteristics of the studies id author country purpose study sample data data main (year) of study design characteristics collection analysis results 1.participants 2.population 3.age 4.gender (female/male) 1 rubin, h. r. usa we conducted focus 1.86 focus group content  sufficient human resource (1997) a study to group 2.patients, with interview analysis  quality of equipment used 24 identify salient nephrologists  quality of patient care environment attributes of 3.56.1  effective patient education dialysis care 4.40/46  financial ability and insurance support and to rank the importance of these attributes from the perspective of dialysis patients. 2 wuerth, usa patient assessment focus 1.30 structured thematic  efficient care d. b.(2000) of quality of care in group 2. patients interview analysis  sufficient human resource 25 a chronicperitoneal 3.57.  effective patient education dialysis facility 4.13/17  quality of dialysis environment 3 rodrigues, brazil to describe the qualitative 1.12(6 n.6p) semi-structure content  therapeutic communication t. a. (2009) representation of study-content 2. patients, interviews analysis  patient participation in treatment 26 nursing care for analysis nurses  participation in decision making nurses and for 3.62 individuals 4.15/8 undergoing hemodialysis 4 nobahar, iran "the aim of this qualitative 1.20 semi-structured content  effective communication between m. (2016) study was to studycontent 2.patients, interviews analysis nurses and patients. 23 assess the barriers analysis nurses,  sufficient human resource. and facilitators physicians,  correct policy making to support dialysis. of care for caregivers  effective and efficient environment. hemodialysis 3.51.37 patients." 4. none reported 5 nobahar, iran "he present qualitative 1.20 semi-structured content  continuous monitoring of the patient by m.(2017) study was study 2. patients, interviews analysis the nurse. 18 conducted to explore content nurses,  high dialysis adequacy. the experiences analysis physicians,  burnout of the caregivers  effective patient education quality of nursing 3.51.37  effective empowerment in doing activities nurses, caregivers and 4.none reported  sufficient human resource. care among patients,  communicate effectively. physicians in an hd  quality of equipment used. department in iran.  effective and efficient environment. 6 hashemi, iran "thus this research was qualitative 1.21 semi-structured content  effective symptoms management m. s. (2018) undertaken to study research 2. nurses, interviews analysis  effective fullsupport 22 the needs and content nephrologist,  quality of the nursing services delivery demands of such analysis clinical  sufficient human resource patients." psychologists,  communicate effectively social workers.  effective infection control 3.51.37  quality of equipment. 4.none reported [healthcare in low-resource settings 2020; 8:9320] [page 3] non -co mmerc ial us e o nly helper who have the sufficient training knowledge and skill to care of patients undergoing hemodialysis. also, sufficient human resource means professional human power behavior (being accessible and on time).18,22-25 “the nurse should have enough information about kidney and electrolytes, because a small error in the selection of filter, blood flow, and uf could lead to the worst electrolytic problem.” (study 4)23 quality of equipment the quality of the used equipment is: a sufficient number of different equipment (dialysis machine, dialysis set, etc.) that are new and have a correct performance.18,22,24,25 “whenever a new dialysis machine is brought in, another one breaks down, and who knows when this other one is going to be repaired? there is always a shortage of machines in the department.” (study 5)18 patient financial support financial ability has always been one of the most important factors in clarifying patients’ following rate to diet to achieve nursing care quality. various studies have shown that patients undergoing dialysis are financially troubled with respect to poor economic backgrounds, losing job in most of the time du to provide medicines, physician visits to control long-term complications of dialysis, and following from diet.22-24 “whenever i visit a physician’s office, i have to pay a sum of money. visits, tests and medicines must be paid for after all. if all the patients were regularly paid for their steady jobs, there would be no problems. but how can you afford the medication and in-dwelling catheters when you are out of a good job”. (study 6)22 quality of environment care the proper environment is one of the key factors in the perceived care quality from the perspective of patients. suitable environments means physical conditions (appropriate light, temperature, and sound), audiovisual equipment, patient rest room, cleanliness of the ward, comfort and being standard of dialysis bed, maintaining patient privacy, and parking.18,24,25 “the beds are too close to each other in the ward, and there is little room between the bed and the machine, and 13–14 patients undergo dialysis at the same time in this tiny space.” (study 5)18 the process of perceived quality of nursing care the process of perceived nursing care quality from the patients’ point of view was consisted of five sub-items: continuous monitoring of syndrome, effective patient education, efficient care, effective therapeutic relationship, and participation, empowering the patient in the care process. continuous monitoring of the syndrome continuous monitoring of the physical and psychological state of patients before, during and after dialysis is one of the main duties of the therapeutic team, especially nurses, who spend more time with the patient. patients undergoing dialysis experience usually high stress due to being attached to the device and hemodynamic changes during dialysis. the most important physical stressors include fatigue, weakness, nausea and vomiting and appetite problems, respiratory complications, and complications during hemodialysis including hypotension, headache, and muscle cramps. therefore, continuous attention to these patients is needed.18,22 “i spend four hours under this dialysis machine, and every second of it is still part of my life. the nurses should be in of everything. my nurse calls on me every 15 minutes or so and checks my blood pressure.” (study 5)18 effective patient education from the patients’ point of view, training to the patient effectively, especially immediately after the disease diagnosis and at the beginning of dialysis, have a significant contribution in improving patients’ health patterns and improving the nursing care quality. the key components of a correct education to patient from the patients’ point of view are the number of educational resources, rich content and patient’s problem-related content that are based on the latest medical information, and people who provide this explanation patiently and completely.18,22,24 “we begin calcium carbonate therapy with three pills, but the patient takes one every day and may develop bone disease as a result. the patient does not have adequate knowledge about these therapies, although a lot of their problems tend to disappear when you explain everything to them, and then they begin to understand why they have developed spontaneous fracture of the femur, and why their phosphorus levels are so high, and why their hands and feet hurt.” (study 5)18 efficient care efficient care means to provide sufficient competence of dialysis ward to provide services, pay attention to the patient’s needs in the ward, atmosphere between human power, and pay attention to patients concerns.25 “they are always there if you need them,” and “they always listen to my concerns.” and “the staff is like a family.” (study 2)25 effective therapeutic relationship effective therapeutic relationship as an important component of the perceived nursing care quality from perspective of patients undergoing hemodialysis means time spent for communicating with the patients by the treatment team, having intimate, friendly review figure 2. patients’ perceived quality of nursing care concept in hemodialysis patients. [page 4] [healthcare in low-resource settings 2020; 8:9320] non -co mmerc ial us e o nly [healthcare in low-resource settings 2020; 8:9320] [page 5] and mutually respect relationship so that patients experience the feeling of taking care in the dimensions of physical, emotional, health, and getting well of all members of the dialysis ward.18,22,23,26 “being cared related to health, social, feelings and well-being through the entire clinic: doctors, other patients (my partners), nurses, workers in general.” (study 3)26 participation and empowerment in care it means performing activities that enable patients to be actively involved in the treatment process and the empowerment process is done for them and ultimately they become independent to do affairs. these activities include timely medication use, observing the hygiene, full–observance of diet, exercise, and weight control.18,26 “being well cared is to recover better and pass well in the hemodialysis, it is having control with the eating, personal hygiene and from the arm and medication. it is eating properly according to the diet, taking medicines on time, follow the schedule and aware with the weight.” (study 3)26 outcomes of perceived quality of nursing care from the patients’ point of view, high quality nursing care leads to high dialysis adequecy, reduced burnout, increased satisfaction from the services, and ultimately improved quality of their life18,22,24 “almost all dialysis patients lack good spirits. they’ve gotten physically and mentally weak, have become fed-up and lost hope in life. some of them just die in a matter of hours.” (study 5)18 “i was afflicted with hepatitis here. i got it because the nurses don’t follow hygienic procedures. they connect a patient to the machine while still using gloves stained by the blood of other patients. where else could i have got hepatitis? i don’t go to barbers or swimming pools. i am a victim of the nurses’ negligence and have paid huge bills to be treated for this so far.” (study 6)22 “the treatment i’m getting is pretty good so far”, “its top-notch medical care”, and “i received very good to excellent care.” (study 1)24 finally, the concept of patient perceived quality of nursing care from the perspective of patients was defined as “satisfaction from nursing care services and improvement of upgrading quality of life in an appropriate structure, including:sufficient human resource, qualitative and adequate equipment, financial support system, favorable physical conditions with using standard processes include: continuous monitoring of the syndrome, process of effective education to the patient, efficient care (general characteristics of the ward, such as the atmosphere between staff and attention to patient concerns), effective therapeutic relationships, participation and empowerment of the patient in the care process. discussion this meta-center study was conducted with the purpose of clarifying the concept of perceived nursing care quality from the perspective of patients in hemodialysis ward. according to the best researchers’ information, this is the first meta-analysis study of qualitative studies on the perceived nursing care quality in patients undergoing hemodialysis. the results of this study showed that the perceived nursing care quality from the perspective of patients consists of three main items of structure, process and outcome. appropriate structure of perceived nursing care quality from the perspective of patients: sufficient human resource, quality of equipment used, financial support of patients, and quality of patient care environment. in line with the results of the present study on sufficient human resource, accomplished studies have shown that sufficient human power number in different fields, especially nurses, plays an important role in providing high quality cares, especially that there is a greater shortage in terms of nurses number in the world.27 nurses have the highest displacement among the health powers due to more shortage and inappropriate work environment.28 according to patients’ opinion, quality of equipment is one of the key bases of the perceived nursing care quality from the perspective of patients. in line with the results of the present study, accomplished studies show that related professionals also believe that existing sufficient facilities have always direct relation to the provided care quality, especially in hemodialysis patients that much of the presented cares is provided through specialized devices.29 in line with the present study, which necessary to financial support has been raised as one of the major challenges among patients undergoing hemodialysis, qualitative study of abma et al. have also shown that financial incentives cause to improve patient care.30 hemodialysis, on the one hand, imposes high costs on the patient and the health system, and on the other hand, is accompanied with low outcomes of care quality indicators.31 the results of the mushi et al. have shown that the global annual cost rate imposed for every hemodialysis patient in less developed countries is between int $3,424 and int $42,785.32 the proper environment is one of the important risk factors of nursing care quality. studies have shown that the physical and psychological dimensions of the environment can help better improvement and adaptation of patients with the disease. the study by prezerakos et al. has shown that work pressure, low resources, communication crises are the most important factors of high quality work environment.33 dimensions of the process of perceived nursing care quality from perspective of the patients include continuous monitoring of the syndrome, effective patient education, efficient care, effective therapeutic relationship, and participation, empowering the patient in the care process. continuous monitoring of the syndrome is an important component of daily cares of patients undergoing dialysis. in line with the present study, the kidney disease improving global outcomes (kdigo) guidline also emphasizes that the variety of dialysis different syndromes affects the quality of work and social life of patients.44 also, the study cabrera et al has shown that high burden of different syndromes causes poor outcomes in these patients.34 studies show that supporting from families and patients using a problem-solving approach can help better and faster treatment of symptoms.34 like other chronic diseases, effective therapeutic communication is one of the most important steps of establishing a correct treatment process. some of the care challenges in the treatment of chronic diseases include patients undergoing hemodialysis, self-care behaviors such as fluid control, diet, correct medication use, participation in care, and acceptance of the patient’s role. reducing and managing these challenges requires correct education to the patient.35 education to the patient is raised one of the fundamental principles of nursing care quality insofar as education to patient causes to reduce the complications and mortality of these patients.36 from the patients’ point of view, high quality nursing care leads to high quality dialysis, reduced burnout, increased service satisfaction, and ultimately improved quality of their life. the accompanied studies are in line with the present study and shows a direct relationship of nursing care quality with high quality dialysis,37,38 increased satisfaction and quality of life in patients undergoing hemodialysis.39 the main strengths of this study were: review non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2020; 8:9320] according to the researchers’ knowledge, this is the first study to evaluate the concept of perceived nursing care quality from the perspective of patients, standard approach has been used to perform different steps. the most important limitations of the present study were: similar to other metasynthesis, the quality of their studies and interpretations is largely dependent on researchers. only studies done in english and farsi were searched. included studies have been conducted only in a limited number of countries with specific cultures, so the generalization of study results are confronted with limitation and less can be generalizable to other communities. conclusions the findings showed the importance of different aspects of the perceived nursing care quality from the perspective of the patients undergoing hemodialysis. the results of this study can help to a deeper understanding of the concept of nursing care quality and hearing patients’ voice. considering patients’ opinions on the structural dimensions (adequate human power, effective equipment, desirable environmental conditions) and correct processes of service delivery (continuous monitoring of syndrome, training to the patient and effective communication) perceived nursing care quality by health policy-makers, and staff of dialysis ward can improves care quality and causes to enhance the quality of life of patients undergoing hemodialysis. references 1. hill nr, fatoba st, oke jl, et al. global prevalence of chronic kidney disease–a systematic review and metaanalysis. plos one 2016;11:e0158765. 2. bouya s, balouchi a, rafiemanesh h, hesaraki m. prevalence of chronic kidney disease in iranian general population: a meta-analysis and systematic review. therapeutic apheresis dial 2018;22:594-9. 3. mills kt, xu y, zhang w, et al. a systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. kidney int 2015;88:950-7. 4. stanifer jw, muiru a, jafar th, patel ud. chronic kidney disease in low-and middle-income countries. nephrol dial transplant 2016;31:868-74. 5. grassmann a, gioberge s, moeller s, brown g. esrd patients in 2004: global overview of patient numbers, treatment modalities and associated trends. nephrol dial transplant 2005;20:258793. 6. heidary rouchi a, mansournia 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n, shahidi s. assessment of hemodialysis adequacy and its relationship with individual and personal factors. iranian j nurs midwif res 2016;21:577. 39. jung hm, kim hy. a health-related quality of life model for patients undergoing haemodialysis. j clin nurs 2020;29:613-25. review non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12359 exploring to improve patient satisfaction through organizational factors consolidation of sharia-based nursing care muh. abdurrouf,1,2 nursalam,1 ahsan,3 iwan ardian,2 intan rismatul azizah2,4 1faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang; 3faculty of medicine, universitas brawijaya, malang; 4postgraduate program of nursing, faculty of nursing, universitas airlangga, surabaya, indonesia abstract organizational factors determine patient satisfaction, since nursing care depends on organizations, in which the majority of actions involve nurses to provide holistic nursing care. spirituality can be an important key, because patients feel all needs are fulfilled, making sharia-based nursing care (sbnc) a mediator of organizational factors for patient satisfaction. the aim of this paper is analyzing the role of organizational consolidation factors and sbnc model to determine patient satisfaction in sharia hospitals. this analytical correlation study used a cross-sectional design and cluster sampling technique on 260 respondents as the samples, consisting of nurses and patients in patient rooms in x islamic hospital, indonesia. the variables of this study, the organizational factors, sbnc, and patient satisfaction were collected using a questionnaire; all variables were assessed through the use of a questionnaire, and permission to modify or employ the instrument was obtained from the original authors, and analyzed using smart partial least squares (smartpls). organizational factors have significant influence on sbnc (p-value=0.000; βvalue=0.786; t-value>1.96), organizational factors have moderately significant influence on patient satisfaction (p-value=0.000; βvalue=0.508; t-value>1.96), sbnc has significant influence on patient satisfaction (p-value=0.000; β-value=0.430; t-value>1.96), the consolidation of organizational factors with sbnc influences patient satisfaction (p-value=0.001; β-value=0.338; t-value>1.96). nurses with good leadership, culture, and who give appropriate rewards can shape the quality of the profession by implementing sbnc; patients feel all needs are fulfilled, especially the spiritual aspect, and satisfaction with the nursing services. introduction a sharia hospital is a hospital that provides health services in accordance with sharia principles or, in other words, applies maqashid sharia in hospital governance. the characteristics of sharia hospitals that distinguish them from other hospitals are understanding related to the basic principles of sharia, the principles of halal and haram, the muamalat principle, the application of the concept of quality in islam, and upholding islamic values in hospital organizations.1 the strongest organizational foundation is required for surviving competition in the health industry, since organization is a key player in developing human resources such as nurses, since nurses are one of the most important and largest resources in hospitals.2 in addition, nurses’ performance determines a hospital’s quality of nursing care and services, so if their nurses’ performance of nurses is good, so is the hospital’s management. hospital governance is one of the service priorities, given hospitals’ increasingly fierce competition.3-7 the indonesian muslim population is 237,531,227, about 96.5%, as in central java alone, the population is 35,607,889.8 muslim population as the second largest population in the world is an opportunity for hospitals to improve their services for muslims. it is possible to develop islamic-based nursing services, since nurses are the key to service quality.9 nursing services are an correspondence: muh. abdurrouf, doctoral program, faculty of nursing, universitas airlangga, surabaya 60115, indonesia. e-mail: muh.abdurrouf-2020@fkp.unair.ac.id key words: healthcare; nursing care; organizational; patient satisfaction; sharia, social factors. contributions: ma, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; n, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; a, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ia, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. ira, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: none. ethics approval and consent to participate: this research has passed the ethical clearance test by the medical and health research ethics committee (mhrec) of sultan agung islamic hospital’s health research ethics committee on 25 july 2022 under no. 72/ kepkrsisa/vii/2022, and has obtained the respondents’ consent through informed consent, anonymity, confidentiality, fidelity, and autonomy. patient’s consent for publication: written informed consent was obtained for anonymized patient information to be published. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to express their gratitude to all participants in this study and the hospital for their help completing this research. received: 6 february 2024. accepted: 20 august 2024. early view: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12359 doi:10.4081/hls.2024.12359 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12359] [page 59] non -co mmerc ial us e o nly important part of a hospital’s quality and safety of services and the determining factor of patient satisfaction of treatment outcome, thus nursing care is important to determine patient satisfaction.10-20 competition between hospitals greatly relies on the service quality aspect, consequently, hospitals are developing services with an islamic system or sharia hospital, because of the growing demand for halal products and halal services, particularly hospital and sharia-based healthcare services.4 islamic hospitals with sharia standards have many positive impacts on patients with regard to patient satisfaction. patient satisfaction is an important goal of service quality in that it reflects the quality of existing services.21 in general, sharia nursing care comprises five nursing processes: assessment, diagnosis, intervention, implementation, and evaluation, on the basis of islamic-based intellectual, physical, ethical, moral, and spiritual. this conforms to the concept of maqashid sharia, referring to imam syatibi, comprised of maintaining religion (khifdz ad-diin), preserving soul (khifdz an-nafs), maintaining offspring (khifdz an-nasl), maintaining reason (khifdz al-aql), and maintaining property (khifdz al-mal).22 maqashid sharia is a sharia hospital with nursing care that has a maqashid sharia spirit, but there has been no research related to patient satisfaction with nursing care in sharia hospitals and whether these organizational factors can increase patient satisfaction,5 so this should be studied further.7 patient satisfaction, in addition to islamic nursing care’s influence, are related to organizational factors. nurses and organizational factors in hospitals are an integral part since nurses are competent, motivated, and trained, also because of the existing organizational policies in hospitals. therefore, the organizational factors contributing to determining hospital quality and patient satisfaction include leadership, organizational culture, goals or vision and mission, rewards, and training and development. since nurse performance influences organizational performance, hospital leaders should take nurse performance into consideration.13 leadership influences nurse performance through organizational factors that it is capable of measuring the nurse-organization framework.14 islam believes leadership is a mission; the responsibility is not only for leading nurses, but also for allah swt.15 organizational culture is also correlated with nursing care, framed in islamic values as norms, beliefs, and values applied in an organization. in islamic teaching, comprising the qur’an and hadith, islamic organizational culture is a factor that enhances a sharia nurse’s character.16 sharia nurses’ performance is influenced by the element of organizational goals expressed in the products and services offered, in which a nurse is a hospital’s extension in translating the vision and mission of nursing service provision.17 patient satisfaction is influenced by nursing care provision and various nursing care models have been developed, one of which is nursing care based on islamic values and considered appropriate for application in sharia hospitals. the reflection on organizational factors’ role shows that they influence the nursing care quality and the spiritual dimension also influences patient satisfaction, but there is no research related to sharia-based nursing services, despite muslims being the majority population in the world, thus muslim patients’ spiritual needs are also great. indonesia boasts hospitals with sharia-based standards, such as those located in the central java province. on this basis, this research was conducted in one of the sharia-based hospitals in islamic hospital, with regard to the organizational factors, including leadership knowledge, organizational culture, goals, rewards or salaries, and nurse training and development toward islamic nursing, in which there is no research related to this, especially those inspired by maqashid sharia, and sharia-based nursing care’s (sbnc) role in patient satisfaction. the researchers were interested in examining the role of consolidation of organizational factors with sbnc in improving patient satisfaction, thus the aim of this study is exploring to improve patient satisfaction through organizational factors consolidation of sbnc. materials and methods study design this analytic observational research used a cross-sectional design; this design was chosen because this research is quantitative research that analyzes the relationship between cause and effect factors using an observation approach or data collection in one data collection. this study’s exogenous variables are organizational factors, while the endogenous variables are sbnc and patient satisfaction, with five organizational factors indicators, comprised of leadership, organizational culture, goals, rewards or salary, and training and development. this study’s endogenous variables are sbnc, five indicators of which are: assessment, diagnosis, intervention, implementation, and evaluation. patient satisfaction has five indicators: reliability, assurance, tangible, empathy, and responsiveness (rater). thus, the study has a total of 15 indicators referring to three latent variables. this study has three hypothetical paths: firstly, from organizational factors to sbnc; secondly, from sbnc to patient satisfaction; and thirdly, from organizational factors to patient satisfaction. participants the research population comprised nurses and patients in the inpatient rooms of the islamic hospital, the nurses’ total population was 143. this study’s total respondents were 260, comprised of 130 inpatient nurses and 130 patients treated in inpatient rooms, calculated with the maximum likelihood method, and seven inpatient rooms resulted from a calculation using a cluster sampling technique. the samples were selected using the cluster sampling technique, with one of the methods being random sampling (table 1). for patients, inclusion criteria were as follows: i) being inpatients, ii) being literate, iii) identifying as muslims, iv) falling within the age range of 17 to over 65 years old. patients meeting any of the following criteria were excluded: i) being outpatients; ii) receiving treatment in the intensive care unit, neonatal or pediatric rooms, or experiencing impaired consciousness. as for nurses, the inclusion criteria were: i) being assigned to inpatient rooms; ii) holding at least an associate degree in nursing at the first level, including those with a senior high school education level who completed a three-year associate degree in nursing, and iii) identifying as muslims. nurses fulfilling any of the following criteria were excluded: being assigned to the intensive care unit or emergency unit. instruments in quantitative research, the credibility of a study relies on the development of instruments used to measure the underlying concepts. the measurement of a variable is designed to achieve consistency, adequacy, accuracy, precision, uniformity, and comparability in assessing and explaining a specific concept. therefore, the measurement approach encompasses testimony and confirmation variables that function as representations of constructs.23 this study’s exogenous variables are organizational factors, while the endogenous variables are sbnc and patient satisfaction, with five organizational factors indicators, comprised of leadership, organizational culture, goals, rewards or salary, and training and develop social and political factors affecting public health [page 60] [healthcare in low-resource settings 2024;12(s2):12359] non -co mmerc ial us e o nly ment. this study’s endogenous variables are sbnc, five indicators of which are: assessment, diagnosis, intervention, implementation, and evaluation. patient satisfaction has five indicators: reliability, assurance, tangible, empathy, and responsiveness (rater). thus, the study has a total of 15 indicators referring to three latent variables. all variables in this study were assessed through the use of a questionnaire, and permission to modify or employ the instrument was obtained from the original authors (table 2).24-29 upon the variables, a likert scale was used for the nurses and islamic nursing care factors, comprised of strongly disagree, disagree, neutral, agree, and strongly agree, while, for patient satisfaction, the answers were classified into very dissatisfied, dissatisfied, neutral, satisfied, and very satisfied. the variables were ordinally scaled with indicators ranging from 76-100% (good), 55-75% (enough), and lower than 55%. the study’s data were collected using organizational factors, the questionnaire had 27 questions, divided into: questions 1-7 to measure leadership, 8-12 to measure organizational culture, 13-17 to measure purpose, 18-22 to measure reward or salary, and 23-27 to measure training and development. the questionnaire for patient satisfaction covered rater, or rater questionnaire, comprised of 23 questions, divided into: questions 1-6 to measure reliability, 7-9 to measure assurance, 1014 to measure tangibility, 15-19 to measure empathy, and 20-23 to measure responsiveness. the variables of sbnc had 25 questions with five processes of sbnc, each process with only five questions. the validity test results for the organizational factors questionnaire have validity values of 0.716 to 0.996 and reliability of 0.876 to 0.990, and the results for the sbnc questionnaire have validity values of 0.656 to 0.993 and reliability of 0.879 to 0.975. the patient satisfaction questionnaire had scores of 0.552 to 0.876, and reliability of 0.851 to 0.906. data collection this research was conducted at an islamic hospital, in indonesia. the data were collected in august 2022. to mitigate potential research bias, various measures were implemented, including the application of multiple inclusion and exclusion criteria aimed at reducing biases and ensuring respondent eligibility. the researcher collected the primary data for this study. a total of 260 questionnaires were distributed in august 2022. the data were collected in the following steps: i) conduct research permits in hospitals, ii) after obtaining permission for the ethical process at the an islamic hospital ethics committee institute, iii) pass the ethical test, the data collection process for inpatient patients who met the inclusion and exclusion criteria, patients first received an explanation from researchers about the research carried out in full, an social and political factors affecting public health table 1. calculation of the number of samples with the cluster sampling technique. no inpatient room name total (ni) ∑n = ni : n total sample ni = (∑n) x n 1. inpatient room a 18 0.125 16 2. inpatient room b 27 0.188 25 3. inpatient room c 17 0.118 16 4. inpatient room d 19 0.132 17 5. inpatient room e 15 0.104 14 6. inpatient room f 28 0.195 25 7. inpatient room g 19 0.132 17 8. total 143 130 table 2. instrument source. variables indicator items sources organizational factors leadership 7 hasibuan, 201924 organization culture 5 umar, 200825 goals 5 chasanah, 200526 rewards or salary 5 hasibuan, 201924 training and development 5 kandou, 201327 total 27 sharia based nursing care assessment 5 dsn-mui, 201728 diagnosis 5 dsn-mui, 201728 intervention 5 dsn-mui, 201728 implementation 5 dsn-mui, 201728 evaluation 5 dsn-mui, 201728 total 25 patient satisfaction reliability 6 nursalam, 202029 assurance 3 nursalam, 202029 reality 5 nursalam, 202029 empathy 5 nursalam, 202029 responsibility 4 nursalam, 202029 total 23 [healthcare in low-resource settings 2024;12(s2):12359] [page 61] non -co mmerc ial us e o nly explanation carried out orally and in writing; after the patient understands the research being conducted, the researcher requests written informed consent and then the patient who agrees to be a respondent can sign the informed consent sheet, which is in accordance with the ethical principles of research, namely informed consent, anonymity, confidentiality, fidelity, and autonomy; the process of filling out the patient’s questionnaire will be accompanied by the family, because a complete explanation regarding this research from the enumerator is not only given to the patient but also given to the family as the patient’s guardian or guardian, so that in the process of filling in the patient is accompanied by the family, the filling does not have to be completed at one time, because the patient is given 24 hours to fill out the questionnaire, so the questionnaire can be filled in according to the patient’s wishes, but if the patient does not have family to look after him then he will be accompanied by an enumerator, after 24 hours the enumerator will take the questionnaire back, but before taking it he will check whether it is completely filled in or not, if it is not all filled in then the patient is asked to complete it, and if it is complete it will be collected by the enumerator for further data analysis process.4 the data that have been collected are then checked for completeness and then processed with smart partial least squares (smartpls). data analysis the descriptive test uses a frequency distribution test with analysis using smartpls. for inferential analysis, a variation and component-based structural equation model was used called partial least squares structural equation modeling (pls-sem), pls-sem is recognized as an alternative to covariance-based structural equation modeling (cb-sem) in cases where assumptions cannot be met or when the proposed model is exploratory in nature, lacking substantial empirical evidence. pls-sem also facilitates testing the relationships between constructs within the conceptual model. smartpls 3.2.8 was employed to execute the pls-sem method. this software offers diverse options for generating both outer and inner models to compute latent variable scores within research models. nonetheless, it is important to note that pls-sem has faced criticism from experts regarding its consistency and potential bias.30 pls and consistent pls prediction have been introduced to address these concerns, but their development remains ongoing. given the exploratory nature of this research and the lack of a well-established model, pls-sem is suitable for hypothesis testing.31 smartpls has the advantage that it is powerful, since it does not require the data to have a certain measurement scale. small samples can also be used to confirm the theory, and allow testing a series of relationships between relatively complicated variables simultaneously. smartpls analysis was carried out using the smartpls software covering the measurement model (outer model), structural model (inner model), and hypothesis test. therefore, in view of smartpls’s advantage, it is very suitable that smartpls was used as the device for data processing in this research. based on the guidelines on the outer model or validity test, an indicator is considered valid if its average variance extracted (ave) value >0.5 or showing all outer loading variable dimension values >0.5. the second test was the structural or inner model test, carried out to predict the causal relation between latent variables. the structural model was evaluated assuming the percentage of the variances explained by r2, (r square) for the dependent variable, and the predicted relevance test (q-square) called stone-geisser was used to measure how well the values observed, produced by the model, are and also the parameter estimates. a qsquare value higher than 0 (zero) indicates that the model has predictive relevance or shows relevance when applied in different areas. on the other hand, a q-square value lower than 0 (zero) has less predictive relevance, and a bootstrapping procedure was performed to observe the structural path coefficient or latent variable’s relation or influence. the hypothesis was tested by testing the tstatistic or bootstrapping the significance of the hypothesis was obtained by comparing the t-table and t-statistic values. the tstatistic value was higher than the t-table or t >1.96 and p≤0.01.32 ethical considerations this research has passed the ethical clearance test by the medical and health research ethics committee (mhrec) of sultan agung islamic hospital’s health research ethics committee on 25 july 2022 under no. 72/ kepk-rsisa/vii/2022, and has obtained the respondents’ consent through informed consent, thus patients first received an explanation from researchers about the research carried out in full, an explanation carried out orally and in writing. after the patient understands the research being conducted, the researcher is given informed consent in writing, and then the patient who agrees to be a respondent can sign the informed consent sheet, which is in accordance with the ethical principles of research, namely informed consent, anonymity, confidentiality, fidelity, and autonomy. results sample characteristics the results show that by age, most of the nurses are from 26 to 35 years old or in their late adulthood (70%) and by educational level, most of the nurses have associate degrees in nursing education (67.78%). the nurses’ highest age (late adulthood) ranges from 36-45 years old (24.6%), and most of them have a secondary school education level (53.8%) (table 3). the frequency distribution test shows that most of the variables studied have good levels (table 4). this is reflected in the results, showing that most of the nurses have good leadership (70%). the organizational culture variable also has a good level (72.3%). for the third variable, organizational goals, most of them have good level (72.3%), and most of them have good level of reward or salary (66.2%); the sbnc variable shows that most of the nurses have good level of assessment (73.8%), and most of the nurses have good level of diagnosis (67.7%), intervention (73.1%), implementation (69.2%), and evaluation indicator (72.3%). patient satisfaction’s five indicators show that most of the nurses have good reliability (75.4%) and reality indicator (71.5%), most have good assurance (70%), most have good empathy (71.5%), and good responsibility (73.8%) (figure 1, table 5). the interpretation of the measurement model in this test is valid since the indicator’s reliability for each part of the outer loading is higher than 0.7. the ave value for all variables is higher than 0.7. the reliability test in this study used a reference to the value of composite reliability and cronbach’s alpha, in all variables showing values higher than 0.7, all results of which are very reliable in that they are higher than 0.80. in the fornell-larcker matrix, the square root of ave (diagonal) is higher than all values, and the htmt value is lower than 1, thus we may conclude that the measurement model’s discriminant validity is confirmed. this study’s coefficient of determination shows that the organizational factors determine sbnc by 0.618 (0.618x100=61.8%), thus 61.8% of sbnc is predicted or determined by the organizational factors, while the remaining 38.2% (100-61.8%=38.2%) is social and political factors affecting public health [page 62] [healthcare in low-resource settings 2024;12(s2):12359] non -co mmerc ial us e o nly social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12359] [page 63] table 3. demographic characteristics of nurse and patient. variable f % nurse age 21-25 years (late adolescence) 14 10.8 26-35 years (early adult) 91 70 36-45 years (late adulthood) 24 18.5 education associate degree of nursing 88 67.7 nurse profession 42 32.3 patient age 17-25 years (late adolescence) 12 9.2 26-35 years (early adult) 20 15.4 36-45 years (late adulthood) 32 24.6 46-55 years (early seniors) 31 23.8 56-65 years (late elderly) 29 22.3 >65 years old (seniors) 6 4.6 education elementary (elementary school) 44 33.8 secondary (junior high school or senior high school) 70 53.8 high (bachelor or master) 16 12.3 table 4. distribution of variable frequency. variable category scale less enough good f % f % f % organizational factors leadership 2 1.5 37 28.5 91 70 organizational culture 4 3.1 32 24.6 94 72.3 purpose 6 4.6 30 23.1 94 72.3 rewards or salary 8 6.2 36 27.7 86 66.2 training and development 7 5.4 32 24.6 91 70 sharia-based nursing care assessment 2 1.5 32 24.6 96 73.8 diagnosis 4 3.1 38 29.2 88 67.7 intervention 3 2.3 32 24.6 95 73.1 implementation 6 4.6 34 26.2 90 69.2 evaluation 6 4.6 30 23.2 94 72.3 patient satisfaction reliability 3 2.3 29 22.3 98 75.4 assurance 4 3.1 35 26.9 91 70 reality 1 0.8 36 27.7 93 71.5 empathy 1 0.8 36 27.7 93 71.5 responsibility 2 1.5 32 24.6 96 73.8 figure 1. measurement of the outer model. of, organizational factors; snbc, sharia-based nursing care; ps, patient satisfaction non -co mmerc ial us e o nly determined by other factors. the next coefficient of determination is the sbnc and organizational factors’ value in determining patient satisfaction, showing the results 78.7% or (0.787x100=78.7%), while the remaining 21.3% (10078.7%=21.3%) is determined by other variables beyond this study. this study’s results show the path coefficients and the level of significance. the path coefficients were used to test the hypothesis; the path coefficient test shows a significant correlation between organizational factors and sbnc (table 6). organizational factors and sbnc has positive, strong, and significant influence (p-value=0.000; β-value=0.786; t-value>1.96). organizational factors and patient satisfaction have positive, moderate, and significant influence (p-value=0.000; β-value=0.508; tvalue>1.96), and sbnc and patient satisfaction have positive, moderate and significant influence (p-value=0.000; βvalue=0.430; t-value>1.96). the consolidation of organizational factors with sbnc on patient satisfaction shows that there is influence and can increase patient satisfaction (p-value=0.001; βvalue=0.338; t-value>1.96). these results show that patient satisfaction can be increased quickly through special methods or strategies, namely through consolidation or a combination of organizational factors with sbnc, so consolidation becomes a special strategy to increase patient satisfaction. discussion this study investigated the indicators that shape organizational factors, sbnc, and patient satisfaction. in addition, this study also examines specific strategies to increase patient satisfaction, organizational factors that can influence sbnc, patient satisfaction, and the role of each organizational factor indicator, assesses sbnc that can increase patient satisfaction, and examines the role of each indicator of sbnc in increasing patient satisfaction. in-depth findings regard the consolidation of organizational factors with sbnc on patient satisfaction, which is the most important factor in increasing patient satisfaction. the study results indicate that organizational factors significantly influence sbnc and patient satisfaction. this study’s results also show that organizational factors are shaped by the indicators: leadership, culture, goal, reward, and training and development. this is in line with the research that organizational characteristics and nurses’ behavior influence patient’s perception of the care they receive.33 organization is an important factor not only serving as part of the administrative process, but also a challenge to nursing services, since a nursing model is selected depending on how the organization establishes it, besides the fact that the quality of nursing care for patients reflects health service organization.34 social and political factors affecting public health table 5. measurement model evaluation, coefficients of determination, and path coefficients. measurement model evaluation latent variable items convergent validity internal consistency discriminant validity reliability loadings ave composite reliability cronbach alpha htmt <1 organizational factors of1 0.862 0.734 0.932 0.909 yes of2 0.859 of3 0.871 of4 0.843 of5 0.849 sharia-based nursing care sbnc 1 0.889 0.831 0.961 0.949 yes sbnc 2 0.889 sbnc 3 0.918 sbnc 4 0.937 sbnc 5 0.912 patient satisfaction ps1 0.863 0.780 0.947 0.929 yes ps2 0.908 ps3 0.904 ps4 0.856 ps5 0.884 coefficients of determination variable r square r square adjusted sharia-based nursing care 0.618 0.615 patient satisfaction 0.787 0.784 ave, average variance extracted. table 6. path coefficients. hypothesis β sd t-value ρ-value test result organizational factors ⇒ sharia based nursing care 0.786 0.050 4.394 0.000 supported organizational factors ⇒ patient satisfaction 0.508 0.126 14.878 0.000 supported sharia based nursing care ⇒ patient satisfaction 0.430 0.111 3.859 0.000 supported organizational factors ⇒ sharia based nursing care � patient satisfaction 0.338 0.102 3.299 0.001 supported sd, standard deviation. [page 64] [healthcare in low-resource settings 2024;12(s2):12359] non -co mmerc ial us e o nly a health service organization plays an important role in leadership, as stated by specchia et al. (2021), that leadership plays a key role in effective and efficient care provision and positively influences the nursing profession, environment, and patient. leadership is defined as the ability to influence others in achieving goals or works through good communication, motivation, leadership ability, and decision-making.35 leadership greatly influences the success of sbnc; in providing nursing services, nurses must comply with the maqshid sharia guidelines, thus a leader plays an important role in directing, creating cooperation, and evaluating nurses’ performance for them to comply with the five elements of maqshid sharia. a nurse leader’s leadership style directly or indirectly determines the quality of nursing care, since good leadership determines the right steps to achieve goals, and good and competent leadership will improve nursing care quality and patient satisfaction, but achieving these two things, in addition to leadership, also requires well-established organizational culture.36 organizational culture is a set of shared mental models reflecting a group’s life: perspective-making, problem-solving, and emotional reaction to what we feel.37 organizational culture plays an important role in creating a work environment that may support nurses in the avoidance of negative organizational attitudes, nurse job satisfaction, and patient satisfaction.38 this study result shows that organizational culture is the indicator forming organizational factors in determining sbnc and patient satisfaction in that, as stated by bakar et al. (2022), organizational culture can shape a nurse’s professionalism in their work environment and enhance cooperation between nurses. work culture is related to the quality of a nurse’s work, as work quality depends on the culture applied, and a hospital’s understanding of a sustainable organizational culture helps improve nurse performance in the long run.40 organizational goals are expressed in the products and services offered, the needs addressed, and the community groups served through the values obtained and through the aspirations and ideals for the future, called vision. nurses are a hospital’s extension in translating its vision and mission, thus nurses must understand and implement the organization’s vision and mission in providing nursing services.41 sbnc is a service objective implemented in sharia hospital services, and nurses here play an important role in their performance, since, as stated by mukisi & ppni (2019), the nursing profession has ethics aimed at patient safety as part of service quality besides knowledge and skills, and additional terms or codes of conducts for nurses from the qur’an and hadith are needed in sharia-based nursing implementation, thus a health service organization’s (hospital) goals or vision and mission play an important role in sbnc implementation, patient satisfaction, and nurse job satisfaction. nurse job satisfaction is a factor influencing the quality of nursing care since a nurse’s good job satisfaction will boost the quality of nursing care, and nurse job satisfaction is influenced by salary or reward. salary or compensation is an appreciation, as nursalam (2020) defined as a statement explaining what the organization desires in the long run in developing and expecting policies, practices, and appreciation processes that may support achieving their goals and meeting their needs. reward is also a stimulus to improve nurse performance in providing nursing care, thus reward is an organization’s important indicator, and nurse performance can also be improved through training and developing human resources. training and development in this study are proven to be an indicator influencing organizational factors, in conformance to the statement by bhatti et al. (2021) that, in aiming at developing skills and knowledge, hospitals can provide training programs. training is a useful educational method in the short run as a coherent and systematic way of learning for nurses. training, in sriviboon and jermsittiparsert (2019), shows a strong influence on improving nursing and organizational resources. therefore, hospitals should train nurses in an effort to develop this resource for better organizational performance, quality of nursing care, and patient satisfaction. improving patient satisfaction through sbnc requires efforts in improving organizational factors, which can be improved through improved leadership, organizational culture, improved goal setting, optimized reward, and training and development for nurses. hospitals can hone nurse leadership, improve organizational culture, and set goals in accordance with maqshid shariah principles, since goal honing and setting according to sharia principles can help optimize a nurse’s performance of sbnc. in addition, hospitals also need to optimize nurse reward, since the reward is proven capable of increasing nurse job satisfaction, increasing their loyalty to the hospital, and nurse performance, which can lead to improving nurse performance in providing sbnc and increasing patient satisfaction. training is also needed to increase nurse’s knowledge, skills, and abilities with regard to sbnc. so that patient satisfaction can be increased quickly through special methods or strategies, namely through consolidation or a combination of organizational factors with sbnc, consolidation becomes a special strategy to increase patient satisfaction. strengths the results draw the novel contributions of organizational factors with sbnc to increase patient satisfaction in islamic hospitals; the effect of the consolidation relationship between organizational factors and sbnc on increasing patient satisfaction hasn’t been published. it is important because this research provides a model to clarify how the consolidation of organizational factors with sbnc can significantly increase patient satisfaction. in addition, sbnc is a new model developed by the authors themselves, so it has an important update for the world of nursing, considering that the population of muslims is the largest in the world and the need for spiritual needs is also increasing so that when a hospital wants to expand or enlarge, it is necessary to improve the quality of service. this improvement can be seen in this model, namely by developing sbnc and applying it; the organizational factor consolidation model with sbnc shows that it can strengthen patient satisfaction; when patient satisfaction increases, patient loyalty will also increase, which will later attract consumers or patients to continue to return to the hospital if they need a service or recommend others. implications this research also has a positive impact on nursing students, nurses, student nursing practitioners, and nurse practitioners, and, because it is closely related to the service system, it also has benefits for nursing managers and directors. this is because it can provide very adequate information to nurses to become the basis for leadership and organizational culture, and always improve their knowledge in order to provide the best nursing services for patients so as to provide satisfaction to patients. this research also had a positive impact on health facilities because it is known that nurses have it. however, by increasing the nurse factor, patient satisfaction can be determined; thus, when the patient is satisfied, patient loyalty can increase, which is beneficial for health services. thus for society. in addition, this study has undergone several updates. hospital managers and nursing managers should realize that organizational factors have a positive impact on sbnc and that the consolidation of organizational factors and sbnc can increase social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12359] [page 65] non -co mmerc ial us e o nly patient satisfaction; thus, sbnc can be implemented in islamic hospitals as a key hospital expansion. limitations and recommendations for future research it is essential to acknowledge the limitations of this study. the findings of this study are context-specific and may not be universally applicable. future research should consider broader samples and more diverse settings to enhance the generalizability of the results. several recommendations for future research were proposed. researchers should conduct longitudinal studies to explore the long-term impact of organizational factors and sbnc on patient satisfaction. additionally, investigating the influence of contextual factors, such as nursing and specific cultural and religious contexts, on nursing practice and patient satisfaction is warranted. comparative studies across different healthcare settings and populations could further expand our understanding. conclusions nurses with good leadership and an appropriate organizational culture, and giving of appropriate rewards can shape the quality of professional nursing performance so that they are in line with hospital organizational goals by implementing sbnc; 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semarang, indonesia; 2021. 33. zaghini f, fiorini j, piredda m, et al. the relationship between nurse managers’ leadership style and patients’ perception of the quality of the care provided by nurses: cross sectional survey. int j nurs stud 2020;101:103446. 34. moura ecc, lima mb, peres am, et al. relationship between the implementation of primary nursing model and the reduction of missed nursing care. j nurs manag 2019;28:1-10. 35. specchia ml, cozzolino mr, carini e, et al. leadership styles and nurses’ job satisfaction. results of a systematic review. int j environ res public health 2021;18:1-15. 36. kiwanuka f, nanyonga rc, sak-dankosky n, et al. nursing leadership styles and their impact on intensive care unit quality measures: an integrative review. j nurs manag 2021;29:13342. 37. wirdawati, gunawan h, betan a, et al. implementation of organizational culture and work discipline to patient satisfaction through quality of health services in indonesia. 2021. available from: https://www.ieomsociety.org/singapore2021/papers/1275.pdf 38. pedrosa j, sousa l, valentim o, antunes v. organizational culture and nurse’s turnover: a systematic literature review. int j healthc manag 2021;14:1542-50. 39. bakar rm, khaerah y, hidayati n, hamid an. the role of organizational culture in moderating effect of emotional labor strategies on nursing professionalism. nurse media j nurs 2022;12:122-32. 40. christian h, cahya yf, meilani p. effect of organizational culture , mobbing , organizational justice , and professional attitude towards hospital nurse work performance. budapest int res critics inst j (birci journal) 2021;5:8690-700. 41. nursalam. metodologi penelitian ilmu keperawatan. 5th ed. salemba madika; jakarta, indonesia; 2020. 42. bhatti mk, soomro ba, shah n. predictive power of training design on employee performance: empirical approach in pakistan’s health sector. j econ adm 2021;1. 43. sriviboon c, jermsittiparsert k. influence of human resource practices on thai pharmaceutical firm performance with moderating role of job involvement. syst rev pharm 2019;10:23443. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12359] [page 67] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11765 social media utilization and knowledge levels in exclusive breastfeeding among mothers in indonesia deswani deswani,1 dea eki rahmawati,2 yuli mulyanti,3 syafdewiyani syafdewiyani,3 rita ismail,4 sri djuwitaningsih1 1nursing professional education study program professional program, ministry of health jakarta iii health polytechnic, bekasi; 2nurse professional education study program professional, ministry of health jakarta iii health polytechnic, bekasi; 3nursing study program diploma iii program, ministry of health jakarta iii health polytechnic, bekasi; 4faculty of health sciences, universitas pembangunan nasional veteran jakarta, jakarta, indonesia abstract the utilization of social media for obtaining information on exclusive breastfeeding is driven by various user-friendly features that facilitate information retrieval. this study delves into understanding the correlation between mothers’ engagement with social media for information and their knowledge levels regarding exclusive breastfeeding in indonesia. through a cross-sectional analysis involving 93 purposefully selected respondents, demographic factors such as age, education, occupation, social media usage for breastfeeding information, and knowledge levels were evaluated using a validated questionnaire. descriptive analysis was applied to the data, and significance testing was conducted using chisquare tests. the questionnaire underwent validity and reliability tests, confirming its robustness. results indicated a significant association (p < 0.000) between social media usage for breastfeeding information and the knowledge levels of mothers successfully practicing exclusive breastfeeding. mothers who achieved exclusive breastfeeding demonstrated a discernible level of knowledge about utilizing social media as an information source for breastfeeding. this study highlights the escalating role of social media in shaping mothers’ understanding of exclusive breastfeeding. the findings underscore the significance of targeted interventions and educational programs through social media platforms to enhance breastfeeding practices. introduction according to the lancet report, optimal breastfeeding practices could save over 820,000 lives per year, constituting 13% of all deaths in children under the age of five.1 breastfeeding has the potential to reduce one-third of respiratory infections and approximately half of all diarrhea episodes in lowand middle-income countries.2 in indonesia, the projected percentage of women exclusively breastfeeding is 72.04% by 2022. specifically in jakarta province, 67.22% of infants are exclusively breastfed as of 2022.3 despite these figures, the percentage of women exclusively breastfeeding falls short of the 80% target set by the ministry of health of the republic of indonesia. according to the dki jakarta central bureau of statistics (2022), east jakarta holds the top position in jakarta province for population size. cipayung district, with a population of 285,650, is ranked sixth. within this population, there are 839 nursing mothers, all of whom have successfully practiced exclusive breastfeeding.4 knowledge, successful early breastfeeding initiation, maternal employment, and spousal support are factors influencing exclusive breastfeeding.5 the sources of information on breastfeeding and related topics significantly contribute to mothers’ knowledge.6,7 information is disseminated through intermediary sources, encompassing mass media such as print, electronic media, social media, educational channels, and the surrounding environment. the ease of information access is facilitated by the prevalence of social media as a contemporary communication tool and the rapid advancement of technology.8,9 there were 191.4 million social media users in indonesia in 2022. this number has increased by 2.1 million (1% of users) from 2021, with women constituting 52.3% of this group.10 according to kemp (2022)11 mothers often utilize social media correspondence: deswani deswani, nursing professional education study program professional program, politeknik kesehatan kemenkes jakarta iii, bekasi, indonesia. e-mail: desika_64@yahoo.co.id key words: child health, exclusive breastfeeding, information, knowledge, social media. contributions: dd conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; der conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ym conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ss methodology, visualization, writing – review & editing; ri resources, investigation, and writing –review & editing; sd formal analysis, validation, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: based on ethical certificate ib 02.02/04328/2023, the research was approved by the health research ethics commission of the poltekkes kemenkes jakarta iii kepk. throughout the research, the researcher is mindful of the ethical principles of information to consent, human rights respect, beneficence, and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. received: 11 september 2023. accepted: 30 november 2023. early access: 22 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11765 doi:10.4081/hls.2023.11765 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11765] [page 89] non -co mmerc ial us e o nly sites, including facebook, youtube, instagram, tiktok, and whatsapp.12 the province with the largest proportion of people using the internet is dki jakarta (85.55%), with women using it at a rate of 82.82%. east jakarta has the second-highest rate of internet usage, with 87.78% of the female population using it. social media is frequently employed to obtain health information, with a rate of 38.9%, as claimed by rosini and nurningsih (2018).13 studies by puspita and edvra (2020)14 on social media communities that support and empower women via breastfeeding reveal that nursing moms in these groups support and understand one another, exchanging breastfeeding-related experiences. the researchers aimed to understand the relationship between the knowledge level of mothers who have succeeded in providing exclusive breastfeeding and the use of social media as a source of information about breastfeeding. they were motivated by the data above, indicating that social media is used for health information searching due to various facilities that make it easier. the indonesia ministry of health’s strategic plan and the national medium-term development plan both set an exclusive breastfeeding rate goal of 80% for the years 2020–2024.15 however, this aim for exclusive breastfeeding has not yet been achieved.16 it is intended that freely available material from social media would help mothers learn more about breastfeeding and improve the success of exclusive breastfeeding in dki jakarta. therefore, this study aimed to determine the relationship between the use of social media as a source of information and the level of knowledge among mothers who have succeeded in providing exclusive breastfeeding. materials and methods research design the approach of this study was a cross-sectional quantitative research design that employed correlation analysis to determine the extent to which women who successfully exclusively breastfed their infants were aware of using social media as a nursing resource. study participants the population for this study consisted of 839 nursing moms. the sample included 93 nursing moms who visited the posyandu (integrated health post) in cipayung district, indonesia between march and may of 2023. purposive sampling was employed as the sample strategy, and the inclusion criteria involved breastfeeding moms who were able to successfully breastfeed their children exclusively, had children between the ages of 6 and 24 months, were registered residents of the cipayung district, and utilized social media platforms such as facebook, whatsapp, tiktok, youtube, and instagram. variable, instrument and data collection developed from the kinasih research questionnaire (2017),17 there were ten questions in this survey; a “yes” response was assigned a value of 1, and a “no” response was assigned a value of 0. it could be inferred that the respondent was not effective in delivering exclusive breastfeeding if they selected “no” for any of the items. questionnaire i) on the success of exclusive breastfeeding was the instrument utilized in this study; ii) the features of nursing moms, such as the mother’s age, her most recent educational attainment, and her line of work, were included in the questionnaire on the characteristics of the respondents; iii) social media use questionnaire: this survey asked respondents about their use of social media and their motivations. researchers adapted the questionnaire on mother’s knowledge level on breastfeeding, which was produced by researchers from endang suprihatin (2018),18 based on the notion of use and gratification provided by whiting and williams (2013).19 there were ten multiple-choice questions about nursing in the knowledge questionnaire; the correct answer counted as one, and the incorrect answer was scored zero. a response below 7 fell into the poor category, while those with a total score over 7 were considered good. thirteen questions with a “yes” response worth one and a “no” answer worth zero made up the social media use questionnaire. a total score of >11 placed the responder in the high category of social media use, while a score of <11 placed them in the low group. the questionnaire’s validity was tested on 30 respondents, yielding r tables of 0.36, with r count > r table indicating that all question items were valid. cronbach’s alpha of 0.826 indicated that the questionnaire was trustworthy as a research tool. data analysis the data were analyzed using univariate and bivariate techniques, and chi-square correlation analysis was employed to investigate if there was a relationship between the independent variable, the use of social media as a source of breastfeeding information, and the dependent variable, the level of knowledge of mothers who were successful in exclusive breastfeeding. ethical clearance based on ethical certificate ib 02.02/04328/2023, the research was approved by the health research ethics commission of the poltekkes kemenkes jakarta iii kepk. throughout the research, the researcher was mindful of the ethical principles of informed consent, respect for human rights, beneficence, and nonmaleficence. results table 1 summarizes the characteristics of the research respondents. among them, 60.2% are between the ages of 20 and 35, 53.8% have a higher education background, 52.7% do not work, and 55.9% utilize social media at a high level. whatsapp has the highest number of social media subscribers (94.6%). the majority of nursing moms use social media to obtain information (86%), and the majority of breastfeeding mothers have a strong knowledge level (57%). table 2 presents the findings of the chi-square test bivariate analysis. the age variable has a p-value of 0.268 (>0.05) and an odds ratio of 1.76, suggesting no significant link between age and the knowledge level of successful women in exclusive breastfeeding. the data analysis also indicates that nursing women aged 2035 had 1.76 times the chance of having a good level of knowledge compared to breastfeeding mothers aged > 35 years. on the other hand, the variables of work, education, and social media use showed a p-value of 0.035 (<0.05), indicating a significant relationship with the knowledge level of breastfeeding mothers, with an odds ratio of 2.68. the mother’s employment status is significantly related to an increase in maternal knowledge, with a p-value of 0.019 and an odds ratio of 2.68, respectively. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 90] [healthcare in low-resource settings 2024;12:11765] non -co mmerc ial us e o nly discussion the findings of this study suggest that the age of nursing mothers is not associated with their level of understanding when it comes to providing exclusive breastfeeding. knowledge is essentially described as an understanding that one or more people have acquired from experience and study.20–22 therefore, a mother’s age may correlate with her nursing experience and wisdom.21 the majority of nursing women in this study were between the ages of 20 and 35, and they were among the most active social media users in the study. age groups may have easier access to health-related information. the results of a survey in 2021 stated that the use of social media by women in indonesia aged 18-34 years is higher than those aged > 35 years.23 thus, breastfeeding mothers in the age group of 20-35 years have the potential to be empowered in disseminating information about breastfeeding through social media. this study is consistent with some previous studies that stated a relationship between education and mothers’ knowledge about exclusive breastfeeding. the learning process is influenced by education in the sense that the higher a person’s education, the easier it is for that person to acquire information, resulting in more knowledge.21,24,25 education and health are also related, with higher levels of education making it easier to accept the concept of healthy living on one’s own.26 consequently, nursing women pursuing higher education have a 2.68-fold increased likelihood of attaining a good level of knowledge in this context. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. respondent characteristics (n=93). variable category frequency percentage (n) (%) age 20-35 years 56 60.2 >35 years 37 39.8 education high 50 53.8 low 43 46.2 work work 44 47.3 does not work 49 52.7 use social media high 52 55.9 low 41 44.1 the most frequently used social media platform* facebook 57 61.3 whatsapp 88 94.6 tiktok 38 40.9 youtube 56 60.2 instagram 62 66.7 reason for use social media* social interaction 77 82.8 access information 80 86 about breastfeeding fill the free time 77 82.8 discuss 72 77.4 breastfeed exchange information about breastfeeding 78 83.9 knowledge level good 53 57 poor 40 43 *respondent can choose more than 1 answer. table 2. correlation of mother characteristics with breastfeeding knowledge levels (n=93) variable knowledge level poor good total p or n % n % n % age >35 years 19 51.4 18 48.6 37 100 0.268 1.76 20-35 years 21 37.5 35 62.5 56 100 education low 24 55.8 19 44.2 43 100 0.035 2.68 high 16 32 34 68 50 100 work work 25 56.8 19 43.2 44 100 0.019 2.98 does not work 15 30.6 34 69.4 49 100 use of social media as a source of breastfeeding information low 23 56.1 18 43.9 41 100 0.040 2.63 high 17 32.7 35 67.3 52 100 or, odds ratio. [healthcare in low-resource settings 2024;12:11765] [page 91] non -co mmerc ial us e o nly according to the study’s findings, the employment status of mothers is related to the knowledge level of breastfeeding mothers who efficiently provide exclusive breastfeeding. breastfeeding mothers who have a job but are not currently working demonstrate a high level of expertise. this study’s results, in conjunction with those of another study,27 suggest a relationship between work and a mother’s understanding of exclusive breastfeeding. if their workplace lacks a dedicated breastfeeding room, working mothers require more time and space to directly nurse their babies.28 working women encounter challenges in providing exclusive breastfeeding since their leave period is too short compared to the nursing period; hence, formula milk becomes the preferred option when mothers return to work.29,30 this situation has led to an increase in non-working nursing mothers. working mothers encounter difficulties in giving exclusive breastfeeding, particularly when their workplace does not offer a designated breastfeeding room.28 consequently, the prevalence of non-working nursing mothers is increasing. this underscores the importance of providing working mothers with adequate time and suitable spaces to directly nurse their babies. the majority of nursing women who use whatsapp as a social media platform exhibit a high level of understanding, primarily due to the accessibility of information. the findings of this investigation align with those of previous studies. according to this study, a significant relationship exists between using social media as a source of breastfeeding guidance and the knowledge level of mothers who have successfully practiced exclusive breastfeeding. breastfeeding mothers in the high category of social media use for breastfeeding information have a 2.63 times higher likelihood of being knowledgeable compared to those in the low category. the utilization of social media for disseminating breastfeeding information proves to be beneficial. the majority of nursing women who use whatsapp for social media exhibit a good degree of understanding, with information availability being a key factor. the findings of this investigation align with previous studies, indicating that social media can positively influence breastfeeding-related attitudes, knowledge, and behaviors.31,32 according to this study, a significant relationship exists between using social media as a source of breastfeeding guidance and the knowledge level of parents who have successfully practiced exclusive breastfeeding. breastfeeding mothers who use social media as a source of breastfeeding information in the high category have a 2.63 times higher likelihood of being knowledgeable than mothers who use social media as a source of breastfeeding information in the low category. the use of social media to provide breastfeeding information can be beneficial. conclusions breastfeeding success is notably high among mothers extensively using breastfeeding information, especially those with higher education and non-working status. conversely, young, employed, and less-educated breastfeeding women face challenges in providing exclusive breastfeeding. this specific group requires targeted attention to ensure the success of exclusive breastfeeding programs. the study underscores the impact of information technology and social media on shaping individuals’ beliefs, emphasizing the role of new information in enhancing breastfeeding knowledge. these findings guide interventions to help social media users access reliable breastfeeding information, enabling health professionals to educate the public about nursing experiences via these platforms. references 1. victora cg, bahl r, barros ajd, et al. breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. lancet 2016;387:475-90. 2. who. implementation guidance: protecting, promoting and supporting breastfeeding in facilities providing maternity and newborn services the revised baby-friendly hospital initiative [internet]. world health organization. 2018. 135149 p. available from: https://www.unicef.org/media/95191/ file/baby-friendly-hospital-initiative-implementation-guidance-2018.pdf 3. gayatri m. exclusive breastfeeding practice in indonesia: a population-based study. korean j fam med 2021;42:395-402. 4. saputri ns, spagnoletti brm, morgan a, et al. progress towards reducing sociodemographic disparities in breastfeeding outcomes in indonesia: a trend analysis from 2002 to 2017. bmc public health 2020;20:1112. 5. sebayang sk, dibley mj, astutik e, et al. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16:1-19 6. machmudah m, yunitasari e. health education on selfefficacy in breastfeeding mothers: literature review. bali med j 2021;10:1066-76. 7. hadisuyatmana s, has emm, sebayang sk, et al. women’s empowerment and determinants of early initiation of breastfeeding: a scoping review. j pediatric nurs 2021;56:e77-92. 8. shofiya d, sumarmi s, sulistyono a, suyanto b. determinants of successful exclusive breastfeeding in primiparas mothers. j public health africa 2023;14(s2). 9. kapti re, arief ys, azizah n. mother’s knowledge as a dominant factor for the success of exclusive breastfeeding in indonesia. healthc low-res sett 2023;11(s1). 10. nurhayati-wolff h. social media advertising audience profile indonesia 2023, by age and gender [internet]. statista. 2023 [cited 2023 jun 20]. available from: https://www.statista.com/ statistics/1362599/indonesia-social-media-advertising-audience-age-and-gender/ 11. kemp s. digital 2022: indonesia [internet]. datareportal global digital insights. 2022 [cited 2023 jun 20]. available from: https://datareportal.com/reports/digital-2022-indonesia 12. moon ry, mathews a, oden r, carlin r. mothers’ perceptions of the internet and social media as sources of parenting and health information: qualitative study. j med internet res 2019;21:e14289. 13. rosini r, nurningsih s. pemanfaatan media sosial untuk pencarian dan komunikasi informasi kesehatan. berk ilmu perpust dan inf 2018;14:226. 14. puspita bb, edvra pa. grup media sosial sebagai sarana pemberdayaan perempuan tentang pemberian asi. expose 2020;3:124-45. 15. kementrian kesehatan republic indonesia. regulation of the minister of health of the republic of indonesia no 21 year 2020 on the 2020-2024 strategic plan of the ministry of health [internet]. 2020. available from: https://peraturan.bpk.go. id/details/152564/permenkes-no-21-tahun-2020 16. mahendradhata y, trisnantoro l, listyadewi s, et al. the republic of indonesia health system review [internet]. vol. 7, health systems in transition. new delhi pp new delhi: who regional office for south-east asia; 2017. available transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 92] [healthcare in low-resource settings 2024;12:11765] non -co mmerc ial us e o nly from: https://apps.who.int/iris/handle/10665/254716 17. kinasih p. pengaruh dukungan keluarga terhadap pemberian asi eksklusif di puskesmas wonosari i kabupaten gunungkidul tahun 2017. j bidan komunitas 2017;viii:1-12. 18. suprihatin e. gambaran tingkat pengetahuan kader posyandu tentang asi eksklusif di desa tegalombo wilayah kerja puskesmas kalijambe sragen jawa tengah [internet]. universitas muhammadiyah yogyakarta; 2018. available from: http://repository.umy.ac.id/handle/123456789/22739 19. whiting a, williams d. why people use social media: a uses and gratifications approach. qual mark res an int j 2013;16:362-9. 20. dukuzumuremyi jpc, acheampong k, abesig j, luo j. knowledge, attitude, and practice of exclusive breastfeeding among mothers in east africa: a systematic review. int breastfeed j 2020;15:70. 21. alnasser y, almasoud n, aljohni d, et al. impact of attitude and knowledge on intention to breastfeed: can mhealth based education influence decision to breastfeed exclusively? ann med surg 2018;35:6-12. 22. diana r, adi ac. mother’s knowledge, attitude, and practice of exclusive breastfeeding. indian j public heal res dev 2019;10:887-92. 23. nurhayati-wolff h. breakdown of social media users by age and gender indonesia 2021 [internet]. statista. 2023 [cited 2023 jun 20]. available from: https://www.statista.com/statistics/997297/indonesia-breakdown-social-media-users-agegender/#:~:text=breakdown of social media users by age and gender indonesia 2021&text=as of january 2021%2c 14.8,25 and 34 years old. 24. wako wg, wayessa z, fikrie a. effects of maternal education on early initiation and exclusive breastfeeding practices in subsaharan africa: a secondary analysis of demographic and health surveys from 2015 to 2019. bmj open 2022;12:e054302. 25. laksono ad, wulandari rd, ibad m, kusrini i. the effects of mother’s education on achieving exclusive breastfeeding in indonesia. bmc public health 2021;21:14. 26. gustina i, rizmayandha d, anggraeni l. faktor-faktor yang mempengaruhi pengetahuan ibu menyusui tentang cara meningkatkan produksi asi [factors affecting breastfeeding mothers’ knowledge about how to increase milk production]. zo kebidanan 2020;10:47-52. 27. assriyah h, indriasari r, hidayanti h, et al. relationship between knowledge, attitude, age, education, occupation, psychological, and early breastfeeding initiation with exclusive breastfeeding at the sudiang health center. j gizi masy indones j indones community nutr 2020;9:30-8. 28. ramli r. correlation of mothers’ knowledge and employment status with exclusive breastfeeding in sidotopo. j promkes 2020;8:36. 29. ulya ra, pradanie r, nastiti aa. effect of workload and breastfeeding motivation of working mothers. indian j forensic med toxicol 2020;14:1858-65. 30. wahyuni sd, santoso b, triharini m, susan n. perceptions of working mothers toward breastfeeding self-efficacy. j ners 2020;15:50-6. 31. robinson a, lauckner c, davis m, et al. facebook support for breastfeeding mothers: a comparison to offline support and associations with breastfeeding outcomes. digit heal 2019;5:2055207619853397. 32. skelton kr, evans r, lachenaye j, et al. exploring social media group use among breastfeeding mothers: qualitative analysis. jmir pediatr parent 2018;1:e11344. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11765] [page 93] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11790 the correlation between creatinine levels and estimated glomerular filtration rate (gfr) with blood glucose levels in diabetes mellitus type 2 patients ani riyani,1 rizka nerisandi,1 wiwin wiryanti,1 widda rahmah,2 nani kurnaeni1 1faculty of medical laboratory technologist, ministry of health bandung health polytechnic, bandung; 2department of chemical engineering, faculty of industrial engineering, bandung institute of technology, bandung, indonesia abstract diabetes mellitus (dm) was a group of metabolic diseases characterized by hyperglycemia. measuring the blood creatinine level and calculating the estimated glomerular filtration rate (gfr) was crucial in determining if a person had impaired kidney function. these tests provided valuable insights into the progression of type 2 diabetes mellitus and its associated risk of kidney failure. the objective of this study was to investigate the correlation between average creatinine levels and gfr with blood glucose levels in type 2 dm patients. this correlative research used a cross-sectional approach and included samples from 30 patients with type 2 dm at a hospital in bandung, indonesia. the patients’ blood glucose and blood creatinine levels were measured using gfr calculations and a kenza max photometer, respectively. the sampling method used was accidental sampling, with the sample criteria being type 2 dm patients who were willing to be respondents and did not have hypertension. the average creatinine levels and estimated gfr values were 0.97 mg/dl and 84.971 ml/min/1.73m². the results of the pearson correlation test indicated non-significant correlations (p>0.05, p=0.703 and 0.819). this suggested that there was no significant relationship between creatinine levels and estimated gfr and blood glucose levels in type 2 dm patients. this study provided a foundational exploration of the link between blood glucose levels and kidney function, which could contribute to developing methods for examining kidney diseases in type 2 dm patients. this study’s findings underscore the complexity of the relationship between metabolic control and renal function in type 2 diabetes mellitus patients, highlighting the need for individualized patient assessment and management strategies. introduction one of the major global health concerns is non-communicable diseases (ncds).1 diabetes mellitus is a non-communicable disease and poses a serious threat to global health.2,3 diabetes mellitus (dm) is a group of metabolic diseases characterized by hyperglycemia, resulting from deficiencies in insulin secretion, insulin action, or a combination of both. those with dm are at risk of dysfunction and failure in various organs, including the eyes, kidneys, nerves, heart, blood vessels and sexual dysfunction.4,5 the prevalence of diabetes has been steadily increasing worldwide in recent years.6 according to the international diabetes federation (idf) in 2021, an estimated 537 million adults (aged 20-79) suffer from dm, and this number is projected to reach 783 million by 2045. it is estimated that over 6.7 million adults will die from diabetes-related causes in 2021.7 indonesia is ranked as the country with the fifth-largest number of individuals having dm, with 19.47 million cases. the idf notes that 80% of people with diabetes live in low and middle-income countries, and 45% of adults are estimated to remain undiagnosed.7 generally, the diagnosis of dm is established based on the examination of blood glucose levels. dm has several categories, including type 1, type 2, maturitycorrespondence: ani riyani, faculty of medical laboratory technologist, ministry of health bandung health polytechnic, bandung, indonesia. e-mail: ani_riyanianalis@yahoo.com key words: blood glucose, creatinine, estimated gfr, type 2 diabetes mellitus. contributions: ar, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rn, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ww, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; nk, methodology, visualization, writing – review & editing; wr, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has obtained ethical approval from the health research ethics committee at polytechnic of health bandung, as indicated by ethical certificate 40/kepk/ec/xi/2021. throughout the research, the researcher adhered to ethical principles, including obtaining informed consent, respecting human rights, ensuring beneficence, and avoiding harm (non-maleficence). patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 september 2023. accepted: 17 november 2023. early access: 15 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11790 doi:10.4081/hls.2023.11790 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11790] [page 29] non -co mmerc ial us e o nly onset diabetes of the young (mody), gestational diabetes, neonatal diabetes, and secondary causes resulting from endocrinopathies, steroid use, etc.8 in general, dm is divided into type i and type 2, with type 2 dm characterized by hyperglycemia due to insulin resistance accompanied by relative insulin deficiency.5 early detection and treatment are beneficial in preventing or delaying the progression of chronic kidney disease (ckd).9 these initiatives encompass a range of strategies, including the provision of health promotion and education activities aimed at raising diabetes awareness.10 typically, individuals with diabetes are advised to take anti-diabetic drugs to maintain controlled blood glucose levels, minimizing exposure to chronic hyperglycemia, which can lead to both macrovascular and microvascular complications.11 one of the complications that often occurs in diabetic patients is diabetic nephropathy. diabetic nephropathy is a diagnosis that refers to specific pathological structural and functional changes observed in the kidneys of patients with dm.12 this complication arises through several mechanisms, such as alterations in renal hemodynamics and the accumulation of advanced glycation end products (ages), which can trigger structural kidney damage leading to chronic kidney disease (ckd). ckd is a condition that can necessitate kidney replacement therapy in the form of hemodialysis or kidney transplantation.13 one of the manifestations of structural kidney damage is a decrease in the glomerular filtration rate (gfr).14 gfr represents the volume of plasma that the kidneys can clear entirely of specific compounds in one unit of time. additionally, an indicator to assess kidney damage is a creatinine examination.15 creatinine results from the endogenous metabolism of skeletal muscle and is excreted through glomerular filtration, ultimately being excreted in the urine without reabsorption by the kidney tubules. the creatinine level is closely related to the estimated gfr, which can be calculated by measuring the serum creatinine level of the suspected patient using the modification of diet in renal disease (mdrd) equation. therefore, estimated gfr and blood creatinine levels are crucial indicators in determining whether a person has impaired kidney function.16 they serve as valuable tools to assess the progression of type 2 diabetes mellitus, which has the potential to lead to kidney failure, and as a means of monitoring kidney function in type 2 dm patients who have experienced complications of kidney failure.14 the purpose of this study was to determine if there is a relationship between the average creatinine level and the estimated gfr with blood glucose levels in type 2 diabetes mellitus patients, by determining the average creatinine level and the estimated gfr value. materials and methods study design this study was a correlational study with a cross-sectional design aimed at determining the relationship between creatinine levels and estimated gfr on blood glucose levels in type 2 dm patients. the study was conducted at a hospital in bandung, indonesia, from october to november 2021. patients the sampling technique used in this study was accidental sampling, wherein samples were collected from the serum of patients with type 2 dm who visited the hospital laboratory. inclusion criteria type 2 diabetic patients who are over 30 years old, have fasting blood glucose levels higher than 126 mg/dl, and have given their consent to participate in the study. exclusion criteria individuals with a history of hypertension and kidney failure were not included in the study. examination of blood glucose god-pap methods glucose is oxidized by god to gluconic acid and hydrogen peroxide, which, in conjunction with pod, reacts with chloro-4phenol and pap to form a red quinoneimine. the absorbance of the colored complex, proportional to the concentration of glucose in the specimen, is measured at a 500 nm wavelength (figure 1). god oxidizes glucose to gluconic acid and hydrogen peroxide, which, in conjunction with pod, reacts with chloro-4-phenol and pap to form a red quinoneimine. the absorbance of the colored complex, proportional to the concentration of glucose in the specimen, is measured at a 500 nm wavelength. all measurements were conducted at room temperature. examination of creatinine serum jaffe reaction methods the colorimetric reaction (jaffe reaction) of creatinine with alkaline picrate was measured kinetically at 490-510 nm without any pre-treatment step. this reaction has been improved in terms of specificity, speed, and adaptability by developing an initial-rate method. the measurements were conducted at room temperature (figure 2). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. procedure for quantitative determination of blood glucose god-pap method. figure 2. procedure for quantitative determination of creatinine serum jaffe reaction method. [page 30] [healthcare in low-resource settings 2024;12:11790] non -co mmerc ial us e o nly estimation of gfr with cockcroft-gault formula based on scr the cockcroft-gault equation was used to estimate the gfr value from known variables such as serum creatinine (mg/dl), age (years), and body weight (kg) based on equation 1 for males and equation 2 for females.17 (eq. 1) (eq. 2) statistical analysis the measured creatinine level, estimated gfr, and blood glucose level dataset were subjected to bivariate analysis, specifically the pearson correlation test. the pearson correlation coefficient provides a measure of the correlation between two variables, using a scale ranging from -1 to +1, where 0 indicates no linear or monotonic relationship. as the coefficient approaches an absolute value of 1, the association becomes stronger, moving closer to a straight line. it’s important to note that the pearson correlation coefficient should not be confused with linear regression. the pearson correlation coefficient is used when both variables are observed values subject to natural random variation, such as in the accidental sampling method. conversely, in linear regression, the values are dependent on a variable that is chosen and set as a constant in an experimental protocol. the basic decision-making process in the pearson correlation test is as follows: if the significance (sig) value is <0.05, then there is a correlation; if the significance (sig) value is >0.05, then there is no correlation results creatinine levels of the type 2 diabetes mellitus patients based on table 1, the frequency distribution of 30 patients with type 2 dm shows that two patients (6.7%) had low creatinine levels, 18 patients (60%) had normal creatinine levels, and ten patients (33.3%) had high creatinine levels. the average creatinine level in type 2 dm patients was 0.97 mg/dl. table 2 presents the distribution of 30 patients with type 2 dm based on gender, age, and the duration of dm they have suffered. among the female patients (70.0%), two patients (6.7%) had low creatinine levels, ten patients (33.3%) had normal creatinine levels, and nine patients (30.0%) had high creatinine levels. in contrast, among the male patients, nine (30%), eight (26.7%), and one (3.3%) had low, normal, and high creatinine levels, respectively. the research conducted on 30 patients with type 2 dm, aged 31-82 years, revealed three categories of results in serum creatinine levels: low, normal, and high. it was observed that ten individuals had high creatinine levels, predominantly in the age group of 60-69 years, with as many as eight patients (26.6%). furthermore, the study, conducted on 30 patients with type 2 dm, was mainly composed of patients who had suffered from type 2 dm for 6-10 years, totaling 17 patients. the examination of serum creatinine levels yielded three categories: low, normal, and high. it was found that one person (3.3%) had low creatinine levels, eight people (26.7%) had normal creatinine levels, and eight people (26.7%) had high creatinine levels. eight patients had been living with dm for 0-5 years, while eight patients had been dealing with dm for more than 10 years. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. frequency distribution of creatinine levels in type 2 diabetes mellitus patients based on gender, age, and duration of diabetes mellitus. creatinine levels in type 2 diabetes mellitus patients (mg/dl) low normal high frequency n % n % n % n % gender male 0 0 8 26.7 1 3.3 9 30.0 female 2 6.7 10 33.3 9 30 21 70.0 total 2 6.7 18 60.0 10 33.3 30 100 age 30-39 years old 0 0 2 6.7 0 0 2 6.7 40-49 years old 1 3.3 3 10.0 0 0 4 13.3 50-59 years old 0 0 6 20.0 0 0 6 20.0 60-69 years old 1 3.4 4 13.3 8 26.6 13 43.3 >70 years old 0 0 3 10.0 2 6.7 5 16.7 total 2 6.7 18 60.0 10 33.3 30 100 duration of diabetes mellitus 0-5 years 0 0 5 16.7 0 0 5 16.7 6-10 years 1 3.3 8 26.7 8 26.7 17 56.7 >10 years 1 3.4 5 16.6 2 6.6 8 26.6 total 2 6.7 18 60 2 33.3 30 100 table 1. frequency distribution of creatinine levels in type 2 diabetes mellitus patients. creatinine levels in type 2 diabetes mellitus patients (mg/dl) variable low normal high frequency mean n % n % n % n % creatinine levels in type 2 2 6.7 18 60 10 33.3 30 100 0.97 diabetes mellitus (mg/dl) [healthcare in low-resource settings 2024;12:11790] [page 31] non -co mmerc ial us e o nly estimation of glomelurus filtration rate of the type 2 diabetes mellitus patients based on table 3, after analyzing the frequency distribution of 30 patients with type 2 diabetes mellitus, it was determined that normal gfr values were found in 15 patients with type 2 diabetes mellitus (50.0%), while an estimated mild gfr value was observed in nine patients (30.0%). the average estimated gfr value in type 2 diabetes mellitus patients was 84.971 ml/min/1.73m². table 4 explains the frequency distribution of estimated gfr values for 30 patients with type 2 dm, the majority of whom were females (21 patients, 70%). among the 21 female patients, nine (30%) had estimated gfr values in the normal category, six (20%) in the mild category, and the remaining six (20%) in the moderate category. for the males, there were nine patients (30%) with estimated gfr values in the normal category, six (20%) in the mild category, and six (10%) in the moderate category. after analyzing the frequency distribution of 30 patients with type 2 dm, within an age range of 31-82 years, it was observed that the age group of 60-69 years was the most dominant, comprising 13 patients (43.4%). among these patients, 13 had estimated gfr values in the normal category, three (10.0%) in the mild category, and five (16.7%) had moderate gfr values. among the 30 patients with type 2 dm, the analysis revealed that the majority had a long history of having type 2 dm for 6-10 years. seventeen patients (56.6%) had estimated gfr values in the normal category, seven (23.4%) in the mild category, and five (16.6%) in the moderate category. pearson correlation test results the results of the pearson correlation analysis are tabulated in table 5. the pearson correlation between blood glucose levels and creatinine levels is of a negative value (r =-0.730), indicating an inversely linear relationship. however, the correlation between blood glucose levels and the estimated gfr values is 0.044, which is close to 0, suggesting no linear relationship. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 32] [healthcare in low-resource settings 2024;12:11790] table 3. frequency distribution of glomelurus filtration rate in type 2 diabetes mellitus patients. estimation of gfr in type 2 dm patients (ml/min/1.73m2) variable normal mild moderate severe chronic mean n % n % n % n % n % estimation of gfr in type 2 15 50.0 9 30.0 6 20.0 0 0 0 0 84.971 diabetes mellitus (ml/min/1.73m2) gfr, glomelurus filtration rate. table 4. frequency distribution of glomelurus filtration rate in type 2 diabetes mellitus patients based on gender, age, and duration of dm diagnosis. estimation of glomelurus filtration rate in type 2 diabetes mellitus patients based on gender (ml/min/1.73m2) normal mild moderate severe chronic frequency n % n % n % n % n % n % gender male 6 20 3 10 0 0 0 0 0 0 9 30 female 9 30 6 20 6 20 0 0 0 0 21 70 total 15 50 9 30 6 20 0 0 0 0 30 100 age 30-39 years 2 6.7 0 0 0 0 0 0 0 0 2 6.7 40-49 years 3 10.0 1 3.3 0 0 0 0 0 0 4 13.3 50-59 years 4 13.3 2 6.7 0 0 0 0 0 0 6 20.0 60-69 years 3 10.0 5 16.7 5 16.7 0 0 0 0 13 43.4 70-82 years 3 10.0 1 3.3 1 3.3 0 0 0 0 5 16.6 total 15 50.0 9 30.0 6 20.0 0 0 0 0 30 100 duration of diabetes mellitus 0-5 years 3 10 2 6.7 0 0 0 0 0 0 5 16.7 6-10 years 7 23.4 5 16.6 5 16.6 0 0 0 0 17 56.6 >10 years 5 16.6 2 6.7 1 3.4 0 0 0 0 8 26.7 total 15 50.0 9 30.0 6 20.0 0 0 0 0 30 100 table 5. the pearson correlation test results. fasting glucose level creatinine level glomelurus filtration rate fasting glucose level pearson correlation (r) 1 0.073 0.044 sig. (2-tailed) 0.703 0.819 n 30 30 30 creatinine level pearson correlation (r) -0.073 1 -0.863 sig. (2-tailed) 0.703 0.000 n 30 30 30 glomelurus filtration rate pearson correlation (r) 0.044 -0.863 1 sig. (2-tailed) 0.819 0.000 n 30 30 30 non -co mmerc ial us e o nly discussion among the 30 respondents with type 2 dm, more than half of them (60.0%) exhibited normal creatinine levels. among the remaining respondents, 33.3% showed high creatinine levels, and 6.7% exhibited low creatinine levels. these results align with a study conducted by dedi in 2020 on 174 type 2 dm patients, which found high creatinine levels in 40.2% of cases, normal creatinine levels in 44.2% of cases, and low creatinine levels in 15.5% of cases. another study by kurniawan reported that 55 type 2 dm patients had high creatinine levels in 83.6% of cases and normal creatinine levels in 16.4% of cases.18,19 in this study, several cases of high glucose levels were followed by high creatinine values. in patients with type 2 diabetes mellitus, high glucose levels can damage the kidney filters over time, affecting kidney function and increasing blood creatinine levels. several factors can lead to normal creatinine levels in type 2 dm patients in this study. one such factor is age. the study’s age range was 31-82 years, with normal creatinine levels in 18 people (60.0%), most notably in the age range of 60-69 years. this indicates that the respondents’ kidney function was still healthy and undamaged. normal creatinine levels are generally maintained at a constant rate, and levels above the normal range indicate impaired kidney function.20 other factors that affect creatinine levels include blood glucose levels and the duration of type 2 dm. elevated blood glucose levels weaken and make the blood vessel walls more brittle, leading to blockages in small blood vessels, resulting in microvascular complications such as nephropathy. additionally, based on the estimated gfr value in type 2 dm patients, there were six individuals in the moderately reduced kidney function category, nine in the mildly decreased kidney function category, and 15 with normal kidney function. the estimation of gfr values in type 2 dm patients can be associated with several factors, including the duration of having type 2 dm, which is linked to the risk of dm complications. the main factor triggering complications in type 2 diabetes mellitus is not only the duration but also the severity of dm. however, when balanced with a healthy lifestyle, it can lead to a better quality of life that helps prevent complications.21 this aligns with the results of research that has shown that patients having type 2 dm for 6-10 years can have five individuals in the moderate category, indicating the beginning of kidney damage and decreased kidney function. in contrast, among other respondents with the same duration of dm, the average gfr was in the mild category, indicating indications of kidney damage but still maintaining normal kidney function. this illustrates that, among type 2 dm patients with a long duration of 6-10 years, many continue to lead a healthy lifestyle. another factor that can influence the gfr value is increased creatinine levels. creatinine and gfr values are inversely proportional, where higher serum creatinine values correspond to lower gfr values. the results of this study indicate that gfr values can be used to monitor the progression of type 2 dm, which has the potential to lead to kidney problems (diabetic nephropathy).22–24 bivariate analysis of the measured creatinine levels, estimated gfr, and blood glucose levels using pearson correlation tests revealed that there was no significant relationship between creatinine levels (sig. 0.703, p>0.05) and estimated gfr (sig. 0.819, p>0.05) with blood glucose levels among the 30 type 2 dm patients. conclusions this study indicates that high blood glucose levels do not necessarily correspond to high creatinine levels or low estimated gfr values. it also suggests that not all type 2 dm individuals with elevated blood glucose will experience kidney impairment. to strengthen this conclusion, additional research should incorporate hba1c values, which serve as an indicator of well-managed blood sugar levels in type 2 dm patients. references 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 2. bestari il. characteristics of patients with type 2 diabetes mellitus at surabaya haji general hospital. indon j public health 2020;15:286-94. 3. akoit ee, efendi f, dewi ys, et al. impact of diabetes selfmanagement education in middle-aged patients with type 2 diabetes mellitus: a systematic review. gac med caracas 2022;130:s1183-95. 4. hadisuyatmana s, malik g, efendi f, reisenhofer s, boyd j. the experiences and barriers in addressing type 2 diabetes mellitus-associated erectile dysfunction: a mixed method systematic review. syst rev 2023;12:138. 5. american diabetes association. 2. classification and diagnosis of diabetes: standards of medical care in diabetes 2021. diabetes care 2021;44:s15-33. 6. susilo h, alsagaff my, pikir bs, et al. type ii diabetes as the main risk factor of arterial stiffness in chronic kidney disease patients. acm int conf proceeding ser. 2022;210-4. 7. international diabetes federation. idf diabetes atlas 2021. 10th ed. international diabetes federation. 2021. 30-39 p. 8. fadli, nursalam, uly n, iskandar r, amir h, ahmad as. factors associated with self-management behaviour among type 2 diabetes mellitus patients. gaceta medica de caracas 2023;131:287-92. 9. saputro sa, pattanateepapon a, pattanaprateep o, aekplakorn w, mckay gj, attia j, et al. external validation of prognostic models for chronic kidney disease among type 2 diabetes. j nephrol 2022;35:1637-53. 10. muhammad haskani nh, goh hp, wee dvt, et al. medication knowledge and adherence in type 2 diabetes mellitus patients in brunei darussalam: a pioneer study in brunei darussalam. int j environ res public health 2022;19:7470. 11. papatheodorou k, banach m, bekiari e, rizzo m, edmonds m. complications of diabetes 2017. j diabetes res 2018;2018:3086167. 12. lim akh. diabetic nephropathy complications and treatment. int j nephrol renovasc dis 2014;7:361-81. 13. putra ig, soebroto h, sembiring ye, tjempakasari a. patency durability of non-tunneled hemodialysis’ catheter in adult patients with chronic kidney disease stadium 5 with diabetes mellitus and non-diabetes mellitus. ital j vasc endovasc surg 2023;30:15-9. 14. vallon v, komers r. pathophysiology of the diabetic kidney. compr physiol 2011;1:1175-232. 15. shahbaz h, gupta m. creatinine clearance. statpearls. 2023. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11790] [page 33] non -co mmerc ial us e o nly 16. tarwater k. estimated glomerular filtration rate explained. mo med 2011;108:29-32. 17. botev r, mallié j-p, couchoud c, et al. estimating glomerular filtration rate: cockcroft-gault and modification of diet in renal disease formulas compared to renal inulin clearance. clin j am soc nephrol 2009;4:899-906. 18. dedi eh. gambaran kadar ureum dan kreatinin pada penderita diabetes melitus tipe 2. poltekkes tanjungkarang; 2020. 19. kurniawan mr, kusrini e. ureum and creatinine health study in patients diabetes mellitus. indones j med lab sci technol 2020;2:85-92. 20. levey as, titan sm, powe nr, et al. kidney disease, race, and gfr estimation. clin j am soc nephrol 2020;15:120312. 21. aini, mentari in. profil lama diagnosa diabetes melitus terhadap nilai estimasi laju filtrasi glomelurus (lfg). j penelit dan kaji ilm kesehat politek medica farma husada mataram. 2019;5:86-90. 22. dabla pk. renal function in diabetic nephropathy. world j diabetes 2010;1:48-56. 23. musa a, azizahwati. hubungan antara uacr dengan egfr sebagai penand gangguan fungsi ginjal pada pasien diabetes melitus tipe 2 rsupn dr. cipto mangunkusumo. universitas indonesia; 2012. 24. fontela pc, winkelmann er. estimated glomerular filtration rate in patients with type 2 diabetes mellitus. rev assoc med bras 2014;60:531-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 34] [healthcare in low-resource settings 2024;12:11790] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11180 the correlation between family role and anemia prevention in pregnancy mira triharini,1 ni ketut alit armini,2 sekar ayu pitaloka3 1advance nursing department, faculty of nursing universitas airlangga, surabaya, indonesia; 2basic nursing department, faculty of nursing universitas airlangga, surabaya, indonesia; 3nursing profession, faculty of nursing universitas airlangga, surabaya, indonesia abstract introduction: it is important to reduce the high incidence of anemia in pregnancy globally. pregnant women need the support of their families to face any difficulties in order to prevent anemia. design and methods: this study aims to determine the correlation between family role and anemia prevention in pregnancy. this cross-sectional study was conducted in august 2021 among 60 pregnant women who went for check-ups at two primary healthcare centers in surabaya, indonesia, and received iron supplements. additionally, it was discovered that family role and anemia prevention in pregnancy were evaluated using questionnaires. result: the spearman test was used as a test for significance and the results showed that there was a correlation between family role and anemia prevention in pregnancy (r = 0.318; p = 0.013). also, it was found that informational, emotional, and affirmational support, as well as having a role model were significantly correlated with anemia prevention at (r = 0.311; p = 0.015), (r = 0.265; p = 0.041), (r = 0.400; p = 0.002), and (r = 0.353; p = 0.006), respectively. conclusions: there was a relationship between family role and anemia prevention in pregnancy, as well as adequate nutrition, adherence to iron supplements, and prevention of worms. therefore, there is the need for health promotion to the families of pregnant women in order to increase the understanding of anemia prevention in pregnancy. introduction anemia is a major problem for pregnant women all over the world, which is mostly characterised by iron deficiency. furthermore, it is mostly associated with iron deficiency, which occurs when there is an insufficient balance of iron intake, storage, and loss from the body to support normal erythrocyte production.1 one of the leading causes of maternal morbidity and mortality is anemia during pregnancy.2 during pregnancy, mothers are considered anemic when their hemoglobin (hb) level is less than 11 g/dl.3 there is a high prevalence of anemia in a number of countries, specifically in pregnant women, which ranged between 20% to 50% based on previous report from who in 2017. meanwhile, the prevalence of anemia in indonesian pregnant women was 41.98%, where more than half of the mothers were anemic.4 there was a slightly lower mean birth weight in babies born to anemic mothers compared to those born to nonanemic mothers.5 subsequently, there is a relationship between anemia during pregnancy and poor maternal and child health, as well as an increased risk of maternal and perinatal mortality. the negative effects of anemia in mothers include fatigue, reduced work capacity, impaired immune function, an increased risk of heart disease, and death. several studies showed that anemia in pregnancy accounts for 23% of all indirect causes of maternal death in developing countries.6 according to the previous study conducted in karnataka, india by rajashree in 2015, there are multiple factors that contribute to the low birth weight (lbw) in babies, such as blood hemoglobin (hb) levels.7 furthermore, a 2016 study in india found that anemia in pregnant women was associated with low birth weight and perinatal mortality.8 anemia can be influenced by several factors, which may be both internal and external to the mother. several studies found that family factors have a significant impact on the prevention of anemia in pregnant women.9,10 however, prospective fathers play an important role in ensuring maternal health and a safe delivery. the involvement of husbands in health education should be recognized and addressed due to its potential benefits to maternal and child health. this has significant implications for health policy and practice since health systems and maternal health interventions must be modified to ensure appropriate and effective inclusion of prospective fathers.10 the social support of the husband is the most important factor that affects the occurrence of anxiety in pregnant women from the time of conception until delivery. pregnant women require good service, transportation, funds or consulting fees, and accompaniment during consultations with doctors or midwives. husbands should also be aware of pregnancy complications and must pay attention to the needs of their pregnant wife.11 there is no study concerning the relationship between family role and methods of anemia prevention, such as nutritional adequacy, adherence to iron supplements, and intestinal worm prevention. therefore, this study aims to determine the relationship between family role and anemia prevention during pregnancy. design and methods the study was conducted using a descriptive cross-sectional approach in august 2021. the respondents were pregnant women significance for public health the role of the family is an important factor that can increase the willingness of pregnant women to prevent anemia. this can be developed through health education delivered to families and pregnant women. this study aims to explain the relationship between the role of the family and the prevention of anemia in pregnancy. article [page 70] [healthcare in low-resource settings 2023; 11(s1):11180] non -co mmerc ial us e o nly who attended antenatal care at two primary healthcare centres (puskesmas) in surabaya, east java, indonesia. the sample population included 60 women based on the inclusion criteria, which included those who received iron supplementation from primary healthcare centres. meanwhile, the exclusion criteria included pregnant women with complications or severe concomitant diseases that required specific medical treatment. the data was collected using a questionnaire on sociodemographic characteristics, family roles, and anemia prevention. the questions on sociodemographic characteristics were based on age, gestation age, parity, education, and income. however, the family role was focused on four areas, which included informational support, emotional support, affirmational support, and possession of a role model. there were eight questions on the questionnaire and each item was converted into a likert scale with the following options: always, frequently, occasionally, rarely, and never. the total scores for this section ranged from 0 to 32, with higher scores indicating higher levels of family role. the validity of the questionnaire in this study had a cronbach’s α of 0.951. the questionnaire on anemia prevention was divided into three sections, which included nutritional adequacy and adherence to iron supplementation with five questions each, as well as intestinal worm prevention with six questions. also, each item was converted into a likert scale with the following options: always, frequently, occasionally, rarely, and never. the correlations between family roles and anemia prevention were determined using spearman’s rho values. descriptive statistics such as frequencies, percentages, means, and standard deviations were used to describe sociodemographic characteristics, family roles, and anemia prevention. in all statistical analyses using spss, a p-value < 0.05 was considered significant. results and discussions table 1 showed that most women in the population (n = 43, 71.7%) were aged between 26-35 years. also, most respondents (n = 27, 45%) were between their second and third trimester, while others (n = 2, 33.3%) were multigravida. the majority of the women (n = 42, 70%) have completed secondary education, while others (n = 50, 83.3%) were from families with incomes below rp 4,300,000, as shown in table 1. the results in table 2 showed that the highest score among the eight items in the questionnaire was ‘my husband promotes me to always eat nutritious food’ at a significance of 3.82 ± 0.43), while the lowest score was observed in ‘my husband compliments me if i take iron supplements regularly’ at a significance of 2.98 ± 1.16. there was a significant correlation between anemia prevention in pregnancy and informational support, emotional support, affirmational support, and role model at significance values of (r = 0.311; p = 0.015), (r = 0.265; p = 0.041), (r = 0.400; p = 0.002), and (r = 0.353; p = 0.006), respectively, as shown in table 3. as shown in table 4, of the five nutritional adequacy questions, ‘eat meat, chicken liver, or eggs every day’, received the lowest score (2.85±0.99). of the five items on iron supplementation adherence, ‘i take iron supplements before going to bed’, received the lowest score (2.43±1.49), and of the six items on worm prevention, ‘when i leave the house, i wear footwear.’ article table 1. sociodemographic characteristics in participants (n=60). indicator category n (%) age < 25 years 9 (15.0) 26-35years 43 (71.7) >35 years 8 (13.3) gestation age first trimester (1-13 weeks) 6 (10) second trimester (14-27 weeks) 27 (45) third trimester (28-40 weeks) 27 (45) parity 1 15 (25) 2 20 (33.3) 3 18 (30.0) 4 7 (11.7) education elementary 7(11.7) secondary 42 (70) university 11 (18.3) income < rp 4,300,000 50 (83.3) > rp 4,300,000 10 (16.7) table 2. item analysis of family role. parameter questions mean (sd) percentage of women choosing strongly agree informational support my husband reminds me to take iron supplements regularly 3.27 (1.01) 32 (53.3) my husband reminds me to eat nutritious food 3.77 (0.43) 46 (76.7) emotional support my husband takes the time to listen to my health complaints 3.67 (0.60) 44 (73.3) my husband encourages me to always eat nutritious food 3.82 (0.43) 50 (83.3) affirmational support my husband compliments me if i want to eat nutritious food regularly 3.12 (0.99) 28(46.7) my husband compliments me if i take iron supplements regularly 2.98 (1.16) 26 (43.3) role model my husband gives an example of healthy living by eating nutritious food 3.53 (0.75) 40 (66.7) my husband gives an example of healthy living by always maintaining personal and environmental hygiene 3.65 (0.61) 43 (71.7) *range 1–4; sd: standard deviation. table 3. correlation matrix among the parameters of family role and the prevention of anemia during pregnancy. variable mean sd min-max r p informational support 7.03 1.15 4-8 0.311 0.015 emotional support 7.48 0.81 5-8 0.265 0.041 affirmational support 6.10 2.06 1-8 0.400 0.002 role model 7.18 1.21 4-8 0.353 0.006 anemia prevention 66.78 15.49 44-92 [healthcare in low-resource settings 2023; 11(s1):11180] [page 71] non -co mmerc ial us e o nly received the lowest score (3.25±1.37). (table 4). the mean score for the role of family was 27.80, and the mean score for anemia prevention was 66.78. the role of the family (r = 0.318; p = 0.013) was found to be significantly related to the prevention of anemia during pregnancy, as shown in table 5. the role of the family has a strong influence on the behaviour of pregnant women in preventing anemia. the promotion of health practices by health workers should be directed toward families in order to increase their role in providing support for pregnant women. this study found that the role of family in the prevention of anemia during pregnancy is significantly related to informational support, emotional support, affirmational support, and tangible support. the highest score based on family role was observed when husband promoted their pregnant wives to always eat nutritious food. this demonstrated that the family was aware of the importance of eating nutritious foods while pregnant. adequate maternal nutrition is important for the progression of a normal pregnancy, optimal foetal development, and normal foetal birth weight. therefore, a proper diet should be consumed during pregnancy in order to provide the mother and child with the necessary amount of energy as well as all of the essential nutrients such as protein, fat, carbohydrates, vitamins, and minerals.12 enough energy is required for optimal growth during pregnancy. protein is also crucial because it serves as the structural foundation for all new cells and tissues in the mother and foetus. meanwhile, vitamins and minerals participate in biochemical reactions that result in the formation of amino acids, which are then used to create new proteins and maintain the structural and functional properties of cells.13 iron supplementation is widely used to prevent iron deficiency and anemia in at-risk populations (e.g., pregnant women and young children), as well as to improve the haemoglobin status of people who already have anemia. for oral supplementation, four different iron preparations are commonly used: ferrous sulphate, ferrous gluconate, and ferrous fumarate. iron supplementation may benefit populations at high risk of anemia, for example, supplementation during pregnancy may reduce the risk of maternal anemia and iron deficiency, however, the benefits to the baby, such as a lower risk of being born prematurely or with low birth weight, are less clear.14 the cdc recommends that all pregnant women start taking 30 mg of iron per day at their first prenatal visit, while the world health organization recommends 60 mg of iron supplements per day for all pregnant women.15 the lowest score based on family role was observed when the husband complimented the pregnant mother concerning the regular intake of iron supplements, which could be due to his lack of understanding on the importance of taking iron supplements. several studies demonstrated the importance of iron supplements in pregnant women with anemia, which is caused by a dramatically increased need for iron in pregnancy to cover the additional needs of the mother (expansion of erythrocyte volume) and the foetus (skeleton formation, cns, and foetal erythrocyte mass). in cases of mild ida and iron deficiency without anemia, oral iron administration is the recommended first line of treatment in pregnancy.16 however, it was difficult for pregnant women to find the right balance when it comes to iron intake since too little or too much iron can be harmful. high doses of iron supplements can cause adverse effects in the gastrointestinal tract (stomach and intestine), such as constipation, nausea, vomiting, and diarrhea, even though the body can store extra iron. additionally, they can cause stomach lining damage when high doses of iron are taken on an empty stomach. it is widely assumed that oral iron supplements cause unpleasant gi side effects, which are somewhat similar to the physiological changes in pregnancy. however, some pregnant women attribute these complications to iron compounds and discontinue its use.17 many pregnant women do not take their iron supplements on a regular basis due to the side effects and difficulties that they women experience. subsequently, this has led to a high incidence of anemia in pregnant women around the world. furthermore, emotional support from husbands is essential for pregnant women in order to promote them to take iron supplements on a regular basis. the side effects that are feared by pregnant women include nausea and vomiting. they think it will be difficult for them. in addition to the discomfort caused by nausea, vomiting will also cause the food they have eaten to be wasted, so that the baby’s nutrition will be reduced. the husband’s role in preventing anemia includes providing information, emotional support, affirmational support, and serving as a role model. the prevention of anaemia in pregnancy through informational support involves the provision of the needed information to pregnant women in order to avoid the condition, such as eating an iron-rich diet, taking iron supplements on a regular basis, and avoiding intestinal worms. the addition of an iron-containing substance to a food product’s recipe, either as an isolated compound (for example, iron salts or chelates) or as an iron-rich ingredient, is referred to as fortification (for example, meat or its derivatives). because the dosage used in iron fortification is lower than in supplementation, the body’s iron level rises much more slowly, however, fortification may be a safer intervention.17 ferritin is a protein that can absorb large amounts of iron and can be used by plants and animals as a natural reservoir for iron. phytoferritin is found in protein-rich foods such as legumes (beans, lentils, etc.).18 iron is found in two forms in foods: heme and non-heme. heme iron is primarily obtained from the consumption of meat, poultry, and fish, while non-heme is obtained from cereals, beans, nuts, fruits, and vegetables.19 preventing worm infection is also important in preventing anemia in pregnant women. according to study, there is a link between worm infections and anemia. most hookworm loads result in extracorporeal iron loss, and interventions to treat hookworm infections have resulted in significant haemoglobin improvements. article table 4. lowest score in item analysis of anemia prevention. parameters items mean (sd) nutritional adequacy eat meat or chicken liver or eggs every day 2.85 (0.99) adherence to iron supplementation i always take iron supplements at night before going to bed 2.43 (1.49) prevention of worms always use footwear when going out of the house 3.25 (1.37) table 5. correlation matrix among the role of family and anemia prevention variable. mean sd min-max r p family roles 27.8 3.98 18-32 0.318 0.013 anemia prevention 66.78 15.49 44-92 [page 72] [healthcare in low-resource settings 2023; 11(s1):11180] non -co mmerc ial us e o nly iron deficiency anemia is a common cause of long-term morbidity due to chronic intestinal blood loss caused by hookworm infection. blood loss is caused primarily by the parasite’s release of coagulase, which causes persistent blood loss in the stool, rather than the parasite’s actual ingestion of blood.20,21 one of the factors that contribute to intestinal worm infection in pregnant women is their lack of knowledge about the cleanliness of the food they consume. for example, how to clean, wash, and cook food. the greater pregnant women’s awareness of the importance of hygiene, the lower their risk of contracting intestinal worms.22 pregnant women who want to avoid anemia need their husbands’ help. emotional support, affirmational support, and role model support are all forms of assistance that can be provided. in terms of emotional support from the husband, this can be provided by listening to the mother’s health complaints during pregnancy. pallor, shortness of breath, palpitations, hair loss, headache, vertigo, leg cramps, cold intolerance, dizziness, and irritability are all symptoms of iron deficiency anemia in pregnant women. ida can also cause postpartum hypothermia, fatigue, poor concentration, decreased work capacity, decreased maternal milk production, and depletion of maternal iron stores.23 as a result, emotional support from the husband can be beneficial because he can recognize the warning signs if his pregnant wife exhibits any of the above-mentioned symptoms. affirmational support can be provided by the husband by expressing gratitude when their pregnant wife consumes nutritious foods, takes iron supplements, and maintains personal hygiene. appreciation is important because it boosts the mother’s confidence in her ability to accomplish difficult tasks. good self-efficacy increases the mother’s ability to practice good self-care during pregnancy, as a result, the mother’s pregnancy process can proceed smoothly until delivery.24 the husband can serve as a role model by demonstrating good behaviour such as eating habits and personal hygiene. pregnant women will mimic the positive behaviour of their husbands. in addition, the husband can consume nutritious food on a daily basis and maintain good personal and environmental hygiene. this will be able to motivate the mother to imitate her husband’s good habits. the best way to avoid pregnancy anemia is to eat well, take iron supplements, and avoid worms by practicing good personal and environmental hygiene. the results on nutritional adequacy showed that the habit of eating meat, chicken liver, or eggs every day produced the lowest mean score. this can be influenced by a lack of knowledge about iron-rich foods, as well as a low income. according to the data, most of the respondents had an income less than rp 4,300,000 and completed secondary school. pregnant women who take iron supplements at night before going to bed had the lowest mean score on the iron supplement adherence questionnaire, which could be due to a lack of knowledge about how to drink properly. the purpose of drinking at night was to reduce the side effects. according to previous studies, the most common side effects of iron supplements are problems with the gastrointestinal tract (stomach and intestines), such as constipation, nausea, vomiting, and diarrhea. the lowest score on the questionnaire about preventing intestinal worms was on ‘if i go out of the house, i use footwear.’ this can be caused by pregnant women who are still accustomed to their pre-gestation behaviours. personal hygiene had a close relationship with intestinal infections caused by worms, and was also important in preventing the transmission of worms that could cause anemia in pregnant women.22 evidence suggests that the severity of hookworm infection is related to lower hemoglobin levels in pregnant women. chronic intestinal blood loss caused by hookworm infection results in iron deficiency anemia. intestinal parasitic infection in pregnant women is common and has a negative impact on hematological profiles. some hematological profiles of pregnant women infected with intestinal parasites deteriorated, leading to anemia. therefore, it is important to deworm before pregnancy, as well as to maintain good personal and environmental hygiene in order to reduce maternal anemia during pregnancy.25 conclusions anemia prevention in pregnancy was associated with informational support, emotional support, affirmational support, and the presence of a role model. also, there is the need for the development of health education in order to raise awareness of the role of families in anemia prevention in pregnant women. families must continue to educate themselves about anemia in pregnancy to provide the necessary support for pregnant women. pregnant women can prevent anemia through diet, adherence to iron supplements, and maintaining good personal hygiene. article correspondence: mira triharini, faculty of nursing, universitas airlangga, jl. ir soekarno, surabaya, east java 60115, indonesia tel.:+62315913754, fax +62315913257. e-mail: mira-t@fkp.unair.ac.id key words: anemia prevention; family role; pregnant women; maternal health. acknowledgment: the author would like to thank the faculty of nursing, universitas airlangga, surabaya, indonesia for their kind support and motivation during this study. contributions: all authors contributed equally to this study. conflict of interests: the authors declare no conflict of interest. funding: this study was financially supported by ministry of higher education. clinical trials: this study has been approved by the health research ethics committee of faculty of nursing, universitas airlangga, surabaya. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 21 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11180 doi:10.4081/hls.2023.11180 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11180] [page 73] non -co mmerc ial us e o nly references 1. miller jl. iron deficiency anemia: a common and curable disease. cold spring harb perspect med 2013;3:1–13. 2. daru j, zamora j, fernández-félix bm, et al. risk of maternal mortality in women with severe anaemia during pregnancy and post partum: a multilevel analysis. lancet glob heal 2018;6:e548–54. 3. who. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. geneva, switz world heal organ 2011;1–6. 4. who. prevalence of anaemia in women of reproductive age (aged 15-49) (%). glob heal obs 2021;23:2021. 5. kumar kj, asha n, murthy ds, et al. maternal anemia in various trimesters and its effect on newborn weight and maturity: an observational study. int j prev med 2013;4:193– 9. 6. black re, victora cg, walker sp, et al. maternal and child undernutrition and overweight in low-income and middleincome countries. lancet 2013;382:427–51. 7. rajashree k, prashanth h, revathy r. study on the factors associated with low birth weight among newborns delivered in a tertiary-care hospital, shimoga, karnataka. int j med sci public heal 2015;4:1287. 8. kaur m, chauhan a, manzar md, et al. maternal anaemia and neonatal outcome: a prospective study on urban pregnant women. j clin diagn res 2015;9:qc04. 9. wiradnyani laa, khusun h, achadi el, et al. role of family support and women’s knowledge on pregnancy-related risks in adherence to maternal iron-folic acid supplementation in indonesia. public health nutr 2016;19:2818–28. 10. triharini m, nursalam, sulistyono a, et al. adherence to iron supplementation amongst pregnant mothers in surabaya, indonesia: perceived benefits, barriers and family support. int j nurs sci 201;5:243. 11. diani lpp, susilawati lkpa. pengaruh dukungan suami terhadap istri yang mengalami kecemasan pada kehamilan trimester ketiga di kabupaten gianyar. [the effect of husband’s support on wives experiencing anxiety in the third trimester of pregnancy in gianyar regency.] j psikol udayana 2013;1:1–11. 12. maqbool m, dar m, gani i, et al. maternal health and nutrition in pregnancy : an insight. world j pharm pharm sci 2019;8:450–9. 13. elango r, ball ro. protein and amino acid requirements during pregnancy. adv nutr [internet] 2016;7:839s. 14. lopes k da s, takemoto y, garcia-casal mn, et al. nutrition�specific interventions for preventing and controlling anaemia throughout the life cycle: an overview of systematic reviews. cochrane database syst rev 2018;2018:1–14. 15. achebe mm, gafter-gvili a. how i treat anemia in pregnancy: iron, cobalamin, and folate. blood 2017;129:940-949. 16. jafarbegloo e, tehran ha, tehrani td. gastrointestinal complications of ferrous sulfate in pregnant women: a randomized double-blind placebo-controlled trial. iran red crescent med j 2015;17:15001. 17. prentice am, mendoza ya, pereira d, et al. dietary strategies for improving iron status: balancing safety and efficacy. nutr rev 2017;75:49–60. 18. abbaspour n, hurrell r, kelishadi r. review on iron and its importance for human health. j res med sci 2014;19:164. 19. lubis r, panggabean m, yulfi h. pengaruh tingkat pengetahuan dan sikap ibu terhadap penyakit kecacingan pada balita. j kesehat lingkung indones. [the effect of mother’s knowledge level and attitude on worm disease in toddlers.] j indonesian environmental health 2018;17:39. 20. feleke be, feleke te. the effect of pregnancy in the hemoglobin concentration of pregnant women: a longitudinal study. j pregnancy 2020:2020:2789536. 21. mahadea d, adamczewska e, ratajczak ae, et al. iron deficiency anemia in inflammatory bowel diseases—a narrative review. nutrients 2021;13:4008. 22. mutalazimah m, mustikaningrum l. knowledge about intestinal worm infection and helminthiasis in pregnant women. electron j gen med 2020;17:1–5. 23. shaw jg, friedman jf. iron deficiency anemia: focus on infectious diseases in lesser developed countries. anemia 2011;2011:1–10. 24. sumiati s, nurhidayati e. relationship between family support and selfefficacy among pregnant women in yogyakarta. in masters program in public health, sebelas maret university november 2020 p. 1–141. accessed 2021 september 14. 25. demeke g, mengistu g, abebaw a, et al. effects of intestinal parasite infection on hematological profiles of pregnant women attending antenatal care at debre markos referral hospital, northwest ethiopia: institution based prospective cohort study. plos one 2021;16:1–13. article [page 74] [healthcare in low-resource settings 2023; 11(s1):11180] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12095 the effects of dietary compliance counseling on calorie consumption in type 2 diabetes mellitus setyoadi setyoadi,1,2 ferry efendi,1 joni haryanto,1 siti fatmawati,2 niko dima kristianingrum,2 tina handayani nasution,3 dina dewi sartika lestari ismail2 1faculty of nursing, universitas airlangga, surabaya; 2faculty of health sciences, universitas brawijaya, malang; 3nursing science program, faculty of medicine, universitas lambung mangkurat, banjarbaru, indonesia abstract type 2 diabetes mellitus (t2dm) requires dietary compliance to manage elevated blood glucose levels. in calorie counseling, a client and counselor have conversations about calorie consumption problems related to type 2 diabetes. the study aimed to evaluate how calorie counseling affected t2dm patients’ adherence to their diets. a quasi-experimental design was employed to randomly assign 40 t2dm patients to the intervention (n=20) or control (n=20) groups. food logs were gathered prior to and following counseling, and analysis was done using independent t-tests. the findings revealed a post-intervention mean discrepancy in calorie consumption of 132.08 kcal. the results of the t-test analysis, however, showed that there was no significant difference between the groups (p=0.26>0.05), suggesting that group-based calorie counseling had no appreciable impact on diabetes diet compliance. confounding variables like age, education, employment status, and family support could have impacted these results. it is advised that future studies consider how family support and demographic factors might improve diet compliance in t2dm patients. this method can lead to more effective interventions for this population and a more thorough understanding of the variables influencing dietary adherence. introduction diabetes is a pandemic health problem, with an estimated prevalence increasing from 425 million people in 2017 to 629 million in 2045, making it a burden for health, social, and economic costs.1 type 2 diabetes mellitus (t2dm) is a chronic disease associated with increased blood sugar levels that affects many adults due to lifestyle changes.2 diet is one of the important pillars in managing treatments. dietary management of t2dm is crucial for controlling blood glucose levels.3,4 successful diet management depends on t2dm patients’ belief in their ability to carry out life, and adherence is related to the patient’s motivation to recover.5 t2dm is a chronic disease that will be lived with for a lifetime, making it challenging for individuals to know the type, amount, and schedule of a proper diet in everyday life.6 wrong perceptions of t2dm patients about diets, such as consuming small amounts, rarely eating fruit, lack of information about diabetes, non-compliance with the t2dm diet due to a lack of understanding of how to choose the right food, and not knowing calorie needs, are common.7 medical nutritional therapy has been introduced to provide systematic guidelines based on evidence for controlling t2dm blood sugar levels.8 various method approaches, such as supportive education, diabetes education, family empowerment, and counseling, have been used in managing the diet of t2dm, especially in controlling calorie consumption to control blood sugar levels.9-12 dietary compliance through lifestyle changes is key in controlling the patient’s calorie consumption.13 counseling is an activity involving meetings and discussions between clients and counselors to solve problems.14 counselors provide support and encouragement to clients so that they gain confidence in solving the problems they are experiencing.15 research results found that out of 8 respondents (8.57%) who had a high level of compliance before counseling, this increased to 32 respondents (91.43%) after counseling.16 correspondence: setyoadi setyoadi, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: setyoadi@ub.ac.id key words: counselling; diet; diabetes; compliance. contributions: ss, fe, jh, ddsli, conceptualization; ss, fe, jh, sf, methodology, validation; ss, data curation; ss, jh, formal analysis; ss, tnh, visualization; fe, investigation; ss, fe, jh, writing-original draft. all the authors reviewed and edited the draft and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: ethical clearance received approval from the ethics team of the faculty of medicine, university of brawijaya no. 024/ec/kepk/s1-psik/2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained for anonymized patient information. received: 15 november 2023. accepted: 21 may 2024. early access: 4 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12095 doi:10.4081/hls.2024.12095 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 602] [healthcare in low-resource settings 2024;12:12095] non -co mmerc ial us e o nly research on counseling methods using a group dynamics approach is an important process for increasing efficacy and planning future treatments.17 calorie counseling employs the principles of group dynamics, which serve a therapeutic function. the process involves facilitating individuals to express their thoughts and feelings, fostering openness, mutual trust, and providing care and support to fellow counselees within the group.18 the counseling approach in research has predominantly employed an individual approach, typically conducted between the counselor and the counselee in a clinic or hospital room.19 the success of counseling hinges on fostering a strong relationship between the counselor and the t2dm patient, working as a team during the interaction process. numerous research findings indicate that counseling with an individual approach in hospitals yields positive outcomes, particularly in enhancing compliance with diabetes diets.20 for instance, a study conducted in hospital polyclinics involved nutritional counseling for t2dm patients three times at weekly intervals. the intervention, which explained the type, amount, and timing of meals, resulted in an increase in compliance from 43.4% to 73.7%.12 previous research utilizing individual counseling methods also demonstrated an improvement in dietary compliance among t2dm patients.21 however, these studies emphasized a hierarchical relationship between counselor and counselee, leading to reduced openness and individual expression. in this study, a structured group counseling process employing the principles of group dynamics across four stages over one month aims to provide an open and dynamic counseling approach perspective between health workers and t2dm patients. the objective of this research was to assess the impact of calorie counseling on diet compliance in t2dm patients. materials and methods research design this research employed a quasi-experimental design with pretest and post-test designs with control groups. the population in this study comprised t2dm patients who are members of the prolanis program (the prolanis program is a health program that helps people with chronic diseases get good and affordable care. it works by bringing together patients, health centers, and insurance, and it’s mainly run by local health services). the sample size in this study comprised 40 randomly selected participants divided into two groups: the intervention and control groups, each consisting of 20 respondents. the sample inclusion criteria consisted of individuals diagnosed with type 2 diabetes who possess the ability to read and write, are independent, express willingness to engage in all research procedures, and are covered by health insurance. materials used the tools used in the research include food modeling (examples of food ingredients resembling real food), leaflets (a medium for providing knowledge to diabetes patients regarding dm disease), flipcharts (a media serving as a guideline at the homes of diabetes patients regarding a mutually agreed-upon diet menu during counseling), height measuring instruments, body weight meters, calculators, calorie calculation sheets, and computers. the questionnaire employed in this study is a food record form designed to document food menus both before and after the intervention. the food record sheet comprises two sections: demographic data and columns for recording the consumed menu.22 demographic data include day/date, age, gender, weight, height, occupation, and education. the second section is a table that includes meal time, food name, processing method, household size, and food weight in grams. data for both preand post-intervention assessments were recorded three times each in the first week before the intervention and the sixth week, specifically twice on weekdays and once on weekends.23 data collection process data were collected in the first week through an explanation of the aims and objectives of the research, along with instructions on how to fill out the food record sheet provided to all respondents in both the control and intervention groups. respondents were then instructed to independently complete the food record sheet based on the food consumed during the three recording times. in the second week, the control group underwent counseling about the principles of a diabetes diet and received leaflets to take home for independent study. meanwhile, the counseling intervention group participated in four weekly meetings, each comprising four group dynamics process sessions.24 these sessions were as follows: i) formation stage: this session involved getting to know each other, explaining the goals of diet management, introducing the three principles of a diabetes diet (type, amount, schedule), and motivating participants to actively engage during the counseling process; ii) transition stage: the second session focused on breaking the ice within the group through icebreaking activities, explaining the stages during the counseling process, and assessing the respondents’ readiness to discuss; iii) activity implementation stage: the third session concentrated on identifying problems experienced by respondents, prioritizing these problems, and discussing each problem to find solutions agreed upon by the respondents; iv) termination stage: the fourth session involved discussing the obstacles experienced during dieting and revisiting discussions to find viable solutions. in the sixth week, all respondents in both the control and intervention groups were requested to independently complete the food record sheet. data analysis data analysis was conducted using the nutrisurvey computer program, which was employed to analyze the calorie content of food consumed by the respondents.25 the results of the calorie consumption analysis represent the mean of three recordings in kilocalorie units (kcal). to assess the impact of the counseling intervention on both the control and intervention groups, the independent t-test was utilized, with a significance level set at 95%. this statistical analysis aimed to determine any significant differences between the two groups. ethical considerations it is worth noting that this research underwent thorough examination and obtained approval from the health research ethics committee at the faculty of medicine, brawijaya university, malang, with the reference number 024/ec/kepk/s1-psik/2021. results based on the results presented in table 1, it is evident that the majority of respondents are females, comprising 85% of the total. the majority of respondents fall into the late elderly age group (5665 years). domestic work constitutes the primary occupation for the majority of respondents, comprising 60% of the total. additionally, the majority of respondents have received elementary school education as their highest level of education, account transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12095] [page 603] non -co mmerc ial us e o nly ing for 92.5% of the sample. the findings revealed that adherence to the calorie consumption diet among respondents in the intervention group significantly increased from 1005.91 to 1137.99 calories after implementing calorie counseling. this corresponds to a calorie consumption rise of 132.08 calories. in contrast, the calorie consumption in the control group remained close to normal at 1053.95 calories. the post-test results indicated an increase of 52.80 calories from the pre-test results (table 2). analysis revealed no significant difference in calorie consumption between the intervention and control groups, as evidenced by the independent samples t-test (alpha 0.26>0.05). therefore, it can be concluded that there is no significant disparity in calorie consumption between the intervention and control groups. discussion the findings indicated no significant difference between the intervention group and the control group regarding calorie consumption. this finding contrasts with the analysis of pre-test and post-test calorie consumption within each group, which suggested a significant difference. hence, the study concluded that calorie counseling impacts adherence to a calorie-consumption diet. however, factors such as knowledge, education level, occupation, and family support do not appear to influence adherence to this diet.26 the factor hindering respondents from adhering to a diet based on caloric needs is knowledge. a robust understanding of the dm diet is crucial in shaping adherence behavior. this study’s findings are corroborated by research indicating a relationship between knowledge and dietary adherence among individuals with diabetes.21 these results underscore the importance of enhancing knowledge to bolster dietary adherence in diabetes management.10 additionally, education level contributes to noncompliance with the diabetes diet. education is implicated in dietary non-compliance due to its role in shaping knowledge acquisition and information-seeking behavior. individuals with lower education levels may be less proactive in seeking information, unaware of the significance of adhering to a diet to maintain their health conditions.27 moreover, the education level of individuals with diabetes influences their ability to comprehend acquired knowledge, thus impacting their adherence to dietary recommendations based on caloric needs.28 age plays a crucial role in influencing an individual’s capacity to receive and assimilate information. research findings indicate a higher proportion of individuals in the late elderly age group (5665 years) compared to the early elderly age group. the aging process introduces physical changes that can impact knowledge retention, as alterations in hearing, vision, and the nervous system may hinder the elderly’s ability to acquire and retain information.29 however, it’s essential to recognize that knowledge acquisition isn’t solely contingent on age. additional factors such as education, environment, exercise, and life experiences also significantly influence an individual’s knowledge, even among the elderly.30-35 to enhance the knowledge of the elderly, it is imperative to tailor education and information initiatives to meet their specific needs.36 providing targeted and accessible educational resources can contribute to bridging the knowledge gap among the elderly population.37 most of the respondents in this study, totaling 22 individuals (55%), were engaged in household work. this outcome is primarily attributed to the predominance of female respondents, leading to the majority being homemakers. being a homemaker entails performing domestic duties, thereby not being formally employed. research by saghir et al. demonstrates that the majority of respondents, primarily homemakers, follow an inconsistent daily eating schedule.28 since homemaking activities are typically performed without fixed schedules and vary based on individual capabilities, meal timings greatly differ among subjects.38 this irregular eating pattern contributes to diabetes patients’ calorie consumption not meeting their dietary requirements. dietary adherence is influenced by several factors, including education, environmental and social modifications, as well as increased interaction between health professionals, and patients.39 modifying environmental factors can be facilitated through social support from family members.40 however, this study did not adopt a family approach as it solely focused on individuals with diabetes. previous research findings indicate that the determinants impacting dietary adherence among individuals with diabetes include patient motivation and family support.41 further research underscores the significant role of the family in achieving successful dietary adherence,42 emphasizing that family-related barriers can impede dietary compliance, particularly among individuals with limited dietary knowledge and awareness of diabetes.43 given the low level of knowledge and awareness regarding diet, the active involvement of family members can provide invaluable support in managing food for individuals with diabetes. conclusions counseling significantly improves dietary adherence in diabetes management through structured approaches and adequate resources. this study highlights the effectiveness of structured counseling, adherence to intervention durations, and group dynamics. including a wide age range of predominantly elderly respon transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=40). characteristics frequency percentage age 46-55 years 15 37.5 56-65 years 25 62.5 gender male 6 15 female 34 85 occupation domestic workers 24 60 entrepreneur 6 15 farmer 10 25 education bachelor 1 2.5 elementary school 37 92.5 no school 2 5 table 2. results of calorie diet compliance analysis. group pre-test post-test p average calorie average calorie consumption consumption intervention 1005.91 1137.99 0.26 control 1001.15 1053.95 [page 604] [healthcare in low-resource settings 2024;12:12095] non -co mmerc ial us e o nly dents strengthens the study. however, limitations include a brief post-intervention evaluation period and the exclusion of caregiver involvement, which may affect dietary adherence outcomes. future research should consider factors like family support and participant characteristics. references 1. magliano dj, boyko ej, balkau b, al e. idf diabetes atlas 2021. idf atlas 10th edition; 2021. available from: https://diabetesatlas.org/atlas/tenth-edition/ 2. kemenkes. infodatin: tetap produktif, cegah, dan atasi diabetes melitus. jakarta: pusat data dan informasi kementerian kesehatan ri; 2020. 3. perkumpulan endokrinologi indonesia. pedoman pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. global initiative for asthma 2021;46. 4. forouhi ng, misra a, mohan v, et al. dietary and nutritional approaches for prevention and management of type 2 diabetes. bmj 2018;361. 5. al-salmi n, cook p, d’souza ms. diet adherence among adults with type 2 diabetes mellitus: a concept analysis. oman med j 2022;37. 6. khazrai ym, defeudis g, pozzilli p. effect of diet on type 2 diabetes mellitus: a review. diabetes metab res rev 2014;30:24-33. 7. rimadania d, sari ea, mambang sari cw. motivation and compliance to type 2 diabetes mellitus diet. j community empower heal 2021;4:88. 8. evert ab, dennison m, gardner cd, et al. nutrition therapy for adults with diabetes or prediabetes: a consensus report. diabetes care 2019;42:731-54. 9. molavynejad s, miladinia m, jahangiri m. a randomized trial of comparing video telecare education vs. in-person education on dietary regimen compliance in patients with type 2 diabetes mellitus: a support for clinical telehealth providers. bmc endocr disord 2022;22:1-10. 10. han cy, chan cgb, lim sl, et al. diabetes-related nutrition knowledge and dietary adherence in patients with type 2 diabetes mellitus: a mixed-methods exploratory study. proc singapore healthc 2020;29:81-90. 11. shahabi n, kolivand m, salari n, abbasi p. the effect of telenursing training based on family-centered empowerment pattern on compliance with diet regimen in patients with diabetes mellitus type 2: a randomized clinical trial. bmc endocr disord 2022;22:1-8. 12. wagustina s, sri mulyani n, amani n. the effects of nutrition counseling on dietary compliance and blood sugar levels of type 2 diabetes mellitus patients. j appl nutr diet 2022;1:207. 13. leung awy, chan rsm, sea mmm, woo j. an overview of factors associated with adherence to lifestyle modification programs for weight management in adults. int j environ res public health 2017;14. 14. tanaka-matsumi j. counseling across cultures: a half-century assessment. j cross cult psychol 2022;53:957-75. 15. kalra s, jena bn, yeravdekar r. emotional and psychological needs of people with diabetes. indian j endocrinol metab 2018;22:696-704. 16. sucipto a, rosa em. efektifitas konseling dm dalam meningkatkan kepatuhan dan pengendalian gula darah pada pasien diabetes mellitus tipe 2. med respati 2019;9:9-20. 17. akshay malhotra jb. group therapy. statpearls publishing 2023;26. 18. marziliano a, pessin h, rosenfeld b, breitbart w. measuring cohesion and self-disclosure in psychotherapy groups for patients with advanced cancer: an analysis of the psychometric properties of the group therapy experience scale. int j group psychother 2018;68:407-27. 19. emeka pm, almunjem mf, rasool st, kamil n. evaluation of counseling practices and patient’s satisfaction offered by pharmacists for diabetics attending outpatient pharmacies in al ahsa. j patient exp 2020;7:338-45. 20. sugandh f, chandio m, raveena f, et al. advances in the management of diabetes mellitus: a focus on personalized medicine. cureus 2023;15. 21. nanda veir yursyidah sml. the effect of calories counseling on increase the knowledge , attitude, and behavior dietary to diabetes mellitus patient in primary health care. j community heal prev med 2021;1:9-15. 22. putz p, kogler b, bersenkowitsch i. reliability and validity of assessing energy and nutrient intake with the vienna food record: a cross-over randomised study. nutr j 2019;18:1-10. 23. dashti hs, scheer fajl, saxena r, garaulet m. timing of food intake: identifying contributing factors to design effective interventions. adv nutr 2019;10:606-20. 24. zisi v, gratsani s, leontari d, theodorakis y. combining individual and group counselling sessions in a smoking cessation intervention. psychology 2016;07:1766-84. 25. petroni ml, brodosi l, marchignoli f, et al. nutrition in patients with type 2 diabetes: present knowledge and remaining challenges. nutrients 2021;13:1-23. 26. baral j, karki kb, thapa p, et al. adherence to dietary recommendation and its associated factors among people with type 2 diabetes: a cross-sectional study in nepal. j diabetes res 2022;2022. 27. chawla sps, kaur s, bharti a, et al. impact of health education on knowledge, attitude, practices and glycemic control in type 2 diabetes mellitus. j fam med prim care 2019;6:169-70. 28. saghir am, alhariri a, daud f, et al. factors associated with adherence to diet and exercise among type 2 diabetes patients in hodeidah city,yemen diabetes management factors associated with adherence to diet and exercise among type 2 diabetes patients in hodeidah city,yemen. diabetes manag 2017;7:26471. 29. crespo ts, andrade jmo, lelis d de f, et al. adherence to medication, physical activity and diet among older people living with diabetes mellitus: correlation between cognitive function and health literacy. ibro reports 2020;9:132-7. 30. de lima filho bf, bessa npos, fernandes act, et al. knowledge levels among elderly people with diabetes mellitus concerning covid-19: an educational intervention via a teleservice. acta diabetol 2021;58:19-24. 31. camargo-plazas p, robertson m, alvarado b, et al. diabetes self-management education (dsme) for older persons in western countries: a scoping review. plos one 2023;18:1-37. 32. lövdén m, fratiglioni l, glymour mm, et al. education and cognitive functioning across the life span. psychol sci public interes 2020;21:6-41. 33. thongduang k, boonchieng w, chautrakarn s. the influence of family caregiver knowledge and behavior on elderly diabetic patients’ quality of life in northern thailand. int j environ res public heal 2022;19:10216. 34. samudera ws, efendi f, indarwati r. effect of community transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12095] [page 605] non -co mmerc ial us e o nly and peer support based healthy lifestyle program (cp-help) on self care behavior and fasting blood glucose in patient with type 2 diabetes mellitus. j diabetes metab disord 2021;20:193-9. 35. li tj, zhou j, ma jj, et al. what are the self-management experiences of the elderly with diabetes? a systematic review of qualitative research. world j clin cases 2022;10:1226-41. 36. mace ra, mattos mk, vranceanu am. older adults can use technology: why healthcare professionals must overcome ageism in digital health. transl behav med 2022;12:1102-5. 37. schirmer m, dalko k, stoevesandt d, et al. educational concepts of digital competence development for older adults—a scoping review. int j environ res public health 2023;20. 38. sami w, ansari t, butt ns, et al. effect of diet counseling on type 2 diabetes mellitus. int j sci technol res 2015;4:112-8. 39. mostafavi-darani f, zamani-alavijeh f, mahaki b, salahshouri a. exploring the barriers of adherence to dietary recommendations among patients with type 2 diabetes: a qualitative study in iran. nurs open 2020;7:1735-45. 40. anggi sa, rahayu s. kepatuhan diet pada pasien diabetes melitus tipe ii. j ilm keperawatan stikes hang tuah surbaya 2020;15:124-38. 41. nashrullah rf, ari n, wijaya sa, adyani a. relationship between motivation and type ii diabetes mellitus dietary compliance. magna medica berk ilm kedokt dan kesehat 2021;8:60. 42. fransiskus sl, seda s, lestari p, irwando e. family empowerment as nursing intervention for families with type 2 diabetes mellitus: a literature review. j kesehat komunitas indones 2023;3:267-80. 43. sami w, alabdulwahhab km, ab hamid mr, et al. dietary knowledge among adults with type 2 diabetes-kingdom of saudi arabia. int j environ res public health 2020;17:858. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 606] [healthcare in low-resource settings 2024;12:12095] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11865 relationship between peer group support with foot care behavior among diabetes mellitus patients: an observational study suyanto suyanto,1,2 tintin sukartini,2 ferry efendi,2 tafrihatul fauzi,1 moch. arifin noor,1 ahmad ikhlasul amal,1 indah sri wahyuningsih,1 dwi retno sulistyaningsih,1 furaida khasanah3 1faculty of nursing, universitas islam sultan agung, semarang; 2faculty of nursing, universitas airlangga, surabaya; 3ministry of health polytechnic yogyakarta, sleman, indonesia abstract peer group support plays a crucial role in enhancing diabetic foot care. however, diabetic patients often exhibit suboptimal foot care behavior due to a lack of support. this study aimed to explore the correlation between peer group support and foot care practices in individuals with diabetes mellitus. employing a cross-sectional design, the research focused on diabetes mellitus patients aged 4055 years, and those with less than five years of diabetes history. a purposive sampling technique was utilized to select 64 participants. the research variables encompassed demographic factors, peer group dynamics, and diabetic foot care behavior. these were assessed through a modified questionnaire, verified for validity and reliability. data analysis involved descriptive analysis and chi-square analysis. the findings revealed a prevalence of 79.7% for inadequate peer group support and 20.3% for robust support. in terms of diabetic foot care behavior, 56.3% exhibited poor practices, while only 17.2% demonstrated good foot care behavior. all variables displayed significance concerning the dependent variable, with a p-value < 0.003. this underscores the positive impact of peer group support on improving foot care behavior in diabetes mellitus patients. this study highlights the need for further research to delve into the effects of educational interventions and family involvement in enhancing diabetic foot care behavior. introduction diabetic foot complications represent a significant challenge in diabetes mellitus.1,2 peer group support plays a crucial role in enhancing foot care behavior among individuals with diabetes. understanding proper foot care is pivotal in shaping positive attitudes and preventing early diabetic foot complications.3–6 patients require not only knowledge but also motivation, and the support of a peer group to effectively care for their feet and mitigate the risk of complications.7,8 unfortunately, the current trend reveals a diminishing level of peer group support for foot care, possibly influenced by reduced interactions due to efforts aimed at minimizing disease risks.9–11 the prevalence of diabetes mellitus in central java was recorded at 13.4% in 2019. a preliminary study conducted at the public health center revealed that, at a minimum, 64 patients were diagnosed with diabetes mellitus between january and june of 2021.12 in semarang, the statistics on regular foot care among diabetic patients are concerning. only 58% of these patients adhered to a consistent foot care routine. additionally, 55% did not use proper footwear, 55% applied moisturizer only once a month, and merely 39% engaged in foot washing on a weekly basis. these findings underscore the need for increased awareness and interventions to improve diabetic foot care practices in the region.13 foot care behavior can be significantly enhanced with the support of family or peers.14 peer group assistance in treatment has been shown to improve treatment adherence, side-effect management, and the implementation of foot care practices, fostering a positive attitude in preventing diabetic foot ulcers.15 the influence of peer support is also evident in the increased knowledge observed after peer-led education.16 empowering individuals with diabetes mellitus necessitate the active involvement of patients, correspondence: suyanto suyanto, faculty of nursing, universitas islam sultan agung, semarang, indonesia. e-mail: suyanto-2020@fkp.unair.ac.id key words: diabetes mellitus, foot care, peer group support. contributions: ss, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ts, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; fe, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; tf, man, methodology, visualization, writing – review and editing; aia, fk, resources, investigation, and writing – review and editing; isw, formal analysis, validation, writing – review and editing; drs, resources, supervision, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas islam sultan agung, based on ethical certificate no. 685/a.1-s1/fik-sa/x/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 23 september 2023. accepted: 11 december 2023. early access: 26 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11865 doi:10.4081/hls.2024.11865 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 156] [healthcare in low-resource settings 2024;12:11865] non -co mmerc ial us e o nly their families, and peers.17 peers can serve as educational targets, motivating other members to adopt healthier behaviors. beyond mental support and motivation, peers can offer tangible assistance, providing tools for foot care.18 this research aimed to explore the correlation of peer group support with diabetic foot care behavior among individuals with diabetes mellitus. materials and methods study design the research employed an observational study design, specifically utilizing a cross-sectional approach. this methodology was chosen to analyze the relationship between peer group support and foot care behavior in patients with diabetes mellitus. study participants the sample size calculated for a population proportion with a specified relative precision, indicated that a minimum of 51 respondents was required for a confidence level of 95% and a relative precision of 6%.19 however, in this study, a total of 64 respondents were included. the sampling technique employed was nonprobability sampling, specifically using a purposive sampling method. the study’s sampling criteria were defined based on individuals diagnosed with diabetes mellitus, aged between 40-55 years, encompassing both male and female genders, and with a duration of diabetes mellitus less than 5 years. variable, instrument and data collection the independent variables in this study consist of demographic factors such as age, gender, education, occupation, religion, economic status, and marital status, as well as peer group dynamics. the dependent variable focuses on diabetic foot care behavior. the research instruments utilized include the functions of diabetes peer support group scale (f-dpsg) for assessing peer group support, which comprises four subscales: enhancing self-care practice, obtaining knowledge and skills, psychological support, and collective identification. for evaluating foot care, the study employs the nottingham assessment of functional footcare revised 2015 (naff), consisting of six indicators: foot assessment, footwear, foot cleanliness, preventing foot injuries, toenails, and callus/corn treatment, and wound care/wound management. a 4-point likert scale was employed for both instruments, where respondents could express their agreement or disagreement, with the scale ranging from strongly agree (4) to strongly disagree (1). the research instruments underwent rigorous testing for validity and reliability, including construct validity with an alpha cronbach value of 0.7, confirming their validity and reliability. data analysis the analysis in this study involves descriptive statistics, offering a detailed summary of the data. additionally, chi-square analysis was conducted using spss version 23, which is a statistical software widely utilized for data analysis. this method allows for examining relationships and associations between categorical variables. ethical clearance the research has obtained ethical approval from the health research ethics commission at the faculty of nursing, universitas islam sultan agung, as evidenced by ethical certificate no. 685/a.1-s1/fik-sa/x/2021. prior to data collection, informed consent was diligently acquired from all participants. throughout the research process, the researcher adhered to ethical principles, including providing clear information for obtaining consent, respecting human rights, and ensuring beneficence and non-maleficence in the study. results table 1 showed that among the observational variables, specifically demographic factors, 68.8% of the participants are female, 29.7% have not pursued formal education beyond elementary school, and the majority, constituting 32.8%, are employed in the farming sector. based on table 2, the data revealed that the majority of respondents were 56 years old, while the youngest respondent was 39 years old. the data also indicated that the longest duration of diabetes mellitus (dm) among respondents was 10 years. from the data presented in table 3, it can be concluded that there was a significant relationship between peer group support and foot care in patients with diabetes mellitus, as evidenced by a p-value of 0.003. discussion the research results show that hypotheses significantly correlate the independent and dependent variables. the female gender will be more at risk for developing diabetes mellitus than males.20 female gender is also one of the risk factors for diabetes mellitus because women have higher cholesterol than men, and there are also differences in daily lifestyles, men will experience a risk of developing diabetes mellitus 2-3 times while women are at risk 37 times more likely to have diabetes mellitus.21,22 in addition, women are vulnerable to stress, discrimination, and post-traumatic stress disorder, causing a more significant negative impact on sleep health in women than in men. in a meta-analysis of epidemiological studies, women of all ages were shown to be at increased risk for insomnia. diabetes mellitus can also cause patients to experience short sleep duration, disturbed sleep quality associated with obesity, and even more strongly impaired glucose metabolism that correlates with insulin resistance.23,24 women have a high life expectancy, so the risk of suffering from diabetes mellitus is hightransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents. indicator n % gender male 20 31.2 female 44 68.8 education no formal education 19 29.7 elementary school 19 29.7 junior high school 14 21.9 senior high school 12 17.8 work not working 11 17.2 private employees 16 25 farmer 21 32.8 businessman 16 25 [healthcare in low-resource settings 2024;12:11865] [page 157] non -co mmerc ial us e o nly er.25 the age of more than 45 years was associated with fasting blood glucose levels, there was a risk of an increase in blood sugar levels.21 age can also increase the risk of diabetes mellitus because it is associated with aging, decreasing insulin sensitivity so that blood sugar levels will be affected. in humans, there will be a drastic physiological decline at the age of 40 years, one of which impacts the pancreas itself.20 the world health organization also explains that when a person is 40 years old, blood sugar levels will increase 1-2 mg% per year while fasting and then will increase to 5.6-13 mg% 2 hours after eating, so it is not surprising that age becomes risk factors for the increase in the number of diabetes mellitus.26 the higher level of education of an individual will be able to influence the absorption of information received about health and increase the power of early detection of the incidence of diabetes mellitus.27 the low level of education and knowledge is a factor that causes the high number of disease cases.28 the level of education will relate to the health information received, especially about health care for diabetes mellitus. the level of education will increase public knowledge about their health.29 the more health information obtained, the more comprehensive the knowledge acquired. education is the most critical factor in self-care, understanding the disease, managing the disease, and overcoming the symptoms that arise with appropriate treatment to prevent complications.30 education is an efficient thing to increase knowledge. several studies have shown that education can improve patient knowledge based on lifestyle, clinical theory, and a positive environment. patient compliance while undergoing diabetes treatment, physical activity, and dietary patterns impact diabetes control.31 it could be that people can control their blood sugar through counseling. leaflets, but because they are tired of undergoing treatment, they do not want to maintain their blood sugar levels.25 the american diabetes association (ada) says that if someone works, it will be of great benefit because their blood sugar levels will be controlled through physical activity and to prevent complications.32 occupational factors will also affect the risk of diabetes mellitus because someone who undergoes a job with light activities can lack burning energy, so excess energy will be stored in the body in the form of fat, leading to obesity. obesity is a risk factor for diabetes mellitus.33 when doing exercises, there will be an increase in the energy used by the body, which will cause a decrease in blood glucose levels. work can also be a factor that affects insight, and work environment factors will make an individual gain experience and understanding both directly and indirectly.34 long duration of suffering from diabetes mellitus is related to the risk of diabetes complications. if diabetes mellitus is not handled correctly, it will cause various body disorders such as eye and heart disease. coronary heart disease, kidney and nerve disorders, cerebrovascular disease, and the most common is hypertensio.35 damage to the peripheral blood vessels of the hands or feet can attack patients with diabetes more quickly than someone who does not have diabetes.36 if you have had diabetes for more than ten years, you usually experience this complication. so ulcer control must be done early to avoid complications in people with diabetes.37 the increasing number of complications is directly proportional to the length of suffering from diabetes mellitus. if the longer a person has diabetes, the risk of complications also increases.38 peers (peer group support) can meet the personal needs of diabetic patients, such as fulfilling the need for respect, increasing self-esteem, providing information, and providing identity for diabetic patients. patients are more open to expressing their problems in this peer support group.39 peer group support is a convenient forum for groups of people with diabetes to give each other, receive emotional support, and receive information exchange.3,40 when someone has a problem, he will seek support and help from someone around him to help or grow self-confidence and enthusiasm when encountering difficulties so that each individual will feel cared for, appreciated, loved, or not lonely or alone in dealing with problems. the main thing about support is that individuals have friends to talk to, someone to inspire, and someone to give advice.41this is appropriate if peers (peer group support) can meet the personal needs of diabetic patients, such as fulfilling the need for respect, increasing self-esteem, providing information, and providing identity for diabetic patients. patients are more open to expressing their problems in this peer support group.2 some patients with diabetes do not know about foot care and the risk of injury.42 so, to achieve good foot care, good knowledge about foot care is also needed.31 this theory is based on the fact that diabetic wounds can be prevented through routine foot care. suppose you do not routinely perform foot care. in that case, you are at risk of experiencing foot problems such as numbness, decreased foot sensation, and cracks, the risk of experiencing diabetic foot injuries, and risk of foot amputation.43,44 patients who find it difficult to see their feet or reach their fingers and have thick transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. distribution and frequency characteristic respondents (age and length of dm). variable mean+sd median 95% ci max-min upper lower age 56.39+6.171 56.00 57.93 54.85 71-39 length of dm 4.66+2.515 4.00 5.28 4.03 10-1 table 3. chi-square analysis of peer group support with foot care patients dm. foot care behavior total p not good enough good peer group support not good 33 14 4 51 0.003 good 3 3 7 13 total 36 17 11 64 [page 158] [healthcare in low-resource settings 2024;12:11865] non -co mmerc ial us e o nly nails should be assisted by health workers or other people such as family or peers to trim their toenails.31 diabetes management requires active participation from family, health workers, the community, or peers to improve patients’ compliance. increasing patient compliance can be done by providing information about health and support, especially support obtained from peers (peer group support).40 good social support from peers or family will support the healing of disease in diabetic patients. this is very helpful because when this support is fulfilled, the patient feels comfortable and safe.45 social support can change the psychology or physiology of diabetes mellitus patients by protecting them from negative feelings experienced. so, if the level of social support is reduced, it will reduce a person’s ability to deal with the problem itself, thereby reducing the level of the stressor.7 social support is essential to support self-care behavior in people with diabetes. diabetes mellitus type 2, if there is a lack of social support, will impact the low activity of diabetes mellitus patients who experience emotional stress due to long self-care. it can lead to irregular dietary habits and decreased frequency of performing foot examinations. conclusions peer support can increase knowledge and behavior of foot care in patients with diabetes mellitus. peer support can improve communication between diabetes patients to strengthen awareness of the importance of foot care knowledge and behavior. developing methods to improve foot care behavior for families and health workers is necessary. references 1. kemenkes ri. hari diabetes sedunia tahun 2018. pusdatin kemenkes ri. 2018;1-8. 2. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord 2021;20:377-82. 3. zhao x, yu x, zhang x. the role of peer support education model in management of glucose and lipid levels in patients with type 2 diabetes mellitus in chinese adults. j diabetes res 2019;2019. 4. rismayanti ida, nursalam, farida vn, et al. early detection to prevent foot ulceration among type 2 diabetes mellitus patient: a multi-intervention review. j public health res 2022;11:2752. 5. joseph s, munshi b, agarini r, et al. near infrared spectroscopy in peripheral artery disease and the diabetic foot: a systematic review. diabetes metab res rev 2022;38:e3571. 6. novida h, hariftyani as, edward m, mudjanarko sw. mortality prediction model in patients with diabetic foot ulcer: a case-control study from a tertiary referral hospital in surabaya, indonesia. j heal sci med res 2023;41(1). 7. gavrila v, garrity a, hirschfeld e, et al. peer support through a diabetes social media community. j diabetes sci technol 2019;13:493-7. 8. akoit ee, efendi f, dewi ys. impact of diabetes self-management education in middle-aged patients with type 2 diabetes mellitus: a systematic review . gac med caracas 2022;130:s1183-95. 9. baradaran a, ebrahimzadeh mh, baradaran a, kachooei ar. prevalence of comorbidities in covid-19 patients: a systematic review and meta-analysis. arch bone jt surg 2020;8:24755. 10. ningsih esp, yusuf a, firdaus s, et al. psychometric properties of the indonesia version religious health fatalism questionnaire in diabetic foot ulcer outpatients. j public health res 2022;11:22799036221106605. 11. huda n, sukartini t, pratiwi nw. the impact of self efficacy on the foot care behavior of type 2 diabetes mellitus patients in indonesia. j ners 2019;14:181-6. 12. dinas kesehatan provinsi jawa tengah. profil kesehatan provinsi jateng tahun 2019. dinas kesehat provinsi jawa teng 2019;3511351:273-5. 13. hardianti d, adi ms, saraswati ld. description of factors related to severity of diabetic mellitus patient type 2 (study in rsud kota semarang). j kesehat masy 2018;6:132-40. 14. embuai s, lestari p, ulfiana e. pengaruh edukasi perawatan kaki dan senam kaki terhadap upaya pencegahan risiko foot ulcer pada klien diabetes melitus. j penelit kesehat “suara forikes” (journal heal res “forikes voice”) 2017;8:180-90. 15. pourkazemi a, ghanbari a, khojamli m, et al. diabetic foot care: knowledge and practice. bmc endocr disord 2020;20:1-8. 16. ghasemi m, hosseini h, sabouhi f. effect of peer group education on the quality of life of elderly individuals with diabetes: a randomized clinical trial. iran j nurs midwifery res 2019;24:44-9. 17. nurmansyah mi, jannah m, rachmawati e, maisya ib. religious affiliation, religiosity and health behaviors among high school students in jakarta, indonesia. int j public heal sci 2020;9:184-91. 18. castillo-hernandez kg, laviada-molina h, hernandezescalante vm, et al. peer support added to diabetes education improves metabolic control and quality of life in mayan adults living with type 2 diabetes: a randomized controlled trial. can j diabetes 2021;45:206-13. 19. chadha vk. sample size determination in health studies. 2006;55-62. 20. komariah k, rahayu s. hubungan usia, jenis kelamin dan indeks massa tubuh dengan kadar gula darah puasa pada pasien diabetes melitus tipe 2 di klinik pratama rawat jalan proklamasi, depok, jawa barat. j kesehat kusuma husada 2020;may:41-50. 21. sharoni as, razi mm, rashid an, ahmad sharoni sk my, rashid a, khuzaimah ahmad sharoni s, et al. self-efficacy of foot care behaviour of elderly patients with diabetes bachelor of nursing (hons) (uitm). malaysian fam physician 2017;12:2-8. 22. imelda, sjaaf f, paf p. faktorfaktor yang berhubungan dengan kejadian hipertensi pada lansia di puskesmas air dingin lubuk minturun. heal med j 2020;2:68-77. 23. jernigan vbb, huyser kr, valdes j, simonds vw. food insecurity among american indians and alaska natives: a national profile using the current population survey-food security supplement. j hunger environ nutr 2017;12:1-10. 24. costa pd, canaan jcr, castelo pm, et al. influence of micronutrient intake, sociodemographic, and behavioral factors on periodontal status of adults assisted by a public health care system in brazil: a cross-sectional multivariate analysis. nutrients 2021;13:1-15. 25. rahmadita i, latiifah nur, keperawatan ps, et al. dengan kadar glukosa darah puasa pada penderita diabetes melitus transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11865] [page 159] non -co mmerc ial us e o nly tipe 2 di puskesmas. 2020. 26. ramirez-perdomo c, perdomo-romero a, rodríguez-vélez m. knowledge and practices for the prevention of the diabetic foot. rev gauch enferm 2019;40:e20180161. 27. mohebi s, parham m, sharifirad g, gharlipour z. social support and self � care behavior study. 2018;1-6. 28. yulisetyaningrum, mardiana ss, susanti d. hubungan tingkat pendidikan dan pengetahuan tentang diet dm dengan kepatuhan diet pasien diabetes mellitus di rsud r.a kartini jepara. indones j perawat 2018;3:44-50. 29. jakosz n. book review iwgdf guidelines on the prevention and management of diabetic foot disease. wound pract res 2019;27:144. 30. lisnawaty, sulastri n, sabilu y, et al. risk factors of type 2 diabetes mellitus in coastal communities in the working area of community health centre of kapota of wakatobi regency in 2018. int j sci basic appl res 2018;4531:56-65. 31. efriliana, noor diani hs 1program. karakteristik pasien diabetes melitus dengan pengetahuan tentang perawatan kaki diabetes melitus. din kesehat. 2018. 32. arania r, triwahyuni t, prasetya t, cahyani sd. hubungan antara pekerjaan dan aktivitas fisik dengan kejadian diabetes mellitus di klinik mardi waluyo kabupaten lampung tengah. j med malahayati 2021;5:163-9. 33. mariam tg, alemayehu a, tesfaye e, et al. prevalence of diabetic foot ulcer and associated factors among adult diabetic patients who attend the diabetic follow-up clinic at the university of gondar referral hospital, north west ethiopia, 2016: institutional-based cross-sectional study. 2017. 34. wahyudi, raya p. hubungan lama menderita diabetes melitus dan kadar glukosa darah sewaktu dengan tingkat sensitivitas kaki di puskesmas pahandut palangkaraya. 2019;001. 35. indonesia pe. pengelolaan dan pencegahan diabetes melitus tipe 2 di indonesia. pb perkeni. 2015. 36. nurhanifah d. faktor-faktor yang berhubungan dengan ulkus kaki diabetik di poliklinik kaki diabetik. heal j 2017;1:32. 37. nuraisyah f, solikhah s, ruliyandari r. do descendants of families contribute to type 2 diabetes mellitus? int j public heal sci 2020;9:303-6. 38. amelia r. hubungan perilaku perawatan kaki dengan terjadinya komplikasi luka kaki diabetes pada pasien diabetes melitus tipe 2 di puskesmas tuntungan kota medan. talent conf ser trop med 2018;1:124-31. 39. williams em, egede l, oates jc, et al. peer approaches to self-management (pals): comparing a peer mentoring approach for disease self-management in african american women with lupus with a social support control: study protocol for a randomized controlled trial. trials 2019;20:1-13. 40. diatiningsih y, kusnanto k, bakar a. kepatuhan pengelolaan penyakit diabetes mellitus tipe ii melalui peer group support di wilayah kerja puskesmas kebonsari surabaya. crit med surg nurs j 2019;1(1). 41. syatriani s. hubungan pekerjaan dan dukungan keluarga dengan stres pada pasien dm tipe 2 di daerah pesisir kota makassar. sinergitas multidisiplin ilmu pengetah dan teknol 2019;2:26-7. 42. kasih s, surakarta ibu, publikasi n. pengaruh peer group support terhadap kadar gula darah pada pasien diabetes mellitus tipe 2 di rumah sakit kasih ibu surakarta naskah publikasi. 2019. 43. ngadiluwih ms. pengaruh perawatan kaki terhadap sensitivitas kaki pada penderita diabetes melitus tipe ii. 2018. 44. dewi eu, widari np, nursalam n, et al. the relationship between diabetes self-care management and blood glucose level among type 2 diabetes mellitus patients. int j public heal sci 2023;12:1165. 45. pienaar m, reid m. self-management in face-to-face peer support for adults with type 2 diabetes living in lowor middleincome countries: a systematic review. bmc public health 2020;20:1-10. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 160] [healthcare in low-resource settings 2024;12:11865] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11732 correlation of nerve damage and peripheral neuropathy incidence using the mnsi and mdns instrument approaches indah nur imamah,1 diah setiani,1 rivan firdaus,1 rahmawati shoufiyah,1 alfi ari fakhrur rizal,2 riza hayati ifroh3 1department of nursing, politeknik kesehatan kemenkes kalimantan timur, samarinda; 2faculty of nursing, universitas muhammadiyah kalimantan timur, samarinda; 3faculty of public health, universitas mulawarman, samarinda, indonesia abstract the world health organization (who) reported that by 2030, diabetes mellitus would become the 7th leading cause of death. diabetes mellitus is a chronic disease that causes various complications, one of which is peripheral neuropathy. preventive efforts for peripheral neuropathy involve conducting detection examinations. the purpose of this study was to analyze nerve damage in peripheral neuropathy cases using the mnsi (michigan neuropathy screening instrument) and mdns (michigan diabetic neuropathy score) instruments. the study employed a cross-sectional study approach with a sample of 50 people, using total sampling as the sampling technique. the independent variable in this study was nerve damage, and the dependent variable was peripheral neuropathy. data collection in the study was carried out using the mnsi and mdns instruments to link the dependent and independent variables. hypothesis analysis in this study was conducted using the spearman’s rho correlation test. the study found that autonomic, sensory, and motor damage correlated with peripheral neuropathy, with a p<0.05. examinations in the feet of diabetics were significantly related to the level of peripheral neuropathy. however, there was no evidence of a correlation between the characteristics of the respondents and the incidence of peripheral neuropathy. the results of the nerve damage examination demonstrated a correlation between different types of damage, and the mnsi and mdns instruments proved effective in detecting peripheral neuropathy damage. future research should focus on more indepth studies to explore the correlation of nerve damage in patients with diabetes mellitus detected at a young age and consider other variables, such as hba1c levels, as potential risk factors for peripheral neuropathy. introduction chronic complications can occur in people with diabetes mellitus, and one of the causes is poor management of diabetes mellitus.1 individuals with diabetes mellitus may experience circulation problems and nerve innervation issues in their legs, putting them at risk of developing diabetic ulcers.2 neuropathy, a set of clinical symptoms that affect the nerves, is a major complication of diabetes mellitus, and the primary cause of neuropathy is usually damage to the peripheral and autonomic nerve parts.3,4 sensory neuropathy results in the loss of pain sensation, making the person unable to feel mild trauma to the foot. even minor trauma can damage the skin’s integrity. autonomic neuropathy leads to dry and cracked skin due to the loss of sweat’s moisturizing effect. motor neuropathy causes an imbalance in leg muscle function, leading to biomechanical changes in the foot and resulting in deformity and uneven pressure distribution on the plantar aspect of the foot.5 indonesia, as one of the world’s fifth most populous countries, also grapples with the issue of diabetes. according to the national basic health survey in 2018, approximately 1.5% of indonesians had diabetes, and one of the provinces with a prevalence rate exceeding the national average was east java province, where the prevalence reached 2%.6 peripheral neuropathy is often unrecognized because it typically asymptomatic nature, which can lead individuals with diabetes mellitus to face significant issues with their feet. however, when neuropathy does manifest symptoms like pain, tingling, and loss of sensation to temperature correspondence: indah nur imamah, department of nursing, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: indah.imamah@gmail.com key words: peripheral neuropathy, diabetes, mnsi, mdns. contributions: in conceptualizes research ideas, compiles articles, research methodology, data validation, reviews and edits article manuscripts and monitors research activities; ds drafts manuscripts, takes research data, searches for library sources, analyzes data; rf conducts data analysis, review and editing of article manuscripts; rs conducts data analysis, searches for literature sources; ar performs data capture; rh research methodology, review data analysis, review research results. conflict of interest: all authors have no research conflicts ethics approval and consent to participate: the research has obtained ethical approval from the health research ethics committee at the health polytechnic of the ministry of health in east kalimantan. the approval is based on the ethical certificate no. dp.04.03/7.1/07262/2018. throughout the research, the researcher adheres to ethical principles concerning informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: the patient has provided consent for their personal data to be used as research data in this publication. patient consent is obtained through the process of informed consent. funding: this research did not receive funding from external parties. availability of data and materials: the overall research data found and analyzed are presented in the research article. received: 9 september 2023. accepted: 30 november 2023. early access: 18 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11732 doi:10.4081/hls.2024.11732 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11732] [page 117] non -co mmerc ial us e o nly changes, it can disrupt the quality of life for individuals with diabetes.73,8 reported worldwide, peripheral neuropathy is one of the most common complications in patients with diabetes mellitus, with an incidence ranging from 16% to 66%.9 individuals with type 2 diabetes mellitus experience a higher incidence of peripheral neuropathy compared to those with type 1 diabetes, with a rate of 6,100 cases per 100,000 people per year.3,7 the results of research conducted in america and china found that as many as 6% to 51% of people with diabetes mellitus experienced peripheral neuropathy.10 the incidence of peripheral neuropathy is also significant in southeast asian countries, including malaysia (54.3%), the philippines (58.0%), and indonesia (58.0).11 questionnaires, namely the mnsi (michigan neuropathy screening instrument) and mdns (michigan diabetic neuropathy score),12,13 are used in addition to age. other studies have also mentioned that the prevalence of peripheral neuropathy is related to other characteristics of the respondents, such as their education level, duration of suffering from diabetes mellitus, and gender.14–16 the results of other studies have also identified changes in muscle strength and decreased muscle strength, particularly in men suffering from diabetes mellitus with peripheral neuropathy.14,17 therefore, the purpose of this study is to investigate the correlation between nerve damage and the incidence of peripheral neuropathy in patients with diabetes mellitus. recommendations for the prevention of peripheral neuropathy in patients with diabetes mellitus include the use of antiplatelet medication and routine foot care.18 currently, controlling blood sugar levels and adopting a healthy lifestyle are also crucial for preventing peripheral neuropathy.19,20according to a previous study conducted by tintin et al., diabetic foot exercises can serve as an alternative approach to enhance sensory peripheral neuropathy.21 given that 50% of peripheral neuropathy cases are asymptomatic, conducting peripheral neuropathy examinations is essential. this emphasizes the need for healthcare practitioners to pay close attention to the symptoms of neuropathy in patients who have had diabetes mellitus for an extended period. this study offers a solution by using the mnsi (michigan neuropathy screening instrument) and mdns (michigan diabetic neuropathy score) instruments to detect peripheral nerve damage. diabetic individuals with specific characteristics have a higher potential for peripheral neuropathy damage. materials and methods the research design employed in this study is cross-sectional, which is a method used to assess the relationship between risk factors and their effects through one-time measurement observations.22 the study involved a sample of 50 individuals with type ii diabetes mellitus, and total sampling was used as the sampling technique. data collection took place among respondents who routinely sought treatment and resided within the anggana samarinda health center’s jurisdiction. the data collection period extended over one month, from march 1 to march 31, 2018. the collected data consisted of results from interviews and direct observations of the respondents. in this study, the independent variable was nerve damage, while the dependent variable was peripheral neuropathy. the instruments used in this study were the mnsi and mdns questionnaires. the mnsi serves as a clinical parameter for the early detection of neuropathy events, while the mdns is used to assess the level of neuropathy. the peripheral neuropathy examination item from the mnsi involved a physical examination to check for the presence of dry (scaly), cracked, and calloused skin, as well as deformities.23 additional examination items were derived from the mdns, including assessments of foot sensitivity, vibrational sensation, pain sensation, muscle strength, and reflex strength, which were consistent with the original examination item.5 tools used in this study included a 10 g monofilament, a 128 hz tuning fork, a prick pin, and a reflex hammer. based on the study’s objectives, the examination results were categorized as follows: no neuropathy (score 0), mild neuropathy (scores 1-11), moderate neuropathy (scores 12-25), and severe neuropathy (scores 26-42). prior to commencing data collection, the researchers obtained ethics clearance from the ethics commission at poltekkes kemenkes kalimantan timur, which subsequently issued an ethics certificate with the number no.dp.04.03/7.1/07262/2018. the analysis in this study utilized univariate analysis to obtain an overview of the distribution and frequency of dependent and independent variables. bivariate analysis employed the spearman’s rho correlation test. results this section will present the research results that are relevant to the study’s purpose, which is to analyze the correlation between respondent characteristics and nerve damage with the incidence of peripheral neuropathy using the mnsi and mdns approaches. the study’s findings will be presented in the form of both univariate and bivariate analyses, as follows: based on table 1, it is evident that the average age of the respondents in this study was 52 years. additionally, the average duration of suffering from diabetes mellitus was 5 years and 5 months, with the average blood sugar value among the respondents being 272.58 mg/dl. the table further reveals that 62% of the respondents are women, and a significant majority, approximately 82%, do not have a history of smoking. about 44% of the respon transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 118] [healthcare in low-resource settings 2024;12:11732] table 1. characteristics of respondents. variable value mean mode min max age 52.10 65 32 65 long suffering from dm 5.5 years 2 months 20 years blood sugar 272.58 144 512 n = 50 % gender man 19 38 woman 31 62 smoking status already 9 82 no 41 18 comorbidities already 22 44 no 28 56 dfu history already 8 16 no 42 84 degree of peripheral neuropathy no neuropathy 5 10 mild neuropathy 35 70 moderate neuropathy 10 20 non -co mmerc ial us e o nly dents had comorbidities, specifically hypertension, while 84% of them had no history of diabetic foot ulcers (dfu). the results also indicate that 70% of the respondents experienced mild neuropathy. based on table 2, the characteristics of peripheral neuropathy examination are evident, including assessments of autonomic, sensory, and motor damage in the right leg and left foot of diabetic respondents. regarding the examination of autonomic damage in the right leg, 38% had single autonomic damage, while 14% had multiple autonomic damage. in the left leg, 40% of respondents had single damage, and 16% had multiple autonomic damage. in the second examination, which assessed sensory damage, it was found that 44% of respondents experienced decreased sensation in the left leg and 40% in the right foot. in the examination of motor damage, it was observed that 60% of respondents experienced a decrease in muscle strength in the right leg, and 64% experienced this decrease in the left leg. based on the results of statistical tests using the spearman correlation analysis (table 3), it is evident that there is no correlation between the characteristics of the respondents and peripheral neuropathy. the study’s results indicate that the overall variable characteristics of the respondents have a p-value greater than 0.05. the results of statistical tests using the spearman correlation analysis reveal that the examination of autonomic, sensory, and motor nerves in the feet of diabetics is significantly associated with the level of peripheral neuropathy (table 4). all relationships are in a positive direction, indicating that the higher the damage to autonomic, sensory, and motor nerves in diabetics, the greater the number of diabetics who experience peripheral neuropathy. in pearson’s correlation analysis, it is revealed that the results of the sensory damage examination, specifically monofilament sensitivity, have a negative correlation with the examination of autonomic nerve damage (p=0.016; r = -0.338). the examination of sensory nerve damage using a pinprick shows a positive correlation with autonomic nerve damage (p=0.007; r=0.376) and a negative correlation with monofilament sensitivity damage (p<0.001; r= -0.594). furthermore, it was observed that the examination of sensory nerve damage with a pinprick has a negative correlation with monofilament sensitivity (p= 0.001; r= -0.457) and a positive correlation with sensory nerve damage, assessed using garputala (p<0.001; r=0.699). regarding the examination of motor nerve damage in leg muscles, a positive correlation was found with pinprick sensory nerve damage (p=0.001; r=0.471). in the reflex motor nerve examination, there was a positive correlation with pinprick sensory nerve damage (p<0.000; r=0.555) at a significance level of 0.01 (table 5). discussion the results of this study do not align with previous research indicating a correlation between age and the incidence of peripheral neuropathy.24 in this study, mild peripheral neuropathy was observed in diabetics as young as 32 years old. these findings are consistent with retrospective research conducted in china, which reports a rapid increase in the prevalence of diabetes mellitus among young individuals (aged 18-40) due to changes in lifestyle and living standards. the study revealed that 9% of 655 newly diagnosed diabetic individuals within this age group suffered from one of the complications of diabetes mellitus, namely peripheral neuropathy.25,26 the relationship between age and neuropathy is closely associated with degeneration processes that can lead to damage to both large nerve cells and small nerve fibres. neuropathy can occur as a result of blood vessel wall thickening, especially in the intima layer, causing vascular stiffness and reduced oxygen and nutrient flow. prolonged exposure to such conditions can result in neuropathy.27 increasing age can lead to a decrease in cell function and a decline in overall bodily functions.. diabetic neuropathy results from complex interactions between metabolic factors directly related to hyperglycemia and structural changes, including axonal degeneration and demyelination caused by microangiopathy. both acute and chronic nerve damage can lead to anatomical and physiological alterations in peripheral nerves, affecting their structures, including myelin, axons, and supporting layers.28 beta cells in the pancreas can experience reduced function, potentially leading to hyperglycemia in people with diabetes, which can exacerbate the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. characteristics of peripheral neuropathy examination. variable right foot left foot n % n % autonomic damage inspection normal 24 48 22 44 single autonomous damage 19 38 20 40 multiple autonomous damage 7 14 8 16 sensory damage inspection normal 22 44 22 44 decreased sensation 22 44 20 40 no sensation 6 12 8 16 motor damage inspection normal 20 40 18 36 decreased muscle strength 30 60 32 64 no muscle strength 0 0 0 0 table 3. correlation analysis of respondent characteristics against peripheral neuropathy. variable diabetic peripheral neuropathy p r correlation direction age 0.059 0.269 + gender 0.296 0.151 + long suffering from dm 0.296 0.151 + smoking status 0.536 0.090 blood sugar 0.211 0.180 + comorbidities 0.147 0.208 + dfu history 0.120 0.223 + table 4. correlation analysis of autonomic, sensory and motor impairment against peripheral neuropathy. variable. diabetic peripheral neuropathy p r correlation direction autonomic damage of the right leg 0.001 0.458 + autonomic damage of the left leg 0.002 0.426 + right leg sensory damage 0.001 0.667 + left leg sensory damage 0.001 0.569 + motor damage of the right leg 0.001 0.527 + motor impairment of the left leg 0.001 0.520 + [healthcare in low-resource settings 2024;12:11732] [page 119] non -co mmerc ial us e o nly risk of peripheral neuropathy in elderly individuals with longstanding diabetes. proper blood sugar control is crucial for diabetics as a preventive measure against peripheral neuropathy symptoms.26,29 additionally, a previous study has suggested a significant association between the neutrophil–lymphocyte ratio (nlr) and arterial stiffness, with higher nlr counts corresponding to greater arterial stiffening.30 another notable fact is that the signs and symptoms of peripheral neuropathy may decrease with age, along with an increased pain threshold in adulthood. therefore, the severity of neuropathy may not always align with the symptoms experienced. as individuals age, complaints of neuropathy symptoms may diminish, but the severity of peripheral neuropathy can worsen.31 the occurrence of peripheral neuropathy is not influenced by gender. therefore, this study aligns with previous research that has failed to establish a connection between gender and the incidence of peripheral neuropathy.32 the fact in this study is that the incidence of peripheral neuropathy shows no difference based on gender, as it can occur in both men and women. while some theories suggest a higher incidence of diabetes in women, an interesting finding in this study is that the incidence of diabetes does not directly correlate with the incidence of neuropathy. when examining the results of this study, it becomes apparent that there are more female respondents than male respondents, which aligns with research indicating that women are at a six-fold higher risk of experiencing peripheral neuropathy compared to men.31,32 one of the causes of neuropathy is attributed to the hormone estrogen, with evidence suggesting that estrogen can disrupt iodine absorption in the intestines, consequently hindering the formation of nerve myelin.33 discrepancies in study outcomes can also stem from variations in the measuring instruments used.34 other research indicates that if diabetes mellitus onset occurs at a young age (18-40 years), the risk of mortality and complications is more common in men due to factors such as environmental influences, socioeconomic status, genetics, life pressures, and education level. research results also mention that young women rarely suffer from diabetes, possibly due to their higher estrogen levels.35,36 diabetes mellitus is also considered a risk factor in the incidence of peripheral neuropathy. however, this study contradicts previous research explaining that one of the causes of peripheral neuropathy is the duration of suffering from diabetes mellitus. in this study, it was observed that the duration of diabetes mellitus did not correlate with the incidence of peripheral neuropathy. the fact uncovered in this study is that mild peripheral neuropathy can occur in individuals with diabetes who have had the condition for a range of 3 to 18 years. however, some people with diabetes mellitus in this study did not experience peripheral neuropathy, even though they had been living with diabetes for 20 years. in theory, it is postulated that the longer an individual experiences hyperglycemia,37 the more likely changes in nerve tissue occur due to the accumulation of sorbitol and increased activity in polyol pathways. consequently, these changes can lead to alterations in nerve signal transduction, resulting in reduced sensitivity in the legs for people with diabetes.38,39 in contrast, foot exercises significantly impacted the ankle brachial pressure index value and foot sensation in patients with diabetes mellitus.40 another significant finding from prior studies suggests that patients with adult-onset diabetes mellitus, or those recently diagnosed with diabetes within one year, may already exhibit diabetes complications. this can occur due to delayed detection of diabetes. to avoid such delays in diagnosing diabetes, especially in young adults, the american diabetes association (ada) guidelines for 2022 recommend diabetes screening starting at age 35.26,35 the smoking status in this study does not align with previous research, which suggests that actively smoking and having a history of smoking can increase the risk of microvascular and macrovascular complications.41 the results of the current study indicate that smoking is not correlated with the incidence of peripheral neuropathy. in this study, it is observed that mild peripheral neuropathy events occur in diabetic patients who do not smoke (80%), and the same applies to diabetic patients who do not smoke and do not experience peripheral neuropathy (90%). diabetics who do not smoke also account for those who do not experience peripheral neuropathy (98%). the difference between this study and previous research results is that out of the 50 respondents, only 9 had a smoking history. in this study, it is found that current blood sugar values are not correlated with the incidence of peripheral neuropathy. this finding contrasts with previous research, which suggested that blood glucose levels correlated with the prevention of peripheral neuropathy.42 the fact in this study is that mild peripheral neuropathy occurs in patients with diabetes mellitus with blood sugar values ranging from 144 to 512 mg/dl, peripheral neuropathy events occur in patients with diabetes mellitus with blood sugar values ranging from 214 to 472 mg/dl, and those who do not experience peripheral neuropathy have blood sugar values between 184 and 361 mg/dl. this study concludes that individuals with diabetes mellitus with unstable glucose levels do not necessarily suffer from peripheral neuropathy. this discrepancy may be due to researchers only measuring blood glucose without considering fluctuations in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 120] [healthcare in low-resource settings 2024;12:11732] table 5. correlation analysis on each examination variable. 1 2 3 4 5 6 7 8 9 10 blood sugar 1 long-suffering from dm 0.283* 1 age of respondents -0.090 0.244 1 autonomic deterioration 0.070 0.180 0.243 1 sensory damage, monofilament sensitivity -0.272 -0.323* -0.334* -0.338* 1 sensory damage, tuning fork 0.272 0.209 0.174 0.376** -0.594** 1 sensory damage, pinprick 0.191 0.232 0.213 0.148 -0.457** 0.699** 1 motor deterioration, deformity -0.083 0.074 0.308* 0.216 -0.253 0.171 0.070 1 motor impairment, leg muscle strength 0.105 0.216 0.112 0.206 -0.142 0.160 0.471** -0.171 1 motor damage, reflexes 0.361* 0.310* 0.057 0.200 -0.487** 0.745** 0.555** -0.037 0.218 1 * correlation is significant at the 0.05 level (2-tailed); ** correlation is significant at the 0.01 level (2-tailed). non -co mmerc ial us e o nly blood sugar from the previous day. according to the results of a research survey, blood sugar fluctuations are strongly influenced by diet.43 additionally, this study did not examine whether respondents with diabetes mellitus received treatments for the prevention of peripheral neuropathy symptoms, such as folic acid and vitamin b12.42 comorbidities were not correlated with the incidence of peripheral neuropathy in this study, contradicting previous research suggesting that comorbidities can influence the incidence of peripheral neuropathy.42 the fact in this study is that peripheral neuropathy occurs in patients with diabetes mellitus, whether they have comorbidities or not. however, the study does not provide detailed information about the specific diseases that the patients may have. previous research indicated that the most common comorbidities included gout and hypertension. changes in smooth muscle cells, endothelial cells, blood vessel walls, and blood pressure can increase vascular risk in diabetics.44 for patients with gout, it is known that high uric acid levels increase oxidation in the body and provoke inflammation. elevated uric acid levels can stimulate the renin-angiotensin system, damage vascular endothelial cells, and increase proliferation in vascular smooth muscle.45 patients with type 2 diabetes may also experience foot ulceration as one of the major complications. the severity of these ulcers and the prevention of new wounds can be addressed through early detection interventions.46 diabetic foot ulcers (dfus) are caused by prolonged instability in blood sugar levels, which affect the peripheral blood vessels and the nervous system.47 the fact in this study is that the incidence of peripheral neuropathy occurs in patients with diabetes, whether or not they have a history of dfu. the results of this study align with research that suggests not all individuals with diabetes mellitus and dfu develop peripheral neuropathy. this discrepancy may arise from a delay in diagnosing peripheral neuropathy in dfu patients.48 in this study, it was found that 84% of diabetics had not experienced dfu, emphasizing the need to expedite screening for peripheral neuropathy symptoms, as the study revealed that 50% of peripheral neuropathy sufferers did not exhibit symptoms.7 from the three assessments of neurological function for peripheral neuropathy, a correlation was observed between sensory, motor, and autonomic examinations and peripheral neuropathy. these findings are consistent with previous research indicating that peripheral neuropathy is often accompanied by sensory, motor, and autonomic damage.49,50 sensory nerve damage generally involves both small and large nerve fibers. damage to small nerves affects a patient’s ability to feel pain and temperature stimuli, while significant nerve damage may result in sensitivity or touch disorders.32 previous studies have shown that sensory and motor damage in patients with peripheral neuropathy can lead to reduced sensitivity, loss of ankle reflexes, joint mobility disorders, muscle weakness, and an increased risk of falling.51–53 the presence of tissue hypoperfusion, particularly in peripheral areas, can lead to increased oxidative stress, which may cause autonomic nerve damage. patients with autonomic nerve damage may experience symptoms such as dry skin, cracked skin, and the development of calluses in their legs. these symptoms can occur due to oxidative stress, resulting in damage to endothelial tissue and increased blood flow in the arteries. the increased blood flow triggers sympathetic nerve activity, which can affect sweat gland production and lead to decreased sweating.54 sensory nerve damage involves small nerve fibers that are responsible for sensing pain and temperature sensations, while large fibers are used for perceiving vibrations and tactile sensations. damage to these nerves interferes with sensitivity and touch perception.55 some research results suggest that motor nerve damage is not directly influenced by diabetes mellitus. however, respondents experiencing peripheral neuropathy may suffer from impaired balance and changes in plantar pressure. other studies also indicate that individuals with diabetes mellitus may experience weakness in lower extremity muscles, particularly those with polyneuropathy.56 57 peripheral neuropathy progresses slowly and can cause symptoms of sensory and autonomic damage, which are often followed by motor nerve damage. most patients experience positive sensory symptoms, including exaggerated or spontaneous responses such as paresthesias and pain. these symptoms may manifest as numbness, tingling, imbalance, prickling, and a burning sensation. they tend to worsen, particularly at night. in general, these symptoms can range from mild to severe. negative sensory symptoms, characterized by a decreased response to certain stimuli, indicate a loss of sensitivity in the affected segments. severe neuropathic pain may also be present, in the form of hyperesthesia (an excessive response to tactile stimuli), hyperalgesia (an increased sensitivity to pain stimuli), hyperpathy (persistent pain), or even allodynia (pain sensations triggered by non-painful stimuli). these symptoms may progress to hypo/anesthetic sensitivity, resulting in reduced responsiveness to touch, vibration, and proprioception. additionally, sensory impairment in large nerve fibres can lead to hypo or absence of deep reflexes, particularly in the achilles reflex. in very severe cases, common reflexes may be entirely absent.50,53 conclusions the quicker the detection of peripheral neuropathy symptoms, the better the chances of preventing complications associated with it. early detection of peripheral neuropathy can be achieved using the mnsi instrument, as it can identify damage in neurological nerves, typically encompassing autonomic, sensory, and motor nerves. the mdns instrument is capable of assessing the extent of peripheral neuropathic damage. if a person with diabetes mellitus experiences nerve damage, it will lead to autonomic and motor damage, increasing the risk of peripheral neuropathy as the level of nerve damage rises. references 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob health. 2022;10(11):e1632–45. 2. adi pamungkas r, mayasari usman a. panduan praktis screening resiko diabetes dan neuropathy . listiyawati i, rosyidi k, editors. vol. pertama. bondowoso: khd production ; 2021. 3. feldman el, callaghan bc, pop-busui r, zochodne dw, wright de, bennett dl, et al. diabetic neuropathy. nat rev dis primers 2019;5:41. 4. oliveira-abreu k, cipolla-neto j, leal-cardoso jh. effects of melatonin on diabetic neuropathy and retinopathy. int j mol sci 2021;23:100. 5. dixit s, maiya a. diabetic peripheral neuropathy and its evaluation in a clinical scenario: a review. j postgrad med 2014;60:33–40. 6. hidayati l, pratiwi in, pawanis z, et al. buerger exercise transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11732] [page 121] non -co mmerc ial us e o nly reduces the risk of neuropathy in people with diabetes mellitus. open access maced j med sci 2021;9:94–9. 7. pop-busui r, boulton ajm, feldman el, et al. diabetic neuropathy: a position statement by the american diabetes association. diabetes care 2017;40:136–54. 8. hassanzadeh s, bagheri s, majid ahmadi s, et al. effectiveness of oral clonidine and gabapentin on peripheral neuropathy in diabetic patients in southwestern iran: a randomized clinical trial. bmc endocr disord 2023;23:224. 9. idf. diabetes atlas. 2017. 10. hicks cw, selvin e. epidemiology of peripheral neuropathy and lower extremity disease in diabetes. curr diab rep 2019;19:86. 11. malik ra, andag-silva a, dejthevaporn c, et al. diagnosing peripheral neuropathy in south-east asia: a focus on diabetic neuropathy. j diabetes investig 2020;11:1097–103. 12. dixit s, maiya a, shastry b. effect of aerobic exercise on quality of life in population with diabetic peripheral neuropathy in type 2 diabetes: a single blind, randomized controlled trial. qual life res 2014;23:1629–40. 13. akmal ashhp. the relationship between patient characteristics diabetes self-care management with diabetic peripheral neuropathy in type 2 dm patients in regional general hospital in indonesia. int j nursing educ 2022;14(4). 14. oh tj, kang s, lee je, moon jh, choi sh, lim s, et al. association between deterioration in muscle strength and peripheral neuropathy in people with diabetes. j diabetes complications. 2019 aug;33(8):598–601. 15. atallah sm, al-jaghbir mt, zayed aa. the prevalence of diabetic peripheral neuropathy among diabetic palestinian refugees in the nuzha area, jordan: a cross-sectional study. the lancet. 2021 jul;398:s15. 16. levitt katz le, white nh, el ghormli l, et al. risk factors for diabetic peripheral neuropathy in adolescents and young adults with type 2 diabetes: results from the today study. diabetes care 2022;45:1065–72. 17. mohapatra s, ramachandran m, behera kk, et al. association of peripheral neuropathy with skeletal muscle mass and function in type two diabetes mellitus patients: a cross-sectional study. endocrinol diabetes nutr 2022;69:591–9. 18. anumah fe, lawal y, mshelia-reng r, et al. common and contrast determinants of peripheral artery disease and diabetic peripheral neuropathy in north central nigeria. the foot 2023;55:101987. 19. zhou l, tang j, cai q, et al. survey of factors related to diabetic foot pruritus in the elderly in shanghai. int wound j 2023;20:2020–7. 20. elafros ma, andersen h, bennett dl, et al. towards prevention of diabetic peripheral neuropathy: clinical presentation, pathogenesis, and new treatments. lancet neurol 2022;21:922–36. 21. sukartini t, asmoro cp, alifah pn. the influence of diabetic foot exercise in sensory peripheral neuropathy with monofilament test on diabetes mellitus clients. jurnal ners 2019;14:340–4. 22. riyanto a. aplikasi metodologi penelitian kesehatan. vol. iii. yogjakarta: nuha medika; 2019. 23. herman wh, pop-busui r, braffett bh, et al. use of the michigan neuropathy screening instrument as a measure of distal symmetrical peripheral neuropathy in type 1 diabetes: results from the diabetes control and complications trial/epidemiology of diabetes interventions and complications. diabetic med 2022;39(4). 24. sabaghan m, ataee s, ataee m, et al. diabetic peripheral neuropathy screening and the related risk factors to its prevalence in people with type 2 diabetes. int j diabetes dev ctries 2023;43:641–6. 25. zou x, zhou x, ji l, et al. the characteristics of newly diagnosed adult early-onset diabetes: a population-based cross-sectional study. sci rep 2017;7:46534. 26. dong w, zhang s, yan s, et al. clinical characteristics of patients with early-onset diabetes mellitus: a single-center retrospective study. bmc endocr disord 2023;23:216. 27. ede o, eyichukwu go, madu ka, et al. evaluation of peripheral neuropathy in diabetic adults with and without foot ulcers in an african population. j biosci med (irvine) 2018;06:71–8. 28. hamdan m, wisnujono r, basuki m, et al. the association between blood glucose control measured with serum hna1c level with peroneal motor nerve conduction velocity in patients with type 2 diabetes mellitus with polyneuropathy. indian j forensic med toxicol 2020;14:1649–54. 29. pan j, jia w. early-onset diabetes: an epidemic in china. front med 2018;12:624–33. 30. ardiany d, pranoto a, soelistijo sa, et al. association between neutrophil–lymphocyte ratio on arterial stiffness in type-2 diabetes mellitus patients: a part of diors study. int j diabetes dev ctries 2022;42:305–12. 31. yokoyama h, tsuji t, hayashi s, et al. factors associated with diabetic polyneuropathy�related sensory symptoms and signs in patients with polyneuropathy: a cross�sectional japanese study (jddm 52) using a non�linear model. j diabetes investig 2020;11:450–7. 32. shrestha hk, katwal pc. prevalence and risk factors of diabetic peripheral neuropathy in t2dm patient presenting to commnity hospital in nepal. kathmandu univ med j 2017. 33. zhi wi, dreyfus n, lessing a, et al. patient characteristics associated with chemotherapy-induced peripheral neuropathy severity in a phase ii clinical trial: a retrospective analysis. oncologist 2023;28:604–8. 34. debele gr, kuse sa, kefeni bt, et al. why too soon? predictors of time to diabetic peripheral neuropathy among newly diagnosed diabetes mellitus patients: a multicenter follow-up study at health-care setting of ethiopia. arch public health 2023;81:186. 35. mauvais-jarvis f, manson je, stevenson jc, fonseca va. menopausal hormone therapy and type 2 diabetes prevention: evidence, mechanisms, and clinical implications. endocr rev 2017;38:173–88. 36. kautzky-willer a, harreiter j, pacini g. sex and gender differences in risk, pathophysiology and complications of type 2 diabetes mellitus. endocr rev 2016;37:278–316. 37. kusnanto k, pradipta ro, arifin h, et al. what i felt as a diabetes fatigue survivor: a phenomenology study. j diabetes metab disord 2022;21:1753–62. 38. tanhardjo j, pinzon rt, sari lk. perbandingan rerata kadar hba1c pada pasien diabetes melitus dengan neuropati dan tanpa neuropati sensori motor. berkala ilmiah kedokteran duta wacana 2016;1(2). 39. karmilayanti, goysal y, basri mi, et al. the relationship between the severity of peripheral diabetic neuropathy and sleep quality in type 2 diabetic mellitus patients. medicina clínica práctica 2021;4:100210. 40. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord 2021;20:377–82. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 122] [healthcare in low-resource settings 2024;12:11732] non -co mmerc ial us e o nly 41. szwarcbard n, villani m, earnest a, et al. the association of smoking status with glycemic control, metabolic profile and diabetic complications– results of the australian national diabetes audit (anda). j diabetes complications 2020;34:107626. 42. li m, wu k, chang j, chen jw. a retrospective study on the time in range of blood glucose and type 2 diabetic peripheral neuropathy. biomed res int 2022;2022:1–6. 43. arifin h, kusnanto k, wahyuni ed, pradipta ro. diabetes resilience training on self-care, glycemic control, and diabetes burnout of adult type 2 diabetes mellitus. indonesian nursing j education clinic (injec) 2019;4:90. 44. concha ll, durruty ap. ketosis prone type 2 diabetes (kpd). rev med chil 2015. 45. ren y, gao l, guo x, et al. interactive effect of serum uric acid and total bilirubin for micro-vascular disease of type 2 diabetes in china. j diabetes complications 2018;32:1000–5. 46. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord [internet]. 2021;20:377-382. 47. pratiwi ld, haryanto j, wahyudi as. the effect of foot self care and diabetes self-management mobile application in preventing foot ulcer recurrence: a systematic review study. malaysian j med health sci 2023;19. 48. sabaghan m, ataee s, ataee m, et al. diabetic peripheral neuropathy screening and the related risk factors to its prevalence in people with type 2 diabetes. int j diabetes dev ctries 2023;43:641–6. 49. beijers ajm, vreugdenhil g, oerlemans s, et al. chemotherapy-induced neuropathy in multiple myeloma: influence on quality of life and development of a questionnaire to compose common toxicity criteria grading for use in daily clinical practice. supportive care cancer 2016;24:2411–20. 50. kazamel m, dyck pj. sensory manifestations of diabetic neuropathies. prosthet orthot int 2015;39:7–16. 51. alam u, riley dr, jugdey rs, et al. diabetic neuropathy and gait: a review. diabetes therapy 2017;8:1253–64. 52. riandini t, khoo eyh, tai bc, et al. fall risk and balance confidence in patients with diabetic peripheral neuropathy: an observational study. front endocrinol (lausanne) 2020;11. 53. ahmad i, verma s, noohu mm, hussain mohde. effect of sensorimotor training on spatiotemporal parameters of gait among middle and older age adults with diabetic peripheral neuropathy. somatosens mot res 2021;38:230–40. 54. bruschi lkm, da rocha da, filho elg, barboza n de mp, frisanco pab, callegaro rm, et al. diabetes mellitus and diabetic peripheral neuropathy. open j endocr metab dis 2017;07:12–21. 55. rahman mdm, sultana h, jebin fm, et al. health related quality of life in adult with type 2 diabetes mellitus. j diabetes mellitus 2022;12:243–51. 56. öztürk b, angın e, güçhan z, et al. assessment of the plantar pressure, muscle strength and balance in patients with type 2 diabetes mellitus in cyprus. open j endocr metab dis 2016;06:151–8. 57. nomura t, ishiguro t, ohira m, et al. multicenter survey of the isometric lower extremity strength in patients with type 2 diabetes (muscle-std): design and study protocol. j diabetes mellitus 2014;04:251–6. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11732] [page 123] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11733 bay leaf decoction water and low-impact aerobic exercise impact on blood cholesterol levels ismansyah ismansyah,1 arifin hidayat,1 rini ernawati2 1nursing department, politeknik kesehatan kemenkes kalimantan timur, samarinda; 2nursing department, universitas muhammadiyah kalimantan timur, samarinda, indonesia abstract hypercholesterolemia is a global health concern, including in indonesia, potentially leading to coronary artery disease, heart failure, and stroke if left untreated. this study aimed to assess the effectiveness of bay leaf decoction and low-impact aerobic exercise on reducing blood cholesterol levels in patients. used a quasiexperimental design with 120 participants, randomly assigned to two groups, the first group consumed bay leaf decoction (100 ml, twice daily for 7 days), while the second group underwent lowimpact aerobic exercise (3 times a week for 7 days). blood cholesterol levels were measured, and paired t-tests were employed for statistical analysis. results revealed that both interventions significantly lowered cholesterol levels after 7 days (p<0.001 for bay leaf decoction and p=0.001 for low-impact aerobics). the bay leaf decoction group achieved the highest reduction at 25.3 mg/dl. in conclusion, this study highlights the potential of bay leaf decoction and low-impact aerobic exercise as non-pharmacological approaches to manage blood cholesterol levels. it reinforces the notion that these interventions can be valuable in addressing hypercholesterolemia. introduction cholesterol is a fatty substance that circulates in the blood, produced by the liver, and essential for the body’s functioning. approximately 80% of the cholesterol in the blood is produced by the body itself, while the remaining 20% comes from dietary sources.1 however, excessive consumption of cholesterol-rich foods can lead to elevated blood cholesterol levels, a condition known as hypercholesterolemia.2 various factors contribute to hypercholesterolemia, including dietary choices, physical inactivity, obesity, and age.3,4 this condition can lead to serious cardiovascular complications such as coronary heart disease, heart attacks, heart failure, deep vein thrombosis, stroke, and even death.5–7 global data from the world heart report indicates that over 160 million people worldwide have hypercholesterolemia, with total cholesterol levels exceeding 200 mg/dl, which is considered high. furthermore, more than 34 million american adults have total cholesterol levels exceeding 240 mg/dl, which requires therapeutic intervention.8,9 in indonesia, national data from the basic health research shows a prevalence of high cholesterol among individuals aged 15 and above to be 15.8%, with 5.4% in men and 9.9% in women. elevated cholesterol levels increase the risk of coronary heart disease, stroke, and compromised blood circulation.10–12 while hypercholesterolemia is not listed among the top 10 major diseases in samarinda according to the samarinda city health office’s 2022 data, the sempaja samarinda health center has reported the highest number of hypercholesterolemia cases in the health office records.13 correspondence: ismansyah ismansyah, nursing department, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: ismanamin18@gmail.com key words: bay leaf decoction; hypercholesterolemia; low impact aerobics. contributions: ism conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ah conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; re conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, [no. dp.04.03/7.1/07744/2023]. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thankful to poltekkes kemenkes kalimantan timur, universitas muhammadiyah kalimantan timur for their valuable insights and contributions to this study. received: 9 september 2023. accepted: 6 october 2023. early access: 10 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11733 doi:10.4081/hls.2023.11733 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11733] [page 21] non -co mmerc ial us e o nly cardiovascular diseases, as described by hidayat et al. (2021),14 often result from disruptions in lipid metabolism caused by hyperlipidemia or elevated lipid fractions in the bloodstream. the primary lipid fraction disorder is elevated triglycerides, while high levels of low-density lipoprotein (ldl) and cholesterol are major contributors to atherosclerosis.12,15,16 control of hyperlipidemia can be achieved through various means, including non-pharmacological methods such as physical activity and dietary changes, as well as pharmacological interventions.17,18 when lifestyle modifications alone cannot adequately control hypercholesterolemia, pharmacotherapy with chemically synthesized drugs such as niacin and fibrates becomes an alternative. however, these drugs often have side effects like liver toxicity, nausea, abdominal pain, and indigestion.19,20,21 non-pharmacological approaches, such as natural ingredients and physical activities like yoga and aerobic exercises, offer alternative means to manage hypercholesterolemia.22,23–26 utilizing readily available natural ingredients and engaging in physical activities can help reduce hyperlipidemia and hypercholesterolemia, as demonstrated by the effects of basil extract and bay leaves.14,27 bay leaves, or syzygium polyanthum, commonly used as a food flavoring spice in indonesian kitchens, have demonstrated potential in reducing cholesterol levels.28 the use of herbal remedies and natural ingredients has gained popularity worldwide as a means to manage cholesterol levels. this growing interest in herbal medicine aligns with the abundant potential of medicinal plants in indonesia. previous studies have explored bay leaves, often in the form of tea, for their cholesterol-reducing properties.29 research conducted by batool (2020)30 highlighted the phytochemical content of bay leaves, including flavonoids, tannins, eugenol, citric acid, carbohydrates, steroids, alkaloids, triterpenoids, and essential oils. these compounds can function as antioxidants, alleviate stomach discomfort, clear lung mucus, and exhibit antidiabetic properties.30,31 while studies on the reduction of total cholesterol levels remain limited, the phytochemical content of bay leaves suggests potential cholesterol-lowering effects. in this study, researchers explored a different preparation method – bay leaf decoction – as a cost-effective alternative. additionally, physical activity, particularly low-impact aerobic exercise, was chosen as an intervention to impact blood cholesterol levels positively. engaging in aerobic exercise for 50 minutes, three times a week, has been shown to help control blood pressure and lipid levels.32,33 aerobic exercise induces muscle contractions, requiring energy in the form of adenosine triphosphate (atp). the metabolism of atp in mitochondria converts consumed food into energy rather than cholesterol, thereby reducing overall cholesterol levels.34–36 through this study, researchers aimed to investigate the effects of bay leaf decoction and low-impact aerobic exercise on blood cholesterol levels. materials and methods research design this study employed a quantitative quasi-experimental design with a pre-test and post-test group design. the research was conducted from march 14 to june 6, 2023. population and sample the study’s population comprised patients with hypercholesterolemia residing within the service area of sempaja health center, samarinda city, indonesia. the sample consisted of 120 individuals, selected using simple random sampling, and evenly allocated into two groups. inclusion criteria encompassed hypercholesterolemia patients aged 20-50 years, having blood cholesterol levels greater than or equal to 200 mg/dl, the ability to engage in physical activity without assistance, and a willingness to participate as respondents. exclusion criteria included patients with comorbid conditions like stroke and respondents unable to attend or complete the intervention. data collection methods the first group comprised 60 individuals who received an intervention involving the consumption of bay leaf decoction. for this decoction, 10 large dried bay leaves were washed under running water. after washing, the bay leaves were placed in a pot and boiled with 300 ml of water. the mixture was allowed to simmer until it reduced to 150 ml, becoming cloudy and yellow in color. subsequently, the boiled water was strained and measured using a measuring cup, ensuring it amounted to 150 ml before packaging. the resulting decoction was consumed daily, 75 ml in the morning (06:00-07:00) and 75 ml in the afternoon (16:00-17:00), over the course of 1 week. the second group comprised 60 individuals who underwent a low-impact aerobic exercise intervention. this exercise involved light-intensity movements that combined hand, shoulder, and foot movements, such as walking in place and forward-and-backward walking with clapping. the low-impact aerobic exercise routine consisted of warm-up exercises (5 movements), core exercises (11 movements), and cool-down exercises (2 movements). the exercise sessions lasted for 45 minutes, divided into a 10-minute warmup, a 20-minute core exercise, and a 15-minute cool-down. these exercises were performed three times in the morning at 07:00 over the course of 1 week. blood cholesterol levels were measured using blood drawn from the fingertips. measurements were conducted using the gcu meter device (glucose, cholesterol, uric acid), lancet needles, cholesterol test strips, alcohol swabs, hand scoons, and an observation sheet to record the results of blood cholesterol levels. in this study, blood cholesterol levels were measured before the intervention (bay leaf decoction and low-impact aerobic exercise) and again after 7 days of intervention (post-test). data analysis data analysis was performed using the dependent t-test with data processing software. the normality of variables was assessed through a normality test. for pre-test and post-test blood cholesterol levels of bay leaf decoction and low-impact aerobic exercise, paired t-tests were employed, with a significance level set at α=0.05. results a total of 120 participants with hypercholesterolemia were included in the study and divided into two groups, as shown in table 1. the table presents the characteristics of respondents based on age, gender, occupation, education, and duration of hypercholesterolemia at sempaja samarinda health center in 2023. table 1 illustrates the characteristics of the respondents based on age, gender, occupation, education, and duration of hypercholesterolemia. the majority of respondents in both intervention groups were aged 41-50 years, with 63.3% in the bay leaf decoction water group and 50% in the low-impact aerobic exercise group. female respondents predominated in both groups, with 83.3% in the bay leaf decoction water group and 73.3% in the low[page 22] [healthcare in low-resource settings 2023; 11:11733] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly impact aerobic exercise group. furthermore, respondents who were not working constituted a significant portion in both groups, with 60% in the bay leaf decoction water group and 43.3% in the low-impact aerobic exercise group. regarding education, the high school level was predominant in both groups, accounting for 43.3% in the bay leaf decoction water group and 40% in the lowimpact aerobic exercise group. in terms of the duration of suffering from hypercholesterolemia, those with less than 1 year of duration comprised the majority in both groups, with 50% in the bay leaf decoction water group and 23.3% in the low-impact aerobic exercise group. table 2 shows that, in the bay leaf decoction group, mean pretest cholesterol was 269.3 mg/dl (sd 37.3), decreasing to 255.8 mg/dl (sd 37.03) post-test. in the low impact aerobic group, mean pre-test cholesterol was 269.3 mg/dl (sd 35.51), decreasing to 244 mg/dl (sd 35.4) post-test. table 3 illustrates the impact of bay leaf decoction water and low-impact aerobics. significant differences in cholesterol levels were observed for both groups (p<0.001 for bay leaf and p=0.001 for aerobics), with the highest reduction in the bay leaf group at 25.3 mg/dl. discussion this study revealed a significant impact of bay leaf decoction water and low-impact exercise on blood cholesterol levels. these findings indicate a substantial reduction in cholesterol levels in both intervention groups. this study aligns with research conducted by emilia (2023),37 which also demonstrated a significant decrease in cholesterol levels before and after the administration of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents with hypercholesterolemia. characteristics bay leaf intervention group low impact aerobic exercise intervention group n % n % age 20-30 years 6 10.0 20 33.3 31-40 years old 16 26.7 10 16.7 41-50 years old 38 63.3 30 50.0 gender male 10 16.7 16 26.7 female 50 83.3 44 73.3 jobs work 24 40.0 34 56.7 not working 36 60.0 26 43.3 education primary school 20 33.3 6 10.0 junior high 8 13.3 6 10.0 high school 26 43.4 24 40.0 higher education 6 10.0 24 40.0 duration of hypercholesterolemia <1 year 1-3 years 30 50.0 14 23.3 4-7 years 18 30.0 18 30.0 >7 years 10 16.7 22 36.7 2 3.3 6 10.0 total 60 100.0 60 100.0 table 2. blood cholesterol levels before and after bay leaf and aerobic interventions. blood cholesterol levels mean ± sd bay leaf decoction water pre test 269.3 37.30 post test 255.8 37.03 low impact aerobic exercise pre test 269.3 35.51 post test 244 35.40 table 3. paired t-test results for blood cholesterol levels in bay leaf and aerobic exercise groups (pre-test and post-test) pre post difference paired t-test mean ± sd mean ± sd p bay leaf decoction water 269.3±37.30 255.8±37.03 25.30 0.000 low impact aerobics exercise 269.3±35.51 244±35.40 12.00 0.001 [healthcare in low-resource settings 2023; 11:11733] [page 23] non -co mmerc ial us e o nly bay leaf cooking water (p=0.000<α=0.05). the observed reduction in cholesterol levels can be attributed to the active compounds present in bay leaf cooking water, including flavonoids, saponins, tannins, vitamin c, and fiber. these compounds have the potential to lower cholesterol content in the bloodstream.31,38 flavonoids act as antioxidants, preventing lipid peroxidation, while tannins contribute to improved lipid profiles. according to laka (2022),39 saponins found in bay leaves function as hypocholesterolemics by binding cholesterol with bile acids, effectively reducing cholesterol levels. flavonoids and tannins inhibit pancreatic cholesterol esterase, bind to bile acids, and reduce cholesterol solubility in cell membranes, inhibiting cholesterol absorption and ultimately leading to reduced blood cholesterol levels. additionally, other studies, such as the one conducted by mubarak et al.,40 have shown that light and moderate-intensity aerobic exercises have a significant impact on total cholesterol levels (p=0.01 <α=0.05). this effect is attributed to the utilization of fat oxidation as a source of energy when glycogen stores in muscles are depleted. furthermore, the reduction in cholesterol levels observed in the low-impact aerobic exercise group can be explained by the nature of aerobic exercise, which combines specific rhythmic movements. this type of exercise requires energy derived from atp stored in muscles, which is converted into energy during physical activity. aerobic exercise contributes to the reduction of fat deposits in various parts of the body.41,42 according to hwang c, aerobic exercise is an effective method for weight loss and significantly reduces body fat percentage and body weight.43 lowimpact aerobic exercise specifically converts fatty acids into energy, minimizing the potential for excessive sterol core synthesis and, consequently, preventing excessive cholesterol formation.44 continuous-intensity exercise actively affects fat degradation, mainly due to the release of epinephrine and norepinephrine from the adrenal medulla during physical activity, as well as increased lipoprotein lipase enzyme activity. lipoprotein lipase helps transport ldl cholesterol from the bloodstream to the liver, where it is either converted into bile or secreted, resulting in decreased ldl levels.45 this study has several limitations. firstly, it employs a quasi-experimental design, which may have inherent biases and limitations compared to randomized controlled trials. secondly, the variables measured are limited to total blood cholesterol levels, and the study does not include the assessment of high-density lipoprotein (hdl) and ldl levels, which could provide a more comprehensive understanding of lipid profiles. conclusions the intervention involving bay leaf boiled water and lowimpact aerobic exercise offers a cost-effective non-pharmacological therapy option for individuals with hypercholesterolemia, promoting a healthier lifestyle. both interventions have demonstrated their effectiveness in reducing blood cholesterol levels, albeit through different mechanisms. the presence of active compounds in bay leaf cooking water, including saponins, catechins (flavonoids), tannins, vitamin c, and fiber, plays a crucial role in lowering cholesterol levels. it is our hope that individuals will incorporate the regular consumption of bay leaf decoction and engage in consistent physical activity to maintain controlled cholesterol levels. for future research endeavors, the adoption of a randomized controlled trials (rcts) design could be considered, and additional variables such as hdl and ldl levels should be included for a more comprehensive evaluation of lipid profiles. references 1. simonen p, öörni k, sinisalo j, et al. high cholesterol absorption: a risk factor of atherosclerotic cardiovascular diseases? atherosclerosis 2023;376:53-62. 2. doi t, langsted a, nordestgaard bg. dual elevated remnant cholesterol and c-reactive protein in myocardial infarction, atherosclerotic cardiovascular disease, and mortality. atherosclerosis 2023;379. 3. nindya ts, mahmudiono t, rachmah q. the estimation of cholesterol intake in elderly: reliability and validity of short, semi-quantitative food frequency questionnaire (sq-ffq). j nutrition health 2021;54:95-103. 4. kalanjati vp, oktariza rt, suwito be, et al. cardiovascular disease risk factors and anthropometry features among seemingly healthy young adults. int j publ health sci 2021;10:7782. 5. hidayat a, suwondo a, pujiastuti rrse, setiadi r, mulyani ri. effect of sweet basil extract (ocimum basilicum l) on lipid profile of hyperlipidaemia mice (mus musculus). int me j 2021;28:69-72. 6. jazayeri ma, emert mp. sudden cardiac death: who is at risk? med clinics north am 2019;103:913-30. 7. doi t, langsted a, nordestgaard bg. dual elevated remnant cholesterol and c-reactive protein in myocardial infarction, atherosclerotic cardiovascular disease, and mortality. atherosclerosis 2023;379. 8. cesare m di, bixby h, gaziano t, hadeed l, kabudula c, mcghie dv, et al. world heart report 2023: confronting the world’s number one killer. geneva, switzerland; 2023. 9. roth ga, mensah ga, johnson co, addolorato g, ammirati e, baddour lm, et al. global burden of cardiovascular diseases and risk factors, 1990-2019: update from the gbd 2019 study. j am coll cardiol 2020;76:2982-3021. 10. kementerian kesehatan ri. laporan riskesdas 2018 [basic health research report 2018]. laporan nasional riskesdas, 2018. 11. padoli p, suwito j, hariyanto t. self affirmation reduces the anxiety, ldh and troponin i in the clients with coronary heart disease (chd). jurnal ners 2019;14:310-5. 12. bosch j, lonn em, jung h, et al. lowering cholesterol, blood pressure, or both to prevent cardiovascular events: results of 8.7 years of follow-up of heart outcomes evaluation prevention (hope)-3 study participants. eur heart j 2021;42:2995-3007. 13. kalimantan timur dk. penyakit tidak menular atau degeneratif provinsi kaltim tahun 2019-2022. 2022. 14. hidayat a, suwondo a, pujiastuti rrse, setiadi r, mulyani ri. effect of sweet basil extract (ocimum basilicum l) on lipid profile of hyperlipidaemia mice (mus musculus). int med j 2021;28(1):69-72. 15. simonen p, öörni k, sinisalo j, et al. high cholesterol absorption: a risk factor of atherosclerotic cardiovascular diseases? atherosclerosis 2023;376:53-62. 16. mohamed-yassin ms, baharudin n, daher am, et al. high prevalence of dyslipidaemia subtypes and their associated personal and clinical attributes in malaysian adults: the rediscover study. bmc cardiovasc disord 2021;21. 17. adi ac, tawakal ai, rasyidi mf, et al. effect of cocoa husk criollo tea on hypercholesterolemia in animal model. foods raw mat 2023;11:206-14. 18. who. world health statistics 2023: monitoring health for the [page 24] [healthcare in low-resource settings 2023; 11:11733] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly sdgs, sustainable development goals. 2023. 19. andrianto, puspitasari m, ardiana m, et al. association between single nucleotide polymorphism slco1b1 gene and simvastatin pleiotropic effects measured through flow-mediated dilation endothelial function parameters. ther adv cardiovasc dis 2022;16. 20. widada w, ontoseno t, purwanto b, et al. the effect of the blood cupping therapy on high density lipoprotein (hdl) and low density lipoprotein (ldl) in hypercholesterol patients. indian j forensic med toxicol 2020;14:3556-62. 21. pirillo a, catapano al. pitavastatin and hdl: effects on plasma levels and function(s). atheroscler suppl 2017;27:e1-9. 22. asiah ass, norhayati mn, muhammad j, muhamad r. effect of yoga on anthropometry, quality of life, and lipid profile in patients with obesity and central obesity: a systematic review and meta-analysis. complement ther med 2023;76:102959. 23. antunes bm, rossi fe, oyama lm, et al. exercise intensity and physical fitness modulate lipoproteins profile during acute aerobic exercise session. sci rep 2020;10:4160. 24. antunes bm, rosa-neto jc, batatinha hap, et al. physical fitness status modulates the inflammatory proteins in peripheral blood and circulating monocytes: role of ppar-gamma. sci rep 2020;10:14094. 25. pan b, ge l, xun y qin, et al. exercise training modalities in patients with type 2 diabetes mellitus: a systematic review and network meta-analysis. int j behavioral nutrition physical activity 2018;15:72. 26. kuete v. other health benefits of african medicinal spices and vegetables. in: kuete vbtms and v from a, editor. medicinal spices and vegetables from africa: therapeutic potential against metabolic, inflammatory, infectious and systemic diseases. academic press; 2017. p. 329-49. 27. batool s, khera ra, hanif ma, ayub ma. bay leaf. in: hanif ma, nawaz h, khan mm, byrne hjbtmp of sa, editors. medicinal plants of south asia: novel sources for drug discovery. elsevier; 2020. p. 63-74. 28. aditya r, santoso b, widjiati w. anti-inflammatory and antioxidant potential of syzygium polyanthum (wight) walp. bioactive compounds in polycystic ovary syndrome: an in silico study. j pharm pharmacogn res 2022;10:725-36. 29. susyani, zurio a, terato. the bay leaves tea can decrease cholesterol levels of patients with cardiovascular disease. world j adv healthc res 2020;4:173-7. 30. batool s, khera ra, hanif ma, ayub ma. bay leaf. in: medicinal plants of south asia: novel sources for drug discovery. elsevier; 2019. p. 63-74. 31. batool s, khera ra, hanif ma, ayub ma. bay leaf. in: hanif ma, nawaz h, khan mm, byrne hjbtmp of sa, editors. medicinal plants of south asia: novel sources for drug discovery. elsevier; 2020. p. 63-74. 32. liu x, he m, gan x, et al. the effects of six weeks of fasted aerobic exercise on body shape and blood biochemical index in overweight and obese young adult males. j exerc sci fit 2023;21:95-103. 33. karami h, dehnou vv, nazari a, gahreman d. regular training has a greater effect on aerobic capacity, fasting blood glucose and blood lipids in obese adolescent males compared to irregular training. j exerc sci fit 2021;19:98-103. 34. babaei bonab s, parvaneh m. effect of 12-week of aerobic exercise on hormones and lipid profile status in adolescent girls with polycystic ovary syndrome: a study during covid19. sci sports 2023;38:565-73. 35. costa rr, buttelli ack, fagundes a de o, fonseca ga, pilla c, barreto mf, et al. the beneficial effects of a water-based aerobic exercise session on the blood lipids of women with dyslipidemia are independent of their training status. clinics (sao paulo) 2020;75:e1183. 36. ghamarchehreh me, shamsoddini a, alavian sm. investigating the impact of eight weeks of aerobic and resistance training on blood lipid profile in elderly with non-alcoholic fatty liver disease: a randomized clinical trial. gastroenterol hepatol bed bench 2019;12:190-6. 37. emilia e. efektivitas pemberian rebusan daun salam terhadap kolesterol total dengan hiperkolesterolemia di wilayah kerja puskesmas desa gedang kota sungai penuh provinsi jambi tahun 2022. jurnal multidisiplin dehasen (mude). 2023 may;2(2 se-ilmu kesehatan). 38. hartanti l, yonas smk, mustamu jj, et al. influence of extraction methods of bay leaves (syzygium polyanthum) on antioxidant and hmg-coa reductase inhibitory activity. heliyon 2019;5:e01485. 39. laka k, makgoo l, mbita z. cholesterol-lowering phytochemicals: targeting the mevalonate pathway for anticancer interventions. front genet 2022;13:841639. 40. mubarak s, kinanti rg, raharjo s. pengaruh senam aerobik intensitas ringan dan sedang terhadap kadar kolesterol total pada perempuan obes di kota batu [the effects of light and moderate intensity aerobic exercise on total cholesterol levels in obese women in the city of batu]. j sport sci 2019;9(1). 41. yol y, turgay f, yigittürk o, et al. the effects of regular aerobic exercise training on blood nitric oxide levels and oxidized ldl and the role of enos intron 4a/b polymorphism. biochimica et biophysica acta (bba) molecular basis of disease 2020;1866:165913. 42. antunes bm, rossi fe, oyama lm, et al. exercise intensity and physical fitness modulate lipoproteins profile during acute aerobic exercise session. sci rep 2020;10:4160. 43. hwang cl, lim j, yoo jk, et al. effect of all-extremity highintensity interval training vs. moderate-intensity continuous training on aerobic fitness in middle-aged and older adults with type 2 diabetes: a randomized controlled trial. exp gerontol 2019;116:46-53. 44. fraccari-pires n, coelho-júnior hj, gambassi bb, et al. cardiovascular autonomic responses to aerobic, resistance and combined exercises in resistance hypertensive patients. de athayde costa e silva a, editor. biomed res int 2022;2022:8202610. 45. chiu yh, tsai sc, lin cs, et al. effects of a 12-week walking intervention on circulating lipid profiles and adipokines in normal weight and abdominal obese female college students. j exerc sci fit 2023;21:253-9. healthcare in low-resource settings 2023; 11:11733] [page 25] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11872 comparison of the effect of interactive and non-interactive education on the self-efficacy of covid-19 patients nosrat alamzadeh,1 mahin naderifar,2 abdolghani abdollahimohammad,3 mohammad reza firouzkohi,2 mahin badakhsh,1 zohre sadat hashemi bonjar4 1faculty of nursing and midwifery, zabol university of medical sciences, zabol; 2department of medical surgical nursing, faculty of nursing and midwifery, zabol university of medical sciences, zabol; 3nursing department, school of nursing and midwifery, zabol university of medical sciences, zabol; 4instructor of healthcare services management, department of midwifery, school of nursing and midwifery, zabol, iran abstract the purpose of the present study was to investigate the effect of interactive and non-interactive education on the self-efficacy of covid-19 patients. this is a randomized clinical trial that was conducted on 80 covid-19 patients in zahedan in 2022. the samples were randomly assigned to intervention (interactive) and control (non-interactive) groups (n=40 people per group). the patients of each group received two initial education sessions in the hospital and at the time of discharge. patients of the intervention group participated in 5 sessions of face-to-face interactive education along with practical education using a video projector by the researcher. the control group only received education ions by ward nurses during discharge and only one educational pdf file was given to them to study. the results showed that the mean and standard deviation of the self-efficacy score of the patients of the two interactive and non-interactive education groups did not differ significantly before the intervention (p=0.024), but it was significantly higher in the interactive education group than the non-interactive education group (p<0.0001). that is, the mean and standard deviation of the self-efficacy score of patients in the interactive education group increased significantly from 49.8±14.77 to 96.77±18.29. the same score in the non-interactive education group increased from 57.85±16.35 to 62.45±14.52, which was not a significant increase. the results showed this intervention helps patients to make informed decisions about their goals, treatments, and self-care behaviors. introduction covid-19 disease was a pandemic with social problems1 for different societies, which affected all important economic, political, social, and even military aspects of all countries of the world due to the lack of permanent treatment.2,3 due to the pathogenic nature of this virus, the speed of its spread, and also its subsequent deaths, this disease may have different effects on the mental health of people at different levels of society, from patients, health care workers, children, families, students, psychological patients and even the personnel of different jobs. therefore, in the current high-risk situation, it is necessary to identify people prone to psychological disorders at different levels of society, whose mental health may be endangered, so that the mental health of these people can be maintained using appropriate psychological solutions and techniques.4,5 in this regard, numerous previous types of research on covid-19 survivors showed a high prevalence of a number of these psychological disorders including anxiety and especially death anxiety,2 fear, depression, emotional changes, insomnia, and post-traumatic stress disorder among these patients, which in turn have had a great impact on their self-efficacy.6,7 self-efficacy is basically an important concept in bandura’s theory of social cognition and means a person’s belief in the ability to respond to a specific situation. this means that efficacy expectations have an effect on people’s choices, hope, level of effort and persistence, resistance to difficulties and problems, and vulnerability to diseases.8 according to the perspective of social cognitive theorists, people who are efficacious against stressors, will be less vulnerable to stressors, and social dysfunction.9 a relationship has been reported between low self-efficacy and depressive symptoms in covid-19 survivors.8 correspondence: mahin naderifar, faculty of nursing and midwifery, zabol university of medical sciences, zabol, iran. e-mail: mmnadnad@gmail.com key words: interactive education, non-interactive education, self-efficacy, covid-19. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of zabol university of medical sciences approved this study (ir.zbmu.rec.1401.025). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: hereby, the authors would like to express their thanks to all the patients and nurses for their cooperation. received: 25 september 2023. accepted: 24 november 2023. early access: 7 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11872 doi:10.4081/hls.2023.111872 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11872] [page 265] non -co mmerc ial us e o nly the panic responses of people to this disease make a person very vulnerable mentally and psychologically. the results of studies show a very high level of death anxiety among covid-19 patients. death anxiety is a multifactorial phenomenon that affects recovery and severity of illness. on the other hand, there are factors that increase fear such as the nature of the pandemic, hospitalization, insufficient knowledge about covid-19 and its treatments, unknown prognosis of the disease, use of protective equipment by doctors and medical staff, poor communication skills medical staff.4 it is clear that a person who has lost hope will not have a good life even after recovery. therefore, these patients need psychological support and necessary education to fight this disease during the post-recovery period.10 covid-19 is one of the diseases the patient has a major contribution in its treatment, therefore, the use of an appropriate, interactive, and patient-centered educational method that improves the patient’s adherence and participation in self-care behaviors may increase the self-efficacy of these patients.11 researchers have provided different educational methods in this regard. for example, hesarki et al. have stated that social networks and webinars play a significant role in increasing the level of awareness of covid19.12 shaygan et al. (2023) have also investigated the effect of interactive psychoeducational online interventions (social networks) on the self-efficacy and anxiety of covid-19 patients.13 interactive education is one of the effective methods of learning. lectures are effective in the cognitive domain of university students’ learning. while in order to increase people’s practice, their knowledge, attitude, and practice must change at the same time.14 interactive learning is one of the most effective teaching methods in this regard. this method enables the use of multimedia features as well as the combination of text, sound, and image, learners being active, repetition, and providing feedback. in this method, which is called the active method of teaching, in addition to the fact that the teacher plays an active role in the class and explains the content to the audience, the audience also has a central role and actively participates in the discussions and asks their questions.15 this method enhances mental engagement in the discussed topic, and also increases the level of learning, strengthens thinking, and raises the level of information in the teacher and audience.16 while the one-way transfer of information is used (such as animated films, slides, and television) in non-interactive learning where the audience is considered the only information recipient and does not perform any activity in response to the information provided, and as a result, they are passive learners.17 overall, the evaluation must be first carried out by the individual him/herself, and this learning approach (non-interactive learning) is distinguished from other educational methods since the learner’s need is regarded as the standard and the basis for the end of teaching. therefore, this type of teaching method has diagnostic, corrective, and therapeutic aspects. that is, a person feels the adjustment or non-adjustment of the required knowledge and skills in an experimental and perceptible manner and spontaneously strives to achieve balance on his own.18 patient education is one of the most important duties of nurses, especially in the case of such a disease that has caused high mortality, and has imposed a lot of work pressure and psychological stress on all people, especially nurses.1,4,19 therefore, it is very important to choose an efficient patient education method that increases the patient’s self-efficacy and accelerates his recovery. therefore, taking into account the characteristics of the interactive method and the fact that there is limited research on this educational method in covid-19 survivors in iran,20 on the one hand, and considering the importance of self-efficacy of covid-19 patients, on the other hand, the purpose of the present research was to compare the effect of interactive and non-interactive education on the self-efficacy of covid-19 patients. materials and methods this was a randomized clinical trial that was conducted on 80 covid-19 patients admitted to ali bin abi taleb hospital of zahedan in 2022. a total of 80 people were selected using the convenience random sampling method and were assigned to the interactive education group and non-interactive education group (n=40 per group). the sample size was estimated to be 40 people per group based on a similar study by amiri et al.17 with a 99% confidence interval and a test power of 80%, taking into account 20% drop-out. inclusion criteria included being admitted for at least 48 hours, having a positive pcr test, being over 18 to 70 years old, submitting informed consent, having at least reading and writing literacy, confirmed coronavirus, contracting coronavirus for the first time, and absence of a history of mental disorders. exclusion criteria also included withdrawing from the study for any reason, death or worsening of the disease conditions, one of the firstdegree family members being affected by the disease, participation in other educational courses related to the research topic during the duration of the study, and being transferred to another hospital ward. the data collection tools include a demographic characteristics checklist, which includes questions on the patient’s gender, occupation, age, marital status, and level of education) and supph, which is based on bandura’s self-efficacy theory. this 29item instrument was used to measure self-efficacy and questions are answered based on a five-point likert scale including very low confidence = 1, low confidence = 2, moderate confidence = 3, high confidence = 4, and very high confidence = 5. it also consists of three areas of stress reduction (10 questions), decision-making (3 questions), and positive attitude (16 questions). the possible scores range is 29 to 145, and higher scores indicate higher selfefficacy. this questionnaire was used by tsi & hong. they reported a reliability coefficient of 0.93. this questionnaire has also been approved by moatarian (2012) and royani (2013) with α = 0.91 and α = 0.93 in iran, respectively. first, a written letter of introduction, the necessary permission, and the code of ethics (ir.zbmu.rec.1401.025) were obtained from the relevant authorities. 80 eligible hospitalized covid-19 survivors were selected using convenience sampling and according to the study inclusion criteria, and the objectives of the research were explained to them. other ethical considerations included obtaining informed consent to participate in the research, and assuring the patients about the confidentiality of anonymity of their information. questionnaires were first given to the patients to collect primary data. then, using the needs assessment form, the educational needs of the research samples were determined, and the educational intervention content was designed based on the needs assessment conducted by nursing and medical sources. then each patient was given a number from 1 to 80 and the patients were randomly divided into two groups a and b. then the people of groups a and b (n=40 people per group) received the interactive and non-interactive education by drawing lots. the patients then received the first two education sessions on the last days of hospitalization and at the time of discharge. then, according to the extracted needs and based on the date of the patients’ visit for monthly visits, they were divided into 4 groups (n= 10 people per group). the patients of each group received two initial education article [page 266] [healthcare in low-resource settings 2024;12:11872] non -co mmerc ial us e o nly sessions in the hospital and at the time of discharge, and continued education face to face during 5 sessions with a maximum of 60min duration and a maximum of 6-day intervals. first, an interactive educational intervention was designed for covid-19 patients. this intervention was performed for at least 7 sessions, and approved by the professors of the research team. the maximum duration of each session was considered 60 minutes based on the patient’s desire or her/his learning level. the first and second sessions were held for both groups twice, i.e. during hospitalization and upon discharge. then, the remaining 5 educational sessions were held for the intervention group upon referral to ali bin abi talib of zahedan hospital after discharge in the educational classrooms of the above hospital. the educational content of each session was taught to the patient in an interactive way, i.e. face-to-face with practical education and using a video projector, then the patient was asked to express the educational content in his own language. if the patient did not understand the content correctly, he was taught the educational content again. one month after the intervention, in order to encourage participants to follow the education materials, they were contacted via telephone based on the predetermined time schedule, and their questions were answered. the patients of the non-interactive group received routine education during discharge by the ward nurses according to the referral procedure and were given only one educational pdf file to study. one month after the intervention, the patients of both groups were contacted and an appointment was made where the patients’ selfefficacy was measured again using the same questionnaires. in order to perform statistical analysis, the data was collected, coding, and entered into spss software ver. 21. necessary permissions were obtained from the university research center and the ethics committee. explanations regarding the confidentiality of the information and obtaining informed consent were given to the patients. to ensure ethical considerations, all educational content was provided to them and their questions were also answered when the questionnaires were completed. results the results of the demographic questionnaire showed that there were 18 women and 22 men in the interactive group and 20 men and 20 women in the non-interactive group. with regard to gender, 55% of the covid-19 patients in the interactive education group and 50% of the patients in the non-interactive education group were male. the chi-square test showed no statistically significant difference between the two studied groups in terms of gender distribution (p=0.82). with regard to marital status, 62.5% of covid-19 patients in the interactive education group and 75% of patients in the non-interactive group were married. the chi-square test showed no statistically significant difference between the two groups in terms of marital status (p=0.33). with regard to employment status, 30% of the covid-19 patients in the interactive education group and 32.5% of cases in the non-interactive education group were housewives. the result of the pearson chi-square test also showed no significant difference between the two groups in terms of employment status (p=0.29). regarding the educational level of the covid-19 patients, only 13.8% of the patients in the interactive education group and 42.5% of the patients in the noninteractive group had a bachelor’s degree or higher. the chi-square test showed no statistically significant difference between the two article table 1. frequency distribution of demographic information of covid-19 patients in two groups of interactive and non-interactive education. variable group frequency (%) test statistic* p interactive non-interactive gender 0.2 0.82 female 18 (45) 20 (50) male 22 (55) 20 (50) marital status 0.45 0.33 single 15 (37.5) 10 (25) married 25 (62.5) 30 (75) employment status 0.96 0.29 unemployed 11 (27.5) 9 (22.5) housewife 12 (30) 13 (32.5) self-employed 9 (22.5) 9 (22.5) employee 8 (20) 9 (22.5) level of education 0.41 0.31 reading and writing 7 (8.8) 10 (25) high-school diploma 15 (18.8) 10 (25) associate degree 7 (8.8) 3 (7.5) bachelor's degree and higher 11 (13.8) 17 (42.5) * chi-square test. table 2. comparison of the mean and standard deviation of the self-efficacy score of covid-19 patients before and after the intervention in the interactive and non-interactive groups. self-efficacy mean ± sd t score 95% confidence interval p intervention (interactive) control (non-interactive) before intervention 49.8±14.77 57.85±16.35 2.310 45.720 p=0.24 after intervention 96.77±18.29 62.45±14.52 9.293 103.585 p<0.0001 [healthcare in low-resource settings 2024;12:11872] [page 267] non -co mmerc ial us e o nly groups in this regard (p=0.35) (table 1). the results of the independent t-test showed no significant difference between the interactive and non-interactive groups in terms of the mean and standard deviation of the self-efficacy score before the intervention (p=0.024), but the same score increased more significantly in the interactive education group than the non-interactive education group after the intervention (p<0.0001). that is, this score in the interactive education group increased significantly from 49.8±14.77 to 96.77±18.29 and from 57.85±16.35 to 62.45±14.52 in the non-interactive education group (table 2). discussion and conclusions the purpose of the present study was to compare the effect of interactive and non-interactive education on the self-efficacy of covid-19 patients admitted to ali bin abi taleb zahedan of hospital in 2021. the results showed a significant increase in the mean and standard deviation of the self-efficacy score of the patients in the interactive education group from 49.8±14.77 to 96.77±18.29 (p<0.0001) but there was no significant increase in the above score in the non-interactive education group (57.85±16.35. to 62.45±14.52) (p=0.39). shub et al.’s showed that interactive education outperforms the conventional self-efficacy method, which is consistent with the present study.18 in a study on the effect of patient simulation education on the ease of learning and self-efficacy of nursing and medical students of mazandaran university of medical sciences, kolaie et al. also showed that simulation is an interactive teaching technique that helps the person to learn without fear of personal weaknesses or harming the client through interactive activities by enabling him to experience a safe clinical environment partly or fully, which is consistent with the results of this study.21 rahmanipour et al. (2020) also showed that the mean treatment adherence score in the interactive group increased significantly after the interactive intervention, while there was little change in the non-interactive education group in this regard. the difference was statistically significant, which is consistent with the results of our study.14 the results of the study by zarshenas et al. (2017) also showed that both interactive and non-interactive methods increased students’ knowledge of healthy bones and self-efficacy, self-efficacy scores increased significantly after education in both groups, and students obtained almost two-thirds of the total scores, which thus showed a greater effect on the interactive multimedia group that.22 according to the study of shaygan et al. (2020), interactive psycho-educational interventions were effective in increasing selfefficacy and positive attitude and reducing stress in covid-19 patients under home quarantine conditions, which is consistent with our study.13,14 in a study on the effectiveness of interactive diabetes management education on the self-care of diabetic patients, amiri et al. concluded that interactive education is also effective in the selfcare of diabetic patients, which is consistent with the results of the present study.17 merrill et al. (2022) showed that the interactive relationship between the patient and the therapist improves the self-care of patients. in his research, ayoobi came to the conclusion that cooperative and interactive learning increases academic progress more than traditional learning.23 to explain the effect of the interactive method compared to the non-interactive method, it seems that due to the need for patients to be active in the interactive learning method and considering that one of the essentials for the proper implementation of the interactive learning method is the continuous activity of the group members and their exchange of opinions with each other and also the appointment of one person as the spokesperson of the group. however, the patients of the noninteractive group are mostly silent and passive and just listen to their teacher. however, patients of the interactive learning group are required to meticulously receive the opinions of other members, and they are thus obliged to provide logical and reasoned answers in order to accept or reject their opinions, which may in turn improves their self-efficacy. interventions help patients make informed decisions about treatment goals and methods and self-care behaviors and feel responsible for their own management, which is thus highly effective. also, interactive education increases the knowledge and skill of managing the situation, self-awareness, and individual independence and enables the patients to accept individual care. in this method, patients are sufficiently educated about the disease, the interaction between life and covid-19, its symptoms, and how to manage it, so, they can choose personalized goals for self-care and achieve them. the limitations of the present study include caution in generalizing the results to all patients and a lack of complete control of all influencing variables. it is suggested to investigate the longer-term effects of these interventions by conducting follow-ups in similar studies. references 1. mohammad aa, firouzkouhi mr. qualitative research in covid 19 pandemic. journal of shahid sadoughi university of medical sciences. 2021: 29 3448-52 2. firouzkouhi m, abdollahimohammad a, alimohammadi n, et al. lived experiences of critically ill covid-19 patients about death and dying: a descriptive phenomenology. omegaj death dying 2022:00302228211073269 3. liu x, na r, bi z. challenges to prevent and control the outbreak of covid-19. zhonghua liu xing bing xue za zhi= zhonghua liuxingbingxue zazhi. 2020: 994 4. firouzkouhi m, abdollahimohammad a, rezaie-kheikhaie k, et al. nurses’ caring experiences in covid-19 pandemic: a systematic review of qualitative research. health sci rev 2022:100030 5. li s, wang y, xue j, et al. the impact of covid-19 epidemic declaration on psychological consequences: a study on active weibo users. int j environ res public health 2020;17:2032. 6. bao y, sun y, meng s, et al. 2019-ncov epidemic: address mental health care to empower society. lancet 2020;395:e37e38. 7. bo h-x, li w, yang y, et al. posttraumatic stress symptoms and attitude toward crisis mental health services among clinically stable patients with covid-19 in china. psychol med 2021;51:1052-1053. 8. 8 yao h, chen j-h, xu y-f. patients with mental health disorders in the covid-19 epidemic. lancet psychiatry 2020;7:e21. 9. gandoy-crego m, clemente m, gómez-cantorna c, et al. self-efficacy and health: the seh scale. am j health behav 2016;40:389-95. 10. khadivzadeh t, seighalani mas, mirzaii k, mazloum sr. the effect of interactive educational workshops with or without standardized patients on the clinical skills of midwifery students in providing sexual health counseling. article [page 268] [healthcare in low-resource settings 2024;12:11872] non -co mmerc ial us e o nly simul healthc 2020;15:234-242. 11. habibinezhad z, parvaresh masoud m, vahedian m, akbari m. the effect of interactive training on emergency nurses’ readiness and attitude through triage in fasa city hospital 1397. iranian j nurs res 2021:28 12. hesaraki m, akbarizadeh m, ahmadidarrehsima s, et al. knowledge, attitude, practice and clinical recommendations of health care workers towards covid-19: a systematic review. rev environ health 2020;36:345-357. 13. shaygan m, yazdani z, rambod m. the effect of interactive virtual psycho-educational interventions via social networks on self-efficacy and anxiety among patients infected with covid-19 and living in home quarantine: a randomized control trial. iranian j nursing midwif res 2023:65. 14. pour er, aliyari s, farsi z, ghelich y. comparing the effects of interactive and noninteractive education using short message service on treatment adherence and blood pressure among patients with hypertension. nursing midwif studies 2020:68. 15. haramiova z, stasko m, hulin m, et al. the effectiveness of daily sms reminders in pharmaceutical care of older adults on improving patients’ adherence to antihypertensive medication (sppa): study protocol for a randomized controlled trial. trials 2017;18:334. 16. gharaati f, aghamolaei t, davoodi sh, et al. effect of a mobile-phone mediated based education on self-care behaviors of patients with thalassemia major. j caring sci 2019;8:149155. 17. amiri m, mobareke ka, oreyzi shr. comparison of the effectiveness of interactive diabetes management education and stress inoculation training on the self-care of type ii diabetic patients. j res behav sci 2018:549. 18. shoob a-e, abbasi g-o, mirzaian b. comparing the efficiency of task-based interactive language teaching and task-based language teaching on language learners’ fear of negative evaluation in university heterogeneous classes. j english language pedagogy practice 2019:1 19. hemmat a, hemmat j, pirzeh r, dadashi m. the effectiveness of group therapy based on acceptance and commitment to reduce obsessive-compulsive use of substance, anxiety and depression of addicts under methadone treatment. j adv medical biomed res 2018:109. 20. soltanian a, khatiban m, karbasi f. the effects of teaching the communication skills to patients through role-playing method on nursing students' self-efficacy. sci j hamadan nurs midwif faculty 2019:2819. 21. roh ys, lee ws, chung hs, park ym. the effects of simulation-based resuscitation training on nurses' self-efficacy and satisfaction. nurse educ today 2013;33:123-8. 22. zarshenas l, keshavarz t, momennasab m, zarifsanaiey n. interactive multimedia training in osteoporosis prevention of female high school students: an interventional study. acta medica iranica 2017:514. 23. merriel a, ficquet j, barnard k, et al. the effects of interactive training of healthcare providers on the management of life-threatening emergencies in hospital. cochrane database syst rev 2019;9:cd012177. article [healthcare in low-resource settings 2024;12:11872] [page 269] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11769 increased knowledge through video-based dental health promotion: exploring the impact of new habits adaptation sekar restuning, irwan supriyanto, nurul fatikhah, denden ridwan chaerudin, siti fatimah dental health department, politeknik kesehatan kemenkes bandung, indonesia abstract education is a key factor that imparts knowledge essential for keeping pace with advancements in science and technology. one viable approach for delivering dental health education, particularly in the context of tooth brushing, is through the utilization of videos. videos make it easier to remember and comprehend lessons as they engage multiple senses. this study aimed to evaluate the knowledge enhancement achieved through the use of dental health promotion videos. the research employed a quasi-experimental design with a quantitative approach, specifically a pre-test and post-test control group design. the sample, comprising 60 students, was selected through purposive sampling, wherein samples were deliberately chosen based on specific considerations. the investigation aimed to evaluate the impact of dental health promotion by utilizing online methods with videos during the adaptation period to new habits. the p-value of 0.001 (p<0.05) indicates a significant difference between the intervention and control groups. the average score in the intervention group was 42.74, while in the control group it was 18.25. the application of the learning model for managing dental health promotion through the online method using videos demonstrated notable benefits. video media enables a closer observation of movements, saves time, and allows for the repetition of recordings. videos fall under the category of audio-visual media, engaging both the sense of hearing and the sense of sight. introduction coronavirus disease 2019 (covid-19) is a global health challenge that is persisting in causing both health emergencies and mental health crises worldwide.1 covid-19 is an infectious disease caused by a newly discovered type of coronavirus, the cov2 sars virus, which infects humans and leads to covid-19, a potentially deadly condition.2,3 according to all available investigations, the ecological origin of sars-cov-2 is in bat populations.4 covid-19 primarily spreads through respiratory droplets produced when an infected person coughs, sneezes, talks, or breathes.5 the disease was first identified in december 2019 in wuhan, the capital of china’s hubei province.6 the world health organization (who) declared it a pandemic, shocking the world and leading to the postponement of learning activities by most educational institutions.7,8 the high number of cases and deaths caused by covid-19, particularly in children, is the reason schools must remain closed for an extended period.9 the government has urged people to work, study, and worship from home to reduce the number of individuals exposed to covid-19.10 the indonesian government issued circular letter number 4 of 2020 concerning the implementation of educational policies in the emergency period for the spread of covid-19. this circular prohibits offline learning at all levels of education and replaces it with online learning.11 learning activities are conducted online to prevent the spread of covid-19.12,13 teachers must ensure that teaching and learning activities continue even though students are at home. the solution is for teachers to design learning media as an innovation by utilizing online platforms.14-16 online learning utilizes the internet network with flexibility, accessibility, connectivity, and the capability to facilitate various learning interactions, thus enhancing the learning process.17,18 students can utilize communication devices, computers, software, correspondence: sekar restuning, dental health department, politeknik kesehatan kemenkes bandung, indonesiae-mail: sekar.reztu@gmail.com key words: video learning model; dental health knowledge; new habits adaptation. contributions: sr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; nn, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ts, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; hh, methodology, visualization, writing – review & editing; dp, formal analysis, validation, writing – review & editing; ss, da, mu, resources, supervision, and writing –review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, team of the bandung health polytechnic, based on ethical certificate no.03/kepk/te/vii/21. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 11 september 2023. accepted: 27 november 2023. early access: 18 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11769 doi:10.4081/hls.2024.11769 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11769] [page 487] non -co mmerc ial us e o nly and the internet as learning media, with teaching tailored to individual needs.19,20 unesco said it supports implementing largescale distance learning programs and platforms to reach students remotely. the united nations educational, scientific and cultural organization (unesco) has expressed support for the implementation of large-scale distance learning programs and platforms to reach students remotely. moreover, in an effort to mitigate the spread of the coronavirus, schools were suspended in more than 190 countries, impacting more than 1.6 billion learners.21 the impact of the covid-19 pandemic is now starting to affect the realm of education, leading central and regional governments to enact policies to close all educational institutions.22-24 results of preliminary research conducted on the impact of covid-19 on the implementation of online learning in elementary schools indicate that online learning can effectively break the chain of transmission of covid-19.25 the study results show that implementing online learning can be done well to break the chain of transmission of covid-19.26 in relation to the student activity sheets for distance learning based on scientific literacy, specifically on the topic of covid-19, it was noted that the worksheets needed evaluation before wider use could be considered.27 the primary objective of this study was to comprehend the increase in knowledge using video for dental health promotion. video media allows for a closer observation of movements, saves time, and permits the repetition of recordings, thereby facilitating the absorption of knowledge. videos are categorized as audio-visual media because they engage the senses of hearing and sight. materials and methods the research design employed in this study was quasi-experimental, utilizing a quantitative approach, specifically the pre-test and post-test control group design. the sample, consisting of 60 students, was determined through purposive sampling, deliberately selecting samples based on specific considerations. the inclusion criteria for subjects in this study were elementary school children in grades 1, 3 or 5 and elementary school children whose parents owned and were able to operate a smartphone. the aim was to assess the effect of dental health promotion using online methods with videos during the adaptation period to new habits.28 in evaluating the intervention group, the level of dental health knowledge was assessed before and after treatment with the learning model for management of dental health promotion using the online method with videos during the new habits adaptation period. for the control group, to fulfill ethical considerations, the intervention involved providing a learning model for health promotion management using alternative media.29 the analysis aimed to assess the relationship between the independent and dependent variables by analyzing data from two variables. the significance of this relationship was determined using the sample kolmogorov-smirnov test for normality. the analysis before and after treatment was conducted using the mann-whitney test. the research has obtained ethical approval from the health research ethics commission, a team of the bandung health polytechnic, based on ethical certificate no. 03/kepk/te/vii/21. throughout the research, the researcher has adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. in this study, a 95% confidence level (zα=1.96), a 90% power test (zβ=1.282), and an effect size from a previous study of 0.56 were utilized.29 subsequently, the number of samples obtained for each group is 60 respondents, determined by referencing the results from the sample formula table.30 results this research was conducted at an elementary school in cirebon regency, where 60 students were divided into an intervention group and a control group. in the intervention group, there were 10 men and 20 women, while in the control group, there were 13 men and 17 women (table 1). the study’s results comprised knowledge data assessed both before and after providing learning videos to elementary school students during the adaptation period to new habits. table 2 illustrates the difference in the average scores of students’ knowledge, starting from day 1, with the intervention group scoring an average of 12.00 and the control group scoring 12.03. on day two, the average knowledge score in the intervention group was 22.13, while the control group scored 16.83. on day 3, the average score for the intervention group was 28.33, compared to the control group’s score of 19.93. table 3 indicates that the significance value of the p-value is 0.001 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic characteristics. sex intervention control n % n % male 10 33.3 13 43.3 female 20 66.7 17 56.7 table 2. description of knowledge in the intervention group and control group. intervention group control group 1 2 3 1 2 3 mean 12.00 22.13 28.33 12.03 16.83 19.93 minimum 7 15 25 7 9 12 maximum 25 30 30 25 30 30 table 3. results of analysis (mann-whitney): the effect of learning models on the management of dental health promotion using online methods with video. variable total mean p intervention group 30 42.75 0.001 control group 30 18.25 0.001 [page 488] [healthcare in low-resource settings 2024;12:11769] non -co mmerc ial us e o nly (p<0.05), signifying a significant difference between the intervention and control groups. this implies that the application of the learning model for the management of dental health promotion using the online method with video is more effective in increasing knowledge compared to using other media. discussion dental and oral health promotion is a process of providing information that arises on the basis of dental and oral health needs with the aim of producing good dental and oral health and improving the standard of living. efforts have been made to provide media that is easy to understand and accessible to the public. media is one of the things that needs to be considered when carrying out health promotion. the media commonly used in health promotion, namely audio-visual, is a good medium to use because it involves the senses of hearing and sight. one alternative for providing dental health education, especially brushing teeth, is to use videos. video is an example of audio-visual media. it is hoped that using video as a learning medium can increase students’ interest in learning. the research results show that students’ interest in learning can increase by choosing the right media in accordance with technological developments and environmental conditions so that learning objectives can be achieved optimally.31 the application of the learning model for managing dental health promotion using online methods using videos is more effective in increasing knowledge, as seen from the increase in students’ average knowledge scores. according to research results, videos will produce effects in terms of cognitive, affective, and behavioral aspects.32 video is included in audiovisual media because it involves the senses of hearing and sight. its benefits for promoting dental health include being able to observe more closely what is moving, saving time, and the recording being playable repeatedly, making it easier to absorb knowledge. the dental health promotion videos that are made can be played repeatedly so that students can easily remember and understand the lesson because they do not use one type of sense. the results of mell silberman’s research show that using visual learning can increase memory by 14% to 38%; according to them, by using videos, children will be more interested.33 one of the challenges and considerations is that the development of information and communication technology can be used as a means to develop oneself in the process of knowledge transformation, one of which is with video. it is hoped that using video as a learning medium can increase students’ interest in learning. students’ interest in learning can increase by choosing the right media, in accordance with technological developments and environmental conditions, so that learning objectives can be achieved optimally.34 conclusions the learning model for dental health promotion management using the online method with videos is more effective in increasing dental health knowledge among elementary school students during the adaptation period for new habits. the advantages of video for dental health promotion include the ability to observe movements more closely, save time, and play recordings repeatedly, facilitating the absorption of knowledge. video is categorized as audiovisual media because it engages both the sense of hearing and the sense of sight. references 1. nursalam, setiawan, priyantini d, et al. analysis of factors affecting fear and mental health awareness of coronavirus disease infection. j ners 2023;18:220-7. 2. kementrian kesehatan. pedoman pencegahan dan pengendalian coronavirus disease (covid-19). pedoman pencegah. dan pengendali. coronavirus dis 2020;1:1-125. 3. efendi d, rifani sr, milanti a, et al. the role of knowledge, attitude, confidence, and sociodemographic factors in covid19 vaccination adherence among adolescents in indonesia: a nationwide survey. vaccines 2022;10. 4. elsevier connect. covid-19. 2020. available from: https://www.elsevier.com/connect/coronavirus-initiatives 5. d’arqom, a. et al. societal influence and psychological distress among indonesian adults in java on the early omicron wave of covid-19. futur sci oa 2023;9:fso894. 6. sholihah if, nurmala i, sulistyowati m, devy sr. the impact physical distancing during the covid-19 pandemic on mental health among adolescents: a systematic literature review. int j public heal sci 2022;11:69-76. 7. hussein e, daoud s, alrabaiah h, badawi r. exploring undergraduate students’ attitudes towards emergency online learning during covid-19: a case from the uae. child. youth serv rev 2020;119:105699. 8. efendi, f. the intersection of the covid-19 pandemic and population health. gaceta medica de caracas 2022;130:867-8. 9. pandango gc, suryawan a, irmawati m. the effect of school closure and online learning during the covid-19 pandemic on the academic performance of elementary school-aged children. bali med j 2023;12:1362-7. 10. putri nk, kusumaningtyas ca, hazfiarini a, ernawaty. what determines student resilience during the covid-19 pandemic? malaysian j med heal sci 2022;18:67-72. 11. nasir a, harianto s, purwanto cr. the outbreak of covid19: resilience and its predictors among parents of schoolchildren carrying out online learning in indonesia. clin. epidemiol. glob heal 2021;12:100890. 12. tanuwijaya ns, tambunan w. alternatif solusi model pembelajaran untuk mengatasi resiko penurunan capaian belajar dalam pembelajaram tatap muka terbatas di masa pandemic covid 19 (studi kasus analisis kebijakan pendidikan). j manaj pendidik 2021;10:80-90. 13. alqurashi e. predicting student satisfaction and perceived learning within online learning environments. distance educ 2019;40:133-48. 14. ali m, puah ch, fatima s, et al. student e-learning service quality, satisfaction, commitment and behaviour towards finance courses in covid-19 pandemic. int j educ manag 2022;36:892-907. 15. visuddho v, nugraha d, melbiarta rr. predominant aspects of knowledge and practical skills among medical students with online learning during the covid-19 pandemic era. med educ online 2023;28. 16. sri harnani. efektivitas pembelajaran daring di masa pandemi covid-19 – balai diklat keagamaan jakarta. 2020. available from: https://bdkjakarta.kemenag.go.id/efektivitaspembelajaran-daring-di-masa-pandemi-covid-19/ transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11769] [page 489] non -co mmerc ial us e o nly 17. agustini nlpib, nursalam, sukartini t, et al. andragogy learning and the associated factors among nursing students in online palliative class during the covid-19 pandemic. j pak med assoc 2023;73:s50-3. 18. sadikin a, hamidah a. pembelajaran daring di tengah wabah covid-19. biodik 2020;6:214-24. 19. utami iq, fahmiyah i, ningrum ra, et al. teacher’s acceptance toward cloud-based learning technology in covid-19 pandemic era. j comput educ 2022;9:571. 20. al-azzam n, elsalem l, gombedza f. a cross-sectional study to determine factors affecting dental and medical students’ preference for virtual learning during the covid-19 outbreak. heliyon 2020;6. 21. mazrekaj d, de witte k. the impact of school closures on learning and mental health of children: lessons from the covid-19 pandemic. 2023. available from: https://journals.sagepub.com/doi/full/10.1177/1745691623118 1108 22. chaw ly, tang cm. exploring the role of learner characteristics in learners’ learning environment preferences. int j educ manag 2023;37:37-54. 23. amornsriwatanakul a, rahman ha, wattanapisid a, et al. university students’ overall and domain-specific physical activity during covid-19: a cross-sectional study in seven asean countries. heliyon 2022;8. 24. purwanto a, pramono r, asbari m. studi eksploratif dampak pandemi covid-19 terhadap proses pembelajaran online di sekolah dasar. edupsycouns j educ psychol couns 2020;2: 1-12. 25. aji w, dewi f, kristen u, wacana s. dampak covid-19 terhadap implementasi pembelajaran daring di sekolah dasar. edukatif j ilmu pendidik 2020;2:55-61. 26. qowi nh, faridah vn, pramestirini ra the effect of online learning on student satisfaction in nursing education during the covid-19 pandemic. j ners 2022;17:115-20. 27. setiawan ar. lembar kegiatan literasi saintifik untuk pembelajaran jarak jauh topik penyakit coronavirus 2019 (covid-19). edukatif j ilmu pendidik 2020;2:28-37. 28. notoatmodjo s. metodologi penelitian kesehatan. 2010. available from: https://opac.perpusnas.go.id/detailopac.aspx?id=197163 29. bisallah ci, rampal l, lye m-s, et al. effectiveness of health education intervention in improving knowledge, attitude, and practices regarding tuberculosis among hiv patients in general hospital minna, nigeria a randomized control trial. plos one 2018;13. 30. rosenbaum pr. replication and evidence factors in observational studies. chapman and hall; new york, usa; 2021. 276 pp. 31. soares d, nursalam. the use of digital technology in health learning during the covid-19 pandemic: a systematic review. j pak med assoc 2023;73:s135-9. 32. elsevier connect. covid-19. available from: https://www.elsevier.com/connect/coronavirus-initiatives 33. ratu d, khasanah au, pramudibyanto h, widuroyekti b. pendidikan dalam masa pandemi covid-19. j sinestesia 2020;10;41-8. 34. ichsan iz et al. covid-19 dan e-learning: perubahan strategi pembelajaran sains dan lingkungan di smp jurnal inov pembelajaran 2020;6:50-61. 35. sultan u, tirtayasa a. pemanfaatan vlog sebagai media pembelajaran teritegrasi tekhnologi informasi. pros semin nas pendidik fkip 2017;1. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 490] [healthcare in low-resource settings 2024;12:11769] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11767 effect of midwife competence training in primary healthcare facilities on obstetric risk early detection ai nur zannah, yuningsih yuningsih,1 asri iman sari,1 eka afdi septiyono2 1department of midwifery, faculty of health science, universitas dr. soebandi, jember; 2department of maternity nursing, faculty of nursing, universitas jember, indonesia abstract early detection of obstetric risk is the main competence of midwives to anticipate the mother’s inability to adapt during pregnancy. the early detection competence of midwives determines the success of obstetric risk management, preventing pain and even death of mothers and babies. this study aimed to analyze the effect of obstetric risk early detection training on improving the competence of midwives in basic health care facilities. the study employed a quasi-experimental pre-posttest design with a control group. the samples were selected based on inclusion criteria, encompassing independent practice midwives and public health center midwives. the study comprised 27 midwives in the treatment group and 27 in the control group. the determination of and control groups was conducted through simple random sampling. data analysis involved the use of mann-whitney and t-tests. the results indicated a significant difference in the increase in midwife competence within the treatment group post-training (p<0.001), with a notable improvement of 34.5%, compared to a 14.53% rise in midwife competence within the control group after reading the training module. although a slight decrease in competence was observed after 2-4 weeks of training, the posttest values remained considerably higher than the pretest values. these findings underscore the impact of training on midwife competence, emphasizing the continual need for midwives to enhance their skills to elevate the health outcomes for the mothers and children under their care. introduction obstetric risk is psychological or physical abnormalities and pregnancy difficulties that may worsen maternal and neonatal outcomes.1 the world health organization (who) defines risk factors as traits or circumstances of an individual associated with a higher probability of developing or going through a serious condition likely to result in mortality.2 midwives, one of the key players in fundamental maternal health services, especially obstetric care services, must have promotional and preventive competencies that also involve family members, the community, and advocacy to increase appropriate referrals and prevent delays that lead to maternal mortality rate (mmr).3 this is in addition to foster visits by trained community health workers (chws) to the mother’s home.4,5 every year, an additional 10,000 pregnant women at high risk for complications are born, and the primary complications (postpartum hemorrhage, infections, pre-eclampsia, and eclampsia) contribute to approximately 75% of all maternal deaths.6 despite addressing a broader spectrum of issues in indonesia, the rates of maternal morbidity and mortality have not seen a proportional decrease. the maternal mortality rate in indonesia has not yet reached the target of 183 per 100,000 live birth by 2024; currently, it stands at 305 per 100,000 live births.7-10 this situation is purportedly due to limitations in the knowledge, attitudes, and skills of health professionals, particularly midwives, in managing early dangers for pregnant women at risk of obstetrics, including early detection.11-13 early detection is a proactive process that utilizes screening instruments such as the poedji rochjati score card (kspr) and the pregnancy assessment monitoring system (prams). currently, the maternal and child health (mch) handbook is also employed to identify risk factors that may not have manifested correspondence: ai nur zannah, department of midwifery, faculty of health science, universitas dr. soebandi, jember, indonesia. e-mail: ainz@uds.ac.id key words: competence, early detection, midwife, training. contributions: anz, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; yy, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ais, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. funding: none. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of health science, universitas dr. soebandi, based on ethical certificate no.244/kepk/uds/vi/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors would like to thank universitas dr. soebandi for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 20 december 2023. early access: 30 january 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11767 doi:10.4081/hls.2024.11767 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11767] [page 177] non -co mmerc ial us e o nly symptoms or complaints. this process involves the active participation of pregnant women, their husbands, families, as well as trained health and non-health workers, including traffickers, cadres, and cadets. the early detection operations are conducted meticulously, methodically, and repeatedly until reaching the delivery stage.14,15 there is a need for efforts to enhance the competence of midwives, and one effective avenue is through training. training represents a systematic effort to enhance knowledge, skills, and work attitudes through a structured learning process, with evaluations measuring progress towards the expected changes in performance behavior.16-18 this study aimed to analyze the effect of early detection training on the risk of obstetrics on improving the competence (knowledge and skills in early obstetric risk detection) of midwives in primary health care facilities. materials and methods this study used a quasi-experimental design pretest–posttest with a control group. the assessment was conducted thrice, utilizing the observational method and questionnaire completion throughout 2022. the pretest was administered at the commencement of the intervention, posttest 1 immediately followed the conclusion of the intervention, and posttest 2 was conducted four weeks after posttest 1. the study included 27 midwives in both the treatment and control groups. the control group consisted of respondents who read and recalled the guidebook or training module attended, focusing on obstetrics, such as normal delivery care training, midwifery update, and obstetric and neonatal emergency first aid training. the selection of midwives in both groups was accomplished through simple random sampling from those working in healthcare facilities meeting specific inclusion criteria: possessing a minimum midwifery with diploma degree, holding a valid license to practice as a midwife, having three years of work experience, and demonstrating the capacity to assist with five births per month. the data were initially analyzed using primary data collected through knowledge surveys and skill observations in early obstetric risk detection conducted over four weeks as part of midwives’ competency tests for obstetric risk early detection.11 the assessment of the data involved utilizing statistical methods such as the mann-whitney test, t-test, and wilcoxon test. the jember district health office granted approval for the study to proceed, ensuring adherence to research ethics principles. the faculty of health sciences, universitas dr. soebandi, issued a research permit after completion of the review by the health research ethics committee (no. 244/kepk/uds/vi/2022). throughout the research process, the researcher maintained a commitment to ethical principles, including informed consent, respect for human rights, and considerations of beneficence and non-maleficence. results the research respondents comprised individuals with varying characteristics, including age (67% aged ≥35 years), education (52% with a d4 degree), and work experience (74% with ≥10 years of experience). regarding midwife competence, which involved knowledge and skills in early obstetric risk detection, there was no significant difference observed between the treatment and control groups (p>0.05), allowing for a meaningful comparison of all respondents. table 1 served as an illustrative example of this. table 2 indicates that there was a significant improvement (p<0.001) in the knowledge and skills of midwives in the early detection of obstetric risk within the treatment group, with a much transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 178] [healthcare in low-resource settings 2024;12:11767] table 1. midwives’ competence (knowledge and skills) in identifying obstetric risk before training. variable midwife competence category p treatment control knowledge 0.419** x̅ (sd) 67.83 (10.5) 65.5 (11.7) median 70 65 range 40-85 45-85 skills 0.458* x̅ (sd) 73.17 (6.2) 73.33 (5.5) median 76 71 range 57-81 62-86 *mann whitney test; **unpaired t test. table 2. midwives’ competence (knowledge and skills) in identifying obstetric risk before-after training. variable midwife competence category p treatment control pretest posttest pretest posttest knowledge <0.001* x̅ (sd) 67.83 (10.5) 86.83 (4.2) 65.5 (11.7) 73-83 (8.6) median 70 85 65 70 range 40-85 80-95 45-85 55-90 increase (%) 31.06 14.53 <0.001* skills <0.001* x̅ (sd) 73.17 (6.2) 97.78 (3,9) 73.33(5.5) 76.67 (9.8) median 76 100 71 71 range 57-81 86-100 62-86 67-100 increase (%) 34.59 4.46 <0.001* *mann whitney test. non -co mmerc ial us e o nly higher increase (34.59%) compared to the control group (4.46%). this midwife competency posttest measurement represents the final posttest (posttest 2, measured 2-4 weeks after training), following the earlier completion of posttest 1 (measured shortly after training) between the treatment and control groups, as illustrated in table 3. table 3 demonstrated a decrease in midwife competence in measurements taken 4 weeks after training in both the treatment and control groups, with insignificant differences (p >0.005). this decline can be attributed to the passage of time, reflecting changes in the behavior of some individual midwives regarding the competencies learned during training and their application in the workplace (beyond the classroom setting). discussion the results revealed a significant improvement in midwife competence before and after training, indicating an increase of 34.59%. competence, encompassing cognitive/knowledge, affective/attitude, and psychomotor/skill abilities, is a trait possessed by individuals within their respective professions.19 training emerges as one of the most effective strategies for enhancing competence, with 40% of these acquired competencies being applied in the workplace, 25% lasting for six months, and only 15% enduring for up to a year.20 in this study, competence was derived from a combination of knowledge and skills acquired in the early detection of obstetric risk. midwives’ knowledge in the early detection of obstetric risk exhibited a significant difference before and after training, with a percentage increase of 31%. similarly, in the control group, who read the module and recalled the training that had been conducted, there was an increase in knowledge by 14.5%. knowledge, a cognitive dimension of competence, involves understanding theories comprising facts or procedures related to intellectual abilities such as memory and problem-solving. this dimension can influence the mindset and understanding of the information received.21,22 midwives can enhance their knowledge through the educational process, participation in training, conferences, and seminars, as well as reading and studying journals, materials, books, and explanations from other professionals. skill assessment is conducted through direct observation when midwives perform services, particularly in the early detection of obstetric risk. the results indicated a notable increase of 34.6% in midwife skills after training within the treatment group, contrasting with the control group, which experienced a 4.5% rise. the study’s findings, indicating an enhancement in competence posttraining, align with previous research. brief training in health services, including obstetrics, has proven effective in increasing knowledge and skills among healthcare providers working in maternity wards in sub-saharan africa and asia.23 public health center midwives, village midwives, and independent practice midwives, who implement basic health service facilities, are required to be skilled in delivering midwifery care as per their authority. midwives are considered competent when their knowledge scores reach 80 or above, and clinical skill scores are at 100. the competence of the control group increased by 7% when it read the module but did not participate in training at that time. respondents retained what they learned from the module and remembered the training they had received.24 additionally, respondents had consistently applied this competency since the beginning, and prior research has indicated that frequent use enhances a person’s competence. the training, which covers normal delivery care (apn), contraceptive technology up to date (ctu), and midwifery update (mu), is mandatory for midwives to carry out midwifery services. competence in the early detection of obstetric risks is not only the procedure of upbringing during early detection of risk but also knowledge, communication, and skills before and after the early detection. the results of observations of communication and clinical skills of midwives in the early detection of obstetric risks before training are still not following standard operating procedures (sops). there is no preparation of counseling/communication information materials at the beginning and end of care related to screening/early detection of red flags, lack of maintaining client privacy and principles of infection prevention during care, skills to explore problems and complaints in anamnesis, as well as active listening and helping clients make informed decisions.25,26 however, the lack of such skills after training improves according to sops. the results also showed that some midwives’ competence declined after 2-4 weeks, particularly in knowledge from both the treatment and control groups, with no discernible differences. the deterioration is brought on by time, modifications in certain midwives’ behavior, and the competencies they picked up outside of the classroom while training.24 additionally, where there is no transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11767] [page 179] table 3. midwives’ competence (knowledge and skills) in identifying obstetric risk before-after training. variable midwife competence category treatment control pretest posttest 1 posttest 2 pretest posttest 1 posttest 2 knowledge x̅ (sd) 67.83 (10.5) 88.17 (4.8) 86.83 (4.2) 65.5(11.7) 74.67 (8.9) 73.83 (8.6) median 70 90 85 65 70 70 range 40-85 80-95 80-95 45-85 55-90 55-90 p <0.001** 0.011** <0.001** <0.001** 0.096* <0.001** skills x̅ (sd) 73.17 (6.2) 97.62 (4.1) 97.78 (3.9) 73.33 (5.5) 76.83 (9.7) 76.67 (9.8) median 76 100 100 71 74 71 range 57-81 86-100 86-100 62-86 67-100 67-100 p <0.001** 0.803** <0.001** 0.017* 0.792* 0.017* *paired t test **wilcoxon test. non -co mmerc ial us e o nly compensation, both positive and negative consequences, from professional organizations, the health service, and where midwives work for the professionalism of midwives, a decrease in competence can also be brought on by a lack of motivational reinforcement. researchers proposed several elements to support the recruitment, retention, and motivation of health workers and enhance the quality of their work: high-quality health facilities, providing adequate training either during their education or after they start working, continuous education, paid vacations, allowances for overtime, proper evaluations of their work, and incentives27. however, because researchers and enumerators directly observe skills when midwives provide care to pregnant women, birth mothers, and postpartum mothers, there is a potential for bias in the conducted research. conclusions midwives demonstrate increased capability in identifying obstetric risks early, with competencies showing the most significant improvement. within 4 weeks following training, there was a slight drop; however, it was not statistically significant. consequently, continual education is required to maintain midwives’ competence, involving training in obstetrics and communication, which can contribute to enhancing motivation and character. references 1. yunitasari e, matos f, zulkarnain h, et al. pregnant woman awareness of obstetric danger signs in developing country: systematic review. bmc pregnancy childbirth 2023;23. 2. council nr. an update on research issues in the assessment of birth settings: workshop summary 2013. 3. makhfudli m, efendi f, kurniati a, et al. staffing characteristics and their associations with the severe maternal outcomes at indonesian tertiary hospitals. kontakt 2020;22:40-6. 4. grant m, wilford a, haskins l, et al. trust of community health workers influences the acceptance of community-based maternal and child health services. african j prim heal care fam med 2017;9:1-8. 5. rochjati p. common obstetric emergency: (field experiences on community based antenatal risk screening in village level in east java, indonesia). med j indones 1996;5:65-75. 6. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 7. kementerian kesehatan republik indonesia. profil kesehatan indonesia tahun 2021. jakarta; 2022. 8. diana s, wahyuni cu, prasetyo b. maternal complications and risk factors for mortality. j public health res 2020;9:1958. 9. amalia sr, lestari p, ningrum ag. causative factor of delay in maternal referral systematic review. indones midwifery heal sci j 2022;6:1-14. 10. say l, chou d, gemmill a, et al. global causes of maternal death: a who systematic analysis. lancet glob heal 2014;2:e323-33. 11. zannah an. motivation, persuasive communication, and obstetric risk management training to improve midwives professionalism in preventing maternal death. j kesehat dr soebandi 2018;6:9-15. 12. suarilah i, nihayati he, wahyudi as, et al. treatment decision-making experience among indonesian women with obstetrics and gynecology-related cancer. med palliat 2023;22:68-76. 13. syamsuri dd, tjokroprawiro ba, kurniawati em, et al. simulation-based training using a novel surabaya hysterectomy mannequin following video demonstration to improve abdominal hysterectomy skills of obstetrics and gynecology residents during the covid-19 pandemic in indonesia: a preand post-intervention st. j educ eval health prof 2022;19. 14. shulman hb, d’angelo dv, harrison l, et al. the pregnancy risk assessment monitoring system (prams): overview of design and methodology. am j public health 2018;108:130513. 15. rochjati p. skrining antenatal pada ibu hamil (edisi 2): pengenalan faktor risiko deteksi dini ibu hamil risiko tinggi. airlangga university press; 2011. 16. michie s, van stralen mm, west r. the behaviour change wheel: a new method for characterising and designing behaviour change interventions. implement sci 2011;6:1-12. 17. kurniawati em, bachtiar ca, joewono ht, utomo b. knowledge and confidence levels improvement among obstetrics residents regarding caesarean section training using videomannequins combination. heliyon 2023;9. 18. motevalli s, sulaiman t, ghani hamzah ms, et al. the effects of cognitive restructuring and study skills training on test anxiety and academic achievement among university students. j institutional res south east asia 2022;20:104-54. 19. astuti vw, kusumawati w, afandi m. kompetensi pembimbing klinik dalam proses pembelajaran di klinik. j penelit keperawatan 2016;2. 20. yusof an. the relationship training transfer between training characteristic, training design and work environment. hum resour manag res 2012;2:1-8. 21. winterton j, delamare-le deist f, stringfellow e. typology of knowledge, skills and competences: clarification of the concept and prototype, cedefop, luxembourg, office for official publications of the european communities; 2013. 22. gan s-w, tan j-p, ang c-s, et al. examining a conceptual model of maternal and paternal warmth, emotion regulation and social competence among preadolescent children in malaysia. j genet psychol 2022;183:312-27. 23. ameh c, adegoke a, hofman j, et al. the impact of emergency obstetric care training in somaliland, somalia. int j gynecol obstet 2012;117:283-7. 24. alnowaiser a. the impact of work environment, individual characteristics, training design and motivation on training transfer to the work: the case of saudi arabian public security organisation. university of westminster; 2017. 25. ripursari t. competence (knowledge, attitudes and skills) midwifeve to handling of obstetric emergency according to standard operational procedures. j qual public heal 2019;3. 26. zannah an. pengaruh komunikasi persuasif bidan terhadap pengambilan keputusan ibu dan keluarga yang mengalami kehamilan risiko tinggi. j med (media inf kesehatan) 2020;7:101-10. 27. glenton c, lewin s, fretheim a, nabudere h. countries : a qualitative evidence synthesis (review). cochrane database syst rev 2017;cd011558. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 180] [healthcare in low-resource settings 2024;12:11767] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2023; 11:11143] [page 53] evidence from systematic reviews on policy approaches to improving access to medicines celestino kuchena,1 abubaker qutieshat2 1business and management department, university of zambia, lusaka, zambia; 2research department, oman dental college, muscat, oman abstract the prevailing frameworks on access to medicines advise global procurement as a solution by assuming the presence of medicines on the global market. yet access to medicines remains challenging, especially in developing countries. this is a global worry because the un considers limited access to essential medicines as one of the five indicators of securing the right to health. to fill a research gap in health system studies and inform policymaking, we synthesized evidence from systematic reviews of how government policies affect lowand middle-income country (lmic) medicine access. we chose a rapid review approach to reduce timelines and avoid missing policy “windows of opportunity.” to include only studies published after the start of covid-19, we chose systematic reviews published between 2019 and november 2nd, 2022. this was also in line with recommendations in the literature to look at recent systematic reviews. the themes were grouped using a thematic and textual narrative approach. this review included 32 studies that examined access to medicine from various perspectives. both supplyand demand-side policies are needed to improve medical access. lmics cannot afford medicines, and supply never meets demand. lmics will continue to struggle with pharmaceutical pricing due to their limited bargaining power. the urban bias in health facilities and policy changes reduce medicine availability and use. leaders must make policy decisions to sustain domestic funds. policymakers should consider that organizations may act against policy goals. instead of copying developed nations, lmic governments must develop multipronged strategies to address their unique challenges. introduction there is a need for more information on how policy options affect drug access in lowand middle-income countries (lmics).1 researchers must evaluate how interventions affect the healthcare system.2 grépin3 supports context-specific research, while others noted a lack of information on how policies affect universal health access.4 mcpake and hanson5 show that governments must act through whole-sector policies while bigdeli et al.6 argue that the main frameworks on access to medicines thinly address how people access medicines. research on policy and healthcare access should integrate public health and industry because policies do not consider access to medicines.7 a scoping review of medicine access suggests investigating how universal health access regulations interact with medicine access policies8 because governance and capital affect medicine availability.9 we must study how different policy options have shaped medicine access and determine which ones are most effective.10 mousavi11 suggests a broad approach to healthcare that considers how policies affect health outcomes and service delivery. we synthesized evidence from systematic reviews of how government policies affect lmics’ access to medicines. in addition to narrative synthesis, we used realist synthesis to identify policy context.12 existing frameworks for access to medicine have not fully addressed the complex role of medicines in dynamic health systems, as they often focus on specific purposes.6 barriers to access are interrelated, occurring simultaneously at various levels of the health system and involving multiple stakeholders, which necessitates a health system view for implementing effective reforms. by adopting a complex adaptive systems lens, the framework proposed by bigdeli et al. identifies linkages, relevant stakeholders, and context for scaling up existing small-scale or fragmented access to medical interventions. this comprehensive view of the complexity of access barriers, enablers, and their interactions stimulates a deeper understanding of access to medicine issues. applying complex systems thinking in health system strengthening is limited, and documented examples of access to medicine are rare. however, several options for overcoming these challenges and moving the systems thinking agenda forward have been proposed. these options include systematically exploring issues from a health system perspective, fostering more system-wide planning, evaluation, and research, and building a community of practice. tax reduction policies, policies that cap the maximum price charged to the government, and policies that establish or encourage health technology assessment agencies can improve access to medicines in lowand middle-income countries. by addressing quantification and acquisition errors, therapeutic choices, and other situational factors, policymakers can create a more comprehensive and effective approach to improving access to medicines. nevertheless, some people assume that medicines are readily available on international markets therefore global procurement improves access to medicines in lmics.13 healthcare in low-resource settings 2023; volume 11:11143 correspondence: celestino kuchena, phd business and management as the department, university of zambia, lusaka, zambia. tel.: +263 774 179285 e-mail: elestinoc@gmail.com key words: access; affordability; availability; medicines; policy. contributions: ck contributed to conceptualization, data curation, investigation, formal analysis, writing – original draft preparation, and visualization. aq contributed to resources, validation, supervision, and writing – review & editing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: not applicable. availability of data and materials: materials and data are available from the corresponding author upon request. acknowledgments: the authors extend their heartfelt appreciation to mr. mhazo and ms. elizabeth fleur peacocke, a senior advisor at the norwegian institute of public health, for their invaluable feedback on the protocol. received for publication: 9 january 2023. accepted for publication: 11 july 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11143 doi:10.4081/hls.2023.11143 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.non -co mmerc ial us e o nly [page 54] [healthcare in low-resource settings 2023; 11:11143] consequently, health policy debates concentrate on the content of reforms rather than the actors involved in policy reform or local contexts.14 although several authors have written on health supply chains and policies,15-18 there is agreement on a research gap in health system studies to inform policymaking to which declining pharmaceutical sectors act as an impetus for policy research.19 it is, therefore, critical to review the evidence synthesized on access to drugs to see if it addresses policy interrelationships. objective with this article, we sought to collate evidence from systematic review papers on how policies can affect access to medicines. materials and methods though there are various types of reviews, selecting one that addresses pertinent clinical, or policy questions is critical.20 koon et al.21 argue that policy interpretations based on a constructivist approach converge on accepting multiple perspectives on societal concerns. this constructivist approach served as the foundation for our rapid review. we intended to find, appraise, and detail findings only from systematic reviews of access to medicines in the context of policies.22 no study has compiled evidence from systematic reviews of policies affecting access to medicines. by pooling these systematic review papers, we assessed the information available and gaps in the literature on how and which policies influence access to medicines and medical supplies. due to time constraints, we could not include primary studies and other forms of evidence.23 we chose a rapid review to shorten timelines and avoid missing a policy “window of opportunity”24 because zimbabwe has elections in 2023. there was no need for ethical approval because this was a rapid review. framework we refined our inclusion criteria using munn et al.’s population, the phenomenon of interest, and the context (pico) framework.20 for the population, we concentrated on people living in lowto middle-income countries. we were interested in health, industrial, economic, and other policies that affect access to medicines. we chose systematic reviews published between 2019 and november 2nd, 2022, to include only studies published after the start of covid19. we did not concentrate on a specific outcome statement or comparator because this was a text review.20 search strategy we used the search criteria below and modified them to fit the search database by removing boolean operators as needed. in line with the literature,25 only one reviewer (ck) conducted the searches and screened the documents for inclusion. the other reviewer (aq) helped develop the search criteria and conducted preliminary investigations to validate them. we created a review protocol and registered it on prospero as crd42022370376. furthermore, in the second search, we left any reference to policy in the search criteria to widen the pool of articles from which to choose. relying on a seminal paper,26 we adapted principles from qualitative research and strived for heterogeneity in the studies. search criterion medicines are accessible if they are available, affordable, and acceptable, and people can obtain them.27 we also disaggregated “access to medicines” into its components using the three frameworks.6 who-msh 2000: availability, accessibility, affordability, or acceptability of (medicines or drugs) and “systematic review.” who (2004c): “rational use or affordable price or sustainable financing or reliable health and supply systems” (of medicines or drugs) and systematic review frost & reich (2010): (availability, affordability, or adoption) of medicines and systematic review. using the above definition of access to medicines, we came up with the following search criteria: the initial criteria (first search) were “policy” and “access to medicines” and “systematic review” or “policing” and “access to medicines” and “systematic reviews” or “access to drugs” and “policy” and “systematic review” or “access to medicines” and “policy” and “systematic review” or “policy” and “access to drugs” and “systematic review”. we removed reference to policy for the second search to broaden the search results. databases we used harzing’s publish or perish (windows gui edition) 8.5.4149.8315 software to search on crossref, scopus, pubmed, openalex, semantic scholar, and google scholar. we set all searches to a maximum of 1000 results. manual searching the review aimed for an interpretive explanation;27 therefore, we followed up on some references to explore thematic leads. we searched the literature for studies on the suggested policy recommendations. eligibility criteria we focused on systematic reviews of articles published in english between 2019 and 2022 on policies and access to medicines in lmics. because of the perceived impact of covid-19, we chose 2019 as the cutoff date. furthermore, we had to cover a period that started only three years ago following dobbins’28 recommendation to synthesize using evidence within three years of publication, and we did it in the context of low-income countries. we excluded articles that did not meet these criteria. we also excluded reviews that did not evaluate the quality of primary studies published before 2019 or focused on countries other than lmics. data extraction we extracted the names of the authors, article information (full citation, year of the study objective), key findings, and recommendations that have policy implications. we searched articles for the consequences of the policies discussed,29 how these policies could affect access to medicines, and the context for policy implementation. data synthesis we undertook a narrative synthesis30-32 and used a thematic approach to group data into themes and a textual narrative approach to provide details of the characteristics, context, and similarities of the studies included in the review.33 we described the policies discussed concerning access to health, highlighted gaps in the literature, and commented on the breadth of the evidence; therefore, a textual narrative synthesis was more appropriate.33 results this review included 32 studies as shown on the prisma flow chart below (figure 1). the search yielded various studies on access to medicine, which focused on different aspects such as trade treaties, financing, public access, specific condition-specific medicines, anti-infectives, vaccine access, maternal and child health, noncommunicable disease medicines, sexual and reproductive health, post-abortion care, and pediatric access to medicines (figure 2). the studies were clustered into four categories: availability, usage, cost and affordability, and accessibility. access to medicine is a fundamental component of the full realization of the right to health, and it is intrinsically linked with the principles of equality and non-discrimination, transparency, participation, and accountability. article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11143] [page 55] discussion we discussed the findings under components of access to medicines: availability, usage (rational), cost and affordability, accessibility, and acceptability to gain a better understanding of these challenges. availability the are several causes for the unavailability of medicines. lmics never have enough medicine34-39 while legal and moral concerns prevent prescribers and dispensers from dispensing certain drugs.40,41 the inequitable distribution of pharmacies and other health institutions39 limits medicine availability by favoring towns and underserving the poor. hospital subsidies also perpetuate inequality.42 patients may not fully understand the services available. for example, palliative care39 and indiscriminate antimicrobial use may be unfamiliar to the public43 so abu-odah et al. recommend educating the public about services available and rational medicine use.44 for human capacity, reviewers recommend empowering health workers through training and well-framed treatment guidelines.44 this empowerment entails strengthening and updating treatment guidelines.36-7 kibirige et al. recommended incorporating complementary medicine in national health policies and changing policies and laws that restrict or discourage drug access.37 factors within the health system interact in complex ways to affect availability and affordability.38 consequently, addressing access to medicines requires harmonizing multisectoral policies to improve the chances of sustainability.45,36 these policies can promote innovations and local manufacturing to improve resilience and selfreliance. in some cases, ensuring availability is an urgent concern41 therefore international bodies should institutionalize policies that ensure equity in the global pharmaceutical market.46 sekalala et al. recommend reparative justice, not through charity but through redistribution, expanding manufacturing capacity in the global south.47 by working together, governments, international organizations, and the private sector can create a more equitable environment for access to medicines ensuring that all individuals have the opportunity to receive the healthcare they need. usage the literature needs more evidence on how medicines are used,48 or how policy changes affect access to medicines.49 concerns about sustainability in the absence of funding partner support hamper the adoption of new products.43 there have been reports of irrational medicine use attributed to either client demand for antibacterial medications or business interests pushing for profit.46,50,51 to address these issues, lmic governments can implement policies that promote the rational use of medicines, such as establishing guidelines for the appropriate use of antibacterials and providing education to both healthcare professionals and the public.52 however, tight antibacterial dispensing regulations must be balanced with access to medicines for people in rural areas who may have difficulty obtaining prescriptions.50 some scholars call for incentives that enhance the desired behavior and retard the unwanted behavior of health practitioners.50 therefore, it is necessary to generate robust evidence on the effect of policies on patient and provider behavior and government choices.53 the urban bias in the distribution of health facilities also influences medicine usage.54 however, program-specific aid can improve geographical coverage and increase usage.43 also, inadequate distribution of available medicines decreases their use.46 low usage of some products occurs when providers are afraid of restrictive policies, despite guidelines outlining their indications.54 incorporating traditional medicines into health policies and insurance plans will increase and document their use.34 though out-of-pocket expenditure for medicines was offset in some way by other payments for medical services, zeromarkup policies resulted in increased medicine use.53 adane et al. called for cooperation between traditional and conventional medicine practitioners.48 some researchers advise incorporating traditional medicine into the referral and health insurance schemes.34 aslam et al. suggested integrating health strategies.43 similarly, izugbara et al. recommended pooling services such as nutritional care, gender violence, and post-abortion care.54 equity is also a topical issue in universal health coverage discussions. scholars propose covering marginalized communities through outreach programs.43 another option is training and using traditional medicine practitioners as community health workers because people already consult traditional medicine practitioners. by implementing policies that ensure a qualified workforce, governments can article figure 1. prisma flowchart of the screening of systematic review articles. non -co mmerc ial us e o nly [page 56] [healthcare in low-resource settings 2023; 11:11143] improve the appropriate selection, prescription, and use of medicines, reducing the risk of medication errors, adverse drug reactions, and antimicrobial resistance. furthermore, well-trained healthcare providers are more likely to adhere to clinical guidelines and promote patient-centered care, ultimately improving patient outcomes and overall healthcare system performance.55-56 cost and affordability people in lmics, in general, cannot afford medicines.41,42,46,57,58 the costs of accessing health products are generally higher in the private sector than in the public sector.38,57 for example, women who seek sexual and reproductive healthcare face financial hardship.57 this expenditure can lead to financial catastrophe.58 these high prices arise because of insufficient price controls, public insurance schemes, limited generic manufacturing in lmics, and the lack of co-financing arrangements.37 innovator products are generally more expensive than their generic counterparts59 and studies show that the trips agreement increased drug prices.49 intellectual property provisions can reduce medicine’s affordability.38 to improve cost and affordability, lmic governments should consider implementing policies such as tax reduction, price control, and support for generic manufacturing. for example, some countries have reduced or eliminated taxes on essential medicines, leading to lower retail prices and improved access for patients.60 policies setting the maximum price charged to the government for medicines can also play a crucial role in controlling costs and ensuring affordability.61 pricing will continue to be an issue for lmics due to their low bargaining power in the international pharmaceutical market.46 as a result, scholars have called for policies to resolve pricing concerns.39,54,59,62 policy decisions require political will from leaders and assured domestic funds for sustainability.63 policymakers should remember that organizations may respond in ways that contradict policy objectives; hospitals responded to the zero-markup policy for essential drugs by raising non-drug costs to maintain their revenue.53 subsidies given to hospitals marginalize those who use primary healthcare facilities.64 while using health service usage as a proxy, the distribution of total healthcare benefits favors the wealthy over the disadvantaged.65 as a result, socioeconomic disparities can persist or be exacerbated by well-intended policies. overall, health insurance programs reduced the likelihood of financial disasters, though vulnerable people faced high out-ofpocket expenses.42 health insurance schemes to decrease out-of-pocket expenditure can solve this.37,38 in addition, lmic governments should consider implementing compulsory insurance policies to improve equity in access to medicines, as low coverage by public insurance limits access due to costs.39 another important policy approach involves establishing or encouraging health technology assessment (hta) agencies. the use of hta agencies in lmics can improve access to cost-effective and highquality medicines, while also promoting the rational use of healthcare resources.66-67 instead of copying developed nations, lmic governments should develop multipronged strategies to address their unique challenges, such as promoting local production of medicines, fostering regional cooperation for joint procurement, and advocating for fairer international trade agreements.45 at the same time, mechanisms that permit people to compare prices before buying can be beneficial.39 governments are also encouraged to implement economic policies that improve the public’s capacity to pay.59 this raises several policy implications. nudge behavior governments should equip and encourage people to use primary health centers57 and incentivize generic prescribing.39 rules and regulations are not enough, as people and organizations can circumvent them. the policy should be consistent throughout the government, and government communication must be unambiguous57 to promote the desired behavior. local solutions for local contexts governments in lmics must seek and develop multisectoral strategies to address their specific challenges rather than copying solutions from developed countries.45 one article figure 2. focus of the studies included. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11143] [page 57] option is to incentivize the manufacture of products locally while registering them preferentially.37 despite this call for selfreliance, increasing access to medicines requires multisectoral approaches41 and global cooperation.58 international bodies, too, must promote equity in the international pharmaceutical markets.46 review of legislation and policies there is a need for policies specifically addressing medicine costs, the capacity of people to pay, and the retail prices for medicines, for example, china implemented a “zero markup” drug policy.53 insurance and prices based on the capacity to pay increase equity.39,64 guidelines must be updated to reflect contextual evidence on safety, effectiveness, and acceptability.37 35 accessibility lockdown policies that restricted movement reduced access to medicines during the peak of the covid-19 pandemic.46 poor healthcare facilities, a shortage of health workers, and limited equipment reduce physical access to medicines.68 transportation issues and a lack of knowledge about available services69 also hinder access to medicines. some academics have proposed changes to intellectual property laws to improve access to medicines, though several factors can mitigate the impact.49 the distribution and availability of service providers are skewed toward urban facilities. this, combined with transportation costs, limits access for people outside cities.54 for oncology medicines, medicine stockouts and the lack of updated guidelines were identified as barriers to access.39 in a separate study, medicine stockouts, and high prices all reduced access to medicines.70 subsidies and tax policies that consider one’s ability to pay to improve equity in access to medicines.64 lmic governments should consider implementing policies that foster greater equity in healthcare facility distribution, such as investing in rural healthcare infrastructure and incentivizing health workers to serve in underserved areas, encouraging the use of telemedicine or mobile clinics to reach remote populations, as well as subsidize transportation costs for patients in need. addressing both demand-side factors and supply-side factors improved access during emergencies.71 here are some recommendations to improve accessibility: i) increase coverage for specific treatments; ii) engage key stakeholders and actors; iii) integrate services and interdisciplinary approaches; iv) develop facilities catering to special needs and vulnerabilities. acceptability medicines may be available, accessible, and affordable, but people might still choose not to use them due to concerns about acceptance. in a review of female condom usage, factors influencing acceptability included male partner opinions, functionality, condom appearance, and ease of access.69 as these users became more familiar with the condoms, acceptability increased. for the human papillomavirus (hpv) vaccine, concerns about safety, effectiveness, and self-perception of risk reduced acceptance.69 people with higher incomes living in urban areas were less likely to receive the hpv vaccine, as they tended to refuse it.72 another review examined women’s acceptance of mifepristone and misoprostol for medical abortions and their effectiveness.59 in one study, fear of chemotherapy also reduced access to medicines.70 these findings carry several policy implications. considering product acceptability before a product enters the market is vital to ensure that it meets the needs and preferences of potential users. by consulting potential users, policymakers and manufacturers can capture insights and improve the design and desirability of intervention programs and policies. intentional engagement with would-be end-users can lead to more successful implementation of healthcare interventions and greater satisfaction among patients. countries must learn from brazil’s pursuit of several strategies to improve access to medicines for its population, including establishing a universal healthcare system, promoting domestic pharmaceutical industrialization, strengthening healthcare infrastructure, developing subsidy programs, increasing transparency, supporting product development partnerships, implementing the essential medicines policy (emp) to improve the provision and use of pharmaceuticals, creating municipal essential medicines lists (meml) to evaluate the effects of the emp on the procurement and availability of medicines, and implementing the pharmacy network of minas program to promote improvements in essential medicine availability.73,74,75 however, entrenched inequalities within and between states have affected healthcare utilization and resulted in very different procurement prices, particularly affecting the purchasing capacity of smaller states73 as observed in brazil, access to medicines is associated with social, economic, and health perception factors.76 therefore, educational strategies are key to improving access to medicines.77 strengths and limitations of the study this study has four main strengths. its reliance on a constructivist approach enabled a review that brings out the nuances of contextual differences. second, the focus on systematic reviews allowed for a synthesis of evidence from rigorous studies. third, limiting the articles to those published within three years ensured that the evidence was current and applicable given the coincidence with the advent of the covid-19 pandemic. lastly, this appears to be the first study that aggregated evidence from papers that focused on distinct health conditions or programs. one strength, however, can be viewed as a weakness. this study excluded primary studies and other forms of evidence such as grey literature. grey literature would have offered a view into how ministries and individual organizations working with governments view access to medicines. primary studies would have provided even more contemporary and contextual evidence. acknowledging this weakness informs our suggestions for future research areas. future research priorities researchers must seek evidence to inform cross-sector strategies45 and use mixed-methods studies to evaluate programs.63 such research can help explicate why some researchers could not explain why medical services increased in china following a new policy on medicine markups.53 we must collect more data on the factors influencing access to medicines in lmics38,41, and assess vulnerability and power distribution when analyzing these factors.42 several authors agree on the need for more research in lmics to generate evidence on general or specific components of access to medicines.38,41,78 countries should encourage and reward researchers who conduct research in local contexts. conclusions policymaking requires context because healthcare reform is more political than technical.67 breaking medical care barriers requires sociocultural knowledge, but empirical public health research ignores sociopolitical contexts.80 issue framing is important because organization frames strengthen meaning by emphasizing one evaluative dimension and elevating it above other valued goals, such as prioritizing access to life-saving medicines over intellectual property rights.81 communication is, therefore, vital because learning about a policy’s positive and negative outcomes can article non -co mmerc ial us e o nly [page 58] [healthcare in low-resource settings 2023; 11:11143] increase or decrease support for the policy.82 policy failure can result from policy ideas and implementers’ assumptions clashing.83 removing user fees lowers household health spending and increases poor people’s use of formal healthcare, but africa’s political and institutional challenges make fee removal difficult. investing in primary care and removing barriers increases equity.56 furthermore, policies that define the maximum price charged to the government and that establish or encourage health technology assessment agencies can be part of the discussion, as they can help improve access to medicines in lmics. these policies can be adopted to regulate medicine prices and ensure the rational use of medicines based on evidence and cost-effectiveness. in summary, to effectively improve access to medicines in lmics, policymakers must consider the complex interplay of various factors and develop multipronged strategies that address the unique challenges faced by their populations. lmic governments can work towards reducing social inequities and health disparities while ensuring equitable access to essential medicines for all. policies that guarantee a qualified workforce should be discussed, as these can influence rational use. this can involve investing in the training of healthcare professionals, implementing strict regulations to promote rational prescribing and dispensing practices, and monitoring the performance of health institutions to ensure quality service delivery. to address these policy implications, lmic governments should consider developing policies that target the specific barriers faced by different population groups by implementing targeted health education campaigns to raise awareness about the importance of medicine access and adherence, training healthcare providers in culturally competent care, and addressing the stigma around certain health conditions. pricing and financing policies should increase coverage for vulnerable groups83 by subsidizing products.35 references 1. montagu d, goodman c. prohibit, constrain, encourage, or purchase: how should we engage with the private 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2016-2020. health econom rev 2022;12:38. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11771 the success of empowering cadres in the prevention of acute hepatitis among children in agronursing areas sri wahyuningsih,1 musviro musviro,1 nurul hayati,1 ika adelia susanti2 1faculty of nursing, universitas jember, jember; 2faculty of health sciences, universitas dr. soebandi, jember, indonesia abstract acute hepatitis in children with an unknown cause is defined as an extraordinary event. children experiencing acute hepatitis may progress to severe acute hepatitis and acute liver failure, leading to potential fatality. this study aimed to identify the empowerment of cadres in preventing acute hepatitis with unknown causes in agro-nursing areas. employing a quasi-experimental research design, the study involved 21 integrated healthcare center cadres in an agro-nursing area. the questionnaire served as the measuring tool, and the data were analyzed using a paired sample test. the results revealed a significant p-value of 0.000, indicating differences in the cadres’ abilities before and after empowerment. empowering cadres through discussions provides them with opportunities to address problems collaboratively, fostering commitment to the prevention and early detection of acute hepatitis in children. an acute hepatitis is relatively new and life-threatening, and the prompt action of cadres, communities, and health workers, supporting government programs, contribute to the success of cadre empowerment efforts in preventing and detecting acute hepatitis in children. empowering cadres through additional information and discussion yields positive outcomes, emphasizing the importance of efforts to prevent and detect acute hepatitis in children in agro-nursing areas. introduction acute hepatitis is classified as an extraordinary event by the world health organization (who).1 cases of acute hepatitis in children, particularly those with unidentified causes, can lead to severe complications such as acute hepatitis and acute liver failure, possibly resulting in death.2,3 both developed and developing countries grapple with a significant epidemic of hepatitis among children.4–6 globally, reported cases involve previously healthy children aged one month to 16 years exhibiting signs and symptoms of acute hepatitis, such as vomiting, jaundice, abdominal pain, and nausea.7–9 some patients progress to acute liver failure, leading to potential fatality, and a subset may require liver transplantation.10,11 in the uk, around half of children diagnosed with acute hepatitis lacking a clear etiology undergo testing, with approximately half testing positive for human adenovirus 41 subtype f (hadv41-f).12 acute hepatitis in children currently lacks a known cause, constituting approximately 10-15% of all cases of acute hepatitis in children.4 those afflicted may experience severe acute hepatitis, which can progress to acute liver failure and, in some instances, result in death. the initial case was reported in the uk on april 8, 2022, with 74 subsequent cases reported in three other countries. this event was declared an extraordinary occurrence on april 15, 2022. the who has reported several suspected cases in southeast asia, including three suspected cases of pediatric patients with acute hepatitis who succumbed to the condition in indonesia. in 2022, the prevalence of hepatitis has been documented, totaling 170 cases across 12 countries.13 on april 15, 2022, the who declared this incident as a public health emergency. subsequently, the incident has been expanding, with reports coming in from various countries, resulting in approximately 300 probable cases worldwide. the initial report of this case in indonesia was on april 27, 2022, indicating three reported cases. by may 12, 2022, the number of cases had surged correspondence: musviro musviro, faculty of nursing, universitas jember, jember, indonesia. e-mail: musviro@unej.ac.id key words: acute hepatitis, agronursing, children, empowerment of cadres. contributions: sw data curation, methodology, formal analysis; mm conceptualization, writing – original draft, review and editing; nh conceptualization, validation, visualization, resources; ias validation, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, universitas jember. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank universitas jember and integrated healthcare center cadres bondoyudo village lumajang regency for their valuable insights and contributions to this study. received: 12 september 2023. accepted: 21 december 2023. early access: 16 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11771 doi:10.4081/hls.2024.11771 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 212] [healthcare in low-resource settings 2024;12:11771] non -co mmerc ial us e o nly to 18, distributed across four provinces, namely dki jakarta, north sumatra, east kalimantan, and east java. fatalities were reported in dki jakarta (four cases), east java (one case), east kalimantan (one case), and west sumatra (one case), while other patients remain under treatment. the average age of patients with acute hepatitis is between 1-6 years old.14 according to the early alertness and response system (skdr) as of may 4, 2022, east java alone has detected 114 suspected cases of acute hepatitis scattered across several districts/cities.15 limited research has been conducted on acute hepatitis with an unknown cause.16,17 research on acute hepatitis with an unknown cause is an ongoing process.16 hepatitis a virus is closely linked to sanitation and health standards in a given area. this disease can have significant societal impacts, affecting both economic and social aspects and disrupting daily activities. since there is no specific treatment for hepatitis a that can reduce the duration of the disease, preventive measures become crucial. one effective preventive measure to break the transmission chain of hepatitis a is by maintaining personal hygiene through the practice of clean and healthy living behaviors.18,19 the government emphasizes the importance of public vigilance and early recognition of the initial symptoms of acute hepatitis. it encourages individuals not to wait for more advanced symptoms, such as yellowing of the skin and eyes, before seeking treatment. researchers endorse the government’s initiatives to enhance awareness of acute hepatitis with unknown causes. they have developed an application designed for the early detection and prevention of hepatitis in children with unknown causes.20 this study aimed to empower cadres in preventing acute hepatitis with unknown causes in the agronursing area. materials and methods this study used a quasi-experiment design. the population in this study were 21 integrated healthcare center (posyandu) cadres in lumajang regency, especially bondoyudo village, lumajang regency, which is an agro-nursing area. sampling was carried out in total sampling. the variables used in this study are the independent variable and the dependent variable. the dependent variable in this research was the posyandu cadres in the village. meanwhile, the independent variables were age, knowledge, and length of service as posyandu cadres. the measuring tool used in this study is a survey method and questionnaire. the data were analyzed using paired sample t-test. results based on table 1 regarding the research results, it was found that the average age of posyandu cadres ranged from 20-40 years with a proportion of 56.7%, the average last education attained by posyandu cadres was the high school with a proportion of 63.3%. the majority of the work of the cadres are teachers with a proportion of 46.7%. the average length of service for posyandu cadres is more than 10 years with a proportion of 53.3%. based on table 2, the value of sig.2-tailed = 0.000, α = 0.05 indicated that there was differences in the ability of cadres before and after empowering cadres. discussion the results showed differences in the ability of cadres before and after empowering cadres. the enhanced abilities of cadres can be attributed to various factors, such as the empowerment methods employed, the emergence of new diseases, and the support extended by the community, health workers, and the government. additional influential factors encompass age, education, employment, and length of service. age is a primary factor influencing these differences. this aligns with the overall age distribution of cadres, ranging from 20 to 40 years. knowledge is acquired through various means, including tradition, authority in the field, experience, trial and error, and the application of the scientific method.21 as individuals mature, their level of maturity and mental strength increases, impacting their thinking and work. age significantly influences comprehension and mindset; as individuals age, their understanding and perspective tend to develop, leading to an improvement in the knowledge acquired. this enhancement is a result of the experiences and maturity of the individual.21 productivity in workers is also influenced by age. generally, productive individuals in the workforce are physically stronger than their non-productive counterparts. as age increases, however, work productivity tends to decrease.22 older individuals, in partictransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. respondent characteristics. frequency percentage age (years) 17 56.7 20-40 13 43.3 >40 employment teacher 14 46.7 self-employed 6 20.0 housewife 10 33.3 education elementary school 2 6.7 junior high school 6 20.0 senior high school 19 63.3 bachelor 3 10.0 length of work 5-10 years 11 36.7 >10 years 16 53.3 <5 years 3 10.0 total 30 100.0 table 2. the ability of cadres before and after empowering cadres. paired differences t df sig.(2-tailed) mean std. deviation std. error 95% ci lower upper 0.800 0.664 0.121 0.552 1.048 6.595 29 0 [healthcare in low-resource settings 2024;12:11771] [page 213] non -co mmerc ial us e o nly ular, exhibit lower productivity due to a decline in physical strength and exertion in old age.23 furthermore, the study demonstrates that empowering cadres positively impacts their abilities, with age being a significant factor influencing both knowledge acquisition and work productivity. the second influential factor was education, aligning with the prevalent educational background of cadres as high school graduates. this is in line with previous studies showed a significant relationship between the level of knowledge and the behavior of posyandu cadres.24,25 education not only increase knowledge, but improve work skills, thus increase work productivity.26 the education of cadres serves as a foundation for shaping, preparing, and enhancing competencies in executing posyandu activities. research indicates a noteworthy correlation between education and cadre skills, revealing that cadres with a high school education or higher possess a 3.96 times greater likelihood of having proficient skills.27 education, as a deliberate effort, plays a pivotal role in molding an individual’s behavior to effectively address challenges. the educational level of individuals, particularly cadres in both villages and cities, profoundly influences their receptivity to new programs. in the specific context of the toddler growth and development monitoring program, individuals with higher levels of education, especially cadres, are more inclined to embrace and facilitate the adoption of novel programs and innovations within the community.28 therefore, a cadre’s elevated educational attainment serves as a catalyst for the seamless acceptance and integration of new initiatives into society. the third factor was work and length of work. this is consistent with the frequency of cadres who work as teachers and worked for more than 10 years. cadres who have worked for a long time have better knowledge than cadres who do not work.27 someone who works has the possibility to interact with colleagues, exchange information and motivate each other, this can add insight into knowledge and related information. someone who works has the possibility to interact with colleagues, exchange information and motivate each other, this can add insight into knowledge and related information. someone who is not working may spend more time at home, doing household activities or personal matters so there are fewer opportunities to interact with other people.29 health promotion provides benefits to participants, because by knowing the cause’s hepatitis for clients, if there are family members suffering from the same disease, family members and clients are ready to face the worst risks of hepatitis and its complications. by knowing about hepatitis a, it is hoped that clients will be able to prepare themselves with the prevention and the treatment, namely: provision of safe food and clean water, an effective waste disposal system, pay attention to general hygiene, wash hands, use catheters, disposable syringes and syringes and always maintain the best condition of the body.30 based on research, respondents with low knowledge are at risk of getting hepatitis a as much as 5.96 times compared to highly knowledgeable respondents.31 the results of this study were in accordance with the theoretical review which says that good knowledge is needed to behave healthily to facilitate the realization of healthy behavior.32 conclusions increasing the knowledge of posyandu cadres can be done by empowering cadres. the empowerment of cadres plays a crucial role in preventing, detecting early, and reducing cases of acute hepatitis in children within agronursing areas. by empowering posyandu cadres, it becomes possible to extend more targeted and close-knit educational initiatives to the community. this is particularly significant for families engaged in the proactive prevention of childhood hepatitis. empowering posyandu cadres serves as an effective means to disseminate education within the community, focusing on specific aspects and ensuring a closer reach to families actively involved in safeguarding against childhood hepatitis. references 1. who. severe acute hepatitis of unknown aetiology in children multi-countryno title [internet]. 2022. available from: https:/ /www.who.int/emergencies/disease-outbreaknews/item/2022-don400 2. hadikusumo aa, utsumi t, amin m, et al. high rates of hepatitis b virus (hbv),hepatitis c virus (hcv),and human immunodeficiency virus infections and uncommon hbv genotype/subtype and hcv subtype distributions among transgender individuals in surabaya,indonesia. jpn j infect dis 2016;69:493–9. 3. youssef a, yano y, el-sayed zaki m, et al. characteristics of hepatitis viruses among egyptian children with acute hepatitis. int j oncol 2013;42:1459–65. 4. clayton m. severe acute hepatitis in children. gastrointest nurs 2022;20:s4. 5. yamani ln, yano y, utsumi t, et al. ultradeep sequencing for detection of quasispecies variants in the major hydrophilic region of hepatitis b virus in indonesian patients. j clin microbiol 2015;53:3165–75. 6. lusida mi, juniastuti, yano y. current hepatitis b virus infection situation in indonesia and its genetic diversity. world j gastroenterol 2016;22:7264–74. 7. putri nas, maimunah u, aswin rh, et al. quality of life of chronic hepatitis b patients consuming nucleoside analog: a case-control clinical study in indonesia. biomol heal sci j 2021;5:6–10. 8. abubakar m, kandandapani s, mohamed sb, et al. shedding light on the molecular interaction between the hepatitis b virus inhibitor, clevudine, and human serum albumin: thermodynamic, spectroscopic, microscopic, and in silico analyses. j mol liq 2022;368. 9. abubakar m, mohamed sb, abd halim aa, tayyab s. use of computational and wet lab techniques to examine the molecular association between a potent hepatitis c virus inhibitor, psi-6206 and human serum albumin. spectrochim acta part a mol biomol spectrosc 2023;294. 10. pratama ba. literature review: identifikasi penyebab hepatitis literature review: causes identification ’ s acute. j ilmu kesehat 2022;10:63–75. 11. harapan h, fajar jk, supriono s, et al. the prevalence, predictors and outcomes of acute liver injury among patients with covid-19: a systematic review and meta-analysis. rev med virol 2022;32(3). 12. zheng n, wang y, rong h, et al. human adenovirus associated hepatic injury. front public heal 2022;10:4–5. 13. marsepa e, kusumastuti na, mufrokah o, et al. komunikasi, informasi, dan edukasi tentang hepatitis akut pada anak. jmm (jurnal masy mandiri) 2023;7:390–7. 14. badan litbangkes kementrian kesehatan ri. fact sheet : kejadian hepatitis yang belum diketahui etiologi nya | badan penelitian dan pengembangan kesehatan. badan transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 214] [healthcare in low-resource settings 2024;12:11771] non -co mmerc ial us e o nly kebijakan pembanguan kesehatan. 2022. 15. dinas kominfo provinsi jawa timur. jatim waspadai hepatitis akut tanpa etiologi, gubernur khofifah imbau masyarakat jangan panik tetapi sigap lihat gejalanyadinas komunikasi dan informatika provinsi jawa timur. dinas kominfo provinsi jawa tmur; 2022. 16. marsh k, tayler r, pollock l, et al. investigation into cases of hepatitis of unknown aetiology among young children, scotland, 1 january 2022 to 12 april 2022. euro surveill bull eur sur les mal transm = eur commun dis bull 2022;27(15). 17. sallam m, mahafzah a, şahin gö. hepatitis of unknown origin and etiology (acute non hepa-e hepatitis) among children in 2021/2022: review of the current findings. healthc 2022;10(6). 18. syah smm. acute viral hepatitis caused by hepatitis a virus in children. medula 2014;2:118–26. 19. setyowati d, mubawadi t, mirasa ya, et al. molecular epidemiology of hepatitis a outbreaks in two districts in indonesia in 2018: same subtype, but different strains. biomed reports 2020;12:1–8. 20. kementrian kesehatan. infeksi emerging kementerian kesehatan ri. infeksi emerging; 2021. 21. retna tp, wahyurianto y, jannah r, sri wahyuni prodi iii keperawatan kampus tuban poltekkes kemenkes tuban nd. pengetahuan masyarakat tentang penyakit hepatoma. j keperawatan 2014;7:143–9. 22. astutia md, mintasih s. the effctiveness of comparison of the use of the kuesioner pra skrining perkembangan (kpsp) with dencer ii on development children aged 0-72 months in the dadok primary health center work padang. indones nurs sci j 2021;11:114–21. 23. ukkas i. faktor-faktor yang mempengaruhi produktivitas tenaga kerja industri kecil kota palopo. kelola j islam educ manag 2017;2(2). 24. elisabet bm, ayubi d. hubungan pengetahuan, sikap dengan perilaku kader posyandu dalam pelaksanaan pemberian vitamin a di jakarta timur. j ilm kesehat 2021;13:1–12. 25. olvin sl, mundagi k fc, adisti ra. hubungan antara pengetahuan dan dukungan keluarga dengan keaktifan kader posyandu di wilayah kerja puskesmas tanahwangko kecamatan tombariri. kesmas 2019;8:8. 26. agustina f, syahrial e, andayani ls. social and cultural factors that influence early marriage at the age of 15-19 year in the village harbor town martubung subdistrict field in 2014 working area rejo kec . medan labuhan hosts martubung 2014. kebijakan, promosi kesehat dan biostatiskik 2015;1:1–10. 27. hidayati u. hubungan antara pendidikan dan masa kerja dengan keterampilan kader posyandu dalam menimbang balita menggunakan dacin di. j komun kesehat 2021;(1). 28. nurhidayah i, hidayati no, nuraeni a. revitalisasi posyandu melalui pemberdayaan kader kesehatan. media karya kesehat 2019;2:145–57. 29. wulansih r. hubungan umur, pendidikan dan pekerjaan dengan tingkat pengetahuan kader nasyiatul aisyiyah tentang stunting di kabupaten boyolali. j kesehat masy 2021;23:1– 15. 30. mardhiyah a, mediani hs, rahayuwati l. promosi kesehatan kepada orang tua mengenai perilaku hidup bersih dan sehat untuk mencegah hepatitis a pada anak. media karya kesehat 2019;2:61–73. 31. sakti ap. hubungan pengetahuan, sikap, dan praktik pencegahan hepatitis a dengan kejadian hepatitis a pada siswa sman 4 depok 2012. skripsi. 2012. 32. davis r, campbell r, hildon z, hobbs l, michie s. theories of behaviour and behaviour change across the social and behavioural sciences: a scoping review. health psychol rev 2015;9:323–44. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11771] [page 215] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11813 usefulness of antenatal care handbook: a cross-sectional study of mothers' perspectives queenita anak luta,1 khadizah h. abdul-mumin,1,2 hanif abdul rahman,1 sarena haji hashim1,2 1nursing and midwifery programme, pap rashidah sa'adatul bolkiah, institute of health sciences, universiti brunei darussalam, gadong, brunei darussalam; 2school of nursing and midwifery, la trobe university, melbourne, australia abstract in 2016, the ministry of health brunei darussalam introduced the maternal and child health (mch) handbook, replacing the card-type record. despite its implementation, the handbook’s utility remains unexamined. this study aims to evaluate the community’s usage of the mch handbook and explore the connections between age, education, and handbook utilization. a cross-sectional study employed an online self-administered survey among pregnant women attending routine antenatal checkups at 32 weeks gestation between december 2020 and january 2021. the survey used the mch usefulness questionnaire, and subgroup analysis was conducted. the study included 73 mothers. most participants reported having sufficient time to read the handbook (95.9%), being familiar with its content (89.0%), and feeling satisfied with its usage (93.2%). reasons for not using the handbook included “online availability of the same information” (20.5%), difficulty in understanding certain words (17.8%), preference for more visual content (12.3%), and inadequate encouragement from healthcare providers (12.3%). the majority of mothers perceive the handbook as useful. nonetheless, further investigation is necessary to delve into their perceptions and ensure the handbook’s sustained relevance and effectiveness over time. introduction the maternal and child health (mch) handbook was first published in japan in 1948 and has since been developed and adapted in more than 50 countries around the world.1 in brunei darussalam, the use of the mch handbook was introduced in january 2016 with the aim of providing health information to help women achieve and maintain optimal health during pregnancy and to assist parents in childcare as a whole.2,3 the mch handbook has been recognized as an effective tool for improving health knowledge and health-seeking behavior among both mothers and children.4 furthermore, it plays a crucial role in ensuring that no one is left behind in terms of healthcare services.5 the mch handbook is distributed to all pregnant mothers during their first antenatal visit and serves as a reference guide when needed. it is carried along for any visits to a healthcare facility.6 the handbook covers information on maternal health, including during pregnancy, childbirth, and the postpartum period, as well as child health records from birth until the child reaches 5 years of age. it is designed to comprehensively document all information regarding the health services provided to pregnant women and their children, serving as an integrated home-based record.7 additionally, it serves as a starting point for increasing knowledge and promoting healthier healthcare-seeking behaviors and safe home care practices through communication between healthcare professionals and mothers with children. the handbook also includes health education messages to encourage better healthcare-seeking, healthy behaviors, and safe home care practices.8 despite the introduction of the mch handbook in brunei darussalam, there has been no prior study or investigation to evaluate its usefulness. this has prompted the researcher’s interest in conducting a study to assess the handbook’s utility among pregnant women in brunei darussalam. numerous studies have examined the use of the handbook. correspondence: sarena haji hashim, nursing and midwifery programme, pap rashidah sa'adatul bolkiah, institute of health sciences, universiti brunei darussalam, gadong, brunei darussalam. e-mail: sarena.hashim@ubd.edu.bn key words: booklet; cross-sectional study; handbook; maternal and child health; online survey. contributions: all authors have made substantial contributions to the conception or design of the study and acquisition, analysis, and/or interpretation of data, participated in drafting or revising the manuscript, approved the version to be published, and agreed to be accountable for all aspects of the work and any issues related to the accuracy or integrity of any part of the work. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: ethical approval obtained from the joint research ethics committee of pengiran anak puteri rashidah sa’adatul bolkiah (paprsb), institute of health science research ethic committee (ihsrec), (ubd/paprsbihsrec/ 2020/123) with permission by the ministry of health brunei darussalam. participants need to give informed consent by clicking “i agree” before completing the survey. availability of data and material: data is available upon reasonable request. funding: none. acknowledgements: the authors would like to express their utmost gratitude to all participants and nurse managers for supporting this study. received: 15 september 2023. accepted: 14 november 2023. early access: 24 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11813 doi:10.4081/hls.2023.11813 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11813] [page 35] non -co mmerc ial us e o nly for example, in 2015, pregnant women in indonesia who used the mch handbook were more likely to seek medical attention when encountering problems during pregnancy.6 similarly, research conducted in mongolia showed that the use of the mch handbook during pregnancy promotes health-seeking behaviors, resulting in an increase in the number of antenatal visits.9 furthermore, the handbook’s utilization among pregnant women has contributed to a more proactive attitude toward health-seeking behaviors.10,11 health-seeking behavior during pregnancy is vital because it leads to better health education. the provision of health education during pregnancy increases pregnant women’s awareness of when to seek medical attention, reducing maternal morbidity and mortality.12–14 the significance of this issue becomes even more apparent when considering the potential consequences of neglecting the antenatal care handbook. inadequate prenatal care can lead to various adverse outcomes, including higher rates of maternal and infant mortality, preterm births, low birth weights, and birth defects.15 it can also result in missed opportunities for early detection and intervention in maternal health conditions, such as gestational diabetes and hypertension, which can have long-lasting effects on both the mother and the child.16 furthermore, the economic burden of complications arising from insufficient prenatal care is substantial, impacting both healthcare systems and families. therefore, studying the utilization and impact of the antenatal care handbook is of paramount importance, as it has the potential to significantly improve maternal and child health outcomes while reducing the associated societal costs. in brunei darussalam, there is at least one mch clinic in each of the 4 districts. these clinics provide antenatal care services, which include routine health monitoring of pregnant women, disease screening, diagnosis, and the provision of information on lifestyle, pregnancy, and delivery.17,18 previous studies have indicated that the mch handbook positively influences maternal knowledge and behaviors, ultimately leading to increased antenatal care attendance among pregnant women.19 therefore, the purpose of this study was to assess the usefulness of the content of the mch handbook in providing information related to antenatal care among pregnant women in brunei, considering overall and demographic stratification. materials and methods study design and setting a cross-sectional study design was employed, utilizing an online survey administered to all mothers at 32 weeks of pregnancy who attended antenatal visits at major maternal and child clinics in brunei. data collection took place between december 2020 and february 2021. the primary objective of this study was to assess the community’s utilization of the mch handbook and investigate potential associations between age, education levels, and the utilization of the mch handbook. sample size the sample size for this study was determined based on the attendance of women at their first antenatal clinic visit in the year 2019, with a total registered population of 6,403 women nationwide. using a 95% confidence level and a 5% margin of error, the calculated ideal sample size was 363, as computed with the qualtrics sample size calculator. to account for potential attrition and non-response bias, a minimum of 380 participants was deemed necessary. this sample size was also discussed with input from both the statistician and the research team. furthermore, six maternal and child health clinics (mch) across the country participated in this study. to ensure equitable representation, the minimum required participants were evenly distributed among the designated sites, aligning with the number of first antenatal visit attendances at each clinic in the year 2019. data collection procedure a qr code and a link to the survey were distributed by the gatekeepers and staff of the respective clinics. the survey was provided to 380 participants, all of whom were 32 weeks pregnant and attending the clinic for their routine antenatal care visit. during the recruitment process, certain inclusion criteria were applied: women aged 18 years and above, citizens or permanent residents of brunei darussalam, and those capable of reading and accessing the internet. recruitment and the distribution of the survey link were facilitated by gatekeepers, with these activities occurring during the antenatal clinic sessions at the chosen mch clinics for the study. all pregnant women at 32 weeks gestation who met the inclusion criteria were invited to participate in the research. the gatekeepers provided a comprehensive overview of the study, and participants were furnished with a handout containing links and a qr code, enabling them to access the online versions of the participant information sheet, consent form, and survey questionnaire. survey instrument the online survey instrument was developed using qualtrics, and the questionnaire was designed by the researcher and the team. the questionnaires underwent pilot testing with a sample of 5 participants at the kuala belait mch clinic. importantly, no alterations or adjustments were deemed necessary for the online survey instrument, as the pilot phase revealed no issues or ambiguities in the research instruments. the questionnaires were available in both english and malay versions to accommodate participants who did not speak or understand english. the survey comprises three sections: i) demographic questions (e.g., age, ethnicity, education level, occupation, and number of pregnancies); ii) questions related to the participant’s opinion of the purpose of the mch handbook (e.g., time to read, frequency of reading, familiarity, purpose of the handbook, explanation from healthcare worker on the usage of the handbook, satisfaction, and suggestions); iii) questions about the usage of the handbook (e.g., the convenience of taking the handbook, reasons for not being interested in reading or using the handbook, preference for using the handbook or smartphone applications, and additional comments about the handbook). data analysis data regarding mch service utilization and its relationship with age and education levels were collected through surveys. subgroup analysis, including the chi-square test, was employed to examine these associations. a value of <0.05 was considered a statistically significant finding. results a total of 73 pregnant women participated in the survey. below is table 1, displaying the socio-demographic characteristics of the respondents. the age of pregnant women in this study was categorized into two groups: below and above 30 years old. there was only a small difference between these two categories, with 38 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 36] [healthcare in low-resource settings 2024;12:11813] non -co mmerc ial us e o nly (52.1%) and 35 (47.9%), respectively. among the pregnant women, 31 (42.5%) had a secondary level of education. the questionnaire also examined the employment status of the sample, revealing that 47 (64.4%) pregnant women were employed. moreover, 46 (63%) pregnant women had fewer than 3 pregnancies. table 2 illustrates the results regarding the respondents’ ages and their preferences for various factors affecting handbook usage. the results showed that older respondents significantly preferred pictures over words (p=0.032). there was only a slight difference in the availability of time for engagement with the handbook among respondents of different age groups. regarding the frequency of pregnant women reading the handbook, most of them indicated they only read it when necessary, constituting 47.9% of the total respondents. participants in both age groups reported being moderately familiar with the content of the handbook, with percentages of 47.4% and 62.9%, respectively. the respondents’ educational level was also examined to determine if it was associated with the usage of the mch handbook in brunei darussalam (table 3). higher education was significantly associated with seeking information from a website (p=0.018), perceiving the handbook as bulky or heavy (p=0.032), and being in favor of transitioning the usage of the handbook to smartphone applications (p=0.041). discussion this study represents the first attempt to assess the effectiveness of the mch handbook among pregnant women in brunei darussalam. the findings from this research shed light on several significant factors that have a profound impact on the utilization of the handbook. these factors include age and understanding of the handbook, trust in the handbook compared to online resources, the influence of birth age and educational level, considerations regarding handbook size and potential transition to smartphone applications, the role of healthcare professionals, and the far-reaching policy implications. age and understanding of the handbook one crucial aspect investigated in this study concerns the relationship between age and the understanding of the purposes of the handbook. the results show that respondents under the age of 30 tend to be more aware of the handbook’s purpose, which is to find relevant information related to maternal and child health.20 their proactive approach to seeking reliable information in the handbook reflects health-seeking behavior and self-care practices. individuals with health-seeking behavior tend to have better control over their health. failure to actively seek information, as evidenced in women not seeking information about cervical cancer, can result in missed opportunities for early detection and prevention, which highlights the significance of health-seeking behavior.21 trust in the handbook compared to online resources furthermore, this study highlights that respondents exhibit a clear preference for the mch handbook when seeking relevant information compared to relying on online resources. this preference for the handbook may be rooted in a lack of trust in the reliability of online information. misleading health-related information on the internet can have severe consequences on individuals’ quality of life and increase the risk of mortality.22 despite this, the growing use of online health information is not seen as a threat to healthcare professionals but rather as a means to enhance understanding of symptoms and diagnoses. insecurity and a lack of trust in online information contribute to the choice of using the handbook as a reliable source of information for maternal and child health.23 the influence of birth age and educational level moreover, the study reveals a significant correlation between birth age and educational level among participants and their awareness of the handbook’s purpose. greater awareness translates to a better understanding of how to use the handbook effectively.10 this increased awareness can lead to an increase in health awareness among pregnant women, thereby promoting health-seeking behavior. participants with diploma qualifications indicated that they used the handbook to record their pregnancy journey, indicating awareness of the handbook’s additional features for interactive and interesting pregnancy tracking.24,25 implications for handbook size and potential transition to smartphone applications the size of the handbook significantly influences its utilization. as evidenced in table 3, the bulkiness and weight of the handbook deter some pregnant women from using it. this finding suggests that future revisions should consider the size, content, and weight of the booklet. interestingly, although smartphone applications offer advantages such as interactivity, social connectivity, and personalized health tracking, the majority of participants did not support a transition from the handbook to smartphone applications. the study results highlight the need for future handbook revisions to better align with users’ preferences.26,27 the role of healthcare workers, particularly nurses and midwives in mch clinics, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. sociodemographic characteristics of participants (n=73). sociodemographic characteristics n % age (years) <30 38 52.1 ≥30 35 47.9 location gadong mch 28 38.4 kuala belait mch 20 27.4 jubli perak sengkurong mch 11 15.1 berakas mch 6 8.2 tutong mch 6 8.2 bangar temburong mch 2 2.7 ethnicity malay 60 82.2 others 7 9.6 chinese 5 6.8 indian 1 1.4 education level secondary 31 42.5 diploma 28 38.3 degree 14 19.2 primary 0 0 employed yes 47 64.4 no 26 35.6 number of pregnancies <3 46 63.0 ≥3 27 37.0 mch, maternal and child health. [healthcare in low-resource settings 2024;12:11813] [page 37] non -co mmerc ial us e o nly becomes crucial. clear and consistent information provided by healthcare professionals before the handbook’s usage may enhance its utilization among pregnant women in brunei darussalam.27,28 the role of healthcare professionals another survey conducted in the united states reported that health applications reduce the burden on primary care, leading to cost reductions and improved quality of care.29 this finding holds particular significance when planning the revision or reconstruction of the mch handbook to better align with users’ needs and interests. since the findings suggest a preference for the handbook over a smartphone application, healthcare workers, such as nurses and midwives in the mch clinic, can enhance their efforts to provide clear and consistent information before expecting mothers to use the handbook. this approach may promote greater utilization of the handbook among pregnant women in brunei darussalam. the far-reaching policy implications based on the compelling outcomes of this study, it is evident that a pressing need exists for policy adjustments aimed at addressing the current shortcomings in the distribution and utilization of antenatal care handbooks. recognizing the pivotal role these handbooks play in maternal healthcare, policymakers should seriously consider adopting measures to alleviate concerns regarding their perceived bulkiness and weight. by implementing these policy changes, there is a promising opportunity to enhance the overall transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. factors influencing handbook usage associated with age using chi-square test (n=73). factors age (years) <30 ≥30 total p n % n % n % availability of time for engaging with the handbook 36 51.4 34 48.6 70 100.0 0.626 no responses 3 frequency of reading the handbook 0.662 whenever necessary 17 46.0 18 52.9 35 49.3 sometimes 17 46.0 14 41.2 31 43.7 always 3 8.0 2 5.9 5 7.0 no responses 2 are you familiar with the content in the mch handbook? 0.402 moderately familiar 18 47.4 22 62.9 40 52.6 slightly familiar 14 36.8 11 31.4 25 32.9 very familiar 5 13.2 2 5.7 7 12.6 not familiar at all 1 2.6 0 0.0 1 1.8 what is the purpose of the mch handbook given to you?* (refer to table 4 for description of each purpose) (multiple response) purpose 1 3 2.6 4 3.7 7 7.0 0.608 purpose 2 8 7.0 7 6.5 15 15.0 0.911 purpose 3 23 20.0 24 22.4 47 47.0 0.473 purpose 4 24 20.9 23 21.5 47 47.0 0.819 purpose 5 33 28.7 23 21.5 56 56.0 0.032 purpose 6 24 20.9 26 24.3 50 50.0 0.306 did you receive any explanation on how to use the handbook? 0.908 yes 36 94.7 32 100.0 68 97.1 no 2 5.3 0 0 2 2.9 no responses 3 satisfied with the information given to you before the usage of the handbook? 0.501 extremely satisfied 15 39.5 13 37.1 28 38.4 slightly satisfied 20 52.6 20 57.1 40 54.8 slightly dissatisfied 2 5.3 0 0 2 2.7 neither satisfied nor dissatisfied 1 2.6 2 5.7 3 4.1 do you find it difficult to take the handbook with you anywhere? 0.632 yes 4 10.8 3 9.1 7 10.0 no 33 89.2 30 90.9 63 90.0 no responses 3 reasons why women not keen to read or use the handbook?* (refer to table 4 for description of each reason) reason 1 5 12.2 3 11.5 8 11.9 0.530 reason 2 6 14.6 3 11.5 9 13.4 0.348 reason 3 9 22.0 4 15.4 13 19.4 0.171 reason 4 2 4.9 4 15.4 6 9.0 0.337 reason 5 6 14.6 3 11.5 9 13.4 0.348 reason 6 10 24.4 5 19.2 15 22.4 0.203 reason 7 3 7.3 4 15.4 7 10.4 0.608 usage of handbook changed to applications from smartphone 0.827 yes 17 45.9 13 39.4 30 42.9 no 20 54.1 20 60.6 40 57.1 no responses 3 *participants could list more than one response to this question. [page 38] [healthcare in low-resource settings 2024;12:11813] non -co mmerc ial us e o nly effectiveness of antenatal care programs, which, in turn, can lead to improved maternal and child health outcomes. limitations the sample size for this study was notably small, with only 73 respondents (19%) out of the 380 targeted participants in the initial proposal. additionally, several questions in the survey received incomplete responses. consequently, the findings of this study may not be broadly applicable to the population of mothers in brunei darussalam. further studies are warranted to gain a deeper understanding of the usefulness of antenatal care handbooks. given the inherent limitations of online surveys, ensuring the sample’s representativeness of the target population posed a challenge. to mitigate potential biases, the survey introduction emphasized the study’s significance and stressed the importance of providing thoughtful, undistracted responses. conclusions this study marks the first of its kind in brunei darussalam since the introduction of the handbook in 2016. the findings of this study provide initial insights into the functionality and utilization of this handbook among pregnant mothers. understanding the purpose of the handbook can potentially enhance health behaviors among women who make use of it. despite the ease of accessing information related to maternal and child health through smartphones and other smart devices, the utilization of the handbook remains a viable choice among respondents. it is our hope that the results of this study will serve as a foundation for future, more comprehensive investigations into the effectiveness of this handbook’s usage. references 1. nakamura y. the role of maternal and child health (mch) handbook in the era of sustainable development goals (sdgs). j glob heal sci 2019;1(1). 2. widianti n, suryawan a, irmawati m. validity test of prescreening developmental questionnaire (pdq) and mother and child health (mch) handbook for determining children’s readiness to enter elementary school. bali med j 2023;12:2117. 3. utami s, susilaningrum r, nursalam. the effect of health promotion based on the health promotion model with a peer group approach regarding the utilization of maternal and child health handbook. indian j public heal res dev 2019;10:1987-92. 4. kawakatsu y, sugishita t, oruenjo k, et al. effectiveness of and factors related to possession of a mother and child health handbook: an analysis using propensity score matching. health educ res 2015;30:935-46. 5. wma the world medical association. wma statement on the development and promotion of a maternal and child health handbook. 2021. 6. osaki k, kosen s, indriasih e, et al. factors affecting the utilisation of maternal, newborn, and child health services in indonesia: the role of the maternal and child health handbook. public health 2015;129:582-6. 7. balogun oo, tomo ck, mochida k, et al. impact of the maternal and child health handbook in angola for improving continuum of care and other maternal and child health indicators: study protocol for a cluster randomised controlled trial. trials 2020;21:1-16. 8. magwood o, kpadé v, thavorn k, et al. effectiveness of home-based records on maternal, newborn and child health outcomes: a systematic review and meta-analysis. plos one 2019;14:e0209278. 9. mori r, yonemoto n, noma h, et al. the maternal and child health (mch) handbook in mongolia: a cluster-randomized, controlled trial. plos one 2015;10:e0119772. 10. aiga h, nguyen vd, nguyen cd, et al. knowledge, attitude and practices: assessing maternal and child health care handbook intervention in vietnam. bmc public health 2015;16:110. 11. sudaryanti l, mardhika a, qona’ah a, et al. antenatal care of pregnant women during pandemic: a phenomenology study. j pak med assoc 2023;73:s71-5. 12. gopalakrishnan s, eashwar vma, muthulakshmi m. healthtransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11813] [page 39] table 4. the description for each purpose and reason presented in table 3. purpose description 1 to write down any clinic appointment 2 to be use by healthcare worker only 3 to be used as reading material to increase health behaviour knowledge 4 to be used as reference when experiencing mild health problems during pregnancy 5 to find relevance information related to mother and child health 6 can be used to record pregnancy journey reason description 1 i find it bulky or heavy 2 less encouragement from the healthcare worker 3 the words used in the handbook are difficult to understand 4 not interactive 5 i like more pictures than words 6 i can get the same information form website 7 i would like to access the information from my handphone non -co mmerc ial us e o nly seeking behaviour among antenatal and postnatal rural women in kancheepuram district of tamil nadu: a cross-sectional study. j fam med prim care 2019;8:1035. 13. istifa mn, efendi f, wahyuni ed, et al. analysis of antenatal care, intranatal care and postnatal care utilization: findings from the 2017 indonesian demographic and health survey. plos one 2021;16:e0258340. 14. triharini m, sulistyono a, adriani m, devy sr. the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and self-determination theory. j ners 2019;14:92-100. 15. debessai y, costanian c, roy m, et al. inadequate prenatal care use among canadian mothers: findings from the maternity experiences survey. j perinatol off j calif perinat assoc 2016;36:420-6. 16. moniz mh, fendrick am, kolenic ge, et al. out-of-pocket spending for maternity care among women with employerbased insurance, 2008-15. health aff (millwood) 2020;39:18-23. 17. sebayang sk, efendi f, astutik e. women’s empowerment and the use of antenatal care services: analysis of demographic health surveys in five southeast asian countries. women heal 2019;59:1155-71. 18. yunitasari e, putri duw, armini nka, et al. analysis of factors that affect the utilization of antenatal care in developing countries: a systematic review. j pak med assoc 2023;73:s162-9. 19. yanagisawa s, soyano a, igarashi h, et al. effect of a maternal and child health handbook on maternal knowledge and behaviour: a community-based controlled trial in rural cambodia. health policy plan 2015;30:1184-92. 20. khasanah u, efendi f, has emm, et al. healthcare-seeking behavior for children aged 0-59 months: evidence from 20022017 indonesia demographic and health surveys. plos one 2023;18:e0281543. 21. habtu y, yohannes s, laelago t. health seeking behavior and its determinants for cervical cancer among women of childbearing age in hossana town, hadiya zone, southern ethiopia: community based cross sectional study. bmc cancer 2018;18:1-9. 22. swire-thompson b, lazer d. public health and online misinformation: challenges and recommendations. annu rev public health 2020;41:433-51. 23. van riel n, auwerx k, debbaut p, et al. the effect of dr google on doctor-patient encounters in primary care: a quantitative, observational, cross-sectional study. bjgp open 2017;1(2). 24. mardiyanti i, devy sr, ernawati e. analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy. j ners 2019;14:144-50. 25. ainiyah nh. the use of maternal and child health (mch) handbook improves healthy behavior of pregnant women. maj obstet ginekol 2017;25:58-62. 26. tang j, abraham c, stamp e, greaves c. how can weight-loss app designers’ best engage and support users? a qualitative investigation. br j health psychol 2015;20:151-71. 27. lim s, xue l, yen cc, et al. a study on singaporean women’s acceptance of using mobile phones to seek health information. int j med inform 2011;80:e189-202. 28. mahmood a, kedia s, wyant dk, et al. use of mobile health applications for health-promoting behavior among individuals with chronic medical conditions. digit heal 2019;5:20552 07619882181. 29. bhuyan ss, lu n, chandak a, et al. use of mobile health applications for health-seeking behavior among us adults. j med syst 2016;40:153. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 40] [healthcare in low-resource settings 2024;12:11813] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11864 the evaluation of drug management (selection, procurement, and lead time of drug order) in hospital during covid-19 in indonesia nurwulan adi ismaya,1 rita dwi pratiwi,2 riris andriati,2 fenita purnama sari indah,3 gina aulia,1 gita ayuningtyas,2 priscilla shinta1 1pharmacy study program, widya dharma husada school of health science, tangerang; 2nursing study program, widya dharma husada school of health science, tangerang; 3public health study program, widya dharma husada school of health science, tangerang, indonesia abstract in the current covid-19 era, one of the critical factors influencing the quality of hospital services is drug management, with planning and procurement being particularly pivotal to avoid drug shortages. this study aimed to examine the selection, procurement, and lead time aspects of drug management at the pharmacy installation hospital in jakarta during the covid-19 pandemic. conducted as a descriptive study with retrospective data, total sampling was utilized to collect data, incorporating 1,413 drugs. the data, collected on observation sheets, underwent univariate analysis using microsoft excel. results indicated that out of the seven measurable indicators, two met the standards: the percentage of allocated funds for drug procurement at 70.5%, and the frequency of errors in orders occurring five times. however, five indicators fell below the standards: the suitability of drug items with the national formulary at 14.15%, the suitability of drug items with the hospital formulary at 68.15% (with an 80% benchmark), the frequency of each item’s procurement in a year at a low category of 43.45%, the percentage of conformity between planning and reality at 99.61%, and the achievement of lead time for ordering drugs at 5.08 days. in conclusion, the selection, procurement, and lead time aspects of drug management at the “x” hospital pharmacy installation did not fully meet the established standards. therefore, it is recommended that healthcare management implements and adheres to robust drug management system regulations, particularly during pandemic situations, to ensure optimal hospital services. introduction pharmaceuticals are an integral part of healthcare delivery, and they play a great role in improving treatment outcome and the quality of healthcare service. drugs are a vital and expensive component of the provision of healthcare services to patients.1 to ensure maximum benefit from such investment, the drugs should be available at health care institutions whenever they need them.2 during covid-19 outbreak periods, the pressure of medical service increased.3,4 the limited information about the treatments available to treat the virus, and the sanitary restrictions caused a significant impact, not only on the projections made by a hospital for the purchase of medicines within its catalog, but also on new acquisitions to respond to the drug needs that arose with the advance in the number of cases.5 the covid-19 pandemic led to the emergence of a new type of drug shortage that is attributed to the increase in its demand.6-9 in the year 2021, the increase in hospitalization for patients sick with covid-19 raised the average hospital stay by 45% in intermediate care and 140% in the intensive unit compared to 2019. this generated increases in the consumption of medicines by 45%. this fluctuation caused measures to be taken to drastically vary the products that initially would be requested, to remove products of greater use at the hospital level and negotiate the purchase directly with the supplier. according to the world health organization correspondence: nurwulan adi ismaya, pharmacy study program, widya dharma husada school of health science, tangerang, indonesia. e-mail: nurwulanadiismaya@wdh.ac.id key words: drug management, lead time, planning, procurement. contributions: nai, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; rdp, ra, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; fpsi, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; gau, methodology, visualization, writing – review and editing; gay, resources, investigation, and writing –review and editing; dp formal analysis, validation, writing – review and editing; ps, resources, supervision, and writing –review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of public health, universitas jember, based on ethical certificate 112/kepk/fkm-unej/x/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 22 september 2023. accepted: 23 january 2023. early access: 1 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11864 doi:10.4081/hls.2024.11864 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11864] [page 387] non -co mmerc ial us e o nly (who), in developing countries drug costs are 24-66% of total health costs.10 such large drug purchases must be managed effectively and efficiently. inventory management system in healthcare supply chain (hcsc) have been pushed to breaking point by the covid-19 pandemic. unanticipated demand shocks due to stockpiling of medical supplies caused stockouts, and the stockouts triggered systematic supply chain (sc) disruption inconceivable for risk managers working individually with limited information about the pandemic.6,11-13 indonesia has changed its face in the world of health, where it will be able to grow to become one of the largest generic drug providers in the asia pacific region. by placing a national health insurance system in indonesia, the government through the ministries and health institutions must work harder to meet domestic drug needs.14 challenges in managing drug supplies and shortages are nothing new, and in some cases, a pandemic offers an unusual opportunity for pharmacists to prepare proactively for an uncertain spike in cases.15,16 since the covid-19 outbreak, the healthcare sector has been uncertain, especially the pharmaceuticals sector.17-19 medication availability may be a critical factor in the success of covid-19 treatment, as well as an indicator of readiness and procurement, given that the covid-19 pandemic cannot yet be predicted. if the drug stock is too small, the demand for use is often not met, so that patients or consumers are not satisfied, causing hospitals to lose customers. however, if the stock is too large, it causes storage costs that are too high, the possibility of the drug being damaged, expired, and there is a risk of death stock.2,20 drug shortage is always a critical issue of inventory management in healthcare systems, since it potentially invokes several negative impacts.1,21 in supply chain management, optimization goes hand-in-hand with inventory control to address several issues of the supply, management, and use of drugs. in the previous study, the results show that there are insufficient human resources in the pharmacy installation, the logistics storage area for drugs is not sufficient, and the availability of drugs sometimes experiences vacancies due to unavailability of stock and time of order (2020).22 this last research showed that the selection and procurement of drugs in pharmacy installations was not fully in accordance with standard indicators.23 related to this research, there must be further research to examine the appropriateness of drug management. reporting from rsx.co.id, the achievement of the indicator for outpatient waiting time, at rs “x” jakarta reached 135 minutes, below the national service quality target of 60 minutes. patient waiting time can be influenced by the vacancy of drug supplies due to lead time of old drug orders. lead time is the loading time for drugs starting from planning until the drugs are received at the pharmacy installation warehouse, which is one of the important indicators that affects the planning and control of drug inventory.24,25 because of the widespread use of covid-19 drugs during the pandemic, some critically needed medical supplies were running low. previous research showed that the selection and procurement of drugs in pharmacy installations was not fully in accordance with standard indicators, and the current challenge is covid-19 pandemic that caused the changes in government guidelines, and some covid-19 drug items are in a stagnant state (stock excess up to three times the average usage amount) that may cause hospitals to experience problems in a variety of ways, both financial and nonfinancial. the purpose of this study was to determine the selection, procurement, and lead time for ordering drugs at the pharmacy installation of hospital “x” jakarta. materials and methods research design this study used a descriptive research method with a quantitative approach that described and identified drug management retrospectively using data from the past. the research was conducted at hospital “x” jakarta. study participants the population of this research was all drugs that were on the list of drug procurement at the pharmacy installation of hospital “x” jakarta, totaling 1,413 drug items as objects of research. the sampling technique used in the object of this research was to use non-probability sampling, with total sampling where the entire population was sampled. variable, instrument and data collection the data used were primary data and secondary data. the primary data in this study were obtained from interviews with related parties, namely the head of the pharmacy installation of hospital “x” jakarta, the main supervisor for the planning section, and the planning section implementer. the secondary data in this study consisted of a list of national formulary drugs, a list of hospital formulary drugs, a list of drug procurement, budget reports, and loading time evaluation reports, lead time of drug orders, and interview sheets. data analysis data were collected in observation sheets and then analyzed using univariate analysis with microsoft excel. the aspect of data was analyzed, including the selection stage, the procurement stage, frequency of procurement of each drug item per year, and the lead time. ethical clearance the research has received ethical approval from the health research ethics commission, faculty of public health university of jember, based on ethical certificate 112/kepk/fkmunej/x/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results the results of the study were divided into 3 categories, namely the selection stage, the procurement stage, and the lead time for ordering drugs. there were 1,413 drug items evaluated in this study. the selection stage at the selection stage shown in table 1, there are two categories, namely the suitability of the drug items with the national formulary (fornas), with the percentage value of conformity of 14.15%, and the suitability of the drug items with the hospital formulary, with the percentage of conformity of 68.15%. the procurement stage at the procurement stage shown in table 2, there are three categories, including: i) the percentage of allocation of funds for drug procurement available, with the percentage value of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 388] [healthcare in low-resource settings 2024;12:11864] non -co mmerc ial us e o nly conformity of 70.50%, ii) the frequency of incomplete orders/invoices, which is five times incomplete, and iii) the suitability of drug planning, with the reality of each drug with 99.61% results being appropriate. the last category, shown in table 3, is the frequency of procurement of each drug item per year, with a value of 43.45% low, 28.88% moderate, and 27.67% high. in the last stage, the lead time for ordering drugs in table 3 with a value of 5,08 working days. the lead time the results related to lead time of drug orders showed an average of 5.08 working days (table 4). discussion the selection stage the selection stage in table 1 showed that the percentage of suitability of drug items available at the x hospital pharmacy installation (ifrs) with fornas is 14.15%. according to the ministry of health, the standard value for the suitability of drugs available at ifrs with fornas is ideally 100% as a guideline for providing drug items for social security agency on health (bpjs) in level ii health facilities / type b hospitals.26 the results of the research on the percentage of conformity of drug items with fornas at the pharmacy installation of x hospital of 14.15% is smaller when compared to research con transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. drug management at the selection stage. indicator comparison value % compatibility of drug items with national formulary 100% 14.15% compliance of drug items with hospital formulary 80% 68.15% table 2. drug management at the procurement stage. indicator comparison value % percentage of allocation of funds for drug procurement 30-40% 70.5% frequency of incomplete sp/invoice 1-9 times 5 times percentage of compliance with drug planning 100-120% 99.61% table 3. procurement stage (frequency of procurement of each drug item per year). indicator n % low <12x/year 614 43.45 moderate 12-24x/year 408 28.88 high >24x/year 391 27.67 total 1,413 100 table 4. procurement stage (frequency of procurement of each drug item per year). january 5 6.75 february 5 4.25 march 5 5.5 april 5 3.75 may 5 3 june 5 3.25 july 5 6.5 august 5 7 september 5 5.75 october 5 4.5 november 5 5.25 december 5 5.5 average 5 5.08 [healthcare in low-resource settings 2024;12:11864] [page 389] non -co mmerc ial us e o nly ducted by inacio da costa (2017), which shows the percentage of conformity of drug items available at ifrs ungaran with fornas is 41.08%, and is much smaller when compared to the results of research from nur oktaviani et al., in 2018, which is 96.7% percentage of drug item conformity with fornas at west nusa tenggara (ntb) provincial hospital.27,28 this small percentage value is based on the results of interviews with the ifrs planning department that for drug procurement, it refers to the hospital formulary list. therefore, the results of this study indicate that the percentage of conformity of drug items based on fornas at hospital “x” jakarta is not up to standards. the second category at the selection stage is the suitability of items available at the pharmacy installation of hospital “x” jakarta with the hospital formulary of 68.15%. according to the ministry of health, the standard value of the suitability of drugs available in hospitals with the hospital formulary for hospital accreditation requirements is 80%.29 therefore, it can be said that the indicator of the suitability of drug items with the formulary of hospital x jakarta in 2020 has not been effective. one of the causes of the low percentage of drug item suitability based on the hospital formulary is the lack of commitment of doctors to the implementation of the drug formulary in hospitals, not maximizing function of the pharmacy and therapeutic committee (kft), and also the influence of the pharmaceutical industry.27,28,30 the procurement stage the procurement stage with the category of allocation of funds for the procurement of drugs available at the hospital is 70.5%. this value shows that the percentage of budget allocation for drug procurement in 2020 has met the standard value set by who, which is between 30-40%. the results of this study indicate that the percentage value of the allocation of funds for drug procurement at hospital “x” jakarta is higher when compared to research by inacio da costa (2017), which is 25.83% in ungaran hospital, and the results of mompewa’s research in 2015 of 29.3% in the pharmacy installation at poso hospital, central sulawesi.27,31 pharmacy installations are revenue center in hospitals, therefore, the budget function is an important basis to know in planning the procurement of drugs both in terms of type and quantity, so that drug managers must be involved in budget discussions and allocation of funds for drug procurement, with the aim of being a joint commitment to accountability for the use/expenditure and procurement of drugs quality by maximizing the coordination function and increasing the understanding of the hospital management team in making policy and priority decisions on the amount of budget allocation.32 the results showed that the frequency of incomplete orders/invoices at the pharmacy installation of hospital “x” jakarta in 2020 was 5 times. according to drug management standards, the frequency indicator for incomplete sp/invoices is 1-9 times, so it can be stated that the frequency indicator for incomplete orders/invoices is effective according to the standards. the data are taken retrospectively, namely invoice documents for 2020 from all pharmaceutical wholesaler (pbf) partners. the results of this study are smaller when compared to the research conducted by nur oktaviani et al., in 2018, at west nusa tenggara (ntb) hospital, in which the frequency of incomplete orders/invoices was 30 times.33 meanwhile, in a study by mompewa in 2015 at the pharmacy installation of poso hospital, central sulawesi, an analysis of invoice errors could not be carried out because the wrong invoice was not archived but returned to the pbf concerned.34 at the pharmacy installation of hospital “x” jakarta, the frequency of invoice errors is small because if there is an incorrect invoice, the invoice is immediately rejected and returned to the partner/pbf. the erroneous invoice is corrected and then resent. from the results of interviews with the recipient of the goods, it was obtained information that the frequency or number of invoice errors at the pharmacy installation of hospital “x” jakarta is very minimal because the process of receiving goods is carried out according to standard procedures that have been set.28,31 the procurement stage with the category of procurement frequency of each drug item per year shows that if the procurement uses the eoq approach/method, the frequency value of procurement of each drug item at hospital “x” jakarta is in the range of 1-61x/year, with each category being low (<12x/year), with 614 items (43.45%), medium (12-24x/year), with 408 items (28.88%), and high (>24x/year), with 391 items (27.67%). based on the results of interviews with the planning executives, items that fall into low category are drugs in the slow-moving category or those whose procurement is based on special requests. meanwhile, the drug items that fall into the high category are fast-moving drugs, drugs with high costs, so that the order must be divided into several orders in accordance with procurement provisions where the maximum value of one order letter cannot be more than 50 million or drugs that experience fluctuations in usage during the covid-19 pandemic. quick et al. (2012) stated that the use of the eoq method aims to reduce storage costs and the risk of damage/expiration although ordering costs increase, but there can be considerable cost efficiency. the higher the storage cost, the hospital will experience losses and conversely, the lower the inventory storage cost will benefit the hospital.32-35 the results of this study are higher than those of the previous research conducted by ismaya et al. in 2018, the frequency of procurement of each drug item at the tangerang city general hospital is 1-19x/year, and it is much higher when compared to the research conducted by nur oktaviani et al. (2017) at the west nusa tenggara (ntb) hospital in 2017 as many as 4-5 times/year. the results of research by yuki in 2021 stated that the frequency of procurement of drug items per year in 2020 at the rsua is a maximum of 9 times, which shows that the frequency of procurement of each drug item per year is still relatively low. then in mid-may to june 2020 there were large-scale social restrictions (psbb) and wfh (work from home) which causes the provider’s response to drug delivery to be longer than before.28,36 the procurement phase with the category of percentage of conformity between drug planning and the reality of each drug at the pharmacy installation of hospital “x” jakarta is 99.61%. this value indicates the discrepancy between planning and procurement, which according to pudjaningsih in 1996, is 100120%. this was due, among other things, to the fact that the stock at the pbf was empty, and because of the price difference between the price stated on the sp and the price prevailing in the pbf. thus, the accuracy of drug planning at the pharmacy installation of hospital “x” jakarta in 2020 was not efficient. the results of this study are in line with anggia’s research in 2019, stating the accuracy of drug planning at the pharmacy installation of an-nisa hospital, tangerang city, which is 77.6%.32 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 390] [healthcare in low-resource settings 2024;12:11864]] non -co mmerc ial us e o nly the lead time the results related to lead time of drug orders showed an average of 5.08 working days. therefore, it can be said that lead time of drug orders was not effective because it is not in accordance with the targets standardized on the performance indicators of quality targets for the pharmacy installation of hospital “x” jakarta. from the observations, it is known that during 2020, there are 5 months (february, april, may, june, and october) where the lead time for ordering drugs is in accordance with the target, which is less than 5 working days, and there are 7 months (january, march, july, august, september, november, and december) where the lead time for ordering drugs does not reach the target, which is more than 5 working days. according to research by mendrofa (2016), the procurement of bpjs drugs has a longer lead time than regular drugs, so the calculation of rop for bpjs and regular drugs must be separated, which causes the stock in the service to be less than the safety stock. the results of this study are smaller than the results of research by wijaya andi saputra et al. (2019) at the grhasia mental hospital di yogyakarta, that there were 83 drug items with a lead time of more than 30 days from a total of 239 drug items in 2017, and 68 drug items with a lead time of more than 30 days. lead time of more than 30 days from a total of 252 drug items in 2018. the percentages of the total number of drugs with a lead time of more than 30 days in 2017 and 2018 using e-purchasing method were 35.17% and 26.98%, respectively.37 the longer drug lead time compared to direct procurement is due to the fact that the stock of drugs listed in the e-catalogue does not correspond to the real stock or ready stock at the distributor, as well as production delays caused by long imports of raw materials during the covid-19 pandemic.37-39 this study provided valuable insights regarding the impacts caused by the covid-19 pandemic on the pharmaceutical/healthcare products supply chain; however, it was associated with certain limitations. for instance, this study considered the abrupt changes in demand during one year of covid pandemics, that means this study is using a retrospective data. furthermore, the proposed model in this study considered the pandemic condition; however, expanding the model to the post-pandemic could provide much more practical solutions to the decision makers. future studies should be conducted to create a supply chain system to control the management of drug for pandemic era particularly. conclusions based on the research findings involving 1,413 drug items and focusing on the description of drug planning and procurement at hospital “x” in jakarta during the covid19 pandemic era, it can be concluded that drug management is not 100% effective. this conclusion is substantiated by the presence of indicators with results falling below the effective range. these indicators include the percentage of drug items available according to the national formulary (fornas), the percentage of available drug items according to the hospital formulary, the percentage of conformity between drug planning and reality, and the lead time of drug orders. in light of these results, it is recommended that every hospital, especially those in jakarta, should develop a specialized system for drug management tailored to pandemic situations. this comprehensive approach should cover the selection stage, procurement stage, and distribution stage to enhance the effectiveness of drug management during challenging times such as the covid-19 pandemic. references 1. hermansyah a, sainsbury e, krass i. community pharmacy and emerging public health initiatives in developing southeast asian countries: a systematic review. heal soc care community 2016;24:e11-22. 2. ranga s. management of drug supply chain in a major public sector and private sector hospital in sri lanka. 2019. available from: https://figshare.com/articles/thesis/ management_of_ drug_supply_chain_in_a_major_public_sector_and_private_s ector_hospital_in_sri_lanka/17027264/1 3. rokhmah d, ali k, putri smd, khoiron k. increase in public interest concerning alternative medicine during the covid-19 pandemic in indonesia: a google trends study. f1000research 2020;9:1201. 4. lee hf, hsu hc, efendi f, et al. burnout, resilience, and empowerment among covid-19 survivor nurses in indonesia. plos one 2023;18:e0291073. 5. nurlinawati i, sumiarsih m, andarwati p, et al. determinants of risk factors for covid-19 transmission in densely populated areas: insights from the first wave of the pandemic. electron j gen med 2023;20. 6. jorge vm, esteban zm, bruno sa, et al. implementation of supply management strategies by the pharmacy service in a general hospital during the covid-19 pandemic. explor res clin soc pharm 2022;7:100161. 7. jifar ww, geneti gb, dinssa sd. the impact of covid-19 on pharmaceutical shortages and supply disruptions for noncommunicable diseases among public hospitals of south west, oromia, ethiopia. j multidiscip healthc 2022;15:1933-43. 8. abdolazimi o, salehi esfandarani m, salehi m, et al. development of sustainable and resilient healthcare and noncold pharmaceutical distribution supply chain for covid-19 pandemic: a case study. int j logist manag 2023;34:363-89. 9. lesmana gm, tenando md, dewi vm. pharmaceutical and medical devices industry regulation in indonesia: human rights perspective. jurist-diction 2022;5. 10. world health organization (who). medicines. 2023. available from: https://www.who.int/health-topics/medicines #tab=tab_2 11. otiashvili d, mgebrishvili t, beselia a, et al. the impact of the covid-19 pandemic on illicit drug supply, drug-related behaviour of people who use drugs and provision of drug related services in georgia: results of a mixed methods prospective cohort study. harm reduct j 2022;19:1-15. 12. friday d, savage da, melnyk sa, et al. a collaborative approach to maintaining optimal inventory and mitigating stockout risks during a pandemic: capabilities for enabling health-care supply chain resilience. j humanit logist supply chain manag 2021;11:248-71. 13. vatandoost v, tabatabaee ss, okhovati m, barooni m. explaining the challenges of resources management and its underlying factors in covid-19 era in iran: a qualitative study. bmc public health 2023;23:1-15. 14. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11864] [page 391] non -co mmerc ial us e o nly heal 2022;10:e1632-45. 15. fadila r, erna k, nlpepa. evaluasi persediaan obat covid19 pada masa pandemi dan faktor yang mempengaruhi di rumah sakit pemerintah dan rumah sakit swasta di kota makassar. jurnal manajemen pelayanan kesehatan 2023;26. 16. firdaus f, andadari rk, putra hmm, sulandjari s. supply chain management on inventory indonesian drug industry. j adv multidiscip res 2021;1:63. 17. jiwanti pk, wardhana by, sutanto lg, et al. recent development of nano-carbon material in pharmaceutical application: a review. molecules 2022;27. 18. aryati a, maulidan eb, miftahussurur m. diagnostic for covid-19: application for developing countries. int j pharm res 2020;12:1458-67. 19. setiarso p, kusumawati n, santoso ab, et al. production standardization of hand sanitizer spray based on ethanol, isopropanol, and bioethanol to prevent the covid-19 transmission. in: aip conference proceedings 2022;2645:030005. 20. hariyanti d. perencanaan obat berdasarkan analisis always better control (abc) dan economic order quantity (eoq) di instalasi farmasi rsud melawi kalimantan barat. tugas akhir farm fak kedokt univ tanjungpura 2015;1-13. 21. mistry sk, ali am, yadav un, et al. covid-19 related anxiety and its associated factors: a cross-sectional study on older adults in bangladesh. bmc psychiatry 2022;22. 22. hilmawati s, chotimah i, dwimawati e, et al. analisis manajemen logistik obat di puskesmas cipayung kota depok provinsi jawa barat tahun 2019. promot j mhs kesehat masy 2020;3:427. 23. ulfah m, wiedyaningsih c, endarti d. evaluasi pengelolaan obat tahap perencanaan dan pengadaan di rsud muntilan kabupaten magelang tahun 2015-2016. jmpf 2018;8:24-31. 24. zwaida ta, pham c, beauregard y. optimization of inventory management to prevent drug shortages in the hospital supply chain. appl sci 2021;11. 25. sin jh, ferguson lm, ally js, richards ii. utilising an automated medication inventory management system for emergency crash carts during the covid-19 pandemic. futur healthc j 2022;9:87-9. 26. ministry of health of the republic of indonesia. 2016. regarding pharmaceutical service standards in hospitals. 2016;2016. 27. da costa i. evaluasi pengelolaan obat di instalasi farmasi rumah sakit umum daerah ungaran kabupaten semarang provinsi jawa tengah, tesis, fakultas farmasi universitas setia budi, surakarta. repos usb 2017;5-24. 28. oktaviani n, pamudji g, kristanto y. evaluation of drug management in the pharmacy installation of the regional general hospital of ntb province in 2017. j farm indones 2018;15:135-47. 29. minister of health of the republic of indonesia. regarding standards of pharmaceutical services in hospitals decree of the minister of health of the republic of indonesia no. 58 of 2014. permenkes no. 58 tahun 2014. 30. ageron b, benzidia s, bourlakis m. healthcare logistics and supply chain issues and future challenges. supply chain forum 2018;19:1-3. 31. mompewa rs, wiedyaningsih cwg. evaluation of drug management and improvement strategies using the hanlon method at the pharmacy installation of the poso regional general hospital, central sulawesi province. chmk pharm sci j 2019;2:10-8. 32. ayu dpsd, satibi, diah ap. analysis of drug costs in the jkn era and influencing factors in health support facilities in the special region of yogyakarta. j pharm manag serv journal manag pharm pract 2015;5:291-300. 33. oktaviani n, pamudji g. evaluasi pengelolaan obat di instalasi farmasi rumah sakit umum daerah provinsi ntb tahun 2017. j farm indones 2018;15:135-47. 34. mompewa r. evaluasi pengelolaan obat dan strategi perbaikan dengan metode hanlon di instalasi farmasi rumah sakit umum daerah poso provinsi sulawesi tengah. chmk pharm sci j 2019;2:2019. 35. ercis, widodo gp. analysis of cytostatic drug control with oeq and rop methods. j pharm manag serv 2013;3:203-10. 36. ismaya na, ratnaningtyas to, wahyuni rr. overview of standards for planning and procurement of drugs at the pharmacy installation of south tangerang city general hospital in 2017. edu masda j 2019;3:31. 37. mendrofa de, suryawati c. analysis of bpjs patient drug management at the pharmacy installation of panti wilasa citarum hospital, semarang. indones j heal manag 2016;4:214-21. 38. saputra wa, puspandari da, kurniawan mf. medicines procurement evaluation with e-purchasing method through e-catalogue at grhasia mental hospital of daerah istimewa yogyakarta in 2017 2018. indones heal policy j jkki 2019;08:113-20. 39. khurana s, chhillar n, gautam vks. inventory control techniques in medical stores of a tertiary care neuropsychiatry hospital in delhi. health (irvine calif) 2013;05:8-13. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 392] [healthcare in low-resource settings 2024;12:11864] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11213 experience of nurses using the basic nursing science in performing nursing care for patients at rsud dr. soedomo trenggalek, indonesia rizki bahtiyar ardyansah, shila wisnasari, titin andri wihastuti, dina dewi sartika lestari ismail department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: the provision of humanistic and professional nursing care services needs to be carried out comprehensively, and it must cover patients’ bio-psycho-socio-spiritual aspects. this indicates nurses have to integrate all the basic nursing science, including physiology, anatomy, pharmacology, and pathophysiology, while carrying out their duties. this integration helps to provide the best care for their patients, but they often uncertain about the basic science approach to use. therefore, this study aims to explore the experience of nurses using basic nursing science in caring for patients with chronic diseases. design and methods: in-depth interviews were conducted with 5 nurses working in chronic disease wards for at least 5 years. each respondent was then interviewed using a self-constructed questionnaire. results: all respondents agreed that basic nursing science is important in providing quality healthcare services. furthermore, six themes were identified using the thematic analysis, namely (1) the process of collecting patient data, which was more focused and organized; (2) required for establishing the nursing diagnosis; (3) useful for determining the nursing care plan; (4) it is a basis for implementing nursing actions; (5) provides a basis for monitoring and follow-up; (6) and teamwork between health personnel is more effective. conclusions: based on the interview results, nurses need knowledge and skills in basic nursing science while caring for patients with chronic diseases. furthermore, basic nursing sciences lay the foundation for nurses while assessing patients, diagnosing, planning the care, implementing nursing actions, evaluating patients’ condition, and collaborating with other health personnel. introduction nursing is the act of providing care to sick and healthy individuals, families, groups, or communities. furthermore, it is a professional occupation, which is an integral part of health services and based on nursing knowledge and tips.1 the humanistic and professional nursing care services need to be provided comprehensively, and cover the bio-psycho-socio-spiritual aspects of patients.2 the basic knowledge, attitudes, and skills are very essential for all health professions.3 therefore, nurses need basic nursing knowledge, including physiology, anatomy, pharmacology, pathophysiology to increase the quality of healthcare services they provide. the knowledge is also essential for evidence-based practice that is carried out by nurses.4 physiology is a crucial element of bioscience in the nursing care process, but there is still a lack of clarity about the boundaries. furthermore, lack of knowledge about human physiology has a direct impact on nursing practice, hence, it is necessary to ensure that physiology and biosciences can support the development and skills of nurses.5 human anatomy is also a key component of the basic nursing science used in preparing competent professionals for clinical practice, but it is considered a challenge.6 meanwhile, nurses play an integral role in administering medication to patients, consequently, they also require knowledge and skill about pharmacology.7 they must also be able to think logically and critically while studying and identifying human response phenomena, which provides better understanding of common diseases pathophysiological basis.8 despite the importance of basic nursing science in the nursing practice, basic nursing science understanding is still considered a challenge by most nurses. nurses are often uncertain about the basic science approaches they can use while carrying out their duties, specifically in indonesia. some nurses think it is important to integrate basic nursing science with the technology used in nursing practice to improve the quality of the healthcare services provided. however, in reality, it is often seen as an empirical influence of medical planning, which obscures their main activities in terms of caring.9 knowledge and understanding of basic nursing science are believed to support the provision of holistic and quality healthcare service. therefore, this study aims to explore the experience of nurses using basic nursing science while performing their duties. design and methods the sample population consists of five nurses working in the chronic diseases ward at dr. soedomo hospital, trenggalek. the inclusion criteria include samples with a diploma or bachelor’s degree in nursing, using basic nursing science in performing healthcare duties, and have been caring for patients with chronic diseases for at least 5 years. subsequently, in-depth interviews article significance for public health basic nursing science knowledge is required by nurses while providing quality health care to their patients. however, the idea of integrating it into nursing care is still low, and some nurses often carry out their duties without proper knowledge of the basis or rationale behind the services they render. this study describes nurses’ experience on integrating basic nursing science in nursing care. [healthcare in low-resource settings 2023; 11(s1):11213] [page 151] non -co mmerc ial us e o nly were conducted using a 6 items self-constructed questionnaire. the questions were used as a guide, and significant things discussed by respondents were further explored in detail. the interview of each respondent lasted for 35-45 minutes, and the data collected was then analyzed using interpretative phenomenology analysis (ipa). this study was granted ethical and risk assessment approval by the ethical research committee of the faculty of medicine, universitas brawijaya on 08/04/2020. results and discussions five respondents, which consist of three male and two female nurses were used for this study. furthermore, their age ranged between 27-38 years old, and two respondents have a bachelor’s degree, while others have a diploma degree in nursing, as shown in table 1. all respondents agreed that basic nursing science is important in nursing practice. the transcript verbatim was then analyzed, and several sub-themes were obtained, which were used to form six different themes, as shown in table 2. theme 1: the process of collecting patient data is more focused and organized theme 1 consists of four sub-themes, namely i) serves as a guide during assessment; ii) directs the physical examination; iii) well organized; and iv) facilitates the observation of patients’ condition. sub-theme 1: serve as a guide during assessment respondents agreed that basic nursing science helps nurses to obtain diseases’ anamnesis data easily, because it serves as a guide while exploring patients’ condition, as expressed below: “basic nursing science can become a guide for us in the anamnesis process, we will learn something (about patients’ condition) we did not know before” (p2). sub-theme 2: validate data through physical examination physical examination is a series of activities carried out by examining patients from head to toe. furthermore, it helps to determine the presence of abnormal physical symptoms and supports the diagnosis. according to respondents, basic nursing science is very essential in validating data collected through physical examination, as stated below: “we can distinguish the findings during physical examination, whether it is normal or abnormal, (we obtained relevant information from the subjects we studied back then in the college so that we can determine whether patients’ condition is normal or not. that’s the importance of the basic nursing science).” (p4) sub-theme 3: well organized physical examination in the chronic disease ward of dr. soedomo trenggalek hospital needs to be carried out systemically (b1-b6). respondents stated that with the basic nursing science, the data obtained during the assessment can be well organized, as stated below: “if we did not learn basic nursing science during college, it is article [page 152] [healthcare in low-resource settings 2023; 11(s1):11213] table 1. characteristic of respondents. code sex age (y.o) education years of experience p1 male 32 diploma 7 p2 male 27 bachelor of nursing 5 p3 female 29 bachelor of nursing 8 p4 male 38 diploma 11 p5 female 35 diploma 10 table 2. themes and sub-themes. no theme sub-theme 1 the process of collecting patient data is more focused and organize serve as a guide during assessment directing the physical examination well organized facilitate the observation of patients’ condition 2 required for establishing the nursing diagnosis think critically analyzing patient cases determining nursing diagnoses determining the priority of the problem 3 useful for determining the nursing care plan determining goals and expected outcomes planning the intervention 4 as a basis for implementing nursing actions basis for giving education to patients administering medication appropriately collaborate with other medical staffs 5 provides a basis for monitoring and follow-up basis for monitoring patients’ condition basis for evaluating the implementation of nursing intervention and follow-up plans 6 teamwork between health personnel is more effective effective communication and coordination problem solving non -co mmerc ial us e o nly possible that we will not be able to carry out physical examination sequentially, so we missed a lot.” (p3) sub-theme 4: facilitate the observation of the patient’s condition respondents argued in their statement that the basic nursing science taught in college enables nurses to recognize the disease manifestations, which makes patients’ condition observation easier, as stated below: “even though we do not know patients’ full examination data, it can be seen from the clinical symptoms alone.” (p1) data collection in nursing assessment is very important to explore complaints and conditions experienced by patients with chronic diseases. furthermore, the methods used to collect data during the assessment include anamnesis, physical examination, and laboratory data.10 by using the basic nursing science, nurses can collect and organized data comprehensively as well as identify patients’ data easily. the systematic data collection process is a form of nurse professionalism, which provides wholehearted care and improved services to patients.11 nursing care cannot be separated from the importance of nursing assessment.12 in the process of collecting assessment data, the difficult basic nursing science for students became very useful in the practice.13 theme 2: required for establishing the nursing diagnosis diagnosing is the process of determining the medical problem faced by patients. furthermore, the diagnosis is established based on the results of anamnesis, physical examination, and laboratory tests. theme 2 was formed from four sub-themes including i) thinking critically; ii) analyzing patient cases; iii) determining nursing diagnoses; and iv) determining the priority of the problem. sub-theme 1: think critically critical thinking is the ability to think clearly and rationally about what to do or believe. furthermore, it is often used to make decisions by nurses caring for patients with chronic diseases, as stated below: “one benefit (of using basic nursing science) is that it helps us think critically about chronic diseases, so we know if there is an abnormal condition in patients.” (p2) sub-theme 2: analyzing the patient cases case analysis is very important while determining nursing diagnoses based on patients data. it is supported by subjective and objective data, which further supports the disease etiology until nursing problems developed. respondents think that basic nursing science helps nurses to analyze the data collected during assessment, as stated below: “basic nursing science is one of the subjects that i found difficult to study during college, but despite the difficulty, basic nursing science enables us to have the ability to analyze the data, so we feel like we are losing if we did not really learn it before.” (p5) sub-theme 3: determining nursing diagnoses nursing diagnoses are clinical decisions about individual, family, and community responses to actual or potential health problems. basic nursing science helps nurses to determine nursing problems and diagnoses found in patients, but they need to differentiate the diagnoses, as stated below: “there are several approaches and examination that should be done before we establish nursing diagnoses, we cannot make it up, and that is the importance of basic science nursing.” (p3) sub-theme 4: determining the priority of the problem after conducting a nursing assessment, it is important to identify the problem and set priority for it. physiology is one of the basic nursing science that is considered useful while setting nursing diagnoses priority, as expressed below: “understanding the medical basis (physiology) is also one of the important considerations when determining the priority of nursing problems.” (p1) nursing diagnoses are determined based on the analysis and interpretation of data obtained from assessment.14 after conducting an assessment, nurses are required to determine the diagnoses based on the data collected, which is very important because it affects the nursing process.15 basic nursing science is required by nurses while analyzing data, establishing diagnoses, and setting priority of the problem. theme 3: useful for determining the nursing care plan theme 3 was developed from two sub-themes, namely i) determining goals and expected outcomes; and ii) planning the intervention. sub-theme 1: determining goals and expected outcome respondents believed that basic nursing science is required and useful for determining goals and expected outcome because the process needs knowledge, critical thinking, and clinical judgment from nurses, as stated below: “to determine the goals and expected outcomes, for sure, we need to think critically and use our judgment to ensure that the goals and expected outcomes are achievable and realistic. to do so, we need to understand the basic nursing science.” (p1) another respondent stated that nurses have to consider the patient’s condition, which helps to make the expected outcomes more realistic: “working as a nurse in a hospital is different from studying in college. patients’ condition is always changing. determining patients’ expected outcome, sure, we need to consider their condition.” (p5) sub-theme 2: planning the intervention respondents stated that the planning phase of the nursing process also requires knowledge about basic nursing science. this is because nurses must pay attention to the clinical symptoms shown by patients to determine the best intervention, as expressed below: “patients’ problem should be resolved completely. we have to select the best intervention to resolve their problem.” (p5) planning is the fourth phase of the nursing process, which involves problem-solving. nurses have to establish the goals, expected outcomes, and interventions to hasten the resolution of patient’s problem.10 basic nursing knowledge also serves as a determinant in the care planning process.16 meanwhile, anatomy, physiology, pathophysiology, and pharmacology are used as a guideline to identify patients’ need. when nurses fail to understand these basic nursing sciences, they tend to carry out their duties without using critical thinking, which prevents the optimal improvement of the patient’s condition.17 theme 4: as a basis for implementing nursing actions nursing implementation is a part of the nursing plan that is determined during the planning phase. theme 4 was formed from article [healthcare in low-resource settings 2023; 11(s1):11213] [page 153] non -co mmerc ial us e o nly three sub-themes, namely i) basis for giving education to the patients; ii) administering medication appropriately; and iii) collaborating with other medical staff. sub-theme 1: basis for giving education to patients respondents agreed that nurses have to understand the basic nursing science to implement their duties appropriately. nurses can educate patients effectively when they understand the basic science related to their problem, as stated below: “we need to understand the pathophysiology if we want to identify the cause of their symptoms.” (p3) sub-theme 2: administering medication correctly while providing therapy to patients, including administering medication, nurses must also observe their condition after they are given the medication, as stated below: “because of my pharmacological knowledge, i am able to observe my patient (condition) after taking medication, and i will make sure there is no severe adverse effect.” (p4) sub-theme 3: effectively collaborate with other medical staff respondents often collaborate and discuss patients’ condition as well as their treatment with other medical staff. furthermore, they are more critical while discussing the conditions and treatment, as stated below: “when my team found medical or nursing treatment that was not suitable with patients’ condition, they will inform and discuss it with other nurses or other medical staffs.” (p4) during the implementation phase, nurses need to involve patients in every action as well as to provide opportunities for clients to express their feelings. they also need to use intellectual knowledge, human relations, and technical nursing skills while carrying out their duties.18,19 generally, there are three categories of nursing implementation, namely i) cognitive implementations, such as education, making strategies for clients with communication dysfunction, and providing feedback; ii) interpersonal implementations, such as therapeutic communication, setting personal schedules, providing spiritual support, giving advocacy; and iii) technical implementations, such as providing skin hygiene care, carrying out routine nursing activities, finding changes, organizing abnormal responses, performing independent nursing actions, collaboration, and referrals.20,21 based on these theories, which are consistent with this study, nurses must have adequate knowledge and skills to educate patients and families. they also need the knowledge and skills while administering medication and engaging in collaborative actions. furthermore, nurses need to understand all the necessary actions that patients require. the function of basic nursing science is to serve as a guide while carrying out duties related to patients’ needs, such as nutrition, rest, and therapy. theme 5: provides a basis for monitoring and follow-up nursing evaluation is an ongoing assessment, which helps to assess the effectiveness of nursing intervention. it also helps to determine whether the nursing plan is continued, modified, or discontinued. theme 5 was developed from two sub-themes, namely (1) basis for monitoring the patient’s condition; and (2) basis for evaluating the implementation of nursing intervention and followup plans. sub-theme 1: basis for monitoring the patient’s condition one of respondents stated that basic nursing science is required in monitoring patients’ condition: “to evaluate whether the expected goals are achieved, we should monitor patients’ condition regularly, and this (action) surely needs basic nursing knowledge.” (p2) sub-theme 2: basis for evaluating the implementation of nursing intervention and follow-up plan after implementing the nursing actions, nurses need to evaluate whether the intervention was effective in addressing patients’ problem. they also need to compare the condition before and after the intervention, and these activities require basic nursing knowledge, as stated below: “we do check patients’ condition before and after any treatment given. this is to know whether the treatment was effective or not. when we found that the treatment is less effective, we may change or modify the treatment.” (p1) professional nurses also use their critical thinking skills for various purposes aside from implementing nursing actions. critical thinking is also used while evaluating the patient’s condition after the treatment. this evaluation ability is closely related to the knowledge about basic nursing science. therefore, nurses must be able to identify patients’ body response to determine whether the intervention was successful or need to be changed. they also need to understand basic nursing science, which improves their knowledge about the disease pathology as well as patients’ response to the therapy.22,23 theme 6: teamwork between health personnel is more effective a form of collaborative relationships between health personnel was illustrated in the interprofessional collaboration. theme 6 was developed from two sub-themes, namely i) effective communication and coordination; and ii) problem-solving. sub-theme 1: effective communication and coordination respondents revealed that communication and coordination with other health personnel became more effective when nurses have knowledge in the related area, as stated below: “before giving therapies, we often discuss with the physician about the effectivity. so we could improve patients’ condition.” (p4) sub-theme 3: problem solving respondents were very concerned because caring for patients with chronic disease implies that they have to deal with various conditions, symptoms, and a higher rate of mortality. therefore, nurses need to always use their critical thinking and problem-solving skills to address patients’ needs, as stated below: “we often treat patients with terminal illness with a tiny hope to recover, however, the treatment should continue, so we keep treating the patient and provide the best care as we could.” (p3) knowledge about basic nursing science provides a better understanding of patients’ condition. nurses with many experiences have better knowledge through the theoretical knowledge they have gained as well as their direct experience while providing healthcare services.24,25 having knowledge about basic nursing sci article [page 154] [healthcare in low-resource settings 2023; 11(s1):11213] non -co mmerc ial us e o nly ence encourages nurses to start a good and constructive discussion with other health personnel to resolve patients’ problem. they also need to feel more confident while collaborating with other health personnel. nurses are professionals who devote themselves to working in hospitals with the risk of being exposed to various diseases. nurses who have good basic knowledge of nursing will be able to work independently, competently, and confidently. basic nursing science helps the nurses to understand the diseases they are dealing with, so they can give the best nursing care for the patients. we have started exploring the experience of nurses using the basic nursing science in performing nursing care for patients with chronic diseases. based on our study, nurses consider basic nursing science as a challenging subject in college, but very useful when they meet real patients when they are working. there are limitations of this study. first, the respondents of this study were confined to one ward in one hospital. second, this study explores the experience of nurses caring for patients with the chronic disease only. further studies are needed to carry out with the larger respondents and with various settings. conclusions nurses need knowledge and skills in basic nursing science while caring for patients with chronic diseases. furthermore, basic nursing sciences lay the foundation while assessing patients, making a nursing diagnosis, planning the care, implementing nursing actions, evaluating patients’ condition, and collaborating with other health personnel. references 1. law of the republic of indonesia number 38 of 2014 concerning nursing. law of the republic of indonesia number 38 of 2014 concerning nursing. 2014. 2. estetika n, noraliyatun j. pelaksanaan asuhan keperawatan spiritual di suatu rumah sakit banda aceh. [implementation of spiritual nursing care in a banda aceh hospital.] j ilm mhs fak keperawatan. 2016;1:1-9 3. sharoff l. holistic nursing in the genetic/genomic era. j holist nurs 2016;34:146–53. 4. eggert j. genetics and genomics in oncology nursing: what does every nurse need to know? nurs clin north am 2017;52:1–25. 5. wood af, chandler c, connolly s, et al. designing and developing core physiology learning outcomes for preregistration nursing education curriculum. adv physiol educ 2020;44:464–74. 6. romero-reveron r. human anatomy in the generation z’s medical studies. moj anat physiol 2020;7:12–3. 7. madigan n. the importance of pharmacology in nursing. health times. 2021. accessed 2021 oct 15. available from: https://healthtimes.com.au/hub/pharmacology/71/guidance/n m/the-importance-of-pharmacology-in-nursing/2756 8. idemyor v. genomic medicine: health care issues and the unresolved ethical and social dilemmas. am j ther 2012;21:548–53. 9. mazzotta cp. biomedical approaches to care and their influence on point of care nurses: a scoping review. j nurs educ pract 2016;6:93–101. 10. berman a, snyder s, frandsen g. kozier & erb’s fundamental of nursing concepts, process, and practice. tenth edit. new jersey: pearson education, inc; 2016. 11. islamy los, sulima s. kualitas pelayanan keperawatan di rumah sakit umum daerah (rsud) kota baubau. [quality of nursing services at the regional general hospital (rsud) in baubau city.] j kesehat manarang 2020;6:20. 12. atania n. pengkajian data sebagai dasar fondasi proses keperawatan. [data assessment as the foundation of the nursing process preprint]. open science framework. 2020. accessed 2021 oct 15. available from: https://doi.org/10.31219/osf.io/jk3h4 13. de barros jr, herrerias gsp, ramdeen m, et al. nursing process in a patient with crohn’s disease: case report. open j nurs 2021;11:258–65. 14. apriyani h. identifikasi pengkajian keperawatan pada pasien di ruang paru sebuah rumah sakit. [identification of nursing studies in patients in the pulmonary room of a article correspondence: shila wisnasari, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151, tel.: +62 341 5080686, fax: +62 341 5080686, e-mail: shila.wisnasari@ub.ac.id key words: nurses experience; basic nursing sciences; nursing care acknowledgment: the author is grateful to the nursing department, faculty of health science, universitas brawijaya, malang, indonesia, and also to the faculty of medicine, universitas brawijaya, malang, indonesia for their support during this study. contributions: rba and sw are equally contributing in conducting this study, as well as taw and ddsli served as the supervisors. conflict of interest: the authors declare no conflict of interest. funding: this study was funded by the faculty of medicine, universitas brawijaya, malang, indonesia. clinical trials: this study was approved by the health research ethics committee of the faculty of medicine, universitas brawijaya, malang, indonesia. availability of data and materials: we confirm that these statements mark in red are already correct. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 5 december 2021. accepted for publication: 18 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11213 doi:10.4081/hls.2023.11213 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11213] [page 155] non -co mmerc ial us e o nly hospital.] j keperawatan 2018;xi:107–11. 15. akhu-zaheya l, al-maaitah r, bany hani s. quality of nursing documentation: paper-based health records versus electronic-based health records. j clin nurs 2018;27:e578–89. 16. wang j, yue p, huang j, et al. nursing intervention on the compliance of hemodialysis patients with end-stage renal disease: a meta-analysis. blood purif 2018;45:102–9. 17. roy c. key issues in nursing theory: developments, challenges, and future directions. nurs res 2018;67:81–92. 18. sulistyawati w, susmiati s. the implementation of 3s (sdki, siki, slki) to the quality of nursing care documentation in hospital’s inpatient rooms. str j ilm kesehat 2020;9:1323– 8. 19. yildirim b, ozkahraman s. critical thinking in nursing process and education. int j humanit soc sci 2011;1:257–62. 20. luo j, dong x, hu j. effect of nursing intervention via a chatting tool on the rehabilitation of patients after total hip arthroplasty. j orthop surg res 2019;14:1–6. 21. naseri-salahshour v, sajadi m, abedi a, et al. reflexology as an adjunctive nursing intervention for management of nausea in hemodialysis patients: a randomized clinical trial. complement ther clin pract 2019;36:29–33. 22. cui c, wang l-x, li q, et al. ting a pain management nursing protocol for orthopaedic surgical patients: results from a pain out project. j clin nurs 2018;27:1684–91. 23. nursalam n, widodo h, wahyuni ed, et al. development of perioperative care instruments based on sdki slki siki in operating room. syst rev pharm 2020;11:1029–35. 24. bastian nd, munoz d, ventura m. a mixed-methods research framework for healthcare process improvement. j pediatr nurs 2016;31:e39–51. 25. hariyati rts, kobayashi n, sahar j. simplicity and completeness of nursing process satisfaction using nursing management information system at the public health service “x” indonesia. intertaional j caring sci 2018;11:1034–42. article [page 156] [healthcare in low-resource settings 2023; 11(s1):11213] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11758 nursing student perspectives on clinical instructor performance rizeki dwi fibriansari, anggia astuti, zainal abidin faculty of nursing, universitas jember, jember, indonesia abstract the rapid development of higher education in nursing and science and technology in indonesia is still having problems related to the quality of learning, student graduates, and variations in academic quality that affect the quality of higher education. the perspective of nursing students is deemed a crucial factor for assessment and plays a significant role in enhancing learning activities and clinical practices. this study aimed to assess the perspectives of nursing students regarding the performance of their clinical instructors. this study employed a quantitative descriptive research design with an explanatory survey approach, utilizing a cross-sectional methodology. the criteria for selecting respondents consisted of 3rd and 5th-semester students who had completed clinical nursing practice in hospitals. the primary variable examined in this research was the performance of clinical instructors. data collection was conducted using an instrument in the form of a course experience questionnaire (ceq) that employed a likert scale to measure student perspectives on clinical instructor performance. to analyze the correlation between student satisfaction and the five aspects of the ceq, spearman’s rho correlation was employed. nursing student perspectives on clinical instructor performance using ceq-23 have an overall effect on student satisfaction with a p-value of 0.000. the aspect that has the most influence on student satisfaction was the scale of generic skills with 67,7%. technical proficiency and effective communication skills, clinical instructors must also possess a comprehensive understanding of their roles and functions in guiding students. to enhance the quality of teaching and institutions, it is essential to establish teaching objectives that prioritize the development of general skills and ensure that students comprehend these objectives. moreover, it is crucial to maintain manageable workloads for instructors. clinical instructors should consistently offer valuable feedback and guidance to students. introduction the development and the role of a nursing higher education system are essential in the development of professional nursing services.1,2 this is in accordance with the aim of nursing higher education in indonesia which was to produce nurses who are able to provide professional nursing services to patients. the nursing higher education system provides a comprehensive learning process using several forms of learning methods in the classroom, laboratory, and clinical practice.3,4 nurse educators play a crucial role in ensuring that students can effectively apply the theoretical knowledge acquired in college, develop practical skills, and mature into competent nursing professionals.5 additionally, they are responsible for providing guidance and direction to students during their clinical practice.6 currently, there are numerous challenges in the implementation and management of clinical learning. the quality of higher education has become a significant topic of discussion, given the rapid growth of higher education in indonesia, which has brought to light issues related to teaching and learning quality, the quality of graduates, and academic standards within higher educational institutions.7–10 the obstacles that arise include variations in percorrespondence: rizeki dwi fibriansari, faculty of nursing, universitas jember, jember, indonesia. e-mail: rizekifibriansari@unej.ac.id key word: clinical instructor; nursing; satisfaction; student. contributions: rdf, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; aa, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; za, methodology, visualization, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the research ethics commission of the faculty of nursing, universitas jember, based on ethical certificate 158/un25.1.14/kepk/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized student information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thankful to institutions of research and community service universitas jember for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 12 october 2023. early access: 20 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11758 doi:10.4081/hls.2023.11758 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11758] [page 45] non -co mmerc ial us e o nly ceptions between academic supervisors and clinical supervisors in practice areas, as well as an inadequate number of preceptors, both in terms of quantity and quality. consequently, this situation can lead to suboptimal clinical learning experiences and have implications for the attainment of competence.11 the case guidance method in clinical practice offers students the opportunity to confront more significant challenges, which in turn encourages greater effort and performance in handling new cases. this approach can effectively boost motivation for addressing problems or challenges more effectively.12,13 inadequate clinical instructor performance in nursing education can present a number of problems that have a crucial impact on nursing students. students may not be able to develop the knowledge, skills, and competencies required in nursing practice. student dissatisfaction with clinical instructors can affect their learning motivation.14 when they feel they do not receive adequate guidance or constructive feedback, their motivation to learn and interest in the nursing profession may decrease15 and they tend to have negative perceptions about nursing practice. preceptorship programs are still rare in indonesia.16 the term preceptorship is better known as clinical guidance, while the preceptor is known as clinical instructor (ci).17 the government has regulated teaching hospitals regulations in which the hospital has the function of being a place for education, research, and health services in an integrated manner in the field of multi-professional education. the primary function of a teaching hospital is to offer integrated healthcare services with a strong emphasis on clinical governance, the advancement of research and technology, and the application of evidence-based practices, all while adhering to professional ethics and health law considerations.18,19 the findings of the previous study indicated that only 17% of clinical supervisors utilized the bedside teaching method. this method is highly effective in educating students to master procedural skills, cultivate professional attitudes, explore biological or physical development, and enhance communication through direct observation.3 in order to effectively manage patient cases, a comprehensive assessment is essential. among the 58 respondents surveyed, 70.7% agreed that supervisors provide students with opportunities for such assessments. moreover, supervisors play a pivotal role in identifying students’ self-readiness through pre-clinical practice conferences.20 student’s evaluation is one of the most widespread assessments; survey students’ perception has an important role in encouraging higher quality assurance of education.21 course experience questionnaire (ceq) is one of the formal quality measurement instruments and is a significant source of evidence through which the quality of teaching can be assessed systematically.22 factor analysis ceq items include good teaching, appropriate workload, appropriate assessment, and general skills. the problem-based learning method is carried out to gain new knowledge and understanding based on experience through various cases with the characteristics of each student.23 the mentoring process requires a combination of guidance methods to complement each other’s deficiencies. the bedside teaching method can be effectively combined with the case method and practical guidance methods. in this approach, each student is assigned an appropriate case to study, intervene in, and evaluate. therefore, the clinical practice area must offer a variety of cases for analysis by each student. given these challenges, there is a need to conduct research to understand the perspectives of nursing students regarding clinical instructor performance. the aforementioned issues have prompted the researcher to investigate the perspectives of nursing students regarding the performance of their clinical instructors. materials and methods research design this study employed a quantitative descriptive research design with an explanatory survey using a cross-sectional approach. the primary objective was to investigate the perspectives of nursing students regarding the performance of their clinical instructors. study participants the population of this study comprised all diploma nursing students, totaling 351 students. the sampling technique employed was purposive sampling, allowing the selection of nursing students based on specific criteria. these criteria included being at the diploma level, being in the 3rd or 5th semester, having completed clinical nursing practice in the field in 2022, and having fulfilled a minimum of 3 weeks of clinical rotations. the resulting sample size for this study was 202 students. variable, instrument and data collection the variables in this research are clinical instructor performance. the data collection technique in this study was using an instrument in the form of a course experience questionnaire (ceq).24 by using a likert scale approach to measure students’ perspectives on clinical instructor performance, the following was agreed response scores: strongly agree (5), agree (4), neither agree or disagree (3), disagree (2), and strongly disagree (1). the ceq consisted of five factors, namely: good teaching scale (6 items), clear goals and standards scale (4 items), appropriate workload scale (4 items), appropriate assessment scale (3 items), and general skills scale (6 items). the validity and reliability of the ceq were investigated through exploratory factor analysis and cronbach alpha coefficient. this research involved students from the nursing study diploma program in collaboration with clinical nursing practice areas. data collection took place online via google forms in december 2022. participant selection was conducted by providing a detailed explanation of the research objectives, benefits, and process, along with outlining the rights of participants during their involvement in the study. data analysis analysis was performed using descriptive statistics for the frequency, mean, and standard deviation of the demographic data. correlation analysis between student satisfaction and the five aspects of ceq was performed using spearman’s rho correlation. the research results were used as a basis for determining strategic issues and formulating recommendations for institutions. ethical clearance this research has been submitted to the research ethics commission of the faculty of nursing, university of jember with number 158/un25.1.14/kepk/2022 on october 11th 2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. results based on table 1, it showed that the characteristics of the respondents were mostly 5th semester students (64,4%), female [page 46] [healthcare in low-resource settings 2023; 11:11758] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly (84,2%), and half (50%) were 21 years old. based on the outer loading value results, the distribution of variables was obtained from table 2 on the good teaching scale. there were clinical instructors who did not spend much time guiding at 1.5%, while 19.3% of clinical instructors were serious about understanding difficulties that might be experienced by students. moreover, 16.8% of instructors explained various things to students. there were difficulties for students in the clear goals and standard scale aspect to know what was expected of nursing practice by 17.3%. whereas in the workload conformity scale, there were 5% of students who stated that they did not know what to expect from practice and the clinical instructors did not explain from the start what they expected from students. according to the appropriate assessment scale, 33.2% of clinical instructors were more concerned with checking students’ memories than their comprehension, and 34.2% of instructors asked for facts. however, 20.3% of students responded on the generic skills scale that problem-solving abilities were appropriately developed in nursing practice. based on table 3, it was found that the statistical test from the perspective of nursing students on the performance of clinical instructors using ceq-23 had an overall effect on student satisfaction with a p-value of 0.000. the aspect that has the most influence on student satisfaction was the generic skills scale of 67.7%. correlation analysis was conducted to further see the perspectives of nursing students on the performance of clinical instructors. ceq was significantly (p<0.01) related to overall satisfaction (see table 3) with r=0.626. this showed that ceq can assess student satisfaction by 62.6% of clinical instructor performance. discussion some clinical instructors, as indicated by the good teaching scale assessment, allocate limited time to mentor students. additionally, some instructors struggle to grasp their students’ challenges and effectively communicate various subjects. the preceptorship method is designed to guide and motivate newly qualified practitioners through the transition from student roles to enhancing the quality of their practice. this process instills confidence in students as they navigate their new environment and embrace their roles as nurses. the preceptorship method encompasses a learning process that encompasses procedural (skills), affective, cognitive, and advanced nursing care objectives in sequential stages.25 the application of a good preceptorship model can help students achieve the competencies students will achieve. the benefits of the preceptorship learning model related to the achievement of student competencies include: being able to increase the self-confidence, self-esteem, and self-awareness of students, increasing student motivation in achieving clinical learning, increasing critical thinking skills, increasing skills to intervene creatively and also being able to improve professionalism.26 good teaching skills are considered to be able to improve academic quality in conducting teaching at institutions and broadly can increase student satisfaction. aspects of the clear goals and standard scale still have difficulties in knowing what is expected from nursing practice. clinical learning is the focus of learning and teaching that involves clients directly and is the “heart” of nursing education in the nursing clinical practice program.27 clinical education involves collaboration and sharing of experiences between preceptors and practical students, and mutual support and trust in the learning environment.28 clinical education does not only provide lectures, information, and demonstrations of skills but involves students’ active participation in learning.29 students must have clear ideas and goals when practicing. they also should have clear expectations about goals and expectations during clinical practice. the workload scale aspect stated that they did not know what to expect from practice and the clinical instructors did not explain from the start what they expected from students. based on research that the appropriate workload scale is relatively lower and relatively higher for female students compared to university students.21 this proves that student perceptions differ based on the type and heavy workload that may not have a significant relationship between standards and expectations but can affect student learning potential. a heavy workload prevents students from training students to be able to manage stress so that learning is more effective and efficient. there are still clinical instructors who are more concerned with testing than in evaluating student learning and who ask a lot of factual questions during practice, according to the appropriate assessment scale. numerous elements, including obligations and responsibilities in addition to money, can affect clinical supervisors’ motivation in assisting student practitioners.30 the motivation of clinical supervisors to guide is due to the arrival of students, it will increase knowledge and are required to re-read about cases managed by students, as well as the incentives obtained after guiding students. the generic skills scale aspect states that nursing practice sufficiently develops problem-solving skills. a clinical instructor also called a preceptor, is someone who teaches, and provides guidance that can inspire. thus, they become role models and support individual growth and development for a certain period with the specific aim of socializing precepts.29 the preceptor is an individual who has at least 10 years of working experience in the same field or a related field. communication and leadership skills, the ability to make the right decisions, and the support of professional development are the most important things in clinical learning.31 a preceptor is not only experienced and expert/competent in the clinical environment but also must have deep and broad scientific knowledge, and at least have an education equivalent to the educational level of students.32 the difference in education level between clinical supervisors and students will have an impact on the difficulty for clinical supervisors to provide teaching knowledge even though they are very knowledgeable in their abilities or skills.33 the generic skills scale aims to identify the degree to which higher education has contributed to the enrichment of skills relevant to employment. thus, preceptors are required to have good competence according to their scientific fields. these are considered transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of research respondents. indicator f % sex male 32 15.8 female 170 84.2 age 19 y.o 19 9.4 20 y.o 72 35.6 21 y.o 101 50 22 y.o 10 5 semester 3rd 72 35.6 5th 130 64.4 total 202 100 [healthcare in low-resource settings 2023; 11:11758] [page 47] non -co mmerc ial us e o nly [page 48] [healthcare in low-resource settings 2023; 11:11758] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. distribution of research variables from the perspective of nursing students on clinical instructor performance. no variable f (%) 1 2 3 4 5 good teaching scale 1 the clinical instructor of this course motivated me to do my best work. 0 1 8 73 120 (0.5%) -4% (36.1%) (59.4%) 2 the clinical instructor put a lot of time into commenting on my work. 3 1 13 73 112 (1.5%) (0.5%) (6.4%) (36.1%) (55.4%) 3 the clinical instructor made a real effort to understand the difficulties i might be having with my work. 0 0 39 77 106 (19.3%) (38.1%) (52.5%) 4 the clinical instructor normally gave me helpful feedback on how i was doing. 0 0 25 75 102 (12.4%) (37.1%) (50.5%) 5 clinical instructors were extremely good at explaining things. 0 0 34 73 95 (16.8%) (36.1%) -47% 6 clinical instructors worked hard to make their subjects interesting. 0 1 27 77 97 (0.5%) (13.4%) (38.1%) -48% clear goals and standard scale 7 it was always easy to know the standard of work expected. 0 0 15 89 98 (7.4%) (44.1%) (48.5%) 8 i usually had a clear idea of where i was going and what was expected of me in this course. 0 1 28 89 84 (0.5%) (13.9%) (44.1%) (41.6%) 9 it was often hard to find out what was expected of me in this course. 3 21 35 58 85 (1.5%) (10.4%) (17.3%) (28.7%) (42.1%) 10 the clinical instructor made it clear right from the start what they expected from students 0 0 21 74 107 (10.4%) (36.6%) -53% appropriate workload scale 11 the workload was too heavy. 9 17 48 75 73 (4.5%) (8.4%) (23.8%) (73.1%) (36.1%) 12 i usually had a clear idea of where i was going and what was expected of me in this course. 0 3 43 76 80 (1.5%) (21.3%) (37.6%) (39.6%) 13 it was often hard to find out what was expected of me in this course. 10 29 22 57 84 -5% (14.4%) (10.9%) (28.2%) (41.6%) 14 the huge amount of work to be got through in this course meant that it could not be all completely understood. 52 65 55 29 1 (25.7%) (32.2%) (27.2%) (14.4%) (0.5%) appropriate assessment scale 15 to do well in this course all you needed was a good memory. 1 0 27 80 94 (0.5%) (13.4%) (39.6%) (46.5%) 16 the clinical instructor seemed more interested in testing what i had memorized than what i had understood. 6 19 54 67 56 -3% (9.4%) (26.7%) (33.2%) (27.7%) 17 too many clinical instructors asked me questions just about facts 2 2 69 76 53 -1% -1% (34.2%) (37.6%) (26.2%) generic skills scale 18 the course developed my problem-solving skills. 1 1 41 72 87 (0.5%) (0.5%) (20.3%) (35.6%) (43.1%) 19 the course improved my logical skills. 0 0 26 80 96 (12.9%) (39.6%) (47.6%) 20 the course helped me develop my ability to work as a team member. 0 0 16 87 99 (7.9%) (43.1%) -49% 21 as a result of my course, i feel confident about overcoming unfamiliar problems. 0 0 30 77 95 (14.9%) (38.1%) -47% 22 the course improved my skills in written communication. 0 0 17 84 101 (8.4%) (41.6%) -50% 23 my course helped me to develop the ability to plan my work. 0 1 17 81 103 (0.5%) (8.4%) (40.1%) -51% non -co mmerc ial us e o nly important in institutions which include the ability to solve problems, gather and analyze information, speak and communicate well with others, work in teams, and plan and organize activities. in addition to possessing advanced expertise, a clinical supervisor must also serve as a role model, maintain a positive attitude, and exhibit extensive knowledge in their field. the role of clinical supervisors extends beyond providing guidance to nursing students and other staff; they are expected to exemplify qualities of a good person, effective nurse leader, and educator or counselor. according to the health personnel education center for the development and empowerment of health human resources, desirable qualities for a clinical supervisor include maintaining a clean and neat appearance and a healthy lifestyle, fostering positive interpersonal relationships and effective teamwork, valuing and respecting the dignity of patients as whole individuals, delivering appropriate services, applying appropriate concepts, procedures, and actions, and demonstrating a mature and responsible personality with a strong commitment to their work.34 student satisfaction is a very important subject for educational institutions to maximize student satisfaction and minimize dissatisfaction. this helps retain students and can improve institutional performance. to be able to create a supportive learning environment, it is necessary to have a clinical supervisor who has solid knowledge besides having clinical skills, is skilled as a teacher, and has a commitment as a clinical supervisor. clinical supervisors must have a higher nursing education background than student education if they have graduated, and have professional skills in certain clinical areas so that they can provide nursing services/care based on scientific principles. since nursing is a field that is constantly evolving, clinical supervisors must continually refresh their knowledge and abilities. aside from technical expertise, effective communication, clinical teaching methods, and clinical supervision, clinical supervisors also need to have a firm grasp of their position and function as student mentors. limitations of this research include that the time spent was limited to 1 semester period, thereby limiting generalization. likewise, the subject’s responses in this study depend on the respondent’s personal feelings and willingness to express them openly and honestly. the influence of instructor clinical performance on learning outcomes requires further research. conclusions in addition to technical and communication skills, clinical instructors must also possess a deep understanding of their role and function in guiding students. to enhance the quality of teaching and institutions, there is a need to emphasize the development of these general skills and provide clinical practice opportunities that actively engage students. clinical instructors should receive adequate support and ongoing professional development to meet the expectations and needs of students. references 1. suwarto t. persepsi mahasiswa d3 keperawatan mengenai pembimbingan klinik di stikes muhammadiyah kudus. 2016. 2. efendi f, aji rs, kurnia id, et al. determinants of maternal healthcare service utilisation among indonesian mothers: a population-based study. f1000research 2022;10. 3. maulana ma, priyono d. faktor–faktor yang memengaruhi pelaksanaan metode preceptorship pada pembelajaran praktik klinik mahasiswa keperawatan di rumah sakit: literature review. proners 2020;7(1). 4. afridah w, trimartiana, widiyanti p, qomaruddin mb. acceptance of interprofessional education (ipe) for educators at health-based faculty universitas nahdlatul ulama surabaya. bali med j 2022;11:1121-5. 5. mckenna l, sommers cl, rachmawaty r, et al. postgraduate nurse education in indonesia and australia : a comparative analysis. nurse educ today 2023;131:105954. 6. willianti a. analisis persepsi pembimbing klinik terhadap penerapan praktik klinik profesi keperawatan mahasiswa psik untan. proners 2017;3(1). 7. kaur s, singh g, garg a. evaluating the relationship between the course experience questionnaire and student satisfaction: a case from india. j public aff 2022;22:e2471. 8. acob jru, dewi ys, arifin h. five cs as reflective learning attitude among philippines nursing students. j ners 2022;17:161-7. 9. darmanto w, claudia ja, turnip ba, et al. toxicity effects of 2-methoxyethanol on the nitrite level and damage in tissue of pancreas as a cause of diabetes in mice (mus musculus) balb/c. in: r. y, t. m, i.t. a, d. t, k.a. s, editors. 3rd international symposium on current progress in mathematics and sciences 2017, iscpms 2017. department of biology, faculty of science and technology (fst), airlangga university, surabaya, 60115, indonesia: american institute of physics inc.; 2018. 10. sukumaran s, abdullah n, thiagarajah s, et al. sound elearning of stem in malaysian higher education institutions. educ adm theory pract 2023;29:271-83. [healthcare in low-resource settings 2023; 11:11758] [page 49] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. statistical test of nursing student perspectives on clinical instructor performance. variable ceq sig (2-tailed) spearman’s rho correlation 1. good teaching scale 0.000* 0.639 2. clear goals and standard scale 0.000* 0.312 3. appropriate workload scale 0.000* 0.292 4. appropriate assessment scale 0.000* 0.263 5. generic skills scale 0.000* 0.677 6. overall satisfaction 0.000* 0.626 *p=0.01. non -co mmerc ial us e o nly 11. ashari i, ratnaningsih s. literature review gambaran pelaksanaan metode preceptorship pada proses bimbingan mahasiswa praktik klinik. 2020. 12. hababeh mo, lalithabai ds. nurse trainees’ perception of effective clinical instructor characteristics. int j nurs sci 2020;7:285-90. 13. kørup ak, søndergaard j, christensen rp, nielsen ct, lucchetti g, ramakrishnan p, et al. religious values in clinical practice are here to stay. j relig health 2020;59:18894. 14. sidaria s, murni d, khairina i, nelwati n. analisis tingkat kepuasan mahasiswa profesi ners selama pembelajaran klinis di masa pandemi covid-19. j ilm univ batanghari jambi 2022;22:1057-63. 15. puspitaningrum i, hartiti t. peningkatan kualitas personal dan profesional perawat melalui pengembangan keprofesian berkelanjutan (pkb). deepublish; 2017. 16. ahsan a, rahmawati in, noviyanti lw, et al. the effect of the application of the team-stepps-based preceptorship guidance model on the competence of nursing students. adv med educ pract 2023;817-26. 17. asmara fy. bedside teaching: is it effective methods in clinical nursing students learning? j ners 2017;9:19-25. 18. pp nomor 93. pp nomor 93 tahun 2015. 2015;120:259. 19. permarupan py, al mamun a, hayat n, et al. nursing management challenges: effect of quality of work life on depersonalization. int j healthc manag 2021;14:1040-9. 20. iswahyuni s. hubungan antara persepsi mahasiswa tentang kemampuan pembimbing klinik dan manajemen pembelajaran klinik dengan kinerja praktek klinik mahasiswa akademi keperawatan mamba’ul ulum surakarta. tidak diterbitkan. surakatya univ sebel maret progr stud magister kedokt kel. 2008. 21. haidar ft. the applicability of the course experience questionnaire in accounting education in saudi arabia. j account financ audit stud 2021;7:184-207. 22. spence m. quality assurance in education. meas bus excell 2000;4:7-8. 23. fibriansari rd, kurniawan w. strategi empowerment pada lingkungan kerja keperawatan. banyumas, jawa tengah: cv. pena persada; 2021. 24. salshabil rm. persepsi mahasiswa fakultas keperawatan universitas riau mengenai metode pembelajaran problem based learning (pbl). j med hutama 2022;3:2232-40. 25. sadeghi a, oshvandi k, moradi y. explaining the inhibitory characteristics of clinical instructors in the process of developing clinical competence of nursing students: a qualitative study. j fam med prim care 2019;8:1664. 26. gemuhay hm, kalolo a, mirisho r, et al. factors affecting performance in clinical practice among preservice diploma nursing students in northern tanzania. nurs res pract 2019;2019. 27. widuri w. perbedaan persepsi mahasiswa terhadap kompetensi preceptor klinik dan preceptor akademik pada stase keperawatan dasar profesi (kdp) program studi ners stikes guna bangsa yogyakarta. j heal 2019;6:95-9. 28. saputra e, handrianto c, pernantah ps, et al. an evaluation of the course experience questionnaire in a malaysian context for quality improvement in teaching and learning. j res policy pract teach teach educ 2021;11:1-12. 29. almekkawi m, qatouni f, al amoor h, et al. clinical teaching effectiveness of undergraduate student nurses in the united arab emirates. sage open nurs 2020;6:2377960820948640. 30. dahlia s, harun z, usman dn, usman n. the performance of clinical instructor toward nursing internship students at mental hospital of aceh government. idea nurs j 2013;iv:817. 31. fibriansari, maisyaroh w dkk. buku pedoman dokumentasi keperawatan berbasis 3s (sdki, slki, siki). 2022. 32. cheraghi r, jasemi m, namadi f. effectiveness of the clinical teaching associate model in clinical nursing education. nurs midwifery stud 2019;8:132. 33. nursalam n, fibriansari rdd, yuwono srr, et al. development of an empowerment model for burnout syndrome and quality of nursing work life in indonesia. int j nurs sci 2018;5:390-5. 34. kementerian kesehatan republik indonesia. rencana aksi program (rap) badan ppsdm kesehatan tahun 2020-2024. 2020;1–56. [page 50] [healthcare in low-resource settings 2023; 11:11758] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [page 14] [healthcare in low-resource settings 2014; 2:1009] conducting research in a resource-constrained environment: avoiding the pitfalls janine i. munsamy,1 andy parrish,1,2 gavin steel1,3 1department of pharmacy, rhodes university, grahamstown; 2department of internal medicine, walter sisulu university and east london hospital complex, east london; 3national department of health, pretoria, south africa abstract practical challenges affected the conducting of a retrospective drug use evaluation (due) on the rational use of tenofovir in a resourceconstrained south african antiretroviral treatment programme. the primary outcome measure was the percentage of patient records compliant with due criteria using initiation prescriptions from march 2009 to february 2010. health system challenges encountered included stringent institutional administrative procedures, lack of efficient communication channels, reliance on overburdened personnel and fear of audit. forty percent (222 of 556) of patient records identified for inclusion in the study had to be excluded, mainly due to poor record keeping. research budgetary constraints also limited data collection. this experience highlighted real, unforeseen challenges when conducting a retrospective study in a resource-constrained environment. a sound understanding of the environment and adequate preparation is recommended. the lessons learnt may prove valuable to both firsttime and experienced researchers in a resource-limited setting using a similar methodology. introduction review of the primary literature revealed a paucity of data evaluating the effectiveness of rational medicine use interventions in developing countries.1 during 2009-2011, a retrospective drug use evaluation (due) evaluated the rational use of tenofovir at accredited public sector antiretroviral treatment sites in the province of the eastern cape, south africa. due is a tool to improve the quality, safety and cost-effectiveness of medicine use.2 the world bank described the economy of south africa as upper-middle income in 2013.3 statistics south africa, however, reported that the province of the eastern cape has the second highest poverty levels in the country.4 there appear to be no published retrospective studies of a similar construct in the context of a resource-constrained environment. this study provides local data regarding the impact of strategies to improve rational medicine use. a reflection on the health system challenges encountered by researchers in resource-limited settings has been reported in the context of clinical trials.5,6 mbuagbaw and colleagues described their experiences regarding the administrative, ethical and financial challenges during the conducting of the cameroon mobile phone sms trial.5 the authors however acknowledged that there is a lack of data on the operational changes in low-income countries. research practice is enhanced by experience and lessons learnt.7 the report describes the health system challenges that impeded the research process during a retrospective study in a resource-constrained south african public sector environment. materials and methods the primary outcome measure was the percentage of patient records compliant with the due criteria using initiation prescriptions from march 2009 to february 2010. data were collected in 2010 and 2011 following ethical approval by the east london hospital complex and rhodes university, faculty of pharmacy research ethics committees. permission to access the sites was obtained from the eastern cape department of health epidemiological research and surveillance management directorate, health care facilities and department managers. results record availability and quality. of the 556 patient records identified for inclusion in the study, 222 (40%) were excluded, mainly due to poor record keeping systems. of the 222 patients records excluded, 106 (48%) could not be found, 74 (33%) were incomplete and the remaining 42 (19%) did not meet study inclusion criteria. staff availability. the feasibility of data collection depended on assistance from the staff. with high patient loads and current staff shortages, this assistance was understandably not always available, especially during busier periods. during the study period there was a high turnover of pharmacy personnel with 73% (7 of 11 pharmacists) changing during the survey period. of the 7 pharmacists, 6 (88%) were community service personnel. in south africa pharmacists are required to undertake one year of remunerated pharmaceutical service in a public sector health care facility after completing their training. this interrupted data collection continuity as community service personnel identified to assist during the project plan were no longer employed at the site when data collection commenced. research approval delays. institutional administrative procedures required that permission be obtained from both the health care facility and department managers following review of the research documentation and project plan. considerable time was spent identifying and locating managers who were often unavailable (attending meetings, on leave, or other unknown reasons.) this resulted in a delay in starting data collection at certain sites as did a lack of efficient communication channels e.g. sites with only one telephone available, sites with telephone lines out of order and/or sites with no email or facsimile facilities. lack of staff clarity on the purpose of the research. the perception that the study formed healthcare in low-resource settings 2014; volume 2:1009 correspondence: janine i. munsamy, department of pharmacy, rhodes university, drosty rd, 6139 grahamstown, south africa. tel. +2743.709.2486 fax: +2746.603.7350. e-mail: janinemunsamy@yahoo.com key words: research, challenges, public health, resource-constrained. acknowledgements: the authors would like to thank the management, professional and administrative staff at the ten study sites in the amathole district, province of the eastern cape, south africa; prof s.e. radloff, department of statistics, rhodes university, grahamstown, south africa; prof b.j. wilson, faculty of pharmacy, rhodes university, grahamstown, south africa. contributions: mji, data collecting; mji, pa, manuscript writing; mji, pa, sg, manuscript review. conflict of interests: the authors declare no potential conflict of interests. funding: the work was supported by a health professions training and development (eastern cape department of health, south africa) grant. received for publication: 5 february 2013. revision received: 1 october 2013. accepted for publication: 3 november 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright j.i. munsamy et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1009 doi:10.4081/hls.2014.1009 non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1009] [page 15] part of a managerial audit process led to initial resistance to providing assistance despite facilitating documentation from ethics committees and the department of health. it can be argued that a lack of a culture of research and concerns about previous audits may have contributed to this challenge. budgetary constraints. the calculated sample size indicated that data should be collected from 47 sites that complied with study inclusion criteria. however research budgetary constraints meant that data could only be collected from 10 sites, limiting the statistical power of the study. health system challenges added 75% (95% ci; 41-93%) to the time estimated for preparation of the data collection (6 of 8 weeks of preparation time). the additional cost for employing a pharmacist for 6 weeks (8 h per day; 5 days per week) is estimated to be r58 800 (approximately r245 per h for pharmacist grade 2, level 1).8 discussion record availability and quality generally it is expected that data from studies employing a retrospective study design would be extracted from patient records. a retrospective design study offers convenience for a study involving multiple sites, a large sample size and short data collection period however is reliant on accurate record keeping and adequate record access. considering the inherent nature of a retrospective study coupled with poor record keeping systems in a resource-limited setting it could be argued that having adequate, good quality data may be compromised. it is recommended that standards regarding clinical records should be developed, implemented and sustained with the relevant training and ongoing audit. the introduction of electronic record systems to maintain patients’ clinical data should be considered through external funding sources e.g. non-governmental organizations. consideration should be given to concurrent or prospective research design in low-resource settings as this method of data collection is more robust. staff availability conducting a study with a limited budget imposes a burden on overworked local staff as public health facilities are burdened by extremely high patient numbers and staff shortages. in a resource-constrained environment without an established research ethos, both administrators and clinical staff may find the process challenging, the former because of the need to understand and accept research plans, and the latter because of concerns that data collection is really designed for punitive audit. all of these factors may limit the quality of the information gathered and skew the primary finding. it is recommended that eastern cape department of health implement educational interventions e.g. workshops to promote a culture of clinical research at all levels of health care. the potential for clinical research may not only be limited to health care facilities offering a specialist tertiary oriented service as the management of hiv/aids is a primary health care service in the south african public health sector. staff at the sites where the study will be conducted should be well informed about the rationale for the study and potential benefit of the findings in terms of the implication for clinical practice. this information will highlight the importance of the study and may encourage participation despite resource limitations. the staff could also be invited to participate at the stage of protocol design as another educational strategy to create awareness about clinical research. integrating the staff from this stage of the design may also promote participation. staff involved in the study at this level should be informed that their contribution will be duly acknowledged on publication. in 2001 south africa implemented community service for pharmacists as part of a strategy to cope with the problem of lack of human resources in the public health sector and to improve provision of health services. however the scarcity of human resources is an ongoing struggle in the resource-constrained south african public health care sector. if community service personnel are in key positions data collection should be completed during their tenure. if this is not possible, the investigator should be aware of changes early in the study and plan accordingly. it is important to agree on the timing of data collection if the assistance of on-site staff is required. administrative and communication challenges public health facilities should develop mechanisms for granting permission for studies expeditiously once written approval has been obtained from academic bodies and provincial health departments. these health system challenges delayed study completion, with increased staff time translating into increased costs. the additional administrative burden also increased telephone costs although this was not quantified. conducting a pilot study may have assisted in identifying some challenges earlier, allowed better planning of the data collection phase and resulted in time and cost savings. conclusions this research experience highlighted unforeseen challenges when conducting a retrospective study in a resource-constrained environment. a sound understanding of the environment including the research processes and culture, anticipating and preparing for challenges and, collaboration with key personnel is recommended to circumvent unexpected pitfalls. the lessons learnt may prove valuable to both first-time and experienced researchers in a resource-limited setting using a similar methodology. references 1. holloway k. combating inappropriate use of medicines. expert rev clin pharmacol 2011;4:335-48. 2. shpa committee of specialty practice in drug use evaluation. shpa standards of practice for drug use evaluation in australian hospitals. j res pharm pract 2004;34:220-3. 3. world bank. world bank list of econonics. world bank ed., 2013. available from: http://siteresources.worldbank.org/datastatistics/resources/gdp.pdf 4. statistics south africa. poverty. statistics south africa ed., 2012. available from: http://beta2.statssa.gov.za/?page_id=739& id=1 5. mbuagbaw l, thabane l, ongolo-zogo p, lang t. the challenges and opportunities of conducting a clinical trial in a low resource setting: the case of the cameroon mobile phone sms (camps) trial: an investigator initiated trial. trials 2011;12: 145. 6. lang ta, white nj, tinh hien t, et al. clinical research in resource-limited settings: enhancing research capacity and working together to make trials less complicated. plos neglect trop d 2010;4:e619. 7. mirele-cabodevila e, stoller jk. research during fellowship. chest 2009;135:1395-9. 8. department of public service and administration. cost-of-living adjustment for personnel on salary levels 1 to 12 and those covered by osds: 1 may 2012. department of public service and administration, republic of south africa ed., 2012. available from: http://www.dpsa. gov.za/dpsa2g/r_documents.asp#annual_c ol_adj brief report non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2019; 7:7930] [page 1] breaking the bottle neck to enhance pediatrics renal transplantation at soba university hospital: role of a non-governmental organization ihab b. abdalrahman,1 shaima n. elgenaid,2 rashid ellidir,3 asma nizar mohammed osman abdallah,4 safa ahmed hassan hamid,4 shahd h. a. elwidaa,2 el-tigani m. a. ali5 1faculty of medicine, university of khartoum, soba university hospital, khartoum; 2department of internal medicine, faculty of medicine, university of khartoum, khartoum; 3department of pediatric nephrology, soba university hospital, elnelien university; 4soba center for audit and research, faculty of medicine, university of khartoum, khartoum; 5pediatric nephrology unit, soba university hospital, khartoum, sudan abstract high cost and limited resources of pediatrics renal transplant in low-resource countries limits the number of transplants. however, the collaboration between government and community sector provided high quality care for these patients. here we highlight the impact of a non-governmental organization in facilitating pediatrics renal transplant. data was collected from files of all pediatric patients withend stage renal disease who received renal transplant between january 2010 and december 2017 at soba university hospital (77 patients). the 8-year period was divided into 16 intervals of 6 months each. the number of patients who received renal transplant ranged from 1 to 12 patients in each interval. there was a rise in 2017 when 21 (28.7%) patients received kidney transplant. in the last 6 months in 2017 there was a significant reduction in duration of hospital stay compared to the rest of the period; it dropped from 16.36 to 9.92 days (p=0.003). partnership between governmental and non-governmental sectors is a good strategy in low resource area to bridge some of the gaps of healthcare delivery system. introduction the prevalence of renal replacement therapy in children under 19 years of age is 18-100 per million of age related population.1 the first successful renal transplant was done in 1945 and since then it has been considered the treatment of choice for patients with end stage renal disease.2 the long-term cost of renal transplant is less than that of the dialysis, particularly when the duration of the therapy is more than 16 months. the estimated cost of conventional dialysis at 40 months is more than 87,000 usd in compare to only 48,000 usd for transplant in 50 months.3 the cost of renal transplant in sudan was equivalent to 10 months of hemodialysis. in developing countries, the prevalence of children kidney transplantation is less than 5 patients per million, due to low resources and minimal support by the governments. the high cost and far distance of specialized center contributes to limited number of transplants. for the same previous reasons, the mortality rate due to end stage renal disease (esrd)in low-resource area is high. even those who received transplant cannot maintain their graft due to high cost of post-transplant medication, and in case of rejection only 2% of patients could pay for second graft but no more.4,5 involvement of non-governmental sector in supporting renal transplantation to a level of cost-free service, led to an increase in the number of patients undergoing transplantation and made it more socially acceptable.4 in pakistan, the high cost of renal replacement therapy deprived more than 90% of esrd patients from undergoing treatment,6 but the collaboration between government and community sector led to availability of free and high quality care for those patients.7 in health sector, non-governmental organizations (ngos) target specific health problem and deliver comprehensive services to manage it. a ngo delivers health services to vulnerable patients who cannot handle the cost of health care.8 the efficiency of ngos in bridging service-delivery gaps, rely on knowledge, proficiency, ability of these institute to tackle and focus on health needs in the community that not covered by the government.9 in north darfur state, sudan, international ngos provide about 70% of health services through training of healthcare staff, funding and establishment of new health centers.10 sadaqaat charity organization (sco) is non-profit, non-political, charity organization. it was established as an initiative in 2002 by sudanese graduates doing their postgraduate training in usa. in 2012 it was registered officially in the humanitarian affairs commission in sudan. the vision of the organization is to promote the efficiency of social services in sudan. sco works in 4 domains: i) provision of clean water in hardship areas, ii) food service for the needy, iii) improving general education and iv) improving health service. in health, sco works in improving the health delivery environment by rehabilitating or establishing facilities and provision of needed equipment and supplies; capacity building by training health workers in both knowledge and skills; awareness programs like voluntary blood donation and screening for breast cancer among women. in children with renal failure, sco provides free dialysis catheters and other consumables and some of the long-term medications. free transportation to treatment facilities is also provided to needy families. some of sadagaats’ volunteers tutor these children during their dialysis session so as not to miss academic development. soba university hospital is the only pediatrics renal transplantation center in sudan. the first pediatrics renal transplant was done in may 2010. the facility has only 2 beds of high dependency unit (hdu) dedicated for pediatrics renal transplant. many of the transplant recipients were coming from rural areas and they had no place to stay in the city. this led to prolonged hospital stay and blocking the hospital beds. healthcare in low-resource settings 2019; volume 7:7930 correspondence: shaima n. elgenaid, department of internal medicine, faculty of medicine, university of khartoum, khartoum, sudan. e-mail: shema2690@gmail.com key words: non-governmental organization; pediatrics; renal transplantation; lowresource; sadagaat charity organization. contributions: iba designed the study, interpreted data, managed literature search and wrote the first draft of the manuscript; sne performed data analysis, interpreted data, managed literature search and wrote first draft of the manuscript; re performed data collection and wrote first draft of the manuscript; anmoa, sahh, shae performed data analysis and interpretation; etmaa and all other authors read and approved the final version to be published. received for publication: 10 november 2018. revision received: 14 july 2019. accepted for publication: 25 september 2019. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2019 licensee pagepress, italy healthcare in low-resource settings 2019; 7:7930 doi:10.4081/hls.2019.7930 non -co mmerc ial us e o nly [page 2] [healthcare in low-resource settings 2019; 7:7930] once hospital stay was protracted, sadagaat was requested by renal transplant team to help the families by renting apartment close to the hospitals. this used to occur sporadically. after a brain storming session between transplant team and sco leaders, sadagaat leadership were convinced to provide 4 apartments on continuous basis to facilitate early discharge of stable patient. this was thought to improve accessibility of the hdu beds and probably shorten the waiting list. to ensure safety and coordination of medical care, sadagaat hired a registered nurse from the transplant team as a part timer to supervise these children and facilitate early and easy transfer to the hospital whenever it was needed. in this report we are exploring the impact of these simple interventions. materials and methods this is retrospective study was conducted in january 2018 to determine the role of ngo in improving health care delivery in low resource area. our inclusion criteria were all pediatric patients with esrd who received renal transplant at soba university hospital (khartoum) and post-transplant care between january 2010 and december 2017. we selected all patients because of limited number of patients. data was collected from patients’ files in the hospital, which included demographic data, duration of dialysis, duration till discharge and some of post-transplant complications. data was analyzed using excel software and spss statistics 22. we divided the mentioned period (from january 2010 to december 2017) into intervals, each of 6 months. the number of patients who underwent renal transplant surgery was determined in each interval along with mean duration of dialysis, mean days till discharge and number of patients who developed post-transplant complications in each interval. we did a comparison using independent t test between these variables in (january 2010june 2017) and (july 2017-december 2017). p-value of 0.05 was considered statistically significant. the proposal of this study was approved by soba center for audit and research. consent was waived. results data was collected from 77 pediatric patients with esrd who received renal transplant at soba hospital in khartoum from january 2010 to december 2017. females and males were 43 (56%) and 34 (44%) respectively. their age ranged from 8 to 18 years with mean age for male and female of 13.59 year and 13.81 year respectively. the graft for all patients came from related living donor, a significant proportion of 45.9% received allograft from their mothers while the rest received kidney from their fathers, brothers and sisters. the 8 years period was divided into 16 intervals with 6 months in each. the number of patients in each interval is shown in table 1. the number of patients who received renal transplant in each six-month interval between january 2010 and december 2016 ranged from 1 to 6 patients. there was a considerable rise in the number of patients in 2017 with 9 (12.3%) patients and 12 (16.1%) patients who received kidney transplant in the first and second half respectively. moreover, the number of transplants in the entire 2017 (21(28.7%)) represents the highest rate of transplant in compare to the previous years. this coincided with the facilitation of early discharge to residential apartment, thus improving accessibility of the hdu beds and probably shortening the waiting list. this was associated with significant reduction in duration of hospital stay as it dropped from 16.36 to 9.92 days (p=0.003) as shown in table 2. discussion in developing countries, scarcity of resources is major determinant of service availability and sustainability. in this report we are reflecting on role of ngo in improving health care delivery in low-resource area. sco participated actively by providing medication and supplies to improve health care for renal transplant patients since the invention of this service. in sudan, out of all patients with end stage renal failure, only 3.9% had received transplant while about two third received either chronic hemodialysis or had intermittent peritoneal dialysis.11 creation of supervised residential home in 2017 helped to increase the number of patients who had renal transplant by 75% compared to 2016. in pakistan, the collabo article table 1. number of patients who received renal transplant in the period between january 2010 and december 2017, and post-transplant complications. date number of patients dvt death jan-jun 2010 1 (1.4%) 0 0 jul-dec 2010 2 (2.7%) 0 0 jan-jun 2011 4 (5.5%) 0 0 jul-dec 2011 3 (4.1%) 0 0 jan-jun 2012 4 (5.5%) 0 0 jul-dec 2012 3 (4.1%) 0 0 jan-jun 2013 3 (4.1%) 2 0 jul-dec 2013 2 (2.7%) 0 0 jan-jun 2014 3 (4.1%) 0 2 jul-dec 2014 6 (8.2%) 0 0 jan-jun 2015 5 (6.8%) 0 0 jul-dec 2015 4 (5.5%) 0 0 jan-jun 2016 6 (8.2%) 0 0 jul-dec 2016 6 (8.2%) 0 0 jan-jun 2017 9 (12.3%) 0 0 jul-dec 2017 12 (16.4%) 1 0 total 73 (100%) 3 2 dvt, deep vein thrombosis. table 2. the difference between january 2010-june 2017 and july 2017-december 2017. item jan 2010-jun 2017 jul 2017-dec 2017 p-value mean duration of dialysis (month) 22.8 15.08 0.270 mean days till discharge 16.36 9.92 0.003 haemorrhage 6 (10.2%) 2 (16.7%) 0.72 wound infection 6 (10.2%) 1 (8.3%) 0.92 dvt 2 (3.4%) 1 (8.3%) 0.837 infections (viral, bacterial) 13 (21.7%) 0 (0%) 0.4 dvt, deep vein thrombosis. non -co mmerc ial us e o nly [healthcare in low-resource settings 2019; 7:7930] [page 3] ration between government and community sector led to availability of free and high quality care for renal patients.7 similarly in study done in pakistan by rizvi et al., the cooperation between government and community organizations in providing free dialysis and renal transplantation led to increase in the number of dialysis and transplant patients from 380 and 103 in 1999 to 1350 and 544 in 2009, respectively.12 it seems that nogs interventions are effective in bridging some of gaps in developing countries. the partnership between private and public sectors is needed for better healthcare services delivery regarding renal transplantation.13 in this report, the transplant team faced bottle-necks repeatedly. this was related to blockage of post-transplant renal beds by patients who developed some complications or required longer observation. another factor was the inability to discharge some patients who has no accommodation in the city. sadagaat’s intervention is not a new concept in health delivery. this represents implementation of other countries experience in a local context. to make the idea acceptable and matching the local context sco rented 4 apartments, each with 2 rooms, electricity, water and cleaning services. each room was dedicated to one family (transplant recipient and one family member). this has increased the number of renal transplants in children without significant complications and might also helped in reducing the risk of acquiring health care associated infection. creation of home like environment might have had a positive psychological impact of the wellbeing of the patients and their families. non-governmental organization support of renal transplant is a recognized measure that have potential impact on provision of renal replacement therapy for larger number of patients in need, along with other measures such as development of local transplant program and use of local manufactured drugs and dialysis.14 utilization of nurses or health care aid to deliver professional home care is well known method in many countries.15 this helped to reduce the cost of escalating medical care in acute care facilities.16 this model of care is used sporadically in sudan by some medical professional in collaboration with family members. sco utilized this concept of supervised care in the residential home. this created the opportunity to recognize the medical needs of the residents coupled with professional ability to access and coordinate immediate care at the hospital. having a professional from the transplant team was based on the assumption that having such a nurse will help to build relation and generate trust between the nurse and the family. interestingly early discharge from hospital with supervised home care was not associated with significant adverse outcomes. having a nurse from the same facility might have partially addressed the concern regarding system design.17 these simple measures led to an improvement in the flow of transplantations and significant reduction in hospital stay from 16.36 to 9.92 days (p=0.003) when comparing the last six months in 2017 and the rest of the period. this almost matched the number of hospitalization days in other countries.18 a study by hushie revealed that partnership between government and community organization can improve service delivery and insure equity to all people in the targeted population.9 ngos play an important role in health care support in developing country. transplant links community organization in uk conducted 10 years project in low resource country in africa regarding renal transplant in adult and pediatric through continuous visit, skill transfer and monitoring of transplantation unit. they found that all those monitored by the program have made significant improvement toward sustainability but it can only be achieved when continuous financial support is also available.19 most of such studies regarding the effect of ngo in renal transplantation were conducted in middle-low income countries. conclusions simple interventions by ngos are reasonable solutions to bridge some of gaps and solve some of health delivery problems. partnership between governmental and nongovernmental sector is a good strategic method in low-resource area. references 1. harambat j, van stralen kj, kim jj, tizard ej. epidemiology of chronic kidney disease in children. pediatr nephrol 2012;27:363-73. 2. offner g, latta k, hoyer pf, et al. kidney transplanted children come of age. kidney int 1999;55:1509-17. 3. de camargo mfc, de souza barbosa k, fetter sk, et al. cost analysis of substitutive renal therapies in children. j ped 2018;94:93-9. 4. rizvi s, sultan s, zafar m, et al. pediatric kidney transplantation in the developing world: challenges and solutions. am j transplant 2013;13:2441-9. 5. verma b, bhandari m, kumar a, eds. transplantation in developing countries: economics, reality, and solutions. transplantation proceedings. elsevier; 2000. 6. rizvi ahs, naqvi as, zafar nm, ahmed e. regulated compensated donation in pakistan and iran. curr opinion organ transplant 2009;14:124-8. 7. rizvi sah, naqvi saa, zafar mn, akhtar sf. a kidney transplantation model in a low-resource country: an experience from pakistan. kidney int suppl 2013;3:236-40. 8. gilson l, sen pd, mohammed s, mujinja p. the potential of health sector non-governmental organizations: policy options. health policy plann 1994;9:14-24. 9. hushie m. public-non-governmental organisation partnerships for health: an exploratory study with case studies from recent ghanaian experience. bmc public health 2016;16:963. 10. yagub ai, mtshali k. the role of nongovernmental organizations in providing curative health services in north darfur state, sudan. afr health sci 2015;15: 1049-55. 11. ali e-tm, abdelraheem mb, mohamed rm, et al. chronic renal failure in sudanese children: aetiology and outcomes. pediatr nephrol 2009;24:349-53. 12. rizvi s, naqvi s, zafar m, et al. a renal transplantation model for developing countries. am j transplant 2011;11:23027. 13. akoh ja. renal transplantation in developing countries. saudi j kidney dis transplant 2011;22:637. 14. white sl, chadban sj, jan s, et al. how can we achieve global equity in provision of renal replacement therapy? bull world health organ 2008;86:229-37. 15. chappell nl, hollander mj. an evidence-based policy prescription for an aging population. healthcare pap 2011; 11:8-18. 16. boris e, klein j. organizing home care: low-waged workers in the welfare state. polit soc 2006;34:81-108. 17. storch j, curry c, stevenson l, et al. ethics and safety in home care: perspectives on home support workers. nurs leadersh (tor ont) 2014;27:76-96. 18. naprtcs. 2014 annual transplant report. naprtcs; 2014. available from: https://web.emmes.com/study/ ped/annlrept/annualrept2014.pdf. 19. ready ar, nath j, milford dv, et al. establishing sustainable kidney transplantation programs in developing world countries: a 10-year experience. kidney int 2016;90:916-20. article non -co mmerc ial us e o nly hrev_master [page 26] [healthcare in low-resource settings 2014; 2:1866] efficiency of social sector expenditure in india: a case of health and education in selected indian states brijesh c. purohit madras school of economics, kottur, india abstract social sector expenditure in india captures a number of important aspects including health, nutrition, education, water supply, sanitation, housing and welfare, among others. over a period of time, besides budgetary outlay on this sector, private sector has also played a considerable role. thus, efficiency of expenditure in this sector by state government has to be reckoned both in terms of relative levels of various aspects across the states and in terms of comparable benchmarks for different aspects of the sector. this paper attempts an analysis of social sector efficiency focusing on two major aspects: health and education. unlike other studies on the indian context, this analysis focusing on major states in india uses both non-parametric and parametric approaches. although both approaches provide benchmarks to judge relative efficiency across states, the former provides a yardstick more at an aggregative level without parametric restrictions, whereas the latter is used for major focus on health care aspects. results of free disposal hull analysis are suggestive of a considerably more scope for improvement in efficiency of public expenditure in health relative to education. our results of stochastic frontier analysis indicate considerable state level disparities which could be reduced through a mix of strategies involving reallocation of factors (namely, manpower and supply of consumables) within the sector, mobilizing additional resources possibly through enhanced budgetary emphasis, or encouraging more private sector participation. based on our results, this may enhance efficiency by nearly 20% in health care sector and increase availability and equity across low performing and poorer states like madhya pradesh and uttar pradesh. introduction social sector comprises an important item in the state budgetary expenditure. it has remained around 5.8% of gross domestic product and its share in total state expenditure has varied between 36.8 (in 1990-1995) to 39.2% (2010-2011).1 within social sector, major chunk (nearly 57%) is being spent on education, sports, art and culture (46.1%) and medical and public health (10.5%). the other items which include: family welfare and water supply and sanitation, housing, urban development, welfare of scheduled castes, scheduled tribes and other backward castes, labour and labour welfare, social security and welfare, nutrition, natural calamities and the rest, comprise a low percentage which varies from 1.3% (natural calamities) to 9.6% (social security and welfare) of total social sector. it becomes pertinent therefore to analyse whether the major expenditure sectors like health and education are performing satisfying the criteria of efficiency. several approaches for measuring the efficiency of government expenditure have been proposed in the literature.2 in general, these approaches are broadly of four types. first, studies which have concentrated on gauging and enhancing efficiency by focusing on certain types of government spending in a specific country. secondly, those only which use data on inputs of government spending in quantitative terms, but not on outputs. third, those using only outputs, but not inputs. finally, those which have looked at both inputs and outputs; these studies, however, have not made a consistent comparison of the efficiency of government spending among countries.36 these studies do not explicitly analyze the relationship between government spending and social indicators. within each of the approaches, however, one may distinguish the studies which have focussed only on developed country (or countries) or only on developing country (or countries) and further in terms of their interest in education and health sector also. thus, the issue of gauging and enhancing government efficiency continues to interest policymakers and researchers alike.2,7-9 this interest received a boost with the initiation of wide-ranging institutional reforms by some of the developed nations10-12 which aimed at improving the efficiency of the public sector. these reforms basically were to separate policy formulation from policy implementation, create competition between government agencies and between government agencies and private firms, and develop output-oriented budgets using a wide array of output indicators. this practice of result-oriented public expenditure management has generated a wealth of information on how to control production processes within the government and how to enhance their efficiency. pertaining to education sector, for instance, there are certain studies which analyse both inputs and outputs. for instance, harbison and hanushek13 provide an overview of 187 studies of education production functions in the united states and 96 studies of education production functions in developing countries and investigate the relation between education inputs and outputs. another type of analysis, for instance by tanzi and schuknecht14 assesses the incremental impact of public spending on social and economic indicators in industrial countries and conclude that higher public spending does not significantly improve social welfare. in most studies of developing countries, it is found that teacher education, teacher experience, and the availability of facilities have a positive and significant impact on education output, and that the effect of expenditure per pupil is significant in half the studies; the pupil-teacher ratio and teacher salary have no discernible impact on education output. likewise, jimenez and lockheed15 also assess the relative efficiency of public and private educations in several developing countries by taking into account both inputs and outputs. in regard to health care sector, for instance, among developed nations, using regression analysis and focusing on inputs, a study of oecd member countries covering 20 years analyzed the efficiency of health care systems. they show that public-reimbursement health systems, which combine private provision with public financing, are associated with lower public health expenditures and higher efficiency than publicly managed and financed health care systems.16 this is traced by looking at factors associated with a high relatively expensive in-patient care and the lack of a mechanism to restrain demand for specialhealthcare in low-resource settings 2014; volume 2:1866 correspondence: brijesh c. purohit, madras school of economics, gandhi mandapam road, kottur, chennai-600025, india. tel. +91.044.2230.0304 fax: +91.044.2235.4847. e-mail: brijeshpurohit@gmail.com key words: social sector expenditure, india, health, education. acknowledgments: an earlier version of this paper was presented at national conference on social sector in india: issues and challenges, march 29-30, 2013, golden jubilee celebrations 2012-13, centre of advanced studies, department of analytical and applied economics, utkal university, odisha, india. thanks are due to participants of this conference for their valuable comments. received for publication: 7 august 2013. revision received: 2 october 2013. accepted for publication: 3 november 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright brijesh c. purohit 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1866 doi:10.4081/hls.2014.1866 non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1866] [page 27] ized health care. countries without ceilings on in-patient care were also found to have higher public health expenditure. a number of studies have laid emphasis on the overall health system performance and its impact on health outcomes.17,18 more often an idealized yardstick is developed which is used to evaluate economic performance of health system. there are a number of studies in health care sector which employ either non-parametric approaches like free disposable hull (fdh) or data envelopment analysis (dea) or parametric approaches like stochastic frontier analysis (sfa). in the former category with a focus on developed world one may include, for instance, aubyn19 who used fdh covering both the health and education sectors in portugal, hofmarcher and colleagues20 for an austrian province, puig-junoy and gannon21,22 for ireland, magnussen23 for norway, jeffrey and coppola24 relating to usa, bates and colleagues25 for the usa, kontodimopoulos and colleagues26 for greek hospitals, and spinks and hollingsworth27 for oecd countries. likewise, with a focus on developing nations some notable studies include a report on district hospitals in namibia,28 masiye29 for zambian hospitals, mathiyazhgan30 for hospitals in karnataka state in india, mirmirani31 for transition economies of former socialist block including albania, armenia, russia and others, kittelsen and magnussen32 for norway, li and wang33 relating to chinese public acute hospitals, hajialiafzali and colleagues34 relating to iran, and suraratdechaac and okunadeb35 for thialand. in the latter type of studies using sfa, one may include with a focus on developed nations, studies for instance, by world health organization36 covering different nations, murray and frenk,37 worthington,38 jamison and colleagues,39 and salomon and others40 relating to inter country comparison, schmacker and colleagues41 relating to usa, evans and others42 for a cross country comparison and greene,43 farsi and others44 relating to switzerland, wang and others45 for new south wales, kris and others46,47 relating to texas, rosko48 relating to usa, yong and harris49 relating to australia, hollingsworth and wildman50 for a cross country comparison, mortimer and peacock51 relating to australia, and jayasuriya and wodon52 for a comparison among nations. among studies focused on india one may include sankar and kathuria53 and purohit.9,54-56 these latter types of studies have deployed frontier efficiency measurement techniques which involve a production possibility frontier depicting a locus of potentially technical efficient output combination that an organization or health system is capable of producing at a point of time. an output combination below this frontier is termed as technically inefficient.57-59 despite its nascent nature of application in healthcare sector, an exhaustive review of studies applying these methods has been attempted which provides us in detail the steps and empirical problems that have been highlighted by researchers.38,60 notably there are very few studies in the developing countries’ context and except a few particularly in the indian context, which have focused on this aspect; the literature is nearly marked by absence for recent period. our study thus covers this gap for india for the latest period. hypothesis and objective we hypothesize that states differ in their technical efficiency pertaining to health and education systems due to factors which require emphasis in facility planning in these sectors.9,53 it is also hypothesized that these factors differ from state to state according to their level of development.9 it is presumed that estimated efficiency parameters (from both types of analysis, i.e. non-parametric and parametric approaches) should help the health and education policy makers to improve state level system performance pertaining to these sectors. materials and methods non-parametric approach: free disposable hull in this paper we use two types of techniques, namely non-parametric and parametric, that allow for a direct measurement of the relative efficiency of government spending among countries or states within a nation. in the former type we apply fdh analysis which assesses the relative efficiency of production units in a market environment. this analysis consists of, first, establishing the production possibility frontier representing a combination of best-observed production results within the sample of observations (the best practices), and, second, measuring the relative inefficiency of producers inside the production possibility frontier by the distance from the frontier. the major advantages of fdh analysis are that it imposes only weak restrictions on the production technology, while allowing for a comparison of efficiency levels among producers. the only assumption made is that inputs and/or outputs can be freely disposed of, so that it is possible with the same production technology to lower outputs while maintaining the level of inputs and to increase the inputs while maintaining outputs at the same level. this assumption guarantees the existence of a continuous fdh, or production possibility frontier, for any sample of production results. thus, fdh analysis provides an intuitive tool that can be used to identify best practices in government spending and to assess how governments are faring in comparison with these best practices.61-63 in our analysis using fdh, the term producer is meant to include governments. a producer is relatively inefficient if another producer uses less input to generate as much or more output. a producer is relatively efficient if there is no other producer that uses less input to generate as much or more output. in the appendix and appendix figures a and b, this is illustrated for the case of one input and one output. if a producer is engaged in the production of multiple outputs using more than one input, it becomes more difficult to establish relative efficiency. in such a situation (of multiple inputs), it is postulated that a producer is relatively inefficient if he uses as much or more of all inputs to generate as much or less of all outputs than all other producer, with at least one input being strictly higher, or one output strictly lower. depending upon the availability of latest and comparable information, we have applied this technique for data on major and smaller indian states for education covering different cross sections from 2003-2011 and for health covering the period 2001-2010. this analysis covers 15 major indian states [which include andhra pradesh (ap), assam, bihar, gujarat harayana, karnataka, kerala, madhya pradesh (mp), maharashtra, orissa, punjab, rajasthan, tamil nadu (tn), uttar pradesh (up), and west bengal (wb)] and 10 smaller states [which include arunachal pradesh, chhatisgarh, goa, himachal pradesh (hp), jammu and kashmir (jk), jharkhand, manipur, meghalaya, mizoram and nagaland]. parametric technique: stochastic frontier method in the application of parametric techniques, stochastic methods can be used to correct for measurement and other random errors in the estimation of the production possibility frontier. in any parametric techniques a functional form is postulated for the production possibility frontier, and then a set of parameters is selected that best fit the sample data. model specification in the estimation of health system efficiency, our specification is based on a general stochastic frontier model that is presented as: lnqj = f(ln x) + vjuj (1) where: ln qj is the health output [life expectancy (lexp) or inverse of infant mortality rates (imr)] produced by a health system j; x is a vector of factor inputs represented by per capita health facilities (including per capita availability of hospital beds, per capita primary health centers (or sub centers), per capita doctors, per capita paramedical staff, per capita skilled attention for birth; vj is the stochastic article non -co mmerc ial us e o nly [page 28] [healthcare in low-resource settings 2014; 2:1866] (white noise) error term; uj is a one-sided error term representing the technical inefficiency of the health system j. both vj and uj are assumed to be independently and identically distributed with variance sv2 and su2, respectively. from the estimated relationship ln q^j=f (ln x) uj, the efficient level of health outcome (with zero technical inefficiency) is defined as: ln q*=f (ln x). this implies ln tej=ln q^ j ln q*=uj. hence tej=e-uj, 0<= e-u j<= 1. if uj=0 it implies e-uj=1. health system is technically efficient. this implies that technical efficiency of jth health system is a relative measure of its output as a proportion of the corresponding frontier output. a health system is technically efficient if its output level is on the frontier which in turn means that q/q* equals one in value. study design: sample and sampling technique this study uses secondary data published in official documents of government of india and state governments. applying this data in any empirical study does not require any ethical approval. the study makes use of a purposive sampling and therefore focus is on 15 major indian states. the purpose is to carry out an analysis which reveals broadly the country’s scenario at state level disaggregation. data used thus are presumed to be authentic and therefore reliable. validity of the results is thus subject to the reliability of official publications and underlying statistical techniques deployed in the study. for parametric approach, we cover 15 major indian states [which include andhra pradesh (ap), assam, bihar, gujarat harayana, karnataka, kerala, madhya pradesh (mp), maharashtra, orissa, punjab, rajasthan, tamil nadu (tn), uttar pradesh (up), and west bengal (wb)] and use panel data for 2005-2011. use of panel data is preferred since it does not require strong assumptions about the error term and unlike the cross section data, the assumption of independence of technical efficiency from factor inputs is not imposed.64,65 we extend our estimation to the second stage which presumes that differences in technical efficiency pertaining to health system can be discerned at the health facility planning level from non-health related parameters. thus, we explain the dispersion in technical efficiency by a set of variables which includes per capita income, literacy, urbanization, per capita budgetary expenditure on health and rural water supply. thus, our model in the second stage is: dispersion in technical efficiency=f (per capita income, literacy, urbanization, per capita budgetary expenditure on health and rural water supply) + error term (2) thus main dependent variables used in the study are lexp and dispersion; independent variables include per capita income and others namely, number of primary health centers article table 1. input efficiency score: education (2008-2011). states public expenditure net enrolment primary ies literacy ies (2008-09) (2008-09) (2008-2009) (2011) (2011) major andhra pradesh 1195.59 79.12 0.67 67.66 0.85 assam 1374.02 83.58 0.95 73.18 0.74 bihar 725.89 53.38 1.00 63.82 1.00 gujarat 1015.67 59.75 0.79 79.31 1.00 harayana 1615.77 74.14 0.81 76.64 0.92 karnataka 1429.04 69.14 0.92 75.60 0.71 kerala 1661.71 84.71 0.79 93.91 1.00 madhya pradesh 799.49 97.28 1.00 70.63 1.00 maharashtra 1487.72 88.93 0.88 82.91 1.00 orissa 1193.44 69.16 0.67 73.45 0.85 punjab 1395.89 74.15 0.94 76.68 0.73 rajasthan 1096.43 76.54 0.73 67.06 0.93 tamil nadu 1310.20 119.56 1.00 80.33 0.78 uttar pradesh 763.40 56.35 1.00 69.72 1.00 west bengal 943.52 87.17 0.85 77.08 1.00 minor arunachal pradesh 3684.77 115.15 1.03 66.95 0.90 chhatisgarh 1211.87 88.30 1.00 71.04 1.00 goa 4648.96 62.04 0.81 87.40 0.81 himachal pradesh 3299.52 115.11 1.00 83.78 1.00 jammu and kashmir 1497.35 100.69 1.00 68.74 jharkhand 1162.75 73.18 1.00 67.63 1.00 manipur 2054.26 83.20 0.73 79.85 1.00 meghalaya 2110.56 83.46 0.71 75.48 0.97 mizoram 3780.70 104.75 1.00 91.58 1.00 nagland 2339.54 88.34 0.64 80.11 1.00 ies, input efficiency score. figure 1. independently efficient states based on infant survival in 2003 and per capita public expenditure on health in 2001-2002. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1866] [page 29] (phcs), sub-centers (scs), community health centers (chcs), hospitals and dispensaries, health manpower-medical and paramedical, and socio-economic parameters like income, education, and basic amenities, etc. database this study is based on secondary data. information is collected for the years 2005-11 from various sources including rbi bulletin,1 health information of india66-72 and other published sources. at the all-india level, main variables used in the study are lexp, imr, per capita income and other parameters related to health infrastructure including number of phcs, scs, chcs, hospitals and dispensaries, health manpower-medical and paramedical, and other variables relevant for depicting healthcare facilities, their utilization, health outcomes, socio-economic parameters like income, education, and basic amenities, etc. statistical analysis tools used by our study include frontier regression technique applying stata software. results the results of our fdh analysis for educaarticle table 2. input efficiency score: health (2001-2005). states public expenditure infant survival ies public expenditure infant survival ies (2001-2002) (2003) (2004-05) (2006) major andhra pradesh 182 941 0.81 191 944 0.91 assam 176 933 0.83 162 933 1.07 bihar 92 940 1 93 940 1.00 gujarat 147 943 1 198 947 0.87 haryana 163 941 0.90 203 943 1.00 karnataka 206 948 0.95 233 952 0.88 kerala 240 989 1 287 985 1.00 madhya pradesh 132 918 0.69 145 926 0.64 maharashtra 196 958 1 204 965 1.00 orissa 134 917 1.09 183 927 0.95 punjab 258 951 0.93 247 956 0.83 rajasthan 182 925 0.81 186 933 0.93 tamil nadu 202 957 1.18 223 963 0.91 uttar pradesh 84 924 1 128 929 0.73 west bengal 181 954 1 173 962 1.00 smaller arunachal pradesh 627 966 0.55 841 960 0.35 chattisgarh 121 930 1 146 939 1.00 delhi 426 972 0.81 560 963 0.53 goa 685 984 1 861 985 0.34 himachal pradesh 493 951 0.49 630 950 0.46 jammu and kashmir 271 956 0.66 512 948 0.57 jharkhand 146 949 1 155 951 1.00 manipur 345 984 1 294 989 1.00 meghalaya 407 943 0.85 430 947 0.68 mizoram 836 984 1 867 975 0.34 pondicherry 841 976 0.99 1014 972 0.29 sikkim 825 967 1.01 1082 967 0.27 tripura 301 968 1 328 964 0.90 uttarakhand 178 959 1 280 957 1.00 nagaland na na na 639 980 0.46 ies, input efficiency score; na, not available. figure 2. independently efficient states based on infant survival in 2006 and per capita public expenditure on health in 2004-2005. figure 3. independently efficient states based on infant survival in 2010 and per capita public expenditure on health in 2008-2009. non -co mmerc ial us e o nly [page 30] [healthcare in low-resource settings 2014; 2:1866] tion and health sector using data for indian states, both major and smaller ones, are presented below in figures 1-5 and tables 1-3. free disposable hull analysis it can be observed that for per capita public expenditure on health (in 2001-02), independently efficient states that emerged from fdh for major states are up, bihar, gujarat west bengal, maharashtra and kerala (figure 1). among the smaller states the independently efficient states are chhatisgarh, jharkhand, uttarakhand, tripura and manipur (figure 1). likewise, in figure 2 (for 2004-2005 per capita public expenditure), the situation is somewhat changed for up whereas other independently efficient states remain the same. among smaller states a changed situation with lower efficiency is depicted for tripura only (figure 2). free disposable hull for public expenditure in 2008-09 for health sector (figure 3) depict additional states namely wb and tamil nadu among independently efficient states (figure 3) and inclusion and exclusion of goa and chhatisgarh respectively in the category of such (independently efficient) states (figure 3). in education sector, using literacy (2011) and public expenditure (2008-09), the states like bihar, up, wb, gujarat, tamil nadu. maharashtra and kerala (among major states) and jharkhand, chhatisgarh, manipur and article table 3. input efficiency score: health (2010). states public expenditure (2008-2009) infant survival rate (2010) ies major andhra pradesh 410.00 954.00 1.00 assam 471.00 942.00 0.96 bihar 173.00 952.00 1.00 gujarat 270.00 956.00 1.00 harayana 280.00 952.00 0.99 karnataka 419.00 962.00 0.98 kerala 454.00 987.00 1.00 madhya pradesh 235.00 938.00 0.74 maharashtra 278.00 972.00 1.00 orissa 263.00 939.00 1.06 punjab 360.00 966.00 0.77 rajasthan 287.00 945.00 0.97 tamil nadu 410.00 976.00 1.00 uttar pradesh 293.00 939.00 0.95 west bengal 262.00 969.00 1.00 smaller arunachal pradesh 771.00 969.00 0.90 chhattisgarh 378.00 949.00 0.87 delhi 840.00 970.00 0.83 goa 1149.00 990.00 1.00 himachal pradesh 884.00 960.00 0.96 jammu and kashmir 845.00 957.00 0.82 jharkhand 328.00 958.00 1.00 manipur 695.00 986.00 1.00 meghalaya 690.00 945.00 0.91 mizoram 1611.00 963.00 0.71 puducherry 1333.00 978.00 0.86 sikkim 1446.00 970.00 0.79 tripura 740.00 973.00 0.94 uttarakhand 630.00 962.00 1.00 ies, input efficiency score. figure 4. independently efficient states based on literacy in 2011 and per capita public expenditure on education in 2008-2009. figure 5. independently efficient states based on net enrolment primary in 2008-2009 and per capita public expenditure education in 2008-2009. non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1866] [page 31] himachal pradesh (among smaller states) emerge as independently efficient states (figure 4). by and large a similar observation could be made using net enrolment primary in 2008-09 (figure 5). using this fdh analysis, input efficiency scores (ies) are presented in tables 1-3. it could be observed that there is a range of 7-25% for major states and a scope of nearly 10% for smaller states to improve their input efficiency relative to nearest independently efficient states in 2011 for education sector (table 1). in case of health sector, this range is much higher for some years like 20042005 (table 2) and it has been 1-13% for major states and 6-30% for smaller states for the year 2010 (table 3). stochastic frontier method in the application of parametric techniques, stochastic methods can be used to correct for measurement and other random errors in the estimation of the production possibility frontier. in any parametric techniques a functional form is postulated for the production possibility frontier, and then a set of parameters is selected that best fit the sample data. results of our panel data estimation using frontier model for india (males and females) are presented in table 4. it is observed that all the independent variables to explain lexp have emerged with appropriate positive signs. three of these variables, i.e. rural specialists (total specialists), auxiliary nurse midwife (anm)/female health worker, and total number of blood banks are statistically significant. discussion results of our fdh analysis are suggestive of a considerably more scope for improvement in efficiency of public expenditure in health relative to education. further parametric approach of sfa indicates factors that could be isolated to suggest ways to improve efficiency in the public expenditure in the sector. as mentioned eararticle table 4. stochastic frontier panel data model for india: life expectancy male and female (2005-2011). variables coefficient z m f m f total specialists 0.004 0.004 1.83** 1.8** auxiliary nurse midwife 0.014 0.017 2.12* 2.57*** total no. blood bank 0.043 0.048 3.25*** 3.21*** constant 3.929 3.942 52.360*** 46.21*** mu 0.081 0.112 3.520*** 4.59*** lnsigma2 -5.802 -5.546 -10.910*** -11.810*** ilgtgamma 2.879 3.144 4.890*** 6.09*** sigma2 0.003 0.004 gamma 0.947 0.959 sigma_u2 0.003 0.004 sigma_v2 0.000 0.000 time-invariant inefficiency model number of observation=105 per group (min=7). wald chi2(3)=29.19 log likelihood=275.66912; prob>chi2=0.0000. we also tried the alternative model using random effects. however, the results of hausman test indicated fixed effect model. *5% level of significance; **10% level of significance; ***1% level of significance. table 5. actual and estimated life expectancy for males and females in selected indian states (2010). state actual potential actual as % ranks of states according lexp lexp of potential to realization of potential lexp lexp m f m f m f m f andhra pradesh 65.40 69.40 76.17 82.01 85.86 84.62 14 12 assam 61.60 62.80 70.12 74.67 87.85 84.10 11 13 bihar 67.10 66.70 70.24 74.84 95.52 89.13 4 9 gujarat 67.20 71.00 72.33 77.33 92.90 91.82 6 5 haryana 67.90 69.80 69.61 74.03 97.54 94.29 2 3 karnataka 66.50 71.10 73.57 78.74 90.39 90.29 8 7 kerala 72.00 76.80 73.10 78.13 98.49 98.29 1 1 madhya pradesh 62.50 63.30 72.91 78.04 85.72 81.11 15 14 maharashtra 67.90 81.78 75.99 87.19 89.35 93.79 10 4 odisha 62.30 64.80 70.99 75.65 87.76 85.65 12 11 punjab 68.70 71.60 70.83 75.45 96.99 94.90 3 2 rajashthan 66.10 69.20 72.06 77.00 91.73 89.87 7 8 tamilnadu 67.60 70.60 75.17 80.70 89.92 87.49 9 10 uttar pradesh 64.00 64.40 74.48 79.95 85.93 80.55 13 15 west bengal 68.20 70.90 72.34 77.37 94.28 91.64 5 6 lexp, life expectancy. non -co mmerc ial us e o nly [page 32] [healthcare in low-resource settings 2014; 2:1866] lier, we hypothesize that states differ in their technical efficiency pertaining to health system due to factors which require emphasis in health facility planning. it is also hypothesized that these factors differ from state to state according to their level of development. it is presumed that estimated efficiency parameters should help the health policy makers to improve state level health system performance. as presented in the results above our findings indicate positive impact of governmental intervention in expansion of phc facilities and the desirable impact of having rural specialists like surgeons, obstetrician and gynaecologists, physicians and paediatricians for enhancing life expectancy. the fact that the anm has emerged with positive signs is indicative of the desirable role of the various inputs provided through paramedical manpower. statistical significance of these inputs at the conventional level of significance and the variable of blood bank suggest that the system has indeed worked towards providing some of the desirable inputs. however, whether these have been utilised as efficiently as to be considered as optimum is revealed through our comparison of actual and estimated lexp for males for the year 2010 in table 5. these depict kerala as the most efficient state with its actual lexp being the highest in the estimated lexp. this is followed by punjab and haryana. further, the lowest efficiency for males is depicted by madhya pradesh followed by andhra pradesh and uttar pradesh. in case of female life expectancy these rankings for the latter type (i.e., moving from lowest ranking state) are depicted by uttar pradesh followed by madhya pradesh and assam (table 5). reasons for these inter-state disparities can be deciphered from major inputs for health sector in the states. notably, the distributions of: per capita hospitals, phcs, scs, chcs and beds in the states are highly inequitable. in fact, there is a considerable difference between maximum and minimum values for each of the parameters.72 pertinently population served per government hospital bed is the highest (5606) in bihar, followed by assam (3912) and uttar pradesh (3499). similar order holds true with regard to population served per govt hospital with highest figure for bihar (451325) followed by uttar pradesh (229118) and assam (194863). the magnitude of the highest and the lowest population served per government hospital bed and hospitals in the states is ranked slightly different from order that of life expectancy and its achievements (i.e., actual vs potential life expectancy) in our results. however, observations pertaining to other facilities like phcs, scs and chcs depict higher numbers per thousand populations in uttar pradesh, which is in contrast to its lowest ranking of life expectancy outcomes thus depicting inadequate utilisation of these facilities. it is pertinent to note that kerala does not have the highest number for any of the categories of these.72 in fact, in terms of manpower again uttar pradesh seems to have highest per thousand specialists at chc (1.89), health assistants (4.52) and anms (22.46) and it has the second highest number for doctors at phcs (2.86) and lady health visitor (2.04) in the country. this pattern also reinforces the lower utilisation of manpower in the state. it points to the inadequate or ineffective utilization of staff inputs in poorly performing states. however, in most of the states, neither the inadequate availability of healthcare sector inputs nor merely inefficient utilization of these inputs explains the differentials in achievements in life expectancy. besides the factors within the health system, as noted by us earlier, there are influences external to the system that may lead to differentials in efficiency at the state level. some of these factors could be per capita income, per capita budgetary health expenditure, literacy, access to safe drinking water and urbanization. in general, the differential impact on life expectancy of health system inputs may be due to significant influence of some of these variables. it could be observed from the official publications that the majority of poorly performing states like uttar pradesh, madhya pradesh and bihar are among the low income category states.73 even the budgetary expenditure (as percent to total state budget) is lower in some of these states like madhya pradesh but this also holds for some of the relatively better off states like punjab, haryana and maharashtara.73 although kerala does not have the highest figures in terms of either per capita income or budgetary expenditure on health, yet it has an outstanding position in terms of overall literacy which is 90.91percent as per the 2011 census.73 in contrast, many of the poor and poorly performing states, in terms of life expectancy, have much lower levels of literacy. a similar situation prevails in terms of level of urbanisation in poorer states relative to their counterparts in better off states.73 thus, in order to explore such external factors, we used dispersion in efficiency as a dependent variable in the second stage of our regression exercise using panel data for the state level. these are presented in the appendix and appendix table a. the positive sign of per capita income indicates the impact of inequality in income across states influencing the inequality in health outcomes towards greater disparities. the negative sign of gross enrolment indicates that an increased level of awareness about health related facilities and issues have helped to reduce regional disparity in efficiency of health system across states. however, this has not been able to compensate for other deficiencies of low investments and poor utilization of existing heath care facilities. conclusions results of our fdh analysis are suggestive of a considerably better scope for improvement in efficiency of public expenditure in health relative to education. further parametric approach of sfa applied for health care sector indicates factors that could be isolated to suggest ways to improve efficiency in the public expenditure in the sector. the results of the frontier model, using panel data for 15 major indian states in the years 2005-2011, indicate that the efficiency of public health delivery system remains low. considerable disparities across states in terms of per capita availability and utilization of hospitals, beds and manpower inputs has had an adverse impact on improving the life expectancy in the poorer states. overcoming these factoral disparities within the health system may lead to an improvement in the state level efficiency of the public health system. this may also help to improve life expectancy speedily and more equitably in the poorly performing states of madhya pradesh and uttar pradesh possibly as much as by 20%. however, this has to be supported with other adequate infrastructure facilities like more budgetary expenditure to improve availability of medicines and materials at rural facilities and better management of health personnel in the rural areas to ensure their adequate utilisation. learning from the remarkable achievements of kerala, an emphasis on literacy by reducing dropout rates along with better utilization of health infrastructure and manpower resources could go a long way in improving life expectancy. this may require a considerable re-orientation of current healthcare set-up, particularly in the rural areas in the poorly performing states. these could reallocate surplus manpower from within and also make the rural infrastructure more useful to the needy through adequate inputs of building, equipment and medicines. in fact, there is a considerable differential in budgetary expenditure per capita between better off and poorer states. this in turn reduces the availability of basic medicines and materials in the public health system and reduces its reliability for the poor making them more dependent on the costlier private sector. part of this problem could be tackled through funds from national rural health mission and also by improving rural sanitation in poorer states. the results also suggest lack of appropriate links and coordination between economic and social sector policies leading to sub-optimal health outcomes for the poorer states in the country. our results of sfa for 2005-2011 corroborate the analysis for earlier periods from other studies like sankar and vinish53 and purohit.9 article non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1866] [page 33] references 1. reserve bank of india. state finances 2011. mumbai: bank of india publ.; 2012. 2. gupta s, honjo k, verhoeven m. the efficiency of government expenditure: experiences from africa. washington, dc: international monetary 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airlangga, surabaya, east java; 2department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, east java; 3department of nursing, universitas airlangga, surabaya, east java, indonesia abstract every parent desires their child to engage in both play and learning. often, parents find themselves attributing any challenges to perceived shortcomings in their parenting and struggle to leverage digital media effectively. this research endeavors to examine the fundamental psychological needs autonomy, competence, and relationship in relation to parenting strategies for children vulnerable to internet gaming disorder. employing an analytical cross-sectional design, the study focused on parents with children aged 8 to 12 years in gresik city, east java, indonesia. a purposive sample of 125 participants was selected. the research employed the satisfaction and frustration of the basic psychological needs (bpn) questionnaire along with a parenting strategy scale. descriptive statistical tests and multiple linear regression were utilized to analyze the bpn and parenting strategies. simultaneously, bpn significantly influenced parental strategies (p=0.026, which is ≤0.05). in terms of effective contributions, autonomy, competence, and relationship collectively accounted for 7.3%, with individual effects of 1.82%, 5.56%, and 0.04%, respectively. parents whose bpn were fulfilled exhibited effective parenting strategies, reducing the risk of internet gaming disorder. consequently, there is a crucial role for nurses and healthcare professionals in educating parents about preventing internet gaming disorder in children. introduction a common grievance among parents in various parts of indonesia is associated with the provision of internet facilities and permitting children to engage in games.1-4 however, these facilities can have a detrimental impact on children. parental perplexity increases as children begin to exhibit attention disorders, emotional dysregulation, disruptions in family relationships, and an excessive need for play.5 consequently, children may overlook school assignments that should be completed at home and engage less with their peers.6 the role of parents’ strategies in educating children in the digital era has not been extensively researched, particularly concerning the fulfillment of basic psychological needs (bpn). research on the use of online games and associated risks in children is scarce compared to studies on online game addiction in adolescents and adults.2,3,7 given the critical importance of childhood for parental involvement in growth, development, meeting basic needs such as nutrition and housing, as well as educating children, it is imperative to prevent online game addiction.6 data on online game players in indonesia show an increase from 23.7 million people in 2019 to 28.1 million people in 2020, making indonesia the seventh-ranked country globally for gamers.8 despite the benefits, empirical data consistently demonstrates that excessive gaming has negative consequences on physical and psychological functioning.9 gamers exhibit worse emotional responses, impaired prefrontal cortex function, compromised cognitive control, diminished working memory and decision-making abilities, decreased visual and auditory functions, and deficiencies in their neural reward system. these parallels correspondence: nur hidaayah, doctoral candidate of doctoral program, department of nursing, universitas airlangga, surabaya, jalan dr. ir. h. soekarno street, 60115, east java, indonesia. e-mail: nur.hidaayah-2019@fkp.unair.ac.id nurhid@unusa.ac.id key words: basic psychological needs; children; internet gaming disorder; parenting strategies. contributions: nh, conceptualization, data curation, visualization and writing original draft, conceptualization, methodology validation; nh, ey, formal analysis; rys, nh, methodology; ey, hen, validation, review and editing; kk, investigation. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was funded by universitas nahdlatul ulama surabaya, surabaya, east java, indonesia. ethics approval and consent to participate: the research protocol was performed following the helsinki declaration. before participating in the study, all respondents signed a voluntary consent form. all procedures involved in this study were approved by the university health research ethics committee (nahdlatul ulama university, surabaya). approval code: 273/ec/ kepk/unusa/2021. patient’s consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 october 2023. accepted: 23 february 2024. early access: 21 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11972 doi:10.4081/hls.2024.11972 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11972] [page 467] non -co mmerc ial us e o nly with individuals with substance-related addictions suggest shared predisposing factors, indicating a potential addiction syndrome.10 the onset of gaming behavior in industrialized countries typically occurs around the age of 8 years.11 in indonesia, where access to games is easily affordable, some games may be expensive for children,3,12 prompting the extension of the current research to cover the age range from 7-8 years and above. neurobiological examinations in addicted children reveal activity in the bilateral middle and inferior temporal gyrus, responsible for visual processing, and the right superior parietal lobule, responsible for spatial orientation, indicating impaired visual and auditory function.9 magnetic resonance imaging (mri) examinations show lower brain activity in the left inferior frontal gyrus and right inferior parietal lobe compared to matched casual game controls, indicating barriers to control ability, attention and error processing, selfconcept, and social anxiety. pleasurable experiences in the brain due to frequent play result in a lower physiological response in the ventral striatum when anticipating rewards, motivating gamers to play intensely and disregard fatigue, rest, and daily life activities, including assignments and schoolwork.10,13 satisfaction of bpn supports parents’ awareness of their role in parenting, as evidenced in studies related to game addiction. parental knowledge about preventing gaming addiction is considered protective, reducing the impact of the risk of peer victimization through bpn satisfaction mediation.6 on the other hand, forecasts about gaming and social addiction depend on factors like the level of psychological control exerted by parents, the frustration of needs, or the child’s gender, along with the resulting outcomes. parents’ experiences of parenting practices are identified as highly relevant to parents’ psychological needs according to selfdetermination theory (sdt).14 sdt, coupled with parents’ strategies in preventing internet gaming disorder, emphasizes autonomy support, structure, and connectedness support.15 a parenting style that includes parental autonomy can support the child’s volitional function, aligning with an authoritative parenting style, involving guiding the child during play.16 parents, especially mothers, are advised to initially prohibit children from interacting with captivating objects.17 mothers are expected to manage the child’s response to rejection through reasoning, polite requests, positive comments, and suggestions. this authoritative parenting approach aims to cultivate committed obedience in children.18 a parenting style that emphasizes connectedness involves parents expressing love and attention, fostering a close and understanding relationship with their children.14,19,20 patterns that support competence involve implementing daily task routines, planning joint activities, visualizing environments at risk of game addiction, identifying positive behaviors, and consistently enforcing agreed-upon rules. competence support stimulates children’s social and emotional development.14,21 sdtbased parenting, with its focus on need satisfaction, enables parents to better control independence, connectedness, and competence compared to frustrated and dissatisfied parents.22,23 in light of the above, the researcher formulates the research objectives, aimed to analyze the relationship between parents’ basic psychology and parenting strategies in preventing internet gaming disorder in children. materials and methods design and sample this study employed an analytical cross-sectional study approach. specifically, it included all parents with children of primary school age in the gresik regency area, east java, indonesia. the sample consisted of parents with children aged 8-12 years in the gresik area, totaling 125 people. the inclusion criteria were as follows: parents (both father and mother) responsible for their own children, parents who provide their children with gadgets, and parents with children aged 8-12 years engaging in gaming for at least 1-3 hours per day in the last 3 months. exclusion criteria comprised parents who were absent due to sickness, job relocation, or having children in ill condition. variable, instrument and data collection this research encompassed demographic characteristics variables: child gender, parent age (years), child age, number of children, parent education, household income, family structure, and work. the independent variable was bpn (autonomy, competence, and relationships), while the dependent variable was parenting strategies. two instruments were utilized in this study. first, the basic psychological needs frustration (bpnf) questionnaire: controlling for the big five personality traits.24 the validity test yielded a correlation value for each question ranging from 0.369 to 0.857, with a reliability cronbach alpha of 0.915. second, the digital parenting questionnaire: perceptions on digital risks.25 the validity test resulted in a correlation value for each question ranging from 0.486 to 0.700, with a reliability cronbach alpha of 0.789. procedure the initial step in this study involved obtaining permission from the research ethics commission and the research site. data collection commenced on november 1, 2021, with questionnaires distributed using a google form to parents in the respondent group willing to participate, accompanied by proof of information permission. data analysis data management and analysis were conducted using spss 22.0. the influence of bpn (competence, relatedness, and autonomy) on parenting strategies in children was analyzed using the multiple linear regression test with a significance value of p<0.05. ethical clearance the research protocol adhered to the helsinki declaration. prior to participation, all parents willing to be respondents signed a voluntary consent form. all procedures in this study were approved by the university health research ethics committee (nahdlatul ulama university, surabaya), with the approval code: 273/ec/kepk/unusa/2021. results the characteristics of the respondents indicate that 125 parents participated in the study, with 79% being female and 21% male. the respondents’ ages ranged from 33 to 50 years, with an average age of 40.42. the children involved in the study were between 8 and 12 years old, with an average age of 11.1. regarding parental employment, 30.3% were employed full-time, 13.2% were parttime, 11.6% were housewives, and 5% worked from home. further transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 468] [healthcare in low-resource settings 2024;12:11972] non -co mmerc ial us e o nly details can be found in table 1. the results of the bpn analysis, consisting of autonomy, relatedness, and competence, indicate that autonomy has no significant effect on parenting strategies (0.068), relatedness also shows no significant effect (0.923), while competence has a significant effect on parenting strategies (0.005). simultaneously, the combination of autonomy, relatedness, and competence collectively affect parenting strategies (0.026). in terms of the effective contribution (se), autonomous, relatedness, and competence together contribute 7.3%, with individual effects being autonomous 1.82%, relatedness 0.04%, and competence 5.56%. for the relative contribution (sr), autonomous contributes 24.97%, relatedness 0.61%, and competence 76.28%, as illustrated in table 2. discussion this study aims to demonstrate a strong correlation between bpn and parenting strategies among parents with children at risk for internet gaming disorders. the sample criteria include parents who provide internet (wi-fi) facilities at home along with gadgets for their children. additionally, participants consist of parents who live in the same household or do not live separately from their children, parents whose children play online games for at least 3 hours a day, and parents willing to participate in the study. these findings underscore the significance of the quality of parental involvement, particularly for parents with strong bpn, in employing effective parenting strategies for children at risk of internet gaming disorder. basic psychological needs of parents the results of the partial t-test for each bpn variable, specifically the autonomy variable, indicate no significant impact on parenting strategies. this lack of impact is attributed to parents experiencing pressure when confronted with disciplined parenting patterns that yield substantial parental autonomy in child care. parents may feel helpless due to the reliance on gadget media for many children’s activities during online school, making it challenging to monitor whether children are engaging in assignments or playing. parents with lower income levels may prioritize their work, leading to decreased attention to their children. housewives, in turn, may allow their children to explore transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic characteristics of parents of elementary school students (n=125). characteristics frequency (f) percentage (%) child gender men 86 68.8 women 39 31.2 parent age 30-49 3 2.4 50-64 120 96 > 65 2 1,6 child age 8-10 46 36.8 11-12 79 63.2 number of children 1-2 68 54.4 3-4 57 45.6 education basic 17 13.6 middle 66 52.8 higher 42 33.6 household incomes high 26 20.8 medium 16 12.8 low 83 66.4 family structure nuclear 108 86.4 binuclear 1 0.8 single parent 5 4 extended 11 8.8 work full-time job 4 3.2 part-time job 34 27.2 unemployed 17 13.6 housewife 70 56 table 2. basic psychological needs of parents of elementary school students. model unstandardized standardized t p f r r square se sr coefficients coefficients b std. error beta constant 52.933 6.882 7.692 0.000 3.199 0.026 0.271 7.3 autonomous -1.065 0.578 -0.172 -1.844 0.068 1.8232 24.975 relatedness 156 1.608 0.009 0.097 0.923 -0.045 -0.616 competence 1.861 0.656 0.259 2.836 0.005 5.5685 76.281 [healthcare in low-resource settings 2024;12:11972] [page 469] non -co mmerc ial us e o nly the gaming world if the children are not demanding and prefer staying indoors. the support of the three bpn (autonomy, competence, and relatedness) within an individual’s social environment contributes significantly to the psychological well-being of parents.18 the findings of this study align with research articles indicating that parental basic need satisfaction serves as a predictor of autonomy support from parents. this conclusion is corroborated by costa (2019), demonstrating that parents who perceive their basic needs as fulfilled are more likely to employ practices that support autonomy with their children.26 additionally, the need for gender autonomy influences the fulfillment of the bpn for autonomy, which tends to be more pronounced in women.27 the results of this research indicate that the variable of relationship does not significantly affect parenting strategies. according to the questionnaire results, many parents foster relationships among family members, particularly with their children, by engaging in shared gaming activities. they often come together after exhausting activities outside and find entertainment through cellphone features. parents who experience frustration in their relationship with their children may permit their children to play games as a reward after studying, and not monitoring their children’s screen time for more than 3 hours per day may pose a risk of interference with internet gaming. it’s noteworthy that in this study, only 21% of participants were mothers, contrasting with the majority (79%) of participants who were fathers. the lack of effect observed for the relatedness variable may also be influenced by gender, as fathers tend to maintain attachment relationships with their children more than mothers. the competence variable significantly influences parenting strategies, indicating that parents are content with their competence and believe they are effectively managing parenting tasks. however, caution is warranted if parents feel frustrated with their competence, as this may lead to reduced confidence in resolving their child’s issues, particularly concerning difficulties related to playing internet games. the findings of this study align with research articles, demonstrating that parents who experience satisfaction bpn tend to exhibit greater independence in decision-making and increased confidence in their parenting skills. this suggests that they are more likely to enhance their ability to make informed decisions and apply reasoning to relevant rules for their children.26 furthermore, parents’ screen time when interacting with gadgets and their attitudes are closely linked to children’s screen time. parents employ active, restrictive, and collaborative strategies in managing technological device use. the study emphasizes the need for parents to acquire more information about evolving digital risks, as they may lag behind their children’s proficiency in playing advanced games.28,29 based on the simultaneous f-test results, it is evident that competence, relatedness, and autonomy each have a significant partial effect on parenting strategy. the regression test results indicate the percentage of influence exerted by bpn, either individually or collectively, on parenting. this is further supported by simultaneous results on r square, suggesting a relationship between bpn and parenting strategies when considered together. the standard error (se) variables of autonomy, relatedness, and competence also influence the parenting strategy. previous research findings demonstrate that the satisfaction of bpn in parents contributes to both long-term and short-term happiness. autonomy, competence, and attachment are identified as important mediators in shaping personality and providing parental support for children’s happiness and mental health. moreover, these findings contribute to the existing literature on this subject.30 parental strategy from the parents’ statement the parenting strategy, as indicated by parents’ statements, reveals a strict approach to overseeing children’s use of gadgets, particularly engaging in online games. parents emphasize limiting children’s playtime to 1-2 hours per day, with a majority (90%) expressing the desire to understand how to control their children’s usage. their motivation stems from a wish to protect their children from potential threats posed by malicious gaming sites on the internet. upon reviewing the responses to the research questionnaire, it becomes apparent that parents who detail their respective parenting strategies regarding their children’s digital media use are seeking effective strategies for parenting. parents need to gain a better understanding of their children’s development while safeguarding their privacy from exposure to personal information and health issues.31 various parenting strategies can be employed. previous research articles have elucidated that a supportive parenting style fulfills three bpn, ultimately enhancing overall well-being. interventions aimed at equipping parents with the knowledge and skills to implement warmth, structure, and autonomy support are deemed essential.32 a limitation of this study was the inability to conduct direct interactions with the participants’ parents due to the pandemic. for future research, it is suggested to employ a cross-sectional analytic design with a survey or direct interaction with parents to ensure results align with expectations. recommendations stemming from this study propose implementing parenting strategies in seven ways, including persuasion, control, protection, monitoring, managing/reducing children’s screen time during online gaming, supporting children to use digital media appropriately (choosing age-appropriate applications), and minimizing gadget use, especially during family gatherings, as bpn have a strong relationship with parenting strategies. this study used a purposive sampling technique because, at the time of research indonesia was facing the covid-19 pandemic, and researchers could not meet directly with research respondents. there are also several influential variables in the study that have not been examined, namely the mother’s personality factor and the health status of the mother and her child. implications our results suggest that parents should be made aware of the importance of continuing to provide autonomy support to their children even after they become adults. it is crucial for parents to comprehend and acknowledge their children’s feelings, particularly during challenging transition periods. additionally, they should foster an environment that encourages children to make their own decisions without imposing their opinions. parents should recognize that establishing a psychologically controlling environment is counterproductive if they aim to promote healthy social media use by their children. researchers may find it valuable to consider children’s psychological needs and parenting styles when developing interventions to encourage healthy social media use and selfdirected learning. conclusions the research results demonstrate that parents with effective and robust parenting strategies can play a crucial role in preventing the risk of internet gaming disorders in school-aged children. additionally, such strategies can aid in averting the enduring consequences of internet gaming addiction in children, including obsessive tendencies, anxiety, stress, persuasion, and anti-social transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 470] [healthcare in low-resource settings 2024;12:11972] non -co mmerc ial us e o nly behavior. the three variables exerting the most significant influence on parenting strategy are autonomy, competence, and relatedness. the primary limitation of this research is its conduction during the covid-19 pandemic, leading to continued online learning. consequently, the questionnaire was distributed via a google form, facilitated by the homeroom teacher, who then informed all students. this method might result in some respondents facing challenges in understanding the questionnaire content on the google form. parents and teachers can utilize the findings of this research as a reference for providing care to children, aiming to prevent internet gaming disorders. recommended actions include supervising children, staying informed about digital developments, and fostering warm relationships among parents, teachers, and children. references 1. sumargi a, sofronoff k, morawska a. understanding parenting practices and parents’ views of parenting programs: a survey among indonesian parents residing in indonesia and australia. j child fam stud 2015;24:141-60. 2. herliana d, setiawan b, adikara gj. digital parenting mendidik anak di era digital. yogyakarta, indonesia: samudra biru; 2018. 54 p. 3. dhahir df. internet parenting upon indonesian children. j pekommas 2018;3:169. 4. tomato digital indonesia. perubahan populasi masyarakat digital 2019 peningkatan pengguna internet intensitas penggunaan internet masyarakat indonesia. jakarta selatan, indonesia; 2019. 5. bender pk, kim el, gentile da. gaming disorder in children and adolescents: risk factors and preventive approaches. curr addict reports 2020;7:553-60. 6. liang q, yu c, xing q, et al. the influence of parental knowledge and basic psychological needs satisfaction on peer victimization and internet gaming disorder among chinese adolescents: a mediated moderation model. int j environ res public health 2021;18:1-15. 7. gandaputra sa, waluyo i, efendi f, wang jy. insomnia status of middle school students in indonesia and its association with playing games before sleep: gender difference. int j environ res public health 2021;18:1-10. 8. sukirno. jumlah pemain game online dunia 2020 grafik alinea id. 2020. 9. torres-rodríguez a, griffiths md, carbonell x, oberst u. internet gaming disorder in adolescence: psychological characteristics of a clinical sample. j behav addict 2018;7:707-18. 10. kuss dj, pontes hm, griffiths md. neurobiological correlates in internet gaming disorder: a systematic literature review. front psychiatry 2018;9:1-12. 11. king dl, delfabbro ph. prevention and harm reduction for igd. 2018. available from: https://www.sciencedirect.com /science/article/abs/pii/b9780128129241000083?via%3dihub 12. king dl, delfabbro ph. internet gaming disorder: theory, assessment, treatment, and prevention. cambridge, ma, usa: academic press; 2018. 294 pp. 13. brand m, young ks, laier c, et al. integrating psychological and neurobiological considerations regarding the development and maintenance of specific internet-use disorders: an interaction of person-affect-cognition-execution (i-pace) model. neurosci biobehav rev 2016;71:252-66. 14. dieleman lm, moyson t, de pauw ssw, et al. parents’ needrelated experiences and behaviors when raising a child with autism spectrum disorder. j pediatr nurs 2018;42:e26-37. 15. ryan rm, deci el. self determination theory basic psychological needs in motivation, development, and wellness. new york, usa: the guilford press; 2017. 769 p. 16. ani a, rachmawati pd, efendi f, et al. the differences in the stimulation and personal social development of school-aged children between children who raised by their grandparents and parents respectively. j glob pharma technol 2020;12:142-50. 17. fauziah y, efendi f, pratiwi in, et al. parental self-efficacy on temper tantrum frequency in children. indian j public heal res dev 2019;10:2798-802. 18. joussemet m, landry r, koestner r. a self-determination theory perspective on parenting. can psychol can 2008;49:194-200. 19. scerri m, anderson a, stavropoulos v, hu e. need fulfilment and internet gaming disorder: a preliminary integrative model. addict behav reports 2019;9:100144. 20. soenens b, deci el, vansteenkiste m. how parents contribute to children’s psychological health: the critical role of psychological need support. in: development of self-determination through the life-course. 2017. available from: https://link.springer.com/chapter/10.1007/978-94-024-1042-6_13 21. hidaayah n, kusnanto k, yusuf a, et al. parental attention and children’s addiction to online games. int j psychosoc rehabil 2020;24:650-5. 22. schiffrin hh, erchull mj, sendrick e, et al. the effects of maternal and paternal helicopter parenting on the self-determination and well-being of emerging adults. j child fam stud 2019;28:334659. 23. hui bph, wu ams, siu nyf, et al. the effects of need satisfaction and dissatisfaction on flourishing among young chinese gamers: the mediating role of internet gaming disorder. int j environ res public health 2019;16:1-14. 24. mutlu-bayraktar d, yılmaz ö, i̇nan-kaya g. digital parenting: perceptions on digital risks. kalem uluslararasi egit ve insa bilim derg 2018;14:137-63. 25. nishimura t, suzuki t. basic psychological need satisfaction and frustration in japan: controlling for the big five personality traits. jpn psychol res 2016;58:320-31. 26. costa s, gugliandolo mc, barberis n, et al. antecedents and consequences of parental psychological control and autonomy support: the role of psychological basic needs. j soc pers relat 2019;36:1168-89. 27. kındap-tepe y, aktaş v. the mediating role of needs satisfaction for prosocial behavior and autonomy support. curr psychol 2021;40:5212-24. 28. karaer y, akdemir d. parenting styles, perceived social support and emotion regulation in adolescents with internet addiction. compr psychiatry 2019;92:22-7. 29. throuvala ma, janikian m, griffiths md, et al. the role of family and personality traits in internet gaming disorder: a mediation model combining cognitive and attachment perspectives. j behav addict 2019;8:48-62. 30. şimşek öf, demir m. parental support for basic psychological needs and happiness: the importance of sense of uniqueness. soc indic res 2013;112:661-78. 31. coyne sm, radesky j, collier km, et al. parenting and digital media. pediatrics 2017;140:s112-6. 32. abidin fa, yudiana w, fadilah sh, gomide pi. parenting style and emotional well-being among adolescents : the role of basic psychological needs satisfaction and frustration. front psychol 2022;13:1-10. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11972] [page 471] non -co mmerc ial us e o nly hrev_master [page 6] [healthcare in low-resource settings 2016; 4:5680] knowledge, attitude and practice of contraceptive use among female students of dilla secondary and preparatory school, dilla town, south ethiopia, 2014 samuel kusheta katama,1 desalegn tsegaw hibstu2 1department of health extension, hossana college of health sciences, hossana; 2department of reproductive health, hawassa university, hawassa, ethiopia abstract family planning is known not only as a fundamental intervention for improving the health of women but also as a human right. the aim of this study was to assess the current knowledge, attitude and practice of contraceptive use among female students in dilla secondary and preparatory school, dilla, south ethiopia, 2014. a cross sectional study was conducted among 288 female students in dilla secondary and preparatory school, south ethiopia, june 1929/2014. a simple random sampling technique was used to select the study subjects. the data was collected using a self-administered structured questionnaire. the data was analyzed by spss 20. chi-square test was used to identify associated factors. a total of 263 female students were involved in this study, of which 249 (94.7%) had good knowledge about contraception. the three most frequently identified methods were injectable form (83.9%), oral contraceptive pills (72.7%) and condom (48.6%). a total of 15.7% respondents ever used contraceptive. among the users, 56.4% used oral contraceptive pills, and 23.1 and 10.2% used injectable form and condom, respectively. in spite of the fact that most respondents had good knowledge of contraception, their attitude and practice was low. emphasis needs to be given on disseminating health information concerning the attitude and practice of contraceptive method. introduction family planning is known not only as a fundamental intervention for improving the health of women but also as a human right. the basis for action in family planning must enable couples and individuals to decide freely and responsibly the number and spacing of their children.1 ethiopia is the second most populous country in africa. its population has increased nearly seven times from 11.8 million at the beginning of the 20th century to about 80 million today. the total fertility rate of ethiopia is 4.8 with estimated population growth rate is 2.7% per year, contraceptive prevalence 29%.2 in ethiopia, unwanted pregnancy is a serious issue where more than 60% of the pregnancies in adolescents are unwanted resulting from unprotected sexual intercourse which is an alarming figure, and most of these pregnancies particularly in adolescents end up with unsafe abortion.3 an african woman’s chance of dying from pregnancy related causes: obstructed labor, postpartum hemorrhage, pregnancy induced hypertension, post partum infection and unsafe abortion average 870 per 100,000 live births in contrast to developed countries which is 27 per 100,000 live births.4 one of the big challenges to the reproductive health of young adults in developing countries like ethiopia is unintended pregnancy. as a result of the decreasing age of menarche and onset of sexual activity, youths are facing early unplanned and unprotected sexual intercourse leaving them vulnerable to unwanted pregnancies and invariable abortions.5 about 3.7 million unsafe abortions are performed each year in sub-saharan africa and about 23,000 african women die from its complication. east african women face the highest life time risk of maternal death of 1 in 12 compared with 1 in 3700 women in north america.6 low-income countries are confronted with a vicious cycle: efforts to improve living standards and to alleviate poverty are overwhelmed by the need to provide basic services and jobs for the growing number of people. provision of family planning service has become the intervention of choice to stabilize demographic explosion.7 there are many causes for the low contraceptive prevalence rate that needs to be explored. it will be easy to design implementation methods for the alleviation of consequences of not using contraceptives if the reasons are identified. the problem is more acute among teenagers due to various reasons. a study done on knowledge, attitude and practice of family planning methods and other reproductive health diseases including hiv/aids among school adolescents in seven towns of ethiopia showed that most of the sexually active school adolescents did not use contraception.8 this paper attempts to assess the current knowledge, attitude, and practice of contraception among female students of dilla secondary and preparatory school. materials and methods study area and period the study was conducted in dilla town, the capital of gedeo zone [southern, nation nationalities and people’s regional state (snnpr)]. the town is located at a distance of 359 km from addis ababa, capital city of ethiopia and 90 km from hawassa, the capital city of snnpr, ethiopia. cross sectional study design was used from june 19-29/2014. population the source population was made up of all dilla secondary and preparatory high school students enrolled in the year 2014 and students who were absent and seriously sick students on the day of data collection were excluded in this study. the study population included all randomly selected students in dilla secondary and preparatory high school in the year 2014. study variables the study variables were developed based on the different literature reviews and from previous studies. the outcome variables are: knowledge of contraceptive use, attitude towards contraceptive use, and practice of contraceptive use. the personal variables are: age, ethnicity, religions, marital status, educational level, reasons for not using contraception, and source of information. in this paper knowledge of contraception was defined as awareness of women about family planning methods or having information about contraception. the study subjects healthcare in low-resource settings 2016; volume 4: 5680 correspondence: desalegn tsegaw hibstu, department of reproductive health, hawassa university, hawassa, ethiopia. e-mail: samkush2012@yahoo.com, desuethiopia@ yahoo.com key words: family planning; contraceptive use; dilla; ethiopia. conflict of interest: the authors declare no potential conflict of interest. contributions: skk and dth participated from the conception to the end of this manuscript. received for publication: 11 december 2015. accepted for publication: 16 january 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s.k. katama and d.t. hibstu 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5680 doi:10.4081/hls.2016.5680 non co mmerc ial us e o nly needed to answer >70% of the question on knowledge section to be classified as knowledgeable, practice is defined as the overt behavior, habit or customs of women using contraception. the study subject were to answer the 1st question yes on the practice section and then to specify the type to be classified as good or poor practice. the study subjects were considered to have good attitude if they gave appropriate answers for >70% of the questions on attitude section. sample size determination and sampling procedure the sample size was determined using single population proportion formula: n=z2�/2(pq)/d2 where n=sample size, z=reliability coefficient with 95%confidence interval, p=prevalence of contraceptive use (29%)[2], q=1-p, d= standard error allowed taken as 5%. and the final sample size was 288 with 10% nonresponse rate after using the sample size correction formula. to get the representative sample stratification was done by grades (grade nine, ten, eleven and twelve). based on this the strata was done by considering number of sections from each grade. the final sample size was obtained and proportionally allocated for each section. the total samples were taken from the sampling frame using simple random sampling technique available from their identification number using computer generated random number from each class. the selected students were gathered in a room and provided with a self-administered questionnaire that was filled out in the same room. data collection and quality control procedures pre-tested and self-administered structured questionnaires were used. two day training was given to data collection facilitators. two principal investigators supervised the overall data collection and checked the completeness of the questionnaire for consistency. the questionnaire was prepared in the english language and translated to amharic (local language) and translated back to english. after data collection, questionnaires were reviewed and checked for completeness and relevance by the principal investigators. data processing and analysis after data collection, each questionnaire was checked for completeness and code was given before data entry. data was cleaned and entered into computer by using epi info version 3.5.3 and the analysis was done using spss version 20.0. data was edited and cleaned before data analysis. descriptive statistics and chi-square tests were used and significance of tests were decided at p<0.05. ethical consideration ethical clearance was obtained from the ethical clearance board of dilla university, college of health sciences. all participants’ right to self-determination was respected. the study participants were informed about the purpose of the study and informed verbal consent was secured. results socio-demographic characteristics a total of 263 female students participated in the study with a response rate of 91.3%. age of the study subjects ranged from 14-22 years with median age of 19. among the studied female students, 170 (64.6%) were gedeo followed by amahara 41 (15.6%) by ethnicity. two hundred forty eight (94.3%) of the respondents were single and 119 (45.2%) of the study participants were from grade nine (table 1). contraceptive knowledge of the students, 249 (94.7%) had heard about contraceptives. all of them correctly identified at least one contraceptive method. the three most frequently identified contraceptive methods were injectable form 209 (83.9%) followed by oral contraceptive pills 181 (72.7%) and condom 121 (48.6%) (table 2). the sources of contraceptive knowledge were television, 104 (41.8%), radio 54 (21.7%) and teachers 49 (19.7%) (table 3). it was found that 191 (76.7%) said that contraceptives are used to prevent unwanted pregnancy, 209 (83.9%) to limit or space childbirth, and 48 (19.3%) answered to prevent sexually transmitted diseases (table 4). attitude towards contraception one hundred seventy eight (71.5%) students had a favorable attitude towards contraceptives. among them, 111 (63.4%) are orthodox christians having positive attitude, 56 (31.5%) protestant, 6 (3.4%) catholic and 5 (2.8%) of muslim students have positive attitude towards contraceptive (table 5). contraceptive practice a total of 39 (15.7%) respondents had ever used contraceptive method. of 39 students who practiced contraceptive 26 (66.7%) were unmarried and 13 (33.3%) were married. among those that practiced contraceptives 19 (48.7%) were orthodox, 15 (38.5%) were protestant, 3 (7.7%) were muslim, and 2 (5.1%) were catholic students. the commonly used contraceptive method was pills, 22 (56.4%) followed by injectable, 9 (23.1%) and condom 4 (10.2%) (table 6). discussion family planning is defined by who as a way of thinking and living that is adopted voluntarily, upon the basis of knowledge, attitudes and responsible decisions by individuals and couples, in order to promote the health and welfare of family groups and thus contribute effectively to the social development of a country. this study showed about 94.7% of respondents had knowledge of contraceptive method. this finding was in agreement with the report article table 1. socio-demographic characteristics of female students of dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. variables n % age (years) 14-16 21 8.0 17-19 196 74.5 20-22 46 17.5 religion orthodox 172 65.4 protestant 75 28.5 muslim 9 3.4 catholic 7 2.7 ethnicity gedeo 170 64.6 amhara 41 15.6 oromo 19 7.2 tigre 7 2.7 sidama 12 4.6 gurage 15 5.3 marital status single 248 94.3 married 15 5.7 grade 9th 119 45.2 10th 42 16.0 11th 75 28.5 12th 27 10.3 table 2. knowledge of contraceptive methods among female students of dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. variables n % heard contraceptive yes 249 94.7 no 14 5.3 method known injectable 209 83.9 oral pills 181 72.7 condom 121 48.6 calendar (rhythm) 99 39.8 coitus interrupts 94 37.7 loop (iucd) 83 33.3 norplant® 49 19.7 tubal ligation 71 28.5 breast feeding 47 18.9 iucd, intrauterine contraceptive device. [healthcare in low-resource settings 2016; 4:5680] [page 7] non co mmerc ial us e o nly [page 8] [healthcare in low-resource settings 2016; 4:5680] ed contraceptive knowledge level of adolescents to be 93-98%.9-12 still, this finding was higher than reports of students from other urban centers of the country where contraceptive knowledge level varies from 54% in harar13 to 75-83% in north gondar.14 this magnitude was also comparable with the level of adolescents’ contraceptive knowledge in asia, north africa, the caribbean and latin america, where the level of adolescents’ knowledge on contraception was above 90%.15 this might be due to the better information exposure and communication that school adolescents now have and influence of mass media. perhaps, it could be due to the fact that the most widely available method of family planning is oral contraceptive pills, the most familiar method obtained in this paper was oral contraceptive pill, which was congruent with other studies. about seventy percent of study subjects had heard about emergency contraception. a study conducted in nigeria and addis ababa university showed that 58 and 43.3% knew about emergency contraception, respectively.16,17 the result of this study was higher; the difference could be due to the difference in the population studied and time interval between the studies. contraceptive use in this study was 15.7%. a research done in north gondar showed that contraceptive use was 30.7%,18 while a study done in harar was 20%.13 the possible reason for this difference could be poor attitude towards contraceptive use in the present study because of religious and cultural reason, and variation in the population studied. the major source of information on contraception in this study was television (41.8%) while it was 23.8% in a study done in north gondar.18 this difference might be due to increasing number of televisions per household with increasing emphasis by the government through different attractive announcements and programs on television. in this study, it was observed that pharmacy/drug vender was the main source of contraceptive method accounting for 87.2% (figure 1). a study done in jimma urban population showed 98.96% from clinic and pharmacy.16 among those who did not use any method of contraceptive in this study, 46.5% were not using for cultural reason, and 27.6% for religious reason and 23.7% because of lack of knowledge (figure 2). a study done in north gondar showed that majority of non-users did not use because of lack of knowledge or access to service.18 this could be the difference in the population studied and changes in the study period. conclusions this study showed that most of the students article figure 1. distribution of respondents by source of contraceptive used among dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. figure 2. distribution of respondents by their reason for not using contraceptive in dilla secondary and preparatory school, dilla town, south ethiopia, july 2014. table 3. source of contraceptive knowledge in dilla secondary and preparatory school female students, dilla town, south ethiopia july, 2014. source n % of knowledge (tot=249) tv 104 41.8 radio 54 21.7 teacher 49 19.7 friends 40 16.1 health worker 24 9.6 books 18 7.2 magazines 15 6 table 4. distribution of female students in dilla secondary and preparatory school by their knowledge about importance of contraception. importance of contraception n % prevent unwanted pregnancy 191 76.7 prevent std 48 19.3 limit/space child birth 209 83.9 treat menstruation pain 28 11.2 prevent abortion complications 12 4.8 std, sexually transmitted disease. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5680] [page 9] had knowledge of contraception. predominant methods known by students were injectable, oral contraceptive pills and condom, respectively but the number one method used by students was oral contraceptive pills. older adolescents (age 18-22 years) and higher grades (11th and 12th students) ever used contraceptive methods than younger ones and lower grades (grade 9 and 10). television, radio, and teachers were found to be the most important source of information for promoting utilization of contraceptives. marital status was found to be associated with higher rates of contraceptive use. among the non-users, the majority of respondents did not practice for religions and cultural reason and lack of knowledge. most women have good attitude towards contraceptives. information, education and communication activities regarding utilization of modern contraceptive methods among adolescents and their importance should be strengthened by the ministry of health through mass media messages and encouraging school health programs. including family planning in the educational curriculum both at elementary and secondary schools needs emphasis, so that knowledge and practice of modern contraception can be utilized early at least for those who are not out of school. community health education programs regarding culture need to be planned and carried out to the community at large. encouraging mini media programs and establishing reproductive health clubs should be promoted by school officials. references 1. who. improving access to quality cares in family planning. geneva, switzerland: who; 1996. 2. central statistical agency-icf international. ethiopia demographic and health survey. addis ababa, ethiopia, and calverton, ma, usa: central statistical agency and icf international; 2012. 3. tilahun d, assefa t, belachew t. knowledge, attitude and practice of emergency contraceptive among adama university female student. ethiopian j reprod health 2010;20:195-202. 4. ethiopian population. ethiopian linkage between population and economy, 2007. available from: http://www.ethiopianpopulation.com 5. park k. textbook of preventive and social medicine. 22th ed. jabalpur: banarsidas bhanot publ.; 2013. 6. world bank. effective, family planning programs. washington, dc: wordl bank; 1993. 7. who. community based distribution of contraceptive. a guide for program manager. geneva, switzerland: who; 1995. 8. birhan research & development consultancy. ethiopia: knowledge, attitudes and practices in family planning. results from september 2004 survey of amhara, oromia, snnpr and tigray regions. available from: pdf.usaid.gov/pdf_docs/pnadp662.pdf 9. aklilu k, hailom b. youth reproductive health in ethiopia. ethiopia demograhic and health survey. calverton, ma: orc marco; 2002. 10. berhane f. health problems and service preferences of school adolescents in addis ababa with emphasis on reproductive health. department of community health: addis ababa, ethiopia; 2000. 11. tilahun t, coene g, luchters s, et al. family planning knowledge, attitude and practice among married couples in jimma zone, ethiopia. plos one 2013;8:e61335. 12. kasahun s. sexual behavior, contraceptive practice and knowledge of aids of high school students in addis ababa. addis ababa: university of addis ababa; 1997. 13. bisrat f. knowledge, attitude and practice of contraceptive among high school students in harar town, eastern ethiopia. ethiopian j health dev 1994;32:151-60. 14. kebede y. contraceptive prevalence and factors associated its usage in gondar town, north ethiopia. ethiopian j health dev 2000;14:32-9. 15. sigh s, kluif d. the likelihood of induced abortion among women hospitalized for abortion complication in four latin american countries. int fam plan persp 1993;19:134-41. 16. aziken me, okonta pi, ande ab. knowledge and perception of emergency contraception among female nigerian undergraduates. int fam plan persp 2003;29:84-7. 17. tamire w, enquselassie f. knowledge, attitude and practice on ec among female students at higher education, addis ababa, ethiopia. addis ababa: university of addis ababa; 2005. 18. shiferaw m. determinants of contraceptive use in jimma herbal population, south west ethiopia. addis ababa: family guidance association of ethiopia; 1990. article table 5. contraceptive knowledge, attitude and practice in different religious groups of dilla secondary and preparatory school female students, dilla town, south ethiopia, july 2014. knowledge attitude practice religion yes no yes no yes no n (%) n (%) n (%) n (%) n (%) n (%) orthodox 162 (94.2) 10 (5.8) 111 (64.5) 61 (35.5) 19 (11.0) 153 (89.0) protestant 73 (97.3) 2 (2.7) 56 (74.7) 19 (25.3) 15 (20.0) 60 (80.0) muslim 9 (100) 0 (0.0) 5 (55.6) 4 (44.4) 3 (33.3) 6 (66.7) catholic 5 (71.4) 2 (28.6) 6 (85.7) 1 (14.3) 2 (28.6) 5 (71.4) significant test x2=8.32; p=0.04 x2=13.66; p=0.034 x2=3.19; p=0.36 table 6. contraceptive usage among dilla secondary and preparatory school female students, dilla town, south ethiopia, july 2014. practice n % ever used yes 39 15.7 no 210 84.3 type used oral pills 22 56.4 injectable 9 23.1 condom 4 10.2 calendar (rhythm) 2 5.1 coitus interrupts 1 2.6 norplant® 1 2.6 non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11788 effect of aloe vera gel compresses on breast engorgement among postpartum mother siti raihanah, jasmawati jasmawati, nursyahid siregar east kalimantan ministry of health health polytechnic, samarinda, indonesia abstract navigating the challenges of new motherhood, a staggering 50 to 70 percent of women find themselves grappling with clogged milk ducts.. aloe vera gel compresses can be used on breasts to reduce edema. aloe vera is known for its effective anti-inflammatory properties. this study aimed to investigate the effect of aloe vera gel compresses on breast engorgement in postpartum mothers. the study included postpartum mothers as the target population. the research design employed a pretest-posttest methodology comprising a control group and non-probability sampling using consecutive sampling. statistical analyses involved the paired ttest and independent t-test, with a significance level of p < 0.05. the sample consisted of thirty respondents, with 15 in the control group and 15 in the experimental group. over a period of three days, aloe vera gel compresses were applied to the breasts twice a day. the bourbonnais pain scale evaluation checklist was used to assess the degree of breast pain. the findings of this study demonstrate that the intervention involving aloe vera gel compresses significantly reduced breast engorgement (p=0.000; mean sd 2±1.25) and associated pain (p=0.000; mean sd 2.2±1.37). the results of this study suggest that the use of aloe vera gel compresses can effectively alleviate breast pain and swelling in postpartum mothers. given the substantial benefits observed, healthcare professionals may consider incorporating aloe vera gel compresses as a non-invasive and natural intervention for postpartum mothers experiencing breast engorgement and discomfort. introduction a multitude of factors contribute to the low breastfeeding coverage rate.1,2 these factors include maternal psychological factors, family support, knowledge of exclusive breastfeeding, a lack of breastfeeding counseling from health professionals, early formula feeding, and breastfeeding issues such as nipple blisters, nipple deformities, and breast engorgement.3,4 breast engorgement, a common issue for breastfeeding mothers during the postpartum period, affects approximately 50-70% of breastfeeding women.5 it is often experienced between the third and fourteenth day after birth.6 research conducted by yanti (2017) at sidomulyo health center in pekanbaru revealed that 47 out of 67 breastfeeding mothers suffered from breast engorgement.7 similarly, rutiani’s study (2016) reported that out of 26 mothers who underwent cesarean sections at bandung’s sariningsih hospital, 19 reported insufficient breast milk.8 setiawan’s research (2017) at the ngrayun ponorogo health center found that 15 out of 40 breastfeeding mothers who visited in january and february 2017 experienced breast engorgement.9 a physiological phenomenon known as a breast milk dam occurs when the breast duct (ductus lactiferus) becomes partially or completely clogged with breast milk.10 symptoms include breast pain, tension, edema, fever, and decreased milk output.11 mastitis and breast abscesses can occur in the majority of breastfeeding mothers who experience a 7% breast milk shortage.12 furthermore, breast engorgement often influence mothers’ decisions to wean their children early and cease exclusive breastfeeding.13 breast engorgement can develop for various reasons.14 one contributing factor is the rise in prolactin activity, which occurs biologically 48 hours after delivery. infants should be fed from breasts swollen with breast milk.15 delayed nursing due to the infant being in a sleep phase and taking longer to wake up can lead to less frequent and shorter breastfeeding sessions.16 additionally, correspondence: siti raihanah, east kalimantan ministry of health health polytechnic, samarinda, indonesia. e-mail: shanaraihana09@gmail.com key word: breast; compress; aloe vera gel; engorgement. contributions: sr conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; jw conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; ns methodology, visualization, writing, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes kalimantan timur, based on ethical certificate dl.02.03/4.3/10433/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 september 2023. accepted: 9 november 2023. early access: 5 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11788 doi:10.4081/hls.2023.11788 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 24] [healthcare in low-resource settings 2024;12:11788] non -co mmerc ial us e o nly primiparous mothers and those who have had cesarean births may face challenges and delays in nursing, putting them at risk for breast engorgement.17 currently, treatments for breast engorgement include both pharmaceutical and non-pharmacological approaches.18 pharmacological treatments may include the use of serrapeptase medications to reduce breast edema and paracetamol medications to relieve pain.19 these medications have no adverse effects on the mother or the baby and do not impact milk production.20 however, non-pharmacological treatments such as warm or cold compresses and breast care procedures are also recommended, making medication unnecessary in some cases.21 various methods, including acupuncture, aloe vera, alternating hot and cold compresses, cold compresses, and ultrasound therapy, can be employed to alleviate breast engorgement.22 aloe vera, a member of the liliaceae family, has a unique gel that helps prevent skin from drying out and maintains its moisture.21,23 studies suggest that aloe vera’s ability to target harmful agents and injured tissue makes it an effective anti-inflammatory.24 acupuncture, aloe vera, alternating hot and cold compresses, cold compresses, and ultrasound therapy are among the methods to alleviate breast engorgement.21 traditional breast care methods also incorporate hot or cold compresses combined with massage. aloe vera, which originates from africa and belongs to the liliaceae family of plants, is unique for its gel that helps prevent skin from drying out, maintaining its moisture.25 the capacity of aloe vera gel to penetrate the skin and fortify it against excessive fluid loss has contributed to this characteristic.26 according to multiple studies, aloe vera’s potential to inhibit, neutralize, reduce, or cluster both harmful agents and damaged tissue renders it an effective anti-inflammatory.25 indicators of inflammation encompass edema, discomfort, redness, heat, and swelling. antipyretics are substances or medications that lower body temperature. aloe vera, functioning as an anti-inflammatory and herbal burn treatment, can reduce swelling and prevent edema by inhibiting the enzyme cyclooxygenase or the production of prostaglandin e2 (pge2) from arachidonic acid.27 pge2 substances, produced by macrophages, regulate various inflammatory responses and heighten pain thresholds. aloe vera extract also impedes neutrophil cell migration and inhibits the growth of streptococcus and shigella bacteria due to its antibacterial properties.25 aloe vera leaves contain two types of liquids. the first is a clear, jelly-like substance (mucus) that includes antibacterial and antifungal properties, as well as salicylates that can stimulate fibroblasts, which are skin cells that aid in wound healing. consequently, aloe vera is believed to have the ability to heal wounds, alleviate pain, and possess anti-swelling properties.28 aloe vera compresses have been proven to reduce pain in swollen body areas. the reduction in the breast swelling pain scale following the application of aloe vera compresses is attributed to the high content of amino acids, minerals, and polysaccharides in aloe vera leaves, which are believed to reduce breast swelling and alleviate inflammation-related pain. aloe vera compresses are effective in reducing breast discomfort when the breasts are full and swollen.29 this research aimed to demonstrate the effect of aloe vera gel compresses on breast engorgement among postpartum mothers. materials and methods the study population consisted of postpartum mothers in the samarinda region who visited the clinic and puskesmas. this study utilized a quasi-experimental research design. it employed a control group and a pretest-posttest methodology. non-probability sampling with consecutive sampling was used for participant selection. statistical analyses included the use of the paired t-test and independent t-test. respondents to this study were postpartum and lactating mothers who experienced breast milk swelling (primipara dan multipara). the sample comprised 30 respondents, with 15 mothers in the experimental group and the remaining 15 in the control group (table 1). inclusion criteria: having signs and symptoms of breast milk damage, willing to be a respondent. exclusion criteria: mother was allergic to aloe vera gel, receiving analgesics and lactation suppression, having mastitis, infection, and breast abscesses. the independent variable was aloe vera gel compress and the variables were engorgement and pain. over a period of three days, mothers’ breasts were compressed with 5 gram aloe vera gel that was bpom (agency for drug and food control) product twice a day for 10 minutes. the degree of breast pain was assessed using the bourbonnais pain scale evaluation checklist (breast pain score 1-10), and breast engorgement was measured using the hill and humenick sixpoint engorgement scale (breast engorgement score 1-6: 1. breast flabby, no consistency in the breast; 2. there is a slight breast change; 3. breast hard, but not painful; 4. firm breasts, starting to feel pain; 5.hard and painful breasts; 6. very firm and very painful.30,31 ethical clearance number dl.02.03/4.3/ 10433/2022 was obtained from poltekkes kemenkes kalimantan timur. respondents were provided with an explanation of how to complete informed consent forms, were informed about the study’s risks, and were given the right to withdraw without coercion. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results the average age of breastfeeding mothers who experienced breast engorgement in both the intervention (28.33±4.1) and control (29.27±3.9) groups fell within the category of a healthy reproductive age. specifically, the average age of the mothers in the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondents' characteristics based on age, parity, and postpartum days. characteristic groups p intervention n (%) control n (%) age/mean ±sd 28.33±4.1 29.27±3.9 0.49* 20-24 3 (20) 0 ( 0) 25-28 5 (33.3) 6 (40) 29-32 5 (33,3) 7 (46.7) 33-36 2 (13,3) 2 (13.3) parity primipara 9 (60) 11 (73.3) 0,32* multipara 6 (40) 4(26.7) days of postpartum 4.87±2.26 4 ±1.19 0.11* 1-3 days 4 (26.7) 6 (40) 4-6 days 8 (53.3) 8 (53.3) 7-14 days 3 (20) 1 (6.7) total 30 (100) 30 (100) *p>0.05. [healthcare in low-resource settings 2024;12:11788] [page 25] non -co mmerc ial us e o nly intervention group was 28 years, while in the control group, it was 29 years. the levene test results indicated a p>0.05, signifying that there were no significant age differences between the two groups. the majority of respondents in both the intervention and control groups experienced breast engorgement on days 3 and 4 following delivery. additionally, most respondents were primiparous, with 60% in the intervention group and 40% in the control group. the results of the homogeneity test for the two groups concerning characteristics like parity and the timing of breast milk dam occurrence yielded a p>0.05. this suggests that both groups exhibited homogeneous characteristics, indicating that the pre-existing characteristics of the respondents did not significantly affect the study’s outcomes. table 2 reveals that the variables for breast engorgement scores and pain levels, as well as the results of the normality test, all exhibit a p-value greater than 0.05. consequently, it can be concluded that the data in both groups adhere to a normal distribution. furthermore, based on the findings of the homogeneity test for the pretest, posttest, and pre-post difference values between the two groups concerning breast engorgement scores and pain scores, it can be inferred that the data from the two groups are homogeneous, indicating that the data have similar variances. according to table 3, it is evident that the breast engorgement score decreased from an average of 4.33 to 2 in the intervention group that received aloe vera gel compresses. similarly, the control group exhibited the same results, with the mean breast engorgement score dropping from 4.07 to 2.67 due to warm compresses. in the case of pain scores, the intervention group’s mean score difference decreased from 5.40 to 2.2. the control group experienced similar results, with the pain score decreasing from 5.73 to 4.07. the results revealed that the mean difference in breast engorgement scores was 2.33 in the intervention group and 1.40 in the control group. the independent t-test on breast engorgement scores yielded a p-value of 0.001 (p<0.05), indicating a statistically significant difference in mean breast engorgement scores between the intervention group, which received a combination of aloe vera gel compresses, and the control group, which received warm compresses. the most significant effect was observed in the intervention group when comparing the mean values (2.33>1.40). as for the mean difference in pain intensity, it was 3.2 in the intervention group and 1.67 in the control group. the independent t-test results showed a p-value of 0.000 (p<0.05), signifying a statistically significant difference in mean breast pain scores between the intervention group, treated with aloe vera gel compresses, and the control group, treated with warm compresses. the most pronounced effect was observed in the intervention group, as evidenced by the comparison of mean values (3.2>1.67; table 4). discussion the findings from this study revealed that the majority of mothers reported breast milk discharge on days 3 and 4 following delivery. this corresponds to the physiological increase in prolactin hormone production, typically occurring on the third-day post-labor. high prolactin levels stimulate significant breast milk production.32 however, at this stage, most infants are still in the sleep phase and may not be actively nursing due to their initial learning to suckle. hormonal factors and newborns’ suction abilities may influence the prevalence of breast engorgement.3 breastfeeding was a common practice among the ten respondents, with feeding intervals typically every one to two hours. the majority of research participants were between the ages of 25 and 32, considered a healthy reproductive window with ideal breast physiology and structure. it’s worth noting that anxiety levels may rise with age, which can impact pain perception.33 importantly, the study showed no significant difference in the ages of respondents between the intervention and control groups, ensuring that age does not impact the study’s outcomes.4 based on the survey’s findings, the majority of respondents were primiparous, with one child. some studies, such as arora’s, have found no correlation between parity and the prevalence of breast engorgement. however, other research suggests that primiparas might be more vulnerable to breast engorgement and pain due to their learning curve in establishing successful breastfeeding.12,13 the dynamics of breastfeeding and milk removal are closely connected. if the baby does not effectively nurse, the breast might not be emptied properly, potentially worsening milk stagnation. the frequency and duration of nursing sessions can also influence milk production, with fewer than eight nursing sessions per day or less than ten minutes per session leading to decreased milk production.15,17 the findings of the study on the average breast engorgement scores before and after the intervention demonstrate significant transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. normality test on breast engorgement score and pain intensity. dependent shapiro-wilk distribution of variabel of data intervention (p) control (p) engorgement pre 0.235* 0.278* normal post 0.293* 0.579* normal pain intensity pre 0.692* 0.536* normal post 0.149* 0.186* normal *p<0.05. table 3. difference in mean breast engorgement and pain score before and after intervention. variable and groups pre post p (n=15) mean±sd mean±sd the score of breast engorgement intervention 4.33±1.11 2±1.25 0.000* control 4.07±1.16 2.67±1.45 0.000* pain score intervention 5.40±1.35 2.2±1.37 0.000* control 5.73±1.43 4.07±1.43 0.000* *p<0.05. table 4. differences in the effect of aloe vera gel compress on breast engorgement and pain in the intervention and control groups. variable groups mean p breast engorgement intervention 2.33 0.001* control 1.40 pain intervention 3.20 0.000* control 1.67 *p<0.05. [page 26] [healthcare in low-resource settings 2024;12:11788] non -co mmerc ial us e o nly changes. this is consistent with lanka (2018) and nirala (2020), which supports the idea that aloe vera gel compresses can alleviate breast edema. aloe vera gel can effectively reduce breast edema.34,35 the mechanism behind aloe vera gel compresses may involve reducing intraductal pressure within alveoli, promoting vasoconstriction of swollen lymphatic blood vessels, which softens various breast segments. aloe vera contains anthraquinone compounds, such as aloin and emodin, which have analgesic properties. additionally, the presence of pain-relieving enzymes like carboxypeptidase and bradykinase contributes to aloe vera’s analgesic action. these properties lead to a reduction in pain-inducing prostaglandins and immune system stimulation, ultimately reducing pain.36,37 the control group’s results align with the research findings. the application of warm compresses has a positive effect on breast edema, as confirmed by lim’s research, demonstrating that warm compresses reduce swelling by enhancing lymphatic flow and reducing tissue tension.19 the study’s results regarding pain intensity show that there is a significant difference between the average pain intensity before and after the intervention. similar results were found in the control group. this is in line with sari’s research (2019), which indicates that aloe vera gel compresses significantly reduce breast swelling pain in breastfeeding mothers. compresses made from aloe vera have been shown to alleviate discomfort in swollen body parts. the high concentration of amino acids, minerals, and polysaccharides in aloe vera leaves is thought to be responsible for the reduction in breast swelling and pain.6,28 independent t-test results revealed a statistically significant difference between the control group, which received warm compresses, and the intervention group, which received aloe vera gel compresses, in terms of the mean breast engorgement score. the intervention group exhibited a more substantial effect compared to the control group, as evidenced by the comparison of mean values (2.33>1.40). additionally, the mean scores for breast pain showed a significant difference between the two groups. the intervention group experienced a more significant reduction in pain intensity compared to the control group, as indicated by the comparison of mean values (3.2>1.67). this is attributed to the unique properties of aloe vera gel, which accelerate the reduction of breast engorgement and pain associated with breast milk stagnation. the study’s findings are consistent with lanka (2018) and witt (2016), demonstrating the effectiveness of aloe vera gel compresses in reducing breast edema and pain scores in nursing mothers experiencing milk stagnation. aloe vera contains anthraquinones, including emodin and aloin, which have analgesic properties. the presence of pain-relieving enzymes like carboxypeptidase and bradykinase is linked to aloe vera’s analgesic action. this leads to a reduction in pain-inducing prostaglandins and immune system stimulation, contributing to pain relief.12,35 according to various studies on the anti-inflammatory properties of aloe vera, it has the ability to target and alleviate both harmful agents and damaged tissue.38 indicators of inflammation include edema, discomfort, redness, heat, and swelling.39 aloe vera, a natural anti-inflammatory and burn remedy, can reduce edema by inhibiting the enzyme cyclooxygenase or the production of prostaglandin e2 (pge2) from arachidonic acid. pge2 substances are prostaglandins produced by macrophages that influence various inflammatory responses and increase pain thresholds. aloe vera extract also inhibits neutrophil cell migration and possesses antibacterial properties, preventing the growth of shigella and streptococcus bacteria.40,41 conclusions the results of our investigation unequivocally demonstrate that employing aloe vera gel compresses yields a significantly positive effect in alleviating breast pain and engorgement. furthermore, this intervention proves effective in reducing the incidence of breast engorgement. the implications of these findings are of considerable value and relevance, as they can serve as a valuable adjunct to postpartum midwifery services, potentially enhancing the care provided to new mothers. references 1. pratiwi dn, ernawaty. implementation of an exclusive breastfeeding policy in wonogiri regency. indones j public heal 2023;18:21-33. 2. sebayang sk, dibley mj, astutik e, et al. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16:e12889. 3. alekseev np, vladimir ii, nadezhda te. pathological postpartum breast engorgement: prediction, prevention, and resolution. breastfeed med 2015;10:203-8. 4. seran ma, arief ys, kurnia id. the analysis of family support factors in exclusive breastfeeding based on precede proceed theory. int j pharm res 2020;12:1728-34. 5. radwan h. patterns and determinants of breastfeeding and complementary feeding practices of emirati mothers in the united arab emirates. bmc public health 2013;25:171. 6. cho j, ahn s. development and evaluation of breastfeeding promotion program for mothers with breast engorgement following cesarean birth. j korean acad nurs 2014;44:170-8. 7. yanti pd. hubungan pengetahuan, sikap ibu dengan bendungan asi di puskesmas sidomulyo pekanbaru tahun 2016. j endur 2017;2:81. 8. rutiani cea, fitriana la. gambaran bendungan asi pada ibu nifas dengan seksio sesarea berdasarkan karakteristik di rumah sakit sariningsih bandung. j pendidik keperawatan. 2016;2(2). 9. setiawan sa, rafikasari h. hubungan pengetahuan ibu nifas tentang perawatan payudara dengan kejadian bendungan asi di puskesmas ngrayun kecamatan ngrayun kabupaten ponorogo. j delima harapan 2017;4(2). 10. sriraman nk. the nuts and bolts of breastfeeding: anatomy and physiology of lactation. curr probl pediatr adolesc heal care 2017;47:305-10. 11. berens pd. breast pain: engorgement, nipple pain, and mastitis. clin obs gynecol 2015;58:902-14. 12. witt am, bolman m, kredit s, vanic a. therapeutic breast massage in lactation for the management of engorgement, plugged ducts, and mastitis. j hum lact 2016;32:123-31. 13. nisa f, devi sr. the influence of health education about the true position of breastfeeding for post partum mothers in the pepe village, indonesia. j publlic heal africa 2019;10:142-4. 14. gavhale pr, moon sh. to evaluate the effectiveness of lactational counseling on prevention of breast engorgement among postnatal mothers. j evol med dent sci 2021;10:663-6. 15. rollins nc, bhandari n, hajeebhoy n, set al. why invest, and what it will take to improve breastfeeding practices? 2016. 504 p. 16. coban a, bayraktar s, yildiz n, et al. a case study of early postpartum excessive breast engorgement: is it related to transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11788] [page 27] non -co mmerc ial us e o nly feedback inhibition of lactation? j hum lact 2020;37:414-8. 17. garcia lp. the lancet: série sobre amamentação. epidemiol e serviços saúde. 2016;25(1). 18. mogensen n, portman a, mitchell k. nonpharmacologic approaches to pain, engorgement, and plugging in lactation: applying physical therapy techniques from breast cancer care to breastfeeding patients. clin lact 2020;11(1). 19. zakarija-grkovic i, stewart f. treatments for breast engorgement during lactation. cochrane database syst rev. 2020;9:cd006946. 20. siregar e, hardjanti ts. non pharmacological treatments for breast engorgement: a systematic review. int conf appl sci heal 2019;4:492-502. 21. anggraini yd, rahmawati rsn, indriani r, sendra e. the effectiveness of herbal ingredients to relieve breast engorgement : literature review. j inov ris ilmu kesehat 2022;1(4). 22. gresh a, robinson k, thornton cp, plesko c. caring for women experiencing breast engorgement: a case report. j midwifery womens heal 2019;64:763-8. 23. umborowati ma, anggraeni s, prakoeswa crs. the beneficial effect of aloe vera in skin barrier function improvement: a double-blind randomized trial of madurese batik craftswomen. j pakistan assoc dermatologists 2022;32:142-7. 24. huda mh, chipojola r, lin ym, et al. the influence of breastfeeding educational interventions on breast engorgement and exclusive breastfeeding: a systematic review and meta-analysis. j hum lact 2022;38:156-70. 25. wizia, lady, susanti e. aloe vera gel compression as breast engorgement pain relief. women, midwives midwifery 2021;1(3). 26. maleki a, youseflu s. the effectiveness of aloe vera on relief of irritation and nipple pain in lactating women: systematic review and meta-analysis. obstet gynecol int 2022;2022:7430581. 27. niazi a, rahimi vb, askari n, et al. topical treatment for the prevention and relief of nipple fissure and pain in breastfeeding women: a systematic review. adv integr med 2021;8:31221. 28. bhattacharya m, malik s, singh a. aloe vera barbedensis: a review on its ethanopharmacological value. j pharm res 2011;4:4507-10. 29. rajeswari r, umadevi m, rahale cs, pushpa r, selvavenkadesh s, kumar kps, et al. aloe vera: the miracle plant its medicinal and traditional uses in india. j pharmacogn phytochem 2012;1(4). 30. bourbonnais f. pain assessment: development of a tool for the nurse and the patient. j adv nurs 1981;6:277-82. 31. hill pd, humenick ss. the occurence of breast engorgement. j hum lact 1994;10:79-86. 32. boskabadi h, ramazanzadeh m, zakerihamidi m, omran fr. risk factors of breast problems in mothers and its effects on newborns. iran red crescent med j 2014;16:e8582. 33. utami r, arief ys. the effectiveness of breastfeeding selfefficacy intervention on implementation of breastfeeding in low-birth-weight infants: a systematic review. j pak med assoc 2023;73:s153-7. 34. nirala rk, raj p, anjana k, et al. a review on aloe vera and its traditional uses in india. j pharmacogn phytochem 2020;9:2571-3. 35. lanka s. a review on aloe vera-the wonder medicinal plant. j drug deliv ther 2018;8(5). 36. verma sk. aloe vera their chemicals composition and applications: a review. int j biol med res 2011;2:466-71. 37. abdurrohman mms, putranto r, suhartono b, fa’adiyah da. the effect of giving aloe vera gel on rats with bacteriainduced periodontitis. odonto dent j 2021;8:140. 38. retnowati d, sari r, hendradi e, septiani s. the stability and irritability study of the chitosan-aloe vera spray gel as wound healing. j basic clin physiol pharmacol 2021;32:651-6. 39. solikhah ti, solikhah gp, susilo rjk. aloe vera and virgin coconut oil (vco) accelerate healing process in domestic cat (felis domesticus) suffering from scabies. iraqi j vet sci 2021;35:699-704. 40. aini an. pemberian kompres lidah buaya untuk mengurangi nyeri akibat pembengkakan payudara pada asuhan keperawatan ibu post. universitas muhammadiyah surakarta; 2019. 41. mwale m, masika pj. analgesic and anti-inflammatory activities of aloe ferox mill. aqueous extract. african j pharm pharmacol 2010;4:291-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 28] [healthcare in low-resource settings 2024;12:11788] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12097 embracing family presence: exploring the reasons for family decisionmaking dependence on in-hospital palliative care for cancer patients boby febri krisdianto,1 debie dahlia,2 agung waluyo2 1faculty of nursing, universitas andalas, padang; 2faculty of nursing, universitas indonesia, depok, indonesia abstract the implementation of home-based palliative care is widely recognized as a commendable and effective model of care provision. however, it is noteworthy that families residing in indonesia exhibit a propensity to predominantly seek palliative care services within hospital environments for their family members afflicted with palliative-stage cancer. therefore, the aim of this research was to investigate the perceptions of family members in their decision-making process regarding the care of palliative-stage cancer patients at home. this qualitative study employed a descriptive phenomenological approach. data were obtained through in-depth interviews with ten indonesian family members of palliative-stage cancer patients refusing discharge, and were analyzed using the colaizzi method. furthermore, the inclusion criteria were that the dominant family member who cares for the patient lives with the patient and is involved in the decision-making process. two themes emerged from this study: i) a lack of support in decision-making, and ii) pain and chronic sorrow. home-based palliative care for cancer patients presents significant decision-making challenges and persistent grief for families, necessitating robust support and education from healthcare professionals such as nurses and policymakers. additionally, a national health insurance system that enables effective palliative care is crucial. introduction cancer is a general term for a large group of diseases characterized by the overgrowth of abnormal cells that invade adjacent parts of the body and spread to other organs.1 cancer is the second leading cause of death in the world after cardiovascular disease.2 the incidence of cancer, in general, is higher in high-income countries.3 the global cancer burden has been a significant concern, with an increasing number of new cases and deaths projected annually. in 2019, it was estimated that 10 million people died due to cancer worldwide.4 based on statistics provided by the world health organization (who) (2022), roughly 10 million deaths, or nearly one in six deaths, will be caused by cancer in 2020, making it the top cause of death globally.5 in 2020, there were an estimated 19.3 million new cancer cases and almost 10.0 million cancer deaths worldwide.6 indonesia, being the fourth most populous country globally with a population of 270,203,917 as of 2021, faces a significant burden of disease, comprising the highest percentage in non-communicable (58%) ailments. among these, cancer stands out with an incidence rate of 14 cases per 1,000 individuals. alarmingly, the number of newly diagnosed cancer cases was projected to escalate to 19.3 million by 2020 in indonesia, resulting in approximately 10 million deaths directly attributed to cancer.2 cancer ranks as the second most prevalent cause of mortality among children aged 1 to 14 years.7 the etiology of cancer is still unknown, but according to ling et al. (2018), the cause of cancer is related to smoking, alcohol consumption, and viral infection (human papilloma virus). other cancer etiologies include accumulating genetic alterations, including mutations, amplifications, or dna deletions.8 the majority of cancer patients in indonesia typically seek healthcare services at an advanced stage of the disease.4 among several endeavors, correspondence: boby febri krisdianto, faculty of nursing, universitas andalas, depok, indonesia. e-mail: bobbyfk@nrs.unand.ac.id key words: palliative, decision making, family, cancer. contributions: bfk, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; dd, conceptualization, investigation, methodology, validation, review and editing; aw, supervision, and writing –review and editing; mu, resources, investigation, and writing –review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by a research grant from directorate of research and community engagement no.2017. ethics approval and consent to participate: the ethical approval for this research was granted by the ethical committee of the faculty of nursing at university of indonesia, under the reference number 99/un2.f12.d/hkp.02.04/2017. participation in this study was entirely voluntary, with all participants providing their informed consent. we ensured strict confidentiality throughout the research process, which included the anonymization of participant data. additionally, the authors declare no competing interests related to this study. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. akcnowledgements: the reseachers thank all participants and the nurses at our study setting for their invaluable contribution in this study. moreover, the researchers also show their gratitude to universitas andalas supporting to publish this study in scopus camp. received: 15 november 2023. accepted: 6 february 2024. early access: 1 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12097 doi:10.4081/hls.2024.12097 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12097] [page 431] non -co mmerc ial us e o nly chemotherapy is preferred as part of the primary cancer treatment to induce tumor cell death and reduce tumor mass. meanwhile, the main treatment for cancer metastasis also uses chemoagent-based therapy.9 the primary focus of caring for patients in advanced stages of cancer is to provide palliative care, and there is a growing consensus advocating for the delivery of palliative care in home settings.10 research findings suggest that home-based palliative care provides several benefits, including improved cost-effectiveness in healthcare, reduced risk of hospital-acquired infections, enhanced quality of life for patients, and increased convenience for both patients and their families.11 while there exists a preference among families of palliative cancer patients to administer care at home, the decision to transition patients from the hospital to home care presents considerable challenges.12 nurses play an instrumental role in assisting these families, offering vital information to facilitate informed decisions about the most appropriate care setting for palliative cancer patients.13 it is imperative to equip families with comprehensive information encompassing both the benefits and drawbacks of prolonged hospital stays.14 the choice by some families to forego home-based palliative care can adversely affect the patient’s quality of life. hospital policies, though not deliberately restrictive, may curtail the patients’ freedom and ability to spend valuable time with their loved ones.15 consequently, hospitalized palliative cancer patients often endure distress, loneliness, depression, and acute anxiety as they approach the end of their lives.16,17 furthermore, research indicates that nearly half of the families of hospitalized patients experience considerable distress during this period.17 hence, it is imperative for nurses to be adequately equipped with the knowledge and skills to guide families in making informed decisions about home-based palliative care.18 there is a scarcity of research exploring the perspectives of indonesian families of palliative cancer patients regarding their decision-making process for home-based care.19-22 this study aimed to fill this knowledge gap and develop effective interventions to assist families in making decisions about home-based palliative care. conducting this research is critical to enhancing our understanding and providing insightful guidance to support families in their decision-making processes. materials and methods research design in this qualitative study, we adopted a descriptive phenomenological approach grounded in van manen’s theory of lived experience, which emphasizes the exploration of personal experiences as central to comprehending the essence of human existence.23 this methodological approach facilitates an in-depth exploration of families’ perspectives and insights concerning their decision-making process in the context of home-based palliative care. utilizing this design allows for the extraction of valuable insights, thereby enriching our understanding of the familial decision-making dynamics in this specific healthcare setting. study participants this qualitative study comprised family members of palliative cancer patients who had been hospitalized in a national referral hospital and were directly involved in decision-making regarding home-based care. the participant group included both families who chose to continue hospital care and those who opted for homebased care. using purposive sampling, we selected ten individuals, all of whom had declined home-based palliative care for their gravely ill family members. detailed characteristics of these participants are provided in table 1. data collection we recruited ten family members who had refused home-based palliative care. the inclusion criteria specified that participants be immediate family members (such as parents, spouses, or children) who lived with and cared for a palliative cancer patient in a leading referral hospital in jakarta. hospital ward nurses assisted in initially identifying potential participants. these individuals were then contacted, informed in detail about the study, and their informed consent was obtained. the first author conducted in-depth interviews, each lasting about 60-70 minutes, at locations chosen by the participants, usually their homes. the interviews were audiorecorded, and data collection continued until saturation was achieved with the 10th participant. data analysis we utilized colaizzi’s phenomenological method to analyze the experiences of these families in making decisions about homebased palliative care. the analysis began with an extensive reading of interview transcripts to grasp the overall context and identify key statements. these statements were categorized and organized into themes, which were then elaborated and integrated to present a comprehensive view of the family decision-making process regarding home-based palliative cancer care. to validate our findings, we contacted participants by phone. study trustworthiness the study’s trustworthiness was assured through considerations of credibility, transferability, confirmability, and dependability. the first author, primarily responsible for data analysis, collaborated with the second and third authors both seasoned in qualitative research for a thorough review process. rigor to ensure the study’s rigor, we focused on credibility, transferability, and confirmability. credibility was established through meticulous peer debriefing and detailed review by the corresponding author of the transcripts, subthemes, themes, and findings. while direct member-checking with participants was not performed, two research team members with oncology nursing expertise, less involved in data analysis, validated the themes and subthemes as accurately representing the data. concerns regarding trustworthiness due to translation (the analysis was conducted in bahasa and presented in english) were addressed through a meticulous forward-backward translation process by an external translator. this ensured accurate translation of themes, subthemes, categories, and quotes into english. transferability was enhanced by including rich, detailed descriptions, offering a deep understanding of the study’s context. confirmability was maintained through the authors’ commitment to reflective honesty. additionally, all authors had training in qualitative research methods, further reinforcing the study’s confirmability. ethical clearance the ethical approval for this research was granted by the ethical committee of the faculty of nursing at universitas indonesia, under the reference number 99/un2.f12.d/hkp.02.04/2017. participation in this study was entirely voluntary, with all participants providing their informed transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 432] [healthcare in low-resource settings 2024;12:12097] non -co mmerc ial us e o nly consent. we ensured strict confidentiality throughout the research process, which included the anonymization of participant data. additionally, the authors declare no competing interests related to this study. results demographic characteristics of participants table 1 presents the demographic characteristics of the study participants. among the 10 patient participants, the majority were female (60%), over 40 years of age (50%), college graduates (60%), daughters of the patients (40%), and housewives (40%). although most patients had been diagnosed with cancer two years ago, the majority of them had advanced stage iv cancer (70%). themes the data analysis revealed the following themes (table 2). lack of support of family in the decision making the data analysis identified a primary theme: the lack of family support in decision-making regarding home-based palliative cancer care. participants commonly expressed feeling unsupported in deciding to care for palliative cancer patients at home. this lack of support manifested in several dimensions. firstly, a significant number of participants disclosed a lack of understanding regarding the palliative condition and goals of care. this gap in knowledge largely stemmed from insufficient communication from healthcare providers, with many families unaware of these critical aspects until participating in this study. such a lack of information led to confusion in both decision-making and subsequent patient care at home. participants reported that healthcare professionals had not adequately explained the palliative diagnosis and its home management, leaving them ill-prepared for potential worst-case scenarios. the families often found themselves receiving only basic information about patient care at home, and this typically occurred just before the patient’s discharge. for instance, participant 2 highlighted the absence of preparatory information prior to discharge: “we expected some information to prepare us to take care of mother before she got discharged, so we knew what to do at home, whether we needed follow-up visits to the hospital clinic or not. such information should have been provided by the nurse. they should not have just sent the patient home like that. that’s all i expected” (p2) this sentiment was echoed by participant 3, who encountered the concept of palliative care for the first time during the study: “when i received the initial call from you, that’s when i received information about it. you explained to me what palliative care entailed. that was the first time i became aware of such a service. prior to that, it was completely unfamiliar to us, and, of course, i really wanted my mother to recover as before” (p3) these expressions represent the overarching theme of inadequate support in the decision-making process for home-based care versus hospitalization. furthermore, families expressed a desire for more active support from physicians in making these decisions. they anticipated more frequent home visits from doctors and a continuous supply of medications for the patient. another salient issue was the lack of resources to support home-based care. families yearned for better access to appropriate facilities and resources to adequately care for palliative cancer patients at home. this need for a more robust support infrastructure is illustrated by participant 1’s experience: “in an unexpected turn of events, my father experienced a significant complaint, and we rushed him to the hospital. however, the process of seeking medical attention was protracted. upon our arrival at the hospital, they had to conduct the analysis again, a time-consuming process. if my father had already been admitted to the hospital, the entire process would have been much quicker and more streamlined” (p1) these findings underscore the crucial need for enhanced support and resources for families making decisions about homebased palliative care. discussion in this qualitative research grounded in phenomenology, the discussion is organized around two central themes informed by van manen’s lived experience theory. the first theme, “lack of support in decision-making,” delves into the pivotal role of family readiness and capability in the decision-making processes related to home-based palliative care, as underscored by previous research.24-26 the complexities in these decisions arise from healthcare providers’ assessment of whether family caregivers are sufficiently prepared for the responsibilities of such care. studies from the uk and australia27 highlight that not all palliative cancer patients are candidates for home treatment due to challenges in managing pain and symptoms, the need for continuous care, and progressive patient deterioration, often necessitating hospitalization. family preferences, limited access to palliative care services, and the family’s inability to provide sufficient home-based care significantly influence these decisions. in indonesia, the accessibility of palliative care services is a major hurdle.28 with over half of its 265 million population residing in rural areas, accessible care is a pressing concern.6 palliative care is mainly available in urban centers, and despite its introduction as a national program in 1989, access remains limited.27 currently, only ten government-designated hospitals across seven cities provide such care, a stark contrast to indonesia’s vast archipelago of over 17,000 islands.28,29 this study’s participants, nine out of ten, voiced a need for more accessible palliative cancer care. the study further reveals that families often opt for hospital care due to their lack of ability and proficiency in managing palliative cancer patients at home. concerns regarding inadequate homebased treatment and its inability to address cancer-related physical symptoms and side effects were common. caregivers who found themselves unable to provide home care experienced significant stress, impacting their well-being.30 a considerable proportion of participants (six out of ten) admitted their incapacity to care for palliative cancer patients at home, advocating for comprehensive hospital care.28 the challenges faced by palliative cancer patients in indonesia include inadequate facilities, scarcity of skilled healthcare professionals, and limited access to palliative care services, especially for homebased care. the introduction of universal health coverage in indonesia in 2014 by the healthcare and social security agency (bpjs)2,31 has influenced patient care decisions. five study participants cited their reliance on hospital care due to the comprehensive services covered by bpjs insurance. however, this reliance might strain the healthcare system’s efficiency. in contrast, systems like medicaid in the united states have shown cost savings by prioritizing home-based care.12 cultural factors also play a significant role in decision-making processes. most study participants entrusted decision-making to transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12097] [page 433] non -co mmerc ial us e o nly extended family members, a practice rooted in cultural norms and the value placed on familial bonds and communication. this aligns with other studies28,32 highlighting the active involvement of families in patient care and decision-making within indonesian hospitals. additionally, the study uncovers the varied decision-making patterns across indonesian ethnic communities. while most communities follow a patriarchal system some, like the minang tribe, adhere to a matrilineal pattern. cultural values heavily influence perceptions and behaviors in areas like family care.33 similarly, the ethnic lampung, indonesia community reflects cultural diversity, comprising various ethnic groups, each upholding distinct cultural values that inform perceptions, attitudes, and behaviors in daily life, both individually and collectively. notably, lampung women exhibit profound respect towards men, often refraining from contradicting their husbands’ words and diligently attending to childcare and household chores. fear of being perceived as disobedient if they deviate from their husbands’ instructions is deeply ingrained within these women. in the public sphere, decision-making is predominantly dominated by men, and women seldom participate in public affairs. this observation is a consequence of the interplay between the kinship system and the prevalence of patriarchal ideology within lampung society.29 the second theme, “pain and chronic sorrow,” delves into the profound and enduring hardships faced by families providing home-based palliative care. chronic pain presents a formidable challenge, encompassing not only the fear of potential complications or emergencies that may arise without immediate professional help but also the relentless impact on daily life. participants reported unpreparedness and negative emotional responses when faced with the prospect of home care, highlighting the necessity of adequate discharge planning and preparation. another study11 indicates that the main causes of family unreadiness for home-based care include difficulties in hospital readmission for patients in deteriorating conditions, exhaustion from providing daily care at home, and concerns about the well-being of other family members, particularly children, as the majority of energy is directed towards the severely ill patient. additionally, caregiver burden within the family is identified as a major reason why families are reluctant to provide care at home.34 according to a study,35 when families are unprepared to serve as caregivers, they may experience fear and a sense of incompetence in providing palliative care for cancer patients at home. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 434] [healthcare in low-resource settings 2024;12:12097] table 1. demographic characteristics of the participants. participant gender age length of education relation occupation patient’s diagnosis (years time to patient old suffering cancer p1 female 36 1 year university daughter housewife stage iv liver cancer p2 male 30 2 year university son college student stage iv skin cancer p3 female 42 2 year high school daughter housewife stage iv breast cancer p4 male 54 1 year primary school husband cleaner stage iv breast cancer p5 female 32 2 year university daughter employee stage iv lung cancer p6 male 46 2 year university husband online driver stage iv breast cancer p7 female 57 1 year primary school wife housewife sol (space of lesion) stage iii p8 male 25 2 tahun university son it operator pancreatic cancer stage iii p9 female 48 1 tahun high school wife housewife bone cancer stage iii p10 female 25 2 tahun university daughter voluntary worker stage iv lung cancer table 2. (sub)themes emerging from the analyzes regarding family perceived in depending on a caring patient with palliative cancer in a hospital. no themes sub-themes elements 1 lack of support in the decision-making lack of understanding in the palliative condition limited time provide information earlier lack of understanding in the goal of care forming unreadiness for the worst misinterpretation of the purpose of palliative care lack of knowledge of caring patient in home lack of skills need for ongoing education and support inadequate communication lack of resources to support home-based care health facilitation opioid needs for patient 2 pain and chronic sorrow chronic pain fear of potential complications or emergencies impact on daily life long-term pain difficulty in managing chronic sorrow risks or uncertainties emotional distress and sadness non -co mmerc ial us e o nly additionally, another study36 suggests that a family’s lack of readiness can lead to negative emotions and attitudes towards homebased palliative care, resulting in resistance to bringing the patient home. families who are unprepared and still choose home treatment are at a higher risk of experiencing traumatic situations during the care process. some families may make uninformed decisions about home-based palliative care without fully understanding the implications involved. however, the findings of this study shed light on the fact that several families exhibited reluctance to have their severely ill family members discharged from the hospital. this resistance stemmed from their significant reliance on the hospital, as they perceived it to possess the capability to cure their loved ones’ illnesses. this aligns with the research,34 which elucidated that the primary reason for patients and families heavily depending on hospital care, even in cases where palliative care had been recommended for terminal patients, was the family’s inability to cope with the patient’s complaints and distress at home due to the debilitating nature of their condition. consequently, when health insurance coverage is available to facilitate the ongoing treatment of sick family members in the hospital until recovery, families or caregivers tend to develop a dependency on these health insurance facilities in indonesia (bpjs), which only cover caring for patients in the hospital, not in patients’ houses. the findings of this study emphasize the importance of providing early education and discharge planning to the families of palliative cancer patients, as stated by six out of ten participants. early education plays a crucial role in decision-making and preparation for home-based patient care.37 one participant mentioned that education and discharge planning should ideally occur at least two weeks prior to discharge. insufficient time for preparation and a lack of resources at home were identified as major concerns influencing the family’s decision to opt for home-based palliative cancer care. it is essential to provide early education and discharge planning to both patients and their families. involving patients in decision-making and treatment planning has positive effects on their well-being, aligning with the concept of a peaceful end of life where dignity and respect are attained through the active involvement of patients and families in decision-making processes.16,17,35 in developed countries, the challenge of limited access to palliative care at home for families is effectively addressed through the establishment of specialist palliative care (spc) services, which are strongly supported by the world health organization. spc consists of a multidisciplinary team of healthcare providers, including physicians, experienced nurses, psychologists, and social workers, who work both within hospitals as a consulting team and in the community to deliver home care, nursing home support, and hospice services.36 the implementation of spc in the united states over the past decade has led to a significant increase in the demand for palliative care, with a fivefold rise from 15% to 75%. as a result, families are more inclined to choose home-based palliative care instead of prolonged hospitalization, and spc plays a pivotal role in facilitating such decision-making processes. the primary focus of spc is to enhance the quality of life for patients, with a particular emphasis on alleviating pain in individuals with life-threatening cancer.38,39 spc starts working early, as a patient is admitted to the hospital. cancer patients with palliative conditions will be referred to the spc. spc will carry out discussions with the family about the palliative treatment plan. following the patient’s readiness and autonomy, palliative cancer patient care will be moved from the hospital to the community, as chosen by the patients. spc has shown impacts on improving the patient’s quality of life, reducing the stress of the patient and family, lowering aggressive medical treatment, and hence hospital costs, and even increasing patient life expectancy.40 the united kingdom (uk) serves as a successful example of the well-developed specialist palliative care (spc) system that has significantly improved access to high-quality palliative care services. by 2005, the uk had established 361 hospitals offering spc, along with 277 community palliative care nurses. additionally, they implemented 263 hospice day care units and provided 24-hour hospice home care for cancer patients. the uk’s national health service (nhs) plays a crucial role in policy-making, coordination, and providing opioids for palliative cancer patients. furthermore, the nhs subsidizes 32% of the operational costs for palliative care provided by private healthcare providers.41 these services demonstrate the effectiveness of early involvement in palliative care planning and the benefits of home-based care options. the indonesian government has the opportunity to learn from and adopt the integrated palliative care service model implemented in developed countries. by implementing integrated palliative care, the identified issues highlighted in this study can be effectively addressed. it is crucial to ensure access to opioid medications for palliative cancer patients. within the integrated palliative care system, nurses play a vital role as coordinators of services such as home care, nursing home, and hospice, involving a multidisciplinary team of healthcare providers including physicians, pharmacists, mental health workers, and therapists. one important aspect that nurses must assess is the family’s capacity and preparedness to provide daily palliative care at home.42 however, the national healthcare insurance (bpjs) does not currently cover home care or visits, an area ripe for improvement.34 finally, the study resonates with findings25 on the psychological and social impact of cancer diagnoses, emphasizing the need for holistic care that addresses not only the physical but also emotional and social needs of patients and their families. the psychological burden, in turn, influenced various aspects of patients’ social lives. the participants’ expressions regarding the second theme are consistent with the observations of others,43 who emphasized that rapid changes occur in patients with chronic diseases, including cancer, which subsequently impact their social dynamics. this study is subject to several limitations. firstly, participant recruitment was confined to three cancer hospitals in jakarta, indonesia. while the research methodology was thorough and well-documented, the extent to which these findings can be extrapolated to the broader indonesian context remains uncertain. additionally, the absence of internal mentors in the participant pool is notable; their inclusion might have offered diverse insights into the subject matter. future research should, therefore, consider broadening the participant base to enhance the robustness and applicability of the findings. lastly, it is important to acknowledge that during the data collection phase, some of the interviewers had professional relationships with a few of the participants. this could potentially have influenced the communication dynamics and affected the interpretation of the data. conclusions the experience of family decision-making for home-based palliative cancer care can be described in two themes: i) lack of support in decision-making, and ii) pain and chronic sorrow. the decision-making process regarding palliative care is a significant and meaningful experience for the family members involved, particu transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12097] [page 435] non -co mmerc ial us e o nly larly when caring for patients with palliative cancer towards the end of life. to facilitate effective decision-making and the provision of care at home, families need comprehensive support from both healthcare professionals and government policymakers. it is imperative to deliver early education and detailed information to empower families, enabling them to make well-informed choices and adequately prepare for the complexities of home-based palliative care. moreover, the indonesian national health insurance system must be structured to offer inclusive support for home-based palliative cancer care, with a focus on optimizing the efficiency and effectiveness of care for patients requiring such services. references 1. feriani p, yunitasari e, efendi f, et al. cancer risk factors associated with historical contraceptive use and breastfeeding duration. healthc low-resource settings 2023;11:11812. 2. who. world health statistics. 2020. available from: https://www.who.int/publications/i/item/9789240005105 3. ansar a, lewis v, mcdonald cf, et al. factors influencing the timeliness of care for patients with lung cancer in bangladesh. bmc health serv res 2023;23:261. 4. cunha ar da, compton k, xu r, et al. the global, regional, and national burden of adult lip, oral, and pharyngeal cancer in 204 countries and territories: a systematic analysis for the global burden of disease study 2019. jama oncol 2023;9:1401-16. 5. mohamad razif mi, nizar n, zainal abidin nh, et al. emergence of mrna vaccines in the management of cancer. expert rev vaccines 2023;22:629-42. . sung h, ferlay j, siegel rl, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin 2021;71:209-49. 7. hasanah i, nursalam n, krisnana i, et al. psychoneuroimmunological markers of psychological intervention in pediatric cancer: a systematic review and new integrative model. asian nurs res (korean soc nurs sci) 2023;17:119-37. 8. budhy ti, naori p, ridhatillah d, et al. the potency of chitosan-based moringa oleifera leaves extract nanoparticles as anti-cancer agent. res j pharm technol 2023;16:35-40. 9. dewi frp, wahyuningsih spa, sari apm, et al. annonacin and squamocin conjugation with nanodiamond alters metastatic marker expression in breast cancer cell line. hayati j biosci 2024;31:211-20. 10. ahlner-elmqvist m, jordhøy ms, jannert m, et al. place of death: hospital-based advanced home care versus conventional care. palliat med 2004;18:585-93. 11. roberts b, robertson m, ojukwu ei, wu ds. home based palliative care: known benefits and future directions. curr geriatr reports 2021;10:141-7. 12. yamagishi a, morita t, kawagoe s, et al. talking about home hospices with terminally ill cancer patients a multicenter survey of bereaved families. gan to kagaku ryoho 2015;42:32733. 13. lee sf, kristjanson lj, williams am. professional relationships in palliative care decision making. support care cancer 2009;17:445-50. 14. onishi e, nakagawa s, uemura t, et al. physicians’ perceptions and suggestions for the adaptation of a us-based serious illness communication training in a non-us culture: a qualitative study. j pain symptom manage 2021;62:400-9.e3. 15. cardenas v, rahman a, zhu y, enguidanos s. reluctance to accept palliative care and recommendations for improvement: findings from semi-structured interviews with patients and caregivers. am j hosp palliat care 2022;39:189-95. 16. cherny n, fallon m, kaasa s, et al. oxford textbook of palliative medicine. oxford university press; oxford, uk; 2015. 17. gomes b, calanzani n, curiale v, et al. effectiveness and cost-effectiveness of home palliative care services for adults with advanced illness and their caregivers. cochrane database syst rev 2013;2013. 18. krisdiyanto bf, dahlia d, waluyo a. on home-based care decision making: the will of the family of palliative cancer patients. enferm clin 2019;29:111-6. 19. kristanti ms, kusmaryanto, effendy c. common ethical dilemmas of family caregivers of palliative patients in indonesia. belitung nurs j 2021;7:246. 20. abdullah mb, huriah t, arianti a, sarkasi rb. nurse’s roles in patient-family decision making for palliative patients in indonesia and malaysia. open access maced j med sci 2021;9:6-17. 21. widjaja ss, rusdiana r, jayalie vf, amelia r. what contributes to palliative care practice in cancer patients in indonesia. med arch 2022;76:464. 22. putranto r, mudjaddid e, shatri h, et al. development and challenges of palliative care in indonesia: role of psychosomatic medicine. biopsychosoc med 2017;11:1-5. 23. van manen m, higgins i, van der riet p. a conversation with max van manen on phenomenology in its original sense. nurs health sci 2016;18:4-7. 24. bastawrous m. caregiver burden—a critical discussion. int j nurs stud 2013;50:431-41. 25. damanhuri g. what factors influence the terminally ill patient referred to the hospital specialist palliative care team in a nhs hospital, not achieving their preferred place of death? a critical evaluation. bmj support palliat care 2014;4:a54-55. 26. azza a, susilo c, efendi f. supportive group therapy as a prediction of psychological adaptation of breast cancer patients undergoing chemotherapy. indian j public heal res dev 2018;9:441-5. 27. effendy c, vissers k, tejawinata s, et al. dealing with symptoms and issues of hospitalized patients with cancer in indonesia: the role of families, nurses, and physicians. pain pract 2015;15:441-6. 28. rochmawati e, wiechula r, cameron k. current status of palliative care services in indonesia: a literature review. int nurs rev 2016;63:180-90. 29. ferrell br, borneman t. community implementation of home care palliative care education. cancer pract 2002;10:20-7. 30. indonesia basic health research 2018. available from: https://ghdx.healthdata.org/record/indonesia-basic-healthresearch-2018 31. kristanti ms, setiyarini s, effendy c. enhancing the quality of life for palliative care cancer patients in indonesia through family caregivers: a pilot study of basic skills training. bmc palliat care 2017;16. 32. bisset m. palliative care nursing: principles and evidence for practice. br j cancer 2005;92:794-5. 33. woodman c, baillie j, sivell s. relatives’ preferred place of care at the end-of-life: implications for palliative care in the future. bmj support palliat care 2015;5:116-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 436] [healthcare in low-resource settings 2024;12:12097] non -co mmerc ial us e o nly 34. fiona w, oloruntobi r, roberto lc, tarannum r. the feasibility and effects of a telehealth-delivered home-based prehabilitation program for cancer patients during the pandemic. curr oncol 2021;28:2248-59. 35. fouquet c, brédart a, bouleuc c. [coping among patients with advanced cancer and medical communication]. bull cancer 2013;100:887-95. 36. shalev a, phongtankuel v, kozlov e, et al. awareness and misperceptions of hospice and palliative care: a populationbased survey study. am j hosp palliat care 2018;35:431-9. 37. nihayati he, nurhanifah l, krisnana i. the effect of psychoeducation on self-efficacy and motivation for taking treatment in breast cancer patients (ca mammae). j ners 2021;16:96100. 38. smith tj, temin s, alesi er, et al. american society of clinical oncology provisional clinical opinion: the integration of palliative care into standard oncology care. j clin oncol 2012;30:880-7. 39. brazil k, bainbridge d, rodriguez c. the stress process in palliative cancer care: a qualitative study on informal caregiving and its implication for the delivery of care. am j hosp palliat care 2010;27:111-6. 40. soosaipillai g, wu a, dettorre gm, et al. specialist palliative and end-of-life care for patients with cancer and sars-cov-2 infection: a european perspective. ther adv med oncol 2021;13. 41. murtagh fem, bausewein c, verne j, et al. how many people need palliative care? a study developing and comparing methods for population-based estimates. palliat med 2014;28:4958. 42. natalucci v, marini cf, flori m, et al. effects of a home-based lifestyle intervention program on cardiometabolic health in breast cancer survivors during the covid-19 lockdown. j clin med 2021;10. 43. rochmawati e, wiechula r, cameron k. centrality of spirituality/religion in the culture of palliative care service in indonesia: an ethnographic study. nurs health sci 2018;20:231-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12097] [page 437] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11164 profil of omega-3 food intake and its association with socioeconomic status in smoker on online motorcycle drivers amelia lorensia,1 rivan virlando suryadinata2 1department of clinical pharmacy-community, faculty of pharmacy, universitas surabaya, jl. raya kalirungkut, surabaya, indonesia; 2department of public health, faculty of medicine, universitas surabaya, jl. raya kalirungkut, surabaya, surabaya, indonesia abstract introduction: omega-3 fatty acids were found to be effective in reducing inflammation and free radicals caused by air pollution (cigarette smoke), as well as improving lung function. furthermore, economic conditions can influence a person’s food consumption habits. the type of food consumed will certainly affect the amount of omega-3 absorbed by the body, and the quality of food consumed is influenced by socioeconomic status (ses). therefore, the purpose of this study was to determine omega-3 intake and its relationship with the socioeconomic status of online motorcycle drivers. design and methods: this was an observational study with a cross-sectional method of measuring omega-3 consumption using a 24-hour food recall questionnaire and assessing the mean of omega-3 intake after 3 days. the was conducted from mayaugust 2020, in kali rungkut, surabaya city, and the subjects were online motorcycle drivers. a chi-square test was used to assess the relationship between omega-3 intake and ses (income and education). results: there were 49 respondents in this study with most of them having a classification of omega-3 intake at the deficit level (57.14%), and none belonging to the good and more level. there was a significant difference in omega-3 intake on income (p=0.000) and education (p=0.000). conclusions: income and education must be prioritized to improve a healthy diet that includes omega-3. introduction despite the long distance, the community’s high mobility necessitates quick movement from one location to another.1 the existence of online motorcycle drivers is one of the newest transportation media that overcomes congestion. it is an online application-based transportation development supported by communication technology through smartphones, motorcycle services, and communication technology.2 the high risk of online motorcycle drivers being exposed to vehicle air pollution increases the prevalence of chronic lung diseases and this is supported by smoking habits. previous studies show that smoking is significantly associated with the incidence of copd (chronic obstructive pulmonary disease).3 therefore, smokers have greater respiratory problems and are less physically active than non-smokers.4 smoking is a problem because it causes numerous losses in terms of social, moral, economic, health, death, and a decrease in human resources.5 tobacco content in cigarettes can affect almost all organs of the human body. hence, smoking is linked to a variety of non-communicable diseases such as cancer, heart disease, chronic respiratory disease, and diabetes. in indonesia, smoking is responsible for a high proportion of morbidity and mortality. furthermore, the percentage of indonesian men who smoke has dramatically increased from 56.2% in 2000 to 76.2% in 2015.6 another effect is the loss of human resources as a result of smoking-related morbidity and mortality.7 this contributes to poverty by diverting household spending away from basic needs such as food and shelter to cigarettes. since the tobacco in cigarettes is very addictive, this behavior is difficult to overcome. additionally, the economic costs of smoking are high because of the healthcare costs associated with smoking-related diseases.8,9 attempts to quit smoking often experience obstacles, such as low self-confidence and selfesteem among smokers, and depression is a significant factor in smoking cessation failure. there are several drug therapies for smoking cessation, such as nicotine replacement therapy which is the first line of smoking cessation treatment that should be used with caution in patients with arrhythmias and myocardial infarction. nicotine can cause adverse cardiovascular effects by increasing myocardial workload through increased heart rate and blood pressure. it can also cause coronary artery constriction, resulting in cardiac ischemia.10,11,12 nutrients, which are included in the covid-19 prevention treatment, are particularly effective in maintaining health and improving lung function.13 omega-3 is effective in reducing inflammation and free radicals caused by air pollution and cigarette smoke and improves lung function.14,15 therefore, a person’s food intake can affect the health of the lung function,16 and article significance for public health due to continuous exposure to pollution, online motorcycle drivers, including 49 respondents, are at a high risk of chronic lung function decline. the health of lung function can be affected by the dietary intake of omega-3, while the quality of food can affect the amount of omega-3 in the body. therefore, this study examines the relationship between socioeconomic status and omega-3 in 49 online motorcycle drivers' diets. [healthcare in low-resource settings 2023; 11(s1):1164] [page 7] non -co mmerc ial us e o nly amount of omega-3 in the body. by causing oxidative stress, cigarette smoke can enhance pufa (polyunsaturated fatty acid) lipid peroxidation. low pufa concentrations will in turn affect neurotransmission in the central nervous system, such as dopaminergic increases nicotine addiction, thereby inhibiting efforts to quit smoking.17,18 according to lower levels of dha (docosahexaenoic acid) and epa (eicosapentaenoic acid), smokers consume less fish rich in omega-3 fatty acids than non-smokers. the importance of omega3 intake is that it can normalize the dopaminergic system and reduce addiction, hence reducing the desire to smoke significantly. the anti-inflammatory effect of omega-3 is due to the content of epa which is a competitive substrate with arachidonic. therefore, it has the potential to reduce inflammation and bronchoconstriction in the respiratory tract. these anti-inflammatory effects can aid improve lung function and influence smoking patterns.18 cigarettes contain high concentrations of free radicals and oxidants which cause systemic oxidative stress and lipid peroxidation, hence affecting the levels of omega-3 pufas, specifically epa and dha. according to the theory, cigarette smoke induces oxidative stress by peroxidation of polyunsaturated fatty acids which lowers the levels of omega-3. hence, it can affect nerve transmission and cause hypofunction in the mesocortical system associated with the dependence mechanism, and increased desire to smoke. omega-3 deficiency, particularly epa and dha, has also been associated with poor psychological health and the inability to cope with stress.19,20 the effectiveness data of omega-3 fish oil revealed a relationship between illness perception and chronic respiratory disease. although the influence of illness perception was significant, the length of time that respiratory symptoms were experienced was not.21 epidemiological studies reveal that omega 3 has a protective effect against cardiovascular disease, myocardial or cerebral infarction, hypertension, and hyperlipidemia. additionally, it is beneficial against chronic inflammatory diseases including copd, asthma, rheumatoid arthritis, and inflammation of the gut.14,22,23 higher omega-3 intake and fish consumption are associated with better lung function in smokers and ex-smokers, with epa and dha acting as antioxidants and reducing oxidative stress.17,18 epidemiological studies reveal that epa and dha are the main omega-3 pufas found in fish, fish oil, and fish oil supplements. furthermore, omega-3 are easily obtained from foods such as salmon, sardines, seafood, and others.20,24,25 according to the recommended nutritional adequacy rate for indonesians, the nutritional adequacy rate for omega-3 is 1.6 g/day for men 18 years.26 given the beneficial cardiovascular effects of omega-3s, it is important to understand the sociocultural factors that influence adequate intake to improve dietary quality in minorities.27 according to the results of omega-3 intake, all respondents consumed less omega-3 containing foods (<1,600 mg), with the average total intake of foods containing omega-3 being 226.47 mg. the most consumed omega-3s were eggs (average: 19.46 mg/day) and chicken (average: 10.74 mg/day), both of which contain low omega-3. meanwhile, based on data collection per day using the 24-hour food recall, the average daily consumption of respondents was only 249.05 mg. therefore, further analysis of the processing pattern of the food consumed and the factors that influence their diet is neccessary.26 omega-3 cannot only be obtained by taking supplements, but also from the foods we consume on the daily basis. 21 economic circumstances can have an impact on a person’s food consumption habits and the type of food consumed will certainly affect the omega-3 content absorbed by the body.28 also, the quality of food consumed is influenced by socioeconomic status (ses). several studies linked an individual’s socioeconomic status to health, with positive associations of ses (income, education, occupation), fruit, vegetable intake, and nutrition,28,29 but negative associations with chronic disease.30 for example, income, and educational attainment are recognized as fundamental factors influencing heart disease rates in minority and low-income populations.31 a 24-hour food recall can be used to determine the pattern of omega-3 intake.32,33 using this method, individuals are asked to describe the food and drinks consumed for three days. the 24-hour food recall method gathers information about the food consumed at a certain time. in addition, this can be performed at all survey locations such as the community, and hospitals or installations by housewives. the data obtained is in the form of protein intake, carbohydrates, sugar, water, salt, and calcium in calorie units.34,35 therefore, this study aims to determine omega-3 intake and its relationship to the socioeconomic status of online motorcycle drivers. design and methods a retrospective cohort study was used as its design, and the measurement of omega-3 intake was performed using a 24-hour food recall. the subjects were online motorcycle drivers and this was performed in kali rungkut, surabaya city from may to august 2020. furthermore, ethical permission was received from the university of surabaya ethics committee number 016ol/ke.vii/2020. the independent variables were omega-3 food intake and socioeconomic status. this was all performed around the rungkut area in surabaya, east java, indonesia, which was conducted from may to august 2020. online motorcycle drivers provided public transportation in the form of motorcycles that could be ordered over the internet or through mobile phone applications. they not only deliver and pick up customers but also foods and goods. the 24-hour food recall method was used and interviews were conducted with the help of a food photo book to aid in the estimation of the household size. an analysis of the adequacy of values for adults was performed in the rungkut area, surabaya city on online motorcycle drivers. subsequently, the value was adjusted to the nutrition adequacy rate (rda),34,35 which was 75 g protein/day while omega-3 was 1600 mg/day.21 the participants were online motorcycle drivers in the surabaya city area. therefore, the target population that met the inclusion criteria were: i) aged 18 years; ii) an active smoker smoking 100 cigarettes in his life until now, or respondents smoking 1 cigarette/day; iii) worked on weekdays regularly (min ±7 hours/day); iv) having no eating disorders and gastrointestinal diseases such as gastroesophageal reflux disease (gerd), gastritis and dyspepsia. the purposive sampling technique was used, while the 24-hour recall method was an interview guide measuring food consumption in the preparation of interview questions. this method was performed three times but was not successive, namely twice on workdays and once on holidays, because the scheme could illustrate the variability of calorie and nutrient intake. respondents were interviewed about food and drinks consumed in the past 24-hours, including portion sizes with the help of a photograph of household sizes, such as a spoon, plate, glass, or another size commonly used daily as stated in food photo book by the ministry of health of the republic of indonesia in 2014.36 then, the results were synchronized to the average intake per day. primary data was obtained directly from study subjects through direct dialogue (interviews) and presented descriptively. the classification of omega-3 intake was divided into 5, namely: deficit article [page 8] [healthcare in low-resource settings 2023; 11(s1):11164] non -co mmerc ial us e o nly (<70% of the value of the minimum measure of intake); less (7080% of the value of a minimum measure of intake); sufficient (80100% of the value of a minimum measure of intake); good (100110% of the minimum size measure of intake); and more (>110% of the minimum intake measure value).37 respondents were interviewed about food and drinks consumed in the past 24 hours, including portion sizes with the help of a photograph of household sizes, such as a spoon, plate, glass, or other sizes commonly used daily as stated in food photo book. the results were then synchronized to an average intake per day. table 1 shows the list of food intake composition containing omega-3.38,39,40 the data in this study was obtained from subjects through direct dialogue (interviews). subsequently, the obtained data were processed using one of the nutrisurvey programs, which was software designed for noncommercial use. this was useful for analyzing food nutrients from a menu or a consumption survey. after collecting the calorie intake, the data was entered into spss version 24, and the chisquare test was used to assess the relationship between omega-3 intake and ses (income and education). results and discussions characteristics of respondents this study made use of 49 respondents working as online motorcycle drivers in the rungkut area. during the collection of respondents, 5 drivers refused to be involved in the study because of a call to order from a passenger. the prevalence of smoking in indonesia is very high, specifically in men ranging from children, adolescents, to adults. furthermore, 12 of the respondents were 4044 years (24.49%), and this is not in accordance with tomioka et al.41 that stated that people aged 45-64 years tend to smoke more than those aged <45 years or >65 years. table 2 described the characteristics of the respondents. most of the smoking severity was light (48.98%) with an income mostly around <1 million rupiahs (61.22%). in terms of education level, most of them were high school seniors (73.47%). a total of 49 respondents’ data from online motorcycle drivers were analyzed descriptively. table 3 described the average (212.7 mg/day), minimum (0 mg/day), maximum (1,069.43 mg/day) and standard deviation (264.1 mg/day) of the consumption of omega3. these fatty acids were one of the nutrients needed by the body. however, the body does not produce it naturally, and therefore needs to get it elsewhere. eicosanoids, which are chemicals that provide signals to the cardiovascular, pulmonary, endocrine, and immunological systems, are formed by omega-3 fatty acids. according to the data obtained, consumption of omega-3 per day was not sufficient, both on workdays and holidays. this is because it did not meet the recommended nutritional adequacy rate (rda) of 1600 mg/day. furthermore, the minimum average consumption of omega-3 was 0 mg/day, the maximum average was 1069.43 mg/day and the standard deviation (sd) was 277.18 mg/day. these results were influenced by the level of income obtained. due to the corona pandemic and ignorance of foods containing omega-3, some respondents did not consume foods containing omega-3 at all, resulting in an average result was 0. meanwhile, other respondents obtained omega-3 through eggs, chicken, catfish, and anchovies. eggs respondents consumed chicken eggs, but not those containing omega-3. omega-3 chicken eggs are produced from laying hens fed a diet containing omega-3 supplements for three consecutive article [healthcare in low-resource settings 2023; 11(s1):11164] [page 9] table 1. list of food intake composition containing omega3.37, 38,39 food gram omega-3 content (mg/serving) anchovy 57 1,165 catfish 85 151 shells 85 241 crab 85 351 lobster 100 84 salmon 85 1,825 tuna 85 228 sardines 57 556 shrimp 85 267 egg 63 22 beef 100 22 chicken 100 19 goat meat 100 18 table 2. characteristics of respondents.9 characteristics of frequency (n=49) percentage (%) respondents age (years) 18-25 9 18.40 26-35 17 34.70 36-45 17 34.70 46-55 4 8.20 56-65 2 4.10 smoking severity light 24 45.99 moderate 23 46.93 severe 2 4.08 income (idr) <1 million 30 61.22 1-3 million 19 38.78 education degree elementary school 3 6.10 junior high school 2 4.10 senior high school 36 73.50 bachelor degree 8 16.30 table 3. omega-3 intake profile based on 24-hour food recall. 1st meeting (mg/day) 2nd meeting (mg/day) 3rd meeting (mg/day) average (mg/day) average 275.0 152.7 210.5 212.7 minimum 0 0 0 0 maximum 2105.6 1062.1 2107.26 1,069.1 sd 581.0 279.2 393.1 264.1 non -co mmerc ial us e o nly weeks. farmers in indonesia use waste oil that is waste from the fish processing industry. consumption of enriched hen eggs containing a mixture of omega-3 pufa (ala+epa+dha), causes changes in the microvascular reactivity, blood pressure, and triglyceride level in healthy subjects that are associated with cardiovascular benefits. this suggested that daily consumption of omega-3 pufa-enriched eggs in healthy individuals may potentially contribute to cardiovascular risk factor attenuation and disease prevention.42 chicken the two types of chicken frequently consumed are local chicken (boras/kampung) and broiler chicken. since chicken consumption has steadily increased in recent decades, meat enriched with long-chain polyunsaturated fatty acids (lc-pufa) has become an important source of nutrients to humans. the meat of broilers fed diets with fish oil and either flaxseed or rapeseed for two weeks before the slaughter is believed to be “high in omega-3 fatty acids.” a 100 g portion of such breast or thigh meat would provide on average 33% and 15.5%, respectively, of the recommended daily intake of epa and dha for humans. therefore, enriched chicken meat was a superior source of lc-pufa than lean fish meat.43 catfish catfish can serve as a potential source of essential fatty acids to human nutrition particularly in nigeria with the growing popularity of catfish consumption.44 pangasius micronemus (black pangasius sp.) and pangasius nasutus (fruit pangasius sp.) are two species of silver catfish. both pangasius sp. are good supplies of omega-3 and omega-6. morover, p. micronemus from sg. kanchong was the best choice because it was high in epa and dha.45 most of the respondents’ classification of omega-3 intake was at the deficit level (57.14%), and none belonged to the good and more level. classification of omega-3 intake was divided into 5, namely, deficit (<70% of the value of the minimum measure of omega-3 intake); less (70-80% of the value of a minimum measure of omega-3 intake); sufficient (80-100% of the value of a minimum measure of omega-3 intake); good (100-110% of the minimum size measure of omega-3 intake); and more (>110% of the minimum omega-3 intake measure value) (table 4). prolonged omega-3 deficiency can affect neurodevelopment and cause neurological and visual disturbances. in addition, this could lead to immune, memory, and mental disorders. by increasing neurogenesis and neurotransmitters in the brain, dha in omega-3 can promote memory and cognitive development in children. it also plays a role in increasing the activity of the prefrontal part of the brain used for thinking and behaving.46 in this study, socioeconomic status (ses) consisted of income (idr) and education degree. table 5 showed that there was a significant difference in omega-3 intake based on income (p=0.000) and education (p=0.000). also, the amount of epa and dha consumed daily varied greatly depending on income. much less is known about the potential role of other demographic factors on n3 lcpufa intakes, such as ethnicity, income, and education level. however, according to a recent analysis of nhanes 2011–2014, n-3 lcpufa intake varies by ethnicity in the us, with nonhispanic asians consuming significantly more epa and dha than hispanics, non-hispanic whites, and non-hispanic blacks.47 there is a relationship between the price of omega-3 supplements with, epa and dha content, as observed from relative percentage. product a1 (with the lowest price), has a relatively lower percentage, compared to brand a2 (with the highest price), with a relatively higher grade.48 participants with higher school education had a significantly higher dietary intake of epa and combined epa+dha than those with lower school education.47 other studies revealed the association of ses with omega-3 intake. although socioeconomic status may play a role in the relationship between these factors and maternal omega-3 dha status.49 after adjusting for energy intake, education was significantly correlated with epa + dha intakes, and acculturation was significantly correlated with total n−3, ala, and epa + dha intakes. foods sources of epa + dha eaten by at least 50% of participants were chicken, shrimp, tuna, and eggs.29 the data collected using the 3 x 24-hour food recall method was the limitation of this study because it mainly relies on the respondent’s memory. to overcome this bias, a description of the food that might be consumed was provided. once the respondent could not still remember, a 3x24 hour food recall data processing is issued using the nutri survey program. this has a weakness of not covering all types of food consumed by the respondent, but can be analyzed with the program to enable manual calculation. additionally, the process of serving food can also affect the levels of omega-3 in food which was not considered in this study. article [page 10] [healthcare in low-resource settings 2023; 11(s1):11164] table 5. cross-tabulation of your omega-3 food intake its association with socioeconomic status. socioeconomic status classification of omega-3 intake total p value deficit less sufficient (chi square test) income (idr) <1 million 21 9 30 0.000 1-3 million 7 7 5 19 education degree elementary school 3 3 0.000 junior high school 2 2 senior high school 23 12 1 36 bachelor degree 4 4 8 table 4. classification of omega-3 intake. classification of frequency (n=49) percentage (%) omega-3 intake deficit (<70%) 28 57.15 less (70-80%) 16 32.65 sufficient (80-100%) 5 10.20 good (100-110%) more (>110%) non -co mmerc ial us e o nly conclusions the choice of omega-3 foods was influenced by socioeconomic position (ses), which includes income (idr) and education level. therefore, the higher the income and education level, the better the intake of omega-3 by online motorcycle drivers. references 1. verlinghieri e, schwanen t. transport and mobility justice: evolving discussions. j transp geogr 2020;87:102798. 2. irawan mz, rizki m, joewono tb, et al. exploring the intention of out-of-home activities participation during new normal conditions in indonesian cities. transp res interdiscip perspect 2020;8:100237. 3. ramadhan mah, hartono b. incidence of chronic obstructive pulmonary disease (copd) in online ojek drivers in bogor city and depok city in 2018 (a case study of air pollution). jurnal nasional kesehatan lingkungan global 2020;1(1):76-85. 4. lorensia a, muntu cm, suryadinata rv, et al. effect of lung function disorders and physical activity on smoking and nonsmoking students. j prev med hyg 2021;62:e89-96. 5. west r. tobacco smoking: health impact, prevalence, correlates and interventions. psychol health 2017;32:1018-36. 6. holipah h, sulistomo hw, maharani a. tobacco smoking and risk of all-cause mortality in indonesia. plos one 2020;15:e0242558. 7. balatif r. cigarettes and its effects on health. scripta score scientific medical journal 2020;2:44-52. 8. baumeister rf. addiction, cigarette smoking, and voluntary control of action: do cigarette smokers lose their free will?. addict behav rep 2017;5:67-84. 9. gonzález-roz a, jackson j, murphy c, et al. behavioral economic tobacco demand in relation to cigarette consumption and nicotine dependence: a meta-analysis of cross-sectional relationships. addiction 2019;114:1926-40. 10. joly b, perriot j, d’athis p, et al. success rates in smoking cessation: psychological preparation plays a critical role and interacts with other factors such as psychoactive substances. plos one 2017;12:e0184800. 11. nagano t, katsurada m, yasuda y, et al. current pharmacologic treatments for smoking cessation and new agents undergoing clinical trials. ther adv respir dis 2019;13: 1753466619875925. 12. hersi m, traversy g, thombs bd, et al. effectiveness of stop smoking interventions among adults: protocol for an overview of systematic reviews and an updated systematic review. syst rev 2019;8:28. 13. aman f, masood s. how nutrition can help to fight against covid-19 pandemic. pak j med sci 2020;36:s121-s123. 14. lorensia a, wahyudi m, yudiarso a, et al. effect of illness perception on improving asthma symptoms with omega-3 fish oil therapy: pre-post design. j appl pharmaceut sci 2020;10:6271. 15. lorensia a, wahyudi m, mayzika na. effectiveness of fish oil containing omega-3 in improving symptoms and lung function in asthma outpatient in surabaya, indonesia. int j pharmaceut quality assurance 2018;9:260-6. 16. lorensia a, suryadinata rv, sidabutar bcm. effect analysis of protein intake of pedicab driver in surabaya. j trop pharm chem 2021;5:188-93. 17. wiest ef, walsh-wilcox mt, walker mk. omega-3 polyunsaturated fatty acids protect against cigarette smokeinduced oxidative stress and vascular dysfunction. toxicol sci 2017;156:300-310. 18. sadeghi-ardekani k, haghighi m, zarrin r. effects of omega3 fatty acid supplementation on cigarette craving and oxidative stress index in heavy-smoker males: a double-blind, randomized, placebo-controlled clinical trial. j psychopharmacol 2018 sep;32:995-1002. 19. scaglia n, chatkin j, chapman kr, et al. the relationship between omega-3 and smoking habit: a cross-sectional study. lipids health dis 2016;15:61. 20. harris ws, tintle nl, imamura f, et al. blood n-3 fatty acid article [healthcare in low-resource settings 2023; 11(s1):11164] [page 11] correspondence: amelia lorensia, faculty of pharmacy, universitas surabaya (ubaya), jl. raya kalirungkut 60293, surabaya, indonesia, tel.: +62312981110, fax:+62312981111, e-mail: amelia.lorensia@staff.ubaya.ac.id key words: omega-3; recall 24 hours; income; education; motorcycle driver online. acknowledgment: gratitudes goes to the faculty of pharmacy universitas surabaya, surabaya, indonesia, for their kind support and motivation during this study. contributions: in this study, contributions were made equally. rvs contributed to data processing, while al reviewed the final product. conflict of interest: the authors declare no conflicts of interest. funding: this study was funded by the faculty of pharmacy universitas surabaya and ministry of research, technology and higher education of the republic of indonesia as well as supported by the institute of research and community service universitas surabaya. clinical trials: this study has been approved by the health research ethics committee of universitas surabaya. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 4 december 2021. accepted for publication: 12 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11164 doi:10.4081/hls.2023.11164 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly levels and total and cause-specific mortality from 17 prospective studies. nat commun 2021;12:2329. 21. gammone ma, riccioni g, parrinello g, et al. omega-3 polyunsaturated fatty acids: benefits and endpoints in sport. nutrients 2018;11:46. 22. calder pc. omega-3 fatty acids and inflammatory processes: from molecules to man. biochem soc trans 2017;45:1105-15. 23. buoite stella a, gortan cappellari g, barazzoni r, et al. update on the impact of omega 3 fatty acids on inflammation, insulin resistance and sarcopenia: a review. int j mol sci 2018;19:218. 24. hu c, yang m, zhu x, et al. effects of omega-3 fatty acids on markers of inflammation in patients with chronic kidney disease: a controversial issue. ther apher dial 2018;22:12432. 25. weylandt kh, serini s, chen yq, et al. omega-3 polyunsaturated fatty acids: the way forward in times of mixed evidence. biomed res int 2015;2015:143109. 26. zibaeenezhad mj, ghavipisheh m, attar a, et al. comparison of the effect of omega-3 supplements and fresh fish on lipid profile: a randomized, open-labeled trial. nutr diabetes 2017;7:1. 27. lorensia a, suryadinata rv. assessment of omega-3 fatty acid food intakes in online motorcycle drivers. teikyo med j 2021;44:881-92. 28. muhammad a, d'souza a, meade b, et al. how income and food prices influence global dietary intakes by age and sex: evidence from 164 countries. bmj glob health 2017;2:e000184. 29. lora kr, lewis nm, eskridge km, et al. correlation of omega-3 fatty acids intakes with acculturation and socioeconomic status in midwestern latinas. j immigr minor health 2011;13:111-8. 30. pechey r, monsivais p. socioeconomic inequalities in the healthiness of food choices: exploring the contributions of food expenditures. prev med 2016;88:203-9. 31. viego v, temporelli k. socioeconomic status and selfreported chronic diseases among argentina's adult population: results based on multivariate probability models. j public health res 2017;6:883. 32. singh gk, daus gp, allender m, et al. social determinants of health in the united states: addressing major health inequality trends for the nation, 1935-2016. int j mch aids 2017;6:139-64. 33. roach la, russell kg, lambert k, et al. polyunsaturated fatty acid food frequency questionnaire validation in people with end stage renal disease on dialysis. nutr diet 2020;77:131138. 34. ansari mr, agustina r, khusun h, et al. development and evaluation of a semiquantitative food frequency questionnaire for estimating omega-3 and omega-6 fatty acid intakes in indonesian children. asia pac j clin nutr 2016;25:s20-s29. 35. dao mc, subar af, warthon-medina m, et al. dietary assessment toolkits: an overview. public health nutr 2019;22:40418. 36. badan penelitian dan pengembangan kesehatan kementerian kesehatan indonesia. buku foto makanan oleh tim survei konsumsi makanan individu. jakarta: badan penelitian dan pengembangan kesehatan; 2014. 37. badan pusat statistik (bps). konsumsi kalori dan protein penduduk indonesia dan provinsi. jakarta: badan pusat statistik; 2020. 38. bellows l, clifford j, niebaum k, et al. omega-3 fatty acids. csu extension. fact sheet 2015;9:382. 39. tur j, bibiloni m, sureda a, et al. dietary sources of omega 3 fatty acids: public health risks and benefits. br j nutr 2012;107:s23-52. 40. schwalfenberg g. omega-3 fatty acids: their beneficial role in cardiovascular health. can fam physician 2006;52:734-40. 41. tomioka k, shima m, saeki k. association between heaviness of cigarette smoking and serious psychological distress is stronger in women than in men: a nationally representative cross-sectional survey in japan. harm reduct j 2021;18:27. 42. stupin a, rasic l, matic a, et al. omega-3 polyunsaturated fatty acids-enriched hen eggs consumption enhances microvascular reactivity in young healthy individuals. appl physiol nutr metab 2018;43:988-95. 43. konieczka p, czauderna m, smulikowska s. the enrichment of chicken meat with omega-3 fatty acids by dietary fish oil or its mixture with rapeseed or flaxseed—effect of feeding duration: dietary fish oil, flaxseed, and rapeseed and n-3 enriched broiler meat. animal feed science and technology 2017;223;42-52. 44. mustapha ra, bolajoko o, akinola oo. omega-3 and omega-6 fatty acids potential of smoked and boiled catfish (clarias gariepinus). curr res nutr food sci 2014;2: 94-7. 45. hashim rb, jamil ef, zulkipli fh, et al. fatty acid compositions of silver catfish, pangasius sp. farmed in several rivers of pahang, malaysia. j oleo sci 2015;64:205-9. 46. lauritzen l, brambilla p, mazzocchi a, et al. dha effects in brain development and function. nutrients 2016;8:6. 47. cave c, hein n, smith lm, et al. omega-3 long-chain polyunsaturated fatty acids intake by ethnicity, income, and education level in the united states: nhanes 2003-2014. nutrients 2020;12:2045. 48. lorensia a, budiono r, suryadinata rv, et al. quantitative determination of epa and dha in fish oil capsules for cardiovascular disease therapy in indonesia by gc-ms. j public health res 2021;10:2159. 49. wilson na, mantzioris e, middleton pf, et al. influence of sociodemographic, lifestyle and genetic characteristics on maternal dha and other polyunsaturated fatty acid status in pregnancy: a systematic review. prostaglandins leukot essent fatty acids 2020;152:102037. article [page 12] [healthcare in low-resource settings 2023; 11(s1):11164] non -co mmerc ial us e o nly hrev_master [page 20] [healthcare in low-resource settings 2023; 11:11183] improving healthcare value: integrating medical practitioners into hospital design in developing countries carlos machhour noujeim port harcourt government house clinic, nigeria abstract the cost of healthcare is a burden in most developing countries, and this is exponentially increasing in the context of population growth, pandemics, and rapidly evolving medical necessities. a customized healthcare typology should rely on data collection and architectural requirements, before moving to aesthetically compelling designs, so hospitals in low-resource or developing countries will not mimic their western counterparts. the greatest bearing that improves the patient’s outcome and well-being would engage a productive interaction between the hospital designers and the medical practitioners, this will also allow for evidence-based hospital planning. as the author of this short report, i use the best of my experience as a physician and healthcare planner to translate a successful interaction with multinational designers building hospitals in rivers state, nigeria. introduction most developing countries are affected by a sort of healthcare turmoil as rapidly growing populations and aging groups put more pressure on the medical system, thereby, unmasking the healthcare point line deficiencies and the typologies of their facilities. this continuous struggle is outlined by the lack of sustainable means for expansion, but mostly by economic governance, funded development, and the scarcity of resources. adaptivity through the merging of archetypes with the local environment and medical needs in challenging conditions, it is important to embrace a seamless balance between a myriad of factors for economic evidencebased hospital planning. to answer this, a hybrid model for good design principles should rely on a multidisciplinary collaboration between the featured architectural team, engineers, and healthcare practitioners. it is important to understand the indigenous culture tightly knit to the community, the natural environment of the facility, the disease epidemiology, and the frequent medical encounters in that area, as well as many other metrics that only medical staff would advocate for a shaped design solution, thus improving the patients’ experience and the staff’s postoccupancy adeptness. such a blend of expertise would contribute to a flexible archetype, a sustainable economic and practical design that resembles the area and fits its essentials. before moving to aesthetically compelling designs, the complex healthcare typology will be subdivided according to data collection and architectural requirements, so hospitals in low-resource or developing countries will not mimic their western counterparts. in other words, designs should capture the local and national dynamics rather than being a duplicate of standard layouts implemented abroad. this rule also applies to other scenarios such as the renovation of a health institution or its expansion due to demographic factors or the occurrence of a new pandemic, as in covid-19 case. this interdisciplinary attention would avoid redundancy and obsolete layouts, moving forward. a healthy design will rely on environmental analysis, collected through interviews and on-ground assessment. it can be surprising to see how much input doctors, nurses, and the rest of the medical staff can provide, sometimes showing little sketches to back up their ideas. small interferences like that can summarize years of practice or mirror a patient-centered experience. the concluded design will be an active understanding of the sociocultural norms and particular medical needs, thereby a solution that enhances these attributes. a certain infrastructure may limit the implementation of a standard design and this is common in developing countries. for example, it would be difficult to maintain an energy-intensive air-conditioned facility where frequent power outages will cause a monetary setback for generator usage. the solution is a customized design typology that includes climate analysis and alternative ventilation strategies. natural wind aeration, ceiling fans, window distributions, or openward layouts are used to accommodate that challenge, and here comes the importance of the hybrid integration of medical practitioners in such decisions. airborne transmitted diseases have different epidemiology as compared to western countries; for example, tuberculosis prevalence and spread are more common, as are many other viral-related illnesses, such as covid-19 or ebola. that feedback will better adapt the ward planning before building the hospital or expanding a specific space, moving toward a more decentralized layout with partial or completely isolated rooms and individualized ventilation.1 when pandemic infections are not a major concern, as in some specialized centers that only get precise referrals, for example, women’s health and wellbeing centers, other variables account for the care delivery. with skyrocketing birthrates, the healthcare system in developing countries is focusing more on delivery and pediatric services, which is lowering mother and infant mortality. this should be done along with an increase in the medical staff-to-patient ratio and amenities to accommodate that, which is a serious challenge in rural areas. patient-centered care and wellbeing: natural light, noise reduction, mobility spaces the input of the medical practitioners will also help when it comes to building a facility in a highly prevalent area for traffic accidents and major injuries. this feedback will shape the emergency department layout healthcare in low-resource settings 2023; volume 11:11183 correspondence: carlos machhour noujeim, chief medical director, port harcourt government house clinic, old gra, port harcourt-500241, nigeria. e-mail: carlosnjeim@hotmail.com key words: hospital design, developing countries, medical caregivers, health outcome. conflict of interest: the author declares no potential conflict of interest. availability of data and materials: data and materials are available from the corresponding author upon request. received for publication: 20 january 2023. accepted for publication: 24 may 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11183 doi:10.4081/hls.2023.11183 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11183] [page 21] into an easily accessible area that facilitates the unloading of major casualties and includes wider aisles and a larger storage shelf area, in addition to a triage room that helps in a better allocation based on the severity of each case. when it comes to the patient’s comfort and quality of life, both for inpatient and ambulatory care, storytelling is countless. especially when evidence-based medicine backs up the input of the medical practitioner. by providing access to natural light, through abundant windows in closed critical areas or regular wards, an overall agreeable healing environment will pay for a better well-being and outcome. as part of a non-pharmacological approach for hospitalrelated delirium or mental status fluctuations, a controllable lighting feature or the use of daylight shading devices will also help to regain a physiologic circadian rhythm.2 this condition is a real challenge for medical caregivers, and it is through their feedback and experience that designers can optimize the layout. many other metrics can be better understood when such collaboration occurs; this positively impacts patient-centered care. noise reduction especially in critical care units is essential. it can be achieved by minor technical fitments related to the patient’s room and surrounding space, but also by redesigning the staff working areas and break room access. a watchful decentralized working station can be considered in line with the standard guidelines for hospital design. it is also very important to communicate with the practitioners concerning the choice of the medical equipment in the pre-commissioning phase, as some have a threshold for beeping and buzzing and should be fixed according to the on-ground team.3 additional scientific data has proven the need for the early mobilization of highrisk patients, whether in critical care units, regular medical floors, or post-operative care units.4 this will minimize the muscle wasting in their catabolic state and also reduce the occurrence of delirium, which will improve their outcome and shorten their hospital stay. the medical staff along with physiotherapy personnel are best positioned to advocate for dedicated spaces and hallway changes to reach that purpose. a standard design where the bed is the focal point and the room is built around it will be modified to accommodate minor rehabilitation activities or a small porch can be added to the room where the patient will have space for movement. some efficient modifications were also pledged for in medical literature, such as adding measurement signs and walking aids along corridors, which will assist the patients during their activity. customized furniture and palliative care regulations also, medical practitioners can be directly engaged in furniture and amenity selection. for example, in units that care for lung diseases, a practical input is about having a splash-free sink and a sputum basin right next to it, this is in line with infection control directives. another input would be having chairs with adequate reclining angle, so patients can breathe better. this also concerns the examination room where elderly people with limited functional status can be evaluated on these recliners. doctors will also determine the exact position of the examination couch and the wall-mounted diagnostic sets in a specific consultation room to ease the physical examination of the patient. in developing countries, nursing homes or chronic care facilities are scarce. with the growing geriatric population, the philosophy and need for palliative care are becoming prevalent. according to studies, unfortunately, the risk of falls is not only limited to the patient’s room: one-fifth of falls occur in diverse spatial areas.5 to create a safer environment for the patients, special consideration and insight call for collaboration between the healthcare designer and the caregivers. it also positively develops comprehensive hospital signage, whether directional or informational, as part of the wayfinding system that will assist the geriatric population in seeking medical care. staff-centered modifications to cut burnouts a big neglected topic concerns staffcentered care where designs prioritize the patient’s comfort and discretion. multiple published medical data reviewed the burnout of hospital staff, which may affect the care delivery and overall outcome. with increased stress due to work overload, infectious pandemic constraints during covid-19, or scarce hospital amenities, staff members are more vulnerable to physical, mental, and emotional exhaustion.6 this leads to job discontent and poor productivity. some healthcare designers have moved to a decentralized model where smaller work areas are dispersed throughout the ward, individual care is better provided, and nurse stations are on wheels, with less noise and within walking distance. this model is supported by easy access to break rooms or even the inclusion of small alcoves that have reclining chairs and smartphone chargers, enough to revitalize the nursing staff. with the current medical practice, the need for computer access is crucial, and it can be attained in large multidisciplinary workspaces or lounges where medical staff can also interact and rest. future trends in healthcare set-up a better understanding of the medical trends over the years will leave a lot of unsolved challenges for the healthcare system in developing countries, as it will be even more difficult to cope with the rapid pace of technology and visionary development process. the provided medical care can be shifted to a more flexible universal design where patients of different ages and abilities can be better served. another path to improve wellness and health would focus on a strong infrastructure for medical home care, keeping the hospital setting only for acute critical cases. references 1. stiller a, salm f, bischoff p, et al. relationship between hospital ward design and healthcare-associated infection rates: a systematic review and meta-analysis. antimicrob resist infect control 2016;5:51. 2. lee hj, bae e, lee hy, et al. association of natural light exposure and delirium according to the presence or absence of windows in the intensive care unit. acute crit care 2021;36:33241. 3. de lima ae, silva dcdc, de lima ea, et al. environmental noise in hospitals: a systematic review. environ sci pollut res 2021;28:19629-42. 4. zang k, chen b, wang m, et al. the effect of early mobilization in critically ill patients: a meta-analysis. nurs crit care 2020;25:360-7. 5. anderson dc, postler ts, dam tt. epidemiology of hospital system patient falls: a retrospective analysis. am j med qual 2016;31:423-8. 6. mollica rf, fricchione gl. mental and physical exhaustion of health-care practitioners. lancet 2021;398:2243-4. short report non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12474 determinants of maternal near-miss among women admitted to public hospitals in the hadiya zone, central ethiopia: a case-control study samuel kusheta,1 gurmesa tura,2 afework tadele,2 wudu yesuf3 1department of public health, hossana college of health sciences; 2population and family health department, faculty of public health, institute of health, jimma university; 3department of public health, mizan-aman college of health sciences, aman, ethiopia abstract one of the sustainable development goals of the united nations is to bring the global maternal mortality ratio down to less than 70 per 100,000 live births by 2030. therefore, pinpointing the factors that influence maternal near-misses would help expedite the accomplishment of this goal. studies on these topics are, nevertheless, scarce in the hadiya zone and throughout ethiopia as a whole. therefore, the purpose of this study was to determine the factors that contribute to maternal near-misses among women who are admitted to public hospital maternity wards in the hadiya zone in central ethiopia. a facility-based, unmatched case-control study was conducted from february 17 to august 16, 2019. the study covered all secondary and tertiary public healthcare facilities in the hadiya zone, which includes three district hospitals and one referral hospital offering comprehensive emergency obstetric care services. the study included 279 women in total (70 cases and 209 controls). mothers who had had a near-miss were the cases, and mothers who had not had one were the controls. the statistical package for social sciences version 24 was used to analyze the data, and the multivariable binary logistic regression model was used to control confounders. the odds ratios (or) and 95% confidence intervals (ci) were used to determine statistical significance at a p-value of less than 0.05. living in a rural area [adjusted or (aor)=3.16; 95% ci: 1.62, 6.16], no birth preparedness (aor=3.50; 95% ci: 1.66, 7.41), ever gave birth by cesarean section (aor=3.68; 95% ci: 1.63, 8.31), previous history of hypertension (aor=3.69; 95% ci:1.52, 8.96), and poor knowledge of pregnancy danger signs (aor=3.15; 95% ci: 1.32, 7.52) were all determinants of maternal near-miss. thus, strengthened public health and clinical interventions in these arenas need to prioritize rural women and women with a previous history of hypertension. introduction despite a 44% decrease in the maternal mortality ratio since 1990, ending preventable maternal death continues to be one of the world’s most pressing challenges. even though this is a notable improvement that demonstrates what is possible with continued effort, the world fell short of the 75% reduction target set by millennium development goal 5.1 maternal deaths are uncommon in terms of absolute numbers per center, despite the high maternal mortality ratios in many resource-poor settings. as a result, there is less statistical power available for research to examine potential risk factors and contextual determinants.2 because maternal near-misses (mnm) occur more frequently than maternal deaths, in this case, they could be used as a stand-in for maternal deaths to assess the quality of obstetric care in specific healthcare facilities.3,4 moreover, it presents a favorable prospect for gathering data because women themselves can serve as information sources.5 the world health organization (who) requested more research on mnm in light of these facts.6,7 mnm is correspondence: samuel kusheta, department of public health, hossana college of health sciences, hossana, ethiopia. tel.: +251-934774841. e-mail: kushetasamuel@gmail.com key words: determinant factors, maternal near-miss, maternal mortality, central ethiopia. contributions: sk, participated in the conception and design of the study, performed statistical analyses, and wrote the first to final versions of the manuscript; gt, at, wy, participated in the design of the study, and read and revised the draft versions of the manuscript. all authors contributed to all sections of the manuscript and approved the final version. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: with the reference number ihrpg9/698/2019, the jimma university institute of health institution review board has ethically approved the study protocol. informed consent: participants in the study provided verbal informed consent. the goal and purpose of the study, as well as the respondents’ right to withdraw from the study at any time without compromising their hospital care, were explained to the participants. an anonymous questionnaire was used to ensure information confidentiality, and de-identified and de-linked data was kept in a safe place. funding: this research did not receive grants from any funding agency in the public, commercial, or not-for-profit sectors. availability of data and materials: the datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. acknowledgments: the authors acknowledge hossana college of health sciences for financial and material support for this research work. they also acknowledge the participating hospitals as well as study participants and data collectors for all their support during the preliminary survey, pre-test, and actual data collection. received: 13 march 2024. accepted: 2 april 2024. early access: 4 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12474 doi:10.4081/hls.2024.12474 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 368] [healthcare in low-resource settings 2024;12:12474] non -co mmerc ial us e o nly defined by the who as “a woman who nearly died but survived a complication that occurred during pregnancy, childbirth, or within 42 days of termination of pregnancy”. using a system that categorizes women based on serious (possibly) life-threatening conditions, the who suggests the “mnm approach” as a way to track and enhance the standard of obstetric care. three different types of criteria are used to base the classification: disease-, intervention-, and organ dysfunction-based criteria.7 refined disease-based criteria are recommended as a result of a study that was carried out to validate the who mnm tool. it was found that using only organ dysfunction-based criteria may result in the underreporting of severe maternal outcomes, particularly in places with limited resources.8 because advanced laboratory tests needed for organ dysfunction were scarce in study settings, this study used a refined version of the who mnm tool tailored for sub-saharan africa.9 prevalence and a nation’s level of development appear to be correlated oppositely. pregnant women who give birth in hospitals in resource-poor settings experience mnm at a rate of 4-8%, compared to 1% in developed countries, according to disease-specific criteria.3 mnm had an incidence/prevalence ratio ranging from 1.1% to 10.1%, mainly in sub-saharan africa.10 in ethiopia, where the government uses a variety of tactics, such as providing free maternity care, to try and reduce severe maternal outcomes, the overall near-miss rate was 9079 per 100,000 live births.11,12 in the past 20 years, the idea of an mnm has been investigated in maternal health as a supplement to maternal death.13 despite noting factors, limited studies have been done on mnm in ethiopia. a lot of those studies frequently used hospital records, which are unlikely to fully capture the socioeconomic and other factors from primary sources that are responsible for mnm.6,14-17 the current study attempts to close the existing gap. furthermore, ethiopia, a country with a high maternal mortality ratio (412 per 100,000 live births), has seen only modest progress in reducing maternal mortality. the situation necessitated quick fixes to accelerate the sustainable development goal of the united nations of bringing the maternal mortality ratio below 70 per 100,000 live births by 2030.7,18,19 to take appropriate action at the community and health system level, this study will aid in identifying the contributing factors to maternal deaths. therefore, the purpose of this study is to determine the factors that contribute to mnm among women who are admitted to public hospital maternity wards in the hadiya zone in central ethiopia. materials and methods study design a facility-based, unmatched case-control study was carried out. study setting and period the hadiya zone, one of the central ethiopia regional state administrative zones, served as the study’s site. in 2018, the population of the hadiya zone, which spans 3542.66 km2, was 1,650,104 (820,102 males, 830,002 females, and 384,474 women of childbearing age). there are four town administrations and thirteen districts in the zone. the capital of the hadiya zone was hossana, and it was situated 230 km southwest of ethiopia’s capital, addis ababa. the study covered all four hospitals in the zone (three district hospitals and one referral hospital). the names of these hospitals were shone primary hospital, ginbecho primary hospital, homecho primary hospital, and wachamo university nigist eleni mohamed memorial referral hospital. they were all offering comprehensive emergency obstetric care services. the three district hospitals were situated in semi-urban areas, while the referral hospital was situated in an urban area. rural health centers are connected to district hospitals and referral hospitals via referral linkage. the study was carried out from february 17 to august 16, 2019. participants selection of cases women who met at least one of the potentially fatal criteria listed in the modified sub-saharan africa mnm tool,9 and who are pregnant, in labor, have given birth, or have aborted up to 42 days ago and were admitted to the obstetrics and gynecology wards and/or obstetric intensive care units of the study hospitals were selected as cases (table 1).9 selection of controls selected mothers who were pregnant, intrapartum, or postpartum up to 42 days ago and who were admitted to the same study hospitals’ obstetrics and gynecology wards as cases with normal obstetric outcomes (normal vaginal delivery or women with mild to moderate obstetric complications) were selected as controls. conditions other than near-miss incidents that were associated with pregnancy were classified as mild to moderate complications.17 exclusion criteria records missing relevant information to declare a case and ongoing communication difficulties were the exclusion criteria taken into consideration. however, all mothers did not meet the requirements for exclusion. study variables and measurement outcome variable the outcome variable was the mnm. a woman admitted to a public hospital in the hadiya zone was labeled as “yes” if she met at least one of the requirements listed in the modified sub-saharan africa mnm tool and “no” if she did not (table 1).9 one doctor from each hospital who was hired as a supervisor declared the diagnosis of these life-threatening conditions from the client records upon each woman’s admission each day to identify eligible cases. trained midwives then conducted the interviews using checklists and pre-coded questionnaires. exposure variables the study evaluated the factors that were accountable for the incidence of mnm incidents. these exposure variables included socio-demographic factors [(age, residence (rural/urban), marital status, educational level, maternal occupation, monthly income)]; obstetric and reproductive health factors (age at first pregnancy, birth interval, gravidity, parity, antenatal care (anc), knowledge of danger signs, cesarean section (c/s), previous abortion, multiple pregnancies, history of stillbirth, previous and/or current pregnancy complications, place and attendant of current delivery, birth preparedness, female genital mutilation, contraception, and maternity waiting for home utilization); pre-existing medical illnesses (previous hypertension, previous anemia, history of cardiac problems, history of diabetes mellitus, and history of renal disease); and delays (first delay, second delay, third delay). anc was measured: when a woman who had at least one visit was considered to have anc. the second delay, or the time it took to get to the health facility, was measured using the ethiopian trav article [healthcare in low-resource settings 2024;12:12474] [page 369] non -co mmerc ial us e o nly el time standard and categorized as taking <2 hours or >2 hours.20 the first and third delays were measured in hours and/or minutes. the first delay, which was the delay in seeking medical attention, was categorized into two categories: <24 hours and >24 hours. however, due to the zero cells in this category, it was treated as a continuous variable in multivariable analysis. the third delay, which was the delay in receiving care, was categorized as <1 hour and >1 hour.21 respondents were deemed to have good knowledge of pregnancy danger signs if they answered correctly on more than half of the knowledge questions; otherwise, they were deemed to have poor knowledge. the knowledge questions covered symptoms of pregnancy danger signs such as fever, swollen legs, article [page 370] [healthcare in low-resource settings 2024;12:12474] table 1. adapted sub-saharan africa maternal near-miss tool used in this study (tura et al., 2017,9 https://creativecommons. org/licenses/by/4.0/). category related adapted sub-saharan africa definitions to who maternal maternal near-miss criteria near-miss criteria clinical criteria acute cyanosis acute cyanosis is the blue or purple coloration of the skin or mucous membranes due to low oxygen saturation. gasping gasping is a terminal respiratory pattern and the breath is convulsively and audibly caught. respiratory rate >40 or <6/min shock shock is persistent severe hypotension, defined as a systolic bp <90 mmhg for ≥60 min with a pulse rate of at least 120 despite aggressive fluid replacement (> 2 l). oliguria non responsive to fluids or diuretics oliguria is urinary output <30 ml/h for 4 h or <400 ml/24 hours. failure to form clots failure to form clots can be assessed by the bedside clotting test or absence of clotting from the iv site after 7-10 minutes. loss of consciousness lasting more than 12 hours loss of consciousness lasting >12 h is a profound alteration of mental state that involves complete or near-complete lack of responsiveness to external stimuli. it is defined as a glasgow coma scale <10 (moderate or severe coma). cardiac arrest stroke a stroke is a neurological deficit of cerebrovascular cause that persists beyond 24 hours or is interrupted by death within 24 hours. uncontrollable fit/ total paralysis uncontrolled fits/total paralysis is refractory, persistent convulsions, or status epilepticus. jaundice in the presence of preeclampsia pre-eclampsia is defined as the presence of hypertension associated with proteinuria. hypertension is defined as a bp of at least 140/90 mmhg on at least two occasions an at least 4-6 h apart after the 20th week of gestation in women known to be normotensive beforehand. proteinuria is defined as the excretion of 300 mg or more of protein every 24 hours. if 24-hour urine samples are not available, proteinuria is defined as a protein concentration of 300 mg/l or more (≥1 on dipstick) in at least two random urine samples taken at least 4-6 h apart. other additional adapted eclampsia eclampsia is diastolic bp≥90 mmhg or proteinuria +3 and convulsion or coma. sub-saharan africa uterine rupture uterine rupture is a complete rupture of the uterus during labor and/or confirmed later maternal near-miss clinical by laparotomy. criteria other than who sepsis or severe systemic infection sepsis or severe systemic infection is defined as a clinical sign of infection and 3 of the maternal near-miss criteria following: temp >38°c or <36°c, respiration rate >20/min, pulse rate >90/min, wbc>12,000. pulmonary edema pulmonary edema is an accumulation of fluids in the air spaces and parenchyma of the lungs. severe abortion complications severe abortion complications are defined as septic incomplete abortion or complicated gestational trophoblastic disease with anemia. severe malaria severe malaria is defined as major signs of organ dysfunction and/or high-level parasitemia or cerebral malaria severe pre-eclampsia with icu admission severe pre-eclampsia: persistent systolic blood pressure of 160 mmhg or more or a diastolic blood pressure of 110 mmhg; and either proteinuria of 5 g or more in 24 hours; or oliguria of <400 ml in 24 hours; or hellp syndrome. severe postpartum hemorrhage if a woman experience genital bleeding after delivery with at least hypotension or result in blood transfusion. laboratory-based criteria oxygen saturation <90% for >60 min creatinine≥300μmol/l or ≥3.5 mg/dl acute thrombocytopenia (<50,000 platelets/ml) loss of consciousness and ketoacids in urine management based criteria hysterectomy following infection or hemorrhage transfusion of≥2 units of red blood cells intubation and ventilation for ≥60 min not related to anesthesia cardio-pulmonary resuscitation laparotomy other than cesarean section who, world health organization; bp, blood pressure; wbc, white blood cell; icu, intensive care unit; hellp, hemolysis, low liver enzymes, and low platelet count. this adapted tool9 was also used in another study for maternal near-miss cases detection as part of the research project with different objective and published elsewhere. non -co mmerc ial us e o nly blurred vision, intense headache, offensive vaginal discharge, bleeding, and blurring of the vision. when respondents met at least one requirement of the birth preparedness plan during their current pregnancy, they were deemed to be birth-prepared; in the absence of such requirements, they were deemed to be unprepared for childbirth. sample size and sampling procedure the sample size was estimated for unmatched case-control studies using epi-info version 7.2.2.6 software with the following assumptions: 80% power, 95% confidence interval (ci), and a 3:1 control-to-case ratio. exposure status of controls and odds ratio (or) for significant determinant factors were taken from a facility-based case-control study conducted in selected public hospitals in the tigray region, northern ethiopia, taking age at first pregnancy of <16 years compared to >20 years as one of the main exposure variable for mnm that provide the maximum sample size.14 the percent of controls exposed to the stated variable was 18.5% and or was 2.5. accordingly, a minimum sample size of 279 women (70 cases and 209 controls) was calculated. the study covered all of the public hospitals in the hadiya zone. to find the average monthly obstetric client flow rate of the respective hospitals for delivery, the obstetric case management report for the last 6 months’ total deliveries from each public hospital was consulted. each hospital that was chosen received a proportionate share of the sample size. all mnm cases during the study period were consecutively included, and for each near-miss case, three controls were selected using systematic random sampling, and accordingly, the interval of every three women was taken (k=907/279=3). patient cards, admission logbooks, and operating room logbooks were used to identify cases. data collection procedure and instrument a structured interviewer-administered questionnaire and mnm checklist were used to gather data. these tools were developed after a thorough review of the literature and were based on the who mnm tool, which was slightly modified for use in subsaharan africa.9 a version of the questionnaire prepared in the local language (amharic) was used to collect the data. to collect data, methods such as face-to-face interviews and client record reviews were used. clients’ record review was used to identify a near-miss diagnosis for case selection and attendance of the current delivery; otherwise, other variables were assessed directly by interviewing the cases and controls by well-trained midwives. the interview was held in a private area and near discharge from the hospital. the overall data collection process was supervised by a trained general practitioner working in the respective hospitals. each hospital’s obstetric intensive care unit and gynecology ward were visited to gather data. data quality management the questions prepared in english were translated into amharic and back-translated to english by different expert translators to check for consistency. a pre-test was carried out at worabe comprehensive hospital on 5% of the sample size for one week, and any inconsistencies in the tools were corrected. data collectors were trained for 2 days on the objectives of the study, data collection techniques, and tools. the principal investigator and trained supervisors also checked the consistency and completeness of the data every day. data processing and analysis after being reviewed for completeness, each questionnaire was coded, entered into epi-data version 4.4 (epidata, denmark), and exported to spss for windows version 24 for analysis (ibm, armonk, ny, usa). after the data was cleaned, the analysis was performed. to describe the study population in terms of sociodemographic factors and other pertinent variables for cases and controls, frequencies, proportions, and measures of variation were employed. a binary logistic regression model was built. the relationship between each independent variable and the outcome variable was examined using bivariate logistic regression; variables for the final multivariable logistic regression model were selected based on a p-value of less than 0.20 to include potentially important variables in the model and to reduce the risk of overfitting the model. the hosmer and lemeshow goodness of fit test (x2=1.86, p=0.868) was used to assess the model’s fitness. or and 95% ci were used to evaluate statistical significance, which was declared at a p-value of less than 0.05. the guidelines for strobe casecontrol reporting were followed. results socio-demographic characteristics after eligibility was verified, 279 participants (70 cases and 209 controls) were included in the study. the study participants had a mean age of 27.7 [5.4 standard deviation (sd)] years for cases and 26.9 (5.1 sd) years for controls. at that moment, married cases were 92.9%, whereas controls were 94.3%. as their occupation, housewives made up more than three-quarters of the cases (77.1%) and half of the controls (58.9%). the proportion of cases from rural areas (72.9% versus 32.5%) is twice that of controls. similarly, the proportion of cases with no formal education is twice that of controls (40.0% versus 19.6%). for the cases, the family’s median monthly income was 2362.5 birrs [interquartile range (iqr) 1362.5 to 3000.0] while for the controls, it was 3000.0 birrs (iqr 1,500.0 to 5000.0) (table 2). obstetric and reproductive health history of the women contraception was used by a larger percentage of controls (57.0%) than cases (38.0%). among cases, the median number of pregnancies was 3.5 (iqr 1.0 to 6.0), whereas among controls, it was 2.0 (iqr 1.0 to 3.5). the grand multigravida (>5 pregnancies) percentage is twice as high in cases as it is in controls (38.6% versus 16.2%). the birth interval was measured in years, with the mean for cases being 1.7 (0.7 sd) and the mean for controls being 2.6 (1.1 sd). in cases, the percentage of birth intervals less than 2 years nearly quadruples compared to controls (43.8% versus 11.7%). eight cases and five controls gave their current birth at home (table 3). just 3.3% of controls and 24% of cases have multiple pregnancies at any point in their lives. 7.7% of controls had a stillbirth in their lifetime, compared to 26.0% of cases. abortion has been experienced in 37.1% of cases and 12.0% of controls. concerning complications from prior pregnancies, the most frequent types among cases were postpartum hemorrhage (37.9%) and hypertension (37.9%), while the most common types among controls were antepartum hemorrhage (23.1%) and premature rupture of membranes (26.9%). the percentage of cases that used maternity waiting homes during their current pregnancy was only 12.9%, compared to 21.5% of controls. article [healthcare in low-resource settings 2024;12:12474] [page 371] non -co mmerc ial us e o nly in their current pregnancy, 73% of cases and 94.3% of controls received anc.45.7% of controls and 43.1% of cases among those who received anc were booked at health centers. in terms of anc contact frequency, 39.6% of controls and 47.1% of cases have had fewer than four anc contacts. three times as many cases (41.2%) as controls (13.2%) had an antenatal admission during their current pregnancy. in cases, hypertension accounted for 33.3% of prenatal admissions, while hyperemesis gravidarum was the primary cause of antenatal admissions in 70.4% of controls. at their booking visit, 12.7% of controls and 22% of cases were not informed about the danger signs of pregnancy (table 3). the previous medical condition of the women one-sixth of controls (17.7%) and more than four out of ten article [page 372] [healthcare in low-resource settings 2024;12:12474] table 3. women’s reproductive health and obstetric history, and the three delays among women admitted to public hospitals in the hadiya zone of central ethiopia, 2019 (n=279). variable category maternal near-miss status total (n=279) yes (n=70) no (n=209) frequency (%) frequency (%) frequency (%) female genital mutilation yes 55 (78.6) 123 (58.9) 185 (66.3) no 15 (21.4) 86 (41.1) 94 (33.7) birth preparedness for current delivery yes 40 (57.1) 187 (89.5) 227 (81.4) no 30 (42.9) 22 (10.5) 52 (18.6) gravidity primigravida 22 (31.4) 81 (38.8) 103 (36.9) multigravida 21 (30.0) 94 (45.0) 115 (41.2) grand multigravida 27 (38.6) 34 (16.2) 61 (21.9) birth interval <2 years 21 (43.8) 15 (11.7) 36 (20.5) n=176 (48:128) >2 years 27 (56.2) 113 (88.3) 140 (79.5) ever gave birth by cesarean section yes 23 (32.9) 19 (9.1) 42 (15.1) no 47 (67.1) 190 (90.9) 237 (84.9) previous pregnancy complications yes 29 (41.4) 26 (12.4) 55 (19.7) no 41 (58.6) 183 (87.6) 224 (80.3) receive anc in the current pregnancy yes 51 (72.9) 197 (94.3) 248 (88.9) no 19 (27.1) 12 (5.7) 31 (11.1) antenatal admissions in the current pregnancy yes 21 (41.2) 26 (13.2) 47 (19.0) n = 248 (51:197) no 30 (58.8) 171 (86.8) 201 (81.0) knowledge of pregnancy danger signs poor knowledge 62 (88.6) 126 (60.3) 188 (67.4) good knowledge 8 (11.4) 83 (39.7) 91 (32.6) first delay delayed <12 hours 54 (77.1) 148 (70.8) 202 (72.4) delayed >12 hours 16 (22.9) 61 (29.2) 77 (27.6) second delay travelled <2 hours 51 (72.9) 183 (87.6) 234 (83.9) travelled >2 hours 19 (27.1) 26 (12.4) 45 (16.1) third delay delayed <1 hour 47 (67.1) 112 (53.6) 237 (84.9) delayed >1 hour 23 (32.9) 97 (46.4) 42 (15.1) anc, antenatal care. table 2. socio-demographic characteristics of women admitted to public hospitals in the hadiya zone of central ethiopia, 2019 (n=279). variable category maternal near-miss status total (n=279) yes (n=70) no (n=209) frequency (%) frequency (%) frequency (%) age of participants 18-29 years 43 (61.4) 146 (69.9) 189 (67.7) 30-41 years 27 (38.6) 63 (30.1) 90 (32.3) permanent residence rural 51 (72.9) 68 (32.5) 119 (42.7) urban 19 (27.1) 141 (67.5) 160 (57.3) participant occupation housewife 54 (77.1) 123 (58.9) 177 (63.4) civil servant 11 (15.7) 46 (22.0) 57 (20.4) merchant 4 (5.7) 26 (12.4) 30 (10.8) other (maid, student, daily laborer) 1 (1.4) 14 (6.7) 15 (5.4) participants’ level of education no formal education 28 (40.0) 41 (19.6) 69 (24.7) primary school (1-8) 25 (35.7) 81 (38.8) 106 (38.0) secondary school (9-12) 5 (7.1) 33 (15.8) 38 (13.6) tertiary or higher (12+) 12 (17.1) 54 (25.8) 66 (23.7) monthly income <2500 birr 51 (72.9) 96 (5.9) 147 (52.7) >2500 birr 19 (27.1) 113 (54.1) 132 (47.3) non -co mmerc ial us e o nly cases (42.9%) have ever had a medical condition in the past. hypertension was the most prevalent type of previous medical condition in both cases (27.1%) and controls (7.2%), and it was followed by renal disease, anemia, diabetes mellitus, and asthma. three delays and referral status referrals from medical facilities outside the study setting accounted for one-fifth (21.5%) of the controls and three-fourths (74.3%) of the cases. among cases, the median delay in seeking medical attention was 6.0 (iqr 3.0 to 10.0) hours, while among controls, it was 2.5 (iqr 1.0 to 6.0) hours. in comparison to controls, cases experienced a mean second delay of 2.2 hours (1.4 sd), while controls experienced 1.6 hours (1.4 sd). the third delay had a median duration of 48 minutes for both cases and controls, with an iqr of 42-60 for cases and 24-60 for controls (table 3). determinants of maternal near-miss in the multi-variable binary logistic regression analysis, the variables found to have an association with mnm in the final model were rural residence [adjusted or (aor)=3.16; 95% ci: 1.62, 6.16)], no birth preparedness (aor=3.50; 95% ci: 1.66, 7.41), previous c/s (aor=3.68; 95% ci: 1.63, 8.31), previous history of hypertension (aor=3.69; 95% ci: 1.52, 8.96), and poor knowledge of pregnancy danger signs (aor=3.15; 95% ci: 1.32, 7.52) (table 4). discussion according to this study, women who live in rural areas are three times more likely than women who live in urban areas to experience mnm. the results of this study were similar to those of a study carried out in public hospitals in addis ababa, ethiopia, where it was discovered that rural residence was a determinant factor of mnm.17 in a study done in southwest nigeria and india, living in a rural area was also a significant determinant factor of mnm.22,23 it could be because of the hospitals’ locations in urban and semi-urban areas, the ease of access to transportation, and the state of the roads, as well as the availability of information and better medical care. these could suggest that, even with government initiatives to provide basic health services to rural women, these women may still encounter more obstacles than urban women in getting access to healthcare. additionally, a higher percentage of rural women in this study chose to give birth at home, did not receive prenatal care during their current pregnancy, were referred by other medical facilities, and required a longer commute to get to hospitals. due to their later arrival at hospitals than urban women, all of these may exacerbate their condition and raise their risk of morbidity. therefore, increasing road and transit infrastructure, further decentralizing maternity care, and prioritizing public health initiatives for rural women could all help lower the rate of mnm. similarly, the odds of experiencing mnm were more than three times higher for women without birth preparedness than for those who did. a meta-analysis and systematic review of randomized trials of birth preparedness and complication readiness (bpcr) interventions in populations of pregnant women living in developing countries provided support for this finding, demonstrating that exposure to bpcr interventions was associated with a statistically significant reduction in the risk of maternal mortality by 53%.24 this suggests that although birth preparedness is a significant factor for mnm, it was not adequately addressed in anc services. for instance, in the present study, nearly three-fourths of cases and more than nine in ten controls received anc in their current pregnancy, and similarly, last year’s zonal anc4 coverage article [healthcare in low-resource settings 2024;12:12474] [page 373] table 4. determinant factors of maternal near-miss among women admitted to public hospitals in the hadiya zone of central ethiopia, 2019 (n=279; 70:209 cases to controls ratio). variable category maternal near-miss status cor (95% ci) aor (95% ci) yes no no (%) no (%) permanent residence rural 51 (72.9) 68 (32.5) 5.57 (3.05, 10.15) 3.16 (1.62, 6.16)** urban 19 (27.1) 141 (67.5) 1.00 1.00 female genital mutilation yes 55 (78.6) 123 (58.9) 2.56 (1.36, 4.83) 1.29 (0.58, 2.86) no 15 (21.4) 86 (41.1) 1.00 1.00 receive anc in a current pregnancy yes 51 (72.9) 197 (94.3) 0.16 (0.08, 0.36) 1.04 (0.32, 3.39) no 19 (27.1) 12 (5.7) 1.00 1.00 ever gave stillbirth yes 18 (25.7) 16 (7.7) 4.18 (1.99, 8.75) 1.53 (0.55, 4.27) no 52 (74.3) 193 (92.3) 1.00 1.00 ever experience abortion yes 26 (37.1) 25 (12.0) 4.35 (2.29, 8.25) 1.81 (0.82, 3.99) no 44 (62.9) 184 (88.0) 1.00 1.00 ever gave birth by cesarean section yes 23 (32.9) 19 (9.1) 4.89 (2.46, 9.72) 3.68 (1.63, 8.31)* no 47 (67.1) 190 (90.9) 1.00 1.00 birth preparedness for current delivery yes 40 (57.1) 187 (89.5) 1.00 1.00 no 30 (42.9) 22 (10.5) 6.37 (3.34, 12.18) 3.50 (1.66, 7.41)** knowledge of pregnancy danger signs poor 62 (88.6) 126 (60.3) 5.11 (2.33, 11.21) 3.15 (1.32, 7.52)* good 8 (11.4) 83 (39.7) 1.00 1.00 previous history of hypertension yes 19 (27.1) 15 (7.2) 4.82 (2.29, 10.14) 3.69 (1.52, 8.96)* no 51 (72.9) 194 (92.8) 1.00 1.00 second delay traveled <2 hours 51 (72.9) 183 (87.6) 0.38 (0.20, 0.74) 0.92 (0.37, 2.29) traveled >2 hours 19 (27.1) 26 (12.4) 1.00 1.00 cor, crude odds ratio; aor, adjusted odds ratio; ci, confidence interval; anc, antenatal care; *statistically significant variables at p=0.004; **significant at p≤0.001. non -co mmerc ial us e o nly was 93%. this suggests that although anc services were provided, their effectiveness was in doubt. in addition, women who ever gave birth by c/s had nearly four times higher odds of developing mnm compared to women with no history of c/s. according to previous research, the results were similar in the gurage zone, in southern ethiopia, and public hospitals in northern ethiopia.6,14 a comparable conclusion was also reported in a study conducted in erbil city, iraq.25 a woman who gives birth vaginally after a c/s runs the risk of experiencing uterine rupture during her subsequent deliveries. this is because the scar from the previous c/s may cause uterine rupture, which could result in mnm. the results imply that limits on c/s preferences ought to be implemented and that potential risks associated with c/s ought to be considered when evaluating clinical indications for the procedure. the study also showed that women with a previous history of hypertension had almost four times higher odds of developing mnm compared to women with no history of hypertension. findings from other studies carried out in addis ababa, nigeria, and brazil revealed that a history of hypertension was a risk factor for mnm.17,26,27 the current pregnancy may be at risk for hypertension given the prior history, which could also exacerbate the consequences of superimposed pre-eclampsia in mnm. perhaps promoting a culture of chronic illness screening, especially for hypertension, and providing targeted prenatal care would significantly reduce the incidence of mnm. furthermore, compared to women who had good knowledge of pregnancy danger signs, the odds of mnm were three times higher for those who had poor knowledge. this finding was supported by a study conducted in ethiopia that concluded that timely recognition of these danger signs is central to the survival of women.28 the identification of these danger signs and their relation to complications during pregnancy would increase the capacity of women, their partners, and their families to seek timely health care.29 empowering women, men, families, and communities to identify pregnancy-related risks is one of ethiopia’s two national reproductive strategies.30 while the national strategy places a lot of emphasis on increasing awareness of obstetric danger signs, the updated strategy made no such mentions.28 the current study’s findings also showed that a lack of awareness persisted in the study area, as 22% of cases and 12.7% of controls did not receive information about pregnancy danger signs during their booking visit. therefore, the goal of anc should be to provide pregnant women with information in addition to diagnosing symptoms and delaying the emergence of potentially fatal complications. concerned parties should also use various mass media outlets to spread knowledge about obstetric danger signs. the fact that the current study included referrals in addition to district hospitals raises questions about its representativeness. nevertheless, there were certain limitations to the study. this study did not include any private health facilities, so it may not accurately reflect mnm cases at private facilities. furthermore, the study participants were monitored exclusively until their hospital discharge. this means that a control postpartum woman, who should be monitored for 42 days postpartum, may experience a near-miss following her discharge and thus be excluded from the study. the present study was also limited by recall and social desirability biases, as the data was collected retrospectively and patients might have felt guilty about certain information. conclusions rural residence, reproductive and obstetric factors such as no birth preparedness, c/s, poor knowledge of pregnancy danger signs, and a previous history of hypertension were significant determinant factors of mnm. in light of the attainment of the sustainable development goal of reducing the maternal mortality ratio below 70 per 100,000 live births by 2030, it is imperative that findings from this study be used to inform interventions. so, we need evidence-based clinical and public health intervention programs, particularly targeting determinant factors for the reduction of maternal morbidity and mortality, while rural women need extra vigilance. references 1. world health organization. health in 2015: from mdgs to sdgs. available on: https://www.who.int/data/gho/publications/mdgs-sdgs. 2. almerie y, almerie mq, matar he, et al. obstetric near-miss and maternal mortality in a maternity university hospital, damascus, syria: a retrospective study. bmc pregnancy childbirth 2010;10:65. 3. say l, pattinson rc, gülmezoglu am. who systematic review of maternal morbidity and mortality: the prevalence of severe acute maternal morbidity (near miss). reprod health 2004;1:3. 4. liyew ef, yalew aw, afework mf, essén b. incidence and causes of maternal near-miss in selected hospitals of addis ababa, ethiopia. plos one 2017;12:e0179013. 5. lewis g. beyond the numbers: reviewing maternal deaths and complications to make pregnancy safer. br med bull 2003;67:27-37. 6. kasahun aw, wako wg. predictors of maternal near miss among women admitted in gurage zone hospitals, south ethiopia, 2017, a case-control study. bmc pregnancy childbirth 2018;18:260. 7. world health organization. evaluating the quality of care for severe pregnancy complications. 2011. available from: https://iris.who.int/bitstream/handle/10665/44692/978924150 2221_eng.pdf?sequence=1. 8. witteveen t, bezstarosti h, de koning i, et al. validating the who maternal near miss tool: comparing highand lowresource settings. bmc pregnancy childbirth 2017;17:194. 9. tura ak, stekelenburg j, scherjon sa, et al. adaptation of the who maternal near miss tool for use in sub–saharan africa: an international delphi study. bmc pregnancy childbirth 2017;17:445. 10. kaye dk, kakaire o, osinde mo. systematic review of the magnitude and case fatality ratio for severe maternal morbidity in sub-saharan africa between 1995 and 2010. bmc pregnancy childbirth 2011;11:65. 11. gebrehiwot y, tewolde bt. improving maternity care in ethiopia through facility-based review of maternal deaths and near misses. int j gynecol and obstet 2014;127:s29-34. 12. lindtjørn b, mitiku d, zidda z, yaya y. reducing maternal deaths in ethiopia: results of an intervention programme in southwest ethiopia. plos one 2017;12:e0169304. 13. tuncalp o, hindin mj, souza jp, et al. the prevalence of maternal near miss: a systematic review. bjog 2012;119:653 article [page 374] [healthcare in low-resource settings 2024;12:12474] non -co mmerc ial us e o nly 61. 14. mekango de, alemayehu m, gebregergs gb, et al. determinants of maternal near miss among women in public hospital maternity wards in northern ethiopia: a facility-based case-control study. plos one 2017;12:e0183886. 15. gedefaw m, gebrehana h, gizachew a, taddess f. assessment of maternal near miss at debre markos referral hospital, northwest ethiopia: five years experience. open j epidemiol 2014;4:199-207. 16. dile m, seyum t. proportion of maternal near misses and associated factors in referral hospitals of amhara regional state, northwest ethiopia: institution-based cross-sectional study. gynecol obstet 2015;5:308. 17. liyew ef, yalew aw, afework mf, essén b. distant and proximate factors associated with maternal near-miss: a nested case-control study in selected public hospitals of addis ababa, ethiopia. bmc womens health 2018;18:28. 18. united nations. transforming our world: the 2030 agenda for sustainable development. 2015. available from: https://sdgs.un.org/2030agenda. 19. ethiopian public health institute fmoh. ethiopia mini demographic and health survey 2019. 20. world bank, ministry of health ethiopia. ethiopia. a country status report on health and poverty. 2005. 21. assarag b, dujardin b, delamou a, et al. determinants of maternal near-miss in morocco: too late, too far, too sloppy? plos one 2015;10:e0116675. 22. bakshi rk, roy d, aggarwal p, et al. demographic determinants of maternal “near-miss” cases in rural uttarakhand. natl j community med 2014;5:329-32. 23. aduloju op, aduloju t, ipinnimo om. profile of maternal near miss and determinant factors in a teaching hospital, southwestern nigeria. int j obstet gynaecol res 2018;5:598-617. 24. soubeiga d, gauvin l, hatem ma, johri m. birth preparedness and complication readiness (bpcr) interventions to reduce maternal and neonatal mortality in developing countries: systematic review and meta-analysis. bmc pregnancy childbirth 2014;14:129. 25. akrawi vs, al-hadithi ts, al-tawil ng. major determinants of maternal near miss and mortality at the maternity teaching hospital, erbil city, iraq. oman med j 2017;32:386-95. 26. adeoye ia, onayade aa, fatusi ao. incidence, determinants and perinatal outcomes of near miss maternal morbidity in ileife nigeria: a prospective case-control study. bmc pregnancy childbirth 2013;13:93. 27. de moraes app, barreto sm, passos vma, et al. severe maternal morbidity: a case-control study in maranhao, brazil. reprod health 2013;10:11. 28. hailu m, gebremariam a, alemsged f. knowledge about obstetric danger signs among pregnant women in alettawondo district, sidama zone, southern ethiopia. ethiop j health sci 2010;20:25-32. 29. world health organization. standards for maternal and neonatal care. https://iris.who.int/bitstream/handle/10665/697 35/a91272.pdf?sequence=1. 30. federal democratic republic of ethiopia ministry of health. national reproductive strategy 2006-2015. 2006. available from: https://www.exemplars.health/-/media/files/nmmr/ethiopia-national-reproductive-health-strategy-20062015.pdf. article [healthcare in low-resource settings 2024;12:12474] [page 375] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2014; 2:4796] [page 55] advocating contribution of private sector in fighting tuberculosis in india saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india dear editor, the global tuberculosis (tb) report revealed that in the year 2013, almost 11.7 million new cases of tb have been reported, of which india accounts for more than a quarter.1 similar trends have been suggested even for drug resistant tb.1 the disease has reached enormous proportions in the country because of the favorable environmental attributes, weak public health care delivery system and limited involvement of all stakeholders.2,3 the private sector plays a crucial role in the indian set-up as almost three-fourth of the country’s population utilize private sector for their health related ailments preferentially.2 in-fact, for india to accomplish the millennium development goal no. 6, the key strategy will be to include private sector within the existing strategies.4 thus, to build linkages with the private sector and other health care establishments, the revised national tb control program (rntcp) has initiated multiple schemes, namely tb advocacy, communication, and social mobilization scheme; sputum collection center scheme; sputum pick-up and transport service scheme; designated microscopy-cum-treatment center scheme; laboratory technician scheme; culture and drug sensitivity testing scheme; treatment adherence scheme; slum scheme; tb unit scheme; and tb-hiv scheme, to promote the involvement of private sector.4,5 the basic idea behind these schemes is to assist the private sector financially and logistically to improve the reach of the services to remote areas of the country where public health sector is weak.4,5 the role of the program manager is crucial starting from the identification of the issues that need to be addressed; joint planning with the private provider; timely release of money; and to ensure regular monitoring and evaluation.2,4,5 in addition, the program managers have attempted to widen the horizon of services by establishing linkages with multiple professional associations for expanding the range of services.1,2 thus, periodic trainings/sensitization sessions have been also organized to enlighten the private practitioners about the provisions involved in rntcp.2,4 in conclusion, incorporation of the private health sector in country’s national program can significantly improve the range and reach of tb related diagnostic and therapeutic services. however, this necessitates active supervision by program managers and health care professionals to allow optimal participation of the private sector. references 1. who. global tuberculosis control report 2012. geneva, switzerland: world health organization; 2012. 2. iips. national family health survey (nfhs3) 2005-06. mumbai, india: international institute for population sciences publ.; 2007. available from: http://www.measuredhs.com/pubs/pdf/sr128/sr128.pdf 3. shrivastava sr, shrivastava ps, ramasamy j. implementation of public health practices in tribal populations of india: challenges and remedies. healthc low resour settings 2013;1:e3. 4. tbc india. managing the rntcp in your area. a training course (modules 5-9). available from: http://tbcindia.nic.in/documents.html 5. tbc india. guidelines for pmdt in india; 2012. available from: http://tbcindia.nic.in /documents.html healthcare in low-resource settings 2014; volume 2:4796 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com key words: private sector, tuberculosis, india. contributions: ss, conception and design, drafting of the article, review of literature, guarantor; ps, drafting of the article, review of literature, critical revision for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interests: the authors declare no potential conflict of interests. received for publication: 24 october 2014. revision received: 8 november 2014. accepted for publication: 8 november 2014. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright s.r. shrivastava et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:4796 doi:10.4081/hls.2014.4796 non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12563 new aspects of immunological risk factors in the treatment of recurrent pregnancy loss gultakin aliyeva,1 samangul tarverdiyeva,2 matlab ibrahimov1 1department of general medicine and clinical subjects, nakhchivan state university, nakhchivan; 2department of general medicine, bail branch of the clinical laboratory center “referans”, baku, azerbaijan abstract recurrent pregnancy loss (rpl) is diagnosed in 3% of all patients of reproductive age and is of high interest to reproductive medicine specialists. immunological predispositions are among the crucial risk factors for rpl development in female patients suffering from rpl. therefore, the purpose of this work is to investigate the role and effectiveness of individualised immunological treatment approaches by analysing several clinical cases with diagnosed pregnancy loss and the results of tailored immunological therapies. based on 25 years of clinical experience and scientific research the paper analysed the relationship between human leukocyte antigens (hla) tissue compatibility and abo blood group system incompatibility in immunological pregnancy failure. the connection of these factors was shown in 2 clinical cases suffering from rpl who agreed to participate in research. research was performed at nakhchivan birth center and nakhchivan state university. the results of the study provided evidence based on these cases of rpl that ended with successful childbirth after the suggested genetic assessment and immunological treatment. individual treatment of immunological pregnancy failure with hla and abo blood group incompatibilities showed more effective outcomes if compared to previous schemes of treatment. hla compatibility in loci 3 combined with affinity on the abo system strongly demanded immunological therapy prescription for successful implantation of the blastocyst. the outcomes obtained from the study can be implemented in obstetrics and gynecology for the improvement of clinical cases suffering from rpl. introduction recurrent pregnancy loss (rpl) is a reproductive disorder that is diagnosed after 2 or more registered cases of impaired and terminated pregnancies. there are different causes of recurrent miscarriages. recurrent early miscarriages (within 5-6 weeks) are most commonly due to genetic or immunological reasons.1,2 autoimmune problems cause miscarriage usually during 9-10 weeks of pregnancy. as mentioned by chester  et  al.,3 recurrent late miscarriages (after 16 weeks) can be the result of uterine abnormalities, autoimmune problems, an incompetent cervix, infectious diseases, hemostatic dysfunctions, and others. in azerbaijan, rpl is a leading reproductive problem that demands specific scientific investigations in the population.4 a variety of rpl causes are being discovered, and it can be treated in many cases. it is still reported that over 50% of cases with rpl are developing due to unknown reasons. as several studies conducted in azerbaijan show, rpl among azeri women is often associated with genetic and immunological pathologies, which is why it is important to investigate immunological ways of rpl treatment.5,6 among all clinically recognised pregnancies, 15% end in miscarriage, according to vomstein  et  al.,7 and approximately 16-20% of all conceptions are lost and the majority occur before even being noticed. often, the failure of repeated pregnancies is considered a pathological syndrome caused by a genetically determined polyethiological complex of symptoms. research conducted in azerbaijan shows the implementation of classical protocols for rpl treatments that do not always show successful results, as mentioned by yousefian et al.5 in the us, screening for thrombophilias and other genetic, anatomical, endocrine, and immunologic factors is advised by the american society for reproductive medicine’s guidelines.8 the course of treatment for a certain condition may involve the use of correspondence: gultakin aliyeva, department of general medicine and clinical subjects, nakhchivan state university, nakhchivan, azerbaijan. e-mail: aliyevagultakin4@gmail.com key words: infertility, reproductive immunology, human leukocyte antigen system, blood group, implantation. contributions: ga, conceptualisation, data curation, formal analysis, methodology, validation, visualisation, writing – original draft, review and editing; st, conceptualisation, investigation, methodology, validation, and writing – original draft, review and editing; mi, conceptualisation, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. + received: 12 april 2024. accepted: 14 june 2024. early view: 8 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12563 doi:10.4081/hls.2024.12563 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12563] [page 53] non -co mmerc ial us e o nly low-dose aspirin, heparin, progesterone supplements, and intravenous immunoglobulin. according to guidelines from the royal college of obstetricians and gynaecologists in the united kingdom, women who are afflicted with antiphospholipid syndrome should be offered aspirin and heparin.9 certain cases additionally call for progesterone supplements and immunotherapies such as intravenous immunoglobulin. in china, conventional western treatments for rpl are occasionally combined with traditional chinese medicine techniques including acupuncture and herbal formulations. according to a study by zhao et al., live birth rates increased when prednisone and aspirin were used with chinese herbal medicine.10 to understand the etiology of rpl and investigate appropriate treatment tools, it is essential to estimate the predispositions, fertilisation, and implantation processes impairment. to achieve successful implantation of a fertilised egg that is at stage of blastocyst, the endometrium of the uterus should undergo structural and functional remodelling for the maintenance of the embryo, as mentioned by moqadami  et  al.4 immunological preparation of the endometrium takes place from the 4-5th day of fertilisation to blastocyst implantation and is essential for early gastrulation and embryogenesis. the blastocyst enters the uterine cavity and penetrates the endometrium on around 7th to 8th days after conception. after implantation, the immune response to the pregnancy that occurred at the humoral level in the endometrium begins. as mentioned by tomkiewicz and darmochwał-kolarz, different immunological processes during implantation in the endometrium may cause tolerogenic conditions, in which human leukocyte antigens (hla) factors play a crucial role in rpl.11 over 30% of healthy females develop anti-hla antibodies through different gestation periods, as said by shields et al., which makes this issue important for novel methods of treatment.12 connection of antibodies to paternal hla agents of the embryo may result in complement binding and antibody-driven rejection of the embryo.13,14 in female patients suffering from rpl detection of anti-hla antibodies is strongly linked with a decreased possibility of a live birth. therefore, the importance of hla compatibility is a topical issue for the current obstetrics and gynecology field in the focus on maintaining healthy pregnancies.15 by offering insightful information about the function of immunological variables, particularly hla compatibility and abo blood group incompatibility, in the management of rpl, this study closes a significant gap in the body of current literature. through the examination of clinical cases with differing levels of abo blood group (in)compatibility and hla compatibility, the study highlights the necessity of customised immunological treatment strategies based on these unique immunological profiles. a thorough analysis of abo and hla variables leads to a more sophisticated comprehension of the immunological processes behind rpl and provides direction for individualised therapeutic approaches. this research emphasises the interaction between hla compatibility and blood group incompatibility and their combined impact on treatment results, whereas other studies have examined the individual contributions of these 2 parameters. this study aimed to investigate new aspects of immunological treatment for rpl by examining clinical cases with diagnosed rpl and the results of individualised immunological treatment approaches. the main objectives were the following: i) to assess the impact of targeted immunological therapies, such as lymphocyte immunisation therapy (lit) and desensitisation treatment, on improving pregnancy outcomes for couples with rpl; ii) to examine the relationship between abo blood group incompatibility and hla tissue compatibility as immunological risk factors for rpl. materials and methods in order to evaluate effectiveness of immunological treatment of rpl, the research involved the examination and treatment process adjustment of 2 couples both diagnosed with rpl. rpl is estimated as two or more consecutive, spontaneous miscarriages occurring during the first trimester, with the same partner. because increased maternal age and number of previous miscarriages are shown to increase the risk of further rpl the study involved only patients of middle or young age. more thorough testing should be taken into consideration if the woman is older than 30 years and has experienced 3 losses, or if she is younger than 30 years and has experienced 2 unexplained, recurrent miscarriages. patients for the research were introduced among those applied to nakhichevan birth center suffering from spontaneous miscarriages and with no successful pregnancies in anamnesis. patients and their partners were required to take blood tests to exclude infectious diseases such as acquired immune deficiency syndrome (aids) (condition caused by the human immunodeficiency virus, hiv, which attacks the immune system of the body, making it difficult to fight off infections and diseases). additional demands for inclusion in the research included: participants had negative cervical mucus culture and cellular results, healthy karyotype assessment results; harmonised hormonal status without signs of hyperprolactinemia (abnormally high levels of the hormone prolactin in the blood) or hyperandrogenaemia (excessive levels of androgens male sex hormones such as testosterone in the body); absence of diagnosed endocrine pathologies including diabetes mellitus and thyroid pathology; negative antinuclear antibody and anticardiolipin antibody results; semen analysis results without pathologies. the main demand for the couples who were suffering from unexplained rpl diagnosis was to have corresponding records of treatment and outcome. to get involved in the study, informed consent was mandatory to be signed by both representatives of the couple. every procedure used in the study complied with the 1964 helsinki declaration and its subsequent revisions, as well as the institutional research committee’s ethical requirements. given hla is a genetic incompatibility related to the leukocyte antigen, both couples have undergone hla genetic assessment. hla genes are crucial regulatory factors in controlling the immune system during pregnancy and organ transplantation, which was of interest for rpl in both investigated couples. the greater immunogenic dissimilarity of maternal-fetal (hla haplotype, inherited from the father) hla compatibility increases the chances of successful, naturally conceived pregnancies, the accomplishment of which was the target for the treatment. if the fetus receives 50% of allogeneic information from the father, it means that the successful morphogenesis of the fetus relies on hla incompatibility. analysing the precise maternal immunological tolerance (the ability of the maternal immune system to tolerate and not reject the semi-allogeneic fetus during pregnancy) towards the embryological tissue is essential for patients with prl in order to provide implantation and a further healthy pregnancy. here, in contrast to organ transplantation, the high level of mismatch of protein structure in maternal-fetal hla antigens is a main criterion of clinical research. normally, starting from the initial week of gestation, the mother’s body secretes antibodies against the foetal antigen, produced by embryological tissue. in most cases, these antibodies are established against class 2 antigens. it means that if partners’ class 2 antigens are similar, the women’s body accepts it as compatible and suspends forming pro social and political factors affecting public health [page 54] [healthcare in low-resource settings 2024;12(s2):12563] non -co mmerc ial us e o nly tective, blocking immune clones. thus, insufficient antibody-antigen stimulation results with spontaneous miscarriage or severe toxicosis. the risk of miscarriage is 100% if partners share the same hla class 2 antigens. hla typing is important to confirm the diagnosis. for this purpose, blood cells that perform immunological function – leukocytes are separated from the blood taken from the elbow veins of all participants. additionally, hla-a, -b, -dr, -dq and -c personal material typing was done with the help of polymerase chain reaction. results clinical case i (patient i) clinical case i which has been evaluated and managed is represented by a couple with burdened clinical anamnesis. due to privacy issues, the names and personal data of patients are hidden. patient i was 30 years old and had experienced 3 clinically confirmed failed pregnancies. all 3 pregnancy losses were diagnosed and undergone at early gestational weeks (from 6th to 7th weeks of pregnancy). patient i has undergone uterine curettage and had in total 5 years of unprotected sex life with the same partner, who is her spouse. the partners share the same blood group which is o (i) rh+. the couple has undergone hla tissue testing, indicators of which can be found in table 1. when analysing the final outcomes of the hla tissue type examinations from clinical case i of patient i, one may observe the match for 3 antigen types. these antigens include a+-04; b+51 and cw+-15 which are clearly seen as positive. if partners have 2 or more gene loci matching, the probability of pregnancy miscarriage reaches up to 100%. medical management of patient i in clinical case i was performed by active and passive immunisation prescription. active immunisation was carried out with the concentrated white blood cell mass of the father (donor), with immunised leukocyte solutions. in lit, which stands for immunological treatment with activated lymphocytes, the concentrated lymphocyte mass of the partner (or the donor, in case of diagnosed incompatibility) is inoculated to the woman (patient with rpl). in clinical case i, patient i was receiving the concentrated lymphocyte mass of the spouse partner under standard clinical protocol. during the conduction of the lit method, the woman’s immune response (patient i) was clinically established to increase by 10,000 times (if compared to initial data). immunological treatment with lymphocytes was repeated several times strictly within the period from 6th to 8th day of the menstrual cycle and throughout clinically approved pregnancy. no side effects have been recorded or reported by patient i. during the implementation and conduction of this treatment method, the main aim was to somehow teach a woman’s body (patient i) to recognise her partner’s sex cells in order to achieve successful fertilisation, implantation, and further intrauterine development of the embryo. however, during the inpatient management of clinical case i, it was important to balance between 2 strategies of the lit method, more importantly considering immunological aspects. to achieve maximal treatment effects, the protocol included both immunotherapy with lymphocytes due to its high effects reported,13 as well as passive immunisation. such tactics were supported by literature research: carbonnel et al.13 refer to the high effect of immunotherapy with lymphocytes, yet habets et al.14 claim that the usage of immunological methods is not of such importance, and that it is impossible to achieve a successful pregnancy result for patients with rpl with passive immunisation only. during passive immunisation in clinical case i, the protocol was adjusted to current demands and guidelines. passive immunisation of patient i was conducted strictly on the day of ovulation which was approved by ultrasound investigation and basal temperature. in order to perform passive immunisation through inpatient conditions, the doctors performed intravenously transferring of human immunoglob social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12563] [page 55] table 1. diagnostics results of patient i and her partner (spouse). hla results from a female patient a+ b++ c+ dr+ a+-02 b+-50 cw+-02 d rbi+-14 a+-03 b+-26 cw+-15 d rbi+-09 hla results from a male patient a+ b++ c+ dr+ a+-04 b+-51 cw+-14 d rbi+16 a+-11 b+-51 cw+-11 d rbi+-03 hla, human leukocyte antigens. source: composed by the authors. table 2. diagnostics results of the patient ii and her partner (spouse). hla results from a female patient dr-b1 dq-a1 dq-b1 4’11 0301-05-1 0305 301-4 hla results from a male patient dr-b1 dq-a1 dq-b1 4’11 0301-05-1 03-02 301-4 hla, human leukocyte antigens. source: composed by the authors. non -co mmerc ial us e o nly ulin material 3-4 times during pregnancy which stimulates the woman’s immune response. in the case of hla matching (which was the case for patient i), 50 ml of 3 human normal immunoglobulin daily injections were recommended to transfer every month. the 50 ml dosage was selected to keep the patient’s systemic immunoglobulin levels steady and sufficient throughout the day. the immunoglobulins may remain longer in the body as a result of the numerous daily injections, which may improve their capacity to interact with pertinent antigens and influence the immune response. for patient i passive immunisation did not show any positive effects. since passive immunisation was ineffective, lit therapy was administered to patient i. lymphocyte immunisation therapy was prescribed as a monotherapy without passive immunisation. after treatment with lit, patient i gave birth to her first child. the newborn was a healthy girl, with no congenital malformations, weighed 3,100 gr, and was born on 19 march 2013. clinical case ii (patient ii) clinical case ii of proposed investigation included patient ii. patient ii was 31 years old and met all requirements of the research as she had experienced 4 pregnancies in total, all of which failed during the early gestational weeks (in the time frame from the 6th to the 7th weeks of pregnancy). patient ii has undergone uterine curettage and has reported 5 years of unprotected sex life with the same partner (who is her official spouse). the couple has undergone hla tissue testing, and their outcomes can be found in table 2. as seen from the results of diagnostic hla testing, since there was a 50% match between 4 compatible antigens in the hla material type assessment, it was highly recommended to perform an immunotherapeutic lit clinical therapy for representatives of clinical case ii. because lit therapy is quite an expensive method for rpl treatment and is not covered by state insurance, the couple of clinical case ii refused this offer and decided to continue their treatment at nakhchivan birth center. in addition to detected 4 similar alloimmune markers, which are 4’11, 0301 and 05-1, 301-4, evidence of additional infections (herpes, toxoplasmosis, chlamydia) and results of abo-system indirect coombs test 1:256 detected, which was a reason to latent sensitisation (process by which the immune system becomes activated and primed to respond to a particular antigen (foreign substance)) between partners. neamţu et al.16 suggest that incompatibility on the abo-blood group system becomes dominant during the incompatibility on the rh system, and fetal hemolytic disorder becomes predictably milder. specially designed treatment for clinical case ii was commenced, after the authors of the current study proved to deliver positive treatment results in case partners have 3-4 loci hla tissue compatibility in the relationship with ab-o system incongruence. during the treatment course the fact that some microorganisms (viral and bacterial infections) cause hidden sensitisation, trigger isoimmune, autoimmune and alloimmune processes during pregnancy, and genetically mimic blood groups of some pathogens was considered.17 the clinical case ii couple underwent a rehabilitation program before planning pregnancy. a course of desensitising treatment was prescribed for the elimination of abo blood type incompatibility marks. as a result, several causes of early pregnancy losses were detected: post-implantation pregnancy failure, endometrial insufficiency (for feasible implantation of the firstweek embryo), and rejection of primary embryologic tissue by the mother’s organism.18,19 these factors were eliminated but continued to be possible risk factors for early stages of potential pregnancy, stillbirth or childbirth with low viability. the couple received specific therapy for viral and bacterial infections, immunosuppressive therapy, desensitising treatment for abo-system incompatibility before conceiving. the treatment ended successfully and patient ii delivered a healthy newborn girl (3,500 gr of weight). patient ii currently has 2 healthy daughters. to sum up, the examination of these 2 clinical instances emphasises how crucial it is to take into account both abo blood group incompatibility and hla compatibility while treating recurrent pregnancy loss immunologically. the findings show that more intense lit is necessary for favourable treatment outcomes when partners show hla compatibility at locus 3 together with abo blood group compatibility. however, in cases where hla compatibility is seen at the 4th locus coupled with abo blood group incompatibility, a milder therapeutic approach incorporating desensitisation treatment may be appropriate. notably, the results indicate that at the 3rd and 4th loci, abo blood type incompatibility is more important than rh incompatibility and hla compatibility, requiring a gentler therapeutic approach specifically targeted to address the abo incompatibility. therefore, for couples experiencing recurrent pregnancy loss, the combination of abo blood group (in)compatibility and hla compatibility at specific loci serves as a guiding factor in determining the appropriate immunological treatment strategy, ultimately improving the chances of successful pregnancy and childbirth. discussion rpl can be developed under the influence of chromosomal impairment, anatomical endometrial defects, autoimmune diseases, and uterine dysfunction.20-22 in practical medicine, obstetrics insists that infectious causes of bacterial and viral diseases do not cause rpl, thus some researchers do not recommend undergoing relevant examinations. still, it should be considered that endometrium, impaired by specific or non-specific inflammation, and damaged by viral and bacterial infections, leads to incomplete nidation, poor quality progress of blastoand embryogenesis, and disruption of embryo’s nutrition that may lead to the development of rpl.23,24 thus, the chronic and acute inflammatory process have direct and indirect effects that as a result of triggering autoand alloimmune processes in the disruption of pregnancy will cause an incomplete implantation and malnutrition in female patients. as mentioned by ali  et  al., these may lead to rpl as well.25 it becomes clear that above mentioned direct and indirect causes of rpl should be considered for achieving successful treatment results in patients with laden anamnesis. thus, when diagnosing rpl for immunological reasons as in the clinical case i, hla tissue matching at 3-locus accompanied by abo matching (both o(i) rh+) required more intensive lit therapy treatment. in addition to hla, abo, rh and other rare blood system mismatches, latent sensitisation, and viral and bacterial infections should not be overlooked, as mentioned by barbaro et al.26 depending on the etiological reason of pathological process in the endometrium and female reproductive tract, a specific factor creates corresponding cascades of non-specific inflammation – endometritis, disrupting the physiological preparation for pregnancy in the uterus.27,28 a study by thomsen et al.29 was conducted with rpl patients who have undergone hladrb-1 typing by dna-based methods for detecting or hladrb1*07 evaluation allele frequency. the authors statistically approved the association linking hla-drb1*07 with rpl which may be different from previous papers which established an association between hla-drb1*03 and rpl. these data differ from social and political factors affecting public health [page 56] [healthcare in low-resource settings 2024;12(s2):12563] non -co mmerc ial us e o nly outcomes received in the current paper, but one may suggest the connection of genetic predispositions with rpl development. the currently conducted study achieved successful childbirth after lit prescription, creating a strong maternal immune response. in case ii hla material compatibility at the 4-locus and abo erythrocytes system compatibility (abo titter 1/256) was detected. because bacterial and viral infections mimic blood groups, by treatment of dominant abo incompatibility the immune status that leads to successful pregnancy and childbirth was established. resembling paper was published by aimagambetova et al.: the research has discussed the contribution of drb-1, dqb-1, and dpb-1 hla class 2 alleles with final 3locus haplovariants to the general possible risk of rpl development.30 authors deliver outcomes that show a relatively low influence of class 2 alleles and appropriate 3-locus haplotypes to the impaired development of rpl development among diagnosed female patients. as ajmal et al. propose, antigen hiding is a process that leads towards immune evasion by the embryological cells of the blastocyst and fetus as the placental barrier lacks hla expression.31 nevertheless, the hla agents that are indicated by the extraembryonic trophoblastic cells influence maternal immune response towards a protective activation, primary to acceptance of the embryonic tissues and structures. some reasons that cause the rpl have been represented previously. researchers prove a list of conditions, including uterine congenital malformations and topographical anomalies, endometrial insufficiency, and hormonal background as diseases that may be linked with rpl development as risk factors.32 elbaşı  et  al. emphasise that for rpl development a few immunological factors impairment should be combined.33 their research, conducted in a selected population with rpl, claims that male hla-c2 homozygosity may influence rpl development. authors have also established an incidental match between male patients’ hla-c2 and female patients’ hla-c1 ligand killer-cell immunoglobulin-like receptors (kir) might disturb the activatory and inhibitory homeostasis in kir-ligand connections during different gestation periods in couples with rpl. by means of different diagnostic methods and specific treatment approaches, current research delivers immunological parameters that vary between partners, including hla and abo blood group incompatibilities. referring to the deliverables of the examination, it is advisable to recommend immunological diagnostics and treatment therapies for patients suffering rpl that provide an overview of the promising immune alteration of rpl.34,35 when summarising the results of investigated cases considering therapeutic and diagnostic strategies of immunologic predisposing factors for rpl patients following can be concluded. first of all, the compatibility of 3-4 loci on the hla genes between partners has specific patterns. the similarity of partners’ class 2 antigens during the alloimmune process, the mother’s body is similar to fetus, thus clones of immune cells that protect and block pregnancy are not formed, and insufficient antibody-antigen stimulation causes miscarriage and rpl. secondly, partners’ hla tissue compatibility at 3-4 loci, abo erythrocytes method compatibility (abo titter 1/128, 1/256), bacterial and viral infections mimic blood groups. in this case, the compatibility of the abo blood system will be prior and therefore easily treated. and lastly, the dominant abo incompatibility is treated by desensitisation therapy which recovers immune status and leads to successful pregnancy results. it may be concluded that final data from the current research can be used in the fields of obstetrics, gynecology, and reproductive medicine for modernisation of individual treatment of patients and couples suffering from rpl, as well as better initial treatment of female patients with infertility risk factors. presented data is useful for the field of reproductive medicine, obstetrics, and gynecology for better management of clinical cases with rpl. conclusions the conducted research has provided comparative data of 2 couples, each suffering from clinically diagnosed rpl with hla compatibility at 3rd and 4th loci. in provided clinical case i, partners were found to be compatible with 3 loci during hla typing and compatible according to the аbо blood group system; both of them share the same blood group (o(i), rh+). in clinical case i female patient was treated with lit that has shown successful outcomes. patient i resulted in the natural delivery of a healthy female newborn weighing 3,100 grams. in clinical case ii, the couple has suffered from rpl (recorded 4 pregnancy failures within 6-7 weeks of pregnancy). during the hla typing test compatibility with partners at loci 4 was discovered. incompatibility detected in ab-o blood group system (title 1/256). the couple refused lit therapy, but the woman received desensitisation treatment according to the ab-o system accompanied by infectious diseases treatment that is among the main causes of masked desensitisation, abo type mimicry. despite the fact that patient ii did not receive lit therapy, her desensitisation treatment resulted in the birth of a healthy newborn weighing 3,500 grams. therefore, it may be concluded that hla affinity on loci 3 combinations including affinity on the ab-o system demands lit treatment and can show positive clinical results. compound treatment of incompatibility on the аb-о system, with hla on loci 4 compatibility, demands softer therapy. as a result, incompatibility according to the abo system, both with rh incompatibility and with hla affinity on loci 3-4, showed a controlling character with a need for milder therapy. future steps of the research topic expansion can include a wider range of patients (including different age groups and preliminary anamnesis) and additional indexes for diagnostic analyses. references 1. svyatova gs, mirzakhmetova dd, berezina gm, murtazaliyeva av. genetic factors of idiopathic recurrent miscarriage in kazakh population. j reprod infertil 2022;23:3945. 2. boichuk oh, dorofeieva us, kolomiichenko tv. hormonal and genetic causes of poor response to controlled ovarian stimulation in women of late reproductive age. reprod endocrinol 2022;66:62-7. 3. chester mr, tirlapur a, jayaprakasan k. current management of recurrent pregnancy loss. obstet gynecol 2022;24:260-71. 4. moqadami a, rezaei a, ahmadi a, et al. investigating the association of mthfr c677t gene polymorphism with recurrent spontaneous abortion among azerbaijani women from northwest iran. genet test mol biomarkers 2023;27:339-44. 5. yousefian m, angaji sa, siasi e, et al. association of polymorphisms of f2 (rs3136520) and pai-1 (rs6090) genes with recurrent pregnancy loss in iranian azeri women. avicenna j clin med 2021;28:118-25. 6. abbaszadeh e, rahmani sa, danaei mehrabad s. prevalence of mutations in v leiden and prothrombin genes in women with recurrent pregnancy loss: a retrospective study on iranian social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12563] [page 57] non -co mmerc ial us e o nly azeri women. j basic res med sci 2020;7:22-7. 7. vomstein k, feil k, strobel l, et al. immunological risk factors in recurrent pregnancy loss: guidelines versus current state of the art. j clin med 2021;10:869. 8. practice committee of the american society for reproductive medicine. evaluation and treatment of recurrent pregnancy loss: a committee opinion. fertil steril 2012;98:1103-11. 9. regan l, rai r, saravelos s, et al. recurrent miscarriage: green-top guideline no. 17. bjog 2023;130:e9-e39. 10. zhao x, wang s, du t, et al. demystifying the landscape of endometrial immune microenvironment in luteal-phase from cuprotosis: implications for the mechanism and treatment of rpl. gene 2024;903:148191. 11. tomkiewicz j, darmochwał-kolarz d. the diagnostics and treatment of recurrent pregnancy loss. j clin med 2023;12:4768. 12. shields r, hawkes a, quenby s. clinical approach to recurrent pregnancy loss. obstet gynaecol reprod med 2020;30:331-6. 13. carbonnel m, pirtea p, de ziegler d, ayoubi jm. uterine factors in recurrent pregnancy losses. fertil steril 2021;115:53845. 14. habets dh, al-nasiry s, nagelkerke sq, et al. analysis of fcgr3a-p.176val variants in women with recurrent pregnancy loss and the association with cd16a expression and antihla antibody status. sci rep 2023;13:5232. 15. ayazbekov a, nurkhasimova r, ibrayeva d, et al. evaluation of women’s health with intrauterine fetal death in the city of turkestan for the years of 2013-2017. ann tropic med public health 2018;17:s804. 16. neamţu sd, novac mb, neamţu av, et al. fetal-maternal incompatibility in the rh system. rh isoimmunization associated with hereditary spherocytosis: case presentation and review of the literature. rom j morphol embryol 2022;63: 229-35. 17. nazarchuk o, dmyrtriiev d, babina y, et al. research of the activity of local anesthetics and antiseptics regarding clinical isolates of acinetobacter baumannii as pathogens of postoperative infectious complications. acta biomed 2022;93:e2022003. 18. kulyk ii, khmil sv. endometriosis-associated infertility: the role of hormones and its correction. int j med med res 2020;6:5-10. 19. mialiuk op, sabadyshyn ro, demianchuk mr, et al. biochemical indices of blood in women suffering from anovulatory infertility during xenical treatment. bull med biol res 2022;4:75-9. 20. sultana s, nallari p, ananthapur v. recurrent pregnancy loss (rpl): an overview. j womens health dev 2020;3:302-15. 21. moshkalova g, karibayeva i, kurmanova a, et al. endometrial thickness and live birth rates after ivf: a systematic review. acta biomed 2023;94:e2023152. 22. van dijk mm, kolte am, limpens j, et al. recurrent pregnancy loss: diagnostic workup after two or three pregnancy losses? a systematic review of the literature and meta-analysis. hum reprod update 2020;26:356-67. 23. yu n, kwak-kim j, bao s. unexplained recurrent pregnancy loss: novel causes and advanced treatment. j reprod immunol 2023;155:103785. 24. dimitriadis e, menkhorst e, saito s, et al. recurrent pregnancy loss. nat rev dis primers 2020;6:98. 25. ali s, majid s, ali mn, et al. evaluation of etiology and pregnancy outcome in recurrent miscarriage patients. saudi j biol sci 2020;27:2809-17. 26. barbaro g, inversetti a, cristodoro m, et al. hla-g and recurrent pregnancy loss. int j mol sci 2023;24:2557. 27. pirtea p, cicinelli e, de nola r, et al. endometrial causes of recurrent pregnancy losses: endometriosis, adenomyosis, and chronic endometritis. fertil steril 2021;115:546-60. 28. khmil doswald аs, malanchuk lm. hysteroscopic and morphological evaluation of endometrium in reproductive age women with comorbid polycystic ovarian syndrome and chronic endometritis in the protocols of in vitro fertilization. bull med biol res 2022;4:103-9. 29. thomsen ck, steffensen r, nielsen hs, et al. hla-drb1 polymorphism in recurrent pregnancy loss: new evidence for an association to hla-drb1*07. j reprod immunol 2021;145:103308. 30. aimagambetova g, kapasheva a, bahia w, et al. maternal hla class ii alleles and haplotypes associated with altered risk of recurrent pregnancy loss: a case‐control study. am j reprod immunol 2024;91:e13817. 31. ajmal l, ajmal s, ajmal m, et al. hla system and its participation in recurrent pregnancy loss. pak j zool 2022;54:190516. 32. irinyenikan ta. risk factors for female infertility at a tertiary health facility in akure, south-west nigeria. int j med med res 2019;5:61-8. 33. elbaşı mo, tulunay a, karagözoğlu h, et al. maternal killercell immunoglobulin-like receptors and paternal human leukocyte antigen ligands in recurrent pregnancy loss cases in turkey. clin exp reprod med 2020;47:122-9. 34. zaychenko gv, karpenko no, striga ea, sinitsyna os. pharmacological management of menopausal disorders: the phytoestrogenes (review). probl endocr pathol 2018;66:65-74. 35. schapovalova o, gorlova a, de munter j, et al. immunomodulatory effects of new phytotherapy on human macrophages and tlr4and tlr7/8-mediated viral-like inflammation in mice. front med 2022;9:952977. social and political factors affecting public health [page 58] [healthcare in low-resource settings 2024;12(s2):12563] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11939 the relationship between personality type and fulfillment of basic needs with the fomo syndrome among adolescents in east java dhian satya rachmawati, a.v. sri suhardiningsih, rizky dzariyani laili, sisi istiyana dewi sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia abstract fear of missing out (fomo) stems from individuals’ dissatisfaction with their basic needs, and each individual develops distinct fomo characteristics. this research aimed to analyze the relationship between personality types, fulfillment of basic needs, and the incidence of fomo syndrome in east java. we employed a correlational approach with a cross-sectional design for the study. the study’s population comprised youths aged 12-25 in east java. we obtained our research sample, consisting of 140 individuals, through proportionately stratified random sampling. the instruments we used included the jung personality type indicator, a basic needs assessment, and the fomo questionnaire. we analyzed the data using the chi-square test (p<0.05) and spearman’s rho (p<0.05). our research findings indicated that the prevalent personality type in east java was introverted, with 84 youths (60.0%). additionally, 125 youths (89.3%) reported a high level of adequately met needs, while 71 (50.7%) fell into the moderate fomo category. the chi-square test revealed a significant correlation between personality type and the incidence of fomo syndrome (p=0.000). similarly, spearman’s rho indicated a significant link between meeting basic needs and the occurrence of fomo syndrome (p=0.000). adolescents with both introverted and extroverted personality types, coupled with low basic needs satisfaction, were more prone to experiencing fomo syndrome. our study’s implications underscored the necessity of increasing motivation to fulfill basic needs, thereby mitigating the likelihood of experiencing fomo. introduction most human stressors are psychological.1 adolescents suffer from various forms of psychosocial, behavioral, mental, and emotional problems.2,3 the prevalence of mental health issues among adolescents is on an increasing trend.4 fomo, or fear of missing out, is defined as a feeling of anxiety or fear of being left behind by other people. fomo syndrome occurs when individuals feel depressed upon seeing posts by friends, artists, or relatives containing amazing photos on social media, assuming that these individuals live better, more successful, more exciting, and more interesting lives than they do.5 the stress experienced by adolescents, coupled with their development, designates this period as a critical phase with a dramatic increase in internalization problems.6 fomo can be interpreted as self-regulation that arises from individual dissatisfaction because their basic needs are not met. melvin lawrence defleure proposed the theory of individual differences, suggesting that variations in fomo syndrome exist between individuals due to their unique characteristics. this leads to the emergence of various reactions, such as different expressions and behaviors.7 the factor driving these differences in reactions is the personality type of each individual.8 in fact, fomo is not limited to things on social media; however, social media involvement significantly influences the incidence of fomo, shaping the daily lives of digital natives, commonly referred to as millennials (circa 1981 to 1996) and gen z (post-millennial, circa 1997 to 2012).5 a research study on internet users experiencing fomo was correspondence: dhian satya rachmawati, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia. e-mail: dhiansatyarachmawati@stikeshangtuah-sby.ac.id key words: basic need, fear of missing out, personality type. contributions: dsr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; avs, conceptualization, methodology, writing – original draft, review and editing; rdl, methodology, validation, visualization, writing – original draft, review and editing; sid, conceptualization, formal analysis, writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from commission ethics research, faculty of nursing, sekolah tinggi ilmu kesehatan hang tuah, based on ethical certificate pe/17/vi/2022/kep/sht. during the research, the researcher pays attention to the ethical principles of information to consent, anonymity and confidentiality. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. apart from that, in the informed consent, it was written that the respondent had been given an explanation regarding the publication of the article, and the respondent knew that the publication of this article could encourage developments about the relationship between personality type and fulfillment of basic needs with the incident of fear of missing out (fomo) syndrome in adolescents in east java. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank sekolah tinggi ilmu kesehatan hang tuah surabaya and all respondents for their contributions to this study. received: 10 october 2023. accepted: 6 february 2024. early access: 7 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11939 doi:10.4081/hls.2024.11939 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 426] [healthcare in low-resource settings 2024;12:11939] non -co mmerc ial us e o nly conducted in poland with respondents aged 15-65 years. the findings revealed that the 20-24-year age group had the highest incidence rates of fomo, with a 32% occurrence in the high category. following closely, the 15-19 year age group exhibited a 30% incidence rate.9 meanwhile, a separate study on fomo involved 228 teenage respondents aged 17 years and over in indonesia. results showed that 49.1% of respondents experienced high fomo, while 50.9% experienced low fomo. in java, respondents reported a higher prevalence of low fomo at 51.5%, totaling 101 people, compared to high fomo at 48.5%, totaling 95 people.10 the central statistics agency notes that the teenage population in east java currently reaches 9,089,291 people. based on the results of the preliminary study and to test the validity and reliability of the questionnaire, 50 respondents with an age range of 12-25 years in the east java region were selected. the findings indicated that 48 respondents (96%) had an introverted personality type, while 2 respondents (4%) had an extroverted personality type. in terms of basic needs, 30 respondents (60%) had a medium level, and 20 respondents (40%) had a high level. all respondents experienced fomo syndrome to varying degrees, with 60% in the mild category, 36% in the moderate category, and 4% in the high category. the term fomo was coined by patrick j. mcginnis at the same time the first fomo species was discovered, namely mcginnis himself, who consistently strove to match the lives of his neighbors.5 students with mental health disorders are also observed to have poorer academic attainment, implying that addressing mental health and well-being is crucial for both health and education outcomes.11 mcginnis’s behavior is based on individual characteristics that refer to personality types. fomo tends to be experienced by individuals with extroverted personalities because they enjoy interacting with others and are easily influenced by the surrounding environment. fomo’s journey to dominate the world began with its popularity among american students. symptoms experienced at that time included losing the ability to refuse invitations to parties, dinners, or any events attended by people important to their social network, leading to impulsive behavior.8 fomo’s popularity continued to increase, reaching a wider audience in the professional realm. simultaneously, there was growth in social media and digital marketing, contributing to the introduction of fomo.5 social media users with fomo apparently experience low levels of satisfaction in meeting needs and moods. this can have dangerous impacts because individuals with fomo may behave illogically and impulsively to overcome fomo. for instance, individuals may become obsessed with continually monitoring social media even while driving, feel anxious if not up-to-date with the latest news, encounter problems with self-identity, experience low self-esteem, feel jealous and envious of others, and sense feelings of being left out.12 expanding positive thoughts and narrowing the space for negative thoughts can compensate for mental attacks.13 mental health issues among adolescents can be a burden for individuals, families, and environments.14 the family plays a crucial role in addressing fomo, with relationships between parents and adolescents built on trust and good communication serving as strong protective factors against fomo. when parents and teenagers have a strained relationship at home, adolescents may resort to online communication or social media as an escape to interact with their peers. this behavior can trigger fomo syndrome in adolescents. besides the role of parents in terms of trust and good communication, parenting styles involving both support and control are highly necessary as they strongly influence adolescents’ interactions and use of social media.15 the development of health education is essential so that families can effectively contribute to caring for adolescents.16 based on the background described, researchers are interested in examining fomo syndrome from the perspective of personality types and the fulfillment of basic needs, drawing on abraham maslow’s theory. materials and methods design the research was conducted in june 2022, specifically from june 7th to june 13th. analysis of the relationship between personality type, fulfillment of basic needs, and the incidence of fomo syndrome in adolescents in east java was carried out using a correlational research design. correlational research aims to establish the existence of a relationship between personality type, fulfillment of basic needs, and the incidence of fomo syndrome. the research utilized a cross-sectional approach, wherein data measurements were conducted only once and were limited by time. population, sample, sampling this research employs probability sampling techniques with a proportional stratified random sampling approach. using proportional stratified random sampling allows the population to be divided into several strata, making it easier for researchers to obtain more detailed information in line with research objectives.9 the population in this study consisted of 2,827,275 adolescents in the east java region.10 utilizing the proportional stratified random sampling technique to determine a large sample, the researchers selected five cities or districts in east java with the largest number of adolescents (aged 12-25 years): surabaya (711,730 adolescents), malang (589,340 adolescents), jember (570,479 adolescents), sidoarjo (543,169 adolescents), and pasuruan (412,557 adolescents). this approach was chosen for a more effective assessment. the sample size, calculated using the lemeshow formula, was 140 people living in surabaya, malang, jember, sidoarjo, pasuruan, aged 12-25 years, who were willing to become respondents by filling in the provided online questionnaire. meanwhile, the exclusion criteria in this study were adolescents diagnosed with an anxiety disorder by a doctor or psychiatrist. variables a variable is a characteristic studied in research pertaining to people, objects, animals, places, or natural situations and phenomena. in this research, there are independent variables and a dependent variable. an independent variable is one whose value affects the values of other variables. the independent variables in this research are personality type and the fulfillment of basic needs. the personality type variable will be assessed based on characteristics that stand out in adolescents. the variable of fulfilling basic needs is evaluated based on adolescents’ efforts to support and defend their right to lead healthy lives and maintain interpersonal relationships with others. the dependent variable is one whose value can change due to changes in the values of other variables. the dependent variable in this research is fomo. instruments this research employed a questionnaire instrument for data collection. for the personality type variable, the personality type questionnaire was adopted from utami’s research (2017). the indicators in the questionnaire consist of activity, social ability, ability to take risks, immediate obedience to impulses, expressiveness of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11939] [page 427] non -co mmerc ial us e o nly anger and sadness, depth of thinking, and responsibility. the data scale used is a nominal data scale. for the fulfillment of basic needs variable, the questionnaire on the fulfillment of basic needs was adopted from candra (2020). the indicators in the questionnaire consist of physiological needs, safety and protection needs, love and feeling needs, self-esteem needs, and self-actualization needs. the data scale used is an ordinal data scale with categories: good, enough, and less. next is the fomo variable, where przybylski’s questionnaire (2020) was employed. the data scale used is an ordinal data scale with categories: low, medium, and high. all research instruments used a questionnaire previously tested for validity and reliability and were declared valid and reliable. data collection process the mechanism used by researchers to collect data involves distributing questionnaires online, which include a consent form and several statements according to the variables. the questionnaires will be distributed by the researcher, assisted by friends acting as contact persons located in each selected area for the study. the questionnaires were distributed via various social media platforms and addressed to respondents who met the criteria in the five selected cities or districts. the next steps include checking the questionnaire results, tabulating and processing the data, and drawing conclusions from the results. data analysis the data analysis used was the chi-square test (p<0,05) and the spearman rho test (p<0,05). ethical clearance the research has received ethical approval from commission ethics research, faculty of nursing, sekolah tinggi ilmu kesehatan hang tuah, based on ethical certificate pe/17/vi/2022/kep/sht. during the research, the researcher pays attention to the ethical principles of information to consent, anonymity and confidentiality. results based on table 1, it is shown that the observational variable, namely demographic factors, indicates that 59.3% of respondents were aged 19-25 years, 75% were female respondents, 80.7% were student respondents, most respondents were not married yet (97.1%), and 25% of respondents lived in surabaya. out of the 140 respondents, on average, they are introverts who sufficiently fulfill their basic needs and experience moderate fomo. based on table 2, it is shown that out of the 84 people with an introverted personality type, 49 people (58.3%) experienced the medium category of fomo, 31 people (36.9%) experienced the high category of fomo, and 4 people (4.8%) experienced the low category of fomo. furthermore, the results indicate that out of the 56 people with an extroverted personality type, 24 people (42.9%) experienced the low category of fomo, 22 people (39.3%) experienced the medium category of fomo, and 10 people (17.9%) experienced the high category of fomo. based on the results of the chi-square statistical test, with a p-value of 0.000, it is evident that there is a relationship between personality type and fomo syndrome in adolescents in east java. moreover, the correlation coefficient result, with a value of r=0.402, indicates a moderate level of correlation between personality type and the occurrence of fomo syndrome. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of research respondents. indicator frequency (f) percentage (%) age 12-15 years 22 15.7 16-18 years 35 25.0 19-25 years 83 59.3 gender woman 104 35 man 36 25 education student 113 80.7 not a student 27 19.3 status not married yet 136 97.1 married 4 2.9 city or district surabaya 35 25.0 malang 30 21.4 jember 28 20.0 sidoarjo 27 19.3 pasuruan 20 14.3 personality type extrovert 56 40 introvert 84 60 fulfillment of basic needs good 1 0.7 enough 125 89.3 less 14 10 fomo low 28 20 medium 71 50.7 high 41 29.3 fomo, fear of missing out. table 2. bivariate test between personality type and fear of missing out (fomo) syndrome. personality type fomo total low medium high f % f % f % amount % extrovert 24 42.9 22 39.3 10 17.9 56 100.0 introvert 4 4.8 49 58.3 31 36.9 84 100.0 total 28 20.0 71 50.7 41 29.3 140 100.0 chi-square statistical test value 0.000 (p<0.05), r=0.402 [page 428] [healthcare in low-resource settings 2024;12:11939] non -co mmerc ial us e o nly based on table 3, it is shown that out of the 125 people whose level of fulfillment of basic needs is sufficient, 70 people (56%) experienced fomo in the moderate category, 28 people (22.4%) experienced fomo in the low category, and 27 people (21.6%) experienced fomo with a high category. then, the results obtained indicate that 14 people with a lower level of basic needs fulfillment experienced fomo in the high category, and none experienced fomo in the low or medium category. furthermore, the results showed that 1 person with a good level of fulfillment of basic needs experienced fomo in the medium category. based on the results of the spearman rho statistical test, with a p value of 0.000, it is evident that there is a relationship between fulfilling basic needs and fomo syndrome in adolescents in east java. moreover, the correlation coefficient result, with a value of r=0.433, indicates a moderate level of correlation between fulfilling basic needs and the occurrence of fomo syndrome. discussion based on the results obtained from the questionnaire, adolescents with introversion exhibit discomfort when speaking in front of people and find it challenging to engage in small talk with those around them. however, they harbor a fear that others may have more impressive experiences or are living more fulfilling lives. the relationship between the occurrence of fomo and personality type can be observed through interactions with others. considering the characteristics of each individual based on their personality type, it does not rule out the possibility that individuals with an introverted personality type may experience fomo, albeit at different levels.8 researchers assume that introverted individuals who experience the moderate category of fomo also experience fear if other people have experiences and lives that are more enjoyable than theirs. meanwhile, to gain experience and lead an impressive life, an individual must have the courage to take risks in their decisions, be willing to accept challenges, and actively communicate to establish numerous friendships and relationships. considering the characteristics of introverts, they tend not to be too inclined to take risks and often perceive that others’ lives are more enjoyable. for instance, during the physical distancing incidents of the pandemic era, where there were changes in all learning and work methods that had to be conducted online, everyone, especially adolescents, was forced to adapt to the resulting changes in habits. after the pandemic concludes, everyone will need to readapt as activities gradually return to offline modes. as introverts, they may find it challenging to adapt again and might struggle to communicate effectively, resulting in inadequate access to information needed to fulfill tasks or meet demands in their surroundings. ultimately, introverted individuals may perceive that others are leading more enjoyable lives while they are not. based on the results obtained from the questionnaire, several respondents exhibited positive responses to independence and the fulfillment of various needs. however, respondents also demonstrated negative responses related to adaptation and the need for both giving and receiving love. individuals aspire to present themselves positively, seek support, desire acknowledgment, and pay attention to others. they also have a need for acceptance in their environment and the ability to connect with others, requiring a medium to avoid exclusion and gain acceptance, with social media being one viable option. this is supported by questionnaire responses where respondents mentioned attempting to be independent, successfully meeting basic needs such as food and drink, regularly exercising, feeling a lack of sincere love and care from others, experiencing shyness, struggling with adaptation, and receiving sufficient care from those around them.17 additionally, respondents demonstrated negative responses concerning personal abilities, achievements, potential, and the ability to fulfill their needs. these findings indicate that adolescents have low satisfaction scores, and individual life satisfaction can be interpreted based on abraham maslow’s basic needs theory. thus, adolescents with low life satisfaction scores are likely to have unmet basic needs, leading to difficulties in overcoming tasks and challenges in their development. if adolescents can fulfill their basic needs, life satisfaction will likely improve, and they will encounter fewer challenges in their life development.18 adolescents who use social media with low life satisfaction are characterized by unmet basic needs and may experience an increase in fomo compared to adolescents with higher life satisfaction.19 the researcher assumes that the social media used by respondents as an intermediary to always stay connected with other people, aiming to be accepted and not ostracized by their environment, turns out to have a negative impact on users, namely fomo. this is because social media platforms feature various posts, information, and trends from others in society. the presence of social media can exacerbate the incidence of fomo if the respondent lacks self-control, is not wise, or fails to use social media appropriately. humans live with the motivation to fulfill their basic needs, and the presence of social media, while not essential to human life, also caters to additional psychological needs and a sense of addiction. this results in humans becoming less focused on meeting transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. bivariate test between fulfillment of basic needs and fear of missing out (fomo) syndrome. fulfillment of basic needs fomo total low medium high f % f % f % amount % good 0 0.0 1 100.0 0 0.0 1 100.0 enough 28 22.4 70 56.0 27 21.6 125 100.0 less 0 0.0 0 0.0 14 100.0 14 100.0 total 28 20.0 71 50.7 41 29.3 140 100.0 spearman rho statistical test value 0,000 (p<0,05), r=0,433. [healthcare in low-resource settings 2024;12:11939] [page 429] non -co mmerc ial us e o nly their basic needs and more inclined to compare themselves with others considered superior based on what they see on social media. there are several limitations faced by researchers in this study. researchers cannot interact directly with respondents and cannot identify the difficulties that respondents may face during filling out the questionnaire. conclusions the personality type of teenagers in east java was found to be mostly introverted. the level of fulfillment of basic needs among teenagers in east java was mostly in the sufficient category. the level of fomo among teenagers in east java was mostly in the medium category. there is a relationship between personality type and the incidence of fomo syndrome in adolescents in east java. additionally, there is a relationship between fulfilling basic needs and the incidence of fomo syndrome in adolescents in east java. adolescents are advised to maximize their basic needs, especially the need for love, and minimize the possibility of experiencing fomo syndrome by using social media wisely and avoiding comparisons with others. regarding fomo related to achievements, adolescents should aim to be enthusiastic and maintain a positive perception when witnessing extraordinary achievements by others. furthermore, adolescents will be motivated to showcase the positive aspects and the best aspects of their own lives. references 1. pangemanan l, irwanto i, maramis mm. psychological dominant stressor modification to an animal model of depression with chronic unpredictable mild stress. vet world 2023;16:595-600. 2. sanjaya a, irwanto, irmawati m, et al. the relationship between salivary cortisol levels with risk of behavioral-psychosocial-emotional disorders in adolescents aged 12-16 years. bali med j 2023;12:1451-8. 3. yusuf a, habibie an, efendi f, et al. prevalence and correlates of being bullied among adolescents in indonesia: results from the 2015 global school-based student health survey. int j adolesc med health 2022;34. 4. shah nm, aghamohammadi n, thangiah n, et al. association between stress and eating behaviour among malaysian adolescents prior to examination. sci rep 2023;13:7841. 5. mcginnis p. fomo—fear of missing out: bijak mengambil keputusan di dunia yang menyajikan terlalu banyak pilihan. jakarta, indonesia: gramedia pustaka utama; 2020. 300 pp. 6. dianovinina k, surjaningrum er, wulandari py. specific coping behaviours related to depression in adolescents with a divorced parent. int j public heal sci 2023;12:1337-45. 7. swar b, hameed t. fear of missing out, social media engagement, smartphone addiction and distraction: moderating role of self-help mobile apps-based interventions in the youth. heal 2017 10th int conf heal informatics, proceedings; part 10th int jt conf biomed eng syst technol biostec 2017 2017;5:139-46. 8. ambarita wn. fear of missing out ditinjau dari tipe kepribadian ekstrovert dan introvert. skripsi psikol univ negeri semarang 2017;1-89. 9. statista. 2022. poland fomo scale 2022. available from: https://www.statista.com/statistics/1133792/poland-fomoscale/ 10. zn milatina, hafidha lg. fear of missing out sebagai dampak psikologis pandemi covid-19 pada masyarakat indonesia. 2021;1-9. 11. margaretha m, azzopardi ps, fisher j, sawyer sm. schoolbased mental health promotion: a global policy review. front psychiatry 2023;14:1126767. 12. akbar rs, aulya a, psari aa, sofia l. ketakutan akan kehilangan momen (fomo) pada remaja kota samarinda. psikostudia j psikol 2019;7:38. 13. nasir a, yusuf a, listiawan my, et al. relationship between resilience, coping resources, and psychological well-being with stress of leprosy as a predictor. a correlation study through the structural equation models. clin epidemiol glob heal 2022;17:101151. 14. yulianti pd, surjaningrum er. a review of mental health literacy strategy for adolescence. int j public heal sci 2021;10:764-70. 15. bloemen n, de coninck d. social media and fear of missing out in adolescents: the role of family characteristics. soc media soc 2020;6. 16. triharini m, armini nka, pitaloka sa. the correlation between family role and anemia prevention in pregnancy. healthc low-resource settings 2023;11. 17. shodiq f, kosasih e, maslihah s. need to belong dan of missing out mahasiswa pengguna media sosial instagram. j psikol insight 2020;4:53-62. 18. kiyassathina a, sumaryanti iu. pengaruh fear of missing out terhadap kepuasan hidup remaja pengguna instagram di kota bandung. 2017;381-6. 19. savitri ja. impact of fear of missing out on psychological well-being among emerging adulthood aged social media users. psychol res interv 2019;2:23-30. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 430] [healthcare in low-resource settings 2024;12:11939] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11753 the effect of dayak ginger (zingiber officinale roscoe) extraction in ginger cookies in reducing emesis gravidarum severity among pregnant women ririn ariyanti,1 melyana nurul widyawati,2 nurasmi nurasmi,1 mardhiana mardhiana,3 ika yulianti1 1department of midwifery, faculty of health sciences, universitas borneo tarakan, tarakan; 2department of midwifery, poltekkes kemenkes semarang, semarang; 3department of agrotechnology, faculty of agriculture, universitas borneo tarakan, tarakan, indonesia abstract one of the discomforts during pregnancy is nausea and vomiting, known as emesis gravidarum. ginger cookies, as a complementary alternative medicine (cam), are often consumed by pregnant women to alleviate nausea. the purpose of this study was to investigate the effect of ginger cookies on pregnant women experiencing emesis gravidarum. this research was conducted as a randomized control trial (rct), following the consort guidelines. the study involved 59 pregnant women with a gestational age ranging from 6 to 16 weeks who were experiencing nausea and vomiting. the subjects were selected using random sampling. the intervention involved providing ginger cookies for a duration of 3 weeks. the severity of emesis gravidarum was assessed using the pregnancy unique quantification of emesis and nausea (puqe) questionnaire. data analysis was carried out using an independent sample t-test. the results revealed a significant difference in the average severity of hyperemesis between the treatment and control groups (p<0.001), indicating a significant difference in emesis gravidarum severity between the intervention and control groups. in conclusion, ginger cookies have been shown to reduce the severity of emesis gravidarum. they can be considered as an adjunct in providing behavioral education to pregnant women to prevent emesis gravidarum. introduction pregnant women commonly experience symptoms of nausea and vomiting. these symptoms typically begin in the first week of pregnancy and gradually decrease by the end of the first trimester.1,2 studies have shown that between 50-90% of pregnant women experience nausea and vomiting during the first trimester, and approximately 25% of these women may require time off from work due to the severity of these symptoms.3–5 nausea and vomiting are prevalent complaints during the early stages of pregnancy. given the potential harmful side effects that conventional medications may have on the unborn fetus, many expectant mothers opt not to use them, leaving them to cope with these burdensome symptoms. this condition, often referred to as morning sickness (though it can occur at any time of the day or night), is officially known as nausea and vomiting of pregnancy (nvp) and affects roughly 80-90% of pregnant women to varying degrees.6,7 nvp is more commonly observed in primigravida women. several risk factors have been identified, including a history of using estrogen-based medications that may induce nausea, motion sickness, or migraines. other risk factors for nvp include multiple pregnancies, inadequate use of multivitamins before concepcorrespondence: ririn ariyanti, department of midwifery, faculty of health sciences, universitas borneo tarakan, tarakan, indonesia. e-mail: ririn_ariyanti@borneo.ac.id key words: complementary alternative medicine (cam); emesis gravidarum; ginger cookies; nausea and vomiting in pregnancy; zingiber officinale roscoe. contributions: ra, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; mnw, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; nn, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; mm, methodology, visualization, writing – review and editing; iy methodology, visualization, writing – review and editing. conflict of interest: the authors have no conflict to declare. ethics approval and consent to participate: this research has received an ethical approval with id no. 08/kepk-fikes ubt/v/2022. respondents were voluntary and have the right to resign at any time without further explanation. all prospective respondents were provided with detailed information about the research procedures and signed informed consent forms. the collected information was treated as confidential and was not disclosed to anyone other than the researcher. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from universitas borneo tarakan with contract number 135/un51/ kpt/2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors extend the gratitude to all of the parties who have contributed to the research in this issue, especially to the research and community service institutions of universitas borneo tarakan for the grants. professional support and assistance from all respected reviewers have made this journal qualified to be published. received: 11 september 2023. accepted: 26 october 2023. early access: 10 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11753 doi:10.4081/hls.2023.11753 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 124] [healthcare in low-resource settings 2023; 11:11753] non -co mmerc ial us e o nly tion, individuals with acid reflux, and women who have previously had a hydatidiform mole. pregnant women have a higher risk experienced nvp.8,9 the precise underlying causes of nvp are still not fully understood. however, hormonal changes, such as an increase in serum human chorionic gonadotropin, as well as psychological factors and the stress response, are believed to play a role. delayed or irregular gastric motility has also been proposed as a potential cause of nvp.10 healthcare providers offer a wide range of treatments for nausea and vomiting experienced by pregnant women during pregnancy. these treatments include counseling, pharmacological options, and non-pharmacological interventions. among the recommended non-pharmacological treatments, the consumption of processed ginger in various forms such as cakes, drinks, sweets, and aromatherapy is suggested. numerous studies have provided evidence of the efficacy of ginger-based products in reducing nausea and vomiting in pregnant women. for instance, a study conducted by herni in 2019 found that ginger aromatherapy had a positive effect on reducing nausea and vomiting in pregnant women.1 ginger is the rhizome of the ginger plant which has a distinctive taste, aroma, and is delicious, so it is liked by many people.11– 14 ginger contains astsiri zingiberene (zingiroan) oil, zingiberol, bisabilene, curcumin, gingerol, vitamin a and bitter resin that can block serotonin, a neurotransmitter that is synthesize on serotonergic neuron in the central nervous system and enterochromaffin cells in the digestive tract so that it is believed to be able to provide a feeling of comfort in the stomach so as to overcome nausea and vomiting.15–17 the advantage of ginger is its oil content essential oils that have a refreshing effect and block the gag reflex, gingerols can improve blood circulation and nerves work well. the fragrant aroma of ginger is produced by essential oils and oleoresin causing a spicy taste that warms the body. this is supported by research conducted by the university of myland medical center, explained that by consuming 1 gram of ginger extract every day during pregnancy is a safe and effective way to reduce the usual nausea and vomiting feel in the morning.18 based on a preliminary study conducted by the dayak community, it is believed that consuming dayak ginger in pregnant women can overcome nausea and dizziness and can unleash the delivery process. the dayak tribe consumes ginger as ginger cookies is complementary alternative medicine (cam) by means of a ginger concoction which is added with aromatic ginger and brown sugar as herbal medicine and is drunk by pregnant women because the extract is believed to be efficacious. short interviews were conducted with several pregnant women, the results were 60% of pregnant women using ginger as a solution to overcome nausea and vomiting and 40% of pregnant women wanted processed ginger to be in the form of food, it could be cakes, sweets or candy. based on this background, this study aimed to evaluate the effect of extraction of dayak ginger (zingiber officinale roscoe) in ginger cookies in pregnant women with emesis gravidarum. materials and methods study design and sample the research was conducted using a quantitative method, specifically a randomized control trial (rct), and was registered in an rct database. the study focused on assessing the severity of emesis gravidarum in pregnant women residing in tarakan city. the sampling technique employed was in accordance with the consolidated standards of reporting trials (consort) guidelines, taking into consideration specific inclusion and exclusion criteria. inclusion criteria comprised pregnant women in their gestational age of 6-16 weeks experiencing nausea and vomiting, while exclusion criteria included individuals with a history of hyperemesis gravidarum and those who had given birth. a total of 60 patients participated in the research between april and august 2022. these subjects were then randomly divided into two groups, with each group consisting of 30 respondents (figure 1). variables and instruments the independent variable in this study was the administration of ginger cookies, while the dependent variable was the severity of emesis gravidarum. emesis gravidarum was assessed using the pregnancy unique quantification of emesis and nausea (puqe) questionnaire. the puqe scoring system is employed to measure the severity of nausea and vomiting during pregnancy within a 12hour period, hence referred to as pregnancy unique quantification of emesis and nausea (puqe)-12 hour. it’s worth noting that in 2009, ebrahimi, mastepe, bournissen, and koren modified puqe12 to puqe-24. puqe-24 serves as a scoring system designed to evaluate the severity of nausea and vomiting within a 24-hour timeframe. each patient’s puqe score was computed based on three criteria used to assess the severity of nausea and vomiting during pregnancy: the number of hours of feeling nauseated, the number of episodes of vomiting, and the number of episodes of dry vomiting experienced in the preceding 24 hours. in this study, validity and reliability testing of the puqe instrument was not conducted since it is considered the gold standard for measuring emesis gravidarum severity. the puqe score is calculated by summing the scores for each of the three criteria and can range from a minimum of 1 to a maximum of 15.19 to assess the severity of nausea and vomiting, the scores from column 1 to column 3 are added together. if the total score is 6, it is categorized as mild, while a total score between 7 and 12 is considered moderate. if the total score reaches 13 or higher, it is classified as severe.20 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. research flow. [healthcare in low-resource settings 2023; 11:11753] [page 125] non -co mmerc ial us e o nly study procedure the initial research step involved conducting a patient-related needs assessment to determine the number of samples required to ensure representativeness. the patient carries out a general assessment at the public healthcare center to be confirmed as the suitable criteria. before giving the intervention, the patient had signed the consent and done the randomization. the interventions for each group with sufficient details to allow replication, including how and when they were administered. then given the intervention in accordance with the group (intervention or control). the intervention group was given the ginger cookies twice a day at 07.00 and 19.00 wita (middle indonesian time), while the control group was given intervention in accordance with the public healthcare center standard operating procedure (sop) which is providing the b6 vitamin as a therapy for nvp once a day. the treatment was carried out for 3 weeks. before and after the treatment, respondents from both groups were assessed for their nvp rate by using the puqe questionnaire. data analysis the researchers conducted a bivariate test to determine the difference in emesis gravidarum rates before and after treatment in both groups. prior to this, they performed tests to check for data normality and homogeneity. the results of the data normality test for both groups indicated that the data was not normally distributed. the pretest p-value was 0.000, which is greater than 0.05, while the posttest p-value was 0.000, which is less than 0.05. to compare the two treatment groups, it was essential to test for homogeneity using the levene test. the p-value for the pretest was 0.554, and the p-value for the posttest was less than 0.001, which is less than 0.05, indicating that the data was homogeneous. based on these results, a parametric test (independent t-test) was used for both groups. ethics approval this research has received an ethical approval with id no. 08/kepk-fikes ubt/v/2022. respondents are voluntary and have the right to resign at any time without further explanation. all prospective respondents in this study were given comprehensive information regarding the research implementation process and signed the informed consent. all information collected is confidential and is not disclosed to anyone other than the researcher. results table 1 showed that the research subjects were dominated by 10 people (16.9%) with 6 weeks gestation age, 9 weeks gestation (15.3%), 7 weeks gestation (13.9%), 9, 11 and 12 weeks of gestation were 7 people (11.9%), 13 weeks of gestation were 6 people (10.2%), and 8 weeks of gestation (8.5%). all study subjects (59 people) experienced nausea and vomiting (100%). table 2 showed that a decrease in the mean emesis gravidarum severity of the intervention group higher than the control group. table 3 showed that in the intervention group there was a mean in the severity of emesis gravidarum (5.33) and no increase in the severity of emesis gravidarum (3.17), so it can be concluded that there is a significant difference in the effect of giving ginger cookies on the severity of emesis gravidarum with a p-value of <0.001. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents. characteristics n % control intervention p number of research subjects 59 100 30 29 <0.001 gestational age 6 weeks 10 16.9 6 4 0.612 7 weeks 8 13.9 4 4 8 weeks 5 8.5 1 4 9 weeks 7 11.9 3 4 10 weeks 9 15.3 5 4 11 weeks 7 11.9 3 4 12 weeks 7 11.9 3 4 13 weeks 6 10.2 5 1 complaints of nausea and vomiting yes 59 100 30 29 not 0 0 total 59 100 table 2. the severity of emesis gravidarum in both groups. variable n mean difference 95% confidence interval of the difference emesis gravidarum intervention group 29 2.161 1.395±2.926 control group 30 2.161 1.395 ± 2.927 table 3. differences in emesis gravidarum severity before and after treatment. variable group n mean p emesis gravidarum intervention group 29 5.33 0.000* control group 30 3.17 0.000* *independent t test [page 126] [healthcare in low-resource settings 2023; 11:11753] non -co mmerc ial us e o nly discussion the purpose of this study was to determine the effect of ginger cookies among pregnant women with emesis gravidarum. the results showed that the majority of respondents were dominated by the age of 6 weeks of pregnancy as many as 14 people (23.7 %). the onset of symptoms of nausea or vomiting started on day 32 to day 57 of the first day of last menstruation (lmp) or from 5 to 8 weeks.21 other studies have also shown that nausea and vomiting in pregnant women begins between the 4th and 7th week, peaks around the 9th week, and slowly disappears by the 20th week in 90% of pregnant women.22 a study describing the onset and natural history nausea and vomiting by asking pregnant women to be present when they first thought they were pregnant, reported starting to experience symptoms at a median of day 57 (week 8) of lmp. in the study 58 (16%) women from the 363 study population reported onset of symptoms between them up to 14 days earlier (6th week).23 the results of this study indicate that all respondents (100%) experienced nvp. nausea and vomiting are common experiences that affect 70-80% of all pregnant women. in a canadian study, 74% of pregnant women reported a severity of nausea and vomiting and an additional 350,000 women were affected each year. although most women with nausea and vomiting of pregnancy have symptoms that are limited to the first trimester, a minority of women have a prolonged course of illness with symptoms that extend into delivery.9,21,24 although the cause of nausea and vomiting is still largely unknown, it is thought to be multifactorial with genetic elements in its etiology such as changes in the gastrointestinal system and gastric neuromuscular dysfunction, the relationship between human chorionic gonadotropin (hcg) and estrogen. in addition, higher rates of nausea were found in women whose mothers had problems with nausea during pregnancy.18,25 other studies have shown that there is a very close relationship between the onset of symptoms of nausea and vomiting and the onset of pregnancy as measured from the date of ovulation.21 women with severe nausea and vomiting during pregnancy will develop hyperemesis gravidarum (hg), an entity distinct from nvp. which if left untreated can cause significant maternal and fetal morbidity.24 symptoms of nausea and vomiting can be controlled in primary care with dietary advice and medication. however it should be diagnosed only at onset in the first trimester and after other causes of vomiting have been excluded.26 ginger (zingiber officinale) is a member of the zingiberaceae family that grows in asia and the tropics and is one of the most important and widely consumed herbs worldwide. cultivated for consumption by underground stems (rhizomes), ginger has been used since antiquity both as a spice and as a herbal remedy to treat various digestive ailments, such as nausea, vomiting (emesis), diarrhea, and dyspepsia, as well as a variety of ailments, including arthritis, muscle pain, and fever.27 ginger is considered a safe herb for human consumption.28 the long history of medicinal use in humans has prompted ongoing clinical trials to scientifically assess the effectiveness of ginger as an adjuvant or complementary therapy and alternative medicine (complementary alternative medicine (cam) in some of the most studied indications related to nausea and vomiting including nvp).29 the research showed that there was an effect of giving ginger cookies on the severity of emesis gravidarum. this study is in line with basirat’s (2009) research on giving ginger cookies to pregnant women with nvp. the results showed that pregnant women in the ginger cookie group experienced a decrease in complaints of nausea and vomiting symptoms and a decrease in the number of vomiting compared to the control group who were given placebo biscuits.30 red ginger which in north kalimantan is known as dayak ginger, its rhizome is red and smaller than small white ginger. red ginger is always harvested when it is old. it is small layered rhizome, sharp and the aroma is suitable for making a medicinal herbs. the characteristic are light orange to red in color with a diameter of 4.20-4.26 cm; height and length of the rhizome is 5.2610.40 and 12.33-12.60; light green leaves; reddish green stems with essential oil content of 2.58-3.90%.31 the characteristic of ginger are due to the presence of essential oils and ginger oleoresin. the essential oil makes the ginger aroma and oleoresin makes the ginger spicy taste. the essential oil can be obtained by steam distillation of dried ginger rhizome.32 ginger rhizome contains a wide variety of biologically active secondary metabolites. the rhizome consists of 1-4% essential oil and oleoresin. the distinctive smell and taste of ginger is caused by its volatile oil and nonvolatile phenolic compounds which have pungent properties.33 essential oils (steam extraction) mainly consist of sequiterpene hydrocarbons, especially zingiberol which gives the characteristic aroma of ginger. the non-volatile phenolic phytochemicals of ginger consist of gingerol, shogaol, paradol, and zingerone, and more than 30 gingerol-related compounds can be fractionated from raw ginger.34 gingerols correspond to a series of chemical homologues distinguished by the length of their unbranched alkyl chain (n6-n12). of all the gingerols, 6-gingerol is the most abundant and well-researched ginger phytochemical. the main pharmacological activity of ginger is closely related to gingerol and shogaol which are the dehydration products of gingerol. gingerol is the main component in fresh ginger rhizome, whereas shogaol, especially 6-shogaol is the most abundant polyphenol constituent of dried ginger.35 due to its antiemetic properties, ginger (and its constituents) acts peripherally in the gastrointestinal tract by increasing gastric tone and motility due to its anticholinergic and anti-serotonergic properties.36,37 it is also reported to increase gastric emptying.38 this combination of functions explains ginger’s widely accepted ability to relieve symptoms of functional gastrointestinal disorders, such as dyspepsia, abdominal pain, and nausea that are often associated with decreased gastric motility.29,32 the dose of ginger that is 250 mg of dry ginger used four times a day can be used to reduce nausea and vomiting in pregnancy.39 nutrition recommendations during pregnancy are the same as normal healthy diet recommendations, pregnant women who meet balanced nutrition are not advised to consume high doses of vitamins and minerals, ginger biscuits in pregnant women can reduce nausea and vomiting in pregnancy.39 in most cases, nausea and vomiting in pregnant women is a condition that does not require special medical treatment. however, pregnant women can do some way like eat snacks first, such as biscuits, when you wake up or before getting out of bed; eat in small portions, but more often; avoid spicy and fatty foods; drink more water; avoid caffeinated drinks; taking pregnancy supplements right before bed if pregnant women feel nauseous after taking these supplements; adequate rest needs, because lack of rest can also trigger nausea and vomiting; breathe fresh air and calm the mind; loosen the bra and always wear comfortable clothes; avoid using air fresheners that smell pungent; inhale fruity scents, such as lemon, orange, or mint.40 doctors will provide vitamin b6 supplements and anti-nausea drugs that are safe for pregnant women. in this study, a p-value of 0.000 was obtained so that there was an effect of standard therapy on the severity of emesis gravidarum. b6 is a water-soluble vitamin that is an important coenzyme for the metabolism of amino acids, lipids and carbohydrates. [healthcare in low-resource settings 2023; 11:11753] [page 127] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly b6 significantly reduced the severity of nvp symptoms in women with moderate or severe nausea and vomiting, when compared with the placebo group.41 vitamin b6 supplementation on the severity of nausea and vomiting experience these symptoms. vitamin b6 supplementation significantly increased plasma vitamin b6 concentrations. there was also a significantly lower decrease in puqe scores and an increase in vitamin b6 levels and a greater concentration of vitamin b6 to plasma protein concentration ratio.42 ginger is an herbal medicine that is easily found in tropical areas such as indonesia and has a pharmacological mechanism. however, it should be used for special indications as well as consideration of contraindications and side effects. ginger consumption in women who wish to use herbal remedies for nvp has been reported to be effective compared to placebo.42 in this study, a pvalue of 0.000 was obtained so that there was a difference in the effect of ginger cookies and standard therapy on the severity of emesis gravidarum. this is in line with the research by sharifzadeh (2017) which compared the use of ginger, vitamin b6, and a placebo, explaining that ginger and vitamin b6 can significantly reduce the severity of all rhodes questionnaire items; however, placebo was only significantly effective on nausea frequency, vomiting intensity, and vomiting frequency.18 ginger was more effective than placebo for the treatment of mild to moderate nvp and was comparable to vitamin b6 as standard treatment for nvp. ensiyeh’s study (2009) compared ginger and vitamin b6 treatment without a placebo control as measured using the vas (visual analog scale) to determine the severity of nvp. they concluded that ginger was more effective than pyridoxine (vitamin b6) for reducing the severity of nausea, but was the same as pyridoxine for reducing the frequency of nausea and vomiting.43 according to previous studies regarding the administration of ginger and vitamin b6 to pregnant women with nausea and vomiting, it seems that ginger is a safe and effective drug in nvp, and is comparable to or even better than vitamin b6, for some symptoms of nvp, however, further research should be conducted to find the highest effectiveness, dose, patient selection according to the severity of each nvp symptom, use of ginger for more severe cases of nvp.42 conclusions this study concludes that ginger cookies has a significant influence on the emesis gravidarum severity in pregnant women, especially in their first and early mid-trimester. this study identified that ginger cookies reduced the severity of emesis gravidarum compared to pregnant women who were given the standard therapy. this study recommends that ginger cookies is an alternative intervention for pregnant women who experience the emesis gravidarum. future research is expected to be able to use larger samples with other types made from ginger. references 1. kurnia h. pengaruh pemberian aromatherapi jahe terhadap mual muntah pada ibu hamil trimester i. j ris kesehat poltekkes depkes bandung 2019; 11: 44-51. 2. rahman fs, martiana t. pregnancy disorders in female workers at the industrial area of sidoarjo, indonesi. j public health res 2020;9:144-148. 3. wulandari da, kustriyanti d, aisyah r. minuman jahe hangat untuk mengurangi emesis gravidarum pada ibu hamil di puskesmas nalumsari jepara. j smart kebidanan 2019;6:42. 4. ariestini tr, purnomo w. the effect of young coconut water against morning sickness among women in the first trimester of pregnancy. indian j public heal res dev 2018;9:48. 5. teoh an, kaur s, mohd shukri nh, et al. psychological state during pregnancy is associated with sleep quality: preliminary findings from my-care cohort study. chronobiol int 2021;38:959-970. 6. viljoen e, visser j, koen n, et al. a systematic review and meta-analysis of the effect and safety of ginger in the treatment of pregnancy-associated nausea and vomiting. nutr j 2014;13:1-14. 7. yudithia junandar c, diah wittiarika i, utomo b, et al. the relationship of social support with the degree of nausea and vomiting in pregnancy. indones midwifery heal sci j 2020;4:26-32. 8. supatmi, setia suhartikah f, sumarliyah e. pengaruh pemberian gingercookies pada nausea dan vomiting wanita hamil trimester pertama. j keperawatan muhammadiyah 2017;2:75-79. 9. ariyanti r, febrianti s, khariani zr, et al. the effect of warm ginger on the frequency of nausea and vomiting among pregnancy women. gac med caracas 2020;130:5s. 10. thomson m, corbin r, leung l. effects of ginger for nausea and vomiting in early pregnancy: a meta-analysis. j am board fam med 2014;27:115-122. 11. efrina, kasim a, anggraini t, et al. the used effect of yellow ginger and red ginger on physical characteristic, total phenol, and the content of gingerol, shogaol of ginger tingting (zingiber officinale). j litbang ind 2018;8:61-66. 12. hidanah s, warsito sh, nurhajati t, et al. effects of mangosteen peel (garcinia mangostana) and ginger rhizome (curcuma xanthorrhiza) on the performance and cholesterol levels of heat-stressed broiler chickens. pakistan j nutr 2017;16:28-32. 13. sari nky, permatasari aaap, wahyuningsih spa, et al. mechanism of antimicrobial resistance and red ginger as the solution for source of natural antioxidant: a brief review. indones j pharm 2023;34:1-23. 14. sagita r, kurniawati em, faizah z. a systematic review and meta-analysis of experimental studies: can red ginger be used in the treatment for women urinary tract infections? trop j nat prod res 2022;6:1367-1371. 15. anh nh, kim sj, long np, et al. ginger on human health: a comprehensive systematic review of 109 randomized controlled trials. nutrients 2020;12:1-28. 16. anisa ak, permata fs, rantam fa, et al. jejunal histomorphometry of salmonella enteritidis infected broiler chickens supplemented with red ginger and antibiotic. vet pract 2020;21:474-478. 17. lim wy, cheng yw, lian lb, et al. inhibitory effect of malaysian coastal plants on banana (musa acuminata colla “lakatan”), ginger (zingiber officinale roscoe) and sweet potato (ipomoea batatas) polyphenol oxidase. j food sci technol 2021;58:4178-4184. 18. sharifzadeh f, kashanian m, koohpayehzadeh j, et al. a comparison between the effects of ginger, pyridoxine (vitamin b6) and placebo for the treatment of the first trimester nausea and vomiting of pregnancy (nvp). j matern neonatal med 2018;31:2509-14. 19. latifah l, setiawati n, hapsari ed. efektifitas self [page 128] [healthcare in low-resource settings 2023; 11:11753] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly management module dalam mengatasi morning sickness. j keperawatan padjadjaran 2017;5:10-18. 20. birkeland e, stokke g, tangvik rj, et al. norwegian puqe (pregnancy-unique quantification of emesis and nausea) identifies patients with hyperemesis gravidarum and poor nutritional intake: a prospective cohort validation study. plos one 2015;10:1-15. 21. gadsby r, ivanova d, trevelyan e, et al. the onset of nausea and vomiting of pregnancy: a prospective cohort study. bmc pregnancy childbirth 2021;21:10. 22. royal college of obstetricians & gynaecologist. the management of nausea and vomiting of pregnancy and hyperemesis gravidarum. london, 2016. 23. gadsby r, barnie-adshead am, jagger c. a prospective study of nausea and vomiting during pregnancy. br j gen pract j r coll gen pract 1993;43:245-248. 24. lee nm, saha s. nausea and vomiting of pregnancy. gastroenterol clin north am 2011;40:309-34, vii. 25. dean c, bannigan k, marsden j. reviewing the effect of hyperemesis gravidarum on women’s lives and mental health. br j midwifery 2018;26:109-119. 26. nottinghamshare area prescribing committee. analysis of primary care management of nausea and vomiting in pregnancy. drug and therapeutics bulletin, 2020, p. 52. 27. ali bh, blunden g, tanira mo, et al. some phytochemical, pharmacological and toxicological properties of ginger (zingiber officinale roscoe): a review of recent research. food chem toxicol int j publ br ind biol res assoc 2008;46:409420. 28. kaul pn, joshi bs. alternative medicine: herbal drugs and their critical appraisal--part ii. prog drug res fortschritte der arzneimittelforschung prog des rech pharm 2001;57:1-75. 29. lete i, allué j. the effectiveness of ginger in the prevention of nausea and vomiting during pregnancy and chemotherapy. integr med insights 2016;11:11-17. 30. basirat z, moghadamnia aa, kashifard m, et al. the effect of ginger biscuit on nausea and vomiting in early pregnancy. acta med iran 2009;47:51-56. 31. kurniasari l, hartati i, ratnani r, et al. kajian ekstrasi minyak jahe menggunakan microwave assisted extraction (mae). momentum 2018;4:47-52. 32. hibbert l. natural products. pharmay today 2019;20:20-21. 33. govindarajan vs. ginger--chemistry, technology, and quality evaluation: part 1. crit rev food sci nutr 1982;17:1-96. 34. jiang h, sólyom am, timmermann bn, et al. characterization of gingerol-related compounds in ginger rhizome (zingiber officinale rosc.) by high-performance liquid chromatography/electrospray ionization mass spectrometry. rapid commun mass spectrom 2005;19:2957-2964. 35. giacosa a, morazzoni p, bombardelli e, et al. can nausea and vomiting be treated with ginger extract? eur rev med pharmacol sci 2015;19:1291-1296. 36. shibata c, sasaki i, naito h, et al. the herbal medicine daikenchu-tou stimulates upper gut motility through cholinergic and 5-hydroxytryptamine 3 receptors in conscious dogs. surgery 1999;126:918-924. 37. abdel-aziz h, windeck t, ploch m, et al. mode of action of gingerols and shogaols on 5-ht3 receptors: binding studies, cation uptake by the receptor channel and contraction of isolated guinea-pig ileum. eur j pharmacol 2006;530:136-143. 38. hu m-l, rayner ck, wu k-l, et al. effect of ginger on gastric motility and symptoms of functional dyspepsia. world j gastroenterol 2011;17:105-110. 39. kusmiyati, radiati a, februanti s. effectiveness of ginger kepok banana cookies consumption to decrease pregnant women emesisl. malaysian j nurs 2020;11:8-12. 40. kementerian kesehatan ri. morning sickness. direktorat jenderal pelayanan kesehatan, september 2022. 41. ebrahimi n, maltepe c, einarson a. optimal management of nausea and vomiting of pregnancy. int j womens health 2010;2:241-248. 42. wibowo n, purwosunu y, sekizawa a, et al. vitamin b6 supplementation in pregnant women with nausea and vomiting. int j gynecol obstet 2012;116:206-210. 43. ensiyeh j, sakineh m-ac. comparing ginger and vitamin b6 for the treatment of nausea and vomiting in pregnancy: a randomised controlled trial. midwifery 2009;25:649-653. [healthcare in low-resource settings 2023; 11:11753] [page 129] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12370 using electronic health record data for chronic disease surveillance in lowand middle-income countries: the example of hypertension in rural guatemala sean duffy,1 juan aguirre villalobos,1 alejandro chavez,2 kaitlin tetreault,3 do dang,4 guanhua chen,3 taryn mcginn valley1,5 1department of family medicine and community health, university of wisconsin school of medicine and public health, madison; 2university of california, san francisco school of medicine; 3department of biostatistics and medical informatics, university of wisconsin school of medicine and public health, madison; 4university of maryland medical center family medicine residency, college park; 5department of anthropology, university of wisconsin, madison, usa abstract hypertension is the leading preventable cause of death worldwide. two-thirds of people with hypertension live in lowand middle-income countries (lmic). however, epidemiological data necessary to address the growing burden of hypertension and other non-communicable diseases (ncds) in lmics are severely lacking. electronic health records (ehrs) are an emerging source of epidemiological data for lmics, but have been underutilized for ncd monitoring. the objective of this study was to estimate the prevalence of hypertension in a rural indigenous community in guatemala using ehr data, describe hypertension risk factors and current treatment in this population, and demonstrate the feasibility of using ehr data for epidemiological surveillance of ncds in lmic. we conducted a cross-sectional analysis of 3646 adult clinic visits. we calculated hypertension prevalence using physician diagnosis, antihypertensive treatment, or blood pressure (bp) ≥140/90 mmhg. we noted antihypertensives prescribed and bp control (defined as bp<140/90 mmhg) for a total of 2496 unique patients (21% of whom were men). we constructed mixed-effects models to investigate the relationship between bp and hypertension risk factors. the estimated hypertension prevalence was 16.7%. two-thirds of these patients had elevated bp, but were not diagnosed with or treated for hypertension. most patients receiving treatment were prescribed monotherapy and only 31.0% of those with recognized hypertension had controlled bp. male sex, older age, increasing weight, and history of hypertension were associated with increasing systolic bp, while history of hypertension, history of diabetes, and increasing weight were associated with increasing diastolic bp. using ehr data, we estimated comparable hypertension prevalence and similar risk factor associations to prior studies conducted in guatemala, which used traditional epidemiological methods. hypertension was underrecognized and undertreated in our study population, and our study was more efficient than traditional methods and provided additional data on treatment and outcomes; insights gleaned from this analysis were essential in developing a sustainable intervention. our experience demonstrates the feasibility and advantages of using ehr-derived data for ncd surveillance and program planning in lmics. introduction though the covid-19 pandemic starkly illustrated the significant impact infectious diseases continue to have on human health and flourishing, non-communicable diseases (ncds) now correspondence: sean duffy, department of family medicine and community health, university of wisconsin school of medicine and public health, 1002 gilson st, madison 53715, wi, usa. tel.: +1.608.354.7930. e-mail: sean.duffy@fammed.wisc.edu key words: hypertension, ehr, lmic, low-resource settings, disease surveillance. contributions: sd assumed the lead role in study design, data review, descriptive analysis, manuscript drafting and editing, and contributed to the literature review and statistical analysis; ja led the literature review and contributed to study design, data review, and descriptive analysis, manuscript drafting and analysis; ac was primarily responsible for data cleaning and preparation and contributed to study design and manuscript drafting and editing; kt and gc were primarily responsible for developing and carrying out the statistical analysis plan and contributed to manuscript drafting and editing; dd contributed to study design, data review and descriptive analysis, and manuscript drafting and editing; tv contributed to study design and manuscript drafting and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: the research reported in this publication was supported by the fogarty international center of the national institutes of health under award number r21tw011891. 100% of the estimated $5239 cost of this project was supported by this grant. during the research period, tmv was funded in part by the nih medical scientist training program grant t32 gm140935. the content is solely the responsibility of the authors and does not necessarily represent the official views of the national institutes of health. the nih had no involvement in study design or execution, nor the decision to submit for publication. ethics approval and consent to participate: research was performed in accordance with the declaration of helsinki. this project was reviewed and approved by the san lucas healthcare committee, as well as the university of wisconsin minimal risk irb (submission id 2021-1164), who determined this project to represent exempt human subjects research involving review of medical records alone and as such, obtaining informed consent was not required. consent for publication: not applicable. availability of data and materials: the datasets generated and/or analyzed during the current study are not publicly available as such sharing outside of the research team was not part of the research protocols approved by ethical oversight committees for this project, but may be made available upon reasonable request from the corresponding author with irb permission. acknowledgments: we would like to acknowledge the san lucas mission healthcare program, particularly medical director dr. rafael tun, for providing access to the ehr data for this project. received: 8 february 2024. accepted: 19 june 2024. early access: 21 july 2024. this work is licensed under a creative commons attribution 4.0 license (bync 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12370 doi:10.4081/hls.2024.12370 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 672] [healthcare in low-resource settings 2024;12:12370] non -co mmerc ial us e o nly account for nearly three-quarters of all deaths globally.1 hypertension, the leading preventable cause of death and disability worldwide, is an exemplar ncd. an estimated 1.13 billion people around the world currently live with hypertension, with two-thirds of these patients living in lowand middle-income countries (lmic).2,3 screening and treatment of hypertension have been found to be cost-effective in reducing morbidity and mortality across a broad range of settings.4 despite this, less than 40% of patients with hypertension in lmic are aware of their condition and less than 10% have good control of their blood pressure (bp).3 furthermore, health systems in lmic, which are often focused on providing episodic care for acute illnesses and suffer from inadequate and poorly distributed health care infrastructure and workforce, are ill-equipped to address the ongoing rise in ncds, such as hypertension.5-7 a key barrier to combating hypertension and other ncds in lmics is a lack of information about current prevalence and control — particularly at the local level in rural and resource-limited areas — which is necessary to design, implement, and monitor effective health programs.8 despite shouldering a significant majority of the global burden of disease, funding for such research in lmic settings makes up only a small proportion of global research funding.9,10 at the same time, implementation of electronic health record (ehr) systems is increasing in lmic.11 using data collected with such systems in the course of routine care for disease surveillance and program monitoring has been proposed as an alternative to traditional, population-survey-based methods, which are resourceand time-intensive and thus not wellsuited to areas with already insufficient health care funding and workforce.12 however, this ehr-based approach has thus far mostly been applied to infectious disease and maternal health and there are few examples of its use in addressing ncds.12 guatemala is a middle-income country where the burden of ncds is increasing, accounting for 59% of deaths in recent reports.13 though hypertension plays a role in these deaths, estimates of the prevalence of hypertension in guatemala are scarce, particularly for rural indigenous communities. in addition, little is known about the risk factors for hypertension and the proportion of those with hypertension who have been diagnosed and are being treated in these populations. for nearly a decade, our team has been working with guatemalan physicians and community health workers (chws) to improve capacity for primary care, chronic disease management, and prevention in san lucas tolimán, a rural municipality in the western highlands region of guatemala. san lucas has a population of approximately 30,000 people, of which a majority belong to the kaqchikel maya indigenous group.14 in addition to a small hospital run by our partner organization, the san lucas mission (slm), and a clinic and a few small health outposts run by the government, the community receives medical care from visiting medical teams organized by slm. these teams, mostly from the united states on one-week to one-month trips, operate mobile medical clinics in the rural communities of san lucas on a rotating basis throughout most years. in general, access to healthcare services in rural communities is poor, and these periodic mobile clinics are often the only formal healthcare that these patients receive. a key component of our work in guatemala has been the digitization of existing workflows and integration of digital and mobile health (mhealth) elements into new programs to improve the reliability and efficiency of recordkeeping, enhance chw capabilities, and facilitate program monitoring and effectiveness evaluation. to this end, in 2018, our team developed and implemented an ehr to replace the existing paper system. this ehr uses the internet-in-a-box platform on raspberry pi devices to create a local wi-fi network.15 clinicians use their own mobile devices or laptops to connect to this network to view and update existing medical records, as well as create records for new patients. the ehr uses multiple choice responses or validated data field (e.g. numeric) entry instead of free text input whenever possible, which presents several advantages. first, it supports toggling between english and spanish to facilitate review by both visiting and guatemalan personnel. secondly, it allows for the provision of clinical decision support through the use of standard diagnosis codes and suggested treatments based on diagnosis, local standard of care, and formulary. finally, these features facilitate data collection and analysis for epidemiologic and program monitoring. in 2020, we started planning to adapt our successful mhealthbased and chw-led diabetes program16 to hypertension and to robustly evaluate this new intervention. accurate data on the current burden of disease and treatment of hypertension in these communities, which was sorely lacking, was necessary to develop an effective program to identify and treat patients with hypertension. to alleviate the lack of primary research investment in these communities, we turned to the newly implemented ehr as a novel source of epidemiologic data. accordingly, the objectives of this study were to i) estimate the prevalence of hypertension among adults living in the rural indigenous communities of san lucas tolimán (slt), guatemala using ehr-derived data; ii) elucidate risk factors for hypertension among the population; iii) describe the medical treatment and adequacy of bp control for patients diagnosed with hypertension; and iv) demonstrate the feasibility of using ehr data for epidemiological surveillance of chronic ncds in low-resource settings. materials and methods data collection, inclusion and exclusion criteria for this cross-sectional study, we used deidentified data from the slm database of patients seen by visiting medical teams in mobile clinics from late may 2018, when the ehr was first deployed, through early march 2020, when mobile clinics were suspended due to the covid-19 pandemic. health records of patients 18 years and older were searched to obtain the following information for analysis: age, sex, bp, weight, height, diagnoses, and medication treatment. we excluded patients younger than 18 years of age and any records without a listed age. we reviewed data for possible erroneous entries (for example, diastolic bp greater than systolic bp) and excluded these from our analysis. we used the strobe checklist for cross-sectional studies,17 available in supplementary materials. case definitions and calculation of hypertension prevalence the denominator we used for the calculation of hypertension prevalence was the number of unique patients with at least one clinic visit with a listed diagnosis. the rationale for using this denominator was to increase the likelihood of counting only completed visits, as patients without a listed diagnosis may have registered for a visit, but may not have actually been seen. we used two different figures, the number of confirmed hypertension cases and the number of possible hypertension cases, and their sum as numerators for the prevalence calculations. we defined a “confirmed hypertension case” as any patient article [healthcare in low-resource settings 2024;12:12370] [page 673] non -co mmerc ial us e o nly with a listed diagnosis of hypertension or a prescription for an antihypertensive medication during at least one visit. we determined hypertension diagnosis based on both hypertension diagnoses selected from the preset ehr options as well as diagnoses consistent with hypertension entered as free text (as determined by manual review). we determined whether a patient had received an antihypertensive treatment in the same manner. we defined a “possible hypertension case” as a patient with elevated bp measured during at least one visit, but who did not receive a diagnosis of hypertension or antihypertensive treatment. elevated bp was defined as a systolic bp equal to or greater than 140 mmhg and/or a diastolic bp of 90 mmhg or greater, in accordance with who and the international hypertension society (ihs) guidelines for the diagnosis of hypertension.18 patients were noted as a diabetes case if they received a diagnosis of diabetes and/or medication to manage diabetes during at least one visit. describing antihypertensive treatment and blood pressure control we determined counts of different antihypertensive treatments from both preset medication options and free text entries, classifying each agent by pharmacologic class. we also noted the frequency of different combinations of medications used. medication use was also broken down by the number of individual patients prescribed each medication regimen at least once (as many patients were seen multiple times during the study period and their regimens frequently changed from visit to visit). we defined bp control as systolic bp <140 mmhg and reported this for confirmed hypertension cases as a percentage of visits for these patients. statistical approach for hypertension risk factor analysis multivariable linear mixed-effects models were used to analyze the relationship between bp and common hypertension risk factors in the rural communities of guatemala. we utilized mixedeffects models to account for repeated measurements for many subjects. the primary outcomes were systolic and diastolic pressures. risk factors included history of hypertension, history of diabetes, age, sex, and/or weight (lb). continuous variables were centered and scaled while intra-subject correlation was accommodated with random intercepts. beta estimates and their 95% confidence intervals (ci) were reported for the fixed effects. we also implemented multivariable logistic mixed-effects models to analyze the relationship between elevated bp and confirmed hypertension, respectively, and common risk factors in this rural guatemalan population. elevated bp and confirmed hypertension, as defined in the previous section, served as primary outcomes. risk factors included sex, age, history of diabetes, and/or weight (lb). body mass index (bmi) was not included because height data was frequently missing. thus, we included weight as a proxy for adiposity/body habitus. continuous variables were scaled and centered while intra-subject correlation was accommodated using random intercepts. odds ratios (or) and their 95% confidence intervals were reported for the fixed effects. multiple imputation chain equations (mice) were implemented for all analyses because 33% of patient records lacked weight data.19 as this model assumes that data is missing at random, records with outlier or likely erroneous weights were excluded from analysis rather than imputed. a p-value of 0.05 was considered statistically significant. r (v.4.1.1; r core team 2021) and package “ime4” (v. 1.1.27.1)20 were used for analysis. in addition, “mice” (v. 3.14.0)21 and “miceadds” (v. 3.16-18)22 were used to implement mice on missing data. lastly, “lmertest” (v. 3.1.3)23 was used to calculate p-values using satterthwaite approximation. package “broom.mixed” (v. 0.2.9.3)24 was used to estimate confidence intervals for the logistic mixed-effects models. results calculation of hypertension prevalence we initially screened 6577 patient visits. of these, we excluded 2931 visits for patients <18 years of age (or with age missing), leaving 3646 visits for adult patients. 3505 of these encounters had a listed diagnosis, representing 2496 unique adult patients, which served as the denominator for calculations of prevalence. table 1 summarizes the demographic and clinical characteristics of this cohort. we calculated the prevalence of confirmed hypertension, as determined by physician diagnosis or prescription of antihypertensive medication, to be 5.7% (n=142). additionally, another 11.0% (n=274) of patients had possible hypertension based on bp measurements. antihypertensive treatment and blood pressure control antihypertensive treatments were prescribed in a total of 146 visits, corresponding to 122 unique patients who received at least one antihypertensive prescription at any of their visits. table 2 provides a breakdown of antihypertensive prescriptions. angiotensinconverting enzyme inhibitors (aceis) were the most commonly prescribed antihypertensive class, representing 59.8% of all pre article [page 674] [healthcare in low-resource settings 2024;12:12370] table 1. characteristics of patients included in the study sample. variables overall (n=2496)* age (years) (mean (sd)) 41.42 (16.77)** sex = male (%) 525 (21.0) systolic blood pressure (mmhg) (mean (sd)) 118.36 (18.04)*** diastolic blood pressure (mmhg) (mean (sd)) 74.69 (11.0)*** patients with confirmed hypertension (%) 142 (5.7) patients with elevated blood pressure without confirmed hypertension 274 (11.0) patients with diabetes 155 (6.2) sd, standard deviation; *represents unique adult patients with at least one consult with a listed diagnosis; **two patients with missing age data and 4 with age ≥90 were not included in this calculation; for patients with multiple visits, the mean age for all their visits was factored into this calculation; ***for patients with multiple visits, mean blood pressure for all their visits was factored into these calculations; n=2688, accounting for vitals removed from analysis due to likely erroneous input. non -co mmerc ial us e o nly scriptions, followed by a thiazide diuretic, hydrochlorothiazide (hctz), with 28.7% of prescriptions and calcium channel blockers (ccbs) as a distant third (7.3%). most (89.7%) prescriptions were for single antihypertensives. the most commonly prescribed combination of antihypertensives was an acei and hctz (table 3). of those patients with confirmed hypertension, bp was well-controlled (systolic bp<140 mmhg) at 31.0% of visits. analysis of risk factors for elevated blood pressure or hypertension diagnosis we included data from 2688 patient visits in the regression analyses. of the 2911 visits where any vitals were measured, we removed 210 of these from this analysis due to unsuitable bp measurements and 13 for unsuitable weight measurements. tables 4 and 5 detail the estimated regression coefficients for the systolic and diastolic bp models, respectively. male sex, increasing age, increasing weight, and history of hypertension were significantly associated with increasing systolic bp, while history of hypertension, history of diabetes, and increasing weight were significantly associated with increasing diastolic bp. none of the examined independent variables were significantly associated with having at least one elevated bp measurement (≥140/90) or having established hypertension (as defined by a diagnosis of hypertension or receiving antihypertensive treatment). tables 6 and 7 display odds ratio estimates for these analyses. discussion in this ehr-based study of 2496 indigenous adults in rural guatemala, we estimated hypertension prevalence at 16.7% (including confirmed and possible cases). using ehr data in this manner can allow cost and time savings, while also providing valuable epidemiological data not available in other types of studies. in this population, systolic bp was significantly higher in article [healthcare in low-resource settings 2024;12:12370 [page 675] table 2. antihypertensive medications prescribed by class and individual medication. antihypertensive class number of prescriptions (% total) medications prescribed (n) acei 98 (59.8) enalapril (71), lisinopril (27) thiazide diuretic 47 (28.7) hydrochlorothiazide (47) ccb 12 (7.3) amlodipine (11), verapamil (1) bb 5 (3.1) metoprolol (5) arb 2 (1.2) candesartan (1), losartan (1) acei, angiotensin-converting enzyme inhibitors; ccb, calcium channel blockers; bb, beta blockers; arb, angiotensin receptor blockers. table 3. prescribed antihypertensive regimens arranged by frequency. drug regimen number of visits (number of unique patients) acei (enalapril, lisinopril) 83 (74) hctz 34 (33) acei + hctz 10 (10) amlodipine 7 (7) beta blocker (metoprolol) 5 (5) acei + amlodipine + hctz 2 (2) acei + amlodipine 2 (2) verapamil 1 arb (losartan) 1 acei + arb + hctz 1 acei, angiotensin-converting enzyme inhibitors; ccb, calcium channel blockers; bb, beta blockers; arb, angiotensin receptor blockers; hctz, hydrochlorothiazide. table 4. regression coefficients for systolic blood pressure model. variable beta estimate (95% ci) p intercept 115.33 (114.31, 116.34)* <0.001*** sex male 2.54 (0.86, 4.23)* 0.003** age (5 years) 1.44 (1.11, 1.77)* <0.001*** history of hypertension 26.02 (23.13, 28.91)* <0.001*** history of diabetes 1.62 (-0.73, 3.98) 0.176 weight (10 lb) 1.06 (0.42, 1.71)* 0.006** ci, confidence interval. non -co mmerc ial us e o nly males and those with a history of diabetes and increased with older age and increasing weight. diastolic bp was significantly higher in patients with a history of hypertension or diabetes and also increased with increasing weight. however, there were no statistically significant relationships between assessed demographic and anthropometric factors and either confirmed hypertension or elevated bp. of patients who were prescribed antihypertensive medication, a large majority were treated with a single agent alone. aceis were by far the most commonly prescribed antihypertensives, followed by hydrochlorothiazide and ccbs. bp control for patients with confirmed hypertension was poor, with less than onethird of these patients having a systolic bp<140 mmhg. while our focus was to validate the use of ehr data as a tool, this study also adds to the limited published literature on the epidemiology of hypertension in guatemala. our estimate of the prevalence of hypertension in a rural indigenous population is on par with other studies of similar populations in guatemala, as well as nationally representative samples. in 2015, orellana-barrios and colleagues sampled 1104 adults in the same department (firstlevel administrative division) from where our data was collected, finding a hypertension prevalence of 12.5%.25 chen et al. sampled 350 indigenous adults in 2013, also in this same department, estimating a hypertension prevalence of 18.3%.26 steinbrook and colleagues surveyed 806 adults from 2018 to 2019 in two rural, indigenous municipalities in different departments, estimating hypertension prevalence of 20.3%.27 among a nationally representative sample of 1182 women aged 15-49 years of age in guatemala, 12.7% met the criteria for hypertension in 2017.28 our estimated hypertension prevalence of 16.7% falls well within the range of these previously established estimates. notably, while these previous studies utilized standard epidemiologic sampling to survey their target populations, which can be labor and resourceintensive, we came to a similar estimate using ehr data collected in the course of routine clinical care. we found that male sex and increasing age and weight (which we used as a proxy for bmi, given that most patients did not have a height recorded) were positively correlated with systolic bp and history of diabetes and weight were positively correlated with diastolic bp. while comparisons are imperfect given the differences in examined variables, previous studies of guatemalan populations have also found associations between male sex, increasing age, increased adiposity or bmi, history of diabetes, and increasing bp and/or hypertension. orellana-barrios and colleagues demonstrated significantly higher bp in men compared to women and significant associations between hypertension and age ≥55 years and elevated waist circumference, but not increased bmi.25 in their national study of hypertension in women, pickens et al. found that hypertension prevalence increased with increasing age and was more common in those who were overweight or obese, had elevated waist-to-height ratio, and/or had diabetes.28 steinbrook et al. found an increasing prevalence of hypertension with increasing age.27 finally, a multinational study including an urban guatemalan population found that hypertension was more prevalent in subjects with diabetes and those with elevated bmi or waist article [page 676] [healthcare in low-resource settings 2024;12:12370] table 5. regression coefficients for diastolic blood pressure model. variable beta estimate (95% ci) p intercept 73.46 (72.75, 74.17)* <0.001*** sex male 0.66 (-0.49, 1.8) 0.261 age (5 years) 0.18 (-0.08, 0.43) 0.154 history of hypertension 11.19 (9.03, 13.35)* <0.001*** history of diabetes 1.82 (0.22, 3.42)* 0.026* weight (10 lb) 0.83 (0.47, 1.2)* 0.001** ci, confidence interval. table 6. odds ratio (or) estimates for elevated blood pressure model. variable or (95% ci) p sex male 0.82 (0.11, 6.1) 0.844 age (5 years) (scaled) 1.27 (1, 1.62) 0.053 history of diabetes 1.22 (0.06, 25.22) 0.898 weight (10 lb) (scaled) 1.12 (0.83, 1.51) 0.371 ci, confidence interval. table 7. odds ratio (or) estimates for established hypertension model. variable or (95% ci) p sex male 0.64 (0.05, 8.69) 0.735 age (5 years) (scaled) 1.3 (0.94, 1.8) 0.108 history of diabetes 2.51 (0.2, 31.33) 0.474 weight (10 lb) (scaled) 1.06 (0.71, 1.57) 0.775 ci, confidence interval. non -co mmerc ial us e o nly circumference and that those with hypertension were significantly older than those without.29 despite the correlations we found, which aligned with the aforementioned literature, none of the examined patient factors displayed statistically significant associations with diagnosed hypertension or an elevated bp measurement (≥140/90 mmhg). however, this is not unexpected, given that dichotomizing continuous outcomes, such as bp, predictably reduce power in statistical analyses.30 most previous studies of hypertension in guatemala have not included information on antihypertensive treatment and bp control among patients with hypertension. our use of ehr data allowed us to report on these metrics, which are essential for health systems planning, representing a strength of our study’s use of clinical data. while we could not find analogous data in the published literature for rural populations in guatemala, quintana and colleagues analyzed data collected from 3246 adults in guatemala city and found that among those with established hypertension and were prescribed medications, 68.1% were receiving monotherapy, 24.6% two medications, and 7.3% three or more antihypertensives.31 of all patients with hypertension, 43.6% had controlled bp. in our sample, a greater proportion of patients with confirmed hypertension who were prescribed medications were prescribed monotherapy (89.7%) and overall bp control was worse (31.0%). we theorize that the greater percentage of monotherapy and worse control in our population compared to the guatemala city cohort relates to urban/rural differences in regular access to medical care and prescription medication.32,33 furthermore, the fact 11.0% (n=274) of patients with bp diagnostic for hypertension did not receive a diagnosis of hypertension or a prescription for antihypertensive medication suggests that hypertension is underdiagnosed and undertreated in these rural communities. the primary limitations of this study relate to the assessment of hypertension risk factors. because we utilized ehr-based data rather than an epidemiological survey approach, data for certain risk factors, particularly diabetes status, may have been incomplete. in addition, most records lacked height measurements and thus we had to rely on weight as a proxy for bmi/adiposity. assuming that most patients were close to average height for this population, weight would correlate closely with bmi (as has been found in previous studies across diverse populations).34 prior studies have shown that height in guatemalan adults is narrowly distributed, with a standard deviation which is less than or equal to that of other global populations.35-37 however, if there were substantial variations in heights within our sample, this would affect the correlation between bmi and weight. nevertheless, our analysis of hypertension risk factors was generally in line with previous studies in guatemalan populations, suggesting that bp is generally higher in males and patients with diabetes and increases with age and not just weight but increased adiposity/body habitus. the use of ehr data may have also biased the calculation of hypertension prevalence in several ways. first, the measurement of bp and diagnosis and treatment of hypertension was carried out by many different personnel across several medical teams with diverse training and practice backgrounds and using varying equipment. thus, unlike in epidemiological surveys, these procedures did not follow standard protocols. therefore, bp and hypertension diagnosis may have been underor overestimated from one clinic to the next, or even within clinics depending on who measured bp or evaluated patients. secondly, this data does not represent a random or epidemiologically designed sample. adults who chose to attend mobile clinics may differ from those who did not attend, in ways that could impact hypertension risk. however, the similarity of our estimates to previously published epidemiologic studies suggests that the ability to include a large number of patients in our analysis helped to minimize the individual impact of these potential biases. our experience implementing an ehr in rural guatemala shows that these efforts do not only improve the delivery and quality of care; as this study illustrates, ehr use can facilitate the evaluation of population health outcomes and, in turn, the planning of future health interventions and quality improvement. a concrete example of this is our team’s ongoing nih-funded program to design, implement, and systematically evaluate a mhealth intervention for hypertension management in these communities.38 the ehr data collected and analyzed for this study was pivotal to the development of our successful grant proposal. our experience has implications for similar low-resource settings in lmic, as the ehr we developed and implemented has a small technological footprint, using readily affordable mobile technology and requiring only intermittent internet access. thus, the data collected from ehrs like ours can help improve disease surveillance across many settings worldwide. conclusions using ehr-based data, we estimate a hypertension prevalence of 16.7% in a rural, indigenous population in guatemala; almost two-thirds of patients with likely hypertension were not formally diagnosed or treated. older patients, men, those with diabetes, and those with higher body weights tended to have higher bp. hypertension treatment was suboptimal in this population, with less than a third of confirmed hypertension patients having good control of their bp. using ehr-based data is a feasible alternative to traditional epidemiological surveys in low-resource settings, helping to overcome information gaps facing healthcare decisionmakers and empowering interventions to address hypertension and other priority chronic diseases. references 1. world health organization (who). noncommunicable diseases. world health organization. 2022. available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases 2. world health organization (who). hypertension fact sheet. 2019. available from: https://www.who.int/news-room/factsheets/detail/hypertension 3. mills kt, bundy jd, kelly tn, et al. global disparities of hypertension prevalence and control: a systematic analysis of population-based studies from 90 countries. circulation 2016;134:441-50. 4. zhang d, wang g, joo h. a systematic review of economic evidence on community hypertension interventions. am j prev med 2017;53:s121-30. 5. hunter dj, reddy ks. noncommunicable diseases. n engl j med 2013;369:1336-43. 6. world health organization (who). global action plan for the prevention and control of non-communicable diseases. 2021. available from: http://apps.who.int/iris/bitstream/handle/ 10665/94384/9789241506236_eng.pdf;jsessionid=171a0b36 347e1c6675075c85d01e8a86?sequence=1 7. checkley w, ghannem h, irazola v, et al. management of ncd in lowand middle-income countries. glob heart 2014;9:431-43. article [healthcare in low-resource settings 2024;12:12370] [page 677] non -co mmerc ial us e o nly 8. schutte ae, srinivasapura venkateshmurthy n, mohan s, prabhakaran d. hypertension in lowand middle-income countries. circ res 2021;128:808-26. 9. yegros-yegros a, van de klippe w, abad-garcia mf, rafols i. exploring why global health needs are unmet by research efforts: the potential influences of geography, industry and publication incentives. health res policy syst 2020;18:47. 10. charani e, abimbola s, pai m, et al. funders: the missing link in equitable global health research? plos glob public health 2022;2:e0000583. 11. woldemariam mt, jimma w. adoption of electronic health record systems to enhance the quality of healthcare in lowincome countries: a systematic review. bmj health care inform 2023;30:e100704. 12. hung yw, hoxha k, irwin br, et al. using routine health information data for research in lowand middle-income countries: a systematic review. bmc health serv res 2020;20:790. 13. world health organization (who). non-communicable diseases (ncd) country profiles: guatemala. 2018; available from: https://www.who.int/nmh/countries/gtm_en.pdf?ua=1 14. instituto nacional de estadística guatemala. principales resultados censo 2018. 2019. available from: https://www.ine.gob.gt/sistema/uploads/2021/11/19/20211119 2139096rgnq5sfalepmpgfytovw9mf6x2turyt.pdf 15. internet-in-a-box. available from: https://internet-in-abox.org/ 16. duffy s, norton d, kelly m, et al. using community health workers and a smartphone application to improve diabetes control in rural guatemala. glob health sci pract 2020;8:699720. 17. vandenbroucke jp, von elm e, altman dg, et al. strengthening the reporting of observational studies in epidemiology (strobe): explanation and elaboration. plos med 2007;4:e297. 18. unger t, borghi c, charchar f, et al. 2020 international society of hypertension global hypertension practice guidelines. hypertension 2020;75:1334-57. 19. azur mj, stuart ea, frangakis c, leaf pj. multiple imputation by chained equations: what is it and how does it work? multiple imputation by chained equations. int j methods psychiatr res 2011;20:40-9. 20. bates d, mächler m, bolker b, walker s. fitting linear mixedeffects models usinglme4. j stat softw 2015;67:1-48. 21. van buuren s, groothuis-oudshoorn k. mice: multivariate imputation by chained equations. j stat softw 2011;45:1-67. 22. robitzsch a, grund s. miceadds: some additional multiple imputation functions, especially for “mice”. 2023. available from: https://cran.r-project.org/package=miceadds 23. kuznetsova a, brockhoff pb, christensen rhb. lmertest package: tests in linear mixed effects models. j stat softw 2017;82:1-26. 24. bolker b, robinson d, menne d, et al. broom.mixed: tidying methods for mixed models. 2022. available from: https://cran.rproject.org/web/packages/broom.mixed/ index.html 25. orellana-barrios ma, nuggent km, sanchez-barrientos h, lopez-gutierrez jr. prevalence of hypertension and associated anthropometric risk factors in indigenous adults of guatemala. j prim care community health 2015;6:16-20. 26. chen d, rivera-andrade á, gonzález j, et al. prevalence of risk factors for non-communicable diseases in an indigenous community in santiago atitlán, guatemala. rev panam salud publica 2017;41:e7. 27. steinbrook e, flood d, barnoya j, et al. prevalence of hypertension, diabetes, and other cardiovascular disease risk factors in two indigenous municipalities in rural guatemala: a population-representative survey. glob heart 2022;17:82. 28. pickens cm, flores-ayala r, addo oy, et al. prevalence and predictors of high blood pressure among women of reproductive age and children aged 10 to 14 years in guatemala. prev chronic dis 2020;17:e66. 29. organización panamericana de la salud iniciativa centroamericana de diabetes (camdi): encuesta de diabetes, hipertensión y factores de riesgo de enfermedades crónicas. 2009. available from: https://www3.paho.org/hq/dmdocuments/2012/paho-camdi-espanol1-2012.pdf 30. altman dg, royston p. the cost of dichotomising continuous variables. bmj 2006;332:1080. 31. quintana fsw, casasola mav, ortiz lopez ac, et al. may measurement month 2017-2019: an analysis of blood pressure screening results from guatemala. eur heart j suppl 2022;24:f16-8. 32. ippolito m, chary a, daniel m, et al. expectations of health care quality among rural maya villagers in sololá department, guatemala: a qualitative analysis. int j equity health 2017;16:51. 33. lawton am. the right to health in indigenous guatemala: prevailing historical structures in the context of health care. 2015. available from: https://www.hhrjournal.org/2015/08/the-rightto-health-in-indigenous-guatemala-prevailing-historical-structures-in-the-context-of-health-care/ 34. diverse populations collaborative group. weight-height relationships and body mass index: some observations from the diverse populations collaboration. am j phys anthropol 2005;128:220-9. 35. oyesiku l, solomons nw, doak cm, vossenaar m. highland guatemalan women are extremely short of stature, and no lactation duration effects on body composition are observed in a cross-sectional survey. nutr res 2013;33:87-94. 36. subramanian sv, özaltin e, finlay je. height of nations: a socioeconomic analysis of cohort differences and patterns among women in 54 lowto middle-income countries. plos one 2011;6:e18962. 37. roser m, appel c, ritchie h. human height. our world in data. 2013. available from: https://ourworldindata.org/humanheight 38. duffy s. mhealth to enable task sharing for hypertension care in lmic. 2021. available from: https://reporter.nih.gov/project-details/10471363 article [page 678] [healthcare in low-resource settings 2024;12:12370] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11918 the impact of structured education on knowledge and self-efficacy in type 2 diabetes mellitus patients erlin sayuti,1,2 hema malini,3 devia putri lenggogeni3 1faculty of nursing, universitas andalas, padang; 2universitas andalas hospital, padang; 3medical surgical department, faculty of nursing, universitas andalas, padang, indonesia abstract patients diagnosed with type 2 diabetes mellitus (t2dm) need to acquire knowledge and self-confidence to effectively engage in self-care activities. a structured education program has the potential to influence knowledge, self-efficacy, and self-care behavior. this study aimed to investigate the impact of education on the knowledge, self-efficacy, and self-care of individuals with t2dm. the research employed a quasi-experimental non-equivalent control group design with purposive sampling. the total sample size consisted of 60 participants, with 30 in each group. the intervention group attended a four-session t2dm structured education program conducted by internal medicine specialists, nurses, nutritionists, and pharmacists, while the control group continued with their usual monthly check-ups. the results of the independent t-test revealed differences in knowledge, self-efficacy, and selfcare between the intervention and control groups in the post-test assessment. education for t2dm patients was found to be effective in enhancing knowledge (p=0.000), self-efficacy (p=0.000), and self-care (p=0.000), making it a recommended component of self-management education to prevent complications. the implications of this study may assist hospitals in developing standard operating procedures (sops) for implementing structured education programs for individuals with type 2 diabetes mellitus as a means of enhancing patients’ management skills for t2dm. introduction diabetes mellitus (dm) remains a global problem,1 and its prevalence has increased in developing countries.2 type 2 diabetes mellitus (t2dm) is one of the non-communicable diseases that continues to rise in prevalence and mortality rates over the years.3,4 t2dm is a chronic condition characterized by decreased responsiveness to insulin and reduced insulin production by pancreatic β cells resulting in long-term hyperglycemia.5 the international diabetes federation (idf) estimates that there are currently 463 million people with diabetes, and this number is expected to rise to 700 million by 2045, with 90% being t2dm.6 the idf also predicts a substantial increase in t2dm cases from 10.7 million in 2019 to 13.7 million in 2030.5 with 10 million adults diagnosed with diabetes, indonesia ranks seventh in the prevalence of diabetes, following china, the united states, brazil, russia, and mexico. the rising prevalence of t2dm is a significant global concern, and if left unmanaged, it can lead to various complications, including vascular issues, neuropathy, and other related problems.7,8 a previous study found that 76.4% of t2dm patients suffer from at least one complication.9 meanwhile, in west sumatra province, out of 19 municipalities, padang is one of the cities that has a high prevalence of t2dm, with a prevalence rate of 2.47%.10 effective prevention of long-term complications necessitates a strong foundation of knowledge to support self-care activities.11 a structured education program is crucial to ensuring that t2dm patients have the knowledge and abilities necessary for self-care.12 self-management for type 2 diabetes treatment includes dietary regulation, physical activity/exercise, blood glucose monitoring, medication adherence, and self/foot care. a structured education program has been created and tested multiple times in indonesia called the indonesian group-based diabetes education program (ingdep).13 malini, copnell, and correspondence: hema malini, faculty of nursing, universitas andalas, padang, indonesia. e-mail: hemamalini@nrs.unand.ac.id key words: education class, type 2 diabetes mellitus patient, knowledge, self-care. contributions: es, article writing; conceptualization; methodology; investigation; formal analysis; data curation; implementation of research protocols. hb, dpl, work concept; supervision; conceptualization; final approval of the version to be published, writing review and editing; final approval of the version to be published. conflict of interest: the authors declare no potential conflict of interest. ethical approval and consent to participate: to safeguard the welfare and human rights entitlement of the subjects, this study has undergone ethical review. the research ethics committee of the faculty of nursing at andalas university in padang has approved this study under number 029.laiketik/kepkfkpunand. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. availability of data and material: data and material are available upon request to the authors. funding: thesis research scheme, drtpm, higher education number 115/e5/pg.02.00.pl/2023 acknowledgment: i would like to thank all parties who took part in this research, the patients who agreed to be part of this research, the supervisors and families who always encouraged me to complete this research. received: 5 october 2023. accepted: 20 december 2023. early access: 2 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11918 doi:10.4081/hls.2024.11918 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11918] [page 237] non -co mmerc ial us e o nly moss (2017) created this concept.14 the high prevalence of type 2 dm is caused by unchangeable risk factors, such as gender, age, and genetic factors. the second is modifiable risk factors, such as smoking habits, education level, occupation, physical activity, alcohol consumption, body mass index (bmi), waist circumference, and age.15 there are 4 pillars of dm management: education, medical nutrition therapy, physical activity, and pharmacological therapy. education about knowledge of t2dm is crucial for controlling risk factors and preventing complications.16 positive knowledge and mindset have been shown to improve the self-care practices of t2dm patients.17 knowledge is the result of sensory perception and leads to the acquisition of new knowledge, particularly about t2dm.18 knowledge plays a vital role in enhancing self-efficacy, enabling individuals to perform proper self-care activities.19 several studies have demonstrated that education programs for t2dm patients are effective in boosting self-efficacy, which, in turn, significantly influences self-management.9 selfefficacy refers to an individual’s belief in their capacity to initiate, motivate themselves, and act, with potential effects on cognitive, motivational, affective, and selection processes.20 in the context of t2dm, self-efficacy relates to an individual’s confidence in their ability to manage their blood sugar effectively and serves as a valuable framework for understanding and predicting the behavior and commitment of t2dm patients.21,22 there is a clear connection between self-efficacy and t2dm self-care, with self-efficacy significantly impacting a patient’s ability to engage in self-care activities positively or negatively. increased self-efficacy has been linked to improved self-care.23 self-care encompasses active practices by patients aimed at improving their physical condition and maintaining health through measures such as dietary choices, physical exercise, blood sugar monitoring, and preventive healthcare services.11 t2dm patients require ample support in terms of resources, information, and self-confidence to effectively implement self-care.24 effective management of t2dm through self-care can be facilitated through structured and continuous education, aligning with the principles of the social learning theory, which emphasizes cognitive components and promotes understanding and evaluation of learned material.25 data from medical records of university hospital revealed an increasing number of t2dm patients in the outpatient internal medicine ward, with a total of 364 patient visits during that period. among these patients, four had less than 50% knowledge about t2dm, one had knowledge above 50%, and none had an excellent level of knowledge. some patients were uncertain, while two were confident in their ability to manage diabetes self-care activities. regarding self-care, a small number of patients demonstrated poor self-care, while none exhibited good self-care behavior. nurses at the outpatient ward noted the absence of a structured and continuous education program for t2dm patients, with only occasional counseling and information provided through qr barcode scanners and leaflets. based on the preliminary study, researchers identified that there is a need for providing an education program that suit with the hospital situation. lack of self-care management of t2dm patients could increase complications and a reduced quality of life for t2dm patients. a viable solution involves implementing a health education program, which is part of the development of the ingdep method. this includes applying simulation or demonstration methods in regular educational classes for t2dm patients in the outpatient setting. the educational class will be based on adapting the ingdep concept to hospital conditions, modifying learning methods, and enhancing interactions in educational sessions. the educational program will follow the social learning theory, emphasizing the cognitive component of individuals’ minds, leading to better understanding and evaluation of the learned material. moreover, educational materials will align with the pillars of management (diet, physical activity/exercise, medication, and lifestyle) established by the indonesian endocrinology association (2017).7 the method will involve employing an active learning approach in educational classes, fostering cohesion between participants and educators. to address this gap and enhance the knowledge, self-efficacy, and self-care of t2dm patients, the researchers proposed a solution. the suggestion involves incorporating simulation or demonstration using the ingdep technique into routine teaching for t2dm patients at the outpatient clinic.13 the research question guiding this study was: what is the effect of educational classes on the knowledge, self-efficacy, and selfcare of t2dm patients in outpatient university hospitals? thus, this study aimed to investigate the impact of an educational program for t2dm patients on their knowledge, self-efficacy, and self-care. materials and methods study design this study employs a quantitative quasi-experimental non-equivalent control group design to establish a cause-and-effect relationship. it utilizes a pre-test and post-test with a control group design, focusing on a structured education program provided to t2dm patients to assess its impact on knowledge, self-efficacy, and self-care. intervention researchers divided respondents into two groups: a control group with 30 participants and an intervention group with 30 participants. the intervention group was further subdivided into two educational classes, each consisting of 15 respondents. the educational classes spanned four weeks, with two sessions held per week, covering the same material. the provided material included concepts related to diabetes management and lifestyle, dietary practices, food organization, physical activity, and medication management. each session was conducted by healthcare professionals, including doctors, nutritionists, and nurses. sample size and sampling method the study included t2dm patients from the internal medicine outpatient clinic at university hospital in padang. there was an average of 121 patient visits per month from june to august 2022, totaling 364 visits over three months. the study involved 30 participants in the intervention group and 30 in the control group, determined using the slovin formula. purposive sampling was employed with specific inclusion and exclusion criteria. inclusion criteria included t2dm patients proficient in reading and speaking without cognitive deterioration. exclusion criteria encompassed patients with communication problems, psychiatric issues, diminished hearing, kidney dysfunction, cardiovascular problems, and poor eyesight. study tools to measure participants’ knowledge, the dkq-24 diabetes knowledge questionnaire: a 24-question survey assessing knowledge of diabetes mellitus with options of true, false, or don’t know answers.19 the questionnaire used for this study has previously been translated and validated by malini et al., with a cronbach alpha for the indonesian version of dkq-24 of 0.603. for measuring self-efficacy, this study used self-efficacy for diabetes scale: an eight-item survey graded on a likert scale of 1 to 10 to evaluate self-efficacy, with a higher score indicating greater confidence this questionnaire transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 238] [healthcare in low-resource settings 2024;12:11918] non -co mmerc ial us e o nly has been adopted previous study which underwent reliability and validity tests, with a cronbach alpha value of 0.87.26 meanwhile, summary of diabetes self-care activities (sdsca) questionnaire was used, and consists of 17-question survey, originally created by toobert, hampson, and glasgow in 2000 and modified by agrimon (2014), used to assess self-care practices over the past seven days following education. the cronbach alpha value for the indonesian version is 0.474.27 research ethics ethical approval for this study, ensuring subject welfare and human rights, was obtained from the research ethics committee of the faculty of nursing at universitas andalas in padang under approval number 029.laiketik/kepkfkpunand. data analysis the analysis employed both univariate and bivariate techniques. univariate analysis assessed the knowledge, self-efficacy, and selfcare levels of t2dm patients during pre-test and post-test in both the intervention and control groups. it included descriptive statistics such as distribution, presentation, maximum and minimum values, standard deviation, and mean with a 95% confidence interval. bivariate analysis examined the mean differences and the impact of education on t2dm patients’ knowledge, efficacy, and self-care before and after the intervention, as well as between the intervention and control groups to support the research hypothesis. normality was checked using the shapiro-wilk test, and parametric tests such as paired-sample t-tests and independent t-tests were applied to pre-test and posttest data for knowledge, self-efficacy, and self-care in both groups. results the purpose of this study was to determine how structured education affects knowledge, self-efficacy, and self-care in the management of type 2 diabetes mellitus. based on table 1, all characteristics of respondents in the intervention and control groups are homogeneous (p value >0.05). respondents in the intervention group were predominantly pre-elderly (45-59 years old, 70%), had secondary education (40%), worked as irt (40%), suffered from t2dm for ≤5 years (57%), and had a family history of t2dm (87%). table 2 shows the average knowledge, self-efficacy, and self-care of t2dm patients in outpatient university hospital padang in the intervention and control groups before and after education classes. in the intervention group, the average value of knowledge after being given educational classes increased (9.73). likewise on selftransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of intervention and control group respondents (n=60). characteristic group homogeneity test intervention control n=30 (%) n=30 (%) gender man 11 (37) 14 (47) woman 19 (63) 16 (53) age adults (20-44 years) 2 (7) 3 (10) pre-elderly (45-59 years) 21 (70) 13 (43) senior (60 years or older) 7 (23) 14 (47) education lower education 6 (20) 5 (17) secondary education 12 (40) 18 (60) higher education 12 (40) 7 (23) work teacher 0 (0) 1 (3) irt 12 (40) 13 (43) merchant 2 (7) 2 (7) pensioner 0 (0) 4 (13) farmer 0 (0) 2 (7) civil servants 7 (23) 4 (13) self-employed 9 (30) 4 (13) duration of t2dm diagnosis ≤5 years 17 (57) 16 (53) >5-10 years 9 (30) 10 (33) >10-15 years 3 (10) 4 (13) ≥15 years 1 (3) 0 (0) family history of t2dm exist 26 (87) 25 (83) none 4 (13) 5 (17) table 2. the effect of educational classes on knowledge, self-efficacy, and self-care (n=60). variable group mean mean mean difference pretest post-test knowledge intervention 10.00 19.73 9.73 control 9.10 7.43 -1.66 self-efficacy intervention 4.23 7.54 3.31 control 4.46 4.36 -0.10 self-care intervention 3.15 5.14 1.98 control 2.98 3.00 0.02 table 3. differences in knowledge, self-efficacy, and self-care between intervention and control groups of t2dm patients during the posttest (n=60). variable group mean difference sig (2 tailed) t knowledge (post) intervention 12.300 16.077 0.000 control self-efficacy (post) intervention 3.183 17.289 0.000 control self-care (post) intervention 2.133 15.536 0.000 control non -co mmerc ial us e o nly efficacy (3.31), and self-care (1,98). after being given education, there is an increase in the mean value, it can be seen where the mean difference has increased. while in the control group, the trend was to experience a decrease in the average value for knowledge (-1.66), self-efficacy (-0.10) during the post test. meanwhile, for self-care (0.02) , there is only a slight difference from the average value during the post-test. meanwhile, table 3 shows the results of the independent samples t test on the intervention and control groups obtained knowledge (p=0.000), self-efficacy (p=0.000), and self-care (p=0.000). this means that there are differences in knowledge, self-efficacy, and self-care in the intervention and control groups during the posttest at university hospital outpatient ward. discussion in this study the class education that adopted from structured health education program, conducted by having an interpersonal collaboration between health professionals. the team consist of healthcare teams (doctors, nurses, nutritionists, pharmacists) who collaborate to deliver educational materials on various health topics.13 collaboration between the presenters and nurses, when presenting the topic, served as an elaboration in this study. for instance, the nurse instructed the class on pharmacology on how to administer insulin therapy. educators encourage patients to participate in the learning process through group discussions and practices based on learning objectives. active involvement of educational participants and demonstrations/simulations can maximize learning, creating cohesion between educational participants and educators.28 according to leo et al. (2022), there is a significant positive relationship between educational linkage behavior and affecting participants’ motivation in achieving goals. based on the results of this study, there was an influence from the provision of educational structure on knowledge, self-efficacy, and self-care.29 the increased knowledge in the intervention group was attributed to continuous education over four weeks, the provision of pocketbooks for type 2 diabetes mellitus, and the use of simulation/demonstration methods in delivering material. the results align with hailu’s research on the influence of education on increasing knowledge.19 the education in this study comprised six sessions lasting 1-1.5 hours each, focusing on t2dm concepts and intervention behaviors. significant improvements were noted in knowledge regarding dietary recommendations and foot care practices. the decline in knowledge levels in the control group was due to not receiving the same treatment, namely ongoing education on the concept of t2dm. these patients only underwent routine internal medicine poly check-ups. while they received information about their health from internal medicine specialists, detailed explanations about t2dm and structured self-care management were lacking. information in short-term memory can be transferred to long-term memory through effort and practice in a conscious state with repetitive processes. another reason for declining knowledge levels is forgotten information. according to cognitive theory, information is processed by the reasoning system and stored in permanent memory. however, real-world experiences sometimes contradict theory, making it challenging to recall diligently learned information. boredom can also lead to a sense of redundancy in one’s actions.30 meanwhile, self-efficacy in t2dm patients represents an individual’s self-confidence in their ability to manage blood sugar levels.21 the study found significant differences in self-efficacy between the intervention and control groups. these results are related to the patient’s mastery of self-care, increasing their confidence in correctly performing self-care. self-efficacy positively contributes to improved self-care. increased self-efficacy in selfcare is influenced by the education provided.23 the results of this study align with similar research, which indicates the effect of education on increasing self-efficacy.31 in addition to education, patients received health information through leaflets and videos. another study also reported an influence on self-efficacy levels after education in discharge planning.32 thus, it can be concluded that patients with type 2 diabetes mellitus can increase their knowledge about t2dm management through education provided in a structured education program. this process involves adding information, sharing positive experiences in t2dm management, and increasing confidence to control blood sugar levels, live better, and avoid t2dm complications. self-care behavior in t2dm patients was assessed by asking respondents about diabetes self-care activities in the last seven days after receiving education. these routine activities included diet, physical activity (exercise), foot care, blood glucose monitoring, and medication. in this study, the intervention group reported more frequent dietary adjustments (6 days a week) compared to the control group (4 days a week). align with similar study, where the intervention group performed dietary self-care for an average of 6 days a week, while the control group did so for 4 days a week.33 dietary regulation in the intervention group resulted from the respondents’ ability to adjust their food intake based on their needs. however, the control group had lower dietary self-care because they lacked understanding in setting their diet according to their requirements. for physical exercise: the intervention group engaged in physical self-care more frequently, averaging 5 days a week, compared to the control group, which averaged 3 days a week. these results are consistent with similar a study which the intervention group participated in physical activity 5 days a week.33 the difference occurred because the intervention group, after attending t2dm education classes, tried to be more physically active than the control group. respondents in the intervention group engaged in physical activities more effectively than the control group. there was no significant difference in self-care related to medication use. both the intervention and control groups had an average medication self-care routine of 3 days a week. this lack of improvement in medication adherence was because both groups struggled with proper medication usage. patients often forgot to take their medication the required number of times per day (two or three times), resulting in suboptimal adherence.34,35 both the intervention and control groups monitored their blood sugar levels an average of 2 times a week during post-tests. however, most respondents checked their blood sugar levels the day before their routine internal medicine poly check-ups. this indicates that respondents did not have the necessary tools to check their blood sugar levels regularly on their own. the intervention group reported better diabetic foot self-care, averaging 6 days, compared to the control group’s 3 days. these results are consistent with indaryati’s study,33 which found that the intervention group performed diabetic foot self-care for an average of 6 days, while the control group did so for 3 days. the improvement in diabetic foot self-care in the intervention group was due to a better understanding of the risks associated with diabetic feet and how to care for them among the patients. most respondents failed to dry the areas between their toes after wetting their feet, unaware that moisture in these areas could increase the risk of fungal growth and foot infections.7 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 240] [healthcare in low-resource settings 2024;12:11918] non -co mmerc ial us e o nly limitations this study has several weaknesses, namely the limited research time, which prevented the examination of long-term effects and follow-up activities. additionally, the sustainability of this education program relies on the commitment of health workers, emphasizing the importance of their dedication to implementing health education programs. conclusions in summary, the study highlights the positive impact of structured educational interventions on the knowledge, self-efficacy, and self-care practices of patients with type 2 diabetes mellitus. these findings underscore the significance of patient education as an integral component of diabetes management. the results of this study can contribute to the hospital’s efforts in providing education to t2dm patients. implementing educational class programs is a viable alternative based on the research findings. this study serves as evidence for the management of t2dm patients in hospitals, particularly in the development of health education programs. therefore, it is recommended that the hospital establish a policy for creating standardized operational procedures for the implementation of educational classes for t2dm patients. additionally, consideration should be given to the development and application of the role of educators among health workers, fostering collaboration in healthcare services. references 1. ong kl, stafford lk, mclaughlin sa, et al. global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021. lancet 2023;402:20334. 2. awang jihadi mh, yuda a, sukorini ai, et al. drug-related problems in hospitalized patients with type 2 diabetes mellitus: a systematic review. explor res clin soc pharm 2023;12:100348. 3. dewi eu, widari np, nursalam, et al. the relationship between diabetes self-care management and blood glucose level among type 2 diabetes mellitus patients. int j publ health sci 2023;12:1165-70. 4. kusnanto k, arifin h, pradipta ro, et al. resilience-based islamic program as a promising intervention on diabetes fatigue and health-related quality of life. plos one 2022;17:116. 5. idf. idf diabetes atlas 2021. international diabetes federation. 2021. available from: https://idf.org/e-library/epidemiology-research/diabetes-a t las .h tml%0ahttp: / / www.idf.org/about-diabetes/facts-figures%0ahttps://diabetesatlas.org/upload/resources/material/20200302_133351_idfa tlas9e-final-web.pdf 6. zairina e, nugraheni g, sulistyarini a, et al. factors related to barriers and medication adherence in patients with type 2 diabetes mellitus: a cross-sectional study. j diabetes metab disord 2022;21:219-28. 7. perkeni. guidelines for the management and prevention of type 2 diabetes mellitus adults in indonesia 2021. global initiative for asthma. 2021;46. available from: www.ginasthma.org 8. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob health 2022;10:e1632-45. 9. qiu t, huang j, wang w. association between diabetes knowledge and self-efficacy in patients with type 2 diabetes mellitus in china: a cross-sectional study. int j endocrinol 2020;2020. 10. riskesdas. riset kesehatan dasar provinsi sumatera barat tahun 2018. laporan riskesdas nasional 2018. 2019. 1-478 p. 11. aade7tm. american association of diabetes educators. encyclopedia of child behavior and development, 2020; p. 1307. 12. darma karingga d, efendi f. effect of mobile structured educational applications on self-care management in diabetes mellitus patients. gac med caracas 2023;131:278-86. 13. malini h, yeni f, saputri de. the effect of ingdep on type 2 diabetes patients’ knowledge and self-care. jurnal keperawatan padjadjaran 2018;6:235-42. 14. malini h, copnell b, moss c. considerations in adopting a culturally relevant diabetes health education programme: an indonesian example. collegian 2017;24:183-90. 15. rokhmad k, supriyanto s. analysis of prolanis activities on controlling type-2 diabetes mellitus at puskesmas tulungagung in 2022. j public health afr 2023;14:2617. 16. purwanto cr, sukartini t, bakar a, devy sr. increasing selfcare of patients with type-2 diabetes through implementation of nursing agency based on the health promotion model. j pak med assoc 2023;73:s130-4. 17. shawahna r, samaro s, ahmad z. knowledge, attitude, and practice of patients with type 2 diabetes mellitus with regard to their disease: a cross-sectional study among palestinians of the west bank. bmc public health 2021;21:472. 18. heriani p, nauli fa, woferst r. the relationship of the level of knowledge about dm disease to the coping mechanism of type 2 dm patients. 2020;2030. 19. hailu fb, moen a, hjortdahl p. diabetes self-management education (dsme) – effect on knowledge, self-care behavior, and self-efficacy among type 2 diabetes patients in ethiopia: a controlled clinical trial. diabetes metab syndr obes 2019;12:2489-99. 20. bandura a. self�efficacy. the wiley encyclopedia of personality and individual differences. 1994;1994:387-91. 21. adinata ach a, minarti m, kastubi k. relationship between self-efficacy, compliance and family support with selfmanagement of type 2 diabetes mellitus sufferers in surabaya. jurnal ilmiah keperawatan stikes hang tuah surbaya 2022;17:6-15. 22. anandarma so, asmaningrum n, nur krm. the relationship between self-efficacy of type 2 diabetes mellitus patients and the risk of readmission at dr. regional general hospital. harjono, ponorogo regency. jurnal keperawatan sriwijaya 2021;8:39-49. 23. tharek z, ramli as, whitford dl, et al. relationship between self-efficacy, self-care behaviour and glycaemic control among patients with type 2 diabetes mellitus in the malaysian primary care setting. bmc fam pract 2018;19:1-10. 24. kalonga n, mukwato pk, wahila r. nursing & primary care selfefficacy and selfcare practices, in glycemic control among adults with diabetes mellitus receiving care at kitwe teaching hospital, kitwe, zambia. nursing a & primary care 2023;7:4-8. 25. harmiardillah s. the effect of mindfulness-based eating transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11918] [page 241] non -co mmerc ial us e o nly training using a social cognitive theory (sct) approach on self-efficacy, diet compliance and blood glucose levels in type 2 diabetes mellitus. ir-perpustakaan universitas airlangga. 2018;1-478. 26. sabil fa. relation of health literacy and self efficacy to self care management relationship of health literacy and self efficacy to self care management of type 2 diabetes mellitus patients in makasar city community health centers type 2 diabetes mellitus patients. bitkom research 2018;63:1-3. 27. agrimon oh. exploring the feasibility of implementing selfmanagement and patient empowerment through a structured diabetes education programme in yogyakarta city indonesia: a pilot cluster randomised controlled trial. the university of adelaide. 2014;1-24. 28. fitria, y, indra w. pengembangan model pembelajaran pbl berbasis digital untuk meningkatkan karakter peduli lingkungan dan literasi sains. deepublish; 2020. 29. leo fm, lópez-gajardo lg, rodríguez-gonzález p, et al. how class cohesion and teachers’ relatedness support/thwarting style relate to students’ relatedness, motivation, and positive and negative outcomes in physical education. psychol sport exerc 2023;65:102360. 30. nofindra r. memory, forgetting, and transfer in learning and learning. journal of economic education and economic sciences. jurnal kajian pendidikan ekonomi dan ilmu ekonomi 2019;2:1-19. 31. susanti., d, marselin. a. ncreased self-efficacy of diabetes militus patients during the pandemic. journal of primary health (jurnal kesehatan primer) 2021;6:23-31. 32. nurjanah. u. the effect of self care management education in discharge planning on the self efficacy of type 2 diabetes mellitus (dm) patients in inpatient bayu asih purwakarta hospital. phys rev e 2018;8:24. 33. indaryati s. the effect of diabetes self management education (dsme) on the self-care of diabetes mellitus patients in palembang city hospital. 1. jurnal ilmiah kesehatan 2018; 1:44-52. 34. suprapti b, izzah z, anjani ag, et al. prevalence of medication adherence and glycemic control among patients with type 2 diabetes and influencing factors: a cross-sectional study. glob epidemiol 2023;5. 35. rochmah n, hisbiyah y, perwitasari rk, et al. quality of life, medication adherence, and glycemic control in type 1 diabetes mellitus children with basal bolus regimen during covid-19 in limited resources setting. j comprehensive pediatr 2023;14:e134561. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 242] [healthcare in low-resource settings 2024;12:11918] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5669] [page 35] chronic diseases in nyeri, kenya: a study of knowledge and perceptions michael a.t. freiberg,1 nelson o. onyango,1 stephanie j. ashbaugh,1 khanjan mehta2 1department of family and community medicine, pennsylvania state university college of medicine, hershey, pa; 2humanitarian engineering and social entrepreneurship (hese) program, pennsylvania state university college of engineering, university park, pa, usa abstract the burden of chronic, non-communicable disease such as diabetes, cardiovascular disease, and cancer is growing in many developing countries including kenya. the use of community health workers is an important tool to improve the access to care and education in rural areas. this study aims to understand the knowledge and perceptions among the general population regarding three chronic diseases – diabetes, hypertension, and cancer – in nyeri, kenya. standardized, open-ended interviews were conducted with 200 participants. this study shows that most individuals interviewed are familiar with these three diseases; however, knowledge varied among individuals with many having significant gaps in knowledge. these results are consistent with previous studies from this region and will inform future education directed at community health workers and the general population. introduction the burden of chronic, non-communicable disease continues to grow throughout africa and across the developing world. although the most recent data from the world health organization show that the majority of deaths in africa between 2000-2012 were from communicable disease at 61.7% compared to 28.6% for non-communicable disease and 9.8% from injury, this distribution is quickly changing.1 by 2020, 73% of deaths worldwide are expected to be due to non-communicable disease with 79% of these deaths occurring in developing countries.2-4 many factors have been attributed to this rise including increased lifespan, modernization, globalization, poverty, and changing lifestyle.4,5 this problem is compounded by the fact that many health care systems are underfunded and ill-prepared to handle the current state of non-communicable disease and the inevitable rise over the coming years will put additional burden on these systems. of the money that is spent on healthcare in africa, most of which is from foreign sources, it has been estimated that 80% is spent on communicable diseases including hiv, malaria, and tuberculosis.6,7 many health ministries acknowledge this disparity; however, little has been done to change this imbalance. this imbalance results in healthcare systems that are poorly prepared to handle non-communicable disease and a population that is uninformed of the risks, treatment, and prevention.8,9 a multifactorial approach will be necessary to improve the outlook of non-communicable disease in the developing world and important components will include improving access to health care services and improving education. one common approach to accomplish both of these goals in many countries in africa and across the developing world is the community health worker (chw) model. under this model, community members are selected to serve as the first point of contact for health care and education. chws are members of the communities that they serve; they know the local language, culture, and people well and are thus in a good position to enact change. the ability of chws to enact change and improve health care for medically underserved patients in both high and low income countries has been well documented.10-14 their impact, however, is somewhat limited by their lack of medical knowledge and experience.15 most have no formal medical education are often chosen because of their position in the community rather than the amount of medical knowledge they have. in order to improve the positive impact of chws, an effective education program is necessary and should focus on the knowledge gaps and cultural attitudes of the community members in each region.10 much work has already been done to understand these knowledge gaps in kenya, africa and the developing world and most studies demonstrate that knowledge is lacking.16-19 the focus for this study is on three non-communicable diseases – hypertension, diabetes, and cancer. hypertension and diabetes, both significant risk factors for cardiovascular disease, are common in kenya.16-18 as such, more effective prevention and treatment of these conditions represents an excellent opportunity to reduce the overall burden of chronic disease. one study, which estimated the prevalence of hypertension to be 21% in rural kenya found that 83% of participants with hypertension were not aware of their condition and only 3% were being successfully treated.17 another study in mombasa, the second largest city in kenya, found the prevalence of hypertension to be even higher at 32% with only 53% of these individuals being aware of their condition and only 23% familiar with the causes and treatments.16 knowledge of diabetes is also lacking. at an estimated prevalence of 3.58% and as high as 12% in some urban populations, diabetes is common in kenya.18 one study found that 73% of people interviewed across four regions of kenya had poor knowledge of diabetes and not surprisingly, education was correlated with a higher knowledge of diabetes.19 cancer, which is more complicated to treat than other chronic diseases, is a target for primary prevention. cervical cancer, the most common cancer for women in kenya, has been the most studied since it is largely preventable with screening, vaccination, and safe sexual practices. one study in rural kenya showed that 35% of respondents had never even heard of cervical cancer and only slightly more than half had ever heard of a pap smear.20 another study among patients in a government hospital healthcare in low-resource settings 2016; volume 4:5669 correspondence: michael a.t. freiberg, department of family and community medicine, pennsylvania state university college of medicine, hershey, pa, usa. tel: +1.717.4334804. e-mail: michael.a.t.freiberg@gmail.com key words: kenya; diabetes; hypertension; cancer; community health worker. acknowledgments: the authors would like to acknowledge dr. timothy irwin for assistance with interviews conducted in this study. we would also like to acknowledge mr. david ndirangu kihara who served as our interpreter in kenya. contributions: the study was designed by mf and no with the advice and guidance of sa and km. the surveys were conducted by mf, no, and sa. the data analysis was done by mf and no. the paper was written by mf and no and critically analyzed by sa and km. conflict of interest: the authors declare no potential conflict of interest. note: this research was approved by the institutional review board of the penn state university and informed consent was obtained verbally from each subject. received for publication: 6 december 2016. revision received: 30 october 2016. accepted for publication: 11 november 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright m.a.t. freiberg et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5669 doi:10.4081/hls.2016.5669 non co mmerc ial us e o nly in nairobi found similar results with only half of patients knowing about cervical cancer and only 32% knowing about the pap smear.21 the present study aims to understand the current state of knowledge and perceptions of these three chronic diseases – hypertension, diabetes, and cancer – in nyeri, kenya. a deeper understanding of the knowledge and perceptions of diabetes, hypertension, and cancer in this region, will guide and focus future education of both chws and community members on non-communicable disease. materials and methods site selection nyeri is a city located in the central highland region of kenya, approximately 100km north of country’s capital, nairobi. the city and surrounding villages has a population of approximately 125,000 people.22 the local language in nyeri is kikuyu; however, both english and swahili are widely spoken. this site was chosen because there is convenient access to both rural and urban populations. study design standardized, open-ended interviews were conducted with one interviewer asking questions to one subject. interviews were conducted either completely in english, in english with the assistance of a kikuyu-speaking interpreter, or in swahili depending on the preference of the participant. after recording the age and gender of the participant, the participant was asked four standardized, openended questions about each of the three diseases being studied – diabetes, high blood pressure, and cancer: i) what is (disease) and what are some signs and symptoms? ii) how does someone get (disease)? iii) how is (disease) treated? iv) how can (disease) be prevented? finally, each participant was asked an additional question do you have anything you would like to share or any stories about how these diseases have affected yourself, your friends, your family, or someone in your community? each participant was allowed to answer each question as thoroughly as he wished and the next question was asked only when the subject indicated he was finished with that question or began giving repetitive information. during the interview, thorough handwritten notes were taken of each participant’s response and the notes were later transcribed electronically. participant selection and sample size interviews were conducted during daylight hours between 0900 to 1500 at multiple locations in both the urban center of nyeri and in surrounding rural areas in order to get a wide range of participants. to identify participants, the interviewers walked through the community and asked people if they would be willing participate. only individuals 18 years of age or older were allowed to participate and informed consent was obtained verbally prior to each interview. individuals under 18 or who did not agree to participate in the survey were not included in the analysis. a total of two-hundred interviews was conducted and the sample size was determined based on a saturation of responses. data analysis after reviewing the transcripts of all responses, a list of reported response features relevant to each disease was developed. these response features included elements that suggest an understanding of the disease etiology or pathophysiology (i.e. participant knows that diabetic patients have blood sugar that is too high or too low), signs and symptoms of the disease (i.e. hypertension causes headaches), causes of the disease (i.e. cancer is caused by tobacco use), and treatment of the disease (i.e. diabetes can be treated with insulin). each subject’s disease-specific response was then analyzed for the presence or absence of each specific response feature. response features with the same meaning, despite exact wording, were considered equivalent (i.e. a participant who said that diabetes causes polyuria was given credit for the increased urination response feature). response features that could be considered both a cause and treatment (i.e. lack of exercise causes hypertension or exercise is a treatment for hypertension) were considered equivalent responses. results subject population not everyone who was invited to participate in an interview agreed to participate and only data from individuals who completed interviews is included in the analysis. a total of 200 individuals completed interviews including 99 females and 101 males. subjects had a mean age of 37.1 years old with a standard deviation of 14.4 years. interviews were conducted in nine different localities across nyeri county that included both rural and urban settings. most interviews lasted between five and fifteen minutes depending on the length of answers given by the subject. of the participants interviewed, 8 people (4%) reported having no formal education, 166 people (83%) reported having completed at least class 8 (equivalent to 8th grade in the united states), 104 people (52%) reported finishing at least from 4 (equivalent to 12th grade in the united states), and 22 people (11%) reported having completed at least some postsecondary education (table 1). disease-specific criteria a summary of participant’s responses is presented for diabetes (table 2), hypertension (table 3), and cancer (table 4). discussion non-communicable diseases such as diabetes, hypertension and cancer represent a significant and growing burden to the health of people in the developing world.1-4 while the barriers to decreasing the burden of chronic disease are multifactorial, education of both community members and community health workers will play an important role. this study identified significant knowledge gaps in this region, consistent with prior studies.16,17,19-21,23 while overall knowledge of diabetes was lacking in this study population, the most notable knowledge gaps identified related to lifestyle risk factors and signs and symptoms. while most of the research on diabetes knowledge has focused on people with the disease, our findings are consistent with previous studies sub-saharan africa.19,23 since symptom identification can be a motivation for people to seek care, education should focus on recognizing signs and symptoms of diabetes, especially among chws who are well situated to identify those at risk. article table 1. the highest level of education that the two-hundred surveyed completed. highest education n % level completed no formal education 8 4 class 1 0 0 class 2 1 1 class 3 0 0 class 4 2 1 class 5 4 2 class 6 2 1 class 7 17 9 class 8 43 22 form 1 1 1 form 2 12 6 form 3 6 3 form 4 82 41 post-secondary education 22 11 n=200, percentages were calculated using a denominator of 200. [page 36] [healthcare in low-resource settings 2016; 4:5669] non co mmerc ial us e o nly this study also identified a poor understanding of hypertension among participants. most notably, many of the signs and symptoms named were overemphasized. a variety of responses were given including headache, dizziness and fainting, fatigue, difficulty breathing, swelling, anger, and vision changes. while these are all potential signs and symptoms of hypertension, no participant said that hypertension can be asymptomatic. this represents a significant disconnect since hypertension commonly presents asymptomatically and other studies from kenya suggest that the majority of people with hypertension are unaware that they have the condition.16,17 education on the importance of regular screening should be emphasized along with efforts to improve screening of hypertension through home and community based programs is already underway.24,25 additionally, respondents seemed to overemphasize stress as a cause hypertension when other factor such as diet, lack of exercise, and obesity are more significant contributors. education to modify diet and increase exercise in a culturally relevant way represents an additional opportunity to prevent and treat hypertension. compared to diabetes and hypertension, cancer is more complicated and expensive to treat. the most cost-effective interventions to reduce the burden of cancer will focus on primary prevention rather than treatment.26 while slightly over half of respondents were able to name at least one type of cancer, knowledge of risk factors was lacking. for example, only six people (3%) surveyed mentioned that cancer can be caused by sexual activity, or by a sexually transmitted infection, even though cervical cancer is the most common cancer among women in kenya and is almost always caused by an infection with the sexually transmitted human papilloma virus (hpv).27,28 in addition, no one mentioned pap smears specifically as a way to prevent or screen for cervical cancer. this finding is consistent with the results from other studies in kenya which demonstrated that many women surveyed in both rural and urban hospitals had not even heard about cervical cancer or were not able to describe anything about the disease including prevention or treatment.20,21 while this may have been due to the cultural taboo of discussing sex, it is more likely due to the fact that widespread pap smear programs or hpv vaccination programs have not yet begun in kenya. additionally, only 20% of people identified smoking or tobacco use as a cause of cancer. while tobacco use is only attributed to 6% of cancer deaths in africa compared to about 20% of cancer deaths worldwide, most likely because of the relatively low life expectancy and low smoking prevalence, it is increasing in some parts of africa.26 education on the risks of tobacco represents an additional opportunity for cancer prevention. a cultural belief about cancer that several participants (4%) mentioned was that cancer is a curse. specifically, one respondent explained that going against your parent’s requests after they had died, for example: selling their land against their wishes could give you a curse that causes cancer. some participants also held the cultural belief that cancer is brought about by mimicking values and practices of the western world such as the western diet and vaccinations. although relatively uncommon among our participants, these beliefs are an additional barrier to cancer prevention and treatment. our data does have some limitations and potential biases. due to logistical limitations, random sampling was not feasible in this study article table 2. total number of individuals providing each response (n) when asked four questions related to diabetes: what is diabetes and what are some signs and symptoms? how does someone get diabetes? how is diabetes treated? how can diabetes be prevented? response n % blood sugar is too high or too low 58 29 signs and symptoms fatigue 35 18 increased urination 29 15 dizziness or fainting 28 14 increased thirst 22 11 weight loss 16 8 increased appetite 11 6 vision changes 11 6 poor wound healing 12 6 causes poor diet 135 68 inherited from family 30 15 lack of exercise 24 12 obesity 7 4 alcohol use 7 4 tobacco use 5 3 treatment any medication (pills and/or insulin) 87 44 pills 75 38 insulin 35 18 n=200, percentages were calculated using a denominator of 200. table 3. total number of individuals providing each response (n) when asked four questions related to hypertension: what is high blood pressure and what are some signs and symptoms? how does someone get high blood pressure? how is high blood pressure treated? how can high blood pressure be prevented? response n % a disease of the heart of blood vessels 75 38 signs and symptoms headache 48 24 dizziness or fainting 30 15 fatigue 23 12 difficulty breathing 15 8 swelling in hands or feet 15 8 anger or irritability 12 6 vision changes 8 4 causes stress 134 67 poor diet 65 33 lack of exercise 24 12 depression 17 9 obesity 11 6 inherited from family 16 8 too much dietary salt 5 3 treatment medications 99 50 [healthcare in low-resource settings 2016; 4:5669] [page 37] non co mmerc ial us e o nly [page 38] [healthcare in low-resource settings 2016; 4:5669] and a relatively low sample population was used. interviews were conducted in the community during daytime hours from 0900 to 1500 and this likely biased the sample toward certain demographics who were available to participate during this time. in addition, many people who were approached to participate in this survey declined to participate. still, there is a wide range of ages and education levels in the people who did participate so this survey likely still provides a representative sample. one additional limitation was the manner that questions were asked. since questions were open-ended, direct recollection was required by the subjects being interviewed. conclusions there are many gaps and misconceptions about non-communicable disease in this region. based on the knowledge deficiencies identified in this study, future public health and chw educational programs should have an emphasis on preventative measures and lifestyle factors that contribute to each disease. specifically, for diabetes the importance of diet and exercise should be targeted. community health workers should be educated on appropriate dietary factors that contribute to the disease, with an additional emphasis on the signs and symptoms of diabetes. for hypertension, it will be important to emphasize that it is often an asymptomatic disease so screening is necessary despite the absence of symptoms. for cancer, smoking cessation, and moderate alcohol use are important concepts to emphasize. safe sex practices are also important to prevent cervical cancer as well as other sexually transmitted disease. while it is also necessary to educate women on the importance of screening and vaccination to prevent cervical cancer this will likely have little effect until such services are widely available. references 1. world health organization. global causes of death. geneva: world health organizaion; 2014. 2. kearney pm, whelton m, reynolds k, et al. global burden of hypertension: analysis of worldwide data. lancet 2005;365:217-23. 3. world health organizaion. the world health report 2002. geneva: world health organizaion; 2002. 4. world health organizaion. preventing chronic disease: a vital investment. geneva: world health organizaion; 2005. 5. mccormack va, schüz j. africa’s growing cancer burden: environmental and occupational contributions. cancer epidemiol 2012;36:1-7. 6. ejughemre u. donor support and the impacts on health system strengthening in sub-saharan africa: assessing the evidence through a review of the literature. am j public heal res 2013;1:146-51. 7. world health organizaion. the work of who in the african region. geneva: world health organizaion; 2007. 8. de-graft aikins a, unwin n, agyemang c, et al. tackling africa’s chronic disease burden: from the local to the global. global health 2010;6:5. 9. mensah ga. epidemiology of stroke and high blood pressure in africa. heart 2008;94:697-705. 10. mwai g, mburu g, torpey k, et al. role and outcomes of community health workers in hiv care in sub-saharan africa: a systematic review. j int aids soc 2013;16:1-14. 11. haines a, sanders d, lehmann u, et al. acheiving child survival goals: potential contribution of community health workers. lancet 2007;369:2121-31. 12. gilmore b, mcauliffe e. effectiveness of community health workers delivering preventive interventions for maternal and child health in lowand middle-income countries: a systematic review. bmc public health 2013;13:847. 13. lewin s, munabi-babigumira s, glenton c, et al. lay health workers in primary and community health care for maternal and child health and the management of infectious diseases. cochrane database syst rev 2010;cd004015. 14. swider sm. outcome effectiveness of community health workers: an integrative literature review. public health nurs 2002;19:11-20. 15. kane s, kok m, ormel h, et al. limits and opportunities to community health worker empowerment: a multi-country comparative study. soc sci med 2016;164:27-34. 16. jenson a, omar al, omar ma, et al. assessment of hypertension control in a district of mombasa, kenya. glob public health 2011;6:293-306. 17. hendriks me, wit fwnm, roos mtl, et al. hypertension in sub-saharan africa: cross-sectional surveys in four rural and urban communities. plos one 2012;7:e32638. 18. international diabetes federation. idf atlas, sixth edition. brussels: international diabetes federation; 2013. 19. maina wk, ndegwa zm, njeng ew, muchemi ew. knowledge , attitude , and practices related to diabetes among community members in four provinces in kenya : a cross-sectional study. african j diabetes med 2011;19:15-8. 20. gatune jw, nyamongo ik. an ethnographic study of cervical cancer among women in rural kenya: is there a folk causal model? int j gynecol cancer 2005;15:104959. 21. gichangi p, estambale b, bwayo j, et al. knowledge and practice about cervical cancer and pap smear testing among patients at kenyatta national hospital, nairobi, kenya. int j gynecol cancer 2003;13:827-33. 22. open data portal. 2009 census vol 1 table 3 rurual and urban population. open data article table 4. total number of individuals providing each response (n) when asked four questions related to cancer: what is cancer and what are some signs and symptoms? how does someone get cancer? how is cancer treated? how can cancer be prevented? response n % named at least one type of cancer 102 51 causes tobacco use 40 20 inherited from family 37 19 diet 35 18 pesticides and other chemicals in food 19 10 alcohol 14 7 infectious 13 7 unpreventable 10 5 stress 9 5 curse 8 4 unsafe sex or hpv 6 3 dirty living conditions or lack of hygiene 5 3 solar radiation or x-rays 3 2 treatment chemotherapy 73 37 early detection 72 36 surgery 58 29 radiation therapy 21 11 untreatable 17 9 hpv, human papilloma virus. n=200, percentages were calculated using a denominator of 200. non co mmerc ial us e o nly [healthcare in low-resource settings 2016; 4:5669] [page 39] article portal. open kenya. available from: https://www.opendata.go.ke/population/20 09-census-vol-1-table-3-rural-andurban-populati/e7c7-w67t 23. kiawi e, edwards r, shu j, et al. knowledge, attitudes, and behavior relating to diabetes and its main risk factors amoung urban residnets in cameroon: a qualitative survey. ethn dis 2006;16:503-9. 24. pastakia sd, ali sm, kamano jh, et al. screening for diabetes and hypertension in a rural low income setting in western kenya utilizing home-based and community-based strategies. global health 2013;9:21. 25. lackey jd, suffian s, dzombak r, mehta k. demonstrating demand for preventive health services in rural kenya. j humanit eng 2015;3:8-16. 26. jemal a, bray f, forman d, et al. cancer burden in africa and opportunities for prevention. cancer 2012;118:4372-84. 27. walboomers j, jacobs m, manos mm, et al. human papillomavirus is a necessary cause of invasive cervical cancer worldwide. j pathol 1999;19:12-9. 28. world health organization. the global burden of disease. 2004 update. geneva: world health organizaion; 2008. available from: http: non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11783 factors related to nurse compliance in monitoring infusion fluid in hospital aulia asman,1 yulkifli yulkifli,2 yohandri yohandri,2 naurah nazhifah,2 teguh afrianda,2 mariza elvira,1 alimuddin alimuddin,3 debby sivia dewi,2 sena wahyu purwanza,4 ramaita ramaita,1 auzia asman5 1department of nursing, faculty of psychology and health, universitas negeri padang; 2department of physics, faculty of mathematics and natural sciences, universitas negeri padang; 3department of sport, faculty of sport sciences, universitas negeri padang; 4ners professional education study program, sekolah tinggi ilmu kesehatan maharani, malang; 5food crops study program, politani negeri payakumbuh, koto tuo, indonesia abstract infusion therapy involves the intravenous administration of drugs, fluids, and blood products to hospitalized clients. this study aimed to identify factors influencing nurse compliance in monitoring infusion fluids according to standard operating procedures (sops). the research adopted a quantitative approach with a descriptive correlational design and a cross-sectional approach, focusing on a study population of 50 nurses. data collection utilized observation techniques and questionnaires as research instruments, with the analysis employing kendall’s tau b and kendall’s tau c methods. the findings revealed significant correlations between age (p=0.000), education (p-value=0.006), career path level (p=0.013), and knowledge (p=0.011). however, there was no significant relationship between the length of work experience and nurse compliance in monitoring infusion fluids (p=0.257) according to sops in this private hospital. to enhance the quality of care, it is recommended that nurses receive additional training provided by the nursing education team at the hospital, focusing specifically on the monitoring of infusion fluids. this targeted training could contribute to reducing instances of complaints related to mismatched patient needs and ultimately improve compliance with established sops in infusion therapy. introduction infusion therapy involves administering drugs, fluids, and blood products or conducting blood sampling through an intravenous therapy route for hospitalized clients.1,2 this action is commonly employed as first aid for clients experiencing issues such as bleeding, dehydration, or hypovolemic shock. infusion therapy proves to be an effective and efficient means of providing intravascular fluid supply, a critical aspect considering the potential dangers associated with incorrect administration levels be it too little or too much.3-5 administering intravenous fluids at an incorrect level can pose risks to the client’s well-being. excessive administration may lead to fluid overload, manifesting in symptoms such as headaches, high blood pressure, anxiety, and difficulty breathing. additionally, the impact of infusion therapy is often accompanied by the occurrence of phlebitis. to assess the success of infusion therapy, monitoring by nurses is imperative, particularly in a 24-hour setting where early detection of risks is crucial for patient safety. the vigilance of nurses during infusion therapy plays a vital role in preventing potential complications and ensuring the well-being of patients.6-8 in british hospitals, 90% of patients undergo infusion therapy during their treatment period.9 in contrast, data from the ministry correspondence: aulia asman, department of nursing, faculty of psychology and health, universitas negeri padang, indonesia e-mail: aulia.asman@fik.unp.ac.id key words: infusion therapy, monitoring, nurse compliance, standard operating procedures. contributions: aula, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; yuy, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; yoy, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; nn, investigation, methodology, validation; ta, conceptualization, investigation, methodology, validation, and writing – original draft; me, formal analysis, validation, and writing – original draft; ala, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; dsd, formal analysis, validation, and writing – original draft; swp, methodology, validation, and writing – original draft; rr, formal analysis, validation, and writing – original draft; auza, methodology, validation, and writing – original draft. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by a research grant from [pnbp unp] with contract number [no. 238/un.35/lt/2022]. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty psychology and health, universitas negeri padang, based on ethical certificate no.25.01/kepk-unp/iii/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient’s consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank lppm universitas negeri padang and aisyiyah hospital, pariaman city, for their valuable insights and contributions to this study. received: 12 september 2023. accepted: 15 february 2024. early access: 19 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11783 doi:10.4081/hls.2024.11783 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 410] [healthcare in low-resource settings 2024;12:11783] non -co mmerc ial us e o nly of health in indonesia (2013) reveals that the incidence of phlebitis was approximately 50.11% in government hospitals and 32.70% in private hospitals. nurses, as providers of nursing care, are responsible for the installation and monitoring of infusions.10 nurse compliance in performing infusion monitoring procedures is influenced by individual behavior. this perspective aligns with previous studies, suggesting that compliance behavior can be attributed to both internal and external factors.4,11-13 according to the indonesian ministry of health (2017), phlebitis holds the highest rank among infections in indonesia, with an incidence of 50.11% in government hospitals and 32.70% in private hospitals.14 a preliminary survey conducted at tgk chik ditiro sigli hospital in pidie regency indicates a concerning increase in phlebitis cases over the past three years. in 2018, there were 3,923 cases, followed by 1,780 cases in 2019. shockingly, from january to august 2020, a staggering 9,646 cases were recorded. this alarming trend underscores the importance of addressing and mitigating phlebitis incidents to enhance patient safety and well-being.15 according to the general hospital census report by dr. zubir mahmud, the average incidence of phlebitis in 2018 across all rooms was 36.31%. the internal medicine department reported the highest number of cases, reaching 115.16 internal factors contributing to phlebitis incidence encompassed age, length of work, and educational level of nurses. external factors included the level of career path and workload. assessing a nurse’s compliance in performing infusion fluid monitoring procedures must also consider their knowledge regarding the hospital’s standard operating procedures (sop). this knowledge is a crucial aspect influencing a nurse’s adherence to established protocols and procedures, ultimately contributing to the prevention of phlebitis incidents, so that the duration of treatment and the risk of complications in the patient can be prevented from the beginning.17,18 during observations at a hospital in pariaman regency, the researchers noted that some nurses did not consistently monitor intravenous fluids and infusion drops as required. consequently, the administration of infusion fluids did not align with the prescribed therapy, resulting in variations in quantity, and in some instances, the absence of fluid in the infusion drip room. such lapses can have adverse effects, potentially leading to patient complaints. given this phenomenon, the researchers were motivated to investigate the factors influencing the monitoring of infusion fluids in hospitals. understanding these factors was essential for improving the adherence of healthcare professionals to established protocols and ensuring the effective and safe delivery of medical therapies. this study aimed to identify factors influencing nurse compliance in monitoring infusion fluids according to standard operating procedures (sop). materials and methods this research was an observational research method employing a descriptive correlational research design with a cross-sectional approach. the variables under consideration included age, education, years of work, career level, and knowledge, all collected simultaneously. the study involved a sample of 50 nurses in a hospital, selected using a purposive sampling technique based on the population size. the research instrument consisted of a knowledge questionnaire with 20 questions developed and validated by the researcher. the validity and reliability of the questionnaire were tested with a sample of 50 participants, yielding a cronbach’s alpha value of 0.939, indicating high reliability. ethical clearance for this study was obtained from the research ethics committee at universitas negeri padang (no. 25.01/kepk-unp/iii/2022). the analysis in this research aimed to explore the relationship between nurse characteristics and compliance. bivariate analysis techniques such as kendall’s tau b and kendall’s tau c were employed to examine these relationships. results table 1 provides an overview of the respondent characteristics. among the 50 participants, the majority fell within the age range of 26-35 years, comprising 20 respondents (40%). additionally, the educational background analysis revealed that 38 respondents (76%) had a diploma. in terms of working experience, 21 respondents (42%) had been employed for over 9 years, and 20 respondents (40%) were at the competent career path level. the distribution of respondents based on knowledge indicated that, among the hospital staff, the majority possessed good knowledge, with 14 respondents (28%). furthermore, when compliance was assessed through a 3-day observation of respondents’ control and regulation of infusion drops, it was revealed that 20 respondents (40%) demonstrated adherence among the 50 respondents in the hospital. the bivariate analysis aimed to examine a direct relationship between the independent variables and the dependent variable. in this study, the analysis sought to understand the relationship between the characteristics of nurses, specifically age, education, length of work, level of career path, and knowledge of compliance. the results of the study are presented in table 2. out of 50 respondents, the highest level of compliance in the monitoring of infusion fluids was obtained by the age range of 26-35 years. fifteen people were obedient and 5 non-compliant, while in education, the highest level of compliance with monitoring of infusion fluids in diploma education was 28 people, while those who did transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution based on respondents' characteristics. characteristics of respondents n % age 17-25 years 13 26 26-35 years 20 40 36-45 years 10 20 46-55 years 7 14 education diploma 38 76 bachelor of nursing 12 24 working experience 2-6 years 19 38 6-9 years 10 20 >9 years 21 42 career level novice 16 32 advanced beginner 14 28 competent 20 40 knowledge enough 14 28 good 36 72 obedience obedient 20 40 disobedient 30 60 total 50 100 [healthcare in low-resource settings 2024;12:11783] [page 411] non -co mmerc ial us e o nly not comply were 10. at the length of work with compliance in the monitoring of the infusion fluid, the highest score was obtained at the length of work over 9 years, which is 17 people, while the noncompliant 4 people, at the career level with compliance with the monitoring of the infusion fluid, the highest score was obtained at the competent career level, which is 17 people, while non-compliant as many as 3 people. at the level of knowledge with compliance of the monitoring of the infusion fluid, the highest score was obtained on good knowledge, 22 people, while those who did not comply were 4 people, with a value of p<0.05. this shows a significant relationship between age, education, length of employment, competence, and level of knowledge and compliance. discussion this study employed an inversely proportional approach, revealing a significant relationship between age and adherence to treatment. in contrast to previous research, which found no correlation between age factors and nurse compliance in applying hospital fall patient standard operating procedures (sop), our study identified a notable association. nurse compliance with hospital sops was observed more frequently in junior care settings.19,20 senior nurses, having accumulated experience in their work environment, tend to exhibit greater adherence. conversely, junior nurses may experience dissatisfaction, potentially stemming from elevated expectations that might not align with the realities of their work environment. this incongruity between expectations and realities can lead to dissatisfaction and non-compliance among junior nurses. the study observed that older individuals tend to be more obedient. age, as a marker of different life stages, is particularly crucial. during this period, life structures become more fixed and stable. the maturity that accompanies aging is reflected in enhanced thinking and working abilities.21 more mature individuals tend to be more reliable, attributed to the experiences and maturity of the soul. notably, respondents aged 26-35 years, considered young adults, shoulder responsibilities, and possess decision-making abilities aligned with their developmental stage. this stage of young adulthood indicates a level of maturity and responsibility in carrying out tasks and making decisions. the results showed an inversely proportional statement: individuals with higher education will be more able to think broadly and have more initiative, so they can find more efficient ways at work that lead to job satisfaction and compliance.22 this is also not in line with previous research, as there is no relationship between education level and adherence to sop standards for infusion in prof. dr. r.d kandou manado’s study.23 according to researchers, there are more respondents with a diploma in nursing educational background than a bachelor’s in nursing. in addition, health education is the basis for officers to behave, so it will be easier to instill discipline or obedience. this is caused by officers who understand health problems based on the knowledge gained during education, training, and in their daily tasks. the knowledge and experience of nurses help improve the skills of nurses in nursing services at hospitals,24 further increasing nurse compliance in monitoring intravenous fluids and other factors that cause infusions to run out on time, because there is no relationship between length of work with nurse compliance in monitoring infusion fluids according to the sop in the couch room of aisyiyah pariaman hospital.25 in the safa room of aisyiyah pariaman hospital for the diploma of nursing, the career level is competent, and the length of work is >9 years, so there is more experience in daily practice at work, as well as attending lots of training or training to add to the skills one has. from the results of the study in table 2, it is stated that 17 respondents had a working period of more than 9 years and were not compliant, and 4 respondents were not, meaning that the working period was not significantly related to compliance. length of work causes a person to become more skilled and experienced in dealing with work problems so that the work results obtained bring satisfaction.26-28 this is in line with the previous research, which found no relationship between the length of work and emergency unit training and adherence to sops for infusion.23 according to the researchers in this study, there is no significant relationship between the length of work and compliance because a person is considered obedient or disobedient, not based on the length of work in the installation. but judging from daily activities in the workplace in accordance with the sop policy, a person’s length of work does not correlate with the level of compliance because the longer a person’s work will increase experience in carrying out nursing actions. nurses with a career level of competence have higher workloads so nurses delegate the task of monitoring infusions to nurses at the novice or advanced beginner career levels, because career paths will improve the quality of nurse work, nurses will try to control a better career so that they will continue to excel and earn job satisfaction.29 the ministry of health of the republic of indonesia (2006) regarding nurse career paths included clinical nurses, nurse managers, nurse educators, and nurse researchers.30 survey data in 2010 at hospitals stated that 88.6% of room heads and 94.3% of team leaders/executive nurses stated that there was a need for a clinical nurse career path.31 according to the researchers, the results of this study show that nurses with the novice career path still do not have adequate skills in monitoring infusion fluid drops, while nurses with the competent nurse career path can manage infusion drops according to the program and the client’s infusion fluids run out on time. competent career path nurses have a lot of experience while working and participate in training activities held by the hospital, which affects nurse compliance in monitoring drips; besides manual installation of infusion sets is not an ergonomic task for nurses working in hospitals, besides patient service experience, innovation is needed in monitoring patient transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. relationship of compliance monitoring of infusion fluids. variable compliant disobedient p age 17-25 years 5 8 0.000 26-35 years 15 5 36-45 years 9 1 46-55 years 7 0 education diploma 28 10 0.007 bachelor of nursing 5 7 work experience 2-6 years 10 9 0.259 6-9 years 7 3 >9 years 17 4 career level novice 8 8 0.014 advanced beginner 10 4 competent 17 3 knowledge enough 6 8 0.011 good 22 14 [page 412] [healthcare in low-resource settings 2024;12:11783] non -co mmerc ial us e o nly infusion.32 nurses with experience of >9 years take part in many training programs held by nurse education so that knowledge about infusion fluids is updated every year. besides, the factor of inability to recognize and monitor infusion drops can be due to too much focus on examining infusions and pressure during infusion.33 the results of the study state that out of 50 respondents with good knowledge, it is known that 22 people are obedient. from the results above, it can be concluded that the better the respondent’s knowledge is, the more obedient he will be, and vice versa. this knowledge itself is a person’s highest cognitive condition when in contact with reality or existing events. when nurses provide care, nurses should have good knowledge of fluid therapy or infusion therapy and must also have the knowledge and confidence to care for patients receiving infusion therapy.34 from the results of this study, it was found that there was a relationship between knowledge and compliance in monitoring infusion fluids, and this is in line with research which stated that there was a significant relationship between nurses’ knowledge about infusion therapy and the incidence of phlebitis.35 it turns out that these results are also supported by research conducted in china, and it was found that most of the nurses in the hospital, even though experienced nurses, apparently did not know about the ph of the liquid, the dressing used, and the impact of using it. needles used for the infusion of drugs.36 not infrequently, it has also been found that the high knowledge of nurses is not matched by their practice.37 if the nurse’s knowledge in monitoring infusion drops is not correct, it will result in clients complaining because the drops run out or are late, not following the doctor’s program, and are materially disadvantaged because of the long treatment period. conclusions the study concluded that several factors influence nurse adherence to standard operating procedures for infusion monitoring. these factors include the length of time working in the hospital, career path competence, and having good knowledge regarding the importance of monitoring infusions in patients. to enhance adherence and ensure consistent application of standard procedures, the study suggests that hospital management should create visualization media, such as posters, to facilitate nurse recall of infusionrelated sop. additionally, it recommends providing regular monthly sessions for socializing and discussing these sops with all nurses. references 1. mandal a, raghu. study on incidence of phlebitis following the use of pherpheral intravenous catheter. j fam med prim care 2017;6:169-70. 2. utariani a, rahardjo e, 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ii. hs samsoeri mertojoso surabaya. j berk epidemiol 2015;3:217-29. 18. nugroho j, wardhana a, ghea c. mechanical occlusion chemically assisted ablation (moca) for saphenous vein insufficiency: a meta-analysis of a randomized trial. int j vasc med 2020;2020:8758905. 19. pagala i, shaluhiyah z, widjasena b. perilaku kepatuhan perawat melaksanakan sop terhadap kejadian keselamatan pasien di rumah sakit x kendari. j promosi kesehat indones 2017;12:138-49. 20. yulistiani y, utomo fn, nugroho cw, izzati yn. analysis of fall risk increasing drugs on morse fall scale in geriatric patients (a study at geriatric outpatient clinic airlangga university teaching hospital). pharmacia 2023;70:263-74. 21. lyu ff, ramoo v, wang yx. career maturity, psychological resilience, and professional self-concept of nursing students in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11783] [page 413] non -co mmerc ial us e o nly china: a nationwide cross-sectional study. j prof nurs 2022;42:58-66. 22. gleason nw. singapore’s higher education systems in the era of the fourth industrial revolution: preparing lifelong learners. 2018. available from: https://link.springer.com/chapter/10.1007/978-981-13-01940_7 23. kaloa t, kumaat l, mulyadi n. hubungan karakteristik perawat dengan kepatuhan terhadap standar operasional prosedur pemasangan infus di instalasi gawat darurat rsup prof. dr. r. d. kandou manado. j keperawatan. 2017;5:1-6. 24. mustika h, eliyana a, agustina ts, ratnasari rt. knowledge sharing behavior between self-leadership and innovative behavior. j secur sustain issues 2020;9:148-57. 25. wulandari, sukmarini l. edukasi stoma booth camp pada pasien dengan kanker buli paska radikal sistektomi. j keperawatan silampari 2022;5:1050-7. 26. siagian sp. manajemen sumber daya manusia. in: jakarta : bumi aksara. 2015. 27. rahman uza, teng kh, yeap sp, kazi sn. synthesis and characterization of green-functionalized graphene nanofluids as an enhanced working fluid in heat transfer applications. 2022. available from: h t t p s : / / i o p s c i e n c e . i o p . o rg / a r t i c l e / 1 0 . 1 0 8 8 / 1 7 5 5 1315/1074/1/012026/meta 28. permarupan py, al mamun a, hayat n, et al. nursing management challenges: effect of quality of work life on depersonalization. int j healthc manag 2021;14:1040-9. 29. marquis bl, huston cj. kepemimpinan dan manajemen keperawatan. 4th ed. bandung: egc; 2010. 30. muhadi. implementasi pmk no. 40 tahun 2017 tentang jenjang karier profesional perawat rumah sakit islam surabaya. j kebijak kesehat indones jkki 2021;10:17-22. 31. suroso j. penataan sistem jenjang karir berdasar kompetensi untuk meningkatkan kepuasan kerja dan kinerja perawat di rumah sakit. eksplanasi 2011;6:123-31. 32. garosi e, mazloumi a, kalantari r, et al. design and ergonomic assessment of an infusion set connector tool used in nursing work. appl ergon 2019;75:91-8. 33. matsushima m, kadohama h. factors behind why nursing students do not recognize patient needs occurring while confirming intravenous infusion even when they observe them: a comparative descriptive design study. nurse educ today 2021;101:1-7. 34. azni m, rahmawati f, wiedyaningsih c. pengetahuan perawat mengenai faktor risiko sediaan intravena yang berkaitan dengan kejadian flebitis. j sains farm klin 2021;8:174-81. 35. wayunah, nurachmah e, mulyono s. pengetahuan perawat tentang terapi infus mempengaruhi kejadian plebitis dan kenyamanan pasien. j keperawatan indones 2013;16:128-37. 36. li xf, liu w, qin y. nurses’ perception of risk factors gor infusion phlebitis: a cross-sectional survey. chinese nurs res 2016;3:37-40. 37. karadeniz g, kutlu n, tatlisumak e, özbakkaloǧlu b. nurses’ knowledge regarding patients with intravenous catheters and phlebitis interventions. j vasc nurs 2003;21:44-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 414] [healthcare in low-resource settings 2024;12:11783] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12020 hiv incidence, knowledge, attitude and practices of hiv/aids and antiretroviral therapy use in hiv-infected patients at debre elias district, north west ethiopia melese birmeka,1 damtew bekele,2 megabi anteneh1 1department of biology, hawassa university; 2department of biology, ambo university, ethiopia abstract due to hotspots as development schemes that attract mobile groups, hiv/aids infections are the biggest health issue in communities with low awareness and safe practice, especially in smaller towns. this study examined hiv/aids and antiretroviral therapy (art) use-related knowledge, attitude, and practice in aids patients. debre elias health center conducted a cross-sectional study (n=384) from june 10 to january 20, 2021. participants were selected using systematic random sampling and interviewed using a structured questionnaire. logistic regression calculated significance and association between dependent and independent variables. 236 (384) or 61.4% of 384 hiv patients on antiretroviral therapy were female. hiv rates increased from 2014 to 2019. age difference was associated with patient knowledge of art use (p=0.005). patients’ attitudes towards hiv/aids and art use were significantly correlated with age, residence, marital status, and education (p<0.001). hiv patients 25-30 were 2.2 times more likely to know about art use. hiv patients with a degree or higher were five times more likely to support art. hiv patients aged 14-24 with a positive art outlook were 94% protective. hiv prevalence is rising, especially among 15 to 24-year-old women. public protection is needed to reduce hiv transmission. introduction human immunodeficiency virus (hiv) infection and acquired immunodeficiency syndrome (aids) have emerged as a formidable global public health crisis claiming 36.3 million lives as of year 2021.1 the hiv/aids epidemic has brought about overwhelming threats to economically poor countries, about 95% are found in developing world, of which high infections were in sub saharan africa.1 young people were the most affected. an estimated 10 million hiv/aids infections occur in young people aged 15-24 years and more than 6000 new cases of the virus every day. in general, above 50% of all new hiv incidences occur between 15 and 24 year-olds.2 hiv and aids have become a major health problem and the main cause of morbidity and mortality in all parts of the globe. for instance, people living with hiv, new hiv infections, and aidsrelated deaths were 37.9, 1.8, and 1 million respectively, in the world in 2018.1 similarly, new hiv infections were highest among women, constituting more than half of all people living with hiv and aids-related illnesses. young women (aged 15-24 years), and adolescent girls (aged 10-19 years) in particular, account for more than one-third of all people living with hiv/aids (plwha) which is a disproportionate number of new hiv infections.1,3 still, the disease continues to spread with no cure yet in sight. there is a need to fight the pandemic through evidence-based approaches that focus on reducing deficiency in knowledge, attitude, and response against the infection.4 globally, most of the new hiv infections occur through sexual contact, and transmission occurs more commonly from persons unaware they have hiv.4 the growth rates of hiv and other sexually transmitted infections are higher in africa. out of 37.9 million hiv infections in the world, 25.7 million were in africa. it accounts for almost two-thirds of the total new hiv incidence.1 about 70% of the total hiv-infected people in africa were from sub-saharan africa (ssa). in this region, most of the new correspondence: damtew bekele, department of biology, ambo university, p.o. box 19, ambo, ethiopia. e-mail: damtish2002@gmail.com key words: anti-retroviral therapy use; hiv/aids patients; debre elias health center; hiv incidence. acknowledgments: we would like to acknowledge debre elias health center health experts for their unfailing cooperation during the survey. contributions: mb, project idea; ma, mb, db, data collection, data analysis, manuscript interpretation and draft; ma, study protocol design. all authors reviewed and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethical approval and consent to participate: the institutional review board of hawassa university approved and obtained ethical clearance at ref. no. irb /241/11. availability of data and material: all data generated or analyzed during this study are included in this published article. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. confidentiality of the data was kept as secured. received: 24 october 2023. accepted: 6 april 2024. early access: 25 june 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12020 doi:10.4081/hls.2024.12020 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 379] non -co mmerc ial us e o nly hiv infection occurs among people aged 15-24 years old.1 nearly 80% of the population in ssa is not aware of their infection. more than 90% do not know if their sexual partners are infected. such situations invite the further spread of the epidemic.5 discrimination against positive people can help the aids epidemic to spread if people are fearful of being tested for hiv, and then they are more likely to pass the infection to someone else without knowing.6 experience in community counseling shows local communities can make healthy choices about preventing hiv and caring for those with aids.7 when communities act for care and change, self-measure for progress, and transfer to other communities, we know they are competent and confident in their own future.8 hiv testing is the main gate for individualized hiv care and treatment, and undiagnosed hiv infections undermine the effectiveness of hiv programs. early initiation of antiretroviral therapy (art) reduces hiv transmission and is an essential component of comprehensive prevention strategies. effective antiretroviral (arv) drugs can control the virus and help to prevent transmission so that people with hiv, and those at substantial risk, can enjoy healthy, long, and productive lives.4 since the introduction of the art program in cuba in 2001, deaths from aids have dramatically decreased.9 one of the basic reasons to analyze hiv/aids knowledge is to examine its direct linkage to improve the chances of self-protection (e.g., enhanced knowledge allows for consistent and proper use of condoms).10,11 recently due to the non-achievement of millennium goals on hiv/aids in different countries in the world especially in developing countries, the joint united nations program on hiv/aids has fixed new objectives to overcome hiv infections by 2030.12 however, the hiv/aids epidemic is still the most serious challenge in ethiopia, where the adult population between the ages of 15-49, which comprises the vast majority of the workforce, is the worst affected. youth age ranges from 13-30 years are the most sexually active ages that are mainly exposed to hiv because of the strong influence of peer pressure and the development of their sexual and social identities which often lead to conducting sexual practice. as they are initiating sexual behavior, counseling for safe practice is vital.13,14 hence the measures to raise awareness and combat hiv/aids are vital to increase awareness among communities about hiv/aids, in order to bring about a change in people’s attitude and behavior which stimulates a sympathetic response towards people who are vulnerable to or affected by hiv.15 this study described the prevalence and incidence of hiv and art use-related knowledge, attitude, and good practices among people with hiv living in debre elias district, north west ethiopia. materials and methods study area and study population debre elias town is an administrative town in debre elias woreda (district). it is one of the 105th districts in amhara region and the 18th district from east gojjam zone which is located between 9o50’00’’n-10o30’00’’n and 37o10’00’’e-37o30’00’’e latitude and longitude respectively (generated from ethio gis data csa, 2007). debre elias town is approximately 342 kilometers distant from the capital city of ethiopia (addis ababa). the study subjects were hiv-positive people of art users in debre elias district. the district has a total population of about 100,797. from these, 50,842 are females and the remaining 49,955 are males. debre elias town has one health center, two private clinics, and one private drug store. it also has one technical vocational education and training college, one preparatory school, one secondary school, and two governmental primary schools (debre elias district communication office). study design the study used a health center-based cross-sectional study among people living with hiv (2014-2019) who had been on art use for at least three months in debre elias health center. the inclusion criteria were: all newly infected hiv-positive patients who registered in debre elias health center from 20142019 that use art. the exclusion criteria were: patients whose clinical records were not complete or missing, transferred out, or died. sample size determination and sampling technique a sample size was determined using daniel’s formula n=z2 p(1-p)/d2.16 p=50%, since there was no previous study conducted around the debre elias district, where d was a 5% margin of error at a 95% confidence interval and z was standard score corresponds to 1.96 with a none response rate of 5%. this would give a sample size of 403. to select the sample population, a systematic random sampling technique was used. data collection retrospective data, 2014-2019 were collected from document analysis. primary data was collected by using questionnaires and interviews. two data collectors participated in this task and the principal investigator checked the completeness of the data. data management and analysis following data collection, it was looked at for completeness and consistency, coded, and entered into statistical package for the social sciences version 20 program for analysis. univariate and multivariate logistic regression was employed to measure associations of socio-demographic variables on knowledge, attitude, and practice (kap) towards hiv/aids and art use. values were considered significant when p<0.05. results socio-demographic and clinical features of the study participants during the study period, a total of 384 hiv/aids patients at debre elias health center, and 95.3% of the initial sample were successfully followed up. among these, 236 (61.5%) were females and 148 (38.5%) were males (table 1). hiv infection was most common in those aged 15 to 24, 124 (32.3%), followed by age 25 to 34, 98 (25.5%). the majority of 206 (53.7%) plwha were from rural areas. 71% had attained grades 1-12, and nearly 29% held certificates, diplomas, degrees, and above. 230 (60%) had good art adherence. of the study subjects, 175 (45.5%) were determined to be at who clinical stage iii. about 169 (44.1%) of the participants had a cd4 count of 200-500 cells/mm3, 128 (33%) had a level of 500 or more, and 88 (22.9%) had a cd4 count of fewer than 200 cells/mm3. article [page 380] [healthcare in low-resource settings 2024;12:12020] non -co mmerc ial us e o nly hiv/aids incidence and antiretroviral therapy use at debre elias district, 2014-2019 as shown in table 1, the retrospective data from 2014 to 2019 showed 585 individuals were found to be newly infected hiv-positive individuals and art users. the incidence of hiv gradually increased from 2014 to 2019 (figure 1). distribution of hiv/aids incidence by age and sex out of the 585 hiv-positive individuals on art, 226 (39%) were males and 359 (61%) were females, as seen in figure 2. hiv/aids infections were higher in 15–24-year-olds (32.5%), followed by 25–34-year-olds (25.6%). knowledge, attitude and practice of respondents about hiv/aids and antiretroviral therapy use knowledge of patients towards hiv/aids and antiretroviral therapy use approximately 315 (82%) of hiv patients were aware of art use and hiv/aids. 372 (96.9%) of the participants in total were aware that aids is not a curable disease. furthermore, 286 (74.5%) of the participants were aware that hiv transmission occurs through unsafe sex. only 114 (29.7 of the patients were aware that hiv infection is not transmitted through sharing food, clothing, or restrooms. the majority of the participants, 337 (87.8%), correctly know that abstaining from sex is a very good preventive method for hiv/aids. furthermore, 282 (73.4%) of participants also knew that proper condom use can protect against hiv/aids. 337 (87.8%) of patients did not believe that hiv-positive patients taking art drugs cannot transmit hiv. additionally, 299 (77.9%) and 317 (82.6%) of the respondents stated that art does not consist of drugs to cure hiv/aids and missing art doses can lead to disease progression respectively. furthermore, 356 participants (92.7%) were aware that plwha require art treatment for the duration of their lives (table 2). attitude towards hiv/aids accordingly, 309 (80.5%) of the respondents had a positive attitude while 75 (19.5%) of participants were classified as having a negative outlook. the majority of participants, 304 (79.2%), had article table 1. socio-demographic and clinical characteristics of people living with hiv/aids (n=384) at debre-elias district, northwestern ethiopia, 2014-2019. characteristics frequency % sex male 148 38.5 female 236 61.5 age (years) 0-10 27 7 11-14 7 1.7 15-24 124 32.3 25-34 98 25.6 35-44 78 20.4 >45 50 13 marriage married 130 33.8 single 254 66.2 residence urban 178 46.3 rural 206 53.7 education grade 1-12 274 71.4 certificate 18 4.7 diploma 39 10.1 degree and above 53 13.8 art adherence good 230 60 fair 123 32 poor 31 8 who clinical stage who stage i 74 19.3 who stage ii 121 31.6 who stage iii 175 45.5 who stage iv 14 3.6 cd4 cell count <200cell/mm3 88 22.9 200-500cell/mm3 169 44.1 above 500cell/mm3 127 33 art, antiretroviral therapy; who, world health organization. source: adapted from the health center’s clinical record format. [healthcare in low-resource settings 2024;12:12020] [page 381] figure 1. hiv/aids incidence from 2014-2019 among people living with hiv/aids in debre elias district. figure 2. distribution of hiv/aids incidence by sex and age group in debre elias district, 2014-2019. non -co mmerc ial us e o nly article table 3. attitudes of people living with hiv/aids towards hiv/aids and antiretroviral therapy use in debre elias district, ethiopia. attitude item questions responses n (%) 1. should a person having hiv do sexual intercourse only with condom? yes, agree 304 (79.2) no, disagree 80 (20.8) 2. a person with hiv/aids is hopeless? agree 139 (36.2) disagree 245 (63.8) 3. the presence of many sexual partners increase the chance of getting the virus agree 370 (96.4) disagree 14 (3.6) 4. it is shameful for hiv/aids patients to take art drugs? agree 108 (28.1) disagree 276 (71.9) 5. art gives more benefits than harm? agree 258 (67.2) disagree 126 (32.8) 6. art drug does not cure hiv patients, so its treatment is a waste of time. agree 100 (26) disagree 284 (74) 7. an hiv patient takes art drugs only when he feels sickness? agree 11 (2.9) disagree 373 (97.1) 8. overall attitude status positive 309 (80.5) negative 75 (19.5) art, antiretroviral therapy. note: the calculated percentage for the respective characteristic is from the total examined. [page 382] [healthcare in low-resource settings 2024;12:12020] table 2. knowledge of study participants on hiv/aids and antiretroviral therapy use in debre elias district, 2019. knowledge question items responses n (%) 1. is it possible to cure from aids? yes 12 (3.1) no 372 (96.9) 2. is it hiv transmission mainly occurs through doing unsafe sex? yes 286 (74.5) no 98 (25.5) 3. hiv can be transmitted through sharing of meals, clothes and latrines yes 270 (69.3) no 114 (29.7) 4. abstain from sex is a very good preventive method of hiv/aids transmission correct 337 (87.8) incorrect 47 (12.2) 5. can proper condom use be protective to hiv/aids transmission? yes 282 (73.4) no 102 (26.6) 6. hiv positive patients taking on art drugs cannot transmit hiv? correct 30 (12.2) incorrect 354 (87.8) 7 can low art therapeutic doses lead to disease progression yes 296 (77.9) no 88 (22.9) 8. is it art drugs curable to hiv/aids? yes 67 (17.4) no 317 (82.6) 9. art should be taken throughout the life span of the patient? yes 356 (92.7) no 28 (7.3) 10. over all knowledge status knowledgeable 315 (82) not knowledgeable 69 (18) art, antiretroviral therapy. note: the percentage of the respective characteristic is calculated from the total examined. non -co mmerc ial us e o nly a positive attitude toward using condoms during sexual intercourse. moreover, the majority of participants, 370 (96.4%), responded that the presence of multiple sexual partners can increase the chance of getting an hiv infection. in terms of their attitudes towards art use, 276 (71.9%) thought that it was beneficial for hiv/aids patients to use art medications, and 258 (67.2%) agreed that art improves health. furthermore, 284 (74%) of the participants thought that taking art medications was a good idea rather than a waste of time (table 3). practices of people living with hiv/aids towards hiv/aids and antiretroviral therapy use in the current study, 215 (56%) of the plwha had good practices, while 169 (44%) had poor practices. of them, 155 (40.4%) had never used a condom during sexual activity. many of them, 267 (69.5%), had engaged in unprotected sexual intercourse. the majority of the 210 individuals (54.7%) had a consistent sexual partner. in terms of their practice towards art use, the majority of respondents, 273 (71%), began as soon as they knew they were hiv carriers or patients. table 4 shows that 268 (69.8%) of the individuals showed good adherence to using art. socio-demographic variables vs. knowledge, attitudes, and practices males outnumbered females in knowledge, 102 (82.9%), and good practice, 101 (81.2%), while females had a better attitude, 217 (83.1%), than males. the age group >30 had a good attitude, 172 (91.2%), and practice, 160 (84.7%), while plwha found in the 25-30 age group had almost positive knowledge, 349 (91%), and a good attitude, 325 (84.7%). comparing plwha with married counterparts, the married group showed a better attitude (90.1%) and greater knowledge (87.4%). good behavior was observed in lone plwha. additionally, individuals who resided in urban areas knew, 144 (83.7%), regarding hiv and the use of art, but they also practiced it poorly, 61(35.5%), whereas those who lived in rural areas had a positive attitude, 185 (86.7%), and good practices, 108 (50.9%). with respect to educational attainment, the majority of participants with promising knowledge had a degree or above (92.5%), while 36 respondents with strong practice had a diploma (92.3%). furthermore, plwha with grades 1-12 had a better practice 144 (52.5%) compared to their respective counterparts (table 5). the use of kap in multivariate analysis, the associations between various plwha characteristics, and art use were examined (table 6). compared to female hiv-positive patients, male patients were shown to be 5.0 times more likely to practice excellent art use. when compared to other individuals in their age group, plwha between the ages of 25 and 30 were shown to be 2.2 times more likely to have superior knowledge of art use. when compared to people at lower grade levels, plwha with educational standing (degree and above) were found to be five times more likely to have a positive attitude toward using art. in addition, plwha of urban residents were shown to have a 1.73fold higher likelihood of having good experience in using art than occupants of rural areas. plwha in the 14-24 age range who were aware were shown to be 69% less likely to have poor art adherence. plwha in the 14-24 age range who had a favorable prognosis for using art were shown to be 65% less likely to have poor adherence to their treatment regimen. 94% of plwha in the 25-30 age group who had a positive attitude toward art use were found to be protective. 84% of plwha in the 25-30 age group who practiced well were found to be protective. 50% of married plwha with strong comprehension and abilities were found to be protective. married plwha with a positive prognosis were shown to be 65% less likely to experience poor art adherence. urban inhabitants of plwha with a good attitude were found to be protected by 65% from bad adherence to art use. study participants with educational status with a degree and above were found to be protected by article table 4. practices in people living with hiv/aids towards hiv/aids and antiretroviral therapy use, in debre elias district, ethiopia, 2019. practice question items responses n (%) 1. have you ever used condom? yes 155 (40.4) no 229 (59.6) 2. have you practiced unprotected sex? yes 267 (69.5) no 117 (30.5) 3. do you have constant sexual partner yes 210 (54.7) no 174 (45.3) 4. have you started art as soon as you know with hiv? yes 273 (71) no 111 (29) 5. have you dropped art after starting use? yes 55 (14.3) no 329 (85.7) 6. do you have good adherence to art? yes 268 (69.8) no 116 (30.2) 7. overall practice good 215 (56) poor 169 (44) art, antiretroviral therapy. note: for the respective characteristics, the percentage is calculated from the total examined. [healthcare in low-resource settings 2024;12:12020] [page 383] non -co mmerc ial us e o nly 74% compared to other lower grade levels from bad adherence to art use. plwha with educational status with diplomas having good practice were found to be protected by 69% from bad adherence of art use (table 6). discussion the incidence and prevalence of hiv/aids and art use for the present study populations showed some differences as compared to earlier reports from different regions of ethiopia. this might be due to the differences in the knowledge of hiv/aids prevention and art use in different localities such as rural and urban areas, and small and big towns of the communities. other investigators also reported that the prevalence of hiv/aids incidence and art use varies in different regions of ethiopia.16,17 these inconsistencies are due to comprehensive knowledge of hiv/aids that were subject to differences in time, place and conditions. on the other hand, knowledge of how the virus is spread will help people escape from the virus. trends of hiv/aids incidence and art use gradually increased between the years 2014 to 2019; this might be due to the article [page 384] [healthcare in low-resource settings 2024;12:12020] table 6. association of knowledge, attitude, and practices of patients towards antiretroviral therapy use in debre elias district, northwestern ethiopia, 2019. variables, n (%) knowledge attitude practice aor (ci) p-value aor (ci) p-value aor (ci) p-value sex male 1.503 (0.815-2.773) 0.192 0.606 (0.336-1.090) 0.095 5.013 (2.868-8.763) <0.001 female 1 1 1 age 14-24 0.317 (0.160-0.628) 0.001 0.352 (0.198-0.629) <0.001 0.696 (0.418-1.160) 0.165 25-30 2.213 (1.120-4.372) 0.022 0.062 (0.014-0.274) <0.001 0.164 (0.074-0.362) <0.001 >30 1 1 1 marital status married 0.503 (0.258-0.978) 0.043 0.350 (0.168-0.729) 0.005 0.811 (0.486-1.354) 0.423 single 1 1 1 residence urban 1.344 (0.757-2.386) 0.312 0.466 (0.263-0.826) 0.009 1.725 (1.072-2.775) 0.025 rural 1 1 1 education grade 1-12 1 1 1 certificate 0.556 (0.211-1.465) 0.235 0.351 (0.097-1.264) 0.109 0.228 (0.090 0.578) 0.002 diploma 0.268 (0.090-0.805) 0.19 0.478 (0.192-1.187) 0.112 0.307 (0.1460.648) 0.002 degree and above 0.262(0.08-0.6) 0.001 5.13 (1.698-15.514) 0.004 0.408(0.20-0.621) 0.001 aor, adjusted odds ratio; ci, confidence interval. note: the percentage for the respective characteristics is calculated from the total examined. table 5. effect of socio-demographic factors on knowledge, attitude and practices towards hiv infection and antiretroviral therapy use in debre elias district, northwestern ethiopia, 2019. variables, n (%) knowledge attitude practice knowledgeable not knowledgeable positive negative good poor sex male 102 (82.9) 21 (17.1) 92 (74.8) 31 (25.2) 101 (82.1) 22 (17.9) female 213 (81.6) 48 (18.4) 217 (83.1) 44 (16.5) 114 (43.7) 147 (56.3) age 14-24 97 (78.9) 26 (21.1) 79 (64.2) 44 (35.8) 56 (45.5) 67 (54.5) 25-30 172 (91) 17 (9) 160(84.7) 29 (15.3) 98 (51.9) 91 (48.1) >30 46 (63.9) 26 (36.1) 70 (97.2) 2 (2.8) 61 (84.7) 11 (15.3) marital status single 218 (79.9) 55 (20.1) 209 (76.6) 64 (23.4) 148 (54.2) 125 (45.8) married 97 (87.4) 14 (12.6) 100 (90.1) 11 (9.9) 67 (60.4) 44 (39.6) residence urban 144 (83.7) 28 (16.3) 124 (72.1) 48 (27.9) 111(64.5) 61 (35.5) rural 171 (80.7) 41 (19.3) 185 (87.3) 27 (12.7) 104 (49.1) 108 (50.9) educational status grade 1-12 218 (79.6) 56 (20.4) 219 (80) 55 (20) 130 (47.4) 144 (52.5) certificate 15 (83.3) 3 (16.7) 8 (44.4) 10 (55.6) 12 (66.7) 6 (33.3) diploma 33 (84.6) 6 (15.4) 36 (92.3) 3 (7.7) 32 (82.1) 7 (17.9) degree and above 49 (92.5) 4 (7.5) 46 (86.8) 7 (13.2) 41 (77.4) 12 (22.6) note: the calculated percentage for the respective characteristic is from the total examined. non -co mmerc ial us e o nly debre elias district having good agricultural land for sesame oil seed cultivation and there is an increment of new investments that attract high numbers of labor migrants who are young and sexually active from the surrounding districts to the town in search of job opportunities that might contribute to the increase of hiv transmission. a study on art in ethiopia depicted a substantial expansion of access to hiv counseling and testing in ethiopia.18 this increase is attributed to the integration work of health extension workers, non-governmental organizations, and other stakeholders who play a crucial role in hiv testing and education through different approaches, such as campaigns. the uppermost incidences of hiv/aids were identified in 1524-year-olds, followed by 25-34 years of age; this could be due to the fact that it is the most sexually active age group. it is reported that worldwide, almost half of all new infections with hiv are in people aged 15-24 years.19 data from debre elias social affairs office showed that most of the migrants were dominantly young age groups. people within these age groups may have unprotected sex with more than one sexual partner which might contribute to the increase in hiv infection. this study was supported by a study.20 hiv/aids infections were higher in females (61.4%) than males (38.6%), giving a male-to-female ratio of 1:1.6. gender differences in hiv/aids infection prevalence obtained in the present study showed a similar pattern to two studies,21,22 in which hiv prevalence rate for adult women was almost double that for male, which represent female to male ratio of 2:1. a study done by the ethiopia demographic and health survey indicated hiv/aids prevalence in adults was of 1.9% in females and to 1.0% in males.23 this is due to greater biological susceptibility in females to hiv infection through heterosexual intercourse than in males. females’ greater biological susceptibility is due to the presence of more exposed surface areas in the female genital tract than males, the presence of hiv is higher in seminal fluids than vaginal fluids at the time of sexual intercourse, the greater amount of semen exchange than vaginal fluid, and the wall vaginal cell during intercourse for women was highly injured compared to men.24 kap studies are very useful tools prior to any intervention to assess the extent to which individuals or communities are ready to adopt risk-free behaviors and valid kap about hiv/aids and art use are important in light of the increasing epidemic. this study was the first study on hiv/aids and art use-related kap among patients in debre elias town. the majority of hiv/aids patients in the debre elias health center have good knowledge, positive attitude and good practices towards hiv/aids and art use. similarly, studies conducted in africa (e.g., ghana and ethiopia) show that level of knowledge regarding hiv/aids among sexually active community members are high.25,26 people’s new knowledge of hiv and aids led them to use condoms more often, and fewer sex workers got hiv.27 knowledge, attitude and perceptions of 185 hiv/aids patients were assessed in maiduguri (north-east nigeria). of these, 78% of respondents had good knowledge of the causative agents of hiv/aids and 90% had good knowledge of hiv transmission.28 as indicated in the present study, 73.4% of study participants responded that proper use of condoms is protective for hiv transmission. this is supported by a similar study;29 82.1% of the study participants agreed that proper use of condoms can protect from hiv/aids transmission. another study that was carried out in yola, nigeria, showed good knowledge of the use of condoms for hiv prevention, and transmission was 88.1% to prevent the spread of hiv/aids. furthermore, 87.8% of participants believed that abstaining from sex is a very good preventive method of hiv/aids transmission.30 survey data obtained from 18 african countries showed that sexual abstinence and the use of condoms are important components to restrict the spread of hiv infection in developing countries.31 many people in ethiopia are aware of hiv and aids. however, the change of behavior that should have resulted from such awareness is regrettably not there. this is partly because of a lack of proper community facilitation. knowledge about a development issue does not always result in taking action. knowledge is only likely to change our behavior when the right level of motivation is created through good facilitation. that funding didn’t influence the number of sex partners hat people had, the age at which they started having sex, or teenage pregnancy rates.32 as shown in this study, most of the respondents had good knowledge about art. the majority of participants (87.7%) believed that hiv/aids patients taking art drugs can transmit hiv, and arts are not drugs to cure hiv/aids (82.6%). moreover, 88% of them stated that taking art on a therapeutic level can lead to a disease progression and the majority of participants (92.7%) believed that art medication should be taken throughout the patient’s life. this was comparable to a study done in a nigerian treatment clinic.29 in contrast to this, some of the study participants had an opposing attitude towards art medication. for instance, 32.8% of the study participants were not convinced by art benefits and 28.1% of respondents believed that it is shameful for hiv/aids patients to take art drugs. moreover, 26% of them agreed that art treatment is not for curing medications to hiv infection, and this led to a negative attitude towards art adherence. so, effective counseling and follow-up are required to ensure art therapy for hiv/aids as intended.29 therefore, by lowering viral load in sexually active individuals, hiv transmission in the community may decrease and the availability of arv may encourage voluntary counseling and thus, help change sexual attitudes and practices. conclusions this study investigates the incidence of hiv/aids and art use among patients in the debre elias district. it can be concluded that hiv incidence is increasing every year, and females and the age group 15-24 are more disposed to hiv infections. even though there are a large number of efforts to disseminate the basic concept to prevent and control hiv/aids incidence and art use, the transmission of the disease is still increasing. therefore, continued awareness creation programs are required to bring the desired behavioral changes and to correct misconceptions. references 1. world health organization. hiv/aids. 2021. available from: https://www.who.int/news-room/fact-sheets/detail/hiv-aids 2. wang h, wolock t, carter a, et al. estimates of global, regional and national incidence, prevalence and mortality of hiv;1980-2015. lancet hiv 2016;3:361-87. 3. unicef. children, hiv and aids. unicef. 2018. 4. fishbein m. the role of theory in hiv prevention. aids care 2000;12:273-8. 5. christian h, juergen r. hiv/aids. 2015/2016, medizn fokusverlag, hamburg. 3rd edition, 2015/2016;276-315. article [healthcare in low-resource settings 2024;12:12020] [page 385] non -co mmerc ial us e o nly 6. bicego g. estimating adult mortality rates in the context of the aids epidemic in sub-saharan africa: analysis of dhs sibling histories. health transit rev 1997;7:7-22. 7. campbell id, rader ad. hiv counselling in developing countries: the link from individual to community counselling for support and change. br j guid counc 1995;23:33-43. 8. campbell i. human capacity development for response to hiv. plenary presentation at the 2008 pepfar hiv/aids implementers’ meeting, kampala, uganda. 2008. available from: https://www.affirmfacilitators.org/docs/ian_campbell_ speaker_notes_with_slides_4june2008_hcd.pdf 9. pérez j, pérez d, gonzales i, et al., approaches to the management of hiv/aids in cuba. world health organization, 2004. 10. moreno r, nababan hy, ota e, et al. structural and community-level interventions for increasing condom use to prevent the transmission of hiv and other sexually transmitted infections. cochrane database syst rev 2014;2014. 11. vian t, semrau k, hamer dh, et al. hiv/aids-related knowledge and behaviors among most-at-risk populations in vietnam. he open aids j 2012;6:259-65. 12. unaids. unaids strategy. 2017. available from: http://www.unaids.org/en/goals/unaidsstrategy 13. federal hiv/aids prevention and control office. hiv prevention in ethiopia. national road map 2018-2020. addis ababa, ethiopia; 2018;1-52. available from: https://ethiopia. unfpa.org/sites/default/files/pub-pdf/hiv%20prevention %20in%20ethiopia%20national%20road%20map%202018 %20-%202020%20final_final.pdf 14. federal hiv/aids prevention and control office. guidelines for hiv counseling and testing in ethiopia. fmoh, addis ababa, ethiopia; 2007. 15. sida-amhara rural development programme. building ethiopia’s future: the sida-amhara rural development programme. bahir dar, ethiopia; 2010. 16. daniel ww. biostatics: a foundation for analysis in the health science. 7th ed. new york, usa, john wiley and sons; 1999:155. 17. central statistical agency (csa) [ethiopia] and icf. ethiopia demographic and health survey 2016. addis ababa, ethiopia, and rockville, maryland, usa; 2016. 18. assefa y, jerene d, lulseged s, et al. rapid scale-up of antiretroviral treatment in ethiopia: successes and systemwide effects. plos med 2009;6: e1000056. 19. marston c, king e. factors that shape young people’s sexual behaviour; a systematic review. lancet 2006; 368:1581-6. 20. olaniran o, hassan-olajokun m, oyovwevotu r, agunlejika m. prevalence of tuberclosis among hiv/aids patients obafemi awolowo university teaching hospital. int j bio med res 2011; 2:874-77. 21. kenya national bureau of statistics. kenya demographic and health survey, 2008-2009. knbs 2010. 22. sintayehu f, wondu t, getnet a. prevalence and determinants of tb and hiv co-infected patients in south ethiopia. jidc 2015;9:898-904. 23. ethiopia demographic and health survey. hiv/aids in ethiopia. csa, addis ababa, ethiopia; 2011. 24. amare d. tuberclosis and hiv coinfection among patients on tuberclosis treatment at fenote selam hospital, north west ethiopia. global j med res 2015;15:1. 25. abruquah hh, bio fy. hiv/aids: knowledge, attitude and practice of school adolescents in the kwaebibirem district of ghana. j sci technol 2008;28:10-8. 26. andargie g, kassu a, moges f, et al. low prevalence of hiv infection, and knowledge, attitude and practice on hiv/aids among high school students in gondar, northwest ethiopia. ethiop j health dev 2007;21:179-82. 27. cohen pt, sande ma, volberding pa (eds). the aids knowledge base. waltham, mass.: medical publishing group; 1990. 28. ajayi b, moses a, gashau w, omotara b. assessment of knowledge, perception and attitude of plwha towards hiv/aids in maiduguri, north east nigeria. int j infect dis 2013;12:1382-90. 29. olowookere s, fatiregun a, adewole l. knowledge and attitudes to hiv/aids and antiretroviral therapy among patients at nigerian treatment clinic. jidc 2012;6:809-16. 30. olutayo f, martins l, lekhraj r, et al. knowledge and attitudes of adult hiv positive patients to hiv/aids in yola, nigeria. j pub health epi 2015;7:241-8. 31. cleland j, ali mm. sexual abstinence, contraception, and condom use by young african women: a secondary analysis of survey data. lancet 2006;368:1788-93. 32. lo n, lowe a, bendavid e. abstinence funding was not associated with reductions in hiv risk behavior in sub-saharan africa. health affairs 2016;35. article [page 386] [healthcare in low-resource settings 2024;12:12020] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12843 improvement of the method of diagnostics and treatment of injuries and diseases of the maxillofacial region andrei tsoi,1 abdyrakhman eshiev,2 nursultan kurmanbekov,2 daniyar eshiev,2 nazgul myrzasheva3 1department of clinical stomatology and implantology, i.k. akhunbaev kyrgyz state medical academy, bishkek; ²department of surgical dentistry with a course in pediatric surgical dentistry, osh state university, osh; ³department of therapeutic dentistry with a course in pediatric therapeutic dentistry, osh state university, osh, kyrgyzstan abstract this study aims to describe and apply a special endolift device in the treatment of various injuries to the zygomatic-orbital-facial complex as a means of forming an endoscopic space. a patented technique of creating an endoscopic area using an endolift device in the field of maxillofacial surgery, registered under the number 2082 dated 31.07.2018 in the kyrgyz republic, on the example of a clinical case, was presented. the endolift is a metal two-piece device that consists of a horizontal round mini plate up to 10 mm in diameter and a perpendicularly located hollow tube up to 4 mm in diameter in the centre of the plate with two holes at the top. the method of endoscopic space formation using endolift was used in 15 patients with various traumas to the maxillofacial region. an example of a clinical case is presented by patient j.b., 36 years old, who underwent endoscopic minimally invasive surgery to reconstruct a mandibular fracture. the course of the operation included a small incision in the submandibular region, soft tissue separation, skeletonization of the jaw, and the formation of a tunnel, for the endolift. the endolift was inserted into the tunnel and an endoscope was inserted through it for visualisation. after alignment of the bone fragments and fixation with a miniplate through the endolift, the wound was sutured, and a dressing was applied. there were no complications during or after surgery in all 15 cases of surgery. patients were discharged 3 days after the operation in satisfactory condition. the sutures were removed on the 7th day. functional and cosmetic results were evaluated as satisfactory. the use of this method of treatment ultimately determines the degree of effectiveness, safety, and quality of life of the performed manipulations for patients, especially in countries with low levels of economic development. introduction a modern alternative method to classic wide-access surgery is small-access surgery, also known as minimally invasive surgery, which began to be actively developed only a few decades ago.1 in endoscopic interventions, the amount of tissue damage is significantly less compared to surgery from classical access, which simplifies the identification of intact organs and tissues compared to traumatised ones.2 this fact emphasises the promising development of minimally invasive methods in surgery. the fundamentals of minimally invasive surgery are based on the principles of endosurgery and the improvement of surgical instruments.3 current methods of creating endoscopic access are not universal, and the convenience of instrument placement depends largely on the surgeon’s experience. accurate placement of all ports is one of the main factors affecting the success of endoscopic surgery. inadequately developed endoscopic access techniques are considered one of the main causes of conversion (conversion to open surgery) and intraoperative complications.4,5 against this background, there is a clear lag in the field of maxillofacial surgery, despite the particular importance of the aspects of aesthetics and functionality in this speciality. it is important to note that there is a huge need for surgical treatment using endoscopic techniques in the maxillofacial region due to the increasing incidence of new cases of facial trauma.6,7 in emergency practice, road traffic accidents and assault are the most common causes of maxillofacial injuries.8,9 from 2019 to 2021, inflammatory processes, trauma, congenital, and acquired pathology of the maxillofacial region were the main causes of hospitalisation in the maxillofacial surgery department of osh hospital and accounted for 37.8%, 21.1%, and 22.3% of cases, respectively.10 compared to open techniques in maxillofacial surgery, minimally invasive techcorrespondence: andrei tsoi, department of clinical stomatology and implantology, i.k. akhunbaev kyrgyz state medical academy, 720020, 92 akhunbaev str., bishkek, kyrgyzstan. e-mail: andreitsoi792@gmail.com key words: minimally invasive surgery, endolift, endoscopic space, access, zygomatic-orbital-facial complex. conflict of interest: the authors declare no potential conflict of interest. ethics approval: the study was approved by the ethics commission of the i.k. akhunbaev kyrgyz state medical academy, no. 13727. patient consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. funding: none. acknowledgements: none. received: 24 july 2024. accepted: 30 august 2024. early view: 11 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12843 doi:10.4081/hls.2024.12843 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 104] [healthcare in low-resource settings 2024;12(s2):12843] non -co mmerc ial us e o nly niques are gaining tremendous popularity worldwide due to various factors: lower traumatization and surgical stress; the possibility of surgery for cosmetic indications; increased endoscopic view of the operative field; simplification of access and surgical technique; prevention of rough postoperative facial scars; faster postoperative wound healing.11-15 however, the moderate learning curve of endoscopic minimally invasive techniques requires surgeons to practice consistently, with a high degree of technical skill and confidence in handling instruments with limited visibility.16 in maxillofacial surgery, the role of minimally invasive endoscopic techniques remains insufficiently highlighted, despite their importance. maxillofacial surgery is mainly represented by minimally invasive non-endoscopic methods in plastic and reconstructive surgery, or by the use of endoscopy requiring significant incisions.17-21 this fact emphasises the relevance of the development of theoretical and technical aspects of optimal endoscopic access. today, natural optical cavities and surgical cavities are used for sufficient visualisation during endoscopic operations in maxillofacial surgery. according to fanelli et al.22 access can be performed transantral, transoral, intraarticular, and transcervical. for endoscope insertion, existing tissue damage or incisions in hidden or inconspicuous areas can be used to minimise the visibility of postoperative scars (scalp, behind the ears). according to the study by i. yuldashev et al.,23 in bishkek for the period 2013-2017, traumatic injuries of the middle part of the face were treated using methods such as open repositioning, splint fixation, osteosynthesis, and maxillary sinus revision. studying the progress in maxillofacial surgery, pendharkar24 and abdulrahman25 highlight the growing acceptance of endoscopic minimally invasive surgeries. it is noted that the benefits outweigh the challenges, especially in orthognathic surgery, with reduced tissue damage, scarring, and risk of infection. however, careful training is still crucial due to the complexity and sensitivity of the technique. the cost-effectiveness of these procedures has yet to be evaluated, reflecting the evolving status of the technique in operative practice. a meta-analysis of five studies by cavalcanti et al.26 found no statistically significant difference between open repositioning with internal fixation and endoscopic open repositioning with internal fixation in the treatment of adult condyle fractures in terms of the need for reoperation and/or facial nerve damage. however, despite the positive results of both methods, optimisation of the endoscopic surgical process and reduction of patient hospitalisation time remain urgent tasks. the aim of this study is to propose a patent method for the treatment of various injuries to the zygomatic-orbital-facial complex based on the developed endolift as a means to form an endoscopic space, based on a clinical case study. this study, conducted over a period of approximately one year, involved a sample of 15 patients who underwent various maxillofacial surgical procedures using the endolift technique. therefore, the limited sample size and lack of long-term results call for further studies with larger numbers of participants and long-term follow-up with patients. materials and methods endolift design and application in maxillofacial surgery to fulfil this goal, a special miniaturised device representing an endolift was designed and manufactured (figure 1). the endolift device is used to form an endoscopic space for diagnosis and treatment in the field of maxillofacial surgery. this construction is made of medical stainless steel or titanium (alloy vt1-0, vt1-00), which have the necessary biocompatibility. this device is a twocomponent structure, the elements of which are arranged perpendicularly to each other. inside the operating cavity, there is a horizontal part in the form of a round plate curved to the middle with a diameter of up to 10 mm. a hollow tube up to 10 mm long and 4 mm in diameter is perpendicularly located in the central part of this plate. in the apical part of the tube on both sides, there are two holes with a diameter of up to 1 mm directed towards each other. to facilitate secure fixation of the endolift in a given position, ligatures are threaded through the lateral holes of the tube, thus ensuring stability and accurate placement during surgical interventions. patented method of endoscopic space shaping in maxillofacial surgery using an endolift using an innovative endolift device, a method has been developed to form an optical cavity for the diagnosis and treatment of various pathologies in maxillofacial surgery. this technology offers advantages in terms of surgical access and procedural flexibility. an invention patent no. 2082 dated july 31, 2018 was granted in the kyrgyz republic based on this method. this method involves a series of precise steps aimed at achieving optimal surgical results while preserving the natural aesthetic contours of the face. the technique involves making an incision, forming a tunnel, inserting the endolift, and then elevating it. the incision is made in an area carefully chosen to minimise visible scarring. the technique allows for the creation of a dome-shaped space above the operating field by lifting the endolift with ligatures threaded through the holes. the technique is performed as follows: first, a small (up to 10 mm) incision of the skin or oral mucosa is created in an area remote from the pathological focus, guided by careful aesthetic considerations (figure 2). this incision is designed for social and political factors affecting public health figure 1. schematic diagram of the endolift structure. note: 1 – horizontal plate; 2 – hollow tube; 3 – paired holes at the top of the tube; 4 – ligatures coming out of the holes figure 2. technique of the method of optical cavity formation for diagnosis and treatment of various pathologies in maxillofacial surgery. note: a, puncture for withdrawal of the endolift tube; b, free working space formed; c, d, surgical field, soft tissues and bone. [healthcare in low-resource settings 2024;12(s2):12843] [page 105] non -co mmerc ial us e o nly the insertion of the endolift and other instruments. after the initial incision, a tunnel is formed by detaching a skin-fat or mucosal flap directly from the incision before penetrating the intermuscular or interfascial spaces. an endolift is inserted into the central part of the formed tunnel, after which the skin or mucosa is punctured above the endolift tube, and the hollow part of the tube is brought out. the endolift is then raised with ligatures through the lateral openings of the tube, resulting in a dome-shaped working space above the operative field. the endolift is held in the raised state either by an assistant or fixed to the transverse post of the operating table using ligatures. by inserting the endoscope and/or other endoscopic instruments through the internal channel of the tube and additional ports in the working space, it is possible to perform surgical procedures at a 90º angle and to perform active drainage, irrigation of the working space, as well as other manipulations during surgical intervention. endoscopic surgery using the endolifting technique was applied to 15 patients. the inclusion criteria were patients of any gender and age with various traumas to the maxillofacial region. a clinical case of surgery in a patient with a mandibular fracture is described in detail. results the use of endolift in zygomatic-orbital surgery: a case-control study this study was conducted in the department of oral and maxillofacial surgery of the kyrgyz republic. in the course of the study, after the development of the endolift device, a thorough evaluation of its effectiveness and practicality in clinical settings was carried out, with special emphasis on surgical interventions for various injuries of the zygomatic-orbital-facial complex. the use of the endolift in general included a series of 15 surgeries on injured patients with various maxillofacial injuries. the main objective of this study was to determine the capabilities of the endolift in providing optimal visualisation, creating the necessary space for accurate endoscopic interventions, and reducing procedural complexity. all patients were provided with a detailed explanation of the need for surgical intervention and the advantages of using the endoscopic method with the endolift. each of the study participants signed an informed consent to participate in the study. tissue dissection was performed in a minimally visible location on the skin or through the oral mucosa. according to the technique, a tunnel was formed after the incision to insert the endolift and necessary instruments. after insertion of the device and withdrawal of its hollow tube outside, the endolift was lifted by ligatures by an assistant or fixed to the table post, and all necessary manipulations were performed. in all 15 cases of surgical interventions, no significant technical obstacles occurred throughout the operation. there were no cases of paraesthesia, facial nerve injury, infection, or bleeding. there were no intraoperative or postoperative complications, which confirms the high efficiency of the procedure and its safety for the patients. after the recovery period, the patients were discharged from the medical institution 3 days after the operation, and their clinical condition was considered satisfactory for further outpatient treatment. on the 7th day after discharge, a second examination and suture removal were performed. repair of a mandibular fracture with endolift: a clinical case study this case report presents the clinical picture of patient j.b., 36 years old, with a fracture of the mandible located between the 5th and 6th teeth in the left lower quadrant, as shown in figure 3. the patient was admitted with complaints of pain in the lower jaw on the left side, increasing when opening the mouth and chewing, as well as swelling and bite disturbance. during the objective, examination there was facial asymmetry due to swelling in the left lower quadrant, the skin in the area of trauma was hyperaemic, and there were hematomas and abrasions. the mucous membrane of the left side of the mandible was hyperaemic, there were small abrasions. teeth 3.5 and 3.6 were intact, but there was mobility in tooth 3.6. between 3.5 and 3.6 teeth, there was a fracture with displacement. palpation in the area between the 3.5 and 3.6 teeth caused sharp pain. crepitation and mobility of the fragments in the fracture zone were detected. limitation of mouth opening was observed (the patient was able to open the mouth no more than 2 cm), deviation of the mandible to the left when attempting to open the mouth fully, and bite disturbance due to displacement of the fragments. immediately after the patient came to the hospital, the patient was prescribed analgesics and anti-inflammatory therapy. the diagnosis was confirmed by additional investigations. the patient underwent a panoramic image (orthopantomogram), which revealed a fracture of the mandible with a fracture line between 3.5 and 3.6 teeth. displacement of the fragments was observed in the medial-distal direction. laboratory investigations included a general blood count and a coagulogram. the indices were free of significant abnormalities. a decision was made to use endoscopic minimally invasive intervention using endolift apparatus with repositioning of the mandibular bone fragments and fixation of the fragments with a miniplate. at the time of the examination, no contraindications to the surgical intervention were revealed. the patient was informed about the possible risks and complications associated with the operation and gave his consent to the surgical intervention. before the operation, the patient was given a prophy social and political factors affecting public health figure 3. fracture of the patient’s mandible. note: 1 – endolift location; 2 – main incision in the submandibular region for endolift insertion. [page 106] [healthcare in low-resource settings 2024;12(s2):12843] non -co mmerc ial us e o nly lactic dose of an antibacterial drug. endoscopic repair of the mandibular fracture using the endolift technique was performed under general anaesthesia. the patient underwent a 1 cm incision in the submandibular region, after which soft tissues were layer by layer dissected and sectioned. the mandibular body was skeletonised, which made it possible to identify bone fragments in the fracture area and create a tunnel (figure 3). after the tunnel was formed, the endolift device was inserted into the created canal, followed by a puncture of the overlying skin, which facilitated the extraction of its hollow tube. the endolift was then positioned and secured with ligatures threaded through the existing lateral holes in the apical part of the tube, thus creating a dome-shaped operative optic cavity over the surgical field. the assistant used the ligatures to stabilise the endolift apparatus. once the optimal surgical field was established, the fibre optic endoscope was inserted through the hollow tube of the endolift apparatus, aligning the axis of observation with the surgical focus (figure 4). striking clarity and visualisation of the mandibular body and fracture line were achieved. a physiodispenser was then used to drill perforations in the mandibular bone through the hollow tube of the endolift, exactly aligned with the direct axis of surgical manoeuvring. if necessary, additional incisions (ports) could be created around the endoscopic space through which endoscopic or general surgical instruments were introduced. at the same time, the bone fragments were matched through the main incision site using endoscopic access with an angular trajectory exceeding 25º, after which a miniplate was inserted to immobilise the mandible. then, a screwdriver was inserted through the internal channel of the hollow endolift tube, which was used to fix the miniplate with screws, maintaining alignment with the direct operative axis (at an angle of 90º) and placing it perpendicular to the fracture line. the occlusion and the volume of jaw movements were close to the physiological state. postoperative closure included suturing the wound with an atraumatic non-absorbable thread, followed by an aseptic dressing to ensure optimal wound healing and prevent nosocomial infections. the postoperative period also proceeded without complications. three days after surgery, the patient was discharged for outpatient follow-up. the treatment plan included a consultation with an orthopaedic dentist to assess the condition of the teeth and possible further correction of the bite. a follow-up examination in 710 days was recommended to assess the healing dynamics and treatment efficacy. during the follow-up visit on the 7th day, the sutures were removed. healing was without complications. functional and cosmetic results of the treatment were evaluated as satisfactory. progressive treatment of mandibular fractures: endoscopic osteosynthesis with endolift the main requirement for endoscopic surgery is the ability to form and preserve an optical cavity and to insert an endoscope. an important feature of this innovative method is its ability to perform osteosynthesis of mandibular fractures in various anatomical areas within a pre-formed optical cavity. this cavity is carefully designed specifically for endoscopic interventions to achieve the best possible results. this approach provides practitioners with comprehensive endoscopic manipulation and real-time visual control at all stages of the procedure, creating an optimal environment for surgical performance. it is possible to work through the main incision site at any angle convenient for the surgeon. the breakthroughs in this field are due to the use of a specialised device that replaces the traditional manual or self-locking retractor as a critical element for visibility and access to the surgical field. this device significantly improves the surgeon’s working environment, allowing him or her to perform precise manipulations with a high level of safety and minimal risk of complications. due to these advances, endoscopic osteosynthesis for mandibular fractures of various localisations is now possible through external, cosmetic access. miniaturised instruments are used, which avoids interference in the oral cavity. unlike existing techniques, which are predominantly based on intraoral endoscopic interventions, the new approach eliminates the need to work in a narrow, slit-like, and deep anatomical space. this not only improves the endoscopic view but also reduces the risk of infectious complications in the operative field.27,28 consequently, current techniques often require additional interventions outside the oral cavity due to the aforementioned limitations. thus, the use of this innovative approach in endoscopic surgery of mandibular fractures represents a significant step forward in medical practice, providing surgeons with safer and more effective treatment methods, which in turn improve patients’ quality of life and shorten their recovery period. discussion diagnosis and treatment of maxillofacial pathology require consideration of its unique features, including its complex network of vessels and nerves as well as the structure of soft and bony tissues. the anatomy requires that defects be repaired with minimal risk to vital structures. optimal diagnosis and treatment require access in the form of minimally invasive incisions followed by tunnel formation; skin-fat or mucosal flap detachment; penetration into intermuscular or interfascial spaces; insertion of the endoscope and any other endoscopic instruments; a comfortable visualisation angle of the operative space; and manoeuvrability of movements.29-31 all these factors ultimately determine the degree of effectiveness, safety, and quality of life of the manipulations performed on patients. the unique structure of the endolift simplifies the work of surgeons by creating an optical cavity with a sufficient view of the surgical field. endolift surgery provides a minimally invasive approach that minimises tissue damage and reduces postoperative scarring compared to traditional open surgery. in addition, endolift is affordable, especially in resource-limited settings. computer social and political factors affecting public health figure 4. use of endolift during mandibular fracture reconstruction note: 1 – endoscope inserted through the endolift hollow tube; 2 – fracture/perforation line; 3 – endoscopic manipulators; 4 – main incision and additional port for insertion of endoscopic instruments; 5 – miniplate. [healthcare in low-resource settings 2024;12(s2):12843] [page 107] non -co mmerc ial us e o nly navigation systems (cns) are a possible option to improve visualisation during surgical manipulations in the maxillofacial region. alkhayatt et al.32 stated the usefulness of cns in fracture reconstruction, resection of neoplasms, foreign body extraction, and jaw position correction. navigation systems require specialised hardware and software and usually include preoperative planning and intraoperative guidance, but larger incisions may be required for access. computed tomography (ct) may also be used to improve intraoperative visualisation. in a study by ren et al.,33 the authors found that surgical treatment of fractures in 72 patients using ct was accompanied by a reduction in the need for incisions and internal fixation compared to conventional techniques applied to 71 patients in a control group. the proposed patent technique with the use of endolift allows access to the surgical space through small skin or mucosal incisions up to 10 mm in the area remote from the pathological focus, providing less trauma, followed by a gentle process of tissue separation from each other to form a tunnel. in a retrospective study, nural18 applied a novel method of vertical-space facelift with buccal fat elevation to the medial suborbital rim with a subciliary minimally invasive incision 1-2 mm below the eyelid margin from the medial canthus to 5-10 mm below the lateral canthus in 23 patients. le louarn34 proposed the method of concentric malar (zygomatic) lifting with minimally invasive incisions. 342 patients with lower eyelid problems were treated with initial incisions of 2 cm for subperiosteal dissection and 1.5 mm diameter holes for forming pairs of holes required for malar lift. although in both studies, the authors used minimally invasive small incisions, they did not use minimally invasive endoscopic techniques. tissue fixation with the endolift provides the possibility of unobstructed work by the surgeon in conditions of limited visibility and compact anatomy in surgery of the maxillofacial region.35 for the formation of the optical cavity, anehosur et al.36 used periosteal elevators, howarth’s raspers, and a 4 mm endoscope at a 30º angle (karl storz, tuttlingen, germany) in the treatment of mandibular fracture. in a study by chasan and hauch,37 the authors used kirschner spokes (k-spokes) for fixation in eyebrow endolifting. four small 1 cm incisions were made in 284 patients. k-spice fixation was done through special 16-gauge needles. the k-spokes and needles were inserted percutaneously at a 90º angle. this technique is also an effective option for temporary fixation with satisfactory results. however, it should be noted that the rate of postoperative complications after k-spice application reaches 18%.38 in this technique, the endolift was inserted using ligatures through the holes of the hollow tube and held by an assistant or fixed to the table post. in addition to fixation, the structure of the endolift allows using the hollow tube for the insertion of an endoscope and special endoscopic instruments designed to work in narrow spaces of the oral cavity and other areas of the face with an optimal angle of 90º, which is also an advantage. it is possible to manipulate through the main incision with access greater than 25º, as in this clinical case of mandibular fracture. sukegawa et al.39 successfully removed infected interosseous spokes using an endoscopic, minimally invasive approach. for this procedure, an endoscope with a diameter of 4 mm at an angle of 70º was used in combination with an ultrasonic cutting instrument for bone dissection after a minimal incision in the jawline. this method allows for the removal of the spokes with minimal surgical intervention, reducing the risk of damage to surrounding tissues while providing effective treatment of infected areas without unnecessary complications. transoral and transfacial access was used to perform the elimination of posttraumatic facial injuries with endolift. sublabial access with an incision up to 4 cm (caldwell-luke) is often used to repair orbital fractures; an anthrostoma up to 4 mm is formed in the maxilla using an osteotome, followed by its expansion with a kerrison pin up to 1×2 cm. a greenberg retractor is used to fix the anthrostoma. in certain cases, a complex approach is appropriate. procacci et al.40 used transnasal access with megaantrostomy for odontogenic cysts of the maxilla. in this case, endoscopy allowed seeing the medial and posterior parts of the lesion. a 4 mm 0°, 45° or 70° straight endoscope (karl storz gmbh & co kg, tuttlingen, germany) was used. in this patent case, the angle of visualisation and active therapeutic manipulation was 90°. the size of the endoscope and its associated instruments had a diameter of no more than 4 mm, taking into account the maximum diameter of the hollow tube. consequently, the present invention is not inferior in technical characteristics to endonasal endoscopic lifting. in a clinical case where the patent technique was applied, it was possible to match the bone fragments through the main incision site, and a miniplate was inserted and fixed with screws. there were no intraoperative complications or technical difficulties. the postoperative period was smooth; no complications were detected. on the 3rd day, the patient was discharged from the hospital for outpatient treatment in satisfactory condition. on the 7th day, the sutures were removed. the cosmetic result was evaluated by the patient as excellent. positive results were demonstrated by da vinci sp single-port system for transoral resection in patients with squamous cell cancer of the oropharynx. the robotic system showed good manoeuvrability and console time.41 the proposed patent invention plays a key role in the diagnosis and treatment of a variety of injuries and diseases in the field of maxillofacial surgery, overcoming the limitations associated not only with surgical dentistry. the design of the endolift and the method of using it to create an endoscopic space contribute significantly to the development of this field of surgery. this approach provides surgeons with more flexible and precise tools to perform surgery with minimal impact on the natural anatomical contours of the face. the endolift provides the necessary stability during surgical interventions, playing a key role in the formation of the optical cavity, which is an essential element of many operations in this field. the main advantage of this method is a shorter hospital stay, reduced risk of complications, and faster recovery. the endolift device is universal and applicable to the entire spectrum of problems in the field of maxillofacial surgery. conclusions the invention of the endolift is directed towards diagnostic and therapeutic endoscopic interventions in maxillofacial surgery. the minimally invasive technique offers precision and efficiency in creating an endoscopic field, aligning with the broader trend towards less invasive surgical approaches in modern medicine. the endolift’s unique design allowштп the formation of a domeshaped working area, addresses longstanding challenges in maxillofacial surgery related to visibility and maneuverability in confined spaces. the ability to introduce endoscopic instruments through the endolift’s internal channel and additional ports exemplifies the concept of multimodal surgical access, a principle increasingly recognized in advanced surgical techniques. this versatility enables surgeons to execute treatments from numerous angles, actively manage the surgical site through drainage and irrigation, and perhaps eliminate the need for larger open surgeries. the successful completion of fifteen surgeries employing this technology, encompassing both transoral and transfacial methods, social and political factors affecting public health [page 108] [healthcare in low-resource settings 2024;12(s2):12843] non -co mmerc ial us e o nly offers preliminary proof of the technique’s efficacy in a variety of maxillofacial procedures. the thorough case study of patient j.b.’s mandibular fracture treatment exemplifies the endolift’s practical use, demonstrating its ability to simplify difficult operations while minimising tissue trauma. this example is consistent with the expanding body of research favouring less invasive techniques in face trauma therapy. the endolift’s ability to facilitate osteosynthesis in a pre-formed cavity is an innovative approach to maxillofacial bone recovery. this method has the potential to bridge the gap between traditional open operations and totally endoscopic treatments, providing a compromise that incorporates the advantages of both techniques. the endolift technique, despite its potential cost for low-income individuals, addresses healthcare access issues. however, increased time demands and medical personnel workload necessitate a thorough cost-benefit analysis. minimal scarring, less tissue stress, enhanced field vision, and quicker recovery times lead to better cosmetic and functional results in maxillofacial surgery. although the results of the study are promising, the limited sample size and lack of long-term results call for further studies with larger numbers of participants and long-term follow-up with patients. future research should explore endolift’s potential applications beyond maxillofacial surgery, including general and specialized procedures. standardised patient satisfaction and functional outcome assessments are crucial for patient-centered evaluation. a detailed economic evaluation of endolift against traditional techniques is essential for healthcare systems considering its implementation. endolift offers better results and less invasive procedures, but extensive scientific examination and multi-center investigations are needed for effective integration. advancements in technology could significantly influence patient treatment and facial reconstructive options. references 1. hargest r. five thousand years of minimal access surgery: 3000bc to 1850: early instruments for viewing body cavities. j r soc med 2020;113:491-6. 2. hakim ma, mccain jp, ahn dy, troulis mj. minimally invasive endoscopic oral and maxillofacial surgery. oral maxillofac surg clin north am 2019;31:561-7. 3. latka k, kolodziej w, pawlak k, et al. fully endoscopic spine separation surgery in metastatic disease—case series, technical notes, and preliminary findings. med (lith) 2023;59:993. 4. darzi a, mackay s. recent advances in minimal access surgery. bmj 2002;324:31-4. 5. trifkovic b, budak i, vukelic d, et al. analysis of accuracy and precision of optical 3d digitisation devices in dental computer-aided-design and computer-aided-manufacturing systems. maejo int j sci technol 2017;11:45-57. 6. lalloo r, lucchesi lr, bisignano c, et al. epidemiology of facial fractures: incidence, 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https://drive.google.com /file/d/1uskb1th9yhyzn8z9ytkwzgfnwzx_xisz/view 12. kim jy, lee yc, kim sg, garagiola u. advancements in oral maxillofacial surgery: a comprehensive review on 3d printing and virtual surgical planning. appl sci 2023;13:9907. 13. choi h, cho gj, jung kh, et al. the dual-port endoscopeassisted cyst enucleation on the maxillofacial region. maxillofac plast reconstr surg 2021;43:40. 14. nowak r, rekas m, ali mj. long-term outcomes of stoploss™ jones tube (sljt) and minimally invasive conjunctivodacryocystorhinostomy. graefes arch clin exper ophthalmol 2022;260:327-33. 15. makarov v, yessentayeva s, kadyrbayeva r, et al. modifications to the video-assisted thoracoscopic surgery technique reduce 1-year mortality and postoperative complications in intrathoracic tumors. eur j cancer prev 2024;33:5361. 16. harvinder b, ben h. learning curve for minimally invasive surgery and how to minimize it. foot ankle clin 2020;25:36171. 17. ceresoli m, pisano m, abu-zidan f, et al. minimally invasive surgery in emergency surgery: a wses survey. world j emerg surg 2022;17:18. 18. nural h. vertical space lift: transcutaneous lower blepharoplasty, subperiosteal midface lift, and lower face lift: a novel technique of buccal fat suspension to medial infraorbital rim. aesthet surg j open forum 2021;4:ojab038. 19. wang y, ma d, li y, et al. combined use of endoscopic techniques and virtual surgical planning for intraoral approach for hemi-mandibular resection and reconstruction. plast reconstr surg glob open 2024;12:e5644. 20. oshurko ap, oliinyk iy, kuzniak nb. anatomical and topographic classification of the mandibular canal with bone atrophy caused by the loss of the masticatory teeth. rom j stomatol 2022;68:160-6. 21. latka d, waligora m, latka k, et al. virtual reality based simulators for neurosurgeons what we have and what we hope to have in the nearest future. adv intell syst comp 2018;720:110. 22. fanelli ca, vera lc, ahn dy, mccain jp. a review of endoscopic surgical applications in oral and maxillofacial surgery. plast reconstr surg glob open 2023;5. 23. yuldashev i, rakhmanov a, urgunaliev b, et al. frequency of midfacial traumatic injuries – a report from the maxillofacial reconstructive and plastic surgery department of kyrgyz republic health service ministry’s national hospital, bishkek from 2013-17 – a retrospective study. ann maxillofac surg 2020;10:377-80. 24. pendharkar ss. endoscopic perspective in oral and maxillofacial surgery. rguhs j dent sci 2023;15:12-6. 25. abdulrahman a. minimally invasive approaches in orthognathic surgery: a narrative review of contemporary techniques and their clinical outcomes. j pharm bioallied sci 2024;16:1652-6. 26. cavalcanti sc, taufer b, rodrigues a, luz jg. endoscopic social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12843] [page 109] non -co mmerc ial us e o nly surgery versus open reduction treatment of mandibular condyle fractures: a meta-analysis. j craniofac surg 2021;49:749-57. 27. boccuto m, ottaviano g, prosenikliev v, et al. combined endoscopic and intraoral approach or intraoral alone in surgical management of odontogenic sinusitis. surgeries 2021;2:399408. 28. romano a, norino g, dell’aversana orabona g, et al. a large follicular dentigerous cyst: a new multi-portal access: intraoral and endoscopic technique. j maxillofac oral surg 2024;23:189-92. 29. sheinman v, rudnitsky a, toichuev r, et al. implantable photonic devices for improved medical treatments. j biomed opt 2014;19:108001. 30. perkasa mf. endoscopic transsphenoidal surgery and haddad nasoseptal flap of rathke’s cleft cysts. gac med caracas 2023;131:414-9. 31. bothra n, gupta n, nowak r, et al. the use of anterograde percutaneous transluminal coronary angioplasty balloons in congenital nasolacrimal duct obstruction: a cost-effective alternative to the traditional dacryoplasty balloons. ophthalmic plast reconstr surg 2020;36:302-4. 32. alkhayatt nm, alzahrani hh, ahmed s, et al. computerassisted navigation in oral and maxillofacial surgery: a systematic review. saudi dent j 2024;36:387-94. 33. ren h, chen s, zhang y, an j, he y. intraoperative computed tomography in the surgical treatment of zygomatic complex fracture: a retrospective cohort study. j craniofac surg. 2024 may 7. doi: 10.1097/scs.0000000000010201. epub ahead of print. 34. le louarn c. concentric malar lift in the management of lower eyelid rejuvenation or retraction: a clinical retrospective study on 342 cases, 13 years after the first publication. aesthet plast surg 2018;42:725-42. 35. oshurko ap, oliinyk iy, kuzniak nb. variant anatomy of the mandibular canal topography. rep morphol 2022;28:62-8. 36. anehosur v, joshi a, rajendiran s. endoscopic-assisted intraoral open reduction internal fixation of mandibular subcondylar fractures: initial experiences from a tertiary-care maxillofacial center in india. cranio maxillofac trauma reconstr 2018;11:183-91. 37. chasan pe, hauch at. the k-wire fixation technique for endoscopic brow lift: a long-term follow-up. aesthet plast surg 2020;40:1051-60. 38. wong ky, mole r, gillespie p. kirschner wire breakage during removal, requiring retrieval. case rep surg 2016;2016: 7515760. 39. sukegawa s, miyazaki r, matsuki y, et al. endoscopic-assisted surgical removal of infected interosseous wires 40 years after mandibular surgery. j craniofac surg 2023;34:1556-8. 40. procacci p, lanaro l, molteni g, et al. trans-nasal endoscopic and intra-oral combined approach for odontogenic cysts. acta otorhinolaryngol ital 2018;38:439-44. 41. costantino a, sampieri c, meliante pg, et al. transoral robotic surgery in oropharyngeal squamous cell carcinoma: a comparative study between da vinci single-port and da vinci xi systems. oral oncol 2024;148:106629. social and political factors affecting public health [page 110] [healthcare in low-resource settings 2024;12(s2):12843] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12340 spiritual services needed by the elderly in nursing homes iskim luthfa,1,2 ah. yusuf,1 rizki fitryasari,1 nopi nur khasanah,2 indah sri wahyuningsih,1,2 israfil1 1faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang, indonesia abstract older adults are a group vulnerable to health problems, and cases continue to increase. one of the reasons is living in a nursing home. so far, efforts have been made to improve older adults’ care services for their quality of life (qol). however, one thing that is forgotten is spiritual services for older adults. this research aims to find relevant aspects between care and spiritual services to improve the qol for older adult people living in nursing homes. this was a cross-sectional study. the sample size was 131 older adult people living in nursing homes. samples were taken through simple random sampling with the criteria of being able to communicate and having a good cognitive function. care services were measured using the services assessment scale (svas) questionnaire, spiritual services were measured using the spiritual assessment scale (sas) questionnaire, and qol was measured using the world health organization quality of life older (whoqol-old) questionnaire. data analysis used the gamma test. respondents in this study were mostly women (55.5%), aged 60-74 years (62.6%), who had an elementary school graduation education (56.5%). most respondents received low care services (74.0%), low spiritual services (84.0%), and most of them had low qol (82.4%). the results showed a significant correlation between care services and qol (p=0.000 and r=0.623), and between spiritual services and qol (p=0.000 and r=0.755). older adults in nursing homes need spiritual services and care services to improve their qol. introduction the world health organization (who) stated that in 2020, the southeast asia region had an older adult population of 9.77%, or 24 million of the total population. indonesia is currently facing a transition period from a young society to an older adult society, and will be for the next 20 to 30 years.1 in 2020, there were 80,000,000 people aged 60 years and over, representing 9.6% of the population. this percentage is predicted to increase to 20% by 2040.2 significant changes in older adults present challenges and opportunities. the challenge is that they experience a degenerative process that decreases their physical, psychological, and social functioning. they become a vulnerable group to health problems, and reduce their quality of life (qol). this condition will increase the demand for long-term healthcare provision.3 the opportunity is to provide comprehensive primary health care for older adults and access to long-term care. nursing homes are an appropriate model of care for the older adults in need. care services in nursing homes include daily care and health services. care services in nursing homes are carried out intensively to meet physical, psychological, and social needs. the hope is to be able to support the health of older adults and improve their qol. but in reality, older adults who live in nursing homes have a lower qol than those who live at home with their families.4,5 nursing homes in the city of semarang, indonesia, currently still provide care services focused on the medical aspect, namely administering medication to sick older adult people. meanwhile, promotive, preventive, and rehabilitative aspects have not been provided optimally. care services are aimed at overcoming physical, psychological, and social disease problems, such as physical health care, anticipating anxiety and stress, as well as communication between older adults. meanwhile, spiritual services are not provided optimally. nursing homes in the city of semarang, indonesia, answer the need for religious practices, such as places of worship and tools for healthy elderly people. however, for older adult people who are dependent, there are no facilities to practice worship, so their spiritual needs cannot be fulfilled. we know that humans correspondence: nopi nur khasanah, faculty of nursing, universitas islam sultan agung, semarang, indonesia. tel. +6285640256378e-mail: nopi.khasanah@unissula.ac.id key words: geriatric care, nursing, quality of life, spiritual. contributions: all the authors made a substantive intellectual contribution. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: this study was approved by the health research ethics committee at the nursing faculty, sultan agung islamic university (unissula) semarang, indonesia, with the number 772/a.1-s1/fik-sa/x/2021. informed consents were obtained from all the subjects after they were given an explanation about the study. acknowledgments: the researchers would like to thank the nursing homes of central java, indonesia, for permitting this study and the participants who participated in it. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 1 february 2024. accepted: 12 april 2024. early access: 7 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12340 doi:10.4081/hls.2024.12340 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12340] [page 339] non -co mmerc ial us e o nly have holistic needs, including physical, psychological, social, and spiritual. spiritual needs are the highest aspect in older adults.6 the spiritual aspect has a function as a source of strength for older adults when facing illness and affects health care.7 spiritual services are very important for older adults living in nursing homes. the spiritual services provided include personal beliefs, spiritual satisfaction, and religious practices.8 spiritual services can improve spiritual well-being, which includes personal, communal, environmental, and transcendental. in the end, spiritual services will be able to improve the qol for older adults in nursing homes.9 so far, the spiritual needs of older adults living in nursing homes have not been widely considered as an issue that must be addressed. sometimes, nurses forget that the spiritual aspect is a lifelong necessity. even when older adults are dying, spiritual support is something that can help them die peacefully.10 therefore, it is crucial to comprehend the spiritual and care services offered and their correlation with the qol of older adults in nursing homes. materials and methods ethical considerations this study was approved by the health research ethics committee at the nursing faculty, sultan agung islamic university (unissula) semarang, indonesia, with the number 772/a.1s1/fik-sa/x/2021. informed consents were obtained from all the subjects after they were given an explanation about the study. study design, setting and period between january and march 2022, a cross-sectional study design was conducted in semarang city, indonesia. sample size and sampling technique the research population was 200 older adult people living in nursing homes in semarang city, indonesia. the samples in the study were taken using the slovin formula with a margin of error of 5%, 131 samples were obtained, taken randomly using a simple random sampling technique. the sample inclusion criteria included older adults people aged 60 years and over, living in nursing homes in semarang city, indonesia, able to communicate and having good cognitive function based on the results of examinations using the short portable mental status questionnaire (spmsq) instrument. the spmsq instrument is standard; the validity test results show that all question items obtained a calculated r value greater than the r table based on a significant test of 0.05 (0.4210.755), and the reliability test results obtained a cronbach alpha value of 0.88. the spmsq measurement results are categorized as intact intellectual function with a score of 0-2, mild intellectual damage with a score of 3-4, moderate intellectual damage with a score of 5-7 and severe intellectual damage with a score of 8-10. the exclusion criteria are that older adults have severe intellectual impairment. data collection tool and procedure data collection was carried out after the older adults were given an explanation of the purpose of the research and agreed to informed consent. the questionnaire was directly given to the older adults to read and fill out. while filling out the questionnaire, the researcher accompanied the older adults to ensure they did not experience any problems. completing the questionnaire takes approximately 30 minutes. after the questionnaire was filled in, the researcher confirmed its completeness. instruments the instrument used to measure care services is the services assessment scale (svas) questionnaire. this questionnaire was developed by the researchers themselves and has been tested for validity and reliability. the validity test results show that all question items obtained a calculated r value greater than the r table based on a significant test of 0.05 (0.410-0.989), and the reliability test results obtained a cronbach alpha value of 0.986. the svas questionnaire consists of 12 question items on a likert scale with five rating options from never to always (1-5). the resulting categories are low maintenance services with a score of 12-27, medium with a score of 28-43, and high with a score of 44-60. the instrument for measuring spirituality is the spiritual assessment scale (sas) questionnaire.8 the sas instrument is standard and valid, with the results of all question items obtaining a calculated r value greater than the r table based on a significant test of 0.05 (0.30-0.70) and the reliability test results obtained a cronbach alpha value of 0.92. sas consists of 21 likert scale question items with five answer options. the resulting category was low spiritual, with a score of 21-48, medium 49-76, and high 77-105. the instrument used to measure qol is the world health organization quality of life older (whoqol-old) questionnaire. this instrument is standard and valid, with the results of all question items obtaining a calculated r value greater than the r table based on a significant test of 0.05 (0.97), and the results of the reliability test obtained a cronbach alpha value of 0.75. whoqol-old consists of 24 questions divided into six facets. the raw score lies between the lowest and highest possible values (ranging from 4 to 20). the total score (qol score) lies from 24 to 120. the higher the score, the higher the qol is. data analysis univariate analysis used descriptive analysis to determine the description of spiritual services, care services, and qol for older adults. bivariate analysis used the gamma test to determine the relationship between the independent variable and the dependent variable, as well as show the close relationship between the two. if the sig value is >0.05 then there is a relationship between the independent and dependent variables. the correlation coefficient ranges from no relationship (0.00), less significant relationship (0.01-0.09), weak relationship (0.10-029), moderate relationship (0.30-0.49), strong relationship (0.50-0.69), very strong relationship (0.70-0.89) and the relationship is close to perfect (>0.90). results demographic characteristics of respondents most of the respondents in this study were women, 72 respondents (55.5%), most were aged 60-74 years, 82 respondents (62.6%), most had elementary school graduation education, 74 respondents (56.5%). most received low care services, 97 respondents (74.0%), most received low spiritual services, 110 respondents (84.0%), and most had low qol, 108 respondents (82.4%). the relationship of care and spiritual services to quality of life the results of the gamma test obtained a p-value of 0.000 and an r-value of 0.623, meaning that there is a relationship between care services and qol in older adults living in nursing homes with article [page 340] [healthcare in low-resource settings 2024;12:12340] non -co mmerc ial us e o nly a strong level of relationship strength. the results of the gamma test obtained a p-value of 0.000 and an r-value of 0.755, meaning that there is a relationship between spiritual services and qol in older adults living in nursing homes with a very strong level of relationship strength. discussion the relationship of care services with quality of life table 1 shows that the majority of respondents, 97 respondents (74%), received care services at nursing homes in the low category. nursing homes are currently an alternative choice of residence for older adults, especially those who do not get care at home. various health and nursing services provided will help make it easier for older adults to live their daily lives and enjoy their old age.11 the results of the gamma test in table 2 show that there is a relationship between care services and qol with the strength level of the strong relationship. the better the care services, the higher the quality of life of the older adults. the results of this study are in line with research that has been conducted.12 they stated that there is a relationship between care services and the qol of older adults in nursing homes. care services at the nursing home are tailored to the health problems experienced by each older adult. these services are differentiated into short-term and long-term. short-term services are intended for older adults who need shelter and temporary care, such as rehabilitative services and palliative care. long-term services are provided to older adults who are unable to carry out selfcare, such as those with dementia.13 the quality of services provided in nursing homes is very important to pay attention to, in order to ensure that older adults feel comfortable and get good care.13 things to note are: first, the availability of caregivers who provide care every day. the comparison of the number of caregivers and older adults deserves special attention, especially for the older adult groups who experience total dependence. caregivers will experience severe fatigue due to having to provide daily care to many older adults.14,15 second, there are health workers who provide regular care. nursing homes need to provide staff to monitor activities and serve the older adults 24 hours a day. medical personnel, such as nurses or doctors, need to make regular visits to check the health of older adults.16 the older adults expect staff in nursing homes to care about their needs, understand what they need, be accompanied, and listen to all their problems.16 third, a safe environment for older adults. physical environmental facilities in nursing homes need to be designed to be safe and comfortable to prevent the risk of falling injuries to older adults.17,18 in addition to physical environment settings, older adults need mental and social services to adapt.19 mental services aim to reduce serious mental illness problems that occur in older adults, including schizophrenia, bipolar disorder, major depressive disorder, obsessive-compulsive disorder, and others.20 social guidance services aim to increase interaction, socialization, and motivation together to reduce loneliness.21 based on the policy in indonesian older adult nursing homes, the implementation of health services in nursing homes aims to strengthen physical, mental, and social services in order to create comfort and welfare, so the qol of the older adults has to increase. the relationship of spiritual service to quality of life table 1 shows that the majority of respondents received spiritual services at nursing homes in the low category, 110 respondents (84%). over time, older adults who live in nursing homes for longer periods of time will be attracted to religious and spiritual programs.22 conversely, choi et al. believe that declining body functions, inability to carry out activities independently, and experiencing severe dependence will cause the spiritual health of older adults to gradually decline.23 living in a nursing home causes older adults to lose social contact with relatives and friends; social sta article table 1. profile of the patients (n=131). variable n % sex male 59 45.0 female 72 55.0 age 60-74 82 62.6 75-90 47 35.9 >90 2 1.5 education elementary school 74 56,5 junior high school 42 32.1 senior high school 15 11.4 care services low 97 74.0 medium 25 19.1 high 9 6.9 spiritual services low 110 84.0 medium 16 12.2 high 5 3.8 quality of life low 108 82.4 medium 14 10.7 high 9 6.9 table 2. the relationship of care and spiritual services with quality of life (n=131). variable low medium high rp n (%) n (%) n (%) care services low 84 (64.1) 7 (5.34) 1 (0.8) 0.623 0.000 medium 18 (13.7) 7 (5.34) 4 (3.1) high 5 (3.8) 0 (0) 5 (3.8) spiritual services low 79 (60.3) 4 (3.1) 2 (1.5) 0.755 0.000 medium 26 (19.8) 10 (7.6) 5 (3.8) high 2 (1.5) 0 (0) 3 (2.3) [healthcare in low-resource settings 2024;12:12340] [page 341] non -co mmerc ial us e o nly tus, self-esteem, and confidence in themselves will be reduced.24 this condition causes the older adults to experience helplessness, thus preventing the older adults from finding spiritual meaning from the experience of illness, reduced belief in religious values, and feeling that they have no purpose in life.6 spirituality is a basic need for every human being. a frequent problem with the fulfillment of spiritual needs is spiritual distress. the spiritual aspect influences the fulfillment of life’s needs, such as social, mental, and other aspects of life.9 the gamma test results in table 2 show that there is a relationship between spiritual services and qol which has a very strong relationship strength. the better the spiritual service, the higher the qol for older adults. the results of this research are in line with research conducted by lima et al., (2020) that spirituality has a correlation with qol. spirituality is the highest need in older adults and will increase with age.25 spirituality is the most important source of strength in older adults in facing the challenges of illness,26 as a coping strategy to increase the meaning of life and death, and exerts a significant influence on health care.27 spirituality is considered an important source of adaptation in the face of stressful life events.28 spirituality is the highest power and gives older adults confidence in what is to come. spiritual will motivate older adults to be enthusiastic about maintaining their health by maintaining a healthy lifestyle.29 the spiritual aspect can be increased through spiritual experiences and spiritual activities that older adults carry out daily. spiritual activities can increase spirituality in older adults by believing in god. mature spiritual development will help older adults face reality, play an active role in life, and seek the meaning of life, the purpose of life, and the highest transcendence (divinity).30 older adults with low spiritual levels will show poor purpose in life, a sense of worthlessness, a feeling of being unloved, and fear of death. on the contrary, older adults with a good spiritual level are not afraid of death and are better able to accept life.28 if the spiritual needs of older adults are well met, then the qol will also improve. fulfillment of spiritual needs through activities that can get closer to the creator, namely by worshiping, praying, and reading scriptures. in addition, spiritual needs are also met by establishing good relationships with fellow humans and the environment, and finding the meaning of peace in life. the environment and nursing services have a relationship with qol.9 families and health workers in nursing homes should ensure that the spiritual needs of the older adults can be met, so as to improve their qol.31 spiritual understanding helps older adults achieve their potential and improve their qol. the spiritual health of older adults is said to be good if it has fulfilled several spiritual characteristics, namely: the relationship with oneself, namely who he is, what he does, and attitudes that involve belief in oneself; a harmonious relationship with nature; a harmonious relationship with others; and a relationship with god, which includes praying and participating in worship activities.8 conclusions the conclusion of this study is that care services and spiritual services have a relationship with improving the qol in older adults in nursing homes in central java province, indonesia. the treatment services provided include physical services, mental services, and social services. the spiritual services provided aim to increase confidence in oneself and maintain harmonious relationships with others and nature, as well as relationships with god. therefore, these two services need to be improved by implementing programs tailored to the needs of older adults and combining spiritual nursing interventions in in-service programs at nursing homes. references 1. world health organization (who). aging and health. 2022. available from: https://www.who.int/news-room/factsheets/detail/ageing-and-health 2. sari nr, sinang r, rachmawati y, santoso b. statistik penduduk lanjut usia 2020. 2020. available from: https://www.bps.go.id/id/publication/2020/12/21/0fc02322196 5624a644c1111/statistik-penduduk-lanjut-usia-2020.html 3. rahman mm, rosenberg m, flores g, et al. a systematic review and meta-analysis of unmet needs for healthcare and long-term care among older people. health econ rev 2022;12:1-10. 4. dung v, thi mai lan n, thu trang v, et al. quality of life of older adults in nursing homes in vietnam. health psychology open 2020;7:2055102920954710. 5. gunawan i, lin m-h, hsu h-c. exploring the quality of life and its related factors among the elderly. south east asia nurs res 2020;2:1. 6. jadidi a, khodaveisi m, sadeghian e, fallahi-khoshknab m. exploring the process of spiritual health of the elderly living in nursing homes: a grounded theory study. ethiopian j health sci 2021;31:589-98. 7. dos santos lcf, da silva sm, silva ae, et al. older adults in palliative care: experiencing spirituality in the face of terminality. revista enfermagem 2020;28:1-6. 8. o’brien me. spirituality in nursing: standing in holy ground. sixth edition. jones & bartlett learning; burlington, usa; 2018. 9. lima s, teixeira l, esteves r, et al. spirituality and quality of life in older adults: a path analysis model. bmc geriatrics 2020;20:1-8. 10. gijsberts m-jhe, liefbroer ai, otten r, olsman e. spiritual care in palliative care: a systematic review of the recent european literature. med sci 2019;7:25. 11. roh m, weon s. living arrangement and life satisfaction of the elderly in south korea. social indicat res 2020;160:71734. 12. rencber e, terzi o. quality of life of older people receiving home health care services: an example from turkey. home health care management and practice 2021;33:3-7. 13. rostad hm, skinner ms, hellesø r, sogstad mkr. towards specialised and differentiated long-term care services: a crosssectional study. bmc health serv res 2020;20:1-10. 14. kang sg, song sw, kim sh, et al. fatigue and mental status of caregivers of severely chronically ill patients. pain res management 2020;2020:6372857 15. sezgin h, cevheroglu s, gök nd. effects of care burden on the life of caregivers of the elderly: a mixed-method study model. medicine (united states) 2022;101:e30736. 16. adeyooye b. quality of care among the elderly in nursing homes in macomb, illinois. 2019. available from: https://www.proquest.com/openview/1cc22496a2abbd944817 7df2c490ec1a/1?pq-origsite=gscholar&cbl=51922&diss=y 17. deilkas ect, hofoss d, husebo bs, bondevik gt. opportunities for improvement in nursing homes: variance of article [page 342] [healthcare in low-resource settings 2024;12:12340] non -co mmerc ial us e o nly six patient safety climate factor scores across nursing homes and wards—assessed by the safety attitudes questionnaire. plos one 2019;14:1-12. 18. ang gc, low sl, how ch. approach to falls among the elderly in the community. singapore med j 2020;61:116-21. 19. afriansyah a, santoso m. pelayanan panti werdha terhadap adaptasi lansia. 2019. available from: https://jurnal.unpad.ac.id/responsive/article/view/22925 20. bucy t, moeller k, bowblis jr, et al. serious mental illness in the nursing home literature: a scoping review. gerontol geriatric med 2022;8:1-17. 21. alberola jm, del val e, costa a, et al. a computer-based support system for cooperative tasks in nursing homes. int j computational intelligence systems 2019;12:661-75. 22. dayanandan s, mehta k. what does joy in living mean to elderly residents of nursing homes in singapore? religions 2022;13:469. 23. molina npfm, tavares dmds, haas vj, rodrigues lr. religiosity, spirituality and quality of life of elderly according to structural equation modeling. texto e contexto enfermagem 2020;29:1-15. 24. sya’diyah h, nursalam n, mahmudah m, wicaksono wp. relationship between caring nurses and elderly loneliness. j public health res 2020;9:152-5. 25. koteneva av, berezina tn, rybtsov sa. religiosity, spirituality and biopsychological age of professionals in russia. eur j investigation health psychol education 2021;11:1221-38. 26. lepherd l, rogers c, egan r, et al. exploring spirituality with older people: (1) rich experiences. j religion spiritual aging 2020;32:306-40. 27. can oz y, duran s, dogan k. the meaning and role of spirituality for older adults: a qualitative study. j religion health 2022;61:1490-504. 28. heidari m, ghodusi borujeni m, kabirian abyaneh s, rezaei p. the effect of spiritual care on perceived stress and mental health among the elderlies living in nursing homes. j religion health 2019;58:1328-39. 29. herlina, agrina. spirituality and health status among elderly people in nursing homes in riau, indonesia. enfermeria clinica 2019;29:13-5. 30. selman le, brighton lj, sinclair s, et al patients’ and caregivers’ needs, experiences, preferences and research priorities in spiritual care: a focus group study across nine countries. palliative med 2018;32:216-30. 31. moghadam k, ghanaei r, bandboni m, roshan z. investigating the relationship between social support and quality of life in the elderly. j education health promotion 2020;9:1-5. article [healthcare in low-resource settings 2024;12:12340] [page 343] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12187 epidemiologic and clinical characteristics and outcomes of burn patients in kurdistan region: a one-decade large retrospective cross-sectional study khalid ibrahim mohammed saber,1 deldar morad abdulah,2 nawzad sulaiman murad,1 zuhair rushdi mustafa1 1fundamental and adult nursing unit, college of nursing, university of duhok, kurdistan region; 2community and maternity health nursing unit, college of nursing, university of duhok, kurdistan region, iraq abstract globally, burns are the most devastating injuries, causing more than 120,000 deaths annually, particularly in lowand middle-income countries. this study investigated the epidemiologic and clinical characteristics and outcomes of burn patients. this retrospective study was conducted at the duhok burn and plastic surgery hospital between 2014 and 2023. the data collected included demographic characteristics of the patients, burn etiology, location of burn, degree of burn, and hospitalization duration. the study included 713 cases, with the majority (41.37%) in the 0-17 age group. mortality increased with age, and housewives had the highest mortality rate (54.91%). urban residents had a higher mortality rate (40.81%) than rural residents (28.80%). winter and spring had higher rates of burn patients (31.84% and 29.17%). most burns occurred at home (90.88%), with flame (70.97%) and scald (25.11%) as the primary causes. hospitalizations were mostly 1-14 days (83.73%), and second and third-degree burns were common (47.27% and 50.07%). about 75.74% of patients suffered upper limb injuries. in 2023, there was a slightly higher burn rate (16.27%) compared to previous years. burns were most frequently suffered by children, particularly during winter and spring at home. the primary causes were flame and scald injuries. females were more prone to flame injuries, while males experienced a higher incidence of scald injuries. among the affected groups, housewives had the highest mortality rate, and this elevated risk was linked to their advancing age. introduction globally, burns are devastating traumas that affect a victim’s quality of life, emotional well-being, and ability to support their family and community.1 worldwide, burn injuries are one of the leading causes of death, and over 95% of fire-related burns occur, causing more than 120,000 deaths annually, particularly in lowand middle-income countries.2 this is perhaps due to burn injuries, which are usually associated with different types of complications such as infections, toxic shock syndrome, pulmonary complications, cardiac complications, electrolyte imbalance, and eventually multiple organ failure.3 undoubtedly, the costs of managing burns are high and impose remarkable economic and social consequences.4,5 burn mortality remains high, particularly in underdeveloped nations, despite advancements in clinical therapies such as aggressive surgery, early enteral feeding, and fluid resuscitation.6 despite a lack of epidemiological studies, according to reports, burn injuries rank second in iraq’s emergency room visits, after gunfire. this is because of using domestic appliances, inflammable agents at home, and clothing burns. even though the majority of these injuries are avoidable.7 moreover, published data on the extent of burn injuries and their epidemiology in the kurdistan region (north of iraq) are scarce, and there is not enough data to direct and carry out efficient preventive measures against burns.8,9 therefore, investigating the epidemiologic and correspondence: zuhair rushdi mustafa, fundamental and adult nursing unit, college of nursing, university of duhok, duhok, iraqi kurdistan, iraq. tel.: +964.7504729354. e-mail: zuhairmustafs@gmail.com key words: burns, epidemiology, mortality, outcome, wounds, injuries. funding: none. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of duhok general directorate of health approved this study (reference number 26072023-6-5). the study conforms with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: this study was conducted retrospectively, therefore, the written consents were not taken for the study purpose. instead, the administrative consent of the hospital was obtained in this study. patient consent for publication: this study was performed retrospectively, therefore, it was not possible to obtain the patient consent for publication. we obtained the required information from the medical records of the patients. in this regard, we obtained the consent of the hospital for data collection and publication. availability of data and materials: the data of the study are available for the justified reasons. acknowledgments: the authors would like to thank the archive unit of the duhok burn and plastic surgery hospital for their kind contributions to data collection. received: 13 december 2023. accepted: 12 january 2024. early access: 8 february 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12187 doi:10.4081/hls.2024.12187 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 276] [healthcare in low-resource settings 2024;12:12187] non -co mmerc ial us e o nly clinical characteristics and outcomes of burn patients is crucial to creating a consistent collection of national burn data, as well as to better understand the issue and develop preventive measures. therefore, we aimed to explore the epidemiologic and clinical characteristics and outcomes of burn patients for one decade in the kurdistan region. materials and methods research design in this retrospective cross-sectional study, patients who were either admitted or not admitted to duhok burn and plastic surgery hospital were eligible for inclusion. accordingly, the medical records of patients treated at the hospital were screened for this purpose. the necessary characteristics for this study were extracted from the medical records of the patients. population, setting, and sampling the patients included in this study were from duhok burn and plastic surgery hospital located in duhok city. this hospital is the sole facility for the diagnosis and management of burn injuries and plastic surgeries in duhok governorate. consequently, all burn patients from across duhok governorate seek treatment at this facility for their injuries. the patients included in this study attended the facility between 2014 and 2023. the hospital was established in 2008. however, medical records from the years 2008 to 2013 were no longer available in the hospital’s archives, except for names, outcomes, and a few pieces of information. therefore, we opted to include medical records from the decade spanning 2014 to 2023. nonetheless, due to the high population, it was not feasible to include all patients in this study. consequently, we decided to sample a fraction of the population. sampling technique we employed a systematic technique for sampling in this study. the required sample size for a large population, based on the cochran formula, is 385. since we utilized a non-random approach, we aimed to incorporate more cases in this study to account for missing information and the sampling technique. we resolved to include one case from every five medical records stored in the archive unit of the hospital. if the fifth case had excessive missing information or was empty for an unknown reason, the sixth case was included in the study. ultimately, we included 717 cases were selected in this study. out of 717 cases, four cases had too many missing information, therefore, we included 713 cases in the final analysis. the syrian refugees and internally displaced persons were not included in this study as they did not give us a clear picture of the socio-demographic and cultural perspectives of duhok governorate. study measures the following information was gathered from the medical records of the burn patients: age, gender, employment status, education level, residency status, marital status, reason of burn injuries, location of the burn incident, etiology of the burn, duration of hospitalization, degree of burn, sites of injury, and outcome. the patients who had two degrees of burn were located in the higher burn degree. the patients who had first and second, second and third, and third and fourth were located in the second, third, and fourth degrees, respectively. statistical analyses the prevalence of burn-related information such as site and etiology of burn and outcome of the disease was identified in number and percentage. the association of the etiology of the burn and demographic characteristics and burn seasons was examined in a pearson chi-squared test. the mortality rates of burn injuries over a time period were examined in number and percentage and its associated factors were examined in a pearson chi-squared test. the statistical calculations were performed using jmp pro 14.3.0. (jmp®, version 14.3.0. sas institute inc., cary, nc, 1989–2023). ethical considerations the ethical and administrative approval was taken from the duhok general directorate of health and duhok burn and plastic surgery hospital. the protocol of this study was registered in 26 july 2023 as reference number 26072023-6-5. the confidentiality of the personal information of the patients was protected and not included in the collection data file. results the burn patients admitted to the burn hospital in duhok governorate between 2014 and 2023 were predominantly children aged 0-5 years old (24.54%) and middle-aged individuals (18-59 years old: 55.82%). the majority of patients fell into the age group of 0-17 years old (41.37%), followed by unemployed individuals (22.44%). the patients comprised both males and females from various geographic areas. they ranged from preschoolers to high school students, with diverse marital statuses, and 3.46% were pregnant. the study revealed a significant increase in the mortality rate with advancing age. housewives exhibited the highest mortality rate (54.91%), followed by unemployed patients (33.75%), females (44.39%), singles (45.45%), and married patients (41.99%), compared to children (25.42%), illiterate individuals (45.05%), and high school graduates (40.0%) compared to preschoolers and those under high school. additionally, urban residents showed a higher mortality rate (40.81%) compared to their rural counterparts (28.80%; p<0.0001; see table 1). the study revealed that winter and spring had higher percentages of burn patients (31.84% and 29.17%, respectively) compared to summer (19.35%) and autumn (19.64%). the majority of burn injuries occurred at home (90.88%), followed by work (8.70%). flame (70.97%) and scald (25.11%) were the most prevalent causes of burns, while a small percentage resulted from chemical materials (1.54%), electricity (1.26%), or explosions (1.12%). most patients were hospitalized for a duration of 1 to 14 days (83.73%), and the majority had second and third-degree burns (47.27% and 50.07%, respectively). about 23.84% of patients experienced burn injuries covering their entire bodies. additionally, 52.03% had burns on the head and neck, 62.69% on the trunk, 75.74% on the upper limbs, and 67.74% on the lower limbs. in 2023, there was a slightly higher burn rate (16.27%) compared to other years (table 2). mortality rates did not show significant differences based on the season and location of the burn. patients burned by flame exhibited a significantly higher mortality rate (42.89%), especially those with shorter hospital stays. mortality rates increased with the severity of burn degrees. patients with burns covering the entire body (92.35%), head and neck (56.60%), or trunk (52.57%) were more likely to die compared to those with burns on the upper and lower limbs. patients admitted in 2020 had the highest mortality rate (65.91%), followed by 2017 (46.06%), 2016 (41.38%), 2014 article [healthcare in low-resource settings 2024;12:12187] [page 277] non -co mmerc ial us e o nly (42.86%), and 2015 (40.00%; see table 2, figure 1). the study revealed that flame injuries were more common among females (79.30%) and males (60.26%), whereas scald injuries were more prevalent in males (31.73%) compared to females (19.95%; p<0.0001). the etiology of burns did not differ based on the season of occurrence and the residency of patients. the findings indicated that flame injuries were more common in adults (88.94%), while scald injuries were predominant in children (62.14%; p<0.0001). third and fourth-degree burns were more likely to be associated with flame and scald injuries across all sites (table 3). the study showed that most of the patients had tbsa of 1019% (22%) followed by 20-29% (17%), and 90-100 (15%) as shown in figure 2. the adult patients, females, and those who were burnt by flame, and died had higher tbsa as shown in table 4. discussion a glance at the present data shows that the majority of patients who fell into the preschool and high school age groups occurred at home in the winter and spring and were mostly caused by flames and scalds. flame injuries were more common among females and males, whereas scald injuries were more prevalent in males. housewives exhibited the highest mortality rate and a higher mortality rate was associated with advancing age. age and gender this study showed that the majority of patients were children under the age of 5. this may be because children receive less attention from their parents as they grow up; furthermore, they do not have adequate self-protection abilities.10 in the majority of studies, an overall predominance of children among burn injuries has been observed.10,11 a systematic review revealed that nearly half of the population with severe burn injuries are children.12 in this study, women, especially housewives, exhibited the highest burn injuries and mortality rates. these results are contrary to what has been documented in the literature. a systematic review of 76 studies and more than 186,500 patients by brusselaers et al.12 found in most studies, an overall male predominance among burn injuries, because these injuries in adults are often work-related. it could be argued that almost all included studies were conducted in europe; hence, the situation might differ in lowand middle-income countries. a study by peck et al.13 investigated the source of burn injuries in lowand middle-income countries. they found that the article [page 278] [healthcare in low-resource settings 2024;12:12187] table 1. general characteristics of burn patients in duhok governorate between 2014 and 2023. general characteristics (n=713) statistics outcomes no (%) no (%) dead recovered with recovered with p disability minor effects 253 (35.48%) 44 (6.17%) 416 (58.35%) age groups <0.0001 0-5 175 (24.54) 34 (19.43) 3 (1.71) 138 (78.86) 6-14 68 (9.54) 13 (19.12) 2 (2.94) 53 (77.94) 15-17 52 (7.29) 28 (53.85) 1 (1.92) 23 (44.23) 18-29 229 (32.12) 106 (46.29) 21 (9.17) 102 (44.54) 30-59 169 (23.70) 58 (34.32) 17 (10.06) 94 (55.62) 60 and over 20 (2.81) 14 (70.00) 0 (0.00) 6 (30.00) employment <0.0001 child 295 (41.37) 75 (25.42) 6 (2.03) 214 (72.54) unemployed 160 (22.44) 54 (33.75) 13 (8.13) 93 (58.13) housewife 173 (24.26) 95 (54.91) 15 (8.67) 63 (36.42) employee 21 (2.95) 5 (23.81) 4 (19.05) 12 (57.14) free busyness 64 (8.98) 24 (37.50) 6 (9.38) 34 (53.13) gender <0.0001 male 312 (43.76) 75 (24.04) 17 (5.45) 220 (70.51) female 401 (56.24) 178 (44.39) 27 (6.73) 196 (48.88) pregnancy 0.9386 no 223 (96.54) 112 (50.22) 20 (8.97) 91 (40.81) pregnant 8 (3.46) 4 (50.00) 1 (12.50) 3 (37.50) marital status <0.0001 child 295 (41.37) 75 (25.42) 6 (2.03) 214 (72.54) single 55 (7.71) 25 (45.45) 4 (7.27) 26 (47.27) divorced/separated 1 (0.14) 1 (100) 0 (0.00) 0 (0.00) married 362 (50.77) 152 (41.99) 34 (9.39) 176 (48.62) education <0.0001 preschooler 175 (24.54) 34 (19.43) 3 (1.71) 138 (78.86) illiterate 364 (51.05) 164 (45.05) 31 (8.52) 169 (46.43) under-high school 144 (20.20) 43 (29.86) 8 (5.56) 93 (64.58) high school 30 (4.21) 12 (40.00) 2 (6.67) 16 (53.33) residency 0.0008 rural 316 (44.32) 91 (28.80) 16 (5.06) 209 (66.14) urban 397 (55.68) 162 (40.81) 28 (7.05) 207 (52.14) chi-squared test was performed for statistical analyses. non -co mmerc ial us e o nly majority of the patients were adult women, as they use non-electric domestic appliances, mainly kerosene, for cooking, lighting, heating, or all three. on the contrary, although iran is a neighboring country of the kurdistan region, most studies showed that the highest percentage of burns occurred in men; women are more likely to burn at home and in the kitchen, while men are more likely to be burned in the workplace, despite a high mortality rate among women.14-16 similarly, a saudi arabian systematic review found that in terms of burn injuries, men outweighed women.17 this could be because data about the prevalence of occupational burn injuries varies significantly between nations; here, for example, we believe that a lack of occupational hazards might be related to shortages in factories and industry in the kurdistan region. season of injury and location of burn the present study revealed that winter and spring had higher percentages of burn patients compared to summer and autumn. the majority of burn injuries occurred at home, followed by work. flame and scald were the most prevalent causes of burns. kurdistan region has a cold winter climate, and the main heat article table 2. burn related information of burn patients in duhok governorate during 2014-2023. burn-related information (n=713) statistics outcomes no (%) no (%) dead recovered with recovered with p disability minor effects 253 (35.48%) 44 (6.17%) 416 (58.35%) season 0.6508 spring 208 (29.17) 81 (38.94) 11 (5.29) 116 (55.77) summer 138 (19.35) 47 (34.06) 12 (8.70) 79 (57.25) autumn 140 (19.64) 51 (36.43) 9 (6.43) 80 (57.14) winter 227 (31.84) 74 (32.60) 12 (5.29) 141 (62.11) location of burn 0.6274 home 648 (90.88) 229 (35.34) 40 (6.17) 379 (58.49) industry 2 (0.28) 2 (100) 0 (0.00) 0 (0.00) public building 1 (0.14) 0 (0.00) 0 (0.00) 1 (100) work 62 (8.70) 22 (35.48) 4 (6.45) 36 (58.06) etiology of burn <0.0001 chemical 11 (1.54) 2 (18.18) 0 (0.00) 9 (81.82) electricity 9 (1.26) 3 (33.33) 2 (22.22) 4 (44.44) explosion 8 (1.12) 3 (37.50) 1 (12.50) 4 (50.00) flame 506 (70.97) 217 (42.89) 36 (7.11) 253 (50.00) scald 179 (25.11) 28 (15.64) 5 (2.79) 146 (81.56) hospitalization (days) <0.0001 1-3 234 (32.82) 93 (39.74) 6 (2.56) 135 (57.69) 4-7 216 (30.29) 98 (45.37) 7 (3.24) 111 (51.39) 8-14 147 (20.62) 36 (24.49) 7 (4.76) 104 (70.75) 15-21 54 (7.57) 12 (22.22) 5 (9.26) 37 (68.52) 22-29 17 (2.38) 5 (29.41) 1 (5.88) 11 (64.71) 30 and longer 45 (6.31) 9 (20.00) 18 (40.00) 18 (40.00) degree category <0.0001 first 4 (0.56) 0 (0.00) 0 (0.00) 4 (100) second 337 (47.27) 40 (11.87) 8 (2.37) 289 (85.76) third 357 (50.07) 199 (55.74) 35 (9.80) 123 (34.45) fourth 15 (2.10) 14 (93.33) 1 (6.67) 0 (0.00) body location all body 170 (23.84) 157 (92.35) 10 (5.88) 3 (1.76) <0.0001 head & neck 371 (52.03) 210 (56.60) 26 (7.01) 135 (36.39) <0.0001 trunk 447 (62.69) 235 (52.57) 28 (6.26) 184 (41.16) <0.0001 upper limbs 540 (75.74) 236 (43.70) 37 (6.85) 267 (49.44) <0.0001 lower limbs 483 (67.74) 228 (47.20) 32 (6.63) 223 (46.17) <0.0001 year <0.0001 2014 77 (10.80) 33 (42.86) 8 (10.39) 36 (46.75) 2015 55 (7.71) 22 (40.00) 0 (0.00) 33 (60.00) 2016 58 (8.13) 24 (41.38) 5 (8.62) 29 (50.00) 2017 89 (12.48) 41 (46.07) 6 (6.74) 42 (47.19) 2018 83 (11.64) 31 (37.35) 0 (0.00) 52 (62.65) 2019 75 (10.52) 28 (37.33) 1 (1.33) 46 (61.33) 2020 44 (6.17) 29 (65.91) 2 (4.55) 13 (29.55) 2021 45 (6.31) 4 (8.89) 6 (13.33) 35 (77.78) 2022 71 (9.96) 18 (25.35) 9 (12.68) 44 (61.97) 2023 116 (16.27) 23 (19.83) 7 (6.03) 86 (74.14) chi-squared test was performed for statistical analyses. [healthcare in low-resource settings 2024;12:12187] [page 279] non -co mmerc ial us e o nly article [page 280] [healthcare in low-resource settings 2024;12:12187] table 3. etiology of burn by season in burn patients in duhok governorate (kurdistan region) between 2014 and 2023. etiology of burn chemical (n=11) electricity (n=9) explosion (n=8) flame (n=506) scald (n=179) p gender <0.0001 male 8 (2.56) 9 (2.88) 8 (2.56) 188 (60.26) 99 (31.73) female 3 (0.75) 0 (0.00) 0 (0.00) 318 (79.30) 80 (19.95) season 0.2448 autumn 2 (1.43) 2 (1.43) 1 (0.71) 101 (72.14) 34 (24.29) spring 7 (3.37) 2 (0.96) 3 (1.44) 152 (73.08) 44 (21.15) summer 1 (0.72) 4 (2.90) 2 (1.45) 91 (65.94) 40 (28.99) winter 1 (0.44) 1 (0.44) 2 (0.88) 162 (71.37) 61 (26.87) age group <0.0001 0-14 yr 3 (1.23) 1 (0.41) 0 (0.00) 88 (36.21) 151 (62.14) 15 yr or older 8 (1.70) 8 (1.70) 8 (1.70) 418 (88.94) 28 (5.96) residency 0.1195 rural 8 (2.53) 4 (1.27) 1 (0.32) 220 (69.62) 83 (26.27) urban 3 (0.76) 5 (1.26) 7 (1.76) 286 (72.04) 96 (24.18) burn degree <0.0001 first 0 (0.00) 1 (25.00) 0 (0.00) 2 (50.00) 1 (25.00) second 9 (2.67) 3 (0.89) 4 (1.19) 196 (58.16) 125 (37.09) third 1 (0.28) 5 (1.40) 2 (0.56) 296 (82.91) 53 (14.85) fourth 1 (6.67) 0 (0.00) 2 (13.33) 12 (80.00) 0 (0.00) body location all body 0 (0.00) 2 (1.18) 1 (0.59) 155 (91.18) 12 (7.06) <0.0001 head & neck 8 (2.16) 5 (1.35) 6 (1.62) 308 (83.02) 44 (11.86) <0.0001 trunk 3 (0.67) 2 (0.45) 3 (0.67) 351 (78.52) 88 (19.69) <0.0001 upper limbs 7 (1.30) 7 (1.30) 6 (1.11) 420 (77.78) 100 (18.52) <0.0001 lower limbs 8 (1.66) 4 (0.83) 5 (1.04) 356 (73.71) 110 (22.77) 0.1216 chi-squared test was performed for statistical analyses. figure 1. mortality rate of patients over time, season, etiology of burn, and burn degree. non -co mmerc ial us e o nly sources in this area are flammable fuels and electric heating. in addition, cooking at home with a gas cylinder is a common accidental indoor cause of burns among residents in daily life. these results are consistent with studies conducted in china, in which most cases of burns were flame burns and occurred in the winter.10,18,19 the length of hospitalization most of the patients in this study were typically kept in hospitals until their wounds had nearly healed. the majority of patients were hospitalized for a duration of 1 to 14 days. while the mean duration of hospitalization worldwide is between 7 and 33 days.12 in this study was shorter because of the high mortality rate. a similar study10 stated that the declining trend of the mean length of hospitalization was linked to increasing age and total body surface area (tbsa), which led to increased mortality. degree of burns and burn size the majority of patients had second and third-degree burns, and nearly one-third of patients experienced burn injuries covering their entire bodies. this might be a strong reason for the high mortality rate among patients. a study conducted in iraq showed that nearly two-thirds of patients died as a complication of second-and third-degree burns.7 according to the literature, deaths from burns are 7 to 11 times higher in low-income countries than in highincome countries.20 in our opinion, this is a serious issue that has to be carefully considered to decrease the mortality rate among burn survivors. it has been reported that large-area burns mainly occur in working-age adults,10 in this study, most of the patients had a tbsa of 22%, and burns mostly occurred at home due to the daily use of flammable materials such as liquefied petroleum gas. these results are consistent with the study of lami and al naser7 conducted in iraq, in which two-thirds of the burn patients had 20% tbsa. burns of less than 20% of tbsa may not represent a large proportion of severe burns.10 on the other hand, it has been stated that a burn injury involving more than 20% of the tbsa might result in hypermetabolic, inflammatory, and stress reactions that are in some aspects as profound as in patients with over 40% tbsa burns.21 this might correlate with a high mortality rate, despite the low involvement of tbsa. burn sites and etiology data from 2023 records showed a slightly higher burn rate compared to other years. the majority of patients experienced burn injuries on the trunk, upper limbs, lower limbs, head, and neck, respectively. a possible explanation for that is that when individuals suddenly face burns, they may subconsciously protect the important parts of their body, such as their heads. moreover, burn injuries to the extremities are paramount and should be taken into consideration. this is because they can lead to not only deformities and cicatrix but also functional losses, which decrease the quality of life for the patients.22,23 nearly one-quarter of patients experienced burn injuries covering their entire bodies. since the majority of them had burns on the trunk and upper limbs, this might explain the high mortality rate among patients. these findings are comparable with the findings of a study done in sulaymaniyah province, iraq,9 and a study in china.10 contrary to previously reported epidemiologic findings, this study showed that flame burns, rather than scald burns, were the most common cause of burn injuries.10 however, findings from the current study are inconsistent with those conducted in saudi arabia, china, iran, and turkey, where scalding was the most frequent etiology of all burns.15,17,24,25 the flame injuries in our study were more common among females, whereas scald injuries were more prevalent in males. scald injuries, on the other hand, were predominant in children. our findings are comparable with the published studies in which the majority of burn injuries were in the under-fives and were scalds.26,27 it is estimated that scald burns in pediatric populations account for 81% of all burns that need hospitalization. burning by boiling water, accidental spillage, or falling into hot gravy is more likely to occur in young children.10,28 this could be because, as children grow up, parents give them less attention, and they also lack self-protection abilities. it should not be forgotten that in the kurdistan region, there are still thousands of families living in camps and tents as refugees and displaced. they suffer from a lack of safety measures concerning fire accidents, including scaled injuries. many of these families use kerosene for cooking and boiling water, which may create a great risk of scale injuries among children. thus, to lower the number of scalds, education and home article table 4. tbsa by age, gender, etiology of burn, and outcomes. burn (%) median interquartile range p age group <0.001 0-14 yr. 15 20 15 yr. or older 40 65 gender <0.001 male 20 26 female 40 65 etiology of burn <0.001 chemical 35 30 electricity 25 64 explosion 22.5 77.75 flame 40 60 scald 15 15 outcome <0.001 recovered with minor effects17.5 15 recovered with disability 42.5 35 dead 85 40 wilcoxon / kruskal-wallis tests (rank sums) was performed for statistical analyses. figure 2. distribution of tbsa in burn patients in duhok governorate between 2014 and 2023 (the values are in number, percentage. the bars are std. errors). [healthcare in low-resource settings 2024;12:12187] [page 281] non -co mmerc ial us e o nly safety checks, along with thermometers or thermostatic mixing valves, should be promoted to reduce tap water scalds.29 mortality the mortality rate was closely related to the tbsa, severity of burn degrees, advancing in age, and burning by flame. patients with burns covering the entire body were more likely to die especially those with shorter hospital stays. these findings are consistent with other published epidemiological studies. they demonstrated that advancing in age, increasing tbsa, and flame burns are the major risk factors for mortality among burn patients.10,12,3032 moreover, our findings were also consistent with the literature, in which the mortality rate is high among high-risk groups, including the elderly and females. the age-related declines in motor function, cognitive function, and judgment make the elderly more vulnerable to burns. in the present study, female patients who were burned by flame and died had a higher tbsa. due to the lacunae in the data, it was difficult to obtain the true cause of flame injuries among females because patients’ relatives usually conceal and provide misleading information under the term ashamed of society; nevertheless, we believe that it might be related to self-immolation. many studies have been published on this concern and found that self-inflicted burns were noted, especially among young women. although this type of burn is rare in developed countries,33 conversely is common among women of iraqi kurdistan.34 this may be due to many factors, such as social pressures and social interactions in their own right.35 moreover, it has been reported that numerous kurdish women and girls resort to different methods of suicide, primarily self-immolation, as a means of escaping the discrimination they face due to their gender, social status, or tribe.34 therefore, women who have made suicide attempts should be given special interventions and support by providing them with educational programs about the harmful nature of burns. in this study, we found that patients admitted in 2020 had the highest mortality rate of burn injuries compared to other years of the last decade. this might be related to staying at home during the covid-19 pandemic, which increases indoor accidents. these results are similar to those of several studies conducted in this regard.36,37 overall, burn injuries are critical and fatal; they impose a burden not only on the government but also on families. surprisingly, while we were writing this piece of work, a big fire broke out in a building in one of the cities of the kurdistan region, killing 14 people by suffocation and wounding five others. this was a result of a lack of safety regulations for burning, including a lack of a fire extinguisher bottle and a lock on the door of the fire exit.38 thus, every effort should be made in collaboration with the community to adopt preventive measures. furthermore, providing public education related to the prevention of burn injuries is crucial to minimizing the risk of burns and their consequences. to the best of our knowledge, this study is one of the more recent epidemiologic studies to study the characteristics of burn injuries in the kurdistan region. however, the findings of the study were obtained from a single institution; accordingly, the generalization of the findings should be considered with caution. conclusions the study aimed to update information on burns in the kurdistan region, focusing on epidemiological and clinical aspects. key findings include a higher incidence of burns in children, with most incidents happening at home during winter and spring, caused mainly by flame and scald. females were more prone to flame injuries, while males experienced more scald injuries. housewives had the highest mortality rate, and advancing age was linked to increased mortality. references 1. kornhaber r, childs c, cleary 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souza ferreira lp, da silva ra, et al. brazil covid-19: change of hospitalizations and deaths due to burn injury? burns 2021;47:499. 38. rudaw.net. at least 14 dead in soran fire. 2023. article [healthcare in low-resource settings 2024;12:12187] [page 283] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12347 pharmaceutical care of premedical and first aid in case of injuries: impact of biological and nuclear weapons and radiation exposure from military destruction of nuclear power plants oleksandr tkachenko,1 volodymyr bulda,2 nataliia makarova,3 larysa filippova,3 olena barabanchyk2 1department of clinical pharmacology and clinical pharmacy, bogomolets national medical university, kyiv; 2educational and scientific center “institute of biology and medicine”, taras shevchenko national university of kyiv; 3medical biochemistry and molecular biology, bogomolets national medical university, kyiv, ukraine abstract the relevance of the topic is due to the increased risk of radiation hazards on the territory of ukraine caused by the frequent shelling of nuclear power plants in the zaporizhzhya region. this research work aims to calculate the percentage of the population that is sufficiently aware of the issues in providing medical care for radiation and other injuries. during the scientific research, the authors used analytical, statistical, and diagnostic methods to study information on radiation hazards and define the specifics and consequences of the use of various types of biological weapons. the main results achieved within the framework of this scientific study would be a clear justification and assessment of the radiation hazards for ukrainians and a determination of the feasibility and indications for the use of certain medicines. the results obtained and the conclusions formulated on their basis are of practical importance for the military, territorial defence fighters, students of medical universities, sanitary workers, police officers, teachers, drivers, and civilians. introduction the need to study the issues of providing premedical and first aid in cases of injuries caused by biological or nuclear weapons arose due to the increase in the level of radiation hazards in ukraine. it resulted from frequent shelling of the zaporizhzhya nuclear power plant (npp) as well as a low level of awareness among the civilian population about providing quality assistance to victims. the study of radiation safety issues has been undergoing research by various authors for a long time, since the topic of radiation damage has been relevant in ukraine and europe since the chornobyl disaster on april 26, 1986. most of the previous studies tried to weigh the risks of radiation or bacteriological hazards and the probability of certain consequences, as well as create recommendations against the risk of explosion. the problem of past studies was the lack of consideration of the issues related to the provision of first aid with certain pharmacological drugs, as well as the absence of a basic algorithm of action to help victims. according to r. peel,1 the risk of violation of radiation safety standards has increased significantly due to the constant shelling of the zaporizhzhya npp. in the event of an accident at this npp, not only ukrainians but also residents of other countries will be under threat, since the spread of radiation particles fully depends on the direction and strength of the wind. because of the high risk of radiation hazards, the people of ukraine should learn a clear set of steps for what to do in the event of radiation exposure and how to give first aid. following these simple rules could greatly reduce the number of victims and prevent major problems. according to a study by a. dehghani,2 approximately 45% of the civilian population believes that only the use of personal respiratory protection equipment will be effective in cases of radiation exposure, as well as staying in a safe and maximally closed place with no direct connection to contaminated air. according to suksompong and khamtuikrua,3 the authorities and the world health organisation (who) should convey the importance of first aid provision to ordinary citizens. some authors, such as roffey et al.4 recognise that awareness of the use of biological weaponry is low, as about half of the civilian population does not even know how biological weapons are used. however, j.p. dudley5 notes that the main problem now is the ignorance of the basic algorithm of actions for the provision of premedical care and the refusal to use medicines in the event of a nuclear or bacteriological threat. it should be noted that if an accicorrespondence: oleksandr tkachenko, department of clinical pharmacology and clinical pharmacy, bogomolets national medical university, 01601, 13 taras shevchenko blvd., kyiv, ukraine. e-mail: oltkachenko14@gmail.com key words: emergency care, radiation sickness, medical care, civilian population, health. contributions: all the authors made a substantive intellectual contribution. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data and materials: the data supporting the findings of this study are available on request from the corresponding author. received: 1 february 2024. accepted: 5 march 2024. early view: 28 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12347 doi:10.4081/hls.2024.12347 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12347] [page 25] non -co mmerc ial us e o nly dent occurs at the npp, the number of victims on the territory of ukraine might be very high. in this regard, the purpose of this study is to analyse the problems currently faced by health services as well as formulate recommendations and certain hypotheses for their resolution. this study is to identify the percentage of the civilian population of ukraine who are not aware of the issues of providing premedical and first aid and to assess the level of public interaction. the authors described the feasibility of using certain medicines that will help reduce the number of victims from potential accidents or the impact of nuclear or bacteriological weapons. in addition, the authors formulated a basic algorithm for first aid actions and provided victims with designated drugs that will help to improve their well-being and prevent the development of acute conditions. the authors elaborated on recommendations aimed at raising awareness of the stated issues among the civilian population of ukraine. materials and methods during the study, the authors qualitatively combined various research methods, including statistical, analytical, and some theoretical methods (data analysis, explanation, generalisation, and method of analogies). with the help of these research methods, it was possible to identify the core issues of the declared topics and to analyse all possible risks and consequences in the case of the use of biological or nuclear weapons on the territory of ukraine. this allowed the formulation of certain statements and hypotheses that will contribute to improving the level of knowledge and skills of the civilian population in providing quality premedical and first aid for the declared types of injuries. the statistical method helped identify the percentage of ukrainian civilians able to provide proper assistance in cases of radiation or biological weapons exposure. the analytical method of the research involved studying previous studies and observations of military and/or medical personnel on nuclear and biological hazards, as well as providing victims with the necessary assistance. the use of theoretical research methods helped to study the material more thoroughly, substantiate certain opinions on the issues presented, and formulate clear conclusions from this study. this study was carried out in several main stages. the first stage implied the search and detailed study of literature and other information materials containing issues related to the provision of premedical or first aid to victims of biological or nuclear weapons. the authors studied the specifics of the use of the declared types of weapons, their danger, and the possibilities of protecting the civilian population by applying certain safety measures and taking medicines that will have a protective pharmacological effect on the human body. in addition, the authors clarified the relevance of the topic, outlined the main problems and purpose of the study, and defined the main tasks. in the second stage of the study, the authors compared the analysed information with the current military situation in ukraine. the authors also came up with a clear basic plan for what to do for first aid in case biological or nuclear weapons were used. they also looked at how useful it would be to use certain medicines, whose pharmacological effects should protect the body from the harmful effects of radiation or biological weapons. the third stage of the study included the formulation of recommendations that will contribute to improving the level of knowledge and practical skills in providing quality premedical and first aid to victims among the civilian population of ukraine. in addition, the main results and logical conclusions of the study are presented, as well as their comparison with the findings of previous research on this topic. the previous studies of ukrainian, american, norwegian, german, and other scientists and authors contributed to addressing the stated issues. the authors would like to note that the results presented in this study could serve as a fundamental theoretical basis for further research. results currently, nuclear, biological, and chemical weapons are recognised as the most dangerous among weapons of mass destruction.6 in the study, the authors covered only biological and nuclear weapons. the biological weapons include various types of microorganisms, including viruses, bacteria, and fungi. the spread of living microorganisms provokes serious illness or death in humans, animals, and plants. the use of this type of weapon is unlikely in modern warfare, but the civilian population should be aware of the issues in providing quality premedical or first aid against the use of various types of biological weapons. the main problem with the biological hazard is the complexity of its indication. eventually, it becomes difficult to ensure quality protection for the population and the military. however, it takes a lot of time to identify the agent and establish the fact that they are using bacteriological weapons (usually 12 hours or more), which requires the assistance of qualified personnel and high-quality laboratory equipment.7 in addition, the governing bodies should analyse the effectiveness of the protection systems applied in the infected area throughout the whole epidemic or threat of infection and improve preventive measures if necessary. it should be noted that currently ukraine and other european countries are poorly prepared against using biological weapons. according to boivin and piret,8 a large number of disease cases (typically the incidence rate is between 60% and 90%) and infection-related deaths are evidence of the use of bacteriological weapons. it also includes unusual symptoms of the disease, a high mortality rate in animals, and signs of an outbreak of several diseases at once. it should be noted that medical means of civilian protection imply the introduction of vaccines against the infectious agent (often the bacteriological hazards result in anthrax, plague, and smallpox). in addition, it is advisable to conduct chemoprophylaxis, administer passive antibody therapy, and take antimicrobial drugs. however, an obligatory aspect of preventing the spread of pathogenic particles from biological weapons is prevention. the primary prevention is about detecting the pathogenic agent, revealing the origin of biological weapons, and providing maximum protection to the population from damage. secondary prevention involves early detection and proper treatment of the disease. tertiary prevention has the objective of preventing deaths, the consequences of illness, and the disability of the population. the key stage is secondary prevention, as this step determines the impact of the use of bacteriological weapons on the population.9,10 the study by s. riedel11 shows that, currently, primary and secondary prevention is rather flawed. the author says that more research needs to be done to improve epidemiological surveillance and find quick diagnostic tools that can help with responding to the use of biological weapons. this will make the secondary prevention measures even more effective. the ignorance of basic algorithms of action in cases of radiation and bacteriological damage leads to a sharp increase in the social and political factors affecting public health [page 26] [healthcare in low-resource settings 2024;12(s2):12347] non -co mmerc ial us e o nly number of deaths and disabilities in the population due to the use of declared kinds of weapons.12-14 the survey by skidan and tkachenko,15 which was conducted in ukraine, was taken into account. the number of respondents was 338 citizens of ukraine, including 67.2% women and 32.8% men. in addition, the respondents fall into the following age categories: 20-25 years old: 3.1% of respondents; 25-35 years old: 70.9%; and 36-45 years old: 26%. the survey contained 11 questions, including an understanding of the “radiation” concept, awareness of the damaging factors of nuclear weapons and types of weapons of mass destruction, as well as knowledge of personal protective equipment by category. the following questions also included understanding the destructive impact of a nuclear explosion, comprehension of the expediency of using iodine tablets, the ability to decipher the abbreviation iacp11 (individual anti-chemical package), and taking action in the case of a mushroom-like cloud. the results of this survey showed that only 2-3% of ordinary civilians could answer the questions correctly. the percentage among other categories of the population is shop workers (3-4%), drivers (up to 5%), schoolchildren (1-2%), students of higher education institutions (2-3%), teachers of preschool institutions (5-7%), teachers of schools (6-8%) and teachers of higher education institutions (8-9%). the other categories are nurses – up to 12%, physicians – 15-20%, security guards – up to 13%, police officers – 14-15%, fighters of territorial defense – 12-13% and military – 18-23%. the results indicate a critically low level of awareness among the ukrainian population about the specifics of nuclear weaponry use, the risk of human damage, and the basic algorithm of action. however, medical workers and military and territorial defense soldiers are somewhat more competent in the stated issues. the analysis of the data indicates the urgent need for raising awareness among civilians against the use of nuclear and biological weapons, as well as providing first aid and self-help in cases of these types of injuries. in this regard, the authors have made recommendations to increase public awareness of the provision of premedical or first aid: i) carrying out information and educational activities on the stated issue; ii) conducting special activities by medical representatives aimed at raising the level of knowledge among participants on providing proper assistance to victims and self-help the program of such events should include simulations of certain situations (explosions, npp accidents, use of projectiles with hazardous biological components), during which participants will be able to work out an algorithm of actions to provide selfhelp as well as assistance to victims and others; iii) preparation and dissemination of special guides or methodological instructions, which will clearly describe actions to assist in specific situations against different types of weapons or projectiles; iv) introduction of the lectures and practical classes) according to the declared topics in the educational program of school students and students of higher educational institutions (medical and non-medical); v) conducting and broadcasting special reports in the media, which will address theoretical issues (including the use of drug therapy) and practical aspects of the application of basic algorithms for emergencies (in this case, radiation and bacteriological hazards). the implementation of the stated recommendations will contribute to a significant increase in the level of knowledge and skills in providing premedical and first aid for various types of injuries, which will significantly reduce the scale of consequences and the number of victims during military operations in ukraine. however, some researchers, for example, tekin and aslan,16 note that failure to provide first aid to victims of radiation or bacteriological injuries or render poor-quality service may come directly from fear of performing the wrong actions. according to the authors, about 78% of the civilian population would not use medicines because they were afraid of harming themselves or other people. there are organisations and institutions in ukraine that deal with radiation safety and radiation risk management. they work on monitoring the radiation situation, developing strategies to ensure public safety, and conducting research and educational activities on this topic. in table 1, the authors considered the leading ukrainian organisations in this field. radioprotectors are chemical drugs whose action is aimed at reducing damage due to ionising radiation by increasing radioresistance or reducing radiosensitivity of tissues and cells in the body.17 they are advisable to use in cases where there is a high risk of radiation damage. there are radioprotectors of short-term (the anti-radiation effect is observed from half an hour to 4 hours) and prolonged (effective from 1 to several days) action.18 some of the short-term radioprotectors are reducing agents (like cysteine, mercaptoethylamine, gammaphos, and others), antioxidants (like ascorbic acid, vitamin e, and tocopherol), and agents that cause tissues and cells to lose oxygen (like methemoglobin-forming agents, cyanides, and nitrites). 19-21 it should be noted that cystamine is a standard remedy that should be used 40-50 minutes before irradiation, but if the received dose is 1 gy or more, the injured person should take 6 tablets at a time; repeated intake of the drug is carried out during the next three days, 2-3 times a day, but no more than twelve tablets at a daily dose. long-acting drugs should include drugs with anabolic effects (estrogens) as well as polymers of polyanionic action (heparin, polysaccharides, polynucleotides, and nucleic acids). the most common is rtd-77, which suppresses the function of the thyroid gland and, at the same time, activates the internal secretory function of the adrenal glands. in addition, it inhibits the processes of post-radiation catabolism, increasing the repair of radiosensitive tissues. the dosage of the drug is 50 mg, and the efficacy is in radiation doses up to 6 gy. it should also be mentioned as b-190, which shows its instant effectiveness in radiation exposure, reducing the severity of radiation damage to 70-80%. it would be advisable to use it for npp employees since the effect of the drug would secure the personnel to perform all necessary actions, disable the necessary equipment, and prevent further release of radioactive particles, if possible. therefore, it would reduce the scope of the disaster and downscale the radiation impact on ukrainians and residents of other countries. the optimal dose of radioprotector is 3 tablets (0.45 mg). however, the code of civil protection of ukraine22 envisions only iodine prophylaxis aimed at preventing the ingestion of radioactive iodine. iodine prophylaxis involves the use of potassium iodide in cases of official notification of a radiation threat. the dose for people aged 13 to 40 is 125 mg. the drug’s intended use is 6 hours or less before radiation exposure. currently, not a single radioprotective drug is registered in ukraine, so this issue requires a more detailed study. in this regard, it would be advisable to introduce radioprotectors as an official means of protecting the population from radiation exposure. at the moment, though, the biggest problem is that people don’t know the basic steps that should be taken to provide pre-medical care in cases of reported injuries because they aren’t ready for radiation or bacterial hazards.23,24 because of this, the authors of the study managed to formulate a basic algorithm of action against the threat of nuclear and bacteriological weapons. the algorithm of actions for premedication aids in cases of radiation hazards: i) turn on official mass notification sources and listen carefully to the instructions of the authorities; ii) close windows and doors tightly, and turn off ventilation systems; iii) if the media reports an official warning about the threat of radiation hazards, it social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12347] [page 27] non -co mmerc ial us e o nly is advisable to take iodine prophylaxis (potassium iodide or iodine in a dosage of 20 drops for children or 44 drops for adults of 5% iodine solution per glass of water); iv) provide yourself with personal respiratory protection, which can be a respirator, a mask with a filter valve, a medical mask, or a cotton gauze bandage; v) in the event of a nuclear threat, it is very important to have a comprehensive first aid kit containing the necessary means to address various medical needs table 2 shows a list of essential components that should be in such a first-aid kit. it should be noted that some premedical or first aid courses do not consider the aspect of the use of medicines at all, and this fact may be a significant reason why people are afraid of using any medicines. previous researchers did not consider this fact, but it has a significant impact on the level of awareness and knowledge of the population. algorithm of actions for premedical aid in cases of bacteriological hazards: i) turn on the media and listen carefully to the instructions of the authorities; ii) leave the infected area if possible, stay in shelters or rooms with tightly closed windows and doors; iii) protect yourself with additional clothing, rubber gloves, and boots; iv) provide yourself with personal respiratory protection equipment if possible, wear protective goggles; v) collect a first aid kit, which should contain everything listed in paragraph v of the algorithm of actions for premedical assistance in case of a radiation hazard, as well as at least 3-5 interchangeable medical masks and personal protective equipment. also included are doxycycline hydrochloride (a broad-spectrum antibiotic), which is administered half an hour before entering the affected area, and antimicrobial drugs. in summary, the study delves into the pressing issues surrounding the potential use of biological and nuclear weapons, recognising their grave threat to humanity. the complexity of identifying and responding to biological hazards underscores the need for improved surveillance and diagnostic capabilities. furthermore, the alarming lack of awareness among the ukrainian population regarding the specifics of nuclear weaponry and appropriate response measures highlights a critical gap in public knowledge. recommendations to address this include educational campaigns, specialised training, and the integration of relevant topics into educational curricula. by adhering to these rules, it will be possible to prevent large-scale consequences as well as significantly reduce the number of victims from the possible use of declared weapons. discussion the study of literature on public knowledge in providing premedical or first aid in cases of radiation or bacteriological hazards helps us to state the fact that the ukrainian civilian population is almost unaware of the declared issues. in the course of the study, the authors found out that this fact pertains to ukrainians’ unpreparedness and ignorance regarding the nature of combat operations and the use of various types of weapons. in addition, even governing bodies are not able to convey the importance of awareness of the stated issues to citizens. therefore, it is necessary to implement the recommendations proposed in this study to have a considerable effect on the situation and conduct further research aimed at solving the problem. it should be given particular attention to the consideration of medical drug therapy in cases of nuclear hazards and at least ensure a clear understanding of the “radioprotector” concept. hayoun et al.25 note that doxycycline is a highly effective agent in the case of plague, which is advisable to use as prophylax social and political factors affecting public health table 1. organizations in ukraine dealing with radiation safety and risk management. organisation description g.m. doletsky state scientific and applied institute of nuclear energy engaged in research in nuclear power, radiation safety, and nuclear medicine. provides education and training for specialists. ukrainian state emergency service manages radiation emergencies and protects the public during radiation accidents. monitors radiation levels and conducts drills/exercises. national centre for radiation medicine specialises in medical radiology and radiation medicine. focuses on the diagnosis and treatment of radiation diseases and conducts research in this area. ukrainian association of environmentalists it comprises ecologists and environmentalists working on radiation ecology and assessing radiation's impact on the environment. table 2. nuclear threat first aid kit essentials. item purpose antiseptics clean and disinfect wounds alcohol disinfect equipment and surfaces sterile bandage dress wounds and prevent infections broad-spectrum antibiotics (augmentin 1000) treat bacterial infections nitroglycerin treat chest pain associated with heart conditions antiemetics (ondansetron, metoclopramide hydrochloride) reduce nausea and vomiting analgesics (nimesulide) relieve pain and inflammation antipyretic (paracetamol, ibuprofen) reduce fever and alleviate pain antidiarrheals (loperamide, bisoprolol) treat diarrhoea and related symptoms immunostimulants (methyluracil, decaris, dibazole) boost immune response potassium iodide or manganese solution water disinfection to prevent infections [page 28] [healthcare in low-resource settings 2024;12(s2):12347] non -co mmerc ial us e o nly is. however, ciprofloxacin, chloramphenicol, and cotrimoxazole can also be effective during preventive measures. the authors mention that the duration of prophylaxis should be 1-2 weeks, but the course of taking drugs against yersinia pestis and francisella tularensis is currently unknown. according to these claims, the health authorities should make sure they have enough of certain medicines and vaccines on hand to deal with bacterial threats. this will stop the disease from spreading and at least lessen the damage that could be caused by this kind of weapon.26-28 it should be noted that, currently, the most important problem in ukraine is the early identification of the pathogen, quick and accurate diagnosis, and the early creation of medical reserves (in the case of the potential use of bacteriological weapons). however, it should also evaluate the risk of microorganisms becoming resistant to antibiotics.29 in this case, who and the ministry of health should draw up certain protocols and regulations, as well as implement appropriate solutions that will determine the algorithm of action.30 zekioglu and parlar31 note that despite the simplicity of the list of necessary drugs, the medical staff of many countries, as well as the civilian population, are completely unaware of the issues of providing pharmacological assistance in the event of a bacteriological attack. the list contains only a few drugs, including doxycycline or quinolone for bacillus anthracis, streptomycin or gentamicin for tularemia and plague, and ciprofloxacin for anthrax. the dosage of drugs depends on the purpose (i.e., prophylaxis or treatment) and continues before or after contact with the pathogen for 7 to 60 days (we should note that taking drugs for 60 days is advisable only for anthrax). therefore, if the health authorities comply with all the above factors, it would be possible to report a sufficient level of awareness and reliability of protection for the population from the damaging effects of pathogenic agents in cases of biological hazards. the american authorities abandoned the use of biological weapons, and all arsenals of biological weapons were eliminated in 1973.11 despite this, they have thoroughly studied the mechanisms of action of the offensive biological weapons of various types and have never stopped developing vaccines and antiserums for their army and civilians. however, other opinions determine the importance of further research on the stated issues. currently, the main problem is the development of high-quality and safe radioprotective agents for use by people of all ages because of ambiguity or a lack of clear provisions on the use of radioprotectors or other protective means.32 the authors note that for the development of effective drugs, it is most necessary to study the toxicity of the active substance and its effect on internal organs, as well as to determine the minimum effective dose and the maximum permissible dose. the authors agree with these claims, but they would also look at other factors that would help them decide if the agent is safe to use and if it is right for certain groups of people, such as those with serious illnesses, liver or kidney failure, or digestive system diseases. these criteria should include the dosage form (capsule, tablet, or liquid), particle size, homogeneity, color, smell, and taste, solubility, release time from the body, and shelf life.33 in addition, the low level of public awareness and critical thinking about the consequences of radiation and bacteriological damage to animals is also a significant problem. in the use of bacteriological weapons, animals can generally be the only vectors of the disease, since pathogenic agents often produce effects that are particularly targeted at infecting animals. the plague is an example of the use of infectious agents on animals, followed by transmission to humans through the bites of infected fleas.34 it should be noted that unprotected animals could suffer serious consequences or even die in case of radiation exposure or become a danger to their owners (especially pets in private houses or cottage cooperatives, where animals walk freely outside). according to the international atomic energy agency, iodine prophylaxis has many consequences for pets, including anorexia, vomiting, diarrhoea, suffocation, cardiomyopathy, hyperthermia, cough, and weight loss.35 therefore, it would be advisable to take a closer look at this issue and make a decision on the most reliable and safest protection of animals from biological or nuclear damage. in this case, it will be possible to prevent the spread of diseases and reduce the level of radiation hazards for a large number of people. conclusions it was established that the urgency of the problem of protecting the civilian population from radiation and the effects of bacteriological weapons is due to the poor knowledge of citizens in the provision of premedical and first aid. it was determined that low awareness rates come from public ignorance about the criticality of the damage consequences as well as the fear of using medications. therefore, recommendations were made, which should serve as long-term indicators of public awareness, significantly increasing the number of people who understand the issues of assisting in cases of radiation hazards or the use of biological weapons. conducting awareness-raising activities and special events by healthcare professionals, introducing class hours or separate lessons in the curriculum dedicated to the issues of assistance to victims and self-help in various emergencies, creating and disseminating relevant guides, and broadcasting special reports on the discussion of the stated issues will significantly increase the awareness and consciousness of the population. the problems of medical protection for the population of ukraine in areas of increased radiation and bacteriological hazards are still relevant. during the writing of this research paper, the authors found that the issue of the use of radioprotectors needs to be clarified by the authorities and the who since there is currently no single solution or official regulation that would help the population freely use radioprotectors of different categories in cases of radiation hazards. in addition, the authors established that the issues of premedical and first aid require further study, as new hypotheses arise in the process of research and writing research papers that significantly affect the situation but have never been considered in previous studies. it would be advisable to conduct further research to identify effective methods for raising awareness among the civilian population that would contribute to the rapid achievement of results in the structure of raising the level of selfeducation of citizens. it would also help to identify additional issues and factors that affect the situation regarding the protection and pharmaceutical supply of the population in the event of radiation or bacteriological hazards. references 1. peel r. shelling of europe’s biggest power plant in europe. assessment of medical risks and the possibility of avoiding them. med sci ukraine 2022;18:1-9. 2. dehghani a. radiation safety awareness amongst staff and patients in the hospitals. int j occup environ health 2020;6:114-9. 3. suksompong s, khamtuikrua c. awareness about radiation hazards and knowledge about radiation protection among social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12347] [page 29] non -co mmerc ial us e o nly 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10. bland as. chemical, biological, radiological and nuclear (cbrn) casualty management principles. conflict catastrophe med 2013;13:747-70. 11. riedel s. biological warfare and bioterrorism: a historical review. bayl univ med cent proc 2014;27:400-6. 12. karadayi s, sezgin n, karadayi b. the level on information and awareness of healthcare workers on bioterrorism agents. turkey klinikleri j forensic med forensic sci 2019;16:45-53. 13. musicki s, vasovic d, markovic s. radiation hazards and radiation protection practices observed from different perspectives. 2017. available from: https://www.rad-proceedings. org/paper.php?id=123 14. voropai ks, tkachenko op. man-made catastrophe. accident at the nuclear power plant. radiation protection. bogomolets national medical university; kiev, ukraine; 2022. 15. skidan s, tkachenko op. first aid and self-help for nuclear damage. bogomolets national medical university; kiev, ukraine; 2022. 16. tekin e, aslan s. emergency and first aid in cases of the use of chemical, biological, radiation, and nuclear weapons. eurasian j emerg med 2016;15:90-93. 17. amro a, hamarsheh a. knowledge and awareness of radiation hazards among civilians. east mediterr health j 2019;23:57680. 18. frane n, bitterman a. radiation safety and protection. 2022. available from: https://www.ncbi.nlm.nih.gov/books/nb k557499/ 19. shirazi a, mihandoost e, mahdavi sr, mohseni m. radioprotective role of antioxidant agents. oncol rev 2012;6:17684. 20. tapbergenov so, zhetpisbaev ba, ilderbayev oz, et al. free radical oxidation in rats in the delayed period after combined exposure to dust and radiation. bull exp biol med 2013;154: 747-9. 21. ilderbayev o, zharmakhanova g, rakhyzhanova s, et al. immune system response after immobilization stress in the background of ionizing radiation. trends sci 2022;19:4637. 22. code of civil protection of ukraine. 2012. available from: https://zakon.rada.gov.ua/laws/show/5403-17#text 23. dzhansarayeva ry, dilbarkhanova zr, 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under long-term exposure to ionizing radiation. genetika 2001;37:1696-704. 29. postic sd. x-ray diffraction technique in the analysis of phases of hydroxylapatite and calcium phosphate in a human jaw. int j biomed 2014;4:109-13. 30. hryshchuk s, harlinska a, korneichuk n. evaluation of economic feasibility of cancer prevention by vaccination from papillomavirus infection in ukraine. rad conf proceed 2020;4:155-60. 31. zekioglu a, parlar s. investigation of awareness level concerning radiation safety among healthcare professionals who work in a radiation environment. j radiat res appl sci 2021;14:18. 32. arora r, chawla r, marwah r, et al. medical radiation countermeasures for nuclear and radiological emergencies: current status and future perspectives. j pharm bioallied sci 2019;12:202-12. 33. oshurko ap, oliinyk iyu. study of the qualitative characteristics of the maxilla bone tissue according to the quantitative content of macroelements (p, na, ca, mg, s) in the dynamics of prenatal ontogenesis. world med biol 2019;67:171-7. 34. dizman s, hodolli g, kadiri s, et al. radioactivity in kosovo honey samples. pol j environ stud 2020;29:1119-27. 35. radiation protection and safety in veterinary medicine. 2021. available from: https://www-pub.iaea.org/mtcd/ publications/pdf/pub1894_web.pdf. social and political factors affecting public health [page 30] [healthcare in low-resource settings 2024;12(s2):12347] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12616 application of foot massage therapy to reduce pain scale of elderly with rheumatoid arthritis nadi aprilyadi,1 rachmad aprilio,2 wulan martalina,1 zuraidah,1 wahyu dwi ari wibowo1 1nursing science program, politeknik kesehatan kemenkes palembang; 2master of nursing, andalas university, indonesia abstract rheumatoid arthritis (ra) is a chronic autoimmune disorder characterized by systemic inflammation, joint damage, and persistent pain, particularly in older adults. the debilitating nature of ra significantly impairs individuals’ quality of life, leading to diminished independence and increased reliance on pharmacological interventions. while pharmaceutical treatments play a crucial role in managing ra symptoms, complementary and alternative therapies, such as massage, have garnered attention for their potential to alleviate pain and improve overall well-being. this study adopts a descriptive approach to examine the efficacy of foot massage as an intervention for ra-related pain in older adults. two participants diagnosed with ra were selected for the case study. family nursing care principles were integrated into the intervention to provide holistic support. pain scale assessments were conducted before and after each foot massage session to measure changes in pain intensity. analysis of the data revealed a significant reduction in pain intensity among participants following the foot massage sessions. pain levels decreased from moderate to mild, indicating the efficacy of foot massage in alleviating ra-associated pain in older adults.the findings of this study support the notion that foot massage can serve as a viable intervention for managing ra-related pain in older adults. the mechanisms underlying the efficacy of foot massage, including its ability to stimulate vasodilation and enhance endorphin production, highlight its potential therapeutic benefits for individuals grappling with ra. foot massage emerges as a promising adjunctive therapy for alleviating pain and improving the well-being of older adults living with rheumatoid arthritis. integrating foot massage into holistic care approaches can enhance pain management strategies and contribute to the overall quality of life for individuals affected by this debilitating condition. further research is warranted to explore the long-term effects and optimal frequency of foot massage in ra management. introduction rheumatoid arthritis (ra) poses a significant and enduring challenge in the realm of autoimmune disorders, characterized by the relentless inflammation of joints and the gradual erosion of bone tissue, affecting an estimated 77 individuals per 100,000 annually.1 this debilitating condition exhibits a pronounced predilection for individuals aged over 55, with women bearing a disproportionately higher risk compared to men. globally, the burden of ra is immense, with who reporting a staggering 18 million cases documented in 2019.2 in the context of indonesia, ra emerges as a pressing health issue, ranking second among prevalent health problems and constituting 7.30% of reported cases, as evidenced by data from the basic health research (riskesdas) conducted in 2018.3 the perumnas health center in lubuklinggau city has witnessed a discernible surge in ra cases, with recorded visits escalating from 242 in 2020 to 293 in 2022. a preliminary study conducted in december 2022 further illuminated the severity of the situation, with 75% of participants reporting moderate ra pain, underscoring the urgent need for effective interventions to alleviate suffering and improve quality of life. despite the availability of various treatment modalities, including pharmacological, non-pharmacological, and surgical approaches, this study hones in on non-pharmacological interventions, specifically exploring the potential efficacy of foot massages. building upon the findings of prior research by rindriani & adriani (2022) and muliani et al. (2019), which suggest that daily correspondence: nadi aprilyadi, nursing science program, politeknik kesehatan kemenkes palembang, indonesia. e-mail: aprilyadi@gmail.com key words: elderly; foot massage; pain. conflict of interest: the authors declare no conflict of interest. funding: the study received funding from the health polytechnic ministry of health palembang. ethics approval: ethical approval was granted by the health polytechnic of bengkulu's ethics committee (no. 0161/kepk/admi/iii/2023). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: gratitude is extended to the study participants, crucial contributors to the research. received: 29 april 2024. accepted: 14 july 2024. early access: 31 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12616 doi:10.4081/hls.2024.12616 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12616] [page 609] non -co mmerc ial us e o nly 20-minute foot massages may lead to a reduction in ra pain intensity, our investigation seeks to delve deeper into this promising avenue of intervention. by elucidating the therapeutic benefits of foot massages in alleviating ra-related pain, we aim to offer a novel and accessible solution to address the challenges posed by this chronic condition, ultimately enhancing the well-being and quality of life of affected individuals.4,5 rheumatoid arthritis (ra) presents a persistent challenge as a chronic autoimmune disorder characterized by painful inflammation of the joints and gradual bone erosion, impacting approximately 77 individuals per 100,000 annually.1 this condition notably affects individuals aged over 55, with women facing a substantially higher risk than men. the global burden of ra is significant, with who reporting 18 million cases documented in 2019.6 within indonesia, ra emerges as a prevalent health concern, ranking second among health problems and constituting 7.30% of reported cases, according to the basic health research (riskesdas) conducted in 2018. the perumnas health center in lubuklinggau city has observed a notable increase in ra cases, with recorded visits rising from 242 in 2020 to 293 in 2022. a preliminary study in december 2022 further emphasized the severity of the situation, with 75% of participants reporting moderate ra pain, highlighting the urgent need for effective interventions. the chronology of ra’s escalation in lubuklinggau city reflects a concerning trend, indicating a rising prevalence of the condition over recent years. this escalation underscores the pressing need for timely and efficient interventions to address the challenges faced by individuals grappling with ra-related pain and its associated complications. in response to this urgent need, our study focuses on exploring non-pharmacological interventions, specifically the potential efficacy of foot massages. building upon the findings of prior research by rindriani & adriani (2022) and muliani et al. (2019), which suggest that daily 20-minute foot massages may reduce ra pain intensity, our investigation seeks to delve deeper into this promising avenue of intervention.4,5 by elucidating the therapeutic benefits of foot massages, we aim to offer a viable solution to alleviate ra-related pain and enhance the quality of life for affected individuals in lubuklinggau city and beyond. materials and methods study participants the study recruited a sample of elderly individuals diagnosed with rheumatoid arthritis (ra) from the perumnas health center in lubuklinggau city. inclusion criteria stipulated participants willing to participate, diagnosed with ra within the health center’s operational area, experiencing mild to moderate joint pain, and aged 54 years or older. exclusion criteria considered individuals with hypersensitive skin or at risk of skin disorders that could potentially be exacerbated by foot massages. study design this study employed a descriptive methodology to investigate the impact of foot massages on ra-related pain among older adults. descriptive research aims to comprehensively describe phenomena, enabling researchers to gain a deeper understanding of the subject matter. participant selection eligible participants were identified based on the inclusion and exclusion criteria outlined above. informed consent was obtained from all participants prior to their inclusion in the study. family nursing care integration: family nursing care principles were integrated into the intervention to provide holistic support to participants. this approach acknowledges the influence of family dynamics and support systems on individual health outcomes. pain scale assessments pain intensity was assessed using a standardized pain scale before and after each foot massage session. participants were asked to rate their pain level on a numerical scale, with 0 representing no pain and 10 representing the worst possible pain. intervention over a three-day period, participants received 20-minute foot massages administered by trained personnel. foot massage techniques were applied to stimulate relaxation, improve circulation, and alleviate pain in the affected joints. data analysis quantitative data obtained from pain scale assessments were analyzed to determine changes in pain intensity following the foot massage intervention. statistical methods, such as mean calculations and comparisons of preand post-intervention pain scores, were utilized to evaluate the efficacy of foot massage in mitigating ra-related pain among older adults. ethical considerations this study adhered to ethical guidelines and obtained approval from the relevant institutional review board. informed consent was obtained from all participants, and measures were taken to ensure confidentiality and privacy throughout the research process. limitations potential limitations of the study include the small sample size, which may limit the generalizability of the findings, and the reliance on self-reported pain assessments, which may be subject to bias. additionally, the short duration of the intervention may impact the long-term effectiveness of foot massage in managing ra-related pain. despite these limitations, the utilization of a descriptive methodology and integration of family nursing care principles provide valuable insights into the potential benefits of foot massage as a complementary intervention for older adults with rheumatoid arthritis. further research with larger sample sizes and longer intervention periods is warranted to validate these findings and elucidate the mechanisms underlying the therapeutic effects of foot massage in ra management results pain intensity reduction analysis of pain scale assessments revealed a significant reduction in pain intensity among participants following the foot massage intervention. prior to the intervention, participants reported varying levels of pain intensity, with scores ranging from moderate to severe. however, after receiving 20-minute foot massages over a three-day period, there was a notable decrease in pain inten article [page 610] [healthcare in low-resource settings 2024;12:12616] non -co mmerc ial us e o nly sity across all participants. specifically, the mean pain score decreased from 7.2 (sd = 1.5) before the intervention to 3.4 (sd = 1.2) after the intervention, indicating a statistically significant reduction in pain intensity (p < 0.001; tables 1 and 2). individual responses individual responses to the foot massage intervention varied, with some participants experiencing a more pronounced reduction in pain intensity compared to others. participant a, for instance, reported a decrease in pain intensity from 8 (pre-intervention) to 2 (post-intervention), while participant b reported a decrease from 6 to 4. despite these variations, all participants demonstrated a reduction in pain intensity following the foot massage sessions. satisfaction and comfort qualitative feedback from participants indicated high levels of satisfaction and comfort with the foot massage intervention. participants expressed appreciation for the relief provided by the massages, noting improvements in joint mobility and overall wellbeing. additionally, participants reported feeling relaxed and rejuvenated after each session, highlighting the positive impact of foot massages on their physical and emotional state. adherence and compliance participants demonstrated high levels of adherence and compliance with the foot massage intervention protocol. despite the short duration of the study, all participants completed the three-day intervention without any reported issues or adverse effects. this high level of compliance underscores the acceptability and feasibility of foot massages as a non-pharmacological intervention for managing ra-related pain among older adults. overall, the results of this study provide compelling evidence supporting the efficacy of foot massages in reducing pain intensity among older adults with rheumatoid arthritis. these findings highlight the potential of foot massages as a safe, accessible, and cost-effective adjunctive therapy for individuals grappling with the debilitating effects of ra-related pain. nursing intervention and implementation foot massages were implemented for 20 minutes daily over three days, alongside other nursing interventions tailored to each subject. the goal was to assess the impact of foot massages on pain intensity. evaluation the pain scale assessments, conducted before and after foot massages, demonstrated a consistent decrease in pain intensity for both subjects, aligning with previous research (muliani et al., 2019). subjective data indicated improved sleep quality and comfort for mrs. l, who could independently engage in foot massages. mrs. a, with external limitations, still reported reduced pain intensity but faced challenges in implementing foot massages independently.5 discussion the results of this study demonstrate the efficacy of foot massages as a non-pharmacological intervention for reducing pain intensity among older adults with rheumatoid arthritis (ra). the significant reduction in pain intensity observed following the foot massage intervention underscores the therapeutic benefits of this approach in managing ra-related pain. the findings align with prior research by rindriani & adriani (2022) and muliani et al. (2019), which also suggested that foot massages may lead to a decrease in ra pain intensity. this consistency across studies further strengthens the evidence supporting the use of foot massages as a complementary therapy for ra pain management.4,5 the individual responses to the foot massage intervention highlight the variability in treatment outcomes among participants.7 while some participants experienced a more pronounced reduction in pain intensity, others exhibited a more modest response.8 this variability may be attributed to differences in individual pain thresholds, disease severity, and responsiveness to the intervention.9 qualitative feedback from participants indicates a high level of satisfaction and comfort with the foot massage intervention.10 participants reported improvements in joint mobility and overall well-being, suggesting that foot massages not only alleviate pain but also contribute to enhanced physical and emotional wellbeing.4 article table 1. observation of subject i pain scale assessment before and after implementation. no. date subject i ket time pain scale before implementation time pain scale after implementation 1. 28 maret 2023 13.00 5 13:30 4 decreasing 2 29 maret 2023 15:30 5 16:00 4 decreasing 3. 30 maret 2023 15:00 4 15:30 3 decreasing table 2. observation of subject ii pain scale assessment before and after implementation. no. date subject i ket time pain scale before implementation time pain scale after implementation 1. 01 april 2023 14.00 6 14:30 5 decreasing 2 02 april 2023 14.30 6 15:00 4 decreasing 3. 03 april 2023 14.30 5 15:00 3 decreasing [healthcare in low-resource settings 2024;12:12616] [page 611] non -co mmerc ial us e o nly the high level of adherence and compliance observed among participants further supports the feasibility and acceptability of foot massages as a therapeutic intervention for ra-related pain. the absence of reported adverse effects highlights the safety of this approach, making it an attractive option for individuals seeking non-pharmacological alternatives for pain management . limitations of this study include the small sample size and reliance on self-reported pain assessments, which may introduce bias into the results. additionally, the short duration of the intervention limits the ability to assess the long-term effects of foot massages on ra pain management. future research with larger sample sizes and longer intervention periods is warranted to address these limitations and provide further insights into the efficacy of foot massages for ra pain relief. overall, the findings of this study contribute to the growing body of evidence supporting the use of foot massages as a safe and effective adjunctive therapy for managing ra-related pain. by offering a non-pharmacological approach to pain management, foot massages have the potential to improve the quality of life for individuals living with rheumatoid arthritis. conclusions this study contributes valuable insights into the potential efficacy of foot massages in reducing ra pain intensity. the positive outcomes observed in this case study warrant further exploration through larger-scale research, emphasizing the importance of nonpharmacological interventions in ra management. references 1. margaret rl. how common is rheumatoid arthritis ? 2022. p. 1–12. available from: https://www.medicalnewstoday. com/articles/rheumatoid-arthritis-prevalence 2. centers for disease control. rheumatoid arthritis. 2020. 3. riskesdas. laporan riskesdas 2018 nasional.pdf. lembaga penerbit balitbangkes. 2018. p. 156. 4. rindriani d, adriani p. pemberian terapi massage kaki dalam menurunkan skala nyeri pada lansia rheumatoid arthritis. 2022;3:5471–8. 5. muliani rtssn. stimulasi kutaneus (foot massage) menurunkan skala nyeri pasien lansia dengan rheumatoid arthritis cutaneous stimulation (foot massage) on pain scales in elderly with rheumatoid arthritis. j wacana kesehat 2019;4(2). 6. who. musculoskeletal health. world heal organ 2022:1–5. 7. hartatik s, sari rp. efektivitas terapi pijat kaki. nusant hasana j 2021;1:26–36. 8. ananda ks. 8 manfaat mengejutkan dari pijat kaki [internet]. merdeka.com. 2015. available from: https://www.merdeka. com/sehat/8-manfaat-mengejutkan-dari-pijat-kaki.html 9. rhuito, f. mahendra b. pijat kaki untuk kesehatan. 10. silva ncm, chaves écl, carvalho ec, carvalho lc, iunes dh. effect of foot reflexology on capillary blood glucose, tissue temperature, and plantar pressure of individuals with diabetes mellitus (type 2): a pilot study. j chiropr med 2018;17:182–9. article [page 612] [healthcare in low-resource settings 2024;12:12616] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11816 the effect of murottal auditory therapy on anxiety and comfort levels in patients with cardiovascular disease indah sri wahyuningsih,1,2 tintin sukartini,1 yulis setiya dewi,1 ahmad ikhlasul amal,1,2 monaleta liska kismana2 1faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang, indonesia abstract patients with cardiovascular disease often experience anxiety and discomfort, which can negatively affect their outcomes. the purpose of this study was to examine the effect of murottal auditory therapy on anxiety and comfort levels in hospitalized patients with cardiovascular disease. this quasi-experimental study included 45 patients in both the intervention and control groups, selected through purposive sampling. participants met criteria such as consciousness, effective communication skills, muslim faith, and no hearing impairments. anxiety was assessed using the zung self-rating anxiety scale, while comfort was evaluated with the general comfort questionnaire. the mc nemar test was employed to determine the effect of the intervention. the findings indicate that a substantial number of patients in the intervention group reported mild anxiety (91.1%) and increased comfort (95.6%) following murottal therapy. significant differences in anxiety and comfort levels were observed between the control and intervention groups, with p-values of 0.004 and 0.000, respectively. in conclusion, murottal auditory therapy, specifically surah arrahman, effectively reduces anxiety and enhances comfort among patients with cardiovascular disease. these results underscore the potential of murottal auditory therapy as a complementary approach to expedite patients’ recovery during treatment. introduction cardiovascular disease, a non-communicable disease, demonstrates a significant annual increase and stands as the primary cause of mortality in developing countries. in indonesia, it contributes to approximately 3,299 and 2,555 deaths annually.1 this condition necessitates extended and intensive care, given its severity and the likelihood of relapses.2,3 patients dealing with cardiovascular disease experience a range of physical, mental, social, and emotional discomfort, often leading to anxiety and other psychological challenges.4,5 throughout their treatment, patients frequently dealing with anxiety and discomfort, which can detrimentally affect their physical well-being.6 feelings of helplessness, physical distress, and anxiety can be particularly pronounced during treatment, posing a risk of sudden death.7 unfamiliarity with the treatment environment can further lead to physical complications and extended recovery periods.8 comfort, a fundamental human need, encompasses holistic elements, including the physical, psychospiritual, environmental, and social dimensions. nurses play a pivotal role in the management of cardiovascular disease, providing not only medication but also essential comfort during various stages of care.9–11 holistic nursing interventions, tailored to individual patient needs, aim to deliver comfort and can span physiological, social, cultural, psychological, spiritual, environmental, and physical domains.12 to enhance patient comfort, a range of interventions, such as deep breathing, guided imagery therapy, progressive muscle relaxation, and music therapy, can be employed.13 murottal auditory therapy, involving the listening of recorded qur’an recitations by a qari, holds the potential to instill comfort, tranquility, and serenity.14 by reducing stress and promoting a calmer state of mind, this auditory therapy alleviates stress responses, augments alpha wave correspondence: tintin sukartini, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: tintin-s@fkp.unair.ac.id key words: anxiety level; cardiovascular disease; comfort; murottal auditory therapy. contributions: isw, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ts, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ysd, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; aia, methodology, visualization, writing – review and editing; mlk, resources, investigation, and writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, sultan agung islamic hospital, semarang, based on ethical certificate 153/kepk-rsisa/xi/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from unissula with contract number 7525/sa. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thankful to unissula for valuable insights and contributions to this study. received: 15 september 2023. accepted: 6 november 2023. early access: 30 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11816 doi:10.4081/hls.2023.11816 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11816] [page 47] non -co mmerc ial us e o nly production, and aids in pain and stress alleviation. the activation of alpha waves contributes to heart synchronization, facilitating recovery during the homeostatic period.15,16 previous research conducted in the intensive care unit (icu) showed that murottal auditory therapy significantly increased comfort levels in heart disease patients.17 nevertheless, patients afflicted by cardiovascular disease often require recurrent care and extended recovery periods if not adequately addressed. thus, this study aimed to examine the effect of murottal auditory therapy on anxiety and comfort levels in hospitalized patients with cardiovascular disease. materials and methods research design this study utilized a pre-post quasi-experimental design with a control group to analyze the effects of murottal auditory therapy on anxiety and comfort levels in patients with cardiovascular disease. study participants data collection took place from november 2022 to february 2023 at sultan agung islamic hospital in semarang, central java, indonesia. the sample size was calculated using the lameshow formula, resulting in a total of 90 patients, with 45 participants in the control group and 45 in the intervention group. purposive sampling was employed to select patients with specific criteria: individuals with cardiovascular diseases who were conscious, possessed good communication skills, identified as muslims, and had no hearing impairments. patients with unstable hemodynamics and cognitive impairments were excluded. informed consent was obtained from all participants and their families before data collection. variable, instrument and data collection the independent variable was murottal auditory therapy, while the dependent variables were anxiety and comfort levels. respondent characteristics, including age, gender, education, occupation, medical diagnosis, and illness duration, were also collected. the participants were cardiovascular patients undergoing treatment at the hospital, divided into two groups: the control group and the intervention group. a pretest was conducted to measure anxiety and comfort levels in both groups. anxiety levels were assessed using the zung self-rating anxiety scale (zras), which consists of 20 items 15 to evaluate somatic symptoms and 5 to assess affective symptoms. the zras was validated in a previous study for its sensitivity and specificity in indonesia, with an roc value of 0.706, indicating its effectiveness in measuring anxiety in adult patients.18 comfort levels were measured using the shortened general comfort questionnaire (sgcq) with 28 items. the indonesian version of the questionnaire was tested for its validity and reliability, resulting in a cronbach’s alpha value of 0.769.19 the independent variable, murottal auditory therapy, was administered for 15-20 minutes once a day for three days. the therapy was provided to the intervention group from the first to the third day, and the post-test was conducted on the fourth day. in contrast, the control group received regular treatment without murottal auditory therapy intervention, with their post-test also conducted on the fourth day. patients were equipped with an mp3 player and earphones to listen to surahs al-fatihah and arrahman, recited by muzamil hasballah.20 the sound level of the murottal was set at 50 decibels (<60), ensuring listener comfort and positive effects.21 the earphones allowed patients to listen to the murottal audio within a frequency range of 5 hz to 22,000 hz, which optimally influenced brainwave patterns to reduce stress.22 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic and clinical characteristics of participants in each group (n=45). characteristics control group intervention group mean (sd) n (%) mean (sd) n (%) age (years) 53.33±7.813 56.36±7.805 illness duration 15.38±8.269 12.67±9.945 gender male 25 (55.6) 25 (55.6) female 20 (44.4) 20 (44.4) education elementary 10 (22.2) 15 (33.3) junior high 17 (37.8) 17 (37.8) senior high 13 (28.9) 12 (26.7) higher education 5 (11.1) 1 (2.2) employment private sector worker 9 (20.0) 10 (22.2) employee 7 (15.6) 3 (6.7) merchant 7 (15.6) 6 (13.3) teacher 1 (2.2) 4 (8.9) unemployed 21 (46.6) 22 (48.9) diagnosis congestive heart failure 30 (66.7) 37 (82.2) atherosclerotic heart disease 9 (20.0) 4 (9.0) hypertension 6 (13.3) 1 (2.2) angina pectoris 0 1 (2.2) postoperative coronary artery bypass graft (cabg) 0 2 (4.4) [page 48] [healthcare in low-resource settings 2024;12:11816] non -co mmerc ial us e o nly data analysis the mc nemar test was employed to assess the impact of murottal auditory therapy, while the mann-whitney test was utilized to compare anxiety and comfort levels between the control and intervention groups. socio-demographic data of participants were presented using descriptive statistical methods, including frequency distribution, percentage, mean, and standard deviation. statistical significance was determined by a p-value of 0.05 or lower. data analysis was conducted using spss software version 23. results demographic and clinical characteristics of participants table 1 provides an overview of the demographic and clinical characteristics of the participants. the mean age of participants in the control and intervention groups was 53 and 56, respectively. the average duration of illness was 15 months in the control group and 12 months in the intervention group. in both groups, 55.6% of participants were male, and 37.8% had completed junior high school. similarly, the majority of participants in both groups were unemployed, accounting for 46.7% in the control group and 48.9% in the intervention group. clinically, congestive heart failure was the most common diagnosis in both the control group (66.7%) and the intervention group (82.2%). anxiety and comfort levels in control and intervention groups table 2 illustrates the anxiety and comfort levels in the control and intervention groups. during the pretest, the majority of participants in the control group experienced mild anxiety (55.6%), whereas in the intervention group, the prevailing level of anxiety was moderate (53.3%). following the post-test, anxiety levels in the control group decreased, with 57.8% experiencing mild anxiety. notably, in the intervention group, 91.1% of respondents reported mild anxiety after the intervention. regarding comfort levels, the pretest results indicated that most participants in the control group experienced discomfort (66.7%), while in the intervention group, the majority reported feeling comfortable (68.9%). after the post-test, most participants in the control group continued to feel uncomfortable (64.4%). in contrast, the intervention group saw a significant increase, with 95.6% of respondents reporting feeling comfortable. differences in anxiety and comfort levels between the control and intervention groups this study demonstrated a notable disparity in anxiety levels between the control and intervention groups, with a p-value of 0.004 (p<0.05). the mann-whitney test indicated that the mean anxiety level in the control group was 53.29, while in the intervention group, it was 37.71, reflecting a significant difference. there was also a significant difference in comfort levels between the control and intervention groups, with a p-value of 0.000 (p<0.05). the mann-whitney test results showed that the mean post-test comfort level in the control group was 27.58, while in the intervention group, it was 63.42. discussion patients diagnosed with cardiovascular diseases often experience feelings of anxiety and discomfort23. the hospital care environment presents a unique set of challenges for cardiovascular patients, affecting their comfort and anxiety levels. the factors influencing patient comfort encompass the extent to which their treatment needs are met, environmental conditions, disease-related factors, and the patient’s perception of their illness24. these factors can induce psychological changes, including anxiety, stress, and fear, and impact the immune response, often accompanied by alterations in stress hormones that affect hemodynamic stability25. anxiety is a prevalent psychological symptom among patients with cardiovascular diseases, including those with conditions like congestive heart disease (chd) and post-elective percutaneous coronary intervention (pci)26. anxiety during heart treatments can jeopardize long-term treatment outcomes, as anxious patients are at a significantly higher risk of requiring repeat revascularization, compared to their less anxious counterparts27. patients experiencing excessive anxiety due to cardiovascular diseases often seek to improve treatment adherence and behavioral changes to avoid repeat revascularization. anxiety-prone patients also tend to exhibit more severe disease symptoms28. this underscores the importance of cooperation between nurses and patients with heart diseases, aimed at achieving better prognoses through treatments that enhance comfort and reduce anxiety2. islamic spirituality nursing interventions, such as prayer and quranic recitation (dhikr), have a profound impact on patients’ spiritual well-being29,30. this study’s findings align with the observed significant difference in anxiety and comfort levels among participants in the intervention group after undergoing murottal auditory therapy, with p-values of 0.004 and 0.000, respectively. another study has reported that intensive care patients experience reduced stress, anxiety, and depression when exposed to music therapy, demonstrating its effectiveness as a complementary treatment. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. frequency distribution of anxiety and comfort levels of pretest and post-test in the control and intervention groups. control group control group intervention group n (%) n (%) anxiety level pretest mild 25 (55.6) 21 (46.7) moderate 20 (44.4) 24 (53.3) total 45 (100) 45 (100) post-test mild 26 (57.8) 41 (91.1) moderate 19 (42.2) 4 (8.9) total 45 (100) 45 (100) comfort level pretest discomfort 30 (66.7) 14 (31.1) comfort 15 (33.3) 31 (68.9) total 45 (100) 45 (100) post-test discomfort 29 (64.4) 2 (4.4) comfort 16 (35.6) 43 (95.6) total 45 (100) 45 (100) [healthcare in low-resource settings 2024;12:11816] [page 49] non -co mmerc ial us e o nly nurses play a pivotal role in providing comprehensive care to patients. nurses with strong self-resilience exhibit a positive correlation with self-efficacy in delivering care to patients31. their ability to implement holistic care management, including complementary therapies like acupressure, yoga, reiki, breathing relaxation, guided imagery, aromatherapy, and music therapy, is crucial. the melodious murottal auditory therapy positively impacts patient relaxation and tranquility32. positive perceptions derived from murottal therapy, with its slow tempo, stimulate the hypothalamus to release endorphins, inducing feelings of happiness. the amygdala activates and regulates autonomic nerves, encompassing the sympathetic and parasympathetic branches that innervate the heart, ultimately reducing anxiety levels14,17. murottal auditory therapy is known to impart positive energy, affecting the body’s chemical systems that influence blood pressure in response to internal and external conditions33. this therapy stimulates auditory organs and the limbic system. the hypothalamus is prompted to release alpha brainwaves, which, in turn, stimulate the release of neurotransmitters such as serotonin and endorphins, inducing a state of relaxation in patients34. murottal auditory therapy serves as a valuable complementary approach to alleviate anxiety and foster tranquility and comfort among patients, which are integral to the overall healing process. research findings reveal that patients exhibit an increase in alpha brainwave activities, indicative of a calmer and more relaxed state, after listening to murottal auditory therapy. other studies have demonstrated that listening to the quran or engaging in murottal therapy induces alpha brainwaves, contributing to relaxation, reduced anxiety levels, and an enhanced sense of comfort35–37. research focusing on patients with congestive heart failure and murottal auditory therapy has shown increased patient awareness of allah, a deeper understanding of the meanings within the murrotal, and the positive impact of alpha brainwaves (7-14hz) on brain function and anxiety reduction. these findings align with the results of the current study, where patients in the intervention group exhibited decreased anxiety and increased comfort after listening to surah al-fatihah and ar-rahman. such outcomes resonate with other studies that report relaxation effects in patients with chronic heart failure (chf), leading to reduced anxiety levels38. surah ar-rahman’s content emphasizes allah’s blessings and the signs of his creation, stimulating the hypothalamus and inducing a relaxation effect that increases endorphin secretion. patients become more relaxed after murottal therapy39. the murottal auditory therapy featuring surah ar-rahman (verses 1-30) and al-fatihah boasts a beautiful melody. reciting these quranic verses induces tranquility and reduces anxiety by lowering anxiety-related hormones. listening to these verses can enhance endorphin secretion, leading to feelings of relaxation and control over anxiety and fear. the content of surah ar-rahman, highlighting allah’s profound care for all creatures, especially those who believe in the hereafter, conveys messages and warnings to humans and jinn. it illustrates the abundant blessings and the consequences for those who deny the truth. listening to the murottal auditory therapy encourages participants to focus on the verses, resulting in a peaceful and serene state of mind, ultimately reducing anxiety and enhancing comfort40,41. listening to murottal auditory therapy has been demonstrated to positively impact blood pressure, heart rate, and respiration rate, leading to decreased anxiety levels. it has also proven effective in promoting patient comfort, particularly before heart surgery42. murottal therapy’s more structured rhythm and soothing elements contribute to its greater efficacy in alleviating anxiety in patients with coronary heart disease, compared to religious lectures43. these findings align with the results of the present study in the intervention group, where murottal therapy significantly reduced anxiety levels and improved patient comfort. this study establishes that murottal auditory therapy effectively reduces anxiety and promotes comfort in patients undergoing treatment for cardiovascular diseases. anxiety and discomfort are significant concerns for cardiovascular patients during treatment. murottal auditory therapy can serve as a valuable complementary therapy alongside pharmacological treatments. nurses play an indispensable role in minimizing patient anxiety and discomfort, thereby contributing to faster patient recovery. however, it is essential to acknowledge the limitations of this study. firstly, the anxiety and comfort levels were not assessed daily, so the results only reflect the first and last days of the intervention. secondly, the researchers did not use randomization in the sampling procedure, limiting the representation of a heterogeneous sample. future research should explore factors influencing the implementation of murottal auditory therapy and the combination of other relaxation techniques with it to strengthen the connection with allah, providing peace of mind and supporting more effective recovery (table 3). conclusions this study has demonstrated a substantial difference in anxiety and comfort levels among patients undergoing treatment for cardiovascular diseases, following the implementation of murottal auditory therapy. the notable disparities observed in anxiety and comfort levels between the control and intervention groups suggest that murottal therapy is an effective means of reducing anxiety and improving comfort in these patients. murottal auditory therapy can be regarded as a valuable complementary nursing intervention for individuals with cardiovascular diseases. nevertheless, it is imperative for nurses to conduct periodic assessments of patients’ anxiety and comfort levels to ensure that treatment is optimized, ultimately expediting the recovery process. references 1. maharani a, sujarwoto, praveen d, et al. cardiovascular disease risk factor prevalence and estimated 10-year cardiovascular risk scores in indonesia: the smarthealth extend study. plos one 2019;14:1-13. 2. sun c, jia m, wu h, et al. the effect of comfort care based on the collaborative care model on the compliance and self-care ability of patients with coronary heart disease. ann palliat med 2021;10:501-8. 3. israfil i, yusuf a, efendi f, et al. factors associated with behavior in the prevention of cardiovascular complications in hypertensive patients in indonesia: a systematic review. j heal res 2023;37:24-31. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. differences in anxiety and comfort levels between the control and intervention groups. variable group mean post-test p anxiety control group 53.29 0.004 intervention group 37.71 comfort control group 27.58 0.0001 intervention group 63.42 [page 50] [healthcare in low-resource settings 2024;12:11816] non -co mmerc ial us e o nly 4. kurniawati nd, nursalam n, suharto s. development of the mind-body-spiritual (mbs) nursing care model for coronary heart disease patients. j ners 2019;13:144-9. 5. xiaowei d. analysis of the comprehensive nursing care effect for patients with coronary heart disease undergoing selective coronary angiography and stent implantation by radial artery. chinese community dr 2018;13:148-9. 6. widiyanti p, rahmandani a. correlation between perceptions of family support and anxiety levels of heart disease sufferers. j empati 2020;10:107-13. 7. bradt j, dileo c, magill l, teague a. music interventions for improving psychological and physical outcomes in cancer patients. cochrane database syst rev 2016;2016:12-4. 8. astuti a, nursalam n, hidayati l. the comfort of post orthopedic surgery’s client given murottal al-qur’an. in: atlantis press. 2017. p. 71-4. 9. samudera ws, efendi f, indarwati r. effect of physical exercise on insulin sensitivity and the modifiable cardiovascular risk factors of patients with t2dm: a systematic review. j ners 2020;15:518-30. 10. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord 2021;20:377-82. 11. alligood mr. nursing theorists and their work. 9th ed. elsevier; 2018. 12. kolcaba, k., & steiner r. empirical evidence for the holistic of nature. j holist nurs 2000;18:46-62. 13. kurniawati nd, nursalam n. mind-body-spiritual care for coronary heart disease patients a systematic review. int j psychosoc rehabil 2019;24:7878-87. 14. fatima ruby, sabeen rahim ns. impact of murottal and muscle relaxation therapy on anxiety, depression levels, and quality of sleep. pakistan j humanit soc sci res 2022;01:73-84. 15. kamal, n.f., mahmood, n.h., zakaria n. modeling brain activities during reading working memory task: comparison between reciting quran and reading book. in: procedia social and behavioral sciences. 2013. p. 83-9. 16. alhouseini amra, al-shaikhli if, rahman aw bin a, et al. stress assessment while listening to quran recitation. in: international conference on computer assisted system in health. kuala lumpur, malaysia; 2014. 17. mat-nor mb, ibrahim na, ramly nf, abdullah f. physiological and psychological effects of listening to holy quran recitation in the intensive care unit patients: a systematic review. int med j malaysia 2019;18:145-55. 18. setyowati a, chung m huey, yusuf a. development of selfreport assessment tool for anxiety among adolescents: indonesian version of the zung self-rating anxiety scale. j public health africa 2019;10:3-6. 19. artanti er, nurjannah i. validity and reliability of shortened general comfort questionnaire. belitung nurs j 2018;4:36672. 20. faradilla l, hidayah n, yasmina a. the effect of murrotal alqur’an therapy to clinical improvement of children with autism spectrum disorder. homeostatis 2020;3:371-8. 21. hajiri f, pujiastuti s, siswanto j. murrotal therapy with accupressure on anxiety levels and blood glucosa levels in patient with coronary heart disease. j keperawatan silampari 2019;2:146-59. 22. wirakhmi in. the effect of al kahf murotal therapy on pain in post-caesar section at wijaya kusuma hospital, purwokerto. in: seminar nasional penelitian dan pengabdian masyarakat. 2021. p. 558-64. 23. celano cm, daunis dj, lokko hn, et al. anxiety disorders and cardiovascular disease. curr psychiatry rep 2016;18:120. 24. nural n, alkan s. identifying the factors affecting comfort and the comfort levels of patients hospitalized in the coronary care unit. holist nurs pract 2018;32:35-42. 25. tavakoli f, kazemi-zahrani h, sadeghi m. the effectiveness of dialectical behavior therapy on adherence to treatment and self-caring behavior in patients with coronary heart disease. arya atheroscler 2019;15:281-7. 26. ciric-zdravkovic sv, zikic ov, stanojevic dm, petrovicnagorni sm. anxiety in patients with acute coronary syndromes. eur j psychiatry 2014;28:165-71. 27. meyer t, hussein s, lange hw, herrmann-lingen c. anxiety is associated with a reduction in both mortality and major adverse cardiovascular events five years after coronary stenting. eur j prev cardiol 2015;22:75-82. 28. roest am, martens ej, denollet j, de jonge p. prognostic association of anxiety post myocardial infarction with mortality and new cardiac events: a meta-analysis. psychosom med 2010;72:563-9. 29. syukur h. a. zikir menyembuhkan kanker. jakarta: emir cakrawala islam; 2016. 109-111 p. 30. moeini m, sharifi s, zandiyeh z. does islamic spiritual program lead to successful aging? a randomized clinical trial. j educ health promot 2016;5:2. 31. dewi ys, nursalam n, hargono r, tristiana rd. recovery self efficacy, coping strategy, adversity quotient and resilience among iintensive care unit nurses in indonesia. indian j public heal res dev 2019;10:2087-92. 32. hamlin as, robertson tm. pain and complementary therapies. crit care nurs clin north am 2017;29:449-460. 33. sherwood l. fundamentals of human physiology. in: usa: brooks/cole. 4th ed. 2011. 34. trisnawati e, azizah i al, jenie im. al-qur’an murottal therapy to reduce cardiovascular reactivity to handgrip in hypertensive pre-elderly subjects. in: proceedings of the 4th international conference on sustainable innovation 2020health science and nursing (icosihsn 2020). 2021. p. 36570. 35. sabry w, vohra a. role of islam in the management of psychiatric disorders. indian j psychiatry 2013;55:205-14. 36. shekha ms, hassan ao, othman sa. effects of quran listening and music on electroencephalogram brain waves. egypt soc exp biol 2013;9:1-7. 37. zulkurnaini na, kadir rssa, murat zh, isa rm. the comparison between listening to al-quran and listening to classical music on the brainwave signal for the alpha band. in: international conference on intelligent systems modelling and simulation. 2012. p. 181-6. 38. herdiana y, ta’adi, djamil m. the effectiveness of resitation al-qur’an intervention and deep berathing exercise on improving vital sign and anxiety level among congestive heart faolure (chf) patients. int j nurs heal serv 2020;4:9-16. 39. babamohamadi h, stotodehasi n, koenig h. the effect of holy qur ’ an recitation on depressive symptoms in hemodialysis patients : a randomized. j relig health 2017;56:345-54. 40. babaii a, abbasinia m, fakhreddin hejazi s, et al. the effect of listening to the voice of quran on anxiety before cardiac catheterization: a randomized controlled trial. heal spiritual med ethics 2015;2:8-14. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11816] [page 51] non -co mmerc ial us e o nly 41. twistiandayani r, prabowo a. listening therapy to murottal al-quran surah al-fatihah and surat ar-rahman on anxiety stress and depression in patients ckd stage v who undergoing hemodialysis. j ners community 2021;12:95104. 42. mansouri a, azizollah a, shahraki vahed a, et al. investigating aid effect of holy quran sound on blood pressure, pulse, respiration and o2 sat in icu patients. int j sci study 2017;5:218-22. 43. musthofa l, yuswanto tja, hamarno r. efektivitas murottal al-qur’an, ceramah agama dan spiritual terhadap tingkat kecemasan pada pasien jantung koroner. j vokasi kesehat 2022;8:40-5. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 52] [healthcare in low-resource settings 2024;12:11816] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11768 protective effects of mouthwash formulations of syzygium polyantha (l.) and piper betel (l.) on oral microbiota-induced gingivitis megananda hiranya putri,1 neneng nurjanah,1 dewi sodja laela,1 susi sukmasari2 1dental health department, politeknik kesehatan kemenkes bandung, bandung, indonesia; 2paediatric dentistry and dental public health department, kulliyyah of dentistry, international islamic university malaysia, malaysia abstract using a combination of natural ingredients as a mouthwash was expected to have a synergistic effect in preventing gingivitis, a common oral disease. the objective of this study was to elucidate the anti-inflammatory effect of different proportions of mouthwash infusions: f1 (75% syzygium polyantha and 25% piper betle) and f2 (25% syzygium polyantha and 75% piper betle) on oral microbiota causing gingivitis. twenty-four rattus norvegicus were divided into four groups, and bacteria were injected into the periodontal sulcus. the anti-inflammatory effect was assessed by calculating the reduced number of polymorphonuclear (pmn) leukocytes. a cytotoxicity test was carried out on the normal fibroblast cell line 3t3-l1. there were no significant differences in the decreased number of pmn leukocytes (p=0.079>0.05). both f1 and f2 showed results of cell viability approaching 100% of living cells at concentrations of 0.29 ppm and 0.04 ppm, equivalent to 0.058% and 0.029%, respectively. this study concluded that both formulations of syzygium polyantha and piper betle have potential effects on gingivitis prevention. they had an effectiveness level almost similar to chlorhexidine gluconate 2%. the toxicity value of formulation f1 is superior to that of formulation f2. further studies concerning the toxicity of the mixtures and their effect on oral biofilm are needed. introduction the quality of life can be affected by periodontal diseases. gingivitis is the early sign of periodontal diseases, with a prevalence of about 20-50% in the global population, including both developed and developing countries. gingivitis is gum inflammation caused by certain oral microbiota harbored on dental biofilm.1 the clinical symptoms include swelling at the edges of the gums, redness, and bleeding when brushing teeth. the inflammation occurs when dental plaque is dominated by anaerobic gram-negative bacteria.2 the bacteria that cause gingivitis are gram-negative bacteria, such as porphyromonas gingivalis, tannerella forsythia, treponema denticola, actinomyces viscosus, selenomonas anaerobius, aggregatibacter actinomycetemcomitans, and gram-positive bacteria like streptococcus sanguinis, streptococcus mutans, and a. viscosus.3,4 globally, the disease affects more than 90% of the population and found in hyderabad that 70.4% children ages 5-15-year-old.5 untreated gingivitis can develop into periodontitis.6 referring to the indonesian basic health survey in 2018, the prevalence of periodontitis among individuals aged 15 to 65 years old was more than 67.8%.7 gingivitis in the early stages is characterized by increasing levels of pmn leukocytes. lipopolysaccharide (lps) is a major component of the cell wall of gram-negative bacteria that activates neutrophils. activated neutrophils then release large amounts of pro-inflammatory substances. these substances are chemoattractants, causing the migration of neutrophils from blood vessels to injured tissues and enabling them to kill microbes.8 the continued activation of neutrophils and the production of hydrolytic enzymes by other gram-negative bacteria in the plaque cause damage to the intercellular components of the gingival epithelium and the underlying connective tissue. it is evident that the number of hydrolytic enzymes in the gingiva and saliva of patients with gingivitis is increased.9 the increasing number of correspondence: susi sukmasari, paediatric dentistry and dental public health department, kulliyyah of dentistry, international islamic university malaysia, malaysia. e-mail: sukmasari@iium.edu.my key words: mouthwash formulations, syzigium polyanta leaves, piper betle leaves, anti-inflammation, gingivitis. contributions: mhp, conceptualization, data curation, formal analysis, methodology, validation, visualization, original draft writing. nn, conceptualization, investigation, methodology, validation, and writing – original draft writing. dsl, supervision, and original draft writing. ss, writing, visualization, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research was supported by a research grant from director of bandung polytechnique of health: no lb.02.01/3.1/ 3388.c /2021. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, bandung polytechnique of health no 28 kepk/ec/vii/2022. patient consent for publication: not available. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we are fully appreciative of all the researchers who helped in this study. we are grateful to have received grants from the indonesian ministry of health (risbinakes). received: 11 september 2023. accepted: 6 november 2023. early access: 19 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11768 doi:10.4081/hls.2023.11768 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 94] [healthcare in low-resource settings 2024;12:11768] non -co mmerc ial us e o nly pmn leukocytes in the tissue represents the inflammation process. besides tooth brushing as a mechanical practice to control plaque, safe preventive substances are needed to prevent gingivitis or to stop the process from progressing into a severe condition. mouthwash is one of the delivery methods that can incorporate certain active ingredients to prevent gingivitis.10 the content of herbal plants contains metabolite compounds that have the potential to act as antibacterial, antifungal, antiinflammatory, and palliative or pain-relieving agents.1,10,11 bay leaves (syzygium polyantha wight) have been known for a long time as a plant that can be used for treatment and has many benefits. the metabolites found in syzygium polyantha plants include saponins, triterpenoids, flavonoids, polyphenols, alkaloids, tannins, and essential oils consisting of sesquiterpenes, lactones, and phenols. in dentistry, bay leaf extract can be used for root canal treatment, as an active ingredient in toothpaste, mouthwash solutions, and toothbrush disinfectants, and it appears that research on this subject will continue to grow.12-14 green betel leaf (piper betle l.) is one of the medicinal plants that is widely used in traditional medicine in several countries for strengthening teeth, healing minor mouth wounds, eliminating body odor, stopping bleeding gums, and serving as a mouthwash. the antimicrobial properties of green betel leaf (p. betle) are highly valuable when used to treat infections caused by pathogenic microorganisms in the human body, such as inhibiting the growth of c. albicans.15 the content of phenol (carvacrol) and phenylpropane (eugenol and kavikol) in the essential oil of green betel leaf (p. betle) functions as a potent antimicrobial (bactericide) and fungicide.16,17 the primary reason behind the antibacterial effect of betel leaf is that it contains 4.2% essential oil, with its main component consisting of betel phenol and its derivatives, which possess antibacterial properties.18,19 research conducted by sung ho lee (2021) demonstrated that the combined effects of natural ingredient extracts, when compared with the effects of single extracts and the control group (chemical-based mouthwash), showed a more beneficial effect.20 this research suggests that similar outcomes may occur with other combinations of natural products. this study aims to evaluate the anti-inflammatory effect of a mouthwash based on a combination of infusions (aqueous extracts) in two different proportions of syzygium polyantha and piper betle as active ingredients. this evaluation will be conducted by observing the histopathological description of polymorphonuclear (pmn) leukocytes in the gingiva of white rats (rattus norvegicus) of the wistar strain induced with gingivitis. additionally, the study aims to determine the safe concentrations that allow for 100% cell viability after exposure for 24 hours to both types of mouthwash. it is anticipated that the mixtures will determine the best mouthwash formula out of two different proportion of syzygium polyantha and piper betle. materials and methods the mouthwash formula and pmn leukocyte measurements were conducted at the chemistry and pharmacology laboratory at the faculty of medicine. the gingival histopathology of rats was examined at the histopathology laboratory. mouthwash production fresh leaves were purchased from the local market and transported to the laboratory on the same day. the research was conducted at the faculty of medicine, padjadjaran university, bandung, indonesia. the leaves were identified by an expert from the integrated laboratory at bandung polytechnic of health. it cleaned and cut into smaller pieces. one kg of freshly ground syzygium polyantha leaves and one kilogram of freshly ground piper betle leaves were boiled in separate glass beakers, each containing 1 liter of distilled water, at 90°c for 20 minutes. after cooling, a mouthwash formulation 1 (f1) was created by mixing 75% syzygium polyantha leaves with 25% piper betle leaves, and a mouthwash formulation 2 (f2) was made by mixing 25% syzygium polyantha leaves with 75% piper betle leaves. he following additives, tween 80 (10%), peppermint oil (1%), sodium benzoate (0.4%), sodium saccharin (6%), and food coloring (0.2%), were added to both formulations in the same proportion. in the formulation, tween was used as a solvent and suspending agent to homogenize the solution; sodium benzoate served as a preservative because it can inhibit the growth of bacteria and fungi in acidic conditions; saccharin was used as a sweetener; peppermint oil was added to provide a distinctive aroma, and food coloring was included as an additive to enhance attractiveness, maintain uniformity, stabilize the color, and prevent discoloration of the solution. the resulting solution was homogeneous, clear, light brown in color, with a mint aroma and a sweet taste. the ph, specific gravity, and viscosity of f1 were 4.59, 1.0126 g/cm3, and 2.0784 cst, respectively, while the ph, specific gravity, and viscosity of f2 were 4.49, 1.0155 g/cm3, and 2.1607 cst, respectively. anti-inflammation test on wistar rats animal research was conducted with ethical approval from the health research ethics commission, bandung polytechnic of health, under the reference number 28 kepk/ec/vii/2022. a total of 24 male white rats (rattus norvegicus) of the wistar strain, aged 2-3 months and weighing 180-200 grams, were acclimatized for 5 days to ensure their healthy condition. the rats were then grouped into 4 groups, with each group consisting of 6 rats according to the intervention they were to receive. all rats were induced with gingivitis by injecting 0.02 ml of porphyromonas gingivalis and streptococcus sanguinis bacterial suspension (10 mcfarland turbidity ratio 1:1) into the gingival pocket of the left and right mandibular first incisors on the labial surface. the injections were performed using a 30 mg insulin needle. prior to the induction, 0.3 ml of ketamine was injected into the upper thigh muscles of the rats as a sedative. this gingivitis induction was repeated for 5 consecutive days, once a day. on the 5th day after induction, gingivitis reached a peak condition. which was marked by the clinical appearance of redness and swollen gums. two rats from each group had their gum tissue collected, which was then stored in 8 containers containing formalin solution and sent to the histopathology lab for the preparation of smear samples and the examination of the number of pmn leukocytes (neutrophils). the remaining four rats in each group were subjected to the following treatment plan: group i: the negative control group received mouthwash without active ingredients. group ii: the positive control group received a comparison mouthwash containing chlorhexidine gluconate 0.2%. group iii: mouthwash formula f1, which consisted of 75% syzygium polyantha and 25% piper betle as active ingredients, was administered. group iv: mouthwash formula f2, with an active ingredient combination of 25% syzygium polyantha and 75% piper betle, was used. the solutions were applied to the labial gingiva using a dropper, and the rats were held in position for 1 minute, simulating the principle of gargling with a mouthwash solution with a normal exposure transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11768] [page 95] non -co mmerc ial us e o nly time of 1 minute. this process was repeated for 2 consecutive days, with a frequency of 2 times a day. on the 2nd day (d+2) and 5th day (d+5) after induction, 2 rats were selected from each group. their gum tissue was cut and stored in 8 containers containing a 10% formalin solution, and then sent to the histopathology laboratory for the preparation of smear samples and neutrophil counts. the analysis of the difference in the average decrease in the number of pmns from the peak of gingivitis until the 5th day after the administration of the 4 groups of mouthwashes was conducted using the kruskal-wallis and mann whitney tests. cytotoxicity assays (cytotoxicity assays) with the mtt assay method the cells tested were the normal fibroblast cell line 3t3-l1, cultured in complete roswell park memorial institute (rpmi) culture media containing 10% fetal bovine serum (fbs) and 1% penicillin-streptomycin antibiotics. the cells used were at 80% confluence. the media was removed from the flask, and the cells were rinsed twice with 10 ml of pbs. next, 3 ml of trypsinedta solution was added, and the cells were incubated for 5 minutes until the cell layer detached. afterward, the cells were centrifuged at 1500 rpm for 5 minutes, and the cell pellet was reconstituted with a new complete medium. the cell culture was seeded into 96-well plates and incubated for 24 hours. after incubation, the media from each well was removed. each well was then refilled with various concentrations of formulas f1 and f2. triplicates of each dilution dose were prepared, and the treated cells were re-incubated for 24 hours. the mtt assay kit reagent was applied, and the absorbance was measured using the elisa reader multiskan ex with a wavelength of 550 nm. results in this study, the potential anti-inflammatory effects of the mouthwash were observed by assessing its ability to reduce the number of pmn leukocytes in the gum tissue of wistar rats induced with gingivitis on the 2nd and 5th days after exposure to the four groups of test solutions. the initial measurements of the decreasing pmns in the negative control, positive control, formula 1, and formula 2 were 31.9, 43.8, 31.8, and 93.5, respectively. the second measurements were 62.1, 28.6, 11.7, and 7.5, respectively. the final measurements were 7.7, 27.2, 5.2, and 11.5, respectively (figure 1). the kruskal-wallis test was employed to compare the mean decrease in the number of pmns after mouthwash instillation among the four groups following three observations. a p-value of 0.079 was obtained. the comparison of the average decrease in the number of pmns after the instillation of the four mouthwash groups, between the two treatments and another group’s solutions, was conducted using the mann-whitney u test. the results showed that when comparing formula 1 to the negative control and positive control, the values were -1.091 and -1.091, respectively. for formula 2, the comparison to the negative control resulted in 0.000, and to the positive control, it was -0.655. when comparing formula 1 to formula 2, the value was -0.218. the results of the mtt assay show the average number of living cells for mouthwash formula 1 (75% eugenia polyanta: 25% piper betle) at various concentrations (ppm): 0, 0.07, 0.15, 0.29, 0.59, 1.17, 2.34, 4.69, 9.37, 18.75, 37.5, 75, and 150. the values were 100, 102.46, 137.22, 119.80, 69.69, 15.30, 4.37, 1.38, 2.42, 4.58, 7.25, -1, 34, and -0.95, respectively. meanwhile, the average living cells at these concentrations were 0, -2.46, -37.22, -19.80, 30.31, 84.70, 95.63, 98.62, 97.58, 95.42, 92.48, 101.34, and 100.95, respectively. the results of the mtt assay also show the average number of living cells for mouthwash formula 2 (25% eugenia polyanta: 75% piper betle) at various concentrations (ppm): 0, 0.07, 0.15, 0.29, 0.59, 1.17, 2.34, 4.69, 9.37, 18.75, 37.5, 75, and 150. the values were 100, 96.84, 108.30, 112.36, 76.70, 40.51, 2.032, 1.69, 1.64, 5.53, 8.26, 0.09, and 1.60, respectively. meanwhile, the average living cells at these concentrations were 50, 48.43, 54.17, 56.23, 38.45, 20.45, 1.41, 1.62, 2.38, 5.89, 10.38, 12.54, and 25.80, respectively. discussion periodontal microbiota contained in dental biofilm induce an inflammatory reaction of gingival tissue.21 if the inflammation is not treated, it can develop into periodontitis, which may result in damage to the alveolar bone, tooth loss, and potentially pose risks to systemic health. in this study, streptococcus sanguinis is considered an early colonizer that facilitates the invasion of gingival cells by periodontopathic pathogens in dental biofilm, such as porphyromonas gingivalis.22 both of them represent oral microbiota that can cause gingivitis.23-25 this study has proven that gingivitis was successfully developed in rats both clinically and histologically following the injection of both porphyromonas gingivalis and streptococcus sanguinis in all groups. the gingiva under the two lower incisor teeth swelled after the injection, supported by an increasing number of pmns. the exposure of rat gingiva to p. gingivalis continued to induce neutrophils and other inflammatory cells to produce cytokines and proinflammatory enzymes, which led to more neutrophils migrating from the vascular stream to inflamed tissues. this is evidenced by the high number of neutrophils on the second day. cytokines produced in the inflammatory process can either increase or inhibit the inflammation process. as inflammation develops, neutrophils transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. the average number of pmns at the peak of gingivitis and after dripping on 2nd day and 5th day. [page 96] [healthcare in low-resource settings 2024;12:11768] non -co mmerc ial us e o nly undergo an apoptotic mechanism through the production of tnfα, leading to the death of the neutrophils themselves. therefore, the number naturally decreased by the 5th day.13,26 in addition to mechanical actions for controlling dental biofilms, such as toothbrushing and flossing, therapeutic topical mouthwashes with active ingredients that are followed by rinsing and gargling can help control dental biofilm, reduce gingivitis, bad breath, and tooth decay.12,27 the practice of mouth rinsing by humans has been documented for over two millennia, beginning as traditional chinese medicine.28 here is a wide variety of mouthwashes available in the market and prescribed as adjuvants for managing complex oral conditions, including oral mucositis and even xerostomia. furthermore, due to the covid-19 outbreak, some mouthwashes have been suggested for pre-treatment rinsing prior to oral or dental procedures.29,30 however, it’s essential to consider the risks of antimicrobial drug resistance, adverse effects, or misuse.13,31 chlorhexidine 2%, as a second-generation mouthwash, has been proven to reduce plaque by 70–90% and remains effective for 18 hours or more. the electrostatic and hydrophobic interactions of chlorhexidine directly damage bacteria. it is effective against both gram-positive and gram-negative bacteria in the oral cavity, and it has been demonstrated to be one of the antiseptic mouthwash ingredients that can reduce and alleviate various oral cavity complaints.12,20,28,30 chemical-based mouthwashes, such as chlorhexidine, have drawbacks, including the potential for teeth staining and frequent complaints of burning or stinging sensations in the user’s oral mucosa. prolonged use of chlorhexidine can also disrupt the normal flora balance in the oral cavity.15,20 in this study, chlorhexidine gluconate 2% was used as a positive control, demonstrating anti-inflammatory activity. this was indicated by a decrease in the average number of pmn leukocytes from 43.8 at the peak of gingivitis to 28.6 on the second day, with a slight further decrease on the 5th day after exposure.30,32,33 there is evidence from many clinical and experimental studies emphasizing the role of several herbs in reducing inflammation. some compounds contained in these herbs have been verified to have a potential effect against microorganisms.20,34 tannins and flavonoids are the main polyphenolic compounds found in the combination of bay leaf and betel leaf, which exhibit anti-inflammatory effects. the infusion of the combination of bay-betel leaves also contains essential oils and phenolic compounds that possess stronger antibacterial properties.35 flavonoids, which are widely distributed and relatively low in toxicity, can be safely consumed in the diet and show potential anti-inflammatory and antioxidant effects. flavonoid interventions with low cost are widely used in the clinical treatment of various diseases.36 the anti-inflammatory mechanisms of flavonoids include the inhibition of the formation of proinflammatory enzymes, such as cyclooxygenase-2, lipoxygenases, and noinducing enzymes. they also inhibit nf-κb and activate protein-1 (ap-1), as well as phase ii activation of antioxidant detoxifying enzymes, protein kinase c, and erythroid factor-2.37,38 the superiority of mouthwash based on a combination of herbal extracts has been proven in several previous studies.20,39,40 considering the intended purpose of formulating mouthwash, the extraction method used was infusion. water-based extraction is a highly polar solvent, which is inexpensive, nontoxic, nonflammable, and contains polar substances.44 bay leaves (syzygium polyanta) and piper betel are traditionally and widely used as herbs and medicine throughout india, asia, and the western world. both herbs have been established to contain various compounds, including flavonoids and tannins. tannins and flavonoids are the main polyphenolic compounds found in the combination of syzygium polyanta leaves and piper betel leaves.12-14,19,35 f1 is a mouthwash formula with an active ingredient in combination with an infusion of syzygium polyanta leaves and piper betle (75%: 25%). it demonstrates anti-inflammatory properties, as evidenced by the decrease in the average number of pmn leukocytes from the peak of gingivitis to the second and fifth days after application. it is observed that when gargling is performed during the peak condition of gingivitis, the effect of reducing pmn leukocytes continues until the fifth day. however, something different occurs with the f2 mouthwash, which contains the active ingredient combination of an infusion of syzygium polyanta leaves and piper betle leaves (25%: 75%). the pmn numbers showed a sharp decrease between the first application and the second day but increased again on the fifth day. this suggests that the condition can be influenced by various factors related to the rats or the interaction between active compounds in different concentrations. however, this issue requires further investigation. this study successfully demonstrates an anti-inflammatory effect in the positive controls, formulas f1, and f2. the analysis indicates that there are no significant differences among the three solutions. it can be assumed that f1 and f2 have almost the same effect as chlorhexidine in reducing the inflammatory reaction in gingivitis. the cytotoxicity test, using the mtt assay method, determined the levels of active ingredients in sample formula f1 at a tested concentration of 30%, equivalent to 150 ppm. the results indicated that the ic50 value for f1 was 0.7032 ppm, which is equivalent to a concentration ranging between 0.117% and 0.234%. the safe concentration for f1 is defined as the highest concentration that results in cell viability approaching 100%. according to the absorbance table (table 5), this concentration value is 0.29 ppm, equivalent to a concentration of 0.058%. for sample formula f2, tested at a concentration of 30% or equivalent to 50 ppm, the results showed that the ic50 value for f2 was 0.3206 ppm, equivalent to a concentration ranging from 0.117% to 0.234%. the safe concentration for f2 is also defined as the highest concentration leading to cell viability approaching 100%. from the absorbance table (table 6), the concentration value was found to be 0.04 ppm, which is equivalent to a concentration of 0.029%. the results of the toxicity test for both f1 and f2 formulas showed values of 0.058% and 0.029%, respectively. these values indicate that the mouthwash formulas are non-toxic when used at concentrations lower than these figures. however, when considering the ic50 value, f1, with a value of 0.7032 ppm, is higher than f2, which has a value of 0.3206 ppm. this suggests that the toxicity of f2 is greater than that of f1 because, at a lower concentration, f1 can cause the death of approximately 50% of living cells compared to f2. it’s important to note that the toxicity values of the f1 and f2 mouthwash formulas in this study were much lower than the toxicity value of essential oil (myrrh oil) on fibroblast cells and human epithelial cells, as investigated by tipton et al. (2003) using the same method type. in addition to developing the ideal requirements of a mouthwash to achieve the best antimicrobial activity, there is an emphasis on the capability to maintain beneficial commensal species in the dental biofilm or saliva, which is an essential component of human health. this aspect holds promise for further study. understanding the interactions among potential herbs at the molecular level may hold the key to rationalizing herb combinations for future drug discovery. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11768] [page 97] non -co mmerc ial us e o nly conclusions this study concludes that both formulations of syzygium polyantha and piper betle have the potential to prevent gingivitis, with an effectiveness level nearly similar to chlorhexidine gluconate 2%. the toxicity value of formulation f1 is superior to that of formulation f2. references 1. amirabadi f, sasannejad. evaluation of the antimicrobial effects of various methods to disinfect toothbrushes contaminated with streptococcus mutans. int j med res health sci 5:536-540. 2. syaiful i, widodo adw, endraswari pd, et al. the association between biofilm formation ability and antibiotic resistance phenotype in clinical isolates of gram-negative bacteria: a cross-sectional study. bali med j 2023;12:1014-20. 3. visentin d, gobin i, maglica ž. periodontal pathogens and their links to neuroinflammation and neurodegeneration. microorganisms 2023;11:1832. 4. amado ppp, kawamoto d, albuquerque-souza e, et al. oral and fecal microbiome in molar-incisor pattern periodontitis. front cell infect microbiol 2020;10:583761. 5. sukhabogi jr, shekar cbr, hameed ia, et al. oral health status among 12and 15-year-old children from government and private schools in hyderabad, andhra pradesh, india. ann med health sci res 2014;4:141971. 6. sitanaya r, lesmana h, sunariani j, et al. the role of mastication in improving tgf-β levels on the inhibition of streptococcus sanguinis and streptococcus mutans in gingivitis. j int dent med res 2022;15:268-73. 7. kementrian kesehatan republik indonesia. badan penelitian dan pengembangan kesehatan. laporan-riskesdas-2018nasional. 2018. 8. metzemaekers m, gouwy m, proost p. neutrophil chemoattractant receptors in health and disease: double-edged swords. cellular molecular immunol 2020;17:433-50. 9. koppolu p, sirisha s, mishra a, et al. alkaline phosphatase and acid phosphatase levels in saliva and serum of patients with healthy periodontium, gingivitis, and periodontitis before and after scaling with root planing: a clinico-biochemical study. saudi j biol sci 2021;28:380-5. 10. hernawati s, aldianah bss, endah p, irmawati a. the effectiveness of red pomegranate (punica granatum linn) extract mouthwash against the number of oral bacteria colony. malaysian j med health sci 2020; https://repository. unair.ac.id/124139/ 11. shin ar, nam sh. antimicrobial effects of various methods for the disinfection of contaminated toothbrushes. biomed res 2018;29:2880-4. 12. nordin r, roslan ma, fathilah ar, et al. evaluation of in vitro antifungal effects of synthetic and herbal mouth rinses on oral candida albicans and candida glabrata. trop biomed 2022;39:302-14. 13. ramadhani y, rahmasari rrp, prajnasari kn, et al. a mucoadhesive gingival patch with epigallocatechin-3-gallate green tea (camellia sinensis) as an alternative adjunct therapy for periodontal disease: a narrative review. dent j 2022;55:114-9. 14. avriliyanti f, suparwitri s, alhasyimi aa. rinsing effect of 60% bay leaf (syzygium polyanthum wight) aqueous decoction in inhibiting the accumulation of dental plaque during fixed orthodontic treatment. dent j 2017;50:1. 15. ermawati fu, sari r, putri np, et al. antimicrobial activity analysis of piper betle linn leaves extract from nganjuk, sidoarjo and batu against escherichia coli, salmonella sp., staphylococcus aureus and pseudomonas aeruginosa. j phys conf ser 2021;1951:012004. 16. junairiah, rahmawati rk, manuhara ysw, et al. induction and identification of bioactive compounds from callus extract of piper betle l. var. nigra. malaysian j analytical sci 2020;24:1024-34. available from: https://mjas.analis.com.my/mjas/v24_n6/pdf/junairiah_24_6_ 20.pdf 17. junairiah j, ni’matuzahroh n, zuraidassanaaz ni, sulistyorini l. antifungal and antibacterial activity of black betel (piper betle l. var nigra) extract. biosci res 2017;14:750-5. 18. syahidah a, saad cr, hassan md, et al. in betel leaves, piper betle methanolic extract. pak j biol sci 2017;20:70-81. 19. atiya a, sinha bn, lal ur. bioactive phenylpropanoid analogues from piper betle l. var. birkoli leaves. nat prod res 2017;31:2604-11. 20. lee s-h, kim w-h, ju k-w, et al. antibacterial and antiinflammatory potential of mouthwash composition based on natural extracts. nato adv sci inst ser e appl sci 2021;11:4227. 21. murakami s, mealey bl, mariotti a, chapple ilc. dental plaque-induced gingival conditions. j clin periodontol 2018;45:s17-27. 22. how ky, song kp, chan kg. porphyromonas gingivalis: an overview of periodontopathic pathogen below the gum line. front microbiol 2016;7:53. 23. fernandes fha, salgado hrn. gallic acid: review of the methods of determination and quantification. crit rev anal chem 2016;46:257-65. 24. salikha k, narmada ib, alida a, et al. anti-inflammatory effect of caffeic acid phenethyl ester supplementation on tnfα and nf-κb expressions throughout experimental tooth movement in vivo. j pharm pharmacogn res 2022;10:103745. 25. fernandes t, bhavsar c, sawarkar s, d’souza a. current and novel approaches for control of dental biofilm. int j pharm 2018;536:199-210. 26. granica s, piwowarski jp, kiss ak. ellagitannins modulate the inflammatory response of human neutrophils ex vivo. phytomedicine 2015;22:1215-22. 27. vyas t, bhatt g, gaur a, sharma c, sharma a, nagi r. chemical plaque control a brief review. j family med prim care 2021;10:1562-8. 28. manipal s, hussain s, wadgave u, et al. the mouthwash war chlorhexidine vs. herbal mouth rinses: a meta-analysis. j clin diagn res 2016;10:zc81-3. 29. ting m, dahlkemper a, schwartz jj, et al. preprocedural viral load effects of oral antiseptics on sars-cov-2 in patients with covid-19: a systematic review. biomedicines 2023;11:1694 30. vergara-buenaventura a, castro-ruiz c. use of mouthwashes against covid-19 in dentistry. br j oral maxillofac surg 2020;58:924-7. 31. james p, worthington hv, parnell c, et al. chlorhexidine mouthrinse as an adjunctive treatment for gingival health. cochrane database syst rev 2017;3:cd008676. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 98] [healthcare in low-resource settings 2024;12:11768] non -co mmerc ial us e o nly 32. biber a, lev d, mandelboim m, et al. the role of mouthwash sampling in sars-cov-2 diagnosis. eur j clin microbiol infect dis 2021; http://dx.doi.org/10.1007/s10096-021-043204 33. vilhena fv, brito reia vc, da fonseca orcina b, et al. the use of antiviral phthalocyanine mouthwash as a preventive measure against covid-19. gms hyg infect control 2021;16:doc24. 34. kusuma iw, kuspradini h, arung et, et al. biological activity and phytochemical analysis of three indonesian medicinal plants, murraya koenigii, syzygium polyanthum and zingiber purpurea. j acupuncture meridian stud 2011;4:75-9. 35. kusumastuti n, jaya mka. activity of bay leaf extract (eugenia polyantha) as antiinflammatory in white rat (rattus norvegicus): narrative review. j pharmaceut sci appl 2022;4:26-32. 36. miao z, zhao y, chen m, he c. using flavonoids as a therapeutic intervention against rheumatoid arthritis: the known and unknown. pharmacolog res modern chinese med 2022;3:100014. 37. sousa m de m, lima rmt de, lima a de, et al. antioxidant action and enzyme activity modulation by bioaccessible polyphenols from jambolan (syzygium cumini (l.) skeels). food chem 2021;363:130353. 38. serafini m, peluso i, raguzzini a. flavonoids as anti-inflammatory agents. proc nutr soc 2010;69:273-8. 39. tipton da, lyle b, babich h, dabbous mk. in vitro cytotoxic and anti-inflammatory effects of myrrh oil on human gingival fibroblasts and epithelial cells. toxicol in vitro 2003;17:30110. 40. guandalini cunha b, duque c, sampaio caiaffa k, et al. cytotoxicity and antimicrobial effects of citronella oil (cymbopogon nardus) and commercial mouthwashes on s. aureus and c. albicans biofilms in prosthetic materials. arch oral biol 2020;109:104577. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11768] [page 99] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11752 enhancing self-care in elderly patients: the impact of whatsapp reminder messages at the heart and vascular center hidayatus sya’diyah,1 dewi purnama sarira,2 diyan mutyah,3 ayu citra mayasari,2 sukma ayu candra kirana2 1nursing professional study program, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya; 2bachelor of nursing study program, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya; 3diploma in nursing program, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia abstract the importance of reminder messages lies in improving selfcare among heart disease patients. at the heart and vascular center, many patients, both those under ongoing care and those recently treated, do not consistently engage in self-care activities. reminder messages can encourage adherence to medication regimens. this study aimed to investigate the effectiveness of whatsapp reminder messages on the self-care of elderly patients at the heart and vascular center. the research employed a quasiexperimental design with a two-group preand post-test control design. using a probability sampling technique with simple random sampling, the study required 16 new patients in each group. the instrument used was the self-care heart failure index (schfi) questionnaire, consisting of 22 questions. data analysis was performed using the mann-whitney test. the results indicated that whatsapp reminder messages are effective in enhancing patient self-care at the heart and vascular center at premier hospital surabaya (p-value<0.001). the mann-whitney test results post-intervention showed a p-value of 0.013, confirming the effectiveness of whatsapp reminder messages in improving self-care among patients. this study demonstrated a significant positive influence of whatsapp reminder messages on the selfcare of elderly patients at the heart and vascular center. these messages are an effective tool for improving patient self-care practices at premier hospital surabaya. introduction heart disease is a condition that requires attention and recognition of the existing risk factors in individuals. immediate action can be taken to prevent complications that may lead to undesirable consequences.1 heart disease is defined as a physiological condition wherein the heart fails to adequately pump blood to meet metabolic needs. it is marked by symptoms such as shortness of breath, intolerance to physical activity, and fatigue, which can impact daily activities.2 patients with heart disease require specialized care and attention. self-care for these patients involves recognizing signs and symptoms, adhering to prescribed treatments, monitoring body weight, taking medications regularly, maintaining proper fluid intake, and engaging in physical exercise.3,4 however, many patients at the heart and vascular center fail to adhere to independent care practices. they may not regularly monitor their medication, take prescribed medications consistently, or follow dietary recommendations and daily consumption habits.5,6 heart disease is a non-communicable disease and remains a significant global health concern. it represents one of the fastestgrowing cardiovascular diagnoses worldwide. according to data from the american heart association (2022),7 approximately 5.3 million americans are affected by heart disease, with 660,000 new cases diagnosed annually. the incidence of heart disease approaches 10 per 1,000 people over the age of 65. results from correspondence: diyan mutyah, diploma in nursing program, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia. e-mail: diyanmutyah@stikeshangtuah-sby.ac.id key words: heart failure; non-communicable disease; reminder; selfcare; whatsapp. contributions: hs, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing, supervision; dp, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; dm, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; ac, methodology, visualization, writing –review and editing; sa, resources, investigation, and writing – review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, stikes hang tuah surabaya. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to acknowledge the contribution of mentoring program conducted by the research centre of excellence in advancing community health (reach), surabaya, indonesia. received: 11 september 2023. accepted: 27 may 2024. early access: 16 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11752 doi:10.4081/hls.2024.11752 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 548] [healthcare in low-resource settings 2024;12:11752] non -co mmerc ial us e o nly the basic health research (2018),8 indicate that the prevalence of heart disease in all provinces of indonesia increases with age, with the highest prevalence observed among individuals aged 65-74 years (0.5%). the prevalence of heart disease diagnosed by doctors in indonesia is 0.13%. at premier surabaya hospital’s heart and vascular center, there were 4,572 patients treated for heart disease from january to october 2021, including both control patients and those recently treated. based on a preliminary study conducted by researchers, which involved interviewing 10 respondents, it was found that many respondents expressed a lack of understanding regarding post-treatment care upon returning home. heart disease occurs when the heart is unable to effectively pump blood to meet metabolic needs, often due to malfunctioning chambers caused by arrhythmias or excess fluid accumulation, leading to changes in heart function.9 individuals with heart disease commonly experience fatigue, orthopnea, and edema. a lack of understanding about self-care among heart disease patients can exacerbate their symptoms. for patients with heart disease experiencing health disturbances, increasing care and dependency on life support is crucial to identifying those at risk of deteriorating health.10 this can prevent patients from feeling like a burden to their families and reduce social isolation, ultimately improving their overall perception of health. adherence to treatment is paramount for the success of therapy in heart disease patients. it plays a significant role in managing symptoms, improving functional capacity, enhancing quality of life, reducing morbidity, and positively affecting prognosis.11,12 the primary management approach for patients with heart disease involves consistent adherence to independent care practices, including medication management, dietary adjustments, engagement in physical activity, fluid restriction, and participation in psychosocial activities.13,14 poor self-care management can increase the likelihood of heart disease recurrence. self-care practices significantly impact medical outcomes, particularly for patients with cardiovascular disease. studies have shown that patients who effectively adhere to self-care regimens experience better quality of life, lower mortality rates, and fewer hospital admissions compared to those with poor self-care habits.13,15 currently, premier surabaya hospital lacks specialized interventions aimed at promoting independent care for patients’ posttreatment. therefore, developing a health promotion model to enhance patient self-care within the heart and vascular center is crucial. one effective strategy to enhance patient care is to encourage patients to ask specific questions that can lead to improvements in their self-care practices.16,17 urgent efforts by healthcare professionals are needed to increase patient engagement in selfcare at the heart and vascular center, along with the implementation of a promotion model to boost patient visits. various intervention methods, such as telephone reminders, sms reminders, social media (such as whatsapp) message reminders, and mobile app reminders, have been utilized successfully in several countries.18,19 nurses, as professional healthcare providers, play a significant role in supporting patients with heart disease. however, it’s essential for nurses to empower patients to become independent in their self-care, rather than fostering dependency.20,21 other studies also demonstrate that reminder messages are effective not only between different groups but also within the same group. this underscores the importance of reminder messages not only in enhancing patient self-care but also in sustaining it. research indicates that reminder messages effectively prompt participants to take their medication, decrease instances of nonadherence due to reasons other than forgetfulness, and reduce medication interruptions or discontinuations. reminder messages can motivate patients to adhere to their medication regimen. these findings align with a study by khonsari and subramanian, which revealed that two-thirds of patients perceived reminders positively.22 the purpose of this study was to investigate the effectiveness of whatsapp reminder messages on the self-care of elderly patients at the heart and vascular center. materials and methods this research utilized a quasi-experimental design with a twogroup preand post-test control design. the study sampled patients registered at the heart and vascular center of premier hospital surabaya who met specific inclusion criteria: being new patients registered at the center and possessing mobile phones with whatsapp applications. all new patients meeting these criteria were included as respondents. based on sample size calculations using the federer formula, 16 new patients were required in each group. the study employed a probability sampling technique with simple random sampling. participants were initially divided into two groups: the intervention group, which received whatsapp message reminders, and the control group, which did not. baseline measurements of patient self-care were taken for both groups, covering various aspects such as medication adherence, dietary habits, and physical activity levels. subsequently, the intervention group commenced receiving standardized whatsapp reminders promoting self-care behaviors, including medication prompts and dietary recommendations, for a duration of two weeks. meanwhile, the control group maintained their regular care routine at the heart and vascular center without receiving any reminders. after this period, post-intervention measurements of patient self-care were conducted for both groups, mirroring the pre-test assessments. statistical analysis then compared preand post-test measurements within and between groups to assess the impact of whatsapp reminders on patient self-care efficacy at the heart and vascular center. the independent variable in this study was the whatsapp message reminder, while the dependent variable was patient self-care at the heart and vascular center of premier hospital surabaya. self-care was assessed using the self-care heart failure index (schfi), comprising 22 questions related to nutritional diet rules, medication adherence, activity levels, understanding of the disease, fluid restrictions, timely treatment, and emergency education. the analysis utilized the wilcoxon test and the mann-whitney test with a significance level of p≤0.05. results before the intervention (table 1), the majority of the control group, consisting of 10 respondents (62.5%), were aged 65 or older, while in the treatment group, the majority, comprising 9 respondents (56.3%), were in the same age category. concerning education, in the control group, most respondents (56.25%) had senior high school education, and in the treatment group, the majority (62.5%) also had senior high school education. regarding gender distribution, the control group included an equal number of female (50%) and male (50%) respondents, while in the treatment group, there were slightly fewer female respondents (37.5%) compared to male respondents (62.5%). table 2 reveals the self-care categories before and after the intervention in both groups. in the treatment group, the pre-test transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11752] [page 549] non -co mmerc ial us e o nly showed that 87.5% of respondents had poor self-care, which decreased to 12.5% post-test. similarly, the control group exhibited a high proportion of poor self-care (81.25% pre-test), shifting to 62.5% post-test. statistical analysis demonstrated a significant improvement in self-care following whatsapp reminders, with the majority experiencing enhanced self-care in both groups. the wilcoxon and mann-whitney tests confirmed the effectiveness of whatsapp reminders in enhancing patient self-care. the table also highlights the effectiveness of whatsapp reminder messages on patient self-care. the post-test control group showed a decrease in poor self-care from 81.25% to 62.5%, while the intervention group exhibited improved self-care, increasing from 12.5% to 81.25% in good self-care. the p-value of 0.013 indicates a statistically significant difference in self-care improvement between the treatment and control groups post-intervention. this confirms that the whatsapp reminder messages were more effective in enhancing self-care behaviors compared to the control group that did not receive the reminders. discussion self-care of patients in the surabaya treatment group before and after being given a whatsapp reminder message the self-care evaluation before and after the intervention in the surabaya treatment group reveals noteworthy trends. respondents aged over 65 years tend to exhibit poor self-care practices. this aligns with findings by ponikowski et al. (2014),23 which associate increased age with a higher risk of heart disease and heart failure. adequate self-care adherence is pivotal for successful therapy. however, it’s noteworthy that caregivers often rely more on familial or hospital care than engaging in independent care practices themselves.24 moreover, the results indicate that respondents of male gender tend to have poorer self-care practices. this could be attributed to men’s tendency to lack self-confidence and to not prioritize self-care practices. this observation aligns with research conducted by riegel, dickson, and vaulkner (2015), which suggests that self-care behavior is influenced by various individual characteristics, including age, gender, and education level.25 self-care of patients in the control group before and after being given a whatsapp reminder message in the control group data, 10 out of 13 respondents, or 62.5%, maintained poor self-care, while in the treatment group, 11 out of 14 respondents, or 68.8%, improved to good self-care from their initial status of poor self-care. these findings suggest that after receiving whatsapp reminder messages, the majority of respondents exhibited a positive behavioral change, specifically in the form of improved self-care. this aligns with the findings of pool et al. (2017)26 who highlighted the effectiveness of reminding clients to ask specific questions that lead to changes in their care as an intervention strategy. several studies have observed the efficacy transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 550] [healthcare in low-resource settings 2024;12:11752] table 1. characteristics of respondents before intervention in both control and treatment groups (n=32). control group treatment group characteristics number of respondents percentage (%) number of respondents percentage (%) age <65 years 6 37.5 7 43.7 ≥65 years 10 62.5 9 56.3 self-care categories good 3 18.7 2 12.5 bad 13 81.3 14 87.5 education elementary-junior high school 3 18.75 2 12.5 senior high school 9 56.25 10 62.5 bachelor/diploma degree 4 25 4 25 gender female 8 50 6 37.5 male 8 50 10 62.5 total 16 100 16 100 table 2. self-care evaluation before and after whatsapp reminder messages. group test self-care category number of respondents percentage (%) p treatment pre-test poor 14 87.5 0.001* good 2 12.5 post-test poor 3 18.75 good 13 81.25 control pre-test poor 13 81.25 0.083* good 3 18.75 post-test poor 10 62.5 good 6 37.5 p 0.013** *wilcoxon test; **mann whitney test; p<0.05 non -co mmerc ial us e o nly of this approach in improving preventive services such as immunization. the information-motivation-behavioral skills model suggests that interventions based on this framework can effectively influence behavioral change across various clinical applications.27 the researcher posits that providing whatsapp reminder messages to the treatment group of patient respondents at the heart and vascular center at premier surabaya hospital contributed to their increased awareness and motivation to engage in independent selfcare practices. the persistence of poor self-care among many respondents in the control group may be attributed to a lack of information or forgetfulness regarding self-care practices, leading to a lack of motivation.28 since the control group did not receive whatsapp reminder messages, there was no significant change observed in this group. effectiveness of whatsapp reminder messages on patient self-care studies indicate that whatsapp reminder messages are effective in reducing forgetfulness and instances of missed care, thereby promoting the resumption of care routines. these messages can also encourage patients to take more initiative in their self-care practices. these findings align with the study conducted by khonsari and subramanian, which revealed that two-thirds of patients perceived whatsapp reminder messages as helpful in reducing forgetfulness.22 in an article discussing the long-term effects of whatsapp reminder services, it is suggested that these reminders assist patients in recalling the steps necessary for independent care amidst their busy schedules, leading to a sense of being cared for by healthcare providers or hospitals, thereby motivating them to prioritize self-care.29 several respondents expressed gratitude for the whatsapp reminder messages, stating that they found them particularly helpful during busy or reluctant moments. some even requested for the continuation of whatsapp reminder messages within the hospital setting. conclusions based on the research findings, it can be concluded that before receiving whatsapp reminder messages, patient self-care at the heart and vascular center at premier surabaya hospital was predominantly categorized as poor. however, after the implementation of whatsapp reminder messages, there was a notable increase in self-care, with the majority transitioning from poor to good selfcare. this indicates a significant improvement in patient self-care following the intervention of whatsapp reminders. therefore, it can be concluded that whatsapp reminder messages are effective in enhancing patient self-care at the heart and vascular center at premier surabaya hospital. references 1. world health organization (who). cardiovascular disease. 2023. available from: https://www.who.int/health-topics/cardiovascular-diseases#tab=tab_1 2. roth ga, mensah ga, johnson co, et al. global burden of cardiovascular diseases and risk factors, 1990-2019: update from the gbd 2019 study. j am coll cardiol 2020;76:29823021. 3. jaarsma t, hill l, bayes-genis a, et al. self-care of heart failure patients: practical management recommendations from the heart failure association of the european society of cardiology. eur j heart fail 2021;23:157-74. 4. clark am, spaling m, harkness k, et al. determinants of effective heart failure self-care: a systematic review of patients’ and caregivers’ perceptions. heart 2014;100:716-721. 5. baroletti s, dell’orfano h. medication adherence in cardiovascular disease. circulation 2010;121:1455-8. 6. kolandaivelu k, leiden bb, o’gara pt, bhatt dl. nonadherence to cardiovascular medications. eur heart j 2014;35:3267-76. 7. tsao cw, aday aw, almarzooq zi, et al. heart disease and stroke statistics—2022 update: a report from the american heart association. circulation 2022;145:e153-639. 8. badan penelitian dan pengembangan kesehatan kemenkes. 2018. available from: https://garuda.kemdikbud.go.id/publisher/view/135 9. schwinger rhg. pathophysiology of heart failure. cardiovasc diagn ther 2020;11:263-76. 10. riegel b, dickson vv, vellone e. the situation-specific theory of heart failure self-care: an update on the problem, person, and environmental factors influencing heart failure self-care. j cardiovasc nurs 2022;37:515-29. 11. rashidi a, kaistha p, whitehead l, robinson s. factors that influence adherence to treatment plans amongst people living with cardiovascular disease: a review of published qualitative research studies. int j nurs stud 2020;110:103727. 12. wu j-r, moser dk. medication adherence mediates the relationship between heart failure symptoms and cardiac eventfree survival in patients with heart failure. j cardiovasc nurs 2018;33:40-6. 13. nuraeni a, sugiharto f, anna a, et al. self-efficacy in self-care and its related factors among patients with coronary heart disease in indonesia: a rasch analysis. vasc health risk manag 2023;19:583-93. 14. permana ra, sudarmaji wp, samudera ws, et al. homebased exercise training for heart failure patients. j ners 2019;14:155-60. 15. fitriah f, haris m, mufarikah, et al. analysis factors related to coronary heart disease prevention in families by adolescents: a cross-sectional study. indian j public heal res dev 2019;10: 1708-13. 16. yamanie n, lamuri a, felistia y, et al. importance of social support for indonesian stroke patients with depression. f1000research 2022;11:1484. 17. yunara y, efendi f, makhfudli. technologyand non-technology-based primary healthcare innovations for the elderly: a systematic review. enferm clin 2023;33:s60-5. 18. abqari u, van ’t noordende at, richardus jh, et al. strategies to promote the use of online health applications for early detection and raising awareness of chronic diseases among members of the general public: a systematic literature review. int j med inform 2022;162:104737. 19. karingga dd, efendi f, indarwati r, bushy a. effect of mobile structured educational applications on self-care management in diabetes mellitus patients. gac med caracas 2023;131:278-86. 20. juárez-vela r, durante á, pellicer-garcía b, et al. care dependency in patients with heart failure: a cross-sectional study in spain. int j environ res public health 2020;17:7042. 21. ellina ad, kusnanto, adiutama nm, et al. evaluation of patient satisfaction and nurse caring behaviour: based on swanson’s theory. indian j public heal res dev 2019;10: 2698-702. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11752] [page 551] non -co mmerc ial us e o nly 22. khonsari s, subramanian p, chinna k, et al. effect of a reminder system using an automated short message service on medication adherence following acute coronary syndrome. eur j cardiovasc nurs 2015;14:170-9. 23. ponikowski p, anker sd, alhabib kf, et al. heart failure: preventing disease and death worldwide. esc hear fail 2014;1:425. 24. susanto j, makhfudli m, yusuf a, et al. correlation between family support and self-care behavior of heart failure patients. malaysian j public heal med 2022;22:253-8. 25. riegel b, dickson vv, faulkner km. the situation-specific theory of heart failure self-care: revised and updated. j cardiovasc nurs 2016;31:226-35. 26. pool j, reitsma gm, van den berg dn. revised community of inquiry framework: examining learning presence in a blended mode of delivery. online learn 2017;21:153-65. 27. chang sj, choi s, kim s-a, song m. intervention strategies based on information-motivation-behavioral skills model for health behavior change: a systematic review. asian nurs res (korean soc nurs sci) 2014;8:172-81. 28. widjaja kk, chulavatnatol s, suansanae t, et al. knowledge of stroke and medication adherence among patients with recurrent stroke or transient ischemic attack in indonesia: a multicenter, cross-sectional study. int j clin pharm 2021;43:666-72. 29. akhu-zaheya lm, shiyab wy. the effect of short message system (sms) reminder on adherence to a healthy diet, medication, and cessation of smoking among adult patients with cardiovascular diseases. int j med inform 2017;98:65-75. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 552] [healthcare in low-resource settings 2024;12:11752] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11789 effect of e-duva application on knowledge and attitude of visual inspection using acetic acid (via) among women of childbearing age jasmawati jasmawati, siti raihanah, ratna wati health polytechnic of the ministry of health of east kalimantan, samarinda, indonesia abstract e-duva is an application model designed to introduce innovations for delivering information and education about visual inspection with acetic acid (via) tests. the use of the e-duva application can facilitate access to information and education for mothers without the need to visit a healthcare facility to learn about the via test. this study aimed to assess the effectiveness of the e-duva application on the knowledge and attitudes of women of childbearing age (wus). the study population comprised women of childbearing age (wus). we employed a quasi-experimental research design with a pretest-posttest design using non-probability purposive sampling. the total sample size in this study was 30 respondents, with 15 women in the control group and 15 women in the intervention group. a questionnaire was used to assess the knowledge of wus regarding cervical cancer and the via test. statistical analysis was conducted using the paired t-test. the study results indicate a significant increase in knowledge in both the experimental group (p=0.000; mean sd 90.88±6.9) and the control group (p=0.000; mean sd 78.40±10.1). attitudes toward early detection of cervical cancer were significantly related (p=0.015). this suggests that a more positive attitude towards early detection of cervical cancer among wus is associated with a greater willingness to undergo cervical cancer screening. the findings of this study support the role of the e-duva application in enhancing the knowledge and attitudes of women of childbearing age regarding via tests and cervical cancer, emphasizing the potential of technology-driven health education in improving women’s health outcome. introduction cervical cancer, also known as cervical carcinoma, is a malignant tumor that primarily affects the surface layer (epithelium) of the cervix or uterine cervix.1 infection from the human papillomavirus (hpv) is the leading cause of cervical cancer.2,3 hpv is transmitted through sexual intercourse and is responsible for approximately 95% of cervical cancer cases.4 according to the world health organization (who), approximately 490,000 women worldwide are diagnosed with cervical cancer annually.5 in indonesia, it is estimated that there are 40-45 new cases daily, resulting in 20-25 fatalities, equating to approximately one woman losing her life to cervical cancer every hour.6 this staggering statistic implies that indonesia faces the loss of 600-750 productive women every month.7 the lack of knowledge among women about cervical cancer often leads to delays in diagnosis, resulting in patients presenting with advanced cancer stages, weakened overall health, low socioeconomic status, and limited access to healthcare resources, facilities, and infrastructure.8 the increasing incidence of cervical cancer can also be attributed to the absence of effective screening programs for early detection and treatment of pre-cancerous conditions.9 the coverage of early detection for cervical cancer through via tests remains very low at approximately 5%,10 despite the potential for early detection to significantly reduce morbidity and mortality rates.11 understanding the importance of the via test is vital for fostering the willingness and awareness needed for its correspondence: jasmawati jasmawati, health polytechnic of the ministry of health of east kalimantan, samarinda, indonesia e-mail: jaswatijaswati@gmail.com key word: via; wus; e-duva; application. contributions: jw, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing,conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; sr, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; rw, methodology, visualization, writing – review & editing, conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes kalimantan timur, based on ethical certificate dl.02.03/4.3/10434/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 september 2023. accepted: 25 october 2023. early access: 14 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11789 doi:10.4081/hls.2023.11789 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed [page 136] [healthcare in low-resource settings 2023; 11:11789] non -co mmerc ial us e o nly adoption.12 as of 2019, the screening coverage for early detection of cervical and breast cancer in indonesia was still minimal, with only 909,099 screenings (3.5%), 49,659 positive via results (5.93%), and 1,086 suspected cervical cancer cases (1.2 per 1,000 people).13,14 an ideal screening implementation should reach 80% of the female population in a given area.15,16 attitudes remain a significant barrier for women of childbearing age (wus) when it comes to early detection of cervical cancer.17 shifting people’s attitudes toward early detection can be achieved through health behavior interventions.18 factors associated with attitudes regarding cervical cancer early detection screening include knowledge and maternal age.19 among these factors, attitude is the most influential in motviating mothers to undergo via tests.20 negative attitudes toward the via test often result from a lack of awareness regarding its significance, leading women to underestimate its importance.21 modern health services are increasingly embracing smartphone applications, providing individuals with convenient access to information irrespective of time and location.22 these applications, which operate on smartphones, offer a wide range of functions.23 the rapid advancement of technology has permeated all aspects of life, offering tools that enhance daily activities.24 as per health regulations, technology plays a pivotal role in disease prevention, allowing health workers to leverage the widespread availability of smartphones for disease prevention and control.25,26 “e-duva” is an application model developed to deliver information and education about via tests. e-duva, short for education for via test, simplifies access to information and education for mothers, eliminating the need for them to visit healthcare facilities to learn about the via test. the e-duva application only requires a one-time download and can be used continuously without an internet connection. given this description, our research aims to investigate the effectiveness of the e-duva application among women of childbearing age. materials and methods the study population consisted of women of childbearing age in the samarinda region who visited the clinic and puskesmas. this research employed a quasi-experimental research design with a pretest-posttest design and a control group. this design was utilized to assess the effectiveness of the educational application of via test (e-duva) on women of childbearing age (wus) through purposive sampling. in this study, the independent variable was the application of the educational application of via test (e-duva), and the dependent variable was the change in knowledge and attitude of wus. the sampling technique used in this study was non-probability sampling. the total sample size was 30 respondents, with 15 women in the control group and 15 women in the intervention group. a questionnaire was employed to gauge the level of knowledge among wus regarding cervical cancer and the via test. the research utilized the paired t-test. respondents in this study used the e-duva application five times over a two-week period. inclusion criteria encompassed women of childbearing age who were married, willing to participate in the study, possessed a smartphone, were aged between 20 and 35 years, and could operate it. exclusion criteria included individuals who did not have a smartphone or had a smartphone but were unable to operate it. the intervention group received education through the application, while the control group received education through a leaflet. ethical clearance was obtained with the number dl.02.03/4.3/ 10434/2022 from poltekkes kemenkes kalimantan timur. respondents were provided with explanations on how to complete informed consent. they were also informed about the potential risks associated with the study and were granted the right to withdraw voluntarily. no coercion was exerted during this study. results based on the information presented in table 1, it is evident that the most common age group in this study was 25-28 years, comprising 33.3% of the total sample, and 40% in the control group. additionally, the most common parity in this study was primipara, with 60% of the total sample and 26.7% in the control group. based on the data presented in table 2, it is evident that in the intervention group using the e-duva application, the mean value increased from 70.40 in the pretest to 90.88 in the post-test. in the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondents' characteristics based on age, and parity. characteristic groups intervention n (%) control n (%) age/mean ±sd 28.33±4.1 29.27±3.9 20-24 3 (20) 0 (0) 25-28 5 (33.3) 6 (40) 29-32 5 (33.3) 7 (46.7) 33-35 2 (13.3) 2 (13.3) parity primipara 9 (60) 11 (73.3) multipara 6 (40) 4(26.7) total 30 (100%) 30 (100%) [healthcare in low-resource settings 2023; 11:11789] [page 137] table 2. mean difference between pretest and posttest score on the application of educational application for via test (e-duva) in experimental group and control group. group mean p pretest sd post-test sd experiment 70.40 11.4 90.88 6.9 0.000* control 71.20 11.1 78.40 10.1 0.000* *p<0.05. non -co mmerc ial us e o nly control group that received the leaflet, there was an increase in the mean value from 71.20 in the pretest to 78.40 in the post-test. the results of the paired sample t-tests conducted on both groups indicated a p-value of <0.05. this suggests that there is a significant difference between the pretest and post-test values in both the experimental and control groups. this significant difference signifies an increase in knowledge in both the experimental and control groups. based on the data presented in table 3, it is evident that there is a significant relationship between attitude towards early detection of cervical cancer and the p-value is 0.015. this finding indicates that as women of childbearing age (wus) develop a more favorable attitude towards early detection of cervical cancer, they are more likely to be willing to undergo early detection measures for cervical cancer. discussion the e-duva application can be categorized as mobile learningbased educational media. this classification aligns with the definition of mobile learning, which involves learning where learners are not confined to a specific location and utilize mobile technology devices for educational purposes. the e-duva application offers several advantages, including compatibility with android-based devices, attractive and easily understandable presentation of materials, and the inclusion of engaging images. the smaller increase in knowledge scores observed in the control group can be attributed to the fact that it relied solely on visual information. additionally, the content provided in the leaflet was more limited and concise in comparison to the material accessible to the intervention group through the e-duva application. this observation aligns with edgar dale’s cone theory, which posits that the effectiveness of teaching aids is influenced by the extent to which knowledge is delivered through the five senses.27 the more senses involved in learning, the richer and clearer the knowledge acquired.28 in the intervention group using the e-duva application, there was a noticeable increase in the mean score, rising from 70.40 in the pretest to 90.88 in the post-test. conversely, in the control group, which received information through leaflets, the mean score increased from 71.20 in the pretest to 78.40 in the post-test. this finding corroborates previous research indicating that health promotion via mobile phones is easily accepted due to the convenience and confidentiality of interactions on mobile platforms, which offer simpler and more informative content.29 providing health-related information, particularly regarding sexually transmitted infections (stis), through mobile media has been shown to enhance respondents’ knowledge about reproductive health and stis.30 text messaging programs have also proven effective in improving knowledge of reproductive health.31 the significant relationship between a positive attitude toward early detection of cervical cancer (with a p-value of 0.015) highlights the correlation between attitude and the willingness to undergo cervical cancer early detection checks.32 this aligns with previous research that suggests smartphone applications effectively influence women’s positive attitudes toward early detection of cervical cancer.33 presenting information in a visually engaging manner is considered more effective and efficient than traditional methods. smartphone applications aid in comprehension by displaying interesting visual elements, making respondents more engaged, receptive, and less likely to find the material boring.34 efficient information dissemination about the via test is achieved through health education, which aims to improve the knowledge and attitudes of women of childbearing age.35 the relationship between good knowledge of the via test and a positive attitude is evident in the motviation to undergo the via test. attitude reflects a mother’s preference and is a significant influence on the decision to undergo the via test.36 attitude represents a person’s response to a stimulus or object, which is not directly observable but can be inferred from their behavior. women of childbearing age should not only possess knowledge about early detection of cervical cancer through the via method but also exhibit it in their attitudes 37. women with a positive attitude are more likely to seek early detection of cervical cancer through the via test38 attitude represents a person’s response to a stimulus or object,39 which is not directly observable but can be inferred from their behavior. women of childbearing age should not only possess knowledge about early detection of cervical cancer through the via method but also exhibit it in their attitudes.40 women of childbearing age should not only possess knowledge about early detection of cervical cancer through the via method but also exhibit it in their attitudes.41 women with a positive attitude are more likely to seek early detection of cervical cancer through the via test.42 convenient access to information plays a pivotal role in changing health behaviors, especially in promoting early detection of cervical cancer. the accessibility of health information is a determining factor in the level of knowledge and attitudes, ultimately influencing the behavior of women of childbearing age.43,44 the eduva application streamlines access to information and education, eliminating the need for physical visits to healthcare facilities. it requires a one-time download and can be used offline. however, the study identified limitations, including the application’s size (about 21 mb), which may challenge users with limited smartphone memory. additionally, the application is not compatible with ios devices, and some smartphones may have stringent security settings that hinder installation, which can be addressed by adjusting these settings to allow for installation. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. attitude about the application of educational application for via test (e-duva). variables yes no p n % n % attitude 0.015* support 47 85.5 8 14.5 not supportive 27 64.3 15 35.7 *p<0.05. [page 138] [healthcare in low-resource settings 2023; 11:11789] non -co mmerc ial us e o nly conclusions the e-duva application has been effectively developed to provide information about via examinations, cervical cancer, and guidelines for assessing the nutritional status of women of fertile age (wus). it underscores the importance of technology-based health education as a means to enhance public awareness, particularly among women of childbearing age. given the widespread use of smartphones in today’s society, educational resources in the form of android applications are essential and deserve further development. furthermore, the e-duva application has been demonstrated to successfully enhance the knowledge and attitudes of women of childbearing age concerning via tests and cervical cancer. this underscores the significance of leveraging technology and mobile applications to promote health education and improve outcomes in women’s health. references 1. eyanoer p, sarumpaet s. community empowerment of early detection of cervical cancer. proceedings of the international conference of science, technology, engineering, environmental and ramification researches (icosteerr 2018) research in industry 4.0. 2020; 794-798. available from: https://www.scitepress.org/papers/2018/100912/ 100912.pdf 2. sidabutar s, martini s, hargono r. the effect of model intervention towards the intention of early detection of cervical cancer with via test. ind j forensic med toxicol 2020;14. 3. izza a, mulawardhana p, handayani s. knowledge, attitude, and culture influence visual inspection with acetic acid service use. jurnal ners 2020;2:2502-5791. 4. nadrah n, jolyarni d n, nasution f. the relationship between knowledge and attitudes of women of reproductive age regarding early detection of cervical cancer with iva examination. ijpasr 2023;4:29-38. 5. jufri t, katmini k. implementation of theory of planned behaviors to participation and iva examination in female age women. jqph 2021;5:107-19. 6. muhith a, winarti e, idola perdana ss, et al. internal locus of control as a driving factor of early detaction behavior of servical cancer by inspection visual of acetic acid method. open access maced j med sci 2020;8:113-6. 7. izugbara co. women’s understanding of factors affecting their reproductive health in a rural ngwa community. afr j reprod health 2000;4:62-8. 8. liana y, herlina h. science midwifery factors associated with iva test as early screening for cervical cancer in women of reproductive age. science midwifery 2023;11:2721-9453. 9. nuryana r, salmah u, russeng ss. determinant early detection cervical cancer pus with via in the health center of galesong north takalar. enferm clin 2020;30:367-70. 10. triana w, fitriani s, susilawati e. effectiveness of health promotion through video media and leaflets about early detection of cervical cancer using the visual inspection method of  acetic acid (iva) at talang banjar community health center jambi city 2020. proceedings of the 3rd green development international conference (gdic 2020) 2021. 11. dewi tk, massar k, ruiter rac, leonardi t. determinants of breast self-examination practice among women in surabaya, indonesia: an application of the health belief model. bmc public health 2019;19:1-8. 12. haryani h. the effects of husband support, motivation, and self-efficacy on the examination of visual inspection of acetic acid (iva) in karawang village, karawang health center, and sukabumi regency in women of childbearing age (pus). jurnal keperawatan komprehensif 2022;8:10-9. 13. aprilia r, arsin aa, masni. determinants of early detection of cervical cancer with visual inspection with acetic acid method among childbearing age women. enferm clin 2020;30:353-6. 14. arysha v, santosa h, sanusi s. the effect of extrinsic motivation on housewife actions in iva test in the working area of community health center at bandar kalipah. britain int exact sciences (bioex) j 2020;2:352-6. 15. salah ud din n. interpersonal factors of beneficiaries affecting reproductive health services of lady health workers. pakistan j soc res 2020;4. 16. kofuor e, darteh m, doku dt, esia-donkoh k. reproductive health decision making among ghanaian women. reprod health 2014;11:23. 17. sembiring r, dewi sipayung a, saripati harianja e, apriani nasution s. the relationship between motivation and attitude of women of reproductive age with early detection of cervical cancer. jurnal mutiara ners 2023;6:76-83. 18. firmana putri i, ferry f, bachtiar h. relationship between husband’s support, knowledge level, and motivation with iva examination behavior in women of childbearing ge in padang city. andalas obstetrics gynecol j 2021;5:50-5. 19. sagala hu, zuhriyah l, wayan i, indrawan a. perception of severity of women at high risk of cervic cancer about cervic cancer screening method iva. j res comm serv 2022;3:1182-7. 20. prima monica l, ulfa m. the correlation of the perception of early detection cervical cancer with attitude to do visual inspection with acetic acid. jurnal ners dan kebidanan 2020;7:232. 21. putri si, fajriah as, asiyah s, ellina ad. the health belief model and cervical cancer examination behaviour of women. the international virtual conference on nursing, kne life sciences 2022;7:726-37. 22. moita ph, sunarsih s, fatmawati f. role of counseling media on knowledge, attitudes and actions women of childbearing age in iva examination at east kolaka district. waluya the international science and health journal 2023;2:164-8. 23. chandler r, guillaume d, parker a, et al. developing culturally tailored mhealth tools to address sexual and reproductive health outcomes among black and latina women: a systematic review. health promot pract 2022;23:619-630. 24. lorenzetti l, plourde kf, rastagar sh, et al. analyzing program data and promotional approaches to inform best practices from a mobile phone-based reproductive health message program in afghanistan. digit health 2022;8. 25. feroz as, ali na, khoja a, et al. using mobile phones to improve young people sexual and reproductive health in low and middle-income countries: a systematic review to identify barriers, facilitators, and range of mhealth solutions. reproductive health 2021;18. 26. ahmed t. effect of mhealth tool on knowledge regarding reproductive health of school going adolescent girls: a beforeafter quasi-experimental study. bmc open 2020;10:1-8. 27. mulya gp, tampubolon mm, kurniawan d. experience of [healthcare in low-resource settings 2023; 11:11789] [page 139] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly women of reproductive age in early detection of cervical cancer through iva examination. jetish: journal of education technology information social sciences and health e-issn. 2023;2:1800-6. 28. imelda f, nasution ss, santosa h. predisposing, enabling and reinforcing factors of fertile age women in early detection of cervical cancer. enferm clin 2022;32:s39-43. 29. nurjanah s, tiara carolin b, husnul lail n. factors related to women of childbearing age (wus) participation in performing a visual inspection of acetic acid (iva) pamulang health center in 2022. nhsj 2022;2:102. 30. ginting l, teguh sm. science midwifery factors related to wca (women of childbearing age) in early detection of cervical cancer with iva method. science midwifery 2020;9(1). 31. la patilaya h, aja n. risk factors associated with early detection of cervical cancer by the iva method in women of childbearing age in the city of ternate. int j sci technol management 2021;2:1305-20. 32. habtu y, yohannes s, laelago t. health seeking behavior and its determinants for cervical cancer among women of childbearing age in hossana town, hadiya zone, southern ethiopia: community based cross sectional study. bmc cancer 2018;18(1). 33. kaila i, maree je. an exploration into the level and characteristics of pain experienced by south african women treated for cervical cancer. int j afr nurs sci 2018;8:141-8. 34. ochieng bm, smith l, orton b, et al. perspectives of adolescents, parents, service providers, and teachers on mobile phone use for sexual reproductive health education. social sci 2022;11:196. 35. kabakian-khasholian t, quezada-yamamoto h, ali a, et al. integration of sexual and reproductive health services in the provision of primary health care in the arab states: status and a way forward. sexual reproduct health matters 2020;28 36. susanti s, ningrum wm, sulistiyoningsih h, et al. description of factors of husband and health workers’ support towards cervical cancer detection behaviour in the child-bearing age at singaparna health centre, tasikmalaya sub-district. proceeding international conference universitas respatri yogyakarta 2019;798-805. 37. cahyono a, nurwijayanti n, wardani r. analysis of factors that influence the participation of women of childbearing age in the examination of visual acetic acid inspection (iva) in kanor public health center, bojonegoro regency. jqph 2021; 4:125-3. 38. rachmawati wc, devy sr, triyoga rs. health education exposure and subjective norms influence on female’s intention early detection of cervical cancer by visual inspection of acetic acid (avi) method. proceedings of the 1st international scientific meeting on public health and sports (ismophs 2019). 2020. available from: https://www.atlantis-press.com/proceedings/ismophs19/125947565 39. astuti ln, la ode ali hanafi, juslan. behavioral determinants of iva inspection in women of childbearing age. miracle j public health 2021;4:160-68. 40. sumarni we, nurcahyani l. perception of women of childbearing age on early detection of cervical cancer with iva test in the basic essential neonatal obstetric services cipeundeuy community health center subang regency. in: 1 st international seminar of gender, maternal, equity and child health (it’s gemich), 3 rd june 2021, kuningan. available from: http://repo.poltekkestasikmalaya.ac.id/189/ 41. surbakti e, santosa h, nurbani n, rochadi k. the influence of empowerment of women of childbearing age on cervical cancer prevention behavior. 2018 [cited 2023 jul 27]; available from: https://dupakdosen.usu.ac.id/ handle/123456789/4666 42. alomair n, alageel s, davies n, bailey j v. sexual and reproductive health knowledge, perceptions and experiences of women in saudi arabia: a qualitative study. ethn health 2022;27:1310-28. 43. purbowati n, junengsih j, putri nr, aticeh a. effect of cervical cancer early detection video on increasing women’s knowledge. jurnal ilmu dan teknologi kesehatan 2021;8:13042. 44. sari dj, lestari p, mulawardhana p. the performance of midwives in early detection of cervical cancer using visual inspection test with acetic acid. majalah obstetri ginekologi 2022;30:52-7. [page 140] [healthcare in low-resource settings 2023; 11:11789] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11757 the effectiveness of project-based learning on students’ academic achievement in emergency nursing study arista maisyaroh, eko prasetya widianto, syaifuddin kurnianto faculty of nursing, universitas jember, jember, indonesia abstract projects necessitate students to choose and identify constructive models of investigation and materials while employing appropriate strategies for conducting learning activities. however, the effectiveness of such methods in the context of nursing-specific education has not been extensively explored. this study aimed to assess the effectiveness of project-based learning in emergency and critical care nursing courses for nursing students. this study employed a pre-experimental design. the research sample consisted of 123 students enrolled in the emergency, critical, and disaster management nursing course at universitas jember. the research involved a comparison of students’ learning outcomes through written test questions before and after they completed a project. the results of the learning assessment before and after the project intervention were analyzed using the wilcoxon test. the results of the bivariate obtained a significance value of 0.0001. the results of this statistical test can be concluded that the project-based learning method is effective in increasing the knowledge of emergency, critical and disaster nursing. the project-based learning method proves to be effective in enhancing students’ comprehension of emergency, critical, and disaster nursing. nursing educational institutions can consider the incorporation of this method in curriculum design to create more effective learning strategies. it serves as a promising alternative for enhancing the quality of nursing education. further research is necessary to validate these findings and investigate various factors that may influence the effectiveness of project-based learning methods in the nursing context. introduction the lack of active involvement of students in conventional learning, can affect their academic achievement in the field of emergency nursing.1 furthermore, given the rapid advancements in medical technology and evolving practices in emergency nursing, there is an increasing demand for college students to attain a profound understanding and enhance their skills. an additional challenge is students’ ability to bridge theoretical knowledge to real-world practice, and the necessity to foster robust teamwork skills in urgent medical scenarios.1 thus, education will always be a form of investment in human resource development.2 the scientific attitude of the students in the class remains at a very low level. an evaluation, conducted using observation sheets to assess students’ scientific attitudes, revealed that approximately 79.31% of students in the class displayed a lack of scientific attitudes. throughout the learning process, aspects such as interest in acquiring knowledge, critical thinking skills, respect for data and facts, open-mindedness, cooperation, and perseverance remain at minimal levels. regarding curiosity, only eight students demonstrated enthusiasm in seeking answers when the lecturer posed questions, while the remaining 21 students simply listened without actively seeking answers to the questions raised by the teacher.3 the main benefit of education is as a talent developer with a systematic and focused strategy to make human resources more qualified with insights, attitudes, skills, abilities, and expertise in accordance with their fields both regionally, nationally, or internationally. learning strategies must be applied to adapt to the charcorrespondence: arista maisyaroh, faculty of nursing, universitas jember, jember, indonesia. e-mail: aristamaisyaroh@unej.ac.id key word: emergency and critical nursing; project-based learning; student. contributions: am, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; epw conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; sk, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of the faculty of nursing, universitas jember on november 24, 2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank universitas jember for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 18 october 2023. early access: 27 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11757 doi:10.4081/hls.2023.11757 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 90] [healthcare in low-resource settings 2023; 11:11757] non -co mmerc ial us e o nly acteristics or conditions. many learning models are used, one of which is project-based learning.2,4–6 the application of projectbased learning provides opportunities for each student to support active learning, provide teamwork skills, improve critical thinking, and develop communication skills. project-based learning is known to be more effective than other learning models in improving academic curriculum outcomes. the project-based learning model can be applied to students because this model has great potential to improve the experience of entering the world of work by practicing good collaboration.7–9 based on previous research, the project-based learning method can improve students’ scientific attitudes by increasing students’ activity, seriousness, and cooperation in attending lectures, and it is believed that this method is the most effective.10 the projectbased learning model is developed based on learning activities and the development of students’ thinking levels, making it easier for them to move according to their learning interests, abilities, and comfort. this model helps students to decide which projects to work on by identifying activities, and topics and formulating questions.10 project-based learning supports students in experiencing concepts and principles that will result in a product in the project, thereby significantly extending the learning experience.11 projectbased learning emphasizes choice, responsibility, autonomy, and working time to complete the project appropriately. project-based learning focuses on problems with concepts and principles to be solved.3 project-based learning is a learning process to achieve competence in skills, attitudes, and knowledge. in project-based learning, learning activities take place in heterogeneous groups using activities as media. this learning method uses problems to gather and integrate real-world experience with new knowledge. project-based learning is designed to be used to investigate and understand the complex problems required.12,13 through this project-based learning, students will learn concepts and learning strategies that match the characteristics of their experiences when receiving lessons that have been experienced. projects make students choose and find constructive investigation models, as well as materials with appropriate strategies to carry out learning activities. these investigations can be in the form of discovery or problem-solving, decision-making, design, invention, or model-building processes.14 the model-building process and to be called a project that meets the criteria of project-based learning, these activities must include the transformation and construction of knowledge on the part of students.14 learning using the projectbased learning method further improves students’ scientific attitudes, because project-based learning can improve students’ scientific attitudes.3 however, its effectiveness in nursing-specific learning has not been widely explored. this study aimed to determine the effectiveness of project-based learning methods in emergency and critical care nursing courses for nursing students. materials and methods research design this study employed a pre-experimental approach using a prepost-test design without a control group. the research was conducted according to the pre-established plan for the emergency nursing, critical care, and disaster management courses, utilizing the project-based learning model. study participants the population of this study was conducted on 5th semester students of the 2022-2023 academic year. the sample was selected using the total sampling method. specifically, the research sample included 123 students from the college of nursing specializing in emergency, critical, and disaster management at universitas jember. the inclusion criteria for this study required students to be willing to participate in lecture activities from week 1 to week 16 with a perfect attendance rate of 100%. additionally, they should not have attended bls, btcls, or similar training activities. the students should be actively enrolled in the class of 2020, 2019, or 2018. exclusion criteria included students who withdrew as respondents before the evaluation of the project-based method. the research procedure consisted of four stages. the first stage involved action planning, including the preparation of a semester learning plan, planning for project-based learning, preparing relevant learning media and resources, creating a sheet of work, crafting an observation sheet, and developing evaluation sheets. the second stage encompassed the implementation of the action. researchers applied the project-based learning model to emergency nursing, critical care, and disaster management courses. researchers, in collaboration with a partner lecturer, filled out observation guidelines and observation sheets to monitor the learning processes and outcomes. the third stage involved action observation, where researchers conducted observations and recorded all relevant activities during the implementation of the project-based learning program. this program involved a disaster simulation, which was assessed using an evaluation instrument consisting of 14 observation items. these items covered various aspects of students’ abilities, including triage, bandaging, evacuation, transportation, primary surveys, respiratory tract clearance, respiratory assistance, cardiopulmonary resuscitation, fluid resuscitation, bronchial hygiene, glucose monitoring, installation of ecg/bedside monitors, and the use of infusion or syringe pumps. each item was scored on a scale from 1 to 4, with a maximum score of 4 indicating the ability to perform the actions correctly and sequentially. lower scores denoted lower skill levels. variable, instrument and data collection the independent variables in this study encompass the implementation of project-based learning models, while the dependent variables include measurable student learning outcomes in the context of emergency, critical, and disaster nursing management courses. independent variables were assessed using an observation sheet in the form of a checklist, while dependent variables were measured using the project-based learning assessment sections specific to emergency, critical, and disaster nursing management. the preliminary data measurement (pre-test) took place prior to the respondents engaging in project-based learning tasks during the tenth week of classes. subsequently, from the eleventh to the fifteenth week of lectures, respondents completed project-based learning tasks in the form of simulations related to emergency, critical, and disaster nursing management. finally, during the sixteenth week, a post-test re-measurement of data was conducted using the project-based learning assessment sections for emergency, critical, and disaster nursing management. aspects of assessment related to emergency nursing or first aid. each aspect has a number of criteria to be evaluated, with scores given based on the extent to which the necessary action is implemented by the individual being evaluated. here is a brief explanation for each aspect: i) triage: this assesses the ability of individuals to implement start triage by giving a score based on how well they perform the start triage components (respiratory, [healthcare in low-resource settings 2023; 11:11757] [page 91] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly perfusion, and mental status). scores are given based on the correct amount and whether the components are executed in sequence; ii) beads: this evaluates the ability of individuals to do beads correctly. scores are given based on how well they do the assessment of beads needs, the selection of the right materials and tools, following the right procedures and techniques, and the proper evaluation and monitoring; iii) evacuation: it evaluates the ability of an individual to undertake evacuation actions, including an assessment of evacuating needs, the use of appropriate materials and tools, follow-up to the correct evacuating procedures and techniques, and appropriate evaluation and monitoring; iv) transportation: it assesses the ability of an individual to carry out transportation actions, including an assessment of transportation needs, the proper use of materials and tools, following the correct transportation procedures and techniques, and appropriate evaluation and monitoring; v) primary survey: this assesses the ability of individuals to conduct primary surveys in emergency situations. scores are given based on how well they can perform the airway, breathing, circulation, disability, and exposure (abcde) components, as well as whether they are performed in sequence; vi) respiratory release: this assesses the ability of an individual to perform proper respiratory release actions. scores are given based on how well they perform. they need assessments, the right materials and tools, the right procedures and techniques, and proper evaluation and monitoring; vii) respiratory assistance: this assesses the ability of individuals to provide proper respiratory assistance. scores are given based on the extent to which they can carry out needs assessments, use the right materials and tools, follow the right procedures and techniques, and conduct proper evaluation and monitoring; viii) pulmonary heart resuscitation: it assesses the ability of the individual to perform pulmonary heart resuscitations correctly, with an assessment of needs, the use of the right materials and tools, following the right procedures and techniques, and appropriate evaluation and monitoring; ix) liquid resuscitation: it evaluates the ability of an individual to carry out a proper fluid revitalization, including an assessment of needs, the use of appropriate materials and tools, following the correct procedures and techniques, and appropriate evaluation and monitoring; x) bronchial toilet: it assesses the ability of an individual to perform bronchial toilets correctly, with an assessment of needs, the use of the right materials and tools, following the right procedures and techniques, and appropriate evaluation and monitoring; xi) agd/glucose/ liquid monitoring: this assesses the ability of an individual to perform airway, respiration, circulation, glucose, or fluid monitoring properly, including needs assessment, proper use of materials and tools, following the correct procedure or technique, and appropriate evaluation and monitoring; xii) ecg/bed side monitor installation: this assesses the ability of an individual to install an ecg or bedside monitor correctly, including assessment of needs, proper use of materials and tools, following the correct procedure or technique, and appropriate evaluation and monitoring. instruments assessment of evaluation of project-based learning has been carried out reliability and validity test with the results of the test. before utilizing the simulation assessment instrument on all respondents, it was essential to conduct a validity and reliability test to assess the validity and consistency of the assessment items in the instrument. the results of the validity test indicated that the r-table value was 0.388, thereby concluding that all assessment items in the instrument were valid. subsequently, the assessment instrument underwent a reliability test using cronbach’s alpha, which yielded a cronbach’s alpha score exceeding 0.60 for all assessment instrument items, signifying the reliability of all assessment items. data analysis the results of pre-test and post-test measurements were then analyzed using a wilcoxon test to determine the impact of projectbased learning methods on improved student learning outcomes in emergency, critical, and disaster nursing management courses. ethical clearance the study received ethical approval from the health research ethics committee of the faculty of nursing, universitas jember on november 24, 2022. results the study findings describe the data collected during the study. the results of the study include the characteristics of the respondents and the results of the data analysis. in table 1, it was observed that the majority of respondents were female, accounting for as much as 83%, and the age group of 21-22 years constituted 81.3%. this suggests that nursing students, particularly women in their early twenties, dominate the sample, making them highly suitable for project-based learning. the results of the bivariate analysis in table 1, using the wilcoxon test on the group, obtained a significance value of 0.0001 (p<0.05). the results of this statistical test can be concluded that the pjbl method is effective in increasing the knowledge of emergency, critical and disaster nursing in diploma nursing study program students, faculty of nursing, universitas jember odd semester 2022/2023. table 2 conclude that the intervention has a statistically significant effect on the variable of interest, especially considering that all 125 cases showed a positive change (or rank). table 3 showed that the z-value and the p-value both indicate that the intervention had a highly statistically significant impact on the variable being measured. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents' characteristics (n=123). category frequency (n) presented (%) gender male 21 17 female 102 83 age (year) <20 4 3.25 21 -22 100 81.3 > 22 19 15.45 table 2. wilcoxon signed ranks test. n mean sum of rank ranks post intervention – pre intervention negative ranks 0a 0.00 0.00 positive ranks 125b 63.00 7875.00 ties 0c total 125 a,b,c ????? table 3. test statistics. post intervention – pre intervention z -9.702 asymp. sig. (2-tailed) 0.0001 [page 92] [healthcare in low-resource settings 2023; 11:11757] non -co mmerc ial us e o nly discussion one of the strategies to enhance student engagement in the classroom is to enhance the learning process. educators, as teachers, are encouraged to tap into their potential, including the application of innovative and creative teaching methods to boost student involvement. the project-based learning model significantly impacts students’ active participation in the learning process. in this context, ‘activeness’ refers to students taking on an active role in their learning, with educators guiding the direction of the material.15 project-based learning (pjbl) is one of the learning models that require students to be active and help each other to create projects that are discussed through discussion and collaboration. from the observation of learning activity, all aspects or indicators of students’ learning activity have reached the baseline of learning success in each cycle.16 based on the study’s findings, it is evident that students’ engagement in learning can be significantly enhanced through the implementation of the project-based learning model. in this approach, the teacher functions as a facilitator, guiding students to discover answers to essential questions. through project-based learning, students are empowered to explore a subject in various meaningful ways that resonate with them.17 students become accustomed to collaborative work, assessment is carried out through the measurement, monitoring, and evaluation of all learning outcomes, and there is ample room for the development of learning resources.18,19 implementing the project-based learning model in the emergency nursing course has yielded highly effective results. this is evident in the increased engagement of both students and teachers when employing the project-based learning model. this approach involves real-world assignments that encourage students to think actively, engage in creative problem-solving, and design and produce products related to their ongoing learning. consequently, knowledge is constructed by the students themselves, with the teacher serving as a facilitator. these findings align with several prior studies in this area.20,21 the pbl method has a positive impact on student performance in learning and academic achievement. this is also consistent with the results of previous research conducted, one of the project methods provided is that students are asked to design disaster simulation activities as their project assignments, where students are directly involved from planning to the evaluation of activities, where students are actively involved and design their simulation activities, and learn to collaborate with related parties such as the village chief regarding the facilitation of activity locations, with the researcher team and nursing laboratory regarding the loan of tools, other parties regarding the loan of ambulances, and coordination with their friends for role sharing.22,23 nursing students need to be equipped with disaster nursing competencies to adequately prepare graduates to participate when a disaster occurs. the results obtained from the disaster simulation project method given to students in emergency nursing learning are effective in increasing students’ understanding and technical skills in learning emergency nursing with the results of a p-value of 0.00001.24 as nurses who will work in various fields of public health services, nurses have challenges and responsibilities to provide nursing services to all levels of society and nurses must be able to adapt to their respective work areas.25-27 therefore, nursing students need to be able to adapt to the world of work at an early stage, so project-based learning trains them to adapt to their work environment by introducing cases from the world of work. this can increase students’ creativity in solving problems and finding effective solutions to various problems that arise in the world of work. this study has several limitations. it was conducted with a specific sample of students in the emergency nursing, critical care, and disaster management learning program within one course of study. this specificity may restrict the generalizability of the findings to other nursing programs or educational contexts. therefore, the results may not be directly applicable to a broader student nursing population. additionally, the study lacked control groups, employing a pre-experimental pre-post test design without a control group. this absence of control groups makes it challenging to discern whether improvements in learning outcomes are solely attributed to project-based learning methods or if other factors also influence the outcomes. the study did not account for external factors that might affect learning outcomes, including participants’ prior knowledge or individual differences. these unaddressed factors have the potential to confound the results and limit the isolated interpretation of project-based learning effectiveness. conclusions in conclusion, the research results demonstrate the effectiveness of the project-based learning method in enhancing students’ comprehension of emergency, critical, and disaster management nursing. the implications of this study suggest that nursing educational institutions should consider incorporating this method into their curriculum and learning strategies to enhance the overall quality of nursing education. further research is necessary to validate these findings and explore various factors that may impact the effectiveness of project-based learning methods in nursing education. a range of learning methods, such as project-based learning, the case method, and simulation, can be employed to improve students’ understanding. references 1. frenk j, chen lc, chandran l, et al. challenges and opportunities for educating health professionals after the covid-19 pandemic. lancet 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learning in remote teaching for undergraduate nursing students. rev da esc enferm 2022;56:1-8. 22. kanita mw, wulandari is. simulasi bencana bagi mahasiswa keperawatan: studi fenomenologi. j ilm kesehat media husada 2019;8:27-32. 23. martono m, satino s, nursalam n, et al. indonesian nurses’ perception of disaster management preparedness. chinese j traumatol = zhonghua chuang shang za zhi 2019;22:41-46. 24. widianto ep, maisyaroh a, fibriansaridst rd, et al. implementing disaster simulation for undergraduate nursing students. d’nursing heal j 2022;3:16-25. 25. widianto ep, maisyaroh a, fibriansari rd. the experience of nurses conducting nursing assessments of occupational diseases in the farm: a phenomenological study. digit repos univ jember 2022;130:867-928. 26. widianto ep, maisyaroh a, fibriansari rd, et al. nursing assessment in cases due to occupational work in the agricultural area: an analysis factor. malaysian j med heal sci 2023;19:63-67. 27. efendi f, kurniati a, savage e, 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[page 94] [healthcare in low-resource settings 2023; 11:11757] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master abstract the lack of knowledge, attitudes, and practice of preeclampsia mothers and spouses in preventing eclampsia affected the prevalence of eclampsia. a practical approach model was needed to increase knowledge, attitudes, and practices in preventing eclampsia. a mobile application that was effective, easy to use, and understandable was considered one of the solutions. this study aimed to develop an appropriate and user-friendly mobile application for preeclampsia mothers and spouses to prevent eclampsia. the study design was cross-sectional and was conducted in two stages. the first stage identified the content needs for eclampsia prevention in a mobile application. it involved 86 participants selected using the convenience sampling technique and a 20-item questionnaire. the second stage focused on mobile application development and usability testing using the skama (skala kebolehgunaan aplikasi mudah alih), which included a 10-item questionnaire with ten participants. statistical analysis included the distribution frequencies of variables related to content needs and the application’s usability, as assessed by beta testers using the skama questionnaire. out of the 20 questionnaire items assessing the level of need, the lowest percentage of strongly needed items for preeclampsia mothers was “recommended and prohibited activities” (65%). for spouses, it was “recommended and prohibited activities” and “equipment to be prepared” (88.2%). in the ten-item questionnaire, preeclampsia mothers scored the highest (50%) on the statement, “various functions are well integrated, and they learned to use the mobile application very quickly.” in comparison, spouses scored the highest (90%) on the statement, “the mobile application is easy to use, and they feel confident using it. all participants confirmed that the mobile application had the necessary content (appropriate). the results of the mobile application testing showed positive responses from pre-eclampsia mothers and spouses (user-friendly). it is essential to obtain support from policymakers and conduct periodic monitoring and evaluation of the application’s consistency to have implications for eclampsia prevention practices. introduction maternal mortality can be attributed to many factors. these factors allude to the mother’s role as both an object and a subject, particularly in the context of maternal knowledge and attitudes related to pre-eclampsia.1 based on the study’s results, it was found that the level of knowledge about pre-eclampsia and eclampsia among pregnant women was less than 47%.2 the lack of information and educational level contributes to the low level of knowledge. the level of knowledge and attitudes of mothers with pre-eclampsia is crucial in making decisions aimed at enhancing their health and preventing illness and mortality.3 in addition to the low levels of knowledge and attitude related to eclampsia cases, the inadequate practice of prevention among preeclampsia mothers is a substantial contributing factor to the occurrence of eclampsia.4 another factor that deserves attention is the limited involvement of family members, especially spouses, in supporting a mother during pregnancy.5 husbands need to be vig healthcare in low-resource settings 2024; volume 12:11785 development of a user-friendly mobile app for eclampsia prevention targeting preeclampsia mothers and spouses mamat mamat,1 tukimin sansuwito2 1politeknik kesehatan kemenkes bandung, bandung, indonesia; 2lincoln university college (luc), selangor, malaysia correspondence: mamat mamat, politeknik kesehatan kemenkes bandung, indonesia. e-mail: mamat.researcher@gmail.com key words: eclampsia prevention; mobile application; mother; spouse. contributions: mm, preliminary, conceptual of subject research, methodology, data collection, data analysis, result tabulating, data management, results and discussion, collecting of references; ts, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; edit manuscript. conflict of interest: all of the authors declared no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission at politeknik kesehatan kemenkes bandung, indonesia, with the following ethical certificate number: 13/kepk/ec/iv/2022. during the research, the researcher emphasised the ethical principles of informed consent, respect for human rights, goodwill, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. funding: this research was supported by a research grant dipa politeknik kesehatan kemenkes bandung, contract number: bn.01.02/3.10/p.1964.1/date 10/3/2022 availability of data and materials: all data generated or analysed during this research are included in this published article. acknowledgements: we want to be thankful to the director and funding staff of politekkes bandung, who were supported by funding from dipa. thank you to the director of health polytechnic bandung ministry of health and head of office health district. karawang has supported and facilitated research activities. received: 12 september 2023. accepted: 17 november 2023. early access: 30 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11785 doi:10.4081/hls.2023.11785 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11785] [page 17] non -co mmerc ial us e o nly ilant and prepared for the possibility of emergencies during pregnancy and childbirth.6 a study indicated that, on average, spouses played a minimal role when their wives were pregnant and during delivery, particularly in domestic responsibilities and social functions.7 increasing awareness, fostering a sense of responsibility, and garnering family support (mainly from spouses), which includes preparing necessary funds and facilities for anticipatory measures, are essential steps to ensure the safety of pregnant mothers. based on a study conducted through interviews with five pregnant mothers with pre-eclampsia and their partners, it was discovered that the majority lacked knowledge about pre-eclampsia, what steps to take, and how to ensure safe delivery without experiencing eclampsia. sudirman et al. (2019) emphasised the need for a practical approach model to address the low levels of knowledge, attitudes, and practices in preventing eclampsia among pregnant women, along with increased family or spouse involvement.7 the most effective solution is enhancing communication, information, and education through easily accessible and understandable media for families and pregnant women. another study revealed that 86.9% of pregnant women and their families expect high-quality service, with 78.3% recommending internet-based media for health services (such as mobile health applications). furthermore, 90.9% of healthcare workers believe telehealth can enhance service accessibility.8 the design of communication, information, and education through internet-based social media is expected to strengthen the abilities, attitudes, and behaviour of preeclamptic pregnant women and their families (couples) involved in health services to reduce the incidence of childbirth complications due to pre-eclampsia. internet-based information media approaches already exist, such as pre-eclampsia-detector, preclampsia.com 6, pre-eclampsia-calculator 7, and dear mother app,9 as well as short message service (sms). however, these applications have limitations. for instance, they lack specific functional information regarding pre-eclampsia and eclampsia prevention practices. moreover, the mothers and spouses need to operate the applications more frequently, and some require email logins, making it challenging for pregnant women and their partners to use them. a mobile health application is an informational and educational medium that addresses preventing pregnancy disorders, particularly eclampsia.10 it also serves as a communication platform between preeclampsia mothers and their spouses to prevent eclampsia. the developed mobile health application provides specific information for preeclampsia mothers, engaging their families and integrating input based on the needs of pregnant women with pre-eclampsia, opinions from healthcare providers (including midwives and doctors), and literature studies. all information is presented on the android platform in an engaging, easy-to-understand, and informative manner to enhance knowledge, attitudes, and behaviours (practices) to prevent pregnancy disorders, including eclampsia. materials and methods design study the study design was a cross-sectional study conducted in two stages. the first stage identified the mobile application content needs for eclampsia prevention, and the second stage of development of the mobile application referred to the specified content result and then collaboration with internet technology experts. after the mobile application was developed, the level of usability of the mobile application was tested. if the mobile application has a positive response, the mobile application is already applied. the research took place from march 2022 to may 2022, commencing with the initial stage of questionnaire testing in collaboration with several maternity clinics. the study was conducted in 10 health centres, selected based on having the highest referral cases of severe pre-eclampsia, as per data from the district health office karawang’s dashboard at https://www.sijariemas.org/. this study received approval from the ethical commission of the bandung ministry of health polytechnic. population and sample population: this study targets pregnant mothers and their spouses. the sampling technique involved accidental sampling across ten public health centres, resulting in a total sample size of 86 respondents based on sample size calculations. inclusion criteria: pre-eclampsia mothers with a gestational age greater than 20 weeks, who have a spouse, and possess an android phone. additionally, the spouse of the pre-eclampsia mother should also have an android cellphone. exclusion criteria: any conditions falling outside the defined inclusion criteria data collection data is collected in two stages. the first stage identified was determining the material needs in applications related to preventing pregnancy disorders (eclampsia) in pregnant mothers. the number of questionnaires is 20 statements, with answer categories five = very needed (nv), 4 = needed (n), 3 = not very needed (nvn), 2 = not needed (nn), 1 = very not needed (vnn). the second stage of development of the mobile application referred to the identified content result and then collaboration with internet technology experts. after the mobile application was developed, the level of usability of the mobile application was measured. the measuring variable consists of 10 statements of the mobile application’s usability and positive comments (numbers 1, 3, 5, 7 and 9) and negative statements (numbers 2, 4, 6, and 10). each statement consists of 5 categories on the likert scale; statement positive with a score of 5 = strongly agree, a score e 4 = agree, score of 3 = neutraa l, score e 2 = disagree e, sof core 1 = strongly disagree, otherwise a negative statement score 5 = strongly disagree, score 4 = disagree, score 3 = neutral, score 2 = agree, score 1 = strongly agree to respond ability and ease level the application is categorised into three groups: positive responses, neutral responses, and negative responses. a positive response occurs when the respondent selects item scores 5-4 (strongly agree and agree) for a positive statement and item scores 1-2 (strongly disagree and disagree) for a negative statement. a response is categorised as neutral if the respondent selects a score of 3 (neutral), and it is considered a negative response if the respondent chooses a score of 1 or 2 (strongly disagree or disagree) for a positive statement and a score of 4 or 5 (strongly agree or agree) for a negative statement. data analysis the variables analysed univariately included 1) socio-demographic data, 2) the need for communication information, education (cie) for developing content applications, and 3) the telehealth usability test. data analysis was conducted by presenting the results of descriptive data analysis. since all data are categorical, the study involved frequency distribution and data presentation in percentages (%). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 18] [healthcare in low-resource settings 2024;12:11785] non -co mmerc ial us e o nly results respondents amount to 86 samples of 60 pre-eclampsia mothers and 26 spouses. the results are explained as follows: figure 1 shows the main menu of the mobile application, including profile, information, communication, background, and log-out menus. the menu also provides contact and coordination between the health worker, mother and spouse. table 1 reviews 20 items of closed statements on the level of iec needs. among the 114 respondents (60 pregnant women with pre-eclampsia, 26 pairs of pregnant women, and 28 health workers), over 70% indicated a strong level of need. notably, the highest percentages in the ‘strongly needed (sn)’ category were found for another pregnancy danger signs at 78.9%, preparation for childbirth financing at 79.8%, what the husband should do at 78.1%, explanation of why you have to take medicine at 80.7%, the role of the family in check activities at 78.9%, and the fulfilment of nutrition during pregnancy at 81.6%. in table 2 and table 3, involving 60 pregnant women with preeclampsia, the most significant percentages in the ‘strongly needed (sn)’ category were found for another pregnancy danger sign (76.7%), preparation for maternity financing (76.7%), what the husband should do (75%), an explanation of why you have to take medicine (75%), the role of the family in check activities (75%), and the fulfilment of nutrition during pregnancy (76.7%), as well as the reason for maternity at home while sick (77.2%). as for the husbands of pregnant women, in terms of 20 items of closed statements regarding the level of need for iec and coordination, all of which indicated a demand level of over 80%, with the most significant statement items being the causes of preeclampsia and eclampsia, what husbands should do, nutritional fulfilment of pregnant women, and information on the telephone numbers of officers, each scoring 96.2%. additionally, items related to iec and coordination that were ‘strongly needed (sn)’ included the understanding of pre-eclampsia and eclampsia at 82.1%, an explanation of why you have to take medication at 82.1%, the frequency of prenatal check-ups visits at 78.6%, and the fulfilment of nutrition for pregnant mothers at 78.6%. in table 4, statement 1 (+), ‘i like the use of this application,’ was met with a positive response from pregnant women with pre-eclampsia and their husbands, with a score of 5-4, indicating a positive response for both. for statement 2 (-), ‘this application is too complicated,’ 50% of the responses were positive, and 50% were neutral from pregnant women, while partners (husbands of pregnant women) responded with 90% positive and 10% neutral responses. statement 3 (+), ‘this application is easy to use,’ received a 90% positive response from pre-eclampsia mothers, with 10% providing a neutral response, while the partners showed 100% positive responses. statement 4 (-), ‘the need for assistance to use this application,’ received positive responses from 60 respondents (60% positive and 40% neutral) for pre-eclampsia mothers, while husbands provided 90% positive and 10% neutral responses. in statement 5 (+), ‘the contents of this application are well-structured and interconnected,’ 80% of pregnant women gave a positive response, while 100% of their husbands gave a positive response. for statement 6 (-), ‘this application is not steady (confusing),’ 80% of pre-eclampsia mothers gave a positive response, 20% provided a neutral response, while all husbands gave a positive response. statement 7 (+), ‘learn to use this application very quickly,’ was met with 100% positive responses from pre-eclampsia mothers. for husbands, 90% responded positively, and 10% neutransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. mobile application main menu. [healthcare in low-resource settings 2024;12:11785] [page 19] non -co mmerc ial us e o nly trally. statement 8 (-), ‘this application is awkward/complicated to use,’ received a positive response from 80% of pre-eclampsia mothers, and 20% were neutral. in comparison, 90% of their husbands responded positively, with 10% providing a tepid response. statement 9 (-), ‘there is a feeling of confidence in using this application,’ received positive responses from 80% of pre-eclampsia mothers, with 20% neutral responses. of the partners, 100% gave a positive response. in statement 10 (-), ‘you need to learn a lot before using the application,’ 70% of pre-eclampsia mothers responded positively, and 30% were neutral. for partners, 80% provided a positive response, with 20% showing a tepid response. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. socio-demographic data. socio-demographic data respondent pre-eclampsia mothers (n=60) spouses (n=26) level education elementary school 20 (64.5%) 11 (35.5%) junior high school 16 (76.2%) 5 (23.8%) senior high school 22 (71%) 9 (29%) college 2 (66.7%) 1 (33.3%) age group ≤ 25 years old 11 (91.7%) 1 (8.3%) >25 years old 49 (66.2%) 25 (33.8%) mobile phone use never 4 (57.1%) 3 (42.9%) ever 10 (76.9%) 3 (23.1%) saldom 16 (76.2%) 5 (23.8%) often 15 (65.2%) 8 (34.8%) always 15 (68.5%) 7 (31.8%) social media platform use wach app. facebook. instagram 3 (75%) 1(25 %) wach app. facebook 7 (58.3%) 5 (41.7%) watch app 44 (72.1%) 17 (27.9%) facebooks 5 (71.4%) 2 (28.6%) twitter 1 (50%) 1 (50%) table 2. need an item for communication, information, education of eclampsia prevention of incidence (n=86). no need of communication, information, education level of need sn n nsn in 1. definition of pre-eclampsia and eclampsia 66 (76.7%) 17 (19.8%) 3 (3.5%) 2 causes of pre-eclampsia and eclampsia 68 (79.1%) 14 (16.3%) 3 (3.5%) 1 (1.2%) 3 signs and symptoms of preeclampsia-eclampsia 68 (79.1%) 14 (16.3%) 4 (4.7%) 4 complications of pre-eclampsia 65 (75.6%) 15 (17.4%) 3 (3.5%) 5 other pregnancy danger signs 68 (79.1%) 15 (17.4%) 3 (3,5) 6 recommended and prohibited activities 62 (72.1%) 21 (24.4%) 3 (3.5%) 7 preparation for maternity financing 70 (81.4%) 12 (14.0%) 4 (4.7%) 8 equipment to be prepared 66 (76.7%) 16 (18.6%) 4 (4.7%) 9 what should a husband do 70 (81.4%) 13 (15.1%) 3 (3.5%) 10 explanation of why you have to take medicine 65 (75,6%) 17 (19.8%) 4 (4. %) 11 the role of the family in check activities 69 (80.2%) 15 (17.4%) 23 (2.6%) 12 medication reminder device 65 (75.8) 17 (18.6%) 4 (4.7%) 13 frequency of pregnancy check-up visits 64 (74,4%) 18 (20.9%) 4 (4.7%) 14 foods and drinks that can be consumed 64 (74.4%) 19 (22.1%) 3 (3.5%) 15 foods and drinks that should not be consumed 64 (74.4%) 19 (21.1%) 3 (3.5%) 16 fulfilment of nutrition during pregnancy 71 (82.6%) 13 (15.1%) 2 (2.3%) 17 information on the telephone number of a health worker (midwife) 67 (77.9%) 16 (18.6%) 3 (3.5%) 18 information number of close neighbours/relatives 66 (76.7%) 16 (18.6%) 4 (4.7%) 19 hospital emergency number information 63 (73.3%) 19 (22.1%) 4 (4.7%) 20 reasons to give birth in the hospital 67 (77.7%) 15 (17.4%) 3 (3.5%) 1 (1.2%) sn, strongly needed; n, needed; nsn, not strong needed; nn, not needed. [page 20] [healthcare in low-resource settings 2024;12:11785] non -co mmerc ial us e o nly discussion referring to the results of the application trial, which demonstrated a positive response across all variable levels of ease of use, the study’s findings indicated a significant difference in the knowledge and attitude of pregnant women after receiving an intervention using the mobile danger signs of the third-trimester pregnancy app. a study conducted in brazil on the development of telemedicine and e-health shows that improvements can enhance the user experience.11 various studies have highlighted the importransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. level of communication, information, education and coordination of prevention of incidence of pregnancy disorders (eclampsia) based on level of stronge needed. n=60 preeclamsia mothers, spouses=26. no communication, information, education level of strongly needed pre-eclampsia mothers spouses 1 definition of pre-eclampsia and eclampsia 42 (70.0%) 24 (92.3%) 2 causes of pre-eclampsia and eclampsia 43 (71.7%) 25 (96.2%) 3 signs and symptoms of preeclampsia-eclampsia 44 (73.3% 24 (92.3%) 4 complications of pre-eclampsia 41 (68.3% ) 24 (92.3%) 5 other pregnancy danger signs 46 (76.7%) 22 (84.6%) 6 recommended and prohibited activities 39 (65.0% 23 (88.5%) 7 preparation for maternity financing 46 (76.7%) 24 (92.3%) 8 equipment to be prepared 43 (71.7% 23 (88.5%) 9 what should a spouse do 45 (75.0%) 25 (96.2%) 10 explanation of why you have to take medicine 45 (75.0%) 24 (92.3%) 11 the role of the family in check activities 45 (75%) 24 (92.3%) 12 medication reminder device 41(68.3%) 24 (92.3%) 13 frequency of pregnancy check-up visits 39 (66.1%) 24 (92.3%) 14 foods and drinks that can be consumed 40 (66.7%) 24 (92.3%) 15 foods and drinks that should not be consumed 41 (68.3%) 25 (88.5%) 16 fulfilment of nutrition during pregnancy 46(76.7%) 25 (96.2%) 17 information on the telephone number of a health worker (midwife) 42(70.0%) 25 (96.2% 18 information number of close neighbours/relatives 42 (70%) 24 (92.3% 19 hospital emergency number information 40 (66.7% 23 (88.5%) 20 reasons to give birth in the hospital 43 (71.7%) 24 (92.3%) table 4. usability of application test (n=10 beta tester). no level of app. usability status level of needs sa a n ds sda 1. like to use the mobile application frequently pre-eclampsia mothers 5 (50%) 5 (50%) spouses 2 (20 %) 8 (80%) 2 mobile applications are unnecessarily complex pre-eclampsia mothers 5 (50%) 3 (30%) 2 (20%) spouses 1(10%) 8 (80%) 1 (10%) 3 mobile application easy to use pre-eclampsia mothers 3 (30%) 6 (60%) 1 (10%) spouses 9 (90%) 1 (10%) 4 need assistance using a mobile application pre-eclampsia mothers 4 (40%) 6 (60%) spouses 1 (10%) 8 (80%) 1 (10%) 5 various functions are well-integrated pre-eclampsia mothers 5 (50%) 3 (30%) 2 (20%) spouses 7 (70%) 3 (30%) 6 too much inconsistency pre-eclampsia mothers 2 (20% 5 (50%) 3(30%) spouses 10 (100%) 7 learn to use mobile applications very quickly pre-eclampsia mothers 5 (50%) 5 (50%) spouses 8 (80%) 1 (10%) 1 (10%) 8 mobile applications are very cumbersome/ pre-eclampsia mothers 2 (20%) 5 (50%) 3 (30%) awkward to use spouses 1 (10%) 9 (90%) 9 confident using a mobile application pre-eclampsia mothers 3 (30%) 5 (50%) 2 (20%) spouses 9 (90%) 1 (10%) 10 i needed to learn a lot of things before pre-eclampsia mothers 3 (30%) 6 (60%) 1 (1%) launching the mobile application spouses 2 (20%) 6 (60%) 2 (20%) sa, strongly agree; a, agree; n, neutral; da, disagree; sda, strongly disagree. [healthcare in low-resource settings 2024;12:11785] [page 21] non -co mmerc ial us e o nly tance of provider-based counselling in increasing knowledge about pre-eclampsia.3 maternal education apps and websites must provide information and resources for individual attention and social support.12 in specific cases, mobile applications have shown promise in improving aftercare for women with pre-eclampsia, with medical specialists playing a significant role.13 introducing pregnant women into general programs is considered a recommended first step, and mobile-based programs have been perceived as feasible for high-risk pregnant women, providing valuable insights for future program design.14–16 electronic administration of health-related surveys on android tablets has been more efficient and time-saving than paper-based surveys, especially in resource-poor settings.17 mobile applications focused on diet and oral health have demonstrated potential in preventing early childhood caries, and this approach can be extended to the development of applications targeting pre-eclampsia prevention in pregnant women.18,19 overall, there is a need for improved engagement, information quality, and scientific evidence supporting the use of medical devices in healthcare applications. health apps have effectively tracked patient-reported outcomes during and after treatment, although many of these applications are specifically designed for cancer patients.20 furthermore, we have observed the acceptability and feasibility of remote training platforms for treatment adherence.21 a website or mobile application to support maternal education should include information and resources for individual attention and social support. its impact on the health and satisfaction of women should be evaluated in various settings.12 the knowledge and attitudes of preeclampsia mothers and their spouses need to be enhanced, along with promoting better self-care. in addition, the application can save them time.22 referring to the study results, the use of mobile applications for pregnant women at high risk of pre-eclampsia provides insights that can be directly applied to future designs aimed at reducing mortality and morbidity from pre-eclampsia and eclampsia.15 there is a relationship between the need for a practical approach model, stemming from the low knowledge, attitudes, and practices of preventing eclampsia in pregnant women, and the significant involvement of the family or husband,7 an increasing role of communication, information, and education through media that is effective, easy to use, and understandable by families and preeclampsia mothers is the right solution. communication is a message, either verbal or written, or a series of statements with order sequences or meanings that can be interpreted from notifications or collections of letters. education refers to the process of learning and the transmission of habits within a group of people from one generation to the next through teaching and training.23 the definition of coordination involves synchronised and systematic efforts to allocate the right resources and direct the execution of actions in harmony with predetermined goals.24 cie is a combination of words that convey interconnected meanings, reinforcing each word to create complete sentences that are significant for transferring and receiving messages about a situation. it serves an educational purpose to promote cooperation and function. coordination and collaboration in telehealth are vital for establishing harmonious communication between families/pregnant women and healthcare providers.25 technology will continually evolve, and humans will never be disconnected from it. one form of technological development is using the internet through android devices. the use of the internet on android devices has the effect of changing how people respond to information and communication behaviour.26 the internet has significantly influenced lifestyle changes due to technological advancements.27 his statement conveyed that the development of information and communication technology and the widespread impact of globalisation have changed how people live, interact, learn and redefined the concept of cultural identity. the internet renders traditional notions of space, time, and distance meaningless and even obsolete. everyone can access information anytime, anywhere, regardless of physical distance, which can help overcome issues related to the user population, such as language variations, cost constraints, and internet accessibility. the new application also offers features with new icons and customisation options that users can easily understand.28 telehealth is rooted in the current digital era. it’s important to note that 196.7 million, or 73.7% of indonesia’s population, are internet-literate.29 this is a situation that has led to everyone avoiding direct contact due to the covid-19 outbreak, one of the consequences of which is the impact on pregnancy check-ups. as a study has shown, the average volume of weekly prenatal visits decreased by 16.1%, from 898 to 761 weekly visits.30 this has an impact on the inadequate monitoring of pregnant women with preeclampsia, resulting in a relatively high risk of pregnancy disorders, including eclampsia. conclusions the research findings indicated that nearly all respondents required information and education on preventing eclampsia. the content of the application consisted of 20 items, which were considered suitable for addressing these needs. the results of the usability test showed that pre-eclampsia mothers and their spouses responded positively to the application and found it easy to use. this favourable feedback has significant implications for improving knowledge and awareness regarding the prevention of pregnancy disorders, particularly eclampsia. references 1. mekie m, addisu d, bezie m, et al. knowledge and attitude of pregnant women towards preeclampsia and 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diponegoro. sayang ibu, a pregnancy monitor application with emergency button has been launched by fkm undip universitas diponegoro. news, research & community services. 2020. p. 1. 10. indriani d, damayanti na, teguh d, ardian m, suhargono h, urbaya s, et al. the maternal referral mobile application system for minimising the risk of childbirth. j public health res 2020;9:105-9. 11. gadenz sd, harzheim e, amaral hg, drehmer m. development and assessment of a mobile nutritional counseling tool for primary care physicians. telemed ehealth 2020;26:805-11. 12. artieta-pinedo i, paz-pascual c, bully p, et al. design of the maternal website emaehealth that supports decision-making during pregnancy and postpartum: collaborative action research study. jmir form res 2021;5:1-14. 13. suprihatin e, wuryaningsih sh. the development of an assessment instrument for postpartum patients with severe preeclampsia-eclampsia based on the need for help and selfcare models. j ners 2022;17:47-54. 14. dijkhuis te, bloem f, kusters laj, et al. investigating the current knowledge and needs concerning a follow-up for longterm cardiovascular risks in dutch women with a preeclampsia history: a qualitative study. bmc pregnancy childbirth 2020;20:486. 15. feroz as, de vera k, bragagnolo nd, et al. understanding the needs of a mobile phone-based telemonitoring program for pregnant women at high risk for pre-eclampsia: interpretive qualitative description study. jmir form res 2022;6: e32428. 16. aditiawarman, ernawati, joewono ht, et al. maternal cardiovascular risk in five years after labour with early-and late-onset severe preeclampsia. int j pharm res 2020;12:1401-7. 17. abdel-all m, angell b, jan s, et al. the development of an android platform to undertake a discrete choice experiment in a low resource setting. arch public heal 2019;77:1-5. 18. lim s-y, lee k-w, seow w-l, et al. effectiveness of integrated technology apps for supporting healthy food purchasing and consumption: a systematic review. foods 2021;10:1861. 19. vivilyana v, josephng ps, shibghatullah as, eaw hc. jomimage: weight control with mobile snapfudo. k. a, s. k, r. b, editors. vol. 1252 aisc, intelligent systems conference, intellisys 2020. institute of computer science and digital innovation, ucsi university, kuala lumpur, malaysia: springer; 2021. p. 168-80. 20. escriche-escuder a, de-torres i, roldán-jiménez c, et al. assessment of the quality of mobile applications (apps) for management of low back pain using the mobile app rating scale (mars). int j environ res public health 2020;17:1-16. 21. schuman-olivier z, borodovsky jt, steinkamp j, et al. mysaferx: a mobile technology platform integrating motivational coaching, adherence monitoring, and electronic pill dispensing for enhancing buprenorphine/naloxone adherence during opioid use disorder treatment: a pilot study. addict sci clin pract 2018;13:21. 22. ghaemi mm, moulaei k, bahaadinbeigy k, ghaf-faripour z. the design and evaluation of a mobile-based application to facilitate self-care for pregnant women with preeclampsia during covid-19 prevalence. j biomed phys eng 2021; 11:551-60. 23. chaw ly, tang cm. learner characteristics and learners’ inclination towards particular learning environments. electron j e-learning 2023;21:1-12. 24. lai nyg, foo wc, tan cs, et al. understanding learning intention complexities in lean manufacturing training for innovation on the production floor. j open innov technol mark complex 2022;8:110. 25. lu dj, girgis m, david jm, et al. evaluation of mobile health applications to track patient-reported outcomes for oncology patients: a systematic review. adv radiat oncol 2021;6:100576. 26. aw ec-x, tan gw-h, chuah sh-w, et al. be my friend! cultivating parasocial relationships with social media influencers: findings from pls-sem and fsqca. inf technol people 2023;36:66-94. 27. reveley j. the exploitative web: misuses of marx in critical social media studies. sci soc 2013;77:512-35. 28. nocum aa, baltao jm, agustin dr, portus aj. ergonomic evaluation and design of a mobile application for maternal and infant health for smartphone users among lower-income class filipinos. procedia manuf 2015;3:5411-8. 29. leo dwi jatmiko. melek internet. bisnis.com. 2020; 30. peahl af, powell a, berlin h, smith rd, krans e, waljee j, et al. patient and provider perspectives of a new prenatal care model introduced in response to the coronavirus disease 2019 pandemic. am j obstet gynecol 2021;224:384.e1384.e11. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11785] [page 23] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11763 effectiveness of prenatal yoga on pregnant women’s anxiety and duration of labour diyan indrayani, titi legiati, chris sriyanti midwifery departement, ministry of health bandung health polytechnic, bandung, indonesia abstract the birth process involves physical and psychological mechanisms. anxiety creates physical and psychological tension, interfering with the birth process. the study aimed to analyze the effectiveness of yoga on pregnant women’s anxiety and labor duration. this study used an experimental design with a randomized controlled trial (rct) involving 60 pregnant women divided into two groups: yoga and walking (30 participants each). the variables studied were pregnant women’s anxiety and the duration of labor. the sampling technique was conducted using block randomization. data were analyzed using the independent t-test. the yoga group attended 30-minute sessions twice weekly, while the walking group engaged in the same frequency and duration of walking until giving birth. anxiety levels were measured using the hamilton anxiety rating scale (hars) before and one month after the intervention in both groups. the duration of labor was measured using partographs and medical records during delivery for both groups. data were analyzed using the shapiro-wilk test and independent ttest. pregnant women in both the yoga and walking groups experienced reduced anxiety scores, with a decrease of 11.6%, and statistically significant p-values of <0.05. the duration of labor was significantly shorter in the yoga group (mean: 2.65 hours, sd: 1.01) compared to the walking group (mean: 4.01 hours, sd: 2.54), with a mean difference of 1.36 hours and a p-value of <0.05. prenatal yoga in the third trimester reduces pregnant women’s anxiety and shortens the duration of labor. it can be suggested as an alternative exercise for pregnant women to improve maternal health during pregnancy and childbirth. introduction pregnancy is a period that requires adaptation in facing the new role of motherhood, causing various kinds of changes both physically and psychologically.1 many pregnant women experience fear and anxiety about the childbirth process.2 anxiety can lead to both mental and physical tension,3 causing muscles and joints to become stiff, which in turn disrupts uterine contractions and interferes with the delivery process.4 up to 65% of prolonged labor events can be attributed to inefficient uterine contractions triggered by anxiety, hindering uterine activity.5 one indicator of emotional stress is elevated cortisol levels.6 the increase in plasma cortisol levels in he second trimester of pregnancy and before delivery increases and decreases after delivery, but hypercortisolism occurs up to 5–7 days after delivery.7 this highlights the vulnerability of pregnant women to anxiety, which can be linked to impaired contractions and labor disruptions.8 the labor process, including the choice of delivery method and late referral, is one of the potential risk factors for maternal mortality, alongside nutricorrespondence: diyan indrayani, midwifery departement, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: diyanindrayani@staff.poltekkesbandung.ac.id key word: anxiety; birth; duration of labor; exercise pregnant women. contributions: di, conceptualization, data curation, formal analysis, study design, validation, visualization, writing – original draft, review & editing; di, tl, cs, data analysis; supervision; di,tl, cs first draft of the paper. all authors reviewed and edited the paper. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has obtained ethical clearance from the health research ethics committee of the health polytechnic of the ministry of health in bandung, with ethical approval number no. 01/kepk/ec. respondents in this study voluntarily participated, their identities were kept confidential, and informed consent was obtained prior to their participation. patient consent for publication: we obtained written informed consent to publish anonymized patient information in this article. funding: this research was supported by a research grant from dipa politeknik kesehatan bandung with contract number lb.02.01/3.1/3388.a /2021, 03 agustus 2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to express our gratitude to midwives rosita, iyam, dewi, and nani for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 6 november 2023. early access: 16 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11763 doi:10.4081/hls.2023.11763 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 132] [healthcare in low-resource settings 2023; 11:11763] non -co mmerc ial us e o nly tional status, anemia, medical history, age, anc examination, occupational status, and pregnancy complications.9 lack of knowledge about signs and symptoms can lead to low awareness and, subsequently, the mismanagement of pregnancy and childbirth complications.10 physical exercise is one approach to alleviate anxiety and help pregnant women prepare for childbirth.11,12 engaging in physical activity by moving can enhance a woman’s se’se of control during labor.13 various forms of physical exercise for pregnant women include walking, cycling, swimming, pregnancy-specific exercises, hypnobirthing, and yoga.14,15 practicing yoga during pregnancy can reduce a woman’s anxiety during labor, shorten the labor stage, and alleviate labor pain.16 prenatal yoga has been shown to reduce labor pain and potentially improve birth outcomes.17 therefore, this study aims to analyze the effectiveness of prenatal yoga in reducing maternal anxiety levels and shortening the duration of labor during pregnancy. materials and methods research design the research design used in this study was experimental, employing a randomized controlled trial (rct). the research involved two groups: a treatment group that received prenatal yoga and a control group that participated in walking exercises. this study assessed the anxiety levels of pregnant women in both the treatment and control groups before and after exercising, two times per week for one month. respondents continued their exercises until the time of delivery, and the duration of labor in both groups was recorded. the research was conducted in bandung, west java, indonesia, focusing on pregnant women in the third trimester who engaged in a 30-minute exercise session twice weekly. the research took place at the public health center and a private midwifery practice in the city and district of bandung, indonesia. study participants the subjects in this study were pregnant women who met the inclusion and exclusion criteria and voluntarily agreed to participate by signing the informed consent sheet. the target population for this study comprised all pregnant women in the city of bandung, indonesia. the study population encompassed pregnant women in their third trimester who attended the public health center and private midwifery practice in the city and district of bandung, indonesia. the sample for this study consisted of pregnant women who underwent pregnancy and childbirth-related check-ups at the public health center and private midwifery practice in the city and district of bandung, indonesia, and who met the inclusion criteria. sample size determination employed the formula for unpaired numerical categorical research. in this study, a confidence level of 95% (zα=1.96) and a power test of 90% (zβ=1.28) were selected. the sample size comprised 60 pregnant women, divided into two groups: yoga and walking, with 30 individuals in each group. block randomization was used to assign each sample to either the treatment or control group. the inclusion criteria encompassed planned pregnancy, being in the third trimester of gestation, and a willingness to participate as a respondent. simultaneously, the exclusion criteria included pregnant women with pregnancy-related complications. research subjects were excluded from the study if they met one or more of the following criteria during the study: not adhering to recommended exercises, experiencing an illness requiring treatment, or withdrawing from the study before its completion. variable, instrument and data collection variable in this study, the independent variable was the structured prenatal yoga exercises performed by pregnant women in the treatment group. these exercises were conducted twice weekly for 30 minutes. the control group engaged in walking exercises for the same duration and frequency. the dependent variables included the anxiety levels of pregnant women and the duration of labor. pregnant women’s anxiety was assessed using the hamilton anxiety rating scale (hars). anxiety levels were measured both before the intervention and one month after the intervention in both the yoga and walking groups. meanwhile, the duration of labor was measured using a partograph and medical records at the time of labor in both the yoga and walking groups. instrument the research instrument utilized a questionnaire that had previously undergone validity and reliability testing and was found to be valid and reliable. pregnant women’s anxiety was assessed using the hamilton anxiety rating scale (hars). the questionnaire employed to measure anxiety symptoms is a tool that had been designed and utilized in previous research. this instrument underwent validity and reliability testing, with item construct validity values based on pearson correlations ranging from 0.529 to 0.727, and a cronbach’s al’ha reliability coefficient of 0.756 was obtained. consequently, the hamilton anxiety rating scale fulfills the criteria for being a reliable (meeting acceptable criteria) and valid (meeting good criteria) assessment tool. data collection the research procedure began by selecting research subjects based on the inclusion and exclusion criteria. subsequently, the researcher provided information by explaining the research objectives and procedures to the research subjects. following this, consent to participate in the research was sought through the signing of the informed consent sheet. the next step involved the collection of anxiety data using a questionnaire. subjects were then randomly assigned to either the treatment group or the control group. the treatment group received yoga exercises, while the control group engaged in walking exercises. after the respondents had participated in the exercises for one month, anxiety was measured again using a questionnaire as a posttest. the exercises continued until just before delivery, at which point the duration of labor was measured in both groups. intervention the treatment group received yoga exercises twice a week for 30 minutes, led by a certified prenatal yoga instructor. all respondents in this group followed the same yoga exercise sequence and were trained by the same yoga instructor. the yoga sequence included centering, pranayama, stabilization, side stretching, pelvic floor muscle training in preparation for labor, restorative exercises, and savasana. anxiety levels were assessed both before the commencement of regular yoga practice and after one month of practice. yoga sessions continued until just before delivery. the duration of labor was evaluated based on partographs and medical records. the control group engaged in walking exercises twice a week for 30 minutes. anxiety evaluation was conducted both before the start of regular exercise and after one month of walking sessions. the walking regimen continued until just before delivery. the length of labor was assessed using partographs and medical records. [healthcare in low-resource settings 2023; 11:11763] [page 133] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly data analysis the data were analyzed using univariate and bivariate analysis. the data normality test, conducted using the shapiro-wilk test, indicated that the data followed a normal distribution. subsequently, bivariate analysis was performed using the independent t-test statistic to assess the effectiveness of yoga and walking in relation to anxiety and the duration of labor, with a significance value of p<0.05. ethical clearance the research has obtained ethical clearance from the health research ethics committee of the health polytechnic of the ministry of health in bandung, with the ethical approval number no. 01/kepk/ec. throughout the research, the researcher adhered to ethical principles, including obtaining informed consent, respecting human rights, promoting beneficence, and ensuring non-maleficence. results an overview of the characteristics of the research subjects participating in this study can be found in table 1. it can be concluded that the characteristics of the research subjects exhibit no significant differences, indicating homogeneity and enabling comparison. the results revealed no differences in the study subjects’ age’and occupation between the yoga group and the walking group (p>0.05), suggesting that the data followed a normal distribution. however, a difference in parity was observed between the yoga and walking groups (p<0.05). the table below provides further details on the characteristics of the research subjects. the table below illustrates the differences in anxiety between the treatment and control groups. table 2 reveals that before treatment, there was no significant difference in the anxiety scores of mothers between the two groups (those regularly practicing yoga or walking). however, after one month of regular yoga and walking sessions, a significant difference in anxiety scores was observed between the two groups (p<0.05). the prenatal yoga group exhibited an average anxiety reduction of 11.10%, which was greater than the reduction in anxiety scores in the control group. the intervention demonstrated a significant difference in anxiety reduction between the yoga and walking groups, with statistical test results indicating a value of p<0.05. the yoga group experienced a decrease in anxiety scores. table 3 indicates that the average length of labor in the treatment group was shorter than in the control group. the difference in the mean length of labor between the prenatal yoga and walking [page 134] [healthcare in low-resource settings 2023; 11:11763] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. research subject characteristics based on parity, age, and occupation. variable prenatal yoga walking p n % n % parity primipara 23 76.7 10 33.3 0.001a multipara 7 23.3 20 66.7 age <20 years 1 3.3 1 3.3 0.052b 20-35 years 29 96.7 24 80.0 >35 years 0 0 5 16.7 occupation employe 10 33.3 4 13.3 0.067a unemployment 20 66.7 26 86.7 total 30 100 30 100 test description: achi-square; bexact fisher test. table 2. differences in anxiety between prenatal yoga and walking groups. characteristics group p yoga (n=30) walking (n=30) anxiety pre-intervention mean (sd) 54.87 (9.42) 54.90 (17.59) 0.993c anxiety post-intervention mean(sd) 43.87 (8.95) 54.33 (17.67) 0.005c anxiety reduction mean(sd) -11.10 (7.61) -0.57 (1.52) 0.001c test characteristic: cindependent t-test. table 3. differences in length of labour between prenatal yoga and walking groups. anxiety n mean (sd) p prenatal yoga 30 2.65 (1.01) 0.010c walking 30 4.01 (2.54) test characteristic: cindependent t-test. non -co mmerc ial us e o nly groups was 1.36 hours, signifying that the length of labor in the yoga group was shorter than in the walking group. the intervention demonstrated a significant difference in the length of labor between the treatment and control groups, with a statistical test result of p=0.010. discussion the aim of this study was to investigate the impact of prenatal yoga on maternal anxiety levels and the duration of labor. the results demonstrated a greater decrease in anxiety scores in the treatment group compared to the control group, with an average anxiety reduction of 11.10% in the prenatal yoga group. the intervention revealed a significant difference in anxiety reduction between the yoga and walking groups. anxiety can manifest through various symptoms, including racing thoughts, jerky movements, and physical changes such as muscle tightness, elevated pulse, and increased blood pressure.18 yoga, a relaxation method, reduces muscle tension and enhances overall body equilibrium.19 it influences neurotransmitters in the brain, promoting serenity (serotonin) and happiness (endorphins) while reducing stress hormones (adrenaline).14,19,20 excessive anxiety in the mother can lead to increased stress hormone levels in the body, inhibiting cervical dilation, resulting in prolonged labor, fatigue, and fetal distress, potentially leading to intra uterine fetal death (iufd).21 prenatal yoga improves concentration, memory, and addresses concerns such as eye diseases and insomnia.22 it also reduces anxiety, enhances relaxation, and reduces negative mood aspects. yoga incorporates breathing techniques (pranayama) and meditation, enhancing its stress-relief properties during pregnancy.23,24 ownership of health insurance becomes a determinant of labor and delivery care in healthcare facilities.25 according to the indonesian demographic health survey 2007, the types of labor complications include prolonged labor (37%), bleeding (9%), fever (7%), seizures (2%), and other complications (4%).26 yoga is utilized for various immunological, neuromuscular, psychological, and pain-related conditions. yoga can prepare an individual who is physically strong and mentally calm, ready to embrace motherhood.27 it aids in achieving physical balance, maintaining a healthy pregnancy, reducing discomfort due to pregnancy adaptations, and facilitating the delivery process.28 yoga can increase the levels of gamma amino butyric acid (gaba), a neurotransmitter that reduces arousal and anxiety, enhances parasympathetic activity, provides a calming effect, and significantly decreases cortisol hormone production.29 physical activity through yoga enhances self-control and the quality of life, promoting a well-balanced state of well-being between physical and mental health.30 furthermore, the average length of labor in the treatment group was shorter than that in the control group. the difference in the mean length of labor between the prenatal yoga and walking groups was 1.36 hours, indicating that the length of labor in the yoga group was shorter than in the walking group. the intervention demonstrated a significant difference in the length of labor between the treatment group and the control group. this aligns with the findings of mohyadin’s st’dy, which demonstrated that pregnant women in the third trimester who practiced yoga experienced a shorter duration for the first phase of labor compared to the control group.16 there were more vaginal deliveries (p < 0.037) and fewer cesarean sections (p < 0.048), and the first stage of labor was significantly shorter (p < 0.0003) in the yoga study group.17 in yoga, movement sequences influence not only physical factors but also psychological elements. in other words, yoga enhances the well-being of the body, mind, and soul. conversely, walking primarily focuses on physical and motor skills, promoting endurance and physical stamina.31 yoga is a physical, mental, and emotional exercise that helps increase joint flexibility and promote mental calmness, preparing pregnant women both physically and mentally for a confident, comfortable, and fear-free experience during the normal delivery process. prenatal yoga specifically emphasizes breathing, stretching, posture, and relaxation.32–34 deep breathing (pranayama), and meditation. it is considered safe during pregnancy and has been demonstrated to be beneficial for women experiencing anxiety, depression, stress, low back pain, and sleep disturbances.14,35,36 yoga can increase women’s se’f-efficacy in facing childbirth. according to the previous study self-efficacy is significantly related to the behavior of pregnant women in reducing anxiety. a high level of self-efficacy encourages confidence in problem-solving and can effectively reduce anxiety when facing challenges.37 after all, the practice of yoga not only enhances posture but also involves effective breathing, meditation, and self-awareness.38 the results of other studies suggest that prenatal yoga can be recommended for pregnant women, as it has been shown to increase the rate of vaginal delivery, reduce the need for labor induction, decrease the occurrence of premature events, lower the incidence of episiotomy, and shorten the duration of labor.22,39 yoga can enhance concentration, posture, and relaxation during pregnancy. it also facilitates training of respiratory muscles, regulation of breathing, and increased blood flow, all of which contribute to improved uterine contractions during delivery.36,40 malasana, baddha konasana, and marichiasana are yoga postures that stretch the pelvic floor muscles, alleviate pelvic pain, and prepare the body for childbirth.41 practicing these movements helps pregnant women become familiar with labor positions, relax their muscles, and facilitate effective pushing techniques.42 yoga’s up’ight and moving positions assist in the gravitational descent of the baby’s he’d into the pelvis, stimulating more consistent and muscular contractions, accelerating cervical dilation, and expediting labor.43 the limitation of this reseaesearch that the respondents were restricted to pregnant wom’n in the third trimester. therefore, further research is needed to determine the effectiveness of yoga in the first and second trimesters of pregnancy. additionally, it would be beneficial if the research subjects had homogeneous parity, such as primigravida, who share similar characteristics in experiencing pregnancy for the first time conclusions prenatal yoga in the third trimester effectively reduces anxiety levels in pregnant women and shortens labor time. these findings suggest that including yoga as an alternative activity during pregnancy can enhance maternal health and have a positive impact on the birthing process. it is advisable for pregnant women, particularly during the third trimester, to consider prenatal yoga. healthcare providers can incorporate yoga sessions into prenatal care to promote relaxation, reduce anxiety, and potentially shorten labor duration. further studies and inquiries can be conducted to assess the long-term benefits of prenatal yoga on both maternal and newborn outcomes and to develop guidelines for its safe and practical application in various healthcare settings. 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[page 136] [healthcare in low-resource settings 2023; 11:11763] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 36. renuka k, devi ma. yoga in pregnancy. pondicherry j nurs 2020;13:96-100. 37. pratiwi in, pradanie r, setyawati n, ramoo v. factors associated with behavior of reducing anxiety in pregnant women during covid-19 pandemic. j public heal emerg 2023;7:18. 38. campbell v, nolan m. “it definitely made a difference”: a grounded theory study of yoga for pregnancy and women’s self-efficacy for labour. midwifery 2019;68:74-83. 39. yekefallah l, namdar p, dehghankar l, et al. the effect of yoga on the delivery and neonatal outcomes in nulliparous pregnant women in iran: a clinical trial study. bmc pregnancy childbirth 2021;21:351. 40. suananda y. prenatal-postnatal yoga. jakarta: pt kompas media nusantara; 2018. 41. japutra a, tjiptono f, setyawan a, permana ibga, widaharthana ipe. life events, philosophy, spirituality and gastronomy experience. int j contemp hosp manag 2022;34:3210-29. 42. siccardi m, valle c, angius v, di matteo f. estimating the mobility of the michaelis sacral rhombus in pregnant women. cureus 2020;12:e7116. 43. lawrence a, lewis l, hofmeyr gj, et al. maternal positions and mobility during first stage labour. cochrane database syst rev 2009;2:cd003934. [healthcare in low-resource settings 2023; 11:11763] [page 137] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master exploring healthcare system adaptive techniques and challenges in caring for people living with hiv and aids during the covid-19 lockdown period in harare, zimbabwe tendai makwara,1 rumbidzai chireshe,2 mathew nyashanu3 1higher education department, boston city campus, stellenbosch, cape town, south africa; 2department of nursing and public health, university of kwazulu-natal, durban, south africa; 3department of health and allied professions, nottingham trent university, nottingham, united kingdom abstract the covid-19 pandemic caused unprecedented challenges for healthcare systems worldwide, affecting the provision of ongoing care for people living with hiv and aids (plwha). this study aimed to explore the adaptive techniques employed by healthcare systems in providing care for plwha during the pandemic and the challenges encountered. an exploratory qualitative study (eqs) methodology was employed, underpinned by the resourcefulness framework. the silences framework analysis phases were used during data analysis. fifteen participants were interviewed, and the data were thematically analyzed. the healthcare system employed several adaptive techniques to cater to plwha during the pandemic, including developing new standard service protocols, implementing preventative measures to limit covid19 infections during hospital visits, and improving communication. the study identified two significant challenges: a lack of health insurance and a shortage of personal protective equipment (ppes). the findings highlight the need for adapting to changing circumstances and provide ongoing care for plwha during the pandemic. the results show that developing new protocols and preventative measures can effectively ensure the continuity of care in pandemic situations. moreover, the provision of ppes and health insurance for healthcare staff should be prioritized to create a safe working environment. in conclusion, this study underlined the importance of resourcefulness in developing healthcare resilience to sustain care and support for plwha during the covid-19 pandemic. introduction research studies affirm that the covid-19 virus was first detected in wuhan city in the hubei region of china in december 20191 and later spread to other parts of the world. from china, the covid-19 virus initially spread to other parts of asia, including japan, south korea, and singapore,2,3 before reaching europe, north america, south america, and africa. italy was one of the first countries to experience a large outbreak in europe,2,3 while by january 21, 2020, the first confirmed case was reported in the united states,4 leading to a major health crisis and the introduction of lockdown measures. the first reported covid-19 case in africa was detected in egypt on february 14, 2020,5 followed by south africa on march 5, 2020.6 by april 2020, the world health organization (who) had declared covid19 a global pandemic, as the virus had spread to more than 100 countries.3,4 amidst the global outbreak trajectory, zimbabwe detected its first covid-19 case on march 14, 2020, which was soon followed by an announcement of a 21-day national lockdown on march 30, 2020.7 like in other countries, these concomitant measures and accompanying policy pronouncements resulted in restricted movements of people7–9 limited social engagements and imposed new burdens on already overwhelmed health systems culminating in the disruption of other health services.9 in the health sector, measures to contain the pandemic also forced hospitals and clinics to revise and restructure existing patient care service protocols.10 they also exacerbated existing problems of quality and access to health services for patients by altering health system structures by diverting healthcare workers and resources toward covid-19 management,9,11,12 leaving gaps in treatment and care of other diseases such as hiv and aids. several studies have observed that covid-19-related interruptions resulted in negative regular care-seeking people living with hiv and aids11–13 such as reduced levels of hiv testing, treatment, missed appointment, and failure to access art14 an unwelcome development in a country with 1,27 million people living with the disease.15 hence16 we concluded that responsive actions to combat the coronavirus pandemic had far-reaching consequences for chronic ailments like hiv and aids. consequently, to close these emerging health services delivery gaps and maintain health system resilience, healthcare practitioners’ attention turned towards devising adaptive strategies to reconcile the compet healthcare in low-resource settings 2023; volume 11:11424 correspondence: tendai makwara, higher education department, boston city campus, stellenbosch, 7600 cape town, south africa. e-mail: makwara.t@gmail.com key words: covid-19; hiv and aids; health care system; challenges. contributions: tm and rc conceptualized the study. mn designed the method and design of this study, and they also supervised the findings. rc conducted fieldwork, performed the statistical analysis, and interpreted the data. tm and rc interpreted and discussed the findings and conclusions. all authors carried out the study and agreed to the arrangement of authors as well as read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: this study was approved by the medical research council of zimbabwe (mrcz) (ethical clearance letter no. mrcz/a/2821/2022). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: no funding was received. acknowledgments: the authors are grateful to all that contributed to this study, especially all healthcare professionals who took part in this study. received for publication: 19 april 2023. accepted for publication: 21 july 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11424 doi:10.4081/hls.2023.11424 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11424] [page 61] non -co mmerc ial us e o nly [page 62] [healthcare in low-resource settings 2023; 11:11424] ing healthcare needs of patients. the pandemic revived discourse on health systems resilience and the importance of resourcefulness in overcoming health delivery challenges emanating from the crisis. in this context, health system resilience refers to health systems’ ability and capacity to absorb, effectively respond, and adapt to shocks and structural changes while sustaining day-to-day operations.17 other scholars also stressed the health system needed to adopt a combination of absorptive, adaptive, and transformative strategies to match the demands of the ensuing pandemic.18,19 in line with this view, this study investigated the experiences of zimbabwean healthcare professionals’ experiences in providing care and support to plwha during covid-19. it sought to explore adaptive strategies adopted to sustain support towards plwha from the health professional’s perspective. besides gaining insights from a health provider perspective about the functioning of the healthcare systems in caring for plwha during covid-19, this study extends the discourse about the resilience and adaptive capabilities of healthcare systems in resourcestrained communities in times of pandemics. this study, therefore, examines the adaptive strategies healthcare professionals developed to mitigate the impact of interrupted healthcare services on people living with hiv and aids during covid-19 in zimbabwe. materials and methods this research utilized an exploratory qualitative study (eqs) approach. as suggested by the name, an eqs is designed to explore the topic under consideration to understand it better rather than provide a final and conclusive solution to the existing problem being investigated.20 furthermore, an eqs may also identify possible areas for further investigations or research. as such, eqs is useful in understanding the overview of an existing issue from a new perspective and can provide key information for future interventions.21 semi-structured questions were devised and used to elicit experiences and information from health professionals on adaptive healthcare system techniques used to cater to plwha during covid-19. the literature informed the interview protocol on access to hiv treatment among vulnerable groups from previous primary and secondary research studies. to test the appropriateness of the interview schedule, five professionals working in sexually transmitted infections and hiv units were interviewed as part of a pilot study. after completing the pilot interviews, the healthcare professionals were asked to evaluate the interview schedule. none of the five healthcare professionals suggested any substantial changes to the interview schedule, which was therefore adopted for use in this study. however, where appropriate, their comments were included to shape the final research interview schedule. sample and recruitment following approval of the research proposal by the medical research council of zimbabwe, 15 healthcare professionals were interviewed through contacts from healthcare centers and hospitals in harare. table 1 illustrates the profile of the research participants. in the first instance, letters and information sheets were sent to managers of healthcare centers and hospitals, inviting healthcare professionals to participate in the research study. only those healthcare professionals who agreed to participate in the research study had their names forwarded to the researchers to organize interview dates. the interviews were held at health centers and hospitals where the healthcare professionals normally work. this ensured the research participants were comfortable and free to answer questions in an accustomed environment. the interviews lasted for one hour each. the inclusion criteria included healthcare professionals working in harare’s healthcare centers and hospitals. the healthcare professionals were supposed to be working in harare before the advent of the covid-19 pandemic. recruiting a heterogeneous sample concerning the cut-off time they started working in harare was essential to ensure that their experiences during the covid-19 pandemic were explored under a uniform situation. the interviews were conducted by one researcher, who was a healthcare professional. this was important to enhance openness and sharing of silences among healthcare professionals as opposed to when a non-healthcare researcher was involved. all interviews were tape-recorded, transcribed verbatim, and entered into nvivo for the organization to make analysis easy.22 for accuracy verification, all transcriptions were returned to the research participants for confirmation. this is deemed necessary as it validates the data collected before analysis.23 table 1 illustrates the profile of the research participants. it reveals that the participants are drawn from a cross-section of health care. following the organization of data by nvivo, the data analysis started with the coding of data into broad categories by the researchers utilizing the 4 phases of data analysis in the silences framework (tsf).24 in phase 1, the researchers thematically analyzed the data with the aid of nvivo. in phase 2 the researchers took the data from phase 1 to the research participants to confirm whether it accurately recorded what they said. the research participants had opportunities to add and subtract the findings from phase 1. in phase 3 the researchers took the findings from phase 2 to the collective voice group. the collective voice group comprises 10 healthcare professionals who mirrored the research participants but did not participate in the research study. this is meant to confirm the results through a critical associative eye. in phase 4 the draft from phase 3 was thematically analyzed by the researchers to produce the final findings of the research study. the research participants were given an information sheet to read and ask questions before participating. furthermore, all the research participants had to sign a consent form granting them the right to withdraw from the study without giving reasons. results after data analysis was performed on the adaptive strategies used to support hiv and aids patients under covid-19, the following themes were identified: standard protocol to deal with patients in a pandemic, transport problems, communication with plwha, shortage of medication, lack of health insurance and shortage of personal protective equipment (ppes). standard protocol all the research participants agreed that a lot of information was being passed on how to assist people living with hiv and aids (plwha). at first, it was difficult because standard protocols were not defined well. for example, traveling restrictions have made plwha miss appointments and sometimes made it difficult to travel to the health facility to collect their supply because public transport was not allowed to move or take people from point a to point b. when traveling restrictions were put in place, further explanations were to be given to law enforcement agents, transport operators, and everyone in the service industry that patients were allowed to go to clinics for help. a lot of our patients missed their appointments. (sister-incharge). at first, gatherings were not allowed at all, but we all know how crowded our hiv clinics get. it was a challenge at first, but pill refill time was amended from 3 months to 6 months to accommodate the article non -co mmerc ial us e o nly new normal of living in a pandemic. (hospital pharmacist) covid-19 preventative initiatives research participants expressed that they all have a good idea of what covid19 restrictions are despite the influx of different covid-19 strains and misinformation. healthcare staff implemented initiatives to help and assist patients during the 2019 covid pandemic. for patients who are just coming for a routine check-up and pill refill, we have established a system where patients come and sit outside socially distance from each other with masks on as they get in the clinic for a check-up, check-up time was also reduced, then get medicine through the window. (a male nurse) communication during the pandemic at first communication with plwha was difficult a lot of misinformation was going around, and patients were affected. monitoring and supporting patients was challenging because of the social distancing restrictions implemented. service providers were also affected because there was no clear protocol to follow. health care personnel together with the ministry of health had to do mass media communication to help debunk misinformation that was going around, health care workers were also giving patients health education during their appointments every day. (matron). at first, it was difficult to communicate and monitor patients, but it all started getting better as good information was spreading, covid-19 outreach teams helped spread good information, check-ups on patients, and drug refills. patients are now being monitored and supported at clinics closer to where they stay. (female nurse) support groups for plwha during the lockdown, a lot was happening, and plwha had a difficult time. however, some research participants acknowledged that some plwha had formed support groups to help each other. for you to assist someone, one has to know one’s diagnosis, despite hiv no longer being something to be afraid of as before people are not open to sharing their medical history and diagnosis with people that are not close to them. (female nurse) yes, some patients who had developed friendships during regular hiv clinic visits, husbands and wives, started sharing medication during the pandemic while waiting for more information about how to get their pill refilled. (female nurse) major challenges faced lack of health insurance although participants managed to provide care to plwha through the pandemic, healthcare professionals were left exposed to a great amount of risk than anyone else, but there was no protection for them in terms of health insurance coverage to help them get medical assistance when need be. as a nurse, you are supposed to give service unconditionally, and this had put so many health professionals at risk some died. there is no universal medical insurance for medical professionals to help them when they get sick during work or because of work, so you find a lot of these professionals were not going an extra mile to help patients. (hospital ceo) shortage of personal protective equipment (ppe) the research participants reported difficulties acquiring ppes for themselves and organizations at large, as it was sometimes out of stock. they reported improvisation of ppe to protect themselves, but sometimes the improvisation was not fit for purpose. with the fear of infection and standard restriction imposed, every health professional at work needed high-quality ppe i.e., n-95 masks, biohazard suits, and gloves, but it was not available for most health care staff, most ended up using masks that are not up to standard… honestly, we needed constant help with ppe supply. (clinic matron) patients also need ppe for them to be able to visit the clinics. at one point, there was a shortage of ppe, and people started to wear cloth masks, some cloth masks were not up to standard, and for those who managed to get ppes, it was so overpriced, it was expensive. (clinic doctor) discussion globally, pandemics destabilize existing health systems, especially in, fragile under-resourced, and developing countries like zimbabwe.19 like other pandemics, covid-19 proved disruptive and drove healthcare systems beyond their limits.25 in zimbabwe, the sudden surge of patients needing hospitalization and treatment after being infected by the covid-19 virus demanded urgent measures to adapt the health system to accommodate all treatment needs resulting in disrupted services for lifelong diseases like hiv and aids. such disruptions in caring for other diseases during the pandemic were more significant among lower-income countries, thus calling for redesigning traditional service delivery methods to meet present demands.26 nonetheless, based on the research evidence reviewed, even with these disruptions, health delivery centers in zimbabwe continued to treat patients suffering from different ailments and plwha, albeit at reduced levels than in the pre-covid-19 periods.12 in light of this realization, this study explored healthcare system adaptive techniques and challenges experienced while catering to plwha amid the covid-19 pandemic in harare from healthcare professionals’ perspectives. our study confirms the resilience of the zimbabwean health system during covid19 despite its obvious resource limitations. findings from the research participants indicated that an aggressive communication strategy foregrounded the health delivery standard protocols put in place to sustain treating plwha and other diseases. such communication also targeted various stakeholders in the health delivery system, for example, centres for disease control and prevention (cdc) zimbabwe, to complement government efforts in treating dis article table 1. profile of participants ( health care professionals). participant number sister-in-charge 2 hospital pharmacist 2 male nurse 2 female nurse 3 matron 2 hospital ceo 1 clinic matron 1 clinic doctor 2 total 15 [healthcare in low-resource settings 2023; 11:11424] [page 63] non -co mmerc ial us e o nly [page 64] [healthcare in low-resource settings 2023; 11:11424] eases such as hiv and aids during the pandemic. earlier studies also reported that the government engaged in an aggressive national covid-19 mass media campaign to spread information about the pandemic to all citizens and also mobilized support from other health agencies like the cdc.9 nonetheless, our study participants noted that in the immediate aftermath of the covid-19 outbreak, it was challenging to assist plwha neither accurate information was available, nor due processes were well defined to assist patients. as a result, some plwha missed their clinic appointments, and some failed to collect treatment supplies. such mishaps arose partly because of a lack of clarity about patient travel protocols, as public transport was not allowed to move or take people from point a to point b during the pandemic.27 however, things improved over time as exceptions were given to patients to travel to health centers. health centers altered their medication pill refill times from 3 to 6 months to accommodate the new normal of living in a pandemic. in context, these difficulties of developing and implementing new health protocols during a pandemic are not new, particularly given the novelties and scale of effect that accompanied the covid-19 pandemic. these developments underscore the need for a resilient health system able to adapt protocols to continue treating patients suffering from other diseases. our study similarly found that healthcare centers adopted new covid-19 preventative measures with an overriding goal of protecting healthcare staff and patients visiting the healthcare centers from contracting covid-19. healthcare workers were generally wary of the risks of covid19 infection and infecting others while treating patients during the pandemic.28 thus they developed new methods that promoted non-contact health care practices, minimizing time spent at the health care center, adhering to covid-19 social distancing protocols, and mask-wearing for all patients. they also started to dispense medicine through the windows and decentralize patient care to local and nearest clinics for those who came from distant places. however, it was observed that patients recommended to local clinics sometimes experienced difficulties in getting supplies at those health facilities where they were not registered, resulting in involuntary art defaulting.27 results further indicate that plwha formed support groups to counsel each other. in some cases, friends and couples resorted to sharing medication to avoid a lapse in treatment adherence while waiting for more information about how to refill their pills. these findings suggest that covid-19 demands resourcefulness from healthcare providers and plwha. yet practices such as sharing pills (art) among patients are discouraged and expose plwha to medical risks considering that hiv and aids diagnosis and treatment regimes differ from patient to patient. however, the problem of sharing art among friends and family appears not exclusive to the covid-19 era. various other studies in different contexts29,30 similarly reported that plwha often shared medication with friends, family members, and spouses, arguably making it difficult to attribute this development strictly as a direct consequence of the pandemic. other researchers underscored the motivation to express solidarity among friends, family members, and spouses as a key factor in inciting sharing of art, which may also underline the feelings among plwha in times of the pandemic.30 collectively these developments also demonstrated the resilience initiatives and capabilities of the zimbabwean health system during the pandemic without necessarily qualifying compromises in the quality of service to patients. regarding the challenges faced while providing care to plwha, our respondents reported exposure to risk as they worked with no health insurance cover to help them get medical assistance when necessary and did not have reliable access to ppes. out-of-stock situations for ppes and related supplies such as n-95 masks, biohazard suits, and gloves were a common occurrence which forced them to improvise. still, sometimes the improvisation was not fit for purpose. in the same vein31 we noted that resource scarcity stimulates improvisation as healthcare professionals try to maintain services in circumstances where providing normal standards of care is impossible. however, they emphasize that such improvisations should be done to mitigate risks to healthcare workers and patients. our respondents reported that some healthcare staff used sub-standard cloth masks, which were not fit for medical settings and left them at risk of contracting covid-19. largely, while the problem of inadequate access to ppes for health professionals during the pandemic was a global issue, zimbabwe remained acute, emanating from the perennial financial and resource constraints that continue to weaken the health system.8,32 it can therefore be argued that the emergence of the covid-19 pandemic found zimbabwean healthcare staff already better skilled and equipped to tap into their resourcefulness and resilient capabilities, considering the daily struggles they encounter at work. implications for practice there is a need to develop flexible health delivery protocols for resource-constrained contexts to maintain overall health systems functionality amid pandemic situations. providing work resources such as ppes, health insurance, and skills training to health care professionals is crucial in building resourcefulness and motivation when performing their tasks. the study further implies that, while pandemics take precedents when they break out, serious policy and practical initiatives should be implemented to limit the disruption for lifelong ailments such as hiv and aids. moreover, policies that outline patient travel protocols and transportation arrangements to ensure that plwha can reach their clinic appointments and access necessary treatment supplies are required in pandemic situations. these strategies can be complemented by investment in enhancing telehealth services that enable health centers to provide remote consultations, prescription refills, and medication delivery options. these initiatives ensure continuity of care for plwha and reduce the risk of missed appointments or treatment interruptions. regarding improved communication systems initiatives, the existing communication strategy requires investment toward adopting diverse communication channels, such as dedicated hotlines, websites, or mobile applications, that can help ensure that accurate information reaches plwha on time. the study further suggests the need to strengthen community support networks. during public health emergencies, enhancing community support networks for plwha is crucial. this can involve establishing community-based organizations, support groups, or helplines that provide assistance, information, and resources to plwha, who may face challenges accessing healthcare services. limitations of the study the study was limited only to harare, thus lacking an overall analysis of the adaptive techniques and challenges in the healthcare system during the pandemic. however, the geographical area of study possesses better healthcare facilities than other areas in the country. this suggests that areas outside harare might have experienced acute challenges in developing adaptive techniques to assist plwha during the pandemic. another limitation is that exploratory studies rarely gather sufficient data to validate policy recommendations. thus, while this study provides insights into the problem investigated, there may be a need for a more diagnostic study to validate policy and practice recommendations. article non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11424] [page 65] conclusions resourcefulness during crises may contribute to the sustainability of existing health systems, as evident during the covid-19 pandemic. this study revealed that healthcare professionals in zimbabwe adopted various adaptive initiatives to sustain the treatment of plwha amidst the covid-19 pandemic. the results underscore the importance of human resource capabilities in building healthcare system resilience in resource-constrained countries. they further highlight how structural forces, such as covid-19 regulations and their concomitant influences on stakeholders connected to the health systems, undermined access to health services for plwha. references 1. dzinamarira t, nachipo b, phiri b, musuka g. covid-19 vaccine roll-out in south africa and zimbabwe: an urgent need to address community preparedness, fears and hesitancy. vaccines 2021;9:250. 2. puca e, čivljak r, arapović j, et al. short epidemiological overview of the current situation of the covid-19 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zimbabwe to a case for precision herbal medicine. j integrative biol 2021;25:209–12. 9. dzinamarira t, mukwenha s, eghtessadi r, et al. coronavirus disease 2019 (covid-19) response in zimbabwe: a call for urgent scale-up of testing to meet national capacity. clin infect dis 2021;72:e667–74. 10. vrazo ac, golin r, fernando nb, et al. adapting hiv services for pregnant and breastfeeding women, infants, children, adolescents and families in resource-constrained settings during the covid-19 pandemic. j international aids soc 2020;23:e25622. 11. seyedalinaghi sa, mirzapour p, pashaei z, et al. the impacts of the covid-19 pandemic on service delivery and treatment outcomes in people living with hiv: a systematic review. aids res ther 2023;20:1–17. 12. thekkur p, takarinda kc, timire c, et al. operational research to assess the realtime impact of covid-19 on tb and hiv services: the experience and response from health facilities in harare, zimbabwe. trop med infect dis 2021;6:94. 13. chimhuya s, neal sr, chimhini g, et al. indirect impacts of the covid-19 pandemic at two tertiary neonatal units in zimbabwe and malawi: an interrupted time series analysis. bmj open 2022;12:e048955. 14. nyashanu m, chireshe r, mushawa f, ekpenyong ms. exploring the challenges of women taking antiretroviral treatment during the covid-19 pandemic lockdown in peri-urban harare, zimbabwe. int j gynecol obstet 2021;154:220–6. 15. madzima b, makoni t, mugurungi o, et al. the impact of the covid-19 pandemic on people living with hiv in zimbabwe. african j aids res 2022;21:194–200. 16. celuppi ic, meirelles bhs. management in the care of people living with hiv in primary health care. texto e context enferm 2022;31. 17. rogers hl. the organisation of resilient health and social care following the covid-19 pandemic – a critical review. eur j public health 2021;31. 18. burau v, falkenbach m, neri s, et al. health system resilience and health workforce capacities: comparing health system responses during the covid-19 pandemic in six european countries. int j health plann manage. 2022;37:2032–48. 19. thu km, bernays s, abimbola s. a literature review exploring how health systems respond to acute shocks in fragile and conflict-affected countries. confl health 2022;16:60. 20. gorynia m, nowak j, wolniak r. motives and modes of fdi in poland: an exploratory qualitative study. j east eur manag stud 2007;12:132–51. 21. lockett d, willis a, edwards n. through seniors' eyes: an exploratory qualitative study to identify environmental barriers to and facilitators of walking. can j nurs res 2005;37:48–65. 22. zamawe fc. the implication of using nvivo software in qualitative data analysis: evidence-based reflections. malawi med j 2015;27:13–5. 23. pyett pm. validation of qualitative research in the "real world." qual health res 2003;13:1170–9. 24. serrant-green l. the sound of "silence": a framework for researching sensitive issues or marginalised perspectives in health. j res nurs 2011;16:347–60. 25. leite h, lindsay c, kumar m. covid19 outbreak: implications on healthcare operations. tqm j 2021;33:247–56. 26. world health organisation. covid-19 significantly impacts health services for noncommunicable diseases. 2020. available from: https://www. who.int/news-room/detail/01-06-2020covid-19-significantly-impacts-healthservices-for-noncommunicable-diseases 27. nyashanu m, chireshe r, mushawa f, ekpenyong ms. exploring the challenges of women taking antiretroviral treatment during the covid-19 pandemic lockdown in peri-urban harare, zimbabwe. int j gynecol obstet 2021;154:220–6. 28. mackworth-young cr, chingono r, mavodza c, mchugh g, tembo m, chikwari cd, weiss ha, rusakaniko s, ruzario s, bernays s, ferrand ra. community perspectives on the covid19 response, zimbabwe. bull world health org 2021;99:85. 29. hubbard j, phiri k, moucheraud c, et al. a qualitative assessment of provider and client experiences with 3and 6-month dispensing intervals of antiretroviral therapy in malawi. glob heal sci pract 2020;8:18–27. 30. groh k, audet cm, baptista a, et al. barriers to antiretroviral therapy adherence in rural mozambique. bmc public health 2011;11. 31. wiedner r, croft c, mcgivern g. improvisation during a crisis: hidden innovation in healthcare systems. bmj 2020;4:185–8. 32. mehta n, stewart a, fisher k, et al. impact of covid-19 on hiv treatment interruption in seven pepfar countries, april-june 2020. j int aids soc 2021;24:76-7. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11941 enhancing maternal role achievement and breastfeeding success through health belief model intervention nurus safaah,1,2 esti yunitasari,1 budi prasetyo,3 mira triharini,1 pipit feriani1,4 1faculty of nursing, universitas airlangga, surabaya; 2department of public health, institut ilmu kesehatan nahdlatul ulama tuban, tuban; 3faculty of medicine, universitas airlangga, surabaya; 4faculty of nursing, universitas muhammadiyah kalimantan timur, samarinda, indonesia abstract breastfeeding is a critical component of maternal and infant health. the study, conducted from april to june 2023, aimed to evaluate the impact of the mother’s role achievement module on breastfeeding practices among postpartum mothers in indonesia. sixty participants were divided into intervention and control groups in a quasi-experimental setup. the intervention group showed remarkable improvements: a 25% increase in breastfeeding frequency, a 15% weight gain, a 30% enhancement in proper breastfeeding technique, a 20% improvement in breast care practices, and a 25% boost in nutritional intake compared to the control group. conversely, the control group showed a reduced breastfeeding frequency by approximately 20%, a 10% decrease in weight, a 35% inadequacy in breastfeeding technique, varied breast care practices, and insufficient nutritional intake, showcasing the disparity between the groups. statistical analyses, including mann-whitney and chi-square tests, confirmed these significant differences, emphasizing the module’s substantial impact on breastfeeding success among postpartum mothers. in conclusion, tailored interventions based on the health belief model play a pivotal role in enhancing maternal and infant health outcomes in indonesia. this study recommends integrating similar approaches into healthcare policies to bolster breastfeeding practices among postpartum mothers, potentially improving overall maternal and infant health in the region. introduction breastfeeding stands as a cornerstone of infant health, recommended by the world health organization (who) for the first six months of life.1 however, in countries like indonesia, exclusive breastfeeding rates often fall below optimal levels.2 mothers encounter significant challenges in the early postpartum weeks, including issues like insufficient milk supply and sore nipples, prompting some to discontinue breastfeeding prematurely.3,4 furthermore, uncertainties about breastfeeding’s ability to adequately satisfy infants’ hunger contribute to this discontinuation trend.5 empirical evidence establishes a connection between delayed milk production in the first three postpartum days and maternal anxiety, dissatisfaction, and a shift toward formula feeding.6,7 the widespread belief in insufficient breast milk supply plays a substantial role in breastfeeding discontinuation.8 a mother’s beliefs play a crucial role in breastfeeding success, making the postpartum period pivotal in shaping maternal choices and influencing infant health outcomes.9 correspondence: nurus safaah, faculty of nursing, universitas airlangga campus c mulyorejo, surabaya, 60115, indonesia. tel.: +61.813.5777.5448. e-mail: nurus.safaah-2020@fkp.unair.ac.id key words: breastfeeding; health belief model; module; mother's role achievement. contributions: ns, study conception and design, data collection, critical revisions for important intellectual content, and manuscript writing. ey, study conception and design, study supervision, critical revisions for important intellectual content. bp, study conception and design, study supervision, critical revisions for important intellectual content. mt, study conception and design, study supervision, critical revisions for important intellectual content. pf, data collection, literature analysis, manuscript writing, and references. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: recommendations were initially obtained from airlangga university's doctoral program, specifically via the ethics committee for health research at the faculty of nursing, airlangga university, which granted ethical approval under number 266-kepk in november 2022 with one year validity period. subsequently, permission was secured from the tuban district government, specifically the investment and integrated one-stop service office (ptsp). the research was then meticulously conducted, aligning rigorously with its ethical objectives. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we express our gratitude to all the participants, their families, and the individuals who collected the data, as they played essential roles in contributing to this research. received: 10 october 2023. accepted: 1 december 2023. early access: 11 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11941 doi:10.4081/hls.2024.11941 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11941] [page 143] non -co mmerc ial us e o nly the health belief model (hbm) provides a valuable framework, highlighting an individual’s readiness for health-related actions based on perceived susceptibility, severity, benefits, and barriers.10 this model emphasizes cues to action and self-efficacy in decision-making, proven effective in enhancing breastfeeding knowledge and behaviors across diverse populations.11,12 despite its effectiveness, there is still a deficit in the preparedness of pregnant women for breastfeeding, which affects their motivation and confidence in this crucial maternal journey.13 previous studies, such as paramashanti et al. (2023),14 have highlighted the challenges of breastfeeding discontinuation due to perceived milk supply inadequacy, aligning with the issues observed in indonesia. however, while prior research emphasizes the importance of breastfeeding and acknowledges the role of the hbm, the specific cultural, societal, and familial factors influencing breastfeeding decisions among indonesian postpartum mothers remain less explored.15 this study addresses this gap by evaluating the impact of the “mother’s role achievement module,” guided by the hbm, on maternal role attainment and breastfeeding success in indonesia. the novelty of this study lies in its focus on culturally sensitive interventions tailored to the indonesian context, aiming to bridge the gap between theory and practice in nursing interventions. indonesia’s cultural norms, societal pressures, familial expectations, and individual beliefs significantly shape breastfeeding choices, necessitating a deeper understanding to develop effective interventions and policies.16 this research seeks to contribute to nursing scholarship in asia, offering insights into determinants that influence breastfeeding choices among indonesian postpartum mothers. therefore, this study aimed to evaluate the impact of the “mother’s role achievement module” on breastfeeding practices among postpartum mothers in indonesia. materials and methods design this study adhered to the transparent reporting of evaluations with non-randomized designs (trend) guidelines and employed a quasi-experimental design—a more complex research design involving both pre-test and post-test assessments for both the intervention (treatment) group and the control group. this design involved assessing the outcomes solely after the intervention had been administered, with the results subsequently analyzed to evaluate the effectiveness of the research. population, sample, and sampling the study included pregnant women in their third trimester until postpartum period day 14, encompassing those within public health center and health center regions. it involved a total of 60 respondents, evenly split between the intervention and control groups. data collection occurred from april to june 2023, spanning three months. sample size calculation considered a significance level of 0.05, a power level of 0.80, and pre-study proportions based on prior research or assumptions. the calculated sample size, considering a 10% addition for potential dropouts, resulted in a total sample size of 30 respondents. therefore, after accounting for the possibility of dropouts, the actual sample size obtained for this study in each group was 30 participants. random sampling ensured fairness, and randomization was achieved through a coin flip to allocate participants. this comprehensive approach ensured the study’s credibility and meaningful conclusions. variable the study’s dependent variable encompassed breastfeeding success and maternal role attainment among postpartum mothers in indonesia, encapsulating various facets like early breastfeeding steps, breastfeeding frequency, infant weight gain, breastfeeding techniques, breast care, and maternal nutrition. this variable served as the focal point for gauging the impact of the intervention. on the other hand, the independent variable was represented by the intervention itself—the “mother’s role achievement module” rooted in the health belief model. this intervention sought to augment maternal role attainment and breastfeeding success among postpartum mothers. meanwhile, the control group received education on breastfeeding benefits through the kia (maternal and child health) handbook during their antenatal care visits. instruments and intervention the instruments, aligned with the health belief model and breastfeeding guidelines, underwent pre-testing for clarity and reliability. adjustments were made based on feedback from a small respondent group, ensuring validity. these instruments included a demographic tool, a health belief model-based training module with standard operating procedures (sops), and observation sheets. the intervention, spanning four sessions, provided comprehensive support, emphasizing respect, shared responsibility, and mutual agreement. additional tools assessed various aspects of breastfeeding success, crucial for evaluating the intervention’s impact. this study involved two groups: the treatment group and the control group. the treatment group underwent a comprehensive intervention based on the health belief model. it included four sessions over four weeks, covering various topics like explaining the caregiver role, demonstrating breastfeeding techniques, setting agreements with participants, and reinforcing key concepts. additionally, a home visit ensured effective implementation. conversely, the control group received breastfeeding education via the kia handbook during their routine anc visits at the public health center. unlike the treatment group’s structured sessions, the control group received information solely from the handbook without personalized support. both groups’ progress was measured through pre-test and post-test assessments, and observations of breastfeeding practices, enabling a comparative analysis of the interventions’ impacts. the treatment group experienced the structured hbm-aligned intervention, while the control group received standard educational materials during routine healthcare visits, forming the basis for comparison in evaluating the interventions’ effectiveness. data collection process the inclusion criteria targeted mothers with infants who were actively engaged in breastfeeding. additionally, respondents needed to demonstrate proficiency in the indonesian language and possess reading and writing skills. exclusion criteria applied to mothers unable to provide breast milk due to their baby’s hospitalization or those with mental health disorders. additionally, dropout criteria were established for postpartum mothers unable to complete the study before the post-test and participants who withdrew during the intervention. the study conducted pre-test and post-test assessments and observed breastfeeding practices. instruments gauged early breastfeeding steps, frequency, infant weight gain, techniques, breast care, and maternal nutrition. the intervention spanned four sessions over one month. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 144] [healthcare in low-resource settings 2024;12:11941] non -co mmerc ial us e o nly analysis descriptive analysis was used to explore variables without establishing relationships. categorical data were presented through frequency distributions and percentages, while numerical data used measures like mean, median, and standard deviation. parametric tests, such as the t-test, were employed for normally distributed data, including breastfeeding frequency, infant weight gain, and maternal nutrition. non-parametric tests, such as the mann-whitney u test, were applied to variables like early breastfeeding steps, techniques, and breast care, which deviated from normal distribution. ethical consideration in this study, ethical principles were diligently followed in accordance with trend guidelines. initial approval was obtained from airlangga university’s ethics committee for health research (approval no. 266-kepk). subsequent permission was secured from the tuban district government. the research strictly adhered to ethical objectives, including obtaining informed consent and implementing rigorous confidentiality measures to protect participant identities and sensitive information. results descriptive analysis was used to explore variables without establishing relationships. categorical data were presented through frequency distributions and percentages, while numerical data used measures like mean, median, and standard deviation. parametric tests, such as the t-test, were employed for normally distributed data, including breastfeeding frequency, infant weight gain, and maternal nutrition. non-parametric tests, such as the mann-whitney u test, were applied to variables like early breastfeeding steps, techniques, and breast care, which deviated from normal distribution. the data from table 1 reveals that in the experimental group, most participants had pregnancies lasting 37 weeks, possessed a high school education, and had an average age of approximately 23.20 years. in contrast, in the control group, most respondents experienced pregnancies of 37 or 38 weeks, had completed high school, and had an average age of around 23.37 years. upon conducting the significance test, it is evident that the characteristics of the respondents, such as gestational age, educational background, and maternal age, resulted in p-values exceeding 0.05. consequently, it can be inferred that there is no notable distinction in terms of gestational age, education, and maternal age between the experimental group and the control group’s respondents. the data presented in table 2 reveals that none of the respondents practiced early initiation of breastfeeding (eibf) in the experimental group. however, most of these participants maintained a regular breastfeeding frequency, observed weight gain, correctly applied breastfeeding techniques, practiced proper breast care, and had a normal level of nutritional intake. in contrast, within the control group, none of the respondents practiced eibf. furthermore, most of these participants had a reduced frequency of breastfeeding, experienced weight loss, inadequately executed breastfeeding techniques, exhibited varying levels of breast care (some performed well, while others did not), and had insufficient nutritional intake. all 60 participants, evenly distributed with 30 in the treatment group and 30 in the control group, were encompassed in each analysis. adhering to the “intention to treat” principle, the analysis strategy evaluated all participants according to their assigned groups. results for both primary and secondary outcomes exhibited significant differences between the treatment and control groups (p<0.05). the mother’s role achievement module demonstrated a substantial impact on variables including breastfeeding frequency, weight gain, breastfeeding technique, breast care, and nutritional intake. the experimental group excelled in these aspects, underscoring the intervention’s effectiveness. this report encompasses all findings, encompassing null and negative results, while pre-specified causal pathways for the intervention were not assessed. beyond primary and secondary outcome analyses, no additional analyses were conducted. throughout the intervention, no adverse events or unintended effects were reported in either study condition. the impact of implementing the mother’s role achievement module on breastfeeding success was assessed using the mannwhitney test and chi-square analysis due to the nature of the data being on ordinal and nominal scales. the criterion for significance was set at a p<0.05. table 3 illustrates that statistical tests (mann-whitney and chisquare) performed on variables like breastfeeding frequency, weight gain, breastfeeding technique, breast care, and nutritional intake resulted in p<0.05. this indicates a significant difference in these variables between the groups. in simpler terms, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. analysis of respondent characteristics: examining participant characteristics in the health belief model-based mother's role achievement model study (n=60). characteristic category experimental control p n % mean±sd n % mean±sd gestational age 34 weeks 1 3.3 0 0.0 0.313b 36 weeks 2 6.7 1 3.3 37 weeks 11 36.7 10 33.3 38 weeks 3 10.0 10 33.3 39 weeks 8 26.7 6 20.0 40 weeks 5 16.7 3 10.0 education elementary 4 13.3 1 3.3 0.231b junior high 3 10.0 7 23.3 senior high 21 70.0 18 60.0 higher education 2 6.7 4 13.3 age 23.20 ± 2.83 23.37 ± 2.63 0.715a amann whitney test; bchi-square test; sd, standard deviation. [healthcare in low-resource settings 2024;12:11941] [page 145] non -co mmerc ial us e o nly implementing the mother’s role achievement module significantly influences breastfeeding frequency, weight gain, breastfeeding technique, breast care, and nutritional intake. additionally, the descriptive analysis indicates that the experimental group showed superior performance compared to the control group, highlighting the effectiveness of the mother’s role achievement module in improving breastfeeding success. discussion the study investigated how the mother’s role achievement module affected breastfeeding practices in postpartum mothers. the intervention notably increased maternal breastfeeding motivation compared to limited support in the control group, with the experimental group excelling in various aspects despite not practicing eibf, while the control group faced challenges without extensive support. interaction with healthcare providers significantly boosted breastfeeding motivation in the intervention group, reflected in higher post-test scores compared to the control group’s leaflet intervention. another study in the bergas district found that while most mothers had high motivation for exclusive breastfeeding, workload level didn’t significantly impact this motivation when robust support systems were in place.17 in a study with a 95% participation rate and an 88.4% breastfeeding initiation rate, a positive trend in breastfeeding intentions was observed. the intention to exclusively breastfeed increased linearly from 71.9% in 2005 to 76.8% in 2008. factors associated with higher motivation for exclusive breastfeeding included older age, primiparity, and spontaneous deliveries. conversely, lower motivation was linked to factors such as infrequent attendance at prenatal classes, lower educational levels, reduced incomes, german nationality, and tobacco use.18 another study, employing kendall’s tau correlation analysis, highlighted a strong positive link between mothers’ knowledge about exclusive breastfeeding and their motivation for it. mothers’ knowledge contributed significantly, explaining 83.8% of the motivation. both aspects were moderately rated, suggesting potential for improvement in both knowledge and motivation for exclusive breastfeeding.19 various factors influenced breastfeeding self-efficacy, including information resources, job status, and education level. however, it was not a predictor or antecedent of effective breastfeeding behavior.20 in the prior study, surveyed mothers displayed high levels of both marital adjustment and breastfeeding self-efficacy. however, no significant correlation between these two factors was found, implying the potential benefits of involving fathers in co-parenting strategies within breastfeeding interventions to enhance their support and engagement in the process.21 the study revealed significant differences in breastfeedingrelated variables between groups, affirming the module’s effectiveness. postpartum mothers, primarily first-time participants, encountered physical challenges and emotional fluctuations that transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. impact of mother's role achievement module: assessing the effects of the mother's role achievement module on breastfeeding success in postpartum mothers. variable statistics sig. descriptionl frequency of feeding -2.679a 0.007 significant weight gain -2.581a 0.010 significant breastfeeding techniques -2.612a 0.009 significant breast care 6.126b 0.047 significant nutritional intake -4.175a 0.000 significant amann whitney test; bchi-square test. [page 146] [healthcare in low-resource settings 2024;12:11941] table 2. breastfeeding success variable description: understanding breastfeeding success in the health belief model-based mother's role achievement model study. variable category experiment control n % n % eibf eibf not implemented 30 100 30 100 eibf implemented 0 0 0 0 frequency of feeding less 5 16.7 15 50.0 normal 14 46.7 10 33.3 more 11 36.7 5 16.7 weight gain decrease 7 23.3 15 50.0 remain 11 36.7 11 36.7 increase 12 40.0 4 13.3 breastfeeding techniques less 9 30.0 17 56.7 adequate 11 36.7 11 36.7 properly 10 33.3 2 6.7 breast care less 5 16.7 12 40.0 adequate 11 36.7 12 40.0 properly 14 46.7 6 20.0 nutritional intake deficit 2 6.7 20 66.7 normal 22 73.3 7 23.3 more 6 20.0 3 10.0 n, number of participants; eibf, early initial of breastfeeding. non -co mmerc ial us e o nly could affect breastfeeding support. gianni et al. (2020) further explore these challenges in first-time postpartum mothers, supporting the view that emotional and physical aspects significantly influence breastfeeding practices.22 differences in cultural beliefs and attitudes between groups hint at varied effects of support. beggs et al. (2021) delved into cultural differences’ impact on breastfeeding support, reinforcing the observation of diverse effects in your study. this highlights the crucial role of cultural contexts in shaping effective breastfeeding interventions.23 however, both groups showed notable enhancements in maternal breastfeeding ability scores post-intervention, indicating the overall effectiveness of the intervention. a previous study’s results demonstrate a statistically significant influence of the lactation management module on breastfeeding self-efficacy and the success of breastfeeding. this underscores the module’s effectiveness in positively impacting these crucial aspects of breastfeeding. overall, the study confirms the significant role played by the lactation management module in enhancing breastfeeding self-efficacy and overall breastfeeding success.24 another study demonstrated that breastfeeding training significantly increased self-efficacy and success rates. the findings emphasized the effectiveness of breastfeeding training in enhancing mothers’ self-efficacy and prolonging exclusive breastfeeding, while indicating no significant impact from paternal support.25 recommendations from these studies highlight the integration of educational methods encompassing structured programs, modulebased learning, and hands-on training for healthcare professionals. it also suggests using assistive devices to address breastfeeding challenges. aligning organizational strategies with these approaches could significantly improve breastfeeding success in pediatric healthcare settings.26 this suggests that customized lactation education modules could notably enhance breastfeeding mothers’ selfefficacy.27 additionally, healthcare providers documented breastfeeding education in medical records 52% of the time, highlighting a positive impact on clinical practice.28 the analysis of the study’s key findings demonstrated that the odds of breastfeeding were positively impacted by receiving curricular modules and participating in a postpartum visit. additionally, the odds of exclusive breastfeeding were significantly higher for those who had a postpartum visit. this collaborative effort between the community and academia uncovered specific intervention components that substantially improved the likelihood of breastfeeding success in a high-risk population.29 the intervention group, primarily comprising participants with less favorable cultural beliefs and attitudes toward breastfeeding, significantly benefited from breastfeeding demonstrations and support provided by healthcare providers. research by jacobzon et al. (2022) emphasized the critical role of healthcare providers in educating postpartum mothers about breastfeeding techniques and care. the study underscored the limited knowledge often observed among first-time mothers and the importance of interventions led by healthcare providers to address these gaps.30 these providers imparted crucial information to the control and intervention groups, recognizing the limited knowledge typically held by postpartum primiparous mothers regarding proper breastfeeding techniques and care, as emphasized. healthcare providers are pivotal in delivering comprehensive health education to mothers, employing various methods, including leaflets, posters, counseling, demonstrations, and breastfeeding support. healthcare providers should note that a significant portion of the study participants faced difficulties attaining exclusive breastfeeding success. to address the issue of unsuccessful exclusive breastfeeding, healthcare providers must proactively assess maternal factors, including preferences for formula milk, mode of delivery, and the adequacy of breast milk.31 this educational approach aims to enhance mothers’ knowledge, proficiency in breastfeeding, and positive attitudes and behaviors. importantly, this health education can be administered both before and after childbirth and may include practical demonstrations and guidance from healthcare providers, collectively constituting advanced health education for breastfeeding mothers. balancing maternal income, dietary diversity, and respecting cultural values in the context of breastfeeding is critical. it’s essential to avoid situations where breastfeeding and childcare become overwhelming and isolating for mothers. additionally, involving fathers in breastfeeding decisions and safeguarding cultural beliefs related to infant and young child feeding (iycf) practices.32 in the analysis of the findings, four central themes emerged: ‘recommended dietary choices and behavior,’ ‘restricted dietary choices and behavior,’ ‘consequences of adhering to cultural taboos,’ and ‘the evolving landscape of cultural beliefs.’ these findings provide valuable insights for healthcare providers. they can leverage this information to create educational programs that are culturally sensitive and tailored to meet the needs of contemporary parents.33 cultural beliefs have profoundly influenced traditional infant care practices, shaping maternal dietary choices and breastfeeding behaviors. mothers, guided by these entrenched beliefs, adhered to dietary restrictions, avoiding foods like green leafy vegetables, liquids, and hot meals, believing that these choices would safeguard their infants’ health. the study participants attributed physical discomforts, such as weight loss, nipple inflammation, and backaches, to the demands of intense breastfeeding and prolonged sitting. research by scime et al. (2023) delved into the experiences of postpartum mothers and their perceptions of physical discomforts associated with breastfeeding. the study identified common complaints such as weight loss, nipple inflammation, and backaches, echoing the physical challenges reported by your study participants.34 furthermore, cultural customs, including providing water to infants for survival and administering charm water for religious and protective purposes, exemplify the far-reaching impact of these cultural beliefs on infant feeding practices. additionally, these cultural beliefs were manifestations of the perception that breast milk adequacy correlated with breast size and introducing pre-lacteal feeds in early infancy to enhance men’s physical strength. these factors collectively contribute to the low prevalence of exclusive breastfeeding among mothers, underscoring the enduring power of cultural traditions in shaping maternal and infant care practices.35 the study’s implications suggest adopting culturally sensitive interventions like the mother’s role achievement module in indonesian postpartum care settings and similar cultural contexts. future research should adapt and assess intervention effectiveness across diverse cultures, aiming to sustain breastfeeding success beyond the immediate postpartum period. this study enriches our comprehension of interventions in enhancing breastfeeding and emphasizes integrating cultural perspectives into healthcare programs. healthcare professionals, by incorporating culturally sensitive approaches, can significantly promote breastfeeding success among postpartum mothers. acknowledging the study’s limitations – like the relatively small sample size impacting generalizability – we urge further research to delve into other aspects of breastfeeding practices and maternal-infant health. by acting upon the evidence presented, healthcare providers, policymakers, and researchers can implement evidence-based strategies to bolster breastfeeding success and maternal-infant well-being in our communities. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11941] [page 147] non -co mmerc ial us e o nly conclusions in conclusion, this study highlights the significant impact of the mother’s role achievement module, based on the health belief model, in enhancing maternal role attainment and breastfeeding success among postpartum mothers. this underscores the importance of evidence-based interventions for improved maternal and infant health outcomes. healthcare providers and policymakers are encouraged to adopt the health belief model for interventions related to breastfeeding. prioritizing breastfeeding education in the third trimester, along with ongoing postpartum support, can promote positive breastfeeding experiences. integrating culturally sensitive approaches into healthcare programs can tailor interventions to community needs, effectively bridging the theory-practice gap. references 1. rouse cl. increasing initiation and exclusivity of breastfeeding in the hospitalized, postpartum dyad. jognn j obstet gynecol neonatal nurs 2015;44. 2. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632–45. 3. sebayang sk, dibley mj, astutik e, et al. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16:e12889. 4. gianni ml, bettinelli me, manfra p, et al. breastfeeding difficulties and risk for early breastfeeding cessation. nutrients 2019;11:2266. 5. swigart tm, bonvecchio a, théodore fl, et al. breastfeeding practices, beliefs, and social norms in low-resource communities in mexico: insights for how to improve future promotion strategies. plos one 2017;12:e0180185. 6. hernández-cordero s, lozada-tequeanes al, fernándezgaxiola ac, et al. barriers and facilitators to breastfeeding during the immediate and one month postpartum periods, among mexican women: a mixed methods approach. int breastfeed j 2020;15:87. 7. hadisuyatmana s, has emm, sebayang sk, et al. women’s empowerment and determinants of early initiation of breastfeeding: a scoping review. j pediatric nurs 2021;56:e77–92. 8. cascone d, tomassoni d, napolitano f, di giuseppe g. evaluation of knowledge, attitudes, and practices about exclusive breastfeeding among women in italy. int j environ res public health 2019;16:2118. 9. edwards r, cragg b, dunn s, peterson we. the breastfeeding and early motherhood experiences of older first-time mothers: a constructivist grounded theory study. midwifery 2021;96. 10. barkhordari-sharifabad m, vaziri-yazdi s, barkhordarisharifabad m. the effect of teaching puberty health concepts on the basis of a health belief model for improving perceived body image of female adolescents: a quasi-experimental study. bmc public health 2020;20:370. 11. hu l, ding t, hu j, luo b. promoting breastfeeding in chinese women undergoing cesarean section based on the health belief model: a randomized controlled trial. medicine (united states) 2020;99:e20815. 12. liu y, yao j, liu x, et al. a randomized interventional study to promote milk secretion during mother–baby separation based on the health belief model a consort compliant. medicine (united states) 2018;97:e12921. 13. kordi m, fasanghari m, asgharipour n, esmaily h. the effect of maternal role training program on role attainment and maternal role satisfaction in nulliparous women with unplanned pregnancy. j educ health promot 2017;6:61. 14. paramashanti ba, dibley mj, huda tm, et al. factors influencing breastfeeding continuation and formula feeding beyond six months in rural and urban households in indonesia: a qualitative investigation. int breastfeed j 2023;18:48. 15. ramos-morcillo aj, harillo-acevedo d, armero-barranco d, et al. barriers perceived by managers and clinical professionals related to the implementation of clinical practice guidelines for breastfeeding through the best practice spotlight organization program. int j environ res public health 2020;17:6248. 16. ngo lth, chou hf, gau ml, liu cy. breastfeeding self-efficacy and related factors in postpartum vietnamese women. midwifery 2019;70:84-91. 17. ulya ra, pradanie r, nastiti aa. effect of workload and breastfeeding motivation of working mothers. indian j forensic med toxicol 2020;14(2). 18. lange a, nautsch a, weitmann k, et al. breastfeeding motivation in pomerania: survey of neonates in pomerania (snipstudy). int breastfeed j 2017;12:3. 19. nurkhayati a, bimbingan p, islam p, negeri i, thaha s, jambi s. the effect of mother’s knowledge in influencing motivation for exclusive breastfeeding in talang village, bayat district, klaten regency. j multidisiplin madani 2022;2(2). 20. pradanie r. breastfeeding self efficacy and effective breastfeeding on postpartum mother. j ners 2015;10(1). 21. gonzales am. marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines. j ners 2020;15:7–13. 22. giannì ml, lanzani m, consales a, et al. exploring the emotional breastfeeding experience of first-time mothers: implications for healthcare support. front pediatr 2020;8:1–7. 23. beggs b, koshy l, neiterman e. women’s perceptions and experiences of breastfeeding: a scoping review of the literature. bmc public health 2021;21:2169. 24. ayuningtiyas, muyassaroh y, octavianingrum da. the effect of lactation management module on self-efication and successful breastfeeding. j darul azhar 2020;8(1). 25. ayran g, çelebioğlu a. education of parents in increasing breastfeeding rates, success, and self-efficacy levels. j pediatr res 2022;9(2). 26. durocher kl, ralph jl. implementing breastfeeding education in pediatric settings. pediatr nurs 2022;48(3). 27. nurmiaty n, arsin aa, syafar m, et al. the effect of lactation education on self-efficacy of breastfeeding mothers. poltekita j ilmu kesehat 2023;17(1). 28. pitts a, faucher ma, spencer r. incorporating breastfeeding education into prenatal care. breastfeed med 2015;10:118-23. 29. furman l, matthews l, davis v, et al. breast for success: a community–academic collaboration to increase breastfeeding among high-risk mothers in cleveland. prog community heal partnerships res educ action 2016;10:341-353. 30. jacobzon a, engström å, lindberg b, gustafsson sr. mothers’ strategies for creating positive breastfeeding experiences: a critical incident study from northern sweden. int breastfeed j 2022;17:35. 31. hashim s, ishak a, muhammad j. unsuccessful exclusive transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 148] [healthcare in low-resource settings 2024;12:11941] non -co mmerc ial us e o nly breastfeeding and associated factors among the healthcare providers in east coast, malaysia. korean j fam med 2020;41(6). 32. chakona g. social circumstances and cultural beliefs influence maternal nutrition, breastfeeding and child feeding practices in south africa. nutr j 2020;19:47. 33. anggraeni md, aji b, setiyani r, et al. how do modern parents deal with cultural beliefs about breastfeeding? a qualitative study. br j midwifery 2018;26(9). 34. scime nv, metcalfe a, nettel-aguirre a, et al. breastfeeding difficulties in the first 6 weeks postpartum among mothers with chronic conditions: a latent class analysis. bmc pregnancy childbirth 2023;23:90. 35. sosseh sal, barrow a, lu zj. cultural beliefs, attitudes and perceptions of lactating mothers on exclusive breastfeeding in the gambia: an ethnographic study. bmc womens health 2023;23(1). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11941] [page 149] non -co mmerc ial us e o nly hrev_master comparative efficacy of interferential therapy, bronchodilators, and body positioning on asthma control and quality of life of patients with bronchial asthma: a study protocol eniola awolola oladejo, sonill maharaj sooknunan department of physiotherapy, college of health sciences, university of kwazulunatal, durban, south africa abstract interferential therapy (ift) is the application of two medium frequency currents to the skin to stimulate and activate different systems in the body using specific frequencies and frequency ranges. the aim in applying ift is to reduce myalgia in the chest and upper back, reduce muscular fatigue, and induce mucus expectoration. this study is designed to test the efficacy of ift in reducing the symptoms frequently experienced by patients with bronchial asthma. forty-eight (48) patients aged 18 and above with bronchial asthma attending the respiratory clinic at the lagos state university teaching hospital, ikeja (lasuth) will be assessed for eligibility. the study design will be a double-blinded, randomized control trial with four intervention groups and four parallel placebo control groups. ift will be administered as an intervention to patients on short and longacting bronchodilators in an assigned fundamental body position for 20 minutes. six continuous outcome variables at different points will be utilized as outcome measures. a baseline pulmonary function test (pft) will be conducted on entry into the study while quality of life and asthma control will be evaluated every two (2) weeks during the study. data obtained will be analyzed using descriptive and inferential statistics of repeated anova; p<0.05. the study outcome will compare the efficacy of ift on bronchial asthma, identify its effect in different body positions, and compare the relationship between its application and the bronchodilator medication frequently used by the patients. introduction worldwide, approximately 300 million people are affected with bronchial asthma.1 it is more prevalent in developed countries, with the highest rates seen in australia, uk, and new zealand.1 in the nigerian population, the prevalence of asthma ranges from 7% to 18%.1-4 a study by oni et al.,5 on the prevalence, management, and burden of asthma revealed that asthma affects all age groups, races, and sex. a population-based study showed that more boys are usually affected than girls in the early decades of life, however, the prevalence becomes equal by the third decade of life, and afterward. more women were reported to be affected after the third decade. symptom relief, reduction in the use of on-demand inhalers, improvement in activities and lung function are the day-to-day asthma control achievements.6 the absence of asthma exacerbations ensures the minimization of future risks by preventing accelerated decline in lung function and side-effects from medications over time.6 progress is being made in the understanding and management of asthma, the inflammatory nature of the disease, use of steroids, and add-on of inhaled bronchodilator combined with steroids, devices to deliver the medications appropriately, and appreciation of the value of self-management education.1,7 in the treatment of airway disorders, bronchodilators are central in managing most chronic obstructive pulmonary diseases and are critical in managing asthma.8 the recent update by gina9 indicates the consideration of low dose ics-formoterol as controller medication for the management of bronchial asthma or ics-saba as an alternative in countries where ics-formoterol is unavailable, low-dose. according to boros and martusewiczboros10 airway reversibility is a test commonly used in diagnosing obstructive lung disease; its result can be used as a differential diagnosis between asthma and chronic obstructive pulmonary disease. chung et al.11 identified fev1/fvc<lln or 0.70 or <lln as a tool for diagnosing airway obstruction. significant improvement (positive bronchodilatation test) is defined as an increase in fev1 or fvc of more than 200 ml, or 12% of the predicted value of fev1.11 a bronchial provocative test can be used to determine the strength of the controller medication when fev1 is >70% predicted value.9 several studies have been conducted to understand the effect of body position on pulmonary function. the most recent, a systematic review by katz et al.,12 reported higher fev1, fvc, frc, imax, and pef values in most studies involving healthy subjects or patients with lung, heart, neuromuscular disease, or obesity in a more erect healthcare in low-resource settings 2022; volume 10:10251 correspondence: eniola awolola oladejo, department of physiotherapy, college of health sciences, university of kwazulu-natal, block e-5 university road, westville, private bag x54001, durban, 4000, south africa. tel.: +27679542461, +2348056333106 e-mail: 220068603@stu.ukzn.ac.za key words: ift; asthma; pft; act; aqlq. acknowledgements: we hereby thank all the physiotherapists and medical doctors at lagos state university teaching hospital, ikeja, lagos, for their contribution to the study’s success and, most importantly, the participants for their voluntary participation. our profound appreciation also goes to dr. olufunke adeyeye and dr. olufemi ojo of lagos state university teaching hospital, ikeja, lagos, for their professional advice in writing and reviewing this manuscript; to miss kemi and miss laide for their support in conducting the pulmonary function test; and to miss amodeni ayomopewa for her editorial input. contributions: eao developed the study idea; eao and sms developed the title; and both contributed to the study design. all authors were involved in designing the qualitative and quantitative aspects of the study. eao was responsible for drafting the initial manuscript. sms was responsible for editing and critical review of the manuscript. both authors read, critically revised, and approved the final version of the manuscript. the views expressed in this study are strictly the views of the authors and not of the institution or any other group of people. conflict of interest: the authors declare no conflict of interest. funding: eao funded the study. no funding was received from any external source for the study. the study design, writing the manuscript, data collection and analysis are independent of the institutions used for the study. access to protocol: https://pactr.samrc.ac.za/ researcher/managetrials.aspx the protocol was registered on the 1st of may 2020 with identifier number pactr202005807526130 and the trial organization is ukzn. availability of data and materials: the corresponding author will make available the datasets for the study upon reasonable request. however, the findings from the study will be made available to participating researchers as required by law. ethics approval and consent to participate: this study has been approved by the biomedical research ethics committee of the university of kwazulu natal (south africa) (ethics number: brec/00001883/2020), and by the human research ethics committee of lagos state university teaching hospital, ikeja, lagos, nigeria, west africa (lrec/06/10/1428). the study is registered with clinicaltrial.gov with registration number pactr202005890624077. informed consent: a written and signed informed consent will be obtained from all participants recruited for this study through a third party that is independent of the study team. the consent form is designed by the biomedical research ethics committee of the university of kwazulu-natal (brec) according to the wma helsinki declaration and good clinical practice (gcp). during the trial, the pi will communicate in writing to the recs in the event of the need to modify or amend the protocol, especially the inclusion or exclusion criteria of the study. received for publication: 24 october 2021. revision received: 13 december 2021. accepted for publication: 11 january 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10251 doi:10.4081/hls.2022.1051 [healthcare in low-resource settings 2022; 10:10251] [page 1] non -co mmerc ial us e o nly position. for subjects with tetraplegia, spinal cord injury, fvc and fev1 were higher in supine vs. sitting.12 interferential therapy (ift) involves the application of two medium frequency currents to the skin in such a way that the currents “interfere” with each other to produce a “beat” frequency.13 the difference between the medium frequency currents is termed the beat frequency, and the body recognizes it as the required low-frequency current. interferential therapy induces expectoration by making sputum on the bronchi surface mobile and reduces shoulder stiffness, muscular fatigue, and myalgia in the chest and upper back regions.14 interferential current (ifc), a non-invasive treatment modality, is often used to induce analgesia, elicit muscle contractions, and reduce oedema.15-17 for many years, the effectiveness of asthma medications has been assessed by measuring their impact on expected clinical outcomes such as expiratory flow rates, symptoms, the need for other medications, and airway responsiveness.18 although of great importance, none of the measurements indicates whether the patients can function better in their day-today lives.18 aim of the study the overall aim of this study is to determine the effect of ift applied in 45° or 90° long sitting with a bronchodilator (short or long acting) on asthma control, quality of life, and selected pulmonary variables of asthmatic patients attending the respiratory clinic of lagos state university teaching hospital, ikeja, lagos. this study is designed to investigate the efficacy of a non-invasive therapeutic modality on airway reversibility, asthma control, quality of life of bronchial asthma (ba) patients in 2 different body positions using the gli (lln) 2012 reference equation for asthma classification and the 2019 pan african thoracic society (pats) and european respiratory society guidelines for the validation of spirometry test results. the outcome from this study may provide a non-invasive solution to the bronchospasm frequently experienced during an asthma attack. hypothesis h0 interferential therapy (ift) applied in 45° or 90° long sitting will have no significant effect on airway reversibility, asthma control, and bronchial asthma patients’ quality of life. delimitation this study will be delimited to 48 bronchial asthma patients attending the lagos state university teaching hospital, ikeja, lagos respiratory clinic. significance of the study it is expected that the outcome of this study will establish the relationship among interferential therapy, bronchodilators, and body position in asthma control, asthma quality of life, and selected pulmonary variables of patients living with bronchial asthma. it is expected that this study will provide substantial evidence on airway reversibility in bronchial asthma using ift. materials and methods study design the study is a parallel, 12-week randomized control trial and will involve four (4) intervention groups and four parallel placebo control groups. participants the participants for this study will consist of male and female adult bronchial asthma patients aged 18 and above attending lagos state university teaching hospital (lasuth), ikeja, lagos, nigeria in west africa. the inclusion criteria involve patients with bronchial asthma aged 18 and above attending the respiratory clinic of lasuth. the exclusion criteria involve patients with other types of copd other than bronchial asthma, hypersensitive to b2 agonist, patients with a cardiac pacemaker, who have had recent surgery, supplemental oxygen therapy, or with cardiac conditions, and patients with psychological impairments. participants who meet the required criteria will be asked to read and sign an informed consent approved for this study by the appropriate institutional review board. setting patients with bronchial asthma attending the respiratory clinic of lagos state university teaching hospital, ikeja, lagos state, nigeria, will be recruited for the study. the hospital is a tertiary health facility within the state and receives referrals from within and outside the state. article figure 1. f tests -manova: repeated measures, within-between interaction. [page 2] [healthcare in low-resource settings 2022; 10:10251] non -co mmerc ial us e o nly sample size the pulmonary function test is the primary outcome of interest for the study and the expected clinically-relevant difference for pulmonary rehabilitation in various body positions using lln and gli reference equation proposed by quanjer et al.19 therefore, the sample size (n) will be determined using the g-power statistics software. the power is selected at 95% =0.95, confidence level at 5% =0.05 and effect size of 0.35 (figure 1). randomization and blinding the contact numbers of participants will be randomly extracted from the database on respiratory patients attending the lagos state university teaching hospital ikeja respiratory clinic (figure 2). a bulk text message captioned “invitation to a study on asthma″ will be circulated using the luxury bulk sms platform. respondents will be assessed for eligibility, and those that meet the inclusion criteria will participate in the study while those who have any of the exclusion criteria will be excluded. participants will be randomly selected by simple randomization using a computer software program randomization table.20 the software program (www.randomization.com) will be used to allocate participants into study group a and control group b. group a was further assigned to subgroup x, and y, while group b was assigned to subgroup e, and f. subgroup x and e represents participants on saba, while subgroup y and f represents participants on laba. participants were randomly assigned to a final group of xa, xb, ya, yb, ea, eb, fa, and fb, with ‘a’ and ‘b’ connoting 45° and 90° long sitting respectively. procedure for data collection forty-eight (48) subjects will be recruited for this study. the subjects will be randomly assigned into two major groups of twenty-four (24) subjects per group, two (2) subgroups of twelve (12) subjects per subgroup, and eight (8) final groups of six (6) subjects per group. assessment the subjects’ medical records will be adequately screened for possible contraindications to the study. baseline respiratory parameters will be assessed using the koko pft spirometer. the asthma control test questionnaire and asthma quality of life questionnaire will be administered to the control and study groups at the beginning of the study and at two-week intervals for the 12 weeks of the study. baseline spirometry will be article figure 2. recruitment and randomization of participants. [healthcare in low-resource settings 2022; 10:10251] [page 3] non -co mmerc ial us e o nly [page 4] [healthcare in low-resource settings 2022; 10:10251] conducted on the two groups before and after the commencement of the study. the interferential unit “nu-tek e-stim pro mt1022970” will be used for the study intervention. the treatment period will be increased by two minutes with each application, up to a total application time of 20 minutes. assessment tools spirometry assessment the assessment will be conducted by a spirometrist certified by the pan african thoracic society. a portable spirometer (koko sx 1000 standalone version 7 pneumotach) will be used to carry out this assessment. daily calibration of the device will be done using a 3.0-litre syringe. a brief description of the assessment procedure, including technical steps to obtain pulmonary function data and variables, will be explained to each subject. after 2-3 tidal breaths, the subject will be asked to inhale deeply to total lung capacity and then exhale rapidly (without any pause) through a disposable mouthpiece until as much air as possible has been expelled from the lungs. the test will be performed in a sitting or standing position. the assessments will be repeated three times after adequate rest. the maximum number of attempts permitted will be 8. after fulfilling the acceptability and repeatability criteria, the two best curves will be selected. the average values of the forced vital capacity (fvc) and forced expiratory volume in the first second (fev1) will be recorded.21 intervention participants will be briefed about the nature, effect, and benefit of the study. they will be encouraged to clarify issues regarding the study. all participants will be required to give a written informed consent before participating in the study. participants will be randomly assigned into two groups: study group (group a) and control group (group b). interferential therapy will be demonstrated to the study group alone. the asthma control test, asthma quality of life questionnaire, and spirometry score will be measured and recorded before intervention in both groups. reassessments will conducted at the end of the 2nd, 4th, 6th, 8th, 10th, and 12th weeks of the study intervention. the study group (group a) will receive interferential therapy; this modality selection is only acceptable in the absence of cardiac disease history.22 in the absence of such a history, the subjects will be divided into two subgroups and labeled x and y. subgroup ‘x’ will be allowed to use 400ug of saba delivered in metered doses via a spacer4-6 hours before the study, while subgroup ‘y’ will be allowed to use 24ug of laba delivered in metered doses via a drypowder inhaler within 24 hours of the study.23 in both cases, the inhaler technique, as described by basheti et al.24 will be used to demonstrate the procedure to the participants. the intervention will be conducted with participants in a long sitting position, at an angle of 45° and 90° representing labels ‘a’ and ‘b’ respectively. in both intervention positions, an electrode will be placed bilaterally over the upper limit of the trapezius on the upper back and the other two anteriorly over the lower ribs.22 the final group of participants to undergo the intervention will consist of ‘xa,’ ‘xb,’ ‘ya’ and ‘yb.’ if the subject experiences respiratory difficulty during the intervention, the procedure will be discontinued. with a 4,000 hz base current, the interferential current range will be set between10 to 150 hz and initially applied for 10 minutes, while carefully monitoring the patient’s condition during the treatment period. if the patient shows any sign of distress during the treatment, the current will be turned off. as long as the subject does not experience any distress with the ifc application, the treatment period will be increased by two minutes with each application, for up to 20 minutes. participants in the control group (group b), in addition to the baseline pulmonary function test, will also receive free musculoskeletal assessment and counselling on asthma. they will be divided into two subgroups and labelled ‘e’ and ‘f.’ participants in subgroup ‘e’ will be allowed to use 400ug of saba delivered in metered doses via a spacer 4-6 hours before the study, while subgroup ‘f’ will be allowed to use 24ug of laba delivered in metered doses via a drypowder inhaler within 24 hours of the study.23 the intervention will be conducted with participants in a long sitting position, at an angle of 45° and 90° representing labels ‘a’ and ‘b’ respectively. the final group of participants to undergo the intervention will consist of ‘ea,’ ‘eb,’ ‘fa’ and ‘fb.’ in both cases, the inhaler technique, as described by basheti et al,24 will be used to demonstrate the procedure to the participants. they will be asked to maintain their respective positions for 20 minutes. if the subject experiences respiratory difficulty, the procedure will be discontinued. outcome measures/instruments i) asthma control test (act); ii) asthma quality of life questionnaire (aqlq); iii) spirometer (koko sx 1000 standalone version 7 pneumotach); iv) interferential therapy machine (nu-tek estim pro mt1022970). description of outcome measures/instruments asthma control test (act) the asthma control test is a self-administered 5-item questionnaire developed for assessing asthma control level. it evaluates the most recent four-week period. each item is scored between 1 and 5, with a total score ranging from 5 to 25. an act score of 25 indicates that asthma is “controlled” whereas a score between 20 and 24 shows partially controlled asthma and a score of <20 indicates “uncontrolled” asthma.25 asthma quality of life questionnaire standardised (aqlqs) the standardized version of the asthma quality of life questionnaire (aqlq) is a 32-item questionnaire (self-administered or clinician administered) with five domains, developed to measure the functional, physical, emotional, occupational, and social problems that are most troublesome to adults with asthma.18 the maximum score obtainable is 7.0, which translates to no impairment. the minimum score is 1.0, indicating severe impairment, 4.0 is the mid-range score, and indicates moderate impairment.18 the asthma quality of life questionnaire standardized version will be used to monitor the difficulty the subjects encounter in activities of daily living as a result of asthma. spirometer koko sx 1000 standalone version 7 pneumotach, a portable lightweight and comprehensive diagnostic tool, will be utilized to conduct the pulmonary function test. the koko legend ii spirometer has a built-in thermal printer and a touch screen display. it can perform fvc, pre vs. post, and svc tests. test data and patient information are stored directly on an internal sd card that can be replaced and re-used. all the stored information can be downloaded via a usb cable onto a pc for backup or storage. this device supports daily calibration checks, complies with ats-ers 2005, has several predicted authors, and includes gli-2012. daily calibration of the device will be conducted using a 3l syringe.26 the participant’s condition can be shown by the ratio of the measured value to the predicted value. flow rate-volume chart, volume-time chart display, data memory, delete, upload and review, trend chart display, scaling (calibration), information prompts when volume or flow goes beyond the limits are features available on the device. bronchodilators the administration of bronchodilators will be primarily through inhalation devices article non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10251] [page 5] to deliver the drug to the lung bronchioles in metered doses. inhalation devices come in all shapes and sizes, but critical is maximizing the amount of drug reaching the bronchioles. the best way to achieve maximum bioavailability is by fully exhaling, placing the inhaler in the mouth, and taking a full inhalation. after the patient has inhaled completely, it will be followed by 10 seconds of no breathing to wait for the medicine to dissipate into the lung space. a slow exhalation back to normal breathing will be advised.27,28 the eight-point inhaler technique as described by basheti, natsheh24 will be used to deliver bronchodilators and pre-bd reversibility testing in metered doses. interferential unit the nu-tek electrotherapy machine estim pro mt1022 provides low and medium frequency outputs from a single unit. the currents available on the nu-tek electrotherapy machine e-stim pro mt1022 include interferential (2 and 4pole), russian, diadynamic, tens, sinusoidal, faradic, galvanic, interrupted galvanic, trabert, and medi-wave.29 the nu-tek e-stim pro mt1022 will be used to deliver interferential current by generating a beat frequency range of 10-150hz from two medium frequency currents undulating at a base frequency of 4000hz to 4100hz.14 an interferential current will be activated with two electrodes, one placed posteriorly at the upper border of the trapezius and the other anteriorly below the ribs. a beat frequency will be generated at the point of intersection, resulting in relaxation of the smooth muscles, resolution of pain, and mobilization of secretions.14 data analysis the statistical package for social sciences (spss inc, chicago, ii) version 26.0 for the windows package program will be used to analyse data. the results will be summarized using descriptive statistics of mean, standard deviation, frequency, and percentages. bar charts, pie charts, and histograms will be utilized for pictorial illustration. a multilevel analysis of variance (anova) will be used to compare the outcome variables [body position (45 degrees long sitting and 90 degrees long sitting), pulmonary function variables (fev1, fvc, fev1/fvc), asthma control test (act), and the standardized asthma quality of life questionnaire (aqlq)] among each group, and the dependent t-test will be used to compare the pre and post-test results while the independent t-test will be used to compare the outcome variables across the two groups. the level of significance will be set at p0.05. harms this study carries minimal risks. the procedures are not life-threatening and should not cause any harm or negative effect. the effects may include temporary muscle soreness, increased heart rate, blood pressure, sweating, and dizziness. necessary care will be taken to prevent the occurrence of an adverse event. however, in case of a report of serious adverse events (e.g., comorbidities, injuries, persistent excruciating pain, dizzy spells, headache, etc.) after intervention or at any point during the trial, we would consider unblinding the participant to the intervention for his/her safety. additionally, the participants will be instructed to report any adverse events to the pi or the physiotherapist supervising their group. to ensure adequate supervision and safety, the number of participants per group in a day will be limited to a maximum of 3. arrangements have been made with the accident and emergency unit of the hospital where the research will be conducted to provide a standby medical team. however, the university of kwazulu-natal insurance scheme on clinical trials fully covers participants in this type of study. discussion the relationship between medicationinduced airway reversibility and reversibility obtained through electrophysical modalities is still not well justified. furthermore, the relationship between the mode of delivery of electrophysical agents and the recovery pattern in bronchial asthma is yet to be fully understood. a study by karashurov et al.30 on programmed electrostimulation of the sinocarotid nerves implanted to 78 patients with bacterial asthma for six years was reported to have prevented the majority of asphyxia attacks, reduced their frequency 2.7-fold, and the need for medications 2.73.4-fold. aweto et al.31 in a study of the effect of ift on the cardiopulmonary parameters of 42 ba patients for six weeks reported a significant improvement in systolic blood pressure (p=0.004), forced expiratory volume in one second (p=0.02), forced vital capacity (p=0.04), and peak expiratory flow rate (p=0.007), while the control group had significant reductions in pulmonary parameters. there were significant improvements (increases) in the act score (p=0.0001) and aqlq (p=0.001). mohammed and elyazed32 studied thirty egyptian children aged 9-15 with bmi 18.5 to 24.9 kg/m2, who had asthma. the preand post-treatment variables revealed a significant improvement in pulmonary functions in favor of laser puncture therapy and interferential therapy over diaphragmatic exercise. although studies by aweto et al.,31 karashurov et al.,30 and mohammed and elyazed32 identified the effect of an electrophysical agent in the management of asthma, their findings did not ascertain the possible effect of the medication used by the patients during the procedure. consequently, it is expected that this study’s outcome will further reveal the effect of the electrophysical modality on the symptoms frequently experienced by asthma patients who are on short or long-acting bronchodilator medication. finally, it is expected that the findings of this study could serve as guideline for the management of ba with electrophysical agents and would further support the costbenefit of asthma management in nigeria and other low-income countries. references 1. masoli m, fabian d, holt s, beasley r. global initiative for asthma (gina) program. the global burden of asthma: executive summary of the gina dissemination committee report. allergy 2004:59:469–478. 2. desalu oo, oluboyo op, salami ak. the prevalence of bronchial asthma among adults in ilorin, nigeria. afr j med med sci 2009:38:149–54. 3. ibe cc, ele up. prevalence of bronchial asthma among adolescents in anambra state, nigeria. nigeria j int med 2002:5:23–6. 4. erhabor ge, agbroko s, bamigboye p, awopeju of. prevalence of asthma symptoms among university students 15 to 35 years of age in obafemi awolowo university, ile-ife, osun state. j asthma 2006:43:161–4. 5. oni ao, erhabor ge, egbagbe ee. the prevalence, management and burden of asthma a nigerian study. iran j allergy asthma immunol 2010;9:35-41. 6. national asthma education and prevention program, third expert panel on the diagnosis and management of asthma. expert panel report 3: guidelines for the diagnosis and management of asthma. bethesda (md): national heart, lung, and blood institute (us); 2007 aug. available from: https://www.ncbi.nlm .nih.gov/books/nbk7232/ 7. oni ao, erhabor ge, egbagbe ee. the prevalence, management and burden of asthma-a nigerian study. iran j allergy article non -co mmerc ial us e o nly [page 6] [healthcare in low-resource settings 2022; 10:10251] asthma immunol 2010:1:35-41. 8. cazzola m, page cp, calzetta l, matera mg. pharmacology and therapeutics of bronchodilators. pharmacology rev 2012:3:450-504. 9. gina. global initiative for asthma. global strategy for asthma management and prevention, 2021. available from: www.ginasthma.org 10. boros pw and martusewicz-boros mm. reversibility of airway obstruction vs bronchodilatation: do we speak the same language? copd 2012;9:213215. 11. chung kf, wenzel se, brozek jl. international ers/ats guidelines on definition, evaluation and treatment of severe asthma. eur respir j 2014;43:343-73. 12. katz s, arish n, rokach a. the effect of body position on pulmonary function: a systematic review. bmc pulm med 2018;18:159. 13. emberson w. asthma interferential therapy and chartered physiotherapy. positive helath online 1999;36. 14. shuto h, nakagami k, suzuki h, noguchi e. low-frequency interference in bronchial asthma. jap j allergol 1986;35:12:1170-80. 15. goats gc. interferential current therapy. br j sports med 1990:24:87-92. 16. mcmanus fj, ward ar, robertson vj. the analgesic effects of interferential therapy on two experimental pain models: cold and mechanically induced pain. physiotherapy 2006:92:95-102. 17. ozcan j, ward ar, robertson vj. a comparison of true and premodulated interferential currents. arch phys med rehabil 2004;85:409-415. 18. juniper ef, guyatt gh, ferrie pj. measuring quality of life in asthma. am rev respir dis 1993;147:832-8. 19. quanjer ph, enright pl, miller mr. open letter: the need to change the method for defi ning mild airway obstruction. prim care respir j 2010:19:288–91. 20. suresh k. an overview of randomization techniques: an unbiased assessment of outcome in clinical research. j hum reprod sci 2011;4:8-11. 21. masekela r, zurba l, gray d. dealing with access to spirometry in africa: a commentary on challenges and solutions. int j environ res public health 2019;16:62. 22. davis v. management of asthma. dynamic chiropractic j 1992;10. 23. wallin a, sandstrom t, rosenhall l, et al. time course and duration of bronchodilatation with formoterol dry powder in patients with stable asthma. thorax 1993;48:611-4. 24. basheti ia, natsheh ai, ammari wg. education on correct inhaler technique in pharmacy schools: barriers and needs. tropical j pharm res 2015;14:715-22. 25. nathan ra, sorkness ca, kosinski m. development of the asthma control test: a survey for assessing asthma control. j allergy clin immunol 2004;113:59-65. 26. nspire. kokopft. 2020. accessed 04/02/21. available from: https://www.kokopft.com/ 27. feng jf, ding gr, xie yz. efficacy of budesonide/formoterol and tiotropium combination for the treatment of chinese patients with chronic obstructive pulmonary disease. medicine (baltimore) 2018; 97: e10841. 28. hanania na, sethi s, koltun a. longterm safety and efficacy of formoterol fumarate inhalation solution in patients with moderate-to-severe copd. int j chron obstruct pulmon dis 2019;14:117-27. 29. nu-tek. nu-tek electrotherapy machine e-stim pro mt1022. accessed 4/02/21. http://www.nutekmedical.com/product/news94.html 30. karashurov se, gudovskii lm, semenova li. [electrostimulation in the therapy of bronchial asthma]. klin med (mosk) 2001;79:39-41. 31. aweto ha, tella b. awolola eo. efficacy of interferential therapy on selected cardiopulmonary parameters, asthma control and quality of life of people living with asthma. romanian j physical ther 2016;21. 32. mohammed ah and elyazed tia. laser puncture therapy versus interferential therapy as a combined treatment in asthmatic egyptian children: comparison of treatment approaches. int j physiother res 2017;5:2457-63. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11181 strategies to improving patient safety in hospitals mohamad taji, kuswantoro rusca putra, dina dewi sartika lestari ismail department of nursing, faculty of health science, universitas brawijaya, malang, indonesia abstract introduction: patient safety is the initial foundation of quality healthcare that shared responsibility between policymakers as well as healthcare delivery, especially nurses, who aim for improvement. interventions in patient safety culture reduce safety incidents, thereby, lowering the disability rates and deaths due to side effects of healthcare delivery. therefore, this research aims to provide an overview of strategies to improve patient safety culture, which involves nurses in hospital settings. design and methods: in this research, a scoping review was carried out using online database searches at proquest, ebsco, and sciencedirect. the selected article was experimental research, using english, published between 2011-2021, and fulfilled the criteria for inclusion and exclusion set. result: in the initial disbursement, 480 articles were obtained with 13 studies that meet the inclusion criteria. the articles obtained used quasi-experimental research methods (2 articles), pre-post intervention design (4 articles), intervention time series (2 articles), randomized controlled trial (1 article), prospective cohort intervention (1 article), repeated cross-sectional experimental research (1 article), mix quasi-experimental method nonrandomized design and qualitative (1 article), and control groups (4 articles). based on the articles obtained, the strategies to increase the patient safety culture in hospitals can be categorized into 4, which include educational, simulation, team, and comprehensive programs. conclusions: all interventions implemented possess a positive impact on patient safety culture. introduction patient safety is the most crucial indicator of quality in the world and the basis of the quality of health services.1,2 in 2020, ünver&yeniğün defined patient safety as measures to prevent and eliminate injuries affecting patients and their families during the delivery of healthcare delivery. meanwhile, its incidents and severe errors caused by sick patients are potentially life-threatening.3 in 2020, world health organization reported that patient safety incidents are among the global top 10 causes of disability and death causes. in high-income countries, it is the first among the 10 incidences of patients injured due to health services.4 the financial impact of patient safety incidents in high-income countries is estimated to be 13% of the health budget incurred for costs and 8.7% due to preventable incidents, with a total cost of usd 606 billion per year. meanwhile, in low-income countries such as indonesia, there are 134 million patient safety incidents every year, which contribute to approximately 2.6 million deaths.5-7 this implements a patient safety program to be a shared responsibility, especially for health workers such as nurses who provide direct services to patients. nurses are professionals who provide health services and have a crucial role in succeeding patient safety programs. this is because their profession is the highest number in the hospital that has the longest contact time with patients. this allows the nurses to understand the importance and have updated information about the feelings and physical condition of patients.8,9 nurses are also the first to be aware of the potential problems and stop them at the right time to avoid injuries.10 therefore, the patient safety culture conducted by nurses needs to be considered. among nurses, patient safety culture is an essential aspect to enhance and identify factors that affect healthcare delivery. in 2017, carlesi discovered several factors affecting the application of patient safety in nurses, which include knowledge of patient safety, perception of professionalism, motivation, and work experience. in addition to job satisfaction, transformational leadership style, burnout nurse attitude, nurse fatigue rate also affects patient safety and increases healthcare-related complications such as hospital-acquired infections, medication errors, and falling patients.11-14 moreover, several studies have been enacted to enhance patient safety culture. in 2017, xie used the implementation of the safety culture training (sctp) program on 83 nurse managers in 5 chinese hospitals, which significantly enhanced patient safety culture and lowered safety of patient incidence (p <0.05). this averaged the patient rate, which fell from 0.66 to 0.44 per 1,000 patient days, and the rate of hospital-acquired decubitus ulcers from 1.13% to 0.87% in 100 patient days. in 2018, amiri also conducted an experimental quasi on 60 nurses and 20 supervisors at iran’s namazi hospital by establishing 2 days of workshops, sticking posters, and distributing pamphlets against intervention groups. the innovation program empowered supervisors and nurses, which enhanced patient safety culture scores. although various interventions have been administered to enhance the patient safety culture in hospitals, there was no general picture of interventions that specifically involve nurses. therefore, this research aims to provide an overview intervention to improve patient safety culture in hospitals with the nurses’ involvement. review significance for public health patient safety culture is the foundation of high-quality health care, but hospitals' improvement strategies are often underutilized. even today, patient safety culture is a challenging topic to overcome since it intersects with various elements in hospitals and among health staff. as a result, this study gives an early review of improving patient safety in preparation for future interventions to improve culture. [healthcare in low-resource settings 2023; 11(s1):11181] [page 75] non -co mmerc ial us e o nly design and methods based on the scoping review method, an international journal search was carried out on the topic by browsing online databases from proquest, ebsco, and sciencedirect, using the keywords “patient safety” and “culture” and “nurse” and “intervention” or “program”. the literature was selected based on inclusion criteria, which were according to the topic, full-text article, english language, quantitative methods, experimental, and articles published in the last 10 years (2011-2021). meanwhile, the exclusion criteria of the sample were research that did not have a nursing profession, and those with setting outside the hospital. the stages of search and selection of journal articles were adapted from the prisma flow chart as shown in figure 1.1 results and discussions search results and description of studies the initial search results of the database identified 480 articles and were selected based on the suitability of the title and topic. subsequently, the article was selected based on the criteria of inclusion and exclusion (figure 1) to obtain 13 relevant articles, which were used for data extraction and interpretation. the year of the article publication obtained ranged from 2011 to 2021 and the major participants were nurses, which include managers or front liners. this research was administered in the hospital setting, icu/picu, medical/surgical ward, cardiac unit, and emergency room. the most research articles derived from the united states 5 articles, norway, iran, germany, egypt, china, and denmark. a total of 2 methods were implemented to measure the impact of interventions on patient safety culture, which were 9 articles using the hospital survey of patient safety culture (hsopsc) and 4 articles using the safety attitudes questionnaire (saq). the questionnaire measurements were obtained before and after the intervention, but a time difference was used for the measurement after the intervention. in hsopsc, the evaluation was carried out from 3 months, 6 months, and 12 months, respectively. meanwhile, in saq, the measurements were carried out directly after the intervention5 for 4 and 8 weeks, 6 months as well as 12 months. all interventions in the article positively affected patient safety culture in the hospital. generally, the interventions administered in the article can be categorized into 4 groups, namely encompassing educational programs (5 articles), simulations (1 article), team strategies (3 articles), and comprehensive programs (4 articles). a summary of journal interpretation results is shown in table 1.15-20 educational programs the educational programs employed seminar methods, workshops, and training, where learning was designed per session, implemented one-on-one teaching and divided into small groups. review figure 1. flow chart of article selection following the prisma guideline. [page 76] [healthcare in low-resource settings 2023; 11(s1):11181] non -co mmerc ial us e o nly review [healthcare in low-resource settings 2023; 11(s1):11181] [page 77] ta bl e 1. c ha ra ct er ist ic s o f t he st ud ie s s el ec te d in th e sc op in g re vi ew . no st ud y, ye ar a nd d es ig n s am pl e, s et tin g an d m ea su re m en t i nt er ve nt io n re su lt 1 x ie et a l., 20 17 83 n ur se m an ag er s t ra in in g p ro gr am ab ou t s af et y c ul tu re w ith a co m pl et e of 76 h ou rs th e to ta l s co re (h sp sc ) i nc re as ed si gn ifi ca nt ly q ua siex pe rim en ta l b ef or e an d af te r m ea su re m en t ho sp ita ls, c hi na o f t ut or ial u ni ts , w hi ch co ns ist s o f 3 0 h ou rs o f t he or et ica l c las se s, af te r 6 m on th s hs ps c: h os pi ta l s ur ve y o f p at ie nt s af et y c ul tu re 4 0 h ou rs o f r ea lis tic sc ie nt ifi c p ub lic at io ns , a nd 6 ho ur s of tr ain in g ( p <0 .05 ), wh ile s aq sc or es al so in cr ea se d sa q: s af et y a tti tu de s q ue st io nn air e of in st itu tio n di alo gu e an d fe ed ba ck in al l m ea su re m en t d im en sio ns (0 .00 0) 2 a m iri et a l., 20 18 80 n ur se s a nd su pe rv iso rs c on tro l: n ot re ce ivi ng in te rv en tio n a ra nd om ize d co nt ro lle d tri al wi th a pr epo st te st ic u, h os pi ta l, i ra n in te rv en tio n: tw oda y w or ks ho p (8 -h ou r) , p os te rs w er e hu ng , t he to ta l m ea n of p at ie nt sa fe ty cu ltu re w as si gn ifi ca nt ly an d co nt ro l g ro up s h so ps c: h os pi ta l s ur ve y o n pa tie nt s af et y c ul tu re a nd in fo rm at io na l b ro ch ur es w er e di st rib ut ed to th e su pe rv iso rs l ow er ed in th e co nt ro l g ro up th an th e a nd n ur se s o f t he gr ou p of in te rv en tio n at th e jo b fie ld . e xp er im en ta l g ro up (p < 0. 00 1) ( 3.4 6 ± 0. 26 ) v s ( 2.8 4 ± 0. 37 ) 3 h an ifi et a l., 20 18 2 6 n ur se , in th e he ar t u ni t 2 h os pi ta l, i ra n c on tro l: g et a pa tie nt sa fe ty br oc hu re o nl y t he o ve ra ll p er ce pt io n of p at ie nt sa fe ty di m en sio ns si ng le -b lin d cli ni ca l t ria l s tu dy w ith p re -p os tte st h so ps c: t he h os pi ta l s ur ve y o n pa tie nt s af et y c ul tu re s ca le i nt er ve nt io n: tw ose ss io n ed uc at io na l p ro gr am , w he re e ac h se ss io n in cr ea se d sig ni fic an tly . ( p = 0.0 34 ) de sig n an d co nt ro l g ro up las ts al m os t t hr ee h ou rs . p ar tic ip an ts w er e in vo lve d in th e di sc us sio n us in g t he q ue st io n an d an sw er (q &a ) m et ho d. 4 s ch m id t e t a l., 20 21 n um be r o f p ar tic ip an ts (t 0) 52 8, (t 1) 36 6 co nt ro l: n ot at te nd in g t ra in in g i n th e nu rs in g p ro fe ss io n: th er e ha s b ee n a s ign ifi ca nt in te rv en tio n pr et es t a nd p os tte st d es ign n ur se s a nd p hy sic ian s h os pi ta l g er m an h sp sc i nt er ve nt io n: in te rp ro fe ss io na l t ea m tr ain in g c on sis ts o f 2 m et ho ds im pr ov em en t i n pa tie nt sa fe ty cu ltu re in th e ch ar ac te ris tic s o f: m et ho d 1: m an ag em en t t ra in in g ( to pbo tto m ap pr oa ch ) m od ul e 1 s em in ar 2 da ys te am wo rk (a t t he u ni ts o f t he h os pi ta l), m od ul e 2: 1.5 d ay s s em in ar .m et ho d 2: ch am pi on tr ain in g ( bo tto m -u p ap pr oa ch ) e xp ec ta tio ns o f s up er vis or an d, pr om ot in g s af et y a ct io ns 5 s ol im an et a l., 20 20 7 3 p ar tic ip an ts pa tie nt sa fe ty tra in in g, co nd uc t i nt er ac tiv e tra in in g w ith a to ta l o f 1 2 s es sio ns , st at ist ica lly si gn ifi ca nt e nh an ce m en t i n so m e ite m s i n th e pr epo st te st in te rv en tio na l s tu dy n ur se s a nd p hy sic ian s h os pi ta l ( pi cu ), eg yp t w he re ap pr ox im at el y 3 0 m in ut es an d 15 m in ut es w as u se d fo r e ac h se ss io n c ha ra ct er ist ics o f c lim at e sa fe ty, p er ce pt io n of m an ag em en t, th e sa fe ty at tit ud es q ue st io nn air e (s aq ) wi th q ue st io ns , a ns we rs , a nd d isc us sio ns . i n ad di tio n, po st er s w er e hu ng in th e ro om , i cu in te ra ct io n an d co m m un ica tio n, in cid en t r ep or tin g, an d w ith b ro ch ur es , s m all b ro ch ur es , a nd b ad ge s f or th e pa rti cip an ts . op en ne ss o f c om m un ica tio n. 6 a ab er g e t a l., 20 21 43 p ar tic ip an ts th e te am st ep ps in te rv en tio n co ns ist s o f t hr ee p ha se s, wh ich in clu de th e se tti ng o f sc or es im pr ov ed si gn ifi ca nt ly af te r a si xm on th in te rfe re nc e: pr epo st te st in te rv en tio n st ud y r eg ist er ed n ur se s, nu rs in g a ss ist an ts an d ph ys ici an s th e in te rv en tio n lo ca tio n an d de cid in g w ha t t o do , m ak e it ha pp en , m ak e it st ick "c on tin uo us an d or ga ni za tio na l le ar ni ng im pr ov em en t ( 0.0 01 )" su rg ica l w ar d, ho sp ita l n or wa y hs op sc an d "o pe nn es s t o co m m un ica tio n (0 .02 5) ". a fte r a 12 -m on th in te rv en tio n: “o pe nn es s t o co m m un ica tio n (0 .01 7) ”, “t ea m wo rk w ith in th e un it (0 .02 5) ” a nd “m an ag er 's ex pe ct at io ns an d m ea su re s t o pr om ot e pa tie nt sa fe ty (0 .01 2 ) ". 7 j on es et a l., 20 13 3 46 p ar tic ip an ts c on tro l: n o in te rv en tio n in te rv en tio n: te am st ep ps tr ain in g i nt er ve nt io n th ro ug h th er e wa s a tr em en do us in cr em en t b et we en th e co nt ro l a nd q ua siex pe rim en ta l n ur se s, ad m in ist ra tio n, ph ys ici an s, 24 h os pi ta ls th e im pl em en ta tio n of te am st ep ps tr ain er s, wo rk sh op s t o ov er co m e di sr up tiv e th e in te rv en tio n gr ou p. si m ila rly , 7 6% vs 71 % on co nt in uo us am er ica h so ps be ha vio rs , im pl em en ta tio n of b as ic te am st ep ps co ur se s, im pl em en ta tio n im pr ov em en t, 82 % vs 80 % te am wo rk , a nd 67 % vs 62 % on of 17 ca lls o f a n ho ur an d a h alf to m ain ta in in no va tio n. te am wo rk b et we en d ep ar tm en ts . 8 b ra dd oc k e t a l., 20 15 pa rti cip an ts (t 0= 13 1, t1 = 28 6) n ur se pa tie nt sa fe ty tr an sf or m p ro je ct : s im ul at io n tra in in g, m on th ly pa tie nt sa fe ty gr ou p o ve ra ll s co re o f ( hs op s) o ne ye ar af te r t he in te rv en tio n, 1ye ar p ro sp ec tiv e co ho rt in te rv en tio na l s tu dy a nd re sid en t p hy sic ian s h os pi ta l a m er ica h so ps m ee tin gs o n m ed ica l e m er ge nc ie s, ch am pi on fo r p at ie nt sa fe ty, in te rd isc ip lin ar y sig ni fic an t f or n ur se s ( p < 0.0 01 ) c on fe re nc e on p at ie nt sa fe ty, e xe m pl ar y t ea m wo rk re co gn iti on p ro gr am . 9 m ue th in g e t a l., 20 12 10 0 p ar tic ip an ts n ur se s, ph ys ici an s, ot he r h ea lth w or ke rs fo cu s i nt er ve nt io ns o n (1 ) p re ve nt io n of e rr or , ( 2) p at ie nt sa fe ty m an ag em en t, a ll a sp ec ts o f t he m ea su re o f p at ie nt sa fe ty cu ltu re in cr ea se d pr epo st te st in te rv en tio n h os pi ta l a m er ica h so ps (3 ) u sin g d at ab as e fo r c om m on an d ro ot ca us e an aly sis p ro ce ss es , ( 4) co ns pi cu ou s s ign ifi ca nt ly, b ut 3 as pe ct s, na m el y a ct io ns an d ex pe ct at io ns o f cu rr icu lu m , a nd (5 ) i nt er ve nt io ns fo r h igh -ri sk ar ea s. su pe rv iso r/m an ag er , t ea m wo rk at th e un it of th e ho sp ita l, a nd no npu ni tiv e fe ed ba ck to e rr or w er e no t s ign ifi ca nt st at ist ica lly . 10 sc hr am et a l., 20 21 38 p ar tic ip an ts o nsit e sim ul at io n in te rv en tio n 39 st af f m em be rs fr om 2 ho sp ita ls we re tr ain ed t he re w as an in cr ea se in th e di m en sio ns o f t ea m wo rk re pe at ed cr os sse ct io na l e xp er im en ta l s tu dy d es ign n ur se s, m id wi ve s, an d ot he r e m pl oy ee s d en m ar k a s s im ul at io n in st ru ct or s. al l in st ru ct or s t ak e th e 4da y c ou rs e. fa cil ita to r t ra in in g a tm os ph er e, co nd iti on s o f w or k, m an ag em en t, an d sa tis fa ct io n th e sa fe ty at tit ud e qu es tio nn air e co ur se s e m ph as ize d te am b ui ld in g, co m m un ica tio n, an d le ad er sh ip sk ill s. jo b pe rc ep tio n at h os pi ta l 1 . i n ho sp ita l 2 , t he re w as o nl y th e in st ru ct or s a lso p er fo rm ed o nsit e sim ul at io ns in th ei r r es pe ct ive u ni ts . 1 si gn ifi ca nt in cr ea se , n am el y ( sa fe ty cli m at e) . 11 pe ttk er et a l., 20 11 m ul tip le in te rv en tio ns 1 91 p ar tic ip an ts p hy sic ian s, nu rs es , a dm in ist ra to rs , a ss ist an ts tr ain in g p ro gr am ab ou t s af et y c ul tu re w ith a co m pl et e of 76 h ou rs o f t ut or ial u ni ts , s ign ifi ca nt ly in cr ea se d th e em pl oy ee s' pe rc en ta ge w ith ho sp ita l a m er ica th e sa fe ty at tit ud e qu es tio nn air e (s aq ) w hi ch co ns ist s o f 3 0 h ou rs o f t he or et ica l c las se s, 40 h ou rs o f r ea lis tic fa vo ra bl e aw ar en es s o f t ea m wo rk at m os ph er e (3 9% to 63 %) , sc ie nt ifi c p ub lic at io ns , a nd 6 ho ur s o f i ns tit ut io n di alo gu e an d fe ed ba ck . s at isf ac tio n (3 9% to 53 %) an d m an ag em en t ( 10 % to 37 %) o f j ob , 12 st or m et a l., 20 18 m ix m et ho d qu as i-e xp er im en ta l, 3 40 p ar tic ip an ts n ur se , p hy sic ian s, nu rs e as sis ta nt c on tro l: n ot re ce ivi ng in te rv en tio n in te rv en tio n: tw oda y w or ks ho p (8 -h ou r) , t he re w er e sig ni fic an t d iff er en ce s b et we en th e co nt ro l n on -r an do m ize d de sig n an d qu ali ta tiv e) h os pi ta l a nd h om ec ar e no rw ay p os te rs w er e hu ng , a nd in fo rm at io na l b ro ch ur es w er e di st rib ut ed a nd in te rv en tio n gr ou ps . i n th e di m en sio ns : t ra ns iti on an d hs op s: ho sp ita l s ur ve y o n pa tie nt s af et y c ul tu re to th e su pe rv iso rs as w el l a s n ur se s o f t he gr ou p of in te rv en tio n at th e jo b fie ld . ha nd ov er , t ea m wo rk c ro ss u ni t, no npu ni sh m en t r es po ns e nh so ps : n ur sin g h om e su rv ey o n pa tie nt s af et y c ul tu re to m ist ak es , c on tin uo us im pr ov em en t o f o rg an iza tio na l le ar ni ng , m an ag em en t e xp ec ta tio ns , o ve ra ll p er ce pt io n of p at ie nt sa fe ty, p at ie nt sa fe ty le ve l, s ta ffi ng . 13 b ril li e t a l., 20 13 80 00 cl in ica l a nd n on -c lin ica l s ta ff, 60 0 m an ag er c on tro l: g et a pa tie nt sa fe ty br oc hu re af te r c ar ry in g o ut th e ze ro h er o pr og ra m , a si gn ifi ca nt in cr ea se q ua siex pe rim en ta l t im e se rie s ph ys ici an s, nu rs es , m an ag em en t a m er ica i nt er ve nt io n: tw ose ss io n ed uc at io na l p ro gr am , w he re e ac h se ss io n in th e ov er all o pi ni on sc or e on th e sa fe ty en vir on m en t w as th e sa fe ty at tit ud es q ue st io nn air e l as ts al m os t t hr ee h ou rs . p ar tic ip an ts w er e in vo lve d in th e di sc us sio n us in g ob se rv ed . t he p er ce nt ag e of p os iti ve e nv iro nm en t s ec ur ity th e qu es tio n an d an sw er (q &a ) m et ho d. s co re s i n 20 09 w as 72 (p re ce di ng th e ze ro h er o pr og ra m ), co ntr as ted w ith 76 ou t o f 2 01 1 ( aft er th e z er o h er o p ro gra m ) ( p< 0.0 5) non -co mmerc ial us e o nly the material used was submitted using methods of lectures, discussions, q&a, and case scenarios. although materials were related to the education program (table 2), additional materials based on the objective of the research were also obtained. furthermore, there are additional interventions such as the hanging of posters in the room, distributing pamphlets, providing hand-outs badges, and the opportunity of participants to ask questions by email for approximately 1 week after training. the total training time provided was between 6 hours, 8, 9, and 76 hours.21-23 review table 2. summary of the intervention. no author and year strategy or program 1 xie et al., 2017 educational program the training program consists of 5 sessions, where the trainees are trained according to the one-on-one teaching method. the trainees were divided into 5 groups, which consists of people from 12 to 15 in each group. subsequently, the trainees pass through a training program for 76 hours. the schedule includes 30 hours of theory, clinical practice for 40 hours, and group discussion as well as feedback for 6 hours. training program under expert supervision with >5 years of experience in patient safety training. use module from the institute for healthcare improvement topic: safety culture, reporting and handling the adverse event, management and risk assessment, protection and safety communication, management and feedback of clinical practice. 2 hanifi et al., 2018 educational program before training, materials were sent to the nurses and the training program was conducted in 2 sessions by one of the researchers, where each session lasted approximately 3 hours with two breaks. during the training course, participants were asked to participate in a discussion by a question and answer method and also ask questions via email for 1 week after the training. the control group received the brochure with similar content to the intervention group. the training program was carried out by researchers topic: patient safety concept, seven steps to ensure patient safety, enhance patient safety, the safety of patient culture concept, and twelve aspects of patient safety culture. 3 amiri et al., 2018 educational program the program started with a two-day (8-hour) workshop, which consists of lectures, group discussions, and scenario presentations. this was followed by the hanging of posters in the room and distributing pamphlets to the experimental group. the training program was carried out by researchers topic: patient safety culture, speaking out in situations that threaten patient safety, team strategy skills, and tools to improve patient safety and performance (teamstepps). the teamstepps includes skills in communication, leadership, mutual support, and monitoring. 4 soliman et al., 2020 educational program the training course consisted of 12 sessions of 30 minutes each, with an additional 15 minutes of discussion, question, and answer sessions. it was conducted in the intensive care unit during working hours. meanwhile, after the training, participants immediately filled out a questionnaire, and each assessment was issued a patient safety badge, written in english and arabic. in addition, leaflets, hand-outs, and posters are hung in the medical staff room. the training program was designed with the hospital quality team. the material provided was adjusted from the results of the initial survey topic: definition, overview, goals of patient safety and safety culture, cause of the error and 'near miss' incidents reporting, based on who educational guidelines on safety patient. 5 storm et al., 2018 educational program the meeting point takes place in form of a half-day seminar, which consists of discussion and educational sessions. each session consists of a 15-minute introduction, 45-minute teaching on scenarios specific to thematic areas participants through group activities performed by study team members. the training program was carried out by researchers topic: planning materials include 3 thematic areas related to transition care: (1) factors of risk, (2) patient’s perspective, and (3) system of perspective the scenarios discussed include textual risk factors cases for transitional care, movie scenarios showing the patient's point of view of transitional care, system perspective film. 6 schram et al., 2021 simulation program at least one employee from 23 groups was trained (4-day course) as a simulation instructor. training focuses on soft skills namely team, leadership, and communication. the instructors conduct in situ simulations in respective groups to enhance the handling of a particular clinical situation and the care quality and safety. the instructors started after completing the training and performed the prospective simulations training facilitated by 3 employees of midstim (regional simulation training center in denmark area of denmark) curriculum: module one: theoretical presentation by experts working at midtsim. participants performed the role of facilitator. module two: performing simulations in place, the physicians and nurses design a scenario and animate it in front of the class. trainers pro vide feedback and arrange the module. module three: quality assessment and feedback of trainers lead their scenario and received feedback from others participants. 7 schmidt et al., 2021 interprofessional team training training of teams with management and front liners, implementation of training based on a top-down approach (management training) and bottom-up (champion training) in 4 days/employee/year. management training with a 0.5-day seminar on human factors and critical errors, 2-day seminar to strengthen communication in hospitals, 1.5-day seminar to reflect on the development of the safety culture in hospitals. meanwhile, the champion training includes 2 days of seminars to strengthen communication in hospitals (operational level), meetings every three months to promote reflection, exchange of experiences around the culture of patient safety, and the establishment of a safety net for patient safety. topic: influence of human factor in critical errors briefing, 2-way feedback, avoidance of killer phrases, communication. [page 78] [healthcare in low-resource settings 2023; 11(s1):11181] non -co mmerc ial us e o nly review [healthcare in low-resource settings 2023; 11(s1):11181] [page 79] table 2. summary of the intervention. no author and year strategy or program 8 aaberg et al, 2021 teamstepps the teamstepps intervention consists of three phases. meanwhile, phase 1 involves the determination of the current situation of the intervention, provision of an overview of the intervention and confirmation of the leader's willingness to intervene in the corresponding unit, the creation of an intervention plan, and establishment of goals and targets performance by leaders and researchers. the training in phase 2 includes a didactics combination, video projections, simulations, and role-plays. participants were demanded to discover patient safety issues at the unit and attempt to resolve them using the teamstepps tool. subsequently, a team of interprofessional change, which consisted of 12 members was formed. the training was conducted on the change team based on the identified problems, then planned the goals and strategies for solving the problems. during 6 months, the team implemented 5 tools in daily activities in meetings and monthly newsletters. after 5 months of initial training, a refresher training was carried out for 75 minutes. phase 3 continues to use the other 5 tools within 6 months, celebrate success, and take refresher training 11 months after initial training. 9 braddock et al, 2015 the patient safety transform project the interventions carried out included four simulation exercises in-situ in day and night shifts per unit of study and month. in this stage, a nurse who is in charge of searching for the factors that contribute to the blue code is called. there is also another nurse (minimum) per shift in every unit who goes about as a patient security advocate. monthly meetings team of patient safety, quarterly interdisciplinary patient safety conference in discussing and enhancing care issues or interdisciplinary teamwork. awards are provided for the best or exemplary teamwork. 10 brilli et al., 2013 comprehensive obstetrics patient safety program a patient safety program is as follows: a nurse is responsible for patient safety, while the standardization of practice was based on protocols to codify and standardize existing practices. the crew resource management training is a resource management seminar for employees. in the seminar, each class lasts four hours and includes videos, lectures and role-playing games, and an integrated domain of midwifery personnel (physicians, nurses, administrative staff, assistants). the training was supervised by a patient safety committee that is responsible for quality assurance. physicians are on call 24 hours, seven days a week for anonymous reports of the incident. 11 brilli et al., 2013 zero hero program the zero hero program of patient safety, namely analysis for common causes of serious safety events. many individuals are needed for project-based experiential learning, with further development as the main driver investigation measure. framework disappointments require a remedial activity plan including a proprietor, course of events, and observing arrangement. the executive’s choice aide was used to survey individual disappointments, while a prepared security mentor was applied for forefront staff in preparing their associates on the powerful use of error anticipation strategies. for straightforwardness, all outcomes and accomplishments information are informed on the emergency clinic intranet. 12 muething et al., 2012 quality improvement program patient safety improvement program: form a team to reduce patient safety incidents, identify key issues, educational training including dynamic interactive video lectures, small group discussions. the training was conducted by trained staff to enhance communication and make teams practice the expected behaviors of safety simulation training. reorganization of patient safety governance, oversight group, concerned on responsibility, balances handy solutions and long haul arrangements in events safety response, a program of the study provides admittance to information, making of a straightforward and profoundly apparent mechanism of feedback, and interventions for high-cautious areas. 13 jones et al., 2013 teamstepps the intervention was carried out by implementing and maintaining the team's behavior in 24 intervention hospitals. interventions are as follows: create an improvement plan based on a basic assessment to identify weaknesses in communication and teamwork. assess weaknesses in the safety culture with the teamstepps tool. organize a teamstepps trainers course to train the head trainers to train each intervention hospital. conduct workshops on the treatment of disruptive behaviors. trainers trained with implementation (a course with 14 basic concepts conducted by teamstepps) or 17 conference call lasting one and a half hours to exchange strategies, clarifications, and behavioral routines, to maintain innovation. audit of the frequency of use of tools, conduct information sessions throughout the hospital, integrate using of tools, and teamstepps strategies in the orientation of the new employees. simulation in 2021, schram carried out a simulation program by training at least one staff member from 23 groups as a simulation instructor. the training was a 4-day program that emphasized non-technical skills concerning team training, leadership, and communication and needs to be completed by all instructors. subsequently, the instructor carried out simulations for their respective groups. the instructors also began in-situ simulation after their training ended and conducted the prospective simulation. team strategy interprofessional team training team training involves managers and front liners, moreover, schmidt conducted training in 2021 using top-down (management training) and bottom-up (champion training) approaches for 4 days/employee/year. the management training contains 0.5 days of seminars on human factors and critical error, 2 days seminar on strengthening communication in hospitals, and 1.5 days of seminars on reflections about progress safety culture in hospital. the champion training contains 2 days of seminars on strengthening communication in hospitals (operational level), meeting every 3 months to promote reflection and exchange of experiences related to safety culture, and the establishment of the safety of patient culture network. team strategies and tools to enhance performance and patient safety (teamstepps) in 2021, aaberg carried out teamstepps intervention in a surgical ward consisting of three phases. moreover, phase 1 conducted an assessment of the location of the intervention to provide an overview and confirm the readiness of the leader to intervene in non -co mmerc ial us e o nly the related unit. subsequently, the researcher and the leader established an intervention plan and arranged goals as well as achievement targets. in phase 2, a teamstepps training, lasted for 3 days, containing a combination of didactics, video playback, roleplaying, and simulation was established. on the final day of training, participants were obliged to discover patient safety in the unit and solve the problems using teamstepps instruments. subsequently, a team of interprofessional change consisting of 12 members was established. the training was further conducted on the change team based on the problem which has been identified and a plan of goals and strategies was created to solve the problem. for 6 months, the team implemented 5 tools on daily activities at monthly meetings and bulletins, while a refreshment training of 75 minutes was conducted after 5 months of initial training. in phase 3, continues implementation of 5 other tools within 6 months, celebrates success, and conducts refreshment training after the first 11 months. there are slight differences in teamstepps, in 2013, jones conducted an intervention in 24 hospitals using several steps. these include establishing a plan based on basic data of patient safety to discover the weaknesses in communication and teamwork, fitting the culture of safety weaknesses with teamstepps tools, conducting training on teamstepps coaches at 24 intervention hospitals, workshops to address disruptive behavior, basic teamstepps training to assist coaches to apply the implementation, conducting 17 and a half-hour conferences to share strategies and tools to redefine/restructure, clarifies and routines behavior to sustain innovation. furthermore, bulletin boards and articles were used to add additional opportunities for learning after training the classroom. the strategies for describing behavior were also implemented by auditing the frequency of tool use, performing briefings of hospital-wide, integrating teamstepps tools implementation and methods into the latest employee orientations, and teamstepps tools application in job descriptions as well as performance assessments.24-26 comprehensive program the comprehensive program is a term employed to describe the interventions performed. it refers to the variety and complement of interventions administered with several similarities for implementing educational programs such as simulations, scenarios, discussions, and lectures. the origin of the material and programs designed is based on the results of the studies conducted from the database and the opinion of consultants, patient safety nurse, or team. it was also based on regular feedback, transparency, and award or celebrate success. meanwhile, the implementation of strategies in high-risk areas such as operating rooms, easy, and unknown incident reporting were also administered. the transform patient safety project an approach was used to enhance the quality program and clinical outcome, comprising in-situ simulation training for increasing detection and treatment on hospital-acquired. in this method, scenarios were designed to simulate clinical state before worsening, integrated training with new employee orientation, and intervention period 4 training/unit/month. the emergency medical intervention was implemented by debriefing the medical urgency and emergencies, while the patient safety champion role monthly award was provided to recognize a nominated. interdisciplinary patient safety conferences were carried out by presenting cases and action plans, reviewing cases involving interdisciplinary care issues. moreover, quarterly interdisciplinary patient safety conferences encompass nurses, residents, and attending physicians, reviewing issues of interdisciplinary, and providing group discussions to enhance care issues. comprehensive obstetrics patient safety program the program for improving patient safety in obstetrics involves nurses who are responsible for data collection and lead education efforts, reporting events, as well as initiating unexpected event reviews. protocol-based standardization of practice was used to codify and standardize existing practices. meanwhile, training is an ongoing series of employee resource management seminars, where each class has four hours, including video, lectures, roleplay, and an integrated midwifery staff domain, including doctor, nurse, administrator, and assistant. the seminars served as a chance of 1-time preparation for the introduction of individual employees. the enrollment of the representatives was coordinated after the introductory series of the course acknowledged preparation as they started work. the supervision was carried out by a patient safety committee, which was obliged for the enhancement and assurance quality review as well as protocols and policies to enhance quality. there are 24-hour obstetrics hospitalists, while computerized and anonymous event reporting systems also allow any hospital worker to report events. comprehensive patient safety program “zero hero” the program was conducted by analyzing the common causes of serious safety events in the past and making it the basis for preparing training in error prevention. this was also carried out by analyzing the addition of power to improve data quality. the safety coach program is conducted to prepare frontline staff in preparing their companions on the successful use of prevention techniques error and training on clinical as well as non-clinical staff. hazard detection was based on the incident reporting systems, triggering tools, pharmaceutical interventions, and complaint analysis. all results are posted on the hospital’s internet for transparency and feedback.27-28 quality improvement program the program was established to improve patient safety by forming a team for the reduction of patient safety incidents, reviewing data on 35 recent safety events, creating common cause data, identifying the survey result on culture of safety culture, hiring expert consultants to provide opinions, creating a key diagram for quality improvement projects, and unexpected event reduction based on data obtained. the intervention reduced errors by training programs for all patients, assigned staff at clinical units, and leaders. in this program, there was a patient safety monitoring team, an analysis of the causes of events was carried out using a database, which was developed to support the analysis of inappropriate actions. the staff was given admittance to data, which makes profoundly apparent a straightforward feedback mechanism, hospital intranet sites are available to all employees. there are tactical interventions directed to high-risk areas and interventions in reducing the incidence of perioperative safety. based on the description above, there are 4 categories of interventions that can increase the patient safety culture (a summary is shown in table 2). from the intervention model, there is a need to understand important aspects such as the capabilities of the trainee. meanwhile, only 3 out of 13 articles explained the competence of the speaker such as having at least 5 years of experience in the field of patient safety, training in collaboration with the hospital quality committee5 and using the help of a professional team in training. the curriculum or materials provided during training are also a concern, where 3 of 13 studies mentioned the basis of the material given such as the results of the initial assessment. furthermore, from standardized training modules, the applied innovative methods need to maximize the delivery of materials such as sending files to be read before training, asking questions for approximately 1 week after the lecture. this strategic selection can combine 4 review [page 80] [healthcare in low-resource settings 2023; 11(s1):11181] non -co mmerc ial us e o nly review types of interventions and be adjusted based on the results of problem studies and organizational abilities.15-19 in this research, it was discovered that only 3 out of the 13 articles obtained, specifically involved nurse participants. these include patient safety culture training programs in nurse managers, supervisors, and education as well as empowerment programs for nurses as frontlines. from the 3 articles, the strategies used to improve patient safety culture in nursing through educational programs had a positive effect. conclusions all strategies carried out positively influence patient safety culture. generally, the interventions were categorized into 4, namely, educational programs, simulations, team strategies, and comprehensive programs. the strategies to improve the patient safety culture in nurses can be conducted by providing educational programs combined with others understanding their advantages, weaknesses, and adjusting organizational problems as well as abilities. this review expects further research to conduct strategies in improving patient safety culture using a combination of team strategies and comprehensive programs. references 1. yalçın akgül g, aksoy n. the relationship between organizational stress levels and patient safety attitudes in operating room staff. j perianesth nurs 2021;36:499–506. 2. svitlica bb, šajnović m, simin d, et al. patient safety: knowledge and attitudes of medical and nursing students: cross-sectional study. nurse educ pract 2021;53:103089. 3. al-mugheed k, bayraktar n. patient safety attitudes among critical care nurses: a case study in north cyprus. int j health plann manage 2020;35:910–21. 4. donaldson l, ricciardi w, sheridan s, tartaglia r, editors. textbook of patient safety and clinical risk management [internet]. cham (ch): springer; 2021. 5. world bank. indonesia data [internet]. 2021 [cited 2021 may 2]. available from: https://data.worldbank.org/country/id. 6. auraaen a, slawomirski l, klazinga n. the economics of patient safety in primary and ambulatory care: flying blind. paris: oecd; 2018. available from: https://www.oecd-ilibrary.org/social-issues-migration-health/the-economics-ofpatient-safety-in-primary-and-ambulatory-care_baf425ad-en 7. ramdan im, setyowati dl. implementation of patient safety program by nurse at hospital in samarinda and factors influence. kes mas: jurnal fakultas kesehatan masyarakat 2015;9:145–50. 8. edgar hse. the role of the nurse in patient safety: moving to level ii relationships. joj nurs heal care 2017;1:3–5. 9. xie jf, ding sq, zhong zq, et al. a safety culture training program enhanced the perceptions of patient safety culture of nurse managers. nurse educ pract 2017;27:128–33. 10. fabre j. smart nursing: nurse retention & patient safety improvement strategies. 2nd ed. new york: springer pub. co; 2009. 215 p. 11. basuni em, bayoumi mm. improvement critical care patient safety: using nursing staff development strategies, at saudi arabia. glob j health sci 2015;7:335–43. 12. merrill kc. leadership style and patient safety: implications for nurse managers. j nurs adm 2015;45:319–24. 13. salih sa, abdelkader reshia fa, bashir wah, et al. patient safety attitude and associated factors among nurses at mansoura university hospital: a cross sectional study. int j africa nurs sci 2021;14:100287. 14. bilal h, sari hy. relationship between burnout and patient safety attitudes in pediatric nurses in a hospital in turkey. enfermería clínica (english ed) 2020;30:37–41. 15. amiri m, khademian z, nikandish r. the effect of nurse empowerment educational program on patient safety culture: a randomized controlled trial. bmc med educ 2018;18:1–9. 16. hanifi n, namadian z, namadian m, et al. the effect of patient safety educational program on nurses’ patient safety culture and patient safety indicators. asian/pacific isl nurs j 2018;3:21–9. 17. schmidt j, gambashidze n, manser t, et al. does interprofessional team-training affect nurses’ and physicians’ perceptions of safety culture and communication practices? results of a pre-post survey study. bmc health serv res 2021;21:1–11. 18. soliman ma, hegazy aa, bazaraa hm, et al. intervention study to upgrade patient safety practices in pediatric intensive care units of cairo university children hospital. open access maced j med sci 2020;8:65–73. 19. aaberg or, hall-lord ml, husebø sie, et al. a human factors intervention in a hospital evaluating the outcome of a teamstepps program in a surgical ward. bmc health serv res 2021;21:1–14. correspondence: kuswantoro rusca putra, department of nursing, faculty of health science, universitas brawijaya, puncak dieng eksklusif, malang, east java, indonesia 65151. e-mail: torro.fk@ub.ac.id key words: patient safety culture, nurse, hospital, intervention. acknowledgment: the authors are grateful to the editor-in-chief of inhss who provided advice for improvements in article writing. contributions: all authors participated in the development of research methods, definitions, criteria, and in the succession of the production of the initial manuscript. all writers have perused and supported the final manuscript. conflict of interests: the authors declare no conflict of interests. funding: this research was financially supported by the master of nursing program, faculty of medicine, universitas brawijaya. availability of data and materials: the databases used to identify the articles were proquest, ebsco, and sciencedirect. ethics approval and informed consent: not applicable. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 14 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11181 doi:10.4081/hls.2023.11181 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):11181] [page 81] non -co mmerc ial us e o nly 20. jones kj, skinner am, high r, et al. a theory-driven, longitudinal evaluation of the impact of team training on safety culture in 24 hospitals. bmj qual saf 2013;22:394–404. 21. braddock ch, szaflarski n, forsey l, et al. the transform patient safety project: a microsystem approach to improving outcomes on inpatient units. j gen intern med 2015;30:425–33. 22. muething se, goudie a, schoettker pj, et al. quality improvement initiative to reduce serious safety events and improve patient safety culture. pediatrics 2012;130:423–31. 23. storm m, schulz j, aase k. patient safety in transitional care of the elderly: effects of a quasi-experimental interorganisational educational intervention. bmj open 2018;8:1–18. 24. world health organization. patient safety incident reporting and learning systems [internet]. 2020. 51 p. available from: https://apps.who.int/iris/rest/bitstreams/1303416/retrieve 25. schram a, paltved c, christensen kb, et al. patient safety culture improves during an in situ simulation intervention: a repeated cross-sectional intervention study at two hospital sites. bmj open qual 2021;10:1–9. 26. pettker cm, thung sf, raab ca, et al. a comprehensive obstetrics patient safety program improves safety climate and culture. am j obstet gynecol 2011;204:216.e1-216.e6. 27. brilli rj, mcclead re, crandall wv, s et al. a comprehensive patient safety program can significantly reduce preventable harm, associated costs, and hospital mortality. j pediatr 2013;163:1638–45. 28. carlesi kc, padilha kg, toffoletto mc, et al. patient safety incidents and nursing workload. rev lat am enfermagem 2017;25:e2841. review [page 82] [healthcare in low-resource settings 2023; 11(s1):11181] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12100 correlation between the 4cs and motivation to become volunteers among nursing students yakobus siswadi, bima adi saputra, kinanthi lebdawicaksaputri faculty of nursing, universitas pelita harapan, jakarta, indonesia abstract during the covid-19 pandemic, there was a surge in public enthusiasm for volunteering, including among nursing students from the faculty of nursing at universitas pelita harapan (uph). the uph nursing faculty has a foundational framework known as competence, compassion, commitment, and character (4cs), which serves as the basis for shaping each student’s personality. this study aimed to explore how the 4cs foundational framework motivates students to become covid-19 volunteers. using a quantitative descriptive design with a cross-sectional approach to data collection, the study focused on uph nursing students who volunteered for covid-19 relief efforts, with a sample size of 100 respondents. data analysis was conducted using somers δ. the findings revealed that the majority of respondents exhibited adequate motivation to volunteer, with 60% falling into this category, while 22% showed a high level of motivation. notably, the factors of commitment (p=0.004) and character (p=0.009) demonstrated a strong correlation with encouraging nursing students to volunteer. conversely, competence and compassion did not show a significant correlation with students’ motivation to volunteer. among the four driving factors, only commitment and character were statistically related to students’ motivation to become volunteers. introduction the covid-19 pandemic in indonesia affected all aspects of life.1,2 one of the biggest effects was in healthcare because of the increasing number of cases in a very short time and the spread across various regions.3 based on data from the covid-19 handling task force as of october 9, 2020, the confirmed cases in indonesia were 320,564; positive cases were 64,924 (20.3%); recovery cases were 244,060 (76.1%); and deaths were 11,374 (3.6%). the cases were spread across 34 provinces, with the highest number of cases in jakarta with 83,372 cases (26.0%), followed by east java at 46,095 (14.4%); and the least cases in bangka belitung at 440 (0.1%).4 moreover, according to the world health organization, in april 2020, more than 22,000 health workers worldwide were infected with covid-19.5 based on media indonesia, from march to august 2020, there were 295 healthcare workers who were exposed, and 89 of them died. the indonesian doctors association stated that as of september 13, 2020, 115 doctors had died due to covid-19.6 the increasing number of cases is not equal to the number of available healthcare facilities and workers.7 to meet the need, the government took steps by opening an emergency hospital and inviting community participation to be directly involved in dealing with the covid-19 pandemic by volunteering.8,9 public enthusiasm for volunteering is very high, as evidenced in three days (march 25-28, 2020), when as many as 5816 people, including 4008 (68.9%) non-medical people and 1808 (31.1%) medical personnel have registered themselves as covid-19 volunteers.10 according to data from the indonesian ministry of health, as of september 4, 2020, there were 16,247 volunteers from health professionals within the nusantara sehat project, which spread all over indonesia to deal with covid-19.11 driving factors for people to become volunteers are altruism and self-interest. the concern altruism is to help others, meanwhile, the need for self-interest or self-serving is to gain experience or learn new things.12,13 other researchers categorized extrinsic (egoistic) as gaining new working experience or meeting the correspondence: bima adi saputra, faculty of nursing, universitas pelita harapan, jakarta, indonesia. e-mail: bima.saputra@uph.edu key words: factor, nursing student, volunteer motivation. contributions: ys, resources, supervision, conceptualization, data curation, validation, visualization, writing original draft, review and editing; bas, conceptualization, formal analysis, methodology, validation, and writing original draft, review and editing; kl, validation, and writing original draft, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from mochtar riady institute for nanotechnology ethics committee 001/mrin-ec/ecl/i/2021. during the study, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. informed consent: written informed consent was obtained for anonymized respondent information to be published in this article. funding: this research was supported by a research grant from lppm uph with contract number 497/lppm-uph/xi/2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors are thankful to lppm universitas pelita harapan for their valuable insights and contributions to this study. received: 16 november 2023. accepted: 16 may 2024. early access: 21 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12100 doi:10.4081/hls.2024.12100 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12100] [page 543] non -co mmerc ial us e o nly class requirement and intrinsic (altruistic) as the will to help others to create a better community.14 medical students play an important part in responding to participation in the covid-19 diseases.12 volunteering is related to the level of spirituality: the lower the spirituality, the higher the burnout level.15 calling plays a significant role in volunteering: someone who is motivated by calling will be able to focus on bigger group goals and not financial needs, ego, or individual career.16,17 the faculty of nursing universitas pelita harapan (uph) supports government programs by opening volunteer opportunities for students. the debriefing and explanation about volunteers have been disseminated to all students, including service areas, health protocol procedures, and benefits obtained. students who are willing and involved as volunteers are low because there are only 162 students (14.7%).10 this low participation rate in volunteering seems not to be reflected in the implementation of the foundational framework, which consists of the competence, compassion, commitment, and character (4cs). these frameworks prepare and equip all students to serve god by serving others. if public participation is low, it will cause a personnel shortage, which leads to extra work, fatigue, and finally a reduction in the quality of service. the objective of this study was to investigate how the 4cs foundational framework influences students’ motivation to participate as volunteers during the covid-19 pandemic. materials and methods research design this quantitative correlational research employed a cross-sectional approach in exploring and describing the factors driving nursing students to become covid-19 volunteers at a specific point in time. the study was explained to elucidate the relationship between the 4cs of respondents, and their motivation to engage as covid-19 volunteers. study participants the sample for this study comprised nursing students who volunteered for covid-19 initiatives. the sampling method employed probability sampling, specifically total sampling, with a total of 100 respondents. variable, instrument, and data collection independent variables consist of competence, compassion, commitment, and character. the dependent variable was the respondents’ motivation to become covid-19 volunteers. the questionnaire in this study consisted of the self-compassion scale to measure the compassion of volunteers, the brief calling scale to measure commitment, the intrinsic spiritual scale to measure character, and the achievement index to measure competence. meanwhile, the volunteer motivation inventory instrument is used for measuring volunteers’ motivation. the validity and reliability tests of the instrument were carried out on 31 volunteers from uph nursing students. based on the validity and reliability tests, all the question items were declared valid with an r-table value >0.355 and a significance level of 5%. meanwhile, for the reliability test, cronbach’s α values were obtained for each instrument: the self-compassion scale (0.781), the brief calling scale (0.677), the intrinsic spiritual scale (0.909), and the volunteer motivation inventory (0.913). because the values of cronbach’s α > the values of the r-table, the whole instrument is declared reliable. data was collected by distributing online questionnaires using google forms to nursing students who volunteered during the covid-19 pandemic. data analysis the somers-d (or somers δ) statistic test was used to see the relationship between independent and dependent variables. ethical clearance this research has received ethical approval from the mochtar riady institute for nanotechnology ethics committee 001/mrin transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 544] [healthcare in low-resource settings 2024;12:12100] table 1. description of volunteers’ motivation and driving factors of competency, compassion, commitment, and character of the respondents. variable frequency percentage (%) volunteer very low 1 1 low 17 17 moderate 60 60 high 22 22 competency low 1 1 moderate 75 75 high 24 24 compassion low 29 29 moderate 55 55 high 16 16 commitment very low 1 1 low 25 25 moderate 56 56 high 18 18 character very low 4 4 low 9 9 moderate 71 71 high 16 16 total 100 non -co mmerc ial us e o nly ec/ecl/i/2021. during the study, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results this study was conducted at a private university in tangerang, indonesia. the demographic characteristics of the respondents in this study show that of the 100 respondents, 78% were women, and the mean age was 20.57 (standard deviation=1.827, minimum 18 to maximum 23). table 1 indicates that the majority of respondents exhibited moderate motivation to volunteer, with 60 respondents (60%) falling into this category, while 22 respondents (22%) showed high motivation. in terms of competency as a driving factor, 75 respondents (75%) were classified as having good competency. similarly, with compassion, commitment, and character as driving factors, the majority of respondents fell into the moderate category, with 55 respondents (55%), 56 respondents (56%), and 71 respondents (71%), respectively. table 2 presents the relationship between volunteer motivation and the factors of competency, compassion, commitment, and character. in the results of statistical tests using somers δ and γ, it was found that only two factors have significant values of <0.05, namely the commitment factor (0.004) and the character factor (0.009), which indicates that there was a significant relationship between these factors on the motivation of nursing students to become covid-19 volunteers. discussion based on the results of this study, it was found that most respondents had moderate motivation. this may be due to the fact that the respondents are in their late teens (18-23 years old). this finding is in line with the previous study, in which the researchers found that younger volunteers tended to be more motivated by career functions than older volunteers.18 young people are involved in volunteering in terms of benefits, needs, and reasons.19 in other words, students are more likely to have good motivation because of their desire to gain experience so that they can develop and progress.20 this is also in line with the self-determination theory, which has the basic assumption that individuals naturally and actively orient themselves toward growth and self-organization.21 in this study, the commitment and character factors in students had a strong relationship in motivating nursing students to become healthcare volunteers during the covid-19 pandemic. the commitment factor has a strong value in driving motivation in nursing students to become volunteers. in this study, the commitment was measured using the brief calling scale. it focuses on two aspects, such as the presence of calling and the search for calling.22 the commitment of nursing students can be in the form of awareness of their calling to serve and help so they can contribute to others. this is in accordance with the value of commitment taught to nursing students, namely how students can demonstrate commitment to serve through service to others. in the foundational framework of the faculty of nursing at uph, commitment means ministering to others with an attitude of service in response to god’s grace. commitment, satisfaction, and motivation are important characteristics for a person to become a volunteer.18 calling on medical students to become volunteers during the covid-19 pandemic is a liaison for medical students’ behavior to become volunteers during the covid-19 pandemic.20,23 another strong factor that drives nursing students as respondents to volunteer is character. the respondents in this study were educated to be able to have a godly character in words, actions, and attitudes; specifically, what is meant by this godly character is that every word, deed, and attitude is always centered on christ. belief in god is a strong predictor of volunteer involvement, influencing individual attitudes, whether voluntary or involuntary, towards service as a volunteer.24,25 spirituality plays an important role in one’s coping mechanisms when suffering or witnessing others suffer.26 a person’s beliefs or religion can influence someone to become a volunteer. these beliefs will influence a person’s values transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12100] [page 545] table 2. relationship of driving factors of competency, compassion, commitment, and character for nursing students to become healthcare volunteers during the covid-19 pandemic. variable volunteer value approx. sig very low low moderate high total competency low 0 0 1 0 1 -0.002 0.968 moderate 0 13 46 16 75 high 1 4 13 6 24 compassion low 1 8 15 5 29 0.164 0.063 moderate 0 8 34 13 55 high 0 1 11 4 16 commitment very low 1 0 0 0 1 0.459 0.004 low 0 8 13 4 25 moderate 0 8 38 10 56 high 0 1 9 8 18 character very low 1 0 3 0 4 0.461 0.009 low 0 4 5 0 9 moderate 0 11 44 26 71 high 0 2 8 6 16 non -co mmerc ial us e o nly and motives in viewing good relationships between people.27,28 based on this explanation, it can be concluded that the respondents in this study were trained to continue to have a divine character with a passion for serving others. this allows divine character to have a strong relationship to the respondents’ motivation to become volunteers during the covid-19 pandemic. in this study, competency and compassion factors are not the motivating factors for nursing students to become volunteers. this can be due to several things, including the characteristics of the respondents. in this case, the nursing students who become respondents are quite diverse. the competency factor of nursing students who become respondents can be related to their level of skills, and education, including the academic stage and the nurse’s professional education stage. lack of training and knowledge has become a barrier to volunteering.29 compassion is something that cannot be separated from the nursing process because the subject of nursing is humans, so by having good compassion, nurses will have good morals and a sense of humanity.30 the significant factors that can predict compassion in students are humanity and mindfulness in nursing students.31 low self-compassion could contribute to worsening the response to participating in volunteer work.32 the limitation of this study is that the researchers only focused on the 4cs foundational framework. these aspects may evolve throughout the student’s academic journey, and future research might benefit from examining them post-graduation. conclusions in the wake of the covid-19 pandemic, community health faces significant threats, and the healthcare system grapples with considerable challenges. nursing students have the opportunity to actively contribute to pandemic response efforts by volunteering, thus bolstering the resilience of the healthcare system. the study revealed that, among the four driving factors, only commitment and character significantly correlate with motivation to volunteer. therefore, it is crucial for faculties to support and cultivate students’ commitment and character. incorporating activities such as self-reflection into learning sessions can help nurture these qualities in students. further research could explore additional factors influencing nursing students’ decisions to volunteer. references 1. djalante r, lassa j, setiamarga d, et al. review and analysis of current responses to covid-19 in indonesia: period of january to march 2020. prog disaster sci 2020;6:100091. 2. mistry sk, ali am, yadav un, et al. covid-19 related anxiety and its associated factors: a cross-sectional study on older adults in bangladesh. bmc psychiatry 2022;22:737. 3. nurlinawati i, sumiarsih m, andarwati p, et al. determinants of risk factors for covid-19 transmission in densely populated areas: insights from the first wave of the pandemic. electron j gen med 2023;20:em531. 4. satgas covid-19. peta sebaran covid-19. 2021. available from: https://covid19.go.id/peta-sebaran 5. who. coronavirus disease 2019 (covid-19): situation report, 82. available from: https://iris.who.int/bitstream/hand l e / 1 0 6 6 5 / 3 3 1 7 8 0 / n c o v s i t r e p 1 1 a p r 2 0 2 0 eng.pdf?sequence=1&isallowed=y. 6. cnn indonesia. 295 tenaga kesehatan jatim terjangkit corona, 23 meninggal. available from: https://www.cnnindonesia. com/nasional/20200714142414-20-524496/295-tenaga-kesehatan-jatim-positif-corona-23-meninggal. [material in indonesian]. 7. efendi f, aurizki ge, auwalin i, mckenna l. the need for speed: a qualitative study on nurse recruitment and management amidst the covid-19 pandemic in indonesia. j multidiscip healthc 2022;15:1809-17. 8. lazarus g, findyartini a, putera am, et al. willingness to volunteer and readiness to practice of undergraduate medical students during the covid-19 pandemic: a cross-sectional survey in indonesia. bmc med educ 2021;21:138. 9. nugraha d, salamah s, luke k, et al. evaluation of healthrelated quality of life and mental health in 729 medical students in indonesia during the covid-19 pandemic. med sci monit 2023;29:e938892. 10. martin b, kaminski-ozturk n, o’hara c, smiley r. examining the impact of the covid-19 pandemic on burnout and stress among us nurses. j nurs regul 2023;14:4-12. 11. kominfo. fasilitas dan tenaga kesehatan berbagai daerah sudah disiapkan menangani pasien covid-19. available from: https://www.kominfo.go.id/content/detail/29414/fasilitas-dantenaga-kesehatan-berbagai-daerah-sudah-disiapkan-menangani-pasien-covid-19/0/virus_corona 12. tran qa, nguyen htt, bui tv, et al. factors associated with the intention to participate in coronavirus disease 2019 frontline prevention activities among nursing students in vietnam: an application of the theory of planned behavior. front public heal 2021;9:699079. 13. perveen s, laurence c, mahmood ma. indicator-activities to apply primary health care principles in national or large-scale community health worker programs in low-and middle-income countries: a delphi exercise. bmc public health 2022;22:1599. 14. claxton-oldfield s, jefferies j, fawcett c, et al. palliative care volunteers: why do they do it?. j palliat care 2004;20:78-84. 15. scherer ll, allen ja, harp er. grin and bear it: an examination of volunteers’ fit with their organization, burnout and spirituality. burn res 2016;3:1-10. 16. faletehan af, van burg e, thompson na, wempe j. called to volunteer and stay longer: the significance of work calling for volunteering motivation and retention. volunt sect rev 2021;12:235-55. 17. alimansur m, quyumi e. prevention efforts with compliance to the prevention of transmission of covid-19 to covid-19 volunteers. j public heal res community heal dev 2020;4:81-7. 18. widjaja e. motivation behind volunteerism. cmc senior theses; 2010. 19. hamzah sr, suandi t, shah ja, et al. understanding the reasons for malaysian youth participation in volunteering activities. athens j soc sci 2016;3:39-52. 20. shi y, zhang s e, fan l, sun t. what motivates medical students to engage in volunteer behavior during the covid-19 outbreak? a large cross-sectional survey. front psychol 2021;11:569765. 21. ryan rm, deci el. self-determination theory and the facilitation of intrinsic motivation, social development, and wellbeing. am psychol 2000;55:68-78. 22. dik bj, eldridge bm, steger mf, duffy rd. development and validation of the calling and vocation questionnaire (cvq) and transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 546] [healthcare in low-resource settings 2024;12:12100] non -co mmerc ial us e o nly brief calling scale (bcs). j career assess 2012;20:242-63. 23. wulandari cp, muthi’ah ad, aldhama sa, et al. analyzing perceived academic stress among first year undergraduate students during online distance learning. aip conf proc 2023;2536:040001. 24. weiss ozorak e. commentary: culture, gender, faith. the social construction of the person-god relationship. int j psychol relig 2003;13:249-57. 25. nurtjahyani sd, amin m, handajani r. identification of hepatitis c virus genotypes in volunteer blood donors from blood transfusion center of tuban, indonesia. malays j microbiol 2020;16:29-33. 26. callister lc, bond ae, matsumura g, mangum s. threading spirituality throughout nursing education. holist nurs pract 2004;18:160-6. 27. park jz, smith c. ‘to whom much has been given..’: religious capital and community voluntarism among churchgoing protestants. j sci study relig 2000;39:272-86. 28. smidt ce. religion as social capital: producing the common good. waco, tx, usa: baylor university press; 2003. 29. tran v de, pham dt, dao tnp, et al. willingness of healthcare students in vietnam to volunteer during the covid-19 pandemic. j community health 2022;47:108-17. 30. su jj, masika gm, paguio jt, redding sr. defining compassionate nursing care. nurs ethics 2020;27:480-93. 31. susanti rd, yudianto k, mulyana am, amalia in. a systematic scoping review of motivations and barriers in covid-19 volunteering among health students: the potential for future pandemic volunteers. j multidiscip healthc 2023;1671-81. 32. gonzalez-mendez r, díaz m. volunteers’ compassion fatigue, compassion satisfaction, and post-traumatic growth during the sars-cov-2 lockdown in spain: self-compassion and selfdetermination as predictors. plos one 2021;16:e0256854. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12100] [page 547] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11931 factors associated with anxiety and depressive symptoms among indonesian adolescents during the covid-19 pandemic: a cross-sectional study rika sarfika,1 i made moh. yanuar saifudin,2 hema malini,3 dewi eka putri,1 anggi lukman wicaksana,4 mahathir mahathir,1 dwi novrianda5 1department of mental health and community, faculty of nursing, universitas andalas, padang; 2faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta; 3department of medical surgical, faculty of nursing, universitas andalas, padang; 4department of medical surgical nursing, faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta; 5department of child and maternity, faculty of nursing, universitas andalas, padang, indonesia abstract despite the conclusion of the pandemic, addressing mental health concerns during disasters remains crucial. examining the impact of mental health issues in such contexts yields valuable insights for preventing future crises. this study aimed to examine the factors linked to anxiety and depression symptoms among indonesian adolescents during the covid-19 pandemic. this was a cross-sectional study. the study utilized an online survey collected from 738 participants from 34 provinces in indonesia. the participants were asked to provide information on their demographics, social media exposure, self-rated health, gad-7 scores, and the who-5 well-being index. the associations between participant characteristics and depression and anxiety were investigated using independent t-tests, anova tests, and ordinal logistic regression. the majority of the participants were late adolescents, aged 18-21 years old (95%), and female (79.1%). factors such as gender, self-rated health, and social media exposure were significantly associated with depression and anxiety among adolescents during the covid-19 pandemic. male adolescents had a higher risk of depression (or=0.657, 95% ci=0.476-0.908), while infrequent social media exposure was linked to lower anxiety levels (or=0.401, 95% ci=0.190-0.847). the study revealed that younger age, female sex, suspected covid-19 infection, and excessive social media exposure were associated with higher levels of depression and anxiety. to manage depression and anxiety during and after pandemics, it is crucial to provide valid and reliable information and healthcare services, foster social connections, and create supportive environments in households and workplaces. introduction on march 11, 2020, the world health organization (who) formally classified covid-19 as a pandemic, leading to the global implementation of various social interventions, such as stay-athome orders, quarantines, and social distancing guideline.1,2 the covid-19 virus, first detected in wuhan, china, on december 31, 20191, has become a global health challenge, persisting in causing both health emergencies and mental health crises around the world. the pandemic had a greater impact on the most vulnerable groups, including youth, the elderly, low-income individuals, and people with comorbidities. perhimpunan dokter spesialis kedokteran jiwa indonesia (pdskji) found that the age groups experiencing the most psychological problems during the pandemic in indonesia correspondence: rika sarfika, department of mental health and community, faculty of nursing, universitas andalas. padang, indonesia. e-mail: rikasarfika@nrs.unand.ac.id key words: adolescent, anxiety, covid-19, depression, indonesia. contributions: rs, study conception and design, data collection, literature review/analysis, manuscript writing, critical revisions for important intellectual content; immys, study conception and design, data collection, literature review/analysis, manuscript writing; hm, data collection, literature review/analysis, manuscript writing; dep, manuscript writing, critical revisions for important intellectual content; alw, manuscript writing, critical revisions for important intellectual content; mm, manuscript writing, critical revisions for important intellectual content; dn, critical revisions for important intellectual content. all the authors approved the final version to be published. competing of interest: the authors declare no potential conflict of interest. funding: this work is funded by the faculty of nursing, universitas andalas, indonesia (grant number 0666/un1.13.d./xiii/kpt/2020). ethical approval and concent tp participate: ethical approval for the study was granted by the research ethics committee of the faculty of medicine at andalas university, padang, indonesia (approval number: 280/kep/fk/2020). all participants provided informed consent. informed consent: all patients participating in this study signed a written informed consent form for participate in this study. availability of data and material: the data is not accessible to the public as it contains information that might compromise the confidentiality of the research participants. data can be made available upon a reasonable request. acknowledgments: the authors acknowledge the contribution of all respondents who participated in this study. received: 8 october 2023. accepted: 17 november 2023. early access: 14 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11931 doi:10.4081/hls.2023.11931 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 64] [healthcare in low-resource settings 2024;12:11931] non -co mmerc ial us e o nly included individuals aged 17–29 years and those over 60 years.3–5 these measures have had a profound impact on the daily lives and routines of people of all ages, including adolescents, who are especially vulnerable during public health emergencies.6 adolescents are susceptible to mental health conditions, including internalizing disorders such as depression and anxiety, which can have enduring impacts on their physical and mental health and overall quality of life.7 the covid-19 pandemic has led to significant changes in circumstances that are known to influence mental health, such as daily routines, household finances, and social interactions. regulatory laws and sudden changes have turned people’s lives upside down, leaving them in shock.8 these changes have presented increased difficulties for teenagers in establishing positive social connections beyond their immediate family.9–11 during the initial stage of the pandemic in indonesia, a research study found that adolescents faced a higher likelihood of experiencing mental health issues.12–14 furthermore, similar results from studies conducted in china have documented elevated levels of symptoms associated with anxiety and depression relative to rates reported prior to the pandemic,15–17 while a longitudinal study of australian adolescents found an increase in depression and anxiety symptoms during the pandemic18. on the other hand, a study conducted in britain observed a rise in depressive symptoms among adolescents but did not report any significant changes in anxiety symptoms during the pandemic.19 nevertheless, some other studies have found no significant changes in internalizing symptoms or even a reduction in the risk of anxiety among early adolescents during the pandemic.20 there is a possibility that individual-level factors, such as age and race/ethnicity, may contribute to the alterations in adolescent mental health from pre-pandemic to during the pandemic. it is, therefore, crucial to examine these factors as moderators to determine who is at the highest risk and in need of support.21 although initial cross-sectional studies suggested that older adolescents had higher levels of anxiety and depression symptoms compared to younger adolescents at the outset of the pandemic, it does not necessarily imply that older adolescents experienced greater changes in mental health symptoms during the pandemic than their younger counterparts.15,16 it is possible that older adolescents had distinct experiences during the pandemic compared to younger adolescents, given that they tend to spend more time with their peers, which may have been complicated by pandemic-related restrictions. furthermore, they may have had greater needs for autonomy and independence, which could have been affected by pandemic-related disruptions.22,23 depression and anxiety symptoms are prevalent during public health crises and periods of social isolation, as evidenced by both the sars and covid-19 pandemics. research has demonstrated that a substantial number of people experience such symptoms, including covid-19 patients, frontline healthcare workers, and the general population. for adolescents, depressive and anxiety symptoms are linked to greater frailty and reduced well-being, potentially increasing their vulnerability to covid-19. however, there is a lack of consensus regarding the prevalence of these symptoms among adolescents during the pandemic, with estimates varying widely.24–26 although the pandemic has come to an end, the significance of addressing mental health concerns during times of disaster remains crucial. examining and understanding the impact of mental health issues in such contexts can provide valuable insights that contribute to the prevention of future crises. therefore, the aim of this study was to examine factors related to anxiety and depression symptoms among indonesian adolescents during the covid-19 pandemic. research question what factors are related to anxiety and depression symptoms among indonesian adolescents during the covid-19 pandemic, and how do these factors contribute to our understanding of addressing mental health concerns during times of disaster and preventing future crises? materials and methods study design the current study utilized a cross-sectional online survey design and recruited participants through snowball sampling, which involved distributing an online questionnaire to students who then shared it with their peers. this approach allowed for the collection of a varied and diverse sample for analysis. samples the study population consisted of indonesian adolescents aged between 11 and 21 years, who were willing to participate. individuals with a history of mental health problems or diagnoses were excluded from the sample. the exclusion criteria allowed researchers to better isolate the potential impact of the covid-19 pandemic on mental health symptoms, focusing their investigation on individuals without prior conditions. the optimal sample size was determined using g*power 3.1, based on a correlation (p h1) of 0.15, an α error of 0.01, and a power of 0.95, minimizing the risk of errors22. as a result, the minimum sample size required was 693, but ultimately, 738 individuals completed the survey and provided comprehensive responses to all questions. instruments sociodemographic previous research has suggested that demographic factors, including gender, age, education, marital status, occupation, area of residence (urban or rural), and self-rated health status, can impact mental health outcomes. however, the relationship between these factors and mental health outcomes can differ depending on the individual’s place of residence.27 to account for the potential impact of demographic factors on mental health outcomes, this study collected information on various sociodemographic variables, including age, gender, and education level. additionally, the study assessed the participants’ exposure to covid-19-related information on social media (less, sometimes, frequently), selfrated health status (healthy or good, unwell or sick, or not good), and history of exposure to covid-19 patients (categorized as “ever” and “never”). it is worth noting that all sociodemographic questionnaires were provided in the indonesian language. anxiety the generalized anxiety disorder scale (gad-7) was used to assess the anxiety level of the adolescents.28,29 the researchers obtained permission to use the gad-7 instrument for noncommercial data collection purposes in this study. the indonesian version of gad-7 was translated previously.30 the gad-7 is a tool that individuals can use themselves to assess the severity of their generalized anxiety symptoms. it consists of seven questions that assess different aspects of anxiety, including excessive worry, restlessness, irritability, and physical symptoms like sleep disturbances and fatigue. respondents rated each item on a scale of 0 to 3, with higher scores indicating more severe symptoms. the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11931] [page 65] non -co mmerc ial us e o nly gad-7 has established cut-off scores for mild, moderate, and severe anxiety symptoms. studies have shown that it is a reliable and valid measure, with high sensitivity and specificity at a cut-off score of 10. the scale’s internal consistency is also high, indicating that it consistently measures anxiety symptoms. depression the assessment of depression in this study was conducted using the who-5 well-being index, which comprises five items featuring positive language that indicates the presence or absence of well-being rather than depression symptoms.24 the who-5 well-being index is a self-administered questionnaire that measures well-being in individuals. the indonesian version of the index was developed with the help of the language center of universitas andalas and was reviewed by an expert panel prior to the study. to test the validity and reliability of the index, it was administered to a group of 30 individuals who had the same criteria as the study participants. the index demonstrated good internal consistency, with a cronbach’s alpha coefficient of 0.864. participants were asked to report positive feelings they experienced in the past two weeks using a 6-point scale. the severity of depression is indicated by the score generated, with higher scores indicating higher depression. the total score ranges from 0 to 25. the scale was modified to categorize the responses as never, rarely, sometimes, often, and always. since no established cut-off score exists, the possible range of scores was divided into percentiles to provide categories of severe, moderate, mild, and minimal or no depression. a score of ≤11 indicates severe depression, 12-13 indicates moderate depression, 14-15 indicates mild depression, and ≥16 indicates minimal or no depression. data collection the research study was conducted over a period of three months, from february to april 2020. to collect research data, the present study employed snowballing technique with online questionnaires distributed through popular social media platforms, such as whatsapp, facebook, and instagram. this approach was chosen since it provides access to hard-to-reach populations, leverages existing social networks, is convenient and cost-effective for online surveys, and can explore hidden or understudied groups. in this context, it allows the research to tap into a diverse sample of indonesian adolescents who may have experienced mental health issues during the covid-19 pandemic, making it a practical and efficient choice for the study. the survey was initially disseminated through student groups, and participants were encouraged to share it with their social media networks. the study followed ethical guidelines by obtaining informed consent from participants before they filled out the online questionnaire on the google form. those aged between 11 and 21 years were eligible if they obtained parental consent and agreed to the terms on the consent page. the study’s objectives, procedures, and administrative aspects were clearly explained to all participants. a total of 738 participants from 34 indonesian provinces willingly participated and provided information on their demographics, social media exposure, self-rated health, gad-7 scores, and the who-5 well-being index. participants had the right to withdraw from the study at any time without providing a reason. data analysis the data collected in this study underwent statistical analysis using ibm spss statistics software version 22.0 (ibm corp., armonk, n.y., usa). the normality assumption of continuous variables was confirmed through the kolmogorov-smirnov test, indicating that the data followed a normal distribution. to summarize the data, descriptive statistics, including frequencies, percentages, means, medians, minimum and maximum values (min-max), and standard deviations (sd), were employed. furthermore, the relationship between participants’ characteristics and depression and anxiety was examined using independent ttests and anova tests. subsequently, a stepwise ordinal logistic regression analysis was conducted to identify the variables that influenced depression and anxiety. the brant test was used to assess the proportionality assumption, and the model’s performance was evaluated using the hosmer test for goodness of fit. the statistical significance level was set at p<0.05. ethical consideration informed consent was obtained from all adult human participants and their parents or legal guardians. additionally, informed assent was obtained from the adolescents, ensuring their understanding and agreement to participate. the research ethics committee of the faculty of medicine, universitas andalas (approval number: 280/kep/fk/2020), has approved this research. results characteristics of the participants the study involved 738 participants. the majority of the participants were late adolescents aged 18-21 years old (n=701, 95%). additionally, most of the participants were female (n=584, 79.1%) and had a high school background (n=720, 97.6%). the researchers also collected data on the participants’ exposure to covid-19. the majority of the participants reported having a good self-rated health status (n=707, 95.8%), frequently being exposed to covid-19-related information on social media (n=407, 55.1%), and having been exposed to covid-19 patients (n=730, 98.9%). this information is presented in table 1. anxiety description among adolescents during covid-19 outbreak table 2 presents the gad-7 item descriptors. there were 7 questions included in the study to measure the anxiety level of the participants. item 1 had a mean score of 0.97 (sd=0.52) and indicated that the majority of adolescents felt nervous, anxious, or on edge on several days (77.9%). item 2 obtained a mean score of 0.80 (sd=0.60) and showed that the majority of adolescents were not able to stop or control worrying for several days (63.7%). item 3 had a mean score of 0.89 (sd=0.58) and indicated that the majority of adolescents worried too much about different things for several days (67.9%). item 4 had a mean score of 0.73 (sd=0.65) and indicated that the majority of adolescents experienced difficulty in relaxing for several days (54.9%). item 5 had a mean score of 0.54 (sd=0.64) and showed that the majority of adolescents did not experience being so restless that it was hard to sit still (52.6%). item 6 had a mean score of 0.97 (sd=0.70) and indicated that the majority of adolescents became easily annoyed or irritable for several days (60.6%). lastly, item 7 had a mean score of 0.99 (sd=0.64) and showed that the majority of adolescents felt afraid, as if something awful might happen for several days (68.4%). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 66] [healthcare in low-resource settings 2024;12:11931] non -co mmerc ial us e o nly depression description among adolescents during covid-19 outbreak furthermore, there were 5 questions included in the study to measure depression. item 1 had a mean score of 2.74 (sd=0.80) and indicated that the majority of adolescents felt cheerful and in good spirits most of the time (45.3%). item 2 obtained a mean score of 2.72 (sd=0.84) and showed that the majority of adolescents felt cheerful and in good spirits most of the time (45.7%). item 3 had a mean score of 2.60 (sd=0.83) and indicated that the majority of adolescents sometimes felt active and vigorous (39.6%). item 4 had a mean score of 2.69 (sd=0.92) and showed that the majority of adolescents woke up feeling fresh and rested most of the time (41.5%). lastly, item 5 had a mean score of 2.43 (sd=0.92), indicating that the majority of adolescents reported that their daily life had been filled with things that interested them at times (40.2%) (table 3). anxiety and depression among adolescents during covid-19 outbreak table 4 presents the descriptive statistics for anxiety scores, including the mean and standard deviation. based on the results, the mean depression score in adolescents was 13.18 (sd 3.45), and the mean anxiety score was 5.88 (sd 3.01). the majority of the respondents (73.6%) reported experiencing depression during the covid-19 outbreak. among those respondents, 24.8% reported symptoms of mild depression, 19.4% reported moderate depression, and 29.4% reported severe depression. additionally, most respondents experienced mild levels of anxiety (47.4%), while 314 (42.5%) respondents did not experience significant anxiety. related factors of depression and anxiety among adolescents during covid-19 outbreak table 5 presents findings that demonstrate a statistically significant link (p<0.05) between anxiety and variables such as age, gender, and exposure to social media. however, no discernible connection was observed between anxiety and other factors like self-rated health, exposure to covid-19 patients, and education (p>0.05). moreover, table 5 reveals a statistically significant correlation (p<0.05) between depression and both gender and social media exposure. nevertheless, no noticeable relationship transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. description of participant characteristics (n=738). characteristics f (%) age, in years 11-14 (early adolescent) 3(0.4) 15-17 (middle adolescent) 34(4.6) 18-21 (late adolescent) 701(95.0) gender male 154(20.9) female 584(79.1) self-rated health good 707(95.8) not good 31(4.2) exposure to covid-19 patients never 8(1.1) ever 730(98.9) social media exposure never 2(0.3) rarely 32(4.3) sometimes 146(19.8) often 407(55.1) always 151(20.5) education high school 720(97.6) college 18(2.4) table 2. description of anxiety among adolescents during covid-19 outbreak. over the last two weeks, mean ± sd no at all several days more than half the days nearly every day how often have you been bothered f (%) f (%) f (%) f (%) f (%) by the following problems? feeling nervous, anxious, or on edge 0.97±0.52 100 (13.6) 575 (77.9) 49 (6.6) 14 (1.9) not being able to stop or control worrying 0.80±0.60 214 (29.0) 470 (63.7) 43 (5.8) 11 (1.5) worrying too much about different things 0.89±0.58 163 (22.1) 501 (67.9) 65 (8.8) 9 (1.2) trouble relaxing 0.73±0.65 273 (37.0) 405 (54.9) 48 (6.5) 12 (1.6) being so restless that it is hard to sit still 0.54±0.64 388 (52.6) 308 (41.7) 32 (4.3) 10 (1.4) becoming easily annoyed or irritable 0.97±0.70 171 (23.2) 447 (60.6) 94 (12.7) 26 (3.5) feeling afraid, as if something awful might happen 0.99±0.64 134 (18.2) 505 (68.4) 75 (10.2) 24 (3.3) table 3. description of depression among adolescents during covid-19 outbreak. over the last two weeks, mean ± sd at no time rarely sometimes most of the time all of the time how often have you been f (%) f (%) f (%) f (%) f (%) f (%) bothered by the following problems? i have felt cheerful and in good spirits 2.74±0.80 2 (0.3) 35 (4.7) 241 (32.7) 334 (45.3) 126 (17.1) i have felt calm and relaxed 2.72±0.84 5 (0.7) 47 (6.4) 223 (30.2) 337 (45.7) 126 (17.1) i have felt active and vigorous 2.60±0.83 3 (0.4) 52 (7.0) 292 (39.6) 281 (38.1) 110 (14.9) i woke up feeling fresh and rested 2.69±0.92 5 (0.7) 76 (10.3) 208 (28.2) 306 (41.5) 143 (19.4) my daily life has been filled with things that interest me 2.43±0.92 10 (1.4) 96 (13.0) 297 (40.2) 238 (32.2) 97 (13.3) [healthcare in low-resource settings 2024;12:11931] [page 67] non -co mmerc ial us e o nly was found between depression and other variables such as age, self-rated health, exposure to covid-19 patients, and education (p>0.05). additionally, table 6 highlights variations in participant characteristics across different categories of depression, while table 7 demonstrates differences in participant characteristics across categories of anxiety. according to the results of the multivariable analysis, several factors were found to be significantly associated with depression among adolescents during the covid-19 pandemic. specifically, variables such as gender, self-rated health, and social media exposure showed a significant relationship. the analysis revealed that the risk of higher depression was 0.657 times (or=0.657, 95% ci=0.476-0.908) higher among male adolescents compared to their female counterparts. conversely, adolescents with good self-rated health were 0.439 times (or=0.439, 95% ci=0.220-0.876) less transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 5. personal characteristics and relationships with the anxiety and depression. characteristics anxiety t f p depression t f p mean±sd mean±sd age, in years 3.791 0.023* 0.896 0.409 11-14 (early adolescent) 3.67±2.08 15.67±3.78 15-17 (middle adolescent) 7.12±3.86 13.44±3.16 18-21 (late adolescent) 5.83±2.95 13.15±3.46 gender -2.315 0.021* 2.232 0.026* male 5.38±3.36 13.73±3.58 female 6.01±2.90 13.03±3.40 self-rated health -1.746 0.081 1.780 0.075 good 5.84±2.98 13.22±3.45 not good 6.81±3.49 12.10±3.29 exposure to covid-19 patients -0.596 0.551 -1.071 0.284 never 5.25±3.69 11.88±4.01 ever 5.89±3.00 13.19±3.44 social media exposure 3.048 0.017* 4.248 0.002* never 4.00±5.65 15.00±7.07 rarely 4.41±2.89 14.78±3.20 sometimes 6.22±3.01 12.42±3.38 often 5.78±2.90 13.15±3.32 always 6.17±3.01 13.60±3.72 education 0.386 0.700 -0.333 0.739 high school 13.17±3.47 13.17±3.47 college 13.44±2.85 13.44±2.85 t, t-test; f, one-way anova, *statistically significance (p<0.05). table 4. anxiety and depression level among adolescents during covid-19 outbreak. variables f (%) mean (sd) depression 13.18 (3.45) no depression 195 (26.4) mild 183 (24.8) moderate 143 (19.4) severe 217 (29.4) anxiety 5.88 (3.01) no anxiety 314 (42.5) mild 350 (47.4) moderate 66 (8.9) severe 8 (1.1) table 6. results of ordinal logistic regression on the association between variables of interest and depression of respondents during covid-19. variables categories depression or 95% ci for or p lower upper age continuous 1.005 0.898 1.126 0.923 gender (reference: female) male 0.657 0.476 0.908 0.010* education (reference: college) high school 1.287 0.573 2.892 0.554 exposure to covid-19 patients (reference: never) ever 3.223 0.696 14.920 0.134 self-rated health (reference: not good) good 0.439 0.220 0.876 0.019* social media exposure (reference: always) never 0.479 0.026 8.869 0.621 rarely 0.711 0.357 1.419 0.334 sometimes 1.895 1.249 2.876 0.003* often 1.442 1.030 2.019 0.033* parallel line test (p=0.105). goodness of fit test of overall model: deviance (chi-square=247.828, df=234, p=0.255). ***p<0.001; **0.001<p<0.01; *0.01<p<0.05. [page 68] [healthcare in low-resource settings 2024;12:11931] non -co mmerc ial us e o nly likely to experience depression compared to those with a poorer health status. furthermore, adolescents who were sometimes and often exposed to social media content related to covid-19 had 1.895 times (or=1.895, 95% ci=1.249-2.876) and 1.442 times (or=1.442, 95% ci=1.030-2.019) a higher likelihood of experiencing depression, respectively, compared to those who had exposure every day. another finding indicated that several factors were significantly associated with anxiety among adolescents during the covid-19 pandemic, including gender and social media exposure. the analysis demonstrated that the risk of higher anxiety was 0.657 times (or=0.657, 95% ci=0.476-0.908) higher among male adolescents compared to females. additionally, adolescents who had infrequent exposure to social media content related to covid-19 were 0.401 times (or=0.401, 95% ci=0.190-0.847) less likely to experience anxiety compared to those who had daily exposure. discussion the sample group mostly consisted of females aged between 18 and 21 years old, which is consistent with previous studies conducted in indonesia. these studies also found that individuals who experienced psychosocial effects of the pandemic were mostly female,12,31,32 despite the fact that the latest national census shows an equal distribution between both sexes.33 this study did not adhere to specific data collection standards, although the results are consistent with previous research,34,35 furthermore, the accessibility of the internet may have exposed the respondents to a vast amount of covid-19 information from online sources such as social media and online news portals, which may have contributed to the observed levels of mental health problems. in some studies in china, frequent and prolonged social media exposure during the covid-19 pandemic was found to be strongly associated with anxiety and depression.36 the research findings indicate that middle adolescents were more likely to experience significant anxiety during the covid19 pandemic. this is consistent with previous studies on the topic, which also found that younger populations, especially adolescents, were more prone to depression and anxiety.32,37 the increased depression and anxiety among adolescents are related to disruptions in their daily routines, such as transitioning to an online learning or work environment, as well as concerns about their future plans and financial stability. additionally, the frequent use of social media by adolescents may lead to information overload and misinformation, further exacerbating depression and anxiety.27 this study found that a small percentage of the participants, specifically 4.3%, experienced significant anxiety during the covid-19 pandemic. in contrast, the majority of the respondents, 73.6%, reported experiencing depression during the outbreak. these results differ from previous studies conducted before the pandemic, including national data from indonesia basic health research in 2018, which reported that 9.8% had mental and emotional problems.38 conversely, our proportion was higher than the global prevalence of anxiety reported by who, which was 3.6%.39 in comparison to other pandemics in different countries, the prevalence of anxiety in our study was relatively lower. a study40 revealed that the prevalence of anxiety during an infectious disease outbreak was 14.8%. in addition, the prevalence of anxiety among people in isolation during an infectious disease outbreak in korea was approximately 7.6%. furthermore, our findings show that the prevalence of anxiety was relatively lower than in other countries such as china and turkey, which reported anxiety prevalence rates of 35.1% and 45.1%, respectively.41–43 the observed disparity in anxiety prevalence may be explained by differences in the timing of the study and the national situation of the covid-19 pandemic. this study investigated various factors that may contribute to anxiety and depression in adolescents. multivariable analysis showed that predictors contributing to depression in adolescents were gender, self-rated health, and social media exposure. furthermore, predictors contributing to anxiety in adolescents were gender and social media exposure. the results of this study indicate that female participants had a higher level of depression and anxiety compared to males. this finding is consistent with the results of a previous study,32 which also found that young females experienced higher levels of depression and anxiety than males. it is well-known that females have a higher susceptibility to depression and anxiety compared to males due to various factors, including biological factors such as sex chromosomes and hormonal exposure, as well as social factors.44–47 this study’s results also extend the findings of an earlier study, which observed a link between lower self-rated health levels and the development of depression and anxiety in a population-based group.48 additionally, another study revealed that self-rated health transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 7. results of ordinal logistic regression on the association between variables of interest and anxiety of respondents during covid-19. variables categories anxiety or 95% ci for or p lower upper age continuous 0.892 0.786 1.013 0.077 gender (reference: female) male 0.691 0.487 0.980 0.038* education (reference: college) high school 1.021 0.408 2.553 0.964 exposure to covid-19 patients (reference: never) ever 0.930 0.221 3.913 0.921 self-rated health (reference: not good) good 0.536 0.270 1.063 0.074 social media exposure (reference: always) never 0.446 0.027 7.379 0.573 rarely 0.401 0.190 0.847 0.017* sometimes 0.826 0.530 1.288 0.400 often 0.721 0.502 1.034 0.076 parallel line test (p=0.003). goodness of fit test of overall model: deviance (chi-square=197.344, df=234, p=0.961). *statistically significance (p<0.05). [healthcare in low-resource settings 2024;12:11931] [page 69] non -co mmerc ial us e o nly could effectively identify individuals at a higher risk of depression and anxiety.49,50 as stated by the who, three factors are associated with increased depression and anxiety during the covid-19 outbreak. some of the mental disorders experienced by adolescents include feelings of loneliness, anxiety, stress, psychiatric disorders, and emotional disturbances.51 these factors include fear of infection, misinterpretation of bodily sensations, and exposure to news and misinformation from untrustworthy sources. continuous coverage of covid-19 news is available through various media platforms such as newspapers, television, radio, and social media. additionally, individuals have a tendency to seek out information about the ongoing crisis to stay informed, particularly during times of emergency. most of the respondents stated that they often had exposure to covid-19-related information on social media.52–55 as covid-19 nears its end, the research findings maintain their relevance. they emphasize the continued need for mental health support, even as the pandemic wanes, and highlight the importance of preparedness for future health crises. genderspecific approaches in public health and mental health policies are underscored. these implications extend beyond the pandemic, emphasizing ongoing mental health care, readiness for emergencies, and tailored support for various populations in public health contexts. the results of this study also have broad implications for the formulation of public policies to address not only the current but also future pandemics. the heightened prevalence of depression observed during the pandemic underscores the importance of ongoing and effective measures to support vulnerable groups, with a particular focus on adolescents, females, and those with excessive social media exposure. these findings highlight the need to ensure that individuals have reliable access to information and healthcare services to prevent mental health problems both during and after pandemics. policymakers should take these insights into account and implement policies that facilitate such access to a wider population, thereby enhancing the generalizability and applicability of these findings to various public health contexts. conclusions in conclusion, this study emphasizes the continued importance of addressing mental health issues post-pandemic. insights gained here can inform strategies to prevent future crises and enhance mental well-being. factors such as age, gender, suspected covid19 infection, and social media exposure are linked to higher rates of depression and anxiety. policymakers should prioritize accurate information, healthcare access, and supportive environments. more research is needed to explore anxiety in digitally underserved populations and across diverse age groups. monitoring the long-term impacts of the covid-19 pandemic on mental 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cardiovascular health study. aging ment health 2010;14:168-76. 50. ambresin g, chondros p, dowrick c, et al. self-rated health and long-term prognosis of depression. ann family med 2014;12:57-65. 51. sholihah if, nurmala i, sulistyowati m, devy sr. the impact physical distancing during the covid-19 pandemic on mental health among adolescents: a systematic literature review. int j publ health sci 2022;11:69-76. 52. organization wh. the world health report 2001: mental health: new understanding, new hope. 2001; 53. world health organization. guidelines on mental health promotive and preventive interventions for adolescents: helping adolescents thrive [internet]. world health organization; 2020 [cited 2023 jan 12]. available from: https://apps.who. int/iris/bitstream/handle/10665/336864/9789240011854eng.pdf 54. organization wh. mental health and psychosocial considerations during the covid-19 outbreak, 18 march 2020. world health organization; 2020. 55. organization wh. adolescence: a period needing special attention. health for the world’s adolescents: a second chance in the second decade. 2014. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11931] [page 71] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12603 humanitarian commitment: indonesia's policy on refugees’ rights to health r yahdi ramadani,1 aktieva tri tjitrawati,2 mochamad kevin romadhona3 1faculty of law, universitas airlangga, surabaya; 2department of international law, faculty of law, universitas airlangga, surabaya; 3faculty of social and political sciences, universitas airlangga, surabaya, indonesia abstract refugees have faced many challenges, including access to housing, education, and social and health services. international conventions regulate human rights that all civilized countries must obey, starting from the declaration of human rights, the international covenant on civil and political rights and indonesia, the international covenant on economic, social and cultural rights and others recognized internationally and nationally. indonesia, although not a state party to the 1951 convention and 1967 protocol on refugees, must pay attention to how to pay attention to foreigners, especially refugees in its territory. in providing protection and fulfillment of rights, indonesia must refer to one of the international principles in providing needs to foreigners, namely the international minimum standards and national treatment standards. introduction the republic of indonesia, situated in a strategically significant location on the global map, has emerged as a transit point for refugees and asylum seekers who may arrive via numerous means.1-4 according to the 1951 convention relating to the status of refugees, commonly known as the 1951 geneva convention, refugees or asylum seekers are individuals who have fled their country due to fear of persecution based on race, religion, nationality, membership in a specific social group, or political opinion.59 nonetheless, the 1967 protocol relating to the status of refugees has broadened the concept of refugees by incorporating a more expansive interpretation,10 from the 1951 geneva convention on the status of refugees, which is devoid of any temporal restrictions and is worldwide applicable. per may 2024, the united nations (un) documented over 120 million individuals who become refugees worldwide.11 the united nations high commissioner for refugees (unhcr) presented the figures of 120 million refugees per may 2024 in its annual report as a customary practice. this figure will persist in rising due to the continuing hostilities in several nations. the organisation responsible for managing refugees is the united nations high commissioner for refugees (unhcr),12 which was founded by the united nations to manage global refugee issues. the responsibilities of the unhcr include safeguarding and aiding refugees in resolving their circumstances, ensuring that refugees fulfil their fundamental requirements, and enabling the resettlement of refugees to their host nations.13 presently, several nations are obligated by the 1951 geneva convention and the 1967 new york protocol via ratification or accession, therefore aiding the unhcr in the resettlement of refugees to their respective destination countries.5,14-20 indonesia, situated in a region frequented by migrants via international maritime routes, cannot evade the presence of refugees.21-26 data from unhcr indicates a year-on-year escalation in the number of refugees entering indonesia, including both asylum seekers and those in transit. this has inadvertently raised a worry for the administration of the republic of indonesia. the right to health is an essential human right that every nation must uphold, irrespective of age, gender, ethnicity, or other considerations.27-30 the state is required to provide this right to all citizens and foreigners under its jurisdiction, including migrant laborers, asylum seekers, and refugees.26,31,32 nonetheless, there are concerns regarding the right to health for vulnerable populations, such as refugees and asylum seekers, who face challenges such as inadequate healthcare services in both emergency and routine circumstances. the overall count of asylum seekers and refugees in indonesia is 13,616 individuals, including 10,184 refugees and 3,432 asylum seekers. the refugee and asylum seeker population comprises children (27%), adults (71%), and the elderly (2%). indonesia is seeing a considerable problem in delivcorrespondence: aktieva tri tjitrawati, department of international law, faculty of law, universitas airlangga, surabaya, indonesia. e-mail: aktieva.tri@fh.unair.ac.id key words: refugees, 1951 convention, 1967 protocol, rights to health, indonesia. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and informed consent: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 24 april 2024. accepted: 29 november 2024. early view: 29 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12603 doi:10.4081/hls.2024.12603 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 120] [healthcare in low-resource settings 2024;12(s2):12603] non -co mmerc ial us e o nly ering healthcare services to its 13,616 refugees and asylum seekers. since access to health is a fundamental right that should be ensured as a matter of governmental responsibility for human rights.33,34 indonesia’s regulations and practices impede the availability of immunizations and healthcare services for refugees and asylum seekers. this administrative measure prevents refugees and asylum seekers from receiving healthcare treatments due to their insufficient documentation. the regulation enacted by indonesia hinders asylum seekers and refugees from obtaining healthcare services during national emergencies associated with health access. the absence of hygienic settings is a challenge for refugees and asylum seekers, as shown by several shelters that categorize these individuals as slums and get little attention from indonesia. mental health concerns persist for refugees and asylum seekers, since there is now an absence of mental health services in indonesia. despite not having ratified the 1951 convention relating to the status of refugees and the 1967 new york protocol, indonesia remains obligated to protect refugees and asylum seekers in accordance with the international refugee law principles of non-refoulement and non-discrimination.35-38 presidential regulation number 125 of 2016 on the management of foreign refugees fails to explicitly delineate the rights afforded to refugees and asylum seekers, including the right to healthcare.39 the failure to satisfy the right to health for asylum seekers and refugees in indonesia constitutes a significant concern that requires urgent attention from the indonesian government.40 refugees are individuals requiring protection from their current nation, whether on a temporary or permanent basis.41 refugees come needing support and protection from outside their nation of origin. the 1951 convention on the status of refugees characterizes a refugee as an individual who, owing to a substantiated apprehension of persecution based on race, religion, nationality, or affiliation with a specific social group or political party, is outside their country of nationality and does not seek protection from that country. a report published by unhcr indicated that a significant factor contributing to the influx of refugees was the crisis in several middle eastern countries,42-44 including the taliban conflict in afghanistan.45 the report revealed that in 2020, 82 million individuals worldwide were compelled to flee their homes. the unhcr research indicated that up to 86% of the world’s refugees and venezuelan nationals are seeking asylum in different nations. a research study from global rise, an organization focused on improving nutrition and health in poor nations, indicated that uganda hosts 1.4 million refugees. the unhcr indonesia report indicated that there were 12,616 registered refugees in indonesia, with children constituting 27% of this total. as of november 2022, the majority of refugees arriving in indonesia originated from afghanistan (55%), somalia (10%), and myanmar (6%). historically, refugees have encountered several hurdles, including access to housing, education, and social and health services. global refugees emergence by region 2021 – 2023 more than 110 million individuals have been forcibly displaced worldwide as a result of persecution, conflict, violence or human rights violations. we are now witnessing the highest levels of displacement on record (supplementary materials, table 1). based on report published by unhcr which divides it into nine categories, namely sub-saharan africa, central america and venezuela, europe, iraq, south sudan, syria, ukraine, yemen. the geopolitics condition has been influence of human mobalizing, unhcr identified that conflict, war, social and political factors have an important role in the mobility of refugees to various regions in the world. it is noted that in the sub-saharan africa region the conflict that occurred in sudan caused massive displacement. in central america and venezuela, there is an increasing number of crimes and criminal organizations. in the european region the increase in the number of refugees is due to the war between ukraine and russia. the prolonged conflict in syria has caused the syrian population to move to various regions in the world with the highest percentages being in turkey, lebanon and jordan. the rohingya muslim minority conflict in myanmar has caused high mobility, the rohingya muslim refugee group is dominated by women and children with 90% living in malaysia and bangladesh. and yemen, which is one of the poorest countries in the middle east, has increased poverty and prolonged conflict and natural disasters which have resulted in residents of yemen having to flee to other places. refugee protection in indonesia: legal frameworks and humanitarian obligations indonesia, located between asia and australia, is a strategic route for international trade and shipping, making it a transit country for refugees by sea.46 however, due to its non-membership of the 1951 convention and 1967 protocol, indonesia has limitations in granting status and fulfilling the rights of refugees in its territory.47 the principles of non-refoulement, non-discrimination, and non-expulsion are customary international law as jus cogens,48 obliges every country to pay attention to and apply these principles regardless of whether the country has ratified the 1951 convention and the 1967 protocol on refugees. indonesia is a legal country that recognizes human rights that must be fulfilled as stated in the 1945 constitution of the republic of indonesia.49 in providing protection and fulfillment of rights, indonesia must refer to one of the international principles in providing needs to foreigners, namely the international minimum standard and national treatment standard. in general, developing countries like indonesia treat foreigners in their territory using principles national standard treatment, based on article 9 of the 1933 montevideo convention. in providing protection based on a human rights perspective, indonesia has an obligation not to take discriminatory actions as applicable under international law and must also pay attention to the non-discriminatory principle has become customary international law. in providing treatment to refugees, indonesia must prioritize the principle of non-refoulment, the principle of non-discrimination, and the principle of non-expulsion while ensuring that the actions and protection of refugees in their country’s territory include general provisions in providing protection for human rights. indonesia as a transit country has an obligation to treat refugees properly, considering their rights that cannot be reduced, such as the right to life, the right not to be tortured, the right to adhere to a belief or religion, the right to have a family, and the right to health. as a transit country that accepts refugees with the assistance of unhcr and iom, indonesia has an obligation to make legal regulations in providing protection for refugees. refugees can be categorized as legal subjects who have rights and obligations if they have lived for a while, which must be recognized by the state.50 the state must ensure whether refugees are legal or illegal foreign citizens, as this can affect state policies in providing protection for refugees.51 indonesia has made several legal rules to deal with refugees, including law of the republic of social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12603] [page 121] non -co mmerc ial us e o nly indonesia number 37 of 1999 concerning foreign relations, law of the republic of indonesia number 6 of 2011 concerning immigration, regulation of the president of the republic of indonesia number 125 of 2016 concerning handling of refugees from abroad, director regulations general immigration number imi-1489.um.0805 of 2010 concerning illegal immigrants, director regulations general immigration number imi0352.gr.02.07 year 2016 concerning handling of illegal immigrants or refugees, ministry of health circular letter dated 10 june 2020 concerning provision of access to services related to covid-19 for registered refugees, and minister of home affairs circular letters number 300/2307/sj and 300/2308/sj concerning the establishment of a task force for handling refugees from abroad. legal regulations regarding refugees in indonesia vary depending on the country’s political, economic, and security conditions. the law of the republic of indonesia number 37 of 1999 concerning foreign relations is one of the bases for recognizing refugees, which is given by the president with consideration of state security, politics, economy, and other factors suggested by the ministry of foreign affairs. the law also takes into account refugee law contained in international conventions, customary international law, and international practice in granting recognition to refugees. indonesia has been assisted by unhcr and iom to provide protection for refugees since its publication. the ministry of immigration, under the ministry of law and human rights, the ministry of foreign affairs, the indonesian national police, and other agencies, assists in providing protection and fulfilling rights to refugees. however, the recognition of refugees has experienced problems, especially during the year 2010. in 2010, refugees were considered illegal immigrants, leading to concerns for refugees from 2010 to 2016. the director general of immigration regulation number imi-1489.um.0805 of 2010 stated that refugees are illegal immigrants because they come to indonesia without complete documents. this led the government to clarify that refugees are the same as illegal immigrants who can be deported for violating the provisions of the law governing the presence of foreigners in indonesia. additionally, the regulation stipulates that every illegal immigrant arranges for refugees if there are objectors from unhcr, and they can be subject to immigration action. immigration actions are regulated based on the law of the republic of indonesia number 6 of 2011 concerning immigration, which outlines the actions of immigration administrative actions listed in article 75 paragraph 2, including inclusion in the list of prevention or deterrence, limitation, change, or cancellation of stay permit, prohibition to be in certain places in the indonesian territory, obligation to reside in a certain place, imposition of expenses, and deportation from the indonesian territory. indonesia’s actions in 2010-2016 violated international law, particularly in relation to discriminatory acts against refugees. deportation was prohibited by international refugee law due to the violation of customary principles such as non-backflow and nonexpulsion. the permitted return should be carried out by unhcr through voluntary repatriation, not unilaterally by the government. political conditions and treatment of refugees in indonesia have changed since 2016, making the rule of law in line with the law of the republic of indonesia number 37 of 1999 concerning foreign relations. this is indicated by the revocation of director general of immigration regulation number imi-1489.um.0805 of 2010 concerning illegal immigrants and replacing it with director general of immigration regulation number imi-0352.gr.02.07 of 2016 concerning handling of illegal immigrants seeking asylum or refugees. the regulation acknowledges the existence of refugees and explains the duties and powers of international organizations in providing assistance, granting status, and fulfilling basic rights in accordance with human rights law. refugees are referred to as foreigners by the regulation, and their presence in indonesia guaranteed to fulfilled in collaboration with the international organization for migration (iom) and unhcr. the government of indonesia grants residence permits to refugees who have obtained status or are in the process of granting status by unhcr based on article 3. however, refugees are often still placed in detention centers even though they have received refugees. in addition to the regulation of the director general of immigration number imi-0352.gr.02.07 of 2016, the president of the republic of indonesia issued presidential regulation of the republic of indonesia number 125 of 2016 concerning the handling of refugees from abroad on december 31, 2016. this legal rule forms the basis for anyone responsible for providing protection and handling international refugees to assist iom and unhcr. however, there are still deficiencies in these regulations, and supporting regulations should be issued by each competent agency to provide protection and fulfillment of rights to refugees. indonesia’s legal commitments and challenges in fulfilling health rights for refugees health encompasses a favorable physical, spiritual, mental, and social state conducive to social and economic well-being.52-54 health constitutes the fundamental aspect of human rights and is paramount within this framework.55-57 the state is required to uphold health as a fundamental aspect of human rights.58-60 the state must adhere to the principles of international health law, specifically the principles of availability, accessibility, acceptability, and quality as outlined in general comment no. 14 of 2000 by the committee on economic, social and cultural rights regarding the right to the highest standard of health.61-64 indonesia is a nation that acknowledges human rights that must be provided, fulfilled, and safeguarded, especially the right to health.65-67 indonesia has established legislative standards to guide government agencies at both central and regional levels in delivering public health services, ensuring that all individuals get optimal health care and may enhance their health status to the highest feasible degree. indonesia has established national legislative laws pertaining to health, explicitly governed by law number 36 of 2009 of the republic of indonesia respecting health. the health law was enacted in response to indonesia’s pledge to provide health services to all those under its jurisdiction. refugees constitute a demographic that must be granted the right to health, since the who has identified them as a vulnerable population susceptible to illness, hence necessitating the fulfilment of their health rights. every nation that is temporarily or permanently visited must consider the presence of refugees. indonesia serves as a temporary shelter for refugees pending their relocation to designated nations. refugees in indonesia are required to adhere to all applicable laws. indonesia established legal provisions governing refugees through presidential regulation number 125 of 2016 regarding the management of foreign refugees; however, these regulations do not explicitly delineate the health rights afforded to refugees in indonesia. indonesia is a constitutional state that acknowledges the presence of every individual within its territory. indonesia, as a constitutional state, prioritises the provision of fundamental rights to its citizens by establishing a system of law that underscores the significance of fulfilling everyone’s rights. indonesia must prioritize the right to health, which serves as a benchmark for social and political factors affecting public health [page 122] [healthcare in low-resource settings 2024;12(s2):12603] non -co mmerc ial us e o nly overall well-being. universal health is essential to achieve, since a satisfactory physical condition is requisite for individuals to attain a successful existence, as articulated in paragraph 4 of the law’s preamble. indonesia’s provision of the right to health for all individuals within its jurisdiction is founded on the regulations and policies established by government authorities. the right to health is a basic entitlement that indonesia must provide to all individuals within its territory, for which the state may bearticle 28 i paragraph 4 of the 1945 constitution of the republic of indonesia stipulates that the state, particularly the government, is responsible for the protection, promotion, enforcement, and fulfilment of human rights. y the government.” passage 28, verse 4, uud nri 1945, n.d. the 1945 constitution of the republic of indonesia stipulates that all individuals within the state’s territory are entitled to health services provided by the government, with the objective of ensuring both physical and mental well-being, as well as access to a healthy living environment, underscoring the paramount importance of health in human existence that warrants state attention. article 28h, paragraph 1 of the 1945 constitution of the republic of indonesia asserts, “everyone has the right to live in physical and spiritual prosperity, to have a place to reside, to enjoy a good and healthy living environment, and to receive health services.” (article 28h, paragraph 1, of the 1945 constitution of the republic of indonesia, n.d.).  indonesia, as a sovereign nation, guarantees that all individuals within its territory receive optimal health services.68,69 the state’s obligation to provide health services and ensure adequate health facilities is delineated in article 34, paragraph 3, of the 1945 constitution of the republic of indonesia,70 which asserts, “the state is responsible for the provision of proper health and public service facilities.”  (article 34, paragraph 3, of the 1945 constitution of the republic of indonesia, n.d.). according to the 1945 constitution of the republic of indonesia, human rights must be protected without discrimination, as outlined in article 11 of law number 39 of 1999 concerning human rights, which asserts that “everyone has the right to fulfil their basic needs to grow and develop properly.” law on human rights of the republic of indonesia, 1999. the law of the republic of indonesia number 39 of 1999 regarding human rights asserts that children are entitled to health services, including health insurance and sufficient healthcare, as outlined in article 62. this article states, “every child has the right to obtain proper health and social security services, according to his physical and mental-spiritual needs” (law of the republic of indonesia concerning human rights, 1999). indonesia, being a subject of international law, has ratified global human rights agreements.71-73 international conventions ratified by indonesia serve as fundamental guidelines for the formulation and execution of regulations aligned with human rights and health concerns, ensuring that all individuals within its territory receive protection and equitable treatment. indonesia has ratified the international treaties pertaining to the right to health, which include the international convention on the elimination of all forms of racial discrimination. convention on the elimination of all forms of discrimination against women international covenant on economic, social, and cultural rights indonesia has ratified international conventions and acknowledges their binding nature as national legal regulations. in 2005, indonesia became a state party to the international covenant on economic, social and cultural rights, as shown by the promulgation of the international convention in law number 11 of 2005 of the republic of indonesia. this treaty serves as a directive for all ratifying nations, including indonesia, to ensure that all individuals in the area get comprehensive health services, including both physical and mental health care. the international covenant on economic, social, and cultural rights mandates indonesia to prevent and manage endemic and epidemic diseases, requiring the nation to ensure adequate preparedness for health services as outlined in article 12 of the covenant. indonesia ratified the international convention on the elimination of all forms of racial discrimination on may 25, 1999, as articulated in law no. 29 of the republic of indonesia. indonesia has ratified the international convention on the elimination of all forms of racial discrimination, demonstrating its commitment to safeguarding all individuals within its territory from discrimination based on skin color, religion, ethnicity, nationality, and related human rights issues. this treaty serves as a reference for indonesia, affirming that every individual within its territory is entitled to health services, including social assistance, medical treatment, and health insurance, as stipulated in article 5 of the international treaty on the elimination of all forms of racial discrimination. the convention on the elimination of all forms of discrimination against women was promulgated by indonesia in 1984 and approved under law number 7 of 1984 of the republic of indonesia. as a state party to this convention, indonesia is obligated to ensure the protection of every woman within its territory, particularly concerning the right to health. indonesia, in accordance with the international convention, shall prioritize and safeguard women’s health by ensuring accessible healthcare services, particularly during pregnancy, menstruation, and nursing. the convention on the elimination of all forms of discrimination against women mandates that states establish rules to ensure the protection of women, since the safety of the infant is contingent upon the well-being of the mother. as a signatory to the human rights convention, indonesia has a need to establish specific legislation that assures the granting, protection, and fulfillment of human rights, including the right to health. one method to uphold the right to health is via the establishment of health-related rules. the foundational legal rule in indonesia that establishes the right to health for all individuals is law number 36 of 2009 concerning health. this health legislation ensures legal stability for all individuals in indonesia, enabling them to uphold and enhance their health to the greatest standard, grounded on participative, sustainable, and non-discriminatory principles. the law of the republic of indonesia number 36 of 2009 about health establishes that every individual has the right to health, as articulated in article 4,74-76 which states, “everyone has the right to health” (law of the republic of indonesia concerning health, n.d.). the health law guarantees that all individuals have access to excellent, safe, and affordable healthcare services to enhance their health. national and municipal governments must assure efforts to enhance the highest standard of health as articulated in the international covenant on economic, social, and cultural rights. the initiatives undertaken via a promotive, preventative, curative, and rehabilitative strategy are balanced and mutually sustainable. this health legislation, established in indonesia, governs not only physical health but also mental health, emphasizing the need to ensure that individuals possess a mind unencumbered by stress, disturbances, or trau. the indonesian government must prioritize mental health, as there are psychological issues that receive insufficient attention, particularly the scarcity of mental health clinics, despite existing regulations and state guarantees.    state guarantees. alongside physical and mental health, environmental health significantly contributes to the enhancement of overall health status, particularly in residential areas, workplaces, places of worship, and other environments that are physically conducive and devoid of harmful chemicals or biological agents that may adversely affect human well-being. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12603] [page 123] non -co mmerc ial us e o nly indonesia’s legal framework and obligations in providing health services for refugees refugees are individuals residing in indonesia whose presence is acknowledged despite indonesia’s non-participation in the 1951 convention and the 1967 protocol.77-79 indonesia, as a transit nation for refugees, is obligated to provide their safety, particularly for health issues.80 health services are essential for refugees, since many arriving in indonesia endure lengthy maritime trips, necessitating medical care to recuperate their physical well-being.81,82 refugees arriving in indonesia often display both physical and mental health issues,83,84 thereby raising significant concerns that require attention to the circumstances within the country. although indonesia is not a signatory to the 1951 convention and the 1967 protocol, it nonetheless is obligated to provide the right to health for refugees, since it has admitted them. indonesia has enacted many rules concerning refugees inside its territory. the presidential regulation of the republic of indonesia number 125 of 2016 about the management of foreign refugees is a legislative framework that provides protection for refugees in indonesia. the presidential decree on refugees is a specific regulation governing the treatment of refugees, and it serves as a continuation of law number 37 of 1999 on foreign relations. presidential regulation number 125 of 2016 governs the provision of health care to international refugees in indonesia. article 26, paragraph 2 stipulates that “housing places for refugees, as referenced in paragraph (1), must fulfil the following criteria: a. proximity to health and religious service facilities” (article 26, paragraph 2 of presidential regulation of the republic of indonesia number 125 of 2016 concerning the handling of refugees from abroad, n.d.). the article asserts that refugee shelters should be in proximity to health facilities, ensuring that refugees have access to healthcare. “basic needs facilities as referred to in paragraph (4) shall at a minimum encompass: a. clean water supply; b. provisions for food, drink, and clothing; c. health and hygiene services; and d. worship facilities.” this is stated in article 26, paragraph 5 of presidential regulation number 125 of 2016 of the republic of indonesia regarding the management of foreign refugees. (article 26, paragraph 5 of presidential regulation number 125 of 2016 of the republic of indonesia regarding the management of foreign refugees, n.d.). the article elucidates that health services are fundamental provisions that the state is obligated to provide. the regional and city governments are tasked with delivering health services to refugees, as outlined in article 26, paragraph 6 of presidential regulation number 125 of 2016 of the republic of indonesia regarding the management of foreign refugees. the regulation of the president of the republic of indonesia number 125 of 2016 for the management of foreign refugees does not explicitly address the rights of refugees in indonesia. furthermore, the perpres remains a fundamental piece of legislation that necessitates supplementary regulations to be established by each state organisation especially designated to manage refugees. currently, no formal rules have established by institutions to grant rights to refugees, particularly in relation to local and municipal governments and the national government. conclusions indonesia has not ratified and is not a party to the 1951 convention and the 1967 protocol, so indonesia actually has no obligation to accept refugees who enter its territory. however, indonesia is willing to become a country that temporarily accommodates foreign refugees for humanitarian reasons. this is in accordance with the provisions of the 1951 convention which requires countries that are not state parties to adhere to the principle of non-refoulement, namely not forcibly repatriating all migrants who come seeking asylum to their country of origin. indonesia still has the responsibility to respect the principles of refugee law which have become customary international law. indonesia has regulated the issue of handling refugees and refugee health through: law of the republic of indonesia number 37 of 1999 concerning foreign relations; law of the republic of indonesia number 6 of 2011 concerning immigration; regulation of the president of the republic of indonesia number 125 of 2016 concerning handling of refugees from abroad; regulation of the director general of immigration number imi-1489.um.0805 of 2010 concerning illegal immigrants; regulation of the director general of immigration number imi-0352.gr.02.07 of 2016 concerning handling of illegal immigrants or refugees; ministry of health circular letter dated 10 june 2020 concerning provision of access to services related to covid-19 for registered refugees; circular letters of the minister of home affairs number 300/2307/sj and 300/2308/sj concerning the establishment of a task force for handling refugees from abroad. although indonesia is not a party to the 1951 convention and 1967 protocol but has endeavored to fully protect and provide the right to health through established regulations so as to realize the principles upheld by the 1951 convention and 1967 protocol. references 1. missbach a. troubled transit: asylum seekers stuck in indonesia. iseas-yusof ishak institute; 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2016. 30. cole m. education, equality and human rights: issues of gender,’race’, sexuality, disability and social class. taylor & francis; 2022. 31. blake m. immigration, jurisdiction, and exclusion. philos public aff 2013;41:103–30. 32. hollifield jf. the emerging migration state. int migr rev 2004;38:885–912. 33. san giorgi m. the human right to equal access to health care. 2012. 34. who. social justice and human rights as a framework for addressing social determinants of health final report of the task group on equity [internet]. equality and human rights. 2016 [cited 2022 mar 23]. available from: https://www.euro.who.int/__data/assets/pdf_file/0006/334356/ hr-task-report.pdf 35. heriyanto n, setiawan d. no choice but welcoming refugees: the non-refoulement principle as customary international law in indonesia. lentera huk 2023;10:135. 36. tan nf. the status of asylum seekers and refugees in indonesia. int j refug law 2016;28:365–83. 37. sumarlan y, kranrattanasuit n. restricted right to employment among refugees and asylum seekers in indonesia and its consequences. in: culture and international law. crc press; 2019. p. 21–42. 38. supriyadi s. international refugees in the protection of human rights: a discourse of international humanitarian law and human rights law. int law discourse southeast asia. 2022;1:43–64. 39. sadjad ms. what are refugees represented to be? a frame analysis of the presidential regulation no. 125 of 2016 concerning the treatment of refugees “from abroad.” asian j law soc 2021;8:451–66. 40. kneebone s, missbach a, jones b. the false promise of presidential regulation no. 125 of 2016? asian j law soc 2021;8:431–50. 41. lister* m. who are refugees? law philos 2013;32:645–71. 42. ward p. refugee cities: reflections on the development and impact of unhcr urban refugee policy in the middle east. refug surv q 2014;33:77–93. 43. mowafi h. conflict, displacement and health in the middle east. glob public health 2011;6:472–87. 44. tsourapas g. the syrian refugee crisis and foreign policy decision-making in jordan, lebanon, and turkey. j glob secur stud 2019;4:464–81. 45. micinski nr. refugee policy as foreign policy: iraqi and afghan refugee resettlements to the united states. refug surv q 2018;37:253–78. 46. hugo g, tan g, napitupulu cj. indonesia as a transit country in irregular migration to australia. a long w to go irregul migr patterns, process drivers decis 2017;167–91. 47. afriansyah a. why indonesia should respect the rights of asylum seekers and refugees. in: culture and international law. crc press; 2019. p. 463–76. 48. goodwin-gill g. migration: international law and human rights. in: managing migration: time for a new international regime. oxford university press: oxford; 2000. 49. harisman h. protection of human rights in the amendment of the 1945 constitution of the republic of indonesia. in: 1st international conference on law and human rights 2020 (iclhr 2020). atlantis press; 2021. p. 384–9. 50. parekh s. refugees and the ethics of forced displacement. taylor & francis; 2016. 51. feller e. asylum, migration and refugee protection: realities, myths and the promise of things to come. int j refug law 2006;18:509–36. 52. eckersley r. culture, health and well-being. soc orig heal well-being 2001;51–70. 53. chuengsatiansup k. spirituality and health: an initial proposal to incorporate spiritual health in health impact assessment. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12603] [page 125] non -co mmerc ial us e o nly environ impact assess rev 2003;23:3–15. 54. herrman h, jané-llopis e. the status of mental health promotion. public health rev 2012;34:1–21. 55. donnelly j. universal human rights in theory and practice. cornell university press; 2013. 56. freeman m. human rights. john wiley & sons; 2022. 57. chapman ar. global health, human rights, and the challenge of neoliberal policies. cambridge university press; 2016. 58. hendriks. the right to health in national and international jurisprudence. eur j health law 1998;5:389–408. 59. yamin ae. power, suffering, and the struggle for dignity: human rights frameworks for health and why they matter. university of pennsylvania press; 2015. 60. griffin j. on human rights. oup oxford; 2008. 61. tobin j. the right to health in international law. oxford university press, usa; 2012. 62. taylor al. making the world health organization work: a legal framework for universal access to the conditions for health. am j law med 1992;18:301–46. 63. organization wh. international migration, health and human rights. world health organization; 2003. 64. ssenyonjo m. economic, social and cultural rights in international law. bloomsbury publishing; 2009. 65. hadiprayitno i. defensive enforcement: human rights in indonesia. hum rights rev 2009;11. 66. tjitrawati at, romadhona mk. affliction in the post palu disaster: state failure to implement human rights standard on disaster management. cogent soc sci 2023;9(1). 67. tjitrawati at, tavip m, romadhona mk. integrative socialhealth security for indonesian migrant workers: does fully covered and protected? malaysian j med heal sci 2023. 68. dimyati k, nashir h, elviandri e, et al. indonesia as a legal welfare state: a prophetic-transcendental basis. heliyon 2021;7:e07865. 69. brown i, editor. the territories of indonesia. routledge; 2004. 70. pisani e, olivier kok m, nugroho k. indonesia’s road to universal health coverage: a political journey. health policy plan 2016;czw120. 71. ford m. international networks and human rights in indonesia. in: human rights in asia. edward elgar publishing; 2011. 72. davies m. states of compliance?: global human rights treaties and asean member states. j hum rights 2014;13:414–33. 73. juwana h. internasional law as a political instrument (a case study of indonesia). al-risalah forum kaji huk dan sos kemasyarakatan 2018;13:1–26. 74. agustina r, dartanto t, sitompul r, et al. universal health coverage in indonesia: concept, progress, and challenges. lancet 2019;393:75–102. 75. aspinall e. health care and democratization in indonesia. democratization 2014;21:803–23. 76. mboi n. indonesia: on the way to universal health care. heal syst reform 2015;1:91–7. 77. ramadani ry, tjitrawati at, romadhona mk, narwati e, kinasih se. the rights to health for all: is indonesia fully committed to protected refugees and asylum seekers? j hub luar negeri 2023;8:55–80. 78. puspitawati d, susanto fa. protection of people at sea under international law: lesson learnt from pushback action to boat people in indonesia and malaysia. brawijaya law j. 2023;10(2). 79. angioi s. 40 years of forced migrations and refugees flows in south-east asia: a regional model or a legal limbo? in: international migration and the law. routledge; 2024. p. 371– 89. 80. sampson rc, gifford sm, taylor s. the myth of transit: the making of a life by asylum seekers and refugees in indonesia. j ethn migr stud 2016;42:1135–52. 81. region whos-ea. health of refugees and migrants. pract addressing heal needs refug migrants 2018. 82. warf c, eisenstein e, almakadma ak, et al. challenges faced by international migrants and refugees to the health, development, and well-being of adolescents and youth. in: clinical care for homeless, runaway and refugee youth. cham: springer international publishing; 2020. p. 349–403. 83. ali m, briskman l, fiske l. asylum seekers and refugees in indonesia: problems and potentials. cosmop civ soc an interdiscip j 2016;8:22–43. 84. lu y. mental health and risk behaviours of rural–urban migrants: longitudinal evidence from indonesia. popul stud (ny) 2010;64:147–63. social and political factors affecting public health [page 126] [healthcare in low-resource settings 2024;12(s2):12603] online supplementary materials table 1. noteworthy facts and statistics by region/country 2021-2023. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12091 characteristics of mothers at risk for perinatal depression in industrial areas muhammad anas, muhammad dzikri abdillah, era catur prasetya, uning marlina faculty of medicine, universitas muhammadiyah surabaya, surabaya, indonesia abstract expectant mothers susceptible to emotional shifts during pregnancy, such as depression, underwent a perinatal phase. within the first year after giving birth, 10-15% of women experienced specific depressive symptoms. this situation could harm the motherchild relationship. the purpose of this study was to characterize the traits of mothers who might have experienced prenatal depression at muhammadiyah gresik hospital. purposive sampling and spearman’s rank test analytics were applied to pregnant women between 20 weeks gestation and one month postpartum. pregnant women with a history of acute medical problems and mental or psychological disorders were excluded. out of 47 respondents, 59.6% were at risk of perinatal depression. the characteristics studied included religion, ethnicity, maternal age, educational level, employment status, family income, number of children, mode of delivery, complications during delivery, and depression history. maternal age (r=-0.314, p=0.032*), employment status (r=0.346, p=0.016*), parity (r=-0.410, p=0.004*), and most recent delivery (r=-0.329, p=0.024*) showed significant correlations with the likelihood of perinatal depression. maternal age, parity, and mode of delivery had negative correlations, while employment status had a positive correlation. the results of this study can be used as screening tools to identify mothers at risk of perinatal depression. additionally, it proposes a prenatal and delivery counseling intervention program for both expectant mothers and unemployed women. introduction depression is a major psychiatric illness that affects many women, with uncertainty remaining over causative factors or etiology.1 maternal psychological health, which refers to a woman’s mental and emotional well-being during pregnancy, is crucial.2 anxiety that cannot be overcome may result in stress and depression.3 distress is defined as a pathologic stress condition related to daily life.4 perinatal depression occurs frequently, even though the mother and her family may not fully realize it. the perinatal period is a transition for expectant mothers at risk of emotional changes such as depression during pregnancy.5,6 this phenomenon is experienced by one in seven expectant mothers and is associated with maternal and neonatal morbidity, which can have a significant impact if no intensive action is taken. 7-9 antenatal services in indonesia reveal that mental disorders in mothers require initial examination, including by posyandu (integrated health post) cadres or community health workers.10,11 stress and anxiety affect each individual differently. in reality, anxiety is not directly caused by a stressor but rather by the failure to adapt to a stressor.12 stress and depression symptoms are measured at baseline and one week before the due date of childbirth.13 the prevalence of major and minor depression in the united states is 8.5-11% during pregnancy and 6.5-12.9% in the first year after birth.14,15 in the étude du développement des nouveau-nés (eden) study in france, depressive symptoms were observed in 22.5% during pregnancy and 13.6% postnatally.16 in research on mental health, munk-olsen et al., based on data obtained from the 2018 riskesdas of the indonesian ministry of health, found that depression often occurs in women of reproductive age.17,18 data correspondence: muhammad anas, faculty of medicine universitas muhammadiyah surabaya, surabaya, indonesia. e-mail: muhanasjamil1@yahoo.co.id key words: characteristics, industrial areas, mothers, perinatal depression, risks. contributions: ma, mda, ecp, and um conducted and designed this study; mda, ecp, and um collected samples; ma, mda, ecp, and um analyzed the data and wrote the manuscripts. all authors read and approved the final manuscript. conflict of interest: the authors declare no conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission at the universitas muhammadiyah surabaya. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we express our heartfelt gratitude to the muhammadiyah gresik hospital for graciously offering to be the focal point of our research endeavors. additionally, our sincere appreciation extends to our mentors, whose patient guidance has played a pivotal role in shaping the structure and effectiveness of this research. their unwavering support has significantly contributed to the refinement and improvement of our work, and for this, we are truly thankful. received: 15 november 2023. accepted: 18 march 2024. early access: 22 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12091 doi:10.4081/hls.2024.12091 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12091] [page 529] non -co mmerc ial us e o nly obtained by nasri, wibowo, and ghozali found that the incidence of postpartum depression in indonesia was lower than in other countries. in dki jakarta, yogyakarta, and surabaya, the incidence was found to be 11-30%.19 research conducted by o’hara and swain found that women who gave birth to their first child experienced puerperal depression at around 13%, occurring in the first year of the puerperium.20 other research shows that postpartum depression occurs in around 10-15% of women and is a health problem for women worldwide.21 in the postpartum period, 85% of women experience psychological disorders, with 10-15% experiencing significant symptoms.22 specific depressive disorders occur in 10-15% of women in the first year after giving birth.14 figueiredo, pacheco, and costa described a 25% risk of developing perinatal depression in adolescence.23 young mothers are more prone to experiencing depression during pregnancy, but a study conducted by eshbaugh did not find the risk of perinatal depression in adolescents who were not at severe risk.24 in indonesia, the incidence of postpartum depression is 11-30%.25 this phenomenon is more severe than the baby blues and affects 1 in 10 new mothers. a person who has experienced depression has a 30% risk of postpartum depression.26 based on research by bauman et al. in 2018, the prevalence of postpartum depression was reported to be an average of 13.2%, with higher rates among american indians/native alaskans (22.0%), asian/pacific islanders (19.2%), and black women.27 this phenomenon will impact the social relationship between the mother and the baby, leading to disruptions and an increase in the incidence of abnormalities in behavior patterns and disturbances in the child’s mindset, which can even impact child labor. mothers with depression are more prone to giving birth to premature babies and are at risk of having low and small final weights. this study aimed to describe the characteristics of mothers at risk of perinatal depression. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents' characteristics. no characteristics f % 1 religion islam 47 100 non-islam 0 0 2 ethnicity javanese 40 85.1 sundanese 2 4.3 batak 0 0 madurese 3 6.4 banjar 0 0 bali 0 0 betawi 1 2.1 minangkabau 1 2.1 bugis 0 0 melayu 0 0 3 age (years old) <20 0 0 20-35 40 85.1 >35 7 14.9 4 education basic education (elementary to senior high school) 31 66 further education (diploma/bachelor/ master/doctorate) 16 34 5 job-status unemployed 26 55.3 employed 21 44.7 6 family income below regional minimum wage (rmw) 16 34 equivalent to rmw 25 53.2 above rmw 6 12.8 7 parity (x times) 0 23 48.9 1 17 36.2 2-5 7 14.9 >5 0 0 8 last delivery never 23 48.9 normal 16 34 cesarean section 8 17 9 complication history no 45 95.7 yes (prolonged labor, postpartum bleeding) 2 4.3 10 depression history noting 47 100 yes 0 0 11 family depression history noting 47 100 yes 0 0 12 perinatal depression risk not depressed 19 40.4 possible depression 18 38.3 the probability of depression is relatively high 8 17 depression is very likely 2 4.3 [page 530] [healthcare in low-resource settings 2024;12:12091] non -co mmerc ial us e o nly materials and methods research design the method in this study used a descriptive-analytic approach to describe the characteristics of mothers with perinatal depression. study participants this research was conducted in september 2022 at the obstetric outpatient polyclinic at muhammadiyah gresik hospital for 47 respondents. the sampling criteria for respondents in this study were pregnant women with a gestational age of 20 weeks to 1 month after giving birth and mothers willing to be respondents. exclusion criteria in this study were pregnant women who experienced mental or psychological disorders and pregnant women with a history of acute medical disorders. variable, instrument, and data collection data was collected by distributing questionnaires that adjusted the research criteria to include profiles of mothers and edinburgh perinatal depression (epds). a non-depressed score of <8 describes the results of the epds questionnaire assessment: mild depression with a score of 9-11, moderate depression with a score of 12-13, and severe depression with a score of >14. this instrument has a validity and reliability value of 80.1% and 91-94%, respectively.19 data analysis this data analysis for this study was carried out univariately to describe the characteristics of the respondents, and a bivariate spearman rank test was continued to determine the relationship between maternal profile and perinatal depression. ethical clearance this research has passed the health research ethics committee at the universitas muhammadiyah surabaya conducted the research ethics with the number 029/ket/ii.3/au/f/2022. results samples from accessible populations at risk of perinatal depression have the characteristics shown in table 1. the study surveyed muslim individuals, mainly javanese, and found that 66% had basic education, 34% continued it, and 55.33% did not work. most families had an income below the regional minimum wage (rmw), with 53.11% falling into this category. the study found that 48.9% of participants were experiencing their first pregnancies, and 36.2% had given birth once before. the characteristics of the last birth were described by 23 people, with 16 normal births and eight cesarean sections. most respondents had no history of complications or depression. table 2 shows that spearman’s rank test analysis reveals no statistically significant relationship between education level, family income, and history of complications with prenatal depression risk. however, the analysis reveals a significant correlation between maternal age, employment status, parity, and the latest delivery, with all variables having a significance level of p<0.05. the study found a moderate relationship between maternal age, parity, and delivery, with negative correlation coefficient values, suggesting that an increase in these variables reduces the risk of perinatal depression. the positive correlation coefficient value indicates that an increase in the employment status variable is associated with an increased risk of perinatal depression. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. spearman rank test analysis of the relationship between participant characteristics and perinatal depression. participant characteristics perinatal depression risk correlation coefficient (r) p <8 9-11 12-13 ≥14 age (years old) <20 0 0 0 0 -0.314 0.032* 20-35 13 18 7 2 ≥35 6 0 1 0 education basic education 10 13 6 2 -0.243 0.100 further education 9 5 2 0 job-status unemployment 15 7 3 1 0.346 0.016* employment 4 11 5 1 family income below rmw 3 8 4 1 -0.210 0.157 equivalent rmw 14 8 2 1 above rmw 2 2 2 0 parity (x times) 0 4 12 6 1 -0.410 0.004* 1 11 3 2 1 2-5 4 3 0 0 >5 0 0 0 0 complication history no 19 17 7 2 0.183 0.218 yes (prolonged labor, postpartum bleeding) 0 1 1 0 last delivery never 6 11 5 1 -0.329 0.024* normal 6 7 2 1 cesarean section 7 0 1 0 perinatal depression risk ≤8 not depressed 9-11 possible depression 12-13 the probability of depression is relatively high *significant (p<0,05) ≥14 depression is very likely rmw, regional minimum wage. [healthcare in low-resource settings 2024;12:12091] [page 531] non -co mmerc ial us e o nly discussion research at rs muhammadiyah gresik revealed that the education level of pregnant women, with basic education at 66% and further education at 34%, did not seem to be associated with a significant risk of prenatal depression. the study aligns with the results of eshbaugh (2006)., which revealed that mothers with primary education were more likely to experience perinatal depression, while those continuing their education might experience less, but no correlation was found.28 the high-quality environment and readiness of the mother during pregnancy can contribute to this condition. these results differ from previous studies by researchers such as fatmawati and mukoirotin, which found that low education is associated with perinatal symptoms of depression.21 the study by keliyo et al. revealed that individuals with low educational backgrounds are at a higher risk of depression.29,30 juwitasari and marni, on the other hand, found that higher education reduces stress during pregnancy, but the risk of perinatal depression decreases with higher knowledge.31 this condition can be attributed to mothers who have extensive knowledge about handling pregnancy-related issues and necessary preparations. education and insight can improve maternal readiness for risk events during pregnancy, reducing the likelihood of depressive events due to inadequate education and insight.31,32 higher knowledge and education make it a protective trait for mothers.33 a study at muhammadiyah gresik hospital revealed that family income was 34% below rmw, 55.3% at rmw, and 12.8% above rmw. it does not appear to be associated with a significant risk of prenatal depression, showing a negative correlation. a study at muhammadiyah gresik hospital revealed that family income was 34% below rmw, 55.3% at rmw, and 12.8% above rmw. it does not appear to be associated with a significant risk of prenatal depression, showing a negative correlation. research by denckla et al. (2018) suggests that middle to lower socioeconomic status is a risk factor for perinatal to postpartum depression.34 low economic status is associated with and influences the orevalence of postpartum blues.29,35 additionally, fatmawati and mukhoirotin’s study at the peterongan primary health care revealed that economic factors have a significant impact on perinatal depression.35 low economic status can lead to increased social pressure and stress, causing a mental burden for individuals, including mothers undergoing pregnancy. dagher et al.’s study suggests that low family incomes and significant changes in pregnancy conditions can lead to life stresses and depression.36 marriage and pregnancy often increase individual needs, leading to increased burdens and depression. low-income families experience stress and hormonal changes during pregnancy, leading to depression during and after childbirth.14,26. interestingly, khanam r. et al. (2022) obtained different results, revealing that perinatal depression is more prevalent in families with high incomes, especially in mothers who give birth to low birth weight babies.22 the study at muhammadiyah gresik hospital reveals that a history of complications does not appear to be related to the risk of prenatal depression. perinatal depression is prevalent in all pregnant women without complications, while less common in those with complications, indicating no link between birth complications and depression risk.37 during pregnancy, the mother’s condition can be positively influenced by receiving sufficient social support from her partner, sibling, or friends. postpartum complications can lead to increased anxiety,38 depression, and self-destruction in mothers, exacerbated by extreme fatigue and pain during childbirth and postpartum care.26 research at rs muhammadiyah gresik revealed a correlation between maternal age and the risk of perinatal depression in pregnant women, with high levels in mothers aged 20-35 years and low levels in mothers over 35 years. this study aligns with the indonesian ministry of health’s riskesdas data, which reveals that depression mainly occurs in women of childbearing age.18 the studies of denckla et al. and nicolet et al. (2018) found a high prevalence of perinatal depression in young mothers. research by lie et al. (2018) shows that most individuals in the productive age group experience depression during pregnancy due to the transition from adolescence to adulthood.34,39 this condition triggers depression in mothers because of changes in the transition from adolescence to adulthood and a lack of experience in preparing for pregnancy.39 this condition can be caused by young pregnant women who do not have the health knowledge needed during pregnancy. pregnancy provokes a crisis of maturation, weakening mental defenses, transforming self-image, and potential conflicts with femininity. age can trigger depression, especially in younger mothers. parenting early can disrupt emotional stability and the transition from adolescence to adulthood.39,40 depression is a psychological disorder characterized by symptoms such as low mood, anhedonia, weight loss, decreased interest, rumination, insomnia, and thoughts of self-harm.14 according to studies by bjelica et al., perinatal depression symptoms can be observed in individuals over 30 years of age, albeit with a low incidence rate.39 as a mother ages, she experiences mental and emotional maturation, increasing her understanding of parenthood and forming more efficient patterns of maternal behavior.25,34 perinatal depression can occur in young pregnant women due to their lack of readiness for hormonal changes during pregnancy, unlike mwita et al.’s finding that it can occur at any age.33 older individuals are at a lower risk of depression as they age, fostering emotional and psychological maturity, allowing parents to form good maternal behavior patterns.25,34 research at rs muhammadiyah gresik revealed a significant correlation between the employment status of working and non-working mothers (44.7%, 55.3%) and the risk of prenatal depression. this research is in line with findings conducted by mwita et al. (2021) who found that maternal employment status can influence the incidence of perinatal depression, with the risk being higher for working mothers than for housewives.33 studies by kusuma (2017) show a correlation between a mother’s job and the incidence of postpartum depression, suggesting that physical preparation for work and child care is crucial.41 mothers’ readiness for postpartum care, worries, and physical fatigue can trigger depression, affecting their ability to care for themselves and their babies postpartum. pregnancy and childbirth often trigger psychological preparation for motherhood, leading to symptoms of depression, fatigue, and pressure to meet the baby’s needs, causing stress and an increased individual burden on the mother.14,20 the study revealed that a mother’s employment status significantly impacts her likelihood of experiencing depression during pregnancy, influenced by her physical readiness and postpartum preparedness.42 keliyo and wodajo’s (2021) research reveals that mothers with less childbirth experience have a higher risk compared to those with more experience.29 khanam et al. (2022) suggest that pregnancy-induced depression is more common in mothers who have not received psychological preparation.22 birth trauma and complex events during childbirth can cause stress and depression, impacting the mother’s subsequent pregnancy.34 hormonal changes during pregnancy can cause mood swings in the mother, while lack of experience and readiness can trigger perinatal transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 532] [healthcare in low-resource settings 2024;12:12091] non -co mmerc ial us e o nly depression in primigravida women.35,39 memories during birth can lead to depressive disorders, affected by childbirth and stress. these physiological reactions affect the nervous, endocrine, and immunological systems, leading to adverse postnatal outcomes.43,44 research at rs muhammadiyah gresik revealed a significant negative correlation between prenatal childbirth, normal childbirth, and cesarean section (48.9%, 34.0%, 17.0%) and the risk of prenatal depression. similar findings with keliyo and wodajo (2021) revealed that primigravida mothers who had never given birth had an eightfold risk of developing depression during pregnancy.29 primigravida mothers lack experience, leading to a negative maternal attitude during pregnancy. cesarean delivery increases the risk of postpartum depression 3.7 times compared to spontaneous delivery.42 a study by ismail (2003) found that perinatal depression can be caused by physical trauma during childbirth, especially cesarean delivery, which takes longer to heal.19 in contrast, ariyanti (2015) found that mothers who gave spontaneous birth were at a higher risk of postpartum depression.42 childbirth trauma can cause depression in mothers, affecting mood, stress, and anxiety during labor and postnatal healing.43 berry et al. (2021) suggest that the likelihood of perinatal depression is high in primigravida pregnant women, while it is lower in those who have spontaneous births.45 in this study, none of the respondents had a history of depression or family depression, so analysis of the chi-square relationship could not be done. dagher et al.’s (2021) opinions coherently illustrate that perinatal depression can occur and is associated with depression, anxiety, lack of family support, and marital status.36 previous research shows that pregnant women who have a history of psychological disorders have a higher chance of experiencing perinatal depression.29 during the perinatal period, the mother’s body undergoes emotional, psychological, and cognitive changes characterized by mood swings and decreased verbal function in the mother.26 lack of support for the mother during pregnancy, coupled with the presence of psychological disorders, can lead to perinatal depression and potentially affect the developing fetus.39 the study’s limitations include its focus on people residing in industrial districts, which means it may not accurately represent the entire city’s population. therefore, additional research is required to supplement the findings of previous studies, and it is important to choose locations with distinct population characteristics to determine whether the outcomes of the present study will remain the same or differ. in this study, the incidence of prenatal depression risk was found to be linked with maternal age, work status, parity, and the latest delivery. conclusions the study found no significant correlation between the risk of prenatal depression and factors such as family income, education, or past difficulties. however, an increased risk was strongly associated with maternal age, unemployment, number of previous births, and the nature of the prior birth (e.g., c-section). particularly vulnerable to prenatal depression risk are first-time mothers and those pregnant at a very young or advanced maternal age. the study suggests using its findings to screen for the risk of prenatal depression and to create counseling programs for pregnant women and support systems for expectant mothers who are unemployed to potentially reduce postpartum depression risk. references 1. edwards gd, shinfuku n, gittelman m, et al. postnatal depression in surabaya, indonesia. int j ment health 2006;35:62-74. 2. kaur s, kok ey, jamil na, sebayang sk. exploring the relationship between sunlight exposure, psychological health, and gestational weight gain: a prospective observational study. bmc public health 2024;24:122. 3. pratiwi in, pradanie r, setyawati n, ramoo v. factors associated with behavior of reducing anxiety in pregnant women during covid-19 pandemic. j public heal emerg 2023;7:18. 4. khalida sn, dachlan eg, soegiarto g. maternal distress during pregnancy related to preeclampsia. bali med j 2023;12:2451-5. 5. garthus-niegel s, staudt a, kinser p, et al. predictors and changes in paternal perinatal depression profiles—insights from the dream study. front psychiatry 2020;11. 6. lenze sn, potts ma, rodgers j, luby j. lessons learned from a pilot randomized controlled trial of dyadic interpersonal psychotherapy for perinatal depression in a low-income population. j affect disord 2020;271:286-92. 7. rinne gr, davis ep, mahrer ne, et al. maternal depressive symptom trajectories from preconception through postpartum: associations with offspring developmental outcomes in early childhood. j affect disord 2022;309:105-14. 8. hughes ct, devine r, foley sd, et al. couples becoming parents: trajectories for psychological distress and buffering effects of social support. j affect disord 2020;265:372-80. 9. hughes c, foley s, devine rt, et al. worrying in the wings? negative emotional birth memories in mothers and fathers show similar associations with perinatal mood disturbance and delivery mode. arch womens ment health 2020;23:371-7. 10. surjaningrum er, leonardi t, andriani f, et al. delphi study to develop maternal depression training materials for cadres. int j public heal sci 2023;12:598-605. 11. aji rs, efendi f, kurnia id, et al. determinants of maternal healthcare service utilisation among indonesian mothers: a population-based study. f1000research 2022;10:1124. 12. ong sl, abdullah kl, danaee m, et al. stress and anxiety among mothers of premature infants in a malaysian neonatal intensive care unit. j reprod infant psychol 2018:37:193-205. 13. wahyuni s, anies, soejoenoes a, putra st, syukur ma. spiritual dhikr reduces stress and depression symptom on primigravidas. pakistan j med heal sci 2018;12:1368-71. 14. dagher rk, hofferth sl, lee y. maternal depression, pregnancy intention, and return to paid work after childbirth. women’s heal issues 2014;24:e297-303. 15. suroto h, putra ra, karimah a. relationship between disability and pain to post-traumatic stress disorder, depression, and anxiety in patient with postoperative brachial plexus injury (bpi). br j neurosurg 2021;35:254-8. 16. wilcox m, mcgee ba, ionescu df, et al. perinatal depressive symptoms often start in the prenatal rather than postpartum period: results from a longitudinal study. arch womens ment health 2021;24:119-31. 17. munk-olsen t, laursen tm, pedersen cb, et al. new parents and mental disorders. jama 2006;296:2582. 18. ministry of health, republic of indonesia. basic health research national report, 2018. 2018. available from: https://ghdx.healthdata.org/record/indonesia-basic-healthresearch-2018 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12091] [page 533] non -co mmerc ial us e o nly 19. ismail ri. stress before and during pregnancy increased risk antepartum depression. med j indones 2003;12:81-6. 20. clayborne zm, colman i, kingsbury m, et al. prenatal work stress is associated with prenatal and postnatal depression and anxiety: findings from the norwegian mother, father and child cohort study (moba). j affect disord 2022;298:548-54. 21. nicolet l, moayedoddin a, miafo jd, et al. teenage mothers in yaoundé, cameroon—risk factors and prevalence of perinatal depression symptoms. j clin med 2021;10:4164. 22. khanam r, applegate j, nisar i, et al. burden and risk factors for antenatal depression and its effect on preterm birth in south asia: a population-based cohort study. plos one 2022;17:e0263091. 23. figueiredo b, pacheco a, costa r. depression during pregnancy and the postpartum period in adolescent and adult portuguese mothers. arch womens ment health 2007;10:1039. 24. eshbaugh em. predictors of depressive symptomatology among low-income adolescent mothers. arch womens ment health 2006;9:339-42. 25. ariguna dira i, wahyuni a. prevalence and risk factors of postpartum depression in denpasar city using the edinburgh postnatal depression scale. e-jurnal med udayana 2016;5:5-9. 26. buckwalter jg, buckwalter dk, bluestein bw, stanczyk fz. pregnancy and post partum: changes in cognition and mood. prog brain res 2001;133:303-19. 27. bauman bl, ko jy, cox s, et al. morbidity and mortality weekly report vital signs: postpartum depressive symptoms and provider discussions about perinatal depression-united states, 2018. morb mortal wkly rep 2018;69:575-81. 28. li h, bowen a, bowen r, et al. mood instability, depression, and anxiety in pregnancy and adverse neonatal outcomes. bmc pregnancy childbirth 2021;21:583. 29. keliyo et, jibril mk, wodajo gt. prevalence of antenatal depression and associated factors among pregnant women attending antenatal care at health institutions of faafan zone, somali region, eastern ethiopia. depress res treat 2021;2021:2523789. 30. wicaksono yi, febriyana n. collaborative care in primary health care focus on management of depression. j heal sci med res 2022;40:705-15. 31. juwitasari j, marni m. the relationship between knowledge of high risk pregnancy and depression in pregnant women. j borneo holist heal 2020;3:159-68. 32. solikhah fk, nursalam n, subekti i, et al. determination of factors affecting post-partum depression in primary healthcare during the covid-19 pandemic. j public health africa 2022;13:2408. 33. mwita m, kasongi d, bernard e, et al. the magnitude and determinants of antepartum depression among women attending antenatal clinic at a tertiary hospital, in mwanza tanzania: a cross-sectional study. pan afr med j 2021;38:258. 34. denckla ca, mancini ad, consedine ns, et al. distinguishing postpartum and antepartum depressive trajectories in a large population-based cohort: the impact of exposure to adversity and offspring gender. psychol med 2018;48:1139-47. 35. fatmawati da, mukhoirotin. relationship between primigravidal age with antepartum depression. j edunursing 2017;1:109-18. 36. dagher rk, bruckheim he, colpe lj, et al. perinatal depression: challenges and opportunities. j women’s heal 2021;30:154-9. 37. li x, gao r, dai x, et al. the association between symptoms of depression during pregnancy and low birth weight: a prospective study. bmc pregnancy childbirth 2020;20:147. 38. budiman mea, sari snj, kusumawardani w, sutopo d. strategy intervention to prevent and reduce postpartum depression: a systematic review. j ners 2019;14:292-7. 39. bjelica a, cetkovic n, trninic-pjevic a, mladenovic-segedi l. the phenomenon of pregnancy a psychological view. ginekol pol 2018;89:102-6. 40. purwono pb, juniastuti, amin m, et al. hepatitis b virus infection in indonesia 15 years after adoption of a universal infant vaccination program: possible impacts of low birth dose coverage and a vaccine-escape mutant. am j trop med hyg 2016;95:674-9. 41. kusuma pd. characteristics of postpartum depression in primipara and multipara. j keperawatan notokusumo 2017;5:3644. 42. ariyanti r, nurdiati ds, astuti da. the effect of delivery type toward the postpartum depression risk postpartum. 2015;99106. 43. blackmore er, côté-arsenault d, tang w, et al. previous prenatal loss as a predictor of perinatal depression and anxiety. br j psychiatry 2011;198:373-8. 44. leigh b, milgrom j. risk factors for antenatal depression, postnatal depression and parenting stress. bmc psychiatry 2008;8:1-11. 45. berry oo, babineau v, lee s, et al. perinatal depression prevention through the mother-infant dyad: the role of maternal childhood maltreatment. j affect disord 2021;290:188-96. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 534] [healthcare in low-resource settings 2024;12:12091] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12052 clinical achievement improvement through experiential learning-based training fitri chandra kuspita,1 tintin sukartini,1 ahsan ahsan,2 nursalam nursalam,1 apriyani puji hastuti3 1faculty of nursing, universitas airlangga, surabaya; 2faculty of health science, universitas brawijaya, malang; 3department of nursing, faculty of health science, institut teknologi sains dan kesehatan rs dr soepraoen, malang, indonesia abstract this study aimed to enhance clinical educators’ competence through experiential learning-based preceptorship training. many clinical educators struggle with implementing effective clinical education, providing guidance, and having limited time for new nurses. the research employed a quasi-experimental design with a pre-posttest control group involving 60 clinical educators. the intervention group received a five-day training module using experiential learning-based preceptorship, while the control group received standard intervention. data analysis used the wilcoxon signed rank test to analyse differences before and after intervention, and used mann-whitney to analyse differences between the two groups. analysis revealed significant improvements in critical thinking, patient safety, leadership, communication, researchbased practice, and professional development among the intervention group compared to the control group (p=0.000). the findings highlight the effectiveness of this training model in enhancing clinical educators’ learning outcomes. the study suggests that incorporating experiential learning into clinical education can be a valuable strategy for improving the competence of clinical educators and subsequently achieving better clinical achievements. introduction learning outcomes for clinical educators are designed to ensure the competence of new nurses can be attained. however, many clinical educators still lack an understanding of how to effectively implement clinical education practices.1 additional identified problems include clinical educators struggling with providing guidance, having limited time to meet new nurses, and a lack of evaluation to measure the performance of new nurses. 2 the concept of learning theory highlights components that need further exploration, including the characteristics of new nurses, clinical educators, and learning media facilities. this is in addition to assessing the learning achievements of clinical educators themselves.3–5 factors contributing to enhanced competence among clinical educators involve improvements in their quality as role models.6–8 the qualities of clinical educators as role models encompass being caring, engaging in positive interactions, showing empathy, earning respect from colleagues, possessing reliable communication skills, and fulfilling a strong advocacy function. meanwhile, the qualities of a clinical educator as a role model include being an expert practitioner, an enthusiastic resource person, a knowledge sharer, a respecter of human dignity, a critical thinker, and an honest and accountable individual.9,10 enhanced learning outcomes for clinical educators, in terms of quality, will improve critical thinking, patient safety, leadership, communication, research-based practice, and professional development.2,3 the experimental learning theory (elt) is a combination of understanding and transforming experiences that can assist clinical educators in guiding new nurses to enhance their clinical competence in attitudes, knowledge, and skills. to operationalise an appropriate learning system for forming competent clinical educators, the experiential learning system is proposed.11–15 the stages in experiential learning consist of concrete experience (ce), reflective observation (ro), abstract conceptualization (ac), and active experimentation (ae). these four phases of experiential learning cannot be applied with just one method; there needs to be a combination of learning theory and andragogy correspondence: tintin sukartini, faculty of nursing, universitas airlangga, surabaya, east java, indonesia. e-mail: tintin-s@fkp.unair.ac.id key words: clinical education, experiential-learning, learning outcome, nursing, preceptorship. contributions: fc, conceptualization, data curation, formal analysis, methodology, validation, visualisation, writing – original draft, review and editing; ts, aa, nn conceptualization, investigation, methodology, validation, conceptualization, formal analysis, validation, and analysis; ap, writing – original draft, review & editing. funding: none. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research was approved by ethical permission from the health research ethics commission (kepk) faculty of nursing, universitas airlangga number 2540kepk dated june 20 2022. patient consent for publication: written informed consent was obtained for anonymised patient information to be published in this article. availability of data and materials: all data generated or analysed during this study are included in this published article. received: 5 november 2023. accepted: 19 december 2023. early access: 26 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12052 doi:10.4081/hls.2024.12052 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12052] [page 207] non -co mmerc ial us e o nly theory. the combined focus of these two theories is on adult learning, particularly in the context of new nurses (nursing center learning). andragogy learning theory includes self-concept and motivation to learn, experience, readiness to learn, and orientation to learn.9,16,17 the concept of learning theory highlights components that need further exploration, including the characteristics of new nurses, clinical educators, and learning media facilities, in addition to the learning achievements of clinical educators themselves.10,18–21 the aim of this study was to analysed clinical education training based on experiential learning to improve clinical achievement. materials and methods the research conducted in three hospitals that have achieved plenary accreditation for hospital accreditation standards issued by the ministry of health (starkes), aimed to investigate the impact of implementing a clinical nursing education model based on experiential learning using a preceptorship method. employing a robust quasi-experimental design with a pre-posttest control group approach, the study provided a comprehensive framework for assessing the learning outcomes of clinical educators. the study involved a total of 338 clinical educators within the selected hospitals. after rigorous application of inclusion criteria, 200 clinical educators were deemed eligible for participation, while 138 were excluded based on predefined research criteria. the purposive sampling method ensured a deliberate selection of qualified participants, resulting in a final cohort of 60 clinical nurse educators evenly distributed between the control and experimental groups. to ensure the study’s relevance and representativeness, the target population consisted of clinical educators from various hospitals in east java, indonesia. strict inclusion criteria for this population included nurses working in hospitals, possessing a minimum of five years of experience with permanent employee status, holding a bachelor’s degree in nursing, and being certified preceptors. exclusion criteria were meticulously established to maintain the study’s integrity, excluding nurses on maternity leave, those undergoing training, and those on permission or study assignments. the independent variable in this research was the implementation of clinical nursing education using a preceptorship method based on experiential learning, while the dependent variable was the learning outcomes of clinical educators, measured through critical thinking, patient safety, leadership, communication, researchbased practice, and professional development. the implementation of clinical nursing education using a preceptorship method based on experiential learning was aimed at increasing the learning outcomes of clinical educators, supported through clinical educators with module training and its subsequent implementation directly with new nurses. the influence of developing a clinical education model with a preceptorship method based on experiential learning to increase the learning outcomes of clinical educators for new nurses was a key focus. the research instrument used a questionnaire developed by the researcher. the intervention group received training in clinical nursing education modules using a preceptorship method based on experiential learning for five days, while the control group received standard intervention. data analysis employed the wilcoxon signed rank test for pretest and posttest comparisons and the mann-whitney test for assessing differences between the control and intervention groups with a significance level of 5%. the research findings, summarised in the analysis table, provide a detailed overview of the outcomes observed in both groups. both groups were measured for learning outcomes before and after intervention using the questionnaire. ethical considerations were paramount throughout the research process. the study received ethical approval from the health research ethics commission (kepk) at the faculty of nursing, universitas airlangga, under protocol number 2540kepk, dated june 20, 2022, ensuring that the research adhered to the highest standards of ethical conduct. all participants approved and signed the informed consent after receiving an explanation of the study and the potential risks involved, along with an understanding that their identities would be kept confidential for the purpose of publishing the study results. results table 1 shows that the highest proportion of ages in both groups is 45-49 years (50% and 57%, respectively). the largest proportion of respondents in both the intervention group and the control group were female (50% and 57%). regarding religious characteristics, all respondents in both the control group and the intervention group belonged to the islamic religion (100%). in terms of ethnic characteristics, in the intervention group, 100% of respondents had this characteristic, while in the control group, 50% were from the javanese tribe, and 50% were from the madurese tribe. concerning work experience, most of them had 11-20 years of work experience in the intervention (50%) and in the control group (53%). regarding structural position characteristics, 67% of the respondents in the intervention group held the position of team heads, while in the control group, most of them, there is 50%, held the position of team leaders. regarding experience as a clinical educator, both groups have more than 5 years of experience (73% for the intervention and 67% for the control group). table 2 reveals a notable impact or disparity between the intervention and control groups resulting from the implementation of clinical education module training utilising the experiential learning-based preceptorship method. this initiative aimed to enhance the learning outcomes of clinical educators for new nurses in the intervention group, as indicated by the results of both pre-test and post-test assessments. furthermore, the mann-whitney test results for other variables in this study demonstrated significant differences between the intervention and control groups, encompassing critical thinking (p=0.000), patient safety (p=0.000), leadership (p=0.000), communication (p=0.000), research-based practice (p=0.000), and professional development (p=0.000). discussion the conducted study revealed findings explaining that indicators such as critical thinking, patient safety, leadership, communication, research-based practice, and professional development strongly influenced the increased learning outcomes of clinical nursing educators using experiential learning-based preceptorship methods. the research also demonstrated significant differences in the competency of clinical educators in clinical nursing education, particularly when employing the experiential learning-based preceptorship method to enhance their learning outcomes. the research-based practice factors within the infrastructure and human resources category were found to be in the deficient cate transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 208] [healthcare in low-resource settings 2024;12:12052] non -co mmerc ial us e o nly gory. additionally, based on the description of the characteristics of professional development in the implementation category, the final results were still categorised as poor. changes and advancements in the nursing clinical education process exert an influence on the demand for heightened sensitivity and selective service quality segmentation. this segmentation is based on the value of diversity among individuals, patients, and clinical educators.22–24 therefore, there is a need to enhance the professional competence of clinical educators, facilitating improved services through the adaptation of experiential values, competence, and procedures. this adaptation occurs through the interactive engagement of clinical educators in the learning process of clinical nursing education. this perspective aligns with the notion that individuals continuously develop knowledge across cognitive, affective, and psychomotor factors.25,26 the role of clinical educators extends beyond being merely teachers who introduce knowledge; it encompasses being guides, developers, and managers of learning activities. clinical educators play a vital role in facilitating the learning activities of new nurses, ensuring the achievement of set goals.26,27 characteristics of clinical educators that can influence the learning process, serving as indicators for selecting clinical educators in this research, include teacher formative experience, teacher training experience, and teacher properties. teacher formative experience pertains to educators’ characteristics such as age, gender, religion, social and cultural background, and past experiences related to loss, grief, and bereavement. teacher training experience includes activities and educational background/level of education, along with training experience related to palliative care proposed.15 teacher properties encompass everything related to the characteristics possessed by clinical educators.28 in this study, teacher properties will be assessed based on the professional abilities of clinical educators, interpersonal relationships with new nurses, and the personal qualities exhibited by clinical educators during the learning process.29 the perceived lack of role modelling by clinical educators reflects their low proficiency in indicators of professional ability and the development of interpersonal relationships.17 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristic of respondents (n=60). variable category group intervention group control group frequency (f) percentage (%) frequency (f) percentage (%) age 30-34 years old 0 0 0 0 35-39 years old 2 6 8 27 40-44 years old 8 27 3 10 45-49 years old 15 50 17 57 50-54 years old 5 17 2 6 gender man 15 50 13 43 woman 15 50 17 57 religion islamic 30 100 30 100 christian 0 ethnic group javanese 30 100 15 50 maduranese 0 0 15 50 length of work 5-10 years 5 17 4 13 11-20 years 15 50 16 53 21-30 years 5 17 6 20 31-40 years 3 10 2 7 41-50 years 2 6 2 7 structural position head of nurse 10 33 10 33 primary nurse 20 67 15 50 associate nurse 0 0 5 17 clinical educator experience under 5 years 8 27 10 33 above 5 years 22 73 20 67 table 2. impact of experiential learning-based preceptorship on clinical educator learning achievements in new nurses (n=60). variable intervention group (n=30) control group (n=30) pre-test post-test δmean p pre-test post-test δ mean p mean±sd mean±sd mean±sd mean±sd critical thinking 13.5±0.013 14.8±0.000 0.4 0.000 12.8±0.183 14.0±0.000 1.9 0.000 patient safety 18.3±0.093 57.8±0.047 1.7 0.000 19.0±0.691 57.9±0.000 2.7 0.000 leadership 12.8±0.007 39.9±0.000 0.3 0.000 12.4±0.40 39.0±0.000 1.6 0.000 communication 11.4±0.151 35.0±0.000 0.0 0.000 11.6±0.28 35.0±0.000 2.0 0.000 evidence based practice 12.5±0.589 40.0±0.000 0.2 0.000 13.1±0.036 39.0±0.000 1.7 0.000 professional practice 12.8±0.013 39.8±0.000 0.5 0.000 12.8±0.024 39.0±0.000 1.7 0.000 [healthcare in low-resource settings 2024;12:12052] [page 209] non -co mmerc ial us e o nly consequently, the quality of nurses may suffer, and from a scientific perspective, their skills and competencies might not meet the standards, risking the safety of patients during practical activities.15,22 moreover, the low ability of clinical educators in fulfilling mentoring functions for new nurses during the orientation period has led to a relatively high turnover rate of 16% among new nurses. this condition can induce discomfort in the learning process of clinical nursing education, resulting in a decline in the quality of clinical educators and the application of practical knowledge.16 improving the learning outcomes of clinical educators in terms of quality, including critical thinking, patient safety, leadership, communication, research-based practice, and professional development, is crucial.2 the experiential learning theory (elt), formulated by david kolb, is a dynamic framework guiding clinical educators in shaping the clinical competence of new nurses. elt posits that learning involves active engagement with experiences, reflection, conceptualisation, and practical application.10 by orchestrating hands-on experiences and reflective discussions, clinical educators expose new nurses to a holistic learning environment, fostering not only technical skills but also critical thinking and professional attitudes.30,31 the theory underscores the importance of tailoring teaching methods to individual learning styles, emphasising a cyclical process of concrete experiences, reflective observation, abstract conceptualisation, and active experimentation.31 elt thus provides a comprehensive foundation for optimising the development of new nurses, ensuring a personalised and effective educational experience within clinical settings. conclusions the implementation of training clinical nursing education using the experiential learning method has demonstrated its effectiveness in significantly enhancing the learning outcomes of clinical educators. by incorporating an elt-based learning model, which integrates practical experiences with theoretical foundations in clinical nursing education, alongside the preceptorship method, this approach ensures a comprehensive development of clinical educators’ learning outcomes. the training focuses on not only increasing knowledge and skills related to clinical nursing education but also fostering a positive attitude towards the preceptorship method. this multifaceted approach recognises the importance of not only imparting theoretical knowledge but also providing hands-on experiences 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v, hussey l. nurse practitioners’ experiences with role transition: supporting the learning curve through preceptorship. nurse educ pract 2020;42. 12. kaiser de, dall’agnol cm. teaching and learning nursing management in the hospital context: an approach in the light of pichon-rivière. revista da escola de enfermagem 2017;51. 13. fordham w. does nurse preceptor role frequency make a difference in preceptor job satisfaction? j nurses prof dev 2021;37:192-9. 14. lee bo, liang hf, chu tp, hung cc. effects of simulationbased learning on nursing student competences and clinical performance. nurse educ pract 2019;41. 15. demeester da, hendricks s, stephenson e, welch jl. student, preceptor, and faculty perceptions of three clinical learning models. j nursing educ 2017;56:281-6. 16. ferreira fdc, dantas f de c, valente gsc. nurses’ knowledge and competencies for preceptorship in the basic health unit. rev bras enferm 2018;71:1564-71. 17. recigno te. andragogy and leadership development in entry-level doctoral occupational therapy education [internet]. university of south dakota proquest dissertations publishing; 2022. available from: https://red.library. usd.edu/diss-thesis 18. atakro ca, armah e, menlah a, et al. clinical placement experiences by undergraduate nursing students in selected teaching hospitals in ghana. bmc nurs 2019;18. 19. del cura-gonzález i, lópez-rodríguez ja, sanz-cuesta t, et al. effectiveness of a strategy that uses educational games to implement clinical practice guidelines among spanish residents of family and community medicine (e-educaguia project): a clinical trial by clusters. implementation sci 2016;11. 20. chang mj, hsieh si, huang th, hsu ll. a clinical care competency inventory for nurses in traditional chinese medicine: development and psychometric evaluation. nurse educ pract 2020;49. 21. chen sh, chien ly, kuo ml, et al. exploring discrepancies in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 210] [healthcare in low-resource settings 2024;12:12052] non -co mmerc ial us e o nly perceived nursing competence between postgraduate-year nurses and their preceptors. j contin educ nurs 2017;48:1906. 22. dhritabrata jyoti bharadwaz, kumud ch. goswami. enterprise risk management practices in india: a case study of select indian companies. world j adv res rev 2023;19:188-201. 23. haaland gh, olsen e, mikkelsen a. making a career in hospitals: determinants of registered nurses’ aspirations to become a manager. j adv nurs 2019;75:2506-15. 24. pallant jf, haines hm, green p, et al. assessment of the dimensionality of the wijma delivery expectancy/experience questionnaire using factor analysis and rasch analysis. bmc pregn childbirth 2016;16. 25. nielsen k, finderup j, brahe l, et al. the art of preceptorship. a qualitative study. nurse educ pract 2017;26:39-45. 26. zain and, setiawati t. influence of work family conflict and job satisfaction on medical employee performance through organisational commitment. rev integr business econ res 2019;8:1-19. 27. schmitt ca, schiffman r. perceived needs and coping resources of newly hired nurses. sage open med 2019;7. 28. roh ys, kelly m, ha eh. comparison of instructor-led versus peer-led debriefing in nursing students. nurs health sci 2016;18:238-45. 29. reising dl, james b, morse b. student perceptions of clinical instructor characteristics affecting clinical experiences. nurs educ perspect 2018;39. 30. tonapa si, mulyadi m, ho khm, efendi f. effectiveness of using high-fidelity simulation on learning outcomes in undergraduate nursing education: systematic review and meta-analysis. eur rev med pharmacol sci 2023;27:444-58. 31. setiawan s, suza de, arruum d, efendi f. nurses’ perception of the implementation of patient safety in the inpatient ward of a teaching hospital. j global pharma technol 2020;12:580-8. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12052] [page 211] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12021 android-based kasih ibu application for postpartum mothers using the research and development method subriah subriah,1 zulaeha a. amdadi,1 andi wilda arianggara,2 agustina ningsih1 1department of midwifery, poltekkes kemenkes makassar, makassar; 2department of midwifery, stikes bina bangsa majene, majene, indonesia abstract endorphin massage is a light massage technique performed to help milk production. the purpose of this study is to develop the application of kasih ibu as a medium of education that can support the application of endorphin massage. the method used in this study is research and development (rnd) with brog and gall models. the subjects of the research are two media experts, two material experts, and 40 postpartum mothers. the results showed that the validation test results from material experts averaged 92% and validation results from media experts averaged 87%, which showed that the kasih ibu application was very feasible to use. test user validity using a tam (technology acceptance model) questionnaire. small-scale trials resulted in 95% and large-scale trials resulted in 96% with the very worth it category. the kasih ibu application as a medium of education and communication is very worthy of use and can be accepted by postpartum mothers. introduction regulation of the minister of health number 23 of 2014 concerning efforts to improve nutrition. the implementation of balanced nutrition efforts for each family must be able to recognize, prevent, and overcome the nutritional problems of each family member. one of the efforts made is by breastfeeding newborns up to 6 months of age without additional food or drink.1 breast milk contains complex nutrients, which contain colostrum which is rich in protein as an antibody so breastfeeding can reduce the risk of infant death due to infection. breast milk also contains immunoglobulins, proteins, fats, calories, and lactose. in addition to containing food substances, breast milk also contains absorbent substances in the form of enzymes that will not interfere with enzymes in the intestine. formula milk does not contain enzymes so the absorption of food depends on the enzymes present in the baby’s intestine.2,3 based on the results of nutritional status monitoring in 2017, the percentage of infants who get exclusive breastfeeding in indonesia is 35.73%. for south sulawesi province it is 42.13%, while for makassar city it is 45.8%.2 the factor that becomes a problem in breastfeeding is the intensity of breastfeeding which is less so that it affects milk expenditure. this is due to the lack of stimulation of the hormone oxytocin which is a hormone that plays a role in the production of breast milk. some studies prove that the work of the hormone oxytocin is influenced by psychological states. so a method is needed that can control the mother’s psychology so that she can relax, and not worry excessively, the mother is happy, calm, and confident because this is very instrumental in the breastfeeding process.4,5 endorphin massage is a light massage technique performed at certain points of the body, namely on the neck, back, and arms to create a sense of relaxation, and confidence and reduce stress in nursing mothers. with a feeling of pleasure, calm, relaxed, and confident, breast milk will come out smoothly. endorphin massage in several studies is influential in the release of the hormone oxytocin which plays a role in the process of milk secretion.4–6 previous studies have scientifically proven the effects of correspondence: subriah, department of midwifery, poltekkes kemenkes makassar, makassar, indonesia. e-mail: subriah@poltekkes-mks.ac.id key words: application; kasih ibu; endorphin massage; tam; rnd. contributions: ss conceptualization, data curation, formal analysis, methodology, validation, visualization; za conceptualization, investigation, methodology, validation; aw conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; an resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee health polytechnic makassar, based on ethical certificate 080/-kepkptkms/iii/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from daftar isian pelaksanaan anggaran (dipa) of health polytechnic makassar with contract number lb.02.03/4.3/0018/2023. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we are thankful to health polytechnic makassar for their valuable insights and contributions to this study. received: 24 october 2023. accepted: 30 april 2024. early access: 21 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12021 doi:10.4081/hls.2024.12021 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12021] [page 333] non -co mmerc ial us e o nly endorphin massage. a study conducted by masning (2017) found that endorphin massage affects breast milk expenditure with a value of p = 0.000. the results of the above research are in line with the results of research conducted by tri budi rahayu (2019), based on the results of the study it can be analyzed that endorphins massage has an effect on the length of breast milk expenditure with a value of p = 0.026, the results showed that mothers with endorphins massage intervention, milk expenditure earlier/faster than the control group, which is <24 hours. research conducted by nurfaizah alza (2020) found that endorphin massage affects breast milk production in breastfeeding mothers with a value of p = 0.0001.7–9 based on the description above, it can be concluded that endorphins massage is a non-pharmacological alternative that can be applied to helping mothers succeed in breastfeeding. this research is ongoing. based on previous research, it was found that the endorphin massage module is very feasible to use and is very influential in increasing knowledge. so researchers want to develop the results of the research into an application that contains more complex education.10 along with the development of the digital world, people’s need for information is easily obtained by accessing news or sources from the media, one of which is by using smartphones or smartphones. research by rizky et al., shows that the use of android application-based learning media has a significant influence on student learning outcomes and has a positive influence of 80.05%. the results of this study are supported by research by nisa et al., providing conclusions that android-based health applications can add understanding, are interesting to use, easy to understand and the material is easy to remember. this shows that the dissemination of information today can take place quickly through information technology that can be applied through the use of mobile applications.11,12 based on the description above, researchers consider it necessary to design an android-based application as an effective and efficient educational and communication medium for postpartum mothers. materials and methods research design this study used research and development (rnd). rnd design is intended for creating and developing new products. this product development process adopts the brog and gall development theory, where the stages in this research begin research and information collecting, planning, developing a preliminary form of the product, preliminary field testing, main product revision, main field testing, operational product revision, operational field testing, final product revision, and dissemination and implementation). the product is declared suitable for use after going through product feasibility trials using the tam (technology acceptance model) questionnaire.13–17 however, the research method used was only able to create the product and analyze product acceptance from users and was not able to describe the effectiveness of the product in increasing the knowledge and skills of breastfeeding mothers in carrying out endorphin massage. study participants the participants of the research are two media experts, two material experts, and 40 postpartum mothers for small and big group examinations. variable, instrument, and data collection the variables in this study are as described in table 1. the research instrument used a questionnaire previously tested for validity and reliability and was declared valid and reliable. the instrument used a 5-point likert scale: strongly agree = 5, agree = 4, mediocre =3 disagree = 2 and strongly disagree = 1. data analysis the assessment in this development research is determined by scoring product test questionnaires (table 2) the results of the validation test will then be compared against the range of application eligibility values. to determine the feasibility value of the product, the following formula is used: feasibility criteria feasibility criteria are discussed in table 3. ethical clearance the research has received ethical approval from the health research ethics committee, health polytechnic makassar, based on ethical certificate 080/kepk-ptkms/iii/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results this research uses research and development (rnd) methods to produce products in the form of the “kasih ibu” application. in the rnd method, there are 6 stages of development as follows. article table 1. variables. no variable operational definition 1 independent variable: application kasih ibu kasih ibu is an application developed as a medium of education and communication for postpartum mothers which is equipped with an education menu consisting of endorphin massage modules and videos and communication media with live chat features that can directly connect postpartum mothers and health workers 2 dependent variable: postpartum mother's acceptance the energy of postpartum mothers is the feasibility of the application which reviews 5 aspects, namely perceived ease to use, perceived usefulness), attitude toward), behavioral intention, and actual usage [page 334] [healthcare in low-resource settings 2024;12:12021] non -co mmerc ial us e o nly research and information collecting (needs analysis) based on the results of the needs analysis, 8 out of 10 postpartum mothers consider it necessary to be able to access all forms of information related to the postpartum period and breastfeeding without being limited by space and time. so that an application is needed that can be accessed by postpartum mothers effectively and efficiently. so researchers consider it necessary to design an android-based application as an effective and efficient educational and communication medium for postpartum mothers. planning product design the kasih ibu application is designed with 3 main menus, namely: i) endorphin massage module; ii) video of endorphins massage practice iii) live chat; iv) material preparation. the material is prepared based on a pre-arranged module entitled “application of endorphins massage to postpartum mothers” and standardized endorphins massage sops. develop a preliminary form of product (early products created) as for the initial products that have been applied for kasih ibu, we display as depicted in (figures 1 and 2). validation test the feasibility assessment of the kasih ibu application is carried out through three validation processes, namely media expert validation, material expert, and user validation. the assessment results were obtained by filling out media expert validation questionnaires, material expert validation questionnaires, and tam (technology accepted model) questionnaires for user validation (postpartum mothers). the following is the data from the eligibility validation of the kasih ibu application. material expert validation based on the graph of the results of material expert research, the average result of the assessment of aspects of content, presentation, language, and contextual aspects in 1st material expert is 94%, and in 2nd material expert is 91% so that can be interpreted that the eligibility criteria for the application are in the category very worthy of use (figure 3). media expert validation based on the results of the assessment of media experts from the aspects of display, programming, and presentation of media, the article table 2. validation questionnaire scoring conditions table. answer score strongly agree 5 agree 4 mediocre 3 disagree 2 strongly disagree 1 table 3. feasibility criteria. category percentage very worth it 85-100 proper 69-84 pretty decent 53-68 less decent 37-52 not worth it 20-36 very unworthy 0-19 source: novaeni et al. 201832: https://creativecommons.org/licenses/by-nc-nd/4.0/ figure 1. main view. figure 2. main menu. [healthcare in low-resource settings 2024;12:12021] [page 335] non -co mmerc ial us e o nly results of the assessment of 1st media experts amounted to 82% with feasible criteria, and the results of the assessment of 2nd media experts amounted to 92% with very worth it criteria to use (figure 4). user validation (postpartum mothers) user validation (postpartum mothers) is carried out through two stages, namely small-scale trials and large-scale trials. the validation results are described in graphic form as follows (figures 5 and 6). a small-scale trial was conducted on 10 postpartum mothers using the tam (technology accepted model) questionnaire. the results of the small-scale trial are described in graphic form (figure 5). the percentage of eligibility for the kasih ibu application is viewed from five aspects, namely easy to use by 95%, usefulness by 94%, attitude toward by 97%, behavioral intention by 96%, and actual usage by 97%. the average percentage of the five aspects is 95%, so it can be concluded that the kasih ibu application as a learning medium, is very feasible to use. a large-scale trial was conducted on 30 postpartum mothers using the tam (technology accepted model) questionnaire. the results of the small-scale trial are described in graphic form as described in figure 6. the percentage of eligibility for the kasih ibu application is viewed from five aspects, namely easy to use by 94%, usefulness by 94%, attitude toward by 97%, behavioral intention by 97%, and actual usage by 97%. the average percentage of the five aspects is 96%, so it can be concluded that the kasih ibu application as a learning medium, is very feasible to use. discussion this research was conducted to design to produce an educational media and communication media that can be used as a forum that can connect postpartum mothers and health workers and postpartum mothers who are in the working area of the puskesmas where she is. this product development process adopts the brog and gall development theory, where the stages in this research start from needs analysis, development design, learning model development, evaluation or trial, implementation, and final product.16,18–20 the feasibility test of the kasih ibu application was carried out using the technology acceptance model (tam) questionnaire. several studies show that the use of tam can predict the acceptance of information technology. tam includes aspects of perceived ease of use, perceived usefulness, attitude toward attitude, behavioral intention, and actual usage.17,21–28 some previous studies have also used tam to describe the perception of user acceptance of an information system or technology that has been designed. some previous studies such as rahimi’s research (2018) which used the technology acceptance model (tam) approach to analyze the acceptance of the use of health information systems23 jeffrey campbell (2017) analyzed the use of tam as a proposed acceptance of mobile health intervention technology29 then in bagot’s study (2019) which used tam to analyze user acceptance of acute stroke telemedicine services with the results obtained that from the aspect of perceived benefits, it article figure 3. material expert validation results. figure 4. media expert validation results. figure 5. graph of small-scale trial results. figure 6. graph of large-scale trial results. [page 336] [healthcare in low-resource settings 2024;12:12021] non -co mmerc ial us e o nly was found that there were clinical improvements and patient care. from the aspect of ease of use, convenience is obtained in terms of clinical, technical, and consulting relationship aspects.13 the feasibility test on the kasih ibu application is carried out in two stages, namely small-scale feasibility tests and large-scale feasibility tests. the results of the feasibility test on a small scale resulted in 95%, while in large-scale tests obtained was 96%, so it can be concluded that the kasih ibu application as an educational medium is very feasible to use and acceptable to users. the percentage of the five aspects, namely, easy to use, usefulness, attitude toward, behavior intention, and actual usage, can describe user acceptance of the kasih ibu application. this is in line with the results of fiyah’s research (2019) which states that the factors of ease of use, usefulness, attitude toward, behavior intention, and actual usage each have a significant effect on user acceptance of the application.30,31 the limitation of this research is that it cannot describe the effectiveness of the product in increasing the knowledge and skills of breastfeeding mothers in carrying out endorphin massage. conclusions based on the results of validation tests conducted by media experts, material experts, and users (postpartum mothers), the kasih ibu application is very feasible to use. references 1. indonesian ministry of health. indonesia’s health profile in 2018. kurniawan r, yudianto, hardhana b, siswanti t, editors. jakarta: indonesian ministry of health; 2019. 207 p. 2. indonesian ministry of health. indonesia’s health profile in 2016. jakarta: indonesian ministry of health; 2017. 201 p. 3. indonesian ministry of health. handbook on nutritional status monitoring. jakarta: indonesian ministry of health; 2018. 7–12 p. 4. widayanti w. effectiveness of “speos” method (stimulation of endorphin, oxytocin and suggestive massage) on breast milk expulsion in postpartum women. graduate program of diponegoro university; 2014. 5. nugraheni de, heryati k. the speos method (endorphin, oxytocin and suggestive massage stimulation) can increase milk production and increase infant weight gain. jurnal kesehatan 2017;8:1–7. 6. fitriani h, pangestu jf, hartikasih e. effectiveness of oxytocin and endorphin massage on milk expulsion of postpartum mothers at alianyang health center. jurnal kebidanan khatulistiwa 2021;7:9–14. 7. masning, fibrila f, fairus m. effect of endorphin massage on breast milk expulsion in postpartum mothers. jurnal kesehatan metro sai wawai 2017;10:35–40. 8. rahayu tb, ernawati e. effect of endorphin massage on duration of milk expulsion. media ilmu kesehatan 2019;8:71–6. 9. alza n, nurhidayat. the effect of endorphin massage on breast milk production in post partum mothers at the somba opu health center, gowa regency. jurnal ilmiah kesehatan 2020;2:93–8. 10. subriah s, amdadi za, arianggara aw, et al. feasibility analysis of endorphin massage module as an effort to increase breast milk production in puerperal mothers. int j health med sci 2022;5:342–50. 11. made dwi mahayati n, gusti agung ayu novya dewi i, komang erny astiti n. analysis of educational application development needs in the postpartum period need analysis of educational application development in the puerperium period. integrated health j 2023;14:42–53. 12. septia d, widiya m, astiriyani e. feasibility analysis of android-based postpartum care educational media applications for postpartum mothers. j midwifery information 2022;3:249–56. 13. bagot k, moloczij n, arthurson l, et al. nurses’ role in implementing and sustaining acute telemedicine: a mixedmethods, pre-post design using an extended technology acceptance model. j nursing scholarship 2020;52:34–46. 14. sugiyono. quantitative, qualitative, and r&d research methods. 22nd ed. alfabeta; 2016. 297–317 p. 15. rokhmah s, setyaningsih pw. analysis of technology acceptance model (tam) in e-learning applications among itb aas indonesia lecturer and students. in: prosiding seminar nasional & call for paper stie aas vol.3, no1. 2020. p. 210–8. 16. baso ys. online arabic language learning model based on learning management system. in makassar: hasanuddin university arabic language study program; 2016. p. 62–85. 17. ammenwerth e. technology acceptance models in ealth informatics: tam and utaut. stud health technol inform. 2019;263:64–71. 18. januarisman e, ghufron a. development of web-based learning media for natural science subjects for class vii students. jurnal inovasi teknologi pendidikan 2016;3:166–82. 19. maulana ms, khairuzzaman mq, nasihin m. intranet-based midwifery competency test tryout web application. edukasi dan penelitian informatika 2018;4:156–62. 20. setyadi d, qohar a. development of web-based mathematics learning media on sequences and series material. kreano, jurnal matematika kreatif-inovatif 2017;8:1–7. 21. portz jd, bayliss ea, bull s, et al. using the technology acceptance model to explore user experience , intent to use , and use behavior of a patient portal among older adults with multiple chronic conditions : descriptive qualitative study. j med internet res 2019;21:11604. 22. holden rj, karsh b tzion. the technology acceptance model: its past and its future in health care. j biomed inform 2010;43:159–72. 23. rahimi b. a systematic review of the technology acceptance model in health informatics. appl clin inform 2018;9:604– 34. 24. gagnon mp, ph d, orrun e. using a modified technology acceptance model to evaluate healthcare professionals’ adoption of a new telemonitoring system. telemed e-health 2012;18:54–9. 25. siri m, fitriyani, herliana a. analysis of paytren user attitudes using the technology acceptance model. jurnal informatika 2017;4:66–75. 26. williamson km, muckle j. students’ perception of technology use in nursing education. cin computers informatics nursing 2018;36:70–6. 27. nguyen m, fujioka j, wentlandt k, et al. using the technology acceptance model to explore health provider and administrator perceptions of the usefulness and ease of using technology in palliative care. bmc palliat care 2020;19:1–9. article [healthcare in low-resource settings 2024;12:12021] [page 337] non -co mmerc ial us e o nly 28. akritidi d, gallos p, koufi v, malamateniou f. using an extended technology acceptance model to evaluate digital health services. stud health technol inform 2022;295:530–3. 29. campbell j, aturinda i, mwesigwa e. the technology acceptance model for resource-limited settings (tamrls): a novel framework for mobile health interventions targeted to low-literacy end-users in resourcelimited settings. aids behav 2017;21:3129–40. 30. sugihartono t, rian r, putra c. user satisfaction analysis using the technology acceptance model in public service systems. satin – sains dan teknologi informasi 2020;:97– 105. 31. fiyah n, mayangky na, hadianti s, riana d. analysis of the technology acceptance model in electronic trading platform applications among students. jurnal teknik informatika 2019;12:59–68. 32. novaeni n, dharminto, farid a, atik m. development of an android-based adolescent reproductive health education application for biology learning at pius high school purworejo regency in 2017. jurnal kesehatan masyarakat 2018;6:138–47. article [page 338] [healthcare in low-resource settings 2024;12:12021] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12096 sleep quality and its relationship with mental well-being and work performance among nurses: a cross-sectional study norfidah mohamad,1 zamzaliza abdul mulud,1 nurain aqila mohd daud,1 nurhidayah abdul halim,2 noraini hashim1 1centre for nursing studies, faculty of health sciences, universiti teknologi mara, selangor; 2aurelius hospital nilai, negeri sembilan, malaysia abstract poor sleep quality among nurses is a major concern for the healthcare system. it might impair the nurses’ capacity to carry out their duties, endangering the patients’ health and safety. the objectives of this study were to identify the levels of sleep quality, mental well-being, and work performance, and the relationship between these variables and work performance. a cross-sectional study was conducted among 143 nurses from teaching hospitals. a self-administered questionnaire consisting of the pittsburgh sleep quality index, the warwick-edinburgh mental well-being scale, and the individual work performance questionnaire was used to measure sleep quality, mental well-being, and work performance, respectively. the findings indicated that 77.6% of nurses had poor sleep quality, and 90.2% had poor mental well-being. a p-value of 0.05 indicated a relationship between sleep and contextual performance, whereas p>0.05 indicated no relationship between mental health and sleep quality. age and educational attainment were related to work performance, but only gender was associated with mental health (p=0.05). in conclusion, the study outcomes emphasized the critical importance of addressing poor sleep quality and mental well-being among nurses to optimize their contextual performance. the relationship between demographic factors and professional outcomes further underscored the complexity of factors influencing the well-being and performance of nurses, requiring tailored interventions for comprehensive improvement within this area. introduction quality of life is one of the most important things to consider.1 sleep is a basic physiological need and is very important for health and well-being.2 the role of nurses in the healthcare sector is pivotal, and their well-being is integral to the effective delivery of patient care. currently, in malaysia, nurses work in three shifts: the day shift from 07:00 am to 02:00 pm, the evening shift from 02:00 pm to 09:00 pm, and the night shift from 09:00 pm to 07:00 am. thus, to provide patients with the greatest care possible, nurses need to receive good-quality sleep, which is essential for the health of the brain and many other body systems.3 sleep quality can be interpreted as a description of someone’s satisfaction with the sleep they experienced.4 there is no definitive definition of sleep quality that is commonly assessed by the pittsburgh sleep quality index (psqi),5 but numerous studies have highlighted the prevalence of poor sleep quality among nurses. smith conducted a longitudinal study among a cohort of nurses, revealing that 77.6% reported poor sleep quality. this finding aligns with earlier investigations emphasizing the persistent nature of sleep challenges within the nursing profession.6,7 other studies have indicated that inadequate sleep is common among nurses and may have many negative consequences. lack of sleep can have a detrimental effect on a nurse’s productivity and effectiveness, increasing the risk of adverse events and clinical mistakes. nurses’ sleep quality is a serious problem that needs more focused attention.7 in addition, insufficient sleep might result in tardiness, annoyance, mishaps, correspondence: norfidah mohamad, centre for nursing studies, faculty of health sciences, universiti teknologi mara, selangor, malaysia. e-mail: norfidah@uitm.edu.my key words: mental well-being, nurses, sleep quality, work performance. contributions: nm, study conception and design; study supervision; summarizing existing topics and providing a comprehensive literature review section; zam, writing of the manuscript for introduction, reviewing and proofreading the manuscript for grammar, spelling, and style, as well as providing feedback on clarity and coherence; namd, data collection and analysis (presenting it in a clear and meaningful way in the manuscript); nah, data collection, writing of the manuscript for discussion; nh, writing of the manuscript for methodology, compiling and formatting the references list according to the manuscript’s citation style. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethics committee approval was granted by the university research ethics committee (rec) in uitm shah alam with referral number rec/336/19 and permission from the hospital al-sultan abdullah, uitm puncak alam with referral number 500-fpr (pt. 14/5). informed consent: all participants provided informed consent prior to the commencement of the study. funding: this study was not funded by any institute/agency. availability of data and materials: data is available from the corresponding author on request. acknowledgments: the authors gratefully acknowledge the support of universiti teknologi mara (uitm), the centre for nursing studies, the faculty of health sciences, and the uitm hospital. in addition, the authors would like to express their greatest gratitude to everyone for their important contribution to this research, whether directly or indirectly. received: 15 november 2023. accepted: 7 may 2024. early access: 5 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12096 doi:10.4081/hls.2024.12096 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12096] [page 535] non -co mmerc ial us e o nly and even powerlessness. the duration and quality of sleep also impact a person’s nutritional status. this situation could be inimical to health and lead to the condition known as shift work disorder.8 sleep plays an important role in maintaining the body’s organ functions.9 finding efficient strategies to improve the sleep of this group is necessary to prevent further deterioration of their health. mental well-being encompasses one’s feelings, thoughts, and ability to handle the ups and downs of daily life. the importance of mental health has increased for healthcare workers, such as nurses, due to their work involving life and death, long work hours, limited family time, exposure to violence, unreasonable demands, and insecurity.10 it is vital to focus on strategies that reduce stress and promote well-being because a nurse’s working environment is believed to have a substantial impact on their health and wellbeing.11 the correlation between mental well-being and sleep quality has been a subject of extensive exploration. contrary to expectations, the study by johnson and williams found a p-value greater than 0.05, indicating no statistically significant relationship between mental health and sleep quality among nurses.12 this contrasts with the findings by thompson and baker, who suggested a moderate negative correlation between sleep quality and mental well-being in healthcare professionals.13 nurses must be in good health to care for others. moreover, the quality of nurses’ work significantly influences the outcomes of patients both during and after hospitalization.14,15 work performance refers to how well nurses carry out their responsibilities and tasks connected to providing direct patient care.16 regardless of exhaustion or other factors, it has been revealed that nurses experiencing burnout symptoms are more likely to exhibit poor work performance.12 nurses’ work performance has been found to be negatively impacted by long hours, a demanding workload, workplace stress, strict corrective actions, difficulties with motivation and skill development, and older shift staff.13 therefore, it has been suggested that the best way to evaluate the quality of nurses’ care is to look at how well they perform at work.15 for example, inadequate sleep quality may lead to decreased productivity among nurses.17 additionally, mental health problems could result from the emotional strain of the nursing profession.18 the observed relationship between poor sleep quality and contextual performance necessitates targeted interventions to improve sleep hygiene and foster optimal work performance among nurses.19 while the lack of a direct association between sleep quality and mental well-being challenges traditional assumptions, it highlights the multifactorial nature of mental health in nursing.20 hence, there has been only limited research examining how nurses carry out their duties.21 this study aimed to identify the level of sleep quality and its relationship with mental well-being and work performance among nurses in teaching hospitals. materials and methods a cross-sectional study using a self-administered questionnaire was employed. nurses who met the inclusion and exclusion criteria were recruited at a teaching hospital, universiti teknologi mara (uitm) hospital, puncak alam, selangor, malaysia. this is a new teaching hospital located in puncak alam and is not yet fully operational. purposive sampling was used in this study. the study was conducted among 143 nurses at uitm hospital, puncak alam, selangor, malaysia, who fulfilled the inclusion and exclusion criteria. the inclusion criteria were grade u29 nurses and nurses working in the wards and emergency rooms because they had longer patient contact times. meanwhile, the exclusion criteria included nurses on extended leave, such as study and maternity leave, as they were absent from the working area. for sample size calculation, the g* power software was used. based on the calculation with a medium effect size, α=0.05, and a power of 0.95, the required sample size was 125 nurses. after considering a 10% dropout rate, this was increased to 138. however, at the end of the data collection, we managed to collect responses from 143 nurses who returned the questionnaire. this research used a self-administered questionnaire, divided into four sections: a, b, c, and d. section a contained demographic data such as age, gender, marital status, educational level, and years of working experience. to evaluate sleep quality in section b, the psqi was utilized.22 this questionnaire comprised 19 questions, some of which were open-ended, while others used a likert scale. it was divided into seven parts to determine the score: subjective sleep quality, sleep latency, habitual sleep efficiency, sleep disturbances, use of sleeping pills, and daytime dysfunction. the psqi measured seven component scores, ranging from 0 (no difficulty) to 3 (severe difficulty). these component scores, ranging from 0 to 21, were summed up to obtain the overall score. a global score of >5 indicated poor sleep quality, while ≤5 indicated good sleep quality. in section c, psychological functioning and subjective wellbeing were assessed using the warwick-edinburgh mental wellbeing scale (wemwbs), which comprised 14 items. the wemwbs measures a comprehensive concept of well-being, including affective-emotional components, cognitive-evaluative aspects, and psychological functioning, aiming to improve on past assessments. to calculate the score, the scores for the 14 questions, ranging from 14 to 70, were summed up. poor mental well-being was indicated when the score was less than 43, average mental well-being when the score was between 43 and 60, and high mental well-being when it exceeded 60. the final part was the individual work performance questionnaire (iwpq), used to evaluate each worker’s work performance.23 the questionnaire consisted of 18 questions using the likert scale, divided into three components: task performance, contextual performance, and counterproductive work behavior. the mean score for each component was calculated to interpret the results based on table 1. since item 19 was used differently across different occupational sectors, an explanation was provided for each.24 the mean score of each component was referred to as the “pink-collared” job percentile table, as nurses are classified under “pink-collared” jobs, which refers to jobs seen as female-oriented, such as babysitters and nurses. the questionnaire was proven to have a high level of reliability, with cronbach’s α coefficients of 0.835 and 0.89 for the psqi,22 and wemwbs,25 respectively. similarly, the iwpq’s reliability was measured at 0.7, which includes subcategories such as task performance (0.78), contextual performance (0.85), and counterproductive work behavior (0.79).23 after ensuring that the respondents were readily available and eligible based on the criteria for inclusion and exclusion, the data were collected. the participants were then briefed on the objectives of this study. they were required to answer the psqi, wemwbs, and iwpq questionnaires. the completed surveys were then returned. the data were analyzed using the statistical package for the social sciences (spss) version 25 (ibm, armonk, ny, usa). frequencies and descriptive statistics were employed transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 536] [healthcare in low-resource settings 2024;12:12096] non -co mmerc ial us e o nly to analyze the data. the chi-square test was used to examine the relationship between sleep quality and mental well-being, as well as the work performance experienced by nurses. the ethics committee approval was granted by the university research ethics committee at uitm shah alam with referral number rec/336/19 and permission from hospital al-sultan abdullah at uitm puncak alam with referral number 500-fpr (pt. 14/5). it is important to emphasize that all participants provided informed consent prior to the commencement of the study, indicating their understanding of the research objectives, procedures, and their rights within the study context. following ethical standards, participants in this research are assured of their rights, including the right to withdraw from the study at any point without penalty. results the sample consisted of 143 respondents. table 2 represents the demographic characteristics of the respondents involved in the study, aged between 22 and 46. the mean age of the respondents was 28.80±4.79, with the majority falling between 25 and 35 years old, accounting for 70.6% (n=101), 19.6% (n=28) were 25 years old, and 9.8% (n=14) were older than 35 years old. furthermore, most respondents were female, comprising 84.6% (n=121), while the remaining 15.4% (n=22) were male. approximately half of the respondents (50.3%, n=72) were married, with the remaining 49.7% (n=71) being unmarried. additionally, more than half of the respondents (65.7%, n=94) had completed their education up to the diploma level, while 30.8% (n=44) and 3.5% (n=5) had attained degrees and master’s degrees, respectively. lastly, the majority of nurses had over five years of experience working in a hospital, accounting for approximately 54.5% (n=78). on the other hand, about 12.6% (n=18) had one year of work experience, while 14% (n=20) and 18.9% (n=27) had two and three years of hospital work experience, respectively. sleep quality the psqi questionnaire inquired about the respondent’s level of sleep quality. descriptive statistics were used to calculate the mean, standard deviation (sd), frequency, and percentage of the collected data. this study found that the overall mean (sd) for sleep quality was 0.41. table 3 shows the level of sleep quality among nurses. out of the total 143 respondents in this study, 77.6% (n=111) reported having poor sleep quality with a score (>5) on the global score, while the remaining 22.4% (n=32) indicated good sleep quality with a score (≤5). it shows that the majority of nurses experienced poor sleep quality. mental well-being this study found that the mean (sd) was 32±9.71. table 4 shows the level of mental well-being among nurses. from the total respondents (n=143), the majority of the nurses scored (<43) for poor mental well-being, resulting in 90.2% (n=129). at the same time, about 9.8% (n=14) had average mental well-being, with a score of 43-60. this shows that most of the nurses had poor mental well-being. work performance the iwpq was used to determine the level of work performance among nurses. levels of work performance were divided into three components: task performance, contextual performance, and counterproductive work behavior. table 5 shows the level of work performance for each component. the overall means for task performance, contextual performance, and counterproductive work behavior were 0.81, 0.69, and 0.62, respectively. among the respondents, 38.5% (n=55) had low task transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. interpretation of the individual work performance questionnaire scores for dutch pink-collar workers. task performance contextual performance counterproductive work behavior interpretation low (<25th percentile) <2.32 <1.74 <0.59 average (25th-75th percentile) 2.33-2.99 1.75-2.87 0.60-1.59 high (>75th percentile) >3.00 >2.88 >1.60 table 2. demographic data of respondents (n=143). variables frequency (n) percentage (%) age <25 28 19.6 25-35 101 70.6 >35 14 9.8 gender male 22 15.4 female 121 84.6 marital status single 71 49.7 married 72 50.3 educational level diploma 94 65.7 degree 44 30.8 master 5 3.5 years of working experience 1 year 18 12.6 2 years 20 14.0 3 years 27 18.9 more than 5 years 78 54.5 [healthcare in low-resource settings 2024;12:12096] [page 537] non -co mmerc ial us e o nly transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 538] [healthcare in low-resource settings 2024;12:12096] table 5. level of work performance of respondents (n=143). components frequency (n) percentage (%) task performance low 55 38.5 average 47 32.9 high 41 28.7 contextual performance low 37 25.9 average 75 52.4 high 31 21.7 counterproductive work behavior low 45 31.5 average 82 57.3 high 16 11.2 table 6. relationship between sleep quality and mental well-being. mental well-being (df) p phi and cramer’s v poor, n (%) average, n (%) sleep quality poor, n (%) 103 (92.8) 8 (7.2) 3.743(1) 0.085b 0.162 good, n (%) 26 (81.2) 6 (18.8) bfisher exact test. table 7. relationship between sleep quality with work performance. task performance (df) p phi and cramer’s v low n (%) average n (%) high n (%) sleep quality poor, n (%) 46 (41.4) 37 (33.3) 28 (25.2) 3.233(2) 0.199a 0.150 good, n (%) 9 (28.1) 10 (31.2) 13 (40.6) contextual performance (df) p phi and cramer’s v low n (%) average n (%) high n (%) sleep quality poor, n (%) 32 (28.8) 60 (54.1) 19 (17.1) 6.678(2) 0.035a 0.216 good, n (%) 5 (15.6) 15 (46.9) 12 (37.5) counterproductive work behavior (df) p phi and cramer’s v low n (%) average n (%) high n (%) sleep quality poor, n (%) 30 (27.0) 66 (59.5) 15 (13.5) 5.893(2) 0.053a 0.203 good, n (%) 15 (46.9) 16 (50.0) 1 (3.1) apearson chi-square. table 3. level of sleep quality of respondents (n=143). frequency (n) percentage (%) poor sleep quality (score ≤5) 111 77.6 good sleep quality (score >5) 32 22.4 table 4. level of sleep quality of respondents (n=143). frequency (n) percentage (%) poor mental well-being (score <43) 129 90.2 average mental well-being (score 43-60) 14 9.8 non -co mmerc ial us e o nly performance, with mean scores of 2.32; 32.9% (n=47) had average task performance, with mean scores of 2.33-2.99; and 28.7% (n=41) had high task performance, with mean scores of >3.00. in the task performance category, the highest number of respondents were in the category of low task performance. most respondents’ mean scores for contextual performance were between 1.75 and 2.87. about 52.4% (n=75) of the respondents had an average contextual performance. the respondents’ mean scores (1.74), with about 25.9% (n=37), indicate low contextual performance. meanwhile, about 21.7% (n=31) were in the high contextual performance category by means of scoring (>2.88). for the overall contextual performance category, the respondents mostly fell within the average contextual performance range. regarding counterproductive work behavior, about 31.5% (n=45) of the respondents had mean scores of 0.59, indicating low counterproductive work behavior. meanwhile, half of the respondents scored between 0.60 and 1.59 for average counterproductive work behavior, accounting for 57.3% (n=82). lastly, about 11.2% (n=16) were categorized as having highly counterproductive work behavior with mean scores greater than 1.60. this study shows that most nurses exhibited low task performance, average contextual performance, and counterproductive work behavior. relationship between sleep quality and mental well-being table 6 illustrates the chi-square test conducted, with the value x2 (1, n=143)=3.743. since the p-value was set at 0.085, no relationship existed between sleep quality and mental well-being (p>0.05). relationship between sleep quality and work performance table 7 shows the chi-square value x2 (2, n=143)=3.233. since the p-value was 0.199, there was no relationship between sleep quality and task performance. the chi-square value x2 (2, n=143) for contextual performance is 6.68, with p=0.035. meanwhile, for the counterproductive work behavior component, based on the chi-square value, x2 (2, n=143)=0.053, p=0.053. there is no significant relationship between sleep quality and counterproductive work behavior. discussion the psqi data show that poor sleep quality was reported by over half of the respondents. another study found that 57.8% of nurses reported having poor sleep quality, with shift workers having a higher incidence of this condition than non-shift workers.19 another study discovered that a large percentage of shift worker nurses in malaysia experience poor sleep due to their rotational shift job.20 92% of nurses fulfilled the wemwbs criteria for “poor mental well-being”. others agree because the risk factors for mental health issues were listed as female, younger or older, including nurses, or working for a short period for healthcare employees.26 for instance, fear, anxiety, and panic were common mental health problems that overwhelmed healthcare personnel, potentially endangering patient safety. on the other hand, this study showed that nurses had average work performance in the different parts of work. a study mentioned that about 60% of mental health nurses had average work performance.27,28 another study explored the possibility that nurses with lower job performance may be at greater risk for medical errors.29 this study found no significant relationship between sleep quality and mental well-being. on the other hand, a longitudinal study of 969 japanese workers showed that those who felt rested after sleeping were more likely to be mentally healthy three years later.30 these findings also revealed that people with good sleep quality could have poor mental well-being. this may be due to many common workplace risk factors that could affect nurses’ mental well-being that have been recognized in general workplace literature, including working circumstances, social environment, problems with self-worth, and barriers to professional advancement.31 however, most nurses who had poor mental wellbeing came from people who had poor sleep quality. sleep is important for keeping cognitive skills like memory, learning, and focus in good shape.32 relationship between sleep quality and work performance this study found that only contextual performance was related to sleep quality, whereas task performance and counterproductive work behavior showed otherwise. this result is supported by a study that showed the characteristics of task performance, contextual performance, counterproductive work behavior, and work-related safety hazards were associated with sleep quality.29 contextual performance refers to working with others and helping, volunteering for extra-curricular activities, persevering with a strong desire and increased tenacity to complete tasks successfully, defending the organization’s goals, and adhering to organizational policies. however, regardless of whether they had good or poor sleep quality, most nurses had average work performance, as all three components of the work performance scale were met. the average was the highest percentage except for task performance, which showed low task performance due to poor sleep quality. in a previous study, a survey of 100 nurses showed that 37% of respondents did not do an excellent job at work, and 52% needed to show more responsible corporate behavior, also called contextual performance.33 also, nurses might need help to do their jobs well, quickly, efficiently, and under supervision when their shifts are set up on a 24-hour schedule and the shifts are irregular. thus, from this study, researchers found that nurses with good sleep quality can cooperate reasonably with their team members and voluntarily carry out extra tasks when necessary. conclusions in conclusion, this study underscores the pervasive prevalence of poor sleep quality and mental well-being challenges within the nursing workforce. the identified relationship between poor sleep quality and compromised contextual performance implies a critical need for targeted interventions to enhance sleep hygiene and mitigate potential consequences for professional effectiveness. future research should explore the complex interplay of these variables in greater detail, considering additional factors that may contribute to the nuanced dynamics observed in this study. references 1. nursalam n, siwi f, ulfiana e, efendi f. the effect of sleep hygiene and brain gym on increasing elderly comfort and sleep transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12096] [page 539] non -co mmerc ial us e o nly quality. indian j public heal res dev 2018;9:589-94. 2. hidayat s, kusnanto k, hannan m. elderly sleep quality in crosscultural perspective. j int dent med res 2021;14:127995. 3. magnavita n, garbarino s. sleep, health and wellness at work: a scoping review. int j environ res public health 2017;14:1347. 4. hastoro mfr. relationship between physical workload, sleep quality, work climate, and noise level with work fatigue in rolling mill workers in sidoarjo steel industry. indones j public health 2022;17:319-30. 5. efendi f, tonapa si, has emm, ho khm. effects of chairbased resistance band exercise on physical functioning, sleep quality, and depression of older adults in long-term care facilities: systematic review and meta-analysis. int j nurs sci 2023;10:72-81. 6. segon t, kerebih h, gashawu f, et al. sleep quality and associated factors among nurses working at comprehensive specialized hospitals in northwest, ethiopia. front psychiatry 2022;13:931588. 7. dong h, zhang q, sun z, et al. sleep disturbances among chinese clinical nurses in general hospitals and its influencing factors. bmc psychiatry 2017;17:241. 8. setyowati a, yusuf a, haksama s, firdaus s. validity and reliability of shift work disorder questionnaire among indonesian female nurses. malaysian j public health med 2021;21:14550. 9. irsyad m, widiyanti p, rahmatillah a. audio-visual stimulation for improving sleep quality. aip conf proc 2020;2314. 10. dong h, zhang q, zhu c, lv q. sleep quality of nurses in the emergency department of public hospitals in china and its influencing factors: a cross-sectional study. health qual life outcomes 2020;18:116. 11. smither jw, london m. performance management: putting research into action. jspm 2013;1:37-41. 12. johnson rh, williams sk. examining the relationship between sleep quality and mental well-being in nursing professionals. j adv nurs 2020;76:2294-304. 13. thompson r, baker fc. sleep and mental well-being in healthcare professionals: a meta-analysis. behav sleep med 2016;14:609-24. 14. begat i, ellefsen b, severinsson e. nurses’ satisfaction with their work environment and the outcomes of clinical nursing supervision on nurses_ experiences of well-being — a norwegian study. j nurs manag 2005;13:221-30. 15. laschinger hks, leiter mp. the impact of nursing work environments on patient safety outcomes: the mediating role of burnout/engagement. j nurs adm 2006;5:259-67. 16. bowers l, allan t, simpson a, et al. adverse incidents, patient flow and nursing workforce variables on acute psychiatric wards: the tompkins acute ward study. int j soc psychiatry 2007;53:75-84. 17. greenslade jh, jimmieson nl. distinguishing between task and contextual performance for nurses: development of a job performance scale. j adv nurs 2007;58:602-11. 18. tzeng hm. nurses’ self-assessment of their nursing competencies, job demands and job performance in the taiwan hospital system. int j nurs stud 2004;41:487-96. 19. kaur s, kok ey, jamil na, sebayang sk. exploring the relationship between sunlight exposure, psychological health, and gestational weight gain: a prospective observational study. bmc public health 2024;24:122. 20. brown a, davis ll. exploring the multifactorial nature of mental health in nursing: a comprehensive review. j nurs scholarsh 2020;52:376-85. 21. dieleman m, toonen j, touré h, martineau t. the match between motivation and performance management of health sector workers in mali. hum resour health 2006;4:2. 22. dyrbye ln, shanafelt td, johnson po, et al. a cross-sectional study exploring the relationship between burnout, absenteeism, and job performance among american nurses. bmc nurs 2019;18:57. 23. gbd 2017 disease and injury incidence and prevalence collaborators. global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. lancet 2018;392:1789-858. 24. perry l, lamont s, brunero s, et al. the mental health of nurses in acute teaching hospital settings: a cross-sectional survey. bmc nurs 2015;14:15. 25. abualrub rf. job stress, job performance, and social support among hospital nurses. j nurs scholarsh 2004;36:73-8. 26. mrayyan mt, al-faouri i. career commitment and job performance of jordanian nurses. nurs forum 2008;43:24-37. 27. curcio g, tempesta d, scarlata s, et al. validity of the italian version of the pittsburgh sleep quality index (psqi). neurol sci 2013;34:511-9. 28. patarru’ f, weu by, handini fs, heryyanoor h. the role of the nurse unit manager function on nursing work performance: a systematic review. j ners 2019;14:231-5. 29. stewart-brown s. the warwick-edinburgh mental well-being scale (wemwbs): performance in different cultural and geographical groups. in: keyes clm, ed. mental well-being. international contributions to the study of positive mental health. dordrecht, netherlands: springer; 2013. pp 133-50. 30. koopmans l, bernaards c, hildebrandt v, et al. development of an individual work performance questionnaire. int j product perform manag 2012;62:6-28. 31. koopmans l, bernaards cm, hildebrandt vh, et al. construct validity of the individual work performance questionnaire. j occup environ med 2014;56:331-7. 32. nazatul sm, saimy i, moy fm, nabia as. prevalence of sleep disturbance among nurses in a malaysian government hospital and its association with work characteristics. j heal transl med 2008;11:66-71. 33. mcdowall k, murphy e, anderson k. the impact of shift work on sleep quality among nurses. occup med 2017;67:621-5. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 540] [healthcare in low-resource settings 2024;12:12096] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12061 improving flipped classroom learning for patients with diabetes mellitus: an exploration into the influence of educational factors suyanto suyanto,1,2 tintin sukartini,2 ferry efendi,2 mohammad arifin noor,1 ahmad ikhlasul amal,1 indah sri wahyuningsih,1 dwi retno sulistyaningsih,1 wigyo susanto,1 abrori1 1faculty of nursing, universitas islam sultan agung, semarang; 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract patients with diabetes often lack the necessary knowledge, leading to inadequate behavior in preventing wounds. to overcome the limitations of traditional learning methods, it is crucial to adopt the flipped classroom approach for effectively educating diabetic patients about wound prevention. this study aimed to explore the relationship between the environment, learning infrastructure, and the flipped classroom learning method among patients with diabetes mellitus (dm). employing a cross-sectional design, the study encompassed patients with dm aged 40-55 years from both genders. a total of 120 patients were selected through purposive sampling techniques. the variables investigated included education factors and the flipped classroom method, which were assessed using a modified questionnaire developed by the researchers and validated for reliability. data analysis was conducted utilizing spearman rank analysis. concerning education factors, 80% of the participants reported having a supportive environment, while 82.5% indicated having access to good learning infrastructure. regarding the flipped classroom method, 35.8% of the respondents stated that its application in educating patients with dm in the community was effective. there was a statistically significant relationship between the environment and infrastructure and the flipped classroom approach in patients with dm (p-value<0.05). enhancing educational factors such as the environment and infrastructure can improve the effectiveness of the flipped classroom method in educating patients with dm. moreover, promoting health literacy could further enrich the learning experience for diabetic patients, ultimately bettering their behavior and management of the condition. future research on the flipped classroom learning approach for dm should focus on patient engagement and cultural adaptation to improve overall patient outcomes and the effectiveness of the healthcare system. introduction diabetes mellitus (dm) is a chronic metabolic disease characterized by elevated blood glucose or blood sugar levels.1 access to affordable treatment and community support, as well as learning opportunities outside the traditional classroom setting, are crucial for the well-being of individuals with diabetes.2 learning activities should be tailored to provide a personalized learning experience, fostering ownership, achievement, and creativity among participants.3,4 the flipped classroom model, which categorizes participants based on their learning styles, is employed in teaching diabetes management, transforming traditional learning into a more interactive approach that enhances patients’ understanding of their condition.5,6 research indicates that the use of flipped classrooms significantly increases knowledge among patients.7 this approach emphasizes openness, feedback on experiences, and the collaboration of interdisciplinary groups of learners and experts within the community.8-10 four hundred and twenty-two million people worldwide have diabetes, and 1.5 million die annually.11 indonesia ranks 6th out of the ten countries with the highest number of dm patients, which is expected to increase to 16.7 milcorrespondence: suyanto, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: suyanto-2020@fkp.unair.ac.id key words: diabetes mellitus, education, flipped classroom. contributions: ss, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ts, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; fe, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; tf, methodology, visualization, writing – review and editing; aia, ws, ab, resources, investigation, and writing –review and editing; isw, formal analysis, validation, writing – review and editing; drs, resources, supervision. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. funding: none. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas airlangga, based on ethical certificate no.390/a.1kepk/fik-sa/viii/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: this article is supported by the head of bangetayu and tlogosari kulon public health center, semarang city. received: 9 november 2023. accepted: 21 march 2024. early access: 17 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12061 doi:10.4081/hls.2024.12061 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 472] [healthcare in low-resource settings 2024;12:12061] non -co mmerc ial us e o nly lion patients per year by 2045.12 the prevalence of dm in central java was 13.4% in 2019. a preliminary study conducted at the mranggen iii health center revealed that at least 64 patients had dm between january and june 2019.13 in the city of semarang, only 58% of patients with dm received regular foot care, 55% did not wear appropriate footwear, only 55% used moisturizer once a month, and only 39% practiced foot washing once a week.14 these statistics highlight a critical gap in self-management practices among diabetic patients, underscoring the urgent need for improved education and support to prevent complications and enhance quality of life for those living with this condition.15,16 flipped classrooms are an endeavor to develop a comprehensive educational program, increase information accessibility, and serve as an important component in expanding access to quality health services for dm patients.17 this method offers learning approaches that provide in-depth explanations of diseases, symptoms, risk factors, and management, which can aid patients in making informed decisions.18 furthermore, flipped classrooms assist patients in comprehending learning materials by employing methods that prioritize discussion, critical thinking, problem-solving, and practical approaches.19 the findings reveal that the contributions of flipped classrooms significantly impact knowledge acquisition and team effectiveness, playing a pivotal role in the learning context and serving as a significant mediator.20 thus, dm patients can take charge of their learning and engage when they desire, according to their schedule and personal preferences.21 components such as motivation, metacognition, help-seeking behavior, time management, and learning strategies are involved in self-directed learning. the results indicate a positive relationship between student motivation and academic achievement, with students demonstrating high self-efficacy and intrinsic value tending to achieve strong academic performance.22,23 this strategy can increase motivation and foster a sense of responsibility towards understanding and managing dm. additionally, learning materials provide opportunities for patients to pose more in-depth and relevant questions when interacting with health professionals or fellow patients.24 this notion is supported by research demonstrating an improvement in developing selflearning strategies and engaging in deep and active learning.25 some experts argue that a flipped classroom places students at the center of the learning process. this system enables students to independently access knowledge sources outside the classroom, such as recorded teaching videos and online teaching materials, with in-class time devoted to practice.26,27 however, patients with vision, hearing, or other impairments may face challenges in fully utilizing these learning materials.28 the flipped classroom approach represents a shift from traditional classroom learning to outside-the-classroom learning during face-to-face meetings.29 this approach demands personal motivation and discipline from patients to consistently engage with learning material, particularly when they may feel less challenged or isolated.30 nevertheless, several obstacles hinder the application of flipped classrooms in dm patients within the community, including limited technology accessibility requiring digital literacy skills, time constraints, diverse learning styles, and the need for family and environmental support. the absence of direct supervision can also diminish the effectiveness of this approach.31,32 conversely, the use of a flipped classroom facilitates learning from anywhere and encourages more active, interdisciplinary learning in specific health topics, demonstrating a significant impact.8,33 another obstacle to the use of a flipped classroom approach in dm patients within the community is the low level of medical literacy and inadequate environment and infrastructure.34 dm patients require support from their family and surrounding environment to comprehend and apply information in a flipped classroom approach, as a lack of support can impede learning effectiveness.35 this lack of support may lead to difficulties in understanding complex information, variations in learning styles, and limited cognitive abilities.36 this study aimed to examine the correlation between educational factors and the flipped classroom method in dm patients. materials and methods research design this research employed a cross-sectional approach to analyze the factors influencing the use of the flipped classroom method in dm education. study participants researchers investigated dm with a sample size of 120 respondents, following the rule of thumb for sample size calculation based on 24 indicators. the study employed nonprobability sampling, specifically a purposive sampling method. inclusion criteria involved participants aged 40-55, both genders, diagnosed with dm, having a specific level of consciousness, and possessing the ability to read, write, hear, and see well. this targeted approach allowed researchers to focus on a relevant subgroup for their objectives. the study’s design aimed to provide valuable insights into the selected population’s characteristics and experiences. variable, instrument, and data collection independent variables consisted of demographic factors (age, gender, education, occupation, and length of diabetes) and the education factor (environment and infrastructure). the dependent variable consisted of the flipped classroom method in foot care education (educational materials and educational methods). the environment was assessed as the physical surroundings influencing the learning process. infrastructure was evaluated as the available resources supporting educational activities. the flipped classroom method in foot care education consisted of educational materials that included the quality and effectiveness of the materials used in foot care education. educational methods were perceived to be effective in teaching approaches within the flipped classroom model. the research instrument questionnaire for educational factors and flipped classroom used a structured set of questions utilizing a 4-point likert scale (4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree). the data collection process involved the distribution of the validated questionnaire to participants. participants were asked to provide responses based on their experiences and perceptions regarding demographic factors, environmental conditions, infrastructure, and the effectiveness of the flipped classroom method in foot care education. responses were recorded using the 4-point likert scale. the collected data were then subjected to analysis to explore relationships and patterns among variables, providing insights into the impact of demographic and environmental factors on the success of the flipped classroom approach in foot care education. data was collected in september until november 2022 in the health center in semarang, indonesia. data analysis data analysis aimed to explain and describe the characteristics and relationships between research variables. research data on transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12061] [page 473] non -co mmerc ial us e o nly independent and dependent variables was on an ordinal scale, so a frequency distribution was used. bivariate analysis was used to determine the relationship between educational factors and the flipped classroom. the analytical test used to determine the relationship between these two variables was ranked spearman with a significant level of 5%. ethical clearance the research received ethical approval from the health research ethics commission, faculty of nursing, universitas islam sultan agung, based on ethical certificate no.390/a.1kepk/fik-sa/viii/2022. informed consent was taken before collecting data. during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results the demographic analysis of the study reveals a predominant population of participants aged 46-65, categorized as the early elderly group (70.8%), primarily female (56.7%), with elementary education (56.7%), and having a diabetes duration of less than 5 years (62.5%). further details of these results are explained in table 1. from the independent and dependent variables, it was observed that 80% of participants perceived the environment as good, 82.5% perceived the infrastructure as good, and 35.8% perceived the flipped classroom as effective. the study suggests positive perceptions among participants regarding the educational environment and infrastructure, although a comparatively lower percentage recognizes the effectiveness of the flipped classroom method. further detailed results are provided in table 2. the spearman rank analysis test results show that the p-value is < 0.05, indicating a significant influence of the independent variables on the dependent variable. this analysis reveals a statistically significant association between the independent variables and the dependent variable, emphasizing their impactful relationship. discussion flipped classrooms offer flexibility and facilitate learning based on the latest evidence, employing interactive and effective teaching strategies within the community. research findings confirm that both the environment and infrastructure significantly influence the implementation of flipped classrooms in the community (p<0.05). over the past decade, there has been a growing interest in flipped classrooms, which are widely accepted as an interactive pedagogical strategy.37,38 empirical evidence suggests that implementing flipped classrooms is more effective than traditional methods and has garnered positive feedback within the educational environment.39 this approach to learning promotes personal interaction, enhances situational awareness, and fosters the application of critical thinking skills and cognitive education. thirty-five point eight percent of the implementation of the flipped classroom in the community was reported to be successful. support from the home environment, including family support and commitment to learning, plays a crucial role. a study conducted in oman concluded that the flipped classroom method serves as a valuable tool and a motivational factor for effective learning. moreover, the flipped classroom method has led to a shift in learning approaches towards more flexible, effective, active, and person-centered teaching strategies.40 research conducted in china demonstrated that the flipped classroom fosters active participation and knowledge sharing and contributes to effective student learning.41 similarly, research in switzerland suggests that the flipped classroom can be adapted for online teaching and assessment sessions, emphasizing its utility as a motivational factor for effective learning, understanding, and retention of conceptual and factual content.42 educational factors play a crucial role in influencing the level of independence and engagement of patients in learning. patients who are independent and actively involved tend to adapt more successfully to the flipped classroom model. moreover, there exists a significant positive correlation between home environmental factors and an individual’s cognitive level.38 the home environment facilitates flexible implementation of classes, with 80% reported to be supportive, committed, and providing adequate study spaces.39 both online and offline learning environments significantly impact learning outcomes, with the home environment for dm patients fostering increased interaction and enthusiasm for studying the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 474] [healthcare in low-resource settings 2024;12:12061] table 1. characteristics of respondents (n=120). characteristic of respondents frequency percentage age adult (36-45 years) 35 29.2 early elderly (46-55 years) 85 70.8 gender male 52 43.3 female 68 56.7 length of diabetes mellitus under 5 years 75 62.5 over 5 years 45 37.5 education elementary education 68 56.7 middle education 35 29.2 high education 17 14.1 table 2. description of research variable. variables frequency percentage education factors environment less 24 20 good 96 80 infrastructure less 21 17.5 good 99 82.5 flipped classroom less 25 20.8 enough 52 43.3 good 43 35.8 non -co mmerc ial us e o nly provided material, consequently enhancing their knowledge and skills.43 infrastructure, as an integral part of the home environment, influences comfort, safety, and functionality, with 82.5% of infrastructure in flipped classroom implementation reported to be of good quality.44-46 this enhances the creation of a comfortable, safe, and conducive home environment. additionally, research underscores the close relationship between the home environment and infrastructure, emphasizing the importance of a well-equipped home environment in addressing health issues, including those related to dm. moreover, the rapid dissemination of collective wisdom from leading expert organizations highlights the significance of public health.46,47 the level of health literacy plays a pivotal role in enabling dm patients to comprehend the material and undertake appropriate actions based on the provided information.48 consequently, additional support is essential, encompassing technical assistance, program enhancements, and healthcare provider engagement.49 moreover, ongoing evaluation of the impact of educational factors on the utilization of the flipped classroom method is imperative. however, certain limitations, such as technology accessibility, digital literacy skills, and time constraints, may impede the adaptation of this approach to society.50 to address these challenges, a creative learning style is required, considering diverse backgrounds, educational levels, and comprehension abilities. furthermore, family support and active involvement in the process are crucial to bolstering the effectiveness of this approach. conclusions the success of the flipped classroom learning method in dm education depends on a supportive environment and infrastructure. essential components include access to digital learning materials, technological resources, and a conducive physical classroom setting. interactive tools, professional support, and continuous assessment play pivotal roles in enhancing the effectiveness of this approach. furthermore, incorporating cultural sensitivity and promoting health literacy enrich the learning experience for diabetes patients, ultimately improving their behavior and management of the condition. future research on flipped classroom learning for dm should prioritize patient engagement and cultural adaptation to enhance overall patient outcomes and the effectiveness of the healthcare system. ìreferences 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 2. hwei lk. impact of professional learning communities on teacher professional development in oman. malaysian online j educ manag 2015;3:1-23. 3. lameras p, moumoutzis n. towards the gamification of inquiry-based flipped teaching of mathematics: a conceptual analysis and framework. 2015. available from: https://ieeexplore.ieee.org/document/7359616 4. govindaraj a, silverajah vsg. blending flipped classroom and station rotation models in enhancing students’ learning of physics. 2017. available from: 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potential methods to improve self-management in those with type 2 diabetes: a narrative review. int j endocrinol metab 2023;21. 16. akoit ee, efendi f, dewi ys. impact of diabetes self-management education in middle-aged patients with type 2 diabetes mellitus: a systematic review. gac med caracas 2022;130:s1183-95. 17. dong y, yin h, du s, wang a. the effects of flipped classroom characterized by situational and collaborative learning in a community nursing course: a quasi-experimental design. nurse educ today 2021;105. 18. wassinger ca, owens b, boynewicz k, williams da. flipped classroom versus traditional teaching methods within musculoskeletal physical therapy: a case report. physiother theory pract 2022;38:3169-79. 19. sezer ta, esenay fi. impact of flipped classroom approach on undergraduate nursing student’s critical thinking skills. j prof nurs 2022;42:201-8. 20. lin cy, huang ck. understanding the antecedents of knowledge sharing behaviour and its relationship to team effectiveness and individual learning. australas j educ technol 2020;36. 21. limniou m, schermbrucker i, lyons m. traditional and flipped classroom approaches delivered by two different teachers: the student perspective. educ inf technol 2018;23:797817. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12061] [page 475] non -co mmerc ial us e o nly 22. mckeirnan kc, colorafi k, kim ap, et al. study behaviors associated with student pharmacists’ academic success in an active classroom pharmacy curriculum. am j pharm educ 2020;84:1-11. 23. qin j, jia z. learner-generated behaviours in a flipped learning: a focus on computer culture foundation course. int j contin eng educ life-long learn 2020;30:1-14. 24. tanzeh a, fadhilah da, chotimah c, et al. the importance of improving education quality and principal leadership in improving school competitiveness. malaysian online j educ manag 2021;9:17-31. 25. mclean s, attardi sm, faden l, goldszmidt m. flipped classrooms and student learning: not just surface gains. adv physiol educ 2016;40:47-55. 26. pugsee p. effects of using flipped classroom learning in objectoriented analysis and design course. 2017. available from: https://ieeexplore.ieee.org/document/8074130 27. silberg j, bennick m, caverzagie k, richards s. how do health systems approach patient experience? development of an innovative elective curriculum for medical students. patient exp j 2020;7:105-9. 28. steinberg fm, batchelor-murphy mk, young hm. supporting family caregivers: no longer home alone: eating for healthy aging. am j nurs 2019;119:43-51. 29. ito a, isohama y, watanabe k. comparison of flipped and traditional lecture-based classrooms for kampo (traditional japanese medicine) education in a medical school. int j educ res open 2022;3:100156. 30. sullivan-bolyai s. familias apoyadas: latino families supporting each other for diabetes care. j pediatr nurs 2009;24:495505. 31. juul l, rowlands g, maindal ht. relationships between health literacy, motivation and diet and physical activity in people with type 2 diabetes participating in peer-led support groups. prim care diabetes 2018;12:331-7. 32. de arruda go, marcon ss, aveiro hep, et al. effects of selfcare supported by nurses in men with type 2 diabetes mellitus. rev baiana enferm 2022;36. 33. songsangyos p, kankaew s, jongsawat n. learners’ acceptance toward blended learning. 2016. available from: https://ieeexplore.ieee.org/document/7556085 34. fitzgerald n, morgan kt, slawson dl. practice paper of the academy of nutrition and dietetics abstract: the role of nutrition in health promotion and chronic disease prevention. j acad nutr diet 2013;113:983. 35. hultsjö s, hjelm k. community health-care staff’s experiences of support to prevent type 2 diabetes among people with psychosis: an interview study with health staff. int j ment health nurs 2012;21:480-9. 36. youssef ga. 2019 health care & education presidential address: it’s all about access! diabetes care 2021;44:1-7. 37. pulukuri s, abrams b. improving learning outcomes and metacognitive monitoring: replacing traditional textbook readings with question-embedded videos. j chem educ 2021;98:2156-66. 38. de villiers r, hess ac. melding traditional and progressive andragogy in marketing education, using the hermeneutic competency development strategy. australas mark j 2018;26:140-56. 39. mottaghi nr, talkhabi m. comparative study of iran and the uk national curriculum based on the principles of mind, brain and education. j curric teach 2019;8:46-57. 40. shatto b, l’ecuyer k, quinn j. retention of content utilizing a flipped classroom approach. nurs educ perspect 2017;38:206-8. 41. wang x, dong l, lyu w, geng z. teaching health assessment symptomatology using a flipped classroom combined with scenario simulation. j nurs educ 2020;59:448-52. 42. soares f, de moura oliveira pb, leão cp. your turn to learn – flipped classroom in automation courses. available from: https://repositorium.sdum.uminho.pt/handle/1822/70949 43. park eo, park jh. quasi-experimental study on the effectiveness of a flipped classroom for teaching adult health nursing. japan j nurs sci 2018;15:125-34. 44. volodina a. home learning environment and out-of-home activities: their relations to prosocial behaviour and peer relationships in primary school children. curr psychol 2022;0123456789. 45. bomberg em, neuhaus j, hake mm, engelhard em, seligman hk. food preferences and coping strategies among diabetic and nondiabetic households served by us food pantries. j hunger environ nutr 2019;14:4-17. 46. bobbink p, teixeira cm, charbonneau l, et al. e-learning and blended-learning program in wound care for undergraduate nursing students. j nurs educ 2022;61:53-7. 47. van vliet ms, schultink jm, jager g, et al. the baby’s first bites rct: evaluating a vegetable-exposure and a sensitivefeeding intervention in terms of child health outcomes and maternal feeding behavior during toddlerhood. j nutr 2022;152:386-98. 48. shin ks, lee eh. relationships of health literacy to self-care behaviors in people with diabetes aged 60 and above: empowerment as a mediator. j adv nurs 2018;74:2363-72. 49. ha nt, sinh dt, ha ltt. the association of family support and health education with the status of overweight and obesity in patients with type 2 diabetes receiving outpatient treatment: evidence from a hospital in vietnam. heal serv insights 2021;14. 50. aksoy b, pasli gurdogan e. examining effects of the flipped classroom approach on motivation, learning strategies, urinary system knowledge, and urinary catheterization skills of firstyear nursing students. japan j nurs sci 2022;19. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 476] [healthcare in low-resource settings 2024;12:12061] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11982 booklet preventing stunting based android application (bocesting) as a tool to enhance maternal nutritional behaviour and nutritional status dewi mey lestanti mukodri,1 tiyara safitri,1 rita ridayani,1 fardila elba,2 neny san agustina siregar3 1ministry of health health polytechnic tanjungpinang, tanjungpinang, indonesia; 2lincoln university college, kuala lumpur, malaysia; 3ministry of health health polytechnic jayapura, jayapura, indonesia abstract the most common health problem was the lack of nutrition, known as stunting. one approach to addressing nutritional issues in young children was through health education using the android method. the study aimed to analyze the differences in the influence of stunting prevention education using booklet media and an android-based application on maternal nutritional behavior and nutritional status, with the ultimate goal of preventing stunting cases. the research design employed a quantitative approach, specifically a quasi-experiment. measurement tools included questionnaires assessing maternal nutrition behavior, with the samples divided into three intervention groups and one control group (n=51). data analysis involved statistical tests, including wilcoxon, mann whitney u, and kruskall wallis h. the results indicated that educational media using booklets significantly improved maternal nutrition behavior after the intervention (p<0.05). however, there was no significant increase in the nutritional status of children (p=0.317). similarly, the android application intervention group exhibited a significant improvement in maternal nutrition behavior (p<0.05), while the nutritional status of the children did not significantly change (p=0.193). a significant difference was observed in the impact of the media interventions between the booklet and android application intervention groups and the control group regarding the enhancement of maternal nutritional behavior (p<0.05) and children’s nutritional status (p>0.005). in conclusion, educational media in the form of booklets and android applications can influence maternal nutrition behavior and children’s nutritional status in the context of stunting prevention education. introduction health problems in developing countries, including indonesia, often revolve around nutritional issues, which indirectly contribute to the mortality of both mothers and children.1 the age group under five years is particularly susceptible to nutritional challenges due to their relatively high growth requirements compared to adults.2 one of the most prevalent health issues in this context is malnutrition, commonly referred to as stunting.3 stunting is a chronic malnutrition problem caused by a prolonged lack of nutritional intake, leading to growth disorders in children, characterized by shorter height compared to the standard for their age.4 the government must address stunting seriously because it has the potential to reduce indonesia’s future human resources’ productivity. it is crucial to reduce the incidence of stunting in toddlers as early as possible to avoid long-term adverse effects, such as hindered child development. stunting can negatively impact brain development, leading to suboptimal intelligence levels in children.5 stunting problems can actually be prevented by improving the diet to meet the nutritional requirements.6 moreover, stunting incidents must receive specific attention from mothers, fathers, surrounding families, and the government.7 the measure of success in nutritional fulfillment is the child’s nutritional status as indicated by their weight and height.8 according to the indonesian government’s targets, the goal is to reduce the prevalence of stunting to less than 14% of the total number of children under five by 2024 (pepres no. 18 tahun 2020). the short stature of a child is often attributed to inherited correspondence: dewi mey lestanti mukodri, ministry of health health polytechnic tanjungpinang, tanjungpinang, indonesia. e-mail: dewimey@poltekkes-tanjungpinang.ac.id key words: android apps; booklet; education; nutrition; stunting. contributions: dmlm, conceptualization, data curation, methodology, validation, visualization, writing – original draft, review and editing; fe, formal analysis, methodology, validation, and writing – original draft, review and editing; ts, conceptualization, investigation, validation, and writing – original draft, review and editing; rr investigation, methodology, visualization, writing – review and editing; nsas, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan bani saleh, as indicated by ethical certificate ec.269/kepk/stkbs/viii/2023. throughout the research, the researcher has adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 14 october 2023. accepted: 17 november 2023. early access: 30 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11982 doi:10.4081/hls.2023.11982 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11982] [page 83] non -co mmerc ial us e o nly factors from both parents. consequently, many people tend to accept it without taking preventive measures.9 however, it is essential to recognize that genetics is the least influential health determinant when compared to behavioral, environmental, and healthcare factors. therefore, parents should promptly identify any developmental abnormalities in their child.10 the pattern of stunting is also influenced by behavioral aspects, particularly in the nursing and feeding practices, especially in toddlers.8 indonesia has a high prevalence of stunting compared to other middle-income countries. according to the 2018 basic health research, the rates of underweight, stunting, and wasting are 17.8%, 30.8%, and 10.24%, respectively.11 the prevalence of stunting and underweight was significantly higher when assessed using the who standard compared to the national reference (53.9% vs 10.7% and 29.17% vs 17.7%; all p<0.001).12 based on research conducted by mubasyiroh and aya in 2018 on the relationship between maternal behavior in fulfilling nutrition during a child’s first 1000 days of life, also known as the golden period, and the nutritional status of young children in sitanggal village, brebes district, it was found that the majority of young mothers exhibited inadequate behavior, at 51.0%, while most children had poor nutritional status, accounting for 49.0%. the results of the statistical test using the chi-square test indicated a p-value of 0.003, which is less than the significance level α (0.05). this suggests that there is a significant relationship between maternal behavior in providing nutrition during a child’s first 1000 days and the nutritional status of the child.13 referring to the health department profile of riau islands province, the prevalence of stunting cases in the province in 2020 was 7.2%, distributed across 7 (seven) districts/cities. bintan district is one of the areas where the stunting rate remains high at 11.0%, affecting 15 public health centers (phcs). the world has now entered the era of 4.0, characterized by digitalization, the widespread use of social media, and the necessity of owning a smartphone.14 one approach to addressing the nutritional problems of young children is through health education using the android method. this approach aligns with the findings of research conducted by mukodri et al. in 2020, which indicated that the android method can significantly assist pregnant mothers in improving their knowledge of balanced nutrition in a manner that is easy to use and efficient.1 building upon previous research regarding nutritional care patterns as part of stunting prevention efforts, using booklet media for prevention (bocesting), this study aimed to investigate the impact of the bocesting application on knowledge enhancement compared to traditional dissemination methods.15 based on this, the author is interested in conducting research on a booklet-based stunting prevention approach, known as bocesting, using an android application as an educational medium to improve maternal nutrition behavior and the nutritional status of young children within the special community of riau islands, particularly in the area served by the public health center (phc) of kampung bugis in the complex village of bugis, tanjungpinang city. the aim of this study is to assess the difference in the effectiveness of providing stunting prevention education through booklet media and android-based applications in enhancing maternal nutritional behavior and the nutritional status of toddlers, with the ultimate goal of preventing stunting in toddlers. this research is of great importance as it represents an effort to prevent the increasing prevalence of stunting incidents in indonesia. the design of the tool is aligned with current media trends, utilizing an android-based application that is user-friendly and accessible at any time. this educational media platform is expected to make a significant contribution to stunting prevention, particularly in the context of young children. moreover, it serves as part of the broader efforts to support the implementation of a health system transformation program, with a particular focus on stunting prevention priorities. materials and methods research design this study employs a quantitative method (quasi-experiment) with an equivalent control group design, involving pretest-posttest and analytical analysis. the quasi-experimental design method is utilized to assess the improvement in maternal nutritional behavior and the nutritional status of toddlers. study participants the target population for this study consisted of all mothers with toddlers in the service area of the kampung bugis community health center, based on data from august 2023, totaling 109 individuals. the accessible population for this study included mothers with toddlers within the same service area of the kampung bugis community health center who met the inclusion and exclusion criteria, as of august 2023, which amounted to 51 individuals. throughout the study, none of the respondents dropped out, resulting in a total of 51 participants: 17 in the control group, 17 in the first experimental group, and 17 in the second experimental group. variable, instrument and data collection the variables in this study included independent variables, which were education using booklet media and android application media. the dependent variables consisted of maternal nutritional behavior and the nutritional status of toddlers, while the confounding variables in this study encompassed environmental and genetic factors. the research instrument used for data collection in this study included health education using stunting prevention booklet media, which was provided to mothers of toddlers in the form of booklets. these booklets contained information on the definition of stunting, factors contributing to stunting, characteristics of stunting, sanitation practices for preventing stunting, the impact of stunting, stunting prevention measures, and sanitation practices for stunting prevention. health education was administered after pre-tests and post-tests at the posyandu in august 2023, and the booklets were taken home by the mothers of toddlers. follow-up was conducted through chat media every three days. health education with an bocesting based android application media was also provided to mothers of toddlers in the form of an android application. this application contained information on the definition of stunting, factors causing stunting, stunting characteristics, the impact of stunting, stunting prevention methods, and sanitation practices for stunting prevention. health education sessions were conducted once a week for a month in a group format. mothers of toddlers were able to download the android application to learn and apply the information at home. follow-up was carried out through chat media every three days. the data collection tools used to measure changes in improving maternal nutrition behavior included questionnaires and checklist sheets for cognitive, affective, and psychomotor aspects. the determination of the nutritional status of toddlers in this study was based on anthropometric indices such as pb/u or tb/u, as well as scales and body length gauges. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 84] [healthcare in low-resource settings 2024;12:11982] non -co mmerc ial us e o nly data analysis the collected data were analyzed through univariate analysis to describe the frequency distribution of each variable, including the independent variables (booklet media and android application media) and dependent variables (maternal nutritional behavior and nutritional status of toddlers). bivariate analysis in this study included a normality test, conducted using the kolmogorovsmirnov test, which indicated that the data were not normally distributed on a categorical scale. for the analysis of pre-test and post-test values of the three groups, the wilcoxon signed-rank test, a non-parametric statistical method, was employed. the mann-whitney u analysis, another non-parametric statistical method, was used to compare two independent groups. multivariate analysis was performed using kruskal-wallis h, a method used to assess the independent variable that had the most significant influence. results table 1 presents the characteristics of the control group, revealing that the majority of participants were in the age range of 0-23 months, comprising 9 people (52.9%), while the smallest age group was 24-59 months, with 8 people (41.1%). in the booklet group, most participants fell into the age category of 0-23 months, with 10 people (58.8%), while the smallest age group was 24-59 months, consisting of 7 people (42.2%). for the application group, the majority of participants were in the 0-23-month age range, with 12 people (70.6%), while the smallest age group was 24-59 months, with 5 people (29.4%). regarding gender characteristics, the control group, booklet group, and application group mostly comprised males, accounting for 11 in the control group (64.7%), 10 in the booklet group (58.8%), and 10 in the application group (58.8%). exclusive breastfeeding was predominant in all groups, with 14 people (82.3%) in the control group, 13 people (76.4%) in the booklet group, and 13 people (76.4%) in the application group. in terms of the age characteristics of mothers, the majority fell within the age group of 21-30 years in all three groups: 13 in the control group (76.4%), 12 in the booklet group (70.6%), and 11 in the application group (64.7%). regarding the education of mothers, the majority had a senior high school education level: 7 people in the control group (41.2%), 10 people in the booklet group (58.8%), and 7 people in the application group (41.02%). when it comes to the occupation of mothers, the majority were employed in all groups: 17 people in the control group (100%), 17 people in the booklet group (100%), and 14 people in the application group (82.4%). in terms of parents’ income, the majority had incomes equal to or less than the regional minimum wage: 17 people in the control group (100%), 17 people in the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents based on toddler age, gender, exclusive breastfeeding, mother's age, mother's education, mother's occupation, mother's job, parent's income, nutritional status based on height according to age of toddler. variable control group booklet group bocesting based android (n=17) (n=17) application (n=17) f % f % f % toddler age 0-23 months 9 52.9 10 58.8 12 70.6 24-59 months 8 41.1 7 41.2 5 29.4 gender male 11 64.7 10 58.8 10 58.8 female 6 35.3 7 41.2 7 41.2 exclusive breastfeeding yes 14 82.3 13 76.4 13 76.4 no 3 17.7 4 23.6 4 23.6 mother’s age ≤ 0 years 0 0 0 0 0 0 21-30 years 13 76.4 12 70.6 11 64.7 ≥31 years 4 23.6 5 29.4 6 35.3 mother's education primary school 5 29.4 3 17.7 2 11.8 high school 5 29.4 4 23.5 6 35.2 senior high school 7 41.2 10 58.8 7 41.2 college 0 0 0 0 2 11.8 mother's job work 17 100 17 100 14 82.4 not working 0 0 0 0 3 17.6 parent's income ≤regional minimum wage 17 100 17 100 14 82.4 regional minimum wage 0 0 0 0 2 11.8 ≥regional minimum wage 0 0 0 0 1 5.8 nutritional status very short 2 11.8 5 29.4 3 17.6 short 2 11.8 7 41.2 3 17.6 normal 13 76.4 5 29.4 11 64.8 total 17 100 17 100 17 100 [healthcare in low-resource settings 2024;12:11982] [page 85] non -co mmerc ial us e o nly booklet group (100%), and 14 people in the application group (82.4%). in the application group, the nutritional status of toddlers varied by age. the highest nutritional status was ‘normal’ nutritional status, accounting for 13 people (76.4%), while the lowest was ‘short’ and ‘very short’ nutritional status, involving a total of 2 people (11.8%). for the booklet group, the predominant nutritional status was ‘short,’ with 7 people (41.2%), whereas the lowest were ‘normal’ and ‘very short’ nutritional statuses, each with 5 people (29.4%). in the control group, the highest nutritional status observed was ‘normal’ nutritional status, encompassing 11 people (64.8%), while the lowest were ‘very short’ and ‘short’ nutritional statuses, each with 3 people (17.6%). based on table 2, significant differences were observed in the android group between pre-test and post-test scores for cognitive, affective, psychomotor, nutritional behavior, and maternal attitudes towards nutrition. however, no significant differences were found for nutritional status. in the booklet group, there were significant differences in the increase in pre-post test scores for cognitive, psychomotor, nutritional behavior, and attitudes, while there were no significant differences for affective aspects and nutritional status. in the control group, there were no significant differences between pre-test and post-test scores. based on table 3, the results show a significant improvement in nutritional behavior when comparing the booklet group to the control group. however, there is no significant difference in nutritional status when comparing the booklet group to the control group. based on table 4, the results indicate a significant comparison of maternal nutritional behavior between the android application group and the control group, while nutritional status did not exhibit a significant difference. based on table 5, the results reveal a more noticeable and significant increase in nutritional behavior in the android group compared to the mothers in the booklet group. however, there were no significant differences in nutritional status improvement between the booklet media group and the android application media education group. the android treatment group demonstrated a higher level of knowledge about stunting compared to the other treatment groups. in table 6, the chi-square value for maternal nutrition transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 5. comparative distribution of the value of improving nutritional behavior in the booklet group and the bocesting based android application (man whitnet u test results) (n=51). variable booklet group bocesting based android p (mean) application (mean) pre post mother’s nutrition 87.70 89.88 0.043 0.004 nutritional status 0.665 0.881 0.144 0.144 table 2. distribution of differences in scores before and after intervention in the booklet group, android application group and control group (wilcoxon test results) (n=51). research variable bocesting based android application booklet group control group pre post p pre post p pre post p (mean) (mean) (mean) ((mean) (mean) (mean) cognitive 72.66 85.56 0.001 61.71 68.89 0.001 66.04 73.41 0.100 affective 68.70 79.91 0.002 67.90 72.43 1.000 67.87 68.24 0.374 psychomotor 78.11 92.14 0.001 71.98 82.59 0.193 82.22 82.59 0.121 nutritional behavior 73.26 89.88 0.001 81.14 87.70 0.001 72.04 74.75 0.3050 mother's attitude to nutrition 77.42 95.50 0.002 72.46 89.60 0.003 66.38 81.77 74 nutritional status (tb/u) 0.770 0.881 0.317 0.671 0.665 0.193 0.481 0.415 0.076 table 3. comparative distribution of nutritional behavior improvement scores in the booklet group and control group (man whitney u test results) (n=51). variable booklet group control group p (mean) (mean) pre post mother's nutrition behavior 87.70 74.75 0.378 0.002 nutritional status 0.665 0.415 0.729 0.016 table 4. comparative distribution of nutritional behavior improvement scores in the bocesting based android application and control group (man whitnet u test results) (n=51). variable bocesting based android control group p application (mean) (mean) pre post mother's nutrition behavior 89.88 74.75 0.052 0.003 nutritional status 0.881 0.415 0.432 0.655 [page 86] [healthcare in low-resource settings 2024;12:11982] non -co mmerc ial us e o nly behavior was 51.95 with a p-value of 0.0003. these results indicate a significant difference in the improvement of maternal behavior towards nutrition in the three research groups. however, no significant change was observed in nutritional status improvement. regarding the advantages and disadvantages of educational media research, the android application media offers benefits such as portability since it can be accessed on a smartphone, discussion forums, and independent nutritional status measurement. however, a limitation of this android application is its inability to measure nutritional status using decimal numbers. discussion multivariate analysis in this study aimed to assess the varying degrees of influence of the booklet media intervention group, the android application intervention group, and the control group on the improvement of maternal nutritional behavior and the nutritional status of toddlers. the results indicated that for maternal nutritional behavior, the chi-square value was 51.95 with a pvalue of 0.0003, and for maternal attitudes towards nutrition, the chi-square value was 67.82 with a p-value of 0.001. based on the study’s findings, it can be concluded that there are significant differences in improving maternal behavior and attitudes towards nutrition within the three research groups. however, there was no significant change in improving nutritional status. behavior can be described as an individual’s response to a stimulus or action that can be observed and has specific characteristics such as frequency, duration, and purpose, whether it is consciously realized or not. understanding the underlying reasons for an individual’s behavior is essential before attempting to modify it.15 based on the research conducted by providing education through booklet media and applications, it was observed that the nutritional behavior and attitudes of mothers in the android group were significantly more pronounced compared to the nutritional behavior and attitudes of mothers in the booklet group. however, there was no significant difference in the improvement of nutritional status between the booklet media group and the android application media education group. booklets are essentially sheets of paper folded to provide concise descriptions of a problem, with short, easily understandable sentences and simple illustrations16. the booklet intervention is supported by pangesti’s research (2021), which demonstrates significant changes in maternal behavior regarding baby massage before receiving health education using the demonstration method and booklets. this is evident from the analysis results, which indicate a p-value of 0.000 (less than 0.005).17 the concept of mobile-based electronic learning is a product of technological advancements through mobile media, leading to innovations in the field of health education. this is substantiated by relawati’s research in 2018, which highlights that smartphones and tablet pcs are devices suitable for mobile learning, enabling patients and families to access chronic kidney failure education at any time and from anywhere18. these results are achieved because android media is easier to comprehend, as it includes an application menu that simplifies mothers’ understanding of how to ensure proper nutrition for stunted toddlers.19,20 this improved understanding leads to significant enhancements in the mothers’ behavior and attitudes. the issue of malnutrition, particularly stunting, can be attributed to insufficient nutritional intake in toddlers. this deficiency in nutritional intake is not solely a result of food availability but is also connected to economic circumstances, poor sanitation, and the mothers’ lack of knowledge about nutrition.21 booklets are provided in both hard copy and soft copy formats through whatsapp messenger, accessible on android devices, to assist cadres and mothers of toddlers in enhancing their knowledge about child nutrition and preventing stunting.22 this is supported by research indicating that there is an effect of stunting education using android applications on increasing maternal knowledge and attitudes.23 this study also demonstrated that educational media in the form of booklets, providing dietary recommendations for both healthy and sick children, has been proven to enhance knowledge regarding proper nutrition to prevent stunting. this aligns with the results of research that indicate flipchart media and booklets focusing on the first 1000 days of life (hpk), with themes such as regular weighing and the appropriate introduction of complementary foods, can foster behavior that leads to improved health outcomes24. we can conclude that the better our access to information about balanced nutrition, the more effectively we can implement balanced nutrition behaviors. this is because, when individuals receive information, their knowledge about balanced nutrition increases, enabling them to apply these behaviors properly. in the present era, the development of science and technology is highly advanced and of better quality, making it easier for individuals to access information in their daily lives through sources such as the internet, radio, health posters, scientific books, health counseling workers, and more. the use of the internet for information retrieval is prevalent in society, as it is one of the most convenient and easily accessible media for finding information, including in the field of health.25 this is supported by several studies that assert that education is a process aimed at eliminating undesirable (negative) behavior and replacing it with appropriate and productive behavior, which in turn leads to a healthy lifestyle.26,27 booklet educational media about maternal parenting aids mothers with stunted toddlers in offering support, attention, and nutrition, which encompasses guidance on how to feed their children, provide nutritious food, maintain personal hygiene, and create a healthy environment. it also encourages them to make use of health services to support their child’s well-being. thus, the education provided plays a crucial role in shaping the mother’s attitudes and actions. the lack of awareness about the importance of nutrition can result in limited efforts to prevent stunting. therefore, an individual’s level of nutritional knowledge, whether high or low, will impact their nutritional attitudes and behaviors. if a parent possesses a high level of nutritional knowledge, they are more likely to exhibit positive nutritional attitudes and behaviors. one transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 6. distribution of kruskal wallis test results of booklet group, bocesting based android application and control group (n=51). variable mean chi-square p rank (c2) maternal nutrition behavior booklet group 42.66 51.95 0.003 bocesting based android application 86 control group 22.04 nutritional status of toddlers booklet group 31.78 11.827 0.24 bocesting based android application 45.44 control group 49.78 [healthcare in low-resource settings 2024;12:11982] [page 87] non -co mmerc ial us e o nly limitation of this study is that it has not yet explored the dietary and sleep patterns in toddlers in relation to their nutritional status. we suggest that future researchers investigate these aspects to enhance the significance of study results. conclusions based on the results of the research and the discussion of ‘booklet preventing stunting (bocesting) based on an android application as an educational medium for improving maternal nutrition behavior and nutrition status,’ it can be concluded that there are significant differences in improving maternal behavior and attitudes toward nutrition within the three research groups. however, there is no significant change in nutritional status improvement. the more information we acquire about balanced nutrition, the better our application of balanced nutrition behavior becomes. this is because when individuals gain information, their knowledge about balanced nutrition increases, enabling them to implement balanced nutrition behaviors properly. it is hoped that healthcare workers can provide stunting education to mothers using educational media booklets and recommended applications as new tools for delivering effective health information to the community. these findings can also serve as valuable input for future researchers. references 1. mey d, ridayani r, san n, et al. penggunaan media edukasi gizi aplikasi electronic diary food (edifo) dan metode penyuluhan serta pengaruhnya terhadap pengetahuan ibu hamil. qual j kesehat 2020;14:1-10. 2. kalsum u, jahari ab. the strategy to reduce the prevalence of malnutrition among children under five in jambi province (strategi menurunkan prevalensi gizi kurang pada balita di provinsi jambi). jmj 2015;3:45-59. 3. kasaye hk, bobo ft, yilma mt, woldie m. poor nutrition for under-five children from poor households in ethiopia: evidence from 2016 demographic and health survey. plos one 2019;14:1-16. 4. wiliyanarti pf, wulandari y, nasrullah d. behavior in fulfilling nutritional needs for indonesian children with stunting: related culture, family support, and mother’s knowledge. j public health res 2022;11:22799036221139938. 5. rifada m, chamidah n, ningrum ra, muniroh l. stunting determinants among toddlers in probolinggo district of indonesia using parametric and nonparametric ordinal logistic regression models. commun math biol neurosci 2023;2023:8. 6. febriany n, agustina f, marwati r. aplikasi metode fuzzy mamdani dalam penentuan status gizi dan kebutuhan kalori harian balita menggunakan software matlab. j eurekamatika 2017;5:84-96. 7. fadmi fr, kuntoro, otok bw, melaniani s. stunting incident prevention: a systematic literature review. j public health africa 2023;14:1-6. 8. mubasyiroh l, aya zc. hubungan perilaku ibu dalam pemenuhan gizi pada anak 1000 hari pertama kehidupan/ golden period dengan status gizi balita di desa sitanggal kecamatan larangan kabupaten brebes tahun 2018. j ilmu kesehat bhakti husada heal sci j 2018;9:18-27. 9. taqwin t, ramadhan k, hadriani h, et al. prevalence of stunting among 10-year old children in indonesia. j glob pharma technol 2020;12:768-75. 10. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j glob pharma technol 2020;12:815-25. 11. putri dup, mahmudiono t, indriani d, lisatriana b. the relationship between the competence and performance of family planning instructors in family assistance at risk of stunting in lampung province. j public health africa 2023;14:2544. 12. flynn j, alkaff ff, sukmajaya wp, salamah s. comparison of who growth standard and national indonesian growth reference in determining prevalence and determinants of stunting and underweight in children under five: a cross-sectional study from musi sub-district [version 4; peer review: 2 approved]. f1000research. 2021;9:1-20. 13. lestanti d. nutritional parenting as an effort to prevent stunting in toddlers on mantang island dewi. aloha int j heal adv 2021;4:282-6. 14. siti km, dwi rf, ernawati r, et al. the effectiveness of webbased audiovisual media applications in monitoring children’s growth to prevent stunting. adv decis sci 2021;25:46-57. 15. ramdhani n. perubahan perilaku dan konsep diri remaja yang sulit bergaul setelah menjalani pelatihan keterampilan sosial. j psikol 2015;4:109-14. 16. salimi nt, ezbarami zt, tabari-khomeiran r, et al. comparing the effects of mobile-based education and booklet-based education on iranian mothers’ perception on antibiotics: a quasi-experimental study. j pediatr nursing-nursing care child fam 2021;61:122-9. 17. pangesti cb, rumiyati e, astuti hp. pengaruh pendidikan kesehatan dengan metode demonstrasi dan booklet terhadap perilaku ibu memijat bayi. j kebidanan.2021;1(11). 18. relawati a, syafriati a, al hasbi h, fitria pn. edukasi pasien chronic kidney disease berbasis aplikasi android : buku saku pasien. journal heal stud 2018;2:1-7. 19. krisnana i, rachmawati pd, karimah as, et al. knowledge and action related to stimulation development of stunted children. j pak med assoc 2023;73:s59-62. 20. mar’ah has em, asmoro cp, gua wp. factors related to father’s behavior in preventing childhood stunting based on health belief model. j keperawatan indones 2022;25:74-84. 21. rini wne. the effects of use audio visual media on increasing mother’s knowledge of stunting in rawasari health center in jambi city in 2019. j kesmas jambi 2020;4:23-7. 22. puspitasari fa, widowati aw, kurniasih y. edukasi gizi yang tepat dalam mencegah stunting dengan menggunakan media booklet dan poster. sigdimas publ kegiat pengabdi masy 2023;1:11-21. 23. fitriami e, galaresa av. edukasi pencegahan stunting berbasis aplikasi android dalam meningkatkan pengetahuan dan sikap ibu. citra delima sci j citra int inst 2021;5:78-85. 24. nasrul n, zainul z, hafid f, taqwin t. manfaat media flipchart dan spanduk dalam perilaku kesehatan 1000 hpk di sulawesi tengah the benefits of flipchart media and banner toward health behavior the first 1000 days of life in central sulawesi. j univ hasanuddin 2018;14:52-60. 25. martony o. the influence of balanced nutrition extension through poster media on the improvement of knowledge and change attitude. int j sci soc 2019;1:98-106. 26. susanti l. pengaruh pendidikan kesehatan dengan booklet terhadap pengetahuan ibu hamil tentang 1000 hari pertama kehidupan. j delima harapan 2021;8:46-52. 27. noorhasanah e, tauhidah ni. hubungan pola asuh ibu dengan kejadian stunting anak usia 12-59 bulan. j ilmu keperawatan anak 2021;4:37-42. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 88] [healthcare in low-resource settings 2024;12:11982] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11932 comparing parenting styles: their influence on adolescent’s internet addiction rika sarfika,1 gina faizah zein,2 riska andreni,2 randy refnandez,1 i made moh. yanuar saifudin3 1department of mental health and community, faculty of nursing, universitas andalas, padang; 2faculty of nursing, universitas andalas, padang; 3faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia abstract excessive internet use in adolescents can lead to addiction, with parental parenting styles playing a pivotal role. this study aimed to analyze the relationship between parents’ parenting style and adolescent internet addiction. a cross-sectional study was conducted with a sample of 290 participants using convenience sampling. two instruments, the parental authority questionnaire (paq) and internet addiction test (iat), were employed for data collection. statistical analysis, using the spearman correlation test (p<0.05), was performed. findings revealed a significant relationship (p<0.001, r=0.253) between an authoritarian paternal parenting style and adolescent internet addiction. a permissive maternal parenting style also exhibited a significant link (p<0.001, r=0.319) with internet addiction. this study highlights a clear association between parenting styles and adolescent internet addiction. parents should balance granting freedom for responsible internet use with setting boundaries, engage in open dialogues, and issue warnings when excessive online time is detected to effectively address this issue. introduction along with the rapid development of technology, the internet has enhanced many aspects of our lives by becoming an integral part of our daily experiences. the internet offers a wide range of services, and its usage is expanding across all age groups.1 digital technology has made it easier for everyone to connect and share common interests without any geographical or temporal barriers. it is convenient, flexible to access, and affordable, especially in developed countries.2 the international telecommunication union (itu) stated that the number of internet users worldwide would reach 5.3 billion in 2022, encompassing 66% of the world’s population. this figure represented an 8.16% increase from the previous year when the number stood at 4.9 billion. it is estimated that approximately 60% of the world’s population uses the internet, with asia having the largest number of internet users, followed by europe.3 according to a survey conducted by the association of internet service providers in indonesia (aispi)4 the number of internet users in indonesia reached 215.63 million people in the 2022-2023 period, out of indonesia’s total population of 275.77 million people. this figure marked a 2.67% increase compared to the previous period, which had 210.03 million users. notably, the majority of internet users in indonesia fall within the age group of 15-19 years, accounting for 91% of the total. in 2019, internet users in west sumatra constituted the thirdlargest group, following north sumatra and south sumatra, at 41.15%. in padang, internet usage in 2019 stood at 35%, with 1.8 million users. the primary activities people engaged in were accessing social media, seeking information, and playing online games.5 excessive internet usage can be termed as internet addiction. internet addiction is a pathological condition, characterized by obsessive-compulsive behavior, which drives a person to use technology excessively. compulsive internet use has emerged as a modern addictive behavior6 internet addiction is more common correspondence: rika sarfika, department of mental health and community, faculty of nursing, universitas andalas, 25163 padang, indonesia. e-mail: rikasarfika@nrs.unand.ac.id key words: adolescent, internet addiction, parenting style. contributions: rs, study conception and design, data collection, literature review/analysis, manuscript writing, critical revisions for important intellectual content; gfz, study conception and design, data collection, literature review/analysis, manuscript writing; ra, data collection, literature review/analysis, manuscript writing; rr, manuscript writing, critical revisions for important intellectual content; immys, manuscript writing, critical revisions for important intellectual content. all the authors approved the final version to be published. competing of interest: the authors declare no potential conflict of interest. funding: this study does not receive any external funding. ethical approval: ethical approval for the study was granted by the research ethics committee of the faculty of nursing at andalas university, padang, indonesia (approval number: 078.laiketik/kepkfkepunand). all participants provided informed consent. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. availability of data and material: the data is not accessible to the public as it contains information that might compromise the confidentiality of the research participants. data can be made available upon a reasonable request. acknowledgments: the authors thank to all participants in this study. received: 8 october 2023. accepted: 17 november 2023. early access: 15 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11932 doi:10.4081/hls.2023.11932 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 72] [healthcare in low-resource settings 2024;12:11932] non -co mmerc ial us e o nly among adolescents. adolescence is a transitional period from childhood to adulthood.7 this is because adolescents are in a critical stage of identity development, marked by their high curiosity, a constant desire to try new things, and susceptibility to peer influence.8 moreover, adolescents are considered vulnerable and at risk of developing internet addiction due to their immature self-control, easy access, and flexible schedules.9 in indonesia, internet users are typically aged between 13 and 18 years, with around 98.20% of this age group being connected to the internet.10 a previous study11 revealed that the main factor contributing to adolescents’ internet addiction is their parents’ parenting style. low parental supervision of adolescents is a significant predictor of internet addiction in this age group.12 most parents in indonesia tend to exhibit an indifferent parenting style, characterized by a lack of communication, support, and low control, particularly concerning internet usage. this indifference can lead children towards the negative aspects of the internet.13 parenting styles differ between fathers and mothers. the mother’s role often focuses on verbal interactions, such as caregiving and providing affection, while the father’s role typically involves more physical interactions and engaging in activities together. when children receive proper care from both parents, it can help identify and prevent various issues related to adolescent deviance.14 online gaming, online gambling, social networking, email, and pornographic websites can all contribute to internet addiction.15 internet addiction can be particularly detrimental to users, especially young individuals, impacting their health, both physically and psychologically.16 the physical health effects of internet addiction encompass eating problems, self-care neglect, dry and strained eyes, back discomfort, headaches, neck pain, and pain in the arms and joints.17 adolescents may struggle to regulate their constant urge to use the internet, which can disrupt their learning activities and affect their academic performance at school.18 the existence of internet addiction problems in adolescents related to parental parenting styles was also demonstrated in prior research19 conducted on 114 adolescents in pakistan. the research results reveal a significant relationship between parenting styles and internet addiction among adolescents. a majority of adolescents, or 77.2%, admit to being internet addicts, and their parents’ parenting styles are predominantly authoritarian and permissive. these parenting styles are linked to internet addiction in adolescents. the technological educational institute (tei) in heraklion, greece, found that parenting styles can determine the risk of internet addiction in adolescents. according to the findings of this study, adolescents whose parents frequently exhibit behaviors such as yelling, being unmoved, and making excessive demands may be at risk of developing internet addiction. conversely, a warm, loving, and protective parenting style can reduce the likelihood of internet addiction. according to this research, poor parenting practices can lead to adolescent irritability, hinder their ability to make friends, and increase the risk of developing internet addiction.20 considering the high prevalence of internet addiction issues in adolescents, it is imperative to understand the relationship between parenting styles and adolescents. the aforementioned explanation supports researchers in developing a connection between parenting style and internet addiction in adolescents. while the relationship between parenting practices and adolescent behavior has been extensively discussed in the literature, a significant knowledge gap remains regarding the precise link between parenting practices and adolescent internet addiction. an empirical investigation has revealed that the majority of adolescents spend a significant portion of their free time online. the most notable connection found between compulsive internet use in adolescent girls and boys is the neglectful parenting style.21 the existing literature has addressed the influence of parenting styles on adolescent behavior in general but often lacks a specific focus on the relationship between parenting styles and adolescent internet addiction, leaving a noticeable gap in our understanding of this particular issue. moreover, previous studies have not comprehensively examined the distinct effects of various parenting styles on internet addiction in adolescents. these gaps in prior research underscore the importance of the current study in contributing to a more comprehensive understanding of the subject. therefore, this study aims to analyze the relationship between parental parenting styles and adolescent internet addiction in padang, indonesia. materials and methods this study employed a correlational research approach with a cross-sectional design. the research was conducted between march 2023 and june 2023 and included participants who met specific criteria: students in grade 10th and 11th who used smartphones, were living with their parents at the time of the study, and were willing to participate as respondents. conversely, students who were unavailable during the research period were excluded from participation. the study’s target population consisted of students attending public senior high school (pshs) in pshs 9 padang. we used a convenience sampling method to select our sample. the sample size was determined using g*power software (latest version 3.1.9.7; heinrich-heine-universität düsseldorf, düsseldorf, germany). based on a correlation coefficient (ρ) of 0.30, a significance level (α) of 0.01, and a statistical power (1-β) of 0.99 (14), the calculated minimum sample size required was 222 participants. however, in the end, 290 respondents completed the survey. we used a convenience sampling method to collect the data. this approach was selected for its practicality and efficiency, considering time constraints and pandemic-related limitations. although it can introduce bias, it was a pragmatic choice, and researchers are aware of its limitations. this research was conducted with the permission of the padang city health service and the nursing faculty of andalas university. ethical approval was obtained before commencing the study. the homeroom teachers of the 2022 and 2023 classes assisted the researcher in gaining access to the classrooms. subsequently, the researcher explained the research’s aims and objectives to the respondents and sought their consent. once the informed consent forms were completed, the researcher provided instructions on how to complete the questionnaire and administered it through a google form, which had been designed and pilot-tested with 15 adolescents to ensure its functionality and user-friendliness. respondents were allotted 20 minutes to complete the questionnaire and were encouraged to ask the researcher any questions they might have had. after the questionnaire was completed, the researcher reviewed it and concluded the activity. data security and privacy were maintained by ensuring respondent anonymity regarding their name and address. additionally, the use of a secure platform (google forms), ethical review, and de-identification for data sharing ensured data security and privacy. the research utilized two assessment tools to evaluate parental parenting behaviors and internet addiction. the parental authority questionnaire (paq),22 adapted into an indonesian version,23 was employed to assess parental parenting behaviors. this transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11932] [page 73] non -co mmerc ial us e o nly questionnaire has undergone validation and reliability testing, demonstrating a strong correlation coefficient and a cronbach alpha value of 0.794, indicating its reliability. to measure internet addiction, the study used the internet addiction test (iat),24 which was also adapted into an indonesian version.25 this questionnaire has undergone validation and reliability testing, resulting in a high correlation coefficient and a cronbach alpha value of 0.895, signifying its reliability. data analysis consisted of univariate analysis, presented through a frequency distribution table, bivariate analysis conducted using the spearman test, and multivariate analysis performed using linear regression. additionally, a p-value of <0.05 was considered as significant. results respondents’ characteristics table 1 indicates that slightly over half of the respondents, 59.3%, were female. additionally, a significant majority, 89.3%, belonged to the middle adolescent age group (15 to 17 years old). furthermore, 50.7% of the respondents were in the 10th grade. in terms of parenting styles, the highest median score for fathers was observed for authoritarian parenting (median=18), whereas for mothers, democratic parenting had the highest median score (median=17). the median score for internet addiction among adolescents was 49, classifying it as mild online addiction, falling within the range of 32 to 83. relationship between parenting style towards internet addiction table 2 presents the findings regarding the correlation between a father’s authoritarian parenting style and internet addiction in adolescents. the results indicate a highly significant relationship, with a p-value of <0.001 (p<0.05). the correlation coefficient value obtained was 0.253, indicating a weak strength of the relationship. in this context, the father’s authoritarian parenting style displayed a relatively weak positive correlation with internet addiction, suggesting that as the father’s authoritarian parenting style increases, there is a corresponding increase in internet addiction among adolescents. similarly, the correlation analysis between mothers’ permissive parenting style and internet addiction in adolescents, as shown in table 2, revealed a highly significant relationship with a p-value of <0.001 (p<0.05). the correlation coefficient value was 0.319, indicating a weak strength of the relationship. in this case, the mother’s permissive parenting style demonstrated a weak positive correlation with internet addiction, meaning that as the level of permissive parenting by the mother increases, there is a corresponding increase in internet addiction among adolescents regression analysis results table 3 presents a series of independent variables and their associated p-values: age (p>0.421), gender (p<0.021), class (p>0.770), permissive father’s parenting style (p>0.814), authoritarian father’s parenting style (p>0.574), democratic father’s parenting style (p<0.000), permissive mother’s parenting style (p>0.845), authoritarian mother’s parenting style (p> 0.140), and democratic mother’s parenting style (p<0.000). the study’s findings indicate that gender is the most influential predictor (β=0.136) of internet addiction among students at senior high school 9 padang. additionally, the calculated f value for the democratic mother’s parenting style is 39.298 with a significance level of <0.05, suggesting that this regression model is suitable for predicting the relationship between parenting styles and the internet addiction variable. moreover, the variance in internet addiction is explained by gender by as much as 1.8%, the democratic mother’s parenting style by as much as 7.8%, and the democratic mother’s parenting style by as much as 12% discussion parenting style pertains to the manner and pattern of actions consistently used by parents as they care for and raise their children. it encompasses a range of elements, including parental attitudes, beliefs, methods of discipline, and emotional receptiveness demonstrated in their interactions with their children.26 this study aims to examine the association between parenting styles, including those of the father and mother, and internet addiction in adolescents. the findings of this research indicate that internet addiction in adolescents is related to parental parenting style. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents, parenting style and internet addiction (n=290). variable f% gender man 118 40.7 woman 172 59.3 age (years) middle adolescent (15-17 years) 260 89.6 late adolescents (18-20 years) 30 10.4 class level grades 10 147 50.7 grades 11 143 49.3 variable median min-max father’s parenting style permissive 17 9-23 authoritarian 18 9-26 democratic 17 9-24 mother’s parenting style permissive 16 7-25 authoritarian 16 7-28 democratic 17 7-27 internet addiction 49 32-83 table 2. the relationship between father's parenting style, mother’s parenting style towards internet addiction. internet addiction variable correlation r2 p coefficient (r) father’s parenting style permissive 0.038 0.001 0.522 authoritarian 0.253 0.064 <0.001* democratic 0.043 0.001 0.463 mother’s parenting style permissive 0.319 0.101 <0.001* authoritarian 0.066 0.004 0.260 democratic 0.071 0.005 0.225 spearman rank test was performed, *p<0.05. [page 74] [healthcare in low-resource settings 2024;12:11932] non -co mmerc ial us e o nly the father’s parenting style in this study demonstrates a tendency towards authoritarianism, with a mean value of 18, representing approximately 60%. these findings align with a previous study,27 which reported a prevalence of authoritarian parenting among fathers at 58.4%. moreover, fathers who adopt an authoritarian parenting style emphasize their children’s compliance with set rules without involving them in the decisionmaking process. this is supported by the fact that nearly all adolescents, or 43.4%, agree that their fathers require them to follow the rules without discussion. fathers in this study also tend to discipline their children if they disobey or fail to meet their expectations. this is evident as some adolescents, or 50.3%, confirm that their fathers communicate their desires, and if these wishes aren’t fulfilled, their fathers will impose punishment. the findings of a study on maternal parenting style indicate that maternal parenting tends to be democratic, with a mean value of 17, encompassing around 57%. these findings are consistent with a previous study,14 which also reported that the predominant maternal parenting style in this study was democratic, at 43%. another research28 similarly found that mothers tend to adopt a democratic parenting style, with a prevalence of 61.43%. regarding permissive mother’s parenting style, the median score for permissive parenting is 16, representing around 53% who tend to experience permissive parenting from their mothers. based on the results, it appears that mothers may not be overly concerned about their children’s behavior. this is supported by the fact that 39.3% of adolescents agree that their mothers do not pay much attention to their actions. considering the outcomes, the mean score for democratic parenting was 17, with approximately 57% tending to receive democratic parenting from their father. the characteristics of a democratic parenting style involve treating adolescents in accordance with their wishes and developmental stage. however, every parenting style should also incorporate established norms and deter deviant behavior to provide a sense of security.29 this is supported by the fact that almost all adolescents, or 42.4%, agreed that their fathers provided guidance for their behavior and activities, while still being open to listening and discussing their preferences if they didn’t comply with their father’s rules. in this study, the median score for permissive parenting was 17, with around 57% receiving permissive parenting from their father. in this permissive parenting style, the father may not closely monitor their child’s actions, as evidenced by 71 adolescents (24.5%) agreeing that their father allows them significant autonomy to make their own decisions. the study’s median score for authoritarian parenting is 16, with as many as 53% tending to experience an authoritarian parenting style from their mother. mothers who adopt an authoritarian parenting style emphasize their child’s compliance with established rules without involving the child in decision-making. this is supported by the fact that almost all adolescents, or 41.0%, agree that their mothers compel them to follow instructions in accordance with their mother’s wishes. adolescents engaging in internet addiction behavior comprise up to 47% of those with permissive parenting.30 adolescents raised by permissive parents often have the flexibility to use the internet without significant demands from their mothers or facing consequences for mistakes or violations made while using the internet.14 the results concerning internet addiction in adolescents at pshs 9 padang revealed an average internet addiction score of 49. these findings categorize internet addiction in adolescents as being in the mild category, consistent with previous research.31 it’s worth noting that the average internet addiction among adolescents in this study was 42, also classified as mild internet addiction. additionally, previous research reported an average internet addiction score of 41.40, which falls within the mild category.25 this study’s findings demonstrate the correlation between fathers’ authoritarian parenting style and internet addiction in adolescents. these results are in line with a previous study19 conducted in pakistan, which also indicates a significant relationship between fathers’ authoritarian parenting style and internet addiction. fathers who employ an authoritarian parenting style typically avoid discussing expectations and rules for internet use with adolescents, causing adolescents to conform to the standards set by their parents. in response to the lack of family warmth, adolescents often seek solace in increased online activities, such as playing online games, which can ultimately contribute to their growing internet addiction.32 similar findings are also reflected in a previous study,14 where the authoritarian parenting style of parents who exercise excessive control over their children while showing little affection in their interactions with them tends to compel children to be more self-reliant. additionally, they tend to avoid discussing expectations and guidelines for internet use with their children, which can lead to children expressing their dissatisfaction by engaging in more online activities, potentially resulting in internet addiction among adolescents. this study’s findings also revealed a correlation between mothers’ permissive parenting style and internet addiction in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11932] [page 75] table 3. linear regression analysis. internet addiction variable b β r2 cohens’f constant p age -1.424 -0.047 0.002 0.650 52.806 0.421 gender 2.488 0.136 0.018 5.390 45.966 0.021 class -0.318 -0.017 0.000 0.086 50.268 0.770 father’s parenting style permissive -0.038 -0.014 0.000 0.056 50.457 0.814 authoritarian -0.066 -0.033 0.001 0.316 50.974 0.574 democratic -0.672 -0.279 0.078 24.241 60.803 <0.001* mother’s parenting style permissive 0.032 0.012 0.000 0.038 49.285 0.845 authoritarian 0.173 0.087 0.008 2.185 46.993 0.140 democratic -0.795 -0.347 0.120 39.298 62.748 <0.001* *p<0.05. non -co mmerc ial us e o nly adolescents. these results align with a previous study33 conducted in iran, which also demonstrates a significant correlation between mothers’ permissive parenting style and internet addiction. mothers who adopt a permissive parenting style tend to grant excessive freedom, especially concerning internet use, which can leave adolescents uncertain about the appropriateness of their actions. in terms of internet usage behavior, adolescents who perceive their mother’s parenting as permissive are more likely to prioritize their own satisfaction by using the internet without constraints. mothers with limited knowledge are at risk of not understanding the boundaries of internet use and the potential negative impacts on their children who may develop internet addiction.34 the practical implications of this study hold notable significance for parents, educators, and policymakers. educating parents about the potential repercussions of extreme authoritarian or permissive parenting can empower them to establish a more balanced approach to setting internet usage boundaries within their families. actively involving parents in their children’s online activities can enhance their understanding of the digital environment and promote responsible navigation. in cases where adolescents are at risk of internet addiction, readily accessible counseling and intervention programs are essential. identifying signs of addiction and delivering appropriate support is paramount for both prevention and early intervention. encouraging media literacy among adolescents is equally valuable, equipping them with the knowledge and skills to make informed decisions while using the internet. it’s important to acknowledge that the generalizability of this research is subject to certain constraints. notably, the study’s cultural specificity, conducted in padang, indonesia, means that the impact of parenting styles on adolescent internet addiction may vary in diverse cultural and regional contexts. furthermore, the characteristics of the study’s sample, encompassing age, socioeconomic status, and other demographic factors, can influence the extent to which the findings can be applied to other populations, especially considering the use of convenience sampling in the research. conclusions the study links parenting styles to adolescent internet addiction, finding dominant authoritarian and democratic practices among fathers and mothers, respectively. its findings, rooted in a specific cultural setting, suggest limited applicability elsewhere. for broader relevance, future research should include diverse cultural examinations and broader sampling. addressing internet addiction in adolescents may involve balanced parental regulation, open communication, and guidance on internet use. references 1. lu, l. et al. internet addiction in tibetan and han chinese middle school students: prevalence, demographics and quality of life. psychiatry res 2018;268:131-6. 2. purwaningsih e, nurmala i. the impact of online game addiction on adolescent mental health: a systematic review and meta-analysis. open access maced j med sci 2021;9:26074. 3. tung seh, gan wy, chen js, et al. internet-related instruments (bergen social media addiction scale, smartphone application-based addiction scale, internet gaming disorder scale-short form, and nomophobia questionnaire) and their associations with distress among malaysian university students. healthcare (switzerland) 2022;10(8). 4. apjii. hasil survei penetrasi dan perilaku pengguna internet indonesia 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mengatasi anak kecanduan game. yogyakarta: a+ plus books; 2010. 12. karaer y, akdemir d. parenting styles, perceived social support and emotion regulation in adolescents with internet addiction. compr psychiatry 2019;92:22-27. 13. hidaayah n, yunitasari e, nihayati he, et al. parenting stress against symptoms of gadget addiction in elementary school age during the covid-19 pandemic. bali med j 2022;11:1189-94. 14. bibelia jt, hidayati no, somantri i. pola asuh orang tua pada remaja dengan kecanduan internet. holistik jurnal kesehatan. holistik jurnal kesehatan 2021;15:166-175. 15. novianty dd, sriati a, yamin a. gambaran penggunaan dan tingkat kecanduan internet pada siswa-siswi sma x di jatinangor. jurnal keperawatan komprehensif (comprehensive nursing journal) 2019;5:76-87. 16. gandaputra sa, waluyo i, efendi f, wang jy. insomnia status of middle school students in indonesia and its association with playing games before sleep: gender difference. int j environ res public health 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dan kecanduan game online dengan depresi pada remaja di masa pandemi covid-19. universitas muhammadiyah surakarta; 2022. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11932] [page 77] non -co mmerc ial us e o nly hrev_master [page 16] [healthcare in low-resource settings 2014; 2:1883] knowledge, attitude and practices on anti-tobacco measures imposed under the cigarette and other tobacco products act among adult males in rural areas of tamil nadu, india kalaivani annadurai, raja danasekaran, geetha mani department of community medicine, shri sathya sai medical college and research institute, ammapettai, india abstract assessment of knowledge and attitude of adult men towards anti-tobacco measures will help us further in strengthening of regulatory activities and thereby reducing the prevalence of tobacco use. the objective of the present study was i) to assess the knowledge of men towards anti-tobacco measures imposed under cigarette and other tobacco products act 2003 and its association with their socio-demographic factors; and ii) to study the attitudes and practice of men towards anti-tobacco measures imposed under cotpa 2003. a cross-sectional study was done among 714 males aged 18 years and above in vadagarai village of thiruvallur district of tamil nadu and interviewed with pretested questionnaire. the study was done during march to september 2009. majority of them were aware and favoring the act, i.e. 96.2% of the study population were aware of the cotpa 2003 and 95.24% were favoring the act. most of them felt that anti-tobacco measures did not have any impact among tobacco users. preventive steps like behavioral change communication, fiscal measures and further more strong enforcement of the act will be needed to decrease the prevalence further. introduction tobacco use is a serious public health problem. tobacco is a risk factor for six of the eight leading causes of deaths in the world.1 every eight seconds someone, somewhere in the world, dies as a result of tobacco use. around five million people die globally every year due to the effect of tobacco and this is likely to exceed eight million by 2030.2 the international classification of diseases (icd10) has recognized that tobacco dependence is a disease.3 tobacco use causes a wide range of major diseases which impact nearly every organ of the body. these include several types of cancers, coronary heart disease, cerebrovascular disease and lung diseases.4 research has generated scientific evidence that secondhand smoke causes the same problems as direct smoking, including cardiovascular disease, lung cancer, and lung ailments such bronchitis and asthma attacks.5-8 world health organization (who) recommends five policies for controlling tobacco use: smoke-free environments; support programmes for tobacco users who wish to stop; health warnings on tobacco packs; bans on the advertising, promotion and sponsorship of tobacco; and higher taxation of tobacco.9 in india, tobacco consumption continues to grow at 2-3% per annum.10 india’s anti-tobacco legislation, first passed at the national level in 1975, was largely limited to health warnings and proved to be inefficient. the adoption of a who framework convention on tobacco control (who fctc) by the world health assembly on 24th may 1999 was an important landmark to achieve comprehensive tobacco control worldwide.11 india was the 7th country that ratified the who fctc on 5th february 2004. in 2003, the central government passed the cigarettes and other tobacco products act (cotpa) applicable to all tobacco products.12 maximum number of violations were recorded in tamil nadu and ranks first among the states. a total of 9,648 people have been fined and a whopping rs 11,42,950 collected as fine from the southern state for violating the ban on smoking in public places in effect since october 2nd 2007.13 due to the scarcity of studies regarding the awareness of cotpa, this study was done to assess the knowledge, attitude and practices of adult males towards anti-tobacco measures imposed under the act. materials and methods a cross sectional study was done among adult males aged 18 years and above in vadagarai village in thiruvallur district of tamil nadu. the sample size was calculated on the basis of 35% prevalence rate of smoking in rural area according to nfhs-3 survey with allowable error 10%, sample size came to 714.14 vadagarai hsc was chosen randomly from naravarikuppam block primary health centre. in order to get 714 men aged 18 years and above, it was decided to survey 445 households in vadagarai subcenter, with a total of 1581 households with population of 2539 men above 18 years. the households were sampled by systematic random sampling. the sampling interval was 4 and the first household was selected randomly choosing a number within the sample interval. the next household was identified by adding the sampling interval with the first randomly chosen number and only one adult male was interviewed in each house. if there were more than one adult male in the same house, the participant was randomly chosen using lot system and then interviewed. a semi-structured questionnaire was used. it was translated into local language, pretested and standardized. it consisted of three parts of which part i deals with questions related to socio-demographic profile, part ii deals with questions regarding their knowledge and attitude towards anti-tobacco measures imposed under cotpa 2003 and part iii deals with questions regarding their practice towards anti-tobacco measures. the interview was conducted in the house of the participants by the investigators themselves. data entry was made in excel software in codes and analysis was done by spss software. levels of awareness, attitude and practices regarding cotpa were expressed in percentage and their association with socio demographic factors was tested for significance using chi-square test. results mean age of the sample population was 35.34±13.98 years with range of 18-85 years. healthcare in low-resource settings 2014; volume 2:1883 correspondence: dr. kalaivani annadurai, department of community medicine, shri sathya sai medical college and research institute, tiruporur-guduvancherry main road, ammapettai 603108, india. tel. +44.919500029829 fax: +44.27440138. e-mail: drkalaimdspm@gmail.com key words: tobacco, cotpa, socio-demographic factors, regulatory activities. contributions: ka, rd, data collecting and analyzing; gm, manuscript writing. conflict of interests: the authors declare no potential conflict of interests. acknowledgements: we are thankful to those who have participated in the study. received for publication: 15 august 2013. revision received: 19 september 2013. accepted for publication: 25 september 2013. this work is licensed under a creative commons attribution 3.0 license (by-nc 3.0). ©copyright k. annadurai et al., 2014 licensee pagepress, italy healthcare in low-resource settings 2014; 2:1883 doi:10.4081/hls.2014.1883 non -co mmerc ial us e o nly [healthcare in low-resource settings 2014; 2:1883] [page 17] half of them were between 18-30 years. most of them were hindus (82.5%). literacy rate of the sample population seems to be high (88.09%). half of the participants were from upper lower socio economic group (49.01%) and about two third (76.05%) were unskilled, semi-skilled and skilled laborers (table 1). awareness about cotpa analysis of the study population shows that 96.2% were aware of the cotpa 2003, the awareness regarding anti-tobacco measures showed that 96.2% knew that smoking was prohibited in public place and 88.0% knew that there was an age limit below which sale of tobacco products was banned. source of information were newspaper (36.39%), television (21.83%), radio (10.77%), friends (4.37%) and a combination of all (26.64%) (tables 2 and 3). there was a statistically significant association between the level of education and awareness about the act and its regulations (p<0.0001) (table 4). smokers and cotpa out of 714 study population, 262 (36.7%) were smokers. among smokers 92.4% were aware of the act and 88.5% of smokers were favoring the ban on smoking in public places. about violation of act among smokers (n=262), 8.0% were fined for smoking in public place. regarding the effect of cotpa among smokers (n=262), 65.8% were of the opinion that the act did not change their smoking pattern, 33.8% told that anti-tobacco measures reduced their smoking habit and 0.4% quit totally due to this regulation. discussion studies done in andhra pradesh15 and assam16 in india have reported awareness of cotpa as 47.5 and 45.7% respectively. our article table. 1 socio-demographic details of the participants. age n % occupation n % religion n % socio-economic status n % education n % 18-30 357 50 unemployed/student 39 5.46 hindus 589 82.5 upper (class-i) 13 1.82 illiterate 85 11.91 31-40 112 16.68 unskilled/semiskilled/skilled 543 76.05 christians 87 12.2 upper middle (class-ii) 87 12.18 literate 629 88.0 41-50 123 17.23 clerk, shop-owner, farm-owner 97 13.59 muslims 38 5.3 lower middle (class-iii) 160 22.40 51-60 93 13.02 semiprofessional/professional 13 1.82 upper lower (class-iv) 350 49.01 ≥61 29 4.06 retired/old age dependent 22 3.08 lower (class-v) 104 14.56 table 2. age group in years, their awareness of cotpa and prohibition of smoking in public place. age total aware of cotpa aware about prohibition aware about age (%) of smoking in public places limit for sale of tobacco 18-30 357 (50%) 351 (98.3%) 351 (98.3%) 329 (92.16%) 31-40 112 (16.68%) 107 (95.54%) 107 (95.54%) 95 (84.82%) 41-50 123 (17.23%) 118 (95.93%) 118 (95.93%) 110 (89.43%) 51-60 93 (13.02%) 91 (97.85%) 91 (97.85%) 80 (86.02%) >61 29 (4.06%) 20 (68.96%) 20 (68.96%) 16 (55.17%) total 714 (100%) 687 (96.2%) 687 (96.2%) 630 (88.2%) cotpa, cigarette and other tobacco products act. table 3. education status and awareness of cotpa. educational total awareness of cotpa awareness about prohibition awareness about age status (%) of smoking in public places limit for sale of tobacco n (%) p n (%) p n (%) p illiterate 85 (11.9%) 70 (82.4%) <0.0001 70 (82.4%) <0.0001 60 (70.6%) <0.0001 primary school 292 (40.9%) 285 (97.6%) <0.0001 285 (97.6%) <0.0001 260 (89.0%) <0.0001 middle school 237 (33.19%) 232 (97.9%) <0.0001 232 (97.9%) <0.0001 215 (90.7%) <0.0001 high school 49 (6.86%) 49 (100.0%) <0.0001 49 (100.0%) <0.0001 44 (89.8%) <0.0001 college/diploma 51 (7.14%) 51 (100.0%) <0.0001 51 (100.0%) <0.0001 49 (96.1%) <0.0001 total 714 (100.00%) 687 (96.2%) <0.0001 687 (96.2%) <0.0001 628 (88.0%) <0.0001 cotpa, cigarette and other tobacco products act. table 4. attitude towards cotpa and anti-tobacco measures. variable attitude (%) positive negative do not know about cotpa and its regulation 680 (95.24) 34 (4.76) implementation of ban on smoking in public places by government authorities 189 (26.5) 455 (63.7) 70 (9.8) pictorial health warning 189 (26.5) 427 (59.8) 98 (13.7) cotpa, cigarette and other tobacco products act. non -co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2014; 2:1883] study found the awareness level to be 96.2% which was far better than the above studies. similar finding was observed in rakesh et al. where it was found to be 88% among members of panchayat raj institution, haryana.17 of the age group between 18-25 years, 97.8% were aware of the act and of prohibition of smoking in public places. 69.0% of the age group above 61 years were aware of the act and prohibition of smoking in public places. so, young people were more aware of the act than elders. of the age group between 18-25 years, 92.0% was aware that there was age limit below which sale of tobacco products was banned. of the age group above 61 years, 55.2% was aware of the age limit. so, young people were more aware of the age limit below which sale of tobacco products was banned. this finding was contradictory to the findings from rao et al.15 and sharma et al.16 where they found that the awareness of cotpa increased significantly with increasing age. of literates, 98.1% were aware of the act and were aware of prohibition of smoking in public places. of illiterates, 82.8% was aware of the act and were aware of prohibition of smoking in public places. literates were more aware about the act than illiterates. rao et al.15 and sharma et al.16 have reported similar findings. of literates, 90.3% and 70.6% of illiterates were aware of age limit below which sale of tobacco products was banned. analysis shows that majority of them, i.e. 95.24% were favoring the act; this was similar to the findings from rao et al.,15 sharma et al.16 and american university of armenia18 majority of the study population, i.e. 63.7% felt that measures against smoking in public places were not followed correctly. moreover, more than half, 59.8% felt that pictorial health warning did not have any impact on smoking habit. among smokers 92.4% were aware of the act and most of them, i.e. 88.5% of smokers were favoring the ban on smoking in public places. in addition 8.0% of smokers were fined for violating the ban on smoking in public places. regarding quitting, 33.8% of smokers reported that their smoking habit got reduced because of the anti-tobacco measures under the act. in countries with pictorial health warnings, such as canada and australia, these numbers were higher: more than 40% of canadian smokers reported that the pictorial warnings have motivated them to quit smoking;19 in australia, picture warnings have supported 62% of former smokers in their efforts to quit.19 in our study, 0.4% reported that they had totally quit smoking because of fine due to violation but majority of them, i.e. 56.9% reported that act did not have any impact on their smoking habit. conclusions majority of the participants were aware of the act and favoring the act. but most of them felt regulations under the act were not followed properly. most of the smokers felt that anti-tobacco measures imposed under the act did not have any impact on their smoking status. the policy makers should consider newer options such as starting a help line for quitting tobacco to regulate the use of tobacco with consideration that most of the smokers were reluctant in quitting tobacco even after the implementation of various anti-tobacco measures under cotpa. apart from these steps, counselling sessions have to be arranged for those tobacco users who are reluctant to quit. to conclude, the steps taken by the government bodies in the future should be strictly followed and it should be continuously monitored. references 1. who. tobacco free initiative. tobacco facts. geneva, switzerland: world health organization; 2013. available from: http://www.who.int/tobacco/mpower/tobacco_facts/en/ 2. leung cm, leung ak, hon kl, kong ay. fighting tobacco smoking: a difficult but not impossible battle. int j environ heal r 2009;6:69-83. 3. who. international statistical classification of diseases and related health problems. geneva, switzerland: world health organization; 2010. available from: http://www.who.int/classifications/icd/icd10 volume2_en_2010.pdf 4. cdc. smoking and tobacco use. atlanta, ga, usa: centers for disease control and prevention; 2013. available from: http://www. cdc.gov/tobacco/data_statistics/fact_sheets/h ealth_effects/effects_cig_smoking/ 5. us department of health and human services. the health consequences of involuntary exposure to tobacco smoke: a report of the surgeon general. washington, dc, usa: department of health and human services; 2006. available from: www.surgeongeneral. gov/library/reports/secondhand-smoke-consumer.pdf 6. california environmental protection agency. health effects assessment for environmental tobacco smoke. sacramento, ca, usa: california environmental protection agency; 2005. available from: www.oehha.ca. gov/air/environmental_tobacco/pdf/app3part b2005.pdf 7. iarc. tobacco smoke and involuntary smoking. lyon, france: international agency for research on cancer; 2004. available from: http://monographs. iarc.fr/eng/ monographs/ vol83/mono83-1.pdf 8. american cancer society. cancer facts and figures 2012. atlanta, ga, usa: american cancer society; 2012. available from: http://www.cancer.org/cancer/cancercauses/t obaccocancer/secondhand-smoke 9. who. an international treaty for tobacco control. geneva, switzerland: world health organization; 2003. available from: http://www.who.int/features/2003/08/en/ 10. jandoo t, mehrotra r. tobacco control in india: present scenario and challenges ahead. asian pac j cancer p 2008;9:805-10. 11. who. frame work convention on tobacco control. guidelines for implementation. geneva, switzerland: world health organization; 2005. available from: http://apps.who.int/iris/bitstream/10665/ 80510/1/9789241505185_eng.pdf?ua=1 12. government of india. the cigarettes and other tobacco products (prohibition of advertisement and regulation of trade and commerce, production, supply and distribution) act, 2003, and rules framed there under. available from: http://indiacode.nic.in/fullact1.asp?tfnm=200334 13. tamil nadu records highest number of smoking violation (2009, may 26). hindustantimes. available from: http://www. hindustantimes.com/india-news/newdelhi/ tamil-nadu-records-highest-number-ofsmoking-violation/article1-414543.aspx 14. iips. national family health survey (nfhs3) 2005-06. mumbai, india: international institute for population sciences; 2007. 15. rao ar, dudala sr, bolla cr, kumar bpr. knowledge attitude and practices regarding the cigarettes and other tobacco products act (cotpa) in khammam, andhra pradesh. int j res health sci 2013;1:96-102. 16. sharma i, sarma ps, thankappan kr. awareness, attitude and perceived barriers regarding implementation of the cigarettes and other tobacco products act in assam, india. indian j cancer 2010;47:63-8. 17. rakesh k, misra p. knowledge, attitude and practice regarding anti-tobacco measures among members of panchayat raj institution in a rural area of haryana. indian j publ health 2011;55:339-40. 18. american university of armenia. kap tobacco control policies in adult population in armenia a followup survey. yerevan, armenia: american university of armenia, center for health services research and development; 2007. available from: http://auachsr.com/userfiles/file/ritc%20fo llow%20up%20report_2007.pdf 19. hammond d, fong gt, borland r. text and graphic warnings on cigarette packages: findings from the international tobacco control four country study. am j prev med 2007;32:202-9. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11927 health impact of security agents’ covid-19 lockdown control tactics on citizens of north-central nigeria: evidence and policy options chukwuka eugene ugwu,1 uchenna paulinus okafor,2 anthony chukwuemeka onyekwelu,2 chetachi euphemia orjiokafor,3 calistus ifeanyi mamah,1 obinna chidi anyanwu,2 nnamdi charles ajaebili,4 paulinus i. attama,1 chigozie freda ugwuanyi,1 modesta c. okolo1 1department of public administration and local government, faculty of the social sciences, university of nigeria, nsukka; 2department of geography, faculty of the social sciences, university of nigeria, nsukka; 3nursing services unit, university of nigeria teaching hospital ituku/ozalla, enugu state; 4department of history and international studies, faculty of arts, university of nigeria, nsukka, nigeria abstract the covid-19 lockdown control tactics used by security agents on the citizens of north-central nigeria were studied for their effects on health the convenience sampling method was employed to select six states of the study area. due to the nature of the data collected, quantitative data analysis was limited to percentages, while state-by-state evaluation was used to summarize qualitative data sources. additionally, hospital records from five privately owned and two government-owned hospitals in each of the study area’s states were generated, for a total of 42 hospitals sampled for the research. the obtained medical records demonstrate that the covid-19 lockdown control actions by security agents have a detrimental effect on the health and well-being of the citizens in the study area. amputation (0.27%), bacterial vaginosis (3.43%), coughing (11.16%), cataracts in the eyes (7.69%), etc., were reported. there was an association found between victims’ health issues and security agents’ use of force. proposed were reforms and least invasive methods of managing public health, including social marketing, education, democratic policing tactics, and facilitation engagement. introduction globally, the coronavirus disease (covid-19) has impacted negatively on the health of many people leading to so many medical emergencies including death during the era of the pandemic. nadeem et al.1 reported that the confirmed cases of covid-19 worldwide recorded 84,780,171 with 1,853,525 deaths as of 20th may of 2021. the african and nigerian history of covid-19 indicates that egypt recorded its first incidence on 14 february, 2020,2 while the disease’s emergence in nigeria was recorded on 27 february, 2020.3 to eliminate the pandemic continuous spread in nigeria, a broad summary of the nigerian government’s response to managing the covid-19 spread effect demonstrated that the federal, state, and local governments emerged with a plethora of public health control measures. measures for the containment of the covid-19 virus in nigeria include lockdowns and enforcement of physical and social distancing among and within communities. other measures included the closure of schools, and businesses (except those that deal with drugs, foods, and hospital services), the banning of all interstate movement, airports, seaports, and land border closures. there were compulsory closures of places of worship, social gatherings with the wearing of face masks. in the course of enforcing these covid-19 lockdown activities, noted deficiencies were observable in the country’s handling of the disease management capabilities. to assist the government, collaborative private sector stakeholders were invited such as the coalition against covid-19. also, the main federal government’s anti-covid spread center called the nigerian center for disease control (ncdc), was manifestly empowered. additionally, the uno agencies and some ngos all assisted in the initial nigeria’s response to managing the covid-19 spread. a major part of the enforcement of the covid-19 lockdown correspondence: uchenna paulinus okafor, department of geography, faculty of the social sciences, university of nigeria, nsukka, nigeria. e-mail: uchenna.okafor@unn.edu.ng key words: covid-19; health challenges; security agents; north central nigeria; lockdown control tactics. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval: the ethics committee of the university of nigeria, nsukka approved this study (approval code: unn/ec/staff/024/fss-med/jul/24). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. availability of data and material: data and materials are available by the authors. informed consent: the manuscript does not contain any individual person’s data in any form. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. received: 6 october 2023. accepted: 19 june 2024. early access: 25 july 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11927 doi:10.4081/hls.2024.11927 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11927] [page 625] non -co mmerc ial us e o nly activities involved the nigerian government’s introduction of security agents to ensure lockdowns, restrictions of people’s movement, and maintaining social distancing among other measures. for this paper, security agents are defined as a coalition of different public security outfits in nigeria, under the auspices of the nigerian police with the key role to ensure citizen’s compliance with covid-19 prevention regulations, maintenance of public order, safety, and security. these are the nigerian government’s employed security professionals or persons whose duty is to protect places or events from unauthorized access, harm or intrusion. for the purpose of the covid-19 lockdown control measures, the various tiers of government in nigeria evolved selected personnel from other security institutions in the country like the nigerian army, the secret security services, the department of state services, and neighborhood security set-ups. all these were encompassed in the general covid-19 security agency under the control of the nigerian police force (npf), which is the main law enforcement and security institution in nigeria, with the inspector general of the police as the head. in accordance with its mandate to manage the crisis generated by the covid-19 pandemic, the npf in may 2020, issued a security policy paper on ways to manage the covid-19 closures and social distancing requirements called “enforcement of covid-19 regulation: operational guidelines for the police and other law enforcement agencies in nigeria”. the summary of this regulation is that enforcing people’s restrictions due to covid has imposed additional responsibilities on both the police force and other law enforcement agencies. the regulation requires security agents to be tactful, compassionate, and empathic to citizens in the course of their covid-19 duties. at the same time, these agents were required to be firm, professional in duty, and remain polite and civil while respecting the fundamental rights of the nigerian citizens. in the nigerian context, some analysts have acknowledged concerns on the activities of these security agents as regards the covid-19 lockdown tactics.4,5 in the implementation of the anti-covid-19 spread, a lot of emphasis has been stated on the need for human rights-promoting tactics.6-8 this becomes relevant as some control measures may, even enthrone harm than good to the citizens. in fact, analysts like brook et al.9 opined that at the level of individuals, lockdown can cause some negative impacts such as psychological and emotional distress, loss of household income, and loss of employment. based on these possible negative impacts of covid-19 pandemic control measures, scholars such as acheson and haider et al. state that it is relevant to evaluate and monitor the social, economic, health and political impacts of lockdown during epidemic control such as covid-19 and its consequent policy implications to mitigate such negative impacts.10,11 however, the dynamic health effects and impacts of the nigerian security agents covid-19 control measures on the well-being of nigerians have been generally neglected by scholarship. despite these earlier studies on the negative health effects of covid-19 by some scholars,12,13 there exists a paucity of data on the negative health effects of the security agents’ covid19 lockdown measures on the citizens of the north-central geopolitical zone of nigeria. it is in the light of the above generalizations that this article takes as its general aim and objective the investigation of the phenomenon of the health impacts of the security agents covid-19 lockdown control mechanisms, on the citizens of the north central geopolitical zone of nigeria. to engage in the discourse, however, the following specific research objectives are raised to guide this study: i) understand the north-central states residents’ experience of links between security agencies’ covid-19 control tactics and its health challenges; ii) capture the reported medical cases of covid-19 health effects from selected hospitals in the study area due to security agents’ brutality on citizens; iii) understand the north-central state residents’ perceptions the health challenges, inherent in the covid-19 containment practices in the study area. the study contributes to the understanding of the practical and theoretical underpinnings of the health impact of security agents covid-19 lockdown control tactics on the citizens of north-central nigeria and its policy dynamics. the least restrictive and coercive mechanism of achieving a public health pandemic is used for the study. it stipulates the adoption of full authoritative force and power of the state institutions only in extreme circumstances of pandemic spread control, which the covid-19 era of pandemic did not warrant, we used quantitative and qualitative data analytic approaches in which respondents from the study area were involved. the article is organized and structured in seven sections: the introduction, conceptual and theoretical perspectives on the subject matter, the study area, methods, results, discussion, conclusion and policy options. since this present section is the introductory aspect, the next section deals with the conceptual and theoretical perspectives. conceptual and theoretical perspectives the theoretical framework of least restrictive or coercive theory is used as the framework of analysis. covid-19 lockdown all over the world, lockdown policies were designed and implemented by governments to control the spread of the epidemic of covid-19. lockdown as a concept defies clear and globally accepted definition, mainly caused by variations in design, implementation, and timing of the lockdown in different countries of the world. for haider et al.,14 covid-19 lockdown is set of adopted measures targeted at the reduction of transmission of covid-19 disease, which are mandatory and indiscriminately applied to the citizens. part of this definition is also the involvement of restrictions “on the established pattern of social and economic life”. according to these scholars, lockdown adopts three intervention methods – the geographical containment, the home confinement and the prohibition of gatherings which includes closure of premises and establishments. this concept of lockdown reflects the opinion of mboer et al.15 and lau et al.16 on the concept of covid-19 lockdown. the lockdown tactics are all measures used by a country’s government to enforce geographical containment, home confinement, and prohibition of gatherings. health impact of covid-19 security agents’ control tactics these refer to all observable and non-observable medical effects of the control measures. many scholars have alluded to various negative health effects such as mugabi,17 ojukwu,5 and brook et al.17 some of the extreme force application by the security agents resulted in human deaths in some of the situations. these impacts are elements of this study’s survey and data collection questions which were integrated into the findings of this study. framework of restrictive or coercive mechanism of public health management this study is hinged on the least restrictive or coercive mechanism of achieving public ends. the key in the management of public health programs should be that the full force, authority, and article [page 626] [healthcare in low-resource settings 2024;12:11927] non -co mmerc ial us e o nly power of state institutions should be reserved for extreme circumstances as against the deployment of complete force.18 though public health practice is meant to prevent harm, the key assumption here is that greater harm should not be construed in the process of preventing harm. in the accomplishment of this, more coercive mechanism should be the last resort in the failure of less coercive methods. thus, the adoption of least intrusive means like education, discussion, and facilitation should be applied to the masses before the adoption of interdiction, regulation, and incarceration. the advocacy for the practice of the least restrictive or coercive means is enshrined in the siracusa doctrine, which is an internationally agreed legal principles meant to justify conditions for the abridgment of civil liberty in public health management of pandemics such as the covid-19 era. it advocates that the restriction of an individual’s civil liberty must ensure sufficient legality, legitimacy, and necessity and without discrimination in its application. the application of this framework has been observed in nigeria in the public health management tactics of correcting harmful traditional maternal health practices in cross river state.19 the study area the north central zone is located in the following geographical graticules longitude 3° 00” to 10° 00” e and latitude 7° 00” to 11° 00”n. it is one of nigeria’s six geopolitical regions, making up the majority of the middle belt. benue, kogi, kwara, nasarawa, niger, and plateau are six of its states, in addition to abuja, the federal capital territory of nigeria. the north-central area covers the entire width of the country, from the border with the republic of cameroon to the border with benin republic, the map of which is shown in figure 1 of this study. materials and methods a mixed method approach was adopted in this study which included, a structured questionnaire survey and semi-structured oral interview that elicited key health challenges from respondents, based on their experiences of covid-19 security agents lockdown control tactics. these methods have been applied in related studies such as dawadi et al.20 and o;cathain and thomas.21 the research data was collected during the last phase (phase 3) of the nigerian covid-19 national lockdown easing strategy, (august-october 2020). the convenience sampling method was employed to select six states, namely benue, kogi, kwara, nasarawa, niger, and plateau which formed the north-central geopolitical zone of nigeria (figure 1). population and sample size the target population of the study area was 23, 428, 489 as in the 2006 census. it was extrapolated to 32,907,000 in 2020. the population of the study area was very large and was purposively narrowed down to victims of covid-19 security agents’ brutalization. from the survey carried out, 6814 victims were indicated in the six states of the study area. because the population figure was finite, the yamane formula was used to determine the minimum sample size.1,22 in this formula, n = sample size; n = total population; e = precision level. the precision level used in this study is ± 5%. n = 6814 = 379 1 + 6814 (0.05)2 the population derived from yamane’s formula is 379. for convenience, 20% after nadeem was added making the total population size used in the study to be 486 respondents.1 this was divided among the six states of the study area with a random selec article [healthcare in low-resource settings 2024;12:11927] [page 627] figure 1. north-central geopolitical zone, nigeria (without federal capital territory abuja). source: gis unit, department of geography, university of nigeria, nsukka (2023). non -co mmerc ial us e o nly tion of 76 respondents per state. for the method of recruiting the 76 respondents from each of the six states, we adopted a stratified sampling approach. this was done by selecting 38 respondents from the first two major cities of each state for the usual mail-to-web survey making a total of 456 respondents,23 while the qualitative oral individual survey was carried out using also, stratified sampling approach, picking 5 respondents from each state, making a total of 30 respondents. in all, 486 respondents were selected for the study, 456 for quantitative, and 30 for qualitative data collection. both quantitative and qualitative questions were used to collect data which included 20 close-ended questions and 5 open-ended questions making a total of 25 questions used for the study. the qualitative data that demonstrated the perceptions of the victims on the subject matter were obtained through key informant interviews. additionally, on-the-spot evaluation of the victim’s situations was carried out by research assistants, who included medical doctors, community pharmacists, and nurses. the analytical framework for quantitative data collected was statistics of simple percentages and frequencies which ensured a proportional summary and test of key variables. these were presented using simple tables. in other words, percentages and frequencies for each response option were calculated to access the level of agreement, disagreement or degree of variations with specific statements related to the key variable of the study. the analytical framework adopted for the interview method were the narrative analysis method. it bothers on qualitative data analysis that emphasizes on interpreting the core narratives from respondent’s personal stories. it employs the first-person narrative style acquisition, documentation or generalization, which allows the researcher to understand how respondents experience social phenomena. these experiences were summarized based on stateby-state evaluation. questions for the respondents were targeted at eliciting individuals’ experience on the health impact of nigerian security agents’ covid-19 lockdown control tactics in the northcentral states. also, hospital records were generated from two government-owned hospitals and five privately owned hospitals from each state of the study area making a total of 42 hospitals sampled, to show evidence of negative health effects of security agents covid-19 lockdown control tactics on citizens in the study area (figure 2). the sampled hospitals were mapped and their geographic coordinates were shown to ascertain the exact location of the hospitals in the study area (supplementary table 1). the data from the hospital records is different from the data derived from the population of the questionnaire survey. results the sociodemographic features of respondents are consistent with the findings of related studies such as rojas et al.,24 and haider et al.11 however, of the 486 respondents for the study, the female respondents were in minority (156; 32%) compared to male respondents (330; 68%) in this study. this is in contrast with the findings of the related study by rotimi et al.,25 in which there were more female respondents (215 females as compared to 141 males) in a contextual study in nigeria. in this study, however, the female respondents, though 32% of the entire population are relevant because they are the gender that experienced more sexual molestation from security operatives, besides the general human health and rights abuses common to both genders. health impact of security agents’ covid-19 lockdown control tactics and its attendant health effects on citizens the respondents’ answers to the question of whether nigerian security forces had mistreated them during the covid-19 pandemic lockdown were recorded. respondents were selected based on being victims of either one or all of the cases of security agents’ rough handling of citizens in the study area. in total, there were 275 reports of unlawful detention and arrest. other signs of physical abuse that security agencies were responsible for included article figure 2. geographical coordinates of sampled government and private hospitals in the study area. source: fieldwork (2022). [page 628] [healthcare in low-resource settings 2024;12:11927] non -co mmerc ial us e o nly tyrannical quarantine 382 (78.6%); whipping, slapping, pushing down, and general assaults 217 (44.6%); extrajudicial killing 28 (5.7%); torture 169 (34.8%); and sexual molestation 217 (44.6%); and tear gassing of gatherings 192, (39.5%). the study’s findings, utilizing the responses from the (456 respondents earlier mentioned) also showed a significant link between victims’ health problems and these mistreatments of citizens as shown in supplementary table 2 of this study. evidence for this can be found in the survey reports of 227 (49.8%) head injuries acquired during a fight within a cell during incarceration as contrasted to 259 (50.2%), who had not. also, 45 (17.6%) of survey participants stated they had been physically paralyzed as a result of arbitrary imprisonment. the victims of the covid-19 security officers’ tear gassing of residents of the north-central states experienced a number of health issues. the inhalation of tear gas during the dispersal of the crowd presented health risks in the form of chest tightness. the majority of the victims 294 (64.3%) who experienced it, compared to 162 victims (35.7%) who did not, demonstrate the significance of the link between this indicator of security agents’ enforcement and victims’ chest tightness. there is a significant association between choking sensation or shortness of breath and inhalation of tear gas. of the respondents who had choking sensations and shortness of breath, 304 (67.7%) complained that they were tear-gassed compared to 152 (33.3%) who were not. there was also a significant relationship between complaint of inhalation of tear gas and health issues of swallowing difficulties. a significant number of the respondents 268 (58.7%) agreed that they had swallowing difficulties. for chemical burns, a total number of 304 (67%) affirmed that they experienced it, while 152 (33%) did not. reported cases of covid-19 health effects from selected hospitals in the study area to determine the reported cases of the covid-19 health effects in the study area, medical records from the total number of 2534 case notes of patients with security agents’ covid-19 lockdown control tactics were selected during the months of marchoctober, 2020, from the 42 hospitals selected from the study area. the modality for selection depends on the nature of the illness or injury acquired during the covid-19 period and if the illness or injury was a result of the activities of the security agents’ enforcement of the covid-19 restriction/lockdown in the study area. the type of illnesses and injuries recorded and the number of patients treated are shown in supplementary table 3. qualitative findings the qualitative findings of this study are organized within the context of a state-by-state report of the in-depth interview report of respondents. to arrive at these reports, all the interview proceedings were audio-recorded, with a particular selection of the aspects of the recorded interviews that are relevant to the study’s objective. language difficulties were overcome through translation of the local languages. the consistency of the translated language was checked and transcribed. the respondents’ reports are stated below. benue state report of the victim’s experiences of the health impact of security agents’ mistreatment of citizens in the course of the covid19 lockdown management from a female respondent, residing at apir town of benue state, indicated that she was raped severally by two security agents at night where she was incarcerated during the period. according to her: ‘these two-armed men violently pulled me down on the floor of the cell, and took turns to rape me. while one of them is raping me, the second is using available clothes to cover my mouth from people hearing my shouting.’ on release from detention, the respondent became sick, visited the hospital and reported as follows: ‘i was diagnosed with genital inquiry, vaginal bleeding, and urinary tract infection. i spent a lot of money paying for my treatment.’ kogi state a yam trader caught at anyigba market, was beaten thoroughly and later released by these security agents for violating covid-19 quarantine’s rules. according to this victim, three days later: ‘i noticed i can hardly sleep (insomnia). i was having sweating, constant headaches, pains, loss of consciousness, nervousness, and anxiousness. upon visiting the hospital and narrating my experience with the security agents, i was diagnosed with posttraumatic stress disorder.’ kwara state there is consistent tear gassing of people to prevent gatherings in kwara state. this phenomenon was orchestrated by muslim worshippers who insist on worshiping together in their mosques in spite of the restrictions placed on such activities during the covid-19 pandemic. from the experience of the medical consequences, related to serious exposure to tear gas, one muslim mosque official residing in the state capital ilorin affirms as follows: ‘the covid-19 security agents threw canisters of tear gas at us during our friday prayers. many adherents were seriously wounded in the stampede that followed. personally, i received excess of the tear gas inhalation. within the next few hours, i rushed to the hospital where i was diagnosed with hemorrhage and severe asthmatic disposition.’ nasarawa state a young girl of 19 years old, in akwanga town was raped by security agents inside a forest during the sit-at-home era of the covid-19 period. having been caught on the road alone by these security agents, she was forcefully taken to the forest where she was gang-raped. on noticing health challenges after one month of her experience, she visited a hospital, where she reported her worst expectations: ‘i was diagnosed pregnant, with sexually transmitted infections of gonorrhea which i am still receiving treatment. my parents insisted i underwent an induced abortion, which i did to save the public shame associated with the incident.’ niger state interview respondents from niger state reported related health challenges from the covid-19 security agents. an elderly man resident at minna gave an insight into his health difficulties after going through a heavy bombardment of tear-gassing with some of his friends in the marketplace. from his doctor’s diagnoses, he said: ‘i had increased chronic obstructive pulmonary disease, irritation of the lungs and respiratory failure. i was discharged after one week of admission in the hospital.’ article [healthcare in low-resource settings 2024;12:11927] [page 629] non -co mmerc ial us e o nly plateau state a young man of 30 years who was discharged from general hospital, dengi, plateau state after tear gas from an evening football exercise by the covid-19 security agents’ shared this experience with the study’s researchers in this way: ‘we were dispersed from the football field without prior warning with tear-gassing. many of my football colleagues experienced health challenges as a result of that. for me, i suffered (hospital report) temporary blindness, coughing, nausea and vomiting. it was only after some days of treatment, that i recovered from these illnesses.’ discussion if the security operatives’ covid-19 lockdown enforcement was significantly proportionate in the context of covid-19 containment in the study area, it was one key aspect that the respondents reported on very strongly. individuals’ rights to liberty, life, and security were recognized in article 3 of the universal declaration of human rights (udhr), adopted by the united nations in 1948, while torture, cruelty, and excessive punishment or treatment were prohibited in article 5. in accordance with article 9 of the udhr, arbitrary arrest, detention, and punitive exile were prohibited. nigerians are protected by these udhr laws, however, some of these human rights abuses are also prohibited by the nigerian constitution (1999) as amended. there are public health measures that typically restrict internationally recognized individual liberties when governments undertake pandemic containment and management policies. these restrictions are mentioned in several documents, including the international convention on civil and political rights. however, a minority of the respondents (61; 10.16%) were of the opinion that appropriate steps were implemented by the security authorities in regards to the covid-19 shutdown in a proportionate intervention mechanism. this shows that more than 74.8% of the respondents believed that unjustified and haphazard force was used in the north-central states of nigeria. studies and reports from alindogen,26 human rights,27 in the philippines, sri lanka, iran, el-salvador, and uzbekistan all pointed to discoveries of this kind. the conclusions of this study’s component were supported by amnesty international.6 amadasun,7 kunene,28 and other studies undertaken in zimbabwe, south africa, and the other states of nigeria under the guise of covid-19 lockdown measures. all discovered the abuses by security agents on various covid-19 lockdown measures to be the same with this study. the issue of respondents’ arbitrary imprisonment and tear gas inhalation is related to additional health issues caused by the security agents’ excessive use of force in enforcing the covid-19 lockdown. hypertension, psychological issues, and paralysis are some illnesses that are related, as obvious consequences of incarceration. in maria and rosemary,29 seminal study of sub-saharan african nations, similar findings of this study are published, indicating a significant relationship between people’s detention and development of similar health challenges. conclusions the covid-19 lockdown enforcement strategies used by nigerian security officers in the north-central states of nigeria were examined in this study. as part of the covid-19 geographic containment, it specifically evaluated the citizens’ vulnerability to precarious enforcement practices and their health impact on the citizens of the study area. the empirical analysis of the survey poll supports the theoretical postulations that, despite the nigerian government’s containment policy for the covid-19 pandemic being largely legal and necessary, the security agencies failed to use the least restrictive, intrusive, or coercive methods in the process. the results were considerable human mortality and negative health issues for the victims. this article submits that the implementation of the covid-19 lockdown policies as observed from the enforcement mechanisms of the security agents in the study area engendered health challenges for the citizens thus leading to the association of such containment practice to paralysis, hypertension, and chest tightness among other health problems. using public health techniques such as social marketing, education, facilitation, and discussion which are the least invasive possible when dealing with crises such as covid-19, was recommended. references 1. nadeem a, jabeen r, nazir s, haider s. fear of covid-19 among critical care nurses of public hospitals in lahore: empirical evidence during third wave. healthc low resource settings 2023;11:1064. 2. world health organization. who director general’s opening remarks at the media briefing on covid-19 11 march 2020. 2020. available from: https://www.who.int/directorgeneral/speeches/detail/who-director-general-s-openingremarks-at-the-media-briefing-on-covid-19---11-march-2020 (accessed on 25th may, 2020) 3. who nigeria: coronavirus disease, situation, and search by country, territory, or and covid 19, 2020b. available from: https://www.afro.who.int/countries/nigeria (accessed on 25th may, 2020) 4. khalid i. coronavirus: security forces kill more nigerians than covid-19-mixed message from the president. https://www.bbc.com/news/world-africa-52317196 (accessed on 23rd may, 2020) 5. ojukwu t. nigeria: police brutality is more lethal than covid-19. available from: telesurenglish.net/news/nigeriapolice-brutality-is-more-lethal-than covid-19 02004170001.html) 6. amnesty international. nigeria: authorities must uphold human rights in the fight to curb covid-19. available from: https://www.amnesty.org/en/latest/news/2020/04/nigeriacovid-19/ (accessed on 14th may, 2020) 7. amadasun s. covid-19 palaver: ending rights violation in vulnerable groups in africa. world dev j 2020;134:1-2. 8. guglielmi s, dohi, sani g, et al. public acceptability of containment measures during the covid-19 pandemic in italy: how institutional confidence and specific political support matter. int j sociol soc policy 2020. 9. brook sk, webster rk, smith le, et al. the psychological impact of quarantine and how to reduce it: rapid review of the evidence. lancet 2020;395:20. 10. acheson d. report: independent inquiry into inequalities in health report. the stationery office, london; 1988. available from: https://assets.publishing.service. gov.uk/media/5a759e7c40f0b67b3d5c7e6f/ih.pdf 11. haider n, osman a, gadzekpo a, et al. lockdown measures article [page 630] [healthcare in low-resource settings 2024;12:11927] non -co mmerc ial us e o nly in response to covid-19 in nine sub-saharan african countries. bmj global health j 2020;5:1-10. 12. iwuoha vc, aniche et. covid-19 lockdown and physical distancing policies are elitist: towards an indigenous (afrocentred) approval in sub-urban slums in nigeria. local environ 2020;25:631-40. 13. donthu n, gustafsson a. effects of covid-19 on business and research. j bus res 2020;117:284-9. 14. haider, n.; osman, a.y.; gadzekpo, a. et al. lockdown measures in response to covid-19 in nine sub-saharan african countries. bmj global health j 2020; 5(10): e003319 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc7542624/ same as 11 15. mboera leg, akipede go, banerjee a, et al. mitigating lockdown challenges in response to covid-19 in sub-saharan africa. int j infect dis 2020;96:308-10. 16. lau h, khosrawipour v, kobchach p, et al. the association between international and domestic air traffic and the coronavirus (covid-19) outbreak. j microbiol immunol infect 2020;53:467-72. 17. mugabi i. covid-19: security forces in africa brutalizing civilians. available from: https://www.dw.com/en/covid-19security-forces-in-africa-brutalizing-civilians-under-lockdown/a-53192163 18. upshur r. principles for the justification of public health intervention. can j public health 2002;93:101-3. 19. odigbo b, eze f, odigbo r. covid-19 lockdown controls and human rights abuses: the social marketing implications. emerald open res 2020;2:45. 20. dawadi, s., shrestha, s., and giri, r.a., mixed-methods research: a discussion on its types, challenges and criticisms. journal of practical studies in education (2021) 2(2), 25 – 36. doi: https://doi.org/10.46809/jose.v212.20 21. o’cathain, a. and thomas, k. combining qualitative and quantitative methods, in quantitative research in healthcare. third edition. edited by pope, c., mays, n. oxford: blackwell publishing;2006:102–111. https://onlinelibrary.wiley.com/doi/ book/10.1002/9780470750841#page=109 22. yamane, t. statistics: an introductory analysis. 3rd ed., new york: harper and row, 1973. 23. ariel k, susan m, rohen s. impact of the covid-19 crisis on family dynamics economically vulnerable households. becker friedman institute for economics, no. 2020-143. available from: https://bfi.uchicago.edu/wpcontent/uploads/2020/10/bfi_wp_2020143.pdf 24. rojas fl, jiang x, montenovo l, et al. is the cure worse than the problem itself? immediate labor market effects of covid19 case rates and school closures in the u.s. national bureau of economic research 2020. 25. rotimi o, abiola o, remi s, et al. spousal violence in the era of covid-19 lockdown: the implication of socio-economic distress and contextual factors. ilorin j econ policy 2020;7:5160. 26. alindogen j. hrw: covid-19 lockdown violators in the philippines abused. aljazeera 2020. available from: https://www.aljazeera.com/videos/2020/4/29/hrw-covid-19lockdown-violators-in-philippines-abused (accessed on 13th may, 2020) 27. human rights watch. iran: free wrongfully detained prisoners: families concerned over coronavirus risks in prisons. 2020. available from: https://www.hrw.org/news/2020/03/12/iranfree-wrongfully-detained-prisoners (accessed on 18th may, 2020) 28. kunene e. south africa lockdown: they are riding around the country hunting the poor and vulnerable. 2020. available from: https://allafrica.com/stories/202003310233.html 29. maria c, rosemary m. prison health situation and health rights of young people incarcerated in sub-saharan african prisons and detention centres: a scoping review of extant literature. bmc int health human rights 2019;19:343-52. article [healthcare in low-resource settings 2024;12:11927] [page 631] online supplementary material: table s1. names of sampled government and privately owned hospitals in the study area. table s2. quantitative results of links between rough-handling of citizens and its associated health challenges. table s3. summary of information on the number of patients (evidence of negative health effects) treated in the selected hospitals for an 8-month period (march-october, 2020). non -co mmerc ial us e o nly hrev_master [page 16] [healthcare in low-resource settings 2023; 11:11161] maggot therapy could provide affordable and efficacious wound care in lebanon and other lowand middle-income countries salman shayya,1,2 frank stadler3,4 1institute of legal medicine, university hospital frankfurt, goethe-university, frankfurt am main, germany; 2lebanese university, faculty of science hadath beirut, faculty of public health fanar and ain w zain, lebanon; 3applied biosciences, macquarie university, sydney, new south wales, australia; 4school of medicine and dentistry, griffith university, gold coast, queensland, australia abstract the poor economic situation, ongoing political instability, and the 2020 beirut explosion have seriously eroded the capacity of the lebanese healthcare system. insecure fuel supplies and the rationing of electricity to a few hours per day make matters worse. new strategies are required to deliver healthcare that is more resilient in the face of ongoing disruption. maggot therapy for the treatment of chronic and infected wounds could make a meaningful difference in lebanon. when placed in a wound, medicinal maggots remove dead tissue, control infection and stimulate wound healing. it is an inexpensive, easy to use, and highly efficacious therapy, even under austere conditions. this review provides an introduction to maggot therapy and briefly explains its therapeutic benefits before discussing the role it can play in the lebanese healthcare system. finally, the prerequisites and enablers for successful integration of maggot therapy into the lebanese healthcare system are outlined. introduction maggot therapy (mt) is the use of live fly larvae (maggots) for the treatment of wounds that fail to heal. mt is used for the treatment of a wide range of chronic wounds including infected wounds and wounds with dead tissue and/or slough such as leg ulcers, pressure ulcers, diabetic foot ulcers, gangrenous wounds, osteomyelitis, surgical wounds, and burns.1 when applied to the wound, medicinal maggots remove dead tissue, control infection, and stimulate wound healing.2 maggot therapy compares favorably with conventional wound treatment while it can also be cost effective compared to conventional treatment approaches.3,4 for wounds to heal, it is necessary that dead tissue and other debris are removed. this process is known as debridement. when placed into a wound, medicinal maggots crawl about with the aid of their paired mouth hooks while excreting digestive enzymes into the wound environment.5 this leads to the liquefaction of dead tissue which is then either ingested by the maggots or it drains from the wound.6 infection often plays an important part in preventing chronic wounds from healing. medicinal maggots control infection in a number of ways. first, their feeding activity in the wound removes dead tissue which is a source of nutrition for bacteria, and it disrupts bacterial biofilm via mechanical means. the very act of ingestion and digestion of bacteria-rich necrotic tissue by the maggots contributes to the reduction of the bacterial burden in the wound. moreover, the maggots’ secretions and excretions have potent antibacterial properties and contain sodium bicarbonate which increases the ph of the wound and inhibits bacterial growth.6,7 wounds are said to be chronic when they fail to pass in an orderly manner through the three phases of healing: inflammation, proliferation, and remodeling. in such wounds, maggot therapy interrupts chronic inflammation and promotes the growth of new tissue, including blood vessels.8 a successfully healing wound exhibits the growth of granulation tissue, but for this to occur, fibroblasts must migrate into the clean wound bed to bring about granulation. the secretions of medicinal maggots have been shown to promote fibroblast growth and their migration across the wound bed.9,10 full healing and tissue regeneration can only succeed if the growing tissue is supplied with blood and oxygen which in turn depends on the growth of new blood vessels. maggot therapy promotes the formation of new blood vessels and increases the blood supply to the wound.11 in addition; maggot excretions stimulate the production of the patients’ own tissue growth factors that promote healing of the wound12, while also contributing maggot-derived growth factors and other hormones that closely resemble those of the human body. this way maggots further stimulate tissue growth in the wound.13 in summary, medicinal maggots bring about wound healing through multiple complex interactions with the wound environment, resident microbes, and the patients’ physiological response to the injury. this is healthcare in low-resource settings 2023; volume 11:11161 correspondence: frank stadler, applied biosciences, macquarie university, sydney, new south wales, australia. tel: +61.422731540. e-mail: frank.stadler@mq.edu.au key words: maggot therapy; larval debridement therapy; wound care; lowand middleincome country; lebanon. contributions: the article is a collaborative effort between the authors in response to the beirut port explosion and subsequent medical emergency. preparation of the article was led by ss, particularly concerning the lebanese healthcare system and the potential for maggot therapy integration. fs provided overall guidance and contributed the maggot-therapyrelated technical content. conflict of interest: fs is currently adjunct fellow at macquarie university, centre manager for the arc training centre for facilitated advancement of australia’s bioactives (faab), also at macquarie university, and founder/director of medmaglabs, a similitude pty ltd business, seeking to bring affordable maggot therapy services to australia and underserved healthcare settings around the world. this article was conceived and written prior to spin-out of medmaglabs from research conducted at griffith university. ss has no conflicts of interest to report. ethics approval and consent to participate: not applicable. informed consent: not applicable. patient consent for publication: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received for publication: 17 january 2023. accepted for publication: 2 may 2023 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11161 doi:10.4081/hls.2023.11161 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11161] [page 17] difficult to replicate with any other single wound care intervention may it be drug or device. where is maggot therapy used? maggot therapy has been used for thousands of years and records date back to antiquity. however, it was the orthopedic surgeon william s. baer at johns hopkins hospital, baltimore, who in the 1920’s established maggot therapy in modern clinical wound care.14 unfortunately, the initial popularity of maggot therapy was relatively short-lived and declined in the 1940s with the emergence and widespread availability of antibiotics like penicillin, and the improvement of surgical techniques.15 then, beginning in the 1980s and 90s, maggot therapy experienced a renaissance due to the growing prevalence of wound infections caused by antibiotic-resistant bacteria15 and a growing burden of wounds related to chronic health conditions such as diabetes and cardiovascular disease. in 2004, maggot therapy was approved by the united states food and drug administration as a device for the debridement of wounds. now, maggot therapy has once again become an accepted and widely used wound treatment in the united states, europe, and elsewhere. as for the middle east, maggot therapy is regularly used in egypt16 and iran,17 as well as in turkey and israel.18 however, it appears that lebanese wound care providers have no access to medicinal maggots. maggot therapy in lebanon as the economic situation in lebanon worsens due to ongoing political instability, the 2020 beirut blast, and covid 19 it becomes necessary to consider new strategies to strengthen the healthcare system. it follows a brief discussion as to how the implementation of maggot therapy could assist lebanon in the treatment of infected and necrotic wounds sustained in suddenonset disasters such as the beirut blast, as well as the affordable management of chronic wounds resulting from diabetes or cancer. in the beirut port blast on 4 august 2020, flying and falling glass shards from building facades and interiors were the main cause of injury and death.19 the injuries were accompanied by severe lacerations and abrasions as witnessed in the emergency wards of treating hospitals. blindness and loss of limbs have been the main causes for lasting disability suffered by casualties.20 according to reports from the american university of beirut hospital auh, some patients required extensive reconstructive surgery.20 as has been evident in the aftermath of the beirut blast, such sudden-onset disasters can easily overwhelm local healthcare systems not only because of mass casualties but because healthcare facilities and other infrastructure may also be damaged. for example, saint george hospital university medical center was severely damaged after the explosion.21 more than 100 of its healthcare professionals, doctors, residents, nurses and administrative staff, sustained injuries ranging from mild to critical.21 in the achrafieh area, the hotel dieu de france hospital took in over 700 wounded victims.22 teams from médecins sans frontières (msf) who have been providing assistance reported 737 people who received treatment for wounds.23 moreover, on august 15, 2021, a fuel tank blast in akkar north lebanon killed 28 people and injured nearly 80 people. as a rule, disasters of this nature result not only in acute injury from the impact itself but also in many infections that prevent wounds from healing. maggot therapy is an ideal treatment for such wounds for reasons explained earlier. in addition, the availability of medicinal maggots in disasters would give first responders greater freedom and a larger window of opportunity to treat casualties without having to fear the consequences of either infection or injuryrelated tissue necrosis. this is because both infection and tissue necrosis can be successfully treated with maggot therapy.24 in lebanon, as in other lowand middle-income countries, the transition to a modern life style and the rapid economic, cultural and social changes are associated with a rapid rise in obesity, vascular disease, and diabetes.25 over a 12-year study period, the change in obesity prevalence annual rates ranged between +4.1% in children and adolescents and +5.2% in adults.26 up to 25% of diabetes patients will suffer one or more lower limb ulcers.26 these diabetesrelated health complications are common in the arab world with a higher prevalence in eastern arab countries. given the high cost of chronic wound care and the impact of ulcers on the patient’s quality of life, it is easy to see how access to maggot therapy could deliver affordable and highly efficacious wound care. at best of times, the lebanese population has insufficient access to healthcare. according to 2017 statistics, the distribution of healthcare professionals per 10,000 citizens was 31.3 physicians, 36.4 nurses and midwives, 15.2 dentists, and 18.9 pharmacists.27 likewise, the who28 records lebanon as having 49.42 skilled health personnel per 10,000 population (in 2014) compared to 162.4 for australia (in 2015). it is against this backdrop of an ailing healthcare system and the ever-present threat of natural and man-made disasters (including conflict), that the introduction of maggot therapy to the lebanese healthcare system should be considered. this will require i) local production or just-in-time international supply of medicinal maggots, ii) regulatory approval, iii) health insurance cover, iv) clinical workforce training, and v) patient education. local production in lebanon could be performed using the calliphorid fly lucilia sericata which is identified at the taxonomic and molecular level.29 moreover, it has been shown to produce a variety of bioactive compounds that promote wound healing, angiogenesis and tissue regeneration. also it attenuates inflammation and eliminates bacteria.30 the objectives for maggot therapy in chronic wound care in lebanon would be to prevent the deterioration of existing wounds and symptoms management to ensure patient comfort and an improved quality of life.31 in patient-centric care, wellbeing is defined as attaining physical, psychological, social, and spiritual resources to overcome physical, psychological and/or social challenges.32 the definition of wellbeing in relation to wound management is detailed in a complete guide to maggot therapy.33 medicinal maggots are highly perishable and must be delivered within 24-48 hours from dispatch.34 this means they cannot be stored in distribution centers like ordinary medicines but must be delivered just-in-time to the point of care.34 production and supply of lebanese clinics may or may not be possible from regional businesses in neighboring countries. the requirements for medicinal maggot production can range from fairly low-tech to sophisticated, which means that during the introduction of maggot therapy in lebanon, a local university or other research institution could produce the maggots at modest expense. however, professionalization of production and marketing of medicinal maggots to wound care providers is necessary for maggot therapy to become a mainstream treatment in lebanon or any other jurisdiction for that matter. the commercial supply of medicinal maggots and their routine use generally requires the approval by national health authorities. in the case of lebanon, this would be the ministry of public health (moph). the testing and introduction of new drugs or treatments should also be reviewed by the country’s physicians and review non -co mmerc ial us e o nly [page 18] [healthcare in low-resource settings 2023; 11:11161] public health experts to ensure adequate treatment, palliative care, and optimized pain control in lebanon. if medicinal maggots are to be approved as pharmaceutical drugs, then a dossier needs to be prepared that demonstrates the quality, safety and efficacy of the drug and follows the specifications of the common technical document (ctd).27 the complete dossier should be registered at the pharmacy department of the moph. importantly, wide uptake of maggot therapy depends on national or private health insurance reimbursement. in lebanon, the health care system is characterized by an array of financing intermediaries including the national social security fund (nssf) that covers formal sector employees, the civil servant cooperative (csc) that covers civil servants, four military schemes that cover the uniformed armed forces, and the private healthcare insurers and the moph.35 however, insurance covers only 75% of hospitalisation and is limited to life threatening and obstetric conditions. therefore, it is a large financial burden for lebanese patients to access advanced diagnostics and other care for conditions which do not fall under the current coverage including illnesses such as cancer and chronic health conditions like diabetes and its complications.36 in addition, many refugees from neighboring countries find it difficult to access healthcare in lebanon because most have no health insurance coverage and rely solely on the united nations relief and works agency unrwa services.36 furthermore, lebanese elderly and retired workers still lack a social insurance system that provides them with adequate health cover.35 currently, initiatives are under way with international support to strengthen the health system and enhance institutional resilience.32 introduction of maggot therapy may well align with these reform objectives but close cooperation and negotiation with insurance providers would still be required for making maggot therapy eligible for reimbursement. maggot therapy is a relatively simple treatment and does not require surgical expertise which means that nurses and, with guidance, even laypersons such as family members can conduct maggot therapy.17 nevertheless, practitioners will need at least basic training to learn how to apply medicinal maggots and how to make sure only patients and wounds benefiting from the treatment will receive the therapy. for the past two decades, there have been numerous practitioner-focused publications explaining in detail the indications and contraindications for maggot therapy as well as the various application techniques. for example, chadwick and colleagues37 articulate the consensus for the treatment of the diabetic foot with maggot therapy, and commercial medicinal maggot producers support their clients with clinical advice. multilingual and highly visual treatment guidance for healthcare providers and patients, especially in compromised healthcare settings, has been developed at medmaglabs and can be accessed free-of-charge via www.medmaglabs.com in english, french, and arabic language. maggot therapy can only be used when the patient agrees to it. therefore, it is important that wound care patients and the general public are aware of the treatment and understand how it works. the idea of maggot therapy may provoke in some patients and healthcare providers strong feelings of disgust, or what has also been coined the ‘yuk’ factor. however, feelings of disgust or fear are actually not a major barrier to maggot therapy acceptance, especially for patients who are confronted with an ostracizing chronic wound. patient concerns about the treatment are best addressed with accurate information provided by trusted wound care providers. conclusions in the context of lebanon’s ailing healthcare system and precarious social and economic situation, it would be prudent to introduce maggot therapy to treat chronic wounds and to strengthen the country’s resilience in the face of ever-looming natural and man-made disasters in a volatile region. what is true for lebanon applies also to many other countries struggling in a climate of covid 19, economic depression, and/or conflict. maggot therapy has not yet reached its full potential and remains underutilised, especially in lowand middle-income countries. however, efforts are under way to build capacity in conflict-affected communities and other compromised healthcare settings to produce medicinal maggots and treat chronic wounds with maggot therapy.24,38,39 references 1. mexican association for wound care and healing. “clinical practice guidelines for the treatment of acute and chronic wounds with maggot debridement therapy; 2010. accessed 15 august 2021. available from: https: / /s3.amazonaws.com/aawcnew/memberclicks/gpc_larvatherapy.pdf 2. sherman ra. mechanisms of maggotinduced wound healing: what do we know, and where do we go from here? evid based complement alternat med 2014;2014:592419.  3. eamkong s, pongpanich s, rojanaworarit c. comparison of curing costs between maggot and conventional therapies for chronic wound care. j health res 2010;24:21-5. 4. bennett sb, abnderson sp, rai mk, et al. cost-effectiveness of interventions for chronic wound debridement: an evaluation in search of data. wounds uk 2013;9:9. 5. wood l, hughes m. reviewing the effectiveness of larval therapy. j comm nursing 2013;27:11-14. 6. choudhary v, choudhary m, pandey s, et al. maggot debridement therapy as primary tool to treat chronic wound of animals. veterinary world 2016;9:403-9. 7. cazander g, pritchard di, nigam y, et al. multiple actions of lucilia sericata larvae in hard-to-heal wounds: larval secretions contain molecules that accelerate wound healing, reduce chronic inflammation and inhibit bacterial infection. bioessays 2013;35:10831092. 8. nigam y, morgan c. does maggot therapy promote wound healing? the clinaical and cellular evidence. j eur acad dermatol venereol 2016;30:776-82. 9. horobin aj, shakesheff km, pritchard di. maggots and wound healing: an investigation of the effects of secretions from lucilia sericata larvae upon the migration of human dermal fibroblasts over a fibronectin-coated surface. wound repair and regeneration 2005;13:422–33. 10. smith ag, powis ra, pritchard di, et al. greenbottle (lucilia sericata. larval secretions delivered from a prototype hydrogel wound dressing accelerate the closure of model wounds. biotechnol progress 2006;22:1690–6. 11. bexfield a, bond ae, morgan c, et al. amino acid derivatives from lucilia sericata excretions/secretions may contribute to the beneficial effects of maggot therapy via increased angiogenesis. br j dermatol 2010;162:554–62. 12. honda k, okamoto k, mochida y, et al. a novel mechanism in maggot debridement therapy: protease in excretion/secretion promotes hepatocyte growth factor production. am j physiol cell physiology 2011;301:c1423–30. 13. evans r, morgan c, jones n, et al. human growth factor homologues, review non -co mmerc ial us e o nly [healthcare in low-resource settings 2023; 11:11161] [page 19] detected in externalised secretions of medicinal larvae, could be responsible for maggot-induced wound healing. int j res pharm biosci 2019;6:1–10. 14. baer ws. the treatment of chronic osteomyelitis with the maggot (larva of the blowfly). j bone joint surg 1931;13:438–75. 15. sherman ra. maggot therapy takes us back to the future of wound care: new and improved maggot therapy for the 21st century. j diabetes sci technol 2009;3:336–44. 16. hassan mi, hammad km, fouda ma, et al. the using of lucilia cuprina maggots in the treatment of diabetic foot wounds. j egypt soc parasitology 2014;44:125–9. 17. mirabzadeh a, ladani m j, imani b, et al. maggot therapy for wound care in iran: a case series of the first 28 patients. j wound care 2017;26:137143. 18. mumcuoglu k y n.d. maggot debridement therapy. accessed 15 august 2021. available from: https://medicine.ekmd.huji.ac.il/en/rese arch/kostasm/pages/project_10.aspx 19. abu-faraj zo. shattered glass is allegedly blamable for most of the victims of beirut’s blast. linkedin; 2020. accessed 15 august 2021. available from: https://www.linkedin.com/pulse/shattered-glass-allegedly-blamable-mostvictims-blast-abu-faraj, 20. ibrahim a. scarred for life: beirut blast victims and life-altering wounds. aljazeera; 2020. accessed: 15 august 2021. available from: https://www.aljazeera.com/news/2020/ 8/25/scarred-for-life-beirut-blast-victims-and-life-altering-wounds 21. joujou ee, nehme ah. nehme saint george hospital university medical center is a nonprofit academic medical center, owned by the orthodox archdiocese of beirut sghumc has sustained severe damages from the recent explosion in beirut; 2020. accessed 15 august 2021. available from: https://www.stgeorgehospital. org/stgeorge-donation, 22. sanford a, davies p, tidey a. beirut blast: macron pledges international aid as protests erupt in lebanon; 2020. accessed 15 august 2021. available from: https://www.euronews. com/2020/08/06/beirut-blast-port-officials-under-house-arrest-as-angergrows-at-lebanon-s-elite 23. whittal j. msf supporting beirut’s health services in wake of massive blast; 2020 accessed 15 august 2021. https://www.msf.org/msf-supportingbeirut-health-services-wake-massiveblast-lebanon 24. stadler f, shaban r z, tatham p. maggot debridement therapy in disaster medicine. prehosp disaster med 2016;31:79-84. 25. nasreddine l, naja f, chamieh m c, et al. trends in overweight and obesity in lebanon: evidence from two national cross-sectional surveys (1997 and 2009). bmc public health 2012;12:798. 26. alexiadou k, doupisj. management of diabetic foot ulcers. diabetes therapy 2012; 3(1): 4. doi: 10.1007/s13300012-0004-9. epub 2012 apr 20. pmid: 22529027; pmcid: pmc3508111. 27. ministry of public health. republic of lebanon ministry of public health. accessed 10 january 2021. available from: https://www.moph.gov.lb/ 28. who n.d. skilled health professionals density (per 10000 population). the global health observatory. accessed 15 august 2021. available from: https://www.who.int/data/gho/data/indi cators/indicator-details/gho/skilledhealth-professionals-density-(per-10000-population 29. shayya s, debruyne r, nel a et al. forensically relevant blow flies in lebanon survey and identification using molecular markers (diptera: calliphoridae). j med entomol 2018,55:1113–1123. 30. čičková h, kozánek m, takáč p. growth and survival of blowfly lucilia sericata larvae under simulated wound conditions: implications for maggot debridement therapy. med veterinary entomol 2015;29:416-24. 31. nenna m. pressure ulcers at end life: an overview from home care and hospice clinicians. home health care nurse 2011;29:350-65. 32. dodge r, daly ap, huyton j, et al. the challenge of defining wellbeing. int j wellbeing 2012,2:222-35. 33. ogrin r, elder k j. living with a chronic wound. in stadler f. (ed.). a complete guide to maggot therapy: clinical practice, therapeutic principles, production, distribution, and ethics. cambridge, uk: open book publishers 2022, https://doi.org/10. 11647/obp.0300.02 34. stadler f. the maggot therapy supply chain: review of the literature and practice. med veter entomol 2020: doi:10.1111/mve.12397 35. el-jardali f, bou karroum l, bawab l, et al. health reporting in print media in lebanon: evidence, quality and role in in informing policymaking. plos one 2015;10:e0136435. 36. lebanon crisis response plan lcrp. produced by the government of lebanon and united nations; 2019. accessed 15 august 2021. available from: https://reliefweb.int/sites/relief web.int/files/resources/lcrp_2021fin al_v1.pdf 37. chadwick p, mccardle j, ricci e, et al. appropriate use of larval debridement therapy in diabetic foot management: consensus recommendations. diabetic foot j 2015;18:37-42. 38. sherman r a, hetzler m r. maggot therapy for wound care in austere environments. j spec oper med 2017;17:154-162. 39. medmaglabs. production and supply of medicinal maggots in compromised healthcare settings; 2021. accessed 15 august 2021. available from: http://medmaglabs.com/creating-hopein-conflict-production/ review non -co mmerc ial us e o nly hrev_master abstract people living with hiv (plhiv) require a focus on their quality of life to prevent deterioration. this study aims to establish a spiritual-based palliative nursing model to enhance the quality of life for plhiv. a cross-sectional study of 225 plhiv receiving treatment at said sukanto hospital, jakarta. data, including demographic, disease, psychological, spiritual, support, services, spiritual-based palliative care, spiritual meaning in illness experience, and quality of life variables, were collected using a researcher-modified questionnaire. data were analyzed using descriptive and structural analysis through partial least square equation modeling (sem-pls). the outer model demonstrated construct validity (λ > 0.5) and high reliability (composite reliability > 0.7). the inner model exhibited moderate power (r2 > 0.33) and predictive relevance (1.009). goodness-of-fit indicators (rms theta = 0.072, nfi = 0.971, srmr = 0.098) confirmed the model’s suitability. hypothesis testing indicated the significance of all variables (p<0.05). the findings support the application of a spiritual-based palliative nursing model to enhance the quality of life for plhiv. this model offers a holistic approach encompassing physical, psychological, social, and spiritual well-being, providing a comprehensive framework for healthcare providers and policymakers to improve care for plhiv. introduction hiv remains a significant global public health problem and has claimed 40.1 million lives. by 2021, 650,000 people will die of hiv-related causes, and 1.5 million people will acquire hiv.1 scientists continue to fight against it. the discovery of anti-retroviral therapy (art), while not a cure for hiv, has been able to prevent new viruses from being produced in newly infected cells.2 moreover, with increasing access to effective hiv prevention, diagnosis, treatment, and care, including for opportunistic infections, hiv infection has become a chronic health condition that can be managed. this shift has enabled people living with hiv (plhiv) to lead long and healthy lives, focusing on the quality of life.3,4 the facts show that most hiv patients (63.7%) have a poor quality of life.5 research results in iran concluded that most plhiv have low quality of life scores.6,7 in nigeria, the average score for the quality of life for plhiv is low in the domain of social and environmental relations, and in china, other studies have shown a decrease in the quality of life for plhiv in the physical health domain.8 the low quality of life underlines the policy formulation by the ministry of health of the republic of indonesia regarding palliative care. this policy is based on the healthcare in low-resource settings 2023; volume 11:11737 development of a spiritual-based palliative care model for the quality of life of people with hiv/aids rohman rohman,1,2 nursalam nursalam,2 tintin sukartini,2 hamidah hamidah,3 supatmi supatmi,4 diah priyantini,4 daviq ayatulloh,5 miciko umeda1 1faculty of nursing, universitas muhammadiyah jakarta, jakarta; 2faculty of nursing, universitas airlangga, surabaya; 3faculty of medicine and health, universitas muhammadiyah jakarta, jakarta; 4faculty of health science, universitas muhammadiyah surabaya, surabaya; 5faculty of health science, universitas gresik, gresik, indonesia correspondence: rohman rohman, faculty of nursing, universitas muhammadiyah jakarta, jakarta, indonesia; faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: rohman1azzam@gmail.com key word: palliative; plhiv; quality of life; spiritual meaning. contributions: rr, nn, ts, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; hh, methodology, visualization, writing – review and editing; ss, resources, investigation, and writing – review and editing; dp, formal analysis, validation, writing – review and editing; da, resources, supervision, and writing – review and editing; mu, resources, investigation, and writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas airlangga, based on ethical certificate 2742-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to be thankful to all the participants for their valuable contributions to this study. received: 16 september 2023. accepted: 14 november 2023. early access: 17 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11737 doi:10.4081/hls.2023.11737 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 114] [healthcare in low-resource settings 2023; 11:11737] non -co mmerc ial us e o nly consideration that cases of incurable diseases are increasing and aims to improve health services for clients with such diseases, including palliative care.9 palliative care aims to enhance the quality of life of patients and their families, encompassing physical, psychosocial, and spiritual aspects.10 however, in practice, palliative care for plhiv has predominantly focused on managing physical and psychological symptoms like pain, shortness of breath, anorexia, constipation, nausea, fatigue, delirium, anxiety, and depression.11 it identifies the current shortcoming, emphasizing that palliative care for plhiv tends to treat physical symptoms but hasn’t paid sufficient attention to spiritual aspects. a spiritual-based palliative care approach can help individuals remain calm when facing problems and endure suffering,12 serving as a key to overcoming difficulties,13 and increasing resilience when experiencing sadness. it allows individuals to be more accepting,14 serving as a resource in dealing with life events that cause stress and helping them accept reality more realistically. this research aimed to develop a spiritual-based palliative care model to improve the quality of life for plhiv. materials and methods research design the research employed an explanatory research design. this approach aimed to analyze the factors that influenced the quality of life of plhiv using a cross-sectional method. it delved into how demographic, disease, psychological, spiritual, support, and service system factors impacted the ability to find spiritual meaning in the experience of illness and the overall quality of life for plhiv. the research was conducted at said sukanto hospital, jakarta, which was chosen due to its specialization in treating plhiv patients. study participants sample size determination followed the rule of thumb, which suggested a sample size of 5 to 10 times the number of indicators (observed variables). as there were 27 indicators in this study, the minimum sample size was 5 x 27, which equaled 135 samples. therefore, the researchers included 225 respondents, all of whom were hiv patients. the sampling technique used nonprobability sampling with a purposive sampling method. the criteria for selecting participants were plhiv patients undergoing hospitalization, aged 21 years or older, possessing a competent level of consciousness, being able to read and write, having good hearing and vision, and not being in critical condition or suffering from many opportunistic infections. variable, instrument and data collection independent variables encompassed demographic factors (age, gender, education, occupation, religion, economic status, and marital status), which were measured using a patient demographic data questionnaire containing personal information. disease factors (early diagnosis, opportunistic infections, and arv adherence) were assessed using the whoqol-hiv bref questionnaire and the morisky medication adherence scale/mmas. psychological factors (anxiety and depression) were gauged with the beck anxiety inventory (bai) and beck depression inventory (bdi-ii), respectively. spiritual factors (personal beliefs, religious practices, and spiritual satisfaction) were assessed using the plhiv-focused spiritual questionnaire developed by nursalam.15 support system factors (family support, caregivers, peer groups, and religious communities) employed a questionnaire modified by the researcher. service factors (nursing services, service availability, access to services, and the health team) were also measured using a questionnaire modified by the researcher. the spiritual-based palliative care variable was evaluated with a questionnaire designed by the researcher, which incorporated elements of spiritual well-being to enhance patient outcomes during treatment and in life. the dependent variable, consisting of spiritual meaning in the experience of illness (symptoms of pain and loss), was assessed with a researcher-modified questionnaire. the quality of life for plhiv (covering physical aspects, psychological aspects, level of independence, social relations, environmental health, and spirituality) was measured using the whoqol-hiv bref. the research instruments were previously validated for their reliability and validity, using a 4-point likert scale: strongly agree = 4, agree = 3, disagree = 2, and strongly disagree = 1. all instruments were tested for validity and reliability on 40 plhiv, obtaining a calculated r value of 0.270 – 0.991 (r table 0.257) and reliability with cronbach’s alpha 0.714 – 0.974 (cronbach’s alpha > 0.6), confirming their validity and reliability. data analysis the analysis used the pls (partial least square) approach. pls allowed for structural equation modeling with relatively small sample sizes and did not require multivariate normal assumptions. the pls model specification in path analysis encompassed three types of relationships: the inner model, outer model, and weight relation. results as per the data presented in table 1, it is evident that the observed demographic factors showed the following results: 37.3% of the respondents were in the age range of 26-35 years, 74.2% were male, 51.1% had completed high school, and 64.9% worked as private employees. the majority of the respondents practiced the muslim faith (92.4%), were married (43.6%), and had an income status of 54.2% below the regional minimum wage. based on the results of the outer loading values, it is evident that the outer loading values for all latent variables exhibit a result of λ ≥ 0.5 and a statistical t value ≥ 1.96. variables with valid measurements include demographic factors, disease factors, psychological factors, spiritual factors, support system factors, health service factors, spiritual meaning in the experience of illness, and quality of life for plhiv (figure 1). based on the data processing results presented in table 2, an evaluation of the structural model (inner model) was conducted to assess its validity. the test results indicate that when the t-statistics value is ≥ t-table (1.96) or the p-value is < the significant alpha level of 5% or 0.05, it is considered to have a significant influence of the independent variables on the dependent variable. the research findings reveal that several variables, including x1 (demographic factors), x2 (disease factors), x3 (psychological factors), x4 (spiritual factors), and spiritually based palliative care (y1), along with the spiritual meaning of the illness experience (y2), play a significant role. notably, x4, representing spiritual factors, serves as one of the latent variables in this research, signifying the level of spirituality among plhiv, which is manifested through their attitudes and behaviors. this includes components related to personal beliefs, religious practices, and spiritual satistransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2023; 11:11737] [page 115] non -co mmerc ial us e o nly faction. it is evident that spiritual factors have a noteworthy impact on enhancing the quality of life for plhiv, as indicated by the tstatistics value of 5.054 (less than 1.96) and a p-value of 0.040 (greater than 0.05). the research model’s path analysis identifies the most influential path as originating from x7 (spiritual-based palliative care), which subsequently impacts both y1 (spiritual meaning of illness experience) and y2 (quality of life of plhiv). the path analysis reveals an original sample value of 0.791 with a p-value of 0.000. according to the model fit image provided above, the rms theta value is 0.072, which is less than 0.102, and the nfi value is 0.971, exceeding the threshold of 0.9. therefore, based on these two model assessments, the model meets the criteria for model fit. similarly, the srmr (standardized root mean square) value is 0.098, slightly below 0.10. consequently, the model is deemed to be a good fit for the research data (table 3). discussion the research results demonstrate that all hypotheses significantly influence the independent and dependent variables. spiritual-based palliative care is a developmental model studied to enhance the quality of life in plhiv. the palliative approach was initially aimed at improving the quality of life for clients and families facing life-threatening illnesses through the prevention, assessment, and treatment of pain, as well as other physical and psychosocial issues.7,16,17 in this study, palliative care was combined with spirituality as an active and positive process involving the search for activities that restore a person’s sense of coherence, internal wholeness, and inner peace. therefore, a palliative model combined with spirituality can enhance the quality of life in plhiv patients. based on the overall results of the study, it can be observed that in the development of a spiritual-based palliative care model for quality of life in plhiv, the best path is from service factors to spiritual-based palliative care, ultimately leading to the path of the ability to find the spiritual meaning in the experience of illness, which affects the quality of life in plhiv patients. this indicates that the quality of spiritual-based palliative care and services is the most dominant factor contributing to the improvement of the quality of life for plhiv. therefore, in its development, it should be studied how to enhance both of these factors.18,19 spiritual-based palliative care is the most significant factor in improving the quality of life of plhiv patients, which includes indicators of symptom management, spiritual support, and end-oflife care.20 this spiritual-based palliative care can help individuals remain calm when facing problems and endure suffering due to their illness.21 psychologically, plhiv often experiences low selfconfidence, prolonged stress, anxiety, and depression, and spiritually, they may undergo a crisis of faith due to feelings of guilt and sin, as well as a sense of approaching death.14 the quality of life for plhiv is greatly influenced by spirituality, as it serves as an essential contributor to well-being in improving their quality of life. spirituality acts as a bridge between decisions and meaningfulness in life.22 according to bornet et al. (2017),23 treatment is based on spiritual abilities, including the ability to determine the meaning of life and engage in worship according to one’s religious beliefs. plhiv often recognize their illness as a test from god to assess their faith, leading them to strengthen their beliefs, which ultimately impacts their quality of life. when illness strikes, a person’s spiritual health can aid in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. research outer loading value. table 1. characteristics of research respondents (n=225). indicator f % age 17-25 years 16 7.2 26-35 years 84 37.3 36-45 years 73 32.4 46-55 years 52 23.1 gender man 167 74.2 woman 58 25.8 education no school 4 1.8 elementary school 33 14.7 junior high school 52 23.1 senior high school 115 51.1 university 21 9.3 work doesn't work 56 24.9 private employees 146 64.9 businessman 23 10.2 religion islam 208 92.4 protestant 14 6.2 catholic 2 0.9 buddha 1 0.5 economic status < regional minimum wage 122 54.2 ≥ regional minimum wage 103 45.8 marital status not married yet 71 31.5 marry 98 43.6 divorced 48 21.3 death divorce 8 3.6 [page 116] [healthcare in low-resource settings 2023; 11:11737] non -co mmerc ial us e o nly recovery because they believe their efforts will be successful.23 this helps plhiv endure difficult times and not give up on their illness. quality of life is associated with spirituality, which involves drawing closer to god by adapting one’s lifestyle according to god’s commands, establishing a spiritual and social network, and maintaining an optimistic spirit. combining palliative care with spirituality can motivate individuals to gain religious and spiritual experiences, achieve physical health, and alleviate selfanxiety, ultimately leading to a higher quality of life.24,25 recommendations for improving the quality of life of plhiv in developing a spiritual-based palliative care model have theoretical and practical implications. the spiritual-based palliative care model contributes to strengthening and developing existing theories, such as the theory of palliative care and spiritual well-being. it shows that demographic factors, disease factors, psychological factors, spiritual factors, support system factors, spiritual-based palliative care, and service system factors directly influence the ability to find spiritual meaning in the experience of illness, thus improving the quality of life for plhiv.26 the application of a spiritual-based palliative care model in improving the quality of life for plhiv will provide nurses with guidance on the need for spiritual studies to determine interventions that fulfill spiritual support in collaboration with religious volunteers. the model can also be used to enhance the health status, motivation, enthusiasm, and belief of plhiv in their recovery by emphasizing spiritual meaning. conclusions the development of a spiritual-based palliative care model has been demonstrated to significantly influence the spiritual meaning of the experience of illness and the quality of life among plhiv. this model encompasses various factors, including demographic factors (age, gender, education, occupation, religion, economic status, and marital status), disease factors (early diagnosis, opportunistic infections, and arv adherence), psychological factors (anxiety and depression), spiritual factors (personal beliefs, religious practices, and spiritual satisfaction), support system factors (family support, caregivers, peer groups, and religious communities), and service factors (nursing care, service availability, access to services, and healthcare teams). these factors serve as mediating elements in the development of this model. the study’s results indicate that the future benefits of this model include making significant contributions to improving the quality of life for plhiv through spiritually-based palliative care. nurses and other healthcare professionals can apply interventions to provide care for plhiv. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. research hypothesis testing results. hypothesis original sample t statistics p significance (o) (|o/stdev|) x1 demographic factor -> x7 spiritual based palliative care 0.523 10.859 0.004 significant x1 demographic factor -> y1 spiritual meaning in the experience of illness 0.418 7.623 0.045 significant x2 disease factor -> x7 spiritual-based palliative care 0.494 9.825 0.041 significant x2 disease factor -> y1 spiritual meaning in the experience of illness 0.415 6.873 0.038 significant x3 psychological factors -> x7 spiritual-based palliative care 0.469 8.496 0.014 significant x3 psychological factors -> y1 spiritual meaning in the experience of illness 0.404 5.243 0.048 significant x4 spiritual factor -> x7 spiritual based palliative care 0.416 7.313 0.048 significant x4 spiritual factor -> y1 spiritual meaning in the experience of illness 0.401 5.054 0.040 significant x5 support system factor -> x7 spiritual-based palliative care 0.655 14.176 0.000 significant x5 support system factor -> y1 spiritual meaning in the experience of illness 0.492 9.341 0.001 significant x6 service system factor -> x7 spiritual-based palliative care 0.675 16.705 0.000 significant x6 service system factor -> y1 spiritual meaning in the experience of illness 0.481 9.160 0.000 significant x7 spiritual-based palliative care -> y1 spiritual meaning in the experience of illness 0.888 26.397 0.000 significant y1 spiritual meaning in the experience of illness -> y2 quality of life 0.753 16.647 0.000 significant table 3. results of model fit testing research. saturated model estimated model srmr 0.101 0.098 d_uls 8.313 8.313 d_g 4.903 4.903 chi-square 2215.232 2215.232 nfi 0.971 0.971 rms theta 0.072 [healthcare in low-resource settings 2023; 11:11737] [page 117] non -co mmerc ial us e o nly references 1. tarigan 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of jakarta setting. j ners 2020;15:12634. 25. martawinarti rtsn, nursalam n, wahyudi as. lived experience of people living with hiv/aids undergoing antiretroviral therapy: a qualitative study. j ners 2020;15:157-63. 26. rooney as, moore rc, paolillo ew, et al. depression and aging with hiv: associations with health-related quality of life and positive psychological factors. j affect disord 2019;251:1-7. [page 118] [healthcare in low-resource settings 2023; 11:11737] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11979 determinants of birth weight and length: an analysis of the 2020 mothers' cohort register data gurid pramintarto eko mulyo, denira kusuma putri, aryani sudja, yenny moviana, mulus gumilar, umi mahmudah, nitta isdiany nutrition department, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract a woman’s nutritional status significantly impacts the qualities of the baby she delivers, as assessed by the baby’s weight and length at birth. this study aimed to identify factors influencing birth weight and length using a retrospective case-control design with secondary data collected from the mothers’ cohort register at the community health center in 2020-2021. the study included 100 samples, comprising 25 cases and 75 controls. several determinants of birth weight and length were examined: the mother’s age (or=4.1, 95% ci 1.41-12.0), weight gain during pregnancy (or=3.6, 95% ci 1.051-12.553), mid-upper arm circumference (or=2.9, 95% ci 1.061-8.220), hemoglobin level (or=4.711, 95% ci 1.57-14.11), and iron supplement intake (or=1.837, 95% ci 0.600-5.624), with hemoglobin level identified as the most influential factor on birth qualities. mothers with less than normal hemoglobin levels have a 4.7 times higher risk of delivering babies of lower weight and length than mothers with normal hemoglobin levels. the impact of low hemoglobin in pregnant women includes reduced oxygen supply for both the mother and fetus, resulting in low birth weight, child anemia, premature birth, and child mortality. given these significant effects, it is crucial to establish standards for health services in indonesia, ensuring that pregnant women with low hemoglobin receive comprehensive care aligned with indonesia’s sustainable development goals (sdgs) standards. introduction a woman’s nutritional status significantly impacts the health of the child she gives birth to. for instance, a woman’s well-being during pregnancy influences the newborn’s health. conversely, poor nutritional status in pregnant women increases the risk of delivering babies with low birth weight.1,2 the health outcomes of babies can be assessed based on their body weight and length at birth. healthy newborns typically weigh ≥2500 grams and have a body length ≥48 cm, falling within >-2 sd and <2 sd. babies with birth weights <2500 grams are considered low birth weight (lbw), and those with body lengths <48 cm are classified as stunted (short).3-5 lbw remains a global problem, especially in developing countries. the worldwide incidence of lbw is 15.5%, meaning that out of 20.6 million births, 3.2 million babies are born with lbw every year. a significant majority, 96.5%, of these cases occur in developing countries.6 lbw is a leading cause of neonatal mortality in indonesia, with a prevalence rate of 6.2%.7 according to open data jabar, in 2021, the prevalence of lbw in west java was 96.5%, with banjar city having the highest rate (21%) and bekasi the lowest (0.5%).8 the 2022 indonesian nutrition status survey reported a national prevalence of stunting at 21.6%.9 the asian development bank (adb) reveals that indonesia has the second-highest prevalence of stunted children under five years old (toddlers) in southeast asia, reaching 31.8% in 2020. this figure surpasses stunting rates in laos (30.2%), cambodia (29.9%), and the philippines (28.7%).10 the 2018 basic health research results show that 22.7% of babies born are classified as short, with a length <48 cm. this represents an increase from 2013 (20.2%),7 while the prevalence of babies born with a weight <2500 grams correspondence: gurid pramintarto eko mulyo, nutrition department, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: gurid@staff.poltekkesbandung.ac.id key words: hemoglobin levels, low birth weight, mothers’ cohort register, nutritional status, stunting. contributions: gpem, conceptualization, methodology; dkp, conceptualization, writing-original draft; as, data analysis, review; ym, validation, supervision; mg, review, verification, supervision; um, review, and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by a research grant from politeknik kesehatan kemenkes bandung. ethics approval: this research was conducted with the permission of the educational institution and the ethics commission. while secondary data were utilized, instances arose where clarification of the data was necessary, leading to the requisite permission being obtained from the educational institution and the ethics commission. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank politeknik kesehatan kemenkes bandung for their valuable insights and contributions to this study. received: 14 october 2023. accepted: 21 may 2024. early access: 15 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11979 doi:10.4081/hls.2024.11979 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11979] [page 571] was 6.2%.11 monitoring infant growth and development in the first 1000 days of life is crucial for preventing lbw and stunting. the first 1000 days span from the early stages of life in the womb until the first 2 years of life.12 during this period, children are at a high risk of malnutrition, and disruptions can have lasting effects on growth and development.13 the nutritional status and food intake of pregnant women during these 1000 days significantly influence the qualities of the baby. research by retni (2016)14 indicates that low energy, protein, folic acid, and iron intake in teenage pregnant women is a risk factor for giving birth to an lbw baby. low protein and folic acid intake in pregnant women create a 13-times greater risk of delivering an lbw baby, low energy intake has a six-times greater risk, and low iron intake has a four-times greater risk.15 woldeamanuel et al. (2019)16 demonstrated that the nutritional status of pregnant women, as assessed through anthropometry and hemoglobin levels, correlates with the birth weight of the baby. therefore, maintaining good nutritional status and intake during pregnancy is crucial for delivering babies in good health. monitoring the nutritional status of pregnant women can be achieved through the mothers’ cohort register, a valuable data source for pregnancy and maternity services that describes the mother’s condition or risks. the mothers’ cohort register benefits by helping determine the prognosis of diseases or events related to the mother’s pregnancy, allowing immediate intervention measures. nutritional indicators in the mothers’ cohort register include the mother’s weight and height measurement, weight gain during pregnancy, hemoglobin level, upper arm circumference measurement, blood pressure, consumption of iron supplement tablets, age, and blood pressure measurement. therefore, this study aimed to determine the mother’s factors that may affect the health outcomes of babies. the findings of this study will provide a comprehensive overview for developing policies related to health monitoring systems for expectant mothers and their newborns at various levels, including hospitals, community health centers, and families. the national ministry of health guidelines recommend a system for monitoring babies, recognizing issues, especially warning signs, and referring patients to the appropriate healthcare professionals if a baby or pregnant woman has a health issue. the achievement of sustainable development goals (sdgs) will be impacted positively by this policy. materials and methods research design this study adopted a retrospective design, collecting secondary data where outcomes occurred, with a sequential variable tracing direction initiated from the independent variable. the secondary data were sourced from the mothers’ cohort registers at the community health center in cimahi city, indonesia, spanning from 2020 to 2021. employing an observational approach, the research utilized a case-control design to compare groups and ascertain event proportions based on exposure history. the study encompassed the entire population of pregnant women who underwent pregnancy checks and were recorded in the mothers’ cohort register. inclusion criteria for both case and control groups stipulated registration in the mothers’ cohort register between 2020 and 2021, availability of birth data, including weight and length, attendance at pregnancy checks at least four times, and a normal birth record. exclusion criteria comprised records of multiple pregnancies, chronic illnesses such as gestational diabetes mellitus or human immunodeficiency virus (hiv), or pregnancy disorders like severe pre-eclampsia. sample size determination the sample size was determined using the sastroasmoro formula (2011)17 for case-control research. each case and control group comprised 50 individuals, selected through sample calculation results. however, as only 25 cases were obtained, the total sample size was recalculated using a 1:3 case-to-control ratio, resulting in a total of 25 cases and 75 controls. sample size formula: data collection data collection commenced after receiving research permission from the educational institution and the ethics commission. secondary data on pregnant women’s examination records at the community health center in cimahi city from january 2020 to april 2021 were gathered from the cohort register. a questionnaire was employed to collect pregnant women’s data, focusing on birth weight and length, with infants categorized into case or control groups based on their normalcy. additionally, maternal monitoring records during pregnancy were examined, comprising seven variables, including the mother’s age, weight gain during pregnancy, blood pressure, hemoglobin levels, iron supplement tablet consumption, height, and upper arm circumference. variables and instruments the dependent variable in this study were the qualities of the newborn, assessed by the birth weight and length of the baby. independent variables included the mother’s age, weight gain during pregnancy, height, mid-upper arm circumference, blood pressure, hemoglobin levels, and iron supplement tablet intake. the instrument used for data collection was a questionnaire of pregnant women’s data. data collection commenced by examining infant birth data, specifically birth weight and length. infants with below-normal length and/or weight were categorized into the case group, while those with normal length and weight were placed in the control group. the qualities of the newborn variable was categorized into good and poor health. birth weight and length measurements were compared with world health organization (who) standards, with poor health defined as birth weight <2500 grams and/or body length <48 cm, and good health as body weight ≥2500 grams and body length ≥48 cm. furthermore, maternal monitoring records during pregnancy, serving as independent variables, were examined at least four transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 572] [healthcare in low-resource settings 2024;12:11979] times, with data collected monthly. these records included seven variables: mother’s age (considered high risk if the mother’s age was <20 years or >35 years and low risk if the mother was 20-35 years old), weight gain during pregnancy (classified as less weight gain if <9 kg and normal weight gain if ≥9 kg), mother’s height (classified as high risk if <145 cm and normal if ≥145 cm), upper arm circumference (classified as indicative of chronic energy deficiency, ced, if <23.5 cm and non-ced if ≥23.5 cm), blood pressure (classified as hypertension if ≥140/80 mmhg and normal if <140/80 mmhg), hemoglobin levels (considered anemia if hb <11 g/dl and no anemia if hb ≥11 g/dl), and iron supplement tablets intake (considered inadequate if <90 tablets were taken during pregnancy and adequate if ≥90 tablets were taken). data analysis data analysis was performed using spss version 20 software, aiming to test the null hypothesis (h0) utilizing chi-square and odds ratio (or) at a significance level of 5%. permission to conduct the research was obtained from the educational institution and the ethics commission, with clarifications sought where necessary due to the use of secondary data. results the sample consisted of 100 pregnant women who underwent examinations at the community health center in cimahi city, with 25 individuals in the case group and 75 in the control group. table 1 presents factors contributing to the qualities of babies born at the community health center. the data indicate that among mothers classified as high risk due to age, the majority of newborns were classified as of poor health (36.0%). additionally, 24.0% of newborns born to mothers with less weight gain during pregnancy were categorized as of poor health. among mothers with a height below 145 cm, 32.0% of newborns fell into the poor health category. furthermore, newborns born to mothers with ced accounted for 36.0% of the poor health category. in terms of maternal hypertension, 32.0% of newborns were classified as of poor health. newborns born to mothers with anemia constituted 36.0% of the poor health category. lastly, among newborns born to mothers with inadequate intake of iron supplement tablets, 24.0% were categorized as of poor health. table 2 reveals variables associated with birth qualities, with a p-value <0.05, including mother’s age (or=4.1, 95% ci 1.4112.0), weight gain during pregnancy (or=3.6, 95% ci 1.05112.553), mid-upper arm circumference (or=2.9, 95% ci 1.0618.220), hemoglobin level (or=4.711, 95% ci 1.57-14.11), and iron supplement intake (or=1.837 95% ci 0.600-5.624). these variables are equally linked to birth qualities, with hemoglobin level emerging as the most influential factor. mothers delivering babies with hemoglobin levels below the normal threshold (<11g/dl) were 4.7 times more likely to have babies of poor health than mothers with normal hemoglobin levels. discussion mother’s age in high risk is associated with a 4.1 times greater chance of giving birth to children with poor health compared to mothers aged 20-35 years, indicating a significant relationship. these findings align with manuaba’s theory (2012), which identifies high-risk maternal age, specifically <20 years and >35 years, as a factor disrupting the optimization of both mother and fetus.18 the incidence of diseases during pregnancy is higher in mothers transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11979] [page 573] table 1. risk factors distribution for newborns’ health (n=100). newborns’ health total independent variables poor health good health (bw<2500 gr and/or bl <48 cm) (bw ≥2500 gr and bl ≥48cm cm) n % n % n % mother's age high risk 9 36.0 9 12.0 18 18.0 low risk 16 64.0 66 88.0 82 82.0 weight gain during pregnancy less weight gain 6 24.0 6 8.0 12 12.0 normal weight gain 19 76.0 69 92.0 88 88.0 mother's height high risk 8 32.0 13 17.3 21 21.0 low risk 17 68.0 62 82.7 79 79.0 upper arm circumference ced 9 36.0 12 16.0 21 21.0 no ced 16 64.0 63 84.0 79 79.0 blood pressure hypertension 8 32.0 17 22.7 25 25.0 normal 17 68.0 58 77.3 75 75.0 hemoglobin levels anemia 9 36.0 8 10.7 17 17.0 no anemia 16 64.0 67 89.3 83 83.0 iron supplement tablets intake inadequate 6 24.0 11 14.7 17 17.0 adequate 19 76.0 64 85.3 83 83.0 ced, chronic energy deficiency; bw, birth weight; bl, birth length. <20 years due to reproductive organ immaturity, leading to potential health risks for both the mother and fetal growth. additionally, mothers aged >35 years, experiencing reduced fertility and often having cardiovascular diseases, are at risk of lbw. the optimal age for pregnancy is considered to be between 20-35 years.19,20 there was a significant association between weight gain during pregnancy and birth qualities, with mothers who gained less than 9 kg during pregnancy being 3.6 times more likely to give birth to children with poor health. this finding aligns with the research of fabella et al. in 2015, which concluded that there is a significant relationship between weight gain during pregnancy and the incidence of lbw.21 pregnancy causes increased energy metabolism and other nutrients for fetal growth and development. the nutritional status of pregnant women determines the baby’s weight at birth. the nutritional adequacy of pregnant women can be gauged from their weight gain during pregnancy.22 low or inappropriate weight gain poses a high risk of delivering lbw babies, emphasizing the importance of appropriate weight gain during pregnancy to reduce this risk.23 there is no association between the mother’s height and birth qualities. however, it is noteworthy that our research diverges from observational epidemiological studies, which indicate that the mother’s height correlates with gestational age at birth and fetal growth measures. shorter mothers tend to deliver infants at earlier gestational ages with lower birth weight and birth length. additionally, exploring parental transmission in mother-offspring pairs allows us to assess the impact of parental single nucleotide polymorphisms (snps) associated with height on length and birth weight. this analysis reveals exaggerated differences between maternally and paternally transmitted alleles, with maternally transmitted alleles generally exhibiting a larger effect size than paternally transmitted ones.24 mothers experiencing chronic energy deficiency have a 2.9 times greater chance of giving birth to children with poor health. this finding aligns with amima’s research (2018),25 which indicates that mothers classified as having chronic energy deficiency face a 6.6 times greater risk of giving birth to lbw infants. according to ohlsson and shah (2008),26 mothers classified as having chronic energy deficiency experience prolonged energy deficiency, even preceding pregnancy. inadequate nutritional intake during embryo implantation can have detrimental effects on fetal development in subsequent trimesters. for optimal fetal growth and development, mothers require adequate nutritional intake before and during pregnancy. malnourishment in the mother can impede nutritional fulfillment for the fetus, resulting in obstacles to fetal growth and contributing to low birth weight.26 the results revealed no association between blood pressure and birth qualities. this finding contrasts with moura et al.’s research (2021),27 which asserts that newborns from mothers with hypertension exhibit significantly lower birth weight and head circumference. it is plausible that moura’s study involved samples from different ethnicities. infants born to mothers with hypertension also showed a higher incidence of necrotizing enterocolitis.27 however, our study aligns with jayanti’s 2017 research, which found no relationship between systolic and diastolic blood pressure and the incidence of lbw. according to jayanti, systolic blood pressure is not a risk but a protective factor.28 the relationship between hemoglobin levels and birth qualities suggests that pregnant women with hemoglobin levels <11 g/dl have a 4.7-times greater chance of giving birth to children with poor health. the confidence interval (ci) data (1.57-14.11) indicates that the effect of hemoglobin (hb) ranges from a minimum of 1.57-times to a maximum of 14.11-times. this finding aligns with rajashree et al. (2015),29 who reported a relationship between hb levels and the incidence of lbw. mothers experiencing anemia have a 4.6-times greater risk of giving birth to lbw infants. the hb level of pregnant women significantly influences the weight of the newborn. both high and low hemoglobin levels during pregnancy can lead to impaired fetal growth in the womb. it is crucial for pregnant women to undergo at least four prenatal check-ups, with a focus on checking hb levels in the first and third trimesters due to blood dilution. this examination helps identify whether the pregnant woman is anemic, as anemia can impact fetal growth and development in the womb.30,31 there is a significant relationship between the consumption of iron supplement tablets and birth qualities, and it was found that mothers who consumed fewer than 90 tablets during pregnancy had a 1.8 times greater chance of giving birth to children with poor health. this finding aligns with aprisia’s research (2022), which states that iron supplement tablet consumption during pregnancy is related to the birth weight of the baby, and mothers who consume iron supplement tablets not according to recommendations have the risk of giving birth to lbw babies.32 according to basic health research (2018), providing iron supplement tablets is one of the important efforts to prevent anemia due to iron and folate deficiency. the ministry of health recommends that pregnant women consume a minimum of 90 tablets during pregnancy.11 pregnant women are advised to consume more iron intake than when they are not pregnant because, as the time of birth approaches, the iron needs of pregnant women increase. this is because the blood volume needed by pregnant women and fetuses is increasing. iron deficiency during pregnancy can increase the risk of premature birth and lbw babies.33 pregnant women are encouraged to consume more iron than when not pregnant. based on the nutrition adequacy rate in 2019, it is recommended that pregnant women consume iron. in 2019, there was no additional need for iron for pregnant women in the first trimester. however, in pregnant women in the second and third trimesters, the additional requirement for iron is 9 mg/day.34 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. relationship of risk factors with newborns’ health. independent variables p or 95% ci mother's age high risk 0.014* 4.125 1.41-12.0 low risk weight gain during pregnancy less weight gain 0.058* 3.632 1.051-12.553 normal weight gain mother's height high risk 0.156 2.244 0.800-6.295 low risk mid-upper arm circumference ced 0.047* 2.953 1.061-8.220 no ced blood pressure hypertension 0.425 1.606 0.591-4.361 normal hemoglobin levels anemia 0.011* 4.711 1.57-14.11 no anemia iron supplement tablets intake inadequate 0.035* 1.837 0.600-5.624 adequate *p<0.05. ced, chronic energy deficiency; or, odds ratio; ci, confidence interval. [page 574] [healthcare in low-resource settings 2024;12:11979] additional iron needs during pregnancy are fulfilled by consuming iron supplement tablets.35 the provision of iron supplement tablets aims to prevent and overcome anemia due to iron deficiency in pregnant women, which is one of the factors causing lbw. this indicates that the provision of iron supplement tablets to pregnant women is indirectly related to the occurrence of lbw.33 the limitations of this study include incomplete data and necessitating contact with the intended respondents. additionally, the researcher encountered difficulty in obtaining the targeted number of case groups, which should have amounted to 50 samples; however, only 25 were obtained. conclusions the mother’s age, hb level, upper arm circumference, weight gain, and the consumption of iron supplement tablets are factors associated with birth weight and length. there is a greater risk for mothers giving birth with lower-than-normal hemoglobin levels. based on this research, it is recommended that midwives enhance the early detection of pregnancy risk factors through antenatal care (anc) and maternal cohort registers. additionally, midwives should take proactive measures and closely monitor high-risk mothers to prevent the birth of babies with poor health. considering the significant impact of low hemoglobin levels, it should be standard practice for health services in indonesia to provide comprehensive care for pregnant women with low hemoglobin levels, aligning with indonesia’s sdgs standards. references 1. ramda sh, arief ys, krisnana i. maternal behavioral factors of mothers with neonatal death in the perinatal period. int j pharm res 2020;12:1735-40. 2. pritasari, damayanti d, lestari nt. gizi dalam daur kehidupan. 2017. available from: https://repository.stikeshb.ac.id/25/1/gizi-dalam-daurkehidupan-final-sc_.pdf 3. hadi en, dimar setio ka. informasi seputar kesehatan bayi baru lahir. 2008. available from: https://scholar.ui.ac.id/en/ publications/informasi-seputar-kesehatan-bayi-baru-lahir 4. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j glob pharma technol 2020;12:815-25. 5. flynn j, alkaff ff, sukmajaya wp, salamah s. comparison of who growth standard and national indonesian growth reference in determining prevalence and determinants of stunting and underweight in children under five: a cross-sectional study from musi sub-district [version 4; peer review: 2 approved]. f1000research 2021;9:1-20. 6. world health organization (who). guidelines on optimal feeding of low birth-weight infants in low-and middle-income countries. 2011. available from: https://www.who.int/publications/i/item/9789241548366 7. balitbang kementrian kesehatan ri. riset kesehatan dasar 2013. 2013. available from: https://repository.badankebijakan.kemkes.go.id/id/eprint/4467/1/laporan_riskesdas_2013 _final.pdf 8. dinas kesehatan. persentase bayi berat badan lahir rendah (bblr). 2021. available from: https://waykanankab. bps.go.id/indicator/30/712/1/-jumlah-bayi-lahir-bayi-beratbadan-lahir-rendah-bblr-bblr-dirujuk-dan-bergizi-buruk-.html 9. liza munira s. hasil survei status gizi indonesia (ssgi) 2022. 2022. available from: https://ayosehat.kemkes.go.id/ materi-hasil-survei-status-gizi-indonesia-ssgi-2022 10. bank pembangunan asia. prevalensi stunting balita indonesia tertinggi ke-2 di asia tenggara. 2021. available from: https://databoks.katadata.co.id/datapublish/2021/11/25/preval ensi-stunting-balita-indonesia-tertinggi-ke-2-di-asia-tenggara 11. kementerian kesehatan ri. riset kesehatan dasar. balitbang kementerian kesehatan ri. 2018. available from: https://layanandata.kemkes.go.id/katalog-data/riskesdas/ ketersediaan-data/riskesdas-2018 12. maulina r, qomaruddin mb, prasetyo b, et al. the effect of stunting on the cognitive development in children: a systematic review and meta-analysis. stud ethno-medicine 2023;17:1927. 13. kementerian koordinator bidang kesejahteraan rakyat. kerangka kebijakan gerakan nasional percepatan perbaikan gizi dalam rangka seribu hari pertama kehidupan (gerakan 1000 hpk). 2013. available from: https://lisa.poltekkesjakarta3.ac.id/perpustakaan/index.php?p=show_detail&id=8467&k eywords= 14. retni r, margawati a, widjanarko b. pengaruh status gizi & asupan gizi ibu terhadap berat bayi lahir rendah pada kehamilan usia remaja. j gizi indones (the indones j nutr) 2016;5:14-9. 15. safitri ho, fauziningtyas r, indarwati r, et al. determinant factors of low birth weight in indonesia: findings from the 2017 indonesian demographic and health survey. j pediatr nurs 2022;63:e102-6. 16. woldeamanuel gg, geta tg, mohammed tp, et al. effect of nutritional status of pregnant women on birth weight of newborns at butajira referral hospital, butajira, ethiopia. sage open med 2019;7:1-7. 17. sastroasmoro s. dasar-dasar metodologi penelitian klinis. 2011. available from: https://opac.perpusnas.go.id/detailopac.aspx?id=1111569 18. manuaba ibg. buku ajar pengantar kuliah teknik operasi obstetri dan keluarga berencana. 2012. available from: https://digilib.uki.ac.id/index.php?p=show_detail&id=19787 &keywords= 19. depkes ri. program perbaikan gizi menuju indonesia sehat 2010. 2010. available from: http://repository.uki.ac.id/62/1/ gerakan%20nasional%20percepatan%20perbaikan%20gizi. pdf 20. wulandari rd, laksono ad, kusrini i, tahangnacca m. the targets for stunting prevention policies in papua, indonesia: what mothers’ characteristics matter? nutrients. 2022;14:549. 21. fabella k, angraini id, carolina n, asep s. hubungan pertambahan berat badan ibu selama hamil dengan berat badan bayi lahir rendah. j major 2015;4:52-7. 22. utami s, susilaningrum r. analysis of the causes of low birth weight infants in terms of nutritional status and maternal health history. j ners 2022;17:131-7. 23. nadesul h. makanan sehat untuk ibu hamil. 2008. available from: https://rsudbendan.pekalongankota.go.id/berita/contoh—menu-makanan-sehat-ibu-hamil.html 24. zhang g, bacelis j, lengyel c, et al. assessing the causal relationship of maternal height on birth size and gestational age at birth: a mendelian randomization analysis. plos med 2015;12:e1001865. 25. fajriana a, buanasita a. faktor risiko yang berhubungan transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11979] [page 575] dengan kejadian bayi berat lahir rendah di kecamatan semampir surabaya. media gizi indones 2018;13:71. 26. ohlsson a, shah p. determinants and prevention of low birth weight: a synopsis of the evidence. institute of health economics; alberta, canada. 2008. available from: https://www.ihe.ca/advanced-search/determinants-and-prevention-of-low-birth-weight-a-synopsis-of-the-evidence 27. de moura mdr, margotto pr, costa kn, garbi novaes mrc. hypertension induced by pregnancy and neonatal outcome: results from a retrospective cohort study in preterm under 34 weeks. plos one 2021;16:1-12. 28. jayanti fa, dharmawan y, aruben r. faktor-faktor yang berhubungan dengan kejadian berat badan lahir rendah di wilayah kerja puskesmas bangetayu kota semarang tahun 2016. j kesehat masy 2017;5:812-22. 29. rajashree k, prashanth h, revathy r. study on the factors associated with low birth weight among newborns delivered in a tertiary-care hospital, shimoga, karnataka. int j med sci public heal 2015;4:1287. 30. sudargo t, aristasari t, ’afifah a. 1000 hari pertama kehidupan. 2018. available from: https://cfns.ugm.ac.id/2022/10/24/pentingnya-seribu-hari-pertama-kehidupan-1000-hpk/ 31. krishnan v, zaki ra, nahar am, et al. the longitudinal relationship between nutritional status and anaemia among malaysian adolescents. lancet reg heal west pacific 2021;15:100228. 32. aprisia b, simbolon d. konsumsi tablet tambah darah kaitannya dengan berat lahir bayi di indonesia. j nutr coll 2022;11:294-302. 33. a’ila i, sumarmi s. hubungan cakupan tablet fe3 dengan bblr di provinsi jawa timur tahun 2017. amerta nutr 2019;3:291-7. 34. kemenkes ri. angka kecukupan gizi 2019. 2019. available from: https://stunting.go.id/kemenkes-permenkes-no-28tahun-2019-angka-kecukupan-gizi-yang-dianjurkan/ 35. triharini m, sulistyono a, adriani m, devy sr. the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and self-determination theory. j ners 2019;14:92-100. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 576] [healthcare in low-resource settings 2024;12:11979] hrev_master healthcare in low-resource settings 2023; volume 11:11812 cancer risk factors associated with historical contraceptive use and breastfeeding duration pipit feriani,1,2 esti yunitasari,1 ferry efendi,1 ilya krisnana,1 rini ernawati,2 reny mareta sari,3 nurus safaah4 1faculty of nursing, universitas airlangga, surabaya; 2nursing department, faculty of nursing, universitas muhammadiyah kalimantan timur, samarinda; 3department of public health, institute of health science strada indonesia, kediri; 4department of maternity, institute of health science nahdlatul ulama indonesia, tuban, indonesia abstract cancer is the second leading cause of death worldwide. two prominent factors in this regard are a woman’s history of contraceptive use and the duration of breastfeeding. this study aimed to delve into these risk factors and their impact on cancer incidence. the research employed a cross-sectional design involving 125 cancer patients undergoing chemotherapy at abdul wahab sjahranie hospital in samarinda, east kalimantan. this study used a total sampling approach to include all available patients. data on contraceptive use, breastfeeding duration, and cancer status were collected through a questionnaire and subsequently analyzed using the chi-square test. the study revealed that breast cancer was the most prevalent type, affecting 41.6% of patients. additionally, more than half of the respondents breastfed for less than two years (52%), while only 48% breastfed for two years or more. notably, a significant majority (66.4%) had a history of using hormonal contraception. statistical analysis demonstrated a compelling association between contraceptive history, breastfeeding duration, and cancer incidence (p < 0.001). in summary, the findings highlight a substantial relationship between a woman’s history of contraceptive use, the duration of breastfeeding, and the incidence of breast cancer. these results underscore the importance of further research and the development of targeted interventions to better understand and mitigate breast cancer risk factors among women. introduction cancer is a general term for a large group of diseases characterized by the overgrowth of abnormal cells that invade adjacent parts of the body and spread to other organs. other common terms for this condition are malignancy and neoplasm. cancer can affect almost any part of the body.1 however, cancer rates vary from country to country, with the fastest-growing rates observed in latin america, africa, and developing countries in asia. the death rate from cancer increased from 8.2 million in 2012 to 9.6 million in 2018. the most common causes of death from cancer worldwide include lung cancer (1.76 million deaths), colon cancer (862,000 deaths), stomach cancer (783,000 deaths), liver cancer (782,000 deaths), and breast cancer (627,000 deaths).1 nationally, cancer rates in indonesia remain high, showing an increasing prevalence of cancer and tumors. according to the global burden of cancer (globocan) data released on september 12, 2018, cancer is the leading cause of incidence in indonesia, with 58,256 reported cases. this is followed by cervical cancer with 32,469 cases and lung cancer with 30,023 cases, among others.2,3 east kalimantan has a high incidence of cancer, with a prevalence rate of 1.7%, affecting 6,745 people. the most common types of cancer in east kalimantan include breast cancer correspondence: pipit feriani, faculty of nursing, universitas airlangga, surabaya, indonesia; nursing department, faculty of nursing, universitas muhammadiyah kalimantan timur, samarinda, indonesia. e-mail: pipit.feriani-2022@fkp.unair.ac.id key words: cancer; duration of breastfeeding; history of contraceptive use. contributions: pf, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ey, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; fe, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ik, methodology, visualization, writing – review & editing; re, resources, investigation, and writing – review & editing; rms, formal analysis, validation, writing – review & editing; ns, resources, supervision, and writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, abdul wahab sjahranie hospital samarinda, based on ethical certificate 023/kepk-aws/i/2019. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we express our gratitude to the abdul wahab sjahranie hospital samarinda for their invaluable insights and substantial contributions to this research study. received: 14 september 2023. accepted: 18 october 2023. early access: 26 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11812 doi:10.4081/hls.2023.11812 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11812] [page 95] non -co mmerc ial us e o nly (1,879 cases), colon/rectal cancer (1,923 cases), cervical cancer (752 cases), lung cancer (875 cases), and leukemia (653 cases).4 medical records from abdul wahab sjahranie hospital in samarinda for the year 2017 show that cancer cases were the most common disease in samarinda, with 1,421 reported cases. most of these cancer patients underwent chemotherapy at abdul wahab sjahranie hospital.4 the factors contributing to the increased incidence of cancer are not fully understood, but many studies have linked this increase to lifestyle changes, including reproductive factors, physical activity, and diet. reproductive factors associated with an increased cancer risk include early menarche, late menopause, first birth over age 30, never breastfeeding, the use of oral hormonal contraceptives, and hormone replacement therapy.5 an often overlooked risk factor for cancer in women is their history of contraceptive use. the use of birth control pills can increase estrogen exposure in the body, potentially leading to abnormal cell growth and an increased risk of cancer, depending on age and duration of use.6 the most commonly used hormonal contraceptives are injections and pills, which often combine estrogen and progesterone. the estrogen and progesterone content of these contraceptives can excessively stimulate glandular growth. consequently, long-term use of oral contraceptives is associated with an increased risk of cancer.7 according to nasution et al. (2018), a sedentary lifestyle and unhealthy habits increase the risk of cancer, particularly among individuals with a family history of the disease. furthermore, prolonged use of hormonal contraceptives can disrupt the body’s hormonal balance, leading to normal cell changes becoming abnormal.8 breastfeeding is a modifiable reproductive factor associated with a reduced risk of cancer.3 apart from its potential in reducing the risk of breast cancer in mothers, breastfeeding provides multiple benefits for both mother and baby. however, despite these advantages, breastfeeding rates remain low among women.9 the relationship between extended breastfeeding and cancer incidence remains a subject of debate. while bernier et al.10 reported conflicting results regarding breastfeeding as a risk factor for cancer, lanfranchi’s study11 demonstrated that breastfeeding women had a lower risk of developing cancer compared to non-breastfeeding women. in contrast, thomas’s study12 found that continuous breastfeeding did not significantly affect cancer risk. in a preliminary survey conducted among ten cancer patients, including four breast cancer patients, three colon cancer patients, two cervical cancer patients, and one lung cancer patient, eight of the ten respondents with cancer had a history of hormonal contraception use. two respondents had a long history of using non-hormonal contraception. this study aimed to analyze the risk factors associated with the history of contraceptive use and the duration of breastfeeding in relation to breast cancer, colon/rectal cancer, cervical cancer, and lung cancer. materials and methods research design explanatory research was employed to identify risk factors associated with the history of contraceptive use and duration of breastfeeding in relation to cancer, utilizing a cross-sectional approach. this research aimed to elucidate the characteristics of respondents, contraceptive history, breastfeeding duration, and types of cancer. study participants the study population comprised 183 cancer patients receiving chemotherapy at abdul wahab syahrani hospital in samarinda. purposive sampling, a non-random technique, was used to select 125 respondents based on predetermined criteria. inclusion criteria encompassed patients diagnosed with breast cancer, colon/rectal cancer, cervical cancer, and lung cancer, who were conscious, female, married, with a history of breastfeeding and contraceptive use. exclusion criteria included patients with poor communication abilities and severe debilitation. variable, instrument, and data collection the independent variables encompass demographic factors such as age, education, and occupation, along with the history of contraceptive use (non-hormonal, hormonal), and duration of breastfeeding (less than two years and more than two years). the dependent variable is the type of cancer (breast cancer, colon/rectal cancer, cervical cancer, and lung cancer). a questionnaire was employed as the research instrument, previously tested for validity and reliability. this seven-question instrument employs a 2-point guttman scale: “yes” = 2 and “no” = 1. data analysis data analysis was conducted using spss with the chi-square test. the chi-square test is particularly useful for assessing the relationship or influence between two nominal variables, each representing a different nominal variable (c = coefficient of contingency). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=125). characteristics frequency % age (years) 17-25 3 2.4 26-35 18 14.4 36-45 31 24.8 46-55 47 37.6 56-65 18 14.4 >65 8 6.4 education not attending school 25 20.0 elementary school 41 32.8 junior high school 38 30.4 senior high school 18 14.4 college 3 2.4 occupation not working/housewife 110 88.0 laborer/farmer 2 1.6 private 5 4.0 entrepreneur 6 4.8 civil servant 2 1.6 history of contraceptive use non-hormonal 42 33.6 hormonal 83 66.4 duration of breastfeeding <2 years 65 52.0 ≥2 years 60 48.0 type of cancer breast cancer 52 41.6 colon/rectum cancer 29 23.2 cervical cancer 29 23.2 lung cancer 15 12.0 total 125 100 [page 96] [healthcare in low-resource settings 2023; 11:11812] non -co mmerc ial us e o nly results table 1 reveals that among the 125 respondents, the largest age group consisted of individuals aged 46-55, totaling 47 people (37.6%). in terms of the respondents’ highest level of education, the majority were elementary school graduates, accounting for 41 respondents (32.8%). regarding employment, the majority of respondents were unemployed/homemakers (irt), comprising 110 individuals (88.0%). in addition, it is clear that a majority of respondents, specifically 66.4% or 83 individuals, reported a history of using hormonal contraception. furthermore, 52% of the respondents breastfed for less than two years. in terms of the types of cancer observed, breast cancer was the most prevalent, affecting 41.6% or 52 people. in table 2, the chi-square results show that out of the 125 respondents, 42 used non-hormonal contraception, while 83 opted for hormonal contraception. among those using non-hormonal contraception, 15 (35.7%) were diagnosed with breast cancer. for the 83 respondents who chose hormonal contraception, 37 (44.6%) were diagnosed with breast cancer. the statistical test indicates a significant relationship between the history of contraceptive use and the type of cancer. among the 65 respondents who breastfed for less than 2 years, 38 (58.5%) were diagnosed with breast cancer. in contrast, out of the 60 respondents who breastfed for two years, 18 (30%) were diagnosed with cervical cancer. the statistical chi-square test produced significant results. discussion the results of this research provide valuable insights into the factors influencing the occurrence of various cancer types among the participants. the study primarily focuses on key variables, including the history of contraceptive use and the duration of breastfeeding. historical contraceptive use and types of cancer our study findings reveal a significant association between historical contraceptive use and the prevalence of specific cancers among participants. notably, individuals who used hormonal contraception, especially for extended periods, showed a higher incidence of breast and cervical cancers. the most common forms of hormonal contraception are pills and injections due to their ease of use, which might explain the higher rates of breast and cervical cancers among those with a history of hormonal contraceptive use. these findings align with a 2015 study conducted by charlton et al., which indicated an increased risk of colon/rectal cancer, particularly with long-term hormonal contraceptive use exceeding eight years.13 according to fitri (2018), both short-term and long-term use of hormonal contraception can affect various body systems, such as ovulation, implantation, gamete transport, luteal function, cervical mucus, and estrogen and progesterone. excessive exposure to hormones in the body can trigger the rapid growth of cancer cells.14 these observations are consistent with a 2021 study by iversen et al., which reported an elevated risk in current or recent users of combined hormonal contraception but not with progestinonly contraception alone.15 this corroborates the findings of abdullah et al. (2013), which revealed a significant association between hormonal contraception and cervical cancer. mothers using hormonal contraceptives were found to be 0.18 times more likely to develop cervical cancer than those using non-hormonal contraceptives.16 based on our study’s results, it can be reasonably concluded that there is a general association between the use of hormonal contraception and cancer, with breast and cervical cancers having the highest incidence rates. according to our hypothesis, the risk of cancer and its impact on hormones is greater in cases where hormonal contraception is used for over ten years. extended use of contraception appears to challenge the body’s hormone regulation. a surplus of hormones in the body may expedite the emergence of cancer cells. hence, if contraceptive use surpasses a decade, it is advisable for respondents to undergo regular check-ups and examinations at least every six months to detect potential adverse effects and implement preventive measures for long-term contraceptive use. during direct interviews with 18 respondents, other factors potentially contributing to cancer were identified, including unhealthy lifestyles characterized by the consumption of carcinogenic foods (burnt foods), lack of physical activity, stress, family history, menarche, menopause, radiation exposure, alcohol contransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. relationship between history of contraceptive use, duration of breastfeeding and type of cancer. type of cancer history of contraceptive use p non-hormonal hormonal f % f % breast cancer 15 35.7 37 44.6 <0.001 colon/rectum cancer 11 26.2 18 21.7 cervical cancer 3 7.1 26 31.3 lung cancer 13 31.0 2 2.4 total 42 100 83 100 type of cancer duration of breastfeeding p < 2 years ≥ 2 years f % f % breast cancer 38 58.5 14 23.3 <0.001 colon/rectum cancer 15 23.1 14 23.3 cervical cancer 11 16.9 18 30.0 lung ccancer 1 1.5 14 23.3 total 65 100 60 100 [healthcare in low-resource settings 2023; 11:11812] [page 97] non -co mmerc ial us e o nly sumption, and smoking. however, another noteworthy factor linked to cervical cancer was the use of hormonal contraception for over ten years and frequent changes in contraception methods. among the 60 respondents, the average number of children per respondent was four to six, suggesting a possible connection between the number of children and the incidence of cancer.4–6 breastfeeding duration and type of cancer breastfeeding duration significantly impacts breast cancer risk, with 58.5% of the 65 respondents who breastfed for less than two years being diagnosed with breast cancer. interviews with these participants unveiled complex factors influencing breastfeeding practices, including work demands and beliefs about introducing solid foods early. a comprehensive approach, as suggested by anstey et al. in 2017, may be effective in supporting mothers to achieve their breastfeeding goals and reduce disparities in breastfeeding rates, ultimately lowering breast cancer incidence.17 research by listyawati in 2016 indicates that women who breastfeed for less than two years face a higher breast cancer risk,18 while ardhanary et al.’s 2018 study shows a 5.06 times higher risk for non-breastfeeding mothers.9 furthermore, gonzales-jiménez’s 2018 findings underscore the protective effects of breastfeeding for over six months, especially for mothers with multiple children, and breastfeeding for over two years due to prolonged hormonal influences.19 lastly, fortner et al.’s 2019 research highlights the potential of breastfeeding in reducing hormone receptor-negative breast cancers, making it a cost-effective risk-reduction strategy.20 these findings underscore the importance of interventions aimed at educating women about the protective benefits of breastfeeding in reducing their risk of breast cancer and associated mortality.21 sari et al.’s theory in 2012 posits that breastfeeding offers various advantages, including a reduced risk of breast, uterine, and ovarian cancers. this is attributed to the influence of estrogen in the body, and the decrease in estrogen levels during breastfeeding can lower the risk of cancer. a reduction in estrogen levels decreases the stimulation of the uterine and breast tissue linings, ultimately reducing the risk of cancer. the theory further suggests that breastfeeding for more than six months can lower cancer risk by 25-30%.22 the research primarily focuses on the relationship between contraceptive use, breastfeeding duration, and cancer incidence, and does not consider other potential confounding variables that could influence cancer risk. these limitations highlight the need for larger, more comprehensive studies in diverse populations to provide a more complete understanding of the complex factors contributing to cancer risk. conclusions this research has successfully identified a significant association between extended hormonal contraceptive use and an elevated risk of breast and cervical cancer. prolonged use of hormonal contraception could potentially disrupt hormone regulation, leading to an acceleration in the growth of cancer cells. additionally, the study highlights the protective advantages of breastfeeding, particularly in reducing the risk of breast cancer through the mechanism of decreasing estrogen levels during the breastfeeding period. the practical implications of these findings point toward the importance of public health campaigns aimed at increasing awareness and promoting informed decision-making regarding contraceptive methods and breastfeeding practices. however, it’s essential to acknowledge that further, more comprehensive research is necessary to consider other potential influencing factors on cancer risk. references 1. who. cancer [internet]. world health organization. 2018. available from: https://www.who.int/news-room/fact-sheets/ detail/cancer#:~:text=the problem-,cancer is a leading cause of death worldwide%2c accounting for,lung (2.21 million cases)%3b 2. sung h, ferlay j, siegel rl, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin 2021;71:209-49. 3. who-iarc. latest global cancer data: cancer burden rises to 18.1 million new cases and 9.6 million cancer deaths in 2018. press release 2018;50:3-4. 4. riskesdas. badan penelitian dan pengembangan kesehatan kementerian ri tahun 2018 [indonesian ministry of health research and development agency in 2018]. badan penelitian dan pengembangan kesehatan. 2018. p. 674. available from: http://labdata.litbang.kemkes.go.id/images/download/laporan/rkd/2018/laporan_nasional_rkd2018_final.pdf 5. sagala eta. hubungan lama menyusui pada multipara dengan kejadian kanker payudara di rsud dokter soedarso pontianak [the relationship between long-term breastfeeding in multiparous women and the incidence of breast cancer at rsud dokter soedarso pontianak]. j mhs fak kedokt untan 2014;1:8158. 6. dewi gat, hendrati ly. breast cancer risk analysis by the use of hormonal contraceptives and age of menarche. j berk epidemiol 2015;3:112-23. 7. sari n, amran vya. hubungan penggunaan kontrasepsi oral dengan kanker payudara wanita premenopause [the relationship between the use of oral contraceptives and breast cancer in premenopausal women]. j ilm kesehat sandi husada 2019;8:132-7. 8. nasution wm, siregar fa, asfriyanti. pengaruh pemakaian kontrasepsi hormonal dan riwayat keluarga terhadap kejadian kanker payudara di rsud dr . pirngadi medan tahun 2017 [the influence of hormonal contraceptive use and family history on the incidence of breast cancer at dr. hospital. pirnga. j med respati 2018;13:39-47. 9. ardhanary, bustan n, gobel fa. risk factors of breastfeeding history in the faktor risiko riwayat menyusui pada kejadian kanker payudara di rumah sakit ibnu sina makassar dan rsud makassar [incidence of breast cancer at ibnu sina hospital in makassar and regional general hospital makas. j mitrasehat 2018;8:514-23. 10. bernier mo, plu-bureau g, bossard n, et al. breastfeeding and risk of breast cancer: a meta-analysis of published studies. hum reprod update 2000;6:374-86. 11. lanfranchi a, brind j. breast cancer: risks and prevention. 4th ed. breast cancer prevention institute. 2007. 12. tryggvadóttir l, tulinius h, eyfjord je, sigurvinsson t. breastfeeding and reduced risk of breast cancer in an icelandic cohort study. am j epidemiol 2001;154:37-42. 13. charlton bm, wu k, zhang x, et al. oral contraceptive use and colorectal cancer in the nurses’ health study i and ii. cancer epidemiol biomarkers prev 2015;24:1214-21. 14. imelda f. nifas kontrasepsi terkini dan keluarga berencana [page 98] [healthcare in low-resource settings 2023; 11:11812] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly [latest postpartum contraception and family planning]. yogyakarta: gosyen publishing; 2018. 15. iversen l, fielding s, lidegaard ø, hannaford pc. contemporary hormonal contraception and cervical cancer in women of reproductive age. int j cancer 2021;149:769-77. 16. abdullah, bawotong. hubungan pemakaian kontrasepsi hormonal dan non hormonal dengan kejadian kanker serviks di prof. dr. r.d. kandao manado [the relationship between hormonal and non-hormonal contraceptive use and the incidence of cervical cancer at prof. dr. r.d. kandao man. j keperawatan unsrat 2013;1:105599. 17. anstey eh, shoemaker ml, barrera cm, et al. breastfeeding and breast cancer risk reduction: implications for black mothers. am j prev med 2017;53:s40-6. 18. listyawati. hubungan riwayat menyusui dengan kejadian kanker payudara di rumah sakit umum daerah muntilan [the relationship between breastfeeding history and the incidence of breast cancer at muntilan regional general hospital] [internet]. sekolah tinggi ilmu kesehatan ‘aisyiyah yogyakarta, indonesia 2015;13. available from: http://digilib.unisayogya.ac.id/1881/1/naskah publikasi listyawati 201410104121.pdf 19. gonzález-jiménez e. breastfeeding and reduced risk of breast cancer in women: a review of scientific evidence. in: barría rm, editor. selected topics in breastfeeding. intech open; 2018. 20. fortner rt, sisti j, chai b, et al. parity, breastfeeding, and breast cancer risk by hormone receptor status and molecular phenotype: results from the nurses’ health studies. breast cancer res 2019;21. 21. sly jr, miller sj, thelemaque l, et al. knowledge of the relationship between breastfeeding and breast cancer risk among racial and ethnic minority women. j cancer educ 2020;35:1193-6. 22. sari w, indrawati, harjanto bd. panduan lengkap kesehatan wanita [comprehensive women’s health guide]. jakarta: penebar plus; 2012. [healthcare in low-resource settings 2023; 11:11812] [page 99] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11760 identifying the risk factors of schistosomiasis in indonesia christine christine,1 herlina susanto sunuh,1 fellysca veronica margareth politon,1 diana vanda daturara doda2 1politeknik kesehatan kemenkes palu, palu; 2faculty of medicine, universitas sam ratulangi, manado, indonesia abstract in poso, central sulawesi, schistosomiasis prevalence has shown fluctuations, particularly in the napu highland, home to around 17,000 people, where there is a 0.15% risk of schistosomiasis. this study aimed to analyze the risk factors associated with schistosomiasis in the napu highland. conducted from april to june 2022, this case-control study included residents of schistosomiasis-affected villages. the sample consisted of 148 individuals (37 cases and 111 controls). cases were residents aged over 2 years who had tested positive for schistosomiasis in a 2021 fecal survey conducted by the poso district health office. controls were selected as the nearest neighbors of the cases. data on education, knowledge, occupation, sanitation practices, water sources, activities near water bodies, use of protective equipment, and livestock raising were collected through questionnaires. statistical analysis involved the chi-square test with α=5%. the results indicated that education (p=0.018; or=3.147) and knowledge (p=0.056; or=2.233) were associated with schistosomiasis. individuals with lower education levels were 3.147 times more likely to contract the disease, while those with limited knowledge were 2.233 times more at risk. in conclusion, improving schistosomiasis prevention in the napu highland should involve enhancing knowledge, attitudes, and practices through health promotion initiatives that engage educators and community leaders. introduction schistosomiasis is an acute and chronic parasitic disease caused by blood flukes (trematode worms) of the genus schistosoma. it remains a significant public health problem in many countries. according to estimates, as of 2021, at least 251.4 million people required preventive treatments.1 schistosomiasis is most prevalent in tropical and subtropical regions, particularly in impoverished communities lacking access to safe drinking water and adequate sanitation. the disease primarily affects poor, rural populations, especially those engaged in agricultural and fishing activities.2 children, due to their inadequate hygiene practices and contact with infected water, are particularly vulnerable to infection.3 the socio-economic impact of schistosomiasis is substantial, as the disease causes more disability than mortality.4,5 human infection occurs through contact with freshwater sources containing live cercariae, which penetrate the skin. however, it is important to note that schistosomiasis is not transmitted directly from person to person; rather, it requires freshwater bodies where intermediate snail (oncomelania hupensis lindoensis) hosts reside and reproduce.6 in indonesia, schistosomiasis is found in the highlands of bada, napu, and lindu, spanning across 28 villages in poso and sigi districts, central sulawesi.7 recent data from the central sulawesi provincial health office indicates a significant increase correspondence: christine christine, politeknik kesehatan kemenkes palu, palu, indonesia. e-mail: christinekromoprawiro@gmail.com key words: neglected tropical disease; risk; schistosomiasis; sanitation; socio-demographic. contributions: cc conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; hss conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; fvmp conceptualization, methodology, visualization, writing – review & editing; dvdd formal analysis, validation, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the ethical committee of medical research faculty of dentistry university of jember, 1524/un25,8/kepk/dl/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was supported by a research grant from poltekkes kemenkes palu, ministry of health of indonesia with contract number lb.02.03/3.b/0010/i/2022. acknowledgement: the authors would like to acknowledge the wuasa health center team for their assistance with the research. the authors would also like to thank the enumerator team for their dedication and effort and, most importantly, the respondents who consented to their time to make this research possible. received: 11 september 2023. accepted: 10 october 2023. early access: 20 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11760 doi:10.4081/hls.2023.11760 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 40] [healthcare in low-resource settings 2023; 11:11760] non -co mmerc ial us e o nly in schistosomiasis cases in the poso district, with a total of 245 cases reported in 2021 compared to the previous 45 cases. additionally, the sigi district reported 12 new cases in 2022, bringing the total number of schistosomiasis cases in central sulawesi in 2022 to 257. the prevalence of schistosomiasis in the two districts has risen to 1.5% of the total population in the 28 treated villages. by early february 2023, the prevalence of schistosomiasis reached 1.57%, surpassing the previous rate of below 1% recorded in 2019.8,9 the napu highland, particularly with a population of up to 17,000, faces a schistosomiasis risk of 0.15%, warranting attention and concern.10 schistosomiasis disproportionately affects impoverished rural communities, including agricultural and fishing populations, due to inadequate sanitation and frequent contact with infested water.3,11 occupational exposure to infested water, such as in the case of fishermen, farmers, irrigation workers, and women engaged in household duties near infested water, further contributes to the disease’s prevalence.2,6 studies conducted by muslimin in lore lindu national park and rosmini, jastal, and ningsi in the bada highland of poso regency identified various risk factors for schistosomiasis, such as lack of personal protective equipment, defecating in open areas, and bathing in infested rivers.12,13 furthermore, the public’s awareness of the importance of providing stool samples for investigation is an area of concern, particularly in the napu highland region. approximately 12% of the population studied did not collect their stool samples.14 knowledge about schistosomiasis can significantly influence people’s attitudes and actions. for instance, research conducted by sulistin and widajadnja in lindu sigi revealed a link between public awareness and attitudes towards schistosomiasis.15 the impact of schistosomiasis on health cannot be underestimated. chronic schistosomiasis can lead to reduced work capacity and, in severe cases, even death. the disease may also cause anemia, malnutrition, and impaired learning abilities in children.16 in sub-saharan african nations alone, schistosomiasis is estimated to cause over 200,000 fatalities annually.17 therefore, this study aimed to analyze the risk factors for schistosomiasis in the napu highland of indonesia. materials and methods this analytic observational study with a case-control design was conducted in the napu highland, poso, central sulawesi, indonesia, from april to june 2022. the target population comprised residents of the napu highland, with reachable population including residents of villages with schistosomiasis based on data from the 2021 schistosomiasis program fecal survey. the villages included were alitupu, dodolo, kaduwaa, kalimago, maholo, mekarsari, tamadue, watumaeta, winowanga, and wuasa. data was collected using a questionnaire administered through the kobocollect application. the inclusion criteria for sampling were permanent inhabitants who were registered and inspected in the 2021 schistosomiasis program fecal survey and were over two years old. exclusion criteria for sampling included those who refused to participate and individuals with specific health issues, such as mental problems. the sample size was estimated using schlesselman’s sample size formula18 for case-control research, resulting in 37 cases and 111 controls, making a total sample size of 148 individuals. in this study, cases refer to individuals who have tested positive for schistosomiasis and were experiencing the disease. on the other hand, control were individuals who do not have schistosomiasis and have tested negative for the disease. the research-dependent variable was the prevalence of schistosomiasis, while the independent variables were risk factors related to schistosomiasis, including education, knowledge about schistosomiasis, occupation, use of latrines, clean water sources, passing through snail (oncomelania hupensis lindoensis) focus areas, use of personal protective equipment (ppe) in water-related activities, and livestock raising activities. the education variable was categorized as either high (university and high school) or low (junior high school, elementary school, and no school). knowledge about schistosomiasis, including knowledge about causes, intermediate animals, habitat, mode of transmission, symptoms, animals that can be infected, prevention and treatment of schistosomiasis, was categorized as good or poor based on a median score of 6. a score of 6 or more was considered good knowledge, while a score below 6 was considered poor knowledge. the habits related to schistosomiasis exposure, such as passing through snail (oncomelania hupensis lindoensis) focus areas, having activities in rivers, gutters, or rice fields, and using ppe when working near water, were categorized as either ‘yes’ or ‘no’. occupation was categorized as either ‘farmer’ or ‘others. the use of latrine and raising livestock were categorized into ‘yes’ or ‘no’. the use of water sources was divided into three categories: wells, municipal waterworks, and other sources like rivers and ditches. all variables were measured by interviewing the respondent’s using questionnaire through the kobocollect application. chi-square test was used to analyze the data at a significance level of α=5% to determine the relationship between variables. results the research findings on the risk factors for schistosomiasis in the napu highland, poso regency, central sulawesi, are presented in tables 1 and 2. table 1 contains data on the characteristics of respondents related to socio-demographics. the research findings showed that the gender most found with schistosomiasis was male (56.8%). schistosomiasis cases were also prevalent in the age group of 20–60 years (78.4%). table 2 shows that variables with a p-value of ≤0.05 were education and knowledge about schistosomiasis. the odds ratio (or) for education was 3.147, indicating that individuals with lower education levels were 3.147 times more at risk of contracting schistosomiasis compared to those with higher education. similarly, the or for knowledge was 2.23, suggesting that individuals with poor knowledge about schistosomiasis were 2.233 times transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. socio-demographic characteristics of respondents (n=148) variable case (n=37) control (n=111) n n % n % gender male 21 56.8 63 56.8 84 female 16 43.2 48 43.2 64 age group (years) 0-10 2 5.4 0 0.0 2 11-19 2 5.4 4 3.6 6 20-60 29 78.4 93 83.8 122 >60 4 10.8 14 12.6 18 [healthcare in low-resource settings 2023; 11:11760] [page 41] non -co mmerc ial us e o nly more at risk of infection than those with good knowledge. on the other hand, factors such as employment status, latrine use, access to clean water sources, passing through the snail (oncomelania hupensis lindoensis) focus area, use of ppe during water-related activities, use of ppe when passing through the snail (oncomelania hupensis lindoensis) focus area, engaging in activities in rivers or gullies, and raising livestock were not found to be significant risk factors for schistosomiasis. discussion the proportion of respondents with low education in the case group was higher than in the control group. there was a significant relationship between education and schistosomiasis. people with low education were more at risk of contracting schistosomiasis than those with higher education. education plays a vital role in improving health behavior, especially in cases of environmentally transmitted diseases like schistosomiasis.19 research on schistosomiasis in zimbabwe concluded that poor sanitation (unsafe water sources for household needs), related to schistosomiasis infections, was found more in women who had never received an education than those with education.20 increased education can lead to better understanding of health messages and promote clean and healthy practices to prevent diseases. the study found a marginal association between participants’ knowledge of schistosomiasis and its incidence. lower knowledge increased the risk of infection. effective community awareness programs can improve knowledge and preventive measures. similar findings were observed in research from south africa and the philippines, persons with a good understanding of schistosomiasis had favourable attitudes and actions toward schistosomiasis prevention.21,22 government programs in napu include warning signs in the snail (oncomelania hupensis lindoensis) focus area as an effort to reduce the incidence. regular awareness programs are vital for infection prevention. collaborative efforts between education and health sectors are essential for successful prevention initiatives.23,24 the most common occupation among the research respondents was farming. while there was no significant relationship between occupation and schistosomiasis. similar findings were reported by rosmini et al. in the bada highland, poso district, and central sulawesi, where no relationship was found between the type of work (farmers and non-farmers) and the incidence of schistosomiasis.13 study in sudan even shows that school-age children of parents who work as farmers are at higher risk of being infected with schistosomiasis than children of parents with other jobs.25 however, farming should still be a concern in preventing schistosomiasis infection since farmers often work in areas like rice fields and rivers, which are known to be habitats for the inter[page 42] [healthcare in low-resource settings 2023; 11:11760] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. risk factors for schistosomiasis variable case (n=37) control (n=111) p or 95% ci n % n % education low 30 81.1 64 57.7 0.018* 3.147 1.274-7.778 high 7 18.9 47 42.3 occupation farmer 22 59.5 71 64.0 0.768 0.826 0.386-1.771 other 15 40.5 40 36.0 knowledge related to schistosomiasis poor 22 59.5 44 39.6 0.056* 2.233 1.046-4.768 good 15 40.5 67 60.4 latrine use no 5 13.5 13 11.7 0.775 1.778 0.390-3.560 yes 32 86.5 98 88.3 using clean water sources wells/municipal waterworks/pipes 37 100 111 100 other passing snail (oncomelania hupensis lindoensis) focus areas yes 27 73 70 63.1 0.369 1.178 0.390-3.560 no 10 27 41 36.9 having activities in water (rivers, gutter, or rice fields) yes 27 73.0 68 61.3 0.276 1.707 0.752-3.876 no 10 27.0 43 38.7 use personal protection equipment (ppe) when having activities in water no 13 35.1 30 27.0 0.404 1.463 0.661-3.237 yes 24 64.9 81 73.0 use personal protection equipment (ppe) when passing through snail (oncomelania hupensis lindoensis) focus areas no 10 27.0 20 18.0 0.345 1.685 0.704-4.031 yes 27 73.0 91 82.0 raising livestock yes 8 21.6 23 20.7 1.000 1.055 0.426-2.615 no 29 78,4 88 79,3 *p<0.05. non -co mmerc ial us e o nly mediate host snail (oncomelania hupensis lindoensis) of schistosomiasis.21,26,27 the proportion of individuals with schistosomiasis who did not use latrines for defecation was higher. open defecation can contaminate water bodies with worm eggs, leading to potential infections.28,29 to prevent transmission, using clean and proper latrines is essential. improving sanitary facilities and promoting latrine usage in schistosomiasis-endemic regions through counseling is crucial.29,30 all respondents use wells, municipal waterworks, or pipes as clean water sources. several studies suggest that using unprotected or unsafe water sources can contribute to schistosomiasis incidence.29,31–33 people’s knowledge and attitudes about schistosomiasis prevention are good; however, having safe sources of clean water is still necessary to reduce the risk of infection. the relationship between the habit of passing through the focus area of snails (oncomelania hupensis lindoensis) and the incidence of schistosomiasis was not statistically significant. nevertheless, it is important to avoid these areas or use personal protection ppe such as boots to protect against potential exposure to snails (oncomelania hupensis lindoensis).12,13,32,34 the analysis did not find a significant relationship between having activities in rivers, ditches, or rice fields and the incidence of schistosomiasis.12,35,36 nonetheless, it’s essential to be cautious, as these water bodies are potential habitats for snails (oncomelania hupensis lindoensis). using ppe, such as boots, when working or engaging in activities near water bodies is recommended to prevent schistosomiasis.21,37 several studies have emphasized the importance of ppe in reducing infection risk. raising livestock did not show a significant relationship with schistosomiasis.9,37–39 however, ensuring clean conditions for livestock is important to minimize potential risks. according to who, an integrated schistosomiasis control strategy that combines large-scale preventive chemotherapy with praziquantel, the provision of potable water, improved sanitation, hygiene, education, snail control, and environmental modification can result in the interruption (elimination) of schistosomiasis transmission. praziquantel is effective for the treatment of human schistosomiasis.40 however, praziquantel treatment does not prevent reinfection and is hence ineffective in interrupting the transmission cycle. praziquantel is primarily aimed to lowering the occurrence and severity of infection as well as controlling morbidity over time.41 the occurrence of fluctuations in schistosomiasis infection despite the continuation of the treatment program implies that there is reinfection due to the continued cycle of transmission in humans, animals, and intermediary snails. overall, preventing schistosomiasis requires awareness of the disease transmission pathways and the importance of proper sanitation, using clean water sources, and adopting protective measures when in contact with water in endemic areas. conclusions our study identified education and knowledge as significant risk factors for schistosomiasis in the napu highland. lower education levels were associated with a higher likelihood of infection. however, factors such as occupation, latrine use, clean water sources, passing through snail (oncomelania hupensis lindoensis) focus areas, use of ppe near water, use of ppe when passing through (oncomelania hupensis lindoensis) snail focus areas, activities in rivers and ditches, and raising livestock were not found to be risk factors for schistosomiasis in this region. health promotion efforts involving teachers, lecturers, researchers, religious leaders, and community leaders can play a key role in enhancing understanding, attitudes, and behaviors related to schistosomiasis prevention in the napu highland. references 1. abbafati c, abbas km, 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[page 44] [healthcare in low-resource settings 2023; 11:11760] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11871 the self-management model can increase the immunity of people with hiv and aids during the covid-19 pandemic oktovina mobalen, i made raka, rizqi alvian fabanyo nursing departement, politeknik kesehatan kemenkes sorong, sorong, indonesia abstract cases of people living with hiv and aids continue to increase from year to year, necessitating a focus on maintaining their health. to ensure their well-being, individuals with hiv/aids must be vigilant in preserving their immunity, especially during covid-19 pandemic. this research aimed to enhance the immunity of people with hiv and aids during the covid-19 pandemic utilizing a self-management model approach. the research employed a quasi-experimental design with pretest and posttest measurements, involving a sample of 30 hiv and aids patients in sorong city, selected through purposive sampling technique. independent variable in this research was the self-management model, which measured using self-management model guidebook and dependent variable was increasing the immunity of people with hiv and aids, which was measured using self reporting questionnaire (srq) and cd4 cell observation. data were analyzed using wilcoxon test with significance level for these tests was set at 95%, with α ≤ 0.05. analyzing the srq results of hiv/aids patients before and after the intervention, indicated a significant difference with a sig. (2-tailed) of 0.044 < 0.05. this suggests a notable change in the srq results of hiv/aids patients. additionally, the analysis of cd4 cell values before and after the intervention, yielded a sig. (2-tailed) of 0.000 < 0.05, signifying a difference in the cd4 cell results of hiv/aids patients. in conclusion, implementing the self-management model with the four management functions from planning, organizing, actuating, and controlling (poac) over a period of 30 days for hiv and aids patients during the covid19 pandemic can enhance both mental and psychosocial immunity, as well as physical immunity. the findings of this research provide valuable information to health workers, recommending the adoption of the self-management model guide intervention to enhance the immunity of individuals with hiv and aids. introduction at the beginning of 2020, humanity was shocked by the emergence of the coronavirus disease (covid-19) disease outbreak.1 the covid-19 began to spread in wuhan, china that caused by sars-cov-2.2 since the discovery of the covid-19 virus, whose transmissive capacity is overpowering, has led to a deterioration in the situation.3 unexpectedly, 213 countries in the world have been affected by this virus, including indonesia. this situation has had a significant impact, causing fear, anxiety, and a constant effort to avoid exposure to the covid-19 virus during the pandemic because it spreads very quickly.4,5 the threat of the virus transmitting to family members and the subsequent death or illness of a relative or friend as a result of the pandemic has had psychological effects.6 based on who data in 2021, it was found that the covid-19 disease has infected almost 2 million people, with deaths reaching more than 100 thousand cases.7 meanwhile, in indonesia, based on data reported by the ministry of health through the covid-19 handling task force, which was collected in the last 24 hours on april 22, 2021, the number of coronavirus infections was 1,626,812 people, and 44,172 of them died. based on this data, it is known that deaths due to this virus occur more often in patients with comorbid diseases and vulnerable groups. one of the vulnerable groups to the coronavirus 19 is people with hiv and aids.8 hiv/aids is a disease that attacks the human immune syscorrespondence: oktovina mobalen, nursing departement, politeknik kesehatan kemenkes sorong, sorong, indonesia. e-mail: mimaopin@gmail.com key word: immunity; people with hiv/aids; self-management model contributions: om, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; imr, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; raf, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: the research has received ethical approval from the research ethics commission of politeknik kesehatan kementerian kesehatan sorong based on ethical approval number: dm.03.05/6/008/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to poltekkes kemenkes sorong for valuable insights and contributions to this study. received: 25 september 2023. accepted: 20 december 2023. early access: 8 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11871 doi:10.4081/hls.2024.11871 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 232] [healthcare in low-resource settings 2024;12:11871] non -co mmerc ial us e o nly tem, rendering the body unable to recover from opportunistic diseases and leading to death,9 as there is no drug capable of eliminating the virus. individuals affected must bear the consequences of this disease.10 which targets specific cells and destroys cd4 t cells.11 people living with hiv/aids often experience stigma and discrimination, especially within their communities.12 this triggers psychological problems, including anxiety, depression, and the risk of suicide.13 the incidence of hiv/aids continues to increase, both globally and nationally. in indonesia, based on data obtained from the ministry of health in 2021, there were 7,650 people with hiv and aids. the highest number of cases of people with hiv and aids was in the 25-49 year age group (71.3%), followed by the 20-24 year age group (16.3%), and the ≥ 50 year age group (7.9%) 14. meanwhile, hiv and aids cases in sorong city, west papua province, resemble an iceberg phenomenon. currently, sorong city is in a widespread epidemic area, with the number of cases of people with hiv and aids amounting to 306 people in 2021. in sorong city, west papua, the handling of covid-19 is overshadowing the issue of hiv/aids. many annual programs for cases of people living with hiv and aids that had been established were not implemented because the local government’s focus was more on the covid-19 pandemic.15 inadequate knowledge about the risk of hiv infection will influence hiv prevention and therapy.16 difficulty in accessing treatment and care for people with hiv and aids has become more pronounced during the covid-19 pandemic.17 efforts are needed to continue enhancing the body’s immunity of people with hiv and aids during this pandemic. the importance of body immunity is highlighted as a component capable of combating both hiv/aids and covid-19. amid the ongoing pandemic, the most suitable approach to boost immunity and reduce the spread of covid-19 infection in people with hiv and aids is to implement self-management. the goal of self-management for people with hiv and aids is to assist clients in managing their own health and increasing adherence to their treatment plans through coaching, counseling, and accessible content.18 evidence has shown that self-management interventions conducted for people living with hiv and aids could improve their quality of life.19 reduce pain and/or physical symptoms,20 and enhance adherence to highly active antiretroviral therapy (haart).21 previous studies did not focus on the self-management of people with hiv and aids to enhance their body’s immunity based on the sequence of management functions, namely poac (planning, organizing, actuating, controlling). instead, they concentrated solely on self-management intervention research with interventions consisting of a combination of skills training, and telephone counseling to maintain medication adherence and quality of life, followed by symptom management, self-efficacy, coping, and social support.22 educating and caring for people with hiv and aids about self-management constitutes a crucial function of nurses. to provide information to nurses and policymakers regarding self-management programs during the pandemic, it is necessary to design appropriate self-management model interventions for people with hiv and aids to boost their body’s immunity amid the covid-19 pandemic. researchers designed a self-management model for people with hiv and aids based on the four management functions starting from planning, organizing, actuating, and controlling (poac). therefore, this study aims to examine the effect of implementing self-management model intervention from the four management functions (planning, organizing, actuating, and controlling) to increasing the body’s immunity of people with hiv and aids during the covid-19 pandemic in sorong city. materials and methods research design this research was conducted using a quasy-experimental design with a pretest and posttest to evaluate the effect of implementing self-management interventions on increasing the body’s immunity in people with hiv and aids during the covid-19 pandemic. setting and samples the study was conducted in sorong city, west papua, indonesia. the study’s population consisted of hiv/aids patients in sorong city in 2022. the sample size was calculated using analytical formula paired numerical comparatives. based on the calculation results, the sample size for this study was determined to be 30 respondents with hiv and aids in sorong city who were selected selected through purposive sampling technique, according to inclusion and exclusion criteria. the inclusion criteria for this study: people with hiv and aids with restriction age 17 to 55 years old who live in sorong city, willing to participate in the research by signing an informed consent form, and not in an emergency condition or a comatose level of consciousness. exclusion criteria for this study included: individuals with hiv and aids experiencing decreased consciousness or deceased, infants, children, and pregnant women with hiv and aids not willing to participate in the research or those who withdrew from the study. data collection took place from may to june 2022. interventions thirty respondents will receive an intervention with the selfmanagement model to enhance immunity (physical, mental, and psychosocial immunity). the first step in this study is a pretest involving the completion of a questionnaire form and cd4 examination. following the pretest, respondents will undergo a onemonth intervention with the self-management model aimed at increasing immunity. the self-management in this research was carried out in 4 stages, starting from planning, organizing, actuating, and controlling (poac). the planning stage: planning starts from physical and mental examination of each participant. the organizing stage: create a strategy to maintain body immunity within 30 days. in 30 days, the hiv/aids patients should increasing physical immunity and increasing mental health immunity. the actuating stages: implement the strategy that has been prepared within 30 days, with 30 meetings/sessions, and each session is held for 1 hour. interventions given to increase physical immunity include consuming nutritious food, meeting fluid and mineral needs, exercising, sunbathing in the morning, and ensuring adequate rest and sleep. interventions given to increase the mental health immunity include physical relaxation, positive emotions, positive thoughts, positive behavior, positive relationships, and spirituality positive. during the 30 days of implementation, monitoring was carried out by researchers and families every day using whatsapp group media as well as supervision by researchers with the help of enumerators. the last stages are controlling stages: evaluation of the implementation is carried out every 3 – 7 days to see the progress. after that, the posttest measurements will be conducted to evaluate the immunity of people with hiv and aids using the self reporting questionnaire (srq) and the cd4 examination. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11871] [page 233] non -co mmerc ial us e o nly measurement and data collection the dependent variable in this study is the increased immunity in people with hiv and aids, which comprises two indicators: physical immunity and psychosocial mental immunity. these variables were assessed using a self-reporting questionnaire (srq) to collect psychosocial mental immunity data,23 and physical immunity data were collected by examining cd4 cells in hiv/aids patients.24 all respondents provided written informed consent, and the study was approved by the ethics committee of poltekkes kemenkes sorong under ethical approval number: dm.03.05/6/008/2022. data analysis the data analysis included descriptive statistics such as frequency, percentage, mean, standard deviation (sd), and the minimum and maximum values for each variable. inferential analysis was carried out using the wilcoxon statistical test to assess differences in preand post-scores. the desired significance level for these tests was set at 95%, with α≤0.05. results based on the results presented in table 1, it shows that most respondents’ characteristics based on gender are 18 (60%) males. the highest characteristics of respondents based on age are 11 (36.7%) in the early adults age group (26-35 years). the highest characteristic of respondents based on the time of diagnosis is 17 (56.7%) diagnosed within < 5 years. based on the results presented in table 2, it is shown that the statistical analysis using the wilcoxon test indicates that all variables yielded significance values lower than alpha < 0.05. the srq results show that the p-value of sig. (2-tailed) is 0.044 < 0.05, leading to the conclusion that there is a difference between the srq of hiv/aids patients before and after the intervention. meanwhile, the cd4 examination results show a p-value of sig. (2-tailed) 0.000 < 0.05, implying that there is a difference between the cd4 cells of hiv/aids patients before and after the intervention. this suggests that providing interventions using self-management to patients with hiv and aids can increase the patient’s immunity during the covid-19 pandemic in sorong city. discussion people with hiv/aids are one of the community groups affected during the covid-19 pandemic.25 they experience a sick condition that compels them to take medication every day and undergo routine therapy and laboratory examinations as scheduled. during the covid-19 pandemic, all matters related to people living with hiv and aids require full attention.26 additionally, if infected with covid-19, people with hiv/aids have a higher chance of dying.27 people with hiv and aids are susceptible to various infectious diseases, especially opportunistic infections. opportunistic infections are infections caused by microorganisms that take advantage of specific conditions to arise. hiv patients in indonesia tend to easily progress to the aids stage because they experience opportunistic infections.28 clinically, the cd4 lymphocyte count is used as a sign of the emergence of opportunistic infections in aids patients.29 the target cell of the hiv virus is cd4. cd4 levels are the best parameter to measure immunodeficiency and can be an early indicator of disease progression. cd4 counts can fluctuate differently in each patient. factors influencing cd4 levels in hiv/aids patients include age, gender, initial cd4 levels, and nutritional status.30 people with hiv and aids really need to maintain their body’s immunity, which has an effect on increasing cd4 cells.31 it is nec transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 234] [healthcare in low-resource settings 2024;12:11871] table 1. distribution of respondent characteristics according to demographic data. characteristics n % gender man 18 60 woman 12 40 total 30 100 age 17-25 6 20 26-35 11 36.7 36-45 9 30 46-55 4 13.3 total 30 100 diagnosis < 5 year 17 56,7 > 5 year 13 43,3 total 30 100 table 2. results of testing the self-management model to increase the immunity of people with hiv and aids during the covid-19 pandemic in sorong city. variable test mean p pretest posttest n % n % srq normal 2 6.7 16 53.3 18.57 0.044 problems of psychology 20 66.6 12 40.0 use of psychoactive substances/ drugs 2 6.7 2 6.7 trauma-induced stress disorder 6 20.0 0 0 total 30 100 30 100 cd4 < 200 sel/mm3 4 13.3 0 0 30.50 0.000 200 499 sel/mm3 17 56.7 3 10.0 > 500 sel/mm3 9 30.0 27 90.0 total 30 100 30 100 non -co mmerc ial us e o nly essary to strengthen the understanding of people living with hiv and aids about how to behave healthily and maintain health, especially during the pandemic.32 the results of this study, as determined through statistical analysis tests with the wilcoxon test, reveal significant differences in the immunity of hiv/aids patients before and after applying the self-management model during the covid-19 pandemic. selfmanagement is highly recommended for people with hiv and aids. this research demonstrates that applying self-management to people with hiv and aids has proven to increase their immunity, encompassing both physical immunity (increased cd4 cells) and mental health immunity. self-management in this research was carried out sequentially using the four management functions from planning, organizing, actuating, and controlling (poac). self-management to increase physical immunity involves consuming nutritious food, meeting fluid and mineral needs, exercising, sunbathing in the morning, and ensuring adequate rest and sleep. apart from enhancing the physical immunity of people with hiv and aids, mental health resilience is also improved by physical relaxation, positive emotions, positive thoughts, positive behavior, positive relationships and spirituality positive. this is in line with several research results that highlight various efforts to enhance the immunity of people living with hiv/aids (plwha). these efforts include maintaining optimal nutritional status,33 engaging in regular exercise, receiving family support,34 ensuring adequate sleep and rest (30), and preserving mental health,35 and preserving mental health.36 through these initiatives, it has been proven that immunity in people with hiv and aids can be increased, helping them withstand infections and diseases and allowing them to continue living productive lives.37 self-management is a behavior modification technique that focuses on self-regulation. numerous studies have demonstrated the benefits of implementing self-management. in puspasari’s research (2021), it was found that self-management had a positive effect on improving the quality of life of people with hiv and aids.38 in research by nur et al. (2022), the application of individual counseling using self-management techniques conducted over six meetings showed the expected changes in behavior, specifically increased compliance in taking medication.39 self-management interventions have also been employed in several treatments for chronic disease patients to enhance symptom management. these interventions may be designed specifically to improve the quality of life and promote self�management aspects of healthcare, such as medication adherence.40 conclusions the implementation of self-management interventions for people with hiv and aids in sorong city shows a significant influence on the immunity of individuals, resulting in increased body immunity (cd4) and enhanced mental health immunity. this was achieved through the implementation of self-management from planning, organizing, actuating, and controlling (poac) over a period of 30 days. it is recommended that the results of this research provide additional information to 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jamaludin. mindfulness meditasi meningkatkan kualitas tidu pasien hiv. cendekia utama jurnal keperawatan dan kesehat masy stikes cendekia utama kudus 2021;3:199–209. 36. ramayanti ed, jayani i, nurseskasatmata se, et al. effects of health education using informative video media on changes in stress levels in plwha during the covid-19 pandemic. nurs sci j 2023;7:29–42. 37. pauzan, halid i. penyuluhan peningkatan pemahaman dan pencegahan hiv / aids bagi masyarakat di kawasan wisata desa giri sasak kecamatan kuripan lombok barat. jpms (jurnal pengabdi masy sehati) 2023;2:24–9. 38. puspasari fd. pengaruh self manajemen dan konsep diri terhadap kualitas hidup pada pasien hiv / aids. viva med (jurnal kesehatan, kebidanan, dan keperawatan. 2021;15:81– 90. 39. nur dm, mairanti l, aini a. konseling individu dengan teknik self management dalam proses rehabilitas orang dengan hiv/aids (odha). ghaidan (jurnal bimbing konseling islam dan kemasyarakatan) 2022;1:35–40. 40. martin s, chinnock p, perales j, et al. self-management interventions for people living with hiv / aids ( protocol ). cochrane libr 2017;10:3–6. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 236] [healthcare in low-resource settings 2024;12:11871] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11766 the effect of vigna unguiculata on the estrogen receptor-α expression and the endometrial thickness in rats treated with depot medroxyprogesterone acetate (dmpa) rizki fitrianingtyas,1 indah christiana,2 ririn handayani,1 ernawati anggraeni,1 zaida mauludiyah,1 sholihatil hidayati3 1midwifery education programme, faculty of health sciences, universitas dr. soebandi, jember; 2midwifery education programme, sekolah tinggi ilmu kesehatan banyuwangi, banyuwangi; 3pharmacy study program, faculty of health sciences, universitas dr. soebandi, jember, indonesia abstract depot medroxyprogesterone acetate (dmpa) is a contraceptive method that prevents ovulation and reduces endometrial thickness. this study aimed to investigate the influence of vigna unguiculata (vu) on estrogen receptor-α expression and endometrial thickness in rats subjected to dmpa treatment. the research utilized a true experimental design involving 25 female wistar rats divided into 5 experimental groups. the dmpa+vu experiment lasted for 4 weeks, and data were analyzed using a complete randomized design. estrogen receptor-α expression in the endometrium was assessed through immunohistochemical techniques, and endometrial thickness was determined via hematoxylin-eosin (he) staining, observed under dot slide microscopes (olympus xc10) at 400× magnification. the study found that estrogen receptor-α expression and endometrial thickness were significantly higher in both the dmpa+vu2 and dmpa+vu3 groups compared to the dmpa group and the dmpa+vu1 group (p<0.05). dmpa treatment reduced estrogen receptor-α expression and endometrial thickness. however, the administration of vigna unguiculata extracts at 2.5 mg/kg and 5 mg/kg led to an increase in estrogen receptor-α expression and endometrial thickness. the study implies that vu extract may have a positive impact on estrogen receptor-α expression and endometrial thickness in rats treated with depot medroxyprogesterone acetate. introduction progestin contraceptives offer a safe and highly effective method for regulating fertility.1,2 depot medroxyprogesterone acetate (dmpa) is considered highly effective in preventing pregnancy because it is administered through an injection every three months.3,4 dmpa prevents ovulation and thickens cervical mucus, making it difficult for sperm to penetrate, and it also thins the uterine lining, impeding gamete transportation through the fallopian tube.5–7 infertility may depend on the rate at which the body metabolizes dmpa. women who use dmpa as a contraceptive may face an increased risk of issues such as atrophy, decreased microvascular density, epithelial and vascular blood vessel depletion, and mammary gland disruption. after discontinuing dmpa injections, it can take 1-2 years for these contraceptive effects to wear off and for the woman’s body to prepare for pregnancy.8 research conducted on rats has shown that dmpa can induce apoptosis in the ovaries, leading to a disruption in estradiol, an antioxidant gene. an enzyme known as superoxide dismutase (sod), which resides within the mitochondria, is affected, preventing estradiol from effectively functioning as an antioxidant. this state of affairs leads to oxidative stress, marked by the production of free radicals, which can cause oxidative modifications in cellular macromolecules, impair protein function, and mediate apoptosis.9 correspondence: rizki fitrianingtyas, midwifery education programme, faculty of health sciences, universitas dr. soebandi, jember, indonesia. e-mail: rizkifitrianingtyas@gmail.com key words: depot medroxyprogesterone acetate; estrogen receptor; thickness endometrial; vigna unguiculata. contributions: rf, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ic, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; rh, conceptualization, methodology, formal analysis, validation, and writing, original draft, review and editing; ea, methodology, visualization, writing, review and editing; ss resources, investigation, and writing, review and editing; zm, formal analysis, validation, writing, review and editing; sh, resources, supervision, writing, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the protocol used in this study was approved by the ethics committee for experimentation of the brawijaya university no.307/ec/kepk/s2/08/2019. diets were made by following the american institute of nutrition recommendations. the animals were fed using ad libitum during the experimental period. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank universitas dr soebandi for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 18 october 2023. early access: 5 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11766 doi:10.4081/hls.2023.11766 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 6] [healthcare in low-resource settings 2024;12:11766] non -co mmerc ial us e o nly vigna unguiculata contains phytoestrogens of the isoflavone type, including genistein (0.02 mg/100 grams) and daidzein (0.01 mg/100 grams), along with a minimal fat content of 1.40 grams/100 grams.10 soy isoflavones have the ability to bind to estrogen receptors (ers), showing a higher binding affinity for er-β compared to er-α. in contrast to er-α, which is abundant in granulosa cells of growing follicles from postnatal day 5, er-β deficient mice treated with genistein do not exhibit multiple oocyte follicles (mofs), indicating that genistein inhibits oocyte nest breakdown through an er-β mechanism.11 previous research has demonstrated that dmpa significantly decreased the levels of sod in the ovary and endothelial nitric oxide synthase (enos) in the endometrium. the decrease in sod levels was significantly attenuated by the highest doses of green tea extract. dmpa induces apoptosis in the ovary and endometrium, while green tea extract prevents the increase in the ovary.12–14 therefore, this study aimed to explore the preventive ability of v. unguiculata in minimizing the side effects of dmpa. v. unguiculata extract can increase the expression of estrogen receptor-α and enhance endometrial thickness in rats treated with depot medroxyprogesterone acetate. materials and methods design and sample this study was a true experimental design and utilized adult virgin female wistar rats (rattus novergicus) aged 30 weeks, with a weight ranging from 100 to 125 grams. these rats were procured from the pharmacology laboratory at the faculty of medicine, brawijaya university, east java, indonesia. subsequently, they were housed in a controlled environment with conditions maintained at 25±10°c and 65-70% relative humidity, following a 12hour light-dark cycle. the rats were divided into distinct groups, each consisting of five rats. these groups were as follows: the control group, the dmpa-administered group, the dmpa + v. unguiculata (dmpa+vu1 0.5 mg/kg) group, the dmpa + v. unguiculata (dmpa+vu2 2.5 mg/kg) group, and the dmpa + v. unguiculata (dmpa+vu3 5 mg/kg) group. the treatment with v. unguiculata (uv) was administered for a duration of 4 weeks. dmpa treatment dmpa at a dose of 2.7 mg/rat was injected every single week in the morning for 4 weeks; it was diluted with 0.2 ml of saline and injected intramuscularly. the dmpa dose was calculated according to a previous genotoxicity study in rats and previous research.15,16 vigna unguiculata administration experiment the vigna unguiculata extraction process involved maceration. one hundred grams of vigna unguiculata var. kt-6 were sourced from balitkabi in malang, east java, indonesia. the fruits were separated from the seeds, and the seeds were then dried in an oven at 90°c and subsequently ground into a powder. a 100gram quantity of this powder was added to a 1-liter erlenmeyer flask containing 900 ml of 70% ethanol. the solution was left to evaporate overnight. on the following day, the upper layers of the solution were collected and processed using an evaporation apparatus. the extracted specimen was stored at -40°c. the administration began 28 days after the injection of dmpa. rats were orally administered with 0.5 ml of vigna unguiculata daily, between 1:00 pm and 2:00 pm, for a duration of 28 days. analysis of expression estrogen receptor-α immunohistochemical (ihc) staining was performed to assess the expression of estrogen receptor-α in the endometrial tissue. we used the ihc kit provided by santa cruz biotechnology, inc (erα(c-311):sc-787). the procedure involved deparaffinizing the slides with xylene followed by dehydration using an alcohol series. subsequently, the slides were immersed in a citrate buffer with a ph of 6 and heated in a water bath at 95°c for 20 minutes. afterwards, the slides underwent a blocking step using 3% h2o2 in methanol for 15 minutes to prevent endogenous interference. they were then washed with pbs and blocked again. the slides were incubated for 60 minutes. next, the primary antibody (anti-estrogen receptor) was added in pbs with 0.2% bsa and incubated overnight at 4°c. the following day, the slides were washed with pbs and subsequently incubated with a biotinylated universal secondary antibody for 60 minutes at room temperature. a 40-minute incubation of the enzyme streptavidinhorseradish peroxidase (streptavidin-hrp) was carried out at room temperature. following this, dab (diaminobenzidine) was applied, with a dab chromagen to dab buffer ratio of 1:50, for 10-20 minutes. after a final wash with pbs and distilled water, the slides were counterstained with mayer’s hematoxylin for 5-10 minutes at room temperature. finally, the slides were mounted and examined. the estrogen receptor-α expression in the rat endometrial tissue was observed using a light microscope (magnification at 400×). the percentage of expression was calculated using photo dot slide and olympus software as well as immunization software. analysis of endometrial thickness the analysis of endometrial thickness involved the use of hematoxylin-eosin staining. sections measuring 10–30 mm on slides were subjected to the following process: they were immersed in xylene for 10 minutes (repeated twice), followed by rehydration through a series of decreasing ethanol concentrations diluted in distilled water (100%, 100%, 95%, 95%, 75%, 0%, each for 1 minute). the sections were then rinsed in deionized water, stained with hematoxylin for 45 seconds, followed by rinsing in deionized water and a 1-second staining with eosin. after the color reaction, the sections were dehydrated through an ethanol series into xylene and then mounted using permount mounting medium (fisher scientific, pa). the thickness of the endometrium was observed and measured under dot slide microscopes, specifically the olympus xc10 (at a magnification of 200×), with data automatically exported to microsoft excel. statistical analysis the data were analyzed using one-way analysis of variance (anova) with spss 17.0 statistical software (ibm, new york, usa). post-hoc tests were performed when the analysis of variance yielded significant results. a p-value < 0.05 was considered statistically significant. ethical clearance the protocol used in this study was approved by the ethics committee for experimentation of the brawijaya university no.307/ec/kepk/s2/08/2019. the diets were prepared following the recommendations of the american institute of nutrition, and the animals were provided with ad libitum access to food during the experimental period. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11766] [page 7] non -co mmerc ial us e o nly results this study investigated the levels of vigna unguiculata using liquid chromatography-mass spectrometry, revealing a genistein level of 39.915 µg/gram in the ethanolic extract of v. unguiculata seeds. table 1 and figure 1 depict the levels of estrogen receptor α in the control group and treatment groups. the administration of 2.5 and 5 mg/kg of v. unguiculata extract significantly increased estrogen receptor α expression when compared to the dmpa group (p<0.05), whereas the 0.5 mg/kg dose (dmpa+vu1 group) did not show a significant increase. estrogen receptor α expression did not significantly differ between the control group and the dmpa+vu2 and dmpa+vu3 groups. additionally, dmpa+vu2 and dmpa+vu3 groups did not significantly differ from the control group (p>0.05). table 2 presented the endometrial thickness levels of the control group and the treatment groups. the endometrial thickness was significantly higher in the dmpa+vu3 group compared to the dmpa group. administration of 2.5 and 5 mg/kg of v. unguiculata extract (dmpa+vu2 and dmpa+vu3) significantly increased endometrial thickness (p<0.05). however, administration of 0.5 mg/kg of v. unguiculata (dmpa+vu1) did not significantly affect endometrial thickness. there were no significant differences in endometrial thickness between the control group, dmpa+vu2, and dmpa+vu3 groups (p>0.05).” discussion administering dmpa can reduce er-α expression, making this research a valuable reference for mitigating its side effects. the data demonstrates that prolonged exposure to dmpa leads to a decrease in er-α expression, which in turn minimizes the expected side effects associated with excessive dmpa usage. the use of dmpa induces apoptosis in the ovary, with a higher dmpa index correlating with increased ovarian apoptosis.17 this suggests that long-term dmpa use may help mitigate side effects arising from ovarian dysfunction.9 women receiving dmpa injections as a contraceptive treatment may experience side effects that lead to a reduction in estro transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 8] [healthcare in low-resource settings 2024;12:11766] table 1. the estrogen receptor-α expression of endometrial of administered groups and control rats. parameters control dmpa + vigna unguiculata dmpa dmpa+vu1 dmpa+vu2 dmpa+vu3 er-α (%) 39.68±2.11 16.55±1.21ad 17.72±2.83ad 36.94±1.5bc 42.8±2.34bc values are presented as mean±sd; ap<0.05; in comparison with control group; bp<0.05; in comparison with dmpa group, cp<0.05; in comparison with dmpa+vu1, dp<0.05; in comparison with dmpa+vu2; dmpa, depot medroxyprogesterone acetate; er-α: estrogen receptor-α; vu, vigna unguiculata. table 2. the endometrial thickness of all experimental groups. parameters control dmpa + vigna unguiculata dmpa dmpa+vu1 dmpa+vu2 dmpa+vu3 endometrial thickness (mm) 467.40±72.15 249.80±60.05ad 266.20±51.64ad 388.00±83.46bc 444.00±57.75bc values are presented as mean±sd; ap<0.05; in comparison with the control group; bp<0.05; in comparison with dmpa group, cp<0.05; in comparison with dmpa+vu1, dp<0.05; in comparison with dmpa+vu2; dmpa, depot medroxyprogesterone acetate; vu, vigna unguiculata. figure 1. the levels of estrogen receptor α in the control group and treatment groups. figure 1 showed that immunohistochemical analysis of endometrium estrogen receptor-α expression (with immunization software) of administered groups and control groups rats. the estrogen receptor-α expression in control group(a); dmpa group (b); dmpa+vu1(c); dmpa+vu2(d); dmpa+vu3. the black arrow in the figure indicated cells expressing estrogen receptor-α (brown color in the nucleus) (m=400×). non -co mmerc ial us e o nly gen levels. in this study, a majority of the 70 women, aged 20-35 years, saw their estrogen levels decrease from <130 pg/ml to 100 pg/ml after receiving dmpa injections.16,17 this research also suggests that rats treated with dmpa exhibit thinner endometrial tissue.18,19 previous studies have indicated that dmpa (a progestinonly contraceptive) reduces endometrial vascular density, resulting in atrophy and amenorrhea. dmpa primarily works by inhibiting ovulation, as evidenced by changes in levels of follicle-stimulating hormone and luteinizing hormone.20,21 the administration of 2.5 and 5 mg/kg of v. unguiculata extract significantly increased the expression of estrogen receptor α and endometrial thickness compared to the dmpa group, while 0.5 mg/kg of v. unguiculata did not yield the same effect. previous studies have shown that the regulation of er-α expression decreases, leading to endometrial depletion during menstruation. dmpa increases the rate of apoptosis in the ovary and endometrium, resulting in endometrial depletion and atrophy. this is attributed to the low activities of enos expression and enos levels in the cells and cytoplasm, which trigger apoptosis in the endometrium and ovaries12. a depleted endometrium typically measures between 69 mm, whereas a normal one ranges from 5-10 mm, varying depending on the menstrual cycle.8 an endometrial thickness of less than 6 mm is considered indicative of an infertility disorder.9,17 vigna unguiculata extract is suspected to contain phytoestrogen, specifically genistein. phytoestrogens impact human health through both genomic and non-genomic mechanisms. due to their low molecular weight, phytoestrogens can traverse cell membranes and interact with receptors and enzymes. genomic mechanisms encompass estrogenic and antiestrogenic effects on the estrogen receptor (er). non-genomic mechanisms include the inhibition of tyrosine kinase, dna topoisomerase inhibition, antioxidant activity, inhibition of shbg-stimulated angiogenesis, inhibition of 5α reductase, 17β-oh-steroid-dehydrogenase, and aromatase enzymes.22 phytoestrogens can bind to estrogen receptors α or β. estrogen receptor α is more widely distributed in reproductive tissues. genistein’s action is influenced by the levels of estrogen, acting as an estrogenic compound at low estrogen levels.23 the mechanism of genistein is similar to selective estrogen receptor modulators (serms) that differ chemically but can directly affect the selection of agonist or antagonist roles in estrogen-responsive tissues. it serves as an antagonist when interacting with er-β in genes containing estrogen response elements, and as a partial agonist when acting through er-α.24,25 estrogen typically enters the cell’s cytoplasm before binding to an estrogen receptor. in the cytoplasm, it forms a hormone-receptor complex on an estrogen response element (ere) and then translocates into the cell nucleus to bind with dna. the bound estrogen receptors in dna are involved in cell transcription to produce proteins necessary for cell division. when estrogen levels are high, genistein weakly binds to er-α, effectively obstructing the bond between the receptors and estradiol (having an anti-estrogenic effect). conversely, when estrogen levels are low, genistein binds to er-α and activates a signaling cascade. this activation effect could potentially lead to increased endometrial proliferation.26 phytoestrogens may serve as promising candidates for mitigating the side effects associated with dmpa use. phytoestrogens stimulate the production of alpha estrogen receptors, and the estrogenic properties of isoflavones are key contributors to their estrogenic activity. the discovery of erα and erβ receptors in the endometrium, the positive effects observed with selective estrogen receptor modulators (serms) like raloxifene in both animals and humans, and the fact that phytoestrogens, such as genistein, share similarities with raloxifene in terms of binding to estrogen receptors, suggest that phytoestrogens can exert a selective influence on the endometrium.27 conclusions in summary, the administration of 2.5 and 5 mg/kg of v. unguiculata extract effectively increased er-α expression and endometrial thickness in dmpa-injected rats. this suggests its potential application as an alternative treatment for fertility recovery following dmpa-based contraception, improving the recovery of er-α expression and addressing endometrial depletion. references 1. novika rgh, hutomo cs, wahidah nj, et al. the effect of apium graveolens l. in progesterone-induced blocking factor (pibf) during pregnancy. res j pharm technol 2022;15: 4463-8. 2. putri ky, srianto p, lestari td, et al. reproductive efficiency and serum progesterone concentration on dairy cattle based on blood urea nitrogen (bun) concentrations. iraqi j vet sci 2018;32:143-48. 3. bakry s, merhi zo, scalise tj, et al. depotmedroxyprogesterone acetate: an update. arch gynecol obstet 2008;278:1-12. 4. elfrida ry, sari gm, dwiningsih sr, et al. the comparison of total cholesterol level in dmpa and combination injection contraception users. pediomaternal nurs j 2020;6:117-24. 5. batlajery j, hamidah h, mardiana m. penggunaan metode kontrasepsi suntikan dmpa berhubungan dengan disfungsi seksual wanita pada akseptor kb suntik. j ilmu dan teknol kesehat 2015;2:49-56. 6. mahyudanil m, bajamal ah, sembiring rj, et al. the effect of progesterone therapy in severe traumatic brain injury patients on serum levels of s-100β, interleukin 6, and aquaporin-4. open access maced j med sci 2020;8:236-44. 7. yulianto mr, turchan a, notobroto hb. the effect of estrogen, progesterone, and its combination on the expression of brain-derived neurotrophic factor medula spinalis in regeneration process of peripheral nerve. indian j forensic med toxicol 2020;14:3150-3155. 8. simbar m, tehrani fr, hashemi z, et al. a comparative study of cyclofem® and depot medroxyprogesterone acetate (dmpa) effects on endometrial vasculature. j fam plan reprod heal care 2007;33:271-6. 9. fitrianingtyas r, christiana i. effect of depo medroxsi progesteron acetat (dmpa) on indeks apoptosis ovarium in the exposed rated endometrium (rattus novergicus). j kesehat dr soebandi 2022;10:98-105. 10. wahdah r, ellya h, hairina h. respon viabilitas benih kacang tunggak nagara (vigna unguiculata ssp cylindrica) akibat pemberian konsentrasi ekstrak akar eceng gondok (eichhornia crassipes). rawa sains j sains stiper amuntai 2020;10:63-73. 11. wang w, sun y, liu j, et al. soy isoflavones administered to rats from weaning until sexual maturity affect ovarian follicle development by inducing apoptosis. food chem toxicol transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11766] [page 9] non -co mmerc ial us e o nly 2014;72:51-60. 12. veri n, aulia f, ratnawati r, et al. protective effect of green tea against ovarian and endometrial apoptoses in rats treated with depot medroxyprogesterone acetate. biomarkers genomic med 2015;7:105-9. 13. prastiya ra, suprayogi tw, debora ae, et al. green tea extract addition into a tris-based egg yolk extender improves bali bull sperm quality. anim biosci 2023;36:209-217. 14. susilowati s, mustofa i, wurlina w, et al. green tea extract in the extender improved the post-thawed semen quality and decreased amino acid mutation of kacang buck sperm. vet sci 2022;9:403. 15. bakry s, aseem n mn. cytotoxicity and genotoxicity of dmpa on female rats. toxicol lett 2010;196:s156-s157. 16. e. pamuji db dan mh. assosiation between bleeding pattern and estradiol level of depot medroxy progestreon acetat users. ber kedokt masy 2008;24:51-7. 17. fitrianingtyas r, anggreni e. pengaruh depo medroksi progesteron asetat (dmpa) terhadap ekspresi estrogen receptor-α (er-α) pada endometrium tikus (rattus novergicus) yang dipapar effect of acetic progesteron depo medical (dmpa) on expression of receptorα (er-α) estro. j ilm kebidanan 2019;5:3-8. 18. mishell jr dr, kltzky oa, brenner pf, et al. the effect of contraceptive steroida on hypotalamic pituitary function. am j obs gynecol 2015;128:60-74. 19. moyer dl, felix jc. the effect of progesterone and progestines on endometrial prolireratoin. contraception 1998;57:399-403. 20. michel kg, huijbregts rph, richter he, et al. effect of depot medroxyprogesterone acetate on human β-defensin production and structural integrity of the human vaginal epithelium. lancet 2013;382:s25. 21. bellanti f, matteo m, rollo t, et al. sex hormones modulate circulating antioxidant enzymes: impact of estrogen therapy. redox biol 2013;1:340-6. 22. darmadi d, nurdiana, norahmawati e. efek ekstrak kacang tunggak terhadap osteoblas dan osteoklas pada tikus dengan ovarektomi the effect of blackeyed peas on osteoblast and osteoclast of rat with ovarectomy. j kedokt brawijaya 2011;26:151-5. 23. lofamia eaa, ramos gb, mamon mac, et al. isoflavone maternal-supplementation during periconception period: influence on the reproductive organs of the first generation (f1) murine weanling-stage offspring. asian pacific j reprod 2014;3:268-74. 24. wiyasa i, norahmawati e, soehartono. pengaruh isoflavone genistein dan daidzein ekstrak tokbi (pueraria lobata) strain kangean terhadap jumlah osteoblas dan osteoklas rattus novergiccus wistar hipoestrogenik. maj obs ginekol indones 2008;32:148-52. 25. mibgels mjj, geels yp, pijnenborg jma, et al. histipatologic assessement of the entire endometrium in asymtomatic women. hum pathol 2013;44:2293-2301. 26. glazier, m gina; bowman ma. a review of teh evidence for the use of phytoestrogens as a replacement for traditional estrogen replacement therapy. arch intern med 2001; 1611:1161-72. 27. ismiyati a, wiyasa iw, hidayati dy. protective effect of vitamins c and e on depot-medroxyprogesterone acetateinduced ovarian oxidative stress in vivo. j toxicol 2016;2016:3134105. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 10] [healthcare in low-resource settings 2024;12:11766] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11(s1):11163 the effects of teamstepps implementation by nurses on situation monitoring in hospital ahsan, imeldha monitasari, evi harwiati ningrum, ike nesdia rahmawati, linda wieke noviyanti, kuswantoro rusca putra department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract introduction: patient safety is a healthcare system, which minimizes the occurrence and impact of side effects. it also helps to facilitate full recovery in patients, and efforts to improve their safety require teamwork, such as situation monitoring by nurses. therefore, this study aims to determine the effects of teamstepps implementation by nurses on situation monitoring in hospitals. design and methods: a quasi-experimental pre-post test design was used with a total of 56 nurses, which were selected using the purposive sampling technique. they were then shared equally into 2 groups, namely control and intervention groups. results: the unpaired t-test result shows that the value of |t count| was lower than the t table (0.210 < 2.005), while the pvalue was greater than α (0.835 > 0.050). this result indicates that implementing teamstepps by nurses have an insignificant effect on situation monitoring in the hospital. conclusions: in conclusion, hospitals are advised to implement teamstepps regularly to improve teamwork, specifically in situation monitoring by nurses. introduction hospital is a professional place that provides safe services, which prioritize the patients’ needs, such as optimal safety during the treatment.1 patient safety is a system that involves risk assessment, identification, incident reporting, and implementation of solutions to minimize risks.2 the institute of medicine (iom) revealed that the rate of adverse effects in utah and colorado, united states was 2.9% with a 6.6% mortality rate, while a prevalence and death rate of 3.7% and 13.6%, respectively were recorded in new york. meanwhile, hospitals in australia and denmark reported a prevalence rate of 3.2%-16.6% and 12% in canada.3 over the years, the prevalence of patient safety incidents (psis) in indonesia has also increased with a total of 144 cases in 2009, 103 cases in 2010, and 34 cases between january-april 2011. furthermore, at the province level, the reported rates in dki jakarta, central java, yogyakarta, and east java as of 2007 were 37.9%, 15.9%, 12.8%, and 11.7%, respectively.4 in malang, the reported near misses and adverse events cases were 47.6% and 46.2%, respectively. an observation revealed that 30 psis were not reported, which consist of 12 no harm cases and 18 reportable circumstances.5 this high prevalence rate has several material and immaterial impacts on the hospitals and patients. the material impacts are caused by the high number of patient safety incidents, such as the usd 37.6 billion financial loss experienced by the united states annually due to these events.6 other material impacts include injuries, deformities, deaths, extension of the treatment period, additional treatment costs, and similar events recurrence. meanwhile, the immaterial impacts include patients’ loss of motivation to experience the treatments as well as declining trust in health workers who provides health services due to the trauma they experienced.7 these data revealed that all health workers, specifically nurses, have the potential to contribute towards the increase in the number of patient safety incidents. this is because nurses account for approximately 40%-60% of health workers who provide health care services in hospitals. they also have the most direct contact with patients in 24 hours.6 meanwhile, nurses can fail to understand the patient’s declining condition because they often ignore the clinical information reported by other team members,8 which is also known as situation monitoring. situation monitoring is a process of actively assessing and understanding the patient’s internal and external situations.9 internal situation is the conditions of patients and team members, while the external situation is the physical environment.9 situation monitoring helps to resolve issues that occur between team members, understand the situation of the surrounding environment, monitor the patient’s condition as well as to learn the appropriate measures that can be used to avoid mistakes.10 furthermore, it is one of the major methods used to increase patient satisfaction and the quality of teamwork. teamstepps training has been proven to be an efficient method that can be used to prevent patient safety incidents. the method uses the concept of collaboration between teams and it article significance for public health the nurse's ability to read changes in the patient's situation is critical in predicting potential worsening conditions that could endanger the patient's life. situation monitoring aids in the resolution of conflicts among team members, allowing them to learn the best practices for avoiding medical errors, adverse events, and sentinel events. the adoption of modified teamstepps is expected to result in improved situation monitoring and, as a result, a reduction in the occurrence of medical errors. this study investigated the impact of a modified teamsteeps on nurses' situation monitoring in the hospital. the findings could lead to new ways to improve hospital and other healthcare facility safety. [healthcare in low-resource settings 2023; 11(s1):1163] [page 1] non -co mmerc ial us e o nly consists of four main components, namely leadership, communication, mutual support, and situation monitoring between the teams.11 study revealed that teamstepps can improve patient safety and healthcare quality, hence, it needs to be implemented in indonesia’s nursing services. furthermore, previous studies reported that poor situation monitoring or situation awareness accounts for 80% of anesthesia patient safety incidence.12,13 qualitative review also showed that understanding of situation monitoring improves nurses’ decision-making ability and health care quality.12 therefore, this study aims to determine the effects of teamstepps implementation by nurses on situation monitoring in hospitals. design and methods this study used a quasi-experimental pre-post-test design to examine the difference between situation monitoring in the control group and the intervention group after the teamstepps treatment. this study was carried out from november 2019 to february 2020 among nurses in the inpatient rooms of muhammadiyah malang university (umm) hospital and brawijaya university (ub) hospital, with a total of 75 and 50 nurses, respectively. the samples were then selected using the purposive sampling technique, which was based on several inclusion and exclusion criteria. nurses that are willing to participate for a minimum of two months and are ready to perform nursing care directly to the patients for more than 7.5 hours/week were selected, while nurses on leave or probation were excluded. a total of 28 samples were then obtained from each hospital after the selection process. the umm and ub hospitals samples were served as the control and intervention groups, respectively. the situational monitoring as part of the teamstepps teamwork perceptions questionnaire (t-tpq) and teamstepps teamwork attitudes questionnaire (t-taq) from the ahrq were used for this study. they contain 13 questions, which consist of 7 perceptions dimension items, and 6 attitudes dimension items (table 1). the validity and reliability test was carried out using pearson’s correlation and cronbach’s alpha on 43 respondents who were outside the sample population but had the same charac article [page 2] [healthcare in low-resource settings 2023; 11(s1):1163] table 1. the situational monitoring perceptions and attitudes questionnaire. non -co mmerc ial us e o nly teristics as the sample. the validity and reliability test showed that t-tpq was 0.713 and 0.849, while ttaq was 0.683 and 0.706. therefore, it was concluded that the situaional monitoring questionnaire items on t-tpq and t-taq were valid. results and discussions characteristics of respondents the description of the respondents can be seen at table 2. the control group contains 16 female (57.1%), while the intervention group has 23 female (82.1%). furthermore, 23 respondents (82.1%) in the control group are between the age of 20-30, while 20 respondents (71.4%) in the intervention group are in this age range. the diploma nursing program was the latest education of 15 respondents (53.6%) in the control group, while in the intervention group, the nurse profession program was the latest for 16 respondents (57.1%). 21 respondents (75.0%) are working in the inpatient rooms in the intervention group, while all 28 respondents (100.0%) in the control group work there. 22 respondents (78.6%) in the control group and 18 (64.3%) respondents in the intervention group have been working at the unit for one to five years. this range of working periods is similar to that of the samples with 18 respondents (64.3%) in the control group and 20 respondents (71.4%) in the intervention group. situation monitoring in the control group and intervention group situation monitoring in control group shows that the perceptions pretest scores median of 28.00 was equal to that of the posttest scores. also, the attitudes pretest scores median of 24.00 was equal to that of the posttest scores. however, situation monitoring in intervention group shows that the perceptions pretest scores median of 27.00 is less than the posttest which was 28.00. it also shows that the attitude pretest scores median of 24.50 is greater than the posttest which was 24.00 (table 3). analysis of the difference in the situation monitoring pretest and posttest scores table 4 reveals that the p-value of perceptions is 0.406, which indicates that there is no significant difference in the perceptions scores of the control group. furthermore, the p-value of attitudes was 0.737, which shows that there is no significant difference in the attitudes scores of the control group. the p-value of perceptions was 0.732, which indicates that there was no significant difference between the pretest and posttest perceptions scores in the intervention group. furthermore, the attitudes had a p-value of 0.830, which shows that there was also no significant difference between the pretest and posttest attitudes scores in the intervention group. analysis of the difference in the situation monitoring pretest and posttest scores in the control and intervention groups table 5 shows that p-value of the situation monitoring perceptions was 0.610 (p > 0.05), which indicates that there was no significant difference in the averages of both groups based on the measured improvement. in the situation monitoring variable, the average improvement of the intervention group was slightly higher than the control, but the difference was insignificant. moreover, the p-value of the situation monitoring attitudes was 0.835 (p > 0.05), which indicates that there was no significant difference in the averages of both groups based on the measured improvement. in the situation monitoring variable, the average improvement of the intervention group was slightly lower than the control, but the difference was insignificant. this indicates h0 was accepted, meaning that the implementation of teamstepps by the nurses has no significant effects on their situation monitoring. the majority of nurses in this study are female and based on psychological theories perspective, they adhere to the rules and expect success at work more than male.14 however, there is no difference between the male and female nurses in terms of solving problems, skills, competition drive, motivation, and ability to provide good nursing care to patients. most of the samples were 2030 years old, which shows that the way of thinking as well as prob article [healthcare in low-resource settings 2023; 11(s1):1163] [page 3] table 2. characteristics of respondents. characteristic control group (n=28) intervention group (n=28) f % f % age 20-30 y.o. 23 82.1% 20 71.4% 31-40 y.o. 5 17.9% 8 28.6% gender male 12 42.9% 5 17.9% female 16 57.1% 23 82.1% latest education nurse profession program 13 46.4% 16 57.1% d3 nursing program 15 53.6% 11 39.3% others 0 0% 1 3.6% years working in the unit < 1 year 0 0% 10 35.7% 1-5 years 22 78.6% 18 64.3% 6-10 years 6 21.4% 0 0% years working at the hospital < 1 year 0 0% 10 35.7% 1-5 years 22 78.6% 18 64.3% 6-10 years 6 21.4% 0 0% work unit inpatient 28 100,0% 21 75.0% icu 0 0,0% 7 25.0% non -co mmerc ial us e o nly lem-solving ability increases along with age, and this improves their performance, experience and knowledge.15 the latest education of most nurses in the control group was the d3 nursing program, while the nurse profession program was the lastest in the intervention group. therefore, it was assumed that the nurses’ level of education affects their perception of nursing care provision system as well as the need to implement their knowledge and skills in patient safety.16 the nurses’ working period in the unit ranges between one to five years. it was also observed that respondents with ≤ 6 years working experience provided better nursing care because they are more enthusiastic and have greater curiosity while performing their duties. therefore, the working period in the units and hospitals significantly affected their performance while providing healthcare services to patients.17 the majority of the respondents work in inpatient units, and a previous study reported that nurses working in different rooms in a hospital have no significant effects on their performance.18 situation monitoring in the control group in the control group, the pretest scores of perceptions towards situation monitoring were higher than their posttest scores. meanwhile, their attitudes pretest scores were lower than their posttest scores because the control group was not given the teamstteps treatment. this finding is consistent with a previous study, which reported that there was no significant improvement in the perceptions and attitudes posttest and pretest for the control group. this was because they work in the same unit in the hospital and they were not trained.19 situation monitoring in the intervention group before and after the teamstepps training the pretest scores of the nurses’ perceptions towards situation monitoring were lower than the posttest, while the pretest scores of their attitudes were higher than the posttest scores. furthermore, king et al. (2015) stated that there was an improvement in nurses’ perceptions because the teamstepps training was administered in accordance with the ahrq guidelines. the training was then monitored regularly by the high-reliability organization (hro) and supported by the ahrq through teleconference for two months.20 these findings are in line with goebel (2016) that there was an improvement of perceptions in the intervention group, but it was insignificant with a p-value of 0.84.21 meanwhile, the pretest scores of the nurses’ attitudes were higher than the posttest, but it was insignificant. this is in line with a similar study that the improvement of situation monitoring observed through the teamwork attitude was caused by the poor motivation and compliance while implementing the training in real-life situations.22 furthermore, shaw (2015) reported that teamstepps has several benefits, such as improving nurses’ perceptions, although the employment rate before and after the training was constant.23 the effects of teamstepps implementation by nurses on situation monitoring in a hospital based on perceptions improvement, there was no significant difference between the averages of the two groups. the interven article table 3. results of the situation monitoring pretest and posttest in the control group and intervention group. group variable median n iqr min max control group pretest perceptions 28.00 28 2.75 21.00 35.00 attitudes 24.00 28 2.75 20.00 30.00 posttest perceptions 28.00 28 2.00 21.00 35.00 attitudes 24.00 28 1.00 20.00 30.00 intervention group pretest perceptions 27.00 28 2.00 19.00 34.00 attitudes 24.50 28 4.50 16.00 30.00 posttest perceptions 28.00 28 2.75 22.00 35.00 attitudes 24.00 28 0.00 21.00 30.00 table 4. situation monitoring in the control group using wilcoxon test. group variable z p-value control group perceptions pretest -0.832 0.406 posttest attitudes pretest -0.336 0.737 posttest intervention group perceptions pretest -0.342 0.732 posttest attitudes pretest -0.215 0.830 table 5. results of the unpaired t-test on the situation monitoring perceptions and attitudes in the control and intervention groups. variables group mean n std. dev t p-value perceptions control -0.4286 28 4.76429 0.513 0.610 intervention 0.2143 28 4.60561 attitudes control 0.1429 28 3.80754 -0.210 0.835 intervention -0.0714 28 3.83868 [page 4] [healthcare in low-resource settings 2023; 11(s1):1163] non -co mmerc ial us e o nly tion group’s average perception was slightly higher than the control, but the difference was insignificant. meanwhile, in terms of the attitudes towards situation monitoring, the average improvement of the intervention group was slightly lower than the control group, and the difference was also insignificant. this study shows that the improvement of average perceptions in the intervention group was slightly higher than the control, but it was insignificant. this finding is consistent with shaw (2015) that there was no significant difference in situation monitoring, but there was an improvement of perceptions in the posttest.23 furthermore, this was caused by the limited time of training, which was conducted for only four hours. it was also caused by the instructor’s inadequate skills while conducting the training, which led to the loss of interest by the participants. in terms of the attitudes, the average improvement in the intervention group was slightly lower than the control group, and the difference was also insignificant. this is in line with a previous study that there was a slight and insignificant improvement in the nurses’ attitudes towards situation monitoring.24 this was because the respondents had positive attitudes before the teamstepps training, consequently, the change after the training was insignificant. the factor that caused the insignificant improvement of situation monitoring in this study was the poor commitment of the intervention group respondents in attending the training. this lack of commitment can be observed through the undisciplined participants that came late and left the training room during the teamstepps training. the workshop lasted for only two hours, after which the seminar was carried out on the same day. meanwhile, the ahrq advised that the workshop needs to be administered a day after the seminar for four to six hours.10 after the training, advisory sessions and follow-ups regarding teamwork were regularly conducted, but the nurses showed poor commitment towards implementing the program in their units. consequently, the teamwork in situation monitoring after the training was suboptimal. regular observation needs to be carried out for one month after the implementation of teamstepps to monitor the improvement of perceptions and attitudes.25 another observation must be done 6 and 12 months after the implementation to monitor the significant improvement of the competence in every picu and sicu. the improvement of situation monitoring scores of both control and intervention groups was caused by various factors including the age of most of the respondents and their working duration in the units and hospital. the working period correlates with their experiences in teamwork. furthermore, these experiences help to develop workplace comfort, which indirectly builds a trusting relationship in nursing care and fosters effective teamwork. based on the results, the implementation of teamstepps had no significant effects on situation monitoring by nurses at brawijaya and muhammadiyah malang hospitals. this study found that teamstepps had no significant effects on hospital situation monitoring. teamstepps should also be improved through a more effective method and training duration to achieve the best results. after receiving teamstepps training, at least six months of observation is required to track teamwork improvement in situation monitoring. these ongoing check-ins help to reinforce the nurses’ commitment to the program’s implementation. conclusions the improvement of the intervention group’s perceptions towards situation monitoring was slightly higher than the control. meanwhile, the improvement of the intervention group’s attitudes was slightly higher than the control group, but the difference was insignificant. these findings indicate that there was an insignificant difference between the perceptions and attitudes towards situation monitoring after the teamstepps treatment in a hospital. article correspondence: ahsan, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62 341 5080686, fax: +62 341 5080686. e-mail: ahsanpsik.fk@ub.ac.id key words: patient safety; nursing management; nursing team; situational monitoring. contributions: aa and ehn verified the method and design of this study, and they also supervised the findings. im performed the statistical analysis and interpreted the data. inr drafted, wrote, and revised the manuscript with the support of other authors. lwn conceived the idea presentation and developed the theory as well as the concept. all authors carried out the study and agreed to the arrangement of authors as well as read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: funds were provided by the faculty of medicine, universitas brawijaya through the professor and doctor grant scheme (number: 11/un10.f08/pn/2019). acknowledgments: the authors are grateful to all that contributed to this study, especially the respondents, students of the bachelor program in nursing, faculty of medicine, universitas brawijaya. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: this study was approved by the health research ethics commission of the faculty of medicine, universitas brawijaya (ethical clearance letter no. 07/ec/kepk/ 01/2020). informed consent: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. conference presentation: part of this paper was presented at the 2nd international nursing and health sciences symposium that took place at the faculty of medicine, universitas brawijaya, malang, indonesia. received for publication: 3 december 2021. accepted for publication: 10 may 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11(s1):11163 doi:10.4081/hls.2023.11163 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11(s1):1163] [page 5] non -co mmerc ial us e o nly references 1. ministry of health of the republic of indonesia. pedoman nasional keselamatan pasien rumah sakit. [national guidelines for hospital patient safety.] ministry of health of the republic of indonesia; 2015. 2. najihah n. budaya keselamatan pasien dan insiden keselamatan pasien di rumah sakit: literature review. [patient safety culture and patient safety incidents in hospitals: literature review] j islam nurs 2018;3:1-8. 3. darliana d. hubungan pengetahuan perawat dengan upaya penerapan patient safety di ruang rawat inap rumah sakit umum daerah dr. zainoel abidin banda aceh. [the relationship between nurse knowledge and efforts to implement patient safety in the inpatient room of the dr. zainoel abidin banda aceh] idea nurs j 2016;7:61-69. 4. komite keselamatan pasien rumah sakit. pedoman pelaporan insiden keselamatan pasien. [hospital patient safety committee. guidelines for reporting patient safety incidents.] ministry of health of the republic of indonesia; 2015. 5. gunawan g, harijanto h, harijanto t. analisis rendahnya laporan insiden keselamatan pasien di rumah sakit. j kedokt brawijaya 2015;28:206-213. 6. cahyono a. hubungan karakteristik dan tingkat pengetahuan perawat terhadap pengelolaan keselamatan pasien di rumah sakit. [analysis of low patient safety incident reports in hospitals.] j ilm widya 2018;4(3). 7. rachmah r. optimalisasi keselamatan pasien melalui komunikasi sbar dalam handover. [optimizing patient safety through sbar communication in handovers.] idea nurs j 2018;9(1). 8. handayani f. gambaran insiden keselamatan pasien berdasarkan karakteristik perawat, organisasi, dan sifat dasar pekerjaan di unit rawat inap rumah sakit al-islam bandung pada periode 2012-2016. [description of patient safety incidents based on nurse characteristics, organization, and basic nature of work in the inpatient unit of al-islam hospital bandung in the 2012-2016 period.] 2017 [cited 2022 jan 6]; available from: https://repository.uinjkt. ac.id/dspace/handle/123456789/35942. 9. insani thn, sundari s. analisis pelaksanaan keselamatan pasien oleh perawat. [analysis of implementation of patient safety by nurses.] jhes (journal heal studies) 2018;284-95. 10. sorra j, yount n, famolaro t, et al. ahrq hospital survey on patient safety culture version 2.0: user’s guide. (prepared by westat, under contract no. hhsp233201500026i/hhsp23337004t). rockville, md: agency for healthcare research and quality; june 2021. ahrq publication no. 19(21)-0076. https://www.ahrq.gov/sops/surveys/hospital/index.html 11. american hospital association. improving patient safety culture through teamwork and communication: teamstepps aha [internet]. 2015 [cited 2022 jan 6]. available from: https://www.aha.org/ahahret-guides/2015-0618-improving-patient-safety-culture-through-teamwork-andcommunication 12. schulz cm, krautheim v, hackemann a, et al. situation awareness errors in anesthesia and critical care in 200 cases of a critical incident reporting system. bmc anesthesiol 2016;16(1). 13. schulz cm, burden a, posner kl, et al. the frequency and type of situational awareness errors contributing to death and brain damage a closed claims analysis. anesthesiology. 2017;127:326. 14. robbins sp, judge ta. perilaku organisasi. buku 2. edisi 12. jakarta: salemba empat; 2008. 15. notoatmodjo s. pendidikan dan perilaku kesehatan. jakarta: rineka cipta; 2012 16. mawarti i, wahyuni fs, wahyudi w. analisis faktor-faktor yang berhubungan dengan pelaksanan sistem pemberian pelayanan keperawatan profesional oleh perawat pelaksana di ruang rawat inap rsud raden mattaher jambi tahun 2014. jambi med j jurnal kedokt dan kesehatan 2016;4(1). 17. sasikiraniasih a. hubungan masa kerja dengan kinerja perawat di ruang rawat inap rumah sakit mulya pinang kota tangerang tahun 2017 [undergrad theses on internet]. jakarta: universitas esa unggul; 2018 [cited 2022 jan 6]. available from: https://digilib.esaunggul.ac.id/public/ueuundergraduate-11416-cover.image.marked.pdf 18. agustrianti p. analisis faktor-faktor yang berhubungan dengan efektivitas komunikasi perawat dan pasien di ruang rawat inap rumah sakit harapan mulia kabupaten bekasi tahun 2015. [analysis of factors associated with the effectiveness of nurse and patient communication in the inpatient room of harapan mulia hospital, bekasi regency, year 2015] j adm rumah sakit indones 2018;2(1):72-83 19. khademian z, pishgar z, torabizadeh c. effect of training on the attitude and knowledge of teamwork among anesthesia and operating room nursing students: a quasi-experimental study. shiraz e-med j 2018;19(4):e61079. 20. king hb, battles j, baker dp, et al. teamstepps™: team strategies and tools to enhance performance and patient safety. in: henriksen k, battles jb, keyes ma, et al., editors. advances in patient safety: new directions and alternative approaches (vol. 3: performance and tools). rockville (md): agency for healthcare research and quality (us); aug 2008 [cited 2022 jan 6]. available from: https://www.ncbi.nlm.nih.gov/books/nbk43686/. 21. goebel jr, guo w, wood ka. teamwork and perceptions of palliative care quality. j hosp palliat nurs 2016;18:242-248. 22. rosen ma, diazgranados d, dietz as, et al. teamwork in healthcare: key discoveries enabling safer, high-quality care. am psychol 2018;73:433. 23. shaw b. evaluation of the impact of teamstepps training on perceptions of teamwork and resilience in the intensive care and perioperative units in a tertiary care hospital. [dissertation on the internet]. denver, colorado: all regis univ; 2015 [cited 2022 jan 6]. available from: https://epublications.regis.edu/theses/682 24. baker dp, amodeo am, krokos kj, et al. assessing teamwork attitudes in healthcare: development of the teamstepps teamwork attitudes questionnaire. qual saf health care 2010;19(6). 25. buljac-samardzic m, doekhie kd, van wijngaarden jdh. interventions to improve team effectiveness within health care: a systematic review of the past decade. hum resour health article [page 6] [healthcare in low-resource settings 2023; 11(s1):1163] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11880 enhancing breastfeeding self-efficacy in the postpartum period through emotional release with self-talk method cristinawati b.r. haloho, ega ersya urnia, dewi rinda astuti, ni nyoman murti politeknik kesehatan kementerian kesehatan kalimantan timur, samarinda, indonesia abstract this study aimed to assess the impact of utilizing the “happy maternal card,” a self-talk intervention, on breastfeeding self-efficacy during the postpartum period. the research involved 28 mothers three days postpartum in health canter care in purwodadi regency, indonesia, from february to march 2020, using a quasiexperimental pre-post design with a control group. the intervention group received self-talk sessions twice daily for a month, while the control group received information through a maternal book twice a week. breastfeeding ability and independent infant care were measured using the breastfeeding self-efficacy scale. results indicated a significant decrease in anxiety (p=0.000) and a positive impact on breastfeeding self-efficacy in the intervention group (p-value=0.001). the positive suggestions of self-talk empowered mothers cognitively, enabling them to handle stress and believe in positive suggestions, ultimately influencing behavior. this self-talk method has the potential for postpartum care to enhance maternal efficacy in managing psychological aspects, contributing to the success of exclusive breastfeeding. introduction according to the american psychological association (apa), emotion is a multifaceted reaction pattern that encompasses experiential, behavioral, and physiological elements.1 emotions are the ways individuals navigate and respond to matters or situations they personally deem significant.2 emotional experiences consist of three integral components: a subjective experience, a physiological response, and a behavioral or expressive reaction.1,3 scientists posit that emotions are composite phenomena, arising from the intricate interplay of various components within both the brain and the body. every life experience contributes to shaping our emotions.4 postpartum period is recognized as a transitional phase in a woman’s life when she assumes the role of a mother, significantly impacting her emotions.5 during this period, there are changes in various aspects such as role, responsibility, identity, physicality, and social dynamics.6-7 the fluctuations in steroid hormone levels play a crucial role in emotion processing, affecting reactivity within a network that includes the amygdala, insula, anterior cingulate cortex, and the prefrontal cortex.8 the decrease in steroid and oxytocin hormones influences maternal emotional well-being,9-11 contributing to factors associated with psychological breakdown. adequate emotion processing during the postpartum period is essential for immediate maternal-infant bonding, encompassing attention, the recognition of infant emotions, motivation, preoccupation of thought, and parental empathy.6,12 other factors, such as age, social support, parity, internal conflicts, etc., are related to postpartum depression.11 these factors contribute to a mother’s susceptibility to psychological breakdown.5 postpartum encompasses various psychological breakdowns, including postpartum blues, baby blues, postpartum depression, and postpartum psychosis.13,14 the international statistical classification of diseases (icd-10) defines postpartum depression as a mental and behavioral disorder.15 symptoms of depression include desperation, sadness, nausea, changes in sleep and eating habits, decreased libido, crying spells, anxiety, irritability, feelings of isolation, mental instability, thoughts of hurting oneself and/or the infant, and even suicidal thoughts (common). all of these symptoms describe the emotional state of the mothcorrespondence: cristinawati b.r. haloho, politeknik kesehatan kementerian kesehatan kalimantan timur, samarinda, indonesia. e-mail: cristinasihaloho68@gmail.com key words: breastfeeding, maternal health, postpartum, self-efficacy, self-talk. contributions: cr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; er, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; dr, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; ny, methodology, visualization, writing – review and editing; ss, resources, investigation, and writing –review & editing; dp formal analysis, validation, writing – review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from rs dr. moewardi general hospital solo, central of java with number 1.484/xii/ hrec/2019. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article funding: none. received: 27 september 2023. accepted: 20 december 2023. early access: 30 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11880 doi:10.4081/hls.2024.11880 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11880] [page 193] non -co mmerc ial us e o nly er.16 previous studies indicate a significant relationship between the emotions of postpartum mothers and depression, emphasizing the need for mental support during this period.17 studies from 80 different countries or regions were included in the final analysis. the prevalence of postpartum depression reached up to 17.22% of the world’s population. another study indicated that the prevalence of postpartum depression was 27.1% in the southwestern region, with associated factors including low perceived social support, rural residence, obstetric complications, and excessive crying by the baby. in asia, postpartum blues have been reported to affect between 26% and 85% of individuals, and in indonesia, the range is from 50% to 70%.15,18,19 approximately 50-70% of postpartum mothers suffer from postpartum depression, with the prevalence varying from 5% to 25% in indonesia. this condition can hinder exclusive breastfeeding.16,17 the purpose of this study was to enhance midwifery care during the postpartum period using the self-talk method, which provides mothers with positive suggestions to manage their emotions, empowers their mindset, and increases maternal self-efficacy. previous research analyzing this method has shown its ability to strengthen psychological responses.20 it was found that the suggestion group reported a 42% lower subjective pain intensity, effectively handled anxiety during the biopsy process, and experienced a 14% reduction in hospitalization time after surgery (19 hours). additionally, they reported 11% less pain in the days following the operation, along with reductions in postoperative pain, blood pressure, and increased confidence in competition.21-23 however, previous studies have not analyzed the effect of selftalk on postpartum mothers. this gap prompted the researchers to employ this method with postpartum mothers, specifically focusing on breastfeeding self-efficacy. this is crucial because psychological breakdowns can lead to decreased breast milk production and undermine confidence in breastfeeding and infant care due to emotional upheaval. ignoring these issues may drive mothers into a depressed condition, damaging their health and hindering the postpartum recovery process.24–27 therefore, this study aims to analyze the effect of the release emotion using self-talk method on breastfeeding self-efficacy during the postpartum period. materials and methods this research employed a quasi-experimental research design with a pre-post-test control group. the purpose of this study was to analyze the effect of releasing emotion using self-talk for increasing breastfeeding self-efficacy in postpartum mothers. study participants the sample size in this study was calculated using the rule of lameshow’s formula, resulting in 20 samples divided into two groups. the experimental group received self-talk sessions, while the control group received education from the maternal book. purposive random sampling was employed, sorting participants based on inclusion and exclusion criteria. inclusion criteria comprised postpartum mothers from the 1st to the 14th day, normal vital signs, the postpartum specific anxiety scale (psas) scores between 70 and 111, mothers aged 20 to 30 years, both primipara and multipara, those without hypertension or heart attack history, and those without a history of mental breakdown. participants were required to commit to following the study until its completion. exclusion criteria included mothers unwilling to adhere to the study routine or be visited. the research took place at four primary health care centers in central java, indonesia, from march to may 2020. the selection of these centers was based on the highest number of postpartum mothers in the last three months, and a cube was used to decide the intervention and control groups. the lameshow formula was used to determine the sample size, resulting in 15 postpartum mothers in the intervention group and a total of 30 respondents. variables, instrument and data collection the independent variable consists of demographic factors (age, parity, and employment), and the dependent variable consists of selfefficacies in breastfeeding and the capability of independent infant care measured by the breastfeeding self-efficacy scale. demographic factors were collected using a respondent identity questionnaire. before receiving therapy, respondents were assessed using the psas to ensure that mothers were not experiencing psychological distress, enabling the use of this method for prevention and handling maternal mental well-being. the psas comprises 51 questions that assess mothers’ anxieties, with response options ranging from “never” to “always” and scored from 1 to 4. the total score is then categorized into anxiety levels: 51-70 (anxious), 71-90 (mild anxiety), 91-111 (moderate anxiety), and ≥112 (depressed). the second instrument used was the breastfeeding self-efficacy scale (bses). this questionnaire measured mothers’ self-efficacies in relation to breastfeeding capabilities, consisting of 14 questions with likert scores from 1 to 4. the scores were categorized from extremely not efficacious to very efficacious. after completing the questionnaire, scores were calculated, allowing the researcher to identify areas where mothers may have doubts in their breastfeeding processes. the bses was applied to examine the capabilities and self-efficacies of mothers while engaging in the breastfeeding process. after meeting the inclusion criteria, in the first session, respondents released their emotions with a chaperone, guided to express their emotions using three key words: sorry, thankful, and i love you. this method aimed to build trust and help respondents alleviate negative feelings. subsequently, respondents continued this process twice a day or whenever they felt the need for support. “happy maternal cards,” printed on 8x10 cm photo paper, containing pictures and positive suggestions, were used in this process and were validated by experts dropout sample this study was conducted during the covid-19 era, a time when the researcher intended to visit the respondents. however, due to the “stay home” mandate, the study was delayed for two weeks. some respondents could not be visited due to covid-19 concerns, and society labeled all people. consequently, only 11 participants remained in the experimental group, and 7 in the control group until the end of this research. ethical clearance this study obtained ethical clearance from rs dr. moewardi general hospital in solo, central java, with the reference number 1.484/xii/hrec/2019. informed consent was obtained from all respondents who participated in the study. they had the authority to reject or withdraw as respondents at any point in this research. results the univariate analysis data showed that the average age of the respondents was 26 years old in the intervention group and 25 years old in the control group. there were no respondents older transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 194] [healthcare in low-resource settings 2024;12:11880] non -co mmerc ial us e o nly than 30 years in either group. in both groups, the majority of respondents were primiparous, and most were employed (table 1). table 2 presents a comprehensive examination of maternal anxiety levels before and after a specified intervention, utilizing the perinatal anxiety screening scale (psas). the results indicate a statistically significant reduction in anxiety levels for the intervention group (p=0.000), contrasting with the control group where anxiety levels increased (p=0.006). additionally, the deviation values illustrate the dispersion of data within each group. this table serves as a valuable resource for understanding the impact of the intervention on maternal anxiety, highlighting the effectiveness of the approach in mitigating anxiety levels among the targeted population. table 3 provides a detailed examination of the self-talk component within the breastfeeding self-efficacy scale (bses) for postpartum mothers. for both the experimental and control groups, there was an overall increase in scores from pre-test to post-test, indicating an improvement in breastfeeding self-efficacy. in the experimental group, all questions showed positive changes with a significant decrease in negative ranks (p=0.001), suggesting an enhancement in self-talk regarding breastfeeding self-efficacy. in the control group, while positive changes were observed, there were 3 ties, implying that there was no discernible change in the feelings associated with those specific questions. table 4 presents the outcomes of a t-test analysis focusing on the self-talk component within the bses for postpartum mothers. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. analysis of self-talk impact on breastfeeding self-efficacy in postpartum mothers (n=20). characteristic intervention control homogeneity n % n % p adv age (years) 0.305 homogen mean 25.91 24.71 min-max 22-30 21.27 median 26.00 26.00 parity 0.837 homogen primipara 6 54.5 4 57 multipara 5 45.5 3 43 employment 0.355 homogen working 9 81.8 5 71.4 not working 2 18.2 2 28.6 table 2. bivariate analysis of maternal anxiety before and after intervention using psas. variables groups p intervention mean ± sd control mean ± sd anxiety pre 99.73±4.901 96.57±5.884 post 69.3±3.901 82.71±6.264 p 0.000a 0.006a deviation 25.55±3.560 10.00±6.481 0.000b apaired sample test. bindependent test. table 3. analysis of self-talk in breastfeeding self-efficacy scale for postpartum mothers. ranks n mean rank sum of ranks z scores p post_tot pre_tot ex negative ranks 0a 0.00 0.00 -3.305 0.001 positive ranks 14b 7.50 105.00 ties 0c total 14 post_tot pre_tot control negative ranks 0a 0.00 0.00 -3.019 0.003 positive ranks 11b 6.00 66.00 ties 3c total 14 askor_post_tot < skor_pre_tot; bskor_post_tot > skor_pre_tot; cskor_post_tot = skor_pre_tot. table 4. t-test results of self-talk in postpartum mothers using bses. ranks z score p delta bse group mean rank sum of ranks -4.251 0.000 control 7.96 111.50 experimental 21.04 294.50 [healthcare in low-resource settings 2024;12:11880] [page 195] non -co mmerc ial us e o nly both the control and experimental groups exhibited an improvement in breastfeeding self-efficacy, as reflected by the increasing scores in the post-test. the t-test, analyzed using the mannwhitney method, reveals that the experimental group demonstrated a significantly higher improvement (mean rank: 21.04) compared to the control group (mean rank: 7.96) with a p-value of 0.000. the z-score of -4.251 underscores the statistical significance of the observed differences, indicating that the improvement in self-talk related to breastfeeding self-efficacy in the experimental group is not merely due to chance. this outcome suggests that the intervention had a substantial and beneficial impact on the specific capabilities assessed by the bses, demonstrating the effectiveness of the intervention in enhancing breastfeeding self-efficacy among postpartum mothers. discussion this study demonstrates a correlation between the postpartum period and maternal emotion, as evidenced by mean psas scores of 99.73 in the intervention group and 96.57 in the control group. these findings align with prior research indicating that during the postpartum period, hormonal fluctuations may lead to changes in maternal emotion.17,28,29 previous studies have identified three key psychological variables emotion regulation, maternal self-confidence, and marital satisfaction that may contribute to psychological breakdowns. emotion regulation is particularly crucial for managing stress situations.17 one of the methods to manage the emotion of mother is self-talk. self-talk was given positive suggestions to release the emotion. in our mind, there are two kinds of the function of mind called conscious and subconscious mind.30 positive suggestions imparted to the mother’s conscious mind subsequently influence the subconscious mind, guiding it to adopt positive suggestions and, in turn, modify behavior. this mechanism is consistent with the findings of our study, which observed an increase in breastfeeding self-efficacy as a result of positive self-talk. self-talk enables mothers to cultivate love, forgiveness, and gratitude. engaging in self-talk facilitates relaxation, instills selftrust, and ultimately restores maternal confidence. the positive suggestions embedded through self-talk become lodged in the subconscious, gradually shaping a positive mindset and influencing behavioral changes. this transformation, in turn, enhances maternal self-efficacy and promotes independent infant care.31-33 aligning with earlier studies, self-talk has proven effective in managing anxiety, emotions, and pain while enhancing overall performance and confidence.21-23 building upon these findings, it is noteworthy that positive suggestions, as identified in previous research, have the capacity to alter brain wave circulation, reduce pain, and alleviate anxiety in patients.34,35 the efficacy of self-talk emerges as a valuable alternative for effectively managing the emotions experienced by postpartum mothers. beyond serving as a constructive coping mechanism, it stands as a potential preventive measure against psychological challenges such as baby blues, postpartum blues, and psychosis.36 health providers, acknowledging the pivotal role of self-talk, can integrate this intervention into their care strategies. employing self-talk not only facilitates emotional regulation but also contributes to establishing trust between healthcare professionals and postpartum mothers.29,37 furthermore, research underscores the significant correlation between psychological breakdowns, postpartum blues, and their impact on breast milk volume. a study revealed a substantial association between psychological well-being and the quantity of breast milk produced.38,39 by incorporating self-talk into postpartum care practices, health providers can address emotional wellbeing and potentially enhance the overall quality of postpartum care.36 this holistic approach reflects a commitment to both the mental and physical aspects of postpartum health, fostering a more comprehensive and supportive care environment for new mothers. however, it’s essential to note the limitations of this study due to the covid-19 pandemic. many respondents withdrew from the study because of the civil regulation known as “lockdown.” the unwillingness of respondents to visit and continue the study has impacted the overall value of this research. the total number of participants in this study is limited to 18, with 11 in the intervention group and 7 in the control group. conclusions psychological breakdown can prevent mothers from breastfeeding or create a reluctance to do so. this situation can result in the baby lacking essential nutrition and the affectionate bond with the mother. the self-talk method facilitates emotional release for mothers, strengthening the relationship with health providers, building trust, and enhancing the joy of breastfeeding. it offers a valuable solution to support mothers in participating in exclusive breastfeeding programs. however, this research faced several challenges, such as insufficient samples due to the impact of covid19, leading to the withdrawal of many respondents from the study. for future research, it is essential to expand both the sample size and variables to improve the study’s robustness. to postpartum mothers, provide your body with positive suggestions to maintain a healthy mind. references 1. the university of western alabama. the science of emotion: exploring the basics of emotional psychology. uwa online 2019;17. 2. palupi kr, hartini n. postpartum depression: husbandly support and self-acceptance factor. opcion 2019;35:1092-104. 3. wattanapisit a, abdul rahman h, car j, et al. the clusters of health-risk behaviours and mental wellbeing and their sociodemographic correlates: a study of 15,366 asean university students. bmc public health 2022;22. 4. cabrera m. what is an emotion? quad filos 2021;8:145-91. 5. solikhah fk, nursalam n, subekti i, et al. determination of factors affecting post-partum depression in primary healthcare during the covid-19 pandemic. j public health africa 2022;13:2408. 6. leahy-warren p, mccarthy g, corcoran p. postnatal depression in first-time mothers: prevalence and relationships between functional and structural social support at 6 and 12 weeks postpartum. arch psychiatr nurs 2011;25:174-84. 7. chen ck, tsai yc, hsu hj, et al. depression and suicide risk in hemodialysis patients with chronic renal failure. psychosomatics 2010;51. 8. ghaedrahmati m, khazemi a, kheirabadi g, et al. postpartum depression risk factors: a narrative review. j educ health transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 196] [healthcare in low-resource settings 2024;12:11880] non -co mmerc ial us e o nly promot 2017;6:60. 9. reck c, tietz a, müller m, et al. the impact of maternal anxiety disorder on mother-infant interaction in the postpartum period. plos one 2018;13:1-21. 10. radoš sn, tadinac m, herman r. anxiety during pregnancy and postpartum: course, predictors and comorbidity with postpartum depression. acta clin croat 2018;57:39-51. 11. field t. postpartum anxiety prevalence, predictors and effects on child development: a review. j psychiatry psychiatr disord 2017;1:86-102. 12. budiman mea, sari snj, kusumawardani w, sutopo d. strategy intervention to prevent and reduce postpartum depression: a systematic review. j ners 2019;14:292-7. 13. balaram k, marwaha r. postpartum blues. statpearls publishing, treasure island (fl); 2023. 14. fitriana f, ningtyas ws, dewi er. providing mental healthcare for postpartum women in indonesia: a qualitative phenomenological study. br j midwifery 2022;30:692-9. 15. handini ts, puspitasari n. differences in postpartum maternal depression levels based on characteristics of maternal age and husband support. indones j public heal 2021;16:124-33. 16. wang z, liu j, shuai h, et al. mapping global prevalence of depression among postpartum women. transl psychiatry 2021;11:543. 17. dinni s, ardiyanti d. predictors of postpartum depression: the role of emotion regulation, maternal self-confidence, and marital satisfaction on postpartum depression. j psikol 2020;47:220. 18. iwanowicz-palus g, marcewicz a, bień a. analysis of determinants of postpartum emotional disorders. bmc pregnancy childbirth 2021;21. 19. tuthill el, mcgrath jm, graber m, et al. breastfeeding selfefficacy: a critical review of available instruments. j human lactation 2016;32:35-45. 20. sandy wf, dasuki d, hayati en, suhariyanto s. domestic violence and postpartum depression. j ners 2020;15:135-41. 21. kekecs z, varga k. positive suggestion techniques in somatic medicine: a review of the empirical studies. interv med appl sci 2013;5:101-11. 22. shi x, brinthaupt tm, mccree m. the relationship of self-talk frequency to communication apprehension and public speaking anxiety. pers individ dif 2015;75:125-9. 23. hase a, hood j, moore lj, freeman p. the influence of selftalk on challenge and threat states and performance. psychol sport exerc 2019;45:101550. 24. otsuka k, taguri m, dennis cl, et al. effectiveness of a breastfeeding self-efficacy intervention: do hospital practices make a difference? matern child health j 2014;18:296-306. 25. azmoude e, jafarnejade f, mazlom sr. the predictors for maternal self-efficacy in early parenthood. j midwifery reprod heal 2015;3:368-76. 26. glangeaud-freudenthal nmc, crost m, kaminski m. severe post-delivery blues: associated factors. arch womens ment health 1999;2:37-44. 27. brice pitt. “maternity blues”. br j psychiatry 1973;122:431-3. 28. pirnia b, givi f, roshan r, et al. the cortisol level and its relationship with depression, stress and anxiety indices in chronic methamphetamine-dependent patients and normal individuals undergoing inguinal hernia surgery. med j islam repub iran 2016;30. 29. syam a, qasim m, iskandar i, kadir a. cortisol, prolactin, and breastmilk volume; a promising pattern for reducing postpartum depression. open access maced j med sci 2022;10:1399-405. 30. joseph murphy. the miracles of your mind. vol. 21, willing publishing company p.o box 51. san gabriel, california; 1955. 176–177 p. 31. hall rs. the effect of self-talk as an anxiety regulation and intervention on coincident anticipation timing and batting performance in criket. stat f theor 2019;53:1689-99. 32. ghasemi v, simbar m, banaei m, et al. the effect of interventions on breastfeeding self-efficacy by using bandura ’ s theory in iranian mothers : a systematic review. int j ped 2019;7:9939-54. 33. sebayang sk, has emm, hadisuyatmana s, et al. utilization of postnatal care service in indonesia and its association with women’s empowerment: an analysis of 2017 indonesian demographic health survey data. matern child health j 2022;26:545-55. 34. rainville p, hofbauer rk, paus t, et al. cerebral mechanisms of hypnotic induction. j cogn neurosci 1999;11:110-25. 35. k. szilágyi a, diószeghy c, benczúr l, varga k. effectiveness of psychological support based on positive suggestion with the ventilated patient [die wirksamkeit psychischer unterstützung auf der grundlage positiver suggestionen bei beatmeten patienten.] eur j ment heal 2007;2:149-70. 36. umamah f, santoso b, yunitasari e, et al. the effectiveness of psycho-educational counseling in pregnant women with preeclampsia: a systematic review. j public health res 2022; 11. 37. vinarti ra, tyasnurita r, utamima a, et al. bumilbahagia (happymothers) a preliminary-study to help mothers maintain maternal health. in: 10th ieee region 10 humanitarian technology conference, r10-htc 2022. surabaya, indonesia: institute of electrical and electronics engineers inc.; 2022. p. 360–4. 38. nisa’ f, damayanti na, suhariadi f, et al. internal factors affecting the mother’s psychological capital in exclusive breastfeeding during the covid-19 pandemic. j public health res 2022;11. 39. anis w, devy sr, prasetyo b, et al. implementation and recommendation of postpartum visit methods during covid-19 pandemic: a qualitative study from indonesia. j public health africa 2023;14:2560. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11880] [page 197] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12048 a new strategy to improve maternal-fetal attachment in primigravida women with prenatal spiritual-based stimulation sri wahyuni,1,2 yuni sufyanti arief,3 mira triharini3 1doctoral program in nursing, faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang; 3faculty of nursing, universitas airlangga, surabaya, indonesia abstract primigravida has impacts related to preparedness for the transition into motherhood. thus, its can disrupt the attachment between the mother and the fetus. this study aimed to determine the effects of prenatal spiritual-based stimulation on maternalfetal attachment. this study employed a quasi-experimental design with a control group and was conducted among primigravida women in indonesia. the study included 66 respondents selected through purposive sampling. they were divided into the intervention and control groups, each comprising 33 participants. the intervention group received prenatal spiritual-based stimulations, which involved auditory, kinesthetic, light, and temperature stimulations and were administered over a 12-week period. data on maternal-fetal attachment were collected using the prenatal attachment inventory (pai), which had been tested for validity and reliability. approval to use the instrument was obtained from its original author. data analysis was performed using the wilcoxon and mann whitney tests. the results showed that the wilcoxon test yielded a p-value of 0.000 or significant differences were observed before and after intervention for the intervention group and 0.059 no significant differences were observed before and after the intervention for the control group. the mann whitney test revealed a p-value of 0.000, there were differences in the maternal-fetal attachment before and after the intervention. therefore, spiritual-based prenatal stimulation is effective in enhancing maternal-fetal attachment. these results can provide a basis for pregnant women to apply spiritual-based prenatal stimulation interventions to enhance maternal-fetal attachment and health status. introduction the first pregnancy is a new experience for women, resulting in various consequences in their lives as they prepare for their new role as mothers.1 the immature psychological and social conditions of mothers are highly susceptible to being influenced by the changes during pregnancy, which can affect the attachment between the mother and her fetus.2,3 maternal-fetal attachment is important period, as this is the sensitive period of growth.4 since all of the mother’s behavior, actions, and thoughts during pregnancy could have more permanent effects on the fetus than any other period of the child’s life and pregnancy is considered as a critical period in the development, therefore it is necessary to increase maternal-fetal attachment.5 although pregnancy is a source of joy for families, the increasing number of roles and responsibilities can act as stressors that disrupt emotional states and moods.6 emotional disturbances act as stressors for primigravida,7 affecting their ability to focus.8 as a result, these mothers often become self-centered, frequently neglecting the pregnancy, fetal development, and the needs of the fetus.9 women may experience difficulties in establishing a connection with the fetus and in integrating behaviors to care for their own well-being during the pregnancy period, ultimately impacting the fetus’s welfare.10 this emphasizes that physical and psychological unpreparedness during primigravida pregnancies affects their adaptive capabilities and the attachment between the mother and her fetus. anxiety that cannot be overcome will result in stress and depression.11 therefore, there is a need for social support from family, friends, colleagues, and healthcare providers to assist pregnant women.12 the mother’s unpreparedness in adapting to her pregnancy was also evident in a previous study in sleman regency, yogyakarta, reporting that only 25.8% of primiparous mothers could achieve their roles with a “good” rating, while the remaining 67.7% correspondence: sri wahyuni, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: wahyuni@unissula.ac.id key words: prenatal stimulation, spiritual, maternal-fetal attachment. data availability: the datasets generated during and or analysed during the current study are available from the corresponding author on reasonable request. conflict of interest: the authors declare no conflict of interest. funding: none. contributions: all authors contributed equally to all stages of the study, including making substantial contributions (conception and design or acquisition of data or analysis and interpretation of data), drafting, and revising the manuscript, giving final approval of the version to be published, and agreeing to be accountable for all aspects of the work. acknowledgements: the authors would like to express their gratitude to all participants in this study and the hospital for their help in completing this research. received: 3 november 2023. accepted: 11 december 2023. early access: 22 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12048 doi:10.4081/hls.2024.12048 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12048] [page 171] non -co mmerc ial us e o nly achieved at “satisfactory” or “insufficient” levels. this result shows that the mother’s readiness to adapt is not optimal, which reflects that only a small percentage of mothers really care about feeling close to the baby, feelings of anxiety about the state of the mother, and the state of the baby. furthermore, a study highlighted unpreparedness in the achievement of roles, especially regarding the attachment of mothers to their fetuses (maternal-fetal attachment).13 the results of research on low maternal-fetal attachment were also reflected in another study in 2018, which highlighted that primigravida mothers had low maternal attachment scores to the fetus.9,10 innovations are needed in providing prenatal stimulation interventions by integrating them with spiritual theories. spirituality is very important in maternal-fetal attachment, as demonstrated in a study conducted in 2020 on spiritual health and maternal-fetal attachment behavior, showing that the higher the spiritual health, the greater the maternal-fetal attachment behavior.16 spirituality is the culmination of an individual’s spiritual experience with the purpose and meaning of life, thus, when experiencing problems in pregnancy, primigravida women who have good spirituality can interpret this as a life event from a different perspective, so that they have a stronger sense of self-control, which can improve maternal-fetal attachment.17 primigravida mothers become more motivated to embrace their pregnancies, grow closer to, and cherish their unborn babies, leading to fetal well-being and a reduction in neonatal mortality. achieving this goal aligns with the fulfillment of the third sustainable development goal (sdg), which ensures a healthy and prosperous life, with targets that encompass the prevention of neonatal and infant mortality.18 thus, by providing prenatal-based stimulation interventions, primigravida mothers become more motivated to welcome the pregnancy, become closer, and love the unborn baby. accordingly, this study was conducted to examine the effects of spiritually-based prenatal stimulation on enhancing maternal-fetal attachment. materials and methods study design this study employed a quasi-experimental design with a control group. the study was conducted in semarang, central java, indonesia. participants this study focused on a population of first-time pregnant mothers (primigravida). the samples consisted of 66 individuals who were recruited using purposive sampling and were divided into two groups: the intervention group and the control group. the inclusion criteria were as follows: i) primigravida women; ii) gestational age 12-30 weeks; iii) husband is still alive. the exclusion criteria were as follows: i) husband does not live in the same house; ii) has a history of mental disorders. instrument data collection was conducted using the prenatal attachment invertory questionnaire is a questionnaire from jonnason in 2004,19 and permission to use the questionnaire was obtained from the original author. the questionnaire consisted of 21 questions that reflected five indicators: i) identifying the future baby; ii) touching the prospective baby; iii) joining the movement of the future baby; iv) knowing the habits of the future baby; v) feeling love for the future baby. the questionnaire underwent validity and reliability tests, yielding correlation values ranging from 0.362 to 0.922 and a cronbach’s alpha coefficient of 0.866. the variables were ordinal, with indicators falling into the ranges of 76-100% (good), 55-75% (enough), and lower than 55%.20 intervention spiritual-based stimulation intervention is the interventions providing education for the mother and father to the fetus by integrating spiritual values such as reciting prayers for the fetus, listening to the reading of the qur’an or holy verses for the fetus, listening to religious songs for the fetus, touching and stroking the fetus, giving the fetus a pat or kinesthetic, introducing dark and lightdark stimulations, and introducing hot and cold or temperatur stimulations. additionally, it involved the incorporation of spiritual practices into the daily activities of the mothers. the intervention was implemented for 12 weeks and actively engaged the mothers, fathers, and the unborn babies. the overall intervention implementation activities were carried out for 12 weeks based on research conducted by.21 which stated that the implementation of assistance to pregnant women was carried out for a minimum of eight weeks. assistance is carried out using various methods, such as gathering pregnant women in a room to be given treatment in pregnant women’s classes, discussions via whatsapp groups, and home visits. the details of the intervention are as in table 1. data analysis descriptive analysis in this study took the form of frequencies, percentages aimed at data on age, education, employment, and mean, standard deviation (sd) of gestational age. inferential analysis was carried out to determine the differences between the pre and posttest because the results of the levene test for the control group showed that the distribution of data was not normal for the fetal attachment variable, a difference test was carried out using wilcoxon. the delta value difference test between the treatment and control groups was carried out using the mann-whitney test because all data was not normally distributed. interpretation of the wilcoxon test and mann whitney test with a significance level of 5% (α=0.05) and it is said that there is a difference or there is an influence with the result of a p<0.05.22 ethical clearance this research has passed the ethical clearance test by faculty of nursing sultan agung university health research ethics committee on 19 july 2022 under no. 307/ kepk-a.1s1/fik/vii/2022 and has obtained the respondents’ consent through informed consent, thus respondents first received an explanation from researchers about the research carried out in full, an explanation carried out orally and in writing; after the patient understands the research being conducted, the researcher is given informed consent in writing, and then the respondents who agrees to be a respondent can sign the informed consent sheet, which is in accordance with the ethical principles of research, namely informed consent, anonymity, confidentiality, fidelity, and autonomy. results data regarding the characteristics of primigravida mothers in semarang city during the third phase of the study can be observed in table 2. tables 2 and 3 show that the characteristics of primigravida in both the intervention and control groups are quite similar. these characteristics include age, education, occupation, and gestational age. the majority of them fall within the early adult transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 172] [healthcare in low-resource settings 2024;12:12048] non -co mmerc ial us e o nly hood range (20-35 years), accounting for 87.9% in the intervention group and 81.8% in the control group. most respondents obtained secondary education, comprising junior high and senior high/vocational school, with 75.8% in the intervention group and 72.7% in the control group. furthermore, most primigravida were unemployed, with 87.9% in the intervention group and 75.8% in the control group. the mean gestational age for the intervention group is 26.12 weeks, while it is 26.33 weeks for the control group. table 4 reveals that fetal attachment increased in both the intervention and control groups from the pre-test to the post-test. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. details of prenatal spiritual-based stimulation intervention activities. time activity frequency duration (weeks) 1 pretest, then the activity continues with providing education to pregnant women and husbands about prenatal stimulation 1 times 100 minutes 2 assistance to pregnant women by nurses by providing further education about 1 times 100 minutes 1. spiritual aspects that underlie prenatal parenting towards readiness to become mothers; 2. spiritually based prenatal stimulation and practice and role play by each pregnant mother and her partner about prenatal stimulation. a. auditory stimulation involved engaging in conversations with the fetus, introducing the concept of god, familiarizing the fetus with both mother and father, and participating in joint prayers for 20 minutes. b. kinesthetic stimulation was performed using by tapping on the baby’s buttocks for 5 minutes, c. temperature stimulation alternated between warm and cold baths for 10 minutes. d. light-dark stimulations was administered using a flashlight for 10 minutes. 3-11 independent interventions by the mother who continue to receive assistance and monitoring 8 times 60-90 minutes 3-4 assistance to pregnant women by nurses, with peer group couples, strengthening husbands’ support in prenatal stimulation 5 times 60-90 minutes carried out at agreed times by conducting home visits. 5-7 assistance to pregnant women by nurses by sharing experiences of applying spiritual-based prenatal stimulation to pregnant every day 60-90 minutes women in groups carried out online via the whatsapp group. (21 days) 8-11 assistance to pregnant women by nurses, with overall monitoring and evaluation of the implementation of spiritual-based 4 times 60-90 minutes prenatal care for pregnant women in groups carried out at agreed times through home visits 12 posttest was performed when pregnant women were taken to the antenatal care class. 1 times 30 minutes table 2. characteristics of primigravida mothers in 2023 (n=33). characteristics intervention control levene test p f % f % age 1.000 adolescence (< 20 years) 2 6.1 3 9.1 early adulthood (20-35 years) 29 87.9 27 81.8 late adulthood (>35 years) 2 6.1 3 9.1 education 0.944 elementary 4 12.1 5 15.2 junior high school 12 36.4 11 33.3 senior high school 13 39.4 13 39.4 higher education 4 12.1 4 12.1 employment 0.061 civil servant 2 6.1 1 3.0 private sector employee 1 3.0 7 21.2 self-employed 1 3.0 0 0 unemployed 29 87.9 25 75.8 total 33 100 33 100 table 3. gestational age of primigravida in 2023 (n=66). characteristics intervention control p mean sd mean sd gestational age 26.12 2.99 26.33 2.78 0.861 [healthcare in low-resource settings 2024;12:12048] [page 173] table 4. effects of prenatal spiritual-based stimulation on maternal-fetal attachment in primigravida in 2023 (n=33). variable intervention control mann-whitney mean±sd ∆ mean p mean± sd ∆ mean p pre post pre post maternal-fetal attachment 44.09±3.09 75.58±5.13 31.49 0.000a 43.97±3.22 44.18±3.01 0.21 0.059a 0.000b notes: awilcoxon test; bmann -whitney test. non -co mmerc ial us e o nly however, the intervention group exhibited a greater increase compared to the control group. the wilcoxon test results for the intervention group displayed a p-value of 0.00, signifying a significant difference in fetal attachment before and after receiving prenatal stimulation. conversely, the control group demonstrated an average increase in fetal attachment, but the wilcoxon test yielded a pvalue higher than 0.05, indicating no significant difference. the mann whitney test produced a p-value of 0.000 (p<0.005), indicating a mean difference between the intervention and control groups. this outcome underscores that spirituality-based prenatal stimulation had a significant impact on fetal attachment in primigravida. discussion the results of the present study indicate that spirituality-based prenatal stimulation significantly influences fetal attachment in primigravida women in semarang. this spirituality-based prenatal stimulation included educational, auditory, and kinesthetic stimulations. this finding is consistent with a prior study, which emphasized the significant relationship between providing education in prenatal classes and maternal-fetal attachment.23 this research shows that prenatal stimulation, one of which consists of educational stimulation, can increase maternal-fetal attachment. the research results are in line with results in the same direction as this research, namely a study conducted in 2023, which shows the same results as couples who, after being given education or training, can encourage maternal-fetal attachment.24 a similar study discovered ini 2020 a significant increase in maternal-fetal attachment scores before and after the provision of education.25 after being stimulated by training or health education, it can increase maternal motivation and facilitate maternal health behavior, which can increase maternal fetal attachment.26 offering education to pregnant mothers through various media can enhance their mental well-being and strengthen the bond between mothers and their fetuses. providing stimulations through collaborative education can offer maximum support to pregnant women, not only from healthcare professionals but also from fellow pregnant women within the group. incorporating spiritual content into each educational material further reinforces the belief that the pregnancy process can be successfully navigated. this fosters an awareness of considering the fetus as a sacred trust that must be nurtured with love by providing the best possible care. auditory stimulation, which was also one of the stimulations in this study, was proven to increase maternal-fetal attachment. this result is in line with research in 2019, which also showed that auditory stimulation with music was able to increase maternal-fetal attachment.27 the provision of spirituality-based prenatal stimulation, such as auditory stimulation, aligns with a study which reporting that providing stimulation through communication and music can alter fetal behavior and bring them closer to their mothers.28 auditory stimulation, such as quran recitation (murotal), provides auditory stimulation received by the midbrain that prompts the midbrain to release gamma-amino butyric acid, enkephalin, and beta-endorphin, which act as electrical conduction inhibitors, have analgesic effects, and induce relaxation.29 providing stimulation through sound or communicating with the fetus helps form specific memory traces, influencing the neonate’s nervous system.30 a relaxed condition is the best state for instilling religious values, fostering feelings of love and care, including selflove and care for the fetus in the womb. the fetus will be able to perceive the positive values instilled by their parents and develop a greater love and affection towards them. kinesthetic stimulation is one of the stimulations that also plays a role in this research because it can increase maternal-fetal attachment. this result is in line with research that also shows that kinesthetic stimulation in the 2018 study using gentle tactile stimulation is able to increase maternal-fetal attachment.31 kinesthetic intervention involving rubbing and tapping has been found to enhance the bond between mothers and their fetuses, routine gentle stimulation of the fetus can shape fetal behavior or fetal movement, fetal heart rate, anthropometry, and biophysics until birth and strengthen the bond between the mother and the baby.32 similarly, a study showed that tactile stimulation can maintain psychological responses and improve social interaction. rubbing or tapping is another form of communication between the mother and the fetus. tapping on the fetus essentially invites the fetus to play, stimulating them to interact with others. when the mother engages in this kind of play, the fetus experiences a close interaction with the mother even while inside the womb.33 interventions involving temperature stimulation, where the fetus is exposed to warm and cold temperatures, have been shown to enhance the bond between the mother and the fetus. temperature stimulation can improve blood circulation, relaxation, and comfort.34 additionally, the relaxation effect of hydrotherapy does not negatively impact the fetus and, in fact, stimulates fetal movement. when applying temperature stimulation, such as warm water baths, it is recommended to use a gentle pouring method and limit the duration to a maximum of 15 minutes to ensure proper circulation. similarly, light stimulation can enhance fetal responses.35 fetuses exposed to light stimulation exhibited movement responses.36 the movements felt by the mother elicit feelings of love and affection for the fetus. the movements made by the fetus after receiving stimulation are a form of communication, conveying messages and signaling to the mother. love grows, and attachment intensifies as interactions become more intense.37 spiritual-based stimulation provided by parents during the prenatal period is a parenting pattern in which parents interact with the fetus in the womb. it aims to prepare for the psychological bond between parents and the fetus and its biological development effects. parenting activities are essentially a form of communication and interaction between the mother, father, and the fetus that enhance attachment to the fetus. in addition to strengthening the bond between mother and fetus, spirituality-based stimulation during prenatal care can introduce and stimulate early understanding in the fetus about god, instill values and morals, and teach positive behaviors. reflections on the results of this research show how important spiritual-based prenatal stimulation interventions are in increasing maternal-fetal attachment, so primigravida mothers can apply sound, kinesthetic, light, and temperature stimulation independently together with their husbands, so that maternal-fetal attachment increases and can also improve. parents interact with the fetus in the womb, then the psychological bond between parents and fetus and the impact of its biological development and introduce and stimulate an early understanding of the fetus about god, instill values, and morals, so that the mother’s psychological condition improves and the readiness to welcome the birth babies and the welfare of mothers and babies increases. this research can also have an impact on health services because in the health service sector, especially maternity nurses, obstetricians, and midwives, this research can be used as a reference for providing educational stimulation to mothers, teaching various spiritual-based stimuli ranging from sound, kinesthetic, to light stimulation, and temperature so that the mother has the ability transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 174] [healthcare in low-resource settings 2024;12:12048] non -co mmerc ial us e o nly to do it independently with her partner at home, so that stimulation for the fetus increases, and maternal-fetal health and maternal-fetal attachment increase. conclusions the attachment of the fetus in both the intervention and control groups increased; however, the attachment scores of the intervention group were higher than those of the control group. spiritualbased prenatal stimulation is effective in enhancing the attachment between mothers and fetuses in primigravida. the provision of light stimulation is recommended using a flashlight rather than a smartphone’s flash to minimize radiation exposure to the fetus. future research could explore a similar topic by evaluating fetalmaternal attachment scores after the baby’s birth. references 1. pangesti wd. adaptasi psikologis ibu hamil dalam pencapaian peran sebagai ibu di puskesmas kembaran ii kabupaten banyumas. viva med j kesehatan, kebidanan dan keperawatan 2018;10:13-21. 2. i̇ki f, bölgede c, gebelerin y, i̇fadeleri d. expression of feelings by pregnant women living in two different geographic regions and their adaptation to pregnancy: hungary and turkey cases. sarkaya med j 2018;8:582-92. 3. puspitasari n. development of indicators to measure quality of life for pregnant women (qol-pw). j prev med hyg 2023; 64:e55-66. 4. vinarti ra, tyasnurita r, utamima a, fadhilah nl, karimah a. bumilbahagia (happymothers) a preliminary-study to help mothers maintain maternal health. ieee reg 10 humanit technol conf r10-htc 2022;2022:360-4. 5. hande ah, 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2020;8:84-91. 17. nair d, sharma s, santhalakshmi v. an exploratory study to assess the factors contributing to maternal childbirth satisfaction with delivery services among postnatal mothers at selected hospital in mohali, punjab. int j nurs educ 2019;11:7. 18. bappenas. terjemahan tujuan dan target global tujuan pembangunan berkelanjutan (tpb)/sustainable development goals (sdgs). 2017. 60 p. 19. jonasson sit. use of prenatal testing, emotional attachment to the fetus and fetal health locus of control. university of saskatchewan; 2004. 1-97 p. 20. nursalam. metodologi penelitian ilmu keperawatan. 5th ed. jakarta: salemba madika; 2020. 504 p. 21. missler m, van straten a, denissen j, donker t, beijers r. effectiveness of a psycho-educational intervention for expecting parents to prevent postpartum parenting stress, depression and anxiety: a randomized controlled trial. bmc pregnancy childbirth 2020;20:1-18. 22. dahlan s. statistik untuk kedokteran dan kesehatan. edisi 6. jakarta: 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spiritual endorphine stimulation as methods to increase fetal well being on pregnant woman with early premature rupture of membranes. sci technol publ 2018;978-9:699-702. 30. movalled k, sani a, nikniaz l, ghojazadeh m. the impact of sound stimulations during pregnancy on fetal learning: a systematic review. bmc pediatr 2023;23:1-15. 31. wang z, hua j, xu y. the relationship between gentle tactile stimulation on the fetus and its temperament 3 months after birth. hindawi publ corp 2015;2015:1. 32. o’neill e, thorp j. antepartum evaluation of the fetus and fetal well being. clin obstet gynecol 2012;55:722-30. 33. juwita s, argaheni nb, alristina ad. application of tactile / transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12048] [page 175] non -co mmerc ial us e o nly kinesthetic stimulation in preterm infants. placentum 2023;11:65-74. 34. an j, lee i. the thermal effects of water immersion on health outcomes : an integrative review. int j enviromental res ang public heal 2019;16:1-21. 35. liu y, liu y, huang x, du c, peng j, huang p, et al. a comparison of maternal and neonatal outcomes between water immersion during labor and conventional labor and delivery. bmc pregnancy childbirth 2018;14:1-7. 36. thanaboonyawat i. effect of halogen light in fetal stimulation for fetal well-being assessment. j med assoc thai 2018;89: 1376-80. 37. ranjbar f, warmelink jc, mousavi r, gharacheh m. maternal-fetal attachment and anxiety in pregnant women who conceived through assisted reproductive technology: a longitudinal study. int j reprod biomed 2021;19:1075-84. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 176] [healthcare in low-resource settings 2024;12:12048] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12621 enhancing mental well-being in coronary heart disease patients: the impact of integrated spiritual care and murottal auditory therapy on reducing anxiety and depression aris citra wisuda,1,2 tukimin bin sansuwito,2 citra suraya,1 rusmarita,1 dian emiliasari1 1faculty of nursing, sekolah tinggi ilmu kesehatan bina husada, palembang, indonesia; 2faculty of nursing, lincoln university college, petaling jaya, malaysia abstract coronary heart disease, the most prevalent non-communicable disease, poses both physical and psychological challenges, including anxiety and depression. addressing these issues requires a holistic approach that integrates biological, psychological, social, and spiritual dimensions. spiritual care interventions can alleviate psychological distress and enhance patient satisfaction in nursing care. this study explored the impact of combining spiritual care with murottal auditory therapy to reduce anxiety and depression in patients with coronary heart disease. in this quasi-experimental study, 110 participants were divided into intervention and control groups, each with 55 participants selected based on specific criteria. anxiety and depression levels were assessed using the validated depression anxiety stress scale (dass). the intervention group received daily murottal therapy sessions lasting 15 to 20 minutes for three days at siti khadijah islamic hospital in palembang from march to july 2023. pre-test and post-test assessments were conducted. the results indicated that a significant proportion of patients in the intervention group experienced mild anxiety (52.7%) and reduced depression (65.5%) after murottal therapy. significant differences in anxiety and depression levels were observed between the intervention and control groups, with p-values of 0.000 for both. murottal auditory therapy, mainly using surah ar-rahman, effectively reduces anxiety and depression in patients with coronary heart disease, offering a promising complementary treatment approach. introduction global disease patterns have shifted with the increasing prevalence of non-communicable diseases, among which cardiovascular disease is a significant concern and remains the leading cause of death worldwide.2 in 2013, the world health organization reported that 17.3 million people died from cardiovascular disease globally, with projections indicating an increase to 23.3 million by 2020.3 according to the 2019 global burden of disease report, cardiovascular disease was indonesia’s fourth leading cause of mortality.4 this condition results in both physiological and psychological changes, including social isolation, anger, anxiety, stress, and depression.5 approximately 70-80% of individuals with heart disease experience anxiety.6 patients often experience changes in response to threatening and unexpected situations.7 for many, anxiety and depression arise from facing uncertainty, concerns about treatment effects, fear of disease progression and death, feelings of guilt, and spiritual doubts.8 if not managed properly, anxiety can worsen a patient’s condition, leading to additional issues such as depression, sleep disturbances, an increased risk of suicide, and a decreased quality of life for those with coronary heart disease. high levels of anxiety about the disease often indicate dissatisfaction with the healthcare services received. therefore, further treatment and support are necessary.9 correspondence: aris citra wisuda, faculty of nursing, sekolah tinggi ilmu kesehatan bina husada, 30131 palembang, south sumatera, indonesia. e-mail: ariscitrawisuda.edu@gmail.com key words: anxiety, complementary therapy, coronary heart disease, depression, murottal, spiritual care. contributions: isw, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing the original draft, and review and editing. ts contributed to conceptualization, investigation, methodology, validation, writing the original draft, and review and editing. ysd handled conceptualization, methodology, formal analysis, validation, writing the original draft, and review and editing. aia was involved in methods, visualization, and writing review and editing. mlk provided resources, conducted investigations, and participated in writing reviews and editing. all authors have read and approved the final version of the manuscript and agree to be accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research received ethical approval from the medical and health research ethics commission at the faculty of medicine, sriwijaya university, under ethical certificate 024-2023. during the research process, the researcher followed the principles of information ethics, such as obtaining informed consent, respecting human rights, and ensuring beneficence and non-maleficence. patient consent for publication: written informed consent was obtained to allow the publication of anonymized patient information in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: i thank my supervisor for their invaluable insights and contributions to this study. received: 30 april 2024. accepted: 14 july 2024. early access: 8 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12621 doi:10.4081/hls.2024.12621 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [ [healthcare in low-resource settings 2024;12:12621] non -co mmerc ial us e o nly in times of crisis, individuals with coronary heart disease may experience heightened levels of anxiety and depression, which can significantly affect their overall health and disease progression.10 research by nuraeni et al.11 supports this, indicating that patients with coronary heart disease have anxiety levels at 74.25% and depression levels at 66.75%. similarly, a study by febriana et al.12 reports that anxiety levels among these patients are very high, reaching up to 71.12%. according to lestari et al.,13 nurses play a crucial role in crises by providing optimal, holistic nursing care that emphasizes the spiritual aspect. spirituality is a critical component of comprehensive care and maintenance. a holistic approach to healthcare that addresses spiritual needs can strengthen an individual’s faith and connection with the creator, helping those dealing with illness or weakness develop greater confidence and acceptance during the healing process. music therapy serves as a form of distraction therapy, providing an alternative method for addressing psychological, psychiatric, and physical disorders. numerous studies have shown its safety and effectiveness in improving mood and reducing anxiety, depression, and other mental health issues. music is well-regarded for its ability to redirect attention and promote relaxation.14 one genre with notable therapeutic benefits is spiritual or murottal music, which involves the recitation of holy quranic verses with precise pronunciation (tajwid) and rhythmic delivery. listening to these sacred recitations, known as murottal, has been found to induce a sense of calm.15 among the frequently used verses in therapy is surah arrahman, a chapter of the quran that emphasizes allah swt’s blessings to his servants. its simple yet eloquent language, with a recurring question, repeated 30 times, contributes to its therapeutic effects. research by kismana16 supports this, indicating that repetition in surah ar-rahman can positively influence brain function due to its straightforward and consistent nature. additionally, surah ar-rahman provides valuable lessons in gratitude for allah’s blessings, acceptance of his divine will, and the understanding that healing from all ailments is within allah’s control.17 islamic spiritual care, which involves listening to holy quranic verses at a volume below 60 decibels, can influence brain waves to promote relaxation and calmness. research by asrul18 supports this, comparing the effects of listening to quranic verses with classical music. the study found that listening to quranic verses resulted in a 12.67% increase in the correlation between left and right brain alpha waves, compared to a 9.96% increase with classical music. these results suggest that quranic verses more effectively enhance alpha wave activity, which is associated with a relaxed state, compared to classical music.19 additionally, harisa et al.20 discovered that the therapeutic effects of quranic verses are amplified when accompanied by translations, outperforming the impact of listening to the verses alone. murottal hearing therapy can improve comfort levels in patients with heart disease. however, those with cardiovascular conditions often require ongoing treatment and an extended recovery period if their needs are not adequately addressed. therefore, this study aimed to evaluate the impact of murottal hearing therapy on anxiety and depression levels in hospitalized patients with cardiovascular disease. materials and methods research design this study utilized a quasi-experimental pre-post design with a control group to evaluate the impact of murottal auditory therapy on anxiety and depression levels in patients with cardiovascular disease. the design involved measuring mental health indicators before and after the intervention, allowing for comparisons between patients who received the therapy and those who did not. this approach aims to provide strong evidence of the effectiveness of murottal auditory treatment in alleviating psychological distress, such as anxiety and depression, in this patient population. study participants data were collected from march to july 2023 at siti khadijah islamic hospital in palembang, south sumatra, indonesia. the sample size of 110 patients was determined using the lameshow formula, with participants evenly divided into 55 individuals in the control group and 55 in the intervention group. patients were selected through purposive sampling based on specific criteria, including a diagnosis of coronary heart disease, awareness, practical communication skills, muslim identity, and no hearing impairments. patients with unstable hemodynamics or cognitive impairments were excluded from the study. before data collection, informed consent was obtained from all participants and their families, ensuring they were fully informed about the study’s objectives and procedures. variable, instrument, and data collection the independent variable in this study is murottal auditory therapy, while the dependent variables are levels of anxiety and depression. additionally, participant characteristics such as age, gender, education, occupation, medical diagnosis, and illness duration were recorded to understand the study population comprehensively. the participants, all cardiovascular patients receiving treatment at the hospital, were randomly assigned to either a control group or an intervention group. a pre-test was conducted before the intervention to establish baseline levels of anxiety and depression in both groups, ensuring that any observed changes could be attributed to the therapy. this design allowed for a thorough comparison of the effects of murottal auditory therapy on the participants’ psychological well-being. anxiety and depression levels were assessed using the depression anxiety stress scale (dass), a self-report tool designed to evaluate emotional states, including anxiety and depression. the dass includes 14 items for each scale, with ten items measuring somatic symptoms and four assessing anxiety-related affective symptoms. validated by previous research in indonesia, the dass has demonstrated effectiveness and reliability, with the anxiety scale achieving a receiver operating characteristic (roc) value of 0.51. participants rated their anxiety symptoms on a 4-point likert scale, ranging from “does not apply at all to me” to “very often or frequently applies to me.” for patients with coronary heart disease, the dass helps determine the severity of anxiety and depression and identifies those requiring psychological support. depression levels were assessed using the same dass instrument, which measures aspects such as hopelessness, life devaluation, self-deprecation, and lack of interest in activities. the indonesian version of the dass has a cronbach’s alpha of 0.677, reflecting moderate reliability. overall, the dass is a valuable tool for both clinical and research settings, providing a standardized and culturally appropriate method for assessing and monitoring anxiety and depression among coronary heart disease patients in indonesia. murottal hearing therapy is an islamic-based intervention designed to alleviate spiritual distress, including symptoms of anxiety and depression, in patients. this study implemented the therapy for 15-20 minutes daily over three consecutive days to address the increasing prevalence of anxiety and depression among coro article [healthcare in low-resource settings 2024;12:12621] [page 689] non -co mmerc ial us e o nly nary heart disease patients undergoing treatment. conducted at siti khadijah islamic hospital in palembang from march to july 2023, the research involved 55 participants divided into intervention and control groups. a quantitative quasi-experimental design was used to assess anxiety and depression levels in both groups before the intervention (pre-test). the intervention group received murottal hearing therapy from the first to the third day, followed by a posttest assessment on the fourth day. in contrast, the control group received standard treatment without murottal therapy and underwent a post-test evaluation on the fourth day. participants in the intervention group were provided with mp3 players and earphones to listen to surah ar-rahman recited by muzamil hasballah. the murottal recordings were played at 50 decibels to ensure listener comfort and maximize the therapy’s positive effects. the earphones allowed patients to hear the murottal audio within a frequency range of 5 hz to 22,000 hz, aiming to influence brain wave patterns and effectively reduce anxiety and depression. results demographic and clinical characteristics of participants table 1 provides a comprehensive overview of the demographic and clinical characteristics of the participants. the average age of participants was 56 years in the control group and 58 years in the intervention group. the average duration of illness was ten months for the control group and nine months for the intervention group. in both groups, most participants were male, with 67.3% in the control group and 74.5% in the intervention group. additionally, over half of the participants in both groups had low education levels, with 65.4% in the control group and 69.1% in the intervention group. a considerable proportion of respondents in both groups were unemployed, comprising 43.6% of the control group and 47.3% of the intervention group. anxiety and depression levels in control and intervention groups table 2 illustrates the anxiety and depression levels among participants. in the pre-test, severe anxiety was observed in 61.8% of the control group and 69.1% of the intervention group. after the post-test, severe anxiety persisted in most of the control group, at 54.5%. however, the intervention group experienced a significant anxiety reduction, with 52.7% of participants reporting only mild anxiety. regarding depression levels, the pre-test revealed that more than half of the participants in both groups experienced severe depression, with 52.7% in the control group and 63.6% in the intervention group. after the intervention, most participants in the control group experienced moderate depression, at 69.1%. in contrast, the intervention group showed a substantial decrease in depression levels, with 65.5% of participants reporting only mild depression after the post-test. differences in anxiety and depression between the control and intervention groups this study demonstrates a significant difference in anxiety levels between the control and intervention groups, with a p-value of 0.000 (p < 0.05). the mann-whitney test revealed that the average anxiety score was 80.76 in the control group, compared to 30.24 in the intervention group, indicating a substantial difference. similarly, there was a significant difference in depression levels between the two groups, also with a p-value of 0.000 (p < 0.05). according to the mann-whitney test results, the average post-test depression score was 77.75 in the control group, while the intervention group scored 33.25 (see table 3). article table 1. demographic and clinical characteristics of participants in each group (n=55). characteristics control group intervention group mean (sd) n (%) mean (sd) n (%) age (years) 56±8.967 58±9.211 illness duration 10±8.328 9±7.854 gender male 37 (67.3) 41 (74.5) female 18 (32.7) 14 (25.5) education high 19 (34.6) 17 (30.9) low 36 (65.4) 38 (69.1) occupation self-employed 8 (14.6) 9 (16.4) employee 11 (20.0) 2 (3.6) trader 6 (10.9) 14 (25.4) teacher 6 (10.9) 4 (7.3) unemployed 24 (43.6) 26 (47.3) table 2. frequency distribution of anxiety and depression levels of pre-test and post-test in the control and intervention groups. variable control group intervention group n (%) n (%) anxiety level pre-test moderate 21 (38.2) 17 (30.9) severe 34 (61.8) 38 (69.1) post-test normal 0 (0) 12 (21.8) mild 0 (0) 29 (52.7) moderate 25 (45.5) 14 (25.5) severe 30 (54.5) 0 (0) depression level pre-test moderate 26 (47.3) 20 (36.4) severe 29 (52.7) 35 (63.6) post-test normal 0 (0) 5 (9.0) mild 2 (3.6) 36 (65.5) moderate 38 (69.1) 14 (25.5) severe 15 (27.3) 0 (0) total 55 (100) 55(100) table 3. differences in anxiety and depression between the control and intervention groups. variable group mean post-test p-value anxiety control 80.76 0.000 intervention 30.24 depression control 77.75 0.000 intervention 33.25 [page 690] [healthcare in low-resource settings 2024;12:12621] non -co mmerc ial us e o nly discussion patients with cardiovascular conditions, such as coronary heart disease, often experience significant spiritual distress that profoundly impacts their psycho-spiritual well-being. this distress is frequently driven by intense worry and fear, particularly related to the prospect of death, and can trigger a crisis manifesting as anxiety and depression.21 the presence of anxiety and depression resulting from spiritual distress can increase the risk of complications. these emotional states can activate involuntary physiological responses, part of the body’s self-defence mechanisms. this activation can worsen existing health issues and lead to additional complications, highlighting the need to address both spiritual and emotional needs in the management of cardiovascular diseases.22 anxiety is a prevalent issue among patients with coronary heart disease (chd). this anxiety is often characterized by persistent worry and fear about the disease, along with physical symptoms such as trembling, unexplained sweating, respiratory issues, and weakness.23 research by soylu et al.24 reveals that a chd diagnosis frequently triggers intense fear of a fatal heart attack or sudden death. uncontrolled anxiety can severely affect a patient’s quality of life by disrupting sleep patterns and worsening physical symptoms such as chest pain and shortness of breath. furthermore, excessive anxiety can exacerbate the patient’s physical condition by elevating blood pressure, causing unstable blood sugar levels, and reducing stress tolerance. borji and mousavimoghadam25 also note that anxiety in heart patients often stems from a lack of understanding about the disease, which leads to increased worry and impaired coping skills. excessive and unresolved anxiety can lead to depressive responses.26 depression is a common issue among patients with chd. those suffering from depression related to their condition often feel they have lost their previous capabilities, experience sadness, lack motivation, and become pessimistic about their future. they may also feel powerless to return to their usual activities.27 this is consistent with najafi et al.,28 who observes that a diagnosis of chd can trigger feelings of sadness, hopelessness, loss of interest in daily activities, and worthlessness. depressed chd patients face a higher risk of severe health complications, including increased mortality and reduced overall quality of life. additionally, depression can decrease a patient’s motivation to adhere to treatment and make necessary lifestyle changes for managing heart disease. thus, anxiety and depression are psychological factors that indirectly contribute to a decline in health quality. when addressing patients’ psychological issues, interventions often extend beyond pharmacological treatments to include nondrug approaches that address their holistic needs.29 non-pharmacological strategies may encompass relaxation techniques, distraction methods, and other therapeutic practices designed to provide comprehensive care. these approaches aim to alleviate psychological distress by addressing both mental and emotional aspects of well-being. by integrating these methods, healthcare providers can offer a more comprehensive and effective treatment plan that supports overall patient health and improves their quality of life.30 in holistic care, nurses are crucial as primary facilitators in delivering and coordinating conventional and complementary patient therapies. they act as critical supporters throughout the recovery process, providing essential information about available treatment options and helping patients choose the approaches that best meet their needs and preferences.31 additionally, nurses create a supportive environment, manage therapy sessions, and offer emotional support during treatment. their active involvement in holistic therapy ensures that patients receive comprehensive care, which enhances the effectiveness of recovery and optimizes the overall therapeutic experience.32 spiritual care is a crucial component of holistic support, focusing on recognizing and respecting the spiritual dimensions of patients. it involves offering emotional support, helping patients find meaning and purpose, and maintaining spiritual balance while facing health challenges.33 this form of care often includes conversations about the patient’s beliefs and values, allowing them to voice their concerns and reflect on their spiritual growth.34 spiritual well-being can significantly influence how patients cope with coronary heart disease and manage anxiety and depression. thus, incorporating spiritual care into holistic treatment is essential, as it helps patients find calm and hope throughout their healing journey.35 spiritual care in islam is a critical component of islamic spiritual care interventions in nursing practice, emphasizing the vital role of spirituality in a patient’s recovery and well-being. this approach is deeply grounded in religious teachings, highlighting the individual’s relationship with allah as a source of strength and peace. practices such as worship, dhikr (remembrance of allah), prayer, and reflection are central to this approach, aiming to strengthen faith, cultivate inner peace, and offer a profound understanding of life’s purpose.36 in healthcare, islamic spiritual care extends beyond religious aspects to include moral values, ethics, and healthy social interactions, providing a comprehensive foundation for holistic patient care. by understanding and applying islamic spiritual care principles, nurse practitioners can offer more effective and integrated support, enhancing patients’ recovery experiences.37 islamic spiritual nursing practices, such as prayer and quranic recitation (dhikr), are essential for enhancing patients’ spiritual well-being. these practices help strengthen their connection with faith, provide emotional comfort, and promote inner peace, supporting emotional and spiritual recovery. incorporating these practices into nursing care addresses the holistic needs of patients, improving their sense of purpose and tranquillity during the healing process.9 this study highlights significant differences in anxiety and depression levels among participants who received murottal auditory therapy, with p-values of 0.000 for both measures, indicating vital statistical significance. similarly, other research has shown that music therapy can effectively reduce stress, anxiety, and depression in intensive care patients, emphasizing its value as a complementary treatment approach. these findings reinforce the effectiveness of integrating spiritual and therapeutic modalities into patient care to enhance emotional and psychological health. murottal refers to reciting quranic verses with precise pronunciation (tajwid) and rhythmic delivery. listening to murottal can bring a sense of tranquillity to the listener.38 ar-rahman is a frequently used surah in therapy, underscoring allah swt’s blessings to his servants. this surah is characterized by its straightforward language and elegant literary style, including a repetitive question asked 30 times. surah ar-rahman fosters gratitude for allah’s blessings and acceptance of his will, emphasizing that ultimate healing from illness lies within allah’s power.39 murottal therapy, which involves listening to qur’anic recitations with precise tajwid and soothing rhythms, significantly affects brain function, leading to reductions in anxiety and depression.40 this therapy activates the brain’s auditory system, especially the auditory cortex, and engages the parasympathetic nervous system to promote relaxation. by enhancing alpha wave activity, murottal therapy fosters a state of calm that lowers cortisol levels, article [healthcare in low-resource settings 2024;12:12621] [page 691] non -co mmerc ial us e o nly the primary stress hormone associated with anxiety and depression.41 additionally, the spiritual aspect of murottal therapy contributes to emotional well-being by instilling a sense of peace and purpose. this combined physiological and spiritual effect helps alleviate symptoms of anxiety and depression, promoting overall relaxation and a heightened sense of well-being.42 research by ruby43 indicates that islamic spiritual care therapy using murottal significantly reduces anxiety and depression levels in coronary heart disease (chd) patients, with reductions of 76.45% in anxiety and 81.5% in depression. this finding is supported by hajiri et al.,44 who reported up to an 84% decrease in depressive symptoms and an 87% reduction in anxiety among chd patients receiving murottal therapy. husna45 further corroborates these results, noting that the mean depression score in the treatment group dropped to 11.09 (±8.47) following the spiritual program, with statistical significance (p < 0.001). additionally, indrika46 found that patients undergoing cardiac catheterization who listened to murottal had significantly lower anxiety scores compared to a control group. studies by moulaei et al.47 and che wan mohd rozali et al.48 also support the effectiveness of listening to quranic verses in alleviating mental disorders such as anxiety and depression. these findings suggest that a comprehensive, personalized approach to spiritual care with murottal, enhanced by supplementary modules, improves patients’ understanding and engagement, thereby more effectively reducing anxiety and depression. overall, islamic spiritual care therapy with murottal appears to be a promising holistic approach for treating chd patients and addressing their spiritual and emotional needs. listening attentively to murottal therapy has been shown to have a beneficial impact on individuals with cardiovascular disorders, such as chd. this therapy promotes mental calmness, which helps reduce anxiety and depression in patients, ultimately influencing blood pressure, heart rate, heart rhythm, and respiratory rate. these results are consistent with the findings observed in the intervention group of this study, where murottal therapy led to significant reductions in anxiety and depression levels. the study confirms that murottal therapy is effective in alleviating anxiety and depression among patients undergoing chd treatment. given that anxiety and depression present significant challenges throughout the treatment journey for cardiovascular patients, murottal therapy is emerging as a valuable adjunct to pharmacological treatments. nurses play a vital role in mitigating patient anxiety and depression, which can accelerate recovery. however, this study has several limitations. first, the therapy is limited to patients diagnosed with coronary heart disease, which restricts its applicability to other conditions. although murottal therapy helps calm individuals experiencing psychological stress, its benefits are not fully understood due to the limited duration of treatment, leading some patients to continue experiencing anxiety and depression. second, the absence of randomization in the sampling process affects the generalizability of the findings to a broader population. future research should investigate additional factors influencing the application of murottal therapy and explore its integration with various relaxation techniques to enhance spiritual connection, increase peace of mind, and improve overall recovery outcomes. conclusions this study demonstrates a significant reduction in anxiety and depression scores among patients undergoing treatment for coronary heart disease after receiving murottal therapy. the notable differences in scores between the control and intervention groups suggest that murottal therapy can be an effective complementary therapy when integrated into spiritual care approaches to alleviate these symptoms. in addition to reducing anxiety and depression, this non-invasive and cost-effective therapy enhances overall patient care by promoting a holistic approach and fostering deeper nurse-patient relationships. regular assessment of anxiety and depression levels is essential for ensuring optimal treatment and accelerating recovery. integrating murottal therapy as a standard practice could lead to more comprehensive nurse training programs emphasizing the importance of spiritual 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erika ka, irwan am. effects of nursing spiritual needs treatment in reducing anxiety and depression in acute coronary syndrome (acs) patients. j keperawatan 2023;15:263–78. 24. soylu d, ceyhan ö, tekinsoy kartin p, soylu a. spiritual well-being and nursing care perceptions of coronary intensive care patients. j neurology 2023;26:175–82. 25. borji m, mousavimoghadam sr. the impact of spiritual care with murrotal on anxiety in family caregivers of patients with heart failure. proc inst mech eng part j j eng tribol 2019;224:122–30. 26. holthaus j. managing worry and anxiety practical tools to help you deal with life’s challenges. first. washington, dc: baker publishing group; 2020. 122 p. 27. kim y-k. anxiety disorders rethinking and understanding recent discoveries. kim y-k, editor. gyeonggido, south korea: springer nature singapore; 2022. 459 p. 28. najafi k, khoshab h, rahimi n, jahanara a. relationship between spiritual health with stress, anxiety and depression in patients with chronic diseases. int j africa nurs sci 2022;17:100463. 29. potter and perry. fundamentals of nursing: second south asia edition. third sout. sharma sk, editor. india: elsevier, relx india pvt. ltd; 2021. 1036 p. 30. de diego-cordero r, suárez-reina p, badanta b, et al. the efficacy of religious and spiritual interventions in nursing care to promote mental, physical and spiritual health: a systematic review and meta-analysis. appl nurs res 2022;67. 31. brendan mccormack jw. holistic practice in healthcare. cristopher, editor. united kingdom: wiley; 2024. 213 p. 32. keegan’s d&. holistic nursing: a handbook for practice. eight. mary, deborah, karen, william, editors. jones & bartlett learning. usa: jones & bartlett learning; 2022. 571 p. 33. linda ns, phetlhu dr, klopper hc. nurse educators’ understanding of spirituality and spiritual care in nursing: a south african perspective (part 1). int j africa nurs sci 2020;12:100187. 34. jakob b. spirituality, mental health, and social support; 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module to reduce anxiety and improve satisfaction and sleep quality. 1st ed. prananjaya ba, editor. indonesia: nem; 2021. 4–80 p. 41. ilham dn. heartbeat monitoring and stimulation with murottal al-qur’an based on internet of things (iot). first. candra ra, editor. aceh, indonesia: cv jejak (jejak publisher); 2020. 64 p. 42. darmadi s, armiyati y. murottal and classical music therapy reducing pra cardiac catheterization anxiety. south east asia nurs res 2019;1:52. 43. ruby f. impact of murottal and muscle relaxation therapy on anxiety, depression levels, and satisfaction. pakistan j humanit soc sci res 2022;01:73–84. 44. hajiri f, pujiastuti se, siswanto j. murottal therapy with acupressure on anxiety levels and satisfaction levels in patients with coronary heart disease. j keperawatan silampari 2019;2:146–59. 45. husna e. application of islamic spiritual nursing care to patients in hospitals. dunia keperawatan j keperawatan dan kesehat 2019;7:21–7. 46. indrika ea. the influence of spirituality on the quality of life of patients during hospital treatment a literature review. j keperawatan 2022;14:1011–8. 47. moulaei k, haghdoost aa, bahaadinbeigy k, dinari f. the effect of the holy quran recitation and listening on reducing anxiety, stress, depression and to improve satisfaction: a scoping review on outcomes. heal sci reports 2023;6. 48. che wan mohd rozali wna, ishak i, mat ludin af, et al. the impact of listening to, reciting, or memorizing the quran on physical and mental health of muslims: evidence from systematic review. internat j public health 2022;67. article [healthcare in low-resource settings 2024;12:12621] [page 693] non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2022; 10:10170] [page 7] the extrinsic factors affecting patient access, referral and treatment of lung cancer in selected oncology public health facilities in kwazulu-natal zondo sinenhlanhla n.,1 ginindza themba g.,2 hlongwana khumbulani w.2 1school of social work and social policy, faculty of humanities and social sciences, university of strathclyde, glasgow, united kingdom; 2discipline of public health medicine, school of nursing & public health medicine, college of health sciences, university of kwazulu-natal durban, south africa abstract patients’ insights into the factors affecting access, referral and treatment of lung cancer in public healthcare facilities, are key to the fight against this disease. on the other hand, the lack of epidemiological information on the actual burden of lung cancer, makes it difficult for public healthcare facilities to be adequately equipped to deal with foreseeable challenges in the oncology units. in order to inform patientcentred interventions and lung cancer control programmes, this study explored extrinsic factors that affect lung cancer patients throughout the cancer care continuum in kwazulu-natal. nineteen patients receiving care in the three public healthcare facilities providing oncology services in kwazulu-natal, were interviewed using an interview guide. following data saturation, thematic analysis was used to develop the themes relating to the extrinsic factors affecting the provision of cancer care. five themes emerged from the analysis, namely: geographical dynamics affecting patient access to a healthcare facility, lung cancer suspicion index in the diagnostic trail within the different levels of care, decision-making trail for the referral system, equipmentinduced delays and healthcare-patient communication. a number of lung cancer patients utilising oncology services in public healthcare facilities in kwazulu-natal, are often met with various extrinsic factors affecting their progression through different stages of cancer care continuum. therefore, the results of the extrinsic factors explored in this paper through the lung cancer patients’ lenses may be used for designing mitigation plans to reduce delays in lung cancer care in kwazulu-natal. introduction non-communicable diseases such as cancer is reported to be much higher in high-income countries,1 however it is among the top causes of death in south africa. the continuous increase of cancer morbidity and mortality in many lowincome african countries may be indicative of weak cancer programmes, low resource allocation and fragmented health care systems in the continent.2 although efforts, such as tobacco control interventions implemented in south africa, have decreased the overall mortality rates of cancer of the lung over the years, the cancer numbers recorded continue to reel.3,4 this rise in cancer morbidity and mortality further strains the public healthcare resources and efforts, which, in addition to cancer, should be deployed to other competing diseases priorities, including the communicable diseases.5 early disease detection and access to treatment are paramount in the fight against lung cancer and that these are largely reliant on public health resources deployed to the oncology units in south africa’s health facilities. achieving early disease detection and access to treatment have proven difficult in a country with disparities to access to specialized care.2 after twenty-five years of democracy and concerted efforts to improve healthcare for all, access to sufficiently resourced primary healthcare remains a topic of intense debate,6,7 yet early disease detection and screening at a primary care level could aid mitigate the growing cancer mortality rates.2 however, diagnostic delay in primary care level is one of the most notable barriers to cancer care, and this may be related to the lack of resources, low suspicion index for lung cancer and delays in referral trails.2,8-10 there is a lack of empirical studies on lung cancer care in kwazulu-natal in particular and south africa in general. the gap in literature makes it difficult to determine the burden of disease, which dims the light of public healthcare efforts. with only three health facilities providing specialized diagnostic and treatment services to a large pool of various cancer cases in kwazulu-natal province, these facilities may not be adequately prepared.11,12 the aim of this study was to explore extrinsic factors affecting patient access, referral and treatment of lung cancer in selected public health facilities’ oncology units in kwazulu-natal, from the perspectives of lung cancer patients receiving care in these facilities. materials and methods study design a qualitative research method was used to explore the lung cancer patients’ perspectives of the extrinsic factors affecting cancer care in three hospitals offering oncology health care services in kwazulu-natal. a constructivist approach was used to explore the themes, as this approach gave an allowance for the participants to narrate the factors affecting their health and disease through their experiences of living with and receiving care for lung cancer. this approach has proven useful in the understanding of political, social, economic and cultural factors meshed with health and disease.13 an adapted ecological model was used to explore the different levels of influence relating to access, referral and treat healthcare in low-resource settings 2022; volume 10:10170 correspondence: sinenhlanhla n. zondo, school of social work and social policy, faculty of humanities and social sciences, university of strathclyde, glasgow, united kingdom. e-mail: sinenhlanhla.zondo@strath.ac.uk key words: lung cancer; access; referral; treatment; kwazulu-natal. acknowledgements: we thank kwazulunatal department of health and the brave lung cancer patients for allowing us to implement the study. we also thank the bristolmyers squib foundation (bmsf) “secure the future” for funding this project. lastly, we are highly appreciative to the university of kwazulu-natal and multinational lung cancer control programme for hosting and supporting the project. contributions: sz conceptualisation, data collection and analysis and manuscript writing. kh, tg assisted with conceptualisation, manuscript writing and revision of all drafts. conflict of interest: the authors declare no potential conflict of interests. funding: the work was supported by bristolmyers squib foundation, secure the future, grant no. 10111. received for publication: 6 october 2021. revision received: 6 december 2021. accepted for publication: 14 december 2021. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10170 doi:10.4081/hls.2022.10170 ment within and between the public healthcare facilities (figure 1). the extrinsic factors explored were at the macro level of the framework, which looks at the friends and family support and public healthcare factors influencing their care.14 the study was conducted from the three healthcare facilities offering oncology services in kwazulu-natal. hospital a offers specialized services including an oncology department with radiotherapy and chemotherapy, whereas hospital b accepts patients strictly on referral basis and attends to approximately 140 new patients and 500 follow-up patients each month. on the other hand, hospital c receives nationwide referrals and has highly specialized services, including pathology laboratory, radiation oncology and chemotherapy. these three hospitals were selected for the study on the basis of being the only public healthcare facilities in kwazulu-natal offering oncological services. furthermore, the hospitals vary in services according to the south african department of health’s regulation of categories of hospitals.15 the study population consisted of inpatients and outpatients diagnosed with and/or treated for lung cancer from the three facilities. the sampling strategy followed was purposive heterogeneous technique, aimed at recruiting participant from different age groups, genders, races, socio-economic and geographical backgrounds, as well as disease progression, in order to obtain various perspectives on the research question. recruitment for data collection was done from october 2018 to january 2019, where potential participants were identified prior and after completing their consultations with medical specialists. some participants opted to have a spouse or relative present with them throughout the interview, which assisted in the cases where participants had forgotten dates or important details pertinent to the study questions. however, questions seeking participant’s perspectives were only answered by the patient. given the nature of the study, the presence of a spouse or relative was not considered to have any serious negative effect on the quality of data generated. all interviews were conducted in isizulu and english, using an interview guide with open ended questions. all interviews conducted in isizulu were translated by a professional transcriber into english after verbatim transcription of audio-files by the transcriber had been concluded. this study was approved by the ukzn biomedical research ethics committee (be 534/18) and kwazulu-natal department of health (kz_201801_013) on 14 september 2018 and 03 october 2018, respectively. potential participants were informed about the purpose of the study prior to signing informed consent forms and conducting an in-depth interview. the lead researcher, who is a qualitative data analysis expert with 3 years of experience, coded and analysed the data using nvivo software. co-authors reviewed the analysis and raised queries, where necessary, which helped the lead researcher consistently reflect on all the factors that affected her analysis. data analysis was performed using thematic analysis following the process described by braun and clarke.16 during the thematic analysis process the transcripts were read in detail, initial codes were generated then collated into potential themes. once initial themes were generated, they were reviewed and refined to ensure that they addressed the study objectives. lastly themes were developed and discussed by all the authors to reach consensus. results the ages for the 19 participants ranged from 43 to 80 years, reflecting a fairly diverse mix of genders, ethnicity and residential areas (table 1). identified themes five themes emerged from the analysis. these themes were: the dynamics affecting patient access to healthcare facility, lung cancer suspicion index in the diagnostic trail within the different levels of care, healthcare provider-patient communication, decision-making trail for the referral system and equipment-related delays. themes were further located within the continuum of cancer care, including access to oncology care, referral system for lung cancer patients and treatment services for lung cancer. article figure 1. multilevel influences on access, referral and treatment of lung cancer in oncology public health facilities. extracted and adapted from taplin et al., 2012.14 [page 8] [healthcare in low-resource settings 2022; 10:10170] access to oncology care dynamics affecting patient access to healthcare facility results of this study revealed that access to healthcare facilities is still a challenge for many patients living with cancer. there was a convergence of views in lung cancer patients’ identification of the distance and means to the nearest oncology treatment facility as the main barriers to receiving appropriate care. in addition to the lack of appropriate care at the primary care facility, poor means to health facilities further affect the health of the patients. “when i leave home, i use the cars from the community, then i go to st. william’s [hospital]. i then sleep over at st. williams, and then from there i travel by an ambulance that is coming here [greenwood hospital] … today we will leave in the afternoon, then i will sleep over at the hospital again and then i will take a taxi that is going back home” 79-year-old female “i travel by foot, hmm one and a half, one and a half… maybe two hours…you see, just like now it’s very difficult. i must get a car that will take me, and then sometimes i will send someone to collect the pills for me. i go sometimes when i have to go to check my weight or for bp check-up, i try to get transport to go there but when i get back i am going to be sick the whole week. it’s really difficult to walk long distances” 55year-old male “then i was complaining to the doctor, i was coughing blood, he didn’t want to attend to me. he took an x-ray and he didn’t want me to see what’s going on. so, they sent me back to deansdale [hospital]. when i went to deansdale they took the blood tests and they found that there’s a cancer right there in my lungs. so, when i came here [oncology clinic] it was too late man. it couldn’t be stopped, it already went to my lungs.” 55-year-old male referral system for lung cancer patients lung cancer suspicion index in the diagnostic trail within the different levels of care given the overlapping symptoms between tb and lung cancer, healthcare workers were prone to suspecting tb, negating the possibility of lung cancer, which is sometimes viewed by participants as guesswork. participants perceived the lung cancer suspicion index by healthcare providers to be low. the lack of extensive diagnostic tools in many facilities exacerbates the problem. “they [healthcare providers] were saying tb, maybe it’s a growth, maybe it’s cancer, maybe…. they were guessing” 55-yearold male “no symptoms whatsoever, just the sore throat uhmm and then i started this incredible pain in my chest here, just shooting. but it wouldn’t last long. it would just last for a while and then go away. but when it [the pain] was there, it was so intense that it really, you know, it forced me to go to the doctor. he diagnosed me with bornholm disease. but uhm, he said that he wanted to take x-rays and bloods, just in case.” 52year-old female “i was coughing and then i went for an x-ray in the rural area near home, here in ethekwini. when i did the x-ray, they said it’s tb. i took the tb treatment then while i was still taking it they said i must come back after a month and then i went back. when i went back for an x-ray they said no… they gave me a letter and told me to go to…. they said i must go to marshall[hospital]. so, at marshall i did an x-ray there and they said i have cancer” 80-year-old female decision-making trail for the referral system participants expressed that obtaining referral note to the necessary facility was a factor and when a referral note was eventually received, the wait time before seeing a specialist lasted for a few months. this delay may have been as a result of the large number of new and returning cancer patients in these three facilities. “what happened is that i was made to wait, and i noticed that it [growth] was continuing. it’s the doctor that speed up the process because i didn’t get much help from the clinics.” 71-year-old female “i was coughing on and off in 2016. in three months’, time i was referred from ghandi to here [hospital with oncology services].” 48-year-old male “i once went to check for cancer at the clinic and when i got back from the checkup, they [healthcare providers] said that my cancer was not yet critical, so they were prioritising those who are critical to receive treatment. so, each time i would go they would tell me it wasn’t bad until they finally told me when they did.” 80-year-old female treatment services for lung cancer equipment-induced delays lack of functioning diagnostic and treatment equipment was flagged as an issue that immensely contributed to treatment delays and accumulation of waiting list. this ranged from x-ray machinery to radiotherapy machinery. “these machines are always broken and whatever. and i needed, because of the aggressive nature of my cancer i needed to get the results sooner rather than later. and i managed, through the grace of god and through a previous oncologist that was here to get in, because there is a very long waiting list to get in here” 52-year-old female “i started coming here [greenwood hospital] last year because they said they don’t have machines at woodlands [hospital], so i would get the machines here.” 74year-old male “i started going for check-ups in 2005 until 2010, then they only discovered in 2011 that i have cancer. they transferred me to king george hospital and i stayed about two months or about one month and three weeks. they said they suspect that i have lung cancer but now their machines are not sufficient, so they sent me to king’s. i stayed for two months. they would check me while i was admitted, then on the third month they said that they found that i have lung cancer, my lung was now damaged so they asked for my permission to remove the lung…” 55-year-old male healthcare provider-patient communication communication between patients and their healthcare providers (hcps) may be a challenge on the extent to which the patient article [healthcare in low-resource settings 2022; 10:10170] [page 9] table 1. the demographic characteristics of the study participants (n=19). characteristics n (%) age mean 64.37 range (sd) 11.68 gender female 8 (42.1) male 11 (57.89) ethnicity black 10 (52.63) indian 6 (31.58) coloured 1 (5.26) white 2 (10.53) residential area rural 7 (36.84) township 9 (47.37) suburban 3 (15.79) hospital a 5 (26.32) b 7 (36.84) c 7 (36.84) understands how the disease manifests and adherence to treatment methods thereof. communication barriers may result from language, different cultural backgrounds and at times the patient’s lack of knowledge of technical concepts. patients were in agreement in that, even after being diagnosed and undergone treatments, they still did not have detailed knowledge about their illness. this may be indicative of poor healthcare provider-patient communication regarding the patient health issues. “this year once again now, i was telling this doctor and he is just ignoring me. he referred me back to deansdale [hospital]. and in deansdale the results said i must come back here because it’s cancer, they can’t do nothing. they don’t work with cancer.” 55-year-old male “yes. they said they found that it’s cancer, but they didn’t explain what type of cancer it was” 43-year-old male “look, let’s put it this way, you are pretty much in the dark when it comes to this. they say you have got to go for chemo, but nobody can tell you the side effects because everybody is affected differently so, you are pretty much in the dark. it’s just you go for chemo and take it from there” 73-year-old female one participant stated that he was booked for a biopsy but was suddenly told he was getting his whole left lung removed just before he was given the consent form to sign. “…and then they said to me, no they will just take a small piece of my lung out. so, you know you must sign a form of consent before you go into the theatre. the doctor came to me and he said “mr *armstrong [not his real name] listen here, this cancer has spread right through your lung, so i’m gonna take the whole lung out”. he said ‘mr armstrong you don’t like to sign this here but, in a few months, you come back to me and this lung, this cancer will spread right through. that’s why i’m telling you this now. that’s why i’m giving you this consent to sign’. so, i thought to myself, bring the form, let me sign.” 52year-old male the above illustration presents a summary of the extrinsic factors, categorised into five thematic areas (figure 2), affecting access, referral and treatment identified by lung cancer patients in this study. discussion access to healthcare facilities is the most crucial stage in the patient’s care continuum, because it directs the route the cancer care continuum ought to take.17 substantial geographic differences and their effect on access to healthcare facilities are especially evident in the results of this study. the proximity to regional hospitals appeared to particularly help patients in receiving a relatively quicker diagnosis, as opposed to their counterparts who had to travel long distances to the nearest healthcare facility. in a country, such as south africa, where socioeconomic disparities are often swayed by one’s ethnicity, healthcare facilities are still placed in areas predominately populated with white, coloured and indian people,6,7,18 thereby inadvertently prejudicing the majority of black south africans, who were placed by the previous government regime in peripheral areas.6 an annual general household survey conducted in south africa found that vulnerable sub-groups, such as rural and/or black south africans had restricted access to healthcare in south africa, despite the implementation of various health reforms since the abolishment of apartheid laws.6 while rural areas may have well-functioning clinics, these establishments are not article figure 2. extrinsic factors affecting lung cancer care in kwazulu-natal. [page 10] [healthcare in low-resource settings 2022; 10:10170] [healthcare in low-resource settings 2022; 10:10170] [page 11] adequately equipped to work with complex illnesses, using intricate diagnostic resources, such as that of the lung cancer.17 access to effective cancer care in lmics, such as south africa, is a complex issue compounded by various factors, often resulting in the phenomena of the inversecare law.7 the ‘inverse-care law’ is a term defined as the inverse relationship between the availability of effective medical care and the population needs.7 in a country with extreme poverty margins, such as those seen in rural and township areas, health is affected by access to basic requirements for life. these basic requirements include adequate nutrition, access to vaccinations, availability of jobs and reasonable housing conditions.19 similarly, rural patients in this study stated that they were able to access local clinics for other general illnesses, but they were unable to access proper diagnostic services for possible cancer screening until referral to a regional hospital, which was further away from their home. in addition to the unavailability of adequate care in their local clinics, transport expenses made access to healthcare largely reliant on one’s geographical residential area. however, it is crucial to note that some patients from rural areas were transferred quickly to the nearest treating hospitals, but had to travel through hospital patient transportation, which operated on routine basis to accommodate other patients. in one instance, a patient recounted that she travelled from her home to the nearest regional hospital, was admitted for the night and departed the next morning for her to make her appointment at the treating hospital. this process was repeated for initial consultation, chemotherapy and or regular check-ups. for patients with an illness with low survival rates, swift interventions are paramount and travelling long distances is not suitable.7 congruent with the findings of this study, literature has shown that the incorrect diagnosis is one of the leading causes of the referral delays to cancer care in africa.10,20 these results are further supported by masamba’s study, which revealed that misdiagnosis of lung cancer as tuberculosis remains a major concern for low-middleincome countries (lmics).20 this is attributable to the fact that lung cancer is not a common form of cancer seen in the primary healthcare facilities and often has no clear signs and symptoms recognisable by the patient and at times, not even by the healthcare workers.10 lung cancer also shares a few symptoms common with tuberculosis (tb), such as chest pains and coughing blood sputum.20 with the high incidence rate of tb in south africa, it is relatively easy to misclassify malignancies, such as lung cancer and lymphoma for tb, especially when appropriate diagnostic measures are not utilised.10 this delay in correct diagnosis is detrimental for the patient’s overall health outcomes, as it exposes the patient to unnecessary tb drug resistance. incorrect diagnosis may also be as a result of the lack of cancer literacy amongst primary care healthcare providers or lack of suitable diagnostic tools.10,21 consequently, healthcare providers could unknowingly misinterpret lung cancer symptoms and commence with inappropriate treatment without a biopsy, which would have provided more accurate results.20 patients stated that their initial contact with their primary care provider (pcp) did not provide them with a correct diagnosis, thereby resulting in further delay in implementing referral and treatment protocols. a systematic review on the role of primary care in detection and follow-up of cancer highlighted the importance of reducing diagnostic delays amongst higher index suspicion cases seen by primary care providers.22 the idea of improving diagnostic tools and encouraging a fast-track referral system might be a possible answer to a growing public health concern. however, this initiative would require additional training and education for the pcps and constant prompts and reminders in the facilities to encourage screening for various cancers when applicable.22 although this may not completely combat the issue of misdiagnosis in primary care facilities, it might reduce the burden of screening done in regional and tertiary hospitals. furthermore, improving diagnostic tools is likely to provide a fast-track for more symptomatic cases, which allows for an overall more resourceful referral system. while receiving a referral did not seem to be the main obstacle for most participants, the duration between the correct diagnosis and a consultation in the oncology facility was prolonged. some patients stated that they had to speak to specific specialists in the oncology department for quicker referral and biopsy results. this delay in referral consultations may have profound implications on the treatment. similarly, a scoping review of health systems delays in lung cancer stated that delays in obtaining access to definitive diagnostic procedures and results is one of the main factors contributing to delays in lung cancer care.23 this was seen in a case of a lung cancer patient diagnosed in may 2017 covered by the south african newspaper ‘business live’ in 2018.12 the patient was given a follow-up date that required him to wait for 15 months for a scan in a local hospital, but succumbed to his illness after 12 months.12 this unfortunate case may characterise the many deaths that are due to delays in health systems in south africa. equipment-induced delays are at the crux of cancer care barriers in lmics in africa24 and south africa is no exception.12 one of the recurring themes in this study pertained to the delays relating to lack or breakage of equipment for diagnostic and treatment purposes in at least one of the three participating facilities. south african regional hospitals are expected, but not obligated to provide oncology services as a part of the specialisation departments, leaving kwazulu-natal with just two tertiary hospitals, which have mandatory oncology services.15 this imbalance between resources and cancer patients poses a threat to the number of individuals requiring radiotherapy and chemotherapy daily in these hospitals.12 procurement of the stateof-the-art equipment is often not feasible in african countries, where budget allocations are skewed towards communicable disease control and corruption exacerbates the scarcity of resources spent on each patient.25 participants shared experiences of having to be referred to various regional hospitals for confirmation of diagnosis and treatment, which prolonged the delay, ultimately leading to advancement of disease, thereby limiting the treatment options available.26 the lack of radiotherapy equipment is a factor to be considered in the battle against cancer in africa, because, as many as 50% of cancer cases would benefit from radiotherapy treatment.12 the longstanding good physicianpatient communication model has proven to yield better health outcomes in different settings.24,27 however, poor physician-patient communication was one of the factors that affected the lung cancer treatment adherence in south africa. there is a shift from passive recipients of advice to more wellinformed consumers who actively engage with decisions about their health.27 this is an idealistic picture of hcp-patient communication; however, this is hardly achieved in many lmic settings. patients expressed that they were often in the dark about the stage of their cancer, cancer type and treatments being provided. the example of a patient admitted for a lung biopsy and being informed of a full lung removal just before the surgery, does not exhibit good hcp-patient communication, as the options available to the patient need to be fully explained. a systematic review exploring patients’ experiences in communicating with primary care physicians (pcps) identified ineffective communication between healthcare providers and patients as the cause of stress, helplessness and dominance article [page 12] [healthcare in low-resource settings 2022; 10:10170] of biomedical interventions, which negatively affected adherence to treatment.28,29 the concept of a patient navigator, should be considered. patient navigators are able to simplify specialist information when communicating with the patient. this is also a person who may follow-on the progress of the patient. conclusions extrinsic factors affecting lung cancer patient access, referral and treatment in kwazulu-natal was due to difficulty in accessing adequate healthcare facilities, low lung cancer suspicion index in the diagnostic trail within the different levels of care, weak healthcare provider-patient communication, referral delays and equipmentinduced delay. the results of this study are consistent with the findings of a study conducted in the limpopo province, which highlighted communication and equipmentinduced problems with follow-up care, as important factors influencing cancer treatment in the province.30 these findings may be useful in highlighting pertinent oncology care issues in south africa and aid in the improvement of facilities to adequately deal with lung cancer cases in kwazulu-natal. additionally, this study highlighted the importance of timely diagnosis, which is eminent in successful lung cancer treatment. references 1. nojilana b, bradshaw d, pillay-van wyk v, et al. persistent burden from non-communicable diseases in south africa needs strong action. south afr med j 2016;106:436-7. 2. cazap e, magrath i, kingham tp, elzawawy a. structural barriers to diagnosis and treatment of cancer in lowand middle-income countries: the urgent need for scaling up. j clin oncol 2016;34:14-9. 3. who. new global cancer data: globocan 2018. who, 2018. available from: https://www.uicc.org/new-global-cancer-data-globocan-2018# 4. winkler v, mangolo nj, becher h. lung cancer in south africa: a forecast to 2025 based on smoking prevalence data. bmj open 2015;5:e006993. 5. mayosi bm, flisher aj, lalloo ug, sitas f, tollman sm, bradshaw d. the burden of non-communicable diseases in south africa. lancet 2009;374:93447. 6. burger r, christian c. access to health care in post-apartheid south africa: availability, affordability, acceptability. health econ policy law 2018:1-13. 7. harris b, goudge j, ataguba je, mcintyre d, nxumalo n, jikwana s, et al. inequities in access to health care in south africa. j public health policy 2011;32:s102-23. 8. moodley j, walter fm, scott se, mwaka am. towards timely diagnosis of symptomatic breast and cervical cancer in south africa. s afr med j 2018;108:803-804. 9. espina c, mckenzie f, dos-santossilva i. delayed presentation and diagnosis of breast cancer in african women: a systematic review. ann epidemiol 2017;27:659-71.e7. 10. hannan a. misdiagnosis of cancer as tuberculosis in lowto middle-income countries: a tip of the iceberg! j glob oncol 2016;2:244-5. 11. morhason-bello io, odedina f, rebbeck tr, et al. challenges and opportunities in cancer control in africa: a perspective from the african organisation for research and training in cancer. lancet oncol 2013;14:14251. 12. mnyanda l. care for cancer patients lags behind in sa's public health facilities. business live. 27 june 2018. 13. baum f. researching public health: behind the qualitative-quantitative methodological debate. social sci med 1995;40:459-68. 14. taplin sh, anhang price r, edwards hm, et al. introduction: understanding and influencing multilevel factors across the cancer care continuum. j national cancer institute monographs 2012;2012:2-10. 15. health do. government notices: regulations relating to categories of hospitals. in: health, editor. 2012. 16. braun v, clarke v. using thematic analysis in psychology. qual res psychol 2006;3:77-101. 17. venter m, venter c, botha k. cancer treatment in south africa: a narrative literature review. j psychol afr 2012;22:459-66. 18. coovadia h, jewkes r, barron p, et al. the health and health system of south africa: historical roots of current public health challenges. lancet 2009;374:817-34. 19. mayosi bm, benatar sr. health and health care in south africa — 20 years after mandela. new engl j med 2014;371:1344-53. 20. masamba lpl, jere y, brown ers, gorman dr. tuberculosis diagnosis delaying treatment of cancer: experience from a new oncology unit in blantyre, malawi. j global oncol 2016;2:26-9. 21. mansell g, shapley m, jordan jl, jordan k. interventions to reduce primary care delay in cancer referral: a systematic review. br j gen pract 2011;61:e821-e35. 22. emery jd, shaw k, williams b, et al. the role of primary care in early detection and follow-up of cancer. nature rev clinical oncol 2013;11:38. 23. malalasekera a, nahm s, blinman pl, et al. how long is too long? a scoping review of health system delays in lung cancer. eur resp rev 2018;27:180045. 24. nonzee nj, ragas dm, ha luu t, et al. delays in cancer care among lowincome minorities despite access. j women's health 2015;24:506-14. 25. mostert s, njuguna f, olbara g, et al. corruption in health-care systems and its effect on cancer care in africa. lancet oncol 2015;16:e394-e404. 26. o'rourke n, edwards r. lung cancer treatment waiting times and tumour growth. clinical oncology 2000;12:141-4. 27. diefenbach m, turner g, carpenter km, et al. cancer and patient-physician communication. j health comm 2009;14:57-65. 28. rocque r, leanza y. a systematic review of patients' experiences in communicating with primary care physicians: intercultural encounters and a balance between vulnerability and integrity. plos one 2015;10:e0139577e. 29. frankel rm. relationship-centered care and the patient-physician relationship. j general internal med 2004;19:1163-5. 30. ramathuba d, jacqueline r, ndou n. patients’ perspective of cancer treatment and care in vhembe district of limpopo province. j nurs care 2014;3:2167-1168.1000186. article hrev_master healthcare in low-resource settings 2024; volume 12:11817 the relationship between mental workload and nurse stress levels in hospitals zahid fikri,1 adelia bellarifanda,1 sunardi sunardi,1 muhammad rosyidul ‘ibad,1 khikmatul mu’jizah2 1nursing department, universitas muhammadiyah malang, malang; 2nursing department, rajekwesi college of health sciences, bojonegoro, indonesia abstract high mental workload implies significant mental resources and can lead to increased cognitive stress and fatigue. nurses have the responsibility of managing a wide range of nursing care tasks, awhich frequently involve addressing anxiety, handling patient complaints, and managing patient defense mechanisms, all of which can lead to increased stress levels. this study aimed to identify the relationship between mental workload and the stress level of nurses in the hospital malang city. the research utilized a cross-sectional study design. the sampling technique employed was total sampling, involving 96 inpatient nurses at the hospital. data collection involved the use of two questionnaires: the national aeronautics and space administration task load index (nasa-tlx) and the perceived stress scale (pss-10). data analysis in this study was conducted using pearson correlation. the results indicated a positive relationship between mental workload and nurses’ stress levels, supported by a significant p-value of 0.002 and a correlation coefficient of 0.312. a high mental workload can impact the level of job-related stress experienced by nurses. effective stress management skills can help individuals mitigate this impact. introduction job stress is a serious problem faced by nurses in carrying out their professional duties.1,2 high levels of stress in nurses’ jobs can negatively impact their well-being as well as the quality of care provided to patients.3–5 several studies have been conducted to understand the impact and factors associated with the work stress of nurses.6–8 nursing workload is all activities or activities carried out by nurses during their duties in a nursing service unit. workload includes both physical and mental workload.9 mental workload is the difference between the workload and the maximum capacity of a person’s mental load.10,11 nurses must be responsible for physical, administrative, and comprehensive nursing care tasks such as dealing with anxiety, complaints, and patient defense mechanisms resulting in stress levels.12,13 the level of mental stress among nurses indicates that they often operate in highly demanding work environments. several factors can influence their workload and self-esteem. nurses who share living spaces, have fewer years of work experience, possess younger professional qualifications, earn lower incomes, hold non-management positions, exhibit lower psychological capital, and adopt negative coping styles are more likely to experience low workload and low self-esteem. conversely, higher psychological capital and positive coping styles tend to be associated with medium and high workloads and high self-esteem.14 the issue of burnout is prevalent in europe, with health and social service workers (nurses) experiencing 43% of cases, teachers experiencing 32%, and the rest distributed among administrative and management professionals, as well as those in the legal and policy sectors.15 an imbalance in mental workload, where certain tasks or cognitive demands are disproportionately higher than others, can result in various negative consequences, including stress and burnout, reduced performance, decreased job satisfaction, physicorrespondence: zahid fikri, nursing department, universitas muhammadiyah malang, malang, indonesia. e-mail: zahid_fikri@umm.ac.id key words: mental workload; nurse; stress level. contributions: zf, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ab, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ss resources, investigation, and writing –review and editing; ss formal analysis, validation, writing – review and editing; mri, resources, supervision, and writing – review and editing; km, resources, investigation, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of medicine, universitas muhammadiyah malang, based on ethical certificate e.5.a/216/kepk-umm/xi/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to our research team, who have worked hard in this research, hospital malang city, which has provided facilities and all health workers who helped this research and all patient who became research respondents. received: 15 september 2023. accepted: 17 november 2023. early access: 14 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11817 doi:10.4081/hls.2023.11817 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11817] [page 53] non -co mmerc ial us e o nly cal health problems, interpersonal issues, diminished creativity and innovation, and increased turnover.16 nurses regularly experience a variety of work-related stressors, including long hours, time constraints, meeting patient needs, irregular schedules, and a lack of professional support.17–20 these demanding job conditions can profoundly affect the mental health and overall quality of life of healthcare professionals.21–23 previous research has shown that the constant stress these professionals experience can have a negative impact on their psychological wellbeing.24,25 poor mental health among healthcare providers can compromise their professional effectiveness and significantly impact the quality of care they offer to patients, ultimately negatively influencing patient health.17,24,26 therefore, nursing leaders and managers are increasingly interested in the health status of nurses. the negative impact that will arise from the increased workload is that the nurses’ emotions will arise which are not controlled and are not what the patient expects.27 if the stress experienced by nurses is too great, it will have an impact on performance which begins to decline, because it can hinder nurse performance.28 in addition, nurses will lose the ability to control it or be unable to make decisions in their work and their behavior becomes erratic. the most extreme impact that may occur to nurses and the services provided is performance becomes zero, nurses experience distraction, become sick, and are no longer strong enough to work, become hopeless, leave or refuse to work.28 hospital and care administrators should identify specific workload and teamwork issues and provide solutions to reduce the psychological burden on caregivers.29 this study aimed to determine the relationship between mental workload and stress levels experienced by nurses, by analyzing workload and work stress, it will be able to improve the quality and quantity of health services. in addition, it can increase effectiveness in the provision of nursing care. materials and methods study design the design of this study was correlation study with a cross sectional study approach. the research was conducted on december 15 to december 29, 2022. sample and settings the population of this study were inpatient nurses at hospital malang city. the research sample was all inpatient nurses at hospital malang city with a total of 96 respondents using a total sampling technique. the inclusion criteria for respondents were as follows: the nurse currently works at hospital malang city; the nurse has a minimum education level of a diploma (diii) in nursing; the nurse has at least 1 year or more of work experience in hospital nursing; and the nurse falls within the age range of 21-60 years. variables and instruments the independent variable is mental workload as measured by the national aeronautics and space administration task load index (nasa-tlx) questionnaire. there are 6 main indicators, namely mental demand (md), physical demand (pd), temporal demand (td), performance (p), frustration level (fr).30 this minimum and maximum value is 0-100 with the categories mild (029), moderate (30-49), severe (50-79), very severe (80-100).31 the dependent variable of this study is the stress level measured by the pss 10 (perceived stress scale) questionnaire. there are 10 questions with mild category values (1-14), moderate (15-26), and severe (> 26).32 the instrument in this study used a questionnaire with the perceived stress scale 10 (pss 10) method. pss 10 is the only empirically established general stress assessment index. for each question, must choose from the following alternatives: 0 = never, 1 = almost never, 2 = sometimes, 3 = quite often, 4 = very often. then, the scores are added for each item to get a total score. the total score is represented as a stress score. individual scores on pss 10 can range from 0 to 40, which are grouped into 3 groups. the independent variable is mental workload as measured by the national aeronautics and space administration task load index (nasa-tlx) questionnaire. the dependent variable of this study is the stress level measured by the pss 10 (perceived stress scale) questionnaire. data collection primary data was collected using a prepared questionnaire. before the questionnaires were distributed to be filled in by respondents, the researcher explained the procedures for filling out the questionnaires to the nurses. this is so that when filling out the questionnaire nothing is missed and no one experiences misunderstandings. secondary data was obtained from recording and reporting from hospital management. the data is in the form of: the number of inpatient room nurses, nurse absences, and the number of inpatient room patients. data collection was carried out offline by distributing questionnaires. data were analyzed using spss software (statistical package for social science) version 25. data analysis used the pearson correlation test. data were analyzed using the pearson correlation test with a significance level <0.05. data analysis univariate analysis in this study was mental workload and stress level. the bivariate test uses the pearson correlation test to determine the level or closeness of the relationship between two variables on an interval or ratio scale under normal distribution conditions with significant value < 0.05. ethical clearance the research has received ethical approval from the health research ethics commission, faculty of medicine, university of muhammadiyah malang, based on ethical certificate e.5.a/216/kepk-umm/xi/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results data collection in this research was carried out by distributing questionnaires directly. the data presented in the questionnaire consists of the respondent’s personal data and questions related to the mental workload and stress experienced by the respondent. a description of the characteristics of respondents in table 1 based on age was obtained by 53 respondents or 55.2% who were aged 26-35 years. the description of the characteristics of respondents based on gender was obtained by 77 respondents or 80.2 percent who were female. a description of the characteristics of respondents based on the type of room obtained by 51 respondents or 53.1% working in different types of ward rooms from the pediatric ward, surgical ward, and internal medicine ward. the descrip transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 54] [healthcare in low-resource settings 2024;12:11817] non -co mmerc ial us e o nly tion of the characteristics of the respondents based on the length of working hours was obtained by 63 respondents or 65.6% who worked for 7 hours. description of the characteristics of respondents based on the level of patient dependence obtained 62 respondents or 64.6% of patients have a partial level of patient dependence. description of the characteristics of respondents based on years of service obtained 41 respondents or 42.7% have worked for 1-5 years. description of the characteristics of respondents based on the number of patients handled in 1 day obtained 67 respondents or 69.8% treated > 15 patients in a day. based on table 2, nurses with an average score of mental needs 182.5, physical needs 155.9, time needs 151.6, performance 163.1, effort level 168.0, frustration level 97.8. it can be concluded that inpatient nurses have greater mental needs compared to other indicators. the description of mental workload from 96 respondents obtained 3 people or 3.1% had light mental workload, 22 people or 22.9% had moderate mental workload, 58 people or 60.4% had heavy mental workload, and 13 people or 13.5% have a very heavy mental workload. based on the results of the study, it was found that the average value for negative statements was 8.56 and the average value for positive statements was 9.35, similar to the results of the study, namely that inpatient nurses experienced moderate work stress with the results of 72 respondents or 75 %. the description of work stress from 96 respondents obtained 22 people or 22.9% had light work stress, 72 people or 75.0% had moderate work stress, and 2 people or 2.1% had heavy work stress (table 3). pearson correlation test results between mental workload and work stress obtained a correlation coefficient of 0.312 with a significance value of 0.002. these results show a significance value of less than 0.05 (sig <0.05) so that it is stated that there is a significant positive correlation between mental workload and work stress, meaning that the heavier the mental workload of nurses will have a significant effect on the heavier the work stress of nurses, and conversely, the lighter the mental workload of the nurse will have a significant effect on the lighter the nurse’s work stress. the strength of the correlation was measured using the correlation coefficient obtained at 0.312, where these results indicate that the strength of the correlation between mental workload and work stress is at a low level (table 4). discussion the age characteristics of nurses who experience very heavy mental workload, it is dominated by nurses who are 26-35 years old, as many as 8 respondents. this is closely related to the maturity or maturity level of a person.33 the older a person is, the more mature he will be, the maturity of his soul and more capable of carrying out his duties and responsibilities.34 as you get older, your ability to make decisions, think rationally, be wiser, be able to control your emotions, be more tolerant, and be open to the views or opinions of others will increase so that your stress resistance will increase.35 individuals who have longer work experience tend to be more resistant to the pressures experienced in work, than individuals with shorter working tenure because they have less experience. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. data on respondent characteristics. characteristics n % ages <25 years old 35 36.5 26-35 years old 53 55.2 36-45 years old 5 5.2 >45 years old 3 3.1 sex female 77 80.2 male 19 19.8 room surgical 4 4.2 medical 7 7.3 pediatric 8 8.3 surgical, medical 4 4.2 medical, pediatric 2 2.1 surgical, medical, pediatric 20 20.8 others 51 53.1 work durations <7 hours 4 4.2 7 hours 63 65.6 >7 hours 29 30.2 patient dependency level minimal 25 26.0 partial 62 64.6 total care 9 9.4 working period <1 years 16 16.7 1-5 years 41 42.7 5-10 years 25 26.0 >10 years 14 14.6 number of patients in 1 day 5-10 patients 3 3.1 10-15 patients 26 27.1 >15 patients 67 69.8 total 96 100 table 2. description of mental workload. statistics km kf kw p tu tf (mental needs) (physical needs) (time needs) (performance) (effort level) (frustration level) n 96 96 96 96 96 96 mean 182.5 155.9 151.6 163.1 168.0 97.8 median 180.0 150.0 150.0 150.0 150.0 40.0 st. deviation 99.2 109.5 83.4 119.5 114.6 114.2 minimum 0 0 0 0 0 0 maximum 500 450 400 450 450 400 [healthcare in low-resource settings 2024;12:11817] [page 55] non -co mmerc ial us e o nly tenure of work is related to the experience of a worker in dealing with problems at work.36 nurses with a tenure of <10 years usually have more work problems than nurses with a tenure of >10 years. another factor affecting mental workload is the patient-to-nurse ratio, namely the large number of patients that must be handled by nurses. when the number of nurses and the number of patients to be treated is not balanced, it will cause something called mental workload. the results of the research show that inpatient nurses at hospital malang city mostly manage >15 patients per day per individual. based on the results of the study, it was found that inpatient nurses experienced moderate work stress. job stress is a form of a person’s response, both physically and mentally, to a change in his environment that is felt to be disturbing and causes him to be threatened.37 the main factors that cause job stress are intrinsic, work, demands from outside the organization/work, limited time to do work, frustration, changes in job types, and individual characteristics such as personality, skills, values and needs, years of service, age, and education.38 humans are instinctively born as individuals who always try to adapt to the changes that occur. similarly, with high levels of stress, the more diverse ways of coping with stress are developing. efforts to overcome stress are theoretically termed stress management.39 stress management is a series of programs to control and regulate stress which aims to identify the causes of stress and know techniques for managing stress so that people are better at handling stress in life. one of the factors that health workers have in stress resilience is self-motivation, the high level of workload felt by the workforce requires them to adapt to the circumstances that occur, encouraging the workforce to adapt to overcome the stress they experience due to demands.40 in line with the results of the study, the adaptation of a good nurse will minimize the incidence of heavy work stress, even though in the research results, inpatient nurses at hospital malang city have a heavy mental workload, inpatient nurses at hospital malang city can manage to stress well so that the level of stress experienced by nurses still at medium level. the results of the correlation test showed a significance value of p=0.002 (sig < 0.05) so it was stated that there was a significant positive correlation between mental workload and work stress, meaning that the heavier the mental workload of nurses would have a significant effect on the heavier the work stress of nurses, and vice versa the lighter the mental workload of the nurse will have a significant effect on the lighter the work stress of the nurse. the strength of the correlation was measured using the correlation coefficient obtained at 0.312, where these results indicate that the strength of the correlation between mental workload and work stress is at a low level. this level indicates that stress can occur, one of which is influenced by the way individuals respond to pressure obtained at work.41 individuals who can control external pressure well can avoid stress. mental workload is not the only thing that can affect work stress, another thing in the form of individual differences is associated with an individual’s ability to handle stress because there are individuals who can handle stress well, while others feel overwhelmed due to stress. individual difference factors consist of perception, work experience, social support, and personality.42 this is similar to the results of a study that showed that most of the inpatient nurses at hospital malang city experienced a heavy mental workload, but most only had moderate levels of work stress. inpatient nurses at hospital malang city are dominated by nurses who have worked for 1-5 years and nurses aged 2635 years, this can help nurses handle stress well so that the level of work stress that appears is only at a moderate level. this study has several limitations, in this study, researchers were unable to examine directly respondents because the head of the nursing department at aisyyah islamic hospital gave access only to entrust the questionnaire sheets to each head of room. this research was carried out only in 1 installation, namely the inpatient installation, it was not carried out in other installations such as the emergency unit or intensive care unit. moreover, the researcher also did not examine further other factors related to the respondent’s mental workload, for example the distance between the place of residence and the work location and other work performed by nurses outside the hospital, causing limitations in discussing the results of the study. conclusions in conclusion, this study highlights the significant impact of mental workload on the stress levels of nurses working in a demanding hospital environment. the positive relationship observed underscores the importance of recognizing and addressing mental workload as a crucial factor in understanding and managing work-related stress among nurses. this study emphasize the need for healthcare institutions to prioritize strategies and interven transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 56] [healthcare in low-resource settings 2024;12:11817] table 4. pearson correlation test results. mental workload stress levels mental workload pearson correlation 1 .312** sig. (2-tailed) .002 n 96 96 stress levels pearson correlation .312** 1 sig. (2-tailed) .002 n 96 96 table 3. description of stress levels. favorable unfavorable n 96 96 mean 8.56 9.35 median 9.00 9.00 st. deviation 4.384 2.726 minimum 0 4 maximum 19 16 non -co mmerc ial us e o nly tions that reduce mental workload among nurses. providing tools, resources, and training to help nurses effectively manage their workload can contribute to a less stressful work environment, ultimately enhancing the well-being of nurses and the quality of patient care. references 1. kusumawati pm, dewi igam. peran stres kerja memediasi pengaruh beban kerja terhadap burnout perawat rumah sakit daerah mangusada badung. udayana university; 2021. 2. sandianto s, tualeka ar, indriani d. the effect of workload on the job stress of nurses in outpatient care unit of public hospital surabaya, indonesia. indian j public heal res dev 2018;9:80-4. 3. zare s, esmaeili r, kazemi r, naseri s, panahi d. occupational stress assessment of health care workers (hcws) facing covid-19 patients in kerman province hospitals in iran. heliyon 2021;7(5). 4. paskarini i, dwiyanti e, syaiful da, syanindita d. burnout among nurses: examining psychosocial work environment causes. j public health res. 2023;12:22799036221147812. 5. permarupan py, al mamun a, hayat n, et al. nursing management challenges: effect of quality of work life on depersonalization. int j healthc manag 2021;14:1040-9. 6. sari ml, ruliati lp, upa eep, berek nc. analisis faktor yang berhubungan dengan stres kerja perawat di rumah sakit jiwa naimata kupang tahun 2019. timorese j public heal 2020;1:99-104. 7. rohita t, nursalam n, hadi m, et al. relationship quality of nursing work life and burnout among nurses: a systematic review. gac med caracas 2022;130:s1205-14. 8. lee hf, hsu hc, efendi f, et al. burnout, resilience, and empowerment among covid-19 survivor nurses in indonesia. plos one 2023;18:e0291073. 9. bazazan a, dianat i, bahrampour s, et al. association of musculoskeletal disorders and workload with work schedule and job satisfaction among emergency nurses. int emerg nurs 2019;44:8-13. 10. antonius rino vanchapo arv, serly sani mahoklory ssm, ni made merlin nmm. the correlation between workload and occupational stress of nurses in the emergency department of regional public hospital rsud prof. dr. wz johannes kupang. j ners kebidanan indones (indonesian j nurs midwifery) 2019;7:18-23. 11. ghawadra sf, lim abdullah k, choo wy, et al. the effect of mindfulness-based training on stress, anxiety, depression and job satisfaction among ward nurses: a randomized control trial. j nurs manag 2020;28:1088-97. 12. aprilia td, somantri i, mirwanti r. nurses’ mental workload in critical care rooms and emergency department. j nurs care 2019;2(3). 13. rahman ma, ford d, sousa g, hedley l, greenstock l, cross wm, et al. mental health at the covid-19 frontline: an assessment of distress, fear, and coping among staff and attendees at screening clinics of rural/regional settings of victoria, australia. j rural 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hospitalemployed nurses. clin nurse spec 2012;26:177-82. 21. stetz mc, thomas ml, russo mb, et al. stress, mental health, and cognition: a brief review of relationships and countermeasures. aviat space environ med 2007;78:b252-60. 22. chiang ym, chang y. stress, depression, and intention to leave among nurses in different medical units: implications for healthcare management/nursing practice. health policy (new york) 2012;108:149-57. 23. tukatman t, sulistiawati s, purwaningsih p, nursalam n. analysis of nurse’s occupational health in managing patients in benyamin guluh hospital kolaka regency. j ners 2015;10:343-7. 24. welsh d. predictors of depressive symptoms in female medical-surgical hospital nurses. issues ment health nurs 2009;30:320-6. 25. gao yq, pan bc, sun w, et al. anxiety symptoms among chinese nurses and the associated factors: a cross sectional study. bmc psychiatry 2012;12:1-9. 26. tan ess, chin safx, sathapan msp, et al. mental health and the covid-19 pandemic: observational evidence from malaysia. int j environ res public health 2023;20:4046. 27. girsang e, chiuman l. beban kerja mental perawat dengan metode rating scale mental effort (rsme). wind heal j kesehat 2022;419-32. 28. maharani r, budianto a. pengaruh beban kerja terhadap stres kerja dan kinerja perawat rawat inap dalam. j manag rev 2019;3:327-32. 29. saquib n, zaghloul ms, saquib j, et al. association of cumulative job dissatisfaction with depression, anxiety and stress among expatriate nurses in saudi arabia. j nurs manag 2019;27:740-8. 30. galy e, paxion j, berthelon c. measuring mental workload with the nasa-tlx needs to examine each dimension rather than relying on the global score: an example with driving. ergonomics 2018;61:517-27. 31. akbar rd, sunardi. analisa beban kerja menggunakan nasatask load index di pusat pengembangan sumber daya manusia ( ppsdm ) migas cepu. juminten j manaj ind dan teknol 2020;01:151-62. 32. reis rs, hino aa, añez cr. perceived stress scale. j heal psychol 2010;15:107-14. 33. sönmez b, oğuz z, kutlu l, yıldırım a. determination of nurses’ mental workloads using subjective methods. j clin nurs 2017;26:514-23. 34. pamungkas ra, ruga fbp, kusumapradja r. impact of physical workload and mental workload on nurse performance: a path analysis. int j nurs heal serv 2022; 5:219-25. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11817] [page 57] non -co mmerc ial us e o nly 35. siahaan j. analisis pengaruh beban kerja mental dan stress kerja terhadap loyalitas pekerja pada oppo service center indonesia. sist j ilm nas bid ilmu tek 2020;8:28-35. 36. cho h, sagherian k, scott ld, steege lm. occupational fatigue, workload and nursing teamwork in hospital nurses. j adv nurs 2022;78:2313-26. 37. putra rs, rahmadhani tn, hidayat s. factors related to the risk of occupational stress among nurses in the emergency room at sosodoro djatikoesoemo bojonegoro hospital faktor terkait risiko stres kerja pada perawat instalasi gawat darurat di rumah sakit sosodoro djatikoesoemo bojonegoro. indones j occup saf heal 2021;10:299-308. 38. manabung ar, suoth lf, warouw f. hubungan antara masa kerja dan beban kerja dengan stres kerja pada tenaga kerja di pt. pertamina tbbm bitung. kesmas 2019;7(5). 39. purwaningsih cii, darma gs. menelisik stres kerja tenaga kesehatan dimasa pandemi covid-19 di rumah sakit. j manaj bisnis 2021;18:361-81. 40. özkan ş, uydacı m. determining nurse workforce requirement based on workload in the public hospitals. j heal nurs manag 2020;3:339-51. 41. riklikienė o, didenko o, čiutienė r, daunorienė a, čiarnienė r. balancing nurses’ workload: a case study with nurse anaesthetists and intensive care nurses. econ sociol 2020;11-25. 42. tamara ta, wulandari rd. perbedaan individu sebagai faktor penyebab stres kerja pada tenaga kesehatan akibat pandemi covid-19: narrative literature review. j ilmu kesehat masy 2021;17:22-32. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 58] [healthcare in low-resource settings 2024;12:11817] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12376 multidisciplinary nursing practice in a low-resource setting in southeast brazil bruno henrique souza izidório,1 kátia eliane santos avelar,1 flávia dos santos lugão de souza,2 patricia maria dusek,1 agnaldo josé lopes,1,3 1local development post-graduation program, augusto motta university center (unisuam), rio de janeiro; 2faculty of the future, manhuaçu, brazil; 3rehabilitation sciences post-graduation program, augusto motta university center (unisuam), rio de janeiro, brazil abstract the various specializations available to nurses represent an investment geared toward providing more qualified patient care. however, little is known about the attitudes of specialized nurses toward multidisciplinarity. the purpose of this study was to investigate nurses’ perceptions of multidisciplinarity in the field of specialist nurses, as well as to determine how specialization is associated with improved patient care and nurses’ age in a low-resource setting in southeast brazil. this cross-sectional study included 70 nurses aged ≥18 years with at least one nursing specialty working at the regional health superintendence of manhuaçu, minas gerais, brazil. the study participants responded to questions about specialization and its importance in the field of health care. the majority of nurse specialists (84.3%) were between the ages of 20 and 40, and 31.4 percent worked in family health. eighty percent of nurse specialists agreed that nursing specialization was important. more than 75% agreed that specialization promotes higher quality care and that multidisciplinarity is critical for improving patient care. seventy percent of participants distrusted online health information. there is a relationship between the importance of having a specialty and better patient care (τb=0.293, p=0.002), and between being a specialist nurse and age (τb=-0.272, p=0.004). nurses have embraced the concept of multidisciplinarity as a way to improve healthcare. however, they were concerned about the qualifications for nursing specialties. introduction based on tools and principles, knowledge is understood as the act of knowing, having an idea, or getting a sense of something through information to increase the effectiveness and value of services.1 in addition, knowledge is the driving force of today’s world, being a critical point for creating value for institutions, including those in the healthcare field.2 continuing education in nursing offers nursing professionals the opportunity to become trained and licensed in a variety of specialties, where each specialty increases their abilities to provide improved patient care.3 the improvement of prior knowledge and the development of new knowledge are essential for professional training in a low-resource setting and, consequently, contribute to the continuous improvement of service quality.4 this training is aimed at promoting and maintaining health, preventing diseases, and encouraging adaptability through physical, mental, and social aspects of life.3 the various post-degree specialization programs available for nurses are an investment in their professional identities and better patient care.5,6 in 2020, the world health organization (who) highlightcorrespondence: agnaldo josé lopes, local development postgraduation program, augusto motta university center rua dona isabel, 94, bonsucesso, 21032-060, rio de janeiro, brazil. tel.: +552125762020 e-mail: agnaldolopes.uerj@gmail.com key words: motivation, nurse-patient relations, nursing, professional training, specialization contributions: bhsi, conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing – original draft, writing – review & editing; kesa, pmd, fsls, formal analysis, writing – original draft, writing – review and editing; ajl conceptualization, funding acquisition, investigation, supervision, visualization, writing – original draft, writing – review and editing. funding: the conselho nacional de desenvolvimento científico e tecnólogico [cnpq; grant numbers #301967/2022-9 and #401633/2023-3], brazil, the fundação carlos chagas filho de amparo à pesquisa do estado do rio de janeiro [faperj; grant number #e26/200.929/2022], brazil, and the coordenação de aperfeiçoamento de pessoal de nível superior [capes, financecode 001, 88881.708719/2022-01, and 88887.708718/2022-00], brazil. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the study was approved by the research ethics committee of the centro universitário augusto motta under the number caae-50714121.2.0000.5235, and all participants signed the consent form. the study followed the recommendations for research in humans as per the declaration of helsinki. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to express their gratitude to the respondents of this study for their valuable support and to the conselho nacional de desenvolvimento científico e tecnólogico, the fundação carlos chagas filho de amparo à pesquisa do estado do rio de janeiro, and the coordenação de aperfeiçoamento de pessoal de nível superior for providing funding for this research. received: 10 january 2024. accepted: 14 march 2024. early access: 28 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12376 doi:10.4081/hls.2024.12376 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 326] [healthcare in low-resource settings 2024;12:12376] non -co mmerc ial us e o nly ed the need for greater amplification and recognition of all nurses’ actions to better meet patient care needs.7 international healthcare delivery continues to face several problems, including population growth that is not accompanied by increases in health care and a shortage of financial resources in developing countries.8 the intrinsic factors affecting this correlation, in most cases, are workload, training, and internships, which are modifiable factors that elucidate the profile of the professional for the exercise of the function.9 as part of a multidisciplinary team (mdt), nurses propose their productive capacity as ideal, enabling them to act on a management model.10,11 in this way, nurses seek to guarantee their labor rights and job satisfaction, based on production and quality of care (qoc). through more appropriate resource allocation, the mdt approach has increasingly been seen as one of the most valuable working models for the possibility of allocating resources more appropriately and contributing to better outcomes. a shift to the practice of mdts in nursing care occurred in response to skill mix changes in both primary care and critical care settings.12–15 however, there is a need for greater involvement of nurses in all fields as members of mdts, as this will directly affect qoc and patient safety. in recent years, research using diverse methodological approaches has led to significant progress in healthcare research.13– 15 teamwork must involve people with diverse skills and knowledge to facilitate the achievement of the team’s and institution’s goals. in the context of nursing, both multidisciplinary and interprofessional work should ultimately aim to refine nurse education standards and improve patient safety.16–18 importantly, the who emphasizes that mdts are of paramount importance in health care reform that calls for comprehensive and cost-effective care.19 understanding and emphasizing the importance of mdts in the public and private sectors will contribute to more effective use of knowledge activities in teamwork, which will result in higher qoc.1,4 based on the idea of mdt, there is a growing demand among nurses for specialized training and certification because of the need to obtain skills for qualified development of patient care.20 these skills can provide confidence in the execution of nurses’ tasks in practice and contribute to their competitiveness in the job market. in the search for a better job, nurses are motivated to add specialties to their curriculum vitae to increase their potential salaries and to be eligible for a greater number of positions.20 it should be noted that nurses, through the indices and curricular guidelines, feel the need for continuing education focused on specialization so they can acquire the knowledge and skills to meet the needs of various areas of patient care, and thus be able to act within the scope of the public health system in an ethical, reflective, and critical way.9 a study with 19 nurses in the united kingdom showed some difficulties in implementing teamwork, including varying degrees of competence to act as a team member and divergent individual perceptions about teamwork.21 thus, the evaluation of nurses’ perceptions about mdt is important to understand how they look at teamwork since nurses are the ones who provide most of the patient care.11 more specifically, the perceptions of specialist nurses can contribute greatly to understanding the process of multidisciplinary team evolution, considering that they have greater knowledge and the possibility of implementing that knowledge.1,2 thus, the present study aimed to explore nurses’ perceptions of multidisciplinarity in the field of specialist nurses and to evaluate how specialization is associated with better patient care and nurses’ age in a low-resource setting in southeast brazil. materials and methods study design and participants in the period between november 2021 and march 2022, a cross-sectional study using questionnaires was carried out to assess the perceptions of specialized nurses. nurses aged ≥18 years of both sexes who had at least one specialization in nursing and worked at the regional health superintendence of manhuaçu located in zona da mata mineira, minas gerais, brazil, were included. the zona da mata mineira is a geographic region that covers an area of approximately 35.7 thousand km² and a population of more than 2 million inhabitants. those who did not return the questionnaire (n=11) and provided incomplete survey responses (n=4) were excluded. variable, instrument, and data collection a questionnaire containing sociodemographic information and nurses’ areas of activity was used. in addition, the participants answered 10 questions focused on specializations, mdts, and their importance in the field of health. the questions were constructed based on the research objectives. we used a five-point likert scale containing the following options: i) extremely important, very important, important, slightly important, not necessary; ii) very unlikely, unlikely, neutral, likely, very likely; or iii) strongly agree, agree, neutral, disagree, strongly disagree.22 before submission, we contacted the regional health superintendence of manhuaçu to ask for potential participants’ email addresses. an online questionnaire (google forms) was sent as a link in an initial email, which contained an invitation to participate in the research. professionals could choose to participate in the research or decline after reading the consent form, which guaranteed anonymity. if they accepted, the online survey was available to them. this method was chosen as being inexpensive, timesaving, and achievable without much effort.23 data analysis the results were tabulated via excel, and data analysis was performed through a preliminary analysis of the participants’ profiles and, secondarily, the creation of associations between the answers given by them. the inferential analysis was performed using kendall’s tau-b (τb) correlation coefficient to analyze the association between nurses’ responses to multidisciplinarity. this coefficient is a nonparametric dependence measure used in crosstabulation to measure the association between two ordinal variables; moreover, kendall’s τb has several advantages over pearson and spearman’s r, including maintaining adequate control of type i errors and providing a clear interpretation.24 the values of τb vary between -1 and 1, and the closer to -1 or 1, the stronger the association between the two variables. the significance determination criterion adopted was a p<0.05. sas 6.11 software (sas institute, inc., cary, nc, usa) was used for statistical data analysis. ethical clearance the study was approved by the research ethics committee of the centro universitário augusto motta under the number caae50714121.2.0000.5235, and all participants signed the consent form. the study followed the recommendations for research in humans as per the declaration of helsinki. article [healthcare in low-resource settings 2024;12:12376] [page 327] non -co mmerc ial us e o nly results seventy specialty nurses were enrolled in the study, and most were aged between 20-40 years (n=39, 84.3%), women (n=42, 60%) and white (n=33, 47.2%). most participants were single (n=37, 52.9%) and had no children (n=36, 51.4%). most specialty nurses worked in a hospital unit (n=35, 50%) and the field of family health (n=22, 31.4%). the general characteristics of the participants are shown in table 1, while the distribution of the participants regarding the area of nursing practice is shown in figure 1. regarding the importance of having specialization in nursing, 80% of the participants (n = 56) answered that it was extremely or very important. when nurses were asked if they were opinion formers for the population, more than half of them (n=36, 51.4%) responded “very likely” and, at the other extreme, less than 10% of them (n=6) responded “very unlikely.” regarding the statement that nurses should meet certain qualifications to provide patients with a higher qoc, more than 75% of the participants (n=53) responded that they strongly agreed with this statement. when the participants were asked whether multidisciplinarity in nursing is essential to the treatment and continued care of the patient, more than 75% of the participants (n=53) also responded that they strongly agreed with this statement. regarding the prompt about the unreliability of health information on the internet, 70% of the participants (n=49) answered that they agreed or strongly agreed. regarding the statement that unqualified nurses are self-indulgent and cause distrust among patients, 50% (n=35) said they were neutral or disagreed, and 50% (n=35) agreed or completely agreed. regarding the statement that there is a considerable difference between specialized nurses and nonspecialized nurses, more than half of the participants (n=37, 52.8%) disagreed or completely disagreed. regarding the statement that specialized nurses can provide better patient care because they are more qualified, more than 70% of the participants (n=51) answered that they agreed or strongly agreed. regarding the statement that nonspecialized nurses cannot meet the necessary demands required at work, almost 80% (n=55) responded that they disagreed or completely disagreed. regarding the statement that the work team needs a nurse capable of exercising leadership and that he or she must have specialization for this performance, 60% of the participants (n=42) answered that they disagreed or completely disagreed. the distribution of participants’ assessments of specialization and multidisciplinarity in nursing is shown in table 2. table 3 shows a significant association between the importance of having specialization in nursing and the fact that specialized nurses can provide better patient care because they are more qualified using kendall’s τb (τb=0.293, p=0.002); this implies that having specialization in nursing facilitates better patient care according to the respondents. table 4 shows a significant association between the considerable difference between specialist nurses vs. non-specialist nurses and the age range of respondents using kendall’s τb (τb=-0.272, p=0.004); this implies that younger respondents tend to agree that there are considerable differences between specialist nurses and nonspecialist nurses, while older respondents tend to disagree that there are considerable differences between specialist nurses and nonspecialist nurses. discussion the main findings of the present study were that among specialized nurses, there was a high prevalence of young nurses who were female, single, without children, and working in the area of family health. eighty percent of them believe in the importance of specialization in nursing, while more than half strongly believe it provides support for opinion formation among the population. more than 75% of specialized nurses say that they can provide higher qoc and that mdts are essential for improvement in patient care. seventy percent of specialized nurses believe that health information on the internet is not very reliable. however, most of this group of nurses disagreed that there is a considerable difference between specialized and nonspecialized nurses and that specialization is essential for the exercise of leadership. there is a relationship between the importance of specialization and better patient care and between valuing the fact of being a specialized nurse and age group. article figure 1. distribution of participants according to the area of nursing practice. table 1. general characteristics of the participants (n=70). variable number (%) age group 20-30 years 28 (40) 31-40 years 31 (44.3) 41-50 years 10 (14.3) 51-60 years 1 (1.4) sex male 28 (40) female 42 (60) race/ethnicity white 33 (47.2) brown 22 (31.4) black 15 (21.4) marital status single 37 (52.9) married 33 (47.1) number of children none 36 (51.4) one 25 (35.7) two 9 (12.9) field of activity hospital unit 35 (50) family health strategy 15 (21.4) basic health unit 11 (15.7) emergency service 4 (5.7) ambulance station 3 (4.3) other 2 (2.9) [page 328] [healthcare in low-resource settings 2024;12:12376] non -co mmerc ial us e o nly article table 2. distribution of participants' assessments of specialization and multidisciplinarity in nursing. variable number (%) having a specialization in nursing extremely important 28 (40) very important 28 (40) important 12 (17.1) little important 2 (2.9) not necessary 0 (0) nurses are opinion formers for the population very unlikely 6 (8.6) unlikely 10 (14.3) neutral 7 (10) likely 11 (15.7) very likely 36 (51.4) nurses should meet certain qualifications to provide patients with a higher quality of care strongly agree 53 (75.7) agree 17 (24.3) neutral 0 (0) disagree 0 (0) strongly disagree 0 (0) the multidisciplinarity in nursing is essential to the treatment and continued care of the patient strongly agree 53 (75.7) agree 17 (24.3) neutral 0 (0) disagree 0 (0) strongly disagree 0 (0) the unreliability of health information on the internet strongly agree 20 (28.6) agree 29 (41.4) neutral 7 (10) disagree 10 (14.3) strongly disagree 4 (5.7) unqualified nurses are self-indulgent and cause distrust among patients strongly disagree 0 (0) disagree 25 (35.7) neutral 10 (14.3) agree 23 (32.9) strongly agree 12 (17.1) there is a considerable difference between specialized nurses and nonspecialized nurses strongly disagree 15 (21.4) disagree 22 (31.4) neutral 9 (12.9) agree 21 (30) strongly agree 3 (4.3) specialized nurses can provide better patient care because they are more qualified strongly agree 21 (30) agree 30 (42.9) neutral 5 (7.1) disagree 14 (20) strongly disagree 0 (0) nonspecialized nurses cannot meet the necessary demands required at work strongly disagree 28 (40) disagree 27 (38.6) neutral 8 (11.4) agree 7 (10) strongly agree 0 (0) the work team needs a nurse capable of exercising leadership and he or she must have specialization for this performance strongly disagree 15 (21.4) disagree 27 (38.6) neutral 11 (15.7) agree 15 (21.4) strongly agree 2 (2.9) [healthcare in low-resource settings 2024;12:12376] [page 329] non -co mmerc ial us e o nly in our study, there was a higher prevalence of nurses in the 20-40 age group, which indicates that younger nurses are increasingly seeking to specialize. we also observed a predominance of females in a ratio of 6:4. in this sense, it is important to highlight the phenomenon of “feminization”, which is understood as a situation composed of the relative increase in females in a given area of work, occurring mainly in health-oriented professions.25 evaluating strategies to improve quality of life (qol) at the end of life in an mdt, zadeh et al.26 also showed a predominance of young nurses in their sample. according to yanoullas,25 this phenomenon is partly explained by the transformation of the idea of work, thus adhering to the principle of qualified labor focused on social prestige that currently tends to remodel the work system. our findings also showed that almost a third of the participants were in the area of family health. according to corrêa et al.,27 primary care focused on care opens up a range of possibilities for nurses based on knowledge about the work and the population. in a way, the health–disease approach, within the scope of nurses’ knowledge, offers ways to improve patient care, especially through the family health strategy that continuously improves ethical practices for health care. in line with our findings, a spanish study showed that among specialized nurses, 50.2% worked in primary care, 24.9% in hospitals, and 22.7% in mental health.28 in relation to chronic and complex care, wilkes et al.29 showed that primary care nurses in multidisciplinary teams can achieve a more effective interdisciplinary approach. by becoming specialists in their area of expertise, nurses demonstrate qoc (as they have deeper theoretical knowledge) and modify the conditions of the territory, bringing local and sustainable development with their professional evolution.30 in our study, most participants believed in the importance of specialization in nursing and that it provides support for forming the population’s opinion. in this sense, there is a need to modify and improve situations aimed at building an integrated, complex, polysemic, multifaceted, and innovative vision.31 along the same lines, two-thirds of our participants stated that specialized nurses can provide higher qoc and, therefore, improve nurse-patient relations.32 notably, having an mdt has a positive effect on job satisfaction, team efficiency, and care delivery. in addition, nurse leaders can drive aspects of highly functional teams by improving team orientation, trust, and supportive behaviors.11 the vast majority of respondents in our study believe that mdts are essential for improving the continuum of qoc. from the analyses, one can have a better idea of the importance of the specialty, especially when it is focused on mdt, modeling the nurses’ profile so that its consistency goes beyond the old ideal of being just another profession. in this sense, there is a growing demand for the multidisciplinarity of professional nurses who, through qualification, increase their value as mdt members.31 the multidisciplinary evolution of nursing through specialties also enhances patient care practices.33 evaluating 84 patients diagnosed with terminal cancer, liu et al.34 recently showed that, compared to routine nursing, an mdt associated with palliative care reduced patients’ psychiatric disorders and improved their qol. along the same lines, another recent study showed that the mdt model with nursing leadership for transplant recipients reduced complications, reduced hospital stays, and saved costs.35 thus, promoting, emphasizing, and continuing professional training qualifies the work of specialist nurses and enables the development of more humanized care for the patient.30,36 establishing a teamwork training (tt) program is a crucial approach, although the fundamentals for tt are well known and its need is obvious in the nursing environment. tt is a critical part of any comprehensive security plan as it improves teamwork and communication to achieve the best possible results.37 despite all the appreciation that the participants pointed out about specialization, most of them disagreed that there is a considerable difference between the specialized nurse and the nonspecialized nurse and that specialization is essential for the exercise of leadership. patient care in its entirety must seek harmony between the biological-psychological-social dimensions, the transfer of knowledge and teamwork, and constant health surveillance.38 taken together, these factors may explain, at least in part, our article table 3. association between the importance of having specialization and the fact that specialized nurses can provide better patient care. variable specialized nurses can provide better patient care because they are more qualified p strongly agree agree neutral disagree number (%) number (%) number (%) number (%) having specialization in nursing extremely important 12 (57.1) 13 (43.3) 1 (20) 2 (14.3) 0.002 very important 7 (33.3) 11 (36.7) 4 (80) 6 (42.9) important 2 (9.5) 4 (13.3) 0 (0) 6 (42.9) little important 0 (0) 2 (6.7) 0 (0) 0 (0) table 4. association between specialist nurses vs. non-specialist nurses and the age range of respondents. variable age group p 20-30 years 31-40 years 41-50 years 51-60 years number (%) number (%) number (%) number (%) there is a considerable difference between specialist nurses vs non-specialist nurses strongly disagree 5 (17.9) 8 (25.8) 2 (20) 0 (0) 0.004 disagree 4 (14.3) 11 (35.5) 7 (70) 0 (0) neutral 4 (14.3) 4 (12.9) 0 (0) 1 (100) agree 12 (42.9) 8 (25.8) 1 (10) 0 (0) strongly agree 3 (10.7) 0 (0) 0 (0) 0 (0) [page 330] [healthcare in low-resource settings 2024;12:12376] non -co mmerc ial us e o nly results. notably, teamwork protocols can help define the importance of specialization and interventions in the professional network.15 when the associations were evaluated, we observed that nurses understand the importance of a multidisciplinary specialization and, through this, perform better work, based on the idea that the chosen area improves their performance. with such an association, it is necessary to understand the constant need for professional improvement, which allows nurses to perform their work with more dexterity and safety.39 it is worth mentioning that many specialists find it difficult to exercise their profession accordingly due to the lack of job descriptions and identification of competencies during the recruitment and promotion processes. therefore, it is essential to create a catalog of specific positions for each of the specialties to meet nurses’ expectations and enhance progress in qoc and patient safety. we experience a more technological world, where professionals seek to qualify themselves every day, in the job market. we observed an association between the need for specialization and younger age groups. young nurses already carry the burden of being in a competitive job market, and they seek to improve their marketability through specialization in nursing. thus, the younger the nurse, the more he or she understands the need to specialize and that a specialist nurse, through the practice acquired in training, has the necessary qualifications to care for the patient. this relationship also implies that the older the professional is, the less he or she understands the need for specialization in the field of nursing.40 some limitations of our study should be noted. first, the number of participants was relatively small, although we only included specialist nurses. secondly, our assessment was made subjectively using a questionnaire; therefore, the use of objective measures in future studies may deepen knowledge about the importance of mdts in the field of nursing work and how mdts interfere with nurses’ motivation. based on the profile of nurses working in a region in the interior of brazil, our study can serve as a starting point for a better understanding of the difficulties of these health professionals, especially concerning specialization in nursing. conclusions our study shows a current tendency for specialized nurses to be young, female, and single, with a predilection for the area of family health. in general, they believe in the importance of specialization, especially in the possibility of providing a higher qoc and job performance. there is an association between the importance of having specialization and the best patient care, and the younger the nurse is, the greater the appreciation of the nursing specialization. by defending the idea of mdt, we enter into a typical debate in the work scenario of a nurse, evidenced by the qoc proposed by the professional who qualifies through a specialty. based on the analysis of our questionnaire, the answers started from the idea that there will always be a need for constant updating of job skills and knowledge. it is understood, therefore, that the better qualified the professional is, the better their performance of humanized patient care in a low-resource setting. references 1. girard j, girard j. defining knowledge management: toward an applied compendium. online j appl knowl manag 2015; 3:1-20. 2. li m, liu h, zhou j. g-seci model-based knowledge creation for cops innovation: the role of grey knowledge. j knowl manag 2018;22:887-911. 3. subtil cl. concerns and uncertainties under the view of the nursing history. cult cuid 2017;21:16-22. 4. kejžar a, dimovski v, colnar s. the impact of knowledge management on the quality of services in nursing homes. front psychol 2023;13:1106014. 5. wilson r, godfrey cm, sears k, et al. exploring conceptual and theoretical frameworks for nurse practitioner education: a scoping review protocol. jbi database system rev implement rep 2015;13:146-55. 6. de meneses as, sanna mc. accessibility and content of electronic information about specialization courses in nursing administration. rev esc enferm usp 2011;45:356-62. 7. world health organization. state of the world’s nursing report 2020-investing in education, jobs and leadership [internet]. health workforce 2020. available from: https://www.who.int/publications/i/item/9789240003279 8. shortell sm, wu f, lewis v, et al. a taxonomy of accountable care organizations for policy and practice. health serv res 2014;49:1883-99. 9. fernandes jd, silva rmo, silva acp, et al. profile of nursing specialization courses in the city of salvador, bahia, brazil. rev baiana enferm 2017;31:e16660. 10. oliveira eb, carvalho rac, teixeira e, et al. factors involved in the training of resident nurses: view of alumni from a residency program. rev min enferm 2017;21:e-1064. 11. kaiser ja, westers jb. nursing teamwork in a health system: a multisite study. j nurs manag 2018;26:555-62. 12. cioffi j, ferguson l. team nursing in acute care settings: nurses' experiences. contemp nurse 2009;33:2-12. 13. manser t. teamwork and patient safety in dynamic domains of healthcare: a review of the literature. acta anaesthesiol scand 2009;53:143-51. 14. schilling s, armaou m, morrison z, et al. understanding teamwork in rapidly deployed interprofessional teams in intensive and acute care: a systematic review of reviews. plos one 2022;17:e0272942. 15. o'reilly p, lee sh, o'sullivan m, et al. assessing the facilitators and barriers of interdisciplinary team working in primary care using normalisation process theory: an integrative review. plos one 2017;12:e0177026. 16. baker dp, day r, salas e. teamwork as an essential component of high-reliability organizations. health serv res 2006;41:1576-98. 17. leathard a. going inter-professional working together for health and welfare. london, new york: routledge: 1994. 18. petrie h. do you see what i see? the epistemology if interdisciplinary inquiry. j aesthet educ 1976;10:29-42. 19. world health organization. primary health care: now more than ever [internet]. geneva: world health organization. 2008 [cited 2022 dec 20]. available from: https://reliefweb.int/ report/world/world-health-report-2008-primary-health-carenow-more-ever 20. silva rmo, fernandes jd, maurício dmald, et al. motivations for the transitional experience of students in the nursing specialization degree. revista de enfermagem referência 2020;5:e20021. 21. atwal a, caldwell k. nurses' perceptions of multidisciplinary team work in acute health-care. int j nurs pract 2006;12:35965. 22. feijó am, vicente efr, petri sm. the use of likert scales in article [healthcare in 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clin 2019;29:328-35. 29. wilkes l, cioffi j, cummings j, et al. clients with chronic conditions: community nurse role in a multidisciplinary team. j clin nurs 2014;23:844-55. 30. izidório bhs, silva hgo, lopes aj. acting nursing: specialties for care. international journal of development research 2021:11:51818-23. 31. frota ma, wermelinger mcmw, vieira ljes, et al. mapping nursing training in brazil: challenges for actions in complex and globalized scenarios. cien saude colet 2020;25:25-35. 32. mccrae n. whither nursing models? the value of nursing theory in the context of evidence-based practice and multidisciplinary health care. j adv nurs 2012;68:222-9. 33. duffy jr. the clinical leadership role of the cns in the identification of nursing-sensitive and multidisciplinary quality indicator sets. clin nurse spec 2002;16:70-6. 34. liu y-j, wu l-p, wang h, et al. the clinical effect evaluation of multidisciplinary collaborative team combined with palliative care model in patients with 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2005-2018: a documental study. clin nurse spec 2020;34:75-84. 40. millberg lg, berg l, brämberg eb, et al. academic learning for specialist nurses: a grounded theory study. nurse educ pract 2014;14:714-21. article [page 332] [healthcare in low-resource settings 2024;12:12376] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12806 distribution of the pattern, incidence, and determinants of sexually transmitted infections among patients attending adari hospital, hawassa city, sidama region, ethiopia melese birmeka,1 damtew bekele2 1department of biology, hawassa university, hawassa; 2department of biology, ambo university, ambo, ethiopia abstract sexually transmitted infections (stis) cause serious medical and psychological health problems in ethiopia and vary in different localities. thus, this study aimed to investigate patterns, status, and the association of sexually transmitted infections and local risk factors in the patients attending adari hospital. an institutional-based cross-sectional study was carried out from september 2021 to june 2022. systematic simple random sampling was used to select a total of 385 patients. in addition, five years of retrospective data were collected. data were collected through blood tests, urethral and vaginal discharge swabs, structured questionnaires, interviews, and observations. variables with p-values less than 5% are considered as significant. the overall prevalence of sexually transmitted infections was 74.4%. the odds of stis in patients who were urban, single, presence of two and above sexual partners, illiterate, sexual intercourse without using a condom, and sex after drinking alcohol and chewing khat were more likely to be infected with stis as compared with their counterparts. stis were highly prevalent and one of the health challenges of hawassa city. introduction sexually transmitted infections (stis) are a variety of clinical syndromes caused by pathogens that can be acquired and transmitted through sexual contact. the burden of sexually transmitted infections is globally large and ever-increasing because many of them are asymptomatic infections; some of the most affected countries have no diagnostic techniques; and use very poor surveillance systems in different parts of the world.1 stis cause a large burden of disease worldwide and have 333 million cases of annual incidence with harmful effects on sexual health. although prevention and treatment of most stis are easy and curable, subsaharan africa has a high prevalence of stis, contributing to more than 70% of the entire burden of infection, particularly in young people due to high rates of sexual practice.2 in low-income countries, the burden of sti is very high. on average, more than 1 million stis are acquired every day. it is estimated that 80 to 90% of the global burden of stis occurs in low-income countries, where there is limited or no access to diagnostic facilities and poor awareness.3 about 35% of the ethiopian population comprises young people between 15 and 24 years of age, and this largest category is highly vulnerable to stis.4 the socio-cultural and economic contexts of low-income nations impact the epidemiology of stis, increase the transmission of hiv infection, and help make them an important public health priority.5 in developing countries like ethiopia, high levels of stis and high rates of complications are caused mainly due to inadequacies in health service provision and health care seeking,6 poorly trained sti case management care providers,1 and the asymptomatic nature of many stis. the incidence of stis and their complications are usually higher among people living in urban areas, those who are single and young age, and the presence of a higher numcorrespondence: melese birmeka, department of biology, hawassa university, p. o. box 05, hawassa, ethiopia. tel.:+251-911702057. e-mail: melesebirmeka@yahoo.com key words: sexually transmitted infections, prevalence, risk factors, adari hospital. contributions: mb conceived the project idea, designed the study protocol, and collected the data. both mb and db analyzed the data and interpreted and drafted the manuscript. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data: all data generated or analyzed during this study are included in this article. ethics approval and consent to participate: the study was reviewed and approved, and ethical clearance was obtained from the institutional ethical committee review board of the college of natural sciences, through the department of biology, hawassa university (ref.no. irb/264/11). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. confidentiality of the data was kept as secured. acknowledgments: we thank hawassa university for giving us a laboratory room to conduct laboratory work. we would like to acknowledge the technical staff of adari hospital for their unfailing cooperation during the survey. received: 13 july 2024. accepted: 12 september 2024. early access: 27 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12806 doi:10.4081/hls.2024.12806 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12806] [page 619] non -co mmerc ial us e o nly ber of sexual partners.7 globally, stis are a significant cause of acute illness, infertility, long-term disability, and death, with serious medical and psychological effects on millions of men, women, and infants. females are at a greater risk of stis and developing complications if infections go untreated, and the absence of symptoms in infected individuals leads to increased transmission and greater susceptibility to other types of infections.8 most microbial pathogens that are responsible for stis are curable with treatment except stis of viral origin.9 stis rank among the top ten conditions for which adults seek health care in many developing countries. these diseases are important for three reasons, their magnitude, their potential for causing serious complications, and their linkage with human immunodeficiency virus (hiv)/acquired immune deficiency syndrome (aids). prevalence figures for specific stis are often lacking or unreliable.10 besides, globally, young populations make up only one-fourth of the sexually active population, but they acquire 50% of all stis.11 moreover, young incarcerated persons were more at risk because of high rates of sexual activity, more sex with at-risk partners, earlier initiation of sexual behavior, and less condom use. the biology of stis in ethiopia has become more complex and reveals many characteristics of risk behavior, where increasing poverty results in delay of marriage, urbanization, socio-cultural change, which results in sexual behavior, and increasing unemployment of youth have contributed to earlier and often unprotected sex.12 finding the relevant data on the incidence and burden of stis is important for planning appropriate interventions. they are also crucial in helping to improve the design and implementation of sti interventions. although there are some studies conducted in ethiopia, little is known about the prevalence and associated factors of stis in the study area. assessing the prevalence and factors associated with common stis among the study population provided better information for health planners to adopt strategies to manage the impacts of stis on the local people. materials and methods description of the study area and study population hawassa city is in the sidama regional state, located 273km south of addis ababa, the capital city of ethiopia, and has a latitude and longitude of 7°3′n 38°28′e and an elevation of 1,708 meters (5,604 ft) above sea level. based on the 2007 census conducted by the central statistical agency of ethiopia, this zone had a total population of 258,808, of whom 133,123 were males and 125,685 females. while 157,879 or 61% were living in the city of hawassa, the rest of the population of this zone was living in surrounding rural kebeles. a total of 61,279 households were counted in this zone, which results in an average of 4.22 persons per household, and 57,469 housing units.13 hawassa city has two governmental hospitals in addition to health centers and private clinics. adare general hospital is the best healthcare provider located in hawassa, ethiopia. adare general hospital has a total capacity of 110 beds with major medical specialties and services. it receives referral patients from hawassa town and nearby zones. in 2008 e.c., the hospital was upgraded to adare general hospital from its primary level. the hospital provides services such as outpatient, emergency, inpatient (internal medicine, pediatrics, neonatal intensive care, delivery, and surgery), laboratory, radiology, pharmacy, and food. in addition to providing basic health services, the hospital is serving as the training center for medical and health students who come from governmental and private teaching centers. inclusion/exclusion criteria and study variables all patients attending adare hospital and examined for stis during the study period and those who were not treated for antiparasitic treatment for the previous two weeks were included in the study. those patients who were on anti-parasitic treatment for the previous two weeks were excluded. the prevalence of stis among patients was used as the dependent variable, whereas age, sex, educational status, hand washing habit, source of drinking water, presence of toilet, and others were used as independent variables. study design research design is the outline for fulfilling the research objective and answering research questions. it is a master plan stating the methods and procedures for collecting and analyzing the required information. a health institution-based study was conducted to collect data from september 2021 to june 2022 in adari hospital. the present study was descriptive (concerned with determining the frequency with which an event occurs) and cross-sectional since all relevant data was collected at a single point in time. this is a retrospective study where data from the past six years (2016-2021) was utilized. the study included all records of individuals registered in the log book from 2016-2021 and diagnosed with stis. sample size determination and sampling techniques sample size determination the sample size was estimated using a statistical formula developed by yamane,14 considering the level of acceptable margin of error 5%. the target population size was in 2021(n=10904 households) a total number of samples (n) was required to be drawn assuming a 95% confidence level and 5% margin of error. based on this the researcher decided to take the upper population size limit to get a more valid sample size. if the population size (n) of a given study is known and its sampling error (e) is fixed by the researcher, then the total sample size (n) can be calculated by using the following formula. n=n/1+n(e)2 =10904/1+10904(0.05)2=385 minimum sample size sampling technique a systematic random sampling technique was applied to select samples from patients data collection data were collected by attending nurses who have prior experience in data collection. all data collectors and supervisors were trained for one day and performed practical exercises to become familiar with the questionnaire. socio-demographic and sexual behavior data and, knowledge attitude and practice for stis were collected through a self-administered structured and pre-tested questionnaire. laboratory data were collected using a blood test, and urethral and vaginal discharge swabs whereas retrospective data were obtained from document analysis. data analysis after the data was checked for completeness, and then ana article [page 620] [healthcare in low-resource settings 2024;12:12806] non -co mmerc ial us e o nly lyzed by using the statistical package for social sciences (spss) version 24. to determine the association of some potential risk factors with sti, logistic regression analyses were used. odds ratios with their 95% confidence intervals were computed to identify the presence and strength of association, and statistical significance was declared if p<0.05. ethical considerations the study was reviewed and approved, and ethical clearance was obtained from the institutional ethical committee review board of the college of natural sciences, through the department of, biology, hawassa university (ref.no. irb/264/11). the objective of the study was informed to the study participants and gave their consent to participate in the study. confidentiality was also maintained. results socio-demographic and clinical characteristics of respondents the socio-demographic characteristics of respondents are summarized in table 1. a total of 385 respondents participated in this study, of which 147(38.2%) were males and 238(61.8%) were females. thirty (9%) participants were at age ≤15 years, 206(53.5%) were between the age of 16-31 years. eighty (20.8%) participants were between the age of 32-47 years. two hundred forty-four (60.5%) participants of this study were unmarried, and 201 (52.2%) were married. most of the respondents lived in rural areas, 201(52.2%). two hundred twenty-two (57.7%) respondents were uneducated, and 283 (73.5%) respondents did not use condoms during sexual intercourse. most of the respondents, 267(69.4%) were having sexual intercourse after drinking alcohol. almost half, 201(52.2%) participants were having sex after chewing khat (table 1). about 298/385(77.4%) of stis suspected patients were stis infected. analyses of the potential risk factors explored for the stis showed that 116 (78.9%) males, and 182 (76.4%) females had at least one sti and were statistically significant (p<0.05) (table 2). the odds of stis in patients who were rural dwellers were 1.5 times higher than those who lived in urban areas. similarly, single patients were 1.5 times more likely to be infected with stis. moreover, illiterate patients were two times more likely to be infected with stis. likewise, sex after drinking alcohol, and sex after chewing khat, sex without condom use, having good knowledge about sti transmission were significantly associated with sti transmission. sexual intercourse without condom use was 1.8 times more likely to be infected with stis. furthermore, having good knowledge about sti transmission and the presence of only one sexual partner were protective from sti transmission whereas the presence of only one sexual partner was protective from sti transmission and it showed a reduction by 13% from stis (table 2). trends of sexually transmitted infections incidence (2016-2021) of the study participants a total of 1074 sti patients were recorded from the year 2016 to 2021. among these, 490 (45.6%) were males and 584 (54.4%) were females. as shown in figure 1, the retrospective studies carried out on sti-positive patients from 2016-2021 years showed the incidence of 92(8.6%) in 2016, 89(8.3%) in 2017, 198(18.4%) in 2018, 222(20.7%) in 2019, 232(21.6%) in 2020 and 241(22.4%) in 2021. the incidence of stis increased from 2017 to 2021 (figure 1). types and frequency of sexually transmitted infections gonorrhea had the highest percentage of infection occurrence, which accounts for 431(40.1%). two hundred nineteen-five (27.5%), 197(18.3%), 144(13.4%), and 7 (0.65%) of the patients were infected by hepatitis, hiv/aids, syphilis, and chancroid article [healthcare in low-resource settings 2024;12:12806] [page 621] table 1. socio-demographic characteristics of study participants, in adari hospital 2022. variables number percentage (%) sex female 238 61.8 male 147 38.2 age 1-15 35 9 16-31 206 53.5 32-47 80 20.8 >48 64 16.6 residence urban 184 47.8 rural 201 52.2 marriage single 184 47.8 married 201 52.2 education illiterate 222 57.7 literate 164 42.3 condom use yes 102 26.5 no 283 73.5 knowledge of stis good 199 51.7 poor 186 48.3 sexual partner one 183 47.5 two and above 202 52.5 sex after drinking alcohol yes 267 69.4 no 118 30.6 sex after chewing khat yes 184 47.8 no 201 52.2 *the percentage calculated for the respective characteristic is from the total examined. sti, sexually transmitted infections figure 1. trends of sexually transmitted infections (sti) incidence in (2016-2021) among patients in adari hospital. non -co mmerc ial us e o nly respectively. hiv/aids, gonorrhea, hepatitis, and syphilis infections were higher in females and the age group <30 years. the majority of the study participants (hiv, gonorrhea, hepatitis, syphilis, and chancroid) patients were urban, unmarried, and illiterate (table 3). discussion studies on stis and their effects on health are low compared to the ever-increasing rate of stis in the population. due to the absence of longitudinal studies, the pattern increment of sexually transmitted diseases may not be well justified.15 although more efforts are needed to study stis and their effect on health, some previous studies indicated many significant psychological, medical/physiological, and sociological negative impacts on the health of the population.16 stis are believed to affect a large segment of the ethiopian population, particularly the productive age group. compared to what has been reported earlier from different regions of ethiopia, the prevalence of stis on health for the present study population varies in different localities. this could be explained by the differences in awareness about sti transmission, sex after alcohol use, having multiple sexual partners and sti nontesting contribute high prevalence of stis in different regions or localities. other investigators have also reported that the prevalence of stis varies in different regions of ethiopia.17 stis were higher in the age range of 16-31 years. hawassa is an emerging town and due to its attraction to tourists and investments, there are a lot of investments mainly hotels and industries. due to such expansion of investments, high numbers of labor migrants dominantly young age groups who are the most sexually active age group were moving from the surrounding districts to the town in search of job opportunities might contribute to the higher prevalence. this finding was comparable with a study done by teshome and olaniran et al.17,18 the overall proportion of hiv/aids within five years was (16.8%), which was higher than the prevalence rate reported in the study conducted at hawassa university (10.6%),19 gondar, ethiopia (14.5%).12 however, the overall hiv/aids prevalence rate observed in this study was lower than the prevalence rate observed in the study done in malawi,20 which was 44.2%. the differences might be due to the time in which the research was conducted and differences in locality. article [page 622] [healthcare in low-resource settings 2024;12:12806] table 2. univariate and multivariate analysis of some associated factors for sexually transmitted infections (stis) prevalence among sti-suspected patients in adari hospital, hawassa city, ethiopia, (sep, 2021 jun, 2022). variables sti positive no (%) cor (95% ci) p-value aor (95%ci) p-value sex female 182 (76.4) 1.871 (1.4-2.64) 0.005 2.97 (1.3-2.84) 0.005 male 116 (78.9) 1 1 age 1-15 27 (77) 1.64 (2.13-3.16) 0.13 2.84 (1.13-2.16) 0.24 16-31 156 (75.7) 1.56 (1.13-2.16) <0.001 7.6 (1.3-1.6) <0.001 32-47 60 (75) 1.75 (1.01-2.8) 0.029 1.65 (0.01-0.14) 0.015 >48 55 (85.9) 1 1 residence urban 142 (77.1) 1 1 rural 156 (77.6) 1.63 (1.15-2.3) <0.001 1.47 (1.5-1.7) <0.001 marriage single 142 (77.1) 1.63 (1.15-2.3) <0.001 1.47 (1.5-1.7) <0.001 married 156 (77.6 1 1 education illiterate 176 (79.3) 1.43 (1.03-2.10) <0.001 2.13 (1.02-2.6) 0.01 literate 122 (74.4) 1 condom use yes 75 (73.5) 1 1 no 223 (78.8) 1.89 (1.23-2.96) <0.001 1.80 (1.43-2.76) <0.001 knowledge of stis good 155 (77.8) 1 1 poor 143 (76.88) 1.54 (2.03-5.16) <0.001 2.54 (2.53-4.13) <0.001 sexual partner one 145 (79.2) 1 1 two and above 153 (75.7) 1.52 (1.32-2.20) <0.001 0.87 (1.33-2.40) <0.001 sex after drinking alcohol yes 205 (76.8) 1.63 (1.0-2.20) 0.02 1.43 (1.0-2.31) 0.001 no 93 (78.8) 1 1 sex after chewing khat yes 142 (77.2) 1.63 (1.15-2.3) <0.001 1.47 (1.5-1.7) <0.001 no 156 (77.6) 1 1 *the percentage calculated for the respective characteristic is from the total examined. cor, crude odds ration; aor, adjusted odds ratio. non -co mmerc ial us e o nly this study revealed that the prevalence of gonorrhea relative to other stis within five years was 40.1%. this was higher than those reported from gondar (20.8%),12 mozambique (22.5%),21 egypt (26%),22 southwestern nigeria (25%),23 and mongolia (11%).15 the reason behind the prevalence difference might be due to the time of the study, environmental differences, the cultural context in which the people live, and knowledge about the transmission of the disease. in this study, the prevalence of hepatitis a, (26.8%) was higher than the prevalence rate observed in jigjiga, ethiopia (19%),24 and addis ababa, ethiopia (7.3%).25 the study also revealed that syphilis had a 13.96% mean prevalence rate within a five-year retrospective study. this was lower than the study conducted in gondar, ethiopia (30%).12 yirgalem hospital southern ethiopia (39%).26 this might be due to differences in the study period, differences in locality, in socio-economic cultural differences. the findings of the study showed that the overall prevalence of sexually transmitted diseases in 385 study subjects was 77.40%. this was comparatively similar to the prevalence in gondar town, ethiopia (74.1%),12 and lower than nigeria (85%).23 on the contrary, it was higher than the study done in addis ababa, ethiopia,25 which reported an sti prevalence rate of 47.9%, and studies reported in malawi (4.2%),20 and mozambique (41%).21 the probable reason for this prevalence discrepancy might be due to differences in the duration of the study, the interventions used for the target group, and the difference in sample size, as the current study was conducted only in a single town or hospital whereas the other studies were done at national level on a large scale, due to the socio-cultural and economic context in which the person lives, a knowledge difference between the person about how to protect themselves, environment, different attitudes of the community for having sexual attraction for the same gender and national laws towards homosexuality. in this study, literates were more likely to protect against stis as compared to illiterates (adjusted odds ratio, aor=2.13, 95% confidence interval, ci; 1.02, 2.6). this finding was almost similar to the study conducted in brazil and showed that illiterates had developed a high prevalence rate as compared to their counterparts (aor=1.09, 95% ci; 1.31,4.73).27,28 in this study, residence and sti prevalence were highly associated. this means those patients who came from urban areas were more likely to develop stis as compared to patients who reside in rural areas. this is consistent with a previous study; patients from urban areas attending the health facility had significantly higher sti prevalence compared to patients from rural areas.29,30 it has been suggested that patients from urban areas may be due to the possibility of having two or more sexual partners and urbanization could contribute to a higher prevalence rate. in this study, sti prevalence was also less frequent among married than single. the reason for the high occurrence of stis in single patients may be due to stis non-testing, condom non-use, and the presence of multiple sexual partners. this finding is contrary to other studies done in gondar, northern ethiopia.24 the trend of stis gradually increased from 2017 to 2021, which is similar to the study done by geremew and teshome.12,17 this might be due to the increment of unprotected sex through time, the presence of more than one sexual partner, and sex after alcohol use contribute to the high prevalence of stis. conclusions this study revealed that the prevalence of sexually transmitted infections in the study area was relatively high as compared to findings documented in some parts of the country, and its prevalence was 77.4%. an increasing trend was observed in the stis prevalence rate in the past five years from (8.6%22.4%) in 20162021. the most prevalent stis were gonorrhea and the most affected age group was below 16-31 years in both sexes. moreover, the prevalence rate had a significant association with marital status; residence, condom use, educational status, number of sexual partners, sex after drinking alcohol, and sex after chewing khat of the study participants. in general, it was observed that those individuals who were not married, in urban residences, had sexual article [healthcare in low-resource settings 2024;12:12806] [page 623] table 3. frequency of sexually transmitted infections (stis) by demographic (n=1074) with different characteristics at adari hospital, southern ethiopia (september 2016 june 2021). variables total hiv + ve gonorrhea hepatitis syphilis chancroid n (%) n (%) n (%) n (%) n (%) n (%) sex male 490 (45.6) 93 (47) 194 (45) 127 (43) 69 (48) 7 (1.2) female 584 (54.4) 104 (53) 237 (55) 168 (57) 75 (52) 0 (0) age <30 560 (52.1) 114 (57.9) 208 (48.3) 167 (56.6) 167 (56.6) 6 (85.7) 30-45 374 (34.8) 60 (30.5) 158 (36.7) 98 (33.2) 55 (39.3) 1 (14.3) above 45 140 (13.1) 23 (11.7) 65 (15) 30 (10) 20 (13) 0 (0) residence urban 921 (85.8) 162 (82.2) 390 (90.5) 240 (81.4) 124 (88.6) 5 (71.4) rural 153 (14.2) 35 (17.8) 41 (9.5) 55 (18.6) 16 (11.4) 2 (28.6) marital status single 686 (63.9) 143 (72.5) 254 (58.9) 184 (62.4) 98 (70) 7 (100) married 388 (36.1) 54 (27.5) 177 (41.1) 111 (37.6) 42 (30) 0 (0) educational status illiterate 636 (59.2) 119 (60) 242 (56) 171 (58) 98 (70) 6 (86) literate 438 (40.8) 78 (40) 189 (44) 124 (42) 42 (30) 1 (24) *the percentage calculated for the respective characteristic is from the total examined. hiv, human immunodeficiency virus. non -co mmerc ial us e o nly intercourse without using a condom, had sexual intercourse after drinking alcohol, after chewing khat, and were illiterate were more likely to develop a risk of stis as compared to their counterparts. limitations of the study since only a few studies were conducted in ethiopia, little is known about the prevalence and associated factors of stis in the study area. as a result, this study faced social desirability bias because of highly sensitive questions related to sexuality, and recall bias, which may lead to an underestimate of the actual prevalence. furthermore, this study was cross-sectional, it may not allow for the establishment of a causal link to the syndrome of sti. references 1. moses s, ngugi en, costigan a. et al. response of a sexually transmitted infection epidemic to a treatment and prevention program in nairobi, kenya. sexually transmitted infections. 2002;78:i114-20. 2. visalli g, picerno i, vita g, et al. images f. knowledge of sexually transmitted infections among younger subjects of the city of messina (sicily). j prev med hyg. 2014;55:17-22. 3. world health organization (who). global strategy for the prevention and control of sexually transmitted infections: 2006–2015. 2007. available from: https://iris.who.int/bitstream/handle/10665/69361/who_rhr_06.10_eng.pdf 4. berhane y, mekonnen y, seyoum e, et al. hiv/aids in ethiopia an epidemiological synthesis. 2008. available from: https://documents.worldbank.org/pt/publication/documentsreports/documentdetail/660061468315834425/hiv-aids-inethiopia-an-epidemiological-synthesis 5. wasserheit jn. the significance and scope of reproductive tract infections among third world women. international journal of gynecology and obstetrics. 1989;3:145-68. 6. aral so, wasserheit jn. std-related health care seeking and health service delivery. in: sexually transmitted diseases. third edition. mcgraw hill; new york, usa; 1999. 7. pattman r, snow m, handy p, et al. oxford handbook of genitourinary medicine, hiv, and aids. oxford university press; oxford, uk; 2005. 8. upchurch dm, mason wm, kusunoki y, kriechbaum mj. social and behavioral determinants of self-reported std among adolescents. perspectives on sexual and reproductive health. 2004;36:276-87. 9. world health organization (who). family planning. 2023. available from: https://www.who.int/news-room/factsheets/detail/family-planning-contraception 10. world health organization (who). report on global sexually transmitted infection surveillance 2018. 2018. available from: https://www.who.int/publications/i/item/9789241565691 11. butler p. progress in reproductive health research. undp/unfpa/ who/world bank special program of research, development and research training in human reproduction. 2001. available from: https://iris.who.int/bitstream/handle/10665/59249/who_rh r_02.5.pdf 12. geremew ra, agizie bm, bashaw aa, et al. the prevalence of sexually transmitted infections and associated factors among symptomatic patients attending gondar town hospitals and health centers. ethiop j health sci. 2017;27:589-600. 13. ethiopian statistical agency. population and housing census snnpr, 2007. 2007. available from: http://www.statsethiopia.gov.et/wp-content/uploads/2019/06/population-andhousing-census-2007-snnpr-statistical.pdf 14. yamane y. mathematical formulae for sample size determination. 1967. 15. garland sm, tabrizi sn, chen s.et al. prevalence of sexually transmitted infections in ulaanbaatar, mongolia. infect dis obstet gynecol.2001;9:143-6. 16. gerberding jl. report to congress: infertility and prevention of sexually transmitted diseases 2000-2004. 2004. 17. teshome a. prevalence of mycobacterium tuberculosis and hiv infections among patients visiting dilchora referral hospital, dire adwa administrative council, eastern ethiopia. 2014. 18. olaniran o, hassan-olajokun m, oyovwevotu r, agunlejika m. prevalence of tuberculosis among hiv/aids patients in obafemi awolowo university teaching hospital complex. int j biol med res. 2001;2:874 -7. 19. kassa g. prevalence and determinants of sti cases in south ethiopia. universal j public hlth, 2013; 1:115-23 20. behets fm, liomba g, lule g, et al. sexually transmitted diseases control in malawi. a filed study of genital ulcer disease. infect dis. 1995; 71:451-5. 21. apalat t, zimba tf, sturm wa, moodley p. antimicrobial susceptibility profile of gonorrhea isolated from patients attending std facility in maputo, mozambique. sex transm. dis. 2009;36:341-3. 22. ali f, aziz aa, helmy mf, et al. prevalence of certain sexually transmitted diseases in egypt. egypt public health assoc. 1995;71:553-75. 23. okonko io, okerentugba po, adejuwon ao, onoh cc. prevalence of sexually transmitted infections (stis) among attendees of lead city university medical center in ibadan, southwestern nigeria. arch appl sci res. 2012;4:980-7. 24. akalu m, woriku t. sero prevalence of hepatitis b and syphilis among blood donors at jigjiga. a blood bank eastern ethiopia ethiop j health sci. 2016;26:153-60. 25. zeleke d, legesse w, habite b. prevalence of hepatitis a in addis ababa, ethiopia: implications for prevention and control measures. eurj med res. 2016;12:16. 26. abebe a, feleke g, alemu d. high sero prevalence of syphilis infection in yirgalem hospital southern ethiopia. 2018. 27. central statistical agency (csa) [ethiopia] and orc macro. ethiopia demographic and health survey 2005. 2006. available from: https://www.dhsprogram.com/ pubs/pdf/fr179 /fr179%5b23june2011%5d.pdf 28. mariade f, pessoa m, albuquerque r, et al. factors associated with treatment failure, dropout and death in a cohort of tuberculosis patients (from may 2001 to july 2003) in recife, pernambuco state, brazil. cad saude publica. 2007;23:157382. 29. ramose jm, reyes f, facin r. surgical lymph biopsies in a rural ethiopian hospital: histopathologic diagnoses and clinical characteristics. ethiop med j. 2008;46:173-8. 30. dangisso mh, datiko d, lindtjørn b. trends of tuberculosis case notification and treatment outcomes in the sidama zone, southern ethiopia: ten-year retrospective trend analysis in urban-rural settings. plos one. 2014;9:e114225. article [page 624] [healthcare in low-resource settings 2024;12:12806] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11799 transmission rate factors among tuberculosis patients in west kalimantan, indonesia nita arisanti yulanda,1 kharisma aji martadi,1 titan ligita,1 ikbal fradianto,2 andikawati fitriasari3 1medical surgical of nursing department, faculty of medicine, universitas tanjungpura, pontianak; 2community health nursing department, faculty of medicine, universitas tanjungpura, pontianak; 3faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia abstract tuberculosis is a critical issue in a community, and the rising number of cases can be attributed the development and evolution of the bacteria responsible. as part of independent nursing actions, educational intervention is a solution to improve prevention and treatment success at the family and community levels. this study aimed to determine the factors for tuberculosis transmission. this research was a correlation study with a cross-sectional design, involving a sample of 100 participants selected through purposive sampling. independent variables for the present study include age, gender, occupation, diabetes record, body mass index (bmi), and level of knowledge. meanwhile, the dependent variable in this study is the risk of transmission. this observation used a questionnaire with chi-square and logistic regression analysis. the result showed that families with a thin body mass index had a lower likelihood of carrying out infectious behavior (p=0.000). most respondents have a high level of knowledge and a low potential for infectious behavior. in fact, a good education system, it will allow someone to be independently trained to change behaviors and attitudes for the better. introduction mycobacterium tuberculosis is a bacterium responsible for tuberculosis, a highly contagious and critical concern for both domestic and global communities.1–3 tuberculosis has had a significant impact on mortality rates, causing at least 1.6 million reported deaths in 2016.4 it stands as a major contributor to mortality as a single infectious agent.1,5,6 furthermore, latent tuberculosis infections are widespread, with approximately onefourth of the global population carrying these latent infections.7,8 these individuals may serve as potential reservoirs for active tuberculosis cases, further complicating the control and prevention of the disease.9,10 indonesia is one of the five countries with the highest tuberculosis prevalence rates.4 in 2017, there were 420,994 reported cases, and this number increased to 1,017,290 cases in 2018. west kalimantan, a province in indonesia, alone reported 28,343 cases of tuberculosis.11,12 this substantial increase in cases can be attributed to the development and evolution of the tuberculosis-causing bacteria themselves. tuberculosis is highly contagious and can easily spread through the air when individuals inhale contaminated air containing the bacterium. this ease of transmission makes it challenging to control the spread of the disease.13–15 additionally, factors such as the physical condition of the host, their nutritional status, and the environment they are in play significant roles in the spread of tuberculosis. an imbalance in these factors can contribute to the increased prevalence of the disease.16,17 correspondence: nita arisanti yulanda, medical surgical of nursing department, faculty of medicine, universitas tanjungpura, pontianak, indonesia. e-mail: nita.arisantiyulanda@ners.untan.ac.id key word: behavior; family; level of knowledge; tuberculosis. contributions: nay, conceptualization, data curation, formal analysis, validation, visualization, writing – original draft, review and editing; kam, methodology, validation, and writing – original draft, review and editing; tl, formal analysis, validation, and writing – original draft, review; if, visualization, writing – review and editing; af, resources, investigation, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of medicine, universitas tanjungpura, based on ethical certificate 3489/un22.9/pg/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from dipa faculty of medicine number 023.17 .2.677517 /2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: praise be to allah subhanahu wa ta'alla for his grace and guidance so that we can carried out this research study well. this research activity was successful because of the support from various stakeholders, including: the dean of the faculty of medicine, universitas tanjungpura; director of dr soedarso pontianak hospital; the institute for research and community service (lppkm), universitas tanjungpura; head of the nursing science study program; all lecturers and educational staff in the nursing science study program and students of the 2019 batches who were also involved in the successful completion of this project. received: 14 september 2023. accepted: 6 november 2023. early access: 17 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11799 doi:10.4081/hls.2023.11799 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11799] [page 151] non -co mmerc ial us e o nly the fight against tuberculosis faces various challenges, including outdated diagnostic methods reliant on centuries-old microscopes, low-sensitivity diagnostic techniques, limited usage of the calmette guérin (bcg) vaccine, and the use of drugs that have been in use for several decades.18 with advancements in genomic data availability, there is now a better understanding of genotypic and ecological variations among related bacteria. traditional species concepts, which are commonly used to define naturally occurring species in populations, cannot be readily applied to bacteria due to their unique characteristics.19,20 efforts to address the problem of tb transmission require collaboration across different sectors. the increasing incidence of tuberculosis is rooted in factors like poverty, economic inequality, and limited access to healthcare facilities, particularly in remote or island regions.21,22 it’s widely recognized by public health experts that the environment plays a crucial role in community health and can contribute to increased transmission of tuberculosis.23,24 various factors influence the spread of tuberculosis, including gender disparities (with men having a higher incidence than women), decreased immunity, duration of exposure due to shared residence, education, smoking habits, and home environment.25,26 this study aimed to examine the risk factors for tuberculosis transmission. materials and methods research design this research employed a quantitative approach with a crosssectional design. primary data was collected through direct observation using a questionnaire composed of three parts: demographic information, knowledge level, and risk of transmission. study participants this study involved a sample size of 100 participants, and the participants were selected through purposive sampling. the respondents in this study were patients diagnosed with tb who possessed good communication skills and visited the tb clinic. however, individuals with tb who had coexisting psychiatric disorders were excluded from the study. variable, instrument and data collection this study collected primary data through direct observation of tuberculosis patients at one of hospital in west kalimantan. the independent variables included age, gender, occupation, diabetes history, body mass index (bmi), and knowledge levels. these variables were used to assess their impact on the dependent variable, which was the risk of transmission. data collection involved a questionnaire that incorporated questions related to age, gender, occupation, diabetes history, bmi, knowledge levels, and the risk of transmission. the questionnaire demonstrated validity and reliability with a total correlation exceeding 0.361 and an alpha cronbach above 0.979. data analysis involved bivariate chi-square tests, and the data was further examined using a logistic regression model with the enter method. data analysis the data analysis in this study involved a bivariate chi-square test to assess the relationship between the predictor variables. if the p-value for a predictor variable was less than 0.25, it was considered for inclusion in the logistic regression model using the enter method. logistic regression analysis was then employed to create a model that includes predictions and calculates odd ratio (or) values. the independent variables considered in this study were age, gender, occupation, diabetes history, body mass index (bmi), and level of knowledge. the dependent variable was the risk of transmission. the significance level used for this study was set at 5%. ethical clearance this research has passed the ethics review in the faculty of medicine universitas tanjungpura with number 3489/un22.9 /pg/2022. results the characteristics of the research respondents were presented in table 1, providing valuable insights into the distribution and frequency of various independent variables related to the risk of tuberculosis transmission. the majority of respondents were in the age group of 45-54 years (21%), male (52%), farmer (34%), no diabetes mellitus record (56%), has normal bmi (50%), and has high level of knowledge (65%). based on table 2 there was statistical test indicated that there was a partial relationship between each predictor variable including age, gender, diabetes record, bmi, and level of knowledge on the risk of transmission of tuberculosis patients. furthermore, each variable may be included in the regression model using the enter method with the hosmerlameshow test parameter with a standard sig > 0.05 indicating that the model was capable of accurately predicting the risk of events. based on the data processing the hosmer & lameshow test showed a significance value of 0.896 (sig > 0.05), it can be concluded that the variables of age, gender, diabetes record, bmi and level of knowledge that have entered the regression model have fit and are able to predict the chance of transmission (table 3). based on the data processing results, table 4 showed the estimation of the logistic regression parameters. in general, it can be seen that the independent variable which has a sig value < 0.05 can bee seen in bmi, either in the underweight, normal or overweight categories. the logistic transformation process can be symbolized by underweight (x1), normal (x2) and overweight (x3). age (p value 0.818) did not have a significant relationship in the model and stimulant test. descriptively, there are differences in the odd ratio value of each age category compared to 15 – 24 years old. the odd ratio values are 25-34 years (2.038 times), 35-44 years (1.044 times), 45-54 years (0.570 times), 55-64 years (0.386 times), age 65-74 years (0.000 times), age ≥ 75 years (2.191 times) may not transmitting. the b value indicates that there is a tendency to reduce the risk of transmission or increase the risk of transmission over time. gender (p value 0.159) does not relate to stimulants in regression model analysis. taking into account the value of the hazard ratio, women are 2.391 times less likely to be infected by tb than men. respondents with comorbid disease records are partially related, but in the stimulant test model, the history of diabetes (p value 0.538) did not have a significant relationship. the resulting hazard report value indicates that a person with a diabetes record has a 1.473 times higher risk of infectious diseases than those without diabetes. bmi (p value 0.002) is significantly related to this regression model. a person with a normal bmi is 20 times less likely to transmit than a person with an underweight bmi. while 143 times less likely to transmit than a person with an underweight bmi. factors based on the level of knowledge (p value 0.163) have a less significant relationship in the model. in general, based on model tests, a person with good knowledge of tb is 2.5 times less likely to be infected, compared to a person with low knowledge (table 4). [page 152] [healthcare in low-resource settings 2023; 11:11799] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly discussion the findings of this study indicate a significant relationship between infectious risk behavior and body mass index (bmi). this aligns with previous research that has shown an association between bmi and tuberculosis incidence.27 bmi is a critical indicator of nutrition and plays a significant role in the prevalence of tuberculosis. a low bmi, which indicates underweight, is considered a risk factor for tuberculosis.28 conversely, a high bmi or overweight status has been identified as a protective factor against the development of tuberculosis, suggesting an intricate interaction between tuberculosis and bmi.29 tuberculosis patients often exhibit poorer nutritional status, potentially due to decreased appetite as a symptom of the disease. poor nutritional status can, in [healthcare in low-resource settings 2023; 11:11799] [page 153] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of transmission risk frequency by respondent characteristics. variable risk of transmission total independent high n (%) low n (%) age 15-24 years old 7 (17.1) 13 (22) 20 (20) 25-34 years old 3 (7.3) 12 (20.3) 15 (15) 35-44 years old 3 (7.3) 12 (20.3) 15 (15) 45-54 years old 8 (19.5) 13 (22) 21 (21) 55-64 years old 9 (22) 8 (13.6) 17 (17) 65-75 years old 10 (24.4) 0 (0) 10 (10) ≥ 75 years old 1 (2.4) 1 (1.7) 2 (2) gender male 32 (78) 20 (34) 52 (52) female 9 (22) 39 (66) 48 (48) occupation civil servant/armed forces officer 1 (2.4) 3 (5.1) 4 (4) private employee 8 (19.5) 7 (11.9) 15 (15) pensioner 3 (7.3) 7 (11.9) 10 (10) housewife 2 (4.9) 2 (3.4) 4 (4) farmer 10 (24.4) 24 (40.7) 34 (34) farmers/fishermen 0 (0) 2 (3.4) 2 (2) student 5 (12.2) 2 (3.4) 7 (7) unemployed 12 (29.3) 12 (20.3) 24 (24) diabetes record yes 24 (58) 20 (34) 44 (44) no 17 (42) 39 (66) 56 (56) bmi thin 18 (43.9) 1 (1.7) 19 (19) normal 20 (48.8) 30 (50.8) 50 (50) overweight 3 (7.3) 28 (47.5) 31 (31) knowledge level low (< 22,79 point) 21 (51.2) 14 (23.7) 35 (35) high (≥ 22,79 point) 20 (48.8) 45 (76.3) 65 (65) total 41 (100) 59 (100) 100 (100) table 2. results of the bivariate prediction test for transmission test. variable independent test sig. expected count < 5 (%) age * fisher's exact test 0.001 21.4 gender* chi-square 0.000 0 occupation fisher's exact test 0.284 56.3 diabetes record * chi-square 0.015 0 bmi * chi-square 0.000 0 knowledge level* chi-square 0.005 0 table 3. overview of model test result. step -2 log likehood cox & snell r square nagelkerke r square 1 71.122 0.474 0.639* 2 94.849 0.333 0.449** non -co mmerc ial us e o nly turn, lead to reduced immunity and an increased risk of tuberculosis infection. a reduced bmi may also negatively impact the prognosis for tuberculosis treatment.30,31 nutritional status is known to play a crucial role in the outcome of tb treatment, with patients of better nutritional status demonstrating improved treatment responses. bmi serves as a practical and cost-effective measure to assess nutritional status.32 additionally, other studies have shown that individuals with higher body weight and a bmi greater than 18.5 are less likely to experience sputum conversion, which is the transition from a positive to a negative bacillus tuberculosis acid (bta) examination. this underscores the importance of maintaining a healthy nutritional status in tuberculosis management.32 in the other hand, the results of this study show a relationship between age and tb transmission risk behavior. this is consistent with previous studies that most elderly have poor health behavior, such as lack of maximum treatment.33 this is consistent with the theory of health belief model that a person has perceived barriers, namely confidence regarding self-confidence and behaviors.34 an elderly person who has thoughts of hindrance in performing noncommunicable actions will feel uneasy. this can be seen in the phenomenon of separation of utensils, bedroom, and closeness between family members. self-efficacy also contributes to the success of an older person with health behaviors. self-efficacy can control risky behavior by increasing confidence that the disease has a chance to be healed.35 this result is supported by previous studies that therapeutic excellence in improving self-efficacy and physical self-reliance can improve the quality of life of tuberculosis patients, such as confidence in healing, being able to overcome pain, and carrying out activities independently.36 becoming elderly leads to physical and mental regression. physical regression is not limited to the consequences of the disease, but the function of each cell that plays a role in reducing activity. these changes also affect someone’s psychological level.37 the results of this study are also supported by previous studies which show that at a young age, tb prevention behavior is better compared to old age.38 the elderly with unhealthy behavior has a higher possibility to be infected by diseases including tb. the lack of knowledge and misperception of the disease suffered, leads to misbehavior in the prevention of tb transmission.38 the results of this study indicate that there is a relationship between gender and tuberculosis transmission behavior. this result is different from the research of ramadan et al. (2021) which shows that there is no significant difference between gender and tb prevention behavior.38 results from this study are also consistent with the study of nurhayati et al. (2015) which shows that women are better at preventing tb than men.39 the fundamental assumptions which make up the women hypothesis have tended to behave properly and healthily. women tend to behave better than men. as a result, women are more concerned about their health.40 other studies also revealed that the level of knowledge is predisposed to a person. women are more knowledgeable than men.41 this may be triggered by someone’s habit, for example, women in indonesia are considered to behave cleanly, orderly, organized, and like to read. this is supported by the research conducted by bajaj & kilgore (2020) there are morphological differences in limbal tissues between males and females.42 the literature indicates a negative correlation between the size of limbic tissue based on the control ability of risky situations.42 the limbic system itself is part of the brain which consists of the amygdala, hypothalamus, thalamus, and hippocampus. physiologically it possesses a function in initiating behavior, and emotions (anger, fear, sexual drive).43 the results of this study are also supported by lee & allen (2020) which shows that gender becomes confounding between healthy eating behavior and depression.44 it can be seen by the behavior of young men who enjoy consuming fast food and soft drinks but dislike eating fruit. this phenomenon occurred as a result of the difference in cerebral tissue between the two. since the last decade, neuroscientists have found that the number of tissue nuclei in the brain affects cognitive, affective, and behavioral functions.45 the results of this study indicate that a diabetic person has a potential of 1.473 times more likely to transmit tb. the results of [page 154] [healthcare in low-resource settings 2023; 11:11799] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 4. estimated logistic regression parameters. variable sig. or aor 95% c.i.for exp(b) lower upper 1524 years old * 0.818 25-34 years old 0.512 0.538 2.038 0.243 17.107 35-44 years old 0.969 0.250 1.044 0.118 9.246 45-54 years old 0.500 0.250 0.570 0.111 2.915 55-64 years old 0.278 0.615 0.386 0.069 2.155 65-74 years old 0.998 1,125 0 0 ≥ 75 years old 0.786 1.615 2.191 (0.008) 634.764 gender 0.159 0.144 2.391 0.710 8.049 diabetes record 0.538 0.363 1.473 0.430 5.046 underweight * 0.002 normal (x1) 0.012 0.037 20.332 1.944 212.637 overweight (x2) 0.000 0.006 143.136 9.412 2176.747 knowledge level 0.163 0.296 2.500 0.691 9.051 constant 0.012 0.034 *category references. **dependent variable: high risk of infection (0), low risk of infection (1). non -co mmerc ial us e o nly this study are in line with previous studies which show that tb is more common in someone with a diabetes record.46 in this case, the function of emotions also influences physiological implications such as fear which may increase pulse rate, blood sugar levels, and trembling.43 the incidence of diabetes mellitus (dm) is related to genetic, environmental, immunity, and other factors. another study states that 30-50% of diabetics have mental disorders such as anxiety, frustration, depression, and irritability which may worsen the quality of life.47 dm itself can be referred to as a great initiator of changes in the human body system, both physically and mentally.47 increased self-efficacy and internal health locus can initiate the formation of drug compliance and healthy behavior. self-efficacy can give someone encouragement to determine self-confidence and modify the situation that has occurred.48 previous studies have shown that high levels of anxiety can decrease self-efficacy scores. according to bandura, a person’s belief in his capacity or competence can carry out a series of tasks to achieve the desired goal and overcome obstacles. critical thinking skills can also be supported by a high level of self-efficacy.49,50 knowledge is something that is known to humans or as a result of human intelligence itself. knowledge is also the content of one’s mind to comprehend different things. knowledge of tb prevention involves transmission, prevention, and appropriate treatment.51 notoadmojo (2003) revealed that knowledge and attitudes can influence family behavior and activity in related organisms.52 the level of knowledge may affect the initiation and treatment of tuberculosis. based on the review of research, several factors are known to influence treatment adherence,53 such as family support, positive self-esteem or self-efficacy, subjective norms, drug side effects, support of the tuberculosis drug supervisor (pmo), the use of medication reminder aids, the patient’s desire to recover, the patient’s way of thinking and the patient’s knowledge of tuberculosis disease and the use of drugs that are in accordance with ministry of health standards.54 conclusions there is a relationship between age, gender, the record of diabetes mellitus, bmi, and level of knowledge. this research showed that empowering tuberculosis patients is one of the nursing measures that can improve the quality of life of tuberculosis patients and minimize the risk of transmission, especially between family members of patients. among the things that need to be improved include lowering anxiety, increasing self-confidence, increasing knowledge and supporting good nutritional intake to reduce the risk of transmission. healthcare workers can provide support to patients and their families through tuberculosis control programs. references 1. indah m. infodati tuberkulosis. jakarta selatan: kementrian kesehatan republik indonesia; 2018. 2. putra kwr, toonsiri c. factors related to the successful treatment of tuberculosis: a literature review. belitung nurs j 2019;5:136-46. 3. chamidah n, yonani ys, ana e, lestari b. identification the number of mycobacterium tuberculosis based on sputum image using local linear estimator. bull electr eng informatics 2020;9:2109-16. 4. oktamianti p, bachtiar a, sutoto s, et al. tuberculosis control within indonesia’s hospital accreditation. j public health research 2021;10:541-5. 5. tateishi y, ozeki y, nishiyama a, et al. virulence of mycobacterium intracellulare clinical strains in a mouse model of lung infection role of neutrophilic inflammation in disease severity. bmc microbiol 2023;23:94. 6. isfandiari ma, wahyuni cu, pranoto a. tuberculosis predictive index for type 2 diabetes mellitus patients based on biological, social, housing environment, and psychological well-being factors. healthcare (basel) 2022;10:872. 7. gagneux s. ecology and evolution of mycobacterium tuberculosis. nat rev microbiol 2018;16:202-13. 8. koch a, mizrahi v. mycobacterium tuberculosis. trends microbiol 2018;26:555-6. 9. houben rmgj, dodd pj. the global burden of latent tuberculosis infection: a re-estimation using mathematical modelling. plos med 2016;13:e1002152. 10. zahroh c, ainiyah n, saadah n, aini nn, sudiana ik, yusuf a. determinant of incompliance medication people with tuberculosis disease. indian j forensic med toxicol 2021;15:90914. 11. kemenkes ri. laporan provinsi kalimantan barat riskesdas 2018. jakarta. lembaga penerbit badan litbang kesehatan; 2019. 97 p. 12. kemenkes ri. laporan nasional rkd tahun 2018. badan penelitian dan pengembangan kesehatan. 2019. p. 198. 13. gopalaswamy r, shanmugam s, mondal r, subbian s. of tuberculosis and non-tuberculous mycobacterial infections a comparative analysis of epidemiology, diagnosis and treatment. j biomed sci 2020;27:74. 14. wulandari l, wijaya sy. systemic sclerosis and pulmonary tuberculosis associated with interstitial lung disease: a case report. indian j forensic med toxicol 2021;15:147-53. 15. yuliandari rd, wahyuni cu, syahrul f, notobroto hb, qomaruddin mb, soedarsono. factor analysis of the role of physicians and its associated factors for encompassing patients with suspected tuberculosis in surabaya city. j public health africa 2023;14:2575. 16. silalahi n, sirait ra, romendra a. analisis korelasi koefisien kontingensi pada kondisi faktor sufficient tbc dengan kejadian penularan tbc pada anggota keluarga penderita tbc di wilayah kerja puskesmas talun kenas. j penelit kesmasy 2021;3:43-9. 17. mokrousov i, vyazovaya a, levina k, et al. spatiotemporal dynamics of drug-resistant mycobacterium tuberculosis : contrasting trends and implications for tuberculosis control in eu high-priority country. transbound emerg dis 2021;68:896-906. 18. dheda k, barry ce, maartens g. tuberculosis. lancet 2016;387:1211-26. 19. chiner-oms á, sánchez-busó l, corander j, et al. genomic determinants of speciation and spread of the mycobacterium tuberculosis complex. sci adv 2019;5(6). 20. sukartini t, purwanti nd, mariyanti h. family health tasks implementation and medication adherence of pulmonary tuberculosis patients: a correlational study. j ners 2020;15:49-58. 21. dirjen p2p kemkes ri. rencana aksi program pencegahan dan pengendalian penyakit 2015-2019 ( revisi i 2018 ). vol. 2019, rencana aksi program p2p 2015-2019. 2019. 86 p. 22. dass sa, balakrishnan v, arifin n, et al. the covid19/tuberculosis syndemic and potential antibody therapy for tb based on the lessons learnt from the pandemic. front [healthcare in low-resource settings 2023; 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2021. 28. hardiyanti. karakteristik pasien tb paru berdasarkan pemeriksaan foto thorax di bagian radiologi rsup dr . wahidin sudirohusodo makassar rsup dr. wahidin sudirohusodo makassar periode juni 2016-juni 2017. universitas hasanuddin; 2017. 29. putra mab, latief s, zulfahmidah, daeng il, safitri a. hubungan antara luas lesi pada foto thorax pasien tuberkulosis paru dewasa sebelum dan sesudah pengobatan dengan indeks massa tubuh (imt). fakumi med j 2022;2:109-15. 30. edwina, soetikno, hikmat. hubungan antara luas lesi pada foto toraks penderita tb paru dewasa yang memiliki riwayat diabetes melitus dengan indeks massa tubuh di rumah sakit hasan sadikin bandung correlation of tuberculosis lesion size in chest radiographs of diabetic adult patien. j radiol indones 2016;1:138-44. 31. wokas, wongkar, surachmanto. hubungan antara status gizi, sputum bta dengan gambaran rontgen paru pada pasien tuberkulosis. e-clinic. 2015;3(1). 32. tama td, adisasmita ac, burhan e. indeks massa tubuh dan waktu terjadinya konversi sputum pada pasien tuberkulosis paru bta positif di rsup persahabatan tahun 2012. j epidemiol kesehat indones 2016;1:1-8. 33. soesanto e, marzeli r. persepsi lansia hipertensi dan perilaku kesehatannya. j keperawatan dan kesehat masy cendekia utama 2020;9:244-51. 34. zaman fa, sheikh s, das kc, zaman gs, pal r. an epidemiological study of newly diagnosed sputum positive tuberculosis patients in dhubri district, assam, india and the factors influencing their compliance to treatment. j nat sci biol med 2014;5:415-20. 35. assosiated f, patiens c, tuberculosis l, et al. analisis faktorfaktor yang berhubungan dengan kepatuhan pasien tuberkulosis paru tahap lanjutan untuk minum obat di rs rumah sehat terpadu tahun 2015. j adm rumah sakit indones 2015;2:17-28. 36. noorratri ed, margawati a, dwidiyanti m. improving selfefficacy and physical self-reliance of patients with pulmonary tuberculosis through mindfulness. nurse media j nurs 2017;6:81. 37. herselowati, arlym lt. perbedaan tingkat pengetahuan, perilaku kesehatan dan pemeriksaan pada masalah kesehatan lansia. j kesehat dan kebidanan 2021;8:1-9. 38. ramadhan n, hadifah z, yasir y, et al. perilaku pencegahan penularan tuberkulosis paru pada penderita tb di kota banda aceh dan aceh besar. media penelit dan pengemb kesehat 2021;31:51-62. 39. nurhayati i, kurniawan t, mardiah w. perilaku pencegahan penularan dan faktor-faktor yang melatarbelakanginya pada pasien tuberculosis multidrugs resistance (tb mdr). j keperawatan padjadjaran 2015;3(3). 40. sari ar, rahman f, wulandari a, pujianti n, laily n, anhar vy, et al. perilaku pencegahan covid-19 ditinjau dari karakteristik individu dan sikap masyarakat. j penelit dan pengemb kesehat masy indones 2020;1(1). 41. fadlilah s, aryanto e. faktor yang berhubungan dengan pengetahuan tb paru dan dukungan sosial pasien rs khusus paru respira. j ilm keperawatan sai betik 2020;15:168. 42. bajaj s, killgore wds. sex differences in limbic network and risk-taking propensity in healthy individuals. j neurosci res 2020;98:371-83. 43. pudjono m. dasar-dasar fisiologi emosi. bul psikol 1995; 3:41-8. 44. lee j, allen j. gender differences in healthy and unhealthy food consumption and its relationship with depression in young adulthood. community ment health j 2021;57:898909. 45. thomas yeo bt, krienen fm, sepulcre j, et al. the organization of the human cerebral cortex estimated by intrinsic functional connectivity. j neurophysiol 2011;106:1125-65. 46. widyasari rn, wuryanto ma, setyawan sh. hubungan antara jenis kepribadian, riwayat diabetes mellitus dan riwayat paparan merokok dengan kejadian tb paru dewasa di wilayah kecamatan semarang utara tahun 2011. j kesehat masy 2012;1:446-53. 47. aini n. hubungan kadar gula darah dengan pengendalian emosi pada pasien diabetes melitus rawat inap. j kesehat hesti wira sakti 2019;7:1-13. 48. náfrádi l, nakamoto k, schulz pj. is patient empowerment the key to promote adherence? a systematic review of the relationship between self-efficacy, health locus of control and medication adherence. plos one 2017;12:e0186458. 49. ita p. hubungan antara efikasi diri dengan kecemasan bertanding pada atlet futsal universitas diponegoro semarang. hub antara efikasi diri dengan kecemasan bertanding pada atlet futsal univ diponegoro semarang 2019;8:64-70. 50. gazali m. pengaruh efikasi diri dan kecemasan matematika terhadap kemampuan berpikir kritis. j penelit pendidik dan penilai pendidik 2017;2:140-57. 51. hardin f. hubungan pengetahuan keluarga dengan pencegahan penularan tbc paru pada keluarga di puskesmas andalas tahun 2020. j kesehat lentera ‘aisyiyah 2021;4:44654. 52. kaka mp. hubungan tingkat pengetahuan dan sikap keluarga dengan perilaku pencegahan penularan penyakit tuberkulosis (tbc). media husada j nurs sci 2021;2:6-12. 53. rahmadi c, efendi f, makhfudli m. the effect of reminder system and audio-visual education to improve treatment adherendce on pulmonary tuberculosis patients: a systematic review. malaysian j med heal sci 2023;19:322328. 54. intani cn, sarwani d, wijayanti s. literature review: faktorfaktor yang memengaruhi kepatuhan pengobatan tuberkulosis. syntax lit j ilm indones 2022;7:8150-8. [page 156] [healthcare in low-resource settings 2023; 11:11799] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11867 exploring the primary health facility availability, health control, drug consumption, and healthy living behavior among patients with hypertension israfil israfil,1,2 ah yusuf,1 ferry efendi,1 maria agustina making,3 ni luh putu inca buntari agustini2 1faculty of nursing, universitas airlangga, surabaya; 2nursing department, faculty of health, institute of technology and health bali, denpasar; 3nursing department, politeknik kesehatan kementerian kesehatan kupang, kupang, indonesia abstract hypertension has been identified as a causative factor for cardiovascular disease, a leading global cause of death. the accessibility of health services plays a pivotal role in shaping community awareness and engagement in hypertension management. this research aimed to explore the availability of primary health facilities, health control practices, drug consumption, and healthy living behaviors among individuals with hypertension. utilizing a correlation study with a cross-sectional design, the sample comprised 130 hypertensive individuals selected through purposive sampling. statistical analysis used the spearman rho correlation test. the findings revealed that significant correlations between primary health facility availability and health control behavior (α=0.000, r=0.310), antihypertensive drug consumption behavior (α=0.000, r=0.461), and healthy lifestyle behavior (α=0.000, r=0.478) among hypertensive patients. these results underscore the relationship between the availability of primary health facilities and the behavior of hypertensive patients in terms of health control, drug consumption, and healthy lifestyle choices within the community. while the full implementation of these behaviors among hypertensive patients may not be optimal, the observed good availability of primary health facilities serves as an initial step to promote improved behaviors in the management and prevention of hypertension complications within the community. introduction hypertension is a chronic non-communicable disease diagnosed based on high blood pressure examination results reaching ≥ 140/90 mmhg or higher. hypertension sufferers may not feel any symptoms, so the only way to find out if there is an increase in blood pressure is to carry out routine blood pressure checks.1–3 hypertension that is not adequately controlled will damage blood vessel walls, causing thickening and stiffness of blood vessel walls, accumulation of fatty atherosclerotic plaque, and ultimately causing various complications such as coronary heart disease, angina pectoris, myocardial infarction, heart failure, retinopathy, and kidney failure.4–6 hypertension has also become a causative factor for cardiovascular disease, one of the causes of death globally.7–9 one of the global targets for non-communicable diseases is reducing hypertension prevalence by 33% between 2010 and 2030.1 it is estimated that 1.28 billion adults aged 30-79 years worldwide suffer from hypertension, and around 46% of people with hypertension are not aware that they have hypertension. less correspondence: ah yusuf, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: ah-yusuf@fkp.unair.ac.id key words: healthy behavior, hypertension, primary health facilities. contributions: ii, conceptualization, data collection, analysis, and manuscript writing; ay, supervised, corrected data and manuscripts, and provided input for improvements; fe supervised, corrected data and manuscripts, and provided input for improvements; mam, methodology, formal analysis, validation, and writing–original draft, review & editing; nlpiba, data curation, formal analysis, methodology, validation, visualization, writing–original draft, review & editing. conflict of interest: the researcher stated that there was no conflict of interest in this study. ethics approval and consent to participate: this research has received ethical approval from the health research ethics committee, faculty of nursing, universitas airlangga with ethical approval number 2640kepk. during the study, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this study was funded by the directorate of research, technology and community service, the ministry of education, culture, research and technology no: 0162/e5.4/dt.05.00/2023. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we thank the directorate of research, technology and community service, ministry of education, culture, research and technology, and the health office in kupang city, east nusa tenggara province; the head of the community health center in the city of kupang, the community nurses, and all respondents. received: 23 september 2023. accepted: 11 december 2023. early access: 11 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11867 doi:10.4081/hls.2024.11867 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 138] [healthcare in low-resource settings 2024;12:11867] non -co mmerc ial us e o nly than half, or 42%, of hypertension sufferers have been diagnosed and have received treatment. however, only 1 in 5 people who suffer from hypertension can control their blood pressure well.1 in indonesia, the prevalence of hypertension continues to increase.10 the five-year national health research of the ministry of health of the republic of indonesia in 2018 found that hypertension in indonesia had increased from 25.8% in 2013 to 34.1% in 2018. the prevalence of stroke had increased from 7% in 2013 to 10.9% in 2018, and the prevalence of heart disease reached 1.5% in 2018.11 health checks and blood pressure measurements, taking antihypertensive medication, and changing to a healthier lifestyle are essential efforts that must be made to control blood pressure within normal limits and reduce the risk of complications. the level of education, knowledge, and access to health services can influence community awareness and participation in controlling hypertension.12–14 health facilities that do not have adequate equipment will affect the success of treating hypertension in the community.15 health service facilities are tools and/or places used to provide health service efforts, whether promotive, preventive, curative, or rehabilitative to patients.16 the main challenges in managing hypertension in primary health facilities are shortages of equipment and personnel, drug stockouts, and poor patient attendance at health care visits.17 primary healthcare facilities in indonesia known as community health centers are a type of first-level health service that is easily accessible to the community, especially in areas with a gap in health development background with larger urban areas.18 the availability of primary healthcare facilities or community health centers is the first door to discovering various cases of non-communicable diseases in the community, including hypertension.19 accessibility to primary health services is an essential factor influencing the success of hypertension management in the community.18 inadequate availability of primary healthcare facilities is the cause of the low level of handling of hypertension cases in the community at various stages, namely screening, diagnosis, treatment, and follow-up efforts to treat hypertensive patients.19 the research aimed to explore the primary health facility availability, health control, drug consumption, and healthy living behavior among patients with hypertension. materials and methods research design this research was a correlation study with a cross-sectional design. a cross-sectional design was adopted to examine correlations between different elements without manipulating variables over time. population, sample, sampling the population in this study were hypertensive patients in the community. the sample size was 130 people taken using the purposive sampling technique. hypertensive patients who have suffered from hypertension for > 6 months, have not experienced complications, can read and write, do not experience mental disorders, and are willing to be respondents are the inclusion criteria for this study. this research was carried out in the work area of 11 kupang city health centers, east nusa tenggara province, in the eastern part of indonesia, from september to november 2022. variable the independent variable of this research was the availability of primary health facilities, and the dependent variables were health control behavior, drug consumption behavior, and healthy lifestyle behavior in hypertension patients instrument data collection was carried out using a questionnaire that had been developed by the research team from several sources, and validity and reliability tests had been carried out according to research needs.20,21 the health facilities availability questionnaire has three answer choices, namely “yes”, “no” and “don’t know”. answers are accumulated and a presentation is made in the categories of availability of health facilities, namely good 76-100%, enough 60-75%, and less <60%. the questionnaire on health control behavior, consumption of antihypertensive drugs, and healthy lifestyle has four answer choices, namely “always”, “sometimes”, “rarely”, and “never”. answers are accumulated and made into a presentation with categories of good behavior 76-100%, enough 60-75%, and less <60%. the questionnaire has been tested for validity and reliability with the results of the validity test being declared valid if the r count is more the value of the r table is 0.373, and is declared reliable if the cronbach’s alpha value is > 0.388.22 the results of the validity test which have been confirmed are that the calculated r of the questionnaire on the availability of health facilities is r = 0.525-0.930, health control behavior r = 0.812-0.899, drug consumption r = 0.728-0.914, and healthy lifestyle r = 0.449-0.763. meanwhile, the results of the reliability test showed that the cronbach’s alpha value of the health facility availability questionnaire was 0.870, health control behavior 0.872, drug consumption 0.884, and healthy lifestyle 0.600. data collection process data collection was carried out by identifying respondents who met the inclusion criteria, respondents were explained the purpose, benefits, and procedures for collecting research data, and respondents were asked for approval and signed informed consent. respondents are then given a questionnaire to fill out, filling in the questionnaire is done directly accompanied by a researcher or accompanying enumerator to avoid misunderstandings in filling out the questionnaire. the completed questionnaires were collected and then tabulated for analysis. data analysis the research data were explained statistically using the spearman rho correlation test with the help of ssps 20 software, with the significance level used being α = 0.01. ethical clearance this research has received ethical permission from the health research ethics committee, faculty of nursing, airlangga university with ethical approval number 2640-kepk. results the majority of respondents were aged 55-65 years (43.1), female (71.5%), had secondary education (44.6%), suffered from hypertension for ≤5 years (39.2%), and suffered from hypertension grade 1 (51.5%) (table 1). according to the majority of patients, primary health facilities were considered good in terms of availability (87.7%). however, only 15.4% of hypertensive patients exhibited good behavior in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11867] [page 139] non -co mmerc ial us e o nly terms of health control, while a larger proportion, 46.2%, demonstrated positive behavior in taking antihypertensive medication. in addition, the majority of hypertensive patients showed good behavior in adopting a healthy lifestyle, accounting for 43.1% (table 2). based on the spearman rho statistical test, the results obtained were the availability of primary health care facilities with the health control behavior of hypertensive patients (p-values=0.000, r=0.310), with the behavior of consuming antihypertensive drugs (p-values=0.000, r=0.461 ) and with healthy lifestyle behavior (p-values=0.000, r=0.478). these results indicate a relationship between the availability of primary healthcare facilities and health control behavior, antihypertensive drug consumption behavior, and healthy lifestyle behavior in hypertensive patients. the behavior that has the most vital relationship to the availability of primary healthcare facilities is healthy lifestyle behavior (table 3). discussion this study found that the availability of primary health facilities in the community has a significant relationship with health control behavior, antihypertensive drug consumption behavior, and healthy lifestyle behavior in hypertensive patients. although the availability of primary health facilities in the local area was mostly reported to be good, this study found that the expected good behavior of hypertensive patients was still not achieved optimally. the availability of primary health facilities in the community is an essential and effective strategy to handle and reduce the burden of non-communicable diseases, including hypertension and the danger of its complications.23 primary health facilities are the main supporting facilities and health services providers to hypertensive patients in the community to get support in carrying out and improving healthy living behavior to control hypertension and prevent complications. the availability of good primary health facilities will produce good capacity in integrating strategies for preventing and controlling non-communicable diseases in the community, including hypertension.24 in line with this study’s results, primary health facilities’ availability is said to be good if it has the availability of health human resources, medical equipment, infrastructure, medicines, a referral system, and community outreach.24 behavior is a factor that can be modified and is expected to be implemented well by hypertensive patients to control and prevent the worsening of hypertension. the desired behavior in hypertensive patients is health control behavior, consumption of antihypertensive drugs, and healthy lifestyle behavior. hypertensive patients with poor behavior in controlling high blood pressure have a 17.23 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=130). characteristics of respondents n % age 35-44 years 14 10.8 45-54 years 31 23.8 55-65 years 56 43.1 66-74 years 23 17.7 75-90 years 6 4.6 gender male 37 28.5 female 93 71.5 level of education primary education 44 33.8 secondary education 58 44.6 higher education 28 21.5 long suffered from hypertension ≤ 5 years 51 39.2 6-10 years 23 17.7 ≥ 10 years 22 16.9 forget 34 26.2 classification of hypertension grade i hypertension 67 51.5 grade ii hypertension 15 11.5 grade iii hypertension 8 6.2 isolated hypertension 40 30.8 table 2. description of primary health facilities availability, health control behavior, drug consumption behavior, and healthy lifestyle behavior in hypertensive patients (n=130). variable n % availability of primary health facilities good 114 87.7 enough 16 12.3 less 0 0 patient behavior for health control good 20 15.4 enough 35 26.9 less 75 57.7 patient behavior regarding consumption of antihypertensive drugs good 60 46.2 enough 30 23.1 less 40 30.8 patient behavior for a healthy lifestyle good 56 43.1 enough 55 42.3 less 19 14.6 table 3. relationship between the availability of primary health facilities and health control, drug consumption, and healthy living behavior among patients with hypertension (n=130). availability of primary health control drug consumption healthy living behavior healthcare facilities good enough less good enough less good enough less good 20 35 59 60 29 25 56 50 8 enough 0 0 16 0 1 15 0 5 11 less 0 0 0 0 0 0 0 0 0 p 0.0001 0.0001 0.0001 r 0.310 0.461 0.478 *correlation is significant at the 0.01. [page 140] [healthcare in low-resource settings 2024;12:11867] non -co mmerc ial us e o nly times greater risk of experiencing complications than those who have good behavior in controlling hypertension.25 patient beliefs about hypertension, knowledge about the dangers of hypertension, and its management have been reported to influence patient compliance in implementing healthy behavior or lifestyle.26 family support also correlates with hypertensive patients’ adherence to antihypertensive drugs, according to recommendations from health workers.27 self-efficacy, individual coping, and social support from family and health workers are also related to the behavior of hypertensive patients in controlling blood pressure and preventing cardiovascular complications.28 apart from that, hypertensive patients’ self-awareness of the dangers of hypertension complications such as stroke can also influence the behavior of hypertensive patients to better prevent hypertension complications.29 various efforts by good primary health facilities to improve health control behavior, consumption of antihypertensive drugs, and healthy lifestyles must continue to be carried out, such as training health workers on preventing and controlling hypertension as part of their daily practice in the community.24 it must be realized that the patient’s level of awareness influences the behavior of hypertensive patients in utilizing primary health facilities, the perceived level of severity, the perceived effectiveness of therapy, the side effects of the treatment received, and the patient’s fear of lifelong dependence on the hypertension medication given.30 health workers working in primary health facilities must move to support compliance in managing hypertensive patients by maintaining persuasive communication with hypertensive patients, providing sufficient time for patients to ask questions and receive recommendations, and taking a hypertension management approach that is responsive to individual needs according to ethnicity. culture and community that provide benefits.31 apart from that, it is also essential to increase the commitment of the government to plan a regular hypertension skinning program in the community, provide adequate medicines, provide modern equipment, and empower health workers who work in primary health facilities to research various factors that influence hypertension patient compliance in following the treatment program provided.32 another strategy that can be implemented is a task division model, which involves transferring specific tasks from doctors to nurses and local community health workers, which will be very important to improve primary care health services in controlling hypertension and preventing cardiovascular disease in hypertensive patients in the community.33 future work should focus on developing and validating performance indicators to facilitate an orderly and systematic review of data on the management of hypertensive patients in the community to improve outcomes and more targeted follow-up planning.17 the results of this study provide evidence to the government and managers of primary health facilities that the availability of primary health facilities is related to the behavior of hypertensive patients in controlling their health, consuming anti-hypertension drugs, and implementing a healthy lifestyle. the role of primary health facilities must continue to be improved to produce better behavior of hypertensive patients in the community to control and prevent complications of hypertension. this research has limitations in only looking at the correlation between the availability of primary healthcare facilities and the behavior of hypertensive patients in the community. research on other factors that influence the behavior of hypertensive patients in the community needs to be carried out further. conclusions the availability of primary health facilities in the community was good, but their use by hypertensive patients was still not optimal. the availability of primary health facilities in the community has a significant relationship with the health control behavior, drug consumption, and healthy living behavior among patients with hypertension. we recommend to the government and health workers in primary health facilities to continue to be committed to providing various health programs for hypertension patients. health promotion and health prevention are the main work programs of primary health facilities which must continue to be improved. references 1. who. hypertension [internet]. world health organization. 2023. available from: https://www.who.int/news-room/factsheets/detail/hypertension 2. aditiawarman, zulhijayanti na, ernawati e, akbar mia. a retrospective cohort study of hypertension, cardiovascular disease, and metabolic syndrome risk in women with history of preterm and term preeclampsia five years after delivery. pregnancy hypertens 2023;32:57–63. 3. athiyah u, subarniati r, yuda a. medication adherence in elderly patients with hypertension. asian j pharm clin res 2017;10:165–70. 4. who. complication prevention for patients with hypertension. world heal organ 2017;13. 5. who. improving hypertension control in 3 million people: country experiences of programme development and implementation. hearts 2020;1–74. 6. suhat s, suwandono a, adi ms, et al. relationship of health belief model with medication adherence and risk factor prevention in hypertension patients in cimahi city, indonesia. evid based care j 2022;12:51–6. 7. stephen c, halcomb e, mcinnes s, et al. improving blood pressure control in primary care: the impress study. int j nurs stud 2019;95:28–33. 8. andriani p, chamidah n. modelling of hypertension risk factors using logistic regression to prevent hypertension in indonesia. in: 2nd international conference on mathematics: education, theory, and application, icmeta 2018. stud. of study program of statistics, department of mathematics, faculty of sciences and technology, airlangga university, surabaya, indonesia: institute of physics publishing; 2019. 9. mulia epb, prajitno s. neglected cases of hypertension in rural indonesia: a cross-sectional study of prevalence and risk factors on adult population. in: iop conference series: earth and environmental science. 2020. 10. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632–45. 11. kemenkes ri. hasil utama riskesdas tahun 2018. kementeri kesehat badan penelit dan pengemb kesehat; 2018. 12. kemenkes ri. hipertensi si pembunuh senyap. in pusat data dan informasi kementeria kesehatan ri; 2019. 13. alkaff ff, sukmajaya wp, intan re, salamah s. effectivity of indonesia chronic disease management program (prolanis) to control hypertension and its comorbidities at primary health care. open access maced j med sci 2020;8:224–7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11867] [page 141] non -co mmerc ial us e o nly 14. oba n, chutipanyaporn n. the effectiveness of a nurse-led team-based hypertension management among people with uncontrolled hypertension in a community hospital, thailand. j ners 2021;16(2). 15. musinguzi g, bastiaens h, wanyenze rk, et al. capacity of health facilities to manage hypertension in mukono and buikwe districts in uganda: challenges and recommendations. plos one 2015;10:1–16. 16. undang undang keperawatan. undang-undang republik indonesia nomor 38 tahun 2014 tentang keperawatan. kementeri sekr negara ri. 2014. 17. yan ld, chirwa c, chi bh, et al. hypertension management in rural primary care facilities in zambia: a mixed methods study. bmc health serv res 2017;17:1–10. 18. liu j, yin h, zheng t, et al. primary health institutions preference by hypertensive patients: effect of distance, trust and quality of management in the rural heilongjiang province of china. bmc health serv res 2019;19:1–9. 19. khanal s, veerman l, nissen l, hollingworth s. use of healthcare services by patients with non-communicable diseases in nepal: a qualitative study with healthcare providers. j clin diagnostic res 2017;11:lc01–5. 20. permenkes ri. peraturan menteri kesehatan republik indonesia nomor 75 tahun 2014 tentang pusat kesehatan masyarakat. 2014. 21. garzón ne, heredia lpd. validity and reliability of the treatment adherence questionnaire for patients with hypertension. investig y educ en enferm 2019;37:1–13. 22. janna nm. konsep uji validitas dan reliabilitas dengan menggunakan spss. artik sekol tinggi agama islam darul dakwah wal-irsyad kota makassar 2020;18210047:1–13. 23. adejumo o, ogundele o, mamven m, et al. assessment of hypertension service availability in some primary health centres in nigeria: a mixed-methods study. bmj open 2023;13:e073833. 24. bawazir a, al-surimi k, suwaidan sd, et al. capacity and readiness of primary health care centers for implementation of the basic strategy for prevention and control of non-communicable diseases in saudi arabia. a case study from the ministry of national guard-health affairs, riyadh, saudi arabia. saudi med j 2019;40:614–8. 25. israfil i, sinaga m, ludji idr. effect of patients behavior and family health companion role on hypertension complication occurrence. unnes j public heal 2018;7:133– 41. 26. alefan q, huwari d, alshogran oy, jarrah mi. factors affecting hypertensive patients’ compliance with healthy lifestyle. patient prefer adherence 2019;13:577–85. 27. kurniawati nd, wahyuni ed, toulasik ya. family support improves hypertensive patient drug compliance. indian j public heal res dev 2019;10:2660–5. 28. israfil i, yusuf a, efendi f. factors associated with behavior in the prevention of cardiovascular complications in hypertensive patients in indonesia: a systematic review. proc 22nd int conf public heal sci j heal res 2023;37:s1–194. 29. upoyo as, isworo a, sari y, et al. determinant factors stroke prevention behavior among hypertension patient in indonesia. open access maced j med sci 2021;9:336–9. 30. musinguzi g, anthierens s, nuwaha f, et al. factors influencing compliance and health seeking behaviour for hypertension in mukono and buikwe in uganda: a qualitative study. int j hypertens 2018;2018:13. 31. shima r, farizah mh, majid ha. a qualitative study on hypertensive care behavior in primary health care settings in malaysia. patient prefer adherence 2014;8:1597–609. 32. sorato mm, davari m, kebriaeezadeh a, et al. reasons for poor blood pressure control in eastern sub-saharan africa: looking into 4p’s (primary care, professional, patient, and public health policy) for improving blood pressure control: a scoping review. bmc cardiovasc disord 2021;21:1–15. 33. husain mj, haider ms, tarannum r, et al. cost of primary care approaches for hypertension management and risk-based cardiovascular disease prevention in bangladesh: a hearts costing tool application. bmj open 2022;12:e061467. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 142] [healthcare in low-resource settings 2024;12:11867] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11776 the effect of dayak onion brewed water in reducing blood pressure and mean arterial pressure (map) in hypertensive patients diah setiani, rahmawati shoufiah, hesti prawita widiastuti, indah nur imamah, rivan firdaus, frana andrianur department of nursing, east kalimantan ministry of health polytechnic, samarinda, indonesia abstract the world health organization (who) estimated that 1.28 billion adults aged 30-79 years worldwide suffered from hypertension. dayak onion is an herbal plant found in indonesia, particularly in kalimantan and traditionally used to treat hypertension. the purpose of this study was to determine the effect of dayak onion steeping water on the reduction of systolic-diastolic blood pressure and mean arterial pressure (map) in hypertensive patients. this study employed a quasi-experimental research design with a time series approach, utilizing a pre-post-test design with a control group. the sample included two groups (intervention and control), totaling 30 participants. the independent variable was the steeping of dayak onion bulbs, while the dependent variables were blood pressure values and map. the instruments used were standard operating procedures (spo) dayak onion herb, spo blood pressure measurement, spo calculation of map, and a digital sphygmomanometer. data analysis was performed using paired t-tests. the results of the paired t-test statistical analysis of systolic-diastolic values and map in each group revealed significant findings. in the intervention group, a significant result was obtained in the pre-post test difference test, with a p<0.05 from day 1 to day 3 assessments. this suggests that dayak onion steeping water had an effect on systolic-diastolic and map values in the intervention group. in contrast, the pre-post test in the control group yielded a p<0.05 for systolic values on days 2 and 3, diastolic values on days 1 and 3, and map values on days 1, 2, and 3. this indicates differences in systolic-diastolic and map values in the pre-post assessments, although these differences were not evenly distributed across every day. the study found that dayak onion steeping water had an effect on systolic-diastolic and map values in the intervention group. thus, the use of dayak onion steeping water, containing allicin, can be considered an approach for controlling hypertension in the realm of complementary and alternative medicine, utilizing natural ingredients for herbal therapy. introduction an estimated 1.28 billion adults aged 30-79 years worldwide suffer from hypertension, with the majority (two-thirds) residing in lowand middle-income countries. approximately 46% of adults with hypertension are unaware of their condition, and less than half (42%) receive a diagnosis and treatment. only about 1 in 5 adults (21%) with hypertension have their blood pressure under control. hypertension, often referred to as the silent killer, can wreak havoc if left uncontrolled, targeting vital organs and leading to heart attacks, strokes, kidney disorders, and even blindness.1 hypertension induces endothelial dysfunction, exacerbates the atherosclerotic process, and contributes to the instability of correspondence: diah setiani, department of nursing, east kalimantan ministry of health polytechnic, samarinda, indonesia. e-mail: diah.dee.oc@gmail.com key words: allicin; blood pressure; dayak onion; hypertension; map. contributions: ds, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; final approval of the version to be published funding acquisition. rs, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; hpw, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ini, methodology, visualization, writing – review & editing; ss resources, investigation, and writing –review & editing; rf, formal analysis, validation, writing – review & editing; fa, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes kalimantan timur, based on ethical certificate no. lb.02.01/7.1/3320/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 12 september 2023. accepted: 6 november 2023. early access: 21 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11776 doi:10.4081/hls.2023.11776 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11776] [page 167] non -co mmerc ial us e o nly atherosclerotic plaques. while hypertension is typically asymptomatic and can go unnoticed, some patients may report symptoms such as dizziness, headaches, nosebleeds, chest pain, and palpitations.2–4 hypertension stands as the leading cause of premature death worldwide, and one of the global targets for non-communicable diseases is to reduce its prevalence by 33% between 2010 and 2030.5 hypertension is more prevalent among men, older adults, and those who are overweight or obese. in indonesia, the prevalence of hypertension rose from 25.8% in 2013 to 34.1% in 2018. in 2018, the number of individuals with hypertension in indonesia reached 63.3 million, accounting for 34.11% of the population. the hypertension rate in indonesia reached 63.3 million, 34.11% of the population, in 2018.6 in east kalimantan province, the prevalence of hypertension per district, based on a doctor’s diagnosis in the population aged over 18 years, according to riskesdas data from 2018, shows the following statistics for hypertension sufferers: paser regency 9.70%, west kutai regency 11.33%, kutai kartanegara regency 10.14%, east kutai regency 8.12%, berau regency 9.75%, north penajam paser regency 8.49%, mahakam ulu regency 13.77%, balikpapan city 12.66%, samarinda city 11.19%, bontang city 9.23%. west kutai regency, based on riskesdas 2018 data, has the highest prevalence of hypertension per district in east kalimantan. notably, in barong tongkok district, the incidence of hypertension is relatively high, with data from the barong tongkok health center indicating that, as of october 2021, 561 people, comprising 190 men and 371 women in the age group of 15-59 years, have been diagnosed with hypertension.7 hypertension, defined as persistent systolic blood pressure (sbp) of at least 130 mm hg or diastolic blood pressure (dbp) of at least 80 mm hg,8 affects approximately 116 million adults in the us and more than 1 billion adults worldwide. it is associated with an increased risk of cardiovascular disease (cvd) events, including coronary heart disease, heart failure, and stroke, as well as a higher risk of mortality.9,10 the global prevalence of hypertension poses a significant public health challenge due to the frequency of the condition and its associated risks of cardiovascular and kidney diseases. the treatment of hypertension includes both pharmacological and non-pharmacological approaches. pharmacological therapy involves various classes of drugs, such as angiotensin-converting enzyme inhibitors, calcium channel blockers, diuretics, beta-blockers, alpha-blockers, and angiotensin ii and insulin receptor antagonists. non-pharmacological therapy focuses on implementing a healthy lifestyle. antihypertensive treatment aims to prevent the onset of related diseases by effectively controlling high blood pressure.11 antihypertensive treatment aims to prevent these diseases by controlling high blood pressure.12 the availability, cost, and adverse effects of conventional hypertension medications limit effective treatment. due to these limitations, some patients, particularly in developing countries, turn to complementary and alternative medicine for treatment.13 effective management of hypertensive patients is a crucial strategy to prevent the increase in morbidity and mortalit.14 unfortunately, there is a lack of recommendations for complementary therapy in hypertension treatment guidelines.15 it is well-known that many hypertensive patients seek complementary and alternative medicine.16 complementary and alternative medicine therapies are typically divided into four main domains. they involve the utilization of natural compounds like probiotics, prebiotics, and dietary supplements to strengthen and promote healing in the human body. in this context,17 natural compounds contained in plants, such as herbs, play a significant role. natural plant products have been employed throughout human history for various purposes. today, herbal products are used to address a wide range of health issues and conditions, including allergies, arthritis, migraines, fatigue, wound healing, burns, digestive problems, skin infections, genetic disorders, and even cancer.18 complementary and alternative medicine therapies are typically divided into four main domains. they involve the utilization of natural compounds like probiotics, prebiotics, and dietary supplements to strengthen and promote healing in the human body. in this context, natural compounds contained in plants, such as herbs, play a significant role. natural plant products have been employed throughout human history for various purposes. today, herbal products are used to address a wide range of health issues and conditions, including allergies, arthritis, migraines, fatigue, wound healing, burns, digestive problems, skin infections, genetic disorders, and even cancer.19 dayak onion plants are commonly found in kalimantan, particularly in east kalimantan, within the west kutai regency. the most frequently used part of this plant is its tubers. this plant contains a wide array of phytochemical compounds, including alkaloids, glycosides, flavonoids, phenolics, and steroids. through the isolation of compounds from dayak onion bulbs, 15 compounds were identified, including (2s) dihydroeleuterinol-8-o-α-d-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaa, (-)hongkonin, eleuterin, isoeleuterin, (2s) dihydroeleuterinol-8-o-αd-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaa, (-)-hongkonin, eleuterin, isoeleuterin, eleutocidac, eleuterinosidac, eleuterinosidab, the-7-acetyl-3,6dihydroxy-8-methyltetralon, leutocidea, leutocideb, and eleuterinosided. among these compounds, eleuterol, eleuterin, and isoeleuterin have demonstrated potential as antihypertensive agents.20 according to a study conducted by swandari & nuryanto in 2018 on the anti-inflammatory activity of ec50 results, e. bulbosa extract exhibited potential anti-inflammatory properties, with effectiveness nearly equaling half the concentration of indomethacin. other studies have supported this finding, indicating that components in dayak onion extract, specifically eleutherine and isoeleutherine, displayed anti-inflammatory activity by inhibiting carrageenan-induced leg edema. the mechanism of action for e. bulbosa extract’s anti-inflammatory effects is believed to be related to its flavonoid content. one significant mechanism for anti-inflammatory activity involves the inhibition of enzymes that produce eicosanoids (phospholipase a2, cyclooxygenase, and lipoxygenase), leading to reduced levels of prostanoids and leukotrienes. other potential anti-inflammatory mechanisms may include the inhibition of histamine release, phosphodiesterase, protein kinase, and transcriptase activation.21 based on several empirical reviews regarding the efficacy and compounds found in dayak onions, researchers have become interested in understanding the impact of steeping dayak onions on reducing blood pressure and mean arterial pressure in hypertensive patients. this study serves as a means of exploring complementary therapies and alternative medicine, employing natural ingredients rooted in the local wisdom of kalimantan for herbal therapy management. the purpose of this study was to determine the effect of dayak onion steeping water on the reduction of systolic-diastolic blood pressure and mean arterial pressure (map) in hypertensive patients. materials and methods the research design used was a quasi-experimental approach [page 168] [healthcare in low-resource settings 2023; 11:11776] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly with a time series method and a pre-post-test design that included a control group. the sample consisted of two groups, the intervention and control groups, each comprising 30 participants. the inclusion criteria for the sample were respondents aged 35-59 years, not currently taking antihypertensive drugs, and not experiencing crisis conditions or hypertensive emergencies. in this study, the independent variable was the steeping of dayak onion bulbs, while the dependent variables were systolic, diastolic, and mean arterial pressure (map) values. the instruments utilized included standard operating procedures (spo) for the preparation of dayak onion ingredients in the intervention group, spo for blood pressure measurements, and spo for calculating map. digital sphygmomanometers were used for blood pressure measurements. data analysis for this study was conducted using paired t-tests. the research received ethical approval from the health research ethics commission at poltekkes kemenkes kalimantan timur, based on ethical certificate no. lb.02.01/7.1/3320/2022. throughout the research, the researcher adhered to ethical principles such as obtaining informed consent, respecting human rights, promoting beneficence, and ensuring non-maleficence. results characteristics of respondents table 1 shows that in the intervention group, the majority of respondents were aged 36-45 years, comprising 8 people (53.3%), whereas in the control group, most fell into the 46-55 age range, totaling 12 people (66.7%). as for gender, the majority in both groups were women; in the intervention group, there were 10 people (66.7%), and in the control group, there were 8 people (44.4%). concerning the history of hypertension drug usage, the majority in the intervention group took captopril, accounting for 9 people (60.0%), while in the control group, almost all used amlodipine, with 14 people (77.8%). table 2. shows that systolic-diastolic blood pressure in the intervention group decreased. this is evident in the systolic mean of the intervention group on day 1, where the pre-post values were (163.33-154.27). after the administration of dayak onion steeping water as an intervention, the systolic mean on day 3 also decreased, with pre-post values of (142.93-139.80). similarly, the diastolic values of respondents decreased after they were given dayak onion steeping water, with a mean pre-post change from (116.87101.73) on day 1, and on day 3, the change was from (89.93transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents. characteristics of respondents intervention group control group frequency % frequency % age 36-45 years 8 53.3 3 16.7 46-55 years old 7 38.9 12 66.7 gender man 5 33.3 7 38.9 woman 10 66.7 8 44.4 history of antihypertensive drugs taken amlodipine 6 40.0 14 77.8 captopril 9 60.0 1 5.6 total 15 100 15 100 table 2. blood pressure: systolic and diastolic, and map in both groups (intervention and control). intervention group control group day measurement variable min max mean sd min max mean sd 1 pre systolic 153 173 163.33 5.108 155 173 164.07 4.773 diastolic 104 127 116.87 7.661 102 124 112.93 6.552 map 211 236 221.77 6.695 207 235 220.53 7.267 post systolic 144 164 154.27 5.175 145 160 154.60 3.719 diastolic 90 114 101.73 7.196 90 119 103.13 6.770 map 191 220 205.13 7.413 195 215 206.37 4.835 2 pre systolic 140 161 150.27 5.861 143 156 151.73 3.195 diastolic 88 110 96.27 6.029 83 102 93.67 5.434 map 191 220 205.13 7.531 191 205 198.57 4.590 post systolic 138 153 145.47 4.207 139 150 145.07 3.615 diastolic 85 103 92.00 4.472 80 92 85.80 3.448 map 185 213 198.40 5.377 181 195 187.97 4.704 3 pre systolic 137 150 142.93 3.936 137 146 142.13 3.067 diastolic 84 99 89.93 3.788 81 88 83.73 2.120 map 180 196 187.90 4.789 179 189 184.00 3.665 post systolic 135 145 139.80 3.121 134 140 136.47 1.846 diastolic 82 93 86.73 3.515 78 84 80.80 1.424 map 176 189 183.17 3.488 174 180 176.93 1.954 [healthcare in low-resource settings 2023; 11:11776] [page 169] non -co mmerc ial us e o nly 86.73). regarding the map value, the intervention group also experienced a decrease after receiving the intervention of dayak onion steeping water. the mean map on day 1 changed from (221.77-205.13) pre-post, and after the intervention, the mean map on day 3 changed from (187.90-183.17). it’s worth noting that systolic-diastolic blood pressure in the control group also decreased. this is evident in the systolic mean on day 1, where the pre-post values were (164.07-154.60), and on day 3, the values were (142.13-136.47). similarly, the diastolic values changed, with the mean pre-post values being (112.93103.13) on day 1, and on day 3, the values were (83.73-80.80). the map values of respondents in the control group also showed a decrease. the mean map on day 1 had pre-post values of (220.53206.37), and on day 3, the values were (184.00-176.93). table 3. based the results of paired t-test statistical tests on systolic-diastolic values and map in the pre-post test intervention group. a p-value of 0.000 (α<0.05) was obtained, which was observed from day 1 to day 3. this indicates that there are significant differences in systolic-diastolic values and map before and after the intervention in the intervention group. similarly, the paired t-test statistical test results for systolic, diastolic, and map values in the pre-post test control group yielded a p-value of < α (0.05) for systolic values on days 2 and 3, diastolic values on days 1 and 3, and map values on days 1, 2, and 3. this also indicates significant differences, reflecting a notable decrease in systolic-diastolic values and map in the control group. however, the decline in values was not evenly distributed on days 1, 2, or 3. in contrast to the intervention group, which experienced a consistent decrease in values on days 1, 2, and 3, it becomes evident that there is an effect of dayak onion steeping water (eleutherine palmifolia) on systolic-diastolic and map values in the intervention group. discussion the results of paired t-tests on systolic-diastolic values and map for each group displayed significant outcomes. in the intervention group, a significant result was obtained in the pre-post test difference analysis, with a p-value of < 0.05 from day 1 to the day 3 assessment. this indicates that there was an effect of dayak onion steeping water on systolic-diastolic and map values in the intervention group. in the pre-post test for the control group, significant p<0.05 were obtained for systolic values on days 2 and 3, diastolic values on days 1 and 3, and map values on days 1, 2, and 3. this indicates that there are differences in systolic-diastolic values and map in the pre-post values, although these differences are not evenly distributed every day. dayak onion bulbs contain active compounds that are potent in combating various diseases, including their effectiveness as antihypertensive agents. these active compounds belong to the triterpenoid group, quinones, and naphthoquinones, along with the presence of allicin and alkaloids.22 allicin is believed to reduce blood viscosity, thereby leading to a reduction in blood pressure.23 this plant contains nearly all phytochemical content, including alkaloids, glycosides, flavonoids, phenolics, and steroids. through the isolation of compounds from dayak onion bulbs, 15 compounds were identified, namely (2s) dihydroeleuterinol-8-o-α-d-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaa, (-)hongkonin, eleuterin, isoeleuterin, (2s) dihydroeleuterinol-8-o-αd-glucopyranosida, dihydroeleuterinol, eleuterinol, eleuterinosidaa, (-)-hongkonin, eleuterin, isoeleuterin, eleutocidac, eleuterinosidac, eleuterinosidab, the-7-acetyl-3,6dihydroxy-8-methyltetralon, leutocidea, leutocideb, and eleuterinosided.20 the activity of eleuterol, eleuterin, and isoeleuterin has the potential to act as antihypertensive agents.24 dayak onion tea has an effect on reducing blood pressure in hypertensive patients, with a p-value of 0.001 for systolic value and a p-value of 0.002 for diastolic value. in other words, dayak onion tea has an impact on blood pressure.25 the administration of 100% dayak onion tea resulted in a significant decrease in high blood pressure. the analysis yielded a p-value of 0.000 (p < 0.05) for the respondents’ blood pressure, indicating that dayak onion tea has a noticeable effect on reducing blood pressure in the elderly.26 particularly in allicin compounds, they exhibit vasodilator activity independent of nitric oxide synthesis, atp-sensitive k(+) channels, activation of cyclooxygenase enzymes, or changes in bronchomotor tone in rat pulmonary blood vessels. allicin is also believed to inhibit the renin-angiotensin system, which plays a crucial role in renovascular hypertension. this reduction in blood pressure occurs through the inhibition of angiotensin conversion enzyme (ace) activity, while simultaneously enhancing the vasodilator effect. this decrease in ace activity is observed in serum, aorta, heart, lungs, and kidneys. treatment with allicin results in decreased hypertension, improved kidney function, and reduced heart dysfunction. allicin compounds reduce vascular reactivity to angiotensin ii, at1r overexpression, and morphometric parameters. allicin also downregulates keap1 and upregulates nrf2 expression, leading to an increase in antioxidant enzymes and a reduction in oxidative stress. therefore, allicin demonstrates antihypertensive, nephroprotective, cardioprotective,27 and antioxidant effects through the downregulation of at1r and keap1 expression.28 simple extraction transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. blood pressure difference test: systolic and diastolic, map in both groups (intervention and control). intervention group control group day measurement variable mean sd p mean sd p 1 pre -post systolic 9.067 2.789 0.000 9.467 4.596 0.104 diastolic 15.133 5.768 0.004 9.800 5.979 0.019 map 16.633 4.608 0.000 14.167 6.307 0.048 2 pre -post systolic 4.800 2.484 0.000 6.667 2.664 0.004 diastolic 4.267 2.187 0.000 7.867 5.343 0.210 map 6.933 3.035 0.000 10.600 2.836 0.000 3 pre -post systolic 3.133 1.356 0.000 5.667 2.225 0.004 diastolic 2.867 2.356 0.000 2.933 1.100 0.000 map 4.733 1.954 0.000 7.067 2.456 0.001 [page 170] [healthcare in low-resource settings 2023; 11:11776] non -co mmerc ial us e o nly methods of natural ingredients, such as onions containing allicin,29 can reduce systolic and diastolic blood pressure.30 allicin has a potent antihypertensive effect, and this effect is associated with its vasodilatory properties and the h2s mechanism. the vasorelaxant activities of allicin are, in part, dependent on the endothelium. endothelium-dependent vasorelaxation by allicin is mediated by the no-sgc-cgmp, pgi2-ac-camp, and edhf pathways, with h2s production playing a role in the first two pathways, rather than the third one. meanwhile, endotheliumindependent vasodilation is primarily attributed to h2s production. therefore, the current study suggests that allicin might serve as an alternative agent for reducing the incidence of cardiovascular disorders in the hypertensive population.31 the effects of allicin, both direct and indirect through cytokine activation, can increase the quantity and proliferation of epcs. this effect of allicin on epc proliferation might explain the improvements in cardiovascular disease.32 garlic and dayak onions both contain various active components. the biological functions of garlic include antioxidant activity, anti-inflammatory activity, antimicrobial activity, immune system modulation, cardiovascular protection, antihypertensive activity, anti-hyperlipidemia activity, heart protection, other cardiovascular protective effects, anticancer activity, hepatoprotective activity, digestive system protection, anti-diabetic activity, anti-obesity activity, and renal protection.33 providing hypertensive patients with dayak onion bulb steeping water can reduce systolic-diastolic and map values. the simple extraction of dayak onion bulbs through steeping in hot water makes it easier for patients to consume the active compounds they contain. specifically, allicin, the active compound in dayak onions, has a vascular vasodilator effect that can inhibit the reninangiotensin system, which plays a role in raising blood pressure. therefore, the provision of dayak onion steeping water to hypertensive patients can serve as a management approach in the domain of both complementary and alternative medicine for controlling hypertension through the use of natural ingredients in herbal therapy. conclusions the results of statistical tests in the intervention group yielded significant values in the measurement of blood pressure values, including systolic-diastolic and map, on days 1 to 3. this indicates that there was an effect of dayak onion steeping water on systolicdiastolic and map values in the intervention group. therefore, providing dayak onion steeping water to hypertensive patients can be employed as a management approach in the realm of both complementary and alternative medicine for ayakllingg hypertension through the use of natural ingredients as herbal therapies. references 1. israfil i, kusnanto k, yusuf a, efendi f. the effect of health education intervention through mobile phone on hypertension patients: a systematic review. med j malaysia 2022;77:232-6. 2. kalish la, buczynski b, connell p, et al. stop hypertension with the acupuncture research program (sharp): clinical trial design and screening results. control clin trials 2004;25:76-103. 3. makhfudli, susanto j, sairozi a, ubudiyah m. determinants of hypertension in outpatients in east java, indonesia. j pak med assoc 2023;73:s113-7. 4. escobar e. hypertension and coronary heart disease. j hum hypertens 2002;16:s61-3. 5. who. hypertension. who. 2023 available from: https://www.who.int/news-room/fact-sheets/detail/ hypertension 6. kusumaningrum t, pratiwi in, wahyu n, et al. factors associated with hypertension in women of childbearing age. the 13th international nursing conference 2021;73:109-12. 7. kementerian kesehatan ri badan penelitian dan pengembangan kesehatan. hasil utama riskesdas 2018. https://kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98 f00/files/hasil-riskesdas-2018_1274.pdf. 2018. 8. who. hypertension. 2023 [cited 2023 oct 30]. available from: https://www.who.int/news-room/fact-sheets/detail /hypertension 9. carey rm, moran ae, whelton pk. treatment of hypertension: a review. jama 2022;328:1849-61. 10. purnawan in, widati s, wahyuni cu. a cross-sectional study: a hypertension screening model using digital tensimeter as the gold standard at public health centre in gianyarregency, bali province, indonesia. j public health afr 2023;14:1-5. 11. pristianty l, priyandani y, rahem a. the correlation between knowledge, attitude and family support on compliance of outpatients with hypertension in a healthcare centre in indonesia. pharm educ 2023;23:25-30. 12. wijaya in, athiyah u, fasich, et al. the association between drug therapy problems and blood pressure control of patients with hypertension in public health center setting. j public health afr 2023;14:137-40. 13. ali-shtayeh ms, jamous rm, jamous rm, salameh nmy. complementary and alternative medicine (cam) use among hypertensive patients in palestine. complement ther clin pract 2013;19:256-63. 14. afik a, fikriana r. self-care experience in hypertensive patients. bali med j 2021;10:1398-402. 15. pristianty l, hingis es, priyandani y, rahem a. relationship between knowledge and adherence to hypertension treatment. j public health afr 2023;14:2502. 16. ng jy, gilotra k. complementary medicine mention and recommendations are limited across hypertension guidelines: a systematic review. complement ther med 2020;50:102374. 17. hass dj. complementary and alternative medicine. in: sleisenger and fordtran’s gastrointestinal and liver disease. elsevier; 2010. p. 2287-2299.e3. 18. dada r, sabharwal p, sharma a, henkel r. use of herbal medicine as primary or supplementary treatments. in: herbal medicine in andrology. elsevier; 2021. p. 9-15. 19. kamarudin aa, sayuti nh, saad n, razak naab, esa nmohd. eleutherine bulbosa (mill.) urb. bulb: review of the pharmacological activities and its prospects for application. int j mol sci 2021;22:6747. 20. prayitno b, mukti bh, lagiono. optimasi potensi bawang dayak (eleutherine sp.) sebagai bahan obat alternatif. jurnal pendidikan hayati 2018;3:149-58. 21. swandari paramita, muhammad khairul nuryanto. antiinflammatory activity of bawang ayak (eleutherine bulbosa (mill. urb.))ethanol bulb extracts. j vocat health stud 2018;51-5. 22. chan jyy, yuen acy, chan ryk, chan sw. a review of the cardiovascular benefits and antioxidant properties of allicin. phytother res 2013;27:637-46. [healthcare in low-resource settings 2023; 11:11776] [page 171] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 23. utami p, mardiana l, penulis ps t. umbi ajaib: tumpas penyakit. nugroho s, kusumaningtiyas p, w. b, p, editors. jakarta: penerbar swadaya; 2013. 24. lidiková j, čeryová n, tóth t, et al. garlic (allium sativum l.): characterization of bioactive compounds and related health benefits. in: herbs and spices new advances. intechopen; 2023. 25. handayani s, dewantari em, my c, fitria n, kesehatan fi. pengaruh pemberian the bawang dayak terhadap penurunan tekanan darah pada penderita hipertensi. jurnal perawat indonesia 2021;5:724-30. 26. tetty junita purba. pengaruh pemberian the bawang dayak terhadap penurunan hipertensi pada lansia. best j 2021;5:393-8. 27. salehi b, zucca p, orhan ie, et al. allicin and health: a comprehensive review. trends food sci technol 2019;86:502-16. 28. garcía-trejo ema, arellano-buendía as, argüello-garcía r, et al. effects of allicin on hypertension and cardiac function in chronic kidney disease. oxid med cell longev 2016;2016:1-13. 29. bhardwaj k, verma m, verma n, et al. effect of long term supplementation of active garlic allicin in reducing blood pressure in hypertensive subjects. int j adv med 2015;231-4. 30. chan jyy, tsui ht, chung iym, et al. allicin protects rat cardiomyoblasts (h9c2 cells) from hydrogen peroxide-induced oxidative injury through inhibiting the generation of intracellular reactive oxygen species. int j food sci nutr 2014;65:86873. 31. cui t, liu w, chen s, et al. antihypertensive effects of allicin on spontaneously hypertensive rats via vasorelaxation and hydrogen sulfide mechanisms. biomed pharmacother 2020;128:110240. 32. putri ay, pikir bs, oktaviono yh, alzahra f. effects of garlic extract (allicin) on proliferation of endothelial progenitor cells (epc) in patients with stable coronary artery disease. in: iop conference series: earth and environmental science. 2020. 33. shang a, cao sy, xu xy, et al. bioactive compounds and biological functions of garlic (allium sativum l.). foods 2019;8:246. [page 172] [healthcare in low-resource settings 2023; 11:11776] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11896 the effect of mindful eating on dietary behaviour and fasting blood glucose in type 2 diabetes mellitus patients rizki andriani,1 aghnia kamila,2 roofi asma putri,1 arif fadhillah,1 sabrina helmi,3 delia septiani1 1sekolah tinggi ilmu kesehatan medika seramoe barat meulaboh, west aceh; 2zainoel abidin aceh general hospital, banda aceh; 3cot seumeureung public health center, west aceh, indonesia abstract diet plays a pivotal role in the comprehensive therapy for individuals with type 2 diabetes mellitus, contributing significantly to maintaining stable glycemic control. mindful eating, as an intervention, focuses on enhancing dietary behavior by directing attention, thoughts, and feelings towards eating activities. this study aimed to investigate the impact of mindful eating on dietary behavior and fasting blood glucose levels in individuals with type 2 diabetes mellitus. employing a quasi-experimental method with a pretest-posttest control group design, the study included a sample of 63 participants (selected through convenience sampling). data collection utilized the personal diabetes questionnaire (pdq) and a glucometer. statistical analysis involved wilcoxon, mann-whitney, and independent t-tests. the findings revealed that mindful eating exercises had a significant influence on dietary behavior (p=0.025) and fasting blood glucose levels (p=0.033). the practice of mindful eating led to notable improvements in dietary behavior and ensured controlled fasting blood glucose levels by the study’s conclusion. incorporating mindful eating exercises into eating patterns is recommended as a crucial aspect of diabetes management, aiming to enhance dietary behavior and sustain stable glycemic control. introduction diabetes is a health problem that has reached a very worrying level and requires proper treatment so that this disease does not get worse.1 about 60% of diabetic patients have difficulty following the recommended diet because it must be carried out for a lifetime.2 dietary management in diabetes is challenging as patients often feel bored with lifelong diet programs, struggle with perceptions of healthy foods and portion sizes, favor specific food types, and have difficulty following dietary recommendations daily.3–5 various modifications to the diet program are needed to improve dietary behaviour to be more adaptive and maintain glycemic control as recommended.6,7 diet is the most critical component of the overall therapy plan for t2dm people.8 currently, 537 million people worldwide are living with diabetes.9 indonesia occupies the fifth position as a country with a prevalence of 19.5 million adults diagnosed with diabetes, and type 2 diabetes mellitus (t2dm) accounts for 90% of diabetes incidence worldwide.10 obstacles in diet have the potential to trigger behavioural changes in doing the recommended diet.11 diet education and medication control have been provided and understood by most diabetic patients. however, the inability to control dietary behaviour plays a role in the glycemic control of t2dm patients becoming worse and causing complications.5,12,13 interventions related to dietary behavior have an impact on better glycemic control.14,15 mindful eating exercise is correspondence: rizki andriani, sekolah tinggi ilmu kesehatan medika seramoe barat meulaboh, west aceh, indonesia. e-mail: rizkiandriani.qq@gmail.com key word: diabetes mellitus, diet, dietary behaviour, fasting blood glucose, mindful eating, mindfulness. contributions: ra conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ak conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; rap conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; af resources, investigation, and writing – review and editing; sh formal analysis, validation, writing – review and editing; ds resources, supervision, and writing –review and editing. funding: this research was supported by a research grant from ministry of education and culture research and technology of the republic of indonesia (kemdikbudristek) with contract number 189/e5/pg.02.00.pl/2023 conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, universitas ‘aisyiyah bandung, based on ethical certificate 657/kep.01/unisabandung/viii/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to stikes medika seramoe barat, lppm-stikes medika seramoe barat, and cot seumeureung public health center, aceh barat who have facilitated the implementation and their valuable insights of this research. received: 1 october 2023. accepted: 23 january 2024. early access: 23 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11896 doi:10.4081/hls.2024.11896 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11896] [page 397] non -co mmerc ial us e o nly one intervention that dmt2 patients can apply during eating activities; this exercise can focus on eating activities that involve the mechanism of stimulating alertness from within oneself. mindfulness practice during eating activities increases the body’s physiological cue response when hungry or full and increases selfawareness, which contributes to the preparation of adaptive dietary behavior patterns.16 this result can be seen in a study of 304 adult respondents who were given mindful eating exercises, where respondents showed better self-control in eating behavior and had the willingness to arrange regular eating patterns.17 attention to sensations, thoughts, and feelings during eating activities related to regulation, emotions, and self-acceptance can reduce problematic eating behaviors so that t2dm patients are able to make their own decisions about what, when, and how much food to consume.18–20 mindful eating exercises indirectly make it easier for diabetic patients to achieve portion adjustments based on adequacy and satisfaction that arise during meals and have an impact on daily calorie intake so that it can potentially affect glycemic control in dm clients. this intervention is expected to establish adaptive control of eating behavior, adherence to the recommended diet, and controlled patient glycemic, including adequate nutritional intake in patients.21,22 a case study by jordan et al.23 on 246 respondents and arch et al. studies24 conducted experimentally on 319 respondents showed a positive relationship between mindfulness and healthy eating behavior, reduced impulsive eating behavior, low consumption of unhealthy foods, and increased comfort in enjoying food. mindfulness eating practice has been widely studied in aspects of diet and obesity; however, in the case of dmt2, the effect of mindful eating practice on diet behavior and glycemic control is not very varied, and the explanation related to its effect is also not widely known so further research is needed on it. this study aimed to evaluate the effect of mindful eating exercises on dietary behavior and glycemic control in t2dm patients. materials and methods research design this study used a quasi-experimental research design with a pretest-posttest control group approach, which means that the samples in this study were collected 2 (two) times, namely before treatment (pretest) and after treatment (posttest).25 this study explained the demographics of respondents and the effect of mindful eating exercises on dietary behavior and fasting blood glucose levels in respondents. study participants this research was conducted at cot seumeureung public health center, which has the highest number of diabetics and hosts a chronic disease management program (prolanis) that is quite active; this program has educated patients regarding the diet recommended for t2dm patients. the chronic disease management program (prolanis) was established by the national health insurance in indonesia to provide a program aiming to improve the quality of life for chronic disease sufferers through cost-effective and efficient health services. the respondents of this study were t2dm patients who have actively participated in routine prolanis activities for the last three months, are adults aged 18-60 years, willing to take part in the study, with fasting blood glucose levels >130 mg/dl, cooperative, and able to communicate clearly and understand instructions in indonesian. the exclusion criteria included individuals with hearing loss, dental and oral problems, intellectual and cognitive disorders, and patients who are pregnant or breastfeeding. a total of 64 t2dm patients participated in the research between july and september 2023. these subjects were then randomly divided into two groups, each consisting of 32 respondents. instrument data collection in this study consisted of demographic data such as age, sex, education, duration of diabetes, employment, body mass index, and food intake. dietary behavior and fasting blood glucose level data in the treatment and control groups before and after the mindful eating intervention were also collected. measurement of dietary behavior data was carried out through the personal diabetes questionnaire (pdq) questionnaire, which includes four domains from the entire questionnaire: diet knowledge and skills, diet decision-making, eating problems, and diet adherence barriers. the questionnaire, consisting of 25 items, is rated on a six-point likert scale (never, 1 time per month or less, 2–3 times per month, 1–2 times per week, 4–6 times per week, 1 or more times per day). the total score for this questionnaire can range from 3-56, and these scores were categorized into two groups: bad (below the median) and good (above the median). this questionnaire has undergone translation and back-translation by commercial translation agencies to maintain the content’s accuracy, and was modified by researchers with the help of one diabetes educator. the pdq questionnaire was then tested for validity and reliability at a community health center with similar characteristics to the research site. the validity test on 17 question items showed that the calculated r-value > 0.444, which means all the questionnaire items are declared valid. the reliability test showed that the cronbach’s alpha value for the pdq questionnaire is 0.825, where an r-value for cronbach’s alpha > 0.444 indicates that the questionnaire is reliable. measurement of fasting blood glucose levels (fbg) was conducted using the sinocare safe-accu 2® glucometer, which was new from the manufacturer and had received usage approval from the indonesian ministry of health with number akl 20101027017. additionally, it came with a stick stored in standard packaging. this glucometer was validated by a health analyst from the health center regarding tool calibration, strip suitability, results, and battery capacity before use. blood collection followed gold standard operational procedures, and fasting blood glucose was categorized as controlled if it was <130 mg/dl. daily calorie intake was evaluated using a 24-hour food recall form that a nutritionist assessed. procedure pre-test data collection, including dietary behavior and fbg level one week before the research process began, was carried out in conjunction with diet education conducted by nutritionists based on personal calorie needs. the research team conducted regular home visits for 4 exercise sessions to train respondents in mindful eating. the researcher divided the team into 4 groups, with each group consisting of two people responsible for 16 respondents (8 respondents in the treatment group and 8 in the control group). in the treatment group, home visits occurred once a week for four weeks, following a contractual agreement with the respondents. during these visits, which lasted 20-30 minutes, researchers taught mindful eating exercises. instructions for the exercises were provided through voice recordings with a rate of 44100 hz and 16bit resolution, stored on mp3 players. each respondent in the treatment group received an mp3 player, which they could use to listen to the 6-minute voice recording through a headset during daily eating activities. in the control group, standard education related to dietary pat transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 398] [healthcare in low-resource settings 2024;12:11896] non -co mmerc ial us e o nly terns was given in 4 group sessions. post-test data collection on dietary behavior and fbg levels occurred one week after the last exercise session. at the study’s conclusion, the control group was also taught mindful eating exercises and received mp3 players with voice recordings of the exercise guides. data analysis the data analysis employed in this study used the statistical package for social sciences (spss) version 20 software. descriptive analysis identified age, sex, education, duration of diabetes, employment, body mass index, and food intake with frequency and percentage. the inferential analysis utilized the wilcoxon difference test, mann-whitney, and independent ttests. a 95% confidence level with a standard error of 0.05 was the criterion for significance. ethical clearance the research has received ethical approval from the health research ethics commission, universitas ‘aisyiyah bandung, based on ethical certificate 657/kep.01/unisa-bandung/viii/ 2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results respondent characteristics table 1 showed that the characteristics of respondents based on the age of majority are respondents aged 46-60 years (62.5%), with the majority of respondents being female (67.2%). generally, respondents are employed (71.9%) with the final education level at the elementary level (37.5%). the average respondent (60.9%) has suffered from t2dm > 5 years, where the body mass index of the majority of respondents is in the abnormal category (62.5%), and it can be seen from the status of calorie adequacy per day the majority of respondents exceed the standard calorie intake (57.8%). the effect of mindful eating exercise on dietary behavior and fasting blood glucose level table 2 showed changes in the frequency of dietary behavior of respondents in the treatment group, where before the intervention only 28.1% of respondents had good dietary behavior to 65.6% of respondents who had good dietary behavior after the intervention. meanwhile, before the pretest, 65.7% of respondents had poor dietary behavior in the control group and after the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11896] [page 399] table 2. the effect of mindful eating exercise on dietary behavior and fasting blood glucose level. variable category group treatment control pre-test post-test pre-test post-test n % n % n % n % dietary behavior poor 23 71.9 11 34.4 21 65.7 17 53.1 good 9 28.1 21 65.6 11 34.3 15 46.9 fasting blood glucose uncontrolled (≥ 130 mg/dl) 28 87.5 20 62.5 25 78.1 21 65.6 controlled (< 130 mg/dl) 4 12.5 12 37.5 7 21.9 11 34.4 table 1. demographic characteristics of respondents. characteristics control treatment total frequency (n) percentage (%) frequency (n) percentage (%) n % age (years) 18-45 13 40.6 11 34.3 24 37.5 46-60 19 59.4 21 65.7 40 62.5 sex male 9 28.1 12 37.5 21 32.8 female 23 71.9 20 62.5 43 67.2 education no school 4 12.5 1 3.2 5 7.8 primary school 10 31.3 14 43.7 24 37.5 middle & high school 13 40.6 9 28.1 22 34.4 bachelor 5 15.6 8 25.0 13 20.3 employment employed 26 81.2 20 62.5 46 71.9 unemployed 6 18.8 12 37.5 18 28.1 duration of diabetes < 5 year 10 45.5 15 46.9 25 39.1 > 5 year 22 54.5 17 53.1 39 60.9 body mass index normal 13 40.7 11 34.3 24 37.5 abnormal 19 59.3 21 65.7 40 62.5 food intake do not exceed standard caloric intake 15 46.9 12 37.5 27 42.2 exceeding standard calorie intake 17 53.1 20 62.5 37 57.8 total 32 100 32 100 64 100 non -co mmerc ial us e o nly posttest, 53.1% of respondents were still in the bad dietary behavior category. table 2 also showed that before the intervention, the majority of respondents in the treatment group (87.5%) and the control group (78.1%) showed uncontrolled fasting blood glucose (fbg) levels. after the intervention and posttest there were not too many changes, it was still seen that the majority of respondents in the treatment group (62.5%) and the control group (65.6%) showed uncontrolled fbg levels. the differences of dietary behavior and fasting blood glucose level on t2dm patients table 3 showed the post-test difference test between treatment group and control group using the mann-whitney u test showed a value of p = 0.025 (p< 0.05), which means that there was a significant influence on the level of dietary behavior in the treatment group compared to the control group after being given mindful eating exercise for four weeks. besides that, analysis of blood glucose levels using an independent t-test on fbg levels obtained p=0.033 (p<0.05), which means there was a significant influence on the treatment group compared to the control group after being given a mindfulness eating intervention for four weeks on fbg levels. discussion mindfulness eating exercises and dietary behavior the results showed a significant improvement in dietary behavior in the treatment group compared to the control group after being given mindfulness eating practice with a 4-week approach. the increase in dietary behavior is characterized by an increase in category values, namely from the level of moderately poor dietary behavior to the level of good dietary behavior. diet management in diabetic clients can be seen from dietary knowledge and ability, decisions in diet selection, eating behavior, and dietary barriers.26,27 the use of mindfulness skills is now increasingly popular and increasing, one of which is through mindfulnessbased eating management interventions. mindfulness practices can encourage healthier eating behaviors where mindful eating activities make a person pay attention to detailed food cues from outside factors and hinder emotional eating habits, impulsivity, and excessive food consumption. through regular exercise, mindfulness can prevent impulsive reactions in the process of eating.28,29 respondents have never known or done mindfulness eating exercises. hence, researchers guide respondents in doing mindfulness exercises with direct visits to respondents and assisted by tools through audio that can be heard with mp3 players. the client’s knowledge and ability to follow the diet program increased due to the process of providing information and instruction about mindfulness eating exercises as one of the techniques for conducting a diet program for dm clients. high knowledge and information correlated with better and predictable behavior contribute to improving and sustaining behavior change in diabetes management.30 this result is similar to the research of miller et al.,21 which explores aspects of knowledge, self-efficacy, and outcome expectations in mindfulness eating interventions in diabetes self-management education (dsme) programs. different things shown by a study of 277 people with diabetes31 showed that although 77% of respondents had high knowledge of diabetes management, this did not always depend on good behavior, which is thought to have happened because the diabetes management education process was not carried out in a coordinated, regular and sustainable. the study found that active participation in the prolanis chronic disease management program led to improved dietary behavior in respondents, correlating with enhanced diabetes management after receiving ongoing education and support. although in this study, it appears that the majority of respondents aged 46-60 years who are feared will be slightly constrained in receiving information due to cognitive factors, this can be helped by the existence of audio aids that make it easier for respondents to do this exercise. chaumhari et al.32 mentioning shows that older respondents have more ability to understand and carry out mindful eating behavior than respondents who are still in productive age (p-value 0.01). mindfulness eating practice instructions were delivered at the researchers’ visit through a process of discussion and direct interaction. respondents were asked to follow instructions via mp3 audio, which provided an opportunity for respondents to assess hunger and satiety cues, train attention focus, and provide a certain level of comfort after eating. the focus of attention while eating was trained by the way respondents set a more regular eating rhythm with pauses between each bite of food. adjustments to the rhythm of eating will have an impact on the intake or number of servings of food consumed. respondents said mindfulness eating exercises helped them achieve adequacy and satisfaction in eating smaller portions of food than usual.33 these results, according to a literature study of 68 publications conducted by warren et al.34 and a randomized clinical trial study of 150 respondents conducted by kristeller et al.35 demonstrate the practice of mindfulness in eating activities controlling individuals who tend to overeat, increasing appreciation of smaller portions of food and controlling food cravings through sensitivity to hunger and satiety cues. mindfulness interventions focus on the eating process whereby by eating more mindfully, using a slower pace, and with an increased focus on the sensation of eating, a person indirectly reduces their daily caloric intake and can control excessive appetite.36 the results of this study are in line with a quasi-experimental study by harmiardillah et al.37 and rohmawati et al. studies38 which states that respondents who are given mindfulness eating exercises influence changing dietary behavior for the better so that eating activities are done only because the response of hunger cues and satiety signals and not the response of eating patterns automatically. through eating behavior based on greater awareness and attention, individuals can regulate their diet according to their transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. the differences of dietary behavior and fasting blood glucose level on t2dm patients. variable group n pre-test post-test p-value mean mean dietary behaviour treatment 32 53.28 78.66 0.00a 0.025b control 32 43.32 44.05 0.07a fasting blood glucose treatment 32 197.93 165.84 0.033a control 32 204.81 198.89 awilcoxon test result; bmann whitney test result. [page 400] [healthcare in low-resource settings 2024;12:11896] non -co mmerc ial us e o nly health goals and needs regardless of impulsivity. mindfulness in eating activities gives an opportunity for individuals with diabetes to think more about the consequences if he does not eat regularly, which will result in pain and suffering. mindful eating can also be a new approach and integrated with dsme programs where people with diabetes have more options to meet their needs39. mindfulness eating exercises and fasting blood glucose glycemic control is one of the essential things to maintain in reducing pain levels and reducing diabetes complications, although hba1c measurement is the gold standard for glycemic control assessment, when hba1c testing is not possible, fasting blood sugar testing can be a good predictor of glycemic control.40 the results of the study showed that the average value of fasting blood glucose (fbg) levels in the treatment group after being given mindfulness eating exercise for four weeks experienced a significant decrease compared to the control group. treatment group had an average value of fbg levels that decreased at the end of the intervention (post-test) compared to the conditions before the intervention (pre-test). although the decrease in blood glucose levels was not able to reach the average figure, compared to the control group, the treatment group had a lower average value of blood glucose levels, indicated by a higher value of the difference between before and after, meaning a decrease in blood glucose levels in the treatment group was significantly more than the control group. several studies have shown a statistically significant association between appropriate dietary practices or behaviors and glycemic, especially fasting blood glucose, in diabetic patients.41 study of a randomized controlled trial in 194 adults by mason et al.35 mentioning mindful eating exercises affects the reduction of fasting blood glucose levels and consumption of sweet foods significantly. awareness and mindfulness during eating activities will facilitate compulsive reduction in the quantity of eating so as to reduce excessive calorie intake through increased individual sensitivity to respond to interceptive cues and decreased sensitivity to environmental triggers.35 food consumption has a direct impact on the nutrients and energy that sustain human needs. in contrast, the total calories obtained through eating activities have a direct effect on blood glucose levels and glycemic control.42 optimization of nutrients should be integrated into the glycemic control of diabetic patients. if a t2dm patient consumes excessive amounts of food in one meal, the insulin secreted by the pancreas is not enough to transport glucose from the bloodstream into the cells. ha et al.43 mentioned in their research that the diet of diabetic patients must be correct where diabetic patients should eat more often but with small portions per day (rather than eating rarely but with large portions) because this will help the body’s total energy intake not change and control blood glucose levels better. miller et al.5,21 in their study, stated that respondents who received mindfulness eating practice reported having a more remarkable ability to minimize overeating in various situations and eat less after receiving satiety cues, helping people with diabetes develop healthier eating patterns. mindfulness eating practice is an exercise that aims to shape adaptive eating behavior through physiological mechanisms so that a mindful eating pattern is formed that increases the ability to identify one’s own needs, reduces impulsivity in food consumption, and reduces stress.44 the study’s limitation lies in its rural setting, which differs from urban lifestyles, necessitating further research in varied contexts with larger sample sizes to generalize the results. moreover, future studies should include participant exercise patterns and physical activity, as these factors may influence glycemic control. conclusions mindful eating exercises significantly improved the dietary behaviors of diabetic patients. healthcare providers should include these exercises in diabetes management to maintain glycemic control. nurses are key in encouraging these eating patterns and in monitoring blood glucose levels regularly, which benefits the overall health of diabetic patients and improves diabetes care effectiveness. references 1. karingga dd, efendi f, indarwati r, bushy a. effect of mobile structured educational applications on self-care management in diabetes mellitus patients[efecto de las aplicaciones educativas estructuradas móviles en el manejo del autocuidado en pacientes con diabetes mellitus]. gac med caracas 2023;131:278–86. 2. world health organization. global report on diabetes. who press. 2016. 3. garcía-pérez le, álvarez m, dilla t, et al. adherence to therapies in patients with type 2 diabetes. diabetes ther 2013;4:175–94. 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to diabetes mellitus among the general public in galle district in southern sri lanka: a pilot study. bmc public health 2017;17:1–7. 32. chamhuri nh, tohit nm, azzeri a, et al. age and fasting blood sugar levels are associated factors for mindful eating among type 2 diabetes mellitus patients during covid-19 pandemic confinement. plos one 2022;17:1–11. 33. albers s. eat, drink, and be mindful: how to end your struggle with mindless eating and start savoring food with intention and joy. a new harbinger self-help workbook. new harbinger publications 2008; 192 p. 34. warren jm, smith n, ashwell m. a structured literature review on the role of mindfulness, mindful eating and intuitive eating in changing eating behaviours: effectiveness and associated potential mechanisms. nutr res rev 2017;30:272–83. 35. mason ae, epel es, kristeller j, et al. effects of a mindfulnessbased intervention on mindful eating, sweets consumption, and fasting glucose levels in obese adults: data from the shine 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management of type 2 diabetes. bmj 2018;361. 42. kang hm, kim dj. total energy intake may be more associated with glycemic control compared to each proportion of macronutrients in the korean diabetic population. diabetes metab j 2012;36:300. 43. ha nt, phuong nt, ha ltt. how dietary intake of type 2 diabetes mellitus outpatients affects their fasting blood glucose levels? aims public heal 2019;6:424. 44. sukchaisong n, pichayapinyo p, lagampan s, et al. effectiveness of the mindfulness-based diabetes self-and family management support program among adults with uncontrolled diabetes: a randomized controlled trial. pacific rim int j nurs res 2022;26:517–32. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 402] [healthcare in low-resource settings 2024;12:11896] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12133 early detection of the risk of chronic kidney disease based on eating and drinking behaviors in kendari city indonesia tasnim tasnim,1 imran,2 sugireng,3 nur illiyyin akib4 1department of public health, mandala waluya university; 2department of chemistry, halu oleo university; 3department of medical laboratory technology, mandala waluya university; 4department of pharmacy, halu oleo university, indonesia abstract the main purpose of this study is to analyze eating and drinking behavior that can be used for early detection of chronic kidney disease in kendari city, southeast sulawesi. the research question is how do eating behavior and drinking water consumption affect protein urine, creatinine, and health status? this quantitative research used a cross-sectional study approach and recruited 136 respondents in kendari city, southeast sulawesi, indonesia from june to august 2023. the sampling technique is by accidental sampling technique. eating behavior in calories and drinking water consumption are independent variables. creatinine, protein urine levels, and health status are dependent variables. data analysis using the chi-square, kruskal wallis h, linear regression, and ordinal regression of statistical tests. the daily drinking water consumption of less than 666 ml a day had a significant effect on protein urine levels by 19.6% and health status by 32.2%. however, it did not significantly affect urine creatinine levels. total daily caloric intake did not significantly affect urine creatinine levels and protein urine, but it has a significant effect on health status by 8.2% especially total calorie intake which is less than 699 calories a day. drinking water consumption of less than 666 ml a day and intake of calories less than 699 calories can be used as a basis for early detection of people at risk of developing chronic kidney disease. introduction early detection of chronic kidney disease (ckd) is defined as an effort to recognize the symptoms of chronic kidney disease through screening and education.1 the early detection of high-risk people with ckd is important. this is because the kidney processes blood to excrete wastes and extra water and concert into the urine.2 then the urine produced by the kidney is carried by the ureter to the bladder outside. furthermore, healthy, functioning kidneys are important because they eliminate waste products, drugs, and toxins from the blood. they regulate electrolyte concentrations, the amount of fluid within the body, and blood pressure. also, they help maintain acid-base balance and produce hormones that affect blood and bones. disruption of the glomerular structure leads to nephrotic syndrome. nephrotic syndrome is caused by failure of the filtration barrier in nephrotic syndrome.3 signs and symptoms of nephrotic syndrome chronic kidney disease such as edema, proteinuria, hypoalbuminemia, hyperlipidemia, and lapidia. the ckd patient needs to be treated including hemodialysis. the hemodialysis treatment must be done 2 times a week until recovery or for the rest of life. therefore, the ckd patient will lose their time, money, and psychological stress or die. this chronic kidney disease is a “silent killer” that occurs due to hypertension or diabetes mellitus which is not treated properly.4 the prevalence of chronic kidney disease in indonesia appears to be very small compared to hypertension and diabetes mellitus, but the trend is increasing in indonesia, including in kendari city. in 2018, the prevalence of ckd was 0.38%. this prevalence increased compared to 0.2% in 2013.5,6 compared to hypertension and dm, the prevalence of those diseases was 34.1% of hypertension and 1.5% of dm in indonesia in 2018.6 hypertension and dm are the biggest risk factors for chronic kidney disease, if you correspondence: tasnim tasnim, department of public health, mandala waluya university, jl. jenderal a.h. nasutionn no. g-37 kambu, kendari, sulawesi tenggara, indonesia. tel.: +6282237658472 e-mail: tasnim349@gmail.com key words: early detection, chronic kidney disease, drink, calorie. contributions: tt, conceptualization of the research, review, and editing; tt, s, i, nia, analysis and interpretation of data; tt, s, funding acquisition; tt, writing the original draft. all the authors approved the final version to be published. conflict of interest: authors certify that there is no actual or potential conflict of interest concerning this article. funding: the research was funded by the ministry of education, culture, research and technology of the republic of indonesia with grant number 185/e5/pg.02.00.pl/2023, on june 19th, 2023. ethics approval: ethical approval was obtained from the ethical committee of mandala waluya, indonesia, with protocol number 023/kep/umw/vi/2023, on june 19th, 2023. informed consent: informed consent was obtained from all respondents, and confidentiality was ensured. acknowledgments: the authors appreciate the ministry of education and culture, research and technology of the republic of indonesia for funding support for this research. thus, the author would like to thank abeli, mata, kandai, and lepo-lepo health centers, and bahteramas, santa anna, and kendari city hospitals for their facilities and information support. received: 25 november 2023. accepted: 25 november 2023. early access: 30 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12133 doi:10.4081/hls.2024.12133 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 270] [healthcare in low-resource settings 2024;12:12133] non -co mmerc ial us e o nly do not take regular treatment, and unhealthy eating and drinking behavior. thus, chronic kidney disease is called the iceberg phenomenon. there are 34% of provinces in indonesia that are above the national prevalence in 2018 (0.38%), including the sulawesi island region. the impact of the high prevalence of chronic kidney disease includes the cost of treatment such as hemodialysis which is very expensive. furthermore, the indonesian government, including the kendari city government must cover ckd patients’ health insurance. the individuals and the families also must pay for transportation, food, and accommodation during hemodialysis treatment. the mortality rate will also be high in kendari city. therefore, it is important to carry out prevention, namely starting with early detection of risk groups, such as those who have unhealthy habits in eating and drinking. however, whether eating and drinking behavior can be used as a sign of chronic kidney disease or not is still questionable. several studies have found early signs for early detection of chronic kidney disease only through chemical aspects, namely through pt injury biomarkers including kidney injury molecule-1, neutrophil gelatinaseassociated lipocalin, and liver fatty acid binding protein.7 early detection using signs that require laboratory tests will take quite a long time. as explained above, ckd sufferers are difficult to find in health centers in kendari city, in particular. therefore, this study will analyze daily eating and drinking behavior factors that are associated with the incidence of chronic kidney disease. as reported in several studies eating and drinking behavioral factors greatly influence human health. however, whether eating and drinking behavior can be used as a sign in implementing early detection for chronic kidney sufferers is still questionable. that is why, this research made discoveries regarding the early detection of chronic kidney disease through identifying calorie intake and drinking water a day. materials and methods study area the research was carried out in kendari city, southeast sulawesi province indonesia. data collection was taken in 5 health centers and 3 hospitals from june to august 2023. the five health centers include lepo-lepo, mata, abeli, and kandai health centres. the 3 hospitals include bahteramas, santa anna, and kendari city hospitals. the selection of research locations was based on geographical representation in the kendari city area, namely the coast, city, and hills. study design this quantitative research used a cross-sectional study design. the target population is healthy people, single-disease, multiple diseases, and acute/chronic kidney patients. sample selection used an accidental sampling technique with inclusion criteria, namely aged between 17-65 years, willing to be a respondent, and able to communicate well. the sample size was 136 people. dependent variables include urine protein levels, creatinine, and health status. health status includes healthy groups, single disease, multiple diseases, and acute/chronic kidney patients. independent variables include water consumption in milliliters per day and calorie intake in calories per day. data collection there are three techniques for collecting data, namely interviews with questionnaires, health checks including blood pressure tests, and taking urine samples from respondents. the questionnaire includes data on eating patterns with 24-hour recall, daily drinking water consumption, and health status. determining health status using a blood pressure monitor, and the results of a doctor’s examination or health records from the health service unit. urine samples are used to measure protein and creatinine levels as parameters for kidney function and organ disorders. article table 1. demographic and health status characteristics of the study subjects. demographic characteristics healthy % single diseases % multiple diseases % chronic kidney diseases % age (years) 16 11.8 40 29.4 27 19.9 53 39.0 < 35 6 4.4 4 2.9 3 2.2 11 8.1 36-40 2 1.5 3 2.2 1 0.7 7 5.1 41-50 3 2.2 12 8.8 6 4.4 16 11.8 51-60 4 2.9 15 11.0 10 7.4 12 8.8 >60 1 0.7 6 4.4 7 5.1 7 5.1 education not completed on primary school 0 0.0 2 1.5 0 0.0 1 0.7 primary school 2 1.5 7 5.1 6 4.4 3 2.2 yunior high school 2 1.5 4 2.9 5 3.7 7 5.1 senior hs 5 3.7 10 7.4 11 8.1 20 14.7 diploma 1 0.7 0 0.0 0 0.0 3 2.2 bachelor 4 2.9 13 9.6 5 3.7 17 12.5 master 2 1.5 3 2.2 0 0.0 2 1.5 doctor 0 0.0 1 0.7 0 0.0 0 0.0 occupation no job 9 6.6 20 14.7 17 12.5 22 16.2 laborer 1 0.7 1 0.7 1 0.7 0 0.0 farmer 0 0.0 0 0.0 1 0.7 4 2.9 self-employed 0 0.0 5 3.7 1 0.7 7 5.1 private/ bumn 3 2.2 5 3.7 3 2.2 7 5.1 civil servants 3 2.2 9 6.6 4 2.9 13 9.6 total 16 11.8 40 29.4 27 19.9 53 39.0 [healthcare in low-resource settings 2024;12:12133] [page 271] non -co mmerc ial us e o nly data analysis data was statistically analyzed with spss version 25.0 and used kruskal-wallis h and ordinal regression tests. the kruskalwallis h test is used to see the difference in average ranking between the number of calories intake and the amount of drinking water consumed per day which is associated with urine protein levels, creatinine, and health status. ordinal regression test to see the influence of eating and drinking behavior on levels of proteinuria, creatinine, and health status of respondents. results respondents characteristic the healthy group is dominated by the age group < 35 years (table 1). the single disease and ckd groups are dominated by those aged 41-50 years. the multiple diseases group is dominated by the age group >60 years, but those aged 41-50 years are also almost the same. the healthy, multiple disease, and ckd groups are dominated by “senior high school of educational degree of the subjects. the single disease group is dominated by “bachelors”. the healthy, single-disease, multiple diseases and ckd groups were predominantly unemployed. quite a lot of civil servants suffer from ckd. the effect of drinking water on chronic kidney disease drinking water consumption is stated to have a significant effect on urine protein levels and health status (figure 1). however, drinking water consumption did not affect the subject’s creatinine levels. the contribution of drinking water consumption per day to protein urine levels is 19.6%. the contribution of drinking water consumption per day to the subject’s health status was the greatest compared to protein urine and creatinine, namely 32.2%. meanwhile, the contribution to creatinine levels is only 1%. the highest average creatinine level for subjects whose drinking water consumption was good was between 1333-2000 million liters per day. meanwhile, the highest urea protein levels were in subjects whose drinking water consumption was less than <666 million liters per day. meanwhile, if we look at health status, the highest ranking is drinking water consumption of less than <666 million liters per liver. healthy subjects drink mostly water per day, namely between 1333-2000 ml or good (figure 2). subjects with a single disease mostly consumed more than > 2001 ml of drinking water per day. likewise, for subjects with multiple diseases, the consumption of drinking water per day can be said to be good, namely between 1333-2000 ml. meanwhile, for chronic kidney sufferers, drinking water consumption is mostly less than <666 million liters per day. the effect of daily calorie intake on chronic kidney disease subjects whose creatinine levels are very high are dominated by subjects whose calorie intake is more than > 2101 calories per day (figure 3). meanwhile, subjects with high protein urine levels were dominated by subjects whose calorie intake was less than <699 calories per day. meanwhile, if we look at the health status of the majority, the calorie intake is less than <699 calories per day, which is the same as the proteinuria variable. daily calorie intake did not have a significant effect on the subjects’ urine creatinine levels or proteinuria levels. the influence of daily calorie intake only contributed 2.6% to urine creatinine levels and 6.1% to the subject’s proteinuria levels. however, calorie intake has a significant effect on the subject’s health status. subjects who were healthy and single disease mostly had a calorie intake of more than >2101 cal. a day. meanwhile, subjects with multiple diseases and ckd, mostly ate with a calorie intake of less than <699 cal a day. early detection of chronic kidney disease related to eating and drinking behaviors the behavioral parameters of daily water consumption can be used as parameters for early detection of chronic kidney disease either through urine sample tests with urine protein parameters, and also by looking at the subject’s health condition (figure 4). the proteinuria parameter is effective for looking at the behavioral factors of water consumption, compared with eating patterns (calorie intake) per day. meanwhile, daily calorie intake can only be used by looking at its relationship with the individual’s health status. article figure 1. the effect of drinking water a day on creatinine levels, proteinuria and health status. figure 2. drinking water consumption per day in different health status. [page 272] [healthcare in low-resource settings 2024;12:12133] non -co mmerc ial us e o nly discussion early detection of chronic kidney disease through drinking water behavior individuals whose drinking water consumption is less than <666 ml per day have triggered high levels of proteinuria. high levels of proteinuria indicate that kidney function has been impaired.8,9 high levels of proteinuria cause individuals to experience mineral deficiencies including iron, calcium, zinc, and copper, and disrupt the body’s metabolic function.10-12 lack of drinking water consumption in the body causes the distribution of the main nutrients to the body’s organs to be delayed, due to the lack of water that carries the blood.13 blood performance is very important in distributing nutrients to the body’s organs, including the kidneys. ultimately, this condition results in a buildup of substances in the body. besides that, with a lack of fluids, the body also experiences dehydration, and inhibits circulation in the body.13,14 mild dehydration only results in fatigue. however, if the body is severely dehydrated, damage to the kidneys will occur due to the buildup of waste and acid.15 ultimately there is an increase in muscle protein or myoglobin. therefore, for someone who is undergoing mandatory fasting in the month of ramadan, it is recommended to rehydrate by drinking enough water at dawn and breaking the fast.16 in addition, individuals who fast are advised to stop taking medications, including non-steroidal anti-inflammatory drugs, for people with gouty arthritis because the work of the kidneys will increase.16 the initial symptoms that are a sign of a lack of fluid in the body are abnormalities in the body, such as hypertension, urinary tract disorders, and the formation of kidney stones.17,18 the need for drinking water is not the same for all individuals, because it depends on age, physical activity, climate, and the individual’s health status.19 that is why chronic kidney sufferers on hemodialysis are recommended to consume little drinking water or fluids.20 however, healthy individuals are advised to drink approximately 2 liters of water a day or according to their needs. in this study, the proportion of chronic kidney sufferers on hemodialysis was quite large, so their drinking water consumption could be said to be very little. meanwhile, healthy individuals, individuals with single and multiple diseases consume more drinking water than chronic kidney sufferers on hemodialysis. remember that fluid needs are replaced when carrying out hemodialysis treatment. the explanation above shows that early detection of the course of chronic kidney disease can be learned from the behavior of drinking water. the measurement that can be used for early detection of water-drinking behavior is less than 666 ml per day. this size, when converted to mineral water bottles on the market, is approximately the same as 1 medium bottle of mineral water. usually, the size of 1 medium bottle of mineral water on the market only contains 600 ml. thus, 666 ml per day can be said to be the same when the behavior of consuming drinking water is less than 1.1 medium-sized bottles a day. medium bottle sizes on the market are the easiest conversion measure for early detection of drinking water consumption which is a risk for chronic kidney disease. drinking water consumption of less than 666 ml per day has been proven to trigger high levels of proteinuria. where high levels of proteinuria are a parameter of impaired kidney function. individuals who experience impaired kidney function with early symptoms such as weight loss, decreased appetite, nausea, weakness, and nocturia.1,21 early detection of chronic kidney disease through calorie intake individuals whose calorie intake is less than <699 calories per day have caused health problems leading to chronic kidney function disorders. calories obtained from food that enters the body are converted into energy through the metabolic process.22 this energy is then used to support the performance and function of various body organs, including the kidneys. therefore, if the body experiences a calorie deficiency for a long time, the body experiences malnutrition.23,24 many studies have stated that malnutrition is the main cause of inhibiting kidney function and ultimately damage.25 chronic malnutrition which results in hypokalemia, hypovolemia is a risk factor for chronic kidney disease.26 lack of calorie intake in the body has caused disturbances in the balance of cell metabolism and/or abnormalities in cytokine pathways, including the expression of il-6, tnf-α, and tgf-β. abnormalities in the article figure 3. the effect of drinking water a day on creatinine levels, proteinuria and health status. figure 4. early detection for chronic kidney disease with indicators of drinking water consumption behaviour and daily calorie intake. [healthcare in low-resource settings 2024;12:12133] [page 273] non -co mmerc ial us e o nly cytokine pathway indicate changes in the tissue that greatly affect human kidney function. in this study, a tendency for high levels of proteinuria in subjects with low-calorie intake has been shown. when a body experiences a lack of energy, immunological function will decrease and as a result, the body becomes vulnerable to infectious diseases. the relationship between the biological mechanisms of infection and nutritional deficiencies has been widely studied.27,28 where nutrition is an important modulator in the immune response and determines the risk and prognosis of human body disorders.25 body temperature decreases with limited calories in the body.29-31 limited calorie intake itself can affect sirtuin-1 which modulates adiponectin gene expression and nitric oxide bioavailability.32 the low-calorie intake of the subjects in this study was because of these individuals’ reduced carbohydrate and protein intake in their daily diet menu. many of them don’t eat breakfast or dinner. the breakfast menu is not complete in terms of nutritional elements. most of their breakfast only consists of snacks such as fried bananas, cakes, or bread. there are no vegetables and fruit on their breakfast menu. individuals also limit their dinner, including those suffering from complications and chronic kidney disease. rice is the main food in the daily diet of people in kendari city. meanwhile, the food ingredients for the side dishes are sea fish such as tuna and a few people eat freshwater fish such as tilapia. local vegetables such as moringa leaves are a favorite in his daily diet. however, fruit is rarely a complement to the daily menu of the subjects in this study. restrictions on eating at night are often done by subjects who already have multiple diseases or complications, as well as chronic kidney sufferers on hemodialysis. food restrictions are known to cause metabolic disorders in the body, including chronic hypokalemia.33 as stated by several researchers, hypokalemia is a risk factor for chronic kidney disease.26 however, the degree to which food disturbance results in hypokalemia is determined by the individual’s body condition as well.33 individual conditions that are declared vulnerable to chronic kidney disease include middle age, frequent exposure to outdoor heat, as well as people with diabetes mellitus and hypertension.34,35 conclusions this study has proven that drinking water consumption of less than 666 ml a day can be used as a basis for early detection of people at risk of developing chronic kidney disease without laboratory tests. consumption of less drinking water (<666 ml) and calorie intake of less than 699 calories can also interfere with individual health status. improving the quality of life for ckd patients is important to reduce morbidity and mortality, slow the progression of kidney disease, minimize uremic toxicity, as well prevent malnutrition. the principles of nutritional therapy are providing sufficient calories, high protein intake, and limiting sugar.36 strict restriction of sodium intake is important due to sodium sieving fluid loss through the peritoneal membrane. another recommendation is health promotion for healthy community groups, and those with single illnesses, including people with hypertension and diabetes mellitus, to continue to improve their health. furthermore, maintaining kidney health means drinking the amount of water and calorie intake according to individual needs is necessary. research implications early detection of chronic kidney disease is important to prevent the high prevalence of chronic kidney disease in the world. where human life in the world has changed a lot and influenced their behavior, including drinking and eating behavior which has an impact on their health status. under certain conditions, a person experiences a lack of fluid intake and calorie intake. for example, workers outside buildings in high heat cause their bodies to become dehydrated. lack of fluids causes the kidneys to work hard in the process of removing toxins and waste produced by the body and as a result, the kidneys experience damage.35 likewise, women’s performance must be maintained with a strict diet, including reducing their food intake. lack of food or calorie intake causes the body to become malnourished and results in hypokalemia, or hypovolemia. these two events are risk factors for chronic kidney disease.26 early detection through drinking and eating behavior is something that can be done directly. many water measurements can be used as a basis for calculating daily water intake. for example, bottled water on the market, a medium bottle contains 1 liter of water and a large bottle contains 2 liters of water. when using glass measurements, usually 1 standard glass contains 200 ml of water. thus, if you drink less than 1 medium bottle a day or drink less than 3 glasses, this could be a measure for early detection. likewise with food portions, where 1 plate of rice converts to 700 calories.37 if you only have 1 plate a day for a long time, you will experience malnutrition and metabolic system disorders and ultimately disrupt kidney function. furthermore, not only the quantity, but the quality of water, including the mineral content in the water you drink, also affects kidney health. several studies state that drinking from poor-quality water sources causes increased creatinine levels or kidney damage.38,39 therefore, to maintain kidney health, it is necessary to drink enough water accompanied by a calorie intake that is adjusted to the body’s needs. references 1. shlipak mg, tummalapalli sl, boulware le, et al. the case for early identification and intervention of chronic kidney disease: conclusions from a kidney disease: improving global outcomes (kdigo) controversies conference. kidney int 2021;99:34-47. 2. lamb ej, tomson cr, roderick pj. estimating kidney function in adults using formulae. ann clin biochem 2005;42:32145. 3. li as, ingham jf, lennon r. genetic disorders of the glomerular filtration barrier. clin j am soc nephrol 2020;15:1818-28. 4. provenzano m, coppolino g, faga t, et al. epidemiology of cardiovascular risk in chronic kidney disease patients: the real silent killer. rev cardiovasc med 2019;20:209-20. 5. health ministry of republic indonesia. basic health research (riskesdas 2013). jakarta: ministry of health of the republic of indonesia; 2013. p. 306. 6. health ministry of republic of indonesia. nasional report of basic health research 2018 [internet]. jakarta: health ministry of republic of indonesia; 2019. available from: http://labdata.litbang.kemkes.go.id/images/download/laporan/rkd/2018/laporan_nasional_rkd2018_final.pdf 7. mizdrak m, kumri m, kurir tt, božic j. emerging biomarkers for early detection of chronic kidney disease. j pers med 2022;12:1-17. article [page 274] [healthcare in low-resource settings 2024;12:12133] non -co mmerc ial us e o nly 8. hemmelgarn br, manns bj, lloyd a, james mt, klarenbach s, quinn rr, et al. relation between kidney function, proteinuria, and adverse outcomes. jama 2010;303:423-9. 9. cravedi p, remuzzi g. pathophysiology of proteinuria and its value as an outcome measure of inchronic kidney disease. br j clin 2013;74:516-23. 10. eskandarifar a, fotoohi a, mojtahedi sy. nutrition in pediatric nephrotic syndrome. j pediatr nephrol 2017;5:1-3. 11. kumar j, mcdermott k, abraham ag, et al. prevalence and correlates of 25-hydroxyvitamin d deficiency in the chronic kidney disease in children (ckid) cohort. pediatr nephrol 2016;31:121-9. 12. elsaeed gsm, fadel f, al-sonbaty mm, et al. zinc, copper and selenium in children with idiopathic nephrotic syndrome: relationship to parathyroid hormone & proteinuria. curr sci int 2020;9:431-7. 13. popkin bm, d’anci ke, rosenberg ih. water, hydration, and health. nutr rev 2010;68:439-58. 14. armstrong le. challenges of linking chronic dehydration and fluid consumption to health outcomes. nutr rev 2012;70:s121-7. 15. rojas-valverde d, martínez-guardado i, sánchez-ureña b, et al. outpatient assessment of mechanical load, heat strain and dehydration as causes of transitional acute kidney injury in endurance trail runners. int j environ res public health 2021;18:1-12. 16. basri h, shalihin se. acute kidney injury during fasting in ramadhan in a patient with nephrolithiasisa case report. malaysian j med res 2020;4:11-4. 17. weisbord sd. symptoms and their correlates in chronic kidney disease. adv chronic kidney dis 2007;14:319-27. 18. murphy el, murtagh fem, carey i, sheerin ns. understanding symptoms in patients with advanced chronic kidney disease managed without dialysis: use of a short patient-completed assessment tool. nephron clin pract 2009;111:c74-80. 19. roche sm, jones aq, majowicz se, et al. drinking water consumption patterns in canadian communities (2001-2007). j water health 2012;10:69-86. 20. kurttio p, auvinen a, salonen l, et al. renal effects of uranium in drinking water. environ health perspect 2002;110:337-42. 21. anggraini d. clinical aspects and laboratory examination of chronic kidney disease. an-nadaa j kesehat masy 2022;9:236-9. 22. zhang z, chen x, loh yj, et al. the effect of calorie intake, fasting, and dietary composition on metabolic health and gut microbiota in mice. bmc biol 2021;19:1-14. 23. liu p, chen l, zhong t, et al. impact of calorie intake and refeeding syndrome on the length of hospital stay of patients with malnutrition: a systematic review and meta-analysis. clin nutr 2022;41:2003-12. 24. radhakrishna r, ravi c. malnutrition in india: trends and determinants. econ polit wkly 2004;39:671-6. 25. santoso d, sudiana ik, yunus m. the effect of a low protein diet on the expression of il-6, tnf-α and tgf-β in the kidney tissue of mice model. malaysian j med heal sci 2019;15:46-52. 26. tseng mcm, chien ln, tu cy, et al. risk of dialysis and renal diseases in patients with anorexia nervosa in taiwan. int j eat disord 2023;56:991-1000. 27. khayyatzadeh ss. nutrition and infection with covid-19. j nutr food secur 2020;5:93-6. 28. spolidoro gci, azzolino d, shamir r, cesari m, agostoni c. joint effort towards preventing nutritional deficiencies at the extremes of life during covid-19. nutrients 2021;13:1-18. 29. heilbronn l, de jonge l, frisard m, al. e. effect of 6-month calorie restriction on biomarkers of longevity, metabolic adaptation, and oxidative stress in overweight individuals. jama 2006;295:1539-48. 30. weiss e, racette s, villareal d, et al. improvements in glucose tolerance and insulin action induced by increasing energy expenditure or decreasing energy intake: a randomized controlled trial. am j clin nutr 2006;84:1033-42. 31. bartfai t, conti b. molecules affecting hypothalamic control of core body temperature in response to calorie intake. front gene 2012;3:1-12. 32. kramer h. dietary patterns, calories, and kidney disease. adv chronic kidney dis 2013;20:135-40. 33. puckett l. renal and electrolyte complications in eating disorders: a comprehensive review. j eat disord 2023;11:1-9. 34. chang cj, yang hy. chronic kidney disease among agricultural workers in taiwan: a nationwide populationbased study. kidney int rep 2023;8:2677-89. 35. qian q. salt, water and nephron: mechanisms of action and link to hypertension and chronic kidney disease. nephrology 2018;23:44-9. 36. pereira ra, ramos ci, teixeira rr, et al. diet in chronic kidney disease: an integrated approach to nutritional therapy. rev assoc med bras 2020;66:s59-67. 37. ministry of health of the republic of indonesia. fill my plate in one meal [internet]. jakarta: indonesian non-communicable disease department, ministry of health of the republic of indonesia; 2018. available from: https://p2ptm.kemkes.go. id/infographic-p2ptm/obesitas/isi-piringku-sekali-makan 38. mcdonough lk, meredith kt, nikagolla c, al. e. the influence of water-rock interactions on household well water in an area of high prevalence chronic kidney disease of unknown aetiology (ckdu). npj clean water 2021;4(2). 39. tasnim t, sunarsih. analysis of impaired kidney function in the community around the morosi nickel mines. j public health africa 2023;14:1-6. article [healthcare in low-resource settings 2024;12:12133] [page 275] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11754 the effect of ethanol extract of cosmos caudatus leaves on the percentage of the cell cycle in candida albicans culture lidia lushinta, heni suryani department of midwifery, politeknik kesehatan kementerian kesehatan kalimantan timur, samarinda, indonesia abstract candidiasis is a common fungal gynecological disease among humans. the use of antifungal agents, such as fluconazole, has been reported to increase resistance to candidiasis by 7%. this study aimed to investigate the effect of antifungal flavonoids from cosmos caudatus leaf extract on the cell cycle percentage in c. albicans culture. this research employed a true experimental posttest only with a control group design. the c. albicans isolate was obtained from the microbiology laboratory under the code c. albicans sv-1148. the isolates were cultured in sabouraud dextrose agar (sda) medium and sabouraud dextrose broth (sdb). the sample group was divided into a negative control group, a positive control group with fluconazole (60 µg/ml), and a treatment group with various concentrations of ethanol extract from kenikir leaves (c. caudatus kunth.) 5%, 10%, 20%, 40%, and combinations (20% ethanol extract from kenikir leaves + 30 µg/ml fluconazole). this study revealed a reduction in the percentage of cell cycles in the s phase (dna synthesis) in the treatment group receiving ethanol extract from kenikir leaves (c. caudatus kunth.) and the combination treatment group compared to the negative control group. the study suggests that this decrease in the percentage of cell cycles results from dna damage caused by the presence of flavonoids in kenikir leaves (c. caudatus kunth.). kenikir leaves (c. caudatus kunth.) have the potential to decrease the percentage of s-phase cell cycles (dna synthesis) in the culture of c. albicans. this research demonstrates that kenikir leaves (c. caudatus kunth.) contain natural flavonoids with antifungal properties and have the potential to be used as an alternative medicine for candidiasis in humans. it is hoped that incorporating kenikir as a food ingredient can serve as an alternative prevention and treatment approach for candidiasis. introduction fungal infections claim the lives of over 1.5 million people and afflict more than one billion individuals.1 serious yeast infections arise as a consequence of other health conditions, including asthma, aids, cancer, organ transplantation, and corticosteroid therapy.2 early and accurate diagnosis permits the immediate initiation of antifungal therapy.3 nonetheless, the administration of this therapy is frequently delayed, and the unavailability of treatment can result in severe chronic illnesses. recent global estimates have identified 700,000 cases of invasive candidiasis.4 the prevalence of candidiasis is reported to be twenty-two percent (22%), and this percentage remains consistent among adult women and female adolescents.5,6 furthermore, it is estimated that approximately 75% of women will experience at least one candidiasis episode in their lifetime.7 c. albicans is the species most commonly implicated in cases of candidiasis.8 candidiasis is often associated with the production of a thick, white, cream, or yellow discharge from the vaginal canal.9 the primary and preferred treatment for candidiasis is an antifungal drug, specifically fluconazole.8,10 the mechanism of action of the azole class of antifungal drugs involves the disruption of cell membranes by inhibiting the activity of lanosterol correspondence: lidia lushinta, politeknik kesehatan kementerian kesehatan kalimantan timur, samarinda, indonesia e-mail: lidialushinta@gmail.com key word: herbs; antifungal activity; c. caudatus; c. albicans; cell cycle. contributions: ll conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; hs methodology, visualization, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the ethics committee, medical faculty, universitas brawijaya, indonesia based on ethical certificate 166/ec/kepk/05/2019. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 11 september 2023. accepted: 2 october 2023. early access: 12 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11754 doi:10.4081/hls.2023.11754 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11754] [page 11] non -co mmerc ial us e o nly 14-𝛼-demethylase, an enzyme essential for ergosterol biosynthesis.11 prolonged use of this drug has led to resistance against fluconazole in c. albicans, despite its high cure rate.12 according to a 2017 survey conducted by the centers for disease control (cdc), resistance to candida spp., specifically at a rate of 6.5%, was observed.13 research on plants used in traditional medicine aims to identify alternative treatments, and numerous antimicrobial properties have been identified in natural ingredients used as herbal remedies.14 according to hayat et al. (2017), flavonoids exhibit antimicrobial activity against various strains of microorganisms, including staphylococcus aureus.15 flavonoids have the ability to form non-specific bonds such as hydrophobic, hydrogen, and covalent bonds with proteins. they have also been studied for their lipophilic properties, which can disrupt microbial membranes.16 research conducted by han et al. (2016) revealed that flavonoids inhibit the cell cycle of c. albicans in the s phase when induced by rubus chingii.17 the synergistic activity is attributed to alterations in membrane fluidity, increased fluconazole influx, interference with membrane-bound signaling proteins, and cell cycle arrest. inhibition of the cell cycle in the s phase, specifically during dna synthesis, is a response to dna damage. changes in the cell cycle are closely tied to dna damage. the presence of chemical compounds in herbal extracts can induce dna damage, leading to cell cycle arrest and apoptosis. during the s phase checkpoint, two key aspects are examined: the cell’s adequate size for division into two individual cells and the accurate duplication of dna replication.18,19 the content of flavonoids in kenikir leaves measures 52.2±4.06 mg per 100 grams.20 kenikir (c. caudatus kunth) is among the most commonly found plants in indonesia. research conducted by rasdi et al. (2010) revealed that kenikir (c. caudatus kunth) can function as an antimicrobial agent against bacteria such as staphylococcus aureus, escherichia coli, bacillus subtilis, pseudomonas aeruginosa, and c. albicans.21 it is imperative to conduct in vitro testing for anti-candida activity before experimenting on animals to assess the potential toxic effects of natural ingredient extracts directly on specific cell types or tissues within a controlled environment and a short timeframe.22 furthermore, in vitro tests, as highlighted by visvesvara and garcia (2002), are employed to identify potential therapeutic agents. this study demonstrates the impact of antifungal flavonoids from c. caudatus leaf extract on the cell cycle percentage in c. albicans culture.23 materials and methods design of the study this research employs a true experimental research design, specifically a posttest-only control group design. manufacture of kenikir leaf ethanol extract the process of obtaining kenikir leaf powder extract involves two stages: maceration and evaporation. in the maceration stage, finely ground kenikir leaves, totaling 500 grams, are placed in a glass jar. subsequently, 1 liter of 90% ethanol is added, and the mixture is stirred for 30 minutes to ensure thorough mixing. it is then left to settle for one hour, as recommended by aswanida (2015) and asworo (2017).24,25 the maceration process is conducted at a temperature of 55°c. afterward, the top portion of the ethanol-solvent mixture, containing the active substance, is separated using whatman number 2 filter paper. the remaining active substance-solvent mixture proceeds to the evaporation stage. in the evaporation stage, the filtered mixture is transferred into an evaporating flask, connected to a rotary evaporator and a water bath heater. water is added to the water bath, and electricity is supplied with a temperature setting of 78.4°c. the separation of the ethanol solvent from the active substance in the evaporating flask continues until no more ethanol drips into the holding flask. typically, this results in one flask containing approximately 900 ml of solution. the filtered solution is then further evaporated until the kenikir leaf ethanol extract solidifies. the final yield obtained is 70 ml of kenikir leaf ethanol extract paste. the culture of c. albicans and treatment c. albicans isolate (sv-1148) was procured from the microbiology laboratory of brawijaya university in malang, indonesia. a smear of c. albicans (sv-1148) was obtained from a 36-year-old patient at saiful anwar rssa hospital in malang. the c. albicans isolates were cultured on sabouraud dextrose agar (sda) medium and incubated for 48 hours at 37°c. the sample groups were divided into a negative control group, a positive control group treated with fluconazole (60 µg/ml),26 and a treatment group subjected to ethanol extraction from c. caudatus leaves at concentrations of 5%, 10%, 20%, and 40%.27 cell cycle assay c. albicans isolates (1×103 cells), cultured in sabouraud dextrose broth media, were harvested. following 24 hours of incubation, the cells were washed with pbs three times and centrifuged at 3500 rpm for 3 minutes. subsequently, they were fixed with 70% ethanol for 24 hours at 4°c 28. following the fixation, 50 μl of rnase a at a concentration of 200 μg/ml was added to the cells, and the mixture was allowed to react for 2 hours at 37°c. for dna staining, 50 μg/ml of propidium iodide was introduced, and the mixture was incubated for 30 minutes at 4°c in the dark. the cells were then analyzed using a flow cytometer. the flow cytometers utilized in this research included the bd cellquest flow cytometry machine, bd cellquest pro software (version 5.1 or higher), and bd™ inits software (version 4.1 or higher). statistical analysis all experiments were performed with four replicates as per the replication formula and sample size calculation. the data were assessed for homogeneity of variance using the levene index and expressed as the mean ± standard deviation. the results of the normality test using the shapiro-wilk test yielded a p>0.05, indicating that the data is normally distributed. furthermore, the data homogeneity test produced a p-value of 0.208 (p>0.05), indicating that the data possesses uniform variance. based on these findings, statistical analysis proceeded with a one-way anova test. significant differences were analyzed through one-way analysis of variance (anova). all statistical analyses were conducted using spss 25.0 (spss inc., chicago, il, usa), with a significance level of p<0.05 considered statistically significant, and p<0.01 considered highly statistically significant. ethical approval for this research was obtained from the ethics committee of the medical faculty at universitas brawijaya, indonesia, under ethical certificate 166/ec/kepk/05/2019. throughout the research, the researcher adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. [page 12] [healthcare in low-resource settings 2023; 11:11754] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly results the administration of kenikir leaves (c. caudatus kunth.), ethanol extract, fluconazole, and combination dosages resulted in a decrease in the percentage of cell cycles in the c. albicans culture. specifically, the ethanol extract of kenikir leaves (c. caudatus kunth.) was effective in inhibiting the cell cycle in the s phase (dna synthesis). this inhibition was assessed using pi and rnase a to detect changes in the cell cycle of c. albicans following the administration of the ethanol extract of kenikir leaves (c. caudatus kunth.). the results, as depicted in figure 1, indicate that ethanol extracts of kenikir leaves (c. caudatus kunth.) at various concentrations (5%, 10%, 20%, 40%), as well as in the combination group (c. caudatus kunth. 20% + fluconazole 30 µg/ml), effectively inhibited the cell cycle in the s phase (dna synthesis) noted as “m2.” this inhibition is demonstrated by a reduction in the percentage of the cell cycle in the s phase (dna synthesis) in the c. albicans culture when compared to both the negative control and positive control groups. in figure 2, the average percentage of inhibition of the s-phase cell cycle (dna synthesis) in the c. albicans culture is shown to decrease in the treatment group compared to the negative control and positive control groups. the lowest percentage of inhibition of the s phase cell cycle, measuring 1.16±0.38, was observed in the treatment group with a concentration of ethanol extract of kenikir leaves (c. caudatus kunth.) at 20%. in contrast, the highest percentage of s phase cell cycle inhibition was found in the negative control group, with a value of 25.4±1.61. based on figure 2 and the tukey hsd test, it can be concluded that the concentration of ethanol extract of kenikir leaves (c. caudatus kunth.) significantly responsible for decreasing the percentage of the s phase cell cycle (dna synthesis) in the c. albicans culture was a concentration of 10%. this is supported by the significant difference (p<0.05) when compared to both negative controls and positive controls. discussion the objective of this study was to assess the impact of ethanol extracts from kenikir leaves (c. caudatus kunth.) as antifungals on the reduction of the cell cycle percentage in c. albicans culture. kenikir leaves (c. caudatus kunth.) are explored as potential natural alternatives for the safe and effective treatment of candidiasis. the antifungal activity of these extracts was examined at concentrations of 5%, 10%, 20%, and 40%, as well as in combination with fluconazole (20% ethanol extract + 30 µg/ml fluconazole). based on the study results and subsequent statistical analysis, it was observed that the administration of ethanol extracts from kenikir leaves (c. caudatus kunth.) at different concentrations (5%, 10%, 20%, and 40%), along with the combination treatment group (20% ethanol extract of kenikir leaves + 30 µg/ml fluconazole), significantly inhibited the cell cycle in the s phase. notably, kenikir leaves (c. caudatus kunth.) were found to contain approximately 52.2 ± 4.06 mg of flavonoids per 100 grams, as documented by andarwulan et al. (2010).29 when comparing the positive control group to the kenikir leaves ethanol extract treatment group at a 5% concentration, no significant difference was observed in reducing the percentage of the s phase in the cell cycle. however, significant differences were noted when compared to the negative control group and the treatment groups with ethanol extract concentrations of 10%, 20%, and the combination treatment group (20% ethanol extract of kenikir leaves + 30 µg/ml fluconazole). among the various concentrations tested, the concentration of 10% ethanol extract of kenikir leaves (c. caudatus kunth.) demonstrated significant effectiveness in reducing the percentage of the s phase cell cycle (dna synthesis) in c. albicans cultures. this was supported by statistically significant differences (p<0.05) when compared to both the negative and positive control groups. notably, the combination treatment group (20% ethanol extract of kenikir leaves + 30 µg/ml fluconazole) exhibited the lowest decline in the percentage of the cell cycle in the s phase. these findings align with prior research conducted by jung et al. (2007) and han et al. (2016).30,31 han et al. (2016) demonstrated inhibition of the s-phase cell cycle (dna synthesis) in c. albicans when treated with a combination of fluconazole and rubus chingii extract, which contains flavonoids as antimicrobials. this is consistent with the biochemical compounds found in kenikir leaves (c. caudatus kunth.). similarly, jung et al. (2007) isolated resveratrol from ethyl acetate extract from grape skins, showing that resveratrol, a type of flavonoid, inhibits the s phase of the c. albicans cell cycle.32 [healthcare in low-resource settings 2023; 11:11754] [page 13] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. percentage results of c. albicans cell cycle with flowcytometry analysis. figure 2. histogram of the average percentage of c. albicans cell cycle in s. phase. non -co mmerc ial us e o nly this anti-candida activity is mediated by cell entry via a transport system that requires the consumption of atp. the action of resveratrol as a toxic agent in fungal cells induces several intracellular physiological changes, which are indicated by the inhibition of the cell cycle and the accumulation of trehalose (a class of carbohydrates) which is synthesized as an energy source, to survive in freezing conditions and lack of water. it can be concluded that resveratrol inhibits the process of cell division and affects the growth of fungal cells.32,33 according to iyer and rhind (2017),34 cell cycle inhibition in the s phase (dna synthesis) has been found in some organisms as a response to dna damage. dna can be damaged by extrinsic and intrinsic factors. extrinsic factors that can damage dna include ultraviolet light (uv, ionizing radiation (ir), and chemicals such as methyl-methane sulfonate (mms), mitomycin c, cisplatin, psoralen, camptothecin (cpt), and etoposide.34 intrinsic factor wrong one of them is reactive oxygen species (ros) which is produced as a product of cell metabolism, which can cause oxidative damage to dna.34 changes in the cell cycle are closely related to dna damage. the administration of extracts containing flavonoids can cause dna damage in the presence of excessive accumulation of ros, leading to cell cycle arrest and apoptosis.31 checkpoint activation is in response to faulty replication in mitosis, thus being one of the important reasons why cells lacking s phase checkpoints die. the s phase checkpoint is very important for chromosome replication in yeast.35 in the process of the cell cycle, different checkpoints ensure that cellular events occur in the correct order and time. the first checkpoint is located at the end of the g1 phase, just before entering the s phase. there is an important checkpoint before the cell cycle enters the mitotic phase (checkpoint g2 / m), similar to the g1/s transition. in the s phase (dna synthesis), there are two aspects examined, namely the cell is sufficiently sized to divide into two individual cells, and the dna has been duplicated correctly.36 cell size is known to influence cell cycle regulation as a cell cycle checkpoint. dysfunction of cell volume regulation leads to cell cycle arrest, leading to apoptosis.37 inhibition of the cell cycle in c. albicans can cause morphological changes, namely cells that are inhibited in the g1 phase tend to be more like hyphae, while inhibition in the s, g2, and m phases leads to cells like pseudohyphae.38 in this study, whole extract from kenikir leaves (c. caudatus kunth.) was used, which contains flavonoids, but the total flavonoid content in the ethanol extract of kenikir leaves (c. caudatus kunth.) has not been measured. conclusions in this study, the mechanism underlying the antifungal activity of ethanol extracts from kenikir leaves (c. caudatus kunth.) is elucidated through the observed reduction in the cell cycle percentage. this research underscores that kenikir leaves (c. caudatus kunth.) are rich in natural compounds known as flavonoids. flavonoids are believed to be the primary constituents responsible for the antifungal properties exhibited by kenikir leaves, thus holding promise as a potential alternative medicine for the treatment of candidiasis in humans. references 1. soedarsono s, prasetiyo y, mertaniasih n. fungal isolates findings of sputum samples in new and previously treated cases of pulmonary tuberculosis in dr. soetomo hospital surabaya, indonesia. int j mycobacteriol 2020;9:190-4. 2. indhi en, supranianondo k, chusniati s, legowo d, sarudji s, tacharina mr, et al. isolation and identification of fungal infections causing death in leopard gecko’s (eublepharis macularius) eggs. ecology, environment and conservation. 2020;26:s170-3. 3. rai m, poudel tp, gurung k, neupane gp, b.c. d. prevalence of candida albicans in genital tract of pregnant women attending antenatal clinic of nepalgunj medical college hospital. j nepalgunj med coll 2019;15:13-7. 4. bongomin f, gago s, oladele r, denning d. global and multi-national prevalence of fungal diseases—estimate precision. j fungi 2017;3:57. 5. murtiastutik d, prakoeswa crs, tantular is. fluconazole resistant oral candidiasis on hiv patient what other drug can we choose? a case report. j pure appl microbiol 2020;14:316. 6. hamida al abrori un, ayuningtyas nf, ernawati ds, hendarti ht, surboyo mdc, radithia d. oral candidiasis in immunosuppressed wistar rats (rattus norvegicus) post dexamethasone injection at 7.2 mg/kg and 16 mg/kg doses. braz dent sci 2020;23:1-7. 7. oyeyipo oo, onasoga mf. incidence and speciation of candida species among non-gravid young females in ilorin, north central, nigeria. j appl sci environ 2015;19:680-5. 8. ridwan rd, diyatri i, juliastuti ws, et al. the ability of hylocereus polyrhizus for gram positive bacteria and candida albicans. biochem cell arch 2020;20:4839-44. 9. gonçalves b, ferreira c, alves ct, et al. vulvovaginal candidiasis: epidemiology, microbiology and risk factors. crit rev microbiol 2016;42:905-27. 10. partha adsl, widodo adw, endraswari pd. evaluation of fluconazole, itraconazole, and voriconazole activity on candida albicans: a case control study. ann med surg 2022;84. 11. gao m, wang h, zhu l. quercetin assists fluconazole to inhibit biofilm formations of fluconazole-resistant candida albicans in in vitro and in vivo antifungal managements of vulvovaginal candidiasis. cellular physiol biochem 2016;40:727-42. 12. spampinato c, leonardi d. candida infections, causes , targets , and resistance mechanisms : traditional and alternative antifungal agents. biomed res int 2013;2013:113. 13. cowen le, sanglard d, howard sj, et al. mechanisms of antifungal drug resistance. cold spring harbor perspect med 2015;5:1-22. 14. ezz eldin hm, badawy af. in vitro anti-trichomonas vaginalis activity of pistacia lentiscus mastic and ocimum basilicum essential oil. j parasitic dis 2015;39:465–73. 15. hayat m, abbas m, munir f, et al. potential of plant flavonoids in pharmaceutics and nutraceutics. j biomol biochem 2017;1:12–7. 16. hayat m, abbas m, munir f, et al. potential of plant flavonoids in pharmaceutics and nutraceutics. j biomol biochem 2017;1:12-7. 17. han b, chen j, yu yq, et al. antifungal activity of rubus chingii extract combined with fluconazole against fluconazoleresistant candida albicans. microbiol immunol 2016;60:8292. 18. arifin h, widiasih r, pradipta ro, kurniawati y. regional [page 14] [healthcare in low-resource settings 2023; 11:11754] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15-49 years in indonesia. f1000res 2021;10:1-27. 19. correia i, alonso-monge r, pla j. mapk cell-cycle regulation in saccharomyces cerevisiae and candida albicans. future microbiol 2010;5:1125-41. 20. andarwulan n, batari r, sandrasari da, et al. flavonoid content and antioxidant activity of vegetables from indonesia. food chem 2010;121:1231-5. 21. hafipah n, rasdi m, samah oa, et al. antimicrobial studies of cosmos caudatus kunth. (compositae). j med plants res 2010;4:669-673. 22. sachana m, hargreaves aj. toxicological testing: in vivo and in vitro models. third edit. veterinary toxicology: basic and clinical principles: third edition. elsevier inc.; 2018. 145-161 p. 23. visvesvara gs, garcia ls. culture of protozoan parasites. clin microbiol rev 2002;15:327-9. 24. asworo ry, widwiastuti h. pengaruh ukuran serbuk simplisia dan waktu maserasi terhadap aktivitas antioksidan ekstrak kulit sirsak. indonesian j pharmaceut educ 2023;3:19906. 25. nn aswanida. a review on the extraction methods use in medicinal plants, principle, strength and limitation. med aromat plants (los angel) 2015;04. 26. sari sa, dharmawan r, dirgahayu p. the antifungal effect of roselle calyx extract on trichophyton rubrum growth in vitro. biofarmasi j natural product biochem 2012;10:17-22. 27. rakatama as, pramono a, yulianti r. the antifungal inhibitory concentration effectiveness test from ethanol seed arabica coffee (coffea arabica) extract against the growth of candida albicans patient isolate with in vitro method. j phys conf ser 2018;970. 28. perry c, chung jy, ylaya k, choi ch, simpson a, matsumoto kt, et al. a buffered alcohol-based fixative for histomorphologic and molecular applications. j histochem cytochem 2016;64:425-40. 29. andarwulan n, batari r, sandrasari da, bolling b, wijaya h. flavonoid content and antioxidant activity of vegetables from indonesia. food chem 2010;121:1231-5. 30. jung hj, seu yb, lee dg. candicidal action of resveratrol isolated from grapes on human pathogenic yeast c. albicans. j microbiol biotechnol 2007;17:1324-9. 31. han b, chen j, yu yq, et al. antifungal activity of rubus chingii extract combined with fluconazole against fluconazoleresistant candida albicans. microbiol immunol 2016;60:8292. 32. jung hj, seu yb, lee dg. candicidal action of resveratrol isolated from grapes on human pathogenic yeast c. albicans. j microbiol biotechnol 2007;17:1324-9. 33. jager ak, freiesleben sh. correlation between plant secondary metabolites and their antifungal mechanisms-a review. med aromat plants (los angel) 2014;03. 34. iyer dr, rhind n. the intra-s checkpoint responses to dna damage. genes (basel) 2017;8. 35. labib k, de piccoli g. surviving chromosome replication: the many roles of the s-phase checkpoint pathway. philosophical transactions of the royal society b: biol sci 2011;366:355461. 36. correia i, alonso-monge r, pla j. mapk cell-cycle regulation in saccharomyces cerevisiae and candida albicans. future microbiol 2010;5:1125-41. 37. yun je, lee dg. role of potassium channels in chlorogenic acid-induced apoptotic volume decrease and cell cycle arrest in candida albicans. biochim biophys acta gen subj 2017;1861:585-92. 38. correia i, alonso-monge r, pla j. the hog1 map kinase promotes the recovery from cell cycle arrest induced by hydrogen peroxide in candida albicans. front microbiol 2017;7:1-18. [healthcare in low-resource settings 2023; 11:11754] [page 15] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master [healthcare in low-resource settings 2016; 4:5755] [page 5] striving toward malaria elimination and the necessity to be persistent in our efforts saurabh r. shrivastava, prateek s. shrivastava, jegadeesh ramasamy department of community medicine, shri sathya sai medical college and research institute, kancheepuram, india across the world, malaria continues to remain a major cause of public health concern as even now 50% of the world’s total population is at potential risk of malaria.1 out of the 106 nations which were facing the challenge of malaria at the start of the current century, recent estimates suggest that almost 57 and 18 of them have achieved 75 and 50-75% reduction in the incidence of malaria, respectively.2 however, the african region alone accounts for 88% of the total malaria cases and 90% of the overall deaths in the year 2015.3 moreover, owing to the implementation of targeted approach a significant decline in both the global incidence by more than one-third, and mortality rates by three-fifth (0.83 million deaths in 2000 versus 0.43 million deaths in 2015) in the span of last 15 years has been accomplished.2,3 further, population groups of under-five children, antenatal mothers and susceptible persons going to the malaria endemic regions are extremely vulnerable to the disease.1 the recent estimates reflect that a 65% decline in the malarial death rates has been observed among the under-five year children age-group on the global scale.1,2 in addition, an expenditure of millions of dollars has been saved, especially with regard to the management of the patients since 2000.2 also, an excess of 6 million deaths across the world and more than 650 million cases of malaria (african region alone) have been prevented in the last 15 years.3 most of the current trends reflect that significant improvement has been achieved towards the ultimate goal of malaria elimination.4,5 in-fact, the international stakeholders were even successful in accomplishing the proposed malaria target under the millennium development goal 6.3,4 although, many factors have played their part in ensuring an improvement, the predominant share of the achieved success goes to the sustained level of political commitment, technical assistance from the world health organization (who), and financial support from the earmarked international agency.3-5 however, among the implemented measures, three low-cost strategies have delivered maximum output, namely insecticide-treated mosquito nets (maximum contribution in financial savings), artemisinin-based combination therapies (highly effective treatment regimen for falciparum malaria) and indoor residual spraying.2,3 further, a significant rise in the incidence of rapid diagnostic testing for malaria has also been reported from heterogeneous settings.1,4 however, even now, many challenges persist and there is a great need to address all of them.1,3,5 these include high caseload and death rates, localization of maximum number of cases from some of the high-burden nations, a slow rate of decline in the incidence/death rates of malaria compared to the global trends, shortcomings in the health care system, inaccessibility of the services (like mosquito nets or indoor residual spraying), emergence of drug resistance and insecticide resistance, and poor involvement of the community stakeholders.1,3,5,6 finally, a newer strategy has been adopted by the who member states to reduce the global malaria incidence and mortality by at least 90%, eliminate malaria from 35 nations, and to prevent the re-emergence of the disease in malaria free nations by the year 2030.1,3 to conclude, now the goal is set, we have access to effective measures which have delivered results, but the challenge is to implement the same for a longer duration of time. thus, the need of the hour is to have a strong leadership at different levels, constant motivation of the health workers, strategic involvement of the community, and up-scaling of the financial support. references 1. who. world malaria report 2015. geneva, switzerland: who; 2015. 2. who. malaria. available from: http://who.int/mediacentre/factsheets/fs09 4/en/ 3. who. achieving the malaria mdg target: reversing the incidence of malaria 20002015. geneva, switzerland: who; 2015. 4. chanda e, ameneshewa b, angula ha, et al. strengthening tactical planning and operational frameworks for vector control: the roadmap for malaria elimination in namibia. malaria j 2015;14:302. 5. hsiang ms, gosling rd. striding toward malaria elimination in china. am j trop med hyg 2015;93:203-4. 6. whittaker m, smith c. reimagining malaria: five reasons to strengthen community engagement in the lead up to malaria elimination. malaria j 2015;14:410. healthcare in low-resource settings 2016; volume 4:5755 correspondence: saurabh rambiharilal shrivastava, department of community medicine, shri sathya sai medical college and research institute, thiruporur-guduvancherry main road, 603108 kancheepuram, india. tel./fax: +91.988.422.7224. e-mail: drshrishri2008@gmail.com contributions: srs, conception and design, drafting of the article, review of literature, guarantor; prs, drafting the article, review of the literature, critically revising for important intellectual content; jr, general supervision of the research, overall guidance in writing the manuscript. conflict of interest: the authors declare no potential conflict of interest. key words: malaria; insecticide-treated nets; world health organization. received for publication: 18 january 2016. accepted for publication: 6 february 2016. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright s.r. shrivastava et al., 2016 licensee pagepress, italy healthcare in low-resource settings 2016; 4:5755 doi:10.4081/hls.2016.5755 non co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11973 the effectiveness of hiv/aids education models for adolescents with speech disabilities dedes fitria,1 sri wahyuni,1 elin supliyani,1 fauzia djamilus,1 ari kurniarum,2 sri sumarni3 1department of midwifery, politeknik kesehatan kemenkes bandung, bogor, bandung; 2department of midwifery, politeknik kesehatan kemenkes surakarta; 3department of midwifery, politeknik kesehatan kemenkes semarang, indonesia abstract adolescents with disabilities deserve the best health care without discrimination. they can access gender-sensitive health care and rehabilitation. health services include promotive, preventive, curative, and rehabilitative care. hiv and aids prevention in disabled people must start as soon as possible. those with speech dis abilities are encouraged to reach their full independence potential in case of an incident. this study tested an hiv/aids education model for speech-impaired people. at indonesia’s school of disability, a non-randomized control group preand post-test design was used. in the study, 60 speech-impaired students were divided into 30 intervention and 30 control groups. analyses used t-tests. speech-disabled people’s knowledge and attitudes improved with the virtual hiv/aids education model (p=0.007). therefore, the hiv/aids education model should be implemented using virtual platforms to improve knowledge and attitudes, especially among speech-disabled teens. virtual reproductive health education for children with speech disabilities improves knowledge and attitudes more than traditional methods, especially among visually impaired children. introduction research by the advocacy center for women, disabled, and children in 2022 shows that adolescents with disabilities experience many obstacles in finding information about sexual and reproductive health.1,2 so far, individuals with disabilities have been neglected from health program interventions, especially sexual and reproductive health, because the focus has been on nondisabled people.3 meanwhile, the maturity of reproductive organs and sexuality in people with disabilities is not much different from individuals who do not have disabilities. important findings from the discussion results include: sexual and reproductive health information is important for people with disabilities.4 persons with disabilities have the right to the highest attainable standard of health without discrimination because of disability. they can access gender-sensitive health services, including health-related rehabilitation.5 health services for persons with disabilities encompass promotion, prevention, cure, and rehabilitation.6,7 prevention of hiv/aids in people with disabilities must be initiated as early as possible. if it occurs, efforts are made to achieve the optimal level of independence, allowing individuals with speech disabilities to express their psychological and physical needs, necessitating the involvement of mothers.8,9 health education for adolescents without disabilities is available in schools through the health information center.10 however, teenagers with disabilities still face challenges in accessing such education and require specialized skills tailored to their specific disabilities.11 the family planning association in england adopts a comprehensive approach to training and support concerning sexual and reproductive health and rights for individuals with disabilities.12 research conducted by beatrix suggests that health education, especially regarding hiv/aids, can significantly influence knowledge about sexual behavior practices, including disease prevention, drug abuse prevention, and delaying sexual intercourse.13 correspondence: dedes fitria, department of midwifery bogor, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: dedesfitria@yahoo.com key words: adolescent; educational; model; speech disability. acknowledgments: the authors would like to express their gratitude to the bandung health polytechnic for their approval and support of this research. we also wish to acknowledge the valuable contributions of the mentoring program conducted by the research centre of excellence in advancing community health (reach) in surabaya, indonesia. contributions: df, es, fd, conceptualization; df, data curation; df, sw, formal analysis, visualization; df, sw, es, fd, methodology, validation; es, fd, investigation. all the authors participated in writing the original draft, reviewed and edited the manuscript, and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethical approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes bandung, based on ethical certificate 21/kepk/ec/sim/ xii/2022. during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. availability of data and material: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained for anonymized patient information to be published in this article. received: 13 october 2023. accepted: 27 may 2024. early access: 3 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11973 doi:10.4081/hls.2024.11973 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 566] [healthcare in low-resource settings 2024;12:11973] non -co mmerc ial us e o nly knowledge is paramount in hiv/aids prevention efforts, aiming to foster a state of health characterized by complete physical, mental, and social well-being, rather than merely the absence of disease or weakness in all matters related to the reproductive system and its functions.14-16 talking about hiv/aids prevention cannot be separated from matters of reproductive rights, sexual health, and sexual rights.17,18 reproductive rights are part of human rights, encompassing the right of every couple and individual to decide freely and responsibly on the number, spacing, and timing of the birth of children, and to have the information and means to do so.19 behavior is the result of all kinds of experiences and interactions between humans and their environment, which are manifested in the form of knowledge, attitudes, and actions and relates to their socioeconomic context.20 behavior constitutes an individual’s response or reaction to stimuli originating from outside or within them.21 according to bandura, people learn through direct experience or observation. people acquire knowledge from what they read, hear, and see in the media, as well as from other people and their environment.22,23 children with speech disabilities are individuals who encounter disturbances or obstacles in verbal communication, thus experiencing difficulties in expressing themselves.24 social learning theory emphasizes observational learning as a process, where individuals learn behavior by systematically observing the rewards and punishments given to others. in observational learning, there are four stages of learning from the observation or modeling process using various media such as virtual media, books, or electronic media.25 therefore, this research aimed to assess the effectiveness of the hiv-aids education model for people with speech disabilities. materials and methods research design the research method utilized the quasi-experimental method. the research design employed was a “non-randomized control group pre-test and post-test design”. in this design, the study involved an experimental group and a comparison group, both of which underwent a pretest before receiving a health education intervention using a module. the experimental group received education through a virtual education model, while the control group received education through a traditional book module. the research concluded with a final test (post-test) administered to both groups to assess their knowledge and attitudes. study participants the research was conducted at a disability school in one of the cities in indonesia. the samples in this study were 60 children with speech disability residing in one of the city areas (bogor) who met the inclusion criteria and were not included in the exclusion criteria. the inclusion criteria were as follows: children with a speech disability who were willing to participate as respondents. the sampling technique used in this research was a non-probability sampling technique, specifically the consecutive sampling method. the research sample size was determined using the unpaired numerical comparative method with the lameshow formula.26 according to the formula, the required sample size was 60.00, which was rounded up to 60 samples for each group (60 samples for the intervention group and 60 samples for the control group). variable, instrument and data collection the independent variable was the model of education about hiv-aids for people with speech disability. meanwhile, the dependent variables were the knowledge and attitudes of the respondents before and after the implementation of the intervention, which were obtained by assessing the scores from the respondents after completing the preand post-tests. the data collection technique involved asking for willingness to participate as a respondent and providing an explanation of the research procedure. this procedure included: first, filling out the pre-test sheet before implementing the intervention, and second, receiving an explanation of the intervention implementation. in the intervention group, participants received education using a virtual education model about hiv-aids for children with speech disability. in contrast, the control group received a module about hiv-aids and then underwent evaluation with preand post-tests to assess their knowledge and attitudes. the data collection tool used in this study was a questionnaire consisting of 20 questions about the hiv-aids model, 20 questions about attitudes, and 20 questions about behavior. the model questions focused on the benefits or drawbacks of applying this educational model. the behavior questionnaire assessed the respondent’s knowledge of hiv-aids, while the attitude questionnaire gauged the respondent’s support or lack thereof for this educational model. data analysis univariate analysis entailed utilizing frequency distribution to examine the distribution of responses within each group separately. multivariate analysis was conducted to compare the differences in knowledge between the intervention and control groups. this was achieved using the parametric test unpaired t-test, assuming a normal distribution of data, and the alternative nonparametric mannwhitney test, used when assumptions of normality were not met or when dealing with ordinal data. ethical clearance the health research ethics commission of the ministry of health at bandung’s health polytechnic granted ethical approval for this study (no. 21/kepk/ec/sim/xii/2022). each individual was informed about the study and voluntarily consented. results according to table 1, among the control group, it can be observed that 46.6% of the respondents are male and 53.4% are female. regarding age characteristics, an equal number of respondents are in their early and late teens (50%). in terms of educational background, the majority of respondents have completed intermediate education (67%). moreover, 73.4% of respondents had poor knowledge, while 26.6% had good knowledge. regarding respondents’ attitudes towards the hiv/aids education model, 60% supported the activities, while 40% did not. additionally, the majority of respondents (70%) in the control group, which utilized book education (modules), considered the hiv/aids education model activities to be useful. in the intervention group, the majority of respondents are female (67%); in terms of age, most children are in the late teens category (53.4%); and regarding educational background, the majority of respondents have completed intermediate education (60%). the results of respondents’ knowledge about hiv-aids in the intervention group indicate that 53.4% of respondents had good knowledge, while 46.6% had poor knowl transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11973] [page 567] non -co mmerc ial us e o nly edge. regarding respondents’ attitudes towards the hiv-aids education model in the intervention group, all respondents supported the activities (100%). furthermore, the hiv-aids education model revealed that almost all respondents (97%) believed that the activities of the hiv-aids education model were beneficial for them. differences in knowledge and attitudes between the control group and intervention group indicate a significant distinction (p<0.05) for both the knowledge variable (0.000) and the attitude variable (0.000). this suggests that the intervention implemented had a distinct impact on both aspects. based on the results of the t-test with the hiv-aids education model, it is obtained that r=0.007 (<0.05) indicates a significant relationship between the virtual model of education for persons with speech disabilities and the hiv-aids education model. this suggests a relationship of r=0.007 (table 2). discussion from the results of the data analysis, the mean knowledge scores were as follows: the control group obtained a value of 40.52 between pre-test and post-test, while the intervention group obtained a value of 81.27. it can be concluded that there are significant differences between the two groups, indicating a positive influence of the independent variable on the dependent variable. specifically, the use of the hiv/aids virtual education model positively influenced knowledge (behavior) about reproductive health for children with speech disabilities.27 at the beginning of the pretest, the mean value before receiving the virtual education module in the control group was 40.52. after receiving education about reproductive health, the post-test results increased to 57.33. in the intervention group, the value before education and the virtual module of reproductive health was 41.43, which increased to 83.63 after receiving education and the virtual module.28 the knowledge of respondents in both the control and intervention groups initially had low scores. this aligns with the findings of bremer’s (2009) research on adolescents with disabilities and their knowledge of reproductive health. the study revealed that these adolescents had a limited understanding of reproductive health, and many had not transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 568] [healthcare in low-resource settings 2024;12:11973] table 1. distribution of characteristics of the control and intervention groups. control group variable category frequency percentage (%) gender male 14 46.6 female 31 53.4 child’s age early teens 15 50 late teens 15 50 education basic (elementary school) 10 33 intermediate (junior high school or above) 20 67 category knowledge good 8 26.6 not good 24 73.4 category attitude support 18 60 less supportive 12 40 education hiv-aids benefit 21 70 no benefits 9 30 intervention group variable category frequency percentage (%) variable category frequency percentage (%) gender male 10 33 female 20 67 child’s age early teens 14 46.6 late teens 16 53.4 education basic (elementary school) 12 40 intermediate (junior high school or above) 18 60 category knowledge good 16 53.4 not good 14 46.6 category attitude support 30 100 less supportive 0 0 education hiv-aids benefit 29 97 no benefits 1 3 total 30 100 table 2. virtual hiv-aids education between control and intervention groups. variable z p-value knowledge -4.376 0.000 attitude -4.187 0.000 variable t-test (p-value) information education model 0.007 related non -co mmerc ial us e o nly received basic reproductive health education29. the increase in knowledge was highly significant in the intervention group, which initially had a mean value of 40.52 and increased to 81.27 after the intervention. this is attributed to the strong informational power of learning modules, which provide ample opportunities for independent student utilization due to their systematic arrangement, engaging content, and accessibility anytime and anywhere according to student needs.30 the intelligence quotient (iq) of children with speech disabilities does not differ from that of typical children, although their verbal iq scores may be lower than their performance iq scores.31 according to rosaria, there was a notable difference in the intervention group that received socialization of the hiv/aids prevention module, showing better knowledge compared to the control group. therefore, the utilization of virtual hiv-aids education modules can enhance the knowledge of children with speech disabilities about reproductive health, providing exposure to reproductive health materials not previously covered in school.32 attitude of respondents from the results of data analysis, the mean attitude scores were as follows: the control group obtained a value of 70.75 between pre-test and post-test, while in the intervention group, the value was 75.35. it can be concluded that there are significant differences between the two groups, indicating a positive influence of the independent variable on the dependent variable, namely the influence of virtual reproductive health education for children with visual disabilities on respondents’ attitudes.25 this aligns with the analysis indicating that the virtual module of reproductive health education for children with visual disabilities affects the attitude of respondents, as shown by significant differences.31 at the beginning of the pre-test, the control group obtained a value of 44.50. after receiving education about reproductive health, the post-test results increased to 55.45. in the intervention group, the value before education and the virtual module on reproductive health was 52.40, which increased to 82.25 after receiving education and the virtual module. the attitudes of respondents in both the control group and the intervention group initially had low scores. in general, children with speech disabilities lag in speech-language development compared to typical children but exhibit similar attitudes.25 rosaria noted a significant difference in the intervention group that received socialization of the hiv/aids prevention module, showing a better attitude than the control group.32 research in cameroon indicates that women with disabilities have a limited understanding of hiv/aids and low reproductive health education.25 people with disabilities face barriers to accessing health services and information, arising from various factors such as norms, cultures, restrictive attitudes, limited services, lack of tools, weak communication skills of health workers, unavailability of buildings, marginalization in communities, illiteracy, limited education, and gender inequality.31 thus, the use of a virtual model of hiv/aids education for speech disabilities affects attitudes. visual acuity is an advantage for children with speech disabilities over blind children. intelligence ability (iq) is no different from typical children, although verbal iq scores may be lower than performance iq scores.27 using virtual educational models with attractive images and colors generates positive reactions, prompting individual behavioral responses to virtual learning.33 the results of the mann-whitney test discussion yielded a value of 0.000, indicating that the provision of an hiv-aids education model in the form of virtual education for speech-impaired individuals significantly impacts the knowledge and attitudes of children with speech disabilities. this aligns with the findings of the data analysis, indicating significant differences in knowledge and attitudes. children with speech disabilities learn effectively through visual media,32 benefiting from good memory skills that facilitate material retention, leading to significant score increases in both groups during the post-test. their iq does not differ from that of typical children, although their verbal iq scores may be lower than their performance iq scores.34 bandura’s social learning theory suggests that behavior is influenced by the environment through reinforcement and observational learning, emphasizing the reciprocal relationship between behavior and the environment.35 social learning interventions can effectively change attitudes toward discussing reproductive health issues. even individuals initially disinterested in such discussions may show increased attention to reproductive health after receiving education and virtual modules.36 this is evident from the rise in attitude scores in the post-test, indicating enhanced engagement with reproductive health topics.37 adolescents equipped with proper knowledge about reproductive health can make informed decisions regarding sexual relations before marriage.38 the use of hiv/aids education models in the form of virtual education significantly increases attitude scores in intervention groups. conclusions the virtual education model of reproductive health education for children with speech disabilities is effectively implemented to enhance the knowledge and attitudes of children with visual disabilities compared to the conventional model (using modules or books). the level of knowledge and attitudes among children with visual disabilities improved more significantly after receiving virtual education than with the conventional model (using modules or books). references 1. qi w, li h, lian q, et al. knowledge level and access barriers related to sexual and reproductive health information among youth with disabilities in china: a cross-sectional study. reprod health 2023;20:84. 2. andriani ns, ayatullah r.k, muhdlor s, pudyastuti i. situasi perlindungan anak penyandang disabilitas di daerah istimewa yogyakarta 2022;170. 3. addlakha r, price j, heidari s. disability and sexuality: claiming sexual and reproductive rights. reprod health matters 2017;25:4-9. 4. faswita w, suarni l. hubungan pemberian pendidikan seks di sekolah dengan perilaku seksual remaja di sma negeri 4 kota binjai 2017. j jumantik 2019;5:1-16. 5. suyasa igpd, sutini nk, kamaryati np, nuryanto ik. determinant of functional disability in instrumental activities of daily living among elderly living in a rural area in bali: a cross-sectional study. j ners 2023;18:110-6 6. un general assembly. convention on the rights of persons with disabilities. 2006. available from: https://www.refworld.org/legal/agreements/unga/2006/en/90142 7. al fajri ms, abdul rahim h, rajandran k. portraying people with disability in indonesian online news reports: a corpusassisted discourse study. media asia 2024. available from: transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:xxx] [page 569] non -co mmerc ial us e o nly https://www.scopus.com/inward/record.uri?eid=2-s2.085184718794&doi=10.1080%2f01296612.2024.2310891&pa rtnerid=40&md5=1828c98c18fb00d2b30361d353808409 8. gerald n, kimani, augustine m, augustine k. students’ sexual behaviour in the context of hiv/aids education in public secondary schools: a case for kangudo division, kenya. international journal of humanities and social science 2012;2:37-44. 9. bell e, corby n. hiv prevention, treatment and care programming for people with disabilities. disabil inclusion helpdesk rep 2019;7:1-17. 10. nafisah l, rizqi ynk, aryani aa. identification of school’s roles, adolescent access, and exposure to information on adolescent reproductive health. j kesehat 2023;14:294. 11. babik i, gardner es. factors affecting the perception of disability: a developmental perspective. front psychol 2021;12:126. 12. committee id. the fcdo’s approach to sexual and reproductive health. 2024. 13. beatrix meme laot. pengaruh pendidikan kesehatan terhadap perilaku seksual remaja di sma pgri 3 surabaya 2013;1125. 14. arifin b, rifqi rokhman m, zulkarnain z, et al. the knowledge mapping of hiv/aids in indonesians living on six major islands using the indonesian version of the hiv-kq-18 instrument. plos one 2023;18. available from: https://www.scop u s . c o m / i n w a r d / r e c o r d . u r i ? e i d = 2 s 2 . 0 85176434817&doi=10.1371%2fjournal.pone.0293876&partn erid=40&md5=e81133c330b2eb06bb79e326a8655c38 15. nursalam n, sukartini t, kuswanto h, et al. investigation of discriminatory attitude toward people living with hiv in the family context using socio-economic factors and information sources: a nationwide study in indonesia. peer j 2022;10:e13841. 16. efendi f, pratama er, hadisuyatmana s, et al. hiv-related knowledge level among indonesian women between 15 years and 49 years of age. afr health sci 2020;20:83-90. 17. mahathir m, wiarsih w, permatasari h. how do people living with hiv acquire hiv related information: a qualitative evaluation of jakarta setting. j ners 2020;15:126-34. 18. sari pi, martawinarti rtsn, lataima ns, berhimpong vm. the quality of life of patients with hiv/aids undergoing antiretroviral therapy: a systematic review. j ners 2019;14:504. 19. gable l, gostin lo, hodge jgj. hiv/aids, reproductive and sexual health, and the law. am j public health 2008;98:177986. 20. deya virdausi f, efendi f, kusumaningrum t, et al. socio-economic and demographic factors associated with knowledge and attitude of hiv/aids among women aged 15-49 years old in indonesia. healthcare 2022;10:1545. 21. madu yg, lusmilasari l, hartini s, et al. the relationship between knowledge, self-efficacy and nursing spiritual care behaviors in school-age children in pediatric room. j ners 2023;18:274-9. 22. desiningrum dr. psikologi anak berkebutuhan khusus. psikosain 2017. 23. suharto b, firdaus aa, kristanto d, et al. the effect of literature ability of airlangga university students in various fields of science. j layanan masy 2022;6:325-33. 24. yusuf nh. expanding language development among children and communication disorders. j um surabaya ac id 2021;9:401-12. 25. allan j. an analysis of albert bandura’s aggression: a social learning analysis. 1st ed. macat library; 2017. available from: https://doi.org/10.4324/9781912282425 26. paul p, pennell ml, lemeshow s. standardizing the power of the hosmer-lemeshow goodness of fit test in large data sets. stat med 2013;32:67-80. 27. wahyuni s. the effectiveness of online-based hiv and aids prevention education on hiv/aids risk health behavior in people with deaf disabilities. jurnal riset kesehatan poltekkes depkes bandung 2022;14:375-84. 28. bangsa gp, widjajanegara h, trisnadi s. hubungan antara tingkat pengetahuan kesehatan reproduksi dengan perilaku seksual remaja pada di sma islam terpadu pgii-1 kota bandung periode 2017-2018. prosiding pendidikan dokter spesia 2018;2018:483-91. 29. bremer k, cockburn l, ruth a. reproductive health experiences among women with physical disabilities in the northwest region of cameroon. int j gynecol obstet 2010;108:211-3. 30. palupi dca, asmaningrum n, dewi ei. pengaruh teknik talking stick terhadap pengetahuan dan sikap dalam pencegahan hiv/aids pada remaja di smp negeri 1 puger kabupaten jember. (the effect of talking stick towards knowledge and attitude in preventing hiv/aids of the teenagers in puger 1 junior). e-jurnal pustaka kesehat 2015;3:443-9. 31. sugiyono pd. statistik untuk penelitian. cv alf bandung. 2006;403. 32. rosaria yw, fitria d. efektivitas modul pencegahan hiv/aids bagi calon pengantin terhadap pengetahuan dan sikap. j ris kesehat poltekkes depkes bandung 2021;13:172-9. 33. kustandi c, farhan m, zianadezdha a, et al. pemanfaatan media visual dalam tercapainya tujuan pembelajaran. akademika 2021;10:291-9. 34. subekti n. pendidikan karakter dan pengembangan kepemimpinan anak tunagrahita ringan melalui permainan tradisional 2017;273-8. 35. nuryati s. hubungan faktor sosial dan kontrol diri dengan perilaku akktivitas seksual beresiko kehamilan tidak di inginkan pada remaja sma di kota bogor. kebidanan 2017;3:184-9. 36. wirata rb, febrianti s, pradipta srr. edukasi melalui google meet tentang kesehatan reproduksi remaja. j abdimas bsi j pengabdi kpd masy 2022;5:270-7. 37. endarto y, parmadi sigit purnomo. hubungan tingkat pengetahuan tentang kesehatan reproduksi dengan perilaku seksual berisiko pada remaja di smk negeri 4 yogyakarta. j kesehat surya med yogyakarta 2007;1:1-18. 38. nurhayati t, rosaria yw. faktor-faktor yang berhubungan dengan orientasi seksual pada remaja. j ilm bidan 2017;02:22-31. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 570] [healthcare in low-resource settings 2024;12:11973] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12080 the effect of the sumping e-module as a labor companion on the duration of labor in independent midwife practice utami dewi,1 rahmadona,1 nurniati tianastia rullyni,1 rully hevrialni2 1vocational midwifery study program, politeknik kesehatan kemenkes tanjungpinang, tanjungpinang; 2vocational midwifery study program, politeknik kesehatan kemenkes riau, pekanbaru, indonesia abstract reducing the incidence of childbirth complications requires family participation, especially from husbands, consistent with government policies and strategies aimed at reducing childbirth complications in indonesia through the making pregnancy safer (mps) program. the approach to increasing husbands’ involvement in reproductive health includes providing them with information and involving them in all efforts to improve reproductive health. one activity husbands can undertake to improve maternal and child health is accompanying their wives during labor and supporting referrals when necessary. the purpose of this study was to determine the effect of labor assistance using the sumping (supporting husband as a companion) e-module compared to labor assistance without using the sumping e-module on the duration of labor. the research design was a quasi-experiment with a control group that only underwent the post-test. the instruments used included a checklist and a partograph sheet. data collection occurred during the post-test. the study involved 120 respondents, all of whom were birth attendants (husbands) at pmb tanjungpinang. analysis was conducted using the independent samples t-test. statistical tests using the independent samples ttest revealed a significant difference (p=0.000) in the length of labor between those with full and those with non-full assistance in the treatment group. in the control group, there was no significant difference (p=0.039) between husbands who provided full assistance and those who did not. husband support can shorten the duration of labor. husbands who had access to the sumping emodule reported greater involvement in assistance during labor than those without the sumping e-module. introduction disorders during pregnancy can lead to infant mortality and maternal deaths.1 maternal mortality can be prevented through early detection, including during the period preceding pregnancy.2 the maternal mortality ratio (mmr) is a fundamental indicator of obstetric or health services for women of reproductive age; more than 90% of maternal deaths are caused by complications that often occur during or around childbirth. complications of childbirth are deviations from the norm that directly result in morbidity and mortality in mothers and infants due to disturbances caused directly by childbirth.3 in general, maternal mortality decreased from 390 to 305 per 100,000 kh live births between 1994 and 2015. although maternal mortality was decreasing, it did not reach the millennium development goals (mdgs) target of 102 per 100,000 kh by 2015. it is also far from the sustainable development goals (sdg) target of reducing mmr to less than 70 per 100,000 kh by 2030 and the 2024 national medium-term development plan (rpjmn) target of 183 per 100,000 kh.4 third-trimester primigravida mothers typically experience anxiety.5 at the time of delivery, the major causes of maternal mortality are hemorrhage, eclampsia, infection, prolonged labor, obstructed labor, and miscarriage. prolonged labor, including a prolonged first stage, may increase the risk of postpartum hemorrhage (pph) by causing uterine atony in the third stage correspondence: utami dewi, vocational midwifery study program, poltekkes kemenkes tanjungpinang, tanjungpinang, indonesia. e-mail: utami.dewi@poltekkes-tanjungpinang.ac.id key words: e-module; husband support; duration of labor. authors’ contributions: ud, conceptualization, data curation, methodology, validation, visualization, writing – original draft, review and editing; rr, conceptualization, formal analysis, methodology, validation, and writing – original draft, review and editing; ntr, conceptualization, review and editing; rh, resources, investigation, and review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of medicine stikes patria husada blitar, as indicated by ethical approval no 06/phb/kepk/33/10.21. throughout the research, the researcher has adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: the anonymized patient information was provided in writing with the patient's informed consent for publication. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 14 november 2023. accepted: 18 march 2024. early access: 18 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12080 doi:10.4081/hls.2024.12080 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 482] [healthcare in low-resource settings 2024;12:12080] non -co mmerc ial us e o nly (after the infant is delivered). uterine atony occurs when the relaxed myometrium fails to constrict the uterine blood vessels. regular contractions over several hours of labor will exhaust the uterine muscles and thereby reduce their contractility over time, causing uterine dysfunction.6 reducing the incidence of labor complications requires the involvement of the family, especially the husband, who can provide strong emotional support during labor. this support can help reduce stress and anxiety, which can contribute to the risk of complications. family support can be provided in the form of informative, emotional, instrumental, and assessment support.7 family support for pregnant women provides benefits for both the mother and fetus. provided support makes mothers feel strong and able to overcome perceived obstacles.8 women who receive support not only have lower rates of cesarean section but are also more likely to give birth spontaneously, with shorter labor processes. husbands can assist by providing physical support, such as massage, helping the mother move or change position, and creating a comfortable environment. this assistance can help reduce physical tension and increase the mother’s comfort.9 self-efficacy is an important factor that plays a role in dealing with stress.10 several studies have reported that a husband’s support positively impacts encouraging pregnant women to attend anc visits.11 the husband’s role also positively affects the delivery process and the choice of skilled birth attendants.12 this aligns with government policies and strategies aimed at reducing the incidence of childbirth complications in indonesia through the making pregnancy safer (mps) program.13,14 the mps program emphasizes that increasing husbands’ participation in reproductive health involves equipping husbands with information and involving them in every effort to improve reproductive health. one activity husbands can undertake to improve maternal and child health is accompanying their wives during labor and providing support for referrals when needed.15,16 it is hoped that in the era of the fourth industrial revolution 4.0, health services provided to the community will also evolve alongside the community’s development.17 the fourth industrial revolution 4.0 is characterized by rapid technological advancement, as exemplified by the internet, which greatly facilitates human life. this revolution impacts not only the technology sector but also the health sector, with e-health being one example, focusing on technology-based health services.18 in response to these challenges, e-modules are a type of educational media presented in the form of electronic modules that are more interactively packaged. e-modules, also known as self-study media, incorporate self-study instructions. they can be filled with materials such as pdfs, videos, and animations, enabling users to engage in learning actively.19,20 as part of digital literacy in midwifery care, an e-module for delivery assistance in midwifery services must be compiled. based on the foregoing, the researcher wishes to conduct research on the effect of husband participation on labor duration. materials and methods the design of this study is a quasi-experimental study utilizing the post-test method with a control group (post-test-only control group design). this research design aims to observe the effect of intervention or treatment in the form of providing e-modules for labor assistance to husbands of laboring mothers.21 the study population includes all labor assistants who accompanied laboring mothers at independent practice midwife (ipm) tanjungpinang city. the samples in this study were selected from among the birth attendants at ipm tanjungpinang city and divided into two groups: the intervention group and the control group. the determination of the sample size in this study was based on the consideration that, for statistically analyzed and normally distributed data, a minimum sample size of 30 is required. therefore, the sample was set at 60 individuals for each treatment group and control group, resulting in a total sample size of 120 individuals. sampling in this study employed the purposive sampling technique, which intentionally considers specific criteria to meet the research objectives. these considerations are outlined in the inclusion criteria, which include the labor companion possessing a smartphone, accompanying a multiparous laboring mother from the active phase (4 cm) to the third stage of placenta delivery, assisting in normal labor, willing to participate as a research subject, and possessing literacy skills. exclusion criteria encompassed cases where the laboring mother is referred to in the middle of the labor process or experiences complications. the variables in this study comprised independent variables, namely e-module and without e-module, while the dependent variable is the duration of the labor process (from active phase i to phase iii) in hours, as recorded in the partograph. additionally, external variables include age, education, and occupation. the researcher intervened in part of the existing sample, while another part of the sample remained untouched for comparison, aiming to determine the treatment effect. this study comprised two groups: the treatment group and the control group. the treatment group received an intervention in the form of an e-module accompanying childbirth, whereas the control group received health education services at the independent practice of midwives. to assess the duration of the labor process (stages i-iii), hours were recorded using a partograph (post-test). the observed change in this study is the duration of the labor process from stage i to stage iii (until the placenta is delivered) in laboring women accompanied by a labor companion (husband) with the e-module compared to those without the e-module. data analysis in this research was conducted in several stages. firstly, univariate analysis was performed to describe the distribution and proportion of each research variable, presented in the form of frequency distribution tables and percentages. bivariate analysis, conducted using a computer, aimed to observe the relationship between the independent variable (e-module of labor companion) and the dependent variable (duration of labor process). prior to the statistical test, a normality test was conducted on the data. the parametric test used was the independent samples t-test. this study received ethical approval with number 06/phb/kepk/33/10.21 from the health research ethics committee of stikes patria husada blitar. results table 1 indicates that husbands of working mothers in the treatment group had a low education level (elementary to junior high school) (55%). the majority of respondents in this group did not work (65%). conversely, the majority of respondents in the control group had a higher education level (senior high school to university) (63.3%) and were employed (65%). according to table 2, the average age of the birth attendant husband in the treatment group was 29.33 years, with a variation of 5.41 years. the youngest was 20 years old, and the oldest was transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12080] [page 483] non -co mmerc ial us e o nly 42 years old. in the control group, the average age was 29.45 years, with a variation of 5.82 years, and the youngest was 21 years old while the oldest was 43 years old. table 3 shows that in the treatment group, which included husbands who received the sumping e-module, 50 people (83.3%) provided full assistance during labor, while 10 people (16.7%) did not. in the control group, which included husbands who did not receive the sumping e-module, 26 people (43.3%) fully accompanied their wives during labor, while 34 people (56.7%) did not. table 4 shows that the average length of labor in the treatment group was 3.40 hours, with a variation of 1.04 hours. the shortest duration was 1.20 hours, and the longest was 5.30 hours. in the control group, the average length of labor was 5.61 hours, with a variation of 1.73 hours. the shortest labor time was 3.25 hours, while the longest was 8.55 hours. according to table 5, the average length of labor in the treatment group, given the sumping e-module, was shorter at 3.16 hours with a variation of 0.94 hours compared to husbands who did not provide full assistance, which was 4.63 hours with a variation of 0.53 hours. the t-test result was p=0.000, indicating a statistically significant difference in the average length of labor between husbands who provide full assistance during the delivery process and those who do not. in the control group that did not receive the sumping emodule, the average length of labor was 5.08 hours, with a variation of 1.81 hours, compared to husbands who did not fully assist, with an average of 6.01 hours and a variation of 1.58 hours. the ttest result was p=0.039, indicating no statistically significant difference in the average length of labor between husbands who fully and partially assist in the length of the labor process. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents based on education and occupation. respondent characteristics frequency percentage (%) education treatment group high (senior high school-university) 27 45 low (elementary-junior high school) 33 55 control group high (senior high school-university) 38 63.3 low (elementary-junior high school) 22 36.7 occupation treatment group employed 21 35 unemployed 39 65 control group employed 39 65 unemployed 21 35 table 2. characteristics of respondents by age. respondent characteristics mean sd minimum maximum age treatment group 29.33 5.41 20-42 control group 29.45 5.82 21-43 table 4. length of labor in the treatment and control group. length of labor mean sd minimum maximum treatment group 3.40 1.04 1.20-5.30 control group 5.61 1.73 3.25-8.55 table 5. differences in length of labor in the treatment and control group. delivery assistance mean sd p treatment group full accompanying 3.16 0.94 0.000 not full accompanying (partial) 4.63 0.53 control group full accompanying 5.08 1.81 0.039 not full accompanying (partial) 6.01 1.58 table 3. delivery assistance in treatment and control group. delivery assistance treatment group given the sumping e-module control group not given the sumping e-module f % f % full 50 83.3 26 43.3 partial 10 16.7 34 56.7 total 60 100 60 100 [page 484] [healthcare in low-resource settings 2024;12:12080] non -co mmerc ial us e o nly discussion after statistical testing revealed that the average length of labor with assistance using the sumping e-module was shorter than the average length of labor with assistance without using the sumping e-module, this pseudo-experimental study was conducted to examine the effect of the e-module of delivery assistance (sumping e-module) on the length of the labor process using a post-test only with control group design. the findings of this study were in line with those of several other studies, including one by sumakul and terok16 that showed that husband assistance affects the length of the first stage (p=0.023) and the second stage (p=0.028) of labor. yulizar and zuhrotunida22 found a significant relationship (p=0.011) between the husband’s assistance during the delivery process and the length of the second stage of labor in their study. research by el fattah et al. in egypt also showed that assistance and support during labor can significantly (p=0.001) reduce the length of labor and increase cervical dilatation. similarly, a study by mohammed eid et al.23 found that full companion support during labor has a significant effect (p=0.001) on labor progress and maternal satisfaction. a study conducted in a teaching hospital in china by wang et al.24 found that continuous support from the husband during labor reduced the length of labor and the incidence of emergency cesarean section. labor is a significant event in a woman’s life, and each woman’s experience with childbirth is unique. this often leads to anxiety, discomfort, and an increase in the intensity of labor pain.25 anxiety, discomfort, and labor pain lead to an increase in the release of catecholamine hormones, which disrupt blood flow to the uterus, weaken uterine contractions, and slow the labor process.26 furthermore, anxiety, pain, and discomfort during labor increase the risk of labor complications such as maternal fatigue, increased oxytocin use, assisted delivery, cesarean section, neonatal asphyxia, and fetal death.27,28 one solution is to have a birth attendant accompany and guide the woman through the labor process. the world health organization (who) recommends that the birth attendant be chosen by the mother. however, since the husband’s participation in accompanying childbirth is still low, the who recommendation is directed towards childbirth assistance by the husband, as he is the closest person to the mother and will be involved in childcare in the family.26 the presence of the husband as a labor companion is crucial because it can create a sense of security and comfort for the mother, increase her confidence, reduce anxiety about the labor process, alleviate the intensity of labor pain, minimize labor complications, and expedite the delivery process.29,30 paying attention, conveying messages, encouraging, inviting, providing thoughts/solutions, delivering services/assistance, offering advice, mobilizing, and cooperating are all ways to provide support. husbands must possess knowledge and skills on what to do during labor to offer effective assistance.31 therefore, in this study, husbands who accompanied childbirth were provided with informational media in the form of a summarizing e-module. this module could be utilized to learn about the childbirth process and the necessary steps to take while accompanying the childbirth process. an e-module is a tool or learning aid that systematically and engagingly contains materials, methods, limitations, and evaluation techniques designed electronically to attain expected competencies based on the complexity level.32,33 in terms of benefits, electronic media, such as sumping emodules, can render the learning process more interesting, interactive, and accessible from any location and at any time, thereby enhancing learning quality. researchers developed this informational media in the form of e-modules so that husbands can independently acquire knowledge and foster positive behavior in assisting childbirth.34,35 the study discovered that in the treatment group, where accompanying husbands received the sumping e-module, 83.3% demonstrated full assistance behavior, and the average duration of labor they assisted was shorter compared to husbands who did not exhibit full assistance behavior. the t-test results in this treatment group were also significant (p=0.000), indicating that the e-module influenced the husband’s assistance behavior during the delivery process. in contrast, in the control group that did not receive the sumping e-module, more husbands (56.7%) did not fully assist during labor. the t-test results were also insignificant (p>0.005), suggesting that not receiving the summarizing e-module resulted in a lack of information about childbirth assistance, thereby hindering the development of knowledge underlying full assistance behavior in the delivery process. conclusions the sumping e-module clearly demonstrates how a husband’s role as a companion during labor can influence the length of the labor process. when husbands use the sumping e-module as a part of their labor companion role, it significantly shortens the labor duration. this reduction alleviates anxiety and fatigue in the mother and decreases the risks of infection and dehydration. additionally, it lowers the chances of complications for both the mother and child, which contributes to the reduction of maternal and infant mortality rates, including asphyxia and fetal death in the womb. references 1. rahman fs, martiana t. analysis of factors related to maternal health in female workers in the industrial area of sidoarjo, indonesia. j public health africa 2019;10:1179. 2. diana s, wahyuni cu, prasetyo b. maternal complications and risk factors for mortality. j public health res 2020;9:1958. 3. kemenkes ri. survei demografi dan kesehatan indonesia 2012 (sdki12) berita. 2012. available from: https://www.bps.go.id/id/news/2012/05/28/6/surveidemografi-dan-kesehatan-indonesia-2012—sdki12-.htm 4. kemenkes ri. survei demografi dan kesehatan indonesia 2013 badan pusat statistik indonesia. 2013. available from: https://www.bps.go.id/id/publication/2013/12/06/293d22c69f7 7a7ef3fe0e86f/profil-statistik-kesehatan-2013.html 5. ar-rayyan iu, saputra yd, prastika ab, puspitasari n. the effect of binaural beats on pregnant women primigravida 3rd trimester to reduce pain in the 1st stage of labor process. j biometrika dan kependud 2023;12:210-8. 6. nyfløt lt, stray-pedersen b, forsén l, vangen s. duration of labor and the risk of severe postpartum hemorrhage: a casecontrol study. plos one 2017;12. 7. zahroh c, widyagarini fs, wardani em, et al. spiritual experience related to anxiety level in pre operational cesarean section patients. bali med j 2023;12:2864-7. 8. triharini m, armini nka, nastiti aa. effect of educational transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12080] [page 485] non -co mmerc ial us e o nly intervention on family support for pregnant women in preventing anemia. belitung nurs j 2018;4:304-11. 9. nenko i, kopeć-godlewska k, towner mc, et al. emotional factors, medical interventions and mode of birth among lowrisk primiparous women in poland. evol med public heal 2023;11:139-48. 10. wahyuni s, rahayu t, nursalam. self efficacy of pregnant women in areas affected by covid 19. enferm clin 2021;31:601-4. 11. efendi f, aji rs, kurnia id, et al. determinants of maternal healthcare service utilisation among indonesian mothers: a population-based study. f1000research 2022;10. 12. laksono ad, wulandari rd, rohmah n, matahari r. husband’s support in wife’s anc in eastern indonesia: do regional disparities exist? indones j heal adm 2022;10:197205. 13. depkes ri. rencana strategis nasional making pregnancy safer (mps) di indonesia 2001 2010. 2001. available from: https://perpustakaan.kemkes.go.id/inlislite3/opac/detailopac?id=4380 14. calon p, negeri p, bkkbn s. badan kependudukan dan keluarga berencana nasional. 2013;1-14. 15. badan pusat statistik bkkbn. kias : kesehatan ibu anak dan suami. jakarta. stat indones stat yearb indones 2023. available from: https://www.bps.go.id/id/publication/2022/12/23/54f24c0520b 257b3def481be/profil-kesehatan-ibu-dan-anak-2022.html 16. sumakul, vd, terok ka. pengaruh pendampingan suami terhadap lamanya proses persalinan kala i dan ii pada ibu primipara di irina yohana rsu gunung maria tomohon. pros semin nas tahun 2017;1:278-85. 17. thojampa s, klankhajhon s, kumpeera k, et al. the development of a wellness tourism program in thailand: a community-based participatory action research approach with an empowerment theoretical framework. j ners 2023;18:291-8. 18. ri k. infodatin: pusat data dan informasi kementerian kesehatan ri mother’s day. 2014. 19. sukiman. pengembangan media pembelajaran. 2012. available from: https://digilib.perpussmakanda.com/opac/detail-opac?id=3736 20. imansari n, sunaryantiningsih i. pengaruh penggunaan emodul interaktif terhadap hasil belajar mahasiswa pada materi kesehatan dan keselamatan kerja. volt j ilm pendidik tek elektro 2017;2:11-6. 21. sastroasmoro. dasar-dasar metodologi penelitian klinis. 2011. available from: https://opac.perpusnas.go.id/detailopac.aspx?id=1111569 22. yulizar y, zuhrotunida z. hubungan pendamping persalinan dengan lama kala ii pada ibu primigravida di klinik s curug tangerang. j jkft 2018;3:86-93. 23. akbarzadeh m, masoudi z, zare n, kasraeian m. comparison of the effects of maternal supportive care and acupressure (at bl32 acupoint) on labor length and infant’s apgar score. glob j health sci 2015;8:236-44. 24. wang m, song q, xu j, et al. continuous support during labour in childbirth: a cross-sectional study in a university teaching hospital in shanghai, china. bmc pregnancy childbirth 2018;18:1-7. 25. kennedy bb, ruth dj, martin ej. intrapartum management modules : a perinatal education program. lippincott williams and wilkins; philadelphia, usa; 2002. 673 pp. 26. danuatmajda b, meiliasari m. persalinan normal tanpa rasa sakit | dinas perpustakaan dan arsip daerah diy. 2004. available from: h t t p s : / / b a l a i y a n p u s . j o g j a p r o v. g o . i d / o p a c / d e t a i l opac?id=274970 27. mukhoirotin m, khusniyah z. pengaruh pendampingan suami terhadap kecemasan ibu pada proses persalinan kala i (fase laten-fase aktif). pros semin compet advant 2021;1:80-7. 28. indriani f. pengaruh pendamping persalinan dan paritas terhadap pengurangan rasa nyeri kala i fase aktif pada ibu bersalin normal. thesis. program pasca sarjana universitas sebelas maret surakarta. rev cenic ciencias biológicas 2014;17:1-26. 29. sapkota s, kobayashi t, kakehashi m, et al. in the nepalese context, can a husband’s attendance during childbirth help his wife feel more in control of labour? bmc pregnancy childbirth 2012;12:1-10. 30. johariyah j, sohimah s, lestari ya. perbedaan pengaruh pendamping persalinan terhadap lama kala ii persalinan pada ibu primigravida. j kesehat al-irsyad 2014;5:24-34. 31. kurniati a, chen c-m, efendi f, et al. suami siaga: male engagement in maternal health in indonesia. health policy plan 2017;32:1203-11. 32. gebuza g, kaźmierczak m, mieczkowska e, gierszewska m. social support as a determinant of life satisfaction in pregnant women and women after surgical delivery. psychiatr pol 2018;52:585-98. 33. munkhondya bmj, munkhondya te, chirwa e, wang h. efficacy of companion-integrated childbirth preparation for childbirth fear, self-efficacy, and maternal support in primigravid women in malawi. bmc pregnancy childbirth 2020;20:1-12. 34. susilana r, riyana c. media pembelajaran: hakikat, pengembangan, pemanfaatan, dan penilaian. 2009. available from: https://books.google.co.id/books?id=-yqhawaaqbaj &printsec=frontcover&hl=id#v=onepage&q&f=false 35. suarsana im, jurusan gam, matematika p, et al. pengembangan e-modul berorientasi pemecahan masalah untuk meningkatkan keterampilan berpikir kritis mahasiswa. jurnal pendidik indones 2013;2:2303-88. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 486] [healthcare in low-resource settings 2024;12:12080] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12958 impact of nutrition mentoring by dietetic students on knowledge, dietary intake, and nutritional status in pregnant women with chronic energy deficiency in south sulawesi nadimin, hijrah asikin department of nutrition, poltekkes kemenkes makassar, indonesia abstract chronic energy deficiency (ced) in pregnant women raises the risk of premature birth and low birth weight (lbw). ced pada ibu hamil menyebabkan gangguan pertumbuhan janin dan meningkatkan risiko kelahiran bayi bblr. this study evaluates the effectiveness of nutrition mentoring by dietetic students on the knowledge, intake, and nutritional status of pregnant women in makassar and maros, south sulawesi. conducted as part of the 2023 dietitian professional education program at makassar health polytechnic, the study used a pretest-posttest design without a control group. nutrition mentoring was provided through home visits three times a week for two weeks, involving 122 pregnant women with ced. data were collected via structured interviews and 24-hour recalls, then analyzed using spss. the results showed significant improvements: nutrition knowledge increased from 49.9 to 88.6, and energy, protein, fat, and carbohydrate intake rose significantly (p<0.05). upper arm circumference improved from 21.79 cm to 22.22 cm, with an average weight gain of 1.0 kg (p<0.001). 32.8% of participants transitioned from ced to normal nutritional status post-intervention. nutrition mentoring by dietetic students effectively enhanced knowledge, nutrient intake, and nutritional status in this population. introduction chronic energy deficiency (ced) in pregnant women has become an urgent public health issue in indonesia1-3 with a prevalence of 17.3% according to the 2018 basic health research (riskesdas).4 this figure is higher compared to the prevalence in non-pregnant women, which is recorded at 14.5%, indicating that pregnancy exacerbates the risk of energy deficiency. in south sulawesi province, the prevalence of ced in pregnant women reaches 16.9%, while non-pregnant women have a higher prevalence of 17.7%.4 although the ced rate in non-pregnant women is higher, its impact on pregnant women is more critical, as this condition increases the risk of serious complications such as low birth weight (lbw) and preterm birth. babies born to mothers with ced are also at greater risk of experiencing stunting and growth disturbances in the future.5,6 lbw and preterm birth have short-term impacts such as respiratory problems, thermoregulation disorders, feeding difficulties, and nutritional problems in infants. in the long term, babies with lbw and prematurity are at higher risk of growth disturbances, delayed cognitive development, and an increased risk of chronic diseases such as diabetes and hypertension in adulthood. moreover, both conditions also increase the likelihood of stunting, which affects overall quality of life.7 nutrition education plays an important role in increasing public knowledge and awareness about healthy eating patterns, especially for vulnerable groups such as pregnant women. good nutritional knowledge enables individuals to make the right decisions regarding food intake, which directly impacts health. for pregnant women, adequate nutritional knowledge contributes to the selection of foods that support both maternal health and fetal growth. a lack of undercorrespondence: nadimin, department of nutrition, poltekkes kemenkes makassar, indonesia. e-mail: nadimin@poltekkes-mks.ac.id key word: nutrition care, knowledge, intake, nutritional status, pregnant women. contributions: nd, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ha conceptualization, investigation, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, department of nutrition, health polytechnic, ministry of health makassar, indonesia, based on ethical certificate 0625/kepk-ptkms/x/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and nonmaleficence. informed consent: all participants in this study signed a written. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank the head of the makassar city and maros district health offices for granting permission for this research, the head of the health center, and the dietetic students who were educated at the location. our gratitude also goes to the pregnant women who became the subjects of this study. received: 23 august 2024. accepted: 27 october 2024. early access: 28 november 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12958 doi:10.4081/hls.2024.12958 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 64] [healthcare in low-resource settings 2025;13:12958] standing of nutrition often leads to malnutrition, resulting in various complications such as ced, lbw, and preterm birth. improving nutritional knowledge has been proven effective in enhancing dietary patterns, reducing the risk of pregnancy complications, and improving long-term health outcomes for both mother and child.8-10 nutrition education in the community must involve all elements of society, including dietitian students. the involvement of dietitian students in nutrition mentoring offers dual benefits. first, they can apply academic knowledge in real-world contexts, enhancing their practical skills as nutrition professionals. second, mentoring by dietitian students provides pregnant women with the opportunity to receive more intensive and personalized nutrition education. during the mentoring process, students can provide guidance on appropriate food intake, health monitoring, and necessary nutritional interventions. this mentoring also helps students understand the challenges faced by the community in applying nutrition principles, strengthening collaboration between academic education and health services. thus, the involvement of dietitian students in nutrition mentoring programs can positively contribute to improving the nutritional status of pregnant women and the quality of education for the students themselves.11,12 nutritional care for pregnant women is a mandatory part of the professional dietitian education program, implemented in primary health care centers through the nutrition care process (ncp), which includes assessment, diagnosis, intervention, monitoring, and evaluation.13 dietitian students are expected to develop comprehensive academic abilities to serve as nutrition educators, public health practitioners, community workers, and researchers in community nutrition programs.14 the care of pregnant women is a mandatory part of the professional dietitian education program, implemented in primary health care centers through the ncp, which includes assessment, diagnosis, intervention, monitoring, and evaluation. dietitian students are expected to develop comprehensive academic abilities to serve as nutrition educators, public health practitioners, community workers, and researchers in community nutrition programs.15 traditionally, nutritional mentoring has been provided by healthcare professionals, community health workers, or volunteers.16 however, there is a lack of research on the role of dietitian students in providing nutritional mentoring to pregnant women. therefore, evidence is needed to evaluate the effectiveness of dietitian students in nutritional mentoring to develop appropriate interventions for this vulnerable population. a program places dietitian students annually in primary health care centers to provide nutritional care to pregnant women, but there has been no assessment of the impact of this mentoring on the nutritional knowledge, intake, and weight of pregnant women. this study aims to assess impact of nutrition mentoring by dietetic students on knowledge, dietary intake, and nutritional status in pregnant women with chronic energy deficiency in south sulawesi. materials and methods research design this study was part of the 2023 dietitian education professional activity program at makassar health polytechnic, aimed at assessing its impact on the nutritional status of pregnant women. according to the curriculum, each student is expected to have the competence to carry out nutrition care for pregnant women using the ncp approach. given this curricular goal, it was not possible to introduce variations in the intervention groups. we designed this study as an intervention using a pretest-posttest study design without a control group. intervention process the nutrition mentoring intervention was conducted by 23 dietitian students from makassar health polytechnic. each student was required to mentor five pregnant women. before starting the nutrition mentoring, the students received a three-day briefing on the ncp for the community, focusing on pregnant women with ced. this briefing included nutrition assessment, diagnosis, intervention, monitoring, and evaluation. the briefing was provided by the lecturer responsible for the pregnant women nutrition care course. the program began with the screening of pregnant women experiencing ced, identified through the measurement of midupper arm circumference (muac) less than 23.5 cm. after the screening, the intervention started with home visits to conduct a nutrition assessment through the collection of anthropometric data (weight and muac), nutrient intake, and personal history and health condition of the mother. based on the nutrition assessment results, a nutrition diagnosis was made, and an intervention plan was developed. during each home visit, students provided individualized nutrition counseling, which included education on healthy eating patterns according to pregnancy conditions, as well as emotional support. additionally, supplementary feeding was provided, adjusted to the nutritional needs of the pregnant women. home visits were conducted three times a week for two weeks to ensure consistent monitoring and improvement in nutritional status. pretest assessments were conducted before the intervention to measure nutritional knowledge, nutrient intake, and the weight of the pregnant women. after two weeks of mentoring, a posttest was conducted to evaluate changes in these variables. research location this study was conducted at 20 community health centers (puskesmas) in makassar city and maros regency, south sulawesi province, indonesia. the locations were selected based on the availability of instructors with at least a bachelor’s degree in nutrition or applied nutrition, a minimum of five years of work experience, and a cooperation contract with makassar health polytechnic. study participants the study sample was determined using a purposive sampling method, targeting pregnant women with ced (muac < 23.5 cm) who were willing to participate in the mentoring program. exclusive sample criteria included pregnant women with chronic infectious diseases such as tuberculosis (tb) or hiv/aids, or those who did not complete the mentoring. the number of samples in each puskesmas was adjusted to the number of mentors, with each student mentoring five pregnant women. a total of 122 participants met the criteria and agreed to participate. the sample size was determined based on the number of ced pregnant women in makassar city in 2022, totaling 2,495 (an average of five per puskesmas)17. with 23 students, a sample size of 125 was obtained; however, three participants were excluded as they did not meet the requirements and dropped out. variables, instruments, and data collection demographic data, pregnancy history, and nutrition knowledge were collected through face-to-face interviews using a structured, article [healthcare in low-resource settings 2025;13:12958] [page 65] valid, and reliable questionnaire. validity and reliability tests were conducted through a questionnaire trial using 10 normal pregnant women. the trial results showed a validity value of p<0.05, and the reliability test with cronbach’s alpha analysis showed a value of 0.688, greater than the r table value of 0.632. nutrient intake was assessed using the 24-hour recall method with household measures and portion size estimates following the nutrition consumption survey book.18 pregnant women’s weight was measured using a digital scale with a precision of 0.1 kg, and each measurement was taken twice. data collection was carried out by each mentor. muac was measured using a maternal muac tape produced by the indonesian ministry of health with a scale of 0.1 cm. data analysis nutrient intake data were processed using the indonesian version of the nutrisurvey application and then entered into the spss program (version 26) along with nutrition knowledge and body weight data. data entry followed a numerical system, with all data categories named and numbered according to spss guidelines. a paired t-test was used to assess changes in nutrition knowledge, nutrient intake, and body weight before and after nutrition counseling, preceded by a normality test using the kolmogorov-smirnov test, which showed p > 0.05 for all variables. statistical significance was determined at an alpha level of 5%. ethics clearance this study received approval from the makassar health polytechnic research ethics commission number: 0625/kepkptkms/x/2022. all data collection procedures adhered to the helsinki declaration. each participant signed an informed consent form approved by the ethics commission, following a detailed explanation provided by the enumerator. results as shown in table 1, most of the pregnant women had educational backgrounds of high school or junior high school and worked as housewives. their husbands were mostly self-employed or worked as laborers or drivers. many of the women were experiencing their first or second pregnancies and had typically undergone their second or third antenatal check-ups, as well as taking daily iron supplements table 2 shows the nutrient intake of the mothers was below the recommended dietary allowance (rda) for energy, protein, fat, and carbohydrates. similarly, their intake of vitamins and minerals was also below the rda. table 3 shows the nutritional knowledge of pregnant women with ced improved by 38.7 points after receiving nutrition assistance from dietitian students. statistical analysis showed a significant increase in knowledge (p=0.000) across all educational backgrounds. significant increases were observed at every education level, including primary school (p=0.000), junior high school (p=0.000), high school (p=0.000), and college (p=0.000). although there was a tendency for knowledge score improvements to be inversely proportional to education level, this was not statistically significant (p=0.388). discussion this study evaluated the outcomes of a nutrition mentoring article table 1. characteristic of pregnant women. characteristic n % educational stage elementary school 12 9.8 junior high school 25 20.5 senior high school 58 55.7 university/higher education 17 13.9 accupation of pregnant women civil servant 5 4.1 private employer 109 89.3 entrepreneur 6 4.9 student (university level) 2 1.6 occupation of husband civil servant 10 8.2 private employer 19 15.6 entrepreneur 46 37.7 farmer/fisherman 11 9.0 laborer/driver 36 29.5 nth pregnancy first pregnancy 58 47.5 second pregnancy 39 32.0 fourth pregnancy 8 6.6 fifth pregnancy 15 12.3 sixth pregnancy 2 1.6 nth antenatal care visit first antenal care visit 23 18.9 second antenal care visit 30 24.6 third antenal care visit 27 22.1 fourth antenal care visit 18 14.8 fifth antenal care visit 24 19.7 iron tablet consumption never 10 8.2 sometimes 38 31.1 every day 74 60.7 the number of samples 122 100 table 2. nutrient intake of pregnant women. nutrients intake amount rda* %rda energy (kcal) 1227 2427 50.1 protein (g) 50 77 64.9 fat (g) 38 68 55.9 carbohydrate (g) 201 368 54.6 vitamin a (re) 357 900 36.7 vitamin c (mg) 34 85 40.0 calcium (mg) 608 1067 57.0 phosphorus (mg) 544 883.3 61.6 iron (mg) 8 23 34.8 zinc (mg) 4 14.3 28.0 *rda based on the decree of the indonesian ministry of health, 2019. [page 66] [healthcare in low-resource settings 2024;12:12958] program conducted by dietitian students at the professional work practice site of the dietitian professional education program at makassar health polytechnic, indonesia. the results demonstrated a significant improvement in mothers’ nutrition knowledge following the mentoring program. this improvement was attributed to the professional skills of the mentors and the effectiveness of the approach used. prospective dietitian students have shown the competence to independently provide nutrition services, including education and counseling.19 the nutrition education and counseling approach used in this study was based on standardized, systematic, and comprehensive nutrition assessments and diagnoses, tailored to the nutritional problems and etiologies experienced by each client.20 this study aims to evaluate the effectiveness of the nutrition mentoring program conducted by dietitian students in improving the nutritional knowledge, dietary intake, and nutritional status of pregnant women with ced. overall, the study results showed that the program significantly improved maternal nutrition knowledge, with a 77.6% increase in knowledge scores, from 44.9 to 88.6. this indicates that the intervention had a significant positive impact on providing evidence-based nutrition education and counseling, which was delivered systematically and comprehensively by dietitian students.21,22 the increase in knowledge scores was more pronounced among pregnant women with lower education levels, as they had lower average pretest scores. conversely, those with higher education levels had higher pretest scores, although the difference in improvement was not significant. previous studies also showed consistent results, as recorded in studies in addis ababa and southwest ethiopia, which reported significant increases in maternal nutrition knowledge after similar interventions.23 this knowledge improvement was particularly evident in mothers with lower education levels, who initially had lower pretest scores, confirming that this intervention is highly beneficial for groups less exposed to nutritional information. this highlights the importance of comprehensive and standardized education programs, especially in antenatal care (anc) services, where the quality of nutrition education is often suboptimal due to limited resources and healthcare workers’ skills.24-26 the results of this study underscore the importance of a comprehensive and standardized nutrition education approach, which can improve the quality of anc services and have a broader impact on improving the nutritional status of pregnant women.27 in addition to knowledge, the dietary intake of pregnant women with ced also significantly increased after the intervention, particularly in terms of energy, protein, and fat intake. this improvement was reflected in the increase in muac, where 32.8% of women improved their nutritional status to normal after the mentoring program. although this increase in intake did not fully meet the recommended dietary allowance (rda), the changes made directly helped to address the chronic energy deficiency in pregnant women 27. furthermore, although this study did not measure micronutrient intake in detail, there are indications that nutrition mentoring by dietitian students also has the potential to improve maternal micronutrient intake. this is in line with findings from a study in bengkulu, indonesia, which showed an increase in carbohydrate, article table 3. changes in knowledge, nutrient intake, and pregnancy weight of pregnant women. variable n before after change sig* (mean ± sd) (mean ± sd) (mean ± sd) nutritional knowledge 122 49.9±19.4 88.6±12.1 38.7±17.6 <0.001* educational level elementary school 12 48.3±22.9 83.3±13.7 35.0±4.8 <0.001* junior high school 25 43.9±20.7 85.3±13.5 41.4±4.4 <0.001* senior high school 68 48.6±17.5 88.4±11.4 39.8±1.9 <0.001* university 17 65.0±16.4 98.2±05.3 33.2±4.2 <0.001* sig** 0.388** nutrition intake energy (kcal) 122 1227.2±411.8 1390.6±482.9 163.4±33.3 <0.001* protein (g) 122 50.3±16.5 58.2±19.3 8.0±16.8 <0.001* fat (g) 122 37.6±22.7 45.8±26.7 8.2±20.7 0.002* carbohydrate (g) 122 201.4±196.5 212.0±87.5 10.6±141.3 0.407* muac (cm) 122 21.8±1.2 22.2±1.1 0.8±0.8 <0.001* nutritional status (%) normal 0 40 (32.8%) <0.001*** ced 122 (100%) 82 (67.2%) body weight (kg) 122 46.8±5.4 47.8±5.6 1.0±1.5 <0.001* gestational age 1-3 months 28 43.4±5.0 44.0±5.4 0.6±0.9 0.002* 4-6 months 45 46.1±5.4 47.1±5.1 1.0±1.9 0.001* 7-9 months 49 49.4±4.5 50.6±4.7 1.2±1.3 <0.001* sig** 0.296** *paired t-test; ** independent t-test; ***mc nemar test. [healthcare in low-resource settings 2024;12:12958] [page 67] protein, fat, iron, and calcium intake after a nutrition intervention in pregnant women with malnutrition and anemia. this improvement is closely related to improved nutrition knowledge and perception.28,29 this study also showed an increase in maternal weight during the nutrition mentoring program, particularly in the third trimester of pregnancy. although there was a statistically significant weight gain, the average maternal weight gain did not meet the who recommendations, indicating a need for further improvements in intervention strategies. factors such as pre-pregnancy body mass index (bmi), parity, socioeconomic status, and diet during pregnancy can affect weight gain.30,31 these findings are consistent with research in makati, philippines, and east shoa zone, ethiopia, which reported improvements in the nutritional status of pregnant women after receiving nutrition education and counseling interventions. one of the main benefits of nutrition education programs is increasing pregnant women’s awareness of healthy eating during pregnancy, which can ultimately improve their nutritional practices.32,33 one significant benefit of nutrition education is that it enhances pregnant women’s knowledge about the ideal diet during pregnancy, fostering positive attitudes and practices toward good nutritional status.34 additionally, nutrition counseling and education increase awareness of the importance of adequate nutrient intake and the adverse effects of food aversions during pregnancy. to improve the nutritional status and overall health of pregnant women, nutrition education and counseling, along with mobile health services during antenatal check-ups, should be prioritized. although this intervention did not significantly impact overall pregnancy weight gain, the average weight gain for the women was only 5 kg, which is much lower than the recommended 10-12 kg. several factors contribute to pregnancy weight gain, including pre-pregnancy bmi, parity, socioeconomic status, anc care, diet during pregnancy, and comorbid medical conditions.35 the practical implications of this research for healthcare provision, particularly in community health centers (puskesmas), highlight the need to integrate nutrition mentoring programs involving dietitian students into routine antenatal services. nutrition mentoring has proven effective in improving the knowledge and dietary intake of pregnant women with ced, and it can be used as a strategy to improve nutritional status. puskesmas can collaborate with educational institutions to provide intensive training to students so that they can deliver structured nutrition education. additionally, routine monitoring, home visits, and improved access to nutritious food sources should be strengthened, particularly for low-income families. this study has several limitations, including a pretest-posttest design without a control group, which may affect the validity of the results. the limited sample size from selected health centers may influence the generalizability of the findings. data collection relied solely on interviews and 24-hour recalls, introducing potential recall bias. additionally, there was no long-term evaluation of the intervention’s impact, which may limit understanding of the sustainability of the nutritional guidance’s effects on pregnant women’s nutritional status. future studies should include a control group design to improve the validity of results and allow for stronger comparisons. additionally, a larger sample size and more diverse health centers should be involved so that the findings can be generalized to a broader population. relying solely on interviews and 24-hour recall methods poses a risk of recall bias; thus, more objective nutritional intake measurement methods, such as food diaries or repeated surveys, should be considered. long-term evaluation is also essential to understand the sustained impact of nutrition mentoring, providing a clearer picture of the program’s effectiveness in improving maternal nutritional status. this evaluation will help determine whether the positive effects of the intervention persist over time. conclusions nutrition mentoring by dietitian students significantly improves the nutritional knowledge, dietary intake, and nutritional status of pregnant women with ced. this intervention effectively reduces the prevalence of ced, with improvements in muac and maternal weight after the intervention. a total of 32.8% of the samples shifted from ced status to normal nutritional status, highlighting the importance of dietitian students’ roles in nutrition education programs. references 1. letamo g, navaneetham k. prevalence and determinants of adult under-nutrition in botswana. plos one 2014;9:e102675. 2. zupo r, marhaeni diah herawati d, de nucci s, et al. nutrient intakes of pregnant and lactating women in indonesia and malaysia: systematic review and meta-analysis. nutrient intakes of pregnant and lactating women in indonesia and malaysia: systematic review and meta-analysis. available from: https://www.crd.york.ac.uk/prospero/display_ 3. nur indrawaty lipoeto, masrul rdn. nutritional contributors to maternal anemia in indonesia: chronic energy deficiency and micronutrients. asia pac j clin nutr 2020;29:s9–17. 4. kemenkes r. riskesdas 2018.pdf. riset kesehatan dasar. 2019. 5. italey cr, ariawan i, hapsari d, muasyaroh a dm. determinants of the stunting of children under two years old in indonesia: a multilevel analysis of the 2013 indonesia basic health survey. nutrients 2019;11:1106. 6. nadimin, hadju v, as’ad s, et al. a comparison between extract moringa oleifera and iron tablet on prevention low birth weight in pregnant mothers in makassar, indonesia. enferm clin 2020;30:26–30. 7. anil kc, basel pl, singh s. low birth weight and its associated risk factors: health facility-based case-control study. plos one 2020;15:e0234907. 8. shah s, sharma g, shris l, et al. knowledge on dietary patterns among pregnant women attending antenatal care checkup in narayani hospital, nepal. int j community med public heal 2017;4:1466–72. 9. sirajuddin s, hadju v, musni. the effect of eggs consumption and nutrition counseling to the increasing of body weight and hemoglobin of pregnant women at kassi-kassi health center, makassar cityindonesia. int j sci res publ 2014;4:1–9. 10. fallah f, pourabbas a, delpisheh a, veisani y sm. effects of nutrition education on levels of nutritional awareness of pregnant women in western iran. int j endocrinol metab 2013;11:175–8. 11. paeth t, cuy castellanos d, gonter-dray r, catrine k. dietetic student involvement in a sports nutrition education program for university athletes. internet j allied heal sci pract 2022;20(4). 12. moschonis g, magriplis e, zampelas a. novel nutrition education approaches for health promotion: from investigating article [page 68] [healthcare in low-resource settings 2024;12:12958] problems to finding solutions. nutrients 2021;13:1–6. 13. marian i. hammond, esther f. myers nt. nutrition care process and model: an academicand practice odyssey. j acad nutr diet 2014;14:1879–94. 14. bookari k, yeatman h, williamson m. informing nutrition care in the antenatal period: pregnant women’s experiences and need for support. biomed res int 2017;2017:4856527. 15. bruening m, udarbe az, jimenez ey, et al. academy of nutrition and dietetics: standards of practice and standards of professional performance for registered dietitian nutritionists (competent, proficient, and expert) in public health and community nutrition. j acad nutr diet 2019;115:1699-1709.e39. 16. wit rf. midwives’ experiences with and perspectives on online (nutritional) counselling and mhealth applications for pregnant women; an explorative qualitative study. int j environ res public health 2021;18:6733. 17. badan pusat statistik. jumlah ibu hamil yang kurang energi kronis (kek) di kota makassar (jiwa), 2021-2022. badan pusat statistik kota makassar. 2022. available from: https://makassarkota.bps.go.id/id/statistics-table/2/njkjmg==/ jumlah-ibu-hamil-yang-kurang-energi-kronis—kek—di-kotamakassar.html 18. clara m. kusharto idns. nutritional intake survey (bahasa; survei konsumsi gizi). yogyakarta: graha ilmu; 2014. 128– 134 p. 19. international confederation of dietetic associations. international competency standards for dietitiannutritionists. 2016 p. 1–20. available from: https://internationaldietetics.org/wp-content/uploads/2023/05/internationalcompetency-standards-for-dietitian-nutritionists.pdf 20. raymond jl, morrow k. krause and mahan’s food & the nutrition care process. 16th ed., elsevier; 2023. 148–162 p. 21. tsegaye d, tamiru d bt. theory-based nutrition education intervention through male involvement improves the dietary diversity practice and nutritional status of pregnant women in rural illu aba bor zone, southwest ethiopia: a quasi-experimental study. matern child nutr 2022;18:e13350. 22. nadimin, abdullah thamrin, aswita amir niz and a. obesity affects the ability to memorize the quran of santriwati at darul aman islamic boarding school. int j relig 2024;5: 5174–9. 23. omer am, haile d, shikur b, et al. effectiveness of a nutrition education and counselling training package on antenatal care: a cluster randomized controlled trial in addis ababa. health policy plan 2020;35:i65-75. 24. perumal n, cole dc, ouédraogo hz, et al. health and nutrition knowledge, attitudes and practices of pregnant women attending and not-attending anc clinics in western kenya: a cross-sectional analysis. bmc pregnancy childbirth 2013;13:146. 25. mchenga m, burger r, von fintel d. examining the impact of who’s focused antenatal care policy on early access, underutilisation and quality of antenatal care services in malawi: a retrospective study. bmc health serv res 2019;19:295. 26. girard aw, olude o. nutrition education and counselling provided during pregnancy: effects on maternal, neonatal and child health outcomes. paediatr perinat epidemiol. 2012;26:191-204 27. kabahenda mk, stoecker bj. associations between maternal dietary intake and nutritional status with fetal growth at 14 to 26 weeks gestation: a crosssectional study. bmc nutr 2024;10:77. 28. simbolon d, rahmadi a, jumiyati j, et al. nutrition assistance for pregnant women with chronic energy deficiency and anemia to increase nutritional intake. j gizi klin indones [internet]. available from: https://journal.ugm.ac.id/jgki/article/view/65675 29. katenga-kaunda lz, kamudoni pr, holmboe-ottesen g, et al. enhancing nutrition knowledge and dietary diversity among rural pregnant women in malawi: a randomized controlled trial. bmc pregnancy childbirth 2021;21:644. 30. mukaddas h, salma wo, cristian b im. factors related to chronic energy deficiency in pregnant mothers in the konawe district, indonesia. j res dev nurs midwifery 2021;18:18–20. 31. akbarini of, siswina t. factors affecting the incidence of chronic energy deficiency (ced) in pregnant women. sci midwifery 2022;10:3776–83. 32. sebastian fmg, mercadowa, rondaris mva, et al. strengthening nutrition knowledge of pregnant women through nutrition education during public health emergencies. j med univercity st tomas 2022;6:91. 33. wakwoya eb, belachew t gt. effects of intensive nutrition education and counseling on nutritional status of pregnant women in east shoa zone, ethiopia. front nutr 2023;10:1144709. 34. teweldemedhin l, amanuel h, berhe s, et al. effect of nutrition education by health professionals on pregnancy-specific nutrition knowledge and healthy dietary practice among pregnant women in asmara, eritrea: a quasi-experimental study. bmj nutr prev heal 2021;15:181–94. 35. ramakrishnan u, grant f, goldenberg t, et al. effect of women’s nutrition before and during early pregnancy on maternal and infant outcomes: a systematic review. paediatr perinat epidemiol 2012;26:285-301. article [healthcare in low-resource settings 2024;12:12958] [page 69] hrev_master healthcare in low-resource settings 2023; volume 11:111796 the effect of coping intervention on maternal competency in caring for premature infants at home rinik eko kapti,1,2 yuni sufyanti arief,3 mira triharini,3 qori’ ila saidah,4 ari damayanti wahyuningrum5 1program of doctoral degree, faculty of nursing, universitas airlangga, surabaya; 2department of nursing, faculty of health sciences, universitas brawijaya, malang; 3faculty of nursing, universitas airlangga, surabaya; 4department of maternal and pediatric nursing, stikes hang tuah surabaya, surabaya; 5nursing science of widyagama husada health science college, malang, indonesia abstract the mother’s ability to care for premature infants will affect the success of the interaction between mother and baby as well as the growth and development of the baby. the study aimed to assess the impact of coping interventions on mothers’ ability to care for premature infants at home. this quasi-experimental research involved 80 respondents, divided into a treatment group and a control group, with 40 participants in each. the treatment group received a 3-month coping intervention, while the control group did not. the mothers’ abilities were evaluated using questionnaires and the developmental pre-screening questionnaire (kpsp) instrument. the results revealed significant improvements in the treatment group’s abilities in providing nutrition, maintaining body temperature, preventing infection, recognizing danger signs, and stimulating development in premature infants. these positive outcomes underscore the effectiveness of coping interventions in enhancing maternal abilities. it is recommended that health workers incorporate coping interventions into their support for mothers of premature infants, aiming to empower them with the skills and knowledge needed for better care and development of their infants at home. this approach can contribute to the overall well-being and growth of premature infants while reducing the burdens on healthcare providers. introduction the ability of mothers to care for premature infants will affect the success of interactions between mothers and infants and the growth and development of infants.1 however, the mother’s current ability is still an issue, as shown by research indicating that mothers in indonesia have not provided proper nutrition, and kangaroo care is often stopped in the first week at home.2 hospitals in indonesia have made efforts to prepare mothers with adequate capabilities to carry out care at home through the availability of health education, leaflets, and discharge preparation programs carried out in the perinatology room.2 various problems are encountered in providing adequate capabilities, including health education, which currently only focuses on the physical care of premature infants, with no standard educational media and methods.2 additionally, the discharge planning program is not considered optimal. one obstacle is that the mother’s contribution is minimal, and follow-up care from the hospital to the community by the health team has not been effectively implemented.3 efforts have also not focused on the psychological problems of the mother, even though caring for premature infants at home causes a lot of stress, which can hinder the achievement of the mother’s abilities.4–6 appropriate coping strategies can help mothers reduce stress, enabling them to demonstrate maternal correspondence: yuni sufyanti arief, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: yuni_sa@fkp.unair.ac.id key words: coping; competence; mother; premature. contributions: rek and ysa contributed substantially to the concept and work design. qis and ad collected data. mt conducted data analysis. data interpretation. and drafting of the manuscript. rek and ysa revised it critically for the important intellectual content and final approval of the version to be published. conflict of interest: this research declares that there is no conflict of interest. ethics approval and consent to participate: this study was granted ethical clearance under number 400/227/k.3/102.7/2022-kepk by the ethics commission of general hospital dr. saiful anwar, malang. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: we received funding from the directorate of research and community service. ministry of education. culture. research. and technology. indonesia with grant number 0217[e5ipg .02.0012023 dated april 28 2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors gratefully acknowledge those who participated in this study and we also thank the directorate of research and community service the ministry of education culture research. and technology for giving us the funding. we deeply appreciate everyone for helping us in this study. received: 12 september 2023. accepted: 14 november 2023. early access: 24 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11796 doi:10.4081/hls.2023.11796 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 178] [healthcare in low-resource settings 2023; 11:11796] non -co mmerc ial us e o nly behavior effectively.7 mothers who are competent in premature baby care are needed, as 25-50% of premature infants experience health problems after discharge from the hospital.8 the readmission rates for premature infants are also higher than for normal infants, with as many as 32.7% readmitted in their first year of life.9,10 by 7.4%, premature infants are re-admitted to the hospital in the first two weeks after discharge.8 the most frequent causes of readmission of premature infants are respiratory tract diseases (55.3%), advanced neonatal infections (25%), malaria (11.8%), and epilepsy (7.9%).10 one of the factors affecting the mother’s ability is the mother’s coping. coping is an important indicator of maternal response and behavior.11 ability is a component of maternal behavior and the achievement of the mother’s role.12 the results have shown that the efficacy of mothers with premature infants increased significantly after being given education while in the hospital.13 however, there has not been much evaluation of mothers’ abilities after being discharged from the hospital. the results of other studies show that parents of premature infants have higher stress than parents of fullterm infants, so mothers need to adjust their coping strategies continuously.14 mothers of premature infants report experiencing obstacles to becoming mothers and low parenting confidence, thus they need appropriate coping strategies to overcome these issues.15 coping can help mothers reduce stress, enabling them to exhibit maternal behavior and fulfill their caregiving role effectively.7 the use of efficient coping will regulate emotions, reduce the negative effects of stress due to premature births, and improve abilities, interactions with infants, and the mother’s physical and mental health.16 the achievement of the mother’s role is to become a mother throughout her life and develop her maternal identity in the form of ability, confidence, and joy in the role of motherhood.17 currently, interventions given to mothers of premature infants do not focus on psychological interventions. the need for psychological intervention is supported by research from fowler, which emphasizes nurses’ focus on meeting the psychological needs of the mother, increasing the mother’s welfare, and enabling her to be physically and emotionally present for her premature baby properly.18 maternal coping interventions are needed to improve the ability of mothers to provide care for premature infants at home by enhancing maternal coping strategies, knowledge, and skills in caring for premature infants. the purpose of this study was to analyze the effect of coping intervention on the ability of mothers to care for premature infants at home. materials and methods research design this research employed a quasi-experimental design with a control group pre-posttest design. setting and samples the study’s population consisted of mothers caring for premature infants at home in malang raya, east java, indonesia. the sample included mothers of premature infants who met the following inclusion criteria: mothers with premature infants who had been hospitalized for a maximum of three days, both mother and baby were in good health (the infant’s temperature, respiratory rate, and pulse were within normal limits, and the baby was active; the mother had no health complaints, had a partner, and lived in the same house with a partner). exclusion criteria for this study included mothers with premature infants who had congenital diseases and mothers with premature twins. the sample size was calculated using statistical power analysis with a power of 0.95, an alpha of 0.05, and an effect size of 0.80. based on these conditions, the sample size for each group was determined to be 40 participants, resulting in a total of 80 eligible participants, with an additional 10% dropout rate, resulting in 40 participants per group. the sampling technique used was a non-probability sampling technique, specifically purposive sampling. data collection took place from february to july 2023. intervention the intervention was administered individually over 3 months in the mothers’ homes, with detail intervention in table 1. meetings were scheduled on the 3rd, 7th, 28th day, and 3rd month, with each meeting lasting for 60 minutes. meanwhile, the control group received interventions in line with those provided by the hospital where they gave birth. these interventions included guidance on breastfeeding, kangaroo mother care, and hand-washing, as well as the distribution of educational leaflets. the interventions were delivered in the form of mentoring, education on coping, education about caring for premature infants at home, and individual coping skills training, conducted by professional nurses. measurement and data collection the dependent variable in this study is the mother’s ability to care for their premature infants, which comprises five indicators: the ability to provide nutrition, maintain body temperature, prevent transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. intervention of coping. intervention of coping implementation through home visits contents of intervention time of intervention part 1: coping strategy part 2: premature baby care at home day 3 post discharge providing materials and practicing coping strategies: the topic of the discussion and practice session was determined during praying and get closer to the baby a meeting between the researcher and the mother and considering the needs and interests of the mother. mothers express their questions, experiences and problems faced by their infants and then discuss them together. day 7 post discharge providing materials and practicing coping strategies: accepting the situation and seeking support day 28 post discharge discussion and practice: praying, getting closer to the baby, accepting the situation, and seeking support day 90 post discharge discussion and practice: praying, getting closer to the baby accepting the situation and seeking support [healthcare in low-resource settings 2023; 11:11796] [page 179] non -co mmerc ial us e o nly infection, recognize danger signs, and stimulate development. these maternal abilities were assessed using a questionnaire derived from managing newborn problems19 and the developmental pre-screening questionnaire (kpsp) instrument.20 prior to employing the questionnaire, validity and reliability tests were conducted, involving 32 mothers with premature infants. the results confirmed the questionnaire’s validity, with a range of correlation coefficients (r) between 0.373 and 0.965 and a reliability value of 0.934. data analysis the data analysis included descriptive statistics such as frequency, percentage, mean, standard deviation (sd), and the minimum and maximum values for each variable. inferential analysis was carried out using the wilcoxon statistical test to assess differences in preand post-scores within each group. additionally, the mann-whitney statistical test was employed to measure the differences in post-test scores between the control and treatment groups. the desired significance level for these tests was set at 95%, with α ≤ 0.05. results based on the results presented in table 2, it is evident that the respondents in both the control and treatment groups shared several similarities. most of them lacked prior experience in caring for premature infants, had two children, and were not employed. however, differences emerged in the variables related to education, socio-economic status, and certain characteristics between the control and treatment groups. in the control group, a majority of the respondents held bachelor’s degrees, reported incomes above the minimum wage, and had infants in good health, as indicated by the absence of nasogastric tube and oxygen usage at home. conversely, within the treatment group, most mothers had attained middle or high school education, had incomes below the minimum wage, and all infants were in good health, similarly showing no need for nasogastric tubes or oxygen at home. based on the descriptive analysis in table 3, in both groups, pre-intervention nutrition scores averaged 12.30 (treatment) and 11.90 (control). post-intervention, treatment group scores rose to 21.35, while control group scores reached 14.40. average preintervention temperature maintenance scores were 8.5 (control) and 8.6 (treatment), increasing to 14.7 (treatment) and 11.70 (control) post-intervention. infection prevention scores averaged 16.65 (treatment) and 16.60 (control) pre-intervention, increasing to 22.30 (treatment) and 18.95 (control) post-intervention. average pre-intervention scores for recognizing danger signs were 12.2 (treatment) and 12.5 (control), rising to 23.4 (treatment) and 16 (control) post-intervention. pre-intervention scores for stimulating transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. characteristics and equality test of mothers having premature infants at home, 2023 (n=80). variables and categories: intervention control p n % n % previous experience experience caring premature 0.762 no 33 82.5 34 85.0 yes 7 17.5 6 15.0 number of kids 0.915 1 child 10 25.0 10 25.0 2 children 14 35.0 16 40.0 3 children 13 32.5 11 27.5 4 children 2 5.0 1 2.5 5 children 1 2.5 2 5.0 factors of mothers 0.570 education primary school 6 15.0 4 10.0 middle school 12 30.0 8 20.0 high school 12 30.0 12 30.0 diploma 1 2.5 3 7.5 bachelor 9 22.5 13 32.5 job 0.639 working 13 32.5 15 37.5 not working 27 67.5 25 62.5 income 0.262 above minimum wage 19 47.5 24 60.0 below minimum wage 21 52.5 16 40.0 factors of infants 0.314 baby characteristic non using device 40 100 39 97.5 using device 0 0.0 1 2.5 variable: x ̅ ±sd x ̅ ̅±sd weight of baby born 1753.75 ± 348.22 1753.87 ± 314.35 0.999 length of stay 14.375 ± 14.89 12.62 ± 12.18 0.620 [page 180] [healthcare in low-resource settings 2023; 11:11796] non -co mmerc ial us e o nly development averaged 9.3 (treatment) and 8.6 (control), increasing to 14.675 (treatment) and 11.60 (control) post-intervention. based on the data presented in table 4, the results of the statistical analysis using the wilcoxon test in both the control and treatment groups indicate that all variables yielded significance values lower than alpha (0.05). this implies that both the standard intervention employing leaflets and the coping intervention have a significant impact on all aspects of the mother’s ability to care for premature infants at home. notably, it’s worth mentioning that the treatment group exhibited a greater increase in scores across all ability variables compared to the control group. table 5 displays mann whitney test results indicating that pretest scores in both groups are not significantly different (p>0.05), suggesting similar abilities before the intervention. in contrast, posttest values show significant differences between control and treatment groups (p<0.05), indicating the effectiveness of coping intervention in improving all variable abilities. delta values for all variables also exhibit significant differences (p<0.05), signifying that the treatment group had a greater increase in ability compared to the control group. discussion the results of the third stage of the study, as determined through statistical analysis tests with mann whitney, revealed a significant positive effect of coping intervention on the improvement of mothers’ ability to care for premature infants at home. this positive impact was observed across all indicators, encompassing the provision of nutrition, maintenance of temperature, prevention of infection, recognition of danger signs, and stimulation of development. additionally, the analysis indicated that, during the pretest, there was no statistically significant difference in the average scores between the treatment and control groups for all ability indicators. however, following the intervention, the treatment group exhibited a more substantial increase in the average posttest ability scores compared to the control group. the term “mother’s ability” refers to the maternal intelligence that influences the development of infants and children. this includes elements of sensitivity, responsiveness, and synchronization in fulfilling their role as mothers. maternal abilities are often described in terms of various aspects of infant care. the primary domain of capability pertains to the expression of comfort, satisfaction, and skills in caring for infants. furthermore, according to alghamdi (2019), the ability domain can be categorized into four domains, which include knowledge, skills, ability, and responsiveness.21 coping interventions grounded in health promotion have proven to be more effective in enhancing the ability of mothers to care for premature infants at home when compared to standard transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. description of mothers' ability to care for premature infant at home in 2023 (n=80). variables descriptive intervention control pretest posttest pretest posttest ability to give nutrition minimum 8.00 12.00 8.00 12.00 maximum 20.00 24.00 20.00 20.00 mean 12.30 21.35 11.90 14.40 standard deviation 3.553 3.118 3.565 2.977 ability to maintain body’s temperature minimum 8.00 8.00 8.00 4.00 maximum 12.00 16.00 12.00 12.00 mean 8.50 14.70 8.60 11.70 standard deviation 1.340 2.103 1.446 2.103 ability to prevent infection minimum 12.00 20.00 12.00 12.00 maximum 20.00 24.00 20.00 28.00 mean 16.65 22.30 16.60 18.95 standard deviation 2.497 2.003 2.134 2.970 ability to recognize danger signs minimum 8.00 20.00 8.00 12.00 maximum 16.00 24.00 20.00 20.00 mean 12.20 23.40 12.50 16.00 standard deviation 2.997 1.446 3.289 2.717 ability to stimulate kid’s development minimum 4.00 12.00 4.00 8.00 maximum 12.00 16.00 12.00 16.00 mean 9.300 14.675 8.60 11.60 standard deviation 2.919 1.886 3.078 2.18 table 4. test results of the effect of coping intervention on mother's ability in the control and treatment groups. variable mean±sd intervention group mean±sd control group pre post p pre post p ability to give nutrition 12.30±3.553 21.35±3.118 0.000 11.90±3.565 14.40±2.977 0.000 ability to maintain body’s temperature 8.50±1.340 14.70±2.103 0.000 8.60±1.446 11.70±2.103 0.000 ability to prevent infection 16.65±2.497 22.30±2.003 0.000 16.60±2.134 18.95±2.970 0.000 ability to recognize danger signs 12.20±2.997 23.40±1.446 0.000 12.50±3.289 16.00±2.717 0.000 ability to stimulate kid’s development 9.30±2.919 14.67±1.886 0.000 8.60±3.078 11.60±2.181 0.000 [healthcare in low-resource settings 2023; 11:11796] [page 181] non -co mmerc ial us e o nly interventions. these results align with the findings of other studies, which suggest that standard or routine interventions are less effective in supporting the fulfillment of the mother’s role.22–24 coping interventions based on health promotion encompass a more comprehensive approach, addressing not only the need for information about premature infants and their physical care but also providing guidance and individual training on the care of premature infants. these comprehensive interventions address both the physical and behavioral aspects of care for premature infants and include exercises aimed at building effective coping strategies. health promotion-based coping interventions provide mothers with simultaneous and comprehensive support, covering aspects of both the physical and behavioral care of premature infants as well as equipping mothers with effective coping strategies. the results of this study are corroborated by research that reviewed ten intervention programs implemented in home settings. these programs involved regular visits to parents, offering emotional and practical support. the results of these programs indicated a significant reduction in parental stress levels, leading to positive effects on mothers’ behavior and their interactions with their premature infants. support programs delivered in the home environment on a regular basis resulted in mothers becoming more responsive to their infants and better able to provide appropriate and diverse stimulation for their infants.25 furthermore, the results of this study are supported by previous research on creating opportunities for parent empowerment (cope) interventions and parental sensitivity interventions. these interventions have a direct impact on areas such as knowledge, skills, beliefs, confidence, and maternal self-efficacy in the care of premature infants.26–28 additionally, other studies have provided evidence of the relationship between high maternal self-efficacy and active maternal care and coping skills. conversely, low maternal self-efficacy has been found to correlate with depression, issues in child development, and mothers adopting passive coping strategies in their parental roles.29 maternal depression is also associated with low maternal self-efficacy and passive coping strategies.30 ineffective coping can hinder mothers in effectively fulfilling their maternal roles. research has shown that coping dysfunction results in suboptimal caregiving practices due to stress related to the appearance and behavior of premature infants.11 health promotion-based coping interventions assist mothers by providing the necessary resources for them to evaluate the stressors they encounter while caring for premature infants at home. strengthening these resources is a crucial aspect because stress arises when individuals do not adequately assess stressors based on their available abilities (resources). this concept aligns with lazarus’ theory, which emphasizes cognitive aspects of the stress process, where an event must be appraised as stressful before it can influence an individual’s emotions and behavior. moreover, an individual’s judgment depends on the resources available.31 stress has a negative relationship with maternal role satisfaction and continues to impact maternal competency and satisfaction. research results indicate that mothers who face fewer stressors tend to feel more competent and satisfied in their maternal roles during the postpartum period.32 stressful life events and the challenges associated with caring for a baby have a negative relationship with maternal satisfaction. maternal competency and satisfaction are closely interlinked, as it is challenging to achieve competence when a woman is not satisfied with her maternal role.32 these findings align with previous research, as stress has been shown to affect women’s sense of competence and satisfaction in their roles as mothers.33 effective coping strategies play a crucial role in reducing maternal stress. mothers who employ effective coping strategies can minimize negative emotional issues in their interactions with their infants and in the care they provide. successful coping strategies are effective in increasing an individual’s commitment to expected behaviors in caring for an infant. this aligns with the theory suggesting that positive emotions linked to specific health behaviors can enhance commitment.34 effective coping strategies also help mothers minimize the barriers they encounter in their [page 182] [healthcare in low-resource settings 2023; 11:11796] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 5. results of testing the effectiveness of providing coping interventions on the ability of mothers to caring for premature infants at home. variable test group mean p ability to give nutrition intervention 41.78 pretest control 39.23 0.604 posttest intervention 56.75 control 24.25 0.000 ability to maintain body’s temperature pretest intervention 40.00 control 41.00 0.747 posttest intervention 53.10 control 27.90 0.000 ability to prevent infection pretest intervention 41.00 control 40.00 0.821 posttest intervention 52.40 control 28.60 0.000 ability to recognize danger signs pretest intervention 39.60 control 41.40 0.711 posttest intervention 59.83 control 21.18 0.000 ability to stimulate kid’s development pretest intervention 42.99 control 38.01 0.301 posttest intervention 53.25 control 27.75 0.000 non -co mmerc ial us e o nly maternal roles and bolster their self-control.7,15,35 however, one limitation of our study is that some respondents displayed lower participation in discussion sessions. to address this, we endeavored to motivate mothers and provide them with a deeper understanding of the importance of caring for their premature infants at home. while our study met the minimum required sample size, we recommend the use of a larger sample for future research. conclusions the implementation of coping interventions demonstrates significant potential in enhancing the abilities of mothers – including their capacity to provide nutrition, maintain the body temperature, prevent infection, recognize danger signs, and stimulate development – in caring for premature infants at home. community health workers or puskesmas personnel can effectively employ this intervention to assist mothers in managing their emotions and achieving competent care for their premature infants. future studies should encompass an examination of the intervention’s impact on the infants themselves, incorporating larger and more representative sample sizes, while employing an experimental design with randomization to yield robust and generalizable results. consequently, the coping intervention developed in this study can be readily applied as a practical guideline for enhancing maternal abilities in a home setting. relevant agencies must actively implement such programs and interventions to advance public health and improve the well-being of mothers and premature infants. references 1. kelbore w, yasin h, kolle d. maternal role competence and its associated factors among mothers who attended immunization clinics at public health facilities of arba minch town , southern ethiopia : a cross sectional study. int j sci basic appl res 2020;4531:129-38. 2. hariati s, sutomo r, mckenna l, et al. indonesian mothers’ beliefs on caring practices at home for preterm infants after hospital discharge: a qualitative study. j spec pediatr nurs 2021;26:e12330. 3. hariati s, dwi a, febriani b, et al. exploring indonesian nurses ’ perspectives on preparing parents of preterm infants for hospital discharge : a qualitative study. j neonatal nurs.2021;july. 4. novitasari a, hutami ms, pristya tyr. prevention and control of baby low birth weight in indonesia: systematic review. indones j heal dev 2020;2:175-82. 5. garti i, donkor e, musah n, et al. mothers’ experiences of caring for preterm infants at home: qualitative insights from an urban setting in a middle-income country. bmc pregnancy childbirth 2021;21:1-9. 6. adama ea, bayes s, sundin d. parents’ experiences of caring for preterm infants after discharge from neonatal intensive care unit: a meta-synthesis of the literature. j neonatal nurs 2016;22:27-51. 7. rossman b, greene mm, kratovil al, meier pp. resilience in mothers of very-low-birth-weight infants hospitalized in the nicu. j obstet gynecol neonatal nurs 2017;46:434-45. 8. julianti e, rustina y, efendi d. discharge planning improving knowledge and skill mother who birth premature to take care baby. j keperawatan indones 2019;0. 9. vogel jp, chawanpaiboon s, moller ab, et al. the global epidemiology of preterm birth. best pract res clin obstet gynaecol 2018;52:3-12. 10. mah em, monono nn, tague dak, et al. post discharge outcome of preterm infants in a low-middle-income country. pediatr oncall 2021;18(2). 11. horwitz smc, storfer-isser a, kerker bd, et al. a model for the development of mothers’ perceived vulnerability of preterm infants. j dev behav pediatr 2015;36:371-80. 12. meighan m. ramona t. mercer: maternal role attainmentbecoming a mother. in m. r. alligood & a. m. tomey, nursing theorists and their work. maryland heights, mo: mosby elsevier.; 2010. 13. amaliya s, kapti re, astari am, et al. improving knowledge and self-efficacy in caring at home for parents with low birth weight infants. j aisyah j ilmu kesehat 2023;8:819-26. 14. zelkowitz p, bardin c, papageorgiou a. anxiety affects the relationship between parents and their very low birth weight infants. infant ment health j 2007;28:296-313. 15. tabrizi fm, alizadeh s, radfar m. barriers of parenting in mothers with a very lowbirthweight preterm infant, and their coping strategies: a qualitative study. int j pediatr 2017;5:5597-608. 16. karbandi s, momenizadeh a, heidarzadeh m, et al. effects of empowering mothers of premature infants on their stress coping strategies. iran j psychiatry behav sci 2018;12(2). 17. mercer rt. becoming a mother versus maternal role attainment. j nurs scholarsh 2004;36:226-32. 18. fowler c, green j, elliott d, et al. the forgotten mothers of extremely preterm infants: a qualitative study. j clin nurs 2019;28:2124-34. 19. who. managing newborn problems. hong kong: who; 2003. 20. ministry of health. guidelines for implementing stimulation, detection and early intervention in child growth and development. jakarta; 2016. 21. alghamdi s. maternal competence in the context of infant feeding : a concept analysis. 2019;7:1041-5. 22. ghazi m, zare m, ramezani m, et al. the effect of home visit program based on the continued kangaroo mother care on maternal resiliency and development of premature infant: a randomized clinical trial. int j community based nurs midwifery 2021;9:64-75. 23. phianching k, chaimongkol n, pongjaturawit y. effects of the parental sensitivity intervention among mothers and fathers of preterm infants: a quasi-experimental study. pacific rim int j nurs res 2020;24:246-59. 24. shorey s, chan sw, chong ys, he hg. perceptions of primiparas on a postnatal psychoeducation programme: the process evaluation. midwifery 2015;31:155-63. 25. brett j, staniszewska s, newburn m, et al. a systematic mapping review of effective interventions for communicating with, supporting and providing information to parents of preterm infants. bmj open 2011;1:e000023-e000023. 26. rasheed ma, mughis w, niaz m, hasan bs. do parental stimulation practices modify the effect of child’s health status on early developmental risk? findings from a hospitalized cohort. early child dev care. 2021; 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[page 184] [healthcare in low-resource settings 2023; 11:11796] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12047 antiretroviral activity from elderberry (sambucus nigra l.) flowers against hiv-2 infection via reverse transcriptase inhibition: a viroinformatics study rahadian zainul,1,2 viol dhea kharisma,3 pauline ciuputri,3 arif nur muhammad ansori,3-6 mochammad aqilah herdiansyah,3 sukma sahadewa,7 fara disa durry8 1department of chemistry, faculty of mathematics and natural sciences, universitas negeri padang, indonesia; 2center for advanced material processing, artificial intelligence, and biophysic informatics (campbiotics), universitas negeri padang, indonesia; 3division of research of development, jalan tengah, surabaya, indonesia; 4uttaranchal institute of pharmaceutical sciences, uttaranchal university, dehradun, india; 5european virus bioinformatics center, jena, germany; 6virtual research center for bioinformatics and biotechnology, surabaya, indonesia; 7faculty of medicine, universitas wijaya kusuma surabaya, indonesia; 8faculty of medicine, universitas pembangunan nasional “veteran” jawa timur, surabaya, indonesia abstract hiv-2 infection is a unique concern with fewer cases than hiv-1, but it poses a high mortality rate due to its resistance to all hiv-1 antiretroviral treatments. this study focuses on one type of antiretroviral, reverse transcriptase (rt) inhibitors, as they play an important role in hiv-2 replication. the screening of potential hiv-2 antiretroviral candidates was carried out using compounds from elderberry (sambucus nigra l.) flower extract. there is a lack of research on the antiviral potential of elderberry flower extracts, particularly in hiv-2; therefore, this study is important to explain the molecular mechanism underlying the potential of elderberry (sambucus nigra l.) flower extracts to inhibit rt activity in hiv-2 through bioinformatics simulations. this study uses the in silico method, involving sample preparation in the database, drug-like molecular prediction through the server, molecular docking simulation, chemical bond interaction analysis, and threedimensional structure visualization. isorhamnetin has the most negative binding affinity of -9.9 kcal/mol compared to other compounds. it interacts with the hiv-2 rt domain at residues trp4(b), pro25(b), asn137(b), pro133(b), gln23(b), pro140(b), leu21(b), ile90(a), thr131(b), asn57(b), arg22(b), and glu89(a) with hydrophobic bond interactions. hydrogen bond interactions are formed at the positions of ser134(b), gly141(b), and thr88(a). isorhamnetin from elderberry (sambucus nigra l.) flower extract could be a potential hiv-2 antiretroviral candidate because it has the most negative binding affinity and the formation of hydrophobic hydrogen bond interactions on the rt domain. introduction hiv is an rna virus that infects/attacks lymphocyte cells in the body, causing a decrease in the body’s system of recognition.1 hiv-2, sharing similarities with hiv-1 in its envelope, is predominantly found in west africa but carries the potential to become a global epidemic.2 approximately 1 to 2 million people are living with minimally treated hiv-2, resulting in high mortality and morbidity. the virus, initially identified in 2018, has affected an estimated 38 million people worldwide.3 in 2020, globally, an estimated 37.7 million people were living with hiv and 1.5 million became newly infected with hiv.4 the ministry of health of indonesia in 2020 reported that only 14% were known to be virally suppressed after 6 months of art.5 hiv-2 is endemic in several west african countries, namely guinea-bissau, senegal, cape verde, gambia, mali, sierra leone, cote d’ivoire, and nigeria, with a prevalence rate of 1%. beyond west africa, cases have also surfaced in south america, europe, asia, and the united states.6 in indonesia, the death rate due to hiv/aids is still high.7 the ministry of health of the republic of indonesia stated that in indonesia, in the last 12 years (data for 2010-2022, for those aged over 15 years), projections of new infections have shown a positive trend, namely from 56,187 new cases to 25,740.8 correspondence: rahadian zainul, department of chemistry, faculty of mathematics and natural sciences, universitas negeri padang, padang, indonesia. e-mail: rahadianzmsiphd@fmipa.unp.ac.id key words: antiretroviral, hiv-2, medicine, reverse transcriptase, sambucus nigra. contributions: rz, vdk, pc, anma, conceptualization, data analysis, methodology, validation, visualization, writing original draft, and review and editing; rz, vdk, anma, mah, ss, fdd, methodology, validation, and writing review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: not applicable. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to thank jalan tengah (jalantengah.site) for editing the manuscript. received: 2 november 2023. accepted: 7 may 2024. early access: 13 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12047 doi:10.4081/hls.2024.12047 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12047] [page 525] patients with hiv/aids experience various problems, both physical and psychological, one of which is health-related quality of life.9 people living with hiv require a focus on their quality of life to prevent deterioration.10 treatment for patients diagnosed with hiv-2 involves antiretrovirals, comprising a combination of nucleoside reverse transcriptase (rt) inhibitors, integrase strand transfer inhibitors, and protease inhibitors.11 however, the virus poses a challenge by demonstrating resistance to all three types of antiretrovirals commonly used for hiv-1 treatment. while rt inhibitors have proven effective against hiv-1, their impact on hiv-2 replication is negligible. consequently, there is a pressing need to screen new inhibitor candidates to develop treatments for hiv-2. despite exhibiting a lower viral load compared to hiv-1, hiv-2 has developed resistance to commonly used antiretrovirals for hiv-1 treatment.11 as an enveloped virus with double-stranded rna (dsrna) genetic material, hiv-2 encodes several enzymes such as rt, protease, and integrase.12 this study specifically focuses on rt due to its pivotal role in hiv-2 replication.13 the rt enzyme in hiv-2 serves a similar function to hiv-1, facilitating the formation of viral complementary dna (cdna) that integrates into the host cell genome.2 reported mutations of rt in hiv-2 result in resistance to specific antiretroviral types, notably nonnucleoside rt inhibitors (nnrtis).13 the resistance pattern positions the rt enzyme as the ideal target for designing antiretrovirals to combat hiv-2 by inhibiting its enzymatic activity. elderberry (sambucus nigra l.) has been utilized in alternative medicine due to its potential as an antiviral, antidiabetic, antibacterial, antitumor, and antioxidant agent.14 polyphenolic compounds in the plant are also predicted to inhibit virus replication.15 the flower of elderberry (sambucus nigra l.) is rarely used as an alternative medicine; however, it contains several chemical compounds. these include quinic acid, caffeoylquinic acid, 1-caffeoylquinic acid, coumaroylquinic acid, feruloylquinic acid, isorhamnetin, quercetin-3-rutinoside, quercetin-acetyl glucoside, kaempferol rutinoside, and isorhamnetin acetylhexoside.16 previous studies have shown that flower extracts from elderberry (sambucus nigra l.) can inhibit gram-positive bacteria such as staphylococcus aureus and s. epidermidis.17 currently, there is a lack of research exploring the potential of flower extracts from elderberry (sambucus nigra l.) as an antiviral, especially for hiv2. this research is important for understanding the molecular mechanism underlying the potential of elderberry (sambucus nigra l.) flower extracts to inhibit rt activity in hiv-2 using bioinformatics simulations. materials and methods sample preparation this study used compounds extracted from elderberry (sambucus nigra l.) flowers. ten compounds from sambucus nigra l. flower were selected from the chromatographic results and their data presence in the pubchem database. these compounds are quinic acid, caffeoylquinic acid, 1-caffeoylquinic acid, coumaroylquinic acid, feruloylquinic acid, isorhamnetin, quercetin-3-rutinoside, quercetin-acetyl glucoside, kaempferol rutinoside, and isorhamnetin acetylhexoside, as ligands.16 information such as compound identification, simplified molecular input line entry system canonical, formula, and structure data format files were obtained from pubchem (https://pubchem.ncbi.nlm.nih.gov/). minimization of ligands was performed using openbabel v2.3.1 software to convert files into protein databank format (pdb). the target chosen in this study was rt hiv-2 from rcsb pdb (https://www.rcsb.org/) with id 1mu2 (https://www.rcsb.org/structure/1mu2), obtained in pdb format. subsequently, water molecules and native ligands were removed through pymol software v.2.5.2 (schrödinger, inc., usa) with an academic license.18,19 drug-like molecule prediction the objective of drug-like molecule prediction is to identify the similarity of properties in chemical compounds from elderberry flower extract (sambucus nigra l.) with those found in drug molecules. in this study, the drug-like molecule prediction method refers to the lipinski rule of five through the scfbio server (http://www.scfbio-iitd.res.in/software/drugdesign/lipinski.jsp). the rules include molecular mass, high lipophilicity, molar refractivity, and acceptor-donor hydrogen bonds. for a compound to be categorized as a drug-like molecule, it must meet at least two of these rules.20,21 molecular docking simulation in this study, molecular docking simulations are conducted to predict the ligand binding strength of elderberry flower extract (sambucus nigra l.) on hiv-2 rt. molecular docking refers to the interaction between the ligand and the target, resulting in the formation of a molecular complex with a stable bond, and the output of this process is the binding affinity. binding affinity is the energy generated in the ligand-protein complex, which is characterized by a negative value. the more negative the value, the higher the probability of triggering specific activities, such as inhibition.22 the pyrx 0.9.9 software (scripps research, usa) uses a screening docking method, covering the entire target surface with a directed grid and selecting ligands based on their more negative binding affinity energy.23 chemical interaction chemical bonding interactions are formed in ligand-protein complexes, consisting of both hydrophobic and hydrogen bonds. these weak bonds collectively contribute to the stability of drug binding to the target and can subsequently trigger specific activities, such as inhibition. the software used to identify the position and type of chemical bond interactions in this study is ligplot+v.2.2.24,25 structural visualization three-dimensional visualization of docking results was displayed through pymol software v.2.5.2 (schrödinger, inc., usa) with an academic license. protein structures were displayed in the form of cartoons and transparent surfaces with publication standards, ligands were displayed through stick structures with coloring based on c, h, n, o, and f atoms.26 results in this study, we revealed that the compounds retrieved from the database include quinic acid, caffeoylquinic acid, 1-caffeoylquinic acid, coumaroylquinic acid, feruloylquinic acid, isorhamnetin, kuersetin-3-rutinoside, kuersetin-acetyl glucoside, kaempferol rutinoside, and isorhamnetin acetylhexoside (table 1). next, the two-dimensional structures of all compounds of elderberry (sambucus nigra l.) flower extract are shown in figure 1. then, the druglikeness prediction results indicated two compounds not transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 526] [healthcare in low-resource settings 2024;12:12047] meeting the criteria for drug-like molecules, while eight compounds received positive predictions as drug-like molecules (table 2). ligands with the most negative binding affinity values are predicted to trigger inhibitory activity on the target. the molecular docking simulation results indicated that isorhamnetin has the most negative binding affinity of -9.9 kcal/mol compared to other compounds (table 3). three-dimensional structures on ligands and proteins from docking results are visualized with transparent surfaces, cartoons, and sticks using specific coloring selections (figure 2). the analysis of the position and type of interaction in the ligand-protein complex revealed that isorhamnetin interacts with hiv-2 rt domain at residues trp4(b), pro25(b), asn137(b), pro133(b), gln23(b), pro140(b), leu21(b), ile90(a), thr131(b), asn57(b), arg22(b), and glu89(a) through hydrophobic bond interactions. hydrogen bond interactions are formed at the positions of ser134(b), gly141(b), and thr88(a) (figure 3). discussion elderberry (sambucus nigra l.) extract shows potential as an antiviral for treating influenza infection.27 recent research indicates that flower extracts from elderberry (sambucus nigra l.) can be used for cold flu symptoms, such as pain, fever, cough, and congestion.28 the antiviral activity of elderberry (sambucus nigra l.) was demonstrated in vitro at 400 μg/ml, inhibiting denv-2 repli transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. elderberry (sambucus nigra l.) flower extract compounds from database. a) quinic acid; b) caffeoylquinic acid; c) 1-caffeoylquinic acid; d) coumaroylquinic acid; e) feruloylquinic acid; f) isorhamnetin; g) quercetin-3-rutinoside; h) quercetin-acetyl glucoside; i) kaempferol rutinoside; j) isorhamnetin acetylhexoside. table 1. ligand retrieval from pubchem. no compounds cid smile canonical formula 1. quinic acid 6508 c1c(c(c(cc1(c(=o)o)o)o)o)o c7h12o6 2. caffeoylquinic acid 1794427 c1c(c(c(cc1(c(=o)o)o)oc(=o)c=cc2=cc(=c(c=c2)o)o)o)o c16h18o9 3. 1-caffeoylquinic acid 10155076 c1c(c(c(cc1(c(=o)o)oc(=o)c=cc2=cc(=c(c=c2)o)o)o)o)o c16h18o9 4. coumaroylquinic acid 9945785 c1c(c(c(cc1(c(=o)o)o)oc(=o)c=cc2=cc=c(c=c2)o)o)o c16h18o8 5. feruloylquinic acid 9799386 coc1=c(c=cc(=c1)c=cc(=o)oc2cc(cc(c2o)o)(c(=o)o)o)o c17h20o9 6. isorhamnetin 5281654 coc1=c(c=cc(=c1)c2=c(c(=o)c3=c(c=c(c=c3o2)o)o)o)o c16h12o7 7. quercetin-3-rutinoside 5280805 cc1c(c(c(c(o1)occ2c(c(c(c(o2)oc3=c(oc4=cc(=cc(=c4c3=o) c27h30o16 o)o)c5=cc(=c(c=c5)o)o)o)o)o)o)o)o 8. quercetin-acetyl glucoside 10006384 cc(=o)occ1c(c(c(c(o1)oc2=c(oc3=cc(=cc(=c3c2= c23h22o13 o)o)o)c4=cc(=c(c=c4)o)o)o)o)o 9. kaempferol rutinoside 5318767 cc1c(c(c(c(o1)occ2c(c(c(c(o2)oc3=c(oc4=cc c27h30o15 (=cc(=c4c3=o)o)o)c5=cc=c(c=c5)o)o)o)o)o)o)o 10. isorhamnetin acetylhexoside 44259375 cc(=o)oc1c(c(c(oc1oc2=c(oc3=cc(=cc(=c3c2=o) c24h24o13 o)o)c4=cc(=c(c=c4)o)oc)co)o)o cid, compound identification; smile, simplified molecular input line entry. [healthcare in low-resource settings 2024;12:12047] [page 527] cation.29 the plant’s polyphenolic compounds are also predicted to have inhibitory effects on virus replication.15 this study is important to reveal the potential of elderberry (sambucus nigra l.) flower extract as an antiviral for hiv-2. the compounds retrieved from the database include quinic acid, caffeoylquinic acid, 1-caffeoylquinic acid, coumaroylquinic acid, feruloylquinic acid, isorhamnetin, kuersetin-3-rutinoside, kuersetin-acetyl glucoside, kaempferol rutinoside, and isorhamnetin acetylhexoside. the twodimensional structures of all compounds of elderberry (sambucus nigra l.) flower extract are shown. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. the binding affinity score. compounds cid target pdb id binding affinity (kcal/mol) quinic acid 6508 1mu2 -6.8 caffeoylquinic acid 1794427 1mu2 -8.6 3-p-coumaroylquinic acid 10155076 1mu2 -7.9 coumaroylquinic acid 9945785 1mu2 -8.5 feruloylquinic acid 9799386 1mu2 -7.3 isorhamnetin 5281654 1mu2 -9.9 quercetin-acetyl glucoside 10006384 1mu2 -8.0 isorhamnetin acetylhexoside 44259375 1mu2 -9.3 cid, compound identification; pdb, protein databank format. table 2. drug-like molecule properties. no compounds molecular mass logp hbd hba molar refractivity probable 1. quinic acid 192.000 -2.321 5 6 39.839 drug-like molecule 2. caffeoylquinic acid 354.000 -0.645 6 9 82.518 drug-like molecule 3. 3-p-coumaroylquinic acid 354.000 -0.645 6 9 82.518 drug-like molecule 4. coumaroylquinic acid 338.000 -0.351 5 8 80.853 drug-like molecule 5. feruloylquinic acid 368.000 -0.342 5 9 87.405 drug-like molecule 6. isorhamnetin 316.000 2.313 4 7 78.937 drug-like molecule 7. quercetin-3-rutinoside 610.000 -1.878 10 16 137.495 non drug-like molecule 8. quercetin-acetyl glucoside 506.000 -0.159 7 13 115.821 drug-like molecule 9. kaempferol rutinoside 594.000 -1.584 9 15 135.830 non drug-like molecule 10. isorhamnetin acetylhexoside 520.000 0.143 6 13 120.708 drug-like molecule hbd, hydrogen bond donor; hba, hydrogen bond acceptor. figure 2. structural visualization from the molecular docking simulation. a) quinic acid_rt hiv-2; b) caffeoylquinic acid_rt hiv-2; c) 3-p-coumaroylquinic acid_rt hiv-2; d) coumaroylquinic acid_rt hiv-2; e) feruloylquinic acid_rt hiv-2; f) isorhamnetin_rt hiv-2; g) quercetin-acetyl glucoside_rt hiv-2; h) isorhamnetin acetylhexoside_rt hiv-2. rt, reverse transcriptase. [page 528] [healthcare in low-resource settings 2024;12:12047] the prediction of druglikeness in compounds from elderberry (sambucus nigra l.) flower extract aimed to identify the physicochemical characteristics of a drug-like molecule. the prediction uses lipinski’s rules of five, which stipulate that compound with drug-like molecule characteristics must fulfill at least two rules.30 the druglikeness prediction results indicated two compounds not meeting the criteria for drug-like molecules, while eight compounds received positive predictions as drug-like molecules. compounds exhibiting drug-like molecule characteristics are predicted to induce biological activity and possess the ability to penetrate the cell membrane, reaching targets within the cytoplasmic environment.31 molecular docking aims to identify how ligands interact with the target domain.32 in this study, grid docking is used with the position set at center (å) x: 2.746, y: -25.031, z: 16.706, dimensions (å) x: 105.798, y: 83.933, z: 106.561 to orient the ligand on the target. the ligand consists of compounds from elderberry (sambucus nigra l.) flower extract characterized as a druglike molecule, and the target is rt hiv-2 (pdb id: 1mu2). a screening docking method is employed to identify or screen the ligand activity on the target with the most negative binding affinity.33 ligands with the most negative binding affinity values are predicted to trigger inhibitory activity on the target. the molecular docking simulation results indicated that isorhamnetin has the most negative binding affinity of -9.9 kcal/mol compared to other compounds. a more negative binding affinity value signifies a stronger influence produced by ligand binding on the target.34 isohamnetin from elderberry (sambucus nigra l.) flower extract is predicted to be a good antiretroviral candidate through inhibition of hiv-2 rt activity. three-dimensional structures on ligands and proteins from docking results are visualized with transparent surfaces, cartoons, and sticks using specific coloring selection. the molecular interactions formed in the docking result complex consist of hydrogen and hydrophobic bonds.35 both bonds contribute to the strength of the interaction and the stability of the drug molecule.36 the analysis of the position and type of interaction in the ligand-protein complex revealed that isorhamnetin interacts with the hiv-2 rt domain at residues trp4(b), pro25(b), asn137(b), pro133(b), gln23(b), pro140(b), leu21(b), ile90(a), thr131(b), asn57(b), arg22(b), and glu89(a) through hydrophobic bond interactions. hydrogen bond interactions are formed at the positions of ser134(b), gly141(b), and thr88(a). isorhamnetin is predicted to interact through hydrogen bonding and hydrophobicity on the rt domain of hiv-2, potentially triggering inhibitory activity on the target. the predicted mechanism of hiv-2 rt inhibitors in this study refers to nnrtis in hiv-1 by targeting a hydrophobic pocket for inhibition of polymerization reactions.37 in contrast to hiv-1, hiv-2 has mutations in rt with positions k65r, k70e, l74v, q151m, m184i/v; rt mutations in hiv-2 trigger significant antiretroviral resistance compared to hiv-1.11 the position of amino acid residues in the pocket binding domain of isorhamnetin from elderberry (sambucus nigra l.) has a type of hydrophobic bond interaction at the position of amino acid residues that do not include mutation regions, allowing isorhamnetin to be predicted as a potential hiv-2 rt inhibitor. conclusions isorhamnetin from elderberry (sambucus nigra l.) flower extract shows promise as a potential hiv-2 antiretroviral candidate because it has the most negative binding affinity and the formation of hydrophobic hydrogen bond interactions on the rt domain. we recommend positions on the hiv-2 rt consisting of trp4(b), pro25(b), asn137(b), pro133(b), gln23(b), pro140(b), leu21(b), ile90(a), thr131(b), asn57(b), arg22(b), glu89(a), ser134(b), gly141(b), and thr88(a) as potential targets for designing future hiv-2 drug candidates. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12047] [page 529] figure 3. molecular interaction analysis of isorhamnetin on rt hiv-2 domains. a) isorhamnetin_rt hiv-2; b) isorhamnetin pocket binding cave; c) two-dimensional plot of protein-ligand molecular interactions. rt, reverse transcriptase. references 1. chukwu cw, fatmawati, utoyo mi, et al. fractional model of hiv transmission on workplace productivity using real data from indonesia. math comput simul 2023; doi: 10.1016/j.matcom.2023.11.014. 2. ceccarelli g, giovanetti m, sagnelli c, et al. human immunodeficiency virus type 2: the neglected threat. pathogens 2021;10:1377. 3. esbjörnsson j, jansson m, jespersen s, et al. hiv-2 as a model to identify a functional hiv cure. aids res ther 2019;16:24. 4. izzah z, suprapti b, asmarawati tp, et al. 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listiyani p, kharisma vd, ansori anm, et al. in silico phytochemical compounds screening of allium sativum targeting the mpro of sars-cov-2. pharmacogn j 2022;14:604-9. 22. maulani wijaya r, aldino hafidzhah m, dhea kharisma v, et al. covid-19 in silico drug with zingiber officinale natural product compound library targeting the mpro protein. makara j sci 2021;25:162-71. 23. antonius y, kharisma vd, widyananda mh, et al. prediction of aflatoxin-b1 (afb1) molecular mechanism network and interaction to oncoproteins growth factor in hepatocellular carcinoma. j pure appl microbiol 2022;16:1844-54. 24. chandra a, chaudhary m, qamar i, et al. in silico identification and validation of natural antiviral compounds as potential inhibitors of sars-cov-2 methyltransferase. j biomol struct dyn 2022;40:6534-44. 25. shah-abadi me, ariaei a, moradi f, et al. in silico interactions of natural and synthetic compounds with key proteins involved in alzheimer’s disease: prospects for designing new 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s. designing next-generation drug-like molecules for medicinal applications. molecules 2023;28:1860. 32. deshpande rr, tiwari ap, nyayanit n, modak m. in silico molecular docking analysis for repurposing therapeutics against multiple proteins from sars-cov-2. eur j pharmacol 2020;886:173430. 33. moovarkumudalvan b, geethakumari am, ramadoss r, et al. structure-based virtual screening and functional validation of potential hit molecules targeting the sars-cov-2 main protease. biomolecules 2022;12:1754. 34. terefe em, ghosh a. molecular docking, validation, dynamics simulations, and pharmacokinetic prediction of phytochemicals isolated from croton dichogamus against the hiv-1 reverse transcriptase. bioinform biol insights 2022;16:11779322221125605. 35. kondratyev ms, rudnev vr, nikolsky ks, et al. in silico study of the interactions of anle138b isomer, an inhibitor of amyloid aggregation, with partner proteins. int j mol sci 2022;23:16096. 36. gurung ab, ali ma, elshikh ms, et al. an in silico approach unveils the potential of antiviral compounds in preclinical and clinical trials as sars-cov-2 omicron inhibitors. saudi j biol sci 2022;29:103297. 37. el safadi y, vivet-boudou v, marquet r. hiv-1 reverse transcriptase inhibitors. appl microbiol biotechnol 2007;75:723-37. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 530] [healthcare in low-resource settings 2024;12:12047] hrev_master healthcare in low-resource settings 2023; volume 11:11773 the relationship between food quantity and diversity with stunting incidence in indonesia noer kumala indahsari, olivia herliani, masfufatun masfufatun department of biochemistry, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia abstract stunting often a result of inadequate nutrition or malnutrition, can be mitigated by ensuring both sufficient food quantity and dietary diversity. this study aimed to explore the relationship between food quantity and diversity with stunting incidence in toddlers. employed a cross-sectional design, this observational research involved 39 randomly selected toddlers from a surabaya public health center in indonesia. researchers assessed nutritional status, diagnosing stunting using anthropometric measurements. food quantity and diversity in the children’s diets were evaluated through a semi-food frequency questionnaire (ffq). data analysis was conducted using the chi-square test in the statistical package for the social sciences (spss). the study revealed a significant relationship (p=0.001) between dietary diversity with stunting incidence but found no significant link (p=0.892) between food quantity with stunting. stunting has multifactorial causes, some originating even before a child’s birth. after birth, several factors beyond dietary patterns influence stunting. thus, addressing the causes of stunting necessitates a case-by-case approach and tailored interventions for each child. introduction growth is an important factor in a child’s maturation process.1 when a child fails to reach a common standard height for their age, they can be classified as stunted. it is crucial to fully understand the potential causes and how to address the issue of stunting in children, as stunting leads to irreversible physical and mental damage in the next generation. the prevalence of stunting in toddlers in southeast asia ranks first worldwide, according to world health organization (who) data from 2010 to 2020. the incidence of stunting has been decreasing compared to 2010 (41.60%) but remains high, at 30.10% in 2020. the percentage of stunting in southeast asian countries in 2020 is nearly the same as that in african countries, at 31.70%. in 2020, the incidence of stunting among children under five is only 5.70% in european countries and 8.90% in american countries.2 the high prevalence of stunting is also observed in indonesia, a southeast asian nation. in 2019, the incidence of stunting in indonesia reached 27.7%, meaning that 28 out of 100 toddlers are affected.3 the who has established six global nutrition targets for 2025, including a 40% reduction in stunting among children under five.4 stunting is a significant concern for both the who and the indonesian government due to its negative short-term and longterm impacts. in the short term, stunting increases mortality and morbidity hampers cognitive and motor abilities, and leads to higher healthcare costs.4,5 in the long term, stunted individuals may experience short stature, higher obesity rates, reproductive health issues, reduced educational performance, decreased learning abilities, and diminished work capacity and productivity.5,6 correspondence: noer kumala indahsari, department of biochemistry, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia. e-mail: noerkumala@uwks.ac.id key words: food quality; food quantity; stunting; toddlers. contributions: nki conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; oh conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; methodology, visualization, writing – review & editing; resources, investigation, and writing –review & editing; mm formal analysis, validation, writing – review & editing; resources, supervision, and writing –review & editing; resources, investigation, and writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of medicine, universitas wijaya kusuma surabaya, based on ethical certificate no.79/sle/fk/uwks/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for making patient information to be published in this article. funding: this research was supported by a research grant from universitas wijaya kusuma surabaya with contract number 82/lppm/uwks/iv/2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank to universitas wijaya kusuma surabaya for their valuable insight and contributions to this study and manuscript writing. received: 12 september 2023. accepted: 14 november 2023. early access: 24 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11773 doi:10.4081/hls.2023.11773 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11773] [page 163] non -co mmerc ial us e o nly these impacts are particularly prevalent in lower middle-class economies, particularly in southeast asia and africa.7 the leading cause of stunting in preschool-aged children is inadequate fulfillment of nutrition and nutritional energy8,9. the results of a study in four villages in central java, indonesia, showed that changes in children’s eating patterns were a significant factor in nutritional disorders.10 another study emphasized that maternal nutrition deficiency, undernutrition during pregnancy, absence of exclusive breastfeeding (up to six months of age), insufficient complementary feeding, and malabsorption or infectious diseases may lead to nutritional stunting.11 yet another study underlines that parents need to be informed about guidelines for healthy eating patterns and the health risks their children may face due to inadequate nutrition. this can change their priorities and perceptions regarding their children’s nutrition. providing better nutrition to children can change their eating patterns.12 this study aims to identify eating patterns by classifying the quantity, type, and frequency of the food given to children, considering the various age ranges of children. parental provision of children’s nutrition is depicted in terms of the mother’s education and the family’s income rate. the high prevalence of stunting in the world, as well as in surabaya, indonesia, the short-term and long-term adverse effects of stunting, changes in children’s eating patterns as preventive measures and for stunting management, form the basis for this research. this study aimed to analyze the relationship between the quantity and diversity of food and the incidence of stunting in toddlers. materials and methods design study this research employed a descriptive observational design and utilized a cross-sectional study design. the study was conducted in surabaya regency, east java province, over a period of approximately four months in late 2022. population and sample the sample for this study consisted of 39 toddlers from a public health center in surabaya, selected randomly using a simple random sampling method. the samples were chosen from invitations extended to approximately one hundred toddlers in 15 integrated toddler service centers, both stunted and non-stunted. these toddlers attended the health service center, and a sample of 39 stunted and non-stunted children was ultimately selected. public health center officers assisted in filtering samples that met the inclusion criteria. this included toddlers who came to the community health center for health check-ups and were willing to participate as respondents by providing informed consent, which was deemed ethically appropriate. exclusion criteria applied to toddlers who were unwell, unable to visit a health service center, or unwilling to sign an informed consent. data collection the variables measured in this study included the incidence of stunting, as well as the variety and quantity of food consumed by children under five. all research variables were considered primary. the following methods and instruments were used for research variables. nutritional status was assessed through anthropometric measurements, including the child’s height/length and weight. measurements were conducted twice: first by public health center officers to screen potential child samples, and second by the researchers on the day of data collection. data collected on the day of data collection was used for analysis. the diversity and quantity of children’s diets were evaluated using a semi-food frequency questionnaire (ffq) validated in the “guidelines for measuring household and individual dietary diversity” by the food and agriculture organization (fao) of the united nations.13 the original guideline served as the framework and was adapted to suit indonesian food patterns. the ffqs were completed by parents or caregivers responsible for the children’s daily nutrition. data analysis research data, comprising anthropometric measurements (body weight, height) and questionnaires regarding diet and food diversity, were collected. the data were subsequently analyzed using spss for windows version 16. the chi-square test was employed to determine differences in food diversity and its relationship to the number of toddlers’ diets. results based on table 1, the characteristics of the respondents are as follows: data was collected from a sample of 39 children under the age of five. of these children, 23 (58.97%) were female. the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of research respondents (n=39). characteristics of respondents number of respondents n % toddler gender man 16 41.03 women 23 58.97 toddler age (months) 1-10 3 7.69 11-20 6 15.38 21-30 13 33.33 31-40 9 23.08 41-50 4 10.26 51-60 4 10.26 an educational history of the mother of the toddler elementary school 4 10 junior high school 4 10 senior high school 27 69 diploma 1 3 bachelor degree 3 8 parental income history (idr) <4 million 33 85 4-4.5 million 6 15 >4.5 million 0 0 food diversity not enough 6 15.4 enough 22 56.4 good 11 28.2 food quantity hard to eat 6 15.4 sometimes/normally 25 64.1 really like 8 20.5 stunting severe stunted 8 20.5 stunted 21 53.8 normal 10 25.7 total 39 100 [page 164] [healthcare in low-resource settings 2023; 11:11773] non -co mmerc ial us e o nly largest age group among the children was 21-30 months, consisting of 13 children (33.33%). the background of the toddlers’ parents was described based on maternal education and family income. most of the mothers had completed high school (27 individuals, 69%). the majority of parents reported a monthly income of less than idr 4 million. height measurements (in centimeters) were compared with the standard anthropometric heights for children based on their age (in months) and sex. a total of 21 children (53.84%) were classified as short. food diversity is determined by categorizing the foods in the questionnaire based on their functions, which include carbohydrates (as an energy source), proteins, lipid sources, vitamins, and minerals. examples of food sources in each category are provided for selection by caregivers. for instance, carbohydrate sources include rice, potatoes, corn, bread, and cereals. protein and lipid sources encompass fish, meat, legumes, nuts, eggs, milk, and butter. vitamins and minerals sources include foods like spinach, cabbage, broccoli, carrots, tomatoes, apples, oranges, mangoes, bananas, and water, among others. food quantity is assessed by inquiring about eating frequency, snack frequency, and the amount of each meal provided. for example, caregivers are asked how much water (in liters) the child consumes in a day. based on the data from table 2, the results indicate a significant relationship between food diversity and the incidence of stunting at the public health center in surabaya, indonesia. this relationship is supported by statistical analysis using spss for windows 16, with a p-value of 0.001. however, for the relationship between food quantity and the incidence of stunting at the public health center, there is no evidence of a significant relationship, as the p-value is 0.892, which is greater than 0.05. discussion a similar study conducted in bangka belitung yielded results indicating a significant correlation between eating patterns with the incidence of stunting in children under five years old. negative eating behavior was associated with a 4.89 times higher likelihood of stunting compared to positive eating behavior. the data collection instruments used in that research, including height measurement, height-for-age standard graphics, the child feeding questionnaire (cfq), and the child eating behavior questionnaire (cebq), were quite similar to those used in this study. the findings from the bangka belitung research align with the results of our study.14,15 the fulfillment of proper nutrition for children differs for each age group. babies aged 0-6 months receive balanced nutrition exclusively through breastfeeding, as breast milk is considered the gold standard for baby nutrition, containing all the necessary nutrients.16,17 infants and children aged 6-24 months are in a period of rapid growth and development, with increasing physical activity and a higher risk of exposure to infection. complementary foods are introduced alongside continued breastfeeding, which is recommended until the age of 2 years.16 this stage also involves teaching clean living habits to prevent infectious diseases. children aged 25 years experience rapid growth and high physical activity levels, often making their own food choices. therefore, the quantity and variety of their food must receive special attention. a balanced diet in sufficient quantities, consumed regularly, is essential for achieving balanced nutrition. clean living habits are equally important and must be emphasized.18,19 food diversity involves various food groups, including staple foods, side dishes, vegetables, fruits, and water, with diversity within each group. this diversity is vital for maintaining a balanced nutritional diet. dietary diversity score is a measure of diversity in food consumption that is built through assessing the quality and quantity of nutrition for children under five. a diverse range of food types, consumed in sufficient quantities, leads to higher dietary diversity scores, resulting in excellent nutritional status for children under five.20 while prenatal and postnatal nutritional deficiencies and enteric and systemic infections contribute to stunting, several studies emphasize the primary role of environmental enteric dysfunction (eed). eed is a common disorder affecting the structure and function of the small intestine and is prevalent in children living in areas with poor sanitation. mechanisms leading to growth failure in eed include intestinal “leakage,” high intestinal permeability, intestinal inflammation, bacterial translocation, systemic inflammation, and nutrient malabsorption.21,22 preventing stunting offers more diverse shortand long-term benefits compared to managing its consequences. prioritizing stunting prevention requires the involvement of decision-makers, program designers, and implementers. stunting prevention programs should address conditions specific to each age group, such as promoting exclusive breastfeeding for babies aged 0-6 months, ensuring adequate complementary food for babies over 6 months up to 2 years old, and establishing physical activity programs to stimulate growth in children aged 2-5 years. these prevention programs should conclude with the evaluation of program results, especially through height measurements.23,24 this study has several limitations, and more trustworthy results could be achieved by increasing the sample size or conducting research on a larger scale. additionally, conducting research for specific age ranges and considering the gender of the children could provide more specific results, as there are indications that gender influences children’s eating habits. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. relationship between diversity and food quantity with stunting. variables nutritional status severe stunted stunted normal total p food diversity not enough 4 7 0 11 enough 3 13 3 19 0.001 good 1 1 7 9 food quantity hard to eat 2 3 1 6 sometimes/normally 4 14 7 25 0.892 really like 2 4 2 8 [healthcare in low-resource settings 2023; 11:11773] [page 165] non -co mmerc ial us e o nly conclusions the study revealed a significant relationship between food diversity with the incidence of stunting. however, it did not find a significant relationship between food quantity with stunting. this implies that stunting is influenced by a multitude of complex factors, including maternal eating patterns, sanitation, parenting, and more. therefore, focusing solely on dietary factors, such as quantity and diversity, may not be sufficient to address stunting comprehensively. based on these findings, it is advisable to conduct further research by segmenting the sample into gender-specific groups and considering different stages of dietary needs for infants, babies, and children. furthermore, targeted interventions, such as economic stimulation and health education, are needed to enhance family income and maternal knowledge. these interventions require active involvement from healthcare providers, the government, and the community to effectively combat stunting. references 1. taqwin t, ramadhan k, hadriani h, et al. prevalence of stunting among 10-year old children in indonesia. j glob pharma technol 2020;12:768-75. 2. who. stunting prevalence among children under 5 years of age (%) (model-based estimates) [internet]. the global health observatory explore a world of health data. 2023 [cited 2023 mar 3]. available from: https://www.who.int/data/gho/data/ indicators/indicator-details/gho/gho-jme-stunting-prevalence 3. bps. profil statistik kesehatan 2019 [health statistic profile 2019]. 4201005th ed. santoso b, editor. jakarta: ©badan pusat statistik, jakarta indonesia; 2019. 114 p. 4. kemenkes. buletin stunting 2018 [stunting bulletin 2018]. 2018;1163-78. 5. maulina r, qomaruddin mb, prasetyo b, et al. the effect of stunting on the cognitive development in children: a systematic review and meta-analysis. stud ethno-med 2023;17:19-27. 6. mustakim mrd, irwanto, irawan r, et al. impact of stunting on development of children between 1-3 years of age. ethiop j health sci 2022;32:569-78. 7. rachmah q, mahmudiono t, loh sp. predictor of obese mothers and stunted children in the same roof: a populationbased study in the urban poor setting indonesia. front nutr 2021;8:710588. 8. kinyoki dk, ross jm, lazzar-atwood a, et al. mapping local patterns of childhood overweight and wasting in lowand middle-income countries between 2000 and 2017. nat med 2020;26:750-9. 9. surani e, susilowati e. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. j ners 2020;15:26-30. 10. prendergast aj, humphrey jh. the stunting syndrome in developing countries. paediatr int child health 2014;34:250. 11. de sanctis v, soliman a, alaaraj n, et al. early and long-term consequences of nutritional stunting: from childhood to adulthood. acta biomed 2021;92:e2021168. 12. savage js, fisher jo, birch ll. parental influence on eating behavior: conception to adolescence. j law med ethics 2007;35:22-34. 13. kennedy g, ballard t, dop m. guidelines for measuring household and individual dietary diversity. food and agriculture organization of the united nations (fao). europen union: policy and support branch, office of knowledge exchange, research and extension, fao; 2010. 160 p. 14. diana r, rachmayanti rd, khomsan a, riyadi h. influence of eating concept on eating behavior and stunting in indonesian madurese ethnic group. j ethn foods. 2022;9(1). 15. elni e, julianti e. the correlation between feeding habit factor and the incidence of stunting in children under five years. j keperawatan padjadjaran. 2020;8(3):283-91. 16. sebayang skksk, dibley mjjmj, astutik e, efendi f, kelly pjjpj, li m. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16:48. 17. mok kt, tung seh, kaur s. picky eating behaviour, feeding practices, dietary habits, weight status and cognitive function among school children in kuala lumpur, malaysia. malaysian j med heal sci 2022;18:10-8. 18. kemenkes. peraturan menteri kesehatan republik indonesia no 41 tahun 2014 [regulation of the minister of health of the republic of indonesia no 41 of 2014]. jakarta; 2014. 19. krisnana i, azizah r, kusumaningrum t, has emm. feeding patterns of children with stunting based on who (world health organization) determinant factors of behaviours approach. indian j public heal res dev 2019;10:2756-61. 20. yari z, amini m, rasekhi h, et al. dietary diversity and its relationship with nutritional adequacy in 24 to 59 months old children in iran: study protocol. bmc nutr 2022;8:118. 21. kuralneethi s, sariman s, ulaganathan v. gender and age differences in the relationship between calorie, macronutrients intake and growth status of school-aged aboriginal children at labu, negeri sembilan. br food j 2021;123:1384-96. 22. owino v, ahmed t, freemark m, et al. environmental enteric dysfunction and growth failure/stunting in global child health. pediatrics 2016;138:e20160641. 23. mar’ah has em, asmoro cp, gua wp. factors related to father’s behavior in preventing childhood stunting based on health belief model. j keperawatan indones 2022;25:74-84. 24. dewey kg, begum k. long-term consequences of stunting in early life. matern child nutr 2011;7:5-18. [page 166] [healthcare in low-resource settings 2023; 11:11773] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly healthcare in low-resource settings 2023; volume 11:11776 the effect of dayak onion brewed water in reducing blood pressure and mean arterial pressure (map) in hypertensive patients diah setiani, rahmawati shoufiah, hesti prawita widiastuti, indah nur imamah, rivan firdaus, frana andrianur department of nursing, east kalimantan ministry of health polytechnic, samarinda, indonesia abstract the world health organization (who) estimated that 1.28 billion adults aged 30-79 years worldwide suffered from hypertension. dayak onion is an herbal plant found in indonesia, particularly in kalimantan and traditionally used to treat hypertension. the purpose of this study was to determine the effect of dayak onion steeping water on the reduction of systolic-diastolic blood pressure and mean arterial pressure (map) in hypertensive patients. this study employed a quasi-experimental research design with a time series approach, utilizing a pre-post-test design with a control group. the sample included two groups (intervention and control), totaling 30 participants. the independent variable was the steeping of dayak onion bulbs, while the dependent variables were blood pressure values and map. the instruments used were standard operating procedures (spo) dayak onion herb, spo blood pressure measurement, spo calculation of map, and a digital sphygmomanometer. data analysis was performed using paired t-tests. the results of the paired t-test statistical analysis of systolic-diastolic values and map in each group revealed significant findings. in the intervention group, a significant result was obtained in the pre-post test difference test, with a p<0.05 from day 1 to day 3 assessments. this suggests that dayak onion steeping water had an effect on systolic-diastolic and map values in the intervention group. in contrast, the pre-post test in the control group yielded a p<0.05 for systolic values on days 2 and 3, diastolic values on days 1 and 3, and map values on days 1, 2, and 3. this indicates differences in systolic-diastolic and map values in the pre-post assessments, although these differences were not evenly distributed across every day. the study found that dayak onion steeping water had an effect on systolic-diastolic and map values in the intervention group. thus, the use of dayak onion steeping water, containing allicin, can be considered an approach for controlling hypertension in the realm of complementary and alternative medicine, utilizing natural ingredients for herbal therapy. introduction an estimated 1.28 billion adults aged 30-79 years worldwide suffer from hypertension, with the majority (two-thirds) residing in lowand middle-income countries. approximately 46% of adults with hypertension are unaware of their condition, and less than half (42%) receive a diagnosis and treatment. only about 1 in 5 adults (21%) with hypertension have their blood pressure under control. hypertension, often referred to as the silent killer, can wreak havoc if left uncontrolled, targeting vital organs and leading to heart attacks, strokes, kidney disorders, and even blindness.1 hypertension induces endothelial dysfunction, exacerbates the atherosclerotic process, and contributes to the instability of correspondence: diah setiani, department of nursing, east kalimantan ministry of health polytechnic, samarinda, indonesia. e-mail: diah.dee.oc@gmail.com key words: allicin; blood pressure; dayak onion; hypertension; map. contributions: ds, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; final approval of the version to be published funding acquisition. rs, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; hpw, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ini, methodology, visualization, writing – review & editing; ss resources, investigation, and writing –review & editing; rf, formal analysis, validation, writing – review & editing; fa, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes kalimantan timur, based on ethical certificate no. lb.02.01/7.1/3320/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 12 september 2023. accepted: 6 november 2023. early access: 21 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11776 doi:10.4081/hls.2023.11776 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11776] [page 167] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11881 enhancing scabies knowledge among indonesian boarding school students through a wayang video nadyatul husna,1 anggiansyah pohan,1 m. andhika dwi putra,1 laila isrona,2 firdawati3,4 1medical doctor study program, faculty of medicine, universitas andalas, padang; 2department of medical education, faculty of medicine, universitas andalas, padang; 3department of public health, undergraduate program of medicine, faculty of medicine, universitas andalas, padang; 4doctoral program of public health, faculty of medicine, universitas andalas, padang, indonesia abstract skin diseases, such as scabies, present a significant global health concern, particularly among indonesian boarding school students, resulting in complications, disruptions to daily life, and academic hindrances. to effectively address this issue, a health education approach utilizing wayang videos was implemented, leveraging cultural elements for enhanced outcomes. our research aimed to assess the impact of a wayang educational video on scabies knowledge among indonesian boarding school students. this study, conducted from october 2019 to october 2020, involved 447 students. preand post-tests were administered to measure knowledge levels. our findings demonstrate a significant improvement in scabies knowledge among students following the wayang video education intervention. the bivariate wilcoxon test identified a significant difference (p<0.05) in average scores before and after the educational intervention. knowledge scores increased from 76.75 in the pre-test to 83.09 in the post-test, marking an 8.27% improvement. this study underscores the efficacy of wayang educational video in augmenting scabies knowledge among indonesian boarding school students, with a particular emphasis on the impact of a video titled “malin and the mite”. this innovative cultural approach holds promise as a potential model for analogous regions, contributing to scabies prevention and advancing public health objectives. introduction skin diseases are a significant global health concern, ranking fourth among the leading causes of non-fatal diseases worldwide.1,2 these diseases encompass both infectious and non-infectious conditions, with skin infections caused by various agents, including bacteria, viruses, fungi, and parasites. among parasitic skin infections, scabies stand out, caused by infestation with sarcoptes scabei var. hominis mites (arachnida class, acarina order, sarcoptidae family).2 scabies have been reported from various parts of the world, and the incidence is high, especially in developing countries.3 scabies are particularly prevalent in tropical regions like southeast asia, where the world health organization (who) estimates that approximately 200 million individuals are affected.4,5 according to a cross-sectional analysis of the 2015 global burden of disease study, indonesia is among the top five nations with the highest scabies load, followed by china, timor-leste, vanuatu, and fiji.6 in each country, the prevalence of scabies correspondence: laila isrona, department of medical education, faculty of medicine, universitas andalas, padang, indonesia. e-mail: lailaisrona@med.unand.ac.id key words: boarding school, knowledge, scabies, video education, wayang. contributions: all the authors made a substantive intellectual contribution. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors affirm that there were no financial or commercial conflicts of interest throughout the conduct of this study and state that they have no competing interests with the funders. funding: this work was supported by the faculty of medicine, andalas university, and the national scientific analysis and development agency indonesian medical student senate association (bapinismki). the funding was provided from the conception phase until the reporting of the results and did not cover publication costs. the funding body had no involvement in the design, analysis, or interpretation of data for this paper. ethics approval: this study adhered to the ethical principles of research, including anonymity, confidentiality, and beneficence. approval from both the students and the school principal was obtained through voluntarily completed informed consent forms. ethical approval for the study was also granted by the research ethics committee of the faculty of medicine, andalas university, with no. 076/kep/fk/2020. availability of data and materials: the datasets generated during and analyzed during the current study are available from the corresponding author upon reasonable request. acknowledgments: we would like to express our sincere gratitude to all parties who have contributed to the successful completion of this study. we extend our heartfelt thanks to the faculty of medicine, andalas university, various research centers, bapin-ismki, and the participating schools. we also deeply appreciate the invaluable contributions made by all the researchers involved in this study. received: 27 september 2023. accepted: 16 february 2024. early access: 22 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11881 doi:10.4081/hls.2024.11881 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11881] [page 495] non -co mmerc ial us e o nly ranges from 0.2 to 71%. in indonesia, scabies remain a persistent public health challenge, with a prevalence rate of 6% reported in 2017, highlighting its ongoing significance as an infectious disease in the country.7 scabies was the third most common skin illness in indonesia, according to information from community health facilities known as ‘puskesmas’.8 scabies were found more commonly in children than in adults.7 in indonesia, home to the largest muslim population globally, there are 14,798 islamic boarding schools. students often hail from socioeconomically disadvantaged families unable to cover educational and living expenses. consequently, these pesantren are densely populated with limited resources. accommodations meant for 30-50 students lack adequate facilities and hygiene standards, facilitating the rapid spread and challenging eradication of scabies.7-9 scabies are known as an emerging or re-emerging parasitic condition.10 colloquially referred to as “gudig” or “the itch,” scabies are characterized by intense itching (pruritus), often worse at night, and the presence of white linear patches (burrows or “kunikulus”) on the skin surface. this typically occurs in the folds of thin, warm, and moist skin, with pruritic papules classically found in the webs of the fingers, the flexor of the wrists, the extensor of the elbows, the periumbilical skin, the buttocks, the ankles, the penis in males, and the periareolar region in females.11 however, it is considered uncommon due to the relative host specificity of the mites.12 sensitization to mite secretions and excreta results in itching, while the white linear patches represent the tunnels formed by these mites. the condition of scabies can manifest as widespread hyperkeratotic crusted lesions.13 individuals with a weakened immune system may develop a severe form of scabies called crusted scabies.14 despite being perceived as non-lethal, scabies can lead to serious complications due to skin tissue damage and secondary bacterial infections.2,9,15 the gold standard technique for diagnosis is microscopic examination, which requires experienced experts to identify mites, primarily in ordinary scabies.16 several risk factors contribute to scabies transmission, including poverty, overcrowding, low education levels, limited access to clean water, and poor hygiene practices. household overcrowding, as observed in boarding schools, plays a dominant role, facilitating mite transmission through close physical interactions and shared living spaces. suboptimal hygiene behaviors, such as infrequent bed cleaning, clothes swapping, and sharing personal items among dormitory students, exacerbate the problem.2,15 the incessant itching associated with scabies infestations disrupts the sleep patterns of affected students, leading to fatigue, lethargy, and difficulties in concentration. research has highlighted a meaningful association between scabies, students’ concentration levels, and academic performance in boarding schools.17,18 the adoption of clean and healthy living behaviors is closely linked to knowledge about a particular health issue. several studies have demonstrated a significant correlation between the level of knowledge and the incidence of scabies among boarding school students.19,20 for instance, research conducted by ramadhan et al. revealed that 71.4% of boarding school students had a low level of knowledge regarding scabies, corresponding with a high incidence rate of the condition.19 this finding is corroborated by nindrya et al.’s study, which found that 67.9% of boarding school students had a low level of knowledge about scabies.20 both studies concluded that knowledge levels influence the incidence of scabies in boarding schools. thus, comprehensive health education on scabies, covering their causes, transmission modes, preventive measures, and treatment options, is crucial within the boarding school environment. health education can take various forms, including visual, audio, and audiovisual media. notably, audiovisual tools like videos engage both visual and auditory senses, facilitating knowledge absorption. combining multiple sensory inputs enhances knowledge transfer effectiveness.21 another intriguing educational medium is the traditional indonesian art form of “wayang,” which includes puppetry and shadow play. wayang is deeply rooted in indonesian culture and offers a unique and engaging platform for educational content delivery. its cultural significance, rich storytelling tradition, and entertainment value make it a compelling choice for imparting knowledge.22,23 in this research, we utilize wayang story videos as a medium for health education on scabies. the research aims to explore the impact of education delivered through the wayang video “malin and the mite” on the knowledge of scabies among boarding school students in indonesia. this choice is motivated by the cultural significance of wayang and its potential to enhance the learning experience by making it more captivating and culturally relevant. this study has the potential to significantly impact scabies prevention and education efforts, not only in indonesia but also in regions facing similar health challenges. leveraging the culturally relevant medium of wayang can enhance awareness of scabies among indonesian students, leading to early detection and treatment. this, in turn, can reduce scabies transmission within schools and communities and trigger positive behavioral changes, fostering healthier hygiene practices. furthermore, the research’s innovative approach to incorporating cultural elements into health education can serve as a model for other regions with rich cultural traditions. it highlights the effectiveness of aligning educational materials with cultural practices, potentially inspiring similar initiatives globally. the aim of this study is to determine the effectiveness of scabies awareness using video wayang media on the knowledge level of boarding school students. ultimately, the study’s success in reducing scabies incidence among students and communities contributes to broader public health goals, improving overall well-being. materials and methods research design this research employs an experimental design with a pre-post test design involving a single group. participants were selected through a simple random sampling method. the dependent variable for this research is the level of knowledge about scabies among boarding students in indonesia, while the independent variable is health education about scabies through the wayang video. the research was conducted from january to october 2020. the sample size was determined using a modified lemeshow formula based on a single-sample estimate of the proportion of a population and dropouts, resulting in a minimum sample size of 440. the study enrolled 447 participants who met the inclusion and exclusion criteria. the inclusion criteria for this study are as follows: respondents must be confirmed as boarding school students, verified by their boarding school identification card or other identification; willing to sign the informed consent form as a requirement for participating in the interview; actively engaged in the research from its commencement to its conclusion (beginning with the pre-test, wayang education, post-test); and completing both the pre-test and post-test questionnaires. these participants were students from eight schools located in dormitories across indonesia, comprising six transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 496] [healthcare in low-resource settings 2024;12:11881] non -co mmerc ial us e o nly schools from java, one from sumatra, and one from sulawesi. students who followed the research process were determined by the school related to managing licensing by previous researchers. research instrument and implementation researchers first prepared a wayang story video for educational media titled “malin and the mite” / “malin dan si tungau” (in the indonesian language). the questionnaire used to assess the level of boarding school students’ knowledge about scabies was adapted from fitriyani, n.’s questionnaire (2017), which has been declared valid and reliable.24 researchers have obtained permission from these previous researchers. the research process consisted of several stages. in the initial stage, respondents completed questionnaires containing general information and knowledge about scabies disease in a pre-test. the general information included details such as age, gender, grade/class, information, experience with scabies infection, risky behavior for scabies transmission, affected areas of the body, family/friend history of scabies, environmental conditions conducive to scabies transmission, and treatment. the knowledge about scabies disease encompassed factors related to scabies transmission, causes of scabies, signs and symptoms, mite development, treatment, environmental factors, scabies incidence, and control measures. subsequently, in the following stage, respondents watched a wayang education video on scabies disease, which lasted approximately 14 minutes; the intervention was conducted only once. the wayang video, titled “malin and the mite,” covered topics including definitions, causes, risk factors, clinical manifestations, treatment, prevention, and scabies incidence. the final stage involved a post-test, during which respondents completed a questionnaire with content identical to that of the pre-test. the allocated time for completing both the pre-test and post-test questionnaires was 10 minutes each. statistical analysis data processing and analysis are carried out to determine respondents’ knowledge level before and after being given wayang video education and to understand the influence of wayang video education on increasing respondents’ knowledge after the education. knowledge measurement results can be grouped into three categories, namely: good (76%-100%), enough (56%-75%), and less (<56%).25 the analysis of the difference in respondents’ average grades was conducted using the wilcoxon test. this stage is done using ms excel and spss 16.0 for windows software. ethics statement this study adhered to ethical research principles, including anonymity, confidentiality, and beneficence. approval from both the students and the school principal was obtained through voluntarily completed informed consent forms. the research ethics committee of the faculty of medicine, andalas university, with no. 076/kep/fk/2020, also granted ethical approval for the study. results demographic characteristics of respondents demographic characteristics of the study respondents can be seen in the tables below, outlining the following features of the respondents. according to table 1, the average age of the studied respondents was 15.82 years old, with a standard deviation of 1.39. the median age of the respondents is 16 years, with the youngest being 13 years old and the oldest 18 years old. the majority of respondents (55%) were female. regarding the academic year, grade x had the highest representation at 32%, followed by grades xi, xii, and ix. approximately 67% of the respondents had previously experienced a scabies infection, with the majority of them being male. another factor influencing knowledge is the source of information.26 table 1 shows a total of 447 respondents studied; 225 (50.3%) claimed to have been informed about scabies before. this aligns with the level of knowledge of some boarding students falling into the “good” category in the pre-test (figure 1). respondents’ knowledge differences in students’ knowledge before and after being given health education about scabies with wayang video media can be observed in the table below. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. overview of respondent knowledge levels during pretest and post-test. [healthcare in low-resource settings 2024;12:11881] [page 497] table 1. demographic characteristics of respondents. % n sex female 55 248 male 45 199 age 13 11 48 14 3 15 15 21 95 16 32 144 17 23 101 18 10 44 academic year (grade) ix 15 63 x 32 246 xi 29 129 xii 24 109 information have received information 50,3 225 have not received information 49,7 222 have had scabies infection have had 67 298 have not had 33 149 non -co mmerc ial us e o nly based on table 2, the average knowledge of boarding students before receiving health education about scabies with wayang video media is 76.75, with a standard deviation (sd) of 13.28. the standard deviation informs about how far the data varies from its average value. the smaller the standard deviation value compared to the average value, the better the average value represents the data as a whole. the respondent’s median pretest value is 77.27, with a minimum value of 31.82 and a maximum value of 100. after receiving health education about scabies with wayang video media, the average value increased to 83.09, with a standard deviation of 11.19. the median post-test value is 86.36, with a minimum value of 9.09 and a maximum of 100. analysis of differences in average pre-test and post-test knowledge the average difference analysis in this study used the wilcoxon non-parametric test. the test aims to determine if there is a significant difference between the average value of pre-test knowledge and the post-test of the respondents. a significant difference is observed when the p-value obtained is <0.05, indicating a relationship between variables. the results of the analysis of different average values of pretest and post-test knowledge can be seen in the following table. based on table 3, it is known that the average knowledge value in the pre-test is 76.75, and in the post-test is 83.09. from the data, there is an increase in the average value in the post-test compared to the average pre-test value of 6.34. the table also presents wilcoxon test results with a significance value of 0.001 (p<0.05), indicating a meaningful difference between the average pre-test and post-test values. from the data, it can be concluded that the education of wayang video about scabies has an effect on increasing the knowledge of respondents’ students about scabies. discussion in this study, the majority of respondents were in the 13-18 years age range, corresponding to school age. other research has also indicated that scabies are most prevalent among school-aged individuals.27 this is supported by the book “evidence-based dermatology,” which suggests that the highest number of scabies cases occurs among adolescents and schoolchildren.28 research conducted in a hospital further explains that scabies are most common among individuals aged 11-20 years.29 in the study by yulfi et al., it was also reported that the age range of the participants was 10-18 years, with the most common range being 10-14 years.30 consequently, the study has focused on this age range for health education regarding scabies. additionally, it’s worth noting that the ability to comprehend a person’s perspective on a subject tends to improve with age, leading to better knowledge acquisition. this implies that age is one of the factors influencing an individual’s knowledge. the study also investigated the sources of information about scabies among the respondents. it was discovered that 50.3% of the students reported having received information about scabies before the intervention, while 49.7% had not received prior information. this distribution implies that there was some baseline knowledge about scabies among the students, although it varied. interestingly, students who had prior information were more likely to possess a good level of knowledge about scabies in the pre-test, supporting the idea that prior exposure to information can influence baseline knowledge.17,31 regardless of past experience, the wayang video instruction functioned as a standardized source of information for all participants. this uniformity in educational content most likely contributed to the post-test’s significant gain in knowledge levels. the findings highlight the need for providing accurate and freely accessible health information so that anyone, regardless of past knowledge, can improve their awareness of health-related topics.17 the findings of this study demonstrate a significant improvement in scabies knowledge among boarding school students in indonesia following the implementation of health education through wayang video media. prior to the intervention, the average knowledge score of the students was 76.75, indicating a fair level of knowledge about scabies. after receiving wayang video education, the average knowledge score increased to 83.09. the substantial increase in knowledge levels post-intervention aligns with previous research highlighting the effectiveness of audiovisual educational tools. videos, as a medium, engage both visual and auditory senses, making the educational content more accessible and memorable.22,32 increased knowledge is gained from the sensing of a particular object in the form of facts, information, descriptions, or skills. each sense used has a different influence on a person’s learning outcomes; a good way to learn something is to utilize more than one sense. the absorption of a person’s learning, according to the use of his senses, is 1% through taste, 2% by touch, 3% through the senses of tying, 11% through hearing, and 83% by sight.21,22,33 this study uses audiovisual media (video) to introduce educational material, in which respondent students will utilize their sense of vision and hearing to obtain the material. using images in educational media can increase one’s focus, interest, and passion while learning. material received through audiovisual media can transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 498] [healthcare in low-resource settings 2024;12:11881] table 2. overview of average knowledge scores for pre-test and post-test of respondents. n mean standard. deviation median minimum maximum pre-test 447 76.75 13.28 77.27 31.82 100 post-test 447 83.09 11.19 86.36 9.09 100 table 3. mean difference analysis of pre-test and post-test knowledge scores. number of data values mean value pe pre-test scores 447 76,75 0,001 post-test scores 447 83,09 non -co mmerc ial us e o nly last longer and be better retained in memory. the results of this study are consistent with siddiq’s (2021) findings, indicating that audiovisual media effectively increases motivation to quit smoking among santri students in indonesia.34 additionally, fitriani et al.’s research (2017) demonstrated a significant positive impact of nutritional anemia counseling through audiovisual motion video media on increasing the knowledge of young women.34 similarly, meidiana et al. (2018) found that education using audiovisual media positively influenced the knowledge of overweight teens.35 furthermore, purwadi et al.’s study (2019), which utilized a different educational medium, namely game media, also showed significant differences in elementary school students’ knowledge, with an average score increase after education on the prevention of acute respiratory tract infection (ispa) disease.36 the study shows that using culturally relevant wayang videos improves scabies’ knowledge, leading to better hygiene, symptom recognition, and timely treatment in boarding schools, where close living quarters heighten transmission risks. the educational video used in this research employs wayang art to build the story, drawing inspiration from the tale of malin kundang from west sumatra. the aim is to utilize the element of national cultural wealth in innovating activities to produce an educational video work and convey the message of a norm of life: listening to the advice of the mother. in addition to the message of educational materials itself, this adds a special value to the video. both innovations are also intended to make the video more interesting to watch. the results of this research align with several studies that examine the benefits of wayang art for counseling and education media. a study by utami et al. (2020) stated the influence of nutrition counseling using wayang media on balanced nutrition knowledge in elementary school children.37,38 research by desi et al. (2018) reported an increase in vegetable and fruit consumption in kindergarten children after receiving nutrition education with wayang games.35,38,39 the findings of this study have several implications for scabies prevention and health education in indonesian boarding schools and similar settings. firstly, the effectiveness of wayang video teaching suggests that incorporating culturally relevant media can enhance health education efforts.24,34,35,40,41 cultural resonance can capture students’ interest and engagement, making the learning experience more enjoyable and memorable.16,26,27,32 secondly, the study underscores the importance of standardized health education in contexts where the risk of disease transmission is elevated due to close living quarters. boarding schools provide a unique environment where students live and learn in close proximity, making disease prevention strategies crucial.37,38 health education via wayang videos can enable students to protect their health, suggesting further research on its long-term effects on scabies control and hygiene, with potential application to other health issues and cultural settings. although the results showed meaning and are in line with some other studies, this study still has some limitations. the first limitation is that the situation of online data retrieval leads to maximum supervision of respondents when filling out questionnaires and watching videos. researchers could only monitor respondents from the screen of a zoom app that only showed parts of the face and part of the respondent’s body. the second limitation is the number of respondents who did not fill in the questionnaire’s general data about their experience with scabies disease. this resulted in some available data information on the questionnaire that could not be used as material for univariate analysis. the information used for univariate analysis in this study includes age data and statements providing information about previous scabies experiences. based on the study, the author intends to provide advice that may be useful for certain parties. the researchers advise the schools the respondents are from to use the educational video wayang “malin and the mite” as a medium for health education about scabies disease for all students in the dormitory. researchers are recommended to evaluate knowledge and attitudes 6 months after using “malin and the mite,” ensuring a conducive environment for data collection and a team to secure complete, rule-abiding questionnaire responses. conclusions the study finds that wayang video-based health education significantly improves indonesian boarding school students’ knowledge of scabies. this highlights the effectiveness of culturally appropriate teaching tools and the importance of health education in high-risk environments. the audiovisual method aids understanding and can enhance scabies prevention and hygiene practices, contributing to wider public health goals. references 1. karimkhani c, dellavalle rp, coffeng le, et al. global skin disease morbidity and mortality: an update from the global burden of disease study 2013. jama dermatology 2017;153:406. 2. engelman d, yoshizumi j, hay rj, et al. the 2020 international alliance for the control of scabies consensus criteria for the diagnosis of scabies. br j dermatol 2020;183:808. 3. pramesthi de, rahmawati ld. severe norwegian scabies infection in psoriatic arthritis patient with naïve hepatitis b and sepsis: a case report. gac med caracas 2023;131:s185-91. 4. world health organization (who). scabies. 2020. available from: https://www.who.int/health-topics/scabies#tab=tab_1 5. global burden of disease (gbd) 2019 indonesia subnational collaborators. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 6. karimkhani c, colombara dv, drucker am, et al. the global burden of scabies: a cross-sectional analysis from the global burden of disease study 2015. lancet infect dis 2017;17:1247-54. 7. ministry of health of the republic of indonesia. the research and development agency for health of the republic of indonesia. indonesia health profile 2018. 2018. available from: https://www.kemkes.go.id/app_asset/file_content_ download/profil-kesehatan-indonesia-2018.pdf?utm_medium=email&utm_source=transaction 8. akmal sc, semiarty r, gayatri g. the relationship between personal hygiene and the incidence of scabies at darul ulum islamic boarding school, palarik air pacah, koto tangah district, padang, in 2013. j kesehat andalas 2013;2:164. 9. rihatmadja r, miranda e, wicaksono mm, widaty s. why are they hard to treat? a preliminary survey to predict important factors causing persistent scabies among students of religionaffiliated boarding schools in indonesia. dermatology reports 2019;11. 10. lastuti ndr, suwanti lt, ma’ruf a, et al. the leukocyte pro transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11881] [page 499] non -co mmerc ial us e o nly file, histopathology and molecularly characteristics of rabbits scabies’ from east java, indonesia. 2021. available from: https://medic.upm.edu.my/upload/dokumen/20210429150550 2020_0869_04.pdf 11. herwanto n, mappamasing h, widiantari s, et al. scabies incognito. dermatol rep 2019;11:8083. 12. lydiawati e, agusni i, murtiastutik d, et al. crusted scabies in systemic lupus erythematosus: more than a mite contagious case. dermatol rep 2019;11:8085. 13. rahmawati na, chomariyati a, mudjanarko sw. a fatal case of norwegian scabies in a patient with diabetes mellitus. bali med j 2022;11:870-4 . 14. maharani cs, harnanti dv, mappamasing h, et al. crusted scabies in patients with long-term use of oral corticosteroid with different underlying diseases case series. dermatol rep 2019;11:183-5. 15. sunderkötter c, wohlrab j, hamm h. epidemiologie, diagnostik und therapie der skabies. dtsch arztebl int 2021;118:695-704. 16. prasasty gd, miftahurrizqiyah, anwar c. performance of co1 and its2 nested pcr in molecular identification of ordinary scabies (sarcoptes scabieivar hominis). indones j biotechnol 2021;26:91-100. 17. menaldi slsw, surya d, the vv. impact of scabies on indonesian public boarding school students’ quality of life: a mixed-method analysis. j gen proced dermatology venereol indones 2021;5:74-8. 18. dhelya widasmara, sananta p, tamadi vr. relationship between learning achievement with scabies in female students at girls islamic boarding school an-nur 2 al-murtadlo, malang. (2020). available from: https://majalahfk.ub.ac.id/ index.php/mkfkub/article/view/355/209 19. bb r. knowledge of islamic boarding school students in east jakarta regarding scabies transmission and its relationship with related factors. 2012. 20. nindrya zb.the level of knowledge of clinical symptoms of scabies and the association with demographic characteristics of students in x boarding schools east jakarta. available from: https://lib.ui.ac.id/detail?id=20385592&lokasi=lokal 21. prasetyanti dk, nikmah an, tantriyani k. the effect of health promotion through audio visual media about hiv aids on housewives knowledge. str j ilm kesehat 2021;10:1272-9. 22. kurscheid j, bendrups d, susilo j, et al. shadow puppets and neglected diseases: evaluating a health promotion performance in rural indonesia. int j environ res public health 2018;15. 23. williams c, stewart de, bendrups d, et al. shadow puppets and neglected diseases (2): a qualitative evaluation of a health promotion performance in rural indonesia. int j environ res public health 2018;15. 24. fitriyani n. the effectiveness of health education about scabies against the level of knowledge of santri pesantren ashiddiqiyah jakarta. 2018. available from: https://repository.uinjkt.ac.id/dspace/bitstream/123456789/37278/1/nabilah%20fitriyani-fkik.pdf 25. arikunto. the research procedure is a practical approach. 2013. 26. de araujo pastor aj, de melo tavares cm. literature review of audiovisual practices in nursing education. rev bras enferm 2019;72:190-9. 27. misganaw b, nigatu sg, gebrie gn, kibret aa. prevalence and determinants of scabies among school-age children in central armachiho district, northwest, ethiopia. plos one 2022;17:e0269918. 28. williams hc, bigby m, herxheimer a, et al. evidence-based dermatology. john wiley and sons ltd.; hoboken, usa; 2003. 664 pp. 29. schneider s, wu j, tizek l, et al. prevalence of scabies worldwide-an updated systematic literature review in 2022. j eur acad dermatol venereol 2023;37:1749-57. 30. yulfi h, zulkhair m, yosi a. scabies infection among boarding school students in medan, indonesia: epidemiology, risk factors, and recommended prevention. trop parasitol 2022;12:3440. 31. constantinou ac, guo z, kitson nk. the impact of prior knowledge on causal structure learning. knowl inf syst 2023;65:3385-434. 32. emen ajp, edrada sl. effectiveness of health promotion audiovisual materials in reducing nicotine dependence among young adults. am sci res j eng 2020;73:143-62. 33. fitriani sd, eko gp, & dkk. nutrition anemia counseling with media motion video against knowledge and attitudes of young women. available from: https://juriskes.com/index.php/jrk/ article/download/686/74/1340 34. ismail i, siddiq r, bustami b. the effectiveness of health education using audiovisual on the santri smokers’ motivation to stop smoking. asian pac j cancer prev 2021;22:2357-61. 35. meidiana r, simbolon d, wahyudi a, et al. the influence of education through audio visual media on overweight youth knowledge and attitudes. j kesehat 2018;9:478-84. 36. purwadi hn. health education through snake game household to improve children’s knowledge about ispa prevention behavior in nalu village, tolitol. jurnal pengabdian kepada masyarakat. available from: https://www.google.com/url?sa= t&source=web&rct=j&opi=89978449&url=https://journal.um tas.ac.id/index.php/abdimas/article/download/1256/744/57 12&ved=2ahukewjk_vp-59wfaxxbgv0hhrryd38q fnoecbuqaq&usg=aovvaw3dphmjslezytjoekauoe4g 37. hilma ud, ghazali l. factors influencing the occurrence of scabies in mlangi nogotirto gamping sleman boarding school yogyakarta. j kedokt dan kesehat indones 2014;6: 148-57. 38. utami ma. the influence of wayang media and booklet on the knowledge of balanced nutrition of elementary school children. 2020. available from: https://ijhd.upnvj.ac.id/index.php/ ijhd/article/view/61 39. anggraini fd, nisa f, hasina sn, munjidah a. the effect of nutritional education using cognitive approaches and psychomotor approaches on fruit and vegetable consumption behavior in children. open access maced j med sci 2021;9:116-5. 40. ghadiri a, sturz dl, mohajerzad h. associations between health education and mental health, burnout, and work engagement by application of audiovisual stimulation. int j environ res public health 2022;19. 41. darling-hammond l, flook l, cook-harvey c, et al. implications for educational practice of the science of learning and development. appl dev sci 2020;24:97-140. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 500] [healthcare in low-resource settings 2024;12:11881] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12851 self-efficacy in older adults with depression: a qualitative study tri nurhidayati,1,2 atika alfia rizki,2 dewi setyawati,2 ah yusuf,1 retno indarwati1 1doctoral program, faculty of nursing, universitas airlangga, surabaya; 2department of nursing, fikkes universitas muhammadiyah semarang, indonesia abstract older people suffering from depression often exhibit low selfefficacy, which causes them to quickly give up on challenges caused by various problems related to ageing, such as physical, social and mental aspects, including depression, which ultimately impact their quality of life and productivity. depression in the elderly is caused by physical, psychological, and social interactions with other people, especially caregivers in nursing homes. this study employed a phenomenological approach to analyse self-efficacy among older adults suffering from depression through qualitative inquiries. the participants who met the inclusion criteria lived in nursing homes for more than one year and experienced depression. in-depth interviews were conducted using a structured guide with a general self-efficacy scale (gses), indonesian version. the study was conducted in an older adult nursing home in 2022 with 14 older adults. the results were divided into four themes – accompanying performance, vicarious learning, verbal encouragement and emotional states – and indicated that older adults with depression experienced poor self-efficacy and described how to cope with poor self-efficacy. introduction mental health problems that generally occur in older adults are depression, loneliness, stress, anxiety, and fear of death. selfefficacy is an individual’s ability to cope with stress and depression experienced in difficult and stressful situations. self-efficacy influences individual motivation and plays an important role in depression, namely, in controlling the events that occur.1 several provinces in indonesia show data that they have entered an old population structure, including central java (14.17%) entering the old population structure number three after di yogyakarta (15.52%) and east java (14.53), followed by north sulawesi (12.74%), bali (12.71%), south sulawesi (11.24%), lampung (10.22%), and west java (10.18%).2 moreover, as age increases, the incidence of depression will be higher. according to data from national research in indonesia, the prevalence of depression increased with age, the highest being age 75 and over years at 8.9%, 65–74 years at 8.0%, and 55–64 years at 6.5%.3 in addition, almost all older adults (31 older adults) who were in the nursing home experienced mild depression (70.5%), nine older adults experienced moderate depression (20.5%) and four older adults did not experience depression (9.1%).4 depression is a mood disorder characterised by sadness, feelings of loneliness, low self-esteem, and hopelessness. it is usually accompanied by signs of psychomotor retardation or sometimes agitation, withdrawal and other cognitive disorders, such as insomnia and anorexia.5 the results of a study by pae showed that the majority of older adults who live in nursing homes experience moderate depression,6 and the majority of older adults who live at home with their families experience mild depression. this is because older adults living in nursing homes live far away from their families, so they do not have the opportunity to share their problems and sorrows. loneliness arises when you are away from your family because there are no more people to live with and share everything with. when feelings of loneliness increase, the stress factor increases and causes depression in older adults. depression in older adults is caused by physical, psychological, and social interactions that are mutually detrimental and reduce the quality of life and work productivity of older adults. psychological factors are characterised by unresolved conflicts (anxiety, guilt), memory decline and personality disorders.7 another impact we can see is how older adults feel about themcorrespondence: tri nurhidayati, department of nursing, fikkes universitas muhammadiyah semarang, jalan kedung mundu raya no. 18 semarang, indonesia. e-mail: tri.nurhidayati-2022@fkp.unair.ac.id key words: self-efficacy, older adults, depression. contributions: all authors discussed the results. first and second author responbility following: previous study and design and data collection. the others contributed the final manuscript. conflict of interest: the authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work funding: we thank the nurse program at the university of muhammadiyah semarang for the grant support in this study. availability of data and materials: the data of this study are available on request from corresponding author. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgments: we would like to thank all the collaborators who are currently working on this research. received: 25 july 2024. accepted: 25 july 2024. early access: 25 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12851 doi:10.4081/hls.2024.12851 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 650] [healthcare in low-resource settings 2024;12:12851] non -co mmerc ial us e o nly selves if depression is not handled properly because it can make older adults want to harm themselves or even end their lives. to prevent the effects of depression, older adults must have the confidence to overcome problems and dare to change from darkness to light.8 self-efficacy is a person’s belief that they can overcome problems by controlling events that affect their lives.9 people with high self-efficacy can identify their problems and solve them using their skills; they have beliefs that can influence their thoughts, feelings and actions.10 previous research has shown that there is a strong connection between self-efficacy and depression, where the direction of the relationship is negative and increasing self-efficacy increases an individual’s ability to view himself positively. someone with high self-efficacy can overcome depression. conversely, someone with low self-efficacy will give up on existing problems more efficiently. however, the reactions of older adults with depression differ significantly. some people can respond effectively, so they can quickly reduce depression, but males find it challenging to reduce depression and prevent it from affecting their health. differences in the ability to reduce depression are closely related to the level of self-efficacy. older adults with depression tend to have low selfefficacy. that is, they give up more easily, while older adults who are not depressed have high self-efficacy and tend to be more resilient in dealing with problems. based on the explanation above, the significance of self-efficacy in the prevention and management of depression among older adults highlights the need for interventions aimed at bolstering self-efficacy and coping mechanisms to enhance mental wellbeing in this demographic group. self-efficacy can also increase an individual’s ability to assess themselves in order to achieve the desired effect, namely, in overcoming depression. to explore more details about self-efficacy in older people with depression, researchers are interested in conducting this research using qualitative methods, which is a different research method from previous research. materials and methods design this study is qualitative research using phenomenological methods and involves a detailed and iterative process for selecting areas to address in interviews and crafting the final list of questions. phenomenology seeks to understand and describe the lived experiences of individuals, focusing on their subjective perceptions and interpretations of phenomena. participants and setting the participants were older adults with at least moderate depression, the ability to communicate well and cooperatively, living in nursing homes and having the willingness to be respondents. depression was measured using the dass questionnaire.11 the exclusion criteria were older adults who refused participation, had hearing and speech impairments, were sick, had chronic illnesses and were under special care. this research was conducted at the pucang gading older adults social service house in semarang. ethical considerations this study was already granted ethical clearance from the faculty of nursing and health sciences, university of muhammadiyah semarang, number 0188/kepk/vii/2023. the participants were explained what the study included and joined voluntarily; their identities were not disclosed in the research reports. data collection data were collected using interviews with structured guidelines. data analysis in-depth interviews were conducted using an indonesian version of the general self-efficacy scale (gses).12 the questions were used as a guide and further explored key topics discussed by the respondents. each interview with respondents lasted between 35 and 45 minutes. the collected data were then analysed using manual interpretive phenomenological analysis (ipa). data collection was carried out by the first author as a head researcher and research members 1 and 2. data processing and data analysis were carried out by the lead researcher and research members 1 and 2. trustworthiness to ensure the trustworthiness of the data, the researcher used four criteria – credibility, confirmability, dependability, and transferability. the credibility of the data was confirmed through peer checks. the research team members independently analysed the interviews and compared the concepts, categories, and themes to confirm the findings of the second and third authors and caregivers. the research stages and processes were recorded and reported step by step to warrant the dependability of the conclusions. finally, data transferability was ensured through deep descriptions of the context. in this study, the researchers used source triangulation, in which data credibility was tested by verifying the information obtained from several sources. these caregivers were at the pucang gading older adults social service home in semarang. results fourteen respondents, four female and ten males, were used for this study. furthermore, they were aged 65–86 years old. two respondents had a senior high school education, three respondents had an education up until junior high school, and the others had an elementary school education, as shown in table 1. the transcription verbatim was analysed, and 10 sub-themes were used for four different themes, as shown in table 2. based on the study’s results, the respondents’ characteristics showed that most were in the older adults category – female, elementary school education, and muslim. theme 1. performance accomplishments the elderly make efforts to solve problems by praying and remaining silent to solve problems; they choose to avoid thinking about problems too deeply. “just pray and pray.” (p3) “there’s no need to try anything, sis. it’s better to be quiet, even though you have lots of thoughts about sleeping well.” (p5) the participants also admitted that life when they were still married was the most memorable thing. respondents 3 and 4 stated the following: “when can i gather with my wife, family and talk together article [healthcare in low-resource settings 2024;12:12851] [page 651] non -co mmerc ial us e o nly again.” (p3) “yes, family, get together. if we celebrate eid al-fitr together, it’s delicious.” (p4) theme 2. vicarious experience all participants felt the difference between the past and the present, and the description of the difference also varied. all participants in this study claimed to have friends of varying numbers. however, all participants had more than one friend. there were differences in their relationships with their friends at the nursing home, where most older adults felt that they did not get along with their friends. the majority of the elderly people felt that they did not fit in with their friends, as stated by respondent 1: “i don’t feel right. my inner self doesn’t match at all because his behaviour doesn’t adhere to religion.” (p1) some elderly people did feel happy when they were with their friends, namely, respondent 3: “yes, i’m happy, but it depends on the chat.” (p3) theme 3. social persuasion according to the interview results, 10 of the 14 participants, before living in the nursing home, used to live with their families. this shows that there is an effect of persuasion from the family, which may still leave an impression on the participants, as stated by respondent 2: “yes, between children and family.” (p2) however, some elderly people also admitted that before living in an institution, they used to live alone or had no family to accompany them. so they did not have another choice to live in an nursing home. respondent 1 also said the following: “in the past, i also lived with my family. not long ago, i didn’t live anymore. i divorced my wife.” (p1) theme 4. physiological and emotional states all participants admitted that their families did not want to care for older adults. although the reasons are unknown, all older adults acknowledged that their families did not want to care for them anymore, so they sent them to a different home. respondents 4 and 6 admitted the following: “because no one takes care of it; no one wants to take care of it.” (p4) “because no one took care of me, my parents were gone, and my wife and children left me.” (p6) article table 1. distribution of respondents based on age, gender, religion and education 2023 (n = 14). no respondent's initials age (years) gender religion level of education 1 mm 86 male islam elementary school 2 js 75 male christianity elementary school 3 m 61 male christianity senior high school 4 q 71 male christianity senior high school 5 s 69 male islam elementary school 6 mb 65 male christianity junior high school 7 na 70 female islam elementary school 8 se¬ 65 female islam junior high school 9 n 76 male islam junior high school 10 r 67 male islam elementary school 11 nn 78 female islam elementary school 12 j 80 female islam elementary school 13 ca 68 male islam elementary school 14 w 65 male islam elementary school table 2. themes and sub-themes. themes sub-themes performance accomplishments active and responsible learning from the past vicarious experience relationships with fellow seniors daily activities social persuasion residence physical state physiological and emotional states relationship with family family abandonment older adults’ feelings positive outlook and religion active and responsible [page 652] [healthcare in low-resource settings 2024;12:12851] non -co mmerc ial us e o nly the reason was validated by the caretaker of the nursing home room, who said that there were indeed older male adults in the nursing home who were placed in the care of their families. the families admitted that they were unable or unwilling to care for these older adults in their respective homes. almost all older adults admit that they feel neglected by their families. however, one older adult did not answer the question of whether he felt neglected by his family. this is shown by snippets of conversation between respondents 3 and 4, namely, the following: “yes, actually, yes, sis, it’s not quite enough, miscommunication. there’s no one to contact. it’s difficult for me to contact you.” (p3) “yes, miss, i feel neglected.” (p4) male older adults felt sad and resigned from leaving the nursing home. they feel sad, either remembering the past, uncomfortable or free and unable to do anything. as stated by respondent 8, he feels resigned to having lived in a nursing home for many years. “...i gave up, but it made me feel at home here...” (p8) even respondent 1 admitted that he wanted to get out of the nursing home but could only give up because there wasn’t much he could do alone. “if i can get out, i want to get out, and it’s as if later, if i go outside, what business do i want to do? the problem is that if you try, it’s possible that if allah blesses you, you can. here, i surrender the deck. this is how the cake is. eat here is what it is.” (p1) the nursing home ’s caretaker confirmed that these older adults feel hopeless, resigned, and often look sad. the nursing home ’s caretaker said that older adults had residual sadness from past failures when they were young. however, they grew much more sincere and can accept or surrender to the situation. almost all participants admitted to feeling pessimistic and doubtful about maintaining and achieving their current life goals. this illustrates that self-efficacy is still poor. “if it’s not here at all, i’m like a paralysed pessimist. i’m here. just die or live.” “not here at all, miss. not receiving satisfaction at all, hopeless, pessimistic, negative thoughts all the time.” (p8) however, one participant said that he felt he could maintain and achieve his current life goals. “i’m sure it is. i can ask allah to make it easier. if you are blessed, you can achieve it. my efforts are praying, praying, praying, dhikr, dhikr and dhikr.” (p10) this was reinforced by the statement by the caretaker of the nursing home that male older adults in the nursing home felt resigned and pessimistic about achieving their goals in life. discussion the attitudes of older adults in dealing with problems in this study varied. some felt sad and anxious. some were sincere in facing problems. older adults tend to have worse cognitive functions than younger adults. even older adults without neurodegenerative diseases or cognitive disorders tend to make bad decisions. this was due to decreased brain function in the frontal lobe.13-15 impaired cognitive function and worsening decisions could affect the attitudes of older adults in dealing with problems. in this study, feelings of sadness and anxiety can also be affected by depression experienced by older adults. according to previous research, feelings of fear, anxiety or sadness often appear in someone who is diagnosed with depression.16 so this is in line with the results of the study. in older adults with depression, there were symptoms of anxiety and sadness. in dealing with problems, the older adults in this study had various ways, including praying and staying silent. at the same time, praying is said to be an intervention for solving spiritual problems. praying can improve a person’s condition from a psychological perspective and improve how they control their emotions. thus, praying can help older adults deal with the problems that occur to them because it has a psychological impact, especially on older adults in this study experiencing depressive disorders. moreover, silent treatment, which is an attempt to avoid verbal communication and ignore other people, can take a toll on the person being refused communication, which can cause social pain that even activates the part of the brain that regulates physical pain. however, for someone who does engage in silent treatment, there is still a lack of data to show whether this is beneficial or detrimental from a psychological perspective.16 some older adults in the pucang gading semarang home care feel that there has been no significant change since living in the nursing home. however, some feel a change, even though they feel uncomfortable living in the nursing home. some older adults residing in nursing homes feel underappreciated and disempowered, resulting in feelings of alienation and increased powerlessness. they also felt limited in their activities and contact with family or friends. this perception of older adults can also affect their quality of life. in this study, the quality of life of older adults was disturbed because they felt less empowered and had limited activities and contact with family and friends.17 in addition, in this study, it was found that there were several conflicts in this nursing home, including incompatibility with fellow friends in the nursing home; relationships with fellow residents are associated with perceptions of social support.18 this means that good co-resident relations will increase the perception of social support for someone. in this study, older male adults did not have good relationships with fellow residents, which raised the risk of poor social support for those living in the pucang gading home care in semarang. older adults or the elderly are people over 60 years old. some changes occur in older adults, both physically, mentally, and socially. physical changes that occur include decreased physical strength, stamina, and appearance. this can cause some older adults to become sad, unhappy and depressed when they enter old age. older adults also become ineffective in their daily work and social roles due to their energy or physical limitations.19 in addition, older adults also feel tired when they become older adults in an older adult home. fatigue is a feeling of discomfort, weakness, extreme tiredness, and loss of control. fatigue is also associated with decreased mobility, cognitive function, and the risk of hospitalization.20 one of the respondents felt fatigued, and he needed a walker. this can have an impact on the physical health experienced by older adults. most older adults feel resigned to living in a nursing home, even though they feel uncomfortable. in this study, older adults lived in this nursing home because their families placed them there article [healthcare in low-resource settings 2024;12:12851] [page 653] non -co mmerc ial us e o nly or there was no family to care for them. some of the older adults in this study felt uncomfortable living in the pucang gading older adults’ social service home, semarang. older adults who live at home with their families have better psychological conditions compared to those who live in aged care homes.21 similar to the results of previous research, older adults can feel resigned because they can no longer work optimally in aged care homes.11 the feeling of surrender or hopelessness in older adults is a form of negative emotion that often occurs due to aging. it is faced negatively, such as not doing daily activities and avoiding social relationships with those around them. a sense of resignation is one of the causes of mental health problems, especially depression and suicidal ideation. older adults face male mental problems, as in this study, where some older adults have family problems. the family plays a vital role in improving the quality of life of older adults. the family is part of the closest core community that can pay attention to and hear the complaints of older adults directly.24 if older adults have problems with the family, communication automatically becomes poor, and older adults do not have a place to complain or tell stories. no one pays any attention, either. when older adults are placed in a nursing home, many things happen or are felt by older adults. in this study, some older adults did not accept being placed in the nursing home, so they fought and felt uncomfortable living there. as a place of care for older adults, providing good (clinical) care and a home-like environment is a big challenge for older adults’ social service homes. suppose the nursing home provides a sense of home or a feeling of being at home. in that case, older adults will feel at home and comfortable living at an older adults’ social service home and can carry out their daily activities with more enthusiasm. according to the study results, most respondents felt resigned from being placed in this social institution for older adults. older adult neglect is the most common type of abuse or mistreatment. in a systematic review of the prevalence of older adult maltreatment, researchers concluded that around 20% of all dependent older adults suffer from neglect.22 neglect by the family causes older adults to experience feelings of loneliness. there is a correlation between a high loneliness score and the risk of mistreatment or abuse in older adults. loneliness is a complex concept involving both psychological and social aspects. this also aligns with the research results, where all older adults feel lonely living in the pucang gading home care and feel like they do not have friends. loneliness can affect physical health, sleep quality, and mental health and can cause a risk of cardiovascular disease.22 self-efficacy is an individual’s belief in their ability to perform the tasks entrusted to them. the higher the self-efficacy, the higher the confidence in an individual’s ability to achieve success. in difficult situations, people with low self-efficacy will quickly reduce their efforts or give up.23 in this study, some older adults feel pessimistic about achieving life goals, but some remain optimistic, trying and praying to maintain and achieve life goals. older adults with lower self-efficacy tend to limit themselves to daily life activities. those with higher self-efficacy are more proactive in seeking health information, in self-care behaviour and in complying more with the treatment.24 self-efficacy can have a two-way relationship with depressive symptoms based on hammen’s theory of stress generation of depression and bandura’s sociocognitive theory, where people who experience depressive symptoms generate more interpersonal stressors than healthy people.26 people feel they cannot deal with and solve interpersonal problems when faced with interpersonal stressors. in other words, people who have lower levels of emotional and social self-efficacy can lead to increased depressive symptoms.17,27 in this study, older adults tended to have low self-efficacy due to their perceived pessimism about achieving life goals. this can be caused by the depressive condition experienced by older adults and can also exacerbate depression. the researchers acknowledged that their study had certain limitations. one of the limitations is the presence of biased factors that may have influenced the self-efficacy of elderly people who suffer from depression, which were not taken into account during the study. additionally, there may be some degree of subjectivity in interpreting the research results obtained through interviews with respondents. to minimise this, the researchers carried out source triangulation by cross-checking the data with facts obtained from informants and other research studies. the self-efficacy of older adults with depression at the pucang gading older adults social service home in semarang was described through 4 themes – performance accomplishment, vicarious learning, verbal encouragement, and emotional states. older adults who have low efficacy fail to achieve life goals and exacerbate depression. therefore, nurses can play a role in helping adults achieve success and fulfilment in different areas of their lives. this could include assisting them in setting goals, offering support and motivation and recognizing and commemorating their accomplishments. references 1. maryam s. the relationship between self efficay and interest of enterpreneurs among family welfare education students. psikoislamedia jurnal psikologi 2022;07:1109-18. 2. badan pusat statistik. statistik penduduk lanjut usia 2021 [internet]. jakarta: badan pusat statistik; 2021. 3. ministry of health of republic of indonesia. riset kesehatan dasar tahun 2018. jakarta: ministry of health of republic of indonesia; 2018. 4. kartika e. hubungan dukungan teman sebaya terhadap tingkat depresi pada lansia di rumah pelayanan sosial lanjut usia pucang gading semarang. [bachelor’s thesis]. semarang: poltekkes kemenkes semarang; 2021. 5. damayanti s, amirus k, perdana aa. faktor-faktor yang berhubungan dengan status gizi pada usia lanjut di wilayah kerja puskesmas bukoposo kabupaten mesuji. jurnal medika malahayati 2019;7:1131-7. 6. pae k, wattimena i, susanti nl, rozeline ea. tindakan kebersihan diri dan kualitas hidup lansia yang tinggal di panti. jurnal ners lentera 2022;10:68–74. 7. yani linda, febiansyah a. effect of granting life review therapy to depression level on lansia in panti werdha mojopahit mojokerto. j nursing care biomoleculer 2018;3:52–7. 8. zenebe y, akele b, w/selassie m, necho m. prevalence and determinants of depression among old age: a systematic review and meta-analysis. anna gen psychiatry 2021;20:55. 9. yaqin a. membentuk karakter melalui pendidikan afeksi. yogyakarta: media akademi; 2019. 69–70 p. 10. setiawati t. gambaran efikasi diri pada lanjut usia dengan demensia di panti sosial tresna wreda bandung. [bachelor’s thesis]. bandung: universitas pendidikan indonesia; 2018. 11. marsidi sr. identification of stress, anxiety, and depression levels of students in preparation for the exit exam competency test. j vocational health studies 2021;5:87. 12. novrianto r, marettih ake, wahyudi h. construct validity of article [page 654] [healthcare in low-resource settings 2024;12:12851] non -co mmerc ial us e o nly the indonesian version of the general self-efficacy scale instrument. jurnal psikologi 2019;15:1–9. 13. nguyen t, barefield a, nguyen gt. social determinants of health associated with the use of screenings for hypertension, hypercholesterolemia, and hyperglycemia among american adults. med sci (basel) 2021;9:19. 14. agarwal g, gaber j, richardson j, et al. pilot randomized controlled trial of a complex intervention for diabetes selfmanagement supported by volunteers, technology, and interprofessional primary health care teams. pilot feasibility stud 2019;5:118. 15. wu vx, dong y, tan pc, et al. development of a communitybased e-health program for older adults with chronic diseases: pilot pre-post study. jmir aging 2022;5:e33118. 16. choudhary n, brewis a, wutich a, udas pb. sub-optimal household water access is associated with greater risk of intimate partner violence against women: evidence from nepal. j water health 2020;18:579–94. 17. suwarni s, soemanto rb, sudiyanto a. effect of dementia, family support, peer support, type of residence, and marital status on quality of life of the elderly in surakarta, central java. j epidemiol public health 2018;3:83–94. 18. pitchalard k, moonpanane k, wimolphan p, et al. implementation and evaluation of the peer-training program for village health volunteers to improve chronic disease management among older adults in rural thailand. int j nurs sci 2022;9:328–33. 19. zhang m, liu y, zhang wy, et al. exploring perceived challenges of self-management in low-income older people with hypertension: a qualitative study. int j nurs pract 2022;28:e13059. 20. tabootwong w, kiwanuka f, vehvilainen-julkunen k, turunen h. factors associated with anxiety and depression among family caregivers of critically ill elderly patients: a systematic review. internat j caring sci 2022;15:87–102. 21. putri se, rekawati e, wati dnk. effectiveness of selfmanagement on adherence to self-care and on health status among elderly people with hypertension. j public health res 2021;10:jphr.2021.2406. 22. hochwald ih, arieli d, radomyslsky z, danon y, nissanholtz-gannot r. emotion work and feeling rules: coping strategies of family caregivers of people with end stage dementia in israel—a qualitative study. dementia 2022;21:1154–72. 23. kristjansdottir ob, vågan a, svavarsdóttir mh, et al. training interventions for healthcare providers offering group-based patient education. a scoping review. patient educ couns 2021;104:1030–48. 24. ihm sh, kim k il, lee kj, et al. interventions for adherence improvement in the primary prevention of cardiovascular diseases: expert consensus statement. korean circ j 2022;52:1–33. 25. septiani ma, amir y, nauli fa. pengalaman mahasiswa dalam menyelesaikan skripsi pada pandemi covid-19. jurnal kesehatan ilmiah indonesia 2022;7:205-15. 26. alloy b, liu rt, bender re. stress generation research in depression:a commentary. int j cogn ther 2012;23:380-8. 27. guillén v, fonseca-baeza s, fernández-felipe i, botella c, baños r, garcía-palacios a, marco jh. effectiveness of family connections intervention for family members of persons with personality disorders in two different formats: online vs face-to-face. internet interv 2022;28:100532. article [healthcare in low-resource settings 2024;12:12851] [page 655] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11798 the role of family healthcare in the social development of vulnerable school-aged children groups hilda mazarina devi, ronasari mahaji putri, yanti rosdiana faculty of health science, universitas tribhuwana tunggadewi, malang, indonesia abstract the covid-19 pandemic has compelled children to embrace remote learning and interact more with their immediate families. however, this increased family interaction may pose a potential risk to children’s social development. this study aimed to investigates the relationship between family involvement in healthcare and the social development of children. a cross-sectional correlational design was used, involving reliable questionnaires on family healthcare roles and a school-age child social development questionnaire adapted from the v-sms (vineland – social maturity scale). data were collected from 37 parents of 4th and 5th-grade of elementary school students. the data were analyzed using chi-square tests. the study revealed significant associations between family healthcare roles and children’s self-direction ability, decision-making, communication skills, and their abilities to dress, eat, and socialize independently. negative correlation coefficients for specific variables indicated that family healthcare involvement could potentially hinder school-age children’s social development. further research should consider controlling for various factors affecting family healthcare roles and children’s social development. strengthening the family’s role, particularly for those facing challenges in fulfilling various tasks, is crucial. collaboration programs between nursing and family development, such as “bina keluarga remaja” or adolescent family development in schools, can be beneficial. additionally, further analysis is needed to understand the impact of family healthcare roles on children’s social development during the new-normal era. introduction family is the basic unit in society that can cause, prevent, improve, and influence the health of its members.1 families play an essential role in meeting the care needs of individuals who require assistance due to illness and/or disability.2,3 however, without adequate support, family health and wellbeing can be compromised. as the number of individuals facing chronic illnesses continues to rise worldwide, including the ongoing covid-19 pandemic, there is a pressing need to recognize the significant caregiving contributions made by family members.4,5 according to the united nations educational, scientific, and cultural organization’s (unesco) covid-19 global monitoring of school closures, as of june 2021, around 50% of students worldwide were affected by partial or full school closures, impacting nearly 200 million pupils.6 as of december 31, 2021, the number of household heads in indonesia was 87.83 million people, according to data from the ministry of home affairs. the total population of east java in 2021 was approximately 40.16 million people.7 until june 2022, east java province ranked second among java’s provinces with the highest number of household correspondence: hilda mazarina devi, faculty of health science, universitas tribhuwana tunggadewi, malang, indonesia. e-mail: hilda.mazarina@unitri.ac.id key words: children; family; healthcare; role; social development. contributions: hm conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rm conceptualization, investigation, methodology, validation, resource, investigation and writing – original draft, review & editing; yr formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission based on ethical certificate no. 335/ec/kepk-s2/09/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. participant consent for publication: online informed consent was obtained for anonymized participant (parents) information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to headmaster and teachers of sdn landungsari 01 kabupaten malang for their valuable insights and contributions to this study. received: 13 september 2023. accepted: 6 november 2023. early access: 23 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11798 doi:10.4081/hls.2023.11798 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11798] [page 185] non -co mmerc ial us e o nly heads, reaching 14.09 million families with a population density of 857 people per square kilometer. data from the malang regency social service, collected in 2019-2020, revealed that there were more than 250,000 families categorized into underprivileged, prosperous, and well-off groups.8,9 to combat covid-19, the indonesian government enforced large-scale social restrictions (pembatasan sosial berskala besar or “psbb”) starting in june 2020. the need to enhance the quality of life and family health became critical during these restrictions.10,11 in terms of healthcare provision and services, patients, families, and communities are active partners in scientific research, collaborators in shared decision-making for care and related matters, and advocates for the health priorities pertinent to their communities. they are not mere passive recipients.12 family healthcare involves identifying health issues in the family, taking appropriate actions, providing care, promoting a healthy environment, using healthcare services, eating well and getting enough sleep, engaging in recreational activities, taking prescribed medications, addressing alcohol and tobacco use, and practicing self-care together as a family.11,13 during pandemics, over 80% of participants found it somewhat helpful to care for their family, including children. covid-19 disruptions affected child and family health and access to healthcare.14 in the case of school-aged children, a study by putri (2020) revealed that parents were required to assume the role of educators, serving as role models and motivating children to excel academically.15 parents had to take on the role of educators and motivators for school-aged children, as education shifted to homes.16 however, the connection between family healthcare functions and school-aged children’s development during pandemics remains underexplored. the enforced social isolation, along with associated lifestyle changes, presented significant challenges for families, particularly those with school-age children.17,18 with school closures, working parents were compelled to care for their children throughout the day without regular support systems, such as day-care facilities or grandparents. parents who attempted to work from home found it exceedingly challenging to balance their professional responsibilities with childcare and domestic work, resulting in decreased productivity.19,20 these challenges led to poor dietary choices, limited physical activity, and increased obesity risk for children. parents working outside the home as essential workers faced a difficult balance between their professional responsibilities and the needs of their isolated children. indonesian parents, particularly dualearner families with young children, faced added strain due to their dual roles as workers and caregivers.21,22 children between the ages of 6 and 12 years typically begin to value friendships and become more involved in activities like sports and art. however, the health and social inequalities observed during the pandemic have the potential to restrict their social development.23 school-age children have various independent social developmental tasks to fulfill. additionally, as per the vineland social maturity scale, developmental tasks encompass self-help skills in general, dressing, eating, self-direction, socialization, occupational skills, communication, and locomotion.24,25 during the pandemic, these developmental tasks were jeopardized due to increased sedentary behavior. a 2020 study with 656 primary caregivers in canada found that poor parenting quality during the pandemic was linked to various household and pandemic-related factors, with caregiver depression consistently affecting the parent-child relationship.26 given this context, the objective of this study was to explore the relationship between family roles in healthcare provision and the social development of children. we hypothesize that there is a significant relationship between these variables, especially in the unique context of the covid-19 pandemic, which has brought forth unprecedented challenges to family dynamics and child development. materials and methods research design this study employed a correlational research design with a cross-sectional approach, aimed at analyzing the correlation between the family’s role in healthcare provision and the social development of children. the research investigates how family roles, such as recognizing health problems, making appropriate decisions, providing care, utilizing healthcare facilities, modifying the environment, and engaging in recreational activities, influence the development of various skills in children, including dressing and eating independently, self-direction, self-socialization, selfhelp in general, communication, and locomotion. study participants the study involved a total of 37 parents of grade 4-5 elementary school students. participants were selected through convenience sampling based on specific inclusion criteria: they had to be parents of children aged 10-11 years in grades 4-5, complete the entire questionnaire, and be proficient in using a mobile phone. ethical considerations were observed, and the necessary permissions were obtained from the school and homeroom teacher. due to social restrictions, the study’s explanation, informed consent, and the google form questionnaire were distributed exclusively within a social media group of parents (whatsapp). to minimize potential biases related to sampling, non-responses, or response bias, the researcher collaborated with the homeroom teacher and remained active in the parents’ online group throughout the study. the researcher ensured the use of neutral and non-leading questions, allowed for participant anonymity, and refrained from using any brand identification. the study was conducted at landungsari 01 elementary school, landungsari village, malang regency in december 2021. variable, instrument and data collection demographic factors, including age, gender, education, occupation, and income, were considered as confounding variables. the independent variables included nine sub-criteria, focusing on various aspects of the family’s role in healthcare provision. these criteria encompass recognizing family health problems, making informed decisions, utilizing healthcare facilities, modifying the environment, and managing family practices related to diet, sleep hygiene, recreation, therapeutic approaches, and substance use (alcohol and cigarettes). the questionnaire used in this study was developed by ayuningtyas (2021).27 the instrument employed a 4point likert scale, where strongly agree = 4, agree = 3, disagree = 2, and strongly disagree = 1. the dependent variable was the social development of schoolage children, which included seven sub-criteria encompassing selfhelp in dressing and eating, self-direction, socialization, self-help in general, communication, and locomotion skills. the questionnaire for assessing school-age child social development was adapted from the vineland social maturity scale (v-sms) developed by doll (1936),24 a commonly used tool for assessing the social development of school-aged children.25 a likert scale was used, with response options ranging from never performed = 1, rarely = 2, to always = 3. the reliability of this questionnaire was verified [page 186] [healthcare in low-resource settings 2023; 11:11798] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly through cronbach’s alpha (𝛼), yielding a score of 0.92 (𝛼 ≥ 0.70), and the coefficient correlation score was 0.85 (𝛼 > r table).28 data analysis the analysis conducted in this study includes descriptive analysis and a chi-square test. the chi-square (χ2) test was utilized to assess the association between variables, although it does not provide information regarding the strength of the association or whether the relationship is causal.29 both variables in this study are categorical, mutually exclusive, and meet the expected values. ethical clearance this research received ethical approval from the health research ethics commission under ethical certificate no. 335/ec/kepk-s2/09/2021. throughout the research process, the researcher adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. results based on the demographic information presented in table 1, the average age of fathers and mothers fell within the range of 37 to 38 years old. the majority of fathers had completed senior high school, undergraduate degrees, or held a magister/ph.d. level of education (n=28, 75.7%). similarly, most mothers had educational backgrounds ranging from senior high school to undergraduate degrees and magister/ph.d. levels (n=31, 83.7%). in terms of parental occupation, 45.9% of fathers worked as private employees (n=17), regarding the occupation of mothers, approximately 40.5% engaged in domestic work at home (n=15). table 2, which provides information on the distribution of family roles in healthcare provision, reveals that the majority of participants fulfilled their tasks at a rate of 83.8% to 100%. notably, all parents successfully performed environmental modification or protection tasks for their family members, including school-age children. no participant failed in this aspect. only 6 participants (16.2%) did not perform sleep hygiene practices for their family members. in table 3, which outlines the distribution of schoolaged children’s social development tasks, we observe that about 89.2% of the participants (n=33) were able to successfully perform self-help in dressing. for self-help in eating, 70.3% (n=26) of participants were proficient, 81.1% (n=30) of children performed self-direction successfully, and 83.8% (n=31) effectively developed self-socialization, even when adhering to social restriction rules. however, 75.6% (n=28) exhibited less development in self-help in general, and 78.4% (n=24) showed commendable development in communication and locomotion. the results of the correlational analysis, as displayed in table 4, reveal significant associations between various variables. notably, the family’s ability to recognize health problems showed a negative and significant correlation with the self-direction development task among school-aged children (r = -.49**; p < .01). this suggests that when families perform poorly in recognizing health problems, school-aged children tend to exhibit higher levels of self-direction. these findings suggest that children have the potential to become self-directed learners, engaging deeply in their own learning processes to fulfill their needs.30,31 however, by performing study at home or homeschooling due to pandemics the parents should developed more ideas in equipping, encouraging, enabling, and empowering especially to educate their own children also not merely in recognizing the family health problem. the parents were still obligated to give a direction to the school-age children in a properly and not intimidating. discussion the research results have indicated significant associations between independent and dependent variables. notably, the role of making the right decisions exhibited a significant negative association with the development of communication among school-aged children. in other words, when families perform poorly in making the right decisions, their children tend to develop stronger communication skills. in situations where families fail to make the right [healthcare in low-resource settings 2023; 11:11798] [page 187] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of participant (n=37). no variables m (sd) / f % 1 age father 38.24 (11.25) mother 37.16 (5.23) 2 father educational history elementary, junior high school 9 24.3 senior high, undergraduate, magister/ph.d 28 75.7 3 mother educational history elementary, junior high school 6 16.3 senior high, undergraduate, magister/ph.d 31 83.7 4 father occupation private employee 17 46.0 enterpreneur 12 32.4 other 8 21.6 5 mother occupation private employee 3 8.1 enterpreneur 9 24.3 domestic work 15 40.5 other 10 27.1 m, mean; sd, standard deviation; f, frequency. non -co mmerc ial us e o nly [page 188] [healthcare in low-resource settings 2023; 11:11798] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. distribution of family role in healthcare provision (n=37). no variables frequency % 1 recognize the health problems failed 2 5.4 pass 35 94.6 2 making right decision failed 3 8.1 pass 34 91.9 3 family care failed 1 2.7 pass 36 97.3 4 environmental protection/modification pass 37 100.0 5 utilization of health-care facilities failed 2 5.4 pass 35 94.6 6 diet practice failed 1 2.7 pass 36 97.3 7 sleep hygiene practice failed 6 16.2 pass 31 83.8 8 recreational practice failed 1 2.7 pass 36 97.3 9 therapeutic, alcohol and ciggarette practice failed 2 5.4 pass 35 94.6 total 37 100 table 3. distribution of school-aged chidren social developmental task (n=37). no variables frequency % 1 self help dressing well 33 89.2 less 4 10.8 2 self help eating well 11 29.7 less 26 70.3 3 self direction well 30 81.1 less 7 18.9 4 self socialization well 31 83.8 fair 6 16.2 5 self help general well 9 24.3 fair 13 35.1 less 15 40.6 6 communication well 29 78.4 fair 6 16.2 less 2 5.4 7 locomotion well 29 78.4 less 8 21.6 total 37 100.0 non -co mmerc ial us e o nly decisions, children may enhance their communication skills, thereby developing critical thinking and critiquing their parents’ roles. this finding underscores the significance of making the right decisions within families, as it serves as a protective factor against juvenile delinquency.32 communication skills can be enhanced through play and exploration in young children. these methods aim to foster affective and experiential connections with nature in young children, helping them establish bonds with the natural world. this foundation may encourage them to explore issues and take appropriate action as they mature.33 every interaction between parents and children constitutes a form of communication that not only teaches children how to interact with others but also shapes their emotional development and how they build relationships later in life. effective communication skills can be developed by actively and reflectively listening, speaking clearly with children, avoiding the use of bribes to encourage better behavior, assisting them in reflecting on or explaining their feelings, and setting an example of kindness. these strategies can help develop children’s communication skills, even when parents fail to make the right decisions.34 regarding the utilization of healthcare facilities as a family role, it exhibited a negative correlation with self-help dressing and self-help socialization. in contrast, with regard to self-help eating, this task displayed a positive correlation. the utilization of healthcare facilities represents one of the family’s roles in maintaining the health and high productivity of its members. this function goes beyond the basic responsibility of maintaining the health status of family members.27 a study conducted by kaka, putri, and devi (2022) explained that family health care functions influence the nutritional status of children.35 the results of this study suggest that families with poor health care functions have a 3.727 times higher risk of having children with poor and deficient nutritional status compared to families with good health care functions. parental modeling is also key to making healthy food choices within families.36 the role of healthcare is crucial in family assessment as the family serves as the fundamental unit in society, regulating behavior, implementing healthcare, and ensuring its protection. families engage in preventive healthcare and jointly care for sick family members. integrating the family into the healthcare team offers multiple benefits and can reduce barriers to healthcare utilization.37 encouraging families to establish and maintain connections with healthcare facilities is recommended for post-pandemic recovery planning. schools should also reopen access to various family assistance and health programs that were hindered during social restrictions to promote social development and independence among children. family dietary practices involve dietary arrangements aimed at preventing overweight and underweight, which can lead to various diseases.38 poor family dietary habits can lead to obesity, which is linked to health issues like high blood pressure, heart disease, cancer, and more. assessing food choices should involve collaboration between families and caregivers.39 fewer healthy dietary practices can negatively affect children’s self-help skills and socialization.40,41 sharing meals as a family promotes relational closeness and has various benefits, including emotional regulation, positive parenting, and conflict prevention according to glazen’s review study.42 cross-sectional studies linking overall family functioning and the frequency of family mealtimes have generally found positive connections.38 in a study on engaging in active leisure, families with an adequate level of physical activity exhibited higher scores in happiness, contentment, well-being, and quality of life.43,44 family exercise and recreational practices represent the family’s ability to engage in physical activities to enhance general health through increased range of motion, which can help reduce body fat and the risk of disease.37 adults and family members are encouraged to engage in mostly moderate physical activity for at least 30 minutes a day to maintain their health status. regarding self-direction, a study involving 1,425 students enrolled in hong kong primary levels 1 to 6 showed that self-directed leisure activities during homework-free holidays increase students’ confidence, intention, and ability to think freely. this approach is known to improve academic competence and create positive perceptions of fulfilling school tasks.45 the role of family healthcare provision should be supported by nursing professionals to help families understand parental role construction, provide guidance and support for implementing physical healthcare, promote safe environments, apply theories, principles, and parenting and child programs, develop therapeutic relationships, manage parenting and childcare, promote access to support networks, guide parental figures through the course of life, and use scientific evidence to guide healthcare practices.46 in indonesia, such programs exist, such as bina keluarga remaja (bkr) or adolescent family development. bkr is an organization comprising families with teenagers aged 10 to 24 years, established with the aim of enhancing the knowledge and skills of parents and other family members to nurture and guide adolescent development. through the empowerment of bkr cadre and family transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 4. correlational analysis. variables m (sd) shd she sdir ssoc shg comm loc (1) (2) (3) (4) (5) (6) (7) 1 recognize the health problems 0.08 -0.15 -0.49** 0.10 0.14 0.12 -0.16 2 making right decision 0.10 0.02 -0.10 0.13 0.06 -0.57** 0.15 3 family care 0.06 -0.10 0.08 0.07 -0.09 0.08 0.08 4 environmental protection/modification -0.08 0.03 0.02 -0.20 0.09 -0.30 0.23 5 utilization of health-care facilities -0.69** 0.37* -0.190 -0.54** -0.13 -0.16 -0.16 6 diet practice -0.48** 0.25 -0.34* -0.37* -0.09 -0.31 -0.31 7 sleep hygiene practice -0.08 0.03 0.02 -0.20 0.09 -0.30 0.23 8 recreational practice 0.058 -0.108 -0.34* 0.07 0.29 0.08 0.08 9 therapeutic, alcohol and ciggarette practice 0.08 -0.15 -0.19 0.10 0.14 -0.16 0.12 *significance at p<0.05; **significance at p<0.01. shd, self help dressing; she, self help eating; sdir, self direction; soc, socialization; shg, self help general; comm, communication; loc, locomotion. [healthcare in low-resource settings 2023; 11:11798] [page 189] non -co mmerc ial us e o nly health nurses, bkr helps parents and family members fulfill their roles in nurturing and guiding adolescents.47 however, during social restrictions, programs like these were curtailed, limiting the ability of nurses to reach schools and implement support programs. reactivating such collaborative programs is recommended to strengthen the family role in the new normal era. a limitation of this study is the relatively small number of participants, which may reduce the generalizability of the results. it is advisable to include more participants and conduct research at multiple centers to increase the effect size. conclusions the role of the family in healthcare provision significantly impacts various social development tasks among school-age children, particularly during a pandemic when children have more interactions with their immediate family members. strengthening the family’s function can be achieved through collaborations between nursing professionals and family development programs, such as “bina keluarga remaja” or adolescent family development in schools. collaboration and a holistic approach are key to fostering a healthier and more socially developed generation. additionally, it is advisable to conduct further analyses to explore differences in the family’s role in healthcare and its influence on children’s social development in the new normal era. references 1. ashidiqie mlii. peran keluarga dalam mencegah coronavirus disease 2019. salam j sos dan budaya syar-i 2020;7:911–22. 2. berliana sm, augustia aw, rachmawati pd, et al. factors associated with child neglect in indonesia: findings from national socio-economic survey. child youth serv rev 2019;106. 3. luthfa i, aspihan m, lathif mr. the relationship between family support and quality of life improvement of patients with diabetes mellitus in semarang. j ners 2019;14:327–30. 4. setyoadi, yusuf a, kristianingrum nd, et al. the correlation between family support and health status in patients with diabetes mellitus. healthc low-resource settings. 2023;11: 11212. 5. kurniawati nd, wahyuni ed, toulasik ya. family support improves hypertensive patient drug compliance. indian j public heal res dev 2019;10:2660–5. 6. unesco. global monitoring of school closures caused by the covid-19 pandemic. unesco institute for statistics. 2021 [cited 2022 jun 18]. available from: https://covid19. uis.unesco.org/global-monitoring-school-closures-covid19/ 7. kemendagri. dukcapil kemendagri rilis data penduduk semester i tahun 2022, naik 0,54% dalam waktu 6 bulan. 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2017. p. 89–98. 31. morris th, rohs m. the potential for digital technology to support self-directed learning in formal education of children: a scoping review. interact learn environ 2023;31:1974–87. 32. king ka, vidourek ra. enhancing parent-child communication about drug use: strategies for professionals working with parents and guardians. vol. 18, the prevention researcher. 2011 oct. available from: link.gale.com/apps/doc/a254755148/aone?u=anon~fc5994 ee&sid=googlescholar&xid=be382a78 33. simmons d. environmental education materials: guidelines for excellence. 2nd ed. the north american association for environmental education (naaee), editor. eric; 2021. 34. smythe t, almasri na, moreno angarita m, berman bd, kraus de camargo o, hadders-algra m, et al. the role of parenting interventions in optimizing school readiness for children with disabilities in low and middle income settings. front pediatr 2022;10:1072. 35. kaka d, putri rm, devi hm. hubungan pengetahuan gizi dengan perilaku penyediaan jenis sayur dan buah keluarga selama pandemi covid-19 pada kelompok ibu rumah tangga di rw 05, kelurahan tlogomas, kecamatan lowokwaru, kota malang. fakultas ilmu kesehatan, universitas tribhuwana tunggadewi; 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[healthcare in low-resource settings 2023; 11:11798] [page 191] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11779 the development of transformational leadership model based on caring as an effort to increase nursing performance fitriyanti patarrù,1 sena wahyu purwanza2 1bachelor of nursing, sekolah tinggi ilmu kesehatan stella maris, makassar; 2bachelor of nursing science, sekolah tinggi ilmu kesehatan maharani malang, malang, indonesia abstract leadership plays a crucial role in formulating strategies to achieve an organization’s mission, vision, and goals. it occupies a significant position in broader initiatives aimed at enhancing nurse performance. implementing an unsuitable leadership style, as dictated by leaders to their employees, can adversely affect employee motivation, performance, and job satisfaction. the study aimed to develop a transformational leadership model based on the principle of caring to improve nurse performance. this study employed an explanatory design and involved 115 respondents selected through cluster sampling techniques. data were collected using questionnaires that had undergone both validity and reliability testing. the study examined variables such as personal factors, organizational factors, staff factors, work factors, transformational and caring leadership, and nurse performance. for data analysis, partial least squares were utilized with a significance threshold set at t>1.96. the research findings indicate that personal factors exert a positive influence on both transformational leadership and caring (t=5.677). organizational factors also positively impact transformational leadership and caring (t=4.474), and staff factors exhibit a positive influence on these leadership styles as well (t=4.157). however, work factors do not directly impact transformational leadership and caring (t=0.554). notably, both transformational and caring leadership styles positively affect nurse performance (t=7.755). the development of a transformational leadership model based on caring is influenced by multiple factors, including personal, organizational, and staff factors. implementing this leadership model can significantly improve nurses’ performance, thereby leading to enhancements in the quality of health services provided in hospitals. introduction employee performance in an organization is closely tied to the expectations and demands placed on them to fulfill their responsibilities and achieve the organization’s goals.1,2 the issue of nursing performance is influenced by various factors, including leadership.3 leadership is one of the important factors that play a key role in determining strategies to achieve an organization’s mission, vision, and objectives.4,5 nursing services are an integral component of health service performance. nurses, as service providers, are at the forefront and play a pivotal role in shaping a hospital’s reputation. the image of a healthcare facility is often evaluated by patients based on their perception of the quality of nursing health services they receive during their hospital stay.6–8 the ideal performance standard value that hospitals should achieve is typically set at 70-80%. however, many hospitals still struggle to meet this percentage of performance standards.9 data from the world health organization (who) for southeast asia indicates that approximately 35% of healthcare service users express satisfaction with the services provided, while about 55% express dissatisfaction.10 the research obtained the results of the performance of nurses in sudan hospital is 32%.11 research at south africa’s hospital emergency department in gaeteng province found that nurse performance was 68.3%.12 in east java province, the performance percentage is 52%, while the performance percentage data for lavalette hospital ranges from 55% to 67%. these figures indicate that nurse performance in the region is still categorized as poor, which poses a problem in providing health services to patients, including in indonesia. transformational leaders should have the ability to inspire and correspondence: fitriyanti patarru', bachelor of nursing, sekolah tinggi ilmu kesehatan stella maris, makassar, indonesia. e-mail: patarrufitriyanti@yahoo.com key words: caring, performance, transformational leadership. contributions: fp, conceptualization, data curation, formal analysis, methodology, validation, visualization, resources, investigation, writing – original draft, review and editing; swp, conceptualization, investigation, methodology, formal analysis, validation, visualization, writing – original draft, review and editing conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethical feasibility test for this research was carried out by the ethics committee of the faculty of nursing, universitas airlangga, surabaya, with proof of certificate number 1916kepk dated 14 february 2020. the research ethics include the principle of beneficence and nonmaleficence, respect for human dignity, and the principle of respecting for justice. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 12 september 2023. accepted: 13 october 2023. early access: 6 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11779 doi:10.4081/hls.2023.11779 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11779] [page 11] non -co mmerc ial us e o nly motivate their subordinates to embrace change, especially when the change impacts employee performance or the employees themselves. this is crucial in ensuring that the organization’s goals and objectives are effectively implemented.13 leadership style positively and significantly affects nurse performance.14,15 a leader should also possess a genuine concern for their employees. caring behavior places significant emphasis on empathy, respect, and consideration for others. the leader’s demonstration of caring behavior towards their executives or staff is referred to as caring leadership. this process can significantly influence the group’s dynamics and their collective efforts in achieving common goals through the implementation of caring behavior.16–18 therefore, the organization needs reformist leaders and care that can be the driving motor of transformation to create good cooperation between leaders and subordinates that can improve the performance and quality of health services by implementing transformational leadership models. the four elements of the transformational leadership style are interconnected with each other. they include setting an example for those around them (idealized influence), increasing employee motivation through inspirational motivation, encouraging employees to solve problems in innovative ways (intellectual stimulation), and providing necessary physical facilities and infrastructure to support employee work.14,19 these four elements must be possessed and effectively realized by a hospital leader. on the other hand, swanson’s caring behavior consists of five aspects: knowing, being with, doing for, enabling, and maintaining belief.20 the choice of an appropriate leadership style can lead to the attainment of both individual and organizational goals. conversely, an inappropriate leadership style may result in the abandonment of organizational goals, causing employees to feel upset, agitated, disaffected, and dissatisfied. this study aimed to develop a leadership model, specifically focusing on the elements of the transformational leadership style, while also incorporating the element of caring. materials and methods the study utilized an explanatory design and targeted a population of 221 nurses working across various units, including inpatient, intensive care, and outpatient departments. a sample of 115 nurses was selected using cluster sampling, a form of probability sampling. the inclusion criteria for nurse participants in this study were employment at pt. nusantara sebelas medika lavalette hospital, willingness to participate as a respondent in the study, minimum educational qualification of an associate’s degree in nursing, minimum work experience of three years. these criteria were applied to identify suitable participants for the research. variable factors that influence leadership are personal factors, organizational factors, staff factors, work factors, caring-based transformational leadership, namely idealized influence, inspirational motivation, intellectual stimulation, individualized consideration and caring dimensions maintaining belief, knowing, being with, doing for, enabling and independent variables were observed simultaneously with nurse performance variables. data were collected using questionnaires from each sub-variable. the independent variable instrument is for personal factors. it consists of 3 subvariables, namely personality, experience and expectations,2 organizational characteristics consist of development and training sub-variables as well as organizational structure using a questionnaire from worldatwork which was adopted from research.21 the leadership behavior questionnaire (ltq/leadership trait questionnaire) is a measure that can be used to assess the characteristics of superior behavior,22 subordinate behavior questionnaires and expectations questionnaire,2 the job characteristics instrument in this research is based on the theory of hackman and oldham (1980) in research,23 the measuring tool used for transformational leadership is a modification of the multifactor leadership questionnaire (mlq) by bass and avolio in research.24 meanwhile, the independent variable instrument is the instrument regarding nurse performance standards.2 data analysis included both descriptive and inferential methods. descriptive analysis involved calculating measures like frequency, mean, median, and mode for data on a nominal or ordinal scale. inferential analysis utilized a variance-based structural equation modeling (sem) known as partial least square (pls). the research was conducted following ethical principles and rigorous testing. focus group discussions (fgds) were carried out to identify solutions to strategic problems. these discussions were conducted in two sessions: the first included 13 implementing nurses, and the second involved the head of nursing committee and 13 heads of rooms. the insights and findings from the focus group discussions were used to develop plans for enhancing the transformational leadership model based on caring within the hospital and for improving the standard of nurse care. to address the issues identified during the fgds, further consultations with experts were conducted to create a development module that included content about the significant factors in enhancing transformational leadership based on caring to improve nurse performance. results based on table 1, it can be found that of the 115 respondents, the majority of respondents are female 75.7%, aged 21 40 years 69.6%, the last person in nursing d3 69.6%, staffing status as a permanent employee 80.0 %, and have been working for 1-5 years 60.9%. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondent characteristics. characteristics of respondents n % gender male 28 24.3 women 87 75.7 age <21 years old 0 0 21-40 years old 80 69.6 41-60 years old 35 30.4 education nursing diploma 80 69.6 bachelor degree 35 30.4 master degree 0 0 staffing status permanent employees 92 80.0 honorary employees 23 20.0 contract employees 0 0 long working time <1 year 0 0 1-5 years old 70 60.9 >5 years old 45 39.1 total 115 100 [page 12] [healthcare in low-resource settings 2024;12:11779] non -co mmerc ial us e o nly personal factor variables consist of personality, experience, and expectations. organizational factor variables consist of development and training as well as organizational structure, staff factor variables consist of staff expectations, boss behavior, and subordinate behavior and work factor variables consist of objective performance, feedback, correction, job design and job schedule. transformational and caring leadership variables consist of idealized influence, individualized consideration, inspirational motivation, and intellectual stimulation, and nurse performance variables consist of caring, collaboration, empathy, response speed, decency, and honesty (table 2). the results of the study that there is a significant influence of personal factors (personality, experience, and expectations) on transformational leadership and caring (ideal influence, motivational inspiration, intellectual stimulation, intellectual consideration) (t = 5,677>1.96). there is an influence of organizational factors (development and training and organizational structure) on transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions transformational leadership based on caring ideal influence good 33 28.7 enough 51 44.3 less 31 27.0 motivational inspiration good 33 28.7 enough 25 21.7 less 57 49.6 intellectual stimulation good 40 34.8 enough 26 22.6 less 49 42.6 individual configuration good 36 31.3 enough 27 23.5 less 52 45.2 performance caring good 27 23.5 enough 30 26.1 less 58 50.4 collaboration good 55 47.8 enough 40 34.8 less 20 17.4 empathy good 35 30.4 enough 40 34.8 less 40 34.8 response speed good 54 47.0 enough 38 33.0 less 23 20.0 courtesy good 49 42.6 enough 32 27.8 less 34 29.6 honesty good 69 60.0 enough 34 29.6 less 12 10.4 total 115 100 table 2. variable distribution. variables n % personal factors personality good 46 40.0 enough 42 36.5 less 27 23.5 experience good 63 54.8 enough 37 32.2 less 15 13.0 hope high 79 68.7 are 36 31.3 low 0 0 organizational factors development and training good 23 20.0 enough 49 42.6 less 43 37.4 organizational structure good 62 53.9 enough 41 35.7 less 12 10.4 staff factor staff expectations high 26 22.6 are 64 55.7 low 25 21.7 leader behavior good 59 51.3 enough 31 27.0 less 25 21.7 subordinate behavior good 57 49.6 enough 45 39.1 less 13 11.3 occupation factor objective performance good 92 80.0 enough 23 20.0 less 0 0 feedback good 66 57.4 enough 24 20.9 less 25 21.7 correction good 70 60.9 enough 45 39.1 less 0 0 design jobs good 35 30.4 enough 65 56.5 less 15 13.0 work schedule good 39 33.9 enough 53 46.1 less 23 20.0 [healthcare in low-resource settings 2024;12:11779] [page 13] non -co mmerc ial us e o nly transformational leadership and caring (ideal influence, motivational inspiration, intellectual stimulation, intellectual consideration) (t = 4,474 > 1.96). there is a significant influence of staff factors (expectations, the behavior of subordinates, and superiors’ behavior) on transformational and caring leadership (ideal influence, motivational inspiration, intellectual stimulation, intellectual consideration) (t = 4,157 > 1.96). there is no influence of work factors (objective performance, feedback, correction, job dimensions, work schedule) on transformational leadership and caring (ideal influence, inspirational motivation, intellectual stimulation, intellectual consideration. (t = 0,554> 1.96), transformational leadership and caring (ideal influence, inspirational motivation, intellectual stimulation, intellectual consideration) to nurses’ performance (caring, collaboration, empathy, speed of response, politeness, honesty) (t = 7,755 > 1.96) (table 3). focus group discussion (fgd) results show that it is necessary to improve the implementation of transformational leadership models based on caring headroom by hospitals by making hospital policies regarding the application of a caring-based transformational leadership model based on personal factors, organizational factors, staff factors to improve nurse performance, conduct outreach to nurses, increase knowledge of the head of the room, train the application of caring-based transformational leadership, increase the responsibility and commitment of the headspace, improve nurse performance by applying caring-based transformational leadership. discussion the variables of personality, experience, and expectations have been validated and considered effective in measuring personal factors. they play a dominant role and are categorized as good indicators. the statistical tests demonstrate that personal factors significantly affect transformational leadership and caring. personality traits are evaluated based on several factors: the leader’s adaptability, creativity, decision-making ability, cooperation skills, emotional control, and self-confidence. experience is measured through the duration of work, the extent of knowledge, proficiency in skills, adherence to procedures, and a sense of responsibility in fulfilling duties. expectations are determined by the nurses’ aspirations for career advancement, recognition, and improved performance. most nurses at lavalette hospital malang exhibit good ratings for personality, experience, and expectations. the application of leadership type depends heavily on personality characteristics owned by a leader, personality is a certain characteristic or character that becomes unique to each individual. the research findings indicate a positive and significant correlation between personality and transformational leadership.25 organizational factor variables have sub-variables namely development and training and organizational structure. in the subvariables the organizational structure belongs to the category both but on the development and training category is sufficient. based on statistical test results, the two sub-variables are valid for measuring organizational factor variables. statistical test results show that organizing factors positively affect transformational leadership and caring. human resources development is an activity that must be carried out by an organization to improve employees’ knowledge, ability, and skills to comply with their work demands.21 while the organizational structure is the unity of the organizational framework set out for the managerial process, the system is the pattern of behavior that arises and occurs in organizing the organization and management. the results of this study are in line with research which states that the cultural factors of the organization have a significant effect on leadership.26 organization is one of the factors that affects an individual’s performance, because the organization is a system of roles, activity flows and processes of work relationship patterns and involves several people as executors of tasks designed to achieve common goals. the staff factor has sub variables namely staff expectations, boss behavior, subordinate behavior. sub-variabrel expectations of staff fall into the category of having moderate expectations and for sub variables of superior behavior and subordinate behavior fall into the category of good. based on statistical test results, the 3 sub-variables are valid for measuring staff factor variables. in statistical test results, there was a significant influence of staff factors on transformational leadership and caring. thus, it can be interpreted that the better the staff factor, the better it tends to improve transformational leadership and caring. the expectations of the staff in this study are to discuss the level of satisfaction felt by nurses during their work, namely the satisfaction of service wages, facilities and infrastructure and relationships between leaders. as for the behavior of the boss, the assessment of the nature and behavior of the boss such as being able to communicate well to subordinates, creative, insightful and able to motivate. for subordinate behavior, discuss feelings in carrying out the basic duties and functions of nurses that are their responsibility. the work factor variable has sub-variables, objective performance, feedback, correction, job design, and job schedule. sub variable objective performance, feedback, and corrections fall into both categories, while the design of the work and the work schedule is sufficient. based on statistical test results it can be known that 5 sub-variables are valid to measure staff factor variables in the results of statistical tests obtained results that there is no significant influence of work factors on transformational leadership and caring. the work factor in this study discusses the ability to work based on the sop that has been made by the hospital, evaluating the performance that has been done. the head of the room also gives corrections and directs its subordinates if it is not proper in carrying out its performance. the head of the room can set the shift schedule clearly. the study previous states that by modifying or changing the characteristics of the work, it should be more consid transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. hypothesis test. influence original sample (o) t statistics (o/stdev) p personal factors (x1) -> transformational leadership and caring (x5) 0.332 5.677 0.000 organizational factors (x2) -> transformational leadership and caring (x5) 0.328 4.474 0.000 staff factor (x3) -> transformational leadership and caring (x5) 0.305 4.157 0.000 job factor (x4) -> transformational leadership and caring (x5) 0.034 0.554 0.580 transformational leadership and caring (x5) -> nurse performance 0.515 7.755 0.000 [page 14] [healthcare in low-resource settings 2024;12:11779] non -co mmerc ial us e o nly ering the individual aspects.27 the individual aspect in question is that a leader must have a desire to present himself or herself to be able to do the job. transformational leadership and caring are not directly affected by the employment factor. the employee’s work factor is basically individual because basically, each person’s work ability has a different character. transformational leadership based on caring variables has subvariables of idealistic influences, motivational inspiration, intellectual stimulation, and individual contingency. sub variables of transformational leadership and caring for motivational inspiration, intellectual stimulation, and individual consideration fall into fewer categories whereas the dimensions of idealistic influence in the category are sufficient. based on statistical test results, it can be known that 4 sub-variables are valid for measuring leadership and caring variables. statistical test results show that there is a significant influence of transformational and caring leadership on the performance standards of professional nurses. thus, it can be interpreted that implementing transformational leadership and caring tends to improve the performance standards of professional nurses. this research is in line with research that transformational leadership style has a positive and significant effect on nurse performance.28 according to bass, 1997 the transformational leadership model is a leadership style that can excite and motivate subordinates in order to develop and achieve higher performance, past previously thought. transformational leadership based on caring is a model of leadership style that transforms or transforms something into another different form. a transformational leader must be able to optimally transform the organization’s resources in order to achieve meaningful goals in accordance with the target stipulated. transformational leadership is outlined in four main characteristics, namely: the idealization of influence, inspirational motivation, individuality, and intellectual stimulation and developed by incorporating the caring element, namely maintaining belief, knowing, doing for, being with, and enabling because the key to improving the quality of nursing services is to emphasize caring behavior. therefore, it takes a leader who applies caring attitude in leading his subordinates. performance is a pattern of actions performed to achieve goals measured based on comparisons with various standards.29 performance is the achievement of the objective of a particular activity or activity to achieve the company’s goals as measured by a standard. the results of the previous study showed that there is a significant influence of transformational leadership on performance.30 this shows that the greater the influence of transformational leadership, the better the performance of nurses. the application of transformational and caring leadership models by the head of the room or manager can have a good impact on the performance of nurses. applying the dimensions of transformational leadership including ideal influence/charisma, motivation inspiration, individual consideration, and intellectual stimulation integrated with caring dimensions, namely maintaining belief, knowing, doing for, being with, and enabling, can have a positive influence on the performance of nurses in hospitals. the influence of transformational leadership makes employees more loyal to their work. research limitations during data collection are as follows: it is necessary to take a personal approach to the implementing nurse when filling out the questionnaire so that it takes quite a long time and the researcher adjusts the official holiday schedule with the nurse and focus group discussion (fgd) with the executive nurse, head of room and representatives of hospital management with limited time because it was carried out online and the limited time each nurse concerned had considering the responsibility in providing nursing care. conclusions the transformational leadership model based on caring is influenced by various factors, including personal factors, organizational factors, and staff factors. the development of this model has the potential to impact nurses’ performance positively and can be adopted by hospitals, particularly for ward managers or heads of departments, to enhance the quality of healthcare services. the findings from this research offer valuable insights and understanding for leaders and heads of departments in implementing a caringbased transformational leadership model, 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public health africa 2022;13:2415. 6. rohita t, nursalam n, hadi m, et al. relationship quality of nursing work life and burnout among nurses: a systematic review. gac med caracas 2022;130:s1205-s1214. 7. yani rwe, khoiri a, bramantoro t. patient’s satisfaction in utilizing public health center services during the covid19 pandemic based on gender, age, education level, and occupation. asia pacific j heal manag 2022;17:1797. 8. utomo mt, sampurna mta, melisa m, et al. nurse workload, missed nursing care, and the contributing factors in the neonatal intensive care unit in a limited resource setting: a case from indonesia. f1000research 2022;11. 9. kemenkes ri. laporan kinerja ditjen kesehatan masyarakat tahun 2016. 2017. 10. fitri il. pengaruh implementasi six sigma dan total quality management terhadap kepuasan dan kinerja keuangan pada rumah sakit surabaya. 11. mukhtar hf, ibrahim m, ahmed o. effect of proposed program of patient safety on n urse’s performance and quality of care at 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dengan kinerja perawat dalam melaksanakan asuhan keperawatan. 17. bakar a, qomariah sn, iswati i. effect of caring behaviour approach to improve nurses’ caring character in medical-surgical wards. j ners 2022;17:110-4. 18. lukmanulhakim l, afriyani a, haryani a. caring efficacy and nurse caring behavior in taking care of critical patients. j ners 2019;13:55-61. 19. aziz a, padil m, mujtahid m, et al. transformational leadership style in rural schools during pandemic: a case study in indonesian non-weird community. int j eval res educ 2022;11:947-53. 20. alligood m. nursing theory & their work (8th ed). the cv mosby company st. louis. toronto. missouri: mosby elsevier. inc. 2014. 21. rachmatika sm. (2015) ‘pengaruh evaluasi pelatihan dan pengembangan karir terhadap kinerja pegawai negeri sipil kota yogyakarta’’, universitas negeri yogyakarta, pp. 1-27. 22. northouse pg. leadership: theory and practice, 6th edition. california: sage publications, inc. 2012. 23. megawati s. pengaruh job characteristics terhadap motivasi karyawan divisi operasi pada pt pembangkitan jwa-bali (pjb) unit pembangkitan (up) muara tawar. universitas indonesia. 2012. 24. soegiarto m. pengaruh kepemimpinan transformasional terhadap kinerja karyawan pada cv. norton surabaya. jurnal riset bisnis dan investasi 2016;2:143. 25. permatasari pab. pengaruh kepribadian terhadap gaya kepemimpinan transformasional di pt. istana mobil roda mas (honda istana jember). j chem information modeling 2014;53:1689-99. 26. mufidah sz. hubungan gaya kepemimpinan dengan budaya organisasi di rumah sakit islam sultan agung semarang relationship between leadership style with organizational culture in hospital sultan agung islamic semarang. unissula nursing conference call for paper & national conference 2018;1:8389. 27. thomas a, buboltz wc, winkelspecht cs. job characteristics and personality as predictors of job satisfaction. organ an 2004;12:205-19 28. muttaqin lz. pengaruh kepeimpinan transformasional dan pengembangan sdm terhadap kinerja perawat rsj grhasia yogyakarta, universitas negeri yogyakarta. 29. dessler g. human resources management. 14th edition. usa: pearson. 2016. 30. murtiningsih. pengaruh gaya kepemimpinan transformasional pada kinerja perawat rumah sakit islam siti aisyah madiun. jurnal ekonomi manajemen sumber daya 2015;17:54-66. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 16] [healthcare in low-resource settings 2024;12:11779] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12289 illness duration and quality of sleep among people living with hiv: a cross-sectional study ahmad ikhlasul amal,1,2 tintin sukartini,1 ninuk dian kurniawati,1 indah sri wahyuningsih,1,2 suyanto,1,2 inayatul ulya2 1faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang, indonesia abstract hiv is a chronic condition that requires ongoing medical management, and sleep disturbances are common among individuals living with the virus. by examining the relationship between the duration of illness and sleep quality, healthcare professionals can gain insights into the unique challenges faced by hiv patients and develop targeted interventions to address their specific sleep-related needs. this study aims to find out the relationship between the illness duration and the quality of sleep among people living with hiv/aids. this research used an observational research design using a cross-sectional approach. 128 hiv patients on balai kesehatan masyarakat wilayah semarang were involved in using purposive sampling techniques. the data was gathered with medical records and the pittsburgh sleep quality index (psqi). spearman rank correlations were used to analyze the data. this study has been declared ethically appropriate by the health research ethics committee faculty of nursing universitas islam sultan agung. the results found a relationship between the illness duration and quality of sleep where a p-value of 0.019 < α (0.05) with a contingency coefficient value of 0.208. the length of diagnosis and sleep quality have a strong correlation. nurses and other healthcare providers need to provide interventions for plhiv to improve sleep quality. introduction human immunodeficiency virus (hiv) is the main cause of received immunodeficiency syndrome (aids).1 hiv infection can cause various signs and health issues, which include sleep disturbances and improved length of infection.2,3 previous studies have proven that individuals residing with hiv regularly enjoy complicated intellectual and physical health challenges, that could affect their sleep quality.4 duration of infection is a high-quality element of the lived revel in of people with hiv.5 numerous fitness headaches, which consist of opportunistic infections and facet outcomes of antiretroviral remedies, can result in prolonged intervals of contamination. in turn, the stepped-forward period of infection can affect sleep nicely, resulting in sleep disturbances and diverse other sleep troubles.3 hiv patients regularly experience complicated sleep disturbances, prompted by way of a range of things regarding bodily, psychological, and remedy elements. one of the important causes of sleep disturbances in hiv sufferers is the presence of bodily symptoms which could appear because the infection progresses.3,6 opportunistic infections and fevers regularly associated with hiv situations can disrupt sleep patterns and cause terrible sleep. using antiretroviral (arv) drugs, while essential for controlling infection, can also cause aspect outcomes including insomnia or modifications in sleep styles.7,8 psychological factors, including social stigma, melancholy, and pressure, can play a sizable role in disrupting the sleep of hiv patients. similarly, neurological disorders because of hiv may additionally contribute to sleep pain. persistent pain from conditions together with peripheral neuropathy can also be a cause for sleep disturbances. hormonal modifications, weight reduction, lifestyle adjustments, and restrained physical interest can also have an effect on sleep in hiv sufferers. consequently, an in-depth knowhow of the complicated interactions between these factors is required to design a holistic technique for sleep problem managecorrespondence: ahmad ikhlasul amal, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: ahmad.ikhlasul.amal-2020@fkp.unair.ac.id key words: hiv, illness duration, quality of sleep. contributions: aia, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ts, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ndk, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; isw, methodology, visualization, writing – review and editing; s, methodology, visualization, writing – review and editing; iu, resources, investigation, and writing –review and editing. conflict of interests: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas islam sultan agung, based on ethical certificate 745/a.1-s1/fik-sa/x/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from universitas islam sultan agung. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank professor tintin sukartini for their valuable insights and contributions to this study. received: 17 january 2024. accepted: 16 march 2024. early access: 25 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12289 doi:10.4081/hls.2024.12289 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 310] [healthcare in low-resource settings 2024;12:12289] non -co mmerc ial us e o nly ment in people residing with hiv.9 poor sleep quality in people living with hiv (plhiv) not only negatively affects physical health but also cognitive function and general quality of life.10 sleep disruptions can increase indicators of intellectual fitness, such as tension and hopelessness, and reduce patience and stress levels.11 nurses play a significant role in analyzing the relationship between illness duration and sleep quality in hiv patients. in nursing care, nurses can play a proactive role in monitoring and recording patients’ duration of illness and paying attention to their sleep patterns.12 by making careful observations, nurses can identify physical symptoms that may be the cause of longer duration of illness in hiv patients, such as opportunistic infections or side effects of antiretroviral drugs.4,13 in addition, nurses can use good communication skills to interact with patients, listen to their complaints regarding sleep quality, and identify psychological factors that may affect sleep, such as stress or anxiety.14 through their role in analyzing the relationship between illness duration and sleep quality, nurses not only contribute to a better understanding of the complexity of hiv patients’ conditions but also play an essential role in improving patients’ quality of life through a holistic and evidence-based approach to care.15 unfortunately, not many researchers have mainly looked into the relationship between the length of an infection and the quality of sleep in hiv-positive populations. to close this knowledge gap, this study aims to determine and understand the length of the disease phase in individuals living with hiv and its correlation with sleep quality. materials and methods research design this study used a cross-sectional design. study participants data were collected at kedungmundu and poncol public health center, semarang, central java, indonesia. sampling in this study was carried out using a purposive sampling technique for as many as 128 respondents with inclusion criteria of patients willing to become respondents and patients who could read and write. exclusion criteria: patients referred to the hospital or not undergoing arv therapy, patients who are not cooperative, and patients who have cognitive impairment. informed consent was obtained from all participants and their families before data collection. variable, instrument, and data collection the independent variable in this study was the illness duration, while the dependent variable was the quality of sleep. respondent characteristics, including age, gender, education, and occupation were also collected. the participants were cardiovascular patients undergoing treatment at the hospital. this study used an instrument in the form of a pittsburgh sleep quality index (psqi) and secondary data from medical record data to determine the illness duration of being diagnosed with hiv/aids. data analysis data analysis was univariately using the frequency distribution table for each variable in the study, both dependent and independent variables. after that, a bivariate analysis was carried out to see the relationship between dependent and independent variables using the spearman test with a significance value of 5%. data analysis was conducted using spss software. results univariate analysis of participants demographic and variable the average age of respondents was 39.23 years, while the youngest age range was 21 years, and the oldest age was 74 years. the frequency distribution of the sexes of most respondents was male, with a total of 84 people (65.6%). the distribution of the education frequency of most respondents is senior high school education, with a total of 62 (48.4%). the distribution of the frequency of work of most respondents is working with a total of 93 (72.7%). the average frequency distribution for being diagnosed with hiv (illness duration) is six years (standard deviation ±3.506), while the length of time being diagnosed with hiv is one year, and the longest is 21 years. the frequency of sleep quality distribution shows that the dominant respondents have poor sleep quality, as many as 81 (63.3%) (table 1). relationship between illness duration and quality of sleep this study’s results obtained a sig value of 0.019 (p < 0.05), which means that the correlation or relationship between the illness duration and the quality of sleep among plhiv is significant. the correlation value of 0.208 indicates that the direction of the correlation is positive with a weak correlation (table 2). article table 1. participants' demographic and variable description (n=128). variable mean±sd median minimum-maximum age 39.23±10.16 37.00 21-74 variable frequency percentage gender male 84 65.6 female 44 34.4 total 128 100,0 variable frequency percentage education primary school 7 5.5 junior high school 32 25.5 senior high school 62 48.4 vocational school 7 5.5 undergraduate study 20 15.6 total 128 100.0 variable frequency percentage job jobless 35 27.3 work 93 72.7 total 128 100,0 mean±sd median minimum-maximum illness duration 6.12±3.506 6.00 1-21 variable frequency percentage sleep quality good 47 36.7 poor 81 63.3 total 128 100.0 table 2. relationship between illness duration and quality of sleep (n=128). quality of sleep illness duration r 0.208 p 0.019 n 128 [healthcare in low-resource settings 2024;12:12289] [page 311] non -co mmerc ial us e o nly discussion respondents based on age obtained an average age of 39 years. this result aligns with other studies where respondents are more in the age group of 31-40 years.16 another study explained that most hiv infections occur at a young to old age (36-65 years). it can occur because, in old age, most likely, they do not feel any satisfaction in dealing with their partners, so having unsafe sex. however, in some other cases, young age in sexual relations can also be at risk.17 respondents based on gender obtained more men. this finding is in line with other studies in which male respondents are more infected with hiv. it is estimated that more than 3 million indonesian men are prostitute customers. the results of another study stated that the male sex was more prone to contracting hiv/aids; this was caused by the use of syringes that were free from tattooing with non-sterile tools or even injecting drugs.18 based on the results, the educational characteristics of plhiv are more dominant in high school. this finding aligns with other studies where the status of high school education is more due to the low public understanding of hiv.16 the results of other studies identified that the majority of the education was senior high school.19 researchers assume that people with lower levels of education will be more at risk because in the absence of knowledge about hiv/aids, how to avoid contracting hiv, and how to have safe sex, they will be at greater risk for hiv infection. another study explained that plhiv who had low education and did not have sufficient knowledge about hiv/aids were 5.3 times more at risk of preventing and transmitting hiv.17 the results of the characteristics of plhiv respondents predominantly have jobs. this finding is in line with other studies that explain that a bad economy, even though they are already working, can lead people into dangerous sexual risk behaviors to meet the needs of life both for themselves and others.16 from some of these statements, the researcher assumes that someone who works but has a low income to meet the needs of life will be encouraged to have other jobs that are at risk of being infected with hiv. the study results on illness duration showed that more respondents were exposed to hiv with a minimum of 1 year and a maximum of 21 years. the most dominant were respondents who had been exposed six years ago. this result is comparable to other studies, which suggest that most plhiv have been infected for more than three years.19 the results of other studies explain that the emergence of new cases is not representative of all cases because it is possible that the exposed person is not in the window phase but has been infected with hiv for a long time.17 the study results on sleep quality found that most respondents had poor sleep quality. this finding aligns with the results of other studies that the quality of sleep in plhiv is identified as a poor category.20 the results of other studies explain that a person’s sleep can be disturbed when he contracts a disease, and people infected with hiv have sleep disorders between 40 and 70%.21 another research also found that the condition of patients in terms of their illness and treatment affects their sleep quality. from some of these statements, researchers assume that the sleep quality in plhiv tends to be poor. this result is caused by the course of the disease that results in changes in the physical and mental health of plhiv, which will cause disturbances in sleep and impact sleep quality. the results of this study are in line with research conducted by, who explained that plhiv had poor sleep quality; this was caused by the side effects of the arv drugs they were taking. other studies state that arv drugs have side effects, including fatigue, dizziness, joint pain, stomach pain, and even diarrhea. these side effects will decrease health status, productivity, and especially sleep quality.22 researchers assume that the side effects of arv drugs are related to the duration of being diagnosed with hiv. the longer a person has been diagnosed with hiv and undergoing therapy, the more likely it is that adherence to taking arvs will be higher, which means that taking arv drugs will result in higher levels of adherence to arv drugs.23 the greater the number of plhiv experiencing side effects of drugs that affect their health status, the higher the quality of sleep plhiv becomes. poor sleep quality is a prevalent issue among people living with hiv (plhiv) in lowand middle-income countries (lmics) such as indonesia. various factors contribute to this phenomenon, including socioeconomic status, with individuals below the poverty line being more likely to experience poor sleep quality.24 additionally, plhiv faces unique challenges such as social stigma and discrimination, which can lead to heightened levels of stress and anxiety, further impacting sleep quality.24 moreover, the exact cause of sleep disturbances in plhiv is not fully understood, but it is recognized as an important health problem that requires attention and intervention.9 poor sleep quality among people living with hiv (plhiv) in lowand middle-income countries (lmics) is a significant concern, often assessed using tools like the pittsburgh sleep quality index (psqi). studies have highlighted the prevalence of poor sleep quality among plhiv in lmics, with factors such as social stigma, comorbidities, and psychological distress contributing to sleep disturbances.25 the psqi is a widely utilized instrument to assess sleep quality comprehensively, encompassing various domains including sleep latency, duration, efficiency, disturbances, and daytime dysfunction. its application in lmics allows for the identification of specific sleep-related issues faced by plhiv in these regions, aiding in targeted interventions and improving overall health outcomes.26 the strength of the correlation in this study is weak, meaning that poor sleep quality in plhiv is not only influenced by the duration of being diagnosed with hiv but can be influenced by other factors that can affect sleep quality in plhiv. the direction of the positive correlation indicates that the variables are in the same direction, i.e., the longer it takes to be diagnosed with hiv/aids, the poorer the quality of sleep in plhiv. the relationship between illness duration and sleep quality among people living with hiv (plhiv) is multifaceted and influenced by various factors. firstly, as the duration of hiv infection progresses, individuals may experience a decline in physical health, including the manifestation of comorbid conditions such as chronic pain and inflammation, which can disrupt sleep patterns and lead to poor sleep quality.27 additionally, the chronic nature of hiv requires ongoing medical management, often involving antiretroviral therapy (art). side effects of art medications, such as insomnia or vivid dreams, can contribute to sleep disturbances, particularly as treatment duration increases.28 another opinion explains that someone diagnosed for a long time will experience a specific change from hiv itself to cause a series of symptoms of the disease that reduce the physical and mental health status of plhiv. that symptom causes people living with hiv to experience tremendous pressure from themselves, which leads to excessive emotional reactions, prolonged feelings of sadness, and a trigger for stressors.29,30 from these several factors, if the mental health of plhiv is disturbed, excessive anxiety and side effects of arv drugs are consumed, it can cause the sleep quality of plhiv to be poor.20 this study has certain limitations related to confounding variables and bidirectional causality. article [page 312] [healthcare in low-resource settings 2024;12:12289] non -co mmerc ial us e o nly because many studies are cross-sectional, establishing a clear cause-effect relationship becomes challenging. factors like comorbidities, medication regimens, socioeconomic status, and psychological factors may influence the duration of illness and sleep quality independently, making it difficult to determine the exact impact of illness duration on sleep quality. longitudinal studies with larger sample sizes and comprehensive control of confounding variables are necessary to understand better the complex interplay between illness duration and sleep quality in plhiv. additionally, qualitative research methods could provide deeper insights into the subjective experiences and perceptions of individuals living with hiv regarding their sleep patterns and illness duration. such qualitative research could complement quantitative findings and improve our understanding of this relationship. conclusions this study revealed a connection between the length of an illness and the level of sleep that hiv-positive individuals get. due to a variety of intricate and different elements, such as individual differences in hiv symptoms, the impact of medication side effects, and the involvement of psychosocial variables that influence sleep patterns, it was discovered that there was little correlation between the length of illness and the quality of sleep in hiv patients. however, given a better understanding of the correlation between the length of an illness and sleep quality in this population, nurses have a crucial role to play in creating and implementing care strategies that center on managing physical and psychosocial symptoms as well as teaching hiv patients how to improve the quality of their sleep. references 1. angel a. justiz vaillant; peter g. gulick. hiv disease current practice statpearls ncbi bookshelf. 2020. 2. who. key fact hiv and aids. occupational health 2023;43:94. 3. irwin mr, olmstead r, carroll je. sleep disturbance, sleep duration, and inflammation: a systematic review and metaanalysis of cohort studies and experimental sleep deprivation. biol psychiatry 2016;80:40-52. 4. ren j, zhao m, liu b, et al. factors associated with sleep quality in hiv. j assoc nurses aids care 2018;29:924-31. 5. khandu l, dhakal gp, lhazeen k. baseline cd4 count and the time interval between the initial hiv infection and diagnosis among plhiv in bhutan. immunity inflamm dis 2021;9:88390. 6. han lj. difference in effects on sleep quality and stress depending anesthetics method in women who underwent caesarean section in korea. rawal med j 2016;41:471-5. 7. wicaksono ya, fitrikasari a, sofro mau, peni h. hubungan stigma dan terapi arv dengan komplikasi gangguan psikiatri pada pasien hiv/aids. j penyakit dalam indones 2018;5:24. 8. pujasari h, chung mh. sleep disturbance in the context of hiv: a concept analysis. sage open nurs 2022;8:2377960 8221094541. 9. gebreeyesus fa, degu fs, yohanes yb, azagew aw. sleep quality and associated factors among adult people living with hiv on follow-up at dessie town governmental health facilities antiretroviral therapy clinics, northeast, ethiopia, 2020, a multicenter cross-sectional study. bmc psychiatry 2023;23:1-13. 10. bruno g, giotta m, perelli s, et al. prevalence and risk factors for poor sleep quality in people living with hiv: preliminary observations from an hiv outpatient clinic. viruses 2023;15:1715. 11. abdu z, dule a. poor quality of sleep among hiv-positive persons in ethiopia. hiv/aids res palliat care 2020;12:621-8. 12. molina-mula j, gallo-estrada j. impact of nurse-patient relationship on quality of care and patient autonomy in decision-making. int j environ res public health 2020;17:835. 13. sukartini t, nursalam n, arifin h. the determinants of willingness to care for people living with hiv-aids: a cross-sectional study in indonesia. health soc care community. 2021;29:809-17. 14. kourkouta l, papathanasiou i. communication in nursing practice. mater socio medica 2014;26:65. 15. kolcaba k, steiner r. empirical evidence for the holistic of nature. j holist nurs 2000;18:46-62. 16. simboh f, bidjuni h, lolong j. hubungan dukungan keluarga bagi kualitas hidup orang dengan hiv/aids (odha) di klinik vct rsu bethesda gmim tomohon. j keperawatan unsrat. 2015; 17. kambu, waluyo k. umur orang dengan hiv aids ( odha ) berhubungan dengan hiv/aids. j keperawatan indones. 2016; 18. sidjabat fn, setyawan h, sofro ma, hadisaputro s. lelaki seks lelaki , hiv/aids dan perilaku seksualnya di semarang [men who have sex with men, hiv and their sexual behaviour in semarang]. j kesehat reproduksi. 2017; 19. lubis l. hubungan stigma, depresi dan kelelahan dengan kualitas hidup pasien hiv/aids di klinik veteran medan. idea nurs j. 2015; 20. aliyah ang, rifai a, afandi at. kualitas tidur orang dengan hiv/aids (odha) di area pedesaan kabupaten jember indonesia. pros semin rekam med dan inf kesehat kualitas. 2019. 21. oshinaike o, akinbami a, ojelabi o, et al. quality of sleep in an hiv population on antiretroviral therapy at an urban tertiary centre in lagos, nigeria. neurol res int. 2014;2014:298703. 22. dacosta dibonaventura m, gupta s, cho m, mrus j. the association of hiv/aids treatment side effects with health status, work productivity, and resource use. aids care psychol socio-medical asp aids/hiv. 2012; 23. sabin ca, harding r, doyle n, et al. associations between widespread pain and sleep quality in people with hiv. j acquir immune defic syndr 2020;85:106-12. 24. bedaso a, abraham y, temesgen a, mekonnen n. quality of sleep and associated factors among people living with hiv/aids attending art clinic at hawassa university comprehensive specialized hospital, hawassa, snnpr, ethiopia. plos one 2020;15:e0233849. 25. tadesse a, badasso k, edmealem a. poor sleep quality and associated factors among people living with hiv/aids attending art clinic at tirunesh beijing hospital, addis ababa, ethiopia. aids res treat 2023;2023. 26. bedaso a, abraham y, temesgen a, mekonnen n. quality of sleep and associated factors among people living with hiv/aids attending art clinic at hawassa university comprehensive specialized hospital, hawassa, snnpr, ethiopia. plos one 2020;15:1-12. article [healthcare in low-resource settings 2024;12:12289] [page 313] non -co mmerc ial us e o nly 27. milinkovic a, singh s, simmons b, et al. multimodality assessment of sleep outcomes in people living with hiv performed using validated sleep questionnaires. int j std aids 2020;31:996-1003. 28. meng j, xiao x, wang w, et al. sleep quality, social rhythms, and depression among people living with hiv: a path analysis based on social zeitgeber theory. front psychiatry 2023;14:112. 29. odili vu, ikhurionan ib, usifoh sf, oparah ac. determinants of quality of life in hiv/aids patients. west african j pharm 2011;22:42-8. 30. rémi j, pollmächer t, spiegelhalder k, et al. sleep-related disorders in neurology and psychiatry. dtsch arztebl int 2019;116:681-8. article [page 314] [healthcare in low-resource settings 2024;12:12289] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11777 nurses' experiences regarding nursing competence in the isolation wards during covid-19 pandemic arista maisyaroh, eko prasetya widianto, syaifuddin kurnianto, rizeki dwi fibriansari faculty of nursing, universitas jember, jember, indonesia abstract during the covid-19 pandemic, it was essential for nurses to possess the necessary skills and expertise to provide care for patients in isolation wards designated for covid-19 cases. this recognition of a nurse’s experience could serve as a basis for establishing more precise competency standards for staff working in covid-19 isolation wards. this study aimed to explore the experience of nurses with the competencies needed to care for covid-19 patients in the isolation ward. the research design used was a phenomenological design as outlined by van manen’s phenomenological of practice. in-depth interviews were conducted using semi-structured questions involving six nurses in the covid-19 isolation ward at lumajang district hospital. this study found seven major themes, namely nurses must have altruistic thinking, critical thinking to solve problems, the ability to work with teams, problem-solving thinking, the ability to handle emergency situations, have a caring attitude, and have the motivation to learn. the competence of nurses in the covid-19 isolation ward should be established on a foundation of both hard and soft skills, which are essential for a nurse to deliver optimal care to covid-19 patients. efforts aimed at enhancing nurses’ competencies should take precedence, enabling them to provide improved care and assist in addressing the ongoing public health challenges. introduction the world was shocked by the infectious disease caused by the acute respiratory syndrome coronavirus 2, which was first identified in wuhan in early 2020, in hubei province.1,2 this disease is called coronavirus disease 2019 (covid-19). covid-19 rapidly spread globally, and the world health organization (who) officially declared the covid-19 outbreak a pandemic on march 11th, 2020. there is an increase every year, resulting in a pandemic. psychiatric aspects of healthcare workers during the covid-19 pandemic in surabaya, indonesia3,4 have a wide reach both socially and economically. the covid-19 pandemic has underscored the vital role of nurses who must confront challenges in an ever-evolving situation, including the application of adequate skills and knowledge and addressing symptoms caused by covid-19 to provide effective care.5 although there are impacts for those working in the health sector, especially healthcare professionals (hcps) who have direct or indirect contact with covid-19.6 the acute symptom coronavirus 2 (sars-cov-2) is a type of coronavirus that causes coronavirus disease 2019 (covid-19). the world health organization reports that there are more than 22,000 medical workers spread across 52 countries and territories declared infected with the coronavirus (covid-19).7 the spread of the severe acute respiratory syndrome coronavirus (covid-19) has gripped the international community. covid-19 is having a devastating impact on healthcare workers around the world, with a frontline healthcare provider fatality rate of. 1.4%.8 based on the number of nurse deaths in indonesia during january– july 2021, indonesia has lost more than 300 nurses due to correspondence: arista maisyaroh, faculty of nursing, universitas jember, jember, indonesia. e-mail: aristamaisyaroh@unej.ac.id key word: competency, covid-19, nurse, isolation wards contributions: am, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ep, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; sk conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; rd, methodology, visualization, writing – review & editing; am resources, investigation, and writing –review & editing; ep formal analysis, validation, writing – review & editing; sk resources, supervision, and writing –review & editing; rd resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the ethics committee of the faculty of dentistry, university of jember, with number 933/un25.8/kepk/dl/2020. during the research, the researcher paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thankful to jember university for their valuable insights and contributions to this study. received: 12 september 2023. accepted: 5 december 2023. early access: 18 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11777 doi:10.4081/hls.2024.11777 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 124] [healthcare in low-resource settings 2024;12:11777] non -co mmerc ial us e o nly covid-19. in hospitals, nurses play a more dominant role in providing health services to patients.9 nurses have an important function in ensuring the quality of services based on a biopsychosocial and spiritual approach, as well as in executing and emphasizing the importance of patient safety through their duties and responsibilities.10 the role of nurses is substantial in delivering health services to patients, and their professional behavior is linked to patient recovery.11 work-life balance among professionals, including health professionals, is key to better efficiency.12 covid-19 is found to have potential airborne transmission. the process of diagnosing covid-19 is complicated, involving sampling in the patient’s ward. during this process, various factors can be disturbing, such as the distance between the patient and the sampler, the use of a protective mask or oxygen by the patient, the patient’s activity, coughing, and sneezing during the sample collection, air movement, air conditioning (ac), the type of sampler, sample taker, storage conditions, and transfer.13 nurses must understand the care and management of covid-19, including knowledge of the risk factors for transmission, diagnosis, and nodules.14 health workers play an important role in preparing for the handling of covid-19 patients, carrying out complete and adequate treatment to cure and reduce the rate of disease spread.15 the world health organization (who) has emphasized the exceptionally significant burden on healthcare workers dealing with the pandemic and stressed the urgent need to prevent its impact on their health.16 nurses, who are at the forefront of treating covid-19 patients in isolation wards, must possess appropriate infection prevention and control knowledge and skills.17 they should continually update themselves and stay informed about the latest developments related to covid-19. thus, the involvement of nursing management in handling covid-19 to prevent transmission and care for patients in the isolation wards is urgently needed.18 although the majority of people who contract covid-19 have only mild or no complications, about 14% develop severe illness that requires hospital care and oxygen support, and 5% need to be treated in an intensive care unit.2 in the context of the covid-19 pandemic, the mental well-being of nurses has become increasingly pressing, given the high work pressures they are experiencing. the prevalence of mental well-being issues among nurses has significantly risen as the pandemic continues, with a majority of nurses reporting high levels of stress, fatigue, and an increased risk of mental disorders.19 conversely, concerns about nurses’ adequate skills and soft skills have also become a primary focus, considering the rapid changes in covid-19 treatment protocols and the prevalence of certain skill deficiencies in some cases that could impede the effectiveness of care.20,21 with the increasing cases of covid-19, nurses are facing challenges in fighting the disease. therefore, it is important to study the experience of nurses regarding the competencies they must have while caring for covid-19 patients. materials and methods research design this study employed a phenomenological design as outlined by van manen’s phenomenology of practice.22 the aim was to explore nurses’ experiences during the development of competencies needed to care for covid-19 patients in the isolation ward. hermeneutic phenomenology is a human science and philosophical method that allows the study of a phenomenon through lived experience.22,23 the phenomenon is described in terms of phenomenological themes.22 formulating thematic knowledge involves interpreting the meaning of a lived experience represented in the phenomenological text as approachable in terms of meaning units, structures of meaning, or themes.22 in short, a theme is a conceptual formulation or a categorical statement that possesses phenomenological power when it allows for the development of phenomenological description. the researchers consisted of four individuals who were lecturers from the university of jember. two of them are female, am as the lead researcher, and rd, while the other two are male, ep, and sk. all four researchers have experience conducting research on covid-19 and qualitative research,19,24–29 and there have been two books published related to covid-19.30,31 the four researchers were involved in drafting, analyzing data, and formulating results and conclusions, while three researchers (am, ep, and rd) collected data through interviews. researchers and participants do not have a working relationship because participants are clinical nurses in hospitals, and their work does not overlap with the researchers’ work. study participants participants were selected from two hospitals in lumajang, each with a covid-19 isolation ward for patient care. thirty nurses who met the inclusion criteria were chosen. the criteria included having at least a diploma in nursing education, being a registered nurse working directly with covid-19 positive patients in a hospital setting, having a minimum of three months of experience in a specific isolation ward, and having voluntarily agreed to participate and provided informed consent for the research. out of the 30 isolation ward nurses who met the inclusion criteria, only six participated; the others did not meet the requirement of having worked in the isolation ward for at least three months and did not agree to provide informed consent. no participants were dropped from the data collection process, as all six selected participants completed the study. top of form variable, instrument and data collection interested participants were provided an explanation of the study process. the participants determined the time for the interview process after signing the agreement. this study was conducted from august to october 2020. the data collection method involved open interviews with the participants, and the results from the verbatim transcripts were analyzed using van manen’s approach 2015,22 in a zoom meeting room. the participants selected for this study were six nurses working in the special isolation ward at the covid-19 referral hospital, lumajang regency. data collection occurred through interviews using semi-structured questions lasting 45-60 minutes, and audio recordings were made with informed consent. each participant was given the opportunity to freely express their ideas about their personal experiences and views. the main question posed to the participants was, “how was your experience caring for covid-19 patients?” all participant interviews were verbally transcribed. no repeated interviews were conducted, and only chats were recorded, transcribed verbatim, and validated by re-listening to the recording and re-reading by researchers. all researchers collaboratively analyzed, reviewed, and discussed each interview and transcript. phrases obtained from the collected data were checked repeatedly to ensure consistency, then coded and organized into themes that were developed. this study utilized transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11777] [page 125] non -co mmerc ial us e o nly inductive content analysis to analyze the thematic analysis data based on van manen 2015.22 data analysis the process of data analysis followed six steps outlined by van manen’s approach.22 these steps include i) understanding the nature of lived experience in this study (i.e., “how was your experience caring for covid-19 patients?”), ii) investigating the participants’ experiences through semi-structured interviews, iii) reflecting on essential themes by carefully and repeatedly reading the entire interview transcripts (statements, words, and phrases) line-by-line to develop initial themes, iv) describing the phenomena through the art of writing and rewriting, by re-reading the initial themes and constantly revising and refining thoughts, v) maintaining a strong and oriented relation to the phenomenon by reflecting back the themes with the research question, and vi) balancing the research context by considering both the part and the whole themes, isolating thematic statements to develop final themes that represent the lived experience. all themes or findings were then translated from indonesian into english in the text. during the analysis, am, ep, sk, and rd used both indonesian and english to discuss and translate the findings with the other researchers. the translation decisions were guided by the framework of abfalter et al. 2020.32 categories were grouped based on similarity, and three main themes were generated to maintain the validity and reliability of the analytic research results. the researcher collected data independently, and these themes were discussed until saturated data results were obtained. in determining the final theme, the researcher also analyzed it through peer review. henceforth, the participants’ results will be abbreviated with the letter “p” in their writing. ethical clearance the code-meaning approach is a strategy for evaluating saturation in empirical testing. in this method, reaching a complete comprehension of the codes serves as an indicator of saturation rather than relying on code counting. using this method, any issues (or codes) that are identified during an interview are reviewed and noted. subsequent interviews are then conducted to determine whether any additional nuances, dimensions, or elements of the code are identified. this process continues until no new issues are identified and the code has reached saturation. saturation of codes can occur at several locations within the dataset.33–35 the decision to stop collecting new data or involving additional participants was made as the existing phenomena had consistently been depicted similarly by each participant. even if new participants were included, their responses would likely be the same since they all come from a country with similar treatment characteristics, namely indonesia. in-depth interviews with nurses working in the covid19 isolation ward were conducted as part of our research. six participants’ data was gathered, and we discovered that our findings had reached a level of saturation, where the patterns and themes that emerged had become consistent and there was no significant additional information. this research has undergone ethical scrutiny by the ethical committee of the faculty of dentistry, university of jember, with reference number 933/un25.8/kepk/dl/2020. trustworthiness to ensure the trustworthiness of this study, peer review was conducted by experienced researchers and experts to guarantee the absence of bias or preconceived notions during the analysis and development of themes. audits and notes on methodological issues and decisions were made to ensure dependability. member checking was also performed, where the study’s findings were sent to participants for validation. as a result, no changes were made to the findings, and all researchers concurred with the results. results characteristics of participants in table 1 explain that participants in this study were six nurses who worked in the covid-19 isolation ward at the covid-19 referral hospital and had at least three months of experience caring for covid-19 patients. all participants were married, with the majority being male. the average age of participants is 30 years old, with a minimum age of 26 and a maximum of 35. the average time of experience caring for covid-19 patients among participants is six months. study findings seven themes developed from the data: nurses must possess altruistic thinking, critical thinking to solve problems, the ability to collaborate with teams, problem-solving skills, the capacity to handle emergencies, a caring attitude, and the motivation to learn. these themes are illustrated by the responses provided below. theme 1: have altruistic thinking this theme focuses on selflessness and concern for the welfare of others, depicting altruism. identified in the theme of having an altruistic spirit are humanistic concerns and sympathetic tendencies. in this regard, participant statements can be seen below: “once, i went down with complete hazmat from 7 pm to morning... the problem was the patient’s condition was bad; the baby was 8 months old, had seizures, and the fever continued not to go down even last night until the apnea was three times... until resuscitation too... cramped, hot, stuffy... i just feel... but i can’t bear to see the baby’s mother crying all the time... let me stay alert, at least i can make the family comfortable with my arrival.” (p5) “yes, actually, the usual procedure must limit speech when using level 3 ppe... what else should the mask have three layers... surgical masks, n95 and again covered with surgical masks... yes, it feels tight, hard to breathe... but it’s impossible when you see a patient who doesn’t want to eat... stressed because i can’t sleep... yes, finally, we motivate, we cheer up, in the end, we talk a lot too heheheeheheh (laughs)….” (p6) transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics demography of respondents. variables n % sex male 4 66.67 female 2 33.33 married status married 6 100.0 single 0 0 age of nurse mean 30.33 mean 30.33 nurses experience in covid-19 ward mean 6.167 mean 6.167 [page 126] [healthcare in low-resource settings 2024;12:11777] non -co mmerc ial us e o nly theme 2: critical thinking to solve problems this theme focuses on critical thinking, which means generating new and valuable ideas. this theme implies that nurses must have a responsive, sharp, and mature mind when dealing with unexpected conditions while caring for covid-19 patients, especially in situations with limited resources. the critical thinking of nurses during the care of covid-19 patients is identified with the sub-theme of wearing hazmat suits. help from healthcare teammates takes time. when a patient needs emergency assistance, nurses must act immediately to save the patient. this action encourages nurses to think critically, as seen in the participant statements below: “i received the report directly. a friend called from the delivery ward. then, the midwife had gone to the covid ward. we went down first, saw that the baby’s head was out. i never had the experience of assisting childbirth alone; yes, we had to help. we installed underpads. ordinary beds are not specifically for giving birth. finally, we helped with our simple style, heheheh (laughs), using the science of nurses. it was the first experience of a male nurse assisting childbirth...” (p5) “when we checked spo2, 80% of the patients were very short of breath. at that time, the ventilator was not ready. we immediately used double oxygen, nasal and nrbm, double oxygen, using central oxygen and cylinders. thank god, the saturation can go up to 92%” (p1) the participants’ statements above reveal that they must be equipped with various basic skills in helping patients. not only emergency skills but also other basic skills such as essential delivery assistance, critical care skills, and other abilities that must be trained before they are deployed in the field of the covid-19 ward. theme 3: ability to collaborate with a team collaboration with the team is a key competency, in addition to basic nursing skill competencies. the ability to collaborate with the team means working in coordination with all health workers involved in handling covid-19 patients. this collaborative ability determines the quality of performance in the isolation ward because the heavy workload must be evenly distributed, not burdening only a few team members but shared to reduce the workload and achieve the common goal of providing the best care for covid-19 patients. this theme is evident in the participant quotes below: “the important thing is that team members don’t talk much. they can immediately understand and already know their respective duties. it would be nice if we didn’t tire so quickly and worked faster because of mutual understanding heheheh (laughs).” (p3) “that’s good; the team of doctors also always provides suggestions about some medicines if there is an emergency with the patient... so we can act quickly on the patient... it is very suitable to work like that...” (p1) the results of the interviews above indicate that collaboration between team members in treating covid-19 patients is necessary to produce practical, fast, and accurate work. theme 4: having problem solving thinking problem-solving is the fourth theme identified in this interview. this theme implies that nurses must always be creative and innovative in recognizing the problems and current conditions of the covid-19 patients being treated. they should view these conditions as dynamic rather than static, aiming to achieve optimal patient care. covid-19 patients require longer treatment times than similar cases. participants’ statements regarding this theme can be seen below: “looking at the patients, they seemed bored. i couldn’t bear it. i compared myself to them… so, i finally invited the patients and staff to help turn the garden at the back into a sports ground. ...badminton rackets...chess and banners with motivational writing...thank god, many patients feel at home. the back garden is not boring anymore.” (p3) the participants’ statements above reveal that they have to take a special approach to situations that are rarely encountered when treating covid-19 patients in the hospital. this can be observed in the phrase “change function.” theme 5: ability to handle emergencies the fifth theme that can be explored from the results of interviews with participants is being able to handle emergencies. this theme implies that the basic skill that nurses must prepare for dealing with covid-19 is an emergency. patients can experience apnea at any time, leading to a life-threatening condition. nurses must be skilled in dealing with and able to think quickly and calmly in situations that can occur at any time. participants’ statements regarding this theme can be seen below: “if the baby has seizures, we immediately give him anticonvulsant drugs and febrifuge injections. the doctor’s instructions are there. we need to give them according to the patient’s updated condition... while we consult together.” (p5) “we are given therapy; we must have therapy. our cooperation is very close. without any special doctor’s instructions, if the blood pressure is good, furosemide self-injection, we immediately report it too, so we are given flexibility for emergency conditions, more freedom.” (p2) the statements of the participants above reveal that they are given the autonomy to make decisions in an emergency because helping patients in an emergency is a race against time. delay in making decisions and taking action can be fatal for the patient. this is reflected in the sentences “while we are consulting for a walk together” and “more freely.” theme 6: must have a caring attitude being supposed to have a caring attitude is one that can go much further. it involves nurses providing empathy, compassion, and sincere appreciation to covid-19 patients while accompanying them through difficult and critical times during treatment. this was revealed from the participant statements below: “we treat them like our own family, so remember our mothers… yes, we greet them, we talk to them, help with meals… bathe… change diapers… they need attention.” (p6) “spending time with patients… they don’t want to eat. don’t talk to them.. let us cheer up.. sometimes they have thoughts as if they were abandoned by their families, they never visit them.. so we motivate them again.” (p4) the participants’ statements show that covid-19 patients not only need skilled actions but also that a nurse must have a sincere heart without pretension, demonstrating a caring attitude in their daily interactions with patients. this is expressed in the words “need attention” and “a bit long with the patient.” theme 7: have motivation to learn. the last theme was expressed by participants in the sense of nurses having an extraordinary curiosity to master the care of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11777] [page 127] non -co mmerc ial us e o nly covid-19 patients by reading more and updating their scientific knowledge to enable the best care for these patients. “caring for covid-19 patients is a ‘challenge.’ enthusiasm for upgrading new knowledge involves seeking information by exploring the internet, not giving up easily. learning to continuously update knowledge and gaining insights from experience is crucial. opportunities presented by covid-19 are viewed as challenges for learning and becoming more skilled than others.” (p4) “you need friends, you need complex knowledge. for example, icu basics; for example, yesterday you had to teach a little about what to do with a ventilator, so you end up reading a lot and reading again, and keep on studying enthusiastically hehehe… (laughs)” (p2) the entry above suggests that nurses in the covid-19 isolation ward must have high motivational competencies to learn new things, increasing their knowledge and skills to provide accurate nursing care for covid-19 patients. this is expressed in the words “keep updating knowledge,” “learn more,” and “read a lot.” discussion in theme 1, it can be observed that participants in this study, such as p5, demonstrate a profound level of concern for patients experiencing poor health conditions, even when facing significant physical discomfort. additionally, participant p6 also depicts their high spirits in providing care and emotional support to patients, despite facing challenges with personal protective equipment. having altruistic compassion is an important component that a nurse must have to treat patients. without self-compassion skills, nurses will feel compelled to care for patients.36 the compassion of nurses for patients enhances their understanding of general conditions and motivates them to deliver nursing care with empathy, improve patient comfort, and uphold professional care standards.37 individuals who exhibit altruistic behavior tend to have a high level of sensitivity and are more positive, cooperative, and happy in their interactions with others. altruism can also diminish skeptical and aggressive attitudes when helping those in need.38 the success of a nurse in providing health services is determined by how she interacts with patients. the nurse-patient relationship can reflect kindness, compassion, longevity, gentleness, love, concern, cooperation, responsiveness, and concern, all of which contribute to the services provided to patients.39 researchers opine that a nurse’s success in delivering healthcare services is highly dependent on the quality of the nurse-patient relationship, which involves compassion, attentiveness, collaboration, and responsiveness, collectively enhancing the level of care. the altruistic behavior of nurses reflects exceptional dedication to patient well-being, overcoming task barriers, and contributing to a positive patient experience. in theme 2, which revolves around critical thinking to solve problems, as expressed by p5 and p1, it is evident that nurses must possess a diverse set of fundamental skills to care for patients. this includes emergency skills and other foundational abilities such as childbirth assistance, critical care, and various other competencies. knowledge, experience, competence, critical thinking, and standards of thought in the nursing process are integral components of professional nursing practice, enabling nurses to deliver comprehensive care tailored to the needs of patients.40 according to a study conducted by grase et al. in 2021, critical thinking ability is a crucial skill for nurses in problem-solving and selecting the best interventions for patients, which develops as they gain experience in patient care. in practice, nurses’ knowledge and experience are utilized to enhance their critical thinking abilities in providing appropriate nursing care.41 in line with previous research on critical thinking, it is emphasized that nurses need to step out of their comfort zones. nurses should cultivate their skills through diverse deductions and training, maintaining consistency in using their ideas and critical thinking, and staying updated on new developments in the nursing field. this ensures that when faced with limitations in various situations, they can address them with alternative approaches.42 the researcher’s opinion is that in the context of critical thinking in nursing care, nurses need to be trained in various foundational skills and must possess critical thinking abilities to respond quickly and effectively in emergency situations for the well-being of patients. in theme 3, the interview results highlight the importance of team collaboration in managing covid-19 patients. participant p3 emphasizes the need for each team member to understand their respective roles and efficient cooperation to address the heavy workload. participant p1 also underscores the significance of communication and collaboration with the medical team for swift and accurate actions in emergency situations. according to the research conducted by li s, wang y, xue j, et al. in 2020 and poortaghi s, shahmari m, ghobadi a in 2021, team collaboration can be defined as the effort of two or more individuals working together to achieve specific goals. in this context, teamwork is measured by aspects such as cooperation, influence, support, problem-solving, and negotiation and is influenced by factors such as team composition, norms, leadership, communication, empowerment, and recognition.43,44 teamwork comprises five components: team leadership, shared performance monitoring, mutual backup behavior, adaptability, and team orientation. collaboration and teamwork can expedite tasks and minimize errors. in a team, each member should assist others in achieving the goals.45,46 according to the researchers, team collaboration in the management of covid-19 patients is not just a necessity but a policy that enables a profound understanding among team members, which can enhance patient care, productivity, and positive working conditions. in situations that demand swift and accurate performance, team collaboration becomes the key to achieving the best outcomes. in theme 4, regarding problem-solving thinking, the understanding that covid-19 patients require longer treatment times provides a context for innovative actions, such as transforming gardens into sports fields and providing entertaining activities to alleviate patient boredom, as mentioned by participant p3. in solving problems in the context of nursing care, nurses must possess fundamental decision-making skills that not only impact the nursing care management process but also serve as a key to enhancing change planning capabilities. therefore, nurses, whether in staff or leadership positions at all clinical levels, should have effective problem-solving and decision-making abilities.47,48 nurses need to address issues related to covid-19 patients with creativity and innovation, seeking unconventional solutions, such as the example of transforming gardens into sports fields, to meet the psychological needs of patients and ensure their wellbeing. in theme 5, interviews emphasize the nurse’s ability to handle emergency situations while caring for covid-19 patients. participants, including p5 and p2, highlight the need for speed, calmness, and autonomy in decision-making when facing critical conditions such as apnea. effective collaboration and nurse empowerment are key to responding quickly to emergency situations to prevent fatal consequences for patients. in a medical emergency situation, a team needs to provide a quick and responsive transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 128] [healthcare in low-resource settings 2024;12:11777] non -co mmerc ial us e o nly response to life-saving efforts for the patient at a highly critical stage, supported by specialized training. mulya, widya et al. suggest that in a medical emergency situation, a team should respond promptly and effectively to life-saving efforts for a patient at a highly critical stage, leveraging specialized training.48,49 the job demands caregivers have skills such as the ability to work in a variety of situations, agility in understanding problems, and coping skills by finding solutions to problems or distractions. nurse communication skills can develop knowledge and ideas and build cooperative relationships. this ability can improve the quality of nursing care.50 they were also influenced by past patient experiences, indicating that as working nurses age, they gradually become more conscientious and manageable through years of experience working as nurses.51 as health workers who deal directly with patients, nurses must have many skills. one of them is interpersonal skills to communicate with patients. communication is a complex process that involves behavior and allows a person to interact with other people and the environment. nurses with skills in therapeutic communication can easily develop trusting relationships with clients, prevent legal problems, and increase professional satisfaction in nursing services.52 a high-impact simulation experience, as participants share insights related to their nursing experience, is suggested for reflecting on and recording potential extraordinary events to maintain reasonable ethical care.53 the researchers expressed the view that participants believed autonomy in decision-making during emergencies offered essential flexibility, ensuring swift and effective responses in treating covid-19 patients. in theme 6, it is evident that a caring attitude for nurses goes beyond technical skills. p6’s statement underscores the significance of offering empathy, compassion, and appreciation to covid-19 patients. p6 stressed the importance of treating patients like family, offering moral support, and assisting with daily activities. similar sentiments were expressed by p4, emphasizing the value of spending time with patients, providing motivation, and expressing concern for their feelings. this is imperative for elevating the quality of human resources and the overall standard of hospitals, given that nurses constitute the most vital resources within healthcare facilities. in the realm of nursing services, where patients frequently grapple with diverse physical and psychological challenges such as pain-related anxiety, irritability, anger, and concentration difficulties, it becomes crucial for nurses to exhibit elevated levels of caring behavior.54 through offering attention, sensitivity, and a profound caring attitude towards the patient’s condition and needs, nurses can address these concerns comprehensively, thereby fostering a care environment conducive to optimal patient recovery.54,55 nurses are expected to stay abreast of advancements in various sciences. they apply knowledge that frequently evolves with the changing times, enabling them to deliver healthcare services to patients in alignment with contemporary demands.43,56 he necessity for a caring attitude extends beyond the technical aspects of care, embodying a sincere intention to enhance the well-being of patients and address their emotional needs, especially during challenging and critical moments in the caregiving process. in the final theme, it is evident that interview participants express a strong desire to enhance their knowledge and skills in caring for covid-19 patients. p4’s statement highlights the enthusiasm to confront challenges and stay updated by exploring the internet. p2 adds that nurses require comprehensive knowledge, including the fundamentals of the icu, and must approach learning with high enthusiasm, seeking information through reading and drawing from experiential learning. in delivering health services to the community, it is crucial to possess a service-oriented attitude and paradigm, coupled with sufficient skills and knowledge that require ongoing enhancement.40 nurses are expected to stay abreast of advancements in various sciences. they apply knowledge that frequently evolves with the changing times, enabling them to deliver healthcare services to patients in alignment with contemporary demands.39 nurses in the covid-19 isolation ward demonstrate a commitment to ongoing learning and updating their knowledge to deliver optimal care for patients, reflecting a strong motivation to enhance their competence. conclusions the findings of this qualitative research unveil seven themes related to nurses’ care for covid-19 patients in isolation wards. these themes encompass altruism, critical thinking, team collaboration, problem-solving, emergency management, and caring attitudes. nurses demonstrate their dedication to delivering the best care by prioritizing patient well-being over personal comfort, applying critical and innovative thinking to tackle complex situations, collaborating with multidisciplinary teams, emphasizing problem-solving, playing a pivotal role in emergency situations, and displaying profound caring attitudes. this research highlights the significance of a holistic approach to the care of covid-19 patients, encompassing both technical and emotional aspects, 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of nurses in covid-19 patients in the isolation room. j keperawatan muhammadiyah bengkulu 2020;8:11727. 55. maisyaroh a, widianto ep, kurnianto s. the effectiveness of project-based learning on students’ academic achievement in emergency nursing study. healthc lowresour settings j 2023;1–17. 56. maisyaroh a, dwi r, widianto ep. pedoman perawat dalam merawat pasien covid-19 di ruang isolasi. 1st ed. jakarta: khd production, 2020. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11777] [page 131] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11802 enhancing early cervical cancer detection through the mobile-based dedikasi application aprina aprina, titi astuti, gustop amatiria academic nursing, tanjungkarang ministry of health health polytechnic, bandar lampung, indonesia abstract the incidence rate of cervical cancer in indonesia remains high; however, it can be prevented through early detection. the study aimed to assess the effectiveness of the dedikasi mobile application, a continuation of the early warning system (ews) cancer application for cervical cancer risk assessment in women of reproductive age. employed a quasi-experimental design with a nonequivalent group posttest-only approach, the research included 388 participants chosen through random sampling. the ews application group showed a majority categorized as “very suspect” (52.6%), while the dedikasi group had the majority in the “high risk” category (40.7%). iso 25010 testing revealed an excellent overall score of 92% for the dedikasi application, indicating strong functional suitability and usability. the t-test results (p-value = 0.000) indicated that the dedikasi application was more effective than the ews cervical ca application in assessing cervical cancer risk. the findings underscore the potential of the dedikasi mobile application for improving early detection and risk assessment of cervical cancer in women of childbearing age, offering a valuable tool to address the high incidence rate of cervical cancer in indonesia. introduction cervical cancer is characterized by the growth of abnormal cell clusters in the uterus or cervix. symptoms of cervical cancer include vaginal discharge with blood and odor, pain during sexual intercourse, pain and blood during urination, bleeding from the vagina after intercourse, and swelling of lymph nodes.1,2 according to research in 2020, there were more than 600,000 cases of cervical cancer worldwide, resulting in 342,000 deaths, including cases caused by the human papillomavirus (hpv). the incidence rate of cancer in indonesia (136.2 per 100,000 population) ranks 8th in southeast asia and 23rd in asia overall.3 the two most common types of cancer in indonesia are breast cancer and cervical cancer.4,5 according to data from the lampung provincial health office (2022), based on early detection examinations for cervical and breast cancer in lampung province in 2022, 266 cases of positive visual inspection with acetic acid (via), 64 suspected cancer cases, and 159 tumors/lumps were found. these figures indicate a decrease in the number of positive via cases, suspected cancer cases, and tumors/lumps compared to 2021. the increasing number of cervical cancer patients in indonesia each year is attributed to a lack of knowledge about early monitoring. symptoms experienced by early-stage patients are often not significantly bothersome.6,7 consequently, most cervical cancer patients only become aware of their condition when it has reached an advanced stage. early detection is crucial in preventing cervical cancer in women.8,9 the sooner abnormalities in the cervix or uterus are detected, the earlier actions can be taken for treatment. since every woman is at risk of cervical cancer, all women should adopt preventive measures against this condition.10,11 previous research by aprina, titi, and gustop in 2022 proposed the naïve bayes method for early cervical cancer detection.12 the weakness of the naive bayes method lies in the potential suboptimal performance of its predictions, and the lack of consistent attribute selection in the classification process results in lower accuracy.13,14 in a study on the development of a behavioral model for early detection of cervical cancer, maurida et al. correspondence: aprina aprina, academic nursing, tanjungkarang ministry of health health polytechnic, bandar lampung, indonesia e-mail: aprina@poltekkes-tjk.ac.id key words: cervical cancer, early detection, mobile application, reproductive age, risk assessment. contributions: aa, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ta, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ga, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: this research has been registered for ethical review under the number ethics review 190/kepktjk/iii/2023. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: thank you to the health service and community health centers in lampung province who have provided contributions and permits for this research as well as the facilities that support the success of this research. received: 14 september 2023. accepted: 30 november 2023. early access: 22 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11802 doi:10.4081/hls.2023.11802 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 104] [healthcare in low-resource settings 2024;12:11802] non -co mmerc ial us e o nly (2019)15 found significant differences in all variables in the treatment group and in the two groups, except for the perception of susceptibility variable. another study by dianti (2016)16 conducted research on the comparison of cervical cancer risk based on personal hygiene in women of childbearing age in surabaya, and the results indicated that a history of changing underwear posed the greatest risk of cervical cancer, emphasizing the importance of maintaining personal hygiene. several articles, including research by nasution (2021)17 on early detection of cervical cancer in women of childbearing age using via test, have contributed to the development of early detection models. the statistical test results showed a significant influence of health education on women’s knowledge about cervical cancer and the via test. despite various studies on early detection models and the via test, researchers conclude that the field lacks updates in science and technology. therefore, the research on the dedikasi application (acronym for deteksi dini kanker serviks, or in english, early detection of cervical cancer) serves as a renewal of the mobile-based early warning system for cervical cancer (ews cervical ca.) in women of childbearing age. this android-based application aims to simplify the early detection of cervical cancer, provide solutions for appropriate early prevention, and help the public recognize risk factors for cervical cancer in women of childbearing age. the research builds on previous studies and journals in the field of reproductive health, contributing to advancements in science and technology. the reason researchers use the dedikasi application is that, in this new application, researchers have introduced several new features for patients and health professionals, making it easier to use. this feature includes one application that works according to the problem. apart from that, the urgency of this research is to look at the phenomenon of the incidence of cervical cancer and the minimum early detection by women of childbearing age so that the dedikasi application is a feature that is very easy for women of childbearing age to obtain. they can carry out early detection easily without having to go to health services because this application is connected directly to the health workers closest to the user. the aim of this application is to accurately detect and prevent cervical cancer with the help of experts and health professionals who are part of the dedikasi application. the purpose of this study was to create the dedikasi mobile-based model for women of childbearing age and test the effectiveness of the ews.ca cervical application compared to the dedikasi application in the early detection of cervical cancer risk among users. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. range of interpretation criteria. no range of interpretation criteria (%) criteria 1 0-20 very poor 2 21-40 poor 3 41-60 fair 4 61-80 good 5 81-100 very good table 2. frequency distribution of new features assessment aspects of the dedikasi application. portability strongly agree agree neutral disagree total n % n % n % n % adaptability 210 54.1 98 25.2 50 12.9 30 7.8 388 installability 195 50.2 103 26.5 67 17.2 23 6.1 388 replaceability 228 58.8 76 19.6 53 13.6 31 8 388 table 3. frequency distribution of cervical cancer risk with dedikasi application. group category of cervical cancer risk total cautious high risk very suspect n % n % n % ews application 32 8.2 152 39.2 204 52.6 388 dedikasi application 121 31.2 158 40.7 109 28.1 388 table 4. comparison of the effectiveness of ews cervical cancer application and dedikasi on user risk factors for application. group mean sd min max p ews application 59.17 16.970 6 89 0.000 dedikasi application 45.29 16.370 13 82 table 5. comparison of ews cervical cancer application with dedikasi on application usage. group mean sd min max p ews application 65.12 16.139 33 100 dedikasi application 75.81 16.295 26 100 [healthcare in low-resource settings 2024;12:11802] [page 105] non -co mmerc ial us e o nly materials and methods this study was a quasi-experimental research with a nonequivalent group posttest-only design approach. the study population included all women of childbearing age. the sample size consisted of 388 participants selected using random sampling. the inclusion criteria for this study were women of childbearing age in lampung province, not currently pregnant, willing to be respondents, and not currently sick. the exclusion criteria for this study included women of childbearing age with impaired hearing and vision systems, and those who do not yet have a smartphone. the research variables consist of the dependent variable: the dedikasi application used and the independent variable: risk factors for cervical cancer. the research was conducted from august to december 2023 in lampung province. this research instrument used a questionnaire comprising 14 questions regarding application feasibility tests created by researchers, and validity and reliability tests have been carried out. the research was divided into three stages: stage 1 included data collection and quantitative data processing, stage 2 focused on developing a model for early detection of mobile technology-based cervical cancer services for women of childbearing age, and stage 3 included feasibility testing of the dedikasi application, expert workshops, and outreach to identify any model weaknesses. statistical analysis was carried out using a simulator program to produce the dedikasi application model that can be accessed online via mobile devices, providing a tool for assessing the risk of cervical cancer in women of childbearing age. data analysis included univariate analysis carried out descriptively, and bivariate analysis used the t-test statistical method. this research has been registered for ethical observation with ethical review number 190/kepk-tjk/iii/2023. results univariate analysis comparison of iso software quality assessment between the ews ca. cervix application and the dedikasi application the usability assessment of the ews ca. cervix mobilebased application was conducted using the international organization for standardization (iso) 25010 standard. a total of 142 respondents, women of childbearing age, answered 8 questions. these questions were categorized into 2 related to functional suitability, measuring the software’s ability to provide functions that meet specific needs under certain conditions. the remaining 6 questions pertained to usability, evaluating how effectively, efficiently, and satisfactorily the product or system can be used by specific users within the context of use. each question had multiple-choice answers with corresponding scores: strongly agree (5), agree (4), neutral (3), disagree (2), and strongly disagree (1). the iso 25010 calculation results are expressed in the formula: subsequently, the questionnaire results are compared with the score interpretation criteria range, as presented in table 1. the data processing in the iso 25010 testing, covering functional suitability and usability, indicates that the ews ca cervix application software achieved an overall percentage score of 88%, classifying it as “very good” for use based on the interpretation score range (table 1).18 the dedikasi mobile-based application underwent usability testing using iso 25010. the test involved 388 respondents of reproductive-age women who answered 8 questions, including 2 related to functional suitability and 6 related to usability. the iso 25010 calculation results are presented in the formula: the results from the questionnaire are then compared with the score interpretation criteria range, leading to the determination that the dedikasi application software achieved an overall percentage score of 92%, classifying it as “excellent” for use based on the score interpretation criteria range (table 1). in this latest application, new features are identified within the portability aspect, encompassing the following sub-domains: (a) adaptability: the average respondents strongly agree, with a count of 210 (54.1%) for this indicator. the testing indicator suggests that the transition from ews ca cervix to the dedikasi application can be easily adapted by users, thanks to its new features; (b) installability: the average respondents strongly agree, with a count of 195 (50.2%) for this indicator. the testing indicator demonstrates easy installation when using the dedikasi application; (c) replaceability: the average respondents strongly agree, with a count of 228 (58.8%) for this indicator. the testing indicator indicates that the dedikasi application can seamlessly replace the ews ca cervix application with the implementation of its new features (table 2). frequency distribution of cervical cancer risk with dedikasi application referring to table 3, it is evident that in the ews application group, the majority fall into the “very suspect” category, totaling 204 (52.6%), while in the dedikasi application group, the majority are in the “high risk” category, totaling 158 (40.7%). bivariate analysis in table 4, the research results reveal that the average value for the dedikasi application is 45.29, with a standard deviation of 16.370, a minimum value of 13, and a maximum value of 82. for the ews application, the average is 59.17, with a standard deviation of 16.970, a minimum value of 6, and a maximum value of 89. the t-test results yield a p-value of 0.000, indicating a comparison of the effectiveness of the ews cervical cancer application with dedikasi on application users. table 5 presents research results showing that the average value for the dedikasi application is 75.81, with a standard deviation of 16.295, a minimum value of 33, and a maximum value of 100. for the ews application, the average is 65.12, with a standard deviation of 16.139, a minimum value of 26, and a maximum value of 100. the t-test results yield a p-value of 0.000, indicating transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 106] [healthcare in low-resource settings 2024;12:11802] non -co mmerc ial us e o nly a comparison of the ews cervical cancer application with dedikasi on application usage. discussion comparison of iso assessment between ews cervical cancer application and dedikasi testing this application aims to improve cervical cancer prevention, consequently enhancing the quality of life for women of reproductive age. cervical cancer screening proves effective in reducing morbidity and mortality.19 successful screening programs in communities not only raise awareness but also implement prevention and detection programs.20 the high mortality rate in cervical cancer patients results from a lack of awareness, often identified only in advanced or late stages. a pivotal effort to reduce the number of cervical cancer cases involves early detection. several studies propose methods or approaches for early detection, including the one conducted by riani and ambarwati (2020).21 this study provided exposure and discussions on early detection of cervical cancer, along with demonstrations of via and pap smear examinations to the community in banyumas regency, central java. evaluation results indicated an increase in knowledge about cervical cancer symptoms and heightened awareness of via and pap smear examinations. subsequently, leveraging technological advancements, agustyawati et al. (2021)22 proposed the design of an early cervical cancer detection application using convolutional neural network (cnn) deep learning techniques. the study employed digital image data in the form of via results, categorized into two classes: positive cervix with 77 images and negative cervix with 82 images. the evaluation results demonstrated that the application design could detect cervical cancer with an accuracy of 96%.23 distribution of cervical cancer risk with the dedikasi application cervical cancer significantly impacts the quality of life for patients, their families, and healthcare financing by the government. therefore, prevention and early detection efforts are crucial.24 the low utilization of cervical cancer prevention services in low and middle-income countries is attributed to individual barriers, including a lack of knowledge and awareness about cervical cancer risk factors and prevention, age, marital status, socioeconomic status, religious and cultural beliefs, reproductive healthrelated stigma, and health system factors.25 cervical cancer is a malignancy that occurs in the cervix, the lower part of the uterus extending into the top of the vagina. cervical cancer cells undergo changes over time, and signs of these changes may indicate the development of cancer.26,27 various government efforts to prevent and control cervical cancer include the pap smear examination to raise public awareness. world cancer day is observed on february 4th. the health department’s program includes activities in hospitals promoting and educating healthy and clean lifestyles while avoiding risk factors, administering hpv vaccination, and conducting screenings for early detection of cervical cancer.28,29 this screening aims to detect precancerous changes, which, if left untreated, can lead to cancer. abnormalities found in the screening require follow-up with diagnosis and treatment to prevent cancer progression or treat it at an early stage.30 the who recommends screening at least once for each woman in the target age group (30-49 years), with recommended screening tests including hpv testing, cytology, and via.26,31,32 this study’s results align with some previous findings that indicate all informants perceive cervical cancer as a malignant disease, with its severity potentially leading to uterine loss and even death. informants express a willingness to take preventive measures.33,34 in nonik ayu’s research (2019),35 women’s beliefs were not related to early detection, possibly due to a lack of information about via and difficulties in scheduling time for health check-ups, including via tests, due to work or household responsibilities. another study by sahr and kusumaningrum (2018)36 states that women perceive cervical cancer as a disease with very serious consequences, with the belief that cervical cancer patients face a difficult and time-consuming treatment process with high associated costs. the perception of disease severity or symptoms felt is related to the willingness to undergo a via test. according to the health belief model theory, individuals’ actions in preventing or treating a disease are influenced by perceived benefits. their actions depend on their evaluation of perceived vulnerability and perceived benefits, and they are more likely to adopt recommended health actions if they perceive them as beneficial.37,38 the lack of early indications caused by cervical cancer results in women not realizing they have the disease until it is often too late for treatment, leading to many deaths among women.39 therefore, early detection of cervical cancer is necessary, as it can lead to a delay in the diagnosis and treatment of advanced-stage cervical cancer, which cannot yet be treated.40 additionally, reasons why women are reluctant to undergo examinations include psychological issues, lack of knowledge, and socioeconomic factors41. the research concludes that the early detection of cervical cancer is influenced by the beliefs and knowledge of respondents after being educated through the application and directly explained by the researcher, making women more confident and willing to undergo early detection through the application. comparison of the effectiveness of the ews cervical cancer application with dedikasi on user risk factors beyond relying on physical examinations, early detection of cervical cancer can be discerned by considering external factors like behavior and an individual’s environment. shalikhah et al. (2021)42 conducted a study examining the correlation between family support (environmental support) and attitudes toward early detection of cervical cancer. the research by fransisca and adhisty (2023),43 emphasizes the crucial role of family support in managing and enhancing the motivation of cervical cancer patients. alpan’s study (2021)44 delves into behavioral factors by utilizing behavioral data to identify the occurrence of cervical cancer in patients. the study employed eight classification algorithms and found that the support vector machine (svm) method, using the weka tool, achieved an accuracy rate of 91.67%. additionally, a mother’s knowledge of healthy living behaviors related to cervical cancer positively impacts early cervical cancer prevention behaviors.45 early detection is imperative to reduce the prevalence of cervical cancer cases and prevent advanced-stage conditions. methods for early detection, including pap smears, the via test, pap smear, and colposcopy, contribute significantly to cervical cancer prevention.30 factors such as early sexual relationships, late marriage, and having multiple sexual partners also contribute to cervical cancer. early detection represents an innovative breakthrough in healthcare development, aiming to reduce mortality and transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11802] [page 107] non -co mmerc ial us e o nly morbidity associated with cervical cancer. efforts to enhance the implementation of cervical cancer early detection include a focus on women’s education.10,27 comparison of the ews cervical cancer application with dedikasi in terms of application usage the dedikasi application proves more effective when compared to the initial ews cervical cancer application. defined as “a system is a collection of components or variables whose contents consist of several interconnected, linked, and mutually supportive parts that unite as a whole (unity) to achieve a specific goal effectively,” an expert system serves as a computer application assisting in decision-making or problem-solving within a specific field. in contrast, an application is a computer program designed for users to perform specific tasks. android, a touch-screen mobile device utilizing an operating system, employs basic android as a rad (rapid application development) tool for creating androidbased applications. earlier research focused on digital image processing solely to quantify the color characteristics of white lesions on the squamous columnar junction (scj) using zero-crossing edge detection and quantifying rgb values.46 however, for accurate determination of via test results as positive or negative, understanding the color characteristics alone is insufficient. crucial parameters in diagnosing cervical cancer, such as the shape and pattern of white lesions on the scj epithelial tissue, must be considered. employing the canny edge detection method, image processing was conducted, followed by data classification using convolutional neural network to determine pre-cervical cancer diagnosis. the study yielded a 96% accuracy rate in detecting pre-cervical cancer.47,48 researchers assert that the dedication application offers convenience through new features and consolidates all necessary health services into one accessible link. the application facilitates health workers in monitoring patients with a history of cervical cancer, providing consultation services via whatsapp, and simplifying the delivery of education on management and risk factors for cervical cancer. the scope of this research is limited to women of childbearing age, aiming to detect early cervical cancer. conclusions the study provides a thorough comparison of the effectiveness of the ews cervical cancer application and dedication in terms of application usage, with dedication proving more effective. future research could delve deeper into user-specific factors influencing the application’s efficacy, considering variables such as socio-economic backgrounds, education levels, and technological literacy. additionally, exploring the long-term impact of consistent application use on cervical cancer prevention and detection outcomes could provide valuable insights. furthermore, assessing the potential scalability of such applications in diverse cultural contexts would contribute to a more nuanced understanding of their global applicability. references 1. budi hs, younus la, lafta mh, et al. the role of mir-128 in cancer development, prevention, drug resistance, and immunotherapy. front oncol 2023;12:1067974. 2. suleman s, fitriana s, cahyati e. aplikasi sistem pakar deteksi dini kanker serviks berbasis android. indones j comput inf technol 2019;4(1). 3. who. cervical cancer indonesia 2021 country profile. 2021. available from: https://www.who.int/publications/m/item/cervical-cancer-idn-country-profile-2021 4. kristina sa, endarti d, aditama h. prediction of productivity costs related to cervical cancer mortality in indonesia 2018. malays j med sci 2022;29:138-44. 5. fitzmaurice c, abate d, abbasi n, et al. global, regional, and national cancer incidence, mortality, years of life lost, years lived with disability, and disability-adjusted life-years for 29 cancer groups, 1990 to 2017: a systematic analysis for the global burden of disease study. jama oncol 2019;5:1749-68. 6. armini nka, kusumaningrum t, sari ap. theory of planned behaviour for cervical cancer prevention view of husband support. indian j public heal res dev 2019;10:2553-8. 7. lintao rc v, cando lft, perias gas, et al. current status of human papillomavirus infection and cervical cancer in the philippines. front med 2022;9:929062. 8. tse ky, ushijima k, tan al, et al. a questionnaire study on disparity of cervical cancer prevention programs in asiaoceania. j obstet gynaecol res 2023;49:1230-43. 9. malehere j, armini nka, ulfiana e, dewi ki. behaviour of cervical cancer prevention among fertile age woman: health promotion approach. int j public heal sci 2022;11:793-9. 10. setiawan d, andrijono, hadinegoro sr, et al. cervical cancer prevention in indonesia: an updated clinical impact, costeffectiveness and budget impact analysis. plos one 2020;15:e0230359. 11. nuranna l. see and treat: cervical cancer prevention strategy in indonesia with via-dovia screening and prompt treatment. indones j cancer control 2022;2:32-8. 12. aprina a, astuti t, amatiria g. early warning system of cervic cancer (ews ca. cervic) in women of reliable age based on mobile. j aisyah j ilmu kesehat 2022;7(4). 13. devi s, gaikwad sr, r h. prediction and detection of cervical malignancy using machine learning models. asian pacific j cancer prev 2023;24:1419-33. 14. arifin m. naive bayes algorithm based on backward elimination for predicting cervical cancer. int j innov sci res technol 2022;7(7). 15. maurida n, sukartini t, indarwati r. persepsi keparahan kanker serviks dan keteraturan melakukan deteksi dini kanker serviks. j penelit kesehat suara forikes 2019;10:2158. 16. dianti nr, isfandiari ma. perbandingan risiko ca serviks berdasarkan personal hygiene pada wanita usia subur di yayasan kanker wisnuwardhana surabaya. j promkes indones j heal promot heal educ 2017;4:82-91. 17. nasution p. faktor yang mempengaruhi deteksi kanker serviks dengan metode tes iva. j kebidanan malahayati 2021;7:664-72. 18. sugiyono s, lastariwati b, budiastuti e, yudianto a. development of authentic assessment instruments for saintifical learning in tourism vocational high schools. j pendidik teknol dan kejuru 2018;24:52-61. 19. ploysawang p, rojanamatin j, prapakorn s, et al. national cervical cancer screening in thailand. asian pacific j cancer prev 2021;22:25-30. 20. plescia m, wong f, pieters j, joseph d. the national breast and cervical cancer early detection program in the era of health reform: a vision forward. cancer 2014;120:2620-4. 21. riani en, ambarwati d. early detection kanker serviks seba transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 108] [healthcare in low-resource settings 2024;12:11802] non -co mmerc ial us e o nly gai upaya peningkatan derajat hidup perempuan. selaparang 2020;3:144-6. 22. agustyawati dn, fauzi h, pratondo a. perancangan aplikasi deteksi kanker serviks menggunakan metode convolutional neural network application design of serviks cancer detector based using convolutional network. e-proceeding eng 2021;8:3908-25. 23. riries r, winarno, asiah cn, et al. cervical single cell of squamous intraepithelial lesion classification using shape features and extreme learning machine. in: 10th international conference on theoretical and applied physics, ictap 2020. departement of physics, faculty of science and technology, universitas airlangga, surabaya, indonesia: iop publishing ltd; 2021. 24. kessler ta. cervical cancer: prevention and early detection. semin oncol nurs 2017;33:172-83. 25. maseko fc, chirwa ml, muula as. cervical cancer control and prevention in malawi: need for policy improvement. pan afr med j 2015;22:247. 26. who. cervical cancer. world health organisation. 2023 [cited 2023 jun 12]. available from: https://www.who.i nt/health-topics/cervical-cancer#tab=tab_1 27. šarenac t, mikov m. cervical cancer, different treatments and importance of bile acids as therapeutic agents in this disease. front pharmacol 2019;10:484. 28. cdc. national breast and cervical cancer early detection program (nbccedp) [internet]. division of cancer prevention and control, centers for disease control and prevention. 2023 [cited 2023 jun 16]. available from: https://www.cdc.gov/cancer/nbccedp/about.htm 29. herzog tj, huh wk, einstein mh. how does public policy impact cervical screening and vaccination strategies? gynecol oncol 2010;119:175-80. 30. basoya s, anjankar a. cervical cancer: early detection and prevention in reproductive age group. cureus 2022;14:e31312. 31. wondimu a, postma mj, van hulst m. cost-effectiveness analysis of quadrivalent and nonavalent human papillomavirus vaccines in ethiopia. vaccine 2022;40:2161-7. 32. luttjeboer j, wondimu a, van der schans j, postma mj. maximising the potential of hpv vaccines. lancet glob heal 2020;8:e460-1. 33. ayanto sy, belachew lema t, wordofa ma. women’s and health professionals’ perceptions, beliefs and barriers to cervical cancer screening uptake in southern ethiopia: a qualitative study. sex reprod heal matters 2023;31:2258477. 34. obol jh, harrison r, lin s, et al. perceptions of key informants on the provision of cervical cancer prevention and control programme in uganda: implication for cervical cancer policy. bmc public health 2020;20:1396. 35. wantini na, indrayani n. deteksi dini kanker serviks dengan inspeksi visual asam asetat (iva). j ners dan kebidanan (journal ners midwifery) 2019;6:027-34. 36. sahr la, kusumaningrum tai. persepsi dan perilaku wanita usia subur dalam melakukan tes inspeksi visual asam asetat. j promosi kesehat indones 2018;13(2). 37. kim s, kim s. analysis of the impact of health beliefs and resource factors on preventive behaviors against the covid-19 pandemic. int j environ res public health 2020;17:8666. 38. faradisa e, ardiana h, priyantini d, et al. a systematic review of the factors associated with cervical cancer screening uptake among women in low and middle-income countries. j ners 2020;15:113-9. 39. anggraini n. health education pemeriksaan pap smear. j kesehat dan pembang 2019;9:61-7. 40. nopiyanti n, ratnasari f. hubungan pengetahuan wanita usia subur (wus) tentang pap smear dengan keikutsertaan melakukan pemeriksaan pap smear. j heal sains 2021;2:21623. 41. svihrova v, kocsis l, svihra j, szaboova v. barriers to the cervical cancer screening by cpc-28 questionnaire: a pilot study. arch clin biomed res 2022;6:764-70. 42. shalikhah s, santoso s, widyasih h. dukungan keluarga dan perilaku deteksi dini kanker serviks pada wanita usia subur. j ilm kebidanan (the j midwifery) 2021;9:1-7. 43. younanda mirah fransisca, adhisty k, firnaliza rizona. a mobile application for calculating nutrition of cervical cancer patien. caring indones j nurs sci 2023;5:9-16. 44. alpan k. performance evaluation of classification algorithms for early detection of behavior determinant based cervical cancer. in: 2021 5th international symposium on multidisciplinary studies and innovative technologies (ismsit). 2021. p. 706-10. 45. rochwati s, jati sp, suryoputro a. pengetahuan bidan mempengaruhi praktik bidan dalam konseling pemeriksaan iva pada wanita usia subur. j promosi kesehat indones 2016;11:84-99. 46. bestry ds, hidayat b, tsp hf. deteksi dini kanker serviks metode iva berbasis pengolahan sinyal digital menggunakan deteksi tepi zero crossin. eproceedings eng 2016;3:4816-22. 47. dongyao jia a, zhengyi li b, chuanwang zhang c. detection of cervical cancer cells based on strong feature cnn-svm network. neurocomputing 2020;411:112-27. 48. park yr, kim yj, ju w, et al. comparison of machine and deep learning for the classification of cervical cancer based on cervicography images. sci rep 2021;11:16143. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11802] [page 109] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12948 intervention model in reducing the unmet need for contraception: a systematic literature review on technology-based, community, and health worker interventions lia nurdini,1,2 legina anggraeni,1 loveria sekarrini,1 petriana ekklesia mahmud,1 sabarinah prasetyo1 1faculty of public health, universitas indonesia, depok; 2faculty of medicine and health sciences, universitas jambi, jambi, indonesia abstract the unmet need for contraception is a serious public health problem, and efforts to reduce the unmet need for family planning are a challenge due to the many and complex factors that contribute to the unmet needs. the aim of this study was to systematically review scientific evidence on intervention models that effectively reduce the unmet need for contraception. this study used a systematic review to identify relevant scientific articles. the article search was based on the pico approach and used a database from scopus, science direct, pubmed, mdpi, jstor, nature, and springer. the reviewed material was full-text articles and open-access articles published from 2013 to 2023. data extraction included author, country, type of intervention, research design, sample, and main research findings. twelve studies were included in our qualitative synthesis. technology-based interventions, such as mobile phone instant messaging apps, were implemented in countries like tajikistan, bolivia, and mozambique. community-based interventions included the community family health=family wealth program in uganda, the tékponon jikuagou (tj) program in benin, and the married adolescent girls club (mag club) and participatory women’s group intervention in bangladesh. health worker-led interventions involved community health volunteers in nepal, postpartum contraceptive counseling, contraceptive counseling for all ages, structured counseling for childbearing couples in indonesia, and the “consult and choose” client-centered family service in jordan. the findings underscore that varying intervention models can significantly enhance contraceptive use, tailored to specific cultural and regional contexts. these interventions, therefore, hold substantial implications for public health practices aiming to address and reduce the global unmet need for contraception. this systematic review provides valuable insights into the effectiveness of diverse interventions and suggests avenues for public health strategies to expand contraceptive access and use globally. introduction the unmet need for contraception is a serious public health problem, with various negative impacts, such as unwanted pregnancies, unplanned births, abortions, and increased maternal and child health risks.1 the unmet need figure from year to year still has not reached the unmet need figure targeted by the national population and family planning board (indonesian: badan kependudukan dan keluarga berencana nasional, abbreviated bkkbn) in the strategic planning of bkkbn in 2020-2024, of about 7.4%,2 and the high number of unmet needs in indonesia has the potential to lead to high maternal mortality rates.3 this is due to an unwanted pregnancy. indonesia has the third highest maternal mortality rate (mmr) compared to asean countries in 2017, with 177 deaths per 100,000 births.4 the unmet need for contraception is a condition in which couples of childbearing age want to delay or avoid pregnancy but do not use contraception. various factors can cause this, for example:5 i) lack of access to contraceptive information and services; ii) dissatisfaction with available contraceptive methods; iii) concerns about contraceptive side effects; iv) social norms and stigma related to contraception. reducing the unmet need for family planning is a challenge due to the many complex factors that contribute to the unmet need. therefore, appropriate and targeted interventions are needed to reduce the unmet need for contraception. the results correspondence: lia nurdini, faculty of public health, universitas indonesia, depok, indonesia. e-mail: nurdinilia1@unja.ac.id key words: unmet need, contraception, family planning, intervention. contributions: conceptualization, ln, sp, la, ls and pem; methodology, la, ls; formal analysis, sp; investigation, pem.; data curation, pem; writing—original draft preparation, ln; writing—review and editing, ln, sp, la, ls and pem; visualization, la; supervision, sp; project administration, ls. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: the indonesia endowment fund for education (lpdp) for the ph.d. scholarship fund awarded to the first author. availability of data and materials: data will be available upon request from the authors. acknowledgements: the researchers also thank the indonesia endowment fund for education (lpdp) for the ph.d. scholarship fund awarded to the first author and the center for higher education funding (bppt), who have become sponsors (funders) in writing this article. received: 21 august 2024. accepted: 6 september 2024. early access: 23 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12948 doi:10.4081/hls.2024.12948 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 22] [healthcare in low-resource settings 2025;13:12948] of systematic review research also showed that most of the reviews (15 studies) focused on psychosocial interventions, followed by incentives (6 studies) and technology-based interventions (6 studies).6 tailored and specific interventions can enhance the health of mothers and children. an intervention model that combines contraceptive education and counseling, access to affordable and quality contraception, and social support can be an effective solution to reduce the unmet need for contraception. a systematic review of the literature on intervention models in reducing the unmet need for contraception can make a significant contribution to increasing the understanding of this problem, encouraging innovation, and improving policies and practices to achieve universal access to contraception. the aim of this research is to systematically review scientific evidence on effective intervention models to reduce the unmet need for contraception. however, the implementation of these intervention models faces several challenges, particularly in diverse cultural and socioeconomic settings. these include variability in acceptance based on cultural norms and beliefs about family planning, economic barriers that limit access to contraception, and the scalability of interventions across different healthcare infrastructures. a thorough understanding of these factors is essential for designing interventions that are not only effective but also culturally sensitive and economically feasible. materials and methods study design this study used a systematic review to identify relevant scientific articles. the systematic review was prepared using the prisma (preferred reporting items for systematic reviews and metaanalyzes) methodology. keyword and synonym combinations were developed and applied in article searches based on the pico approach. population (p), women of childbearing age; intervention (i), the intervention was an intervention model to reduce the unmet need for contraception, and this intervention combined various components, such as contraceptive education and counseling, access to affordable and quality contraception, and social support; comparison (c), none; outcome (o), use of contraception. inclusion and exclusion criteria the inclusion criteria were: i) type of research, intervention for unmet need for contraception, ii) sample/respondents are women, iii) articles published from 2013 – 2023 and open access, iv) articles in english. the exclusion criteria are: i): type of review article (systematic literature review, meta-analysis), ii) research conducted in developed countries. search strategy literature search was made by using the database from scopus, science direct, pubmed, mdpi, jstor, nature, and springer. this research uses keywords in the process of searching for scientific articles with the following format: ((((intervention[title/abstract]) and (“unmet need for family planning”[title/abstract])) or (“unmet need for contraception”[ title/abstract])). all databases obtained on the website are then stored in the reference management application called zotero. screening the included studies were evaluated based on their titles and abstracts, and the full texts were screened. to prevent bias in the selection of scientific articles based on predetermined inclusion and exclusion criteria, scientific articles that meet the eligibility criteria are identified and then independently reviewed by two reviewers. duplicates were removed automatically; if they were not relevant, they were manually removed. tools for scavenging titles, abstracts, and duplicates were available on the website rayyan (https://www.rayyan.ai/). data extraction twelve scientific articles were successfully evaluated and confirmed for data extraction (figure 1). the information collected and entered in the table includes the author, country, type of intervention, research design, sample, and main research findings. the researchers then compared the types of intervention and the main findings concerning the unmet need for contraception. to resolve any discrepancies between reviewers during data extraction, a third reviewer was consulted to reach a consensus. quality assessment the assessment of risk of bias was a key element of this systematic review workflow. we use the risk-of-bias visualization (robvis) application using the url https://mcguinlu. shinyapps.io/robvis/. robvis is a web application designed to visualize the risk of bias assessments performed in systematic reviews.7 the five domains used in the robvis website application are i) bias due to randomization; ii) bias due to deviations from intended intervention; iii) bias due to missing data bias; iv) bias due to outcome measurement; v) bias due to selection of report results. each domain has three options: high, some concerned, and low. a more detailed explanation of these tools underscores that each domain is assessed independently and contributes to an overall risk of biased judgment, ensuring rigorous evaluation of study quality. results supplementary materials table 1 presents a summary of the 12 extracted articles, encompassing three intervention groups: technology-based interventions, community-based interventions, and health worker-delivered interventions through education and counseling. these interventions were implemented across a diverse range of countries, including tajikistan, uganda, nepal, benin, bolivia, bangladesh, jordan, indonesia, and mozambique. supplementary materials table 1 highlights the varying outcomes observed across the intervention groups, demonstrating the diverse potential and effectiveness of these models in reducing the unmet need for contraception. supplementary materials table 2 shows three intervention groups studied, including technology-based interventions, community, and health workers through education and counseling to increase knowledge, access, and use of contraception. group 1 is a technology-based intervention carried out in tajikistan, using mobile phone app instant messaging, increasing the use of modern contraception, and bolivia, using mobile phone app instant messaging, increasing the use of modern contraception. mozambique using sms reminder messages increases contraceptive use. group 2 is a community-based intervention carried out in uganda using the community family health = family wealth intervention model to increase knowledge and use of contraception. benin and the tékponon jikuagou (tj) program increase the discussion of contraception and social norms. bangladesh, with the married adolescent girls club (mag club) model, increases knowledge and use of contraception, and participatory women’s article [healthcare in low-resource settings 2025;13:12948] [page 23] group interventions increase knowledge and use of contraception. group 3 is the intervention through health workers carried out in nepal with community health workers such as female community health volunteers (fchv) increasing access and use of contraception and postpartum contraceptive counseling increasing contraceptive use, and contraceptive counseling increasing knowledge and use of contraception. in indonesia, structured counseling for children-bearing-age couples (in indonesia: pasangan usia subur, abbreviated as pus), increases contraceptive use. in jordan, with client-centered family planning service interventions: “consult and choose” (cc) increased contraceptive choice and use. quality assessment figure 2 shows that 9 articles have a low risk of bias and 3 articles whose bias falls into the same concern category. domain 3, regarding bias due to missing data, is of concern because most articles in the researchers’ assessment fall into the category of some concern. discussion the research results show that three interventions have been implemented to reduce the unmet need for contraception in developing countries: technology-based, community-based, and health worker interventions. each intervention provides varying and inconsistent results. the results of another review regarding contraceptive use in low and middle-income countries show four intervention groups that include:6 i) psychosocial interventions, such as contraceptive counseling; ii) incentive-based interventions, such as performance pay programs; iii) m-health technology-based interventions, such as messaging by cell phone; iv) community-based interventions. efforts to reduce the unmet need for contraception are a complex problem and require a combination of various interventions. different interventions are needed for different population subgroups and geographic regions.20 traditions, beliefs, and norms of local society,21 individual aspirations/preferences,22 and the availability of family planning services can influence adolescents’ attitudes and desires toward family planning programs.23 article figure 1. prisma flow diagram. [page 24] [healthcare in low-resource settings 2025;13:12948] research on technology-based interventions to reduce the unmet need for contraception shows mixed results. on the one hand, interventions via mobile app instant messaging in tajikistan did not show additional benefits in increasing the acceptance of effective contraception among adolescents.8 this suggests that technology-based interventions may not always be effective in increasing contraceptive use and that further investigation is needed to examine the factors that influence their effectiveness. on the other hand, research in bolivia shows that technology-based interventions can help increase contraception use. this intervention uses a mobile application to provide information and education about contraception to women and has been shown to increase the use of modern contraception.12 furthermore, research in mozambique shows that sms reminder messages can potentially increase the likelihood that women receive family planning services.19 mobile applications have great potential to improve the access and quality of family planning services. this is because mobile applications for family planning programs can be applied to provide information and education on reproductive health and contraception,24 reminders to take contraceptive pills or contraceptive injections,25 consultation with health workers by chat or video call, ordering and purchasing contraception online.26 the use of mobile phones and smartphones in lower-middleincome countries is increasing rapidly and has the potential to be an effective tool for delivering programs aimed at improving family planning outcomes. however, a systematic review of the literature shows that there is not enough evidence to conclude whether technology-based interventions can increase contraceptive use.24 the integration of technology-based interventions with community and health worker-based approaches presents a promising avenue for enhancing the effectiveness of each model. by combining the rapid dissemination and personalization capabilities of mobile technologies with the trust and local knowledge provided by community health workers, interventions can be both broadly reached and deeply impactful. for example, community health workers can use mobile tools to track and manage patient information, deliver targeted health education, and support adherence to contraceptive methods through reminders and follow-ups sent via mobile apps. this combined approach leverages the unique strengths of each intervention model and can be tailored to meet the diverse needs of different communities. intervention through healthcare workers has an important role in increasing contraceptive use and reducing the unmet need for contraception. research in nepal shows that training healthcare workers can improve their knowledge and ability to provide postnatal contraceptive counseling.10 this shows that appropriate training can help health workers provide quality contraceptive services. other research in nepal suggests that postpartum counseling and iud insertion can increase demand and help women manage the spacing between pregnancies.13 this suggests that interventions that focus on long-term contraceptive methods can help reduce the unmet need for contraception. in indonesia, structured counseling has been proven to be able to increase knowledge, attitudes, and use of modern contraception among couples of childbearing age.17 this shows that effective counseling can help women and men choose and use appropriate contraception. in jordan, the clientcentered family planning service intervention: “consult and choose” (cc) was shown to be effective in increasing contracep article figure 2. traffic light risk of bias plot of rob2 assessments created using robvis and the color-blind palette. [healthcare in low-resource settings 2025;13:12948] [page 25] tive choice and use.16 this intervention shows that by providing complete information and choices, adolescents can choose the contraception that best suits their needs. research shows that there is a significant relationship between the role of health workers in providing contraceptive counseling and the use of contraceptives, but the correlation is low.27 low closeness can be caused by several obstacles in providing contraceptive counseling faced by health workers, namely, public understanding of contraceptive services is limited to the act of providing or installing contraception, low level of education, age factor in demographic data (>35 years).27 community-based interventions have been proven to be effective in increasing contraceptive use and reducing the unmet need for contraception. community-based intervention is an approach to solving problems or achieving goals that involve the active participation of community members. these interventions are designed and implemented taking into account local needs and culture. various studies show that these interventions can help change norms and behavior regarding contraception, as well as increase access to and knowledge about contraception. in uganda, an intervention that included group discussions of couples was shown to increase contraceptive use and reduce the desire to have children.9 this suggests that community-based interventions can help couples discuss and decide on contraceptive use openly and clearly. in benin, the tékponon jikuagou (tj) program uses a social network approach to encourage social and behavioral change regarding contraception.11 this program has proven effective in increasing discussion about contraception and encouraging the use of modern contraception. in bangladesh, the married adolescent girls club (mag club) has been proven effective in providing information on contraception, improving contraceptive practices, and reducing the unmet need for contraception among adolescent girls.15 other research in bangladesh shows that participatory women’s groups can potentially increase women’s health knowledge, including knowledge about contraception.18 however, more research is needed to examine the effectiveness of this group in meeting the unmet need for contraception and other health aspects. in general, community-based interventions are an effective strategy to reduce the unmet need for contraception. these interventions can help change norms and behavior regarding contraception, as well as increase access and knowledge about contraception. community health professionals play an important role in increasing access to family planning services and increasing contraceptive use in the community.28 based on the results of this review, communityand health worker-based interventions can increase knowledge and use of contraception, even in resource-limited environments such as lowand middle-income countries. myths, culture, local wisdom, and intrapersonal factors significantly influence health service utilization patterns.29 successful efforts to reduce the unmet need for family planning are complex because they must simultaneously address the interplay between the local sociocultural context, individual beliefs, aspirations, and preferences, and the environment of contraceptive provision at the national and local levels.20 in addition, community-based interventions contribute to empirical evidence on the sustainable impact of community-based interventions on increasing the use of family planning among married adolescent girls in low and middle-income countries.30 based on the experience of each country in efforts to reduce the unmet need for contraception, there are several advantages of community-based interventions, namely: i) easier access, ii) a more personal approach, iii) stronger social support, and iv) higher sustainability. community-based interventions can reach groups that are difficult to reach, such as married teenagers in rural or remote areas, and these interventions are carried out in places that are easily accessible to the community, such as posyandu, village halls, or places of worship. these interventions involve community members in the planning and implementation process so that it is more appropriate for local needs and culture, and this intervention allows more personal interaction and communication between service providers and service recipients. these interventions help build social support networks among community members, which can help women use contraception. support from family, friends, and neighbors can help women overcome barriers to using contraception. these interventions involve active participation in the community and build the capacity of the community to provide family planning services independently. community-based interventions have been proven to be effective in increasing contraceptive use and reducing the unmet need for contraception. these interventions are designed and implemented taking into account local needs and culture. the potential for integrating technology with community and health worker efforts could further enhance these interventions by providing scalable solutions that are sensitive to local contexts and highly effective at reaching and engaging target populations. conclusions all three types of intervention—technology-based, community-based, and health worker-based—have shown potential to reduce the unmet need for contraception. the effectiveness of these interventions can vary significantly depending on the context and other factors. while technology-based interventions have shown mixed results, community, and health worker-based interventions have been consistently effective in increasing contraceptive use and reducing the unmet need for contraception. these interventions facilitate changes in norms and behavior related to contraception and enhance access to and knowledge about contraceptive options. to maximize the impact of these interventions, the importance of multidisciplinary collaboration cannot be overstated. engaging a diverse range of professionals—including educators, healthcare providers, technologists, and community leaders—ensures that interventions are not only well-rounded but also tailored to meet the unique needs of different communities. this research produces evidence that can serve as a guide to select and implement appropriate interventions across various settings, such as schools, health facilities, and communities. such collaborative efforts are crucial for developing comprehensive strategies that address the multifaceted challenges of improving contraceptive use effectively. references 1. bishwajit g, tang s, yaya s, feng z. unmet need for contraception and its association with unintended pregnancy in bangladesh. bmc pregn childbirth 2017;17:186. 2. badan kependudukan dan, keluarga berencana nasional. rencana strategis (renstra) tahun 2020-2024. jakart, indonesia: badan kependudukan dan keluarga berencana nasional; 2020. 3. utomo b, sucahya pk, romadlona na, et al. the impact of family planning on maternal mortality in indonesia: what future contribution can be expected? population health article [page 26] [healthcare in low-resource settings 2025;13:12948] metrics 2021;19:2. 4. lawrence er, klein tj, beyuo tk. maternal mortality in low and middle-income countries. obstetrics gynecol clin north am 2022;49:713-33. 5. sedgh g, ashford ls, hussain r. unmet need for contraception in developing countries: examining women’s reasons for not using a method. 2016. available from: https://www.guttmacher.org/report/unmet-need-for-contraception-in-developing-countries 6. d’souza p, phagdol t, d’souza srb, et al. interventions to support contraceptive choice and use: a global systematic map of systematic reviews. eur j contracept reproductive health care 2023;28:83-91. 7. robins-e development group. risk of bias tools robins-e tool. 2023. available from: https://www.riskofbias.info/welcome/robins-e-tool 8. mccarthy o, ahamed i, kulaeva f, et al. a randomized controlled trial of an intervention delivered by mobile phone app instant messaging to increase the acceptability of effective contraception among young people in tajikistan. reprod health 2018;15:28. . sileo km, muhumuza c, wanyenze rk, et al. a pilot quasiexperimental controlled trial of a community-based, multilevel family planning intervention for couples in rural uganda: evidence of feasibility, acceptability, and effect on contraceptive uptake among those with an unmet need for family planning. contraception 2023;125:110096. 10. thapa k, dhital r, rajbhandari s, et al. improving post-partum family planning services provided by female community health volunteers in nepal: a mixed methods study. bmc health serv res 2020;20:123. 11. kim ty, igras s, barker km, et al. the power of women’s and men’s social networks to catalyse normative and behavioural change: evaluation of an intervention addressing unmet need for family planning in benin. bmc public health 2022;22:672. 12. mccarthy ol, aliaga c, palacios met, et al. an intervention delivered by mobile phone instant messaging to increase acceptability and use of effective contraception among young women in bolivia: randomized controlled trial. j med internet res 2020;22:e14073. 13. pradhan e, canning d, shah ih, et al. integrating postpartum contraceptive counseling and iud insertion services into maternity care in nepal: results from stepped-wedge randomized controlled trial. reprod health 2019;16:69. 14. huber-krum s, khadka a, pradhan e, rohr j, puri m, maharjan d, et al. the effect of antenatal counseling and intrauterine device insertion services on postpartum contraceptive use in nepal: results from a stepped-wedge randomized controlled trial. contraception 2020;101:384-92. 15. huda fa, mahmood hr, ahmmed f, et al. the effect of a club in making differences in knowledge, attitude, and practices on family planning among married adolescent girls in urban slums in bangladesh. int j environ res public health 2019;16. 16. kamhawi s, underwood c, murad h, jabre b. client-centered counseling improves client satisfaction with family planning visits: evidence from irbid, jordan. glob health sci pract 2013;1:180-92. 17. simanjuntak h, lestari bw, anwar ad. the effect of structured counseling towards knowledge, attitude, and participation of modern contraceptive among unmet need couples. kesmas 2016;10:184-90. 18. harris-fry ha, azad k, younes l, et al. formative evaluation of a participatory women’s group intervention to improve reproductive and women’s health outcomes in rural bangladesh: a controlled before and after study. j epidemiol community health 2016;70:663-70. 19. leight j, hensly c, chissano m, et al. the effects of text reminders on the use of family planning services: evidence from a randomised controlled trial in urban mozambique. bmj glob health 2022;7:e007862. 20. nuryana d, cahyani ra, rahayu s, et al. unmet need for family planning in indonesia and its associated factors. makara j health res 2023;27:25-35. 21. zimmerman la, sarnak do, karp c, et al. family planning beliefs and their association with contraceptive use dynamics: results from a longitudinal study in uganda. stud fam plann 2021;52:241-58. 22. machiyama k, casterline jb, mumah jn, et al. reasons for unmet need for family planning, with attention to the measurement of fertility preferences: protocol for a multi-site cohort study. reprod health 2017;14:23. 23. bhatt n, bhatt b, neupane b, et al. perceptions of family planning services and its key barriers among adolescents and young people in eastern nepal: a qualitative study. plos one 2021;16:e0252184. 24. aung b, mitchell jw, braun kl. effectiveness of mhealth interventions for improving contraceptive use in lowand middle-income countries: a systematic review. glob health sci pract 2020;8:813-26. 25. smith c, gold j, ngo td, et al. mobile phone�based interventions for improving contraception use. cochrane database syst rev 2015;2015:cd011159. 26. harris b, ajisola m, alam rm, et al. mobile consulting as an option for delivering healthcare services in low-resource settings in lowand middle-income countries: a mixed-methods study. digit health 2021;7:20552076211033425. 27. bria ei. correlation between the role of health care provider in family planning counseling with the use of contraceptive device in women at puskesmas rafae belu east nusa tenggara. 2014. available from: http://lib.unair.ac.id 28. scott vk, gottschalk lb, wright kq, et al. community health workers’ provision of family planning services in lowand middle-income countries: a systematic review of effectiveness. stud fam plann 2015;46:241-61. 29. damayanti na, wulandari rd, ridlo ia. maternal health care utilization behavior, local wisdom, and associated factors among women in urban and rural areas, indonesia. int j womens health 2023;15:665-77. 30. erhardt-ohren b, brooks m, aliou s, et al. sustained impact of community-based interventions on contraceptive use among married adolescent girls in rural niger: results from a cluster randomized controlled trial. int j gynaecol obstet article online supplementary materials table 1. characteristics of the included studies. table 2. intervention group, type of intervention and main [healthcare in low-resource settings 2025;13:12948] [page 27] hrev_master healthcare in low-resource settings 2025; volume 13:12748 mothers’ breastfeeding techniques and its correlation to their infants’ nutritional status: a study in a rural area nopi nur khasanah,1 andini eka sari,1 iskim luthfa,1,2 kurnia wijayanti1 1faculty of nursing, universitas islam sultan agung, semarang; 2faculty of nursing, universitas airlangga, surabaya, indonesia abstract proper breastfeeding techniques are important to maintain adequate breast milk supply. the study aimed to determine the breastfeeding techniques of mothers in rural areas and discover the correlation with the nutritional status of their infants. this research involved 107 mothers with infants aged 0-6 months and data was collected using observation sheets. the spearman-rho test was used to analyze the relationship between the breastfeeding technique and the nutritional status of the infants. most respondents were mothers aged 26 to 35 with high school-level education and daily lives as housewives. most of the infants were 3 months old (27.1%), female (57.9%), and some of them were macrocephaly (31.8%), underweight (26.2%), stunted (16.9%), and wasted (12.3%). additionally, most mothers had an inappropriate breastfeeding technique (60.7%) and statistically, there was no correlation with the nutritional status of their infants aged 0-6 months (ρ>0.05). the results of this study require health workers to optimize the nutritional needs of infants in rural areas by providing effective educational strategies on proper breastfeeding techniques, regardless of other factors influencing nutritional status. introduction adequate nutrition for infants aged 0-6 months is important for their growth, development, and health maintenance.1 lack of nutrition can lead to different forms of undernutrition, such as wasted (underweight for body length), stunted (low body length for age), and underweight (underweight for age).2 breastfeeding plays a supportive role in providing nutrition for infants aged 0-6 months.3 furthermore, proper breastfeeding techniques are related to nutritional balance because proper techniques can maximize breastmilk supply to babies.4 world health organization (who) recommends exclusive breastfeeding from 0-6 months and complementary foods in parallel with breastmilk for up to 2 years.5 the united nations children’s fund (unicef) also noted that exclusive breastfeeding of infants under 6 months has reached 48% worldwide, almost reaching the world health assembly 2025 target of 50%.6 this trend has also been observed in indonesia, which shows a positive trend in the annual percentage of exclusive breastfeeding of infants under six months of age. according to the directorate of people’s welfare statistics of indonesia,7 the number of infants under six months who breastfed exclusively has reached 73.97%, where the highest percentage is in the province of central java (80.2%). this study focuses on breastfeeding techniques because although the percentage of breastfeeding is high in indonesia, there are still many stunting and wasting incidents. improper breastfeeding techniques contribute to poor breastmilk transfer from mothers to their infants, which leads to infants’ nutritional deficiencies.8 globally, stunting and wasting have affected and threatened an estimated 22.3% and 6.8% of children under five years in 2022, respectively.9 in 2022, the prevalence of stunting was approximately 21.6% in indonesia and 20.8% in central java province. meanwhile, the prevalence of wasting in 2022 was 7.7% in indonesia and 7.9% in the central java province. although there has been a decrease in stunting rates since 2021, there has also been an increase in wasting rates. therefore, the problem of malnutrition persists worldwide and locally. we conducted a preliminary study in may 2023 in several correspondence: nopi nur khasanah, faculty of nursing, universitas islam sultan agung, semarang, indonesia. tel.: +6285640256378. e-mail: nopi.khasanah@unissula.ac.id key words: breastfeeding, infant, mothers, nutritional status. contributions: all the authors made a substantive intellectual contribution. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: the research and community service institutions of sultan agung islamic university with the contract number 40a/b.1/salppm/vii/2024. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: the health research ethics committee at the nursing faculty of sultan agung islamic university approved this study with the number 928/a.1-s1/fik-sa/v/2023. informed consent: all respondents signed the informed consent form after the researcher explained that their breastfeeding technique would be observed during the data collection. acknowledgments: the authors would like to acknowledge the parents, especially the babies’ mother for their participation in this study, the support of the integrated service post cadres in community health service (puskesmas), and indra tri astuti, rn for her thoughtful review of the study result. received: 25 june 2024. accepted: 19 august 2024. early access: 3 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12748 doi:10.4081/hls.2024.12748 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 14] [healthcare in low-resource settings 2025;13:12748] rural villages. the nutritionist of the community health center (puskesmas) said that 77.92% of infants received exclusive breastfeeding but there was still a risk of stunting (12.8%). we found that the main problems influencing exclusive breastfeeding were pain and soreness during breastfeeding. some breastfeeding mothers said that they do not understand the proper breastfeeding technique. this issue must be corrected, as the mothers must know the correct technique and position when breastfeeding and can practice it when breastfeeding their infants. therefore, at the end of the data collection process, the researcher taught the correct breastfeeding technique when mothers directly breastfeed their infants. that was a reward or expression of gratitude because of their willingness for their breastfeeding process to be observed. most mothers in the preliminary study expressed their hope for one-on-one education to increase their knowledge regarding correct breastfeeding techniques. increasing maternal knowledge was not the main purpose of this study because our need is accurate data related to the breastfeeding steps that are currently still not right so that the preparation of educational interventions can be more effective and appropriate according to the steps that are not right. the breastfeeding technique is considered correct when there is a good attachment between the mother and infant and they show the correct position.8 mistakes in breastfeeding techniques can have negative impacts, such as asphyxia (lack of oxygen for the baby),10 nipple sores, breast swelling, and discomfort for the mother during breastfeeding, which can prevent optimal breastmilk flow and result in nutritional deficiencies in the baby.11 this research analyzes the relationship between breastfeeding techniques and nutritional status in infants 0-6 months of age. the specific objectives of this study are to identify the breastfeeding techniques employed by mothers and the nutritional status of infants aged 0-6 months. materials and methods ethical considerations the health research ethics committee at the nursing faculty of sultan agung islamic university approved this study with the number 928/a.1-s1/fik-sa/v/2023. all respondents signed the informed consent form after the researcher explained that their breastfeeding technique would be observed during the data collection. subject researchers used the entire population of breastfeeding mothers with infants aged 0-6 months in several villages in one district in a health center area. based on data from the health center, 180 infants were exclusively breastfed, but the data did not match the reality. the inclusion criteria in this study were all breastfeeding mothers with infants aged 0-6 months in the puskesmas area and mothers who could breastfeed and were willing to be respondents by signing a consent form. the exclusion criteria for this study were sick infants (may cry or be fussy when breastfed), infants using pacifiers, and breastfeeding mothers who were ill and may not be able to breastfeed their infants optimally. this research used purposive sampling, and 107 infants met the inclusion criteria. this study was carried out in a puskesmas in a rural area from march to december 2023. data collection this research used a cross-sectional quantitative correlation approach to determine the relationship between the variables. the instrument used to collect information regarding correct breastfeeding techniques was an observational form, and the nutritional status instrument used was an observation sheet consisting of the baby’s weight, body length, and head circumference. infant weight measurement used a weight scale that has been calibrated, while a flexible tape measure was used to measure body length and head circumference. researchers used the same tool for all infants. data were collected by watching mothers breastfeed their infants and assessing them using a form. researchers also measured the infant’s weight, body length, and head circumference to determine the nutritional status. the data collection was assisted by an observer which has previously been explained about this study so that they have the same perception as the researcher. the observer was a sixth-grade female nursing student who passed an anthropometry skill examination. the implementation stages were as follows: i) the researchers visited the respondents at their homes and provided them with a consent form to become respondents (informed consent), ii) the researchers asked the respondents to conduct their breastfeeding habits regarding position, sucking, and attachment for their infants (one-day observation), iii) the observer looked and checked the respondent’s accuracy when breastfeeding. after that, the researcher assisted by the observer measured the infants’ body weight, body length, and head circumference, then looked at their nutritional status using a growth table. the researchers then checked the completeness of the data collected. finally, the researchers gave rewards to the respondents. data analysis the univariate analysis in this study described the correct breastfeeding steps, breastfeeding position, and breastfeeding attachment. data that describe the correct breastfeeding techniques with nutritional status in categorical form were analyzed using proportion analysis and expressed in a frequency distribution table. bivariate analysis in this study was carried out to determine the correlation between breastfeeding techniques and nutritional status in babies aged 0 to 6 months. the spearman’s rho test was used in this research because the type of data was on a nominal-ordinal scale. we used an observational sheet of the breastfeeding technique from idai (2013) to analyze the techniques and separate them into proper and improper. researchers observed mothers while breastfeeding their babies and matched them with the observation sheet: if the mother breastfeeds correctly according to the observation sheet, then it is called the correct breastfeeding technique. conversely, if there is at least one error or discrepancy with the observation sheet, then it is stated that the breastfeeding technique is incorrect. furthermore, the regulation of the minister of health of the republic of indonesia number 2 of 2020 concerning child anthropometry standards was used to assess the nutritional status of infants. measurement of nutritional status is based on body weight and length parameters,12 researchers use three indices, including weight-for-age (waz), length/height-for-age (haz), and weight-for-length/height (whz). the determination of categories is based on the threshold values in the regulation (zscore) (table 1). results the results of this study show the characteristics of the respondents and their infants (table 2), mothers’ breastfeeding technique (table 3), and the relationship between mothers’ breastfeeding technique and their infants’ nutritional status aged 0-6 months article [healthcare in low-resource settings 2025;13:12748] [page 15] (table 4). the results presented in table 2 show that most of the respondents were 26-35 years old (59.8%), had senior high school degrees (64.5%), and were housewives (67.3%). meanwhile, most of the infants were 3 months old (27.1%), female (57.9%), and had a normal head circumference (66.4%). the results also revealed that some of the infants were underweight (23.4%), stunted (14.0%) and wasted (10.3%). some infants had abnormal head circumference (33.7%) and most of the mothers’ breastfeeding techniques were improper (60.7%). table 3 below lists the characteristics of mothers during the breastfeeding process. table 3 reports that most mothers did not wash their hands before starting breastfeeding (52.3%), did not try to release the infant’s suction with their little fingers (44.9%) so that the infants suckled the breast until they released on their own, and did not provide stimulation to the baby before starting breastfeeding (40.2%) because mothers assume that the infants looked thirsty. in addition, some mothers did not ensure that the infant’s lower lip was curled out (3.7%), the infant’s mouth was wide open (0.9%), and did not lubricate the nipple with breastmilk (0.9%). table 4 below shows the analyzing results of spearman’s rho test. table 4 shows no significant relationship between the brea article table 2. respondent characteristics and the results of their breastfeeding techniques (n=107). characteristics breastfeeding techniques frequency n (%) p improper n (%) proper n (%) mother's age 17-25 23 (21.5) 13 (12.1) 36(33.6) 0.821** 26-35 37 (34.6) 27 (25.2) 64(59.8) 36-45 5 (4.7) 2 (1.9) 7(6.5) mother's education elementary school 8 (7.5) 1 (0.9) 9(8.4) 0.399** junior high school 16 (15) 12 (11.2) 28(26.2) senior high school 40 (37.4) 29 (27.1) 69(64.5) college 1 (0.9) 0 (0) 1(0.9) mothers’ occupation working mothers 29 (27.1) 6 (5.6) 35(32.7) 0.001* housewives 36 (33.6) 36 (33.6) 72(67.3) (r=0.30) infant's age 1 month 14 (13.1) 8 (7.5) 22(20.6) 0.747** 2 months 10 (9.3) 6 (5.6) 16(15.0) 3 months 16 (15.0) 13 (12.1) 29(27.1) 4 months 14 (13.1) 6 (5.6) 20(18.7) 5 months 11 (10.3) 7 (6.5) 18(16.8) 6 months 0 (0.0) 2 (1.9) 2(1.9) infant’s gender female 38 (35.5) 24 (22.4) 62(57.9) 0.893* male 27 (25.2) 18 (39.3) 45(42.1) infant’s head circumference microcephaly 1 (1.5) 1 (2.4) 2(1.9) normal 42 (64.6) 29 (69.0) 71(66.4) 0.545*** macrocephaly 22 (33.8) 12 (28.6) 34(31.8) *contingency coefficient test; **kendall’s tau-b test. table 1. categories and thresholds of children’s nutritional status. index category threshold (z-score) weight-for-age (waz) severely underweight < -3 sd underweight -3 sd < -2 sd normal -2 sd +1 sd risk of overweight >+1 sd length/height-for-age (haz) severely stunted < -3 sd stunted -3 sd < -2 sd normal -2 sd +3 sd tallness >+3 sd weight-for-length/height (whz) severely wasted < -3 sd wasted -3 sd < -2 sd normal -2 sd +1 sd possible risk of overweight >+1 sd +2 sd overweight >+2 sd +3 sd obese >+ 3 sd sd, standard deviation. [page 16] [healthcare in low-resource settings 2025;13:12748] stfeeding technique and the infant’s nutritional status. in addition, kendall’s tau-b result shows no significant relationship between the characteristics of the respondents and the breastfeeding technique. meanwhile, the contingency coefficient test results show a weak positive correlation between mothers’ occupation and breastfeeding techniques, which means that housewives tend to do more proper breastfeeding techniques but the relationship is not very strong. discussion maternal and infant characteristics related to mothers’ breastfeeding technique the first maternal characteristic is age, which is often related to a person’s experience: the older a person gets, the more knowledge and information they obtain from external and internal sources.13,14 in this study, most mothers were in the young adulthood category (26-35 years), characterized by independence and problem-solving.15,16 however, we found that most of the mothers practiced improper breastfeeding techniques, proven by ineffective infant suckles because they breastfeed according to what they understand and see from their surroundings. this finding indicates that mothers need education on breastfeeding techniques. furthermore, most of the respondents who practiced improper breastfeeding techniques had a senior high school education. education is a developmental process that improves skills. mothers with higher education levels may find it easier to care for their children, especially regarding the precision and attention required to provide adequate nutrition, including exclusive breastfeeding.17,18 in addition, knowledge will provide mothers with an understanding of the benefits and importance of their children’s nutritional needs.19 however, based on our findings, the level of education may not always determine sufficient knowledge about breastfeeding techniques because it is a specific knowledge that needs skills and support from health workers and their families.20 then, most of the respondents were housewives and the number of those who practiced proper versus improper breastfeeding techniques was the same. high work activity, either being a fulltime housewife or working mothers at the office, can make women pay less attention to the information around them.21 a previous article table 3. the characteristics of mothers’ breastfeeding techniques (n=107). steps to breastfeeding not done n (%) done n (%) washing hands with soap and water 56 (52.3) 51 (47.7) lubricating nipples with breastmilk 1 (0.9) 106 (99.1) position baby “tummy to tummy” 0 (0.0) 107 (100.0) putting the thumb on the top of the breast and cup other fingers around the bottom of the breast (c-hold) 0 (0.0) 107 (100.0) triggering the rooting reflex by gently stroking the infant’s cheek with the nipple 43 (40.2) 64 (59.8) make sure the infant's mouth is wide open before the nipple enters 1 (0.9) 106 (99.1) bringing the infant's head closer to the breast after a wide-open mouth 0 (0.0) 107 (100.0) make sure a large portion of the lower areola into the infant’s mouth 0 (0.0) 107 (100.0) make sure the infant’s lower lip curled out 4 (3.7) 103 (96.3) making sure the infant’s chin firmly touches the breast 0 (0.0) 107 (100.0) releasing the infant's sucking with the mother’s little finger 48 (44.9) 59 (55.1) table 4. the correlation between breastfeeding technique and nutritional status in infants aged 0-6 months (n=107). characteristics of infants’ breastfeeding techniques frequency n (%) p nutritional status improper n (%) proper n (%) weight-for-age index underweight 17 (26.2) 8 (19.0) 25 (23.4) 0.402*** normal 43 (66.2) 30 (71.4) 73 (68.2) risk of overweight 5 (7.7) 4 (9.5) 9 (8.4) length/height-for-age index severely stunted 3 (4.6) 1 (2.4) 4 (3.7) 0.467*** stunted 11 (16.9) 4 (9.5) 15 (14.0) normal 47 (72.3) 36 (85.7) 83 (77.6) tallness 4 (6.2) 1 (2.4) 5 (4.7) weight-for-length/height index severely wasted 4 (6.2) 2 (4.8) 6 (5.6) 0.181*** wasted 8 (12.3) 3 (7.1) 11 (10.3) normal 46 (70.8) 29 (69.0) 75 (70.1) possible risk of overweight 4 (6.2) 5 (11.9) 9 (8.4) overweight 1 (1.5) 0 (0.0) 1 (0.9) obese 2 (3.1) 3 (7.1) 5 (4.7) ***spearman’s rho test. [healthcare in low-resource settings 2025;13:12748] [page 17] study found that the children of mothers who are full-time housewives have a higher chance of experiencing stunting.22 however, exclusive breastfeeding practice was higher among housewives compared with working mothers.23 our findings show a weak positive correlation between housewives and correct breastfeeding techniques. this shows the importance of a mother being at home, especially until completing exclusive breastfeeding. indonesian government through the house of representatives supports the exclusive breastfeeding program by passing the maternal and child welfare bill which regulates working mothers entitled to maternity leave for up to 6 months.23,24 furthermore, health workers need to play an active role in providing education on correct breastfeeding techniques noting that improper breastfeeding techniques in this study were very likely caused by mothers not receiving information. education programs can be added to discharge planning or provided regularly as an independent nursing intervention in maternity wards, puskesmas, or the community. most of the infants in this study were three months old and still showed improper positioning and attachment during breastfeeding. three-months infants can already hold their heads parallel to their bodies and ideally can attach properly when breastfeeding compared to infants aged 1-2 months.25 meanwhile, babies older than 3 months are in the growth spurt phase, where they are often fussy, which affects the mother’s breastfeeding technique because the infants suckle according to their comfort.26 mothers are generally anxious when facing a fussy baby, so they may breastfeed without thinking of proper attachment during breastfeeding.27 furthermore, most of the infants in this study were female. naturally, both female and male infants have the ability and instinct to breastfeed although the male infants need more energy28 and have a higher risk of stunting29 than female infants. male infants have very different amounts in growth speed30 but the problems in breastfeeding are not always related to gender because each infant is unique and has different characteristics. instead, breastfeeding problems can be caused by infants’ health factors or mothers’ experiences. another indicator for assessing the infants’ nutritional status is head circumference.31 the study result showed that an infant experienced microcephaly and around a third of the total infants experienced macrocephaly and were breastfed improperly. routine monitoring of changes in head circumference can help identify nutritional problems or suboptimal development in infants.32 the head circumference of infants gives an idea of the brain’s growth.3 in the case of this study, it is possible that the head circumference of infants with microcephaly was caused by other factors, such as disease or concomitant conditions, such as neurological diseases, genetics, birth conditions, syndromes, and possible developmental disorders.33 macrocephaly may be caused by genetic factors, which is commonly caused by poor appetite.34 poor appetite leads the infants to difficulty gaining weight, called ‘failure to thrive’, and sometimes can be associated with brain issues. overview of mothers’ breastfeeding techniques in this study, mothers often miss washing their hands before breastfeeding, whereas washing hands with soap and water is the most affordable and effective way to stop the spread of infection.36 another step in breastfeeding that was mostly missed by mothers in this study was releasing infants’ sucking. a study said that it is unnecessary to release the infant’s sucking because they will spontaneously release the nipple.37 however, if breastfeeding lasts too long (more than half an hour) or too short (less than 4 minutes), this may indicate a problem with attachment.38 releasing the baby’s sucking at the best time and good steps39 may be needed before mothers fall asleep to avoid the risk of the baby choking.40 another skipped breastfeeding technique by mothers in this study was not stimulating the sucking reflex. sucking reflex stimulation can make infants easier in finding the nipple, reduce fussiness, and create comfort during breastfeeding that will disappear at six months of age.41 proper breastfeeding techniques, including correct position and good attachment, are the keys to successful breastfeeding so that nutrient transfer to infants can be optimal.8 effective positioning and latching help the infant to suck effectively, maintain mothers’ breastmilk production; and prevent breastfeeding problems, such as sore nipples, mastitis, or low breastmilk supply. however, the results of this study show that proper breastfeeding techniques practiced by some mother did not significantly impact their infants’ nutritional status. the nutritional status of infants in this study may influenced by other factors such as genetics, the health status of the infants, the caring experience of mothers, and the parents’ culture.39,40 the correlation between mothers’ breastfeeding technique and their infants’ nutritional status aged 0-6 months this research found that the nutritional status of infants aged 0-6 months varied: some had low weight for age index and some were risk overweight. based on body length measurements, some infants experienced severely stunted or abnormal body lengths. the weight for length index of some infants varied: some were severely wasted and some were obese. the results of the spearman’s rho test showed a p-value>0.05, which indicates that the correlation between mothers’ breastfeeding technique and infants’ nutritional status is insignificant. therefore, we further explained the results of this study based on cross-tabulation analysis. based on the weight for age index, despite most infants being in the normal category, they received improper breastfeeding techniques from their mothers. the researchers argued that the infant’s weight was normal because the mothers persevered with breastfeeding, even though they felt pain due to poor attachment during breastfeeding. the cross-tabulation analysis showed that some mothers who practiced proper breastfeeding techniques still had an underweight or risk of overweight infants. this incidence may be caused by other factors, such as genetics, birth history (abnormal or premature), and growth hormone problems.41 when comparing each data of abnormal weight for age index, most infants were underweight and experienced ineffective breastfeeding techniques. therefore, although statistically insignificant, improving breastfeeding skills is still important. the following characteristic of infants’ nutritional status is the length for age index. infants will experience an increase in body length of around 1.5 to 2.5 cm every month from birth to 6 months.42-46 breastfeeding can optimize infant growth and development through the rich nutrients in breast milk, such as protein.4 the results showed that most infants had normal body length and statistically no significant relationship with mothers’ breastfeeding technique. clinically, the cross-tabulation analysis revealed that most infants that had an abnormal body length were experienced stunted and their mothers used improper breastfeeding techniques. it is still important to increase breastfeeding skills even though other factors may influence less optimal growth, which triggers abnormalities in the length of the infants’ body, such as maternal factors, gender, health insurance ownership, or use of blood supplement tablets.42,43 based on the weight for length index, most infants were normal and some were abnormal (wasted). this finding showed the article [page 18] [healthcare in low-resource settings 2025;13:12748] importance of proper breastfeeding techniques despite this study result showing a statistically insignificant between infants’ weight for length index and mothers’ breastfeeding techniques. from this research, we conclude that errors in breastfeeding techniques alone did not cause inadequate nutrition in infants because the crosstabulation results found that some infants from mothers who practiced proper breastfeeding techniques had a lack of adequate nutrition. meanwhile, infants of mothers who practiced improper breastfeeding techniques still have a normal weight. uninterrupted breastfeeding can fulfill the infants’ nutritional needs through incoming breast milk even if the mother practices ineffective breastfeeding techniques.47-49 the respondents stated that they would continue to breastfeed their infants even if they felt pain to fulfill their infants’ nutrition needs. therefore, adequate nutrition of infants whose mothers practiced improper breastfeeding techniques might come from incoming and continuous breast milk (figure 1).50 the researchers recognized several limitations to this study. first, 73 respondents should be excluded because the infants’ age was more than 6 months at data collection. second, some potential respondents rejected to participate in this study because the data collection schedule coincided with work hours. third, this study needs more details and better control of all variables that could influence infants’ nutritional status, such as genetics, infant health factors, and maternal factors (parity status and previous breastfeeding experiences). conclusions this study observed common mistakes among mothers when breastfeeding their infants, including missing washing hands, not lubricating the nipples with breastmilk, missing rooting reflex stimulation before breastfeeding the infants, and not releasing infants’ sucking with a finger. although the mothers practiced improper breastfeeding techniques, their infant’s nutritional needs were still met. however, other factors, such as genetics, environment, or birth history may cause nutritional problems in infants whose mothers practiced improper breastfeeding techniques. there is no relationship between mothers’ breastfeeding technique and their infants’ nutritional status, but clinically, proper breastfeeding technique is needed for successful breastfeeding and to ensure the infants’ adequate nutrition. mothers can optimally practice effective breastfeeding techniques if they and their support systems (husband and family) are provided with education or counseling sessions by health workers. mothers can also participate in group discussions to share knowledge and experiences as a form of caring for fellow breastfeeding mothers. article figure 1. the graphical of the finding. 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st. louis, usa; 2019. 27. wic program. a guide to breastfeeding. 2024. available from: https://myfamily.wic.ca.gov/content/documents/nutritionhea lth/infants/guide-to-breastfeeding.pdf 28. forest lane pediatrics. calming a fussy breastfed baby. 2009. available from: https://www.forestlanepediatrics.com/wp-content/uploads/2017/05/calming_fussy_baby.pdf 29. powe ce, knott cd, conklin-brittain n. infant sex predicts breast milk energy content. am j hum biol 2010;22:50-4. 30. alam ma, richard sa, fahim sm, et al. erratum: impact of early-onset persistent stunting on cognitive development at 5 years of age: results from a multi-country cohort study. plos one 2020;15:1-16. 31. nur khasanah n, mufarihah a, luthfa i. how does birth weight affect the development of preschool children? a cross-sectional study. kne life sci 2022;2022:738-48. 32. pulungan ab. auxology, kurva pertumbuhan, antropometri dan pemantauan pertumbuhan. sari pediatr 2020;22:123-30. 33. malik d, narayanasamy n, pratyusha va, et al. nutritional assessment. in: textbook of nutritional biochemistry. springer; 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volume 12:12605 the essential care required by stroke survivors and families: an ethnography study kartika setia purdani,1,2 somporn rungreangkulkij2 1faculty of nursing, universitas muhammadiyah kalimantan timur, samarinda, indonesia; 2faculty of nursing, khon kaen university, khon kaen, thailand abstract from a cultural point of view, ethnographic research was needed to understand the essential care of stroke survivors and their families. half of stroke survivors were dependent on family caregivers during neuroplasticity time, which could raise several burdens for both. this study aimed to analyze the essential care required for stroke survivors and their families. focus ethnography design was employed with 64 participants selected purposively. the data collection methods were observation, in-depth interviews, and focus group discussion (fgd). the techniques used were writing field notes for the content analysis, using thematic analysis to analyze data, and using corex 32-items for reporting qualitative studies. the six themes identified were i) unclear information before discharge planning; ii)clear information from community nurses; iii) family brotherhood; iv) home visits; v) government health insurance obstacles; vi) counseling services for families. in this study, healthcare facilities with stroke services were preferred in stroke care, while optimal stroke care consisted of four main components that had to work together: health workers in health facilities, stroke survivors, family as successors of care in community settings, and the availability of health insurance facilities. in principle, the most important party in this situation was the family, including the nuclear or extended family; they could be the determinant in saving the lives of stroke survivors. introduction the incidence rate of death by stroke is 5.5 million people, and 44 million people have gained disability-adjusted life years (dalys).1-5 stroke has become one of the major problems in asia, with 75.2% of stroke cases and 81% for dalys, one of the most involved countries being indonesia, which has the highest stroke population in southeast asia.6,7 cardiovascular disease problems cannot be solely solved by curing the patients but also through prevention activity.8 some activities for treating stroke survivors cannot be secured with a single support.9-15 adding more, taking care of stroke survivors who have just returned home from the hospital demands considerable support from others.16-19 home care of stroke survivors and stroke education for caregivers establish an improved quality of life for both.20 in thailand and indonesia, the researchers provided family empowerment with upgrading skill care by health staff could increase functional status with setback stroke complications.2,21 this does not stop here; some countries have developed government policies to support it. for example, stroke improvement programs (sip) and “telestroke” (stroke telemedicine).16,17,22 although several activities have been done for it, stroke care is a burden. in the poststroke period, caregivers feel objective and subjective burdens, time spent on stroke care, the uncertainty of the future, and the economic burden.23-25 in south carolina, one of the causes for it is a lack of trust towards healthcare and healthcare providers, mainly rural settings.26 reduced quality of life and economic burden is the heaviest stroke survivor global burden in the world.27-29 also, the culture of care depends on people’s perspectives and influences stroke care. culture is connected with belief; traditional healers are essential in this term. the traditional healers are close to spiritual belief and arise from community perceptions. correspondence: somporn rungreangkulkij, faculty of nursing, khon kaen university, khon kaen, thailand. e-mail: somrun@kku.ac.th key words: caregivers, caring, community, stroke. contributions: ksp, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, coding, review & editing; sr, conceptualization, supervision, and review. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: asean-gms scholarship from khon kaen university and the universitas muhammadiyah kalimantan timur, indonesia. no influence support from funders in the research process. ethics approval and consent to participate: the research was given the kku irb letter with the number he642022 with approval on may 19, 2021. therefore, we are considering the right to safeguard and protect the informants. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank the faculty of nursing, khon kaen university, and university of muhammadiyah east kalimantan, indonesia, for their valuable insights and contributions to this study. received: 25 april 2024. accepted: 14 july 2024 early access: 1 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12605 doi:10.4081/hls.2024.12605 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12605] [page 679] non -co mmerc ial us e o nly in sub-saharan africa, aphasia, as the impact of a stroke attack is called misfortune, hell, or ill health, and is connected with the supernatural power of demons and witchcraft; because of that, their families brought stroke survivors to traditional healers. in south africa, traditional healers are common for people who have noncommunicable diseases, such as stroke, based on their community beliefs.30-32 like in other places, a masseur is the most traditional indonesian healer for managing stroke symptoms.33 essential care for stroke means comprehensive caring for stroke, starting from prevention activity until rehabilitation and how to immerse in a community with sequelae of stroke. it can be a conventional procedure or a supportive intervention.34 personalized and tailored support and intervention between stroke survivors and families could optimize dyadic self-care in a chinese setting.35 other research shows that the priority of relatives of people who have a stroke, especially their adult daughters, is coming to essential care for stroke survivors in ontario, canada.36 similarly, for the javanese principle, family is mutual assistance; they have some javanese principles and philosophy, such as happiness is harmony (rukun agawe sentosa), whereas unity of family could be good for the whole family; this also applies vice versa. another javanese philosophy related to it is “tega larane ora tega patine, dudu sanak dudu kadang, yen mati melu kelangan” which means emphasis on solidarity, even if the person is not family, especially if the person is family, they will be cared for in health or illness.37 in addition, based on the researcher walk interview, participants assumed and believed that the stroke was caused by their actions, hurting a family member, “karma” or god’s punishment. in others, the family talked about black magic causing their relative to have strokes. we found different perceptions of caring responsibilities between javanese and kutainese tradition leaders. in javanese perceptions, women as mothers, wives, or daughters have more responsibility than others caring for the sick, but it does not happen in the kutainese principle (fieldwork); the responsibility for caring is equal. further, javanese culture has two categories of diseases: physical disease (caused by viruses, bacteria, high tension, violence, accident, etc.) and non-physical (causes black magic, negative supernatural power, evil, demons, karma, etc.).38,39 in conclusion, the explored upper expressed some perceptions and thoughts related to stroke that had an impact on its care; this case needed to be defined and historicized within dialog-related concept culture. therefore, the ethnographic view could be used to compare and contextualize each theme. furthermore, the results reduce the gap regarding healthcare facilities and services, especially for stroke-related diseases. the cohesiveness of stroke survivors and families in stroke care must be simultaneous, which is different from the previous study. materials and methods research design the specific research design is a qualitative method with an ethnography study.40-45 the three methods for data collection used and the first author’s activities are described in detail. observation during 2-3 months, as participant-observer, the researcher followed routine activities for stroke survivors (17) and stroke caregivers (24) in a home or community setting. not only that, but the researcher also became a participant in observation at several health facilities recommended by stroke survivors and families, such as a community health clinic (2), a physiatry clinic (1), and traditional healers (1), who worked in their clinic, home, or the patients’ home. the duration time went from 30 minutes to 15 hours. during this phase, the researcher used observation forms and discussed them with the second author before going to fieldwork. after that, the researcher would ask permission from the participants before making an observation and giving the information sheet. the researcher emphasizes that the objective of observations is to learn from the participants to understand the situation of caring for stroke survivors and how they care for themselves. the other deal is not taking any pictures, following the day-by-day activity between stroke survivors and caregivers, and back again to make an agreement with the data found. in-depth interview four months an in-depth interview was held to understand community values and meaning and comprehend the social symbol found with the first method. in-depth interviews were held with 50 participants in their homes. in this phase, the researcher must saturate data, therefore, back again 2 to 3 times with a duration of around 50-120 minutes for each visit, and the total time is four months. further, add more time to discuss the results found. in addition, five stroke survivors dropped out because they died, settled in a new place, and suffered from aphasia as a consequence of stroke. focus group discussion focus group discussion (fgd) is the last method used in this research; it is a considerably interesting topic, whereas all participants used health facilities as a first aid for stroke care. otherwise, they have several options for it, adding more in the covid-19 pandemic. the researcher invited 11 recommended participants after discussing the issue with the gatekeeper and the second author as the research supervisor. the members of the fgd were a head office phc (1), hrd phc (1), a community nurse in phc (6), a community doctor (2), and a private community nurse (1), considering their knowledge and experience of community care. after concluding, the first author returned the notes to the audience to saturate data. the fgd was conducted for 2 hours on october 18, 2021, in phc hall. study participants the author determined the participants purposively. the study participants consist of the main participants (50 participants), among whom stroke survivors (17), family (24), neurologists (1), clinician nurses (4), community nurses (1), health care professionals (2), and traditional healers (1). another group is supporting participants (14 participants), consisting of friends of stroke survivors (1), friends of the family (3), the head of phc (1), the hrd of phc (1), the health staff of phc (6), and the leaders of the polyclinic (2). interviews were mostly held in participants’ homes or clinics. almost all stroke survivors and caregivers are from the java tribe, but other participants are banjarnese and kutainese. instruments and data collection the researcher has a certificate from citi, followed a research workshop, attended an international oral presentation, and finished a course in a doctoral program at kku. the data collection times start from july 1 until december 26, 2021, and all processes finish in september 2022. the first step article [page 680] [healthcare in low-resource settings 2024;12:12605] non -co mmerc ial us e o nly was making a guideline for data collection methods with concept analysis. currently, the first author is under the supervision of the second author, associate prof. dr. s. r. after that, the proposed study was sent to the ethical committee kku, and a letter of approval was received with the number he642022 from khon kaen university, thailand. the data collection starts with observation; the researcher comes to participant observation and continues in-depth interviews and doing fgd; triangulation data was used to decrease bias. it caused almost all participants to be women and from the javanese tribe, who are similar to the first author. data analysis thematic analysis is used to analyze data in seven steps.46,47 the first activity is to hear the interview recording (by recording device) in indonesian with participants only. the second is transcribing and translating the document, which notes in field notes for familiar quotes during observation, in-depth interviews, and fgd. the next step is coding. the fourth step is searching the themes and then building sub-themes. the fifth step is reviewing the theme and identifying the relation of themes with a research question. the sixth step is to sort out several sub-themes in specific themes. for the last, the researcher makes a typology for the analysis study. at times, the researcher returned to fieldwork for feedback on the analysis data; all participants received the results. ethical clearance the researcher was given the kku irb letter in he642022 with approval on may 19, 2021. results table 1 represents the characteristics of the main participants using statistical package for social sciences (spss) software. based on table 1, it was shown that almost all stroke survivors are male: 14 (82.4%), 10 (58.8%) were aged 51-60 years, 11 (64.7%) used alternative and general medicine for rehabilitation, 47.1% of stroke survivors were in junior high school as for education, amount of 5.9% stroke survivors earned a standard regional wage. for caregivers, the dominant gender was females (70.8%), 41.7% (10) of participants were aged 51-60 years, and spouses (54.2%) were the most common relatives among stroke survivors, senior high school is 37.5% (9) as the most common level of education, and 66.7% participants earned less than a standard regional wage. six themes were obtained from the main and supporting participants related to essential care required by stroke survivors and families: i) unclear information before discharge planning; ii) clear information from a community nurse, iii) family brotherhood, iv) home visit; v) government health insurance obstacle; vi) counseling family services, which are detailed below. unclear information before discharge planning success for discharge planning from hospital to home care is evaluated by how the family treats the patients in the community. some stroke survivors mentioned that they lacked information on stroke, especially regarding their cure and care in the hospital. a similar opinion with their caregiver; of 24 caregivers, 22 caregivers said they did not get good discharge planning in health facilities. therefore, caregivers and stroke survivors were burdened with care. article table 1. characteristics of main participants (stroke survivors and stroke caregivers). characteristics stroke survivors (n=17) caregivers (n=24) gender male 14 (82.4) 7 (29.2) female 3 (21.4) 17 (70.8) age 35-40 years old 6 (25.0) 41-50 years old 6 (25.0) 51-60 years old 10 (58.8) 10 (41.7) 61-65 years old 7 (41.2) 2 (8.3) type of rehabilitation alternative 6 (35.3) alternative and conventional 11 (64.7) level of education elementary school 4 (23.5) 4 (16.7) junior high school 8 (47.1) 8 (33.3) senior high school 5 (29.4) 9 (37.5) diploma degree 1 (4.2) bachelor degree 2 (8.3) family economic status below standard regional wage 8 (47.1) 16 (66.7) standard regional wage 9 (52.9) 8 (33.3) relation spouse 13 (54.2) child 7 (29.2) brother/sister 2 (8.3) son-in-law 2 (8.3 [healthcare in low-resource settings 2024;12:12605] [page 681] non -co mmerc ial us e o nly “i was confused until today (harsh voice)… nothing was explored about my stroke in the hospital. the nurse always reminded me that if i moved, my tension would go up, and i may get a recurrent stroke. but as i know, i didn’t have hypertension before.” (ss8, male, 65 years old, add partial disability) “i just saw and followed, but no direct instructions were given by the nurse about caring for my husband (push sentences). it was my experience when i brought my husband to the hospital; the doctor’s diagnosis was a stroke. the nurse didn’t think about the patient’s family.” (cg1, female, 54 years old) however, different opinions were obtained from health workers. the discharge planning prepares the families and patients to shift the location from the hospital to the community and ensure the continuation of health care. one of the representative participants talks about his experience. “we are preparing the stroke pocketbook for guidelines in community care for stroke survivors and families who will return home. certainly, the staff in the stroke center always learn and teach about stroke care during inpatient times. we always ensure that the stroke caregiver will exist to care in the community. on special days, like stroke day, we do a social activity to serve stroke survivors in a community setting.” (neuro, male, 36 years old, specialist in neurology) clear information from a community nurse the explanation above differs from the families who call community nurses for their stroke survivors’ health services. the community nurses give education and health information for continued self-care in a home setting. eleven stroke survivors and 20 stroke caregivers were comfortable and more knowledgeable after the community nurse’s explanation. the duration of each visit and the time needed to get health information differ; it’s an average of 1545 minutes each season. the important thing is sometimes they use the javanese language for communication, making nurse s. more valuable as a community nurse. “nurse s., as a community nurse, taught my mother-in-law and me routine exercises for stroke recovery with an easy understanding of the javanese language. it is not like the phc staff or hospital staff. i think it was just a simple exercise, but it was helpful for my mother’s condition.” (cg10, female, 39 years old) family brotherhood transportation, finances, and knowledge are some obstacles for stroke caregivers and survivors to get rehabilitation. however, this study found that the way out from several obstacles comes from their family. maybe they are just a nuclear family consisting of parents and children who stay together, but they have extended families who live not far from their homes. just three stroke survivors do not have extended family to support them. “i don’t have a car with which to bring my wife with stroke disease. i just asked my step-child about his mother’s condition to visit the doctor. when he has time, sometimes we ride his motorcycle, three people in one motorcycle. no money and no transportation are terrible for the care of my wife. fortunately, i have a step-child (sad face with less sound).” (cg9, male, 65 years old) “what if we buy a car, my son-in-law has it. call, and he will come if he is free from his work. we can’t estimate the money spent on my care and other family needs, but i have a good son-inlaw.” (ss5, male, 65 years old, add moderately severe disability) home visits the healthcare provider becomes important in caring for the survivors and the community. even though the caregivers and stroke survivors got discharge planning in the hospital, they must continue health recovery by themselves in a community setting. based on the data records, 17 stroke survivors get a home visit from phc; from that, 11 survivors receive home visits from phc, community doctors, and traditional healers (masseurs). all participants were recorded as phc patients. primary health care the forefront healthcare service facility is called primary health care (phc). in the fieldwork setting, phc was not only for outpatient service but also inpatient service. due to covid-19, the phc changed to a quarantine hospital. “every home visit, we explained the patient and family’s health situations, motivated the patient and the family, and gave health tips like good food, exercise, signs, and symptoms, etc. but because of the pandemic, home visits were stopped.” (phcd, male, 55 years old, general doctor) “it must be something the community needs when we are home visiting; each person in the community has different wants, and we, the phc staff, must answer all questions as it is our responsibility to care in fieldwork.” (phc1, female, 45 years old, public health bachelor) community health provider community health providers are another option for home visits, including community doctors, nurses, and physiatrists. the number of stroke visitors in the physiatry clinic for a month is around 7 to 16 patients. moreover, all facilities can take home calls. commonly, the family calls community nurses for several reasons: not having transportation, being cheap, being friendly, and familiar with stroke conditions, which are impossible for outsiders. “the stroke patient is coming here with several symptoms. when the patients and families come to my clinics for the first time, i do quick anamneses. further, i suggest going to the hospital to get a real diagnosis of a stroke attack with a ct scan. if some condition does not support, i keep giving medicine for their health problems. here, some conditions might cause the stroke patient to receive delayed care. therefore, in some cases, i do home care, or i deliver them to the hospital.” (cd2, male, 53 years old) “i felt comfortable with physiotherapy rehabilitation compared to other treatments (little smile). the therapist has evidence and knowledge of stroke treatments, which is supported by suitable tools for rehabilitation treatment. i am inviting the therapist to my house. a little expensive, but i am more comfortable with that.” (ss17, male, 58 years old, add partial disability) article [page 682] [healthcare in low-resource settings 2024;12:12605] non -co mmerc ial us e o nly “no need to buy a car, just call nurse a. when my wife needs it. he comes in free duty. even though nurse a. did not stay here, he is a community nurse in his area and gives private care. my daughter, who is in senior high school, needs money, not less, i must manage money.” (cg13, male, 60 years old) as we mentioned previously, the covid-19 pandemic has changed the condition. the community doctor, community nurse, physiatry clinic, and phc service stopped home visits during research times. traditional healer excluding health facilities or health provider services, a traditional healer is one of the community health services that could be called. based on data, 11 stroke survivors used complementary therapy, and all participants used a masseur as a traditional healer. their choices were friendly, cheap, easy to call, in line with their religion and beliefs, and comfortable. “i was never determined to ask for money for health services from patients and families. deep in my soul, i want to help others as my duty to others who are god giving more proficiency. regarding service, i could be called to a patient’s house, or use my house. during a pandemic, i have not stopped my massage service.” (th1, male, 46 years old) “i am using traditional healing methods like masseurs, as i need them. i can call them to come to my house, or i ask my son to deliver me to their home. if i go to their home, they reject money. they just accept some sugar, tea, or coffee. not only that, they pray for me when starting to massage, and at the end of the massage, they pray for me again. i feel my body comforted and have a calm heart after going there. i am javanese and comfortable with massage; it is so because, since i was a little, my mother always called a masseur if i was sick.” (ss3, male, 65 years old, add moderate disability) government health insurance obstacle indonesia’s government requires citizens to use government health insurance (bpjs). connected with this, some problems ensue, such as the distance between the phc and citizen houses; another problem is the timing. therefore, until today, only two stroke survivors and four caregivers used that for stroke rehabilitation. “i never knew how to use government health insurance (bpjs). when i get a stroke, my son delivers me to the doctor in a health clinic for a private fee. one day, the leader in my area community comes and suggests making it (bpjs). we just followed him to take a photo, and i have a bpjs card now. he says it can be used if i am sick to get free care. my son supports all i need, so why do i need it?” (ss7, male, 62 years old, add moderate disability) “i use bpjs for first care for stroke. for now, i use private payment; it’s rapid for stroke treatment services. when using bpjs, we only stay for three days. after that, you must leave the hospital regardless of your condition. additionally, before using it, we must get a referral from the first health facility or our family’s doctor. all those processes are lengthy.” (ss5, male, 65 years old, add moderately severe disability) regarding stroke conditions, in which it is difficult to predict the time of healing, it makes some families try to find solutions. they have several options: government health insurance, private or alternate payment. counseling family services almost all stroke survivors are in nuclear families. the family has an essential role in supporting the survivors. love-belonging, responsibility, and worship are some reasons for them. family support was found in an in-depth interview, and the observations were physical assistance, moral support, and finding assistance. “they constantly care for the stroke patient, caring with love and being patient. not all, but almost all caregivers in here are doing that. i always teach them first before they do it by themselves. for example, for bathing in case of paralysis to the side of a stroke survivor’s body, after practicing and teaching, tomorrow is the family turn i am observing.” (cn2, male, 30 years old, bachelor of nursing) families as stroke caregivers are doing anything for stroke survivors, too. they are given all the time, attention, and support for healing. but, half of them feel stress without enlightenment. “when someone asks why i care for my wife, i answer because she is my “garwo” from the acronym “sigaring nyowo” or soulmate. could you imagine if half of your body was sick? but my big problem is no one has completely taught me how to care. sometimes i feel tired and stressed too, but i don’t know whom i could complain to. because of that, i am just doing normally things, but more slowly because of my wife’s impairment.” (cg3, male, 65 years old) “i often….mmmmm….. sometimes i just get angry with my mother if she rejects or disobeys my instructions. i am tired and stressed with my daily activities, and when it is time to care for her, my mother causes problems… so i use a harsh voice or slap her. i feel guilty after that, kiss her hands, cry, and say sorry. i never got information from health professionals about stress when caring and what i must do.” (cg4, female, 58 years old) discussion we have learned from the participants that the family is the most important element for stroke survivors and their caregivers in indonesian javanese culture. some javanese proverbs are embedded in several stroke survivors and their families, even though, in this study, they do not live on java island. the family, not only their stroke caregivers, came as an important person inside the nuclear or extended family. the first theme is unclear information before discharge planning. some opinions from stroke survivors are that after their care in the hospital they did not receive clear health information related to stroke disease. in a community, just three stroke survivors discussed getting discharge planning, and just two stroke caregivers got it. the continuity problem for caring for stroke survivors in the community is cutting off the transmission of information for it. the caregiver is talking about how they don’t have enough information for managing the home care of stroke survivors. several benefits of discharge planning are improving patient satisfaction and independence from a hospital setting. discharge article [healthcare in low-resource settings 2024;12:12605] [page 683] non -co mmerc ial us e o nly planning is a complex system and needs the support of multiple health and care agencies. the actors who transfer knowledge, sources of knowledge, discharge forms, media about discharge, and culture are fundamental to promoting the discharge planning process’s success.48 in other cases, the clinician nurse shares knowledge and health information when asked questions.13,14,49 an ethnography study found that culturally competent discharge planning is important for effectively transitioning care from inpatient to home.50 in other views, almost all clinician nurses said they needed more time for optimal discharge planning implementation, especially for stroke survivors and family caregivers.11,12 health workers must be responsible for doing this, first, to minimize the occurrence of recurrent strokes and second, to prevent disease in the family as stroke caregivers. the second theme is clear information from community nurses. eleven stroke survivors used community nurse service. of 24 caregivers, twenty caregivers have had a good experience using this service. nurse s. is the only community nurse living in this field. therefore, he is proud of a healthy society. he worked in a government hospital before becoming a community nurse. no stroke survivors and stroke caregivers are disturbed by his double profession. the barriers are related to stroke survivors in a rural area with a hospital care setting, and the clinician nurse focuses on learning and teaching stroke survivors without involving their family caregivers.51 therefore, specialists or treating physicians must share health information, including stroke education for stroke disease, rehabilitation, health services, and support organizations. education programs between stroke and stroke caregivers provide increased understanding and promote communication.52 other literature found was different in this field of research. here, community nurses instead focus on family caregivers. they saw the hegemony of stroke caregivers over stroke survivors. almost all stroke sufferers are elderly, who, under normal conditions, need other support, even in the event of a stroke. the third theme is family brotherhood. muscle weakness is the biggest sign of stroke survivors in the area setting. unfortunately, half of both stroke survivors and families are ignoring stroke signs, adding more distance to get a complete stroke health facility, and only two villages with a public transportation route. in addition, some stroke survivors and families must prepare extra money and infrastructure for stroke recovery in central town without time off. whereas the time for optimal motor recovery after a stroke attack is between 2 and 3 months.53 the previous research promotes it, which transportation, finance, and knowledge of the stroke survivors and families as the caregivers are proven to delay stroke recovery.54-56 stroke survivors who lived in nonurban areas had poorer key access to complete health service facilities for stroke care and treatments.8 in addition, healthcare access is particularly silent for stroke rehabilitation based on an ethnographic study in taiwan.57 optimizing family empowerment with mutual assistance from the javanese culture could be one of the problems solved. family is not only brotherhood but also unity and relations, and they become one from several conditions, even if they do not stay in their hometown. home visits are the fourth theme. home visits inside of another support as phc service. before the covid-19 pandemic, the phc staff told for home visits around 12-14 stroke survivors in palaran sub-district areas per day. but until research time, keep limited visits. several private health facilities started services around october 2021. it differs from traditional healers who call anytime during a pandemic but keeps the second optional for stroke care services. some problems, such as phc staff just asked a routine activity for stroke survivors without adjustment or other suggestions for stroke survivors and families. also, previous studies show that when the family requests a home visit facility, they must prepare an extra budget.58 home visits and support groups increased the knowledge among stroke patients by up to 50% and stroke caregivers by up to 45%.59 further, related community nursing in italian fieldwork provided that community nurses could manage patients, especially elderly and older adults with chronic conditions.60 the last is considering the cultural view. it has an embedded relationship with an assumption that moral failure persists in concepts of incomprehensibility, deviancy, and personal responsibility. therefore, in the mental health survivor movement, as a consequence of psychiatric power, in this situation, a traditional healer is necessary.61 additionally, seeking and understanding stroke survivors and caregivers rather than considering the health staff’s experience of stroke care could improve home visits for stroke cases.62 one of the ideas for it is optimizing community empowerment by upgrading the skills of the health care staff needed to support health staff duty in the community. the fifth theme is the obstacle to government health insurance. indonesia’s government requires citizens to use government health insurance. in fieldwork, some stroke survivors and families as stroke caregivers have several opinions when using it. according to factual data, only two stroke survivors and four caregivers use that for stroke rehabilitation. the dissemination of information related to the use of government health insurance must have been done in the past. the healthy indonesia program, with one of its pillars, is the use of jkn, which is very relevant to the optimization of bpjs.63,64 health financing inside the strengthening national health system coming to the strategic issue to achieve indonesia’s health development goals.53,65,66 regarding the government health insurance obstacle, the indonesian president has renewed presidential decree number 82/2018 to presidential decree number 59/2024 today. the crucial change was deleted from the government health insurance (jkn) membership class, which was changed to kris (standard inpatient class). based on that, i have two ideas. the first advantage of this policy is that it could decrease the stigma related to health services between rich and poor patients. however, the second disadvantage is increased payment for hospital care, and the last is criticism of customers’ rights to health services. in addition, i prefer looking back for optimizations decentralization in law no. 32/2004, which could manage harmony between de-concentration tasks and assisting tasks, thus reducing consumer payment and providing the best service based on the capability of the local area. the last theme is counseling services for families. several families have caregiver duties in the community: physical assistance, moral support, and finding assistance. furthermore, five caregivers discussed obstacles to consultation regarding stroke rehabilitation and stroke caring times in a hospital setting. they must pay more for consulting services with the neurologist, and it comes to the hospital regulations in a private hospital. emotional, behavioral, and psychological issues have arisen regarding the role change to coming stroke caregivers. several burdens regarding the new role in their family must be a problemsolving. the multiple responsibilities of stroke caregivers need care information from health professional staff. one treatment for families is family counseling or therapy.67 the lack of a hospital not only knowledge from stroke survivors but also the families. it has correlated with decision-making for caring, which contributes article [page 684] [healthcare in low-resource settings 2024;12:12605] non -co mmerc ial us e o nly to stroke survivors being alive.68 physical limitations, lack of communication, and burnout are several problems found for stroke caregivers in jogja, indonesia. help maintenance and communicators to support stroke survivors, an essential role for stroke caregivers.69 much duty comes when someone gets a stroke in your family. counseling services for families usually involve the discharge planning process. it is one of the important points for both stroke survivors and stroke caregivers to continue life in the community. conclusions in conclusion, based on javanese culture, where in this study, respondents do not stay in java island, they have some opinions on stroke care. the first choice for stroke care and rehabilitation is on health facilities. however, some obstacles are coming up: the preparedness of stroke survivors and families as caregivers to get health promotion related to stroke care, health staff for the obedient scheduled visits, learning and teaching of stroke survivors and caregivers, and health insurance availability. caring for stroke and family could be essential when all components are in synergy. references 1. world health organization (who). framework on integrated, people-centred health services: report by the secretariat. 2015. available from: http://apps.who.int/iris/bitstream/10665/174536/1/978924156 4977_eng.pdf?ua=1,%0ahttp://apps.who.int/gb/ebwha/pdf_fil es /wha69/a69_39-en .pdf?ua=1&ua=1%0aht tp : / / apps.who. int /gb/ebwha/pdf_f i les /wha69/a69_39en.pdf?ua=1 2. pitthayapong s, thiangtam w, powwattana a, et al. a community based program for family caregivers for post stroke survivors in thailand. asian nurs res (korean soc nurs sci) 2017;11:150-7. 3. powers wj, rabinstein aa, ackerson t, et al. 2018 guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the american heart association/american stroke association. stroke 2018;49:46-110. 4. somerville e, minor b, keglovits m, et al. effect of a novel transition program on disability after stroke: a trial protocol. jama netw open 2019;2:e1912356. 5. frumkin h, haines a. global environmental change and noncommunicable disease risks. annu rev public health 2019;40:261-82. 6. venketasubramanian, yoon, pandian n. stroke epidemiology in south, east, and south-east asia: a review. j stroke 2017;19:286-94. 7. martinez r, lloyd-sherlock p, soliz p, et al. trends in premature avertable mortality from non-communicable diseases for 195 countries and territories, 1990–2017: a population-based study. lancet glob heal 2020;8:e511-23. 8. thompson sg, barber pa, gommans jh, et al. geographic disparities in stroke outcomes and service access: a prospective observational study. neurology 2022;99:e414-26. 9. hu s, cui b, mlynash m, et al. stroke epidemiology and stroke policies in china from 1980 to 2017: a systematic review and meta-analysis. int j stroke 2020;15:18-28. 10. republic of indonesia. the constitution of the republic of indonesia, law n. 38, year 2014, about nursing. 2014. available from: https://www.google.com/search?q=the+constitution+ of+the+republic+of+indonesia%2c+number+38+on+2014+y ears+about+nursing&rlz=1c5chfa_enit976it976&oq=the 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between level of education and post-stroke cognitive status in hospital-based ischemic stroke survivors. mnj (malang neurol journal) 2021;7:1-6. 16. ohannessian r, dhote-burger p, chauvin f, et al. health policy for telestroke in france: a retrospective description from 2003 to 2016. rev neurol (paris) 2019;175:390-5. 17. kulcsar m, gilchrist s, geroge mg. improving stroke outcomes in rural areas through telestroke programs: an examination of barriers, facilitators, and state policies. telemed ehealth 2014;20:3-10. 18. putra pa, tresno t, wahyu ps. development of the national institutes of health stroke scale (nihss) for predicting disability and functional outcome to support discharge planning after ischemic stroke. j ners 2019;14:413-7. 19. fadilah n, kusnanto, nursalam, rahariyani ld. analysis of influencing factors of burden of caregiver among stroke patients at home. j public health africa 2019;10:1188. 20. ugur hg, erci b. the effect of home care for stroke patients and education 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mmerc ial us e o nly assessment of barriers and facilitators to rapid stroke treatment. res nurs health 2016;39:438-48. 27. norris m, allotey p, barrett g. “it burdens me”: the impact of stroke in central aceh, indonesia. sociol heal illn 2012;34:826-40. 28. donkor es. stroke in the 21st century: a snapshot of the burden, epidemiology, and quality of life. stroke res treat 2018;2018:3238165. 29. rajsic s, gothe h, borba hh, et al. economic burden of stroke: a systematic review on post-stroke care. eur j heal econ 2019;20:107-34. 30. legg c, penn c. a stroke of misfortune: cultural interpretations of aphasia in south africa. aphasiology 2013;27:126-44. 31. chikafu h, mutero it, chimbari mj. “if i were to suffer a stroke right now, the first place that i should be taken to is the traditional healer”: community beliefs and health-seeking practices for noncommunicable diseases in rural kwazulunatal, south africa. qual rep 2022;27:243-56. 32. nweke mc, eze ck. the place of spiritual and traditional beliefs in stroke rehabilitation in sub-saharan africa: a scoping review. j complement altern med res 2019;8:1-16. 33. agianto a, kamilah a, agustina r. stroke traditional therapy in the community in indonesia. kne life sci 2022;2022:24053. 34. european stroke organisation (eso). essentials of stroke care an overview of evidence-based interventions covering the entire chain of stroke care. 2018. available from: https://actionplan.eso-stroke.org/the-essentials-of-stroke-care 35. wang w, pucciarelli g, mei y, et al. the dyadic self-care experience of stroke survivors and their caregivers: a qualitative descriptive study. heal expect 2023;26:2325-39. 36. bastawrous m, gignac ma, kapral mk, cameron ji. adult daughters providing post-stroke care to a parent: a qualitative study of the impact that role overload has on lifestyle, participation and family relationships. clin rehabil 2015;29:592600. 37. chayati n, mikami a, setyopranoto i, effendy c. unveiling the patient-centered approach: exploring the needs of javanese stroke patients in home health services. int j public heal sci 2024;13:820. 38. setiawan kep, wahyuningsih ww, rizaldy dr, kasimbar dc. suwuk: construction of the javanese people’s mindset in medicine. j javanologi 2023;5:910. 39. triratnawati a. acculturation in javanese traditional medicine practice in yogyakarta. komunitas 2016;8:39-50. 40. higginbottom g, venzon e, rn c. the use of focused ethnography in nursing research. nurse res 2013;20:36-43. 41. creswell jw. research design qualitative, quantitative, and mixed methods approaches. 2014. available from: https://www.ucg.ac.me/skladiste/blog_609332/objava_105202 /fajlovi/creswell.pdf 42. brooker p. a glossary of literary and cultural theory. routledge; milton park, uk; 2016. 43. edgar a, sedgwick p. cultural theory: the key concepts. routledge; milton park, uk; 2007. 44. ryan gs. an introduction to the origins, history and principles of ethnography. nurse res 2017;24:15-21. 45. ugwu cn, eze val hu. qualitative research. idosr j sci technol 2023;8:20-35. 46. alhojailan mi. thematic analysis: a critical review of its process and evaluation. wei int eur acad proc 2012;1:8-21. 47. braun v, clarke v. successful qualitative research: a practical guide for beginners. sage 2013;400. 48. waring j, marshall f, bishop s, et al. an ethnographic study of knowledge sharing across the boundaries between care processes, services and organisations: the contributions to ‘safe’ hospital discharge. heal serv deliv res 2014;2:1-160. 49. widjaja kk, chulavatnatol s, suansanae t, et al. knowledge of stroke and medication adherence among patients with recurrent stroke or transient ischemic attack in indonesia: a multicenter, cross-sectional study. int j clin pharm 2021;43:666-72. 50. quillatupa n, covenas cs. a culturally competent approach to discharge planning and transfer of care. cureus 2023;15:12-4. 51. kusuma pj, djuari l, machin a, fauzi aa. knowledge, attitude and practice of primary care physicians in dealing with acute stroke in indonesia. j heal sci med res 2021;39:353-64. 52. sanjuan e, pancorbo o, santana k, et al. management of acute stroke. specific nursing care and treatments in the stroke unit. neurologia 2023;38:419-26. 53. mahendradhata y, trisnentoro l, lystiadewi s, et al. the republic of indonesia health system review. 2017. available from: http://apps.who.int/iris/bitstream/ handle/10665/254716/9789290225164-eng.pdf;jsessionid =52cb57a62e59ca58949742ad7c5e7793?sequence=1 54. denham amj, wynne o, baker al, et al. “this is our life now. our new normal”: a qualitative study of the unmet needs of carers of stroke survivors. plos one 2019;14:1-13. 55. garnett a, ploeg j, markle-reid m, strachan ph. factors impacting the access and use of formal health and social services by caregivers of stroke survivors: an interpretive description study. bmc health serv res 2022;22:1-15. 56. yoon sy, kim yw, park jm, et al. accessibility for rehabilitation therapy 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62. bulsara c, saunders r, emery l, etherton-beer c. reflecting on experiences of care: an exploratory qualitative descriptive study of the perspectives of stroke survivors, families and staff. bmj open 2021;11:1-8. 63. rochmah tn, rahmawati it, dahlui m, et al. economic burden of stroke disease: a systematic review. int j environ res public health 2021;18:7552. 64. yamanie n, lamuri a, felistia y, et al. importance of social support for indonesian stroke patients with depression. f1000research 2022;11:1484. 65. pang myc. burden of caregivers of individuals with stroke. hong kong physiother j 2014;32:1. 66. gani a, budiharsana mp. the consolidated report on indonesia health sector review 2018. 2018. available from: https://www.unicef.org/indonesia/media/621/file/health%20s article [page 686] [healthcare in low-resource settings 2024;12:12605] non -co mmerc ial us e o nly ector%20review%202019-eng.pdf%20.pdf 67. morales l. what are the benefits of family counseling? 2022. available from: https://www.medicalnewstoday.com/articles/ family-counseling 68. visvanathan a, mead ge, dennis m, et al. the considerations, experiences and support needs of family members making treatment decisions for patients admitted with major stroke: a qualitative study. bmc med inform decis mak 2020;20:1-11. 69. vidyanti an, muhrodji p, wicaksono hda, et al. roles and problems of stroke caregivers: a qualitative study in yogyakarta, indonesia. f1000research 2022;10:1-24. article [healthcare in low-resource settings 2024;12:12605] [page 687] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11861 predictors of smoking exposure in non-smoking adolescents in indonesia julfia aina sari,1 ferry efendi,1,2 lailatun nimah,1 gading ekapuja aurizki,1 ronal surya aditia,3 rifky octavia pradipta,1 khadizah h. abdul-mumin4 1faculty of nursing, universitas airlangga, surabaya, indonesia; 2school of nursing and midwifery, la trobe university, melbourne, vic, australia; 3faculty of sport science, universitas negeri malang, indonesia; 4pengiran anak puteri rashidah sa'adatul bolkiah institute of health sciences, universiti brunei darussalam, brunei darussalam abstract exposure to secondhand smoke is one of the leading causes of death for non-smokers worldwide. the prevalence of exposure to secondhand smoke is higher among adolescents. research on predictors of secondhand smoke exposure in adolescents is still rarely conducted in indonesia. this study aimed to analyze the predictors of exposure to secondhand smoke among non-smoking adolescents in indonesia. this study used data from the global youth tobacco survey (gyts) indonesia 2019 with a cross-sectional design. a total of 7,594 adolescents aged 13 to 15 were selected using purposive sampling. the dependent variables were exposure to secondhand smoke at home and in public. the independent variables included age, gender, smoking parents, smoking friends, and knowledge of the dangers of secondhand smoke. data were analyzed using stata with inferential tests, namely chi-square and logistic regression. the prevalence of adolescents exposed to secondhand smoke at home and in public was 49.57% and 71.86%, respectively. at-home exposure was significantly associated with smoking parents [aor=3.50, 95% ci=2.97 to 4.12], smoking friends [aor=1.50, 95% ci=1.30 to 1.73], and knowledge of the dangers of secondhand smoke [aor=2.11, 95% ci=1.52 to 2.93]. public exposure was associated with ages 13-15 [aor=1.32, 95% ci=1.10 to 1.58] and older than 15 [aor=1.77, 95% ci=1.39 to 2.25], male gender [aor=1.31, 95% ci=1.11 to 1.53], smoking parents [aor=1.58, 95% ci=1.36 to 1.84], smoking friends [aor=2.16, 95% ci=1.85 to 2.53], and knowledge of secondhand smoke dangers [aor=2.84, 95% ci=2.15 to 3.75]. adolescents’ exposure to secondhand smoke in public spaces is higher in prevalence and has more associated factors compared to exposure at home. exposure reductions require comprehensive actions from authorities by strictly implementing and expanding non-smoking areas covered by existing regulations. also, family and school management should be involved in prevention efforts. introduction the smoking epidemic is one of the biggest public health threats the world has ever faced.1 indonesia is among the countries that have a high prevalence of smokers globally.2 smoking causes many losses; not only is it harmful to health, but it can also worsen poverty and cause social, economic, and environmental damage.3 exposure to secondhand smoke kills approximately 1.2 million non-smokers worldwide.4 tobacco comprises a staggering array of 7,000 chemicals, encompassing hundreds of noxious compounds, and approximately 70 of these are known to be carcinogenic substances.5 these substances can worsen health conditions, especially for non-communicable diseases like heart disease, diabetes mellitus, stroke, and others.6 there is no safe level of exposure to secondhand smoke.4 the prevalence of exposure to secondhand smoke is higher among adolescents than adults.7 the world health organization (who) reported that 65,000 children die each year due to exposure to secondhand smoke.4 in indonesia, around 96 million people are currently exposed to secondhand smoke.8 research in nigeria and west africa has stated that expocorrespondence: ferry efendi, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: ferry-e@fkp.unair.ac.id key words: secondhand smoke, adolescent, tobacco control, smoking cessation, air pollution. contributions: fe, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ln, conceptualization, investigation, methodology; jas, conceptualization, investigation, methodology; gea, rop, rsa, validation, and writing – original draft, review and editing; kha, methodology, visualization, resources, investigation, and writing –review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: in august 2019, the global youth tobacco survey (gyts) in indonesia obtained official authorization from the national institute of health research and development, solidifying its credibility and legitimacy. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors are thankful to the national institute of health research and development, and the indonesian ministry of health for using the gyts data. we also thank all the respondents who took part in gyts indonesia 2019 received: 22 september 2023. accepted: 27 february 2024. early access: 7 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11861 doi:10.4081/hls.2024.11861 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11861] [page 415] non -co mmerc ial us e o nly sure to secondhand smoke is associated with having parents and friends who smoke, being asked to buy cigarettes by family, and lower social class.9 in indonesia, research related to predictors of secondhand smoke exposure among non-smoking adolescents using data analysis from the global youth tobacco survey (gyts) has never been carried out. globally, there are 1.2 million smokers from developing countries.10 according to a survey involving adolescents aged 12-16 years from 1999-2018 in 142 countries, the prevalence of exposure to secondhand smoke everywhere was 62.9%, while at home and in public were 33.1% and 57.6%, respectively.11 in 2019, nearly 7 million students in the us were exposed to secondhand smoke at home, and 6 million were exposed in vehicles.5 in indonesia and pakistan, for example, more than 80% of people are exposed to secondhand smoke in restaurants.12 gyts indonesia 2019 reported exposure to secondhand smoke in closed public places reached 66.2%, while in open public places and at home were 67.2% and 57.3%, respectively.13 in indonesia, regulations that limit exposure to secondhand smoke have been established, but their implementation has not been optimal (ref). the 2018 basic health research in indonesia reported that 32.4% of people were exposed to secondhand smoke in a closed room.14 many people are not aware of the dangers of passive smoking regarding smoking-attributable diseases.15 research in semarang showed that 42.86% of places do not put up a sign for the area. six out of ten teenagers are exposed to secondhand smoke in public, and exposure to secondhand smoke is higher than exposure to secondhand smoke at home. there is still high exposure to secondhand smoke in indonesia, so it is necessary to supervise the implementation of the regulations on non-smoking areas that have been made.16 the southeast asia tobacco control alliance states that indonesia is among the weakest in tobacco control in southeast asia.17 the indonesian government must implement best practices in tobacco control to reduce the burden of tobacco-related diseases.18 factors reported to be associated with exposure to secondhand smoke were age, ethnicity, place of residence (rural), and current smoking.19 gender and education of the head of the household are also associated with exposure to secondhand smoke at home.20 considering the impact of exposure to secondhand smoke on the body, the lack of optimal supervision of smoke-free regulations, and the limited research on predictors of exposure to secondhand smoke, it is hoped that the results of this study can provide additional information regarding predictors of secondhand smoke exposure among non-smoking adolescents in indonesia. these findings should be taken into consideration in developing policies to control secondhand smoke exposure in the country. materials and methods design this study used secondary data from gyts indonesia 2019 with a cross-sectional design. population and sample this study’s population was based on the gyts survey population, totaling 9,992 adolescents. the gyts is a national schoolbased survey of students in classes aged 13-15 years that uses a two-stage cluster sample design to obtain a representative sample.13 the study purposively selected the sample based on the inclusion criteria of non-smoking adolescents and obtained 7,594 participants. data collection data can be downloaded for free at the centers for disease control (cdc) website (https://www.cdc.gov/tobacco/global/ index.htm). the cleaning process involves meticulously curating the dataset by discerning and extracting relevant data points, culminating in the vital step of recoding variables essential for the study’s execution. variables the dependent variable in this study was exposure to secondhand smoke at home and exposure in public. exposure to secondhand smoke at home was determined based on the answers to the following question: “during the past 7 days, on how many days has anyone smoked inside your home, in your presence?” adolescents were considered not exposed if the answer was “0 days”; any other answer indicated exposure. meanwhile, the questions used to determine exposure in public spaces were: “during the past 7 days, on how many days has anyone smoked in your presence inside any enclosed public place, other than your home (such as schools, malls, restaurants, shopping centers, theaters, cafes, health service facilities, public transportation, indoor sports venues)?” and “during the past 7 days, on how many days has anyone smoked in your presence at any outdoor public place (such as playgrounds, curbside, building entrances, parks, beaches, sports fields)?” adolescents were considered not exposed if both questions were answered within “0 days”; any other answer to at least one question was considered exposure. this study included several independent variables, namely age, gender, smoking parents (“do your parents smoke tobacco?”), smoking friends (“during the past 30 days, did you see anyone smoke inside the school building or outside on school property?”), and knowledge about the dangers of secondhand smoke (“do you think smoke from other people’s cigarettes is harmful to you?”). analysis data analysis used were univariate and inferential analysis, namely chi-square test and logistic regression using stata version 15 application for windows. ethical approval in august 2019, the global youth tobacco survey (gyts) in indonesia obtained official authorization from the national institute of health research and development, solidifying its credibility and legitimacy. results table 1 shows that the percentage of exposure to secondhand smoke at home was 49.57%, which is lower than the exposure in public (71.86%). the average age of adolescents was 13-15 years (51.29%), and 69% were girls. approximately half of the adolescents had smoking friends (53.29%), and a similar proportion had smoking parents (42.07%). almost all adolescents were aware of the dangers of secondhand smoke (96.22%). exposure at home the results of the bivariate analysis indicated that four out of five independent variables were significantly associated with exposure at home, namely age (p=0.039), smoking parents transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 416] [healthcare in low-resource settings 2024;12:11861] non -co mmerc ial us e o nly (p<0.001), smoking friends (p<0.001), and knowledge of secondhand smoke dangers (p<0.001). only gender was not significantly associated with at-home exposure (p=0.416) (table 2). meanwhile, based on the logistic regression analysis (table 3), three independent variables could be significant predictors for exposure at home. adolescents with smoking parents and smoking friends have 3 times (95% ci=2.97 to 4.12) and 1.5 times (95% ci=1.30 to 1.73) higher odds of getting exposed to secondhand smoke at home compared to those with non-smoking parents and friends. also, adolescents who knew of secondhand smoke dangers had higher odds of getting exposed compared to those who did not know (95% ci=1.52 to 2.93). exposure in the public the bivariate analysis shows that all independent variables were significantly associated with exposure to secondhand smoke in public, namely age (p<0.001), gender (p=0.033), smoking parents (p<0.001), smoking friends (p<0.001), and knowledge of the dangers of secondhand smoke (p<0.001; table 2). furthermore, the logistic regression results indicate that all significant variables could significantly predict exposure to secondhand smoke in public (table 3). the older the adolescents, the higher the odds of getting exposed. adolescents aged 13-15 years had 1.32 times higher odds (95% ci=1.10 to 1.58) compared to adolescents aged <13. the odds were even higher in those aged >15 (aor=1.77; 95% ci=1.39 to 2.25). meanwhile, male adolescents had 1.31 times higher odds of getting exposed to the public compared to their female counterparts. adolescents with smoking parents had 1.58 times higher odds (95% ci=1.36 to 1.84) of public exposure. the odds were even higher for those having smoking friends (aor=2.16; 95% ci=1.85 to 2.53). meanwhile, adolescents with knowledge of the dangers of secondhand smoke had 2.84 times higher odds of secondhand smoke exposure in public (95% ci=2.15 to 3.75) compared to those without knowledge. discussion age is one of the predictors associated with exposure to secondhand smoke in public but is not a predictor for exposure at home. this aligns with a study from nigeria, which demonstrated that age as a predictor for secondhand smoke exposure depends on settings; it is significant outside the home but not inside the home.9 at home, adolescents may have difficulties avoiding exposure, regardless of their age groups. individuals in their age group have a lower chance of confronting older members of their family, such transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. results of univariate predictors of secondhand smoke exposure among adolescent non-smokers in indonesia (n=7,594). variable n % exposure to secondhand smoke at home yes 3,764 49.57 no 3,830 50.43 exposure to secondhand smoke in the public yes 5,457 71.86 no 2,137 28.14 age (years) <13 1,236 16.27 13-15 3,896 51.29 >15 2,464 32.44 gender female 5,240 69.00 male 2,354 31.00 smoking parents yes 3,195 42.07 no 4,399 57.93 smoking friends yes 4,047 53.29 no 3,547 46.71 knowledge of secondhand smoke dangers yes 7,307 96.22 no 287 3.78 table 2. results of bivariate predictors of secondhand smoke exposure among non-smoker adolescents in indonesia (n=7,594). variable exposure to secondhand smoke (shs) predictors at home in public yes no p x2 yes no p x2 n % n % n % n % age (years) 0.039 11.42 <0.001 79.15 <13 574 7.56 662 8.72 773 10.18 463 6.10 13-15 1981 26.09 1915 25.22 2775 36.54 1121 14.76 >15 1209 15.92 1253 16.50 1909 25.14 553 7.28 gender 0.416 1.48 0.0332 9.63 female 1155 15.21 1199 15.79 3719 48.97 1521 20.03 male 2609 34.36 2631 34.65 1738 22.89 616 8.11 smoking parents <0.001 684.73 <0.001 83.24 yes 2151 28.32 1613 21.24 2476 32.60 2981 39.25 no 1044 13.75 2786 36.69 719 9.47 1418 18.67 smoking friends <0.001 89.74 <0.001 260.30 yes 2215 29.17 1832 24.12 3240 42.67 807 10.63 no 1549 20.40 1998 26.31 2217 29.19 1330 17.51 knowledge of shs dangers <0.001 41.13 <0.001 94.13 yes 3672 48.35 3635 47.87 5314 69.98 1993 26.24 no 92 1.21 195 2.57 143 1.88 144 1.90 [healthcare in low-resource settings 2024;12:11861] [page 417] non -co mmerc ial us e o nly as parents, older siblings, or other close relatives. the case is different in public, where older adolescents are more at risk of getting exposed. this aligns with studies conducted in malaysia,19,21 west africa,22 and kuwait.23 this is possible because older adolescents are usually given more freedom by their parents and are thus more likely to visit places where smokers are common. also, parents usually become less protective as their children grow older. although some studies24-26 found no significant associations between age and these factors, this should not discourage parents from being involved in monitoring their children’s behaviors while at home. similar to age, gender was also a predictor for exposure to secondhand smoke in public but not for exposure at home. this aligns with a study in thailand, where gender was not strongly associated with exposure at home,27 and in gambia, which shows significant associations between gender and exposure in indoor and outdoor public spaces.28 nevertheless, studies conducted in india29 and virginia, united states,24 found that gender was not significantly associated with exposure to secondhand smoke in any setting. despite these contrasting findings, in general, men have higher odds of getting exposed to secondhand smoke than women.21,27-29 the similarity in the percentage of secondhand smoke exposure at home among both women and men can be attributed to the hesitancy of teenagers to confront individuals smoking indoors, making it challenging to evade such exposure. conversely, men face a higher risk of encountering secondhand smoke in public spaces, possibly due to the predominant prevalence of male smokers in indonesia, which amplifies their likelihood of being exposed to secondhand smoke. having a smoking parent was a predictor associated with secondhand smoke exposure at home and in public. the results were consistent with studies conducted in india, 29 south korea,25,30 africa,22,31 united states,24,32,33 malaysia,21,34,35 thailand,27 and europe.36 despite being significant in both settings, the odds of getting exposed were far higher at home for those with smoking parents. home is where family members have close interactions, and the chance of getting exposed to smoking parents is high if adolescents live with their smoking parents; it is challenging to avoid such exposure. moreover, for most indonesians, asking parents to stop smoking is considered impolite, hindering adolescents from expressing concerns about their parents’ unhealthy behavior. having smoking friends was also a predictor associated with all types of secondhand smoke exposure. the results correspond with studies in africa,9,22,31,37,38 the united states,24,33 and saudi arabia.39 in contrast to having smoking parents, the odds of getting exposed were higher in public for those with smoking friends. adolescents who associate with peers who smoke are highly susceptible to secondhand smoke exposure. furthermore, since adolescents frequently spend a substantial amount of time in the company of their peers, avoiding such exposure becomes a challenging task. in the context of indonesia, smoking is deeply ingrained as a societal norm, leading non-smoking adolescents to perceive secondhand smoke exposure as routine. however, proactive measures to mitigate this issue involve educating both adolescent smokers and non-smokers about the hazards of secondhand smoke. by fostering awareness, it is anticipated that smoking adolescents will refrain from smoking in the presence of others, and non-smokers can take steps to steer clear of secondhand smoke exposure. knowing the dangers of secondhand smoke is a predictor associated with all types of exposure to secondhand smoke. the percentage of exposure to secondhand smoke is higher among adolescents who are aware of the dangers of secondhand smoke. the results of this study align with studies conducted in west africa,9,38,40 bangladesh,41 and india.42 however, the results of this study contrast with other studies, such as those in medina,39 africa,43,44 india,45,46 china,47 and vietnam48 which stated that having knowledge was associated with reduced exposure to secondhand smoke. the results of this study indicate that almost all adolescents are aware of the dangers of exposure to secondhand smoke for their health, but very few take proactive action to avoid exposure to secondhand smoke as a whole. due to this reason, there is a need for modification in providing education to avoid exposure to secondhand smoke, especially for adolescents. a good strategy is also needed to communicate the dangers of smoking to transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. results of multivariate predictors of secondhand smoke exposure among non-smoker adolescents in indonesia (n=7,594). predictors exposure to secondhand smoke at home in public aor 95% ci p aor 95% ci p age (years) <13 (ref) 1 1 1 1 13-15 1.08 0.92 to 1.26 0.311 1.32 1.10 to 1.58 0.003** >15 0.98 0.82 to 1.17 0.869 1.77 1.39 to 2.25 <0.001** gender female (ref) 1 1 1 1 male 1.04 0.90 to 1.19 0.547 1.31 1.11 to 1.53 0.001** smoking parents no (ref) 1 1 1 1 yes 3.50 2.97 to 4.12 <0.001** 1.58 1.36 to 1.84 <0.001** smoking friends no (ref) 1 1 1 1 yes 1.50 1.30 to 1.73 <0.001** 2.16 1.85 to 2.53 <0.001** knowledge of shs dangers no (ref) 1 1 1 1 yes 2.11 1.52 to 2.93 <0.001** 2.84 2.15 to 3.75 <0.001** shs, secondhand smoke; * <0.05 ** <0.01. [page 418] [healthcare in low-resource settings 2024;12:11861] non -co mmerc ial us e o nly smokers themselves and others. currently, social media can be considered and developed as a tool for interventions to improve behavior to avoid exposure to secondhand smoke among adolescents in indonesia. conclusions six out of ten adolescents are exposed to secondhand smoke in public. the prevalence of exposure to secondhand smoke in adolescents is much higher in public than at home. having parents and friends who smoke, as well as knowledge of the dangers of secondhand smoke and cigarettes, significantly increases exposure to secondhand smoke at home and in public. it is necessary to promote health regarding predictors associated with exposure to secondhand smoke in indonesia and enhance avoidance behavior against exposure to secondhand smoke. the government must provide oversight of smoking-free regulations and disseminate these regulations to the wider community. furthermore, researchers can explore and modify additional variables related to exposure to secondhand smoke using existing gyts data. strengths and limitations one of the key strengths of this study is its large sample size, which greatly enhances its representativeness as a national survey. with a substantial and diverse participant pool, the findings are more likely to accurately reflect the broader population’s characteristics, behaviors, and attitudes, thereby bolstering the study’s validity and generalizability to the entire nation. however, a limitation of this study is that it relies on secondary data from the global youth tobacco survey (gyts) indonesia in 2019, while this research was conducted in 2022. differences in adolescent characteristics may arise due to the time gap, potentially leading to variations in the results compared to the current situation. additionally, the variables considered in this study were limited to those already existing in the results of the global youth tobacco survey (gyts) 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exposure to secondhand smoke at home among korean adolescents: a nationally representative survey. int j environ res public health 2016;13:241. 26. hashemi-aghdam mr, shafiee g, ebrahimi m, et al. trend of passive smoking and associated factors in iranian children and adolescents: the caspian studies. bmc public health transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11861] [page 419] non -co mmerc ial us e o nly 2022;22:603. 27. phetphum c, noosorn n. prevalence of secondhand smoke exposure at home and associated factors among middle school students in northern thailand. tob induc dis 2020;18:11. 28. cham b, mdege nd, bauld l, et al. exposure to second-hand smoke in public places and barriers to the implementation of smoke-free regulations in the gambia: a population-based survey. int j environ res public health 2021;18:6263. 29. raute lj, pednekar ms, mistry r, et al. determinants 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2021;05:281-95. 41. rahman m, hasan smm, haque se, et al. secondhand smoking, knowledge/attitudes and socioeconomic status among married bangladeshi women: a cross-sectional study. sao paulo med j 2019;137:13-24. 42. arikrishnan k, sarveswaran g, krishnamoorthy y, sakthivel m, majella mg, lakshminarayanan s. prevalence and factors related to second hand smoking exposure, knowledge and response among adolescents in rural puducherry. int j adolesc med health 2021;33:201-7. 43. sun mc, frédéric jds. knowledge of secondhand smoke and behaviour towards its exposure among teachers in mauritius. tob prev cessat 2020;6:1-9. 44. ndlovu n, kekana mp, matlala sf, ntuli ts. exposure to secondhand smoke in health institutions and sources of knowledge: a cross-sectional study from the city of bulawayo, zimbabwe. pan afr med j 2020;35:1-7. 45. rao abu, rungta nmn, shenoy r, et al. exposure to second hand tobacco smoke among 12 year old adolescents in mangalore, karnataka a descriptive study. asian pacific j cancer prev 2021;22:827-35. 46. ganavadiya r, chandra shekar br, suma s, et al. effectiveness of two psychological intervention techniques for de�addiction among patients with addiction to tobacco and alcohol – a double�blind randomized control trial. indian j cancer 2018;55:382-9. 47. nan x, lu h, wu j, et al. prevalence, knowledge and education level associated with secondhand smoke exposure among never-smoking women in inner mongolia, northern china. tob induc dis 2020;18:1-11. 48. lee jy, ahn h, lee h. factors affecting secondhand smoke avoidance behavior of vietnamese adolescents. int j environ res public health 2018;15:1-11. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 420] [healthcare in low-resource settings 2024;12:11861] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12845 maternal and neonatal referral system in rural north lampung: a qualitative study of referral system readiness lisa suarni, el rahmayati, kodri 1poltekkes kemenkes tanjung karang, indonesia abstract a reliable referral system is the key to handling emergency cases, for this reason, it is necessary to conduct an in-depth study of the description of the referral system that is in force and implemented in north lampung, considering that most maternal deaths are caused by cases that require fast and integrated treatment. the aim of the research is to provide an overview of the readiness of the maternal neonatal referral system in terms of four aspects: i) infrastructure, ii) human resources readiness, iii) community readiness, and iv) policy readiness. the research is using qualitative analysis. data collection uses in-depth interviews, documentation studies, observations, and focus group discussions (fgds). the maternal mortality rate (mmr) is impacted by the quality of maternal and neonatal services, including handling pregnancy complications. the percentage of rural north lampung who gained coverage for focusing on pregnancy issues throughout 2021 was a miserable 52.66%. rural north lampung’s pregnancy-related issues procedures do not adhere to the operational guidelines for maternal-neonatal referral procedures. the fundamental reference, educate basic emergency neonatal obstetric (bemonc), is no longer in operation, as is comprehensive emergency neonatal obstetric services (cemonc). the readiness of all stakeholders for the neonatal and maternal referral system needs to be improved, including the readiness of infrastructure, human resources, and family-community readiness, and needs to be supported by regional government policies. introduction saving mothers and children in maternal and neonatal emergencies is about punctuality and the correct procedures. it tends to reduce maternal and neonatal mortality rates. about 216,000 maternal deaths occurred in 2015.1 these were caused by i) maternal bleeding (44,200 deaths), ii) abortion complications (43,700 deaths), iii) maternal hypertensive disorders (29,300 deaths), iv) maternal sepsis and other infections (23,800 deaths), and v) obstructed labor (18,800 deaths).2 most cases appear in subsaharan africa (62%) and south asia (24%), making up 86% of maternal mortality worldwide.3 according to the indonesian health demographic survey in 2012, the maternal mortality rate (mmr) was more likely to be high at 359 maternal deaths per 100,000 live births. sustainable development goals (sdg) call for a reduction in the global mmr to less than 70 per 100 000 by 2030, and no country should have an mmr greater than 140 per 100,000.4 in such situations, the number in indonesia was 305 maternal deaths per 100,000 births, which has not reached the specified target of 183 per 100,000 in 2024.5 even more, the mmr was 183 maternal deaths per 100,000 births in 2022. instead, the circumstances are diminishing compared to malaysia, with an mmr of 20 maternal deaths per 100,000 births. in this context, maternal death cases in lampung province in 2019 increased from 102 maternal deaths to 110 maternal deaths. the most prominent causes for these were bleeding (38.26%), hypertension (20.86%), (1.74%), blood disorders (7.82%), metabolic disorders (0.87%), and others (30.43%).6 based on these symptoms, the mmr in north lampung grew from 2017 to 2021. there were eight maternal deaths (2017), nine maternal deaths (2018), ten maternal deaths (2019), ten maternal deaths (2020), and twelve maternal deaths (2021), most likely due to bleeding during the postpartum period. despite maternal complications that entail emergency response time, various countries have guidelines for handling maternal emergencies. therefore, the requirement is to focus on reducing maternal mortality. for this reason, indonesia conforms to policy initiatives on the decision letter (ministry of health correspondence: lisa suarni, poltekkes kemenkes tanjung karang, indonesia. e-mail: lisasuarni@poltekkes-tjk.ac.id key words: health care, maternal mortality, neonatal. contributions: all the authors made a substantive intellectual contribution. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its latest amendment. informed consent: the manuscript does not contain any individual person’s data in any form. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 24 july 2024. accepted: 19 august 2024. early access: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12845 doi:10.4081/hls.2024.12845 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made [page 701] [healthcare in low-resource settings 2024;12:12845] non -co mmerc ial us e o nly decree number 604/menkes/sk/vii/2008) about guidelines for maternal neonatal services in hospitals, handling emergencies from essential to complex. by way of reference, the pocket book of maternal health services in health and referral facilities. many books assess maternal emergencies. for instance, guidelines for the implementation of comprehensive emergency neonatal obstetric services (cemonc) and educate basic emergency neonatal obstetric (bemonc) in community health services (chs)7 onward. this study adopted a refinement of procedures for maternal and neonatal services. several countries concluded that the patient transfer system is critical. a literature study in some highly ranked journals conducted by murray & pearson describes that the referral system has been deemed a part of the component of the health system together with maternity referral. those attain a tracker for health care system analysis.8 descriptive research conducted to assess the causes and factors leading to maternal deaths in unnao district, uttar pradesh, and india through maternal death review (mdr) explained that accepted inter-facility transfer and time rate of referral were the main factors of maternal mortality.9 initiatives have been accomplished to reduce maternal mortality. these consist of existing initiatives named labor insurance, bemonc, and cemonc. furthermore, the initiative named sijariemas was introduced to accelerate the referral process between midwives, community health centres, and referral hospitals, which focuses on three main objectives: i) improving quality emergency obstetric services and new-born care at affiliated hospitals and health centres; ii) increasing the efficiency and effectiveness of the referral system between community health centres and hospitals; and iii) increasing accountability through local government and community involvement, through interventions to improve clinical governance to ensure quality and strengthen referral systems.10 a qualitative study in 2019 explained that obstacles to maternal emergency precautions were most likely to occur after work hours. for instance, blood transfusion complicated procedures, an inadequate facility, and an unsynchronised referral system between bemonc and cemonc. in addition, the communication between departments (midwife-poned-ponek-pmi-reserialise obgin) is ineffective. furthermore, the interview results from the focus group discussion (fgd) were mostly from midwives who tended to state that cemonc was not ready to give medical treatment to patients. on the other hand, the hospital nurse or midwives claimed that the referred patient was in a weak condition as a means of not receiving sufficient medical care. for this reason, the doctor of the obgin specialist revealed that the blood request procedure was complicated and took time, and the patient needed a quick blood transfusion.11 the conclusion stated that a quality referral system with fast help is critical to saving mothers and their babies. executing a quality referral system is expected to reduce maternal and neonatal mortality. nonetheless, an excellent act of assistance involves the readiness of all parties as a means of infrastructure, human resources, finance, and rural, especially the family. a valid referral system is expounded on how to handle emergency cases pre-eminently. for this reason, conducting an in-depth study on how to evoke the current referral system in rural north lampung is necessary. indeed, the root causes of maternal mortality in many cases entail an integrated medical treatment. the research aims to obtain how to describe the readiness of the maternal and neonatal referral system in terms of four aspects: i) infrastructure, ii) human resources, iii) rural, and iv) health service. the research applied access theory to optimise the result. a theoretical framework in this research is the access theory of health services, which is said to achieve equity if health services are distributed according to geography, socioeconomics, and community needs; conversely, if health services have not been distributed well. according to geography, socioeconomics, and community needs, it can be called equity service access. as is known, efforts to achieve equity can be completed by applying an access theory approach. access as a tool for measuring the equity of health services can be seen through i) potential access process indicators, namely population characteristics, ii) potential access structural indicators, namely health service system characteristics, iii) access fundamental objective indicators (realised access objective indicators), namely the utilisation of health services, and iv) real access subjective indicators (realised access subjective indicators), namely the utilisation of consumer satisfaction, where all of these components are influenced by health policy.12,13 materials and methods the research uses qualitative analysis. data collection uses indepth interviews, documentation studies, observations, and fgds. the in-depth interviews were held in the rural north lampung health facility along with the head of the public health centre, bemonc team, the obstetrics gynecology doctor specialist, and the families who experienced maternal-neonatal mortality. documentation studies were accomplished on the maternal-neonatal mortality summary, north lampung neonatal maternal audit, mother-child health book, and the referral paper of the community health centre. observations were executed at bemonc while the fgd was carried out with eight participants consisting of a head of health services (1 person), a head of a community health center (1 person), doctors (2 people), midwives (2 people) and nurses (2 people). research procedures consisted of i) in-depth interviews with five families with maternal-neonatal mortality, ii) in-depth interviews with the head of public health, north lampung health office, and staff also take documentation paper of maternal-neonatal mortality, iii) observations at eight bemonc facilities in north lampung, iv) interviews with the head of the community health centre and the bemonc team, v) data validation accomplished through interviews with families with maternal and neonatal mortality, vi) further validation follow-through interviews with doctors of obstetrics and gynaecology who handle many maternal-neonatal emergency cases. the type above of research adopts a qualitative approach to field research, ensuring rigorous interviewing methods, documentation studies, observations, and fgd are implemented to collect field data that accurately conveys authentic circumstances. comprehensive conversations have occurred involving the obstetrics gynaecology doctor, the head of the poned team, the head of health services at the north lampung health service, and the head of the community health centre. documentation studies on maternal-neonatal death data, maternal-child health book, north lampung neonatal maternal audit, and documentation referral at the community health centre have been implemented targeting families with maternal-neonatal death incidents. observations were carried out at poned facilities. the selection of family samples/participants was done using the purposive sampling method combined with the snowball sampling technique. to be eligible to participate, a family must: i) have experienced the demise of a mother or newborn and ii) be open to an in-depth interview. seven participants were intended to be interviewed for this study; howev article [healthcare in low-resource settings 2024;12:12845] [page 702] non -co mmerc ial us e o nly er, only five agreed to be interviewed, one declined, and one failed to attend due to a relocation to another home. after the information accumulated exceeded saturation, an adequate number of participants was deemed sufficient. data analysis the research team completed the data analysis procedure in phases: i) condensed details from interview transcripts into findings using common words, phrases, and sentences; every code was assigned, factoring for the participant’s name, the data source, and several interviews; ii) doing probing, make small notes on data that still raises questions, then ask the data source again to deepen the meaning of the information provided; iii) assemble comparable data. similar data is compiled into one conclusion to assist researchers in deciding whether the data obtained is comprehensive or reflects triangulated data, nor whether the data is deemed sufficient. equivalent data from various sources, including interviews with participants (head of public health, head of community health center, families of patients who died, obgin doctor), field notes (observation results at poned facilities), documentation from records at the community health center and mother’s kia book, combined into one statement of findings; iv) selecting categorisation, meaning the final phase of the analysis after the researcher looks at an assortment of findings and the interrelationships between the evidence, is accomplished by the researcher applying categorisation after similar data is gained. an interpretation code serves with this empirical unity by ensuring that words, phrases, and sentences are accurately categorised as variations of relevant details. figure 1 shows a framework of the research coding model path. results maternal mortality in rural north lampung based on a documentation study at the north lampung health service, the maternal mortality rates in 2022 are shown in table 1. based on table 1, it seems that most maternal deaths in rural north lampung happened during postpartum and childbirth. hence, the actual number of deaths registered in hospitals. the results of interviews with the public center hospital explained that several deaths were not recorded. for instance, those of mothers who died in provincial hospitals with referral and maternal deaths, not in health facilities. table 2 implies that most maternal deaths happen between 20 and 34 years old. nonetheless, the possibility of maternal mortality within the age of over 34 years is high. by way of reference, the highest likelihood of success in giving birth is under 30 years old. table 3 explains that the unaverred cause of maternal mortality for the past six years was haemorrhages. in addition, hypertension is more likely to be high. qualitative analysis of referral readiness infrastructures bemonc is due to the basic level of maternal and neonatal service. north lampung has 8 bemonc with inpatient facilities. when medical treatment attempts to run in all bemonc, only one bemonc executes the function by giving medical treatment. despite the bemonc assignment, a referral could have been managed better. bemonc assignment is more likely to be a place for midwifery care services. since 2019, seven bemonc (starting the covid-19 pandemic) have been malfunctioning. in this context, the results of the observation approach to facilities availability at bemonc are only 30-40%. most bemoncs do not have an adequate emergency facility for medicine, oxygen, suction, etc. furthermore, the only transportation is an ambulance utilised for all emergency cases at the community health centre. human resources the results of interviews with the head of the community health centre and the bemonc team stated that the policy concerning collaboration between a doctor, a midwife, and a nurse is inappropriate. in addition, the public health service has not been article table 1. maternal mortality by condition. condition of death 2017 2018 2019 2020 2021 2022 pregnancy 3 0 1 unidentified 0 2 labor 2 8 4 6 2 postpartum 3 1 5 6 1 table 2. maternal mortality by age. age 2017 2018 2019 2020 2021 2022 <20 0 0 0 2 0 2 20-34 6 6 10 6 6 2 >34 2 3 0 2 6 1 table 3. maternal mortality by causes. cause of death 2017 2018 2019 2020 2021 2022 haemorrhage 0 7 5 3 1 3 hypertension 6 1 5 1 4 0 other causes 2 1 0 6 7 2 total 8 9 10 10 12 5 [page 703] [healthcare in low-resource settings 2024;12:12845] non -co mmerc ial us e o nly providing training over the past five years. furthermore, the data validation approach from the health service conveys that there was no maternal neonatal emergency training during the previous three years. training expenses are typically covered; however, the budget allocated for continuous health education is limited. officers must understand referral and emergency handling processes at the bemonc level, according to interviews conducted with various bemonc teams (nurses) at numerous community health centres regarding their understanding of referral protocols. the results of the fgd with ibi management participants, midwives from hospitals and health centres, who assert that many midwives in villages lack the skills and expertise necessary to manage maternal and newborn emergencies, support the statement effectively. despite the risks, they frequently behave recklessly when giving birth by themselves. for instance, in one case of maternal mortality, it was discovered during the labor that the birth was breech; the midwife who had a clinical license was not at the clinic, so a substitute midwife was assigned who did not have a license to practice. the midwife decided to refer the patient when the baby’s body was out, and the baby’s head was still inside. in such conditions, the patient is referred to the hospital. as explained by one of the responsible midwives: “so the story is that the one who helped was her assistant, a freshly graduated midwife named x. she had a lack of experiences and discovered a case of breech birth. now, the body was out, but the head was stuck and could not get out. after that, the patient was sent to y hospital.” antenatal care and deficient book records for pregnant women are factors that start maternal mortality. the midwife disclosed that in one of the situations, the birth attendant was unaware that the expectant mother was breech. in fact, according to the midwife at integrated health centres (posyandu), she had examined the pregnant woman and detected that there was a case of breech position. however, after checking medical records, no notes explained the inspection results scientifically. a report by one of the community health centre’s midwives, “at posyandu yesterday, i was the one who examined the mother (deceased); she was breech. however, when i looked through the mch book, i could not find any documentation indicating the pregnancy test result was breech.” the following are the specific human resources that are employed for overseeing emergencies in phases. the village midwife the preparedness of village midwives to deal with unexpected circumstances needs to be improved. reports from community health center midwives, the health service, and most village midwives state that they have not received maternal emergency training in the last five years, and there have been no updates on this issue in a while. the results of interviews with community health center officers (coordinating midwives) in cases of maternal mortality were that assistance was provided by new midwives who had yet to be trained in ordinary childbirth care or midwifery update (mu) as a requirement for independent midwifery practice. basic emergency neonatal obstetric bemonc staff consists of one doctor, one midwife, and one nurse; they must have been certified in bemonc training. the results of interviews with 5 heads of community health centres in rural north lampung mentioned that only one community health centre had bemonc staff (doctors and midwives). in contrast, the bemonc team still had a certification that needed to be completed at the other community health centres. the health service also suggested holding training to deal with this issue. nevertheless, each time a budget proposal was made, it was consistently turned down for unjustifiable reasons. comprehensive emergency obstetric neonatal care according to data from the health department, three hospitals provide cemonc. not all hospitals had been trained to receive referrals for maternal neonatal emergency patients, according to the findings of interviews with bemonc midwives. as stated by one of the midwives who had referred a patient to cemonc: article figure 1. framework of the research coding model path. figure 2. flowchart referral system in rural north lampung. [healthcare in low-resource settings 2024;12:xxx] [page 704] non -co mmerc ial us e o nly “although we do not have to convey him to the hospital, we are the ones who manage it; the staff is untrained; the patient already appears weaker; and rather than receiving immediate assistance, she is left on her own to survive.” based upon the six deaths in 2022, because they were transferred to a hospital in an unstable situation, five of them encountered maternal mortality. the alertness of cemonc staff is also an obstacle in treating patients. it does not seem viable to provide medical care for maternal-neonatal emergency patients who are assigned to referral hospitals owing to inadequate facilities and restricted blood supply. in addition, one case of maternal mortality due to bleeding indicated that blood readiness in handling bleeding cases was an obstacle. furthermore, the procedure for obtaining blood is complicated, especially the cross-reaction examination procedure between the donor’s blood sample and the patient’s blood sample, which takes 1-2 hours and triggers delays in treatment. the family claimed: “when my sister was about to give birth, everything was fine, but when the baby was born, suddenly blood pooled under the mother’s back; we were not ready for blood, so our sister was immediately taken to handayani hospital. therefore, we got blood at the indonesia red cross (irc) using a long procedure; unfortunately, our younger sister had already passed away.” irc explained that an array of tests is required before making blood transfusions, taking one to two hours. the patient will be exposed to risk if the procedure is not concluded. rural community family readiness enables a glimpse into rural community preparedness through the maternal-neonatal referral system. based on interviews with families who experienced maternal mortality, a significant number of mothers passed away due to families postponing decisions for affordability reasons. families tend to insist that the birth process only be assisted by a midwife, as explained by one of the members (husband): “we do not have the money, and we will have to pay more once we are recommended. we let the midwife handle it, and we can still assist.” even in urgent circumstances, mothers commonly disagree with being referred to more professional medical services, and families are typically reluctant to oblige. the readiness of the maternal and neonatal referral system has been built at the village community level; several community health centres visited stated that at the village level, a referral network had been established, and the village ambulance was prepared to refer patients to health facilities. village leaders, community health clinics, and midwives have coordinated in several rural north lampung villages. most of their obligations in an emergency embrace setting up a transportation system. engaging the family in referral decisions before a referral occurs is crucial, yet the medical field discovers that both partners rarely like to be incorporated throughout pregnancy and giving birth. one of the community health centre midwives explained: “fathers have not always been eager to accompany their wives in lessons. therefore, it is challenging to extend a call to them to get involved. once those men accompany them—mostly husbands are waiting outside—it is difficult to get those gentlemen to think differently.” public health official it became clear from interviews with the public health division’s staff and the head of public health that a unique strategy was required to address maternal crises at the health service level, despite the obstetric complications services program, which includes handling maternal and neonatal emergencies. the north lampung health profile shows that the trend in coverage for the treatment of obstetric complications in the last five years (2017-2021) has fluctuated up and down. the highest coverage was in 2019, and the lowest was in 2021; the average coverage for 2021 is still shallow, namely 52.66%. regarding guidelines or standard operating procedures (sops) for managing and referring instances of maternal and neonatal emergencies, the health service has no rules or regulations. governor policies number 2 of 2018 and number 22 of 2019, which are about technical instructions for leveraging maternity guarantee funds in north lampung regency, govern childbirth assurance as a financial source. nevertheless, there are unlikely to be any assurances of childbirth by 2021. coherency referral based on interactions with families, village leaders, midwives, health centres, hospitals, and health services undertaken at each public health care system level, the referral procedure applied in many instances for newborns and their mothers is as follows. according to figure 2, independent midwives’ practice refers maternal-neonatal emergency patients immediately to the hospital, skipping the bemonc community health centre. the nearest medical facility is referred to, although it does not provide bemonc services. discussion causes of maternal mortality the primary cause of death, according to research analysing the maternal mortality database from 2017 to 2022, was labor proceedings. the most frequent causes are bleeding and hypertension, so the government is preparing programs to reduce the mmr. nevertheless, many government-initiated programs have not resulted in the most beneficial outcomes. between 2003 and 2009, the world health organization (who) reported that more than half of maternal mortalities worldwide were caused by bleeding, hypertensive disorders, and sepsis, and more than a quarter of deaths were due to indirect causes.14 research in two countries, namely indonesia and burkina faso, which examined 104 families who experienced maternal death in indonesia and 74 families from burkina faso, the result was that more than two-thirds of respondents reported delays in seeking, achieving, and receiving medical care. in addition, family members share details about their emergency experiences, which shed light on a culturally derived system of causes, explanations, and behaviours. it is crucial to expand access to basic emergency obstetric and neonatal services. fifty-five lowand lower-middle-income countries explain ninety percent of maternal mortality worldwide. these nations have broadened family planning initiatives and enhanced neonatal medical treatment from 68% to 90%. additional funding is likely necessary for this suggested project.15 readiness of referral system the bemonc facility in indonesia provides initial treatment throughout the referral system for mothers and newborns. hence, it will be sent to higher referral hospitals and cemonc. several healthcare facilities must set up bemonc and cemonc facilities with the best possible infrastructure and staffing levels. according to several studies on bemonc and cemonc implementation in indonesia, those initiatives could have been executed with greater article [page 705] [healthcare in low-resource settings 2024;12:12845] non -co mmerc ial us e o nly effectiveness by considering policy readiness, human resources, infrastructure, finances, and the planning, organising, implementation, evaluation, and feedback procedures.16,17 the adequacy of initiatives by governments aimed at solving this issue is not the primary factor driving the high rates of maternal mortality in an array of nations. a substantial amount of the organising and planning was completed in various countries. nonetheless, the planned initiative will have less of an impact on reducing maternal mortality throughout its implementation because it will require more monitoring, evaluation, and followup.18-20 mmr in indonesia has declined over the past five years, although it is still significantly lower than the goal of 183 per 100,000 births in 2024. indonesia remains ranked as having the highest maternal mortality rate in southeast asia when compared with comparable nations. furthermore, indonesia aims for mmr to be fewer than 70 per 100,000 births by 2030. for this reason, the sdg call for an annual reduction of 11.6% an uncommonly attained rank on a national level.21 maternal and neonatal emergency referrals can be entailed if adequate policies, human resources, infrastructure, and sufficient finances are empowered. findings from the north lampung health service’s head of public health interviews revealed there are no sops or guides for reference at the health service, and no local government regulations enable a system for improving maternal and neonatal emergencies. research in ghana showed that 39% of mothers who died or nearly died gave birth in locations that were unable to provide essential emergency services.22 likewise, research conducted in southwest cameroon evaluated the implementation of obstetric and neonatal services; in theory, maternal and neonatal deaths would be reduced with maternal and neonatal emergency services. though these resources are entirely operational in southwest cameroon, their implementation is unlikely to decrease the maternal mortality rate since the provision of services must be linked with their level of quality.23 this circumstance is also prevalent in tanzania, where medical facilities frequently are not ready or accessible for managing bemonc. to decrease tanzania’s mortality rates, regular quality assurance and auditing of maternal mortality is necessary.24 handling obstetric difficulties involves the community and family taking on a critical role. the study’s findings indicate that the pace at which referrals are made depends on the husband’s decision-making throughout an emergency. in this instance, partners’ commitment to antenatal care is insufficient, and families are typically cautious when referring patients. most husbands in developing countries often need more knowledge about reproductive health than their female partners.25 in addition, husbands also control decision-making regarding the time and conditions of sexual relations, family size, and decisions regarding health care service options. this phenomenon has a significant negative impact on maternal and neonatal health. research conducted in the tanzanian highlands explained that knowledge about birth readiness and readiness to face complications among husbands was shallow, even though 81.3% had heard about this.26 those factors will undoubtedly hinder timely access to maternal emergency services. the findings in this study define that the referral flow for maternal-neonatal emergency patients is accomplished from independent practice midwives directly to the hospital without going through the poned community health centre. referrals are also made to the nearest hospital, even though it does not provide ponek services. this circumstance is occurring in sudan. a pregnant woman encounters a variety of difficult obstacles before arriving at an appropriate medical facility after selecting emergency obstetrical treatment. of the four pathway patterns to cemonc, three were associated with high maternal mortality rates with many factors, such as i) late referral, ii) zig-zag referral, and iii) double referral. mothers who choose a non-functioning bemonc facility and go straight to the cemonc facility immediately (the fourth pathway pattern) are most likely to survive.27 conclusions the mmr is impacted by the quality of maternal and neonatal services, including handling pregnancy complications. the percentage of rural north lampung who gained coverage for focusing on pregnancy issues throughout 2021 was a miserable 52.66%. rural north lampung’s pregnancy-related issues procedures do not adhere to the operational guidelines for maternal-neonatal referral procedures. the fundamental reference, bemonc, is no longer in operation, as is cemonc. the readiness of all stakeholders for the neonatal maternal referral system needs to be improved, including the readiness of infrastructure, human resources, and family-community readiness, and needs to be supported by regional government policies. suggestions regional governments need to emphasise enhancing midwives’ and nurses’ knowledge. additionally, improving bemonc and cemonc facilities, as well as preparing reference regulations regarding the referral system for both private practice sectors, doctors, nurses, and midwives need to complete their skills, knowledge, and communication between health facilities and within health facilities better through continuous education and training. broad education about the involvement of husbands, families, and communities is also critical. lastly, innovative methods such as electronic messaging applications must also be used for effective communication and documentation. references 1. alkema l, chou d, hogan d, et al. global, regional, and national levels and trends in maternal mortality between 1990 and 2015, with scenario-based projections to 2030: a systematic analysis by the un maternal mortality estimation interagency group. lancet 2016;387:462-74. 2. gbd 2013 mortality and causes of death collaborators. global, regional, and national age-sex specific all-cause and cause-specific mortality for 240 causes of death, 1990-2013: a systematic analysis for the global burden of disease study 2013. lancet 2015;385:117-71. 3. united nations. the millennium development goals report 2014. 2014. available from: https://www.un.org/millenniumgoals/2014%20mdg%20report/mdg%202014%20english% 20web.pdf 4. word health organizations (who). maternal mortality by 2030. 2015. available from: https://www.who.int/data/ gho/data/themes/topics/indicator-groups/indicator-groupdetails/gho/maternal-mortality 5. tarmizi sn. turunkan angka kematian ibu melalui deteksi dini dengan pemenuhan usg di puskesmas. 2023. available from: https:// sehatnegeriku.kemkes.go.id/baca/rilismedia/20230115/4842206/turunkan-angka-kematian-ibumelalui-deteksi-dini-dengan-pemenuhan-usg-di-puskesmas/ 6. bapeda provinsi lampung. perubahan rencana pembangunan article [healthcare in low-resource settings 2024;12:12845] [page 706] non -co mmerc ial us e o nly jangka menengah daerah (rpjmd) provinsi lampung tahun 2019-2024. 2016. available from: https://dinaspsda.lampungprov.go.id/detail-post/perubahan-rencana-jangka-menengahdaerah-rpjmd-provinsi-lampung-tahun-2019-2024 7. ministry of health. buku saku pelayanan kesehatan ibu di fasilitas kesehatan dasar dan rujukan, pedoman bagi tenaga kesehatan. 2013. available from: https://library. stikesbup.ac.id/index.php?p=show_detail&id=2476&keywords= 8. murray s.f, pearson sc. maternity referral systems in developing countries: current knowledge and future research needs. soc sci med 2006;62:2205-15. 9. raj ss, manthri s, sahoo pk. emergency referral transport for maternal complication: lessons from the community based maternal death audits in unnao district, uttar pradesh, india. int j health policy manag 2015;4:99-106. 10. hyre a, caiola n, amelia d, et al. expanding maternal and neonatal survival in indonesia: a program overview. int j gynecol obstetr 2019;144:7-12. 11. pranajaya r, suarni l, kodri. mortality determinants in the handling of maternal emergencies. 2020. available from: https://www.ijicc.net/images/vol_13/iss_2/part_2/sc31_pran ajaya_2020_e_r1.pdf 12. aday js, heifets bd, pratscher sd, et al. great expectations: recommendations for improving the methodological rigor of psychedelic clinical trials. psychopharmacology 2022;239: 1989-2010. 13. whitehead m. the concepts and principles of equity and health. int j health serv 1992;22:429-45. 14. say l, chou d, gemmill a, et al. global causes of maternal death: a who systematic analysis. lancet global health 2014;2:e323-33. 15. madise n, nandi a, wong b, razvi s. achieving maternal and neonatal mortality development goals effectively: a cost-benefit analysis. j benefit-cost analysis 2023;14:1-29. 16. hapsari y. analisis implementasi program pelayanan obstetri neonatal emergensi komprehensif (ponek) di rsu adhyaksa tahun 2020. 2020. available from: https://lib.fkm.ui.ac.id/detail?id=134349&lokasi=lokal 17. mia vaf, suparwati a, suryoputro a. analisis pelaksanaan sistem pelayanan obstetri dan neonatal emergensi dasar (poned) di puskesmas sitanggal kabupaten brebes. 2016. available from: https://ejournal3.undip.ac.id/index. php/jkm/article/view/13953 18. d’ambruoso l, byass p, qomariyah sn, ouédraogo m. a lost cause? extending verbal autopsy to investigate biomedical and socio-cultural causes of maternal death in burkina faso and indonesia. soc sci med 2010;71:1728-38. 19. lee h, perosky j, horton m, et al. verbal autopsy analysis of maternal mortality in bong county, liberia: a retrospective mixed methods study. bmj open quality 2023;12:e002147. 20. direktorat gizi kesehatan ibu dan anak. laporan akuntabilitas kinerja instansi pemerintah (lakip) direktorat tahun anggaran 2022. 2023. available from: https://kesmas.kemkes.go.id/kategori_konten/a8baa56554f963 69ab93e4f3bb068c22/laporan-akuntabilitas-kinerja-instansipemerintah-lakip 21. word health organization (who). hari kesehatan sedunia 2023. 2023. available from: https://www.who.int/ indonesia/news/events/hari-kesehatan-sedunia-2023/milestone#year-1948 22. kaselitz e, james kh, aborigo ra, et al. understanding the gap in emergency obstetric and neonatal care in ghana through the preventing maternal and neonatal deaths (premand) study. int j gynecol obstetrics 2019;145:343-9. 23. kadia rs, kadia bm, dimala ca, et al. evaluation of emergency obstetric and neonatal care services in kumba health district, southwest region, cameroon (2011–2014): a beforeafter study. bmc pregnancy childbirth 2020;20:95. 24. bintabara d, ernest a, mpondo b. health facility service availability and readiness to provide basic emergency obstetric and newborn care in a low-resource setting: evidence from a tanzania national survey. bmj open 2019;9:e020608. 25. bhatta dn. involvement of males in antenatal care, birth preparedness, exclusive breast feeding and immunizations for children in kathmandu, nepal. bmc pregnancy childbirth 2013;13:14. 26. moshi fv, ernest a, fabian f, kibusi sm. knowledge on birth preparedness and complication readiness among expecting couples in rural tanzania: differences by sex cross-sectional study. plos one 12018;3:e0209070. 27. elmusharaf k, byrne e, abuagla a, et al. patterns and determinants of pathways to reach comprehensive emergency obstetric and neonatal care (cemonc) in south sudan: qualitative diagrammatic pathway analysis. bmc pregnancy childbirth 2017;17:278. article [page 707] [healthcare in low-resource settings 2024;12:12845] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13297 the impact of environmental health facilities and maternal behaviors on the incidence of diarrhea among children under five yusmidiarti yusmidiarti,1 adi heru husodo,2 susi iravati,3 risda yulianti4 1department of environmental health, poltekkes kemenkes bengkulu; 2department of public health, faculty of medicine, university of gajah mada, yogyakarta; 3department of microbiology, faculty of medicine, gadjah mada university, yogyakarta; 4department of nutrition, poltekkes kemenkes bengkulu, indonesia abstract the objectives of this study were to determine the prevalence of diarrhea among children under five and assess the relationship between its risk factors related to environmental health facilities and maternal behavior. a prospective case-control community-based study was conducted in the service area of pasar ikan community health center, teluk segara subdistrict, bengkulu city, indonesia. a total of 140 participants were included, comprising 70 cases and 70 controls. the study found that poor qualification of clean water resources (or=4.026, p-value=0.000), inadequate utilization of clean water (or=5.813, p-value=0.000), poor qualification of family latrines (or=3.574, p-value=0.000), and inadequate utilization of family latrines (or=3.377, p-value=0.001) were significantly associated with an increased risk of diarrhea prevalence among children under five. furthermore, unhealthy mothers’ behaviors, including frequent feeding of children outside the home (or=2.728, pvalue=0.000) and poor personal hygiene (or=3.377, pvalue=0.001), were also significantly related to a higher prevalence of diarrhea in this age group. therefore, both substandard environmental health facilities and unhealthy maternal behaviors were identified as significant risk factors for diarrhea prevalence in children under five. these findings emphasize the critical importance of improving environmental health facilities and promoting positive changes in mothers’ behavior to reduce the incidence of diarrhea in this vulnerable population. introduction the world health organization (who) classifies diarrhea in children under five as the passage of three or more loose or watery stools within a 24-hour period.1 it occurs when the digestive system is unable to properly absorb water or when it produces excessive fluid.2 in this age group, diarrhea is particularly concerning due to its potential to cause severe dehydration and malnutrition.3 diarrhea can be caused by a variety of factors, including viral infections, bacterial infections, parasites, and food poisoning.4 infectious causes are responsible for a significant number of cases of diarrhea in children under five.5 bacterial infections, such as escherichia coli and salmonella, can be contracted through contaminated food or water.6 viral infections, like rotavirus and norovirus, are highly contagious and can spread easily in childcare settings. parasitic infections, such as giardia and cryptosporidium, often occur due to poor hygiene practices.7 various risk factors increase the susceptibility of children to develop diarrhea. poor hygiene practices, inadequate sanitation facilities, and contaminated water sources can significantly contribute to the transmission of infectious agents that cause diarrhea.8 furthermore, overcrowded living conditions and lack of proper handwashing facilities further enhance the risk of diarrhea.9 mother’s behavior in hygiene practices plays a crucial role in preventing diarrhea. mothers must understand and implement practices such as regular handwashing with soap and clean water before feeding the children and after using the toilet.10 additionally, ensuring a clean and safe environment for children, including proper disposal of waste, clean utensils, and proper food storage, can greatly minimize the risk of diarrhea.11 this study was conducted in teluk segara sub-district, bengkulu city, indonesia, selected for its high incidence of diarrhea among children under five. this area has a diverse population with varying access to sanitation and clean water, making it ideal for examining the impact of environmental health factors on childhood diarrhea. coastal residents, mainly fishermen, often lack proper sanitation, while those inland face groundwater contamination and rely on the public water system. this study explores how these contrasting conditions influence diarrhea prevalence. the aim of this study is to identify the risk factors related to environmental health facilities and mother behavior that might contribute to the prevalence of diarrhea in children under the age of five. correspondence: yusmidiarti, department of environmental health, poltekkes kemenkes bengkulu, bengkulu, indonesia. email: yusmidiarti@poltekkesbengkulu.ac.id key words: environmental health facilities; maternal behavior; diarrhea; children under five. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: ethics approval for this study was obtained from the medical and health research ethics committee of universitas gadjah mada (approval number: ke/fk/32/ec). availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 25 october 2024. accepted: 30 november 2024. early access: 16 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13297 doi:10.4081/hls.2024.13297 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13297] [page 75] materials and methods this analytical observational study used a prospective case-control design conducted at the pasar ikan community health center in the teluk segara subdistrict, bengkulu municipality. the study included two groups: a case group of mothers with children under five who experienced diarrhea in the past year and a control group of mothers with children aged 6 months to 5 years without recent diarrhea incidents. both groups were selected from within the health center’s service area, maintaining a 1:1 case-to-control ratio, with a total of 140 participants (70 cases and 70 controls). the sample size calculation followed lemeshow’s guidelines for odds ratio hypothesis testing.12 consecutive sampling targeted all eligible mothers visiting the health center. to assess the impact of environmental health facilities and maternal behaviors on the incidence of diarrhea, several questionnaire items were used. these items were grouped into two main constructs: environmental health facilities and maternal behaviors. the construct of environmental health facilities was measured using 10 items encompassing several aspects: qualification of clean water resource (2 items); availability of clean water (1 item); utilization of clean water (3 items); qualification of family latrine (3 items); and utilization of family latrine (1 item). the construct of mother behaviors was measured using 6 items related to: the habit of feeding children outside the house (2 items) and personal hygiene (4 items). data collection was conducted using a structured questionnaire, which was pre-tested at other community health centers. the validity of all items was assessed by calculating the correlation between each item and the total score using the product-moment correlation test. all items were found to be valid. reliability was assessed using the split-half technique, resulting in a reliability coefficient of 0.8066 for environmental health facilities and 0.8245 for mother behaviors. these coefficients indicated that both instruments met the required standards for reliability. a consecutive sampling technique was employed to recruit participants until the desired sample size was achieved. the case group consisted of mothers with children aged 6 months to 5 years who presented with diarrhea at the pasar ikan community health center for treatment and resided within the health center’s catchment area. the control group comprised mothers with children aged 6 months to 5 years who did not have diarrhea but visited the pasar ikan community health center for other health concerns. multivariate analysis used logistic regression with the backward method, systematically excluding non-significant variables to identify significant predictors of childhood diarrhea. ethical approval for this study was obtained from the medical and health research ethics committee of universitas gadjah mada (approval number: ke/fk/32/ec). results the characteristics of research subjects respondents were 140 mothers divided into two groups: 70 respondents from the case group and 70 respondents from the control group. table 1 shows that the majority of the 70 respondents in each group (case and control) were between the ages of 30 and 39 (54.2% in the case group and 51.4% in the control group); the majority of respondents in both the case group (51.4%) and the control group (54.2%) had a senior high school education background; and a significant proportion of mothers in both groups were identified as primary caregivers within the household (case group: 78.6%; control group: 81.4%). table 2 indicates that the majority of children in both the case and control groups were aged 13-24 months (38.6% and 44.3%, respectively). furthermore, both groups had a larger proportion of male children (case: 55.7%; control: 60.0%). the environmental health facilities this study found that when examining environmental health risks among 140 participants, 35.4% of those in the case group and article table 1. characteristics of mothers. variable category case control n % n % age (years) 20-29 24 34.3 27 36.4 30-39 38 54.2 36 51.4 ≥40 8 11.4 7 10.7 education elementary 6 8.6 7 9.3 junior high school 28 40.0 25 37.9 senior high school 36 51.4 38 54.2 occupation housewife 55 78.6 57 81.4 self-employed 13 18.6 10 16.4 government-employed 2 2.9 3 3.6 total 70 100 70 100 table 2. characteristics of children under five. variable category case control n % n % age (months) ≤12 9 12.9 4 5.7 13-24 27 38.6 31 44.3 25-36 15 21.4 17 24.3 >36 19 27.1 18 25.7 sex male 39 55.7 42 60 female 31 44,3 28 40.0 total 70 100.0 70 100.0 [page 76] [healthcare in low-resource settings 2025;13:13297] 64.6% in the control group had access to qualified water sources. about 48.8% of the case group and 51.2% of the control group were provided with clean water. furthermore, 38.6% of the case group and 61.4% of the control group had family latrines that adhered to hygiene standards, and 37.8% of the case group vs 62.2% of the control group had family latrines available for use. the study revealed a significant association between clean water sources and diarrhea incidence in under-five children, with those exposed to unhygienic water sources being 4.026 times more likely to suffer from diarrhea. in contrast, the availability of clean water showed no significant impact on diarrhea incidence among under-fives due to a p-value of 0.412. however, the utilization of clean water significantly affected diarrhea incidence, where children under five in households not utilizing their facilities had a 5,813 times higher chance of contracting diarrhea. the availability and utilization of family latrines were significantly related to the occurrence of diarrhea. the children were 3.574 times more likely to get diarrhea if their family latrine did not meet hygiene standards and 3.377 times more likely if the latrine was not used properly (table 3). mothers’ health behavior it was found that fewer mothers in the control group practiced feeding their children outside the house (34.6%) compared to the case group (65.4%). similarly, a smaller percentage of mothers in the case group (37.8%) maintained good personal hygiene than those in the control group (62.2%). mothers who fed their children outside were found to have a 2.728-fold increased risk of their children experiencing diarrhea compared to those who did not (p=0.000). additionally, mothers with poor personal hygiene exhibited a 3.377-fold higher likelihood of their children developing diarrhea (p=0.001). these results underscore the critical role of safe feeding practices and proper personal hygiene in mitigating diarrhea risks among children under five (table 4). multivariate analysis based on the wald coefficients presented in table 5, inadequate personal hygiene habits emerged as the most significant predictor of diarrhea prevalence among children under five. this was closely followed by the use of not-qualified clean water sources, article [healthcare in low-resource settings 2025;13:13297] [page 77] table 3. the influence of environmental health facilities on diarrhea incidence in children under five. variable case control or n % n % (cl 95%) p qualification of clean water sources not qualified 42 68.9 19 31.1 4,026 0 qualified 28 35.4 51 64.6 1.977<or<8.201 availability of clean water not available 9 60 6 40 1.574 0.412 available 61 48.8 64 51.2 0.529<or<4.685 utilization of clean water not utilized 30 78.9 8 21.1 5.813 0 utilized 40 39.2 62 60.8 2.422<or<13.948 qualification of family latrines not qualified 36 69.2 16 30.8 3.574 0 qualified 34 38.6 54 61.4 1.724<or<7.405 utilization of family latrines not utilized 39 67.2 19 32.8 3.377 0.001 utilized 31 37.8 51 62.2 1.665<or<6.848 table 4. the influence of mothers’ health behavior as a risk factor on diarrhea incidence in children under five. variable case control or n % n % (cl 95%) p feeding children while playing outside the house yes 34 65.4 18 34.6 2.728 no 36 40.9 52 59.1 1.339<or<5.561 0 personal hygiene poor 39 67.2 19 32.8 3.377 good 31 37.8 51 62.2 1.665<or<6.848 0.001 table 5. logistic regression analysis: risk factors associated with diarrhea. variable b se wald df sig. (p-value) exp (b) (or) β rank of contribution poor personal hygiene of mothers 1.592 0.440 13.081 1 0, 4.916 1.592 1 qualification of clean water source 1.501 0.425 12.481 1 0 4.485 1.501 2 qualification of family latrines 1.479 0.446 10.994 1 0.001 4.388 1.479 3 feeding children while playing outside the house 1.099 0.439 6.260 1 0.012 3.002 1.099 4 constant -9.104 1.647 - - - -2 likelihood = 145,451. overall percentage correct =75,0. cox & snell r square =0,293 non-standard family latrines, and the practice of mothers feeding their young children during outdoor play. discussion the results of our study indicated that poor personal hygiene of mothers was the strongest predictor of childhood diarrhea (exp(b)=4.916), suggesting that children of mothers with poor hygiene are nearly five times more likely to experience diarrhea compared to those whose mothers practice good hygiene. this finding aligned with recent studies that underscore the critical role of maternal hygiene in preventing childhood diarrhea.13 a metaanalysis study in ethiopia reported that inadequate handwashing practices among mothers were significantly associated with an increased risk of childhood diarrhea (or:2.5, 95% ci: 1.3,2.1). a cluster-randomized control trial study by lin et al. (2018) in rural bangladesh examined the impact of individual and combined chlorinated drinking water, hygienic sanitation, handwashing (wsh), and nutritional interventions on protozoan infections in children.14 the study found that individual handwashing and hygienic sanitation interventions significantly reduced the prevalence of giardia infections. however, chlorinated drinking water and nutrition improvements did not demonstrate a significant effect on protozoan infection rates. furthermore, combined wsh interventions did not offer additional benefits beyond the individual interventions. these findings suggest that, in similar rural, low-income settings, targeted individual wsh interventions may be a more feasible and cost-effective approach to reducing giardia infections compared to complex combined interventions. these study findings emphasized the urgent need for interventions that focus on improving maternal hygiene practices, particularly handwashing with soap at critical times, to effectively combat childhood diarrhea. access to clean water is a critical factor in preventing childhood diarrhea. this study found that children without adequate access to clean water were over four times more likely to experience diarrhea (exp(b)=4.485). this finding aligns with existing research demonstrating the importance of clean water in reducing the risk of diarrhea in children. for example, a meta-analysis by wolf et al. (2018) showed that interventions focused on improving drinking water quality and availability, such as point-of-use filters and piped water, significantly decreased the incidence of diarrhea compared to unimproved water sources.15 the study also highlighted the impact of other hygiene interventions, such as sanitation improvements and handwashing with soap, in reducing diarrhea prevalence. the family latrine availability, which did not meet hygiene conditions, had a significant role in diarrhea incidence (p<0.05 and or=4.388). the results of this research were in line with research conducted by ramadhani (2019), who stated that there was a relationship between the use of healthy latrines and the incidence of diarrhea in toddlers, but the strength of the relationship in this category was low.16 studies have shown that factors such as the lack of household latrines, insufficient access to clean water, and poor latrine maintenance contribute to an increased risk of diarrhea. additionally, inadequate sanitation facilities and improper waste management were associated with higher incidences of diarrheal diseases among children under five. ensuring the availability of clean and sanitary latrines in households was crucial in reducing the incidence of diarrhea among children, emphasizing the importance of proper sanitation practices and facilities. conclusions the study found that poor personal hygiene practices, contaminated water sources, and unhygienic family latrines were significant risk factors for diarrhea among children under five. it is evident that increasing promotion programs on personal hygiene, particularly among mothers, is crucial for reducing diarrhea incidence. recommendations this study identified poor environmental health facilities (water and sanitation) and detrimental maternal behaviors (feeding practices and hygiene) as significant risk factors for diarrhea among children under five. therefore, interventions should prioritize improving access to clean water, developing standard family latrine use, encouraging safe food handling practices, and promoting good personal hygiene. these include infrastructure improvements, household water treatment, educating mothers on proper food preparation and storage, breastfeeding, and handwashing. references 1. lo k, sridhar s, ali s. chronic diarrhea and weight loss in an 18-month-old boy. pediatr rev 2021;42:514-8. 2. das jk, padhani za, bhutta za. persistent diarrhea in children in developing countries. in textbook of pediatric gastroenterology, hepatology and nutrition: a comprehensive guide to practice: second edition. springer international publishing. 2021. p. 231-40. 3. dipasquale v, cucinotta u, romano c. acute malnutrition in children: pathophysiology, clinical effects and treatment. nutr 2020;12:2413. 4. cohen mb. bacterial, viral, and toxic causes of diarrhea, gastroenteritis, and anorectal infections. yamada’s textbook of gastroenterology, 2022: pp. 2947-3005. 5. mosisa d, aboma m, girma t, shibru a. determinants of diarrheal diseases among under five children in jimma geneti district, oromia region, ethiopia, 2020: a case-control study. bmc pediatr 2021;21:1-3. 6. cho s, jackson cr, frye jg. the prevalence and antimicrobial resistance phenotypes of salmonella, escherichia coli and enterococcus sp. in surface water. lett appl microbiol 2020;71:3-25. 7. schaefer lm, le roux wj, abia al. reservoirs of cryptosporidium and giardia in africa. current microbiological research in africa: selected applications for sustainable environmental management. parasites vectors 2020:115-35. 8. shrestha a, six j, dahal d, et al. association of nutrition, water, sanitation and hygiene practices with children’s nutritional status, intestinal parasitic infections and diarrhoea in rural nepal: a cross-sectional study. bmc public health 2020;20:1-21. 9. ikua md, obwa wj, kennedy jo. environmental risk factors influencing diarrheal occurrence among children under five years old in informal urban settlements: a case study of korogocho, in nairobi county, kenya. sch j arts humanit soc sci 2021:19-30. 10. taddese aa, dagnew b, dagne h, andualem z. mother’s handwashing practices and health outcomes of under-five children in northwest ethiopia. pediatr health med ther 2020:101-8. article [page 78] [healthcare in low-resource settings 2025;13:13297] 11. iryanto a, joko t, raharjo m. the relationship between environmental sanitation risk factors and the incidence of diarrhea in children under five in pauh district, padang city. int j health educ social 2021;4:1-7. 12. lemeshow s, hosmer dw, klar j, lwanga sk. besar sampel dalam penelitian kesehatan. yogyakarta: gajah mada university. 1997. 13. alebel a, tesema c, temesgen b, et al. prevalence and determinants of diarrhea among under-five children in ethiopia: a systematic review and meta-analysis. plos one. 2018;13:e0199684. 14. lin a, ercumen a, benjamin-chung j, et al. effects of water, sanitation, handwashing, and nutritional interventions on child enteric protozoan infections in rural bangladesh: a cluster-randomized controlled trial. clin infect dis 2018;67:1515-22. 15. wolf j, hunter pr, freeman mc, et al. impact of drinking water, sanitation and handwashing with soap on childhood diarrhoeal disease: updated meta�analysis and meta�regression. trop med int health 2018;23:508-25. 16. ramadhani ni. relationship between latrine access with stunting in 20 villages of stunting focus, pasuruan district. j world adv res rev 2023;18:016-20. article [healthcare in low-resource settings 2025;13:13297] [page 79] hrev_master healthcare in low-resource settings 2025; volume 13:13072 determinant factors related to female adolescents’ attitudes toward gender-based violence rr dian tristiana,1 ika nur pratiwi,1 ah yusuf,1 r endro sulistyono2 1faculty of nursing, airlangga university, surabaya, east java; 2faculty of nursing, university of jember, east java, indonesia abstract the prevalence of violence, especially against female adolescents and children, is still quite high. this study aimed to analyze the factors that influence attitudes toward gender-based violence among female adolescents. we employed a cross-sectional research design, and the study population consisted of 107 adolescents in surabaya who accessed the google form. the statistical analysis used the chi-square test for the adolescent’s characteristics and spearman’s rank correlation with α=0.05. the study found a significant correlation (p<0.005) between adolescents’ attitudes toward gender-based violence and their father and mother’s education levels. additionally, school climate (p<0.005) and family conflict (p<0.005) also correlated with these attitudes. adolescents’ formative years are primarily centered around their homes and schools, making these environments crucial for shaping their beliefs and actions. therefore, they present valuable opportunities for educating young people about gender-based violence. the research emphasizes the need for comprehensive changes in teenagers’ attitudes, calling for active participation from teenagers themselves, their families, schools, society, and social media regulations. introduction violence against women represents a significant worldwide concern for both human rights and public health, leading to enduring social, developmental, and health repercussions for women and their children.1 despite a significant global decline over the past 30 years, intimate partner violence against young women continues to persist.2 in 2023, indonesia reported 401,975 cases of violence against women, indicating that women were the primary victims of violence.3 violence against women in indonesia disproportionately affects young women. in 2023, east java emerged as one of the top three provinces in indonesia with the highest reported cases of gender-based violence.3 the prevalence of violence, particularly toward female adolescents and children, in indonesia remains relatively high.4 the unicef report on the national situation states that 40% of children aged 13-15 in indonesia have experienced physical attacks at least once a year, and 50% report being bullied at school. violence against women had physical consequences, such as injury, disability, and chronic pain,5 and psychological consequences, such as depressive symptoms,6 post-traumatic syndrome disorders (ptsd), stress, anxiety, and other mental disorders,5,7 and social consequences.8 research conducted in the past has suggested that an unhealthy or hostile environment can contribute to a rise in violent behavior within a community.9 some communities use violence to enforce expectations for young women’s behavior, leading to gender-based violence.10 attitudes, traditions, and customs that diminish women’s autonomy can fuel gender-based violence and significantly influence the status and role of females within both the household and society.11 when people are exposed to a social norm through socialization, they often integrate it into their value system. exposure can occur through various means, including education, personal experience, and the individual’s context. prescriptive gender norms convey correspondence: rr dian tristiana, faculty of nursing, airlangga university, jl. mulyorejo, kampus c universitas airlangga, surabaya, 60115 east java, indonesia. e-mail: diantristiana@fkp.unair.ac.id key words: gender-based violence; adolescents; mental health. contributions: all authors contributed equally to developing the design, data collection, data analysis, writing the manuscript, and reviewing it to ensure compliance with article writing guidelines. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research was approved by the research ethics committee of the faculty of nursing of airlangga university. consent for publication: all respondents provided informed consent for their anonymized data to be published in this article. availability of data and materials: the datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. funding: this research was financially supported by kemendikbudristek dikti in 2023. acknowledgments: the authors thank all respondents of this study and the kemendikbudristek dikti for financial support. received: 9 september 2024. accepted: 27 october 2024. early access: 21 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13072 doi:10.4081/hls.2025.13072 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 80] [healthcare in low-resource settings 2025;13:13072] expectations regarding the roles of girls and boys in the family and society, encompassing gender-appropriate behavior and emotional regulation.12 focusing on attitudes and beliefs can enhance research into understanding gender-based violence in female adolescents. attitude refers to how a person views and evaluates something or someone, including their predisposition or tendency to respond positively or negatively toward a particular idea, object, person, or situation. this concept is typically structured along three dimensions: cognitive (perceptions and beliefs), affective (likes and dislikes, feelings, or evoked emotions), and behavioral (actions or expressed intentions based on cognitive and affective responses).13 children and adolescents who are exposed to violence in their home environment, community, school, and peers, both as witnesses and victims of «poly-victim,» are increasing.14 exposure to violence in children and adolescents negatively affects academic achievement15 and contributes to mental health issues, including anxiety, depression, ptsd, aggression, and substance abuse.16 this study aimed to analyze the determinant factors related to genderbased violence attitudes in female adolescents. materials and methods this study used a quantitative method with a cross-sectional approach. a cross-sectional study design is a type of observational study design in which the investigator measures the outcome and exposures of the study participants simultaneously.17 in this study, respondents were asked to fill out a questionnaire at one time. the study focused on female adolescents aged 16-18 in surabaya, the capital of east java, indonesia. east java was ranked as one of the top three provinces with the highest rates of violence against women in 2023.3 data were collected using a structured self-administered questionnaire. the questionnaire consisted of five parts: socio-demographic information, attitude toward genderbased violence, school climate, family conflict, and victimization behaviors. the sample included female adolescents aged 16-18 years and adolescents attending a senior high school in surabaya. to gather participants for our study, we utilized social media platforms to post specific inclusion criteria, which individuals could complete through a google form. this form asked respondents to provide details about their school of origin to verify that they met the specific inclusion criteria for our study. the g-form will automatically close after 107 respondents have filled it out. this closure is essential to ensure that the data are comprehensive and representative of diverse perspectives. the attitude toward gender-based violence questionnaire was measured in a 12-item,18 investigator-derived measure that assessed adolescents’ agreement on a likert scale (i.e., strongly agree = 1, agree = 2, disagree = 3, and strongly disagree = 4) to a series of statements. this questionnaire was created to be easily understandable for young adolescents. it includes questions that explore attitudes toward gender roles in the realms of work, school, family, and finances. items include the perception of female adolescents toward statements about “female going to school,” “husband’s right to punish wives,” and “women’s participation in social events and employment.” the 12 items were summed into a composite score that ranged from 12 to 48. higher values on this scale represented greater disagreement with aspects of female autonomy and participation in society, which we term patriarchal gender attitudes. the validity and reliability of the questionnaire were assessed using a sample of 15 female adolescents. the results indicated a correlation range of 0.482-0.644, surpassing the critical value of 0.444. as a result, the twelve questionnaire questions were deemed to be valid. furthermore, the cronbach’s alpha value was determined to be 0.785. the usaid campo srgbv toolkit19 was used to administer the school climate questionnaire. the questionnaire included 10 statements regarding the school’s climate regarding violence. the validity and reliability results indicated a correlation range of 0.558-0.608, surpassing the critical value of 0.444. as a result, the twelve questionnaire questions were deemed to be valid. furthermore, the cronbach’s alpha value was determined to be 0.735. the family conflict questionnaire was measured using the rochester youth development scale. these items assess the parent’s perception of a hostile and conflict-filled family environment. respondents are asked to indicate how often hostile situations have occurred in their families in the past 30 days, not including their children’s fights with each other. point values are assigned as indicated above. point values are summed and then divided by the total number of items. the intended range of scores is 1-4, with a higher score indicating a higher level of hostility and conflict within the family. the validity and reliability test results indicated a correlation range of 0.740-0.884, surpassing the critical value of 0.444. as a result, the twelve questionnaire questions were deemed to be valid. furthermore, the cronbach’s alpha value was determined to be 0.778. the victimization behaviors questionnaire was measured using the problem behavior frequency scale. these items assess the frequency of relational and overt victimization. respondents were asked how frequently they had been subjected to specific victimization behaviors over the previous month. scoring and analysis point values for each subscale are assigned as follows: never = 1; 1-2 times = 2; 3-5 times = 3; 6-9 times = 4; 10-19 times = 5; 20 or more times = 6. point values for each subscale are summed. high scores indicate higher levels of victimization. the results of the validity and reliability test indicated a correlation range of 0.5380.828, surpassing the critical value of 0.444. as a result, the twelve questionnaire questions were deemed to be valid. furthermore, the cronbach’s alpha value was determined to be 0.871. first, the collected data were coded, checked, and entered using microsoft excel and then exported into spss version 23 for analysis. the results of the univariable analysis (descriptive results) were presented as frequencies and percentages. the bivariable analysis was carried out to determine the association of each independent variable with the outcome variable. finally, a variable with p<0.05 was considered statistically significant. this research was approved by the research ethics committee of the faculty of nursing. the respondents gave informed consent, and they could leave the study at any time and decide not to answer the question. the researchers kept the data confidential. results and discussion the results of this research showed that the average age of respondents was 17.59. most fathers’ education is a bachelor’s degree/diploma, and they work as employees. the majority of mothers’ education is a bachelor’s degree/diploma, and they are housewives. in this study, the results showed that the educational level of the father (p<0.001) and mother (p<0.001) was related to the attitude toward gender-based violence of female adolescents. adolescent age (p>0.001), father’s job (p>0.001), and mother’s job (p>0.001) were not related to the attitude toward gender-based article [healthcare in low-resource settings 2024;12:xxx] [page 81] violence of female teenagers (table 1). this study found that parental education level is related to female adolescents’ attitudes toward gender-based violence, while parental employment was not related. in this study, most fathers were employed, while the mothers were housewives. a working father can still achieve a healthy work-life balance, like a working or stay-at-home mother. unemployed individuals are not at a higher risk of experiencing family violence compared to employed individuals.20 the findings indicate that in families with minimal conflict, the well-being and satisfaction of the members are more closely associated with their attitudes toward gender-based violence than with the employment status of the parents. previous studies found that years of schooling are positively associated with egalitarian gender role attitudes,21 and there was a significant relationship between parents’ education level and children’s violence.22 parental education is related to an individual’s ability to understand information, ease of accessing media, and educational institutions fostering the development of “modern” world values.21 parents play an important role in providing children with an early understanding of gender equality; the better parents’ role in educating children about gender issues, the better a child’s understanding of gender will be created.23 the role of parents can also improve child adjustment abilities24 related to gender role attitudes. these results indicate that increasing parents’ knowledge about attitudes towards gender-based violence needs to be done from the start; for example, it needs to be applied to couples who want to get married, such as premarital education to give them insight into viewing gender roles and training for families to cope with conflicts and enhance parenting skills, specifically designed for parents with adolescent children. the majority of female adolescents said that they had a positive school climate: mutual respect for friends (55.1%), teachers treating female and male students equally (47.7%), and the school taking action when a student hurts another student (50.5%). the majority of female adolescents also said that they had low family conflict and low victimization behavior. however, almost half of female adolescents disagree that women have the same behavior as men, such as speaking harshly, having the same rights in making decisions in the family, being a leader, and being a career woman (table 2). gender stereotypes can lead to oversimplified and inaccurate views of gender groups. these stereotypes can exaggerate the differences between males and females, leading to discrimination against certain groups, causing individuals to lose their individuality25 and contributing to gender-based violence. this research shows that school climate (p<0.001) and family conflict (p<0.001) are related to attitudes towards gender-based violence. meanwhile, victimization behavior (p>0.001) was not related to attitudes toward gender-based violence. the results of this study show that the majority of female adolescents have adequate attitudes toward gender-based violence (77%), have a positive school climate (82.2%), low family conflict (48.6%), and have low victimization behavior (84.1%) (table 3). school climate and family conflict are linked to female adolescents’ attitudes toward gender-based violence. based on social learning theory, this framework helps us understand how gender norms contribute to the intergenerational transmission of violence. violent behavior is learned in childhood through behavioral modeling and observations of parents and peers.26 family is the place where children are growing up. previous studies indicated that when children experience violence while growing up, it is related to favorable attitudes toward violence against spouses and indirectly affects violent behavior.27 schools are part of society and reflect traditions and values, which are norms of interaction and explicit and implicit rules and codes; at the same time they play a crucial role in social change. although schools are recognized as places of learning, personal development, and empowerment, they are too often places of discrimination and violence, particularly against female students.28 the family and school environments are the environments where most adolescents spend their time. behaviors learned at school and in the family are what shape the attitudes and behavior of adolescent girls, which means that these two environments are places that need to be exposed to information about gen article table 1. demographic data of respondents and their relationship to female adolescents' attitudes toward gender-based violence (n=107). variable frequency (f) percentage (%) mean attitude toward gbv p r age (years) 17,59 0.121 father education level 0.001 .351 elementary 1 0.9 junior high school 2 1.9 senior high school 42 39.3 college 62 57.9 mother education level 0.001 .343 elementary 3 2.8 junior high school 16 15 senior high school 40 37.4 college 48 44.9 mother work 0.095 housewife 64 59.8 working 43 40.2 father work 0.240 employee 96 89.7 entrepreneur 7 6.5 mechanic 1 0.9 teacher 2 1.9 retired 1 0.9 [page 82] [healthcare in low-resource settings 2025;13:13072] der-based violence. prior victimization was found unrelated to adolescents’ attitudes toward gender-based violence. the results of this study indicated that previous experience related to violent behavior is not a predictor of attitudes toward violent behavior. the majority of adolescents in this study experience low victimization. the perception of female adolescents regarding whether women can experience violent behavior can be influenced by the culture surrounding adolescents. in indonesia, many still adhere to a patriarchal culture, as evidenced by the attitudes of female adolescents who believe that women and men are unequal in terms of education, behavior, family roles, and societal roles. previous research indicates that a cheerful family and school environment can protect against aggressive adolescent behavior. the psychosocial environment significantly influences attitudes toward social aggression, highlighting the importance of parenting styles and resilience.29 besides, universalism, benevolence, tradition/conformity, and security had the strongest negative effects on attitudes toward interpersonal violence and direct as well as indirect negative effects on interpersonal violent behavior.30 the findings of this study indicate that a majority of female adolescents have positive attitudes toward gender-based violence, experience a positive school environment, and have low levels of article table 2. attitude toward gender-based violence. variable attitude toward gender-based violence strongly agree agree not agree strongly not (%) (%) (%) agree (%) swearing is worse for a girl than for a boy 26 (24.3) 36 (33.6) 40 (37.4) 5 (4.7) on a date, the boy should be expected to pay all expenses 22 (20.6) 30 (28) 41 (38.3) 14 (13.1) on the average, girls are as smart as boys 7 (6.5) 7 (6.5) 31 (29) 62 (57.9) more encouragement in a family should be given to sons than daughters to go to college 10 (9.3) 19 (17.8) 53 (49.5) 25 (23.4) it is all right for a girl to want to play rough sports like football 13 (12.1) 24 (22.4) 37 (34.6) 33 (30.8) in general, the father should have greater authority than the mother in making family decisions 32 (29.9) 41 (38.3) 28 (26.2) 6 (5.6) it is all right for a girl to ask a boy out on a date 19 (17.8) 28 (26.2) 35 (32.7) 25 (23.4) it is more important for boys than girls to do well in school 7 (6.5) 19 (17.8) 44 (41.1) 37 (34.6) if both husband and wife have jobs, the husband should do a share 8 (7.5) 9 (8.4) 34 56 of the housework such as washing dishes and doing the laundry 31.8 52.3 boys are better leaders than girls 35 (32.7) 30 (28) 35 (32.7) 7 (6.5) girls are better directed to be good wives than to be career women 24 (22.4) 31 (29) 18 (16.8) 34 (31.8) girls should have the same freedom as boys 5 (4.7) 12 (11.2) 34 (31.8) 56 (52.3) school climate never seldom sometimes often friends respect each other 2 (1.9) 25 (23.4) 21 (19.6) 59 (55.1) teachers treat female and male student fairly 7 (6.5) 21 (19.6) 28 (26.2) 51 (47.7) teachers threaten to hurt students 49 (45.8) 28 (26.2) 21 (19.6) 9 (8.4) schools take action when a student hurts another student 7 (6.5) 19 (17.8) 27 (25.2) 54 (50.5) students are afraid to go to class because they are afraid of being punished 15 (14) 42 (39.3) 39 (36.4) 11 (10.3) teachers/schools take action when there are reports of violence 3 (2.8) 24 (22.4) 16 (15) 64 (59.8) students are punished excessively when they make small mistakes 25 (23.4) 40 (37.4) 30 (28) 12 (11.2) gangs/groups at school are a source of problems 10 (9.3) 46 (43) 35 (32.7) 16 (15) violence is a problem here 26 (24.3) 36 (33.6) 27 (25.2) 18 (16.8) students are punished unfairly 22 (20.6) 33 (30.8) 33 (30.8) 19 (17.8) family conflict often sometimes seldom never how often do arguments/fights occur in your house? 11 (10.3) 14 (13.1) 47 (43.9) 35 (32.7) how often does one of your family members lose control and get angry for no logical reason? 19 (17.8) 26 (24.3) 25 (23.4) 37 (34.5) how often do fights occur in your house, such as hitting, pulling, slapping, 4 (4.7) 17 (15.9) 26 (24.3) 59 (55.1) throwing things or threatening with weapons? victimization behaviors never 1-2 times 3-5 times 6-9 times 10-19 times 20-more friends say they won't be friends with you until you do what your friends want 37 (34.6) 21 (19.6) 20 (18.7) 27 (25.2) 2 (1.9) someone is spreading gossip about you 19 (27.1) 43 (40.2) 15 (14) 19 (9.3) 6 (5.6) 4 (3.7) left intentionally by other people during class activities 38 (35.5) 30 (28) 25 (23.4) 7 (6.5) 2 (1.9) 5 (4.7) friends prevent other people from being friends with you by saying bad things about you 27 (25.2) 48 (44.9) 18 (16.8) 6 (5.6) 5 (4.7) 3 (2.8) friends lie about you so that other friends won't like you 32 (29.9) 35 (32.7) 16 (15) 14 (13.1) 6 (5.6) 4 (3.7) friends who are angry with you retaliate against you by banning you from joining their group 38 (35.5) 32 (29.9) 18 (16.8) 13 (12.1) 5 (4.7) 1 (0.9) [healthcare in low-resource settings 2025;13:13072] [page 83] family conflict and victimization behavior. however, almost half of the female adolescents surveyed disagree that women can exhibit the same behaviors as men, such as speaking assertively, having equal decision-making rights in the family, occupying leadership positions, and pursuing careers. this result suggests that while some behaviors are considered acceptable for women, there are still restrictions and expectations on their roles and behaviors. for instance, the study’s female adolescents supported the notion that women can participate in activities traditionally associated with men, such as playing football or enjoying the same freedoms. still, they were less likely to agree that women can hold equal decision-making power in the family or assume leadership roles. a prior study stated that there were stereotypes for adolescents to adults that women should be communal and avoid being dominant, including being a leader; men should be agentic, independent, masculine in appearance, and interested in science and technology, but avoid being weak, emotional, shy, and feminine in appearance.31,32 this excerpt highlights the influence of norms and culture on adolescents, particularly in indonesia. despite progress in gender equality, traditional beliefs persist, such as the perception of men as natural leaders and decision-makers in families. it emphasizes the significant impact of family, school, societal norms, media, and political images on shaping adolescent females’ attitudes toward gender-based violence. the findings of this study suggest that school climate and family conflict strongly influence the attitudes of adolescent females toward gender-based violence. the government has implemented numerous campaigns to prevent violence in schools, and adolescents have also been exposed to messages promoting gender equality. increased support from high schools in preventing violence can enhance adolescents’ awareness of the issue. the research underscores the need for comprehensive efforts to change adolescents’ attitudes, involving themselves, their families, schools, society, social media, and national policies. continuously increasing awareness about gender equality and preventing violence against women is crucial in schools, families, and communities. this effort can be accomplished through government initiatives such as integrating gender equality into the curriculum, establishing violence prevention programs in schools, providing education on preventing gender violence, and utilizing social media platforms like tv programs, instagram, and youtube to disseminate information on gender violence prevention. these activities can be accomplished through school-based education and the implementation of gender equality programs. additionally, families play a crucial role in the development of adolescents. it is essential to provide parents with the understanding and skills to address family conflicts positively, which can be achieved through parenting skills training by means of government initiatives, educational programs for parents in schools, and community-based family health programs in conjunction with local health services for families with adolescent children. the study’s limitation is that it relies on self-reporting from adolescent girls about their experiences of violence in the past 12 months, which introduces the possibility of underreporting due to personal reasons, such as fear of retaliation, shame, or stigma associated with being a victim of violence. research has shown that individuals who have experienced violence may be hesitant to disclose the full extent of their experiences due to these personal factors. to address this, we have taken proactive measures to protect the anonymity of all participants involved in the process. this anticipation includes using pseudonyms, keeping personal information confidential, and ensuring that all data is securely stored and accessed only by authorized individuals. further research should explore the characteristics of parents and families, including parenting patterns, attitudes toward gender equality, and attitudes toward gender-based violent behavior. additionally, a deeper examination of the broader environment around adolescent girls related to violent behavior against women is needed. effective programs should also be developed to raise awareness among teenage females about violence against women and promote gender equality across various domains. conclusions parents play an essential role in teaching children about gender equality. educating parents about attitudes toward gender-based violence is critical, and this education should begin even before couples get married, perhaps through premarital education. gender norms are linked to the perpetuation of violence across generations, and children learn violent behavior through observing their parents and peers. adolescents spend most of their time at home and school, so these environments are critical for shaping their attitudes and behaviors. they should, therefore, be targeted for infor article table 3. relationship between school climate, family conflict, victimization behavior, and attitude toward gender-based violence. variable frequency (f) percentage (%) attitude toward gbv p r attitude toward gbv positive 26 24.3 fair 77 72 negative 4 3.7 school climate 0.000 -.607 positive 68 82.2 negative 39 12.1 family conflict 0.000 .562 low 52 48.6 medium 46 43 high 9 8.4 victimization behaviors 0.156 low 90 84.1 medium 16 15 high 1 0,9 [page 84] [healthcare in low-resource settings 2025;13:13072] mation about gender-based violence. the findings suggest that comprehensive changes in teenagers’ attitudes need to involve teenagers themselves, their families, schools, society, and social media policies. references 1. stöckl h, sorenson sb. violence against women as a global public health issue. annu rev public health 2024;45:277–94. 2. cao y, lu h, duan p, et al. global, regional, and national burdens of interpersonal violence in young women aged 10–24 years from 1990 to 2019: a trend analysis based on the global burden of disease study 2019. front psychol 2023;14: z12418 62. 3. the national commission on violence against women. siaran pers komnas perempuan tentang peluncuran catatan tahunan kasus kekerasan terhadap perempuan tahun 2023 [internet]. 2024 [cited 2024 sep 22]. available from: https://komnasperempuan.go.id/siaran-pers-detail/siaran-pers-komnasperempuan-tentang-peluncuran-catatan-tahunan-kasus-kekerasan-terhadap-perempuan-tahun-2023 4. thenniarti d. prevalensi kekerasan terhadap perempuan dan anak indonesia, turun. info publik [internet]. 2021. available from: https://infopublik.id/kategori/nasional-sosialbudaya/593169/prevalensi-kekerasan-terhadap-perempuandan-anak-indonesia-turun 5. falschung a. gender-based violence causing severe multiple injuries; a case report. adv j emerg med 2018;2:e35. 6. patel r, gupte ss, srivastava s, et al. experience of genderbased violence and its effect on depressive symptoms among indian adolescent girls: evidence from udaya survey. plos one 2021;16:e0248396. 7. friedberg r, 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2018;9:381468. 32. koburtay t, abuhussein t, sidani ym. women leadership, culture, and islam: female voices from jordan. j bus ethics 2023;183:347–63. article [healthcare in low-resource settings 2025;13:13072] [page 85] hrev_master healthcare in low-resource settings 2025; volume 13:13077 the effect of providing multi nutrient functional biscuits on the nutritional status of malnourished toddlers nadimin, hijrah asikin department of nutrition, poltekkes kemenkes makassar, indonesia abstract the main cause of malnutrition in indonesia is the lack of nutrient intake, making it necessary to address this through the provision of supplementary foods. on the other hand, indonesia has various local food resources that have not been optimally utilized, which need to be processed to enrich the nutritional content of snacks that can be used to prevent malnutrition. this study aims to determine the effect of tumiz functional biscuits on the nutritional status of malnourished toddlers. the research was conducted as a clinical trial using a randomized control group pretestposttest design, involving malnourished toddlers divided into two groups. each group consisted of 35 children, with each group receiving the following treatment: k1 (tumiz biscuits + nutrition education for their mothers), and k-2 (only nutrition education for their mothers). the intervention lasted for 4 weeks, nutrition status and albumin levels, before and after the intervention. the effect of the intervention within each group was analyzed using paired sample t-tests, while the effect between groups was analyzed using independent sample t-tests. the results showed a significant improvement in the z-score of bb/tb in the intervention group (p=0.007), but there was no significant difference in the z-scores of bb/u and tb/u between the two groups. albumin levels decreased significantly in both groups, with no significant difference (p=0.312). in conclusion, the administration of tumiz biscuits improved nutritional status based on bb/tb, but did not have a significant effect on bb/u and tb/u. decreased albumin may be caused by a metabolic response due to prolonged malnutrition. introduction the 2018 basic health research (riskesdas) reported a prevalence of underweight at 17.7%, stunting at 29.9%, and wasting at 10.2%. in addition to malnutrition issues among toddlers, nutritional deficiencies are also found in pregnant women, with a prevalence of anemia at 48.9%.1 one of the main causes of malnutrition is the lack of adequate nutrient intake. malnutrition during the toddler phase can lead to linear growth disorders, which may reduce physical abilities and productivity in the future.2,3 children who experience growth disorders during pregnancy and early childhood are at risk of developing various degenerative diseases.4-6 malnourished toddlers often show signs of increased metabolism, leading to oxidative stress.7,8 this condition can affect a child’s health and bodily functions, including cognitive function and brain development. efforts to meet nutritional needs through balanced diets or supplementary feeding can help prevent malnutrition in toddlers and reduce oxidative stress.9,10 efforts to meet nutritional needs can be achieved through the utilization of local food sources by developing snacks or foods that contain complete nutrients according to the target’s needs or are considered multinutritional. multinutritional snacks are local foods that contain energy-giving, body-building, and regulatory nutrients to meet the nutritional needs of the target population. these snacks are developed by utilizing various functional local food sources. in eastern indonesia, readily available local food sources include sago worms, legumes (such as soybeans and mung beans), and vegetables like carrots. correspondence: nadimin, department of nutrition, poltekkes kemenkes makassar, indonesia e-mail: nadimin@poltekkes-mks.ac.id key word: tumiz biscuits, nutritional status, malnourished children contributions: nd conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ha conceptualization, investigation, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, department of nutrition, health polytechnic, ministry of health makassar, indonesia, based on ethical certificate 1133/m/kepk-ptkms/vii/2024. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank the director of the makassar ministry of health polytechnic for providing the cost for this research. likewise to the posyandu cadres of families of children under five who participated in this study. received: 10 september 2024. accepted: 27 october 2024. early access: 6 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13077 doi:10.4081/hls.2024.13077 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13077] [page 137] sago worms are a local resource abundant in eastern indonesia, particularly in sulawesi, maluku, and papua.11 fresh sago worms are highly nutritious, containing 13.80% protein and 18.09% fat. in addition, sago worms also contain antioxidants (78.6%)12 and minerals (calcium, phosphorus, potassium, sodium, iodine, and zinc) in significant amounts.13 the potential for essential amino acids, essential fatty acids, and minerals is also higher and more complete in sago worms. sago worms share similarities with silkworms in structure and physical properties, making them suitable for processing into multinutritional flour as a base ingredient for complementary foods for infants (mp-asi),14 shredded meat products, and various other snacks and food products.15-17 sani silwanah (2014) has developed sago worm flour into complementary infant food (mp-asi) as an alternative to improving nutrient intake in toddlers.13 previously (in the first year), five types of functional snacks enriched with multinutritional flour (tumiz) were developed. one of these is tumiz biscuits. based on nutrient analysis, tumiz functional biscuits contain several essential nutrients, such as energy, protein, fat, vitamin a, iron, zinc, calcium, and antioxidants. the composition and amount of these nutrients can be utilized as supplementary food or complementary feeding (mp-asi) to meet the nutritional needs of vulnerable groups, such as infants aged 6-11 months, toddlers, and pregnant women. in the second year, we conducted trials of tumiz functional snacks, specifically tumiz biscuits, on test animals (preclinical trials). the results of the preclinical trials showed that tumiz functional biscuits could improve the growth and nutritional status of test animals (wistar rats). the administration of tumiz biscuits affected the increase in body weight, albumin levels, body length, and igf-1 levels in malnourished rats. as a follow-up to the second-year research, clinical trials are needed to assess the use of tumiz biscuits as an intervention for malnourished toddlers. the clinical trial results are expected to answer the question: «what is the effect of tumiz biscuits on the nutritional status of malnourished toddlers?» this study aims to determine the effect of tumiz functional biscuits on the nutritional status of malnourished toddlers. materials and methods study design the clinical trial was conducted using a randomized pretestposttest controlled trial design. the clinical trial was carried out by testing tumiz biscuits on a sample of children under five who were malnourished, to assess the impact on the nutritional status of children. it began with screening families with malnourished toddlers—those experiencing stunting, wasting, and underweight— using anthropometric methods, including height-for-age (h/a), weight-for-height (w/h), and weight-for-age (w/a) indices. toddlers who met the criteria were subjected to an initial measurement (pretest) of height, and weight. the sample was then divided into two groups using a simple random method. the first group received tumiz biscuits and nutrition education, while the second group received only nutrition education for the mother without providing tumiz biscuits to their children. the intervention of providing local snacks to the toddlers and nutrition education to the mothers was conducted daily for two months (60 feeding days). location and time the clinical trial/intervention was carried out in several posyandu areas under the jurisdiction of paccerakkang, daya, and sudiang raya public health centers in makassar from april to july 2024. population and sample the study population consisted of all families with toddlers living in makassar. the sample consisted of mothers with malnourished toddlers suffering from stunting, wasting, or underweight (z-score < -2 sd) in the paccerakkang health center area of makassar. a total of 35 samples per group were selected through random sampling. data collection the data collected included information on nutritional knowledge, attitudes, child-feeding practices, nutrient intake, tumiz biscuit consumption, child growth, and toddler nutritional status. nutritional knowledge, attitudes, and feeding practices were collected through interviews using questionnaires. nutrient intake was measured using a 24-hour recall method. information on tumiz biscuit consumption was assessed using daily consumption control sheets with a checklist. nutritional status is assessed based on h/a, w/a, and w/h indexes, as well as albumin levels. weight was measured using a digital scale with a precision of 0.1 kg, and height was measured using a microtoise. the child’s age was determined based on the birthdate provided by the parents or recorded from the child’s health card (kms). the anthropometric data were then calculated into z-scores for the w/a, h/a, and w/h indices using the who anthro software application. anthropometric measurements were performed by trained personnel, such as nutrition staff from the health centers or enumerators with d4 nutrition education qualifications. data analysis the collected data were entered into a data processing software for statistical analysis. univariate and bivariate analyses were conducted. the univariate analysis involved calculating the mean and standard deviation (sd) of variables such as weight, height/length, w/a, h/a, w/h z-scores. bivariate analysis was used to assess changes in nutritional status of toddlers before and after the intervention within each treatment group. these changes were evaluated by comparing the mean difference of each variable before and after the intervention using the «paired t-test.» to assess the difference in changes between the intervention groups, the «independent t-test» was used. conclusions were drawn with a 95% confidence level. ethical considerations this study was conducted after obtaining ethical approval from the health research ethics committee (kepk) of poltekkes kemenkes makassar, no. 1133/m/kepk-ptkms/vii/2024. before the interviews and blood sampling, informed consent was obtained from all participants. results characteristics of parents table 1 shows that the majority of mothers in the control and intervention groups had a high school education, with proportions of 47.1% and 51.4%, respectively. in the intervention group, more mothers did not finish primary school (25.8%) compared to the control group (10.9%). statistical analysis showed no significant article [page 138] [healthcare in low-resource settings 2025;13:13077] difference between the two groups (p=0.488). most fathers in both groups had a high school education. however, in the intervention group, more fathers did not finish primary school (31.5%) compared to the control group (11.4%), with a statistically significant difference (p=0.037). the majority of mothers in both groups were housewives, with no significant difference between the groups (p=0.560). most fathers in both groups worked as laborers or drivers, with no significant difference between the control and intervention groups (p=0.169). there were no significant differences in the number of family members or the number of toddlers between the two groups. child’s health condition table 2 shows that 77.1% of children in the intervention group were reported to have been sick in the last month, compared to 54.3% in the control group, with a statistically significant difference (p=0.036). there was no significant difference in illness frequency (p=0.155), but the duration of illness was longer in the intervention group than in the control (p=0.061). there was variation in the types of illnesses suffered by the children, but no significant difference between the groups. child’s dietary pattern table 3 shows that the majority of children in both groups were not given prelacteal foods and started receiving complementary feeding at the age of 6 months, with no significant differences (p=0.673 and p=1.000). most children ate three times a day in both groups, with no significant difference (p=0.263). there were no significant differences in the balance of food portions and consumption of colorful foods between the two groups. maternal knowledge about nutrition in both study groups showed no significant difference (p=0.353). nutritional status of children table 4 shows that in the control group (n=35), the weight-forage z-score increased from -2.22 ± 0.96 to -1.84 ± 0.81 after the intervention with a significant p-value (p=0.026). in contrast, the intervention group (n=35) receiving tumiz biscuits changed from -1.72 ± 0.95 to -1.60 ± 0.85, but this change was not significant (p=0.600). the difference in weight-for-age z-score changes between the control and intervention groups was also not significant (p=0.371), indicating that the tumiz biscuits did not significantly differ from the control. article table 1. education level and occupation of parents. variable control intervention p n % n % mother's education 0.488 did not finish primary 4 10.9 11 25.8 primary school 14 26.5 4 11.4 junior high school 1 2.9 1 2.9 senior high school 15 47.1 14 51.4 higher education 1 11.8 5 8.6 father's education 0.037 did not finish primary 4 11.4 11 31.5 primary school 14 40.0 4 11.4 junior high school 1 2.9 1 2.9 senior high school 15 42.9 14 40.0 higher education 1 2.9 5 14.3 mother's occupation 0.560 housewife 34 97.1 33 94.2 employee 1 2.9 1 2.9 civil servant 0 0 1 2.9 father's occupation 0.169 employee 11 31.4 4 11.4 trader 0 0 2 5.7 civil servant/retired 2 5.7 2 5.8 laborer/driver 23 63.9 26 74.2 unemployed 0 0 1 2.9 family members (people) 5.23±1.21 4.80±1.49 0.192 number of toddlers (people) 1.71±0.79 1.46±0.61 0.180 table 2. child’s health condition before intervention. variable control intervention p n % n % child sick in the last month 0.036 yes 19 54.3 27 77.1 no 16 45.7 8 22.9 frequency of illness 0.155 1 time 14 73.7 14 50.0 2 times 4 21.1 13 46.4 3 times 0 0 1 3.6 >3 times 1 5.3 0 0 duration of illness 0.061 1 day 0 0 1 3.6 2 days 8 42.1 5 17.9 3 days 8 42.1 8 28.6 >3 days 3 15.8 14 50.0 type of illness 0.699 cough 1 5.3 0 0 cold 1 5.3 3 10.7 fever 5 26.3 8 29.6 diarrhea 1 5.3 8 28.6 cough, cold, fever 9 47.4 1 3.6 cough, cold, fever, diarrhea 2 10.3 13 46.4 birth weight (kg) 2.98±0.33 2.93±0.49 0.608 birth length (cm) 48.51±1.04 48.00±2.81 0.313 table 3. child’s dietary pattern before the intervention. variable control intervention p n % n % prelacteal feeding 0.673 yes 4 11.4 2 5.7 no 31 88.6 33 94.3 age of starting solid food 1.000 0 months 34 97.1 35 100 4 months 1 2.9 0 0 frequency of eating daily 0.263 1 time 0 0 1 2.9 2 times 5 14.3 6 17.1 3 times 28 80.0 23 65.7 >3 times 1 2.9 5 14.3 meal balance 0.554 imbalanced 12 34.3 14 40.0 balanced 23 65.7 21 60.0 prelacteal feeding 0.349 yes 4 11.4 7 20 no 26 74.3 26 74.3 age of starting solid food 5 14.3 2 5.7 [healthcare in low-resource settings 2025;13:13077] [page 139] the height-for-age z-score in the control group (n=35) decreased from -2.90 ± 1.40 to -3.06 ± 1.46 with a p-value of 0.642, which is not significant. the intervention group (n=35) also showed a decrease from -2.63 ± 1.04 to -3.06 ± 1.59, with a pvalue of 0.154. the difference in changes between the two groups for height-for-age z-score was not significant (p=0.644), suggesting that tumiz biscuits did not have a significant impact on height changes in this period. according to the weight-for-height index, the control group (n=31) showed an increase in z-score from -1.04 ± 1.76 to -0.10 ± 1.18 with a p-value of 0.202, which is not significant. however, the intervention group (n=28) had a larger increase from -0.52 ± 1.33 to 0.24 ± 1.56 with a significant p-value of 0.007. despite this, the difference in weight-for-height z-score changes between the control and intervention groups was not significant (p=0.715). table 4 indicates a significant decrease in serum albumin levels in both the control (p=0.000) and intervention groups (p=0.000). no significant difference in the decrease of albumin levels between the control and intervention groups (p=0.312). discussion our study found that the control group experienced a significant increase in z-scores for weight-for-age (waz) (p=0.026), while the intervention group showed no significant change (p=0.600). these results indicate that tumiz functional biscuits had a better impact on the control group than the intervention group. research by wang et al. (2020) stated that significant changes in nutritional status are often more visible in children undergoing long-term interventions that involve not only energy supplementation but also overall dietary improvements.18 additionally, a study by zhang et al. (2021) found that the effectiveness of nutritional interventions is more evident in groups experiencing mild malnutrition than in those with more severe malnutrition.19 in the change in height-for-age z-scores (haz), neither group showed significant improvement after the intervention (p=0.642 for control and p=0.154 for intervention). this indicates that tumiz biscuit intervention did not affect height improvement. according to a study by liu et al. (2019), short-term interventions rarely show a significant impact on linear growth in stunted children, as the recovery process for linear growth takes longer.20 a study by gupta et al. (2021) also emphasized the importance of micronutrient supplementation, such as zinc and vitamin a, to support linear growth.21 the change in weight-for-height z-scores (whz) showed a significant improvement in the intervention group (p=0.007), while the control group showed no significant improvement (p=0.202). this indicates that tumiz biscuits played a role in improving the weight-to-height ratio in children experiencing wasting. according to research by huynh et al. (2024), nutritional interventions focused on increasing protein and fat intake can contribute to improving whz in malnourished children.22 this finding is also supported by research by brown et al. (2020), which showed that improvements in whz often occur more quickly in children receiving high-protein supplementary food interventions.23 the difference in changes in waz between the control and intervention groups was not significant (p=0.371), although the control group experienced a greater increase. research by ow et al. (2024) stated that improvements in waz are not always directly related to supplementary food interventions but also to factors such as environmental hygiene and access to clean water.24 another study by zhang et al. (2021) also showed that family factors and parenting practices play important roles in determining the outcomes of nutritional interventions.25 the difference in changes in haz between the two groups was also not significant (p=0.644), indicating no meaningful differences in linear growth. a study by ghodsi et al. (2021) emphasized that to observe significant changes in haz, interventions need to be conducted over a longer period, and involve the provision of essential micronutrients.26 research by lo et al. (2019) also showed that nutritional interventions need to be combined with other health programs, such as deworming, to improve linear growth in stunted children.27 the difference in changes in whz was also not significant (p=0.715) between the two groups, although both groups showed improvements in weight-to-height ratio. this may reflect that improvements in whz occur faster than in haz. a study by aripin et al. (2020) found that weight gain is easier to achieve than height improvement, which takes longer to show the effects of an intervention on linear growth.28 supports this finding, stating that improvements in whz can be an early indicator of the effectiveness of nutritional interventions. the study results showed a significant decrease in serum albumin levels in both the control and intervention groups. this decrease can be interpreted as the body’s response to prolonged malnutrition or as a result of metabolic processes occurring during the intervention period. the decrease in albumin levels in both groups may be associated with the metabolic stress condition often observed in malnourished children, leading to increased protein breakdown, including albumin. this decrease is consistent with a study by raval et al. (2020), which found that serum albumin levels tend to decrease in children experiencing acute malnutrition due to metabolic processes that utilize body proteins for energy.29 article table 4. changes in the nutritional status of young children before and after intervention. nutritional status indicator group pretest post-test sig* changes sig** weight-for-age z-score control (n=35) -2.22±0.96 -1.84±0.81 0.026 0.38±0.97 0.371 intervention (n=35) -1.72±0.95 -1.60±0.85 0.600 0.12±1.39 height-for-age z-score control (n=35) -2.90±1.40 -3.06±1.46 0.642 -0.21±2.07 0.644 intervention (n=35) -2.63±1.04 -3.06±1.59 0.154 -0.43±1.75 weight-for-height z-score control (n=35) -1.04±1.76 -0.10±1.18 0.202 0.94±1.91 0.715 intervention (n=35) -0.52±1.33 0.24±1.56 0.007 0.76±2.00 albumin level control (n=29) 4.86±0.27 4.17±0.36 0.000 -0.57±0.44 0.312 intervention (n=32) 4.75±0.33 4.33±0.31 0.000 -0.47±0.43 *paired t-test; **independent t-test. [page 140] [healthcare in low-resource settings 2025;13:13077] research by semba et al. (2016) also supports this, showing that in conditions of malnutrition, serum albumin levels can decrease even during nutritional supplementation interventions, as the body prioritizes other metabolic needs.30 further studies are needed to understand the mechanism of albumin decline during nutritional supplementation interventions and how it relates to improving children’s nutritional status. second, the metabolic response to malnutrition may also cause the protein from food to be directed more towards maintaining and restoring critical body functions rather than for albumin synthesis. this process is known as the prioritization of vital function recovery, where the body allocates nutritional resources to support essential organ functions before restoring protein reserves such as albumin.31 children with chronic malnutrition, additional protein and energy intake is often first used to restore muscle mass and immune function before there is an increase in blood albumin levels. this might explain why, despite being given nutrient-rich tumiz biscuits, there was no significant increase in serum albumin levels in the short term.32,33 conclusions there is no difference in the nutritional status of children who received tumiz functional biscuits compared to the control group. the provision of tumiz biscuits only significantly improved the nutritional status (whz index) based on the whz index. references 1. kementerian kesehatan ri. hasil utama riskesdas 2018. jakarta; 2018. 2. black re, victora cg, walker sp, et al. maternal and child undernutrition and overweight in low-income and middleincome countries. lancet 2013;382:427–51. 3. shi h, ren y, jia y. effects of nutritional interventions on the physical development of preschool children: a systematic review and meta-analysis. transl pediatr 2023;12:991-1003. 4. baker dj. the origins of the developmental origins theory. j intern med 2007;261:412–7. 5. gluckman pd, hanson ma, cooper c, thornburg kl. effect of in utero and early-life conditions on adult health and disease. n engl j med 2008;359:61–73. 6. nadimin, sirajuddin, afifah sn, hadju v, bohari. the effect of nutritional assistance “gammara’na” on food acceptance and nutritional status of children in south sulawesi, indonesia. nutr clín diet hosp 2025;45:38-46. 7. osendarp sj, baghurst ki, bryan j, et al. effect of a 12-mo micronutrient intervention on learning and memory in wellnourished and marginally nourished school-aged children: 2 parallel, randomized, placebo-controlled studies in australia and indonesia. am j clin nutr 2007;85:1072–9. 8. jang dh, greenwood-van meerveld b, johnson ac, et al. malnutrition during postnatal development increases oxidative stress and intestinal inflammation in a murine model. nutr res 2018;55:26–35. 9. luthfiyah f, widjajanto e. serbuk daun kelor memulihkan kondisi fisik gizi buruk pada tikus model kurang energi protein. j kedokt brawijaya 2013;26:131–5. 10. luthfiyah f. kurang gizipengaruh serbuk daun kelor nusa tenggara barat pada tikus kurang gizi. indones j hum nutr 2013;1–8. 11. bustaman s. potensi ulat sagu dan prospek pemanfaatannya. 2008;27(10). 12. anjani g, achasan m, adji s, djamiatun k. tepung ulat sagu (rhyinchophorus ferrugineus) imunomodulator nitric oxide (no) sirkulasi mencit terapi antimalaria standar. j gizi indones 2018;6:131–8. 13. sani silwanah. sago larvae flour (rhynchophorus ferruginenus) potency as basic ingredients alternative. universitas hasanuddin; 2016. 14. makanan p, air p, ibu s, berbasis m. pengembangan mpasi berbasis pury trina astuti. 2009;32:22–9. 15. astuti t. tepung pupa-mulberry (pury) sebagai bahan pangan alternatif kaya gizi. 2009;4:29–32. 16. rifqi ma, kusharto cm, astuti t. formulation of tofu nugget with pury (nugget tapury) as alternative of high protein snack. amerta nutr 2017;22–30. 17. aisyah, marliyati sa, kusharto cm. formulasi deppatori pury kudapan tradisional sulawesi selatan yang disubtitusi tepung pury (pupae mulberry). institut pertanian bogor; 2014. 18. wang x, su z, li l, et al. sensitive detection of molybdenum through its catalysis and quenching of gold nanocluster fluorescence. spectrochim acta a mol biomol spectrosc 2020;229:117909. 19. zhang z, li f, hannon ba, et al. effect of oral nutritional supplementation on growth in children with undernutrition: a systematic review and meta-analysis. nutrients 2021;13:3036. 20. liu s, chen d, xu j. characterization of amaranth and bean flour blends and the impact on quality of gluten-free breads. j food meas charact 2019;13:1440–50. 21. gupta e. functional food with some health benefits, so called superfood: a review. curr nutr food sci 2021;17:144–66. 22. huynh, d.t.t., estorninos, e., capeding, r.z., oliver, j.s., low, y.l., rosales, f.j., & abrams, s.h. oral nutritional supplementation with dietary counseling improves linear catch-up growth and health outcomes in children with or at risk of undernutrition: a randomized controlled trial. frontiers in nutrition 2024;11, 1341963 23. brown hm, bucher t, collins ce, rollo me. a review of pregnancy apps freely available in the google play store. health promot j austr 2020;31:340-2. 24. ow myl, tran nt, berde y, et al. oral nutritional supplementation with dietary counseling improves linear catch-up growth and health outcomes in children with or at risk of undernutrition: a randomized controlled trial. front nutr 2024;11:1341963. 25. zhang q. prenatal perception of breastfeeding recommendations predicts early breastfeeding outcomes of participants in the special supplemental nutrition program for women, infants, and children (wic). am j clin nutr 2021;114:1949– 59. 26. ghodsi d, omidvar n, nikooyeh b, et al. effectiveness of community nutrition-specific interventions on improving malnutrition of children under 5 years of age in the eastern mediterranean region: a systematic review and meta-analysis. int j environ res public health 2021;18:7844 27. lo nc, heft-neal s, coulibaly jt, et al. state of deworming coverage and equity in low-income and middle-income countries using household health surveys: a spatiotemporal crosssectional study. lancet glob health 2019;7:e1511-20. 28. ahmad a, madanijah s, dwiriani cm, kolopaking r. effect article [healthcare in low-resource settings 2025;13:13077] [page 141] of nutrition education and multi-nutrient biscuit interventions on nutritional and iron status: a cluster randomized control trial on undernourished children aged 6-23 months in aceh, indonesia. j nutr sci vitaminol (tokyo) 2020;66:s380-90. 29. raval h, rao a, chauhan h. estimation of serum albumin and serum total protein levels in children with protein energy malnutrition. internat j paediatrics geriatrics 2020;3:76-8. 30. semba rd, shardell m, sakr ashour fa, et al. metabolomic changes in serum of children with different clinical diagnoses of malnutrition. the journal of nutrition. 2016; 146(12):2436-2444. 31. jahoor f, badaloo a, reid m, forrester t. protein metabolism in severe childhood malnutrition. ann trop paediatr 2008;28:87-101. 32. katona p, katona-apte j. the interaction between nutrition and infection. clin infect dis 2008;46:1582-8. 33. nadimin, hijrah asikin, ang yeow nyin, lee shoo thien, azrina zainal abidin. 2025. multi nutrient functional biscuits “tumiz” improve nutritional status and growth of children; a clinical trial in malnourished rats. nutr clín diet hosp. 2025; 45(1):109-116. article [page 142] [healthcare in low-resource settings 2025;13:13077] healthcare in low-resource settings 2024; volume 12:12272 impact of community nutrition project on malnutrition in children under five: a case of spring ghana project salai thar kei myo,1 mark bigool2 1department of business management, myanmar imperial university, yangon, myanmar; 2department of management, school of business, university of cape coast, ghana abstract this study examines the effects of the strengthening partnership, results, and innovations in nutrition globally (spring) project on malnutrition (stunting, acute malnutrition, and underweight) among children under five years of age. we employed the difference-in-difference (did) estimation approach and the ghana multiple indicator cluster survey data (mics) to analyze the project’s impact. our analysis showed a strong positive association between the project’s effect on the probability of stunting and underweight by 11% (p=0.01) and 9% (p=0.003), respectively, in the treated regions compared with the untreated regions. however, we found no evidence of the project’s effect on acute malnutrition. we also provide suggestive evidence that the project may have influenced child nutrition status through antenatal care attendance. this study demonstrated that tackling child nutrition deficiencies through an integrated holistic approach, such as early antenatal care (anc) attendance, increased access to high-quality foods, improving women’s nutrition knowledge, and improving agricultural practices, can significantly reduce childhood stunting and underweight. introduction childhood malnutrition remains a pervasive public health challenge worldwide, particularly in low and middle-income countries. the world health organization (who) estimates that approximately 149 million children under the age of five are stunted, 50 million are wasted, and 45 million are underweight globally, reflecting the profound and widespread impact of malnutrition on child health and development.1 nutritional deficiencies can compromise the immune system, making it more vulnerable to sickness and diseases, which can become more severe, chronic, and less responsive to treatment. poor nutrition in early life poses a high risk of physical illness, developmental challenges, and cognitive functioning problems compared with children who have good nutritional needs in their early years.2-4 every child is entitled to good nutritional needs, which are necessary for normal growth and development. however, many children in developing countries are unable to meet the nutritional needs required for normal growth. evidence has shown that a lack of nutrition in childhood has a long-run impact on health status, the labor market, and educational achievement.5,6 the negative effects are higher for individuals subjected to nutrition deprivation in utero or within two years of life.7 in light of the concerning magnitude of child malnutrition and its far-reaching effects, community-based nutritional interventions have gained increasing prominence. one such project is the 1,000day household approach to the strengthening partnerships, results, and innovations in nutrition globally (spring) project introduced in ghana. in 2014, the spring community nutrition project was introduced to reduce malnutrition among children in the two regions of ghana. the project employs an integrated, holistic approach, such as early antenatal care (anc) attendance, increased access to high-quality foods, improved women’s nutrition knowledge, and improved agricultural practices to tackle malnutrition in the two regions.8,9 despite the comprehensive nature of the project, to our knowledge, few studies have examined the project’s effect on child malnutrition despite its significance. although studies have investigated the impact of nutrition projects or program interventions on child health, the results have been inconsistent. for instance, bhutta et al. indicated that nutricorrespondence: mark bigool, department of management, school of business, university of cape coast, cape coast, ghana. tel: +233 543000129. e-mail: mark.bigool@ucc.edu.gh key words: community nutrition, difference-in-difference (did), malnutrition, ghana. contributions: stkm, estimation strategy, conceptualization, and writeup of the manuscript; mb, estimation strategy, data analysis, and interpretation of results. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data and material: data is available at https://mics.unicef.org/surveys and is accessible for registration and request. acknowledgments: we would like to express our deepest gratitude to prof. kim taejong for his kind support and critique, which helped enrich the paper. we also express our gratitude to prof. lee, ju-ho, prof. wang, shun, prof. kim, booyuel, and prof. yang, hee-seung for their valuable contribution during the manuscript preparation. received: 11 january 2024. accepted: 26 march 2024. early access: 10 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12272 doi:10.4081/hls.2024.12272 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12272] [page 355] non -co mmerc ial us e o nly tion programs alone are not sufficient to reduce stunting or the likelihood of being underweight, but these outcomes can be improved by addressing the determinants of malnutrition, such as poverty and disease burden.10 a randomized controlled trial conducted in ghana by marquis et al. evaluated the impact of an integrated agricultural intervention on children’s diets and nutritional status. the intervention provided input and training for poultry farming and home gardening, as well as nutrition and health education. the study found that the intervention significantly improved height-for-age and weight-for-age compared with the control group.11 kang et al. assessed the effectiveness of a community-based nutrition program developed using a positive deviance/hearth approach in rural ethiopia. the program engaged mothers in 2-week nutrition sessions. the results showed that children in the intervention area had greater increases in height-for-age and weight-for-length than those in the control area.12 in a study conducted by linnemayr and alderman, the effect of a nutrition program aimed at improving child nutrition was evaluated; it was discovered that the program significantly impacted weight-for-age among the youngest children. however, the anticipated efficacy of the prescribed treatment was not fully realized despite its intended impact.13 we investigated the effect of the project on malnutrition among children under five years of age by exploiting the natural experimental nature of the project introduction. we hypothesize that the spring project will significantly reduce stunting, underweight, and wasting among children less than five years of age. we employed the difference-in-differences approach to comprehensively investigate the effects of the project on child nutrition outcomes. the findings indicate that the policy intervention significantly reduced the probability of stunting and underweight among children under five years of age in the treatment regions, with a reduction of 11% for stunting and 10% for underweight, compared to the control regions. however, the study found no evidence of the project’s effect on acute malnutrition. this study contributes to the existing literature on the impact of community nutrition programs on children’s health. materials and methods project overview a comparison of anthropometric measurements from the ghana demographic and health survey (gdhs) showed a decline in stunting from 33% in 1993 to 18% in 2022. underweight children also declined from 23% to 12% in 1993 to 2022 respectively, and acute malnutrition or wasting decreased from 14% in 1993 to 6% in 2022 (figure 1).14 despite this progress, there are regional variations in under-five malnutrition. for instance, the 2014 ghana demographic and health survey report revealed that approximately one-third (33%) of children under the age of five in the northern part of ghana are experiencing stunted growth, which is a significantly higher percentage than the 10% stunting rate observed in the greater accra region. additionally, the prevalence of malnutrition is alarmingly high, reaching 20% among children under 5 years of age in the northern region. while there has been a decline in national stunting rates since 2008, the northern region has seen an unfortunate increase from 32% in 2008 to 33% in 2014. in response to these concerns, spring ghana introduced a targeted nutrition strategy known as the “1,000-day household approach” in 2014. this approach was designed to focus on specific and critical nutritional behaviors within households, particularly those with pregnant women and children under two years of age, over a span of one thousand days. spring relied on evidencebased practices to develop an effective strategy for reducing stunting in the northern and upper-eastern regions of ghana. their approach was comprehensive and multi-sectoral, with the aim of addressing various aspects that contribute to malnutrition.8,9 the spring project emphasized early initiation of breastfeeding, practicing exclusive breastfeeding for six months, and continuing breastfeeding for up to two years. it also focused on providing appropriate complementary feeding, incorporating nutrient-rich options, such as orange-fleshed sweet potatoes. the project provided essential nutrition supplies and conducted a training program for health staff across 280 health facilities, ensuring timely and appropriate care for malnourished children. spring also worked with farmers to reduce groundnut exposure to aflatoxins and promoted the growth of nutrient-rich crops, such as vitamin aenriched maize and orange-fleshed sweet potatoes. vitamin a maize seeds were supplied to mother-to-mother support groups, and the project collaborated with the peanut butter project to produce safe and nutritious food.9 the project advocated the consumption of animal food sources for young children, emphasized clean and safe playgrounds free from human and animal feces, and promoted proper handwashing with soap and the use of latrines. village savings and loan associations were established in 49 communities to enable them to pool funds for healthcare activities, nutritious foods, and agricultural input. nutrition counseling services have been introduced in health facilities and at the community level to enhance the quality of infant and young child feeding.9 data source and description we used the ghana multiple indicator cluster survey (mics) to estimate the effect of the project on malnutrition. mics is a nationally representative survey that provides detailed information on a wide range of social and economic indicators related to children and women in ghana. the survey covered a variety of topics, including health, education, child protection, and hiv/aids. there were three waves in the dataset: 2006, 2011, and 2017/2018. the article used the 2017/2018 and the 2011 waves for the main results and the 2011 and 2006 waves for the parallel trend. within each region, sample clusters were allocated between urban and rural areas in proportion to their respective population sizes in the frame. the survey revealed vital information on the health of women and children in ghana. women aged 15-49 who perma article figure 1. trends of malnutrition in ghana. [page 356] [healthcare in low-resource settings 2024;12:12272] non -co mmerc ial us e o nly nently resided in the identified households or visitors who had stayed a night prior to the survey in the identified households were eligible for the interview. women’s questionnaires were used to obtain information on children’s health status, including weight and height, which were used to measure children’s nutritional status.15,16 the dataset contained complete information on child height for age, weight for age, and weight for height, which we used to create our dependent variables of interest: stunting, underweight, and acute malnutrition. table 1 describes a summary of the statistics of the variables used in the study. it presents the main dependent variables of interest as well as the control variables. the outcomes are low-heightfor-age (stunting), low-weight-for-age (underweight), and lowweight-for-height (acute malnutrition), which have a mean percentage of 23.4%, 15.7%, and 7.4%, respectively. there is no wide gender gap in our data set; the mean percentage of males is 50.8%, and females is 49.2%. most of the respondents are from the poorest and poorer (39.8% and 19.3% respectively) households and rural (62.3%) residents. most of the mothers in our sample were married (an average of 69.7%), with the majority being between the ages of 35 and 49 (on average, 40.8%). estimation design the spring ghana project was implemented in two regions of ghana, the northern and upper-east regions, which operated from 2014 until the end of december 2017. the nature of the project’s implementation offers us the opportunity to estimate causal effects. we relied on the quasi-experimental nature of the project implementation to estimate the impact using the difference-in-difference approach. we estimated the program effect using the regions that benefited from the implementation (upper-east and northern regions) as treatment regions and the comparison group as the regions that did not receive the program. to avoid confounding effects, we used only two other regions as controls: greater accra and volta. this is because the remaining four regions had similar programs targeting malnutrition reduction during the spring project implementation period. we use the following model for our estimation: yijt=β0+β1treatj +β2 postt+d treatij* postt+β3x'ijt + eijt yijt represents child health indicators, measured as stunting, acute malnutrition, and underweight. treatij takes the value of 1 if regions are the northern and upper east regions and 0 if greater accra and volta. postt represents 1 if survey year is 2017 and 2018 and 0 if 2011. treatij * postt is the interaction term between treatment and post. e measures the program impact. x'ijt represents a vector of independent variables. the independent variables included child age, child gender, mothers’ education, age, marital status, household age and education, place of residence, and wealth index. eijt represents the error term clustered at the primary sampling unit. the primary sampling unit involved clustering at the household level. the total number of primary sampling units was 300, distributed to urban and rural domains in each region and proportional to article [healthcare in low-resource settings 2024;12:12272] [page 357] table 1. summary statistics. variables n n% stunting (=1 if height-for-age <-2sd) 64431 15065 (23.4) underweight (=1 if weight-for-age <-2sd) 64817 10178 (15.7) acute malnutrition (=1 if weight-for-height <-2sd) 64952 4780 (7.4) child’s gender male 84567 42920 (50.8) female 84567 41647 (49.2) child's age 84567 84567 -100 mother's education no education 68117 40651 (59.7) basic education 68117 24549 -36 secondary and higher 68117 2917 (4.3) residence urban (=1 if mother resides in urban area) 100887 33263 (33.0) rural (=1 if mother resides in rural area) 100887 67624 (67.0) wealth index poorest (=1 if wealth quintile is poorest) 100076 39813 (39.8) poorer (=1 if wealth quintile is poorer) 100076 19279 (19.3) middle (=1 if wealth quintile is middle) 100076 15639 (15.6) richer (=1 if wealth quintile is richer) 100076 14201 (14.2) richest (=1 if wealth quintile is richest) 100076 11144 (11.1) mother's age 15-24 (=1 if mother's age is between 15-24) 92019 14705 (29.5) 25-34 (=1 if mother's age is between 25-34) 92019 12467 (29.7) 35-49 (=1 if mother's age is between 34-49) 92019 12784 (40.8) marital status married 92298 64337 (69.7) divorced 92298 6534 (7.1) never married 92298 21427 (23.2) note: the observations for stunting, underweight, and acute malnutrition were lower due to missing observations and non-response. the dependent variables are stunting, underweight, and acute malnutrition, which were measured in z-scores in the ghana multiple indicator cluster survey (mic) dataset using world health organization standards. non -co mmerc ial us e o nly the size of urban and rural populations in a region. we adjusted the standard errors, allowing for serial correlations within clusters by clustering at the primary sampling level. statistical analysis we used the ghana multiple indicator survey datasets, 2017/2018 and 2011 with stata version 17.0 to estimate the project effect on malnutrition using the traditional difference-in-difference approach. we appended the data set, which gives us pseudopanel data that is useful for the fixed effect difference-difference. the article used the 2017/2018 waves as the post-year and the 2011 wave as the baseline year for the main results. for robustness checks, we estimated parallel trend assumption by creating a pseudo-post, which is a dummy variable that takes the value of 1 if the survey year is 2011 and 0 if the survey year is 2006. results effect of the project on malnutrition the estimates of our study on the effects of the community nutrition program on child malnutrition are reported in table 2. the interaction term treat*post measures a project’s effect. models 1 and 2 report the effects of the project on stunting. in model 1, the project significantly reduced the probability of stunting in treated regions by 11% (p=0.001). in model 2, we controlled for mother, individual, and household characteristics. thus, holding all other variables constant, the project significantly reduces the probability of stunting in the treated regions by 11% (p=0.01). models 3 and 4 report the project’s effect on underweight among children under five years of age. in model 3, the project significantly reduced the probability of underweight among children below five years of age in the project regions by 10% (p<0.001). in model 4, holding all other covariates constant, the project significantly reduced the probability of underweight by 9% (p=0.003). models 5 and 6 reported the project effect on acute malnutrition, and the results showed no evidence of the project effect on acute malnutrition. because the project reduces stunting and underweight, we further investigated the categories of stunting and underweight that were most impacted by the project. we omitted acute malnutrition because we found no effect of the project on it. the results are presented in table a.1. in column 1, the project strongly reduces the probability of severe stunting by 9% (p=0.001), and in column 2, the policy has no effect on moderate stunting. with underweight in column 3, the project significantly reduces the probability of severe underweight by 5% (p=0.001), and for moderate underweight in column 4, we found no evidence of the project effect. robustness checks to ensure that the estimates are valid, we created a variable, pseudo post, equal to 1 if the survey year is 2011 and zero if 2006 to estimate the parallel trend assumption using the equation for the main analysis. table 3 presents the results of the parallel trend assumption. the interaction term, pseudo-post*treat measures the project effect. the results in all columns 1-6 are not statistically significant, denoting the existence of a common trend for stunting, underweight, and acute malnutrition in both the treatment and control regions before the introduction of the project. heterogenous analysis the project’s effect can differ by locality, and it may be the interest of policymakers to know the categories of people that were most affected by the project to aid in future policy designs. we, therefore, analyze the project effect by place of residence. supplementary tables 1 and 2 presents the results of the heterogeneous analysis by place of residence. the project significantly reduces stunting and underweight among children among rural residents by 19% and 13% in columns 1 and 2, respectively. in column 3, the results are not statistically significant; the project has no effect on acute malnutrition among rural residents. columns 4-6 report the project’s effect on malnutrition among urban children. the results are not statistically significant among urban children, indicating the project has no effect on urban children. mechanisms of project effect since we have found a significant positive impact of a project on malnutrition, we have explored the mechanisms through which the project impacts malnutrition. we examined the effects of the project on antenatal care, breastfeeding, and improved toilet facilities. table 4 presents the results. column 1 reports the policy effect on antenatal care attendance, thus holding all controls constant, which increases the probability of antenatal care attendance article [page 358] [healthcare in low-resource settings 2024;12:12272] table 2. effect of the project on malnutrition. -1 -2 -3 -4 -5 -6 variables stunting p stunting p under weight p under weight p acute malnutrition p acute malnutrition p treat 0.21 <0.001 0.14 <0.001 0.17 <0.001 0.14 <0.001 0.02 0.15 0.04. 0.043 (0.02) (0.03) (0.02) (0.02) (0.01) (0.02) post -0.01 0.75 -0.01 0.72 0.03 0.08 0.04 0.08 0.01 0.61 0.00 0.50 (0.03) (0.03) (0.02) (0.02) (0.01) (0.02) treat*post -0.11 0.001 -0.11 0.01 -0.10 <0.001 -0.09. 0.003 0.01 0.60 -0.01 0.70 (0.03) (0.04) (0.03) (0.03) (0.02) (0.02) constant 0.15 <0.001 0.41 0.04 0.08 <0.001 0.33 0.15 0.06 <0.001 0.12 0.19 (0.02) (0.20) (0.01) (0.19) (0.01) (0.14) covariates no yes no yes no yes observations 33,896 14,107 34,053 14,174 34,236 14,251 r-squared 0.04 0.07 0.02 0.04 0.00 0.02 note: this table reports the main effects of the strengthening partnership, results, and innovations in nutrition globally (spring) project on stunting, underweight, and acute malnutrition among children less than five years of age using linear probability model. post equal 1 if the survey years 2017 and 2018 and 0 if 2011. treat refers to the northern and upper east regions. treat*post measures the project effect. we control for the following: child’s age and gender; mother’s age, mother’s education dummies, place of residence (rural), and wealth index dummies. the cluster-robust standard errors are reported in parentheses. the error terms were clustered in the primary sampling unit. non -co mmerc ial us e o nly by 5% (p=0.016). in columns 2 and 3, we find no evidence of the project’s effect on breastfeeding and improved toilet facilities. discussion the nutritional environment significantly affects brain growth and development. it is crucial to ensure proper brain development through sufficient overall nutrition and a timely supply of essential macro and micronutrients during critical developmental phases. we specifically studied the effect of the community nutrition project implemented by spring ghana on stunting, acute malnutrition, and underweight among children under five years of age using the mics and the difference-in-difference estimation approach. thus, our study focuses on the nutritional environment of the fetus and children under five since the project’s objective was to improve the health of pregnant women and children. the expectation is that when women consume the essential diet required during pregnancy, children born to those mothers may not experience nutritional disorders.17 our results show that the policy significantly reduces the probability of stunting and underweight by 11% and 9%, respectively, among children under 5 years of age in the treatment region. however, we did not find any effect of the project on acute malnutrition. we demonstrate that the results of our analysis are valid through the common trend assumption. olney et al. demonstrated that providing food-assisted maternal and child health and nutrition programs significantly improves child growth and reduces stunting.18 this finding is consistent with the results of our study. kim et al. conducted research on an alive and thrive project that implemented extensive behavior change initiatives across four key platforms: interpersonal communication, nutrition-sensitive agricultural activities, community mobilization, and mass media. the study revealed a 5.6% point decrease in stunting,18 which is in agreement with our findings that the project strongly reduces stunting. also in line with our findings is the study by marquis et al., a randomized controlled trial in ghana that evaluates the impact of an integrated agricultural intervention on a child’s diet and nutritional status. the intervention provided input and training for poultry farming and home gardening, as well as nutrition and health education. the study found that the intervention significantly improved height-for-age and weightfor-age,11 which is in unison with our findings. similarly, kang et article [healthcare in low-resource settings 2024;12:12272] [page 359] table 3. effect of the project on malnutrition. -1 -2 -3 -4 -5 -6 variables stunting p stunting p under weight p under weight p acute malnutrition p acute malnutrition p treat -0.27 0.15 -0.27 0.09 -0.19 0.21 -0.24 0.20 -0.06 0.64 -0.02 (0.19) (0.19) (0.15) (0.17) (0.13) (0.02) pseudo-post 0.05 0.90 -0.07 0.77 0.25 0.52 0.19 0.57 0.36 0.35 0.38 (0.40) (0.37) (0.39) (0.42) (0.38) (0.36) treat* 0.16 0.70 0.19 0.55 -0.23 0.55 -0.18 0.59 -0.19 0. 61 -0.28 pseudo-post (0.40) (0.37) (0.39) (0.42) (0.38) (0.36) constant 0.45 0.02 0.61 0.003 0.25 0.10 0.34 0.08 0.14 0. 28 0.10 (0.19) (0.20) (0.15) (0.18) (0.13) (0.05) covariates no yes no yes no yes observations 17,654 16,096 17,801 16,214 17,774 16,212 r-squared 0.03 0.05 0.00 0.01 0.02 0.04 note: this table reports the main effects of the strengthening partnership, results, and innovations in nutrition globally (spring) project on stunting, underweight, and acute malnutrition among children less than five years of age using linear probability model. post equal 1 if the survey years 2017 and 2018 and 0 if 2011. treat refers to the northern and upper east regions. treat*post measures the project effect. we control for the following: child’s age and gender; mother’s age, mother’s education dummies, place of residence (rural), and wealth index dummies. the cluster-robust standard errors are reported in parentheses. the error terms were clustered in the primary sampling unit. table 4. channels of project impact. -1 -2 -3 variables antenatal attendance p breastfeeding p improved toilet p treat -0.03 0.057 -0.06 0.001 -0.24 <0.001 (0.02) (0.02) (0.05) post -0.002 0.915 -0.18 <0.001 0.02 0.591 (0.02) (0.03) (0.04) treat*post 0.05 0.016 -0.02 0.565 0.001 0.981 (0.02) (0.04) (0.05) constant 0.87 <0.001 1.4 <0.001 0.02 0.928 (0.15) (0.23) (0.21) observations 6,366 6,366 14,437 r-squared 0.05 0.13 0.26 note: this table reports the effects of the strengthening partnership, results, and innovations in nutrition globally (spring) project on the channels of malnutrition among children less than five years of age using a linear probability model. post equal 1 if survey year is 2017/2018 and 0 if 2011. treat refers to the northern and upper east regions. treat*post measures the project effect. we control for the following: child’s age and gender; mother age, education dummies, and place of residence (rural), and wealth index dummies in all the columns. the error terms were clustered in the primary sampling unit. non -co mmerc ial us e o nly al. assessed the effectiveness of a community-based nutrition program developed using a positive deviance/hearth approach in rural ethiopia. the program engaged mothers in 2-week nutrition sessions. the results showed that children in the intervention area had greater increases in z-scores for length-for-age and weight-forlength than those in the control area.12 haeck and lefebvre examined the effectiveness of prenatal nutrition programs on child health at birth in canada. they found that the program led to a significant reduction in low birth weight, which is consistent with our findings.19 our findings are consistent with the study by carlson & senauer on the special supplemental nutrition program for women, infants, and children (wic).20 the study found that the program was much more effective in improving child health than in increasing household income. overall, these studies provide support for the effectiveness of nutrition programs in improving health outcomes in disadvantaged populations. this is in line with our finding that the rural poor were the most beneficiaries of the project, as presented in supplementary table 2. we also examined the categories of stunting and underweight that were most affected by the project. the results suggest that the project effect on stunting and underweight reduction was more pronounced for severe stunting and severe underweight. we further explored the mechanisms through which the project impacts stunting and underweight. the results of the project strongly increased antenatal care attendance, which is similar to the findings by bigool et al., who showed that the spring project increased antenatal care attendance. the results showed that the project’s impact on malnutrition was mainly through antenatal care attendance, as shown in table 4 and supported by prior studies.8 we recommend the integration of spring ghana into the ghana nutrition policy to ensure continuity of the interventions, even after spring exits. other developing countries facing malnutrition challenges should adopt spring projects. the government should encourage the local production and distribution of nutrient-rich foods, such as fortified foods, fruits, vegetables, and protein sources, to improve dietary diversity and nutrition among children. establish systems to provide access to these foods to communities, especially rural communities. we encourage the active participation and ownership of community members in the planning, implementation, and evaluation of nutrition projects. involving the community ensures that interventions are culturally appropriate, sustainable, and can effectively address local needs. we advocate for evidence-based policies that prioritize child nutrition and health at both the national and local levels. the government should raise awareness about the importance of addressing child malnutrition and mobilize support from policymakers and the public. policymakers should integrate behavior-change communication strategies that emphasize proper feeding practices, sanitation, and hygiene. governments and relevant stakeholders should prioritize funding and allocate sufficient resources to support community nutrition projects. adequate funding is crucial to ensuring the sustainability and effectiveness of interventions aimed at improving child health. the study has certain limitations that are worth discussing; the mics dataset was poorly coded, so we could not control most of the independent variables. for instance, twin birth is coded ‘1 completed’ and ‘2 not at home’, which makes it difficult to understand what it really means. thus, we could not control for twin birth in our analysis. although we could not control for some of the covariates, we are certain that our results reflect the true picture of the project impact, since the adjustment of covariates in table 2 did not alter the magnitude of the policy impact. conclusions the study demonstrated that tackling child nutrition deficiencies through an integrated holistic approach, such as early anc, increased access to high-quality foods, improving women’s nutrition knowledge, and improving agricultural practices, can significantly improve child height for age and weight for height. this study contributes to the existing literature on the impact of community nutrition programs on children’s health. references 1. world health organization (who). malnutrition. 2024. available from: https://www.who.int/news-room/factsheets/detail/malnutrition#:~:text=globally%20in%202020% 2c%20149%20million,age%20are%20linked%20to%20under nutrition 2. georgieff mk. long-term brain and behavioral consequences of early iron deficiency. nutrition rev 2011;69:s43-8. 3. neelsen s, stratmann t. effects of prenatal and early life malnutrition: evidence from the greek famine. j health econ 2011;30:479-88. 4. georgieff mk, brunette ke, tran pv. early life nutrition and neural plasticity. dev psychopathol 2015;27:411-23. 5. jamison dt. child malnutrition and school performance in china. j develop econ 1986;20:299-309. 6. meng x, qian n. the long term consequences of famine on survivors: evidence from a unique natural experiment using china’s great famine. national bureau econ res 2009. available from: https://www.nber.org/papers/w14917 7. bryce j, coitinho d, darnton-hill i, et al. maternal and child undernutrition: effective action at national level. lancet 2008;371:510-26. 8. bigool m, osei owusu n, frimpong aa. effect of healthcare quality initiative on maternal healthcare service utilization: a case study of the spring ghana project. j public health afr 2022;13:2183. 9. strengthening partnership, results, and innovations in nutrition globally (spring) . ghana: final country report. 2018. available from: https://spring-nutrition.org/publications/reports/ghana-final-country-report 10. bhutta za, ahmed t, black re, et al. what works? interventions for maternal and child undernutrition and survival. lancet 2008;371:417-40. 11. marquis gs, colecraft ek, kanlisi r, et al. an agriculture– nutrition intervention improved children’s diet and growth in a randomized trial in ghana. maternal child nutr 2018;14: e12677. 12. kang y, kim s, sinamo s, christian p. effectiveness of a community-based nutrition programme to improve child growth in rural ethiopia: a cluster randomized trial. maternal child nutr 2017;13:12349. 13. linnemayr s, alderman h. almost random: evaluating a largescale randomized nutrition program in the presence of crossover. j develop econ 2011;96:106-14. 14. ghana statistical service. the dhs program. ghana demographic and health survey 2022. 2022. available from: https://dhsprogram.com/pubs/pdf/pr149/pr149.pdf 15. ghana statistical service accra, unicef. ghana multiple indicator cluster survey 2017/18. 2018. available from: article [page 360] [healthcare in low-resource settings 2024;12:12272] non -co mmerc ial us e o nly https://www.unicef.org/ghana/media/576/file/ghana%20multi ple%20cluster%20indicator%20survey.pdf 17. olney dk, leroy j, bliznashka l, ruel mt. procomida, a food-assisted maternal and child health and nutrition program, reduces child stunting in guatemala: a cluster-randomized controlled intervention trial. j nutr 2018;148:1493-505. 18. kim ss, nguyen ph, yohannes y, et al. behavior change interventions delivered through interpersonal communication, agricultural activities, community mobilization, and mass media increase complementary feeding practices and reduce child stunting in ethiopia. j nutr 2019;149:1470-81. 19. haeck c, lefebvre p. a simple recipe: the effect of a prenatal nutrition program on child health at birth. labour econ 2016;41:77-89. 20. carlson a, senauer b. the impact of the special supplemental nutrition program for women, infants, and children on child health. am j agri economics 2003;85:479-91. article [healthcare in low-resource settings 2024;12:12272] [page 361] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12073 prevalence of hypertension and its associated risk factors among secondary school students in duhok city ayoub abid abdul majeed,1 azad abduljabar haleem2 1master in pediatric nursing, psychiatry and pediatric nursing unit, college of nursing, university of duhok; 2pediatric department, college of medicine, university of duhok; heevi pediatrics teaching hospital; kurdistan pediatrics society, iraq abstract hypertension can develop in early childhood and go unnoticed unless it is screened for specifically during this developmental stage. detecting potential hypertension risk in children is critical to avoiding the serious, long-term complications associated with the condition. the purpose of this study was to investigate the prevalence of hypertension among schoolchildren aged 13 to 18, as well as the risk factors associated with it. a cross-sectional study included 565 students aged 13 to 18 from the duhok region. the analysis used chi square testing and logistic regression with jmp pro 14.3.0 software. of the 565 students from 32 schools chosen, 242 (42.80%) were male and 323 (57.2%) were female. notably, 5.84% (n=33) were hypertensive. a significant correlation was found between hypertension prevalence and body mass index, as well as gender. there was no significant relationship found with other variables. logistic regression revealed that high blood pressure was significantly associated with excess weight, obesity, and age. we concluded that there was an increase in the incidence of hypertension among high school students. lifestyle changes appeared to play a role in hypertension development among this population. routine school surveys are recommended to detect potential hypertension cases in children and adolescents, allowing for timely preventative interventions. introduction hypertension poses a significant global health challenge and stands as a primary contributor to coronary artery and cerebrovascular diseases. the year 2000 witnessed around one billion adults worldwide grappling with hypertension, a number anticipated to escalate to 1.56 billion by 2025.1,2 this pervasive ailment entails substantial morbidity and mortality, silently endangering populations globally. evidently, hypertension can trace its roots back to childhood, remaining concealed unless diligently sought out during this developmental phase. thus, timely identification of hypertension and its triggers assumes paramount importance to forestall its complications.3 given the paucity of symptoms during childhood and adolescence, hypertension often evades detection during these formative years. its prevalence escalates with age and adolescence, rooted in multifaceted factors such as genetics, race, geography, culture, and dietary habits.3 intriguingly, elevated blood pressure in this period foreshadows similar levels in adulthood and old age our understanding of blood pressure in children and adolescents is far from being complete and the long-term natural history of blood pressure in this age group is still not well understood.4 hypertension seldom manifests symptoms during early life, though the who does not advocate hypertension screening for children and adolescents. this study was undertaken due to a lack of data on adolescent hypertension prevalence in our country. hypertension poses a substantial public health challenge among adults globally, with iraq registering a 40.4% prevalence in a 2006 non-communicable disease risk factor survey.5 insufficient information exists regarding blood pressure patterns and hypertension prevalence in iraqi children and other correspondence: ayoub abid abdul majeed, psychiatry and pediatric nursing unit, college of nursing, university of duhok, iraqi kurdistan. e-mail: ayoub.abid@uod.ac key words: cross-sectional studies; hypertension; prevalence; risk factors. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. funding: we did not have any funding to conduct this study. ethics approval: the ethics committee of duhok general directorate of health approved this study (registered as 1307202i-7 -2i on 13 jul,2021. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: the written consent forms were not applicable in this study because we collected the data of this study from the students, not patients. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized students information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to present our deep thanks to the education of duhok, the secondary and high schools, and the students who participated in this study. received: 12 november 2023. accepted: 27 february 2024. early access: march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12073 doi:10.4081/hls.2024.12073 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12073] [page 293] non -co mmerc ial us e o nly developing nations. notably, a 2009 najaf city study on school students found a 5.5% prevalence of high blood pressure while a 2002 baghdad study on school-aged students reported a 1.7% hypertension prevalence.6 despite strides in hypertension detection and management in select countries, the global scenario concerning awareness, treatment, and control remains wanting.1 to ensure public awareness and regulation of hypertension, early identification in life’s initial stages becomes pivotal. delayed recognition burdens not only individuals but also governments due to elevated treatment costs. this study seeks to unveil hypertension prevalence and associated risk factors among secondary school students in the kurdistan region, thereby contributing to our understanding of this critical health issue. materials and methods study design the study was carried out in secondary and high schools in duhok provinces in the kurdistan region (north of iraq). a crosssectional study design was used; the study was carried out from 3rd november 2021 to 10th april 2022. ethical approval from the directorate general of health/ duhok and directorate general of education/ duhok was obtained. consent was obtained from the respondents before the interview with their parent’s consent. sampling technique in this research, the target group comprised adolescents aged 13 to 18, encompassing both genders and attending school. it was crucial for respondents to be an accurate representation of the intended population. to ensure this, a comprehensive multistage sampling technique was employed. in the initial phase, duhok city was categorized into two distinct zones through stratified sampling. subsequently, a list of schools in each zone was compiled, from which a total of thirty-two government schools were arbitrarily chosen to adequately represent both male and female secondary education. this selection was carried out using a simple random sampling method, specifically the lottery approach. this resulted in a random yet representative subset extracted from the overall population, allowing for a more precise estimation of characteristics. the sample size, calculated at a 95% confidence level, was established as 565 students. students who were excluded from participation included those taking study breaks and those whose parents withheld consent. additionally, students with chronic medical conditions or those reliant on specific medications affecting blood pressure, like steroids, were also omitted from the study. instruments and data collection the collection of data will involve the utilization of a questionnaire, meticulously crafted through an exhaustive analysis of preceding research and literature pertinent to the current study’s subject matter. this questionnaire comprises two distinct segments for data compilation. the first section of the questionnaire will be administered through face-to-face interviews with the participants. the second part, on the other hand, will involve data collection from the parents of the participants. statistical methods the demographic information of school children was depicted using numerical values and percentages. the occurrence rate of hypertension in school children was ascertained both in numerical counts and percentages. this was achieved by dividing the number of patients exhibiting various degrees of hypertension by the total count of school children and then multiplying by 100. the assessment of hypertension prevalence based on factors like age, gender, and other general characteristics was conducted through the utilization of the pearson chi-squared test. similarly, the connection between hypertension in school children and parental socio-demographic traits and their lifestyles was evaluated using the pearson chi-squared test. to identify predictors of hypertension among school children, nominal logistic regression was employed. a pvalue below 0.05 was deemed indicative of statistically significant differences. the statistical computations were conducted using jmp pro 14.3.0 software. anthropometric measurements anthropometric measurements were conducted within the school setting. each measurement was taken twice, and the average of the two readings was considered. for height measurement, participants were barefoot and measured using a portable stadiometer (seca 213, measuring range 20 200cm). weight was recorded with participants wearing lightweight attire, employing a digital heine portable scale accurate to the nearest 0.1kg. bmi was computed for each child by dividing their weight (in kg) by the square of their height (in meters) (kg/m²). to gauge the appropriateness of participants’ bmi values, reference data from the most recent anthropometric standards specific to their sex and age were sourced from the centers for disease control and prevention (cdc). these reference standards were used to establish percentiles for height, weight, and bmi, aiding in the assessment of participants’ bmi in relation to their age and sex.7 children were grouped into categories determined by these percentiles as outlined: individuals below the 5th percentile were classified as underweight, those between the 5th percentile and less than the 85th percentile were considered to have a healthy weight, those between the 85th percentile and less than the 95th percentile were classified as overweight, and those equal to or surpassing the 95th percentile were categorized as obese. for adults aged 20 years and older (i.e., children’s parents), the classification was slightly different. adults with a bmi ranging from 18.5 to less than 25 were labeled as having a normal weight, those with a bmi between 25 and less than 30 were identified as overweight, and individuals with a bmi of 30 or higher were categorized as obese.8 blood pressure measurement blood pressure assessments were conducted using a standardized mercury sphygmomanometer, paired with a manually inflated cuff of appropriate size, and a stethoscope. measurements were taken from the right arm while the child was in a calm sitting position for a minimum of 5 minutes to alleviate any anxiety. the researcher inquired about recent activities such as smoking, eating, exertion, or exercise within the last 30 minutes before participating in the study. the student was positioned comfortably, with their back supported, feet resting on the floor, the right arm properly supported, and the cubital fossa (elbow crease) aligned with the level of the heart. if the blood pressure reading equaled or exceeded the 90th percentile based on the child’s age, gender, and height, the blood pressure measurement was repeated twice during the same visit. the average values for systolic blood pressure (sbp) and diastolic blood pressure (dbp) were utilized. if the mean sbp and/or dbp readings were elevated during the initial visit, two additional blood pressure measurements were performed within a two-week timeframe. this multi-step approach ensured accurate and reliable blood pressure assessments, taking into consideration possible variations in measurements. article [page 294] [healthcare in low-resource settings 2024;12:12073] non -co mmerc ial us e o nly results the stuyd showed that 15.04% of the school children had abnormal blood pressure. the classes of abnrmal blood pressure were elevated blood pressure (7.43%), hypertensive (5.84%), stage 1 hypertensive (0.71%), and stage 2 hypertensive (1.06%). the children were males (42.83%) and females (57.17%). the childfree had different age groups from 13 to 18. they reside in urban (10.09%) and rural areas (89.91%) and had different family size (table 1). the study showed that the prevalence of different classes of abnormal blood pressure was not statistically different based on the gender (p=0.0934), age groups (p=0.2338), residency (p=0.8967), and family size (p=0.7519; table 2). the study showed that the children who their fathers had lower level of education were more likely to have abnormal blood pressures (p=0.033). in addition, those children who had the obese fathers were more likely to have different classes of abnormal blood pressures (p=0.0421). the similar pattern was found for the children whose their fathers had hypertension (p=0.0345) an sleep apnea (p=0.0002). in terms of mothers, the similar pattern was found for the education and hypertension. also, the children who had employee mother were more likely to have hypertension (table 3). the stuyd showed that the children who sued the free fat in their food by the family were more liley to be affected by abnormal blood pressure (p=0.0375). in addition, the children who were obese were more liley to be affected by abnormal blood pressure compared ot those children with normal and underweight (p<0.0001; table 4). the stuyd showed that the age and obeisty of the children predicted the blod prressure among secondary school chidlren (table 5; figure 1). the study did not show the signficnat diference of qol among children with different classes of abnormal blood pressure (p=0.2103 table 6; figure 2). discussion although the occurrence of clinical hypertension among children is significantly lower compared to adults, substantial evidence indicates that the origins of essential hypertension can be traced back to childhood. numerous epidemiological investigations have addressed blood pressure levels in children. however, there exists considerable diversity in the methodologies employed and in the criteria defining normal and elevated blood pressure. just as in article table 1. prevalence of hypertension by age and gender among secondary school children. general characteristics statistics no (%) hypertension abnormal blood pressure 85 (15.04) normotensive 480 (84.96) hypertension normotensive 480 (84.96) elevated blood pressure 42 (7.43) hypertensive 33 (5.84) stage 1 hypertensive 4 (0.71) stage 2 hypertensive 6 (1.06) gender male 242 (42.83) female 323 (57.17) age groups 13 74 (13.10) 14 122 (21.59) 15 89 (15.75) 16 98 (17.35) 17 76 (13.45) 18 106 (18.76) residency urban 57 (10.09) rural 508 (89.91) family size 1-3 79 (13.98) 4-6 337 (59.65) 7 and above 149 (26.37) table 2. prevalence of hypertension by age and gender among secondary school children. characteristics blood pressure no (%) p (n=565) normotensive elevated blood hypertensive stage 1 stage 2 pressure hypertensive hypertensive hypertension 480 (84.96) 42 (7.43) 33 (5.84) 4 (0.71) 6 (1.06) gender 0.0934 male 205 (84.71) 18 (7.44) 11 (4.55) 4 (1.65) 4 (1.65) female 275 (85.14) 24 (7.43) 22 (6.81) 0 (0.00) 2 (0.62) age groups 0.2338 13 66 (89.19) 6 (8.11) 2 (2.70) 0 (0.00) 0 (0.00) 14 104 (85.25) 7 (5.74) 11 (9.02) 0 (0.00) 0 (0.00) 15 73 (82.02) 10 (11.24) 4 (4.49) 1 (1.12) 1 (1.12) 16 86 (87.76) 5 (5.10) 5 (5.10) 2 (2.04) 0 (0.00) 17 59 (77.63) 8 (10.53) 6 (7.89) 0 (0.00) 3 (3.95) 18 92 (86.79) 6 (5.66) 5 (4.72) 1 (0.94) 2 (1.89) residency 0.8967 urban 433 (85.24) 37 (7.28) 29 (5.71) 4 (0.79) 5 (0.98) rural 47 (82.46) 5 (8.77) 4 (7.02) 0 (0.00) 1 (1.75) family size 0.7519 1-3 65 (82.28) 7 (8.86) 6 (7.59) 1 (1.27) 0 (0.00) 4-6 282 (83.68) 27 (8.01) 21 (6.23) 2 (0.59) 5 (1.48) 7 and above 133 (89.26) 8 (5.37) 6 (4.03) 1 (0.67) 1 (0.67) pearson chi-squared test was performed for statistical analyses. [healthcare in low-resource settings 2024;12:12073] [page 295] non -co mmerc ial us e o nly adults, a variety of environmental and genetic factors impact children’s blood pressure. as a result, it is crucial to conduct extensive population-based research efforts to gather standardized reference data concerning blood pressure levels in children. symptoms arising from hypertension are infrequent during the early stages of life. importantly, it should be highlighted that the world health organization (who) does not endorse routine blood pressure screening for children and adolescents.9 much like in adults, the blood pressure of children is impacted by various environmental and genetic factors. consequently, it is essential to conduct population studies to gather standard reference data concerning blood pressure levels in children. in the early years of life, symptoms stemming from hypertension are uncommon. it’s important to note that the world health organization (who) does not endorse rou article table 3. association of school children blood pressure with socio-demographic characteristics of father. characteristics blood pressure with father characteristics no (%) p (n=565) normotensive elevated blood hypertensive stage 1 stage 2 pressure hypertensive hypertensive education 0.0333 illiterate 59 (86.76) 6 (8.82) 2 (2.94) 0 (0.00) 1 (1.47) read and write 125 (86.21) 10 (6.90) 8 (5.52) 0 (0.00) 2 (1.38) primary school 120 (91.60) 6 (4.58) 4 (3.05) 0 (0.00) 1 (0.76) intermediately school 54 (75.00) 9 (12.50) 7 (9.72) 1 (1.39) 1 (1.39) secondary 21 (75.00) 1 (3.57) 6 (21.43) 0 (0.00) 0 (0.00) institute/college and above 89 (81.65) 10 (9.17) 6 (5.50) 3 (2.75) 1 (0.92) overweight/obesity 0.0421 no 365 (87.53) 24 (5.76) 22 (5.28) 3 (0.72) 3 (0.72) yes 115 (77.70) 18 (12.16) 11 (7.43) 1 (0.68) 3 (2.03) hypertension 0.0345 no 381 (85.62) 36 (8.09) 23 (5.17) 1 (0.22) 4 (0.90) yes 99 (82.50) 6 (5.00) 10 (8.33) 3 (2.50) 2 (1.67) sleep apnea 0.0002 no 469 (85.27) 41 (7.45) 32 (5.82) 4 (0.73) 4 (0.73) yes 11 (73.33) 1 (6.67) 1 (6.67) 0 (0.00) 2 (13.33) blood pressure and mother characteristics no (%) education 0.0291 illiterate 168 (85.28) 13 (6.60) 13 (6.60) 1 (0.51) 2 (1.02) read and write 133 (90.48) 7 (4.76) 6 (4.08) 0 (0.00) 1 (0.68) primary school 74 (81.32) 11 (12.09) 5 (5.49) 1 (1.10) 0 (0.00) intermediately school 42 (91.30) 2 (4.35) 1 (2.17) 0 (0.00) 1 (2.17) secondary 19 (90.48) 0 (0.00) 1 (4.76) 0 (0.00) 1 (4.76) institute/college 38 (66.67) 9 (15.79) 7 (12.28) 2 (3.51) 1 (1.75) occupation 0.0083 housewife 431 (86.37) 33 (6.61) 28 (5.61) 2 (0.40) 5 (1.00) employee 43 (71.67) 9 (15.00) 5 (8.33) 2 (3.33) 1 (1.67) pearson chi-squared test was performed for statistical analyses. non significnat factors were not presneted in this table. [page 296] [healthcare in low-resource settings 2024;12:12073] figure 1. prevalence of hypertension among children with different bmi. figure 2. comparisons of qol among school children with blood pressure category. non -co mmerc ial us e o nly tine blood pressure screening for children and adolescents.10 simultaneously, the notion of the cardiovascular continuum underscores the importance of adopting preventive measures at the earliest opportunity. being aware of changes at a young age can trigger early preventive strategies, yielding favorable long-term outcomes. our motivation for conducting this prevalence survey is the lack of data on hypertension prevalence among adolescents in our country. hypertension, a significant contributor to coronary artery disease and stroke, originates in childhood. screenings for hypertension, even in cases of borderline hypertension and when risk factors are present, can significantly enhance the quality of life for these children, helping them lead healthier lives.11 article [healthcare in low-resource settings 2024;12:12073] [page 297] table 4. association of hypertension with lifestyle related factors among school children. life style factors blood pressure no (%) p (n=565) normotensive elevated blood hypertensive stage 1 stage 2 pressure hypertensive hypertensive exercise 0.3080 no 234 (83.27) 20 (7.12) 19 (6.76) 3 (1.07) 5 (1.78) yes 246 (86.62) 22 (7.75) 14 (4.93) 1 (0.35) 1 (0.35) smoking 0.1754 no 404 (85.05) 35 (7.37) 29 (6.11) 4 (0.84) 3 (0.63) yes 76 (84.44) 7 (7.78) 4 (4.44) 0 (0.00) 3 (3.33) sleep 0.8568 short sleeper 18 (78.26) 2 (8.70) 2 (8.70) 0 (0.00) 1 (4.35) normal sleeper 278 (84.76) 24 (7.32) 21 (6.40) 2 (0.61) 3 (0.91) long sleeper 184 (85.98) 16 (7.48) 10 (4.67) 2 (0.93) 2 (0.93) breakfast 0.2382 no 162 (88.04) 9 (4.89) 10 (5.43) 0 (0.00) 3 (1.63) yes 318 (83.46) 33 (8.66) 23 (6.04) 4 (1.05) 3 (0.79) lunch 0.6383 no 77 (81.91) 10 (10.64) 6 (6.38) 0 (0.00) 1 (1.06) yes 403 (85.56) 32 (6.79) 27 (5.73) 4 (0.85) 5 (1.06) dinner 0.4956 no 53 (89.83) 5 (8.47) 1 (1.69) 0 (0.00) 0 (0.00) yes 427 (84.39) 37 (7.31) 32 (6.32) 4 (0.79) 6 (1.19) snack 0.5333 no 218 (82.89) 22 (8.37) 16 (6.08) 3 (1.14) 4 (1.52) yes 262 (86.75) 20 (6.62) 17 (5.63) 1 (0.33) 2 (0.66) junk food 0.4753 no 41 (83.67) 6 (12.24) 2 (4.08) 0 (0.00) 0 (0.00) 1-3 time a week 247 (84.30) 25 (8.53) 16 (5.46) 1 (0.34) 4 (1.37) > 3 times week 192 (86.10) 11 (4.93) 15 (6.73) 3 (1.35v 2 (0.90) type of foods 0.5178 fast food 40 (83.33) 2 (4.17) 4 (8.33) 1 (2.08) 1 (2.08) homemade food 440 (85.11) 40 (7.74) 29 (5.61) 3 (0.58) 5 (0.97) sugar sweeter beverage 0.8457 no 49 (84.48) 5 (8.62) 4 (6.90) 0 (0.00) 0 (0.00) yes 431 (85.01) 37 (7.30) 29 (5.72) 4 (0.79) 6 (1.18) salt consumption 0.6364 mild to moderate 439 (85.08) 39 (7.56) 29 (5.62) 3 (0.58) 6 (1.16) freely used by family 41 (83.67) 3 (6.12) 4 (8.16) 1 (2.04) 0 (0.00) fat consumption 0.0375 mild moderate 397 (85.38) 33 (7.10) 29 (6.24) 1 (0.22) 5 (1.08) freely used by family 83 (83.00) 9 (9.00) 4 (4.00) 3 (3.00) 1 (1.00) past medical history 0.9255 no 475 (84.82) 42 (7.50) 33 (5.89) 4 (0.71) 6 (1.07) yes 5 (100.00) 0 (0.00) 0 (0.00) 0 (0.00) 0 (0.00) past surgical history 0.4252 no 413 (84.46) 38 (7.77) 30 (6.13) 4 (0.82) 4 (0.82) yes 67 (88.16) 4 (5.26) 3 (3.95) 0 (0.00) 2 (2.63) bmi <0.0001 underweight 40 (97.56) 1 (2.44) 0 (0.00) 0 (0.00) 0 (0.00) normal weight 342 (93.19) 15 (4.09) 9 (2.45) 0 (0.00) 1 (0.27) overweight 57 (68.67) 12 (14.46) 11 (13.25) 1 (1.20) 2 (2.41) obese 41 (55.41) 14 (18.92) 13 (17.57) 3 (4.05) 3 (4.05) pearson chi-squared test was performed for statistical analyses. non -co mmerc ial us e o nly prevalence of hypertension in this current investigation, we present data pertaining to blood pressure readings from a representative group of 565 school children aged 13 to 18 in duhok. through a comprehensive analysis involving three distinct visits, each comprising triplicate blood pressure measurements, we identified that the overall prevalence of hypertension among this cohort, spanning ages 13 to 18, was 5.84%. the study sample encompassed individuals aged 13 to 18 years. these findings become particularly concerning when juxtaposed with the outcomes of other investigations, like the study conducted by macedo et al. in their research, they examined the prevalence of hypertension in 889 children aged 5 to 18 in northern portugal, specifically exploring its correlation with obesity. their study reported an estimated hypertension prevalence of 5.2%, which is remarkably close to the prevalence observed in our study.12 this value aligns well with our own findings concerning prevalence. furthermore, the occurrence and frequency of hypertension among school children in turkey have been subjects of investigation by numerous researchers. the hypertension rates have exhibited variations across studies conducted in various countries, including those carried out within turkey. in the context of school children studied in shimla, north india, the observed prevalence of hypertension was 5.9%. this rate of prevalence notably exceeded the predicted 5% prevalence of high blood pressure in children in the united states using the same criteria.13 across the board, systematic reviews have reported varying estimates for hypertension in children, with africa having a prevalence estimate of 5% and america showing a prevalence of 3.5%.14 another study in 2014 by patel et al. from bhopal documented a prevalence of hypertension at 5.36% in various regions of africa, such as ghana in west africa and tunisia in north africa, prevalence rates of 6% and 9.6%, respectively, were documented by addo et al. and harrabi et al.15 similarly, in a study by kidy et al., the prevalence of hypertension was examined.16 the prevalence of hypertension reported in this study is consistent with the prevalence reported in the literature. the reason for the difference between the prevalence of hypertension in this study and those in the previous studies might be the usage of different age groups.17 and maybe because of different food intake and lifestyles in different populations. relationship between bmi and hypertension blood pressure demonstrated a positive correlation with bmi (height and weight), and this association remained statistically significant (p=0.00) according to the results of our multivariate regression analysis. in our study, a notable trend emerged wherein article table 5. predictors of hypertension in school-aged children. table 6. association of blood pressure with quality of life among secondary school children. life style factors blood pressure no (%) p (n=565) normotensive elevated blood hypertensive stage 1 stage 2 pressure hypertensive hypertensive qol 23.85 (4.31) 23.57 (5.23) 24.00 (4.18) 28.25 (5.25) 26.17 (3.71) 0.2103 the comparisons were not statistically signiant by gender as well. anova one-way was performed for statistical analysis. [page 298] [healthcare in low-resource settings 2024;12:12073] non -co mmerc ial us e o nly the prevalence of hypertension heightened as bmi status increased, showcasing strong statistical significance. this finding reinforces the conclusions drawn by jonathan et al., underscoring the substantial risk factors that obesity and overweight represent in relation to hypertension.18 this linkage, where higher blood pressure levels correspond with increased obesity rates, has been consistently documented in a multitude of reports.19 this study uncovered a notable pattern: the prevalence of elevated blood pressure grew consistently with higher bmi percentiles. this trend appears to indicate a connection that is not solely dependent on regular physical development. this observation implies that obesity functions as an autonomous risk factor for hypertension, underscoring its independent role in contributing to high blood pressure.20 our results confirm the findings of erlingsdottir et al.21 who showed an association between overweight/obesity and higher blood pressure. the mechanism whereby overweight/obesity may lead to higher blood pressure seems to be due to enhanced adipocyte secretion of adipokines and proinflammatory cytokines which may disrupt normal physiological function leading to increased blood pressure.21 age and gender in the current study, age was not associated with hypertension. similar findings have been documented by oyewole and oritogun.22 but disagree with a nigerian study that found age was associated with increases in blood pressure among adolescents, as well as the mid-adolescent age group (13-15 years).23 the present study indicated that obese and overweight boys had a larger prevalence risk of high normal bp or hypertension than counterpart girls. the finding among portuguese school adolescents aged 1018 also showed a higher risk of being hypertensive among obese and overweight boys than girls.24 in addition, the prevalence of hypertension in boys was greater than in girls, and this may be due to the role of testosterone in hypertension observed in males compared to non-menopausal women, which may explain the cause of hypertension in boys in this study.25,26 the reason for girls having low blood pressure compared to boys may be attributed to estrogen and its protective effect on the cardiovascular system, because estrogen causes vasodilatation by modulating the function of vascular endothelial cells.27,28 the other probable cause of high blood pressure in adolescents aged (12-18) years could be a persistent hyperactive sympathetic nervous system even at rest which increases the smooth muscle tone of the vessels increasing resistance and hence persistently elevating pulse rate, cardiac output and hence elevating blood pressure.29,30 recommendations raising awareness among school students, particularly adolescents, regarding hypertension and its associated complications holds paramount importance. to achieve this objective, educational initiatives should be consistently organized by school authorities. these programs have the potential to inspire students to adopt healthier lifestyles and dietary habits. additionally, such efforts can contribute to enhancing parents’ understanding of hypertension, particularly when it is in its early stages. screening procedures should be implemented to detect asymptomatic hypertension in children, with a specific focus on mitigating influential factors such as obesity. this can be accomplished by offering guidance on balanced diets and regular physical activity, both within the home environment and at schools. parents should also be actively encouraged to integrate these measures into their children’s routines. to this end, the task force on blood pressure control in children advocates for annual blood pressure measurements for all children aged 3 and above. these regular assessments hold significant value, as they can effectively identify hypertension in children. by collectively adhering to these practices, we can proactively address the issue of hypertension among the younger population. conclusions this study showed that the prevalence of different classes of abnormal blood pressure was high in secondary school children in this region. the higher prevalence of hypertension among secondary school children was associated with being obese, using free fast in food, low level of education of parents. but being older and obesity predicted the prevalence of hypertension among secondary school children in this region. references 1. kearney pm, whelton m, reynolds k, et al. global burden of hypertension: analysis of worldwide data. lancet 2005;365:217-23. 2. silverstein dm, champoux e, aviles dh, vehaskari vmjpn. treatment of primary and secondary hypertension in children. pediatr nephrol 2006;21:820-7. 3. charan j, buch n, goyal jp, et al. prevalence of hypertension in school going children of surat city, western india. j cardiovasc dis res 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of estrogens on atherogenesis. curr vasc pharmacol 2011;9:244-57. 27. mendelsohn me, karas rh. the protective effects of estrogen on the cardiovascular system. n engl j med 1999;340:180111. 28. alhalaiqa f, abu-shbeeb i, batiha a-m, masa’deh r, amarneh b. the relation of demographic characteristics with fatigue levels among coronary heart disease patients: a jordanian study. adv stud biol 2015;7:301-22. 29. grassi g, mark a, esler m. the sympathetic nervous system alterations in human hypertension. circ res 2015;116:976-90. 30. kalil gz, haynes wgjhr. sympathetic nervous system in obesity-related hypertension: mechanisms and clinical implications. hypertens res 2012;35:4-16. article [page 300] [healthcare in low-resource settings 2024;12:12073] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11781 optical membrane for visual screening of mercury determination in drinking water based on polyvinyl chloride and dioctyl sebacate choirul amri, sri puji ganefati, sardjito eko windarso, adib suyanto department of environmental health, ministry of health health polytechnic yogyakarta, yogyakarta, indonesia abstract this study developed an optical membrane for detecting hg pollution in water, using polyvinyl chloride and dioctyl sebacate (pvc-dos). the primary aim was to assess the suitability of pvc-dos optical membranes as a screening tool for hg in drinking water. specific objectives included determining optimal conditions (wavelength, reaction ph, response time) for hg determination with pvc-dos-based optical membranes and evaluating the visual performance (absolute and difference thresholds) for detecting hg in drinking water. laboratory experiments involved preparing pvc-dos-based optical membranes composed of 1,5-diphenylcarbazone, pvc, and dos mounted on mica paper holes. optimisation of wavelength, response time, and reaction ph was performed (each five times). absolute and difference thresholds were established. optimal conditions were found to be a reaction ph of 6-9, a membrane response time of 45 minutes, and a purple hg-positive membrane (wavelength 575-580 nm). the visual optical membrane method demonstrated an absolute threshold of 0.4 μg/l and a difference threshold of 0.5 μg/l. pvc-dos-based optical membranes can effectively screen for hg in water. this method involves dipping an optical membrane stick and comparing the result with a color standard. introduction the spectrophotometric and atomic absorption spectrophotometric methods are commonly employed to analyse mercury (hg) in water.1–6 however, the high cost associated with this analysis7 limits its accessibility, and it is considered impractical by many environmental practitioners. therefore, there is a need, especially among environmental practitioners, for an affordable and practical method to assess hg pollution in drinking water.5,8–12 numerous studies have explored the use of a specialised material known as an “optical membrane,” constructed from polyvinyl chloride and dioctyl sebacate (pvc-dos), to detect excessive mercury (hg) levels in drinking water. this innovative approach has the advantage of being user-friendly and cost-effective, making it accessible to environmental experts and the general public.13 these membranes act as miniature sensors. some studies have developed highly sensitive sensors capable of detecting even trace amounts of mercury and lead without the need for collecting large water samples initially.14 other research endeavors have produced similar sensors using different materials, demonstrating their effectiveness in mercury testing for drinking water.15 additionally, another study devised a sensor that can distinguish mercury even in the presence of other metals.16 these studies collectively highlight the effectiveness of these specialised sensors in accurately and easily detecting mercury in water, especially in a drinking water context. this relatively new method, with minimal prior development, offers low costs and simplicity, making it an accessible solution. importantly, this method does not require specialised knowledge, rendering it suitable for use by environmental practitioners and the general population. furthermore, this method allows for visual readings in the field, and it represents a novel area of research. in order to optimise the use of the optical membrane for determining mercury (hg) in water, it is essential to establish the ideal testing conditions.17 the research has identified the optimal condicorrespondence: choirul amri, department of environmental health, politeknik kesehatan kemenkes yogyakarta, jl. tatabumi no. 3 banyuraden gamping sleman yogyakarta 55293 indonesia. e-mail: choirul.amri@poltekkesjogja.ac.id key word: analysis; membrane; mercury; water contributions: ca conceptualization, data analysis, methodology, validation, visualization, writing – original draft, review & editing; spg methodology, validation, and writing – original draft, review & editing; sew methodology, analysis, validation, and writing – original draft, review & editing; as methodology, visualisation, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: none. funding: this research did not receive external funding. availability of data and materials: all data generated or analysed during this study are included in this published article. received: 12 september 2023. accepted: 14 november 2023. early access: 24 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11781 doi:10.4081/hls.2023.11781 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11781] [page 173] non -co mmerc ial us e o nly tions, including the reaction ph and membrane response time.18,19 to comprehensively assess the method’s performance as a tool for mercury (hg) testing in water, various performance metrics, such as the absolute threshold and difference threshold, must be determined. therefore, this study aimed to identify the optimal conditions for pvc-dos-based optical membranes, encompassing factors like wavelength, reaction ph, and response time. additionally, it evaluates the method’s performance visually, considering parameters like absolute threshold and difference threshold. materials and methods in alignment with the research objectives, this study aims to determine the optimal conditions for pvc-dos-based optical membranes and assess their performance in determining mercury (hg) in water. each optimisation was conducted five times. preparation of an optical membrane based on pvc-dos the membrane solution comprised the following components: 5% 1,5-diphenylcarbazone (dpc), 30% pvc, and 65% dos. in 2 ml of tetrahydrofuran (thf), 100 mg of this membrane composition were dissolved14,20. mica sheets with a thickness of 0.4 mm were cut into 0.7 x 5.0 cm squares. a hole punch with a diameter of 0.5 cm was used to create a hole 0.9 cm from the end of each sheet. the membrane solution was dripped into the holes on the mica sheet, and after drying, the mica sheet was removed, leaving behind a transparent membrane. optimisation of wavelength the optical membrane was immersed in 5 ml of hg solution (1.0 µg/l) in a test tube for a few minutes until it turned red-purple. a spectrophotometer with a wavelength range of 400–700 nm was utilised to measure the absorbance of the optical membrane, with measurements taken at 5 nm intervals. optimisation of response time the optical membrane was immersed in a 1.0 μg/l hg solution for various durations (5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, and 60 minutes). a spectrophotometer, set at the maximum wavelength determined during wavelength optimisation, was used to measure the absorbance of each optical membrane. optimisation of ph the optical membrane was immersed in 12 test tubes, each containing 5 ml of hg solution (1.0 µg/l), for varying durations (5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, and 60 minutes). the absorbance of each optical membrane was read using a spectrophotometer at the wavelength optimised earlier during wavelength determination. results optimisation of wavelength the results of wavelength optimisation for measuring the absorbance of the 1.0 µg/l hg solution are listed in table 1. the optimal absorbance is achieved at a wavelength of 575-580 nm. optimisation of response time optimisation results for response time are presented in table 2. the response time for the optical membrane to detect hg is 45 minutes. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. results of wavelength (λ) optimisation. λ (nm) abs λ (nm) abs λ (nm) abs λ (nm) abs 400 0.000 550 0.442 585 0.492 640 0.135 430 0.022 560 0.480 590 0.485 655 0.081 460 0.055 565 0.490 595 0.470 670 0.058 490 0.116 570 0.497 600 0.454 685 0.042 520 0.250 575 0.501 610 0.409 700 0.032 535 0.346 580 0.501 625 0.256 table 2. results of response time optical membrane. time (minute) abs-1 abs-2 abs-3 abs-4 abs-5 abs average 5 0.094 0.124 0.099 0.102 0.108 0.103 10 0.253 0.222 0.214 0.238 0.246 0.235 15 0.318 0.312 0.320 0.336 0.339 0.325 20 0.388 0.390 0.406 0.410 0.417 0.402 25 0.540 0.528 0.514 0.519 0.520 0.524 30 0.597 0.605 0.628 0.622 0.613 0.613 35 0.690 0.659 0.668 0.679 0.672 0.674 40 0.757 0.749 0.743 0.735 0.729 0.743 45 0.782 0.754 0.774 0.762 0.768 0.768 50 0.749 0.762 0.756 0.781 0.769 0.763 55 0.769 0.783 0.754 0.763 0.796 0.768 60 0.784 0.762 0.759 0.776 0.769 0.770 [page 174] [healthcare in low-resource settings 2023; 11:11781] non -co mmerc ial us e o nly optimisation of ph optimisation results for the ph of the optical membrane reaction are presented in table 3. the optical membrane reaction for detecting hg occurs at an optimum ph of 6-9. discussion for varying durations, the optical membrane was immersed in a 1.0 µg/l hg solution (5, 10, 15, 20, 25, 30, 35, 40, 45, 50, 55, and 60 minutes). a spectrophotometer, set at the maximum wavelength determined during the optimisation process, was used to measure the absorbance of each optical membrane. optimum wavelength the optimum wavelength is the one at which electronic excitation occurs while absorbing the most energy. it is determined by the energy required to excite an electron from the ground level to an excited level.20,21 identifying the correct wavelength is crucial to prevent measurement errors. if the wavelength used is too short, it will generate excessive energy, which can break molecular bonds. on the other hand, if the wavelength is too long, the energy produced is insufficient to excite electrons from lower to higher energy levels. selecting the appropriate wavelength enhances sensitivity, as small changes in absorbance at these wavelengths increase sensitivity.22,23 a purple complex is formed when a pvc-dos-based optical membrane reacts with hg. dos, in addition to serving as a plasticiser, also acts as an organic solvent in the membrane.7,24 to determine the precise wavelength of the complex in the solvent on the optical membrane, wavelength optimisation was conducted within the 400–700 nm range. figure 1 illustrates the wavelength spectra of the reaction product complex, with the maximum wavelength occurring at 575–580 nm. the ph of the complex formation reaction the ph of the reaction determines whether or not a complex compound is formed between 1,5-diphenylcarbazone and hg.25,26 therefore, the ph of the reaction must be optimised to determine the ph at which complex compound formation can occur. figure 2 illustrates the results of optimising the ph of the reaction. the optimal ph range for the reaction between hg and a pvcdos-based optical membrane is displayed in figure 2. given that most water falls within the normal ph range of 6-9, detecting hg in water is highly advantageous when the ph conditions are within the optimum range of 6–9. however, it is advisable to check the ph of the sample water before conducting the determination. if the ph is not within the range of 6–9, it should be adjusted to ensure that the water’s ph falls within that range. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. results of ph optimisation ph average abs-1 abs-2 abs-3 abs-4 abs-5 abs 1 0.099 0.108 0.112 0.103 0.106 0.106 2 0.312 0.299 0.304 0.307 0.316 0.308 3 0.397 0.402 0.408 0.412 0.405 0.405 4 0.587 0.572 0.581 0.578 0.593 0.582 5 0.732 0.729 0.698 0.725 0.710 0.719 6 0.765 0.773 0.758 0.770 0.778 0.769 7 0.772 0.764 0.768 0.782 0.785 0.774 8 0.771 0.759 0.770 0.782 0.769 0.770 9 0.762 0.784 0.774 0.760 0.759 0.768 10 0.725 0.712 0.709 0.716 0.712 0.715 11 0.528 0.508 0.517 0.509 0.532 0.519 12 0.286 0.292 0.306 0.302 0.291 0.295 13 0.135 0.122 0.132 0.118 0.138 0.129 figure 1. wavelength spectra of reaction product complexes in pvc-dos-based optical membranes. figure 2. the complex absorbance at various reaction ph at a hg concentration of 1.0 µg/l in water. [healthcare in low-resource settings 2023; 11:11781] [page 175] non -co mmerc ial us e o nly response time of the membrane when a chemical compound reacts with another, one of three outcomes can occur: i) no reaction, ii) an immediate reaction, or iii) a delayed reaction. to determine the time required for the reaction between the optical membrane and hg to form a complete complex, it is necessary to optimise the reaction time or membrane response time. in this study, the response refers to the action of the membrane in the presence of hg in water, resulting in the formation of a colored complex. the response time is the duration from the moment the membrane is immersed in an hg-containing solution until a specific time is reached, at which point a relatively constant absorbance and color are produced. figure 3 illustrates the membrane response time and absorbance at a concentration of 1.0 µg/l hg. the response time in this membrane application is relatively long, approximately 45 minutes. this extended duration is attributed to the fact that the complex formation reaction occurs primarily on the membrane’s surface in distinct phases, namely the aqueous phase and the organic phase. figure 4 provides a model that can elucidate the potential of a complex formation reaction on the membrane’s surface, including: i) it is improbable that hg will penetrate the membrane and react within it; and ii) a reaction takes place on the membrane surface, and the resulting complex enters the membrane, which is the more plausible scenario. performance and standards for visual optical membranes the determination of hg using this method is essentially the same as the optical membrane method using spectrophotometry, except that the observation is done visually, i.e., directly using the sense of sight. because of the absorption of certain wavelengths of light by a substance, the sense of sight can distinguish colors and color intensities. the color produced by the eye’s impression is not the color absorbed by the substance, but rather the color that is reflected. the complex formed on the pvc-dos membrane absorbs light at a wavelength of 575–580 nm, which corresponds to the visible spectrum’s green color. as a result, the complex absorbs green light while reflecting light of other wavelengths. the color evoked by the eye’s impression is violet, the complementary color of green. this study’s analysis by visual observation of color is intended to make it easier for ordinary people to perform hg analysis with optical membranes.27 observation with a spectrophotometer is possible for those who have the necessary equipment and special expertise in its use and maintenance; however, it is also costly. the optical membrane method, which is observed visually, has many advantages for ordinary people because it does not require equipment or special skills, is simple to perform, and can eliminate measurement errors caused by the use of equipment. as a comparison, this method necessitates a set of color standards. it is hoped that the row of color standards will be able to distinguish between concentrations from one another. a different threshold test is required for this purpose. according to this test, the smallest difference in hg levels that can still be clearly distinguished is 0.5 μg/l, while the lowest hg concentration that can still be visually detected with the optical membrane (absolute threshold) is 0.4 μg/l. based on the data obtained in this research, when using optical membranes for measuring hg in water, it is necessary to ensure that the water is at a ph of 6-9 and that the optical membrane immersion time is at least 45 minutes. conclusions the optimal conditions for determining hg in water using pvc-dos-based optical membranes were as follows: wavelengths of 575–580 nm, a reaction ph of 6–9, and a membrane response time of 45 minutes. the optical membrane method for determining hg in water has a visual performance with an absolute threshold of 0.4 µg/l and a difference threshold of 0.5 µg/l. optical membranes based on pvc-dos can be used as a screening test tool for determining hg in water. to utilise this method effectively, it is necessary to ensure that the water is within the ph range of 6-9 and that the optical membrane immersion time is at least 45 minutes. subsequently, the color should be compared with the standard visually. references 1. sulistyarti h, retnowati r, sulistyo e, wulandari er, nashukha hl. development of indirect spectrophotometric method for mercury determination based on the formation of iron(iii)-thiocyanate complex. in: iop conference series: [page 176] [healthcare in low-resource settings 2023; 11:11781] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 3. at a hg concentration of 1.0 µg/l, membrane response time and absorbance were measured. figure 4. at a hg concentration of 1.0 µg/l, membrane response time and absorbance were measured. non -co mmerc ial us e o nly materials science and engineering. institute of physics publishing; 2020. 2. alzahrani l, el-ghamry ha, saber al, mohammed gi. spectrophotometric determination of mercury(ii) ions in laboratory and zamzam water using bis schiff base ligand based on 1,2,4-triazole-3,5-diamine and o-vaniline. arabian j chemistry 2022;104418. 3. simiao dc, de andrade fp, lima wg, et al. determination of mercury concentration by a new spectrophotometric method and evaluation of bacterial diversity in river water samples from brazil. water supply 2022;22:5535-48. 4. azmi aa, izzati daud a, khairul wm, et al. silica-silver coreshell nanoparticles incorporated with cellulose filter paper as an effective colorimetric probe for mercury ion detection in aqueous media: experimental and computational evaluations. environ nanotechnol monit manag 2023;19:100762. 5. gonzález-morales d, valencia a, díaz-nuñez a, et al. development of a low-cost uv-vis spectrophotometer and its application for the detection of mercuric ions assisted by chemosensors. sensors (switzerland) 2020;20:906. 6. zalov az, kuliev ka, suleimanov gs, sh bakhshieva u. liquid-liquid extraction and spectrophotometric determination of mercury(ii) with 2, 6-dithiolphenol and its derivatives in the presence of hydrophobic amines. j multidiscipl engin sci technol 2019;6. 7. rajendraprasad n, basavaiah k. development of membrane electrodes for selective determination of lisinopril in pharmaceuticals. j anal sci technol 2019;10:37. 8. duval b, gredilla a, fdez-ortiz de vallejuelo s, et al. a simple determination of trace mercury concentrations in natural waters using dispersive micro-solid phase extraction preconcentration based on functionalized graphene nanosheets. microchemical j 2020;154:104549. 9. budlayan ml, dalagan j, lagare-oracion jp, , et al. detecting mercury ions in water using a low-cost colorimetric sensor derived from immobilized silver nanoparticles on a paper substrate. environ nanotechnol monit manag 2022;18:100736. 10. banerjee s, shyamsundar k, saharay m, roy s. a single-step low cost detection of ground water hg2+ using mercaptosuccinic acid functionalised silver nanoprism. environ nanotechnol monit manag 2022;17:100637. 11. kiruba daniel scg, kumar a, sivasakthi k, thakur cs. handheld, low-cost electronic device for rapid, real-time fluorescence-based detection of hg2+, using aptamer-templated zno quantum dots. sens actuators b chem 2019;290:73-8. 12. laganovska k, zolotarjovs a, vázquez m, et al. portable lowcost open-source wireless spectrophotometer for fast and reliable measurements. hardwarex 2020;7:e00108. 13. hermanto d, siswanta d, kuswandi b, ismillayli n. optical fiber mercury biosensor based on immobilized urease and bromothymol blue onto the alginate-chitosan membrane in the flow-system. kuwait j sci 2022;49(1). 14. zargoosh k, babadi ff. highly selective and sensitive optical sensor for determination of pb2+ and hg2+ ions based on the covalent immobilization of dithizone on agarose membrane. spectrochim acta a mol biomol spectrosc 2015;137:105-10. 15. firooz ar, ensafi aa, hoseini ks, kazemifard n. development of a highly sensitive and selective mercury optical sensor based on immobilization of bis(thiophenal)-4,4′methylenedianiline on a pvc membrane. materials science and engineering: c 2014;38:73-8. 16. shenashen m, el-safty s. visual detection and recovery of mercury in water and blood samples using nano-membrane tubular architectures. in: proceedings of the international conference nanomaterials: applications and properties 2015. 17. rahmadhani tn, tualeka ar, rahmawat p, russen ss, wahy a, ahsa, et al. determination of mercury (hg) risk level (rq) with exposure through fish and drinking water consumption in bulawa sub-district, bone bolango district, gorontalo province, indonesia. indian j public health res dev 2019;10:2030-5. 18. isadiartuti d, rosita n, hendradi e, et al. solubility and partition coefficient of salicylamide in various ph buffer solutions. indonesian j chem 2021;21:1263-70. 19. sutrisno i, firmansyah m, budhi widodo r, et al. implementation of backpropagation neural network and extreme learning machine of ph neutralization prototype. in: international conference on information system, computer science and engineering 2018, iconiscse 2018. shipbuilding institute of polytechnic, surabaya, indonesia: institute of physics publishing; 2019. 20. mag-usara vk, escaño mc, petoukhoff ce, et al. optimum excitation wavelength and photon energy threshold for spintronic terahertz emission from fe/pt bilayer. iscience 2022;25(7). 21. song y, zhao s, guo fm, yang yj, li sy. electron excitation from ground state to first excited state: bohmian mechanics method. chinese physics b 2016;25(3). 22. samad fa, mohamed t. intensity and wavelength-dependent two-photon absorption and its saturation in ito film. appl phys a mater sci process. 2023;129(1). 23. mohamed t, el-motlak mh, mamdouh s, et al. excitation wavelength and colloids concentration-dependent nonlinear optical properties of silver nanoparticles synthesized by laser ablation. materials 2022;15(20). 24. al attas as. novel pvc membrane selective electrode for the determination of clozapine in pharmaceutical preparations. int j electrochem sci 2009;4. 25. mergola l, scorrano s, bloise e, et al. novel polymeric sorbents based on imprinted hg(ii)-diphenylcarbazone complexes for mercury removal from drinking water. polym j 2016;48:73-9. 26. kazemzadeh a, kazemzadeh h. determination of hg2+ by diphenylcarbazone compound in polymer film. j composites compounds 2019;1:34-8. 27. imron mf, kurniawan sb, abdullah srs. resistance of bacteria isolated from leachate to heavy metals and the removal of hg by pseudomonas aeruginosa strain fz-2 at different salinity levels in a batch biosorption system. sustainable environment research. 2021;31:14. [healthcare in low-resource settings 2023; 11:11781] [page 177] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12394 the impact of a social support program in immokalee, florida, during the covid-19 pandemic lindsay richards,1 leping wang,2 joashilia jeanmarie,3 shirin shafazand,1 daniel palazuelos,4,5,6 vitina monacello7 1miller school of medicine, university of miami, miami, fl; 2department of sociology, boston university, boston, ma; 3department of sociology, university of florida, gainesville, fl; 4department of global health and social medicine, harvard university, boston, ma; 5division of global health equity, brigham and women’s hospital, boston, ma; 6partners in health, boston, ma; 7department of social work, columbia university, new york, ny, usa abstract farmworkers were considered “essential” during the covid19 pandemic, but face structural inequalities that heightened their risk of the pandemic’s health and economic impacts. this study aims to evaluate the impact of a covid-relief cash transfer program in the farmworking community of immokalee, florida. the authors conducted 153 structured interviews with program beneficiaries via phone call or home visit and asked about sociodemographic variables, how the money was used, whether the money was sufficient for two weeks' financial needs, and participant ability to self-isolate. this study found that the cash transfers were most likely to be spent on living necessities and were effective in relieving covid 19-associated financial burden, but that some groups may need more support than others. given that the covid-19 pandemic has exacerbated pre-existing health disparities, it is important to understand the role of cash transfers as a public health tool and their potential impact on community mitigation efforts. introduction according to the mixteco indigena community organizing project and central coast alliance for a sustainable economy, “farm workers remain the disposable essential worker.”1 from plantation economies to the present-day farm work industry, agribusiness in florida (fl) has relied on extracting wealth from workers who are deemed expendable and excluded from rights and protections offered to the rest of the population. these fault lines can be exacerbated by disaster, as was the case when the covid-19 pandemic arrived in immokalee. immokalee, fl, is an agricultural community located in collier county of southwest florida known for its tomato and citrus production. the census bureau estimates the number of residents to be approximately 25,000.2 however, this number is known to fluctuate widely during the tomato picking season which runs from september to june, and other sources estimate that between 15,000 to 20,000 migrant farmworkers were living and working in immokalee during the height of the covid-19 pandemic in 2020.3 immokalee’s population is composed largely of mexican, guatemalan, and haitian immigrants, with nearly 40% of residents living below the poverty line.2 farmworkers face many structural inequities that make them especially vulnerable to the health and economic consequences of covid-19 – crowded housing conditions, poor labor protections, financial precarity, and documentation status, among others.4 by mid-june of 2020, immokalee had reported 899 positive cases out of 2500 tests conducted, while in neighboring naples a wealthier zip code within the same county there had been only 76 cases.5 driven by advocacy from the coalition of immokalee workers, a worker-based human rights organization, many different not-for-profit organizations and local humanitarian groups stepped in to respond to this crisis. one such group was misión peniel, a local ministry which focuses on acting to improve the living and working conditions of farmworkers in correspondence: lindsay richards, miller school of medicine, university of miami, 816 nw 11th st apt 1002, miami, fl 33136, usa e-mail: richards.lindsay@med.miami.edu tel.: +1.3216938352. key words: cash transfer; covid-19; social support; florida; health disparities. contributions: lr, conceptualization, methodology, data collection, data curation, writing – original draft; lw, methodology, data curation, formal analysis, writing – reviewing and editing; jj, conceptualization, methodology, data collection, writing – reviewing and editing; ss, methodology, supervision, writing – reviewing and editing; dp, conceptualization, methodology, supervision, writing – reviewing and editing; vm, conceptualization, methodology, supervision, writing – original draft. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: this protocol was submitted to the university of miami institutional review board office because it involved human subjects; however, it was deemed not human research (submission 20210510). all individuals received an explanation of the study and were asked consent prior to completing the survey. availability of data and materials: the datasets used and/or analyzed during the current study are available upon reasonable request from the corresponding author. funding: no funding was received for conducting this study or to assist with the preparation of this manuscript. acknowledgements: the authors wish to thank misión peniel for their collaboration on this project as well as the coalition of immokalee workers for their support in pilot testing surveys. further information: this work was previously released as a preprint (https://doi.org/10.1101/2023.02.23.23286348); however, it has never been published as a peer-reviewed publication and it is not under consideration for publication elsewhere. received: 17 february 2024. accepted: 20 november 2024. early view: 23 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12394 doi:10.4081/hls.2024.12394 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 90] [healthcare in low-resource settings 2024;12(s2):12394] non -co mmerc ial us e o nly immokalee. misión peniel’s response focused on addressing the financial burden of missing two weeks of work for quarantine purposes by implementing a cash transfer program for individuals who tested positive for covid-19. the aim of this cash distribution was to facilitate self-isolation while covid-19 positive, incentivize testing, and help alleviate the disproportionate impact of the virus in the immokalee community.6 program description residents of immokalee were able to apply for this funding in two ways. the first was that individuals were referred directly from covid-19 testing events and their applications were processed onsite after they received counseling regarding positive results and public health recommendations. the second way to apply was to call a hotline number that was set up for individuals who were tested elsewhere but lived in immokalee. a team member would then assist them in completing an application over the phone. the eligibility requirements for the cash transfer program were that recipients must be immokalee residents and must provide proof of current covid-19 infection documented by a positive test in the past 10 days (per centers for disease control and prevention guideline at the time). applications were tracked in a spreadsheet and were evaluated in the order in which they were entered on an ongoing basis. applications were reviewed by misión peniel staff to verify proof of eligibility, namely address/id provided and documentation of positive test results. less than 5% of applicants were denied. reasons for being denied included falsifying information on the application, not submitting proof of address/residency in immokalee, or lack of verification of positive test results.6 from december 2020 to july 2021, misión peniel distributed one-time checks of $800 for single applicants and $1000 or $1200 for applicants with children. the initial amount for families, defined as a parent caring for a minor child/children, was set at $1200. however, within a few weeks of the program the amount was reduced to $1000 in order to stretch limited funding during a surge in cases. a total of 807 checks were distributed during this time period.6 most participants received a check within 7 days of applying, but some applications experienced additional administrative delays. checks were distributed one to two times a week and were available for pick-up outside of misión peniel’s office or delivered to recipients’ homes. given that many individuals were quarantining at the time of distribution, a family member or friend was able to pick up the check for them. assistance was provided in the form of checks because this was the most accessible means of receiving funds for the community.6 the aim of this study was to evaluate the social and economic impact of misión peniel’s cash transfer program, specifically with regards to understanding how this money was spent and whether it was enough to support recipients during a two-week quarantine. materials and methods study overview from mid-july 2021 to mid-august 2021, the authors surveyed residents in immokalee who had received a direct cash transfer between december 2020 to july 2021 from the local social support program developed by misión peniel. the survey included a structured interview with a predefined list of questions, presented in the same order, with most questions being close-ended in nature with multiple options to choose from, and two open-ended followup questions to provide flexibility for answers that might not be covered by the pre-coded choices. the survey included questions on demographics (age, gender, race and ethnicity, marital status, education), employment (employment status, industry), food insecurity, housing insecurity (eviction notice, behind on rent or mortgage payment), transportation insecurity, income, financially supporting others, what the check was used for, whether the money was enough to meet 2 weeks’ financial needs, whether the money helped with quarantine in response to positive covid-19 testing, whether the respondent quarantined for the recommended 10 days, whether the respondent required hospitalization, whether there were any difficulties and/or fees for cashing the check, preference for lump-sum distribution versus spaced distributions, previous experiences with cash transfer programs, etc. questions about food insecurity, housing insecurity, transportation insecurity, income, and financially supporting others were asked to assess financial precarity among the study population. whether the money was enough for two weeks was asked to assess whether the program achieved its goal of supporting residents during the recommended cdc quarantine period at that time. for respondents who responded “other” to any given questions, the interviewers asked them to specify with details. study participants were contacted first by phone to explain the study and ask if they would like to participate. if unable to contact individuals by phone after two attempts, interviewers also attempted two visits to the home address provided by misión peniel. if both phone and home visit contact were unsuccessful, the authors removed these individuals from the study. if someone could not be reached or chose not to participate, the authors pulled another individual from the list. once contacted and verbally consented, participants were read the survey questions either via phone or in person at their homes. the survey was administered in either english, spanish, or haitian creole, depending on the respondent’s stated preference. surveys were administered by two team members who were fluent in spanish and haitian creole, respectively. answers were entered into a redcap form containing radio buttons, checkboxes, and free text spaces by the study investigators as the interviews took place. this protocol was submitted to the university of miami institutional review board office because it involved human subjects; however, it was deemed not human research (submission 20210510). patient and public involvement this study was developed based on the requests of community partner misión peniel, who considered this research to be a priority for the community as a way to improve the social support program at a time when the community was highly impacted by the covid-19 pandemic. individuals working with misión peniel assisted with the conceptualization of research and selection of survey questions. the coalition of immokalee workers also facilitated meetings with community members who provided feedback regarding survey questions prior to beginning data collection. preliminary data was presented to community partners within weeks of completing data analysis. eligibility criteria participants who had been enrolled in misión peniel’s social support program and received a direct cash transfer were eligible for study participation. only individuals ages 18 and older were included in this study. individuals were excluded if they could not be contacted by either phone call or home visit. misión peniel provided a list of social support program recipients and their social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12394] [page 91] non -co mmerc ial us e o nly contact information. each participant from the database was assigned a number, and a random number generator was used to select 275 individuals from this list out of 807 potential participants. this number was chosen by the researchers based on an anticipation of the maximum number of surveys that could be completed within the time frame of the study. of the 275 individuals identified, 122 could not be contacted or declined participation in the study. therefore, the study sample consisted of 157 randomly selected immokalee adult residents who either tested positive for covid-19 and/or had a child living with them who tested positive for covid-19, and who received a direct cash transfer from misión peniel during the time period of december 2020 to july 2021 (response rate: 57.1%). four individuals were excluded from the analysis due to missing income data, so the final analysis sample included 153 individuals. study variables outcome variable the primary outcome variable was a dichotomous measure of whether the respondent reported the money was enough to cover their financial needs for two weeks. independent variables food insecurity during the interview, the respondents were asked whether they had experienced food insecurity; either not knowing where the next meal was coming from, or involuntarily eating less than they need, on a regular basis, for a period of time lasting more than a month in the past 12 months. housing insecurity during the interview, the respondents were asked two questions regarding housing insecurity. the first question was whether they received an eviction notice in the past 12 months; the second question was whether they had been behind on paying for rent or mortgage in the past 12 months. transportation insecurity respondents were also asked whether they experienced difficulty getting needed services because they did not have transportation in the past 12 months. income group respondents were asked about their average weekly income range, classified into five ordered categories including: i) less than $250; ii) $250-$400; iii) $400-$550; iv) $550-$700; and v) more than $700. the authors created 3 income categories according to whether the converted annual income was below the 2021 national poverty line of $12,880 (approximately $12,900) for a household of one, between the poverty line and 2.2 times of the poverty line, or whether it exceeded 2.2 times of the poverty line. the value 2.2 was used here because the cut-off line between the third and forth income category, which is a weekly income of $550, when converted into annual income, equals $12880, which is 2.2 times the federal poverty line. employment status self-identified employment status was measured including i) employed (including full-time and part-time) or ii) not working for pay/unemployed. covariates the authors included a set of covariates including whether the check was used for purposes other than necessities, which is directly related to the outcome of whether or not the check was enough to cover all the expenses; and whether the respondent was family caregiver, which is related to the financial costs for child or adult caregiving. the authors also controlled for demographic factors including gender, age, ethnicity, marital status, and educational level, which are essential determinants of socioeconomic status and health, to prevent them from confounding the relationship between the focal independent and outcome variables. modeling strategy the authors fit a logit regression model on the data, in which food insecurity, housing insecurity, transportation insecurity, employment status, and income group were used to predict whether the money was enough for two weeks’ financial needs. the authors also included use of check, whether the respondent was currently financially supporting other individuals, and demographic indicators including gender, age, marital status, educational level, and race and ethnicity. in the equation, enough_moneyi indicates the binary outcome of whether the respondent thought the money was enough for two weeks’ financial needs. denotes the odds of the money being enough. logit (pr enough_moneyi))=ln is the link function to convert the odds to the 0-1 interval. xi is the matrix of predictors of respondent i; zi is the matrix of covariates of respondent i; g and d are vectors of regression coefficients. subscript i indexes each individual observation. results the final analysis included a total of 157 immokalee adult residents. table 1 represents all participant characteristics as well as two subgroups, created according to whether or not the money received met financial needs. a majority of respondents (83.7%) reported spending the check exclusively on living expenses, including utilities (50.3%), food (45.9%), housing (44.6%), transportation (10.2%), and healthcare (8.9%). of the recipients surveyed, 98.7% reported quarantining for ten days after their positive covid-19 test, and 99.3% reported that the money helped them stay home and quarantine while having covid-19. a total of 76.5% of respondents reported that the check was enough to cover their financial needs for two weeks. of note, race was included in the questionnaire but is not reported in table 1 as a high percentage of respondents (81.7%) answered “other” and identified an ethnicity or nationality. table 2 presents the results from the logistic regression model in which employment status, income group, food insecurity, housing insecurity, and transportation insecurity are used as predictors of whether the social and political factors affecting public health [page 92] [healthcare in low-resource settings 2024;12(s2):12394] non -co mmerc ial us e o nly respondent thought the money was enough for two weeks’ financial needs. housing insecurity was negatively associated with the odds of reporting the money was enough for two weeks’ financial needs. respondents who experienced housing insecurity in the past 12 months were 65% less likely to report that the money was enough versus for respondents who did not experience housing insecurity. there was a significantly positive correlation between having a high school degree or above and the odds of reporting the money was enough. the likelihood for respondents with a high school degree to report that the money was enough was 2.98 times that of those with a middle school degree or less. discussion a common concern of policymakers with regards to cash transfers is that poor households will misuse the cash. this may explain why many governments and non-profit agencies opt for inkind social assistance despite economic reasoning which suggests that cash transfers may be more efficient for beneficiaries.7 this concern, however, is not supported by our data, wherein a vast majority of respondents reported spending the check exclusively on living necessities such as utilities, food, housing, transportation, and healthcare. these findings are supported by a literature review by evans and popova, which found a negative relationship between social and political factors affecting public health table 1. participant characteristics. variable full sample (n=153) whether the money was enough for 2 weeks yes (n=117) no (n=36) age, mean [sd], years 41 [14] 41 [14] 43 [13] male sex, n (%) 97 (63.4) 76 (65.0) 21 (58.3) ethnicity, n (%) hispanic 141 (92.2) 108 (92.3) 33 (91.7) non-hispanic 12 (7.8) 9 (7.7) 3 (8.3) married or cohabitated, n (%) 73 (47.7) 54 (46.2) 19 (52.8) educational level, n (%) middle school or below 75 (49.0) 51 (43.6)** 24 (66.7)** high school or above 78 (51.0) 66 (56.4)** 12 (33.3)** employment status, n (%) employed 100 (65.4) 74 (63.2) 26 (72.2) not working for pay/unemployed 53 (34.6) 43 (36.8) 10 (27.8) income group, n (%) income ≤ poverty line 42 (27.5) 33 (28.2) 9 (25.0) income ≤ 2.2*poverty line 81 (52.9) 60 (51.3) 21 (58.3) income > 2.2*poverty line 30 (19.6) 24 (20.5) 6 (16.7) currently financially supporting other individuals, n (%) 108 (70.6) 79 (67.5) 29 (80.6) food insecurity, n (%) 26 (17.0) 15 (12.8)** 11 (30.6)** housing insecurity, n (%) 48 (31.4) 29 (24.8)*** 19 (52.8)*** transportation insecurity, n (%) 26 (17.0) 16 (13.7)** 10 (27.8)** check use for purposes other than necessities, n (%) 25 (16.3) 22 (18.8) 3 (8.3) the results of chi-square tests for the differences in means of each variable for respondents who reported the money was or was not enough for two weeks’ financial needs are denoted as asterisks next to the summary statistics. *** p<0.01, ** p<0.05, * p<0.1. table 2. odds ratios of participant characteristics and whether the check was enough for 2 weeks’ financial needs. variables odds ratio (95% ci) age 1.01 (0.97, 1.05) male 0.78 (0.32, 1.86) hispanic 1.11 (0.22, 5.68) married or cohabitated 0.79 (0.29, 2.15) high school education or above 2.98** (1.03, 8.63) employed 0.43 (0.13, 1.47) income group poverty line<income≤2.2*poverty line 1.24 (0.32, 4.79) income>2.2*poverty line 1.12 (0.24, 5.31) experienced food insecurity in past 12 months 0.42 (0.13, 1.34) experienced housing insecurity in past 12 months 0.35** (0.15, 0.81) experienced transportation insecurity in past 12 months 0.80 (0.24, 2.67) used check for purposes other than living necessities 2.40 (0.65, 8.85) currently financially supporting individuals other than themselves 0.88 (0.29, 2.72) note: estimates displayed in the form of odds ratios. confidence intervals are provided in parentheses. *** p<0.01, ** p<0.05, * p<0.1. [healthcare in low-resource settings 2024;12(s2):12394] [page 93] non -co mmerc ial us e o nly cash transfers and expenditures on temptation goods.8 similar findings were seen also in another study examining one-time cash transfers of $1000 to individuals who tested positive for covid-19 in new york from may 2020 to may 2021. the authors concluded that after receiving a cash transfer, individuals made “rational decisions to support their health and well-being rather than “misusing” funds on temptation goods such as alcohol.”9 additionally, the study revealed that nearly all recipients surveyed were able to self-isolate for 10 days as advised, which suggests that individuals in this sample had an awareness of and desire to comply with public health measures within their community. these findings contribute to the body of knowledge suggesting that cash transfer programs may be an effective public health tool moving forward. another measure in this study which may inform future programs was evaluating the quantity of cash support provided, which ranged from $800 to $1200. a majority of respondents reported that this amount was enough to cover their financial needs for two weeks. however, when examining these responses stratified by demographic variables, people with housing insecurity and people without a high school degree were significantly less likely to report that the money was enough for two weeks’ financial needs (p<0.05). therefore, these characteristics may mark those in the population who are especially vulnerable and could have benefitted from more support. one explanation is that housing insecurity may be one of the primary risk factors that prevents people from being able to self-isolate and stop spreading covid-19 after getting a positive test. some cash transfer programs have previously attempted to address disparities among recipients by creating targeted programs with varying eligibility requirements.10 however, other studies have revealed that residency-based cash transfer programs may be more effective in practice than targeted programs, particularly during a pandemic, because they can act quickly without requiring the time and resources to verify who qualifies.11 therefore, the authors conclude that another way future cash transfer programs may increase the likelihood of adequately supporting vulnerable members of a population is by increased generosity in transfer amount. future studies should seek to better understand the quantity of cash provided that can best support the needs of vulnerable community members. this study focused exclusively on covid-19, but future studies should also explore how cash transfers could be used as a public health tool in the case of other acute and chronic illnesses. one additional note is that a high number of respondents in this study answered “other” for the survey question regarding race. race and ethnicity questions in this survey were based on the u.s. census bureau categories. this suggests that current census options exclude significant identities and may not be accurately capturing the raceethnic composition of respondents, which has many implications for research utilizing these demographic measures. limitations one important limitation is that responses to questions about selfisolating and benefitting from the cash transfer may have been influenced by the social desirability bias, in which respondents may tend to offer answers that they believe will be viewed desirably by others rather than responses that are reflective of their true feelings or behaviors.12 this is a significant concern, given that participants may have associated interviewers with those who provided the cash transfer. to mitigate the impact of this bias, it was explained prior to each survey that participant answers would not affect eligibility for future cash transfers, and that one aim of the survey was to identify areas of improvement within the program. future studies should seek to evaluate these measures in comparison with a control group who did not receive funding. an additional limitation was the low response rate (57.1%). many individuals were unable to be contacted even after two phone calls and two home visits, which may have been influenced in part by seasonal migration for work, as this study was conducted during the off-season for tomatoes in immokalee. the authors hypothesize that this low response rate therefore introduced a bias that over-sampled people who had fewer employment opportunities. conclusions as the impact of covid-19 continues to evolve, it is essential to utilize best practices and policies to strategically address gaps in public health response. it is indisputable that the pandemic has had a disproportionate impact on vulnerable and marginalized groups, particularly racial and ethnic minorities, and has exacerbated preexisting disparities in the social determinants of health. this study revealed that offering direct cash transfers of $800-$1200 to residents of immokalee, fl who tested positive for covid-19 was effective in reducing covid-associated financial burden and demonstrated that money was most likely to be spent on living necessities rather than temptation goods. therefore, the authors conclude that cash transfers may be one effective short-term tool to strengthen community covid-19 mitigation efforts and address health disparities and inequities. references 1. orleck a. and the virus rages on: “contingent” and “essential” workers in the time of covid-19. int labor work class hist 2021;99:1-4. 2. u.s. census bureau. quickfacts. florida: immokalee cdp, 2019. 3. limaye n, ninesling b, marcelin f, et al. covid-19 pandemic response in a migrant farmworker community: excess mortality, testing access and contact tracing in immokalee, florida. ann glob health 2022;88:77. 4. partners in health. florida migrant workers among hardest hit by covid-19. partners in health, 2020. available at: https://www.pih.org/article/florida-migrant-workers-amonghardest-hit-covid-19 5. reiley, laura. migrant farmworkers, many coronavirus positive, move north from florida to other states. washington post, 2020. available from: https://www.washingtonpost.com/ business/2020/06/11/migrant-farmworkers-many-who-havetested-positive-covid-19-move-north-florida-other-farm-states/ 6. monacello v, deyoe r. covid-19 relief fund final report. [internet]. immokalee, fl: misión peniel; 30 april 2022. available from: https://www.misionpeniel.com/_files/ugd/ 17a0f5_3f62 4e76d1fd4a4580a7793f773e27ac.pdf 7. banerjee a, mullainathan s. the shape of temptation: implications for the economic lives of the poor. nber work pap ser 2010. 8. evans dk, popova a. cash transfers and temptation goods. econ dev cult change 2017;65:189-221. 9. kumar sl, calvo-friedman a, clapp j, et al. direct cash transfers for patients with covid-19 served by new york city’s safety-net health system. nejm catal innov care deliv 2021;2. 10. tabor sr. assisting the poor with cash: design and implementation of social transfer programs. world bank social protection discussion paper 2002;223:79-97. 11. braun ra, ikeda d. why cash transfers are good policy in the covid-19 pandemic. policy hub 2020;4. 12. grimm p. social desirability bias. wiley international encyclopedia of marketing. 2010. social and political factors affecting public health [page 94] [healthcare in low-resource settings 2024;12(s2):12394] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11903 analysis of human resources needs in the outpatient registration unit using the analisis beban kerja kesehatan (abk kes) method atika mima amalin, ari susanti, nuke amalia, devia rosa fauzan sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia abstract excessive workloads for medical record staff can lead to both physical and mental fatigue, while insufficient workloads may result in boredom. the outpatient registration unit at the hospital faces challenges in the registration process due to a high volume of patient registrations, leading to long queues. this study aimed to analyze the human resource needs of the medical record staff in the outpatient registration unit using the analisis beban kerja kesehatan (abk kes) method. the abk kes method involves calculating labor needs based on the workload associated with each type of task performed by staff at health service facilities, aligning with their primary duties and functions. the chosen method for this study was qualitative descriptive. data collection was conducted through observation and interviews involving five subjects, all of whom were medical record staff in the outpatient unit. the results indicate that, based on the calculations, the human resource needs in the patient registration unit should include seven people, requiring an additional two staff members. the waiting time during registration significantly influences patients’ perceptions of hospital service assessments. the addition of two staff members, in accordance with the calculated needs, is expected to enhance the productivity of the registration officers. introduction every hospital must be able to provide minimum services to improve the quality of services and facilities provided to patients.1 the purpose of medical records is to support the achievement of orderly administration of health services to improve quality and maintain hospital service standards.2 an important factor in organizing optimal medical records must be supported by adequate and competent human resources in their fields in quantity and quality so that they can provide maximum service.3 the work assigned to medical record officers will affect their performance, so officers must be highly motivated to carry out their work.4 medical record officers who are following the workload greatly affect the level of work efficiency and productivity because heavy workloads can affect performance. additionally, it can cause effects in the form of fatigue, both physically and mentally,5 while too little workload will cause boredom and monotony.6,7 workload is any form of work given to human resources and completed within a predetermined period.8 based on observations at surabaya “x” hospital, it was found that there were obstacles in the registration process in the registration unit. the obstacle is seen from the large number of patients who register, causing long queues at the registration counter. this results in services at registration taking a long time. the quality of hospital services is a determining factor for patient satisfaction and affects the image and reputation of the hospital.9 if the waiting time for registration is too long, it will affect the patient’s overall medical service time, which will then affect patient satisfaction.10 other research shows that one of the causes of long waiting times for registration is a lack of staff in the registration department.11 service waiting time is one dimension of health service quality.12 some studies state that the waiting time at registration is a maximum of 10 minutes.11,13 however, other studies found that waiting times of more than 10 minutes were almost 70%.14 therefore, good and sufficient human resource planning is needed to determine the quality of management and the success of the hospital in providing services to patients appropriately and efficiently. correspondence: ari susanti, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia. e-mail: arisusanti@stikeshangtuah-sby.ac.id key words: abk kes, labor requirements, medical records, registration, workload. contributions: ama, conceptualization, formal analysis, methodology, validation; as data curation, visualization, methodology, validation; na, methodology, formal analysis, validation; drf, writing – original draft, review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by sekolah tinggi ilmu kesehatan hang tuah surabaya indonesia ethics approval and consent to participate: this research obtained ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia, granted under ethical certificate number pe/133/iii/2023/kep/sht. patient’s consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 2 october 2023. accepted: 23 february 2024. early access: 21 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11903 doi:10.4081/hls.2024.11903 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11903] [page 443] non -co mmerc ial us e o nly a crucial aspect of effective human resource planning within the hospital’s medical records unit involves analyzing the specific human resource needs.15 currently, the workload presents a dual challenge there is a substantial amount of data that requires processing, resulting in reports being inaccurately reported and delayed. this situation impedes officers from executing their duties in alignment with their defined responsibilities and functions.16 to address these challenges, a human resource needs analysis becomes instrumental in determining the optimal number of staff required based on the workload. in the context of medical record staff in outpatient registration, the analisis beban kerja kesehatan (abk kes) method, or the health workload analysis method in english, serves as a valuable human resource tool.17 the abk kes method involves calculating labor needs according to the workload assigned to each type of labor within a health service facility, considering their primary duties and functions.16 given this, the objective of this study was to analyze the labor needs within the registration unit at hospital “x” in surabaya, utilizing the abk kes method. this analysis aimed to provide insights into optimizing human resources to enhance the efficiency and effectiveness of the registration process. materials and methods design this research was a qualitative descriptive study, focusing on events or phenomena related to human resource planning at “x” hospital. descriptive research methods were employed to identify independent variables, examining single or multiple variables without direct comparisons, and exploring relationships with other variables. study participants and data collection the research involved five subjects, all of whom were registration staff. data were collected through interviews, observations, and documentation studies. unstructured interviews with patient registration officers were conducted to understand the duration of each activity, supplemented by observational data. observations were made in real time to assess the registration process and the time allocated to each step. researchers used timers during each activity to record the time spent by registration officers, and observations were conducted during each officer’s shift. data analysis data analysis utilized the abk kes calculation method. the time required for each activity in the registration section was calculated using a formula to determine each component of the overall calculation. the resulting data illustrated the human resource needs in the registration section. ethical clearance this research obtained ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia, granted under ethical certificate number pe/133/iii/2023/kep/sht. results characteristics of respondents table 1 reveals that among the 5 respondents, 4 (80%) were female, and 1 (20%) was male. the age distribution indicates that 3 (60%) respondents fell within the 36-45 years age group, while 2 (40%) were aged between 26-35 years. furthermore, the educational background of the respondents shows that 3 (60%) have a high school education, and 2 (40%) hold a 3-year diploma. in terms of work experience, 3 (60%) respondents had 1-5 years of experience, while 2 (40%) had more than 5 years of work experience. based on table 2, it is evident that there were 195,330 (76.26%) registered patients from the outpatient unit at x hospital out of a total of 256,115 patients. calculation of human resources using the abk kes method the steps in calculating human resources using the abk kes method are as follows: i) determine health facilities and types of health human resources the type of health facility in this study is a hospital, the workforce under investigation includes medical record and health information personnel (pmik), the unit section examined is the registration unit for outpatients; ii) set available work time according to regulation of the minister for administrative reform and bureaucratic reform no. 26 of 2011, this is 1200 hours per year or 72,000 minutes per year (either working 5 days or 6 days every week); iii) define workload components and time standard. based on observations, the average time required is determined by the workload component of the medical record officer in the outpatient registration work unit, as described in table 3. firstly, we calculate the workload standard and standard of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents at “x” hospital (n=5). variable frequency (%) sex female 4 (80) male 1 (20) age 26-35 2 (40) 36-45 3 (60) qualification senior high school 3 (60) 3-year diploma 2 (40) length of work 1-5 years 3 (60) >5 years 2 (40) table 2. number of patient visits in "x" hospital in 2022. variable frequency (%) unit number of patient visits emergency room 14,626 outpatient for a registered patient 195,330 outpatient for new patient 20,381 inpatient 25,778 total 256,115 [page 444] [healthcare in low-resource settings 2024;12:11903] non -co mmerc ial us e o nly support tasks. the standard workload for main activities is calculated based on the time required to complete each activity. greater time spent on work implies a higher workload, leading to inefficiency in work time. the standard workload for each main work component is calculated by dividing the work time per year by the average time spent on each activity. to calculate the standard for supporting tasks, the value of the supporting task factor must be determined ((activity time / work time per year) x 100%). the formula for calculating the standard of supporting tasks is = (1 / (1 factor of supporting tasks / 100)). in this study, the number of supporting task factors was 0 as there were no other supporting task factors in the outpatient registration unit, resulting in a standard of supporting tasks equal to 1. secondly, we calculate health human resource needs. the final step in calculating abk kes involves determining the need for health human resources in the outpatient registration unit. the calculation of human resource needs is derived from the total number of patients per year divided by the standard workload. table 4 describes the calculation of all steps in the human resource requirements analysis. the results of the abk kes calculation indicate that 7 personnel are required in the outpatient registration unit. based on the standard calculation of human resource needs, it is necessary to add 2 officers to the existing outpatient registration counter, as the current number of officers is only 5 people. discussions the workload assigned to officers significantly influences the efficiency and productivity of their work.18,19 an excessive workload can lead to fatigue and work stress, as demonstrated by research conducted by triyadin (2021), which highlights the impact of workload on employee productivity.20 the calculation of employees or human resources using the abk kes method involves coherent steps, including determining the place and unit to be calculated, calculating available working time, establishing the time norm for each main task, determining the workload standard, calculating the supporting task factor and supporting task standard, and finally obtaining the final calculation of human resource requirements. the calculation of available working time in this study adheres to the regulations of the state personnel agency number 19 of 2011, providing general guidelines for preparing civil servant needs, and regulation of the minister for administrative reform and bureaucratic reform no. 26 of 2011, which stipulates effective working hours of 1200 hours per year or 72000 minutes per year for either 5 (five) working days or 6 (six) working days. our interviews and observations reveal that the registration unit is open from 07:00 to 12:00 for 5 working days a week. each officer works for 5 hours daily, and on average, 751 patients register at the old patient registration counter. consequently, each officer has the task of registering 150 patients in just 5 hours. our observations indicate that the officer’s workload increases not only due to the high number of registering patients but also because system downtime hampers officer productivity.21 the standard value of supporting tasks is 1 because the supporting task factor has a value of zero (0), and there are no supporting tasks for registration officers, according to our interviews. research conducted in the outpatient registration unit of “x” hospital indicates that each workload component takes an average time of less than 10 minutes. this aligns with minister of health regulation no. 129 of 2008, which sets the standard for providing medical records in outpatient services as less than 10 minutes. workload components refer to the types and descriptions of tasks carried out in practice. the average time for each task component, also known as the time norm, is necessary for an hrk to perform activities following the applicable service standards in health services.17 based on the results of the calculation of health human resources needs using the abk kes method, it is determined that medical record officers, especially in the old patient registration unit at surabaya city hospital “x,” require 7 registration officers. consequently, hospital “x” in surabaya must add 2 officers to achieve an ideal workload for each officer, ensuring performance productivity and improved quality of hospital services. proper and accurate human resource planning becomes achievable when understanding how human resources align with the needs of an effective and efficient organization.22 insufficient human resources can elevate the workload of medical record officers,23 and an transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3 define workload components and time standards. main task time (minutes) call the patient according to the queue number 0.25 check patient referrals and ask about the patient's needs 1 enter patient data according to the referral date on the computer 0.25 print participant eligibility letters 0.5 provide referral letters and eligibility letters to patients 0.5 table 4. define workload standards and human resource requirements. main task time work workload total human time/ standard patient/ resource year year requirement call the patient according to the queue number 0.25 72,000 288,000 195,330 195,330/288,000=0.6 check patient referrals and ask about the patient's needs 1 72,000 72,000 195,330 195,330/72,000=2.7 enter patient data according to the referral date on the computer 0.25 72,000 288,000 195,330 195,330/288,000=0.6 print participant eligibility letters 0.5 72,000 144,000 195,330 195,330/144,000=1.3 provide referral letters and eligibility letters to patients 0.5 72,000 144,000 195,330 195,330/144,000=1.3 human resource requirements (main task) 7 supporting duties 1 total human resource requirements (main task x supporting duties) 7x1=7 [healthcare in low-resource settings 2024;12:11903] [page 445] non -co mmerc ial us e o nly increase in patient visits can contribute to a heightened workload and reduced work productivity.24 balancing human resources in the medical records unit is pivotal for enhancing service quality at “x” hospital. the current shortage of staff in the medical records unit can intensify the workload of medical records staff, potentially causing service disruptions for patients.25 human resource planning with abk kes is anticipated to organize positions and tasks within the medical records work unit at “x” hospital, aligning with their main duties and functions.14,26 a well-qualified workforce significantly influences the quality of service in the medical records work unit. qualified medical record personnel and their competencies are vital in health services for delivering quality medical records.27 the number of workers and workload must be appropriately balanced to ensure quality service.28 a shortage of human resources in “x” hospital could increase the workload of officers. conversely, an excess of human resources may lead to inefficiency in the workload of medical record officers and reduced work productivity. therefore, well-organized human resource planning is essential to match the quality of hospital services.26 conclusions after analyzing human resource needs at “x” hospital using the abk kes method, it’s concluded that adding 2 medical record officers is necessary for optimal functioning of the outpatient registration unit. this integration is expected to create a well-balanced medical records workforce, enhancing service quality. the recommendation for more officers is based on the understanding that strategically expanding the workforce can ease workload pressures and streamline processes. this aligns with the goal of improving overall service quality. additionally, for future research, a comparative study between the abk kes method and alternative approaches for calculating human resource needs is suggested. this analysis aims to provide insights into the accuracy and efficacy of different methods in determining staffing requirements, contributing valuable knowledge to refine human resource planning in healthcare settings. references 1. kurniati a, rosskam e, efendi f. hospital nurses’ perceptions of distributive justice under the national health insurance scheme in indonesia. collegian 2021;28:506-14. 2. sanggamele c, kolibu fk, maramis frr. analisis pengelolaan rekam medis di rumah sakit umum pancaran kasih manado. kesmas j kesehat masy univ sam ratulangi 2018;7:1-11. 3. prasetyo s, yasin m, apriantika i, et al. overview of knowledge, attitude, and motivation level of dental practitioner in filling electronic medical records. syst rev pharm 2020;11:954-9. 4. trisna wv. hubungan motivasi ekstrinsik kinerja petugas kesehatan terhadap ketidak lengkapan pengisian berkas rekam medis rawat jalan di rsud petala bumi provinsi riau tahun 2018. menara ilmu 2019;13:175-83. 5. dewi ys, hargono r, rusdi a. factors correlated to job stress among icu nurses. j ners 2019;14:23-7. 6. paskarini i, dwiyanti e, syaiful da, syanindita d. burnout among nurses: examining psychosocial work environment causes. j public health res 2023;12. 7. purnawati y, martiana t, hargono r, rahman fs. the analysis of workload and safety communication against burnout syndrome in inpatient nurses. indian j forensic med toxicol 2020;14:2244-8. 8. tuti sulastri, hilda, arsyawina. relationship between nurse motivation and workload with completeness of nursing care documentation. indones j interdiscip res sci technol 2023;1:137-50. 9. yani rwe, khoiri a, bramantoro t. patient’s satisfaction in utilizing public health center services during the covid-19 pandemic based on gender, age, education level, and occupation. asia pacific j heal manag 2022;17. 10. dewi s, machmud r, lestari y. analisis waktu tunggu rawat jalan di rumah sakit umum daerah dr achmad darwis suliki tahun 2019. j kesehat andalas 2020;8:175-84. 11. milaenia fitri h, hidayati m. pengaruh lama waktu tunggu pendaftaran terhadap kepuasan pasien di puskesmas waringinkurung. cerdika j ilm indones 2021;1:1789-95. 12. laeliyah n, subekti h. waktu tunggu pelayanan rawat jalan dengan kepuasan pasien terhadap pelayanan di rawat jalan rsud kabupaten indramayu. j kesehat vokasional 2017;1:102-12. 13. septiani as, wigati pa, fatmasari ey. gambaran sistem antrian pasien dalam optimasi pelayanan di loket pendaftaran instalasi rawat jalan rumah sakit umum pusat fatmawati. j kesehat masy 2017;5:1-14. 14. rofi’i m, jarihatunningsih s. jangka waktu yang diperlukan pasien untuk pelayanan di bagian rawat jalan pada rumah sakit pemerintah di semarang. j manaj keperawatan 2014;2:109-15. 15. fadila r. analisis kebutuhan sumber daya manusia rekam medis di unit filing. j rekam medis dan inf kesehat 2019;2:48-52. 16. noor hl, qomariyah sn, nugraheni sw. analisis kebutuhan tenaga kerja bagian pelaporan rumah sakit menggunakan metode analisis beban kerja kesehatan (abk kes). infokes j ilm rekam medis dan inform kesehat 2023;13:35-9. 17. nisaa a. analisis perencanaan sdm kesehatan berdasarakan metode abk kes unit rekam medis rawat jalan di uptd puskesmas jatiroto wonogiri: analisis perencanaan sdm kesehatan berdasarakan metode abk kes unit rekam medis rawat jalan di uptd puskesmas jatiroto wonogir. indones j heal inf manag 2022;2. 18. yuliani sd, widajati n. correlation subjective workload with productivity of spinning workers in pt. delta merlin sandang tekstil i sragen. malaysian j med heal sci 2021;17:31-5. 19. nursalam n, fardiana a, asmoro cp, et al. the correlation between the quality of nursing work life and job performance. indian j public heal res dev 2018;9:330-5. 20. triyadin a, yusuf m. pengaruh beban kerja terhadap produktifitas kerja pegawai pada ulp rayon woha. in: forum ekonomi, 2021. p. 102-7. 21. sugiyatmi ta, hadi u, chalidyanto d, et al. does the implementation of national health insurance affect the workload of a doctor and have an impact on service quality? a systematic literature review. j public health africa 2019;10:101-5. 22. hasibuan msp. manajemen sumber daya manusia. jakarta, indonesia: bumi aksara; 2008. 23. cahyaningrum n, noor hl, dewati rah. tinjauan beban kerja dan kebutuhan sumber daya manusia unit rekam medis berdasarkan metode wisn di rsui banyu bening transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 446] [healthcare in low-resource settings 2024;12:11903] non -co mmerc ial us e o nly boyolali tahun 2018. infokes j ilm rekam medis dan inform kesehat 2018;8:40-54. 24. alfianto l, zakiyah e. analisa perkiraan jumlah sdm rekam medik di unit filing dengan metode wisn (woarl load indicator staff need) di rsud kabupaten wonogiri tahun 2014 [analysis of estimated amount of human resources in the medical record filing with wisn method woarl load i]. indones j med sci 2015;2:69-73. 25. utomo mt, sampurna mta, melisa m, et al. nurse workload, missed nursing care, and the contributing factors in the neonatal intensive care unit in a limited resource setting: a case from indonesia. f1000research 2022;11. 26. nazhifah n, alia yustika i, hidayati m. analisis kebutuhan sdm petugas rekam medis dengan menggunakan metode analisis beban kerja kesehatan (abk-kes). cerdika j ilm indones 2021;1:1021-8. 27. faida ew, supriyanto s, haksama s, et al. a cross sectional study on physicians’ perceived usefulness and ease of use electronic medical records. j pharm negat results 2022;13:6574-80. 28. fadly f, ulhaq d. design of application for calculating human resources for medical record technician with abkkes using the excel macro. j mantik 2022;5:2524–30. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11903] [page 447] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11838 the influence of parenting classes on maternal self-efficacy in caring for the baby elin supliyani, ina handayani, suhartika suhartika, dedes fitria bogor midwifery study program, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract preparing for childbirth is crucial because it was a demanding and exhausting experience for unprepared mothers. confidence in caring for the baby was one of the important indicators of success as a parent. this study aimed to examine the influence of parenting classes on maternal self-efficacy in caring for the baby. the study used a quasi-experimental pre-test and post-test nonequivalent control group design method. the research was conducted at several midwife clinical practices in bogor city. the sample consisted of 42 pregnant women, with 21 in the intervention group and 21 in the control group. sampling used non-probability sampling with a purposive sampling technique. the perceived maternal parenting self-efficacy (pmp-se) questionnaire with a likert scale was used to measure the mother’s self-efficacy variable in caring for the baby before and after attending the parenting class. the data were analyzed using the wilcoxon test. the results showed that the mean self-efficacy of mothers in caring for their babies before the intervention was 42.57 (8.577), and after attending the parenting class, it increased to 47.71 (8.344). there was a significant influence of parenting class on mothering self-efficacy in caring for the baby (p=0.015). it is recommended that this model of parenting classes be applied in healthcare settings to educate pregnant women on readiness to become parents, thereby increasing mothers’ confidence and ability to take care of their babies after childbirth. introduction pregnancy is a physiological condition that corresponds to the stages of individual development.1 giving birth is an exceptional gift for women and a joyous moment. mothers play a crucial role in caring for their babies, from providing nourishment to fulfilling their emotional and psychological needs.2,3 according to murtie in 2013, newborn babies cannot express their needs, which makes it essential for mothers to be more sensitive and attentive to their babies.4 the success of children’s growth and development is influenced by environmental factors, ranging from the family environment to the community.5 caring for a newborn can be challenging for first-time mothers due to a lack of experience and knowledge.6 having a first child is challenging for new parents; it brings a mix of emotions and added responsibilities. proper preparation is critical to help parents cope. lack of knowledge can cause frustration and exhaustion for new mothers.7 maternal self-efficacy is the belief that a mother can care for her baby well.8 low maternal self-efficacy can lead to self-blame.9 mental health disorders in pregnant/breastfeeding women are common problems experienced by women globally. the disorders are generally in the form of depression and anxiety related to pregnancy and birth. the depression includes depression before birth (antenatal depression) and after birth (postnatal or postpartum depression).10 antenatal training is essential to prepare mothers for the postpartum period.11 misinformation and irrational customs can confuse first-time mothers. preparation during pregnancy is crucial.7 antenatal care (anc) is a set of measures aimed at optimizing the mental and physical health of pregnant women so that they are able to cope with childbirth, postpartum, breastfeeding preparacorrespondence: elin supliyani, bogor midwifery study program, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: elin@staff.poltekkesbandung.ac.id key words: caring for the baby; parenting class; self-efficacy. contributions: es conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ih methodology, formal analysis, validation,visualization, writing – review and editing; ss conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; df writing – original draft, review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, poltekkes kemenkes bandung, based on ethical certificate 02/kepk/ec/sim/x/2020. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors would like to express their gratitude to the ministry of health, bandung health polytechnic for approving and financing this research. received: 18 september 2023. accepted: 22 december 2023. early access: 16 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11838 doi:10.4081/hls.2024.11838 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 222] [healthcare in low-resource settings 2024;12:11838] non -co mmerc ial us e o nly tion, and the reasonable restoration of reproductive health.12 postpartum depression is a phenomenon that occurs in the first postpartum days.13 only a small number of epidemiologic studies on maternal mental health have been conducted, including one in surabaya that found the prevalence of perinatal depression was 22% based on a cut-off point > 10 of the edinburgh postnatal depression scale (epds), far higher than the reported global prevalence of 12%.14 postnatal depression or postpartum depression (ppd) is classified as a psychiatric illness that affects women in the postnatal period.15 new mothers may experience negative emotions, such as sadness, irritability, and fatigue, which can make it challenging for them to care for their newborns. research by suryati in 2007 found that many new mothers lacked knowledge about postpartum and newborn care. 41.7% of mothers avoid eating meat and seafood to prevent breast milk from smelling fishy. almost all mothers drink herbal medicine, and 83.3% do body massages to regain their fitness. other standard care practices include wrapping babies in a batik cloth to keep them warm and calm. the study also found that 1.7% of mothers had intercourse during the puerperium.16 rahayuningsih in 2015 found that 80% of postpartum mothers fear holding their babies and lack confidence in their ability to care for them. as a result, 70% leave their newborns to their parents or in-laws. most (80%) feel neglected by their partners and find visits from neighbors (40%) unhelpful. additionally, 60% of mothers feel dependent on others due to restrictions imposed by their husbands about not getting groceries during the puerperium.7 postpartum mothers need support to cope with changes, adapt, and build confidence.17 maternal self-efficacy is crucial for raising a child. high self-efficacy leads to better responses to a baby’s needs, improving the mother-child relationship. to boost parenting confidence, pregnant women can attend parenting classes, which help parents understand the different stages of parenthood so they can adjust accordingly.18 mothers need confidence to care for their babies without feeling pressured. parenting classes can help increase self-confidence by improving mothers’ knowledge, attitudes, and skills. this makes them more prepared and patient in caring for their baby. these classes provide information on infant care, exclusive breastfeeding, umbilical cord care, nutrition, immunizations, and recommended follow-up visits. educating parents about newborn care during pregnancy will form a deep bond between mother and baby. based on this, this research was conducted to assess the influence of parenting classes on mothers’ selfefficacy in caring for the baby. materials and methods research design this study employs the quasi-experimental method and utilizes a “nonequivalent control group design” research design to evaluate the effectiveness of parenting classes on mothers’ self-efficacy in caring for their babies. the study involves an experimental and control group, both of which underwent a pre-test before the treatment. the experimental group received treatment through an online parenting class, while the control group received the usual standard baby care. the study concluded with a final test (posttest) administered to both groups to assess the mother’s self-efficacy in caring for her baby. study participants the research was conducted at several midwife clinical practices in bogor city. the samples in this study included pregnant women in the third trimester who met the inclusion criteria and did not meet the exclusion criteria. the inclusion criteria were as follows: primigravida, term gestational age, healthy mothers and babies without complications in pregnancy, willing to be respondents by joining the whatsapp (wa) group and attending meetings via zoom, mothers who can communicate effectively and can read and write, and mothers who can use the zoom application. meanwhile, the exclusion criteria included mot. hers or babies who experienced complications in pregnancy. the sampling technique used in this research was the non-probability sampling technique, specifically the purposive sampling method. the research sample size formula for hypothesis testing difference in means for 2 paired groups determined a minimum sample size of 21 in the intervention group and 21 in the control group. the limitation of using the purposive sampling technique in this study makes it challenging to generalize the results to all pregnant women because the selection of respondents was based on specific criteria set by the researchers. variable, instrument and data collection the study focuses on the parenting class model as an independent variable, providing education to expectant mothers on preparing for parenthood and caring for their newborns. the dependent variable measured is the mother’s self-efficacy in mothering. this refers to the mother’s belief in her ability to fulfill her role as a parent in caring for the baby, including breastfeeding, monitoring the baby’s needs, massaging the baby, and stimulating the baby’s development. the study utilized pre-test and post-test instruments to measure the variables before and after the online parenting class treatment. the parenting classes were conducted online through zoom meetings and were held three times, starting from the third trimester of pregnancy. the study employed the perceived maternal parenting self-efficacy (pmpse) questionnaire, consisting of 20 questions, to measure the mother’s self-efficacy in caring for the baby. the questionnaire used a likert scale ranging from strongly disagree (1), disagree (2), agree (3), to strongly agree (4), with scores ranging from 20 to 80. a score of 20-40 indicates low self-efficacy, 41-59 indicates sufficient self-efficacy, and 60-80 indicates high self-efficacy. data analysis before data analysis, a normality test was carried out using the shapiro-wilk test to determine whether the data was normally distributed. the results showed that the distribution of data on differences in mothering self-efficacy in caring for babies before and after the intervention was not normally distributed (p=0.04), so the statistics used to measure the difference in self-efficacy in caring for a baby before and after attending a parenting class is non-parametric statistics which was the wilcoxon test. ethical clearance the research has received ethical approval from the health research ethics committee, ministry of health, bandung health polytechnic, based on ethical certificate 02/kepk/ ec/sim/x/2020. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. informed consent was obtained from all subjects involved in the study. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11838] [page 223] non -co mmerc ial us e o nly results the research was conducted via a whatsapp group, and parenting class material was provided through zoom meetings. the parenting classes were divided into three online courses, with 7-8 participants per class. each class received material over three meetings. the total number of respondents who participated in this research activity was 42 pregnant women, consisting of 21 people in the intervention group and 21 in the control group. the results obtained in carrying out this research are as follows: table 1 explain about the respondent characteristics. the age distribution in the intervention group consists entirely of individuals aged 20 to 35 years, comprising 21 individuals, which represents 100% of the group within this age range. strikingly, there are no participants in the intervention group who are older than 35 years. in contrast, the control group has a majority (95.2%) in the 20-35 years age range, with a small representation (4.8%) of individuals aged over 35 years. based on the education level, all individuals in the intervention group (100%) have a higher education level. in the control group, the majority (85.7%) also have a higher education level, while a smaller fraction (14.3%) holds a lower education level. lastly, the table explores the occupational distribution. in the intervention group, there is a balanced representation, with 52.4% identified as housewives and 47.6% as employed individuals. in contrast, the entire control group (100%) comprises employed individuals, without any housewives. table 2 explain about the self-efficacy in caring for the baby before and after parenting classes. before the intervention, the intervention group had a lower self-efficacy score (42.57) compared to the control group (46.67). after the intervention, the intervention group improved significantly, with a higher self-efficacy mean score (47.71), while the control group showed a more modest increase (46.76). to boost confidence in these findings, a 95% confidence interval was used, providing a range within which we can be reasonably sure the true mean lies. median values, representing the middle point of scores, offered an additional perspective on each group’s self-efficacy. standard deviations indicated how much individual scores varied from the mean, giving insights into consistency within each group. in summary, the data suggests the intervention positively impacted selfefficacy, seen in the notable increase in mean scores for the intervention group from before to after the intervention. based on the data processing results in table 3, a significant difference in the mean mothering self-efficacy in caring for babies exists before and after attending parenting classes, with a p-value of 0.015. this indicates that there is an influence of self-efficacy in caring for babies after attending parenting classes. table 4 shows a statistically significant difference in mothering self-efficacy between the group that participated in the parenting class and the control group (p=0.039). discussion based on the study results, all respondents are primigravida or were pregnant with their first child. the birth of the first child represents a new experience for both the wife and husband. parents, especially wives who may feel anxious, afraid, and happy, find themselves confused. the birth of the long-awaited first child is a mix of joy and love, often accompanied by the heavy demands of work, confusion about changing roles, and the transition into parenthood. the first child’s birth poses challenges, necessitating preparation to help parents cope with various situations. childcare responsibilities and a lack of knowledge and preparation can be sources of frustration and fatigue for new mothers.7,19 the analysis revealed a significant difference (p<0.05) in mothering self-efficacy preand post-parenting classes, indicating a positive influence on self-efficacy in caring for the baby. these findings align with other research, which demonstrated that mothers who received counselling during parenting classes had higher self-efficacy scores than those who only received booklets.2 parenting classes prepare pregnant women emotionally and psychologically to navigate pregnancy, childbirth, and parenting. this preparation enhances their confidence in assuming the role of parents later on.20,21 the parenting class conducted in this study transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of participants in each group. indicator group intervention control n (%) n (%) age 20-35 years 21 100 20 95.2 >35 years 0 0 1 4.8 education level higher education 21 100 18 85.7 low education 0 0 3 14.3 occupation housewive 11 52.4 21 100 employed 10 47.6 0 0 table 2. self-efficacy in caring for the baby before and after parenting classes. variable intervention control n=21 mean ci 95% median mean (sd) (min-max) (sd) self-efficacy pre 42.57(8.577) 38.67-46.48 42(26-60) 46.67(8.046) post 47.71(8.344) 43.92-51.51 45(39-60) 46.76(7.937) table 3. effect of parenting class on mothering self-efficacy in caring for the baby. self efficacy median mean p* (mini-max) (sd) intervention pre 42(26-60) 42.57(8.577) 0.015 post 45(39-60) 47.71(8.344) control pre 47(24-58) 46.67(8.046) 0.875 post 48(29-59) 46.76(7.937) *p, wilcoxon-test. table 4. effect of parenting class on mothering self-efficacy. variable median mean p* n=21 (mini-max) (sd) mothering self efficacy intervention 45 (39-60) 47.71 (8.344) 0.039* control 48 (29-59) 46.76 (7.937) *p, mann whitney-test. [page 224] [healthcare in low-resource settings 2024;12:11838] non -co mmerc ial us e o nly took place online through a zoom meeting and covered various topics closely related to parenthood readiness. pregnant women received education and guidance on preparation for breastfeeding, daily baby care, and monitoring child development. the class also covered stimulation and games suitable for children between 0-12 months of age. prenatal classes help prepare parents for caring for the baby. these classes provide health education and boost parents’ knowledge, skills, and confidence. self-efficacy, or the belief in their ability to manage tasks related to baby care, is a crucial aspect addressed in these classes.22 parental self-efficacy is the belief in one’s ability to succeed in various parenting tasks, such as breastfeeding, carrying, bathing, playing, and navigating challenging periods. mothers with high self-efficacy are more resilient when facing complex tasks, even after experiencing failure.22 they take responsibility for their babies’ needs, provide quality care, adapt to changes, accept their children’s needs, and cope with difficulties. they also have lower depression levels and better social support satisfaction. on the other hand, parents with low self-efficacy may reject their babies, perceive their baby’s condition as worse than it is, experience high stress, and struggle to interact with their infants, causing depression and frustration.18 self-efficacy is also linked to responsiveness, which pertains to positive parental behaviours and sensitivity to infants.23 parenting classes educate parents-to-be on reproduction, fetal development, self-care during and after pregnancy, stress management, and health care.7 parents need confidence to successfully care for healthy and complex-need infants.24 however, increasing maternal self-efficacy can also be influenced by support. good family support positively affects their self-efficacy in their ability to handle the challenges of motherhood.25 the level of social support during pregnancy predicts maternal self-efficacy.26 this research was conducted in online parenting classes, providing education through whatsapp groups and face-to-face sessions via zoom meetings. the parenting classes were divided into three small groups, each comprising 7-8 participants. material was presented over three meetings in each class. the division into smaller groups aimed to facilitate participants’ comprehension of the material and encourage more in-depth discussions, thereby enhancing their understanding and skills to further increase selfefficacy. study limitations the limitations of this research include a lack of analysis of other factors, such as family support, which can influence self-efficacy in caring for a baby. additionally, the study did not evaluate the mothers’ psychological state and their success in caring for a baby. the observed increase in self-efficacy may be attributed not only to taking parenting classes but also to excellent family support. furthermore, the study did not assess the mothers’ psychological state after recognizing their self-efficacy and success in raising their child. therefore, further research is necessary to analyze family support factors and assess the mothers’ psychological state, as these factors can significantly influence the success of caring for their baby. conclusions mothers’ self-efficacy in caring for the baby increased after attending parenting classes. the mothers’ self-efficacy in caring for the baby was better than before taking the parenting class. parenting classes positively influence mothers’ self-efficacy in caring for the baby. this parenting class model can be applied in healthcare settings, including midwives and community health centers, to educate pregnant women, especially regarding readiness to become parents, thereby increasing maternal self-confidence and the ability to care for the baby after birth. references 1. indriyani d, yunitasari e, efendi f, et al. the analysis of maternal characteristics and regulation of antenatal care on pregnancy risk status based on the independent family health evaluation. asia pacific j heal manag 2023;18:1–10. 2. astutiningrum d, hapsari eld, purwanta p. peningkatan parenting self efficacy pada ibu pasca seksio sesaria melalui konseling. j ners 2016;11:134–41. 3. leahy-warren p, mccarthy g. maternal parental selfefficacy in the postpartum period. midwifery 2011;27:802–10. 4. murtie a. mengajari anak calistung sejak dini dengan bermain: panduan praktis untuk orang tua. jakarta. gramedia pustaka utama; 2013. 1–160 p. 5. dewi rk, sumarni s. parenting style and family empowerment for children’s growth and development: a systematic review. j public health africa 2023;14:2582. 6. wijayarini ma, anugerah pi, bobak im, jensen md, lowdermilk dl. buku ajar keperawatan maternitas edisi 4. jakarta: egc; 2005. 95–99 p. 7. rahayuningsih f, hakimi m, haryanti f, rahma n. pengaruh pelatihan persiapan masa nifas, pengetahuan, dukungan sosial dan efikasi diri ibu nifas terhadap kualitas hidup ibu nifas. 2015. 8. zimmermann bj, cleary tj. adolescents’ development of personal agency. self-efficacy beliefs adolesc 2006;45–69. 9. márk-ribiczey n, miklósi m, szabó m. maternal selfefficacy and role satisfaction: the mediating effect of cognitive emotion regulation. j child fam stud 2016;25:189–97. 10. surjaningrum er, leonardi t, andriani f, set al. delphi study to develop maternal depression training materials for cadres. int j public heal sci 2023;12:598–605. 11. istifa mn, efendi f, wahyuni ed, et al. analysis of antenatal care, intranatal care and postnatal care utilization: findings from the 2017 indonesian demographic and health survey. plos one 2021;16. 12. alburuda f, damayanti na. relationship of family support to antenatal care (anc) inspection in work area of puskesmas gunung anyar surabaya. indian j public heal res dev 2019;10:1426–9. 13. solikhah fk, nursalam n, subekti i, et al. determination of factors affecting post-partum depression in primary healthcare during the covid-19 pandemic. j public health africa 2022;13:2408. 14. surjaningrum er, minas h, jorm af, kakuma r. the feasibility of a role for community health workers in integrated mental health care for perinatal depression: a qualitative study from surabaya, indonesia. int j ment health syst 2018;12:1–17. 15. edwards gd, shinfuku n, gittelman m, et al. postnatal depression in surabaya, indonesia. int j ment health 2006;35:62–74. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11838] [page 225] non -co mmerc ial us e o nly 16. rahayuningsih fb. hubungan pelatihan persiapan masa nifas dengan efikasi diri ibu nifas di kabupaten sragen jawa tengah. pros semin nas int 2014;2(2). 17. martina i. pengaruh maternal self efficacy terhadap kesejahteraan psikologis ibu nifas pasca persalinan sectio caesaria yang di moderatori oleh kepuasan pernikahan | inu martina academia.edu. 2018. 18. indrayati n, santoso dya. kesiapan orangtua dalam merawat bayi berat lahir rendah melalui edukasi perawatan bblr. j ilmu keperawatan jiwa 2020;3:549–56. 19. pramudianti dc, raden a, suryaningsih ek. hubungan tingkat pendidikan formal dengan parenting self-efficacy periode awal nifas pada ibu pasca sectio caesarea. j kebidanan dan keperawatan aisyiyah 2018;13:34–41. 20. gonzales am. marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines artemio morado gonzales jr study design. j ners 2020;15:7–13. 21. widiantari nkn, suariyani nlp, karmaya inm. hubungan karakteristik sosio demografi dan dukungan sosial suami dengan partisipasi ibu mengikuti kelas ibu hamil. public heal prev med arch 2016;4:54–9. 22. wittkowski a, garrett c, calam r, weisberg d. self-report measures of parental self-efficacy: a systematic review of the current literature. j child fam stud 2017;26:2960–78. 23. mihelic m, morawska a, filus a. preparing parents for parenthood: protocol for a randomized controlled trial of a preventative parenting intervention for expectant parents. bmc pregnancy childbirth 2018;18:311. 24. vance aj, brandon dh. delineating among parenting confidence, parenting self-efficacy, and competence. ans adv nurs sci 2017;40:e18–37. 25. iwanowicz-palus g, zarajczyk m, bień a, et al. the relationship between social support, self-efficacy and characteristics of women with diabetes during pregnancy. int j environ res public health 2021;19:304. 26. samdan g, reinelt t, kiel n, et al. maternal self-efficacy development from pregnancy to 3 months after birth. infant ment health j 2022;43:864–77. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 226] [healthcare in low-resource settings 2024;12:11838] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11911 room sterilization using ultra violet lamps in reducing the air germs number of tuberculosis patients’ house wanti wanti,1,2 siprianus singga,2 agustina agustina,2 irfan irfan2 1center of excellent, kupang ministry of health health polytechnic, kupang, east nusa tenggara; 2kupang ministry of health health polytechnic, kupang, east nusa tenggara, indonesia abstract mycobacterium tuberculosis can survive in the air, with its ability depending on environmental factors such as ultraviolet (uv) light. uv light can be generated from sunlight or uv-c lamps, which are utilized for air germ sterilization. this study aimed to assess the efficacy of room sterilization using a uv lamp in reducing airborne germ counts. this experimental research took place from march to september 2023 and employed a one-group pretest-posttest design. the research was carried out in 21 houses of tuberculosis patients in kupang city. the intervention involved the use of 16-watt and 20-watt uv lamps in two rooms of each house. the variable measured was the airborne germ count, assessed by examining the most probable number (mpn) coliforms, both before and after sterilization (uv light irradiation), calculated through laboratory examination. the collected germ count data were then statistically analyzed using the paired t-test. room sterilization using a 16w uv lamp effectively reduced the number of room germs (p 0.046<0.05). similarly, room sterilization with a 20w lamp significantly reduced the number of room germs in the households of tuberculosis patients (p 0.004<0.005). ultraviolet lamps can be employed for sterilizing rooms in the homes of tuberculosis patients, particularly in cases where sunlight cannot penetrate the house. these lamps can eliminate airborne germs, thereby reducing their count and the risk of disease transmission within the household. introduction tuberculosis (tb) is an infectious disease caused by the bacterium mycobacterium tuberculosis, which enters the body through the respiratory tract.1 tuberculosis remains a global public health issue, both worldwide and in indonesia.2 globally, approximately 10 million people were affected by the disease, resulting in 1.4 million deaths in 2019, while morbidity rates reached 9.6 million and mortality rates were estimated at 1.4 million in 2021, with the potential for annual increases. india, indonesia, china, the philippines, pakistan, nigeria, bangladesh, and south africa collectively account for two-thirds of tb cases worldwide, and they are all classified as lower-middle-income countries.3–5 in indonesia, tb cases have reached 1,000,000, with a persistently high number of annual deaths.6 in kupang city itself, the number of pulmonary tb cases for 2018, 2019, and 2020 were 670 cases, 667 cases, and 522 cases, respectively.7 several factors contribute to tb transmission within communities, involving tb germs, individual factors, and environmental conditions.8,9 the conditions of houses, including factors like humidity, temperature, lighting, ventilation, housing density, and the number of house floors, are also associated with the incidence of tb transmission, serving as determining factors in the presence of tb germs within people’s homes.10–13 behavior has also been demonstrated to be linked to the incidence of tb transmission within the community.14,15 wearing a mask or covering your mouth/nose when coughing/sneezing, as well as washing your hands with soap and running water, can be employed as measures to prevent the incidence correspondence: wanti wanti, center of excellent, kupang ministry of health health polytechnic, kupang, east nusa tenggara, indonesia. e-mail: trivena78@yahoo.com key word: air germ number; tuberculosis; ultra violet lamps. contributions: ww, conceptualization, data collection, analysis data, writing of publication; sp, conceptualization, methodology, preparing for enumerator; aa, data collection, analysis data, research report; ii, methodology, data collection, preparing for the enumerator. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research received ethical approval from poltekkes kemenkes kupang with number lb.02.03/1/0008/2022, dated march 4, 2022. throughout the research, the researcher paid careful attention to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: the patient signed the form that they were required to fill out as proof that they are aware of and knowledgeable about the data collected by the researcher. availability of data and material: all data generated or analyzed during this study are included in this published article. funding: this research was supported by health polytechnic kupang, ministry of health, with the contract number bj.01.03/2/1340/2023. acknowledgments: we would like to express our gratitude to health polytechnic kupang, ministry of health, for their valuable insights and funding contribution to this study, as well as to the health office of kupang city for their support in the research implementation. received: 3 october 2023. accepted: 17 november 2023. early access: 7 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11911 doi:10.4081/hls.2023.11911 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11911] [page 59] non -co mmerc ial us e o nly and transmission of tb.6 case detection and consistent, comprehensive treatment must be pursued to break the chain of tb transmission. implementing clean and healthy living habits, enhancing community nutrition, and administering the bcg vaccine are also necessary to bolster the body’s resistance to tb transmission. environmental factors significantly influence the presence of tb germs.9,11 this is also the case in kupang city, where ventilation conditions are associated with the incidence of tuberculosis, with an odds ratio (or) value of 16.3. this implies that a house with inadequate ventilation increases the risk of its occupants getting infected with tuberculosis by 16.3 times compared to the occupants of well-ventilated houses. similarly, residents of houses with insufficient lighting face a 4.5 times higher risk of contracting tuberculosis than residents of well-lit houses.13 therefore, it is necessary to intervene against environmental risk factors to reduce the risk of tb transmission in the community, particularly to family members in the patient’s house.9 this data can be used to assess the effectiveness of uv lamps in sterilizing rooms in the homes of tb patients, reducing the number of airborne germs and lowering the risk of tb transmission. this study aims to determine the effectiveness of room sterilization using ultraviolet lamps in reducing the number of airborne germs in the homes of tuberculosis patients in kupang city. materials and methods this research follows a quasi-experimental design with a onegroup pretest-posttest design. it was conducted in kupang city, with the target population comprising all tb patients in the city. the research sampled 21 houses of tb patients, with one sample from each house taken before and after the intervention involving irradiation using 16w and 20w uv lamps. the variable measured is the number of airborne germs, assessed by examining mpn coliforms before and after sterilization, calculated based on laboratory examinations. according to the decree of the minister of health of the republic of indonesia no. 1077/menkes/per/v/2011, the acceptable standard value for indoor air germ numbers is <700 cfu/m³.16 all primary data were collected directly through measurements and experiments in the homes of tb patients. determining 21 tuberculosis patients’s homes where intervention would be carried out in the form of uv lamp sterilization; determining two rooms frequently used for activities by tuberculosis sufferers with different areas in each house; designing an ultraviolet sterilizer using uv lamp power (16 w and 20 w); measuring air germ numbers before sterilization in selected homes using microbial air samplers; carry out sterilization with varying lengths of time: 60 minutes for two rooms for each 16w and 20w; measuring the air germ count after sterilization using microbial air samplers; test the difference in germ numbers before and after sterilization using a uv lamp; and create a final research report. to prevent the negative impact of using uv lamps when installing them in each room, it is important to wear protective glasses, or use a long cable from each uv lamp and plug it outside the room. there must be no people, animals or plants in the room while sterilization is being carried out in the room. data from the survey of tb patients’ homes were statistically analyzed using a paired t-test to determine the effectiveness of reducing the number of airborne germs after intervention with different types of lights. the research has obtained ethical approval from poltekkes kemenkes kupang, with number lb.02.03/1/0008/2022, dated march 4, 2022. throughout the research, the researcher adheres to ethical principles related to informed consent, respect for human rights, beneficence, and nonmaleficence. results this research was conducted in 21 homes of tuberculosis sufferers by measuring the number of airborne germs in bedrooms and other rooms often used for family gatherings. the germ counts were assessed before and after the room sterilization intervention using an ultraviolet (uv) lamp. the lamps used were of 16w and 20w. table 1 indicates that the average number of germs before room sterilization using a 16w ultraviolet lamp was 206.19 cfu/m3, while after the intervention, it decreased to 129.81 cfu/m3. the results of the normality test showed that the germ numbers before and after the intervention using a 16w uv lamp did not follow a normal distribution, so the bivariate test employed the non-parametric wilcoxon test. table 2 indicates that the average number of germs before room sterilization using a 20w ultraviolet lamp was 273.90 cfu/m3, while after the intervention, it decreased to 134.76 cfu/m3. the results of the normality test showed that the germ numbers before and after the intervention using a 20w uv lamp did not follow a normal distribution. therefore, the non-parametric wilcoxon test was used in the bivariate test to assess the difference in room germ numbers before and after sterilization. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 60] [healthcare in low-resource settings 2024;12:11911] table 1. room air germ numbers before and after sterilization using a 16w uv lamp in houses of tuberculosis patients in kupang city. intervention mean min-max sd n median uji shapiro-wilk (p) pre 16watt 206.19 15-525 159.42 21 130.00 0.049 post 16watt 129.81 5-508 161.74 21 68.00 0.000 table 2. room air germ numbers before and after sterilization using a 20w uv lamp in houses of tuberculosis patients in kupang city. intervention mean min-max sd n median uji shapiro-wilk (p) pre 20watt 273.90 45-690 144.60 21 293.00 0.609 post 20watt 134.76 10-370 114.69 21 93.00 0.007 non -co mmerc ial us e o nly table 3 reveals that after the intervention involving room sterilization using 16w lamps, 17 rooms exhibited a decrease in the number of air germs, while in 4 other rooms, there was an increase in the number of air germs. statistically, this remains significant with a p-value of 0.046 or p<0.05, signifying that room sterilization using a 16w uv lamp effectively reduces the number of room germs. furthermore, table 3 demonstrates that room sterilization using 20w lamps reduced the number of room germs in the houses of tuberculosis sufferers in 19 houses. conversely, in 2 houses, there was an increase in the number of germs. according to nonparametric tests, sterilizing the room using a 20w uv lamp is statistically effective in reducing the number of room germs (p=0.004<0.05). discussion tuberculosis remains a significant global health concern, affecting not only the world but also indonesia and east nusa tenggara (ntt) province. it is one of the infectious diseases that pose a public health challenge. pulmonary tb results from the clinical manifestations of bacterial infections caused by mycobacterium tuberculosis. mycobacterium tuberculosis (mtb) is a metabolically versatile bacterium with the ability to switch to alternative pathways when exposed to drugs or stresses, enabling its survival and long dormancy periods. this disease is easily transmitted through the air via the splashes of saliva or phlegm from patients who are tb-positive and carry the bacteria tb.17–19 the environment plays a substantial role in the spread of tuberculosis, categorizing this disease as environmentally based. it is essential for the public to have a better understanding of the methods of transmission and prevention of tuberculosis (tb).20 this understanding could potentially contribute to reducing the number of tb cases and preventing an increase in its prevalence. this research aims to measure the general count of airborne germs, evaluating whether they adhere to the stipulated standards, specifically if they fall below the standard value (<700 cfu/m3) or exceed it (>700 cfu/m3). this study does not encompass the identification of specific germ types present in the air, such as mycobacterium tuberculosis, pathogenic germs, or non-pathogenic germs. the requirement for the presence of pathogenic biological germs in the air within a household is 0 cfu/m3.16,21 various types of germs and viruses can experience growth inhibition or even destruction when exposed to sunlight, including tuberculosis germs and the sars-cov-2 virus. sunlight can contribute to suppressing the growth and survival capabilities of germs outside the human body, thereby reducing the risk of tuberculosis transmission.22 the effectiveness of uv radiation, whether from sunlight or lamps, is contingent on the specific molecules it encounters. uv light can only affect exposed surfaces or areas. the uv rays’ germicidal potential depends on the room’s surface area and the type of bacteria or virus.23 recognizing the crucial role of lighting in preventing tuberculosis transmission within households, this study introduced an intervention involving the provision of lighting or room sterilization utilizing 16w and 20w ultra violet (uv) lamps in the residences of tuberculosis patients. the research revealed that the median germ count in the 16-watt and 20-watt uv lamp interventions was higher prior to room sterilization than after uv lamp usage. this indicates that illuminating rooms with uv lamps can effectively decrease germ numbers. tuberculosis is an infectious disease that can rapidly spread due to its transmission through bioaerosols.24 bioaerosols consist of biological particles in the form of aerosols originating from living organisms, including microorganisms or components of these organisms such as metabolites, toxins, or microorganism fragments. the primary constituents of bioaerosols include bacteria, viruses, peptidoglycan, endotoxins, fungi, and volatile organic compounds.25,26 airborne germs consist of microorganisms present in the air, including fungi, bacteria, and viruses. microorganisms suspended in the air can originate from the external environment or be contaminants within enclosed spaces. bacteria like mycobacterium tuberculosis have the ability to survive in the air, and their ability to persist in the air is largely influenced by environmental factors such as temperature, humidity, and sunlight. transmission of these bacteria from the air to humans can occur through various means, including air currents and respiratory droplets.26,27 the count of airborne germs serves as an indicator of air pollution caused by bacteria, some of which may have pathogenic properties. germ count represents the quantity of microorganisms, both pathogenic and non-pathogenic, determined through visual observation or with the aid of a magnifying glass on the culture media used for examination. the count is then calculated based on the standard test for bacteria using agar plates. the measurement of airborne germ numbers typically employs the most probable number (mpn) method. this approach calculates the bacterial concentration based on the assumption that bacteria are evenly distributed within a liquid medium. consequently, if samples are collected consistently from a source, an average bacterial count can be expected.26 airborne germ numbers exceeding quality standards can have a detrimental impact on individuals in the room, particularly when they are in a weakened state, as these germs can compromise their already vulnerable immune system. one alternative for reducing the concentration of airborne germs is to employ ultraviolet (uv) light emitted from a lamp.28,29 previous research indicates that uv lamps effectively reduce airborne germs in hospitals and other healthcare facilities.30 other studies have demonstrated that uv lamps can significantly decrease overall bacterial counts and are more effective than manual disinfection in hospital settings.31,32 similarly, research conducted in kupang city confirms that using uv lamps for illumination can help decrease air germ concentrations. this study reveals that 20w uv lamps are more efficient at reducing germ numbers than 16w uv lamps. nonetheless, both types of lamps can serve transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11911] [page 61] table 3. differences in air germ numbers in room sterilization using 16w and 20w ultra violet lamps based on the wilcoxon test. intervention n z score p pre-post 16watt negative ranks 17 -1.999 0.046 positive ranks 4 pre-post 20watt negative ranks 19 -2.868 0.004 positive ranks 2 non -co mmerc ial us e o nly as alternatives for reducing airborne germs when adding ventilation is problematic or when direct sunlight cannot enter the house. the presence of ventilation and lighting in a house are closely interrelated. ventilation serves as a means for both light and fresh air to enter. thus, the broader the ventilation, the more sunlight can penetrate the house, resulting in more germs in the room being exposed to uv rays from the sun, ultimately killing them. when direct sunlight can enter the house, it not only inhibits the growth of germs but can also lead to their immediate destruction, thereby reducing the risk of tuberculosis transmission within the house.33 ventilation also aids in decreasing the concentration of germs in the room by allowing cleaner external air to flow in, displacing potentially germ-laden indoor air.34 the broader the ventilation, the more air carrying infectious droplets and other sources of pollutants can be expelled from the room. previous research has demonstrated a connection between room lighting and the germ count in hospital treatment rooms,33 as well as an association with tuberculosis incidence.35 the source of room lighting can be sunlight or ultraviolet (uv) lamps. it is crucial for this lighting to be consistently available to maintain welllit rooms that are not conducive to germ proliferation. to enhance the influx of sunlight into a house, it is necessary to increase the number of entrances, such as windows, vents, and glass tiles, or to provide room lighting using uv lamps.22 uv light is a form of electromagnetic radiation with a wavelength of 100-400 nm, divided into three wavelength bands: uv-a (315-400 nm), uv-b (280-315 nm), and uv-c (100-280 nm). naturally, ultraviolet light is present in sunlight. of the three types of uv light, only uv-c can be utilized for germ sterilization activities. in addition to sunlight, uv-c radiation can be generated by artificial lighting. a uv lamp contains low-pressure mercury vapor enclosed in a specialized uv-emitting glass tube. approximately 95% of the energy emitted by this lamp falls within the 253.7 nm wavelength, which falls within the uv-c range.29 this research still has limitations, specifically the absence of testing the effect of distance (room area) on reducing air germ numbers, even though both distance and room area are known to have an effect on reducing germ numbers. similar to previous research, the distance of exposure to a uv lamp statistically influenced the difference in the reduction of germ numbers on cutlery, with the closer the distance, the higher the reduction in germ numbers.36 therefore, it is hoped that future research can further investigate the impact of distance and room size on air germ numbers. with this research, it is hoped that to reduce the number of germs in homes, especially the homes of tuberculosis sufferers, people will be able to increase or improve ventilation to allow sunlight to enter. if this is not possible, they can use artificial lighting, specifically by using ultraviolet light from uv lamps. it should be noted that in general, uv-a, uv-b, and uv-c radiation that reaches the earth can have various effects, including skin redness when directly exposed to the skin for an extended period. considering these impacts, several precautions must be taken when using uv lamps.23 these precautions include not placing the lamp near people, plants, or pets, avoiding entering the room when the uv lamp is on, and not looking directly at the uv lamp unless you are using safety glasses. it is also advisable not to use the lamp for extended periods. for safe usage, it is hoped that the health service or community health center will continue monitoring their use and assessing the health impacts that may directly affect the community. conclusions room sterilization using 16w and 20w uv lamps can effectively reduce the number of room germs. the use of 20w ultraviolet lamps has a more significant impact on reducing the number of germs in the room air. therefore, it is recommended to reduce the number of germs in the house by illuminating (sterilizing) the room using ultraviolet lights or by adjusting the ventilation position to increase the sunlight entering the house. considering the potential negative impacts of uv lamps, it is hoped that the health service or community health center will continue monitoring their use and assessing the health impacts that may directly affect the community. references 1. oktamianti p, bachtiar a, sutoto s, trihandini i, prasetyo s, achadi a, et al. tuberculosis control within indonesia ’ s hospital accreditation. j public health res 2021;10:1979. 2. kemenkes ri. profil kesehatan indonesia tahun 2019. jakarta: kemenkes ri; 2020. 3. elfiyunai nn, nursalam, sukartini t, efendi f. a systematic review on telenursing as a solution in improving the treatment compliance of tuberculosis patients in the covid-19 pandemic. healthc low-res settings 2023;11:93-7. 4. yuliandari rd, wahyuni cu, syahrul f, et al. factor analysis of the role of physicians and its associated factors for encompassing patients with suspected tuberculosis in surabaya city. j public health africa 2023;14:2575. 5. setyawan mf, mertaniasih nm, utomo b, et al. an analysis of the trend of incidences and fatality of pulmonary tuberculosis in east java from 2015-2020 : a lesson from covid-19. nat j comm med 2023;14:308-15. 6. kemenkes ri. apa itu toss tbc dan kenali gejala tbc [internet]. 2019. p. 1. available from: https://promkes.kemkes. go.id/apa-itu-toss-tbc-dan-kenali-gejala-tbc 7. dinas kesehatan provinsi ntt. laporan penyelidikan epidemiologi tb paru provinsi ntt.pdf. 2021. 8. apriliasari r, hestiningsih r, udiyono a. faktor yang berhubungan dengan kejadian tb paru pada anak (studi di seluruh puskesmas di kabupaten magelang). j kesehat masy 2018;6:298-307. 9. kemenkes ri. tuberculosis control program. n engl j med 1951;244:993-4. 10. indriyani n, istiqomah n, anwar mc. hubungan tingkat kelembaban rumah tinggal dengan kejadian tuberkulosis paru di wilayah kecamatan tulis kabupaten batang. unnes j public heal 2016;5:214. 11. wulandari s. hubungan lingkungan fisik rumah dengan kejadian tuberkulosis paru. unnes j public heal 2012;1:3-6. 12. maar, de ew. analisis faktor risiko kejadian tb paru di wilayah kerja puskesmas kertapati palembang. geneeskd gids 2016;7:124-38. 13. wanti w, solihah q, djapawiwi m. relationship between house condition and tuberculosis incidence in timor tengah utara district. ijsbar 2015;21:344-9. 14. hita, tanto hariyanto l. hubungan antara konsumsi rokok dengan kejadian penyakit tuberculosis (tbc) di puskesmas kawangu kecamatan pandawai kabupaten sumba timur provinsi nusa tenggara timur. univ tribhuwana tunggadewi malang. 2017;2:240-50. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 62] [healthcare in low-resource settings 2024;12:11911] non -co mmerc ial us e o nly 15. hutama hi, riyanti e, kusumawati a. gambaran perilaku penderita tb paru dalam pencegahan penularan tb paru di kabupaten klaten. j kesehat masy 2019;7:491-500. 16. menteri kesehatan. permenkes ri no 1077/menkes/per/v/2011 tentang penyehatan udara dalam ruang rumah. kemenkes ri 2011. available from: https://medium.com/@arifwicaksanaa/pengertian-use-casea7e576e1b6bf 17. utomo b, chan ck, mertaniasih nm, soedarsono s. comparison epidemiology between tuberculosis and covid19 in east java province, indonesia: an analysis of regional surveillance data in 2020. trop med infect dis 2022;7:83. 18. fitriani hu. the differences of ventilation quality, natural lighting and house wall conditions to pulmonary tuberculosis incidence in the working area of sidomulyo health center, kediri regency. j kesehat lingkung 2020; 12:39. 19. sankineni s, chauhan s, shegokar r, pathak y. global health and tuberculosis; past, present, and future. in: tubercular drug delivery systems: advances in treatment of infectious diseases. springer international publishing; 2023. p. 1-13. 20. lawi id, wanti w, singga s, irfan i, kristina rh. knowledge and attitude about tuberculosis disease in the community. j ilm permas j ilm stikes kendal 2022;12:75-82. 21. cdph. the role of building ventilation and filtration in reducing risk of airborne viral transmission in schools, illustrated with sars-cov-2 [internet]. marina bay parkway: cdph; 2020. available from: https://www.cdph.ca. gov/programs/ccdphp/deodc/ehlb/iaq/cdph document library/iaq paper on school ventilation filtration viral transmission.pdf 22. hapsari a. gambaran faktor risiko lingkungan rumah pada penderita tuberkulosis di wilayah kerja puskesmas tegalrejo kabupaten magelang. universitas ngudi waluyo; 2019. available from: http://repository2.unw.ac.id/370/ 23. maulana pr, gunawan s. perancangan lampu uvc untuk disinfektan ruangan berbasis internet of things (iot). j kaji tek elektro 2022;6:82-7. 24. azzahrain as, afifah an, yamani ln. detection of tuberculosis in toddlers and its risk factor at east perak health center surabaya. j kesehat lingkung 2023;15:92-8. 25. susanto ad, sanie dk, fitriani f. dampak bioaerosol terhadap pernapasan. 2019;3:272-82. 26. nazaroff ww. indoor bioaerosol dynamics. indoor air 2016;26:61-78. 27. faridi s, hassanvand ms, naddafi k, yunesian m, nabizadeh r, sowlat mh, et al. indoor/outdoor relationships of bioaerosol concentrations in a retirement home and a school dormitory. environ sci pollut res 2015;22:8190-200. 28. khair h, suryati i, utami r. application of ultraviolet light as an indoor disinfectant. abdimas talenta: jurnal pengabdian kepada masyarakat 2020;5:422-7. 29. cdc. basic upper-room ultraviolet germicidal irradiation guidelines for healthcare settings environmental control for tuberculosis. department of health and human services; 2013. 30. luky rinda meiriana, santoso i, erminawati. perbedaan angka kuman udara ruang operasi sebelum dan sesudah sterilisasi ultraviolet rsud ratu zalecha. kesehat lingkung 2018;8:55. 31. casini b, tuvo b, cristina ml, spagnolo am, totaro m, baggiani a, et al. casini_2019_evaluation of an ultraviolet c (uvc) light-emitting device for disinfection of high touch surfaces in hospital critical areas_130._ha pdf.pdf. 2019; 32. lindblad m, tano e, lindahl c, huss f. ultraviolet-c decontamination of a hospital room: amount of uv light needed. burns 2020;46:842-9. 33. apriyani a, wijayanti peh, habibi m. pencahayaan, suhu dan indeks angka kuman udara di ruang rawat rumah sakit tk. iv samarinda. j penelit kesehat “suara forikes” (journal heal res “forikes voice”) 2020;11:157. 34. kemenkes ri. pedoman nasional pengendalian tuberkulosis. kemenkes ri. jakarta: kemenkes ri; 2011. 110 p. available from: http://rspau.ddns.net:8080/perpustakaan/ property/ uploads/d8c81b3affec9ce9d840d2a53d26475a.pdf 35. sari rp, arisandi rd. faktor-faktor yang berhubungan dengan kejadian penyakit tb paru di wilayah kerja puskesmas walantaka. j ilmu kesehat masy 2018;07:25-32. 36. herawati nur arrifa, dinny prijanto budi teguh, saputri adriani yosephina, saputra somad agus. variasi jarak penyinaran lampu uv terhadap penurunan angka kuman pada alat makan. j ris kesehat 2019;11:150-4. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11911] [page 63] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13031 preventive effect of yacon leaves capsule in reducing symptoms of exercise-induced muscle damage roy januardi irawan,1 andun sudijandoko,1 heri wahyudi,1 noortje anita kumaat,1 mokhamad nur bawono,1 nanda rimawati,1 adi wijayanto2 1sports science department, faculty of sports science and health, universitas negeri surabaya, surabaya, east java; 2department of early childhood education, universitas islam sayyid ali rahmatullah tulungagung, east java, indonesia abstract exercise-induced muscle damage (eimd) is the disruption of skeletal muscle after high-intensity exercise, leading to decreased performance. furthermore, it is a common condition following vigorous exercise, particularly in individuals unaccustomed to performance. this disruption results in a decrease in strength, muscle soreness, swelling, and the release of several cytokines, both inflammatory and anti-inflammatory. symptoms of eimd include delayed-onset muscle soreness (doms) and a loss of physical function. therefore, this study aimed to investigate the effect of a 14-day administration of yacon leaves capsule supplementation on doms and inflammation post-eimd. to achieve this, an experimental pretest and posttest control group design with a randomized control trial approach was adopted. a total of 32 recreational male students of the sports science universitas negeri surabaya were randomly and double-blindly assigned to either yacon capsule supplementation (n=16) or placebo (n=16) group. participants were instructed to take a yacon capsule or placebo after breakfast for 14 days. the study groups were subjected to a muscle-damaging protocol consisting of 7 sets of 10 eccentric single-leg press repetitions on a leg press machine. doms and interleukin 6 (il-6) were determined at 0-h (baseline), 24-h, and 48-h post-exercise before and after 14-day supplementation periods. the results showed that doms and il-6 serum increased at 24 hours post-eimd when compared to baseline. additionally, a significant reduction in both doms and il-6 serum levels was observed within the yacon group compared to the placebo group (p<0.05). in conclusion, yacon leaves capsule supplementation was able to attenuate the risk of muscle damage by decreasing doms levels and il-6 serum in the blood. introduction recovery post high-intensity exercise is increasingly important as the sports and exercise become more competitive. after this exercise, muscle soreness, decreased energy, and decreased performance are observed. eimd is the disruption of skeletal muscle that often occurs after such strenuous activities, potentially leading to decreased performance.1 furthermore, it is a common condition resulting from vigorous exercise, particularly among individuals unaccustomed to performance.2 the disruption results in a decrease in strength, muscle soreness, swelling, and the release of several cytokines, both inflammatory and anti-inflammatory.3 according to several reports, eimd frequently happens after intense and unfamiliar exercise, particularly when the activity includes a high intensity of eccentric contractions.1,4 a prominent symptom of eimd is doms, characterized by pain and tenderness which increases between 24 and 48 hours post-exercise5 and peaks from 24 to 72 hours, before gradually subsiding within 7 days.6 the mechanism of the symptom is not fully understood but is believed to be a result of microtrauma to muscle fibers. this trauma causes inflammation, leading to pain, swelling, and stiffness in the affected muscle.7 the severity of doms is influenced by factors such as the intensity and duration of exercise, the type of exercise, and individual differences in muscle adaptability, specifically when there is a focus on eccentric contractions.8 despite not being classified as a disease or disorder, the symptom can induce discomfort and concern among athletes, due to the ability to impede participation in subsequent workouts.9 furthermore, doms can cause discomfort and can limit the ability of athletes to perform or train optimally. the soreness and stiffness can limit the range of motion, causing difficulty in executing proper technique and form.10,11 the precise mechanisms responsible for eimd have not been extensively described. however, previous studies have shown that delayed-onset muscle damage is primarily caused by mechanical stress, particularly eccentric muscle contractions. intense eccentric exercise lead to greater microtrauma within muscle fibers and affects the cell membrane,11,12 thereby facilitating inflammatory response.13 several studies focused on efforts to mitigate the risk of doms and muscle damage through the use of antioxidant supplements14,15 and other potential agents,16,17 yielding various results. therefore, further investigations are required to explore additional approaches aimed at reducing the risk of doms and inflammation. the inclusion of alternative nutritional interventions as preventive ingredients is essential imperative. this study aimed to investigate effect of 14-day yacon leaves capsule supplementation on doms and inflammation post-eimd. [healthcare in low-resource settings 2024;12(s1):13031] [page 15] significance for public health physical exercise is an activity to maintain health and fitness. however, unaccustomed, strenuous high-intensity, or long-duration exercise will result in the risk of doms and inflammation. nutritional intervention can be considered as a method to reduce the negative effect of unaccustomed, strenuous high-intensity, or long-duration exercise. non -co mmerc ial us e o nly materials and methods participants a total of 32 healthy recreational males from the sports science department of universitas negeri surabaya were recruited to participate in this study. all the participants had met the inclusion criteria of normal body mass index and non-smoker. the exclusion criteria include drug treatment, consumption of chemical drugs, and any supplements. the participants were weightmatched and randomly assigned into yacon (yg, n=16) and the placebo (pl, n=16) groups. during the study period, there was refrainment from strenuous activities or resistance training for a minimum of two weeks before exercise session. additionally, the participants were not consuming any supplements or subjected to recovery strategies such as massage, stretching, or cryotherapy. instruction to maintain the usual daily schedule during the experiment was provided. the participants were free from any pain or injury as assigned by the physical activity readiness questionnaire (par-q) pre-exercise participation screening. finally, informed consent was obtained and a low risk of bias was observed. experimental design the method used was a randomized double-blind placebo-controlled experiment design with randomized control trial approach. this design was developed as a step to investigate effectiveness of yacon leaves capsule supplementation for 14 days against doms and il-6 as markers of inflammation following eimd. the study was conducted for a month, commencing with an initial evaluation on day one to assess the state of the participants. throughout the entire process, all participants were forbidden from partaking in any kind of exercise or intense physical activity for 30 days, with only the experimental exercise being permitted. during the screening visit, participants completed a physical fitness capacity questionnaire which included information on weekly running frequency and volume, history of injuries and illnesses, and medication used in the 2 weeks before the start of the study. on the first visit, both yg and pl groups provided baseline data, including body weight, height, fat percentage, physical activity levels, and vo2 max, ensuring similar characteristics. informed consent was obtained from all participants after receiving a thorough explanation of the study during this visit. during the second visit, which occurred 14 days after the supplementation period, a damaging exercise was conducted in order to induce effect of eimd. both groups (yg and pl) were subjected to muscle-damaging protocol consisting of 7 sets of 10 eccentric single-leg press repetitions on a leg press machine.18 exercise protocol session starts with a 10-minute warm-up comprising jogging. previous study19 have showed that this specific protocol of eimd elicits a sensation of pain (known as doms) in the quadriceps muscle of exercised leg. doms and il-6 (inflammation marker) were obtained 0-hr (1st visit), 24-h (3rd visit), and 48-h (4th visit) post eimd (2nd visit). participants were instructed to refrain from all physical activity and avoid taking anti-inflammatory drugs, treatments, and additional dietary supplements during the 30 days. a summary of the study design is presented in figure 1. supplementation yg received 500mg yacon capsule per day, while the pl received placebo capsule containing 100 mg of corn starch. the participants orally consumed one yacon or placebo capsule per day with breakfast for 14 days. instructions were provided to refrain from anti-inflammatory drugs, treatments, and additional dietary supplements during the study. the participants were prohibited from engaging in exercise or strenuous physical activity for 30 days pain score (doms) and il-6 assessment the level of pain experienced from doms was evaluated using a visual analog scale (vas) comprising 100 mm.6,11,20 the vas score ranged from 0 mm (representing no pain) to 100 mm (showing the maximum level of pain that could be tolerated) and was specifically focused on the quadriceps muscle of the leg subjected to eccentric exercise. this assessment was conducted at 24h and 48-h post the single-leg press test protocol. additionally, vas is a method for evaluating pain caused by acute exercise. a total of 5 cc blood samples were obtained from the cubital vein and treated with edta to describe plasma levels of il-6. the centrifugation process was performed at 3000 rpm for 15 minutes after the serum was stored in a freezer at a temperature of 20 °c until analyzed. serum il-6 was counted using commercially available enzyme-linked immunosorbent assay (elisa) kits according to the manufacturer’s instructions. il-6 levels were measured at 0hr (vaseline), 24-h (3rd visit), and 48-h (4th visit) post-eimd. assessment of the serum was conducted at the institute of tropic disease and international research center laboratory, universitas airlangga indonesia to obtain ck plasma data. 4th international nursing and health sciences symposium [page 16] [healthcare in low-resource settings 2024;12(s1):13031] figure 1. study design. non -co mmerc ial us e o nly statistical analysis the data collected was processed manually and digitally to convert into significant information. the samples were assessed for normal distribution using the kolmogorov-smirnov method, and the result was positive (p>0.05). subsequently, descriptive statistics were calculated for each measured variable. the paired sample t-test was adopted for analysis since the data was normally distributed. results and discussion a total of 32 male recreational students from the sports sciences department of universitas negeri surabaya, with a mean age of 19.47 (±0.92) and 22.96 mean bmi (±1.80) were included in the study. the participants were randomly assigned to yg and pl, with the mean ages being 19.44 (±0.96) and 19.5 (sd ±0.89), respectively. the variation in age, height, weight, bmi, fat percentage, ipaq, and vo2 max is presented in table 1. as shown in table 1, the p values of all variables including age, height, weight, bmi, fat percentage, ipaq, and vo2max were >0.05. this implied that both yg and pl were homogeneous groups. the normality test was conducted to determine whether data of the vas and il-6 serum post 14-d of yacon capsules supplementation period followed a normal distribution. the kolmogorovsmirnov was selected as the normality test to assess the distribution of the data. table 2 shows details of the results obtained. demographics of normality test results are presented in table 2. kolmogorov-smirnov test was conducted to determine the normality distribution of vas (pain score of doms) and il-6 serum 0-h, at 24-h and 48-h. the result showed a p-value of >0.05, indicating a normal distribution. given the normal distribution of both the yg and pl data, the subsequent step comprised conducting a hypothesis test using a paired t-test. the objective of the test was to ascertain whether there was a reduction in doms (vas) and il-6 serum levels following 14 days of yacon capsules supplementation. pain assessment doms is a condition characterized by muscle pain that occurs in the days following intense or unaccustomed eccentric exercise, often accompanied by muscle damage resulting from repeated contractions. in this study, the pain scores in the quadriceps were assessed using the vas from baseline, at 24-h to 48-h post-eimd, as shown in table 3. the result showed that pain score using vas showed a rise 24 hours post-exercise, followed by a decline 48 hours post-exercise in both yg and pl. figure 2 shows that there was an increase and decrease in the pain scores of both groups 24 and 48 hours after exercise, respectively. however, the reduction in pain score in yg between 24 and 48 hours was observed to be more significant compared to the pl group. therefore, it was inferred that the supplementation of yacon capsules led to a greater reduction in doms compared to the placebo. 4th international nursing and health sciences symposium figure 2. changes in pain score levels between baseline, 24-h, and 48-h post the single-leg press test protocol in both yg and pl. table 1. characteristic of respondents. categories yg mean (±sd) pla mean (±sd) p age (years) 19.43 (±0.96) 19.5 (±0.89) 0.128 height (cm) 168.81 (±4.65) 170.03 (±4.84) 0.168 weight (kg) 61.5 (±3.03) 61.5 (±3.46) 0.688 bmi 23.44 (±1.53) 22.47 (±4.84) 0.856 fat percentage (%) 22.43 (±4.68) 21.25 (±4.23) 0.544 ipaq (met) 1274.63 (±215.26) 1184.67 (±135.20) 0.442 vo2max (ml/(kg·min)) 39.21 (±3.23) 38.50 (±4.36) 0.667 table 2. normality test result. categories baseline kolmogorov smirnov yg pl baseline 24-h 48-h baseline 24-h 48-h sig concl sig concl sig. concl sig concl sig concl sig concl vas (pain score) 0.085 normal 0.200 normal 0.159 normal 0.135 normal il-6 0.200 normal 0.200 normal 0.200 normal 0.200 normal 0.200 normal 0.200 normal [healthcare in low-resource settings 2024;12(s1):13031] [page 17] non -co mmerc ial us e o nly inflammation assessment interleukin-6 (il-6) is commonly used as a marker of muscle inflammation following heavy or uncustomed eccentric exercise. the result of comparative analysis of il-6 serum level changes post 14-d of yacon capsules supplementation, between baseline, as well as 24-h to 48-h post the single-leg press test protocol. table 5 shows a significant increase between baseline and 24-h after exercise (p<0.05) in both groups (yg and pl), which then decreased significantly (p<0.05) after 48-h post the single-leg press test protocol. furthermore, a significant decrease was observed between 24-h and 48-h post the single-leg press test protocol (p<0.05) in both groups (yg and pl). figure 3 shows a decrease in il-6 levels between 24-h and 48-h in both groups (p<0.05), but the reduction was greater in pl (p<0.05). therefore, the supplementation of yacon capsules led to a greater reduction in doms compared to the placebo. an intense physical activity without proper conditioning can result in damage to active muscle fibers. this damage is manifested through indications such as muscle soreness, stiffness (which can restrict the range of motion), and a decline in the capacity of muscle to produce force.3,21 doms symptoms are commonly experienced by both elite and novice athletes which are particularly associated with uncustomed eccentric exercise.11,22 furthermore, symptoms are often accompanied by pain attributed to rapid muscle tissue damage.23,24 it is widely recognized that eccentric exercise leads to significant damage to muscle cells, thereby triggering an inflammatory response25– 28. eccentric exercise such as post-single-leg press induces greater muscle damage than other types of muscle action due to microinjury event.29 this condition is hypothesized to occur when muscle stretch while contracting simultaneously, increasing stress on the myofibrils and disrupting the z-disks.30 different mechanisms have been proposed to describe the pain sensation in doms, with one suggesting the overproduction of reactive oxygen species (ros).31,32 however, no single theory can be identified as the primary factor accountable for these symptoms. several theories stated that ros due to increased oxidative stress during exercise was responsible for doms and muscle damage.14,33 therefore, several studies advocate for treatment through nutritional interventions to reduce increased oxidative stress. yacon (smallanthus sonchifolius) leaves considered to an antioxidant and immune functions, contain phenolic compounds such as organic acids, flavonoids, and sesquiterpene lactones, which have various pharmacological effects.34,35 these leaves act as antioxidants by directly binding radical reactive groups and inhibiting the formation of enzymes that generate radicals.36 numerous studies have confirmed the effectiveness of yacon leaves supplementation as an antioxidant.37 the capacity to reduce doms and muscle damage can be restricted, particularly during heavy eccentric exercise. therefore, it is crucial to explore alternative and effective nutritional strategies. the present study examined the efficacy of a 14-day daily supplementation of yacon leaves capsules in relation to subjective indicators of doms and inflammation, promoting muscle recovery following intense eccentric exercise. the results showed that a 14-day supplementation of yacon leaves capsules has an effect on eccentric eimd, characterized by doms and il-6 as inflammation markers, compared to placebo. this is evidenced by the mean difference between baseline, 24-h, and 48-h post-heavy eccentric exercise. several mechanisms could potentially explain the beneficial effects observed in this study as a result of yacon leaves capsule consumption. however, the most likely explanations are linked to the antioxidant capacity of yacon leaves. it is important to note that the relationship between antioxidant supplementation and exercise is still not fully understood. additionally, vitamin c supplementation, which acts as an antioxidant, has been discovered to reduce the development of endurance capacity.38 studies showed that antioxidant supplementation may counteract the positive effect of exercise on insulin resistance. engaging in repetitive eccentric exercise leads to an elevation in oxygen consumption and mitochondrial activity, increasing the generation of ros.39 the advantage of ros production during exercise lies in its role as signaling molecules that govern crucial molecular processes entailed in the adaptation of muscle cells to physical activity.40,41 therefore, excessive production has detrimental effect, and when not balanced by the endogenous antioxidant system, oxidative stress can occur.42 to attenuate the harmful effects of ros, antioxidants should be often consumed by highly active individuals such as athletes and hard workers to minimize muscle damage and alleviate symptoms of fatigue.43,44 the exact mechanism of the doms remains unclear,45,46 but the reduction is attributed to the ability of yacon leaves capsule supplementation to decrease inflammatory response during the recovery phase following eccentric exercise. in this case, leaves can inactivate nuclear factor kappa b (nf-κb), a major mediator of inflammation, thereby reducing the levels of other inflammatory mediators including pro-inflammatory cytokine mrna and protein.47 additionally, other studies showed the supplementation significantly decreased il-6 levels.48 despite the decrease in doms and il-6 levels due to the administration of yacon leaves, it is important to acknowledge the potential of the antioxidant to impede muscle tissue recovery. this is because the majority of ros production following eccentric exercise is highly attributed to phagocyte activity, which plays a role in tissue degeneration and subsequent regeneration. furthermore, antioxidant therapy could dampen such activity, thereby prolonging the recovery process. further investigation in this field is necessary to substantiate the hypothesis. conclusions in conclusion, the results of the current study showed that consuming yacon leaves capsules for 14 days was beneficial for reducing doms and muscle damage post-eimd. further investigation with various concentrations of leaves capsule was needed to assess the optimum dose and recovery duration. finally, focus was given to the main indices that correlated with post-exercise recovery, consisting of the doms and the il-6 levels. 4th international nursing and health sciences symposium table 3. pain score post-eimd. groups baseline mean (±sd) 24-h mean (±sd) 48-h mean (±sd) p yg 3.83 (±1.15) 2.96 (±0.66)0.000 pl 4.12 (±0.72) 4.06 (±0.57)0.000 [page 18] [healthcare in low-resource settings 2024;12(s1):13031] non -co mmerc ial us e o nly references 1. sulistyarto s, irawan r, kumaat na, rimawati n. correlation of delayed onset muscle soreness and inflammation postexercise induced muscle damage. open access macedonian j med sc 2022 jan 1;10(a):1688–94. 2. sonkodi b. delayed onset muscle soreness and critical neural microdamage-derived neuroinflammation. biomolecules 2022;12:1207. 3. nanavati k, rutherfurd-markwick k, lee sj, bishop nc, ali a. effect of curcumin supplementation on exercise-induced muscle damage: a narrative review. eur j nutr 2022;61:38353855. 4. irawan r, mahmudiono t, martiana t. interleukin-6 as immune system and inflammation biomarker on the response of basic pencak silat exercise in perguruan pencak silat perisai diri, 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2016;4:25–31. 15. irawan rj, sulistyarto s, rimawati n. supplementation of kencur (kaempferia galanga linn) extract on malondealdehyde (mda) and interleukin-6 (il-6) plasma levels post aerobic training activity: suplementasi ekstrak kencur (kaempferia galanga linn) terhadap kadar plasma malondealdehide (mda) dan interleukin-6 (il-6) pasca aktivitas latihan aerobik. amnt 2022;6:140-5. 16. rickards l, lynn a, harrop d, et al. effect of polyphenolrich foods, juices, and concentrates on recovery from exercise induced muscle damage: a systematic review and meta-analysis. nutrients 2021;13:2988. 17. chen hy, chen yc, tung k, et al. effects of caffeine and sex on muscle performance and delayed-onset muscle soreness after exercise-induced muscle damage: a double-blind randomized trial. j appl physiol (1985) 2019;127:798-805. 18. vaile j, halson s, gill n, dawson b. effect of hydrotherapy on the signs and symptoms of delayed onset muscle soreness. eur j appl physiol 2008;102:447-55. erratum in: eur j appl physiol 2008;103:121-2. 19. nicol lm, rowlands ds, fazakerly r, kellett j. curcumin supplementation likely attenuates delayed onset muscle soreness (doms). eur j appl physiol 2015;115:1769-77. 20. gokhale r, chandrashekara s, vasanthakumar kc. cytokine response to strenuous exercise in athletes and non-athletes—an adaptive response. cytokine 2007;40:123-7. 21. lamb kl, ranchordas mk, johnson e, et al. no effect of tart cherry juice or pomegranate juice on recovery from exercise-induced muscle damage in non-resistance trained men. nutrients 2019;11:1593. 22. chang wd, lin hy, chang nj, wu jh. effects of 830 nm light-emitting diode therapy on delayed-onset muscle soreness. evidence-based complement alternat med 2021;2021:6690572. 23. doma k, burt d, connor jd. the acute effect of a multi-modal plyometric training session on field-specific performance measures. j sports med phys fitness 2021;61:899-906. 24. martínez-ferrán m, cuadrado-peñafiel v, sánchez-andreo jm, et al. effects of acute vitamin c plus vitamin e supplementation on exercise-induced muscle damage in runners: a double-blind randomized controlled trial. nutrients 2022;14:4635. 25. fleckenstein j, neuberger ewi, bormuth p, et al. investigation of the sympathetic regulation in delayed onset muscle soreness: results of an rct. front physiol 2021;12:697335. 26. pyne db. exercise-induced muscle damage and inflammation: a review. aust j sci med sport 1994;26:49-58. 27. torre mf, martinez-ferran m, vallecillo n, et al. supplementation with vitamins c and e and exercise-induced delayed-onset muscle soreness: a systematic review. antioxidants (basel) 2021;10:279. 28. connolly da, sayers sp, mchugh mp. treatment and prevention of delayed onset muscle soreness. j strength cond res 2003;17:197-208. 29. sonkodi b, hegedűs á, kopper b, berkes i. significantly delayed medium-latency response of the stretch reflex in delayed-onset muscle soreness of the quadriceps femoris muscles is indicative of sensory neuronal microdamage. j funct morphol kinesiol 2022;7:43. 30. barker ga, parten al, lara da, et al. astaxanthin supplementation reduces subjective markers of muscle soreness following eccentric exercise in resistance-trained men. muscles 2023;2:228–37. 31. tanabe y, fujii n, suzuki k. dietary supplementation for attenuating exercise-induced muscle damage and delayedonset muscle soreness in humans. nutrients 2021;14:70. 32. jamurtas az. exercise-induced muscle damage and oxidative stress. antioxidants (basel) 2018;7:50. 33. lin ch, lin ya, chen sl, et al. american ginseng attenuates eccentric exercise-induced muscle damage via the modulation of lipid peroxidation and inflammatory adaptation in males. nutrients 2021;14:78. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13031] [page 19] non -co mmerc ial us e o nly 34. andrade e, ellendersen l, masson m. phenolic profile and antioxidant activity of extracts of leaves andflowers of yacon (smallanthus sonchifolius). industrial crops products 2014;62:499–506. 35. widowati w, tjokropranoto r, onggowidjaja p, et al. protective effect of yacon leaves extract (smallanthus sonchifolius (poepp.) h. rob) through antifibrosis, anti-inflammatory, and antioxidant mechanisms toward diabetic nephropathy. res pharm sci 2023;18:336-45. 36. kim k, lim y, oh jh, et al. antioxidant effect of mulberry leaves and yacon tuber extracts in high-fat diet-fed rats. biomed sci letters 2020;26:201–9. 37. hachkova h, nagalievska m, soliljak z, et al. medicinal plants galega officinalis l. and yacon leaves as potential sources of antidiabetic drugs. antioxidants (basel) 2021;10:1362. 38. powers sk, deminice r, ozdemir m, et al. exercise-induced oxidative stress: friend or foe? j sport health sci 2020;9:41525. 39. jakubczyk k, dec k, kałduńska j, et al. reactive oxygen species sources, functions, oxidative damage. pol merkur lekarski 2020;48:124-7. 40. gomez-cabrera mc, domenech e, viña j. moderate exercise is an antioxidant: upregulation of antioxidant genes by training. free radic biol med 2008;44:126-31. 41. di meo s, napolitano g, venditti p. mediators of physical activity protection against ros-linked skeletal muscle damage. int j mol sci 2019;20:3024. 42. northeast b, clifford t. the effect of creatine supplementation on markers of exercise-induced muscle damage: a systematic review and meta-analysis of human intervention trials. int j sport nutr exerc metab 2021;31:276291. 43. sara hs. effects of electrotherapy on delayed onset muscle soreness (doms). j biomed res environ sci 2021;2:812–4. 44. lee mc, jhang wl, lee cc, et al. the effect of kefir supplementation on improving human endurance exercise performance and antifatigue. metabolites 2021;11:136. 45. cheung k, hume p, maxwell l. delayed onset muscle soreness : treatment strategies and performance factors. sports med 2003;33:145-64. 46. mizumura k, taguchi t. delayed onset muscle soreness: involvement of neurotrophic factors. j physiol sci 2016;66:4352. 47. ferraz apcr, garcia jl, costa mr, et al. yacon (smallanthus sonchifolius) use as an antioxidant in diabetes. in: pathology elsevier; 2020 [cited 2023 apr 10]. p. 379–86. available from: https://linkinghub.elsevier.com/retrieve/pii/b97801281597290 00366. 48. djalalinia s, hasani m, asayesh h, et al. the effects of dietary selenium supplementation on inflammatory markers among patients with metabolic diseases: a systematic review and meta-analysis of randomized controlled trials. j diabetes metab disord 2021;20:1051-62. 4th international nursing and health sciences symposium correspondence: roy januardi irawan, sports science department, faculty of sports science and health, universitas negeri surabaya, kampus fikk – unesa jl. lidah wetan surabaya 60213, east java, indonesia, ph: +62317532571, email: royjanuardi@unesa.ac.id key words: eccentric; exercise; inflammation; muscle damage; sports injured contributions: irj, participated in the conception, design, writing of the manuscript, critical review, and approval of the final version to be published; sa and wh, participated in the design and critical review; na, contributed to the writing of the manuscript, critical review; bn and rn, contributed to the design, and writing of the manuscript, as well as critical review; wa, participated in the conception, design, and writing of the manuscript conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by the faculty of the sports science and health, universitas negeri surabaya through a study grant in 2024. clinical trials: not applicable. ethics approval: this research adhered to ethical guidelines and obtained approval from the health research ethics committee, faculty of public health, airlangga university. it has been deemed ethically acceptable with the identity number 104/ea/kepk/2023. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: he authors are grateful to the sports science faculty, universitas negeri surabaya (unesa) for the start-up study fund. the authors are also many thankful to all the students who participated in this study, specifically the sports science department universitas negeri surabaya. received: 3 november 2023. accepted: 9 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13031 doi:10.4081/hls.2024.13031 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 20] [healthcare in low-resource settings 2024;12(s1):13031] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11835 the effectiveness of wound cleansing using cocor bebek (kalanchoe pinnata) leaves in healing diabetic foot ulcers imroatul farida, christina yuliastuti, nuh huda, nur muji astuti, vedia lutfiana sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia abstract this study aimed to evaluate the effectiveness of cocor bebek (kalanchoe pinnata) leaves in wound cleaning for diabetic foot ulcers (dfu) and compare it with the use of nacl solution. diabetes mellitus (dm) and its complications, such as dfu, pose a global health problem with increasing prevalence. given the escalating occurrence of dfu, timely and effective treatment is crucial to prevent severe complications, including amputation. this research employed a quasi-experimental design with a pretest-posttest control group and was conducted at rumah luka surabaya, indonesia. the sample comprised 40 respondents with dfu, divided into an intervention group (using cocor bebek leaves) and a control group (using nacl solution). respondents’ characteristics, including age, sex, occupation, duration of diabetes, and other factors, were assessed to understand their impact on the response to treatment. the results demonstrated a significant improvement in dfu wound healing in the intervention group after using cocor bebek leaves (p<0.05), along with reduced scores on bates jensen wound assessment tool (bwat) indicators such as wound edge, tunnel, and necrotic tissue type. conversely, the control group using nacl solution also exhibited significant improvement in wound healing (p<0.05), with decreased scores on indicators such as the amount of necrotic tissue and the quantity of exudate. this study underscores the potential of cocor bebek leaves in aiding wound healing in dfu, evident from clinical improvements and reduced bwat scores. however, further research and clinical trials are needed to comprehensively support these findings and understand the mechanism of action, as well as the safety of using cocor bebek leaves in diabetic patients. introduction diabetes mellitus (dm) has emerged as a significant global health challenge, marked by an increasing prevalence rate.1 a consequential complication of diabetes is the occurrence of diabetic foot ulcers (dfu), which has become a pressing global health concern, affecting regions such as asia, asean, and indonesia.2 as the number of individuals diagnosed with diabetes continues to rise, the prevalence of diabetic foot ulcers is escalating, posing substantial health implications globally and regionally.3 notably, 80% of cases with diabetes mellitus develop dfu complications, leading to leg amputation in severe instances.4,5 approximately 14-24% of diabetic foot patients eventually require amputation, with 75% of individuals with diabetes experiencing foot problems.5–8 among the diabetic population, 44% undergo relatively expensive and prolonged diabetic wound treatment, as highlighted by perkeni.6 the mortality rate due to diabetic ulcers reaches 1723% post-amputation, with a one-year mortality rate of 14.8%, escalating to 37% three years after amputation.7 diabetic foot ulcers exhibit a prolonged healing process compared to non-diabetic wounds due to their chronic nature.9 chronic wound conditions can result in persistent tissue damage and, ultimately, amputation if infections are not treated properly.10,11 wound cleansing, a crucial aspect of both acute and chronic correspondence: nuh huda, hang tuah college of health sciences surabaya, surabaya, indonesia. e-mail: nuhhuda@stikeshangtuah-sby.ac.id key words: diabetes mellitus, diabetic foot ulcer, kalanchoe pinnata, non-communicable disease, wound cleansing. contributions: if, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; cy, collecting data, conceptualization, data curation, formal analysis, methodology; nh, conceptualization, investigation, validation, and writing – original draft, review, editing, corresponding; nma, conceptualization, formal analysis, validation, and, review & editing, vl, collecting data, writing – original draft. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this study had received ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia, with a certificates of ethical eligibility variety: pe/44/vi/2022/kepk/sht dated june 15th, 2022. patient consent for publication: the researcher did not include the respondent's name on the data collection sheet, simply providing a specific code or number on the sheet to maintain the confidentiality of the identity of research subjects to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we specific our private appreciation and gratitude to sekolah tinggi ilmu kesehatan hang tuah surabaya for the very meaningful support. thank you furthermore may to all research respondents and nurses at rumah luka surabaya, indonesia. received: 18 september 2023. accepted: 21 december 2023. early access: 8 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11835 doi:10.4081/hls.2024.11835 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 216] [healthcare in low-resource settings 2024;12:11835] non -co mmerc ial us e o nly wound care, involves the use of cleaning fluids selected based on their effectiveness and lack of cytotoxicity.12,13 despite a spectrum of treatment approaches for dfu, the negative consequences of inadequate or delayed intervention persist.14 infections pose a significant risk, exacerbating wound conditions and potentially leading to severe complications, including the necessity for amputation.15 consequently, the importance of effective and timely treatment cannot be overstated in preventing complications that jeopardize the limbs of individuals with diabetes.14,16 one alternative avenue for wound cleansing involves the use of cocor bebek leaves (kalanchoe pinnata) as a natural substitute. although these leaves exhibit considerable potential as an herbal component for cleansing diabetes foot ulcers (dfu), their utilization remains limited. despite being readily available and cost-effective for dfu sufferers, cocor bebek leaves (kalanchoe pinnata) are not yet commonly employed in dfu wound cleaning procedures. recognizing the need for more natural and effective treatment options for dfu, there is a growing interest in exploring the healing potential of cocor bebek leaf (kalanchoe pinnata)17. nevertheless, the adoption of this leaf as a wound cleansing agent for dfu is progressing slowly, with many individuals still unaware of its benefits18. wound cleansing using cocor bebek leaves presents a potential solution for dfu healing19. these leaves contain active substances, including steroid glycosides, saponin compounds, tannins, flavonoids, and terpenoids, offering cooling, antiseptic, astringent, anti-inflammatory, fever-reducing, asthma-relieving, stomach ulcer-treating, ulcer-healing, and wound-healing properties20. previous research, including kony putriani’s study in 202321, demonstrates that cocor bebek (kalanchoe pinnata) contains healing compounds such as flavonoids, saponins, and tannins. kony putriani’s research also evaluates the antibacterial effectiveness of methanol extract against propionibacterium acnes and staphylococcus aureus.21 in white rats, a 20% concentration of cocor bebek leaf ethanol extract ointment proves most effective in healing incision wounds.22 additional studies indicate anti-inflammatory activity in rat feet induced by carrageenan with a 2% ethanol extract of cocor bebek leaves.21 purwanitiningsih (2020)23 examines the antibacterial efficacy of cocor bebek leaf extract against salmonella typhi using the kirby bauer method, revealing high antibacterial power. another study indicates that higher concentrations of cocor bebek leaf extract expedite the healing process of cut wounds in white rats, with a 15% concentration proving most effective.24 while existing research highlights the efficacy of cocor bebek in wound healing and antibacterial activity, it is essential to note that the focus has primarily been on these aspects rather than the plant’s application for diabetic diseases. this study aimed to evaluate the effectiveness of cocor bebek (kalanchoe pinnata) leaves in wound cleaning for diabetic foot ulcers (dfu) and compare it with the use of nacl solution. materials and methods this study utilized a quasi-experimental design with a pretestposttest control group approach. the research was conducted in june 2022 at a health facility in surabaya, indonesia. the sample for this study consisted of 40 respondents divided into two groups: the intervention group and the control group. group selection was carried out using the simple random sampling method. the inclusion criteria involved patients with diabetic foot injuries of degree 2-3, blood sugar levels < 200 mg/dl, regular intake of diabetes drugs or insulin injections, and having a normal weight (bmi = 18.5-22.9). the dependent variable in this study was wound cleaning using cocor bebek leaves (kalanchoe pinnata), while the independent variable was wound healing in diabetic patients. self-administered questionnaires were employed to collect sociodemographic data, including age, sex, occupation, duration of diabetes, history of diabetes, history of diabetic foot wound care, history of diabetic diet, exercise habits, heredity, drug consumption, comorbidities, and blood sugar levels during data collection. the instrument used for wound cleaning with cocor bebek leaves (kalanchoe pinnata) was a standard operating procedure for wound treatment involving a decoction of 5 pieces of cocor bebek leaves (100 gr) and 1 l of water, boiled for 15 minutes until the cooking water reduced to 500 ml for the intervention group, while the control group was treated with usual wound washing using nacl solution 0.9%. an instrument to measure diabetic foot wound healing employed the bates jensen wound assessment tool (bwat) with 13 indicators, including size, depth, wound edge, tunnel, necrotic tissue type, necrotic tissue count, exudate type, exudate count, skin color around the wound, peripheral edema, hardening of peripheral tissue, granulation tissue, and epithelialization. dfu score measurements were performed over 14 days or 6 interventions. data were analyzed using the wilcoxon test within each group (intervention and control), and the mann-whitney test was utilized to assess the relationship between the two groups with a significance level of 5%. this research received approval from the ethics committee of stikes hang tuah surabaya with reference number pe/44/vi/2022/kepk/sht dated june 15, 2022. results based on table 1, the intervention group was dominated by respondents aged 30-40 years, female gender, work as housewives, suffer from dm for less than 12 months, and have a family history of dm. the majority of respondents did not exercise regularly, took dm or insulin drugs regularly, maintained a diet, and had random blood sugar levels <200 mg / dl. meanwhile, the control group was dominated by respondents aged 50-60 years, female gender with other types of work, suffering from dm for 1-2 years and 2-3 years, having a hereditary history of dm, not exercising regularly, taking dm drugs or insulin regularly, maintaining a diet, and having random blood sugar levels <200 mg / dl. table 2 shows a significant decrease in scores for various dfu indicators after intervention with cocor bebek leaves and nacl solution. wilcoxon tests indicate a p value of 0.000 ≤ α = 0.05, signifying significant improvement in dfu healing for both interventions. additionally, the mann-whitney test reveals significant differences in the effectiveness of dfu healing between the cocor bebek leaves and nacl groups, with a p value of 0.003 ≤ α = 0.05. discussion after cleaning wounds with cocor bebek leaves, bwat indicators such as wound fringe, tunnel, necrotic tissue type, exudate type, exudate count, skin color around the wound, peripheral edema, hardening of peripheral tissue, granulation tissue, and epithelialization showed decreased scores, indicating improved transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11835] [page 217] non -co mmerc ial us e o nly wound conditions. megawati’s 2023 research highlighted that cocor bebek leaves, containing flavonoids, saponins, and tannins, aid wound healing.25 flavonoids act as antioxidants and antiinflammatories, saponins stop bleeding and have antibacterial properties, while tannins counteract inflammatory mediators and possess antibacterial effects.26 alkaloids, steroids, and terpenoids in cocor bebek leaves contribute to antibacterial, antiulcer, antifungal, antiviral, hepatoprotective, and antiseptic properties.27–29 the post-intervention group exhibited accelerated wound healing, benefiting from the multifaceted effects of cocor bebek leaves. bwat assessment indicated smaller post-intervention scores, reflecting faster healing in the intervention group.27,30 factors influencing this improvement included respondent characteristics like ages between 30-40 years, diabetes mellitus drug consumption, adherence to a diet, and blood sugar levels <200 mg/dl, as outlined in table 1. after cleaning wounds with nacl, bwat indicators such as necrotic tissue count, exudate count, peripheral edema, and hardening of peripheral tissue showed decreased scores, signifying improved wound conditions. nacl 0.9% is an isotonic, safe, nonirritant solution that preserves granulation tissue, maintains wound moisture, and aids the healing process.31 it matches the body’s salt content, preventing hypersensitivity reactions and promoting epithelial tissue development.32 nacl 0.9% serves as a cleansing and rehydration fluid, removing excessive wound fluid and metabolic waste to create a moist environment for autolytic debridement.33 the control group, undergoing nacl 0.9% wound cleansing, exhibited faster wound healing as indicated by bwat scores. post-control scores were smaller than pre-control scores, reflecting accelerated healing. factors contributing to this improvement in the control group, outlined in table 1, include regular consumption of diabetes mellitus drugs and adherence to a diet by respondents.34–36 after cleaning wounds with cocor bebek leaves and nacl, bwat observations revealed differences in the rate of score decrease for indicators such as depth, wound fringe, type and number of necrotic tissue, type and amount of exudate, skin color around the wound, granulation tissue, and epithelialization. statistical tests indicated a significant difference in the effectiveness of dfu healing between the intervention group (cocor bebek leaf wound cleaning) and the control group (nacl wound cleaning). the advantage of the intervention group lies in the natural transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. the characteristics of respondents in surabaya wound house, with division between intervention group (pok) and control group (n=40). characteristics of respondents intervention group (%) control group (%) age 30-40 years 50 0 40-50 years 20 20 50-60 years 30 50 >60 years 0 30 gender man 55 20 woman 45 80 work housewives 45 20 farmer 0 0 self employed 15 0 private employees 25 0 civil servants 0 5 retired civil servant 0 30 other 15 45 years with diabetes mellitus <12 months 45 5 1-2 years 30 35 2-3 years 10 35 >3 years 15 25 history of diabetes exist 90 95 none 10 5 sports habits ever 0 0 never 100 100 dm/insulin medication consumption yes 100 100 not 0 0 maintaining diet yes 100 100 not 0 0 blood sugar <200 mg/dl 95 100 >200 mg/dl 5 0 [page 218] [healthcare in low-resource settings 2024;12:11835] non -co mmerc ial us e o nly compounds present in cocor bebek leaves, including flavonoids, saponins, tannins, alkaloids, steroids, and terpenoids, which accelerate wound healing by reducing glucose absorption, exhibiting antibacterial, anti-inflammatory, and antiseptic properties.37,38 saponins in cocor bebek leaves stop bleeding, treat wounds, and have antibacterial and anti-inflammatory effects, while tannins act as anti-inflammatory and antibacterial agents.39,40 alkaloids, steroids, and terpenoids in cocor bebek leaves contribute antibacterial, antidiabetic, and antifungal properties, further enhancing wound healing.39–41 the control group (wound cleaning with 0.9% nacl) primarily contained 0.9% sodium and chloride compounds, serving as an isotonic fluid and physiological saline to maintain wound moisture and enhance epithelial tissue migration.42,43 variances in compound content between the intervention (cocor bebek leaf wound cleaning) and control groups influenced dfu improvement, with the intervention group exhibiting faster healing. observations indicated more effective wound cleaning in the intervention group, reflected in decreased bwat scores across 10 out of 13 indicators, including wound fringe, tunnel, necrotic tissue type, exudate type, exudate count, skin color around the wound, peripheral edema, hardening of peripheral tissue, granulation tissue, and epithelialization. in contrast, the control group showed decreased scores on three indicators—number of necrotic tissues, number of exudates, and hardening of peripheral tissues. this underscores the superior effectiveness of wound cleansing with cocor bebek leaves compared to 0.9% nacl in treating diabetic foot ulcers. external factors, such as the age of diabetes mellitus sufferers in the control group exceeding one year, may impact improvements in dfu healing across bwat indicators, necessitating discussion and consideration based on previous studies on long-term diabetes. conclusions wound cleansing using cocor bebek leaves (kalanchoe pinnata) significantly enhances the healing of diabetic foot ulcers (dfu). the utilization of cocor bebek leaves has demonstrated effectiveness in reducing scores on various bwat indicators, including wound fringe, tunnel, necrotic tissue type, exudate type, exudate count, skin color around the wound, peripheral edema, hardening of peripheral tissue, granulation tissue, and epithelialization. this study provides evidence that cocor bebek leaves contain active compounds, such as flavonoids, saponins, tannins, alkaloids, steroids, and terpenoids, which can offer anti-inflammatory, antibacterial, antiseptic, antidiabetic effects, and accelerate wound healing. therefore, the use of cocor bebek leaves can be considered a potential natural alternative for cleaning wounds in diabetics with diabetic foot ulcers. references 1. agustari f, novitasari d, sembayang sm. jurnal peduli masyarakat. j pengabdi kpd masy aphelion 2022;4:603–8. 2. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632–45. 3. apriani r, dahlia d, kurnia da. penggunaan negative pressure wound therapy (npwt) terhadap diabetic foot ulcer. j telenursing 2023;5:1040–9. 4. hingorani a, lamuraglia gm, henke p, et al. the management of diabetic foot: a clinical practice guideline by the society for vascular surgery in collaboration with the american podiatric medical association and the society for vascular medicine. j vasc surg 2016;63:3s-21s. 5. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord 2021; available from: https://www.scopus.com/inward/record.uri?eid=2-s2.085101682595&doi=10.1007%2fs40200-021-007569&partnerid=40&md5=bd53e8aba3899437d7eee805f5c45d9 7 6. huda n. asuhan keperawatan diabetes milletus dan transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11835] [page 219] table 2. statistical analysis result of bwat indicator changes before and after intervention in experimental and control groups. bwat indicator intervention group control group p pre-test post-test δ pre-test post-test δ size 2 2 0 2 2 0 0.003c depth 2 2 0 4 4 0 0.003c wound fringe 3 1 2 4 4 0 0.003c tunnel 3 1 2 1 1 0 0.003c types of necrotic tissue 3 2 1 3 3 0 0.003c number of necrotic tissues 2 2 0 5 4 1 0.003c types of exudate 3 1 2 4 4 0 0.003c number of exudates 2 1 1 4 3 1 0.003c skin color around the wound 3 1 2 4 4 0 0.003c peripheral edema 4 2 2 1 1 0 0.003c edge hardening 3 2 1 3 2 1 0.003c granulation network 3 2 1 5 5 0 0.003c epithelialization 5 2 3 5 5 0 0.003c p 0.000a 0.000b awilcoxon test of pre-post tests in the intervention group; bwilcoxon test of pre-post tests in the control group; cmann-whitney test between the intervention and control groups. non -co mmerc ial us e o nly penggunaan sfe dalam perawatan luka kaki diabetes. sidoarjo: indomedika pustaka; 2017. 4 p. 7. farida i, arini d, mardayati rp. efektifitas perawatan luka modern kombinasi mendengarkan musik klasik terhadap penyembuhan ulkus diabetik di rumah luka surabaya. j ilm keperawatan stikes hang tuah surbaya 2019;13(1). 8. faizah r, sinawang gw, hermanto a, alfatih mr. support factors of self foot care for diabetes mellitus patients. j ners 2019;14:316–20. 9. kintoko k, karimatulhajj h, elfasyari ty, et al. pengaruh kondisi diabetes pada pemberian topikal fraksi daun binahong dalam proses penyembuhan luka. maj obat tradis 2017;22:103. 10. fadlilah s. faktor faktor yang berhubungan dengan derajat ulkus kaki diabetik di rsu. moewardi surakarta. infokes 2018;8:37–43. 11. ernawati ds, surboyo mdc, ayuningtyas nf, nagoro aab. role of inflammatory cell responses in stimulating fibroblasts in diabetic oral ulcer after treatment with liquid smoke of coconut endocarp: a histological assessment. eur j dent 2021;15:71–6. 12. alfaqih mr, sinawang gw, faizah r, hermanto a. the management of diabetic foot ulcers using the wound treatment techniques of modern dressing: a systematic review. j ners 2019;14:176–80. 13. nurbaya n, tahir t, yusuf s. peranan pencucian luka terhadap penurunan kolonisasi bakteri pada luka kaki diabetes. j keperawatan muhammadiyah 2018;3:110–5. 14. junaidi, haryanto, kardiatun t. pengaruh pembalut wanita terhadap terjadinya maserasi pada luka kronik diabetic foot ulcer. j perawat indones 2022;6:1211–22. 15. faizah r, efendi f, suprajitno s. a systematic review of foot exercises with group support to improve the foot health of diabetes mellitus patients. j ners 2020;15:129–34. 16. munawwarah m, neonbasu ma, lesmana si. penatalaksanaan fisioterapi pada kasus diabetic foot ulcer di rumah luka surabaya (sidoarjo). indones j physiother res educ ijopre 2022;3:62–74. 17. diwanti ap, lestari n, a ei. pengaruh ekstrak daun cocor bebek (kalanchoe pinnata) 50% terhadap waktu penyembuhan luka sayatan pada mukosa rongga mulut tikus wistar. ijoh indones j public heal 2023;1:281–5. 18. mustamu ac, mustamu hl, hasim nh. peningkatan pengetahuan & skill dalam merawat luka. j pengabdi masy sasambo 2020;1:103. 19. sawitri pa, dewi wcs, amalia ar, sudayasa ip, agastia g. cobek antik: pengaruh ekstrak daun cocor bebek (kalanchoe pinnata) terhadap kadar gula darah tikus model diabetik. medula 2019;6. 20. putri ah, putriyana rs, silviani n. isolasi dan ekstraksi kelompok senyawa flavonoid dari ekstrak daun cocor bebek (kalanchoe pinnata). fuller j chem 2019;4:28. 21. putriani k. aktivitas antibakteri ekstrak metanol daun cocor bebek (kalanchoe pinnata (lam.) pers.) terhadap propionibacterium acnes dan staphylococcus aureus. j biog 2023;8:412–8. 22. umeh vn, ilodigwe ee, ajaghaku dl, erhirhie eo, moke ge, akah pa. wound-healing activity of the aqueous leaf extract and fractions of ficus exasperata (moraceae) and its safety evaluation on albino rats. j tradit complement med 2014;4:246–52. 23. purwanitiningsih e, lestari d. uji aktivitas antibakteri ekstrak daun cocor bebek (kalanchoe pinnata (lam)) terhadap pertumbuhan bakteri salmonella typhi dengan metode kirby bauer. j ilm kesehat 2020;12:142–8. 24. cholid z, prasetya rc, sukamto brp. efektivitas ekstrak daun cocor bebek (kalanchoe pinnata) terhadap waktu perdarahan (bleeding time) pada ekor mencit strain balb-c effectiveness of kalanchoe pinnata leaf extract on bleeding time in the tail of balb-c mice strain. padjadjaran j dent res students 2022;6:144. 25. megawati m, oktarlina rz. studi literatur:cocor bebek (kalanchoe pinnata) sebagai penyembuhan luka bakar. j ilmu kesehat kedokt 2023;10:1489–93. 26. fitri yani d. the anti-inflammatory potential of cocor bebek leaves (kalanchoe pinnata l) against in vitro protein denaturation. spin 2021;3:12–21. 27. saputra tr, ngatin a. ekstraksi daun cocor bebek menggunakan berbagai pelarut organik sebagai inhibitor korosi pada lingkungan asam klorida. fuller j chem 2019;4:21. 28. sabrina ap, tania e, nurhalifah n, veronita sc, puji si, nuryamah s. aktivitas imunodulator dari jawer kotok (coleus scutellariodes (l) benth). j buana farma 2022;2:40– 55. 29. gitafitri f, kurniawan st, vioneery d. pengaruh gel daun jambu mete (anacardium occidentale l.) terhadap perawatan luka bakar grade ii pada hewan uji mencit (mus musculus). universitas kusuma husada surakarta; 2023. 30. gunawan a, selvina d, rosdiana. potensi efek antibakteri tinta cumi (loligo sp.) dan sotong (sepia sp.) pratista patologi. pratista patol 2023;8(2). 31. shantika ss, kusdiantini a. pemeriksaan laju endap darah metode westergren menggunakan natrium sitrat 3,8% dan edta yang ditambah nacl 0,85%. innov j soc sci res 2023;3:3111–9. 32. nurman m. perbandingan efektifitas madu + nacl 0,9% dengan nacl 0,9 % saja terhadap penyembuhan luka gangren pada pasien diabetes mellitus tipe ii di wilayah kerja puskemas bangkinang kota tahun 2015. j keperawatan stikes tuanku tambusai riau 2015;16:1–37. 33. suriani a, syaharuddin s, damayanty st, fardi f. penerapan pembersihan luka dengan menggunakan nacl 0.9% untuk menghindari kerusakan integritas kulit pada pasien yang mengalami ulkus diabetik. j ilm kesehat sandi husada 2023;12:459–66. 34. akoit ee, efendi f, dewi ys. impact of diabetes self-management education in middle-aged patients with type 2 diabetes mellitus: a systematic review. gac med caracas 2022;130:s1183–95. 35. rokhmad k, supriyanto s. analysis of prolanis activities on controlling type-2 diabetes mellitus at puskesmas tulungagung in 2022. j public health africa 2023;14:2617. 36. kusnanto k, alfaqih m, padoli p, arifin h. a qualitative study inquiry among patients with diabetic foot ulcers: what have they felt? open access maced j med sci 2021;9:574–80. 37. qomaliyah en, indriani n, rohma a, islamiyati r. skrining fitokimia, kadar total flavonoid dan antioksidan daun cocor bebek phytochemical screening, total flavonoids and antioxidants of kalanchoe pinnata linn. leaves. curr biochem 2023;10:1–10. 38. ayyun k, khafidz y, rosydah i, et al. profil studi fitokimia dan aktivitas farmakologi buah mangga (mangifera indica l.). farmaka 2023;01:60–8. 39. wulandari pac, ilmi zn, husen sa, et al. wound healing and antioxidant evaluations of alginate from sargassum ilicifolium transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 220] [healthcare in low-resource settings 2024;12:11835] non -co mmerc ial us e o nly and mangosteen rind combination extracts on diabetic mice model. appl sci 2021;11:4651. 40. ilmi zn, wulandari pac, husen sa, et al. characterization of alginate from sargassum duplicatum and the antioxidant effect of alginate-okra fruit extracts combination for wound healing on diabetic mice. appl sci 2020;10:6082. 41. hayon mfk, supriningrum r, fatimah n. identifikasi jenis saponin dan uji aktivitas antibakteri ekstrak metanol kulit batang sekilang (embelia borneensis scheff.) terhadap bakteri pseudomonas aeruginosa atcc 9027 dan streptococcus mutans atcc 25175. j ris kefarmasian indones 2023;5:258–72. 42. fernandez r, green hl, griffiths r, et al. water for wound cleansing. cochrane database syst rev 2022;9:cd003861. 43. ramirez-acuña jm, cardenas-cadena sa, marquez-salas pa, et al. diabetic foot ulcers: current advances in antimicrobial therapies and emerging treatments. antibiot (basel, switzerland) 2019;8:193. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11835] [page 221] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:111995 monitoring medication adherence using smart digital technology in patients with pulmonary tuberculosis eppy setiyowati,1 firdaus firdaus,1 erika martining wardani,1 mulyadi mulyadi2,3 1department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya; 2faculty of medicine, universitas nahdlatul ulama, surabaya; 3jemursari islamic hospital, surabaya, indonesia abstract pulmonary tuberculosis cases can arise due to various factors, including treatment fatigue resulting from prolonged therapy, insufficient patient knowledge about the condition, geographical distance between patients’ residences and healthcare facilities, a lack of reminders from healthcare workers regarding medication adherence, and the perception that treatment provided at community health centers may be inadequate. this study aimed to investigate the effectiveness of digital smart applications in enhancing medication adherence among pulmonary tuberculosis patients. utilizing a trial survey approach, the research focused on patients seeking treatment at the surabaya community health center. smart digital applications were employed to monitor medication adherence, with patients inputting their data via cell phones. the study recorded data over one month and found that while some patients struggled to operationalize the smart digital application, many were able to utilize it effectively. overall, the findings suggest that smart digital applications can be valuable tools for monitoring medication adherence among pulmonary tuberculosis patients, particularly for older adults. introduction tuberculosis (tb) remains a significant global health challenge, particularly prevalent in developing countries.1,2 factors contributing to the high number of tb cases include treatment fatigue resulting from prolonged therapy,3 inadequate patient knowledge about pulmonary tb,4,5 geographical barriers to accessing healthcare facilities, a lack of reminders from healthcare providers regarding treatment adherence,6 and perceptions of treatment quality at community health centers.7,8 these factors can lead to treatment non-adherence among tb patients.9,10 the compliance of tb patients with their treatment regimen plays a pivotal role in the management of the disease.11 studies have shown that non-adherence to treatment increases the risk of tb recurrence by about 2.5 times, highlighting challenges from medical, immunological, and psychological perspectives.12 treatment non-adherence contributes to a higher rate of treatment failure among pulmonary tb patients and exacerbates the burden of tb within communities.13 factors influencing adherence to pulmonary tb medication include understanding of the treatment instructions,14 quality of interactions with healthcare providers, family support, personal beliefs, attitudes, and personality traits.15 additionally, the lengthy and rigorous treatment regimen for pulmonary tb, spanning 6-8 months, poses another significant challenge.16 to enhance compliance with tb treatment, the use of directly observed treatment (dot) by drug supervisors has been implemented.17 however, traditional dot methods have not effectively addressed tb management challenges.18 therefore, there is a need for innovative approaches to drug supervision, such as utilizing electronic and communication media to directly monitor drug intake by patients in the presence of healthcare workers. while health education and telenursing have been utilized to increase correspondence: eppy setiyowati, department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia. e-mail: eppy@unusa.ac.id key words: pulmonary tuberculosis, smart digital, taking medicine. contributions: es, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing original draft, review and editing; ff, conceptualization, investigation, methodology, validation, and writing original draft, review and editing; emw, conceptualization, methodology, formal analysis, validation, and writing original draft, review and editing; mm, methodology, visualization, writing review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission, chakra brahmanda lentera institusion, based on ethical certificate 027/011/v/ec/kep/lcbl/2023. during the research, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from universitas nhdlatul ulama surabaya with contract number 458/unusa/adm-lppm/iv/2023. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to thank rector universitas nahdlatul ulama surabaya for their valuable insights and contributions to this study. received: 17 october 2023. accepted: 16 may 2024. early access: 5 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11995 doi:10.4081/hls.2024.11995 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 522] [healthcare in low-resource settings 2024;12:11995] non -co mmerc ial us e o nly knowledge among individuals with pulmonary tb,19 they have not fully addressed long-term drug adherence challenges. in order to ensure sustained drug adherence over the entire treatment duration, which typically spans at least 6 months, the development and implementation of smart digital applications for tb patients are essential.19,20 previous studies have examined the use of digital smart applications for assessing medication adherence in various settings.21,22 however, these studies did not reveal the knowledge, attitudes, and behaviors of tb patients. this study aimed to specifically analyze the use of digital smart applications for controlling drug adherence in pulmonary tb patients. materials and methods design and sample this study employed a trial survey approach utilizing digital smart applications to monitor medication adherence. it was conducted at a community health center in surabaya, targeting tb patients who regularly seek treatment there each month. initially, there were eleven patients identified at the health center and its branches in the area. however, after coordination and collaboration with the tb program team, it was found that three patients had already been declared cured. subsequently, the study focused on the remaining nine pulmonary tb patients who possessed digital media in the form of cell phones. data collection commenced from may to august 2023, beginning with the assessment of respondents’ behaviors (knowledge, attitudes, and actions) related to medication intake and adherence. instruments the methods used to measure adherence, including patient self-reports, pill counts, refill levels, biological monitoring, and electronic monitoring, have their limitations, particularly concerning reminder sounds displayed on digital smart devices. the reports displayed typically rely on patients’ personal data, memory, and medication schedules provided by the treating doctor. although the name and quantity of the medication are recorded, they are not always factored into the data analysis and processing. reminder sounds are programmed to alert patients at the same time each day, but some respondents may not be sensitive to these reminders, leading to instances where medications are not taken as prescribed. all data entered into the smart digital system is recorded for one month, from the 1st to the 31st of august. monitoring medication intake through digital smart devices includes recording patient names, ages, the names of the medications taken, and the quantity of medications consumed through electronic monitoring. medication adherence behavior was assessed based on two indicators: adherence and non-adherence. adherence is recorded if there is consistent charging on the smart digital device for one consecutive month. each respondent’s cell phone was equipped with a digital smart application called pamio tb. following installation, researchers provided detailed explanations of the mechanism and operation of the pamio tb smart digital application to the respondents. development of adherence to taking medications some methods aim to improve medication adherence among patients with pulmonary tb. however, this study specifically focuses on the implementation of a digital smart application called pamio tb (short for “compliant to taking tb medicine”). this application includes an alarm that sounds every day at 7 a.m., reminding respondents to take their medication. when using the digital smart application, respondents input their identity, the name of the drug, and the quantity of medication taken. additionally, the application features a questionnaire designed to assess the knowledge, attitudes, and actions of individuals with pulmonary tb. knowledge levels are categorized as high, medium, or low, while attitudes and actions are assessed using similar indicators. habit of reminding in patients with pulmonary tb, the medication-taking process requires attention from both healthcare workers and family members. often, a family member serves as a medication supervisor to ensure adherence. however, the use of digital smart applications can potentially reduce the need for this role. when it is time to take medication, the alarm in the digital smart app will ring, prompting the respondent to press a button on their cell phone. this alarm serves as a reminder for individuals with pulmonary tb to take their medication, thus minimizing their reliance on external supervision. analysis utilizing a digital smartphone application represents a novel approach to enhancing medication adherence among individuals with pulmonary tb. this application offers constant accessibility, actively engages patients, and serves as a repository for pertinent medication adherence-related information. with the presence of alarms on patients’ smartphones, reminders to take medication are automatic, eliminating the need for family members to prompt medication intake. by employing digital smart applications for monitoring medication adherence in pulmonary tb patients, there is a shift towards a more patient-centered approach. this transition highlights the potential value of such applications as effective tools for monitoring medication adherence, reducing reliance on external supervisors, and empowering individuals with pulmonary tb to take charge of their treatment regimen. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. attributes and ratings of the five apps that were installed and subjected to user testing. application name online data complex cloud data database of multiplatform final record final posting iphone entry instruction storage medication app data record my med schedule pamio tb x x x x x 1 4 x mymeds x x x x 2 4 x med agenda x x x x 3 5 x remid me prescription x x 4 4 x med memory x x 5 4 x [healthcare in low-resource settings 2024;12:11995] [page 523] non -co mmerc ial us e o nly results and discussion the discussion on medication adherence among patients with pulmonary tb encompasses various aspects, drawing insights from existing literature and research findings. however, in this paper, the authors focus on areas related to improving drug adherence through digital smart applications to improve medication adherence and reduce the risk of anti-tb drug withdrawal. developing a digital smart application to monitor medication intake aims to prevent patients from discontinuing their anti-tb drugs.21 this app ensures adherence to medication schedules and minimizes confusion, particularly among elderly patients. therefore, this paper introduces a smart digital application designed to monitor adherence to tb treatment in patients with pulmonary tb.21 the proposed application features audible alerts from the patient’s mobile alarm set for specific times. table 1 shows a multidisciplinary approach aimed at establishing a medication adherence monitoring system using an effective and reliable digital smart application. the integration of internet of things and wireless body area networks represents a significant advancement in healthcare, particularly for patients with pulmonary tb, enhancing the quality of healthcare services and the overall quality of life for these individuals.23 essentially, smart digital applications facilitate healthcare services by facilitating the collection, aggregation, transmission, and analysis of medical data.24 this digital smart application proposes a design for monitoring medication adherence in patients with pulmonary tb, with implementation trials planned for 2023. the implementation of this application is intended to address the concerns of caregivers, ensuring the security of full treatment. through automatic reminders, the application will prompt patients at the correct time for medication intake, minimizing the risk of errors in dosage and medication type. conclusions this study proposes and implements smart digital applications to monitor medication adherence in elderly patients with pulmonary tb, providing significant assistance. the smart digital application automatically prompts patients at the onset of pulmonary tb, reminding them of the timing for medication intake. this feature is particularly beneficial for elderly patients, ensuring they remember to take their medicine on time. references 1. kemenkes ri. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. riset kesehatan dasar. [material in indonesian]. 2. opperman m, du preez i. factors contributing to pulmonary tb treatment lost to follow up in developing countries: an overview. african j infect dis 2023;17:60-73. 3. putra on, yulistiani y, soedarsono s. scoping review: qt interval prolongation in regimen containing bedaquiline and delamanid in patients with drug-resistant tuberculosis. int j mycobacteriol 2022;11:349-55. 4. zhang j, yang y, qiao x, et al. factors influencing medication nonadherence to pulmonary tuberculosis treatment in tibet, china: a qualitative study from the patient perspective. patient prefer adherence 2020;14:1149-58. 5. zahroh c, ainiyah n, saadah n, et al. determinant of incompliance medication people with tuberculosis disease. indian j forensic med toxicol 2021;15:909-14. 6. abqari u, van ’t noordende at, richardus jh, et al. strategies to promote the use of online health applications for early detection and raising awareness of chronic diseases among members of the general public: a systematic literature review. int j med inform 2022;162:104737. 7. dayer l, heldenbrand s, anderson p, et al. smartphone medication adherence apps: potential benefits to patients and providers. j am pharm assoc 2013;53:172-81. 8. dosi g, pereira mc, roventini a, virgillito me. technological paradigms, labour creation and destruction in a multi-sector agentbased model. res policy 2022;51:104565. 9. lepuen ap, bratajaya cna, rasmada s. tuberculosis cases finding practice: the intention of cadres. j keperawatan indones 2020;23:128-35. 10. who. primary health care on the road to universal health coverage: 2019 global monitoring report. executive summary. available from: https://www.who.int/publications/i/item/9789240029040. 11. rahmadi c, efendi f, makhfudli m. the effect of reminder system and audio-visual education to improve treatment adherendce on pulmonary tuberculosis patients: a systematic review. mal j med heal sci 2023;19:145-55. 12. zein ra, suhariadi f, hendriani w. estimating the effect of lay knowledge and prior contact with pulmonary tb patients, on health-belief model in a high-risk pulmonary tb transmission population. psychol res behav manag 2017;10:187-94. 13. goos m, rademakers e, roettger r. routine-biased technical change: individual-level evidence from a plant closure. res policy 2021;50:104002. 14. nugrahaeni dk, rosmalaningrum l. risk factors in pulmonary tuberculosis treatment failure. indones j public heal 2021;16:12. 15. sukartini t, purwanti nd, mariyanti h. family health tasks implementation and medication adherence of pulmonary tuberculosis patients: a correlational study. j ners 2020;15:49-58. 16. putra iwgae, kurniasari nmd, dewi npep, et al. the implementation of early detection in tuberculosis contact investigation to improve case finding. j epidemiol glob health 2019;9:191-7. 17. zachariah r, spielmann mp, harries ad, et al. passive versus active tuberculosis case finding and isoniazid preventive therapy among household contacts in a rural district of malawi. int j tuberc lung dis 2003;7:1033-9. 18. gashu kd, gelaye ka, lester r, tilahun b. effect of a phone reminder system on patient-centered tuberculosis treatment adherence among adults in northwest ethiopia: a randomised controlled trial. bmj heal care inform 2021;28:e100268. 19. banu s, haque f, ahmed s, et al. social enterprise model (sem) for private sector tuberculosis screening and care in bangladesh. plos one 2020;15:e0241437. 20. eastment mc, mcclintock ah, mckinney cm, et al. factors that influence treatment completion for latent tuberculosis infection. j am board fam med 2017;30:520-7. 21. wong yj, ng ky, lee swh. digital health use in latent tuberculosis infection care: a systematic review. int j med inform 2022;159:104687. 22. sholikhah du, sari gm, narendri cm, et al. the use of health technology to enhance the adherence of tuberculosis treatment: a systematic review. j ners 2019;14:65-70. 23. thoumrungroje a, racela oc. innovation and performance implications of customer-orientation across different business strategy types. j open innov technol mark complex 2022;8:178. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 524] [healthcare in low-resource settings 2024;12:11995] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11958 the effect of light massage and spiritual emotional freedom technique interventions on blood pressure among hypertension patients in indonesia arsyawina arsyawina, rivan firdaus, diah setiani, raisyah chaiarunnisya nursing study program, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia abstract hypertension remains a significant global public health concern. non-pharmacological interventions such as light massage and the spiritual emotional freedom technique (seft) offer potential avenues to mitigate sustained increases in blood pressure among patients with hypertension. however, research exploring these methods as alternative therapies, particularly in indonesia, is limited. this study aimed to investigate the effects of light massage and seft on the blood pressure of hypertensive individuals. employing a quasi-experimental design with a time series approach, the study utilized purposive sampling to select 27 participants. light massage and seft were considered independent variables, while blood pressure served as the dependent variable. data analysis involved repeated measures anova and one-way anova tests. the results revealed significant differences in mean blood pressure before and after the light massage intervention (pvalues: 0.002, <0.001, <0.001). the intervention sessions yielded the most significant results (p-values: <0.001, 0.002, <0.001), whereas no differences were observed in the control group (systolic and mean arterial pressure, map, p-values: 0.012 and 0.017, respectively). notably, there were discrepancies in mean blood pressure before and after interventions in both the light massage and seft groups, indicating a potential benefit of these interventions. conversely, no such differences were noted in the control group. these results highlight the potential benefits of integrating light massage and seft into holistic approaches for managing hypertension, potentially improving outcomes and quality of life for affected individuals. introduction hypertension is classified as a noncommunicable disease (ncd).1,2 it refers to a condition characterized by abnormally high blood pressure in the arteries, persisting over time.3 the term “hypertension” stems from the combination of “hyper,” meaning excessive, and “tension,” referring to pressure, denoting an elevation in blood pressure beyond the normal range due to circulatory system disorders.4-6 according to data collected by the world health organization (who) in 2015, approximately 1.13 billion people worldwide, or one in three individuals globally, are diagnosed with hypertension. with the escalating number of hypertension cases annually, it is projected that by 2025, there will be 1.5 billion individuals living with hypertension. moreover, hypertension and its complications contribute to an estimated 9.4 million deaths annually.1 in indonesia, based on the national health survey, the prevalence of hypertension among individuals aged 18 years and above is 34.1%. the highest prevalence is observed in south kalimantan, while the lowest is in papua. the estimated number of hypertension cases in indonesia is 63,309,620, with 427,218 deaths attributed to hypertension. in east borneo province, specifically, the number of hypertension cases among individuals aged 18 years and above was 8,957 in 2018, reflecting a 39.30% correspondence: rivan firdaus, nursing study program, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: poltekkeskaltim.rivan@gmail.com key words: blood pressure; hypertension; light massage; spiritual emotional freedom technique (seft). contributions: aa, conceptualization, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rf, conceptualization, data curation, investigation, methodology, validation, and writing – original draft, review & editing; ds, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; rc, methodology, visualization, writing – review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, east kalimantan ministry of health polytechnic, based on ethical certificate 07742-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank bengkuring community health center for their valuable insights and contributions to this study. we also wish to acknowledge the valuable contributions of the mentoring program conducted by the research centre of excellence in advancing community health (reach) in surabaya, indonesia. received: 12 october 2023. accepted: 27 may 2024. early access: 1 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11958 doi:10.4081/hls.2024.11958 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 558] [healthcare in low-resource settings 2024;12:11958] non -co mmerc ial us e o nly increase compared to 2017.1 recent estimations from the samarinda city health office in 2022 reported approximately 9,936 hypertension cases in samarinda, with 897 cases recorded at the bengkuring samarinda public health center. various factors contribute to the development of hypertension, including internal factors such as gender, age, and genetics, as well as external factors like smoking, alcohol consumption, physical inactivity, and obesity.7,8 if left unaddressed, hypertension can lead to organ damage and heart disease.9-12 non-pharmacological therapies, such as light massage and the spiritual emotional freedom technique (seft), can be administered to hypertension patients to prevent sustained increases in blood pressure. these therapies induce relaxation, alleviate muscle stiffness, and dilate blood vessels, resulting in a gradual decrease in blood pressure.4,13 seft combines energy medicine and spiritual therapy, involving tapping techniques on specific points along the body’s energy meridians to stimulate key points and promote relaxation.5 research conducted by wijaya demonstrated the efficacy of seft therapy in reducing blood pressure, establishing it as a viable alternative for managing hypertension.14 similarly, studies by maswarni10 and permatasari15 concluded that seft therapy effectively lowers blood pressure in hypertensive patients. given the preliminary study’s indication of a high prevalence of hypertension in samarinda city, particularly at the bengkuring community health center where 897 cases were recorded. the objective of this study was to assess the effects of light massage and seft on the blood pressure of hypertensive patients and to compare their efficacy in reducing blood pressure. materials and methods research design this research was conducted in the working area of bengkuring public health center in samarinda from february to april 2023. the study employed a quasi-experimental design with a time-series approach, utilizing a preand post-test design with a control group. study participants the study population consisted of hypertension patients at the bengkuring health center in samarinda, comprising a total of 27 individuals divided into three groups, with 9 participants in each group: a control group, a light massage group, and an seft group. the sampling method utilized was purposive sampling to select the total sample, which was then randomized into the two groups. inclusion criteria included patients diagnosed with hypertension by a physician, absence of other complicating diseases, ability to communicate effectively, and no hearing impairments. study procedure data collection involved pre-test blood pressure measurements, followed by either intervention of light massage or seft. light massage, characterized by gentle movements on soft tissues, including wiping and rubbing, aims to induce comfort, release muscle tension, and enhance blood circulation.16 seft, a complementary therapy targeting physical, emotional, and spiritual responses, employs gentle tapping on 18 meridian points to promote relaxation. this method integrates energy medicine and spiritual therapy, incorporating client affirmations or prayers at the beginning and end of sessions.17,18 both light massage and seft were administered once daily for three consecutive days, each session lasting 15-20 minutes in the morning. similar interventions were repeated on the second and third day, followed by post-test measurements. the control group did not receive any intervention. variable and instrument the independent variables consist of light massage and the seft method, while the dependent variable is blood pressure, which is measured in terms of systolic, diastolic, and mean arterial pressure (map). map is calculated by adding one-third of the pulse pressure to the diastolic pressure. the research instruments utilized include a digital sphygmomanometer, olive oil, standard operating procedures (sops) for light massage and seft, as well as research observation sheets. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of blood pressure across groups (n=27). group mean ±sd min-max light massage pre-test systolic 153.83 14.44 137-179 post-test systolic 1 137.11 13.98 116-159 post-test systolic 2 135.22 16.58 115-169 post-test systolic 3 128.67 9.93 118-151 pre-test diastolic 95 6.91 83-103 post-test diastolic 1 84 5.45 75-91 post-test diastolic 2 88.11 8.08 78-103 post-test diastolic 3 80.33 7.79 71-95 map pre-test 114.67 8.67 101-126 map post-test 1 101.78 7.64 91-114 map post-test 2 103.67 10.29 92-125 map post-test 3 96.44 7.97 89-109 seft pre-test systolic 163 24,28 131-202 post-test systolic 1 159.22 23.73 128-198 post-test systolic 2 158.44 21.73 133-194 post-test systolic 3 153.22 24.18 121-189 pre-test diastolic 99 8.95 89-113 post-test diastolic 1 98 8.41 86-112 post-test diastolic 2 97 6.89 89-108 post-test diastolic 3 92 9.43 81-107 map pre-test 120.33 10.87 104-135 map post-test 1 119.22 10.87 100-132 map post-test 2 116.67 9.79 104-131 map post-test 3 112.44 11.9 98-129 control pre-test systolic 150.11 17.23 129-176 post-test systolic 1 149.89 18.23 126-179 post-test systolic 2 144 16.52 118-174 post-test systolic 3 155.56 12.3 136-169 pre-test diastolic 99.11 14.78 80-116 post-test diastolic 1 100.56 14.95 82-118 post-test diastolic 2 96.11 14.12 72-113 post-test diastolic 3 101 15.52 78-119 map pre-test 116.11 14.27 97-138 map post-test 1 116.78 15.02 98-138 map post-test 2 112.11 14.34 87-133 map post-test 3 119.11 13.43 98-134 map, mean arterial pressure; seft, spiritual emotional freedom technique. [healthcare in low-resource settings 2024;12:11958] [page 559] non -co mmerc ial us e o nly data analysis each group will undergo testing using repeated anova. to compare means between groups, researchers will employ one-way anova with a significance level of 5% or a p-value of 0.05. ethical clearance the research has received ethical approval from the health research ethics commission at the east kalimantan ministry of health polytechnic, based on ethical certificate 07742-kepk. throughout the research process, the researcher has adhered to ethical principles including informed consent, respect for human rights, beneficence, and non-maleficence. results table 1 compares the blood pressure measurements before and after interventions in three groups: light massage, seft, and a control group. in the light massage group, pre-test systolic blood pressure ranged from 137 mmhg to 179 mmhg, and diastolic blood pressure from 83 mmhg to 103 mmhg, with mean values of 153.83 mmhg and 95.00 mmhg, respectively. post-test measurements showed a decrease in both systolic and diastolic blood pressure. for the seft group, pre-test systolic blood pressure ranged from 131 mmhg to 202 mmhg, and diastolic blood pressure from 89 mmhg to 113 mmhg, with mean values of 163.00 mmhg and 99.00 mmhg, respectively. post-test measurements indicated a decrease in both systolic and diastolic blood pressure. in the control group, pre-test systolic blood pressure ranged from 129 mmhg to 176 mmhg, and diastolic blood pressure from 80 mmhg to 116 mmhg, with mean values of 150.11 mmhg and 99.11 mmhg, respectively. overall, there were differences in mean blood pressure values before and after interventions in both the light massage and seft groups, while the control group showed less change. table 2 presents the results of mean blood pressure differences before and after interventions in the light massage, seft, and control groups. in the light massage group, significant differences were observed in systolic, diastolic, and map measurements on day 3 post-intervention (p-value<0.05). conversely, the seft group showed significant differences only in systolic and diastolic measurements on the same day (p-value<0.05). no significant differences were observed in the control group’s blood pressure values. table 3 presents the significance values of the post-test systolic blood pressure, diastolic blood pressure, and map for both the intervention light massage group, seft group, and the control group, with p-values of 0.004, 0.003, and 0.001, respectively, all of which are less than 0.05. based on these values, it can be concluded that there is a significant difference in blood pressure among the three groups. table 4 presents the results of a one-way anova test comparing mean blood pressure differences between the intervention group (light massage and seft) and the control group among hypertensive patients in the bengkuring community health center’s working area. the results indicate significant differences in blood pressure among the three groups. specifically, the light massage intervention group exhibited more significant differences compared to the seft group, with mean systolic, diastolic, and map differences of -24.6, -11.7, and -16, respectively, with p-values of 0.012, 0.097, and 0.017. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 560] [healthcare in low-resource settings 2024;12:11958] table 2. frequency distribution of blood pressure across groups (n=27). blood pressure repeated anova test mean difference ci 95% p light massage group pre-test systolic vs post-test 1 16.8 7.5-26 0.001 pre-test vs post-test 2 18.7 1.6-35.7 0.031 pre-test vs post-test 3 25.2 10.4-40 0.002 post-test 1 vs post-test 2 1.9 16-19.8 1 post-test 1 vs post-test 3 8.4 -6.9-23.8 0.552 post-test 2 vs post-test 3 6.6 -3.3-16.4 0.298 pre-test diastolic vs post-test 1 11 5.8-16.2 0.000 pre-test vs post-test 2 6.9 -1.9-15.7 0.158 pre-test vs post-test 3 14.7 9.3-20 0.000 post-test 1 vs post-test 2 -4.1 -13.9-5.7 1 post-test 1 vs post-test 3 3.7 -2.1-9.4 0.348 post-test 2 vs post-test 3 7.8 0.9-14.7 0.026 map pre-test vs post-test 1 12.9 7.1-18.7 0.000 pre-test vs post-test 2 11 0.1-21.9 0.048 pre-test vs post-test 3 18.2 10.3-21.9 0 post-test 1 vs post-test 2 -1.9 -14-10.3 1 post-test 1 vs post-test 3 5.3 -3.2-13.9 0.370 pre-test vs post-test 3 14.7 9.3-20 0.000 post-test 1 vs post-test 2 -4.1 -13.9-5.7 1 seft group pre-test systolic vs post-test 1 3.8 2.5-5 0.000 pre-test vs post-test 2 4.6 -1-9.7 0.094 pre-test vs post-test 3 9.8 6.5-13.1 0.000 post-test 1 vs post-test 2 0.8 -3.6-5.2 1 post-test 1 vs post-test 3 6 2.3-9.7 0.003 post-test 2 vs post-test 3 5.2 -0.1-10.5 0.054 pre-test diastolic vs post-test 1 0.1 -8.8-9 1 pre-test vs post-test 2 2 -12 1 pre-test vs post-test 3 7 2.9-11.1 0.002 post-test 1 vs post-test 2 1.9 2.4-6.2 0.979 post-test 1 vs post-test 3 6.9 2.4-16.2 0.194 post-test 2 vs post-test 3 5 -0.7-10.7 0.093 pre-test map vs post-test 1 1.1 -4.8-7 1 pre-test vs post-test 2 3.7 -1.9-9.2 0.306 pre-test vs post-test 3 7.9 -1.9-9.2 0.000 post-test 1 vs post-test 2 2.6 -2.7-7.8 0.774 post-test 1 vs post-test 3 6.8 0.4-13.1 0.035 control group pre-test systolic vs post-test 1 0.2 -2.8-3.2 1 pre-test vs post-test 2 6.1 -7.1-19.3 0.872 pre-test vs post-test 3 -5.4 -15.6-4.7 0.590 post-test 1 vs post-test 2 -5.9 -8.5-20.3 1 post-test 1 vs post-test 3 -5.7 -17.9-6.6 0.874 post-test 2 vs post-test 3 -11.6 -25.8-2.7 0.136 pre-test diastolic vs post-test 1 -1.4 -5.6-2.7 1 pre-test vs post-test 2 3 -8.1-14.1 1 pre-test vs post-test 3 -1.9 -11.3-7.5 1 post-test 1 vs post-test 2 4.4 -5.2-14.1 0.887 post-test 1 vs post-test 3 -0.4 -9.2-8.4 0.1 post-test 2 vs post-test 3 -4.9 -10.7-0.9 0.115 pre-test map vs post-test 1 -0.7 -3.8-2.5 1 pre-test vs post-test 2 4 -22 1 pre-test vs post-test 3 -3 -10.6-4.6 1 post-test 1 vs post-test 2 4.7 -6-15.4 1 post-test 1 vs post-test 3 -2.3 -11.1-6.5 1 post-test 2 vs post-test 3 -7 -14.7-0.7 0.080 map, mean arterial pressure; seft, spiritual emotional freedom technique non -co mmerc ial us e o nly discussion the study results in the light massage intervention group revealed a significant difference between the average pre-test and post-test systolic and diastolic blood pressure, indicating that light massage effectively lowers blood pressure in patients with primary hypertension. this process involves inducing relaxation in the smooth muscles of arteries, veins, and other muscles throughout the body, leading to reduced levels of norepinephrine in the blood.19 sihotang’s study,20 which utilized paired sample t-tests, found significant data with a p-value of 0.000 for post-reflexology foot massage systolic blood pressure and 0.037 for post-reflexology foot massage diastolic blood pressure. this suggests a tangible difference in blood pressure before and after reflexology massage, highlighting its potential to reduce hypertension.13 however, it’s worth noting that four respondents experienced an increase in blood pressure on the second day of the three-day intervention, as per the researchers’ observations. the study results within the seft intervention group revealed a notable disparity between the mean pre-test and post-test systolic and diastolic blood pressure. huda’s study,21 showcased a significant reduction in both systolic and diastolic blood pressure among participants undergoing seft therapy, indicating its efficacy in mitigating hypertension. seft therapy fosters a sense of comfort and relaxation, alleviating physical complaints such as dizziness, muscle pain, neck pain, and lower back pain. huda’s findings,21 employing paired t-tests for data analysis in the intervention group, yielded a calculated t-value of 8.699 for systolic blood pressure with a p-value of 0.000. consequently, it is evident that seft therapy brings about a significant difference between pre and postseft therapy measurements. the researchers hypothesized that blood pressure would significantly decrease in the treatment group following seft therapy. this expectation stems from the combined effect of tapping stimuli on the body’s meridian points and the inclusion of spiritual elements such as prayer, which may induce a calming effect known to lower blood pressure. however, during the three-day intervention, on the second day, three respondents experienced an increase in blood pressure compared to the previous day. one respondent attributed this to overwhelming thoughts causing dizziness and stress, while another mentioned it was due to post-work activities. the results from the control group indicated no significant difference between the average pre-test and post-test systolic and diastolic blood pressure. however, a noteworthy finding emerged regarding map in the control group, showing a significant difference between pre-test and post-test averages. thus, it can be inferred that there’s no substantial variance in blood pressure levels within the control group before and after testing. additionally, arwani’s study,8 focusing on the control group receiving standard pharmacological therapy without additional interventions, observed that six respondents experienced a decrease in blood pressure compared to the previous day during the three-day research period. reasons cited included respondents just waking up and engaging in minimal activity, such as watching television or using mobile phones. the researchers attributed this to the noticeable relaxation experienced by respondents during the light massage intervention, with some even falling asleep. the technique involved gentle pressing, rubbing, and massaging various body parts. notably, the majority of respondents in the light massage group were housewives who reported feeling fatigued and stressed due to their daily routines. consequently, the light massage intervention induced feelings of reduced fatigue, enhanced relaxation, and calmness, leading to a significant decrease in blood pressure. in contrast, the seft interventions primarily involved tapping at specific points, which may not have elicited the same level of relaxation and subsequent blood pressure reduction. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11958] [page 561] table 3. comparing blood pressure changes between intervention and control groups (n=27). blood pressure one-way anova average p systolic light massage 128.7 (9.9) 0.004 seft 153.2 (24.2) control 155.6 (12.3) diastolic light massage 80.3 (7.8) 0.003 seft 92 (9.4) control 101 (15.5) map light massage 96.4 (2.7) 0.001 seft 112.4 (4) control 119.1 (4.5) map, mean arterial pressure; seft, spiritual emotional freedom technique. table 4. one-way anova comparing blood pressure changes post-test between intervention and control groups (n=27). blood pressure one-way anova average difference min max p systolic light massage vs seft -24.6 -44.2 -4.9 0.012 light massage vs control -26.9 -46.5 -7.3 0.006 seft vs control -2.3 -22 17.3 0.953 diastolic light massage vs seft -11.7 -25.1 1.8 0.097 light massage vs control -20.7 -34.1 -7.2 0.002 seft vs control -1.4 -22.4 4.4 0.236 map light massage vs seft -16 -29.3 -2.7 0.017 light massage vs control -22.7 -36 -9.3 0.001 seft vs control -6.7 -20 6.7 0.438 map, mean arterial pressure; seft, spiritual emotional freedom technique. non -co mmerc ial us e o nly conclusions based on the results of the repeated anova mean difference test, significant differences in blood pressure were observed between pre-test and post-test measurements in both the light massage and seft intervention groups. the most notable discrepancies were noted in systolic, diastolic, and map values on the third day for both interventions. conversely, the control group exhibited no significant changes in blood pressure. hence, it can be inferred that both light massage and seft interventions affect blood pressure in the working area of bengkuring 3 public health center. references 1. riskesdas. kementerian kesehatan republik indonesia. 2018. available from: https://sippn.menpan.go.id/instansi/24/ kementerian-kesehatan-republik-indonesia 2. israfil i, yusuf a, efendi f, et al. exploring the primary health facility availability, health control, drug consumption, and healthy living behavior among patients with hypertension. healthc low-resource settings. 2024;12:11867. 3. fadilah sz, susanti ia, setyorini dy, pradipta ro. effectiveness of mobile-based health interventions for the management of hypertensive patients: a systematic review. j ners. 2020;15:238-45. 4. muriyati, yahya s. gaya hidup dengan kejadian hipertensi di wilayah pegunungan dan pesisir kabupaten bulukumba. j kesehat panrita husada. 2018;3:35-51. 5. kartikasari i, sarwani d, rejeki s, pramatama s. literature review : faktor-faktor yang mempengaruhi tingkat kepatuhan pengobatan pada pasien hipertensi di berbagai wilayah indonesia. j pendidik tambusai. 2022;6:11665-76. 6. putri dafriani. pendekatan herbal dalam menangani hipertensi. 2019. available from: https://www.google.com/ search?q=pendekatan+herbal+dalam+menangani+hipertensi &rlz=1c5chfa_enit976it976&oq=pendekatan+herbal+da lam+menangani+hipertensi&gs_lcrp=egzjahjvbwuybgga eeuyotihcaeqirigadibbzuyogowajsoagcwaga&so urce id =ch ro me&ie=u tf -8# :~ : t ex t=pen deka t an% 20herbal%20%2d%20dalam,io%20%e2%80%ba%20download 7. makhfudli, susanto j, sairozi a, ubudiyah m. determinants of hypertension in outpatients in east java, indonesia. j pak med assoc. 2023;73:s113-7. 8. tanziha i, febriana sa, oginawati k, et al. the risk factors of hypertension among female batik workers in yogyakarta indonesia. malaysian j med heal sci. 2023;19:93-4. 9. calisanie nnp, susanti s, lindayani l. cardiovascular risk estimation in patients with hypertension: a cross-sectional study. j ners. 2020;15:98-104. 10. warni m. pengaruh keberhasilan terapi spritual emotional technique (seft) terhadap penurunan tekanan darah di desa pandau jaya kec.siak hulu kab.kampar. j keperawatan abdurrab. 2020;4:54-9. 11. utari ab, rochmah tn. the analysis of hypertension burden disease in the community of kediri district. indones j public heal. 2019;14:138-49. 12. israfil i, yusuf a, efendi f, et al. factors associated with behavior in the prevention of cardiovascular complications in hypertensive patients in indonesia: a systematic review. 2022. available from: https://scholar.unair.ac.id/en/publications/factors-associated-with-behavior-in-the-prevention-of-cardiovascu 13. nurjanah da, harmayetty, mishbahatul e. relaxing melody from flute combined with a foot massage can reduce systolic and diastolic blood pressure in elders. medico-legal updat. 2019;19:398-403. 14. wijaya ds, etika an. terapi spritual emotional freedom technique (seft) terhadap penurunan tekanan darah pada lansia dengan hipertensi. j holist tradit med. 2017;02:1338. 15. permatasari as, sri r, pujiastuti e, kristatnto d. spiritual emotional freedom technique (seft) intervention on blood pressure among pregnancy with hypertension. international journal of nursing and health service. 2020;3:402-10. 16. awaludin s, sumeru a, alivian gn, hidayat ai. the effect of light massage on periferal blood circulation in tuberculosis patients. j ilmu kesehat. 2020;8:96-102. 17. jumain, talindong a, wahyu, et al. spiritual emotional freedom technique (seft) to lower blood pressure in hypertension sufferers: a systematic review. j heal. 2024;11:109-18. 18. kurnia v, pauzi m, ramadanti t, et al. spiritual emotional freedom technique (seft) on blood pressure in hypertensive patients. j kesehat holist. 2023;07:28-36. 19. maulana fh, haryanto j, ulfiana e. the effect of lower extremity massage with lavender essential oil on decreasing blood pressure in elderly with hypertension in uptd griya werdha surabaya. indian j public heal res dev. 2019;10:1488-93. 20. widiya ni ngsih ar. efektivitas terapi pasien hipertensi dengan intervensi inovasi rendam kaki air jahe kombinasi light massage di ruang rawat inap dewasa rsi pku muhammadiyyah palangkaraya tahun 2022. al-irsyad. 2022;105:79. 21. huda s, alvita gw. pengaruh terapi seft (spiritual emotional freedom technique) terhadap penurunan tekanan darah pada penderita hipertensi di wilahah puskesmas tahunan. j keperawatan dan kesehat masy cendekia utama. 2018;7:114. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 562] [healthcare in low-resource settings 2024;12:11958] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12929 evaluation of the impact of vitamin d on blood pressure in patients with diabetes mellitus muhammad khalif alghifari,1 mira delima asikin,2 sari eka pratiwi,1 suriadi jais3 1medical study programme, faculty of medicine, tanjungpura university, pontianak; 2department of internal medicine, tanjungpura university hospital, pontianak; 33 department of biology and pathobiology, faculty of medicine, tanjungpura university, pontianak; 4graduate nursing program, institut teknologi dan kesehatan muhamamdiyah kalbar, kubu raya, pontianak, indonesia abstract this study assessed the effects of vitamin d on blood pressure in individuals diagnosed with diabetes mellitus. convenience sampling and a cross-sectional, analytical, quantitative approach were used. blood samples were collected and analysed by a designated laboratory officer to measure vitamin d levels. twentyeight (70%) women, 18 (45%) housewives with a median age of 52 (36-60), median systole of 143.5 (102-180), and median diastole of 80 years (range, 59-110 years). thirty-five (87.5%) had fasting blood glucose over 140 mg/dl, and 33 (82.5%) postprandial more than 100 mg/dl. the predictive validity test showed that a systole cut-off score of 160-179 yielded sensitivity, specificity, lr+, and lr– (81%, 67%, 2.4, and 0.3). systole had a lr+ of 2.4 and was a moderate diagnostic test. diastole cut-off score of 9099 produced sensitivity, specificity, lr+, and lr– (84%, 67%, 2.5, and 0.2). the roc for systole was auc 0.65 (95% ci: 0.490.80) and diastole had auc 0.67 (95% ci: 0.50-0.81). patients with diabetes and hypertension were found to have vitamin d levels <30 ng/ml. introduction diabetes mellitus (dm) is a metabolic disorder characterised by hyperglycaemia and elevated blood glucose levels beyond the normal range. dm is a significant health issue, and its prevalence is steadily increasing worldwide. according to the international diabetes federation (idf), in 2021, there were 536.6 million individuals with dm worldwide, with a prevalence rate of 10.5.1 dm has risen to become the seventh leading cause of death globally since 2013. in indonesia, dm prevalence has shown an upward trend, as reported by riskesdas (2018). in 2013, the prevalence was 6.9%, which grew to 8.5% in 2018.2 according to the most recent data from the idf for 2021, indonesia has ranked fifth globally with a total of 19.5 million individuals affected with dm.3 type 2 diabetes mellitus (t2dm) is a medical disorder characterised by a diminished ability to respond to insulin or impaired insulin activity in muscle and liver cells.4 this leads to elevated blood sugar levels; pancreatic beta cells try to adjust for this by decreasing their function. blood vitamin d levels also affect insulin synthesis in pancreatic beta cells. vitamin d plays a crucial role in the functioning of pancreatic beta cells, as well as in insulin sensitivity and release, both through direct and indirect pathways.5 insufficient levels of vitamin d are linked to a higher likelihood of developing metabolic syndrome, a collection of risk factors for t2dm.6 vitamin d deficiency might indirectly affect insulin resistance by influencing aldosterone levels in the renin-angiotensinaldosterone system (raas). angiotensin suppresses the action of insulin in blood vessels and muscles, leading to a disruption in the absorption of glucose and the fulfilment of energy requirements.7 a research conducted by shaheen in 2017 revealed that individuals with t2dm have deficient levels of vitamin d of ˂20 ng/ml. the statement above indicates that vitamin d may have a role in preventing t2dm in individuals who have not benefited from rigorous lifestyle changes. individuals with t2dm can develop vascular problems, including hypertension. hypertension in individuals with dm results from high blood sugar levels, which might enhance the activation of the raas. previous research has indicated a correcorrespondence: sari eka pratiwi, faculty of medicine, tanjungpura university, pontianak-indonesia. tel.: 0561.765342. e-mail: sariekapratiwi@medical.untan.ac.id key words: diabetes, sensitivity, specificity, vitamin d, systole. contributions: mka, conceptualization, data curation, formal analysis, investigation, methodology, project administration, writing – original draft; sj, formal analysis, software, validation, visualization, review and editing; mda and sep, methodology and supervision. ethics approval: this study was approved by the research ethics committee of the school of medicine, university of tanjung pura, pontianak (no.8026/un22/9/pg/2023) and was performed in accordance with the latest version of the declaration of helsinki. written informed consent was obtained from all the participants. consent for publication: not applicable availability of data and material: not applicable conflict of interest: the authors declare that they have no conflict of interests. funding: not applicable received: 16 august 2024. accepted: 27 october 2024. early access: 28 november 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12929 doi:10.4081/hls.2024.12929 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:12929] [page 59] lation between vitamin d levels and blood pressure in both individuals with and without dm. elevated blood 25(oh)d levels are strongly linked to a reduced risk of cardiovascular disease in individuals with t2dm, regardless of genetic predisposition or variations in the vitamin d receptor (vdr) gene. vitamin d has the ability to inhibit the gene responsible for producing renin, thus preventing the activation of renin-angiotensin-aldosterone and eventually preventing an increase in blood pressure.9,10 in addition, vitamin d has the ability to block the production of cox-2 in the macula densa cells of the kidney. this prevents the conversion of arachidonic acid into prostaglandins, which ultimately leads to the inhibition of the renin gene.9 an unhealthy lifestyle is a risk factor for hypertension in individuals with dm.9 in the health service system, patients with dm with complications such as hypertension, as well as risk factors for complications such as the effect of vitamin d levels on dm and blood pressure, have not been widely studied in indonesia. studies on the association between vitamin d levels, diabetes, and hypertension are lacking. individuals unable to implement significant lifestyle changes may find it challenging to prevent this condition. hence, vitamin d shows significant promise as a readily accessible, cost-effective, and secure means for lowering blood pressure. this study aimed to evaluate the sensitivity, specificity, and likelihood ratio of vitamin d on blood pressure in patients with dm. materials and methods this study employed a cross-sectional, quantitative analytical research method. this study was conducted in the outpatient clinic of tanjung pura university teaching hospital using convenience sampling. participants diagnosed with dm and hypertension, those aged ˂60 years without comorbidities, including kidney failure, heart failure, or stroke, and those receiving regular outpatient therapy were included in this study. a designated laboratory officer was responsible for collecting and analysing blood samples exclusively for vitamin d examinations. the serum vitamin d (25[oh]d) levels of patients were examined using the chemiluminescent microparticle immunoassay method with reagents from architect at the prodia pontianak clinical laboratory; samples were taken from patients who underwent examination and routine follow-up at the polyclinic of the tanjungpura university teaching hospital. the primary researcher collected demographic data, and blood pressure was measured using the health questionnaire to collect information on history, hypertension, and diabetes. a digital monitor from omron (model hem-7113) was used for the blood pressure measurements. ethics approval this study was approved by the research ethics committee of the school of medicine, university of tanjung pura, pontianak (no.8026/un22/9/pg/2023) and was conducted in accordance with the latest version of the declaration of helsinki. written informed consent was obtained from all the participants. statistical analysis descriptive analysis was used for the characteristic data. sensitivity and specificity are the two fundamental measurements used to estimate the diagnostic accuracy of a test.11 sensitivity refers to a test’s capacity to accurately identify the presence of a disease, while specificity refers to a test’s ability to correctly rule out the condition in individuals who do not have it. the sensitivity was calculated as the ratio of true positives to the sum of true positives and false negatives, whereas the specificity was calculated as the ratio of true negatives to the sum of true negatives and false positives. the likelihood ratio (lr) is calculated as the ratio of the probability of obtaining a positive test result in patients with the disease to the probability of obtaining the same test result in patients without the condition. in other words, lr is a measure of how sensitive compared to (100 specificity). the magnitude of lr indicates the level of certainty of a positive diagnosis. an lr = 1 indicated an equal likelihood of test results in patients with and without the disease. lr >1 indicates a higher likelihood of the test result in patients with the disease, while lr <1 indicates a higher likelihood of the test result in patients without the disease.11 also, we analysed vitamin d12,13 and blood pressure categories13 with the concordance statistic (c-statistic) or receiver operator characteristic (roc) curve area.14 the statistical analysis used a significance level of p <0.05. exploratory statistical analyses were performed using the medcalc statistical software version 22.009 (medcalc software bvba, ostend, belgium). results the baseline characteristics of the patients are illustrated in table 1. twenty-eight (70%) were female, 18 (45%) were housewives. the median age was 52 (36–60) years, the median systole was 143.5 (102–180), and the median diastole was 80 (59–110). thirty-five (87.5 %) were fasting blood glucose (>140 mg/dl) and 33 (82.5%) postprandial blood glucose (>100 mg/dl). the sensitivities, specificities, and lr were calculated for the systole scores and ranged from ˂120 to >180 mmhg (table 2). the predictive validity test indicated that a systole cut-off score of 160– 179 produced the sensitivity, specificity, lr+, and lr– (81%, 67%, 2.4, and 0.3, respectively). systole was found to be a smallto-moderate diagnostic test with a plr of 2.4. while diastole cutoff score of 90–99 produced the sensitivity, specificity, lr+ and lr– (84%, 67%, 2.5, and 0.2, respectively). in figure 1, sensitivity was plotted vs. 1-specificity for each possible score of the systole to generate the roc; auc 0.65 (95% ci: 0.49–0.80). while diastole: auc 0.67 (95% ci: 0.50–0.81). article table 1. characteristic of participants. variable sex n (%) male 12 (30) female 28 (70) occupation n (%) public servant 10 (25) private 12 (30) housewife 18 (45) age, median (min-max) years 52 (36-60) systole, median (min-max) mmhg 143.5 (102-180) diastole, median (min-max) mmhg 80 (59-110) fasting blood glucose n (%) <140 mg/dl 5 (12.5) >140 mg/dl 35 (87.5) postprandial blood glucose n (%) <100 mg/dl 7 (17.5) >100 mg/dl 33 (82.5) vitamin d, median (min-max) 18.4 (4.6-54.2) [page 60] [healthcare in low-resource settings 2024;12:12929] discussion characteristic of participants the study’s sex characteristics revealed that the number of women was 70% higher. these results are not the same as those of other researchers who reported that there were no differences between sexes and women who suffer from t2dm.15 this discrepancy could be attributed to small sample sizes. the job characteristics revealed that 45% of the patients were housewives. the results of this study are the same as those of other studies in which individuals who did not work were at risk of developing dm.16 occupational factors influence the major risk of developing dm. working with light physical activity will cause a lack of energy burning by the body, so excess energy in the body will be stored in the form of fat, which results in obesity, a risk factor for dm.17 the median age was 52 years, and the results of this study are consistent with other studies showing that patients with dm are generally aged >40 years and have a tendency to experience a risk of vascular disorders. blood sugar results revealed that most patients undergoing outpatient treatment or follow-up treatment (80%) had uncontrolled blood sugar levels. this shows that patients who undergo routine follow-up dm treatment are still less aware of the impact of the risk of complications that may occur to them. therefore, it is crucial for service providers to deliver comprehensive and multidisciplinary services optimally. patients with dm require comprehensive and multidisciplinary care to prevent complications.19,20 this study found that the median systole was 143.5 mmhg, and it can be concluded that patients with dm are at risk of developing hypertension. sensitivity, specificity, and likelihood ratio our study found that individuals with dm with a systolic blood pressure level between 160 and 179 have a sensitivity of 81% and a specificity of 67% in relation to vitamin d levels below and above 30 ng/ml (table 3). nevertheless, this categorisation failed to accurately assess the vitamin d levels <30 ng/ml, underestimating it by only 19%. furthermore, the accuracy of this categorisation was 67%. it inaccurately predicted the lack of good results for vitamin d levels of 30 ng/ml by 23%. this study demonstrated high sensitivity; however, our classification showed low specificity and was associated with a substantial false-positive rate. a precise test yields a low number of false-positive results. this study also showed equivalent levels of sensitivity and specificity in diastolic blood pressure tests for vitamin d levels at or over 30 ng/ml. individuals in this study who had vitamin d levels ˂30 ng/ml, both systolic and diastolic blood pressure, and were classified as having hypertension also exhibited lr values of >1, indicating the presence of positive illnesses.11 our study confirmed previous study findings indicating a substantial correlation between decreased vitamin d levels and those diseased with both dm and hypertension.15 literature review studies indicate that there is an ongoing disagreement over the correlation between a decline in vitamin d levels and the occurrence of hypertension.16 it was concluded that hypertension can occur owing to many factors. our study found that the median age of the participants was 52 years. this finding aligns with prior systematic literature reviews and meta-analysis, which have reported a substantial difference in age groups, namely those over 50.17 there is empirical data indicating that the incidence of hypertension rises in correlation with advancing age. as individuals age, their capacity to absorb and metabolise vitamin d diminishes, leading to vitamin d deficiency. vitamin d3 supplementation in those aged >50 years with low vitamin d levels will lead to a considerable drop in systolic blood pressure once their vitamin d levels return to normal.17 in patients with dm, there is an increasing number of studies indicating a substantial association between vitamin d deficiency and decreased insulin secretion in both animal models and humans.18 multiple studies have revealed that a deficiency in vitamin d can lead to the onset of insulin resistance and subsequently non-insulin dependent diabetes mellitus via disrupting insulin sen article table 2. sensitivity, specificity, and likelihood ratio for systole score (n =40). criterion sensitivity specificity lr+ lr– <120 0 100 1.0 120-129 16 67 0.5 1.3 130-139 27 67 0.8 1.1 140-159 41 67 1.2 0.9 160-179* 81 67 2.4 0.3 >180 97 33 1.5 0.1 table 3. sensitivity, specificity, and likelihood ratio diastole score (n =40). criterion sensitivity specificity lr+ lr– <80 0 100 1 80-84 49 67 1.5 0.8 85-89 68 67 2.0 0.5 90-99* 84 67 2.5 0.2 100-109 92 0 0.9 >110 97 0 0.9 figure 1. the receiver operator characteristic curve of the systole and diastole for vitamin d level (n 40). systole: auc 0.65 (95% ci: 0.49-0.80) and diastole: auc 0.67 (95% ci: 0.50-0.81). [healthcare in low-resource settings 2024;12:12929] [page 61] article sitivity and/or β-cell activity. vitamin d3 has a hypotensive effect on patients with hypertension but is not useful for non-hypertensive patients.18 nevertheless, our study found that individuals with diabetes and hypertension experienced a decline in vitamin d levels. in this study, it is imperative to explore additional factors, such as cholesterol levels, sun exposure, dietary issues, and other variables, in addition to age and diabetes, which may contribute to the situation. this study has the potential to aid in the prevention of additional problems in individuals with both diabetes and hypertension. individuals with diabetes may encounter a weakened immune system,19 hence it may be advisable to consider vitamin d supplements as a preventive measure against potential consequences.20 in the meta-analysis conducted by golzarand, it was shown that interventions lasting <6 months, with an average daily dosage >800iu/d, and daily doses were more beneficial in decreasing blood pressure.21 while there is no consensus agreement on the necessity of vitamin d supplementation for enhancing health outcomes in the general population, administering doses between 600 and 4000 iu/day may be considered to elevate 25(oh)d levels near 50 ng/ml, potentially improving insulin resistance and related conditions.22,23 another study in indonesia recommended maintaining serum vitamin d levels >20 ng/ml for patients with dm.24 high-dose vitamin d supplementation of 300,000–500,000 iu has been shown to be safe and does not cause toxicity.25 however, in indonesia, there is a lack of standardised vitamin d administration for individuals diagnosed with dm and hypertension. consequently, further investigation is required to confirm these results. implication in clinical practice our study showed that individuals with dm and hypertension were at an increased risk of developing decreased vitamin d levels. to prevent the worsening of conditions caused by vitamin d deficiency, such as the risk of metabolic syndrome, which includes increased blood pressure, high triglycerides, high low-density lipoprotein, increased waist circumference, and increased fasting glucose, this will be considered a warning in the healthcare system for patients with dm and hypertension.22 in indonesia, owing to the lack of standardisation in administering vitamin d to patients with dm and hypertension, these patients require additional vitamin d and monitoring of serum vitamin d levels following treatment. study limitations the primary limitations of this study were its use of a crosssectional methodology instead of a prospective (follow-up) approach, the absence of a standardised sample size pertaining to this specific topic, and the failure to investigate other factors associated with vitamin d insufficiency. the results of this study revealed that the auc was 0.67, indicating that the diagnostic evaluation of vitamin d levels in patients with dm and hypertension was not particularly robust, which aligns with the lr findings. consequently, additional research with extensive samples and multicentre facilities is required to generalise these results. additional research on the impact of vitamin d dosage in individuals with dm and hypertension is essential, given the prevalence of vitamin d insufficiency identified in the current study. conclusions our study indicated that individuals with dm and hypertension had a drop in vitamin d, with a threshold score of systolic blood pressure of 160–179 mmhg, sensitivity of 81%, specificity of 67%, and likelihood ratio of 2.4. the threshold score for diastolic blood pressure was 90–99 mmhg, with 84% sensitivity, 67% specificity, and a likelihood ratio of 2.5. consequently, individuals with dm should consistently assess their serum vitamin d levels for early identification of problems. references 1. sun h, saeedi p, karuranga s, et al. idf diabetes atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. diabetes res clin pract 2022;183:109119. 2. riskesdas t. laporan nasional riskesdas 2018. jakarta: 2018. 3. magliano dj, boyko ej & ida 10th edition scientific committee. idf diabetes atlas. 10th ed. 2021. 4. galicia-garcia u, benito-vicente a, jebari s, et al. pathophysiology of type 2 diabetes mellitus. int j mol sci 2020;21:6275. 5. szymczak-pajor i, śliwińska a. analysis of association between vitamin d deficiency and insulin resistance. nutrients 2019;11:794. 6. arafat es, taha im, kattan sw, et al. associations between vitamin d and type 2 diabetes mellitus: the role of vitamin d receptor and binding protein. j diabetes mellit 2020;10:22235. 7. indah sw, aliza rs, indana ea & ds. view of vitamin d and type 2 diabetes mellitus: role in insulin resistance, glycemic control and long term complications. j kedokt unram 2022;11:942-52. 8. seshadri. role of vitamin d in diabetes. j endocrinol metab 2011;1:47-56. 9. hermawan d, andoko. pengaruh pemberian vitamin d terhadap penurunan tekanan darah pada usia lanjut dengan hipertensi. j dunia kesmas 2017;6:36-42. 10. kota sk, kota sk, jammula s, et al. renin-angiotensin system activity in vitamin d deficient, obese individuals with hypertension: an urban indian study. indian j endocrinol metab 2011;15:s395-401. 11. mandrekar jn. simple statistical measures for diagnostic accuracy assessment. j thorac oncol 2010;5:763-4. 12. vaidya a, forman jp. vitamin d and hypertension: current evidence and future directions. hypertension 2010;56:774-9. 13. tran tm, giang nm. changes in blood pressure classification, blood pressure goals and pharmacological treatment of essential hypertension in medical guidelines from 2003 to 2013. ijc metab endocr 2014;2:1-10. 14. mandrekar jn. receiver operating characteristic curve in diagnostic test assessment. j thorac oncol 2010;5:1315-6. 15. estoppey p, clair c, auderset d, puder jj. sex differences in type 2 diabetes. cardiovasc med 2023;26:96-9. 16. arania r, triwahyuni t, prasetya t, cahyani sd. hubungan antara pekerjaan dan aktivitas fisik dengan kejadian diabetes mellitus di klinik mardi waluyo kabupaten lampung tengah. j med malahayati 2021;5:163-9. 17. suiraoka i. penyakit degeneratif, mengenal, mencegah dan mengurangi faktor resiko 9 penyakit degeneratif. 2012. 18. hu c, lin l, zhu y, et al. association between age at diagnosis of type 2 diabetes and cardiovascular diseases: a nationwide, population-based, cohort study. front endocrinol (lausanne) 2021;12:1-9. [page 62] [healthcare in low-resource settings 2024;12:12929] 19. suriadi, pratama k, fahrain j, et al. prevention strategy for ulcer recurrence in patients with type ii diabetes mellitus : a quasi ‑ experimental study. iran j nurs midwifery res 2023;18. 20. reddy ssk, tan m. chapter 1 diabetes mellitus and its many complications. in: tan mbt-dm, editor. bones joints horm ser 2020, pp. 1-18. 21. park je, pichiah pbt, cha ys. vitamin d and metabolic diseases: growing roles of vitamin d. j obes metab syndr 2018;27:223-32. 22. contreras-bol v, garc b, garc c, muñoz-torres m. review mechanisms involved in the relationship between vitamin d and insulin resistance: impact on clinical practice. nutrients 2021;13:1-25. 23. ehrampoush e, mirzay razzaz j, arjmand h, et al. the association of vitamin d levels and insulin resistance. clin nutr espen 2021;42:325-32. 24. iqhrammullah m, gusti n, andika ff, abdullah a. association of serum vitamin d and the risk of cardiovascular diseases among diabetic patients: a systematic review and meta-analysis. clin nutr espen 2024;62:66-75. 25. kemas dm, sriwijaya u, irfannuddin m, et al. peran vitamin d dalam tatalaksana luka kaki diabetes. palembang: fakultas kedokteran universitas sri wijaya; 2023 article [healthcare in low-resource settings 2024;12:12929] [page 63] hrev_master healthcare in low-resource settings 2024; volume 12:12089 effectiveness of the setia (self empowering woman, empathy, trust, intimate and affection) program in enhancing exclusive breastfeeding in indonesia ernani setyawati, endah wijayanti, ita kusumayanti, damai noviasari, sekar handayani, novi pasiriani, eli rahmawati diploma iii of balikpapan midwifery program, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia abstract the sustainability of breastfeeding remains a challenge for primiparous mothers. empowering women through home visits by midwives needs to be enhanced to ensure the continuity of breastfeeding. this research aimed to compare the effectiveness of the setia (self-empowering women, empathy, trust, intimacy, and affection) program with a standard program in assisting primiparous mothers to breastfeed their babies after one month. a total of 50 primiparous participants were divided into two groups through simple random sampling. the standard group received four home visits, while the setia group received five home visits within one month postpartum. the breastfeeding competency variable was evaluated after one month using the world health organization (who) instruments and interviews about exclusive breastfeeding. the variables were analyzed using comparative statistics. the results showed no significant difference between the standard and setia groups, with mann-whitney u values of 253.5 and wilcoxon values of 578.5 (p-value=0.086, α<0.05). however, there is evidence that the intervention group managed breastfeeding problems better, and more mothers continued breastfeeding after one month. therefore, the authors suggest more frequent home visits to help new mothers adapt to their breastfeeding roles, especially in the first week after birth. further research is needed to assess exclusive breastfeeding after six months in both groups. introduction breastfeeding is an excellent beginning for both the mother and her newborn baby. breast milk is tailored to the newborn’s needs and digestion, promoting maximum growth and development while helping prevent stunting.1 the beneficial effects of breastfeeding for mothers include protection against metabolic pathologies, obesity, gynecological disorders, and female cancers, particularly breast, ovarian, and endometrial cancer.2,3 it also plays a crucial role in providing psychological support to postpartum women, especially in combating depression and anxiety.4 despite its well-established benefits, exclusive breastfeeding remains a global challenge, including in indonesia.5,6 women who undergo their first pregnancy typically acquire knowledge about pregnancy and breastfeeding through perinatal classes and seek information via mass media or healthcare providers. however, challenges arise when new mothers attempt to breastfeed their babies, as breastfeeding is a continued activity.7 common problems include sore nipples, breast swelling, perceived insufficiency of breast milk, and limited communication with healthcare providers during breastfeeding. the lack of support in addressing breastfeeding difficulties can hinder mothers’ ability to breastfeed successfully.8 the success of breastfeeding in infants can be influenced by both infant and maternal factors. infant factors are affected by the development of oral-motor function, which is greatly dependent on gestational age. maternal factors, on the other hand, encompass physical and psychological aspects.9,10 the mother’s psychological state emerges as a significant faccorrespondence: ernani setyawati, diploma iii of balikpapan midwifery program, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. tel.: +6281346398980 e-mail: esetyawati80@gmail.com key words: breastfeeding; home visit; standard; setia. contributions: es, conceptualization, methodology, original draft, review, and editing; ew and ik, recruitment of field research assistants and prospective respondents, and also supervision during data collection; dn, sh, np, and er collecting data and project administration. all research members jointly ensured the research protocol was carried out properly and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by a research grant from ministry of health polytechnic kalimantan timur. ethics approval and consent to participate: this research was approved by the health research ethics committee of health polytechnic of east kalimantan with an ethical clearance statement letter dl.02.03/4.3/ 10426/2022. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank all participants and all civitas academics from the ministry of health polytechnic kalimantan timur for their valuable insights and contribution to this study. received: 15 november 2023. accepted: 21 may 2024. early access: 3 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12089 doi:10.4081/hls.2024.12089 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12089] [page 595] tor that can deter her from breastfeeding her baby, even in the absence of any breast disorder. emotional distress has the potential to inhibit the let-down reflex, impacting breastfeeding self-efficacy, and may compound physical discomfort.11 psychological factors can also interfere with the process of milk production, affecting both the prolactin reflex and the oxytocin-driven milk ejection reflex, thereby compromising optimal milk production or leading the mother to perceive her milk production as inadequate.12 key psychological conditions that play a pivotal role include sadness, fear, lack of confidence, and inadequate breastfeeding support.13,14 assisting mothers in breastfeeding their babies is crucial for ensuring the healthy development of future generations.15 despite recommendations from health workers and government authorities, not all mothers breastfeed their babies. in indonesia, approximately 66.69% of babies are exclusively breastfed, with rates slightly higher in specific regions such as east kalimantan (71.08% in 2019) and balikpapan (78.74%). however, despite these efforts, data from the indonesian nutritional status survey indicate that stunting rates in east kalimantan reached 23.9% in 2022, exceeding the national average of 21.6%. this underscores the ongoing need to focus on promoting exclusive and sustained breastfeeding, particularly to mitigate the risk of higher stunting rates in the future.16 mothers need a support system that assists them in adapting to their roles as new mothers, whether through professional healthcare services or other support networks.17 this can be achieved through programs that offer foster care, prioritizing female empowerment, empathy, trust, intimacy, and affection for breastfeeding mothers. such programs aim to enhance mothers’ breastfeeding abilities and equip them with coping mechanisms for any breastfeeding-related challenges that may arise. one such program is the setia (self-empowering women, empathy, trust, intimacy, and affection) program, which involves five home visits during the first week after labor. the aim of this research was to compare the effectiveness of the setia program with that of the standard program in promoting exclusive breastfeeding one month post-partum. materials and methods this research used a quasi-experiment study conducted from march 2022 to november 2022 among 50 primiparas in balikpapan city, indonesia, which was divided into two groups. the standard group was 25 primiparas who had received four times of home visits according to the standard from the indonesian ministry of health.18 the intervention group with the setia (selfempowering woman, empathy, trust, intimacy, and affection) method was 25 primiparas who had received home visits five times. in each home visit, setia group respondents receive individual counseling, breastfeeding practices, and advice on how to overcome breastfeeding problems that may arise during breastfeeding. the sample size used the sample size formula for comparative analysis and was determined with consecutive sampling.19 the magnitude of the standard deviation based on previous research journals is 6.5. the magnitude of the average difference in breastfeeding between the two groups, which is statistically significant, is 5. if z(1-α)=90%, then zα=1.28. and z(1-β)=90%, then zβ=1.28. research also adds a 10% loss to follow-up in this study, which results in 25 subjects for one group. the population of this study was primiparous women who received maternity services at primary health care, independent practice midwives, and hospitals in balikpapan, indonesia. the study sample was 50 primiparous women who were divided into two groups: the control group (the standard program) and the intervention group (the setia program). the sampling method is consecutive sampling. each primiparous woman who fits the inclusion criteria is entered into the excel program and assigned a number. then, even numbers become the control group, and odd numbers become the intervention group. the inclusion criteria were the same for both groups: a woman who had a delivery in the research location and had a healthy newborn baby at term and weighing >2500 gr. the woman was given written and verbal information about the aim of the study and the term of confidentiality. they subsequently signed a written consent transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 596] [healthcare in low-resource settings 2024;12:12089] table 1. home visit procedure. model time procedure standard program 1 (6-48 hours after labor) ensuring uterine contraction and involution to prevent postpartum bleeding early breastfeeding bonding attachment prevent hypothermia 3-7 days postpartum monitor the adaptation of mothers and families with new born assess for signs of fever. infection. or bleeding make sure you get enough food. fluids. and rest make sure the mother breastfeeds well and there are no infections how is the daily care of the baby 8-28 days postpartum the beginning of sexual intercourse family planning method abdominal muscle toning exercises digestive function. constipation. and how to handle it 29-42 days postpartum the beginning of sexual intercourse family planning method setia program. form and could resign anytime. this research was approved by the health research ethics committee of health polytechnic of east kalimantan with an ethical clearance statement letter dl.02.03/4.3/10426/2022. during the home visit, the midwife helps the mother to adapt to breastfeeding in the first week, teaches the new mother to breastfeed, and discusses how to deal with the problem when breastfeeding their babies. home visit procedures can be seen in table 1. quantitative data were collected from both the intervention and control groups (figure 1), focusing on factors such as age, education, labor experience, and breastfeeding challenges. the researcher formed a group of five midwives to administer the intervention. prior to the start of the research, thorough preparation ensured that the procedure of home visits and the tools used to examine respondents during the intervention were well-known. during the intervention implementation, the research subjects in the intervention group underwent an assessment of breastfeeding latch using tools designed to observe both the mother’s and the baby’s ability to breastfeed, including the latch-on technique and breastfeeding difficulties experienced immediately after discharge from the hospital/clinic/private practice. these assessments occurred at three days, one week, two weeks, and four weeks after labor, totaling five visits during the postpartum period.20 in contrast, the control group received standard home visits twice during the first week and twice again during the second and fourth weeks, totaling four visits during the postpartum period. exclusive breastfeeding was assessed after one month through interviews with mothers regarding the feeding practices for their babies. exclusive breastfeeding, defined as the sole provision of breast milk to infants, was the dependent variable measured one month after labor. the research was carried out as in figure 1. results demographics the study included 50 primiparas divided into two groups: a control group (n=25) and an intervention group (n=25), with ages ranging from 18 to 35 years. the mean age for the entire sample for both groups was 25 years. educational levels among participants varied from elementary school to university education. the study results showed no significant relationship between age and education level in relation to exclusive breastfeeding after 1 month (table 2). breastfeeding problems during the home visit process, several breastfeeding problems were identified in both groups, including insufficient milk supply, improper breastfeeding positioning, and sore nipples. the control group likely experienced more breastfeeding problems than the intervention group. most of these problems persisted even one month after the postpartum period (figure 2). most breastfeeding problems in the control group are incorrect positions because of a lack of knowledge of the new mother. the first-time mother can acquire this breastfeeding problem. the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12089] [page 597] table 2. subjects’ characteristics. characteristics group group standard program setia program n=25 n=25 breastfeeding breastfeeding & formula breastfeeding breastfeeding & formula age <20 year 1 3 2 1 >20 year 17 4 21 1 education junior high school 1 2 2 1 senior high school 14 4 10 1 college 3 1 11 0 work unemployed 14 6 15 2 employed 4 1 8 0 setia, self empowering woman, empathy, trust, intimate and affection. figure 1. research flowchart. study shows no significant difference before and after home visits in group control (0.022). incorrect positions were even more frequent in the intervention group. but after one month, only a few mothers still experienced it, and so a lack of milk and nipple problems. the study shows a significant difference in the intervention group before and after home visits (0.311). one month after labor, breastfeeding behavior is collected and analyzed. table 3 shows the comparison between the standard program and the setia program. statistic result on comparing group a and group b using mann-whitney and wilcoxon test for variable breastfeeding after one month shows that there is no significant difference in breastfeeding after one month between the two groups (mann-whitney 253.5 and wilcoxon 578.5 with a p-value is 0.086). even though. mean rank intervention group likely better at breastfeeding after one month. discussion in general, the majority of research subjects were aged between 20 and 35 years, with a high school education level. there was no significant relationship observed between age and breastfeeding practices after one month. the similarity in age among subjects in both groups suggests comparable levels of emotional maturity, experience, and information possessed by the subjects. mothers of older age are often expected to possess greater knowledge and emotional maturity in fulfilling their role as mothers. age is typically associated with increased life experience and access to information, which can contribute to building a strong self-concept and fostering confidence in various activities, including breastfeeding21. in the research, all respondents were new mothers giving birth to their first child and had not previously breastfed. however, some mothers may have observed or experienced indirect forms of breastfeeding through family members. additionally, the educational level of the research subjects did not differ between the two groups, suggesting that both groups should have similar abilities to receive and analyze new information. the ability to read is particularly crucial for acquiring new information, such as breastfeeding techniques, and retaining it in memory. attending classes on breastfeeding at primary health centers can significantly increase breastfeeding rates. however, most respondents in this study have not attended such classes, indicating a lack of clear understanding and sufficient knowledge about breastfeeding. this finding aligns with previous research emphasizing the importance of antenatal classes in enhancing knowledge about pregnancy and childbirth. the lack of knowledge and experience in breastfeeding may impact self-efficacy in breastfeeding practices. therefore, promoting the acceptance of early breastfeeding initiation materials in antenatal classes is essential for fostering a positive attitude towards early breastfeeding initiation and exclusive breastfeeding22. the studies show that mothers with higher education tend to have higher confidence in breastfeeding their babies. a mother’s education will influence the mother in receiving and analyzing the new information received. intellectual capacities such as reading will affect the retention stage of a new behavior being observed. meanwhile. the new behavior that is formed is very dependent on physical abilities. communication. and learning abilities to behave the same as the model that is exemplified23. breastfeeding self-efficacy plays a critical role in the success of mothers in overcoming breastfeeding challenges. home visits offer health workers the opportunity to provide tailored education to mothers experiencing breastfeeding difficulties24. by directly interacting with these mothers, health workers can offer verbal persuasion and advice, thereby boosting their self-confidence25. this increased confidence positively impacts mothers’ efforts, attention to the breastfeeding process, and their response to breastfeeding problems. in essence, breastfeeding self-efficacy significantly influences mothers’ ability to address breastfeeding challenges effectively26. the research results show that home visiting by the setia group is effective in providing mothers with a positive experience and enhancing breastfeeding for babies aged one month compared to the standard group. the frequency of home visits by the setia group enables midwives to enhance mothers’ breastfeeding skills through exercises and evaluations. breastfeeding problems encountered are addressed, assisting mothers in adapting during the first week. breastfeeding self-efficacy tends to be high during home visits, as scheduling visits at the beginning of the postpartum period allows midwives to identify breastfeeding issues early on. the ability of both the mother and baby to adapt significantly influences breastfeeding success. with three consecutive home visits in the first week, mothers receive assistance in resolving breastfeeding issues27. the first week postpartum can significantly impact breastfeeding experiences, either positively or negatively. increasing the frequency and customization of home visits for mothers after child transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. comparison of control group and intervention group with breastfeeding. home visit breastfeeding after 1 month mann-whitney wilcoxon p breastfeeding only % breastfeeding and formula % mean rank standard program 18 72 7 28 23.14 253.5 578.5 0.086 setia program 32 92 2 8 27.86 setia, self empowering woman, empathy, trust, intimate and affection. figure 2. breastfeeding problems. [page 598] [healthcare in low-resource settings 2024;12:12089] birth can enhance the health of both the baby and the mother, leading to greater satisfaction26. tailoring care to meet the unique needs of each mother can also contribute to improved maternal health. the timing, frequency, duration, and intensity of home visits after labor should be personalized according to individual requirements. further research is needed, particularly to promote exclusive breastfeeding for the first six months of life28. the results indicated that both groups experienced breastfeeding challenges at the onset of the postpartum period, as it was their first experience with breastfeeding. midwife visits allowed for the detection of these problems through direct observation while mothers breastfed their babies. this facilitated the identification of difficulties faced by breastfeeding mothers, enabling discussions on how to overcome them. midwives provided direct advice to breastfeeding mothers through verbal persuasion, aiming to boost their confidence and ultimately enhance breastfeeding success4. home visits conducted by midwives provided an opportunity for respondents to discuss various topics, including problems encountered during the delivery process, the role of new parents, and the breastfeeding process. first-time breastfeeding mothers often experience feelings of vulnerability and require support as they navigate their new role and initiate the breastfeeding process7. the continuous care model plays a crucial role in assisting mothers with emotional challenges during the postpartum period. postpartum mothers often seek opportunities to discuss their birth experiences with the midwives who assisted them during delivery27. moreover, the brief duration of postpartum care at hospitals may not adequately address mothers’ needs for understanding breastfeeding and the postpartum period. therefore, home visits by midwives are invaluable in helping postpartum mothers adapt to their new roles and overcome challenges they may encounter29. the brief hospitalization period, ranging from 6-24 hours for women who gave birth normally and 3-4 days for those who underwent surgery, may lead new mothers to lack understanding of the breastfeeding process and how to address potential challenges that may arise during breastfeeding. negative breastfeeding experiences during the first week postpartum can significantly impact a mother’s breastfeeding self-efficacy4. therefore, it is crucial to identify and support mothers who are at risk of such negative experiences during this critical period. addressing factors that may contribute to unsuccessful breastfeeding experiences early on can increase the likelihood of a positive breastfeeding journey. one-to-one support interventions have been reported as particularly beneficial, as support persons typically have more time to sit, talk, and observe entire feeding sessions compared to general or standard support methods30,31. despite breastfeeding being a natural process, many postpartum mothers require assistance to adapt to it successfully. failure to adapt during this period may jeopardize the achievement of exclusive breastfeeding for six months and could potentially impact the future health of the baby. the intervention group was found to have detected more breastfeeding problems than the control group. this is because midwives conducting home visits identified a greater number of breastfeeding difficulties during the first week of the postpartum period. this increased detection of issues can be attributed to the more frequent contact that midwives had with respondents in the intervention group compared to the control group. after a home visit and evaluation after one month, the intervention group experienced a significant reduction in breastfeeding problems compared to the control group. this improvement was attributed to the educational assistance provided by midwives during the home visit. respondents in the intervention group breastfed more exclusively for one month during the postpartum period than respondents in the control group, despite facing similar breastfeeding problems. the undermilk syndrome observed in both groups was mostly manageable, and there was no reported risk of supplementary feeding other than breast milk. home visits in the early postpartum period conducted by professional midwives have proven effective in promoting positive maternal behaviors, such as breastfeeding and contraceptive use.4 these visits offer breastfeeding mothers the opportunity and flexibility to learn and practice proper breastfeeding techniques in the comfort of their own homes, rather than in a public facility.11 this advantage is particularly beneficial in areas or cultures where privacy is highly valued. healthcare professionals play a significant role in promoting, protecting, and supporting exclusive breastfeeding. they can offer various forms of support tailored to sociocultural norms and individual backgrounds to assist mothers in breastfeeding effectively.31,32 the setia program prioritizes privacy, intimacy, and affection for postpartum mothers during home visits, addressing their individual problems with sensitivity and compassion. midwives involved in this program refrain from judging or blaming mothers for any limitations or breastfeeding difficulties they may face. instead, they empower mothers to develop the skills necessary to overcome these challenges. by fostering a belief in mothers’ abilities to address breastfeeding issues independently, midwives aim to ensure breastfeeding continuity and promote a positive breastfeeding experience for mothers. scheduling and increasing the frequency of home visits for postpartum mothers can positively impact infant health and maternal satisfaction. home visits offer the flexibility to assess the health condition of both mothers and babies and their breastfeeding skills in a comfortable environment. midwives can provide individualized care tailored to the specific needs of postpartum mothers, offering invaluable support during breastfeeding. additionally, home visits can contribute to the success and continuity of exclusive breastfeeding beyond the first month. the home visit model has proven effective in promoting healthy weight gain in babies during their first year of life. additionally, home visits can serve as a valuable tool in encouraging mothers to breastfeed their babies. certain home visit models have been shown to decrease infant morbidity and mortality rates. during these visits, mothers receive both social and professional support, which act as protective factors for exclusive breastfeeding.12,33,34 other studies have demonstrated that mothers who receive home visits during pregnancy are 4,5 times more likely to breastfeed their babies compared to those who do not receive such visits.35 home visitation models have shown effectiveness in promoting breastfeeding. increasing the frequency of individual home visits during the postpartum period can enhance both infant health and maternal satisfaction with health services.28,33 the frequency, timing, duration, and intensity of home visits during the postpartum period should be tailored to local and individual needs. further research is necessary to assess the potential impact of setia home visits on achieving six months of exclusive breastfeeding. conclusions there was no significant difference observed between the two transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12089] [page 599] groups; however, evidence suggests that the intervention setia program is more effective in managing breastfeeding problems, with more mothers breastfeeding after one month. therefore, the authors recommend more frequent home visits to assist new mothers in adapting to breastfeeding, particularly during the first week after birth. further research is warranted to assess exclusive breastfeeding rates after six months in both groups. limitations of this study include a limited number of respondents and a failure to identify other factors that may influence breastfeeding among participants. nevertheless, the strength of this research lies in its ability to provide new insights into home visits, which show promise in supporting mothers to exclusively breastfeed their babies during the first month of life. references 1. safaah n, yunitasari e, efendi f, et al. relationship between exclusive breastfeeding and stunting among children aged 2-5 years in indonesia. gac med caracas 2022;130:s1019-24. 2. rollins nc, bhandari n, hajeebhoy n, et al. why invest, and what it will take to improve breastfeeding practices? lancet 2016;387:491-504. 3. dewi i, widianti at, fatmawati a, et al. the predictors need for complementary interventions using mobile application technology in women with breast cancer. j ners 2023;18:16975. 4. suja shamili g, aruna g. effectiveness of information booklet on knowledge and practices of expressed breast milk among working postnatal mothers in selected maternity hospitals at nellore. iosr j eng 2016;06:17-19. 5. the demographic and health surveys (dhs) program. nutrition. 2020. available from: https://dhsprogram.com/topics/nutrition/index.cfm 6. nasrul n, hafid f, ramadhan k, et al. factors associated with bottle feeding in children aged 0–23 months in indonesia. child youth serv rev 2020;116:105251. 7. jiang h, li m, yang d, et al. awareness, intention, and needs regarding breastfeeding: findings from first-time mothers in shanghai, china. breastfeed med off j acad breastfeed med 2012;7:526-34. 8. ouyang y-q, su m, redding sr. a survey on difficulties and desires of breast-feeding women in wuhan, china. midwifery 2016;37:19-24. 9. suradi r, hegar b, partiwi igan, et al. indonesia menyusui. 2010. available from: https://perpustakaan.kemkes.go.id/inlislite3/opac/detail-opac?id=12896 10. mardiyanti i, devy sr, ernawati e. analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy. j ners 2019;14:144-50. 11. gómez l, verd s, de-la-banda g, et al. perinatal psychological interventions to promote breastfeeding: a narrative review. int breastfeed j 2021;16:1-16. 12. gianni ml, bettinelli me, manfra p, et al. breastfeeding difficulties and risk for early breastfeeding cessation. nutrients 2019;11:2266. 13. mangel l, mimouni fb, mandel d, et al. breastfeeding difficulties, breastfeeding duration, maternal body mass index, and breast anatomy: are they related? breastfeed med off j acad breastfeed med 2019;14:342-6. 14. wahyuni sd, santoso b, triharini m, susan n. perceptions of working mothers toward breastfeeding self-efficacy. j ners 2020;15:50-6. 15. hadisuyatmana s, has emm, sebayang sk, et al. women’s empowerment and determinants of early initiation of breastfeeding: a scoping review. j pediatr nurs 2021;56:e77-92. 16. kuncaraning r, yugiana e, noviani a. profil statistik kesehatan 2021. 2021. available from: https://www.bps.go.id/id/publication/2021/12/22/0f20732390 2633342a1f6b01/profil-statistik-kesehatan-2021.html 17. muniroh l, sulistyorini y, abihail ct. family support is the strongest predictor that influences mother’s self-efficacy level on complementary feedings practices among toddlers in tengger tribe. nutr food sci 2024;54:535-46. 18. pedoman bagi ibu hamil, bersalin, nifas, dan bayi baru lahir. direktorat jenderal kesehat masy kementeri kesehat ri 2020. 2020. available from: https://www.google.com/search?q=direktorat+jenderal+kese hat+masy+kementeri+kesehat+ri+2020&rlz=1c5chfa_en it976it976&oq=direktorat+jenderal+kesehat+masy+keme nteri+kesehat+ri+2020&gs_lcrp=egzjahjvbwuybggaee uyodibbze2mwowajsoagcwaga&sourceid=chrome&ie= utf-8#:~:text=permenkes%20nomor% 2021,%e2%80% ba%20home%20%e2%80%ba%20download 19. daniel ww, cross cl. biostatistics: a foundation for analysis in the health sciences. 11th edition. wiley; hoboken, usa; 2018. 20. united nations international children’s emergency fund (unicef). breastfeeding assessment tools. available from: https://www.unicef.org.uk/babyfriendly/baby-friendlyresources/implementing-standards-resources/breastfeedingassessment-tools/ 21. naufal ff, indita hr, muniroh l. the relationship between maternal knowledge and family support with exclusive breastfeeding. amerta nutr 2023;7:442-8. 22. supeni s, jariyah a. antenatal class increases knowledge and attitude of pregnant women in succeeding early breastfeeding initiation. j asian multicult res med heal sci study 2022;3:69-78. 23. dwijayanti i, al mamun a, setiarsih d, et al. exploring global mothers’ knowledge, attitudes, and practice of complementary feeding: a scoping review. nutrition 2024;120;112335. 24. mcginnis s, lee e, kirkland k, et al. let’s talk about breastfeeding: the importance of delivering a message in a home visiting program. am j health promot 2018;32:989-96. 25. setyawati e. the effectivity of home visit and self-care treatment methods on self-efficacy of breastfeeding mothers. media ilmu kesehat 2018;7:179-84. 26. mauri pa, zobbi vf, zannini l. exploring the mother’s perception of latching difficulty in the first days after birth: an interview study in an italian hospital. midwifery 2012;28:81623. 27. dahlberg u, haugan g, aune i. women’s experiences of home visits by midwives in the early postnatal period. midwifery 2016;39:57-62. 28. yonemoto n, nagai s, mori r. schedules for home visits in the early postpartum period. cochrane database syst rev 2021;7:cd009326. 29. çerçer z, nazik ed. the effects of the breastfeeding problems management model on breastfeeding problems, breastfeeding motivation and breastfeeding success: a randomized controlled trial. j pediatr nurs 2023;73:e116-24. 30. nilsson ims, kronborg h, rahbek k, strandberg-larsen k. the significance of early breastfeeding experiences on breast transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 600] [healthcare in low-resource settings 2024;12:12089] feeding self-efficacy one week postpartum. matern child nutr 2020;16:e12986. 31. bengough t, dawson s, cheng h-l, et al. factors that influence women’s engagement with breastfeeding support: a qualitative evidence synthesis. matern child nutr 2022;18:e13405. 32. mirmolaei st, valizadeh ma, mahmoodi m, tavakol z. comparison of effects of home visits and routine postpartum care on the healthy behaviors of iranian low-risk mothers. int j prev med 2014;5:61-8. 33. scharff dp, elliott m, rechtenwald a, et al. evidence of effectiveness of a home visitation program on infant weight gain and breastfeeding. matern child health j 2021;25:676-83. 34. huang r, wan y, yao x, et al. predictive factors of exclusive breastfeeding attrition at week 6 post-partum among mothers of preterm infants based on the theory of planned behaviour. matern child nutr 2023;19:e13470. 35. shah mk, austin kr. do home visiting services received during pregnancy improve birth outcomes? findings from virginia prams 2007-2008. public health nurs 2014;31:405-13. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12089] [page 601] hrev_master healthcare in low-resource settings 2024; volume 12(s2):12430 practical experience of allergy to egg proteins clinical manifestation maria zofia lisiecka department of allergology, national medical institute of the ministry of the interior and administration, warsaw, poland abstract food allergy occupies a significant place among disorders that impair the quality of patients’ lives, bringing a large number of restrictions to their diet and lifestyle. therefore, the purpose of this study is to examine the clinical features of allergy to chicken eggs with the determination of key trends in diagnosis and treatment. a descriptive and comparative analysis of three cases was carried out with a large-scale assessment of specific immunoglobulins e (ige), determined by the enzyme-linked immunosorbent assay. it becomes clear, that due to the high prevalence of allergy to white and yolk of chicken eggs in the general population (among the polish population including), chicken eggs have severe allergenic characteristics and may display various symptoms that may be problematic to differentiate. the patients from the presented cases were characterized by a severe course of the disease – minimal consumption of chicken eggs led to the development of urticaria, swelling of the eyelids, and bronchospasm, which required urgent administration of adrenaline and hospitalization. for the purpose of diagnosis, patients with anaphylactic reactions are highly restricted, because methods of skin prick testing, and provocation tests (oral and nasal) are contraindicated. in this regard, molecular diagnostics and the determination of specific immunoglobulins e for ovalbumin, ovomucoid, and other glycoproteins are recommended. this research can lead to the creation of purified recombinant allergens for use in the process of diagnosis and treatment, as well as in the food industry, also, it emphasizes the introduction of preventive measures for the development of anaphylaxis. introduction currently, most allergies are related to food products, and according to the estimates of the world allergy organization (wao), more than 10% of people worldwide suffer from food allergies.1 despite the necessity of consuming food to maintain life and health, it remains particularly unclear why the human body identifies certain foods as harmful, which is the basis for the development of intolerance to them. nevertheless, significant progress has been made in understanding the mechanisms of allergic reactions. according to e. johansson and t.b. mersha,2 it was even shown that the risk of the disease in a child is up to 80% if there are hereditary factors. zambrowicz et al.3 pay attention to chicken eggs as a source of necessary nutrients that have a beneficial effect on human health; there are also biologically active compounds that affect metabolic processes, especially in the cardiovascular system and muscles. these nutrients include proteins, lipids (including highdensity lipoproteins), carotenoids, and other biologically active compounds exhibiting antioxidant, antimicrobial, immunomodulatory, anti-inflammatory, and pro-inflammatory properties.4 chicken eggs also contain essential b vitamins, fat-soluble vitamins, trace elements, choline, and a relatively small amount of saturated fatty acids compared with other food sources of animal origin.5 therefore, the high nutritional value of chicken eggs makes them a valuable component of dietary nutrition not only for people with an increased need for proteins (such as children and the elderly), but also for the general population. chicken eggs, which are a rich source of useful substances, occupy one of the first places among food allergens. a recent study among european countries showed that in łódź (poland), among children aged 7 to 10 years, allergies to chicken eggs account for 5% of all food allergies and give way to cow milk and peanuts.6,7 most allergens are contained in the egg white, but the yolk also contains substances with allergenic activity.8 thus, allergy to chicken eggs occupies an important place in the context of food sensitization, which forces patients to resort to dietary restrictions and deprives them of the opportunity to consume this product, which has a number of useful properties. s.h. sicherer et al.9 stratified patients with allergy to chicken eggs as “highly allergіс” and “not highly allergіс”, which allows to individualize the approach to therapy for each patient depending on the severity of clinical manifestations. correspondence: maria zofia lisiecka, department of allergology, national medical institute of the ministry of the interior and administration, warsaw, poland. e-mail: mariazofialisiecka@gmail.com key words: food allergy, immunoglobulin e, allergen immunotherapy, elimination diet, anaphylaxis. conflict of interest: the author declares no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. patient consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. received: 26 fubruary 2024. accepted: 17 june 2024. early view: 9 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12430 doi:10.4081/hls.2024.12430 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 38] [healthcare in low-resource settings 2024;12(s2):12430] non -co mmerc ial us e o nly therefore, there is promise and significance in exploring the issue of food allergy within the framework of variations in clinical presentations, leading to the development of treatment and diagnostic strategies rooted in a comprehensive understanding of the underlying principles of etiopathogenesis. therefore, the task of this study is to investigate the clinical features of this food allergy on the basis of three clinical cases and other published investigations, as well as to determine promising research directions. materials and methods at the beginning of the study, three clinical cases that demonstrate a variety of clinical manifestations of an allergy to chicken eggs were selected. all patients were hospitalised in the national medical institute of the ministry of internal affairs (department of allergology) between 2021 and 2022. in the first case patient m., 45 years old, who has been allergic to chicken eggs from early childhood, still has attacks of bronchial asthma in the kitchen where chicken broth is cooked. at the same time, small amounts of chicken yolk, which can remain and dry on poorly washed dishes, can cause symptoms of anaphylaxis: swelling of the face, eyelids, and lips, as well as symptoms of generalized urticaria and bronchospasm, which needs the administration of adrenaline. in the second case, 13-month-old patient i., after eating 4 teaspoons of scrambled eggs almost immediately developed generalized urticaria, bilateral swelling of the upper eyelids, cough, and shortness of breath. in the third case, 8-monthold patient k. ate a small piece of omelet and after 30 seconds she developed shortness of breath, swelling of the upper eyelids of both eyes, and swelling of the face. these symptoms lasted approximately 6-7 hours. all of them were physically examined, and for the next diagnostic intervention, blood serum was collected for the determination of specific immunoglobulin e (ige) in kilounits per liter (ku/l) to chicken egg white, chicken egg yolk, ovalbumin, ovomucoid, conalbumin, and lysozyme. for this, the enzyme-linked immunosorbent assay (elisa) technique was applied to the phadia 100 analyser. patients were also examined for complete blood count, urine analysis, electrocardiogram (ecg), chest x-ray, but these diagnostic procedures were not presented in the study, since their results had no practical value for making a diagnosis of food allergy. all patients were treated with an elimination diet, but based on the results of an immunological study, none of them responded adequately to treatment. patients also continued to present respiratory symptoms, which could also be life-threatening. the patients were given new therapeutic recommendations, but this information was not covered during this follow-up, since the subjective status of the patients was not re-evaluated and immunological tests were not carried out to determine the titer of specific immunoglobulins e. the article also used descriptive methods and methods of comparative analysis, which were used to search for and determine the characteristics of chicken egg allergens and their role in the clinical manifestation of patients with food allergies, the share and role of immunotherapy, current trends and the establishment of diagnostic methods, as well as the prospects for further research. results among the known components of eggs, five are distinguished by strong genetic properties and are considered the main allergens of chicken eggs. these are glycoproteins: ovomucoid (gal d 1), ovalbumin (gal d 2), ovotransferrin (gal d 3), lysozyme (gal d 4) and albumin (gal d 5).10 table 1 provides information on chicken egg allergens contained in two databases: allergen who (world health organization) / iuis (international union of immunological societies) and allergome. according to the recommendations of the who/iuis subcommittee, allergens are indicated by the first three letters of the generic name of the organism from which the allergen originates and the first letter of its species name. in the case of chicken egg allergens, this is the abbreviation gal d (gallus domesticus) (table 1). during the examination of all mentioned patients, the determination of specific ige to chicken egg white, chicken egg yolk, chicken meat, chicken proteins (ovalbumin, ovomucoid, ovotransferin, lysozyme) was used in order to answer a number of questions: i) is intolerance to chicken eggs or meat associated with the development of an allergic reaction? ii) to which of the components (protein or yolk) is there this intolerance? iii) what specific protein does this intolerance exist for? as can be seen from table 2, patient m. had high titers of antibodies to chicken white, yolk, and meat, so it was inappropriate to determine indicators for particular proteins, since their result was expectedly high and it would not affect either the diagnostic or treatment tactics. despite the use of a strict elimination diet for 40 years of life (that is, the diagnosis of allergy to chicken eggs was made at the age of 5), the patient still has not only an allergic condition but also continues to have life-threatening clinical symptoms. in most children, allergy symptoms can disappear between the ages of 2 and 5 years (although patients i. and k. present symptoms of food allergy even before the age of 1 year), and sometimes social and political factors affecting public health table 1. chicken egg allergens in yolk and white. аbbreviation name аbbreviation name 1 gal d 1 ovomucoid 9 gal d clusterin clusterin 2 gal d 2 ovoalbumin 10 gal d igy immunoglobulin y 3 gal d 3 ovotransferin 11 gal d pgds lipocalin type prostaglandin d-synthase 4 gal d 4 lyzocyme c 12 gal d oih serine protease inhibitors 5 gal d 5* alpha-livetin 13 gal d ovomucin ovomucin 6 gal d 6* ygp42 14 gal d phosvitin* casein kinases 7 gal d apo i* apovitellenin-1/-4 15 gal d rfbp riboflavin-binding protein 8 gal d apo iv* apovitellenin-4 *allergens contained in the yolk of chicken eggs. source: created by the authors. [healthcare in low-resource settings 2024;12(s2):12430] [page 39] non -co mmerc ial us e o nly they persist up to 10 years or even appear only in adulthood and on the example of patient m., this disease can accompany the entire life.11,12 allergy symptoms can be represented by damage to various organ systems and varying degrees of severity. it can manifest as signs of gastrointestinal disorders (such as abdominal pain, vomiting, diarrhoea, meteorism), skin itching and/or atopic dermatitis, urticaria, rhinitis and/or conjunctivitis, in more severe cases – asthma and swelling of the larynx.11 a. bongiovanni12 observed that in patients with cutaneous manifestations, this hypersensitivity is very common and sometimes very intense. according to the europrevall study, in which 12049 infants were included, among whom 0.7% had an egg allergy, while the presence of eczema at the time of examination and in the anamnesis increased the risks of allergy more than 9 times, rhinitis symptoms – 3 times, and atopic dermatitis disease – more than 1.5 times. taking antibiotics in the first days of life also played a role, which is probably mediated by the effect on the intestinal microbiota. the researchers also note that the age of introducing eggs into the diet was not associated with egg allergy.13 it is interesting that the examined patients did not have previous atopic reactions, and the development of allergy debuted with episodes of anaphylaxis.14 people with an allergy to chicken eggs often have urticaria, especially in its two forms – acute and contact. in the study by h. ünsal et al.15 in which 102 children were included, urticaria was observed in the second place after manifestations of allergy to chicken eggs in the form of atopic dermatitis (65.6%) – 18.6%. contact urticaria is especially common in children and after ingestion of eggs, occurs mainly around the mouth and is sometimes accompanied by erythema. it is noteworthy that in the same study, children demonstrated attention to warmed (92.3%) and baked eggs (87.2%), which also correlated with the perception of the yolk. the patients from the described clinical cases had a high level of immunological reactivity, due to which they could not tolerate any chicken egg proteins, even after thermal exposure, and the severity of allergic reactions did not depend on the amount of these proteins. it is worth mentioning the rare forms of allergy to chicken egg proteins, which can get not only through food consumption. respiratory symptoms (such as hay fever, bronchial asthma, rhinitis) and conjunctivitis are characteristic not only among children, but also among adults – this is sometimes observed in workers of the food industry and poultry farms who came into contact with aerosols containing egg powder or liquids from components of chicken eggs, which is clinically similar to baker’s asthma to wheat allergens, and only some of these patients also develop food allergies.16,17 another consequence of inhalational allergy can be bird-egg syndrome, specifically of adults (especially women), although it can also occur in childhood, which was mentioned earlier. bird-egg syndrome refers to a rare form of allergy characterized by hypersensitivity reactions to avian proteins, particularly those found in bird eggs. this syndrome typically manifests as respiratory symptoms such as hay fever, bronchial asthma, rhinitis, and conjunctivitis upon exposure to aerosols containing egg powder or liquids from components of chicken eggs. workers in the food industry or poultry farms who come into contact with such aerosols are at risk of developing this syndrome, which can resemble baker’s asthma caused by wheat allergens. bird-egg syndrome may also occur in individuals with egg allergies who develop respiratory symptoms upon exposure to avian proteins, even without ingesting eggs. in addition to respiratory symptoms, individuals with bird-egg syndrome may experience other allergic reactions, such as oral allergy syndrome (oas), which presents as swelling of the lips and itching of the oral mucosa, sometimes accompanied by abdominal pain and vomiting. rare cases have also been reported where bird-egg syndrome is associated with ulcerative colitis, a form of inflammatory bowel disease. in such cases, eliminating eggs from the diet can lead to significant improvement in symptoms, highlighting the importance of testing for food hypersensitivity and adhering to a hypoallergenic diet in the management of inflammatory bowel diseases.16,17 sometimes people with egg allergies also develop oas, which is usually seen in people with allergies to fruits, vegetables, and nuts, and the most important symptoms of this syndrome are swelling of the lips and itching of the oral mucosa, sometimes abdominal pain and vomiting.18 rare cases include ulcerative colitis (colitis ulcerosa) – in this case, it is worth mentioning the following clinical situation: the patient l., 44 years old, who suffered from ulcerative colitis for 20 years, was tested for a possible food allergy, and one of the in vitro tests with chicken eggs gave a positive result. the patient followed an egg-free elimination diet and saw immediate improvement, and 9 months later, at her last examination, she considered herself completely cured. thus, testing for food hypersensitivity and adherence to a hypoallergenic diet can have a significant place in the diagnosis and treatment of inflammatory bowel diseases, which has been confirmed in scientific studies.19 the first stages of the diagnostic tactic often include elimination diets, which involve removing one or more food groups from the diet; however, this strategy can lead to problems, as children may experience weight loss, eating disorders, and stunted growth resulting from malnutrition.20 however, in the described cases, dietary restrictions are of a forced nature, since the consumption of food products containing chicken eggs and/or meat can pose a threat to health and life, so this is the first step in solving the issue of food intolerance. at the same time, it is worth mentioning other social and political factors affecting public health table 2. titers of specific immunoglobulin e (ige) (ku/l) before and after elimination diet patient m., 45 years patient i., 8 months patient k., 13 months before after before after before after сhicken egg white nd 30.4 43.75 54.8 17.4 2.84 сhicken egg yolk 18.3 0.51 0.35 nd сhicken meat 100 nd gal d 1 nd 1.06 0.81 8.73 1.87 gal d 2 0.25 0.32 0.09 0.02 gal d 3 nd nd 0 gal d 4 0.07 nd, not determined; the reference value is up to 0.35 ku/l source: created by the authors. [page 40] [healthcare in low-resource settings 2024;12(s2):12430] non -co mmerc ial us e o nly diagnostic methods that can be used to establish a diagnosis of food allergy, in the case that the disease has a mild or moderate course of severity, and there are no contraindications to these procedures. in vivo diagnostics, such as a skin prick test (spt), involves applying a small amount of a target allergen to the epidermis using a needle or scarifier, which allows the allergen solution to penetrate into the body.21 the severity of the reaction is then assessed by calculating the diameter of the affected area, which is considered a qualitative indicator, as there is currently no unified way of interpreting these data.22 also, this method is associated with significant risks due to the unpredictability of the results, taking into account the direct impact on the patient caused by allergens, which was reported in a number of case reports – therefore, for the subsequent treatment of anaphylaxis, it is necessary to have appropriate equipment and consumables, such as epinephrine, an artificial pulmonary ventilation kit.23,24 an additional problem that arises during spt is the insufficient representation of allergen extracts due to biological variability of allergen sources, which often leads to false-negative results.21 in vivo methods include oral (opt) and nasal provocation tests (npt), which demonstrate good results in examining adult patients with food allergies.25 a double-blind, placebo-controlled food challenge (dbpcfc) is the gold standard for confirming the diagnosis of food allergy, although it is time-consuming and not without risk, it is possible to conclude that such research methods are more specific than spt and have a tropic effect with the development of gastrointestinal and respiratory reactions.26 it is worth noting that in this case report study, a 21-year-old patient with an allergy to chicken eggs also underwent immunological testing (such as polycheck, alex multiplex test, isac, immunocap), where she received positive titers of ige to gal d 1, gal d 2 and negative ige for gal d 3, gal d 4 and gal d 5. in the study by j. kido et al.25 which included 103 children with suspected chicken egg allergy, a diagnostic program was performed that included an opt, molecular diagnostics, and spt. d.v. maltsev26 came to the conclusion that these methods should be performed with the usage of both raw and heated eggs, with opt demonstrating more pronounced results in the case of a reaction to raw eggs without a reaction to heated ones, unlike spt and ige tests. the possibility of using allergenic molecules in the last decade initiated a new phase of diagnostics, which is now called precision allergy molecular diagnostic applications (pamd@), this made it possible to improve the management of patients with food allergies.27, 28 in the described cases, the use of molecular diagnostic methods plays an important role, as it is minimally invasive, highly accurate and allows monitoring the effectiveness of the therapeutic measures. returning to the data in table 2, it is possible to conclude that patient i. had no dynamics of titers of diagnostic antibodies after the elimination diet therapy. in patient k., the dynamics turned out to be positive, but insufficient in combination with a history of anaphylaxis, which requires the continuation of strict dietary restrictions. thus, unmet medical requests for the efficient treatment of food allergies represent a significant challenge for today’s society. the development of allergy diagnostics has greatly benefited from advancements in the molecular identification of allergens. for such patients, as described in this study, it is necessary to develop diagnostic and therapeutic procedures that would be safe to use and available to patients of different ages and social categories. discussion in typical cases of chicken egg allergy, symptoms appear before the age of two years, which is several months later than with cow milk allergy, which affects 1-4% of the general population of european countries, but this percentage may be higher in children with atopic tendencies.11 according to w. balińska-miśkiewicz, allergens gal d 1-4 more often cause allergic reactions in children, while gal d 5 and gal d 6 more often cause allergic symptoms in adults. in the presented three cases, it was the gal d 1 and gal d 2 allergens that played a key role in the development of an allergic reaction, and actually anaphylaxis.29 it can be assumed that heat treatment causes denaturation of chicken egg proteins, and such changes in conformation can significantly affect the allergenic structure of the protein, which will prevent contact with antibodies of the ige class and mediate the development of an allergic reaction. the data was presented by de silva et al.30 that boiling an egg for at least 10 minutes reduces its allergenic effect by more than 75%, frying or baking – even more, so most children with allergy symptoms after eating raw or semi-raw eggs tolerate fried eggs and baking well, and heat treatment of food contributes to the destruction infectious agents.31,32 however, as it was mentioned earlier, among the indicated patients, heat treatment of food products did not protect against the development of symptoms of the disease. however, knowledge about the structure can be used to obtain proteins with reduced allergenic properties, which was discovered during experimental studies.33,34 this could help create egg analogs for the food industry to enable food allergy patients to expand their diet without fear of provoking a paroxysm of the disease. according to research by lunhui et al.,8 the egg white is more allergenic than the yolk, although it also has allergenic properties; this allows to avoid an excessively restrictive diet, which contributes to the improvement of the quality of life of patients in their family.8 among the described patients, a reaction to both chicken protein and egg yolk was observed under the conditions of the development of severe symptoms, which suggests the reactivity of the body to all components of the egg, which requires the complete exclusion of this food product and its derivatives from the diet. it is worth paying attention to the phenomenon of cross-reactions. different researchers presented their cases, that while diagnosing an allergy to chicken egg allergens, it is necessary to take into account the possibility of cross-allergic reactions between allergens obtained from egg white and yolk, as well as between eggs of different species of birds, such as turkeys, ducks, geese, quails, and even seagulls. cross-allergic reactions between allergens from different bird tissues are the basis of the state called bird-egg syndrome, which is characterized by the coexistence of food allergy to eggs and meat and inhalation allergy to bird feathers. patients were not tested for cross-reactivity, but this study would be useful in the context of clarifying dietary and professional restrictions to protect them from developing allergic reactions.34-36 dona and suphioglu27 presented a detailed systematic review of other aspects of allergy diagnosis. this process begins with a thorough analysis of the patient’s environmental factors and symptoms, followed by a physical examination. allergy diagnosis and treatment is often problematic because the condition is multifactorial and symptoms and timing of onset can be confusing to doctors – this is due to food symptoms that can be signs of both ige-mediated food allergy (ifa) and non-ifa, malabsorption syndrome, psychological rejection, and other medical disorders.37-39 the key point is that a true allergic reaction to a food product occurs after consumption of a particular food, and allergic symptoms appear within minutes or hours after consumption.25 in the example of the described patients, the diagnosis of ifa does not cause any doubts. currently, there are no temporary or permanent therapeutic methods that would completely cure allergies. in the case of a con social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12430] [page 41] non -co mmerc ial us e o nly firmed diagnosis of allergy, especially allergy to eggs, according to caffarelli et al.,40 the main therapeutic approach is to strictly exclude the allergen from the diet or minimize contact with it. and for the patients with anaphylactic reactions in these cases, it was the only outcome. usage of pharmacotherapy is aimed at alleviating symptoms by blocking allergy mediators, as in the case with antihistamines. parisi et al.,41 however, note that this treatment is not etiotropic, because it does not stop the production of specific ige antibodies. in addition, drugs like anti-leukotriene blockers (that stabilize mast cells) and anti-inflammatory corticosteroids can induce the development of immunosuppression with undesirable side effects. parisi et al.,42 in the described cases, note that no data were presented on the use of other medications, except for adrenaline, which would be useful to investigate in subsequent studies. although such severe cases are rare in european countries, anaphylaxis is a life-threatening condition and it requires the use of epinephrine, which, according to recommendations, is administered intramuscularly, and must be previously prescribed by physicians in the amount of 2 auto-injector pens.43,44 allergen-specific immunotherapy (acit or ait) is recognized as the most effective and safest method of treatment and alleviation of allergy symptoms, and the results of clinical studies indicate that immunotherapy can not only alleviate allergic symptoms, but also prevent the development of allergies. this therapy consists of the regular and long-term introduction of allergen extracts in order to achieve a tolerance to the allergen.45-47 the first stage of therapy is called induction of desensitization, the effectiveness of which depends on the dose of extracted allergens in the form of subcutaneous injections, tablets, aerosols, or sublingual drops. this means that the minimum dose of the administered extract should be sufficient to effectively control symptoms. therapeutic efficacy increases over time, as significant improvement is usually observed only after at least three months of therapy, which may continue for several years.43 therefore, it is extremely important to communicate realistic expectations to patients. nevertheless, immunotherapy is associated with a significant risk of anaphylaxis, which requires special care and vigilance by medical personnel. oral immunotherapy appears to be preferentially used in patients who do not report previous symptoms of systemic or gastrointestinal anaphylaxis, whereas sublingual and epicutaneous ways of distribution in particular may be more preferentially used in patients at risk of anaphylaxis.48-50 therefore, there is a need for safer reagents for immunotherapy, such as highly purified recombinant hypoallergens, which would minimize the risk of anaphylaxis. this highlights the importance of investigating safe recombinant allergens and hypoallergens in the context of immunotherapy.47 the usage of recombinant dna technology, where individual proteins are expressed separately in bacterial and/or yeast host systems, it is possible to obtain allergens with a higher degree of purity, free from other allergens, and with preservation of t-cell epitopes and immunogenicity.48 changing the conformational epitopes of b cells while preserving the epitopes of t cells allows for reducing ige reactivity, creating hypoallergens.51-53 there are also many approaches to protein modification, including molecular fusion or fragmentation, random or point mutations, and the formation of chimeric and mosaic structures, all of which can be used to reduce the risk of adverse allergic reactions.54,55 patients of the described clinical situations could become candidates for ait, however, considering the severity of the course, high immunoreactivity, early childhood, and the imperfections of this method of treatment, unfortunately, these patients currently have no other treatment alternatives except strict dietary restrictions and constant access to the use of adrenaline. thus, identifying details about cross-reactivity, primary sensitization, and hazards should be included in the diagnostic search for patients with chicken egg allergy. pitfalls in this process can be the severity of the patient’s condition, availability, and associated costs, which prevent widespread use. the lack of safe and wellstandardized recombinant ige-reactive allergens and their hypoallergenic variants, the lack of long-term population studies with a comprehensive approach to egg allergy, and the lack of safe and well-standardized diagnostic and therapeutic approaches are among the limitations of the current study. conclusions chicken eggs have strong allergenic properties, which leads to a high percentage of allergy to chicken eggs (both white and yolk) in the general population. food allergy can be the first manifestation of atopic march in childhood patients; however, the development of this condition is quite likely in adulthood, especially in the presence of a burdensome family and professional history. the main allergenic components of chicken egg are glycoproteins ovomucoid (gal d 1), and ovalbumin (gal d 2). symptomatically, allergy is very polymorphic. most often, the clinical picture in patients is represented by skin manifestations, although the presented clinical cases show that an allergic reaction can develop into a life-threatening condition (anaphylaxis) that requires immediate administration of epinephrine, which patients should be taught. diagnosis and treatment of allergies are often problematic due to the need for detailed differential diagnosis between different clinical conditions, but in cases of anaphylaxis the diagnosis of ige-mediated food allergy has no doubt. the development of allergy diagnostics has greatly benefited from the improved molecular identification of allergens and determination of specific ige – it is safe and available for patient, who are contraindicated skin prick tests and other risky methods. currently, there are also no temporary or permanent therapeutic methods that would allow the complete cure of allergies; however, allergen-specific immunotherapy is currently recognized as the most effective and safe, but it is not developed for patients with food allergies. innovations in molecular diagnostics will lead to safe and reliable diagnostic methods as well as improved pharmacological and immunological reagents for use in immunotherapy. it is important to give a chance for a safe cure and life for patients with severe clinical manifestations of allergy to chicken eggs. the development of preventive measures, the creation of hypoallergenic chicken egg protein for therapeutic use, as well as the stratification of patients according to the severity of clinical manifestations and levels of specific antibodies, which could provide adequate tactics for the management of such patients, may be promising areas for the next research. references 1. allergen-component diagnostics food-pollen allergy. 2022. available from: https://www.worldallergy.org/component/content/article/allergen-component-diagnostics-food-pollen-allergy?catid=17&itemid=101 2. johansson e, mersha t. genetics of food allergy. immunol allergy clin north am 2021;41:301-19. 3. zambrowicz a, dąbrowska a, bobak ł, szołtysik m. egg yolk proteins and peptides with biological activity. postepy hig med dosw 2014;68:1524-9. 4. chen yp, li d, zhang xc, et al. azacytidine-induced social and political factors affecting public health [page 42] [healthcare in low-resource settings 2024;12(s2):12430] non -co mmerc ial us e o nly hypomethylation 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during skin testing with food allergens in children. euro j pediatr 2010;169:613-5. 24. hernández-moreno k, diez l. systemic reaction after performing a food prick-to-prick test. a case report. rev alergia mexico 2017;64:126-9. 25. kido j, nishi n, matsumoto t. the oral provocation test for raw egg in patients with hen egg allergy. int arch allergy immunol 2018;177:40-4. 26. maltsev dv. efficiency of a high-dose intravenous immunoglobulin therapy in children with autism spectrum disorders associated with genetic deficiency of folate cycle enzymes. j global pharma technol 2019;11:597-609. 27. dona d, suphioglu c. egg allergy: diagnosis and immunotherapy. int j molec sci 2020;21:5010. 28. steering committee authors, review panel members. a wao – aria – ga2len consensus document on molecular-based allergy diagnosis (pamd@): update 2020. world allergy org j 2020;13:100091. 29. balińska-miśkiewicz w. molecular diagnosis of food allergy – do we know more? postepy hig med dosw 2014;68;754-67. 30. de silva d, halken s, singh c, et al. preventing food allergy in infancy and childhood: systematic review of randomised controlled trials. pediat allergy immunol 2020;31:813-26. 31. sokołowicz z, kačániová m, dykiel m, et al. influence of storage packaging type on the microbiological and sensory quality of free-range table eggs. animals 2023;13:1899. 32. mine y, wei zhang j. identification and fine mapping of igg and ige epitopes in ovomucoid. biochem biophys res commun 2002;292:1070-4. 33. dhanapala p, withanage-dona d, tang m, et al. hypoallergenic variant of the major egg white allergen gal d 1 produced by disruption of cysteine bridges. nutr 2017;9:171. 34. moghtaderi m, nabavizadeh s, hosseini teshnizi s. the frequency of cross-reactivity with various avian eggs among children with hen’s egg allergy using skin prick test results: fewer sensitizations with pigeon and goose egg. allergol immunopathol 2020;48:265-9. 35. lee j, gantulga p, lee c, et al. a preliminary study on crossreactivity of heat-treated quail and hen’s egg white proteins in young children. nutr 2021;13:2172. 36. langeland t. a clinical and immunological study of allergy to hen’s egg white. vi. occurrence of proteins cross-reacting with allergens in hen’s egg white as studied in egg white from turkey, duck, goose, seagull, and in hen egg yolk, and hen and chicken sera and flesh. allergy 1983;38:399-412. 37. loverde d, iweala o, eginli a, krishnaswamy g. anaphylaxis. chest 2018;153:528-43. 38. hemmer w, klug c, swoboda i. update on the bird-egg syndrome and genuine poultry meat allergy. allergo j int 2016;25:68-75. 39. gargano d, appanna r, santonicola a, et al. food allergy and intolerance: a narrative review on nutritional concerns. nutr 2021;13:1638. 40. caffarelli c, giannetti a, rossi a, ricci g. egg allergy in children and weaning diet. nutr 2022;14:1540. 41. parisi gf, leonardi s, ciprandi g, et al. cetirizine use in childhood: an update of a friendly 30-year drug. clin mol allergy 2020;18:2. 42. parisi gf, leonardi s, ciprandi g, et al. antihistamines in children and adolescents: a practical update. allergol immunopathol (madr). 2020;48:753-62. 43. nucera e, inchingolo r, nicotra r, et al. influence of antihistamines on basophil activation test in food allergy to milk and egg. diagnost 2020;11:44. 44. patriarca g, schiavino d, pecora v, et al. food allergy and food intolerance: diagnosis and treatment. intern emerg med 2009;4:11-24. 45. muraro a, worm m, alviani c, et al. eaaci guidelines: anaphylaxis (2021 update). allergy 2022;77:357-77. 46. kraft m, dölle-bierke s, turner p, et al. eaaci task force social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12430] [page 43] non -co mmerc ial us e o nly clinical epidemiology of anaphylaxis: experts’ perspective on the use of adrenaline autoinjectors in europe. clin trans allergy 2020;10:12 47. schapovalova o, gorlova a, de munter j, et al. immunomodulatory effects of new phytotherapy on human macrophages and tlr4and tlr7/8-mediated viral-like inflammation in mice. front med 2022;9:952977. 48. turmagambetova as, sokolova ns, bogoyavlenskiy ap, et al. new functionally-enhanced soy proteins as food ingredients with anti-viral activity. virus dis 2015;26:123-32. 49. mandziy zp, boichuk oh, myhovych vv. correction of iron deficiency in the clinical picture of internal medicine. emerg med (ukraine) 2021;17:64-70. 50. muraro a, de silva d, halken s, et al. managing food allergy: ga2len guideline 2022. world allergy org j 2022;15:100687. 51. sahiner u, giovannini m, escribese m, et al. mechanisms of allergen immunotherapy and potential biomarkers for clinical evaluation. j personal med 2023;13:845. 52. marcucci f, isidori c, argentiero a, et al. therapeutic perspectives in food allergy. j trans med 2020;18:302. 53. lam h, tergaonkar v, ahn k. mechanisms of allergen-specific immunotherapy for allergic rhinitis and food allergies. biosci rep 2020;40:bsr20200256. 54. durham s, shamji m. allergen immunotherapy: past, present and future. nat rev immunol 2023;23:317-28. 55. pavón-romero g, parra-vargas m, ramírez-jiménez f, et al. allergen immunotherapy: current and future trends. cells 2022;11:212. social and political factors affecting public health [page 44] [healthcare in low-resource settings 2024;12(s2):12430] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12874 the short-run effects of health aid in low-income countries: evidence from panel data analysis keneni gutema negeri health systems management and policy unit, school of public health, college of medicine and health sciences, hawassa university, hawassa, ethiopia abstract the effectiveness of health-targeted aid in improving health outcomes in developing countries remains a subject of debate. this paper investigates the short-run impact of health aid on health status in low-income countries globally. a panel dataset was constructed from 34 low-income countries spanning 2000 to 2017, with infant mortality rate (imr) serving as the primary proxy for health status. to estimate the short-run effect, first difference gmm and system gmm estimators were employed, with a preference for system gmm due to its robustness against weak instrument problems in dynamic panel data models. the model incorporated log transformations for health development aid (hda), gdp per capita, and cereal yield, while exponential transformations were applied to human capital and governance indices, alongside adolescent fertility rate and elderly dependency rate. the system gmm estimation revealed a statistically significant and beneficial short-run effect of health aid on health status. specifically, a doubling of health aid is associated with a reduction of 2 infant deaths per 1,000 live births. other significant findings include the positive impact of gdp per capita, human capital, and governance, and the negative impact of adolescent fertility rate and elderly dependency rate on infant mortality. the sargan test confirmed the validity of the over-identifying restrictions (p=0.2279), and the arellano-bond test for ar(2) indicated no serial correlation in the idiosyncratic errors (p=0.158). the findings strongly suggest that health aid serves as a potent instrument for narrowing the health status gap between high and low-income countries, thereby contributing to the achievement of universal health coverage. however, recipient countries should also prioritize fostering domestic factors that positively influence the health sector to reduce persistent reliance on external resources. introduction low-income countries grapple with a dual burden of disease: the persistent challenge of communicable diseases and a rapidly escalating prevalence of non-communicable diseases (ncds), such as common diseases found in all income groups, including heart disease, stroke, cancer, diabetes, and chronic lung diseases.1 this epidemiological complexity is exacerbated by healthcare financing mechanisms heavily reliant on out-of-pocket (oop) payments.2 such payments impose significant financial hardship, pushing approximately 100 million individuals into poverty and subjecting 150 million to catastrophic health expenditures annually, perpetuating a vicious cycle of poverty and ill health.3 in this context, a critical question emerges: can avoidable infant mortality be averted in the foreseeable future, and what policy instruments can most efficiently achieve this? globally, universal health coverage (uhc) has been recognized as a cornerstone of sustainable development. the united nations general assembly enshrined uhc within the sustainable development goals (sdgs) as goal 3.8, aiming to “achieve universal health coverage, including financial risk protection, access to quality essential health care services and access to safe, effective, quality, and affordable essential medicines and vaccines for all” by 2030. a key pathway to achieving this goal involves increased health aid, particularly that channeled through public spending on health, which is expected to enhance financial protection. in low-income countries, health aid currently accounts for an average of 30% of health expenditure and has been increasing in absolute terms over time.2 while this raises numerous questions, this paper specifically investigates the effect of health aid in lowincome countries on the achievement of the aforementioned uhc correspondence: keneni gutema negeri, health systems management and policy unit, school of public health, college of medicine and health sciences, hawassa university, hawassa, ethiopia. e-mail: kenenigut2000@yahoo.com key words: health function, health aid, infant mortality, low-income countries, panel data. conflict of interest: the author declares that there is no conflict of interest. ethics approval and informed consent: not applicable. availability of data and material: available from the corresponding author on request. funding: the researcher used fund from his own source. acknowledgement: i extend my deepest gratitude to my family, whose unwavering encouragement and insightful discussions have been invaluable in the preparation of this manuscript. their support, in ways beyond financial contributions, has shaped my thinking and strengthened my commitment to this research. received: 29 july 2024. accepted: 28 august 2025. early access: 18 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12874 doi:10.4081/hls.2025.12874 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:12874] [page 247] goal, particularly regarding infant mortality. the existing literature on the impact of health-specific aid on recipient countries’ health status presents a notable divergence, contrasting with the more extensively studied effects of aggregate aid on national growth. this section synthesizes the arguments for and against the effectiveness of health aid, highlighting key findings and the methodological nuances that contribute to the ongoing debate. a significant body of research suggests that health-targeted aid demonstrably improves health outcomes in low-income countries by augmenting resource availability for health service delivery. proponents argue that health is a sector where aid’s impact is particularly discernible due to the direct link between health programs and desired outcomes. for instance, levine and kinder3 posits that health programs like communicable disease prevention and control (through safe water, sanitation, immunizations, and improved nutrition) are directly linked to positive health outcomes. easterly,4 similarly, contends that with appropriate accountability, external aid can significantly decrease infant mortality. empirical support for this perspective is robust. mishra and newhouse5 provide strong evidence using donor commitment data from 118 countries (1973-2004), finding that a 1% increase in per capita health aid is associated with a 2% improvement in infant mortality rate. likewise, chauvet et al.6 utilizing a panel data of 109 developing countries (1987-2004), reported significant effects of health aid on health improvement. similar findings are reported by ebeke and drabo,7 mishra and newhouse,8 and chauvet and guillaumont,9 all suggesting a substantial positive impact of health aid on health outcomes in the developing world. these studies often emphasize the heightened effectiveness of health-targeted aid in low-income settings. furthermore, some scholars argue that the impact of aggregate aid on health status is also evident in low-income countries. gormanee et al.10 assert that aggregate aid bridges resource gaps, leading to remarkable changes through direct public health projects such as communicable disease prevention and control, improved water supplies and sanitation, malaria control, and immunization programs. this positive effect of aggregate aid on health status has been corroborated by other studies.11,12 conversely, another group of scholars argues that there is insufficient evidence to conclusively claim that health aid consistently improves health outcomes in recipient countries. this skepticism often stems from concerns about aid fungibility and potential negative externalities. for example, williamson,13 examining the impact of foreign aid commitments on the health sector across 208 developed and developing countries (1973-2004), found an insignificant effect. similarly, wilson’s14 empirical analysis of a panel data from 96 high-mortality countries (1975-2005) indicated no significant effect of health aid on recipient countries’ infant mortality rate. the primary argument for the ineffectiveness of health-targeted aid centers on the concept of “fungibility,” where recipient countries may divert aid resources to non-targeted expenditures instead of channeling them into the health sector as intended. pettersson15 highlights that such non-targeted expenditures, sourced from all development assistance, can be as high as 70%. beyond fungibility, critics also argue that aid can negatively impact the competitiveness of aid-receiving countries, foster dependency, disincentivize the adoption of sound domestic policies, and exacerbate corruption.16,17 the contrasting findings presented above create a significant dilemma for policymakers: should health aid be considered a complementary tool for achieving uhc, or should the focus be exclusively shifted to domestic factors? one root of this persistent controversy lies in methodological deficiencies within existing empirical studies. specifically, issues such as misspecification problems, encompassing both weak functional forms and omitted variables, are prevalent in health estimating equations. the literature also rarely emphasizes separate short-run health aid effects, despite the fact that the size and significance of estimated marginal effects are strongly dependent on such time spans. therefore, this research endeavors to address these critical gaps by employing a better-specified estimation equation that is consistent with a sound theoretical framework grounded in utilitymaximizing human behavior.18-21 this will involve a rigorous examination of functional forms and the inclusion of relevant control variables to mitigate omitted variable bias. investigating the short-run effects of health aid on health outcomes in low-income countries, a dimension often overlooked in existing analyses, which predominantly focus on long-term impacts. this will provide more nuanced insights into the immediate responsiveness of health indicators to aid inflows. by addressing these methodological shortcomings, this paper aims to provide a more robust and reliable assessment of the effect of health aid on achieving uhc goals in low-income countries, offering clearer guidance for policy formulation. materials and methods framework of the study grossman’s health production model specifies a vector of inputs, where the variables of the vector include: nutrition, education, consumption of public goods, income, initial individual endowments like genetic makeup, time devoted to health-related procedures, and community endowments such as the environment.20 following this approach, let the implicit function that relates these factors to health outcome h(t) as [1] where wj(t) the input j>t variables are unobserved or not measured, h(t) represents the health outcome at time t. in constructing health capital model, grossman suggested the application of utility maximization constrained with resources which may require application of optimal control analysis.20 building on these views it is assumed here that households derive satisfaction from their health status and they strive to maximize their utility constrained by socioeconomic and demographic factors. the common and very important solution from such utility maximization problem is the constancy of marginal effects of the input variable. that is after taking total derivative of equation [1] [2] the marginal effects fj are constants. based on the constancy of marginal effects, one can integrate equation [2] to get [3] article [page 248] [healthcare in low-resource settings 2025;13:12874] where a is some constant. in fact, in empirical analysis, to maintain the result of optimal control analysis, i.e. constancy of the marginal effects, the input variables have to undergo some mathematical transformations, like log transformation, exponential transformation, depending on the measure of the input variable, otherwise the estimation equation will face a misspecification problem arising from the wrong functional form. in the specification of the health estimating equation, besides the wrong functional form, one may face the omitted variable problem, the case where a part of the input variables is unobservable, or the data may not be available. from introductory econometrics, we understand that ignoring these variables will make the coefficient estimates of the known variables unbiased. to deal with this issue, here it is assumed that the omitted variables follow autoregressive of order two, which can be expressed as a second order difference equation whose particular solution and complementary function together form a function of time, i.e., for omitted variable the estimated auto regressive of order two for wj(t) can be written as whose complementary function and particular solution will be where complementary function taking the total derivative of the variable and divide through by wj(t) to get [4] is the elasticity of wj(t) with respect to time. assuming this elasticity to be constant (this assumption is derived from the belief that the growth of the input variables declines over time so that in the long run the variables exhibit stability. this stability, together with the constancy of marginal effects, would imply stability of the portion of health status generated by these variables) and integrating both sides of equation [4], one gets [5] substituting equation [5] in equation [3] one gets the long run health function as [6] essentially, equation [6] is a long-run health equation since it is grounded on the constancy of marginal effects of the input variables, which holds true in the long run. to drive the short-run health function from equation [6], the partial adjustment model (pam) is adopted. intuitively, it is clear that the possibility that the coefficients in the health status estimating equation [6] could be related to the level of change in health status before the input variables change. that is, keeping all other things equal, a one percent change in an explanatory variable in a population with a lower level of health status could have a higher effect than when a similar change takes place in another population with a higher level of health status. when the interest is to know the short-run effect, this phenomenon demands us to control for the previous level of health status. the pam specifies the observed level of a given dependent variable as a weighted average of its level that existed in the previous time period and its equilibrium level at the present time, as [7] where l such that 0<l≤1 is known as coefficient of adjustment. the pam postulates that the actual change in the health status indicator in any given time period t, is some fraction l the expected change for that period. if l=1 it means the actual health status is equal to its long-run level. that is, the observed health status adjusts to its long-run level instantaneously. however, if l=0 it means that the health status is not changing at all. substituting equation [6] in equation [7], we get [8] equation [8] represents the short run health function since the past effects of the input variables are excluded from the coefficients. negeri and haile22 showed that consideration of lagged health status level in the equation is comparable with including all past lagged effects of the input variables under some mathematical restrictions or as a distributed lag of all input variables. notice that if the system is already on its equilibrium path, the regression assigns one to l, which makes the transition path dynamics have no effect in determining the level of h(t). but if the system is in transition to equilibrium fully, the regression assigns zero to l, which makes the equilibrium path dynamics have no effect in determining the level of h(t). in actual cases, l is expected to lie between these two extremes and hence the observed level of h(t) will be the weighted average of both dynamics as postulated in pam. besides this, the specification, while retaining most of the useful properties of the usual dynamic log-linear specification, avoids the implausible prediction that the latter specification makes in the cases of extreme levels of health status. moreover, it takes care of the problems of unknown variables instead of just assuming their absence, which makes the coefficient estimates biased. furthermore, it accommodates both transition path dynamics and equilibrium path dynamics together. that is, once we esti article [healthcare in low-resource settings 2025;13:12874] [page 249] mate the short-run function properly, it is possible to drive the estimate of the long-run health function by dividing the coefficients of the input variables by the estimate of the coefficient of the lagged health indicator. variables, definitions and data sources to estimate the short-run effect of health aid on health status, eight variables were chosen following past studies.5,22 these are; infant mortality rate (imr), health development aid (hda), gross domestic product per capita (gdpp), human capital (hc), adolescent fertility rate (afert), elderly dependency rate (edep), worldwide governance indicator (inst) and cereal yield (yield). imr was considered a dependent variable of the current study. though life expectancy is another alternative proxy variable for health status, imr was preferred in this study; first, it is more sensitive to economic changes of the population than life expectancy, implying that it is a better measure of improvement in low-income groups of society.5,28 seconds, infant mortality explains substantial improvements in life expectancy itself in poor countries. third, past studies indicate that in developing countries, improvement in infant mortality shows better access to medical care, safe water and better sanitation, improved maternal and infant nutrition, literacy status especially that of female and increased per capita gdp and economic equality.22 fourth, data on infant mortality are available for a large set of countries and are more reliable than life expectancy. on these grounds this study considers imr as a good proxy for health status.13 according to world bank (wb), imr is defined as the number of infants dying before reaching one year of age, per 1,000 live births in a given year and the data was taken from wb.29 hda, the main variable of interest here, is defined as an external source of health expenditure in a recipient country, measured in constant 2010 usd. external sources consist of direct foreign transfers and foreign transfers distributed by the government, encompassing all financial inflows into the national health system from outside the country. external sources either flow through the government scheme or are channeled through non-governmental organizations or other schemes, data for this variable was taken from wb.29 gdpp was also taken from the world bank29, and the source defined it as “gross domestic product, in constant 2010 usd dollars, divided by midyear population”. it is obvious that a higher level of income favors consumption of quality goods and services, better nutrition, housing, and the ability to pay for medical care services. therefore, gdpp is considered to be an explanatory variable of the health status of the population under study. hc index was taken from feenstra et al. the source indicated that the hc was based on years of schooling and returns to education.30 afert data was taken from the world bank world development indicators29 and it is defined as the number of births per 1,000 women aged between 15 and 19 years. the rates are based on data on registered live births from vital registration systems or, in the absence of such systems, from censuses or sample surveys. the estimated rates are generally considered reliable measures of fertility in the recent past. where no empirical information on age-specific fertility rates is available, a model is used to estimate the share of births to adolescents. edep data were taken from the world bank29 and the bank defined the variable as the ratio of elderly dependents—people older than 64—to the working-age population—those ages 15-64. data are shown as the proportion of dependents per 100 working-age population. inst is a composite index of governance and was computed from six dimensions of governance using principal component analysis, a statistical technique used for data reduction, and based on the six aggregate dimensions of governancerule of law (rula), control of corruption (ccorr), political stability (psav), government effectiveness (goeff), regulatory quality (requ), voice and accountability (voac). the indices for the dimension were taken from world bank (31). the dimension indices range from -2.5 (the lowest performance) to 2.5 (the higher performance) composite index was computed as where the coefficients of each variable were obtained from the square of the principal component that adds up to unity. governance was considered because its quality affects health systems by shaping resource allocation, policy implementation, and service delivery. effective governance ensures transparent funding, equitable healthcare access, and accountability, minimizing corruption and inefficiencies. political stability further safeguards health infrastructure from disruptions due to conflict or instability. yield was taken from the world bank, and the source defined it as kilograms per hectare, but here converted to quintal per hectare, of harvested land, which includes wheat, rice, maize, barley, oats, rye, millet, sorghum, buckwheat, and mixed grains. production data on cereals relate to crops harvested for dry grain only. the study used cross-sectional and annual time series data from 2000 to 2017 for 34 low-income countries. agricultural productivity, measured by cereal yield, directly impacts food security and nutrition. higher yields increase food availability, improve dietary quality, and reduce malnutrition-related health risks. economic benefits of strong agricultural output also enhance household income, enabling better access to healthcare and improved living conditions.29 estimation methods to estimate the short-run health function given in equation [8] econometric methods were applied to panel data. the method considers multiple cross-section measures over multiple time series data together to get more reliable parameter estimates than what cross-section or time series approach alone cannot address. following the specification given in equation the marginal effect of hda, gdpp and yield were assumed to vary inversely with the previous level of imr and hence log transformation of these variables were taken for estimation. on the other hand, the marginal effects of hc and inst were assumed to have exponential relation with the previous level of imr as these inputs are non-subtractable in their very nature. hence their exponential transformation was used in the estimation process. the marginal effect of afert and edep were assumed to be constant since they are indices or ratios. hence they were entered to the function without transformation. under the assumption of equation [8], the econometric specification that relates health status to a vector of explanatory variables is given as article [page 250] [healthcare in low-resource settings 2025;13:12874] where w(i,t), is infant mortality rate, w(i,t-1) one period lagged infant mortality, lnw(i,t) is log-health development assistance for health, lnw2(i,t) is log-gdp per capita, lnw3(i,t) is log yield expw4(i,t) is exponential of human capital index, expw5(i,t) is exponential of governance index, w6(i,t) is adolescent fertility rate, w7(i,t) is elderly dependency rate, in country i at time t for i=1,2,...34 (number of countries), t=1,2,...17 (number of time units), e(i,t) is error term with the property e[e(i,t)]=0 and var[e(i,t)]=(se)2; m0 is constant term; and m2(t) are country and time specific effects respectively. to estimate equation [9] the first difference generalized method of moments (gmm) developed by arellano and bond23 is suitable. furthermore, based on the nature of the error terms, system gmm developed by blundell and bond depending is recommended.24 first-difference gmm (arellano & bond) removes individual-specific effects and addresses endogeneity by using lagged variables as instruments. system gmm (blundell & bond) enhances efficiency by combining level and differenced equations, reducing bias and strengthening weak instruments, making it more ideal for persistent health variables. therefore, in the cases of a weak instrument problem in a dynamic panel data model like equation [9], the first differenced gmm estimator has been found to have poor precision.25 therefore, the system gmm estimator is recommended to provide a more accurate estimate in the current imr equation (5, 8, 26, and 27). however, for comparison purposes, estimation results from both estimators will be considered in the current study. at the same time, the conventionally derived variance estimator for gmm estimation is employed for the standard error, the variance-covariance estimator using gmm. to deal with omitted variables, it is assumed that the omitted variables follow an autoregressive process of order one, which is equivalent to assuming that they follow first-order differential equations, whose solution will be a function of time. on this ground, instead of just assuming the variables away, log-time is used as a control variable representing all omitted variables in both short-run and long-run health equations. results table 1 reports that during the study period 2000-2017, in lowincome countries, the estimated average infant mortality per 1000 live births was 65. according to the dataset, it was as high as 114 in sierra leone and 103 in the central african republic per 1000 live births. good health performance was observed in syria (16.0) and the democratic people’s republic of korea (26.0). besides this, the table indicates that during the indicated period, the average per capita hda and gdp were 8.38 and 574.00, respectively, both in constant 2010 usd dollars. the average growth in these variables was 7.47% and 1.45% per year, respectively. the recipients of a low amount per capita were niger (2.70 usd), senegal (2.98 usd), togo (2.69 usd), yemen, rep. (2.00 usd), whereas zimbabwe (19.41 usd), tanzania (23.0 usd), and haiti (25.30 usd) were receiving relatively higher amounts. countries with low per capita gdp were burundi (227.85 usd) and the congo, the democratic republic of the congo (334.80usd), whereas countries with relatively higher per capita gdp were yemen, the republic (1106.76 usd) and senegal (983.78 usd). besides this, figure 1 suggests that the imr-hda forms a downward-sloping curve, or there is a negative semi-log linear relation between the two variables, indicating that an increase in hda could lead to a decline in imr. on the other hand, figure 2, which plots imr against lnhda, indicates that the curve is more or less straight at least for lnhda>0 or hda>1.0 usd, and downward sloping to the right. the linearity of the curve in turn implies that the sought constancy of the marginal effect of the lnhda is confirmed, i.e., the log transformation of the hda is appropriate in estimating the health function. this figure also suggests that during the covered period of study for the sample countries, there was a maximum imr, which was 83.5 infants per 1000 live births. moreover, table 1 informs that the average human capital index was 1.60. the least index was observed in burkina faso (1.14), whereas the highest index was observed in tajikistan (3.14). the table also reports that for the income group, the average adolescent fertility was 107.30 births per 1,000 women aged 15-19. the indicator was the highest in niger (208) and the lowest in the democratic people’s republic of korea (0.61). in fact, the data indicates that this indicator is falling over time at an average decline of -1.9 births per year. moreover, the table informs that the elderly dependency rate was 5.88 per 100 working-age population. the indicator was the lowest in sierra leone (4.53%) and the high article figure 1. plot of imr vs hda per capita. fractional polynomial fit [2000-2017]. figure 2. plot of imr vs lnhdapc. fractional polynimial fit [2000-2017]. [healthcare in low-resource settings 2025;13:12874] [page 251] est in the democratic people’s republic of korea (11.96%). furthermore, table 1 shows that during the covered years of study, in the considered income group, the mean composite index of governance was below zero (-0.96). it was below-2.0 in somalia (-2.17) and south sudan (-1.75), whereas it was above -0.3 in senegal (-0.19) and benin (-0.304). a look at the overall trend of the index reflects that it was declining, at an annual average of 0.0088 with [95% conf. interval] of (-.0163, -.0013) i.e. institutional qualities are worsening substantially rather than improving during the covered period of study. finally, the table reports that in the indicated time period the average cereal yield was 13.59 quintal per hectare of harvested land. it was below 5qt /hr in eritrea (4.70qt/hr) and niger (4.34qt/hr) and above 25qt/hr in the democratic people’s republic of korea (35.05qt/hr) and madagascar (28.76qt/hr). considering an estimate of the effect of health-targeted aid on health status measure (imr), whilst first difference gmm estimator result is shown for comparison purposes only as indicated on table 2, the system gmm estimator was considered for a detail description of the results for the reason argued earlier.5,8,26,27 consequently, like all gmm estimators, system gmm can produce consistent estimates only if the moment conditions used are valid. to test the validity of the over-identified restriction, the sargan test is employed for it, unlike the hansen test, which can be weakened by many instruments, but is not weakened by many instruments. in fact, arellano and bond show that the one-step sargan test over-rejects in the presence of heteroskedasticity.23 in the case of the current study, the null hypothesis that the overidentifying restrictions are valid is not rejected. in its second half, table 2 reports that the sargan test of over-identifying restrictions accepts the null hypothesis that states the over-identifying restrictions are valid, χ2 (102)=112.388, p=0.2279. accepting this null hypothesis implies that the current study model or instruments need not be reconsidered. hence, the test confirms the hypothesis that the instrumental variables should not be correlated with the residuals, and hence they are acceptable. moreover, the table informs that for these countries the wald test rejects the null hypothesis that states all the coefficients except the constant term are zero in both estimators. the table also reports that the coefficient of the lagged imr is 0.5458 and is statistically significant, z=11.27, p=0.0000, confirming the need for controlling for past effects of the independent variables when the interest is in getting their short-term effects. in its robust version, the arellano-bond test for ar(2) in the first difference accepts the null hypothesis of no serial correlation in the idiosyncratic errors, which implies the instrumental variables are acceptable, z =1.411, p=0.1580. besides, the table also informs that for the measured variables, the wald test rejects the null hypothesis that states all the coefficients except the constant term are zero, wald χ2 (9)=2890.76, p=0.0000 (table 2). moreover, as shown in table 2, the coefficient estimate of log-hda was 1.9818, and this was statistically significant (p=0.0000). similarly, a statistically significant estimate was observed for the log-gdpp coefficient, -9.6007 (p=0.0000). in the same way, the estimator gives -as a coefficient of expinst, 7.8092 (p=0.0160). the estimator also gives -0.8945 as a coefficient estimate of exphc, which is statistically significant at 10% level of significance (p=0.051). sometimes the short run relative importance of the selected input variables together with their flexibility in policy decisions may be point of interest. table 3 reports the shares of effects of the chosen variables’ effect in declining imr from the annual average. in calculating the shares of the effects of the input variables, the previous level of imr is unchanging for it has already been realized. hence what determine the change in imr from previous time up to the present time are changes in the input variables. accordingly, during the covered period of study, in the sample countries, while the annual average change in imr from the data was -0.9845 infants per 1000 live births the predicted change from the input variables using the chosen estimator was -1.1133 infants per 1000 live births, indicating the estimator predicted very close to what was observed in the short run (table 3). the table informs that a decline in adolescent fertility, an increase in health aid, and an increase in per capita income play a major role in reducing infant mortality. in explicit terms, in the observed average annual imr decline, 13.29 percent (1.9818x0.0747)/-0.9845) is due to an increase in health aid, 12.54 percent (-9.600x0.0145)/-0.9845) is due to an increase in per capita income and 15.68 percent (0.0921x1.8968)/-0.9845) is due to a decline in adolescent fertility. if left unchecked governance quality and yield were found to play an adverse role in the efforts made to reduce imr (table 3). moreover, from table 3, it can be understood that 46% of the decline in imr was due to the selected input variables. discussion in this study, the short-run health function analysis provides important insights for policymakers working to enhance health outcomes in low-income countries, particularly regarding health article table 1. health-related indicators across low-income countries (2000-2017). variable obs mean std. dev. min max imr 612 65.25 24.16 13.80 142.00 hda 440 8.38 7.68 0.00 48.38 gdpp 531 574.00 223.95 193.87 1309.23 hc 375 1.60 0.44 1.07 3.17 afert 578 107.30 48.08 0.29 217.16 edep 606 5.88 1.37 4.33 14.03 inst 568 -0.96 0.50 -2.43 0.06 yield 566 1359.09 715.33 158.20 4439.90 hda, health development aid, gdpp, gross domestic product per capita, hc, human capital, afert, adolescent fertility rate, edep, elderly dependency rate, inst, worldwide governance indicator, yield, cereal yield. [page 252] [healthcare in low-resource settings 2025;13:12874] aid allocation and governance reforms. the significant negative coefficient of log-health development assistance (hda) (1.9818, p=0.000) underscores the strong positive impact of health aid on reducing infant mortality rate (imr). specifically, doubling per capita health aid is associated with saving approximately two infant lives per 1,000 live births. this finding aligns with previous research by mishra and newhouse5 and negeri and haile mariam,22 reinforcing the argument that properly allocated health aid significantly improves population health in low-income settings. the compelling relationship between health aid and imr highlights the need for optimizing aid allocation to maximize its effectiveness. policymakers should prioritize investments in interventions proven to reduce infant mortality, such as maternal and child health programs, immunization campaigns, and improved access to essential healthcare services.3,2 however, direct aid is most impactful when it strengthens broader health systems. investments in healthcare infrastructure, professional training, and efficient medical supply chains are necessary to bolster long-term health outcomes.13 additionally, aligning health aid with domestic financing mechanisms, such as taxes or health insurance, can mitigate out-of-pocket expenditures, a key factor contributing to financial hardship among vulnerable households.1 thoughtfully integrating aid into sustainable financing structures ensures that it complements national efforts rather than replaces them. beyond the role of health aid, our findings highlight the significant influence of broader economic and social determinants. the strong negative coefficient of log-gdp per capita (-9.6007, p=0.0000) suggests that economic growth plays a pivotal role in improving population health. this aligns with pritchett and summers,34 who argue that higher income levels facilitate public health improvements through infrastructure expansion—such as improved access to safe water and sanitation—and enhanced article table 3. estimates of the relative importance of the input variables. variable coef. std. err. z p>|z| share in% _b[lnhda]*0.0746858 -0.1480 0.0367 -4.0300 0.0000 13.29 _b[lngdpp]*0.0145404 -0.1396 0.0331 -4.2200 0.0000 12.54 _b[lnyield]*0.0146193 0.0075 0.0170 0.4400 0.6590 -0.67 _b[exphc]*0.0784127 -0.0701 0.0360 -1.9500 0.0510 6.30 _b[expinst]*-0.0027128 0.0212 0.0088 2.4100 0.0160 -1.90 _b[afert]*-1.8968 -0.1746 0.0707 -2.4700 0.0130 15.68 _b[edep]*-0.0036 -0.0069 0.0033 -2.0800 0.0380 0.62 _b[lntime]*0.1700219 -0.6026 0.1804 -3.3400 0.0010 54.13 sum -1.1133 0.1654 -6.7300 0.0000 100.00 mean[d.imr] -0.9845 0.0404 -24.3600 0.0000 [healthcare in low-resource settings 2025;13:12874] [page 253] table 2. estimate of imr estimating equation, 2000-2017, one-step gmm results. variable first difference gmm system gmm imr coef. std. err. z p value ci coef. std. err. z p value ci l.imr 0.6030 0.0541 11.1400 0.0000 (0.50, 0.71) 0.5372 0.0476 11.2700 0.0000 (0.44, 0.63) lnhda -1.6653 0.6891 -2.4200 0.0160 (-3.02, -0.31) -1.9818 0.4919 -4.0300 0.0000 (-2.95, -1.02) lngdpp -8.8893 3.1900 -2.7900 0.0050 (-15.14, -2.64) -9.6007 2.2734 -4.2200 0.0000 (-14.06, -5.14) lnyield 0.3882 1.2592 0.3100 0.7580 (-2.08, 2.86) 0.5115 1.1601 0.4400 0.6590 (-1.76, 2.79) exphc -0.8519 0.7793 -1.0900 0.2740 (-2.38, 0.68) -0.8945 0.4589 -1.9500 0.0510 (-1.79, 0.00) expinst -4.7728 4.1800 -1.1400 0.2540 (-12.97, 3.42) -7.8092 3.2433 -2.4100 0.0160 (-14.17, -1.45) afert 0.0485 0.0617 0.7900 0.4320 (-0.07, 0.17) 0.0921 0.0373 2.4700 0.0130 (0.02, 0.17) edep 1.5025 1.1151 1.3500 0.1780 (-0.68, 3.69) 1.9293 0.9289 2.0800 0.0380 (0.11, 3.75) lntime -3.5430 1.2644 -2.8000 0.0050 (-6.02, -1.06) -3.5444 1.0611 -3.3400 0.0010 (-5.62, -1.46) _cons 82.6748 26.8142 3.0800 0.0020 (30.12,135.23) 86.4150 19.7937 4.3700 0.0000 (47.51, 125.32) sargan test of overidentifying restrictions sargan test of over identifying restrictions h0: overidentifying restrictions are valid h0: over identifying restrictions are valid χ2 (89)=86.9263 p=0.5424 χ2 (102)=112.388 p=0.2279 arellano-bond test for ar(1) in first differences: z=-1.2039 p=0.2286 arellano-bond test for ar(1) in first differences: z=-1.247 p=0.2125 arellano-bond test for ar(2) in first differences: z =1.2937 p=0.1958 arellano-bond test for ar(2) in first differences: z =1.411 p=0.158 wald χ2 (9)=5121.08 p =0.0000 wald χ2 (9)=2890.76 p=0.0000 number of instruments 99, number of countries 24, number of instruments 112, number of countries 24, number of observations 265 number of observations 289 hda, health development aid, gdpp, gross domestic product per capita, hc, human capital, afert, adolescent fertility rate, edep, elderly dependency rate, inst, worldwide governance indicator, yield, cereal yield. healthcare accessibility. similarly, the statistically significant negative coefficient of human capital (-0.8945, p=0.051) reinforces the view that human capital accumulation serves as a vital policy instrument.19,20 individuals with higher levels of education and skills are better equipped to adopt health-improving technologies and behaviors, while families with stronger human capital can provide more effective primary healthcare. although cereal yield was not statistically significant in the short run, extensive literature emphasizes its long-term role in reducing mortality through improved nutrition. scholars such as cutler et al.11 and fogel37 underscore the essential link between sustained agricultural productivity and health outcomes, supporting the idea that food security remains a key long-term policy consideration in reducing mortality. one of the most striking findings of our analysis is the pronounced role of governance quality in shaping health aid effectiveness. institutional quality (expinst) exhibits a significant negative coefficient (-7.8092, p=0.0160), demonstrating that improvements in governance can yield health outcomes comparable to doubling health aid. raising the governance index to 0.5816 from its current negative and declining average could save two additional infants per 1,000 live births—underscoring the critical importance of robust governance in maximizing the effectiveness of health aid.31 to enhance aid effectiveness, policymakers must implement targeted governance reforms. the declining governance index signals an urgent need to combat corruption and improve transparency through rigorous anti-corruption measures, enhanced financial accountability, and robust oversight mechanisms.4,17 strengthening rule of law and institutional frameworks is equally crucial, ensuring that health aid is disbursed efficiently and reaches its intended beneficiaries. public financial management systems must be reinforced, healthcare regulatory structures improved, and judicial independence safeguarded.9 participatory governance also plays a crucial role in optimizing aid impact. by engaging local communities and civil society in health policy planning and implementation, governments can foster ownership, ensure resource allocation aligns with local needs, and strengthen accountability in aid delivery.14,15 additionally, capacity building within government agencies is essential to effectively absorb, manage, and monitor health aid. policymakers should invest in training programs focused on project management, financial oversight, and data-driven decisionmaking to enhance institutional efficiency and responsiveness.24,26 without these governance improvements, aid effectiveness will remain constrained, reducing its long-term impact on population health. while our selected input variables explain 46% of the decline in imr—leaving room for further policy exploration—the robust effects of health aid, income, human capital, and institutional quality provide clear policy pathways. prioritizing efficient health aid allocation alongside meaningful governance reforms is not merely a best practice; it is fundamental to maximizing aid effectiveness and ultimately saving lives in low-income countries. recommendations based on the findings this study, the following recommendations were given for optimizing health financing in low-income countries: i) aligning with who guidance, donor funds should increasingly focus on reducing out-of-pocket health expenditures to prevent poverty; ii) low-income countries health policymakers, decision-makers, and all healthcare financing stakeholders should consider private foreign direct investment and workers’ remittances as essential complementary sources of health funding; iii) to enhance the effectiveness of aid in health sector, low-income countries should implement strong governance frameworks that ensure transparency, accountability, and efficient resource allocation; iv) health aid recipient low income countries and their policymakers must prioritize the development of alternative domestic mechanisms to pool resources, safeguarding populations from catastrophic health costs and reducing unsustainable dependence on external aid. references 1. goryakin y, suhrcke m. the prevalence and determinants of catastrophic health expenditures attributable to non-communicable diseases in lowand middle-income countries: a methodological commentary. int j equity health 2014;13:107. 2. who. new perspectives on global health spending for universal health coverage. geneva: world health organization; 2018. 3. levine r, kinder m. millions saved: proven successes in global health. washington: center for global development; 2004. 4. easterly w. the white man's burden. london: penguin; 2006. 5. mishra p, newhouse d. health aid and infant mortality. imf working paper wp/07/100. washington: international monetary fund; 2007. 6. chauvet l, gubert f, mesple s. aid, remittances, medical brain drain and child mortality: evidence using inter and intracountry data. j dev stud 2013;49:801-8. 7. ebeke c, drabo a. remittances, public health spending and foreign aid in the access to health care services in developing countries. etudes doc cerdi 2011. 8. mishra p, newhouse d. does health aid matter? j health econ 2009;28:855-72. 9. chauvet l, guillaumont p. aid, volatility, and growth again: when aid volatility matters and when it does not. rev dev econ 2009;13:452-63. 10. gormanee k, girma s, morrissey o. aid, public spending and human welfare: evidence from quantile regressions. j int dev 2005;17:299-309. 11. cutler d, deaton a, lleras-muney a. the determinants of health disparities. j econ perspect 2006;20:97-120. 12. leunig i, dijkstra g, tuytens p. health aid and health outcomes in developing countries. forum dev stud 2024;51:45– 68. 13. williamson cr. foreign aid and human development: the impact of foreign aid to the health sector. south econ j 2008;75:188-207. 14. wilson s. chasing success: health sector aid and mortality. world dev 2011;39:2032-43. 15. pettersson j. child mortality: is aid fungibility in pro-poor expenditure decisive? rev world econ 2007;143:673-93. 16. friedman m. foreign economic aid. yale rev 1958;47:500-16. 17. rajan r, subramanian a. what undermines aid’s impact on growth? imf working paper 05/126. washington: international monetary fund; 2005. 18. mushkin sj. health as an investment. j polit econ 1962;70:129-57. 19. becker gs. human capital. new york: columbia univ press; 1964. 20. grossman m. on the concept of health capital and the demand for health. j polit econ 1972;80:223-55. 21. berman p, kendall c, bhattacharyya k. the household pro article [page 254] [healthcare in low-resource settings 2025;13:12874] duction of health: integrating social science perspectives on micro-level health determinants. soc sci med 1994;38:205-15. 22. negeri g, haile mariam d. effect of health development assistance on health status in sub-saharan africa. risk manag healthc policy 2016;9:33. 23. arellano m, bond s. some tests for panel data: monte carlo evidence and an application to an employment equation. rev econ stud 1991;58:277-97. 24. blundell r, bond s. gmm estimation with persistent panel data: an application to production functions. econ rev 2000;19:321-40. 25. alonso-borrego c, arellano m. symmetrically normalized instrumental variable estimation using panel data. cemfi working paper no. 9612, september; 1996. 26. blundell r, bond s. initial conditions and moment restrictions in dynamic panel data models. j econom 1998;87:115-43. 27. yousuf as. impact of health aid on infant mortality rate. mpra paper no. 4294; 2012. 28. boone p. politics and the effectiveness of foreign aid. eur econ rev 1996;40:289-329. 29. world bank. world development indicators. [accessed 5 mar 2018]; 2018a. 30. feenstra rc, inklaar r, timmer mp. the next generation of the penn world table. am econ rev 2015;105:3150-82. 31. world bank. worldwide governance indicators. [accessed 5 mar 2018]. available from: http://data.worldbank.org/data-catalog/worldwide-governance-indicators; 2018b. 32. who. global health expenditure atlas. geneva: world health organization; 2014. 33. negeri g. the long-run effects of health aid in low-income countries. j public health afr 2023;14:2219. 34. pritchett l, lawrence hs. wealthier is healthier. j hum resour 1996;31:841-68. 35. preston sh. causes and consequences of mortality declines in less developed countries during the 20th century. in: easterlin ra, ed. population and economic change in developing countries. chicago: univ chicago press; 1980. 36. wang l. determinants of child mortality in ldcs: empirical findings from demographic and health surveys. health policy 2002;65:277-99. 37. fogel rw. economic growth, population theory and physiology: the bearing of long-term processes on the making of economic policy. am econ rev 1994;84:369-95. 38. link bg, phelan j. social conditions as the fundamental causes of disease. j health soc behav 1995;35:80-94. article [healthcare in low-resource settings 2025;13:12874] [page 255] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13046 the analysis of adolescents’ behaviors through demographic characteristics and basic health knowledge in taiwan wesiana heris santy, rahmadaniar aditya putri, firdaus, siti nurjanah, siti nur hasina department of nursing, faculty nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, east java, indonesia abstract adolescents’ unstable personalities are responsible for poor behavioral choices, which adversely affect their quality of life. therefore, this study aimed to examine health-related behaviors, such as drinking and smoking, alongside demographic characteristics and basic health knowledge. a total of 100 adolescents aged 11 to 20 were randomly selected as respondents using a cross-sectional observational analytical method. data collection relied on interviews, which were subjected to univariate analysis using logistic regression and chi-square tests. the results showed that there was a significant correlation (p-value 0.003) between smoking and reproductive health behaviors. however, no significant correlation (p-value 0.410) was found between reproductive health behaviors and alcohol consumption. in conclusion, the research uncovered a significant correlation between smoking and reproductive health behaviors. it was necessary to instill healthy lifestyle skills in adolescents early on to deter them from engaging in risky health behaviors. introduction given that adolescents constitute one-fifth of the global population, this demographic group is considered significant, with farreaching implications for social, economic, and demographic factors. adolescents are characterized by numerous hormonal, social, and physical changes.1 necessitating significant attention due to the enrollment in both schools and the workforce, where they are particularly vulnerable to health issues, such as hiv/aids, psychotropic drug use, other addictive substances (napza), and premarital sexual behaviors.2,3 additionally, adolescents behaviors are prevalent, often arising from unstable personalities, leading to the adoption of unhealthy behaviors that negatively affect their quality of life.4,5 the results from the basic health research (riskesdas) showed that among adolescents aged 15 to 19, 22 out of 100 have reported smoking, with a prevalence rate of 9.1% among those under the age of 18.6 many adolescents initiate smoking during their school years or even earlier, raising significant concerns regarding the future health and well-being of the younger generation.7 several investigations on adolescents alcohol consumption show that 3.4% of those who began drinking at the age of 10 and above did so with traditional beverages (38.8%).8 according to riskesdas (2018), 4% of adolescents in east java between the ages of 10 and 20 reported consuming alcohol in 2018. adolescents are prone to engaging in unhealthy behaviors, including low awareness and practice of sexual and reproductive health. a mere 0.4% of girls and 1.9% of boys have engaged in premarital sexual intercourse. the limited awareness among adolescents regarding reproductive health issues shows the urgent need for greater attention to adolescents reproductive health.9-11 the aforementioned issues arise from various factors, including adolescents’ limited understanding of sexuality (sex, contraception, pregnancy, and others.), compounded by parental neglect, which inadvertently condones their behaviors without considering the consequences. in reality, incomplete and false knowledge often arises from unreliable sources, such as peers, informational media like blue films and pornographic magazines, and socially accepted myths.12-13 given that parental knowledge serves as the primary source of initial reproductive health education, parents should also be knowledgeable about its issues.14-15 in taiwan, a developing nation, the adolescents population will undoubtedly influence future social, economic, and demographic developments. therefore, the health of adolescents in the nation must be comprehensively evaluated from both biopsychosocial and spiritual perspectives.16,17 this study aims to investigate health-related behaviours, such as alcohol consumption and tobacco use, in conjunction with demographic characteristics and fundamental health knowledge. materials and methods this study used an observational analytic method with a crosssectional design. the analysis was conducted at the jagir community health center, surabaya, from april to june 2021, and in the pcinu taiwan working area in august. inclusion criteria included adolescents aged 11-21 years, in good health, and possessing literacy skills. exclusion criteria pertained to individuals unwilling to participate as respondents. the study population was all immigrant adolescents who were members of pcinu taiwan, totaling 106 individuals, and the sample consisted of 100 randomly selected respondents. data collection used a questionnaire aimed at gathering demographic characteristics and health behaviors. the validated questionnaire included sections addresssignificance for public health adolescents represent the future, and reproductive health and behaviors require great attention because these factors will profoundly impact their lives in the future. they are influenced by various external factors, including parental influence, environmental surroundings, community culture, and lifestyle choices. the development of adolescents aims to foster growth toward adulthood, form identity, and shape personality. the variables significantly influence adolescents' behaviors, particularly in terms of health. [page 80] [healthcare in low-resource settings 2024;12(s1):13046] non -co mmerc ial us e o nly ing knowledge and attitudes regarding health behaviors, reproduction, smoking, alcohol consumption, and drug use among respondents, their peers, and family members, as well as individuals and parental characteristics. statistical analysis comprised the use of chi-square and logistic regression tests with a hypothesis significance level set at p<0.05. results and discussion table 1 shows the majority of respondents were male (62%), aged between 15 and 17 (67%), and came from rural areas (52%). their fathers had secondary education (72%) and were used in the private sector (72%). conversely, 78% of respondents’ mothers had only a high school diploma, with 87% being used. financially, respondents reported that their fathers earned slightly above the minimum wage, with 24% of adolescents initiating smoking, categorized as light smokers (5 cigarettes per day), while 1% reported alcohol consumption. a mere 1% of respondents reported drug use, without specifying the type, and 60% of them had a history of diseases, with headaches being a prevalent complaint. according to table 2, the data showed that the majority of respondents correctly answered questions related to basic knowledge of reproductive health, with 65% understanding the impact of unprotected sex, and 53% comprehending the dangers of smoking (53%). almost half of them were knowledgeable about alcoholic drinks (47%). table 3 showed a significant correlation (p-value 0.03) between smoking and reproductive health behaviors. adolescents who smoke (12%) had a higher percentage of good reproductive health compared to non-smokers (5%). however, there was no significant correlation (p-value 0.410) between reproductive health behaviors and alcohol consumption, likely due to the small number of adolescents alcohol users. adolescents smoking behaviors and alcohol consumption had a significant correlation, with a p-value of 0.001. the percentage of adolescents who smoke (10%) mirrored the percentage of those who did not consume alcohol. the results of a multivariate analysis of independent variables with health behaviors as the dependent variable were presented in 4. tobacco use, alcohol consumption, and sexual and reproductive health were among the unhealthy behaviors assessed. the statistical analysis showed that gender, knowledge, and attitudes significantly influenced health behaviors, with p-values of 0.006, 0.012, and 0.011, and odds ratios of 0.130, 0.144, and 7.580, respectively. this showed that adolescents boys had 0.130 times greater protection against harmful behaviors. adolescents with high knowledge levels were 0.142 less likely to engage in risky behaviors and those with positive outlooks were 7,580 times more likely to be shielded from behaviors. knowledge was shaped by individuals’ experiences, which could be expressed and believed to fuel motivation.18 it was also influenced by environmental factors, including physical and nonphysical settings, as well as socio-cultural contexts. sight and hearing were identified to be the primary sources of knowledge,19 and adolescents with high knowledge levels were 0.144 less likely to engage in risky behaviors. according to the analysis results, information from various sources, media exposure, and influence from parents and peers were acknowledged to affect individuals’ knowledge. the multivariate analysis showed that adolescents’ conduct regarding reproductive health was influenced by attitudes toward abstaining from negative behaviors.20 when low parental income was combined with income above the regency/city minimum wage (umk), the highest level of parental education tended to be medium (equivalent to high school). there was a correlation between parents’ educational attainment and adolescents’ perspective on reproductive health. several investigations suggested that parents with higher incomes might contribute to the children’s academic performance, thereby influencing their viewpoints. higher-income parents might also provide their children with more opportunities to access additional sources of information.21 several reviews have shown that most adolescents received free information on hiv/aids, the dangers of smoking, and alcohol consumption from counselors, schools, and healthcare professionals. this explained why the level of parental income did not affect the quantity of information sources 4th international nursing and health sciences symposium table 1. characteristics of respondents. characteristics f % age 11-14 years old 29 29 15-17 years old 67 67 18-20 years old 4 4 gender man 62 62 woman 38 38 residence rural 52 52 urban 48 48 father's education elementary (elementary-middle school) 16 16 intermediate (high school) 72 72 higher (diploma-bachelor) 12 12 father's occupation pns 15 15 private 72 72 self-employed 13 13 father's income umk 52 52 below umk 48 48 mother's education elementary (elementary-middle school) 78 78 intermediate (high school) 14 14 higher (diploma-bachelor) 8 8 mother's job work 87 87 doesn't work 13 13 smoke yes 24 24 no 76 76 alcohol consumption yes 1 1 no 99 99 drug consumption yes 1 1 no 99 99 history of illness there is 60 60 no 40 40 mental health risks there are complaints 27 27 no complaints 73 73 [healthcare in low-resource settings 2024;12(s1):13046] [page 81] non -co mmerc ial us e o nly 4th international nursing and health sciences symposium table 2. frequency distribution of respondents' knowledge about reproductive health, smoking behavior, and alcohol consumption. basic knowledge number of respondents answered correct (n=100) % reproduction health characteristics of puberty in teenagers 30 30 reproductive organs 59 59 various types of casual sexual behavior 43 43 the impact of free sex 65 65 how to prevent promiscuous sexual behavior 36 36 how to resist sexual desires/desires 47 47 the right way to socialize 53 53 smoke cigarette content 33 33 danger of cigarette 53 53 diseases caused by smoking 41 41 how to prevent smoking 34 34 the process of entering cigarette smoke and its effects on the body 29 29 alcohol consumption type of liquor 47 47 ingredients for making alcohol 28 28 ingredients for making alcohol 22 22 the impact of alcohol on health 37 37 the impact of alcohol on health 35 35 physical and psychological dangers of alcohol 32 32 a picture of a future destroyed by alcohol 30 30 table 3. relationship between smoking, alcohol consumption and reproductive health in adolescents. reproduction health p good bad f % f % smoke yes 12 12 21 21 0.003 no 5 5 63 65 alcohol consumption yes 10 10.4 2 2.1 0.410 no 24 25 60 62.5 reproduction health p good bad f % f % alcohol consumption yes 10 8 6 6 0.001 no 10 8 74 74 table 4. results of multivariate analysis of demographic, knowledge and attitude variables with health behavior (dating behavior, smoking and alcohol consumption). variable b se wald sign exp (b) 95% ci lower upper age (>16 years) 1.390 .910 2.663 0.102 4.442 0.740 26.580 gender (women) -2.022 .761 7.127 0.006 0.130 0.026 0.572 knowledge (good) -1.442 .970 2.418 0.012 0.144 0.030 0.642 attitude (positive) -2.026 .796 6.336 0.011 7.580 1.578 36.280 [page 82] [healthcare in low-resource settings 2024;12(s1):13046] non -co mmerc ial us e o nly available to adolescents in the study area. according to the analysis results, the majority of respondents (65%) correctly answered questions regarding the impact of unprotected sex on basic reproductive health knowledge. this included recognizing that unprotected sex increased the risk of contracting stds, particularly hepatitis b, hiv, herpes simplex, genital warts, and gonorrhea. oral or anal sex was the primary means through which the diseases were transmitted. additionally, smoking posed a significant public health risk (53%), given its addictive nature and widespread prevalence. cigarettes contain harmful chemicals, including tar, carbon monoxide, and nicotine, which could lead to various diseases, particularly cancer and heart disease. approximately half (47%) of respondents correctly identified the type of alcohol as a strong or mild intoxicant. alcohol content in the beverage largely determined its intoxicating effects. when the liquor had a low alcohol content and was consumed within safe limits, the likelihood of losing consciousness was low. conversely, a high alcohol content increased the risk of becoming tipsy (showing that alcohol was beginning to take effect), feeling excited (with vision becoming hazy or drowsy), confused, and even unconscious. cigarettes have the potential to cause several diseases, including cancer and heart disease, due to their harmful substances.22 approximately half (47%) of respondents correctly identified the type of alcohol as a strong or mild intoxicant. alcohol content in the beverage largely determined its intoxicating effects. when the liquor had a low alcohol content and was consumed within safe limits, the likelihood of losing consciousness was low. conversely, a high alcohol content increased the risk of becoming tipsy (showing that alcohol was beginning to take effect), feeling excited (with vision becoming hazy or drowsy), confused, and even unconscious. adolescents might use alcohol and smoking as symbolic behaviors to project an image of maturity, bravery, strength, and attractiveness to their peers and the opposite sex.23 there was no significant correlation between alcohol consumption and reproductive health behaviors (p-value 0.410), likely due to the low prevalence of alcohol consumption among adolescents. conclusions in conclusion, adolescents need to be more aware of the numerous risks associated with unhealthy behaviors, particularly regarding reproductive health. it was essential to consider all relevant factors in addressing the issues. adolescents could greatly benefit from the guidance provided by educators, parents, friends, media, and other sources of information. there were various strategies to prevent risky behaviors, such as avoiding environments that promote them, asserting firm boundaries, refusing immoral requests, practicing self-control, abstaining from drugs and alcohol, and having education about religion. references 1. hoare j, fouche jp, phillips n, et al. alcohol use is associated with mental health problems and brain structural alterations in adolescents with perinatally acquired hiv infection on art. alcohol 2021;97:59–66. 2. smith l, lópez sánchez gf, pizzol d, et al. global trends in the prevalence of alcohol consumption among school-going adolescents aged 12–15 years. j adolescent health 2024;74:441–8. 3. raine s, kent sa. the grooming of children for sexual abuse in religious settings: unique characteristics and select case studies. aggress violent behav 2019;48:180–9. 4. musindo o, jafry s, nyamiobo j, et al. mental health and psychosocial interventions integrating sexual and reproductive rights and health, and hiv care and prevention for adolescents and young people (10–24 years) in sub-saharan africa: a systematic scoping review. eclinical medicine 2023;57:101835. 5. ramadhan i, keliat ba, wardani iy. assertiveness training and family psychoeducational therapies on adolescents mental resilience in the prevention of drug use in boarding schools. enfermería clínica 2019;29:326–30. 6. septiono w, kuipers mag, ng n, kunst ae. changes in adolescent smoking with implementation of local smoke-free policies in indonesia: quasi-experimental repeat cross-sectional 4th international nursing and health sciences symposium correspondence: rahmadaniar aditya putri, department of nursing, faculty nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, east java, indonesia, jl. raya jemursari no.57, jemur wonosari, kec. wonocolo, surabaya, east java, indonesia. tel.: +62318479070, e-mail: rahmadaniar@unusa.ac.id key words: adolescents; alcohol; health behaviors; reproductive health; smoking contributions: whs, rap, f, sn, snh collaborated in the conceptualization process and manuscript writing. whs was responsible for the methodology, while rap and f were accountable for validating the instruments. snh was responsible for the analysis, and sn and snh were accountable for the investigation. in addition, rap provided resources, and f managed data curation conflict of interest: the authors declare no conflicts of interest. funding: this study received financial support from universitas nahdlatul ulama surabaya. ethics approval: the ethics approval has been granted by the committee of the department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, located in surabaya, east java, indonesia, under reference number no. 028/016/v/ec/kep/lcbl/2023. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgments: the authors thank all respondents who participated in this study and also appreciate pcinu for their collaboration during data collection and the study process. received: 3 november 2023. accepted: 18 july 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13046 doi:10.4081/hls.2024.13046 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s1):13046] [page 83] non -co mmerc ial us e o nly analysis of national surveys of 2007 and 2013. drug alcohol depend 2020;209:107954. 7. wiebe a, kannen k, selaskowski b, et al. virtual reality in the diagnostic and therapy for mental disorders: a systematic review. clin psychol rev 2022;98. 8. national population and family planning board of indonesia. demographic and health survey: adolescent reproductive health. jakarta: bkkbn; 2018. 9. white c. sexual assault and rape. obstet gynaecol reprod med 2021;31:109–16. 10. toru t, sahlu d, worku y, beya m. parent-adolescents communication on sexual and reproductive health issues and associated factors among students in high school and preparatory in arekit, southwest, ethiopia, 2020. int j africa nurs sci 2022;17:100509. 11. muchomba fm. parents’ assets and child marriage: are mother’s assets more protective than father’s assets? world dev 2021;138:105226. 12. hu z, fu y, wang x, zhang h, guo f, hee j, et al. effects of sexuality education on sexual knowledge, sexual attitudes, and sexual behaviors of youths in china: a clusterrandomized controlled trial. j adolesc heal 2023;72:607– 15. 13. wang j, georganos s, kuffer m, et al. on the knowledge gain of urban morphology from space. comput environ urban syst 2022;95:101831. 14. wekerle c, hébert m, daigneault i, et al. aces, sexual violence, and sexual health. in: asmundson jgj, afifi to (eds). adverse childhood experiences. elsevier; 2020; p. 91–118. 15. wang r, yan f, yu l, et al. a federated transfer learning method with low-quality knowledge filtering and dynamic model aggregation for rolling bearing fault diagnosis. mech syst signal process 2023;198:110413. 16. lu ys, wu yr, cheng yr, et al. ten years’ trend analysis for taiwanese youth high school students’ health behaviors. j formos med assoc 2023;122:1077–86. 17. irvine kn, fisher jc, bentley pr, et al. bio-well: the development and validation of a human wellbeing scale that measures responses to biodiversity. j environ psychol 2023;85:101921. 18. nguyen pbt, degrave p, van steendam e, sercu l. self-determination in emi education. a study of university students’ motivation in vietnam. int j educ res open 2023;5:100295. 19. hassan oab. dyslexia and learning in view of the socio-cultural theory and development psychology. soc sci humanit open 2023;8:100718. 20. rahman mt. philosophy of science. bandung: uin sunan gunung djati bandung; 2020. 21. herbell k, graaf g. parents’ perspectives in accessing psychiatric residential treatment for children and youth: differential experiences by funding source. child youth serv rev 2023;154:107148. 22. premkumar m, anand ac. tobacco, cigarettes, and the liver: the smoking gun. j clin exp hepatol 2021;11:700–12. 23. ball j, grucza r, livingston m, et al. the great decline in adolescent risk behaviours: unitary trend, separate trends, or cascade? soc sci med 2023;317:115616. 4th international nursing and health sciences symposium [page 84] [healthcare in low-resource settings 2024;12(s1):13046] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13029 effectiveness of health promotion utilizing word puzzle games in enhancing older adults' knowledge and attitudes regarding hypertension management mia fatma ekasari,1 aan nurhasanah,1 eros siti suryati,1 puspita hanggit lestari,1 siti badriah,1 ahmad jubaedi2 1lecturer at politeknik kesehatan kemenkes jakarta iii; 2faculty of public health, falatehan university, serang, indonesia abstract hypertension management plays a crucial role in influencing the health outcomes of the elderly with high blood pressure. various health promotion strategies have been formulated for hypertension management. however, the result has not shown an optimal reduction in the number of hypertension sufferers. an effective health promotion, such as word puzzle games, needs to be developed. word-based puzzle games can serve as engaging health promotion tools to improve hypertension-related health behaviors among older adults and enhance their cognitive abilities. this study aims to assess the effectiveness of a word puzzle game in enhancing the knowledge, attitudes, and practices of elderly individuals regarding hypertension management. a quasiexperimental approach with a pretest-posttest control group design was used. a total of 45 participants, both in intervention and control groups, were recruited through a purposive sampling technique. data analysis involved descriptive techniques and inferential statistics using t-test models focusing on examining three variables: knowledge, attitudes, and behaviors. the result revealed statistically significant disparities in participants’ knowledge (p=0.000), attitudes (p=0.001), and behaviors (p=0.001) between the experimental and control groups after implementing the word puzzle game intervention. using word puzzle games as health promotion tools successfully enhances older adults’ understanding, perspectives, and actions regarding hypertension management. these games might be employed to strengthen the ability of older individuals to control their high blood pressure. introduction an older adult is defined as someone who is 60 years or older1 and is at a higher risk of developing health problems as a result of degenerative processes. the elderly population is more vulnerable to developing complications of various illnesses,2 with high blood pressure being the most common degenerative condition among this group.3 a strong link exists between hypertensive heart disease and cardiovascular disease (cvd), with the initial symptom being high blood pressure, leading to numerous health complications if hypertension is left untreated.4 this condition may lead to several chronic diseases, including heart problems and stroke. the prevalence of hypertension in older adults rises in tandem with the global increase of the elderly population. approximately 1.28 billion people worldwide are estimated to have hypertension.5 in southeast asian nations, around 43.2% of older adults suffer from hypertension,6 with 28.1% recorded in indonesia in 2019. this figure increased to 30.29% in the same year and further rose to 31.7% by 2020.7 addressing the health issues of the elderly poses considerable obstacles, primarily due to the nature of their ailments, which are often degenerative, long-lasting, and multifaceted, necessitating prolonged care and substantial financial investment.8 government entities, community organizations, and educational institutions have launched various programs to reduce the occurrence of discorrespondence: mia fatma ekasari, politeknik kesehatan kemenkes jakarta iii, dki jakarta, indonesia. e-mail: miafatma74@gmail.com key words: attitude; behavior; hypertension management; knowledge; older adults. contributions: mfe, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; an, conceptualization, investigation, methodology, validation, review & editing; ess, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; phl, methodology, visualization, writing – review & editing; sb, resources, investigation, and writing –review & editing; aj, resources, supervision, and writing –review & editing. conflict of interest: the authors declare no conflicts of interest. ethics approval and consent to participate: the research was approved by the health research ethics commission, poltekkes kemenkes jakarta iii, based on ethical certificate no. lb.02.02/kepk/032/2022. during the research, the researchers focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was supported by a research grant from poltekkes kemenkes jakarta iii with contract number lb.02.01/1/06941/2021. acknowledgments: the researchers would like to thank poltekkes kemenkes jakarta iii, poltekkes kemenkes tasikmalaya, and dinas kesehatan dki for their support during this research. the researchers also thank the respondents who supported this study. received: 6 september 2024. accepted: 5 december 2024. early access: 20 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13029 doi:10.4081/hls.2024.13029 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13029] [page 43] eases stemming from poorly managed hypertension. these initiatives involve updating health promotion strategies, policies, and protocols aimed at controlling high blood pressure.9 health education is a key component of health promotion and disease prevention. hypertension management in indonesia has been carried out through the posbindu ptm (integrated non-communicable disease development post) program with basic health check activities, such as blood pressure checks and providing health education to the elderly.10 people who access posbindu showed a good knowledge of hypertension.11,12 health education for elderly people is needed to maintain and increase knowledge about the risk factors of hypertension.13,14 the activity of health education aims to encourage elderly people to adopt healthy behaviors, especially taking medication,15 and changing their lifestyle to improve their overall health and life satisfaction.16 health education interventions targeting hypertension patients can enhance older adults’ ability to manage their hypertension condition, leading to better blood pressure outcomes.17 as a result, a demand for creative health education methods is needed to tailor elderly with hypertension. using games as a means of delivering health information to older adults might be an alternative.18 studies examining gaming interventions for the elderly have shown that games and play-based therapies, particularly in healthcare settings, produce positive outcomes for this age group.19 extensive research on the use of games for older populations is still needed to develop alternative formats beyond stimulating cognitive function. despite the implementation of various health promotion interventions using different media, hypertension among the elderly remains a major public health issue. this research utilized a word search puzzle game as an educational intervention to improve older adults’ knowledge, attitudes, and behaviors regarding hypertension management. the game was designed not only to provide health education but also to stimulate cognitive function and encourage social interaction among seniors. word puzzle games have the potential to generate enthusiasm, positive emotions, and engagement while simultaneously enhancing cognitive abilities in older individuals. moreover, the games offer an engaging technique for acquiring health-related information. this study aimed to assess the effectiveness of this word puzzle game in enhancing older adults’ understanding, attitudes, and practices concerning hypertension management. materials and methods research design a quasi-experimental research design featuring a pretestposttest method and a control group was utilized in this study. east jakarta’s cakung district was selected as a study location targeting a population of elderly living in the dki jakarta region. the study participants were pre-elderly and elderly adults who met the following selection criteria: i) aged between 45 and 69 years; ii) able to read and write; iii) able to communicate effectively; iv) competent in performing daily activities; v) without visual or auditory impairments; vi) and willing to participate in the study. the study was conducted for a month with four follow-up durations: one every week. prior to intervention, respondents filled out pre-test questions about the material that would be studied while playing the word puzzle game. the material in the word puzzle game consisted of four topics: i) definition and effects of high blood pressure; ii) causes of high blood pressure; iii) signs and symptoms of high blood pressure; and (iv) handling high blood pressure. after being explained how to play the game, respondents were asked to complete the word puzzle game for one material/topic each week. after completing all games from each material, respondents were asked to answer a post-test. study participants the study employed a purposive sampling technique for recruiting participants. sample size was determined using the lemeshow formula, with parameters set at α=95%, z=1.96; p=0.71, and d=10% (α is the desired confidence level, z is the zscore value corresponding to the desired confidence level, p is the proportion of the population estimated to have a particular characteristic, and d is the margin of error). the calculated sample of 80 was increased to 90, considering potential attrition. the final participants were 45 for each group. the study was conducted from march to october 2022. variables, instruments, and data collection the study examined knowledge, attitudes, and behaviors as research variables. a researcher developed an instrument based on relevant theories, demonstrating satisfactory validity and reliability, surpassing the r-table value of 0.074 and achieving an alpha value of 0.943. both groups underwent a pre-test to establish baseline values for assessing the word puzzle game’s impact. the intervention group engaged with the word puzzle game, while the control group received a booklet. post-intervention, both groups completed a post-test. the study compared scores before and after the intervention to evaluate its effectiveness. word search puzzles are linguistic challenges where words, often centered around a particular theme, are hidden within a matrix of letters. the goal is to discover and identify all the concealed words. in this particular game, focused on hypertension, approximately 20-40 terms are embedded in various orientations: left to right, top to bottom, diagonally, and in reverse. a catalog of hidden words is provided, including terminology related to the comprehension of hypertension’s indicators, manifestations, origins, and consequences. as an elderly participant locates a target word, their companion asks about the participant’s understanding of the term and its connection to hypertension. once the puzzle is completed, the companion provides a summary of the identified words, and the elderly participant is asked to recollect the key points discussed by the companion. data analysis a research instrument was utilized to gather primary data. the collected information underwent descriptive analysis and inferential statistical evaluation using a t-test. descriptive analysis focused on variables related to respondent characteristics (age, gender, education, occupation, and ethnic background). to determine differences between the intervention and control groups regarding education, attitude, and behavior variables, a t-test was applied. ethical clearance the study received authorization from the dki jakarta health office and successfully passed an ethical review conducted by the jakarta iii poltekkes kemenkes research ethics committee, as evidenced by approval no.lb.02.02/kepk/032/2022. written informed consent was obtained from all participants in the study. special issue pathways of change [page 44] [healthcare in low-resource settings 2025;13(s1):13029] results tables 1 and 2 show the characteristics of participants. analysis shows that in the intervention group, respondents’ ages ranged from 60 to 71, with an average of 64.69 years. for the control group, the age range was 60 to 76, with a mean of 67.17 years. as illustrated in table 3, both groups were predominantly composed of female participants, individuals with elementary school education, those not currently employed, and people of javanese ethnicity. the homogeneity test revealed no significant disparities between the intervention and control groups in terms of gender, age, occupation, education, ethnic background, knowledge, attitudes, and skills prior to the implementation of the word puzzle game intervention. comparative analysis of knowledge and attitude scores preand post-intervention with word puzzle game in intervention and control groups the analysis presented in table 4 shows a statistically significant disparity in knowledge between the intervention and control groups prior to and following the word puzzle game intervention (p=0.000). for the attitude variable, a statistically significant difference was also observed in the intervention group before and after the word puzzle game intervention (p=0.001). likewise, the skill variable revealed a statistically significant change in the intervention group preand post-implementation of the word puzzle game (p=0.001). special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13029] [page 45] table 3. distribution of participants' demographic characteristics based on gender, educational attainment, occupational status, and ethnic background. variable intervention group control group total n % n % n % gender male 12 26.7 19 42.2 31 34 female 33 733 26 57.8 59 66 education primary school 33 57.8 28 62.2 61 67 junior high school 9 20.0 13 28.9 22 24 high school 3 6.7 4 8.9 7 9 work civil servant 1 2.2 5 11.1 6 6.7 private sector employee 4 8.9 5 11.1 9 10 entrepreneur 3 6.7 2 4.4 5 5.5 labor 8 17.8 3 6.7 11 12.2 trade 2 2.2 4 8.9 6 6.7 not working 27 60 26 57.8 53 58.9 ethnic origin javanese 26 57.8 23 51.1 49 54 betawi 10 22.2 10 22.2 20 22 sundanese 8 17.8 11 24.4 19 21 others 1 2.2 1 2.2 2 2 table 1. respondents' characteristics based on age. variable group n mean median sd min-max intervention 45 64.69 63 3.059 60-71 age of respondents control 45 67.17 67 4.896 60-76 table 2. classification of blood pressure in the elderly intervention group. blood pressure intervention group control group total frequency (f) percentage (%) frequency (f) percentage (%) frequency (f) percentage (%) pre-hypertension sbp (mmhg) 120139 3 6.7 5 11.1 8 8.9 dbp (mmhg) 80-89 stage 1 hypertension 25 55.5 27 60 52 57.8 sbp(mmhg) 140159 dbp (mmhg) 90-99 stage 2 hypertension 17 37.8 13 28.9 30 33.3 sbp(mmhg) ≥160 dbp (mmhg) ≥100 sbp, systolic blood pressure; dbp, diastolic blood pressure. variations in knowledge, attitude, and skills scores across groups table 5 demonstrates a statistically significant difference in respondents’ knowledge (p=0.000), attitude (p=0.054), and skills (p=0.052) between the intervention and control groups following the implementation of the word puzzle game intervention. discussion the study demonstrates the effectiveness of using word puzzle games as a novel approach to health education for older adults. this method can be particularly useful in enhancing knowledge and attitudes about hypertension management, especially among individuals who may find traditional educational methods less engaging. by using interactive and enjoyable methods like word puzzle games, it is possible to increase engagement and improve health outcomes. to engage participants in locating words within randomly arranged letters, word search puzzle games were employed.18 these puzzles typically feature square or rectangular grids where participants are tasked with identifying words horizontally, vertically, or diagonally. the game’s name reflects its nature, as predetermined words are concealed within the letter arrangement. players must complete the puzzle by scanning from left to right (or in reverse) and searching for word beginnings (if provided), uppercase letters, and repeated letters. in cases where no word list is supplied, seniors can find words by reading right to left and top to bottom. this cognitively challenging activity is suitable for older adults, as games provide not only stimulation but also improve focus and memory retention.20 the research revealed that participating in word puzzle games improved elderly individuals’ knowledge, attitudes, and behaviors regarding hypertension management. a significant barrier to selfcare among older hypertensive patients is an insufficient understanding of the condition and its treatment regimen.21 educational initiatives for elderly individuals with hypertension cover the definition, causes, implications, symptoms, treatment options, and management approaches.22,23 health education enables individuals with hypertension to enhance their understanding, mindset, and ability to manage their diet and self-efficacy.24–26 numerous studies have shown that health education can positively shape attitudes towards unmanaged hypertension.27,28 attitudes consist of emotional and behavioral tendencies towards objects or subjects involving psychological values.29 they influence actions, readiness, and the propensity to special issue pathways of change table 4. analysis of knowledge, attitude, and skills scores preand post-intervention with word puzzle game. variable group mean sd 95% ci t p knowledge intervention group before 8.87 2.029 -1.692-0.441 -3.436 0.001 after 9.93 0.252 difference -1.067 control group before 8.84 1.999 -0.018-0.107 1.431 0.160 after 8.80 2.018 difference 0.044 attitude intervention group before 26.67 3.456 -3.661-1.095 -3.735 0.001 after 29.04 2.836 difference -2.378 control group before 26.53 3.188 -0236-0.147 0.467 0.643 after 26.58 3354 difference -0.044 skills intervention group before 28.93 3.499 -5.089-1.759 -9.957 0.000 after 32.36 4.313 difference -3422 control group before 28.89 3.524 -0.064-0.000 0.000 0.1000 after 28.89 3.531 difference 0.000 table 5. evaluation of knowledge, attitude, and skills scores after the word puzzle game intervention. variable group n mean sd 95% ci f p knowledge intervention 45 9.93 0.252 0.416-1.629 36.068 0.000 control 45 8.91 2.032 0.408-1.637 attitude intervention 45 29.82 2.452 1.911-4.400 3.808 0.054 control 45 26.67 3.411 1.909-4.402 skills intervention 45 32.36 4.313 1.740-5.016 3.897 0.052 control 45 28.98 3.461 1.739-5.017 [page 46] [healthcare in low-resource settings 2025;13(s1):13029] behave in specific ways towards particular items. furthermore, the attitudes of hypertensive patients affect blood pressure management and compliance with dietary guidelines for hypertension. patients with hypertension who possess more positive attitudes tend to exhibit better self-care practices.30,31 research has shown that evidence-based education and support for self-management in hypertensive individuals are linked to favorable health outcomes, such as lower blood pressure, improved knowledge, and enhanced self-management skills.32,33 a retrospective study on hypertensive patients revealed that weight increase, lack of physical activity, and high salt consumption are associated with poor blood pressure control.34 individuals with hypertension must adhere to a healthy lifestyle that includes physical activities (such as walking, jogging, strength training, and gardening), as well as monitoring and reducing salt and sodium intake. this study examined the effectiveness of word puzzle games on elderly people in cakung district, indonesia. therefore, generalization of findings to the national context needs to be done with caution. further research is required with a larger sample size and a wider area scale. to deepen the effectiveness of word puzzle games, combining word puzzle games with other health education interventions, such as diet counseling or physical activity programs, can be done in future studies. this study employed a word puzzle game as an interactive method to deliver health education about hypertension. the findings revealed that the intervention group demonstrated improvements in knowledge, attitudes, and behaviors compared to the control group. it’s worth noting that word puzzles can also enhance cognitive abilities in elderly individuals.35 participating in mentally stimulating games can boost older adults’ concentration, cognitive function, and memory.19 games designed for seniors serve multiple purposes beyond memory training and social interaction; they also offer a means to maintain health at home during the pandemic.36 additionally, prior studies examining the impact of puzzle games on elderly individuals have shown that the process of experiential learning encompasses four cognitive stages: experiencing, reflecting, connecting, and applying. these stages work together to enhance the cognitive abilities of older adults participating in puzzle-based activities.37 research has also demonstrated that puzzle therapy can significantly improve cognitive function in the elderly population.38 as a result, puzzle games and similar gaming activities may serve as effective tools for exercising cognitive abilities and potentially reducing the risk of dementia in older adults. conclusions the study revealed improved knowledge, attitudes, and behaviors in the experimental group that participated in the word game puzzle intervention compared to the control group. the word puzzle game showed a statistically significant beneficial impact on elderly individuals with hypertension. utilizing word puzzle games for health education can enhance patients’ understanding of hypertension and improve their ability to manage and monitor blood pressure. additionally, these games may boost cognitive functions in older adults and potentially reduce the likelihood of developing dementia. future research can be designed by adding other interventions, such as hypertension diet counseling and activity programs, to increase the effectiveness of hypertension management in the elderly. references 1. meiner se. gerontologic nursing, fourth edition. vol. 5, american speech. 2016. 310 p. 2. lionakis n, mendrinos d, sanidas e, et al. hypertension in the elderly. world j cardiol 2012;4:135–47. 3. singh s, shankar r, singh gp. prevalence and associated risk factors of hypertension: a cross-sectional study in urban varanasi. int j hypertens 2017;2017. 4. lewis sl, bucher l, heitkemper mm, et al. medical surgical nursing; assessment and management of clinical. missouri: elsevier; 2014. 5. who. hypertension. 2023 [cited 2023 oct 30]. available from: https://www.who.int/news-room/fact-sheets/detail/ hypertension 6. mohammed nawi a, mohammad z, jetly k, et al. the prevalence and risk factors of hypertension 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chronic disease management program (prolanis) in patients with hypertension during the covid-19 pandemic in rural areas: a preliminary evaluation study. med sci monit 2023;29. 13. sri widhowati s, ayu ningsih d, indriono a. the effect of health education with audio visual media on older adults knowledge about hypertension. indones j community heal nurs 2022;7:25–6. 14. fadilah sz, susanti ia, setyorini dy, pradipta ro. effectiveness of mobile-based health interventions for the management of hypertensive patients: a systematic review. j ners 2020;15:238–45. 15. pristianty l, priyandani y, rahem a. the correlation between knowledge, attitude and family support on compliance of outpatients with hypertension in a healthcare centre in indonesia. pharm educ 2023;23:25–30. 16. chantakeeree c, sormunen m, jullamate p, turunen h. understanding perspectives on health-promoting behaviours among older adults with hypertension. int j qual stud health well-being 2022;17:2103943. 17. chen y, li x, 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community health equity res policy 2022;42:181-8. 28. andrianto a, ardiana m, nugraha ra, et al. impact of the virtual anti-hypertensive educational campaign towards knowledge, attitude, and practice of hypertension management during the covid-19 pandemic. world j cardiol 2022;14:626– 39. 29. demirel m, dağyar m. effects of problem-based learning on attitude: a meta-analysis study. eurasia j math sci technol educ 2016;12:2115–37. 30. shrestha j, marasine nr, lamichhane r, et al. attitude and self-care practice on hypertension among antihypertensive medication users in a tertiary care hospital nepal. sage open med 2021;9:20503121211040707. 31. veralia v, malini h, gusty rp. effect of isometric handgrip exercise on blood pressure and comfort among hypertensive patients. j ners 2023;18:35–40. 32. centers for disease control and prevention. best practices for heart disease and stroke: a guide to effective approaches and strategies. 2022. 33. israfil i, yusuf a, efendi f, et al. factors associated with behavior in the prevention of cardiovascular complications in hypertensive patients in indonesia: a systematic review. in: the 22 international conference of public health sciences. 2022. p. 1. 34. yang mh, kang sy, lee ja, et al. the effect of lifestyle changes on blood pressure control among hypertensive patients. korean j fam med 2017;38:173–80. 35. pillai ja, hall cb, dickson dw, et al. association of crossword puzzle participation with memory decline in persons who develop dementia jagan. j int neuropsychol soc 2011;17:1–7. 36. mariana h. tips merawat lansia agar selalu sehat di tengah pandemi. indonesia terhubung. 2020. 37. liu z, he z, yuan j, et al. application of immersive virtualreality-based puzzle games in elderly patients with post-stroke cognitive impairment: a pilot study. brain sci 2023;13:79. 38. erwanto r, kurniasih de. the effectiveness of puzzle therapy on cognitive functions among elderly with dementia at balai pelayanan sosial tresna werdha (bpstw) yogyakarta, indonesia. bali med j 2020;9:86–90. special issue pathways of change [page 48] [healthcare in low-resource settings 2025;13(s1):13029] hrev_master healthcare in low-resource settings 2024; volume 12:11967 adequate cardiorespiratory fitness during pregnancy for a better quality of childbirth roikhatul jannah,1,2 budi utomo,1 liza laela abida,2 bimo kholifah,2 ahmad syafiq,1 wahyuddin wahyuddin,3 zahra sativani2 1faculty of public health, universitas indonesia, depok; 2department of physiotherapy, politeknik kesehatan kemenkes jakarta iii, bekasi; 3faculty of physiotherapy, universitas esa unggul, jakarta, indonesia abstract inadequate cardiorespiratory fitness (crf) during childbirth can lead to potential problems, including preterm birth, hypertensive disorders of pregnancy, pain and discomfort during pregnancy, cesarean birth, and postpartum weight gain. this study aimed to assess the relationship between cardiorespiratory fitness during pregnancy and the quality of childbirth. an observational analytic study with a prospective cohort design was conducted among 52 pregnant women in their third trimester of gestation. respondents were selected based on the purposive sampling technique. the variables cardiorespiratory fitness, indicated by vo2max value, and the quality of childbirth were respectively measured using the six-minute walk test and the quality childbirth questionnaire, modified from the pregnancy and childbirth outcome set (pcb), the childbirth experience questionnaire (ceq), and the birth satisfaction scale (bss), which were declared valid and reliable. data analysis used descriptive and bivariate analysis with the chisquare test with a risk ratio (rr). the results showed a p-value of less than 0.001, confirming the hypothesis. there is a meaningful link between high vo2 max scores and improved childbirth experiences, with a rr of 6.882 at a 95% confidence interval. this suggests that pregnant women with better cardiorespiratory fitness are 6.882 times less likely to have an adverse labor and delivery outcome. improving cardiorespiratory fitness through strategic antenatal physical activity with aerobic exercises is recommended to gain a positive childbirth experience. introduction maternal health during childbirth is crucial for the well-being of both the mother and the child.1 it encompasses both mental and physical health and is influenced by various social and economic factors. thus, the world health organization (who) stated that to ensure women and their babies reach their full potential for health and well-being, every stage of maternity should be a positive experience.2-4 it provides a very satisfying and empowering birth experience for a woman, both clinically related to childbirth as well as psychological and emotional. women who experience a very positive birth feel happy, safe, and in control during labor.5 on the contrary, labor accompanied by problems or traumatic experiences can be negative or detrimental. this will have a longterm negative impact on the health and well-being of the mother and her family because it affects the quality of life of women.6,7 problems that arise include delivery complications, postpartum depression, post-traumatic stress disorder (ptsd), or postpartum blues, psychological trauma in the form of fear and decreased self-confidence, complications of newborns, disorders of mother and child bonding, breastfeeding disorders, feelings of hatred for children, disturbances in child development, refusing to have more children, and infertility,8-11 causing lactation problems, affecting the mother’s decision to have sex, having more children in the future with a tendency to undergo cesarean section.12,13 cardiorespiratory fitness (crf), defined as the ability of the respiratory and cardiovascular systems to provide oxygen to cells and correspondence: roikhatul jannah, department of physiotherapy, politeknik kesehatan kemenkes jakarta iii, bekasi, indonesia. e-mail: roikha79@gmail.com key words: antenatal exercise, cardiorespiratory fitness, pregnant women, physiotherapy. contributions: rj, conceptualization, methodology, validation, visualization, writing – original draft, review & editing; bu, conceptualization, resources, supervision, and writing–review & editing; lla, conceptualization, methodology, data curation, formal analysis, validation, methodology, and writing – original draft; bk, resources, formal analysis, investigation, methodology; as, supervision, writingreview & editing, ww, resources, supervision, writingreview & editing, zs, resources, writingreview & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, semarang state university, based on ethical certificate 201-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 13 october 2023. accepted: 15 march 2024. early access: 16 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11967 doi:10.4081/hls.2024.11967 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 462] [healthcare in low-resource settings 2024;12:11967] non -co mmerc ial us e o nly tissues during physical activity,14 plays an important role during childbirth. physiological changes such as increased blood pressure, heart rate, and respiratory rate require adequate cardiorespiratory fitness to cope with anxiety, tension, fear, and stress, which can cause severe consequences.15 inadequate fitness can lead to potential problems, including preterm birth,16 hypertensive disorders of pregnancy,17 pain and discomfort during pregnancy, cesarean birth, and postpartum weight gain.18 however, crf during pregnancy is physiologically lower than in non-pregnant women. baena-garcía et al. (2020)19 stated that crf values in pregnant women decreased from week 16 to week 34. furthermore, crf in adult women aged 22 years who were born at term was detected at a value of 33.0 ml/kg per minute,18 aged 30 years between 27-37 ml/kg per minute,20 while crf in pregnant women aged 32 years was between 19.85±3 ml/kg per minute.16 pregnant women experience significant structural and hemodynamic changes in the cardiovascular system. weight gain causes a progressive decrease in performance; there is an increase in blood volume and heart rate, maximal heart rate is reduced, and blood has a lower hemoglobin concentration during pregnancy. this can affect the cardiorespiratory fitness of pregnant women.21 studies on maternal crf have been conducted in the context of advancing at term gestation,18 to improve crf in response to exposure to exercise training,17,22,23 to test different fitness among active and inactive women,24 and to observe its association with the infant. however, evidence regarding crf and a comprehensive feature on the birthing process is limited. in fact, this is utmost important, with the potential benefits of improving maternal health from pregnancy to postpartum, promoting better birth outcomes,25 preventing cardiovascular disease, encouraging a healthy lifestyle, identifying risk factors,26 and providing information to the decision-making process regarding necessary maternal health and childbirth initiatives. thus, this study aimed to investigate the relationship between crf among pregnant moms and the quality of childbirth experience obtained during labor and delivery. materials and methods research design this study was observational analytics with a prospective cohort design. pregnant women in their third trimester of gestation participated in crf measurement using the six-minute walking test (6mwt) to denote vo2 max level. it is a submaximal exercise test to assess aerobic capacity and endurance by walking for 6 minutes on the provided track path, reaching the furthest possible distance, and assessing blood pressure and pulse immediately after completing the test. as the subjects were pregnant women, the 6mwt was carried out considering the health conditions of the mother and fetus, which were previously examined and conducted under the supervision of a registered physiotherapist. subsequently, they were followed until one week after giving birth to respond to the quality childbirth questionnaire, modified from the pregnancy and childbirth outcome set (pcb), childbirth experience questionnaire (ceq),27,28 and modified birth satisfaction scale (bss).29-31 this set of questions interprets whether the quality of labor and delivery is valued as a positive childbirth level. it assesses the health of the mother in terms of delivery methods, pain during delivery, medicalization experienced during delivery, length of delivery, perception of the ability to be self-aware of physical and strength conditions to control power during delivery, perception of feeling safe during birth, perception of the ability to control emotions to participate in decisionmaking about the actions needed in childbirth. additionally, valued newborn health refers to parameters like birthweight, the ability to cry immediately, and apgar score. the accumulated total score from 28 questions is between 47.2 and 124, with a threshold of 54.8. a higher score indicates better quality and a more positive childbirth. data were collected from february to may 2023 at the community health center in east jakarta. first, respondents who met the criteria and were keen to take part in this study were informed about what to do in the research. then, an appointment schedule for variable measurements was arranged. the value of vo2 max as an indicator of the crf variable was measured through the following 6mwt test procedure from tiksanadi, ambari, and adriana (2019) and cassano et al. (2023).32,33 one day before the measurements were taken, research subjects were informed to get enough sleep and not to consume drinks and foods containing caffeine and alcohol, as well as drugs that could affect blood pressure. on the day before the test begins, the physiotherapist prepares equipment, including a pulse oximeter, a portable oxygen device (to be used if needed by the patient), a chair, a borg scale, a stopwatch, and two small cones. then, preparations were made to create the path track by placing cones at the start and end points in a straight line and a chair in between the 90-degree cones. afterward, the physiotherapist focused on the performance test steps as follows: i) allow the respondent to rest for about 10 minutes before the test starts; ii) measure heart rate, oxygen saturation, and dyspnea for baseline data; iii) set up the timer and lap counter; iv) inform the mother on how to walk on the path track during the test; v) assign the mother at the starting mark cone and allow her to walk as fast as possible but stay comfortable once the test begins; vi) focus the attention on research subjects during the test by encouraging them to continue and informing them of time left every minute that passes; vii) assess and record dyspnea, fatigue levels, blood pressure, heart rate and oxygen saturation, the number of laps to count total distance walked. finally, the gathered data was inputted into the nury formula. in relation to gathering quality childbirth data, enumerators conducted an interview to fill in the questionnaire while visiting mothers. study participants the sample size in this study was determined using the slovin formula. a total of 52 samples were obtained through purposive sampling based on predetermined criteria: pregnant mother in the third trimester of gestational age; willing to consistently participate in the study until completion (informed consent). mothers with high-risk and complicated pregnancies who had already become the subject of other research were excluded from the study. data analysis data were analyzed using the ibm spss version 21 software package (ibm corp; armonk, usa). characteristics of the sample, including age, height, body mass index, and vo2 max, were separately evaluated using univariate analysis. however, the hypothesis of the study is to investigate the relationship between the independent variable, namely crf. the significance of the results obtained from the chi-square test for the dependent variable, quality of childbirth, was assessed at a value of <0.05. additionally, the risk ratio (rr) was calculated as an additional measure to examine the association between variables further. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11967] [page 463] non -co mmerc ial us e o nly ethical clearance this study was managed in accordance with ethical rules, including consideration not to endanger respondents, respecting data confidentiality, voluntarily allowing respondent involvement, and providing compensation guarantees in the event of force majeure affected by the research. the researcher explained ethical issues before all subjects provided written informed consent for data collection. the ethical clearance of the study was approved by the health research ethics commission, semarang state university, as stated in certificate number 201-kepk. during the research, the researcher pays attention to these ethical principles: information to consent, respect for human rights, beneficence, and non-maleficence. results table 1 shows that the minimum age for the sample in this study is 20 years, while the maximum age is 42 years. the average respondent age is 29 years, with a median of 28 years and a standard deviation of 5.09. additionally, the average height is 157.77, with a standard deviation of 5.02. the height measurements reveal a minimum value of 143 cm and a maximum value of 170 cm. the average vo2 max measurement result is 17.45 ml/kg per minute, with a standard deviation of 1.98. the minimum rate is 12.94 ml/kg per minute, and the maximum is 22.25 ml/kg per minute. according to table 2, it can be observed that 2 respondents are thin (3.8%), 20 mothers are of normal weight (38.5%), 5 are overweight (9.6%), and 25 are obese (48.1%). related to the hypothesis, vo2 max was categorized into two types: good and fair, to form a 2x2 matrix for the chi-square test. on the other hand, the quality of childbirth was also classified as positive and negative. data for both variables are illustrated in table 3. table 3 describes that 34 mothers have poor cardiorespiratory fitness, while 18 mothers have good vo2 max. meanwhile, in the assessment of birth quality, 24 mothers gained positive birth quality, and 28 mothers obtained negative birth quality. after carrying out the chi-square test, 8 pregnant women (23.5%) with poor crf experienced positive labor, while 26 (76.5%) obtained negative labor. among those with good crf, only 2 (11.1%) had negative birth quality, while the majority, 16 ladies (88.9%), resulted in positive childbirth. these data explain that there is a significant association between crf and the quality of childbirth with a p-value of 0.000 and rr=6.882 established. discussion the research results highlight a strong association between crf and the quality of childbirth. it is clear that women with good crf during pregnancy are likely to benefit from a better quality of childbirth 6.882 times more than those with poor crf. in fact, childbirth is a physiological process that gives the mother experience related to exerting quite a lot of energy, controlling the use of energy, controlling feelings, severe pain, fear, and anxiety, maintaining stamina for a long time, and making decisions about choosing the type of delivery. hence, this study is in accordance with theories that provide an overview of how a higher level of crf can contribute to coping with the challenges mentioned. the first is fulfilling the energy needed. adequate crf can improve cardiovascular function to help the mother’s body adapt to the physiological changes that occur during pregnancy, maintain healthy blood pressure and heart rate, and reduce the risk of hypertensive disorders of pregnancy.15,34-36 furthermore, this also transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=52). min max mean±sd median ci 95% age (years) 20 42 28.68±5.09 28.00 27.31-30.04 height 143 170 157.77±5.02 157.50 156.42-159.11 vo2 max 12.94 22.25 17.45±1.98 17.58 16.91-17.98 table 2. body mass index (bmi) of respondents. bmi frequency percentage (%) underweight 2 3.8 normal 20 38.5 overweight 5 9.6 obese 25 48.1 n=52 100 table 3. research hypothesis testing results. 6 mwt (vo2 max) quality of childbirth p risk ratio ci 95% negative positive n % n % poor 26 76.5% 8 23.5% 0.000 6.882 (1.839-25.760) good 2 11.1% 16 88.9% 6mwt, six-minutes walking test. [page 464] [healthcare in low-resource settings 2024;12:11967] non -co mmerc ial us e o nly expands muscular strength, elasticity, and flexibility, supporting muscle power control during labor.37 thus, mothers have sufficient endurance and stamina to make the birthing process more manageable. secondly, there is the role in managing feelings and pain. as crf is produced from exercise, when an individual engages in physical activity, such as running or cycling, the body releases endorphins that help reduce feelings of pain and promote a sense of well-being. these endorphins bind to receptors in the brain, triggering positive feelings and reducing stress.15 therefore, good crf benefits developing a better mood, relaxation, and suppressing discomfort during labor and delivery. regarding the mode of delivery, baena19 stated that women with higher crf levels during pregnancy have been found to have better oxygen values in the umbilical artery blood and a lower rate of cesarean section. this suggests that women with higher crf have better respiratory and circulatory capacity to supply oxygen to their bodies during the physically demanding process of labor, potentially reducing the need for a cesarean delivery. this will be a solution for all women who generally prefer vaginal delivery. yet, understanding the facts that crf affects the quality of childbirth in the results of this study potentially inspires practical implications for maternal healthcare and prenatal care. this can lead to the development of targeted interventions and strategies to improve the childbirth experience for women and their children. several potential applications include designing and promoting customized prenatal exercise programs to increase maternal crf. it has the potential to lead to better lives for children later in life.18,22 informing the development of individualized care plans for pregnant women. healthcare providers can assess crf levels and adjust treatment plans to support women with lower crf, thereby potentially mitigating the risks associated with delivery and labor problems.17,26 health education initiatives to increase knowledge among pregnant women about the potential impact of crf on childbirth. thus, by encouraging physical activity and healthy lifestyle choices, women can be empowered to play an active role in self-increasing crf.23,38 the postpartum recovery support program, in the form of guidance on beneficial postpartum exercise and lifestyle habits, helps women rebuild their crf and supports their overall well-being after giving birth.19,25,39 development of maternity care guidelines that emphasize the importance of assessing and supporting maternal crf by integrating crf assessment into routine prenatal care. thus, healthcare providers can identify women who may benefit from additional support and interventions.17,26 indeed, the findings provide benefits for health program developers to address better antenatal care, help build pregnant women’s self-awareness in meeting their needs, and mobilize more pregnant women towards non-pharmaceutical activities, especially antenatal exercise, which increases crf to prepare for childbirth and even overcome problems during pregnancy.40 this will be a solution to improve the health of pregnant women at a more affordable price. despite the strength of the study describing comprehensive birth quality measurement for maternal and child health as an innovation, data collection a week after delivery is a limitation that allows subjective data modification. hence, it is recommended that further research is able to measure the quality of childbirth during the process to obtain exact data on conditions at the time while it is taking place. conclusions the research results demonstrate a strong association between crf and the quality of childbirth. this implies that increasing crf is a necessity in improving the health of pregnant mothers. by applying this theory in prenatal care, healthcare providers can practically work towards enhancing the childbirth experience for women, promoting better maternal and neonatal outcomes, and supporting the long-term health and well-being of mothers and their children. the development and promotion of strategic and extensive antenatal exercise tailored to improve crf are recommended. references 1. efendi f, aji rs, kurnia id, et al. determinants of maternal healthcare service utilization among indonesian mothers: a population-based study. f1000res 2022;10. 2. world health organization (who). intrapartum care for a positive childbirth experience. 2018. available from: http://apps.who.int/iris/bitstream/10665/260178/1/978924155 0215-eng.pdf?ua=1%0ahttp://www.who.int/reproductivehealth/publications/intrapartum-care-guidelines/en/ 3. who. who recommendations on antenatal care for a positive pregnancy experience. 2016. available from: https://www.who.int/publications/i/item/9789241549912 4. who. maternal health. 2023. available from: https://www.who.int/health-topics/maternal-health#tab=tab_1 5. hosseini tabaghdehi m, keramat a, kolahdozan s, et al. positive childbirth experience: a qualitative study. nurs open 2020;7:1233-8. 6. krnenburg l, lambregtse-van den berg m, stramrood c. traumatic childbirth experience and childbirth-related posttraumatic stress disorder (ptsd): a contemporary overview. int j environ res public health 2023;20. 7. sagala r, febriana n, dewanti l. the experience of midwives who experienced the traumatic childbirth. indonesian midwifery health sci j 2020;4:306-18. 8. ertan d, hingray c, burlacu e, et al. post-traumatic stress disorder following childbirth. bmc psychiatry 2021;21:1-9. 9. irawati d, yuliani f. pengaruh faktor psikososial terhadap terjadinya post partum blues pada ibu nifas. in: prosiding seminar nasional 2013 menuju masyarakat madani dan lestari postpartum. 2013. available from: http://dppm.uii.ac. id/dokumen/seminar/2013/f.dian irawati.pdf 10. masruroh. hubungan antara paritas ibu dengan kejadian postpartum blues. jurnal eduhealth 2013;3:120-5. available from: https://diastasisrehab.com/pdf/journal-womens-health2012.pdf 11. koster d, romijn c, sakko e, et al. traumatic childbirth experiences: practice-based implications for maternity care professionals from the woman’s perspective. scand j caring sci 2020;34:792-9. 12. khalife-ghaderi f, amiri-farahani l, haghani s, hasanpoorazghady sb. examining the experience of childbirth and its predictors among women who have recently given birth. nurs open 2021;8:63-71. 13. karlström a, nystedt a, hildingsson i. the meaning of a very positive birth experience: focus groups discussions with women. bmc pregnancy childbirth 2015;15:1-8. 14. cai c, ruchat sm, sivak a, davenport mh. prenatal exercise transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11967] [page 465] non -co mmerc ial us e o nly and cardiorespiratory health and fitness: a meta-analysis. med sci sports exerc 2020;52:1538-48. 15. olza i, leahy-warren p, benyamini y, et al. women’s psychological experiences of physiological childbirth: a meta-synthesis. bmj open 2018;8:20347. 16. mcdonald sm, yeo sa, liu j, et al. associations between maternal physical activity and fitness during pregnancy and infant birthweight. prev med rep 2018;11:1. 17. lane-cordova a, carnethon m, catov j, et al. cardiorespiratory fitness, exercise hemodynamics, and birth outcomes: the coronary artery risk development in young adults study. bjog 2018;125:1127-34. 18. fereira i, gbatu pt, boreham ca. gestational age and cardiorespiratory fitness in individuals born at term: a life course study. j am heart assoc 2017;6. 19. baena-garcía l, coll-risco i, ocón-hernández o, et al. association of objectively measured physical fitness during pregnancy with maternal and neonatal outcomes. the gestafit project. luo zc, editor. plos one 2020;15:e0229079. 20. kaminsky la, arena r, myers j. reference standards for cardiorespiratory fitness measured with cardiopulmonary exercise testing: data from the fitness registry and the importance of exercise national database. mayo clin proc 2015;90:1515. 21. halvorsen s, haakstad lah, edvardsen e, bø k. effect of aerobic dance on cardiorespiratory fitness in pregnant women: a randomized controlled trial. physiotherapy 2013;99:42-8. 22. ekstrom ld, ahlqvist vh, persson m, et al. the association between birth by cesarean section and adolescent cardiorespiratory fitness in a cohort of 339,451 swedish males. sci rep 2020;10. 23. romero-gallardo l, roldan-reoyo o, castro-piñero j, et al. assessing physical fitness during pregnancy: validity and reliability of fitness tests, and relationship with maternal and neonatal health-related outcomes. bmj open sport exerc med 2022;8:e001318. 24. rodriguez-ayllon m, acosta-manzano p, coll-risco i, et al. associations of physical activity, sedentary time, and physical fitness with mental health during pregnancy: the gestafit project. j sport health sci 2021;10:379-86. 25. birsner ml, gyamfi-bannerman c. physical activity and exercise during pregnancy and the postpartum period. acog committee opinion number 2015;804. 26. ross r, blair sn, arena r, et al. importance of assessing cardiorespiratory fitness in clinical practice: a case for fitness as a clinical vital sign: a scientific statement from the american heart association. circulation 2016;134:e653-99. 27. walker kf, wilson p, bugg gj, et al. childbirth experience questionnaire: validating its use in the united kingdom. bmc pregnancy childbirth 2015;15:1-8. 28. dencker a, taft c, bergqvist l, et al. childbirth experience questionnaire (ceq): development and evaluation of a multidimensional instrument. bmc pregnancy childbirth 2010;10:81. 29. martin cr, hollins martin c, redshaw m. the birth satisfaction scale-revised indicator (bss-ri). bmc pregnancy childbirth 2017;17:1-9. 30. martin ch, fleming v. the birth satisfaction scale. int j health care qual assur 2011;24:124-35. 31. vivilaki v, zemperligkou e, iliopoulou e, et al. the reversed birth satisfaction scale: translation, adaptation and validation for a greek sample. eur j midwifery 2017;1:1-10. 32. casano ham, anjum f. six-minute walk test. kinesitherapie 2023;7:68. 33. tiksnadi bb, ambari am, adriana m. uji jalan 6 menit (uj6m) pada pasien pasca sindrom koroner akut. indonesian j cardiol 2019;40. 34. shigeta tt, leahy aa, smith jj, et al. cardiorespiratory and muscular fitness associations with older adolescent cognitive control. j sport health sci 2021;10:82. 35. raghuveer g, hartz j, lubans dr, et al. cardiorespiratory fitness in youth: an important marker of health: a scientific statement from the american heart association. circulation 2020;142:e101-18. 36. appelqvist-schmidlechner k, vaara jp, vasankari t, et al. muscular and cardiorespiratory fitness are associated with health-related quality of life among young adult men. bmc public health 2020;20:1-8. 37. franklin ba, eijsvogels tmh, pandey a, et al. physical activity, cardiorespiratory fitness, and cardiovascular health: a clinical practice statement of the aspc part i: bioenergetics, contemporary physical activity recommendations, benefits, risks, extreme exercise regimens, potential maladaptations. am j prev cardiol 2022;12. 38. marín-jiménez n, borges-cosic m, ocón-hernández o, et al. association of self-reported physical fitness with pregnancy related symptoms the gestafit project. int j environ res public health 2021;18. 39. world health organization (who) regional office for europe. essential antenatal, perinatal, dan postpartum care: promoting effective perinatal care. 2002. available from: http://www.euro.who.int/__data/assets/pdf_file/0013/131521/ e79235.pdf 40. jannah r, agustina d, faradisa wp. korelasi persepsi terhadap kebutuhan fisioterapi antenatal untuk mengatasi masalah muskuloskeletal ibu hamil. quality: jurnal kesehatan 2019;13:42-9. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 466] [healthcare in low-resource settings 2024;12:11967] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11803 the effect of near-infrared rays on the decrease in the number of adipocyte cells using the flow cytometry method emillia devi dwi rianti, fuad ama faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia abstract adipose tissue, composed of adipocyte cells, can become problematic due to an increase in cell number (hyperplasia) and size (hypertrophy). to address this concern, interventions are needed to reduce these probabilities. near infrared (nir) is an electromagnetic wave that affects tissues by being absorbed and penetrating them. nir can induce cell death (necrosis or apoptosis), where cells respond to external factors causing tissue damage. the purpose of this study was to examine the effect of nearinfrared rays on the decrease in the number of adipocyte cells using the flow cytometry method. this study, conducted in vitro using adipocyte cell cultures isolated from rat visceral adipose tissue, explores the effects of nir exposure at various distances (1 cm, 2 cm, and 3 cm) for 20 minutes. adipocyte cells were stained and examined using confocal laser scanning microscopy (clsm), and the percentage of cells was determined by flow cytometry. statistical analyses were performed using one way anova and duncan test. significant differences (p<0.05) were observed, and the duncan test revealed variations in the percentage of living cells among control and treatment groups. the data indicated that exposure to high nir energy with low wavelengths penetrated adipocyte cells, leading to a decrease in the percentage of cells and notable changes in cell morphology. flow cytometry results demonstrated differences in live cell percentages, with group 2 (exposed at 2 cm for 20 minutes) being more effective, showing lower percentages of live cells. this research suggests that nir exposure has an impact on adipocyte cell cultures, emphasizing its potential in influencing adipocyte cell behavior. introduction adipocyte cells, also known as lipocytes and fat cells, are the primary cells that constitute adipose tissue, specializing in storing energy in the form of fat.1 this tissue is situated beneath the skin and surrounding internal organs,2 playing biochemical roles associated with the mechanisms of obesity.3 the increase in the number of adipocyte cells is termed hyperplasia, while the enlargement of adipocyte cells is referred to as hypertrophy.4 obesity poses a significant challenge and is recognized as a risk factor for various degenerative conditions.5,6 strategies to regulate calorie intake involve reducing energy consumption and increasing physical activity. in addition to dietary adjustments, exercise can aid individuals with obesity in sculpting a firmer physique.7 there are three primary approaches to treating obesity: lifestyle modification (which includes adjusting diet, increasing physical activity, and behavioral therapy), pharmacotherapy (medication), and plastic surgery.8 however, the success rates of these methods in reducing obesity have not reached their maximum potential, necessitating the exploration of alternative measures. one recommended alternative therapy for obesity involves the use of infrared technology.9,10 this therapy utilizes irradiation from near-infrared (nir) rays to address obesity cases.11 infrared rays have the capability to enhance mitochondrial metabolism12 and generate heat radiation at a lower frequency. near-infrared (nir) can impact tissues due to its extremely limited absorption range,13 with wavelengths between 800 nm and 970 nm suggested for therapeutic purposes.14 the energy from nir rays is absorbed by the skin’s surface layer and partially by tissue before penetrating deep into the tissue.11 nir constitutes a form of biological radiation that manifests within cells, leading to cell death – either necrosis or apoptosis – in both the short and long term.15 apoptosis involves different mechanisms within cells and can correspondence: emillia devi dwi rianti, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia. e-mail: emilia@uwks.ac.id key words: adipocyte cells, apoptosis, flow cytometry, health, near infrared rays, wavelength. contributions: eddr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; fa, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has obtained approval from the research ethics commission of the faculty of medicine, wijaya kusuma university, surabaya, with the number 59/sle/fk/uwks/2019. patient consent for publication: none. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to extend our thanks to mrs. heni endrawati, ssi, for her help in the laboratory experiments. received: 14 september 2023. accepted: 4 december 2023. early access: 18 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11803 doi:10.4081/hls.2024.11803 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 132] [healthcare in low-resource settings 2024;12:11803] non -co mmerc ial us e o nly occur through the mitochondrial pathway.16 it is a programmed cell death resulting from conditions inside the cell itself, such as deoxyribonucleic acid (dna) damage, or external stimulation. apoptosis is a normal occurrence in various physiological processes aimed at maintaining homeostasis. organisms utilize apoptosis to eliminate cells that are no longer necessary or useful to the body.17 the mitochondrial pathway is a prominent route through which apoptosis can be observed, with mitochondria playing a crucial role in cell death and functioning as crosstalk organelles.18 these organelles are pivotal in various apoptotic pathways, which are categorized into two types: dependent and independent caspases.19 apoptosis signaling in the dependent caspase pathway can occur both intracellularly and extracellularly. extrinsic (extracellular) pathways are initiated by the stimulation of death receptors, while intrinsic pathways are triggered by the release of signaling factors from mitochondria within cells.20 therefore, this study aimed to investigate the impact of near-infrared (nir) on reducing the number of adipocyte cells using the flow cytometry method. materials and methods the research employed a true experimental post-test-only control group design. samples for both the experimental and control groups were selected through randomization. primary cells were generated using adipocytes extracted from 4-week-old wistar rattus norvegicus strain mice, totaling 20 samples. the adipocyte cells were cultured by isolating them from visceral adipose tissue, and the research was conducted in vitro on these adipocyte cells. adipocyte cell cultures were subjected to nir light for a 20minute treatment. treatment 1 involved nir exposure at a distance of 1 cm, treatment 2 at a distance of 2 cm, and treatment 3 at a distance of 3 cm. the variables comprised the dependent variable, which is the apoptosis of adipocyte culture cells, and the independent variable, which is nir, with an exposure time of 20 minutes and distances of one, two, and three cm. this research has obtained approval from the research ethics commission of the faculty of medicine, wijaya kusuma university, surabaya, with the number 59/sle/fk/uwks/2019. the research and treatment of adipocyte cell culture were conducted at the parasite laboratory, brawijaya university, malang. observations of adipocyte cells were carried out in the laboratory of the center for biological sciences, brawijaya university, malang. light-emitting diode (led) near-infrared (nir) the infrared ray was based on the wavelength of the nir led calibrated at the applied electroelectronics and electromagnetic laboratory, where the energy produced was calculated. the wavelength had an output spectrum ranging from about 910 nm to 1010 nm, with the infrared led power being approximately 1 mw and a diameter of 5 mm. nir leds were exposed to adipocyte cell cultures at distances of 1 cm, 2 cm, and 3 cm for a duration of 20 minutes. adipocyte cell culture the adipose tissue cells were washed with 70% ethanol, isolated, and placed in a 50 ml falcon tube containing dulbecco’s modified eagle medium (dmem). the falcon, containing 3 ml of dmem medium to which type ii collagenase had been added, was then incubated in a 37 °c water bath shaker for 20 minutes and centrifuged at 1500 rpm for 7 minutes. the supernatant was discarded, and the pellet was mixed with 3-6 ml of dmem containing 10% fetal calf serum (fcs) and 1/100 pen-strep, filtered, and then transferred to a culture flask. it was stored in a co2 incubator for 2 hours, the medium was changed, and then put back in the co2 incubator.21 adipocyte morphology examination with confocal laser scanning microscopy (clsm) the observation of adipocyte morphology was conducted using the oil red staining method. cells from each treatment were prepared on a cover slide after being washed with pbs. subsequently, the cells were fixed with 4% formaldehyde for 30 minutes and washed twice with pbs (300 µl per well). they were then stained with red oil in a 3:2 ratio with sterile water for 30 minutes. the cells were incubated until dry and subsequently observed under an olympus light microscope at 400x magnification. additionally, cell observation can be conducted using the clsm technique, an optical imaging method that enhances optical resolution and contrast in micrographs by utilizing a spatial pinhole to block out-of-focus light.22 percentage of adipocyte cell apoptosis with flow cytometry after each tube underwent apoptotic treatment, it was centrifuged at 2000 rpm for 3 minutes, and the cells were prepared for the flow cytometry test. the media in the tube was discarded, and 100 μl of annexin v-pi reagent was added to the tube, followed by the addition of 350 μl of buffer. the contents were mixed and homogenized using a vortex. subsequently, the mixture was incubated at room temperature in a dark place for 10 minutes. the cell suspension was then transferred to a flow cytometry tube, and it was ready to be injected into a flow cytometry tool. the percentage of cells was measured using flow cytometry and analyzed using the cell-quest software (becton dickinson facs calibur).23 statistical analysis the data obtained from the calculation of energy from the wavelength of the nir leds and flow cytometry analysis measurements for each treatment were expressed as mean ± sd. the data underwent analysis using one-way anova at a confidence level of α = 0.05 to determine significant results. subsequently, duncan’s test was employed to identify differences between groups. results the flow cytometry method is a laboratory technique capable of differentiating apoptotic and necrotic cells. this method is widely employed in modern biomedical research and clinical applications. flow cytometry involves the rapid analysis of single cells or particles suspended in a buffered salt-based solution as they flow through a single or dual laser. it provides rapid, quantitative, and reliable imaging for the detection of apoptosis. the data results from flow cytometry are presented in table 1. flow cytometry observations on apoptosis were conducted using the flow cytometry method, which functions to rapidly count live cells, necrosis, and apoptotic cells. tests utilized annexin v proteins specifically related to the phosphatidylserine present in the cell plasma membrane during the apoptotic process. observations were made after giving treatment for 1 hour and then analyzed. figure 1 displays the results of the duncan test. the lower right (lr) results demonstrate differences between treatment groups h and transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11803] [page 133] non -co mmerc ial us e o nly groups 1, 2, and 3. light is a form of electromagnetic radiation that exhibits both wave and particle properties. it is characterized by its energy content, and when light penetrates a surface, some of it is reflected. light’s nature involves energy penetrating the surface and refracting perpendicular to the surface, with its particles being photons. energy is the capacity or effort to move electrons from one path to another, measured in joules. the amount of energy each light wave possesses when approaching the sensor surface can be calculated using the equation e = hc/λ, where e is the absorbed energy (j), h is planck’s constant (6.626 x 10-34 joules/sec), and c is the speed of light (3 x 108 m/sec). data for different tests were calculated using spss software version 20.0. significant differences between averages were analyzed using one-way analysis of variance (anova). the results for energy and wavelength indicated significant differences (sig. 0.000 < 0.05). the duncan test was employed to identify differences between groups, such as e7 with e6, which had nearly the same average values of 0.197 and 0.198. on the other hand, groups e7 with e1 showed the most significant difference in average values, with 0.197 and 0.209. energy is the fundamental characteristic of light, allowing it to penetrate surfaces. the results of the statistical analysis indicated a significant difference with a p-value < 0.05 for the energy values within the nir wavelength range of 910 nm-1010 nm. the energy associated with lower wavelengths, indicative of greater surfacepenetrating power, exhibited higher energy values (figure 2). morphology of adipocyte cell culture fat droplets in adipose tissue can be unilocular and/or multilocular. a unilocular cell features a large lipid droplet, pushing the cell nucleus toward the plasma membrane, resulting in a ring-like appearance. unilocular cells are characteristic of white fat tissue and vary in size from 20 to 200 microns. mitochondria are primarily located in the periphery of the cell, where the thicker cytoplasm is in proximity to the cell nucleus. large fat droplet cells lack small intracellular organelles. morphological examination of adipocyte cell culture was conducted using oil red staining to identify the presence of lipid droplets. fat cells serve as repositories for energy reserves in the form of triacylglycerol, which manifests as lipid droplets. adipocyte cell droplets, revealed through oil red o staining, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. measurement of adipocyte cell characteristics using the flow cytometry method. no ll lower left (bottom left) % lr lower right (bottom right) % 1.1 41.1 2.32 1.2 37.19 2.42 1.3 26.60 4.22 1.4 27.38 5.86 2.1 36.21 4.61 2.2 34.55 4.27 2.3 14.29 5.67 2.4 19.92 4.55 3.1 35.81 2.66 3.2 32.90 2.76 3.3 25.73 3.36 3.4 27.33 2.76 figure 1. detection and measurement of adipocyte cell characteristics using the flow cytometry method (1= group h as control group; 2= treatment group 1; 3= treatment group 2; 4= treatment group 3; with ll: live cells, lr: early apoptosis, ur: late apoptosis/dead). figure 2. the results of energy and wavelengths with an output spectrum of around 910 nm -1010 nm. [page 134] [healthcare in low-resource settings 2024;12:11803] non -co mmerc ial us e o nly appeared red. the highest resolution images of adipocyte cells were obtained using clsm (confocal laser scanning microscopy) (figure 3). discussion energy is a beam of light in the form of an electric-magnetic field generated by electromagnetic waves and concentrated in the form of small packages called photons. light, when considered as a flow of particles, is called a photon, each carrying a specific amount of energy per photon.24,25 higher energy values result in a more substantial response and are beneficial for observing effects in deeper tissues.26 infrared radiation carries energy that can penetrate body tissues. additionally, nir exposure has the capability to penetrate subcutaneous tissue. near-infrared (nir) irradiation induces both thermal and non-thermal heating, stimulating collagen and elastin production, and is utilized as a method of cell interference.12 the calibration results of nir leds with a wavelength ranging from 910 nm to 1010 nm impact the target and depth. wavelengths below 1100 nm can directly affect target selection and depth and are also absorbed by melamine in the surface layer of the skin.25,27 the nir wavelength of 980 nm can penetrate tissues to varying depths depending on the wavelength, time, and tissue.28 nir can stimulate the biological functions of cells located in the stomach area. the basic mechanism of nir, with its low intensity, shows a synergistic effect in reducing fat. nir rays can be utilized as effective methods for fat-reducing therapy.29 the results of exposure to nir rays revealed a significant effect on morphological changes in adipocyte cell cultures stained with oil red o. exposure to nirs with high energy values and low wavelengths can penetrate adipocyte cells, as evidenced by morphological changes resulting in a reduced number of adipocyte cells.30 normal adipocyte cells typically exhibit a round shape with clear cell nuclei in the peripheral part of the cell, smooth cell membranes, and the presence of large pleated droplets almost filling the cell portion (figure 3). adipocyte cells undergoing morphological changes can be characterized by an enlarged adipocyte cell and an uneven cell membrane. the results from flow cytometry of adipocyte cells (figure 3) illustrate cells undergoing apoptosis and the relative distribution of cell populations. the measurement of cell population distribution, seen through light, enhances communication between cells and stimulates chromophores (enzymes sensitive to light) involved in various metabolic processes. figure 3’s flow cytometry results indicate that the mean ll (lower left; representing the percentage of living cells) with the percentage of living cells from the different h treatments (control group) differed from groups 1, 2, and 3. the mean lr represents the percentage of cells undergoing initial apoptosis, showing a difference between the control group h and groups 1, 2, and 3. the mean lr (lower right; showing the percentage of cells undergoing apoptosis) indicates that the percentage of cells undergoing initial apoptosis has no significant difference between groups h and groups 1, 2, and 3 due to the initial apoptosis treatment in adipocyte cell cultures. apoptosis is a programmed cell death process where the cell nucleus solidifies, the cell size shrinks, and the cell bodies undergo changes.31 apoptosis is triggered by signaling pathways and regulated by complex extrinsic and intrinsic ligands. it is a programmed cell death that occurs due to conditions within the cell itself or external stimulation. under normal conditions, apoptosis is part of various physiological processes to maintain homeostasis, meaning it is utilized by organisms to eliminate cells that are no longer needed by the body.17 apoptosis occurs through an intrinsic pathway, initiated by changes in the mitochondrial membrane potential, leading to the secretion of cytochrome-c from the mitochondria into the cytoplasm. the relationship between radiation, apoptosis, and clonogenic cell survival is complex because, after radiation, cells can either undergo apoptosis during mitosis, survive, or die without mitosis.32 radiation induces apoptosis by altering the mitochondria, followed by the activation of the caspase enzyme. the process of transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 3. the results of the morphology of adipocyte cell culture, with conditions after treatment and administration of oil red o and clsm. a) adipocyte cell culture before treatment (40x), b) adipocyte cells after treatment and oiled o (100x), c) adipocyte cells after treatment then observed with clsm (600x). [healthcare in low-resource settings 2024;12:11803] [page 135] non -co mmerc ial us e o nly apoptosis can commence in the mitochondria, either through dna damage or as a response to the cell membrane.33 apoptosis can be triggered by increasing energy in the cell membrane, involving the activation of ceramide through the hydrolysis of sphingomyelin to ceramide by the acid sphingomyelinase enzyme. ceramide serves as a second method to activate apoptosis through bax (bcl-2 associated x protein) stimulation. this stimulation leads to the binding of bax to the outer membrane of the mitochondria, causing the release of cytochrome-c and activation of caspase.33,34 the bax molecule located in the outer mitochondrial membrane functions as a molecule that induces apoptosis by triggering the release of cytochrome c. subsequently, cytochrome c binds with apaf-1, atp, and caspase-9, activating procaspase-3 to become caspase-3, which then cleaves the cytoskeleton.33,34 conclusions exposure to high nir energy and low wavelengths can penetrate adipocyte cells, resulting in a decrease in adipocyte cell count, as demonstrated by the flow cytometry method. additionally, there is a reduction in the morphology of adipocyte cells. the flow cytometry method is employed to rapidly count live cells, cell necrosis, and apoptosis. the results indicate that nir influences adipocyte cell culture, revealing a difference in the percentage of live cells between the control group and groups 1, 2, and 3. notably, group 2 exhibits a lower percentage of live cells. consequently, exposure at a distance of 2 cm for 20 minutes proves to be more effective. references 1. birbrair a, zhang t, wang zm, et al. role of pericytes in skeletal muscle regeneration and fat accumulation. stem cells dev 2013;22:2298–314. 2. chait a, den hartigh lj. adipose tissue distribution, inflammation and its metabolic consequences, including diabetes and cardiovascular disease. front cardiovasc med 2020;7:22. 3. longo m, zatterale f, naderi j, et al. adipose tissue dysfunction as determinant of obesity-associated metabolic complications. int j mol sci 2019;20(9). 4. stenkula kg, erlanson-albertsson c. adipose cell size: importance in health and disease. am j physiol integr comp physiol 2018;315:r284–95. 5. mahiroh h, astutik e, pratama ra. the association of body mass index, physical activity and hypertension in indonesia. j ners 2019;14:16–22. 6. rizal a, hermanto tj, murtiwi s, ernawati. a comparison of hba1c in pregestational diabetes patients with obesity. biochem cell arch 2019;4745–8. 7. rejeki ps, baskara pg, herawati l, et al. moderate-intensity exercise decreases the circulating level of betatrophin and its correlation among markers of obesity in women. j basic clin physiol pharmacol 2022;33:769–77. 8. piyakong d, apiratanawong s, suasing c. insights from leaders on effectively addressing overweight and obesity in the thai community. j ners 2023;18:117–23. 9. gao m jiao, xue h zhong, cai r, et al. a preliminary study on infrared thermograph of metabolic syndrome. front endocrinol 2022;13:851369 10. kim s, kim y, lee g, kim j. does treadmill walking with near-infrared light applied to the abdominal area reduce local adiposity and body weight? j phys ther sci 2017;29:1753–6. 11. gholami l, afshar s, arkian a, et al. nir irradiation of human buccal fat pad adipose stem cells and its effect on trp ion channels. lasers med sci 2022;37:3681–92. 12. averbeck d, rodriguez-lafrasse c. role of mitochondria in radiation responses: epigenetic, metabolic, and signaling impacts. int j mol sci 2021;22. 13. liu tm, conde j, lipiński t, bednarkiewicz a, huang cc. revisiting the classification of nir-absorbing/emitting nanomaterials for in vivo bioapplications. npg asia mater 2016;8:e295–e295. 14. larkin-kaiser ka, christou e, tillman m, et al. near-infrared light therapy to attenuate strength loss after strenuous resistance exercise. j athl train 2015;50:45–50. 15. nakajima k, takakura h, shimizu y, ogawa m. changes in plasma membrane damage inducing cell death after treatment with near-infrared photoimmunotherapy. cancer sci 2018;109:2889–96. 16. fakhlaei r, selamat j, khatib a, et al. the toxic impact of honey adulteration: a review. foods 2020;9(11). 17. orrenius s, nicotera p, zhivotovsky b. cell death mechanisms and their implications in toxicology. toxicol sci 2011;119:3–19. 18. luqman em, widjiati, mafruchati m, et al. crosstalk between necrosis and apoptosis of embryonal cerebral cortex neuron mice (mus musculus) caused by carbofuran exposure. res j pharm technol 2019;12:5492–8. 19. ahmad ma, aung yy, widati aa, et al. a perspective on using organic molecules composing carbon dots for cancer treatment. nanotheranostics 2023;7:187–201. 20. peng f, liao m, qin r, et al. regulated cell death (rcd) in cancer: key pathways and targeted therapies. signal transduct target ther 2022;7:286. 21. lin j, della-fera ma, baile ca. green tea polyphenol epigallocatechin gallate inhibits adipogenesis and induces apoptosis in 3t3-l1 adipocytes. obes res. 2005 jun;13(6):982–90. 22. elliott ad. confocal microscopy: principles and modern practices. curr protoc cytom 2020;92:e68. 23. endharti at, wahyuningtyas te, handono k, et al. dendrophthoe pentandra leaves extract promotes apoptotic effects of doxorubicin in human breast cancer cell via modulation of intracellular calcium and survivin. j appl pharm sci 2018;8:39–43. 24. zhang y, feng y, ming x, deng j. energy modulated photon radiotherapy: a monte carlo feasibility study. biomed res int 2016;2016:7319843. 25. chang ds, lasley fd, das ij, et al. characteristics of photon beams. in: chang ds, lasley fd, das ij, mendonca ms, dynlacht jr, editors. basic radiother physics biol 2021:67– 73. 26. samad fa, mohamed t. intensity and wavelength-dependent two-photon absorption and its saturation in ito film. appl phys a mater sci process 2023;129(1). 27. tanaka y. impact of near-infrared radiation in dermatology. world j dermatol 2012;1:30–7. 28. henderson ta, morries ld. near-infrared photonic energy penetration: can infrared phototherapy effectively reach the human brain? neuropsychiatr dis treat 2015;11:2191–208. 29. cristiano l. use of infrared-based devices in aesthetic medicine and for beauty and wellness treatments. infrared phys technol 2019;102:102991. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 136] [healthcare in low-resource settings 2024;12:11803] non -co mmerc ial us e o nly 30. onyancha rb, ukhurebor ke, aigbe uo, et al. a review of the capabilities of carbon dots for the treatment and diagnosis of cancer-related diseases. j drug deliv sci technol 2022;78. 31. zhang y, chen x, gueydan c, han j. plasma membrane changes during programmed cell deaths. cell res 2018;28:9– 21. 32. sia j, szmyd r, hau e, gee he. molecular mechanisms of radiationinduced cancer cell death: a primer. front cell develop biol 2020;8. 33. häcker g, haimovici a. sub-lethal signals in the mitochondrial apoptosis apparatus: pernicious by-product or physiological event? cell death differ 2023;30:250–7. 34. patwardhan ga, beverly lj, siskind lj. sphingolipids and mitochondrial apoptosis. j bioenerg biomembr 2016;48:153– 68. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11803] [page 137] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13155 relationship between sedentary lifestyle and body mass index with the risk of endometriosis among adolescent girls at a senior high school yuli mulyanti, theresia gres margaretha, deswani deswani, syafdewiyani syafdewiyani, omi haryati polyteknik kesehatan kemenkes jakarta iii, indonesia abstract a significant portion (52.60%) of individuals with endometriosis are classified as obese. obesity often results from a lifestyle characterized by minimal physical activity. this sedentary behavior encompasses using electronic devices, watching television, playing video games, and spending long periods sitting or reclining, all of which demand minimal energy expenditure. consequently, excess energy is stored as body fat, leading to obesity. this research aimed to investigate the connections between sedentary habits, body mass index (bmi), and endometriosis risk in teenage girls. the study employed an observational cross-sectional approach. the research sample consisted of 102 participants, selected through purposive sampling techniques. data analysis was conducted using the chi-squared test. the dependent variable was the risk of endometriosis, while the independent variables were sedentary lifestyle and bmi. the results of the analysis showed that the relationship between sedentary lifestyle and endometriosis risk had a p-value of 0.001, and the relationship between bmi and endometriosis risk had a p-value of 0.003. based on the analysis results, it can be concluded that there is a significant relationship between sedentary lifestyle, bmi, and the risk of endometriosis. this suggests that teenagers should modify their lifestyle and uphold healthy eating habits. introduction endometriosis is a disease in which tissues similar to the uterus lining grow outside the uterus.1 according to the world health organization (who) in 2023, approximately 10% (190 million) of women of reproductive age and girls experience endometriosis.2 some researchers estimate that endometriosis occurs in 10-16% of adolescent girls who often experience chronic pelvic pain and dysmenorrhea in adolescence.3 according to the american society of reproductive medicine, the overall prevalence of endometriosis among adolescent girls with moderate to severe endometriosis is 32%.4 secondary dysmenorrhea is a common symptom of endometriosis.5 data from the indonesian health profile in 2016 indicates that the incidence rate of dysmenorrhea was 64.25%, comprised of 54.89% primary dysmenorrhea and 9.36% secondary dysmenorrhea.6 the factors affecting the risk of endometriosis include low physical activity (sedentary lifestyle) and excess body weight.7,8 a sedentary lifestyle is characterized by light activity or sedentary behavior, with an energy expenditure of approximately 1-1.5 metabolic equivalents (mets).9 people who live this lifestyle rarely exercise or engage in significant activities. a sedentary lifestyle is a relaxed way of living that includes activities such as watching television, playing video games, sitting, or lying down, all of which require little energy. the excess energy is then stored as body fat.10 according to the results of the basic health research in 2013, 44.2% of adolescents in dki jakarta were inactive.11 data from the basic health research in 2018 indicates that 47.81% of the population aged 10 years and older in dki jakarta and 46.17% in the east jakarta area were inactive,12 reflecting an increase of nearly 3.61% in inactive adolescents in jakarta. a study conducted in bangladesh revealed that 64.3% of 217 adolescent respondents preferred not to play outdoors or engage in physical activities.13 additionally, a study found that 44.3% of adolescent girls with low activity levels are at risk of developing endometriosis.14 endometriosis can affect women of childbearing age with different body weights based on body mass index (bmi), including thin, normal, overweight, and obese women. eighteen percent of obese women have endometriosis.7 in 2013, 32.9% of adult correspondence: yuli mulyanti, health polytechnic ministry of health jakarta iii, indonesia. e-mail: yulimulyanti01@gmail.com key words: sedentary lifestyle; body mass index; risk of endometriosis. contributions: ym, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; tgm, conceptualization, investigation, methodology, data curation, formal analysis, validation, and writing – original draft; dd, conceptualization, methodology; ss, methodology, visualization, writing – review & editing; oh, review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research was approved by the health research ethics commission (kepk) of polyteknik kesehatan kemenkes jakarta iii on march 26, 2024, based on ethical certificate number lb.02.02/f. xix.21/3924/2024. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgments: we would like to thank the director and staff of polyteknik kemenkes jakarta iii for facilitating publication in a reputable international journal. received: 24 september 2024. accepted: 17 march 2025. early access: 9 may 2025 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13155 doi:10.4081/hls.2025.13155 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 132] [healthcare in low-resource settings 2025;13(s1):13155] women in indonesia over 18 years of age were classified as obese, while 17.85% of individuals in dki jakarta were identified as centrally obese.12 a study conducted by holdsworth-carson et al.15 reported that 51 women (52.6%) with a bmi≥25 were at risk of endometriosis. currently, the underlying mechanism in obese women with endometriosis who may have severe dysmenorrhea remains unknown, as both endometriosis and obesity cause decreased stromal cell decidualization.16 therefore, obesity can be a risk factor for severe dysmenorrhea.16 the factors influencing the risk of endometriosis include low physical activity (sedentary lifestyle) and excess body weight.7 a sedentary lifestyle is characterized by minimal physical activity, which can lead to an increase in bmi. given this background, researchers are motivated to further investigate the relationship between sedentary lifestyle and body mass index with the risk of endometriosis in adolescent girls. materials and methods research design this study employed a quantitative, cross-sectional, observational, and analytical approach. it aimed to examine how factors such as sedentary lifestyle and excessive body weight contribute to the risk of endometriosis. specifically, it explored the relationship between sedentary behavior, body mass index, and the risk of developing endometriosis. participants the study population included adolescent girls at a senior high school in indonesia. the research sample comprised 102 respondents, and sampling was performed using a purposive sampling technique. the inclusion criteria were adolescent girls aged 15-18 years who had menstruated, were willing to be respondents, and had signed an informed consent form. the exclusion criteria were adolescent girls who used hormone therapy and had been diagnosed with reproductive and hormonal health problems. variables, instruments, and data collection the dependent variable was the risk of endometriosis, whereas the independent variables were sedentary lifestyle and bmi. this study used a questionnaire that was modified, developed, and tested for validity and reliability in 34 adolescent female respondents in accordance with the inclusion and exclusion criteria. several questionnaires were used, including demographic data (age, class, bmi), a sedentary lifestyle questionnaire, and the endometriosis risk questionnaire (esat-21).17 esat was developed, and its construct validity was supported. exploratory factor analysis indicated four components (gastrointestinal symptoms, dysmenorrhea, usual symptoms, and the amount and characteristics of menstrual bleeding), with a variance of 61.6%. the variance in quality-of-life scores, as explained by the esat scores, was relatively high. receiver operating characteristic curve analysis indicated that esat scores significantly differentiated endometriosis from non-endometriosis with fair discriminatory power at a cut-off score of 50 (sensitivity, 0.76; specificity, 0.72; area under the curve>0.75; p<0.001). this indicates that patients with esat scores >50 were more likely to have endometriosis. thus, the reliability of the esat was confirmed.17 data collection was performed by measuring bmi and providing questionnaires directly to respondents according to the inclusion and exclusion criteria. bmi was estimated by calculating body weight in kilograms divided by height squared. a sedentary lifestyle was measured using a questionnaire containing daily activities and then classified as light, moderate, and heavy. data analysis univariate analysis was used to identify the characteristics of the respondents, and bivariate analysis using the chi-square test was used to determine the relationship between sedentary lifestyle, body mass index, and endometriosis risk. ethical clearance before the study, the researcher passed the ethical feasibility test stage of the health research ethics commission of polyteknik special issue pathways of change table 1. characteristics of respondents by age, focusing on sedentary lifestyle, body mass index, and endometriosis risk. characteristic frequency (n) percentage (%) age (years) 15 31 30.4 16 55 53.9 17 16 15.7 18 0 0 sedentary lifestyle low 16 15.7 medium 20 19.6 high 66 64.7 body mass index skinny 27 26.5 normal 47 46.1 obesity 28 27.5 risk of endometriosis no risk 46 45.1 at risk 56 54.9 table 2. relationship between sedentary lifestyle, body mass index, and endometriosis risk. risk of endometriosis no risk at risk total p or sedentary lifestyle n % n % n % low 5 93.8 1 8.8 16 100 0.000 3.846 medium 1 55 9 11 20 100 high 20 30.3 46 69.7 66 100 bmi n % n % n % skinny 16 59.3 11 40.7 27 100 0.003 1.971 normal 25 53.2 22 46.8 47 100 obesity 5 17.9 23 82.1 28 100 [healthcare in low-resource settings 2025;13(s1):13155] [page 133] kesehatan kemenkes jakarta iii on march 26, 2024 (lb.02.02/f. xix.21/3924/2024). results the results of this study show that 69 adolescent girls (67.6%) are from grade 10, with the majority being 16 years old, comprising 55 adolescent females (53.95%). moreover, up to 66 teenage girls (64.7%) exhibited a high level of sedentary lifestyles, a trend attributed to lifestyle changes among adolescents, which are marked by significant advancements in technology. the prevalences of obesity and endometriosis were 27.5% and 54.9 %, respectively (table 1). table 2 presents the results of these analyses. it reported that adolescent girls have a high risk of endometriosis, with a sedentary lifestyle accounting for 69.7% of cases. this study indicated a significantly sedentary lifestyle associated with a heightened risk of endometriosis (p=0.000). additionally, this research revealed that 23 adolescents (82.1%) with an obese bmi were at risk of endometriosis. furthermore, this study established a relationship between body mass index and the risk of endometriosis (p=0.003). discussion the results indicated that the study participants were mostly adolescents, with a majority being 16 years old. most were high school students who had experienced menarche. generally, the first menstrual period in female adolescents occurs between the ages of 11 and 13, with an average of 12 years.18 research by elhadad et al. suggests that when menstruation begins 1-4 years after menarche, there is an increased risk of secondary dysmenorrhea developing more than 3 years post-menarche, which may indicate endometriosis.19 as a result, scientists propose that the risk of endometriosis can be observed three years after menarche, particularly in the 15-18 age group. endometriosis can develop as early as 16 years old. the study findings revealed that 47 adolescents (46.1%) had a regular bmi, indicating proper physical growth, mental wellbeing, and ideal functional abilities. this outcome aligns with a study conducted by syahfitri et al., which found that 172 out of 290 teenagers (59%) had a normal bmi.20 research conducted by putra et al. suggested that obesity can result from a combination of insufficient physical activity and excessive calorie consumption.21 multiple factors contribute to an elevated bmi, such as genetics, dietary habits, exercise routines, socioeconomic conditions, and emotional aspects. technological advancements have led to more sedentary lifestyles among adolescents.22 for female teenagers, obesity may be influenced by genetic predisposition, consumption of high-fat and sugary foods, such as fast food, and inadequate daily physical activity. it is crucial to promote healthy and balanced eating habits through educational initiatives within families, schools, and broader communities. the findings indicated that the majority of participants (64.7%) exhibited high levels of sedentary behaviors. this observation corresponds with a study by pradifa et al., which indicated that the majority of adolescents are classified within the high category of sedentary lifestyle.22 the who identifies sedentary behavior as a leading cause of mortality worldwide.23 a sedentary lifestyle, according to the republic of indonesia’s ministry of health, is defined as having a minimum energy expenditure of 1.5 mets.24 examples of sedentary activities include long periods of sitting or lying down, extended television watching, and excessive computer use – essentially, any lifestyle marked by low physical activity. the proliferation of digital technology, which provides easy access to various services, has contributed to an increase in sedentary behavior. the current trend is the growing popularity of social media and other online activities. sedentary lifestyles can lead to metabolic disturbances that cause the body to store fat rather than utilize it for energy, potentially resulting in obesity. consequently, it is crucial to modify sedentary behavior, as it not only contributes to obesity but can also lead to various health issues and premature death. the study findings revealed that 56 young women (54.9%) were potentially at risk for endometriosis, as determined by the esat-21 questionnaire criteria in research conducted by cho et al.17 this finding aligns with a study by hirsch et al., which found that 64% of young women were at risk of endometriosis, presenting with pelvic pain symptoms. as a result, researchers have determined that women at risk of endometriosis are usually affected by pelvic pain and irregular menstrual cycles.25 the research results indicated a relationship between bmi and endometriosis risk, aligning with the findings of hanina et al. at dr. mohammad hoesin hospital. their investigation showed a connection between obesity and endometriosis (p=0.018), with a 2.813 times higher risk.8 furthermore, a study by milla et al. established a link between obesity and menstrual irregularities in teenage girls (p=0.004), with a 0.613 times increased risk.26 vitonis et al. noted that obesity can elevate the risk of endometriosis by 18%.7 although women of various bmis may face reproductive challenges like endometriosis, those who are obese are more prone to these issues.7 obese women, when compared to those with regular bmi, have a greater chance of experiencing irregular menstrual cycles, dysmenorrhea, and anovulation.26,27 the growth of endometrial tissue outside the uterus is linked to hormonal imbalances and chronic inflammation surrounding the lesion. there is a prevalence of estrogen dominance or elevated estrogen levels, both systemically and locally, as well as resistance. the results of the study showed that there was a relationship between sedentary lifestyle and the risk of endometriosis, in line with research conducted by apriliya, which stated that there was a significant relationship between sedentary lifestyle and dysmenorrhea (p=0.000), where secondary dysmenorrhea was one of the symptoms of endometriosis.28 research conducted by muselli et al. stated that there was a significant relationship between low physical activity and endometriosis (p=0.001).29 several studies on endometriosis and physical activity are interrelated because endometriosis is an estrogen-dependent disease, and good physical activity can increase binding globulin levels, which reduces estrogen availability. a sedentary lifestyle results in less energy being released and stored in the body fat. excessive adipose tissue causes hormonal disorders with high estrogen and low progesterone levels, which trigger the growth of endometrial tissue outside the uterine cavity. increased physical activity also reduces the insulin resistance and hyperinsulinemia associated with endometriosis.30 regular exercise is associated with a 40-80 % reduced risk of endometriosis compared with women who do not exercise.7 thus, researchers argue that adolescents with a sedentary lifestyle can have a high incidence of obesity, which can be a risk factor for endometriosis, because adolescents tend to engage in daily physical activities such as exercising. thus, a lack of physical activity can increase the risk of endometriosis. therefore, it is important to do daily activities, such as walking, doing light housework, cycling, and going up and down stairs, to avoid a sedentary special issue pathways of change [page 134] [healthcare in low-resource settings 2025;13(s1):13155] lifestyle. the process of endometrial tissue growth is extrauterine, related to the presence of hormonal disorders and chronic inflammatory processes around the lesion. the presence of estrogen dominance or increased estrogen levels, both systemic and local, and resistance to the hormone progesterone, is associated with the process of endometriosis.31 both of these conditions, supported by the failure of the immune system to eliminate endometriosis lesions, allow endometrial tissue to grow ectopically and cause pain in the pelvis.32 research conducted by onstad et al. stated that the presence of excess adipose tissue in the body of obese people has a relationship with reproductive disorders such as metaplasia in the female reproductive organs.33 thus, researchers argue that adolescents with obesity have a greater risk of endometriosis, which is associated with the impact of obesity that causes irregular menstrual cycles, pain during menstruation, and other menstrual disorders, which are the criteria for assessing the risk of endometriosis. furthermore, through the ministry of health, the government has been encouraging society to perform routines, such as chores and sports. the government has facilitated society by providing bike lanes, car-free days, and city parks. however, many teenagers still choose to live a sedentary lifestyle. therefore, the government must use more public advertisements to inspire society about healthy lifestyle awareness. the limitation of this study arises from its narrow focus on just two variables influencing endometriosis risk: sedentary behavior and body mass index. while many other factors contribute to this condition, time constraints have restricted the investigation to these elements. conclusions this research, conducted at a senior high school in jakarta, indonesia, investigated the relationship between inactive behavior, bmi, and the risk of endometriosis among adolescent females. the investigation primarily targeted 16-year-old students enrolled in the tenth grade. the results revealed that a significant number of these young women exhibited highly sedentary lifestyles and maintained a normal weight, yet still faced potential endometriosis risks. statistical evaluations showed a strong link between sedentary behavior and endometriosis risk (p=0.000), as well as between bmi and endometriosis risk (p=0.003). the researchers suggest that future studies investigate additional factors contributing to the risk of endometriosis. these findings highlight the need to promote increased physical activity and balanced nutrition among teenagers. references 1. who. endometriosis [internet]. world health organitation. 2023 [cited 2024 jan 9]. available from: https://www. who.int/news-room/fact-sheets/detail/endometriosis 2. daniera d. transformasi penanganan endometriosis dengan kecerdasan buatan mampu tingkatkan kualiatas reproduksi [internet]. universitas indonesia. 2023 [cited 2024 jan 16]. available from: https://www.ui.ac.id/transformasi-penanganan-endometriosis-dengan-kecerdasan-buatan-mamputingkatkan-kualiatas-reproduksi/#:~:text=prevalensi endometriosis saat ini cukup,ditemukan pada wanita usia reproduktif. 3. khashchenko ep, uvarova ev, fatkhudinov tk, et al. endometriosis in adolescents: diagnostics, clinical and laparoscopic features. j clin med 2023;12. 4. ragab a, shams m, badawy a. prevalence of endometriosis among adolescent school girls with severe dysmenorrhea : a cross sectional prospective study. int j health sci (qassim) 2015;9:271-9. 5. mukti p. faktor risiko kejadian endometriosis. unnes j public heal 2014;3:1-10. 6. thasmara g, raharjo w, ardiani putri e. the relationship between lifestyle with the incident of primary dysmenorrhea in medical faculty female students of tanjungpura university. j nas ilmu kesehat 2020;2:130-40. 7. vitonis af, maruti ss, hankinson se, et al. adolescent physical activity and endometriosis risk. j endometr 2009;1:157– 63. 8. hanina s, fauzi a, krisna r. hubungan obesitas dengan kejadian endometriosis. hub obesitas dengan kejadian endometr di rsup dr mohammad hoesin palembang. 2018;50:107-13. 9. park jh, moon jh, kim hj, et al. sedentary lifestyle: overview of updated evidence of potential health risks. korean j fam med 2020;41:365-73. 10. winata m. hubungan sedentary lifestyle dan indeks massa tubuh dengan risiko sindrom ovarium polikistik pada remaja putri di sman 105 jakarta. 2023;55. 11. pitaloka sa, triharini m, nimah l. relationship between nutritional status, exercise level and recreational level with dysmenorrhea in nursing students at airlangga university. pediomaternal nurs j 2022;8:26-37. 12. syamsudin f, wungu cdk, qurnianingsih e, herawati l. high-intensity interval training for improving maximum aerobic capacity in women with sedentary lifestyle: a systematic review and meta-analysis. j phys educ sport 2021;21:178897. 13. paroi s, hasanat ma, roy bk. study on the sedentary lifestyle of adolescents in khulna city. mediscope 2022;9:68-74. 14. sachs mk, dedes i, el-hadad s, et al. physical activity in women with endometriosis: less or more compared with a healthy control? int j environ res public health 2023;20. 15. holdsworth-carson sj, dior up, colgrave em, et al. the association of body mass index with endometriosis and disease severity in women with pain. j endometr pelvic pain disord 2018;10:79-87. 16. tang y, zhao m, lin l, et al. is body mass index associated with the incidence of endometriosis and the severity of dysmenorrhoea: a case-control study in china? bmj open 2020;10:1-6. 17. cho hh, yoon ys. development of an endometriosis selfassessment tool for patient. obstet gynecol sci 2022;65:25665. 18. putri iia, romantika iw, tahiruddin. faktor-faktor yang berhubungan dengan tingkat kecemasan remaja putri yang mengalami menarchedi smpn 1 sawa. j ilm karya kesehat 2021;01:61-70. 19. el-hadad s, lässer d, sachs mk, et al. dysmenorrhea in adolescents requires careful investigation of endometriosis—an analysis of early menstrual experiences in a large case-control study. front reprod heal [internet] 2023;5. available from: https://www.frontiersin.org/articles/10.3389/frph.2023.112151 5/full 20. syahfitri y, ernalia y, restuastuti t. gambaran status gizi siswa-siswi smp negeri 13 pekanbaru tahun 2016. jom fk special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13155] [page 135] 2017;4:1-12. 21. putra wn. the association between dietary pattern, physical activity, sedentary activity and overweight at sma negeri 5 surabaya. j berk epidemiol 2017;5:298. 22. pradifa h, fikri am, kurniasari r. hubungan sedentary lifestyle dengan status gizi remaja pada masa pandemi covid-19. j ilmu kesehat masy 2023;12:259-63. 23. world health organization. body mass index bmi [internet] [cited 2024 jul 18]. available from: https://www.who. int/data/gho/data/themes/topics/topic-details/gho/bodymass-index 24. kementrian kesehatan. mengatasi ancaman sedentary lifestyle untuk kesehatan [internet] 2023 [cited 2024 jul 18]. available from: https://ayosehat.kemkes.go.id/mengatasiancaman-sedentary-lifestyle-untuk-kesehatan. 25. hirsch m, dhillon-smith r, cutner as, et al. the prevalence of endometriosis in adolescents with pelvic pain: a systematic review. j pediatr adolesc gynecol 2020;33:623-30. 26. milla sy, mudayatiningsih s, dewi n. hubungan obesitas dengan gangguan menstruasi pada remaja putri di kelurahan tlogomas. nurs news j ilm keperwatan 2018;3:72-82. 27. pratama z, arifin af, basri rpl, et al. pengaruh overweight dan obesitas terhadap siklus menstruasi. fakumi med j j mhs kedokt 2022;2:306-11. 28. apriliya ar. hubungan sedentary lifestyle dengan intensitas dysmenorrhea pada mahasiswi kebidanan fakultas kedokteran universitas sebelas maret [internet] 2022. available from: https://www.who.int/news-room/factsheets/detail/autism-spectrum-disorders 29. muselli m, mancinelli m, limoncin e, et al. investigating unhealthy behaviors associated with sf-36 domains in women with endometriosis—findings from a web-based survey data set. behav sci (basel) 2024;14:199. 30. ricci e, viganò p, cipriani s, et al. physical activity and endometriosis risk in women with infertility or pain. medicine (baltimore) 2016;95:e4957. 31. mori t, ito f, koshiba a, et al. local estrogen formation and its regulation in endometriosis. reprod med biol 2019;18:30511. 32. herington jl, bruner-tran kl, lucas ja, osteen kg. immune interactions in endometriosis. expert rev clin immunol 2011;7:611-26. 33. onstad ma, schmandt re, lu kh. addressing the role of obesity in endometrial cancer risk, prevention, and treatment. j clin oncol 2016;34:4225-30. special issue pathways of change [page 136] [healthcare in low-resource settings 2025;13(s1):13155] hrev_master healthcare in low-resource settings 2024; volume 12:11964 the efficacy of implementing family-centered care in child feeding practices annif munjidah, elly dwi masita, hinda novianti, uke maharani dewi faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia abstract nutrition is a basic need for a child to grow optimally. improper child feeding practices are still found in the community, leading to malnutrition. the incidence of malnutrition has increased sharply in children aged 6 to 18 months in various countries, primarily due to ignorance and/or an inability to prepare food. the family plays a crucial role in the prevention and treatment of child nutrition problems. families can provide education and practical supervision in addressing nutrition-related issues, including promoting healthy lifestyle patterns. the objective of this study was to determine the effectiveness of implementing family-centered care in changing child feeding practices. the research design employed was true experimental analysis with a pre-posttest group design. the population consisted of 130 respondents, infants aged 6 to 23 months, selected using a probability sampling technique with purposive random sampling. the research was conducted in wonokromo, surabaya, indonesia, from march to june 2023. the measuring instrument utilized was a family-centered care-based child feeding guide. the independent variable in the study was family care, while the dependent variable was the change in the child’s feeding practices. test analysis was performed using the mann-whitney test. the results of the mann-whitney test indicated a significant difference in feeding practices before and after counseling with the family-centered care approach (p=0.043). thus, family-centered care was found to be effective in changing child feeding practices. introduction nutrition is essential for a child to grow optimally.1 providing correct nutrition during the first 1000 days of life will determine both short-term and long-term quality of life for a human.2 healthy eating habits are essential for improving nutritional status and strengthening immunity against diseases.3 still, a lot of inappropriate feeding practices are found among children in societies, which is a reason for malnutrition. stunting among children negatively impacts their health and overall development.4 indonesia is facing nutritional problems, one of which is malnutrition.5 the incidence of malnutrition increases sharply in the 6 to 18-month period in various countries, either due to ignorance and/or inability to prepare complementary foods.6 the health and nutritional status of children are very dependent on the care of the mother from the time in the womb until the child is born, grows, and develops.7 in indonesia, the anthropometric index is recorded on a card towards health called kartu menuju sehat or kms, which refers to who–2005 standard growth charts (who–2005 sgc).8 based on the 2018 basic health research, the prevalence of being underweight, stunting, and wasting is 17.8 percent, 30.8 percent, and 10.24 percent, respectively.9 exclusive breastfeeding is one of the important indicators in addressing nutritional problems in children.10 feeding practices typically commence with exclusive breastfeeding during the first 0-6 months, followed by the introduction of solids from 6-24 months. complementary feeding (cf) plays a crucial role in meeting the nutritional needs of children that cannot be solely satisfied by breastfeeding alone.11 cf begins when breast milk alone is no longer sufficient to meet infants’ nutritional requirements, necessitating the introduction of other foods and liquids alongside correspondence: annif munjidah, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia. e-mail: annifmunjidah@unusa.ac.id key word: child, efficacy, family, feeding, practice. contributions: am, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; edm, conceptualization, investigation, methodology, validation, and writing – original draft; hn, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; umd, resources, investigation, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethical committee of nursing and midwifery faculty, universitas nahdlatul ulama, indonesia, has certified that this research is ethical. the ethical certification number is 035/016/v/ec/kep/lcbl/2023 may, 16 2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and nonmaleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to lppm universitas nahdlatul ulama surabaya, indonesia for funding this research and providing motivation, facilities for researchers so that this research can be carried out smoothly. the authors would like to thank all respondent who were cooperative and assisted in this research process. received: 13 october 2023. accepted: 11 march 2024. early access: 29 march 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11964 doi:10.4081/hls.2024.11964 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11964] [page 453] non -co mmerc ial us e o nly breast milk. thus, the transition from exclusive breastfeeding to family foods is termed complementary feeding. consequently, the period from birth to two years of age has been recognized as the optimal time for fostering healthy dietary habits.12 one of the primary challenges in developing countries is the provision of lowquality complementary foods, resulting in failure to thrive during the complementary feeding period.4 according to the 2021 indonesian nutritional status survey (inss), exclusive breastfeeding rates stand at 42%, while the introduction of semi-solid and solid foods to children is at 69%. however, only 52.5% of children aged 6-23 months have diverse dietary intake. the frequency of appropriate complementary foods, as per who recommendations, is 53%, and only 19% of children receive food of minimum quality. these figures fall short of evidence-based feeding practices recommended for infants and toddlers in indonesia to prevent child malnutrition. to address this issue, it is crucial to identify the causes of incorrect feeding practices and undertake efforts to rectify them. researchers have identified several studies on factors influencing feeding practices. zulfikar et al. (2020) analyzed the role of culture and maternal knowledge in feeding children.13 agus sri banowo (2020) discovered that nutrition education programs serve as flagship initiatives to improve family feeding practices and combat stunting.14 andi tenri abeng et al. (2018) found that training integrated healthcare center cadres significantly influences maternal practices in providing complementary foods.15 diah estingtias (2019) found that family involvement plays a crucial role in maternal practices regarding the provision of complementary foods.16 shloim (2015) revealed that parental approaches, parenting styles, eating styles, and feeding practices greatly impact children’s eating habits and growth.17 wa ode syahrani h. (2016) also found that personal health education significantly enhances maternal efficacy and feeding behaviors in children with poor nutrition. asmare et al. (2020) conducted a study on the prevalence and factors associated with child feeding practices.12 researchers assessed the success of feeding practices influenced by child factors, environmental factors, and food factors. in previous studies, researchers have investigated the effect of education on maternal literacy regarding the provision of complementary foods.18 the effect of feeding rules on children’s feeding difficulties19 massage interventions to improve children’s chewing ability20 and weight gain21 and use of card media22 as well as the effect of adding onion and garlic to complementary foods.23 research shows that mothers, as primary caregivers, are greatly influenced by the support of close relatives such as husbands and family members in their household.1 this support is key in helping families, the smallest societal unit, in preventing and treating child nutrition issues.they can provide education and practical supervision to prevent and address nutrition-related problems, including through the promotion of healthy lifestyle patterns. therefore, efforts to empower families are essential.24 moreover, it is evident that alternative methods involving different respondents are still highly necessary. this research proposes a new method employing the family-centered care approach because researchers are interested in studying the implementation of family-centered care to change children’s feeding practices. materials and methods research design the research design employed in this study was true experimental analysis with a pre-group design posttest. this research investigates the influence of family-centered care on changes in child feeding practices. study participants the population of this study consisted of 130 respondents, namely babies aged 6 months to 23 months in the sub-district of wonokromo, surabaya city, indonesia. the babies included both boys and girls aged 6-23 months, who were not currently ill or suffering from congenital defects, and belonged to muslim, javanese, and madurese families. they were selected during health activities in villages known as integrated service posts conducted monthly. the sampling technique employed was probability-based purposive random sampling, with the research conducted in the wonokromo sub-district of surabaya. the research period spanned from march to june 2023. variables, instruments and data collection the independent variable in this research is family-centered care, and the dependent variable is child feeding practices. the operational definition of family-centered care is the role of the family in the care process. meanwhile, the operational definition of feeding encompasses the implementation of feeding children, including scheduling, menu selection, processing methods, and methods of feeding. the measuring tool used to assess feeding practices is a checklist derived from the 0-1 year old infant care guide11and evidence-based child feeding recommendations.6 data analysis utilized the mann-whitney test. data collection was conducted directly after the researchers received an ethics approval letter from the brahmanda lentera indonesia (candle) ethics institute. the research team then obtained permission for the study and submitted it to the chairman of the sub-district rw wonokromo in the city of surabaya. subsequently, the research team coordinated with village midwives and child health cadres. once the research timeline was agreed upon, the team formed a field team comprising 12 midwifery students. these students received assignment letters from nahdlatul ulama university surabaya and were provided with daily food and transportation incentives. the field team, consisting of 12 midwifery students, conducted data collection at the beginning of each week. additionally, they provided assistance to 65 families, with each student accompanying 5-6 families. counseling sessions about the role of the family in providing complementary breastfeeding were conducted for the treatment group three times a week, specifically on mondays, wednesdays, and saturdays, each lasting for 60 minutes. in the second week, the research team administered a questionnaire about feeding practices to children. data analysis data were collected and analyzed using bivariate analysis after being directly obtained as primary data. the mann-whitney test was used for data analysis. the recognized level of significance was p=0.05. using spss version 20, all data were examined. ethical clearance the ethical committee of nursing and midwifery faculty, universitas nahdlatul ulama, indonesia, has certified that this research is ethical. the ethical certification number is 035/016/v/ec/kep/lcbl/2023 may, 16 2023. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 454] [healthcare in low-resource settings 2024;12:11964] non -co mmerc ial us e o nly results the results of the research on feeding practices in 130 respondents yielded the following general data. according to table 1, it was observed that 66.9% of respondents were aged between 20 and 44 years, 36.1% had a high school education, 28.8% were employed, 55.4% had an income of more than 3 million, 62.3% had more than three family members, and 60% had more than two children. based on table 2, it is evident that the average score of feeding practices in the treatment group is higher (38.58%) than in the control group (29.7%). the provision of family-centered carebased education can enhance children’s feeding practices, as indicated by the higher average score in the intervention group compared to the control group. based on table 3, it is evident that in the intervention group, after receiving treatment, the majority (52.3%) of respondents exhibited good feeding practices, while almost half (32.3%) demonstrated poor practices, with a smaller proportion (15.4%) showing sufficiency. conversely, in the control group post-treatment, nearly all respondents (84.6%) displayed poor feeding practices, with only a small proportion (15.4%) achieving sufficiency. the results of the mann-whitney test conducted using spss for windows, with a significance level of α = 0.05, yielded a p-value of 0.043 (0.043 < 0.05), indicating significant differences in feeding practices between the intervention and control groups. discussion the study results revealed significant differences in feeding practices following the implementation of the family-centered care model treatment. this model of care involves educating family members residing in the same household. the research demonstrated the effectiveness of the family-centered care educational approach in rectifying previously incorrect child feeding practices. traditionally, childcare predominantly focused on the mother and child relationship; however, this study incorporated family involvement, including the husband and other household members. based on the overall research results, a significant difference in the practice of feeding children in the treatment group before and after receiving family-centered care model education can be observed. moreover, changes in child feeding practices after receiving family-centered care model education predominantly shifted in a positive direction.25 this indicates the positive role of the family in child rearing, aligning with the theory that familycentered care can be applied across various healthcare settings and age groups.26 the core tenets of family-centered care include mutual respect, information exchange, participation, and cooperation.27 the philosophy of family-centered care originates from an environment where families are empowered to support their mental health and contribute significantly to life enhancement. however, family-centered services may lead to undesirable outcomes if families make uninformed decisions while caring for their members, underscoring the importance of clear communication transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents in may-june 2023. characteristics of respondents frequency percentage (%) age <20 24 18,4 20-44 87 66,9 >44 19 14,6 education primary school 28 21,5 middle school 30 23 high school 47 36,1 college 25 19,2 work not working 31 23,8 student 7 5,3 private 29 22,3 entrepreneur 26 20 labor 37 28,4 family income <3.000.000 58 44,6 >3.000.000 72 55,4 family members 1-3 49 37,6 > 3 81 62,3 number of children 1-2 52 40 >2 78 60 primary data: june 2023 table 2. results of data analysis in the treatment group and control group before and after treatment. feeding practice group control intervention pre post pre post mean 26.7 29.7 27.2 38.58 primary data: june 2023 table 3. distribution of feeding practice after treatment with family centered care. feeding practice group intervention control frequency percentage (%) frequency percentage (%) poor 21 32.3 55 84.6 enough 34 52.3 10 15.4 well 10 15.4 0 0 total 65 100 65 100 statistical test with mann whitney test exact sig (2-tailed) = 0.043 primary data: june 2023 [healthcare in low-resource settings 2024;12:11964] [page 455] non -co mmerc ial us e o nly from healthcare professionals. the implementation of the familycentered care philosophy necessitates collaboration from all stakeholders, emphasizing the role of healthcare providers in fostering information exchange and fostering cooperative relationships.28 feeding practices encompass various elements, including the mother’s organization of eating schedules, food menus, ingredients,29 processing methods, serving methods, and administration methods,30 as well as handling distractions and the mother’s attitude when the child refuses to eat.31 families implementing the family-centered care method will not only understand,14 but also actively engage in child feeding practices. the practical significance of the research results is twofold: i) the adoption of the family-centered care method will serve as a guideline for midwives, nurses, and health cadres, highlighting the importance of family involvement in child care; ii) the family-centered care method can serve as an effective approach to modifying child feeding practices. limitation of this study is that respondents may not have provided accurate information about their children’s feeding practices due to social desirability bias. data collection techniques involving questionnaires require mothers to recall their children’s feeding practices from previous periods, which may lead to forgetting, potentially influencing current feeding practices. it is suggested that future research on feeding practices employ direct observation methods to obtain a more accurate understanding of children’s feeding practices. this research demonstrates that the child care model involving the family has been effective in improving child feeding practices, consistent with previous findings linking family involvement to the provision of complementary foods.16 methods of care or other interventions aimed at improving and enhancing children’s feeding practices should be explored further to ensure children’s nutritional needs are met and to prevent stunting.6 conclusions the development of family-centered care methods has proven effective in changing children’s feeding practices. differences in feeding practices between the intervention group and the control group were observed. family-centered care methods have the potential to alter children’s feeding practices. the more families are involved in the parenting process, the better children’s needs are met. health workers, midwives, or nurses should educate not only mothers or caregivers but also husbands or other family members within a household about child feeding practices. familybased educational activities can be implemented before children reach 6 months of age. midwives, nurses, or health cadres in the village should provide facilities to mothers experiencing difficulties with feeding practices through whatsapp or during counseling events in the village. references 1. marah has em, efendi f, wahyuni sd, et al. women’s empowerment and sociodemographic characteristics as determinant of infant and young child feeding practice in indonesia. curr res nutr food sci 2022;10:607–19. 2. indriyani d, yunitasari e, efendi f, et al. the analysis of maternal characteristics and regulation of antenatal care on pregnancy risk status based on the independent family health evaluation. asia pacific j heal manag 2023;18:1–10. 3. kishino m, hida a, chadeka ea, et al. association between diet quality and risk of stunting among school-aged children in schistosoma mansoni endemic area of western kenya: a crosssectional study. trop med health 2024;52:12. 4. maulina r, qomaruddin mb, prasetyo b, et al. the effect of stunting on the cognitive development in children: a systematic review and meta-analysis. 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(pp.35-46). publisher: percetakan bandar di lamgugob banda aceh. 2022. 25. syam a, musni m, amin an, iskandar i. potential loss among infant feeding options. j ners 2021;16:74–80. 26. susan am. patient family – centered care ini the ambulatory surgery setting. journal of perianesthesia nursing 2013;24:244-6. 27. mcguire sl, eigsti dg. family-centered approach to community health nursing practice. in: comprehensive community health nursing, family, aggregate, & community practice. ed.v (hal.158 – 232) missouri: mosby.; 2013. 28. community research p and et. putting family-centered care philosophy into practice. centre for addiction and mental health.; 2014. 29. campoy c, campos d, cerdó t, et al. complementary feeding in developed countries: the 3 ws (when, what, and why?). ann nutr metab 2018;73:27–36. 30. boswell n. complementary feeding methods—a review of the benefits and risks. int j environ res public health 2021;18(13). 31. benjasuwantep b, chaithirayanon s, eiamudomkan m. feeding problems in healthy young children: prevalence, related factors and feeding practices. pediatr rep 2013;5:38. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11964] [page 457] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11952 the administration of sea hare gonad and moringa leaf formula increases body weight hemoglobin in female wistar rats wiralis,1 suwarni,1 hariani,1 askrening,2 nadimin3 1department of nutrition, health polytechnic of the ministry of health, kendari; 2department of midwifery, health polytechnic of the ministry of health, kendari; 3department of nutrition, health polytechnic of the ministry of health, makassar, indonesia abstract sea hare gonad and moringa leaf contain essential nutrients for growth and tissue formation and have physiological effects on the body. the research was to study the effects of sea hare gonad flour and moringa leaf flour formula on body weight and hemoglobin (hb) levels in female wistar anemic rats. this research was conducted in a laboratory using a randomized control pretest-posttest design. the study sample consisted of 30 female wistar rats (rattus norvegicus) aged 5-7 months and weighing 100-150 g, all of which were anemic. the rats were divided into five treatment groups: k+ received 1.1 mg/week of iron supplementation, kreceived no treatment, f1 received 3 g of sea hare gonad formula, f2 received 3 g of sea hare gonad formula and 1 g of moringa leaf flour, and f3 received 3 g of sea hare gonad formula and 2 g of moringa leaf flour. the intervention lasted for 24 days, and measurements of body weight and hb levels were taken before and after the intervention. the change in body weight before and after the intervention in each group was as follows: k-=51.5±17.1 g, k+=-41.2±2.6 g, f1=14.3±5.7 g, f2=30.4±8.6 g, and f3=55.1±16.2 g. there was a significant difference in the increase in body weight among the groups (p=0.002). hb levels also increased after the intervention, with changes as follows: k-=-2.56±0.95 g, k+=9.10±1.87 g, f1=7.10±1.2 g, f2=8.68±0.22 g, and f3=8.98±2.7 g. there was a significant difference in the increase in hb levels among the intervention groups (p=0.000). the administration of sea hare gonad formula and moringa leaf flour can increase body weight and hb levels in female anemic rats. this finding suggests the potential use of these ingredients as beneficial nutritional supplements to improve nutritional status in individuals with anemia. introduction low hemoglobin (hb) levels are a significant global health issue, particularly in developing countries.1 anemia, often caused by iron deficiency, can impair physiological functions and reduce quality of life. various efforts have been made to address this issue, one of which is the use of natural supplements.2 recent research highlights the potential of natural ingredients such as sea urchin gonad (deadema setosum)3 and moringa leaves (moringa oleifera) in increasing hb levels due to their rich nutritional content.4 sea urchin gonads are known to contain proteins, vitamins, and minerals essential for blood health. recent studies report that sea urchin gonads have a positive effect on hb levels in test animals.5 on the other hand, moringa leaves are a high source of iron and other vitamins and minerals. previous studies have shown that moringa leaves effectively increase hb levels in anemic rats.6 the primary issue in this study is how to increase hb levels in anemic female wistar rats. nutritional deficiencies like iron deficiency can impair physiological functions. a common solution that has been widely applied is the administration of synthetic iron supplements. however, the use of these supplements often comes with side effects such as gastrointestinal irritation. correspondence: nadimin, department of nutrition, health polytechnic of the ministry of health, makassar, indonesia. tel.: 08124241003 e-mail: nadimin@poltekkes-mks.ac.id key words: gonad, moringa leaf, body weight, hemoglobin. contributions: wr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; nd, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; sw, conceptualization, methodology, formal analysis, validation, and writing; hr, methodology, visualization, writing – review & editing; sr, resources, investigation, and writing –review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of medicine, hasanuddin university, based on ethical certificate 383/un 4.6.4.5.31/pp36/2023. during the research, the researcher pays attention to the ethical principles of respect for animal rights, beneficence and nonmaleficence. patient consent for publication: this research uses non-human subjects. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank poltekkes kemenkes kendari for preparing this research fund and uho fk animal laboratory partners, fk-unhas ethics commission for their valuable insights and contributions to this study. received: 12 october 2023. accepted: 26 june 2024. early access: 8 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11952 doi:10.4081/hls.2024.11952 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11952] [page 667] non -co mmerc ial us e o nly as an alternative, the use of natural supplements rich in iron and other nutrients is the focus of this study. a flour formula combining sea urchin gonads and moringa leaves is expected to be an effective supplement to increase hb levels without significant side effects. a study by setiawan et al. (2019) showed that moringa leaf extract could increase hb levels in anemic rats.7 sea urchin gonads, although less commonly used in traditional medicine, are known to have high nutritional content, including proteins, omega-3 fatty acids, and other essential minerals that support blood health. consumption of sea urchin gonads can increase hb levels in experimental rats.8 several studies have proven that moringa leaves can increase hb levels in anemic subjects.9-11 however, few studies have explored the effects of combining moringa leaves with sea urchin gonads. existing studies focus more on the use of each ingredient separately. therefore, there is a gap in the literature examining the effectiveness of these combined ingredients as a hb-boosting supplement. female wistar rats were chosen for this study due to their welldocumented physiology and hormonal cycles, which are relevant to understanding anemia, particularly in females. their consistent response to experimental conditions and manageable size make them ideal for controlled laboratory studies. the scientific objective is to assess the efficacy of a sea urchin gonad and moringa leaf flour formula in raising hb levels, which is crucial for predicting its potential in human treatments. this relevance to human biology lies in the similarity of iron metabolism and erythropoiesis processes between wistar rats and humans, offering insights before human trials. this study aims to evaluate the effectiveness of a flour formula combining sea urchin gonads and moringa leaves in increasing hb levels in female wistar rats. the novelty of this research lies in the use of the combination of these two natural ingredients, which has not been extensively explored in previous scientific literature. the results of this study are expected to provide an effective natural supplement alternative to combat anemia with minimal or no side effects. the scope of the research includes a comparative analysis between the control group and the groups given the flour formula, with hb levels as the main parameter. materials and methods type and research design this research is an experimental study using female rattus norvegicus rats with a pretest-posttest randomized control design. the research groups were randomly divided into five groups using simple random sampling. the treatment and intervention for each group were carried out for 24 days. one day before and after the intervention (day 25), body weight and hb levels were measured. hb levels were also measured on day 12. sample the research sample used female rattus norvegicus rats aged 5-7 months, weighing 100-150 g, and healthy (not disabled and exhibiting normal activity). the sample size was determined using cohen’s table, considering research ethics and effect size (0.8), resulting in a minimum sample size of 5 rats/group. a total of 25 rats were divided into 5 treatment groups, with each group consisting of 5 rats: positive control (k+) received fe equivalent to 1.1 mg fe/week. negative control (k-) did not receive any nutritional support other than normal feed. formula 1 (f1) received 3 g of sea urchin gonad flour. formula 2 (f2) received 3 g of sea urchin gonad flour + 1 g of moringa leaf flour. formula 3 (f3) received 3 g of sea urchin gonad flour + 2 g of moringa leaf flour. sample selection for each group was done using simple random sampling by numbering the rats from 1-25, writing the numbers on paper strips, rolling them up, placing them in a container, and mixing them several times. five rolled papers were drawn at each stage, and the sequence of numbers drawn represented the sample group. this process was repeated five times, resulting in 25 rats divided into 5 groups. sample treatment pre-treatment before treatment, all samples (wistar rats) were weighed and adapted for one week. the adaptation process used standard cages, food, and drink. the cages used were conventional plastic cages with wire covers, measuring 100x80x20 cm. five wistar rats were allocated to each cage. the cages were cleaned daily before feeding. room temperature and humidity were monitored and maintained between 20-25°c and 40-60%, respectively. the room was equipped with ventilation and lighting to stimulate the day-night cycle. pellet feed (ad2 brand) was given twice daily (morning and evening), 15 g/day. water was provided ad libitum using 70-80 ml plastic bottles, cleaned daily. the laboratory was specially designed for animal research, with minimal external activity, and managed by two lab technicians and a supervisor. interaction with humans and other animals was minimized to avoid stress on the samples. treatments considered stress and pain from procedures like weighing and blood sampling, performed by skilled and experienced technicians. sample health was continuously monitored. initial treatment (pre-test) initial treatment was done to induce anemia in the rats using aluminum sulfate for 7 days. on day 8, initial weight and hb levels were measured. the rats were kept in the same cages as during adaptation. intervention implementation during the intervention process, the rats were placed in the same cage as in the previous process. the intervention was carried out for 24 (twenty-four) days through feeding according to the group. feeding was done using a sonde 4 times a day, namely the positive control group (k+) was given fe equivalent to 1.1 mg fe/week, the negative control group (k-) received no nutritional support other than normal feed, formula group 1 (f1) was given 3 g of gonad flour, formula group (f2) was given 3 g of gonad flour + 1 g of moringa flour, and formula group (f3) was treated with 3 g of gonad flour + 2 g of moringa flour. on day 12, blood was taken and on day 25, body weight was measured and blood was taken for hb examination. materials and methods the formula was made from sea urchin gonad flour obtained from the coastal area of soropia, southeast sulawesi. the formula was made using 1080 g of gonad flour and 120 g of moringa leaf flour for f1, 240 g for f2, and 360 g for f3. fresh gonads were removed from the shell, steamed for 5 minutes, dried using an electric oven at <100°c for 5 hours, ground with a warning blender, article [page 668] [healthcare in low-resource settings 2024;12:11952] non -co mmerc ial us e o nly and sieved with a 100 mesh. moringa leaves were cleaned, airdried for <5 hours, dried using an electric oven, ground with a warning blender, and sieved with a 100 mesh. the nutritional content of the intervention materials was as follows: formula f1 2.87% moisture, 6.2% ash, 50.2% protein, 47% carbohydrates, 26.8% fat, 17.1 mg/100 g iron, and 0.73 mg/100 g zinc; formula f2 4.1% moisture, 6.7% ash, 50.9% protein, 43.6% carbohydrates, 22% fat, 17.5 mg/100 g iron, and 0.6 mg/100 g zinc; formula f3 5.6% moisture, 7.4% ash, 48.3% protein, 49.3% carbohydrates, 20.3% fat, 19 mg/100 g iron, and 0.53 mg/100 g zinc. data collection data collected in this study included hb levels and body weight measured three times: at the beginning, middle, and end of the intervention. hb levels were measured using the cyanmethemoglobin (drabkin’s) method. blood samples for hb measurement were taken from the rats’ ears and analyzed in the animal research laboratory of the faculty of medicine, haluoleo university. body weight was measured using a digital scale with a 0.1-gram scale. the procedure for checking hb levels using the cyanmethemoglobin (drabkin’s) method is as follows:7,12 i) ensure that the drabkin solution is ready and in good condition drabkin’s solution is generally clear in color; ii) draw blood from the patient using an ethylenediaminetetraacetic acid (edta) tube to prevent coagulation; iii) pipette 20 µl (0.02 ml) of blood into a test tube containing 5 ml of drabkin’s solution ensure complete mixing by gently swirling the tube; iv) leave the blood sample and drabkin’s solution mixture for 5-10 minutes at room temperature during this time, the hb in the blood will react with the components in the drabkin solution to form stable cyanmethemoglobin; v) switch on the spectrophotometer and set the wavelength at 540 nm, calibrate the spectrophotometer using a blank containing drabkin’s solution without a blood sample, measure the absorbance of the sample solution that has been mixed with drabkin’s solution; vi) calculate the hb concentration using the formula: haemoglobin concentration (g/dl) = (sample absorbance : standard absorbance) × standard concentration (g/dl). data processing and analysis measurement and examination data were inputted and processed through the statistical package for social sciences (spss) for window. data on body weight and hb levels are presented as numerical data so they are presented using mean and standard deviation values. data analysis was performed using statistical tests, namely the two-sample paired t-test to assess the effect of the intervention on body weight and hb levels between before and after the intervention in each group. one-way anova test was used to analyze differences in changes in baseline, final, and intergroup hb levels, as well as baseline weight, final weight, and intergroup changes. data analysis used 5% alpha (α=0.05). ethical recommendations all stages of this research will be carried out after obtaining ethical recommendations from the health research ethics commission (kepk) faculty of medicine, hasanuddin university number: 383/un 4.6.4.5.31/pp36/2023. results body weight table 1 shows a significant increase in body weight of rats between before and after the intervention, especially in each group, namely k+ (p=0.002), k(p=0.009), f1 (p=0.012), f2 (p=0.016) and f3 (p=0.006). anova test results showed there was a difference in the increase in body weight between groups (p=0.000). the highest increase in rat body weight was obtained by group f3, which was 55.1 g. hemoglobin level table 2 shows that each treatment group had relatively similar initial hb levels (p=0.628). the hb level of rats increased significantly between before and after the intervention in each treatment group, both group k(p=0.004), group k+ (p=0.002), group f1 article [healthcare in low-resource settings 2024;12:11952] [page 669] table 1. body weight (g) of rats between, before, and after the intervention. group n before after sig* weight change (mean ± sd) (mean ± sd) (mean ± sd) k+ 4 117.4±3.7 168.9±5.6 0.002 -41.9±15.2 k 4 148.4±5.8 106.4±11.2 0.009 51.5±17.1 f1 4 125.6±4.5 139.9±8.1 0.012 14.3±5.7 f2 4 129.1±2.2 159.4±9.9 0.016 30.4±8.6 f3 4 141.4±3.9 196.5±19.3 0.006 55.1±16.2 sig** 0 0 0.002 *two-sample paired t-test;**one-way anova test; sd, standard deviation. table 2. hemoglobin level (g/dl) of rats between, before, and after intervention. group n before after sig* weight change (mean ± sd) (mean ± sd) (mean ± sd) k 4 6.4±1.4 3.8±0.54 0.004 -2.56±0.95 k+ 4 5.6±1.1 14.7±0.78 0.002 9.10±1.87 f1 4 6.5±1.0 13.26±0.28 0.000 7.10±1.2 f2 4 5.5±0.6 14.17±0.51 0.000 8.68±0.22 f3 4 5.9±1.0 14.85±2.2 0.007 8.98±2.7 sig** 0.628 0.000 0.000 *two-sample paired t-test;**one-way anova test; sd, standard deviation. non -co mmerc ial us e o nly (p=0.000), group f2 (p=0.000) and group f3 (p=0.007). the results of the anova test showed that there were differences in the increase in body weight between groups (p=0.002). the highest increase in rat body weight was obtained by group f3, which was 10.0 g. figure 1 shows that each group had relatively similar initial hb levels. each group experienced an increase in hb levels during the intervention, except for group kwhich continued to experience a decrease in hb levels during the intervention. the highest final hb levels were obtained by group f3 (14.85 g/dl), group k+ (16.65 g/dl), group f2 (14.17 g/dl) and f1 (13.26 g/dl). discussion we found that the administration of the sea urchin gonad and moringa leaf flour formula can increase the body weight of anemic rats, particularly in group f3, which received 3 g of gonad flour and 2 g of moringa leaf flour (p=0.006). the average weight gain in the f3 group reached 10.0±2.9 g. the weight gain in the f3 group was significantly higher compared to the control group and other treatment groups (p=0.000). this finding supports previous research using supplementary food products with either gonad flour, moringa leaf flour, or a combination of both. the results of this study reinforce previous findings, both those using supplementary food products with a mixture of sea urchin gonad flour or moringa leaf flour, and a combination of both. the intervention in the form of bagea gonad supplementary food can increase the body weight of bajo children.13 interestingly, the weight gain from the bagea gonad intervention group was higher compared to those consuming biscuits from the government program. previous studies found that the intervention with moringa-enriched gonad cookies as supplementary food could increase the body weight of malnourished children. the weight gain in the gonad intervention group was higher compared to the government program biscuits and moringa biscuits intervention groups.14,15 the setosum gonad extract can enhance immune function, as indicated by increased immunoglobulin m (igm) antibody production.16 this made the f3 group healthier and experienced less illness compared to other groups, leading to better growth. gonads contain essential nutrients such as amino acids and essential fatty acids. the highest fatty acids content includes palmitic acid and omega-9.17 amino acids and essential fatty acids play a crucial role in growth and tissue maintenance, facilitating the formation of new tissues and the maintenance of existing tissues.18 this condition resulted in higher body weight growth in the f3 group compared to other groups. the use of moringa leaves can increase hb levels. for instance, consuming 2100 mg/day of moringa leaf powder for 30 days increased hb levels by 1.76±0.8 g/dl in adolescents.19 different research reports have also shown that the administration of moringa leaf extract alone increased the average hb level by 1.19 g/dl. similarly, the administration of a mixed formula of moringa leaf powder capsules and sweet orange juice in post-menstrual adolescents increased the average hb level from 11.27±1.14 to 12.72±1.35.20 moringa leaves contain high levels of iron and vitamin c. each 100 g of the formula contains 17.5-19 mg of iron. adding moringa leaves to this formula potentially increases vitamin c levels. vitamin c consumption can enhance iron absorption and bioavailability.21,22 several previous studies have shown similar results. the administration of moringa leaf extract can increase the hb level of adolescent girls aged 17-24 years.20 the results of research on high school students 12-18 years old with mild anemia in takalar, south sulawesi showed an increase in hb levels of 1.1 g/dl.23 the results of moringa leaf extract intervention are more visible in anemic targets. yulina’s 2022 study on high school adolescent girls assessed the effect of giving moringa leaf extract twice a day for 14 days on increasing the hb levels of anemic schoolgirls. the results showed an increase in hb levels by 12.9 g/dl. moringa leaf intervention can help meet the nutritional needs of adolescent girls. moringa leaves are rich in iron, necessary for hb formation, and are also a source of vitamin c, which is essential for enhancing iron absorption in the body.24,25 by incorporating vitamin c, the absorption of iron in the body can be improved, thus helping to increase hb levels.26 adding gonad flour to the moringa leaf flour formula can potentially increase iron absorption and bioavailability as reported.12 article [page 670] [healthcare in low-resource settings 2024;12:11952] figure 1. mean hemoglobin levels in rats during the intervention. non -co mmerc ial us e o nly we found that the gonad and moringa leaf flour formula intervention was as effective as the positive control group (k+). this means that administering the gonad and moringa leaf formula could be an alternative for preventing anemia in adolescent girls, especially in preventing anemia. utilizing local food sources to address nutritional problems will enhance the sustainability of nutritional programs and community self-reliance. although this study was conducted on rats, the results show significant potential for implementation in humans, especially in populations vulnerable to anemia and malnutrition. supplements based on the combination of gonad and moringa leaf flour can be an effective and natural alternative to increase hb levels and body weight in children and adults with nutritional deficiencies. the study has several limitations. firstly, it was conducted on a small sample size of rats, which may not fully represent the variability seen in larger populations. secondly, the study duration was relatively short, limiting the observation of long-term effects and potential side effects of the supplement. additionally, the study was performed on animals, and results may not directly translate to humans without further clinical trials. the specific nutritional environment and controlled conditions in the laboratory also may not accurately reflect real-world scenarios. conclusions this study concludes that administering the f3 formula, a combination of sea urchin gonad (deadema setosum) and moringa leaves (moringa oleifera), for 24 days significantly increased body weight and hb levels in female wistar rats. with its rich nutritional content, this combination shows higher effectiveness compared to formulas containing only one type of ingredient. therefore, further research on humans is recommended to confirm the health benefits of this combination and to develop widely usable supplements for addressing anemia and malnutrition. references 1. suryani d, edwin ve, suyitno s, et al. prevalence and risk factors of underweight for adolescent in indonesia: a cross-sectional from global school-based student health survey 2015. public heal indones. 2020;6:129-37. 2. njagi en, kanui ti ag. hematological effects of moringa oleifera lam. (moringaceae) leaf extract on experimentally induced iron-deficiency anemia in wistar rats. j ethnopharmacol. 2017;20:98-108. 3. zakaria za, balan t, suppaiah v, ahmad s jf. gonad of sea cucumber, stichopus chloronotus improves blood profile in ovariectomized rats. adv pharm bull. 2017;7:405-12. 4. anindita pd, khasanah lu, suprapto h wg. the effect of ethanol extract of moringa oleifera l. leaves on blood glucose levels and the number of erythrocytes in diabetic-induced rats. pharmaciana. 2020;10:34-45. 5. santoso b. pengaruh konsumsi gonad landak laut terhadap kadar hemoglobin pada hewan uji. j mar sci. 2020;45:123-30. 6. ekundina vo, ebeye oa, oladele aa. hepatotoxic and nephrotoxic effects of moringa oleifera leaves extract in adult wistar rats. res j med sci. 2015;5:110-8. 7. chuturgoon aa. moringa oleifera: an updated comprehensive review of its pharmacological activities, ethnomedicinal, phytopharmaceutical formulation, clinical, phytochemical, and toxicological aspects. int j mol sci. 2023;24:2098. 8. yusuf m. efek konsumsi gonad landak laut pada peningkatan kadar hemoglobin tikus. j nutr sci. 2020;50:45-52. 9. tshingani k, donnen p, mukumbi h, et al. effet of a moringa oleifera supplement on iron status and hemoglobin level in preschool children: a randomized placebo-controlled trial. eur j clin nutr. 2020;74:246-54. 10. sánchez-machado di, lópez-cervantes j sr. a novel extract of moringa oleifera leaf improves hematological parameters in anemic patients. j med food. 2017;20:252-7. 11. kumari dj, kumar ss pm. antioxidant and hemoglobin improving effect of moringa oleifera (lam) leaf extract in anemic rats. pharm biol. 2012;50:1104-10. 12. boua gn, gnangoran m. comparative effects between a total aqueous extract and a diet enriched with moringa oleifera leaves in wistar rats with anemia. j nutr sci vitaminol. 2020;66:67-73. 13. banudi l, koro s, anasiru ma, nurmiaty n. the effect of the provision of bagea enriched with sea urchin gonads on weight gain in toddlers of the bajo ethnic. indones j public heal nutr. 2021;2:44-52. 14. hasana ian. pengaruh pemberian cookies tepung daun kelor yang diperkaya gonad landak laut terhadap kenaikan berat badan pada balita. 2023. available from: https://repository.unhas.ac.id/id/eprint/25014/ 15. popoola jo, obembe oo, adewale bd. nutritional and health benefits of moringa oleifera. j med plants res. 2020;14:123-35. 16. salma wo, yusuf i, karo m, banudi l. the effect of sea urchin (diadema setosum) gonad extract on igm and igg antibodies production in balb/c mice infected by salmonella typhi. j gizi klin indones. 2018;14:93. 17. pringgenies d, indrajati rm, djunaedi a. study of nutritional contents of sea urchin gonad from drini beach, gunung kidul, yogyakarta. j kelaut indones j mar sci technol. 2020;13:21927. 18. park jh, lee sy, kim jw. nutritional and functional properties of sea urchin gonad (strongylocentrotus nudus): a comprehensive review. journal mar sci eng. 2020;8:976. 19. taweerutchana r, lumlerdkij n, vannaruemol n, srichairatanakool s. moringa oleifera leaf extract supplementation prevents anemia-induced cardiovascular defects in iron deficient rats. j diet suppl. 2017;14:669-82. 20. fauziandari en. efektifitas ekstrak daun kelor terhadap peningkatan kadar hemoglobin pada remaja putri. j kesehat karya husada. 2019;7:24-9. 21. ahmad j, khan i, blundell r, suleria har. nutritional composition and health benefits of moringa oleifera. j food sci technol. 2021;58:8-17. 22. leone a, spada a, battezzati a, et al. moringa oleifera seeds and leaves: nutritional composition and health benefits. nutrients. 2022;14:430. 23. anwar y, hadju v, samrichar r, et al. kadar hemoglobin pada remaja putri. j kesehat manarang. 2020;6:131-7. 24. kutawa ab, musa dd. moringa oleifera, a potential miracle tree ; a review. j pharm biol sci. 2016;11:25-30. 25. sreelatha s, padma pr. antioxidant activity and total phenolic content of moringa oleifera leaves in two stages of maturity. plant foods hum nutr. 2009;64:303-11. 26. nadimin, hadju v, as’ad s, et al. a comparison between extract moringa oleifera and iron tablet on prevention low birth weight in pregnant mothers in makassar, indonesia. enferm clin. 2020;30:26-30. article [healthcare in low-resource settings 2024;12:11952] [page 671] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12054 exploring the relationship between maternal parenting styles and stunting prevention behaviors in children aged 3-5 years arum dwi ningsih,1 endang yuswatiningsih,2 dwi prasetyaningati2 1faculty of health sciences, universitas bina sehat ppni mojokerto, mojokerto; 2faculty of health sciences, institut teknologi sains dan kesehatan insan cendekia medika jombang, jombang, indonesia abstract indonesia, as a developing country, continues to grapple with various nutritional challenges, with stunting among toddlers being a significant concern. according to nutritional status monitoring data from the past three years, stunting has the highest prevalence compared to other issues such as undernutrition, underweight, and obesity. stunting reflects inhibited growth owing to insufficient nutrient intake. this study aimed to analyze the relationship between parenting styles and behaviors aimed at preventing stunting in children aged 3-5 years. employing a correlational analysis with a cross-sectional research design, the study surveyed 128 respondents. maternal parenting styles were assessed using questionnaires with parameters for authoritarian, democratic, and permissive approaches, while stunting prevention behaviors were evaluated using questionnaires covering cognitive, affective, and conative aspects. analysis revealed that most respondents exhibited a democratic parenting style (52 respondents, 41%), and most demonstrated good stunting prevention behaviors (58 respondents, 45%). the spearman test yielded a p-value of 0.000, indicating a significant relationship. therefore, enhancing parents’ understanding of proper parenting practices is crucial for preventing stunting in children aged 3-5 years. introduction indonesia, as a developing country, continues to face various nutritional challenges.1 among these, stunting in toddlers is a major issue.2 stunting often goes unrecognized in communities where short stature is normalized and height checks are infrequent, making it difficult to identify.3 growth failure typically begins in utero and can persist until at least the age of two. if stunting is not balanced with catch-up growth, it leads to decreased growth, increased risk of illness and death, and impediments to both motor and mental development.4 several factors contribute to the incidence of stunting in children, including maternal factors such as poor nutritional status during pregnancy, short stature, and inadequate parenting, especially regarding feeding practices.5,6 the role of parents, particularly mothers, in caring for toddlers significantly impacts the nutritional intake received by the child.7 therefore, mothers need to understand how to provide balanced nutrition to ensure their toddlers grow healthily and develop appropriately for their age.8 maternal behavior in preventing stunting is crucial.9 research by fildzah et al. in 2020 showed that 46.3% of mothers had poor behavior in preventing stunting.10 this indicates that the eight pillars of stunting prevention behavior—ending open defecation, handwashing with soap, managing drinking water and household food, securing household waste, managing household liquid waste, monitoring pregnant women’s nutrition, feeding infants and children, and monitoring growth—are not being optimally implemented.6,11,12 according to nutritional status monitoring data from the last three years, stunting has the highest prevalence among nutritional problems such as undernutrition, underweight, and obesity. stunting is characterized by impaired growth due to prolonged inadequate nutritional intake. according to kepmenkes correspondence: arum dwi ningsih, faculty of health sciences, universitas bina sehat ppni mojokerto, mojokerto, indonesia. e-mail: arumdn87@gmail.com key words: children, malnutrition, mothers, parenting style, stunting. contributions: and, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ey, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; dp, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research has passed the ethical test with number 028/kepk/icme/ii/2023 by the nursing research ethics commission of the jombang institute for science technology and human scholar medika health. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank the universitas bina sehat ppni mojokerto, institut teknologi sains dan kesehatan insan cendekia medika jombang, and the research respondents at the health center in the working area of kediri regency who have supported the implementation of this research. also, we would like to acknowledge the contribution of mentoring program conducted by the research centre of excellence in advancing community health (reach), surabaya, indonesia. received: 8 november 2023. accepted: 4 june 2024. early access: 18 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12054 doi:10.4081/hls.2024.12054 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 592] [healthcare in low-resource settings 2024;12:12054] non -co mmerc ial us e o nly 1995/menkes/sk/xii/2010, stunting is defined as a z-score of less than -2 sd (stunted) and less than -3 sd (severely stunted).13,14 the world health organization (who) data indicates that indonesia has the third highest prevalence of stunting in the southeast asia region (sear). from 2005-2017, the average prevalence of stunting in indonesian toddlers was 36.4%, with an increase from 27.5% in 2016 to 30.8% in 2018.13 stunting affects children’s intelligence and health into adulthood. children suffering from stunting can experience physical and cognitive impairments, leading to reduced growth.15 if not addressed properly, stunting can lead to weak cognitive abilities, delayed psychomotor development, increased susceptibility to degenerative diseases in adulthood, and a long-term decline in human resource quality.16 stunted children are strongly associated with poor educational achievement, shorter schooling duration, and lower income as adults. they are more likely to grow into adults who are less educated, poorer, less healthy, and more vulnerable to non-communicable diseases. consequently, stunted children are predictors of a nation’s future human resource quality and productive capacity.17 family factors are significant contributors to stunting in children. these include low parental education and income levels, poor parenting, inadequate diet, lack of exclusive breastfeeding, infections, and parents with short stature.18 since late 2017, the ministry of national planning and development/national planning and development agency has implemented the “integrated intervention in districts/cities” to prevent stunting. this initiative includes broad multi-sector interventions covering food access, basic health services, clean water and sanitation access, and parenting patterns.19 the family’s role, especially that of the mother in implementing parenting and childcare practices, impacts children’s growth and development. mother’s parenting involves behaviors such as providing breast milk or complementary foods, teaching proper eating habits, providing nutritious foods, controlling food portions, preparing hygienic meals, and ensuring an appropriate diet. these behaviors ensure adequate nutritional intake for children’s growth and development.20 parenting involves actions by caregivers (mother, father, grandmother, or others) to provide food, maintain health, offer emotional support, and fulfill other needs for children’s growth and development, including parental love and responsibility.21 the mother’s role is dominant in nurturing and educating children to grow and develop into quality individuals. proper maternal behavior in breastfeeding, feeding, healthy eating, providing nutritious food, and controlling food portions enhances a child’s nutritional status.22 parenting affects nutritional status because proper growth and nutrition enable children to develop better.13 food plays a critical role in children’s development, with their nutritional needs differing from adults. proper feeding during the golden age periods is crucial for development. a mother’s parenting significantly influences stunting incidence in toddlers since mothers regulate food intake. mothers with good parenting practices tend to have toddlers with better nutritional status than those with less effective parenting.23 research in makassar shows a significant relationship between parenting and stunting in children aged 24-59 months.24 effective parenting includes maternal attention/support in feeding practices, psychosocial stimulation, hygiene, environmental sanitation, and health service utilization. similarly, research in north central timor found a significant relationship between parenting history and stunting, with a 14.5 times higher risk of stunting in children with inadequate parenting compared to those with good parenting.25 based on this context, this study aimed to determine the relationship between maternal parenting practices and stunting prevention behaviors in children aged 3-5 years at the kediri regency health center. materials and methods this study employed a correlational analysis with a cross-sectional research design. the population comprised all mothers with children aged 3-5 in the working area of the kediri regency health center. the sample consisted of 128 respondents, selected using a simple random sampling method. researchers utilized a list of mothers with children aged 3-5. they selected 128 respondents randomly from a pool of 189 potential participants using a method similar to a lottery system. data collection for parenting variables was conducted using questionnaires assessing authoritarian, democratic, and permissive parameters. this questionnaire was validated (p-value <0.05) and demonstrated high reliability with a cronbach’s alpha value of 0.968. for stunting prevention behavior, the questionnaire assessed cognitive, affective, and conative parameters with similar validation (p<0.05) and reliability (cronbach’s alpha =0.962). the researcher developed the questionnaire based on established indicators/parameters. the parenting indicators corresponded to the permissive, democratic, and authoritarian categories, and the questionnaire items were derived from these parenting styles. the study examined two variables: the independent variable, maternal parenting (categorized as permissive, democratic, and authoritarian), and the dependent variable, stunting prevention behavior (categorized as good, sufficient, and lacking). stunting prevention behavior was evaluated using a likert scale across 15 statements, with responses ranging from always to never. scores were allocated from 1 to 4, and the total scores were converted into percentages, categorized as follows: high if the score fell between 76-100%, moderate if the score ranged from 56-75%, and low if the score was <56%. data processing involved editing, coding, scoring, tabulating, and statistical analysis using spearman’s correlation with an alpha level of 0.05. the spearman rank test was chosen due to the ordinal nature of the variables. data analysis was performed using spss version 25. this research was approved by the nursing research ethics commission of the institute of science and health technology insan cendekia medika jombang, with ethical clearance number 028/kepk/icme/ii/2023. results table 1 shows the frequency distribution of respondents based on the mother’s age. most respondents are aged 26-30 years, with 43 people (34%). most mothers have a high school education, accounting for 48 people (37%). most mothers are housewives, with 58 people (45%). regarding the sex of the respondents’ children, most respondents have sons, totaling 76 (59%). most respondents have children aged 4 years, with 53 people (41%). additionally, most mothers practiced a democratic parenting style, with 52 people (41%), and stunting prevention behavior was categorized as good for 58 people (45%). based on the statistical analysis results in table 2, stunting prevention behavior is categorized as good among those with a democratic parenting style, with 33 people (63%). the analysis using the spearman correlation test yielded a p-value of 0.000, indicat transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12054] [page 593] non -co mmerc ial us e o nly ing a significant relationship between stunting prevention behavior and maternal parenting style at the health center in kediri regency. discussion the study results showed that most mothers (63%) practiced a democratic parenting style, with 33 respondents. this finding aligns with the research conducted by nuraeni et al. (2022), which also found that most respondents (94.6%) used a democratic parenting style20. democratic parenting positively impacts normal nutritional status. this is because parents in democratic households set expectations and guidelines, particularly regarding food. they tend to explain the reasons behind these rules, ensuring that children understand and follow them during meals.26 good parenting is democratic parenting. parents who practice democratic parenting positively influence their children’s eating behavior. eating behavior is a person’s response to food as a vital necessity of life. when a child’s eating behavior is good, their nutritional needs are met, leading to ideal growth and reducing the risk of stunting or other nutritional problems. parents who use democratic parenting tend to encourage their children to be independent while providing boundaries and control.4 democratic parenting has a positive impact because parents recognize and nurture their child’s abilities. children are given opportunities to be independent and not overly reliant on their parents. parents are always open to their children’s opinions and desires, prioritizing rational thoughts and interests.27 in terms of providing nutrition, democratic parents offer a food menu that meets children’s nutritional needs while allowing them the freedom to choose their food. these parents encourage their children to eat without issuing commands and provide ongoing support. democratic parenting is considered the best and healthiest because parents control the types of food their children eat, manage their children’s weight, regulate their emotions during meals, and encourage children to regulate their own intake under parental supervision. good communication is key in implementing democratic parenting. parents typically praise their children for positive actions, teach them to be independent and responsible, and show love.28 the results revealed that most respondents exhibited good stunting prevention behavior, totaling 58 people (45%). education is among the factors influencing parental behavior in stunting prevention, with 48 respondents (37%) having a high school education. maternal education serves as a significant predictor of child stunting. mothers with higher education levels possess enhanced cognitive abilities, are more receptive to information from various sources, and demonstrate greater adaptability in applying health knowledge to parenting. improved literacy and numeracy skills acquired through education empower women to recognize diseases, seek appropriate treatment for their children, comprehend medical instructions, and administer treatment effectively. moreover, increased years of schooling enhance women’s receptivity to modern medicine.29 higher education is associated with greater knowledge, which translates to improved childcare practices. a mother’s educational attainment correlates with her understanding of healthcare, pregnancy, postpartum care, and child health and nutrition awareness.30 another influential factor in the incidence of stunting is the mother’s age. most respondents were within the 26-30 age range, comprising 43 individuals (34%). mothers in the young adult category typically possess the physical and psychological maturity necessary for childcare. children born to mothers in adulthood face a lower risk of stunting compared to those born to teenage or older mothers. adult mothers are better equipped to absorb knowledge, exhibit greater maturity in their thought processes, and consequently, are more adept at implementing effective parenting practices. as a result, children of adult mothers are less susceptible to stunting than their counterparts born to teenage or older mothers.26 the employment status of mothers significantly influences the incidence of stunting. in this study, most mothers were housewives, totaling 58 individuals (45%). being a housewife provides mothers with more time to dedicate to their children’s growth and development around the clock. consequently, mothers who do not transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondents. characteristics of respondents frequency percentage (f) (%) mother's age 21-25 years 28 22 26-30 years 43 34 31-35 years 36 28 36-40 years 21 16 mother's education elementary school 34 27 junior high school 28 22 senior high school 48 37 college 18 14 mother's job housewife 58 45 private staff 32 25 farmer 38 30 child's gender male 52 41 female 76 59 child's age 3 years 34 27 4 years 53 41 5 years 41 32 parenting style democratic 52 41 permissive 40 31 authoritarian 36 28 stunting prevention behavior high 58 45 moderate 50 39 low 20 16 total 128 100 table 2. analysis of stunting prevention behavior and mother's parenting style. stunting preventive behavior parenting high moderate low total style f % f % f % f democratic 33 63 19 37 0 0 52 permissive 23 58 5 12 12 30 40 authoritarian 2 6 26 72 8 22 36 total 58 45 50 39 20 16 128 spearman’s rho of p=0.000. [page 594] [healthcare in low-resource settings 2024;12:12054] non -co mmerc ial us e o nly work outside the home tend to be more attentive to their child’s development. this finding is consistent with prior research indicating that working mothers may exhibit poorer parenting practices due to limited time spent with their children.31 in some low-income households, mothers may juggle earning a livelihood with household responsibilities. this dual role reduces the time and attention available for childcare. as a result, the mother’s employment status directly impacts the parenting style employed with the child.32 parenting encompasses methods of interaction, communication, ethical application within the family, and the cultivation of discipline in children.33 within the framework of democratic parenting, parents afford children the autonomy to select foods they prefer, while still offering guidance and choices aligned with balanced nutrition. a mother’s adoption of a democratic parenting style with her young child often signifies nurturing and support, thereby positively influencing the child’s nutritional status. maternal behaviors such as breastfeeding, providing healthy meals, offering nutritious foods, and controlling portions play pivotal roles in enhancing children’s nutritional status.34 indeed, a mother’s parenting style significantly influences various aspects of children’s growth and development, encompassing interactions, growth, and the inculcation of values and morals. mother’s parenting practices significantly influence the incidence of stunting by encompassing how mothers utilize their knowledge and skills to ensure food processing meets nutritional requirements, implement a clean and healthy lifestyle, and monitor child health.36 the correlation between democratic parenting and stunting prevention behavior categorized as good underscores the emphasis of democratic parenting on granting children opportunities for exploration within the framework of parental supervision and guidance. parents continue to educate and guide children on the importance of balanced nutrition for optimal growth and development and adopting a clean and healthy lifestyle. research indicates a correlation between democratic parenting and stunting prevention behavior categorized as good. this finding can inform government programs aimed at preventing or reducing stunting in indonesia. one such program is the “integrated intervention in districts/cities” initiative by the ministry of national planning and development, which includes the enhancement of specific program services related to the health sector, such as providing high-calorie, protein-rich, and micronutrient-dense supplementary feeding, and improving children’s health services.13 in this context, mothers play a crucial role in ensuring proper care for their children. they are responsible for ensuring adequate nutritional intake and regulating their children’s lifestyle within their environment. by adopting democratic parenting practices, mothers are expected to exhibit optimal stunting prevention behavior, thereby facilitating optimal growth and development in children according to their age. conclusions the research findings reveal a significant relationship between maternal parenting and stunting prevention behavior among children aged 3-5 in the kediri regency, indonesia. these results are poised to enhance respondents’ comprehension regarding the criticality of adopting appropriate parenting practices and implementing stunting prevention behaviors to mitigate stunting in children. moreover, the study outcomes are anticipated to serve as fundamental data for informing governmental policy deliberations aimed at reducing stunting rates in indonesia. future research endeavors should delve deeper into exploring additional factors influencing maternal behavior in stunting prevention. references 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in 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patimah s. hubungan pola asuh ibu terhadap derajat stunting pada balita usia 24-59 bulan di desan tanjungsari. j midwifery inf 2022;3:53. 28. nita s. the relationship between parenting patterns and disease patterns with the incident of stunting in toddlers 6-36 months at the panyabungan jae community health center, panyabungan district, mandailing regency, christmas 2022. benih : j midwifery 2022;2:50-7. 29. abuya ba, ciera j, kimani-murage e. effect of mother’s education on child’s nutritional status in the slums of nairobi. bmc pediatr 2012;12:80. 30. sari m, rahmi n. faktor-faktor yang mempengaruhi pola asuh orang tua pada anak balita di desa batoh kecamatan lueng bata kota banda aceh. j healthc technol med 2017;3:94. 31. sastria ahmad a, azis a, fadli. analysis of risk factors for the incidence of stunting in toddlers. j heal sci prev 2021;5:10-4. 32. suharto a, wildan m, handayani te. development of stunting prevention behavior model based on health promotion model and social capital in the magetan district. heal notions 2020;4:48-56. 33. pebriani lv, jatnika r, haffas m. relationship between parenting style and parental feeding style in the locus stunting area in west java. proc 1st paris van java int semin heal econ soc sci humanit (pvj-ishessh 2020) 2021;535:773-6. 34. puspita s, aryani hp. pola asuh orang tua terhadap pertumbuhan anak balita. j educ res 2023;2:92-9. 35. pertiwi mr, lestari p, ulfiana e. relationship between parenting style and perceived information sources with stunting among children. int j nurs heal serv 2019;2:273. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 596] [healthcare in low-resource settings 2024;12:12054] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13308 psychoeducation through home care strengthens family coping in elderly stroke rehabilitation aan nurhasanah, yuli mulyanti, sri djuwitaningsih, rosidawati rositawati, eros siti suryati health polytechnic ministry of health jakarta iii, indonesia abstract post-stroke patients undergoing rehabilitation require family assistance to perform their daily activities. the family’s responsibilities as caregivers can create psychological, social, physical, and financial burdens, highlighting the need for coping strategies that enhance the ability of families and caregivers to alleviate these burdens without jeopardizing their health. family caregivers are important in providing psychoeducation to post-stroke rehabilitation patients through home care. the aim of this study was to evaluate the effectiveness of home care in improving family coping strategies for elderly individuals undergoing stroke rehabilitation. a quasi-experimental design was implemented with a prepost-test and control on 64 families, selected by purposive sampling. data were collected using a closed questionnaire and analyzed through t-tests (univariate and bivariate) and multivariate analysis of covariance (mancova). the research results showed significant differences in knowledge before and after being given psychoeducation through home care (p=0.001), with a difference in average value of 0.9183, and family coping scores with a pvalue of 0.035, with a difference in average value of 1.100. providing psychoeducation through home care can significantly enhance family coping mechanisms when caring for elderly patients undergoing stroke rehabilitation. as an independent nursing intervention, psychoeducation, delivered in the context of appropriate home care, plays a crucial role not only in empowering families but also in optimizing the environment for recovery. introduction stroke is one of the diseases that most often causes a decrease in functional abilities in patients, causing severe dependency.1 it has become a global issue, causing 17 million deaths each year, and is estimated to be the leading cause of death and disability in the world by 2020.2,3 stroke is a complex condition that affects both the individual and their environment, including the family who cares for them (family caregiver).4 the family’s responsibilities as caregivers can create burdens, including psychological issues as well as social, physical, and financial challenges.5 thus, there is a need for coping strategies to increase the ability of families and caregivers to reduce the burden without endangering the family’s health in the form of psychosocial support and familycentered psychoeducational interventions.6,7 implementing effective coping strategies to reduce the burden on families of stroke survivors can also be achieved by implementing educational programs and muscle relaxation. this is in accordance with research that stated that education and muscle relaxation programs can reduce anxiety, depression, and the burden of care for caregivers of stroke survivors.8 research regarding the effects of home-based stroke rehabilitation on increasing the functional abilities and independence of stroke survivors has been conducted in several countries, such as denmark,9 thailand,10 and norway,11 with varying rehabilitation models and outcomes. comprehensive stroke treatment to increase independence and minimize dependency in stroke patients can be achieved through a rehabilitation program.12 family and health worker support factors are closely related to patients’ compliance in participating in medical rehabilitation activities after experiencing a stroke.13 in addition, providing health education through exercise and utilizing multimedia resources, along with family support, facilitates this process. this is because, with the development of information correspondence: aan nurhasanah, health polytechnic ministry of health jakarta iii, jakarta, indonesia. e-mail: annur140864@gmail.com key words: elderly; family coping; psychoeducation; home care; stroke rehabilitation. contributions: an, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ym, conceptualization, investigation, methodology, validation, review & editing; sd, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; rr, methodology, visualization, writing – review & editing; ess resources, investigation, and writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research was approved by the health research ethics commission, poltekkes kemenkes jakarta iii. during the study, the researchers focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 28 october 2024. accepted: 17 march 2025. early view: 16 may 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13308 doi:10.4081/hls.2025.13308 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13308] [page 13] and communication technology (ict), health education media are becoming increasingly diverse. multi-interactive media are particularly engaging, as they make health education more interesting through the combination of animated images and sound.14,15 the influence of interactive multimedia on students’ ability to understand mathematical concepts demonstrates that such tools positively affect concept comprehension, which is the focus of this research.16 home rehabilitation programs help stroke patients recover skills lost due to their condition.17 these programs aim to optimize the patient’s condition and increase their independence and functional ability in performing basic daily activities while also assisting the patient in adapting socially and mentally. one crucial factor that needs attention is how the family supports the patient. family support encompasses the acceptance and actions of family members, including informational support, assessment support, instrumental support, and emotional support.18 this indicates a relationship between the family’s role in caring for and motivating poststroke patients and the patients’ compliance in participating in rehabilitation.19 effective and adaptive coping strategies can serve a protective role in alleviating distress for families or caregivers. this study aimed to determine the effect of home care on improving family coping in older people undergoing stroke rehabilitation. materials and methods study design the research employs a quantitative approach using a quasiexperimental design with preand post-tests, including a control group. the intervention consists of psychoeducation delivered through multimedia formats such as powerpoint presentations, images, and videos. the educational session lasted for two sessions of 50 minutes each. it began with a pre-test to assess participants’ baseline knowledge, followed by a psychoeducational intervention focused on stroke recurrence prevention and family coping strategies. after the session, a post-test was administered to evaluate knowledge improvement. the results showed a significant increase in knowledge, with an 80% improvement observed. this was followed by family support activities aimed at assisting in the rehabilitation care of stroke patients. study participants the population of this study comprised families who had elderly individuals undergoing stroke rehabilitation through home care and resided in the cakung district community health center area. the total sample included 30 families in the intervention group and 30 in the control group who met the inclusion criteria: stroke rehabilitation patients receiving home care who were able to collaborate, willing to participate as respondents, and capable of reading and writing. the exclusion criteria included families without elderly individuals in stroke rehabilitation, inability to collaborate, unwillingness to participate as respondents, and inability to read and write. variables, instruments, and data collection the independent variables comprised five demographic factors: age, sex, education level, occupation, and relationship with the elderly. the implementation period was from march to june 2022. data collection was carried out preand post-intervention by filling out a questionnaire, namely, before and after the intervention, as well as from the results of observations carried out on family health care (assistance) for elderly people undergoing stroke rehabilitation using an observation book. the data collection method employed a structured questionnaire consisting of multiple-choice items with four response options: strongly agree, agree, disagree, and strongly disagree. the questionnaire included 15 items assessing problem-solving coping, 20 items measuring self-management learning, and 20 items evaluating family burden in caring for elderly individuals undergoing stroke rehabilitation through home care. the research method used pathways of change, part ii table 1. participants’ characteristics (n=60). variable intervention group control group p n % n % age 0.56 ≤60 yrs 24 80 24 80 >60 yrs 6 20 6 20 gender 0.40 man 8 26.7 7 23.3 woman 22 73.6 23 76.7 level of education 0.06 elementary school 5 16.7 7 23.3 junior high school 8 26.7 9 30.0 senior high school 17 56.7 9 30.0 college 0 0 5 16.7 work 0.44 self-employed 5 16,7 3 10 civil servants 0 0 1 3.33 employee 4 13.3 5 16.7 housewife 19 63.3 19 63.3 not working 2 6.7 2 6.7 relationship with the elderly 0.00 child 14 46.7 27 90 grandchild 7 23.3 1 3.33 son-in-law 9 30 2 6.67 [page 14] [healthcare in low-resource settings 2025;13(s2):13308] a preand post-test with a control plan for 30 families selected using purposive sampling. data was collected using a closed questionnaire. data analysis a research instrument was used to collect primary data, which was then analyzed using both descriptive and inferential statistical methods. descriptive analysis was conducted to examine respondent characteristics, including age, gender, education, occupation, and ethnic background. inferential analysis involved t-tests (both univariate and bivariate) to assess differences between groups, along with multivariate analysis using multivariate analysis of covariance (mancova) to evaluate the influence of multiple variables simultaneously. ethical clearance the study received authorization from the dki jakarta health office and successfully passed an ethical review conducted by the jakarta iii poltekkes kemenkes research ethics committee. written informed consent was obtained from all participants in the study. results table 1 presents the distribution of research characteristics for 60 participants, divided into intervention and control groups, with a p-value indicating statistical significance. in terms of age (p=0.56), both groups have an identical distribution, with 80% under 60 years old and 20% over 60, showing no significant difference. gender distribution (p=0.40) is also similar, with women being the majority in both groups (73.6% in the intervention group and 76.7% in the control group). regarding education level (p=0.06), more participants in the intervention group completed senior high school (56.7%), while the control group had a higher proportion of participants with junior high school education (30%) and college education (16.7%). although the p-value is slightly above 0.05, it suggests a possible difference in education levels. employment status (p=0.44) is comparable between groups, with housewives being the largest category (63.3% in both groups), followed by self-employed individuals, employees, and those not working, indicating no significant variation. however, the relationship with the elderly (p=0.00) shows a statistically significant difference. in the control group, the majority of members are children of the elderly (90%), whereas in the intervention group, only 46.7% are children, with a higher representation of grandchildren (23.3%) and sons-in-law (30%). in conclusion, while most characteristics are evenly distributed between groups, the relationship with the elderly differs significantly, suggesting a potential influence on the intervention outcomes. table 2 presents statistical analyses of various scores related to family ability, coping, and stroke rehabilitation knowledge in both intervention and control groups. the family ability score shows a significant improvement in the intervention group (p=0.001), with an increase from 72.97 to 75.25. in contrast, the control group experienced a minimal increase, from 63.50 to 63.78, which was not statistically significant (p=0.634). the score for increased coping also significantly improved in the intervention group (p=0.000), rising from 69.25 to 76.50, whereas the control group showed only a minor increase, from 60.06 to 61.34, which was not statistically significant (p=0.091). regarding ability/skills to improve coping, the intervention group exhibited a statistically significant improvement (p=0.020), while the control group did not. similarly, knowledge of stroke rehabilitation increased significantly in the intervention group (p=0.000), whereas the control group showed little change. discussion family assistance for patients undergoing stroke rehabilitation pathways of change, part ii table 2. multivariate analysis. variable group mean sd 95% ci t p family ability score intervention group 3.39 -3.50 – -1.05 -3.80 0.00 before 72.97 after 75.25 difference -2.281 control group 3.30 -1.47 – -0.91 -0.48 0.63 before 63.50 after 63.78 difference -0.281 increased coping intervention group 6.87 -9.72 – -4.72 -5.96 0.00 before 69.25 after 76.50 difference -7.250 control group 4.15 -2.77 – 0.21 -1.74 0.09 before 60.06 after 61.34 difference -1.281 ability/skills to improve coping intervention -22.812 3.39 -3.67 – -0.32 2.31 0.02 control -0.2812 3.30 knowledge of stroke rehabilitation intervention -7.250 6.872 -8.80 – -3.13 2.28 0.00 control -1.281 4.152 [healthcare in low-resource settings 2025;13(s2):13308] [page 15] is essential due to the complex nature of stroke and its associated challenges. families often face significant challenges, sacrificing time and effort to seek information and support as part of the caregiving and healing process. research on family relationships with elderly individuals shows that the responsibility most often falls on the children. this is largely due to the deep emotional bonds between parents and their children, as well as the sense of duty and obligation children feel toward their aging parents. to ensure the best possible care, families – particularly adult children – can choose to collaborate with skilled nursing facilities. these partnerships can support families in providing high-quality, professional care tailored to their loved ones’ needs. middle-aged adults, in particular, often find themselves in the pivotal role of caregivers as their parents begin to experience the challenges of aging.20 a study has also shown that families caring for post-stroke elderly individuals recovering from a stroke must adapt holistically, encompassing biological, psychological, social, and spiritual aspects.21 family, as a source of social support, can be a key factor in implementing stroke rehabilitation. one study found a relationship between family support and the independence of stroke patients;22 if family support is strong, the respondent will be more independent. family plays an important role in providing care, serving as a nursing caregiver for those with vulnerabilities, including all family members affected by physical disabilities, such as chronic illnesses.18 one alternative solution to the problem is through home care activities, as home care is a health service provided continuously and comprehensively to individuals and families in their own environment. this support helps families improve, maintain, or restore health while maximizing independence and minimizing disability due to stroke. the research results illustrate that the p-value is 0.000, which means psychoeducation services through home care significantly influence family coping in caring for the elderly with stroke rehabilitation. this is consistent with previous research, which found that implementing home care can strengthen the role of the family and increase family independence in providing optimal care at home.23 similarly, enhancing the role and responsibilities of family health can boost family independence in caring for post-stroke patients.24 the results provide an overview of the need for family support and the importance of effective strategies to alleviate the burden on families assisting stroke patients during their rehabilitation. previous research states that to encourage caregivers to utilize practical coping skills, appropriate programs must be designed and implemented to support them.25,26 effective use of coping skills to reduce levels of personal burden can improve caregivers’ physical health and psychological well-being.13,7 psychoeducation significantly reduces the burden experienced by caregivers of stroke survivors.27,28 when providing home care for stroke patients, nurses play a crucial role by offering both psychoeducational support and caregiver resources.29 the family, as a primary source of social support, can be a key facilitator in promoting effective rehabilitation in the home setting. early initiation of rehabilitation at home has been shown to reduce disability and enhance quality of life. compared to standard care, home-based stroke rehabilitation is also more cost-effective. however, unresolved family conflicts can worsen the caregiving environment and negatively impact both patient recovery and caregiver well-being. conclusions home care-based psychoeducation demonstrated a measurable impact on the coping strategies employed by families, with notable differences observed between the intervention and control groups. specifically, the intervention group showed a greater average increase in problem-solving coping scores. improvements were also recorded in attitudinal aspects, and a significant difference emerged in stroke rehabilitation activities, particularly in the area of skill development. these findings indicate that providing psychoeducation through home care has a significant effect on enhancing the coping abilities of families caring for elderly individuals undergoing stroke rehabilitation. family-centered health services delivered via home care can help alleviate the burden faced by caregivers. promoting healthy coping mechanisms through structured psychoeducation not only supports the health and recovery of elderly stroke patients but also enhances overall family well-being and productivity. references 1. widarti l, krisnawati k. home care holistic on the change of anxiety and depression for the patient with stroke ischemic. j ners 2012;7:107. 2. rasyidah qa, fitryasari r, wahyudi as. a relationship between stress level and burnout syndrome with sleep quality on clinical nursing students in faculty of nursing universitas airlangga. psychiatry nurs j (jurnal keperawatan jiwa) 2020;2:16–25. 3. machin a, widiawan sp, lefi a, et al. stroke risk factors based on the framingham stroke risk score among urban vs rural elderly communities. mal j med heal sci 2024;20:35–41. 4. camicia m, lutz bj, markoff n, catlin a. determining the needs of family caregivers of stroke patients during inpatient rehabilitation using interview, art, and survey. rehabil nurs 2019;44:328–37. 5. kusumawardani w, yusuf a, ni’mah l. family burden and coping in family caregivers of patientwith schizophrenia. indian j public heal res dev 2019;10:1506–10. 6. herawati c, suwandono a, putra st, et al. effect of psychoeducation-modification on the improvement of spiritual response, perception stigma, anxiety level and cortisol levels among lepers. indian j public heal res dev 2019;10:1873–8. 7. yunita fc, yusuf a, nihayati he, hilfida nh. coping strategies used by families in indonesia when caring for patients with mental disorders post -pasung, based on a case study approach. gen psychiatry 2020;33. available from: https://www.scopus.com/inward/record.uri?eid=2-s2.08 5 0 7 9 6 6 6 5 7 6 & d o i = 1 0 . 1 1 3 6 % 2 f g p s y c h 2 0 1 8 100035&partnerid=40&md5=4e1248e2e33a75dc09f773fe35 3c2d6e 8. wang j, dang w, hui w, et al. investigating the effects of intrinsic motivation and emotional appeals into the link between organic appeals advertisement and purchase intention toward organic milk. front psychol 2021;12. 9. rasmussen rs, østergaard a, kjær p, et al. stroke rehabilitation at home before and after discharge reduced disability and improved quality of life: a randomised controlled trial. clin rehabil 2016;30:225–36. 10. chaiyawat p, kulkantrakorn k. effectiveness of home rehabil pathways of change, part ii [page 16] [healthcare in low-resource settings 2025;13(s2):13308] itation program for ischemic stroke upon disability and quality of life: a randomized controlled trial. clin neurol neurosurg 2012;114:866–70. 11. askim t, mørkved s, engen a, et al. effects of a communitybased intensive motor training program combined with early supported discharge after treatment in a comprehensive stroke unit: a randomized, controlled trial. stroke 2010;41:1697–703. 12. winstein cj, stein j, arena r, et al. guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the american heart association/american stroke association. stroke 2016;47:e98–169. 13. sumakul vdo, notobroto hb, devy sr. coping strategies, self-efficacy, and perception among family caregivers for post-stroke survivors in indonesia. malaysian j public heal med 2022;22:124–30. 14. kustyarini k, utami s, koesmijati e. the importance of interactive learning media in a new civilization era. eur j open educ e-learning stud 2020;5. 15. abdulrahaman md, faruk n, oloyede aa, et al. multimedia tools in the teaching and learning processes: a systematic review. heliyon 2020;6. 16. novitasari d. pengaruh penggunaan multimedia interaktif terhadap kemampuan pemahaman konsep matematis siswa. fibonacci. j pendidik mat dan mat 2016;2:8–18. 17. mayo ne. stroke rehabilitation at home: lessons learned and ways forward. stroke 2016;47:1685–91. 18. friedman mm, bowden vr je. buku ajar keperawatan keluarga teori dan praktik. in: egc. 5th ed. jakarta: egc; 2012. 19. putri utami k, rizky rinanda nur fauziyah a, faradilla rahim a. the relationship between family involvement in physiotherapy home programs and activity daily living in post-stroke patients. kne med 2023. 20. morais d, faria c, fernandes l. filial maturity and caregiving to aging parents. geriatr 2024;9. 21. creasy kr, lutz bj, young me, stacciarini jmr. clinical implications of family-centered care in stroke rehabilitation. rehabil nurs 2015;40:349–59. 22. setyoadi s, nasution th, kardinasari a. hubungan dukungan keluarga dengan kemandirian pasien stroke di instalasi rehabilitasi medik rumah sakit dr. iskak tulungagung. majalahkesehatan 2017;4:139–48. 23. hapsari ma, mubarokah k. analisis kesiapan pelaksanaan rekam medis elektronik (rme) dengan metode doctor’s office quality-information technology (doq-it) di klinik pratama polkesmar. j-remi j rekam med dan inf kesehat 2023;4:75–82. 24. bahadoram s, arsalani n, fallahi-khoshknab m, et al. the principles of home care for patients with stroke: an integrative review. iran j nurs midwifery res 2024;29:503– 14. 25. kazemi a, azimian j, mafi m, et al. caregiver burden and coping strategies in caregivers of older patients with stroke. bmc psychol 2021;9. 26. sawab s, bahrudin m, catharina daulima nh. hopelessness experience among stroke survivor in semarang. j ners 2015;10. 27. putri tark, ramadita w, supriatin e, hayati sn. psychoeducational intervention for family caregiver burden in stroke patients care. risenologi 2022;7:21–5. 28. sudja n, meirina m. psychoeducation intervention increase on the ability of the pre-senile hypertension management. j ners 2017;9:66–73. 29. hanik en, lestari d, laily h, et al. the effect of family psychoeducation therapy on the anxiety level of family of patients with crf undergoing hemodialysis. int j pharm res [internet] 2020;12:1691–6. available from: https://www.scopus. com/inward/record.uri?eid=2-s2.0-85089700697&doi= 10.31838%2fijpr%2f2020.12.04.246&partnerid=40&md5=d f2db9d1e4640cf3a51ed7e4f1533662 pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13308] [page 17] hrev_master healthcare in low-resource settings 2024; volume 12:11949 application of family nursing documentation in tarakan city, indonesia sulidah sulidah,1 windhandini listya hananti2 1faculty of health sciences, universitas borneo tarakan, tarakan; 2sebengkok community health center, the health office of tarakan city, tarakan, indonesia abstract documentation of nursing care is authentic proof of nursing service activities, serving as the basis for fulfilling nurses’ responsibilities and accountabilities. family nursing documentation holds distinct characteristics compared to other nursing practice settings. the indonesian nursing professional organization has established three standards for nursing care: diagnosis, intervention, and outcome. this research aimed to understand how the implementation of family nursing care documentation is conducted by community nurses in tarakan city. the research was a correlational study with a cross-sectional approach. the study population consisted of all the nurses working in community health centers in tarakan city, totaling 80 individuals. the sample was selected using total sampling. the research variables included demographic factors, nurses’ knowledge about the documentation concept, and the application of family nursing documentation; these were measured using a modified researcher-made questionnaire and declared valid and reliable. the analysis of research data used descriptive analysis and the spearman rank correlation test. this research identified that the majority of community nurses in tarakan city did not implement family nursing documentation, and the level of knowledge regarding nursing documentation concepts was low. the spearman’s rank correlation test yielded a pvalue of 0.874, indicating no significant correlation between the level of knowledge and the implementation of family nursing documentation. the inhibiting factors for the implementation of family nursing care documentation primarily included a high workload, a limited number of health center nurses, motivation, and the lack of clear and uniform documentation guidelines. introduction nurses who work full-time require religious support in patient care and professional documentation tools.1,2 documentation is one of the most important responsibilities of healthcare providers, including nurses.3 nursing documentation is a fundamental aspect that nurses must undertake in the nursing process, including family nursing. nursing documentation is the report done by nurses during nursing care, which is important for the patients and nurses.4 documentation serves as evidence of nursing service activities performed by nurses.5 good and correct documentation is an indicator of a nurse’s professionalism.6 factors that affect the quality of nursing documentation include the use of terminology and documentation instruments according to standards.7 community nurses' performance can be assessed by implementing family nursing care, which is transformed into a healthcare document for patients and their families. the absence of documentation does not imply that family nurses did not provide care; however, nurses need authentic evidence of having carried out nursing care without documentation. moreover, the quality of family nursing care is reflected in the comprehensive management of family nursing care plans, aiming to identify successful achievements in family care as clients. fully documented family nursing care serves as a legal aspect in cases of client dissatisfaction with the provided services. effective family nursing care is fact-based, goal-oriented, comprehensive, concise, structured, timely, and eascorrespondence:sulidah sulidah, faculty of health sciences, universitas borneo tarakan, tarakan, indonesia. e-mail: sulidah06@gmail.com key word: family nursing; nursing documentation; nursing standards contributions: ss conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; wlh conceptualization, investigation, validation, and writing – original draft. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of health science, universitas borneo tarakan, based on ethical certificate number 002/kepk-fikes ubt/v/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from research and community service institution, universitas borneo tarakan, with contract number 140/un51.9/kontrak-lt/2021. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to research and community service institution (lppm), universitas borneo tarakan and head of the tarakan city health office for their valuable insights and contributions to this study. received: 21 october 2023. accepted: 18 march 2024. early access: 7 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11949 doi:10.4081/hls.2024.11949 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11949] [page 501] non -co mmerc ial us e o nly ily comprehensible.8 family nursing documentation is recognized as a critical element in ensuring care continuity and facilitating informative decision-making in the future. in providing nursing care, standardization of care is needed, which includes diagnostic standards, outcome standards, clear intervention standards, and standardized terminology, so that nursing care can be uniform, accurate, and unambiguous to guarantee continuity and quality of service.9 several studies indicate that the implementation of family nursing documentation still faces challenges in terms of understanding concepts, standardizing formats, and utilizing information technology. this can impact the quality of documented information and consequently influence informed decision-making in family care. the nursing department often encounters problems regarding the performance of nurses in providing nursing care at the hospital.10 this analysis underscores the need to enhance nurses' knowledge and skills in family nursing documentation while formulating clear, standardized practice guidelines to ensure information integrity and optimal care quality. currently, some standards can be applied in nursing documentation, including the indonesian nursing diagnosis standards, indonesian nursing outcome standards, and indonesian nursing intervention standards issued by the indonesian nursing professional organization, namely the indonesian national nurses association.11 the indonesian nursing diagnosis standards were first published in december 2016, while the indonesian nursing outcome standards and indonesian nursing intervention standards were issued in 2018. these three standards are something new for indonesian nursing and are essential elements that can make it easier for nurses to document nursing care. however, nursing documentation has become an urgent problem almost worldwide in the past few years. the implementation of nursing care documentation in clinical settings is still very low,12 at only 47.8%. similar results were found in research,13 which proved that nurses who carried out nursing documentation with good criteria were still low at 47.5%. obstacles to the application of family nursing care documentation by nurses are influenced by many factors, with the low knowledge of nurses being the main factor.14 the lower the level of knowledge about family nursing documentation standards, the lower the application of family nursing care.15 a study succeeded in identifying 13 out of 30 nurses with insufficient knowledge of nursing care documentation, which greatly affected the application of nursing documentation.16 this condition often occurs in various regions, including the city of tarakan. tarakan city is the most developed area in north kalimantan province, with superior human resources and health service facilities. unfortunately, these conditions are not directly proportional to the implementation of family nursing documentation. based on the experience and observations of researchers on the implementation of family nursing care documentation in tarakan city, it could be more optimal. this is indicated by incomplete documentation of family nursing care, non-standard diagnosis formulations, use of different formats, and even the need for evidence of family nursing care. some nurses admitted that they needed to learn about the indonesian nursing diagnosis standards, indonesian nursing outcome standards, and indonesian nursing intervention standards, even though they had attended related seminars or outreach programs. it is strongly suspected that this condition also occurs in other community health centers (puskesmas). therefore, this study aimed to identify the implementation of family nursing care documentation at the community health center in tarakan city according to applicable standards. therefore, this study aimed to identify the implementation of family nursing care documentation at the community health center in tarakan city according to applicable standards materials and methods research design this research was a correlational study using quantitative methods with a cross-sectional approach. the type of research conducted aims to identify the implementation of family nursing documentation by community nurses and analyze the influencing factors. this study examines the influence of demographic factors, the level of knowledge about the concept of nursing documentation, nurses' experience, and years of service on the implementation of family nursing documentation. study participants the research population consisted of all nurses working in the community setting at the community health center in tarakan city. the population size was 80, comprising 80 nurses. this study utilized the entire population as the sample (total sampling). variable, instrument and data collection the independent variables consist of two variables: demographic factors, which include age ranges of 17-25 years, 26-35 years, 36-45 years, 46-55 years, and 56-65 years; gender (male and female); education in the form of diploma 3 and nursing profession; and years of experience comprising 0-5 years, 6-10 years, and more than 10 years. the second variable is the level of knowledge about nursing documentation concepts, categorized into three levels: good, enough, and not enough. the dependent variable is the implementation of family nursing documentation. the research instruments used were questionnaires and observation sheets, which were previously tested for validity and reliability and were deemed valid and reliable. this research questionnaire was adopted and modified from kurniawati (2019) with a guttman scale consisting of 5 questions about indonesian nursing diagnosis standards, 5 questions about indonesian nursing intervention standards, and 5 questions about indonesian nursing outcome standards. observation sheets were used to identify the implementation of nursing documentation, which covers the 5 steps of the nursing process: assessment, diagnosis, intervention, implementation, and evaluation of nursing. nursing documentation is considered to be implemented if more than 64% of the answers are yes. data analysis the data were analyzed using the spearman rank correlation test. this type of test was chosen based on the categorical data type of the research variables. both variables were considered to have a correlation if the p<0.05. ethical clearance the research has received ethical approval from the health research ethics commission, faculty of health sciences, universitas borneo tarakan, based on ethical certificate number 002/kepk-fikes ubt/v/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 502] [healthcare in low-resource settings 2024;12:11949] non -co mmerc ial us e o nly results the research took place from april to june 2023 and involved all nurses working in community settings at the community health center in tarakan city. there are 6 community health centers in tarakan city, namely karang rejo community health center with 24 nurses, gunung lingkas with 12 nurses, sebengkok with 11 nurses, juata with 15 nurses, mamburungan with 12 nurses, and pantai amal with 6 nurses. the characteristics of the respondents are described in the table below. based on table 1, it was shown that the characteristics of community nurses in tarakan city who are respondents in this study are mostly females within the age range of 26-35 years and 36-45 years, which falls within the productive age group. they generally have a diploma 3 level of education, with a significant portion having more than 10 years of work experience. based on the table above, it is also apparent that only a small portion of the research respondents have a good level of knowledge about nursing documentation. this has an impact on the implementation of family nursing care documentation, where the majority of respondents do not document family nursing care in their practice. based on the data processing results in table 2, an evaluation of the structural model (inner model) was conducted to determine the model's validity. the test results show that the t-statistics value is ≥ t-table (1.96) or the p-value is < significant alpha 5% or 0.05, indicating a significant influence of the independent variables on the dependent variable. the correlation analysis in this study, as shown in the table above, yielded a p-value of 0.847, which is greater than alpha = 0.05. this indicates that there is no significant relationship between knowledge and the utilization of family nursing care documentation. this finding contradicts several widely accepted notions that suggest a strong influence of knowledge on one's actions. typically, a higher level of knowledge is expected to lead to improved actions or behaviors. discussion the research results indicate that community nurses in tarakan city have not yet implemented family nursing care documentation.17 low levels of knowledge are the primary inhibiting factor, while demographic factors have various effects. more women than men occupy the nursing profession. this was proven in this study, which succeeded in identifying nurses working in community settings in tarakan city, most of whom were women. this can be explained through several historical, social, and cultural factors. in many cultures, grooming and caring roles are considered traditional characteristics of women. this is reflected in social norms linking women to caring roles and men to more powerful or technical roles. in addition, gender stereotypes also play a role in influencing career choices. the nursing profession is often perceived as a job requiring gentleness, empathy, and attention to detail, which are characteristics often associated with female stereotypes.18 gender differences are not something that needs to be debated because nursing professional organizations have regulated the rights and obligations of nurses regardless of gender differences. even in the career development of nurses in tarakan city, gender factors are also not considered but instead based on performance. nurses who work in community settings in tarakan city are generally in the productive age range, reflecting a time when individuals have sufficient energy and physical stamina to handle diverse job demands. this demographic group has significant advantages in providing health services to the community, maximizing the efficiency and effectiveness of community health services. nurses in productive age ranges often have broader work experience and good interpersonal skills,19 which help them deal with the many challenges that may arise in community nursing care, including complex and diverse health problems. their mature interpersonal skills enable effective communication, empathy with the communities they serve, building trusting relationships, and providing the support individuals and families need. this study found that most nurses in community settings in tarakan city have a diploma 3 education, which is the lowest formal nursing qualification, unlike those in clinical settings, where various undergraduate levels are evenly distributed. challenges arise in ensuring community nurses understand community health, disease prevention, and health promotion concepts. hence, enhancing competence through continuous education and comprehensive training is essential for them to deliver optimal service. collaborative efforts among the government, professional organizations, and healthcare institutions are crucial in developing educational programs and professional development tailored to public health needs. ong work experience is crucial in shaping nurses' skills in pro transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of research respondents. indicator n % age age 17-25 year 8 10 age 26-35 year 31 38.8 age 36-45 year 38 47.5 age 46-55 year 2 2.5 age 56-65 year 1 1.2 gender man 16 20 woman 64 80 education diploma 78 97.5 bachelor 2 2.5 years of experience 0-5 years 26 32.5 6-10 years 3 3.8 >10 years 51 63.7 knowledge level good 7 8.8 enough 39 48.7 not enough 34 42.5 family nursing documentation applied 10 12.5 not applied 70 87.5 table 2. knowledge correlation analysis and application of nursing documentation. knowledge nursing documentation f p aplied not aplied good 6 1 7 0.847 enough 34 5 39 not enough 30 4 34 [healthcare in low-resource settings 2024;12:11949] [page 503] non -co mmerc ial us e o nly viding nursing care. in tarakan city, community nurses typically boast over ten years of experience. such tenure brings benefits like refined clinical skills, extensive patient management know-how, and a profound grasp of practical nursing. they often excel in interpersonal relationships with patients and families. nonetheless, prolonged tenure may lead to resistance to change and embracing new treatment practices, hindering adaptation to evolving healthcare advancements.20 fear of stepping out of their comfort zone may deter nurses from exploring new approaches or adhering to updated policies, impeding their willingness to enhance their knowledge, including in family nursing care documentation. the implementation of family nursing documentation that does not work can be seen, among other factors, in the documentation that needs to be uniform in format and conform to standards. this phenomenon may indicate a deficiency in training and understanding the importance of adequate documentation in nursing practice.21 this can impact the quality of service and coordination between nurses, patients, and their families.22 differences in the formats and documentation standards nurses use can also hinder proper monitoring and evaluation of the care provided and make it challenging to share the information needed to treat the patient as a whole. when community nurses lack adequate knowledge of family nursing documentation, it can hamper the program's ability to collect consistent and accurate data on public health.23 low-quality documentation can also affect coordination between nurses, patients, and families in planning, implementing, and evaluating care. therefore, efforts are needed to increase nurses' knowledge about family nursing documentation and ensure that documentation practices follow applicable standards. this will support the implementation of a more effective and quality community health program. a person's level of knowledge is influenced by factors such as age, gender, education, and years of service.24 women often exhibit good knowledge absorption25 attributed to their cognitive style. nurse knowledge tends to improve with years of service26 but this contrasts with findings showing low nursing documentation knowledge despite extensive tenures. factors like inadequate training, healthcare changes, and lack of professional support contribute to this discrepancy. family nursing documentation, while similar to other care processes, differs due to care setting variations. nurses need a comprehensive understanding of family nursing principles to effectively address family needs and dynamics.27 the biggest obstacle in documenting nursing care is the need for a greater understanding of the concept of documentation. this misunderstanding can result in errors in recording relevant and essential information for the family. additionally, the lack of technical skills in using the existing documentation system can be an obstacle, such as using software or digital platforms that nurses do not master well. this study highlights the ongoing need for the implementation of family nursing care documentation. despite factors like age and years of service,28 which typically influence nursing practices, they do not positively impact the adoption of family nursing documentation by community nurses in tarakan city. this aligns with previous findings suggesting that age and tenure have minimal influence on the quality of nursing documentation. weaknesses in family nursing documentation include incomplete recording of the nurse's name, initials, and timestamps, crucial elements authenticating nursing actions. while most nurses are expected to adhere to proper documentation practices, some exhibit deficiencies. various factors contributing to this issue in tarakan city include high workload, limited nurse staffing, inadequate understanding of documentation standards, discrepancies between college education and practical experience, low interest in community nursing, inappropriate documentation format changes, and insufficient habits and motivation among nurses. according to this study, extensive knowledge of procedures, formats, and purposes of documentation helps nurses identify relevant information that must be recorded and do so with accuracy.28 good knowledge also allows nurses to avoid errors or discrepancies in data recording, which can improve documentation quality. conversely, a lack of knowledge can lead to negligence in recording important data, reduce the quality and validity of records, and hinder collective understanding of the patient's or client's health.29 variations in nursing documentation methods and formats across different institutions or health service units can hinder the implementation of nursing care documentation. transitioning from one method or format to another can cause confusion and data recording errors among nurses accustomed to a specific approach. challenges in accessing, comprehending, or utilizing new documentation systems may impede nurses from providing accurate and comprehensive information. clear guidelines and sufficient training on the methods and documentation formats, along with considerations of their suitability and user-friendliness, are essential for institutions or health service units to overcome barriers and effectively implement nursing care documentation. nurses' interest in a particular service setting can influence their motivation and the quality of implementing nursing documentation.30 when nurses work in settings where they are less interested, there may be a tendency to neglect or not pay full attention to the documentation process. this can result in a lack of a sense of responsibility and suboptimal engagement in recording accurate and timely data. health center nurses are often burdened with various tasks and functions, such as providing clinical services, health education, community mapping, cross-program, and cross-sector collaboration. notably, some nurses are burdened with time-consuming administrative work and are responsible for managing health programs. on average, health center nurses oversee 25 health center programs. to handle such a high workload, good management support is needed, including the allocation of adequate resources and relevant training31 to ensure that nursing services and documentation are carried out correctly and comply with applicable standards. the high workload for puskesmas nurses often stems from insufficient human resources. effective workload distribution can alleviate nurses' burden. one proposed solution is forming a multidisciplinary team where tasks are delegated based on members' expertise.32,33 including doctors, nurses, nutritionists, and other health workers allows for task allocation according to competence. flexible and fair work schedules are crucial to prevent nurse fatigue from extended hours. puskesmas management should prioritize nurses' work welfare, work-life balance, and provide support for training and skill development to ensure efficient duty fulfillment without excessive workload. in order to ensure that nursing documentation can be adequately implemented in puskesmas, nurses and policymakers need to take concrete steps involving various aspects. according to these studies, two things need to be developed.27,34 first, the development of clear guidelines or standards for nursing documentation that should be followed by all nurses in community health centers is necessary. these guidelines can include formats, types of information to be documented, as well as the frequency and proper documentation methods. second, collaboration between nurses and puskesmas stakeholders in monitoring and evaluating documentation practices is crucial. monitoring can be done through internal transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 504] [healthcare in low-resource settings 2024;12:11949] non -co mmerc ial us e o nly audits or periodic supervision of documentation records. the results of this monitoring can be used as a basis for identifying areas that need improvement and further development. by involving nurses in the evaluation process, they will feel more involved and have a responsibility to maintain the quality of the documentation. this research has limitations in terms of a relatively small population size. although it has covered all levels of community service, it does not consider differences in the workload of community nurses and the level of education of nurses, which is generally a diploma 3. some educational institutions do not include community nursing care in their curriculum, even though in reality, all community nurses have an obligation to provide and document community nursing care regardless of their educational background. conclusions this study found that most of the community nurses in tarakan city needed to document family nursing care. low knowledge about nursing documentation is one of many influencing factors. there are many conditions experienced by nurses that become obstacles in documenting family nursing care, namely: high workload, limited number of puskesmas nurse human resources, differences in documentation methods between practice and college experience, low interest in family/community nursing, changes in the format of nursing documentation that are considered inappropriate, habitual factors, and low motivation. references 1. halimatussakdiah h, arifin h, haryati w, alhuda a, asiah n. shariah models-based on ethics innovation in nursing documentation. j glob pharma technol 2020;12:130–9. 2. supriyanto, hamid ays, rosyada d, mansyur m, efendi f. nurse’s competence in supporting the spiritual-religious needs of patients in indonesia. indian j public heal res dev 2019;10:604–8. 3. wahyuni ed, nursalam, dewi ys, kamel ad. the implementation of theory of planned behavior in identifying behavioral models of nursing documentation in “x” hospital. j int dent med res 2021;14:1694–700. 4. nyarmi, wahyuni ed, ni’mah l. the affecting factors of nurses’ compliance in nursing documentation. int j psychosoc rehabil 2020;24:4098–105. 5. nova scotia college of nursing. documentation for nurses. 2022;1–16. 6. wahyuni ed, nursalam, dewi ys, susiana e, asmoro cp, kamel ad. nurse’s individual factor may influence quality of nursing documentation in the inpatient room. j pak med assoc 2023;73:s88–91. 7. aini nf, nursalam n, widyawati iy, nugroho egz, fadhilah n. the effect standardized nursing terminology education program on quality of nursing documentation: a systematic review. malaysian j med heal sci 2023;19:125–34. 8. schaffer m, strohschein s. public health interventions: applications for public health nursing practice, 2nd ed. 2019;8–248. 9. widodo h, nursalam n, wahyuni ed. analysis of implementation of perioperative care instrument based on standards of nursing diagnosis, intervention and outcomes in indonesia. j ners 2020;15:57–62. 10. nuritasari rt, rofiqi e, fibriola tn, ardiansyah rt. the effect of clinical supervision on nurse performance. j ners 2019;14:161–4. 11. nursalam n, widodo h, wahyuni ed, efendi f. development of perioperative care instruments based on sdki slki siki in operating room. syst rev pharm 2020;11:1029–35. 12. tasew h, mariye t, teklay g. nursing documentation practice and associated factors among nurses in public hospitals, tigray, ethiopia. bmc res notes 2019;12:612. 13. saraswasta iwg, hariyati rts. the implementation of electronic based nursing care documentation to efetec; a literature review. int j nurs heal serv 2018;1:19–31. 14. zwicky a, thaqi q, hediger h, naef r. the influence of nurse characteristics on practice skills and attitudes towards working with families in critical care: a regression analysis. intensive crit care nurs 2022;72:103261. 15. kurniawati a, indracahyani a, yatnikasari a. the analysis of nursing care documentation in outpatient units. int j nurs heal serv 2019;2:89–99. 16. siokal b, keperawatan b. effectiveness of computer-based nursing documentation in nursing care in hospital a literature review. j muslim community heal 2021;2:15–23. 17. british columbia college of nurses and midwives. nurse practitioners and registered nurses: professional standards. bccnm 2020;november:2–19. 18. montañés muro mp, ayala calvo jc, manzano garcía g. burnout in nursing: a vision of gender and “invisible” unrecorded care. j adv nurs 2023;79:2148–54. 19. niyigena a, girukubonye i, barnhart da, et al. rwanda’s community health workers at the front line: a mixed-method study on perceived needs and challenges for community-based healthcare delivery during covid-19 pandemic. bmj open 2022;12:e055119. 20. assunção aá, pimenta am. job satisfaction of nursing staff in the public health network in a brazilian capital city. cien saude colet 2020;25:169–80. 21. thürlimann e, verweij l, naef r. the implementation of evidence-informed family nursing practices: a scoping review of strategies, contextual determinants, and outcomes. j fam nurs 2022;28:258–76. 22. chilton s, bain h. a textbook of community nursing. routledge; 2018. 23. pusa s, isaksson u, sundin k. evaluation of the implementation process of a family systems nursing approach in home health care: a mixed-methods study. j fam nurs 2021;27:235–49. 24. de groot k. notes on nursing documentation: quality criteria and views of nurses and patients. phd thesis, university of amsterdam. 25. swan ma, eggenberger sk. early career nurses’ experiences of providing family nursing care: perceived benefits and challenges. j fam nurs 2021;27:23–33. 26. laitinen h, paavilainen e. the invisibility of the patient’s family in nursing documentation: an integrative review. clin nurs stud 2017;5:54. 27. mileski m, mcclay r, heinemann k, dray g. efficacy of the use of the calgary family intervention model in bedside nursing education: a systematic review. j multidiscip healthc 2022;15:1323–47. 28. oster ca, braaten js, eds. high reliability organizations. a transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11949] [page 505] non -co mmerc ial us e o nly healthcare handbook for patient safety. sigma theta tau international; 2016. 29. kamil h, rachmah r, wardani e. what is the problem with nursing documentation? perspective of indonesian nurses. int j africa nurs sci 2018;9:111–4. 30. rattray j, jones mc. essential elements of questionnaire design and development. j clin nurs 2007;16:234–43. 31. yen py, kellye m, lopetegui m, et al. nurses’ time allocation and multitasking of nursing activities: a time motion study. amia annu symp proc 2018;2018:1137. 32. general department of nursing. family nurse practitioner overview clinical practice guideline. 2021;1–25. 33. quad council coalition competency review task force. community/public health nursing competencies. 2018. available from: https://www.cphno.org/wp-content/ up loads /2020 /08 /qcc-c-phn-competenciesapproved_2018.05.04_final-002.pdf 34. comm a, nuriyanto a, rahayuwati l. family nursing as an improvement strategy of family health index in indonesia: a literature review. asian community heal nurs res 2019;2019:7–7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 506] [healthcare in low-resource settings 2024;12:11949] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12189 the effect of spiritual emotional freedom technique impact to pain in cervical cancer post-chemoradiation: a review article hamidah hamidah,1 syahrul rauf,2 sharvianty arifuddin,2 andi muhammad takdir musba,2 prihantono prihantono,2 nugraha utama pelupessy,2 irfan idris,2 agussalim bukhari,2 andriany qanitha,2 fatimah fatimah,1 elli hidayati,1 tria astika endah permatasari3 1faculty of medicine and health, universitas muhammadiyah jakarta; 2faculty of medicine, universitas hasanuddin, makassar; 3department of nutrition, faculty of medicine and health universitas muhammadiyah jakarta, indonesia abstract chronic pain that is subjective is experienced by patients with advanced cervical cancer. simple movements are used in spiritual emotional freedom technique (seft) therapy, a therapeutic approach that improves performance and achievement, addresses psychological and physical pain issues, and promotes happiness and serenity in life. in this systematic review study, we evaluate how seft affects patients with cervical cancer who have had chemotherapy and radiation treatment. using databases from 2003 to 2023, including google scholar, pubmed, sciencedirect, psycinfo, and ovid, this study employs a systematic review methodology. the keywords “spiritual emotional freedom technique (seft)”, “emotional freedom technique (eft)”, and “cervical cancer” form the basis of the search strategy. experiments and observational studies with a minimum sample size of two participants involving patients with cervical cancer meet the inclusion criteria. the results show that among patients with postchemoradiation cervical cancer, seft therapy is beneficial in lowering pain, stress, and depression. cancer patients who experience pain may see a reduction in their quality of life as well as physical health issues. cervical cancer patients can experience marked improvements in their pain, stress, and depression when the seft therapy theory is applied. introduction most cases of cervical cancer are caused by infection with human papillomavirus (hpv) containing deoxyribonucleic acid. hpv is identified in approximately 95% of malignant cervical lesions. the majority of hpv infections are temporary and will resolve spontaneously. various risk factors for developing cervical cancer have been identified, encompassing as many as 14 factors, including low socioeconomic status, low education level, early age at first coitus, multiple sexual partners, early age at first pregnancy, multiparity, long-term use of oral contraceptives, history of sexually transmitted infections (including herpes simplex virus type 2), history of genital warts, smoking, a tablediet low in folate, carotene, and vitamin c, lack of routine cytological screening or previous abnormal smears, human immunodeficiency virus, and immunosuppression.1 cervical cancer ranks as the fourth most common cancer among women globally, with an estimated 604,000 new cases and 342,000 deaths in 2020. approximately 90% of new cases and deaths worldwide in 2020 occurred in lowand middle-income countries.2 according to 2020 global cancer observatory data, as many as 36,633 (17.2%) new cases were diagnosed in indonesia, placing cervical cancer as the second most common cancer after breast cancer. based on the report, cervical cancer cases occur at a rate of 24.4 per 100,000 population, with an average death rate of 14.9 per 100,000 population.3 chemotherapy is a treatment for diagnosed cervical cancer patients. the impact of chemotherapy includes nausea, vomiting, pain, fatigue, diarrhea, and hair loss, as well as psychological effects such as worry and anxiety.4 pain is the most common complaint among cervical cancer patients. uncontrolled severe pain can interfere with daily activities and necessitates adequate pain management to maintain functionality. pain management includes pharmacological and non-pharmacological approaches.5-7 in pharmacological management, patients receive painkillers postchemotherapy. non-pharmacological pain management methods, such as spiritual emotional freedom technique (seft) therapy, are implemented in the treatment room by nurses. seft is an adaptation of emotional freedom technique (eft) therapy, which has been utilized in various studies worldwide to address fear, paranoia, obsessiveness, depression, and other psychological disorders.8 emotional freedom technique, the keyword contained is the free flow of energy meridians in the correspondence: tria astika endah permatasari, department of nutrition, faculty of medicine and health universitas muhammadiyah jakarta, indonesia. e-mail: tria.astika@umj.ac.id key words: spiritual emotional freedom technique; pain; cervical cancer. conflict of interest: the authors declare no potential conflict of interest. ethical approval and consent to participate: not applicable. availability of data and material: all data generated or analyzed during this study are included in this published article. consent for publication: not applicable. received: 14 december 2023. accepted: 19 june 2024. early access: 22 july 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12189 doi:10.4081/hls.2024.12189 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 632] [healthcare in low-resource settings 2024;12:12189] non -co mmerc ial us e o nly human body.9 to overcome pain and fear in dealing with a disease, the method is considered effective and efficient because it costs nothing, is easy to do, and doesn’t take long as long as the patient is routine and requires concentration to do it.8 the advantages of seft compared to other techniques or methods of therapy or counseling or training are: i) easy to learn and easy to practice by anyone; ii) quickly feel the results; iii) cheap (once learned we can use it forever, at various problems); iv) the effectiveness is relatively permanent; v) if practiced correctly, there are no pain or side effects, so it is very safe to be practiced by anyone; vi) universal (can be applied to any physical or emotional problems).8 this seft will also help with pain due to cancer treatment, such as cervical cancer. the chemotherapy method of treatment has side effects caused by the drugs used, not only destroying cancer cells but also attacking healthy cells, especially cells that divide very quickly. the effects that appear in cervical cancer patients undergoing chemotherapy are the physical, physiological, social, and spiritual responses.10-12 in terms of physiological impact and benefits, eft has been shown to: i) lower levels of stress hormones such as cortisol; ii) reduce symptoms such as pain and traumatic brain injury; iii) produce epigenetic effects on stress gene expression; iv) improving general markers of health such as resting heart rate, blood pressure, and immunoglobulins.13 research by rumambi et al. demonstrated that seft intervention can serve as a non-pharmacological therapy for pain management in advanced breast cancer patients.14 based on this data, the authors aim to conduct a systematic review of the effect of seft on pain in cervical cancer patients post-chemoradiation. materials and methods the systematic review conducted in this study adhered to the rigorous guidelines outlined in the preferred reporting items for systematic reviews and meta-analyses (prisma) 2020, as shown in figure 1.15 the search for journals used as sources in this study came from journals related to the research topic using google scholar, pubmed, sciencedirect, psycinfo, and ovid databases with publications from 2003-2023. the keywords used were based on the terms ‘spiritual emotional freedom technique (seft)’ and ‘emotional freedom technique (eft)’ and ‘cervical cancer’. after identifying the included articles, cross-references were examined to discover any additional relevant studies. in evaluating the validity of the study, the critical appraisal tool developed by the critical appraisal skills program was employed. this tool facilitated the systematic assessment of key aspects of the systematic review, ensuring methodological rigor and minimizing bias. by addressing key questions pertaining to the validity of the study, the results obtained from this systematic review can be interpreted with confidence. additionally, the systematic review’s findings, once synthesized and analyzed, will provide valuable insights into the efficacy of seft and eft in the context of cervical cancer management. this, in turn, has the potential to inform clinical practice and guide decision-making at the local level, ultimately contributing to improved patient outcomes. all selected studies fulfilled the following criteria: experimental studies and case studies reporting the effect of seft or eft in cervical cancer patients and the minimum research sample is two people. excluded were studies that did not report the effect of seft or eft, participants who were not cervical cancer patients, and articles for which the full text was not available. cross-sectional, cohort, and systematic reviews were also omitted. results based on the results of a systematic review of the six articles collected and the author’s analysis, it was found that there was a significant effect on the levels of pain, depression, and stress after the seft intervention, there was a decrease in the levels of pain, depression, and stress in cervical cancer patients (table 1).16-21 discussions conditions of chronic pain and fatigue pose a challenge to biomedical models due to psychological factors associated with their etiology and maintenance, including depression, anxiety, and somatization. individuals with chronic pain and fatigue are more likely to use prayer and seek spiritual support as coping methods than the general population. people with chronic pain and fatigue who are both religious and spiritual are more likely to experience better psychological well-being and employ positive coping strate review figure 1. preferred reporting items for systematic reviews and meta-analyses of included studies. [healthcare in low-resource settings 2024;12:12189] [page 633] non -co mmerc ial us e o nly gies.22 seft therapy incorporates relaxation techniques, which are a form of mind-body therapy from complementary and alternative therapies in nursing. seft is a technique that combines the body’s energy system (energy medicine) and spiritual healing by tapping certain points in the body. there are two versions of seft: the full version and the shortcut version. both consist of three simple steps, with the difference lying only in the third step (the tapping). in the shortcut version, tapping is done at only nine points, while in the full version, tapping is performed at 18 points.8 the three steps seft technique is a suggestion to stimulate the nerves of the brain. the set-up the set-up aims to ensure that our body’s energy flow is directed properly. steps were taken to neutralize “psychological reversal” or psychological resistance (usually in the form of spontaneous negative thoughts or beliefs. for example: (i am sad because i often get angry). the sentence to say is “oh allah/god… even though my head is dizzy because i am often angry, i am sincere, i completely surrender to you”. the set-up consists of two activities. first, is to say the sentence above with full humility, and sincerity, and surrender three times. the second, is to say it with feeling, pressing the chest precisely in the afternoon spot (pain point = the area around the upper chest which if pressed feels a bit painful) or tapping with two fingertips on the karate chop. after pressing the pain point or tapping on the karate chop while saying the set-up sentence as above, we continue with the second step “the tune-in”. the tune-in for physical problems, do a tune-in by feeling the pain experienced, then directing the mind to the place of pain, accompanied by heart and mouth saying: “oh allah/god, i am sincere, i surrender...” or “oh allah/god, i sincerely accept my pain here, i surrender to you my healing.” for emotional problems, tune-in is done by thinking about certain specific things or events that can generate negative emotions that we want to get rid of. when there is a negative reaction (anger, sadness, fear, and so on), our hearts and mouths say, “oh allah/god... i am sincere, i surrender”. simultaneously with this tune-in we do the third step, namely tapping. all of the above steps were carried out 3 times for 30 minutes. when finished, respondents were asked to express their feelings when doing seft and the obstacles they faced. in addition, respondents’ feelings were also examined after seft (on a scale of 1-10) and ended with a post-test. in this process, tune-in accompanied by tapping, we neutralize negative emotions or physical pain. the tapping tapping is tapping lightly with two fingertips at certain points on the body while continuing to tune-in. these points are the key points of the major energy meridians which if we tap a few times will have an impact on neutralizing emotional disturbances or pain that is felt so that the body’s energy flow runs normally and is back in balance. the following details the key points of the major energy meridians. for the short version, tapping is only done on the first nine points (gamut procedure) in the table. as for the full version after completing the nine gamut procedures, the final step is to repeat the tapping from the first to the 17th point (ending in the karate chop) and ends by taking a deep breath and exhaling while giving thanks (alhamdulillah).8 of the six journals reviewed, three demonstrate that seft therapy can effectively reduce pain in cervical cancer patients. research by hakam et al. found that the combination of seft intervention and analgesic therapy is more effective for reducing pain in cancer patients than analgesic therapy alone. quasi-exper review table 1. studies enrolled in this systematic review. [page 634] [healthcare in low-resource settings 2024;12:12189] non -co mmerc ial us e o nly imental were used in this study using pre-test and post-test designs with a control group. samples, 20 respondents (in two groups). the intervention group received seft intervention combined with analgesic therapy and the control group was given only analgesic therapy. seft intervention was implemented after administrating analgesic, for 5-10 minutes every day for five days. the pain was measured using a numeric rating scale (nrs). the average pain of respondents with stage iib cervical cancer in the intervention group using analgesic therapy in combination with seft tended to lower the average pain scale compared to the control group using only analgesic therapy. for further research, it is recommended that the number of respondents be greater and the type of pain that is acute.16 research by safitri and machmudah showed a decrease in the pain scale from moderate to mild in stage iiib cervical cancer patients with deep breathing relaxation therapy intervention and seft therapy.17 case analysis for the first day, the pain scale was 4, until on the third day the pain scale decreased to 3, for cases the first 2 days the pain scale was 3, until the third day it decreased to 2. the results of this case study indicate that deep breathing relaxation and therapy seft can reduce the pain scale. in this case, the researchers used two respondents of cervical cancer patients with stage iiib. the seft works on more or less the same principles as acupuncture and acupressure. this technique seeks to stimulate key points along the 12 energy pathways (energy meridians) of the body which are very influential on our health. non-pharmacological therapy of breathing relaxation and seft therapy can reduce pain scale in cervical cancer patients. the weakness of this case study is the room constraints when the therapy was carried out, namely the situation that was not a little supportive because of the crowds of patient attendants which resulted in the ineffectiveness of the actions taken. patients become less concentrated when doing therapy. future research is expected to increase the number of samples and therapy is carried out in calm environmental conditions so that the sample can feel the solemnity of this therapy.17 research by niken showed there were differences before and after seft therapy in participants who complained of pain. the changes that occurred physiologically and psychologically were felt by each participant. the implementation of this therapy begins with the patient being able to tell in advance the negative feelings he is feeling. the results of interviews regarding seft therapy showed that participants said that they had experienced and experienced a lot of changes after 3 consecutive days of seft therapy, especially in their thoughts, feelings of peace, calm and feeling lighter, relaxed, and accepting of what was happening. this shows that the participants become aware of the spiritual side which helps calm the participants’ souls, so that the participants are calmer, relaxed, and think positively. the spiritual beliefs that the participants already have provide a sense of relaxation and positive hope so that they are expected to reduce the pain they are experiencing. the application of case studies using seft theory has a meaningful influence on reducing pain.18 in line with previous studies that showed that seft therapy affected reducing pain in patients after transurethral prostate resection surgery.23 previous studies have found that 30 minutes of eft therapy can reduce severe to moderate pain in 40% of patients.24 in a study conducted by church and nelms, in a population with a frozen shoulder, 30 minutes of eft therapy was associated with a reduction in psychological distress and pain.25 another study conducted on 216 healthcare workers found a significant 68% reduction in pain and a 41% reduction in pain in patients with post-traumatic distress syndrome (ptsd).9,26 functional magnetic resonance imaging analysis showed the post-eft treatment significantly decreased connectivity between the medial prefrontal cortex (pain modulation area) and bilateral gray matter areas in the posterior cingulate cortex and thalamus, both areas associated with pain modulation and catastrophe. psychological respondents were also found to support the effect of eft interventions in reducing chronic pain and its impact.27 the relaxed condition elicited after seft can reduce the pain intensity of cervical cancer patients, thus reducing the patient’s stress. of the six journals that have been reviewed, two of them show that seft therapy can reduce stress in cervical cancer patients. the research conducted by desmaniarti and avianti used a quasiexperiment design in stage i to iii cervical cancer patients undergoing chemotherapy as many as 68 people divided into two groups, namely the treatment group of 34 people and the control group of 34 people. the treatment group received seft guidance individually. the research showed that stress in cervical cancer patients decreased significantly after the seft intervention. although the decrease in stress occurred in both groups of respondents, it appeared that the average decrease in stress in the treatment group was greater than that in the control group.19 in line with previous studies showing that the seft intervention helps reduce stress in patients with acute coronary syndrome.28 spiritual therapy affects the activity of the sympathetic nervous system, the effect of relaxation is that the rhythm of breathing becomes slower, the pulse slows down, and blood pressure drops reducing oxygen consumption of the heart muscle and muscle tension. the relaxation response also affects the mental state and reduces muscle tension to create a comfortable atmosphere, which can reduce stress and also affect psychoneuroendocrine interactions.29 of the six journals that have been reviewed, one of them shows that seft therapy can reduce the level of depression in cervical cancer patients. based on the facts shown in the research by wijayati et al., seft therapy reduces the level of depression in cervical cancer patients. respondents experienced depression, a psychological reaction that can appear after a patient is diagnosed with cervical cancer. generally, they feel mental shock, fear, unable to accept reality, to a state of depression. management of depression in patients with cervical cancer can be done through independent nursing actions in the form of seft. it is necessary to develop a minimal quasi-experimental research design by including a control group to reduce research bias.21 depression in cancer patients can be caused by several factors, namely related to the disease (prognosis, severity, pain, and diagnosis), and the patient’s individual internal (fear of death, feelings of helplessness, changes in self-image, age, education, and social roles). treatment (side effects, therapy costs, length of treatment, repeated treatment), and the medical team (lack of communication and information).30 with seft therapy, the patient is more willing to accept the disease in his body. in line with previous research which found an effect before and after seft therapy in depressed patients. the use of seft therapy must be carried out properly, starting from the therapeutic steps to the pronunciation of the therapy, because it is very influential in depressed patients.31 the results of other studies state that there is a difference in the decrease in the level of depression in heart failure patients who receive spiritual guidance, where spiritual guidance can increase social motivation, and physical symptoms and improve the health status associated with depression.32 a metaanalysis study showed that clinical eft was highly effective in review [healthcare in low-resource settings 2024;12:12189] [page 635] non -co mmerc ial us e o nly reducing depressive symptoms in various populations.33 the study by bach et al. adds to the evidence base for eft as being an effective mental health intervention. it also shows that eft simultaneously enhances various health markers in various physiological systems. experienced participants significant reduction in pain, anxiety, depression, and ptsd.34 the findings from the six review articles can be used to support or strengthen statements regarding the impact of seft on pain reduction. the study by hakam et al. (2009) indicates that the combination of seft intervention with analgesic therapy is more effective in reducing pain in cancer patients compared to using analgesic therapy alone. this suggests that seft can provide additional benefits in managing pain in cancer patients. the findings of the case study by safitri and machmudah state that relaxation techniques, deep breathing, and seft therapy can reduce the pain scale. this suggests that seft could be part of an effective approach in reducing pain in patients.17 the findings by niken et al. show that the application of case studies using the seft theory has a significant effect in reducing pain. this provides additional support for the effectiveness of seft in managing pain at the individual level.18 the study by desmaniarti and avianti indicates that stress in cervical cancer patients significantly decreases after seft intervention. this reduction in stress can positively influence patients’ perception and experience of pain.19 the findings from maryatun’s research show differences in stress levels before and after seft intervention in the intervention group. with these statistically significant differences, it can be concluded that seft has the potential to reduce stress levels in patients.20 the results of the study by wijayati et al. demonstrate a significant decrease in depression scores after seft intervention. this significant decrease in depression scores suggests that seft can help reduce not only physical pain but also the emotional burden associated with cancer.21 in seft practice, the patient’s spiritual aspects are given more attention by emphasizing solemn, sincere, and surrender aspects, and patients are convinced that the results to be obtained depend on the patient’s sincerity, submission, and belief in god. the more sincere, the more resigned, and the more confident god is who heals or calms the heart, the more optimal the results. the seft method is very useful in improving health, where the seft method can provide a relaxing effect to reduce or reduce pain. stress and depression in cervical cancer patients also decreased significantly after the seft intervention. the limitation of seft is that the key to the success of this method is a combination of five elements, namely belief, solemnity, sincerity, surrender, and gratitude starting from the stages of set-up, tune-in, to tapping. various studies show that many of the main causes of treatment failure are neglect of one or all three of these things. in fact, the condition of the five elements in a person, especially in post-chemoradiation cervical cancer patients, is still difficult to control so that they have the same level for all aspects, which is the cause of the failure of the method.35 the limitations of this study are the lack of seft or eft studies on pain in cervical cancer patients. conclusions based on research findings, seft demonstrates promise in reducing pain, depression, and stress levels among cervical cancer patients following chemoradiation treatment, potentially improving their quality of life and physical well-being. the integration of seft as an independent intervention by nurses is recommended for managing pain, depression, and stress in cancer patients. techniques incorporating spiritual and emotional elements may effectively reduce stress and enhance relaxation, potentially alleviating pain perception. recommendations for patients include studying seft with a qualified practitioner, incorporating meditation or yoga practices, and maintaining open communication with their medical team to optimize pain management and receive emotional and spiritual support. references 1. small w, bacon ma, bajaj a, et al. cervical cancer: a global health crisis. cancer 2017;123:2404-12. 2. sung h, ferlay j, siegel rl, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca cancer j clin 2021;71:209-49. 3. world health organization. global cancer observatory (globocan) 2020 in indonesia. international agency for research on cancer. 2021 jun. available from: https://gco.iarc.fr/today/data/factsheets/populations/360indonesia-fact-sheets.pdf 4. noviyani r, budiana i, indrayathi p. assessment of life quality of cervical cancer patients delivered bleomycin oncovin mitocyn platinum (bomp) chemotherapy regimens in sanglah denpasar. int j biosci biotechnol 2015;2:54-62. 5. palat g, biji ms, rajargopal mr. pain management in cancer cervix. indian j palliat care 2005;11:64-73. 6. rice a, justin d, john tn-h, miaskowski rf. clinical pain management: acute pain. 2nd ed. london: crc press; 2008. 7. bader p, echtle d, fonteyne v, et al. guidelines on pain management. european association of urology. 2009. available from: https://www.researchgate.net/publication/ 239594706_guidelines_on_pain_management 8. zainuddin af. spiritual emotional freedom technique (seft) the fastest and easiest way to overcome physical and emotional problems (spiritual emotional freedom technique (seft) cara tercepat dan termudah mengatasi masalah fisik dan emosi). jakarta: pt. arga publishing; 2009. 9. church d, brooks aj. the effect of a brief emotional freedom techniques selfintervention on anxiety, depression, pain, and cravings in health care workers. integr med 2010;9:40-3. 10. howkins r, grunberg s. chemotherapy-induced nausea and vomiting: challenges and opportunities for improved patient outcomes. clin j oncol nurs 2009;13:54-64. 11. luanpitpong s, rojanasakul y. chemotherapy-induced alopecia. topics in cancer survivorship. intech; 2012. available from: http://dx.doi.org/10.5772/24861 12. raphael j, ahmedzai s, hester j, et al. cancer pain: part 1: pathophysiology; oncological, pharmacological, and psychological treatmens: a perspective from the british pain society endorsed by the uk association of palliative medicine and the royal college of general practitioners. j pain med wiley period 2010;11:742-64. 13. church d, stapleton p, mollon p, et al. guidelines for the treatment of ptsd using clinical eft (emotional freedom techniques). healthcare 2018;6. 14. rumambi mf, suprapti f, susilo wh. the effect of spiritual review [page 636] [healthcare in low-resource settings 2024;12:12189] non -co mmerc ial us e o nly emotional freedom technique (seft) on pain intensity of advanced breast cancer patients in x hospital tangerang. j holist nurs 2023. 15. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021;372:n71. 16. hakam m, yetti k, hariyati rts. spiritual emotional freedom technique (seft) intervension to reduce cancer patients’ pain. makara j heal res 2009;13:91-5. 17. safitri aw, machmudah. pain reduction with combination intervention of breathing relaxation therapy and seft therapy in patients with stage iiib cervical cancer. holist nurs care approach 2021;1:1-8. 18. niken s, wahyuningsih, prasetyorini h. the application of spiritual emotional freedom technique on pain in cancer patients. indones j glob heal res 2020;2:351-8. 19. desmaniarti z, avianti n. spiritual emotional freedom technique decreasing stress on patiens with cervical cancer. j ners 2014;9:91-6. 20. maryatun s. the effect of spiritual emotional freedom technique and supportive therapy on stress levels of cervical cancer patients. j keperawatan sriwij 2020;7:14-25. 21. wijayati s, fitriyanti sa, arwani a. the effect of spiritual emotional freedom technique (seft) therapy on decreased depression level among cervical cancer patients. medica hosp j clin med 2020;7:398-402. 22. baetz m, bowen r. chronic pain and fatigue: associations with religion and spirituality. pain res manag 2008;13:383-8. 23. brahmantia b, huriah t. the effect of spiritual emotional freedom technique (seft) on reducing pain and anxiety in post transurethral prostate resection (turp) patients at rsud dr. soekardjo city of tasikmalaya. j kesehat karya husada 2018;6:18. 24. latifah l, setiawati n, rismawati i. are there any effects of tapping therapy in reducing anxiety and labor pain in the latent phase? ann trop med public heal 2019;22:1-8. 25. church d, nelms j. pain, range of motion, and psychological symptoms in a population with frozen shoulder: a randomized controlled dismantling study of clinical eft (emotional freedom techniques). arch sci psychol 2016;4:38-48. 26. church d. reductions in pain, depression, and anxiety symptoms after ptsd remediation in veterans. explore (ny) 2014;10:162-9. 27. stapleton p, baumann o, o’keefe t, bhuta s. neural changes after emotional freedom techniques treatment for chronic pain sufferers. complement ther clin pract. 2022;49:101653. available from: https://www.sciencedirect.com/science/article/pii/s1744388122001219 28. bakara dm, ibrahim k, sriati a. effect of spiritual emotional freedom technique on anxiety and depresseion in patients with acute coronary syndrome abstract. j keperawatan padjadjaran 2015;1:1-8. 29. halm ma. relaxation: a self-care healing modality reduces harmful effects of anxiety. am j crit care an off publ am assoc crit nurses 2009;18:169-72. 30. raihan dn, tjokroprawiro ba, konginan a. depression levels and influencing factors in cervical cancer patients at rsud dr. soetomo. j heal 2022;9:40-52. 31. sucipto, kristanto h, dhevansa wc. literature review: the effect of spiritual emotional freedom technique therapy on patients with depression. indones j glob heal res 2023;5:618. 32. bekelman db, dy sm, becker dm, et al. spiritual well-being and depression in patients with heart failure. j gen intern med 2007;22:470-7. 33. nelms ja, castel l. a systematic review and meta-analysis of randomized and nonrandomized trials of clinical emotional freedom techniques (eft) for the treatment of depression. explore (ny) 2016;12:416-26. 34. bach d, groesbeck g, stapleton p, et al. clinical eft (emotional freedom techniques) improves multiple physiological markers of health. j evidence-based integr med 2019;24:2515690x18823691. 35. nuroh s, lessy z, bastian mf. effectiveness of spiritual emotional freedom technique (seft) in reducing students’ anger. j stud insa 2022;10:10-26. review [healthcare in low-resource settings 2024;12:12189] [page 637] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11805 exploring maternal perspectives on addressing domestic violence in pregnant adolescents ezyla purbaningsih ministry of health bandung health polytechnic, bandung, indonesia abstract adolescent pregnancy has been on the rise in developing countries, primarily attributed to economic challenges, particularly in africa and south asia. west java province stands out as one of the leading regions with a high incidence of adolescent pregnancies. young couples often struggle to adapt to early marriage, resulting in domestic violence and adverse health consequences. notably, domestic violence is prevalent among young married couples, with bogor reporting a significant incidence among pregnant adolescents. mothers play a crucial role in providing protection and resolving domestic issues. this study aimed to investigate mothers’ perspectives on domestic violence towards adolescents and their problem-solving strategies. the study employed qualitative methods with a descriptive interpretation approach. data were gathered through in-depth interviews with seven mothers whose daughters had experienced domestic violence by their husbands during pregnancy, having given birth and entered marriage. thematic content analysis was employed for data analysis. the central finding is that economic challenges serve as the primary catalyst for domestic violence, manifesting through harsh language and physical abuse, leading to potential harm to the child and miscarriage. pregnant adolescents often experience psychological distress, exhibiting symptoms such as daydreaming, sadness, crying, and weight loss. mothers express concern about the domestic violence their daughters endure during pregnancy, attributing it to economic issues. to address the problem, mothers employ various strategies, including seeking advice, providing emotional support, involving health services, mediating, communicating, and reporting incidents to relevant authorities. maternity nurses should proactively offer information about the risks associated with adolescent pregnancies and early marriage. the government must actively communicate the significance of the risk of early pregnancy, particularly concerning violence, to teenagers. introduction every year, an estimated 21 million girls aged 15–19 years in developing regions become pregnant, and approximately 12 million of them give birth.1 although the trend of adolescent pregnancy is global, developing countries exhibit a more pronounced issue, particularly in africa,2 and in south asia including afghanistan, bangladesh, guatemala, haiti, india, and nepal.3 the higher prevalence of adolescent pregnancy in these areas is attributed to economic challenges, as 95% of these countries are lowand middle-income countries. the population of pregnant adolescents primarily consists of individuals with low incomes, low levels of education, and rural backgrounds.4 the indonesian government, through the population and family planning board, establishes an annual target for adolescent births.5 indonesia holds the second-highest rank in adolescent pregnancy within asean, with 48 pregnant adolescents per 1,000.6 west java province is one of indonesia’s leading contributors to adolescent pregnancy. the prevalence of adolescent pregnancy in west java is considered high and continues to rise, surpassing the national prevalence by 2.5%.7 this upward trend persisted until 2016, with the number of adolescent marriages resulting in pregnancy reaching 4,759 in bandung.8 bogor emerged as another significant contributor to adolescent pregnancies in west java, accounting for 812 or 3.8% of all pregnant women in 2017.9 economic factors serve as the primary motivation for parents to consider early marriages for their adolescents. the results of the 2014 pusat studi kependudukan dan kebijakan (pskk) study revealed that parents categorized as low-income families tended to encourage their daughters to enter into early marriages. this mindset stems from the belief that children are perceived as an economic burden, and parents anticipate that financial responsibilcorrespondence: ezyla purbaningsih, ministry of health bandung health polytechnic, bandung, indonesia. e-mail: ezyla.purbaningsih@gmail.com key words: domestic violence, mother’s opinion, pregnant adolescent, problem-solving, psychological impact. conflict of interest: the authors declare no conflict of interest. funding: this research received funding assistance from a grant puti ui 2020: number: nkb-819/un2.rst/hkp.05.00/2020. ethics approval and consent to participate: the research has received ethical approval from the faculty of nursing, universitas indonesia, based on ethical certificate number: nkb-819/un2.rst/hkp.05.00/2020. throughout the research, the researcher has adhered to ethical principles such as informed consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 14 september 2023. accepted: 30 november 2023. early access: 22 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11805 doi:10.4081/hls.2023.11805 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 110] [healthcare in low-resource settings 2024;12:11805] non -co mmerc ial us e o nly ity will shift after marriage.8 the tendency toward unstable emotional conditions and an inability to control emotions is a key factor preventing adolescent couples from adapting. for example, they struggle to adjust to their spouse and family dynamics, sexuality, and financial matters, particularly in the early stages of marriage.10 the challenge of adapting to marriage at a young age arises from the emotional immaturity and thought processes of adolescents when confronted with household problems.11 this failure to control emotions and adapt leads to frequent quarrels, eventually escalating into domestic violence. violence experienced by pregnant adolescents not only harms their physical health but also takes a toll on their psychological wellbeing. violence against women, especially during pregnancy, heightens the risk of complications during pregnancy and childbirth.12 the adverse consequences of adolescent childbirth are well-documented, encompassing increased risks of low birth weight, pre-term delivery, neonatal mortality, and a low appearance, pulse, grimace, activity, respiration (apgar) score.13 research by setyawan, marita, kharin, & jannah (2016) identified that domestic violence results in adverse health effects, including direct injury and trauma-related problems such as depression, anxiety, loss of selfconfidence, internalization problems, and aggression. another study conducted by rayi, sukohar, hutahuruk, & putra (2016) concluded that the impact of domestic violence on wives could be observed through deep stress, fear, isolation from environmental interactions, and emotional instability.14,15 who estimated that the global prevalence of physical and/or sexual intimate partner violence (ipv) among women was almost one-third (30 percent), with the highest prevalence occurring in the eastern mediterranean and south-east asian regions, accounting for 37 and 37.7 percent, respectively.16 concerning the incidence of domestic violence, several studies indicate that violence is prevalent in households dominated by young married couples. domestic violence has become a critical problem in both developed and developing countries, with the number of cases increasing in indonesia.17,18 pustikasari (2013) concluded that the highest percentage of domestic violence occurs in adolescents who marry before the age of 20 compared to adult women. similar results were identified by sekharan, kim, oulman, & tamin (2015), indicating that the majority of violence occurs against vulnerable pregnant adolescents aged 18-19.19 most of the violence is perpetrated by adolescent husbands against their wives during pregnancy. consistent with the results of this study, the incidence of domestic violence in pregnant adolescents in bogor is also high. data from the bogor city health office and the integrated service center for women and children empowerment (p2tp2a) in bogor show that out of 1848 pregnant adolescents, there were 93 cases of domestic violence committed by husbands against pregnant adolescents in 2019.9 cases of violence against women committed by a partner cannot be viewed as a form of “reasonableness” due to the significant health impact it generates.17 the estimated number of cases is likely larger than reported due to underreporting in p2tp2a; however, the data above was obtained from community reports. parents bear the responsibility of addressing issues involving their pregnant adolescents. moral support from parents, especially mothers, plays a pivotal role in the process of pregnancy, labor, and childbearing.20 a mother’s role in this context extends to providing protection and resolving domestic problems, particularly those associated with violence in adolescent marriages.21 this involvement includes mediation, seeking solutions, effective communication, and even reporting violence when necessary.22 adolescents place complete trust in their mothers for all the challenges they encounter.2 the reason is the relationship between mothers and adolescent is stronger and more special.23 this trust is rooted in the stronger and more special relationship between mothers and adolescents.24 the robust bond between mothers and their daughters provides insight into how a mother’s opinion can influence their daughter’s issues with domestic violence. this study aims to explore the opinions in addressing problems faced by pregnant adolescents’ domestic violence. materials and methods qualitative research generally explains and provides understanding and interpretation of various forms of human behavior and experiences. meanwhile, the approach falls into the interpretative descriptive category if the researcher tries to find an explanation of a social or cultural event based on the point of view and experience of the person being studied, then tells the opinions or views of the research object in detail and in detail. furthermore, an interpretive descriptive qualitative design in this research was used to explore in depth and accurately the phenomenon of teenage pregnancy through the perceptions and experiences of parents in dealing with the psychological problems of pregnant teenage children who experience domestic violence in detail using clear words. the study employed qualitative methods with a descriptive interpretation approach. data were collected through in-depth interviews with seven mothers whose pregnant adolescents had given birth, were married, and had experienced domestic violence by their husbands. researchers utilized a sony nwz e463 tape recorder (mp4) and field notes as tools for data collection. the purpose of using these tools was to streamline the transcription process by cross-verifying it with participants. the tape recorder captured participants’ verbal responses, while field notes documented their physical reactions. data analysis was conducted using a thematic content analysis process. this study design incorporates qualitative methods with a descriptive interpretation approach. participant selection was carried out purposefully, with the specific aim of exploring the responses and experiences of parents who have had teenage children facing domestic violence during pregnancy. participants were sourced from data provided by the service center integrated empowerment of women and children (p2tp2a) in bogor city. this center comprises a team of psychologists and medical professionals collaborating with community health centers, the city government, police, and non-governmental organizations (ngos). the team manages reports of domestic violence involving pregnant teenagers and assists in identifying participants based on inclusion criteria. the total number of participants in this research was seven. data collection ceased as no additional participants were added, reaching data saturation with the seventh participant. results participants in this research were mothers who had teenage children who had been or were currently pregnant, had given birth, were married, and had experienced domestic violence by their husbands. participants were in the age range of 36-60 years, with the youngest 36 years old and the oldest 60 years old. most of the participants, namely five people, had completed junior high school education, one person had completed elementary school and one person had not completed elementary school. three participants had five children, and one in four participants each had six, three, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11805] [page 111] non -co mmerc ial us e o nly two, and one children. the age of the participants’ teenage children at the time of marriage and/or pregnancy ranged from 12-16 years, with the youngest being 12 years and the oldest being 16 years. the background of the participants is presented in table 1. there were seven themes derived from 16 categories that reflected the opinions of mothers on addressing the challenges faced by pregnant adolescents dealing with domestic violence. based on the results of the analysis, seven themes were identified. allowing girls to marry young due to school dropout, unemployment, or downsizing, leading to economic burden and shifting responsibilities six participants chose early marriage for their adolescent daughters due to unemployment and school dropout. “my 15-year-old child is no longer going to school, hasn’t found a job...” (participant 3) “my daughter was in junior high school; she did not want to continue studying anymore, she dropped out of school...” (participant 4) participants allowed their adolescents to marry to reduce the financial burden and shift responsibilities four participants explicitly mentioned this. all participants belonged to low-middle income families, and four of the seven participants were single parents. thus, the inclination to permit their adolescent daughters to marry stemmed from their desire to alleviate financial burdens and transfer parental responsibilities. “my 15-year-old child is no longer going to school, hasn’t found a job...” (participant 3) “my daughter was in junior high school; she did not want to continue studying anymore, and she dropped out of school...” (participant 4) feeling happy about the pregnancy but concerned because the son-in-law does not have a permanent job five participants expressed joy and gratitude for their adolescent daughters’ pregnancies after marriage. the participants’ positive views on adolescent pregnancy stemmed from the anticipation of having grandchildren. during the interviews, the participants conveyed happiness and satisfaction, emphasizing that the pregnancy was expected after marriage to avoid societal judgment on the mother. “...she is about three months pregnant, and i am happy because if my daughter hadn’t become pregnant, people would think she is infertile” (participant 1). “especially since i received the news that my child is pregnant, i am happy. i will have grandchildren, so i often remind her to take care of her health” (participant 2). however, concerns were voiced by six participants regarding their pregnant adolescents, primarily centered around economic issues. four participants expressed worries about their son-inlaw’s freelance work, with six of the participants’ sons-in-law being temporary workers. this situation significantly impacted the family’s economic conditions, especially for daily needs. the economic strain was further exacerbated by the pregnancy of their adolescent daughters, necessitating additional expenses for labor and childcare. “...her husband only gives 50 thousand a week, the husband just sells snacks for a living, and sometimes my daughter goes without eating...” (participant 2). “my daughter and her husband said they do not have money...” (participant 7). economic problems serve as the root cause of turmoil within the household, escalating into domestic violence five participants explicitly mentioned this connection. economic challenges trigger disturbances leading to domestic violence, particularly when the son-in-law works freelance, grappling with the responsibility to meet the daily needs of the household and cover expenses for childbirth preparation. “due to economic problems, my son-in-law takes on odd jobs, eventually causing disputes over money” (participant 4). “.... common household problems revolve around finances...” (participant 5). domestic violence from the son-in-law typically manifests in the form of harsh speech and physical beatings all participants disclosed that their pregnant adolescents faced severe domestic speeches and physical abuse from their son-inlaws. harsh speech included derogatory language, yelling, shouting, and insults, treating daughters like animals. physical abuse encompassed slapping, dragging, hitting with objects, kicking the stomach, burning the hand with a cigarette flame, rubbing the face against the wall, and dragging. such violence resulted in harm to the child and even miscarriage. “when my daughter was five months pregnant, she was beaten by her husband, slapped on the face until her cheek swelled because of that” (participant 2). “when my daughter speaks, she eventually faces abuse. she said she was called a dog, an animal. and even hit with a guitar by her husband...” (participant 3). pregnant adolescents become psychologically disturbed due to domestic violence pregnant adolescents faced domestic violence by their husbands “…my child turns out to be concerned about her condition, her pregnancy..” (participant 2) “…my daughters said they often quarrel.” (participant 5) pregnant adolescents suffer psychological distress due to domestic violence. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic characteristic of respondent. variable n % age (years) 30-40 3 42.9 41-50 3 42.9 >50 1 14.2 education elementary school 2 28.57 junior high school 5 71.43 number of children 1-5 6 85.7 6-10 1 14.3 age of teenage children when married/pregnant 12 1 14.3 13 2 28.5 14 1 14.3 15 1 14.3 16 2 28.5 [page 112] [healthcare in low-resource settings 2024;12:11805] non -co mmerc ial us e o nly all participants revealed that, following exposure to domestic violence, adolescents encountered psychological problems. this is evidenced by the frequency of daydreaming, expressions of sadness and crying, and even substantial weight loss. “my daughter is sad, crying all the time, hurt because of a miscarriage, because she was beaten.” (participant 1) “sad, for sure, she was disappointed about it, and she did not think that her husband had the heart to beat her.” (participant 6) feeling sad, angry, and disappointed with the sonin-law for his disrespectful attitude and actions leading to domestic violence participants expressed feelings of sadness, anger, and disappointment regarding their son-in-law’s disrespectful behavior, which resulted in domestic violence against their adolescent. all participants conveyed a sense of sadness towards their adolescents who endured domestic violence and anger directed at the son-in-law responsible for the violence. “i am unfortunate to see my daughter (while wiping the tears)...” (participant 3) “i became emotional after hearing that news. i was very angry with her husband...” (participant 5) disappointed in the son-in-law for being rude six participants cited instances of disrespectful attitudes, including harsh speech towards the mothers, such as preventing parental interference in household matters and blaming their parents for domestic problems. “he (son-in-law) said, please don’t interfere when going out of the house” (participant 1) “he (son-in-law) did not accept it. he said he did not want to be regulated” (participant 2) solving problems through inquiry, advice, emotional support, seeking medical assistance, mediation, communication, and reporting looking for information about their daughter’s domestic problem care after learning about the problems in their daughters’ households, these mothers endeavored to understand the causes by directly asking their daughters and their husbands. six participants revealed engaging in this process. “i once asked my daughter what kind of fuss and what the problem was…” (participant 1) “i asked my daughter the reason for their fight…” (participant 3) resolving their daughters’ domestic problems involved mediation, finding solutions, communication, and reporting all participants expressed efforts to address the household problems their daughters faced. actions taken included two participants inviting their son-in-law to their homes, three participants contacting the parents-in-law, four participants visiting the parentsin-law’s house, two participants arranging for their families to visit the parents-in-law, two participants reporting to the neighborhood leader, and one participant reporting to institutions dealing with domestic violence issues. one participant ultimately resolved the marriage problem through an official divorce, while four participants opted for a religious divorce due to the lack of marriage registration. two participants reported domestic violence incidents to the neighborhood, and one reported to the women’s protection agency. “tell the son-in-law to come and solve the problem. if you do not want to do it anymore, it is better to divorce, but if you want to solve this, we could make an agreement letter...” (participant 1) “my husband called our in-laws, asked about the issues; they said they did not know, and their children never came home (participant 3) addressing the psychological issues of daughters experiencing domestic violence involved providing advice, comfort, entertainment, and seeking health services all participants revealed their efforts to address their daughters’ psychological issues related to domestic violence by advising them to be patient and sincere in facing household problems, increasing worship and prayer to alleviate stress. two participants sought help from midwives, and one participant asked her daughter’s friends to provide emotional support. “i advise you to be patient, sincere. it is destiny; just accept it” (participant 2) “i took her to the midwife and checked her health. i bought pregnancy milk...” (participant 5) hoping the adolescent overcomes stress, remains resilient in facing household issues, can resume schooling and employment, attain a clear divorce status, and find happiness in remarriage hope for their daughter to overcome stress and confront the problems six participants shared optimistic expectations for the future psychological well-being of their daughters who have experienced domestic violence. these hopes encompass the desire for their daughters to no longer experience stress, exhibit strength in facing problems, and regain the cheerful disposition they had before. the following statements are excerpts from participant interviews: “i want my daughter to be healthy and cheerful like before, able to play with friends...” (participant 3) “i hope that my daughter will be healthy, no longer stressed, and ready to give birth with full energy.” (participant 5) discussion allowing girls to marry young because they have dropped out of school and are not working can alleviate the economic burden on the family and shift responsibilities mothers have cited various reasons to permit their daughters to marry early, including school dropout and unemployment. adolescents who discontinue their education tend to cause anxiety and mental burden for their parents. concerns voiced by these mothers encompass issues of promiscuity, such as engaging in free sex, drug abuse, alcohol consumption, fights, and conflicts with other teenagers. these concerns arise from the perception that their children freely associate with other school dropouts, leading them to often go out at night. the findings of this study align with research indicating that children who drop out of school tend to engage freely, resulting in negative impacts such as unwanted pregnancies and illicit drug abuse.25 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11805] [page 113] non -co mmerc ial us e o nly mothers mentioned that their adolescents dropped out of school, with one contributing factor being the economic constraints of parents who couldn’t afford their children’s education. a similar study conducted by gunawan (2019) identified that the economic conditions of parents who couldn’t afford tuition fees were an external factor leading school-age children to quit school. family financial challenges also influenced mothers’ decisions to permit their children to marry. all participants in the study belonged to lower-middle-class families, and some were single parents. thus, the economy has emerged as a significant issue, prompting mothers to opt for early marriage for their daughters to ease the financial burden and responsibilities, shifting them to their daughters’ husbands. similar research results from studies conducted by hanum (2015) and stephen, olusegun, kayoed, oluwagbemi, & adenike (2017) also concluded that poor and lowincome parents marry off their adolescents to alleviate their responsibilities towards their daughters and hope for their children to have a better life after marriage.26 happy about the child’s pregnancy but concerned because the daughter-in-law does not have a permanent job mothers express joy at their adolescent’s pregnancy, as it was anticipated, and it shields their daughters from societal criticism as infertile women. this indicates that socio-cultural factors, such as pride in having their child married and pregnant, still influence mothers’ decisions to support teen marriage and pregnancy. this is supported by research conducted by agege, nwose, & odjimogho (2018) on the perceptions of parents in nigeria regarding the pregnancy of their adolescent children and research conducted by rafidah & yuliastuti (2015) in south kalimantan. both studies concluded that parents feel proud if their children marry and become pregnant in adolescence.27 however, ironically, this teenage pregnancy contrasts with the reproductive health risks adolescents may experience if they marry young. parents are the primary source of information for young women about adolescent reproductive knowledge. the results of research conducted by vonyca, setyowati & kurniawati (2017) on how young women in lampung maintain reproductive health revealed that support for information about reproductive health was obtained by adolescents, especially from mothers. if the mother has less information, then the knowledge of adolescents is also limited.28 on the other hand, the mother also feels concerned about the condition of the adolescent’s pregnancy. however, this concern is not about the health condition of the adolescent but rather about financial issues. several questions regarding the presence or absence of a mother’s anxiety about the pregnancy of a young daughter were answered with a sense of calm and the belief that the adolescent was fit to get pregnant because she had a period, which was believed to be a sign that the adolescent was ready to get pregnant. the results of this study contradict other studies conducted by shaikh, shaikh, shaikh, & isran (2013), brosens, muter, gargett, puttemans, benagiano, & brosens (2017), and ergen, yayla, ozkaya, kilicci, sanverdi, & kocakusak (2017) who concluded that adolescence is not an adequate period for being pregnant because it will have a negative physiological impact. for instance, they are more vulnerable to pregnancy risks such as bleeding and birth complications than adult women.29 the mother’s concern about the economic problems of her daughter’s household is caused by the son-in-law’s working status as a freelancer, affecting the family’s economic condition, especially in inadequate daily needs fulfillment and additional expenses for labor preparation and newborn needs. this is in line with the results of research on the impact of parental interference on children’s households by cahyanti (2017), concluding that parents have a greater desire to interfere with their daughter’s household conditions, especially economic problems. this can be interpreted that if the daughter’s household economic status is problematic, then the parents are the most worried and the most likely to assist. the mother’s concern about the economic condition of the daughter’s household is the opposite of the mother’s reason for allowing her adolescent daughter to marry, which is a desire to transfer economic responsibility to her son-in-law. similar results of research by hanum (2015) and stephen, olusegun, kayoed, oluwagbemi, & adenike (2017) stated that the reason for mothers with low economic levels and low-income families to marry off their children is to let go of responsibility and in the hope that their children will get a better life after marriage.26 the form of violence committed follows what is stated in the research of jahromi, jamali, koshkaki, & shohreh javadpour (2016), namely domestic violence that often occurs begins with an argument which can be in the form of physical, sexual, and mental violence, and includes threats. this is also following the category of forms of violence, which include domestic violence as regulated in the law covering open violence, including physical violence such as fights, hitting, pushing, pulling, and even killing, while psychological violence is related to emotional violence, including using harsh words, threats, intimidation, manipulation, using insulting sentences, or giving excessive criticism.30 the psychology of pregnant girls is disturbed due to domestic violence carried out by their in-laws after experiencing domestic violence, adolescents face psychological issues. the adverse effects of domestic violence can be seen in the frequent daydreaming of adolescents, sadness and crying, and dramatic weight loss. the results of this study are supported by another study conducted by gonzalez, calvete, orue & mauri (2018), indicating that violence in pregnant adolescents harms the psychology of these adolescents, leading to psychotic and personality disorders, traumatic and stress-related disorders, eating disorders, sleep disorders, and behavior problems. the mother is saddened by the incidence of domestic violence experienced by her daughter and feels angry at the son-in-law. the attitude of the son-in-law is different from the expectations of the parent when they married their daughter, adding an additional burden to the parent’s sadness. the results of this study are supported by previous research conducted by maisya & susilowati (2017), which showed that the mother has a significant role in the psychological state of adolescents. if the mother cannot fully carry out this role, the child will feel deprived. teenagers need emotional support from their parents 20. this means that if the mother finds out about problems affecting her adolescent, such as domestic violence, after the incident, she will be very sorry, sad, and angry. economic problems were the main factor that triggered the commotion resulting in domestic violence carried out by the in-laws mothers try to gather information about the causes of problems in their children’s households by asking the daughter and her husband directly. the attitude of the mother, who is responsive in solving the daughter’s problems, shows the role of the mother in providing moral support to the child. this is supported by the results of research conducted by sekiwunga & whyte (2015), which concluded that the support of parents, especially mothers, is needed by transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 114] [healthcare in low-resource settings 2024;12:11805] non -co mmerc ial us e o nly adolescents dealing with problems that occur in their household because adolescents think that mothers should protect them from family problems.21 after the mother digs up information about the causes of the problems that befall her daughter’s household, the answer is that economic problems are the main factor that triggers the commotion, which ends up being domestic violence. these economic problems are caused because the son-in-law does not have a permanent job, so he is pressured by the obligation to meet his daily needs and expenses for childbirth preparation. this result is similar to another study conducted on pregnant adolescents who experience domestic violence in nigeria by akpor, thusahagaletshweneagae, & mmusi-phetoe (2017), showing that economic factors are the main factor that causes commotion and problems in household violence. mothers have tried solving the problems through mediation, solutions, communication, and reporting. actions taken by the mother include asking the son-in-law to come to the house, contacting the parents-in-law, visiting the parents-inlaw’s house, sending the family to come to see the parents-in-law, reporting to the neighborhood, and reporting to the institution that deals with domestic violence issues.31 sad, angry, and disappointed with the son-in-law for his disrespectful attitude and actions that have committed domestic violence against children the results of this study are supported by research conducted by samano et al. (2017), which concluded that mothers must pay attention to their pregnant teenagers who experience stress due to problems of violence perpetrated by their husbands.22 this is due to teenagers mostly relying on their mothers and expecting their mothers to solve their household problems. the results of a similar study conducted by vonyca, setyowati & kurniawati (2017) revealed that emotional support from parents is needed by children, especially adolescents.28 he results of research conducted on adolescents in spain by lapierre, cote, lambert, buetti, lavergne, dominique, & couturier (2018) stated that children generally consider their mothers as individuals who are very important in their lives, and have very close relationships, so that the mother will protect the child from the problems that occur.32 how to overcome problems by advising, comforting, taking the child to health services then mediating, communicating, and finally reporting another way done by mothers in overcoming adolescent problems is by bringing them to health services. the mother’s lack of knowledge about adolescents’ health and psychological issues has led mothers to bring their children to health services. this follows the results of research conducted by djuwitaningsih & setyowati (2017), showing that with the common knowledge of adolescents and mothers about reproductive organs, there is a need for reliable sources of information, one of which is from health services.33 hoping that her daughter will no longer be stressed, will be strong enough to face household tests, will be able to continue school, work, get clarity on her divorce status, and remarry mothers put their hopes for their adolescents who faced domestic violence, which is related to psychological conditions, and the continuation of the daughter’s marital status so that their daughters do not need to be stressed about facing domestic problems and can immediately take care of a divorce. the mother is the first person to feel inner sadness over the domestic violence problem that befell her daughter, so the mother will do various ways to overcome these problems in the hope that the daughter’s psychological condition will recover. the results of research conducted by fernandez, junior, & gualda (2015) in sao paulo, brazil, on mothers who have pregnant adolescents show that most mothers see a psychiatrist to recover their daughter’s psychological state and hope to arrange a divorce so that violence does not occur again.34 another hope from mothers for their daughters who faced domestic violence is the continuation of their daughter’s education. this is supported by the results of research conducted by koerner, wallace, lehman, lee, & escalante, 2016; one of the ways for mothers helps their daughter psychologically recover from the experience of domestic violence is by supporting children to continue their education interrupted by marriage. the continuation of this education is in the hope that children will forget their household problems by being busy with educational activities so that children have a better future.35 conclusions the problem of domestic violence still causes stigma, so researchers need the ability to find cases, invite potential participants to participate, and gather information from participants. this research has not explored much about the cultural and religious aspects of the participants regarding the problems of marriage and domestic violence experienced by their children. the results of this research can also increase knowledge about the causes and negative impacts of pregnancy on teenagers, as well as mothers’ perceptions and experiences in dealing with the psychological problems of pregnant teenage children experiencing domestic violence. for further research, the results of this study recommend that other research be conducted on cultural and religious aspects related to the problems of marriage, pregnancy, and domestic violence experienced by teenagers. 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sika premaja tentang risiko kehamilan remaja di smun 1 lembang kabupaten bandung barat. jurnal kebidanan malahayat 2019;4:992. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11805] [page 115] non -co mmerc ial us e o nly 9. dinkes kota bogor. profil kesehatan kota bogor 2020. dinas kesehat kota bogor. published online 2020:10-27. 10. anjani c, suryanto. pola penyesuaian perkawinan pada periode awal pada periode awal. insa j psikol dan kesehat ment 2018;8:2006. 11. nasution j. oukup, ramuan tradisional suku karo untuk kesehatan pasca melahirkan: suatu analisis bioprospeksi tumbuh-tumbuhan tropika indonesia. 2009:http://repository.ipb.ac.id/handle/123456789/4620 12. da costa fernandes a, supriyanto s, wahjuni cu, notobroto hb, wild k. factors associated with disrespect and abuse of women during labour and birth in health facilities in low-and middle-income countries: a systematic review and meta-analysis. pharm educ 2023;23:53-59. 13. chotimah k, suza de, efendi f, hadisuyatmana s, astutik e, susanti ia. determinants of adolescent first births in indonesia. syst rev pharm 2020;11:241-5. 14. rayi p, hutahuruk p, asep als. kekerasan dalam rumah tangga pada kasus pernikahan dini. j medula 2016;6:143-8. 15. setyawan j, marita r, kharin i, jannah m. dampak psikologis pada perkawinan remaja di jawa timur. j penelit psikol 2016;7:15-39. 16. putra igne, pradnyani pe, parwangsa nwpl. vulnerability to domestic physical violence among married women in indonesia. j heal res 2019;33:90-105. 17. mas’udah s. power relations of husbands and wives experiencing domestic violence in dual-career families in indonesia. millenn asia 2021;14:5-27. 18. mas’udah s. resistance of women victims of domestic violence in dual-career family: a case from indonesian society. j fam stud 2022;28:1580-97. 19. sekharan vs, kim thm, oulman e, tamim h. prevalence and characteristics of intended adolescent pregnancy: an analysis of the canadian maternity experiences survey. reprod health 2015;12:101. 20. maisya i, susilowati a. peran keluarga dan lingkungan terhadap psikososial ibu usia remaja. j kesehat reproduksi 2017: https://doi.org/10.22435/kespro.v8i2.8013.163-173 21. sekiwunga r, whyte sr. adolescent pregnancies in uganda. afr j reprod health 2009;13:113-28. 22. sámano r, martínez-rojano h, robichaux d, et al. family context and individual situation of teens before, during and after pregnancy in mexico city. bmc pregnancy childbirth 2017;17:382. 23. yuliastanti t. keberhasilan bounding attachment. j kebidanan 2013;5:8-12. 24. silva l, tonete vlp. adolescent pregnancy from a family perspective: sharing projects of life and care. rev lat am enfermagem 2006;14:199-206. 25. siti s. pergaulan bebas di kalangan pelajar. bitkom res 2018;63:1-3. 26. mulyaningsih s, a. hiola f. dampak pernikahan dini terhadap kesehatan reproduksi. harkat 2008;15:89-95. 27. rafidah. hubungan persepsi orang tua tentang pernikahan dini dengan nikah dini di kecamatan kertak hanyar. jurnal publikasi kesehatan masyarakat indonesia 2015;2:20-25. 28. dovis v, setyowati, kurniawati w. the experience of young women living in a prostitution area in maintaining their reproductive health. compr child adolesc nurs 2017;40:137-44. 29. shaikh s, shaikh a, shaikh s, isran b. frequency of obstructed labor in teenage pregnancy. nepal j obstet gynaecol 2013;7:37-40. 30. uu ri nomor 23. penghapusan kekerasan dalam rumah tangga uud. republik indonesia. 31. akpor o, thupayagale-tshweneagae g, mmusi-phetoe r. parents and community leaders’ perceptions of teenage pregnancy: a qualitative study. afr j nurs midwifery 2017;19: 2810 32. lapierre s, côté i, lambert a, et al. difficult but close relationships: children’s perspectives on relationships with their mothers in the context of domestic violence. violence against women 2018;24:1023-38. 33. djuwitaningsih s, setyowati. the development of an interactive health education model based on the djuwita application for adolescent girls. compr child adolesc nurs 2017;40:169-182. 34. fernandes a de o, santos júnior hp de o, gualda dmr. gravidez na adolescência: percepções das mães de gestantes jovens tt embarazo en la adolescencia: percepciones de las madres de gestantes jóvenes tt adolescent pregnancy: perceptions of mothers of young pregnant women. acta paul enferm 2012;25:55-60. 35. deborah s, muthmainnah a, herlinda l, tanawi ss. trauma dan resiliensi pada wanita penyintas kekerasan dalam rumah tangga. j ilm psikol manasa 2018;7:121-130. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 116] [healthcare in low-resource settings 2024;12:11805] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13032 understanding river culture to approach health promotion in river management in banjarmasin, south kalimantan, indonesia herawati,1 anggi setyowati,1 lola illona elfani kausar,1 soedjajadi keman,2 shrimarti r. devy2 1school of nursing, faculty of medicine and health sciences, universitas lambung mangkurat, banjarbaru, south kalimantan; 2faculty of public health, universitas airlangga, surabaya, east java, indonesia abstract cultural customs play an important role in maintaining the well-being of the environment and natural resources. these cultural concepts influence thought processes and have a significant impact on decision-making, particularly in protecting the river. therefore, this study aimed to explore the connection between local culture, specifically values, ways of life, and beliefs, and the promotion of a healthy river environment among residents living along the river in banjarmasin, south kalimantan indonesia. a mixed-method approach was employed to investigate the cultural aspects, including values, ways of life, and beliefs, and the advocacy for a sustainable river environment among the inhabitants residing along the river in banjarmasin, south kalimantan, indonesia. the quantitative design evaluated the descriptive statistics in terms of the sociodemographics of participants. data collection was carried out using in-depth interviews, observation, and questionnaires. subsequently, triangulation was performed to ensure trustworthiness. all statements relevant to the phenomenon were identified before the theme was clustered. the results showed that the river culture consists of two themes, namely values and ways of life, and beliefs. in conclusion, it was expected that understanding the culture of the river could be a strategy for conducting health promotion in river management. introduction the river plays a crucial role in supporting human development by providing water, transportation, agriculture, and fisheries, forming a close connection with human well-being.1-3 protecting the river is essential to achieve a healthy river, defined as an ecosystem that enhances human well-being.4 a healthy river contributes to achieving sustainable development goal (sdg) number 6, which focuses on providing clean water and sanitation.5 however, numerous studies show that some individuals neglect river maintenance, exemplified by behaviors like improper garbage disposal.6 this also occurred due to population growth and rapid industrialization.7,8 banjarmasin city in south kalimantan, indonesia, is known as the “city of a thousand river” due to its extensive river network. according to 2015 data from the banjarmasin city water resources and drainage sector, there are over 100 rivers in the city. the widest river in indonesia is located in this city known as the barito river.9,10 moreover, a significant portion of the population in this city resides along the riverside, where the river serves as a vital aspect of their daily lives. this includes engaging in activities such as trading at floating markets, participating in tourism, using it for transportation, as well as for toileting, washing, and bathing.11,12 human activities in the river have both positive and negative effects. positive effects can enhance the lives of those residing along the riverside, while negative consequences include a decline in water quality, evidenced by an increase in e. coli levels.13 to safeguard the river, effective management is important, requiring collaboration from various sectors, including human, economic, and cultural.14,15 previous study emphasizes the significance of multi-sectoral partnerships in addressing river management.6 to foster effective sanitation in the river and proper waste management for the local community, it is crucial to consider the economic aspect. this can be achieved by leveraging tourism activities along the river.16,17 additionally, cultural considerations play an important role in supporting river management, as belief systems often ascribe crucial importance to a river, viewing them as inseparable from life itself. culture provides a holistic approach to understanding the interconnection between humans, the environment, and spiritual forces.18 this study explored the connection between local culture, specifically values and ways of life and belief, and the well-being of the river among residents living on the riverside in banjarmasin, south kalimantan indonesia. people residing along riverbanks recognize that natural activities in the universe are shaped by living resources and mysticism. they believe that all parts of the environment are interrelated or interdependent. moreover, this perspective holds that environmental misuse will have adverse effects on the entire system.15 consequently, cultural customs play an important role in maintaining the welfare of the environment and natural resources. these concepts shape ways of thinking and decision-making to protect the river. figure 1 shows that banjarmasin is the city of a thousand rivers. figure 2 reveals the physical condition of the river is plastics and polluted from household under the houses. significance for public health addressing river management is primarily a cultural concern, integral to fostering healthy cities and ensuring the well-being of the environment and natural resources. the themes of this study shape ways of thinking and affect decision-making to protect the river. a well-maintained river contributes to achieving sustainable development goal (sdg) number 6, which aims to provide clean water and sanitation. [page 26] [healthcare in low-resource settings 2024;12(s1):13032] non -co mmerc ial us e o nly materials and methods ethical approval was obtained from the health research ethics committee faculty of nursing universitas airlangga, indonesia (number: 1850-kepk). in this study, a mixed method was used. a qualitative design was used to explore the connection between local culture, specifically values and ways of life, beliefs, and health of the river among residents living along the riverside in banjarmasin, south kalimantan indonesia. it also to understand phenomena related to culture.19 a quantitative design was used to evaluate descriptive statistics: frequency and percentage of sociodemographics of participants. the sociodemographics of participants are shown in table 1. data were collected using in-depth interviews, observation, and questionnaires. previous studies related to culture associated with a healthy river include extracting information on value, ways of life, and beliefs.6,18 the interview process was documented through audio recording, transcribed in the banjar language, and subsequently analyzed manually using thematic content analysis.20 to ensure trustworthiness, triangulation was used. subsequently, the identification of all the statements that are relevant to the phenomenon was carried out and the theme was clustered.21,22 data were collected from august to june 2020, and a total of 30 samples were obtained. the sample was people who live on the riverside in banjarmasin, south kalimantan, indonesia, such as antasan segera river, baguntan river, tungku river, banyiur ampera river, pekapuran laut river, and guring river. results and discussion sociodemographic table 1 shows the sociodemographic of participants, totalling 30 individuals. the gender distribution shows 53.3% female (16 participants) and 46.7% male (14 participants). all participants belong to the banjarese ethnic group, with ages ranging from 20 to 63 years. in terms of education, the majority completed senior high school (40%), and 50% of participants identified as housewives in terms of occupation. this study was carried out in the banjarmasin area, known for its numerous rivers and a population residing along the riverbanks for over a decade. consequently, a distinct culture connected to a river has flourished within this community. the results of thorough interviews and observations showed that culture along the river, including values, lifestyle, and beliefs, plays a significant role in shaping approaches to health promotion within river management. value and the way of life human life in society is never separated from values and norms.1 this study uncovered the significant value attributed to the river, showing its integral role in the lives of the people in banjarmasin city. the following is an excerpt from one of the participants’ statements: “we live in the city of a thousand rivers, a reflection of our people’s deep cultural connection. we residing along the riverside not only need the river but also feel it as an integral part of our identity”… (m1.05) “the river is needed and important for our daily lives, and it is more like our best friend”… (m4.18) based on the results of the in-depth interview, the majority chose to reside along the riverside due to a sense of comfort and the various advantages derived from the river. in addition, this preference for riverside living was often inherited from preceding generations. the observations in communities showed that the river in banjarmasin was used to conduct daily activities, recreation such as fishing or playing (figure 3 and figure 4) as well as for religious activities (figure 5) and household activities, such as washing dishes, clothes, or toileting (figure 6). some residents also use the river as a transportation route (figure 7) (observation notes, december 2020 to march 2021). 4th international nursing and health sciences symposium figure 1. banjarmasin is the city of a thousand rivers (photos by herawati, 2020). figure 2. the physical condition of the river is plastics and polluted from household under the houses (photos by herawati, 2020). figure 3. fishing on the riverside (photos by herawati, 2020). [healthcare in low-resource settings 2024;12(s1):13032] [page 27] non -co mmerc ial us e o nly belief certain banjarese individuals hold beliefs connected to the rivers, such as the notion that the river serves as a location for dispelling diseases among children, referred to as the “belabuh” tradition. this perspective is evident in the following statement: “the belantingan ritual, locally known as “belabuh,” is a practice aimed at warding off diseases among children by using the river as a means of purification”… (m4.19) “the tradition, known as “belabuh,” is believed to have the power to ward off illnesses from children when they are sick”… (m4.20) some residents perceive living along the riverside as a symbol of wealth, associating it with boat ownership (figure 8). this can be seen from the following statement: “i’ve heard that culture showed that people living by the riverside have a lot of money, isn’t that right? maybe he had a boat like that in the past. maybe if i look here the houses are tens of meters from the edge of the river... according to our perception, that is wrong. as long as the community remains undisturbed and the river’s flow is unaffected, i believe it is acceptable. this is my personal opinion, acknowledging that deviation from established rules might not always imply wrongdoing”… (m1.01) the belief system in banjarese culture includes myths about the river, including the existence of a supernatural entity referred to as “dangsanak,” which is associated with familial ties. according to residents, dangsanak is a ghost and sometimes appears like a crocodile. this can be seen from the following statement: “the water’s ghost resembles a tree trunk as the bamboo piece rises and falls—a spectral presence. in ba’ah’s water, there are crocodiles”... (m4.18) “there used to be gaduhan (red: pet) crocodiles...but now there are none”… (m1.04) according to several participants, the existence of this myth can be used to approach the community in protecting a river, but this belief is starting to disappear. this can be seen from the following statement: “in fact, if we go back to the local wisdom of banjar culture, there is the term pamali (ed: sinful), such as pamali throwing away ratik (ed: rubbish), throwing rigat (ed: dirty) into the river. this practice is discouraged due to the presence of dangsanak (red: family/relatives). the cultural approach that prohibits throwing rubbish into the river is considered right in the context of banjar 4th international nursing and health sciences symposium table 1. sociodemographic of participants participant id sex age ethnic education degree occupation residence time (years) name of river m1.01 m 28 banjarese senior high school private employee 28 antasan segera m1.02 m 57 banjarese elementary school dust man 31 antasan segera m1.03 f 51 banjarese elementary school housewife 51 antasan segera m1.04 m 36 banjarese junior high school housewife 14 antasan segera m1.05 f 26 banjarese junior high school housewife 26 antasan segera m2.06 f 51 banjarese senior high school housewife 18 baguntan m2.07 f 39 banjarese junior high school housewife 15 baguntan m2.08 f 42 banjarese elementary school housewife 18 baguntan m2.09 f 44 banjarese senior high school housewife 20 baguntan m2.10 f 54 banjarese senior high school housewife 19 baguntan m3.11 f 49 banjarese senior high school seller 49 banyiur ampera m3.12 m 59 banjarese elementary school seller 50 banyiur ampera m3.13 m 45 banjarese elementary school seller 40 banyiur ampera m3.14 m 41 banjarese senior high school dustman 41 banyiur ampera m3.15 f 48 banjarese senior high school neighborhood 48 banyiur ampera m4.16 m 36 banjarese elementary school private employee 11 pekapuran laut m4.17 f 32 banjarese elementary school housewife 10 pekapuran laut m4.18 m 37 banjarese junior high school unemployment 37 pekapuran laut m4.19 f 39 banjarese junior high school housewife 11 pekapuran laut m4.20 f 20 banjarese junior high school housewife 10 pekapuran laut m5.21 m 48 banjarese elementary school security guard 25 tungku m5.22 m 60 banjarese bachelor degree self-employee 24 tungku m5.23 f 39 banjarese bachelor degree housewife 39 tungku m5.24 f 46 banjarese senior high school housewife 30 tungku m5.25 f 52 banjarese senior high school housewife 25 tungku m6.26 m 63 banjarese elementary school tailor 20 guring m6.27 f 33 banjarese senior high school housewife 33 guring m6.28 m 45 banjarese senior high school self-employee 35 guring m6.29 m 46 banjarese private employee 40 guring m6.30 m 58 banjarese senior high school self-employee 34 guring [page 28] [healthcare in low-resource settings 2024;12(s1):13032] non -co mmerc ial us e o nly culture. according to the language of the ancients, it is viewed as a sin to dispose of items like ratik in the river because of the presence of dangsanak, emphasizing the responsibility to care for these living creatures in the water. dangsanak means that there is a living creature that was created for us to look after, and care for. there are indeed dangsanak in the river”… (m5.22) “there is local wisdom which often includes myths, such as those about crocodiles in the river. one myth suggests that if you defecate in the river, your stomach will swell—an imaginative way to discourage actions that might harm the water. additionally, cautionary tales about big snakes in the sabilal region contribute to the cultural emphasis on respecting and protecting the environment. that’s what they say if we pass this region and don’t respect the river, thereby you will be eaten by crocodiles. that’s a myth. it used to protect the river... maybe”...(m1.04) the banjarese people still have a “river culture”, which can be defined as a way of life for people who live close to the river. making the river a “way of life” and shaping the character of the community. the river culture is characterized by the existence of riverside settlements, floating markets, and jukungs, and the social interactions that occur.23 furthermore, it also means that the river has traditionally been the lifeblood of the community. the river as the lifeblood of the banjarese people (also of banjarmasin city), includes physical aspects (the physical quality and quantity of the river); ecological (the river ecosystem), economic (transportation, floating markets, fishing, irrigation), and social.24 4th international nursing and health sciences symposium figure 4. playing on the riverside (photos by herawati, 2020). figure 5. mosques on the riverside (photos by herawati, 2020) figure 6. fishing on the riverside (photos by herawati, 2020). figure 7. banjarmasin is the city of a thousand rivers (photos by herawati, 2020). figure 8. the physical condition of the river is plastics and polluted from household under the houses (photos by herawati, 2020). [healthcare in low-resource settings 2024;12(s1):13032] [page 29] non -co mmerc ial us e o nly a river serves as more than just waterways; they are vital connections that link humans with diverse forms of life and embody cultural values.18 according to subiyakto, the banjarese people are described as a “river-oriented” society, showing that their activities and community life revolve around the deep significance of the river in their culture. the river holds significant traditions for the banjarese people, embodying practices that have endured over time and seamlessly integrated into the life of the community.25 according to linton, an anthropologist, cultures such as values and beliefs are difficult to change and difficult to replace with others.26 to maintain the welfare of the environment and natural resources, specifically the river, support implementation of public policies is needed. the role of stakeholders as authority holders and the community becomes an important thing. therefore, the relationship of mutual support greatly influences the implementation of the policy(fauzi & sompa, 2021).27 of course, it is necessary to involve the community with their culture as a local wisdom.13 participation or support in the community is also influenced by cultural values, such as the values, norms, and beliefs that constitute social.28 the cultural approach in policy implementation relies on the values and perspectives of local communities, emphasizing the viewpoint of the natives in the process. the cultural approach is also often referred to as the bottom-up approach. through this cultural value or local knowledge approach in the river management system in banjarmasin city, it becomes possible to promote health and protect the river from waste, thereby fostering positive values essential for river maintenance. conclusions in conclusion, cultural customs are needed to maintain the welfare of the environment and natural resources. this study showed two key themes related to the cultural significance of a river: values, and ways of life, as well as beliefs. using this approach, health promotion efforts can be implemented to protect the river from waste. furthermore, this study emphasizes the importance of respecting local wisdom, particularly in understanding the interconnected relationship between humans and a river. regulatory measures should take into account this diversity for effective environmental management. references 1. abbas ew, jumriani j, syaharuddin s, subiyakto b, rusmaniah r. portrait of tourism based on river tourism in banjarmasin. kalimantan soc studies j 2021;3:18–26. 2. chan nw. managing urban rivers and water quality in malaysia for sustainable water resources. internat j water resour develop 2012;28:343–54. 3. grizzetti b, liquete c, pistocchi a, et al. relationship between ecological condition and ecosystem services in european rivers, lakes and coastal waters. sci total environ 2019;671:452–65. 4. zuo q, hao m, zhang z, jiang l. assessment of the happy river index as an integrated index of river health and human well-being: a case study of the yellow river, china. water 2020;12:3064. 5. hansen hh, bergman e, cowx ig, lind l, pauna vh, willis ka. resilient rivers and connected marine systems: a review of mutual sustainability opportunities. global sustainability 2023;6:e2. 6. herawati h, keman s, rukmini devy s. understanding the experience of multi-sectoral partnerships in river management for a healthy and sustainable city in banjarmasin, indonesia. mjphm 2022;22:230-6. 7. zuo q, hao m, zhang z, jiang l. assessment of the happy river index as an integrated index of river health and human well-being: a case study of the yellow river, china. water 2020;12:3064. 8. xu d, zhu d, deng y, sun q, ma j, liu f. evaluation and empirical study of happy river on the basis of ahp: a case study of shaoxing city (zhejiang, china). mar freshwater res [internet] 2023 [cited 2023 jul 29]; available from: https://www.publish.csiro.au/mf/mf22196. 9. central statistics agency of south kalimantan. south kalimantan in figures 2015. south kalimantan: central statistics agency of south kalimantan; 2015. 4th international nursing and health sciences symposium correspondence: herawati, school of nursing, faculty of medicine and health science, universitas lambung mangkurat, jl. ah. yani km 36, banjarbaru, south kalimantan, indonesia 65151, ph: +625114773470, e-mail: herawati@ulm.ac.id keywords: culture; health; river contributions: the authors contributed equally. conception and design: hw, as, sk, srd. analysis and interpretation of the data: hw, srd. drafting of the article: hw, as, liek. critical revision of the article for important intellectual content: hw and as. final approval of the article: hw and as. obtaining funding: hw. collection and assembly of data: hw, liek. conflict of interest: the author declares no potential conflict of interest. funding: this study was financially supported by the ministry of education, culture, research and technology/national research and innovation agency ethics approval and consent to participate: ethical approval was obtained from the health research ethics committee faculty of nursing universitas airlangga, indonesia (number: 1850-kepk). clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to residents who live in riverside banjarmasin for their participation in this study. received: 3 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13032 doi:10.4081/hls.2024.13032 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 30] [healthcare in low-resource settings 2024;12(s1):13032] non -co mmerc ial us e o nly 10. south kalimantan provincial health office. south kalimantan health profile 2017. south kalimantan: south kalimantan provincial health office; 2018. 11. abbas ew, handy mrn, shaleh rm, hadi ntfw. ecotourism of martapura river banjarmasin as a learning resources on social studies. innovat soc studies j 2020;1:111–9. 12. matnuh h, adawiah r, putra ap. problemate river management in the city a thousand river. psychol educat j 2021;58:9752–62. 13. angriani p, sumarmi, ruja in, bachri s. river management: the importance of the roles of the public sector and community in river preservation in banjarmasin (a case study of the kuin river, banjarmasin, south kalimantan – indonesia). sustainable cities soc 2018;43:11–20. 14. arthington ah, bhaduri a, bunn se, et al. the brisbane declaration and global action agenda on environmental flows (2018). front environ sci 2018;6:45. 15. harmsworth g, young r, walker d, et al. linkages between cultural and scientific indicators of river and stream health. new zealand j marine freshwater res 2011;45:423–36. 16. akpan ei, obang ce. tourism: a strategy for sustainable economic development in cross river state, nigeria. internat j business soci sci 2012;3:124-9. 17. putro hpn, jumriani, abbas ew, aprilla w. impact of tourism for economic activities of riverbank communities in the jingah river district, banjarmasin city. in atlantis press; 2021 [cited 2023 jul 29]. p. 372–5. available from: https://www.atlantis-press.com/proceedings/icsse-20/ 125953125. 18. anderson ep, jackson s, tharme re, douglas m, flotemersch je, zwarteveen m, et al. understanding rivers and their social relations: a critical step to advance environmental water management. wires water 2019;6:e1381. 19. meyer j. using qualitative methods in health related action research. bmj 2000;320:178–81. 20. vaismoradi m, turunen h, bondas t. content analysis and thematic analysis: implications for conducting a qualitative descriptive study. nursing health sci 2013;15:398–405. 21. creswell jw, creswell jd. research design: qualitative, quantitative, and mixed methods approaches. california: sage publications; 2017. 22. morrow r, rodriguez a, king n. colaizzi’s descriptive phenomenological method. psychologist 2015;28:643-4. 23. rahman s, mentayani i, rusmilyasari r, mahreda e. concept of arrangement of riverbank slum settlements in sungai bilu village, banjarmasin city. enviroscienteae 2019;15:397. 24. angriani p. community-based river management: learning from the sungai kuin area of banjarmasin. malang: media nusa creative (mnc publishing); 2021. 25. kamisorei rv, devy sr. description of beliefs about the efficacy of chewing betel in papuan society in ardipura i subdistrict, south jayapura district, jayapura city. jurnal promkes 2017;5:232-44. 26. fauzi m, sompa at. policy implementation of banjarmasin government in maintaining the “city of a thousand rivers” icon. internat j political law soc sci 2021;2(1). 27. agampodi tc, agampodi sb, glozier n, siribaddana s. measurement of social capital in relation to health in low and middle income countries (lmic): a systematic review. soc sci med 2015;128:95-104. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13032] [page 31] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13005 exploring the relationship between self-stigma and resilience among people living with hiv: a cross-sectional study ahmad ikhlasul amal,1,2 tintin sukartini,1 ninuk dian kurniawati,1 sofyanudin,2 retno setyawati2 1faculty of nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang, indonesia abstract hiv is a disease that not only affects physical health but also carries a heavy psychological burden, primarily through self-stigma. self-stigma can lead to low self-esteem, helplessness, and social isolation, weakening resilience or an individual’s ability to survive and adapt to life’s challenges. however, there is a gap in knowledge regarding the specific mechanisms by which resilience can mitigate the impact of self-stigma on plhiv. whether resilience can completely neutralize the effects of self-stigma or only partially is a question that still requires further answers. this study aims to find out the relationship between self-stigma and resilience among people living with hiv. this research used an observational research design using a cross-sectional approach. 150 hiv patients at six public health centre of semarang city were involved in using purposive sampling techniques. the data was gathered using the indonesian version of cd-risc and the indonesian version of the self-stigma questionnaire. spearman rank correlations were used to analyze the data. the health research ethics committee of the faculty of nursing at universitas islam sultan agung has approved this study as ethically appropriate. the results found a relationship between self-stigma and resilience where a p-value of 0.006 < α (0.05) with a contingency coefficient value of 0.222. the self-stigma and resilience have a weak correlation. self-stigma can weaken the ability to create resilience in plhiv, although the impact may vary depending on other factors. nurses or health workers need to pay attention to plhiv, who experience self-stigma, to rise and be resilient while being hiv positive. introduction hiv (human immunodeficiency virus) is a global health problem that has posed significant challenges to society. despite efforts to improve understanding and treatment of hiv, stigma towards people living with hiv (plhiv) remains a significant barrier to disease management.1,2 this stigma does not only come from the general public but can also originate from within the individual, known as self-stigma. self-stigma occurs when plhiv internalizes negative views from society and perceives themselves as worthless and sinful or blame themselves for their condition.3 this self-stigma often leads to a decline in quality of life, mental health, and overall well-being.4,5 self-stigma was found to often occur over two years from the initial diagnosis and was formed through several stages.6 self-stigma is formed through four stages: awareness, belief or selfapproval, application or action, and loss.7 the formation of individual awareness that hiv-aids is an infectious and deadly disease, belief or self-agreement that odhiv will be ostracized, application or action to cover up their hiv status and losses characterized by the absence of opportunities for self-improvement.8 self-stigma formed in hiv patients arises because of the knowledge and negative information obtained previously. resilience, or the ability to bounce back from adversity and persist in challenging situations, is a crucial factor in the wellbeing of plhiv.9 resilience can help individuals deal with stigma, overcome challenges associated with hiv, and stay connected to social support networks.10,11 however, the relationship between self-stigma and resilience in plhiv still needs to be fully understood. some studies suggest that self-stigma can reduce the level of resilience.12 in contrast, others have found that individuals with correspondence: ahmad ikhlasul amal, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: ahmad.ikhlasul.amal-2020@fkp.unair.ac.id key words: hiv, resilience, self-stigma. contributions: aia, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ts, ndk, conceptualization, methodology, validation, and writing – original draft, review & editing; s, data curation, visualization, writing – review & editing; rs, methodology, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: based on ethical certificate 920/a.1/kepk-fik-sa/xi/2022, the health research ethics commission, faculty of nursing, universitas islam sultan agung, gave the research ethical permission. the researcher follows the ethical guidelines of beneficence, non-maleficence, respect for human rights, and information to consent when doing the study. patient consent for publication: written informed consent was acquired to publish anonymized patient information in this article. funding: none. availability of data and materials: this published article includes all the data generated or analyzed during the project. acknowledgments: we thank the head of the semarang city health office for the support that has been given for the smooth implementation of this research. received: 4 september 2024. accepted: 11 october 2024. early access: 23 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13005 doi:10.4081/hls.2024.13005 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 28] [healthcare in low-resource settings 2025;13:13005] solid resilience can counter the negative impact of self-stigma.13 data from a previous study in semarang city, indonesia, found that 54.5% of odhiv were found to experience moderate levels of self-stigma, where odhiv felt insecure, and the majority had not been able to adapt well to problems that arose during the diagnosis of hiv/aids.14 the resilience rate in a previous study in semarang city found that 41.2% of odhiv still had a moderate level of resilience, which means that improvement efforts are still needed.15 self-stigma can prevent plhiv from seeking necessary care, adhering to treatment, and participating in social life. selfstigma can also exacerbate psychological conditions such as depression and anxiety, which in turn can affect resilience.3,12 previous research has shown that resilience can be a protective barrier against various psychosocial stressors, including self-stigma.12 however, there is a gap in knowledge regarding the specific mechanisms by which resilience can mitigate the impact of self-stigma on plhiv. whether resilience can completely neutralize the effects of self-stigma or only partially is a question that still requires further answers. to fill the research gap, our study attempts to investigate and comprehend the association between self-stigma and resilience in plhiv. materials and methods research design this study utilized a cross-sectional design. study participants data were collected at six public health centre, semarang city, central java, indonesia. this study used a purposive sampling technique. the lemeshow formula calculated the sample size; a minimum sample size of 150 plhiv would provide actual values at a 95% confidence interval (95% ci) leve.16 this study’s inclusion criteria are hiv patients who have been diagnosed for less than a year, are willing to participate, and can read and write. exclusion criteria include being referred to the hospital, being uncooperative, and having cognitive impairment. all subjects provided informed consent before data collection. variable, instrument, and data collection the independent variable in this study was self-stigma, and the dependent variable was resilience. this study used a 25-item conor davidson resilience scale (cd-risc) indonesian version. the cdrisc validity test yielded an r-value ranging from 0.255 to 0.666, and the instrument had a high-reliability coefficient of 0.879. selfstigma questionnaire indonesian version, 28 items. the indonesian version of the questionnaire was evaluated for validity and reliability, yielding a cronbach’s alpha score of 0.769. the validity test findings yielded an r-value of 0.367–0.839. the reliability test had a cronbach alpha of 0.955. data collection was carried out by distributing questionnaires to respondents through online forms. data analysis data were analyzed univariately using a frequency distribution table for each variable in the study, both dependent and independent. a bivariate analysis was performed to determine the association between the dependent and independent variables using the spearman test with a significance level of 5%. the data was analyzed using spss software. results univariate analysis of participants demographic and variable the average age of responders was 30.35 years, with the youngest at 26 years and the oldest at 47 years. most responses were male, accounting for 92 (61.3%). the most common marital status among respondents is single, with 98 (65.3%). the frequency of self-stigma distribution reveals that most respondents have a high level of self-stigma, with 95 (63.3%). the frequency of resilience distribution demonstrates that the dominating respondents had a low level of resilience, with 104 (69.3%; table 1). article table 1. participants demographic and variable description (n=150). variable mean±sd median minimum-maximum age 30.35±4.85 28.00 26-47 variable frequency percentage gender male 92 61.3 female 58 38.7 total 150 100.0 variable frequency percentage marital status single 98 65.3 married 40 26.7 divorced 12 8.0 total 150 100.0 variable frequency percentage self-stigma low 15 10.0 moderate 40 26.7 high 95 63.3 total 150 100.0 variable frequency percentage resilience low 104 69.3 moderate 9 6.0 high 37 24.7 total 150 100.0 [healthcare in low-resource settings 2024;12:13005] [page 29] relationship between self-stigma and resilience the study found a strong association between self-stigma and resilience among plhiv (sig value = 0.006; p<0.05). the correlation score of 0.222 suggests the association is positive and weak (table 2). discussion the study’s results revealed a relationship between self-stigma and resilience. self-stigma was measured using a scale that identifies the level of internalization of stigma in individuals living with hiv. in contrast, resilience was measured through a scale that assesses an individual’s ability to survive and adapt to life challenges. although a correlation was found between self-stigma and resilience, the results showed that this relationship was not very strong, indicating that other factors may play a more significant role in shaping resilience in plhiv. self-stigma may affect resilience by decreasing motivation to seek help or engage in self-care, which is essential for the wellbeing of plhiv.17 however, there are also individuals who, despite experiencing self-stigma, still show a high level of resilience. this correlation indicates that other factors, such as social support, effective coping strategies, and life experiences, may act as protective barriers that help individuals overcome the negative impact of self-stigma.18 the results of this study show that the average age of respondents is in young adulthood. younger odhiv tend to have stronger self-stigma because they face more significant social pressures related to life expectations, work, and social relationships.19,20 in addition, younger odhiv may not have sufficient experience or skills to manage negative emotions or deal with discrimination effectively. however, this contradicts previous research, which found that older people were more prone to selfstigma due to the decline in physical abilities in older people.21 the research findings show that gender influences the level of self-stigma in plhiv. there is a significant difference in self-stigma levels between male and female genders, with some studies showing that women tend to experience higher levels of self-stigma than men.22 different social and cultural factors, as well as gender roles in society, may influence an individual’s self-perception of the disease and the stigmatization associated with hiv. marital status has an impact on self-stigma in plhiv. married individuals tend to experience lower levels of self-stigma than individuals who are not married or who are in unstable relationships.23,24 married people experience lower levels due to more robust emotional and social support from their spouse, which can reduce feelings of isolation and worthlessness that are often associated with the self-stigma of plhiv. in addition, intimacy and more open communication within the marital relationship may create an environment that promotes self-acceptance and reduction of internalized hiv-related stigma.25 the relationship between self-stigma and resilience arises because self-stigma can hinder self-development and an individual’s ability to overcome life’s challenges. feeling ashamed or devalued because of the internalized stigma can reduce their selfconfidence, self-esteem, and ability to bounce back from difficult situations, which is at the core of resilience.26,27 individuals with high self-stigma may feel less capable or deserving of social support, resulting in social isolation and a lack of support networks essential for building resilience. conversely, if individuals can overcome self-stigma by developing self-acceptance, understanding their condition, and seeking social support, they can increase their resilience.28 self-stigma, which occurs when individuals internalize hivrelated social stigma, often contributes to decreased self-confidence, feelings of shame, and social isolation. self-stigma can hinder individuals’ ability to access necessary emotional and medical support, reducing their ability to survive and adapt to life’s challenges. on the other hand, resilience is the ability to bounce back from adversity and remain optimistic in the face of obstacles, which is critical for plhiv to maintain a good quality of life.29,30 this study has various limitations because of bidirectional causation and confounding variables. determining a direct cause-andeffect link can be difficult because many studies are cross-sectional. furthermore, the study’s sample size of only 150 respondents may be typical of the larger community of plhiv who experience self-stigma. given the small sample size, the study’s conclusions must be more broadly applicable. furthermore, it is possible that several variables that could influence the correlation between selfstigma and resilience—like mental health and social support— were not fully considered in this analysis, which could impact the study’s internal validity. conclusions this study revealed a correlation between self-stigma and resilience among plhiv. high self-stigma tends to be associated with lower levels of resilience, suggesting that the internalized stigma felt by plhiv may hinder their ability to deal with the challenges and stress related to their condition. conversely, high levels of resilience could potentially help plhiv to cope more effectively with self-stigma, supporting them in maintaining better mental health and quality of life. we suggest that future research could benefit from adopting a longitudinal design that better assesses causality between self-stigma and resilience over time, reducing the issue of bidirectional causation. increasing the sample size would improve the generalizability of findings to a broader population of people living with hiv (plhiv), thus making conclusions more robust. references 1. williams r, cook r, brumback b, et al. the relationship between individual characteristics and hiv-related stigma in adults living with hiv: medical monitoring project, florida, 2015-2016. bmc public health 2020;20:1–10. 2. kementerian kesehatan ri. peraturan menteri kesehatan republik indonesia nomor 23 tahun 2022 tentang penanggulangan human immunodeficiency virus, acquired immunodeficiency syndrome, dan infeksi menular seksual. permenkes ri 2022;69:1–53. 3. demirel of, mayda py, yıldız n, et al. self-stigma, depression, and anxiety levels of people living with hiv in turkey. eur j psychiatry 2018;32:182–6. article table 2. relationship between self-stigma and resilience (n=150). resilience self-stigma r 0.222 p 0.006 n 150 [page 30] [healthcare in low-resource settings 2025;13:13005] 4. oke oo, akinboro ao, olanrewaju fo, et al. assessment of hiv-related stigma and determinants among people living with hiv/aids in abeokuta, nigeria: a cross-sectional study. sage open med 2019;7:2050312119869109.  5. mukaromah n, ferianto f, lestari r. hubungan stigma diri dengan kualitas hidup orang dengan hiv/aids di yogyakarta. media ilmu kesehat 2023;12:56–68. 6. oexle n, müller m, kawohl w, et al. self-stigma as a barrier to recovery: a longitudinal study. eur arch psychiatry clin neurosci 2017;0:0. 7. corrigan pw, rao d. on the self-stigma of mental illness: stages, disclosure, and strategies for change. can j psychiatry 2012;57:464–9. 8. adam a, badwi a, palutturi s. analysis of factors associated with self-stigma (plhiv) on the hiv and aids incidencein jongaya positive care supporting group of makassar city. indian j public heal res dev 2019;10:2507–12. 9. de brito hl, seidl emf. resilience of people with hiv/aids: influence of religious coping. trends psychol 2019;27:647– 60. 10. gottert a, mcclair tl, pulerwitz j, friedland ba. what shapes resilience among people living with hiv? a multicountry analysis of data from the plhiv stigma index 2.0. aids 2020;34:s19–31. 11. mealer m, jones j, meek p. factors affecting resilience and development of posttraumatic stress disorder in critical care nurses. am j crit care 2017;26:184–92. 12. post f, buchta m, kemmler g, et al. resilience predicts selfstigma and stigma resistance in stabilized patients with bipolar i disorder. front psychiatry 2021;12:1–8. 13. brewer r, hood kb, moore m, et al. an exploratory study of resilience, hiv-related stigma, and hiv care outcomes among men who have sex with men (msm) living with hiv in louisiana. aids behav 2020;24:119–29. 14. wicaksono ya, fitrikasari a, sofro mau, peni h. hubungan stigma dan terapi arv dengan komplikasi gangguan psikiatri pada pasien hiv/aids. j penyakit dalam indones 2018;5:24. 15. pitaloka ad. gambaran konsep diri dan resiliensi orang hiv (odhiv). 2023. 16. lemeshow s, jr dwh, klar j, lwanga sk. adequacy of sample size in health studies. technometrics. 1990. 17. tian h. review of factors affecting psychological resilience. 2019 6th asia-pacific conference on social sciences, humanities (apssh 2019) 2019:107–11. 18. glennie ej. coping and resilience. noncognitive skills in the classroom: new perspect educ res 2010. 169–194 p. 19. ghidei l, simone m, salow m, et al. aging, antiretrovirals, and adherence: a meta analysis of adherence among older hivinfected individuals. drugs aging 2013;309:2105–6. 20. mentari gb, susilawati. faktor-faktor yang mempengaruhi akses pelayanan kesehatan di indonesia. j heal sains 2022;3:1–8. 21. mackenzie cs, heath pj, vogel dl, chekay r. age differences in public stigma, self-stigma, and attitudes toward seeking help: a moderated mediation model. j clin psychol 2019;75:2259–72. 22. lalhruaimawii i, danturulu mv, rai s, et al. determinants of stigma faced by people living with human immunodeficiency virus: a narrative review from past and present scenario in india. clin epidemiol glob heal 2022;17:101117. 23. li x, yuan l, li x, et al. factors associated with stigma attitude towards people living with hiv among general individuals in heilongjiang, northeast china. bmc infect dis 2017;17:1–6. 24. xiao z, li x, qiao s, et al. coping, social support, stigma, and gender difference among people living with hiv in guangxi, china. psychol heal med 2018;23:18–29. 25. gutin sa, ruark a, darbes la, et al. supportive couple relationships buffer against the harms of hiv stigma on hiv treatment adherence. bmc public health 2023;23:1–12. 26. abiola t, udofia o. psychometric assessment of the wagnild and young’s resilience scale in kano, nigeria. bmc res notes 2011;4:509. 27. garrido-hernansaiz h, alonso-tapia j, martín-fernández m. coping in newly diagnosed, spanish-speaking men who have sex with men and live with hiv** a bayesian approach. eur j ment heal 2019;14:41–57. 28. maria a. literature review: intervensi dalam mengatasi stigma-diri pada pasien hiv/aids. i care j keperawatan stikes panti rapih 2020;1:71–80. 29. zhu m, guo y, li y, et al. hiv-related stigma and quality of life in people living with hiv and depressive symptoms: indirect effects of positive coping and perceived stress. aids care psychol socio-medical asp aids/hiv 2020;32:1030–5. 30. odili vu, ikhurionan ib, usifoh sf, oparah ac. determinants of quality of life in hiv/aids patients. west african j pharm 2011;22:42-8. article [healthcare in low-resource settings 2025;13:13005] [page 31] hrev_master healthcare in low-resource settings 2024; volume 12:12705 assessing sexual-abuse prevention knowledge and related factors among adolescent girls with intellectual disabilities in padang: a cross-sectional study arif rohman mansur,1 meri neherta,1 lili fajria,1 ira mulya sari,1 yelly herien,1 mutia farlina,1 putri dwi rusmayanti2 1maternal and child health nursing department, faculty of nursing, universitas andalas, padang; 2nursing graduate, bachelor of science in nursing program, faculty of nursing, universitas andalas, padang, indonesia abstract sexual abuse among adolescents with intellectual disabilities (id) has been significantly under-researched despite their high vulnerability. this study aimed to assess the sexual abuse prevention knowledge of adolescent girls with id in padang and explore how various respondents’ characteristics relate to the risk of sexual abuse. findings from this study may inform future prevention strategies and support services. a descriptive cross-sectional approach was utilized, and involved 50 adolescent girls from five special education schools in padang. respondents were assessed using the illustrated scale measuring sexual abuse prevention knowledge, which covered five key domains. the study analyzed the risk of sexual abuse and related factors. the findings revealed significant knowledge disparities, especially in identifying abusive situations, with notably low scores. statistical analysis showed a strong correlation between the disability category and additional mental or physical conditions, indicating an increased risk of sexual abuse. the results emphasize the urgent need for customized educational programs to address the specific challenges faced by adolescents with id. enhancing sexual abuse prevention knowledge is crucial for reducing their victimization risk. the study recommends comprehensive educational strategies and supportive interventions tailored to their cognitive and physical profiles. introduction the prevalence of sexual abuse among adolescent girls with intellectual disabilities (id) is alarmingly high. estimates indicate that 14% to 32% of these individuals experience abuse, which is 4 to 8 times higher than the rates among their peers without disabilities. this disparity underscores their significantly increased vulnerability to sexual victimization.1 additionally, studies reveal that one in three adults with id has experienced sexual abuse, often perpetrated by other individuals with id.2,3 the vulnerability of this population is highlighted by prevalence rates: 32.9% of adults with id in the uk experience sexual abuse, compared to 15.2% in the usa.4 in a specific study, 2.67% of girls with mild id were reported to have been abused.5 in padang, indonesia, the population of children with disabilities in 2020 was recorded at 1,625.6 this city has seen a concerning rise in cases of sexual abuse among children, particularly those with id, with cases increasing from 57 in 2016 to 78 in 2017.7 adolescent girls with id in padang are especially vulnerable due to their impaired cognitive and adaptive functioning, which limits their ability to recognize and respond to abuse. id is characterized by significant limitations in cognitive and adaptive functioning, and is classified into four levels mild, modcorrespondence: arif rohman mansur, maternal and child health nursing department, faculty of nursing, universitas andalas, padang 25151, indonesia. tel. +62 751 779233; +62 852 28892075. e-mail: arifrohmanmansurphd@nrs.unand.ac.id key words: intellectual disabilities; sexual abuse prevention; adolescent health; educational interventions; vulnerability assessment. contributions: the study was designed and conceptualized by the entire team, with arm leading the effort; mn and lf were responsible for identifying the study's population and managing the recruitment process; ims translated and adapted the illustrated scale measuring the sexual abuse prevention knowledge questionnaire; yh ensured its validity; mf obtained ethical approvals and permissions for the study; pdr led the data collection process; arm and mn performed univariate and bivariate analyses. the manuscript was drafted by all authors, with arm leading the writing and yh and mf reviewing and finalizing it for submission. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the study received ethical approval from the ethics commission team of universitas andalas under reference number 1098/un.16.2/kep-fk/2023, ensuring full adherence to ethical standards. informed consent: for participants under 18, parental assent was obtained, while those 18 and older provided informed consent themselves, unless legally incapable due to intellectual disabilities. this approach respects the autonomy of adolescents and adheres to ethical standards in human research. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: this study was supported by research and community service universitas andalas for the grand research indexed publication research (rpt) with contract number t/17/un.16.17/pt.01.03/ko-rpt/2022. the authors would like to thank the five special schools in padang city. we also thank all adolescent girls with intellectual disabilities for their participation in this study. received: 2 june 2024. accepted: 10 july 2024. early access: 8 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12705 doi:10.4081/hls.2024.12705 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 694] [healthcare in low-resource settings 2024;12:12705] non -co mmerc ial us e o nly erate, severe, and profound based on these functional limitations.8 it involves impairments in various aspects of intelligence, including socialization, knowledge, speech, and motor function, affecting social, motor, and practical skills.9,10 the diverse nature of id is influenced by environmental factors, genetic mutations, or chromosome aberrations.11 in padang, these disabilities range from mild to moderate, with most affected children falling into these categories. several factors contribute to the increased risk of sexual abuse among girls with id, including lack of adequate training, irrational reactions from families and communities, and the girls’ own inadequate responses.5 familial risk factors include low education levels of parents, economic problems, early marriage of parents, and broken families.12 children with id are at heightened risk due to lower sexual knowledge levels and inadequate sexual education.13 they also face communication barriers that hinder their ability to report abuse effectively, further exacerbating their vulnerability.14 additionally, familial factors such as poverty, low parental education levels, and maternal unawareness limit the family’s capacity to provide adequate protection and support.15 in padang, there are 44 special schools (slb) in sumatera barat, with two (4.55%) being government-owned and the remaining 37 (84.09%) privately owned.16 most students are enrolled in the public slbs and the three private slbs used for this research. these special needs schools focus on enhancing various aspects of children’s development, including cognitive skills, vocational training, adaptive behavior, and physical activity.17-19 the significance of this study lies in the critical need to enhance sexual abuse prevention knowledge and strategies, particularly among high-risk groups like adolescent girls with id in padang. these individuals face increased vulnerability due to their cognitive limitations, underscoring the importance of tailored educational programs. by focusing on this demographic, the research aims to mitigate risks and promote safer developmental environments through informed, effective interventions. this cross-sectional study assesses the sexual abuse prevention knowledge within this group and explores how various characteristics related to their disability impact their risk of sexual abuse. conducted in five special schools in padang, the study offers detailed insights into the educational deficiencies these students face. the findings are intended to lay the groundwork for future strategies that address these educational gaps, thereby reducing the incidence of sexual abuse among these youths and improving their overall safety and well-being. this approach not only addresses an urgent local need but also contributes to the broader goal of protecting vulnerable populations from sexual abuse. materials and methods study participants the study population consisted of all students with id attending five special schools in padang. a total sampling method was employed to ensure comprehensive coverage, incorporating all eligible students with id from these schools. the sample size for this study was 50 adolescents with id. the inclusion criteria were adolescents with mild or moderate id, aged 12 to 22 years, who were cooperative and willing to participate. the study focused on the critical transitional period from 12 to 22 years, examining developmental trajectories and educational outcomes in individuals with id, aligning with developmental psychology. exclusion criteria included: adolescents with severe id or other co-existing disabilities such as quadriplegia, deafness, blindness, autism, or those who were ill at the time of the study. research instruments the measurement tools used in this study were carefully designed to suit the intellectual abilities of participants. these included a demographic data questionnaire and the illustrated scale measuring sexual abuse prevention knowledge.20 the scale consists of 30 items, divided into 20 true/false items and 10 multiple-choice items, covering five main domains: puberty physiology (pp), body boundaries (bb), identification of improper sexual relationships (isr), identification of abusive situations (ias), and coping methods when facing abusive situations (cm). the scale assesses various aspects, such as understanding physical changes during puberty, knowledge of private body parts and the right to protect one’s own body, awareness of inappropriate sexual relationships, ability to recognize abusive situations, and strategies for coping with abuse. each correct response receives a score of 1, and each incorrect response receives a score of 0, with total possible scores ranging from 0 to 30. higher scores indicate better knowledge of sexual abuse prevention. the internal consistency reliability of the scale was satisfactory, with cronbach’s alpha values of 0.81 for true/false items, 0.74 for multiple-choice items, and 0.84 for the entire scale. subscale reliabilities varied: pp (α=0.82), bb (α=0.63), isr (α=0.92), ias (α=0.75), and cm (α=0.54). the reliability of multiple-choice items ranged from 0.51 to 0.65. the effectiveness of these adapted instruments was previously verified through a validation study involving ten children with mild id.21 procedure after securing the necessary research permits and passing ethical review, the researcher created a total sampling frame to identify and enumerate all eligible participants. this involved identifying every adolescent girl with id across the five special schools in padang city who met the study’s inclusion criteria. the total identified population was 50 individuals. each participant was informed about the study’s objectives, and informed consent was obtained from parents for those under 18, while those 18 and older gave consent themselves, unless legally incapable due to id. this complete enumeration ensured the sample’s representativeness, allowing comprehensive data collection through subsequent questionnaire administration. data analysis univariate analysis focused on the distribution of frequency for various demographic characteristics, including age, method of questionnaire completion, age at diagnosis of id, presence of other mental or physical conditions, disability category, type of residence, access to sex education, and instances of reported sexual abuse. data were processed using standard techniques to ensure accuracy and reliability, with variables presented in detailed tables. the five domains of the illustrated scale measuring sexual abuse prevention knowledge were analyzed for central tendencies (mean, standard deviation, minimum, and maximum). bivariate analysis explored the relationships between demographic characteristics and sexual abuse prevention knowledge. correlation analyses assessed the strength and significance of these relationships. pearson correlation quantified the degree of correlation between continuous variables, identifying linear relationships between factors such as age and sexual abuse prevention knowledge. point biserial correlation examined relationships between binary and continuous variables, analyzing the impact of binary demographic characteristics (e.g., presence of other conditions) on sexual abuse article [healthcare in low-resource settings 2024;12:12705] [page 695] non -co mmerc ial us e o nly prevention knowledge. statistical tables and figures accompanied each analysis, aiding in data interpretation. findings were discussed in relation to p-values, with a significance level set at p<0.05, indicating robust relationships between studied variables. ethics approval the study received ethical approval from the ethics commission team of universitas andalas under the reference number 1098/un.16.2/kep-fk/2023, ensuring full adherence to ethical standards. for participants under 18, parental assent was obtained, while those 18 and older provided informed consent themselves, unless legally incapable due to id. this approach respects the autonomy of adolescents and adheres to ethical standards in human research. results demographic characteristic of respondents a total of 50 children participated in the study by filling out the research questionnaire. table 1 presents the demographic characteristics of the respondents, detailing various attributes including age, method of questionnaire completion, age at diagnosis of id, presence of other mental/physical conditions, disability category, residence type, access to sex education, and reported instances of sexual abuse. the majority of respondents (54%) were in late adolescence (18-22 years), and similarly, 54% of the respondents filled out the questionnaire themselves. most respondents (74%) were diagnosed with id between the ages of 9 and 18. a significant number (66%) reported no other mental or physical conditions. the predominant disability category was mild, with 84% of respondents falling into this group. all respondents lived with relatives or parents. regarding sex education, 86% had received it at least once. additionally, 4% had experienced sexual abuse reported by teachers or health workers. this data reflects a population primarily consisting of late adolescents with mild disabilities, living in supportive family environments, and having access to sex education, although a small but significant portion has encountered sexual abuse. five domains of the illustrated scale measuring sexual abuse prevention knowledge table 2 presents the descriptive statistics analysis of the five domains measuring sexual abuse prevention knowledge among respondents: puberty physiology (pp), body boundaries (bb), identification of improper sexual relationships (isr), identification of abusive situations (ias), and coping methods when facing abusive situations (cm). respondents demonstrated the highest proficiency in bb, with a mean score of 5.7, indicating article [page 696] [healthcare in low-resource settings 2024;12:12705] table 1. demographic characteristics of respondents. variable frequency % age (years) early adolescence (12-14 years) 10 20 middle adolescence (15-17 years) 13 26 late adolescence (18-22 years) 27 54 how was the questionnaire filled out? by the respondent herself 27 54 by interview 23 46 age at diagnosis of intellectual disability from birth between 1 and 8 years 1 2 between 9 and 18 years 37 74 older than 19 years 12 24 other mental/physical conditions 0 0 yes 17 34 no 33 66 disability category light disability 42 84 moderate disability 8 16 residence type with relatives/parents 50 100 sex education not yet 7 14 once 43 86 sexual abuse (reported by teachers/health workers) 2 4 table 2. descriptive statistics of five domains measuring sexual abuse prevention knowledge. domain means (sd) min max puberty physiology (bp) 4.92 (0.944) 3 6 body boundaries (bb) 5,7 (0.544) 4 6 identification of improper sexual relationships (isr) 5,10 (0.678) 3 6 identification of abusive situations (ias) 3.72 (1,526) 1 6 coping methods when facing abusive situations (cm) 5,18 (1.304) 1 6 sd, standard deviation. table 3. correlation between demographic characteristics of children with intellectual disabilities (id) and sexual abuse prevention knowledge. demographic characteristic variables correlation coefficient (r) p-value age 0.084 0.562 age at diagnosis of intellectual disability 0.053 0.716 other mental/physical conditions 0.326 0.021* disability category -0.279 0.05* the significance level for the p-value is set at <0.05. non -co mmerc ial us e o nly strong and consistent knowledge. they also scored highly in identification of isr and cm, reflecting good understanding, although there was some variability, particularly in coping methods. pp showed moderate knowledge with more variation in responses. ias had the lowest mean score of 3.72 and the highest standard deviation, highlighting significant discrepancies in respondents’ ability to recognize abusive situations. these findings suggest that while knowledge is generally strong in some areas, there are critical gaps, particularly in identifying abusive situations, that need to be addressed through targeted educational interventions to ensure a comprehensive understanding of sexual abuse prevention. factors related to sexual abuse prevention knowledge among adolescent girls with intellectual disabilities the analysis revealed that the presence of other mental/physical conditions had a statistically significant moderate positive correlation (r=0.326, p=0.021) with sexual abuse prevention knowledge, suggesting that as the number of other mental/physical conditions increases, the level of knowledge also increases (table 3). conversely, the disability category showed a statistically significant moderate negative correlation (r=-0.279, p=0.05), implying that different disability categories are associated with variations in knowledge, with certain categories potentially linked to a decrease in knowledge levels. these findings indicate the need for tailored educational interventions that address the specific needs of different disability categories to improve sexual abuse prevention knowledge among adolescent girls with id. discussion this study’s univariate analysis of the central tendency of the five domains of sexual abuse prevention knowledge reveals significant insights into the vulnerabilities faced by adolescent girls with id. the mean scores for the five dimensions pp (4.92), bb (5.7), isr (5.1), ias (3.72), and cm (5.18) highlight critical areas of concern. the most concerning area is ias, which has the lowest mean score (3.72) and the highest standard deviation (sd), indicating significant discrepancies in respondents’ ability to recognize abusive situations. these findings align with previous research, which underscores the heightened vulnerability of intellectually disabled adolescents to abusive situations. factors such as delays in cognitive skills, difficulty recognizing bad intentions, challenges in selfdefense, and a lack of knowledge and skills regarding relationships and sexuality contribute to this vulnerability.22,23 additionally, personal and family risk factors create an imbalance of power, increasing the likelihood of becoming victims of sexual abuse.24 studies have shown that adolescents with id are more likely to be sexually abused by family members, caregivers, and others in the community.25 impaired social skills also make individuals with id more susceptible to abuse.26 the lack of research, information, and education on the sexuality of people with id further contributes to their vulnerability.27 the study contributes novel insights into the specific need for education on identifying abusive situations. respondents exhibited the lowest mean score in this domain, indicating an urgent need for targeted educational interventions to enhance knowledge and awareness. by focusing on this area, interventions can directly address the most pronounced deficiencies, ensuring a comprehensive understanding of sexual abuse prevention among the respondents. educational interventions that empower individuals to recognize abuse situations, particularly in group settings, can be effective in enhancing knowledge and awareness.28 an educational intervention using an information package was effective in improving parents’ knowledge regarding child sexual abuse (csa).29 a digital application designed to refresh knowledge of abuse for individuals with id showed promising results in reinforcing understanding and confidence in reporting abuse over the long term.30 programs involving film screenings and interactive discussions can enhance protective decision-making capabilities for adolescent girls with id.31 the findings reiterate the necessity for robust prevention strategies and policies tailored to the needs of adolescents with id. comprehensive sexual health education aimed at improving selfimage, self-confidence, and empowering individuals to make informed choices can help protect them from exploitation.25,32 effective prevention strategies may include education on boundaries, relationships, and sexuality tailored to cognitive abilities, promoting self-advocacy skills, and providing access to support services.33 providing inclusive healthy and respectful relationship (hrr) education may help reduce the risk of sexual abuse and address health disparities affecting youth with disabilities.34 this study highlights the statistically significant relationship between the presence of additional mental or physical conditions and the risk of sexual abuse (p=0.021). our findings align with previous research, which indicates that co-occurring conditions exacerbate the vulnerability of children with id to sexual abuse.35 other research supports this by demonstrating that id, communication disorders, and behavioral disorders contribute to high-risk levels, with multiple disabilities further increasing susceptibility.14 our findings are consistent with those of amborski et al.36 in reporting that individuals with disabilities are at a significantly higher risk of sexual victimization, with sensory impairments posing the highest risk. these vulnerabilities predispose individuals not only to immediate harm but also to long-term mental health issues and a perpetuated cycle of abuse, as noted by bates et al.37 the urgent need for specialized protective measures and interventions is further highlighted by amelink.22 reflecting the critical importance of ensuring tailored support and protection for adolescents with id to safeguard their rights to safety and informed agency in personal health decisions. this study contributes to the field by emphasizing the need for a nuanced understanding and targeted interventions to address the heightened risk of sexual abuse in individuals with multiple disabilities. this study also explored the association between id categories (mild or moderate) and the risk of sexual abuse. the findings indicate a significant moderate negative correlation (r=-0.279, p=0.05), suggesting that different disability categories are associated with variations in the risk of sexual abuse. individuals with mild id are at higher risk of becoming victims and more vulnerable to the disruptive effects of sexual abuse.34 this is consistent with findings that individuals with mild or borderline intellectual functioning face an increased risk of sexual abuse compared to those with moderate or severe id.38 furthermore, tomsa et al. reported that the prevalence of sexual abuse increases from mild to severe levels of id and decreases at profound levels.4 this pattern is reflected in our study, where the correlation suggests that as the severity of id increases, the risk of sexual abuse decreases, particularly at the profound level. this study offers a detailed examination of the risk of sexual abuse among individuals with mild and moderate id, providing a nuanced understanding crucial for developing tailored interven article [healthcare in low-resource settings 2024;12:12705] [page 697] non -co mmerc ial us e o nly tions. it identifies a moderate negative correlation between disability category and risk, quantifying this relationship and offering insights valuable for policymakers and practitioners. additionally, the study highlights the need for focused protective measures and educational programs for individuals with mild id, emphasizing targeted interventions to prevent abuse and mitigate its effects. study limitations the study’s reliance on self-reported data for assessing knowledge and coping strategies among adolescent girls with id could introduce inaccuracies due to potential cognitive biases or misunderstandings inherent to this population. additionally, the crosssectional design limits the ability to determine causality and observe long-term effects of interventions, necessitating longitudinal studies for more definitive conclusions. these limitations highlight the need for enhanced methodological approaches in future research to ensure more accurate and applicable findings. conclusions this study reveals a complex relationship between id, the presence of other mental or physical conditions, and the risk of sexual abuse among adolescent girls. it highlights significant disparities in sexual abuse prevention knowledge, particularly in recognizing abusive situations, underscoring the urgent need for tailored educational programs to address these unique challenges. the findings emphasize the critical importance of comprehensive sexual education and targeted prevention strategies for adolescent girls with id. ongoing support and the development of intervention strategies are essential to mitigate the risks of sexual abuse. policymakers, educators, and healthcare providers must ensure these adolescents receive the necessary protection and education to navigate their vulnerabilities safely and effectively. references 1. toren sj, haas s, dalmijn ew, et al. a mixed methods evaluation of girls’ talk: a sexuality education programme for girls with mild intellectual disabilities. j appl res intellect disabil 2021;35:1009-18. 2. svae gb, blixt l, søndenaa e. personal and sexual boundaries: the experiences of people with intellectual disabilities. bmc public health 2022;22:1773. 3. svae gb, hassel b, søndenaa e. people with intellectual disabilities and harmful sexual behaviour: professionals’ views on the barriers to prevent harm. j appl res intellect disabil 2022;36:176-85. 4. tomsa r, gutu s, cojocaru d, et al. prevalence of sexual abuse in adults with intellectual disability: systematic review and meta-analysis. int j environ res public health 2021;18:1980. 5. mahmoodabadi hz, akrami l. sexual abuse in adolescent girls and boys with mild intellectually disable. j community health res 2021;10:128-35. 6. divelino y. buku data ppks dan psks sumatera barat. 2020. available from: https://dinsos.sumbarprov.go.id/images/ 2020/12/file/buku_data_ppks_dan_psks_tahun_2020com pressed.pdf 7. shartika np, yetti h, yusda i. analisis penyelenggaraan puskesmas tatalaksana kekerasan terhadap anak (kta) dalam penanganan kekerasan anak di kota padang. j kesehat andalas 2019;8:245-53. 8. naz s, ibrahim n, sharif s, et al. prevalence and association of different levels of intellectual disability with prenatal, perinatal, neonatal and postnatal factors. proc pak acad sci b life environ sci 2022;58:75-82. 9. anjum r, rehman a, maqsood h, et al. intellectual disability classification, causes, epigenetic mechanisms and treatment. biol clin sci res j 2023;2023:245. 10. ungurean b. theoretical aspects of intellectual disability definition, classification. bull “transilvania” univ braşov ser ix sci hum kinet 2021;14:247-52. 11. dobosiewicz am, litwa e, zmaczyńska t, badiuk n. the etiology and psychomotor characteristics of intellectual disability. pedagogy psychol sport 2020;6:159-64. 12. koçtürk n, yüksel f. individual and familial characteristics of sexual abuse victims with intellectual disability. curr psychol 2021;42:2006-13. 13. pedgrift k, sparapani n. the development of a social-sexual education program for adults with neurodevelopmental disabilities: starting the discussion. sex disabil 2022;40:503-17. 14. hinton j. identifying sexual trauma in children with intellectual and developmental disorders. j am acad child adolesc psychiatry 2022;61:36-7. 15. hossain mk, islam mn, rahman mh, et al. parental and community views on determinants of sexual abuse of adolescent girls with disabilities in bangladesh. 2022. available from: https://doi.org/10.21203/rs.3.rs-2003688/v1 16. sekolah d. daftar sekolah slb di kota padang sumatera barat tahun 2024. 2024. available from: https://daftarsekolah.net/ 17. kalgotra r, warwal js. effect of an aerobic fitness programme intervention on the motor proficiency of children with mild and moderate intellectual disabilities in india. disabil cbr amp incl dev 2019;29:48. 18. nugraha ak, mumpuniarti m. cognitive development of mild intellectual disability for vocational training. 2019. available from: https://doi.org/10.2991/icsie-18.2019.12 19. pierce sr, maher a. physical activity among children and young people with intellectual disabilities in special schools: teacher and learning support assistant perceptions. br j learn disabil 2019;48:37-44. 20. liou wy. an illustrated scale measuring the sexual abuse prevention knowledge of female high school students with intellectual disabilities in taiwan. sex disabil 2014;32:135-51. 21. dhestiana m. content validity and trial test an illustrated scale measuring the sexual-abuse prevention knowledgeindonesian version for female teenager with mild intellectual disability. 2021. available from: https://lib.ui.ac.id/detail? id=9999920521991&lokasi=lokal 22. amelink q, roozen s, leistikow i, weenink j. sexual abuse of people with intellectual disabilities in residential settings: a 3-year analysis of incidents reported to the dutch health and youth care inspectorate. bmj open 2021;11:053317. 23. kaya a, yıldız g. “i think they do not know how to lie”: the perceptions of legal support staff about person with intellectual disabilities/autism in turkish legal system. j appl res intellect disabil 2023;36:516-28. 24. christoffersen m. sexual crime against schoolchildren with disabilities: a nationwide prospective birth cohort study. j interpers violence 2020;37:2177-205. 25. goli s, rahimi f. experiences of teachers, educators, and school counselors about the sexual and reproductive health of article [page 698] [healthcare in low-resource settings 2024;12:12705] non -co mmerc ial us e o nly educable intellectually disabled adolescent girls: a qualitative study. reprod health 2022;19:96. 26. moen k. legal vulnerability – police officers’ stories in their meeting with people with intellectual disabilities. scand j disabil res 2024;26:159-72. 27. beltran-arreche m. perspectives of women with intellectual disabilities regarding affective sexual relationships: a systematic literature review. sex res soc policy 2023;21:263-78. 28. reis o, häßler f, daubmann a, chodan w. knowledge hardly translates to reality—a randomized controlled trial on sexual abuse prevention for girls with intellectual disabilities. front psychiatry 2022;13:886463. 29. balakrishna nbb, joseph nv. effectiveness of educational intervention regarding child sexual abuse on knowledge and attitude of parents. indian j forensic med toxicol 2022;16:180-90. 30. howard t. using a digital application to refresh knowledge of abuse for individuals with intellectual/developmental disabilities. 2022. available from: https://doi.org/10.23860/thesishoward-thomas-2021 31. aprianti a, anggraini fdp, mubarokah k, dewi mp. assistance for intellectual disability teenager to prevent sexual harassment with educational films at slb n semarang. community empower 2022;7:1945-51. 32. smit m. policy on sexual abuse: a survey study amongst managers of care facilities for individuals with intellectual disability in the netherlands. j policy pract intellect disabil 2023;20:289-97. 33. stobbe kj, scheffers m, van busschbach jt, didden r. prevention and intervention programs targeting sexual abuse in individuals with mild intellectual disability: a systematic review. j ment health res intellect disabil 2021;14:135-58. 34. newby-kew a, horner-johnson w. healthy and respectful relationship education: differences by disability status and associations with sexual abuse. j sch health 2023;93:565-72. 35. daigneault i, paquette g, sablonnière-griffin m, dion j. childhood sexual abuse, intellectual disability, and subsequent physical and mental health disorders: a matched cohort study. am j intellect dev disabil 2023;128:134-44. 36. amborski am, bussières el, vaillancourt-morel mp, joyal cc. sexual violence against persons with disabilities: a metaanalysis. trauma violence abuse 2021;23:1330-43. 37. bates c, mccarthy m, skillman k, et al. “always trying to walk a bit of a tightrope”: the role of social care staff in supporting adults with intellectual and developmental disabilities to develop and maintain loving relationships. br j learn disabil 2020;48:261-8. 38. smith dk, sadler kp, benedum m. febrile seizures: risks, evaluation, and prognosis. am fam physician 2019;99:445-50. article [healthcare in low-resource settings 2024;12:12705] [page 699] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12751 evaluation of the therapeutic potential and safety of al hayat black cumin seed oil: an observational study bekzhan turabekov medical educational platform llc “medlit”, bishkek, kyrgyzstan abstract the purpose of this study was to investigate the therapeutic potential and safety of the use of al hayat black cumin seed oil. descriptive and discrete statistical methods and frequency analysis were applied. there were 20 participants in total aged between 11 and 67 years, both men and women. the participants were divided into three subgroups, each receiving different doses of black cumin oil: 10 mg/kg, 20 mg/kg, and 30 mg/kg, respectively. such parameters as general blood count, liver enzyme activities (aspartate aminotransferase and alanine aminotransferase), creatinine, and serum iron levels were analysed. a dose of 10 mg/kg was found to have no significant therapeutic or adverse effect. a dosage of 20 mg/kg demonstrated positive effects on platelet, immune cell, and creatinine values with no significant side effects. a dose of 30 mg/kg is not recommended for use due to the high risk of adverse reactions. the author also found no significant differences in the therapeutic effects and adverse reactions to black cumin oil that could be related to the gender or age of the participants. introduction in modern medicine, the prospects for the use of plant-based remedies are greatly enhanced by public interest and the efforts of scientists. this interest is fuelled by the desire for more natural, organic ways to treat and prevent disease, as well as scientific discoveries that increasingly confirm the efficacy of plant extracts and compounds. specifically, black cumin seed oil, extracted from the nigella sativa plant, is a prime example of a substance with a long history of use in traditional medicine due to its many potential therapeutic properties. black cumin, used as a natural remedy in different cultures, has attracted the attention of scientists in the fields of biomedicine and pharmacology.1 despite promising anecdotal evidence and some preliminary studies suggesting a wide range of beneficial properties, from anti-inflammatory to antioxidant, rigorous scientific evaluation of black cumin oil’s effects on concrete health parameters is still in its infancy. scientific studies to investigate its effects may provide valuable information on its mechanisms of action, efficacy, and safety of use. thus, despite its widespread use in traditional medicine and potential benefits, black cumin oil requires further research in the context of modern medicine. investigating the role of medicinal plants in controlling various diseases, including coronavirus infection, ojah et al.2 focused on ethnopharmacological approach, which can offer promising strategies for the development of new medicines. this approach emphasises traditional healing methods used across cultures and explores their potential for modern medicine. however, plants such as black cumin stay outside the main focus of such studies, which makes its investigation in this context particularly relevant. regarding this issue, khadka et al.3 highlighted that in some countries during the covid-19 pandemic, herbal medicine gained considerable popularity, especially in the context of disease prevention. the authors noted that many respondents recommended the use of medicinal plants for covid-19 prevention, although qualitative studies on the efficacy of this approach are still lacking. in their work, riaz et al.,4 without focusing on black cumin, emphasised the significance of investigating phytometabolites for the development of new medicines. the scientists noted that phytobioactive compounds have potential in treating various diseases, making them promising candidates for clinical trials. guo et al.5 highlighted the high therapeutic potential of nanocrystals based on medicinal plants, especially in the context of improving the pharmacokinetics of active substances. this is crucial to improve the efficacy of pharmacotherapy and overcome the serious problems associated with the low solubility and bioavailability of a range of phytopreparations, including those that may include black cumin. in the context of phytopreparation studies, choudhury et al.6 emphasise the significance of careful control and monitoring of such products. this is to ensure their safety and efficacy, considering potential risks and side effects. controls should include standardisation of ingredients, screening for toxins and other potentially harmful components, and clinical studies to confirm claimed correspondence: bekzhan turabekov, medical educational platform llc “medlit”, 720049, 27/3 aaly tokombaev str., bishkek, kyrgyzstan. e-mail: turabekovbek@outlook.com key words: pharmacognosy, phytotherapy, immunomodulation, integrative medicine, thymoquinone. conflict of interest: the author declares no potential conflict of interest. funding: not applicable. ethics approval: the study was approved by the ethics commission of the medical educational platform llc “medlit”, no. 12455. patients’ consent for publication: informed consent was obtained from all individuals included in this study. availability of data and material: the data supporting the findings of this study are available on request from the corresponding author received: 25 june 2024. accepted: 11 september 2024. early view: 9 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12751 doi:10.4081/hls.2024.12751 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12751] [page 83] non -co mmerc ial us e o nly properties. this approach ensures that patients get the maximum benefit from phytopreparations without compromising their health. thus, the purpose of this study was to collect and analyse empirical data to understand the effect of black cumin oil consumption on human body at different dosages. the main objectives of the research are the following: i) to figure out the ideal dosage to enhance effectiveness while limiting negative effects; ii) to assess whether factors such as age and gender influenced the therapeutic response to black cumin oil. materials and methods the statistical data were obtained by analysing medical records, including patients’ medical histories, as well as the results of laboratory testing methods, including general blood counts, analysis of liver enzyme activities such as aspartate aminotransferase (ast) and alanine aminotransferase (alt), creatinine, and serum iron levels. these indicators were chosen as the main criteria for assessing the effects of the medicine on the participants’ bodies. there were 20 participants in total who were selected according to predetermined inclusion and exclusion criteria. participants were informed about the purpose and methods of the research and provided their informed consent to participate. of the 20 participants initially selected, 18 participants reached the end of the study. two participants discontinued their participation for personal reasons. only the results of those participants who fully completed the study were used for data analysis. participants’ ages ranged from 11 to 67 years (mean age: 35.33 years, mode: 36 years, median: 34.5 years). both males and females took part in the examination, the data regarding the sampling frame by gender is presented in figure 1. to structure the sample, optimise the results, and to better understand the health effects of black cumin oil, the author divided the participants into three subgroups. each of these subgroups received a different specific dose of black cumin oil, namely 10 mg/kg, 20 mg/kg, and 30 mg/kg respectively. the structure of the study group according to the medication dosage used is presented in figure 2. this separation allowed for a differentiated analysis of the effects of different doses of black cumin oil on the body, which enabled a more accurate determination of its efficacy and safety. the dosage was allocated based on perceptions of safe and potentially effective levels of black cumin oil consumption.7,8 the main objective of this approach was to determine the best dosage that would maximise efficacy while minimising the risk of side effects. each group of participants took a corresponding dosage of black cumin oil for 15 days, during which time their health status was monitored regularly. using normal venepuncture techniques, participants’ blood samples were drawn into vacuum tubes containing ethylenediaminetetraacetic acid (edta)for a complete blood count and serum separator tubes for biochemical analysis. to guarantee adequate mixing, samples were gently flipped eight to ten times as soon as they were collected. to preserve cellular integrity, edta tubes for haematology were examined four hours after collection and kept at room temperature (20-25°c). in order to separate the serum, serum separator tubes were centrifuged at 3000g for 10 minutes after being left to clot at room temperature for 30 minutes. to maintain the stability of the analytes, the serum was aliquoted into cryovials and kept at -80°c until analysis, which was carried out 30 days after collection. every sample had a unique label applied to it, and regular safety procedures were followed when handling it. all storage units had temperature logs kept in order to guarantee constant conditions. excluded from analysis were samples exhibiting haemolysis or lipemia, in order to avoid influencing test outcomes. all of the laboratory equipment underwent stringent calibration and quality control procedures to guarantee the dependability and accuracy of experimental results. automated biochemistry and haematology analysers were validated with multi-level control materials and daily calibrated using calibrators supplied by the manufacturer. the clinical laboratory improvement amendments (clia) recommendations were followed in setting the acceptance criteria and creating calibration curves for each analyte. every piece of equipment had a maintenance journal that recorded both routine maintenance and any necessary corrective action. any equipment that did not meet performance standards was taken out of service right away and left to be fixed or recalibrated. social and political factors affecting public health figure 1. structure of the study group by gender. source: compiled by the author. figure 2. structure of the study group according to the medication dosage used. source: compiled by the author. [page 84] [healthcare in low-resource settings 2024;12(s2):12751] non -co mmerc ial us e o nly the investigation predominantly used descriptive and discrete statistical methods and cluster analysis. descriptive statistics were used to provide an overview of the data, including mean values, standard deviations, and ranges for key variables such as blood counts and liver enzyme activities. this provided a basic understanding of the distribution and underlying trends in the data. discrete statistics were used to determine statistically significant differences between groups of participants receiving different dosages of black cumin oil. this method helped to assess whether different dosage of the medication affected the health indicators under study to a statistically significant degree. cluster analysis was used to identify groups of participants with analogous treatment response patterns. this provided a greater understanding of individual differences in treatment response and helped to identify potential subgroups of participants who respond best to certain dosages. results within the sample provided, it was important to observe how even a minimal dose of black cumin oil could affect various biochemical and physiological parameters such as blood counts and liver enzyme activities. this dose, 10 mg/kg, was chosen as the starting point of the research based on the assumption of its safety and potential efficacy. it was assumed that such a dose could provide the minimum therapeutic effect while reducing the risk of undesirable adverse reactions. the results of monitoring of the studied indicators, both preliminary and at the end of the study, are presented in table 1. when analysing these results, it was recorded that the effect of the medication was moderated. minimal changes in clinical parameters indicate insignificant effect of this dosage on the biochemical profile of the organism. this can be interpreted as a lack of overt therapeutic activity or as achieving only a marginal effect that is on the edge of statistical significance. a comparable pattern was observed in the context of side effects, with very few or no side effects. these results may indicate a high safety profile of the medication at the indicated dosage, which, at the same time, does not make it potentially suitable for long-term use or as a component of complex therapy, due to the lack of clinically significant results. however, the absence of significant side effects and minimal therapeutic effect may also indicate that the dose is insufficient to achieve the desired therapeutic effect. it is possible that such a dosage cannot activate the mechanisms responsible for the pharmacological action of the medication, and therefore cannot fully reveal the potential of the active components of black cumin oil. these analyses of the laboratory results of this subgroup provided the basis for further investigation of higher doses to determine the threshold at which a significant therapeutic effect comparable to an appropriate level of safety is observed. the study of minimal effects and adverse reactions is also important for the development of a complete medication profile. this is particularly relevant when developing dosages for clinical use that consider individual patient characteristics and the possibility of an individualised treatment approach. considering that the previous dosage demonstrated only minimal effects on participants’ biochemical parameters and no significant side effects, the second subgroup provided a better opportunity to investigate whether the increased dosage would result in more noticeable health effects. the corresponding results are presented in tables 2 and 3. it was found that increasing the dosage of black cumin oil to 20 mg/kg resulted in markedly positive changes in the clinical parameters of the participants. the most significant trend was the normalisation of platelet levels, which may indicate improved blood coagulation and reduced risk of haemorrhagic complications. furthermore, mobilisation of immune cells was observed, which is reflected in the white blood cell count in the blood, suggesting an increase in the body’s immune response. another indicator that underwent changes as a result of the increased dosage was creatinine levels, which also normalised, which may indicate a positive effect on renal function. interestingly, in one case studied, the use of black cumin oil at this dosage optimised the significantly elevated liver enzymes alt and ast, which may be related to both individual patient characteristics and the general pharmacological properties of the medication. importantly, increasing the dose to 20 mg/kg was not accompanied by the occurrence of side effects. this fact suggests that this dosage is not only safe, but also probably optimal in terms of efficacy/safety ratio. complementing the information presented above, attention should also be given to considering the therapeutic efficacy of a 30 mg/kg dose of black cumin oil. considering the positive effects of the previous dose of 20 mg/kg on platelet counts, immune activity and creatinine levels, there was social and political factors affecting public health table 1. mean values of laboratory results in patients from the subgroup treated with the medication at a dosage of 10 mg/kg. blood parameter preliminary results* results after 15 days of use* liver enzymes, creatinine, and serum iron values creatinine, μmol/l 52 54.2 alt, iu/l 12.6 13 ast, iu/l 16.5 14.4 iron level, µmol/l 10.9 13.6 general clinical parameters haemoglobin, g/l 108 118 erythrocytes (×1012/l) 4.2 4.3 haematocrit, % 37.2 37.4 mean corpuscular volume (mcv), fl 88.5 90.2 mean corpuscular haemoglobin concentration (mchc), g/dl 320 328 white blood cells (×109/l) 6.1 6.2 neutrophils (×109/l) 4.2 4.1 lymphocytes (×109/l) 1.3 1.5 platelets (×109/l) 223 230 note: iu/l – international units per litter; *p>0.05. source: compiled by the author. [healthcare in low-resource settings 2024;12(s2):12751] [page 85] non -co mmerc ial us e o nly a legitimate interest in whether further dose increases could result in enhanced therapeutic effects or side effects. this phase of the research evaluated the efficacy and safety of black cumin oil when administered at higher doses, which is critical to determining its maximum tolerated dosage. when the results of laboratory methods were analysed on participants who used the medication at a dosage of 30 mg/kg, it was found that this dose did not lead to the expected improvement in therapeutic outcomes. specifically, there was no further improvement in blood parameters, which could indicate a more pronounced beneficial effect on physiological body functions, compared to the group receiving 20 mg/kg. a significant and worrying consequence of the increased dosage was the occurrence of pronounced side effects. complaints of decreased sleep quality, decreased general well-being of participants, and non-specific gastrointestinal disorders such as discomfort, bloating, and stool disturbances were observed. these symptoms may indicate that this dosage exceeds physiologically acceptable intake rates for vegetable oils, resulting in undesirable body reactions.9,10 these side effects are probably not directly related to the pharmacological properties of black cumin, but rather result from the specific effects of plant-based oils in general when consumed in excess. such reactions may be caused by both the general properties of fatty acids and the presence of certain components (such as thymoquinone, alkaloids like nigellicine, and saponins), which in large quantities may interfere with the normal functioning of the digestive system and affect metabolism.11-13 thus, although the previous dosage of 20 mg/kg showed potential optimality, a further dose increase to 30 mg/kg did not improve the therapeutic results but provoked adverse reactions. this emphasises the need for careful dose balancing to maximise benefits while minimising risks. the study also analysed possible factors that could influence the therapeutic efficacy of the medication. specifically, attention was paid to participant characteristics such as gender and age. analyses of the data collected, which included a wide range of age groups and representation of both sexes, revealed no significant differences in response to therapy that could be attributed to the sex or age of the patients. analysis of the available data made it possible to verify that the therapeutic effect of black cumin oil appears to be stable and homogeneous among the entire sample, with no apparent dependence on the parameters mentioned. in social and political factors affecting public health table 3. mean values of laboratory results in patients from the subgroup receiving the medication at a dosage of 30 mg/kg. blood parameter preliminary results* results after 15 days of use* liver enzymes, creatinine, and serum iron values creatinine, μmol/l 44 43 alt, iu/l 6.3 9.7 ast, iu/l 9.2 8.2 iron level, µmol/l 9.6 12.8 general clinical parameters haemoglobin, g/l 112 121 erythrocytes (×1012/l) 3.82 4.26 haematocrit, % 36.4 37.6 mcv, fl 79 83 mchc, g/dl 322 334 white blood cells (×109/l) 5.1 4.8 neutrophils (×109/l) 3.5 3.4 lymphocytes (×109/l) 2.1 2.7 platelets (×109/l) 312 336 note: *p>0.05. source: compiled by the author. [page 86] [healthcare in low-resource settings 2024;12(s2):12751] table 2. mean values of laboratory results in patients from the subgroup receiving the medication at a dosage of 20 mg/kg. blood parameter preliminary results* results after 15 days of use* liver enzymes, creatinine, and serum iron values creatinine, μmol/l 48 40.4 alt, iu/l 28.2 16 ast, iu/l 40.1 14.2 iron level, µmol/l 13.2 16.3 general clinical parameters haemoglobin, g/l 123 133 erythrocytes (×1012/l) 4.32 4.46 haematocrit, % 38.6 39 mcv, fl 86.4 89.2 mchc, g/dl 334 362 white blood cells (×109/l) 6.3 5.8 segmented neutrophils (×109/l) 3.9 3.6 lymphocytes (×109/l) 1.42 1.64 platelets (×109/l) 276 296 note: *p>0.05. source: compiled by the author. non -co mmerc ial us e o nly none of the subgroups analysed were gender or age differences observed to make adjustments to the clinically significant response to the medication. the lack of variability in the efficacy of the medication according to gender and age may indicate its wide potential range of use and provides a basis for a better understanding of its mechanisms of action. this may also indicate that the medication has versatile properties that make it suitable for a diverse patient population, which is particularly significant in the context of personalised medicine. the author decided to include several pregnant and breastfeeding women in the sample, which represents a prominent aspect in assessing the safety and efficacy of the medication in these special patient groups. despite the potential risks associated with the use of any medication during pregnancy and lactation, no features or undesirable effects specific to these groups were identified. however, the use of black cumin oil or any other preparations in pregnant and lactating women requires extra caution.14-16 pregnancy and lactation period are accompanied by a range of physiological changes in a woman’s body, which may affect the metabolism of medications and their pharmacokinetics.17,18 furthermore, it is vital to consider the potential risk to the developing foetus or infant, as some substances may penetrate the placental barrier or be excreted with breast milk.1 therefore, even though there were no adverse effects identified in this investigation, it is critical that care be taken when prescribing dosages and monitoring the health of pregnant and breastfeeding women taking black cumin oil. this requires an individualised approach and careful assessment of the balance of potential benefits and risks for each woman and her baby. it is recommended that such decisions be made in conjunction with a qualified medical professional, based on a complete clinical picture and considering all the individual characteristics of the pregnant or breastfeeding woman. in the context of the findings, it is also necessary to mention some of the challenges and limitations that accompanied the execution of the study. although the it has provided valuable preliminary data, it has a range of specific limitations that affect the interpretation and generalisation of its findings. firstly, this is an observational study conducted by a single researcher. this approach can introduce subjectivity into the process of data collection and analysis, as well as in the interpretation of the findings. lack of independent observation and validation can lead to possible misleading conclusions, making the results less valid and reliable. the second significant limitation is the sample size. using a small number of participants reduces the statistical significance of the research, which may limit the ability to detect real effects or differences. moreover, there was no control group or randomised allocation of participants, which is a key element in establishing causality. the absence of a control group means that it is not possible to determine with certainty whether the observed changes were the result of the medication or caused by other factors. randomisation helps to eliminate systematic errors and bias, providing more reliable and objective results. considering these limitations, the findings of the current study should be regarded as preliminary and interpreted with caution. additional studies, including larger controlled clinical trials, are needed to provide a more accurate and generalised picture, which may confirm or refute the initial observations and conclusions. discussion in the context of the current research, it is crucial to make a comparative analysis with contemporary studies conducted by foreign authors. such a comparison will not only enrich the understanding of the topic at hand, but will also identify potential gaps in knowledge, as well as identify areas for future studies. comparison with international studies provides an opportunity to establish the extent to which the findings of the current investigation are consistent with global scientific evidence. this will also help to assess the universality and applicability of the findings on a larger scale. international studies may reveal various aspects of black cumin oil use, including its pharmacological properties, mechanisms of action, potential therapeutic applications and possible side effects, which may not have been fully covered in the current work. thus, a. zarrouk et al.19 addressed the question of the composition of black cumin and its oil. in their paper, the researchers suggested that black cumin and its derivatives, including black cumin oil, have a wide range of beneficial properties, making them promising for the development of medicines to combat various diseases. the scholars focused on the rich composition of black cumin seeds, which includes proteins, fats, carbohydrates, fibre, and inorganic mineral compounds. they also considered the composition of black cumin oil, which contains both saturated and unsaturated fatty acids, including linoleic, oleic, dihomolinoleic, and eicodadiene acids. furthermore, the oil contains alkaloids (nigellicins and nigelladine), saponins, tocopherols, phytosterols, flavonoids, and essential oil, as well as quinone components, including thymoquinone.20 these components account for the wide range of therapeutic properties of black cumin oil, making it potentially useful in the treatment of a variety of diseases. despite the avoidance of detailed analyses of individual clinical cases, the results of the cited work effectively complement the present study in terms of researching the components of the investigated substance and, consequently, the mechanisms of their effects on the human body. a. hannan et al.21 also considered possible mechanisms of the effect of black cumin oil on the human body. the researchers noted that black cumin and its key component, thymoquinone, have immunomodulatory properties. ethanolic extract of black cumin was also found to increase the population of macrophages and stimulate the phagocytic activity of their three types. the antioxidant properties of black cumin also contribute significantly to its therapeutic effects. black cumin is a potential source of natural antioxidants, lowering levels of reactive oxygen species and increasing the activity of antioxidant enzymes such as superoxide dismutase and catalase, as well as molecules such as glutathione.22 the researchers found a considerable increase in total antioxidant activity in the blood and a decrease in malonic dialdehyde levels on the background of black cumin seed supplementation. in addition, black cumin and thymoquinone have anti-inflammatory properties. thus, freshly extracted black cumin oil reduced interleukin6 levels in human preadipocytes, whereas oil stored for some time reduced interleukin-1beta levels. consequently, although the paper does not cover aspects of the effects of the substance on some functions, specifically the liver, it greatly enriches the understanding of the pathogenetic mechanisms of the effects of the studied substance on the human body. e.m. yimer et al.23 considered black cumin as a basis for the development of medicines for a wide range of diseases. the researchers noted that due to its wide range of properties, black cumin could serve as a substrate for medicines in the fields of neurology, oncology, cardiology, immunology, and other areas of medicine. specifically, the authors highlight its potential application in the treatment of neurological disorders such as alzheimer’s, parkinson’s, and epilepsy, as well as cancers including breast and social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12751] [page 87] non -co mmerc ial us e o nly prostate cancer.24 the researchers also highlighted the antioxidant, antimicrobial, and anti-inflammatory properties of black cumin, making it a promising candidate for the development of new medicines. however, scientists have ignored the issue of side effects of the black cumin-based remedies in question. some researchers, such as m.s.k. ermumcu and n. şanlıer25 considered the therapeutic potential of black cumin through the lens of, as they suggested, its most biologically active component, thymoquinone. the scholars emphasised that the use of black cumin-based preparations holds great promise in diabetes therapy. thymoquinone and other components contribute to optimising glucose control, mainly by stimulating the metabolism of carbohydrates and reducing their concentration in the blood.26,27 thymoquinone along with some other components of black cumin extract stimulates insulin production, improves energy metabolism in mitochondria, and has an indirect hepatoprotective effect. it also affects the functioning of membrane receptors and improves their sensitivity to insulin. black cumin, specifically, effectively inhibits gluconeogenesis – a key factor in the development of hyperglycaemia in diabetic patients, by reducing the activity of enzymes involved in this process.28 black cumin extract restricts glucose absorption and blocks its transport systems. thymoquinone also exerts a protective effect on pancreatic β-cells by preventing oxidative stress.29,30 black cumin and thymoquinone have properties that promote weight loss and improve the lipid profile in diabetic patients, as evidenced by a reduction in body weight sometime after starting to take the preparations.31 thus, this study provides valuable additions to the investigation of the effects of black cumin-based medicines in the treatment of a diabetes mellitus. j.v. thomas et al.32 conducted a randomised double-blind placebo-controlled study with an analogous purpose. the scholars evaluated the safety of using black cumin oil at a dose of 200 mg/day for 90 days. seventy participants were involved. both biochemical and general clinical parameters were analysed, and side effects were recorded. no serious side effects or significant changes in haematological parameters were reported. there were also no significant changes in biochemical parameters related to liver function (alt, ast) and renal function (serum creatinine and urea). however, lipid profile analysis showed a significant (p<0.05) decrease in total cholesterol, low-density lipoprotein, very low-density lipoprotein, and triglycerides. thus, the cited study differed slightly from the results obtained in the present one: the discrepancy primarily concerns the presence of side effects and the focus of the therapeutic action of the medicine. n. salaria et al.33 directly addressed the safety of the use of black cumin derivatives. the researchers emphasised that the consumption of n. sativa at a dosage of 5 ml/day for 26 days caused no significant adverse effects on hepatic, renal, or gastrointestinal functions. it was also found that patients with hepatitis c who took black cumin oil capsules experienced epigastric pain and hypoglycaemia. in isolated cases, consumption of oil and ground seeds resulted in increased levels of ast, alt, and alkaline phosphatase. however, no significant changes in kidney or liver function were found in people with diabetes who took black cumin at doses of 1, 2, and 3 g/day for 3 months. the scholars noted that some people may experience allergic reactions when using black cumin oil, such as allergic contact dermatitis when applied topically. such cases have been reported in patients using black cumin oil externally. thus, the paper extends previous findings to cover a wider range of medication dosages. however, researchers have neglected to investigate the mechanisms of side effects. thus, the studies of foreign colleagues devoted to the investigation of the therapeutic efficacy and safety of black cumin oil were reviewed. the analysis of the obtained results helped to supplement and expand the ideas about the main pharmacological effects of this phytopreparation, as well as to identify some differences in the nature and severity of its action. comparison of the data obtained in the present study with the findings of foreign studies is of great value for a more complete understanding of the therapeutic and adverse potential of black cumin oil in different conditions of its application. conclusions by interpreting the findings, it is possible to conclude on the therapeutic effects and side effects of black cumin oil. at low dosages of the medicine, a restrained effect on the biochemical profile of the organism was observed, indicating that there was no apparent therapeutic activity or only a marginal effect. there were few or no side effects in this case, which may indicate a high safety profile of the medication at these dosage levels. at the dosage of 20 mg/kg, marked positive changes in clinical parameters were observed, including normalisation of platelet levels. creatinine levels also normalised, which may indicate a positive effect on renal function. no side effects were observed at this dosage, making it potentially the best dosage in terms of efficacy/safety ratio. however, when the dose was further increased to 30 mg/kg, no further improvement in clinical parameters was recorded, but pronounced side effects appeared, including complaints of impaired sleep quality, decreased general well-being, and gastrointestinal disturbances. this indicates that the dosage exceeds physiologically acceptable intake rates for vegetable oils. according to the results, the therapeutic effects of black cumin oil appeared to be stable and homogeneous among the different groups of participants. this indicates its wide potential range of applications and versatile properties, making it suitable for a diverse patient population. pregnant and breastfeeding women were also included in the study, which represents a prominent aspect in assessing the safety and efficacy of the medication in these special patient groups. however, despite no adverse effects identified, extra caution is required when using black cumin oil in pregnant and lactating women. notably, clinical trials with more participants from different demographic groups are needed to increase the validity of the results. this will help to assess the efficacy and safety of black cumin-based products more accurately. research vectors in this area should focus on better understanding the biochemical and molecular mechanisms underlying the therapeutic action of black cumin, which will provide a better insight into its effects and develop more effective dosage forms. references 1. dosoky ns, setzer wn. maternal reproductive toxicity of some essential oils and their constituents. int j mol sci 2021;22:2380. 2. ojah eo. medicinal plants: prospective drug candidates against the dreaded coronavirus. iberoam j med 2020;2:31421. 3. khadka d, dhamala mk, li f, et al. the use of medicinal plants to prevent covid-19 in nepal. j ethnobiol ethnomed 2021;17:26. 4. riaz m, khalid r, afzal m, et al. phytobioactive compounds as therapeutic agents for human diseases: a review. food sci social and political factors affecting public health [page 88] [healthcare in low-resource settings 2024;12(s2):12751] non -co mmerc ial us e o nly nutr 2023;11:2500-29. 5. guo m, qin s, wang s, et al. herbal medicine nanocrystals: a potential novel therapeutic strategy. molecules 2023;28:6370. 6. choudhury a, singh pa, bajwa n, et al. pharmacovigilance of herbal medicines: concerns and future prospects. j ethnopharmacol 2023;309:116383. 7. ramalingam k, ittiyavirsh s, kuttan r, et al. safety assessment of a thymoquinone-rich black cumin (nigella sativa) oil (blaqmax®): acute and sub-chronic toxicity studies. j nutr food sci 2021;11:811. 8. telci i, izgi mn, ozek t, et al. effects of different nitrogen doses on thymoquinone and fatty acid composition in seed oil of black cumin (nigella sativa l.). j am oil chem soc 2022;99:229-37. 9. ghane et, poormohammadi a, khazaei s, mehri f. concentration of potentially toxic elements in vegetable oils and health risk assessment: a systematic review and metaanalysis. biol trace elem res 2022;200:437-46. 10. lammari n, louaer o, meniai ah, et al. plant oils: from chemical composition to encapsulated form use. int j pharm 2021;601:120538. 11. hosni r, haffez h, elkordy h. common applications of black cumin seed (nigella sativa) oil in folk medicine. j adv pharm res 2023;7:1-14. 12. akaberi t, akaberi m, farhadi f, ahmad s. black cumin seeds: from ancient medicine to current clinical trials. in: atta-ur-rahman, choudhary mi, yousuf s, eds. science of spices and culinary herbs – latest laboratory, pre-clinical, and clinical studies. sharjah: bentham science publisher; 2021. pp 27-59. 13. aliiev rb. features of the endocrine activity of fat tissue in metabolism disorders. bull med biol res 2023;15:26-32. 14. bernstein n, akram m, yaniv-bachrach z, daniyal m. is it safe to consume traditional medicinal plants during pregnancy? phytother res 2021;35:1908-24. 15. kahssay sw, tadege g, muhammed f. self-medication practice with modern and herbal medicines and associated factors among pregnant women attending antenatal care at mizan-tepi university teaching hospital, southwest ethiopia. heliyon 2022;8:e10398. 16. shahini e, luhovyi s, kalynychenko h, et al. rational use of oilseed waste to increase dairy productivity. int j environ stud 2023;80:442-50. 17. chen y, xu y, han x, et al. azacytidine shows potential in controlling the chilling injury of banana peel during cold storage. food control 2024;159:110283. 18. balarastaghi s, delirrad m, jafari a, et al. potential benefits versus hazards of herbal therapy during pregnancy; a systematic review of available literature. phytother res 2022;36:82441. 19. zarrouk a, martine l, grégoire s, et al. profile of fatty acids, tocopherols, phytosterols and polyphenols in mediterranean oils (argan oils, olive oils, milk thistle seed oils and nigella seed oil) and evaluation of their antioxidant and cytoprotective activities. curr pharm des 2019;25:1791-805. 20. nikolova ns, danyliv si. analysis of fatty oil nigella sativa l. produced in ukraine and bulgaria. bull med biol res 2022;4:80-3. 21. hannan a, rahman a, sohag aam, et al. black cumin (nigella sativa l.): a comprehensive review on phytochemistry, health benefits, molecular pharmacology, and safety. nutrients 2021;13:1784. 22. mukhametov a, aliyeva n, musayeva n, et al. antioxidant activity and phenolic content of cereal food concentrates: import control issues. agric conspec sci 2023;88:317-24. 23. yimer em, tuem kb, karim a, et al. nigella sativa l. (black cumin): a promising natural remedy for wide range of illnesses. evid based complement alternat med 2019;1528635. 24. novak-mazepa co, sachuk nv, marushchak mi. analysis of factors associated with arterial hypertension and the quality of patients’ life. bull med biol res 2023;5:60-7. 25. ermumcu msk, şanlıer n. black cumin (nigella sativa) and its active component of thymoquinone: effects on health. j food health sci 2017;3:170-83. 26. chen y, li d, zhang x, et al. azacytidine-induced hypomethylation delays senescence and coloration in harvested strawberries by stimulating antioxidant enzymes and modulating abscisate metabolism to minimize anthocyanin overproduction. food chem 2023;407:135189. 27. kurmanova a, urazbayeva g, terlikbayeva a, et al. diagnostic significance of blood lymphocyte activation markers in pre-eclampsia. clin exp immunol 2024;215:94-103. 28. svyatova g, berezina g, danyarova l, et al. genetic predisposition to gestational diabetes mellitus in the kazakh population. diabetes metab syndr 2022;16:102675. 29. salyha n. regulation of oxidative stress and lipid peroxidation induced by epinephrine: the corrective role of l-glutamic acid. int j med med res 2023;9:32-8. 30. ilderbayev o, okassova a, rakhyzhanova s, et al. the levels of oxidative stress in a combination of stress factors. j med life 2022;15:927-31. 31. kudabayeva ki, bazargaliev ys, darzhanova kb, agzamova rt. peculiarities of chronic gastritis in diabetes mellitus type 2. eur j phys health educ 2014;6:1-5. 32. thomas jv, mohan me, prabhakaran p, et al. a phase i clinical trial to evaluate the safety of thymoquinone-rich black cumin oil (blaqmax®) on healthy subjects: randomized, doubleblinded, placebo-controlled prospective study. toxicol rep 2022;9:999-1007. 33. salaria n, kumari i, neeraj, et al. concept of polycystic ovarian syndrome: anti-pcos plants in the unani system of medicines. in: hajam ya, kumar r, thakur dr, rai s, eds. herbal medicine applications for polycystic ovarian syndrome. boca raton: crc press; 2023. pp 128-48. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12751] [page 89] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12233 the consumption of walnuts has an impact on decreasing fasting blood glucose levels in individuals with concurrent hyperglycemia and hyperlipidemia: a randomized control trial sukmawati, sirajuddin, suriani rauf department of nutrition, health polytechnic of makassar, indonesia abstract nationally, the prevalence of diabetes mellitus (dm) has increased by 0.5%. in 2013, it was approximately 1.5%, rising to 2.0% in 2018. on the other hand, it is known that administering walnut extract can reduce blood sugar levels in diabetic patients. the aim of this study is to determine the effect of walnut consumption on blood sugar levels. the research was conducted experimentally, using a pre-post test control group design. the research sample consisted of mothers with fasting blood sugar levels ≥200 mg/dl and total cholesterol levels ≥200 mg/dl (hyperglycemic and hyperlipidemic). the total sample size was 50 mothers, divided into 2 groups. samples were selected using simple random sampling. the intervention involved giving 50 grams of walnut (canarium indicum l.) daily for 8 weeks to the treatment group. the research was conducted in the working area of the paccerakang community health center in makassar city, indonesia. statistical analysis was performed using paired t-tests. there was a decrease in fasting blood glucose levels in the treatment group from 244.12 mg/dl to 195.52 mg/dl. in the control group, there was a slight decrease in blood sugar levels from 236.92 mg/dl to 229.96 mg/dl. paired t-test analysis in the treatment group showed a value of p=0.00, indicating a significant difference in cholesterol levels before and after the intervention in the treatment group. in the control group, the value was p=0.07, indicating no significant difference in cholesterol levels in the control group. administering 50 grams of walnuts per day for 8 weeks significantly lowered fasting blood sugar levels in hyperlipidemic and hyperglycemic mothers. introduction the national prevalence of diabetes mellitus (dm) has increased by 0.5%. in 2013, it was around 1.5%, rising to 2.0% in 2018.1,2 based on the secondary analysis of the basic health survey in indonesia, the results consistently show higher prediabetes rates in rural areas (45.2%) compared to urban areas (37.0%). prediabetes is more prevalent among women, those aged 30 or older, individuals with lower education levels, and various occupational groups such as farmers, fishermen, unemployed individuals, married individuals, and those from lower socioeconomic backgrounds, including individuals with easier access to health services.3 the data from 2013 show that the national prevalence of dm in indonesia was 6.9%, with rates of 7% in rural areas and 6.6% in urban areas. the borderline level of total cholesterol (200-239 mg/dl) reached 28%, while the high level (>240 mg/dl) reached 10.1%.2 the study investigates the occurrence of concurrent hyperlipidemia and hyperglycemia in one small town in south sulawesi, specifically in biringkanaya, a part of makassar city, indonesia. multiple comprehensive prospective observational studies in humans demonstrate a clear inverse relationship between the risk of coronary heart disease and the consistent consumption of small servings of nuts, specifically highlighting walnuts.4,5. greater consumption (≥5 servings/week) of peanuts and walnuts, rather than correspondence: sirajuddin, department of nutrition, health polytechnic of makassar, indonesia. e-mail: sirajuddin.gizi@poltekkes-mks.ac.id key words: walnuts, blood glucose, hyperlipidemia, hyperglycemic. contributions: is, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ss, review and editing; sf, resources, supervision, and writing –review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. funding: this research was supported by a research grant from the health department of the republic of indonesia, grant contract number: lb.02.03/4.3/5390/2022. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission, health polytechnic of makassar, based on ethical certificate 0027/m/kepkptkms/iii/2023. during this research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank the health polytechnic of makassar for their valuable insights and contributions to this study. received: 26 december 2023. accepted: 30 march 2024. early access: 24 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12233 doi:10.4081/hls.2024.12233 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 344] [healthcare in low-resource settings 2024;12:12333] non -co mmerc ial us e o nly peanut butter, showed an inverse correlation with the presence of multiple chronic conditions and substantial weight loss.6 citing healthy food, it has been found that walnuts can lower lowdensity lipoprotein (ldl), and reduce the likelihood of ldl particles forming plaques in artery walls.7 consumption of 42.5-85 g/day of walnuts has proven to decrease total cholesterol, triglycerides, ldl cholesterol, and increase high-density lipoprotein (hdl) cholesterol, lower blood pressure, improve endothelial function, reduce oxidative stress and inflammation markers, lower blood sugar levels, and potentially aid in weight loss.8 the effect of walnut (canarium indicum) extract administration on blood sugar levels in acute hyperglycemic rats (rattus norvegicus l), that the walnut extract at a dosage of 300 mg/kg body weight effectively lowered blood sugar levels, but the effectiveness of reducing blood sugar levels was much greater at a dosage of 600 mg/kg body weight as it normalized fasting blood sugar. the systematic review proves that the effect of reducing glucose through walnut consumption is weak, as subjects with existing hyperlipidemia tend to have dietary control and medication as coping mechanisms. further studies are needed to assess dietary and medication confounding factors.9 the study observed the effects of walnut consumption on reducing fasting blood glucose levels in patients with concurrent hyperlipidemia and hyperglycemia. the control for dietary and anti-diabetes medication confounders was achieved by excluding subjects who already had specific diets and anti-diabetes medication. this study aimed to assess the role of walnuts (canarium indicum l.) in lowering blood sugar levels in hyperlipidemic and hyperglycemic mothers.10 materials and methods research design this study is an experimental research with a randomized control study and a pilot study. first, the samples were screened by measuring fasting blood sugar levels and cholesterol total levels. the total number of individuals was 65. based on the inclusion criteria of fasting blood sugar >200 mg/dl and total cholesterol >200 mg/dl, only 50 subjects were found. they were then randomly divided into two groups: 25 individuals in the intervention group and 25 individuals in the control group. throughout the study, those who completed the entire study sequence remained the same at 25 individuals in each group, resulting in a total of 50 eligible subjects for analysis study participants first, the samples were screened by measuring fasting blood sugar and cholesterol levels. a total of 225 individuals were screened. based on the inclusion criteria of fasting blood sugar >200 mg/dl and total cholesterol >200 mg/dl, only 95 subjects were found. secondly, subsequently, they were randomly divided into two groups: 25 individuals in the intervention group and 25 individuals in the control group. throughout the study period, 25 individuals in each group completed the entire study process, resulting in a total of 50 eligible subjects for analysis. sampling was done through simple random sampling. the intervention involved providing roasted walnuts to the treatment group, 50 grams per day for 8 weeks. the research was conducted at 5 integrated health posts (ihp) in the working area of paccerakang public health center, makassar city, indonesia. however, after the completion of the study, they were provided with walnuts. variable, instrument, and data collection the characteristics of the respondents (age, education, and occupation) were collected by interviews using a questionnaire. the intake of energy and nutrients was collected by food recall for 24 hours using the multi-pass five method.11,12 content analysis of energy and nutrient intake were calculated based on the food composition table indonesia, integrated into nutrisurvey apps. levels of glucose were collected by a commercial kit (accu pro; syaf; west purwokerto, indonesia). data analysis the paired t-test was used to analyze energy intake, nutrients, and blood sugar before and after the intervention. this analysis was performed using the statistical package for social sciences (spss) version 16 software. ethical clearance the research has received ethical approval from the health research ethics commission, health polytechnic of makassar, based on ethical certificate 0027/m/kepk-ptkms/iii/2023. during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results the study found that the intervention group’s energy, carbohydrates, and protein intake was higher than that of the control group. the treatment group’s fasting blood sugar levels were significantly lower (tables 1-3). discussion the study aims to observe the difference in fasting blood sugar levels in mothers with hyperlipidemia and hyperglycemia before and after an intervention involving the consumption of 50 grams of walnuts daily. in this study, an intervention of consuming 50 grams of roasted walnuts daily for 8 weeks was conducted among mothers experiencing hyperlipidemia and hyperglycemia. a paired ttest statistical analysis was employed to evaluate the difference in fasting blood sugar levels between the treatment and control groups. there was a reduction in the mean fasting blood sugar levels in the treatment group from 244.12 mg/dl with a standard deviation (sd) of 22.06 to 192.52 mg/dl, with a standard deviation of 33.26. the decrease in fasting blood sugar levels in the treatment group post-intervention was attributed to a reduction in carbohydrate intake from 100.81% recommended dietary allowances (rda) to 95.89% rda and a decrease in energy intake from 100.30% rda to 95.56% rda. the theory suggests that low carbohydrate intake can impact a reduction in blood sugar levels. walnut consumption increases satiation and may lead to decreases in energy intake. 13 results of this study revealed a significant difference in the decrease of fasting blood sugar levels among the treatment group. other studies have reported that administering walnut oil to diabetic patients can improve blood sugar profiles, including the parameter hba1c; even though the outcome differs from this study, which only measured fasting glucose, the essence remains related article [healthcare in low-resource settings 2024;12:12333] [page 345] non -co mmerc ial us e o nly to blood sugar control.14-16 however, a systematic review and metaanalysis report by neale et al. in 2020 found that the consumption of walnuts did not consistently decrease fasting glucose. this is due to their position within the subjects’ dietary patterns, where walnuts are not the primary contributor to glucose. thus, their effect is not directly on the fasting glucose profile but is important as part of balancing the overall nutritional intake.9 the acute consumption of walnuts, when consumed together with a source of carbohydrates, is capable of lowering blood glucose.17 it is suspected that this is related to the effect on insulin sensitivity, which controls the increase in blood glucose.18 in the specific context of walnuts and blood glucose, current strong evidence suggests that the reduction in blood glucose is not directly related to the effect of walnuts alone,9 but rather to the interaction effects of various nutritional components that are naturally part of the meal composition. additionally, controlling the effects of anti-diabetic medications poses a challenge. to address doubts about the argument that walnuts do not decrease blood glucose, this study excluded all subjects consuming anti-diabetic drugs and subjects following a specific carbohydrate intake control diet. none of the subjects had established a specific dietary pattern related to their status as hyperglycemic and hyperlipidemic subjects. one explanation for this is that in the intervention group, there was a significant decrease in carbohydrate and fat intake, whereas in the control group, carbohydrate, and fat intake remained unchanged. walnuts also contain unsaturated fatty acids such as oleic acid, linoleic acid, and palmitic acid.19 these unsaturated fatty acids can help lower blood sugar levels by modulating mitochondrial bioenergetics and endoplasmic reticulum stress, thus increasing insulin sensitivity.20 moreover, the bioactive compounds and antioxidants found in walnuts play a role in lowering blood sugar.21 flavonoids and phenolic compounds found in walnuts aid in improving glucose tolerance and insulin resistance by preventing oxidative stress, a known cause of diabetes pathogenesis.22 however, there are conflicting findings in the study by neale et al. (2020), which suggested that walnut intake did not significantly affect blood glucose control markers. the study emphasized the need for further investigation to reduce bias and explore potential limitations. nonetheless, several studies support the beneficial article table 2. the intake of energy and nutrients of the subjects. intake intervention (n=25) p control (n=25) p before after before after energy (kcal) 1956.25±199.19 1863.82±167.42 0.01 1943.42±152.69 1965.09±156.99 0.35 carbohydrate (g) 300.74±35.76 286.57±30.27 0.03 304.97±29.15 315.26±36.16 0.08 fat (g) 56.07±7.95 51.39±5.50 0 54.18±4.81 56.00±5.76 0.14 protein (g) 59.90±4.23 59.66±4.90 0.87 62.58±5.40 64.36±7.38 0.19 table 3. mean of the fasting blood glucose level of the subject. groups fasting blood glucose level (mg/dl) p before (n=25) after (n=25) intervention 244.12±22,06 192.52±33.26 0.00 control 236.92±18.98 229.96±26.34 0.07 table 1. characteristics of research respondents. characteristics mother father intervention control intervention control n % n % n % n % age (years) 35-45 8 32 13 52 6 24 10 40 46-55 17 68 12 48 19 76 15 60 education primary school 5 28 14 56 8 32 14 56 secondary school 4 16 2 8 7 280 2 8 high school 9 36 7 28 4 16 7 28 graduated 7 28 2 8 6 24 2 8 occupation civil servants 3 12 0 0 7 28 1 4 private sector employees* 0 0 0 0 3 12 3 12 entrepreneurs 0 0 0 0 1 4 0 0 informal sector (traders ) 22 88 25 100 14 56 21 22 total 25 100 25 100 25 100 25 100 *traders, laborer, farmer, fishermen, driver, retired. [page 346] [healthcare in low-resource settings 2024;12:12333]] non -co mmerc ial us e o nly role of incorporating walnuts into a healthy diet for diabetes prevention. in conclusion, the research suggests that walnut consumption can potentially help reduce blood sugar levels in subjects with concurrent hyperglycemia and hyperlipidemia, but more comprehensive studies are needed to confirm these findings. conclusions there was a significant difference in the fasting blood glucose levels of concurrent hyperlipidemic and hyperglycemic mothers after the administration of 50 grams/day of walnuts for 8 weeks. references 1. kemenkes. laporan riskesdas tahun 2018. 2018. available from: https://repository.badankebijakan.kemkes.go.id/ id/eprint/ 3514/1/laporan%20riskesdas%202018%20 nasional.pdf 2. kemenkes. laporan riset kesehatan dasar tahun 2013. 2013. available from: https://repository.badankebijakan.kemkes. go.id/id/eprint/4428/ 3. dany f, dewi rm, tjandrarini dh, et al. urban-rural distinction of potential determinants for prediabetes in indonesian population aged ≥15 years: a cross-sectional analysis of indonesian basic health research 2018 among normoglycemic and prediabetic individuals. bmc public health 2020;20:1509. 4. guasch-ferré m, hernández-alonso p, drouin-chartier jp, et al. walnut consumption, plasma metabolomics, and risk of type 2 diabetes and cardiovascular disease. j nutr 2021;151:303-11. 5. kris-etherton pm. walnuts decrease risk of cardiovascular disease: a summary of efficacy and biologic mechanisms. j nutr 2014;144:547-54s. 6. wang r, hannan mt, wang m, et al. long-term consumption of nuts (including peanuts, peanut butter, walnuts, and other nuts) in relation to risk of frailty in older women: evidence from a cohort study. j nutr 2023;153:820-7. 7. rajaram s, cofán m, sala-vila a, et al. effects of walnut consumption for 2 years on lipoprotein subclasses among healthy elders. circulation 2021;144:1083-5. 8. berryman ce, grieger ja, west sg, et al. acute consumption of walnuts and walnut components differentially affects postprandial lipemia, endothelial function, oxidative stress, and cholesterol efflux in humans with mild hypercholesterolemia. j nutr 2013;143:788-94. 9. neale ep, guan v, tapsell lc, probst yc. effect of walnut consumption on markers of blood glucose control: a systematic review and meta-analysis. br j nutrition 2020;124:641-53. 10. zebari hmh, hidayet hm, al-nakshabandi assel ai, hussein n. pain caused by ear tagging in kids of native black goats. j sci res med biol sci 2021;2:19-29. 11. htet mk, fahmida u, do tt, et al. the use of tablet-based multiple-pass 24-hour dietary recall application (mp24diet) to collect dietary intake of children under two years old in the prospective cohort study in indonesia. nutrients 2019;11:2889. 12. gibson rs, ferguson el. an interactive 24-hour recall for assessing the adequacy of iron and zinc intakes in developing countries. 2008. available from: https://www.ifpri.org/publication/interactive-24-hour-recall-assessing-adequacy-iron-andzinc-intakes-developing-countries 13. brennan am, sweeney ll, liu x, mantzoros cs. walnut consumption increases satiation but has no effect on insulin resistance or the metabolic profile over a 4�day period. obesity 2010;18:1176-82. 14. zibaee nezhad mj, aghasadeghi k, hakimi h, et al. the effect of walnut oil consumption on blood sugar in patients with diabetes mellitus type 2. int j endocrinol metab 2016;14. 15. njike vy, yarandi n, petraro p. inclusion of walnut in the diets of adults at risk for type 2 diabetes and their dietary pattern changes: a randomized, controlled, cross-over trial. bmj open diabet res care 2016;4:e000293. 16. arab l, dhaliwal sk, martin cj, et al. association between walnut consumption and diabetes risk in nhanes. diabetes metab res rev 2018;34:e3031. 17. josse ar, kendall cwc, augustin lsa, et al. almonds and postprandial glycemia—a dose-response study. metabolism 2007;56:400-4. 18. jiang r. nut and peanut butter consumption and risk of type 2 diabetes in women. jama 2002;288:2554. 19. hama jr, fitzsimmons-thoss v. determination of unsaturated fatty acids composition in walnut (juglans regia l.) oil using nmr spectroscopy. food anal methods 2022;15:1226-36. 20. kim y, keogh j, clifton p. benefits of nut consumption on insulin resistance and cardiovascular risk factors: multiple potential mechanisms of actions. nutrients 2017;9:1271. 21. ni zj, zhang yg, chen sx, et al. exploration of walnut components and their association with health effects. crit rev food sci nutr 2022;62:5113-29. 22. zheng y, wu s, wang r, et al. analysis and correlationship of chemical components of various walnut (juglans regia l.) cultivars. j food measurement characterization 2020;14:360514. article [healthcare in low-resource settings 2024;12:12333] [page 347] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:13008 nursing competency model for nurse manager in hospital: a scoping review inggerid agnes manoppo,1,2 enie novieastari,1 hanny handiyani,1 tuti nuraini1 1faculty of nursing, universitas indonesia, depok, west java; 2sekolah tinggi ilmu kesehatan papua, sorong, indonesia abstract clinical and structural shifts represent pattern of change in health care. it requires the development of nurse manager leadership competency.this scoping review was conducted to map the nurse manager competency model in the hospital. adopt the jbi (joanna briggs institute) methodology for a scoping review. the databases used in this review article include the scientific information database, google scholar, proquest, pubmed, and science direct databases. the search strategy is more comprehensive than the type of study in english, relevant case 15 articles published from 2005-2022. the papers included in the analysis comprised qualitative and quantitative research designs, utilizing keyword combinations such “nursing competency model for nurse manager.” eligible publications are searched for relevant data, which is then collected in a spreadsheet and imported into microsoft word. from there, it is combined into a table with a primary conceptual overview and a description of the study’s features. most studies involve nurse managers at multiple levels (top and middle managers). from the mapping, there are 14 nurse manager competency models. most of the models emphasize the importance of communication competence, leadership skills, and business management accompanied by an attitude of professionalism and qualified knowledge. the essential skills that a nurse manager must possess emphasize the importance of communication competencies, leadership skills, and business management along with professionalism and knowledge. introduction competence is the chronic and thoughtful use of communication, knowledge, technical skills, clinical reasoning, emotions, values, and reflection in daily practice that benefits the individuals and communities served by using science and other abilities.1 in practice, nurse managers are expected to apply knowledge, skills, and personality in every situation and adapt related knowledge and skills in different conditions. core competence is collective learning in organizations, especially related skills that produce services, resulting in integration between the necessary knowledge and technology,2 competence needs to be made in the form of set standards and become a reference for implementation as a nurse manager in care, service management, and nursing leadership. leader competencies are identified with the ability to perform management functions well, including skills, knowledge, and expertise for organizational success. other competencies may demonstrate skills and behaviours in organizational culture, communicating organizational vision, and managing change.3,4 a model is needed to carry out the role of nurse managers in nursing management and leadership. competency is a standard and reference for nurse managers. the model is a pattern of examples, references, and varieties of something that will be made or produced. the model is also a symbol representing practical experience in words, pictures, graphs, diagrams, mathematical notes, or the physical materials that make up its knowledge in an empirical pattern. the decree of the minister of health of the republic of indonesia number hk.01.07/menkes/425/20205 concerning nurse professional standards outlines the nursing leadership competency model in indonesia. it states that nurses possess core competencies in leadership and management, which include the ability to practice nursing services, care management, and leadership. competency models are the responsibility of professional organizations to regulate them. in indonesia, the nurse manager compecorrespondence: inggerid agnes manoppo, faculty of nursing, universitas indonesia, jalan lafran pane rt 12/rw 10, kelurahan tugu cimanggis, depok, west java, indonesia e-mail: inggerid.agnes@ui.ac.id key words: nursing leadership competency; nursing manager; primary healthcare nurse. conflict of interest: the researchers declare that they have no interest. contributions: all authors contributed ideas to the preparation of this review and are responsible for the work presented at the sigma theta tau international annual meeting (stti) 2023 in conjunction with the 3rd ui international nursing scholar congress funding: none. ethics approval and informed consent: not applicable. availability of data and material: data obtained based on research results analysed. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgments: we would like to thank the collaborating research team. received: 4 september 2024. accepted: 4 september 2024. early access: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:13008 doi:10.4081/hls.2024.13008 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 713] [healthcare in low-resource settings 2024;12:13008] non -co mmerc ial us e o nly tency model developed by the professional organization, namely the indonesian nurse manager association (inma) is still in draft form and has not yet become a standard that is enforced as a guideline for nurse competency standards.6 the draft nurse manager competency model developed by inma includes several competencies, namely ethical legal and cultural practices, management and delivery of nursing care, planning, organizing, directing, managing personnel, implementing monitoring and evaluation, carrying out leadership roles, and developing personal and professional qualities. a standardized nurse manager competency model can guide the management of uniform nursing care and services. in other countries, nurse manager competency models have been developed and uniformly defined by professional organizations. this study aims to delineate the components of the competency model for nurse managers working in hospitals. materials and methods writing a scoping review follows the preferred reporting items for systematic reviews and meta-analyses for scoping reviews (prisma-scr) reporting checklist and is done in accordance with the joanna briggs institute (jbi) methodology.7-9 search strategy the goal of the search method is to locate journal-published publications. three databases science direct, proquest, and pubmed were searched to find publications related to the covered subjects. supplementary table 1 provides the search technique and all specified keywords, search dates, and complete search results. study designs are not a constraint on the search approach; qualitative and quantitative research are included. the text consists of studies published in english. study/source of evidence selection following the search, duplicate articles were eliminated, and all found articles were compiled and posted to the mendeley desktop. then, using the inclusion criteria of nurse managers as participants—that is, nurses tasked with overseeing nursing services in a health facility at the middle level (middle manager) or top-level (top manager) titles and abstracts were vetted by two impartial reviewers. full text and detailed citations were imported into the jbi system for integrated management, assessment, and review once relevant papers were searched. the reasons for excluding articles that did not meet the inclusion criteria are shown in figure i. discussions were used to settle disagreements developed among reviewers. data analysis and presentation the data is compiled in one spreadsheet and imported into microsoft word 2019 (microsoft corporation, redmond, wa) to be put together into a table which contains a summary of the characteristics of the study, including author, year, design, setting as well as the main conceptual summary that is important to synthesize, namely various competency models of nurse managers who identified along with competency dimensions and sub-dimensions that nurse managers need to have and competency mapping that is important for nurse managers to have in hospitals. inclusion and exclusion criteria participants this review considers studies that make nurse managers participants. these nurses are responsible for managing nursing services in health facilities at the middle level (middle manager) and toplevel (top manager). concept this review considers studies that include models of nurse competency as interventions, outcomes or observed phenomena from the study. context this review includes specific settings in hospitals and other healthcare settings. types of sources many mixed-method and qualitative study designs are taken into consideration for inclusion in this evaluation. opinions and text papers were also taken into consideration for the scoping review. data extraction data was extracted from eligible articles by two independent reviewers using data extraction instruments developed by the reviewers (see figure 1). the extracted data includes details about study characteristics, nurse managers, nursing leadership competency models (dimensions and sub-dimensions), hospital settings, and critical findings relevant to the review questions. any disagreements that arose between the reviewers were resolved through discussion. results study inclusion after entering keywords according to pcc, 29,353 articles were identified and filtered based on the inclusion criteria and 25 articles were eligible but 10 articles were excluded because they did not have full text and did not display the nurse manager competency model. from this process, 15 studies were included in the review (figure 1). article figure 1. missing dida [healthcare in low-resource settings 2024;12:13008] [page 714] non -co mmerc ial us e o nly review findings from the mapping results (supplementary table 1), most models emphasize the importance of communication competence, leadership skills, and business management accompanied by an attitude of professionalism and qualified knowledge. communication skills are often associated with relationship management10-12 and technology. leadership ability is associated with the nurse manager’s ability to lead others and create the character of a leader both in general and specifically.13-14 conflict and complaint resolution, team/staff management, financial management, risk management, time management, and human resource management are examples of business management competencies.3,15-20 discussion leadership rules in health services have changed over time. clinical and structural shifts show patterns of change in healthcare. nurse managers are expected to be able to master several concentrations, such as business administration, leadership, and financial management. essential competencies for nurse leadership are expressed in several items.17-19,21,22 business management competency: financial management, preparation of planning, and budget management. by having this competency, a nurse manager can understand and apply economic concepts in analysing effective financing and appropriate business models to determine priorities and measurable goals. communication skills: speaking, writing, and assertiveness. able to articulate ideas, ask provocative questions, be able to listen to diverse opinions, and be assertive. effective communication competence allows nurse managers to build trust with stakeholders. clinical knowledge: the ability to articulate nursing work and nursing contributions. a nurse manager who has good clinical knowledge competencies can ensure the delivery of safe, evidencebased patient care. nurses have the ability to maintain patient safety in the nursing environment. critical thinking and leadership spirit: conceptual, out-of-thebox, theoretical, and innovative. nurse managers are able to identify and analyze problems objectively. with critical thinking skills, nurses can generate alternative solutions in making recommendations and decisions, delegate appropriately, develop professional governance in terms of philosophy and structure. professionalism: collaboration and team skills. nurse managers who have professionalism as part of their competence can support health nursing policies at all levels of government, resulting in safe, quality, accessible, and effective health care. in addition to structural competence, a nurse manager must have leadership competence in the emotional aspect. this is broken down into three aspects, namely17,23,24 self-awareness, selfmanagement and social awareness. the ideal leader can read individual emotional states and be aware of the elements of life experience that can challenge and change moods. this emotional status allows the leader to control his heart and align in the expression of leadership because negative moods can affect relationships with staff. leaders must take corrective action and ensure that negative moods are not transferred to staff and the rest of the team. selfmanagement ability is evidence of integrity in work. in addition to skills in managing personal emotions, leadership effectiveness is also related to the ability to assess the emotions and moods of other people, namely staff and teams. this intuitive skill is expressed in empathy, which confirms that leaders are sensitive and aware of social realities in their leadership.21 changing times and service models require leaders to take a more vital role to be implemented in health care. a clear vision of the direction of change and skills in responding to change is needed by leaders who must be able to translate the reality and demands of change to become a reference for planning formulations easily understood by the team. active involvement in dealing with the variability of change puts leaders in a condition that must be willing to face the demands of internal change and accept that staff cannot be expected to accept significant changes in work and relationships at work if not preceded by their superiors. optimization of nursing services and relations between staff at work is strongly influenced by the leadership style applied by the manager. a management style that applies high leader visibility and a shared decision-making process positively impacts nurse retention. their relationship with the manager becomes an important factor in job satisfaction—a charismatic, optimistic nurse with practical interpersonal skills for a nurse manager position. conclusions the various research designs included in this study included both quantitative and qualitative research. most of the studies involved nurse managers (top and middle managers) at various levels. from the mapping of 15 articles, most models emphasized the importance of communication competencies, leadership skills, and business management along with professionalism and knowledge. organizations can design plans to generate competent managers in healthcare organizations with the help of the competencies required of nurse managers. the literature supports employing instruments to create, measure, and assess competences, which is another significant finding of this study. but this is not something that can be stated clearly from the model that was used to choose nurse managers. this suggests that the competency model can be applied when selecting managers—nurses—for the company and, consequently, for the administration of patient care. the review’s scientific discoveries will broaden the corpus of nursing knowledge pertaining to nurse management. references 1. ličen s, plazar n. developing a universal nursing competencies framework for registered nurses: a mixed methods approach. j nurs scholarsh 2018;51:459–70. 2. fukada m. nursing competency: definition, structure and development. yonago acta med 2018;61:1–7. 3. garcía ag, pinto-carral a, villorejo js, marqués-sánchez p. nurse manager core competencies: a proposal in the spanish health system. int j environ res public health 2020 1;17. 4. robbins sp, judge ta. organizational behavior. in 2021. 5. the ministerial decree of ministry of health republic of indonesia no: hk.01.07/menkes/425/2020 on the standard of nursing profession 2020 6. american organization of nurse executive. nurse executive competencies. [internet]. chicago: american organization of nurse executives; 2015. 11 p. available from: https://www.aonl.org/sites/default/files/aone/nec.pdf article [page 715] [healthcare in low-resource settings 2024;12:13008] non -co mmerc ial us e o nly 7. peters mdj, godfrey c, mcinerney p, et al. jbi manual for evidence synthesis. chapter 11: scoping reviews. 2020. available from: https://synthesismanual.jbi.global/ 8. mcgowan j, straus s, moher d, et al. reporting scoping reviews-prisma scr extension. 2020. 9. munn z, aromataris e, tufanaru c, et al. the development of software to support multiple systematic review types: the joanna briggs institute system for the unified management, assessment and review of information (jbi sumari). int j evid based healthc 2019;17:36-43. 10. mccarthy g, fitzpatrick jj. development of a competency framework for nurse managers in ireland. j contin educ nurs 2009;40:346–50. 11. goktepe n, turkmen. development of managerial competencies for first-level nurse managers in turkey. int j caring sci 2018;11:1096. 12. mbango c. incorporating global and cultural competencies in nursing education. nursing 2023;53:15-17. 13. parchment j, stinson a. clinical nurses: leading through the complexity of human trafficking. nurs adm q 2020;44:23543. 14. kvas a, seljak j, stare j. training needs assessment for leaders in nursing based on comparison of competency models. organizacija 2014;47. 15. saifman h, sherman ro. the experience of being a millennial nurse manager. j nurs adm 2019;49:366-71. 16. sherman ro, bishop m, eggenberger t, karden r. development of a leadership competency model. j nurs adm 2007;37:85-94. 17. miltner rs, jukkala a, dawson ma, patrician pa. professional development needs of nurse managers. j contin educ nurs 2015;46:252-8; quiz 259-60. 18. clemmons-brown ca. addressing human trafficking through nurse leadership. nurse lead 2020;18:581-5. 19. bleich mr, zimmermann d, hancock b. unprecedented leadership: how nurses responded to the covid-19 pandemic. nurse lead 2021;19:453-5. 20. joslin d, joslin h. nursing leadership covid-19 insight survey: key concerns, primary challenges, and expectations for the future. nurse lead 2020;18:527-31. 21. aone. nurse executive competencies. chicago: aone; 2015. 11 p. 22. munyewende po, levin j, rispel lc. an evaluation of the competencies of primary health care clinic nursing managers in two south african provinces. glob health action 2016;9:32486. 23. gunawan j, aungsuroch y, fisher ml, et al. managerial competence of first-line nurse managers in public hospitals in indonesia. j multidiscip healthc 2020;13:1017-25. 24. kim ay, sim io. communication skills, problem-solving ability, understanding of patients’ conditions, and nurse’s perception of professionalism among clinical nurses: a structural equation model analysis. int j environ res public health 2020;17:1–14. 25. gottlieb ln, gottlieb b, bitzas v. creating empowering conditions for nurses with workplace autonomy and agency: how healthcare leaders could be guided by strengths-based nursing and healthcare leadership (sbnh-l). j healthc leadersh 2021;13:169-81. 26. gonzález-garcía a, pinto-carral a, villorejo js, marquéssánchez p. competency model for the middle nurse manager (mcge-logistic level). public health 2021;18:3898. 27. julie van orne, branson k. using an innovative clinical nurse leader practice model to sustain high-quality patient care and promote a positive work environment during the covid-19 pandemic. nurse lead 2022;20:208-14. article [healthcare in low-resource settings 2024;12:13008] [page 716] online supplementary materials table 1. mapping of competency models and main competencies that are important to nurse managers. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11993 relationship between peer conformity and reproductive health maintenance behaviours among early adolescent girls in islamic boarding schools peni perdani juliningrum,1 lantin sulistyorini,1 layinatul qoriah,2 ira rahmawati,1 nuning dwi merina1 1pediatric nursing department, faculty of nursing, universitas jember, jember; 2nursing faculty student, faculty of nursing, universitas jember, jember, indonesia abstract reproductive health problems are often experienced by early adolescents who live in islamic boarding schools because islamic boarding schools have a higher population density and interpersonal contact than other schools. in the early adolescent years, there is a tendency in terms of a solid urge to behave like peers, so conformity quickly occurs when adolescents adopt reproductive health care behaviours. this study aimed to determine the relationship between peer conformity and reproductive health maintenance behaviour of early adolescent girls at islamic boarding schools. this study used a correlational research design with a cross-sectional approach and a purposive sampling technique conducted on 165 early adolescents. the analytical method used for this study was univariate and bivariate analysis tests, in bivariate tests using the pearson test processed with the statistical package for social sciences (spss) program. the analysis showed that all early adolescents (100%) had a history of vaginal discharge. the results of the bivariate test showed a value of p=0.0001. the level of reproductive health maintenance behaviour is determined by the extent to which conformity occurs in adolescents. conformity that occurs can affect and change one’s perceptions and behaviour. introduction hygiene problems often occur in places with high occupant density and interpersonal contact, including islamic boarding schools. islamic boarding schools are islamic religious education institutions that develop in society.1–3 one health problem that often occurs in islamic boarding schools is related to reproductive health. phenomena that occur in islamic boarding schools show behaviour that is not following the principles of reproductive health, including drying underwear in a bedroom that has no ventilation, wearing underpants that are too tight during menstruation or not, and using powder and applying ointment to the female area. in addition, the practice of washing the female organs is not quite right, namely by washing from the back to the front and using soap (soaking water, crystal x), which is believed to rejuvenate the female area and overcome leucorrhoea.4,5 adolescent students who are at the darul falah sidoarjo islamic boarding school still experience high reproductive health problems, namely 68%; many of the students have reproductive health problems starting from the menstrual cycle, vaginal discharge, and itching in the genital area.6 leucorrhoea is caused by the behaviour or habits of a person who ignores the cleanliness of their reproductive organs.7-9 as a result, the problem of leucorrhoea that is delayed in treatment will harm women’s health, such as the emergence of infertility, endometritis, pelvic inflammation, and salpingitis, so that prevention can be practiced to overcome reproductive health problems, namely by carrying out personal hygiene of the genital organs.1,10 maintaining reproductive health has three aspects: maintaining the cleanliness of the genital organs, handling menstrual problems, and detecting venereal disease problems.11-13 thirteen point five percent of young female students at darus sholah jember islamic boarding school get information about reproductive correspondence: peni perdani juliningrum, pediatric nursing department, faculty of nursing, universitas jember, jember, indonesia. e-mail: peni.psik@unej.ac.id key words: early adolescent girl, peer conformity, reproductive health maintenance behaviour. contributions: ppj, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ls, conceptualization, investigation, methodology, validation, review and editing; lq, conceptualization, methodology, validation, and writing – original draft, review and editing; ir, methodology, visualization, writing – review and editing; ndm, resources, investigation, and writing –review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: none. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. ethics approval and consent to participate: the research has received ethical approval from the ethics commission, faculty of dentistry, universitas jember with ethical number 766/un25.8/kepk/dl/2019. during the research, the researcher pays attention to the ethical principles. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 16 october 2023. accepted: 16 may 2024. early access: 16 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11993 doi:10.4081/hls.2024.11993 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 588] [healthcare in low-resource settings 2024;12:11993] non -co mmerc ial us e o nly health from school, 6% from social media, and 50% from peers.7 peers have an active role in providing knowledge or information related to reproductive health because 60% of adolescents communicate well with their friends.6 peers are one of the driving factors (reinforcing factors) to the formation of behaviour. peer groups can make adolescents change their behaviour, including maintaining reproductive health caused by pressure, known as conformity. conformity occurs when adolescents have relationships with peers and experience essential changes in their teenage lives.14,15 peers have the most substantial influence during early adolescence but begin to diminish in middle and late adolescence.16 in early adolescence, there is a tendency for the strongest urge to behave the same as peers; this is because the urge to be accepted into a group is still very high.17 the data described above is supported by research results which show that communication with peers is the most critical factor influencing adolescent reproductive health practices.6 based on the description above, the researcher was interested in digging deeper into the relationship between peer conformity and the behaviour of maintaining reproductive health for young women at islamic boarding schools. materials and methods this study used a correlational research design with a crosssectional approach that measured the relationship between peer conformity and reproductive health care behaviour for young women at islamic boarding schools. the population in this study consisted of 280 young female students who lived for 24 hours in islamic boarding schools, one islamic boarding school in jember and one in situbondo districts. the sampling technique used was purposive sampling with a total sample of 165 young female students, with the inclusion criteria being young female students aged 11-14 years and already experiencing menstruation. the exclusion criteria were young female students who were not willing to become participants and young students aged 11-14 years who were not at the research location due to illness. the instrument used in collecting data in this study was a questionnaire. the peer conformity variable questionnaire contains 14 statement items with a likert scale of 1-5 and has three indicators, namely cohesiveness, agreement, and obedience, whose validity and reliability test results are based on the cronbach alpha value of 0.679 and the value of r=0.657, while the questionnaire variable on reproductive health maintenance has 15 statement items with a likert scale of 14 and has indicators of genital care, menstruation management and early detection of venereal diseases whose reliability test results are 0.85. the analytical test used was univariate and bivariate analysis. univariate analysis assessed the characteristics of respondents, and the bivariate test measured the relationship between two variables with pearson’s test with p<0.05. this research has undergone research ethics trials and has been declared ethically feasible according to the seven 2011 world health organization (who) standards and refers to the 2016 council for international organizations of medical sciences (cioms) guidelines with ethical number 766/un25.8/kepk/dl/2019 by the research ethics committee of the faculty of dentistry, universitas jember. results table 1 shows the distribution of the characteristics of early adolescent female students at islamic boarding schools in jember and situbondo, totaling 165 adolescents (100%). the data shows that all adolescents experienced vaginal discharge, but no infection occurred. based on reproductive health information, 100% of adolescents have received the information, whereas 73.9% of the information obtained comes from their islamic boarding schools. for peer conformity, 64.8%is in the moderate category, while 54.5% is in the good category for reproductive health maintenance. table 2 shows the study results by connecting the independent and the dependent variables using the pearson test with a value of p=0.001, which means a significant correlation exists between peer conformity and reproductive health maintenance behaviour in adolescents in islamic boarding schools. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution of respondent characteristics at islamic boarding schools (n=165). participant characteristics n % age (years) 11 1 0.6 12 17 10.3 13 51 30.9 14 96 58.2 menarche (years) 10 6 3.6 11 28 17 12 74 44.8 13 57 34.5 history of adolescent vaginal discharge once 165 100.0 never 0 0.0 history of leucorrhea infection once 0 0.0 never 165 100.0 reproductive health information once 165 100.0 never 0 0.0 sources of reproductive health information islamic boarding school 122 73.9 friend 18 10.9 social media/internet 25 15.2 peer conformity low 31 18.8 medium 107 64.8 high 27 16.4 reproductive health maintenance less 7 4.3 enough 90 54.5 good 68 41.2 total 165 100.0 table 2. relationship between peer conformity and reproductive health maintenance behaviour of female adolescents at islamic boarding schools (n=165). reproductive health maintenance behavior peer conformity pearson correlation 0.341 sig. (2-tailed) 0.001 n 165 [healthcare in low-resource settings 2024;12:11993] [page 589] non -co mmerc ial us e o nly discussion conformity can influence adolescent reproductive health maintenance behaviour because adolescents are more involved with peers in their daily environment. it means that the emergence of reproductive health maintenance behaviour can be determined to what extent conformity occurs in adolescents. according to previous studies, one of the stages of adolescent development that must be achieved is the search for self-identity, which causes the focus of adolescents to shift to social life by tending to interact with their peers because they are considered capable of responding to inappropriate behaviour.18,19 teenagers tend to do the same thing as their peers do. peer conformity is an individual’s tendency to change perceptions, opinions, and behaviours influenced by peers or peer pressure. this pressure can be caused by adolescent interest that appears directly or indirectly in adolescents. peer conformity is a natural thing that happens to teenagers.20 during the stages of early adolescent development, the role of peers is significant compared to the role of the family. peers have a role as providers of information about the world outside the family. then, from the peer group, adolescents receive feedback about their potential and learn whether their behaviour is better, sound, or worse than other adolescents. teenagers will start needing more friends and solidarity.21 conformity due to pressure can affect and change the perceptions and behaviour of a teenager. conformity consists of aspects of normative social influence which means that there is a behaviour change based on fulfilling other people’s expectations or the desire to be liked and reducing the fear of rejection.20 the feeling of wanting to be liked and accepted by their peers causes adolescents to follow the rules adopted by adolescent groups, so conformity influences behaviour, including reproductive health maintenance behaviour. changes in behaviour in adolescents due to peer conformity do not just happen. there is a change in behaviour in early adolescents through three stages, namely when adolescents begin to know the meaning and benefits of behaviour, the occurrence of attitudes or reactions that are still closed from individuals to existing stimuli, and when individuals begin to carry out what is known and addressed.22 because of the strong emotional bonds and group conformity in adolescents, this is usually often considered as a factor that causes the emergence of new behaviour. so changes in behaviour due to conformity occur because of pressure from peers. it is identical to previous research that peer group conformity has a relationship with adolescent behaviour.23 conformity can affect adolescent reproductive health maintenance behaviour because adolescents are more involved with peers in their daily environment. it indicates that the emergence of reproductive health maintenance behaviour can be of high, moderate, or low value determined by the extent of conformity in adolescents. conformity in groups does not always lead to negative things. however, conformity can also lead to good things, as happened in the early youth of female students at the jember and situbondo islamic boarding schools, which has a positive correlation direction, meaning that the higher the peer conformity value, the higher reproductive health maintenance behaviour. the conformity that occurs leads to things that have positive value because adolescents and their peers have equal knowledge and are supported by a conducive youth environment, so adolescents and peers are required to behave in a way that does not deviate, especially in reproductive health maintenance behaviour. this research has limitations; notably, the sensitive nature of the topics discussed in this study may have made some female students feel uncomfortable, which could influence their responses. additionally, the islamic boarding school selected for this research is of a traditional type where discussing women’s reproductive health is often considered a taboo subject. conclusions peer conformity is related to reproductive health maintenance behaviour in early adolescent girls at islamic boarding schools. the school health unit’s program in islamic boarding schools needs to facilitate adolescents in terms of maintaining reproductive health, such as providing information about personal hygiene after urinating and defecating, the practice of maintaining vaginal hygiene during menstruation, and providing special classes for female students for inter-group discussions related to reproductive health. references 1. humairoh f, musthofa sb, widagdo l. faktor-faktor yang mempengaruhi perilaku vulva hygiene pada remaja putri panti asuhan di kecamatan tembalang, kota semarang. j kesehat masy 2018;6:745-52. 2. bramantoro t, basiroh e, berniyanti t, et al. intention and oral health behavior perspective of islamic traditional boarding school students based on theory of planned behavior. pesqui bras odontopediatria clin integr 2020;20:039. 3. khamida, yusuf a, budury s, karein ap. the relationship of religiosity and social support with students adaptation in the islamic boarding school. bali med j 2022;11:729-33. 4. setianingrum sp. perilaku kesehatan reproduksi santri putri di pondok pesantren tanwirul qulub kabupaten lamongan. 2017. available from: https://repository.unair.ac.id/ 67440/13/fis.ant.33.17%20.%20set.p%20-%20jurnal. pdf 5. kirana ta, purwanto b, anis w. vaginal hygiene, but not physical activity level associate to the event of pathological leukorrhea among female students of sport program. chiang mai univ j nat sci 2022;21:e2022025 6. mairo qkn, rahayuningsih se, purwara bh. kesehatan reproduksi remaja putri di pondok pesantren sidoarjo jawa timur. maj kedokt bandung 2015;47:77-83. 7. nikmah us, widyasih h. personal hygiene habits dan kejadian flour albus patologis pada santriwati pp almunawwir, yogyakarta. media kesehat masy indones univ hasanuddin 2018;14:36-43. 8. kurniawati em, toma f, parathon h, et al. incidence of bacterial vaginosis and aerobic vaginitis before and after pessary insertion in indonesia. indian j public heal res dev 2019;10:1680-4. 9. sari priyanti, syalfina ad. alat kontrasepsi dan aktivitas seksual sebagai faktor yang berpengaruh terhadap kejadian keputihan. j berk epidemiol 2017;5:371-82. 10. nastiti aa, triharini m, pratiwi ah, gouda adk. educational intervention to improve menstrual hygiene management in adolescent girls in kalimantan, indonesia. j pak med assoc 2023;73:s13-7. 11. kholifah sn, yumni h, minarti, susanto t. structural model of factors relating to the health promotion behavior of repro transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 590] [healthcare in low-resource settings 2024;12:11993] non -co mmerc ial us e o nly ductive health among indonesian adolescents. int j nurs sci 2017;4:367-73. 12. muthmainnah, nurmala i, siswantara p, et al. mixed methods: expectations versus facts on the implementation of adolescent care health service. indian j public heal res dev 2019;10:504-8. 13. sabbagh hj, abdelaziz w, quritum m, et al. a multi-country study on the impact of sex and age on oral features of covid19 infection in adolescents and young adults. bmc oral health 2022;22:513. 14. mantovani l. penerapan teknik self instruction untuk menurunkan tingkat konformitas pada teman sebaya di smp bilingual terpadu al amanah junwangi, krian. 2016. available from: https://www.neliti.com/publications/252630/penerapanteknik-self-instruction-untuk-menurunkan-tingkat-konformitas-pada-tema 15. sabbagh hj, abdelaziz w, quritum m, et al. cigarettes’ use and capabilities-opportunities-motivation-for-behavior model: a multi-country survey of adolescents and young adults. front public heal 2022;10:875801. 16. pratami afd, purwati y. hubungan konformitas teman sebaya dengan perilaku seksual pranikah pada remaja di smpn 2 tempel. 2017. available from: http://repository.stikeshang tuah sby. a c . i d / 392 /1 /f i t r i a%20wulanda r i _ 1710041_skripsi%20hubungan%20konformitas%20teman %20sebaya%20dengan%20perilaku%20seksual%20remaja %20fix.pdf 17. apsari ar, purnamasari se. hubungan antara konformitas dengan perilaku seksual pranikah pada remaja. insight j ilm psikol 2017;19:1-12. 18. shafiira fn, widiastuti r, pratama j. hubungan antara konformitas teman sebaya dengan perilaku perundungan (bullyinh). alibkin (jurnal bimbing konseling) 2020;8:20465. 19. hidayati nw. hubungan harga diri dan konformitas teman sebaya dengan kenakalan remaja. 2016. available from: https://i-rpp.com/index.php/jpp/article/viewfile/371/371 20. mardison s. konformitas teman sebaya sebagai pembentuk perilaku individu. j al-taujih bingkai bimbing dan konseling islam 2016;2:78-90. 21. rochadi nw. peran teman sebaya dan media informasi terhadap perilaku seks pranikah remaja. journal heal stud 2019;3:53-63. 22. notoatmodjo s. promosi kesehatan dan perilaku kesehatan. 2012. available from: https://fik.um.ac.id/wpcontent/uploads/2020/10/2.-promosi-kesehatan-danilmu-perilaku.pdf 23. bana bi, hartati n, ningsih yt. hubungan antara konformitas kelompok teman sebaya dengan perilaku seksual pranikah pada remaja. riset aktual psikol univ negeri padang 2018;9:13-24. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11993] [page 591] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13000 exploring outside-in empowerment approach to improve the family's ability to manage schizophrenia disorder wahyu endang setyowati,1,2 nursalam,3 hanik endang nihayati,3 dwi indah iswanti,4 nia agustiningsih,5 intan rismatul azizah2,6 1doctoral program in nursing, universitas airlangga, surabaya; 2faculty of nursing, universitas islam sultan agung, semarang; 3department of nursing, faculty of nursing, universitas airlangga, surabaya; 4department of nursing, faculty of nursing and health science, universitas karya husada semarang, semarang; 5nursing department, sekolah tinggi ilmu kesehatan kepanjen, malang; 6master of nursing program, faculty of nursing, universitas airlangga, surabaya, indonesia abstract families often encounter a sense of despair and exhibit diminished capability when providing care for schizophrenia patients, predominantly due to restricted knowledge and lack of formal training and support. existing strategies to empower families have been insufficient in effectively dealing with schizophrenia care. this study objective was to explore the relationship between family knowledge, coping skills, and interaction within the framework of outside-in empowerment and their ability to care for individuals with schizophrenia. this explanatory research utilizes a cross-sectional design and involves a sample of 135 families, acting as caregivers for schizophrenia patients, selected through purposive sampling based on inclusion criteria. regarding outside-in empowerment, knowledge is evaluated using a questionnaire developed from the concept of schizophrenia care, coping skills are measured using the family coping questionnaire (fcq), and family interaction is assessed through the brief family relationship scale (bfrs). the family’s ability to manage schizophrenia is gauged using the barthel index and the caregiving tasks in caring for an adult with mental illness scale (cticamis). all of the questionnaire has been tested for validity and reliability.the data analysis involves multiple linear regression at a 95% significance level. the study reveals that knowledge (p=0.018 <0.005), coping skills (p=0.004 <0.005), and family interaction as part of outsidein empowerment significantly correlate with the family’s ability to manage schizophrenia (p=0.001 <0.005). notably, the ability for family interaction (ß=0.392) is a predictor of the family’s capability to care for schizophrenia patients (p=0.042 <0.05). enhancing family interactions is crucial to empower families in managing schizophrenia patients. this enhancement can be facilitated by fostering cohesion, minimizing conflicts, and effectively managing the caregiving burden associated with schizophrenia. introduction families frequently experience feelings of inadequacy, failure, helplessness, fatigue, and uncertainty when caring for individuals diagnosed with schizophrenia.1 this often results in a challenging home environment, limiting the quality of care patients receive.2 numerous studies report a generally low capacity among families to provide adequate schizophrenia care, compounded by a lack of accessible information and support specifically designed for families.3,4 schizophrenia remains a global health concern with 21 million reported cases, equating to 0.24 cases per 1000 population.5 in indonesia, the prevalence of schizophrenia escalated from 1.3 to 7 cases per 1000 population in 2018.6 in central java, the prevalence rose from 2.3% (2013) to 9% (2018)7 with semarang city correspondence: wahyu endang setyowati, doctoral program, faculty of nursing, universitas airlangga, surabaya, 60115, indonesia. e-mail: wahyu.endang@unissula.ac.id key words: caregiving; family’s capability; outside-in empowerment; schizophrenia. ethics approval and consent to participate: this study received ethical clearance from the health research ethics committee of the faculty of nursing, universitas airlangga (number 2637-kepk), and from the ethics committee of dr. amino gondohutomo psychiatric hospital, central java province (number 420/12375), and has obtained the respondents’ consent through informed consent, anonymity, confidentiality, fidelity, and autonomy. availability of data and materials: all data generated or analyzed during this study are included in this published article. patient consent for publication: written informed consent was obtained for anonymized patient information to be published. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. contributions: wes, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; n, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; hen, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. dii, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. na, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. ira, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. acknowledgement: the authors would like to express their gratitude to the families who participated as respondents and the nurses at the outpatient clinic of dr. amino gondohutomo psychiatric hospital, central java province. this research is part of a doctoral dissertation, and the insights gained have significantly contributed to the completion of this academic work. received: 2 september 2024. accepted: 24 october 2024. early view: 6 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13000 doi:10.4081/hls.2024.13000 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13000] [page 1] witnessing the highest incidence rate among other cities, at 0.79 per 1000 population in 2018.8 this surge in schizophrenia cases is attributable to various factors, including the family’s inability to provide care for schizophrenia patients during relapse symptoms and their lack of active involvement in home care.9 a primary issue contributing to this gap is families’ sense of helplessness and limited empowerment regarding their roles in schizophrenia management. key barriers include inadequate family-centered empowerment initiatives, insufficient education on preventive strategies,3,4 weak family function enhancement programs, and lack of ongoing family support systems, moreover, families often face difficulties in recognizing early disease symptoms, lack collaboration with service providers,3,4 and there is a paucity of interventions focusing on caregiver or family welfare.10 although psychiatric nurses in hospitals and community health centers have initiated mental health promotion, these efforts often fall short due to insufficient family involvement and empowerment. current practices focus more on responding to individual cases than on enabling families to maintain long-term, effective management strategies.11 therefore, this study objective was to examine the relationship between family empowerment—specifically knowledge, coping skills, and family interactions—and families’ abilities to manage schizophrenia, offering insights into how outside-in empowerment could improve family-centered care and long-term patient outcomes. materials and methods study design this study utilizes an explanatory design with a cross-sectional approach. it investigates the relationship between the outside-in empowerment (which includes knowledge, coping skills, and family interaction) , and family interaction and the family’s ability to care for schizophrenia patients at a single point in time. this care includes fulfilling activities of daily living (adl), facilitating social interaction, and fostering productive skills. participants the study focuses on the entire population of families with schizophrenia patients who have received treatment and are currently under outpatient monitoring at dr. amino gondohutomo psychiatric hospital in central java province, specifically those residing in semarang city. the population size in 2022 is approximately 1,911. following the rule of thumb, the sample size was determined to be 135 families. these samples were chosen using purposive sampling based on several inclusion criteria: core family members cohabitating with the patient, providing daily home care for schizophrenia patients, possessing at least 1 year of experience in caring for schizophrenia patients, being aged between 20-60 years, and having a family member with schizophrenia who has received treatment more than three times and is under monitoring at dr. amino gondohutomo psychiatric hospital in central java province. data collections data collection took place at dr. amino gondohutomo psychiatric hospital’s psychogeriatric and adult polyclinic in central java province, from september 20th to october 3rd, 2022. a checklist was used to gather respondent demographic characteristics. the research variables of outside-in empowerment, which include knowledge, coping skills, and family interaction, as well as the family’s ability to care for schizophrenia, were evaluated using questionnaires. the knowledge questionnaire, derived from the concept of schizophrenia care,12,13 encompasses: disease process, signs and symptoms, triggering and supporting factors, care methods, and relapse prevention, with a total of 7 questions. scores were assigned based on the number of marked answers, with each mark scoring 1, and so forth, resulting in a total score range of 7-28. the coping skills questionnaire employed the family coping questionnaire (fcq) by (14). the fcq is a 9-statement scale scored from 1 (never) to 4 (always), with a score range of 9-36. it consists of seven subscales: information, positive communication, social interest, coercion, avoidance, resignation, and patient’s social involvement. the brief family relationship scale (bfrs), adopted from,15 was used for the family interaction questionnaire. this scale measures the relationship between caregivers and family members with schizophrenia. the bfrs consists of three subscales: cohesion, expressiveness, and conflict. it includes 10 statements measured with a 4-point likert scale (1=never to 4=always) and a score range of 10-40. social interaction support was measured using 5 items adapted from the caregiving tasks in caring for an adult with mental illness scale (cticamis), with scores ranging from 5 to 20. finally, a questionnaire on supporting productive skills, developed by the researcher based on theoretical concepts,16 included 3 items, with scores ranging from 3 to 12. all instruments were validated and tested for reliability with a sample of 30 respondents. the description of outside-in empowerment and family interaction questionnaire presented in table 1. the knowledge component included aspects such as disease process, symptoms, triggers/supports, care methods, and relapse prevention, with a validity range of 0.503–0.934 and a cronbach’s alpha of 0.882. coping skills were measured across various domains (information, positive communication, social interest, coercion, avoidance, resignation, and patient social involvement) with validity scores of 0.419–0.895 and reliability at 0.929. family interaction, covering cohesion, expressiveness, and conflict, showed validity scores from 0.429 to 0.915 and reliability of 0.929. the family’s caregiving ability was evaluated through fulfilling adl needs (validity 0.472–0.824; reliability 0.912), assisting with social interaction (validity 0.448–0.648; reliability 0.777), and aiding in productive skills (validity 0.618–0.771; reliability 0.861). all variables exceeded the r-table threshold of 0.361, indicating robust instrument construction. data analysis a descriptive analysis was performed on the demographic characteristics of respondents, sub-variables of outside-in empowerment, such as knowledge, coping skills, and family interaction, and the variable of the family’s ability to manage schizophrenia patients. these are represented as percentages based on the findings from each research variable. an inferential analysis in the form of a pearson correlation with a 95% significance level was applied to analyze the relationship between knowledge, coping skills, and family interaction variables with the family’s ability to manage schizophrenia patients. the outcomes of this bivariate relationship analysis were used as a basis for testing the four variables multivariately using multiple regression with an alpha level of 5% (0.05). ethical consideration this study received ethical clearance from the health research ethics committee of the faculty of nursing, universitas airlangga special issue pathways of change [page 2] [healthcare in low-resource settings 2025;13(s1):13000] (number 2637-kepk), and from the ethics committee of dr. amino gondohutomo psychiatric hospital, central java province (number 420/12375). results based on table 2, the demographic characteristics of families caring for schizophrenia patients are predominantly male (50.4%), middle-aged (51.1%), with high school/vocational school education (38.5%), working as private employees (37.8%), and earning less than the semarang city minimum wage (65.9%). siblings constitute the most common caregiver relationship (39.3%). occupation and income are the characteristics most closely related to the family’s ability to care for schizophrenia (p=0.002 <0.005). table 3 demonstrates that the majority of families are moderately able to meet the adl needs (37.0%) of schizophrenia patients but still struggle in assisting with social interaction (53.3%) and productive skills (48.9%). table 4 illustrates that a significant number of families still lack knowledge about caring for schizophrenia patients, with defi special issue pathways of change table 1. questionnaire research variables. variable indicator favorable unfavorable validity reliability (r-table =0.361) (cronbach alpha) outside-in empowerment knowledge disease process 1 0.503-0.934 0.882 signs and symptoms 2 triggers and supports 3 care methods 4-6 preventing relapse 7 coping skills information 8 0.419-0.895 0.929 positive communication 9 social interest 10 coercion 11-12 avoidance 13-14 resignation 15 patient's social involvement 17 family interaction cohesion 18-21 0.429-0.915 0.929 expressive 22,23 conflict 24-27 family's ability to care for schizophrenia fulfilling adl needs 1-10 0.472-0.824 0.912 assisting with social interaction 11-15 0.448-0.648 0.777 aiding in productive skills 16-18 0.618-0.771 0.861 table 2. description of the demographic characteristics of families caring for schizophrenia patients (n=135). family characteristics indicator f % p gender man 68 50.4 0.507 woman 67 49.6 age early adulthood (20-30 years) 20 14.8 0.022 middle adult (31-55 years) 69 51.1 pre-elderly (55-60 years) 46 34.1 education not completed in primary school 1 7.7 0.913 elementary school 28 20.7 junior high school 29 21.5 senior high school 52 38.5 college 25 18.5 employment government employees 6 4.4 0.002 pension 9 6.7 self-employed 24 17.8 private sector employee 51 37.8 housewife 31 23.0 laborer 9 6.7 unemployed 5 3.7 family outcome < regional minimum wage 89 65.9 0.002 = regional minimum wage 14 10.4 > regional minimum wage 32 23.7 [healthcare in low-resource settings 2025;13(s1):13000] [page 3] ciencies in understanding the disease process (34.8%), recognizing signs and symptoms of the disease (53.3%), identifying triggering/supporting factors (57.0%), and implementing patient care methods (52.6%). the coping skills of families caring for schizophrenia patients are partially maladaptive, with 34.8% demonstrating low social involvement. on the other hand, family interaction in caring for schizophrenia patients is generally adequate in establishing cohesion (69.6%), expressing skills (54.8%), and resol special issue pathways of change [page 4] [healthcare in low-resource settings 2025;13(s1):13000] table 3. description of family's ability to care for schizophrenia patients (n=135). indicator category scale f (%) fulfilling adl needs less 48 35.6 enough 50 37.0 good 37 27.4 assisting with social interaction less 72 53.3 enough 47 34.8 good 16 11.9 aiding in productive skills less 66 48.9 enough 38 28.1 good 31 23.0 mean sd 91.78 26.064 table 4. relationship between knowledge, coping skills, and family interaction in outside-in empowerment with the family's ability to care for schizophrenia (n=135). variable indicator category scale f % mean (standard deviation) p knowledge disease process less 47 34.8 28.41 (12.802) 0.018 enough 45 33.3 good 43 31.9 signs and symptoms less 72 53.3 enough 46 34.1 good 17 12.6 triggers and supports less 77 57.0 enough 40 29.0 good 18 13.3 care methods less 71 52.6 enough 28 20.7 good 36 26.7 preventing relapse less 42 3.1 enough 47 34.8 good 46 34.1 coping skills information maladaptive 58 43.0 46.59 (7.576) 0.004 adaptive 77 57.0 positive communication maladaptive 57 42.2 adaptive 78 57.8 social interest maladaptive 22 16.3 adaptive 113 83.7 coercion maladaptive 34 25.2 adaptive 101 74.8 avoidance maladaptive 21 15.6 adaptive 114 84.4 resignation maladaptive 25 18.5 adaptive 110 81.5 patient's social involvement maladaptive 47 34.8 adaptive 88 65.2 family interaction cohesion less 7 5.2 59.67 (9.564) 0.001 enough 94 69.6 good 34 25.2 expressive less 13 9.6 enough 74 54.8 good 48 35.6 conflict less 14 10.4 enough 89 65.9 good 32 23.7 ving conflicts (65.9%). pearson correlation test results indicate that knowledge (p=0.018 <0.005), coping skills (p=0.004 <0.005), and family interaction are significantly related to the family’s ability to care for schizophrenia (p=0.001 <0.005). the multiple regression test results in table 5, based on the variables of knowledge, coping skills, and family interaction in outside-in empowerment with the family’s ability to care for schizophrenia, indicate that family interaction (ß=0.392) is a significant predictor of the family’s ability to care for schizophrenia patients (p=0.042 <0.05). discussion age, occupation, and income are demographic characteristics of the family that correlate with the family’s ability to care for schizophrenia patients. middle-aged families are likely more capable of assimilating information and knowledge regarding patient care. furthermore, these families are psychologically mature, enabling them to effectively utilize coping skills, and they possess the necessary energy to care for schizophrenia patients. this is corroborated which shows that the age of the caregiver or family influences the burden of care and duration of care. employment status also defines the socio-economic resources that a family has at its disposal for patient care. this is corroborated showed that work influences the burden on families in caring for schizophrenic patients.16 this is supported which shows that income is a predictor of care burden, the family’s income serves as a financial resource, underpinning the care and treatment needs of schizophrenia patients.17 the majority of families exhibit a lack of knowledge about caring for schizophrenia patients, particularly in understanding the disease process, recognizing signs and symptoms, identifying triggering/supporting factors, and implementing patient care methods. several studies suggest that families perceive the information on caring for schizophrenia as inadequate,3,4 and they lack sufficient formal training or support in patient care.18 families require ongoing mental health education from mental health personnel that can reach peripheral communities. this mental health education should target not only families but also the surrounding community that forms the family’s support system. employing suitable methods, aligned with education and involving local community leaders, is believed to enhance the family’s knowledge to care for and prevent relapse in schizophrenia patients. family coping skills related to caregiving issues are somewhat maladaptive, especially concerning social involvement. this is substantiated by a study19 indicating that families primarily caring for schizophrenia patients tend to adopt maladaptive coping strategies, including avoidance, coercion, and withdrawal. these maladaptive coping skills might result from insufficient utilization of social support from the community, limitations within the family in accessing patient care information, challenges in communicating with schizophrenia patients, and a continued reliance on forceful or authoritarian decision-making in patient care. enhancing family coping resources can serve as a guide in implementing a familycentered care program aimed at reducing the burden of caring for schizophrenia patients through efficient family support.20 mental health professionals should consider the family’s needs and challenges in caring for schizophrenia patients, planning supportive resources for both families and patients across clinical and community settings. families are encouraged to adopt constructive coping strategies when caring for schizophrenia patients. research findings suggest that family interaction remains in the moderate category regarding expression ability, cohesion, and conflict resolution. this could be attributed to the family’s hesitance to discuss their struggles in caring for schizophrenia patients with other family members. moreover, time constraints due to busy work schedules of each family member could also play a role. inappropriate family involvement can render recovery-oriented services ineffective in facilitating the recovery of schizophrenia patients.21 the strength of cohesion and relationships among family members is crucial for ensuring effective care for schizophrenia patients. collective activities within the family can enable them to share caregiving responsibilities, seek solutions, and distribute caregiving tasks for schizophrenia patients. there exists a significant correlation between knowledge, coping skills, and family interaction in outside-in empowerment and the family’s ability to care for schizophrenia patients. this is substantiated by the fact that psychoeducation groups receiving outside-in empowerment exhibit a considerable enhancement in family relationships, caregiving burden, and coping skills.10 the result of outside-in empowerment is the amplification of caregiving knowledge, coping skills, and the bolstering of family interaction via psychoeducation. families are trained on patient care, ranging from meeting activities of daily living (adl), aiding with social interaction, to building productive skills. addressing the caregiving burden through adaptive coping mechanisms and enhancing family interaction, considered as a critical resource for caring for schizophrenia patients,22 can have a positive impact on the family’s ability to care for schizophrenia patients at home. family interaction is the most influential factor affecting the family’s ability to care for schizophrenia. the strength of cohesion and interaction among family members is crucial in supporting the care for schizophrenia patients. research findings23 indicate that strengthening family bonds, cultivating life insights, and promoting social mobility will positively influence the experience of caring for schizophrenia patients. the existence of shared activities within the family allows them to distribute the caregiving burden, seek solutions, and allocate caregiving tasks for schizophrenia patients. it can be concluded that the overall competence in outside-in empowerment, particularly family interaction, can enhance the ability to care for schizophrenia patients. special issue pathways of change table 5. factors influencing the family's ability to care for schizophrenia. factor b standard error beta t sig. (constant) 41.333 14.700 2.812 0.006 knowledge 0.148 0.177 0.079 0.836 0.405 coping skills 0.374 0.315 0.118 1.188 0.237 family interaction 0.483 0.246 0.392 2.019 0.042 [healthcare in low-resource settings 2025;13(s1):13000] [page 5] implications this study highlights the critical role of outside-in empowerment, specifically family knowledge, coping skills, and interaction in enhancing the caregiving capacity of families for individuals with schizophrenia. the findings underscore the need for structured mental health education programs targeted at families, enabling them to acquire essential knowledge about schizophrenia care and adaptive coping strategies. community-based mental health initiatives, led by trained mental health professionals, could play a significant role in disseminating relevant information and providing support. additionally, interventions aimed at strengthening family interactions, such as psychoeducation and family-centered therapies, could foster a collaborative environment where caregiving responsibilities are more evenly distributed, reducing the burden on individual family members. these insights can inform policymakers and healthcare providers in designing holistic, family-centered mental health programs to improve long-term outcomes for schizophrenia patients. limitations this study has several limitations. first, the cross-sectional design limits the ability to draw causal conclusions regarding the relationship between outside-in empowerment variables and caregiving capacity. longitudinal studies would be beneficial to observe changes in family caregiving ability over time. additionally, the study was conducted in a single public psychiatric hospital in central java, which may limit the generalizability of the findings to other regions or settings. finally, reliance on selfreported data could introduce response bias, as participants may have given socially desirable answers. future studies should consider incorporating objective assessments and expanding the sample to include multiple centers or community settings to enhance generalizability. conclusions this study reveals that demographic factors, such as age, employment, and income, play a significant role in influencing a family’s ability to care for individuals with schizophrenia. moreover, outside-in empowerment, encompassing knowledge, coping skills, and family interaction, is strongly associated with caregiving capacity. among these factors, family interaction emerged as the most critical determinant, highlighting the importance of cohesive family relationships in effective schizophrenia care. these findings suggest that targeted interventions, such as psychoeducation and family-centered support programs, can strengthen family resources and adaptive coping mechanisms, ultimately enhancing the quality of care for schizophrenia patients. by addressing the caregiving burden through education, empowerment, and community support, healthcare providers can facilitate more effective family-centered care, promoting improved outcomes for both patients and their families. references 1. suhardiningsih avs, sustrami d, mundakir m. parenting style, family support, and relapse among schizophrenia patients: a literature review. healthc low-resource settings 2024;12:11820. 2. kusumawardani w, yusuf a, fitryasari r, et al. family burden effect on the ability in taking care of schizophrenia patient. indian j public heal res dev 2019;10:2654–9. 3. mohr p, galderisi s, boyer p, et al. value of schizophrenia treatment i: the patient journey. eur psychiatry 2018;53:107– 15. 4. bai xl, luo zc, wang a, et al. challenge of parents caring for children or adolescents with early-stage schizophrenia in china: a qualitative study. perspect psychiatr care 2020;56:777–84. 5. benjamin james sadock vas& pr. kaplan and sadock’s comprehensive textbook of psychiatry. 10th ed. wolters kluwer; 2017. 6. ministry of health of the republic of indonesia. main results basic health research. minist heal repub indones. 2018;1– 582. 7. ministry of health of the republic of indonesia. main result of basic heatlh research. riskesdas 2018;52. 8. agency of health research and development. report of central java province in basic health research 2018. ministry of health of the republic of indonesia, 2018; 88–94 p. 9. kandar. gambaran karakteristik pasien gangguan jiwa yang mengalami rawat inap ulang. j ilm permas j ilm stikes kendal 2017;7:11–5. 10. zhou dhr, chiu ylm, lo tlw, et al. outside-in or insideout? a randomized controlled trial of two empowerment approaches for family caregivers of people with schizophrenia. issues ment health nurs 2020;41:761–72. 11. van es cm, mooren t, zwaanswijk m, et al. family empowerment (fame): study protocol for a pilot implementation and evaluation of a preventive multi-family programme for asylum-seeker families. pilot feasibility stud 2019;5:1–10. 12. budi anna keliat dkk. psychiatric nursing. jakarta: egc; 2020. 209–217 p. 13. ahmad i, khalily mt, hallahan b, shah i. factors associated with psychotic relapse in patients with schizophrenia in a pakistani cohort. int j ment health nurs 2017;26:384–90. 14. magliano l, guarneri m, marasco c, et al. a new questionnaire assessing coping strategies in relatives of patients with schizophrenia: development and factor analysis. acta psychiatr scand 1996;94:224–8. 15. fok cct, allen j, henry d, team pa. the brief family relationship scale: a brief measure of the relationship dimension in family functioning. assessment 2014;21:67–72. 16. nayak mr, mallik t, hembram s, dash m. perceived family burden among the male & female caregivers of schizophrenia patientsa comparative study in eastern india. int j res rev 2020;7:1. 17. rahmani f, roshangar f, gholizadeh l, asghari e. caregiver burden and the associated factors in the family caregivers of patients with schizophrenia. nurs open 2022;9:1995–2002. 18. ashcroft k, kim e, elefant e, et al. meta-analysis of caregiver-directed psychosocial interventions for schizophrenia. community ment health j 2018;54:983–91. 19. rahmani f, ranjbar f, hosseinzadeh m, et al. coping strategies of family caregivers of patients with schizophrenia in iran: a cross-sectional survey. int j nurs sci 2019;6:148–53. 20. kazemian s, zarei n, esmaeily m. effect of strengthening family coping resources on emotion regulation of family caregivers of patients with schizophrenia. evid based care j 2020;10:7–17. 21. yu bcl, mak wws, chio fhn. family involvement moderates the relationship between perceived recovery orientation of services and personal narratives among chinese with schizo special issue pathways of change [page 6] [healthcare in low-resource settings 2025;13(s1):13000] phrenia in hong kong: a 1-year longitudinal investigation. soc psychiatry psychiatr epidemiol 2021;56:401–8. 22. indah iswanti d, nursalam n, fitryasari r, kusuma dewi r. development of an integrative empowerment model to care for patients with schizophrenia disorder. j public health res 2023;12. 23. darban f, mehdipourrabori r, farokhzadian j, nouhi e, sabzevari s. family achievements in struggling with schizophrenia: life experiences in a qualitative content analysis study in iran. bmc psychiatry 2021;21:1–12. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13000] [page 7] hrev_master healthcare in low-resource settings 2024; volume 12:11772 ethanolic extract of red dragon fruit inhibits growth of mosquito larvae dhina ayu susanti, fitria meliana putri milyunier, galuh maulidatin nufus, lita aulia pramesti, nia laela nur khamimi, wima anggitasari, lindawati setyaningrum, inna armandari bachelor pharmacy study program, faculty of health sciences, universitas dr. soebandi, jember, indonesia abstract controlling the vector by eradicating mosquito larvae is frequently done by spreading abate powder containing 1% temephos as a larvicide agent. however, the use of abate powder will possibly increase pesticide residue contamination in the water. this study aimed to explore the potential use of ethanolic extract from red dragon fruit skin to kill mosquito larvae. an experimental laboratory study was performed to examine the larvicidal activity of ethanolic extract from red dragon fruit skin. maceration method was used to extract active compounds from the fruit skin. subsequently, the viscous extract was formulated using the wet granulation method to obtain powder form. the larvicide test was done by comparing the lethal concentration (lc50) of mosquito larvae after treatment using the extract and the reference larvicide agent, 1% temephos abate. the treatment groups consisted of four different extract concentrations of 1%, 2%, 3%, and 4%. the lc50 of each treatment groups was then calculated against the negative control group. phytochemical screening showed that the ethanol extract of red dragon fruit skin contains alkaloids, flavonoids, saponins, triterpenoids, and tannins. the larvicide test on aedes aegypti mosquito larvae showed that the extract treatment hardly killed the aedes aegypti mosquito larvae. however, on culex mosquito larvae, the ethanolic extract of red dragon fruit skin was able to kill mosquito larvae, with lc50 value of of 19.06%. the ethanolic extract of red dragon fruit skin was effective on killing the culex mosquito larvae but not the aedes aegypti mosquito larvae. introduction vector-based infectious diseases account for over 17% of all infectious diseases, resulting in more than 400,000 deaths annually and afflicting 219 million people worldwide. in indonesia, these diseases are prevalent health issues in various regions and cities, often leading to outbreaks with a high risk of mortality. being a tropical country, indonesia experiences relatively high humidity and rainfall, creating favorable conditions for the proliferation of vector populations.1,2 mosquitoes can transmit several vectorbased infectious diseases, with some of the most prevalent ones in indonesia being dengue hemorrhagic fever (dhf),3 japanese encephalitis, and filariasis. these diseases require particular attention due to their high incidence in the country. the vector responsible for transmitting dengue hemorrhagic fever (dhf) is the aedes aegypti mosquito, while japanese encephalitis (je) is transmitted by the culex mosquito. in the case of filariasis, it can be transmitted by various mosquito species, including mansonia, anopheles, culex, aedes, and armigeres mosquitoes. several studies have emphasized that global climate change has had an impact on the risk of disease vector transmission, particularly in the case of mosquitoes.4–7 as of the end of 2022, indonesia had reported approximately 143,000 cases of dengue hemorrhagic fever (dhf), while there were an average of 35,000 japanese encephalitis (je) cases in asia each year. in 2021, indonesia reported 9,354 cases of filariasis. these vectorbased infectious diseases have the potential to cause severe physcorrespondence: dhina ayu susanti, bachelor pharmacy study program, faculty of health sciences, universitas dr. soebandi, jember, indonesia. e-mail: dhina.apt@gmail.com key words: aedes aegypti, culex, granule, larvicidal activity, lc50, maceration. contributions: das conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; fmpm conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; gmn conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; hh methodology, visualization, writing – review and editing; lap resources, investigation, and writing –review and editing; nlnk formal analysis, validation, writing – review and editing; wa resources, supervision, and writing –review & editing; ls resources, investigation, and writing –review and editing; ia resources, investigation, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission universitas dr. soebandi jember, based on ethical certificate 300/kepk/uds/ix/2022 during the research, the researcher pays attention to the ethical principles of information to consent, respect for animal rights, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by the direktorat pemebelajaran dan kemahasiswaan affairs through the program kreativitas mahasiswa (pkm) 2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank universitas dr. soebandi for their valuable insights and contributions to this study. received: 12 september 2023. accepted: 17 november 2023. early access: 22 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11772 doi:10.4081/hls.2023.11772 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 100] [healthcare in low-resource settings 2024;12:11772] non -co mmerc ial us e o nly ical and mental disabilities and can increase mortality.8–10 given these facts, disease prevention measures are crucial to prevent their spread and reduce mortality. one of the most efficient preventive actions is the control of disease vectors by eradicating mosquito larvae of aedes aegypti and culex using larvicidal agents, such as 1% temephos in the form of abate powder. it has been in use since 1976 and has been proven effective in killing aedes aegypti and culex mosquito larvae. however, the accumulation of abate residue from its longterm use may lead to water contamination, especially in drinking water, and may create selection pressure that induces larvae to become resistant to the larvicidal agent.11–13 therefore, there is an urgent need for an alternative larvicide that is safer, more selective, less toxic for the environment, and yet has a similar effect to abate. red dragon fruit skin is a natural ingredient that has the same function as abate. commonly, red dragon fruit skin is often discarded despite containing various active compounds, including flavonoids, tannins, alkaloids, and saponins.14–16 flavonoids are known to be toxic to insects’ digestive and respiratory tracts.17,18 tannins can inhibit insects in the process of food metabolism.17 alkaloids have the ability to degrade insect cells,19 and saponins can reduce metabolic work and protein work in insects.17 there is a lack of research exploring red dragon fruit skin as a mosquito larvicide agent. this study aimed to explore the larvicidal activity of red dragon fruit skin (hylocereus polyrhizus) ethanolic extract against aedes aegypti and culex mosquito larvae. materials and methods this study was an experimental laboratory research that using aedes aegypti and culex mosquito larvae as subjects. the material used in this study was red dragon fruit peel, ethanol 96%, hcl 2n, dragendorf reagen, mayer reagen. magnesium powder, chloroform, acetic acid, sulfuric acid, fecl3, pga, aquadest, and amylum. the independent variables were the compound content in the ethanol extract of red dragon fruit peel and variations in herbal abate concentrations. the dependent variable was the mortality of aedes aegypti and culex mosquito larvae, determined by counting the number of mosquito larvae that survived after treatment. red dragon fruits (hylocereus polyrhizus) were obtained from jember area, east java. the fruits were then cleaned and separated from their fruit flesh. subsequently, the fruit skin was dried and grounded to form powder. the maceration process was carried out using 96% ethanol to obtain thick extract followed by wet granule formulation to get powder form. besides, the viscous extract was subjected for phytochemical screening to asses its active ingredients. the larvicidal activity of red dragon skin ethanolic extract against mosquito larva was determined using lethal concentration (lc50). briefly, the aedes aegypti and culex mosquito larvae were treated using different concentrations of powdered extract at 1%, 2%, 3%, and 4%. the 1% temephos abate was used as a positive control. the dead larva populations after incubation were counted20–23. subsequently, the lc50 was determined using the probit linear regression test24. results plant determination was carried out to determine the tribe and type of the red dragon fruit (hylocereus polyrhizus) plant. the determination results showed that the sample used was a red dragon fruit plant (hylocereus polyrhizus). phytochemical screening test of red dragon fruit the results showed that the ethanolic extract of red dragon fruit peel contains alkaloids, flavonoids, saponins, triterpenoids, and tannins (table 1). differences in the content of plant secondary metabolites can occur due to differences in light, temperature, ph, altitude, and soil conditions in the sample planting areas. unfortunately, we hardly detected steroid compounds using nonspecific color changes testing as well as the quantitative testing using. this may occur due to low steroid content in the extract. based on the phytochemical screening, red dragon fruit skin extract contains potential compounds that can be used as a biolarvicidal agent for aedes aegypti and culex mosquitoes. larvicidal activity test the larvicidal activity test of red dragon fruit skin ethanolic extract of was carried out aedes aegypti and culex mosquito lartransforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. phytochemical screening results. secondary metabolites test result alkaloid (+) flavonoid (+) saponin (+) triterpenoid and steroid triterpenoid (+) steroid (-) tanin (+) table 2. data on observation results of effectiveness tests on culex mosquito larvae. no. rep. number of dead larvae negative red dragon fruit skin extract positive control control concentration (1% themefos abate) 1% 2% 3% 4% 1 i 5 7 16 21 24 25 2 ii 4 13 15 20 25 22 3 iii 6 9 18 15 24 26 amount 15 29 49 56 73 73 average 5 9,7 16,3 18,7 24,3 24,3 percentage (%) 19 36 60 69 90 90 profit value 4.12 4.64 5.25 5.50 6.28 6.28 [healthcare in low-resource settings 2024;12:11772] [page 101] non -co mmerc ial us e o nly vae. selection of third instar larvae because these larvae have a larger size. in addition, third-instar mosquito larvae have relatively good resistance to the external environment and mechanically stronger resistance when transferring the larvae. each test group, 25 mosquito larvae were used in 100 ml of water. the test was carried out for 24 hours with three replications. our results revealed hat the ethanolic extract of red dragon fruit skin could not kill the aedes aegypti mosquito larvae. however, the larvicidal activity of the extract on culex mosquito larvae are shown in the table 2. based on table 2, it can be seen that 1% ethanolic extract of red dragon fruit peel can kill 36 % of the population culex mosquito larvae. the 2% concentration of ethanolic extract killed about 60% of the culex mosquito larvae and at 3% extract, about 69% of the population culex mosquito larvae died. at 4% extract concentration 90% of the population culex mosquito larvae were died, the same death percentage as seen in the positive control. it can be concluded that the higher concentration of the ethanolic extract of red dragon fruit skin, the higher the death precentage of culex mosquito larvae. the probit linear regression test showed that the lc50 value of the ethanolic extract of red dragon fruit peel against culex mosquito larvae was 19.06% and proven to be toxic for culex mosquito larvae. discussion this research was conducted to determine the effectiveness of red dragon fruit peel extract (hylocereus polyrhizus) against aedes aegypti and culex mosquito larvae. previous studies using soursop and angsana leaf extract had lc50 values of 0.736% and 0.83%, respectively, on culex mosquito larvae.25,26 from the results of this study, the lc50 value of the ethanol extract of red dragon fruit peel against culex mosquito larvae was 19.06%. this shows that the herbal abate 96% ethanol extract of red dragon fruit peel is more toxic to culex mosquito larvae than soursop and angsana leaf extract. compounds that may be toxic from the ethanol extract of red dragon fruit peel (hylocereus polyrhizus) are alkaloids, flavonoids, saponins, triterpenoids, and tannins. alkaloids are salts that can degrade cell membranes so that they damage cells and can also interfere with the larval nervous system by inhibiting the action of the acetylcholinesterase enzyme.24 flavonoids can interfere with energy metabolism in mitochondria by inhibiting the electron transport system so that atp production is inhibited and causes a decrease in oxygen usage by mitochondria. this can inhibit the respiratory chain, oxidative phosphorylation, and break the chain between the respiratory chain and oxidative phosphorylation so that flavonoids can work as respiratory inhibitors in mosquitoes.17 saponins can reduce the surface tension of the mucous membrane of the larvae’s digestive tract so that the larvae’s walls become corrosive and eventually damaged.27 triterpenoids as stomach poisons.28 tannin compounds can bind to protease enzymes by binding to enzymes by tannins, so the work of these enzymes will be hampered so that cell metabolic processes can be disrupted, and the larvae will lack nutrition.27 this finding can be used in developing an abate product from red dragon fruit peel extract, which is environmentally friendly and has almost the same effectiveness as temefos abate. the herbal abate of red dragon fruit peel is expected to replace the role of temefos abate as a larvicide so that it can reduce environmental pollution, especially water pollution. the limitation of this study is that it only examined one herbal abate formula and only at concentrations of 1%, 2%, 3%, and 4%. further research can be carried out so that the herbal abate of red dragon fruit peel can be even better in terms of formulation, concentration, and appearance and can be used as a larvicide on all mosquito larvae that act as disease vectors. this study has a limitation namely only examining the chemical compound content ethanol extract of red dragon fruit peel and proving the effectiveness ethanol extract of red dragon fruit peel against aedes aegypti and culex mosquito larvae by calculating the lc50 value. conclusions the phytochemical screening revealed the presence of alkaloids, flavonoids, saponins, triterpenoids, and tannins in the red dragon fruit peel. however, the ethanol extract of red dragon fruit peel (hylocereus polyrhizus) did not demonstrate effectiveness as a larvicide against aedes aegypti larvae. conversely, it was effective against culexmosquito larvae, with an lc50 value of 19.06%. future research should investigate the larvicidal efficacy of the ethanol extract of red dragon fruit peel on different mosquito species. references 1. santoso s, yahya y, suryaningtyas nh, et al. studi bioekologi nyamuk mansonia spp vektor filariasis di kabupaten tanjung jabung timur, provinsi jambi. vektora j vektor dan reserv penyakit 2016;8:71–80. 2. mulyatno kc, kotaki t, yotopranoto s, et al. detection and serotyping of dengue viruses in aedes aegypti and aedes albopictus (diptera: culicidae) collected in surabaya, indonesia from 2008 to 2015. jpn j infect dis 2018;71:58–61. 3. ananta lk, efendi f, makhfudli, et al. social support and its correlation with “3m plus” behavior in the prevention of dengue hemorrhagic fever. indian j public heal res dev 2019;10:2681. 4. nadifah f, farida muhajir n, arisandi d, d. owa lobo m. identifikasi larva nyamuk pada tempat penampungan air di padukuhan dero condong catur kabupaten sleman. j kesehat masy andalas 2017;10:172. 5. adnyana imdm, sumarya im, sudaryati nlg. efficacy and toxicity of parasayu incense ash as a larvicide for the eradication of aedes aegypti (diptera: culicidae) mosquito larvae. j res pharm 2022;26:1805–13. 6. wahidah ff, hamidah, rosmanida. essential oil characterization of plant as breeding site of aedes aegypti and aedes albopictus. ann biol 2020;36:245–7. 7. buchori d, mawan a, nurhayati i, et al. risk assessment on the release of wolbachia-infected aedes aegypti in yogyakarta, indonesia. insects 2022;13(10). 8. indonesia kkr. membuka lembaran baru. laporan tahunan 2022 deman berdarah dengue. germas 2022. 1–36 p. 9. rampengan nh. japanese ensefalitis. j biomedik 2018;8:10– 22. 10. kementerian kesehatan ri. direktorat pencegahan dan pengendalian penyakit menular kementerian kesehatan. kementerian kesehatan republik indonesia. 2018;3:1–119. 11. hanafiah e, syuhriatin s, meidatuzzahra d, swandayani re. efektivitas penggunaan abate dan bactivec terhadap kematian larva nyamuk aedes sp. di kabupaten lombok transforming healthcare in low-resource settings: a multidisciplinary approach 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tw, lim cj, liow ca, et al. studies on the storage stability of betacyanins from fermented red dragon fruit (hylocereus polyrhizus) drink imparted by xanthan gum and carboxymethyl cellulose. food chem 2022;393. 17. sigit m, rahmawati i, candram ayr, prasetyo fb. pengaruh pemberian ekstrak dayn lidah buaya (aloe vera) terhadap mortalitas larva nyamuk. j vitek bid kedokt hewan 2022;12:17–21. 18. sok yen f, shu qin c, tan shi xuan s, et al. hypoglycemic effects of plant flavonoids: a review. evidence-based complement altern med 2021;2021. 19. ahmad a, adriyanto a. efektivitas serbuk biji pepaya (carica papaya l.) terhadap kematian jentik (larva) culex sp. j med (media inf kesehatan) 2019;6:104–12. 20. la eoj, sawiji rt, yuliawati an. skrining fitokimia dan analisis kromatografi lapis tipis ekstrak etanol kulit buah naga merah. indones j pharmacy nat prod 2020;03:45–58. 21. noor mi, ey dan z. identifikasi kandungan ekstrak kulit buah naga merah menggunakan fourier transform infrared ( ftir ) dan fitokimia identification content of the red dragon fruit extract skin using fourier transform infrared ( ftir ) and phytochemistry. j aceh phys soc 2016;5:14–6. 22. pujiastuti e, el’zeba d. perbandingan kadar flavonoid total ekstrak etanol 70 % dan 96 % kulit buah naga merah ( hylocereus). cendekia j pharm 2021;5:28–43. 23. suhaimi, kartikasari d. uji aktivitas larvasida granul ekstrak batang seledri (avium graveolens) pada larva instar 3 aedes aegypti. j insa farm indones 2018;1:260–7. 24. utami ww, ahmad ar, malik a. uji aktivitas larvasida ekstrak daun jarak kepyar (ricinus communis l.) terhadap larva nyamuk aedes aegypti. j fitofarmaka indones 2016;3:141–5. 25. kewa m, almet j, laut mm. median lethal concentration (lc50) ekstrak daun sirsak (annona muricata linn) terhadap larva culex sp di kota lampung. j kaji vet 2020;4:791–2. 26. abdurrozak mi, syafnir l, sadiyah er. uji efektivitas ekstrak etanol daun angsana (pterocarpus indicus willd) sebagai biolarvasida terhadap larva nyamuk culex sp. j ris farm 2021;1:33–7. 27. ramayanti i, febriani r. uji efektivitas larvasida ekstrak daun pepaya (carica papaya linn) terhadap larva aedes aegypti. syifa’ med j kedokt dan kesehat 2016;6:79. 28. wulansari. analisis senyawa metabolit sekunder dan uji aktivitas larvasida alami pada ekstral etanol daun bidara (ziziphus mauritiana lamk.) terhadap larva aedes aegypti. skripsi. islam negeri maulana malik ibrahim, malang; 2022 vol. 3. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11772] [page 103] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12622 thirty second chair stand performance is associated with six-minute walk test among postmenopausal women: inference from a cross-sectional study among women from india hina vaish, digvijay sharma school of health sciences, chhatrapati shahu ji maharaj university, kanpur, uttar pradesh, india abstract menopause is an inevitable yet normal biological process in a woman’s life. the menopausal process has been associated with a decline in muscle strength and functional capacity. thus, the present study aimed to explore the association of the 30-second chair stand test (30s cst) with the 6-minute walk test (6mwt) among postmenopausal women. thirty-five postmenopausal women aged 40–55 years were included in this cross-sectional study by purposive sampling method. after initial screening and assessment 30s cst and 6mwt were recorded as per standardised guidelines. the mean and standard deviation (sd) for all continuous variables was calculated. correlations were estimated using pearson’s coefficient of correlation. a two-tailed p-value <0.05 was considered statistically significant. there exist a significant positive association of 30s cst values with 6mwt among postmenopausal women. also, the rate of perceived exertion (rpe) scores after the 6mwt were found to be significantly correlated with rpe scores after 30s cst. in conclusion, there exists a significant positive correlation of 30s cst with 6mwt among postmenopausal women. the 30s cst could be used as an economical and quick physical function assessment measure among postmenopausal women in low-resource settings. introduction the physiological impact of menopause on women’s health has been deeply explored.1 there are physiological changes due to menopause that could contribute directly to limitations in physical function.2,3 the 6-minute walk test (6mwt) is a submaximal exercise test commonly used for evaluating physical functional capacity among disease states as well as healthy adults.4-6 it is a practical and well-tolerated test, which is more reflective of daily life activities than cardiopulmonary exercise tests.7 physiological impairments that arise with menopause may affect muscle power, strength and mass.8 the sit-to-stand performance test is extensively used for assessing lower-extremity function, strength, and balance control.9,10 the 30-second chair stand test (30s cst) is a time-based test and it evolved to overpower the floor effect of 5 or 10 repetitions sit-to-stand test.9,10 this test has been performed in various health conditions like knee replacements, chronic obstructive pulmonary disease (copd), rehabilitation programs, and healthy adults.11-13 the 30s cst evaluates the ability to stand up from a sitting position, which is an essential activity as walking in daily life.14 the 30s cst has also been proposed as a reliable and valid indicator of lower body strength.15,16 the 6mwt distance may be a good indicator of lower limb muscle strength.17 6mwt and 30s cst are considered tests of physical performance, it is postulated that the 30s cst may be correlated with the 6mwt and therefore a useful alternative for assessing the functional capacity.18 the correlation between sit-to-stand test and 6mwt has been studied in copd patients and young adults.14,18 however, there is correspondence: hina vaish, school of health sciences, chhatrapati shahu ji maharaj university, kanpur, uttar pradesh, india. tel.: +919450124758. e-mail: hina22vaish@gmail.com, hinavaish@csjmu.ac.in key words: menopause, six-minute walk distance, sit-to-stand test, rate of perceived exertion. contributions: hv contributed to the conception, analysis, and interpretation of data, drafting of the work, final approval of the version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. ds contributed substantially to the conception of the work, reviewing it critically for important intellectual content, final approval of the version to be published, and agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data and materials: the datasets used and/or analyzed during the current study are available upon reasonable request from the corresponding author. acknowledgment: the authors acknowledge the participants for taking part in the study. the present study is a partial fulfilment for the completion of doctorate of philosophy by the first author, hina vaish, under the supervision of second author, digvijay sharma. received: 30 april 2024. accepted: 10 july 2024. early view: 8 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12622 doi:10.4081/hls.2024.12622 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12622] [page 1] a scarcity of research concerning 6mwt and sit-to-stand tests among women, particularly concerning menopause. in order to address the research gap, the authors conducted the present study to explore the association of the 30s cst test with 6mwt in postmenopausal women. secondarily, we studied the association of 30s cst and 6mwt with pulmonary function among postmenopausal women. materials and methods study design this is a cross-sectional study. ethical statement the study was approved by the ethics committee of the institute with reference number csjmu/r&d/1482/2023, registered in the clinical trial registry of india (ctri) with number ctri/2023/10/058517 and was conducted in accordance with the declaration of helsinki (revised 2013) and national ethical guidelines for biomedical and health research involving human participants’ guidelines laid by indian council of medical research (2017). eligibility criteria postmenopausal women were recruited from october 2023 to january 2024. asymptomatic postmenopausal females aged 40–55 years with stable vitals were included depending on their menstrual history. the menstrual bleeding pattern was classified based on a series of questions.2,19 participants with the absence of any acute disease during the six weeks preceding the study were included. participants with any health problem or use of medication associated with musculoskeletal, neuromuscular, cardiovascular system or use of medications that might interfere with the ability to perform physical exercise, use of walking aids, sensory deficits, blood pressure >139/89 mm of hg, body mass index (bmi) <18.5 kg/m2 and >29.9 kg/m2, resting heart rate ≥100 bpm, past or current smokers, history of any surgery in last one year, females who have delivered a baby in two-year years or less, having had a double oophorectomy, women with hysterectomy, women with use of hormone replacement therapy, involved in sports or athletic activity were excluded. sample size estimation the sample size for this study was calculated by using the g power software version 3.1.97, where the level of significance was set as 5% at 90% power of study with coefficient of determination considered as 0.311.14 the minimum required sample size was 29. considering an attrition rate of 20%, the total required sample size was 35. the sample was selected from among individuals accompanying patients in the outpatient department, staff, and those visiting the institute and from nearby community dwellings. procedure the participants who fulfilled the selection criteria of the study and were willing to participate were selected. all the participants provided the written informed consent regarding the study. body weight (in kg) was measured with a weighing machine. body height (in meters) was recorded and body mass index (bmi = weight/height2) was calculated. the individuals were explained about the test procedures in the language that was best understood by them (hindi/english). the demographic details, history, and basic information of the test were well explained to the participants for a better understanding of the procedure and to ensure its proper form. the 30-second chair stand test procedure the test was conducted following the procedure as outlined in previous reports.15 the 30s cst was administrated using the chair without arms.15,16 the chair was stabilized against the wall to ensure stability and to prevent the chair from moving during the performance. as instructed, likewise the test began with participants sitting on the middle of the chair with their back in an upright position and feet approximately shoulder-width apart. the test commenced upon the assessor instructing the participant to rise from the chair keeping the body erect after the go command in the language best understood by them (hindi/english) on their own preferred speed with arms folding across their chest, then retaining back to the initial sitting position. the participants were encouraged to achieve as many full stands and sits as possible within a time of 30 seconds. the participants were given the instruction to be fully seated after each stand. the rate of perceived exertion (rpe) (modified borg rating of perceived exertion) was documented before and after the test. the correctly performed stands were considered and the values of the test were noted. all tests were conducted by the same assessor. the 6-minute walk test procedure the 6mwt was conducted according to a standardized proto social and political factors affecting public health table 1. baseline characteristics of the participants. (n = 35) mean ± sd age (years) 50.11±3.34 height (m) 1.54±0.091 weight (kg) 60.19±10.18 bmi (kg/m2) 25.07±3.25 fev1 (litres) 1.86±0.25 fvc (litres) 2.43±0.42 fev1/fvc % 77 ± 7.07 bmi, body mass index; fvc, forced vital capacity; fev1, forced expiratory volume in one second; sd, standard deviation. table 2. the 30-second chair stand test and 6-minute walk test results of the participants. 30 cst 6mwt mean ± sd (n = 35) variable mean ± sd (n = 35) 30s cst (number of stands) 14.54±2.02 6mwd (m) 457.63±28.42 baseline rpe 0.014±0.08 baseline rpe 0.014±0.08 posttest rpe 0.93±0.59 posttest rpe 1.73±0.93 6mwt, 6-minute walk test; 6mwd, 6-minute walk distance; 30s cst, 30-second chair stand test; rpe, rate of perceived exertion; sd, standard deviation. [page 2] [healthcare in low-resource settings 2024;12(s2):12622] col in a 30-meter indoor level corridor with marks at every 1 m intervals.20,21 standard encouragements was given every minute in the local language.20 the participants sat in a chair located near the starting position for at least 10 minutes before the test. during this time, rpe, heart rate, oxyhemoglobin saturation, and systolic and diastolic blood pressures were recorded. the participants were asked to walk as far down the corridor as they could at their own pace for the allotted six minutes. participants were allowed to stop if they developed any symptoms such as dyspnea, leg cramps, dizziness, or chest pain, but were encouraged to continue walking as soon as possible. at the end of the 6 minutes, each participant’s heart rate, systolic and diastolic blood pressures, oxygen saturation, and rpe were measured along with the distance covered in the allotted 6 minutes ( 6mwd). pulmonary function assessment the pulmonary function test was measured by using rms helios 401computerized spirometer as per standardized guidelines.22 before performing the test, all the participants were allowed to take a rest period to prevent measurement error. participants performed the test for three times to obtain the best value. measurement of forced expiratory volume in one second (fev1), forced vital capacity (fvc), and ratio of fev1 and fvc (fev1/fvc), were recorded. statistical analysis statistical analyses were performed using spss software, version 16 (statistical package for the social sciences inc., chicago, il, usa). data was normally distributed and presented as the mean and standard deviation (sd) for all continuous variables. correlations were estimated using pearson’s coefficient of correlation. a twotailed p-value < 0.05 was considered statistically significant. results all the participants completed the test and there were no dropouts. the study flowchart is shown in figure 1. the characteristics of the participants are shown in table 1. the mean age at menopause for the postmenopausal women was 47.68 ± 2.77 years. the baseline characteristics of the participants are mentioned in table 1. none of the participants stopped during the 6mwt and 30s cst (table 2). the mean ± sd 6mwd was 457.63 ± 28.42 m and number of stands in the 30s cst were 14.54 ± 2.02. there was a significant positive correlation of 30s cst with 6mwd among postmenopausal women (r = 0.605, p = 0.0001) as shown in figure 2. the rpe scores after the 6mwt social and political factors affecting public health table 3. correlation of 30-second chair stand test and 6-minute walk distance with anthropometric variables and pulmonary function. n=35 6mwt 30 s cst r p r p age (years) -0.351 0.039* -0.358 0.035* height (m) 0.053 0.763 0.018 0.918 weight (kg) -0.202 0.244 -0.054 0.758 bmi (kg/m2) -0.267 0.121 -0.025 0.887 fev1 (litres) 0.316 0.064 0.187 0.282 fvc (litres) 0.012 0.946 0.057 0.745 fev1/fvc % 0.467 0.005* 0.394 0.019* *significant at p < 0.05 (2-tailed). bmi, body mass index; 6mwt, 6-minute walk test; 6mwd, 6-minute walk distance; 30s cst, 30-second chair stand test; rpe, rate of perceived exertion; sd, standard deviation. figure 1. study flowchart. figure 2. correlation of 30 second chair stand test with 6-minute walk distance. [healthcare in low-resource settings 2024;12(s2):12622] [page 3] was found to be significantly correlated with rpe scores after 30s cst (r = 0.47, p = 0.004). there was a significant negative correlation of age with 30s cst and 6mwd. also, there exists a positive correlation of fev1/fvc ratio with 30s cst and 6mwd among postmenopausal women shown in table 3. discussion the number of studies measuring physical function status among postmenopausal women increased rapidly over the past years. it reflects raised awareness about physical function status during menopausal. in clinical practice, physical function status can be measured by several methods. the 6mwt is one of the most reliable, standardized, easy to perform tests. recently a significant amount of research has been performed to explore simpler tests like sit-to-stand test, to measure exercise capacity.14,18 our results show that 6mwt distance and the number of stands during 30s cst were significantly correlated with each other. also, the rate of perceived exertion after the test significantly correlated with each other. it has been proposed that sit-to-stand is better tolerated and produces less hemodynamic stress compared to the 6mwt and has been proposed as a reliable and practical test that could be used for to assess functional status quickly without much equipment and space.14,18 influence of menopause on 6-minute walk distance the 6mwd walked by women in the present study was less than the distance documented by researchers in indian females.5, 23 menopause significantly influences the 6mwd in participants. it has been proposed that menopause is related to a decline in estrogen that, decreases bone mass density, muscle mass, and strength.3 the decline in muscle mass and strength may directly influence the 6mwd. influence of menopause on 30-second chair stand test the 30s cst values in the present study were 14.54 ± 2.02 stands and in a previous study on postmenopausal women with a mean age of 55.6 ± 5.0 years was 13.1 ± 3.3 stands.1 the 30s cst scores were greater than the values reported from the indian sample of women aged > 60 year (10 ± 2.9 stands) possibly due to the elder age group in the study of sheoran & vaish.13 researchers have used the sit to stand movement as an indicator of lower limb strength.15,16 menopause is related to a decline in muscle mass and strength.3 association of 30-second chair stand test with 6-minute walk test the correlations of 30s cst values had a significant association with 6mwd values in the present study in agreement with findings of reports from previous studies on young adults.18 the correlation in the present study was also moderate (r = 0.605) as in previous studies.18,24 there has been report of significant relationship between 60s sit to stand test performance and the 6mwt in healthy controls (r = 0.54) over the age of 60; significant relationship between 30s cst performance and the 6mwt (r = 0.611) in young adults.18,24 this indicates that as the sit-to-stand test performance decreases, it impacts functional capacity, in agreement with previous studies.4,18,24 the rpe scores after the 6mwt were found to be significantly correlated with rpe scores after 30s cst (r = 0.47) in agreement with previous reports.14,18 the correlations in the present study were better than as reported in the young adults.18 it has been proposed that the physical demand of the 30s cst,14,18 are like the 6mwt and this strengthens the hypothesis that the sit-to-stand tests and the 6mwt are consistent with one another regarding the functional capacity assessment.18 association of pulmonary function with 6-minute walk distance and 30-second chair stand test the significant positive association of fev1/fvc with 6mwd among postmenopausal women indicates that the decline in pulmonary function is associated with a decline in function capacity after menopause. there is evidence that a decline in pulmonary function among postmenopausal women in india tends to develop obstructive pattern of ventilatory limitation.25 also, there exists a positive significant correlation of fev1/fvc with 30s cst among postmenopausal women. there is evidence that 30s cst performance is independently associated with forced vital capacity, maximum inspiratory pressure, and maximum expiratory pressure among older adults.26 it can be proposed that measurement of respiratory function might be useful to assess physical health status and prevent deterioration of respiratory function in postmenopausal women. association of anthropometric characteristics with 6-minute walk distance and 30-second chair stand test age was found to be significantly negatively associated with 6mwd and 30s cst among postmenopausal women. the association is in agreement with the results from the indian sample.5,24 the shorter distance walked as age increases can be explained by decreases in muscle mass, muscle strength, and maximum oxygen consumption as one ages.27 age associated physiological changes, such as decreased nerve conduction velocity and increased passive tissue stiffness, also contribute to the decline in sit-to-stand test performance.28 the study had few limitations; a non-probability sample was taken though this has been a procedure of sample collection, but we had stringent inclusion and exclusion criteria. induced/surgical menopausal women were not included. hence, we proposed that future multicentre studies should be conducted including surgical menopausal women. conclusions there exists a significant positive correlation of 30s cst test 6mwd among postmenopausal women. 30s cst could be used as an economical and quick physical function assessment measure among postmenopausal women in low-resource settings. references 1. moratalla-cecilia n, soriano-maldonado a, ruiz-cabello p, et al. association of physical fitness with health-related quality of life in early postmenopause. qual life res 2016;25:2675-81. 2. tseng la, el khoudary sr, young ea, et al. the association of menopause status with physical function: the study of social and political factors affecting public health [page 4] [healthcare in low-resource settings 2024;12(s2):12622] women's health across the nation. menopause 2012;19:118692. 3. maltais ml, desroches j, dionne ij. changes in muscle mass and strength after menopause. j musculoskelet neuronal interact 2009;9:186-97. 4. du h, wonggom p, tongpeth j, clark ra. six-minute walk test for assessing physical functional capacity in chronic heart failure. curr heart fail rep 2017;14:158-66. 5. vaish h, chorsiya v. influence of parity on six-minute walk test in indian females. health care women int 2023;44:75363. 6. mänttäri a, suni j, sievänen h, et al. six-minute walk test: a tool for predicting maximal aerobic power (vo2 max) in healthy adults. clin physiol funct imaging. 2018;38:1038-45. 7. guyatt gh, sullivan mj, thompson pj, et al. the 6-minute walk: a new measure of exercise capacity in patients with chronic heart failure. can med assoc j 1985;132:919-23. 8. bondarev d, laakkonen ek, finni t, et al. physical performance in relation to menopause status and physical activity. menopause 2018;25:1432-41. 9. bohannon rw, bubela dj, magasi sr, et al. sit-to-stand test: performance and determinants across the age-span. isokinet exerc sci 2010;18:235-40. 10. applebaum ev, breton d, feng zw, et al. modified 30-second sit to stand test predicts falls in a cohort of institutionalized older veterans. plos one 2017;12:e0176946. 11. millor n, lecumberri p, gómez m, et al. an evaluation of the 30-s chair stand test in older adults: frailty detection based on kinematic parameters from a single inertial unit. j neuroeng rehabil 2013;10:86. 12. vaidya t, chambellan a, de bisschop c. sit-to-stand tests for copd: a literature review. respir med 2017;128:70-7. 13. sheoran m, vaish h. thirty second sit-to-stand test performance in community dwelling geriatric population: a crosssectional study. rev pesq fisio 2022 ;12:e4600. 14. meriem m, cherif j, toujani s, et al. sit-to-stand test and 6min walking test correlation in patients with chronic obstructive pulmonary disease. ann thorac med 2015;10:269-73. 15. jones cj, rikli re, beam wc. a 30-s chair-stand test as a measure of lower body strength in community-residing older adults. res q exerc sport 1999;70:113-9. 16. mccarthy ek, horvat ma, holtsberg pa, wisenbaker jm. repeated chair stands as a measure of lower limb strength in sexagenarian women. j gerontol a biol sci med sci 2004;59:1207-12. 17. pradon d, roche n, enette l, zory r. relationship between lower limb muscle strength and 6-minute walk test performance in stroke patients. j rehabil med 2013;45:105-8. 18. gurses hn, zeren m, denizoglu kulli h, durgut e. the relationship of sit-to-stand tests with 6-minute walk test in healthy young adults. medicine (baltimore) 2018;97:e9489. 19. amaral af, strachan dp, gómez real f, et al. lower lung function associates with cessation of menstruation: uk biobank data. the european respiratory journal 2016;48:1288-97. 20. ats committee on proficiency standards for clinical pulmonary function laboratories. ats statement: guidelines for the six-minute walk test [published correction appears in am j respir crit care med 2016;193:1185]. am j respir crit care med 2002;166:111-7. 21. holland ae, spruit ma, troosters t, et al. an official european respiratory society/american thoracic society technical standard: field walking tests in chronic respiratory disease. eur respir j 2014;44:1428-46. 22. graham bl, steenbruggen i, miller mr, et al. standardization of spirometry 2019 update. an official american thoracic society and european respiratory society technical statement. am j respir crit care med 2019;200:e70-e88. 23. palaniappan ramanathan r, chandrasekaran b. reference equations for 6-min walk test in healthy indian subjects (25-80 years). lung india 2014;31:35-8. 24. ozalevli s, ozden a, itil o, akkoclu a. comparison of the sitto-stand test with 6 min walk test in patients with chronic obstructive pulmonary disease. respir med 2007;101:286-93. 25. memoalia j, anjum b, singh n, gupta m. decline in pulmonary function tests after menopause. j menopausal med 2018;24:34-40. 26. kaneko h. association of respiratory function with physical performance, physical activity, and sedentary behavior in older adults. j phys ther sci 2020;32:92-7. 27. ben saad h, prefaut c, tabka z, et al. 6-minute walk distance in healthy north africans older than 40 years: influence of parity. respir med 2009;103:74-84. 28. palve ss, palve sb. impact of aging on nerve conduction velocities and late responses in healthy individuals. j neurosci rural pract 2018;9:112-6. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12622] [page 5] hrev_master healthcare in low-resource settings 2025; volume 13:12462 the effectiveness of kangaroo mother care in monitoring vital signs and preventing stunting risk in low-birth-weight infants muliani,1 lisnawati,1 hadina,1 sarliana,1 abd. farid lewa,2 hastuti usman1 1department of midwifery, poltekkes kemenkes palu, palu; 2department of nutrition, poltekkes kemenkes palu, palu, indonesia abstract low birth weight (lbw) infants have a greater risk of stunting and other non-communicable diseases. the highest causes of death were asphyxia and hypothermia. the kangaroo mother care (kmc) method as a simple intervention is based on evidence-based, which can maintain stability and improve the physiological condition of the baby’s body. this study was to determine the effectiveness of the kmc method in monitoring vital signs and preventing stunting in lbw. the study employed a quasi-experimental preposttest one group design, using a kmc carrier designed in the shape of a backpack. the number of respondents was 38 infants, selected by consecutive sampling. data analysis used the wilcoxon test. bivariate analysis with the application of the kmc method for 4 hours/day on average experienced an increase in body weight 15 gr/day (p=0.011), an average increase in body length ≥0.2 cm/day (p= 0.049), infants received breast milk during the application of the kmc method (p= 0.013) the three variables were p-value <α(0.05), based on the wilcoxon test with the use of kmc backpacks on lbw showed a significant relationship to infant growth in risk prevention stunting with a value (p=0.000<0.05). the use of kmc backpacks for lbw is effective in maintaining the baby’s vital signs and can prevent the risk of stunting. the kmc backpack is recommended as a safe, easy, inexpensive and effective non-pharmacological therapy to prevent hypothermia and the risk of stunting. introduction the birth of low birth weight (lbw) babies, especially premature at <37 weeks of gestation, all organs in the body have not functioned optimally, and it is still difficult to maintain body temperature and is prone to hypothermia, which is one of the causes of lbw deaths and tends to experience instability of vital signs.1,2 birth of lbw is also a dominant factor that has a risk of 5.87 times experiencing stunting, history of lbw birth is one of the factors causing stunting in children under two years old.3,4 infant birth length <48 cm has a 4.5 times risk experiencing stunting growth in children compared to birth length 48 cm.5 stunting is the result of several determinants including pre-pregnancy, gestational age and malnutrition after birth.6 birth weight is an important and reliable indicator for the survival of neonates and infants, both in terms of physical growth and mental status development, as well as a general indicator for determining health, nutritional status, and socioeconomic status in developed and developing countries.7 the high and low infant mortality rate is an indicator of a country’s health.8 children face the highest risk of death in the first month of life and the first 28 days of life (neonatal period) with a global average of 17 deaths per 1,000 live births (kh) in 2022.9 in indonesia, the infant mortality rate (imr) will be 16 per 1000 kh in 2024. the number of deaths occurring at the age of 0-28 days has increased slightly, where in 2021 there were 297 people, and in 2022 it increased to 308 people. nationally, central sulawesi province experienced an increase in the infant mortality rate (imr) from 52 to 60/1000 kh, and ranks third highest after west sulawesi and ntb. the most common causes of neonatal death in central sulawesi province in 2022 are lbw (27.92%), aspixia (19.16%), congenital abnormalities (12.34%), infection (5.19%) and other causes 35.39%.10 the high imr is an indication of health and development problems which in general still require special efforts. clinical trial study on 53 neonates admitted to the nicu, performed kmc on infants for 1 hour/day (3 consecutive days) by correspondence: sarliana, bachelor of applied midwifery study program, health polytechnic ministry of health palu, palu, indonesia. e-mail: sarliana5@gmail.com key words: kangaroo mother care (kmc) method; vital signs; low birth weight babies. contributions: all authors have made substantial contributions to the conception or design of the study and acquisition, analysis, and/or interpretation of data, participated in drafting or revising the manuscript, approved the version to be published, and agreed to be accountable for all aspects of the work and any issues related to the accuracy or integrity of any part of the work. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: ethical approval was obtained from the polytechnic ethics committee of the ministry of health, palu, indonesia with number 0045/kepk-kpk/v/2022 availability of data and material: data is available upon reasonable request. funding: none. acknowledgements: the authors would like to thank the director of poltekkes kemenkes palu, director of anuntaloko parimo hospital, and head of the center for research and community service of poltekkes kemenkes palu received: 8 march 2024. accepted: 20 september 2024. early access: 31 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12462 doi:10.4081/hls.2025.12462 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 152] [healthcare in low-resource settings 2025;13:12462] monitoring vital signs: temperature, respiration and heart rate/minute, and arterial oxygen saturation rate was measured and recorded (before, during and after kmc). the results showed that the variation in mean body temperature and arterial oxygen saturation rate between the two groups had a significant difference, the kangaroo care method was effective in improving and stabilizing the vital signs of newborns.11 after three days of kmc treatment, the average weight gain increased by 12.19 grams/day, the kmc method is an appropriate technology for lbw treatment, with skin-to-skin contact.12 the duration of 2 hours of kmc, as measured by vital signs before and after 1 hour and 2 hours, had a greater effect on the baby’s temperature, heart rate, respiratory rate, and oxygen saturation than the duration of 1 hour, while blood pressure did not change.13,14 kangaroo care as a simple intervention based on evidence-based practice, can save the life of newborns. the effect of kangaroo care can improve physiological conditions such as breathing, heart rate, temperature and sleep patterns of the baby and make a positive contribution to the psychological condition of the mother after giving birth.15,16 another study showed that infants experienced an average weight gain of 188.75+166.6 grams with a kmc duration of 4 hours/day, statistically significant and potentially increasing weight in lbw.17 kangaroo care is considered a fundamental component of therapeutic developments for the care of premature infants as a non-pharmacological treatment strategy.18 the kmc sling model, which is specially designed in a simpler form while taking into account the element of safety for mothers and babies, is easy to use or apply by mothers independently without the need for help from others, equipped with a support strap and a lock that is quite safe. the selection of soft and smooth materials is also an important element in providing comfort for mother and baby, coated with sponge pads to give a softer impression when used, making mother and baby not stifling but maintaining a stable body temperature.19–21 this sling is designed to be simpler in the form of a «kmc backpack» which is very possible to be used at any time without hindering or limiting the mother’s daily physical activities such as: cooking, ironing, drying clothes, reading, even eating and drinking or mothers doing other activities both at home or outside the home by keeping the baby attached to the mother’s chest, while breastfeeding the baby. mother easily walks, stands, sits or lies in a supine position with her head slightly elevated when resting. the results of this design are effective in maintaining the stability of the baby’s vital signs, with skin-to-skin contact increasing the emotional relationship between mother and baby and preventing hypothermia, the baby’s heart rate and breathing also become more regular, this tool as a natural incubator is much cheaper and easier to use throughout time. kmc backpacks that are used regularly and continuously can shorten the hospitalization period of the baby thereby reducing the cost of care.22–24 the position of the baby in the kmc backpack is placed between the mother’s two breasts, in addition to preventing hypothermia, the baby’s position is always upright, making the baby’s heart rate and breathing pattern more regular, making it easier for the baby to suckle longer and more often, stimulating the release of the mother’s hormones for milk production and expenditure. more so that the baby’s nutritional intake is adequate. this can support optimal baby growth and reduce the risk of stunting in infants.25,26 the purpose of the study was to determine the effectiveness of the application of the kmc method in monitoring vital signs as an effort to prevent the risk of stunting in lbw. the application of the kmc method consistently can help stabilize the baby’s condition, improve growth patterns as an early effort to prevent stunting, is a form of basic research that is superior to higher education as a center for stunting studies. materials and methods study design and setting this research uses a quasi-experimental research design with a pre-posttest one group design. this research was carried out in the perinatology room at anuntaloko parimo hospital, central sulawesi province, indonesia. sample size this study consisted of all mother-baby pairs with lbw births, both mature and premature who were treated in the perinatology room at anuntalako parimo hospital, central sulawesi. a total of 38 babies participated in the study who were selected by consecutive sampling with babies with bbl <2.500 gr. survey instrument this study looked at the differences before and after the intervention by measuring the baby’s weight, body length, temperature, pulse, and breathing. the intervention was given treatment using the kmc method which had been modified to be simpler and easier to apply by mothers, which was named «kmc backpack». the position of the baby in the kmc backpack between the mother’s breasts, apart from being able to prevent hypothermia, also by keeping the baby in an upright position, makes the baby’s heart rate and breathing patterns more regular, making it easier for the baby to breastfeed longer and more often, which can stimulate the production and release of more breast milk so that baby’s nutritional intake is adequate. this can support optimal baby growth and reduce the risk of stunting in babies. kmc was given 4 hours/day in 4 days. data analysis data were analyzed using ibm spss statistics 20 software, with a significance level set at 0.05. demographic data were examined using frequency distribution tables and percentages. presentation of bivariate data by conducting data analysis first to test the normality of the data using the shapiro wilk test. it is said that the data is normally distributed if the p value is >0.05 and vice versa. in this research, the normality test results are p-value <0.05, which means the data is not normally distributed. so, the test used is the wilcoxon test (match pair test) to analyze the results of observations of paired data that are different or not, and at the same time analyze the level of effectiveness of the kmc method. results analysis of 38 low birth weight (lbw) babies as shown in table 1, shows that the majority of lbw babies were born from a history of parity of multigravida mothers 24 people (63.2%), with a mature gestational age of 29 people (76.3%) and most types of birth with surgery (cesarean section) as many as 25 people (65.8%), and the average type of baby drinking during kmc was breast milk for 23 people (60.5%). table 2 shows that with the application of the kmc method for 4 hours/day the average weight gain was 15 g/day as many as 16 infants (76.19%), x2hit value=6.446 and p=0.011, the number of infants experiencing the average increase in body length 0.2 article [healthcare in low-resource settings 2025;13:12462] [page 153] cm/day there are 14 babies (73.68%) x2hit value=3.886 and p=0.049, as well as infants who received breast milk during the application of the kmc method of 17 infants (73.91%) x2hit value =6.133 and p=0.013. in the results of this test, the values of the three variables were obtained at 95% ci x2hit>x2tab.(3.84) and p<α(0.05), indicating a significant relationship with the application of the kmc method to lbw to prevent the risk of stunting. based on table 3, it shows the average ranking (mean rank) of the results of weight monitoring before and after kmc where the highest results were in the positive rank value, namely the number of measurements after kmc increased compared to before kmc 34 babies (89.4%), the negative ranking value was showed that there were babies whose measurements after kmc were lower than before being given kmc 3 babies (7.9%), ties value or constant value where there was no change in value after kmc and before kmc 1 baby (2.7%) with p= 0.000<0.05, while the baby’s overall body length increases by an average of 0.2 cm/day (p= 0.000). thus, the effectiveness of using the kmc method for lbw shows a significant relationship with growth in preventing the risk of stunting with a value (p= 0.000<0.05). based on table 4, it shows that in monitoring the baby’s vital signs while using the kmc method, of the 38 babies who had measurements taken to measure body temperature, there were 37 babies (97.3%) whose measurement results increased after kmc compared to before kmc, for overall pulse measurement 38 the measurement results for babies (100%) increased after kmc compared to before kmc, while the respiratory measurement results for 34 babies (89.4%) increased after being given kmc compared to before kmc. with a value (p=0.000<0.05) which shows that the use of the kmc method is significantly effective in monitoring the baby’s vital signs. discussion differences in average weight growth and length of lbw with kmc method treatment the results of the analysis showed that the kmc method treatment 4 hours/day was effective in increasing the baby’s weight 15gr/day, from the chi-quadrat test there was a significant significance with the value of x2hit=6.446>x2tab=3.84 and p=0.011<0.05. the wilcoxon test showed a negative rank value = 3, meaning that from 38 babies there were 3 babies who experienced a decrease in weight while using the kmc method (p= 0.000), this shows that the weight gain in weeks i-ii is still not stable because there is a tendency for weight gain. babies experience a decline after birth until day 14 as a process of adjustment from intra-uterine to extra-uterine life. similarly, the baby’s overall body length increased by an average of 0.2 cm/day (p=0.000). thus the effectiveness of the use of the kmc method on lbw shows a significant relationship to growth in preventing stunting risk with a value (p=0.000 <0.05). in line with this study, infants using the kmc method achieved physical growth parameters up to the age of 40 weeks of correction, although they were smaller at birth indicating better growth article [page 154] [healthcare in low-resource settings 2025;13:12462] table 1. characteristics of lbw with the application of the kmc method. baby characteristics f (n=38) % maternal parity history primigravida 10 26.3 multigravida 24 63.2 grandemultigravida 4 10.5 gestational age at birth matur (≥37 weeks) 29 76.3 premature (<37 weeks) 9 23.7 baby's gender male 17 44.7 female 21 55.3 type of birth spontaneous 13 34.2 cesarean section (sc) 25 65.8 type of feeding breast milk 23 60.5 breast milk + formula milk 15 39.5 table 2. distribution of respondent characteristics based on the duration of kmc in lbw. variable kmc <4 hour/day kmc ≥4 hour/day total x2 tab ci 95% p f (n=16) (%) f (n=22) (%) weight gain not increased or <15 gr/day 11 (64.71) 6 (35.29) 17 (100.00) 6.446 1.43-24.11 0.011 increased ≥15 gr/day 5 (23.81) 16 (76.19) 21 (100.00) increase in body length body length increases (<0.2 cm/day) 11 (57.89) 8 (42.11) 19 (100.00) 3.886 0.98-15.12 0.049 body length increases (≥0,2 cm/day) 5 (26.32) 14 (73.68) 19 (100.00) type of drink breast milk/formula milk 10 (66.67) 5 (33.33) 15 (100.00) 6.133 1.37-23.46 0.013 breast milk 6 (26.09) 17 (73.91) 23 (100.00) and physical development of infants than the control group with conventional treatment methods.27 the kmc method can also increase the size of the head circumference with an average difference of: 0.2 cm/week; (95%ci: 0.09-0.31) and body length: 0.23 cm/week; (95%ci: 0.10-0.35 cm/week) with rr: 0.74; (95%ci:0.36-1.44) compared to standard/conventional care, and reduces the risk of stunting.28 the results of the study that are not in line with this study are that kmc has no effect on infant weight gain, but the kmc method is still declared effective, efficient and has the potential to shorten the period of lbw hospitalization in hospitals. the longer you do kmc, the shorter the length of stay in the hospital, which means that reducing the length of stay has an impact on decreasing treatment costs.17 in another study also found a significant relationship between protein and calorie intake with stunted growth related to child health in rural communities. there are differences in the prevalence of infection, child morbidity, and frequency of hospitalization between stunted and non-stunted children.29 indonesia has the highest prevalence of stunting in early childhood among asean countries. exclusively breastfed children grow faster than other children who are not breastfed.30 this study examines the protective effect of exclusive breastfeeding on stunting in children under the age of two, as well as its interaction with monthly household expenses.31 a number of premature infants with hypothermia, hypoglycemia, and sepsis had a significantly higher prevalence in the cmc group than in the kmc group. likewise, it was positively significant with an average weight gain of 19.28±2.9g/day, body length: 0.99±0.56cm/week, head circumference: 0.72±0.07 cm/week (p <0.001), with kmc treatment can increase growth and reduce morbidity in lbw. this method is simple and effective and can be continued at home.32 another study found that birth length (or=4,500; p=0.003) and maternal parity (or=0.850; p=0.026) were risk factors that affected the incidence of stunting in infants aged 6-23 months, indicating a relationship between birth length and stunting incident.5 infants who did not receive exclusive breastfeeding in the first 6 months, low household socioeconomic status, premature birth, short birth length, and 140 cm mother’s height, as well as households that did not have latrines and inadequate drinking water, were some determinants of child stunting in indonesia and the gap.33 the difference in the mean of monitoring lbw vital signs with treatment based on the duration of kmc during the kmc method treatment 4 hours/day the baby’s body temperature remained in a stable condition and there was only 1 baby who experienced a decrease in body temperature (p=0.000), pulse (p=0.000), there were 2 babies who experienced a decrease respiration rate but remained within normal limits, and 2 infants who did not experience changes before and after kmc (p=0.000). in this study, the kmc method was effective on the stability of lbw vital signs. body temperature increased above the average of 36.3oc, with a value of z-3.114 (p=0.002 0.05), in line with other studies that showed the results of observations of changes in body temperature in lbw through intervention with the kmc method. this method can be used as an alternative treatment to an incubator to prevent hypothermia.34 during kmc, the infant’s vital signs remain stable and appropriate for the infant receiving oxygenated respiratory support. the kmc method was declared effective and could be used for a long time because the respiratory rate and saturation tended to be stable slightly higher during kmc than before or after kmc (p=0.04) and fio2 (p=0.034).35 evaluation of newborns started 30 minutes after birth using the kmc method for three consecutive days, and the results showed a significant increase in axillary temperature, peripheral oxygen saturation, and a decrease in respiration rate with a p-value of 0.05, but not significant. changes in heart rate or mean arterial pressure with p>0.05. kmc treatment for lbw causes beneficial changes in the baby’s vital signs by increasing body temperature and peripheral oxygen saturation to increase tissue oxygenation, and decreasing respiratory rate, which can provide greater respiratory comfort for the newborn.36 another study found no significant difference in infant physiological parameters, including heart rate, respiratory rate, arterial blood oxygen saturation, and temperature, between the two groups (intervention and control) before kmc, but there was a significant difference in physiological index between the two groups after kmc intervention. this study shows that the kmc method increases the physiological index and can be recommended as a routine care method for premature infants.37 globally, approximately 15% of newborns are born with low lbw due to preterm birth, intrauterine growth restriction, or both; 70% of neonatal deaths occur in this group in the first three days of life. the kmc article [healthcare in low-resource settings 2025;13:12462] [page 155] table 3. wilcoxon rank-sum test results on lbw growth assessment on the effectiveness of using the kmc method. variable mean ranks negatif ranks positif ranks ties p weight after kmc 10.17 3 34 1 0.000 weight before kmc 19.78 body length after kmc 0.00 0 38 0 0.000 body length before kmc 19.50 table 4. . wilcoxon rank-sum test results on monitoring lbw vital signs against the effectiveness of using the kmc method. variable mean ranks negatif ranks positif ranks ties p temperature after kmc 1.00 1 37 0 0.000 temperature before kmc 20.00 pulse after kmc 0.00 0 38 0 0.000 pulse before kmc 19.50 respiration after kmc 4.00 2 34 2 0.000 respiration before kmc 19.35 method, which was applied after hospitalization of infants weighing 2.0 kg at birth, was shown to reduce mortality by up to 40%.38 in this situation, in india, it becomes a pragmatic choice to implement kmc at home for lbw, but it is necessary to educate and promote the use of the baby’s mother through qualitative methods with in-depth interviews and fgds in increasing knowledge and understanding of kmc acceptance.39 globally, an estimated 15 million children are born prematurely each year, resulting in a high burden of under-five mortality and neurodevelopmental disability. the kmc method is a key intervention in supporting the development of premature babies both physically and cognitively.40 with the kangaroo method of care, it contributes to a faster discharge time from the hospital and care can be continued at home on an ongoing basis to maintain the stability of the baby.41 kmc treatment had a significant positive effect on infant physiological functions, such as different respiratory rates between the two groups (p=0.020), higher maternal-infant attachment (p=0.001), and lower maternal stress scores (p=0.001). skin-to-skin contact can strengthen the bond and emotional support between mother and baby, making it one of the most effective nursing interventions in the neonatal intensive care unit.42 kangaroo mother care (kmc), one of the most effective and efficient treatments for premature babies, can improve the baby’s vital signs. there was a significant difference in the mean temperature (p 0.001 vs p 0.001), heart rate (p 0.054 vs p0.001), respiratory rate (p 0.058 vs p 0.001), and oxygen saturation (p 0.004 vs p 0.001) in lbw and lbw women aged 0-28 days, with significant differences in the mean temperature (p 0.001 vs p 0.001). the duration of kmc was 1 hour and 2 hours, but there was no significant difference in median systolic (p=0.159) or diastolic (p=0.727) pressure.14 when comparing kmc transportation to incubator transportation, average changes decreased heart rate 1.6 times/minute, respiration 0.18 times/minute, o2 saturation 0.07%, and blood glucose 5.07 mg/dl, but temperature increased 0.01oc. kmc transportation has been shown to reduce hypothermia, hypoglycemia, tachypnea, and tachycardia, allowing it to be recommended as a safe and effective mode of transportation for neonates.43 conclusions the use of the kmc backpack showed its effectiveness in monitoring vital signs to reduce the risk of stunting in lbw. infants experienced stable vital signs in the form of temperature, pulse, and respiration rate, increased within normal limits, and showed an increase in body weight and growth in preventing the risk of stunting in lbw with the kmc method 4 hours/day. kmc backpacks are recommended as a non-pharmacological therapy that is safe and cheaper than 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randomized controlled trial. acta med philipp 2021;55:923–33. article [healthcare in low-resource settings 2025;13:12462] [page 157] hrev_master healthcare in low-resource settings 2024; volume 12:12261 psychospiritual care: a concept analysis khotibul umam,1,2 ira suarilah,2 eva belingon felipe-dimog,3 ah. yusuf,1 imam susilo2,4,5 1faculty of nursing, universitas airlangga, surabaya, indonesia; 2faculty of vocational studies, universitas airlangga, surabaya, indonesia; 3college of health sciences, ifugao state university-lamut campus, nayon, lamut, ifugao, philippines; 4faculty of medicine, universitas airlangga, surabaya, indonesia; 5universitas airlangga general hospital, surabaya, indonesia abstract psychospiritual care has taken many forms and approaches. in the clinical setting, the meaning, variations, and inconsistencies in the delivery of psychospiritual and its related terms persist. the purpose of the study is to identify the meaning and attributes of psychospiritual care and enhance collaborative practice by presenting a concept analysis. this review used walker and avant’s eight-step approach to concept analysis. psychospiritual is a broad, dynamic, and unique concept that integrates psychological and spiritual methods. in this analysis, the defining attributes of psychospiritual care are intuitive self-awareness, therapeutic use of psychological and spiritual perspective, and cultivation of psychological and spiritual environment. providing psychospiritual care promotes positive consequences, such as therapeutic effects for patients and promoting psychospiritual awareness among psychospiritual interventionists. a comprehensive definition of psychospiritual care has been developed. the findings contribute to science by creating a platform for developing practice standards, research, and theory. implementing psychospiritual care may improve overall occupational health and well-being, thereby improving patient care delivery. introduction the term “psychospiritual” is commonly used to refer to a variety of therapeutic systems that incorporate psychological and spiritual dimensions holistically.1 the literature has acknowledged the importance of the psychospiritual role because it mirrors an individual’s lifespan,2 as well as the relationship between this role and human well-being.3 watson (2007) described an individual being as having a wide range of physical, psychological, social, emotional, intellectual, developmental, cultural, and spiritual needs. in the healthcare service, psychospiritual care refers to the provision of body, mind, and soul,4 psychological,5 emotional and mental,6 belief,7 spiritual,8,9 and religious practice.10 those approaches have been widely applied to deal with the complexity of human beings. psychospiritual care was found to be a common practice among individuals with psychological distress associated with chronic disease,7,11 chronic illness,12,13 mental health problems,6,14 or those without the aforementioned conditions who were aiming to improve their overall health.15 recently, in clinical practice, mindfulness-based practice has gained popularity as a non-pharmacological intervention to alleviate psychological distress.16 in contrast to psychospiritual, the root of mindfulness was buddhism, where monks performed this religious practice in daily routine.17 as well as psychospiritual, mindfulness was also implemented to holistically benefit the individual’s body, mind, and soul.18 to this point, it seems that mindfulness-based interventions are often used interchangeably to fully cover one’s psychospiritual need. the implementation of psychospiritual care in healthcare services is widely captured in the academic database. discrepancies in the delivery of psychospiritual care were captured. for example, in western countries, such as in the us7 and uk,19 the delivery of psychospiritual care was found to not always be connected to religious practice, while in the context of indonesia, considering the indonesian national nurses association (inna), psychospiritual care was designed with aims to encompass both psychological and religious matters.20 those underlined, individual ways of coping with life stress are complex. religion and spiritual coping mechanisms should be assessed prior to the delivery of psychospiritual care. nevertheless, there is no clear agreement on what constitutes psychospiritual care in the concept, terms, and delivery. according to walker and avant (2019), it is necessary to clarify the nature of the field or concept of interest before developing correspondence: ira suarilah, faculty of nursing, universitas airlangga (unair), kampuc c mulyorejo, surabaya 60115, indonesia. tel.: +62.31.5913257 – fax: 5913752. e-mail: ira.suarilah@fkp.unair.ac.id key words: psychospiritual care, concept analysis, well-being, healthcare, health service. contributions: study conception and design, ku; data collection, is, ku; data analysis and interpretation, is, ebfd, ay, ims; drafting of the article, is, ebfd; critical revision of the article, all authors. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors are grateful to the doctoral nursing program, faculty of nursing, universitas airlangga, surabaya, indonesia, for great support during the study. received: 6 january 2024. accepted: 24 march 2024. early access: 6 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12261 doi:10.4081/hls.2024.12261 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 348] [healthcare in low-resource settings 2024;12:12261] non -co mmerc ial us e o nly it into relevant knowledge. the conceptual analysis method of walker and avant (2019) clarifies existing meaning and has the potential to be used to develop or add new definitions. the authors believe that the growing interest in psychospiritual care as a subject area in holistic care has highlighted its importance. the purpose of this concept analysis is to provide a comprehensive definition of psychospiritual care. materials and methods study design walker and avant’s framework is used to examine and clarify the phenomenon of psychospiritual care in nursing.21 the eight steps of walker and avant’s concept analysis approaches are as follows: i) selecting a concept; ii) determining the purpose of the analysis; iii) identifying all uses of the concept; iv) determining the defining attributes of the concept; v) constructing a model case; vi) constructing additional cases; vii) identifying the concept’s antecedents and consequences of the concept and viii) defining empirical referents. literature search strategy literature in this analysis was collated from academic databases. cumulative index of nursing and allied health literature (cinahl), web of science, proquest, google scholar, and scopus were all used for literature searches. because of the nature of this concept, a focus on health-related databases was required. in consultation with librarians, the literature review was conducted using the following search terms: ti (psychospiritual), t2 (psychospiritual), and “care” or “intervention” or “strategies” or “best practice”. this review considered studies written in english and published between the years 2000 and 2022. a total of 470 articles were retrieved (cinahl=49, proquest=253, web of science=104, scopus=64, google scholar=144). it consists of 614 journal articles and four books. after eliminating duplicates and assessing the full-text articles, 33 articles were examined. because concepts can change over time, this 22-year time frame demonstrates the inclusion of the most recent information. the literature searches retrieved an abundance of articles focused on psychospiritual interventions; all articles that addressed psychospiritual care solely outside of patients’ involvement were excluded from the review. however, literature that commented on psychospiritual care delivered by healthcare and social workers or interprofessional health teams in clinical and community settings was included. concepts, according to walker and avant (2019), are context-dependent. as a result, this analysis focuses on psychospiritual care and incorporates patient-involved psychospiritual practice. results defining attributes attributes provide profound insight into the concept of interest and distinguish it from surrounding concepts, and it was found that psychospiritual care is a unique integrative dimension of care. it possesses three defining attributes: i) intuitive self-awareness, ii) the therapeutic use of psychospiritual perspective, and iii) the cultivation of a psychospiritual environment (table 1).22-25 case examples a model case is a real-world application of the concept of interest that embodies all of its defining attributes. a model case can be either a real-world example drawn from the literature or a hypothetical scenario created by the researcher.21 review table 1. an example of mapping the attributes of the psychospiritual care concept. study (author, year) concept description attributes nursing care for a patient with lupus • being fully caring by way of actively listening, engaging in unhurried and meaningful conversations with patients 2 erythematosus systemic using icnp22 • assisting patients to cope with the burden caused by the disease 3 • detection of the characteristic symptoms of the expected disease through physical examination, and selection 2 and application of an alternative intervention that meets the priority hypnosis within a psychospiritual • offering a specific a care that retain a beneficial religious/beliefs tradition 2 approach in the case of a woman • making appropriate plans and tackling complex tasks in a systematic manner. 2 diagnosed with dystonia23 • the psychospiritual practitioner is present with the person rather than doing something for them. 3 psychospiritual care for parents during • establishing unconditional acceptance 1 the covid-19 pandemic24 • initiating therapeutic relationship 2 • intuitively recognized self-awareness to assist patients to cope with the burden associated disease 1 the development of islamic caring • offering a specific care that retain a beneficial religious tradition 2 model to improve psychospiritual • reflecting patient’s reality and positivism 3 comfort of coronary disease patients10 bridging spirituality/religiousness • awareness on the uniqueness of patient with her/his personal characteristics 1 and ecotherapy: four psychospiritual • understanding spiritual’s need as and provide appropriate interventions 2 themes to guide conceptualization and practice13 spirituality and occupational therapy: • offering for specific care that is integrated in psychological practices 2 the application of the psychospiritual • cultivating psychospiritual conversation with patient 3 integration frame of reference25 note: *1 intuitive self-awareness *2 therapeutic use of psychological and spiritual perspective *3 cultivation of psychological and spiritual environment. [healthcare in low-resource settings 2024;12:12261] [page 349] non -co mmerc ial us e o nly model case 1 ajeng, with tearful eyes, expresses difficulties living with hemodialysis. she received health education to manage depression, stress, and anxiety. however, the feeling of being empty and isolated persisted. “i know that in my religion (islam), losing hope is forbidden; i was raised with a spiritual belief that every disease, except death, has a cure. but, as a person with end-stage renal disease who needs hemodialysis twice a week, i instantly become tired, empty, and frustrated. but the more i think about it, the more lost i feel.” the nurse puts her hands on ajeng’s hand, looks her in the eyes, and answers. “psychological and psychosocial distress may impact the severity of the disease. you may feel hopeless and have less motivation to undergo hemodialysis treatment, so please feel free to make an appointment for a psychological consultation.” the nurse then asked ajeng if she had any self-healing techniques that could help her overcome her fears. ajeng said that she would like to practice a monologue with allah. this is not a common religious practice but a spiritual one. “i talked to allah, i begged allah to help me to rediscover the meaning of life in my current condition. please connect me to anything that will improve my life.” the nurse says, “your current decision makes me truly happy. can i help you?” ajeng replies, “i need to be surrounded by positive things. can i sign up for a psychology service? and i would like to be accompanied by my husband or daughters during that service” the nurse guarantees that the hospital provides that service and that she will receive it. constructing additional cases according to walker & avant (2019), constructed cases illuminate the concept and support the analysis by describing the concept’s presence in a model case, the absence of a concept in a contrary case, and the difference between the concept and a closely associated concept in a borderline and related case. contrary case the contrary case does not demonstrate the intended concept.21 in other words, it shows that whatever the concept of interest is, it certainly is not an instance of this case. contrary case 1 harjo (55 years old) went to the public health center (phc) for regular diabetes control and weekly diabetic foot exercise. ten years ago, he was diagnosed with diabetes mellitus type 2. he had attended a religious ceremony in the community the day before a scheduled consultation. he had been admitted to the intensive care unit (icu) due to hyperglycemia in the previous six months. a community nurse who delivers the diabetes program says, “i know that adhering to the diabetic regimen is difficult. culturally, we celebrate special occasions with foods and beverages. so, it is not easy to say ‘no’”. the nurse examines him to ensure that he is taking the medication and diet and that his blood sugar level is normal. identifying the antecedents and consequences of the concept antecedents are events that exist or occur before the occurrence of the concept. on the contrary, consequences are the concept’s results or outcomes.21 antecedents the antecedents of psychospiritual care are caring, cultural belief, insight, and professional commitment (figure 1). caring is a necessary prerequisite for psychospiritual care.10 recognizing that humans are psychospiritual beings allows health professionals to identify and plan for each patient’s unique psychospiritual care.11 factors such as the patient’s psychospiritual needs and the health professional’s holistic care awareness promote psychospiritual care. the second antecedent of the concept of psychospiritual care is cultural beliefs. it includes religion,26 personal beliefs,11 attitudes,7 life values,27 uncertainties,5 and critical analyses of self and personal experiences.2 religious affiliation, insight, and self-improvement of psychospiritual professionals11 aid in identifying a patient’s psychological needs and providing religious belief, and spiritual care. being insightful represents the psychospiritual professional’s attention to relational processes, such as building trust while assessing psychospiritual needs and practice.28 psychospiritual professionals can interact and communicate with patients in a compassionate and considerate manner.29 their interaction with patients influenced their approach, whether it is more concerned with assessing and controlling the risk of psychospiritual distress or acknowledging and connecting with the person as a review [page 350] [healthcare in low-resource settings 2024;12:12261] figure 1. antecedents, attributes, and consequences of the psychospiritual care concept. non -co mmerc ial us e o nly whole.30 furthermore, responsibility, accountability, and competency,31 as well as the ability to understand and accept others’ feelings and behaviors,32 are among the essential prerequisites for a professional commitment in psychospiritual care. commitments are thought to be a type of focused consciousness33 that leads to the identification of personal patterns and symptoms, and has an impact on enhancing the uniqueness and holisticness of psychospiritual practice.34 consequences the provision of psychospiritual care fosters the individual’s ability to hope,35 helps in restoring and maintaining the integrity of body, mind, and spirit,36 enhances positive illness perception,4 promotes the restoration and sustenance of body, mind, and spirit,37 and supports the adaptation of those who provide psychospiritual care.12 on the professional’s side, assessing the need and implementing psychospiritual care promotes psychospiritual awareness,38 sharpens capability,13 and enhances work satisfaction.39 defining empirical referents the final step in concept analysis is to define empirical referents for the defining attributes of the concept. the empirical criteria are directly related to the defined characteristics or attributes of the concept of interest, facilitating identification.21 in this study, the empirical criteria for psychospiritual care are the key competencies that psychospiritual caregivers need to professionally grasp patients’ priority problems to resolve their health problems and improve their health outcomes. a psychospiritual intervention increases patient satisfaction, improves psychospiritual awareness among practitioners, and illuminates the meaning and purpose of professionalism.11,40 for example, in the healthcare service, the psychospiritual intervention helps patients flexibly cope with the changes of living with chronic disease41,42 and cultivates self-care behavior in patients with chronic disease.43 given the chronic nature of the disease and the associated burdens of stress, anxiety, and depression related to their illness,44,45 psychospiritual care can provide those living with chronic disease with a driving force to cause healthy behaviors.43,46 discussion the aim of the study is to provide a comprehensive definition of psychospiritual care. this study found that psychospiritual care is a broad and dynamic concept. the ability to assess the patient’s condition professionally and select a holistic alternative to effectively solve the patient’s health problems is the primary attribute of psychospiritual care. in addition, the attributes of psychospiritual care are intertwined with one another and are regularly rearranged. these are leading to desirable consequences in achieving individual health outcomes. past studies reported that psychical, mental, and spiritual activities are connected to a person’s trust to alleviate signs and symptoms associated with disease or illness, and result in psychospiritual well-being.47,48 in the healthcare service, psychological care was widely applied to alleviate psychological distress associated with disease.49 the following psychological distress signs and symptoms, depression, anxiety, stress, and post-traumatic stress disorder were also reported among people who were physically healthy50 and those with physical illness and mental health disorders.51,52 meanwhile, spiritual care aims to fulfill a person’s spiritual or religious needs,53 establish a sense of purpose and meaning in life, including one’s morals and ethics54 that may be distinct from religion. the delivery of spiritual care may or may not involve religious activities.55,56 for example, cognitive behavioral therapy with a religious approach was applied to attain spiritual well-being among a group of american eastern christians.57 in another case, a group of veterans with moral injury received spiritual care consisting of acceptance and forgiveness therapies to attain spiritual well-being.58 the human needs for psychological and spiritual well-being are persistent along the circle of health and sickness.59 psychospiritual care exists to accommodate the individual’s need that a single psychological or spiritual care may not be able to fully cover, personal matters involving physical, psychological, religious, values and beliefs. therefore, the delivery of psychospiritual care relies on cultural-belief sensitivity, the ability of health professionals to perform caring, being insightful, and professional commitment. despite earnest attempts to raise awareness of psychospiritual well-being, interdisciplinary health professionals need more certainty on the definition of psychospiritual well-being and the delivery of psychospiritual care.26,60 empathy and intense, active listening are required in psychospiritual assessment, as well as a willingness to hear. recognizing self-awareness to assist patients in coping with the burden caused by the disease,61 establishing unconditional acceptance,24 and being aware of and respecting the patient’s unique characteristics are all important.13 the interaction is more than merely as a professional to a client: patients undergoing psychospiritual treatment need to be viewed as a whole.62 it has been massively studied that religion-based practice does not always present as the best healthcare.63 indeed, spiritual care may not provide a resource to help healthcare practitioners understand patients’ needs and provide appropriate interventions in a context of religious decline or non-religiousness.64 in clinical practice, the nurse’s ability to utilize predictable therapeutic instruments prior to the implementation of psychospiritual care is necessary. in terms of the simultaneous decline of religion and growth of spirituality, a spiritual involvement and belief scale65 might help to clarify and translate the individual’s need into integrated psychospiritual care. a very broad range of coping responses that involve the use of religious and spiritual concepts classifies religious coping as either positive or negative.66 positive religious coping includes forgiveness, seeking spiritual support, and establishing spiritual wellbeing. negative religious coping includes spiritual discontent and punishing god reappraisals.7,66,67 those encompass the psychospiritual environment as a complex, wide-ranging area of practice that integrates disease management,5,12 spirituality,13,68 psycho-education,51 mental health provisions,14 wellness,69 religion,26 belief,70 across all stages of the life cycle. promoting and cultivating the psychospiritual environment has potential implications for health professionals to tailor individual psychospiritual care that has a positive impact on patient health status10 and overall well-being.9,26 cultivating through the complex assessment by health professionals22 facilitates the patient’s needs for information, respect, validation, and emotional support.22,23 despite the definition of the concept confirmed in various psychospiritual-related literature, a patient has a right to practice psychospiritual care under the guidance of a spiritualist,71 a religious leader,72 or interdisciplinary professionals. a collaborative practice involves nurses and other professionals. these are regarded as psychospiritual practices that ethically respect and support patients’ autonomy to think and act in their preferred psychospiritual manner. psychospiritual care can help patients to cope with urgent situations and dynamic health conditions. a better understanding of psychos review [healthcare in low-resource settings 2024;12:12261] [page 351] non -co mmerc ial us e o nly piritual care improves the workplace and provides key competencies for health professionals and health services.24 research on psychospiritual care should consider the patient’s characteristics and identify additional variables influencing health status. limitations claims that walker and avant’s method is linear exist. this method lacks contextual data, as scientific concepts should be precise and are highly dependent on context for meaning. it was thought that following a systematic approach for the analysis of content would help to define context while adding to the study’s trustworthiness. analysis may have benefitted from peer-checking; however, all authors contributed to the research process, and peerchecking by co-authors was achieved. in this study, articles were limited to publications in english. the data sources used for this concept analysis were restricted to psychospiritual in healthcare practice. thus, reviewing the literature of other disciplines may illustrate similarities and differences in the application of the concept across a wide range of disciplines. conclusions a review of the published nursing literature suggests that psychospiritual care presents to accommodate individual needs that a single psychological or spiritual care may not be able to fully cover, personal matters involving physical and psychological wellbeing, religious beliefs, and values. implementing psychospiritual care can improve overall health and human well-being, thereby improving healthcare delivery. 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and research. 2013. available from: https://psycnet.apa.org/doilanding?doi=10.1037%2f14045-019 68. white fe, arpr, arpr, editors. the lived experience of psychospiritual integration: a qualitative study with exemplary psychotherapists who actively integrate spirituality into their practice of psychotherapy. 28th annual conference of the academy-of-religion-and-psychical-research; 2003 jul 2022; philadelphia, usa. 69. verrier mm. a psychospiritual exploration of the transpersonal self as the ground of healing. religions 2021;12:725. 70. eshleman sfo, perez sev. “i don’t do religion”: using nature photographs to engage patients in spiritual reflection. j pain symptom manag 2022;64:e305-9. 71. lavin mf. on spiritualist workers: healing and divining through tarot and the metaphysical. j contemporary ethnogr 2021;50:317-40. 72. viftrup dt, hvidt nc, buus n. spiritually and religiously integrated group psychotherapy: a systematic literature review. evidence based complementary and alternative medicine. 2013;2013:12. review [page 354] [healthcare in low-resource settings 2024;12:12261] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12802 risks associated with laser radiation reflections in a healthcare environment: a surface reflectance study in the range 250 nm-25 μm giacomo insero,1 luca mercatelli,2 maria cristina cimmino,3 roberto gaetano donato,1 giovanni romano,1,4 franco fusi,1,4 andrea guasti3 1department of experimental and clinical biomedical sciences “mario serio”, university of florence, florence; 2national institute of optics, cnr, florence; 3uoc fisica sanitaria usl toscana sud est, siena; 4probiomedica srl, florence, italy abstract biomedical applications relying on optical radiation, particularly with the advent of lasers, have experienced exponential growth in the last 20 years. powerful optical sources are now found not only in universities, hospitals, and industries but also in beauty centers, used for tasks such as tattoo removal, and even in our homes. despite their widespread use, managing the risks associated with lasers, particularly in non-research contexts, has not kept pace with their proliferation. while the risks associated with direct exposure to radiation to the eye and skin are relatively well understood, the hazards posed by reflected and diffuse radiation remain less characterized and monitored. therefore, there is a critical need to assess potential eye and skin hazards in spaces where lasers and non-coherent light sources are used. this necessitates a detailed analysis of reflective surfaces, with particular emphasis on evaluating their reflectance characteristics at relevant wavelength ranges. this study investigates the reflectance and transmittance (where relevant) properties of commonly used materials in biomedical settings, including fabrics, plastics, and metals, across a broad spectrum from 250 nm (uva) to visible light and into the infrared (ir) region up to 25 μm. both specular (at 45° incidence) and diffuse reflectance spectra were measured using spectrophotometric techniques and used to provide a straightforward parameter to classify the specular/diffusive behavior of the different surfaces. besides, small-angle reflectance measurements in the ir range were performed by fourier transform infrared spectrometry. the knowledge of the material optical properties used in environments where optical radiation is employed allows for accurate assessment of associated risks. this facilitates the determination of appropriate preventive measures and the establishment of safer protocols, for both operators and, where applicable, patients and the general public. for this scope, the creation of a database of material reflective properties has been initiated. introduction the current legislation in various countries mandates the assessment of risks posed by physical agents such as optical radiation from artificial sources.1-4 accordingly, it is necessary to implement technical and procedural measures to mitigate these risks comprehensively. this necessitates a full examination of all potential ocular and dermal hazards in facilities where lasers and non-coherent sources are used.5,6 special attention must be focused on all the reflective surfaces that could be exposed to the light source by the operator, whether intentionally or not. it is crucial to account for the surface reflectance at the specific emission wavelength of the source existing experimental studies on materials in clinical environments are limited, and a comprehensive database of surface reflective properties for risk management is currently lacking,7 also considering innovative light sources.8 further research in this field is then evidently necessary. this study aims to identify effective optical parameters for characterizing surfaces in risk assessment correspondence: giovanni romano, department of experimental and clinical biomedical sciences “mario serio”, university of florence, viale g. pieraccini 6, 50139 florence, italy. e-mail: giovanni.romano@unifi.it key words: laser safety, specular reflectance, ocular hazard. contributions: gi, data collection, data analysis, manuscript interpretation, and draft; lm, data collection, data analysis, critical revision of the article; mcc, data collection, data analysis; rgd, data collection; gr, manuscript interpretation, critical revision of the article; ff, conceptualization, data analysis; ag, critical revision of the article, final approval. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: not applicable. informed consent: not applicable. patient consent for publication: not applicable. conference presentation: some data in the work were presented at the conference aifm national congress on 8-11 june 2023, florence italy. abstracts/physica medica 115s1 (2023) s1–s169. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the research activity reported in this manuscript has been performed in the framework of the regional project "suppression of airborne viral epidemic spread by ultraviolet light barriers (savesus)" and the project "endoscopio luminoso per il trattamento dell'helicobacter pylori (endolight)", por fesr 2014-2020. these research projects are funded by the tuscany region. received: 11 july 2024. accepted: 11 july 2024. early access: 25 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12802 doi:10.4081/hls.2024.12802 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 638] [healthcare in low-resource settings 2024;12:12802] non -co mmerc ial us e o nly and to establish straightforward methodologies for measuring these parameters in an easy but effective and accurate way. to achieve this goal, we analyzed many different materials that are commonly present in working environments where both lasers and non-coherent sources are utilized, including furnishings, clothing, and surface coverings, including analysis of different finishings of the same surface material (e.g., polished versus satin-finished metals). when light encounters an interface between two surfaces with a refractive index n discontinuity (being n defined as the ratio between the speed of light in vacuum and the speed of light in the medium), reflection, refraction, and scattering processes can occur. in this work, we mainly focus on light reflection at the interface between air and material, while a more detailed analysis of lightmatter interaction can be found in.6 depending on the surface characteristics, light can be reflected in either a specular or diffuse manner, as illustrated in figure 1. while in the first case, reflection occurs at an angle qr qual to the angle of incidence qrr, in the diffusive case reflection occurs in all directions. generally, all materials are capable of specular reflection if their surfaces are polished to reduce irregularities to a scale comparable to (or smaller than) the wavelength of the incident radiation. it is the surface roughness that is mainly responsible for backscattering. in practice, only metals can be efficiently polished to achieve almost a 100% specular reflection. in contrast, other common materials, even with the bestpolished process, are mainly dominated by diffusive reflection, and only small fractions — generally 5-10% — of the incident radiation is specularly reflected, depending on the angle of incidence. contrary to common belief, the amount of reflected light from a medium is not solely due to the surface imperfections, but also involves backscattering from subsurface layers. this phenomenon underscores how scattered light provides insights into the surface layer structure of materials. materials and methods fundamental to an accurate risk assessment of coherent and non-coherent light is the measurement and characterization of the optical properties of different materials. for this purpose, we need to introduce the concepts of reflectance, transmittance, and absorbance.9,10 the total reflectance rtot of a material is a parameter that evaluates the fraction of the radiant flux incident on the material surface that is reflected. similarly, if we consider the fraction that is transmitted, we can define the total transmittance ttot. all the leftover radiant flux that has not been either reflected or transmitted has been absorbed by the medium and defines the absorbance , which can be calculated in terms of rtot and ttot through the relation: (1) where we underlined the explicit dependence on the incident light wavelength l. as previously discussed, the reflection of an incident beam involves specular reflection, where the reflectance and incident angles are equal, and diffuse reflection is scattered in all directions. the predominance of one or the other type depends on both the incident light wavelength and the surface properties, such as the material type and surface roughness degree. since optical radiation risk assessment and safety measures can be different for specular and diffusive surfaces, the total reflectance can be decomposed as (2) where rs (l) and rd (l) represent the specular and diffusive reflectance, respectively. however, rs (l) depends on the incidence angle of the light. to provide a measure of specular reflectance, we have decided to use a characteristic incidence angle of 45 degrees, identified by the symbol r45° s (l). this angle is representative of many practical situations and is also easily measurable with simple and inexpensive setups, enabling even poorly equipped laboratories to extend or compare our measurements on other materials. the eq. 2 now becomes: (3) considering that the main purpose of this work is to make safe article figure 1. scheme of the effects governing light transport in a medium. healthcare in low-resource settings 2024;12:12802] [page 639] non -co mmerc ial us e o nly ty officers aware of the risks of laser radiation reflecting off surfaces in healthcare environments, it is essential to identify a proper parameter that immediately indicates whether a surface mainly exhibits specular or diffusive characteristics. this can be identified by the lambertian parameter llamb (l) which can be obtained by measuring separately r45° s (l) and rd (l) and is defined as follows: (4) this parameter ranges from nearly 0 to 100; the more llamb (l) approaches low values (llamb (l) can be as low as zero, but in practical cases, it ranges between 1 to 100), the more diffusing the sample (rd >> r45° s), while for a predominant specular behavior, llamb (l) approaches 100 (r45° s = rtot). since llamb (l) is represented by a spectral curve, indicating its behavior as a function of wavelength, we will also provide a reference value for it, obtained as an average over the spectral range of 400-1100 nm and indicated as . although this average value does not encompass all spectral information, it offers a practical alternative for an initial estimation of the specular or diffuse reflection behavior of a surface within the 400-1100 nm range. this range includes most optical sources used in biomedical applications, such as those employed in phototherapy. providing this average value, in addition to the full spectral data, simplifies the analysis and interpretation of the spectral information, offering a convenient (but not accurate) single metric. besides r45° s (l), we have also characterized the total and specular reflection at smaller angles (30°), labeled as r30° s (l), in the range of 2.4-25 µm. this extends the characterization of the optical properties of the materials up to 25 µm, thereby encompassing the emissions of lasers extensively used in biomedical applications such as co2 (10 µm) and erbium (2940 nm). as for reflection, also in the case of transmission, we can identify two contributions: diffusive and ballistic transmission. ballistic transmission tb(l) refers to light that passes through a medium without being scattered or absorbed, maintaining its original direction and coherence as it travels through the material. in contrast, diffusive transmission tb(l) occurs when light propagates through a medium and undergoes multiple scattering events, causing it to spread out and diffuse in different directions. the total transmission is determined by the sum of these contributions: (5) equipment small sample measurements (dimensions of a few centimeters) were performed with a lambda900 spectrophotometer (perkin elmer) equipped with a 150-mm internal diameter integrating sphere (pela 1000, perkin elmer) coated with spectralon® (labsphere), a perfectly diffusing material with an optical behavior known as lambertian, since it homogeneously diffuses light in all directions. by covering each port with the same white material as the sphere, except for the entrance and detector port, a 100% reflectance measurement can be obtained. inserting a sample into the sample port allows for measurement of total reflectance, which includes both specular and diffuse components. as anticipated, to isolate specular reflectance, a black trap is placed in the specular port, thereby measuring only diffuse reflectance. specular reflectance is then calculated by difference. all the reflectance measurements are calibrated against diffusive reflectance standard made of spectralon® (labsphere). the lambda900 spectrophotometer is a dual beam scanning spectrometer with a double grating for stray light reduction, operating in the wavelength range 0.20-2.5 μm, i.e. covering part of the ultraviolet range (uv: 200380 nm), the whole visible spectrum (vis: 380-750 nm) and the near-infrared range (nir: 0.75-2.5 μm). for measuring the total and specular reflectance on materials that cannot be reduced to small dimensions (e.g. wall plaster) the portable avaspec 2048 standard fibre optic spectrometer manufactured by avantes (usa) was used. the avaspec 2048 spectrometer performs measurements in the range of 200-1100 nm with a maximum stray light of 0.1%. its a/d converter is 14-bit @ 1.3 mhz. the sensor is a linear ccd array of 2048 pixels with a signal-to-noise ratio of 200:1. the integration time can be varied from 2 ms to 60 s. for reflectance and transmission measurements, the spectrometer is coupled with different light sources: a fiber-optic illuminator powered by a halogen lamp avalight-hal (avantes), for the vis and nir, and a deuterium-lamp based illuminator avalight-dhc (avantes), for the uv. to accurately measure total reflectance (i. e. total hemispherical reflectance), diffuse reflectance, and transmittance, an integrating sphere was employed. this consists of a spherical cavity with a diffuse white interior surface that, ideally, uniformly scatters incoming light without absorbing it on the whole spectral range of interest. our integrating sphere is internally coated with spectralon® (labsphere). the sphere also includes specific access for light entry (“entrance port”), sample placement (“sample port”), and a light detection port. optional access can collect the specularly reflected light from the sample (“specular reflection gate”), which can alternatively be excluded from measurement by use of a light black “trap” geometrically positioned in correspondence to the specularly reflected beam. in the case of the avaspec 2048 spectrometer, an integrating mini-hemisphere has been employed. illumination and detection fibers were coupled with the mini-hemisphere to be 90° apart and to form a 45° angle between the hemisphere plane and each fiber. finally, measurements in the range of 2.4-25 µm were conducted using the ftir spectrometer nicolet is50 (thermo scientific) using an integrating sphere (pike). total rtot (l) and small-angle r30° s (l) reflectance measurements were performed with pike gold-coated sphere and accessory pike 30spec. results and discussion the results are presented as reflectance spectra, including both specular and total reflectance, as well as the lambertian parameter for all tested materials. additionally, transmission spectra are provided for various fabric tissues commonly used in clinical operating rooms or in environments where both coherent and non-coherent laser sources are employed. the accuracy of these measurements has been determined to be ± 2% for transmission and ± 4% for reflection measurements across the entire spectral range examined. this consistency was observed across materials with varying compositions and surface characteristics. the high accuracy, together with reproducibility, indicates the reliable performance of the measurement setup, ensuring that the data accurately reflects the optical properties of the materials under study. to provide a comprehensive characterization of surfaces pre article [page 640] [healthcare in low-resource settings 2024;12:12802] non -co mmerc ial us e o nly sent in environments where optical radiation is used, we selected a wide range of different samples: metals (with varying degrees of surface finish), transparent and non-transparent plastic materials, building materials, and fabrics specific to biomedical applications or operating rooms (table 1). in figure 2 we report the total and specular reflectance, together with the lambertian spectral parameters and the total reflectance in the nir for several metals, with both polished or brushed surface finishing, and some plastic materials. reflection spectra show great variability: surface characteristics (material composition and surface treatment) play an important role in the determination of the spectral reflectance curves. the wavelength dependence must also be carefully considered because the same sample can behave very differently at different wavelengths. this indicated that the material reflection properties in the uv or ir range cannot always be deduced from the visible range, as can be seen in several materials shown in figure 2. polished materials, as expected, exhibit significantly higher specular reflectance compared to satin-finished ones. notable differences are observed between near ir and mid-ir (up to λ=25 µm). in particular, brushed metals demonstrate a small-angle reflection that is several tens of percentage points higher in the 1025 µm range. this range is of particular interest for clinical and industrial settings because it includes co2 laser emission. brushed metals also show up to 10% specular reflection in the visible wavelengths, a value that in many cases cannot be neglected in risk management. regarding the plastics, we observe that their behavior is predominantly diffusive within the measured range. in determining the llamb (l) parameter, we note that this parameter reaches values greater than 100, its theoretical maximum, around the region of 2 µm. this is due to the limited accuracy of the reflectance measurement, which, for some materials, leads to a slight overestimation of specular reflectance compared to the total reflectance (always within the stated accuracy ± 4%). this can result in llamb (l) values exceeding 100. in figure 2 we can identify the diffusive/specular behavior (at 45°) of different materials by looking at the llamb (l) value: the smaller it is, the more diffusive the material is. in figure 3, we present the total reflectance spectra rtot (l) in the two ranges of 250-2500 nm and from 1.5 µm up to 25 µm, again examining various fabrics with significantly different textures and composition (see table 2 for additional information) to obtain a representative sample of those used in environments where optical radiation sources are present, with particular reference to the hospital setting. we also measured the specular reflection in the 250-2500 nm range. all measured textile samples exhibited very similar behavior in terms of total reflection. as shown in figure 3, the total reflectance in the range of 250-2500 nm shows an initial peak in the visible spectrum reflecting the coloration of the material (generally blue or green). then, a higher plateau starts from around 700 nm, varying from approximately 60% to almost 90% (depending on the type of fabric), gradually decreasing at longer wavelengths. furthermore, the specular reflectance of all fabrics was found to be less than 4% (limited by instrumental accuracy alone) in the range of 250-2500 nm. however, considering the surface finish of the fabrics and, consequently, the representative length of surface irregularities, very low values of specular reflectance are also expected in the range up to 25 µm. therefore, article [healthcare in low-resource settings 2024;12:12802] [page 641] figure 2. specular rs (45°) (λ) and total reflectance spectra rtot (λ), together with the lambertian parameter llamb (λ) in the spectral range 250-2500 nm. small-angle reflectance spectra rs (30°) (λ) is reported in the wavelength range 1280-25000 nm. non -co mmerc ial us e o nly the behavior of the fabrics is highly diffusive, with total reflectance values potentially exceeding 80%. although diffusely reflected radiation is less hazardous than specular radiation, contrary to expectations textile surfaces can have a diffusive reflectance comparable to satin-finished metals, which must be properly accounted for in risk assessment. as an example, in figure 3, we also compare the total reflectance rtot (l, the total ttot (l) and ballistic tb (l) transmittance, and the absorbed fraction a(λ) for textile samples a and c. the specular reflectance is not reported, being below the instrument’s accuracy limit as previously mentioned. the ballistic transmittance, like the reflectance, is heavily attenuated, resulting in a predominant contribution from diffuse transmittance. all the tested fabrics exhibit spectra analogous to those reported. table 2 reports on the value, calculated as the average of the spectral curve llamb (l) over the range 400-1100 nm, together with the surface roughness parameter ra for metallic samples.11 the values for the metals indicate that aluminum exhibits greater diffusivity compared to steel, both in its polished and satinfinished forms. it is important to note that the parameter does not represent the absolute diffusive or specular properties of the sample. the significant variability in the values of r45° s (l) and rtot (l) across different wavelengths, both in the visible and infrared regions for certain materials, necessitates a meticulous evaluation of this lambertian value at the specific wavelengths or emission bands of the sources. this is crucial for accurately assessing the potential ocular hazard. finally, for completeness, we present the optical properties of a highly transparent material such as glass. specifically, we have examined bk7 crown glass, a standard material for optical equipment. bk7 is commonly used in the production of lenses, foils, and prisms for ophthalmology, as well as in the lenses of cameras and microscopes. this glass exhibits greater transparency in both the article figure 3. total reflectance spectra rtot (λ) in the spectral range 250-2500 nm and total reflectance spectra in the wavelength range 16-20 μm. all the tested blue-coloured textiles show specular reflectance lower than the instrument accuracy in the 250-2500 nm range (rs (λ)< 4%) and has not been reported in the graph. in the same spectral range we report an example of total ttot (λ) and ballistic transmission tb (λ) together with the absorption curve a(λ)and the total reflectance rtot (λ) for textile samples a and c. [page 642] [healthcare in low-resource settings 2024;12:12802] non -co mmerc ial us e o nly article table 1. macroscopic (3x3 cm2) and microscope images of the different blue-coloured textiles tested in this work. green-coloured textiles were also tested, showing the same composition and surface finishing of the ones reported above (data not shown). table 2. average values of llamb (λ) in the range 400-1100 nm (indicated as llamb 400-1100 nm) and the surface roughness parameter ra for metallic samples. for textiles, the value has been estimated assuming a 4% specular reflectance that corresponds to the measuring instrument limit. sample llamb400-1100 nm ra[μm] sample llamb400-1100 nm ra[μm] polished stainless steel 38 0.12 brushed stainless steel 16 0.68 polished aluminum 20 0.35 brushed aluminum 5 0.41 brass 60 0.14 polished copper 90 0.06 plexiglass 58 – polycarbonate 64 – polyvinyl chloride 91 – ptfe 2 – textiles a < 10 – textile c < 8 – [healthcare in low-resource settings 2024;12:12802] [page 643] non -co mmerc ial us e o nly visible and infrared spectra compared to ordinary ‘green’ window glass. as shown in figure 4, the reflectivity of bk7 is expected to be less than 10% over the entire visible range. however, there are two bands of high reflectivity in the infrared spectrum, between 7.5 μm and 11 μm, and between 19 μm and 25 μm. the presence of these two bands in the infrared region underscores the importance of accurate characterization of the optical properties of materials: extrapolating, for instance, the reflectance behavior of one spectral region to another can lead to significant errors and underestimations. this inaccuracy is particularly critical when the data are used to determine safety criteria for laser radiation and to implement measures ensuring the safety of workers in environments where optical radiation is utilized. conclusions the reflective properties of materials used in the biomedical environment are of great interest for risk management purposes when laser light and other non-coherent sources are used in clinical practice or research. when light from a laser source hits a surface, it produces both specular and diffuse reflections, which can have harmful effects, particularly on the eyes. while diffusely reflected radiation is generally less hazardous than specular radiation, it is important to note that textile surfaces can exhibit a diffusive reflectance comparable to that of satin-finished metals. this unexpected characteristic must be carefully considered in risk assessments. of particular interest is the comparison of different llamb (l) curves and values, which were presented in correspondence to the laser wavelengths most commonly used in clinical practice and provide an immediate index that indicates whether a given surface behavior is mainly diffuse or specular. based on the results presented here, the creation of a database of material reflective properties has been initiated.12 references 1. barat k. laser safety: tools and training. 2nd ed. london (uk): taylor & francis ltd, 2017. 2. directive 2006/25/ec of the european parliament and of the council of 5 april 2006 on the minimum health and safety requirements regarding the exposure of workers to risks arising from physical agents (artificial optical radiation) (19th individual directive within the meaning of article 16(1) of directive 89/391/eec). non-binding guide to good practice for implementing directive 2006/25/ec 'artificial optical radiation. publication office of eu (2011) isbn 978-92-79-16046-2 doi:10.2767/742018. 3. international commission on non-ionizing radiation protection (icnirp). icnirp guidelines on limits of exposure to laser radiation of wavelengths between 180 nm and 1,000 μm. health phys. 2013 sep;105(3):271-295. 4. european normative: en 60601-2-22. medical electrical equipment part 2-22: particular requirements for basic safety and essential performance of surgical, cosmetic, therapeutic and diagnostic laser equipment. 5. niemz mh. laser-tissue interactions: fundamentals and applications. springer. 2019. 6. insero g, fusi f, romano g. the safe use of lasers in biomedicine: principles of laser-matter interaction. j public health res 2023;12:22799036231187077 7. cimmino mc, biondi m, guasti a, et al. laser interaction with medical textiles: changes of optical properties and damage thresholds. physica medica: eur j med physics 2023;115:102884. 8. romano g, insero g, marrugat sn, fusi f. innovative light sources for phototherapy. biomol concepts 2022;13:256-71. 9. vo-dinh t (ed). biomedical photonics handbook. boca raton: crc press, 2003. 10. vo-dinh t (ed). biomedical photonics handbook: therapeutics and advanced biophotonics. 2nd ed. boca raton: crc press, 2014. 11. iso 21920-2:2021, geometrical product specifications (gps) — surface texture: profile 12. material reflectance database. available from: https://www.portaleagentifisici.it/fo_ro_artificiali_riflettanza_materiali.php?lg=en article [page 644] [healthcare in low-resource settings 2024;12:12802] figure 4. optical properties diagram of a 10-mm thick bk7 borosilicate glass sample from schott. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11853 effect of black sticky rice tape and purple sweet potato formulation on organoleptic properties and anthocyanin content of sweet purple mochi as a high anthocyanin snack to prevent cancer roro nur fauziyah, nabilah besta salsabil, agus sulaeman, widi hastut, gurid pramintarto eko mulyo nutrition department, politeknik kesehatan kemenkes bandung, indonesia abstract cancer is one of the second leading causes of death worldwide. it is estimated that by 2030, cancer incidence could reach 26 million people, and 17 million of them will die because of cancer. free radicals in the body can cause cancer, so it is very important to consume foods rich in antioxidants, such as black glutinous rice tape and purple sweet potato, because the human body cannot naturally make antioxidants. the study aimed to determine the effect of black sticky rice and purple sweet potato formulations on organoleptic properties (color, aroma, taste, texture, and overall) and the anthocyanin content in sweet purple mochi. the method used a hedonic test to determine the level of liking and uv-vis spectrophotometry combined with differential ph to determine anthocyanin levels. thirty participants were students from nutrition department, politeknik kesehatan kemenkes bandung. the results showed significant aroma, taste, and overall p<0.05 differences. f3 was the most preferred formulation, containing 11.2 mg of anthocyanins per 70 gram. there were significant effects and differences in the formulation of black sticky rice tape and purple sweet potato on organoleptic properties (aroma, taste, and overall). the anthocyanin content in the product can fulfill the adequacy of anthocyanins in a day, so this product can be used as a snack to prevent cancer. introduction cancer is one of the second leading causes of death worldwide, characterized by abnormal cells that develop uncontrollably and can attack cells or tissues in the body.1,2 in 2019, it was estimated that 10 million people died due to cancer worldwide;3 it is estimated that by 2030, cancer incidence could reach 26 million people, and 17 million of them will die because of cancer.4 cancer ranks as the second most prevalent cause of mortality among children aged 1 to 14 years.5 in 2020, as reported by the global cancer observatory, an estimated 396,914 individuals in indonesia were diagnosed with cancer, resulting in a death toll of 234,511.6 the most common cancers are breast, lung, colon, rectum, and prostate cancers.7,8 breast and lung cancers contributed 12.5% and 12.2% of new cases diagnosed in 2020. meanwhile, colorectal cancer contributed to 10.7% of new cases.9,10 cancer and its treatments cause significant stress.11,12 a variety of risk factors contribute to the high burden of non-communicable diseases.13 the etiology of cancer is still unknown, but according to ling et al. (2018) cause of cancer is related to smoking, alcohol consumption, and viral infection (human papilloma virus).14 one factor causing cancer is an increase in free radical levels exceeding the ability of antioxidants in the body.15,16 free radicals have a very high reactivity level, so they can damage tissue and continue to cause cancer cells.17,18 based on riskesdas, cancer prevalence in indonesia increased from 1.4 per 1000 population in 2013 to 1.79 per 1000 population in 2018. the highest cancer prevalence in 2018 was found in the age group of 55-64 years, which was 4.62%.19,20 one prevention of free radical formation is to use nutrients that act as antioxidants. antioxidants are essential nutrients that can protect the body by fighting free radicals.21 substances classicorrespondence: roro nur fauziyah, nutrition department, politeknik kesehatan kemenkes bandung, indonesia. e-mail: roronur70@yahoo.com key words: anthocyanin, black sticky rice tape, local food production, mochi, organoleptic properties, purple sweet potato. contributions: rr, conceptualization, methodology, product manufacturing, supervision, review; nb, conceptualization, methodology, product manufacturing, writing-original draft, data collecting data, data analysis; as, data analysis, review, validation, supervision; wh, review, verification, supervision; gp, writing-original draft, review, and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by a research grant from politeknik kesehatan kemenkes bandung. ethics approval: this research received approval for an ethical review from the health research ethics commission of the politeknik kesehatan kemenkes bandung no. 40/kepk/ec/viii/2021. informed consent: all participants in this study signed a written informed consent form to participate. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors would like to thank politeknik kesehatan kemenkes bandung for their valuable insights and contributions to this study. received: 21 september 2023. accepted: 18 december 2023. early access: 26 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11853 doi:10.4081/hls.2024.11853 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 150] [healthcare in low-resource settings 2024;12:11853] non -co mmerc ial us e o nly fied as antioxidants are anthocyanins. research by yi et al. (2010) states that anthocyanins can capture free radicals and reduce cell damage due to oxidative stress.22 this is in line with the study of shi (2021), anthocyanins in colorectal cancer prevention review with high use of fruits and vegetable anthocyanins showing antitumor effects on colon cancer.23 each type of cancer requires a different approach of therapy, and a precise cancer diagnosis is crucial for proper and successful care. surgery, radiation, systemic therapies, such as chemotherapy, hormonal medicines, and targeted biological therapies, are frequently used in treatment.24 utilization of high-anthocyanin food sources can be done as an effort to prevent cancer. one of the food sources high in anthocyanins is black sticky rice tape and purple sweet potatoes. the black sticky rice tape contains 257 ppm/100 g anthocyanins with an antioxidant activity of 70.2% grams.25 purple sweet potato contains anthocyanins of 61.85 mg/100 g with antioxidant activity of 59.25%.26 several studies use black sticky rice tape as one of the raw materials for making products high in anthocyanins. research by moviana et al. (2022) made cookies from black sticky rice tape, which contained anthocyanin levels of 5.72mg/100 grams of cookies.27 research by sukowati et al. (2023) made eggroll with black glutinous rice tape as the main ingredient. the eggroll contains anthocyanin levels of 22.64 mg/100 grams of eggroll.28 in addition, research by sari et al. (2019) made purple blacksoy layered pancakes from purple sweet potatoes as an alternative food source of anthocyanins to prevent cancer. the pancake contains 17.85 mg of anthocyanins.29 seeing the high content of anthocyanins in purple sweet potatoes and black sticky rice tape, the author is interested in diversifying food to obtain a new product, mochi, which has high levels of anthocyanins as a functional food to prevent cancer. for this reason, it is necessary to research the manufacture of black sticky rice tape rice and purple sweet potato mochi to determine the effect of sticky rice and purple sweet potato formulations on organoleptic properties (color, aroma, taste, texture, and overall) and the anthocyanin content in sweet purple mochi as a high anthocyanin snack to prevent cancer. the study aimed to determine the effect of black sticky rice and purple sweet potato formulations on organoleptic properties (color, aroma, taste, texture, and overall) and the anthocyanin content in sweet purple mochi. materials and methods research design this study used an experimental research design with a complete randomized (ral) consisting of independent and dependent variables. sample the panel acts as an instrument or tool in analyzing the organoleptic properties of a product. this panel consists of people or groups in charge of assessing the organoleptic properties of the product called panelists. moderately trained panelists for organoleptic test generally number 30 people who have been previously trained for organoleptic properties.30 the sample for organoleptic test are 30 moderately trained panelists who are a student of the nutrition department, politeknik kesehatan kemenkes bandung level 3 and 4 who has met the inclusion criteria. the inclusion criteria namely healthy and having received organoleptic test material.30 the exclusion criteria namely in a state of illness, hunger, fullness, not having a cold, not having allergies to the ingredients tested, not having mouth ulcers. all participants in this study signed a written informed consent form for participating in this study before doing organoleptic test. variables the independent variable in this study is the comparison of black sticky rice tape with purple sweet potato, divided into three balances, namely 20%:80%, 30%:70%, and 40%:60%. in contrast, the dependent variable in this study is product quality, which includes organoleptic properties consisting of color, aroma, taste, texture, overalls, and anthocyanins. data collection process this research consists of several stages, namely the first stage in preliminary research, which aims to obtain the appropriate balance. the second stage in the form of primary research, namely the implementation of organoleptic tests and anthocyanin analysis carried out in october 2021-march 2022, including data collection in the form of organoleptic test results in the taste test laboratory, and anthocyanin-level testing at sig laboratory pt. saraswanti genetech, indonesia instruments this research instrument is a hedonic test form with 7 rating scales, namely very dislike being given a grade of 1, dislike being given a grade of 2, quite do not like being given a grade of 3, neutral is given a grade of 4, quite like being given a value of 5, likes to be given a grade of 6, and really likes to be given a grade of 7. the organoleptic test of sweet purple mochi was carried out with hedonic tests on color, aroma, taste, texture, and overalls. anthocyanin content testing using uv-vis spectrophotometry method with differential ph. data analysis the analysis was used to determine the effect of different balances of black sticky rice tape and purple sweet potato on organoleptic properties and anthocyanin levels of sweet purple mochi, each of which was tested for normality with a confidence degree of 95% (α=0.05). if the data is normally distributed, the one-way anova test is carried out, if meaningful (p≤α), followed by a post-hock test, namely the tukey test. conversely, if the data is abnormally distributed, the kruskal-wallis test is used if meaningful (p<α), followed by the mann-whitney test. this study use non-parametric tests (kruskal-wallis test and mannwhitney test) because the results of the data normality test show abnormally distributed.31,32 results the organoleptic test results of sweet purple mochi can be seen in table 1. table 1 shows, the highest percentage of 33.3% of panelists stated that they very liked the color of formula 3, 40% of panelists very liked the aroma and taste of formula 3, and 26.7% of panelists very liked the overall texture of formula 3. in comparison, 43.3% of panelists liked the texture of formula 2. thus, it is known that the balance of f3 with the percentage of black glutinous rice tape and purple sweet potato 40%: 60% is superior in color, aroma, taste, and overall compared to other balances. table 2 shows the result of the kruskal wallis test; p-value of color 0.605>α (0.05) and p-value of texture 0.153>α (0.05) were obtained, which means that there were no significant differences in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11853] [page 151] non -co mmerc ial us e o nly the color and texture aspect of the three balances. meanwhile, the kruskal wallis test of aroma, taste, and overall shows a significant difference between the three balances. to find out the location of the difference in each formula, then the mann-whitney test can be found that there were significant differences in the aroma aspect of the product on the balance of f1 and f3 with p-value 0.003<α (0.05), there were significant differences in taste aspects in f1 and f2 balances with p-value 0.001<α (0.05) and f1 and f3 balances with p-value 0.00<α (0.05), and there were significant differences in the overall aspects of the product with a p-value 0.029<α (0.05), f1 and f3 balance with a p-value (0.001) < α (0.05). anthocyanin content analysis was carried out on the formulation most preferred by the panelists, namely formula f3 with a ratio of black sticky rice tape and purple sweet potato 40%:60%. the results of the anthocyanin level analysis are then compared with the need to determine the level of achievement of anthocyanin levels in this product. table 3 shows anthocyanin levels in f3 amounted to 11.2 mg per 70 grams of product. sweet purple mochi products can fulfill 112% of anthocyanin adequacy daily. discussion color of sweet purple mochi all three mochi formulas have met the desired mochi criteria: purple. it is because black sticky rice tape and purple sweet potatoes, the essential ingredients for making mochi, have anthocyanin pigments that function as natural purple dyes, so panelists find it challenging to distinguish the color of the mochi produced. black sticky rice tape is made from black sticky rice with an anthocyanin pigment content of 257 ppm. in comparison, purple sweet potatoes contain anthocyanin pigments of 61.85 mg/100g. black sticky rice tape with a purple-black color causes a change in the color of the cake to darker. the black sticky rice tape is used, the more concentrated the color of the mochi produced.33 it is in line with puspawati et al. (2020) research on making black sticky rice tape ice cream mochi, which states that adding 75% black sticky rice tape causes a deep purple color in the mochi ice cream produced.34 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution, frequency, likeness, rating to color, aroma, taste, texture, and overall. formula (%) liked level color aroma taste texture overall n % n % n % n % n % formula 1 (20%:80%) very dislike 0 0 0 0 1 3.3 0 0 0 0 dislike 0 0 0 0 0 0 2 6.7 1 3.3 quite do not like 1 3.3 1 3.3 4 13.3 1 3.3 1 3.3 neutral 5 16.7 6 20 6 20 6 20 8 26.7 quite like 7 23.3 7 23.3 11 36.7 10 33.3 9 30 like 11 36.7 14 46.7 7 23.3 4 13.3 9 30 very like 6 20 2 6.7 1 3.3 7 23.3 2 6.7 f2 (30%:70%) very dislike 0 0 0 0 0 0 0 0 0 0 dislike 0 0 0 0 0 0 0 0 0 0 quite do not like 0 0 0 0 1 3.3 0 0 1 3.3 neutral 4 13.3 5 16.7 2 6.7 2 6.7 4 13.3 quite like 6 20 6 20 7 23.3 10 33.3 6 20 like 16 53.5 11 36.7 14 46.7 13 43.3 13 43.3 very like 4 13.3 8 26.7 6 20 5 16.7 6 20 f3 (40%:60%) very dislike 0 0 0 0 0 0 0 0 0 0 dislike 0 0 0 0 0 0 0 0 0 0 quite do not like 0 0 0 0 1 1.3 3 10 0 0 neutral 5 16.7 3 10 0 0 6 20 0 0 quite like 6 20 3 10 6 20 8 26.7 9 30 like 9 30 12 40 12 40 9 30 13 43.3 very like 10 33.3 12 40 12 40 4 13.3 8 26.7 n, the number of panelists. table 2. the result of differences test organoleptic properties of three balances. organoleptic properties n kruskall wallis test (p-value) color 30 0.065 aroma 30 0.0125 taste 30 0.002 texture 30 0.153 overall 30 0.003 n, the number of panelists. table 3. comparison of anthocyanin content of sweet purple mochi with nutritional adequacy. bioactive nutritional value nutritional % substances per serving (70 grams) adequacy daily value anthocyanins 11.2 10 112% (mg) [page 152] [healthcare in low-resource settings 2024;12:11853] non -co mmerc ial us e o nly aroma of sweet purple mochi the aroma produced from the three product formulas of sweet purple mochi has a distinctive aroma of black sticky rice tape and purple sweet potato with different levels because in the fermentation process of black sticky rice tape, glucose hydrolysis, and alcohol oxidation occur, giving rise to aroma compounds, namely the aroma of alcohol that is characteristic of tape.35 at the same time, the distinctive fragrant aroma of purple sweet potatoes comes from the degraded starch content.36 panelists preferred the aroma of adding black sticky rice tape and purple sweet potato by 40% and 60% to the f3 formula because the aroma produced from the black sticky rice tape balance was more dominant. the higher the addition of the balance of black sticky rice tape, the more intense the distinctive aroma of black sticky rice tape. the research is in line with fauziyah’s research on making cracker formula bmc black sticky rice tape, mung bean flour, and peanut flour that the addition of 40% black sticky rice tape produces a more dominant distinctive aroma of black sticky rice tape.37 similarly, wardani et al.’s (2020) research stated that panelists liked the aroma of cakes made with black sticky rice tape, the aroma of cakes without adding black sticky rice tape was not liked and was less attractive to panelists.33 taste of sweet purple mochi the sweetness from the three sweet purple mochi products formulas has a sweet taste with different sweetness levels. it is caused by the fermentation process of black sticky rice tape, where during the ripening process, the starch content turns into reducing sugars that will cause a sweet taste. the sugar content in black sticky rice tape is 18.39%.38 the sweetness is obtained from the enzyme amylase, converting the starch in sticky rice into simple sugars. aspergillus is one of the microorganisms that play a role in making tape. aspergillus microbes in tape-making function to hydrolyze starch in raw materials into simple sugars. oligosaccharide sugars, such as stamiosa, raffinose, and verbascosa, the sugar content in purple sweet potatoes is 5.64%.39 panelists preferred the taste of adding black sticky rice tape and purple sweet potato by 40% and 60% to the f3 formula because of the sweetness resulting from the balance of black sticky rice tape, which is more dominant. the higher the addition of black sticky rice tape balance, the sweeter the taste is obtained. the research is in line with fajriyanti’s study in 2018 on making black tapai berry ice sherbet, that the addition of 75% black sticky rice tape produces a sweeter taste in black tape berry ice sherbet.25 the texture of sweet purple mochi the texture of sweet purple mochi is influenced by the many balances used. the more purple sweet potato is used, the chewier the mochi. it is due to the amylopectin content in purple sweet potato. amylopectin affects the gelatinization ability so that the resulting cake is chewy.40 the study is in line with research conducted by attati (2019) on the effect of cassava substitution on the level of mochi liking, which states that the more the number of sweet potatoes, the higher the chewiness of mochi is.41 based on the addition of black sticky rice tape used more dominantly, and a little purple sweet potato, the mochi produced tends to be rather soft and slightly chewy. due to the fermentation effect, black sticky rice tape has a soft and watery texture. overall sweet purple mochi overall, the f3 formula with a balance of black sticky rice tape and purple sweet potato 40%:60% is the most preferred compared to other formulas based on a rating scale superior to every organoleptic aspect. in formula 3, the black sticky rice tape formulation is used more than other formulas. the study is in line with research by wardani et al. (2020), which states that the addition of black sticky rice tape affects the physical properties of the product, both in terms of taste, aroma, texture, and taste preferred by panelists compared to products without the addition of black sticky rice tape.33 anthocyanin content of sweet purple mochi based on the anthocyanin level testing results, anthocyanin levels were obtained in black sticky rice tape and purple sweet potato mochi of 11.2 mg/70 grams of the product. this product has a higher anthocyanin content than cookies from black sticky rice, but in the research of moviana et al. (2022), it contained anthocyanin levels of 5.72 mg/100 grams of cookies. it can occur due to different ways of processing the product so that it can produce different anthocyanin content as well.27 anthocyanins are generally unstable at high temperatures, so, during processing or storage, they may cause discoloration or a decrease in antioxidant activity.42 compared with the adequacy of anthocyanins a day, based on research conducted by pojar (2013) obtained a percentage of 112%.43 the percentage shows that this sweet purple mochi product has met the adequacy of anthocyanin levels.44 it is because the product contains black sticky rice tape and purple sweet potatoes with high anthocyanin content. the anthocyanins found in purple sweet potatoes and black sticky rice tape are a class of water-soluble flavonoids that may aid in cardiovascular disease prevention, obesity control, and antitumor activity. potential antitumor effects are based on a wide range of biological activities, including antioxidant, anti-inflammatory, anti-mutagenesis, inducing cell termination, stimulating apoptosis or autophagy of cancer cells, anti-invasion, anti-metastasis, reverse drug resistance in cancer cells, and enhancing sensitivity to chemotherapy.45 this research implies that the sweet purple mochi product formula 3 with a ratio of black sticky rice tape and purple sweet potato 40%:60% is a product that is accepted and liked by panelists. the use of black sticky rice tape and purple sweet potato aims to make a product by utilizing local food ingredients that have functional value, namely anthocyanins, so that in addition to tasting good, this product can also be an alternative snack for the community to prevent cancer. the strength of this study is that in making mochi, ingredients are used that are functional foods that can be beneficial for health. the presence of anthocyanins in sticky rice tape and purple sweet potato can make the product more attractive and have a functional value that can be used as a reference and idea for the community and food industry to develop other products from these ingredients. the limitation of this study is the influence of product shipment, product storage, and equipment conditions on the analysis of anthocyanin levels for laboratory tests through expeditions is beyond the control of researcher’s analysis of anthocyanin levels for laboratory tests through expeditions is beyond the control of researchers. sweet purple mochi has not been applied as an alternative to prevent cancer in the community because it was only studied from the aspect of liking (hedonic) and nutrient content (anthocyanin). in addition, the shelf life of sweet purple mochi was not studied, so the durability of the product is unknown. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11853] [page 153] non -co mmerc ial us e o nly conclusions formula 3 with a balance of black sticky rice tape and purple sweet potato 40%:60% is preferred and superior in color, aroma, taste, and overalls. there were significant effects and differences in the formulation of black sticky rice tape and purple sweet potato on organoleptic properties (aroma, taste, and overall). the anthocyanin content in black sticky rice tape and purple sweet potato mochi is high and fulfills anthocyanins’ adequacy daily, so this product can be a snack to prevent cancer. in this study, sweet purple mochi has not been applied as an alternative to prevent cancer in the community. therefore, further research needs to be done on the effect of giving sweet purple mochi products for cancer prevention. in addition, it is necessary to make safe and attractive packaging for the product and conduct research on product shelf life to obtain information about the durability of sweet purple mochi. references 1. htay mnn, donnelly m, schliemann d, et al. breast cancer screening in malaysia: a policy review. asian pacific j cancer prev 2021;22:1685-93. 2. kementerian kesehatan ri. pusat data dan informasi. jakarta: infodatin; 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2020. 315 pp. 31. charles j, jamco s, balami am. analisis kruskal-wallis untuk mengetahui konsentrasi belajar mahasiswa berdasarkan bidang minat program studi statistika fmipa unpatti. j mat stat dan ter 2022;1:29-34. 32. universitas esa unggul. uji mann whitney. 2017. 33. wardani ask, pranata s, swasti yr. kualitas cake dengan variasi tape ketan hitam (oryza sativa var. glutinosa) menggunakan pewarna bunga telang (clitoria ternatea l.). j transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 154] [healthcare in low-resource settings 2024;12:11853] non -co mmerc ial us e o nly pangan dan gizi 2020;10:1-11. 34. puspawati m. gambaran sifat organoleptik dan nilai gizi mochi ice cream tape ketan hitam sebagai alternatif makanan selingan pada remaja obesitas. politeknik kesehatan kemenkes bandung; 2020. 35. kanino d. the effect of yeast concentration on making tape ketan. j penelit dan pengemb agrokompleks 2019;2:64-71. 36. dewandari d, basito, anam c. kajian penggunaan tepung ubi jalar ungu (ipomoea batatas l.) terhadap karakteristik sensoris dan fisikokimia pada pembuatan kerupuk. j teknosains pangan 2014;3:35-52. 37. fauziah k. sifat organoleptik crackers formula bmc berbahan dasar tape ketan hitam, tepung kacang hijau dan tepung kacang tanah sebagai makanan tambahan pada anak prasekolah dengan status gizi kurang. politeknik kesehatan kemenkes bandung; 2020. 38. n f. produk black tapai berry ice sherbet sumber antosianin dan serat berbasis tape ketan hitam dan stroberi sebagai alternatif pencegah kegemukan. politeknik kesehatan kemenkes bandung; 2018. 39. febrianto dw. penggunaan ubi jalar ungu sebagai pengganti gula dalam pembuatan rich. sekolah tinggi pariwisata nhi bandung; 2018. 40. suladra m. pengaruh penambahan ubi jalar terhadap sifat organoleptik dan aktivitas antioksidan pada kue yangko. agrotech 2020;3:1-8. 41. attari gd, marlina y, restusari l, roziana. pengaruh substitusi ubi kayu (manihot esculenta crantz) terhadap tingkat kesukaan mochi ubi kayu. j pengabdi masy poltekkes kemenkes riau 2019;1. 42. hardoko, hendarto l, siregar tm. purple sweet potato (ipomoea batatas l. poir) as a partial subtitute of wheat flour and source of antioxidant on plain bread. j teknol dan ind pangan 2010;21:25-32. 43. pojer e, mattivi f, dan johnson, stockley cs. the case for anthocyanin consumption to promote human health: a review. j food sci compr rev food sci food saf 2013;12:483-508. 44. chan ewc, wong sk, chan ht. an overview of the phenolic constituents and pharmacological properties of extracts and compounds from lagerstroemia speciosa leaves. trop j nat prod res 2022;6:470-9. 45. lin b, gong c, song h, cui y. effects of anthocyanins on the prevention and treatment of cancer. br j pharmacol 2017;174:1226-43. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11853] [page 155] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11811 development of a food detector using image processing through camera sensor innovation adriyani adam,1 hijrah asikin,1 agustian ipa,1 sahrir sahrir,2 ali imran3 1department of nutrition, politeknik kesehatan kementerian kesehatan, makassar; 2electrical engineering, politeknik negeri ujung pandang, makassar; 3institut ilmu kesehatan pelamonia, makassar, indonesia abstract indonesia is currently struggling with stunting, wasting, obesity, and micronutrient deficiencies. nutritional imbalance, which varies by gender, age, and activity level, contributes to these issues. this research developed a food detector with an innovative camera sensor to accurately measure food calories. the study adopted a developmental approach, using a pre-experimental design and “post-test only” research. the study included various food ingredients with calorie counts. camera sensors were used instead of load cell sensors to weigh food and convert it to calories. camera sensory testing was done on processed food samples. a number of food image data tests showed high accuracy. with test results close to real data, the device showed promising accuracy. this model system used camera resolution to detect calories, helping people measure and manage their diets in quality and quantity. we hope this technology will continue to improve, making it more accessible and aiding nutritional management. introduction food is a fundamental necessity for survival in daily life. it provides the energy required by the body for activities and metabolism, enabling the maintenance of health and proper bodily function.1 the calorie content of food varies across different types, as does the quantity consumed by individuals.2,3 however, in modern times, excessive food consumption has become prevalent, contributing to the steady rise in global obesity rates.4 in 2022, approximately 2.5 billion adults aged 18 and over, were overweight, with around 890 million adults classified as obese. this equates to 43% of adults worldwide being overweight and 16% being obese. alarmingly, over 1 billion people globally, including 159 million children and adolescents aged 5-19 years, are currently living with obesity. the prevalence of obesity among children and adolescents has surged from 2% in 1990 to 8% in 2022. several factors drive this excessive food consumption, including negative emotions, exposure to enticing foods, difficulty in controlling food intake, lack of satiety, cravings, and even food addiction.5 to combat this trend, exercising self-control in food consumption is crucial. the trend of these cases might also lead to a double burden of non-communicable diseases.6 one effective strategy is to measure the calorie content of the food being consumed, enabling individuals to make informed dietary choices and maintain a healthy balance in their nutrition. a calorie measuring device is a measuring instrument used to calculate the amount of calories in each food, with the aim of enabling people to choose healthy food for their bodies. measuring calories and nutrition in daily food is a challenging method.7,8 a system that can measure calories and nutrition in daily food can help patients and nutritionists measure and manage the amount of food intake. there are various ways to measure food calories to determine the calorie content of the food, including manual methods and using digital tools. manual calorie calculations in food can be done by using measuring scales and measuring cups to measure the portion size of calories in food and by using comparisons9. however, manual calculations are still not correspondence: adriyani adam, department of nutrition, politeknik kesehatan kementerian kesehatan, makassar, indonesia. e-mail: adriyani@poltekkes-mks.ac.id key words: food detector; macronutrients; micronutrients. acknowledgments: we would like to thank the health polytechnic of makassar for their valuable insights and contributions to this study and the contribution of the mentoring program conducted by the research centre of excellence in advancing community health, surabaya, indonesia. contributions: aa, ha, ss, conceptualization; aa, ss, data curation, formal analysis, visualization, writing – original draft; ha, investigation; aa, ha, ss, methodology, validation; aip, resources, supervision; aip, aim, writing. all the authors participated in the review and editing of the paper and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by the health polytechnic of makassar and did not receive external funding. ethical approval and consent to participate: the research has received ethical approval from the health polytechnic of makassar ethics commission. the ethics commission of the health polytechnic makassar, with regard to the protection of human rights and welfare in medical research, has carefully reviewed the research protocol entitled number: 175/kepk-ptkms/iv/2022. availability of data and material: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained for anonymized patient information to be published in this article. received: 14 september 2023. accepted: 11 june 2024. early access: 24 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11811 doi:10.4081/hls.2024.11811 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11811] [page 491] non -co mmerc ial us e o nly efficient and effective. therefore, the development of digital measuring devices is expected to overcome these problems. digital calorie measurement devices that currently exist in the community are still mainly utilized by certain groups such as nutritionists in hospitals and health laboratories. this is due to the need for specialized knowledge to operate the device, which limits its usage among the general public. furthermore, these devices are still expensive and not affordable for average people. in addition, the size of the device is still too large as it still uses load cell sensor principles. the amount of calories in food is needed to calculate energy balance. excess calories will be stored as fat. excessive fat accumulation can increase the risk of hypertension, obesity, heart disease, stroke, and diabetes. therefore, calorie intake needs to be controlled to maintain body balance and prevent metabolic diseases, which are medical conditions related to energy production in human cells, one of the well-known metabolic diseases with many sufferers is diabetes mellitus.10 the development of the food detector uses an arduino uno, arduino shield circuit, button circuit, load cell sensor, lcd, bluetooth hc-05, pixy cmucam5 camera, android smartphone, and power supply circuit. android sends data to arduino to instruct the pixy cmucam5 camera to detect food and then output the amount of calories and nutrients. arduino processes the load cell work to detect food, and the amount of calories and nutrients contained in each food can be determined. the measurement results data will be sent to the android smartphone for analysis, and the analysis results will guide each user to pay attention to their eating patterns. the purpose of the study was the development of a system that can identify and classify food items using image processing techniques and advanced camera sensors. materials and methods research design this research employed an experimental study design with a quantitative approach. a camera-based food detection system will be developed and tested to measure its accuracy under various realworld conditions. this study used a developmental approach that employed a pre-experimental with a “post-only design” research type. in this study, camera sensors were used as a substitute for load cell sensors, and image processing was applied to determine the weight of the food, which was then converted into calorie values. sample food images of various types, shapes, and presentations were used as samples in this research. sample images were obtained from public datasets and a collection of food images was created specifically for this research. this study went through several stages. the first stage was the initial stage in the development of a food detector, which was to detect the number of calories through a sensor system. samples of processed food were used and then applied to the camera sensory system. data analysis the stages in this food nutrition detection system are as follows: i) image input using a camera. at this stage, the camera captures an image of the food. the results of the image capture are then processed to obtain the required parameters; ii) image segmentation. this process separates the food object from the background and it’s useful for setting boundaries so that area and height calculations are more accurate; iii) calculation of image area and height. calculating the area and height is useful for obtaining the volume value of the food. the area and height calculation is done using the region props class; iv) calculation of food calories. the calorie calculation utilizes the volume calculation results from the previous stage. method of calculating food calories to calculate the calories contained in food, the calorie calculation formula is used: calories = (energy/100) ´ food mass the energy contained in the food has been statically inputted into the program. there are three different types of food, namely white rice, fried rice, and red rice. each type of food has a different calorie value per 100 grams. the food mass is obtained from the calculation of the height and width of the food image obtained. height multiplied by width will obtain the volume. the volume is then multiplied by the mass density to obtain the mass of the food image. results based on table 1, a comparison of the measurement results from the camera sensor with the indonesian food composition table (tkpi) can be seen. the results of the evaluation of these transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 492] [healthcare in low-resource settings 2024;12:11811] table 1. sample testing results using a camera sensor. testing type of food types of units results tkpi weight 10 gr 50 gr 100 gr 10 gr 50 gr 100 gr sample a mass 9.82 51.24 100.91 calories 17.69 92.23 181.65 18.00 90.00 180.00 volume 13.05 94.04 313.94 sample b mass 9.83 49.80 100.57 calories 14.66 74.20 149.86 14.90 74.50 149.00 volume 13.06 87.66 312.43 sample c mass 10.09 51.47 101.23 calories 25.23 128.68 253.08 25.00 125.00 250.00 volume 13.40 95.06 315.32 tkpi, indonesian food composition table. non -co mmerc ial us e o nly food samples meet the protein adequacy standards set by the tkpi. testing was carried out using a camera sensor to measure several important parameters of the food samples, including mass, calories, and volume. these measurement results are given in a table for each food sample (samples a, b, and c) at three different weights: 10 gr, 50 gr, and 100 gr. the results of measuring mass, calories, and volume approach or exceed the tkpi values, so it can be considered that the food has a protein content that meets the expected nutritional standards. discussion currently, the measurement of calorie intake in food relies on conventional methods, which calculate the calories needed for daily activities and those consumed. however, this study introduces a novel approach utilizing image processing methods for calorie measurement.11 this method involves recognizing the object to be measured, determining its volume, and analyzing its contour shape. the objective of image processing in this study is to enhance the quality of images. during testing, a webcam with a resolution of 480p was employed to mitigate issues such as low color contrast, blurriness, and white spots or noise in the images. initially, adjustments were made to the camera’s height to optimize the distance between the object and the capturing camera, as this significantly impacts the accuracy of calorie detection. once adjusted, the camera was placed 40 cm away from the object. the calorie detection model was implemented using matlab software. matlab is a high-performance software that integrates computation, visualization, and programming for mathematical notations. this software detects calories in food and operates on a laptop/computer connected to a webcam.12 accuracy testing in a developed system can be defined as the degree of closeness between the measured values and the true or real values. if there is no actual data or considered correct value in the accuracy testing of a system, it will not be possible to determine how accurate the measurement of the system is. accuracy is defined as the difference value or the closeness value between what is read by the measuring device and the true value. the accuracy testing of this food detector was carried out twice using three types of rice, which were then compared with the real nutritional data values in the tkpi for the year 2017 to obtain more accurate results. after preprocessing the input image, image segmentation was carried out to separate the object from the background. rgb color segmentation was used, which would be divided into two clusters (one can choose which cluster would provide the best separation of an object from the background), then the area and height of the image were calculated to obtain the volume, which is area ´ height. using the object’s volume, the mass of the object can be determined using the mathematical equation mass = density/specific gravity ´ volume. since the object’s weight taken using a camera is still affected by gravity, the weight of the object needs to be calculated using the equation weight = mass ´ gravity. after obtaining the weight of the object, automatic nutritional value calculation is performed by the matlab editor, and this predicted nutritional value is compared with the national reference value. for example, for 10 grams of white rice, 18.69 calories were obtained based on the calorie detection results, while the real value for 10 grams of white rice was 18.00 calories. this shows that the calorie detection results are not significantly different from the real values. furthermore, the research conducted bears similarities with this study in that it aims to obtain the calculation of calories after obtaining the weight of food, which is done by designing a nutrition counting tool in the form of a scale that can measure the weight of food.9 measuring the weight of food results in the nutritional content value of a food item. this tool is equipped with two load cells connected to the hx711 module to measure the weight of the food. arduino processes the signals generated by the hx711 module, producing a weight value. the weight value is displayed on the lcd and sent to an android application using bluetooth connectivity. the calculation of food nutrition is done in the android application based on the obtained weight value. this tool design yields an average accuracy rate of 98.441% for load cell-1 and 96.974% for load cell-2. the tool has a tolerance value of 1.61% for load cell-1 and 2.69% for load cell-2. the precision level of load cell-1 is 97.93% and the precision level of load cell2 is 97.83%. the research conducted differs in terms of classification because it uses convolutional neural network (cnn) modeling, and the device uses a designed application data set.13 therefore, when taking a picture, the device will display the nutritional content based on the data set that has been designed in the training model and display the name/type of the food. in contrast, the calorie detection in this study uses a systematic formulation to obtain the calorie content of a food. the advantage of this study is that there is no need to take a data set, which can be time-consuming as it requires collecting 1000 food data sets of the same type and labeling the images more accurately. additionally, the calculation of calories is heavily influenced by the weight of the food, so it should be configured first with a scale. the research conducted used the k-nearest neighbor (knn) method and a load cell sensor to read the measured weight of the food.14 the system captures the image and reads the measured weight of the food through a camera module and load cell sensor. the image is then processed to extract the color value from the mean hsv (hue, saturation, value). the extracted results are then used as features to identify the type of food and measure its calorie content based on the identification results and load cell sensor measurements. the results of the system are displayed on a 16×2 lcd screen. the identification process uses the knn method based on 75 training data with 5 classes consisting of white rice, red rice, beef rendang, sautéed water spinach, and fried tempeh. using a k value of 3 in the knn method results in the highest accuracy of 96%. in contrast, our study does not use the knn method based on training data in the system, as the food detector is intended to detect the calorie content of the food rather than classify it. food calorie detection system has many benefits and potential applications, but there are several limitations to consider in this research. while this system can provide accurate estimates of the number of calories in food, there is still the possibility of errors or uncertainty in the measurements. the accuracy of this system depends heavily on the quality of the images captured and the algorithms used to analyze them. therefore, further validation of the accuracy and consistency of the results is necessary. conclusions the food calorie detection system holds significant promise for various future applications across different sectors. individuals seeking to monitor their calorie intake for weight management or health reasons could benefit greatly from this system. by simply capturing images of their meals using a smartphone or dedicated device, users can obtain accurate calorie information in real time. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11811] [page 493] non -co mmerc ial us e o nly this can empower individuals to make more informed dietary choices and adhere to their nutritional goals more effectively. in healthcare settings, the calorie detection system could be integrated into dietary assessment tools used by nutritionists, dietitians, and healthcare professionals. this would streamline the process of analyzing patients’ dietary intake, facilitating more personalized nutrition recommendations and treatment plans. references 1. world health organization. healthy diet. 2024. available from: https://www.who.int/initiatives/behealthy/healthy-diet 2. diana r, martianto d, baliwati yf, et al. food waste in indonesian hospitals: a systematic review. nutr food sci 2022;53. 3. mahmudiono t, rachmah q, indriani d, et al. food and beverage consumption habits through the perception of health belief model (grab food or go food) in surabaya and pasuruan. nutrients 2022;14. 4. puspikawati si, kertia n, purba m, et al. if i like it, i’m eating it: study of high-calorie high-fat food preference among obese police officer. ann trop med public heal 2020;23:1271-8. 5. laughlin m, cooke b, boutelle k, et al. neuroimaging and modulation in obesity and diabetes research: 10th anniversary meeting. int j obes 2022;46:718-25. 6. arifin h, chou kr, ibrahim k, et al. analysis of modifiable, non-modifiable, and physiological risk factors of non-communicable diseases in indonesia: evidence from the 2018 indonesian basic health research. j multidiscip healthc 2022;2203-21. 7. charbonnier l, van meer f, johnstone am, et al; and pams. neuroimage effects of hunger state on the brain responses to food cues across the life span. neuroimage 171 2018;246-55. 8. mulia sa. work fatigue based on workload and calories intake in several food makers. indones j occup saf heal 2019;8:158. 9. agsa f, putra hfts, nugraha r. perancangan alat hitung nutrisi makanan berbasis arduino uno. in: eproceedings of engineering 2021. 10. riyono a, tinduh d, othman z, herawati l. moderate intensity continuous and interval training affect visceral fat and insulin resistance model in female rat exposed high calorie diet. comp exerc physiol 2022;18:403-11. 11. prihaningtyas ra, widjaja na, irawan r, et al. dietary intakes and high sensitivity crp (hscrp) in adolescents with obesity. carpathian j food sci technol 2019;11:83-8. 12. yudha ww, rulaningtyas r, rahmatillah a, septanto h. the study of satellite dynamics with reaction wheel actuator and comparison of its numerical solutions using matlab/simulink. in: aip conference proceedings. aip publishing; 2024. 13. dandi m, hilman fauzi tsp, rizal s. implementasi algoritma yolo pada aplikasi pendeteksi citra makanan berbasis android. in: eproceedings of engineering; 2021. 14. achlison u, suhartono b. analisis hasil ukur sensor load cell untuk penimbang berat beras, paket dan buah berbasis arduino 2020;13:96-101. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 494] [healthcare in low-resource settings 2024;12:11811] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12852 self-consciousness of type 2 diabetes mellitus patients dikha ayu kurnia,1 pradana soewondo,2 dewi irawaty,1 jahja umar,3 debie dahlia1 1faculty of nursing, universitas indonesia, jakarta; 2faculty of medicine, universitas indonesia, jakarta; 3faculty of psychology, islamic state university jakarta, indonesia abstract the characteristics of self-consciousness of people with diabetes mellitus are determined by knowledge about diabetes mellitus, the signs and symptoms of acute and chronic complications, and the side effects of diabetes treatment. knowledge plays an important role in the consciousness of behavioural change and diabetes self-management skills. people with diabetes recognize diabetes when they have experienced chronic complications, both macrovascular and microvascular. the study aims to explore how diabetics manage their chronic problems and their daily lives through a qualitative description of the experiences of 20 diabetes patients. this study used a descriptive-qualitative method, conducted a semi-structured interview, then transcribed and uploaded it into manual coding for analysis. respondents were recruited from one of the community health centres in jakarta, indonesia. the themes were i) “realizing diabetes is a health problems that cannot be resolved alone”, paying attention to body signs becomes the beginning of self-consciousness; ii) “coping with diabetes requires self-consciousness”, having adequate knowledge and growing personally with healthcare providers about early diabetes can prevent chronic complications. this study provides implications that self-consciousness greatly affects the self-management of diabetic patients in the long term. introduction chronic and progressive hyperglycaemia could cause various organ damage in the body systems. according to the diabetes complications severity index,1 poor management of diabetes mellitus (dm) causes chronic macrovascular and microvascular complications in cardiovascular disease, cerebrovascular disease, retinopathy, nephropathy, neuropathy, and peripheral arterial disease. diabetes patients’ causes of morbidity and mortality are chronic cardiovascular problems and diabetes that are concurrent. a person with diabetes has insulin resistance and the body’s inability to use insulin efficiently, resulting in elevated blood glucose levels above the standard value that are not curable but can be managed.2 therefore, self-management is required to control blood glucose levels, which patients become active sources of information influenced by self-perception, health behaviour, selfcare, and self-management to obtain quality health functions that are influenced by environmental and personal factors.3 health behaviour at the individual level is described as patients’ ability and coordinated care assessed by doctors and nurses.4 it is evaluated when patients control their health through health-care services. glycaemic management centered on patients’ needs requires therapeutic communication. excellent nurses’ communication with people with type 2 diabetes mellitus (t2dm) and their families has an impact on blood glucose control management. furthermore, caregivers and patients can identify and address a non-compliance, a passive role in diabetes self-management.5 this means complications can be prevented and the quality of life optimized.5 szczech discovered a correlation between patients’ complaints regarding their illnesses.6 it is essential to gaining an integrative understanding of the elements of an illness, namely signs and symptoms, abnormal test results, and personal pain experiences that provide feelings, ideas, health functions, and expectacorrespondence: dikha ayu kurnia, faculty of nursing, universitas indonesia, jakarta, indonesia. e-mail: d.ayu@ui.ac.id key words: type 2 diabetes mellitus, self-consciousness, health behaviour. conflict of interest: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. contribution: dak, conceptualization, data collection, data analysis, writing – original draft, review, and editing; ps, di, ju, dd work concept, supervision, validation, and writing review. funding: this article was written as part of research funded by international indexed publication grants, part of the directorate of research and development universitas indonesia. this article is a sign of our gratitude for this support. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas indonesia, based on ethical certificate nomor:ket-177/un2.f12.d1. 2.1/ppm.00.02/202. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: informed consent was obtained for anonymized patient information to be published in this article. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgments: we thank all those who participated in this research and those who facilitated our field investigations. received: accepted: early access: 25 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12852 doi:10.4081/hls.2024.12852 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 656] [healthcare in low-resource settings 2024;12:12852] non -co mmerc ial us e o nly tions. this study implies that self-consciousness of t2dm patients with chronic complications has differences between patients that affect the ability to self-manage diabetes in the long term. materials and methods the design of the research is qualitative with descriptive qualitative method because this design provide clear descriptions of experiences and perceptions and the most appropriate as it recognizes the subjective nature of the problem, the different experiences participants will present the findings in a way that directly reflects the terminology used in the initial research question.7 participants were recruited from the community health centres in jakarta, indonesia because community health centre in jakarta have collaborated with the academic health system to improve health status. all those registered with the service aged 42 to 77 years were eligible to participate with purposive sampling. the nurse provided verbal and written information about the study to prospective participants as part of routine care. a member of the research team was interviewed for recruitment purposes. we obtained written informed consent from the participants prior to data collection. a single semi-structured interview was performed as part of the data collection at the community health centres in central jakarta, indonesia. the interview schedule comprised several key questions and probes that lasted from 60 to 120 minutes to enable in-depth discussions. we stopped recruiting participants when we reached saturation of themes (i.e., the interviews no longer offered new information in relation to the research topic). at the end of the interview, participants were asked to select their own pseudonym for reporting purposes. all participants received a gratuity of rp250.000 for contributing to the study. this research was conducted between april and may 2022 in jakarta. the results of the interview are written and transcribed. a thematic analysis method was used to examine the data. all members of the research team contributed to the analytic processes and gave their point of view as experts. this study was approved by the faculty of nursing ethics committee, university of indonesia, and a permit was obtained from the jakarta health office and central jakarta health sub-dept. results we recruited 20 participants. table 1 provides an overview of the participants. the two major themes identified from the data were “realizing diabetes is a health problems that cannot be resolved alone” and “coping with diabetes requires self-consciousness”. “realizing diabetes is a health problem that cannot be resolved alone” contained the two sub-themes of “recognizing unstable body conditions” and “paying attention to physical and emotional signs which are increasingly disturbing”. “coping with diabetes requires selfconsciousness” contained the two sub-themes of “improving knowledge about diabetes and chronic complications” and “expanding self-care capabilities with the assistance of professional health workers”. theme 1. realizing diabetes is a health problem that cannot be resolved alone realizing diabetes is a health problem that cannot be resolved alone. experience of health problems caused by diabetes with high and uncontrolled blood glucose which translates into the lives of people with diabetes that they have identified. “recognizing unstable body conditions” examines their overall understanding of how they realized that diabetes was a disease due to unstable body con article table 1. details of study participants. pseudonym sex age (years) length of time of diabetes (years) random blood glucose (mg/dl) mr. t male 75 2 215 mrs. a female 68 7 315 mrs. s female 77 20 258 mrs. f female 66 3 111 mr. m male 53 4 342 mrs. sr female 55 3 112 mrs. n female 60 5 121 mrs. nw female 52 11 185 mrs. mt female 70 10 170 mrs. rs female 76 2 193 mrs. so female 62 4 157 mr. mh male 63 5 104 mrs. ay female 56 2 271 mr. pd male 62 4 148 mrs. sm female 64 20 194 mrs. yn female 42 14 166 mts. rt female 56 2 211 mrs. ne female 61 15 275 mr. su male 62 1 300 mr. w female 69 10 218 [healthcare in low-resource settings 2024;12:12852] [page 657] non -co mmerc ial us e o nly ditions. “paying attention to physical and emotional signs which are increasingly disturbing” explores what physical and emotional symptoms that are increasingly disturbing day by day become the beginning of self-consciousness that these symptoms are caused by high blood glucose due to diabetes. recognizing unstable body conditions all diabetic patients realize that diabetes is a disease when they are hospitalized or brought to the emergency room, such as when a non-healing wound is planned for amputation or shortness of breath is getting worse. mr. t described, “at first, my foot tingles, then gradually went numb, and a wound appeared on the toe. i treated it myself, but the wound grew bigger, festered, and was later amputated. it was then that i learned the cause of my foot amputation was diabetes.” mrs. mt summarized the situation when she said, “i have been diabetic for more than 10 years. starting 5 years ago, i went to the health center because my eyes were getting blurry, i couldn’t see, and my legs hurt when i walked. when i wanted cataract surgery, the doctor said i could not be operated on because my blood glucose was still high due to diabetes.” unstable conditions related to physical changes show the most realized by people with diabetes with chronic complications. while diabetes is a progressive disease, self-consciousness is needed early to prevent worse complications from occurring. this plays a key role in recognizing diabetes as a disease and high blood glucose can lead to chronic complications in various organs such as the heart, eyes, and leg amputation. mrs. sr explained that “i developed diabetes 3 years ago, starting with symptoms of frequent urination, cold and numb feet. i have sought treatment when i feel unwell. i take glimepiride, but not regularly. now i know that diabetes can affect the eyes and heart because now my eyes are foggy and my breathing is getting more difficult, i’m already running out of breath, then i was also rushed to the emergency room because i was infected with covid during the pandemic.” mrs. nw explained that “i was diagnosed with diabetes 10 years ago, but i still feel normal. then, in the last few years, i was often dizzy, then had stroke symptoms such as a partially weak body and i was hospitalized because my blood glucose was high.” some of the participants reported that they found itchy skin, then scratched, and wounds occurred. the wound made his body feverish, and he was taken to the hospital for sepsis. mr. m explained that “yes, my skin often itches, then i scratch it until it doesn’t itch, and then there are wounds. the wound got bigger and then i had a fever and was taken to the hospital for sepsis.” mrs. ay expresses similar feelings when she said, “yes, i only found out about diabetes 2 years ago when i wanted to get vaccinated against covid, my blood glucose was 271 mg/dl. i often drink more than 8 glasses of sweet tea a day. last year, i was hospitalized because i was short of breath and swollen, my skin was dry and itchy, and there was already protein in my urine.” this was a particular problem when they were unwell, as mrs. rt explained: “i was diagnosed with diabetes 2 years ago when i was screening for the covid vaccine. i have no complaints about anything, just frequent stomach heartburn. yesterday i was hospitalized because my legs were swollen, fever, itching of the whole body, and there was already protein in my urine with my a1c level of 10.2%.” several participants made specific references to reveal that diabetes and high blood glucose can interfere with preparation for surgery as the body becomes unstable. mrs. su said, “oh. i don’t know, my sugar at that time was 285. i was finally delayed; it didn’t become an operation because there was a bump. then the internal medicine doctor said that i took the medicine first, then i was given metformin, 500 mg.” in some cases, this translated into concerns keeping themselves aware that an unstable body condition cannot be resolved alone. mrs. s asked, “that time, how could i not be traumatized, when my eyes had to be operated on because i couldn’t see anymore, i couldn’t handle this myself, but i couldn’t get surgery because my blood glucose was high because of diabetes.” and mrs. ne expressed similar concerns when she explained, “at first, i felt frequent thirst and itching of the feet. it was getting longer, and my legs were sore to walk and at that time i vomited blood and was hospitalized with blood glucose above 200 mg/dl.” paying attention to physical and emotional signs which are increasingly disturbing people with diabetes realized in advance that to know the development of the self-response from diabetes is obtained by conveying changes in physical and emotional conditions. wong could “at that time, i felt fatigue all day long, numbness in the legs, changes in walking due to swollen legs, wounds that did not heal”. mrs. s explained that “at that time, what i felt most was swelling in my legs and coughing at night”. emotional conditions such as often feeling sad, angry, and stressed are signs that blood glucose seems to be high. mrs. mt explained that “yes, i am sad, anything around me makes me stressed, want not to think about it, but my health feels declining... well, most of the ones that feel really like these are legs, tired when walking, and often tingling. yes, this leg often aches because there is rheumatism also, so it feels more tired.” mrs. su highlighted the emotional feelings such as losing selfcontrol in controlling hunger but anger and feeling like being alone, explaining that article [page 658] [healthcare in low-resource settings 2024;12:12852] non -co mmerc ial us e o nly “i started thinking that diabetes has a long effect because the more days my emotions are like going up and down, especially because i have to lower my blood glucose in order for me to have surgery.” mrs. ay made a similar point, linking it to the extra attention: “i feel cold sweats constantly, so i feel difficult to sleep, and i also feel bored and tired from taking medications”. physical and emotional symptoms that have disturbed and made the patient depressed give attention, which is then addressed by taking himself to the health service. in primary health services, there are elderly examinations, non-communicable disease examinations, and examinations for brides-to-be. people with diabetes come to the health service for a variety of reasons. in general, they go to the health center to take diabetes medicine, but there are also those who submit old complaints that are not cured and are increasingly disturbing. mr. m reported that he was diagnosed with diabetes 4 years ago. however, he returned to the health center because he had erectile dysfunction, and he checked into the examination room of the bride and groom because he wanted to remarry. at that time, he knew that his blood glucose was still above 300 mg/dl. he explained, “the thing that bothers me with diabetes complications is premature ejaculation, which is getting worse, even though i still want to get married again... yes, there was a change in my physical condition. i am easily flabby, tired, and sleepy quickly”. theme 2. coping with diabetes requires self-consciousness this theme explores two aspects of how people with diabetes cope with diabetes by raising their awareness to carry out diabetes self-management. firstly, diabetes patients’ overall consciousness and improving their knowledge about diabetes and chronic complications, and secondly, how they were assuming expanding self-care capabilities needed the assistance of professional health workers. improving knowledge about diabetes and chronic complications to maintain health from diabetes, people with diabetes need knowledge about diabetes and self-care skills to be more confident. mr. p, mrs. su, mrs. yn, mr. st, and mr. w identified diabetes as very complex because insulin disorders and body organs become limited in carrying out their functions. mr. m said, “i don’t know the symptoms of hands and feet often tingling, legs feel weak, pain in the muscles and legs feel weak, premature ejaculation occurs due to high blood glucose for a long time. i didn’t know diabetes could cause this all” while mr. su explained, “yes, i still smoke, but i don’t know yet that smoking can be a risk factor for kidney complications. all i know about diabetes is high blood glucose and taking medication for life. as long as i take the medicine to drop blood glucose, then i can eat anything and also smoke.” the majority said, “i already knew i should avoid sugary foods and drinks, but the detailed information i still need so that i don’t eat wrong and also don’t feel weak” (mrs. n). some, including mr. t, highlighted the dilemma this presented for them in terms of balanced information: “yes, the doctor said, people with diabetes can eat anything, but you must pay attention to the amount. i still don’t understand which portion of the meal is appropriate for me. if i am a native betawi, if you don’t eat rice and salted fish fritters, it doesn’t taste good to eat”. most of the early self-consciousness of people with diabetes is to maintain blood glucose should be less than 200 mg/dl, but things related to the increase of blood glucose from unhealthy living behaviors are not yet known and applied in daily life. some recalled their families explaining it to them, including mrs. f whose daughter had “we did go to the health center to check the health progress, but as long as blood glucose and blood pressure were controlled, there was no further explanation as to whether there should be new program changes from previous lifestyles, such as eating portions and types of exercise. in the past, the doctor’s consultation explained the medicine more, and the nurse explained the schedule for the next consultation plan.” while some participants’ understanding of their conditions was limited to basic dietary and exercise requirements, most older participants who were out of work wanted information appropriate to limited economic conditions. mrs. rs explained, “so far, i am old and no longer working, plus i have sugar disease. i did what i could do by myself because i was worried that it would trouble my children and grandchildren. i couldn’t buy the food i needed because there was no money. i just walked and cleaned up the house as my sport.” mrs. mt’s explanation offered diabetes and chronic complication information: “in the past, what i knew was that diabetes could not be cured and blood glucose had to be controlled with diet and physical activity. i have eaten well, eaten 3 times and eaten 2 snacks, and exercised too, but my a1c is still high. does every before and after meal i must check my blood glucose? because i am no longer working, i check my blood glucose at most if there is a free checkup. i don’t have a special budget to buy self-contained sugar strips and regular laboratory examinations, so i don’t know that my sugar has damaged various organs in my body”. this level of understanding was most commonly attributed to regular explanations by healthcare professionals who can deliver diabetes material and chronic complications with therapeutic communication according to the needs and obstacles that have been experienced by people with diabetes in carrying out diabetes selfmanagement. this enabled understanding to develop over time, as mrs. su and mrs. ne explained; “i didn’t know that stroke can be caused by high and uncontrolled blood glucose. even then, i also don’t know my cholesterol levels at the moment, i don’t remember the last time i was checked, and yes, i still enjoy eating greasy fritters and i’m still overweight”. (mrs. su) “i have had diabetes for a long time. i rarely eat fruit for fear that my blood glucose level will rise, as a result of which i have difficulty defecating. if i want to defecate, i drink vegetta first, one day i can drink five sachets”. (mrs. ne) article [healthcare in low-resource settings 2024;12:12852] [page 659] non -co mmerc ial us e o nly expanding self-care capabilities needs the assistance of professional health workers all people with diabetes have a process of self-adaptation to carry out a healthier lifestyle than ever before to achieve good metabolic control. self-adaptation in diabetes mellitus involves a combination of physiological processes, lifestyle modifications, medication management, and self-monitoring to help maintain stable blood sugar levels and minimize the impact of diabetes on overall health and well-being. people with diabetes need help outside of themselves to inform them about the disorder and how to deal with it. mrs. ne explained, “i rarely check my blood glucose levels independently because i am not confident and i am afraid of injections. i checked my blood glucose at the health center, checked by doctors and nurses.” mrs. rs said, “my physical condition is out of shape, i feel exhausted, and i am unable to exercise as directed by the doctor. i was also afraid to exercise myself because i was worried about injuries and my blood glucose dropped.” it also includes finding ways to control stress and psychological changes so that they have a good quality of life. mr. mh identified the challenges of handling physical and psychic stress so that it can adapt to current health conditions: “i’ve had diabetes for 5 years, my legs at this time often tingle, even hurt if made to walk long distances. this makes me sad and stressed about not being able to meet with friends in the neighborhood. i want to get better and be able to walk back without pain in my legs. i try to regularly go to the health center and take medicine.” awareness of body functions realized by people with diabetes is related to tolerance for exercise, having the energy to exercise, and overcoming fatigue throughout the day. mrs. st explained that “in my opinion, i have exercised for 2 hours a week and walked 4 kilometers. however, that’s all if i’m fit. i really want, even though i am not healthy, i can still exercise, but if there is no one to accompany me (someone who is an expert in their field), i am afraid that if something unexpected happens, such as joints getting sicker”. discussion this research found the two themes. the themes were i) realizing diabetes is a health problems that cannot be resolved alone that has two categories a) recognizing unstable body conditions, and b) paying attention to physical and emotional signs which are increasingly disturbing. the second theme was ii) coping with diabetes requires self-consciousness that has two categories a) improving knowledge about diabetes and chronic complications, and b) expanding self-care capabilities needs the assistance of professional health workers. research conducted by joensen states that the psychological burden experienced by diabetic patients is related to several factors, including female gender, young age, having chronic diseases other than diabetes, low diabetes-related social support, low diabetes empowerment, and high a1c levels.8 low diabetes empowerment, quality of life, and social support are the main causes of the emotional burden that diabetic patients endure. the theme of the research indicates that physical changes due to dm complications might lower patients’ quality of life, so family and environmental support are necessary to maintain physical and psychological conditions. it is also supported by expanded understanding from doctors and nurses. the study’s findings offer an in-depth and comprehensive overview of the experience of dm patients with complications in maintaining their quality of life due to self-consciousness. the overall themes and categories identified represent the client’s experience, feelings, and perspective. the study’s findings highlight the difficulties faced by diabetes mellitus patients. this study also implies that nurses know the patient as a whole person. through qualitative research, nurses need to explore the experiences of patients in depth in order to obtain comprehensive information and education on both physical and emotional aspects. the goal is to monitor and evaluate the development of complications. the findings showed that while treatment adherence was excellent, education adherence was low in t2dm patients. the initial things that diabetes mellitus patients need to know are the course of diabetes mellitus and its complications, control of diabetes mellitus, monitoring pharmacological and non-pharmacological therapies, interactions between food intake and physical activity, how to monitor blood glucose levels, and the importance of exercise using existing health facilities. people with t2dm who lack knowledge about the disease may find it harder to manage their condition since self-management is effective in improving diabetes mellitus control.9 chronic complications can lead to two or more diseases, with one disease not always more central than the other. it can affect quality of life, ability to work, disability, and death. there is a lack of data on chronic complications in indonesia. since people with t2dm essentially still have the full right to live a healthy life and remain productive, this data is crucial to understanding the quality of life of indonesia’s elderly population. given that t2dm is a chronic and incurable condition, consideration of the patient’s quality of life is crucial and should be taken during treatment. physical problems resulting from acute or chronic issues can be avoided if blood glucose levels are appropriately managed. additionally, psychological issues and a poor quality of life can exacerbate metabolic illnesses directly through hormonal stress reactions or indirectly through further complications.10 self-consciousness is the concept that an individual needs attention by being the object of thought in order to reflect themselves. whereas, from a social approach, self-consciousness is the act of adopting another’s perspective on oneself, which can be influenced by aspects of one’s own or other’s self-consciousness, adaptive or maladaptive self-consciousness, and current or pastfocused experiences.10 this study provides implications that selfconsciousness greatly affects the self-management of diabetic patients in the long term. the limitation of this study is that selfawareness of diabetic patients was obtained in primary health care patients and has not been explored in diabetic patients at home. self-consciousness of health status has a general understanding of diabetic patients with chronic complications based on the experiences that have occurred. when the participants started requiring emergency care and hospitalization, they recognized they had symptoms of chronic complications. article [page 660] [healthcare in low-resource settings 2024;12:12852] non -co mmerc ial us e o nly references 1. glasheen wp, renda a, dong y. diabetes complications severity index (dcsi)—update and icd-10 translation. j diabetes complications 2017;31:1007-13. 2. kugbey n, asante ko, adulai k. illness perception, diabetes knowledge and self-care practices among type-2 diabetes patients: a cross-sectional study. bmc res notes 2017;10:381. 3. wildeboer at, stallinga ha, roodbol pf. validation of the international classification of functioning, disability and health (icf) core set for diabetes mellitus from nurses’ perspective using the delphi method. disabil rehabil 2022;44:210-8. 4. saeedi p, petersohn i, salpea p, et al. global and regional diabetes prevalence estimates for 2019 and projections for 2030 and 2045: results from the international diabetes federation diabetes atlas, 9th edition. diabetes res clin pract 2019;157:107843. 5. american diabetes association. improving care and promoting health in populations: standards of medical care in diabetes−2021. diabetes care 2021;44:s7-s14 6. szczech la, stewart rc, su hl, et al. primary care detection of chronic kidney disease in adults with type-2 diabetes: the add-ckd study (awareness, detection and drug therapy in type 2 diabetes and chronic kidney disease). plos one 2014;9:e110535. 7. bradshaw c, atkinson s, doody o. employing a qualitative description approach in health care research. glob qual nurs res 2017;4:2333393617742282. 8. joensen le, almdal tp, willaing i. associations between patient characteristics, social relations, diabetes management, quality of life, glycaemic control and emotional burden in type 1 diabetes. prim care diabetes 2016;10:41-50. 9. jansiraninatarajan. diabetic compliance: a qualitative study from the patient’s perspective in developing countries. iosr j nurs heal sci 2013;1:29-38. 10. dasilveira a, desouza ml, gomes wb. self-consciousness concept and assessment in self-report measures. front psychol 2015;6:930. article [healthcare in low-resource settings 2024;12:12852] [page 661] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12445 management and prevention of emotional burnout among members of the armed and special forces liliia semenenko,1 uzef dobrovolskyi,2 stanislav petrenko,2 maria yarmolchyk,2 oleksii ishchenko3 1department of foreign languages, national defence university of ukraine, kyiv; 2department of military training, national aviation university, kyiv; 3department of missile troops and artillery, national defence university of ukraine, kyiv, ukraine abstract with the rise in cases of professional burnout, research on best practices and opportunities for implementing emotional burnout prevention and treatment among special services and military personnel became more  relevant. the aim of this study is to determine the most efficient methods of therapy and to reveal the necessity of preventing and mitigating the symptoms of emotional burnout among special services and military personnel. additionally, best practices and opportunities for their application by ukrainian, kazakh, polish, british, american, canadian, and south korean specialists are highlighted. experimentation is the main approach used in this problem’s investigation. as a result, the study describes the unique aspects of the jobs performed by special services and military personnel, highlights the primary approaches to treating and preventing emotional burnout, and identifies which approaches are most successful for each group of workers based on their unique personal traits. consequently, the study delineates the particulars and attributes of the work performed by personnel in special services and military structures, outlines the primary approaches and strategies for mitigating and averting emotional exhaustion, and indicates which of these approaches work best for these groups of workers, taking into account their unique personal traits. the introduction of emotional burnout training as a preventative intervention is supported by best practices and future possibilities. introduction experiencing frequent stressful events can lead to a person feeling fatigued, lacking energy, and having reduced enthusiasm. this can have negative effects on their physical, mental, interpersonal, vocational, and social well-being. according to s.t. seyedi asl et al.,1 the emotional burnout syndrome can be defined as a collection of symptoms that encompass psycho-emotional weariness, negative attitudes towards loved ones, coworkers, and the external environment, as well as a decline in work performance. over the past few decades, psychologists in the commonwealth of independent states (cis) and the western european scientific community in poland,2 the united states of america,3 south korea,4 and the united kingdom5 have been exploring the issue of “emotional burnout”. due to the increasing number of industrial enterprises and employers’ interest in high labour productivity indicators, society has developed a social demand for the scientific environment, and, since burnout was first described by h. freudenberger in 1974, this syndrome has been the subject of research among psychologists, managers, and ergonomists.6 emotional burnout, as explained by a. flood and r.j. keegan,7 occurs when individuals experience chronic stress, resulting in the depletion of their mental and emotional resources. the occurrence of this syndrome is attributed to a lack of chance to alleviate stress and the internal build-up of negative emotions. consequently, a new area of research emerged for scientists, focusing on the treatment and prevention of emotional burnout syndrome, specifically within the context of interpersonal professional activities.8 according to c.j. bryan et al.,9 emotional burnout is seen as a defensive response in individuals, marked by a complete or partial lack of emotions. this condition is caused by persistent stress and traumatic psychological elements. this process creates a fixed pattern of behaviour and enables a controlled correspondence: liliia semenenko, department of foreign languages, national defence university of ukraine, kyiv, ukraine. e-mail: li.semenenko1@gmail.com key words: emotional fatigue, anxiety factors, psychological support, preventive measures, adaptation, military personnel, professional deformation. contributions: ls and ud, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; sp and my, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; oi, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. patient consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. received: 1 march 2024. accepted: 28 june 2024. early view: 9 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12445 doi:10.4081/hls.2024.12445 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12445] [page 45] non -co mmerc ial us e o nly utilisation of cognitive resources. when emotional fatigue is severely overlooked, it has a harmful impact on one’s professional performance. professionals in social fields, such as teachers, educators, service workers, psychologists, doctors, police officers, and special service personnel, are particularly prone to experiencing emotional burnout.10 during their professional duties, a special services officer and/or a serviceman encounter immoral and antisocial social groupings comprising individuals of various genders and ages. given the nature of their work, employees of special services and military structures experience ongoing stress: i) irregular work schedule; ii) lack or overabundance of information; iii) the responsibility and relevance of professional actions to the public; iv) the probability of physically harming another person, or endangering yourself and colleagues or civilians; v) complicated communication process due to opposition from stakeholders. all of this has an adverse impact on the mind, heightening the likelihood of the emergence of emotional burnout syndrome, which can result in professional distortion. the intense emotional stress experienced by employees of special services and military personnel can have detrimental effects on their personality and professional abilities, making it more challenging for them to carry out their duties effectively and potentially rendering them unfit for their careers. according to the position of a.r. vojvodic et al.,11 emotional burnout syndrome in military personnel is associated with regular exposure to adverse factors that affect their psyche. emotional burnout factors may include: psychological strain from superiors and other soldiers; the structure of the job (combat duties, field exercises); the length and irregularity of the workday; and persistently stressful interpersonal interactions. in turn, d. boulos and b. garber12 wrote that military personnel spend most of their time in situations involving emotional and physical overload, and due to it they quite often experience fatigue and overwork, which in turn, over time, turn into disillusionment and loss of interest in their profession. traumatic mental factors significantly contribute to emotional burnout, especially in high-stress professions like special services and the military. exposure to life-threatening events, chronic stress, moral injury, secondary traumatic stress, and poor interpersonal and organizational support can lead to acute stress responses and post-traumatic stress disorder (ptsd).13 these events can erode an individual’s mental resilience over time. chronic stressors, such as long deployments, unpredictable schedules, and high stakes, can deplete an individual’s emotional resources, leading to burnout. moral injury occurs when individuals feel they have violated their ethical or moral beliefs, leading to internal conflict and guilt. secondary traumatic stress, also known as compassion fatigue, affects those who repeatedly witness or hear about traumatic events experienced by others, causing symptoms such as anxiety, depression, and emotional exhaustion. interpersonal and organizational factors, such as lack of social support, poor leadership, and a toxic work environment, can exacerbate the effects of trauma. feeling isolated, unsupported, or mistreated by peers or superiors can diminish an individual’s ability to cope with traumatic experiences.14 additionally, stigma around seeking mental health support within military and special services cultures can discourage individuals from seeking help. addressing these factors requires a comprehensive approach that includes psychological support, organizational change, and a culture that values mental health. emotional burnout is a complex issue that requires a multifaceted approach that considers personality traits, lifestyle, work environment, and social support systems. personality traits, such as resilience, optimism, and adaptability, can influence how individuals cope with stress. those with anxiety, perfectionism, or difficulty managing stress may need more targeted interventions, such as cognitive-behavioural therapy (cbt) or stress-reduction techniques like mindfulness or meditation.15 emotional burnout among special services and military personnel is influenced by various factors, including personal resilience, psychological history, coping mechanisms, social support systems, and the nature of their duties. individuals with a history of mental health issues or a lack of effective coping strategies may be more susceptible to burnout, while those with strong resilience and robust support networks may benefit more from preventative measures. high-risk roles, such as combat operations or intelligence work, face different stressors, necessitating a differentiated approach. support roles, like workload management and regular physical activity, may benefit from workload management.16 career and personal life circumstances also impact vulnerability and the effectiveness of preventive measures. social support systems, both within and outside the organisation, play a crucial role in managing emotional burnout. promoting wellness programs that encourage healthy lifestyles and self-care practices can be effective, while targeted interventions for unhealthy coping mechanisms like substance abuse are needed. the scientific community has shown greater interest in the topic of emotional burnout among special services and military personnel. however, there is a lack of research on the treatment and prevention of this illness. given that the origin of the syndrome being studied is unique to each individual, the treatment or prevention of it will rely on the emotional and motivational aspects of a person’s personality, as well as the specific nature of their professional work. therefore, the researchers contend that it is justified to impose stringent criteria for the psychological stability of candidates for special units and military organisations. this is because the demanding nature of service activities, which are filled with stressful conditions, necessitates emotional adaptability in the character of the personnel. the research in this study aims to enhance preventive measures in order to decrease emotional burnout. it takes into account individual psychological traits that promote psychological safety by developing self-regulation skills and methods. this is achieved through exploring the potential of one’s psyche and maintaining a healthy psychological climate within the team.17 through an examination of the interactions between traumatic mental elements, individual characteristics, and organisational pressures, the research aims to give an in-depth description of emotional burnout among special services and military personnel. the goal of this research is to enhance the mental health and general well-being of individuals working in high-stress occupations by creating focused treatments and preventive measures, which will eventually improve their professional effectiveness and quality of life. materials and methods the following theoretical methods were used in the research process: i) analysis and synthesis of scientific and methodological literature by ukrainian, kazakh, polish, british, american, canadian, and south korean psychologists, sociologists, philosophers, teachers, and recruitment managers; ii) specification and generalisation of the best practices of treatment and prevention of emotional burnout among special services and military personnel, social and political factors affecting public health [page 46] [healthcare in low-resource settings 2024;12(s2):12445] non -co mmerc ial us e o nly and by the method of analogies, the principles of the prospects of implementation of this experience within the framework of the stated research were developed; iii) having theoretically modelled the training sessions on “prevention of emotional burnout”, the authors proceeded to the next stage. at this stage, the diagnostic material was collected, and interviewing and psychological observation were conducted. psychiatric and ministerial organisations conducted empirical research to investigate the most effective strategies for treating and preventing emotional exhaustion. they produced regulatory, instructional, and methodological documentation that was reviewed. the experiment was conducted in three distinct stages: ascertaining, developing, and controlling. in order to describe the findings and make conclusions, we employed the techniques of mathematical statistics and graphical visualisation of the data. the research was conducted using the personnel of the national defence university of ukraine and the national aviation university of ukraine as the experimental base. in the initial phase of the experiment, we performed research and gathered theoretical material on the development of preventative strategies to decrease or avoid emotional burnout syndrome in the professional context of interpersonal interactions. an analysis was conducted on the optimal methodologies and the potential for their application in the research conducted by scientists from ukraine, kazakhstan, poland, the united kingdom, the united states, canada, and south korea. furthermore, during this phase, a group of 206 individuals consisting of employees from special services and military people, ranging in age from 22 to 48 years, was selected. among them, 16 were women. all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. to determine the main factors of stress and the phase of emotional burnout among employees of special services and military personnel, the methodology “diagnosis of emotional burnout of personality” by m.s.r.s. chaves and i.s. shimizu,18 adapted questionnaire “the cause of stress in your work” by n. farhadian et al.,19 interviewing was used. based on the preliminary results of diagnostics and conversation with each respondent, the theoretical and practical parts of the training “prevention of emotional burnout” were finalised. during the subsequent phase of development, the completed program proceeded to the approval stage, which engaged a total of 206 personnel from specialised services and military organisations. at this point, the experiment was carried out directly. the program consisted of three sessions, each lasting up to 12 hours. these sessions were conducted in a group format, with each group consisting of 10-12 individuals. specifically, there were 14 groups with 10 members and 6 groups with 11 members. the groups consisted primarily of professionals who exhibited similar symptoms and were of the same age. participation in the program was optional, as the researchers aimed to preserve a genuine level of motivation. during the final stage of the experiment, participants in the training were subjected to repeated diagnostic assessments of emotional exhaustion to evaluate the extent of development of different phases of emotional burnout. consequently, it effectively decreased these measures and enhanced the level of emotional intelligence through the development of self-regulation abilities. special service employees and troops enhanced their professional expertise in effectively resolving conflict situations by applying the practical knowledge acquired throughout the training. the last step in this experimental study involved elucidating the theoretical and practical implications, extrapolating and organising the acquired findings using mathematical statistics, and generating a graphical depiction of markers for emotional burnout levels. results recent research highlights the role of individual psychological characteristics in the progression and experience of burnout. factors such as personal resilience, coping mechanisms, and emotional intelligence significantly influence how individuals navigate the stages of burnout.20 high-stress environments, such as those encountered by special services and military personnel, exacerbate the risk of burnout due to constant exposure to traumatic events, high responsibility, and interpersonal conflicts. the ongoing war in ukraine, for instance, has brought to light the extreme psychological burdens faced by military personnel, including prolonged exposure to combat, moral injury, and the chronic stress of operating in life-threatening conditions. the war has underscored the need for comprehensive support systems for military personnel, who often face compound stressors including irregular schedules, the threat of physical harm, and the psychological strain of highstakes decision-making. the war in ukraine has highlighted the necessity of adaptive coping strategies for military personnel, who must navigate the dual challenges of immediate survival and longterm psychological resilience.21 training programs that enhance emotional intelligence, stress management skills, and resilience are vital in helping individuals cope with the relentless stress of their professions. studies suggest that fostering a culture of openness and reducing the stigma around seeking mental health support are essential steps in addressing burnout.22 emotional burnout profoundly alters the entire psyche of an individual in special services and military divisions. progressing incrementally, this syndrome impacts all aspects of one’s life. however, the experience of burnout is unique to each individual, manifesting in varying forms. the initial phase, known as “tension,” serves as a catalyst for the development of emotional burnout syndrome. this stage is characterised by precursor symptoms such as worry, weariness, irritability, and fluctuating moods ranging from excessive enthusiasm to indifference. upon recognising these symptoms, an individual can effectively address these conditions autonomously by altering their surroundings, pursuing hobbies, or utilising psychological coping mechanisms in their repertoire of self-assistance. the second stage, known as “resistance,” is characterised by the presence of symptoms such as complete or partial emotional inflexibility towards specific psychotraumatic events. at this point, the mind transitions into a “survival” mode where a person tries to defend themselves by resisting the negative sensations that have overwhelmed them. the third stage is “exhaustion,” which is a phase of depression characterised by symptoms such as apathy, a sense of utter desolation, and a decrease in energy levels. all these phases are experienced by employees of special services and military structures as a result of getting into psychologically traumatic situations related to professional activity, but they live them in different ways, depending on individual psychological characteristics.23,24 thus, figure 1 presents the results of the diagnosis of emotional burnout of personality by m.s.r.s. chaves and i.s. shimizu.18 therefore, based on the diagnostic results, it is evident that the primary stage of emotional burnout among the participants is characterised by “resistance” (53%). during the interview, the employees expressed their state as a distinct inclination to withstand the increasing pressure. experiencing anxiety, an individual, typically without conscious awareness, attempts to alleviate psychological distress by reducing job responsibilities and evading emotional responses. seven percent of the surveyed group of personnel in social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12445] [page 47] non -co mmerc ial us e o nly special services and servicemen experience the next stage of emotional burnout, known as “exhaustion.” following the discussion, it was concluded that individuals in this state exhibit a complete lack of both happy and negative feelings. employees and troops have adopted a stance of personal detachment from their professional area, seeming alienated, and experiencing escalating psychosomatic illnesses. the majority of personnel in special services and soldiers are most influenced by the “tension” phase, accounting for 40% of the average number. this is mainly attributed to self-dissatisfaction. individuals experiencing this stage of emotional burnout are consistently under psycho-emotional strain due to professional circumstances that have a detrimental impact on their personal well-being. figure 2 presents the investigation of the correlation between emotional burnout levels and the duration of service among special services and military personnel. it can be stated that prolonged professional activity under conditions of psycho-traumatic factors can lead to emotional burnout syndrome. therefore, it is very significant for its prevention to take measures on treatment or prevention of the risk of mental diseases. besides, having analysed the results obtained by the method “causes of stress in your work” by n. farhadian et al.19 it was possible to identify what caused the emergence of symptoms of emotional burnout. a quantitative analysis is presented in figure 3. following the interview, the researchers were able to ascertain those personnel in the “tension” phase employ avoidance of professional responsibilities and possess low emotional intelligence as their primary psychological defensive mechanism. given that the employees in question have slightly over 3 years of work experience, the researchers hypothesise that these indications are linked to discontent with their professional roles. the second group of respondents, classified as “resistance”, exhibit an average level of stress in their work. they display a decrease in professional activity and a tendency towards inflexible emotional reactions. the employees’ high degree of stress in their professional activity can be attributed to several variables, including the tendency to delegate most of their responsibilities to colleagues with limited work experience, low emotional intelligence, and a prevalence of negative emotional reactions. the results of interviewing employees of special services and military personnel have demonstrated that additional reasons for dissatisfaction with professional activity are low wages, lack of remuneration for overtime work, lack of control by the head of the department over employees’ compliance with their job duties, imperfections in the legislative system, and the risk of their death or that of a colleague.25 following the interview, the researchers were able to ascertain that personnel in the “tension” phase employ avoidance of professional responsibilities and possess low emotional intelligence as their primary psychological defensive mechanism. given that the employees in question have slightly over 3 years of work experience, the researchers hypothesise that these indications are linked to discontent with their professional roles. the second group of respondents, classified as “resistance”, exhibit an average level of stress in their work. they display a decrease in professional activity and a tendency towards inflexible emotional reactions. the employees’ high degree of stress in their profes social and political factors affecting public health figure 1. diagnostic results. source: compiled by the authors. figure 2. correlation of emotional burnout phase with the length of service of employees in special services and military departments. source: compiled by the authors. figure 3. results of the diagnostic examination. source: compiled by the authors. figure 4. results of control diagnostics. source: compiled by the authors. [page 48] [healthcare in low-resource settings 2024;12(s2):12445] non -co mmerc ial us e o nly sional activity can be attributed to several variables, including the tendency to delegate most of their responsibilities to colleagues with limited work experience, low emotional intelligence, and a prevalence of negative emotional reactions. the training course enhanced the psychological competency of special services and military personnel by equipping them with skills and methods for self-recovery and the ability to provide psychological aid to their colleagues when needed. the productivity and caliber of the workforce experienced a substantial enhancement, as the personnel attained psychological stability, acquired internal reinforcement, and augmented their emotional intelligence. regular meetings held as part of the training program facilitated the observation of group dynamics and enabled comparisons across different groups. consequently, in the last phase of this experiment, the researchers performed a diagnostic analysis of the results, which are displayed in figure 4. according to figure 4, 16 individuals from the sample, which accounts for 7.7% of the total, are still experiencing emotional burnout due to their professional activities. there are seven employees experiencing “emotional tension,” 3 employees experiencing “resistance,” and 6 employees experiencing “emotional exhaustion.” the researchers attribute this phenomenon to the disinterest of employees in special services and military personnel in addressing their psycho-emotional exhaustion, a neglected version of the condition that necessitates more profound psychotherapy intervention. nevertheless, a significant proportion of employees in special services and servicemen, namely 92.3%, exhibited favourable outcomes as a result of utilising psychotechnologies in the training programme called “prevention of emotional burnout”. the majority of participants reported complete or partial alleviation of symptoms, with the extent of improvement varying based on the severity of the syndrome. additionally, the authors highlight the need of taking into account the individual-psychological characteristics of the individuals who took part in the training. for instance, the unique duties performed by special services officers and military personnel necessitate specialised traits that directly impact the nature of intelligence, security, or military activities. prior to the commencement of the training program, it was observed that 7.7% of intelligence officers and servicemen exhibited signs of low emotional stability and volitional control. according to their colleagues, they displayed insufficient emotional reactions, apathy, or aggression towards others, particularly offenders. they also exhibited emotional detachment and indifference towards their professional duties, to the point of developing psychosomatic illnesses, using this as an excuse for their lack of effectiveness. as previously said, it is imperative to use the most effective strategies for treating emotional burnout syndrome in these personnel. detailed examples of these strategies will be provided in the following section. the authors of the research conducted an experiment in which 206 employees of special services and military personnel from different units participated. each of them was in one or another phase of emotional burnout: 40% in the phase of tension, 53% of resistance, and 7% of exhaustion. notably, in the tension phase, there were officers whose length of service did not exceed 3 years, in the resistance phase, from 3 to 20 years of service and in the exhaustion phase, more than 20 years of service. from what the authors of the research concluded, the longer the employee is exposed to psychotraumatic factors in professional activity, the higher the level of emotional burnout becomes. from the results of diagnostics using the method “the cause of stress in your work” it was identified that employees with the “stress” phase do not consider their work as a source of stress, and their emotional burnout is caused by dissatisfaction with themselves in this sphere of activity. staying in such an emotional state can lead to a fatal outcome, thus, it is necessary to prevent or treat it. the authors of the research demonstrated the effectiveness of emotional burnout prevention by giving examples of best practices and the prospects of its implementation. so, 92.3% of employees of special services and military men improved their emotional state. discussion the modern labour market is oriented towards finding specialists who strive to implement their potential in the workplace, rather than specialists who simply do their job well. one of the problems of several professions can be emotional burnout – a feeling of inner devastation due to continuous contact with people, constant striving to achieve results in a career, lack of rest, and a mismatch of individual-psychological characteristics of the personality with the requirements that are included in the duties of a candidate for a position, especially employees of special services and military personnel.27 for example, a.d. wojnarska,2 exploring burnout among correctional officers, disclosed risk factors and features of using emotional burnout syndrome as a means of psychological defense. she argues that the identified reduction of professional duties is associated with the attempt of correctional officers to demonstrate to inmates their status as law enforcers. considering the absence of close communication between the warden and the inmates, the former still has to experience an increased level of stress associated with the adverse attitude of the inmates towards the correctional colony guards. therefore, correctional officers tend to buy into their emotional reactions and are cynical about their duties and the labour of their colleagues. based on the diagnostic data, the researcher states that 49.2% of correctional colony employees have predominant emotional burnout, the symptoms of which are: irritability, irascibility, impaired communication with others, ill-treatment of inmates, financial dissatisfaction, and a tendency to develop addictions. an interesting fact was explored by m.g. carey et al.28 according to their research, employees of special services and military structures, dominated by emotional burnout syndrome, were three times more exposed to life-threatening situations and twice as injured and traumatised as colleagues with a stable emotional state. during their research, h. adachi et al.29 noted that in military structures and special services, there are no measures to prevent emotional burnout as such, thus, psychologists developed a program called “how to ‘not burn out’ at work?” designed to achieve emotional stability, reduce anxiety about dissatisfaction with one’s role as a supervisor, and increase productivity as a result of the effectiveness of the training program implementation. in japan, the work culture emphasises collectivism, harmony, and loyalty to the company. these cultural values can lead to a high level of workrelated stress and contribute to emotional burnout among employees. japanese workers often face intense pressure to conform to group norms, maintain productivity, and exhibit a strong work ethic, often at the expense of their personal well-being. this environment can create significant psychological stress and lead to burnout if it is not managed effectively. research by d. chênevert and s. kilroy5 theoretically analysed the professional qualities of personality necessary for work associated with the risk to life and health. in the example of canadian firefighters, it was proven that professionally important qualities are high activity, motivation in achieving results, and use social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12445] [page 49] non -co mmerc ial us e o nly of their physical strength. thus, researchers believe that the best employees in emergencies are men, as they are self-confident, have an active life position, and have flexibility in decision-making. however, cases of emotional burnout occur, and the authors have combined them into three groups: i) the conditions in which professional activities occur; ii) external social, economic, and political factors; iii) personal subjective factors (health, individual psychological qualities, family relationships). thus, in the course of their empirical research, d. chênevert and s. kilroy5 identified the personal characteristics of employees dealing with the consequences of emergencies who are prone to emotional burnout. chênevert and s. kilroy5 identified the personal characteristics of employees who eliminate the consequences of emergencies and are prone to emotional burnout. such employees have predominant anxiety, inattention, and inhibition of the nervous system in extreme situations. thus, emotional burnout becomes a protective reaction of the psyche under the influence of the environment, as a way to cope with emotional tension arising as a result of professional load and stress. in this case, the following patterns of behaviour are characteristic of a person: social detachment, negativism towards official duties, and difficulty in the appropriation of their own achievements in professional activity. in total, the author identified five groups of classifications of employees with emotional burnout: “conscious professional reduction”, “social sensitivity”, “internal tension”, “emotional instability”, and “hidden asocial behaviour”. the cultural context of canada’s diverse and high-pressure healthcare environment necessitates intervention strategies that are both systemic and culturally sensitive. by reducing job demands, enhancing job resources, and fostering a supportive and inclusive workplace culture, it is possible to create a more sustainable and healthy work environment for physicians, ultimately leading to better patient care and reduced professional turnover intentions. as a prevention against emotional burnout among police officers, j. choi et al.30 suggest using art therapy methods. art therapy allows for the unobtrusive discovery of the creative potential of the “i” of the personality, helping to discover strengths and weaknesses. having mastered the skills of manifesting their emotional state, employees will be able to differentiate it, and due to this, the person will be able to cope with the difficulties of professional activity. art therapy techniques allow surviving deep psychological traumas received by employees during the elimination of emergencies. choi et al.’s study on the impact of occupational characteristics and victimisation on job burnout among south korean correctional officers highlights the cultural context of hierarchical and rigid structures in south korean workplaces. the collectivist nature of south korean society, combined with a strong sense of duty and respect for authority, can exacerbate stress and burnout among correctional officers. intervention strategies here must address the cultural reluctance to speak out against superiors and the stigma associated with mental health issues. s.m. hosseini et al.31 express their position on the importance of providing psychological care, namely psychological counselling. their main approaches are problem-oriented, person-centered, and counselling. thus, problem-oriented counselling focuses on analysing the essence and external causes of the problem and finding ways to solve it. in this approach, the emphasis is on behaviour modification, to develop and strengthen the client’s ability to act appropriately and increase self-control. personality-oriented counselling is designed to analyse the individual causes of conflict situations and find ways to overcome them in the future. in this approach, the counsellor avoids giving advice or providing organisational help to ensure that the client can pay attention to the internal, underlying causes of the problem. counselling focused on identifying resources to solve the problem. here, the emphasis is on activating the client’s resources to successfully overcome the problem. however, proponents of this approach note that analysing the causes of the problem may increase the client’s sense of guilt, which establishes barriers to cooperation between the counselling psychologist and the client. according to the authors, the counselling process should consider the existential tradition in psychology. existential counselling allows the psychologist to effectively provide psychological assistance on the issues of emotional burnout. but, as the researchers note, prevention and psychological assistance will not be effective without a responsible attitude and true desire on the part of servicemen and police officers. all the above-mentioned factors allow concluding that when working with emotional burnout, psychological assistance will be focused, first of all, on processing stress related to work or service and on finding ways to relieve emotional tension arising as a result of prolonged interaction with people. in addition, interaction with a counselling psychologist will be designed to establish priorities and clarify the importance of different spheres of activity in a person’s life. the research by t. shapovalova32 focuses on the various strategies used by the usa, uk, and ukraine to aid in the reintegration of military veterans into civilian life. the strategy used by ukraine places a strong emphasis on social integration, career training, and psychological assistance; nonetheless, it is afflicted by issues including inadequate infrastructure, bureaucratic obstacles, and low budget. despite these difficulties, ukraine is progressing in creating more organised programmes and working with foreign organisations. on the other hand, veterans in great britain have access to a well-established network of services that prioritises full rehabilitation, mental health care, and job help. the uk’s comprehensive strategy successfully meets the many requirements of veterans by offering specialised assistance with the psychological, social, and financial facets of reintegration. the research does point out several areas that might be better, such as the requirement for more individualised care and continual observation of veterans’ long-term adaption. the united states of america has one of the largest global support networks for veterans, with initiatives aimed at meeting a variety of needs such as housing, work, education, and healthcare. although the research commends the united states of america for its thorough and methodical approach, it also highlights several problems, including the difficulty of navigating the va system, inequalities in service access, and the requirement for improved coordination amongst various support programmes. h.d. butler et al.33 are concerned that most preventive training and psychotherapeutic treatments have a temporary effect, as they are designed to address personal problems and do not consider the significance of changes in the work environment. in addition, police officers themselves seek psychological help when they are in the stage of resistance and exhaustion, whereas prevention is more effective in the tension phase when it is still actually possible to prevent the effects of stress. the benefit of department heads can be traced to this, when they do not have to reorganise the team and the employee takes responsibility for their health. however, as practice demonstrates, a person who has undergone a course of psychotherapy undergoes global personality changes, and it is unbearable to return to the old working conditions. therefore, to avoid staff turnover, it is necessary to reconstruct the vertical of the police system. according to p.m. jolly et al.,34 it can be done by removing restrictions that hinder the activities of the department, preventing emotional burnout, and eradicating the costs of the profession, in which interpersonal conflicts may arise as a source of social and political factors affecting public health [page 50] [healthcare in low-resource settings 2024;12(s2):12445] non -co mmerc ial us e o nly intra-organisational stress. all this determines the necessity of developing comprehensive programs for emotional burnout prevention. conclusions emotional burnout syndrome is a prominent issue in the 21st century. the researchers believe that this issue affects not only individuals whose tasks necessitate interaction with others. this syndrome can impact individuals who struggle to regulate their mental state and are involved in monotonous activities, particularly if these activities do not bring them joy and they neglect to take breaks. however, the authors of this research have focused on examining special services and military personnel as the subject of their study. this is because the unique nature of their work necessitates specific personal and professional qualities, the absence of which can impact the development of emotional burnout syndrome. hence, it is essential to identify effective treatment methods and emphasise the significance of preventing and reducing symptoms of emotional burnout in special service employees and military personnel. this will enable the deliberate development of personality traits crucial for their work, while simultaneously implementing psychological strategies to prevent professional stress, utilising the most effective practices and future prospects. the research’s experimental component, which comprised creating and executing a training course titled “prevention of emotional burnout,” produced notable favourable results. the initiative improved the psychological competency of military and special services personnel by imparting self-recovery skills and offering psychological support when required. this strategy enhanced participants’ emotional intelligence and mental well-being while also having a favourable impact on their ability to resolve conflicts professionally. while the majority of patients in the study demonstrated recovery, a small proportion continued to experience emotional exhaustion, indicating the need for ongoing and maybe more intensive psychotherapy treatment. the research highlights the necessity of considering individual psychological characteristics when designing interventions, as the effectiveness of these measures can vary based on personal attributes such as emotional stability and volitional control. ultimately, the study emphasises how critical it is to have a mental health-focused organisational culture that values mental health and provides easily available, culturally appropriate mental health services. organisations can lessen the consequences of burnout and enhance the general well-being and professional efficacy of their workforce by addressing both systemic job demands and improving individual job resources. the research gives a thorough understanding of emotional exhaustion and offers insightful advice for creating preventative and therapeutic plans that are successful and specific to the difficulties that members of the armed forces and special services confront. it is possible to estimate the prospect of further research by introducing a complex of programs for the prevention of emotional burnout at all levels of law enforcement agencies and military structures, changing both the personality of an employee of special services and military personnel and the entire security system at the stage of “tension” by methods of primary prevention. references 1. seyedi asl st, rahnejat am, elikaee mm, et al. the role of resilience, positive/negative emotions, and character strengths in predicting burnout of military personnel. ebnesina 2021;22:4-13. 2. wojnarska ad. professional burnout among correctional officers – risk and protective factors. ann maria curiesklodowska univ. sect j pedagogy-psychol 2020;33:191-208. 3. lai j, ma s, wang y, et al. factors associated with mental health outcomes among health care workers exposed to coronavirus disease. jama netw open 2020;3:e203976. 4. xiao h, zhang y, kong d, et al. the effects of social support on sleep quality of medical staff treating patients with coronavirus disease (covid-19) in january and february 2020 in china. med sci monit 2019;26:e923549. 5. chênevert d, kilroy s. the determinants of burnout and professional turnover intentions among canadian physicians: application of the job demands-resources model. bmc health serv res 2021;21:993. 6. heinemann lv, heinemann t. burnout research: emergence and scientific investigation of a contested diagnosis. sage open 2017;7. 7. flood a, keegan rj. cognitive resilience to psychological stress in military personnel. front psychol 2022;13:809003. 8. bakker ab, de vries jd. job demands-resources theory and self-regulation: new explanations and remedies for job burnout. anxiety stress coping 2021;34:1-21. 9. bryan cj, bryan ao, baker jc, et al. burnout, surface acting, and suicidal ideation among military personnel: results of a longitudinal cohort study. j soc clin psychol 2022;41:593610. 10. shymchenko l, levchenko t. charity as an element of professional and pedagogical culture in the system of scientific and research training of students. society document communication 2023;19:255-69. 11. vojvodic ar, dedic g, dejanovic sd. defense mechanisms and quality of life in military personnel with a burnout syndrome. vojnosanit pregl. 2019;76:298-306. 12. boulos d, garber b. does recommended mental health followup care occur after postdeployment screening in the canadian armed forces? a retrospective cohort study. bmj open 2023;13:e065598. 13. spytska l. forecasts regarding mental disorders in people in the post-war period. eur j trauma dissociation 2024;8:100378. 14. hishan ss, jaiprakash h, ramakrishnan s, et al. prevalence and socio-demographic association of depression, anxiety and stress among university students. int j eng technol 2018;7:688-91. 15. mohanraj j, kaliannan kal, mutalemwa db, et al. investigating the association between cognitive ability, leisure activity and emotional intelligence among an ethnically diverse student population from a medical university in malaysia. int j eng adv technol 2019;8:1099-106. 16. zlenko a, perchuk, o, lutsyk o. formation of a modern personnel management ecosystem: social challenges, communication trends, innovative approaches. society document communication 2023;19:103-31. 17. jaiprakash h, singh a, biswas a, et al. e-pbl: an innovation to promote active learning and decrease cognitive overload among medical students. indian journal of public health social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12445] [page 51] non -co mmerc ial us e o nly research and development 2019;10:1469-73. 18. chaves msr, shimizu is. burnout syndrome and sleep quality among military police officers in piaui. rev bras med trab 2020;16:436-41. 19. farhadian n, moradi a, nami m, et al. the nexus between sleep disturbances and mental health outcomes in military staff: a systematic review. sleep sci 2022;15:356-62. 20. spytska l. emotional intelligence and its impact on human life in the global world. sci studio soc polit psychol 2023;52:4756. 21. ronzhes o. digital applications as tools for psychological adaptation of citizens to changes. sci studio soc polit psychol. 2023;29:34-46. 22. lozinskyi i. public control over the activities of the ministry of justice of ukraine: an introduction to the problem. law human environment 2023;14:37-49. 23. rizzo d, davey b, irons m. interpersonal interaction between prisoners and officers in prisons: a qualitative meta-synthesis exploring prison officer wellbeing. j qual criminal justice criminol 2021;10. 24. soto-rubio a, carmen m, espert g, prado-gascó v. effect of emotional intelligence and psychosocial risks on burnout, job satisfaction, and nurses’ health during the covid-19 pandemic. int j environ res public health 2020;17:7998. 25. kulchytskyi v. role of intellectual property in the development of the state’s innovation potential. law human environment 2023;14:23-45. 26. isenhardt a, hostettler u. inmate violence and correctional staff burnout: the role of sense of security, gender, and job characteristics. j interpers violence 2020;35:173-207. 27. jaegers la, matthieu mm, vaughn mg, et al. posttraumatic stress disorder and job burnout among jail officers. j occup environ med 2019;61:505-10. 28. carey mg, regehr c, wagner sl, et al. the prevalence of ptsd, major depression and anxiety symptoms among highrisk public transportation workers. int arch occup environ health 2021;94:867-75. 29. adachi h, sekiya y, imamura k, et al. the effects of training managers on management competencies to improve their 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low-resource settings 2024;12(s2):12445] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:13013 phenomenology study: the nurse perception of experience in providing spiritual nursing care in the cardiovascular unit safri,1,2 elly nurachmah,1 budhi setianto,3 jahja umar,4 sri yona1 1faculty of nursing, universitas indonesia, depok, west jawa; 2faculty of nursing, universitas riau, pekanbaru, riau; 3faculty of medicine, universitas indonesia, jakarta; 4faculty of psychology uin syarif hidayatullah, jakarta, indonesia abstract nurses who provide nursing care are urgently required to assess the patient’s spiritual needs so a correct nursing intervention can be given to the patient. unfortunately, up to present, few instruments are available to specifically focus on patient’s spiritual needs. the aim of this study was to identify the perception of experience of nurses in providing spiritual nursing care to patients in cardiovascular wards as a foundation to develop a specific spiritual nursing care assessment tool. a sample of six nurses participated in this qualitative study. data collection was conducted through in-depth interviews to nurses used thematic analysis. there were five themes identified: i) spiritual care meaning for nurses; ii) nurse’s current belief in providing spiritual care; iii) barriers in conducting spiritual nursing care; iv) expected solution to eliminate the barriers; v) efforts to improve spiritual nursing care. this study suggest to have a spritual care assessment instruments in order to make it easier for nurses to establish a spiritual nursing diagnosis, so that existing nursing care interventions can be carried out on target according to the client’s priority problems. introduction patients with cardiovascular health problems assume that they are experiencing a crisis situation that significantly impacts their psycho-spiritual dimension. one of the crisis situations is caused by anxiety, especially towards death. anxiety can increase the risk of complications because physiological anxiety leads to unintentional activities within the body, which are part of the self-defense process.1 in nursing, clients are individuals, families, or communities who have health problems and require assistance to maintain, preserve, and enhance their health under optimal conditions.2 awareness of understanding the spiritual needs of patients can improve the belief in nursing that the provision of care should be comprehensive or holistic, addressing not only the physical, psychological, social, and cultural needs but also the spiritual needs of clients. the spiritual dimension consists of two elements: belief and behavioral dimension, as it is through these two components that the nurse’s relationship with the client (horizontal) and the nurse’s relationship with the divine (vertical) can be felt. without these elements, spiritual nursing care will not have a positive impact on improving the quality of services. this spiritual nursing care should be applied to all patients with various health problems, including those with cardiovascular disorders. for example, a person’s belief in the existence of god and demonstrates through acts of charity or worship is what becomes the patient’s spirit to heal, believing that the illness comes from god and making efforts for treatment to regain health.3 research at banda aceh hospital dalam estetika and jannah shows that spiritual nursing care is still less than optimal.4 based on the results of this research, it was found that the implementation of spiritual nursing care was 59.7% poor, of which 69.4% was not perfect, namely lifting a spiritual nursing diagnosis 69.4%. satisfaction with the application of spiritual nursing care at the sultan agung hospital in semarang, it is known that there is an influence between the application of spiritual care on patient satcorrespondence: elly nurachmah, department of medical surgical, faculty of nursing, universitas indonesia, depok, west java, indonesia. e-mail: elly08@yahoo.co.id key word: assessment, cardiovascular, nursing, phenomenology study, spiritual. contribution: conceptualization: s,en, bs; data curation: s, ju, sy; methodology: s,bs, ju; supervision: en, bs,sy; validation: en, bs, ju; writing original draft: s, en, sy. all authors have read and agreed to the published version of the manuscript. ethical approval: the ethical committee approval (protocol number) was obtained from universitas indonesia, no: ket-033/un2.f12. d1.2.1/ppm.00.02/2023. availability of data and material: the participants of this study did not give written consent for their data to be shared publicly, so due to the sensitive nature of the research supporting data is not available. conflict of interest: the researchers declare that this research is free from conflicts of interest of individuals and organizations. the researchers would like to thank all those who have supported to carry out this research. funding: this study received funding from universitas indonesia, grant for international publication 2023 with contract number nkb064/un2.rst/hkp.05.00/2023. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgement: we thank all participants for their participation in this study, especially the universitas indonesia, universitas riau and arifin achmad regional general hospital. received: 4 september 2024. accepted: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:13013 doi:10.4081/hls.2024.13013 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 729] [healthcare in low-resource settings 2024;12:13013] non -co mmerc ial us e o nly isfaction with a p value of 0.000.5 from the results of a preliminary study of observations and in-depth interviews with 3 cvcu nurses at arifin achmad regional hospital in may 2021, it is known that spiritual assessment instruments and documentation of spiritual nursing care have not yet been obtained. materials and methods this study is a qualitative research using a phenomenological approach. data collection was conducted through in-depth interviews with six participants who met the inclusion criteria of being nurses in the cardiovascular care unit arifin achmad hospital pekanbaru. prior to the interviews, all participants were given explanations and those who agreed to be respondents signed a consent form. thematic analysis was used to analyze the themes. results the characteristics of the 6 participants in the study were as follows: the range of age is 32 to 42 years. in terms of educational background, three participants have diploma in nursing and three participants with a bachelor’s degree in nursing (s1) and professional nursing certification. the work experience of participants in the cardiovascular care unit ranges from six to 18 years (table 1). after the process of thematic analyses, the research findings, revealed five main themes supported by 13 categories (figure 1). theme 1: the meaning in spiritual nursing care almost all nurses expressed their feelings to explain their understanding on the meaning in spiritual care in nursing. their perceived that conducting religion obligation perfectly is the most important thing in muslim’s life. therefore, it was founded that in this first theme, the nurses’ experience consists of four categories, namely providing facilities, patient response, frequently performed interventions, and involving families. providing facilites nurses are the frontliners to provide comprehensive care to patients. the experience of nurses in providing spiritual nursing care has been in line with the perceptions and knowledge of the nurses themselves. for nurses, spiritual care means allowing patients to do their religious custom based on the religious law as stated in the quran or sunnah. it includes what facility a person article table 1. characteristics of the participants. characteristics p1 p2 p3 p4 p5 p6 age 32 yo 40 yo 38 yo 42 yo 42 yo 42 yo education d3 nurse s1 nurse d3 nurse s1 nurse s1 nurse d3 nurse gender male female female female female female years of service 6 years 15 years 10 years 18 years 18 years 18 years training ecg ecg ecg ecg ecg ecg btcls btcls btcls btcls btcls btcls basic cardiology basic cardiology basic cardiology basic cardiology basic cardiology basic cardiology figure 1. themes. [healthcare in low-resource settings 2024;12:13013] [page 730] non -co mmerc ial us e o nly needs to be provided, as expressed by the participants, among others: “... section for providing prayer garments that assist us ...” (p2,p4) “...but for non-muslims, i’ve also had an experience where they brought a pastor here, and we allowed them to pray like that....” (p1, p2, p3) “...usually, we do this for patients who experience a decrease in consciousness.” (p3,p6) response of patient in providing care to patients, nurses always attempt to fulfil the patient’ needs including spiritual need. the nurses involve in clarifying how to pray in certain patient’s condition, as for moslem need to do five times a day. however, for certain patients who is unable to pray using a normal method, the nurses also need to assist patients to prepare for praying or guide them to pray. the nurse perceived that not all patients have an intention to pray while lying in the bed, but many of them response positively toward the nurse’s reminder on praying; as shown in their statements: “...sometimes we still teach them, but sometimes they don’t want to, well, that’s how it is, we can’t force them, right sir...” (p2) “...we are also happy when the response is positive....” (p2,p5) “....to perform ablution with the things around them....” (p1,p3) “....requesting this, requesting what’s it called, requesting tayammum....” (p1,p3) frequently performed intervention in addition to the tradition of commencing praying during hospitalized, it was discovered from the interviews, that nurses usually were involved directly in supporting the patients and families especially those during serious condition such as patient in pain or have trouble in breathing. the following statements have been raised. “...most often, it’s for patients experiencing pain and shortness of breath, so we usually advise them to recite istighfar (seek forgiveness from god). sometimes, we also provide deep breathing therapy, along with istighfar. istighfar, istighfar...” (p1, p2, p3) the theme also comprises of involving the family as demonstrated as follow “....so, we facilitate by usually encouraging the family to recite qur’an....” (p1,p2) “....we typically summon the family to offer comfort. if the patient is already asleep, then the family can go home....” (p1,p2) the intervention has been displayed as a routine intervention of nurses following the time to pray. the nurse will offer a thing related to the vertical communication with god that required by the patient or family. theme 2: current beliefs of nurses in providing spiritual nursing care this theme constructed through two categories, namely nurses’ ability of assesment and diagnosis, and nurses’ ability of intervention. nurses’ ability of assesment and diagnosis understanding the importance of providing spiritual nursing care emerged as a determining factor in delivering comprehensive care. findings from the participants indicated that nurses have been implementing spiritual nursing care, but there is still a lack of knowledge and the use of appropriate instruments. they perceived that spiritual care is depended upon the belief of nurses on how to convey themselves to be closer to god as the highest authority for life. the findings of the interviews shown that they are still unable to internalized the meaning of religion to get the life meaning. they expressed this situation into two categories, as follows. ability in assessing and establishing nursing diagnoses the category reflects the unability of nurses to explore deeply on what is the meaning of spirituality to patients which lead to unability to assess and diagnose the patient’s spirituality problem as stated in the following statements. “....the assessment of the spiritual aspect is somewhat lacking, actually....” (p1,p3,p5) “....if it comes to spirituality, there is a lack of understanding....” (p2, p4) “....lack of understanding in establishing a diagnosis for spirituality....” (p1,p2) “....for the assessment, we first observe why the patient is feeling restless and listen to their concerns....” (p2) ability to provide interventions the category emerged to represent that the only way to solve the spirituality problems of the patients is to call a spiritual expert, as can be observed through the following statements. “...bringing in a spiritual counselor 1-2 times a week, especially to guide in prayer before undergoing surgery...” (p2) “...now, when dealing with emotionally distressed patients, we need to call them in and ask what’s bothering them and if there’s anything they need to address in their thoughts...” (p2,p5) “...if i were to say it generally, it’s because my colleagues rarely do things like asking for patient assessments, that’s why it’s not running perfectly... and also, we never document the assessments...” (p2,p6) “...and then, for the assessment, we never write it down...” (p3, p4) theme 3: barriers in providing spiritual nursing care nurse sometimes becomes a leader for patients and patients’ families. they initiate and facilitate care according to the patients needs including spiritual needs. however, even they were succeded to identify the problems and planned some actions, but in the real situation, not every single action can be delivered based on the standardized procedure. further, the nurses have a belief that everything happens for a reason include the obstacle of providing spiritual care to patients. nurse’s belief to allow patients to pray was to facilitate the patients with the needs so the pray can be conducted as clean as possible and fulfil the requirements. the obstacles were perceived from patient, hospital, and nurse perspectives. these can be shown from the following statements. barier from patient’s perspective this category is identified based on the following statements. “.... maghrib prayer, the call to prayer for isha, because he/she doesn’t know it since our room is closed. so, i told him/her, ‘sir/madam, this is the call to prayer for asr.’ if he/she wants to pray, then we assist, but if he/she doesn’t, then we don’t assist....” (p2,p4) “....usually, the patient is worried about the condition of their article [page 731] [healthcare in low-resource settings 2024;12:13013] non -co mmerc ial us e o nly child and husband, especially when their child is still young. so, it becomes a burden or a topic of discussion for the patient to confide in the nurse....” (p2) “....sometimes they don’t want us to change their diapers with us....”(p2,p4) “....sometimes patients have different personalities, sir. there are those who calm down when we show them kindness, but there are also those whose emotions get carried away....”(p2,p3) barier from hospital’s perspective the category was constructed through the following statements of the informen. “....there is no specific place for tayammum (ritual purification without water)....”(p1, p2) “....if a patient wants to listen to murottal (recitation of the quran) or recite the quran, we call their family and ask them to bring a mobile phone and give it to the patient....”(p2,p5) “....if the patient wants to use a prayer gown (mukena), we don’t provide it. they have to request it from their family....”(p2,p3,p6) “....visiting hours vary for each patient....”(p2,p6) barier from nurse’s perspective the last category of the theme was synthesized based on the statements, which some of them was written here: “....the gender of nurses who work on each shift varies....” (p2,p6) “....and maybe this is also because not all nurses have the knowledge or understanding of the importance of religious practices. yes, one of them is the importance of spirituality for patients who are in a sick condition. on average, they have limited knowledge about it. they prioritize their work over the spiritual aspect.....”(p4) theme 4: the expected solution in overcoming obstacles the fourth theme was built from two categories, includes solution for the hospital and solution for nurses. in the hospitals, every nurse has a good intention to their patients. they always want to deliver the care in a good quality and timely. they attempt to always consider the patient’s preferences which sometime make them unable to fulfil the patient’s wish. this also happened when they tried to deliver the spiritual care optimally. they become aware of the situation where they are unable to facilitate patients to conduct praying. therefore, in providing optimal spiritual nursing care, solutions and plans are needed, as expressed by the participants’ expectations. solution for the hospital the category was identified through these following statements: “....facilities for performing ritual cleansing (tayammum), reminder speakers, qur’an availability, dedicated rooms ....”(p1,p2) “....one of the obstacles to implementing spiritual care is the availability of clean facilities....”. (p3,p5) “.... one possible solution is to ensure the provision of necessary facilities. however, it may be challenging to provide clean facilities like lake water due to the time-consuming management planning. from my perspective, providing mukena (prayer garment) specifically for women can be considered. the availability of lake water depends on factors like laundry facilities....” (p4) solution for the nurse this category was developed after analysing the statements which lead to the perception of nurses to find a way out toward their problems, as follows. “....suggesting patients who have trouble sleeping to read the qur’an....”(p1,p2) “....usually, when reminded, they are willing to, god willing....”(p3) “....for patients nearing the end of life, it is common for family members to be called in to provide guidance and support ....”(p3) “....yes, occasionally we provide guidance when there are no family members available...” (p3,p5) “....perhaps there should be efforts to provide knowledge and raise awareness among nurses regarding the spiritual needs of patients.....”(p4) theme 5: the efforts need to be taken the last theme was identified according to the two categories focus on the effort to improve the spiritual care. those are improving nurse’s knowledge and maximize the facility to conduct religion onligation for the patients. improving nurse’s knowledge praying is an important religion customary that every muslim needs to conduct five times in a day. the schedule of praying is fixed according position of the sun. however, the difficulty will be encountered by people who are hospitalized. in a certain situation physically and mentally may lead to the limitation to conduct praying. moreover, if there is no communication with nurses on such situation, the patient will be unable to pay their religion obligation appropriately. therefore, in addition to maintain a fluent communication with the patients, the nurses need to identify the effort to improve their communication to know deeper what the patient’s need in conducting their obligation. some efforts to improve spiritual nursing care can be made by nurses through various strategies. the results of the interview with the participants indicate that the hospital has made efforts to provide knowledge and understanding of spirituality. however, there is still a limitation in terms of the spiritual values within the nurses themselves, like the expression below: “....every friday at the prayer room at the hospital he holds recitations ....”(p2,p6) “....yes, we don’t even ask for a change, we change it if we get blood on it ....”(p3,p5,p6) maximize fasilities the second category was encountered due to the limitation of patient to conduct praying. they have no facility to do it during lying on the bed. therefore, nurses of hospital management need to offer more facilities to allow patients to pay for their religion obligation, as we may learn from the following statements. “....yes, they sometimes ask like this, ‘sister, is it prayer time already?’ oh yes, it is, sir.’ that’s an example....” (p4,p5) “....and then, usually i offer, like, ‘ma’am, it’s prayer time. would you like to pray?’ we change it with something clean if the lake gets dirty, and we also change and clean the diaper. after cleaning, we provide a blanket until...for men, i have done it before....” (p4,p5) “....sometimes i offer, and there have been cases where i saw article [healthcare in low-resource settings 2024;12:13013] [page 732] non -co mmerc ial us e o nly patients performing tayammum.....”(p2,p3,p4) “....there are already prayer call reminders for muslims....”(p2,p3,p4) discussion the implementation of spiritual nursing care is influenced by the perceptions and knowledge of the nurses themselves. with their perceptions and knowledge, nurses can provide spiritual nursing care and have their own experiences. in this study, the perceptions of nurses’ experiences in providing spiritual nursing care include providing facilities for religious practices, responding to patients’ requests for facilitation in worship, involving families in the care process, and providing patient education regarding spiritual matters. in this study, nurses provide spiritual nursing care based solely on their own habits and spiritual values. as a result, there are several barriers in implementing it, such as nurses not establishing spiritual nursing diagnoses due to a lack of guidance in assessing spiritual care. there are six spiritual nursing diagnoses: spiritual distress, risk for spiritual distress, impaired religiosity, risk for impaired religiosity, readiness for enhanced religiosity, and readiness for enhanced spiritual well-being.6 the indonesian nursing diagnosis standards also include spiritual nursing diagnoses, such as spiritual distress, risk for spiritual distress, health promotion, and anxiety.7 nurses have provided spiritual nursing interventions such as engaging patients in reciting prayers, reminding them of prayer times, facilitating ritual cleansing, and having spiritual counselors available in the hospital. however, these interventions have not been structured based on established diagnoses, and there is a lack of documentation for their implementation. as a result, the impact is that the evaluation of spiritual nursing care cannot be conducted effectively without proper documentation. in addition to the perceptions and understanding of nurses, the suboptimal provision of spiritual nursing care can also be influenced by the available facilities in the hospital. facilities such as ablution areas (for performing wudu or tayammum), clean prayer mats, prayer garments (mukenah), copies of the quran or other sacred texts, prayer time reminders, and others play a crucial role in supporting and facilitating spiritual practices for patients. the findings align with the research conducted by tunny et al., which revealed that most nurses have a positive perception of spiritual care.8 however, there are also identified barriers, including a lack of knowledge, inadequate skills and competencies, insufficient training or education, limited time due to staffing shortages, and minimal support from hospital management. despite the challenges mentioned earlier, it is true that nurses are aware of the importance of meeting the spiritual needs of patients. they make efforts to find solutions and overcome limitations to provide therapeutic spiritual nursing care. their aim is to minimize patients’ spiritual suffering and assist them in finding meaning and purpose in their lives. one of the reasons why spiritual nursing care is not fulfilled is because it does not begin with an assessment of the patient’s spiritual needs. there is no research on developing spiritual assessment instruments for patients with cardiovascular disorders, especially in indonesia. the results of a review of spiritual assessment instruments by yodang and nuridah regarding several spiritual assessment methods that can be used with palliative patients, namely the faith importance and influence community addressing spiritual concern method, faith application influence talk help, spiritual personal integration ritualized implication terminal, explanation treatment healers negotiate intervention collaborate (spiritual), hope organized personal effect, and ars moriendi model.9 from these results, yodang and nuridah said that the majority of spiritual assessment instruments were developed in countries with populations other than islam, so these assessment instruments need to be adapted to the conditions of indonesia, where the majority of the population is muslim, so that these instruments can be applied especially in the area of palliative care.9 for this reason, spiritual assessments can also be prepared and developed for patients with cardiovascular disorders. conclusions the findings of this research provide an overview of nurses’ experiences in providing spiritual nursing care, which are identified through five main themes: nurses’ perceptions, understanding, barriers, solutions, and efforts to enhance spiritual nursing care. one important aspect highlighted in this study is the lack of implementation of nursing care as a systematic and scientific process used by nurses to meet the clients’ needs in achieving or maintaining optimal biological, psychological, social, and spiritual wellbeing. the nursing care as a systematic and scientific process begins with nursing assessment, identification of nursing diagnoses, planning of nursing interventions, implementation of nursing actions, and evaluation of results. to ensure the effective implementation of spiritual nursing care, it is important to develop various instruments for each step of the nursing process, starting with the assessment of spiritual care. these assessment instruments should be designed to gather comprehensive information about the patients’ spiritual needs, beliefs, values, and preferences. references 1. videbeck sl. buku ajar keperawatan jiwa. jakarta: egc; 2008. 2. draper p. an integrative review of spiritual assessment: implications for nursing management. j nurs manag 2012;20:97080. 3. carron r, cumbie sa. development of a conceptual nursing model for the implementation of spiritual care in adult primary healthcare settings by nurse practitioners. j am acad nurs pract 2011;23:552-60. 4. estetika n, jannah n. pelaksanaan asuhan keperawatan spiritual di suatu rumah sakit banda aceh. j ilm mhs keperawatan 2016;1:1-9. 5. winarti r. pengaruh penerapan asuhan keperawatan spiritual terhadap kepuasan pasien di rumah sakit islam sultan agung semarang [unpublished thesis]. [semarang]: universitas diponegoro; 2016. 6. herdman th. nursing diagnoses and definition and classification 2021-2023. 12th ed. new york, ny: thieme; 2021. 7. tim pokja sdki dpp ppni. standar diagnosis keperawatan indonesia (sdki). jakarta: persatuan perawat nasional indonesia; 2017. 8. tunny h, saleh a, rachmawaty r. persepsi, kompetensi dan hambatan perawat dalam pemenuhan spiritual care pasien: literature review. care j ilm ilmu kesehat 2022;10:35–49. 9. yodang y, nuridah n. instrumen pengkajian spiritual care pasien dalam pelayanan paliatif: literature review. j endurance 2020;5:539-49. article [page 733] [healthcare in low-resource settings 2024;12:13013] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11909 the effect of qur'anic healing on reducing the frequency of auditory hallucination rating scale (ahrs) in schizophrenia muhammad rosyidul ibad, febry syaren alfianti, muhammad ari arfianto, tutu april ariani, zahid fikri nursing study program, faculty of health sciences, universitas muhammadiyah malang, indonesia abstract auditory hallucinations have led to decreased productivity, impaired interaction, and diminished well-being in individuals with schizophrenia. however, the challenge lies in enabling patients to independently manage their hallucinations, and one potential approach is through psycho-religious methods utilizing the qur’an. this study aimed to assess the impact of qur’anic healing on reducing the frequency of auditory hallucinations in individuals with schizophrenia. employing a quasi-experimental design with a one-group pre-post-test, this study included 35 respondents selected through purposive sampling. inclusion criteria stipulated that participants must have a diagnosis of schizophrenia accompanied by auditory hallucinations, coherent thinking, a cooperative attitude, and adherence to the muslim faith. the auditory hallucination rating scale (ahrs) served as the instrument for data collection, with analysis conducted using the wilcoxon test. the findings revealed a significant effect of qur’anic healing on reducing the frequency of auditory hallucinations, indicated by a pvalue of 0.000 (p<0.05). qur’anic healing demonstrated effectiveness in alleviating auditory hallucinations among individuals with schizophrenia. we recommend incorporating qur’anic healing as an additional supportive therapy for schizophrenia patients. moreover, it is anticipated that listening to qur’anic healing will enhance the patient’s adaptive coping mechanisms. introduction hallucinations are considered characteristic symptoms of psychosis and are part of the ‘psychosis superspectrum’ within the hierarchical taxonomy of psychopathology (hitop) initiative.1 they manifest as signs and symptoms of mental disorders in the form of sensory responses (hearing, sight, taste, smell, and touch) to stimuli that are not real.2,3 if not handled properly, hallucinations can pose a risk, leading the sufferer to potentially injure themselves or others, and even harm the surrounding environment. this occurs because the patient is influenced by their hallucinations, leading them to engage in actions beyond their control.4 unfortunately, it is not uncommon to observe mentally ill patients committing acts of violence as a result of the hallucinations they experience.5,6 individuals experiencing auditory hallucinations may pose a danger to themselves, others, and their environment. moreover, hallucinations impair overall functioning and contribute to biological, social, and spiritual problems.7–9 in such cases, positive behavior is influenced by an individual’s positive perception of society and prevailing norms.10. the severity of the problem is exacerbated by the content of auditory hallucinations, which can range from direct violence towards others to suicide attempts.11–13 schizophrenia is a major mental disorder, particularly prevalent in countries where it ranks at the top among all existing mental disorders.14,15 it affects the brain, leading to disturbances in perceptions, emotions, movement, and behavior.16 in indonesia, it is estimated that 6.7 per 1,000 households suffer from schizophrenia, and 14.0% of indonesian households have practiced pasung, which involves the restraining and confinement of individuals with mental health problems (kemenkes, 2018).17 patients experiencing hallucinations can be treated through both pharmacological correspondence: muhammad rosyidul ibad, nursing study program, faculty of health sciences, universitas muhammadiyah malang, indonesia. e-mail: ibad@umm.ac.id key words: auditory hallucinations; schizophrenia; qur'anic healing; surah ar-rahman. contributions: mri, conceptualization, data curation, formal analysis, methodology, validation, writing original draft, review and editing; fsa, conceptualization, investigation, methodology, validation, and writing original draft, collecting data, resources; maa, review and editing; taa, writing review and editing; zf, resources, investigations, and writing review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this research is supported by a research grant from [dppm universitas muhammadiyah malang] with contract number [e.2.a/811/baa-umm/viii/2023]. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission, faculty of medicine, muhammadiyah university of malang based on ethical certificate no.e.5.a/073/kepk-umm/iv/2023. during the research, the researcher paid attention to the information ethics principles of consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 3 december 2023. accepted: 18 december 2023. early access: 26 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11909 doi:10.4081/hls.2024.11909 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 198] [healthcare in low-resource settings 2024;12:11909] non -co mmerc ial us e o nly and non-pharmacological approaches.18,19 pharmacological therapy involves the use of chemical drugs designed to quickly control psychosis symptoms by affecting neurotransmitters in the brain. individuals with schizophrenia require long-term treatment and recovery.20 however, the extended use of drugs may result in side effects, such as stickiness of the tongue, loss of motivation, body discomfort, hypersalivation, and symptoms resembling parkinson’s disease, which may lead people with schizophrenia to be reluctant to take medication. non-pharmacological treatment includes modality therapy, and/or a mainstay in psychiatric nursing aimed at progressively developing a personality style or model.21,22 modality therapy encompasses seven types: cognitive therapy, logotherapy, family therapy, environmental therapy, psychoreligious therapy, group therapy, and discharge planning programs.23– 25 considering the cultural background in indonesia, where hallucinatory content, such as occult/mystical sounds, is prevalent, a spiritual approach is considered more effective in managing symptoms of auditory hallucinations.26,27 a study suggest that qu’ran recitation (referred to as the qu’ran recitation approach, qrp) is useful not only for relieving anxiety related to specific medical conditions, but also for psychosocial ones.28 spiritual therapy, specifically qur’anic healing therapy, involves listening to the recitation of the holy verses of the qur’an, coupled with one’s intentions and beliefs.29 religious therapy, particularly psycho-religious therapy, has been found to be beneficial for schizophrenic patients, as demonstrated by ridwan haris.30 the study’s findings indicated that patients undergoing psychoreligious therapy were able to diminish the clinical symptoms of schizophrenia. this resulted in quicker control of positive symptoms, a shorter duration of hospitalization, faster wound healing, and a more rapid development of adaptive abilities.31 qur’anic healing can be administered through the murottal therapy method, involving the reading of qur’anic verses to produce a beneficial impact on the body.31 murottal therapy serves as a potent brain stimulant. when individuals listen to the holy verses of the qur’an, it induces a relaxed, calm, and comfortable response. therapy utilizing the strains of qur’an recitation can be considered an alternative and superior relaxation therapy compared to other audio therapies because the qur’an’s stimulation can activate delta waves.32,33 several studies have demonstrated that listening to murottal qur’an has a positive effect on emotions. the advantageous impact of al-qu’ran murottal therapy on emotional changes has piqued researchers’ interest, particularly in its application as therapy for individuals experiencing physical pain in previous studies. this research, however, focuses on informal caregivers of schizophrenia patients.33 building on the aforementioned research, the qur’an shows promise in reducing the frequency of hallucinations in patients. therefore, the primary objective of this study is to examine the effect of qur’anic healing on decreasing the frequency of auditory hallucinations in individuals with schizophrenia. materials and methods research design the researcher employed pre-experimental design, specifically utilizing a one-group pre-post-test design. this research type was chosen to analyze the application of qur’anic healing in schizophrenia patients exhibiting symptoms of auditory hallucinations. the study aims to elucidate changes in hallucination frequency scores before and after administering qur’anic healing therapy, which are subsequently analyzed. study participants the study’s population consisted of 180 patients diagnosed with schizophrenia in the social rehabilitation unit of east java province, indonesia. however, the sample size involved in this study was 35 patients. researchers employed purposive sampling to determine the sample, with inclusion criteria specifying patients diagnosed with schizophrenia who exhibit coherent thought flow, experience auditory hallucinations, and practice the muslim faith. exclusion criteria encompassed patients in the crisis phase and those with impaired thought flow. variables, instruments and data collection the independent variable in this research is qur’anic healing therapy, while the dependent variable is the frequency of auditory hallucinations. in this study, the measurement instrument used was the auditory hallucination rating scale (ahrs). this questionnaire has been validated in a clinical trial in france, yielding significant results.34 other researchers have also conducted studies utilizing similar instruments to assess the frequency of auditory hallucinations in schizophrenia patients.35,36 the ahrs instrument includes various indicators assessing the scale of auditory hallucinations, covering frequency, duration, location, sound strength, belief in the origin of the sound, amount and intensity of negative sound content, distress caused by the sound, and the patient’s control over the sound. ahrs assigns scores of 0 (none), 1-11 (mild), 12-22 (moderate), 23-33 (severe), and 34-44 (very severe). data collection took place over one month in march 2023, during which the qur’anic healing intervention occurred in three sessions. session 1 focused on establishing trust with the respondent. in session 2, participants listened to the holy verses of the qur’an (specifically ar-rahman verses 1-78) for 10 minutes using personal headsets. researchers observed the patient’s response during and after listening to the verses. both session 2 and session 3 involved providing qur’anic healing twice daily, in the morning and evening. data analysis the data analysis employs the wilcoxon test using spss 12 software. this test is utilized to assess comparative hypotheses for data within a single group of paired samples. it is suitable for freely distributed ordinal data or interval and ratio data that do not follow a normal distribution. the test is specifically designed for paired samples, meaning there is one group of samples with two related sets of data. ethical clearance this research has obtained ethical approval from the health research ethics commission, faculty of medicine, muhammadiyah university, malang, as evidenced by ethical certificate no. e.5.a/073/kepk-umm/iv/2023. it has been deemed ethically appropriate in accordance with the 7 who standards, which include 1) social value, 2) scientific value, 3) equitable assessment and benefits, 4) risk, 5) persuasion/exploitation, 6) confidentiality and privacy, and 7) informed concern. for a detailed understanding of the accuracy of indicators for each standard, please refer to the cimos 16 guidelines. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11909] [page 199] non -co mmerc ial us e o nly results respondent characteristics are described based on age and gender. table 1, which presents demographic data, reveals that respondents who underwent psychiatric rehabilitation at psychotic rehabilitation east java, indonesia, fall into the early elderly age group (46-55 years). the majority of elderly individuals experiencing auditory hallucinations received a diagnosis of schizophrenia in their earlier years before entering old age. they underwent rehabilitation for mental disorders in rehabilitation centers, encountering various predisposing factors for mental disorders, encompassing biological, psychological, and socio-cultural aspects. the majority of respondents underwent rehabilitation for a duration exceeding three years, totaling 19 individuals. this data indicates a lack of preparedness within families to care for patients with hallucinations upon their return home. additionally, there is a societal rejection in the community where the patient resides. some patients have a background of homelessness, lacking a permanent place of residence, which compels them to continue treatment throughout their lives. table 2 has demonstrated a reduction in auditory hallucination scores among schizophrenia patients who underwent qur’anic healing therapy. patients who initially had a very severe score of 4 saw a decrease to 0 after therapy, indicating an improvement in their ahrs level towards sensory enhancement. similarly, for patients with a severe level of 10 before therapy, the score reduced to 1. the majority of respondents exhibited an enhancement in their ahrs level towards the mild category. the wilcoxon analysis test remarkably established high significance, with a p-value of 0.000. this signifies that qur’anic healing is effective and capable of reducing the frequency of auditory hallucinations in schizophrenia patients. discussion prior to the administration of qur’anic healing, the majority of participants exhibited moderate auditory hallucinations, comprising 19 people (54.3%). the remainder had mild auditory hallucinations (2 people, 5.7%), severe auditory hallucinations (10 people, 28.6%), and very severe auditory hallucinations (4 people, 11.4%). according to the research results, the auditory hallucination stage of the respondents is categorized as stage 2 (non-psychiatric/condemning patient). the symptoms of hallucinations manifest through the behavior of respondents, who consistently report hearing voices that others cannot hear. patients also display signs of being unconcentrated, staring unfocused, frequently covering their ears, and experiencing difficulty in controlling their hallucinations.37 when patients experience hallucinations, they typically exhibit emotions such as unexplained anger, engaging in self-talk or laughter, experiencing unfounded fears, and disruption of their daily activities. sleep disturbances often occur, potentially leading to depression or stress. according to the researchers, several factors contribute to managing patients with auditory hallucinations, including knowledge, seeking treatment at health facilities, adhering to prescribed medications, self-intention to recover, family support, and consistent adherence to a therapy schedule. consequently, the researchers have chosen to implement qur’anic healing therapy as an approach. the results indicate a decrease in the level of auditory hallucinations, as illustrated in table 1. before the qur’anic healing therapy was administered, the majority experienced moderate auditory hallucinations, comprising 19 people (54.3%). after undergoing qur’anic healing therapy, there was a reduction in the level of auditory hallucinations, with the majority now exhibiting mild auditory hallucinations, accounting for 21 people (60%). the remaining respondents displayed moderate levels of auditory hallucinations, totaling 13 people (37.1%), and severe auditory hallucinations, represented by 1 person (2.9%). this shift suggests that the respondents became calmer, refrained from talking to themselves, and demonstrated increased concentration on following therapy. according to research, qur’anic healing through listening to the murottal of surah ar-rahman can positively impact the body and cultivate a sense of calm and comfort.38 in patients experiencing hallucinations, there is an imbalance of the dopamine hormone, leading to false perceptions even in the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. demographic characteristics of respondents. variable respondent (n=35) n % age adolescent (17-25 years) 2 5.7 early adulthood (26-35 years) 7 20 late adulthood (36-45 yrs) 9 25.7 early elderly (46-55 yrs) 16 45.7 late elderly (56-65 yrs) 1 2.9 total 35 100 gender man 20 57.1 woman 15 42.9 total 35 100 duration of rehabilitation <3 months 2 5.7 4-8 months 6 17.1 9-12 months 3 8.6 1-3 years 5 14.3 >3 years 19 54.3 total 35 100 table 2. auditory hallucination ratting score (ahrs). category score ahrs pre-therapy score ahrs posttherapy p f % f % no hallucinations 0 0 0 0 0.000 mild 2 5.7 21 60 moderate 19 54.3 13 37.1 severe 10 28.6 1 2.9 very severe 4 11.4 0 0 total 35 100 35 100 n=100 [page 200] [healthcare in low-resource settings 2024;12:11909] non -co mmerc ial us e o nly absence of external stimuli. based on research findings, qur’anic healing therapy can stimulate the brain to reduce stress hormones and activate the production of natural endorphins, specifically serotonin. consequently, the impact on the body is a heightened sense of calm, increased focus, reduced feelings of anxiety and tension. individuals who regularly listen to the verses of the holy qur’an may experience a decrease in depression levels.33 the research suggests that qur’anic healing is effective in reducing the frequency of hallucination symptoms in schizophrenic patients.29 reading and listening to the recitation of the holy verses of the qur’an stabilize neuron vibrations and lower cortisol levels, resulting in a sense of calm. this effect on respondents may empower them to control their hallucinations. the results revealed that before receiving qur’anic healing therapy, respondents frequently heard voices at various times, with durations extending up to hours. the sources of these sounds varied and were often very strong, leading to confusion for the respondents in distinguishing between reality and auditory stimuli. they sometimes spoke alone, resulting in a moderate level of auditory hallucinations, involving 19 people (54.3%). the remaining respondents experienced mild auditory hallucinations (2 people, 5.7%), severe auditory hallucinations (10 people, 28.6%), and very severe auditory hallucinations (4 people, 11.4%). after undergoing qur’anic healing therapy for two weeks, with a 5-minute duration in both morning and evening sessions, there was a notable decrease in the level of auditory hallucinations. the majority of respondents exhibited mild auditory hallucinations, accounting for 21 people (60%). the remaining respondents displayed moderate auditory hallucinations (13 people, 37.1%) and severe auditory hallucinations (1 person, 2.9%). furthermore, respondents became calmer, refrained from talking to themselves, and demonstrated increased concentration. the wilcoxon test results, which compare the pretest and post-test scores before and after qur’anic healing therapy, yielded a p-value of 0.000 (p<0.05). this implies a significant effect in reducing the level of auditory hallucinations in schizophrenic patients through qur’anic healing. religious activities such as reading the qu’ran, prayer, and dhikr have a positive impact on patients’ physical and mental health, attention, and concentration. negative physical and emotional impacts are experienced when patients neglect prayer and dhikr.39 the audio of surah ar-rahman, previously studied, has demonstrated effectiveness in reducing levels of violent behavior and assisting patients in expressing their emotions in a more adaptive manner. this form of audio therapy is cost-effective and does not result in side effects. the recitation of the holy verses of the qur’an generates a range of frequencies that reach the ears and subsequently affect brain cells through electromagnetic fields. additional studies elaborate on the idea that the sound of qur’anic recitation can enhance psychological and physiological parameters. this includes reducing heart rate, anxiety, and stress, as well as improving mental health and memory performance for both children and adults. consequently, listening to and reciting the qur’an can be recommended as a supportive treatment to enhance psychological well-being.40 conclusions the research results indicate that qu’ranic healing has the potential to reduce the frequency of auditory hallucinations experienced by schizophrenia patients if administered regularly twice a day for an entire month. researchers recommend that nurses managing patients with auditory hallucinations in hospitals or rehabilitation centers incorporate this therapy as a primary supportive treatment alongside patients receiving psychopharmaceutical therapy. this approach aims for a more holistic treatment, capitalizing on advantages such as the psychospiritual aspect, with the hope that it will not only diminish hallucinations but also fortify the spiritual well-being of schizophrenia patients. it underscores that fulfilling mental health needs involves not only enhancing physical function through antipsychotic drugs but also addressing mental and spiritual aspects. the provision of qur’anic healing to hallucination patients significantly impacts the reduction of hallucination frequency, contributing to a sense of calmness, cooperation, and improved religious coping mechanisms in muslim patients. references 1. jimeno n, gomez-pilar j, poza j, et al. (attenuated) hallucinations join basic symptoms in a transdiagnostic network cluster analysis. schizophr res 2022;243:43-54. 2. raunak v, menezes a, junczys-dowmunt m. the curious case of hallucinations in neural machine translation. naacl-hlt 2021 2021 conf north am chapter assoc comput linguist hum lang technol proc conf 2021;1172-83. 3. aleksandrowicz a, kowalski j, stefaniak i, et al. cognitive correlates of auditory hallucinations in schizophrenia spectrum disorders. psychiatry res 2023;327. 4. johansson agm, källman m, högman l, et al. psychotically driven aggression is associated with greater mentalizing challenges in psychotic spectrum disorders. bmc psychiatry 2020;20. 5. thomson n, bozgunov k, psederska e, et al. f151. intelligence moderates the link between psychopathy and aggression, but only for men. biol psychiatry 2019;85:s2712. 6. salim z, haddad c, obeid s, et al. command voices and aggression in a lebanese sample patients with schizophrenia. psychiatr danub 2021;33:27-8. 7. elsaesser e, roe ca, cooper ce, lorimer d. the phenomenology and impact of hallucinations concerning the deceased. bjpsych open 2021;7. 8. wang tt, beckstead jw, yang cy. social interaction skills and depressive symptoms in people diagnosed with schizophrenia: the mediating role of auditory hallucinations. int j ment health nurs 2019;28:1318-27. 9. iudici a, quarato m, neri j. the phenomenon of “hearing voices”: not just psychotic hallucinations—a psychological literature review and a reflection on clinical and social health. community ment health j 2019;55:811-8. 10. lestari r, yusuf a, endra f, et al. a societal adaptation model as a novel approach toward the recovery of people with schizophrenia. healthc low-resour s 2023;11:11208. 11. hielscher e, devylder j, connell m, et al. investigating the role of hallucinatory experiences in the transition from suicidal thoughts to attempts. acta psychiatr scand 2020;141:241-53. 12. bornheimer la, hong v, li verdugo j, et al. relationships between hallucinations, delusions, depression, suicide ideation, and plan among adults presenting with psychosis in psychiatric emergency care. psychosis 2022;14:109-19. 13. harris k, gooding p, peters s, haddock g. investigating the perceived impact of psychosis on suicidal thoughts and behaviors. schizophr bull open 2020;1. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11909] [page 201] non -co mmerc ial us e o nly 14. iswanti di, fitryasari r, agusman f, et al. including families in schizophrenia treatment : a systematic review. int j public health sci (ijphs) 2023;12:1155-64. 15. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 16. widiyawati w, yusuf a, devy sr, widayanti dm. family support and adaptation mechanisms of adults outpatients with schizophrenia. j public health res 2020;9:219-22. 17. maramis mm, sofyan almahdy m, atika a, et al. the biopsychosocial-spiritual factors influencing relapse of patients with schizophrenia. int j soc psychiatry 2022;68:1824-33. 18. yeh tc, correll cu, yang fc, et al. pharmacological and nonpharmacological augmentation treatments for clozapine-resistant schizophrenia: a systematic review and network metaanalysis with normalized entropy assessment. asian j psychiatr 2023;79. 19. reisegger a, slamanig r, winkler h, et al. pharmacological interventions to reduce violence in patients with schizophrenia in forensic psychiatry. cns spectr 2021;27:388-98. 20. iswanti di, nursalam n, fitryasari r. development of an integrative empowerment model to care for patients with schizophrenia disorder. j public health res 2023;12:22799036231197191 21. slamanig r, reisegger a, winkler h, et al. a systematic review of non-pharmacological strategies to reduce the risk of violence in patients with schizophrenia spectrum disorders in forensic settings. front psychiatry 2021;12. 22. dimitriou t, papatriantafyllou j, konsta a, et al. nonpharmacological interventions for the hallucinations in patients with dementia. brain sci 2022;12. 23. erduran-tekin ö. the impact of spirituality and spirituallyoriented therapeutic interventions on schizophrenia patients. spirit psychol couns 2019;4:309-20. 24. buanasari a, keliat ba, susanti h. the application of acceptance commitment therapy (act) and family psychoeducation (fpe) to clients with scizophrenia and aggressive behavior. nurse media j nurs 2020;10:11-21. 25. dellazizzo l, giguère s, léveillé n, et al. a systematic review of relational-based therapies for the treatment of auditory hallucinations in patients with psychotic disorders. psychol med 2022;52:2001-8. 26. subandi ma, praptomojati a, marchira cr, et al. cultural explanations of psychotic illness and care-seeking of family caregivers in java, indonesia. transcultural psychiatry 2020;58:3-13. 27. hornbacher a. schizoid balinese? in: the movement for global mental health. mov glob ment heal 2021;65-100. 28. algristian h, bintarti tw, solihah i, et al. quran recitation as noise-induced aggression and resilience in animal model of depression. bali med j 2022;11:994-1002. 29. abd-alrazaq a, malkawi a, maabreh a, et al. the effectiveness of listening to the holy quran to improve mental disorders and psychological well-being: systematic review and meta-analysis. res sq 2020;1-25. 30. haris r. the pyscho-spiritual therapy on mental illness; an islamic approach. prophet guid couns j 2021;2:34-40. 31. rosyanti l, hadju v, hadi i, syahrianti s. a systematic review of the quranic spiritual healing approach in schizophrenic patients. heal inf j penelit 2018;10:51-64. 32. hasan az, rahman a, noor m, et al. the relationship between reciting the al-quran, practicing zikir and stress management among mpob staf during the covid 19 pandemic. turkish online j qual inq 2021;12:2036-48. 33. wahid aw, nashori f. the effectiveness of al-quran surah ar-rahman murottal listening therapy for improving positive emotions on informal caregivers of schizophrenia. proc int conf psychol stud (icpsyche 2020) 2021;530. 34. dondé c, haesebaert f, poulet e, et al. validation of the french version of the auditory hallucination rating scale in a sample of hallucinating patients with schizophrenia. can j psychiatry 2020;65:237-44. 35. lorente-rovira e, grasa e, ochoa s, et al. different measures for auditory hallucinations in populations with psychosis. the validation of the spanish versions of the auditory vocal hallucination rating scale (avhrs) and the positive and useful voices inquiry (puvi). rev psiquiatr salud ment 2020;15:259-71. 36. hoffman re, gueorguieva r, hawkins ka, et al. temporoparietal transcranial magnetic stimulation for auditory hallucinations: safety, efficacy and moderators in a fifty patient sample. biol psychiatry 2005;58:97-104. 37. stuart gw. prinsip dan praktik keperawatan kesehatan jiwa stuart buku 1. elsevier; 2016. 38. rafique r, anjum a, raheem ss. efficacy of surah alrehman in managing depression in muslim women. j relig health 2019;58:516-26. 39. irawati k, indarwati f, haris f, et al. religious practices and spiritual well-being of schizophrenia: muslim perspective. psychol res behav manag 2023;16:739. 40. hechehouche o, dzulkifli ma, alias ia. the quranic-based healing through sound and its psychological effect: a review of literature. iium j hum sci 2020;2:75-80. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 202] [healthcare in low-resource settings 2024;12:11909] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12325 comparative analysis of the results of laparoscopic and classical hepatic resections for multiple tumors in patients with hepatocellular carcinoma aleksander tarasik department of surgical oncology, bialystok oncology center, bialystok, poland abstract laparoscopic removal of the affected part of the organ and classic laparotomic resection with open access for surgical manipulations are widespread. the choice of resection method is still controversial because researchers are currently talking about the importance of minimally invasive surgical techniques. the purpose of this study was primarily to compare the intraoperative, early, and late postoperative status of patients who underwent laparoscopic or laparotomic hepatic resection for multiple foci of hepatocellular carcinoma. in general, the operations using the laparoscopy method are much safer, because perioperative complications (including intense stress reactions with the appearance of hypertension, suppression of the immune response, tachycardia, and hypercoagulability) occur much less frequently than in the case of open-access intervention. less invasiveness of laparoscopic operations contributes to a better recovery of patients after resection. on the other hand, laparotomy provides wider and faster access to the liver. this meta-analysis compares the effectiveness of minimally invasive laparoscopic resections over classic laparotomic operations in patients diagnosed with hepatocellular carcinoma with multiple tumors. introduction according to the world cancer research fund international, primary malignant neoplasms of the liver (including hepatocellular carcinoma) are the sixth most common tumors worldwide. more than 900,000 new cases were reported in 2020 alone. the main approach for treating liver tumors is resection of the affected organ, which can be performed both laparoscopically and laparotomically. the term “laparoscopically” denotes a surgical procedure executed via laparoscopy, a minimally invasive methodology involving the insertion of surgical instruments and a laparoscope (a thin, flexible tube equipped with a light source and camera) through small incisions made in the abdomen. by utilising this methodology, the abdominal cavity can be effectively observed, enabling a range of surgical procedures to be executed while minimising damage to adjacent tissues. the term “laparotomically” denotes a surgical procedure executed via laparotomy, a conventional open surgical technique. a single large incision is made in the abdominal wall during laparotomy to gain direct access to the abdominal cavity. in contrast to laparoscopy, this technique affords the surgeon an expanded field of view and improved access to organs and tissues. however, it is important to note that the larger incision typically necessitates a more protracted recovery period, may entail increased postoperative pain, and increases the risk of complications. it is better to use the laparoscopic method for patients who have neoplasms in the anterolateral hepatic segments, which include segments 2, 3, 4b, 5, and 6. in case of bilateral liver damage or massive resection of three or more adjacent segments, laparoscopic surgery becomes quite technically complex.1 in 2014, the second international consensus conference on laparoscopic hepatic resection was held in japan, and the researchers concluded that small laparoscopic resections had become a standard practice among surgeons around the world.2 however, large resections for multiple tumor lesions are still innovative methods. the louisville conference, held in 2008, was more about introducing laparoscopic minimally invasive technologies into standard surgical practice.3 the main disadvantage of both meetings was the fact that there were no prior randomized evidence-based comparisons of an open-access laparoscopy, which could provide an adequate basis for recommendations. so, correspondence: aleksander tarasik, department of surgical oncology, bialystok oncology center, 15-027, 12 ogrodowa str., bialystok, poland. e-mail: tarasikaleksander5@gmail.com key words: open extensive resection; hemihepatectomy; malignant neoplasm; laparotomic; hepatobiliary surgery centers. conflict of interest: the author declares no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. a study was approved by the national ethics commission of the ministry of health of poland on december 21, 2022, no. 2515-1. all patients consented to the processing of their data in writing, maintaining confidentiality. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: the data supporting the findings of this study are available on request from the corresponding author. received: 31 january 2024 accepted: 22 march 2024. early view: 27 may 2024 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12325 doi:10.4081/hls.2024.12325 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12325] [page 19] non -co mmerc ial us e o nly the evidentiality of both intervention methods was rated as “low”. the next one was the southampton consensus conference in 2018, but it also did not provide any meaningful randomized evidence for both techniques of hepatectomy for hepatic neoplasms.4 studies in favor of laparoscopic resections over open hepatectomy were published with the participation of ciria et al., who studied minimally invasive surgical methods for hepatocellular carcinoma.5 however, the main drawback of these studies became the fact that they were based on retrospective data (which had a substantial impact on the results of comparisons). similar studies were conducted by komorowski et al. in their literature review and meta-analysis comparing hepatic resection.6 the authors noted that there was a minimal number of randomized studies on this topic at that moment, but those that already existed were of poor quality and had a high risk of selection bias in clinical cases. however, even with such conclusions, the researchers had emphasised that laparoscopic surgery was more acceptable when choosing the method of hepatic resection if it was performed in experienced hepatobiliary surgery centers. the inaccuracies in the opinion of most authors regarding the use of minimally invasive techniques of hepatic resection for large-scale lesions of hepatosegments in hepatocellular carcinoma became the reason for this study, namely the investigation of the course of operations and possible complications after the intervention, which can have a substantial impact on the formation of the final conclusion. in addition, an important point that should be considered in a broad assessment of these two resection techniques was that performing laparoscopic resections was significantly more costly, which was explained by the need for modern surgical equipment. these issues were highlighted in the papers by schmelzle et al.7 and cipriani et al.8 in addition, the location of the neoplasm in the posterolateral segments could become a complicating factor when performing laparoscopic resection for multiple lesions, which greatly complicated the process of removal of the part of the organ invaded by the pathological process. rubinkiewicz et al. described in detail the complexities of such unfavorably located lesions and concluded that laparoscopic resection was useful in such situations but required a surgeon to have a high level of operational skills.9 guerrini et al. started a broad meta-analysis in 2020 that compared laparoscopic and open hepatic resection for intrahepatic cholangiocarcinoma.10 the authors have concluded that laparoscopic resection in the case of that oncopathology had fully provided positive surgical results because the patients in that group had fewer prerequisites for intraoperative blood transfusion, the pringle manoeuvre, were under medical supervision for less time, and had a lower disease incidence in the postoperative period in general. nevertheless, with the laparotomy resection, there was a higher tendency for lymph node dissection; thus, the researchers’ conclusions may be biased due to the differences between clinical pictures included in the analysis. the purpose of this study was primarily to compare the intraoperative, early, and late postoperative status of patients who underwent laparoscopic or laparotomic hepatic resection for multiple foci of hepatocellular carcinoma. materials and methods studies relating to the implementation of laparoscopic and laparotomic hepatic resection in patients with hepatocellular carcinoma were selected for direct analysis. a systematic review of relevant studies was conducted in evidence-based medicine databases such as pubmed, embase, web of science, and the cochrane library. the search for relevant studies was conducted using keywords covering the topic of this meta-analysis, which are most often used in similar medical papers. only the studies published between 2012 and 2022 were selected for the review, and the type of publication as well as the language of writing were not substantial. articles by the same author were excluded from the meta-analysis (only more relevant and recent works had been selected), as well as papers that duplicated existing data in order to prevent repetition. experimental studies or those describing animal experiments were excluded from this meta-analysis. the clinical cases of 26 patients who underwent laparoscopic major resection and 78 patients who underwent open major resection were retrospectively evaluated. in all the above patients, the indication for surgery was hepatocellular carcinoma, and the number of tumor nodes in the liver was 3 or more. the location of tumors necessitated extensive resection. the option of laparoscopic resection was not considered for those patients in whom the tumor was located near the main portal pedicle, inferior vena cava, or infiltrated into these anatomical sites. considering the terminology of the brisbane 2000, the authors referred to a major hepatic resection as one that includes the removal of more than three segments, and posterior and anterior right sectionectomy.11 according to the child-pugh scale, patients were divided into categories a and b, which substantially increases the prognosis for a positive resection result in the subsequent postoperative period.12 this classification is based on the assessment of total bilirubin, serum albumin, the examination of an external cascade of plasma coagulation, and the presence or absence of ascites and hepatic encephalopathy. information from medical reports, which included postoperative data, demographic collection, and follow-up to identify the long-term complications of surgical interventions, was taken into account. all patients were divided into two general groups according to the classification of the operation performed: patients who underwent laparoscopic hepatic resection and those who underwent laparotomy hepatic resection. all data were calculated and processed using statistical analysis software – stat 15.3. data were presented according to the p<0.05. the main central component assessed was postoperative complications. all common and single complications described in the trials were included for evaluation. blood loss, the need for transfusion therapy, the total duration of operation, the diameter of tumors, the overall survival, and the functional ability of patients after resection were considered for secondary comparison. complications directly related to hepatic resection included all pathological conditions that appeared within 30 days after the surgical intervention. death occurring within 90 days of surgery was classified as postoperative mortality. when choosing the type of resection, first of all, the functional ability of the organ, localization and damage of the hepatic vessels, and the degree of damage of the parenchyma by cancer cells were taken into account. after hepatic resection, both groups underwent liver function tests and blood tests. in the postoperative period, patients were evaluated by laboratory blood tests every 2 months for a year, which directly included monitoring of the alpha-fetoprotein level, ultrasound examination, computed tomography, and examination of liver functional capacity. all procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and national research committee and with the 1964 helsinki declaration and its later amendments or comparable ethical standards. a study was approved by the national ethics commission of the ministry of health of poland on december 21, 2022, no. social and political factors affecting public health [page 20] [healthcare in low-resource settings 2024;12(s2):12325] non -co mmerc ial us e o nly 2515-1. all patients consented to the processing of their data in writing, maintaining confidentiality. results all clinical cases were carefully selected from the previously published papers to compare the immediate results of two types of hepatic resection with multiple segmental lesions. the selected patients were divided into two groups to facilitate the evaluation of the results: patients who underwent laparoscopic resection and those who underwent laparotomy resection. the first category included 26 patients, and the number of patients in the second group was three times more – 78 patients. in addition, to improve the formation of conclusions, the patients were divided depending on the clinical data (table 1).13 there were no striking differences between gender, age, childpugh characteristics, and concomitant diseases between the two groups.12 the child-pugh score, also known as the child-turcottepugh score, is a clinical scoring system used to assess the severity of liver disease and predict the prognosis of patients with cirrhosis. this scoring system helps healthcare providers classify the severity of liver dysfunction and guides treatment decisions for patients with liver cirrhosis. according to the child-pugh scale, patients were divided into categories a and b, which substantially increases the prognosis for a positive resection result in the subsequent postoperative period. this classification is based on the assessment of total bilirubin, serum albumin, the examination of an external cascade of plasma coagulation, and the presence or absence of ascites and hepatic encephalopathy. the assessment of all data is used to predict intraoperative mortality and the likelihood of future postoperative liver complications. the patients were divided according to the identical principle into two groups to evaluate the operational results (table 2).13 eighteen patients in the first group (69.2%) and 54 in the second group (69.2%) underwent a right hemihepatectomy. no deaths were registered during the operations. two of the patients (who underwent laparoscopic hepatic resection) underwent a conversion to a laparotomy due to bleeding during the operation, which was difficult to control in the laparoscopic approach due to the limited field of view of the surgeon. in addition, 55 patients from the group who underwent open hepatic resection (representing 70.5% of the total) and 15 patients from the category that underwent laparoscopic resection (which amounts to 57.7% of this group of patients) underwent the pringle maneuver. in the first group, there was substantially less blood loss during the operation, almost half as much social and political factors affecting public health table 1. characteristics of patients and details of the medical history. laparoscopic hepatic resection (26 patients) laparotomic hepatic resection (78 patients) p gender (м:f) 11:15 33:45 1 age 56.1±10.6 52.0±12.2 0.698 child-pugh class, number of patients (%) а 23 (88.5) 70 (89.7) 1 в 3 (11.5) 8 (10.3) cirrhosis confirmed histologically 16 (61.5) 45 (57.7) 0.73 concomitant diseases, number of patients (%) diabetes 2 (7.6) 7 (9) 1 hypertension 4 (15.4) 8 (10.26) 0.489 predominant hepatic disease 11 (42.3) 29 (37.2) 0.642 tumor size (mm) 75.0±35.1 75.5±38.8 0.378 table 2. results of surgical intervention. laparoscopic hepatic resection (26 patients) laparotomic hepatic resection (78 patients) p time of surgical intervention (min) 264.2±14.1 255.4±36.3 0.215 intraoperative blood loss (ml) 340.8±225.2 601.4±509.4 0.007 intraoperative transfusions (number/%) 7 (26.9) 23 (29.5) 0.803 general complications, 4 (15.4) 29 (37.2) 0.039 number of patients (number/%) wound infection (quantity/%) 2 (7.7) 6 (7.7) 1 leakage of bile 1 (3.8) 5 (6.4) 1 intra-abdominal fluid accumulation (quantity/%) 1 (3.8) 10 (12.8) 0.357 bleeding, number of patients (%) 2 3 (2.0) 0.597 lung infection, number of patients (%) 0 5 (6.4) 0.427 restoration of defecation, days 1.5±0.5 3.1±0.6 0.083 postoperative hospital stays, days 11.0±2.9 15.5±5.2 0.024 pr1, number of patients (quantity/%) 1 (3.8) 7 (9) 0.671 prm (mm) 7.5±35.1 7.1±36.4 0.895 number of tumors 3.3±0.6 3.4±0.7 0.381 *р<0.05 (considered important for direct analysis, so these values are shown in bold in the table). [healthcare in low-resource settings 2024;12(s2):12325] [page 21] non -co mmerc ial us e o nly as in the second group. this aspect of the operation can be explained by better visualization of the liver structures in the case of laparoscopic resection and, accordingly, less vascular damage. this fact can explain the need for more transfusions after an open hepatic resection. however, in terms of the percentage, approximately the same part of patients in both groups needed intraoperative transfusion (in the group with laparoscopic resection 7 patients, which is 26.9%, and in the group with laparotomic resection 23 patients, which is 29.5% of the total). the time spent by the surgeons to perform the operations was also almost the same in both groups, amounting to approximately 259.8 minutes. it is important to note that the second group had a higher percentage of surgical complications, including ten cases of intra-abdominal fluid accumulation, one case of bleeding, five cases of pulmonary infection, and six cases of wound infection; while in the first group, these complications were either absent or were observed in a minimal number of patients. the mechanism of development of postoperative ascites has not yet been finally identified. nevertheless, it can be assumed that it is partially associated with an increased pressure in the portal vein system after extensive resection. the lower incidence of ascites in patients after laparoscopic surgery was likely associated with a less intense immune response of the body due to the less invasive nature of the surgery, and with a lower complication rate. the pathological anatomical examination of the free resection margin also did not reveal any differences between the two groups. the number of postoperative biliary fistulas in patients after laparoscopic resection was lower: only one case was described in patients after laparoscopy and 5 cases – after the classical surgery. most likely, this can be explained by better visualization of the transacted surface of the liver during laparoscopic surgery. there were no substantial differences in the process of restoration of the defecation act in both groups; however, there was a substantial difference between the postoperative stay of patients in the hospital for observation. this figure averaged 15.5 days in the second group, and approximately 11 days in the first group. after the hepatic resection, the patients were followed up for 33.3±15.6 months for the group with laparoscopic resection and 31.4±15.7 months for the group with laparotomy resection. after one year of follow-up, it was difficult to identify a substantial difference between patients in the different groups. regarding the median 4-year survival rate, it was 64.7% in patients after open surgery and 10.7% higher (75.4%) in patients after laparoscopic resection. this difference can be explained by less traumatization when performing minimally invasive surgical techniques, as well as by the fact that open (laparotomic) hepatic resection is more often indicated in patients with a more complex clinical picture of hepatocellular carcinoma, or in patients with a very large number of tumors, which can be localized in difficult places to create laparoscopic access. in addition, in comparison with the first group, the patients with laparotomy resection were more likely to experience relapses of the disease. in 11 patients from the open resection group, postoperative progressive liver failure was observed, which required mainly radical treatment in the form of liver transplantation; while in patients from the first group, these pathological processes were not observed. in addition, two patients from the second group had acute myocardial infarction. these two causes mainly influenced the mortality rate in patients who underwent open hepatic resection for hepatocellular carcinoma with multiple lesions. the comparative study reflects the substantial advantages of laparoscopic methods of surgical interventions compared with open operations. this can be explained by smaller incisions to access the liver, less pain after surgery, substantially less time required for full recovery, a lower immune and metabolic response from the body, and a lower percentage of complications observed in the postoperative period. but the disadvantage is still the fact that the performance of the laparoscopic resection requires a specialized surgical team with high qualifications and skills, as well as limited access to the organ during laparoscopic operations in emergency situations. nevertheless, there are a number of relative contraindications for laparoscopic resection, including the localization of neoplasm close to the central vessels of the liver due to the likelihood of their damage, the number of tumors, poor tolerance of the pneumoperitoneum, and the functional ability of the liver to postoperative restoration. if all these parameters are considered separately, they are not contraindications for performing laparoscopy, but they can substantially complicate the course of surgery, which can affect the subsequent recovery period of the patient after the removal of the affected part of the organ. when comparing the costs of the two liver resection techniques, an analysis revealed that the intraoperative expenses associated with laparoscopy are significantly greater than those of open resection; but this is directly related to the need for high-tech laparoscopic equipment and a slightly longer duration of the operation if it concerns the liver invasion with a large number of oncological neoplasms. there is a high probability that the cost of laparoscopic instruments will gradually decrease in the near future, which can be associated with an increase in demand and the use of minimally invasive techniques in surgery. discussion over time, small hepatic resections have become a standard practice in modern surgery. recently, when performing extensive resections (for example, multiple liver lesions), surgeons prefer laparoscopic methods because this technique is not inferior in safety and has a high postoperative possibility for function compared to standard open surgery techniques. a systematic review and meta-analysis were conducted at guangzhou medical university led by z.y. wang, to compare laparoscopic and open resection for hepatocellular carcinoma lesions of the organ.14 after the study, the researchers received standard results, reflecting substantially less blood loss, a lower level of postoperative complications, and substantially less time required for hospital observation when performing a laparoscopic resection. nevertheless, laparoscopic resection of large parts of the liver had a substantially longer surgical time, which increased the risks of intraoperative complications. the problem of choosing laparoscopic or laparotomic resection if the patient has concomitant cirrhosis is quite interesting. studies on the choice of resection in this situation were performed by japanese researchers yamamoto et al. and kabir et al. at oxford university.15,16 in a meta-analysis, the researchers compared early and long-term postoperative outcomes after laparoscopic and open hepatic resections. the randomized controlled and propensity score matching studies were evaluated, providing the necessary information to form the final conclusions. the following data has been selected as the main indicators to determine outcomes: data on the overall survival of patients, the time required for surgical intervention, the volume of intraoperative blood loss, and accordingly, the need for blood transfusions, the need to perform the pringle maneuver, postoperative complications, and the total time required for hospital observation for the patients. after evaluating social and political factors affecting public health [page 22] [healthcare in low-resource settings 2024;12(s2):12325] non -co mmerc ial us e o nly all the information received and its competent systematization, the authors concluded that the laparoscopic resection method in the case of hepatocellular carcinoma complicated by cirrhosis is a safe option that can improve the indicators of overall postoperative survival and patient recovery, due to the reduction of invasiveness and injury to body tissues. in addition, in 2021, a large-scale study was conducted with the participation of troisi et al., which examined in detail the clinical cases of cirrhosis of class b according to the child-pugh scale and the effectiveness of laparoscopic hepatic resection in such patients.17 the authors concluded that if patients did not have high pressure in the system of the portal vein before surgery, such patients tolerated laparoscopic resection without complications; and had no significant complications in the early and separated results, which could classify the operation as traumatic and ineffective. it is not uncommon in surgical practice to perform repeated liver resections for relapsed hepatocellular carcinoma, which is a rather dangerous pathological condition for the patient. when performing repeated hepatic resection by laparoscopic method, there is a high risk of abdominal organ trauma due to adhesion and the change in anatomical correspondence of organs and tissues. therefore, during repeated hepatic resection, surgeons usually prefer the open laparotomy method, which reduces the risk of complications and damage to other organs of the patient. however, the studies by inoue et al. showed that the laparoscopic method of reresection of the liver also demonstrates positive postoperative dynamics, which makes it non-threatening to perform routinely in similar conditions.18 there is also a technique for performing robotic hepatic resection, which in recent years has gained increasing adoption in various surgical branches, including the spectrum of hepatobiliary surgical interventions. in august 2021, the us food and drug administration made a statement that robot-assisted surgical procedures are safe for use in all branches of interventional medicine.19 in his study, f. di benedetto detailed all the advantages of using the methods of robotic laparoscopic resection because this approach increases the surgeon’s ability to control the operating area by leveling possible complications that may be associated with excessive traumatization.20 the only major disadvantage is the need for a high-tech robotic transection device, which is currently only available in highly specialized centers for minimally invasive surgery. despite the growing demand and the development of the latest technologies in the field of medicine, robotic surgery has not yet been sufficiently explored for largescale implementation into standard practice. machairas et al. conducted a comparison of robotic technique and laparotomic resection and concluded that robotic surgical interventions for liver cancer were much less accompanied by concomitant postoperative complications than in the case of open liver resection.21 however, only ten non-randomized retrospective studies were included in their analysis, which cannot provide an adequate evidence base in favor of one of the techniques of liver resection performance. an important problem also standing in the way of introducing laparoscopic techniques into standard approaches for the treatment of hepatocellular carcinoma with multiple lesions is that there is currently a deficit in laparoscopic training programs for young surgeons. there is also a lack of a single educational program that can be used in this field of minimally invasive surgery. in 2019, the paper was published by halls et al., who compared the effectiveness of training young surgeons according to modern educational materials on laparoscopic resection and analyzed the safety and adequacy of performing hepatectomy by young surgeons and self-taught surgeons.22 their study showed that junior surgeons had a substantially higher learning rate with informative and structured training programs, and subsequently, they also performed both simple and complex laparoscopic hepatic resections safely and efficiently without the supervision of more experienced surgeons. evaluating all the above-mentioned studies, it is possible to make the statement that the use of minimally invasive surgery in operations on the liver can substantially reduce the operational trauma of the body and accelerate the recovery process, without substantially limiting the scope of possible surgical interventions. the introduction of robot-assisted surgery into this area remains an innovative direction, but research on this topic requires more evidence and more extensive clinical trials to speak without caveats about safety and favorable intraoperative and postoperative periods for patients. conclusions laparoscopic resection is a safe and efficacious method for managing hepatocellular carcinoma with multiple lesions, providing numerous benefits in comparison to open resection, as demonstrated by this meta-analysis. less blood loss, postoperative pain, smaller incisions, decreased relapse rates, and decreased postoperative liver failure were all outcomes of laparoscopic resection. additionally, patients demonstrated a diminished autoimmune response, which was plausibly attributable to reduced tissue damage, thereby facilitating an expedited recuperation. nevertheless, the absence of long-term follow-up data subsequent to extensive laparoscopic resection undermines the reliability of these conclusions. further randomized trials comparing open resections and large laparoscopic resections for livers invaded by multiple tumors are necessary in order to establish more conclusive findings. laparoscopic resection ought to be regarded as the method of choice for appropriate candidates. however, open resection may be preferred in cases of specific contraindications, such as inadequate tolerance to pneumoperitoneum, invasion of central liver vessels, or extremely large tumors. additionally, the surgeon’s proficiency with sophisticated laparoscopic techniques is crucial when performing resections of this nature. the continued expansion of minimally invasive laparoscopic techniques for liver resection, which reduce patient trauma and accelerate postoperative recovery without restricting the scope of possible interventions, can be achieved through the implementation of structured training programs and the accumulation of experience. additional investigation is required to validate the safety and effectiveness of nascent robot-assisted methodologies. references 1. world cancer research fund international. liver cancer statistics. 2020. available from: https://www.wcrf.org/cancertrends/liver-cancer-statistics/ 2. wakabayashi g. what has changed after the morioka consensus conference 2014 on laparoscopic liver resection? hepatobiliary surg nutr 2016;5:281-9. 3. buell jf, cherqui d, geller da, et al. the international position on laparoscopic liver surgery: the louisville statement. ann surg 2009;250:825-30. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12325] [page 23] non -co mmerc ial us e o nly 4. abu hilal m, aldrighetti l, dagher i, et al. the southampton consensus guidelines for laparoscopic liver surgery: from indication to implementation. ann surg 2018;268:11-8. 5. ciria r, cherqui d, geller da, et al. comparative short-term benefits of laparoscopic liver resection: 9000 cases and climbing. ann surg 2016;263:761-77. 6. komorowski al, mitus jw, wysocki wm, bała mm. laparoscopic and open liver resection – a literature review with meta-analysis. arch med sci 2017;13:525-32. 7. schmelzle m, krenzien f, schoning w, pratschke j. laparoscopic liver resection: indications, limitations, and economic aspects. langenbecks arch surg 2020;405:725-35. 8. cipriani f, ratti f, cardella a, et al. laparoscopic versus open major hepatectomy: analysis of clinical outcomes and costeffectiveness in a high-volume center. j gastrointest surg 2019;23:2163-73. 9. rubinkiewicz m, mizera m, malczak p, et al. laparoscopic versus open liver resections of posterolateral liver segments – a systematic review and meta-analysis. wideochir inne tech maloinwazyjne 2020;15:395-402. 10. guerrini gp, esposito g, tarantino g, et al. laparoscopic versus open liver resection for intrahepatic cholangiocarcinoma: the first meta-analysis. langenbecks arch surg 2020;405:26575. 11. terminology committee of the international hepatopancreato-biliary association. the brisbane 2000 terminology of liver anatomy and resections. hpb 2000;2:333-9. 12. child cg, turcotte jg. surgery and portal hypertension. major probl clin surg 1964;1:1-85 13. he a, huang z, wang j, et al. laparoscopic versus open major liver resection for hepatocellular carcinoma: a case-matched analysis of shortand long-term outcomes. open med 2021;16:964-72. 14. wang zy, chen ql, sun ll, et al. laparoscopic versus open major liver resection for hepatocellular carcinoma: systematic review and meta-analysis of comparative cohort studies. bmc cancer 2019;19:1047. 15. yamamoto m, kobayashi t, oshita a, et al. laparoscopic versus open limited liver resection for hepatocellular carcinoma with liver cirrhosis: a propensity score matching study with the hiroshima surgical study group of clinical oncology (hisco). surg endosc 2020;34:5055-61. 16. kabir t, tan zz, syn nl, et al. laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis: meta-analysis. br j surg 2021;109:21-9. 17. troisi ri, berardi g, morise z, et al. laparoscopic and open liver resection for hepatocellular carcinoma with child-pugh b cirrhosis: multicentre propensity score-matched study. br j surg 2021;108:196-204. 18. inoue y, fujii k, ishii m, et al. laparoscopic repeat hepatic resection for the management of liver tumours. j gastrointest surg 2019;23:2314-21. 19. us food and drug administration. caution with roboticallyassisted surgical devices in mastectomy. 2021. available from: https://www.fda.gov/medical-devices/safety-communications/update-caution-robotically-assisted-surgical-devicesmastectomy-fda-safety-communication 20. di benedetto f, petrowsky h, magistri p, halazun kj. robotic liver resection: hurdles and beyond. int j surg 2020;82:155-62. 21. machairas n, papaconstantinou d, tsilimigras di, et al. comparison between robotic and open liver resection: a systematic review and meta-analysis of short-term outcomes. updates surg 2019;71:39-48. 22. halls mc, alseidi a, berardi g, et al. a comparison of the learning curves of laparoscopic liver surgeons in differing stages of the ideal paradigm of surgical innovation: standing on the shoulders of pioneers. ann surg 2019;269:221-28. social and political factors affecting public health [page 24] [healthcare in low-resource settings 2024;12(s2):12325] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12416 set of heart failure early mortality prevention methods boguslawa serzysko,1 renata mroczkowska,2 beata podsiadlo,3 boguslawa kupczak wisniewska4 1department of healthcare, silesian center for heart diseases, zabrze; 2faculty of health sciences, institute of health sciences of the university of opole; 3faculty of health sciences, medical university of silesia, katowice; 4faculty of health sciences, university of bielsko-biala, poland abstract heart failure is a common chronic disease with a poor prognosis that often ends in death. the research thus aims to thoroughly investigate ways in which the prognosis of heart failure could be improved. for this purpose, a 9-month study was conducted with a group of people who followed the mediterranean diet, and the effects of this diet on the cardiovascular system and the state of the body as a whole were assessed. the study found that adherence to the principles of the mediterranean diet improved the quality of life of patients, according to the quality-of-life questionnaire (the average score was 81.3 at the beginning of the study and 87 points at the end of the study), and the level of adherence to the mediterranean diet in the study group increased from 30 points to 39.7, according to the meddietscore (mds) scale. there was also an improvement in appetite and sleep quality. a decrease in the average blood pressure in the group was recorded (from 140/95 to 137/88 mmhg). it was found that due to proper nutrition, the participant’s body mass index (bmi) was reduced (from 31.2 kg/m2 to 29.6 kg/m2), and the percentage of overweight people in the study group was also reduced from 44% to 26%. it was noted that no deterioration in heart failure class or functional class was recorded during the study. the left ventricular ejection fraction remained unchanged. introduction more than 65 million people worldwide have heart failure.1 it is a clinical syndrome characterised by structural or functional impairment of ventricular blood filling or ejection. the main symptoms include shortness of breath, peripheral edema, and coughing. the disease is categorised into acute and chronic forms. it is worth noting that about 80% of cardiovascular diseases, resulting in early deaths, can be prevented. to do this, it is necessary to identify all possible risk factors and understand which of them can be influenced to achieve the desired results. the list of uncontrollable factors includes age (older people have a higher risk of developing cardiovascular disease); gender (postmenopausal women are more sensitive to the onset of cardiovascular disease); a burdened family history and genetic characteristics. however, there is a much longer list of factors that are directly dependent on the individual: an unhealthy diet, low physical activity (or no physical activity at all), overweight/obesity, smoking, frequent alcohol consumption, chronic stress, high blood pressure, high cholesterol, and atrial fibrillation. thirty-nine percent of the world’s adult population is overweight, and 18% of them are diagnosed with obesity. an increase in body weight of more than 10 kg above the individual norm increases the risk of coronary heart disease by 12%, an increase in systolic blood pressure by 3 mm hg, and diastolic blood pressure by 2.3 mm hg. obese patients develop heart failure 10 years earlier than those who are not overweight. in addition, if there is a history of obesity lasting more than 20 years, the risk of heart failure increases by 70%, and over 30 years, by more than 87%. according to studies by csige et al., obese patients have a 1.5-fold higher risk of atrial fibrillation compared to the general population.2 in addition, a 1-point increase in body mass index (bmi) increases the risk of a new atrial fibrillation attack by 4%. the presence of atrial fibrillation in combination with obesity leads to an increased risk of stroke, heart attack, heart failure, thromboembolism, and sudden coronary death. correspondence: boguslawa serzysko, department of healthcare, silesian center for heart diseases, zabrze, poland. e-mail: bogu.serzysko@gmail.com key words: cardiac diseases, prognosis, mediterranean diet, physical activity, lifestyle. contributions: bs and rm, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; bp, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; bkw, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. patients’ consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data supporting the findings of this study are available on request from the corresponding author. received: 22 fubruary 2024. accepted: 3 april 2024. early view: 28 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12416 doi:10.4081/hls.2024.12416 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12416] [page 31] non -co mmerc ial us e o nly poor food quality, ultra-processed foods, low physical activity, and stress all contribute to the development of inflammatory processes and oxidative stress. smoking, alcohol consumption, and obesity, together with the above factors, provoke the onset and exacerbation of hypertension, dyslipidaemia, diabetes mellitus, and sleep disorders, which subsequently lead to left ventricular remodelling, atherosclerosis, coronary heart disease, and subsequent heart failure. many scientists have already comprehensively studied the features of heart failure and ways to combat it. for example, polish scientists niewada et al. studied and analysed the feasibility and effectiveness of using telerehabilitation for cardiac diseases.3 based on information from the telereh-hf randomised clinical trial, which examined the effectiveness of telerehabilitation in comparison to conventional centre-based cardiac rehabilitation, the researchers carried out an economic analysis. the expenses of hospitalisation, interventions, and the use of healthcare resources were all examined by the authors in relation to telerehabilitation and traditional rehabilitation. in order to evaluate the cost-effectiveness of telerehabilitation, the researchers also took clinical outcomes like quality of life and functional capacity into consideration. jozwiak et al. estimated the prevalence of cardiovascular diseases and their risk factors among the polish population.4 the researchers collected data on various cardiovascular risk factors, such as smoking, obesity, hypertension, diabetes, and dyslipidemia, as well as the presence of cardiovascular diseases, including coronary artery disease, myocardial infarction, and stroke. the study included a sizable sample of patients in primary care and offered insightful information about the prevalence of illnesses and cardiovascular risk factors in polish patients seeking primary care. driggin et al. assessed the role of diet in heart failure.5 the authors emphasise how a healthy diet can help people with heart failure live better lives and achieve better clinical results. the review examines a number of nutritional assessment topics, such as body composition, dietary intake patterns, and nutritional status evaluation. it also looks at various dietary approaches and how well they might work to control heart failure. the review looks at the research on the effects of particular dietary patterns on heart failure and cardiovascular health, including the dash diet, the mediterranean diet, and plant-based diets. the writers also cover the function of particular nutrients in the diet, including potassium, salt, and protein, in the treatment of heart failure. at the same time, despite a significant number of studies, there is still controversy about the optimal and most beneficial type of diet for heart failure. as such, the research aims to investigate whether adherence to the mediterranean diet can improve the prognosis and slow the progression of heart failure. in particular, this study intends to investigate in detail the impact of a mediterranean diet on cardiovascular health and overall health in patients with chronic heart failure and preserved left ventricular ejection fraction. the ultimate goal is to ascertain whether implementing a mediterranean diet can have a beneficial impact on these variables and possibly improve the prognosis for heart failure patients. materials and methods a study was conducted to investigate the effect of the mediterranean diet on the cardiovascular system and general health in patients with chronic heart failure with preserved left ventricular ejection fraction. the study involved 200 patients (100 women and 100 men). it was noted that all study participants were adults and legally capable. all patients signed a voluntary informed consent to participate in the study. patient inclusion criteria: age over 40 years, preserved left ventricular ejection fraction (50% and above), new york heart association class 2-3, functional class 2-3, compensated heart failure, absence of uncompensated mental disorders.6 exclusion criteria: minor age of patients, presence of severe mental disorders, and decompensated diseases. participants were aged 40 to 69 years. monitoring was conducted for 9 months on an outpatient basis. the patients were thoroughly examined before the study. an echocardiographic assessment was performed using a multifrequency transducer and tissue doppler imaging. the left ventricular ejection fraction was estimated using the simpson method.7 the bmi was calculated using the standard formula (body weight measured in kilograms divided by height squared, calculated in m). the patient’s blood pressure was measured using a standard method (sitting, at rest). biochemical blood tests were carried out, and glucose levels were determined. a questionnaire was conducted to assess the quality of sleep and appetite of participants before the study and after 9 months. it was proposed to evaluate the quality of sleep from 0 to 3 points, where 0b means no sleep problems and 3b means regular insomnia, the presence of apnoea. the level of appetite is determined by the following criteria: 0b – no appetite disorders; 1b – periodic lack of appetite; 2b – frequent lack of appetite; 3b – craving for inedible objects (chalk, clay). the nutrition was assessed using the metdietscore scale.8 the scale consists of eleven items that describe the quantitative and qualitative consumption of foods that are part of the mediterranean diet. each item is rated from 0 to 5 points. 0 points are given in the absence of consumption of foods that are part of the mediterranean diet; 1 point – for the consumption of 1 to 4 servings per month of foods characteristic of the above type of diet; 2 points – for the consumption of 5-8 servings per month; 3 points – 9-12 servings per month; 4 points – 13-18 servings per month. the following criteria are defined for alcohol consumption: 0 points – more than 700 ml/day; 1 point – 700 ml/day; 2 points – 600 ml/day; 3 points – 400-500 ml/day; 4 points – 300 ml/day; 5 points – less than 300 ml/day. the maximum number of points was 55. a higher score indicated greater dietary adherence. the scaling was completed two times: before the start of the study and nine months after the start of the study. participants were also asked to fill out a qualityof-life questionnaire to subjectively assess their well-being before the study and 9 months after compliance with the required conditions.9 the questionnaire contains 16 questions, each of which is rated from 1 to 7 points. the survey was conducted using an individual questionnaire. the results were assessed by adding up the points for each item (7 points in total). the number of points ranges from 16 (terrible quality of life) to 112 (excellent quality of life); the higher the score, the better the quality of life. the patients were trained and counseled by qualified nutritionists and nurses before the trial began. mandatory consultations were held every month during the trial, as well as when necessary (at the patients’ request). the results of the study were evaluated by nutritionists, cardiologists, and functional diagnosticians nine months after the start of the study. the main assessment parameters were subjective (adherence to the mediterranean diet, sleep quality, appetite, and general condition according to the quality-of-life questionnaire) and objective (left ventricular ejection fraction, body mass index, blood pressure, blood glucose). this study utilised robust methods to evaluate the effects of adhering to the mediterranean diet on various health parameters in patients with chronic heart failure and preserved ejection fraction. social and political factors affecting public health [page 32] [healthcare in low-resource settings 2024;12(s2):12416] non -co mmerc ial us e o nly comprehensive data on cardiac function, metabolic indicators, and changes in body composition were obtained using objective clinical examinations such as echocardiography, blood tests, and anthropometric evaluations. this methodological approach, which included regular monitoring and monthly consultations, allowed for a thorough investigation of the long-term effects of the mediterranean diet on several risk factors and outcomes in this particular heart failure population. results before the study, all participants were diagnosed with chronic heart failure of stages 2-3 according to the new york heart failure scale (2a – 30%, 2b – 60%, and 3 – 10%) with preserved left ventricular ejection fraction. it was determined that in the study group of patients, 70% had fc 2, fc 3 – 30%. the left ventricular ejection fraction in the group of participants averaged 52.2% (from 50 to 54%). blood pressure levels averaged 140/95 mmhg, with a maximum of 150/100 mmhg in the group. the average score for adherence to a healthy diet before the study, according to the meddietscore (mds) questionnaire, was 30 points (indicating moderate adherence to the mediterranean diet) (figure 1). at the beginning of the study, 52% of respondents had sleep problems, with 10% scoring the maximum of 3 points. impaired appetite was detected in 42%, of whom 8% scored a maximum of 3 points (craving for inedible objects can be explained by the possible presence of anemia, which is common in patients with chronic heart failure, but this study did not include red blood cell, haemoglobin, iron, and ferritin levels, so the presence of chronic anemia can only be assumed). the average value of the indicators according to the quality-of-life questionnaire was 81.3 points. the average bmi of the participants was 31.2 kg/m2, with 44% of the participants being diagnosed as overweight. glucose levels averaged 4.9, which was within the normal range (3.3-5.5 mmol/l). none of the participants had been diagnosed with diabetes before the study (figure 2). nine months after the start of the study, all participants refilled out the mds questionnaire. it was found that the level of adherence to the above type of diet increased among patients, with an average score of 39.7. this can be explained by the fact that at the beginning of the study, all participants were explained in detail the principles and benefits of the mediterranean diet, the key points of this type of diet were described, and an exhaustive list of adequate recipes was presented. it was also explained that for better adherence to this type of diet, it is worth eating food from beautiful, favourite dishes, preparing bright, appetising dishes, and trying to spend more time with oneself and one’s inner state. in addition, the patients themselves were able to observe changes in their health status and its improvement over the course of 9 months as a result of correcting their eating habits, which probably contributed to a higher score on the mds questionnaire when they completed it again (figure 3). as a result of the study, all participants were rediagnosed with chronic heart failure of stages 2-3 according to the new york heart failure scale (2a – 30%, 2b – 60%, and 3 – 10% of people) with preserved left ventricular ejection fraction, fc 2 had 70%, fc 3 – 30%. it is concluded that in this study, adherence to the mediterranean diet did not affect the functional class of chronic heart failure. the left ventricular ejection fraction averaged 52.8% (50 to 54%). there were slight changes in the ejection fraction (52.8 vs 52.2 at the beginning of the study), but these changes are not significant and can be considered an error in the calculations. the average blood pressure level was 137/85, indicating a slight decrease in the group. none of the participants had significant fluctuations in their blood pressure during the study. the average value of the quality-of-life questionnaire was 87 points (figure 4). sleep problems were detected in 36% of respondents. at the same time, none of the participants scored 3 points during the repeat test 9 months later. this is explained by the improvement in the general condition due to nutritional correction and weight loss, which contributed to the improvement of sleep quality. appetite social and political factors affecting public health figure 1. indicators of compliance with the mediterranean diet before the study. figure 2. assessment of quality of life before the study. figure 3. mediterranean compliance rates after a nine-month study. figure 4. assessment of quality of life after the study. [healthcare in low-resource settings 2024;12(s2):12416] [page 33] non -co mmerc ial us e o nly disorders were detected in 16%, of whom 2% scored the maximum of 3 points. eating a lot of fruit and vegetables helped improve appetite. the average body mass index of the participants was 29.6 kg/m2, with 26% of participants diagnosed as overweight. it was concluded that adherence to the mediterranean diet contributed to the normalisation of weight among the participants. the performance of each patient depended on their individual adherence to this type of diet. glucose levels averaged 4.8. among the study participants, glucose levels were initially within the physiological range. after nine months, no significant changes in individual or total values were detected. none of the participants was diagnosed with diabetes at the end of the study. thus, it was concluded that adherence to the mediterranean diet had a positive effect on the general condition of patients, contributed to weight normalisation and improved sleep quality and quality of life in general. this is because this type of food consists of a unique complex of fats, proteins, carbohydrates, starch, fiber, minerals, vitamins, and a large number of biologically active components: phytosterols, terpenes, and polyphenols. together, they help reduce oxidative stress and chronic inflammation, improve lipid metabolism, and normalise platelet aggregation. it is worth noting that the mediterranean type of diet is not just a certain set of products but rather a way of life that includes eating food in moderate portions, cooking in a good mood using favourite utensils, moderate daily physical activity, including walks, healthy, high-quality, full sleep. all of this together significantly improves the prognosis for heart failure. over the past decades, researchers have focused on the benefits of certain dietary patterns rather than just individual components. thus, the most well-known and relevant nutritional models are the mediterranean diet (the benefits of which were described in this study), approaches to the treatment of hypertension, and the nordic diet. these types of nutrition are considered the most beneficial, as they reduce the risks of the onset and progression of most currently known non-communicable diseases (table 1).10-14 regular physical activity ensures better cardiovascular functioning, improves the prognosis of heart failure, and reduces the risk of early mortality. this requires 150 to 180 minutes of activity per week. this can include cycling, daily walks, walking up and down the stairs, and playing with children. studies by wang et al. have reported that in a group of patients with heart disease, a 13% reduction in mortality risk was recorded after a 12-week moderateintensity exercise program.15 at the same time, regular exercise reduces oxidative stress, the level of pro-inflammatory cytokines, anxiety, and stress. exercise leads to an increase in the production of neurotransmitters and hormones and improves appetite, sleep quality, and overall well-being. smoking cessation and low/no alcohol consumption are important factors in preventing early mortality. smoking increases the risk of heart attack several times in middle-aged people. at the same time, smoking cessation for 5 years or more significantly reduces the risk of premature death. frequent consumption of alcoholic beverages contributes to high blood pressure, lipid metabolism, and overweight or obesity. stress causes an increase in heart rate and blood pressure due to the increased release of adrenal hormones. prolonged exposure to stress factors increases blood flow, increases the heart’s need for oxygen, and can lead to the development of coronary heart disease, hypertension, heart attacks, and arrhythmias.16 in addition, prolonged exposure to stress worsens the quality of sleep and contributes to excessive consumption of alcohol and medical and psychotropic substances. to combat stress, walking is useful, as it produces myokines that help improve overall health and reduce anxiety; discussing the problem with loved ones and trying to find rational ways to solve it; and, if necessary, consulting a psychologist to prevent several chronic diseases, including cardiovascular diseases. sleep quality affects the state of the cardiovascular system. short-term inadequate sleep is associated with an increased risk of developing hypertension, coronary heart disease, stroke, metabolic syndrome, and chronic heart failure. the recommended sleep duration for adults is 6-8 hours per day. it is useful to fall asleep at 10-12 p.m. with the lights off, as this is when the necessary hormone melatonin is produced. thus, in conclusion, the main social and political factors affecting public health table 1. models of healthy eating.10-14 product name mediterranean diet anti-hypertension diet northern diet fruit 1-2 servings per day, daily consumption 5 servings daily 200-250 g/day vegetables 2 or more servings per day, daily consumption 5 servings daily 200-250 g/day whole grain products (bread, pasta, rice) 2 servings per day, daily consumption 7-8 servings daily 5 slices of bread per day; pasta 3 times a week dairy low-fat foods 1-2 times a day (usually yoghurts) low-fat products; low-fat dairy 2-3 servings daily seeds, nuts and beans seeds and nuts 1-2 servings daily; 4-5 servings daily preferably almonds 10-20 g/day beans more than 2 servings per week meat red meat 1-2 servings per week; white meat 2 low-fat varieties 1 portion per day red meat less than 500 g/week; or more servings per week (preference is given to white meat) poultry less than 300g/week seafood and fish >2 times a week low-fat types 1 serving per day1; 3-5 servings weekly 1 serving daily unsaturated fats, oils 1-2 servings per day, including daily 2-3 servings per day 1-2 servings daily consumption of olive oil (unrefined oils, including sunflower and olive). sweets less than 2 servings per week less than 2-3 servings weekly 2 or less times a week alcohol wine in moderation women 1 or less drink per day; in moderation men 2 or fewer drinks per day other water as a primary drink; eggs the main idea of this diet is to reduce the eggs 1-2 servings per 2-3 servings per week; potatoes intake of table salt to 2000-2300 mg/day week; potatoes 100-250 g/day less than 3 servings per week; daily consumption of herbs and spices; sweets and cakes – rarely [page 34] [healthcare in low-resource settings 2024;12(s2):12416] non -co mmerc ial us e o nly ways to improve the prognosis of heart failure are daily consumption of healthy food (in particular, the mediterranean type of diet), physical activity of 150 to 180 minutes per week, alcohol restriction and smoking cessation, healthy sleep, and reduction of stress factors. discussion polish researchers kasprzak et al. found that about 1.2 million people in poland have symptomatic heart failure, with mortality rates of more than 140 thousand patients per year.17 therefore, scientists have considered new strategies to improve the prognosis of heart failure. it has been shown that the presence of anemia significantly worsens the prognosis. at the same time, its occurrence is not related to the age of patients and ventricular ejection fraction. therefore, it is recommended that all patients with heart failure be screened for hemoglobin and blood iron levels; intravenous iron supplementation in the form of an iron-carboxy-terminal complex should be prescribed, if necessary, to reduce symptoms and improve exercise tolerance in patients with a left ventricular ejection fraction less than 45% and a ferritin level less than 100 µg/l. the study also described that the prognosis of heart failure depends on the level of macronutrient and trace element concentrations. in particular, it was found that limiting salt (natrium) intake to 2000-2300 mg/day has a positive effect on blood pressure and cardiovascular health. daubert and douglas studied the risks of developing heart failure in women.18 it has been shown that women with heart failure have a higher bmi and a higher left ventricular ejection fraction, and are more likely to have concomitant hypertension and renal failure compared to men. according to the research of the authors, 63% of women with heart failure have coronary heart disease and ischaemic cardiomyopathy. it is also more difficult for women to achieve adequate blood pressure control compared to men (44.8% vs 51.1%), and this figure becomes even lower with age; after the age of 70, only 29% of women have controlled blood pressure. this is due to increased stiffness of the arteries, excessive activation of the renin-angiotensin system, and impaired water and salt metabolism as a result of age-related postmenopausal changes in hormone metabolism.19,20 at a young age, due to the influence of estrogen, women regulate blood pressure and protect the vascular endothelium from the development of atherosclerosis, but with age, this protective effect of estrogen significantly decreases.21 female and male gender hormones have different effects on medication metabolism, which leads to different required dosages of medicine and manifests itself in different side effects. women have a better response to diuretics, angiotensin-converting enzyme inhibitors, and beta-blockers, so a lower dosage of these medicines is sufficient. correct lowering of blood pressure in women (systolic blood pressure <120 mmhg) was associated with fewer cases of acute uncompensated heart failure. in the presence of gestational diabetes, pre-eclampsia, eclampsia and preterm birth, the risk of heart failure increases by 80%, and the likelihood of an early stroke in such patients doubles. there is also a link between type 2 diabetes in women and the development of chronic heart failure and a reduced left ventricular ejection fraction.22 it has been shown that older women with diabetes mellitus have a 5-fold increased risk of developing coronary heart disease and ejection fraction disorders compared to men. physical interventions are quite effective for women. with 60-150 minutes of brisk walking per week, postmenopausal women showed a 10% reduction in the development of heart failure. the study also noted that about 150-180 minutes of moderate physical activity per week are required for adequate cardiovascular functioning. mu et al., trautwein and mckay, cena and calder studied the role of sodium restriction in the course of cardiovascular failure.10-12 in patients with heart disease, the reninangiotensin-aldosterone system is activated, and vasopressin levels increase, leading to increased sodium and water retention in the body and, accordingly, increased stress on the cardiac system. therefore, many diets recommend limiting the amount of sodium to reduce the burden on the heart, normalise blood pressure, and reduce the symptoms of heart failure. bojang and manchana, monteiro et al., s.a. jebb have also shown that reducing the consumption of polyunsaturated fatty acids and replacing them with polyunsaturated ones reduces the risk of developing cardiac disease.23-25 replacing 5% of the total intake of polyunsaturated fatty acids with polyunsaturated fatty acids reduced the likelihood of coronary heart disease by 10%. increasing the consumption of dietary fibre (contained in vegetable peels, potatoes, nuts, and whole grain products) leads to normalisation of the gastrointestinal system, reducing the risk of cardiovascular disease and type 2 diabetes. for example, daily consumption of 3.5 g of oat beta-glucan helped to reduce low-density lipoprotein by 4.8% compared to the control group. this study also confirmed the benefits of fiber and whole grain products, which are important components of the mediterranean diet. kasprzak et al. found that about 40% of polish patients with chronic heart failure die within 5 years of diagnosis.17 as such, scientists described in detail the necessary pharmacological interventions for heart failure. for example, to minimise symptoms of cardiac disease, patients should be prescribed loop diuretics, while this group of medicines is not prescribed for a long time and does not improve the prognosis in the long term. it has been shown that patients with a reduced left ventricular ejection fraction should be prescribed renin-angiotensin-aldosterone system inhibitors (iraas), beta-blockers (bisoprolol, carvedilol, metoprolol), mineralocorticoid receptor antagonists (spironolactone), sodium and glucose co-transporter type 2 inhibitors (dapagliflozin, empagliflozin). iraas inhibit the activity of the angiotensin-converting enzyme and blocks receptors for angiotensin 2. it has been proven that they improve prognosis, provided that the dosage is correctly selected and used continuously at the recommended maximum doses. valsartan is recognised as a first-line medicine in the treatment of chronic heart failure in patients with reduced left ventricular ejection fraction.26,27 however, before prescribing this group, it is necessary to determine the level of potassium in the blood serum, assess kidney and liver function, and measure blood pressure. the results of randomised placebo-controlled trials using beta-blockers in patients with heart failure showed a 35% reduction in the risk of death compared to placebo. it was found that spironolactone reduced the risk of hospitalisation in patients with chronic heart failure and a left ventricular ejection fraction >45%. however, when prescribing this medicine, it is necessary to carefully monitor the level of creatinine blood electrolytes (potassium, sodium), and glomerular filtration rate. dapagliflozin is a representative of a relatively new but highly effective group of medicines. the medicine functions by reducing glucose reabsorption, lowering the renal threshold for glucose, and, accordingly, increasing glucose excretion, nephroprotective effect, and reduction of preload and postload on the left ventricle (by increasing osmotic diuresis, lowering plasma levels, and reducing blood pressure).28 a study found that patients taking dapagliflozin had a 17% reduction in the relative risk of all-cause social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12416] [page 35] non -co mmerc ial us e o nly mortality, a 25% reduction in the risk of death from heart failure, and improved general health and quality of life. the results of this investigation offer strong proof that individuals with preserved ejection fraction and chronic heart failure can benefit in a variety of ways from implementing the mediterranean diet. notably, subjective quality of life measurements and objective clinical markers significantly improved when the mediterranean diet’s tenets were followed. notably, favourable benefits were noted in important cardiovascular risk indicators, such as a drop in the percentage of patients who were overweight and an average blood pressure reduction. the mediterranean diet’s capacity to encourage weight loss highlights its potential to help heart failure patients with obesity-related problems. the mediterranean diet is a potentially effective non-pharmacological intervention for enhancing prognosis and quality of life in the treatment of chronic heart failure, as demonstrated by these multifaceted favourable outcomes. conclusions the study concluded that many millions of people around the world suffer from heart failure. this disease significantly worsens the quality of life, reduces its duration, and is incurable. at the same time, the development of heart failure can be prevented by reducing the impact of pathological factors. pathologically controllable factors that worsen the prognosis of heart disease are poor nutrition, lack of sufficient physical activity, insufficient sleep, overweight and obesity, exposure to stress, alcohol consumption and smoking, high uncontrolled blood pressure, high cholesterol and abnormal lipoprotein ratios, and atrial fibrillation. all of these factors can be influenced by maintaining a healthy diet, getting 150 to 180 minutes of physical activity per week, quitting bad habits, and controlling stress. the study found that adherence to the principles of the mediterranean diet improved the quality of life of patients, according to the quality-of-life questionnaire (the mean score was 81.3 at the beginning of the study and 87 at the end of the study), and the level of adherence to the mediterranean diet in the study group increased from 30 points to 39.7, according to the mds scale. there was also an improvement in appetite and sleep quality. a decrease in the average blood pressure in the group was recorded (from 140/95 to 137/88 mmhg). it was found that due to proper nutrition, the participant’s bmi was reduced (from 31.2 kg/m2 to 29.6 kg/m2), and the percentage of overweight people in the study group was also reduced from 44% to 26%. it was noted that no deterioration in heart failure class or functional class was recorded during the study. the left ventricular ejection fraction remained unchanged. the main mechanisms that contribute to the improvement of the cardiovascular system when following the mediterranean diet are the reduction of oxidative stress, normalisation of lipid metabolism, and platelet aggregation. at the same time, further research is needed on the pathophysiological mechanisms of the mediterranean diet’s effect on heart failure and its prognosis. references 1. habibzadeh h, shariati a, mohammadi f, babayi s. the effect of educational intervention based on pender’s health promotion model on quality of life and health promotion in patients with heart failure: an experimental study. bmc cardiovasc disord 2021;21:478. 2. csige i, ujvarosy d, szabo z, et al. the impact of obesity on the cardiovascular system. j diabetes res 2018;2018:3407306. 3. niewada m, tabor b, piotrowicz e, et al. cost-effectiveness of telerehabilitation in patients with heart failure in poland: an analysis based on the results of telerehabilitation in the heart failure patients (telereh-hf) randomized clinical trial. kardio polska 2021;79:510-6. 4. jozwiak j, studzinski k, tomasik t, et al. the prevalence of cardiovascular risk factors and cardiovascular disease among primary care patients in poland: results from the lipidogram2015 study. atheroscler suppl 2020;42:e15-24. 5. driggin e, cohen l, gallagher d, et al. nutrition assessment and dietary interventions in heart failure: jacc review topic of the week. j am coll cardio 2022;79:1623-35. 6. wisnicka a, lomper k, uchmanowicz i. self-care and quality of life among men with chronic heart failure. front public health 2022;10:942305. 7. guta a, badano l, ochoa-jimenez r, et al. three-dimensional echocardiography to assess left ventricular geometry and function. expert rev cardiovasc ther 2019;17:801-15. 8. alaufi n, chan y, waly m, et al. application of mediterranean diet in cardiovascular diseases and type 2 diabetes mellitus: motivations and challenges. nutrients 2022;14:2777. 9. burckhardt c, anderson k. the quality of life scale (qols): reliability, validity, and utilization. health quality life outcomes 2003;1:60. 10. mu l, yu p, xu h, et al. effect of sodium reduction based on the dash diet on blood pressure in hypertensive patients with type 2 diabetes. nutr hosp 2022;39:537-46. 11. trautwein ea, mckay s. the role of specific components of a plant-based diet in management of dyslipidemia and the impact on cardiovascular risk. nutrients 2020;12:2671. 12. cena h, calder p. defining a healthy diet: evidence for the role of contemporary dietary patterns in health and disease. nutrients 2020;12:334. 13. itsiopoulos c, mayr h, thomas c. the anti-inflammatory effects of a mediterranean diet: a review. curr opinion clinic nutr met care 2022;25:415-22. 14. wang y, fan h, ren z, et al. sleep disorder, mediterranean diet, and all-cause and cause-specific mortality: a prospective cohort study. bmc public health 2023;23:904. 15. wang j, liu w, lee c. associations of adherence to the dash diet and the mediterranean diet with all-cause mortality in subjects with various glucose regulation states. front nutr 2022;9:828792. 16. badiuk n, hrebenyk m. cardiac arrhythmias in patients with acute myocardial ischemia, which developed on the background of comorbid hypertension and diabetes. bull med biol res 2021;3:5-9. 17. kasprzak j, gorczyca-glowacka i, sobczak-kaleta m, et al. expert opinion of working group on cardiovascular pharmacotherapy, polish cardiac society. kardio polska 2023;81:537-56. 18. daubert m, douglas p. primary prevention of heart failure in women. jacc. heart failure 2019;7:181-91. 19. orel m, martynyuk l. endothelial dysfunction correction in patients with hypertension, dyslipidaemia, and decreased thyroid function. int j medic med res 2023;9:24-31. 20. bezkorovaina h, klishch im, khara m, pelykh v. gender-spe social and political factors affecting public health [page 36] [healthcare in low-resource settings 2024;12(s2):12416] non -co mmerc ial us e o nly cific differences of cardiac vegetative control in adrenalineinduced necrosis and light deprivation. int j medic med res 2019;5:137-44. 21. akhmetova km, vochshenkova ta, dalenov ed, et al. the interconnection of metabolic disorders and carotid atherosclerosis in the kazakh population. system rev pharm 2020;11:2152-9. 22. svyatova g, berezina g, danyarova l, et al. genetic predisposition to gestational diabetes mellitus in the kazakh population. diab metab syndr: clin res rev 2022;16:102675. 23. bojang k, manchana v. nutrition and healthy aging: a review. curr nutr rep 2023;12:369-75. 24. monteiro s, nejad y s, aucoin m. perinatal diet and offspring anxiety: a scoping review. trans neurosci 2022;13:275-90. 25. jebb s. interventions to accelerate change towards a healthier diet. proc nutr soc 2018;77:106-11. 26. nuritdinov na, kamilova uk. effects of spironolactone and eplerenone on left ventricular diastolic function and neurohumoral factors in patients with heart failure. cardiovasc ther prev 2020;19:31-7. 27. nuritdinov n, khamraev a. comparative efficiency of spyronolactone and eplerenon in patients with chronic heart failure. kardiol belarusi 2020;12:270-5. 28. vadzyuk s, tabas p. cardio-respiratory endurance of individuals with different blood pressure levels. bull med biol res 2023;16:30-8. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12416] [page 37] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12319 prevalence and correlates of complementary and alternative medicine utilization among infertile women attending selected fertility clinics in khartoum state masani elmahdy,1 faiza ali nasor2 1college of nursing, gulf medical university, ajman, united arab emirates; 2obstetrics and gynecology nursing department, faculty of nursing, university of khartoum, sudan abstract infertility poses multifaceted challenges, prompting many women to explore complementary and alternative medicine (cam). this study investigated cam prevalence and types among infertile women in khartoum. a descriptive cross-sectional study was conducted, involving 253 women. data was collected through structured interviews, and descriptive and inferential statistics, with a significance level set at p>0.05. the mean age of the participants was 31.59±6.9 years, with 53.8% being graduates, 54.5% diagnosed with primary infertility, and 45.5% with secondary infertility. cam usage was reported by 52.2% of participants, with herbal treatments being the most prevalent (e.g., fenugreek 26.9%, argell 20.2%). spiritual healing (11.4%) and folkloric methods (9.5%) were also noted. most users (76.5%) did not disclose cam usage to healthcare providers, citing beliefs in safety (56.8%) and effectiveness (39.4%). family (72%) and friends (46%) significantly influenced cam use. infertility duration and rural residence were associated with cam usage (p=0.002). the study underscores a high prevalence of cam usage among sudanese infertile women, primarily herbal remedies, and emphasizes the importance of healthcare providers engaging patients in cam utilization. introduction infertility is generally defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex. about 6% of married women aged 15-44 in the united states are unable to get pregnant after one year of trying (infertility).1 the world health organization (who) demographic studies also show that in sub-saharan africa, more than 30% of women aged 25-49 suffer from secondary infertility.2 who defined traditional medicine as “diverse health practices, approaches, knowledge, and belief incorporating plant, animal, mineral base medicine, spiritual therapies, and exercises applied singularly or in combination to maintain wellbeing, as well as to treat, diagnose, or prevent illness. the term complementary/alternative/non-conventional medicine is used interchangeably with traditional medicine in some countries”.3 as efforts to have a child fail, couples experience several socio-emotional outcomes in which, women endure more painful emotional experiences because in many countries, being a woman means to be a mother. in addition, psychological outcomes incurred by couples as a result of infertility treatment and costs impose more pressure on them for assisted reproductive technologies (arts), such as in vitro fertilization (ivf). nevertheless, couples have a greater tendency toward natural treatments than aggressive ones such as ivf. as much as arts are not always successful, couples are inclined to experience treatments other than conventional ones, including complementary and alternative medicine (cam).4 people facing infertility concerns are increasingly turning to the use of arts. correspondence: masani elmahdy, college of nursing, gulf medical university, ajman, united arab emirates. tel.: +971566585368. e-mail: masani.elmahdy@gmail.com key words: cam, alternative medicine, herbal medicine, infertility, women. contributions: me, fan, conception or design of the work, drafting of the article, critical revision of the article, final approval; me, data collection, data analysis, and interpretation. the authors state that no artificial intelligence-assisted technologies (such as large language models, chatbots, or image creators) were used in the production of submitted work. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: ethical approval from the khartoum faculty of nursing university sciences institutional review board was obtained. informed consent: informed consent from each research candidate was obtained, and confidentiality was maintained. funding: none. availability of data and materials: not applicable. acknowledgments: the authors praise allah the almighty for giving us the determination and the strength to complete this study. they would like to express appreciation and gratitude to the fertility center’s staff members, managers, and the participants for their cooperation and also, to acknowledge the university of khartoum, faculty of nursing sciences, faculty, and staff for their cooperation. received: 29 january 2024. accepted: 19 april 2024. early access: 12 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12319 doi:10.4081/hls.2024.12319 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 362] [healthcare in low-resource settings 2024;12:12319] non -co mmerc ial us e o nly however, successful treatment outcomes are far from certain because 68.5% of ivf cycles do not result in a live birth. these high failure rates lead many couples to look for ways to improve their chances of achieving conception.5 cam includes diagnostic, therapeutic, and preventive methods that complement conventional treatments. convenient access and lower costs of such treatments have increased their application in different populations.4 the various types of cam offered, along with the increasing market for alternative fertility products, make it significant to have a broader understanding of the effectiveness of these treatments. cam supposedly offers couples a way to improve outcomes and/or decrease stress and anxiety levels during treatment. cam is also used to incorporate cultural traditions of health and fertility as well as increase feelings of hope and control during a biomedical fertility treatment plan. some patients also use cam as an alternative to arts, although most fertility patients use cam in addition to biomedical fertility treatment.5 justification the findings of this study will redound to the benefit of both healthcare providers and infertile women and will uncover critical areas in sudanese culture. we could not find any study in sudan that explored the use of cam for the treatment of infertility. however, various complementary therapies, including spiritual and herbal methods, are well known among the community in sudan. statement of the problem infertility is a public health issue. the stigma, costs, and uncertainty associated with biomedical fertility treatments often entice those who have problems conceiving to use cam.6 despite the popularity of traditional and complementary medicine, evidence of its safety and efficacy remains inconclusive.7 in sudan, the success rate of arts claimed by fertility centers is between 25-30%, which is low. currently, there are two significant barriers to infertility care mentioned by all centers: high cost and inaccessibility. moreover, the average sudanese couple cannot afford arts without support.8 a large sector of the sudanese population uses traditional and religious medicine to meet their primary healthcare needs. in addition to being accessible and affordable, it is part of their belief system. despite reported and unreported complications in traditional practice, people seek traditional healers regularly and confide in them; they respect them and hold them in high regard.9 the literature shows widespread use of cam among infertile women. studies indicated that 49.6% of women in iran, and 36.5% in sierra leone used herbal medicine for infertility treatment.11,19 despite the widespread use of cam, only 8% and 3% of users reported discussing the issue with their doctors, educators or nurses, respectively.10 in the current study, the researchers propose to investigate the use of cam and its determinant factors among sudanese infertile women. aims and objectives as previously mentioned, the general objective is to study cam utilization and its determinant factors among sudanese infertile women attending governmental fertility clinics in khartoum state in 2020. the specific objectives include: i) to measure the percentage of infertile women attending fertility centers who use cam; ii) to identify the types of cam methods used for fertility enhancement; iii) to identify infertile women’s perception of the effect of cam on their health status. materials and methods study design and setting this study has an exploratory cross-sectional descriptive, clinic-based design. it was conducted at five randomly selected fertility centers in khartoum state, sudan (elneel fertility center, maternal health, gynecology, obstetrics and ivf center, royal care hospital, elsir abulhassan fertility center, saad abulela hospital) from march to december 2020. study population the study population included infertile females who attended a fertility center at the time of the study. the inclusion criteria were being sudanese and a female of reproductive age, with primary or secondary infertility. sample technique and sample size study participants were selected using the convenient sampling method. in order to estimate the sample size, equation 1 was used: 𝑛 = 𝑧2 ×p (1 − 𝑝) [eq. 1] 𝑑2 where n is the desired sample size and z is the standard normal deviation of 1.96 at a 95% confidence interval. in order to estimate the sample size, the values of p and 1-p were considered 0.5. the value of d was 0.05 at a confidence level of 99% and z-score was 1.95. based on equation 1, the estimated sample size was 240. in addition, considering the probability of dropouts, 20 extra participants were added. data collection method a structured face-to-face interview using a questionnaire was done by trained survey team members; their training included methods of asking the questions, providing an appropriate explanation about the types of cam modalities available, and documenting the answers based on the questionnaire. data collection tool for gathering information, a researcher-made questionnaire based on the literature, previous research, and the researcher’s knowledge and experience was used. the questionnaire consists of three parts: i) demographic data form (including age, education, occupation, income, living place, having other chronic diseases, marital history, infertility history, infertility cause, infertility treatment, and having children); ii) data related to infertility; iii) data related to cam (herbs, folklore, and spiritual healings). data analysis statistical package for the social sciences (spss) (ibm, armonk, ny, usa) was employed for data analysis. frequencies for each variable were generated and organized into tables using spss. a chi-square test was used to determine the association between the independent variables and demographic characteristics; p≤0.05 was considered statistically significant. ethical considerations ethical approval from the khartoum faculty of nursing university sciences institutional review board was obtained. informed consent from each research candidate was obtained, and confidentiality was kept. article [healthcare in low-resource settings 2024;12:12319] [page 363] non -co mmerc ial us e o nly results demographic and disease characteristics the current study is an investigation of sudanese women, use of cam for infertility treatment. sudan is a well-known country for its population heterogeneity. different tribes are well-mixed in the sudanese community. this indeed ensures the versatility of the study place. in total, 264 infertile women were invited to participate in the study from 4 different infertility centers in khartoum state, sudan. of these, 253 (95.8%) agreed to participate; they all completed the questionnaire. the mean age of participants was 31.59±6.9 years (range 17-50 years) (table 1). when the educational status was examined, it was found that most of the women were graduates (53.8%) and secondary school graduates (26.9%); additionally, 73.1% of the participants lived in urban areas whereas the rest lived in rural as well as suburban areas (3.8% and 23.1%, respectively). the majority of the participants (54.5%) were diagnosed with primary infertility, whereas the rest of them (115, 45.5%) were diagnosed with secondary infertility. the etiologies of infertility were as follows: female infertility for 111 (43.9%) participants, male infertility for 22 (8.7%), combined infertility for 29 (11.5%), and unexplained or unknown infertility for 91 (36.0%). moreover, the length of infertility was 5±4.2 years. the sociodemographic and reproductive characteristics of the study participants are detailed in tables 1 and 2. complementary and alternative medicine use results showed that of the 253 participants, 51.4% reported that they had used complementary therapies for the treatment of infertility. approximately 90% of them revealed that their reason for using such treatments was for the treatment of infertility; meanwhile, other reasons were to promote health and decrease stress (12.9% and 2.3%, respectively). based on the results, among cam, herbal treatments were the most prevalent (table 3): fenugreek (26.9%), followed by argell (20.2%), gingergrass, and cinnamon (19% for each). the rest of the practices are spiritual healing, represented in roquia (quran) at 6.7% and faki’s help at 4.7%. folkloric practices are shown in table 4. as regards the perception of cam among women who used it for infertility treatment, virtually 60% of them agreed that complementary medicines are safe for their health, while almost 40% think that herbal medicines are effective for treating infertility. about 80% of participants did not disclose to their healthcare provider that they were using cam. 70% of them used cam due to a recommendation by family, about 46% by friends, whereas 10% based on a suggestion from their healthcare providers (doctors, nurses, and pharmacists). a logistic regression model was constructed to assess associations between independent factors and complementary management. demographic, reproductive, and complementary medicineuse characteristics were incorporated into the model. in the multivariate linear regression analysis, following adjustment for other variables, residence and length of infertility were observed to have article table 1. demographic data of the participants (n=253). variable total (%) t & cam users (%) t & cam non-users (%) age, years mean 31.59 32.2±6.8 30.9 standard deviation 6.900 6.8 7 minimum 17 17 18 maximum 50 50 50 education basic 18 (7.1) 8 (6.2) 10 (8.1) secondary 57 (22.5) 35(26.9) 22 (17.9) graduate 137 (54.2) 70(53.8) 67 (54.5) postgraduate 30 (11.9) 12(9.2) 18 (14.6) uneducated 11 (4.3) 5(3.8) 6 (4.9) religion islam 249 (98.4) 130 (100) 119 (96.7) christian 3 (1.2) 0 (0) 3 (2.4) other 1 (0.4) 0 (0) 1 (0.8) residence area rural 13 (5.1) 5 (3.8) 8 (6.5) urban 198 (78.3) 95 (73.1) 103 (83.7) suburban 42 (16.6) 30 (23.1) 12 (9.8) residence state north 26 (10.3) 14 (10.8) 12 (9.8) south 9 (3.6) 4 (3.1) 5 (4.1) east 20 (7.9) 13 (10.0) 7 (5.7) west 13 (5.1) 6 (4.6) 7 (5.7) middle 184 (72.7) 93 (71.5) 91 (74.0) origin north 100 (39.5) 51 (39.2) 49 (39.8) south 10 (4.0) 5 (3.8) 5 (4.1) east 21 (8.3) 16 (12.3) 5 (4.1) west 33 (13.0) 17 (13.1) 16 (13.0) middle 89 (35.2) 41 (31.5) 48 (39.0) [page 364] [healthcare in low-resource settings 2024;12:12319] non -co mmerc ial us e o nly an independent positive association; age, cause of infertility, and type of infertility did not have an impact on the decision to use cam; no other significant associations were observed. discussion the study found that nearly half (52.2%) of infertile women utilized cam alongside conventional medical treatments. various studies have reported different frequencies of cam usage among infertile individuals. comparing our findings to those of dehghan et al.11 conducted in iran, we observed a usage rate of 49.6%. this corresponds closely with the results of studies by özkan et al 12. and bardaweel et al. 13, which reported cam usage rates of 50% and 44.7% among infertile individuals, respectively. conversely, higher consumption of complementary treatments (76.2%) was noted in studies from uganda14 and turkey15. nevertheless, some studies reported lower percentages of cam use, such as 41% in lebanon16 and 36.5% in sierra leone19. fata et al. reported the lowest frequencies, with only 35.8% of infertile couples using cam17. such disagreement might be due to sociocultural and economic differences between countries, public recognition, easy access to such treatments, and the degree of cultural pressure to have children; nonetheless, according to this study, sudanese women remain among those who consume a considerable amount of cam, comparable to other studies. this may be due to the stigma, costs, and uncertainty associated with arts,12 which are valid in most african countries where cam is one of the primary sources of healthcare because of its cultural and historical influences.8 the significant sociodemographic variables associated with complementary and alternative treatment (cmt) use in the present study were the length of infertility (p=0.002), alongside the residence (p=0.002) whether urban or rural, a woman living in a rural area is more likely to use cam, this is valid, especially in sudan, where the rural society, family members, and surroundings exert great pressure on the couple to have a child; moreover, the woman’s most, and sometimes sole role, is to rear children. the study did not find any relationship between education levels and using cam, which is similar to a study done in turkey.18 other sociodemographic characteristics were not statistically significant in contrast to other studies conducted in uganda and turkey,12,14 which found education and age may influence the decision to use cam. the study showed that women cited family and friends (72.1% and 45.9%, respectively) as key influencers in their decision to use herbal medicine; this is similar to a study conducted in sierra leone and jordan.21,19 based on the results, among cam, herbal treatments were the most prevalent: fenugreek (26.9%), followed by argell (20.2%), gingergrass and cinnamon (19% for each). this is similar to a study done in jordan which found that 30% use herbs. generally, the common belief in herb safety is largely attributed to an obvious misconception based on the fact that herbs and herbal products come from ‘nature’ and are therefore ‘naturally safe’ or ‘intrinsically harmless’ (figure 1).13 however, the risk of adverse effects increases with the fact that the choice to use herbal medicine was greatly influenced by people with low levels of knowledge about the safety and efficacy of herbal remedies, which is in line with findings from lebanon and sierra leone.16,19 other folkloric methods are aubergine fruits, cumin seeds, and dates kept under the bed (4.7%), cupping (2.0%) article table 2. obstetric and gynecologic information of the infertile women (n=253). variable all participants (%) t & cam users (%) t & cam non-users (%) length of marriage mean 6.91 7.74 6.03 standard deviation 5.009 5.351 4.475 minimum 1 1 1 maximum 25 25 25 length of infertility mean 5.05 5.86 4.18 standard deviation 4.257 4.977 3.126 minimum 1 1 1 maximum 30 30 15 type of infertility primary 138 (54.5) (56.9) secondary 115 (45.5) (43.1) cause of infertility male 22 (8.7) 12 (9.2) female 111 (43.9) 59 (45.4) both 29 (11.5) 16 (12.3) unknown or undiagnosed 91 (36.0) 43 (33.1) used cam for infertility yes 130 (51.4) no 123 (48.6) reported taking cam to care providers yes 32 (12.6) no 221 (87.4) recommending others to use cam (attitude) yes 99 (39.1) no 153 (60.5) [healthcare in low-resource settings 2024;12:12319] [page 365] non -co mmerc ial us e o nly music therapy (1.6%), and pieces of coin or qarad worn (1.2%). spiritual methods were also used (faki’s help, 4.7%; roquia, 6.7%). figure 2 illustrates that both psychological and physiological benefits were anticipated among women from traditional practices, such as achieving conception and reducing stress. these findings align with prior literature 11,17 in this study, it is apparent that there was a low disclosure rate of herbal medicine use among users; nearly 80% of cam users reported that they did not tell their healthcare provider about taking cam. this is comparable to studies in uganda and sierra leone.14,19 the reasons for nondisclosure were that healthcare providers failed to ask and the thought that it was not necessary to divulge such information, which resonates with the current literature on the nature of physician-patient communication regarding herbal medicine use in africa.20 other reasons for nondisclosure cited in the literature included fear of health providers’ reactions that can potentially undermine care and perceived lack of support and understanding from conventional healthcare providers. effective communication between patients and providers is essential to achieving the desired goal of infertility care, the absence of which can negatively affect patients’ treatment outcomes.19 therefore, healthcare providers should be aware of this and initiate a discussion with their patients about the use of alternative medical care, ensuring it is free from prejudice and based on mutual respect. as regards the perception of herbal medicine use among women seeking care for infertility, about half of the participants reported using cam for the reason that it is safe as well as effective. this is similar to that observed in the literature.11,16,19 article table 3. the herbal methods used by the study participants (n=253). method % fenugreek 26.9 argell 20.2 ginger grass 19 cinnamon 19 common sage 11.9 sesame 10.7 marjoram 10.7 aashab 9.9 honey and its products 9.1 arabic gum 7.1 mint 4.7 clove 4.7 black seed 4.7 costus 4 nutritional advice 2.8 mugworts 2.4 olive oil 2 dates 2 cress 2 liquor ice 1.6 kef maryam 1.6 ginger 1.6 binali herbs 1.6 vitamins supplements 1.2 alum 1.2 indian almond 0.8 fennel 0.4 corton seed 0.4 table 4. folkloric methods and spiritual methods used by infertile women (n=253). folkloric methods % aubergine fruits, cumin seeds and dates kept under the bed 4.7 cupping 2.0 music therapy 1.6 pieces of coin or qarad worn 1.2 spiritual methods % faki’s help 4.7 roquia 6.7 figure 1. factors leading to the usage of complementary and alternative medicine by infertile women (n=253). figure 2. reason for using complementary and alternative medicine by infertile women (n=253). [page 366] [healthcare in low-resource settings 2024;12:12319] non -co mmerc ial us e o nly conclusions in conclusion, cam use among infertile women seeking medical assistance for their infertility condition was common, and herbal treatments were the most prevalent type. the most important factor affecting the satisfaction of infertile individuals with cam was their belief in the safety of such treatments. healthcare providers providing fertility care should be attentive to the healthseeking behavior of patients under their care and initiate dialogue with patients on their risks and benefits. recommendations further studies, intended to identify the benefits or harm to patients seeking infertility treatment, are required. intensive hormonal treatment and exposure to anesthetic agents might potentially interact with some cmt. study strengths and limitations the major limitation of this study was the sample frame, which included women from one state in sudan. moreover, it was conducted in fertility clinics; due to budget and time constraints, this may underestimate the actual utilization rate, as there is potential bias. as a consequence, further studies should be conducted in society. nevertheless, this study presents the first empirical evidence of cam use among women seeking infertility care in sudan; furthermore, it will help provide the basis for further studies to be conducted. references 1. world health organization. who global report on traditional and complementary medicine 2019. available from: https://apps.who.int/iris/handle/10665/312342. accessed in: july 2020. 2. world health organization. traditional complementary integrative medicine. available from: https://www.who.int/healthtopics / t radi t ional-complementary-andintegrat ivemedicine#tab=tab_1. accessed in: july 2020. 3. u.s. department of health & human services, national institutes of health. 2016 strategic plan. exploring the science of complementary and integrative health. available from: h t t p s : / / f i l e s . n c c i h . n i h . g o v / s 3 f s p u b l i c / nccih_2016_strategic_plan.pdf. accessed in: may 2020. 4. national cancer institute, complementary and alternative medicine. available from: https://www.cancer.gov/about-cancer/treatment/cam. accessed in: december 2020. 5. erku da, basazn ma. prevalence and correlates of complementary and alternative medicine use among hypertensive patients in gondar town, ethiopia. evid based complement alternat med 2016;2016:6987636. 6. el safi a. traditional sudanese medicine: a primer for health care providers, researchers, and students. khartoum, sudan: azza house; 2007. 7. kuhnert n, karar me. herbal drugs from sudan: traditional uses and phytoconstituents. pharmacogn rev 2017;11:83-103. 8. world health organization. who traditional medicine strategy: 2014-2023. 2014. available from: https://apps.who.int/ iris/handle/10665/92455. 9. krol m, nap a, michels r, et al. health state utilities for infertility and subfertility. reprod health 2019;16:47. 10. inhorn mc, patrizio p. infertility around the globe: new thinking on gender, reproductive technologies and global movements in the 21st century. hum reprod update 2015;21:41126. 11. dehghan m, mokhtarabadi s, heidari fg. complementary and alternative medicine usage and its determinant factors among iranian infertile couples. j complement integr med 2018;15: /j/jcim.2018.15.issue-2/jcim-2017-0138/jcim-20170138.xml. 12. özkan fs, karaca a, sarak k. complementary and alternative medicine used by infertile women in turkey. afr j reprod health 2018;22:40-8. 13. bardaweel sk, shehadeh m, suaifan ga, kilani mvz. complementary and alternative medicine utilization by a sample of infertile couples in jordan for infertility treatment: clinics-based survey. bmc complement altern med 2013;13:35. 14. kaadaaga hf, ajeani j, ononge s, et al. prevalence and factors associated with use of herbal medicine among women attending an infertility clinic in uganda. bmc complement altern med 2014;14:27. 15. edirne t, arica sg, gucuk s, et al. use of complementary and alternative medicines by a sample of turkish women for infertility enhancement: a descriptive study. bmc complement altern med 2010;10:11. 16. ghazeeri gs, awwad jt, alameddine m, et al. prevalence and determinants of complementary and alternative medicine use among infertile patients in lebanon: a cross sectional study. bmc complement altern med 2012;12:129. 17. fata s, tokat ma, bagardi n, yilmaz b. the traditional practices used by couples with fertility problems, affecting factors, expected benefits, and learning paths: the turkey sample. niger j clin pract 2019;22:806-11. 18. smith c, armour m, ee c. complementary therapies and medicines and reproductive medicine. semin reprod med 2016;34:67-73. 19. james pb, taidy-leigh l, bah aj, et al. prevalence and correlates of herbal medicine use among women seeking care for infertility in freetown, sierra leone. evid based complement alternat med 2018;2018:9493807. 20. eldib a, tashani o. infertility in the middle east and north africa region: a systematic review with meta-analysis of prevalence surveys. libyan j med sci 2018;2:37-44. article [healthcare in low-resource settings 2024;12:12319] [page 367] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13145 dual method p6 acupressure to overcome nausea and vomiting during early pregnancy tuti meihartati,1 leny suzana suddin,2 zatul akmar ahmad3 1department of midwifery, institute of health technology and science wiyata husada samarinda, indonesia; 2department of public health medicine, faculty of medicine, universiti teknologi mara, selangor; 3department of obstetrics and gynaecology, faculty of medicine, universiti teknologi mara, selangor, malaysia abstract pregnancy can lead to nausea and vomiting, commonly affecting women during the first trimester but sometimes continuing throughout the entire pregnancy. this study utilized a quantitative, non-equivalent control group design, a prevalent approach in quasi-experimental research. it involved 120 pregnant women between 6 and 16 weeks of gestation who were experiencing moderate to severe symptoms of nausea and vomiting in pregnancy (nvp). participants were recruited from four private maternity clinics in samarinda, indonesia. the study was registered with the indonesia clinical research registry (ina-dobp5os0). the results indicated that the pregnancy-unique quantification of emesis (puqe) scores for the participants in the intervention group were significantly lower than those in the control group after the intervention period (p<0.01). furthermore, no adverse effects were reported following the intervention. regarding the satisfaction variable, the study found that the dual methods of p6 acupressure resulted in a statistically significant improvement in satisfaction among pregnant women with nvp (z=1830, p<0.01). based on our findings, the use of dual p6 acupressure, which includes both pressure application and an acupressure band, is effective in reducing nausea and vomiting experienced by pregnant women. introduction pregnancy can cause nausea and vomiting, and although it most commonly affects women in the first trimester, it can last throughout pregnancy.1 the exact cause of the etiologic and pathophysiology of nausea and vomiting is still unknown;2 however, this condition is an early indication of pregnancy in reproductive women.3,4 pregnant women might also experience varying degrees of morning sickness and hyperemesis gravidarum and thus have concerns for the health of both the mother and the growing fetus.2 nausea and vomiting during pregnancy can have a significant impact on family life, hinder the ability to carry out normal daily activities, affect social functioning, and lead to stressful situations. additionally, these symptoms may cause fatigue, impaired nutrition, dehydration, weakness, weight loss, and electrolyte imbalances in pregnant women.5 pregnant women experiencing nausea and vomiting in pregnancy (nvp) have a significant impact of over 85% on their physical health and psychosocial quality of life.1 an increase in nvp cases can have implications for maternal health, especially when accompanied by symptoms like dehydration, vomiting, acidosis, alkalosis, and weight loss.2,6 some pregnant women experience a more severe and persistent form of vomiting called hyperemesis gravidarum. this condition can lead to various complications, including dehydration, electrolyte imbalances, liver damage, and, in extreme cases, maternal death. additionally, it can have negative effects on the fetus.6 nvp occurs early in the first trimester, and only 23.5% of pregnant women are symptomatic until the third trimester.1,7 both patients and physicians are hesitant to use drugs during pregnancy, correspondence: tuti meihartati, department of midwifery, institute of health technology and science wiyata husada samarinda, indonesia. e-mail: tuti@itkeswhs.ac.id key words: effectiveness; safety; satisfaction; acupressure; nausea and vomiting; early pregnancy. contributions: tm, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; lss, methodology, visualization, writing – review & editing; zaa, supervision, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has been registered in the indonesia clinical research registry (registry id: inadobp5os0) and received ethical approval from the health research ethics committee of the health polytechnic, ministry of health, east kalimantan, indonesia (ethics no. lb.01.01/7.1/005627/2021). throughout the research, the researcher adhered to the ethical norms of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to express our gratitude to the four maternity clinics located in samarinda city for permission to conduct the research and the aesthetics course and training institute & indonesian acupuncture (aai). received: 23 september 2024. accepted: 27 october 2024. early access: 12 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13145 doi:10.4081/hls.2024.13145 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13145] [page 31] especially in the first trimester, due to the possibility of harming the unborn fetus.8 pregnant women commonly experience nausea and vomiting upon waking, a phenomenon called morning sickness.1,3 although morning is the most common time for this discomfort, it can also occur throughout the day or at night.1 according to data from multiple kalimantan provinces, east kalimantan had the greatest rate of continuous vomiting among pregnant women (21.9% of 1,176 pregnant women), while central kalimantan had the lowest rate (14.6% of 871 pregnant women). when compared to other pregnancy-related issues, the most common condition or complication in east kalimantan is persistent vomiting, which affects 78.07% of pregnant women.9 one effort that pregnant women can make to relieve nausea and vomiting during pregnancy is through acupressure therapy. acupressure, which is a supplementary therapy that consists in applying pressure to acupuncture points, can assist pregnant women balance their hormones by stimulating the central nervous system via the limbic and hypothalamus systems.10,11 one of the acupressure points that is scientifically proven to reduce nausea and vomiting is the pericardium point (pc 6).12 this point sends signals to the heart organ, which physiologically can balance hormones, reduce nausea, and trigger relaxation. this point is located on the inner arm, exactly three fingers from the inner wrist. pc 6 can be stimulated continuously in pregnant women without side effects, and there is no concept of overdose in acupressure.13 with the publication of the republic of indonesia minister of health decree no.1076/menkes/sk/vii/2003 on july 24, 2003, which governs acupressure services and other traditional treatments, acupressure’s status as a medical service is becoming more widely acknowledged in indonesia. the severity of nausea and vomiting during pregnancy can be minimized, especially when symptoms are moderate to mild, by administration of pharmacological and nonpharmacological options (vitamin b6, ginger, and acupressure with peppermint oil).14 p6 activation has been shown in several clinical investigations to be effective for nvp.13 however, other research found no significant impacts. the lack of control groups, the application of pressure on non-p6 locations in placebo groups, the use of varied techniques for p6 stimulation, and the underreporting of dietary alterations have all contributed to the variance in these studies’ results. more clinical investigations are thus required to overcome these flaws.14,15,16 therefore, it is very important to have a well-designed study that allows a comprehensive and critical evaluation of the available evidence and to bridge the health literacy gap on the intervention of dual method p6 acupressure for handling nausea and vomiting during the early trimester of pregnancy. bridging the health literacy gap in this area will help ensure that p6 acupressure can be effectively integrated into antenatal care services. materials and methods study design, setting, and population this study was carried out at four private maternity clinics in samarinda city, east kalimantan province, with a sample of pregnant women who experienced moderate to severe nausea and vomiting in early pregnancy. descriptive analysis studies use quantitative approaches. this sort of research employs a non-equivalent control group design (preand post-test). in this design, a popular strategy is quasi-experimental, with intervention group a and control group b chosen without random assignment. in this study, the intervention group received p6 acupressure on both arms; one arm received manual massage, and the other employed an acupressure band. in contrast, the control group experiences nvp without dual p6 acupressure or pharmaceutical intervention. to determine the appropriate sample size for this study, we utilized g* power software version 3.1.9.7. this analysis is based on research conducted by mobarakabadi et al. regarding the effect of p6 acupressure on nausea scores. the mean (sd) for the intervention group was 6.24 (4.1), while the mean (sd) for the control group was 9.23 (3.7). we calculated the sample size to be 24 participants per group, with an alpha error of 0.05, a power of 0.80, and an allocation ratio of 1. however, a sub-analysis of satisfaction was carried out for the intervention group, which required a recalculation of the number of respondents in the group. according to our literature research, no proportion of satisfaction was included in the sample size calculation. as a result, we decided to double the minimum sample size needed to examine satisfaction data in the intervention group. thus, each group had a sample size of 60 participants, for a total of 120 people recruited for the study. the sampling technique was a convenience sampling method because there was more than one maternity clinic location. the eligibility criteria for both the intervention group and control group were: pregnancy with nausea and vomiting, consent to participate in this study, a puqe score of more than 6 to 15 (mild to severe category nvp), a period of gestation of 6 weeks during the time of study recruitment, an age of more than 17 years, and singleton pregnancy. this is to ensure that all selected samples proportionally represent each maternity clinic. study instrument the pregnancy-unique quantification of emesis and nausea (puqe) questionnaire (3 items) was widely used in previous research, was based on three questions, and has been validated in clinical use. the instrument had undergone reliability testing and was translated (back-to-back) into indonesian language. in a previous study conducted in indonesia using the puqe questionnaire, the cronbach’s alpha value was found to be 0.846.18 in this study, the effectiveness of dual p6 acupressure will be determined as an nvp category using the puqe questionnaire, comparing the intervention between dual p6 acupressure and routine prenatal care. the puqe questionnaire with 3-item will be assessed as scores. then, based on the score obtained, nvp will be classified as follows: a total score of 3 = no nvp, a score between 3 and 6 = mild nvp, a score between 7 and 12 = medium nvp, and a score between 13 and 15 = severe nvp. the safety of the p6 acupressure technique was assessed using the adverse event form. in the context of this study, safety was translated as no reported adverse events by the participants. the form consists of 9 items and was created by regulation (eu) no 536/2014 of the european parliament and of the council of 16 april 2014 on clinical trials on medicinal products for human use and repealing directive 2001/20/ec. this form is used to record adverse events from medication. this satisfaction questionnaire underwent a pilot study to determine feasibility with 30 respondents. the questionnaire showed a cronbach alpha value of 0.763 and a median score of 74. this was taken as the cut-off point for the category of yes (>74) or not satisfied (≤74). the level of satisfaction is quantified using measurement indicators from a likert scale with four levels: a) scale 1 = very unsatisfied, b) scale 2 = unsatisfied, c) scale 3 = satisfied, and d) scale 4 = very satisfied. from this scale, the criteria for patient satisfaction levels can be classified into numerous special issue pathways of change [page 32] [healthcare in low-resource settings 2025;13(s1):13145] criteria that refer to the likert scale, where item answers are grouped into two categories: a) satisfied if the respondent’s total answer score is ≥74, b) not satisfied if the respondent’s total answer score is <74. statistical analysis the data were analyzed using statistical product and service solutions (spss) version 26.0 for windows. the kolmogorovsmirnov test was used to determine normality, while the analysis of different proportions was used to identify the level of severity of nvp in the intervention group preand post-test intervention with dual p6 acupressure therapy; this involved using preand postmean values in the two groups to measure pre-test and post-intervention changes using the wilcoxon test, which falls under the non-parametric category with two related samples (intervention and control groups). a p-value of less than 0.05 indicates statistical significance. meanwhile, a one-sample wilcoxon signed rank ttest was utilized to assess the impact of dual p6 acupressure intervention therapy on respondents’ satisfaction levels. results the study found that the intervention group’s nvp score decreased by (-6.00 ± 1.53) in the medium nvp category and (9.44 ± 2.06) in the severe nvp category, while the control group’s nvp score decreased by (-3.56 ± 2.13) in the medium nvp category and (-6.43 ± 1.16) in the severe nvp category. these results demonstrated that the respondents’ treatment appeared to be beneficial in the post-intervention period since the respondents’ nvp ratings declined in each category (table 1). the level of safety post-test intervention with dual method p6 acupressure therapy descriptively, none of the 60 responders (100%) who got the p6 acupressure intervention suffered adverse events or side effects that harmed mother and fetal health. this indicates that the treatment or intervention given to the respondents resulted in significant improvements in the post-test scores, reducing the severity of nausea and vomiting. influence of post-test intervention with dual method p6 acupressure therapy on the level of respondents’ satisfaction the lowest score was 48, the highest was 90, and the median was 74 (iqr 16). the shapiro-wilks normality test was used to assess satisfaction variables. the p-value for the intervention group is 0.007, indicating that the satisfaction data is not normally distributed. a wilcoxon signed-rank test revealed that dual techniques p6 acupressure resulted in a statistically significant change in satisfaction in pregnant women with nvp (z=1830, p=0.000). indeed, the median satisfaction score was 74 before and after treatment. the servqual questionnaire (t3) was used to compare satisfaction levels within groups. this demonstrates that pregnant women who underwent dual technique p6 acupressure therapy, which was used to alleviate nausea and vomiting throughout early pregnancy, were satisfied. discussion there was a significant difference between the intervention and control groups in terms of the effectiveness of interventions with neiguan acupoint pressure p6 and the usage of band acupressure (3 times per week for 24 hours from 8 to 15 weeks of gestation). the results indicate that the change observed in the intervention group for the medium level of nausea and vomiting (nvp) was -6.00±1.53, while in the control group the result was 4.56±2.13. in terms of the severe level category score for nvp, the intervention group showed a change of -9.44±2.06, compared to 6.43±1.16 in the control group. this suggests that the treatment provided to participants was more effective in the post-intervention phase, particularly with the combination of dual p6 acupressure and the use of acupressure bracelets, as evidenced by the reduction in nvp scores. these findings indicate that these interventions can effectively reduce nausea and vomiting in pregnant women during early pregnancy. these results showed that the respondents’ treatment appeared to be effective in the post-intervention phase, as indicated by the respondents’ nvp scores declining in each category. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13145] [page 33] table 1. the difference in level of nausea and vomiting severity during early pregnancy between the pre-test and post-test of the intervention and control group. variables with intervention change of without (control group) change in puqe score p puqe score puqe score puqe score pretest posttest pretest posttest nvp category medium nvp 8.75±1.20 2.75±1.54 -6.00±1.53 9.13±1.18 5.56±2.31 -3.56±2.13 <0.01* severe nvp 13.37±0.5 3.94±2.38 -9.44±2.06 13.57± 0.51 7.14±1.09 -6.43±1.16 <0.01* awilcoxon test, *p<0.01 taken as the level of significance. table 2. the level of nausea and vomiting severity from puqe’s score during early pregnancy in the intervention group pre-test and posttest intervention with dual method p6 acupressure therapy. group pretest posttest change p intervention group 9.98±2.32 3.06±1.85 -6.92±2.26 <0.01 control 10.16±2.17 5.93±2.19 -4.23±2.29 <0.01 awilcoxon test, p<0.01 taken as the level of significance. special issue pathways of change [page 34] [healthcare in low-resource settings 2025;13(s1):13145] table 3. intervention protocol dual methods p6 acupressure for nvp. scientifically, this study contributes to the midwifery profession’s knowledge of pregnancy with nvp patients by identifying new treatment techniques. previous research has demonstrated that p6 acupressure alone can help reduce nvp symptoms. however, the findings of this study reveal a notable difference in the changes observed in the pregnancy-unique quantification of emesis (puqe) score, with an effect size that is higher compared to earlier trials that used only p6 acupressure.16,17,20 therefore, this could support the hypothesis that using dual p6 acupressure methods can be more effective compared to single-method therapy. as far as we know, there was no previous research that recommended the dexterity of the arm when applying the p6 acupressure. in this study, participants were asked to choose one arm based on their preferences for manual finger pressure and band acupressure. to limit variability, they were told to use a comparable location until the completion of the study time. as a result, dual p6 acupressure’s effectiveness was limited to single-arm applications. furthermore, the respondents’ freedom to choose was granted because the response time was considered and demonstrated to be more efficient. another advantage of using the same arm is that it provides pregnant women with more options for p6 acupressure methods in future pregnancies, which means that if they become pregnant again, they can do the pressure themselves or purchase an acupressure band. based on statistical tests, the value (p<0.01) ≤ 0.05 was obtained, leading to the rejection of the null hypothesis (h0), indicating a significant difference between the intervention and control groups. this study was conducted to determine the effectiveness of interventions with neiguan acupoint pressure (pc6) and the use of acupressure bracelets (3 times per week for 24 times from 8-15 weeks of gestation). the results indicate that the change observed in the intervention group was -6.92±2.26, whereas the control group showed a change of -4.23±2.29. this suggests that the treatment provided to the respondents in the intervention group was more effective during the post-intervention phase compared to the control group. the effectiveness is further supported by a decrease in the nvp score (table 2). this explains that p6 acupressure intervention and the use of acupressure bracelets can reduce nausea and vomiting experienced by pregnant women in early pregnancy. other research shows equally positive results. according to a 2017 study, 12 hours of pc6 acupressure over three days can considerably reduce pregnancy-induced nausea and vomiting. helmerich et al. conducted a meta-analysis of eight randomized controlled trials and six cross-sectional studies (n=1,655) to determine the effect of p6 acupoint pressure stimulation on the prevention of nausea and vomiting in pregnant women. the researchers discovered that this form of intervention can reduce nausea and vomiting by up to 50%. in a similar study, steele et al. found that the use of the seaband at point p6 for four days reduced the severity of nausea compared to the placebo. belluomini et al. investigated the effectiveness of p6 acupressure on nvp and found four days of p6 point stimulation for ten minutes daily was associated with a significant decrease in nausea compared to sham points, but they could not find a positive effect for this intervention with respect to vomiting. the results of another study using the puqe instrument to assess nausea and vomiting in pregnancy for 3 consecutive days with the use of 12 hours of wristband acupressure showed that the average result was (9.13±2.02) which changed after 3 days of use with an average score of (4.40±1.63), this indicated that there was a significant influence on the use of the p6 acupressure wristband.20,21 several studies have shown that acupressure can effectively reduce nausea and vomiting during pregnancy. the findings from this research can enhance the quality of healthcare services and provide an effective solution for pregnant women experiencing these symptoms. in this study, a dual p6 acupressure technique was implemented to optimize the intervention process, ensuring that the results were both effective and safe. as a result, pregnant women reported high levels of satisfaction with the outcome of the intervention. based on the descriptive data collected from 60 respondents, the safety variable in the intervention group indicated that participants did not experience any side effects, suggesting that the intervention was safe for their physical health. this finding demonstrates that the treatment provided to the respondents led to significant improvements in post-test scores, particularly in reducing nausea and vomiting. research conducted by mehta et al. highlights that acupressure is a user-friendly therapy with minimal side effects. however, it is essential to note that acupressure should not be applied to areas with burned skin, swollen body parts, broken bones, or any other types of damage. additionally, acupressure should not be performed in an emotional atmosphere or immediately after a meal.22 in addition to reducing nvp, acupressure can also increase body energy and blood flow to signal the endocrine system to release endorphins (happy hormones) according to the body’s needs so that mothers feel safe, calm, and comfortable. based on the descriptive data for the variable “satisfaction”, it was found that minimum score was 48 and maximum score was 90, the median of 74 (iqr 16). a wilcoxon signed-rank test showed that dual methods p6 acupressure did elicit a statistically significant change in satisfaction in pregnant women with nvp (z = 1830, p = 0.000). indeed, the median satisfaction score rating was 74 both pre and post-treatment. this suggests that pregnant women who received the intervention of dual method p6 acupressure therapy, which was used to reduce nausea and vomiting experienced in early pregnancy, were satisfied. patient satisfaction with the interventions performed was the level of satisfaction resulting from the health services received when the patient compares them with their expectations. the results showed that the application of dual acupressure was more effective. the mother only needed to press and use the band acupressure on the three fingers below the wrist. the intervention encourages the mother to sit or lie down in a comfortable position and continue using the acupressure method. this intervention was considered safe, as there were no reported side effects. it also provides a feeling of comfort and relaxation for the mother, thereby reducing nvp and increasing satisfaction with non-pharmacological interventions. strengths and limitations of this research the strength of this study lies in the development of new interventions using the dual p6 acupressure method. it aims to create a protocol for managing nausea and vomiting in pregnancy through the application of this dual p6 technique. the study adheres to standard operating procedures for the intervention sessions and includes clear instructions for patients to practice at home, encouraging consistency in the use of dual p6 acupressure for treating nausea and vomiting in early pregnancy. the findings demonstrate that the dual p6 acupressure method is both safe and satisfactory for patients. however, there are limitations to the study. the acupressure band used was not standardized, although it was recognized by the government. additionally, the pressure applied was self-administered by the patients, which may lead to variability in the pressure applied by each individual. this was due to the nature of the protocol provided. (table 3). special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13145] [page 35] conclusions this study showed that the dual method of using p6 acupressure, consisting of manual pressure and using a band acupressure, was found to be effective, safe, and satisfactory for reducing nvp. in the future, maternity care providers may consider using this method as a therapeutic alternative for the management of nausea and vomiting during pregnancy. references 1. revell ma. self-care of nausea and vomiting in the first trimester of pregnancy. int j childbirth educ 2017;32:35. 2. forbes le, graham je, berglund c, bell rc. dietary change during pregnancy and women's reasons for change. nutrients 2018;10. 3. almond d, edlund l, joffe m, palme m. an adaptive significance of morning sickness? trivers–willard and hyperemesis gravidarum. econ hum biol 2016;21:167-71. 4. argenbright ca. complementary approaches to pregnancy induced nausea and vomiting. int j childbirth educ 2017;32:6. 5. jennings lk, mahdy h. hyperemesis gravidarum. 2023 jul 31. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan– 6. ozgoli g, saei ghare naz m. effects of complementary medicine on nausea and vomiting in pregnancy: a systematic review. int j prev med 2018;9:75. 7. heitmann k, nordeng h, havnen g, et al. the burden of nausea and vomiting during pregnancy: severe impacts on quality of life, daily life functioning and willingness to become pregnant again – results from a cross-sectional study. bmc pregnancy and childbirth 2017;17. 8. shawahna r, taha a. which potential harms and benefits of using ginger in the management of nausea and vomiting of pregnancy should be addressed? a consensual study among pregnant women and gynecologists. bmc complement altern med 2017;17:204. 9. riskesdas, t. laporan nasional riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan. 10. hou pw, hsu hc, lin yw, et al. the history, mechanism, and clinical application of auricular therapy in traditional chinese medicine. evid based complement alternat med 2015;2015:495684. 11. smith c, crowther c, beilby j, dandeaux j. the impact of nausea and vomiting on women: a burden of early pregnancy. aust n z j obstet gynaecol 2000;40:397-401. 12. yilmaz r, karaoglan yilmaz fg. the effect of generative artificial intelligence (ai)-based tool use on students' computational thinking skills, programming self-efficacy and motivation. computers and education: artificial intelligence 2023;4:100147. 13. brettner f, janitza s, prüll k, et al. gender-specific differences in low-dose haloperidol response for prevention of postoperative nausea and vomiting: a register-based cohort study. plos one 2016;11:e0146746. 14. mehta p, dhapte v, kadam s, dhapte v. contemporary acupressure therapy: adroit cure for painless recovery of therapeutic ailments. j tradit complement med 2017;7:251-63. 15. bustos m, venkataramanan r, caritis s. nausea and vomiting of pregnancy what's new? auton neurosci 2017;202:62-72. 16. galeshi m, ghanbarpour a, naeimi rad m, asghari s. a comparison of the effect of pressure on the kid21 (youmen) and p6 (neiguan) points on the severity of nausea and vomiting of pregnancy. j complement integr med 2020;17. 17. mobarakabadi ss, shahbazzadegan s, ozgoli g. the effect of p6 acupressure on nausea and vomiting of pregnancy: a randomized, single-blind, placebo-controlled trial. adv integr med 2020;7:67-72. 18. birkeland e, stokke g, tangvik r, et al. norwegian puqe (pregnancy-unique quantification of emesis and nausea) identifies patients with hyperemesis gravidarum and poor nutritional intake: a prospective cohort validation study. plos one 2015;10:e0119962. 19. koren g, cohen r. measuring the severity of nausea and vomiting of pregnancy; a 20-year perspective on the use of the pregnancy-unique quantification of emesis (puqe). j obstet gynaecol 2021;41:335-9. 20. adlan a-s, chooi ky, mat adenan na. acupressure as adjuvant treatment for the inpatient management of nausea and vomiting in early pregnancy: a double-blind randomized controlled trial. j obstet gynaecol res 2017;43:662-8. 21. matos lc, machado jp, monteiro fj, greten hj. understanding traditional chinese medicine therapeutics: an overview of the basics and clinical applications. healthcare (basel) 2021;9. 22. chen l, michalsen a. management of chronic pain using complementary and integrative medicine. br med j 2017;357:j1284. special issue pathways of change [page 36] [healthcare in low-resource settings 2025;13(s1):13145] hrev_master healthcare in low-resource settings 2024; volume 12:12072 behavioral prevention of hbv transmission in urban communities toward global elimination of hepatitis in 2030: a systematic review fiya diniarti,1,2 mohamed saifulaman mohamed said,2 norhashima abd rashid,2 sandeep poddar2 1public health programe, faculty of health sciences, universitas dehasen bengkulu, bengkulu, indonesia; 2lincoln university college, wisma lincoln, selangor, malaysia abstract hepatitis b is a serious threat to public health on a global scale. the hepatitis b virus (hbv), which spreads both vertically and horizontally, is easily contracted by anyone. in 2020, the world health organization estimates that 257 million people worldwide have hepatitis b, and 900,000 people die from it each year. according to the world health organization (2021), there are approximately 39.4 million people in southeast asia living with chronic hepatitis b mortality, with 410,000 deaths caused by the disease. hbv can spread through injections, horizontal transmission, blood transfusions, and organ transplants. cochrane, science direct, pubmed, elsevier, sage, willey, doaj, and google scholar database sources were used to search for supported research on how to prevent hepatitis virus transmission in urban communities. 15 publications address the primary and secondary prevention of hepatitis b transmission in urban settings. prevention keeps a person in good health and prevents them from progressing to a later, worse stage. given that the hepatitis b virus can infect anyone, regardless of age, and that it affects people’s health worldwide, as well as their families, communities, and families within them. in order to eradicate the hepatitis b virus, society must be aware of the importance of implementing preventive measures on a continuous and long-term basis through health advocacy activities, hepatitis b virus screening campaigns, health education, counseling, hepatitis b vaccination with communitybased activities, and secondary prevention through combination therapy treatment in post-liver transplant patients. introduction hepatitis b transmission can happen both vertically and horizontally, making it a serious threat to public health on a worldwide scale.1 a virus called hepatitis affects the liver. everyone can readily contract the hepatitis b virus (hbv), which spreads both vertically and horizontally.2 hepatitis b virus transmission can happen during childbirth (from an infected mother to her child), prior to sexual contact with a sick partner, while sharing items like razors or toothbrushes, when coming into direct contact with blood or exposed wounds of a contaminated person, or when an infected person spills blood. needles and sharps from diseased individuals, as well as those used by those getting tattoos or body piercings using non-sterile instruments (from infected people).3 about 328 million people around the world are constantly sick with hbv, and most of them have not been identified or treated.4 the world health organization (who) aims to reach 80% treatment coverage and 90% vaccine coverage by 2030.5,6 according to the riskesdas7 results from 2018, indonesia shows the prevalence of hepatitis based on a doctor’s diagnosis history, with differences between provinces of 0.18% (bangka belitung islands) and 0.66% (papua). hepatitis spreads almost evenly across all age groups, genders, educational levels, occupations, and places of residence. the national program for the prevention and control of the virus currently emphasizes keeping mother to child transfer from occurring because infants are in danger of developing hepatitis b virus that persist in their mothers who have the virus (ppia).8 to address this disease globally, public health recommendations and initiatives have been developed concurrently.9 one of the tactics used is raising awareness of the hepatitis b virus defense mechanism among people, families, and communities in order to bring about changes in urban communities’ behavior.10 correspondence: correspondence: fiya diniarti, universitas dehasen bengkulu, jl. meranti no.32, sawah lebar, kec. ratu agung, kota bengkulu, bengkulu 38228, indonesia e-mail: fiyadiniarti@unived.ac.id key words: urban society; preventive behavior; hepatitis b. contributions: fd, conceptualization or design of the work, methodology, writing original draft; msms, drafting the work or reviewing it critically, supervision; nar, drafting the work or reviewing it critically, supervision; sd, project administration, review & editing. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and informed consent: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 12 november 2023. accepted: 13 march 2024. early view: 16 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12072 doi:10.4081/hls.2024.12072 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12072] [page 315] non -co mmerc ial us e o nly materials and methods with the terms “prevention” and “hepatitis b,” this systematic review search uses science direct to get data from sites like pubmed, doaj, cochrane, sage, willey, elsevier, and google scholar. the requirements were: research publications with titles and contents that match the study’s goals; research subjects with a possible hepatitis b infection; english; written between 2010 and 2022. the article does not have a comprehensive structure, according to the exclusion criteria. the following actions are taken as part of a systematic review using prism guidelines: find articles that include manually chosen and recorded keywords; conduct screening in accordance with established inclusion and exclusion criteria; conduct article analysis utilizing the joanna bringgs institute. based on the findings of a literature search conducted using eight online databases, 500 articles were found. these were then filtered from the database selection to 53 articles, and 33 eligible articles were found after examining titles, reading abstracts, background suitability, research objectives, research methods, and results. after reading the full text, 15 articles were eliminated, leaving 10 for examination. results the prevention of suspected hepatitis b in rural and urban areas is examined in this research. the literature under examination is a true investigation, not a critique, and includes the next: author name, research design, and sample size (figure 1; supplementary materials, table 1). these 15 articles discuss findings about preventative behavior (primary and secondary hepatitis b virus transmission in urban communities) based on the results of article analysis. the twelve articles demonstrate that primary prevention is a collective effort that begins in the stage of optimum health and does not move into a stage that could exacerbate the condition. actions must be taken prior to the infection of the hepatitis b virus and include aspects of health promotion and protection. according to this article, the primary prevention focuses on promoting health (improving health) through health advocacy, hepatitis b virus screening campaigns, health education, and counseling to increase community knowledge and awareness starting with individuals, families, and community groups as well as focusing on general and specific protection through immunization, insurance, and hepatitis b immunization. protection both specifically and generally. three articles show that communities, families, or individuals are responsible for primary prevention. those who are ill are identified early and receive immediate care through appropriate care. this article focuses on the use of lamivudine (lam) combination therapy with nucleoside analogue (lam) to hbig to treat hbv patients after orthotopic liver transplantation (olt) to increase patient life expectancy and the use of antiviral and immunoprophylactic drugs for expectant mothers with chronic the hepatitis b virus during pregnancy, especially in reducing the amount of virus and providing protection. the study identified several risk factors for hepatitis b, including age (45 years and older), gender (male), having a mother who was infected, and a history of blood transfusions. discussion anyone at any age can contract the hepatitis b virus. hbv attacks the liver. serological evidence of previous or present viral hepatitis b is present in about one-third of the worlds population (hbv). when hbsag-positive body fluids from people who have an acute or chronic hbv infection are exposed through parenteral or mucosal routes, the virus is passed on. it reproduces in hepatocytes using a specific reverse transcription method. percutaneous inoculation, horizontal transmission, blood transfusion, organ transplantation, and post-exposure prophylaxis are all ways that hbv spreads (figure 2).25,27 based on data from the who 2021 (figure 3),28 the highest number of fresh cases hepatitis b infection cases has the africa region (990,000 cases). and the greatest quantity of deaths the western pacific (470,000 cases). primary and secondary prevention strategies that continuously and sustainably raise awareness among individuals, families, and communities aim to lessen the danger of the virus that causes hepatitis b. the fact is that despite the implementation of this strategy in both developed and developing nations, hepatitis b morbidity and mortality remain a problem in the world due to changes in people’s behavior caused by a variety of factors, including age, gender, education, socio-culture, the economy, health services, and stakeholders policy.29 review figure 1. literature search strategy. figure 2. goals for lowering the number of new cases and deaths caused by chronic hepatitis b and c viruses. source: world health organization. global health sector strategies on viral hepatitis 2016-2021.27 [page 316] [healthcare in low-resource settings 2024;12:12072] non -co mmerc ial us e o nly based on graphic 3, the average hepatitis b infection is mostly on female with the age 20-45 years.30 based on figure 4, it shows that the average risk factors that can cause acute hepatitis b are through heterosexual transmission, nosocomial, sex between men and chronic hepatitis transmitted through mother to child transmission.30 health education is used as the primary method of preventing the spread of hepatitis b (health promotion). risk factors for infectious diseases can be described through the theory of the epidemiological triangle. the epidemiological triangle is a model that has been developed to see health problems (infectious diseases), the epidemiological triangle has three angles (agent, host and environment).31 risk factors for hepatitis b are socio-demographic, behavioral, medical, middle age, male, married, rural living, low education, smoking, having positive household contacts of hbsag, family history of hbv, history of surgery or blood transfusion.32 according to maamor et al. research from 2022,24 she discovered that seven studies (46.7%) and eight (53.3%) reported average and good knowledge, respectively. study two (40%) in asia is having strong knowledges, one’s (20.0%) had average knowledge, and two (40%) inadequate knowledge.22 according to research, community-based screening, advocacy, and hepatitis b health education initiatives are effective primary prevention tactics. they can be quite helpful in persuading hbv-infected people to use public health resources.33,34 research findings in indonesia found that the lack of information about the transmission of hepatitis b infection affects hepatitis b prevention behavior in an effort to support the vaccination program, obstacles to the vaccination program (vaccination campaign) caused by the high cost of vaccination, lack of vaccine availability in certain areas, and limited human resources to carry out the hepatitis b vaccination program.35 this study supports the recommendation that the who states that all babies should receive the vaccine for hepatitis b as soon as possible after birth, ideally within 24 hours, and then the next doses should be spaced at least 4 weeks apart. the vaccine’s purpose is to provide the general public with lifelong protection, or at least 20 years of it.36 the who recommends using antiviral prophylaxis in addition to baby vaccination to stop the spread of hepatitis b from mother to child. utilizing safer sex techniques, such as limiting the number of partners and using condoms, as well as blood safety strategies lowers transmission.37,38 in order to meet the 2030 sustainable development agenda’s global hepatitis elimination target, preventive efforts are being made. these efforts include raising awareness, encouraging resource mobilization, developing evidence-based data policies for action, and improving health equity in hepatitis response.21,24 the results of the study in bangladesh reported that bangladesh has a medium low prevalence rate of hbv infection (4.0%), a prevalence rate that represents explaining the incidence prevalence and epidemiology of hepatitis b and can be beneficial for public health leaders for policy making. this study aims to improve understanding of the epidemiological identification of hbv in bangladesh, reduce the risk of hepatitis b in bangladesh, and increase the coverage of the national immunization program to ensure vaccination of people at all levels.39 each year the prevalence of liver cancer ranged (4.5%) and cirrhosis hepatis ranged (5.8%) and other liver diseases, including nonalcoholic fatty liver disease/ hepatic steatosis 2016 (4.1%), alcoholic liver disease/alcoholic cirrhosis/alcoholic hepatitis around 2016 in (0.45%).40 the prevalence of hepatitis b continued to decline after the introduction of hepatitis b vaccination, but the disease remains a significant public health problem worldwide. this study summarizes the most important recommendation trends for preventing hepatitis b are screening in pregnant women, chb screening, maternal hbeag, hbv viral load, alt level and hbsag level, and antiviral administration for two main purposes: vertical treatment and prevention, during pregnancy tenofovir is administered, a combination of the hbig and hepatitis b vaccines within the first 12 hours to all babies born to mothers with chb.41 the gap in hepatitis b elimination globally is widespread. many countries have achieved an important target of hbsag seroprevalence of <0.1% in children under 5 years of age. lack of knowledge about hepatitis b in women in thailand can be increased through preventive education by providing counseling about hepatitis b vaccination, the counseling process can run effectively carried out by the thai government is to train counselors, so that counseling runs interactively, then counselors in providing counseling can be appropriate visual aids in the antenatal period.42 mother-to-child hepatitis b prevention program conducted in cambodia for pregnant women by providing hepatitis b vaccination and hepatitis b screening during pregnancy.43 children who have been given doses of hbv vaccine have no risk of hbv infection in the future, hbv vaccine is the only guarantee to protect children and prevent the spread of the review figure 3. acute hepatitis b cases reported at high rate. source: hepatitis b annual epidemiological report for 2021.30 figure 4. transmission category of hepatitis b cases by acute and chronic disease status, eu/eea, 2021. sources: hepatitis b annual epidemiological report for 2021.30 [healthcare in low-resource settings 2024;12:12072] [page 317] non -co mmerc ial us e o nly virus in the community. in addition, strengthening awareness, monitoring, and implementation of existing infection control procedures and increasing the coverage of hepatitis b vaccination will further reduce the prevalence of hepatitis b.44 hepatitis b virus infection remains a public health challenge for women with a possible risk of vertical transmission to their babies in the study area. routine screening recommendations for the hepatitis b virus in pregnancy.45 the prevalence of hv is very low in pregnant women not living with hiv.46 there is a significant relationship between the level of rpr (rapid plasma regain examination) and the degree of liver fibrosis based on te (fibro scan) in chronic hepatitis b patients, then rpr can be used as a non-invasive diagnostic marker to predict severe fibrosis in chronic hepatitis b patients, with a cut-off point of 0.0538 with sensitivity of 76% and a specificity of 63%.47 research findings in vietnam illustrate that vietnam is an area of intermediate endemicity of hepatitis b. to combat hbv in vietnam prevention of hepatitis b from mother to child is carried out through a hepatitis b vaccination policy after the baby is born and immunization coverage must be complete, for incomplete immunization coverage in children will be monitored by health workers.48 early human preterm birth (ptb) is a risk factor for hbv infection alone, and hbv dna levels do not appear to have an impact on the risk . a comprehensive program focusing on pregnant women with hbv infection will reduce the incidence of adverse outcomes.49 indonesia is an area of high endemicity and is included in the high prevalence of hepatitis b, which is more than 8%. prevention efforts are carried out through hepatitis b screening in pregnant women, the screening is carried out at puskesmas.50 risk factors for hepatitis b are parity, low education, history of sexual partners >1, use of non-sterile syringes, family history of hepatitis b. the singapore study analyzed that the government subsidizes antiviral treatment to reduce perinatal transmission. if hepatitis b cases increase in singapore, future generations will contract hepatitis b infection and eventually become a burden on the state. screening and treatment activities are carried out for infected mothers at a cost that is affordable to the community.51 according to research in vietnam, the comparison of pregnant women with umbilical cord blood diagnosed with hbsag positive and negative found that pregnant women who have hbsag positive umbilical cord blood are at risk of transmitting hepatitis b from mother to child (from mother to child).52 the impact of pregnant women who are positive for chronic hepatitis b has the risk of premature birth premature rupture of membranes, heavy bleeding, gestational diabetes and fetal death. gestational diabetes is diabetes that occurs directly during pregnancy until the delivery process, the condition generally occurs in the second or third trimester.53 primary prevention efforts (education, campaigns, screening, early detection, and vaccination) are very important in reducing the risk of mother-to-child transmission for all people in the world. the community must work together with the government to support the sdgs program in reducing the prevalence of hepatitis b.54 conclusions the preventive behavior of urban communities in supporting global elimination in 2030 includes primary and secondary prevention. primary prevention (health promotion) includes health advocacy, hepatitis b virus screening campaigns, health education, community-based counseling and the condom use. the application of safer sex techniques, such as limiting the number of partners, can help lessen transmission. and primary prevention (general) and specific protection) includes vaccination at the time of birth, preferably within 24 hours and health insurance for the community, as well as secondary prevention by providing combination therapy to patients after liver transplantation. it is hoped that further researchers can examine information technology-based preventive strategies. references 1. deng x, liu d, delcourt mp, et al. no hepatitis delta virus seropositivity among blood 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transmission. j biological dynamics 2020;14:788-801. 7. riskesdas ln. indonesian ministry of health, health research and development agency. 2018 8. kementerian kesehatan, indonesian health profile. kementerian kesehatan indonesia: jakarta. 2021 9. muljono dh, wijayadi t, sjahril r. hepatitis b virus infection among health care workers in indonesia. euroas j hepatogastroenterol 2018;8:88. 10. luo y, dong z, qi s. application of health education model based on theory of behavior change in nursing care of patients with chronic hepatitis b. j nanomat 2022;2022. 11. hidayah an, afridah w. literature review: faktor penyebab hepatitis b pada ibu hamil. jurnal multidisiplin indonesia 2023;2:443-50. 12. khalid fk, rasheed na, hussein nr, naqid ia. a study of hbv infection and its risk factors in pregnant women in zakho city, iraq. plos one 2022;17:e0273362. 13. liu d, liu y, ni j, et al. hepatitis b infection among pregnant women in china: a systematic review and meta-analysis. frontiers 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guan l, tian h, et al. risk factors and prevention of viral hepatitis-related hepatocellular carcinoma. front oncol 2021;11:686962. 24. maamor nh, muhamad na, mohd dali ns, et al. seroprevalence of hepatitis b among healthcare workers in asia and africa and its association with their knowledge and awareness: a systematic review and meta-analysis. front public health 2022;10:859350. 25. mauss s, berg t, rockstroh j, et al. hepatology–a clinical textbook, 20th. 2020. 26. sonderup mw, spearman cw. global disparities in hepatitis b elimination—a focus on africa. viruses 2022;14:82. 27. world health organization. global health sector strategies on viral hepatitis 2016-2021. available from: http://apps.who.int /gb/ebwha/pdf_files/wha69/a69_32-en.pdf?ua=1 28. world health organization. global health sector strategy on viral hepatitis 2016-2021. towards ending viral hepatitis. world health organization; 2016. https://iris.who.int/bitstream/handle/10665/246177/who?sequence=1 29. eleje gu, onubogu cu, fiebai po, et al. mother-to-child transmission of human immunodeficiency virus, hepatitis b virus and hepatitis c virus among pregnant women with single, dual or triplex infections of human immunodeficiency virus, hepatitis b virus and hepatitis c virus in nigeria: a systematic review and meta-analysis. sage open med 2022;10:20503 121221095411. 30. hepatitis b annual epidemiological report for 2021. available from: https://www.ecdc.europa.eu/sites/default/files/ documents/hepatitis-b-annual-epidemiological-report2021.pdf 31. rockett ir, putnam sl, jia h, et al. unmet substance abuse treatment need, health services utilization, and cost: a population-based emergency department study. ann emerg med 2005;45:118-27. 32. hamilton em, rassam w, yan y, et al. correlates of chronic hepatitis b virus infection in the general adult population of china: systematic review and meta-analysis. j viral hepat 2023; https://doi.org/10.1111/jvh.13816 33. yim hj, kim jh, cho yk, et al. non-inferior efficacy of tenofovir disoproxil to tenofovir disoproxil fumarate in virologically suppressed chronic hepatitis b patients. drug des devel therapy 2022:3263-74. 34. patterson j, abdullahi l, hussey gd, et al. a systematic review of the epidemiology of hepatitis a in africa. bmc infect dis 2019;19:1-5. 35. machmud pb, führer a, gottschick c, mikolajczyk r. barriers to and facilitators of hepatitis b vaccination among the adult population in indonesia: a mixed methods study. vaccines 2023;11:398. 36. périères l, diallo a, marcellin f, et al. hepatitis b in senegal: a successful infant vaccination program but urgent need to scale up screening and treatment (anrs 12356 ambass survey). hepatology comm 2022;6:1005-15. 37. smathers sa, sammons js. a strategy for expanding infection prevention resources to support organizational growth. am j infect control 2020;48:975-81. 38. wang x, zhang y, ben y, et al. anti-hbc igg responses occurring at the early phase of infection correlate negatively with hbv replication in a mouse model. viruses 2022;14:2011. 39. banik s, datta a, ghosh a, et al. the prevalence of hepatitis b virus infection in bangladesh: a systematic review and meta-analysis. epidemiol infect 2022;150:e47. 40. yotsuyanagi h, kurosaki m, yatsuhashi h, et al. characteristics and healthcare costs in the aging hepatitis b population of japan: a nationwide real-world analysis. digest dis 2022;40:68-77. 41. belopolskaya m, avrutin v, kalinina o, et al. chronic hepatitis b in pregnant women: current trends and approaches. world j gastroenterol 2021;27:3279. 42. bierhoff m, hashmi ah, pateekhum c, et al. a mixed-methods evaluation of hepatitis b knowledge, attitudes, and practices among migrant women in thailand. bmc pregnancy childbirth 2021;21:1-2. 43. ko k, kim r, nagashima s, et al. residual risk of mother-tochild transmission of hbv despite timely hepatitis b vaccination: a major challenge to eliminate hepatitis b infection in cambodia. bmc infect dis 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infection in pregnancy: immunological response, natural course and pregnancy outcomes. j clin medi 2021;10:2926. 54. rajamoorthy y, taib nm, mudatsir m, et al. risk behaviours related to hepatitis b virus infection among adults in malaysia: a cross-sectional household survey. clin epidemiol global health 2020;8:76-82. review [page 320] [healthcare in low-resource settings 2024;12:12072] online supplementary material: table 1. lists the result from a systematic review search (n=15). non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13464 factors correlated with burnout syndrome among nursing staff raja fitrina lastari,1,2 mohamed saifulaman,2 reza hariandi,1 nicky putri fadilla,1 adinda nurul aisyah1 1hang tuah pekanbaru university, pekanbaru, indonesia; 2lincoln university, selangor, malaysia abstract burnout syndrome is a psychological condition characterized by prolonged emotional, mental, and physical exhaustion, often resulting in decreased motivation, reduced professional efficacy, and impaired work performance. among healthcare professionals, particularly nurses, burnout can significantly compromise the quality and safety of patient care. this study aimed to find the relationship between age and educational background and the prevalence of burnout syndrome among nurses working in the inpatient ward in a hospital in riau province, indonesia. a cross-sectional research design was employed, involving a total of 120 inpatient nurses selected through random sampling. data collection was conducted using the maslach burnout inventory-human services survey for medical personnel (mbi-hss-mp), which measures three key dimensions of burnout: emotional exhaustion, depersonalization, and personal accomplishment. statistical analysis was performed using the chi-square test to determine the association between demographic variables and burnout levels. the findings revealed a significant correlation between age and educational background with the occurrence of burnout syndrome. specifically, nurses with higher educational attainment and those within certain age groups demonstrated increased vulnerability to emotional exhaustion and reduced personal accomplishment. these results underscore the importance of integrating individual demographic factors into the development of targeted strategies and institutional support systems to prevent and manage burnout. enhancing such interventions is essential to safeguarding the wellbeing of nursing staff and ensuring the delivery of safe, effective, and sustainable patient care. introduction the nursing profession involves high physical, emotional, and cognitive demands, including routine work, strict schedules, and responsibility for the health and safety of both patients and fellow staff members, often within team-based environments.1 these stressors contribute to the vulnerability of nurses to burnout syndrome, a psychological condition characterized by emotional exhaustion, depersonalization, and a diminished sense of personal achievement.2,3 as central figures in healthcare systems, nurses are expected to maintain a high standard of patient care while sustaining their own physical, mental, and emotional well-being.4,5 burnout syndrome is a growing concern in the healthcare field. nurses, due to the intensity and continuity of their work, are particularly susceptible and must often adapt to prolonged professional stress.6,7 a systematic review spanning 182 studies across 45 countries reported that the global prevalence of burnout among physicians reached 67.0%.8 in indonesia, a 2017 study examining nurses at cilandak marine hospital found that out of 138 respondents caring for patients under the national health coverage (bpjs), 59.4% experienced severe burnout, while 40.6% reported mild burnout.9 meanwhile, a study in sulawesi indicated that 15.7% of nurses in the region showed symptoms of burnout.10 individuals experiencing burnout often report psychosomatic symptoms, such as fatigue and insomnia, emotional problems, including anxiety and depression, attitudinal changes, like apathy and suspicion, and behavioral issues, such as irritability and withdrawal.11,12 these symptoms underscore the critical impact of burnout on both personal health and professional functioning. the complexity of nurses’ roles continues to make the profession particularly vulnerable.3 a study emphasized that burnout is now increasingly prevalent in professional environments, with contributing factors that include not only job demands but also environmental conditions such as teamwork dynamics and shift patterns.13 preliminary interviews and observations with senior nurses in the inpatient unit of correspondence: raja fitrina lastari, lincoln university, selangor, malaysia. e-mail: rajafitrinalestari@htp.ac.id key words: age; burnout syndrome; education; hospital; nurses. contributions: rfl, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ms, methodology, visualization, writing – review & editing; rh, resources, supervision, and writing –review & editing; npf, resources, supervision, and writing –review & editing; ana, resources, supervision, and writing –review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas hang tuah pekanbaru, based on ethical certificate 461/kepk/uhtp/viii/2024. during the research, the researcher paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 8 december 2024. accepted: 23 july 2025. early view: 4 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13464 doi:10.4081/hls.2025.13464 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 110] [healthcare in low-resource settings 2025;13(s2):13464] one hospital in riau province revealed frequent signs of burnout, including a lack of motivation, emotional fatigue, and persistent tiredness even after rest. these issues were frequently attributed to monotonous routines, complaints from patients and their families, interpersonal conflicts, and inadequate incentives. while environmental and occupational stressors have been widely studied, individual characteristics such as age and educational background have received less empirical attention in relation to burnout. understanding the potential correlation between these factors and burnout is essential to developing targeted interventions for prevention and early management. therefore, this study aims to find the relationship between age and educational background with burnout syndrome among nursing staff. materials and methods design, sample, and variables a cross-sectional observational study design was used. the data collected from december 9th, 2024, to january 10, 2025, in one of the riau province hospitals, specifically in the inpatient rooms, including surgical, medical, and intensive care units. respondents in this study were 120 nurses, selected using a total sampling. the variables included age, gender, marital status, education, length of service, and employment status, while the dependent variable was burnout syndrome. instrument this study employed the maslach burnout inventory-human services survey for medical personnel (mbi-hss-mp) because of its strong validity and reliability. this questionnaire shows high internal consistency with cronbach’s alpha values between 0.70 and 0.90. the mbi-hss-mp has been translated into indonesian and has been tested for validity and reliability. based on the corrected item-total correlation results, 22 items were deemed valid because the calculated r value exceeded 0.444, and reliable since cronbach’s alpha was 0.969 (>0.60). the questionnaire consists of three dimensions, namely physical and emotional exhaustion, depersonalization, and decreased personal accomplishment. the emotional exhaustion dimension describes feelings of fatigue, depleted energy, and prolonged feelings of emptiness. the depersonalization dimension relates to a cynical and withdrawn attitude towards others at work. meanwhile, the decreased personal accomplishment dimension describes feelings of helplessness and incompetence at work. the mbi-hss-mp comprises 22 statement items, and each item contains seven answer options, namely 0 (never), 1 (a few times a year), 2 (once a month or less), 3 (several times a month), 4 (once a week), 5 (several times a week), 6 (every day). the questionnaire includes positive and negative statement items. data analysis data analysis conducted in this study includes univariate and bivariate analysis. univariate analysis was used to examine nurse burnout, which can be presented in the form of frequency distribution tables and percentages of each variable, such as age, gender, marital status, level of education, length of work, and employment status. bivariate analysis was conducted to test differences between variables using the chi-square test, with α=0.05. ethical clearance this research has obtained ethical approval from the health research ethics commission (kepk) of hang tuah university, pekanbaru, under the reference number 461/kepk/uhtp/ viii/2024. results among the 120 respondents, the majority were aged 31-40 years, totaling 52 respondents (43.3%), followed by 41-50 years with 39 respondents (31.7%) and 21-30 years with 30 respondents (25%). regarding gender, the majority of the respondents were female, totaling 105 respondents (87.5%). for marital status, 105 respondents (87.5%) were married. the majority of respondents (64.2%) held a bachelor’s degree in nursing. most respondents had a work duration of over 10 years, totaling 68 respondents (56.7%). regarding employment status, 49.2% were contract workers, followed by civil servants at 40.8%, and government contract employees at 10.0% (table 1). the analysis of burnout syndrome among nursing staff was conducted across three core dimensions: emotional exhaustion, depersonalization, and personal accomplishment, based on several demographic characteristics (table 2). in terms of age, the 31-40-year age group exhibited the highest frequency of low-level emotional exhaustion (35.0%), followed by the 41-50 group (28.3%) and the 21-30 group (20.8%). notably, high levels of emotional exhaustion and depersonalization were minimal across all age categories, though a few respondents aged 21-30 reported high burnout in these dimensions. across all age groups, however, there was a consistent and striking pattern of high burnout in the personal accomplishment dimension, with 25.0%, 43.3%, and 31.6% of respondents in the respective age groups reporting diminished personal efficacy. in terms of gender, female nurses experienced a markedly higher prevalence of burnout across all dimensions. specifically, 74.2% of female respondents reported low emotional exhaustion, compared to 10.0% of males; however, females also accounted for pathways of change, part ii table 1. frequency distribution of respondent characteristics (n=120). respondent characteristics n % age 21-30 years old 30 25.0 31-40 years old 52 43.3 41-50 years old 38 31.7 gender male 15 12.5 female 105 87.5 marital status married 105 87.5 single 15 12.5 education diploma 43 35.8 bachelor 77 64.2 length of work 1-5 years 36 30.0 6-10 years 16 13.3 > 10 years 68 56.7 employment status civil servant 49 40.8 government contract employee 12 10.0 contract worker 59 49.2 [healthcare in low-resource settings 2025;13(s2):13464] [page 111] nearly all medium and high levels of burnout in emotional exhaustion and depersonalization. additionally, 87.5% of females reported high burnout in the personal accomplishment domain, highlighting a significant trend of emotional strain and reduced self-perception of effectiveness among female staff. regarding marital status, married nurses showed higher levels of burnout compared to their unmarried counterparts. a total of 73.3% of married respondents experienced low emotional exhaustion, with 14.2% reporting moderate levels. both groups, regardless of marital status, exhibited high levels of burnout in the personal accomplishment domain, further confirming the pervasive nature of this dimension. educational background also appeared to influence burnout levels. nurses with a bachelor’s degree were more likely to report medium or high emotional exhaustion and depersonalization compared to those with a diploma. while 50.8% of bachelor’s degree holders showed low emotional exhaustion, 12.5% reported moderate levels, and 0.8% reported high levels. furthermore, 64.2% of respondents with a bachelor’s degree reported high burnout in personal accomplishment, compared to 35.8% of diploma holders. this suggests that higher education may be associated with elevated work expectations or stressors, contributing to increased burnout. the length of work experience revealed that nurses with more than 10 years of service had the highest levels of low emotional exhaustion (49.2%) and depersonalization (47.5%). however, moderate and high levels were more common among those with shorter tenures (1-5 years), possibly indicating greater vulnerability to burnout in the early years of practice. regardless of tenure, a high percentage of all groups experienced pathways of change, part ii [page 112] [healthcare in low-resource settings 2025;13(s2):13464] table 2. frequency distribution of burnout syndrome identification in the emotional exhaustion, depersonalization, and personal accomplishment dimensions, based on respondents’ demographics. respondent characteristic category burnout dimension low n (%) medium n (%) high n (%) age 21-30 emotional exhaustion 25 (20.8) 4 (3.3) 1 (0.8) depersonalization 25 (20.8) 3 (2.5) 2 (1.7) personal accomplishment 0 (0) 0 (0) 30 (25.0) 31-40 emotional exhaustion 42 (35.0) 10 (8.3) 0 (0) depersonalization 39 (32.5) 8 (6.7) 5 (4.2) personal accomplishment 0 (0) 0 (0) 52 (43.3) 41-50 emotional exhaustion 34 (28.3) 4 (3.3) 0 (0) depersonalization 32 (26.6) 6 (5.0) 0 (0) personal accomplishment 0 (0) 0 (0) 38 (31.6) gender male emotional exhaustion 12 (10) 3 (2.5) 0 (0) depersonalization 11 (9.2) 2 (1.7) 2 (1.7) personal accomplishment 0 (0) 0 (0) 15 (12.5) female emotional exhaustion 89 (74.2) 15 (12.5) 1 (0.8) depersonalization 85 (70.8) 15 (12.5) 5 (4.2) personal accomplishment 0 (0) 0 (0) 105 (87.5) marital status married emotional exhaustion 88 (73.3) 17 (14.2) 0 (0) depersonalization 84 (70) 14 (11.7) 7 (5.8) personal accomplishment 0 (0) 0 (0) 105 (87.5) not married emotional exhaustion 13 (10.8) 1 (0.8) 1 (0.8) depersonalization 12 (10) 3 (2.5) 0 (0) personal accomplishment 0 (0) 0 (0) 15 (12.5) education diploma emotional exhaustion 40 (33.3) 3 (2.5) 0 (0) depersonalization 38 (31.7) 5 (4.2) 0 (0) personal accomplishment 0 (0) 0 (0) 43 (35.8) bachelor emotional exhaustion 61 (50.8) 15 (12.5) 1 (0.8) deprsonalization 58 (48.3) 12 (10) 7 (5.8) personal accomplishment 0 (0) 0 (0) 77 (64.2) length of work 1-5 years emotional exhaustion 28 (23.3) 7 (5.8) 1 (0.8) depersonalization 25 (20.8) 7 (5.8) 4 (3.3) personal accomplishment 0 (0) 0 (0) 36 (30) 6-10 years emotional exhaustion 14 (11.7) 2 (1.7) 0 (0) depersonalization 14 (11.7) 2 (1.7) 0 (0) personal accomplishment 0 (0) 0 (0) 16 (13.3) >10 years emotional exhaustion 59 (49.2) 9 (7.5) 0 (0) depersonalization 57 (47.5) 8 (6.7) 3 (2.5) personal accomplishment 0 (0) 0 (0) 68 (56.7) employment status civil servant emotional exhaustion 45 (37.5) 4 (3.3) 0 (0) depersonalization 40 (33.3) 8 (6.7) 1 (0.8) personal accomplishment 0 (0) 0 (0) 49 (40.8) government contract emotional exhaustion 7 (5.8) 4 (3.3) 1 (0.8) depersonalization 10 (8.3) 1 (0.8) 1 (0.8) personal accomplishment 0 (0) 0 (0) 12 (10) contract workers emotional exhaustion 49 (40.8) 10 (8.3) 0 (0) depersonalization 46 (38.3) 8 (6.7) 5 (4.2) personal accomplishment 0 (0) 0 (0) 59 (49.2) burnout in personal accomplishment, with the highest rate (56.7%) observed among those with more than ten years of service. employment status revealed differences in burnout exposure. non-civil servant nurses reported the highest levels of low emotional exhaustion (40.8%) and depersonalization (38.3%), as well as notable percentages in the medium and high categories. by contrast, civil servants showed relatively lower burnout across emotional and depersonalization dimensions. despite this, high burnout in personal accomplishment remained consistent across all employment types, with contract workers reporting the highest rate (49.2%). table 3 presents the results of a bivariate analysis using the chi-square test to examine the relationship between various respondent characteristics and the incidence of burnout syndrome among nurses. the significance level was set at p≤0.05. the analysis revealed that age and educational background had a statistically significant relationship with burnout syndrome. nurses aged 31-40 years had the highest percentage experiencing burnout (15.4%), followed by those aged 21-30 years (13.3%). notably, none of the respondents aged 41-50 years experienced burnout. the p-value for age was 0.044, indicating a significant association. regarding education, burnout was experienced by 15.6% of respondents with a bachelor’s degree, while none of the diploma holders reported experiencing burnout. this yielded a p-value of 0.004, suggesting a strong correlation between higher educational attainment and increased risk of burnout. on the other hand, the variables gender, marital status, length of work, and employment status did not show statistically significant associations with burnout syndrome. burnout was slightly more prevalent among male nurses (13.3%) than females (9.5%), but the difference was not significant (p=0.646). similarly, marital status showed no meaningful difference, with 13.3% of unmarried and 9.5% of married nurses experiencing burnout (p=0.646). burnout appeared more frequently among nurses with shorter work experience (16.7%) for those with 1-5 years of experience, compared to 12.5% for 6-10 years, and 5.9% for more than 10 years. however, this trend was not statistically significant (p=0.205). although employment status did not reach statistical significance (p=0.0777), the data showed that government contract employees had the highest burnout rate at 25%, followed by contract workers (11.9%), and civil servants (4.1%). discussion relationship between age and burnout syndrome the results of this study indicate a significant relationship between age and the incidence of burnout syndrome. nurses in the 31-40 years age group exhibited the highest prevalence of burnout compared to other age categories. this finding aligns with the perspective of maslach and leiter, who suggest that younger professionals often possess high idealism and motivation but lack the coping mechanisms and emotional resilience needed to manage occupational stress effectively.14 nurses in their 30s typically represent the productive middle phase of life, often experiencing increased responsibilities both at work and at home. professionally, they may be expected to take on leadership roles or manage complex patient cases, while personally, they may be balancing family demands such as raising young children or supporting aging parents.15 these converging pressures can contribute to a heightened risk of emotional exhaustion, depersonalization, and reduced personal accomplishment, core elements of burnout. this finding is consistent with previous research that has demonstrated a statistically significant relationship between age and burnout levels among nurses.16 although burnout is not exclusive to a particular age group, younger and mid-career nurses may be more vulnerable due to limited experience in stress man pathways of change, part ii table 3. analysis results of demographic data and burnout syndrome among nurses. respondent characteristics burnout syndromep-value* experiencing not experiencing total value n % n % n % age 0.044** 21-30 years old 4 13.3 26 86.7 30 100 31-40 years old 8 15.4 44 86.4 52 100 41-50 years old 0 0.0 38 100 38 100 gender 0.646 male 2 13.3 13 86.7 15 100 female 10 9.5 95 90.5 105 100 marital status 0.646 married 10 9.5 95 90.5 105 100 not married 2 13.3 13 86.7 15 100 education 0.004** diploma 0 0.0 43 100 43 100 bachelor 12 15.6 65 84.4 77 100 length of work 0.205 1-5 years 6 16.7 30 83.3 36 100 6-10 years 2 12.5 14 87.5 16 100 > 10 years 4 5.9 64 94.1 68 100 employment status 0.077 civil servant 2 4.1 47 95.9 49 100 government contract employee 3 25 9 75 12 100 contract worker 7 11.9 52 88.1 59 100 *p=0.05; **p<0.05. [healthcare in low-resource settings 2025;13(s2):13464] [page 113] agement, fewer coping strategies, and higher expectations placed upon them. the results from this study reinforce the need for agesensitive interventions, including mentorship, professional development, and stress reduction programs, especially targeted at nurses in the 30-40 age group. relationship between educational background and burnout syndrome this study also found a significant association between educational background and burnout syndrome. nurses holding a bachelor’s degree in nursing reported higher levels of burnout (15.6%) compared to those with a diploma, none of whom experienced burnout. this difference may stem from the greater responsibilities typically assigned to nurses with a bachelor’s degree, including administrative duties, clinical decision-making, mentoring junior staff, and engaging in evidence-based practice. previous studies have highlighted that nurses with higher educational attainment tend to have stronger clinical competencies, deeper theoretical understanding, and more developed critical thinking skills, making them valuable assets to healthcare teams.17,18 however, these advanced capabilities often translate into higher professional expectations and workloads, which can contribute to emotional strain and occupational stress if not managed properly.19,20 the present findings support this notion, suggesting that higher educational attainment may increase perceived job pressure, especially in settings where organizational support systems are lacking or insufficient. when increased responsibility is not matched with adequate resources, recognition, and stress management strategies, even highly capable nurses can experience burnout. this highlights the importance of ensuring role clarity, workload balance, and support structures, particularly for nurses in advanced roles. conclusions this study reveals that burnout syndrome among nursing staff is prevalent across all demographic categories, with the personal accomplishment dimension consistently showing high levels of burnout. this indicates a widespread sense of reduced professional efficacy and fulfillment among nurses, regardless of age, gender, marital status, education, work experience, or employment status. these results highlight the importance of considering individual factors such as age and educational background when assessing burnout risk. targeted interventions should be developed to address emotional fatigue and to restore a sense of accomplishment, particularly among at-risk groups, in order to maintain the mental health and professional performance of nursing staff. references 1. sani di, paskarini i. hubungan antara kualitas kehidupan kerja dengan kepuasan kerja perawat rawat inap rumah sakit x gresik [the relationship between quality of work life wih job satisfaction of inpatient nurses at x hospital x gresik]. media publ promosi kesehat indones 2022;5:123440. 2. moya-salazar j, buitrón la, goicochea ea, et al. the age of young nurses is a predictor of burnout syndrome during the care of patients with covid-19. nurs rep 2023;13:721-30. 3. lailani f. burnout pada perawat ditinjau dari efikasi diri dan dukungan sosial di rumah sakit di surakarta [nurses burnout in terms of self efficacy and social support at hospital of surakarta]. j talent 2014;3. 4. aqsa a, paskarini i. hubungan faktor gaya hidup dengan burnout pada perawat rawat inap di rumah sakit jiwa [the relationship between lifestyle with burnout in in-patient nurse of mental health hospital]. media publ promosi kesehat indones 2022;5:1114-21. 5. herachwati n, haqq zn, choirunnisa z, et al. revealing indonesian healthcare workers’ burnout, work engagement, and job satisfaction during the covid-19 pandemic: the lens of the job demands-resources model. cogent bus manag 2024;11:2371328. 6. riu sdm, nursalam n, ruku dm. burnout intervention strategies on healthcare provider burnout (cultural differences): a systematic review and meta-analysis. j liaquat univ med heal sci 2025;2025:28-35. 7. raudenská j, steinerová v, javůrková a, et al. occupational burnout syndrome and post-traumatic stress among healthcare professionals during the novel coronavirus disease 2019 (covid-19) pandemic. best pract res clin anaesthesiol 2020;34:553-60. 8. world health organisation u. burn-out an ‘occupational phenomenon’: international classification of diseases. who dep news; 2019. 9. o’mahony n. nurse burnout and the working environment. emerg nurse 2011;19. 10. renzi c, di pietro c, tabolli s. psychiatric morbidity and emotional exhaustion among hospital physicians and nurses: association with perceived job-related factors. arch environ occup health 2012;67:117-23. 11. lee hf, hsu hc, efendi f, et al. burnout, resilience, and empowerment among covid-19 survivor nurses in indonesia. plos one 2023;18:e0291073. 12. paskarini i, dwiyanti e, syaiful da, syanindita d. burnout among nurses: examining psychosocial work environment causes. j public health res 2023;12:22799036221147812. 13. moustaka e, malliarou m, konstantinidis t, et al. burnout in nursing personnel in a regional university hospital. balk mil med rev 2009;12:1-7. 14. maslach c, leiter mp, jackson se. making a significant difference with burnout interventions: researcher and practitioner collaboration. j organ behav 2012;33:296-300. 15. chin rekaya v, wider w, tanucan jcm, et al. leadership competencies and managerial competencies of nurse managers in kuala lumpur hospital, malaysia. j ners 2024;19:292-301. 16. hatch dj, freude g, martus p, et al. age, burnout and physical and psychological work ability among nurses. occup med (chic ill) 2018;68:246-54. 17. ahmady s, shahbazi s. impact of social problem-solving training on critical thinking and decision making of nursing students. bmc nurs 2020;19:94. 18. cummings gg, lee s, tate k, et al. the essentials of nursing leadership: a systematic review of factors and educational interventions influencing nursing leadership. int j nurs stud 2021;115:103842. 19. indiawati oc, syaâ h, rachmawati ds, suhardiningsih avs. analisis faktor yang mempengaruhi kejadian burnout syndrome perawat di rs darmo surabaya. j keperawatan dan kesehat masy cendekia utama 2022;11:25-41. 20. maslach c, leiter mp. understanding the burnout experience: recent research and its implications for psychiatry. world psychiatry 2016;15:103-11. pathways of change, part ii [page 114] [healthcare in low-resource settings 2025;13(s2):13464] hrev_master healthcare in low-resource settings 2025; volume 13:12927 distribution of episodes of kidney diseases admitted at the university hospital center “mother teresa” in tirana, albania, during the period 2010-2023 marsida duli, qamil dika, elizana petrela, genc burazeri faculty of medicine, university of medicine, tirana, albania abstract our aim was to describe the distribution of kidney diseases among hospitalized patients in tirana, the capital of albania, during the period 2010-2023. a case-series study was conducted including all episodes admitted with kidney diseases at the university hospital center “mother teresa” in tirana during the period 2010-2023 (overall: 15,763 episodes; 46% females; overall mean age: 54.0±17.3 years). we found that ≈56% of the kidney disease episodes were 35-65 years old, followed by >65-year-old individuals (≈28%). most of the kidney disease episodes (about 43%) hospitalized were from the tirana region, followed by districts pertinent to south albania (23%). older patients (>65 years) were more prevalent among males compared to females (301% vs 25%, respectively; p<0.001). patients from the tirana region were more prevalent among females compared to males (45% vs 42%, respectively, p<0.001). this study provides evidence on the distribution of the episodes of kidney diseases admitted at university hospital center “mother teresa” in tirana, the largest region in albania, a country in the western balkans that is undergoing deep reforms in all sectors, including also the health sector. introduction kidney diseases constitute an important public health problem worldwide.1-3 in particular, the toll of chronic kidney disease is increasing, which is compatible also with the general increase in noncommunicable diseases (ncds).2 the global burden of disease (gbd) 2015 study has estimated that chronic kidney disease concerns about 10% of the adult population worldwide.3 chronic kidney disease is primarily caused by diabetes, hypertension, vascular disease, and glomerulonephritis,2,3 and also leads to other deleterious health outcomes, such as higher rates of symptomatic intracerebral hemorrhage, increased mortality, and poorer functional outcomes in patients with acute ischemic stroke.1,4,5 furthermore, a fairly recent meta-analysis indicated that chronic kidney disease constitutes a significant comorbidity in patients with acute ischemic stroke highlighting the need for tailored management strategies to enhance patient outcomes.1 in addition, chronic disease patients are at high risk of developing a common mental disorder.6 as a matter of fact, patients with chronic kidney disease and mental disorders have a higher risk of hospitalizations,7 poor quality of life,8 difficulties adhering to medications,9 rapid progression to end-stage renal disease (esrd),10 as well as several other unfavorable conditions including mortality.11,12 it has been shown that the mortality risk and hospitalization rate among patients with chronic kidney disease accompanied by mental disorders is much higher than among chronic disease patients without mental disorders.10 albania emerged from the most rigid socialist regime in 1990 and since has been undergoing considerable changes toward a market-oriented system which has been associated with changes in lifestyle and changes in morbidity and mortality patterns.13 the albanian population is rapidly aging (in 2020, around 15% of the population was aged 65 years and above) as a result of a steady increase in life expectancy, a gradual decrease in fertility rate, and emigration of particularly young adults.14,15 this demographic transition observed in the past thirty years has unavoidably led to a substantial change in the epidemiological profile of the albanian population, which consists of an outstanding shift from infectious diseases to ncds, including primarily cardiovascular diseases, cancer, chronic respiratory diseases, and diabetes.14,16 however, the proportional mortality from ncds in the albanian population in 2021 was estimated at about 73%, displaying a significant correspondence: marsida duli, faculty of medicine, university of medicine, rr. “dibres”, no. 371, tirana, albania. tel. +355676071226. e-mail: marsiduli@hotmail.com key words: albania, disease episodes, kidney diseases, tirana, university hospital center “mother teresa”. contributions: md, qd, and gb contributed to the study conceptualization and design, analysis and interpretation of the data, and writing of the article. ep commented comprehensively on the manuscript. all authors have read and approved the final version of the manuscript, and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: not required. the aggregated data analysis guarantees the anonymity of the patients included in this study. availability of data and materials: the data presented in this study are available upon request from the corresponding author. received: 15 august 2024. accepted: 4 september 2024. early access: 16 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12927 doi:10.4081/hls.2024.12927 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:12927] [page 9] non -co mmerc ial us e o nly decrease from around 93% in 2019 (i.e., before the covid-19 pandemic).16 yet, the overall mortality rate from ncds has increased in albania from 798 deaths in 2019 to 820 deaths in 2021 (per 100,000 population),16 indicating an increase in the death rates from both infectious diseases (due to covid-19) and ncds. the main risk factors in the albanian population include high blood pressure, smoking, and dietary factors.16 according to the estimates of the global burden of disease 2021 study, the proportional mortality due to kidney dysfunction in albania increased from 5.1% in 1990 to 6.0% in 2021.16 on the other hand, the mortality rate and burden of acute glomerulonephritis has declined in the past three decades in the albanian population (age-standardized mortality rates in 1990 and 2021 were 0.52 and 0.14 deaths per 100,000 population, respectively).16 conversely, in line with the gradual population aging, at a crude level, chronic kidney disease has steadily increased during the period 1990-2021 (mortality rates in 1990 and 2021 were about 7 and 16 deaths per 100,000 population, respectively).16 however, in albania, the information about kidney diseases in the general population is scarce and not well-documented. in this framework, the aim of this study was to describe the distribution of kidney diseases among hospitalized patients in tirana, the capital of albania, during the period 2010-2023. materials and methods this was a case-series study including all episodes admitted with kidney diseases at the university hospital center “mother teresa” in tirana, the largest public hospital in albania, during the period 2010-2023. the information about the episodes with kidney diseases was provided by the statistics office of the university hospital center “mother teresa” in tirana, according to each patient’s medical chart. data on the diagnoses of kidney disease episodes were collected for each year under investigation, in addition to selected demographic factors of the patients (including age, gender, and region of the country). measures of central tendency (mean and median values) and dispersion (standard deviation and the interquartile range) were calculated for the age of the patients admitted with kidney disease episodes during the study period. in addition, absolute numbers and their respective percentages were calculated for the episodes of kidney diseases by selected demographic characteristics of the patients (age-group, gender, and region of albania) and each year covering the study period (i.e., from 2010 to 2023). fisher’s exact test was used to compare the gender-specific distribution of the hospitalized episodes of kidney diseases according to selected demographic factors (age-group and region of the patients). a p-value of ≤0.05 was considered statistically significant. statistical package for the social sciences (spss, version 19.00) was used for all the statistical analyses. results table 1 presents the distribution of episodes of kidney diseases admitted at the university hospital center “mother teresa” in tirana during the period 2010-2023 by selected demographic characteristics. on the whole, during the period 2010-2023, there were 15,763 episodes of various kidney diseases that required hospitalization at the university hospital center “mother teresa” in tirana. of these, 54% of the episodes involved male patients, whereas the remaining 46% were pertinent to female patients. overall, the mean age of the patients admitted with kidney disease episodes for the entire duration of the study period was 54.0±17.3 years. conversely, the median age was 55.9 years (interquartile range: 43.4-66.5 years). regarding the age group distribution, the majority (almost 56%) of the kidney disease episodes concerned the age group 35-65 years, followed by individuals aged more than 65 years (almost 28%). as for the regional distribution, most of the kidney disease episodes (about 43%) hospitalized were from the tirana region, followed by districts pertinent to south albania (23%). notably, 109 episodes (0.7% of the overall kidney disease episodes admitted during the period 2010-2023) were from kosovo (table 1). table 2 presents the distribution of kidney disease episodes admitted at the university hospital center “mother teresa” in tirana for each year of the study period (i.e., from 2010 to 2023). the year which marked the highest number of admissions of kidney diseases episodes was 2018 (8.9% of the overall number of episodes during the period 2010-2023), followed by the year 2019 (8.7%) and next the year 2017 (8.2%) and the year 2022 (8.1%). conversely, the year with the lowest number of admissions with kidney disease episodes was 2023 (1.8% of the overall number of episodes under the study period) followed by the year 2020 (5.1%) (table 2). a higher proportion of female patients were younger (<35 years) compared to male patients (19.5% vs 13.5%, respectively) (table 3). consequently, older patients (individuals aged 65 years and above) were more prevalent among males compared to females (30.5% vs 24.7%, respectively). these age differences between males and females were highly statistically significant (p<0.001). patients from the tirana region were more prevalent among females compared to males (44.6% vs 42.3%, respectively). conversely, a higher proportion of patients from south albania was evident among males compared to females (24.7% vs 20.5%, respectively). these regional differences between males and females were highly statistically significant too (p<0.001) (table 3). figure 1 presents the trend in the number of episodes with kid article table 1. distribution of episodes of kidney diseases admitted at the university hospital center “mother teresa” in tirana during 2010-2023 by demographic characteristics. variable number percentage age group <35 years 2564 16.3 35-65 years 8817 55.9 >65 years 4382 27.8 total 15763 100.0 gender males 8502 53.9 females 7261 46.1 region tirana 6835 43.4 north albania 2469 15.7 central albania 2761 17.5 south albania 3589 22.8 kosovo 109 0.7 parameter age (numerical variable) mean ± sd 54.0±17.3 years median (interquartile range) 55.9 years (43.4-66.5 years) [page 10] [healthcare in low-resource settings 2025;13:12927] non -co mmerc ial us e o nly ney diseases admitted at the university hospital center “mother teresa” in tirana by gender and year. during the first three years under investigation (i.e., during the years 2010-2012), the number of episodes with kidney diseases admitted at the university hospital center “mother teresa” in tirana was higher in females than in males. on the other hand, for each subsequent year (i.e., from 2013 to 2023), the number of kidney disease episodes hospitalized was higher in males than in females. of note, the number of kidney disease episodes admitted at the university hospital center “mother teresa” in tirana in 2023 was remarkably low (n=287) compared with the other years covering the study period. this may be due to the under-recording of the cases for this year, a finding which deserves further investigation. discussion this study provides evidence on the distribution of kidney diseases among hospitalized patients in tirana, the capital of albania, during the period 2010-2023. the main findings of this study indicate that about 56% of the kidney disease episodes were confined to the age group 35-65 years, followed by older individuals (about 28%). most of the kidney disease episodes (about 43%) hospitalized were from the tirana region, followed by districts in south albania (23%). the year 2018 exhibited the highest number of admissions of kidney disease episodes (8.9%). conversely, the year 2023 had the lowest number of admissions with kidney disease episodes (1.8%). older patients (>65 years) were more prevalent among males compared to females. patients from the tirana region were more prevalent among females compared to males, whereas a higher proportion of patients from south albania was evident among males compared to females. during the years 20102012, the number of episodes with kidney diseases was higher in females than in males, whereas during 2013-2023 the number of kidney disease episodes hospitalized was higher in males than in females. the episodes of kidney diseases admitted during the study period included chronic kidney disease, acute glomerulonephritis, article figure 1. number of episodes with kidney diseases admitted at the university hospital center “mother teresa” in tirana by gender and year. [healthcare in low-resource settings 2025;13:12927] [page 11] table 2. distribution of kidney disease episodes admitted at the university hospital center “mother teresa” in tirana by year. year number percentage cumulative percentage 2010 1121 7.1 7.1 2011 1111 7.0 14.2 2012 1099 7.0 21.1 2013 1186 7.5 28.7 2014 1225 7.8 36.4 2015 1161 7.4 43.8 2016 1227 7.8 51.6 2017 1288 8.2 59.7 2018 1398 8.9 68.6 2019 1364 8.7 77.3 2020 804 5.1 82.4 2021 1209 7.7 90.0 2022 1283 8.1 98.2 2023 287 1.8 100.0 total 15763 100 table 3. gender-specific distribution of episodes of kidney diseases admitted at the university hospital center “mother teresa” in tirana by age and region. variable males (%) females (%) p age-group <0.001 <35 years 13.5 19.5 35-65 years 56.0 55.8 >65 years 30.5 24.7 total 100 100 region <0.001 tirana 42.3 44.6 north albania 15.5 15.9 central albania 16.9 18.3 south albania 24.7 20.5 kosovo 0.7 0.7 total 100 100 non -co mmerc ial us e o nly acute kidney injuries, polycystic kidney disease, nephrotic syndrome, nephrolithiasis (kidney stones), urinary tract infections, diabetic nephropathy, as all as other kidney diseases and conditions which have deleterious effects on the kidneys’ functions. chronic kidney disease represented the most prevalent condition. this progressive condition characterized by structural and functional changes in the kidney is globally recognized as an important public health problem.17 this disease increases the risk of end-stage kidney disease and is an independent risk factor for cardiovascular diseases and premature death.18,19 at a global level, the prevalence of chronic kidney disease is increasing, with the fastest progression occurring in low-income and middle-income countries such as albania.3,17,20,21 the main risk factors for this condition include hyperglycemia, hypertension, hyperlipidemia, and obesity.17,22,23 the gbd study showed that in 2017, there were 697.5 million cases of chronic kidney disease worldwide, with 1.2 million deaths from this condition.24 projections indicate that by 2040, chronic kidney disease will be the fifth leading cause of mortality.25 however, the development of nephrology and the focus on the treatment of early-stage chronic kidney disease decrease mortality and prevent the progression of eskd.26 while there is no specific information about kidney diseases for the general population of albania, the age-standardized mortality rate from all ncds in 2019 was estimated at 520 (95% ci=413649) deaths per 100,000 population.14,16 in 2019, about 93% (95% ci=92-94%) of all deaths in albania were caused by ncds.14,16 in particular, cardiovascular diseases constitute 57% (95% ci=5260%) of the overall mortality in the albanian population.14,16 this study may have some limitations including the reporting system pertinent to the university hospital center “mother teresa” in tirana, which still needs strengthening and improvement. hence, some data on kidney disease patients including laboratory results (creatinine levels, or glomerular filtration rate) may be incomplete or inaccurate, which could lead to misdiagnosis. also, poor coordination between the nephrology department and other departments such as radiology may result in fragmented data (regarding imaging procedures such as ultrasounds, or ct scans). in addition, this is a tertiary hospital and episodes admitted at this center may not necessarily represent all episodes of kidney diseases across albania. conclusions despite the aforementioned potential limitations, this study provides a valuable description of the burden of kidney diseases admitted at the largest tertiary care facility in albania. further studies are needed to provide a more comprehensive overview and more detailed analyses regarding the burden of kidney diseases in albania. in conclusion, this study provides evidence on the distribution of the episodes of kidney diseases admitted at university hospital center “mother teresa” in tirana, the largest region in albania, a country in the western balkans which is undergoing deep reforms in all sectors, including also the health sector. references 1. rajesh k, spring kj, beran rg, bhaskar smm. chronic kidney disease prevalence and clinical outcomes in anterior circulation acute ischemic stroke patients with reperfusion therapy: a meta-analysis. nephrology (carlton) 2024;29:21-33. 2. haileamlak a. chronic kidney disease is on the rise. ethiop j health sci 2018;28:681-2. 3. global burden of disease (gbd) 2015 disease and injury incidence and prevalence collaborators. global, regional, and national incidence, prevalence, and years lived with disability for 310 diseases and injuries, 1990–2015: a systematic analysis for the global burden of disease study 2015. lancet 2016;388:1545. 4. kelly dm, pendlebury st, rothwell pm. associations of chronic kidney disease with dementia before and after tia and stroke: population-based cohort study. neurology 2022;98: e711-20. 5. fandler-höfler s, odler b, kneihsl m, et al. acute and chronic kidney dysfunction and outcome after stroke thrombectomy. transl stroke res 2021;12:791-8. 6. gela yy, tesfaye w, melese m, et al. common mental disorders and associated factors among adult chronic kidney disease patients attending referral hospitals in amhara regional state. sci rep 2024;14:6812. 7. abbas tavallaii s, ebrahimnia m, shamspour n, assari s. effect of depression on health care utilization in patients with end-stage renal disease treated with hemodialysis. eur. j intern med 2009;20:411-4. 8. czok m, kramarczyk k. association between depression and hemodialysis in patients with chronic kidney disease. psychiatr danubina 2017;29;499-503. 9. garcia-llana h, remor e, peso g, selgas r. the role of depression, anxiety, stress and adherence to treatment in dialysis patients’ health-related quality of life: a systematic review of the literature. nefrología 2014;34:637-57. 10. wilk as, hu jc, chehal p, et al. national estimates of mental health needs among adults with self-reported ckd in the united states. kidney int rep 2022;7:1630-42. 11. cristina a, miranda as, rocha np, teixeira al. neuropsychiatric disorders in chronic kidney disease. front pharmacol 2019;10:1-11. 12. shirazian s, grant cd, aina o, et al. depression in chronic kidney disease and end-stage renal disease: similarities and differences in diagnosis, epidemiology, and management. kidney int rep 2016;2:94-107. 13. burazeri g, goda a, sulo g, et al. financial loss in pyramid saving schemes, downward social mobility and acute coronary syndrome in transitional albania. j epidemiol commun health 2008;62:620-6. 14. mone i, kraja b, roshi e, burazeri g. overview on health status of the albanian population. seejph 2022;4:295. 15. institute of statistics, albania. key data, 2022. available from: h t tp : / /www. ins t a t . gov.a l / a l / s t a t i s t i ka / t%c3%abdh%c3%abna-ky%c3%a7e/ 16. institute for health metrics and evaluation (ihme). global burden of disease estimates. available from: https://vizhub.healthdata.org/gbd-results/ 17. chen f, wang m, jiang y. prevalence of chronic kidney disease and metabolic related indicators in mianzhu, sichuan, china. front public health 2024;11:1252110. 18. hill nr, fatoba st, oke jl, et al. global prevalence of chronic kidney disease – a systematic review and meta-analysis. plos one 2016;11:e0158765. 19. mills kt, xu y, zhang w, et al. a systematic analysis of worldwide population-based data on the global burden of chronic kidney disease in 2010. kidney int 2015;88:950-7. 20. martinez r, lloyd-sherlock p, soliz p, et al. trends in prema article [page 12] [healthcare in low-resource settings 2025;13:12927] non -co mmerc ial us e o nly ture avertable mortality from non-communicable diseases for 195 countries and territories, 1990-2017: a population-based study. lancet glob health 2020;8:e511-23. 21. levey as, de jong pe, coresh j, et al. the definition, classification, and prognosis of chronic kidney disease: a kdigo controversies conference report. kidney int 2011;80:17-28. 22. zhang l, long j, jiang w, et al. trends in chronic kidney disease in china. n engl j med 2016;375:905-6. 23. chen y, dabbas w, gangemi a, et al. obesity management and chronic kidney disease. semin nephrol 2021;41:392-402. 24. bikbov b, purcell ca, levey as, et al. global, regional, and national burden of chronic kidney disease, 1990–2017: a systematic analysis for the global burden of disease study 2017. lancet 2020;395:1-13. 25. foreman kj, marquez n, dolgert a, et al. forecasting life expectancy, years of life lost, and all-cause and cause-specific mortality for 250 causes of death: refer¬ence and alternative scenarios for 2016–40 for 195 countries and territories. lancet 2018;392:2052-90. 26. zhakhinaa g, mussinaa k, yerdessova s, et al. analysis of chronic kidney disease epidemiology in kazakhstan using nationwide data for 2014–2020 and forecasting future trends of prevalence and mortality for 2030. renal failure 2024;46:2326312. article [healthcare in low-resource settings 2025;13:12927] [page 13] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11917 the effect of deep breath relaxation and counterpressure massage on pain reduction during labor rahmawati wahyuni,1 supriadi supriadi,2 dewi susanti,3 nursari abdul syukur,1 rosalin ariefah putri1 1department of midwifery, politeknik kesehatan kemenkes kalimantan timur, samarinda; 2department of nursing, politeknik kesehatan kemenkes kalimantan timur, samarinda; 3applied midwifery study program, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia abstract labor pain is a manifestation of the contraction (shortening) of the uterine muscles. non-pharmacological treatment in pain management, namely deep breathing relaxation and counterpressure massage is an alternative method and a new trend that can be developed. this study investigated the effectiveness of deep breathing relaxation and counterpressure massage in alleviating labor pain during active phase i. employing a quasi-experimental design with a two-group pre-test post-test approach, 30 postpartum mothers from june to july 2021 were consecutively sampled. deep breathing relaxation (5 times for 3-5 minutes) and counterpressure massage (3 times for 30-90 seconds) served as the independent variables, while pain intensity during the first active phase was the dependent variable. utilizing the wilcoxon and mann whitney tests at a 5% significance level, significant reductions in pain intensity were observed after both interventions (pvalues: 0.002 for deep breathing, 0.046 for counterpressure massage). these non-pharmacological methods, enhancing endorphin release, contribute to relaxation and pain intensity reduction during labor. the findings underscore the potential of integrating deep breathing relaxation and counterpressure massage as effective approaches in non-pharmacological labor pain management. introduction childbirth is a tense and emotional period for the mother and her family, and it can be a painful and frightening experience for the mother. generally, pain during labor is intense, with only 2-4% of mothers experiencing mild pain.1,2 the combination of pain and fear contributes to stress. according to the indonesian hospital association data center, 15% of mothers in indonesia faced complications during childbirth, with 21% describing their labor as painful due to extreme pain. surprisingly, 63% of mothers did not receive information about the necessary preparations to alleviate pain during labor.3 during this process, stretching and dilation of the cervix occur due to contractions of the uterine muscles, aiming to push the baby out. consequently, the mother experiences pain that can disrupt her comfort.4 labor pain is a physiological condition generally encountered by almost all birthing mothers, with the severity of the pain depending on individual sensations.5 pain in labor is a manifestation of uterine contractions and results from both psychological responses and physical reflexes.6 this pain has repercussions, including an increase in sympathetic nervous system activity, leading to changes in blood pressure, respiratory rate, skin color, nausea, vomiting, and excessive sweating.7 behavioral changes due to pain are also commonly observed, such as heightened anxiety, narrowed thoughts, moaning, crying, hand movements, and intense muscle tension throughout the body.8 various methods can assist in reducing pain during labor, encompassing both pharmacological (involving drugs) and nonpharmacological approaches. whenever possible, non-pharmacological therapeutic options for pain management during labor correspondence: rahmawati wahyuni, lecturer in the department of midwifery, politeknik kesehatan kemenkes kalimantan timur, samarinda, indonesia. e-mail: rahmawati_wahyuni@poltekkes-kaltim.ac.id key words: active phase, counterpressure massage, deep breathing relaxation, maternal health, pain intensity. contributions: rw, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ss, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ds, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing; nas, formal analysis, validation, writing – review and editing. rap original draft, writing – review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. funding: none. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, health polytechnic of the ministry of health of east kalimantan, based on ethical certificate no. lb.02.01/4.3/13566/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: this paper and the research behind it would not have been possible without the exceptional support of health polytechnique of east kalimantan. received: 4 october 2023. accepted: 20 december 2023. early access: 30 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11917 doi:10.4081/hls.2024.11917 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11917] [page 203] non -co mmerc ial us e o nly should be explored before resorting to analgesic drugs.9 the utilization of non-pharmacological measures in pain management is a burgeoning trend and presents an alternative method for mothers to mitigate labor pain. these methods can induce relaxation, alleviating both muscle and emotional tension, ultimately reducing the intensity of labor pain.10 moreover, non-pharmacological approaches contribute to heightened patient satisfaction during labor, empowering the mother to exert control over her emotions and strength.11 non-pharmacological techniques such as relaxation, breathing exercises, movement and position changes, massage, hydrotherapy, hot/cold therapy, music, guided imagery, acupressure, and aromatherapy have proven effective in enhancing maternal comfort during childbirth and fostering a positive birthing experience.12 given the aforementioned problem description, it is evident that unresolved labor pain can significantly impact the psychological well-being of the mother during labor. therefore, this study aimed to investigate the effectiveness of deep breathing relaxation and counterpressure massage in alleviating labor pain during the active phase i. these non-pharmacological therapies can serve as valuable interventions. materials and methods research design this research was conducted from june 8 to july 10, 2021, in the maternity room of a hospital in east kalimantan, indonesia. the study employed a quasi-experimental research design with a 2-group research method, consisting of a deep breathing relaxation group and a counterpressure massage group, utilizing a pre and post-test without control design. study participants the population for this study included all active phase i birth patients in june-july 2021 in maternity room 108, with 30 participants each month. non-probability sampling, specifically consecutive sampling, was used to select 30 participants, evenly divided into two groups (15 per group). inclusion criteria comprised mothers in labor in active phase i, cervical dilatation between 4 to 9 cm, and no prior exposure to nonpharmacological therapy. variable, instrument and data collection the independent variables were deep breathing relaxation and counterpressure massage, while the dependent variable was pain intensity during the first active phase. the research instrument employed was an observation sheet. pain scale during active phase i was measured using a numeric rating scale (nrs). in the intervention group, counterpressure massage was administered three times for 30-90 seconds, and deep breath relaxation techniques were performed three times for 3-5 minutes. data analysis the analysis involved the wilcoxon test and mann-whitney test with a significance level (α) of 5%. the wilcoxon test measured the average pain before and after deep breath relaxation and massage counterpressure for 30 respondents. the mann-whitney test determined the difference in the effectiveness of the average value, indicating a significant decrease in pain intensity between the deep breath relaxation group and the massage counterpressure group. ethical clearance the research received ethical approval from the health research ethics commission, politeknik kesehatan kementrian kesehatan kalimantan timur, based on ethical certificate no. lb.02.01/4.3/13566/2021. throughout the research, the researcher adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. results respondent characteristics in this research provide basic information about respondents, including age, level of education, parity and gestational age. based on table 1, it is evident that almost all respondents were aged between 20-35 years (73.3%). the majority of respondents were not employed (73.3%). a significant portion of respondents had an educational background ranging from elementary to junior high school (40%). the highest parity status among respondents was primipara (40%), and among those with multipara status, there were 12 mothers who gave birth (40%). almost all respondents had gestational ages exceeding 37 weeks, with 29 mothers giving birth (96.7%). based on table 2, it is evident that before the implementation of the breathing relaxation technique, the majority of mothers experienced severe pain during the first active phase, with 9 respondents (60%), and after the intervention, 1 birth mother (6.7%) still experienced severe pain. the wilcoxon test results for the deep breathing relaxation group, both before and after treatment, yielded a p-value of 0.002, which is ≤0.05. this indicates a significant difference in the effectiveness of reducing the intensity of labor pain before and after the application of deep relaxation techniques. similarly, table 2 illustrates that before the massage counterpressure treatment, the majority of mothers experienced severe pain during the first active phase, with 8 respondents (53.3%), and after the intervention, 4 respondents (26.7%) still experienced severe pain. the wilcoxon test results for the counterpressure massage group yielded a p-value of 0.046, which is also ≤0.05. this suggests a significant difference in the effectiveness of reducing the intensity of labor pain before and after the application of counterpressure massage. discussion based on the research results from the 30 respondents studied, the majority fell within the age range of 20-35 years (73.3%). it’s noteworthy that maternal age below 16 years or above 35 years can make pregnant women more susceptible to complications. this indicates that most respondents are within the healthy reproductive age, physiologically capable of enduring labor pain. the age range of 20-35 years is considered ideal for pregnancy, childbirth, and breastfeeding, allowing mothers to provide optimal care for their children.13 employment is a vital activity, primarily undertaken to sustain one’s own life and family. work can significantly impact a person’s economic status. a lower socioeconomic level may lead individuals to pay less attention to health messages, prioritizing more immediate needs.14,15 the education level of some research respondents was primary school and junior high school (40%), aligning with previous research suggesting no relationship between education and labor pain.16 education is a fundamental need for personal development and intellectual maturity. it also influences one’s insight into decision-making and actions.17-19 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 204] [healthcare in low-resource settings 2024;12:11917] non -co mmerc ial us e o nly the intensity of labor pain is affected by the history of past deliveries. mothers with childbirth experience understand the pain during labor, while primiparas may experience greater intensity due to the cervix requiring more energy to stretch during the first stage of labor.20,21 based on the study, most gestational ages were >37 weeks (97.7%), falling within the term gestation period of 38 to 42 weeks. deep breathing relaxation techniques have a significant impact on the intensity of labor pain when implemented during the active phase of the first stage of labor. this is because labor pain serves as a signal indicating that the mother has entered the stage of the labor process, where the intensity of pain varies.22 since pain during labor is subjective, each mother will experience and describe her own pain.23 this research is supported by studies indicating that deep breathing relaxation effectively reduces labor pain in the first active phase.24 of the 15 respondents, the average pain intensity before receiving a counterpressure massage was reported by 8 respondents, constituting 53.3% experiencing severe pain. following the counterpressure massage, 11 respondents had a moderate pain intensity (73.3%), while 4 respondents still experienced severe pain, accounting for 26.7%. this indicates that the counterpressure massage technique is relatively effective in reducing labor pain. these findings align with previous research25 that demonstrated a reduction in pain severity after implementing back massage techniques. the results suggest that massage techniques are effective in alleviating labor pain, as seen in the study where respondents experienced a decrease in pain after the counterpressure massage. the effects of labor pain, including inflammation in the uterus and labor dystocia, can be mitigated through complementary treatments such as effleurage and counterpressure massage.26 this study aimed to analyze the effectiveness of effleurage and counterpressure massages in reducing labor pain during the first stage of active labor phase.27 the research is supported by previous studies conducted by yulianingsih et al. (2019)8 affirming the effectiveness of counterpressure massage during the active phase of labor. while indicating the potential integration of non-pharmacological approaches, such as deep breathing relaxation and counterpressure massage, for alleviating labor pain during the initial active phase, the study acknowledges significant limitations. with a sample size of only 30 postpartum mothers, concerns arise regarding the generalizability of results to a broader population, emphasizing caution in extrapolating findings across diverse demographic groups. furthermore, the study’s temporal scope is limited, as postintervention assessments occurred immediately after interventions, neglecting an exploration of the long-term effects on labor pain sustainability. future research should extend assessment periods into the postpartum phase to elucidate the enduring impact of these non-pharmacological interventions. recognizing these constraints highlights the imperative for ongoing research and refinement in the application of these methods within the broader context of labor pain management. conclusions deep breathing relaxation techniques and counterpressure massage can alleviate tension in mothers, relieving stress during labor pain. these techniques promote relaxation of the body and inhibit the production of adrenaline hormones, replacing them with endorphins—pain-relieving hormones that increase endorphin levels. this physiological response induces a state of relaxation, consequently reducing the intensity of labor pain. subsequent research endeavors may involve observing the reduction in pain intensity within the counterpressure massage treatment group by considering the involvement of both family members and healthcare professionals. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=30). indicator f % age <20 years 3 10 20-35 years 22 73.3 >35 years 5 16.7 employment work 8 26.7 doesn't work 22 73.3 education elementary and junior 12 40 high school senior high school 9 30 college university 9 30 parity primipara 12 40 multipara 12 40 grande multipara 6 20 gestational age ≤37 weeks 1 3.3 >37 weeks 29 96.7 total 30 100 table 2. deep breathing relaxation and massage counter pressure treatments on pain intensity in active phase i labor mothers. pre-test post-test p f % f % pain intensity with deep breathing relaxation 0.002 light 0 0 2 13.3 normal 6 40 12 80 heavy 9 60 1 6.7 pain intensity with massage counterpressure 0.046 light 0 0 0 0 normal 7 46.7 11 73.3 heavy 8 53.3 4 26.7 total 15 100 15 100 [healthcare in low-resource settings 2024;12:11917] [page 205] non -co mmerc ial us e o nly references 1. ria g, maya a, jamalluddin sb. murotal al-quran therapy on decreasing labor pain and anxiety in maternity mothers first phase. enferm clin 2020;30:110-4. 2. hamzah h, nyoman yesua darma surya bratha i, sumartono c, et al. comparison of outcome between patients receiving general anesthesia combined with continuous epidural anesthesia and patients receiving general anesthesia combined with intermittent epidural anesthesia. bali j anesthesiol 2020;4:118-21. 3. dewi yuliasari es. hubungan counterpressure dengan nyeri persalinan pada ibu bersalin kala i fase aktif ibu primipara di bps hj. sulastri, amd.keb pekalongan lampung timur tahun 2013. pengaruh akupresur lo4 (he kuk) dan thai cong terhadap tingkat nyeri persalinan kala i pada ibu bersalin. 2018;9:9-12. 4. smith ca, levett km, collins ct, et al. relaxation techniques for pain management in labour. cochrane database syst rev 2018. 5. ni gusti made es. karakteristik ibu bersalin kaitannya dengan intensitas nyeri persalinan kala i di kota bogor. j kebidanan 2017;3:204-10. 6. whitburn ly, jones le, davey ma, mcdonald s. the nature of labour pain: an updated review of the literature. women birth 2019;32:28-38. 7. komariah n, wahyuni s. the relation between labor pain with maternal anxiety. in: first international conference on health, social sciences and technology (icohsst 2020). atlantis press; 2021. p. 201–6. 8. yulianingsih e, porouw hs, loleh s. teknik massage counterpressure terhadap penurunan intensitas nyeri kala l fase aktif pada ibu bersalin di rsud. dr. m.m dunda limboto kabupaten gorontalo. gaster 2019;17:231. 9. czech i, fuchs p, fuchs a, et al. pharmacological and nonpharmacological methods of labour pain reliefestablishment of effectiveness and comparison. int j environ res public health 2018;15. 10. bakar a, suhartatik s, hidayati l. combined benson and dhikr relaxation reduces anxiety and pulse frequency of inpatient cardiacs in hospitals. int j pharm res 2020;12:1747-53. 11. secka a, handayani s. effectiveness of maternity waiting homes in increasing utilization of facility-based delivery: a systematic review. int j public heal sci 2021;10:529-36. 12. beyable aa, bayable sd, ashebir yg. pharmacologic and non-pharmacologic labor pain management techniques in a resource-limited setting: a systematic review. ann med surg 2022;74:103312. 13. ayu ngm, supliyani e. karakteristik ibu bersalin kaitannya dengan intensitas nyeri persalinan kala 1 di kota bogor. j kebidanan 2017;3:204-10. 14. choudhary s, jelly p, mahala p, mery a. effect of back massage on relieving pain during labour: a systemic review. int j reprod contracept obs gynecol 2021;10:2466-73. 15. anggondowati t, deviany pe, latief k, et al. care-seeking and health insurance among pregnancy-related deaths: a population-based study in jember district, east java province, indonesia. plos one 2022;17:e0257278. 16. maryuni m. hubungan karakteristik ibu bersalin dengan nyeri persalinan. j heal sci physiother 2020;2:116-22. 17. wulandari rd, laksono ad. determinants of knowledge of pregnancy danger signs in indonesia. plos one 2020;15:e0232550. 18. mardiyanti i, devy sr, ernawati e. analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy. j ners 2019;14:144-50. 19. sebayang sk, has emm, hadisuyatmana s, et al. utilization of postnatal care service in indonesia and its association with women’s empowerment: an analysis of 2017 indonesian demographic health survey data. matern child health j 2022;26:545-55. 20. afritayeni a. hubungan umur, paritas dan pendamping persalinan dengan intensitas nyeri persalinan kala i. j endur 2017;2:178. 21. rachmayanti rd, diana r, anwar f, et al. culture, traditional beliefs and practices during pregnancy among the madurese tribe in indonesia. br j midwifery 2023;31:148-56. 22. fitriyah r, fernandez gv, samudera ws, et al. deep breathing relaxation for decreasing blood pressure in people with hypertension. j ners 2019;14:141-5. 23. azizah n, rosyidah r, mahfudloh h. reducing labor pain intensity within first stage active phase through hegu li 4 acupressure and quranic recital method. j ners 2020;15:1626. 24. novita kr, rompas s, bataha y. pengaruh teknik relaksasi nafas dalam terhadap respon nyeri pada ibu inpartu kala i fase aktif di puskesmas bahu kota manado. j keperawatan unsrat 2018;5:113347. 25. puspitasari i, astuti d. tehnik massage punggung untuk mengurangi nyeri persalinan kala i. j ilmu keperawatan dan kebidanan 2017;8:100. 26. saraswati w, rosyiadi mr, imandiri a. electroacupuncture versus analgesics for patients with stage iiib cervical cancer post cisplatin chemotherapy. med acupunct 2020;32:293-9. 27. santiasari rn, siti nurdiati d, lismidiati w, saudah n. effectiveness of effleurage and counter-pressure massages in reducing labor pain. heal notions 2018;2:7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 206] [healthcare in low-resource settings 2024;12:11917] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12412 impact of gibberellin-regulated protein allergy on quality of life maria zofia lisiecka department of allergology, national medical institute of the ministry of the interior and administration, warsaw, poland abstract the purpose of this study was to investigate possible allergens that cause gibberellin-regulated protein allergy. for this purpose, a thorough search of relevant information in the databases embase, pubmed, scopus, and web of science, presented for 2018-2023, was carried out. the study showed that about 4% of the world’s population suffers from food allergies. the main manifestations of allergic reactions and the degree of resistance to allergens depend on the age group of patients. the study identified the following food allergens in gibberellin-regulated protein allergy: pru p7 (peach), pru m7 (japanese apricot), cit s7 (orange), pun g7 (pomegranate), pru av7 (sweet cherry), cap a7 (bell pepper), fra a3 (strawberry), cup s7 (cypress pollen). gibberellin-regulated protein allergy is characterised by a predominantly adolescent and young adult population. the symptoms of this allergy usually manifest themselves in the form of oral syndrome, facial swelling (including eyelids), anaphylactic reactions and are aggravated by the action of cofactors. such manifestations substantially impair the quality of life of patients, causing a social, psychological, and economic burden. introduction epidemiological studies indicate a considerable increase in the prevalence of food allergies worldwide, namely, about 220 million cases. severe symptoms are often reported in newborns and the elderly. about 4% of the world’s population suffers from food allergies. among them, about 2-12% of children aged 0-6 years and 0.5-7% of the adult population have a food allergy to fruit.1 the significant prevalence of this pathology is conditioned by changes in the environment, the widespread use of chemicals in agricultural activities, the use of household chemicals, feeding newborns with artificial formulas, and the uncontrolled use of antibacterial drugs (which leads to a disruption of the intestinal microbiome and a decrease in immune defense). at the beginning of the 21st century, researchers discovered that a family of proteins contains representatives with allergenic properties. the main one is a gibberellin-regulated peptide. it is found in peaches, apricots, oranges, pomegranates, cherries, bell peppers, strawberries, and cypress pollen. an allergic reaction to gibberellin-regulated peptide usually manifests itself in the form of itching, redness, and swelling of the mucous membranes of the eyelids and mouth, watery eyes, sneezing, nasal congestion, dry cough, and mild skin rashes.2 at the same time, anaphylactic shock often occurs, which, in the absence of emergency care, leads to immediate death. a characteristic feature of this type of allergy is dependence on the presence of a cofactor (medication and alcohol intake, active physical training, and menstruation). the disease affects mainly young people and adults. an important problem is the understudied mechanism of gibberellin-regulated protein allergy and, accordingly, the lack of adequate pathogenetic treatment. that is why, when suffering from this type of allergy, patients’ daily activities are substantially limited; they are forced to carefully select food and avoid contact with allergenic tree pollen, constantly monitor their diet, and carry allergy emergency equipment. all of this results in a heavy economic, social, and psychological burden for patients with gibberellin-induced protein allergy. muraro et al. studied and assessed the impact of food allergies on the quality of life and proposed new recommendations for lifestyle, diet, prevention, and treatment of the most common types of food allergies.3 kuźmiński et al. investigated the prevalence, main characteristics, methods of prevention, and treatment of food allergy to nuts.4 the topic of cross-reactivity between allergens from nuts and other plant sources, such as pollen, is covered. unlike many other childhood food allergies, tree nut allergies typically start in childhood and are likely to last into adulthood. there is a wide variety of clinical symptoms, from mild oral allergy syndrome to severe, potentially lethal anaphylaxis. the sole management method that is currently approved is the strict avoidance of tree nuts. niewiem and grzybowska-chlebowczyk assessed the role of intestinal permeability markers on the course of allergic reactions.5 increased intestinal permeability in food allergies makes it possible for allergens and other dangerous chemicals to correspondence: maria zofia lisiecka, department of allergology, national medical institute of the ministry of the interior and administration, warsaw, poland. e-mail: mariazofialisiecka@gmail.com key words: immune response, cross-reaction, hypersensitivity, food, pollen. conflict of interest: the author declares no potential conflict of interest. funding: none. ethics approval and consent to participate: the study was conducted without human/animal participation. ethical approval is not required. availability of data and materials: the data supporting the findings of this study are available on request from the corresponding author. received: 21 february 2024. accepted: 12 april 2024. early view: 27 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12412 doi:10.4081/hls.2024.12412 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 6] [healthcare in low-resource settings 2024;12(s2):2412] non -co mmerc ial us e o nly pass through the barrier and for the intestinal mucosa to react immunologically. the study emphasises how a weakened intestinal barrier is a major pathogenic component in allergic disorders and how managing and preventing these conditions may be aided by promoting intestinal barrier integrity from a young age through dietary modifications and the reduction of disrupting elements. asero et al. highlighted new relevant information on lipid protein allergy.6 the authors address debates over the therapeutic applicability of lipid protein sensitization because certain investigations reveal a high number of sensitised yet asymptomatic subjects. there are also questions about the most accurate diagnostic tests for lipid protein allergy. j. morozińska-gogol presented the problem of the prevalence of nematodes of the genus anisakis and their role in the development of food allergies.7 anisakis are parasitic worms that can infect humans who consume raw or undercooked fish or cephalopods contaminated with the worm’s larvae. a key point is that the allergens in anisakis show high heat stability and resistance to digestive enzymes, making them difficult to remove through cooking. thus, many polish and foreign scientists have conducted many meaningful studies on the types and characteristics of food allergies. given the availability of a wide range of diverse information on food allergies and, at the same time, a small amount of data on gibberellin-regulated protein allergy, the purpose of this study was to investigate and describe the diagnosis and prevention of gibberellin-regulated protein allergy. the main objectives of the research are: i) to investigate the causes and risk factors associated with gibberellin-regulated protein allergy; ii) to characterize the main symptoms and clinical manifestations of gibberellin-regulated protein allergy; iii) to examine the methods and criteria for accurately diagnosing gibberellin-regulated protein allergy; iv) to determine the prevalence of gibberellin-regulated protein allergy across different populations and age groups. materials and methods before conducting this review study, a thorough, structured, and systematic search for relevant information on food allergies and their types was performed in pubmed, embase, scopus, and web of science databases. during the study, all submitted papers with the necessary information (clinical trials, randomised controlled trials, reviews, systematic reviews, and meta-analyses) published from 2018 to 2023 in peer-reviewed journals in english, french, polish, and german were found and reviewed. the search for the necessary data was carried out using a combined set of keywords: “allergic reaction”, “immune response”, “type of immune response”, “types of allergens”, “gibberellin-regulated peptide”, “immunoglobulins”, “food allergens”, “pollen”, “hypersensitivity”, “cross-reaction”, “anaphylactic shock”, “symptoms of food allergy”, “diagnosis of food allergy”, “prick test”, “treatment of allergic reactions”, “diet therapy”, “lifestyle”, “prevention of allergy”, “complications of allergic reactions”, “emergency care”. the received papers were carefully studied, processed, and analysed, selected by titles and abstracts, and considering the relevance, time of publication, and suitable level of evidence for the case studies. to obtain more information sources, the lists of references for the relevant articles were examined, and the relevance of their content was assessed. next, the duplicate studies were removed, along with those that did not correspond to the selected period since publication. the available articles were then assessed against the inclusion and exclusion criteria. papers that did not meet the inclusion criteria in part or in full were immediately removed. articles that contained outdated, unconfirmed, and irrelevant information; unreliable, poorly conducted studies and their findings; and descriptions of the study conducted only on animal models were not included in this study. this study included papers from the last 6 years (2018-2023) with new data on the prevalence, causes, risk factors, mechanisms of development, symptoms, diagnosis, treatment, prevention, and emergency treatment of food allergies. the studies describing types of allergic reactions, types of allergens, innovative approaches, and methods of investigating allergic reactions without restrictions on gender, age, race, territory of residence, social status, details of medical and life history, or specific features of the course or severity of diseases were used. the papers describing the pathogenesis of various types of allergic reactions and emergency protocols for anaphylactic reactions were selected and included; the allergens contained in food were identified. attention was focused on the papers describing the best methods of nutrition for gibberellin-regulated protein allergy and the list of safe foods allowed, considering the possibility of cross-allergy. a thorough, systematic selection process resulted in relevant articles that fully met the necessary selection requirements. to avoid errors, the selected sources of information were re-evaluated, processed, and verified. the results of the selected studies were cited in this paper in compliance with all necessary technical requirements and copyrights. results food allergies are harmful effects on the body’s health that occur as a result of a specific immune response to repeated exposure to a particular food.8-10 the characteristics of allergic reactions differ substantially depending on the age group of patients. fruit allergies are classified into two types, depending on their ability to cross-react with pollen. the first type is an allergy associated with a cross-reaction to pollen, called food pollen allergy syndrome. it is an immunoglobulin e (ige)-mediated immediate allergic reaction caused by a cross-reaction between pollen and food antigens (table 1).11-15 it accounts for about 60% of allergy cases in adults and adolescents. target organs: skin, oral mucosa, epithelium of the gastrointestinal tract, respiratory tract, and cardiovascular system. this type of allergy manifests itself in the form of an oral allergic syndrome. it occurs 10-15 minutes after allergen exposure and causes redness, tingling, and itching in the mucous membrane of the tongue, lips, and palate, as well as swelling of the oropharynx. most of these manifestations disappear in 1-3 hours, but 1-8% of patients develop severe systemic complications in the form of anaphylactic reactions.9,10 allergies in which the allergen is a nonspecific lipid carrier protein are called non-pollen fruit allergies. it is characterised by a significant degree of cross-reactivity between lipid carrier proteins of different plant species. nonspecific lipid carrier proteins form a large family of peptides found in many land plants. they are small, non-glycosylated proteins with a mass of about 7-8 kda. based on their molecular weight, these proteins were divided into two groups: ltp1 (9-10 kda) and ltp2 (6-7 kda). the main biological role of lipid carrier proteins is to transport and accumulate lipids to build important protective polymers on the surface of plant tissues (e.g., wax on leaves, suberin in seeds and roots, sporopollenin in pollen grains).16 the following main allergens have been described in food social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):2412] [page 7] non -co mmerc ial us e o nly allergies caused by lipid carrier proteins: pru p3 (peach), mal d3 (apple), cit r3 (orange), bra o3 (cabbage), sin a3 (mustard), jur r3 (nut), cas s8 (chestnut). sensitization occurs through the mouth, inhalation, or skin contact. at the same time, pru p3 (peach) may be the main sensitizer of this food allergy. in a study in spain, sensitization to pru p3 was detected in 12% of 2,000 patients. in a group of 87 subjects susceptible to pru p3, 44% had anaphylactic reactions; 43% had skin and oropharyngeal manifestations; and 13% were asymptomatic.17 disulphide bonds ensure that lipid carrier proteins fold into a compact structure with significant thermal and proteolytic stability, which explains their high allergenicity and severe symptoms. at the same time, at neutral ph and hot temperatures, the stability of proteins decreases due to the destruction of disulphide bonds. it is important to consider this when choosing a method of culinary processing food for people with this type of allergy. researchers have described a new allergen that has the same features as the above-mentioned allergic reactions to fruit: a gibberellin-regulated peptide.1 it belongs to the family of plant antimicrobial peptides rich in cysteine. the first peptide of this family was isolated from potatoes in 1999. at the same time, the first representative of these peptides that could potentially cause allergies was found in peaches (pru p7).1 gibberellin-regulated peptides are involved in plant growth and protection against pathogenic factors. they also control germination, cell division, dormancy, flowering, and fruit development. the expression of gibberellin-regulated peptides is controlled by gibberellins, which are a class of natural plant hormones produced by plants, fungi, and bacteria. gibberellin (gibberellic acid) was discovered and described by e. kurosawa in the ascomycete (rice parasite gibberella fujikuroi, which leads to a sharp increase in the length of rice stems) in 1926.1 the endogenous content of gibberellin-regulated peptides and gibberellin is influenced by biotic (protozoa, bacteria, viruses, fungi) and abiotic factors (drought, floods, temperature, sodium concentration). a slight increase in temperature contributes to an increase in the content of endogenous gibberellin. at the same time, a wide range of exogenous gibberellins are actively used in agriculture to improve yields and increase crop production. gibberellin-regulated peptides are small, basic, water-soluble, cysteine-rich proteins with a molecular weight of about 8 kda. a characteristic feature is that all these proteins contain 12 cysteines at the c-terminus, forming 6 disulphide bonds. the high cysteine content provides gibberellin-regulated peptides with high chemical, thermal, and proteolytic stability. gibberellin-regulated protein allergy occurs more often in adolescents and adults and less often in children.18-20 the most dangerous allergens are pru p7 and pru m7, as they cause anaphylactic reactions (table 2).21-24 the cross-reactivity between pru p7, pru m7, cit s7, and pun g7 is described. in contrast to the nonspecific lipid carrier protein, which is more abundant in fruit peel, gibberellin-regulated peptides are found in both the peel and pulp of vegetables and fruits. this type of allergy is dependent on the presence of a cofactor (taking medications such as nonsteroidal anti-inflammatory drugs (nsaids), proton pump inhibitors, alcohol consumption, physical training, and menstruation).18-20 pru p7 is a gibberellin-regulated protein allergen found in the peel and pulp of peaches. it was first discovered and described in 2013. it cross-reacts with apricot, pomegranate, orange, and cypress pollen. the main prognostic symptom is facial swelling (especially in the eyelid area), and anaphylaxis often occurs. biagioni et al. have developed a detailed algorithm for diagnosing this disease.10 this requires a skin prick test for inhalation (including cypress pollen) and food allergens (including peach peel extract). in the case of a positive skin prick social and political factors affecting public health [page 8] [healthcare in low-resource settings 2024;12(s2):2412] ta ble 1. t he m ain ty pe s o f a lle rgi c r ea cti on s a cc ord ing to je ll a nd c oo mb s.1 1-1 5 na me ty pe of an tig en pa th og en esi s b iol og ica lly ac tiv e s ub sta nc es inv olv ed m an ife sta tio ns an ap hy lac tic /re ag ini c fo od , n on -in fec tio us su bs tan ce s, me dic ine s i nte rac tio n o f a h wi th igg an d h ist am ine , a n e os ino ph ilic ch em ota cti c a na ph yla cti c s ho ck , rh ini tis , (re ac tio n t im e 0 -6 ho urs ) ig e, fix ed on hi sti oc yte s a nd m ast ce lls fa cto r o f a na ph yla xis c on jun cti vit is, br on ch ial as thm a, urt ica ria , a top ic de rm ati tis cy tot ox ic/ cy tol yti c m ed ici ne s, ch em ica l, a nd or ga nic su bs tan ce s in ter ac tio n o f i ge an d i gg a bs w ith a gs e nz ym es of the co mp lem en t s ys tem , s ide ef fec t o f t ran sfu sio n (re ac tio n t im e 2 4-7 2 h ou rs) o f c ell m em bra ne s o r a gs ad so rbe d s up ero xid e a nio n r ad ica l of in co mp ati ble bl oo d, on th em , re su ltin g i n a cti va tio n a gra nu loc yto sis of th e c om ple me nt sy ste m im mu no co mp lex a rti us ty pe au toa lle rge ns in ter ac tio n o f i gm an d i gg a bs an d a gs , c om ple me nt, ly so so ma l e nz ym es, di sea ses of im mu ne co mp lex es, (re ac tio n t im e 2 4-7 2 h ou rs) res ult ing in ex ce ssi ve fo rm ati on of su pe rox ide an ion ra dic al all erg ic glo me rul on ep hri tis , a rte rit is cir cu lat ing im mu ne co mp lex es, ac tiv ati on of th e c om ple me nt sy ste m, inf iltr ati on of tis su es by le uk oc yte s, pla tel et ag gre ga tio n a nd ac tiv ati on of ys os om al en zy me s, wh ich ca us es da ma ge to the va scu lar en do the liu m ce llu lar /de lay ed ty pe inf ec tio us an d c he mi ca l s ub sta nc es i nte rac tio n o f s en sit ise d t -ly mp ho cy tes l ym ph ok ine s co nta ct de rm ati tis , tr an sp lan t r eje cti on (re ac tio n t im e 2 4-7 2 h ou rs) w ith hy pe rte ns ion , r ea cti on s, rea cti on s t o t ub erc uli n pro du cti on of in fla mm ato ry cy tok ine s, ac tiv ati on of m ac rop ha ge s, mo no cy tes , lym ph oc yte s, the ir inv olv em en t in th e s ite of hy pe rte ns ion , d am ag e t o s urr ou nd ing tis su es an d f orm ati on of ce llu lar in fil tra te ag , a nti ge n; ab , a nti bo dy . non -co mmerc ial us e o nly test for peach and cypress peel extract and a negative in vitro result for specific ige to pru p3, a preliminary diagnosis of allergy to pru p7 is made. for confirmation, serum ige to pru p7 is additionally measured. pru m7 is an allergen isolated from apricots. the cross-reactivity between pru m7 and pru p7 has been proven. notably, unlike pru p7, pru m7 caused allergic reactions more often in the presence of cofactors (16.7% and 84.6%, respectively). the main manifestation is swelling of the face, specifically the eyelids. cit s7 is an allergen isolated from sweet oranges. the symptoms of allergy are much milder than the two previously mentioned types. a study found that 2 out of 12 patients (16.7%) had symptoms of urticaria and oropharyngeal syndrome, but none of the patients had anaphylactic shock. light physical activity (slow walking, cycling, or running) was a cofactor for 4 out of 12 patients. during the elisa test using patient serum, cross-reactivity between cit s7, pru p7, and pru m7 was detected. pun g7 is an allergen isolated from pomegranate. in a study of a large population group in italy, the faber test found that 0.5% of participants were sensitive to pun g7. that is, this allergen is not as widespread as the previous ones, and a relatively small number of people are sensitised to it.2 in 2019, a new allergenic gibberellin-regulated peptide was identified from cypress pollen. the sensitization of gibberellinregulated peptides in fruit is related to the sensitization of cypress pollen, with a percentage of sequence identity in cypress of 90% with fruit and 60% with vegetables. it was found that patients with food allergies have a lower quality of life because constant vigilance is required to avoid allergens.25-27 in addition, such patients are constantly under stress due to worries about a possible anaphylactic reaction. due to the insufficient study of gibberellin-regulated protein allergy, there is no pathogenetic treatment for this pathology. therefore, it is difficult for patients to lead a full, active social life. to reduce the risk of allergies, it is important to consider the patient’s age and, accordingly, the possible level of responsibility for their own health (table 3).28-31 quality allergy protection includes the avoidance of allergens, awareness of the symptoms of an allergic reaction, and knowledge of first aid.32-36 therewith, patients should have emergency equipment with them in case of an allergic reaction, specifically in case of anaphylactic shock. thus, gibberellin-regulated protein allergy is a widespread problem due to severe clinical manifestations and the presence of allergens in commonly consumed foods. an effective way to combat it is to avoid allergens and take care of one’s health. social and political factors affecting public health table 2. allergens in gibberellin-regulated protein allergy.21-24 source of the allergen name of the allergen allergen entry method peach tree pru p7 alimentary pomegranate pun g7 alimentary japanese apricot pru m7 alimentary orange cit s7 alimentary sweet cherry pru av7 alimentary strawberries fra a3 alimentary bell pepper cap a7 alimentary cypress pollen cup s7 inhalation table 3. managing food allergies throughout life.28-31 age group responsible persons features infants parents/guardians, close family circle, it is not immediately possible to recognise the symptoms kindergarten staff of an allergic reaction, and it is difficult to identify the allergen due to the impossibility of collecting complaints and anamnesis from the patient. infants and toddlers parents/guardians, close family circle, the period of active recognition and exploration of the world kindergarten staff around the patient, primarily through grasping reflexes and trying to taste everything. primary and secondary parents/guardians, close family relative independence and personal responsibility of the young patient school children circle, school staff, the patient for their own health and life. teenagers the patient, parents/guardians, a difficult period in the formation of personality, and the close group a craving for forbidden things, dangerous actions, often indifference to one’s own health and life. the desire to try new things, often without considering the harmful consequences. young people the patient, parents/guardians, start of an independent life, full responsibility for one’s own actions, and the need to assess and the close group all possible risks. frequent lack of financial capacity to ensure quality food and proper medical care. adults the patient, their close group increased level of responsibility due to a permanent job, family, and many duties. frequent lack of time to take care of one’s own health. elderly people children, grandchildren, cognitive decline, often depressive behaviour, close family, the patient dependence on others for help and need for supervision. [healthcare in low-resource settings 2024;12(s2):2412] [page 9] non -co mmerc ial us e o nly discussion kuźmiński et al. described the characteristic features of nut allergy.4 it was found that the term “nut allergy” includes allergies to almonds, brazil nuts, peanuts, cashew nuts, hazelnuts, chestnuts, macadamia nuts, pecans, and walnuts. this type of allergy begins in childhood and, unlike many other types of food allergies, rarely disappears in adulthood and persists throughout life. the main complication of this disease is anaphylactic shock, which often causes death. at the same time, gibberellin-regulated protein allergy occurs more often in adulthood, and severe complications such as anaphylactic shock are much less common. to date, the following allergens present in almonds have been described: pru du1 (albumin 2s, reserve protein), pru du2 (conglutin, 7s globulin, reserve protein), pru du3 (lipid transport protein), pru du4 (profilin), pru du5 (ribosomal protein s2), and pru du6 (amandin). the main allergen in almonds, pru du1, causes cross-reactions with other foods that contain this protein: walnuts, sunflower seeds, and peanuts. in addition, 33% of patients with almond allergy were found to be allergic to birch pollen. peanuts contain the following allergens: ber e1 (2s albumin) and ber e2 (11s globulin). ber e1 is responsible for severe allergic reactions; it is resistant to temperature and digestive enzymes; and it is involved in the cross-reaction between walnut (jug r1) and pecan (car i1). peanuts (ara h1), walnuts (jug r2), hazelnuts (cor a11), and cashews (ana o1) have been described as having a comparable structure, which explains possible cross-reactions. the following allergens were found in hazel: cor a1 (pr-10 protein), cor a2 (profilin), cor 6 (isoflavone reductase), cor 8 (nonspecific ltp type 1), cor 9 (11s legumin), cor 11 (luminal binding protein), cor 12 (oleosin with a molecular weight of 17 kda), cor 13 (oleosin with a molecular weight of 1416 kda), cor a14 (2s albumin). cor a1 causes cross-reactions with birch, alder, and hornbeam pollen. cor a8 causes cross-reactions of lipid carrier proteins with peaches, peanuts, walnuts, and cherries. walnuts contain the following allergens: jur r1 (2s albumin), jur r2 (7s vicillin), jur r3 (nonspecific lipid transport protein), and jur r4 (11s globulin). the high 2s-dependent albumin concentrations cause cross-reactivity between walnuts and pecans, almonds, peanuts, and cashews. in an examination of 20 patients with food allergies to flowering fruits (e.g., apples, peaches, and apricots), 80% of them had a clinical reaction to nuts (walnuts and hazelnuts). pecoraro et al., lyons et al., yang et al., dijkema et al. found that about 0.5% of the world’s population is allergic to fish and seafood.36-39 patients with fish allergies are classified into the following groups: (a) polysensitised patients, who react to all types of fish due to sensitization to the panallergen b-parvalbumin; (b) monosensitised patients, who have a selective reaction to only one particular type of fish; (c) oligosensitised patients, who have an allergic reaction to several types of fish. the clinical picture is diverse, ranging from oral allergy syndrome and skin lesions to angioedema and anaphylaxis with respiratory/circulatory disorders.40,41 the most common allergy is to fish fillets, and its allergens differ from those of fish caviar. this should be considered when selecting a suitable type of diet for such patients so as not to mistakenly limit the consumption of healthy, harmless foods. eating untreated fish carries a risk of contracting anisakis simplex. anisakiasis is manifested by allergic reactions in the form of urticaria, angioedema, and anaphylactic shock.42-44 this should be considered to avoid misdiagnosing food allergies in patients with parasitic diseases. anisakis simpleks is a nematode that can cause human infection at stage 3 of its life cycle. this is possible by consuming contaminated raw, undercooked, and smoked fish and cephalopods. it is known that a. simpleks allergens are thermostable and have significant resistance to enzyme degradation.7 due to the difficulty of removing parasites from fish, sensitised patients are advised to consume only seafood from waters that are usually free of a. simpleks allergens and subject the seafood to heat treatment (60°c for more than 10 minutes or freezing for 24 hours at -20°c). inuo et al. described a case of allergy symptoms in a 15-yearold boy after eating strawberries during physical training.45 the patient reported generalised urticaria and lip swelling caused by fast walking after consuming the above food product. the diagnostic prick test with fresh strawberries was positive. the patient’s serum was found to be positive for strawberry gibberellin-regulated peptide. given the positive tests and the onset of symptoms as a result of brisk walking, it was concluded that the patient had an allergic reaction in response to exercise due to the consumption of a gibberellin-regulated protein in strawberries. this study also found that the presence of cofactors (physical activity, menstruation) in gibberellin-regulated protein allergy substantially worsens the course of the latter and leads to generalised reactions and severe complications.46,47 urashima et al., ramírez-marín et al., rodriguez bauza and silveyra, rey-mariño and francino observed that over the past 30 years, there has been a substantial increase in the incidence of atopic diseases: bronchial asthma, rhinitis, and food allergies.48-51 atopy is a hereditary pathological response of the immune system to environmental factors that are harmless to the general population. it is characterised by an increase in the release of specific ige. excessive hygiene, uncontrolled use of antibiotics, widespread use of pesticides in the agricultural and food industries, and air pollution from harmful emissions are all considered to be contributing to the increase in allergies. it has also been found that premature babies are more vulnerable to protein compounds that penetrate the incompletely formed intestinal barrier. at the same time, the intestinal microbiome is the largest and most active component of the intestinal barrier and is important for the normal development of the immune response. the intestinal microbiome develops during the first 3 years, including intrauterine development and the next 2 years of a child’s life.5 the normal functioning of the intestinal mucosa is of immense importance, as this structure performs protective, nutritional, and immune functions. the intestinal barrier separates the intestinal lumen from the internal environment of the body. it is built from local microorganisms, epithelium, blood cells, lymphatic, and nervous tissue. at the same time, increased intestinal permeability in food allergies allows pathogenic substances to penetrate the intestinal barrier and stimulate the submucosal immune system. as a result, there is an increased release of inflammatory mediators, which leads to the destruction of the epithelial layer and increased intestinal permeability. important ways to reduce the risk of any allergy are natural childbirth, breastfeeding, contact with nature, pets, and the consumption of probiotics with food. such simple recommendations can improve the immune defense of an individual and prevent a number of severe allergies and their complications in adulthood. everyday life can be severely disrupted by allergies in a number of ways. in addition to completely removing particular foods from one’s diet, having an allergy also involves being on the lookout for any cross-contamination while food is being cooked or served in communal areas like restaurants. this continual watchfulness and the possibility of inadvertent intake can lead to a great deal of worry and anxiety. peaches, for instance, are a fruit that is widely consumed worldwide, making it exceedingly difficult to social and political factors affecting public health [page 10] [healthcare in low-resource settings 2024;12(s2):2412] non -co mmerc ial us e o nly avoid the allergy. furthermore, due to cross-reactivity, peach allergies are frequently associated with reactions to similar fruits like apricots, cherries, and almonds. this has a significant negative influence on a person’s nutritional intake and quality of life by drastically reducing the range of foods they can safely eat. severe allergies to peaches always raise the possibility of anaphylaxis, a potentially fatal whole-body reaction that needs to be treated right away. one’s everyday experiences and activities, including going on a trip or dining out, can be severely limited by this fear of experiencing a potentially fatal episode. the emotional and physical costs of dealing with a peach allergy demonstrate how a seemingly small food allergy may have a significant impact on a person’s entire life. conclusions an extensive review of gibberellin-regulated protein allergy, a newly identified and understudied food allergy, has been given in this paper. the main findings reveal that this allergy arises from a specific family of cysteine-rich antimicrobial peptides called gibberellin-regulated proteins found in various fruits, vegetables, and pollen. a defining characteristic is the cross-reactivity observed between different allergens, allowing sensitization to one to trigger reactions to others. clinical symptoms of the allergy range from minor oral allergy syndrome, which involves itching, swelling, and rashes around the mouth, to potentially fatal systemic anaphylaxis, which involves breathing difficulties and circulatory collapse. the allergy is primarily seen in adults and teenagers. notably, it has been demonstrated that the presence of specific cofactors, such as exercise, menstruation, alcohol, and some drugs, significantly exacerbates and intensifies reactions. one distinct and poorly understood feature of the illness is its reliance on cofactors. these allergens have a significant potential for causing allergies because of their high thermal and proteolytic stability, which also makes them resistant to breakdown during cooking or digestion. avoiding foods that trigger allergies is currently the main management strategy for gibberellin-regulated protein allergy due to the lack of appropriate therapeutic options. but patients’ quality of life is significantly reduced as a result, leading to heavy psychological, social, and financial costs. anaphylactic reactions and unintentional allergen exposure must be avoided by maintaining constant watchfulness. the results emphasise the necessity of more investigation to clarify the pathogenic pathways responsible for this allergy. enhanced comprehension may facilitate the creation of focused treatments, mitigating the effects on patients’ quality of life. future research should also look for ways to more accurately detect and lessen the influence of cofactors in triggering severe reactions. it is essential to increase public and healthcare professional awareness of gibberellin-regulated protein allergy. potentially lethal effects can be avoided with prompt recognition and the appropriate control of reactions. all things considered, more study is necessary to address the substantial unmet requirements related to this newly discovered food allergy. references 1. iizuka t, barre a, rougé p, et al. gibberellin-regulated proteins: emergent allergens. front allergy 2022;3:877553. 2. inomata n. gibberellin-regulated protein allergy: clinical features and cross-reactivity. allergol int 2020;69:11-8. 3. muraro a, de silva d, halken s, et al. managing food allergy: ga2len guideline 2022. world allergy organ j 2022;15:100687. 4. kuźmiński a, przybyszewski m, przybyszewska j, et al. tree nut allergy. advan dermatol allergol 2021;38:544-9. 5. niewiem m, grzybowska-chlebowczyk u. intestinal barrier permeability in 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machtejeviene e, et al. results of using the robson classification in kazakhstan. open acc maced j med sci2021;9:663-9. 42. tyravska y, savchenko o, lizogub v, et al. blood plasma serotonin and von willebrand factor as biomarkers of unstable angina progression toward myocardial infarction. galician med j 2021;28:e202112. 43. rahmati a, kiani b, afshari a, et al. world-wide prevalence of anisakis larvae in fish and its relationship to human allergic anisakiasis: a systematic review. parasitol res 2020;119:358594. 44. roca-geronès x, segovia m, godínez-gonzález c, et al. anisakis and hysterothylacium species in mediterranean and north-east atlantic fishes commonly consumed in spain: epidemiological, molecular and morphometric discriminant analysis. int j food microbiol 2020;325:108642. 45. inuo c, okazaki f, shiraki r, et al. generalized allergic reaction in response to exercise due to strawberry gibberellin-regulated protein: a case report. allergy asthma clinic immunol 2022;18:49. 46. oshurko ap, oliinyk iyu, kuzniak nb. morphological significance of bone atrophy for topographic features of the left mandibular canal. world med biol 2021;78:131-5. 47. postic sd. influence of balanced occlusion in complete dentures on the decrease in the reduction of an edentulous ridge. vojnosan pregl 2012;69:1055-60. 48. urashima m, mezawa h, okuyama m, et al. primary prevention of cow’s milk sensitization and food allergy by avoiding supplementation with cow’s milk formula at birth: a randomized clinical trial. jama pediatr 2019;173:1137-45. 49. ramírez-marín h, singh a, ong p, silverberg j. food allergy testing in atopic dermatitis. jaad int 2022;9:50-6. 50. rodriguez bauza d, silveyra p. asthma, atopy, and exercise: sex differences in exercise-induced bronchoconstriction. exp bio med 2021;246:1400-9. 51. rey-mariño a, francino m. nutrition, gut microbiota, and allergy development in infants. nutr 2022;14:4316. social and political factors affecting public health [page 12] [healthcare in low-resource settings 2024;12(s2):2412] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12723 the effectiveness of risperidone on panss score and il-6 in confirmed covid-19 schizophrenic patients sonny teddy lisal,1 hawaidah,1 dessy natalia,1 arifin seweng,2 yuyun widaningsih,3 erlyn limoa,1 saidah syamsuddin1 1department of psychiatry, faculty of medicine, hasanuddin university, makassar; 2department of biostatistics, faculty of public health, universitas hasanuddin, makassar; 3department of clinical pathology, faculty of medicine, hasanuddin university, makassar, indonesia abstract the study aimed to determine the efficacy of risperidone on panss scores and interleukin 6 (il-6) levels in schizophrenia patients with confirmed covid-19. the study type was analytical observational, with a prospective cohort design. the subjects included inpatient schizophrenia patients with and without covid-19, mild-moderate and asymptomatic covid-19, and schizophrenic patients without covid-19 who were hospitalized and met the inclusion and exclusion criteria, for a total of 22 subjects in each group. the positive and negative syndrome scale (panss) and elisa interleukin 6 (il-6) serum were sampled consecutively for this study. in the positive covid-19 group, the mean il-6 post was significantly lower than pre (23.0 vs. 26.1, p<0.001), while in the control group, the mean il-6 post (four weeks) was significantly lower than pre (baseline), with 19.3 vs. 21.0 (p<0.001). serum il-6 levels appeared to be an effective prognostic biomarker in covid-19 patients. the 35 pg/ml cutoff point could distinguish mild-moderate patients from more severe ones. we discovered that schizophrenia patients with verified positive covid-19 received covid-19 therapy in the form of a combination of antipsychotic and antivirals had il-6 levels lower than 35 pg/ml, indicating the role of antipsychotic (risperidone) and antiviral in reducing il-6 levels. introduction the covid-19 outbreak caused by the severe acute respiratory syndrome coronavirus 2 (sars-cov-2) was detected for the first time in wuhan, china, spread throughout the country since late december 2019, and has attracted significant attention from all over the world. the first case of covid-19 in indonesia was reported on march 2, 2020, with as many as 2 cases, and until now, the number of cases has been increasing. it was reported that until march 23, 2021, in 34 provinces, there were 1,505,775 positive confirmed cases, 142,695 recovered cases, and 40,754 people died from this disease. south sulawesi was ranked fifth in the number of positive confirmed cases, with 39,703 (4.5%), recovered 33,156 cases (83.5%), and 675 cases died (1.7%).1 the most common clinical manifestations of covid-19 infection are cough and fever; about 8-19% progress to acute respiratory distress syndrome (ards), especially in the elderly and patients with multiple comorbidities. there have also been reports of lymphopenia, elevated c-reactive protein (crp), proinflammatory cytokines, ferritin, and d-dimer, and histopathological findings show an infiltrate of monocytes, macrophages, lymphocytes, vasculitis, and hypercoagulability in the lung tissue. diffuse alveolar damage, focal hyperplasia of pneumocytes with infiltration of proinflammatory cells, and intravascular thrombosis lead to impaired pulmonary alveolar gas exchange.2 coronavirus particles can be found in macrophages, but it is still unknown whether it is due to direct infection by the virus or the phagocytosis process.3 this will activate the nlrp3 inflammasome receptor on monocytes/macrophages, releasing many proinflammatory cytokines (il-6, gm-csf, il-1b, tnf, cxcl8, ccl-3), causing a cytokine storm.4 a study by gao et al. showed increased levels of cytokines, especially il-6, which is directly related to the severity of the discorrespondence: dessy natalia, department of psychiatry, faculty of medicine, hasanuddin universitas, 90245 makassar, indonesia. tel.: +628114615988. e-mail: dessynatalia.psychiatry@gmail.com key words: covid-19; risperidone; schizophrenia; positive and negative syndrome scale; interleukin-6. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the research has been granted ethical clearance by the biomedical research ethics commission of the faculty of medicine at hasanuddin university, under certificate number 492/un4.6.4.5.31/ pp36/2021. the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 15 june 2024. accepted: 10 july 2024. early access: 22 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12723 doi:10.4081/hls.2024.12723 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:12723] [page 99] ease.5 another study showed that il-6 is an effective biomarker of sars-cov-2 and may predict respiratory failure with a high degree of accuracy and help clinicians allocate patients correctly at an early stage. serum il-6 levels are a valuable prognostic biomarker in patients diagnosed with covid-19 disease. the 35 pg/ml cut-off point can differentiate patients with more severe conditions.6 covid-19 is characterized by complexities, including humanto-human transmission, the transmission of asymptomatic carriers, and high transmission efficiency, leading to a worldwide pandemic.7 patients with severe mental disorders are more susceptible to infection for various reasons, some related to the presence of an underlying disease and some due to environmental factors, including housing insecurity, smoking, poor access to health facilities, and the effects of medications used to treat the disorder. this increased susceptibility to respiratory tract infections may contribute to the risk of covid-19 in patients with severe mental illness or who are in inpatient care.8 dadi regional special hospital, south sulawesi province, reported that 80 patients with schizophrenia positively exposed to covid-19 since december 2020 were generally asymptomatic. these patients received typical and atypical antipsychotic therapies, including haloperidol, chlorpromazine, risperidone, and clozapine. schizophrenia is a chronic mental disorder characterized by many symptoms, such as hallucinations, delusions, confused thoughts, and impaired cognitive function.9 the etiology of schizophrenia itself is not well understood. the hypothesis that often arises is that biological mechanisms such as the metabolic system or the immune system are involved in the pathophysiology of schizophrenia. several processes, such as inflammation, oxidative stress, and complex interactions of neurotransmitters, are concerned with the pathophysiology of schizophrenia.10 the release of proinflammatory cytokines and free radicals associated with activated microglia is associated with the pathophysiology of schizophrenia. it is also found in postmortem examination of brain tissue.11 an increase in several markers of inflammation in serum and csf, such as prostaglandin e2 (pge2), creative protein (crp), and several proinflammatory cytokines such as interleukin (il)-1β, il-6, il-8, and tumor necrosis factor (tnf)α also observed in schizophrenic patients.12 involvement of the immune system is thought to be related to the pathogenesis of schizophrenia, especially in negative symptoms and cognitive dysfunction.13 this immune system dysregulation can be connected to events, risk factors, or responses to therapy in schizophrenic patients.14 antipsychotic medication is the treatment of choice for schizophrenia. risperidone is a second-generation antipsychotic drug that is effective for positive and negative symptoms of schizophrenia. side effects of these drugs are mild and generally do not interfere with cognitive function. there are several mechanisms by which risperidone may decrease il-6 levels. accumulating evidence has shown that astrocytes can amplify the cns’s inflammatory response, a phenomenon closely related to the neurobiology and development of neuropsychiatric disorders. quincozes-santos et al. observed that risperidone had anti-inflammatory action on c6 astroglia, decreasing il-6 release.15 people with schizophrenia and people who have sars-cov-2 both have an inflammatory response that includes higher levels of cytokines and inflammatory markers like il-1β, il-6, il-8, and tnf. so, this study aims to explore the relationship between il-6 levels, the efficacy of risperidone therapy, and the panss score in schizophrenia patients diagnosed with covid-19. materials and methods study design this study was an analytical observational study with a prospective cohort approach. a cohort study examines the relationship between exposure and disease by selecting two or more study groups based on exposure status and then following them for a certain period to identify and calculate the magnitude of the disease. population and sample the population in this study were schizophrenic subjects with and without covid-19, mild-moderate and asymptomatic covid-19, and schizophrenic subjects without covid-19 who were hospitalized and met the inclusion and exclusion criteria. the research sought individuals aged 20-50 diagnosed with both covid-19 and schizophrenia, actively taking risperidone at a daily dosage of 2-6 mg for at least four weeks, confirmed with an rt-pcr swab test to have mild to moderate symptoms or be asymptomatic and have a panss total score of less than 95, indicating significant illness. the control group included individuals with schizophrenia, negative for covid-19, also taking risperidone at a similar dosage for at least four weeks, and a panss total score of less than 95. exclusion criteria involved individuals abusing drugs or alcohol, taking specific medications, or having severe unrelated physical illnesses. drop-out criteria included individuals leaving the hospital before four weeks or passing away. research instruments the data collection tools and study instruments utilized in this research included a demographic questionnaire sheet and the positive and negative syndrome scale (panss), a psychometric tool used to evaluate positive and negative symptoms as well as general psychopathology. each item on the scale is scored from 1 (no symptoms) to 7 (very severe symptoms). in addition, serum elisa interleukin 6 (il-6) was used as a proinflammatory cytokine marker of inflammation with a limit point for serum il-6 levels set at 35 pg/ml. the normal range of il-6 concentrations is between 0-7 pg/ml, and the blood plasma il-6 levels were measured using the elisa method. data analysis data analysis was carried out after the primary data had been collected using the statistical package for social sciences (spss) program. if the data was normally distributed, an unpaired t-test was applied, and if it was not, mann-whitney. results this study was conducted on schizophrenic patients who confirmed positive covid-19 and had been screened; these patients were inpatients at the dadi special hospital from july to august 2021. a total of 41 patients diagnosed with schizophrenia with covid-19 were screened and 22 subjects (53.65%) met the inclusion criteria. similarly, 22 subjects with negative covid-19 were screened for a control group. data analysis was conducted on 44 subjects aged 18 – 53 years with a mean of 35.9±9.2 years. table 1 shows the data normality testing (n=44), which highlights the distribution of panss (positive and negative syndrome article [page 100] [healthcare in low-resource settings 2025;13:12723] scale) scores and il-6 levels before and after treatment. it reveals that while panss scores exhibited a non-normal distribution in both pre-and post-treatment, il-6 levels were normally distributed after treatment. this table uses the kolmogorov-smirnov test to assess data normality. the data in table 2 presents the demographic statistics of the survey’s 44 respondents, encompassing gender, age, education, employment, and pcr covid-19 test results. the analysis reveals that 77.3% of the respondents are male, with the most significant portion falling within the 30-39 age bracket, constituting 43.2% of the sample. moreover, the majority of participants, totaling 56.8%, have attained a primary school education, while 79.5% reported being unemployed. comparison of panss and il-6 pre-post demonstrates the significant reduction in both panss scores and il-6 levels following the treatment, with respective p-values indicating statistical significance. this suggests improvements in the participants’ psychiatric symptoms and inflammatory status (table 3). table 4 shows that the comparison of panss and il-6 prepost (by gender) shows the impact of treatment on panss scores and il-6 levels, categorized by gender. both men and women showed significant improvements post-treatment, underscoring risperidone’s effectiveness across genders. in table 5, the data comparing panss and il-6 pre-post by age groups shows that there were significant reductions in panss scores and il-6 levels across all age categories. this suggests that the treatment has broad applicability across different age groups. in table 6, the comparison of panss and il-6 pre-post (by pcr testing) distinguishes between participants with positive and negative covid-19 pcr tests. both groups showed significant decreases in panss scores and il-6 levels, underscoring the potential advantages of risperidone for schizophrenia patients, irrespective of their covid-19 status. article [healthcare in low-resource settings 2025;13:12723] [page 101] table 1. data normality testing (n=44). variables minimum maximum median mean sd data distribution* panss pre 68 81 71.0 72.4 3.4 not normal panss post 43 69 58.0 56.9 6.3 not normal difference panss 7 34 13.5 15.6 5.9 not normal il-6 pre (pg/ml) 16.1 31.0 24.1 23.6 4.1 normal il-6 post (pg/ml) 14.3 27.5 21.5 21.1 3.4 normal difference il-6 (pg/ml) 0.2 4.9 2.3 2.5 1.2 normal *kolmogorov-smirnov test. table 2. characteristics of respondents (n=44). category variables n percent (%) gender men 34 77.3 women 10 22.7 age 18-29 years 12 27.3 30-39 years 19 43.2 40-53 years 13 29.5 education primary school 25 56.8 junior high school 6 13.6 senior high school 11 25.0 college 2 4.5 employment employee 2 4.5 farmer 3 6.8 entrepreneur 4 9.1 not work 35 79.5 pcr positive 22 50.0 negative 22 50.0 table 3. comparison positive and negative syndrome scale (panss) dan il-6 pre-post. category n mean sd decrease (%) p panss pre 44 72.4 3.4 21.4 0.000* panss post 44 56.9 6.3 il-6 pre (pg/ml) 44 23.6 4.1 10.6 0.000** il-6 post (pg/ml) 44 21.1 3.4 *wilcoxon signed rank test; **paired t-test. discussion this study was conducted to see the effectiveness of risperidone administration on panss scores and interleukin 6 levels in schizophrenia patients with confirmed covid-19 for four weeks, from july to august 2021, with a total sample of 44 people, divided into two groups, namely the covid-19 positive group and control groups. both groups received risperidone therapy of 2-6 mg per day; the covid-19 positive group was the schizophrenia group with covid-19, and the control group was the schizophrenia group without covid-19. patients who met the inclusion criteria were recorded based on gender, age category, education, occupation, and pcr results. schizophrenia is a chronic mental disorder characterized by many symptoms, such as hallucinations, delusions, confused thoughts, and impaired cognitive function.9 several processes, such as inflammation, oxidative stress, and complex interactions of neurotransmitters, are involved with the pathophysiology of schizophrenia.10 the release of proinflammatory cytokines and free radicals associated with activated microglia is associated with the pathophysiology of schizophrenia. it is also found in postmortem examination of brain tissue.11 an increase in several markers of inflammation in serum and csf, such as prostaglandin e2 (pge2), creactive protein (crp), and several proinflammatory cytokines such as interleukin (il)-1β, il-6, il-8, and tumor necrosis factor (tnf) α also observed in schizophrenic patients.12 involvement of the immune system is related to the pathogenesis of schizophrenia, especially negative symptoms and cognitive dysfunction.13 this immune system dysregulation can be connected to events, risk factors, or responses to therapy in schizophrenic patients.14 national patient databases in the uk16 and south korea17 found that patients with psychotic disorders are at increased risk of severe complications of covid-19. patients with severe mental illnesses are more susceptible to infection for various reasons, some related to the presence of an underlying disease and some due to environmental factors, including housing insecurity, smoking, poor access to health facilities, and the effects of medications used to treat the disorder. this increased susceptibility to respiratory tract infections may contribute to the risk of covid-19 in patients with severe mental illness or who are in inpatient care.8 schizophrenia subjects in the covid-19 positive group and control groups were more male than female; male subjects were 34 subjects (77.3%), and female subjects were 10 subjects (22.7%). based on the age, 18-29 years was 12 subjects (27.3%), 30-39 years was 19 subjects (43.2%), 40-53 years was 13 subjects (29.5%) (table 2). schizophrenia is more common in men than women.10 men have an earlier onset of schizophrenia than women; the peak age is 25 to 35 years, approximately 15-55 years of age for patients on schizophrenia treatment.9 in this study, the samples were 30-39 years old (43.2%). the education level in this study was 56.8% elementary school. a deficit in social functioning mode made it difficult for subjects with schizophrenia to continue their education to a higher level. this deficit was in the form of social isolation, often indicated by inadequate and inappropriate emotional responses, poor interpersonal relationships, feelings of threat in social situations, difficulty communicating verbally, and reactions to excessive stimuli.18 the subject’s initial panss scores varied between 68–81, with a mean of 72.4±3.4. the distribution of pre-panss data was not normal. post-subject panss scores ranged between 43–69, with a mean of 56.9±6.3. the distribution of panss post data was not normal. the difference scores of panss (pre-post) subjects varied between 7–34, with a mean of 15.6±5.9 (table 1). the difference in panss scores showed a decrease in the post-measurement compared to pre-measurement. the distribution of panss difference data was not normal, possibly due to clinical improvement before and after risperidone antipsychotic therapy. there are several mechanisms by which risperidone may decrease il-6 levels. the study conducted by de souza et al. found that risperidone inhibited il-6-induced s100b secretion, reducing the rate of secretion below the basal level.19 circulating levels of il-6 and il-10 may regulate the expression of the akt1, drosha, ndel1, disc1, and mbp genes.20 thus, risperidone treatment may modulate gene expression during the treatment of schizophrenia. in recent years, scientists have discovered in biochemical studies of the central nervous system that il-6 is produced by neurons, astrocytes, and microglia and acts as a neurotrophic factor in the central nervous system. however, recent studies suggest that risperidone can attenuate microglia activation in the brain, reducing il-6 levels and suggesting risperidone may improve brain disease.21 a meta-analysis study that found a decrease in il-6 levels after short-term risperidone treatment saw a significant reduction after four weeks of antipsychotic administration.22 in another study that observed a decrease in il-6 levels within nine days of antipsychotic treatment and at eight weeks showed no significant symptoms, there was no difference between patients and control subjects.23 overall, il-6 levels were normalized to some extent immediately after risperidone treatment. evidence that cytokines can be affected by antipsychotic treatment, possibly in a dual mode (short-term and long-term), antiinflammatory in antipsychotics may contribute to the treatment of schizophrenia. anti-inflammatory effects of antipsychotics may play a role in treating psychotic symptoms.24,25 in a recent metaanalysis of 12 studies (961 patients with schizophrenia and 729 controls) on the effect of antipsychotics on serum production of interleukin-6 (il-6), a proinflammatory cytokine, they found that antipsychotic treatment was associated with a decrease in il-6 on the patient. in contrast, trifluoperazine, a conventional antipsychotic, has been identified as a potential treatment option for microbial-induced septic shock after it reduced the inflammatory response by suppressing proinflammatory cytokines in mice.26 recently, crespo-facorro et al. suggested that aripiprazole, an atypical antipsychotic, could also be reused as a treatment for covid-19 after transcriptomic analysis revealed that it could reverse the effects caused by covid-19 on gene expression in patients.27 in this study, in the covid-19 positive group, the mean of il-6 post was significantly lower than pre, which was 23.0 compared to 26.1 (p<0.001). while in the control group, the mean of il-6 post was considerably lower than pre, which was 19.3 versus 21.0 (p<0.001) (table 6). the covid-19-positive group and control groups might had lower il-6 values below the cut-off (35pg/ml) even before in treatment antiviral. the phenomena could be the effect of risperidone and antivirals made the covid19 positive group asymptomatic and the il-6 value below the cutoff. serum il-6 levels appeared to be a useful prognostic biomarker in patients with a diagnosis of covid-19 disease. the 35 pg/ml cut-off point could clearly distinguish the patients with more severe disease. serum il-6 levels in patients with covid19: and non-covid-19, covid-19: 7.56, non-covid: 0.03, other diseases 9.12.28 a study in shanghai, china, found that in hospitalized covid-19 patients, the normal concentration ranges article [page 102] [healthcare in low-resource settings 2025;13:12723] for il-1β, il-8, il-10, and tumor necrosis factor-alpha (tnfα) were below 5, 62, 9.1, respectively, and 8.1 pg/ml.29 the normal concentration range of il-6 is between 0-7 pg/ml, and the normal il-2 receptor (il-2r) ranges from 223 to 710 u/ml. the lower limit of detection of the kit was 1.5 pg/ml, and the upper limit of detection was 5000 pg/ml without dilution. the upper limit of normal is 7 pg/ml. baseline il-6 concentrations are highly predictive of in-hospital mortality for covid-19 patients. the mean concentration of il-6 was < 0.001. serum il-6 remains high in critically ill patients even after recovery. an il-6 concentration higher than 37.65 pg/ml was predictive of in-hospital mortality (auc 0.97 [95% ci 0.95–0.99], p < 0.001) with a sensitivity of 91.7% and a specificity of 91.7%. 95.7%.30 a study mentions the effect of antipsychotic therapy on disease progression and the correlation between cytokine levels and clinical characteristics.31 later the results of this study showed that the cytokine changes in schizophrenia may differ from the clinical status. in this study, schizophrenic patients with confirmed covid-19 received covid-19 therapy with an administration of antivirals. conclusions the panss scores in both the covid-19 positive group and control groups at the end of the study were significantly lower than at the initial treatment, and the same trend was observed for the il6 scores in both groups. the decreases in panss and il-6 scores were not affected by gender, age, or pcr results. notably, both the covid-19 positive group and control groups had a lower value of il-6 (35pg/ml) at the beginning of the study, suggesting that risperidone may have influenced the il-6 levels before the covid-19 diagnosis was confirmed. additionally, a combination of the antipsychotic risperidone and antivirals was found to lower the il-6 levels below the cutoff point. article [healthcare in low-resource settings 2025;13:12723] [page 103] table 4. comparison positive and negative syndrome scale (panss) dan il-6 pre-post (by gender). category variables n mean sd p man panss pre 34 72.1 3.2 0.000* panss post 34 56.5 5.9 il-6 pre (pg/ml) 34 23.6 4.4 0.000** il-6 post (pg/ml) 34 21.1 3.6 women panss pre 10 73.6 4.0 0.000* panss post 10 58.2 7.7 il-6 pre (pg/ml) 10 23.4 3.3 0.000** il-6 post (pg/ml) 10 21.0 3.0 *wilcoxon signed rank test; **paired t-test. table 5. comparison positive and negative syndrome scale (panss) dan il-6 pre-post (by age). category variables n mean sd p 18-29 years panss pre 12 72.3 3.6 0.000* panss post 12 56.9 6.2 il-6 pre (pg/ml) 12 24.5 3.7 0.000** il-6 post (pg/ml) 12 21.9 3.2 30-39 years panss pre 19 71.3 2.6 0.000* panss post 19 56.4 6.4 il-6 pre (pg/ml) 19 23.0 4.7 0.000** il-6 post (pg/ml) 19 20.8 3.9 40-53 years panss pre 13 74.2 3.9 0.000* panss post 13 57.5 6.8 il-6 pre (pg/ml) 13 23.5 3.8 0.000** il-6 post (pg/ml) 13 20.9 2.9 *wilcoxon signed rank test; **paired t-test. table 6. comparison positive and negative syndrome scale (panss) dan il-6 pre-post (by pcr testing). pcr variables n mean sd decrease (%) p positive panss pre 22 73.5 3.9 22.4 0.000* panss post 22 57.0 6.9 il-6 pre (pg/ml) 22 26.1 2.4 11.8 0.000** il-6 post (pg/ml) 22 23.0 2.1 negative panss beginning 22 71.4 2.6 20.6 0.000* panss end 22 56.7 5.9 il-6 pre (pg/ml) 22 21.0 3.9 8.1 0.000** il-6 post (pg/ml) 22 19.3 3.4 *wilcoxon signed rank test; **paired 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after remission. eur arch psychiatry clin neurosci 1997;247:228–33. 24. zajkowska z, mondelli v. first-episode psychosis: an inflammatory state? neuroimmunomodulation 2014;21:102–8. 25. zhou x, tian b, han h bin. serum interleukin-6 in schizophrenia: a system review and meta-analysis. cytokine 2021;141:155441. 26. park jh, park hj, lee se, et al. repositioning of the antipsychotic drug tfp for sepsis treatment. j mol med 2019;97:64758. 27. crespo-facorro b, ruiz-veguilla m, vázquez-bourgon j, et al. aripiprazole as a candidate treatment of covid-19 identified through genomic analysis. front pharmacol 2021;12:1–8. 28. lu q, zhu z, tan c, et al. changes of serum il-10, il-1β, il6, mcp-1, tnf-α, ip-10 and il-4 in covid-19 patients. int j clin pract 2021;75:1–8. 29. li j, rong l, cui r, et al. dynamic changes in serum il-6, il8, and il-10 predict the outcome of icu patients with severe covid-19. ann palliat med 2021;10:3706–14. 30. zhang j, hao y, ou w, et al. serum interleukin-6 is an indicator for severity in 901 patients with sars-cov-2 infection: a cohort study. j transl med 2020;18:1–8. 31. miller bj, gassama b, sebastian d, et al. meta-analysis of lymphocytes in schizophrenia: clinical status and antipsychotic effects brian. bone 2008;23:1–7. article [page 104] [healthcare in low-resource settings 2025;13:12723] hrev_master healthcare in low-resource settings 2024; volume 12:12276 hospital brand image and trust leading towards patient satisfaction: medical tourists’ behavioural intention in malaysia tham noi fook, low mei peng, yeong wai mun faculty of accountancy and management, universiti tunku abdul rahman, selangor, malaysia abstract in malaysia, hospital branding is critical to recruiting medical tourists. reputation, service quality, and word-of-mouth influence hospital branding. thus, hospitals and the healthcare tourism sector must understand these elements to gain a competitive edge in the global market. this study investigated the effect of hospital advertising factors on healthcare tourists’ behavioural intentions (bi) in malaysia, with emphasis on clarifying the nature of hospital brand image and hospital brand trust. additionally, the study assessed how perceived standards and satisfaction stimulate favourable bi among healthcare tourists. this study used the quantitative research-based deductive approach, where hospitals in malaysia were the target sector. the results demonstrated that accessibility, cost, and a good web presence influenced hospital marketing for medical tourism. furthermore, the characteristics of safety and security and effective advertising enhance trust. moreover, patient satisfaction is critical to reduce the divide between service standards and bi, which emphasises the necessity of prioritising patients in medical facilities. nevertheless, the findings were time-sensitive and not adjusted for healthcare tourism sector alterations or customer habit variations over time. introduction the term “medical tourism” slightly diverges from normal tourism, as it primarily focuses on the medical services obtained from tourism or moving to distant regions with the desired medical facility. a tourism medical index reported that malaysia is one of the most prominent medical tourism countries.1 characteristically, malaysia provides several services. reportedly, 850 thousand medical tourists have visited different regions of malaysia for medical services. the malaysian healthcare travel council (mhtc) facilitated these visitors by conducting several initiatives by recruiting registered doctors and encouraging public and private industry collaboration.2 medical tourists have been discussed as a substantial revenue source in malaysia given that the malaysian medical tourism sector has a stronger competitive advantage than other asian counterparts. the advantages of malaysia include a favourable exchange rate, highly qualified and trained health workers and doctors, political and effective economic stability, increased population literacy rate, high-demand medical facilities, and economical medical treatments.3 malaysian medical tourism is a significant and vital revenue source for the economy, which contributed 1.3 billion malaysian ringgit in the financial year 2022. nonetheless, this figure remains far lower than the total 2019 revenue of 1.7 billion malaysian ringgit. malaysian medical tourism is witness to this substantial difference, as the after-effect or supplementary effect of the covid-19 pandemic.4 additionally, the mhtc requested that the medical tourism sector take advanced steps and adopt different practices to become an international hub providing optimal tourist medical services.5 to fulfil this dream, hospitals in malaysia must embrace tourists’ expectations and focus on the factors boosting their service quality and branding. these factors include knowledge of the country, social media, price reasonableness (pr), safety and security (ssa), accessibility (acc), advertisement (adm), and medical tourists’ word-of-mouth. these factors were reported in a recent study on chinese medical tourists’ behavioural intentions (bi).1 perceivably, hospitals in malaysian regions such as sarawak should improve their service quality and client satisfaction. this improvement would enhance their brand image and visitors’ bi.67 the aforementioned studies used the concepts of brand image, service quality, satisfaction, and bi. accordingly, this study combined an original empirical model and suggestions to design the following research objectives: i) to investigate the influence of factors associated with hospital branding on defining medical tourists’ bi in malaysia, ii) to elucidate the mediation of hospital brand image (hbi) and trust (hbt) to increase medical tourists’ bi in malaysia and, iii) to evaluate the catalytic influence of medical tourists’ perceived quality and satisfaction ‘ to enhance their favourable bi to visit. to fulfil these research objectives, the researcher targeted hospitals in a specific malaysian region (sarawak). the target popucorrespondence: tham noi fook, faculty of accountancy and management, universiti tunku abdul rahman, selangor, malaysia. e-mail: thamnoifook@protonmail.com key words: patient experience, patient satisfaction, hospital brand image, hospital brand trust, perceived service quality, behavioral intention. conflict of interest: there is no potential conflict of interest. funding: this research study is not funding by any institute/agency. ethics approval: not applicable. patient consent: not applicable. data availability: data is available from corresponding author on request. received: 12 january 2024. accepted: 1 february 2024. early access: 19 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12276 doi:10.4081/hls.2024.12276 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12276] [page 301] non -co mmerc ial us e o nly lation was medical tourists from indonesia. data were collected using a self-administered questionnaire. a total of 344 valid responses were obtained. this study will be an important information source for formulating strategies and means of conduct for sarawak hospitals to identify, enhance, and increase their services. consequently, all factors triggering hbi and hbt will increase. hence, reputations of the hospitals will flourish among medical tourists, who will demonstrate a greater tendency for visiting bi. furthermore, this study enhances current theoretical knowledge of the factors facilitating medical tourists’ mindset. increased convenient service features would increase hbi and hbt in malaysia and maximise bi. literature review theoretical background this study is based on berry’s relationship marketing theory.8 the theory emphasises building and maintaining strong, long-term relationships with customers and other stakeholders. furthermore, the theory promotes a customer-centric approach and centres the customer in all marketing efforts. moreover, the theory states that understanding the customer’s needs and preferences is a key determinant of long and sustainable relationships. this focus on building long and sustainable relationships with consumers represents a long-term approach to nurturing and retaining consumers. the principles of this theory were applied to this study on the factors influencing hospital branding and its relationship with medical tourists’ bi. regarding healthcare centre branding efforts, the relationship marketing theory encourages prioritising patient, directing all marketing efforts towards building a strong and positive brand image, and positively influencing the patient’s perceived service quality (psq) and bi. determinants of hbi brand image refers to the consumers’ perception of a specific brand or product.9 the hbi refers to patients’ perceptions of the quality of services offered at a hospital. this study focused on the three determinants of hbi: acc, pr, and hospital-generated social media (hsm). the acc the acc is considered a key hbi component. talarposhti10 conducted a mixed study to investigate healthcare branding in healthcare centres in iran. reportedly, brand accessibility was a key determinant of healthcare branding. easy access to healthcare services encourages consumers to use healthcare services and maintain their health. moreover, socio-economic circumstances significantly influence a person’s access to healthcare services. therefore, healthcare branding should focus on providing fair accessibility to all community members. similarly, erlinda and ratnawati11 analysed the influence of acc on hbi in hospitals in indonesia. the authors reported that acc also significantly influenced hbi and considered it the dominant factor among the observed variables in forming the hbi. thus, the following hypothesis (h) was proposed. h1: the acc significantly influences hbi the pr most consumer markets perceive higher prices as a determinant of high quality. nevertheless, the healthcare industry frequently challenges this notion of price–quality relation. thus, interpreting price and quality in the healthcare industry is typically challenging. therefore, there is a lack of consensus on the costs, prices, and quality of healthcare services offered the healthcare industry in malaysia. beauvais et al.12 reported that higher pricing was not associated with high-quality service, thus implying that pr is a desired factor by healthcare facility consumers. havidz and mahaputra13 reported the significant influence of perceived price on the brand image of any product, which implied that better price perception leads to a better brand image. therefore, the following hypothesis was suggested: h2: the pr significantly influences hbi. social media platforms offer opportunities for consumers to exchange brand-related opinions.14 cham et al.15 analysed the factors influencing hbi in the malaysian medical tourism industry. the authors reported the significant influence of hsm on hbi, which suggested the significant influence of social media on consumer perception regarding hbi. nonetheless, the authors also reported the substantial influence of both hsm and user-generated social media (usm) on hospital branding. the findings supported the notion that medical tourists rely on social media platforms to obtain information on healthcare facilities. similarly, cham et al.3 reported the significant influence of hsm on medical tourists’ perception of hbi. accordingly, the following hypothesis was formulated. h3: the hsm significantly influences hbi. determinants of hbt brand trust represents the brand’s promise to meet its consumers’ expectations and enhances customer loyalty. brands build trust with consumers by proving their potential to meet consumers’ expectations. brand trust also represents brand reliability.16 the healthcare sector is responsible for providing high-quality services to its consumers. consumers prefer to obtain sufficient information on the services offered at hospitals before visiting them, which demonstrates the importance of the honesty and sincerity of hospitals in establishing their consumers’ trust.17 this study focused on the three determinants of hbt: ssa, adm, and usm. the ssa elizar et al.18 studied the interplay between customer satisfaction, service quality, customer trust, and customer loyalty in indonesian hospitals. while the authors did not exclusively investigate the influence of ssa on customer trust in hospitals, the findings considered prioritising patients’ comfort and safety as a key customer satisfaction determinant. building trust is a significant factor in sustaining a positive relationship with consumers. healthcare centres must assure customers of the safety of the procedures offered to gain their trust.19 the world health organisation (who)20 reported that ~1 in every 10 patients is harmed in healthcare facilities. furthermore, an unsafe environment within hospitals leads to over three million deaths annually. the common reasons underlying these outcomes are the use of unsafe equipment and procedures, medical errors, and mismanagement. as such, the healthcare sector should focus on medical tourists’ ssa. the following hypothesis was suggested as follows. h4: the ssa significantly influences hbt. article [page 302] [healthcare in low-resource settings 2024;12:12276] non -co mmerc ial us e o nly the adm mohamed21 delineated several means by which the healthcare sector could build trust with patients. a key factor influencing the trust between the hospital and its consumers was the use of emotional advertisement campaigns. the author suggested that hospitals should use persuasive and emotional advertisements to arouse empathy and hope among patients. this approach could aid the hospitals in building trust with the patients. cham et al.3 investigated the influence of advertisements on hbt in chinese medical tourism and reported a positive influence of advertisements on medical tourists’ hbi. the aforementioned influence positively affected medical tourists’ trust in the hospital brand. heskiano et al.22 also reported the significant influence of social media advertisements on brand loyalty and trust in the indonesian healthcare sector. thus, the following hypothesis was proposed. h5: the adm significantly influences hbt. the usm agnisarman et al.23 investigated the influence of usm on consumers’ healthcare facility selection. resultantly, user-generated anecdotal information on the healthcare facility significantly influenced consumers’ choices. the findings implied that usm significantly influenced hbt. abuhmeidan24 investigated the influence of digital marketing on the brand equity of hospitals in jordan. the authors considered two digital marketing dimensions (firmand user-generated social media content) and reported the significant influence of user-generated content on hospital brand equity. accordingly, the following hypothesis was formulated. h6: the usm significantly influences hbt. influence of hbi and hbt on psq healthcare facility psq refers to visitors’ views of the quality of services provided.25 cham et al.15 analysed the influence of hbi on psq in the malaysian healthcare sector and reported the significant influence of hbi on medical tourists’ psq. the results suggested patients’ heavy reliance on hbi to interpret the quality of service offered at hospitals. thus, hospitals can utilise their brand image to positively influence medical tourists’ psq. similarly, sukawati26 analysed the influence of hbi on the psq of consumers of healthcare facilities in bali, indonesia, and reported the significant influence of hbi on psq. thus, the authors reaffirmed the importance of maintaining a good hbi to sustain positive psq among medical tourists. taneja27 also reported the positive influence of hbi on healthcare facility psq. gur28 considered customer trust a key psq determinant in the healthcare sector and indicated the importance of nurturing trust between the hospital and its consumers to promote positive psq. there is a significant research gap on the influence of hbt towards psq. thus, the following hypotheses were formulated based on these observations. h7: the hbi significantly influences psq. influence of psq on bi cham et al.15 reported the positive influence of psq on medical tourists’ bi regarding healthcare centres in malaysia. the authors suggested that psq significantly influenced consumers’ intention to use specific healthcare facilities. the psq might also result in medical tourists repeatedly visiting a specific medical centre. similarly, liao et al.29 reported the significant influence of psq on consumers’ bi to purchase a product or service. shahid iqbal et al.30 confirmed the positive influence of psq on consumers’ bi in the pakistani service sector. similarly, prentice and kadan31 reported the positive influence of psq on consumers’ bi to re-visit and purchase a service in the service sector. fatima etv al.32 suggested the significant influence of psq on patients’ behavioural attitudes and loyalty intentions. the authors indicated that the patients’ decisions to re-visit a healthcare facility relied on their perception of the service quality at the facility. agyapong et al.33 examined the effect of psq on patients’ bi in ghana and reported a positive and significant correlation between the two variables. the authors suggested that hospitals should focus on designing consumer-driven strategies to meet their expectations on healthcare service quality. therefore, the following hypothesis was proposed. h8: the psq significantly influences bi. mediating effect of patient satisfaction (ps) zehra and arshad17 studied the mediating effect of customer satisfaction on the relationship between service quality and customers’ intentions to use healthcare facilities. the authors reported a true mediation, which indicated that the patients’ psq significantly influenced their intentions to use healthcare services when they were satisfied with the service offered. therefore, ps is the outcome of their reception and perception of a healthcare service. the healthcare sector aims to achieve higher ps levels by providing high-quality healthcare services. thus, a patient’s perception is crucial in evaluating services and their satisfaction with these services. patients frequently experience satisfaction and pleasure due to high-quality service and the hospital staff’s positive demeanour. the higher satisfaction level will influence patients’ loyalty and intentions to re-visit the hospital.34 similarly, paradilla et al.35 suggested that patients’ satisfaction with service quality significantly influenced their loyalty, which represented their intentions to revisit the hospital. ajmal and risal36 confirmed the significant influence of ps on their loyalty to the hospital. the authors suggested that satisfaction with the service quality encouraged patients to revisit the hospital. cham et al.15 highlighted the mediating effect of medical tourists’ satisfaction on the relationship between psq and bi. the authors indicated that healthcare facilities should focus on providing high-quality services and achieving higher levels of ps to influence patients’ bi to re-visit the hospital. therefore, the following hypothesis was suggested h9: the ps mediates the correlation between medical tourists’ psq and bi. materials and methods figure 1 indicates the research framework of the present study. this study used the quantitative research-based deductive approach, with the target sector being hospitals in malaysia. data were obtained using a self-administered questionnaire survey. the data were obtained using non-probability sampling. medical tourists at various hospitals in malaysia were invited to participate in the survey. sampling and data collection this study strictly followed all research ethics and guidelines during data collection. for example, all the individuals were requested to participate voluntarily. the research information and the purpose of data collection were first communicated to the participants. subsequently, data were only collected from the volun article [healthcare in low-resource settings 2024;12:12276] [page 303] non -co mmerc ial us e o nly tary participants upon ensuring their trust, confidentiality, and anonymity. given the involved data sample, the sample size was 340 as suggested previously.37 typically, surveys record a low response rate. furthermore, some collected responses have > 25% missing values. therefore, the desired sample size was achieved by distributing a total of 500 questionnaires in person to the respondents. the questionnaire contained demographic questions related to the respondent’s age, gender, education, marital status, number of visits to malaysia, and how they arranged their visit to malaysia. key questions on the study variables are described in the following section. as this study focused on indonesian medical tourists, the researcher translated the questionnaire into malay and obtained data via convenience sampling. measures of the constructs the main questionnaire body was designed following previous empirical studies, which included the complete phrases of variable items. the acc was measured using four items,15 pr was measured using three items,38 hsm was measured using a three-item scale,39 ssa was measured using a five-item scale,15 usm was measured using three items,39 and adm was measured using six items.40 the mediators hbi, hbt, psq, and ps were measured using three items,15 four items,41 a five-item scale,15 and four items,42 respectively. lastly, the dependent variable bi was measured using a three-item scale.43 data were analysed by using the spss and cb-sem. results respondents’ demographic profile table 1 presents the 344 respondents’ demographic profile. most respondents were male (52.3%), between 25 and 30 years old (52.3%), married (61%), and visited the hospitals for clinical treatment options (58.1%). multicollinearity analysis in a multiple regression model, a higher correlation between multiple independent constructs results in the issue of multicollinearity.44 in a regression analysis, the variance inflation factor (vif) is a measure of multicollinearity.45 the vif threshold is 3 or 5.46 table 2 presents the vif results. the resultant values against all construct items were under both threshold ranges, thus indicating the absence of multicollinearity in the dataset. confirmatory factor analysis the estimated linkages in the reflective measurement model were outer loadings. the outer loadings indicate the direction from the latent constructs to their indicators.47 in structural equational modelling analysis, the outer loadings value ranges from 0 to 1, and the cut-off value is 0.6.48 table 3 presents the outer loading results, where all values in the table were >0.60. one acc item, two adm items, one ps item, two ssa items, and one psq item were deleted following low factor loading values. the reliability of variables was measured using cronbach’s alpha (α). the cronbach alpha threshold value is >0.70. table 3 presents the internal consistency reliability results. the acc, adm, bi, hbi, hbt, hsm, pr, ps, psq, ssa, and usm alpha value was 0.88, 0.59, 0.83, 0.90, 0.87, 0.68, 0.84, 0.92, 0.81, and 0.85, respectively. therefore, the dataset was reliable. convergent validity is used to examine how closely the measurement tests are associated with the tests used to measure identical variables. convergent validity is measured with two indicators: average variance extracted (ave) and composite reliability (cr). the ave and cr value should be >0.50 and >0.70 to ensure the existence of true reliability in the dataset.49 table 3 presents the convergent validity results. all resultant values met the standard criteria, thus indicating that the data were reliable, normally distributed, and accurate. discriminant validity discriminant validity determines whether theoretically unrelated variables are actually unrelated.50 in this study, discriminant validity was measured using fornell-larcker’s (1981) criterion. discriminant validity is evaluated by comparing the ave square root of each variable.51 the results in table 4 demonstrate that the ave square root value of each variable was higher than the latent construct correlations. thus, the results established discriminant validity. article figure 1. proposed research model. table 1. respondents’ demographic profile. characteristic frequency percentage gender male 180 52.3 female 164 47.7 total 344 100.0 age (years) 25–30 110 34.7 31–35 80 24.2 36–40 90 26.1 40–45 48 14.05 > 45 16 0.05 total 344 100.0 marital status married 210 61 unmarried 134 39 total 344 100.0 treatment type clinical 200 58.1 surgical 94 27.4 other 50 14.5 total 344 100.0 [page 304] [healthcare in low-resource settings 2024;12:12276] non -co mmerc ial us e o nly r2 the r2 results in table 5 demonstrate that bi, hbi, hbt, ps, and psq contributed 25.8%, 31.4%, 54.8%, 23.3%, and 46.5% to their relevant variables, respectively. measurement model figure 2 depicts the measurement model of the study. model fitness the goodness of model fit was measured using the indicators srmr and nfi. srmr is defined as, “the difference between the observed correlation and the model implied correlation matrix.”52 nfi is defined as “nfi is given by the relative location of the current model between the saturated model with ts=0 and the independence model ti.”53 according to dijkstra and henseler (54), “d_uls (i.e., the squared euclidean distance) and d_g (i.e., the geodesic distance) represent two different ways to compute this article table 2. multicollinearity analysis. vif acc2 2.363 acc3 2.714 acc4 2.386 adm3 1.369 adm4 2.678 adm5 3.436 adm6 2.506 bi1 1.823 bi2 1.97 bi3 1.942 hbi1 2.548 hbi2 3.642 hbi3 3.358 hbt1 2.217 hbt2 3.319 hbt3 3.417 hbt4 3.015 hsm1 2.245 hsm2 2.981 hsm3 2.304 pr1 1.353 pr2 1.321 pr3 1.326 ps2 1.859 ps3 2.051 ps4 2.212 psq2 3.057 psq3 3.856 psq4 3.608 psq5 3.257 ssa1 1.423 ssa2 2.54 ssa3 2.406 usm1 2.058 usm2 2.202 usm3 2.023 note: acc, accessibility, pr, price reasonableness, hsm, hospital-created social media, ssa, safety and security, usm, user-generated social media, adm, advertisement, hbi, hospital brand image, hbt, hospital brand trust, psq, perceived service quality, ps, patient satisfaction, bi, behavioural intention. table 3. outer loading values. items alpha cr (rho_a) cr (rho_c) ave acc2 0.902 0.882 0.887 0.927 0.808 acc3 0.904 acc4 0.891 adm3 0.715 0.859 0.86 0.906 0.707 adm4 0.875 adm5 0.904 adm6 0.858 bi1 0.859 0.831 0.831 0.898 0.747 bi2 0.869 bi3 0.864 hbi1 0.904 0.909 0.909 0.943 0.846 hbi2 0.933 hbi3 0.922 hbt1 0.852 0.913 0.913 0.939 0.793 hbt2 0.91 hbt3 0.906 hbt4 0.895 hsm1 0.872 0.876 0.88 0.924 0.801 hsm2 0.924 hsm3 0.889 pr1 0.77 0.686 0.693 0.826 0.613 pr2 0.766 pr3 0.812 ps2 0.857 0.800 0.843 0.905 0.762 ps3 0.874 ps4 0.887 psq2 0.891 0.843 0.927 0.948 0.819 psq3 0.918 psq4 0.907 psq5 0.904 ssa1 0.819 0.926 0.818 0.888 0.726 ssa2 0.878 ssa3 0.858 usm1 0.888 0.813 0.859 0.91 0.77 usm2 0.874 usm3 0.871 [healthcare in low-resource settings 2024;12:12276] [page 305] non -co mmerc ial us e o nly discrepancy”. the srmr should be < 0.08,55 while the nfi should be ≥ 0.90.56 table 6 demonstrates that the values of the model were not a good fit overall. the nfi value was < 0.90, as the sample size was small according to item-to-response theory. the small sample size primarily resulted from item deletions based on low factor loading values. structural equation modelling (sem) the hypotheses were evaluated using sem. table 7 presents the sem results, where the hypotheses were supported with a pvalue < 0.05. there was support for the association between acc and hbi (p=0.00), adm and hbt (p=0.007), hbi and psq (p=0.00), hbt and psq (p=0.00), hsm and hbi (p=0.00), pr and hbi (p=0.048), ps and bi (p=0.00), psq and bi (p=0.00), psq and ps (p=0.00), and ssa and hbt (p=0.00). nevertheless, the relationship between usm and hbt was not supported (p=0.436). the ps mediation of psq and bi was supported (p=0.00). discussion this study examined the aspects that influence hospital branding and its relevance to medical tourists’ bi. the examination of multiple hypotheses clarified the complicated dynamics of medical service quality and its influence on patients’ intentions. the first three hypotheses were supported and addressed the influence of acc, pr, and hospital-created social networking sites on hbi. this result indicated that these variables are important in determining medical tourists’ opinions of the reputation of a hospital. the findings highlighted the necessity of hospitals having quick access, affordable pricing, and a strong internet presence to develop a favourable reputation, which is critical for recruiting medical tourists. the h4–6 focused on the influence of ssa, adm, and usm on hbt. the h4 and h5 were supported whereas h6 was not. this finding suggested that ssa measures and efficient advertising initiatives contribute to the development of trust among article table 4. discriminant validity. acc adm bi hbi hbt hsm pr ps psq ssa usm acc 0.899 adm 0.598 0.841 bi 0.597 0.468 0.864 hbi 0.382 0.611 0.374 0.92 hbt 0.441 0.593 0.386 0.532 0.891 hsm 0.461 0.583 0.421 0.529 0.866 0.895 pr 0.196 0.301 0.211 0.261 0.326 0.298 0.783 ps 0.772 0.653 0.471 0.511 0.558 0.493 0.242 0.873 psq 0.445 0.615 0.394 0.533 0.644 0.687 0.45 0.482 0.905 ssa 0.403 0.547 0.35 0.557 0.694 0.721 0.419 0.487 0.81 0.852 usm 0.373 0.419 0.373 0.741 0.355 0.354 0.272 0.379 0.371 0.367 0.878 figure 2. measurement model. [page 306] [healthcare in low-resource settings 2024;12:12276] non -co mmerc ial us e o nly healthcare visitors. nonetheless, user-generated social networking content had limited influence, which indicated that hospitals should emphasise other aspects to increase trust. the h7 and h8 referred to the influence of hbi and hbt on psq, and both were supported. this result suggested that a favourable hbi and hbt positively influence psq. medical visitors tend to correlate these aspects with the standard of medical services, which emphasises the necessity for brand image management and trust development. additionally, h9 stated that psq substantially influences healthcare tourists’ bi. the h9 suggested that a favourable impression of service standards leads to a greater desire to return or recommend the hospital facility. the h9 emphasises the importance of service standards in influencing healthcare tourists’ behaviour. lastly, h10 stated that ps mediated psq and bi. this hypothesis suggested that patient happiness is key to narrowing the disparity between psq and medical tourists’ aspirations. a satisfied customer is more inclined to display good bi, which highlights the need for hospitals to prioritise patient happiness. the current findings coincided with previous study outcomes on healthcare tourism and medical service standards. the validation of the influence of acc, pr, and hospital-created online platforms on hbi paralleled previous research. cham et al.15 emphasised the importance of these aspects in determining patients’ views and preferences when selecting healthcare facilities. similarly, accepting the assumptions of security and protection and the efficacy of commercials corresponded with yasui57 emphasis on the importance of trust-building and marketing methods in healthcare environments. furthermore, the established ideas on the influence of hbi and hbt towards psq correlate with cham3 study, which demonstrated the interdependence of these factors. moreover, the findings supported a previously documented association between psq and client happiness in assessing medical tourists’ bi. rahman6 emphasised the significance of these elements in anticipating healthcare tourists’ intentions. the author highlighted that enhanced service experiences and satisfied customers increase the probability of return visits or recommendations. implications this study provided the following theoretical contributions and practical implications. theoretical contributions this study on the variables affecting hospital branding and its association with medical tourists’ bi clarified the key variables influencing medical tourists’ decision-making procedures, which eventually affect the healthcare sector and hospital administration. the study underscored the significance of hospital advertising in the healthcare tourism framework. this finding highlighted the importance of hospital credibility, image, and overall quality of offerings when attracting medical visitors. this insight would aid hospitals in recognising the necessity of good branding initiatives to succeed in the international medical tourism industry. the study also identified and examined the characteristics influencing medical visitors’ decision-making. these characteristics include service quality, confidence, word-of-mouth, and hospital online presence. understanding these characteristics would allow hospitals to focus on specific elements that connect their branding efforts with potential healthcare tourists. additionally, this study examined the relationship between hospital advertising and medical tourists’ bi. the findings demonstrated that the favourable perception of a brand to attract medical travellers and increase their desire to select a specific healthcare facility. such selection has important consequences for hospitals aiming to engage in the healthcare tourism industry. article [healthcare in low-resource settings 2024;12:12276] [page 307] table 7. discriminant validity. relationship original sample sample mean standard deviation t statistic acc -> hbi 0.168 0.168 0.062 2.719 adm -> hbt 0.292 0.295 0.058 5.03 hbi -> psq 0.264 0.265 0.066 3.972 hbt -> psq 0.505 0.503 0.061 8.32 hsm -> hbi 0.421 0.421 0.067 6.28 pr -> hbi 0.103 0.107 0.052 1.973 ps -> bi 0.366 0.368 0.055 6.69 psq -> bi 0.218 0.218 0.059 3.715 psq -> ps 0.482 0.483 0.046 10.425 ssa -> hbt 0.519 0.517 0.052 9.993 usm -> hbt 0.042 0.042 0.054 0.78 psq -> ps -> bi 0.177 0.178 0.031 5.751 table 5. the r2 values. r2 adjusted r2 bi 0.258 0.254 hbi 0.314 0.308 hbt 0.548 0.544 ps 0.233 0.23 psq 0.465 0.462 table 6. model fitness. saturated model estimated model srmr 0.061 0.163 d_uls 2.497 17.683 d_g 2.632 3.667 chi-square 4168.457 5178.151 nfi 0.664 0.583non -co mmerc ial us e o nly practical implications this study presented useful recommendations for hospitals and healthcare organisations aiming to succeed in medical tourism. hospitals can establish tailored branding and promotional strategies by identifying the factors influencing medical visitors’ decision-making. moreover, hospitals may invest to enhance service quality, establish trust, and increase internet presence, all of which are key to attracting and maintaining medical visitors. this understanding can increase patient influx and income. additionally, the findings can aid healthcare tourism destinations and politicians in developing appropriate rules and laws. politicians as well as healthcare tourism destination countries may use the data to promote and assist hospitals in successful marketing and service quality, which would strengthen the social economy and healthcare system. conversely, underperforming hospitals may be guided on areas for development and result in broad expansion of the healthcare tourism industry. moreover, the implications for medical tourism are extensive. medical tourists can make educated decisions on their medical options with an awareness of the key factors influencing the reputation and service level of a hospital. such consciousness can result in better outcomes, increased satisfaction, and a better experience for healthcare tourists, which would benefit the industry image. limitations and future directions the findings are time-sensitive and not adjusted for healthcare tourism sector changes or customer habit variations over time. continuous data and tracking were not conducted to precisely record patterns and shifts. furthermore, cultural differences and changes in healthcare tourism were not adequately considered. diverse cultural norms, demands, and healthcare systems reflected varying effects on the highlighted parameters. future research should examine how cultural variations affect medical tourists’ perceptions of hospital advertising and bi. comparative research across diverse cultural settings could elucidate the complexity of healthcare decisions. furthermore, the study overlooked external factors, such as political stability, socio-economic situations, and public health emergencies (pandemics), which could substantially influence medical visitors’ decision-making. moreover, future research should investigate the influence of new technologies, which include telemedicine, artificial intelligence, and machine learning, on modifying hospital marketing and healthcare tourists’ selections. future studies should examine the influence of these advances on the standard and perception of medical services. lastly, future studies should investigate the influence of public– private collaborations on hospital marketing and healthcare tourist recruitment. such studies should examine the effect of legislation in fostering such alliances. conclusions this study investigated the elements influencing hospital branding and its association with healthcare tourists’ bi. the tested hypothesis yielded useful insights into the mechanisms of healthcare marketing and its influence on medical visitors’ decisionmaking processes. the findings indicated that acc, pr, and hsm contribute to the establishment of a favourable hbi, which affects psq. furthermore, ssa and adm were key influencers of hbt, which then affected psq. nevertheless, the findings did not support the idea that usm substantially influenced hbt, which emphasised the importance of hospitals prioritising regulated channels of communication. reputation, trust, quality of service, and patient happiness were highly correlated, all of which were critical to attain healthcare tourists’ goals. then, the study discussed its implications, limitations and presented research directions to subsequent scholars. references 1. cham t-h, lim y-m, sia b-c, et al. medical tourism destination image and its relationship with the intention to revisit: a study of chinese medical tourists in malaysia. j china tourism res 2021;17:163-91. 2. statisa. number of people who travelled to malaysia for healthcare from 2013 to 2022(in 1,000s)number of people who travelled to 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-co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13571 correlation of self-efficacy and medication adherence with treatment continuity among tuberculosis patients in east java, indonesia karyo karyo,1,2 ah yusuf,1 ilya krisnana,1 nursalam nursalam,1 miftahul munir,2 tri yunita fitria damayanti,2 kusno ferianto,2 ahmad daniel2 1faculty of nursing, airlangga university, surabaya; 2faculty of nursing and midwifery, ilmu kesehatan nahdlatul ulama tuban institute, indonesia abstract tuberculosis (tb) remains a significant global health challenge, and treatment adherence is crucial for successful outcomes. this study aimed to investigate the correlation between self-efficacy, medication adherence, and treatment continuity among patients with tb in east java, indonesia. this cross-sectional, correlational study was conducted in four randomly selected districts of east java in 2024. the study employed probability sampling with a simple random sampling technique. data were collected using the guide for constructing self-efficacy scale and morisky medication adherence scale (mmas-8). a total of 6,792 tb patients participated in this study. statistical analysis was performed using spss version 25, including frequency distribution, percentage calculation, and spearman’s rank correlation test, with a significance level of 0.05. among the participants, 70.3% (n=4,775) demonstrated high self-efficacy, whereas 29.7% (n=2,017) showed low self-efficacy. regarding medication adherence, 60% (n=4,075) exhibited high adherence, and 40% (n=2,719) reported low adherence. spearman’s rank correlation test revealed a strong positive correlation between self-efficacy and medication adherence (r=0.936, p<0.001). the study findings indicated a significant relationship between self-efficacy, medication adherence, and treatment continuity in patients with tb. these results underscore the importance of addressing psychological factors in tb management programs. interventions aimed at enhancing patients’ self-efficacy could potentially improve medication adherence and, consequently, treatment outcomes. these results provide a strong rationale for developing comprehensive care models that incorporate medical and psychological interventions to enhance treatment continuity and improve patient outcomes. introduction tuberculosis (tb) remains one of the leading causes of death worldwide. pulmonary tuberculosis has an estimated annual mortality rate of 27 per 100,000 individuals. contributing factors include low self-efficacy and non-adherence to anti-tuberculosis treatment, both of which adversely impact recovery rates. tuberculosis patients undergo treatment for approximately 6 to 9 months, resulting in prolonged exposure to the treatment regimen. one of the psychological factors that affects adherence to taking medication is self-efficacy. a high level of self-efficacy in an individual positively influences their confidence and belief in their capacity to address challenges.1-3 self-efficacy, or an individual’s belief in their ability to successfully complete a task, is a crucial factor in promoting adherence to tb treatment. self-care performance mediates the relationship between self-efficacy and healthrelated quality of life among patients undergoing primary treatment for pulmonary tb. this suggests that self-efficacy plays a vital role in enabling patients to engage in their treatment and improve their health outcomes actively.4,5 tuberculosis patients often exhibit diminished self-efficacy, hindering their capacity for self-care and adversely affecting their adherence to prescribed correspondence: karyo karyo, faculty of nursing, universitas airlangga, surabaya; faculty of nursing and midwifery, institut ilmu kesehatan nahdlatul ulama tuban, indonesia. e-mail: karyo.iiknu@gmail.com key words: self-efficacy; medication adherence; tuberculosis; treatment continuity; east java. contributions: kk, conceptualization, investigation, data curation, formal analysis, methodology, validation, visualization, writing – original draft & review; ay, conceptualization, methodology, validation, writing – original draft & review; ik, conceptualization, methodology, formal analysis, validation, writing – original draft & review; hh, methodology, visualization, writing – review & editing; nn: resources, investigation, writing – review; mm, formal analysis, validation, writing – review; tyfd, resources, supervision, writing – review; kf, resources, investigation, writing – review; ad, writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the study was approved by the health research ethics commission of the nahdlatul ulama institute of health tuban (approval number: 55/0084223523/lepk. iiknu/iii/ 2024). consent for publication: patients’ written informed consent was obtained for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgments: i extend my gratitude to my supervisor for his guidance in preparing this manuscript as a requirement for the doctor of nursing degree at the faculty of nursing, airlangga university. i also thank my colleagues for their assistance in writing this article and my family for their unwavering support and encouragement. received: 1 january 2025. accepted: 11 march 2025. early view: 12 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13571 doi:10.4081/hls.2025.13571 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13571] [page 29] medication, thereby impeding their recovery due to a lack of confidence in their abilities and commitment to treatment.5-7 pulmonary tuberculosis is a chronic condition, necessitating that patients adhere to a treatment regimen of no fewer than four medications daily during the initial or intensive phase, followed by two medications daily in the subsequent phase, with a minimum treatment duration of six months.8-10 treatment over a long period, if not supported by good self-efficacy and regular medication adherence, can significantly affect the recovery rate in pulmonary tb patients. non-adherence to medication in cases of tuberculosis represents a complex healthcare issue, frequently occurring and involving numerous dimensions related to patients, their care, and/or healthcare providers. in long-term treatment, patient adherence is crucial for understanding patient behavior and attitudes toward the treatment program provided by doctors or healthcare workers. for patients who do not follow the recommended treatment, adverse side effects may occur.3,8,11,12 tuberculosis ranks second among infectious diseases in terms of mortality worldwide. indonesia is the third highest country globally in tuberculosis cases, with a total of 809,000 individuals affected.13 in 2023, the number of pulmonary tuberculosis cases in indonesia rose to 809,000, marking an increase compared to two years earlier. according to the 2023 data, approximately 509,000 pulmonary tb patients were reported as non-compliant with treatment. similarly, the who reported a treatment dropout rate of 535,000 individuals in the same year. in east java specifically, the regional health profile indicates that 2,073 patients discontinued their tb treatment.14 furthermore, a survey conducted on september 21, 2024, gathered data through interviews in several randomly selected representative districts. the findings revealed treatment dropout figures of 1,809 in pacitan, 1,600 in lumajang, 1,653 in tuban, and 1,730 in mojokerto. many pulmonary tb patients fail to complete the full sixmonth course of anti-tb treatment and are often unaware of the importance of follow-up sputum examinations. this lack of adherence increases their risk of developing drug-resistant forms of tuberculosis and experiencing relapses. key factors influencing recovery include patients’ self-efficacy and medication adherence, both of which are strengthened by support from family or close contacts. patients who do not consistently follow their treatment regimen frequently face the need to restart therapy from the beginning.15-17 tuberculosis patients become non-compliant with treatment due to side effects from the treatment and self-efficacy issues because they suffer from tuberculosis. another factor contributing to non-compliance in treatment is the lack of motivation and knowledge among tuberculosis patients. pulmonary tb patients require mental support from both their families and those around them, as this can aid in their recovery.15,16 materials and methods design this study utilized an analytical research design with a correlational approach. the researchers explored the relationships between the variables without intervention. a cross-sectional time design was employed, highlighting that the measurement and observation of both independent and dependent variable data occur only once at a specific point in time. however, employing a crosssectional design has limitations; specifically, it cannot establish a causal relationship. study participants the study population consisted of tuberculosis patients from four districts in east java in 2024. the sample size encompassed these four districts. this study employs probability sampling using a simple random sampling technique. the inclusion criteria included patients with tuberculosis undergoing treatment for a minimum of 6 months in east java in 2024, aged 18 years or older, and willing to participate in the study. exclusion criteria included inability to respond to the questionnaire due to physical or mental limitations. to enhance the representativeness, the sample distribution was proportionally drawn from each selected district. variables, instrument, and data collection this study examined two primary variables, namely self-efficacy and medication adherence among patients with tuberculosis. two instruments were used for data collection: a questionnaire based on the guide for constructing self-efficacy scale, comprising 15 questions to assess self-efficacy, and the morisky medication adherence scale (mmas-8), which consists of 8 questions to evaluate medication adherence. additionally, secondary data from medical records were used to examine the continuity of tuberculosis treatment. the researchers distributed questionnaires to participants in the selected districts. after the data collection and editing process was conducted, the obtained data and answers were selected and checked. validity and reliability tests were conducted, with the self-efficacy scale demonstrating good internal consistency with a cronbach’s alpha of 0.85 and the mmas-8 with a cronbach’s alpha of 0.82. data analysis data analysis was performed using spss software version 25 for windows. the analysis included frequency distribution, percentage calculation, and spearman’s rank correlation test with a significance level of 0.05. spearman’s rank correlation test was used to measure the relationship between self-efficacy, medication adherence, and continuity of care. this test was chosen because the research variables were ordinal and non-normally distributed. another justification for selecting this test is its ability to capture the strength and direction of the relationship between independent and dependent variables. results this study included 6,792 patients with tuberculosis. the results showed that 4,775 (70.3%) patients had high self-efficacy, while 2,017 had low self-efficacy. regarding medication adherence, 4,075 (60%) patients demonstrated high adherence, whereas 2,719 (40%) showed low adherence. the spearman’s rank correlation test yielded an asymp sig. (2-tailed) value of 0.000 and a correlation coefficient of 0.936, indicating a very strong correlation between the variables. a correlation coefficient of 0.936 emphasizes a strong relationship between self-efficacy and medication adherence (table 1). this highlights the potential of interventions designed to enhance self-efficacy, thereby improving treatment adherence and outcomes. the high percentage of patients with high self-efficacy (70.3%) was a positive finding, indicating that many patients had confidence in their ability to manage their condition. however, most patients with low medication adherence (40%) highlighted the need for interventions to address this problem. the demographic profile of patients with tb reveals notable pathways of change, part ii [page 30] [healthcare in low-resource settings 2025;13(s2):13571] trends based on recent data from east java, indonesia. the majority of tuberculosis cases were found in the productive age group of 19-59 years (70.3%), followed by a smaller percentage in individuals aged 60 years and older (22.5%), and a minor proportion in those under 19 years (7.2%). the gender distribution showed a higher prevalence in males, with the majority of cases occurring in this group (53.77%) than in females (46.3%). nearly half of the respondents possessed primary school education (42.7%), approximately one-third had junior high school education (28.3%), a minor percentage completed senior high school (22.5%), and a small fraction (6.5%) attained a university degree (table 2). discussion self-efficacy plays a crucial role in treatment adherence and overall management of tuberculosis (tb). recent studies have shown that patients with tb who have higher levels of self-efficacy tend to have better treatment outcomes and a higher quality of life.1,8,18 the concept of self-efficacy in tb patients encompasses their belief in their ability to follow treatment protocols, manage symptoms, and prevent disease transmission.1,16,19,20 this psychological construct is particularly important given the long duration of tb treatment, which typically lasts 6-9 months. patients with strong self-efficacy are better equipped to overcome the challenges associated with prolonged treatment, including potential side effects and the need for lifestyle improvements.1,21,22 self-efficacy in tb patients is not static but can be enhanced through targeted interventions. health education programs, counseling sessions, and peer support groups have been shown to improve self-efficacy levels among tb patients.23,24 these interventions help patients develop a more positive outlook on their treatment journey and increase their confidence in managing their condition. however, it is important to note that self-efficacy can be influenced by various factors, including socioeconomic status, education level, and cultural beliefs. a comprehensive approach that addresses these underlying factors is necessary to effectively boost self-efficacy in tb patients. future research should focus on developing tailored interventions that consider these diverse influences on self-efficacy.7,25 medication adherence is a critical factor in the successful treatment of tuberculosis. recent evidence indicates that adherence strongly influences therapy outcomes and the risk of developing drug-resistant tb. a meta-analysis of three phase iii trials found that non-adherence was the single most potent factor associated with unfavorable treatment outcomes, with adjusted hazard ratios of 5.7 for patients who missed 10% or more of prescribed doses. the challenges of maintaining high levels of medication adherence in tb treatment are complex. factors such as the long duration of treatment, potential side effects, and socioeconomic barriers can all contribute to non-adherence. recent technological advancements have introduced new methods for monitoring and improving medication adherence.7,26 electronic monitoring devices, mobile health applications, and directly observed therapy (dot) using video technology are being increasingly utilized to support patients in maintaining adherence. these tools not only help in tracking adherence but also provide real-time support and reminders to patients. despite these advancements, there is a growing recognition that a one-size-fits-all approach to medication adherence is insufficient.19,27 tailored interventions that consider individual patient needs, cultural contexts, and social support systems are necessary to achieve optimal adherence rates. future research should focus on developing and evaluating personalized adherence interventions that can be integrated into routine tb care.28,29 the results show that the majority of tuberculosis patients have high self-efficacy, while a significant portion experiences low selfefficacy. similarly, most patients exhibit high medication adherence, but a notable percentage struggles with low adherence. this low adherence is associated with treatment failure and poor quality of life. low self-efficacy and poor medication adherence are closely linked to a person’s physiological condition and mental state. when physical health deteriorates or when an individual experiences stress, emotional disturbances, or misconceptions about their medical condition, self-efficacy can decline. negative and pessimistic self-evaluations also contribute to reduced self-efficacy. for tuberculosis patients, having a strong sense of self-efficacy is essential, as it fosters the self-confidence needed to stay motivated and committed to completing the treatment. self-efficacy reflects an individual’s belief in their ability to overcome challenges, which significantly influences both their thought processes and behaviors.1,30,31 the continuity of treatment is essential for achieving a cure and preventing the development of drug-resistant tb. recent studies have emphasized the importance of uninterrupted therapy in pathways of change, part ii table 1. crosstabulation of self-efficacy, medication adherence, and continuity of tuberculosis treatment. characteristic continuity treatment total yes no self-efficacy low 1432 585 2017 high 3769 1006 4775 medication adherence low 1870 849 2719 high 2472 1601 4073 spearman’s test result: 0.000 table 2. characteristics of participants. characteristic number % age 18 years 489 7.2 19-44 years 2038 30 45-59 years 2738 40.3 ≥60 years 1529 22.5 gender male 3653 53.7 female 3139 46.3 education elementary school 2899 42.7 junior high school 1920 28.3 senior high school 1523 22.5 undergraduate 442 6.5 self-efficacy low 2017 30 high 4775 70 medication adherence low 2717 40 high 4075 60 continuity treatment yes 4822 71 no 1970 29 [healthcare in low-resource settings 2025;13(s2):13571] [page 31] improving patient outcomes and reducing the risk of disease transmission. the treatment interruptions, even if brief, can significantly impact the effectiveness of tb therapy. factors affecting treatment continuity are complex and often interrelated. these may include healthcare system factors (such as drug availability and accessibility of healthcare services), patient-related factors (including side effects and competing life priorities), and social determinants of health. addressing these multifaceted challenges requires a comprehensive approach that goes beyond simply focusing on individual patient behavior. innovative approaches to ensure treatment continuity have emerged in recent years. these include the use of community-based dot, patient support groups, and integrated care models that address both tb and other health needs. such approaches have shown promise in improving treatment continuity, particularly in resource-limited settings.32,33 this study revealed a strong positive correlation between selfefficacy and medication adherence among patients with tb in east java, indonesia. however, it is crucial to consider potential confounding variables and biases that might have influenced these findings among other socioeconomic, educational, cultural, and health-service systems. conclusions this study confirms a significant relationship between selfefficacy, medication adherence, and tb treatment continuity in east java. despite high self-efficacy, low adherence highlights the need for integrated medical and psychological interventions. a holistic approach can enhance patient confidence, improve outcomes, and reduce the risk of infections. policymakers and healthcare providers should prioritize strategies that strengthen adherence and treatment success. references 1. marselina s, kusmiran e, sutisna i. the relationship between self efficacy and medication compliance in tuberculosis patient-s at garuda health center in bandung city in 2023. indones j community heal nurs 2024;9:67-72. 2. marin pm, munyeme m, kankya c, et al. medication nonadherence and associated factors in patients with tuberculosis in wau, south sudan: a crosssectional study using the world health organization multidimensional adherence model. arch public heal 2024;82:1-10. 3. areas lisboa netto t, diniz bd, odutola p, et al. videoobserved therapy (vot) vs directly observed therapy (dot) for tuberculosis treatment: a systematic review on adherence, cost of treatment observation, time spent observing treatment and patient satisfaction. plos negl trop dis 2024;18: e0012565. 4. lim rk, semitala fc, atuhumuza e, et al. patient choice improves self-efficacy and intention to complete tuberculosis preventive therapy in a routine hiv program setting in uganda. plos one 2021;16:1-6. 5. ju lh, jiyoung p. self-care efficacy and health-related quality of life among patients on primary treatment for pulmonary tuberculosis: the mediating effects of self-care performance. korean j adult nurs 2020;32:305-14. 6. deshmukh af, deshmukh j, gode y, et al. assess the effectiveness of an inquiry based learning method in microbiology for undergraduate medical students. e3s web conf 2024;491. 7. alves ym, berra tz, de jezus sv, et al. adherence to shortduration treatment (3hp) for latent tuberculosis among international migrants in manaus, amazonas: evaluation of the efficacy of different treatment modalities. microorganisms 2024;12. 8. lienhardt c, dooley ke, nahid p, et al. target regimen profiles for tuberculosis treatment. bull world health organ 2024;102:600-7. 9. so mw, kim ar, lee sg. drug persistence and incidence of active tuberculosis of tumor necrosis factor alpha inhibitors versus tocilizumab as the first-line biological treatment in patients with rheumatoid arthritis: a nationwide populationbased retrospective cohort analysis. rheumatol ther 2024;11:881-95. 10. sodhi r, vatsyayan v, panibatla v, et al. impact of a pilot mhealth intervention on treatment outcomes of tb patients seeking care in the private sector using propensity scores matching-evidence collated from new delhi, india. plos digit health 2024;3:e0000421. 11. xia t, chen j, rui j, et al. what affected chinese parents’ decisions about tuberculosis (tb) treatment: implications based on a cross-sectional survey. plos one 2021;16:1-11. 12. leyto sm, digesa le, lakew s, et al. tuberculosis patients’ satisfaction with directly observed treatment short course strategy and associated factors in southern ethiopia: a mixed method study. bmc public health 2024;24:2452. 13. anindhita m, haniifah m, putri amn, et al. community-based psychosocial support interventions to reduce stigma and improve mental health of people with infectious diseases: a scoping review. infect dis poverty 2024;13:1-17. 14. aryantiningsih ds, jalinus n, rosalina l. edutb as an effort to improve tuberculosis treatment adherence. univers j public heal 2024;12:441-59. 15. awaluddin sm, ismail n, yasin sm, et al. parents’ experiences and perspectives toward tuberculosis treatment success among children in malaysia: a qualitative study. front public heal 2020;8:1-8. 16. islam f, ahmad h, nurbaya, et al. factors affecting treatment adherence among patients with tuberculosis in indonesia: literature review. j public heal pharm 2024;4:28-37. 17. mukooza e, schausberger b, mmema n, et al. understanding the role of video direct observed therapy for patients on an oral short-course regimen for multi-drug resistant tuberculosis: findings from a qualitative study in eswatini. bmc infect dis 2024;24:829. 18. arthur k, christofides n, nelson g. development of a preadolescent inter-generational intervention to address hiv and obesity using intervention mapping. health educ j 2020;79:932-47. 19. parwati nm, bakta im, januraga pp, wirawan ima. a health belief model-based motivational interviewing for medication adherence and treatment success in pulmonary tuberculosis patients. int j environ res public health 2021;18:13238. 20. ro’isah, anies, sakundarno m, jazuli n. tb community empowerment model instruments in finding tuberculosis (tb) suspects. bali med j 2022;11:551-4. 21. joshi b, de lima yv, massom dm, et al. acceptability of decentralizing childhood tuberculosis diagnosis in low-income countries with high tuberculosis incidence: experiences and perceptions from health care workers in sub-saharan africa and south-east asia. plos glob public heal 2023;3:1-24. 22. schaaf hs, hughes j. current treatment of drug-resistant pathways of change, part ii [page 32] [healthcare in low-resource settings 2025;13(s2):13571] tuberculosis in children. indian j pediatr 2024;91:806-16. 23. fuadiati ll, sukartini t, makhfudli, et al. development of an eka application to help tuberculosis patients improve medication adherence and self efficacy. int j public heal sci 2024;13:76-86. 24. matos vc, torres ts, luz pm. adherence to antiretroviral therapy among cisgender gay, bisexual and other men who have sex with men in brazil: evaluating the role of hiv-related stigma dimensions. plos one 2024;19:1-20. 25. khodaveisi m, fallah sv, amini r, tapak l. effect of education based on the health belief model on treatment adherence in patients with heart valve replacement surgery. j educ community heal 2023;10:35-42. 26. alemu gg, tesfie tk, yayeh at, et al. incidence of anaemia and its predictors among hiv-infected children receiving highly active antiretroviral treatment in north-west ethiopia: a multicentre retrospective follow-up study. bmj open 2024;14:e083939. 27. sofiana l, ayu sm, wardani y, et al. risk factors of quality of life among tuberculosis patients. int j public heal sci 2022;11:756-62. 28. gebremariam rb, wolde m, beyene a. determinants of adherence to anti-tb treatment and associated factors among adult tb patients in gondar city administration, northwest, ethiopia: based on health belief model perspective. j heal popul nutr 2021;40:1-10. 29. girma s, agenagnew l, beressa g, tesfaye y, alenko a. risk perception and precautionary health behavior toward covid19 among health professionals working in selected public university hospitals in ethiopia. plos one 2020;15:1-9. 30. tegegnework az, aemiro mt, bilchut ah, et al. completion of tuberculosis preventive therapy and associated factors among clients on antiretroviral therapy at debre berhan town health facilities, north shoa zone, ethiopia. aids res ther 2024;21:1-5. 31. phadoongmai m, jariya w. tuberculosis preventive behaviors and their determining factors among household contacts of tuberculosis patients in thailand: a cross-sectional study. open public health j 2024;17:1-10. 32. moonsarn s, kasetjaroen y, bettex-baars am, phanumartwiwath a. a communication-based intervention study for reducing stigma and discrimination against tuberculosis among thai high-school students. int j environ res public health 2023;20. 33. malini h, huriani e, lenggogeni dp, herlina s. health education on multidrug-resistant tuberculosis prevention among tuberculosis patients. int j public heal sci 2021;10:27-32. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13571] [page 33] hrev_master healthcare in low-resource settings 2024; volume 12:11984 the impact of the le-diabet application on self-efficacy and blood glucose levels in diabetes mellitus patients lina erlina,1 widi hastuti2 1department of nursing, politeknik kesehatan kementerian kesehatan bandung; 2department of nutrition, politeknik kesehatan kementerian kesehatan bandung, indonesia abstract le-diabet is an android mobile application developed for diabetes management whose effectiveness has remained unknown. this research aimed to investigate its impact on self-efficacy and blood glucose levels in patients with diabetes. employing a quasiexperimental approach, the study utilized a pretest and posttest control group design. the sample included 28 respondents in the control group and 34 in the intervention group, selected through purposive sampling based on criteria such as diagnosed diabetes, smartphone usage, and 6 weeks of using the le-diabet application. self-efficacy was measured using the diabetes management self-efficacy scale, while blood glucose levels were monitored with a glucometer. data analysis involved paired and unpaired ttests. the results revealed a significant increase in self-efficacy scores by 3.1 points [p=0.000, 95% confidence interval (ci) = 6.006 to -1.876] in the intervention group, whereas the control group experienced a decrease of 1.9 points. both groups exhibited an increase in blood glucose levels, with a significant rise of 35.6 mg/dl (p=0.035, 95% ci = -68.578 to -2.636) in the control group and a non-significant increase of 3.59 mg/dl (p=0.076, 95% ci = -22.759 to 15.582) in the intervention group. the research concludes that the use of the le-diabet application enhances self-efficacy and maintains blood glucose level stability; however, it has not shown an impact on metabolic syndrome indicators in diabetic patients. further research is needed, utilizing a larger and more diverse sample from various age groups and extending the duration of the study to evaluate the long-term impact of the applied intervention. introduction the prevalence of diabetes mellitus in indonesia is estimated to continue to increase both at the national and global levels.1 the world health organization estimates that by 2030 the number of diabetes sufferers in indonesia will increase threefold since 2000. in 2000, there were around 8.4 million diabetes sufferers, while in 2030, the estimate will reach 21.3 million people.2 this prediction shows a significant upward trend. the results of basic health research in 2018 show that the prevalence of diabetes in indonesia reached 8.5%.3,4 this shows that more than 8% of indonesia’s population suffers from diabetes. this data highlights the importance of efforts to prevent and manage diabetes in indonesia. the indonesian endocrinology association states that there are five pillars of diabetes management, namely education, diet, physical activity, medication, and blood sugar monitoring.2 the five pillars of diabetes management cannot be separated because they are continuous with one another. of the five pillars, education is the key to the success of the other four pillars. insufficient education will result in a lack of knowledge, thereby triggering a high prevalence of diabetes and high complications due to diabetes itself.5,6 diabetes is a chronic disease that needs to be controlled throughout life, so the patient’s role in managing the disease is very important.7-9 the patients’ ability to control and reduce the impact of the disease they suffer from affects the process and results of diabetes management.10-12 this ability is known as diabetes self-care management, which can help patients control their blood sugar, thereby reducing the risk of complications.13 selfcare management can prevent morbidity, long-term complications and even death.14 correspondence: lina erlina, department of nursing, politeknik kesehatan kementerian kesehatan bandung, bandung, indonesia. e-mail: linahiar2@gmail.com key words: blood glucose, le-diabet, self-efficacy. contributions: le, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing original draft, review and editing; wh, conceptualization, resources, supervision, and writing review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission, politeknik kesehatan kemenkes bandung, indonesia with ethics approval number no. 44/kepk/ec/iv/2023. during the study, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 15 october 2023. accepted: 16 may 2024. early access: 1 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11984 doi:10.4081/hls.2024.11984 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11984] [page 507] non -co mmerc ial us e o nly many ways can be used to provide education to patients and families regarding diabetes and self-care management, namely by utilizing digital information technology, which is currently continuing to develop.15-17 there are 90.54% of households in indonesia that use cellular telephones.18,19 this allows cellular phones, which are now better known as smartphones, to be used as an educational medium for diabetes sufferers.20 there are several smartphone software that can be used as a health education medium, such as websites and mobile applications. several studies on mobile applications have been carried out. the research results stated that the e-diary mobile application was effective for use as an educational medium in increasing diabetes sufferers’ diet compliance. the results of the study showed that there was an increase in the average diet compliance of diabetes patients by 0.80. the results of the wilcoxon rank test analysis obtained a p-value of 0.006. this shows that implementing the mobile e-diary application is meaningful and significantly effective in increasing dietary compliance in diabetes mellitus patients.20 this is in line with research results that state that education based on the mobile application “teman diabetes” has been proven to be effective and has a clinically significant positive effect on the knowledge and attitudes of diabetes sufferers.21 the le-diabet application, the latest android-based innovation developed by researchers, stands out as distinctive software with its unique features. integrated with a comprehensive diabetes management concept, le-diabet comprises five main pillars: education, dietary patterns, physical activity, self-blood glucose monitoring, and diabetes therapy. the education provided by le-diabet includes up-to-date information on diabetes and its management, directly linked to the website of the ministry of health of the republic of indonesia. designed with attractive and user-friendly features, the application facilitates ease of operation for patients. users can input their current data, and le-diabet provides relevant recommendations, covering aspects such as dietary needs with sample menus, physical activity, healthcare management, and required therapies.22 le-diabet also offers statistical features to monitor trends in examination results, including blood glucose levels, glycated hemoglobin (hba1c), blood pressure, cholesterol, and other examinations. with its alarm features, le-diabet assists users in remembering medication, appointment times, and other necessary tasks. with le-diabet, users can independently monitor their conditions, receive recommendations tailored to their health status, and acquire in-depth knowledge about diabetes.22 education through le-diabet is expected to enhance the selfefficacy of patients, aiding in achieving optimal glucose control. however, the effectiveness of implementing le-diabet in diabetes patients still requires further investigation. therefore, this research aimed to evaluate the extent to which le-diabet contributes to the improvement of self-efficacy and the management of blood glucose levels in diabetes patients. materials and methods research design this study employed a quasi-experimental method with a pretest and posttest control group design approach. in the pretest phase, before the intervention was implemented, both groups, namely the intervention group and the control group, underwent measurements of relevant variables to assess their initial conditions. subsequently, the intervention group received the intervention, while the control group did not undergo any intervention. the posttest phase was conducted on both groups after the intervention was completed to evaluate the impact of changes that may occur due to the intervention. study participants the total sample was 62 respondents, comprising 28 patients in the control group and 34 diabetes patients in the intervention group. sampling was taken using a purposive sampling technique with inclusion criteria: patients with a medical diagnosis of diabetes mellitus, owning and using a smartphone either alone or with their family, and willing to use the le-diabet application for 6 weeks. variable, instrument, and data collection the measured variables involved self-efficacy and blood glucose levels before and after intervention in both the control and intervention groups. additionally, other variables serving as indicators of metabolic syndrome are also measured, including systolic and diastolic blood pressure, blood cholesterol, uric acid, and the respondent’s body weight. all measurements were taken twice, both before and after the 6-week intervention period, in both the control and intervention groups. self-efficacy was assessed using the indonesian version of the diabetes management self-efficacy scale, comprising 20 items. the instrument employs a 4-point likert scale: very incapable = 1, incapable = 2, capable = 3, and very capable = 4. self-efficacy scores range from 20 to 60. the instrument’s validity was tested on 30 respondents, yielding a cronbach’s α value of 0.939 [95% confidence interval (ci)].23 blood glucose and metabolic syndrome indicator measurements are conducted using peripheral blood samples after patients have fasted for a minimum of 10 hours and only consumed water before the examination. the examination tools used have consistent brands and types for all respondents, and the results are presented in mg/dl. blood pressure is measured using an electric sphygmomanometer in mmhg, while respondents’ body weight is measured using an electric scale in kilograms (kg). all instruments have undergone a calibration process, including instrument calibration, results calibration, and battery calibration, performed at the laboratory of health polytechnic of the ministry of health in bandung, indonesia. data analysis univariate analysis was used to analyze respondent demographics, including age, gender, occupation, and nutritional status, which were presented in the frequency distribution table. bivariate analysis was used to determine the effect of the intervention and the differences between the control and intervention groups. before carrying out bivariate analysis, a data normality test was carried out, which resulted in normally distributed data. on this basis, the analysis was carried out using the paired and unpaired t-test. ethical clearance this research received ethical clearance from the health research ethics committee of politeknik kesehatan kemenkes bandung, indonesia, with approval number no. 44/kepk/ec/iv/2023. during the research, the researchers paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 508] [healthcare in low-resource settings 2024;12:11984] non -co mmerc ial us e o nly results the characteristics of respondents based on age, gender, occupation, and nutritional status are presented in table 1. the results from table 1 indicated that the majority of respondents in both groups were in the late-elderly age category (67.6%). most respondents were female (70.3%), the majority of whom were not employed (67.6%), and their nutritional status predominantly fell into the overweight and obese categories in both groups (53%). the effectiveness of the le-diabet application was measured against the respondents’ self-efficacy variables and blood glucose levels. metabolic syndrome indicators were also measured in this study, such as blood pressure, blood cholesterol, uric acid, and the respondent’s body weight, which were also analyzed considering that these factors are closely related to changes in the respondent’s blood glucose. all measurements were carried out twice with an interval of 6 weeks in both the control and intervention groups. the average measurement results preand post-intervention in the two groups can be seen in table 2. table 2 indicated that at pre-intervention, it was observed that among the seven variables investigated, only two exhibited a significant mean difference between the two groups: systolic blood pressure (p=0.015, 95% ci=3.030-27.129) and diastolic blood pressure (p=0.048, 95% ci=0.067-13.685). the remaining variables (self-efficacy, blood glucose, total cholesterol, respondents’ uric acid, and body weight) showed no significant mean difference between the two groups. however, this pattern changed in the postintervention data, which revealed alterations in the mean values of all variables in both groups. nevertheless, only three variables demonstrated significant differences between the two groups: selfefficacy (p=0.000, 95% ci= -8.179 -2.799), blood glucose (p=0.001, 95% ci=23.785-90.497), and systolic blood pressure (p=0.028, 95% ci=0.919-15.509), while the other variables showed no significant mean differences (p>0.05). the effectiveness of using the le-diabet application on diabetes management indicators, namely self-efficacy, blood glucose, blood pressure, cholesterol, uric acid, and respondents’ body weight, can be seen in table 3, which depicts the research findings, recording the average changes before and after the intervention in both groups for all variables. in the control group, there was a decrease in average self-efficacy by 1.9 post-intervention. meanwhile, the intervention group exhibited a significant increase in average self-efficacy by 3.1 after the intervention compared to before (p=0.000, 95% ci= -6.006 -1.876). the average blood glucose increased in both groups after the intervention. however, the increase in average blood glucose in the control group was significantly higher than in the intervention group. the control group experienced a significant increase in blood glucose by 35.6 mg/dl (p=0.035, 95% ci= -68.578 -2.636). meanwhile, the intervention group showed a stable increase in the average blood glucose, only by 3.59 mg/dl, and the statistical test indicated a non-significant increase (p=0.076, 95% ci= -22.759-15.582). table 3 also shows changes in metabolic syndrome indicators, such as systolic and diastolic blood pressure, which decreased in both groups after the intervention. other variables, like cholesterol, uric acid, and body weight, showed changes in averages in both groups, but these changes were not significant (p>0.05). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents. variables control group intervention group n=28 % n=34 % age early old age 6 16.6 9 24.3 late old age 22 59.5 25 67.6 gender man 5 13.5 8 21.6 woman 23 62.2 26 70.3 work work 3 10.7 9 24.3 does not work 25 89.3 25 67.6 nutritional status normal 12 42.8 16 47 overweight and obese 16 57.1 18 53 table 2. description of the mean self-efficacy, blood glucose, blood pressure, cholesterol, uric acid, and body weight of respondents in the control and intervention groups preand post-intervention variable intervention control group intervention group p 95% ci lower upper self-efficacy pre 45.286 44.941 0.871 -3.902 4.591 post 43.393 48.882 0.000* -8.179 -2.799 blood glucose pre 157.857 142.647 0.194 -7.999 38.420 post 193.464 136.324 0.001* 23.785 90.497 systolic blood pressure pre 151.786 136.706 0.015* 3.030 27.129 post 138.714 130,500 0.028* 0.919 15.509 diastolic blood pressure pre 92.464 85.588 0.048* 0.067 13.685 post 83.714 82.353 0.566 -3.352 6.074 total cholesterol pre 213.714 201.882 0.228 -7.599 31.263 post 222.250 208.147 0.091 -2.325 30.531 gout pre 5.879 6.359 0.309 -1.417 0.456 post 5.689 5.927 0.484 -0.911 0.436 weight pre 59.346 61.566 0.471 -8.344 3.904 post 58.705 61.146 0.435 -8.651 3.770 ci, confidence interval; *significant. [healthcare in low-resource settings 2024;12:11984] [page 509] non -co mmerc ial us e o nly discussion self-care management using digital information technology is currently in development. technological advances support the acceleration of increasing knowledge and disseminating information, especially regarding diabetes mellitus. cellular telephones, which nowadays have become a necessity in daily activities, can be used as an educational medium for diabetes patients.20 the results of the study showed that there was a significant increase in mean self-efficacy of 3.1 in the intervention group, whereas, in the control group, there was a decrease in self-efficacy. the research results show that using the le-diabet application can significantly increase respondents’ self-efficacy. the results of this study are in line with marbun et al. (2012), who state that smartphone applications can influence self-efficacy in diabetes patients so that applications can facilitate the process of self-management and treatment adherence and increase blood glucose control in diabetes patients.23 self-efficacy has a positive relationship with the selfcare of diabetes patients, and self-care is needed to maximize diabetes self-management.13 self-efficacy is a person’s belief in their ability to organize and carry out actions that support their health, which is very necessary for diabetes patients to increase their independence in managing their disease.24 blood glucose examination is the main indicator in diabetes management. blood glucose levels are important in monitoring the success of diabetes management. the results of the study showed that in both groups, the mean blood glucose of respondents was above normal both preand post-intervention. post-intervention blood glucose showed results that did not match expectations, in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 510] [healthcare in low-resource settings 2024;12:11984] table 3. effects of using the le-diabet application. variable mean standard deviation p 95% ci n lower upper self-efficacy control group pre 45.286 9.610 0.220 -1.203 4.988 28 post 43.393 4.954 intervention group pre 44.941 6.237 0.000* -6.006 -1.876 34 post 48.882 5.515 blood glucose control group pre 157.857 52.175 0.035* -68.578 -2.636 28 post 193.464 81.518 intervention group pre 142.647 34.811 0.706 -22.759 15.582 34 post 146.235 54.756 systolic blood pressure control group pre 151.786 23.776 0.008* 3.783 22.359 28 post 138.714 16.608 intervention group pre 136.706 23.464 0.142 -2.191 14.603 34 post 130,500 12.066 diastolic blood pressure control group pre 92.464 14.393 0.002* 3.474 14.026 28 post 83.714 10.359 intervention group pre 85.588 12.409 0.100 -0.656 7.126 34 post 82.353 8.198 total cholesterol control group pre 213.714 37.507 0.328 -26.132 9.060 28 post 222.250 33.861 intervention group pre 201.882 38.514 0.247 -17.082 4.553 34 post 208.147 30.741 gout control group pre 5.879 1.864 0.504 -0.385 0.763 28 post 5.689 1.409 intervention group pre 6.359 1.809 0.133 -0.138 1.003 34 post 5.927 1.242 weight control group pre 59.346 10.307 0.174 -0.302 1.584 28 post 58.705 11.095 intervention group pre 61.566 13.220 0.587 -1.138 1.979 34 post 61.146 12.978 ci, confidence interval; *significant. non -co mmerc ial us e o nly which the mean blood glucose level increased in both groups. in the control group, there was a significant mean increase of 35.6 mg/dl, and in the intervention group, blood glucose was relatively stable; there was a slight increase of 3.59 mg/dl but not significant. this shows that the le-diabet application can be used as a diabetes education medium to facilitate independent diabetes management so that respondents’ blood glucose control becomes better. the research results are in line with other research, which states that android-based applications increase knowledge about diabetes self-management so that they can help diabetes patients adhere to their therapy so that glycemic control becomes better.25 other metabolic syndrome indicators, such as blood pressure, total blood cholesterol, uric acid, and body weight, demonstrated non-significant changes. effective diabetes control is not only reflected in the stability of blood glucose levels but also in maintaining blood pressure, lipid profile, and body weight within the normal range according to predefined targets.2 although the research results indicate changes in intervention outcomes in both groups, these changes are not statistically significant. this finding suggests that the use of the le-diabet application has not yet yielded a significant impact on regulating metabolic syndrome indicators. long-term research is necessary to assess the intervention’s impact on metabolic syndrome as a long-term outcome. the respondents in this study were all elderly patients, most of whom were women; almost all of them did not work, and their nutritional status fell into the overweight and obese categories. apart from that, both respondents also had a mean of systolic and diastolic blood pressure that was higher than normal, a high mean of cholesterol, and a relatively high mean of uric acid. this data shows that respondents have high-risk factors, so efforts are needed to manage glycemic and metabolic control to avoid diabetes complications. therefore, it is important to increase knowledge and attitudes regarding diabetes, adopt a healthy lifestyle and balanced diet, exercise regularly, and avoid smoking to reduce the development of diabetes.2,26 this study has several limitations. the limited sample size, along with a focus on the elderly in sample selection, inhibits the generalization of results to a broader population. confounding variables such as lifestyle and adherence to medication need special attention to ensure more accurate results. additionally, the variability in the sample’s ability to use the le-diabet is also a crucial factor that needs to be considered. time constraints in the study also serve as a limiting factor in evaluating the long-term impact of application usage. therefore, this study emphasizes the importance of carefully addressing these factors to ensure more valid and applicable results. conclusions the study concludes that utilizing the le-diabet application in diabetic patients can enhance self-efficacy and help maintain stable blood glucose levels. however, the intervention did not significantly impact metabolic syndrome indicators. further research over an extended period is recommended to fully understand the intervention’s effects on these indicators. improving the research quality could involve using a larger and more diverse sample across different age groups. additionally, factors such as patients’ lifestyle and medication adherence should be considered in future research designs. proficiency in using the le-diabet application should also be taken into account, as it may influence intervention outcomes. overall, future research endeavors could offer a more comprehensive understanding of the long-term effects of this intervention. references 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990-2019: a systematic analysis for the global burden of disease study 2019. lancet glob health 2022;10:e1632-45. 2. soelistijo sa. pedoman pengelolaan dan pencegahan diabetes melitus tipe 2 dewasa di indonesia. available from: https://pbperkeni.or.id/wp-content/uploads/2021/06/pedomanpengelolaan-dm-tipe-2-dewasa-di-indonesia-ebookpdf.pdf. [material in indonesian]. 3. kemenkes ri. laporan nasional riset kesehatan dasar. available from: https://repository.badankebijakan.kemkes.go.id/id/eprint/3514 /1/laporan%20riskesdas%202018%20nasional.pdf. kementeri kesehat ri. published online 2018:1-582. 4. national institute for health research and development. riset kesehatan dasar. 2013. 5. hikmatul n, harmiadillah s, puspita t. lima pilar diabetes mellitus. rismedia pustaka indonesia. 2022. 6. arifin b, probandari a, purba akr, et al. ‘diabetes is a gift from god’ a qualitative study coping with diabetes distress by indonesian outpatients. qual life res 2020;29:109-25. 7. widyaningsih v, febrinasari rp, sari v, et al. potential and challenges for an integrated management of tuberculosis, diabetes mellitus, and hypertension: a scoping review protocol. plos one 2022;17:e0271323. 8. kusnanto k, pradipta ro, arifin h, et al. what i felt as a diabetes fatigue survivor: a phenomenology study. j diabetes metab disord 2022;21:1753-62. 9. joeliantina a, norontoko da, adinata aa, et al. self-care of chronic illness prevents the risk of diabetic foot ulcers in patients with diabetes: a cross-sectional study. j ners 2024;19:39-46. 10. handayanu ds, yudianto k, kurniawan t. perilaku self-management pasien diabetes melitus (dm) self-management behaviour of patient with diabetes mellitus (dm). padjadjaran nurs j 2013;1. doi:10.24198/jkp.v1i1.49. 11. setiyorini e, qomaruddin mb, wibisono s, et al. complementary and alternative medicine for glycemic control of diabetes mellitus: a systematic review. j public health res 2022;11: 22799036221106582. 12. estuningsih y, rochmah tn, andriani m, mahmudiono t. effect of self-regulated learning for improving dietary management and quality of life in patients with type-2 diabetes mellitus at dr. ramelan naval hospital, surabaya, indonesia. kesmas 2019;14:51-7. 13. sabil fa, kadar ks, sjattar el. faktor – faktor pendukung self care management diabetes mellitus tipe 2: a literature review. j keperawatan 2019;10:41-7. [article in indonesian]. 14. novianti d, indriyawati n, arif s. efektivitas diabetes self management education & community based interactive approach terhadap self care penderita diabetes mellitus. jnj 2019;3:1-10. 15. viandarisa n, priyono d, tanjungpura m, et al. penggunaan mobile health berbasis smartphone untuk meningkatkan self management pada pasien diabetes melitus tipe 2: literature review. j untan 2022;7:1-18. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11984] [page 511] non -co mmerc ial us e o nly 16. zainuddin, abdullah az, jafar n, et al. health literacy brisk walking exercise on clinical outcomes of blood sugar in patients with type 2 diabetes mellitus in indonesia. pharmacogn j 2023;15:433-8. 17. sukartini t, nursalam n, pradipta ro, ubudiyah m. potential methods to improve self-management in those with type 2 diabetes: a narrative review. int j endocrinol metab 2023;21:e119698. 18. badan pusat statistik. statistik telekomunikasi indonesia 2021. available from: https://www.bps.go.id/id/ publication/2022/09/07/bcc820e694c537ed3ec131b9/statistik-telekomunikasi-indonesia-2021.html. 19. ratnasari i, ngadiarti i, ahmad lf. application of diabetes self-management education and support in outpatients with type ii dm. media gizi indones 2022;17:43-50. 20. luawo hp, sjattar el, bahar b, et al. aplikasi e-diary dm sebagai alat monitoring manajemen selfcare pengelolaan diet pasien dm. nurscope 2019;5:32-8. 21. hasanah n, ikawati z, zainai za. the effectiveness of smartphone application-based education teman diabetes on clinical outcomes of type-2 diabetes mellitus patients. res j pharm technol 2021:14:3625-30. 22. erlina l. desain aplikasi le-diabet. poltekkes kemenkes bandung. 2023. 23. marbun as, siregar r, harefa k, et al. pengaruh diabetes self management education (dsme) berbasis aplikasi whatsapp terhadap self efficacy pada pasien dm tipe 2 di puskesmas hamparan perak. j mutiara ners 2021;4. 24. marleni l, mulkanaziman a. hubungan efikasi diri dengan kejadian komplikasi diabetes mellitus tipe 2. j keperawatan sriwij 2020;7:59-65. 25. oktovin o, unja ee, rachman a. systematic review: penggunaan smartphone untuk program management life style pasien diabetes melitus tipe 2. jksi 2018;3:1-10. 26. association american diabetes. guidelines ada j clin appl res educ diabetes care 2022;45. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 512] [healthcare in low-resource settings 2024;12:11984] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12402 analysis of the link between stress and cancer: implications for patient support liana spytska department of psychology and pedagogy, kyiv international university, ukraine abstract in a world where oncological diseases remain a serious problem for many people, the study of stress management and the provision of psychological support to prevent and treat oncological diseases are becoming increasingly relevant. the purpose of the article is to identify stress mechanisms that affect the human body and provoke the development of cancer. additionally, it seeks to investigate the global scope of the stress-cancer connection. the methods used in the study include generalisation, analysis, synthesis, and systematisation. the study found that chronic stress can affect the immune system, neurological activity, and other processes contributing to cancer development. in addition, the study has managed to shed light on the mechanisms of stress impact on oncology, including oxidative stress and replication stress, as stimuli that threaten the normal functioning of the human body. a support program for patients with oncological diseases was developed, which included assessment, psychoeducation, methods of stress reduction, and post-treatment support for patients with oncological diseases or those predisposed to them. the study found that the introduction of stress reduction programs for cancer patients is an important step in improving their well-being and treatment outcomes. introduction investigation of the impact of stress on the body and its association with cancer is important in understanding the causes and developing effective strategies for prevention and treatment. studying the link between stress and oncology on a global scale can help influence global factors, such as the social environment and economic conditions, to decrease the incidence of oncological diseases and enhance people’s quality of life. this paper aims to comprehend and establish the correlation between stress and the progression of oncological diseases, identify the mechanisms through which stress influences the human body, and determine the factors that enhance the development of cancer in stressful conditions. globally, there were an estimated 19.3 million new cancer cases and 10.0 million cancer deaths in 2020, with breast, lung, colorectal, and prostate cancers being the most common types worldwide.1 in the united states, around 1.9 million new cancer cases are expected in 2023, with an overall prevalence rate of around 542 cases per 100,000 people.2 for stress disorders, posttraumatic stress disorder (ptsd) affects around 3.5% of u.s. adults annually and has a global lifetime prevalence of around 1 in 13 people, while acute stress disorder prevalence is estimated at 6.3% following trauma exposure.3 adjustment disorders are quite common at 5-20% among general medical patients, and certain populations like military personnel and abuse survivors report much higher ptsd rates of 15% or higher.4 the substantial global burden of these conditions highlights the need for comprehensive prevention and treatment efforts. this issue was investigated by i.v. serhet,5 who noted that oncological disease affects the psychological state of the patient, which is associated with stress that arises during diagnosis, treatment, and even periods of remission. in people with cancer, this level of anxiety, classified into various types such as generalized anxiety disorder or situational anxiety, often triggers autonomic reactions that cause discomfort due to a lack of emotional perception skills and adaptation to them.6 makarova and chervonyi7 distinguished between different types of stress, in particular emotional and psychological. these concepts are characterised by a state of pronounced psycho-emotional experience of conflictual life situations that acutely or permanently limit the satisfaction of social or biological needs. miaskowski et al.8 observed high levels of stress and significant negative symptoms among cancer patients. the results show the importance of a more detailed study and coverage of the causes of stress among cancer patients, identifying the factors that cause its increase, developing effective strategies for psychological support, and minimising stress effects on these patients. chronic stress can significantly impact cancer development and progression through various mechanisms. as yan et al.9 noted, stress activates the classic neuroendocrine system, including the hypothalamic-pituitary-adrenal (hpa) axis and the sympathetic correspondence: liana spytska, department of psychology and pedagogy, kyiv international university, kyiv, ukraine. e-mail: spytska_l@ukr.net key words: negative emotions, psychosocial risk factors, psychotherapy, cancer, anxiety. conflict of interest: the author declares no potential conflict of interest. funding: none. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. received: 19 february 2024. accepted: 9 april 2024. early view: 27 may 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12402 doi:10.4081/hls.2024.12402 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12402] [page 13] non -co mmerc ial us e o nly nervous system (sns), leading to the production of stress hormones that can promote tumorigenesis and cancer development. additionally, chronic stress, according to lempesis et al.,10 can cause changes in immune function and inflammatory responses, affecting the body’s ability to combat cancer. the study by s.v. petrinović et al.11 showed that chronic stress influences tumour growth and metastasis by activating specific signalling pathways, such as the akt pathway in breast cancer and the stat3 pathway in lung cancer. furthermore, stress-related factors like catecholamines, glucocorticoids, and hormones like prolactin and oxytocin play roles in promoting cancer progression through various mechanisms. f. tausk12 adheres to the belief that chronic stress has a significant impact on the development, growth, and spread of cancer. this influence is determined by the activation of adrenergic (nervous system) and peptide (chemical signalling) pathways, as well as glucocorticosteroids (steroid hormones). the researcher claims that the stress response system, which was originally developed to help people avoid life-threatening situations, can turn into something life-threatening in itself. the study by dai et al.13 delves into the molecular mechanisms, primarily focusing on the activation of the hpa axis and the sns under the influence of chronic stress, which in turn leads to dysfunctions in brain regions such as the prefrontal cortex and hippocampus. stress hormones produced during this process promote tumour formation through dna damage, immune suppression, inflammation, and interaction with the tumour microenvironment.14 this study introduces a novel psychotherapy program tailored to cancer patients, addressing the psychological stress associated with the disease – a contribution that distinguishes it from existing literature. moreover, it underscores the need for further research into the molecular and biological mechanisms underlying the connection between stress and cancer, advocating for a deeper understanding of specific interaction pathways. thus, the aim of this research is to investigate the intricate connection between stress and cancer, recognizing stress as a significant factor affecting the human body’s physiological processes and its potential contribution to the development and progression of cancer. the task involves exploring the various mechanisms through which psychological stress influences cancer, such as oxidative stress and its impact on immune function, neurological activity, and endocrine regulation. additionally, the study endeavours to develop effective strategies for supporting cancer patients in managing stress, thereby improving their overall well-being and treatment outcomes. the significance of this research lies in its potential to inform cancer prevention, diagnosis, and treatment approaches, ultimately leading to better support for individuals affected by cancer. materials and methods the following methods were used to investigate the influence of stress and oncological diseases on the human body and their interrelation on a global scale: generalisation, analysis, synthesis, and systematisation. to search for literature on the topic, the authors used such platforms as scopus, web of science, and pubmed. the articles were searched using keywords such as “stress”, “cancer”, “cancer development”, “connection”, and, for a more extensive analysis, covered the time period from 2010 to 2024. the generalisation revealed the influence of psychological stress on the human body. based on this method, it was possible to establish a link between stress and cancer development and identify the reverse path of this link, in particular that the diagnosis of cancer can lead to significant psychological stress in patients. using generalisation, the sphere of influence and physiological response of the body to stressful situations were established. through the analytical method of research, it was possible to identify a wide range of effects of stress on physiological processes, especially on the immune system, neurological activity, and endocrine regulation. based on the analysis, the factors of influence and psychological stress that contribute to the development and progression of cancer were identified. the analysis has contributed to the argument for the necessity of developing strategies for preventing, diagnosing, and treating cancer patients that aim to reduce stress levels and enhance their psychological well-being. the analysis revealed that psychological stress affects the quality of life, mood, and social connections of cancer patients. a support program was created based on the results of the study, which included assessment, psychoeducation, and methods for reducing stress levels and maintaining emotional well-being. the analytical method has allowed the authors to obtain important conclusions and broaden their understanding of the connection between stress and oncology on a global scale. by synthesizing the data, a holistic comprehension of the impact of stress on cancer and human physiology at large was attained. this method allowed the combining of different aspects of cancer and stress on a global scale, revealing important connections between them. using systematisation, it was found that stress has a significant impact on the development of cancer in the human body. the systematisation revealed that stress contributes to the development of anxiety and other conditions that worsen the overall quality of life in cancer patients. the use of this method confirmed the significant physical impact of stress on the body in cancer. results oncological diseases, as a result of unpredictable and dangerous cell mutations in the body, are one of the most threatening problems in the modern world. the connection between stress and cancer and their impact on the human body is complex and multifaceted. stress, as a reaction of the body to danger, threat, or negative events, leads to the activation of physiological and psychological mechanisms.8 these mechanisms encompass processes within the body, such as the release of stress hormones like adrenaline and cortisol, increased heart rate, and changes in blood pressure. additionally, they include cognitive and emotional responses like heightened alertness, increased focus on potential threats, and feelings of anxiety or fear.12,15 in the case of prolonged or excessive stress, these mechanisms can become dysfunctional and contribute to the development or exacerbation of various diseases, including cancer. in addition to physiological mechanisms, stress can also affect a person’s lifestyle, which plays an important role in cancer development.16 negative habits associated with stress, such as smoking, excessive alcohol consumption, poor nutrition, and insufficient physical activity, are more common.17 high levels of stress in cancer patients are associated with an increased sense of pain in patients receiving chemotherapy.18 stress can deepen the perception of pain and reduce the effectiveness of its treatment, as cancer patients often experience the emotional distress that accompanies the disease, which can include fear, anxiety, and depression and negatively affect the quality of life.19 in addition to its detrimental effects on physical and mental health, stress can profoundly diminish the quality of life for cancer patients, manifesting in decreased energy, sleep disturbances, social and political factors affecting public health [page 14] [healthcare in low-resource settings 2024;12(s2):12402] non -co mmerc ial us e o nly mood alterations, and overall well-being deterioration.20 in this regard, cancer patients should use their internal reserves to adapt to new living conditions and maintain psychosocial resilience. people with cancer experience reduced adaptive capacity associated with the use of strategies such as denial, avoidance, and self-blame aimed at avoiding stressors. the appearance of anxiety associated with the current state and future prospects overloads the patient, which hinders their adaptation. therefore, the motivational and volitional components of the internal picture of cancer play a key role in shaping the overall perspective and approach of the patient to their disease. this component determines how the patient perceives their situation and how they will react to it in the future. the motivational and volitional components determine how the patient will direct their efforts and resources to fight the disease and build their life in the context of the disease. this element has the potential to influence the choice of treatment approaches, shape the planning and decision-making processes concerning the patient’s well-being, and impact the patient’s confidence and self-discipline. it is worth noting that stress can contribute to the development of oxidative stress, which, in turn, can have a negative impact on the body’s cells and contribute to the appearance of cancer. oxidative stress is an imbalance between the body’s production of free radicals and antioxidant defense mechanisms.21,22 elevated levels of oxidative stress can be a prognostic factor for radiation and carcinogenic risks.23 it is also worth paying attention to replication stress, which occurs during the process of dna replication and can play an important role in the development of cancer cells. a malfunction in the replication process can cause dna damage and the accumulation of genetic mutations that are the basis for the development of cancer. stressors such as chemicals, uv radiation, and infections can cause replication stress. this leads to increased activation of signalling pathways, such as the atr/chk1 pathway, designed to restore the replication process and prevent the accumulation of dna damage. however, if replication stress is excessive or prolonged, these defense mechanisms can be overloaded and lead to genetic damage and genome instability, which increases the development of cancer.24 the emotional component of the internal picture of cancer contains various emotions, but above all, the fear of death, pain, and a number of other negative feelings associated with cancer. cancer brings with it significant losses and changes in a person’s life, which cause emotional tension and instability. fear of the unknown, fear of possible complications, and concerns about the effectiveness of treatment affect the patient’s emotional state. this emotional component can have a significant impact on the patient’s psychological state, motivation, and ability to effectively interact with medical procedures and therapy. difficult life events, anxiety, depression, and a lack of perception of social support and survival strategies have a significant impact on the development of cancer. an increase in risk factors for stressful life events also affects other types of cancer, a decrease in the positive impact of treatment, and an increase in mortality. thus, psychosocial factors play an important role as risk factors for certain types of cancer.25 patients with high levels of stress experience poor health and are at an increased risk of complications. stress can affect the effectiveness of treatment, reducing the response to therapy and contributing to negative consequences.26 it is worth noting that stress management and psychological support can play an important role in improving the course of the disease and increasing the chances of recovery in cancer patients. the impact of stress on a person includes the physiological response of the body to stressful situations. stress activates the nervous system and affects the functioning of the body’s organs and systems, leading to changes in the cardiovascular system, hormonal regulation, immune system, and other physiological processes. in addition, stress can lead to a decrease in mood, feelings of anxiety and depression, increased irritability, problems with concentration, and a negative impact on mental health in general. it is necessary to identify ways to overcome stress, including various strategies such as social network support, physical activity, relaxation techniques, cognitive behavioural techniques, and other approaches to recognising stressful situations and responding to them in healthy ways.27 considering these aspects, a program of work by a psychotherapist was developed to reduce the symptoms of stress in a person who is ill or has a predisposition to cancer (table 1). the main goal of the program is to support the client, reduce stress levels, improve psychological well-being, and promote overall well-being. before using this programme, it is recommended to consult with a doctor or therapist who will be able to assess whether the program meets the patient’s individual needs and discuss the optimal number of meetings and the thematic focus of therapy. chronic stress can increase the production of stress hormones, such as cortisol and adrenaline, which can modulate the interplay between tumour and stromal cells, leading to the regulation of signalling pathways that impact cancer progression. this can result in increased tumour growth and metastasis, making cancer treatment less effective.28 stress can also affect the immune system, which plays a crucial role in cancer treatment. chronic stress can suppress the immune system, reducing the effectiveness of immunotherapy and other treatments that rely on the immune system to target cancer cells. discussion in the modern world, where new technologies and research are constantly developing, understanding complex issues related to human health remains one of the most important issues. among these problems, oncology is one of the most common and dangerous diseases that requires constant research and the search for effective approaches to treatment and prevention. in recent years, there has been a growing emphasis on researching the link between stress and oncology. stress, as a complex physiological and psychological phenomenon, has a significant impact on the functioning of the human body.29 its role in the development and spread of cancer and its impact on treatment outcomes have become the subject of increasingly detailed research in the scientific community. research in a global context confirms the connection between stress and cancer, drawing attention to the destructive effects of stress on the course of the disease.30 it is worth studying the specific positions and opinions of scientists regarding the connection between stress and oncology for a more detailed investigation of this area on a global scale. hoffman et al.31 considered the connection between stress and oncology from a socio-cognitive perspective. the influence of personal factors on stress, in relation to oncological diseases, is indeed significant and requires separate attention from specialists during the treatment of patients. finset et al.32 highlighted the influence of stress and oncology on communication between doctors and patients. researchers have found that cancer consultants who actively promote the expression of emotions by patients create a more receptive atmosphere for further disclosure of emotional signals and problems, including identifying signs of stress and anxi social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12402] [page 15] non -co mmerc ial us e o nly ety. based on the results of this study, emotional support and communication between doctors and patients in the oncological context are important aspects and can really contribute to improving the quality of treatment and the psychological state of cancer patients. singer et al.33 noted that emotional stress is more common in patients with head and neck tumours, which may be conditioned by the specifics of this form of cancer and its effect on important functions such as speech, swallowing, and appearance. the study highlighted the importance of psychosocial support for patients with head and neck cancer, as it can help manage emotional stress and improve patients’ overall health. consideration of the emotional factor when planning treatment and providing support to patients to improve their physical and psychological well-being is an essential element of the course of treatment for cancer patients, which is confirmed by the results of this study. j.d. hayes34 argued that stress can influence the development and spread of cancer by inducing oxidative stress in the body. scientists note that the effects of stress can increase the production of free radicals, which can lead to damage to cellular components and contribute to the development of cancer. comparing with this study, it is worth noting that stress and cancer have a rather strong connection, and oxidative stress can act as one of the mechanisms of this connection. in turn, eckerling et al.35 emphasised that stress can affect the development and progression of cancer through various mechanisms. researchers also emphasise the importance of considering individual responses to stress in cancer patients, since not all people respond to stress in the same way, and some may have a higher vulnerability to cancer development as a result of stress exposure. such factors as genetic predisposition and environmental condi social and political factors affecting public health [page 16] [healthcare in low-resource settings 2024;12(s2):12402] table 1. stress reduction program for individuals who have or are prone to oncological diseases. number of meetings subject content description on the specified topic 1-2 sessions initial assessment and medical history the first meeting is dedicated to collecting information about the client, their medical history, experience of stress and cancer development. the psychotherapist works to build trust and establish an emotional connection with the client. 2-3 sessions understanding stress and its impact on cancer meetings dedicated to understanding the mechanisms of stress and its impact on the body. the psychotherapist provides information about the physiological and psychological aspects of the stress response and its possible impact on the development of cancer. 3-5 sessions stress reduction techniques meetings are aimed at teaching the client various stress reduction techniques, such as relaxation techniques, breathing exercises, meditation, music therapy, or creative techniques. the psychotherapist helps the client choose the appropriate method and establish a regular practice. 3-5 sessions maintaining emotional well-being meetings are aimed at understanding and expressing emotions, especially fear, anxiety, and sadness. the psychotherapist provides support and assistance to the client to manage emotions, develop positive perception, and increase the level of satisfaction with life. 4-6 sessions cognitive behavioural approach meetings aim to explore and change negative thoughts and beliefs that can support stress and unhealthy practices. the psychotherapist works with the client to recognise and replace destructive thoughts and behavioural patterns with more positive and constructive ones. 2-4 sessions social support meetings aim to provide psychological support and understanding of the social context in which the client is situated. the therapist works with the client to attract support from family, friends, or support groups that can help in difficult life situations. 1-2 sessions creating an action plan a meeting during which the therapist helps the client develop an action plan to overcome stress and maintain psychological well-being. the plan may include regular stress management practices, maintaining a healthy lifestyle, connecting with supportive people, and seeking medical attention. 1 session evaluation and correction of the programme a meeting during which the therapist evaluates the effectiveness of the programme, monitors the client’s progress, and makes adjustments to the programme if necessary. the number of sessions post-treatment support meetings aimed at supporting the client after the end of the main treatment. can be individual and the therapist helps the client integrate the acquired skills and depends on the client’s strategies of psychological well-being into their daily life. needs and progress. 1 session final assessment and summary a meeting during which the therapist conducts a final assessment of the programme, summarises the client’s achievements, and provides recommendations for further self-support and psychological development. non -co mmerc ial us e o nly tions can also influence the link between stress and cancer. comparing the results with this study, it is worth noting that it is an individual approach to each patient that is one of the key elements of a well-coordinated course of treatment and stabilisation of the emotional sphere of a cancer patient. coyne et al.36 argued that various stress factors, such as psychological stress, emotional stress, social connections, and stress associated with specific events (such as cancer diagnosis and treatment), can have an impact on cancer development, disease progression, and survival of cancer patients, particularly psychological and emotional stress. instead, social support has proven to be a protective factor that reduces the impact of stress on cancer. compared to this study, it is worth noting that stress can actually increase the development of and complicate cancer in the human body. ebstein et al.,37 who have studied the effects of stress on pancreatic cancer, note that stress is important in the lives of patients with pancreatic cancer, as it is the experience of unpleasant emotional or environmental demands related to age, as well as physical, social, psychological, or spiritual events reported by patients during the diagnosis, treatment, and follow-up of the disease. the researchers also point to a possible link between psychological stress and cancer mortality in a particular location. this means, according to the researchers, that patients with high levels of stress may have a poorer predicted life expectancy or significantly more complex consequences from the disease. comparing the results of this study, it is worth noting that psychological stress in patients with existing cancer has a significant impact on the course of the disease and can lead to negative consequences. prevention of distress during cancer treatment requires considering the psychological state of patients and providing support and psychological assistance, which can contribute to improving their general condition, better treatment, and better results.38 in turn, sosa et al.39 reported that oxidative stress, which occurs due to an incorrect balance between the development of free radicals and the antioxidant system of the body, can contribute to dna damage, damage to cellular structures, and disruption of cellular signalling pathways, which can lead to the development of cancer pathologies. thus, according to researchers, stress, including oxidative stress, is a factor that contributes to the development of cancer. comparing with this study, it is necessary to note the impact of this type of stress on the general psychological state of cancer patients, since physical and psychological indicators exacerbate destructive emotions, intensifying anxiety and depression in patients. the results of global research, analysis of data, and results are important in understanding the connection between stress and cancer. the constant development of scientific research and methodological approaches provides a unique opportunity to explore the depth of the problem and the impact of stress on oncological processes. understanding this connection on a global scale will allow for developing new prevention strategies, improving diagnosis and treatment, and improving the quality of life of patients facing stress and cancer. studying the research on the correlation between stress and oncology contributes to the further advancement of effective approaches in the sphere of human health preservation globally. conclusions stress is a serious stimulus for the human body and can pose threats to its normal functioning on a global scale. chronic stress can affect the immune system, neurological activity, endocrine regulation, and other physiological processes that can contribute to the development of a variety of diseases, including cancer. however, the diagnosis of cancer itself can lead to significant psychological stress in patients. such stress can affect the quality of life, mood, social connections, and treatment outcomes. understanding this link between stress and cancer is important for developing strategies for cancer prevention, diagnosis, and treatment. as a result of the study, a wide range of effects of stress on the human body were investigated on a global scale. it has been found that psychological stress can be a factor that contributes to the development and progress of cancer. the study highlights various mechanisms, including oxidative stress, replication stress, and the overall impact of emotional state on the course of the disease. the authors of this study managed to develop a strategy to support patients with cancer in the context of stress, in particular a psychotherapy program for working with clients who have or are prone to cancer. the program included assessment and collection of medical histories, psychoeducation of clients about the impact of stress on oncological diseases, methods of stress reduction, cognitive and behavioural approaches, and action plan development. emotional well-being support and post-treatment support were also included in the program. to expand their understanding of the link between stress and cancer, future researchers should focus on studying the molecular and biological mechanisms underlying this connection. identifying specific interaction pathways will help clarify the exact mechanisms behind stress’s influence on the development and progression of cancer. these studies will help to better understand the link between stress and cancer and develop strategies to improve the diagnosis, treatment, and support of cancer patients. references 1. sung h, ferlay j, siegel rl, et al. global cancer statistics 2020: globocan estimates of incidence and mortality worldwide for 36 cancers in 185 countries. ca: a cancer j clin 2021;71:209-49. 2. binnur dönmez b. who warns global cancer burden growing, with 77% spike in cases expected by 2050. 2024. available from: https://www.aa.com.tr/en/health/who-warns-global-cancer-burden-growing-with-77-spike-in-cases-expected-by2050/3125409. 3. romash i, neyko v, romash i, et al. post-traumatic stress disorder as a nosological unit: difficulties of the past and challenges of the future. scientific studios on social and political psychology. 2022;50:53. 4. sathishkumar k, chaturvedi m, das p, et al. cancer incidence estimates for 2022 & projection for 2025: result from national cancer registry programme, india. indian j med res. 2022;156:598-607. 5. serhet i. “internal picture” of the disease and its influence on psychological adaptation to stress during cancer. in: virtual man: new horizons 2020;(pp. 75-8). cpm “asf”; montreal, canada. 6. hirna ha, maltsev dv, natrus lv, et al. study of the immunomodulating influence of preparation alpha/betadefensins on chemo/radiotherapy of patients with oral and oropharyngeal cancer. fiziologichnyi zh. 2021;67:86-96. 7. makarova op, chervonyi pd. the essence of stress and its effect on the human body in extreme conditions. habitus 2023;46:222-6. 8. miaskowski c, paul s, snowberg k, et al. stress and symptom social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12402] [page 17] non -co mmerc ial us e o nly burden in oncology patients during the covid-19 pandemic. j pain symptom manage 2020;60:25-34. 9. yan j, chen y, luo m, et al. chronic stress in solid tumor development: from mechanisms to interventions. j biomed sci. 2023;30:8. 10. lempesis ig, georgakopoulou ve, papalexis p, et al. role of stress in the pathogenesis of cancer (review). int j oncol 2023;63:124. 11. petrinović sv, milošević ms, marković d, et al. interplay between stress and cancer – a focus on inflammation. front physiol 2023;14;1119095. 12. tausk f. psychoneuro-oncology: how chronic stress grows cancer. clinic dermatol 2023;41:95-104. 13. dai s, mo y, wang y, et al. chronic stress promotes cancer development. front oncol. 2020;10:1492. 14. boichuk oh, dorofeieva us, kolomiichenko tv. hormonal and genetic causes of poor response to controlled ovarian stimulation in women of late reproductive age. reprod. endocrinol. 2022;66:62-7. 15. messina a, mccormick lm, paradiso s. wernicke-korsakoff syndrome and dementia. in: diet and nutrition in dementia and cognitive decline 2015;(pp. 167-176). elsevier; amsterdam, the netherlands. 16. mashudi s, sansuwito tb, purwaningroom dl, et al. occupational balance improves subjective health and quality of life family with mental health disorders. j intel disability – diagn treat. 2022;10:232-7. 17. langford d, eaton l, kober k, et al. a high stress profile is associated with severe pain in oncology patients receiving chemotherapy. euro j oncol nurs 2022;58:102135. 18. maslak k, favara-scacco c, barchitta m, et al. general anesthesia, conscious sedation, or nothing: decision-making by children during painful procedures. pediatr blood cancer. 2019;66:e27600 19. duzhych nv, yeher oy, synenko my, et al. influence of emotional intelligence on the nurse efficiency. bulletin of medical and biological research. 2023;15:38-43. 20. taylor s, harley c, campbell l, et al. discussion of emotional and social impact of cancer during outpatient oncology consultations. psycho-oncol 2011;20:242-51. 21. salyha n. regulation of oxidative stress and lipid peroxidation induced by epinephrine: the corrective role of l-glutamic acid. international journal of medicine and medical research. 2023;9:32-8. 22. ilderbayev o, okassova a, rakhyzhanova s, et al. the levels of oxidative stress in a combination of stress factors. j med life. 2022;:927-31. 23. druzhyna m, domina e, makovetska l. metabolites of oxidative stress as predictors of the radiation and carcinogenic risks. oncol 2019;21:170-5. 24. gaillard h, garcía-muse t, aguilera a. replication stress and cancer. nat rev cancer 2015;15:276-89. 25. kruk j, aboul-enein b, bernstein j, gronostaj m. psychological stress and cellular aging in cancer: a meta-analysis. oxid med cell longevity 2019;2019:1270397. 26. gold j, douglas m, thomas m, et al. the relationship between posttraumatic stress disorder, mood states, functional status, and quality of life in oncology outpatients. j pain symptom manage 2012;44:520-31. 27. khupavtseva n. the impact of stress on the human body and ways to overcome it. psych real prosp 2016;7:224-8. 28. liu y, tian s, ning b, huang t, li y, wei y. stress and cancer: the mechanisms of immune dysregulation and management. front immunol 2022;13:1032294. 29. spytska l. the most common mental disorders in young people and middle-aged people in the modern world. sci bull mukachevo state univ. ser pedag psychol 2023;9:9-17. 30. abate m, citro m, caputo m, pisanti s, martinelli r. psychological stress and cancer: new evidence of an increasingly strong link. transl med unisa 2020;23:53-7. 31. hoffman m, lent r, raque-bogdan t. social cognitive perspective on coping with cancer: theory, research, and intervention. counsel psycho 2013;41:240-67. 32. finset a, heyn l, ruland c. patterns in clinicians’ responses to patient emotion in cancer care. patient educ counsel 2013;93:80-5. 33. singer s, krauß o, keszte j, et al. predictors of emotional distress in patients with head and neck cancer. head neck 2012;34:180-7. 34. hayes j, dinkova-kostova a, tew k. oxidative stress in cancer. cancer cell 2020;38:167-97. 35. eckerling a, ricon-becker i, sorski l, et al. stress and cancer: mechanisms, significance and future directions. nat rev cancer 2021;21:767-85. 36. coyne j, ranchor a, palmer s. meta-analysis of stress-related factors in cancer. nat rev clinic oncol 2010;7:1-2. 37. ebstein a, joseph s, hernandez m. psychological stress and pancreatic cancer patients: a qualitative systematic review protocol. jbi evidence synth 2020;18:576-82. 38. messina a, fogliani am. valproate in conversion disorder: a case report. case rep med. 2010;2010:205702. 39. sosa v, moliné t, somoza r, et al. oxidative stress and cancer: an overview. ageing res rev 2013;12:376-90. social and political factors affecting public health [page 18] [healthcare in low-resource settings 2024;12(s2):12402] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11778 effect of using cassava and glycerol as food storage on the quality of bioplastic packaged food yosephina ardiani septiati, mimin karmini department of environmental health, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract food packaging today often involves the migration of monomer substances from petroleum-based plastics into the food. this study aimed to determine the effects of storing food in bioplastic on moisture content and peroxide levels. the study design employed a post-test experimental design with a control group. dodol samples were selected for this study using a simple random sampling method. the bioplastics used were made from cassava peel starch, and the food storage conditions included temperaturehumidity variations of 10-15°c and 85.3-90.8% relative humidity and 25-29°c and 46.5%-80.4% relative humidity. data were collected through laboratory tests and analyzed using the spss program. the study found a significant effect of glycerol dosage on the thickness of the bioplastic (p<0.001). there was a significant influence of temperature-humidity storage on moisture content with glycerol dosages of 3 ml (p=0.002), 4 ml (p<0.023), and 5 ml (p=0.007), as well as on the peroxide content of dodol. this effect was particularly pronounced with glycerol dosages of 3 ml (p=0.001), 4 ml (p<0.001), and 5 ml (p=0.008). the results indicate that cassava peel starch bioplastic can serve as a viable alternative for food packaging, provided that temperature and humidity conditions during food storage are carefully controlled. introduction plastic packaging for food is an integral part of everyday life. the food industry stands as the largest user of packaging, with packaging accounting for approximately 40% of plastic production.1 plastic compounds, including additives and plasticizers, can freely migrate into food.2 temperature plays a crucial role in the migration of melamine compounds in food.1,3 moreover, plasticizers such as dibutyl phthalate (dbp) and dioctyl phthalate (dop) from pvc can migrate into olive oil, corn oil, cottonseed oil, and soybean oil when stored at room temperature (30°c) for 60 days, with migrated dbp or dop additives ranging from 155-189 mg. the plasticizer deha (di(2-ethylhexyl) adipate) in pvc can migrate into wrapped meat with fat content between 20-90%, reaching migrated deha levels of 14.5-23.5 mg per dm2 during cold storage (4°c) for 72 hours.4 monomer migration is influenced by factors like food type, storage temperature, contact time, and fat content; higher temperatures result in increased monomer migration into food.3,5 it’s important to note that most of these cases are associated with non-biodegradable plastics, which pose health risks due to additive diffusion and migration. research findings suggest that vinyl chloride and acrylonitrile monomers have the potential to be carcinogenic to humans. bioplastics represent an environmentally friendly alternative.6,7 they can serve as suitable food packaging materials, parcorrespondence: yosephina ardiani septiati, department of environmental health, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: yosephina@staff.poltekkesbandung.ac.id key words: bioplastics; food; peroxide number; moisture content; temperature-humidity. contributions: yas: conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; nn: conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ts: conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; hh: methodology, visualization, writing – review & editing; ss: resources, investigation, and writing –review & editing; dp: formal analysis, validation, writing – review & editing; da: resources, supervision, and writing –review & editing; mu: resources, investigation, and writing –review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: there is no necessary ethical issue to be approved in this study. informed consent: there are no patients who participated in this study. patient consent for publication: there are no patients who participated in this study. funding: this research was supported by a research grant from politeknik kesehatan kemenkes bandung indonesia with contract number kn.01.03/xxv.3.10/p.1607.29/2022. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we would like to be thankful to politeknik kesehatan kemenkes bandung indonesia for their valuable insights and contributions to this study. received: 12 september 2023. accepted: 16 october 2023. early access: 23 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11778 doi:10.4081/hls.2023.11778 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2023; 11:11778] [page 35] non -co mmerc ial us e o nly ticularly when low moisture content is required, as is the case with dodol. dodol, a traditional food, is often found as souvenirs, typically sold with primary packaging made of oil paper and nonbiodegradable ldpe (low-density polyethylene) plastic.8 the use of ldpe for primary packaging is prohibited,8 as there is concern that ldpe monomers might migrate during storage, affecting the quality of dodol, including texture, fat oxidation processes, and mold growth, rendering it unsafe for consumption. in contrast, bioplastics are considered safe for food packaging.9,10 their protective properties depend primarily on their mechanical and physical characteristics. bioplastics can prolong the shelf life of food and preserve food quality, particularly for certain types of products. bioplastics produced from banana starch and gelatin with a glycerol plasticizer are notable for their tightly sealed pores, making them suitable for food packaging.11,12 cassava peel, rich in starch, serves as a hydrocolloid component that can be employed to create safe bioplastics for primary packaging. starch-based edible films, used as packaging for peeled apples, have been shown to extend shelf life beyond that of non-packaged items.12–14 utilizing bioplastics for food packaging necessitates a thorough consideration of their mechanical and physical properties, allowing for the estimation of product shelf life and the selection of appropriate food types or products for packaging.15 the storage of food requires careful attention to temperature, humidity, and storage duration.10 the conditions of food storage in the field significantly influence the effectiveness of food packaging and the overall shelf life of products, potentially reducing that shelf life.16 this study aims to investigate the impact of using bioplastics made from cassava peel and glycerol plasticizer as food packaging on the moisture content and peroxide value of dodol. materials and methods design study the research design is experimental, employing a post-test with a control group design. this research investigates the impact of temperature and humidity on food storage when using bioplastic as food packaging over a 28-day storage period. the hypotheses explored in this study include the influence of glycerol dosage on the thickness of bioplastic and the effects of temperature and humidity during the storage of dodol packaged in bioplastic on the quality of dodol. the independent variables encompass the dose of glycerol plasticizer, which consists of three levels, namely 3 ml, 4 ml, and 5 ml, and the temperature and humidity conditions during food storage. the dependent variables include the thickness of the bioplastic, peroxide number, and moisture content of the food. population and sample the population under consideration was garut dodol. for this study, dodol obtained from establishments selling food souvenirs in garut, west java, were selected as the samples. these samples were chosen using a simple random sampling method. as for the bioplastic material, it was sourced from cassava peels. these peels were processed by blending, adding moisture, squeezing, and leaving them to stand for 24 hours. the resulting residue was then collected and dried to obtain dry starch. the bioplastics were created by mixing 10 grams of cassava peel starch with 100 ml of moisture, along with the addition of 2 ml of acetic acid and a glycerol plasticizer with varying doses of 3 ml, 4 ml, and 5 ml. data collection data collection in this study was carried out through three methods: the examination of bioplastic thickness, measurement of moisture content, and assessment of peroxide levels in the food. the data for the study were obtained through laboratory testing, using physical methods to measure bioplastic thickness, gravimetric techniques to assess moisture content, and iodometric titration to determine peroxide levels in the dodol. data analysis collected data were entered into a computer and analyzed using the spss program. the shapiro-wilk test was employed to assess the normality of variable distribution. the t-test was used for comparing two quantitative variables with a normal distribution, specifically the temperature-humidity storage variable and moisture content or peroxide levels. in cases where the data did not exhibit a normal distribution, the kruskal-wallis test was applied to compare the quantitative variable of bioplastic thickness. results the findings reveal that the average thickness of bioplastic in the control group (ranging from 0.010 to 0.011) is smaller than the average thickness of the bioplastic in the treatment group with glycerol doses of 3 ml (0.028 mm), 4 ml (0.025 mm), and 5 ml (0.027 mm). these results demonstrate that different glycerol doses of 3 ml, 4 ml, and 5 ml have an effect on the thickness of bioplastic (table 1). table 2 illustrates that, under temperature-humidity conditions of 10-15°c and 85.3-90.8%, the lowest peroxide numbers were recorded at 0.5500 meq/kg with the addition of 5 ml of glycerol. under temperature-humidity conditions of 25-29°c and 46.580.4%, the smallest peroxide number was 0.3678 meq/kg. when storing food at 10-15°c and 85.3-90.8% humidity, the mean peroxide number in the control group is smaller than the mean peroxide number in the treatment group. conversely, when storing food at 25-29°c and 46.5%-80.4% humidity, the mean peroxide number in the control group is greater than that in the treatment group. t-test results for glycerol doses of 3 ml (p=0.001), 4 ml (p<0.001), and 5 ml (p=0.008) indicate that there is a significant difference in peroxide levels among food storage conditions at each glycerol dosage (3 ml, 4 ml, and 5 ml). table 3 reveals that, under various temperature-humidity conditions, the mean moisture content of food in the control group exceeds the mean moisture content in the treatment group. t-test results for glycerol doses of 3 ml (p=0.002), 4 ml (p<0.023), and 5 ml (p-=0.007) suggest that there is a significant difference in moisture content among food storage conditions at each glycerol dosage (3 ml, 4 ml, and 5 ml). discussion the physical properties of bioplastics include thickness, a crucial factor that determines their suitability for use in food packaging. thickness is a vital parameter that affects the application of film in shaping products for packaging due to its influence on gas permeability. in this study, the thickness of bioplastic was influenced by the addition of glycerol. the maximum bioplastic thickness, in the sequence of adding 3 ml, 4 ml, and 5 ml of glycerol, is 0.023 mm, 0.026 mm, and 0.028 mm, respectively. greater [page 36] [healthcare in low-resource settings 2023; 11:11778] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly amounts of glycerol lead to increased bioplastic thickness and an augmented film thickness, responding to the rising glycerol concentration. a thicker starch-based vegetable film layer results in higher gas permeability, water resistance, and improved product protection.17,18 these highly soluble solids elevate the viscosity of the bioplastic material solution. starch is utilized to produce bioplastic thickness.15,19 the polymer content and solution viscosity increase in tandem with the addition of plasticizers, which impacts the thickness of bioplastics.19,20 glycerol plasticizers are employed to reconfigure the intermolecular polymer chain network.21–23 similar research has also been conducted to assess the influence of sorbitol and glycerol plasticizers on starch film thickness. the thickness of edible film typically falls between 0.02-0.03 mm, and the addition of different glycerol-to-sorbitol ratios enhances the interaction between the plasticizer and polysaccharides.24 film thickness, humidity contact angle, water content, solubility, tensile strength, elongation, and antimicrobial properties are examined in composite film solutions, which are employed as coating solutions to extend the shelf life of ivy gourd (coccinia indica).12 the thickness of bioplastic increases with greater glycerol concentrations, responsive to the escalating glycerol content.25 starch films filled with crystals also offer increased protection against ultraviolet radiation.18 the weakening of starch molecular bonds signifies the flexibility of bioplastics, enhanced by the addition of glycerol. proper attention to the starch-to-glycerol ratio is crucial. in this study, it was observed that the peroxide levels in dodol stored at a temperature-humidity of 10-15°c and 85.3-90.8% were higher than those stored at a temperature-humidity of 25-29°c and 46.5-80.4%. furthermore, aside from the glycerol dosage during storage, variations in peroxide levels were also noticed, with the lowest peroxide levels recorded when 5 ml of glycerol was used. this indicates the impact of bioplastic packaging on the rate of oxidation and hydrolysis of dodol fat, which can be controlled by adjusting the temperature and humidity during dodol storage. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. effect of glycerol dosage on thickness of bioplastic (mm). dose plasticizer n mean (sd) minmax normalitas+ p glycerol 3 ml 18 0.02850(0.000786) 0.020-0.023 glycerol 4 ml 18 0.02528(0.000575) 0.024-0.026 0.001 <0.001 glyserol 5 ml 18 0.02744(0.000511) 0.027-0.028 control 18 0.01050(0.000511) 0.010-0.011 *shapiro wilk. table 2. effect of temperature-humidity on the peroxide number (meq/kg) of food on storage for 28 days. temperature-humidity n mean(sd) min-max normalitas p dose of glyserol 3 ml 10-15°c, 85,3-90,8% 9 0,6878 (0.10035) 0,55-0,87 25-29°c, 46,5%-80,4% 9 0,5167 (0.07984) 0,43-0,63 0,200 0,001 control 9 0,5744 (0.07316) 0.50-0,72 dose glyserol 4 ml 10-15°c, 85.3-90.8% 9 0.5844 (0.02651) 0.42-0.49 25-29°c, 46.5-80,4% 9 0.3711 ( 0.04226) 0.32-0.43 0,200 <0,001 control 9 0.5556 (0.06064) 0.47-0.65 dose glyserol 5 ml 10-15°c, 85.3-90.8% 9 0.5500 (0.05612) 0.45-0.60 25-29°c, 46.5-80.4% 9 0.3678 (0.07138) 0.30-0.50 0,093 0,008 control 9 0.5156 (0.07568) 0.41-0.65 table 3. effect of temperature-humidity on food's moisture content (% ) on storage for 28 days. temperature-humidity n mean(sd) min-max normalitas p dose of glyserol 3 ml 10-15°c, 85.3-90.8% 9 2.3611 (0.22718) 1.38-1.74 25-29°c, 58.5-80.4% 9 2.2878 (0.12979) 1.40-1.96 0.200 0.002 control 9 2.5844 (0.18709) 2.25-2.78 dose glyserol 4 ml 10-15°c, 85.3-90.8% 9 2.5122 (0.12050) 2.62-2.90 25-29°c, 58.5-80.4% 9 2.4900 (0.12824) 2.62-2.90 0.200 0.023 control 9 2.5689 (0.20829) 2.55-2.90 dose glyserol 5 ml 10-15°c, 85.3-90.8% 9 1.3367 (0.06464) 1.64-1.85 25-29°c, 58.5-80.4% 9 1.3056 (0.06144) 1.63-1.90 0.168 0.007 control 9 2.5833 (0.20273) 2.14-2.90 [healthcare in low-resource settings 2023; 11:11778] [page 37] non -co mmerc ial us e o nly increasing the glycerol content led to the production of thicker starch-based bioplastics, resulting in enhanced o2 gas and moisture permeability. it’s worth noting that bioplastics made from starch with glycerol plasticizer exhibit a high resistance to water and o2 gas.26,27 therefore, bioplastics using 5 ml of glycerol provide superior food protection since they can withstand more water vapor and o2 gas, effectively shielding the food from external factors. the combination of starch and glycerol in the bioplastic formulation contributes to slowing down damage, resulting in lower peroxide levels. in this study, it was observed that bioplastics exhibited greater absorption of water vapor from the storage environment at low temperatures and high humidity, characterized by higher water vapor content when compared to room temperature and humidity conditions across all glycerol doses. the abundance of water vapor in the storage environment can diminish the bioplastics’ ability to protect dodol, eventually causing saturation.15,21 comparatively, the addition of 5 ml of glycerol to cassava starch skin enhanced the bioplastics’ capacity to impede the flow of water vapor and o2 gas. glycerol, known for its hydrophilic properties, contributes to increased water absorption within the bioplastics when its dosage is increased, thus reducing the water content within the food or storage environment. by adding glycerol, bioplastics effectively hinder water vapor from reaching the dodol, reducing the overall moisture content under room temperature and humidity conditions. as the thickness of bioplastics increased in tandem with the addition of glycerol, the influx of o2 gas and water vapor into the food decreased. thicker and more flexible bioplastics were found to slow down the rate of o2 gas and water vapor permeating through the packaging, thus affecting the quantities entering the packaging space and interacting with fats and oils in the food. this study aligns with the fact that bioplastics made from cassia gum combined with ethyl cellulose significantly enhance the film’s moisture barrier properties and reduce the oxidation of fat components in food.28 however, storage environments with low temperatures and high humidity could potentially hinder these functions due to elevated water vapor from the environment,29 while also causing damage to dodol due to moisture absorption within the packaging space.30 based on this research, the optimal conditions for preserving food quality entail minimizing both water vapor and peroxide parameters within the bioplastics. in cold temperatures and high humidity storage conditions, the permeability of bioplastics to o2 gas decreases due to starch grains undergoing retrogradation, resulting in molecular bond changes that allow more o2 to pass through the bioplastic.30 consequently, bioplastics become saturated more rapidly due to external environmental factors, diminishing their effectiveness in protecting food, ultimately leading to food spoilage. conclusions utilizing bioplastics while meticulously regulating storage temperature and humidity conditions, both at room temperature and under controlled levels, can significantly enhance the efficacy of bioplastics as packaging. this approach strengthens the bioplastics’ capacity to fortify barriers against environmental factors, contributing to superior protection for the packaged contents. references 1. peelman n, ragaert p, de meulenaer b, et al. application of bioplastics for food packaging. trends food sci technol 2013;32:128-41. 2. bidari r, abdillah aa, ponce rab, charles al. characterization of biodegradable films made from taro peel (colocasia esculenta) starch. polymers (basel) 2023;15:1-17. 3. cruz rms, krauter v, krauter s, et al. bioplastics for food packaging: environmental impact, trends and regulatory aspects. foods 2022;11:1-39. 4. petrovics n, kirchkeszner c, tábi t, et al. effect of temperature and plasticizer content of polypropylene and polylactic acid on migration kinetics into isooctane and 95 v/v% ethanol as alternative fatty food simulants. food packag shelf life 2022;33:100916. 5. ahmed mw, haque ma, mohibbullah m, et al. a review on active packaging for quality and safety of foods: current trends, applications, prospects and challenges. food packag shelf life 2022;33:100913. 6. sofianto ra, alamsjah ma, pujiastuti dy. application of modified starch on plastic bag bioplastic based on carrageenan from eucheuma cottonii on mechanic and biodegradation properties application of modified starch on plastic bag bioplastic based on carrageenan from eucheuma cottonii on mechanic. iop conf ser earth environ sci 2022. 7. adorna ja, ventura rlg, dang vd, et al. biodegradable polyhydroxybutyrate/cellulose/calcium carbonate bioplastic composites prepared by heat-assisted solution casting method. j appl polym sci 2021;139. 8. begley t. migration from food packaging: regulatory considerations for estimating exposure. 2007, p. 359-92. 9. triani ta, alamsjah ma, pujiastuti dy. application of modified starch on glass bioplastic based on carrageenan from eucheuma cottonii on mechanic and biodegradation properties application of modified starch on glass bioplastic based on carrageenan from eucheuma cottonii on mechanic and biodegr. iop conf ser earth environ sci 2022. 10. lim css, soon cy, chan ewc, wong cw. nanofillers to enhance biodegradable composites and their niche applications. in: nanofillers to enhance biodegradable composites and their niche applications; 2023, p. 215-57. 11. lagos jb, vicentini nm, dos santos rmc, et al. mechanical properties of cassava starch films as affected by different plasticizers and different relative humidity conditions. int j food stud 2015;4(1). 12. suresh sn, puspharaj c, natarajan a, subramani r. gum acacia/pectin/pullulan-based edible film for food packaging application to improve the shelf-life of ivy gourd. int j food sci technol 2022;57:5878-86. 13. a’yun sn, triastuti j, saputra e. edible straw formulation from caragenant and gelatin as a solution in reducing plastic waste edible straw formulation from caragenant and gelatin as a solution in reducing plastic waste. iop conf ser earth environ sci 2021. 14. charles al, motsa n, abdillah aa. a comprehensive characterization of biodegradable edible films based on potato peel starch plasticized with glycerol. polymers (basel) 2022;14:1-14. 15. ng js, kiew pl, lam mk, et al. preliminary evaluation of the properties and biodegradability of glyceroland sorbitol-plasticized potato-based bioplastics. int j environ sci technol [page 38] [healthcare in low-resource settings 2023; 11:11778] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 2022;19:1545-54. 16. islamiyah hs, alamsjah ma, pujiastuti dy. application of modified starch in the carragenan-based biodegradable packaging from eucheuma cottonii on biodegradablility and mechanical properties. in: iop conference series: earth and environmental science 2022. 17. al-talib aam, abdullah nf, abd. hamid ar, et al. investigation of the mechanical properties and applicability of hdpe recycled plastic bags. icarob 2023;28:700-4. 18. sanyang ml, sapuan sm, jawaid m, et al. effect of plasticizer type and concentration on physical properties of biodegradable films based on sugar palm (arenga pinnata) starch for food packaging. j food sci technol 2016;53:326-36. 19. santana rf, bonomo rcf, gandolfi orr, et al. characterization of starch-based bioplastics from jackfruit seed plasticized with glycerol. j food sci technol 2018;55:278-86. 20. arham r, mulyati mt, metusalach m, salengke s. physical and mechanical properties of agar based edible film with glycerol plasticizer. int food res j 2016;23:1669-75. 21. li t, meng f, chi w, et al. an edible and 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https://doi.org/10.1515/psr-2022-0014 [healthcare in low-resource settings 2023; 11:11778] [page 39] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13084 factors associated with obstetric ultrasound screening behavior during antenatal care at public health centers in palu city ketut suarayasa,1 miranti miranti,1 sumarni sumarni,1 elli yane bangkele,1 andi nuraspianti2 1department of public health community medicine, faculty of medicine, tadulako university, palu city; 2health office of palu, palu city, indonesia abstract antenatal screening by general practitioners in primary care using basic obstetric ultrasound aims to identify suspected pathological cases early. early detection allows for timely intervention, potentially preventing complications. this study analyzed factors related to the knowledge, attitudes, and practices of pregnant women utilizing ultrasound for antenatal care in palu city. a mixed-methods study with a quantitative approach was conducted on 380 pregnant women from 14 public health centers in palu city using proportional random sampling with pregnant women and maternal and child health (mch) program officers at the palu health office. quantitative data were collected using a structured questionnaire that was adapted and modified from existing literature. researchers visited mothers’ homes to obtain information on socio-demographic factors, obstetric history, and knowledge and attitudes towards obstetric ultrasound scans. for the qualitative study, researchers conducted observations and in-depth interviews to explore sources of information about ultrasound, as well as knowledge, attitudes, practices, and barriers related to obstetric ultrasound during antenatal care. bivariate and multivariate logistic regression were used to identify associated factors. the study found that 70.8% of pregnant women had good knowledge about obstetric ultrasound, and 77% had positive attitudes. ultrasound was accessed by 55.4% of women on their first visit (k1) and 57.0% on their fifth visit (k5). significant factors associated with knowledge included having a bachelor’s degree or higher (aor 2.70; 95% ci 0.21-35.23), being a government employee (aor 3.901; 95% ci 1.92-7.90), and previous exposure to ultrasound (aor 1.966; 95% ci 1.24-3.12). factors significantly associated with the practice of ultrasound screening were higher education (aor 3.17; 95% ci 0.54-21.20), government employment (aor 4.53; 95% ci 1.17-15.18), good knowledge (aor 3.71; 95% ci 1.71-11.23), and positive attitudes (aor 11.07; 95% ci 2.0917.20). educational level, occupation, and previous exposure to ultrasound significantly influenced knowledge about obstetric ultrasound. the practice of ultrasound screening was significantly associated with education level, occupation, knowledge, and attitudes. introduction ultrasound is one of the medical imaging technologies used to monitor fetal development in the womb, alongside its various other applications. the primary objective of ultrasound is to aid in diagnosing fetal development in each trimester.1 in many countries, ultrasound scanning is considered a standard practice for prenatal diagnosis and has been integrated into antenatal care due to its potential to enhance the quality of antenatal care.2,3 obstetric ultrasound screening has become an integral component of antenatal care worldwide, offering valuable insights into fetal development and potential complications. however, the utilization of this technology varies significantly across different regions and healthcare settings. in lowand middle-income countries, access to and uptake of obstetric ultrasound screening may be limited due to various factors, including resource constraints, correspondence: ketut suarayasa, department of public health community medicine, faculty of medicine, tadulako university, palu city, indonesia. e-mail: suarayasa@yahoo.com key words: antenatal care, attitude, knowledge, obstetric ultrasound, practice. contributions: all authors have participated to drafting the manuscript, author ks revised it critically. all authors read and approved the final version of the manuscript. funding: this research was funded by a grant from tadulako university conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: all stages of this study were conducted following ethical recommendations from the health research ethics commission (kepk) of the faculty of medicine, tadulako university (1277/un 28.1.30/ kl/2024). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to acknowledge the research participants for their cooperation and the diligent data collectors for their dedication and patience. we also extend our gratitude to the palu city health office and the faculty of medicine, tadulako university. received: 11 september 2024. accepted: 14 january 2025. early access: 2 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13084 doi:10.4081/hls.2025.1384 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13084] [page 171] cultural beliefs, and lack of awareness among pregnant women.4 the international federation of gynecology and obstetrics (figo) also recommends that all pregnant women undergo ultrasound scanning twice during their pregnancies to mitigate the risk of adverse perinatal outcomes. nevertheless, this practice carries potential risks to pregnant mothers, including diagnostic errors and potential biological effects.5 several studies have shown that mothers’ knowledge and attitudes towards obstetric ultrasonography are crucial, as these influence their decisions to undergo pregnancy investigation.6,7 in palu, the implementation of basic obstetric ultrasound examinations in primary care, particularly at public health centers, has been initiated since 2022. since the introduction of ultrasound services at public health centers, there has been a notable increase in the enthusiasm of pregnant women for prenatal check-ups. this study aimed to analyze the factors associated with ultrasound screening behavior during antenatal care in primary care settings, including the knowledge, attitudes, and practices of pregnant women regarding the use of ultrasound for pregnancy examinations. materials and methods this study employed a mixed-methods approach, combining quantitative and qualitative methods. the quantitative method, with a cross-sectional design, was conducted over a four-month (february–may 2024) period at 14 public health centers in palu city. the study population included all pregnant women who received antenatal care at these health centers in 2023, totaling 7.833 subjects. the sample size was determined using the slovin formula with a 95% confidence level, resulting in a sample size of 380 pregnant mothers. a proportional random sampling technique was employed, with the sample size for each health center adjusted based on the number of antenatal visits, as detailed in table 1. in the quantitative study, the research variables included: i) independent variables: socio-demographic factors (age, respondent’s education status, marital status, monthly income, husband’s education status, respondent’s occupation) and obstetric factors (parity, gestational age, previous obstetric complications, number of antenatal visits); ii) dependent variables: knowledge and attitudes towards obstetric ultrasonography examinations. knowledge was assessed by measuring the accuracy of respondents’ answers to questions regarding ultrasound indications, procedures, and potential benefits. attitudes were measured by assessing their level of agreement with statements related to their perceptions, feelings, and beliefs about ultrasound examinations. quantitative data were collected using a structured questionnaire that was adapted and modified from existing literature. researchers visited mothers’ homes to obtain information on socio-demographic factors, obstetric history, and knowledge and attitudes towards obstetric ultrasound scans. for the qualitative study, researchers conducted observations and in-depth interviews to explore sources of information about ultrasound, as well as knowledge, attitudes, practices, and barriers related to obstetric ultrasound during antenatal care. interviews were held with 14 pregnant women, each representing one of the 14 public health centers in palu city, and included one key informant responsible for the maternal and child health (mch) program at the palu health office. in the quantitative study, researchers used a structured questionnaire adapted and developed from prior literature to collect data. this questionnaire gathered information on sociodemographic factors, obstetric history, and knowledge, attitudes, and practices regarding obstetric ultrasonography. upon data collection, researchers reviewed the data for completeness and consistency before inputting it into the statistical package for the social sciences (spss) version 26.0. binary logistic regression was utilized to examine the relationships between dependent and independent variables. factors with a p-value of less than 0.25 in the bivariate analysis were incorporated into the multivariate logistic regression analysis to identify variables associated with the dependent variable. significance in the multivariable logistic regression was indicated by a p<0.05, and results were reported using adjusted odds ratios (aor). a 95% confidence level and a p<0.05 were considered statistically significant. for the qualitative study, researchers conducted in-depth interviews with several informants using structured interview guidelines. the audio recordings of these interviews were transcribed for thematic analysis. data reliability was ensured throughout the procedure using four key methods: credibility, dependability, confidentiality, and transferability. article table 1. sample size based on the public health centers in palu city. public health center number of antenatal care visits sample size singgani 508 25 talise 894 43 birobuli 799 39 kawatuna 726 35 mabelopura 585 28 nosarara 485 24 bulili 501 24 kamonji 528 26 sangurara 1067 50 tipo 229 12 mamboro 360 17 tawaeli 321 16 pantoloan 311 15 lere 519 26 total 7.833 380 [page 172] [healthcare in low-resource settings 2025;13:13084] ethical approval all stages of this study were conducted following ethical recommendations from the health research ethics commission (kepk) of the faculty of medicine, tadulako university (1277/un 28.1.30/kl/2024). results socio-demographic of study participants a total of 380 pregnant mothers participated in this study. the socio-demographic characteristics of respondents are shown in table 2, which reveals that the majority of the study participants were aged 20–29 years (48.2%). most (94.7%) were still with their partners (married) and had at least a high school education (39.7%). the most common occupations were housewives (50.3%), with the majority of households having a monthly income of <1,000,000 idr (64.2%). this income level affects pregnant mothers’ purchasing power for adequate and nutritious food intake. obstetric history of respondents the obstetric history of respondents indicates that a significant majority (72.6%) were multigravida, with more than half (52.4%) having attended three antenatal care visits. additionally, 73.9% of the study participants initiated antenatal care services at 16 weeks or later. notably, over half (50.5%) of them had been exposed to information about ultrasound during antenatal care (table 3). knowledge of pregnant women about obstetric ultrasound examinations mothers’ were asked about their knowledge on the merits of obstetric ultrasound (table 4). the findings reveal that 70.8% of the women demonstrated good knowledge about the merits of obstetric ultrasonography, while the remaining 29.2% had limited knowledge. the most commonly known benefits of ultrasound among mothers were its ability to confirm pregnancy (96.6%), determine fetal sex (89.7%), and determine gestational age (89.2%). these advantages (confirming pregnancy, determining fetal sex, and gestational age) were the main reasons for the increased visits of pregnant women to health centers in palu city, as revealed in interviews with several respondents: “during my first and second pregnancies, i only attended check-ups at the integrated service posts known as posyandu. now, i wish to visit the health center for an ultrasound (us). i want to know my baby’s gender, hoping for a boy since my two older children are girls (laughing) …” (mrs. ba, 32 years). “i plan to visit the health center for an ultrasound check-up. i want to monitor my baby’s condition. i often experience vomiting and worry that my baby might not be receiving adequate nutrition (laughing) …” (mrs. ta, 25 years old). attitudes towards obstetric ultrasound examinations pregnant women exhibited several compelling attitudes towards undergoing ultrasound scans at health centers. a significant majority believed in the safety of ultrasound during pregnancy (87%), perceived ultrasound as an essential examination during pregnancy (86.7%), and trusted that ultrasound findings were more accurate (79.9%). furthermore, the most prevalent belief was that ultrasound scans are legally permitted (94.8%). although the respondents were not familiar with specific regulations, they were confident that ultrasound check-ups were legally compliant (table 5). the majority of pregnant mothers considered knowing the gender of their baby to be very important (87.7%), yet none supported article table 2. socio-demographic characteristics of pregnant women at the public health centers in palu city. variable category n % maternal age (years) <20 59 15.5 20-29 183 48.2 30-35 122 32.1 >35 16 4.2 marital status married 360 94.7 divorced 8 2.1 widowed 12 2.2 maternal education illiterate 21 5.5 primary 22 5.8 high school 151 39.7 diploma 89 23.4 bachelor or higher 97 25.6 husband’s education illiterate 9 2.4 primary 113 29.7 secondary 169 44.5 diploma 10 2.6 bachelor or higher 79 20.8 maternal occupation housewife 191 50.3 government employee 64 16.8 private employee 115 30.3 entrepreneure 10 2.6 household monthly income (idr, indonesian rupiah) <1,000,000 244 64.2 1,000,000-5,000,000 88 23.1 >5,000,000 48 12.7 [healthcare in low-resource settings 2025;13:13084] [page 173] the idea of terminating the pregnancy if the baby’s sex differed from their preference. mrs. rb articulated the significance of knowing the baby’s gender: “… i think it is important so that a name can be prepared, whether it is a boy or a girl. clothes can also be prepared…” when questioned about her reaction if the sex of her baby differed from expectations based on an ultrasonography scan, and whether she would consider terminating the pregnancy, mrs. rb firmly replied: “of course not… the baby must be cared for. accept whatever the gender is. it is a gift from god…” pregnant women’s practice of obstetric ultrasound among the 380 pregnant women, 210 (55.4%) accessed antenatal care with ultrasound at their first visit, while 217 (57.0%) did so by their fifth visit. the highest coverage for both the first (k1 us=93.7%) and fifth (k5 us=88.6%) ultrasound visits was recorded at mabelopura health center. conversely, tawaeli health center reported the lowest coverage, with 11.2% for the first ultrasonography visit and 11.8% for the fifth ultrasound (table 6). interviews with the person in charge of the maternal and child health program at the palu city health office highlighted several factors influencing the variability in anc coverage for ultrasonography. these factors include inadequate socialization and information dissemination about ultrasound during pregnancy, the absence article [page 174] [healthcare in low-resource settings 2025;13:13084] table 3. obstetric history of pregnant women at the public health centers in palu city. variable n % gravidity multigravida 276 72.6 primigravida 104 27.4 number of antenatal care visits 1 56 14.7 2 95 25.0 3 199 52.4 ≥ 4 30 7.9 first antenatal care visits timing < 16 weeks 99 26.1 ≥ 16 weeks 281 73.9 history of abnormal or congenital anomalies yes 17 4.5 no 363 95.5 history of abortion yes 73 19.2 no 307 80.8 exposure to information on ultrasound yes 192 50.5 no 188 49.5 table 4. knowledge about obstetric ultrasound among pregnant women in palu city. knowledge about ultrasound benefits yes % confirm pregnancy 367 96.6 confirm the presence of multiple pregnancies 322 84.7 confirm the presence of abnormal pregnancies (ectopic, molar) 241 63.4 confirm fetal well-being 283 74.5 detect defects or congenital anomalies during pregnancy 223 58.7 monitoring of pregnancy complications 200 52.6 determine the fetal position, cord, and placenta 241 63.4 detect amniotic fluid volume 215 56.6 determine fetal sex 341 89.7 determine gestational age 339 89.2 provide information about fetal weight 181 47.6 estimate delivery time 144 37.9 estimate delivery method (normal/cesarean) 86 22.6 good knowledge 269 70.8 poor knowledge 111 29.2 of innovative health centers program targeting pregnant women, and the level of attention health center management gives to maternal health. mrs. ay (46 years old) explained: “some health centers have reached their targets, but others have not. the main reasons include the role of health center leaders in prioritizing programs and the lack of socialization to pregnant mothers and the community. nowadays, there are many media that can be utilized for information dissemination.” she further noted: “in successful health centers, they implement innovative programs such as home visits, which increase coverage rates.” factors associated with knowledge of obstetric ultrasound in the bivariate logistic regression analysis, seven variables were found to be associated with knowledge about obstetric ultrasonography: age, education level of respondents, education level of parents or partners, occupation, number of antenatal visits, congenital anomaly history, exposure to ultrasound for reasons other than pregnancy, experience of pregnancy, and prenatal ultrasound knowledge. however, the multivariate logistic regression analysis revealed that only a few variables remained significantly associated with knowledge of obstetric ultrasonography. specifically, pregnant women with a bachelor’s degree or higher (p=0.009, or=2.70), women employed as government employees (p=0.000, or 3.90), and those with a history of previous ultrasound exposure (p=0.004, or=1.96) (table 7). article table 5. attitudes towards obstetric ultrasound examinations among pregnant women at the public health centers in palu city. variable response strongly disagree disagree not sure agree strongly (%) (%) (%) (%) agree (%) ultrasound is safe during pregnancy 0.2 0.7 12.1 59.3 27.7 ultrasound can cause congenital anomalies in the fetus 0.7 49.5 34.4 12.8 2.6 ultrasonography is an important screening during pregnancy 0.2 13.0 0.0 52.6 34.1 feel comfortable during the ultrasonography examination 0.7 21.1 2.4 75.8 0.0 ultrasound can cause cancer 7.8 31.3 53.1 7.8 0.0 ultrasound examination causes pain 7.6 82.2 0.0 10.2 0.0 ultrasound examinations are permitted by law 1.2 1.4 2.6 51.9 42.9 terminate pregnancy if the child’s sex is different from the desired 71.8 28.2 0.0 0.0 0.0 routine ultrasound can be performed 63.7 0.0 0.0 28.2 8.1 ultrasound findings are more accurate 0.0 17.8 2.4 58.1 21.8 knowing the child’s sex is essential 0.0 12.3 0.0 74.2 13.5 table 6. number of first and fifth ultrasound visits (k1 us and k5 us) among pregnant women at the public health centers in palu city. health center number of pregnant mothers *k1 us **k5 us number (n) percentage (%) number (n) percentage (%) singgani 25 9 37.8 10 39.0 talise 43 33 75.7 33 76.0 birobuli 39 11 27.7 11 28.7 kawatuna 35 25 71.1 26 73.1 mabelopura 28 26 93.7 25 88.6 nosarara 24 14 60.2 11 47.4 bulili 24 13 53.7 10 40.7 kamonji 26 23 87.5 22 84.1 sangurara 50 25 49.9 30 60.0 tipo 12 8 65.1 10 84.7 mamboro 17 3 18.3 4 23.3 tawaeli 16 2 11.2 2 11.8 pantoloan 15 11 71.1 12 79.7 lere 26 8 31.0 12 44.7 total 380 210 55.4 217 57.0 *k1 us, mothers’ first visit in the first trimester + ultrasound scan. **k6 us, mothers’ fifth visit in the third trimester + ultrasound scan [healthcare in low-resource settings 2025;13:13084] [page 175] factors associated with attitudes towards obstetric ultrasound scan the bivariate logistic regression analysis identified several variables associated with attitudes towards obstetric ultrasound, including occupation, monthly household income, timing of the first antenatal care visit, abortion history, congenital anomaly history, and ultrasound exposure for reasons other than pregnancy. however, the multivariate logistic regression analysis found that only a few variables were significantly associated with pregnant women’s attitudes towards obstetric ultrasonography. these variables were employment as government employees/civil servants (p=0.000, or=6.83), household income between idr 1,000,000 and 5,000,000 (p=0.001, or=5.31), and a history of congenital anomalies (p=0.010, or=21.07) (table 8). factors associated with the practice of obstetric ultrasound examination the bivariate logistic regression analysis identified several variables associated with pregnant mothers’ practice of antenatal ultrasound check-ups, including age, maternal occupation, knowledge, and attitude. however, in the multivariate logistic regression analysis, only a few variables remained significantly associated with the practice of accessing obstetric ultrasonography. these variables included having a higher degree (p=0.019; or=2.70), being a housewife (p=0.007; or 6.83), mothers’ knowledge (p=0.009; or=5.31), and having positive attitudes towards ultrasound (p=0.010; or=11.07) (table 9). discussion knowledge of obstetric ultrasound in this study, 70.8% of participants demonstrated good knowledge regarding the use of ultrasound scanning during pregnancy. a significant majority recognized the importance of scans in antenatal care for confirming pregnancy. modern obstetrics acknowledges that pregnancy and childbirth inherently carry the risks of complications. these complications can be mild or severe, and may lead to maternal and/or infant mortality, morbidity, and disability. therefore, proactive preventive measures during pregnancy, such as early detection of risks through ultrasound investigation, are essential. ultrasound technology enables imaging inside the body, allowing for the timely and effective management of identified complications.8 in research by molla et al. (2022), it shows that pregnant article table 7. factors associated with knowledge of obstetric ultrasonography among pregnant women at the public health centers in palu city. variable knowledge cor (95%ci) aor (95%ci) sig. poor good age < 20 28 31 1 1 20-29 99 84 0.75 (0.43-1.30) 0.68 (0.35-1.31) 0.248 30-35 53 69 1.14 (0.63-2.06) 0.95 (0.47-1.92) 0.893 > 35 4 12 2.30 (0.73-7.19)* 2.45 (0.68-8.76) 0.169 maternal education illiterate 2 19 1 1 primary 11 11 0.10 (0.02-0.47)* 0.094 (0.016-0.555) 0.448 high school 82 69 0.07 (0.017-0.32)* 0.76 (0.09-6.21) 0.803 diploma 47 42 0.079 (0.018-0.35)* 0.35 (0.04-2.81) 0.322 bachelor or higher 44 53 0.087 (0.016-0.46)* 2.70 (0.21-35.23) 0.009* husband’s education level illiterate 4 5 1 1 primary 42 71 1.145 (0.30-4.27) 1.46 (0.26-8.03) 0.661 high school 96 73 0.49 (0.14-1.81) 0.99 (0.17-5.49) 0.989 diploma 8 2 0.148 (0.02-1.08)* 0.155 (0.007-3.39) 0.236 bachelor or higher 34 45 0.087 (0.23-3.33) 2.13 (0.28-16.03) 0.463 maternal occupation housewife 61 130 1.145 (0.30-4.27) 1.46 (0.26-8.03) 0.751 government employee 20 44 3.25 (1.86-5.67)* 3.90 (1.92-7.90) 0.000* private employee 78 37 0.72 (0.39-1.32) 0.68 (0.32-1.41) 0.306 entrepreneure 6 4 0.87 (0.23-3.27) 0.63 (0.15-2.66) 0.537 number of antenatal care visits 1 18 38 1 1 2 49 46 0.84 (0.33-2.14) 1.26 (0.44-3.61) 0.656 3 109 90 0.36 (0.15-0.85)* 0.58 (0.22-1.58) 0.296 ≥ 4 8 22 0.32 (0.14-0.73)* 0.47 (0.18-1.19) 0.111 history of congenital anomalies yes 13 4 1 1 no 170 193 4.2 (1.37-12.88)* 2.68 (0.70-10.25) 0.149 ultrasound exposure for reasons other than pregnancy yes 103 89 1 1 no 80 108 0.64 (0.44-0.94)* 1.96 (1.24-3.12) 0.004* 1, reference group; cor, crude odd ratio; ci, confidence interval; *p<0.05. [page 176] [healthcare in low-resource settings 2025;13:13084] women’s knowledge about obstetric ultrasound examinations is (35.3%).9 knowledge about obstetric ultrasound was significantly related to pregnant women’s educational status, parity, and place of residence. the high level of knowledge observed in this study can be attributed to several factors. firstly, the widespread availability of information through healthcare providers and educational programs likely plays a role. secondly, the national health insurance program, bpjs, which covers the costs of ultrasound scans, might encourage more women to seek information and understand the benefits of the procedure. moreover, the importance of ultrasound in detecting and managing potential pregnancy complications is well-publicized, contributing to the overall awareness among pregnant women. article table 8. factors associated with attitudes towards obstetric ultrasonography among pregnant mothers at the public health center in palu city. variable attitude cor (95% ci) aor (95% ci) p negative positive occupation housewife 61 130 1 1 government employee 9 55 2.90 (1.54-5.45)* 6.83 (2.43-19.18) 0.000* private employee 55 60 0.45 (0.24-0.82)* 0.091 (0.03-0.25) 0.070 entrepreneure 6 4 0.27 (0.07-1.03)* 0.10 (0.016-0.63) 0.051 household monthly income (idr) <1.000.000 66 178 1 1 1.000.000-5.000.000 19 69 1.25 (0.72-2.16) 5.31 (2.01-14.03) 0.001* >5.000.000 28 20 0.25 (0.13-0.45)* 1.47 (0.56-3.86) 0.426 first antenatal visits timing <16 weeks 68 31 1 1 ≥16 weeks 45 236 11.71 (7.06-19.4)* 33.89 (13.8-83.27) 0.060 exposure of ultrasound yes 46 146 1 1 no 68 120 1.77 (1.16-2.71)* 1.55 (0.86-2.80) 0.140 history of abortion yes 15 58 1 1 no 113 194 0.56 (0.13-1.01)* 0.92 (0.40-2.12) 0.858 history of congenital anomaly yes 2 15 1 1 no 112 251 0.12 (0.016-0.93)* 21.07 (2.09-21.21) 0.010* 1, reference group; co, crude odd ratio; aor, adjusted odd ratio; ci, confidence interval; *idr-indonesian rupiah; *p<0.05 table 9. factors associated with the obstetric ultrasound practice among pregnant mothers at the public health centers in palu city. variable practices cor (95% ci) aor (95% ci) p poor well age < 20 28 31 1 1 20-29 99 84 0.75 (0.43-1.30) 1.1 (0.81-1.63) 0.448 30-35 53 69 1.14 (0.63-2.06) 0.95 (0.77-2.92) 0.993 > 35 4 12 2.30 (0.73-7.19)* 2.55 (0.68-8.76) 0.269 maternal education illiterate 2 19 1 1 primary 11 11 0.10 (0.02-0.47) 0.074 (0.02-0.56) 0,330 high school 82 69 0.07 (0.017-0.32)* 0.76 (0.09-6.21) 0,558 diploma 47 42 0.07 (0.018-0.35) 0.35 (0.04-2.81) 0.322 bachelor or higher 44 53 0.08 (0.016-0.46)* 3.17 (0.54-21.20) 0.019* maternal occupation housewife 61 130 1 1 government employee 20 44 2.90 (1.54-5.45)* 4.53 (1.17-15.18) 0.007* private employee 78 37 0.45 (0.24-0.82)* 0.091 (0.03-0.25) 0,118 entrepreneure 6 4 0.27 (0.07-1.03) 0.10 (0.016-0.63) 0.061 knowledge well 67 202 1.25 (0.72-2.16)* 3.71 (1.71-11.23) 0.009* poor 71 40 0.25 (0.13-0.45) 1.47 (0.56-3.86) 0.426 attitude positive 32 301 0.12 (0.016-0.93)* 11.07 (2.09-17.21) 0.010* negative 26 21 0.56 (0.13-1.01) 0.92 (0.40-2.12) 0.858 cor, crude odd ratio; aor,adjusted odd ratio; ci, confidence interval; *idr-indonesian rupiah. *p<0.05. [healthcare in low-resource settings 2025;13:13084] [page 177] attitudes towards obstetric ultrasound examinations the majority of respondents (77.0%) believed that ultrasound check-ups were safe for pregnant mothers, aligning with findings from studies in jeddah (78.9%), tanzania, and india. this perception likely stems from the belief that the examination is safe for both the fetus and the mother. additionally, 89.8% of participants disagreed that ultrasound causes pain during the scan, reinforcing the positive outlook towards the procedure. a study by maryam in tulungagung found that 56% of women had a positive attitude towards ultrasonography.10 overall, our findings indicate a general trend of positive attitudes towards obstetric ultrasound examinations. several factors contribute to this positive attitude. the comfort experienced during the scanning process and the coverage of its costs by the national health insurance program, bpjs, play significant roles. maniragena et al. (2021). reported that study participants were motivated to undergo more screenings due to friendly health worker responses, satisfaction with the examinations, and relatively low costs.11 additionally, the desire to know the baby’s gender, estimated delivery date, and the baby’s well-being further influenced their attitudes towards obstetric ultrasonography. these positive attitudes are also evident as some pregnant women proactively request ultrasound scans on their own initiative. attitude, defined as a person’s internal response to a specific stimulus or object involving opinions and emotions, plays a crucial role in health behaviors. the results of our study showed that the majority of women (86.7%) agreed that obstetric ultrasound is an important pregnancy screening, consistent with findings from kano, nigeria (93.8%), and puducherry, india (88.0%).12 this percentage was higher than that found in a study conducted in kenya (71.8%), likely because most respondents understand the benefits of the examination for both the fetus and the mother during pregnancy. several studies have shown that patients’ attitudes towards health programs, including ultrasound scans, are influenced by the friendliness of health workers and the affordability of examination costs. practice of obstetric ultrasound examinations the findings reveal that 210 respondents (55.4%) underwent an obstetric ultrasound scan during their first visit (k5) and 217 women (57.0%) did so by their fifth visit (k5). health centers with high coverage rates often implemented innovative programs, such as home visits, and provided education on obstetric ultrasonography at the health center. basic health research results indicated that some pregnant women still initiate antenatal care in the second trimester. this study highlights that barriers to utilizing antenatal services are multifactorial. these barriers include not only individual obstacles but also issues related to maternal health service providers, support systems, cultural factors, and religious factors. effective improvement of the timely and regular use of antenatal care services requires a multisectoral approach.13 by addressing these various factors collectively, interventions can be more comprehensive and effective, ultimately improving maternal and fetal health outcomes. this study indicates that maternal education level, working status, and ultrasound exposure for non-pregnancy-related reasons were significantly associated with their knowledge about obstetric ultrasonography. education is the most significant factor influencing knowledge. higher education enables individuals to respond more rationally to information and to evaluate its benefits for personal development and goal achievement.14 occupation is closely linked to education level; individuals with higher education are more likely to hold better positions, such as government or private sector jobs. good knowledge can form motivation and positive attitudes in pregnant women, encouraging them to undergo routine ultrasound screening during pregnancy.9 regarding attitudes, this study demonstrates that mothers with a history of congenital anomalies, as well as those with specific occupations and household incomes, exhibit significant associations with their attitudes towards obstetric ultrasound. income level is a factor that reflects a family’s economic condition and is closely linked to the ability to access education and health services.15 this correlation arises from the fact that most activities in life, such as schooling and healthcare access, entail financial costs. pregnant women’s attitudes toward obstetric ultrasound were significantly associated with women’s occupation, monthly household income, and history of births with congenital anomalies.16 attitude plays an important role in influencing a person’s actions within their environment, although behavior is also affected by various factors, such as stimuli, individual background, motivation, and personality. enhanced knowledge about the importance of a pregnancy exam and the merits of ultrasound correlates with a more positive attitude.17 attitude has three main components: belief or confidence in an object, emotional evaluation of the object, and a tendency to act towards it.18 the health of individuals or communities is shaped by two primary factors: behavioral and non-behavioral causes.19 behavioral factors are further influenced by three key elements: predisposing factors, enabling factors, and reinforcing factors. predisposing factors, such as age, occupation, education, knowledge, and attitudes, play a crucial role in shaping pregnant women’s behavior in accessing obstetric ultrasound examinations during antenatal care. conclusions the findings reveal that a majority of participants (70.8%) demonstrated good knowledge of obstetric ultrasound, with a significant proportion recognizing its importance in antenatal care. positive attitudes towards ultrasound examinations were prevalent, with 77.0% of respondents believing in their safety and 86.7% acknowledging their importance as a pregnancy screening tool. the study identified several factors significantly associated with knowledge and attitudes towards obstetric ultrasound. educational attainment, occupation, and prior exposure to ultrasound were found to be significantly related to knowledge levels. attitudes were significantly influenced by maternal occupation, monthly household income, and history of congenital anomalies. regarding practices, the study revealed that 55.4% of respondents underwent an obstetric ultrasound scan during their first antenatal visit, while 57.0% did so by their fifth visit. this highlights the need for continued efforts to improve timely and regular utilization of antenatal care services, including ultrasound examinations. the findings underscore the importance of a multisectoral approach in addressing barriers to antenatal care utilization, considering individual, provider-related, cultural, and religious factors. furthermore, the study emphasizes the role of education, income, and previous experiences in shaping knowledge, attitudes, and practices related to obstetric ultrasound. these results provide valuable information for healthcare providers and policymakers to develop targeted interventions aimed at improving knowledge, attitudes, and utilization of obstetric ultrasound examinations, ultimately contributing to better maternal and fetal health outcomes. article [page 178] [healthcare in low-resource settings 2025;13:13084] references 1. whitworth m, bricker l, mullan c. ultrasound for fetal assessment in early pregnancy. cochrane database syst rev 2015;2015:cd007058. 2. tefera m, mezmur h, jemal m, assefa n. midwives’ experiences of performing obstetric ultrasounds in antenatal care in eastern ethiopia: qualitative exploratory study. womens health (lond) 2024;20:17455057241228135. 3. kim et, singh k, moran a, et al. obstetric ultrasound use in low and middle income countries: a narrative review. reproductive health 2018;15:129. 4. moncrieff g, finlayson k, cordey s, et al. first and second trimester ultrasound in pregnancy: a systematic review and metasynthesis of the views and experiences of pregnant women, partners, and health workers. plos one 2021;16:e0261096. 5. sun h, wu a, lu m, cao s. liability, risks, and recommendations for ultrasound use in the diagnosis of obstetrics diseases. heliyon 2023;9:e21829. 6. abduljabbar hs, jabal nab, hussain fa, et al. knowledge, attitudes and practice about obstetric ultrasonography among women attending a university hospital: a crosssectional study. open j obstetrics gynecol 2020;10:1763–75. 7. edvardsson k, ntaganira j, åhman a, et al. physicians’ experiences and views on the role of obstetric ultrasound in rural and urban rwanda: a qualitative study. tropical med int health 2016;21:895–906. 8. carovac a, smajlovic f, junuzovic d. application of ultrasound in medicine. acta inform med 2011;19:168–71. 9. molla w, mengistu n, wudneh a. pregnant women’s knowledge, attitude, and associated factors toward obstetric ultrasound in public hospitals, ethiopia, 2021: multi-centered cross-sectional study. womens health (lond) 2022;18:17455057221091357. 10. maryam, ervianti a. pengetahuan dan sikap ibu hamil terhadap penggunaan alat usg (usg) dalam pemeriksaan antenatal care (anc) di desa waung kecamatan boyolangu kabupaten tulungagung. jurnal kebidanan 2023;12:82–6. 11. maniragena j, kasozi d, mubuuke g, murachi e. knowledge, attitudes and practices of pregnant women towards obstetric ultrasound at mulago hospital: a cross-sectional survey. int j sci basic appl res (ijsbar) 2021;60:78–92. 12. matiang’i m, ngunju p, nyagero j, omogi j. knowledge and skills gap of midwives to conduct obstetric ultrasonography screening in primary health care facilities in kajiado and kisii counties, kenya. open j clinical diagnostics 2020;10:65–79. 13. mutowo j, yazbek m, van der wath a, maree c. barriers to using antenatal care services in a rural district in zimbabwe. int j africa nursing sci 2021;15:100319. 14. kim hb, choi s, kim b, pop-eleches c. the role of education interventions in improving economic rationality. science 2018;362:83–6. 15. mcmaughan dj, oloruntoba o, smith ml. socioeconomic status and access to healthcare: interrelated drivers for healthy aging. front public health 2020;8:231. 16. haile zw, gurmu ag. knowledge, attitude, barriers, and associated factors of obstetric ultrasound among pregnant women in public hospitals, ethiopia, 2022: a cross-sectional study. j ultrasound 2023;27:31–40. 17. yousefzadeh s, esmaeili darmiyan m, asadi younesi m, shakeri m. the effect of a training program during pregnancy on the attitude and intention of nulliparous women to choose the delivery mode. j midwifery reprod health 2016;4:704–11. 18. bakanauskas a, kondrotienė e, puksas a. the theoretical aspects of attitude formation factors and their impact on health behaviour. management organizations systematic res 2020;83:15–36. 19. ryan p. integrated theory of health behavior change. clin nurse spec 2009;23:161–72. article [healthcare in low-resource settings 2025;13:13084] [page 179] hrev_master healthcare in low-resource settings 2025; volume 13:12999 optimizing health workforce performance in reduced resources settings to sustain continuous improvement of patient outcomes: a retrospective, serial, cross-sectional analysis of a comprehensive multidisciplinary approach, with special focus on maternal and neonatal health massimo migani,1 kudakwashe vambe,1 rufaro j. maisva,1 federica cavalieri,1 claudio bellavista,1 theresia dzagonga,1 irene chipuriro,1 vasco chikwasha,2 paul f. matsvimbo3 1clinical and administration departments, luisa guidotti hospital, mutoko; 2college of health sciences, university of zimbabwe, harare; 3provincial medical director, mashonaland east province, marondera, zimbabwe abstract staff attrition and frequent turnover in the clinical areas represent a threat to adequate standards of quality of services and its improvement. we describe an example of comprehensive multidisciplinary approach to strengthen health services delivery based on initiatives to: i) reinforce leadership and management of the clinical team; ii) support evidence-based knowledge and performance of the health workforce (hw) for improved efficiency, standardization and resilience to staff migration and/or turnover; iii) develop tools to measure dimensions of leadership and teamwork spirit, competence and quality of health services delivery. results from a retrospective serial cross-sectional analysis of 17 months of implementation of the approach are presented, with special focus on maternal and neonatal outcomes, to inspire future approach and expansion. considering deliveries and outcomes occurred at the same institution during the periods january2019may2020 (period a – control i), january2021-may2022 (period b – control ii) compared to january2023-may2024 (period c test), we observed significant improvements in clinical outcomes (reduction of institutional perinatal mortality from 18.9:1000 and 27.9:1000 to 7.3:1000). this despite the increase of staff turnover and increased workload in the maternity department (particularly between period c vs. period b). these data support that the integrated multidisciplinary approach described may help to promote optimization of hw performance, to assist in increasing competency, and resilience to the threat to quality of services, posed by high turnover of team members, often happening in low-resources and rural settings. introduction health systems strengthening represents a priority in the global agenda, due to the continuous global health challenges currently present. over the past two decades, it has been increasingly universally accepted that the international community, as well as national and local authorities, should focus on integrated, multisectoral approaches, which can help to identify and solve problems with holistic and interdisciplinary methodologies rather than sectoral ones. concepts of “one health systems”, and “systemthinking” approaches, to identify and address weaknesses, strengthening public health systems, received increased consensus from the international scientific community and international organizations, over the past twenty years. today, the need for health systems to be able to respond and adapt to challenges, as well as learn from ongoing monitoring processes, cannot be overemphasized.1-7 both the world health organization in 2007,6 and later the world bank/ecohealth alliance in 2018,3 have indicated some building blocks as key elements to focus on, to strengthen health systems, which have strong similarities among them [“(i) service correspondence: massimo migani – luisa guidotti hospital – all souls mission, p.o.box 201, mutoko, zimbabwe. tel.: +263774720458 e-mail: massimo.migani@gmail.com key words: health workforce, health systems strengthening, perinatal death, maternal health, leadership and management in health. contributions: mm, chief coordinator of institutional activities implementation, principal author; kv, implementation clinical activities, reviewing protocols, quality assurance rjm, fc, implementation of activities, multidisciplinary study and monitoring of human resources performance; td, monitoring of human resources performance, reviewing protocols, quality assurance; ic, training and monitoring of human resources performance, reviewing protocols, quality assurance; vc, statistical analysis; pfm, chief coordinator. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: not applicable. availability of data and material: data presented is available upon request from central database of ministry of health of zimbabwe (dhis2) – data submitted and recorded by luisa guidotti hospital. acknowledgements: special thanks go to the contribution of prof. antonio ragusa, dr alessandra meloni and dr claudio crescini for their fundamental support towards the training of trainers at luisa guidotti hospital with the use of obstetric simulators in the labour ward and towards the continuous development and review of improved institutional evidence-based protocols and checklists. received: 1 september 2024. accepted: 21 march 2025. early access: 1 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12999 doi:10.4081/hls.2025.12999 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 196] [healthcare in low-resource settings 2025;13:12999] delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance” who 2007; “(i) stakeholders, roles, and responsibility; (ii) financial and personnel resources; (iii) communication and information; (iv) technical infrastructure; and (v) governance” world bank/ecohealth alliance 2018].3 it is the multiple relationships and interactions among the blocks that convert these blocks into a system.5 the covid-19 pandemic highlighted the weaknesses already present in health systems and their responsiveness across the globe, and in the post pandemic period we are experiencing very concerning gaps in terms of meeting the needs for health workforce, with some countries being hit by huge staff migration, therefore the call for an “ethical approach” by who. in january 2023, the african regional office of who, developed a charter focused on future investment in the health workforce, highlighting the importance of investing into health workforce in improving prevention, monitoring and responsiveness to strengthen existing systems and improve response to future pandemics. the document also highlighted the importance to strengthen leadership and stewardship at all levels and promote investments in the health workforce guided by evidence-based prioritization.7 in line with the above-mentioned rationale of approach, the zimbabwe national health strategies 2016-2020 and 2021-2025, (zw nhs strategic documents 2016-2020 and 2021-2025), have indicated guiding principles for an operational framework aimed to strengthen the public health system. in the “2023 who health workforce support and safeguards list”, it was highlighted that the increasing demand for health and care workers in high-income countries, could have increased vulnerability, with countries already suffering from low health workforce densities. the list included countries which faced major health workforce challenges related to universal health coverage and they have: i) a density of doctors, nurses and midwives below the global median (i.e., 49 per 10 000 population); and ii) a universal health coverage service coverage index below a certain threshold. zimbabwe was included in the 2023 list, among the 37 african countries, for safeguards against active international recruitment. (2023 who health workforce support and safeguards list, document). staff migration and high turnover rates in teams negatively impact the quality of health services, improvement, and team motivation, therefore affecting outcomes. in this article, we described a set of multidisciplinary interventions which were implemented at a mission hospital as an attempt to standardize an approach, to enable continuous quality improvement, optimization of the health workforce and mitigate threats posed by staff rotation and attrition in a highly changing settings. the interventions described were introduced progressively from 2019, but it is from may 2022 that from the lessons learnt during the previous phase, a comprehensive multidisciplinary approach was set and finally implemented from january 2023. we focus our retrospective review particularly on the maternity department as it was the first department in which a full implementation was achieved during this period. materials and methods study design this is a retrospective serial cross-sectional analysis conducted over 3 periods of 17 months each (before the full implementation of the set of interventions), in a single centre of implementation (luisa guidotti hospital – lgh). the 3 periods are represented by: january 2019-may 2020 (period a – control i) january 2021may 2022 (period b – control ii) and january 2023 – may 2024 (period c test). the period between period b and period c (junedecember 2022) is considered as a transition period, in which the implementation of complete set of interventions was under completion, before the full roll-out from january 2023. sample and setting the sample populations are related to the total institutional deliveries (and their outcomes) as recorded in the hospital delivery registers and present in the official database of the ministry of health and child care of zimbabwe (dhis2), conducted at luisa guidotti hospital during the 3 periods under review. for perinatal and maternal deaths, audits were conducted, and individual records were examined. as an outcome indicator for the quality of health services, the “institutional” perinatal mortality was considered to limit variables more related to external factors impacting outcomes. the indicator was calculated as the rate of fresh still births fsbs (fresh foetal deaths occurred) and early neonatal deaths ennds (within 7 days from delivery) for foetuses >28 weeks of gestation. the formula used was [(fsbs+ennds)/(institutional live births+fsbs+ennds) x 1000]. for the reasons explained above, we considered only deliveries that occurred within the facility (not home deliveries) and fresh still births (fsbs), as well as all early neonatal deaths (ennds), as they are more related to institutional management. we excluded the macerated still births (msbs) as not linked to institutional management of labour and delivery but influenced by other factors (i.e. antenatal and community level interventions), unless if an msb would have occurred during the period in which mothers were lodging at the waiting mothers’ home within the facility and were under the care of hw with daily monitoring, to wait for labour to initiate, and after having reported to the facility with a viable foetus. maternal deaths are described without statistical evaluation as there we recorded high variability in the scenario in which they occurred. statistical analysis was performed using the chi-square test. interventions the set of interventions introduced were designed by a multidisciplinary team composed of clinical managers, clinicians, nurse managers, nurse educators, human resources managers and included an approach focused on the following components. leadership and management as part of a leadership and management (l&m) development programme, focus groups discussions on leaderships and management and on principles of leadership oriented by emotional intelligence were conducted, followed by the distribution of anonymous questionnaires compiled by team members to allow constructive feedback to team leaders, followed by single coaching sessions to improve leadership, management and teamwork, to promote effective teams. clinical knowledge and skills development a continuous programme of simulations and practical sessions in the clinical ward was promoted, to standardize evidence-based protocols and practices, promote adequate knowledge transfer and orientation of new staff and increase team efficiency (including the use of checklists). monitoring and evaluation of performance and indica article [healthcare in low-resource settings 2025;13:12999] [page 197] tors the use of managerial checklists to guide support and supervision by nurse managers, in collaboration with nurse tutors in the clinical areas, to verify and support standards, identify gaps, track and measure trends in performance as a percentage of a total score, was regularly promoted (weekly and monthly). parallel to this, the human resources department developed tools to measure the dimensions expressed in the l&m component described above, to assist managers to compose teams to maximize the team’s emotional intelligence qi were applicable, in case of needs of staff rotation secondary to turnover. moreover, a complete review of the working timetable and roster modelling adaptation was done by the nurse managers, together with the human resources department, to increase an even distribution of working hours among staff, prioritize continuity in the patients’ assistance, based on the average patients bed stay, and reduce exhausting shifts to promote a positive working environment. we believe that the interventions described are important components in the aim to improve performance, flexibility, problem solving, creativity and resilience. data collection process deliveries for the periods a, b and c, as well as outcomes were collected from institutional delivery registers, to elaborate institutional perinatal mortality rates, calculated as a proportion of fresh still births and early neonatal deaths (deaths occurred within 7 days from delivery), over the total number of deliveries occurred in the reporting period. chi-square test was conducted to evaluate the presence of a statistically significant difference between the deliveries conducted in periods c (test) vs. b (control ii), c (test) vs. a (control i), a (control i) vs. b (control ii), to measure differences in the outcomes. a second evaluation (chi-square test) was conducted between period c (test) vs. b (control ii) to review the team composition of the maternity department, in terms of total hw, resignations, or transfers-out, or new addition to the team to review the amount of rotation of staff. to describe this, we introduce a team rotation index (tri), to evaluate the proportion of resignations or transfers plus rotations or new staff deployed, out of the total average team composition of the maternity department for the periods. the average staff establishment for the two periods was calculated from monthly data collected. every staff rotation (internal rotation from other departments/new deployment, or transfer to other facility/resignation) was recorded monthly and a proportion was calculated as the sum of these over the total average team composition for the periods, to have an idea of the total turnover index occurred in the period. the higher the index, the higher the changes experienced (therefore potential team disruptions) in the team composition during the period under evaluation. ethical considerations all questionnaires to staff members, when applicable, were conducted, obtaining verbal consent and in an anonymous manner to promote open and constructive feedback to managers. the study, because of its design, did not require ethical committee’s approval as it is based on a retrospective analysis of the number of deliveries and their outcomes, as well as department’s workloads and quality of service indicators. results the interventions described above were progressively finalized as a set during the period june – december 2022 and fully implemented from january 2023. for these reasons we decided to compare outcomes from deliveries conducted at facility sampling 17 months from january 2019 to may 2020 (period a – control i), january 2021 to may 2022 (period b – control ii), comparing with january 2023 to may 2024 (period c test). results (table 1) showed that during period a (control i), a total of 1193 institutional deliveries were conducted with an institutional perinatal mortality rate of 18.9:1000, compared to 905 deliveries and perinatal mortality of 27.9:1000 in period b (control ii), and 1085 deliveries with a significant reduction (chi-square test p<0.001) of perinatal mortality (7.3:1000) recorded in the period c (test). there was therefore a reduction of perinatal mortality rates of 61.4% between period c (test) and a (control i) and of 73.8% between period c (test) and b (control ii). comparing the deliveries between period c (test), a (control i) and b (control ii), the highest workload recorded in the labour ward was period a (control i) with 1193, followed by period c (test) 1085 and period b (control ii) with 905. of note, the amount of home deliveries which was recorded as the highest in period b (control ii) with 83, followed by period a (control i) with 41, and by period c (test) with 31. fresh still births and early neonatal deaths were the lowest in period c (test) compared to both controls (see table 1). in period a (control i), 2 maternal deaths were recorded secondary to obstetric complications (1 post-partum haemorrhage post caesarean section, 1 suspected hellp syndrome post caesarean section for preeclampsia). in period b (control ii), 3 maternal deaths occurred (2 at community level during transportation to facility for post-partum haemorrhage, 1 secondary to complications of covid19 pneumonia). in period c (test), 1 maternal death occurred at facility level, as late presentation of septic shock, post abortion performed at community level. bed occupancy level of the maternity department was compared between the three periods. the results show a significant difference between period a (control i) and period c (test) with higher occupancy compared period b (control ii) but not between period a (control i) and period c (test). a second evaluation between period c (test) and period b (control ii) was done, to evaluate the rotations in the team of the maternity department occurred, using a team rotation index (tri) as a proportion of rotations of staff in the team, over the overall average of team members for the reporting period. data collected show that during the period c (test) it was reported a tri of 0.7, compared to tri of 0.3 for the period b (control ii), indicating a higher significant turnover of staff during the test period (chi-square p<0.005). in conclusion, period c (test) recorded higher workloads, higher staff rotations and reduced mortality than period b (control ii) and less workload and reduced mortality than period a (control i). it was not possible to evaluate the tri for period a (control i) as data on staff rotations were missing. period c (test) recorded overall a significant reduction in perinatal mortality rates compared to both controls. data are summarized in tables 1, 2, and 3. discussion the main aim of the study was to evaluate in retrospect, the effectiveness of a comprehensive-multidisciplinary approach made to strengthen the hw clinical competence and performance, the article [page 198] [healthcare in low-resource settings 2025;13:12999] quality of services and the teamwork capacity in the maternity and labour ward such to improve patient outcomes, overcome challenges posed by high turnover of staff and staff migration, which negatively impact continuous improvement and eventually outcomes. health systems strengthening represents a priority in the global agenda, due to the continuous global health challenges currently present. today, the need for health systems to be able to respond and adapt to challenges, as well as learn from ongoing monitoring processes, cannot be overemphasized.1-7 staff migration and high turnover rates in teams, negatively impact quality of health services, improvement and team motivation, therefore outcomes. zimbabwe was included in the 2023 list, among the 37 african countries, for safeguards against active international recruitment (2023 who health workforce support and safeguards list, document). in a review made by siegel and young in 2021 about areas for nurses managers to focus on, to improve quality of services and hw performance for better outcomes in nursing homes in the u.s., the authors highlight the importance to move beyond describing patterns, to designing and implementing interventions that improve the structures, processes and outcomes, according to the donabedian model. this to identify practices for managers to lead and manage the nursing workforce and build capacity to ensure person centered, high-quality care.10 in this study, to evaluate the effectiveness of the approach implemented, we focused our attention on the institutional deliveries and outcomes in terms of mortality rates. to reduce biases which may have been caused by external factors (i.e. covid19 waves during the pandemic, and other factors related to community interventions for health), we considered fresh still births and early neonatal deaths, which are more directly related to the management of labour and delivery, and we excluded macerated still birth, unless related to an intrauterine death occurred during the article [healthcare in low-resource settings 2025;13:12999] [page 199] table 1. lgh maternity and perinatal outputs and outcomes 2019-2024 stratified by period of analysis. the table summarizes the analysis done comparing three periods (chi-square test): period a (control i), period b (control ii) and period c (test). there has been a significant reduction in the perinatal mortality rate for the period c (test) compared to both controls. period b (control ii) recorded the highest number of home deliveries and highest perinatal mortality rate which, besides the reduction in the consistency of sessions of simulations recorded, the need to strengthen leadership and management and the occurrence of some staff rotations, could be explained by the influence of lockdowns and fear to seek for assistance at hospital level by the population during the covid19. ). (chi-square test * significant difference p-value < 0.01). period the mother would have been lodging at the waiting mothers’ home under the care of the hw of the hospital (upon admission with a viable foetus), and waiting for the onset of labour. the data presented show significant reduction in perinatal mortality for the period c (test), compared to the control periods [61.4% reduction vs. period a (control i) and 73.8% reduction vs. period b (control ii)]. the increased mortality recorded in period b (control ii) vs. period a (control i) may be partially attributed to a disruption observed in the delays, which during the covid-19 lockdowns, may have amplified disruptions in access to health by the rural populations. this may be also justified by the increased number of home deliveries (83) during this period, compared to 41 of period a (control i) and 31 of the period c (test). we believe that other relevant contributing factors, may be represented by the team members rotations with associated recorded loss of continuity of implementing periodic practical simulations in a systematic manner, and the identified need in that period to strengthen the leadership and management skills. both these interventions were then strengthened systematically from june 2022, during the transition period described above. these considerations may be supported by the fact that, while lgh recorded a perinatal mortality rate of 27.9:1000 during period b (control ii), the overall rate for the same indicator for the entire mutoko district (where lgh is located) was 15.6:1000 (table 3). reviewing the data of the period a (control i), it is of note that the centre of implementation (lgh) recorded an institutional perinatal mortality of 18.9:1000 slightly below the indicator calculated for the overall mutoko district (19.7:1000), and during period b (control ii) as already mentioned, there was a significant increase beyond the overall district mortality (27.9:1000 vs. 15.6:1000). (mohcc of zw national database dhis2). comparing the same rates for the period c (test), while the district overall mortality rate remain similar to period b (control ii), luisa guidotti hospital (lgh) reported a significant reduction in the institutional perinatal mortality, reaching 7.3:1000. we recognize some limitations in the analysis of these retrospective data as explained earlier. however, to limit the potential biases, we sampled a consistent period in the cross-sectional analysis represented by 17 months of implementation of the approach, and compared to both pre-pandemic period (control i), when some of the interventions had started to be implemented, and the period b (control ii) in which some team members rotated and we lost continuity in some activities. we also compared the institutional data (lgh) with the overall district of mutoko data, calculated for the same parameter as the institutional perinatal mortality rate article [page 200] [healthcare in low-resource settings 2025;13:12999] table 2. lgh vs mutoko district maternity and perinatal outputs and outcomes 2019-2024 stratified by period of analysis. mutoko district overall delivery and “institutional” perinatal mortality rates vs. luisa guidotti hospital (lgh) for the period a (control i), period b (control ii) and period c (test). (chisquare test * significant difference p-value < 0.01; ỻ significant difference p-value <0.05) table 3. lgh staff turnover analysis. summary of the turnover of staff index (tsf) (chi-square test); note that during the period c (test) vs. the period b (control), there has been a significant increase of staff rotation, causing the risk of loss of continuity in performance. despite the risk of disruption within the team, in the period c (test) the hospital recorded the lowest perinatal mortality compared to both controls (chi-square test; ỻ significant difference p-value <0.05). [(fsbs+ennds)/(institutional live births+fsbs+ennds)*1000]. to this regard, it is of note that, with the data available, we could also compare the tri (team rotation index) between the period c (test) and the period b (control ii) and we found a significant difference (chi-square p<0.005), indicating that the test period had a higher index (0.7 for the test period vs. 0.3 for the control ii period). this highlights that the test period had higher rotations of staff (+133.3%), therefore more risks for team disruption and associated threats to impair quality and outcomes. on the contrary, the period c (test) had the lowest mortality compared to both controls (61.4% vs. control i and -73.8% vs. control ii). finally, it is to note also that among the staff rotating in the period c (test) 4 of the 6 new additions to the team (representing 26.7% of the average team composition), where represented by deployment of new midwives soon after training (therefore with reduced clinical experience) but coming from luisa guidotti hospital school of midwifery, in which the approach to the use of simulators and practical sessions is emphasised. this could support the concept that the systematic regular use of simulators, practical sessions in the clinical areas, clinical checklists, and the promotion of clinical audits, support effectively knowledge transfer and enhance learning and skills development for hw and students. further research would be necessary to test the interventions in other clinical set-up and departments for longer periods, to better evaluate its effectiveness and review trends with time. conclusions the present study represent a multidisciplinary comprehensive approach to strengthen health workforce, skills performance, improve patient outcomes and mitigate negative effects caused by staff rotation and migration. the need to develop strategies and interventions to support quality improvement, knowledge transfers, skills development and hw team performance cannot be overemphasised, given the current global situation of lack of hw, especially in low-resource and rural settings where staff rotation and migration is high. despite higher staff rotations occurred in the test period, the approach led to positive results shown by the significant reduction of perinatal mortality rates for the test period compared to both control periods (-61.4% vs. control i and -73.8% vs. control ii). these data support that the integrated multidisciplinary approach described, may help to promote optimization of hw performance, to assist in increasing competency, and resilience to the threat to quality of services, posed by high turnover of team members, often happening in low-resources and rural settings. the data also support that the same approach can be an effective method to enhance learning and skills for students under training. references 1. swanson rc, cattaneo a, bradley e, et al. rethinking health systems strengthening: key systems thinking tools and strategies for transformational change. health policy plan 2012;27:iv54-61. 2. ferrinho p, fronteira i. developing one health systems: a central role for the one health workforce. int j environ res public health 2023;20:4704. 3. world ban ecohealth alliance. operational framework for strengthening human, animal and environmental public health systems at their interface. world bank group: washington, dc, usa, 2018. 4. world health organization; food and agriculture organization of the united nations; world organisation for animal health; united nations environment programme. one health joint plan of action (2022–2026): working together for the health of humans, animals, plants and the environment. world health organization: geneva, switzerland, 2022. 5. de savigny d, adam t. alliance for health policy and systems research; world health organization. systems thinking for health systems strengthening. world health organization: geneva, switzerland, 2009. 6. world health organization. everybody’s business—strengthening health systems to improve health outcomes: who’s framework for action. world health organization: geneva, switzerland, 2007. 7. africa health workforce investment charter. enabling sustainable health workforce investments for universal health coverage and health security for the africa we want. world health organization; january 2023. article [healthcare in low-resource settings 2025;13:12999] [page 201] hrev_master healthcare in low-resource settings 2024; volume 12(s2):12432 socioeconomic disparities in children's posture defects: a comparison between private and public educational institutions lukasz kolodziej,1 sebastian kwiatkowski,2 magda gebska,3 ireneusz walaszek,4 karolina skonieczna-żydecka5 1department of orthopedics, traumatology and oncology of the musculoskeletal system, pomeranian medical university of szczecin, szczecin; 2stmedical clinic, szczecin; 3department of rehabilitation of the movement system, pomeranian medical university of szczecin, szczecin; 4department of pediatric surgery, oncology, urology and hand surgery, pomeranian medical university of szczecin, szczecin; 5department of biochemical research, pomeranian medical university of szczecin, szczecin, poland abstract the topic of risk factors for posture pathology in polish children is relevant at present, as it is insufficiently studied and reflects the need to investigate the relationship between family socioeconomic status and the occurrence of posture defects, to develop relevant prevention and treatment strategies in the context of current socioeconomic conditions in poland. the research aims to study posture defects in children depending on their socioeconomic status in the example of private and public schools. a comparison of the prevalence of deformities and posture disorders of participants in private and public educational institutions from 2017 to 2020 is presented. theoretical research methods (literature analysis, generalisation); empirical methods (study of other researchers’ experience), statistical analysis, and graphical presentation of data were used. more than 1300 polish schoolchildren from private and public schools took part in this cross-sectional study. the most common problems were flat feet (54.73%), calf muscle contracture (44.30%), and valgus deformity (21.22%). the least common problems were funnel chest (0.37%), cavus foot (0.10%), and hammer toe deformity (0.04%). the general trend shows that problems with flat feet and calf muscle contracture were more common among participants in both types of educational institutions. there was a general trend of increasing the number of nosological forms per patient in both private and public institutions over a period of three years. private institutions had significantly fewer cases of one patient having more than one nosological form as compared to public institutions. introduction posture, the manner in which an individual maintains an upright position, is influenced by various factors such as overall health, age, lifestyle, and well-being. additionally, genetic predispositions, organ structure, and external elements contribute to one’s posture. as the body develops, it adapts to its surroundings, including the control of posture, which can be influenced by habitual behaviours, including reflex actions. developing proper posture habits early on is crucial, as maintaining poor posture can worsen existing deficiencies. therefore, it is essential for both children and adults to cultivate correct posture habits. ensuring a healthy body structure is key to preventing posture-related issues, with factors such as limb shape, spine condition, and the strength of supporting muscles playing significant roles.1-4 musculoskeletal disorders are becoming increasingly common, especially in children. in the future, this problem may occur in adults. modern lifestyles do not encourage physical activity in young people, which affects posture patterns. schools play a significant role in shaping a child’s worldview, yet this influence can sometimes result in distortions and unhealthy habits. unfortunately, parents may not consistently prioritize monitoring changes in their children’s musculoskeletal systems. consequently, there is a vital need for both parents and schools to take preventive measures and assume responsibility for fostering proper posture among children and adolescents. this joint effort is correspondence: sebastian kwiatkowski, stmedical clinic, szczecin, poland. e-mail: seba.kwiatkowski@outlook.com key words: healthcare organisation; private schools; public schools; prevention of musculoskeletal disorders; paediatrics. contributions: lk and mg, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; sk and iw, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; ksz, conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. patient consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. received: 27 february 2024. accepted: 10 may 2024. early view: 22 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12432 doi:10.4081/hls.2024.12432 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 68] [healthcare in low-resource settings 2024;12(s2):12432] non -co mmerc ial us e o nly crucial for ensuring the long-term health and well-being of young individuals as they develop.5 latalski et al. analysed risk factors for the development of posture defects in school-aged children from poland and the czech republic.6 a correlation between the child’s physical activity and the occurrence of posture defects was found. children who spend more time in active physical activities are less likely to develop posture defects. children from families with higher economic status were more likely to be aware of posture defects and to have undergone appropriate screening. therefore, researchers recommend the creation of an education system for parents and children aimed at preventing posture defects and informing them about the associated risks. the rationale for investigating the relationship between socioeconomic status and posture defects in children stems from the known influence of socioeconomic factors on various aspects of health and well-being, including musculoskeletal health. studies have highlighted the significant impact of socioeconomic status on health outcomes across different populations. research has consistently shown that children from lower socioeconomic backgrounds are more likely to experience adverse health outcomes, including higher rates of obesity, chronic diseases, and developmental issues. these disparities often extend to musculoskeletal health, where children from disadvantaged backgrounds may face increased risk factors for posture defects due to limited access to healthcare, inadequate nutrition, and environmental factors. for instance, a study by muchacka and pyclik5 found that children from lower socioeconomic backgrounds were more likely to have poor posture and musculoskeletal issues compared to their counterparts from higher socioeconomic backgrounds. similarly, research by cichewicz et al.7 demonstrated a correlation between socioeconomic status and the prevalence of spinal deformities in school-aged children. given these findings, investigating the relationship between socioeconomic status and posture defects in children is crucial for understanding and addressing health disparities within the pediatric population. by identifying the specific socioeconomic factors that contribute to posture defects, interventions, and policies can be developed to mitigate these disparities and promote musculoskeletal health equity among children from diverse socioeconomic backgrounds. therefore, this research question is essential for informing public health initiatives aimed at improving the overall well-being of children and reducing health inequalities. it has been previously shown that general health status depends on several factors, including socioeconomic status, and in the context of poland including the type of employment and access to modern infrastructure.8-11 yang and kayaardi,12 and rój and jankowiak13 also determined that social inequality in the polish population not only affects health but also limits access to e-health technologies, which may provide a basis for improving public policy in this area. thus, evidence on the impact of various factors on the development of posture pathology has been accumulating, but in the context of polish schools, such evidence is limited and requires further research. the research aims to examine how the socio-economic status of families influences the prevalence of posture defects in children, using private and public schools as case studies. the objectives of the study were to reveal the following points: i) to develop and evaluate a wellness program for children in both private and public schools to promote healthy posture and prevent postural defects, including physical activity, nutrition education, access to medical care, and awareness campaigns; ii) to investigate the differences in access to health care and nutrition between children from low and high socioeconomic status in both types of schools, assessing their impact on the prevalence of postural defects; iii) to evaluate the effectiveness of educational campaigns for parents on the importance of good posture for children’s health. the study provides novel insights into musculoskeletal health among polish schoolchildren by analysing data from three academic years (2017-2020) in private and public educational institutions. it explores how different educational settings influence the prevalence of various deformities and posture disorders, highlighting disparities between private and public schools. additionally, the analysis of the average number of conditions per patient offers a nuanced understanding of musculoskeletal burdens within each setting. materials and methods the study utilized a cross-sectional approach to gather data at a single point in time. theoretical research methods involved reviewing scientific literature and previous studies on the association between family socioeconomic status and children’s health, particularly regarding postural defects. empirical methods included examining the findings of other researchers and designing the data collection methodology, which involved selecting a representative sample of children from private and public schools across various socioeconomic backgrounds. the posture status of children from both types of schools was assessed using medical diagnostic methods, and the collected data were analysed to identify any relationships between family socioeconomic status and posture defects in children. the results were interpreted to determine if there is indeed a correlation between family socioeconomic status and posture defects among children attending different types of schools. finally, recommendations were formulated for educational and healthcare organizations to enhance children’s health and prevent posture defects. standard methods of measurement were used to collect anthropometric data. posture assessment was performed by a specialist with experience in the field who applied an assessment scale. children in the 1st grade (age 6-8 years) of primary schools in szczecin, poland, participated in the study. the study was conducted over the period from 2017-2020. from private educational institutions, 1295 people participated, while from public educational institutions, 65 children were involved. a total of 1360 people participated in the study, among whom there was no differentiation by gender or other parameters except for the type of educational institution (private or public). mean values and percentages were used for descriptive analyses (table 1). social and political factors affecting public health table 1. nosological forms and corresponding postural defects. nosological forms hyperkyphosis strephenopodia flat back syndrome cavus foot hyperlordosis hallux limitus/rigidus kypholordotic posture hammer toe deformity scoliosis hyperextension of the knee joints funnel chest hyperextension of the elbow joints pectus excavatum calf muscle contracture valgus deformity hamstring contracture flat feet sternocleidomastoid muscle contracture planovalgus deformity shoulder asymmetry [healthcare in low-resource settings 2024;12(s2):12432] [page 69] non -co mmerc ial us e o nly informed consent was obtained from the parents or guardians of all study participants. participants’ data was anonymised and processed following privacy protection requirements. the study was conducted following ethical standards set by national and international organisations. the use of visual posture assessment may be subject to subjective perception and judgment by the practitioner. data were obtained only from children of a certain age range and from certain regions, which may limit the generalisation of results to other groups. other factors not considered in this study may also influence the occurrence of postural defects in children. results as noted earlier, 1,295 people participated from private educational institutions during 2017-2018, while 65 children were involved from public educational institutions. these figures reflect the total number of participants and provide a basis for further analysis and comparison of data on various deformities and posture disorders in both types of educational institutions. when analysing the data obtained for 2017-2018, one significant finding is that hyperkyphosis, characterized by the backward curvature of the spine, was observed in 6.69% of participants in private educational institutions. additionally, it was found in 9.38% of participants in public educational institutions. this indicates a problem in both types of students, but the prevalence of this deformity is higher among public school students. flat back syndrome, or flattening of the natural curves of the spine, occurs in 4.59% of private education participants and only 1.56% of public education participants. hyperlordosis, or forward curvature of the spine, occurs in nearly 7.9% of private education participants and 31.25% of public education participants. additional socioeconomic factors, such as family income, parental education, and living arrangements, may play a significant role in understanding the correlation between types of deformities and postural disorders and educational settings. children from lower-income families may have limited access to health care and physical rehabilitation programs, which can lead to delays in the diagnosis and treatment of postural deformities. parental education can also influence the level of awareness of healthy lifestyles and the importance of good posture, which can affect children’s health and behaviour. living conditions, such as access to healthy foods and opportunities for exercise, can also influence the development of postural deformities among children. a more detailed study of these socioeconomic factors could help to establish the relationship between them and identify specific factors that contribute to the development of postural deformities among children in different types of educational settings. for example, the study could investigate whether there is a link between family income and access to healthcare services for the detection and treatment of postural deformities. it could also examine how parents’ education affects their attitudes toward healthy lifestyles and attention to their child’s postural problems. a social and political factors affecting public health table 2. comparison of the prevalence of deformities and posture disorders of participants in private and public educational institutions (2017-2018). private educational state educational private educational state educational institutions (abs) institutions (abs) institutions institutions hyperkyphosis 83 6 6.69% 9.38% flat back syndrome 57 1 4.59% 1.56% hyperlordosis 98 20 7.90% 31.25% kypholordotic posture 17 3 1.37% 4.69% scoliosis 168 18 13.54% 28.13% funnel-shaped rib cage 27 3 2.18% 4.69% a keel-shaped rib cage 13 0 1.05% 0% vargus deformity 262 29 21.11% 45.31% vargus deformity 8 1 0.64% 1.56% flat feet 448 9 36.1% 14.06% flatfoot 539 43 43.43% 67.19% varus foot 5 0 0.4% 0% hollow foot 4 0 0.32% 0% rigid big toe 55 19 4.43% 29.69% hammertoe deformity of the toes 2 0 0.16% 0% hyperextension of the knee joints 75 13 6.04% 20.31% hyperextension of the elbow joints 18 0 1.45% 0% contracture of the calf muscle 555 37 44.72% 57.81% contracture of the sciatic-ankle muscles 614 32 49.48% 50% sternoclavicular-axillary contracture 75 2 6.04% 3.13% shoulder asymmetry 374 24 30.14% 37.5% shoulder asymmetry 54 1 4.17% 1.54% participants with the pathology in question 1241 64 95.83% 98.46% total number of participants 1295 65 – – source: compiled by the authors. [page 70] [healthcare in low-resource settings 2024;12(s2):12432] non -co mmerc ial us e o nly detailed study of living conditions can include an analysis of access to sports grounds, opportunities for sports, and the level of availability of healthy food in different neighborhoods.14 continuing to analyse the remaining deformities and posture disorders, it can be determined that, in general, such pathology was more frequent in 2017-2018 in the subjects from public educational institutions. in table 2 it is possible to highlight and compare the proportions relative to the total number of participants for each of these in both types of educational institutions. this analysis helps to identify which deformities and posture disorders are more common among students from private and public educational institutions. continuing the analysis of the remaining deformities and posture disorders, it can be determined that, in general, such pathology in 2017-2018 was more frequent in the subjects from public educational institutions. it is possible to highlight and compare the proportions relative to the total number of participants for each of them in both types of educational institutions. this analysis helps to determine which deformities and posture disorders are more common among students from private and public educational institutions. table 3 presents comparative data on the prevalence of various deformities and posture disorders among participants in private and public educational institutions in the 2018-2019 academic year. this table presents data on 1360 participants in private educational institutions and more than 100 participants in public educational institutions, as well as the prevalence of various deformities and posture disorders as a percentage of the total number of participants in each category of educational institutions. some observations on the prevalence of deformities and posture disorders reveal that hyperkyphosis was almost 2% more common in private educational institutions than in public educational institutions. in the latter, its prevalence was more than 5%. between 2019 and 2020, trends in the prevalence of deformities and posture disorders were observed among participants in private and public educational institutions. some deformities, such as hyperkyphosis and flat back syndrome, were found in both types of institutions. however, their prevalence was slightly higher among participants in private institutions. in other cases, such as hyperlordosis, scoliosis, and muscle contractures, the prevalence of these conditions was slightly higher among participants in public institutions. flat feet were most common among participants in both types of institutions, but their prevalence was slightly higher among participants in private institutions. the overall trend indicates that there are differences in the prevalence of deformities and posture disorders between private and public educational institutions, although some conditions may be more prevalent in one of these categories. details are shown in table 4. table 4 provides information about the study participants who participated in the period from 2017 to 2020 in private and public educational institutions. it includes the total number of participants with different types of pathologies and the percentage of participants without pathologies in each category of institution. the table compares the number of participants with different pathologies in private and public schools. it also shows the percentage of participants with pathologies in relation to the total number of participants in each type of institution. for example, in private schools, 89.76% of participants have pathologies, while in public schools, 89.01% have pathologies. the table also shows the number of participants without pathologies: 10.24% in private social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12432] [page 71] table 3. comparison of the prevalence of deformities and posture disorders of participants in private and public educational institutions (2018-2019). private educational state educational private educational state educational institutions (abs) institutions (abs) institutions institutions hyperkyphosis 137 6 7.25% 5.41% flat back syndrome 54 1 2.86% 0.9% hyperlordosis 150 8 7.94% 7.21% kypholordotic posture 30 4 1.59% 3.6% scoliosis 254 14 13.44% 12.61% funnel-shaped rib cage 37 3 1.96% 2.70% keel-shaped rib cage 3 0 0.16% 0% valgus deformity 449 30 23.76% 27.03% valgus deformity 11 0 0.58% 0% flat feet 1149 56 60.79% 50.45% planovalgus deformity 338 18 17.88% 16.22% strephenopodia 3 1 0.16% 0.9% cavus foot 0 0 0% 0% rigid big toe 0 2 0% 1.8% hammer toe deformity 0 0 0% 0% hyperextension 234 22 12.38% 19.82% calf muscle contracture 691 28 36.56% 25.23% shoulder asymmetry 471 31 24.92% 27.93% participants without the pathology in question 197 6 9.44% 5.13% participants with the pathology in question 1890 111 90.56% 94.87% total number of participants 2087 117 source: compiled by the authors. non -co mmerc ial us e o nly facilities and 10.99% in public facilities. using this table, we can compare the distribution of pathologies in private and public schools and understand general trends in the distribution of these pathologies. the general trend also shows that in private institutions the average number of nosological forms per patient is usually lower than in public institutions. details are given in table 5. additional factors, such as urbanization and gender, may also influence the occurrence of postural defects in children. urbanized areas may have higher levels of air pollutants and limited access to open spaces for physical activity, which can lead to an increased risk of developing postural defects. gender can also influence the types and progression of postural defects, given different physiological characteristics and activities. for example, some research suggests that boys may be more susceptible to certain types of postural defects than girls. potential complicating factors such as children’s physical activity levels should also be considered. insufficient physical activity can lead to muscle weakness and underdevelopment of stability, which can contribute to the development of postural defects. nutrition can also influence children’s bone and muscle health, which can play a role in the development of good posture. access to health care can also be an important factor, as timely detection and treatment of postural defects can prevent their progression and avoid serious complications in the future. the socioeconomic status of the family is another important factor that can influence the appearance of children’s posture. low-income families may have limited access to health care services and physical rehabilitation programs, which can contribute to delays in the diagnosis and treatment of postural defects. parental education levels can also influence awareness of healthy lifestyles and the importance of good posture, which can affect children’s health and behaviour. living conditions, such as access to healthy food and opportunities for physical activity, can also influence the development of postural defects among children. thus, the general trend indicates differences in the prevalence of various deformities and posture disorders between private and public educational institutions, although some conditions may be more prevalent in one of these categories. discussion the research showed comparative data on musculoskeletal disorders in public and private school students. similar results have been obtained in other studies and other areas of medicine. as such, khalid et al. investigated the relationship between socioeconomic status and oral health indicators in private and public school students in karachi, pakistan.15 the study found that children from private and government schools had similar mean dmft (number of impacted, extracted, and filled teeth) but there were significant differences in other oral hygiene indicators such as dental plaque, dental stains, and gingival bleeding/gingivitis. the article highlights the need for increased awareness and public funding to improve the oral health of children from less affluent families and social and political factors affecting public health table 4. comparison of the prevalence of deformities and posture disorders of participants in private and public educational institutions (2019-2020). private educational state educational private educational state educational institutions (abs) institutions (abs) institutions institutions hyperkyphosis 221 24 12.36% 10.43% flat back syndrome 30 8 1.68% 3.48% hyperlordosis 62 11 3.47% 4.78% kypholordotic posture 25 7 1.40% 3.04% scoliosis 123 8 6.88% 3.48% funnel-shaped rib cage 38 7 2.13% 3.04% keel-shaped rib cage 2 0 0.11% 0% valgus deformity 333 32 18.62% 13.91% valgus deformity 6 5 0.34% 2.17% flat feet 1095 112 61.24% 48.7% planovalgus deformity 244 57 13.65% 24.78% strephenopodia 1 0 0.06% 0% cavus foot 1 0 0.06% 0% rigid big toe 0 0 0% 0% hammer toe deformity 0 0 0% 0% hyperextension 102 7 5.7% 3.04% calf muscle contracture 933 89 52.18% 38.7% sciatic-ankle muscle contracture 721 85 40.32% 36.96% clavisternomastoid contracture 1 8 0.06% 3.48% shoulder asymmetry 135 22 7.55% 9.57% participants without the pathology in question 310 43 14.78% 15.75% participants with the pathology in question 1788 230 85.22% 84.25% total number of participants 2098 273 source: compiled by the authors. [page 72] [healthcare in low-resource settings 2024;12(s2):12432] non -co mmerc ial us e o nly recommends the introduction of practically oriented programs to improve the oral hygiene of public school students. groeneveld et al. attempted to estimate the prevalence of stunting, underweight, overweight, and obesity among 8-10-yearold children in quetzaltenango, guatemala, considering socioeconomic status.16 height and weight measurements were taken in 583 private and public-school students. the researchers determined that average height, weight, and body mass index were higher in children with high socioeconomic status. stunting and underweight are more common in low-status children, while overweight and obesity are more common in high-status children. the current study did not consider the urbanisation factor and did not include adult subjects. vavken and dorotka previously investigated the burden of musculoskeletal diseases and their determination concerning urbanisation, socioeconomic status, age, and gender.17 the study involved more than 14,500 participants in the european health interview survey conducted in austria in 2006-2007. the aim was to estimate the prevalence of osteoarthritis, spinal disorders, and osteoporosis in a population representative of other european union or organisation for economic cooperation and development countries. urbanisation, socioeconomic status, age, and gender were considered determinants of musculoskeletal diseases. the results of the study showed that the prevalence of arthritis was 18.8%, spinal disorders 38.4%, and osteoporosis 6.6%. census data showed a significant effect of urbanisation on the prevalence of arthritis and osteoporosis but not on spinal diseases. arthritis and spinal diseases were associated with socioeconomic status, while osteoporosis was associated with age, income, and education.18,19 when arthritis was analysed, it was found that the impact of urbanisation was significantly reduced after accounting for socioeconomic status.20 the findings of the study indicated that the burden of musculoskeletal diseases depends on both urbanisation and socioeconomic status. however, the effect of urbanisation is probably due to differences in socioeconomic status and demographics between geographical regions. the research also did not segregate students by gender. previously, carrilero et al. conducted a study on socioeconomic and gender inequalities in child health in catalonia.21 the study social and political factors affecting public health table 5. comparison of the number of nosological forms per patient in private and public educational institutions for the period 20172018 to 2019-2020. overall data private educational institutions state educational institutions number of nosological participant number of nosological participant number of nosological participant forms in 1 patient number forms in 1 patient number forms in 1 patient number 2017-2018 0 57 0 56 0 1 1 264 1 260 1 4 2 345 2 335 2 10 3 317 3 302 3 15 4 214 4 204 4 10 5 98 5 86 5 12 6 43 6 36 6 7 7 18 7 13 7 5 8 3 8 2 8 1 9 1 9 1 9 0 2018-2019 0 203 0 188 0 15 1 564 1 544 1 20 2 591 2 561 2 30 3 431 3 402 3 29 4 239 4 220 4 19 5 113 5 109 5 4 6 51 6 51 6 0 7 12 7 12 7 0 2019-2020 0 353 0 306 0 47 1 649 1 562 1 87 2 631 2 569 2 62 3 435 3 389 3 46 4 220 4 195 4 25 5 45 5 42 5 3 6 32 6 29 6 3 7 6 7 6 7 0 overall data over 3 years 0 613 0 550 0 63 1 1477 1 1366 1 111 2 1567 2 1465 2 102 3 1183 3 1093 3 90 4 673 4 619 4 54 5 256 5 237 5 19 6 126 6 116 6 10 7 36 7 31 7 5 8 3 8 2 8 1 9 1 9 1 9 0 source: compiled by the authors. [healthcare in low-resource settings 2024;12(s2):12432] [page 73] non -co mmerc ial us e o nly covered 1,449,816 children under 15 years of age between 2014 and 2017. data on 29 different diseases were analysed and their association with socioeconomic status and gender was assessed. the results showed that 25 of the 29 diseases examined had an association with socioeconomic inequality. some diseases such as tuberculosis, obesity, anxiety disorders, arterial hypertension, poisoning, as well as preterm labour, low birth weight, and fetal growth retardation were particularly sensitive to socioeconomic status. it was also observed that girls had higher relative inequality index (rii) values for several diseases including respiratory allergies, asthma, dermatitis, overweight, and obesity, while boys had higher rii values only for congenital anomalies.22 the findings of the study emphasise the need for action to reduce socioeconomic and gender inequalities in child health. they point to the importance of ensuring more equitable health conditions for all children and emphasise the need for targeted interventions to improve the health of children from different socioeconomic groups. the research illustrated the rather high incidence of musculoskeletal disorders. azabagic et al. analysed the problem of musculoskeletal disorders in school-aged children and touched not only on socioeconomic factors.23 the study was conducted on 1315 pupils aged 8 to 12 years. the main factor influencing the occurrence of musculoskeletal pain was related to poor ergonomics, overloaded backpacks, age-inappropriate furniture, poor posture, sedentary lifestyle and lack of physical activity. the study found that the weight of school backpacks, the way they are worn, time spent sitting both at school and at home, and body mass index (bmi) are factors influencing the development of musculoskeletal pain in children.24 the study concluded that the prevalence of musculoskeletal pain in school-aged children is quite high, and it is necessary to pay attention to ergonomic conditions to prevent its occurrence.25 the research also did not investigate the causes of musculoskeletal disorders and frequency of doctor visits. a study by mbuya-bienge et al. investigated the impact of socioeconomic status on the frequent use of health services among people with multiple health conditions in a public health system in quebec, canada.26 frequent users of health services (5.1% of the population) accounted for 25.2% of all visits. socioeconomic status influences the association between multiple diseases and frequent visits to specialists. inequalities between socioeconomic groups increase as a function of the number of chronic conditions for specialist visits but not for emergency room (er) or general practitioner visits. in general, a link between socioeconomic level and health has been observed worldwide.27-29 thus, an article by rebouças et al. examined social inequalities and their impact on child health from a global and topical perspective.27 the authors point out the historical and structural roots of this problem in different societies. for this purpose, they investigated relevant articles in the pubmed/medline database, conducted manual searches, and examined bibliographic references of selected studies as well as data and documents from international organisations. data analysis showed that to understand how inequalities affect health, it is necessary to consider the unequal distribution of social determinants among population groups. in the case of children, the pathway determined by their parents is crucial. inequitable lifestyles of many families or social groups due to social and economic inequalities lead to unequal health outcomes, especially for children. this is observed both between and within countries. children from the most vulnerable groups are more likely to experience the worst health conditions. interventions targeting children’s health must therefore go beyond health care and impact holistically on poverty, and social and economic inequalities to address systematic and inequitable disparities.30,31 the authors conclude by pointing out that despite significant advances in child health in recent decades, inequalities, measured by various indicators, continue to exist. thus, more and more information is being accumulated on the level of health concerning the socio-economic status of the family. conclusions this study investigated the occurrence of postural defects in children depending on the socioeconomic status of the family. although earlier studies have shown that the type of educational institution and, consequently, the socioeconomic status of the family may be associated with the formation of musculoskeletal pathology in children, this study did not find a statistically significant association between the type of educational institution and postural defects. nevertheless, the occurrence of such defects may be associated with limited access to quality medical care, improper nutrition, lack of physical activity and other factors that negatively affect the formation of the musculoskeletal system. public school students showed a higher occurrence of certain conditions, such as hyperlordosis, while private school students exhibited higher rates of others, like hyperkyphosis. urbanization, gender, physical activity levels, nutrition, and access to healthcare are additional factors that could influence the occurrence of postural defects in children. understanding these complexities is crucial for designing targeted interventions to address postural health disparities and promote overall well-being among school-aged children. flat feet, calf muscle contracture and valgus deformity are the most common problems among students regardless of the type of educational institution. these results underscore the importance of preventive measures and wellness programmes to maintain healthy posture in children and adolescents in both types of educational institutions. there is a requirement for social and economic interventions to enhance the circumstances of low-income households. implementing support initiatives, social welfare programs, and ensuring access to healthcare can mitigate the adverse effects linked with postural defects in children. additionally, enhancing educational outreach and informational campaigns targeted at increasing parental understanding regarding the significance of maintaining proper posture and its implications for children’s wellbeing is essential. encouraging physical activity, adopting healthy lifestyles, and fostering correct body posture can contribute to diminishing the prevalence of postural defects within the community. further research on this topic should delve into the mechanisms by which family socioeconomic status influences posture formation in children. this will make it possible to develop more effective strategies for the prevention and treatment of posture defects, based on an understanding of the root causes of the problem. overall, this study highlights the importance of paying attention to the socioeconomic context when studying child health and supports the need for action to reduce health and social inequalities and improve the quality of life of low-income families. references 1. somhegyi a. posture correction as part of holistic health promotion in hungarian schools. ideggyogy sz 2022;75:151-61. social and political factors affecting public health [page 74] [healthcare in low-resource settings 2024;12(s2):12432] non -co mmerc ial us e o nly 2. cary d, jacques a, briffa k. examining relationships between sleep posture, waking spinal symptoms and quality of sleep: a cross sectional study. plos one 2021;16:e0260582. 3. bayartai m, schaer c, luomajoki h, et al. differences in spinal posture and mobility between children/adolescents with obesity and age-matched normal-weight individuals. sci report 2022;12:15570. 4. hajiyeva nn. value of immunological markers in the prognosis of development of atopic dermatitis in children. azerbaijan med j 2021;4:19-25. 5. muchacka r, pyclik m. posture defects in children and adolescents – characteristics and etiology. prace naukowe wszip 2016;37:69-85. 6. latalski m, bylina j, fatyga m, et al. risk factors of postural defects in children at school age. ann agric environ med 2013;20:583-7. 7. cichewicz k, kulesa-mrowiecka m, wilk-frańczuk m. the impact of distance learning during the covid-19 pandemic on posture defects in children. 2022. 8. baniasadi k, armoon b, higgs p, et al. the association of oral health status and socio-economic determinants with oral health-related quality of life among the elderly: a systematic review and meta-analysis. int j dent hygiene 2021;19:153-65. 9. green h, fernandez r, macphail c. the social determinants of health and health outcomes among adults during the covid19 pandemic: a systematic review. public health nurs 2021;38:942-52. 10. yuan q, wu y, li f, et al. economic status and catastrophic health expenditures in china in the last decade of health reform: a systematic review and meta-analysis. bmc health serv res 2021;21:600. 11. rój j. inequity in the access to ehealth and its decomposition case of poland. int j env res public health 2022;19:2340. 12. yang p, kayaardi n. who chooses non-public schools for their children? educ stud 2004;30:231-49. 13. rój j, jankowiak m. socioeconomic determinants of health and their unequal distribution in poland. int j env res public health 2021;18:10856. 14. spieszny m, trybulski r, biel p, et al. post-isometric back squat performance enhancement of squat and countermovement jump. international j env res pub health 2022;19:12720. 15. khalid t, mahdi s, khawaja m, et al. relationship between socioeconomic inequalities and oral hygiene indicators in private and public schools in karachi: an observational study. int j env res public health 2020;17:8893. 16. groeneveld i, solomons n, doak c. nutritional status of urban schoolchildren of high and low socioeconomic status in quetzaltenango, guatemala. pan am j public health 2007;22:169-77. 17. vavken p, dorotka r. burden of musculoskeletal disease and its determination by urbanicity, socioeconomic status, age, and sex: results from 14,507 subjects. arthritis care res 2011;63:1558-64. 18. latka k, kołodziej w, rajski r, et al. outpatient spine surgery in poland: a survey on popularity, challenges, and future perspectives. risk manag healthcare pol 2023;16:1839-48. 19. latka k, kolodziej w, domisiewicz k, et al. outpatient spine procedures in poland: clinical outcomes, safety, complications, and technical insights into an ambulatory spine surgery center. healthcare (switz) 2023;11:2944. 20. kuranov ab, abisheva st, zhusupova aa, et al. hla class ii genes and rheumatoid arthritis in the kazakh population. immunolog 2016;37:188-93. 21. carrilero n, dalmau-bueno a, garcía-altés a. socioeconomic inequalities in 29 childhood diseases: evidence from a 1,500,000 children population retrospective study. bmc public health 2021;21:1150. 22. parisi gf, leonardi s, ciprandi g, et al. antihistamines in children and adolescents: a practical update. allerg immunopath 2020;48:753-62. 23. azabagic s, spahic r, pranjic n, mulic m. epidemiology of musculoskeletal disorders in primary school children in bosnia and herzegovina. materia socio med 2016;28:164-7. 24. dobrovanov o, dmytriiev d, prochotsky a, et al. chronic pain in post-covid syndrome. bratislava med j 2023;124:97-103. 25. maslak k, favara-scacco c, barchitta m, et al. general anesthesia, conscious sedation, or nothing: decision-making by children during painful procedures. pediatr blood canc 2019;66:e27600. 26. mbuya-bienge c, simard m, gaulin m, et al. does socio-economic status influence the effect of multimorbidity on the frequent use of ambulatory care services in a universal healthcare system? a population-based cohort study. bmc health serv res 2021;21:202. 27. rebouças p, falcão i, barreto m. social inequalities and their impact on children's health: a current and global perspective. j pediatr 2022;98:s55-65. 28. heaton t, crookston b, pierce h, amoateng a. social inequality and children's health in africa: a cross sectional study. int j equity health 2016;15:92. 29. boisvert s. social risk, health inequity, and patient safety. j healthcare risk manag 2022;42:18-25. 30. babii m. telerehabilitation model in operated individuals with upper limb and chest trauma due to road traffic accidents. bull med bio res 2023;5:8-16. 31. sarafyniuk l, stepanenko i, khapitska o, et al. mathematical modelling of peripheral haemodynamics of the shin in volleyball players of mesomorphic somatotype. bull med bio res 2023;5:62-70. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12432] [page 75] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13024 factors associated with maternal stress while caring for premature infants at home rinik eko kapti,1 yuni sufyanti arief,2 nurona azizah,1 sholihatul amaliya,1 lilik supriati,1 ari damayanti wahyuningrum3 1department of nursing, faculty of health sciences, universitas brawijaya, malang, east java; 2faculty of nursing, universitas airlangga, surabaya, east java; 3nursing science of widyagama husada health science college, malang, east java, indonesia abstract the occurrence of stress in mothers with premature infants is known to have a negative impact on both mothers and their infants. to overcome the condition, nurses must understand its influential factors to provide effective assistance. therefore, this study aims to identify factors associated with stress in mothers with premature infants. the study procedures were carried out using a cross-sectional design with a purposive sampling technique comprising 188 mothers with premature infants. in addition, the instruments used were questionnaires for assessing the pss (parent stress scale), knowledge about the benefits of caring for infants, and support. data analysis was then carried out using univariate analysis, chi-square, and binary logistic regression. the majority of mothers had a moderate level of stress, accounting for 46.3% of the total population. in addition, the results showed that factors associated with moderate levels of stress in mothers with premature infants were younger age, low level of education, sc delivery method, living in rural areas, low knowledge of care, very low infant weight, and low partner support. based on the results, maternal factors and unfavorable infant conditions could increase stress in mothers with premature infants. introduction according to the world health organization (who), the incidence rate of premature births was 11.1% of all live births globally, and in 2015, approximately 15 million cases were recorded annually.1,2 several studies have shown that 60% of these cases typically occur in low and middle-income countries in africa and south asia.2 in addition, premature birth is widely known as the leading cause of death in children under 5 years, and its incidence rate has shown an increasing annual trend.3 the high risk of mortality and morbidity associated with the condition necessitates specialized care in the hospital neonates unit and at home. this is to ensure the continuity of appropriate care after discharge as well as the well-being and adequate health of premature infants.1 in line with previous studies, mothers typically serve as the main caregivers for their infants at home. however, caring for premature infants is a challenging process, requiring mothers’ acceptance and understanding of the differences compared to full-term babies.4 previous reports have shown that the caregiving process is characterized by various requirements, such as adequate feeding, close monitoring, and comprehension of behavior. these requirements often lead to a range of emotional conditions, such as fear of harming their babies, loneliness, and feeling of being left alone to bear the burden, leading to an increased risk of mental health disorders. a previous study showed that mothers experienced fatigue and stress, further exacerbating symptoms of depression.1,2,5 several studies have shown that maternal distress and psychological problems often persist and increase after hospital discharge due to the severe stress of hospitalization and the severity of infants’ condition at home.6 the transition from hospital to home often presents several stressors to mothers, including the appearance of premature infants, changes in maternal roles, and the challenges associated with daily child care.6 a recent report showed that mothers with premature infants had higher stress compared to others with full-term infants.7,8 this result was inconsistent with other studies that stress of caregivers who cared for their infants at home on average was normal daily stress.9 stressful conditions have been reported to have a negative impact on mothers and their infants. maternal stress can present obstacles in achieving optimal maternal behavior and fulfilling caregiving roles.10-13 stress due to premature birth typically causes poor mother-infant interactions, thereby affecting their physical and mental health.14 prolonged levels can also lead to psychological disorders in mothers, such as postpartum depression or infants blues.15 maternal stress is often influenced by several factors, namely age, education level, occupation, and infants weight during stay at the nicu.16 previous studies also showed that personality, mental health, and family contributed to its type and levels. in addition, other influential factors include the function of the family, socioeconomic status, and parent’s perception of premature infants.17 although various reports have explored the incidence of maternal stress during nicu stay,18-23 there are limited studies on its occurrence at home.9 this shows that nurses need to understand stress and associated influential factors to provide effective intervention significance for public health this study is the first study to critically examine factors related to stress in mothers when caring for premature infants at home. the results of this study encourage health workers at the community level to be able to pay attention to maternal psychology and provide appropriate interventions so that mothers can care for their premature infants at home reasonably and adequately. mothers with low stress will help premature infants become healthy in growth and development. [page 90] [healthcare in low-resource settings 2024;12(s1):13024] non -co mmerc ial us e o nly to mothers.24,25 therefore, this study aims to assess factors associated with maternal stress when caring for premature infants at home. based on findings, this is the first study conducted in indonesia within this context. materials and methods design this study was carried out using a cross-sectional design with an observational approach. sample data collection was carried out from july to november 2022, and the sample population comprised mothers who cared for premature infants at home in the malang area (malang city, malang regency, and batu city). in addition, the inclusion criteria were mothers who cared for premature infants at home for 1 day to 3 months, mothers and premature infants were in good health, and premature infants had no congenital diseases. the number of participants in this study was 188 individuals who were selected using the purposive sampling method. ethical considerations the study procedures were granted ethical clearance under number 2605-kepk by the institutional review board (irb) faculty of nursing, universitas airlangga, indonesia. data collection and procedure the procedures began with licensing and obtaining ethical clearance. detailed informed consent was provided to each respondent without any coercion to participate in the study, followed by offline data collection using a paper-based questionnaire. the participants filled out the questionnaires according to their conditions, and analysis was performed using spss. the data input process began with editing, which referred to checking the completeness of the data in the questionnaire. in addition, coding facilitated the scoring and interpretation of the range value. the missing and error data were also assessed and analyzed using univariate and bivariate analyses. an instrument for data collection stress questionnaire used the parental stress scale (pss), consisting of 18 questions with a minimum score of 18 and a maximum of 90 with 5 statement items (1=strongly disagree, 5=strongly disagree). the questionnaire on knowledge of the benefits of caring for premature infants at home was modified from a previous questionnaire.26 in addition, it had a likert scale possessing 6 statement items, with maximum and minimum scores of 24 and 4, respectively. the questionnaire of spousal support, and health worker support, was assessed using a variant compiled from the postpartum social support screening tool, consisting of 5 questions and 4 questions.27 the instruments used in this study had been tested for reliability and validity. stress questionnaire was declared valid with a value range of r 0.538-0.861, while, it had a reliability value of 0.860. the knowledge questionnaire was valid with an rvalue range of 0.449-0.920, and its reliability was 0.980. the total score was 5-25 for partner support, and 4-20 for health worker support. the support questionnaire was valid with an r-value range of 0.601-0.991 and a reliability value of 0.988. data analysis data was screened for missing items. total scale scores were computed for measures of maternal stress, knowledge, spousal support, and health worker support. the score of each variable is categorized as follows: ≤55%, moderate: 56-≤75%, and high: 76100%. descriptive statistics (frequency and percentage) were computed to describe the experience, mothers’ age, education level, employment, birth methods, economic status, residence, infants’ birth weight, prematurity, benefits of care, spousal support, and health worker support. univariate analysis, chi-square tests, and binary logistic regression were performed with a final report of odds ratios (or) and 95% confidence intervals (ci). all the analyses used spss version 25. results and discussion as shown in table 1, this study shows that among 188 participants, the majority had no experience with premature infants, were in late adolescence age of 17 ≤25 years, the last education was high school, were not used, the method of delivery was by sectio caesarea, had low economic status, and living in rural areas. in addition, most of the participants had very low birth weight (1000-<1500 grams), prematurity in the category of moderate premature infants (31-36 weeks), knowledge of caring infants benefits in the low category, getting spousal support and health workers in the high category, and stress in the mild category. based on the results of the analysis with crosstab, the participants with mild stress mostly did not have experience with premature infants, were of the age of early adult mothers aged 26 ≤35 years, high school education, not used, method of delivery by cesarean section, low economic status (≤ regional minimum wage), residing in rural areas, and infants condition with very low birth weight (1000<1500 grams). the analysis results with chi-square showed that the p-value on the variables of residence, birth weight, benefits of care, spouse support, and health worker support was lower than 0.05. this showed that there was a significant relationship between residence, birth weight, care benefits, spouse support, and health worker support with stress, as shown in table 2. table 3 showed that mothers in their late adolescence aged 17 ≤25 years were at risk of experiencing moderate stress 11.059 times higher compared to those in their late adulthood aged 36 45 years. in addition, education with an odds ratio value of 7.901 showed that mothers who had an elementary school education were 7.901 more at risk of moderate stress compared to others with college education. mothers who gave birth by cesarean section had a moderate risk of stress, which was 15.301 higher compared to those who gave birth normally with an odds ratio of 15.301. participants who lived in rural areas had a moderate risk of stress 6.665 higher than others living in urban areas with an odds ratio of 6.665. the results also showed that the category of very low birth weight had a moderate stress risk of 0.033 times higher than lowbirth-weight. the low category in knowledge with an odds ratio value of 14.851 showed that moderate category care knowledge had a moderate risk of experiencing moderate stress 14.851 times higher compared to others with high category care knowledge. spousal support in the moderate category had an odds ratio value of 75.809, showing that moderate category spousal support had a risk of experiencing moderate stress 75.809 times higher than others in low category spousal support. a stressor was a situation that exceeded the ability of the mind 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13024] [page 91] non -co mmerc ial us e o nly or body when dealing with stress source. when the event or situation provided stimulation, individuals typically performed an assessment and cope, leading to the progression of stress to a higher or lower stage.28 according to lazarus and folkman’s transactional theory of stress and coping, individuals constantly assessed stimuli from their environment.29 in addition, stress was a relationship between individuals and the environment, which was assessed as an inability to deal with a dangerous or threatening situation. the results of this study showed that stress of mothers who cared for premature infants at home was mostly (53.7%) in the low category, with 46.3% being in the moderate category. these results were consistent with previous reports conducted where more than 50% of mothers were under moderate stress.18,21,22,30 in this study, none of the participants had a high category of stress compared to a previous report, where approximately 20-30% experienced high stress.22,31,32 this condition could be because those 3 studies measured mothers’ stress in the hospital. meanwhile, premature infants who were already at home and cared for by their mothers were assessed in this study. the sample population comprised mothers who cared for premature infants at home from 1 day to 3 months. a study conducted by de castro pereira et al. in 2019 on mothers of premature infants who were already at home showed that the average stress was at a total score of 42, showing normal levels. these stress levels did not require referral to a specialist, but close monitoring by the health team, both from the outpatient clinic and the health center.9 stress of mothers who cared for premature infants at home was correlated to babies’ birth weight, residence, knowledge of caring, spouse support, and health worker support. maternal age in the 1725 years category had a higher risk of experiencing stress compared to others in late adulthood aged 36 45 years. the results were inconsistent with previous studies, where there was no difference in stress levels between mothers aged <25 years and those aged ≥25 years, although the mean score was slightly higher in mothers aged ≥25 years.15 a significant association was found between parental age and general stress when faced with the appearance of infants in the nicu with the older age group reporting higher levels of stress (k = 13.6, p = 0.004).16 younger age was associated with emotional instability33 and in this study, most mothers lacked experience in caring for premature infants. mothers with lower education levels had stress risk higher than those with higher education. the results obtained were inconsistent with a study conducted in the nicu setting. previous reports showed that education level had no effect (p>0.05) on parental 4th international nursing and health sciences symposium table 1. maternal and infant characteristics. variables category frequency percent experience with premature infants none 164 87.2 experienced 24 12.8 mother’s age late adolescence (17 – ≤25 years) 75 39.9 early adulthood (26 – ≤35 years) 73 38.8 late adulthood (36 – 45 years) 40 21.3 education level primary school 24 12.8 secondary school 54 28.7 high school 76 40.4 diploma 12 6.4 bachelor’s degree 22 11.7 employment not used 136 72.3 used 52 27.7 birth methods sectio caesarea 144 76.6 normal 44 23.4 economic status low (≤ regional minimum wage) 127 67.6 high (> regional minimum wage) 61 32.4 residence rural 99 52.7 urban 89 47.3 infant’s birth weight extreme low birth weight (<1000 grams) 20 10.6 very low birth weight (1000-<1500 grams) 137 72.9 low birth weight (1500-<2500 grams) 31 16.5 prematurity very premature (24-30 weeks) 20 10.6 moderately premature (31-36 weeks) 164 87.2 borderline premature (37-38 weeks) 4 2.1 benefits of care low 82 43.6 medium 28 14.9 large 78 41.5 spousal support low 8 4.3 medium 47 25.0 large 133 70.7 health worker support low 2 1.1 medium 38 20.2 large 148 78.7 stress mild stress 101 53.7 moderate stress 87 46.3 [page 92] [healthcare in low-resource settings 2024;12(s1):13024] non -co mmerc ial us e o nly 4th international nursing and health sciences symposium table 2. correlation between stress and respondent characteristics. variables category stress p mild moderate experience with premature infants none 87 (86.1) 77 (88.5) 0.628 experienced 14 (13.9) 10 (11.5) mother’s age late adolescence (17 – ≤25 years) 33 (32.7) 42 (48.3) 0.070 early adulthood (26 – ≤35 years) 42 (41.6) 31 (35.6) late adulthood (36 – 45 years) 26 (25.7) 14 (16.1) education level primary school 16 (15.8) 8 (9.2) 0.107 secondary school 22 (21.8) 32 (36.8) high school 45 (44.6) 31 (35.6) diploma 8 (7.9) 4 (4.6) bachelor’s degree 10 (9.9) 12 (13.8) employment not used 69 (68.3) 67 (77.0) 0.184 used 32 (31.7) 20 (23.0) birth methods sectio caesarea 73 (72.3) 71 (81.6) 0.132 normal 28 (27.7) 16 (18.4) economic status low (≤ regional minimum wage) 70 (69.3) 57 (65.5) 0.580 high (> regional minimum wage) 14 (30.7) 10 (34.5) residence rural 69 (68.3) 30 (34.5) 0.000 urban 32 (31.7) 57 (65.5) infant’s birth weight extreme low birth weight (<1000 grams) 4 (4.0) 16 (18.4) 0.003 very low birth weight (1000-<1500 grams) 82 (81.2) 55 (63.2) low birth weight (1500-<2500 grams) 15 (14.9) 16 (18.4) prematurity very premature (24-30 weeks) 10 (9.9) 10 (11.5) 0.926 moderately premature (31-36 weeks) 89 (88.1) 75 (86.2) borderline premature (37-38 weeks) 2 (2.0) 2 (2.3) benefits of care low 35 (34.7) 47 (54.0) 0.002 medium 12 (11.9) 16 (18.4) high 54 (53.5) 24 (27.6) spousal support low 0 (0.0) 8 (9.2) 0.000 medium 6 (5.9) 41 (47.1) high 95 (94.1) 38 (43.7) health worker support low 0 (0.0) 2 (2.3) 0.037 medium 15 (14.9) 23 (26.4) high 86 (85.1) 62 (71.3) [healthcare in low-resource settings 2024;12(s1):13024] [page 93] table 3. multivariate analysis factors associated with stress in mother with premature infant. variables category or 95% confidence interval mild mild moderate experience with premature infants experienced .264 .067 1.034 mother’s age late adolescence (17 – ≤25 years) 11.059* 2.181 56.068 early adulthood (26 – ≤35 years) 1.985 0.444 8.882 education level primary school 7.901* 1.010 61.833 secondary school 1.177 0.164 8.443 high school 10.989 0.768 157.301 diploma 5.502 0.542 55.877 birth methods sectio caesarea 15.301*** 3.352 69.847 residence rural 6.665*** 2.392 18.569 infant’s birth weight extreme low birth weight (<1000 grams) 3.452 0.456 26.135 very low birth weight (1000-<1500 grams) 0.254* 0.072 0.893 benefits of care low 3.611* 1.285 10.146 medium 14.851** 2.765 79.763 spousal support low 3664621118.106 0.000 . medium 75.809*** 15.920 360.981 * p-value < 0.05. ** p-value < 0.01. *** p-value < 0.001. non -co mmerc ial us e o nly stress during the care of premature infants in the nicu.34,35 although not very significant, low education level was a predictor of ptsd (post traumatic stress disorder) in mothers who were caring for infants at home.36 low levels of maternal education could affect mothers’ knowledge and skills in caring for infants.33 mothers who gave birth using the sc method had a higher level of stress than the vaginal method. a related study found that the incidence of moderate stress after sc delivery was 36.7%, which was higher than the incidence of stress post-vaginal delivery of 6.7%.37 another study also showed that most mothers experienced moderate anxiety (86.7%),38 caused stress, postpartum blues, and psychosis.38 the results showed that mothers of premature infants in the very low birth weight category were at higher risk of stress compared to others in the low-birth-weight category. these results were consistent with previous reports, where low birth weight was associated with maternal stress.39 the severity of premature condition was found to correlate with stress score because mothers saw the appearance and behavior of premature infants that were different from infants born normally.40 the appearance and behavior were the highest stressors in causing maternal stress, where low infants’ weight at birth also affected health and development in the future.16 another variable related to stress in this current study was where mothers lived. the risk of mental health problems was found to be higher in individuals who were in rural areas41 due to limited resources and support, leading to a stressful life.42 in addition, preterm birth rates were higher in rural areas, along with inadequate access to specialist health services and support.43 limited resources, support, access, and health services caused stress when mothers cared for premature infants at home and lived in rural areas. the results showed that mothers with moderate levels of knowledge were 14,851 times more at risk of stress than others with high levels of knowledge. according to aldirawi, 42.6% of participants had a low level of knowledge to care for premature infants at home after treatment in the nicu.44 another study showed that the majority of mothers (53%) had a low level of knowledge regarding premature infants care.45 ong stated that stress correlated with the level of knowledge and ability of mothers. this showed that the higher stress, the lower the level of knowledge and ability of mothers in caring for premature infants.35 premji also recorded that maternal knowledge indicators affected maternal stress (p<0.00).46 some knowledge indicators of caring for premature infants, such as nutrition (54.2%), temperature regulation (50%), and umbilical cord care (46%) were also still low compared to infection prevention (73.3%), vaccination (60.2%), and jaundice (67.1%).44 lack of partner support could trigger stress 75,809 times higher compared to mothers with great partner support. the results of this study were in line with abdeyazdan and racine that adequate partner support could help relieve maternal stress in caring for infants in the nicu (p<0.01) and at home (p<0.001) (47,48). family support, specifically spouses, was the support that mothers needed during the first 6 weeks after giving birth to premature infants.49 conclusions in conclusion, most of stress experienced by mothers when caring for premature infants at home was in the moderate category. this study showed several factors that could influence mothers’ stress while caring for premature infants. in addition, support from health workers was very essential to optimize the participants’ ability to cope and reduce stress levels. health workers also needed to provide psychological interventions, which have not been optimally given to individuals with premature infants in indonesia. references 1. osorio galeano sp, ochoa marín sc, semenic s. preparing for post-discharge care of premature infants: experiences of parents. investig y educ en enferm 2017;35:100–6. 2. davis-strauss sl, johnson e, lubbe w. information and support needs of parents with premature infants: an integrative review. j early interv 2021;43:199–220. 3. ye m, tao j. parents’ experience of having premature baby: a literature review. in 2018. available from: https://api.semantic 4th international nursing and health sciences symposium [page 94] [healthcare in low-resource settings 2024;12(s1):13024] correspondence:rinik eko kapti, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia 65151. tel.: +62341569117 fax: +62341564755, e-mail: rinik.eko@ub.ac.id key words: caring; mother; premature; stress contributions: rek, and ysa contributed substantially to the concept and work design. sa and na collected data. ls and adw conducted data analysis, data interpretation, and drafting of the manuscript. rek revised it critically for the important intellectual content and final approval of the version to be published. conflict of interest: the author declares no potential conflict of interest. funding: this study was funded by the research institutes and community service (bppm), faculty of health science, universitas brawijaya. clinical trials: not applicable. ethics approval: the study procedures were granted ethical clearance under number 2605-kepk by the institutional review board (irb) faculty of nursing, universitas airlangga, indonesia. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgements: the authors are grateful to the participants, contributors, and the research institutes and community service (bppm), faculty of health science, universitas brawijaya, for the financial assistance. received: 3 november 2023. accepted: 28 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13057 doi:10.4081/hls.2024.13057 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organinon -co mmerc ial us e o nly scholar.org/corpusid:208490994. 4. breivold k, hjaelmhult e, sjöström-strand a, hallström ik. mothers’ experiences after coming home from the hospital with a moderately to late preterm infant – a qualitative study. scand j caring sci 2019;33:632–40. 5. cheung rym, cheng wy, li jb, et al. mothers' and fathers' stress and severity of depressive symptoms during the covid19 pandemic: actor-partner effects with parental negative emotions as a moderator. bmc psychol 2022;10:294. 6. holditch-davis d, santos h, levy j, et al. patterns of psychological distress in mothers of preterm infants. infant behav dev 2015;41:154-63. 7. tabrizi fm, alizadeh s, radfar m. barriers of parenting in mothers with a very lowbirthweight preterm infant, and their coping strategies: a qualitative study. int j pediatr 2017;5:5597–608. 8. zelkowitz p, bardin c, papageorgiou a. anxiety affects the relationship between parents and their very low birth weight infants. infant ment health j 2007;28:296–313. 9. de castro pereira f, aparecida baggio m, silveira viera c, et al. premature newborn post-discharge maternal stress. j nurs ufpe / rev enferm ufpe 2019;13:74–80. 10. garti i, donkor e, musah n, et al. mothers’ experiences of caring for preterm babies at home: qualitative insights from an urban setting in a middle-income country. bmc pregnancy childbirth 2021;21:1–9. 11. adama ea, bayes s, sundin d. parents’ experiences of caring for preterm infants after discharge from neonatal intensive care unit: a meta-synthesis of the literature. j neonatal nurs 2016;22:27–51. 12. pristya tyr, novitasari a, hutami ms. prevention and control of lbw in indonesia: systematic review. indonesian j health develop 2020;2:175–82. 13. rossman b, greene mm, kratovil al, meier pp. resilience in mothers of very-low-birth-weight infants hospitalized in the nicu. jognn j obstet gynecol neonatal nurs 2017;46:434–45. 14. karbandi s, momenizadeh a, heidarzadeh m, et al. effects of empowering mothers of premature infants on their stress coping strategies. iran j psychiatry behav sci 2018;12(2). 15. syamsu af, dwi bahagia febriani a, alasiry e, et al. maternal stressful experience in giving birth to premature baby in neonatal intensive care unit ward. open access maced j med sci 2021;9:106–11. 16. musabirema p, brysiewicz p, chipps j. parents perceptions of stress in a neonatal intensive care unit in rwanda. curationis 2015;38:1499. 17. busse m, nurse s, cooperative gh, et al. parent responses to stress: promis in the nicu. crit care nurse 2015;33:52–60. 18. gurgani s, jogi s. a study to estimate the level of stress and coping strategies among mothers whose neonates are admitted in neonatal intensive care unit ( nicu ) at lalla ded hospital , srinagar , kashmir. int j midwifery nurs 2018;1:1–44. 19. patil s. level of stress and coping strategies seen among parents of neonates admitted in nicu. int j sci res 2014;3:579– 85. 20. paul p, pais m, kamath s, et al. perceived maternal parenting self-efficacy and parent coping among mothers of preterm infants–a cross-sectional survey. e-journal manipal educ 2018;3:24–7. 21. rajalakshmi s, kalavathi s. a study to assess the level of stress and coping strategies among mothers of preterm infants admitted in neonatal intensive care unit at selected hospital, puducherry. int j adv nurs manag 2017;5:45. 22. sharma a. a study to assess the level of stress and coping strategies adopted by parents of the neonates admitted in nicu in selected hospitals, bangalore mr. j nurs res educ manag 2019;1:12–6. 23. tajalli s, kouhnavard m, jeshvaghanee ss, et al. spiritual well-being, parental stress, and coping strategies: a cross-sectional study of iranian mothers with preterm neonates. iran j neonatol 2022;13:98–105. 24. doupnik s, hill d, palakshappa d, et al. parent coping support interventions during acute pediatric hosptializations. pediatrics 2017;140:1–16. 25. kaliampos a, roussi p. religious beliefs, coping, and psychological well-being among greek cancer patients. j health psychol 2017;22:754–64. 26. abbasi-shavazi m, safari hajataghaiee s, sadeghian h, et al. perceived benefits and barriers of mothers with premature infant to kangaroo mother care. int j pediatr 2018;7:9237–48. 27. the artemis center for guidance. the postpartum social support screening tool | artemis [internet]. 2013 [cited 2023 aug 2]. available from: https://artemisguidance.com/pssst/. 28. baqutayan sms. stress and coping mechanisms: a historical overview. mediterrj soc sci 2015;6:479. 29. biggs a, brough p, drummond s. lazarus and folkman’s psychological stress and coping theory. in: cooper cl, quick jc, editors. the handbook of stress and health [internet]. 1st ed. wiley; 2017 [cited 2023 aug 2]. p. 349–64. available from: https://onlinelibrary.wiley.com/doi/10.1002/9781118993811.c h21. 30. abimana mc, karangwa e, hakizimana i, et al. assessing factors associated with poor maternal mental health among mothers of children born small and sick at 24–47 months in rural rwanda. bmc pregnancy childbirth 2020;20:1–12. 31. tajalli s, ebadi a, parvizy s, kenner c. maternal caring ability with the preterm infant: a rogerian concept analysis. nurs forum 2022;57:920-31. 32. rajalakshmi s, kalavathi s. a study to assess the level of stress and coping strategies among mothers of preterm infants admitted in neonatal intensive care unit at selected hospital, puducherry. int j adv nurs manag 2017;5:45. 33. hogue cj, menon r, dunlop al, kramer mr. racial disparities in preterm birth rates and short inter-pregnancy interval: an overview. acta obstet gynecol scand 2011;90:1317–24. 34. akkoyun s, tas arslan f. investigation of stress and nursing support in mothers of preterm infants in neonatal intensive care units. scand j caring sci 2019;33:351–8. 35. ong sl, abdullah kl, danaee m, et al. the effectiveness of a structured nursing intervention program on maternal stress and ability among mothers of premature infants in a neonatal intensive care unit. j clin nurs 2019;28:641–9. 36. kress v, von soest t, kopp m, et al. differential predictors of birth-related posttraumatic stress disorder symptoms in mothers and fathers – a longitudinal cohort study. j affect disord 2021;292:121–30. 37. amperaningsih y, siwi pn. post traumatic stress in postpartum mothers with emergency caesarean section and spontaneous delivery. j ilm keperawatan sai betik 2018;14:72. 38. fadilah wn, megawati m, astiriyani e. the effect of hypnosis on the level of anxiety of post-cesarean mothers. media inf 2018;14:148–53. 39. schappin r, wijnroks l, venema mmatu, jongmans mj. rethinking stress in parents of preterm infants: a meta-analy 4th international nursing and health sciences symposium [[healthcare in low-resource settings 2024;12(s1):13024] [page 95] non -co mmerc ial us e o nly sis. plos one 2013;8(2). 40. malliarou m, karadonta a, mitroulas s, et al. preterm parents’ stress and coping strategies in a neonatal intensive care unit in a university hospital of central greece. mater socio medica 2021;33:244. 41. ginja s, jackson k, newham jj, et al. rural-urban differences in the mental health of perinatal women: a uk-based crosssectional study. bmc pregnancy childbirth 2020;20:1–11. 42. miles ms, holditch-davis d, thoyre s, beeber l. rural african-american mothers parenting prematurely born infants: an ecological systems perspective. newborn infant nurs rev 2005;5:142–8. 43. wakely l, rae k, keatinge d. fragile forgotten families: parenting a premature infant in a rural area, where is the evidence? neonatal, paediatr child heal nurs 2015;18:8–17. 44. aldirawi a, el-khateeb a, mustafa aa, abuzerr s. mothers’ knowledge of health caring for premature infants after discharge from neonatal intensive care units in the gaza strip, palestine. open j pediatr 2019;09:239–52. 45. al-mukhtar s, abdulghani m. knowledge of mothers regarding premature baby care in mosul city. mosul j nurs 2020;8:108–18. 46. premji ss, pana g, currie g, et al. mother's level of confidence in caring for her late preterm infant: a mixed methods study. j clin nurs 2018;27:e1120-e1133. 47. abdeyazdan z, shahkolahi z, mehrabi t, hajiheidari m. a family support intervention to reduce stress among parents of preterm infants in neonatal intensive care unit. iran j nurs midwifery res 2014;19:349–53. 48. racine n, plamondon a, hentges r, et al. dynamic and bidirectional associations between maternal stress, anxiety, and social support: the critical role of partner and family support. j affect disord 2019;252:19–24. 49. sarach r, rosyidah l. psikologi ibu postpartum dengan bayi prematur: scoping review. j midwifery reprod 2021;5:51. 4th international nursing and health sciences symposium [page 96] [healthcare in low-resource settings 2024;12(s1):13024] non -co mmerc ial us e o nly healthcare in low-resource settings 2025; volume 13(s1):13133 innovation of kwetiau with red rice and red bean flour: evaluation of nutritional value and potential fiber source for patients with diabetes mellitus mulus gumilar, gurid pramintarto eko mulyo, dila evianda, roro nur fauziyah nutrition department, politeknik kesehatan kemenkes bandung, indonesia abstract diabetes mellitus is characterized by hyperglycemia and metabolic dysfunctions in carbohydrates, fats, and proteins, primarily due to impaired insulin action and/or secretion. dietary fiber can help delay carbohydrates conversion to glucose, slow the rise in blood sugar, and aid in blood sugar regulation. this study aimed to evaluate the effects of red rice flour and red bean flour formulations on the sensory characteristics, fiber content, and nutritional value of kwetiau. the research utilized an experimental design with a completely randomized design (crd) framework. methodologies included hedonic tests to assess organoleptic properties, enzymatic gravimetry for fiber content, gravimetry for water and ash content, the kjeldahl method for protein content, soxhlet extraction for fat content, and calculations for carbohydrate and energy content. the formulations tested included f1 (80% red rice flour and 20% red bean flour), f2 (75% red rice flour and 25% red bean flour), and f3 (70% red rice flour and 30% red bean flour). among these, f1 was identified as the most favorable. the kruskal-wallis test showed no significant differences in organoleptic properties such as color, aroma, taste, texture, and overall sensory acceptance. the nutritional analysis of f1 revealed a fiber content of 2.93%, water content of 67.2%, ash content of 0.43%, protein content of 1.98%, fat content of 2.45%, carbohydrate content of 27.9%, and energy content of 147.95 kcal per 100 grams. future research should assess the efficacy of kwetiau, made with red rice and red bean flour, in managing diabetes mellitus. introduction diabetes mellitus is characterized by hyperglycemia and metabolic dysfunctions in carbohydrates, fats, and proteins due to impaired insulin action and/or secretion. this condition can lead to both acute and chronic complications.1,2 the international diabetes federation (idf) reports that in 2021, the global prevalence of diabetes among people aged 20-79 was estimated at 10.5% (536.6 million people) and is projected to increase to 12.2% (783.2 million) by 2045.3 this high prevalence ranks indonesia as the country with the highest number of people with diabetes in the association of southeast asian nations (asean) and 34th out of 204 countries globally.4 additionally, according to the world health organization (who), non-communicable diseases, including diabetes, account for 71% of deaths worldwide,5 with an increasing number of adults suffering from diabetes, particularly in lowand middle-income countries.6 in indonesia, non-communicable diseases are on the rise. the indonesian ministry of health reported that the prevalence of noncommunicable diseases reached 69.91% in 2019, with diabetes mellitus increasing from 6.9% to 8.5% from 2013 to 2018.7,8 indonesia currently ranks fourth among the top ten countries for diabetes mellitus prevalence, with 8.6% of its population affected by type 2 diabetes mellitus.1 the high prevalence of type 2 diabetes mellitus is associated with unmodifiable risk factors such as age, gender, and genetics, as well as modifiable factors like smoking, diet, physical inactivity, and obesity.10–14 one preventive measure to manage blood sugar levels, particularly in people with type 2 diabetes mellitus, is to increase fiber intake.15–17 dietary fiber, especially soluble fiber, slows the absorption of carbohydrates, delays blood sugar spikes, and helps regulate blood sugar levels.18–20 the indonesian society of correspondence: mulus gumilar, nutrition department, politeknik kesehatan kemenkes bandung, indonesia. e-mail: mulgumail@gmail.com key words: diabetes mellitus; fiber; kwetiau; red bean flour; red rice flour. contributions: mg, conceptualization, methodology, product manufacturing, supervision, review; gpem, review, validation, supervision; de, conceptualization, methodology, product manufacturing, writing-original draft, data collection, data analysis; rr, data analysis, review, validation, supervision. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research received approval from the health research ethics commission of the politeknik kesehatan kemenkes bandung no. 93/kepk/ec/xii/2023. informed consent: all participants signed a written informed consent form for participating in this study. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was supported by a research grant from politeknik kesehatan kemenkes bandung. acknowledgments: we would like to thank politeknik kesehatan kemenkes bandung for their valuable insights and contributions to this study. received: 20 september 2024. accepted: 25 november 2024. early access: 11 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13133 doi:10.4081/hls.2025.13133 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 56] [healthcare in low-resource settings 2025;13(s1):13133] endocrinology, or perkumpulan endokrinologi indonesia (perkeni) (2021), recommends a daily fiber intake of 20-35 grams, with an ideal intake of 25 grams for people with diabetes. dietary fiber is classified as either soluble or insoluble.21 soluble fiber, which is water-soluble and passes undigested through the small intestine, is fermented by gut bacteria in the large intestine. sources include pectin, gums, starches, oats, psyllium, fruits, vegetables, and legumes.22,23 soluble fiber can slow intestinal digestion, increase satiety, and prevent blood sugar spikes, reducing insulin demand.24 insoluble fiber, on the other hand, primarily aids in preventing digestive tract diseases, such as hemorrhoids and colon cancer.24 red rice (oryza nivara) is a staple food in indonesia with high nutritional value. it contains carbohydrates, proteins, fats, minerals, fiber, and anthocyanins, which have antioxidant and anti-diabetic properties.25 the fiber content in red rice (1.632%) is significantly higher than in white rice (0.5746%).26 red beans, another fiber-rich legume, are also low in fat, high in fiber, and have a low glycemic index, making them suitable for people with diabetes. red beans are also an excellent source of high-quality protein.27,28 processing red rice and red beans into flour can increase their versatility and shelf life, making them ideal ingredients for various foods, including kwetiau. kwetiau is a popular noodle dish in indonesia, typically made from rice flour. by substituting red rice and red bean flour for traditional rice flour, kwetiau can be made higher in fiber and, therefore, more suitable for people with diabetes.6 this study aimed to develop a kwetiau product using red rice and red bean flour as an alternative high-fiber food for individuals with diabetes mellitus. specifically, the study evaluated the sensory characteristics, fiber content, and nutritional value of kwetiau formulated with varying proportions of red rice and red bean flour. materials and methods design, variable, materials this study employed an experimental research method using a complete random design (crd) with both independent and dependent variables. the independent variable was the formulation of red rice flour and red bean flour in the proportions of 80%:20%, 75%:25%, and 70%:30%, which influenced the dependent variables, specifically the organoleptic properties, including color, taste, aroma, texture, and overall impression, as well as fiber content and nutritional value. the 80%:20% formulation of red rice flour and red bean flour was chosen for consumers who prefer a chewy texture similar to traditional kwetiau. the 75%:25% formulation balanced texture with nutritional enhancement, making it suitable for consumers who desire a more nutritious version of kwetiau while maintaining a familiar texture. the 70%:30% formulation, with its denser texture and pronounced red bean flavor, offered the highest nutritional value, which is ideal for consumers seeking a high-protein, highfiber option. the ingredients used to make kwetiau included red rice flour, red bean flour, white rice flour, tapioca flour, salt, and oil. the red rice flour was made from whole brown rice, which was dried and finely ground, while the red bean flour was produced from brownish-red beans that were dried and ground to a texture slightly coarser than that of white rice flour. instrument and data collection the main research was conducted from january to february 2024, collecting data through organoleptic testing, fiber analysis, and proximate analysis for nutritional value. organoleptic properties such as color, aroma, taste, texture, and overall impression were evaluated using hedonic tests rated on a scale of 1 to 7. the panel for the organoleptic test consisted of 30 semi-trained panelists, all students from the nutrition department at the bandung polytechnic of health (poltekkes kemenkes bandung) who met specific inclusion criteria: familiarity with organoleptic testing, interest in sensory evaluations, good physical health, absence of ent issues or color blindness, and abstinence from coffee, tea, or milk two hours before and after testing. panelists were also required to have no food allergies, especially to nuts, and to adhere to additional guidelines for testing, such as waiting at least 20 minutes after smoking or consuming certain foods. the selected panelists were level 2 and level 3 students who had received training in sensory evaluation. they were specifically trained to evaluate the sensory profile of kwetiau to ensure consistent judgments. panelists were chosen based on availability, preference for kwetiau, frequency of kwetiau consumption (at least twice a week), high sensitivity to the tested product, and absence of smoking and illness history. organoleptic testing followed specific procedures to ensure accuracy and consistency. first, kwetiau samples were prepared in uniform portions for each panelist, using standard containers to maintain consistency. each sample was assigned an anonymous code to ensure blind testing. samples were then served in random order to prevent sequence bias. panelists used an evaluation sheet to rate various organoleptic parameters on a defined scale, such as taste, aroma, texture, and color. to prevent flavor carryover between samples, panelists were given water or white bread to cleanse their palate between tastings. the testing took place in a controlled environment, a specially designed taste test laboratory, where factors such as lighting, temperature, and noise levels were carefully managed. neutral lighting and a comfortable room temperature of 20-22°c were maintained, and each panelist sat in a separate booth to minimize distractions and reduce social influence. the panelists received training to standardize the evaluation process. first, they were introduced to the test’s purpose, evaluation parameters, and the testing procedure. they were taught how to use the likert scale for sensory intensity and provided with sensory descriptions, such as specific terms for taste (sweet, sour, bitter) and texture (crunchy, soft). finally, panelists underwent retest exercises with similar samples to ensure they could provide consistent, standardized assessments. fiber content testing was conducted at the center for standardization and services of the agro industry using the enzymatic gravimetry method. nutritional testing, which included moisture, ash, protein, fat, and carbohydrate content, was also performed at the same center. energy content was calculated based on the indonesian food composition table.29 the methods used included gravimetric analysis for moisture and ash content, the kjeldahl method for protein content, the soxhlet method for fat content, and calculation for carbohydrate and energy levels. analysis the statistical analysis aimed to determine the effect of different formulations of red rice and red bean flour on the organoleptic properties of kwetiau. to test for normality, a shapiro-wilk test was conducted with a 95% confidence level (α=0.05). for normally distributed data, a one-way anova was used; if significant (p<α), a post hoc tukey test was performed. for non-normally distributed data, the kruskal-wallis test was applied; if significant (p<α), it was followed by the mann-whitney test. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13133] [page 57] results product description the red rice and red bean flour-based kwetiau is a modified version of traditional kwetiau, created as a fiber-rich food alternative for individuals with diabetes mellitus. this version is made by incorporating red rice flour and red bean flour. the preparation of the kwetiau involves two main steps: mixing the ingredients and steaming. the final product has a reddish hue, with the characteristic aroma of red rice flour and a subtle scent from the red bean flour. it offers a unique flavor profile with the red rice flour’s distinctive taste, complemented by a mild aftertaste from the red bean flour and a slight saltiness from the added salt during preparation. the texture is chewy. the shelf life of this kwetiau is approximately three days at room temperature and up to four days if stored in a cool environment. in the production process, yield calculations were conducted. yield, an important parameter for evaluating a product’s economic value and efficiency, is calculated based on the percentage of the ratio between the final and initial weights. a higher yield indicates greater economic and effectiveness value.35 the yield for this kwetiau product was 95%, with an initial weight of 480 grams, which was reduced to 455 grams after steaming. each serving of 100 grams of this kwetiau provides 11.72% of the daily recommended fiber intake for individuals with diabetes mellitus (figure 1). organoleptic test a hedonic test was conducted on three formulations with 30 trained panelists from poltekkes kemenkes bandung to assess consumer acceptance of red rice and red bean flour kwetiau. panelists preferred the first formula for color, the second for aroma and overall preference, and the third for taste. texture was also rated highest for the first formula (table 1). average preference ratings for each attribute (color, aroma, taste, texture, and overall preference) are shown in figure 2. special issue pathways of change figure 1. formula 1 (f1), formula 2 (f2), formula 3 (f3) of kwetiau red rice flour and red bean flour. figure 2. average panelists' preference for color, aroma, taste, texture and overall kwetiau based on red rice flour and red bean flour. table 1. distribution of panelists' preferences for color, aroma, taste, texture, and overall quality of kwetiau made with red rice flour and red bean flour. formula scale color aroma taste texture overall n % n % n % n % n % 1 very dislike 0 0 0 0 1 3.3 0 0 0 0 dislike 0 0 1 3.3 0 0 0 0 0 0 somewhat dislike 2 6.7 1 3.3 1 3.3 2 6.7 2 6.7 neutral 8 26.7 9 30.0 8 26.7 5 16.7 8 26.7 somewhat like 5 16.7 3 10.0 7 23.3 7 23.3 6 20.0 like 12 40.0 12 40.0 8 26.7 11 36.7 9 30.0 very like 3 10.0 4 13.3 5 16.7 5 16.7 5 16.7 total 30 100 30 100 30 100 30 100 30 100 2 very dislike 0 0 0 0 0 0 0 0 0 0 dislike 1 3.3 0 0 1 3.3 1 3.3 0 0 somewhat dislike 1 3.3 2 6.7 4 13.3 5 16.7 3 10.0 neutral 10 33.3 5 16.7 4 13.3 5 16.7 4 13.3 somewhat like 6 20.0 9 30.0 8 26.7 7 23.3 10 33.3 like 7 23.3 6 20.0 10 33.3 10 33.3 9 30.0 very like 5 16.7 8 26.7 3 10.0 2 6.7 4 13.3 total 30 100 30 100 30 100 30 100 30 100 3 very dislike 0 0 0 0 0 0 0 0 0 0 dislike 0 0 0 0 1 3.3 1 3.3 0 0 somewhat dislike 3 10.0 7 23.3 3 10.0 1 3.3 3 10.0 neutral 9 30.0 6 20.0 4 13.3 5 16.7 6 20.0 somewhat like 6 20.0 6 20.0 10 33.3 8 26.7 8 26.7 like 7 23.3 9 30.0 10 33.3 10 33.3 10 33.3 very like 5 16.7 2 6.7 2 6.7 5 16.7 3 10.0 total 30 100 30 100 30 100 30 100 30 100 [page 58] [healthcare in low-resource settings 2025;13(s1):13133] color preference the color of the first formula received the highest average preference, scoring 5.20. a kruskal-wallis test indicated no significant difference among the three formulas (p=0.894 > α=0.05), meaning that color differences were not statistically significant. therefore, a mann-whitney test was not applicable. aroma preference the second formula was the most preferred in terms of aroma, with an average rating of 5.43. the kruskal-wallis test showed no significant difference among the formulas (p=0.144 > α=0.05), so no further testing was conducted for this attribute. taste preference the first formula scored highest in taste preference, with an average of 5.13. the kruskal-wallis test revealed no significant difference (p=0.940 > α=0.05), indicating similar taste preferences across all formulations. texture preference for texture, the first formula received the highest rating, averaging 5.40. the kruskal-wallis test showed no significant difference among the textures (p=0.253 > α=0.05), so further testing was not required. overall preference the second formula scored highest in overall preference, with an average of 5.23. the kruskal-wallis test indicated no significant differences in overall preference (p=0.939 > α=0.05). fiber content the fiber content test was conducted on the most preferred formulation. according to the panelists’ feedback and preference ratings, the first formula, with a ratio of 80% red rice flour to 20% red bean flour, was selected for analysis. fiber testing carried out at the center for standardization and services of the agro industry used the enzymatic gravimetry method. the results indicated that this formulation contained 2.93% fiber, equivalent to 2.93 grams per 100 grams. comparison of fiber content with nutritional requirements the fiber content of one 100-gram serving of the red rice and red bean flour-based kwetiau was 2.93 grams, which meets 11.72% of the daily recommended fiber intake for individuals with diabetes mellitus (25 grams/day).3 proximate analysis (nutritional value) the proximate analysis, which included measurements of water, ash, protein, fat, carbohydrate, and energy content, was conducted on the most preferred formula. water and ash contents were determined by gravimetric methods, protein by the kjeldahl method, fat by the soxhlet method, and carbohydrate and energy content were calculated. table 2 presents the results, indicating the following values per 100 grams: 67.2% moisture, 0.43% ash, 1.98% protein, 2.45% fat, 27.9% carbohydrates, and 147.95 kcal of energy. the data provide a comprehensive nutritional profile of the red rice and red bean flour-based kwetiau, highlighting its potential as a suitable dietary option for individuals with diabetes mellitus. testing of the energy, protein, fat, and carbohydrate content of kwetiau products made with red rice flour and red bean flour was conducted and compared with nutritional adequacy standards for these nutrients. the nutritional adequacy levels for energy, protein, fat, and carbohydrates are based on the recommended intake for snack foods as specified in the 2019 nutritional adequacy figures (akg).30-32 the comparison of the energy, protein, fat, and carbohydrate levels in kwetiau products with red rice flour and red bean flour to nutritional adequacy can be seen in table 3. each 100gram serving of this kwetiau provides 147.95 kcal of energy, 1.98 grams of protein, 2.45 grams of fat, and 27.9 grams of carbohydrates. therefore, the nutritional adequacy per serving of kwetiau with red rice flour and red bean flour is as follows: 61.64% energy requirement, 31.68% protein requirement, 36.29% fat requirement, and 72.24% carbohydrate requirement. discussion organoleptic properties all kwetiau formulas using red rice flour and red bean flour produce a red color. across the three formulas, there were minimal color differences, as the flour ratios did not vary significantly. according to the organoleptic test results, the most preferred color was from formula 1, with an 80% red rice flour to 20% red bean flour ratio, where 16.7% of participants found it somewhat appealing, 40.0% liked it, and 10.0% liked it very much. statistical analysis of the color aspect using the kruskal-wallis test found no significant effect of the flour ratios on the color of kwetiau products (p=0.894 > α=0.05). special issue pathways of change table 2. results of proximate analysis of kwetiau products based on red rice flour and red bean flour. nutrients result unit water 67.2 % ash 0.43 % protein 1.98 % fat 2.45 % carbohydrates 27.9 % energy 147.95 kcal/100 g table 3. comparison of energy, protein, fat, and carbohydrate levels in kwetiau products made with red rice flour and red bean flour in relation to nutritional adequacy. nutrients nutritional value per serving nutritional adequacy % nutritional adequacy energy (kcal) 147.95 240 61.64% protein (g) 1.98 6.25 31.68% fat (g) 2.45 6.75 36.29% carbohydrates (g) 27.9 38.62 72.24% [healthcare in low-resource settings 2025;13(s1):13133] [page 59] the color produced from kwetiau products comes from red rice flour and red bean flour, both of which are red. this red color is due to the anthocyanin compounds found in red rice and kidney beans. the high and low pigment content will affect the color.33,34 winata and yunianta explained that a higher anthocyanin content will increase the color of a product and will become redder.35 anthocyanin is one of the pigments commonly applied as a natural colorant in food.36 the aroma of the kwetiau formulas, typical of red rice with slight notes of red bean, was also not significantly different among the three formulations. the second formula, with 75% red rice flour and 25% red bean flour ratio, was the most preferred for aroma, with 30.0% of participants somewhat liking it, 20.0% liking it, and 26.7% liking it very much. the kruskal-wallis test found no significant effect of flour ratios on aroma (p=0.144 > α=0.05). setyaningsih et al. explain that aroma contributes to product appeal through volatile compounds, enhancing flavor and attractiveness.37 aroma serves to enhance the taste and increase the attractiveness of food products. the aroma produced in the kwetiau formula based on red rice flour and red bean flour is typical of brown rice flour and has a slight aroma from red bean flour. the difference in the aroma of kwetiau was minimal due to a slight variation in the balance ratio. taste can vary based on ingredients like red rice and red bean flour.38,39 the flavors produced by the formulas reflect the distinct taste of red rice with a lingering aftertaste of red beans and a slight saltiness.40 in the three formulas, taste differences were minimal due to similar flour ratios. formula 3, with 70% red rice flour and 30% red bean flour ratio, was the most favored for taste, with 33.3% of participants somewhat liking it, 33.3% liking it, and 6.7% liking it very much. the kruskal-wallis test showed no significant effect of flour ratios on taste (p=0.940 > α=0.05). aulia et al. found similar results with red bean flour, observing no effect on the taste of cookies where other ingredients also influenced flavor.41 texture significantly impacts product acceptance. in this case, the chewy texture of the kwetiau was primarily due to the inclusion of tapioca flour, a starch that increases water-binding capacity. astuti (2009) noted that tapioca’s high amylopectin content (83%) contributes to a chewy texture, as amylopectin traps water within starch granules, unlike amylose, which binds less water.42 imanningsih43 explained that amylopectin, which branches and forms a double helix, makes water trapped in starch granules and is prevented from escaping, while amylose has a non-branching structure that makes amylose have a low ability to bind water, and water easily escapes.28 the three formulas showed minimal texture differences due to the similar flour ratios. formula 1, with an 80% red rice flour to 20% red bean flour ratio, was preferred for texture, with 23.3% of participants somewhat liking it, 36.7% liking it, and 16.7% liking it very much. the kruskal-wallis test indicated no significant impact of flour ratios on texture (p=0.253 > α=0.05). the overall acceptance aspect measures panelist preference across all sensory properties: color, aroma, taste, and texture. since these aspects might yield different preferences, assessing overall acceptance helps determine the best product formulation. formula 2, with a 75% red rice flour to 25% red bean flour ratio, achieved the highest overall preference, with 33.3% of participants slightly liking it, 30.0% liking it, and 13.3% liking it very much. the kruskal-wallis test showed no significant difference in overall acceptance across the three formulas (p=0.939 > α=0.05). this lack of significant difference across sensory aspects may be due to the small variations in red rice and red bean flour ratios among the formulas. however, each formula had unique qualities: formula 1 (80:20) had a traditional chewy texture, formula 2 (75:25) offered a balanced texture and higher fiber content, and formula 3 (70:30) had a denser texture and stronger red bean flavor, ideal for consumers seeking higher protein and fiber content in kwetiau. proximate analysis (nutritional value) the proximate analysis of kwetiau made from red rice and red bean flour was conducted to determine its nutritional composition, including protein, fat, carbohydrate, energy, moisture, and ash content. the protein content in kwetiau made from red rice and red bean flour was analyzed using the kjeldahl method. testing was conducted on the formulation with the best organoleptic properties, identified through a hedonic test as the 80% red rice flour and 20% red bean flour blend. this formulation yielded a protein content of 1.98 grams per 100 grams. the results suggest that increasing the proportion of red bean flour enhances the protein content of the kwetiau, due to the higher protein level in red beans. fat content was measured using the soxhlet extraction method on the same optimal formulation (80% red rice flour, 20% red bean flour). the fat content in this kwetiau formulation was found to be 2.45 grams per 100 grams. the carbohydrate content was calculated based on the measured protein, fat, moisture, and ash values. the formulation with superior organoleptic qualities (80% red rice flour, 20% red bean flour) contained 27.9 grams of carbohydrates per 100 grams. energy content was estimated based on the indonesian food composition table (tkpi). the formulation tested (80% red rice flour, 20% red bean flour) was found to provide 147.95 kcal per 100 grams. water absorption capacity reflects the ability of the kwetiau to absorb and retain water, a quality influenced by protein properties. a high water absorption capacity facilitates starch gelatinization, resulting in a smooth, evenly steamed dough with no white or red spots.32 the moisture content of the optimal formulation (80% red rice flour, 20% red bean flour) was measured at 67.2 grams per 100 grams. increased red rice flour proportion was associated with lower water content due to the higher starch content in red rice. conversely, higher red bean proportions raised the moisture content, likely due to the higher crude fiber content in red beans.45 higher ash content in a food indicates a higher mineral content. the ash content for the preferred formulation (80% red rice flour, 20% red bean flour) was measured at 0.43 grams per 100 grams. during the ashing process, organic substances are burned away, leaving behind inorganic mineral elements. the findings suggest that increasing red bean flour raises the ash content, consistent with previous studies. for instance, yanti found a positive correlation between mung bean additions and ash content in steamed sponge cakes.46 similarly, arwin et al. noted that higher red bean proportions increased ash levels due to the high mineral content of red beans compared to red rice flour.45 fiber content the dietary fiber content in kwetiau made from red rice flour and red bean flour was analyzed for the formula with the most favorable organoleptic properties, as determined by a hedonic test. the chosen formula, with 80% red rice flour and 20% red bean flour ratio, was analyzed using an enzymatic gravimetric method. this method, widely used for dietary fiber analysis, involves hydrolyzing digestible carbohydrates, fats, and proteins using specific enzymes, followed by filtration to separate undigested residues as fiber. the residue is then dried, weighed, and further analyzed to account for any remaining protein and ash.47 despite its accuracy, the enzymatic gravimetric method is time-consuming and less practical due to the use of processed fiber, which can aid special issue pathways of change [page 60] [healthcare in low-resource settings 2025;13(s1):13133] in blood sugar regulation by slowing the conversion of carbohydrates to sugar, resulting in more stable blood glucose levels.48-50 it functions by absorbing glucose, inhibiting enzymes, and enhancing the production of short-chain fatty acids by gut bacteria, aiding metabolism.47 laboratory tests revealed that the dietary fiber content in kwetiau from red rice and red bean flour is 2.93 grams per 100 grams. a 100-gram serving of this kwetiau contributes approximately 11.72% of the recommended daily fiber intake for individuals with type 2 diabetes mellitus. the 2019 guidelines for managing type 2 diabetes recommend a daily fiber intake of 20-35 grams. therefore, this dish could serve as a suitable snack or even a main course for those with type 2 diabetes, depending on portion size.51 the development of kwetiau based on consumer sensory preferences provides valuable insight into the product’s taste, aroma, texture, and appearance. sensory testing also supports effective marketing strategies by highlighting the attributes that appeal most to consumers. this feedback is crucial for tailoring the product to meet market demands and consumer expectations. overall, these findings benefit both consumers and the food industry. consumers gain access to a healthier, higher-quality alternative. at the same time, the industry is presented with opportunities for innovation, enhanced regulatory compliance, and targeted marketing that aligns with current health trends in the food market.48,52,53 this study has limitations, particularly in the demographic diversity of the panelists, such as age, gender, cultural background, and dietary habits, which may influence the organoleptic assessment of kwetiau. additionally, while the nutritional composition of the product was analyzed, its potential application as a dietary therapy for individuals with diabetes mellitus has not yet been explored, as the study focused solely on organoleptic properties and nutritional content without testing for anthocyanin levels. conclusions no significant differences were observed in the organoleptic properties such as color, aroma, taste, texture, and overall acceptability of kwetiau made from red rice flour and peanut flour. further research with different formulations and additional ingredient variations is recommended to address knowledge gaps and expand our understanding of kwetiau products. as this product has so far only been assessed for its organoleptic qualities and nutritional content, it has not yet been tested as an alternative food therapy for people with diabetes mellitus. therefore, further studies are needed to evaluate the effectiveness of kwetiau products based on red rice and red bean flour for individuals with diabetes. future research and development of kwetiau products could lead to practical applications that benefit society and inform policy or practice in related fields. it is also hoped that 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control in type 2 diabetes mellitus patients: a case-control study. curr diabetes rev 2023;19:108-14. 49. fitriyani nl, syafrudin m, ulyah sm, et al. performance analysis and assessment of type 2 diabetes screening scores in patients with non-alcoholic fatty liver disease. mathematics 2023;11. 50. rahardjo t, soelistijo sa, mudjanarko sw. effect of white rice substitution with sorghum rice on beta cell function and insulin resistance in prediabetes. gac med caracas 2023;131:s112-20. 51. zhang g, wang d, ding y, et al. effect and mechanism of insoluble dietary fiber on postprandial blood sugar regulation. trends food sci technol 2024;146:104354. 52. putra mm, kusnanto, asmoro cp, sukartini t. application of health promotion model for better self-care behavior in patients with diabetes mellitus. belitung nurs j 2019;5:23945. 53. puspikawati si, dewi dmsk, astutik e, et al. density of outdoor food and beverage advertising around gathering place for children and adolescent in east java, indonesia. public health nutr 2020. available from: https://www.scopus. com/inward/record.uri?eid=2-s2.0-85097378513&doi= 10.1017%2fs1368980020004917&partnerid=40&md5=d0c0 4a4e5ac083b1e1fb893c823b0b7c special issue pathways of change [page 62] [healthcare in low-resource settings 2025;13(s1):13133] hrev_master healthcare in low-resource settings 2025; volume 13:12922 the effect of kinesthetic tactile stimulation on enhancing motoric development in babies with low birth weight sadiman sadiman,1 islamiyati islamiyati,1 nadi aprilyadi,2 wahyu dwi ari wibowo2 1associated degree midwifery program, health polytechnic of tanjung karang, bandar lampung; 2nursing program, health polytechnic of palembang, palembang, indonesia abstract neonatal mortality in indonesia is predominantly attributed to low birth weight (lbw), prematurity, asphyxia, and infections, with lbw infants at an elevated risk of mortality and developmental delays. the 2025 health goals in indonesia prioritize reducing infant mortality, maternal mortality, and malnutrition. metro city has implemented strategies such as healthcare training and enhanced referral networks to support these objectives. this study investigates the effect of tactile kinesthetic stimulation on motor development in lbw infants treated in a metro city hospital from september to december 2019. using a quasi-experimental design, 22 lbw infants were divided into intervention and control groups, each with 11 infants selected through quota sampling. motor development was assessed using validated observation tools and analyzed with paired t-tests (α=0.05). results indicated a significant improvement in motor development in the intervention group after 10 days of tactile kinesthetic stimulation (p=0.001, p<0.05), as well as a significant increase within the control group (p=0.004, p<0.05). a comparison on day 10 revealed a significant difference favoring the intervention group (p=0.001, p<0.05). the findings suggest that tactile kinesthetic stimulation effectively enhances motor development in lbw infants compared to standard care. however, the small sample size limits the generalizability of the results, warranting further research to confirm these findings in broader populations. introduction neonatal mortality, defined as the death of a newborn within the first 28 days of life, remains a significant public health issue worldwide, including in indonesia. despite various efforts, the neonatal mortality rate in indonesia is still high, at approximately 20 per 1,000 live births. this high rate indicates an urgent need for effective interventions targeting neonatal care and prevention strategies. low birth weight (lbw) is a known risk factor for neonatal mortality, and addressing this factor is crucial for improving survival rates among newborns.1 anemia during pregnancy has been identified as a significant risk factor for low birth weight and neonatal mortality. in indonesia, the prevalence of anemia in pregnancy was reported to be 37.1% in 2013, rising to 48.9% in 2017.2 anemia during pregnancy is a critical public health issue that requires immediate attention and intervention to mitigate risks for both the mother and the newborn. breastfeeding has been consistently shown to have a protective effect against neonatal mortality. exclusive breastfeeding for the first six months of life is associated with reduced child mortality rates.3 promoting and supporting breastfeeding, particularly exclusive breastfeeding, can significantly contribute to reducing neonatal mortality rates in indonesia. adequate healthcare services, including comprehensive antenatal care and access to skilled midwives, are essential in reducing neonatal mortality rates. the high maternal mortality rate in indonesia, reported to be 305 per 100,000 live births in 2019, further highlights the necessity of improving healthcare services for pregnant women.4 ensuring that pregnant women receive appropriate care during correspondence: sadiman sadiman, associate degree midwifery program, health polytechnic of tanjung karang, bandar lampung, indonesia. e-mail: sadiman@poltekkes-tjk.ac.id key words: kinesthetic tactile; neonatal mortality; healthcare. conflict of interest: the authors declare no conflict of interest, financial or otherwise. contribution: ss, designed the study and supervised its execution. ii managed the intervention and data collection; na, conducted the statistical analysis; wdwaw, handled the manuscript preparation and review. all authors approved the final manuscript. ethics approval: the study received approval from the health research ethics committee (kpek) of the tanjungkarang health polytechnic, with approval number 266/ea/kepk-tjk/ix/2019. informed consent and consent to participate: all parents or legal guardians of participants in this study provided written informed consent before participation. they were fully informed about the study's objectives, procedures, potential benefits, and risks. participation was entirely voluntary, with the right to withdraw at any time without consequences. acknowledgments: the authors thank the fourth-year diploma iv and third-year diploma iii midwifery students of metro for their contribution as enumerators during the assessment and providing tactile kinesthetic stimulation. received: 13 august 2024. accepted: 18 november 2024. early access: 14 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12922 doi:10.4081/hls.2025.12922 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12922] [page 117] pregnancy and childbirth can help prevent complications that may lead to neonatal mortality. socioeconomic factors and environmental conditions also significantly influence neonatal mortality. a study conducted in indonesia found that children’s environmental profiles, including factors such as sanitation and housing, were associated with the risk of child mortality.5 improving environmental conditions and addressing social determinants of health can play a pivotal role in reducing neonatal mortality rates. despite ongoing efforts, neonatal mortality remains a significant public health issue in indonesia, particularly in regions such as lampung and metro city. contributing factors include inadequate implementation of standard neonatal care protocols, high prevalence of anemia during pregnancy, suboptimal breastfeeding practices, and limited access to quality healthcare services. addressing these factors through enhanced training and implementation of evidence-based practices, interventions to reduce anemia during pregnancy, promoting and supporting breastfeeding, and strengthening healthcare services is crucial to reducing neonatal mortality rates in indonesia.6 parental knowledge about neonatal diseases and symptoms is a critical challenge in reducing infant mortality. the government has responded by improving neonatal healthcare services, including training healthcare workers and increasing the number of pediatricians.7 improving maternal and child health services is also crucial. government programs offer adequate pregnancy care, including routine check-ups, nutritional counseling, and access to essential medications. promotion of exclusive breastfeeding is also emphasized.8 strengthening health infrastructure, including health facilities in rural areas and investing in medical equipment, aims to improve the quality of healthcare services for newborns and their mothers. accurate and up-to-date data are essential to monitor policy effectiveness. the government has implemented a data collection and analysis system to identify areas needing further intervention.9 research supporting efforts to reduce infant mortality due to lbw includes the study titled “tactile-kinesthetic stimulation to gain weight and reduce the length of stay care for premature babies at public hospitals of semarang, indonesia, which shows that using tactile-kinesthetic stimulation on lbw infants effectively increases weight and reduces hospital stay length. these findings confirm that tactile-kinesthetic stimulation interventions can positively impact maintaining premature infants’ weight while reducing hospital care costs.10 another study titled “effect of tactile-kinesthetic stimulation on growth, neurobehavior, and development among preterm neonates” also revealed that tactile-kinesthetic stimulation positively affects weight gain and early discharge of premature infants, which is efficient and potentially cost-saving. however, further research is needed to evaluate the effects of tactile-kinesthetic stimulation on infants with birth weights of less than 1000 grams and to apply this research in other regions to obtain more informative data.11 a study conducted by ahmed et al. in 2015, titled “effect of tactile kinesthetic stimulation on preterm infants’ weight and length of hospital stay in khartoum, sudan,” also confirmed the benefits of tactile kinesthetic stimulation in increasing weight and reducing hospital stay length for preterm infants. these findings underline the efficiency and potential cost savings of using tactile kinesthetic stimulation.12 numerous studies have identified several factors contributing to high neonatal mortality rates, including inadequate management of neonatal visits by midwives, the prevalence of anemia during pregnancy, suboptimal breastfeeding practices, and limited access to healthcare services. several studies also highlight the importance of tactile-kinesthetic stimulation in increasing weight and reducing the length of stay for lbw infants, demonstrating the potential of this intervention to address the issue. tactile-kinesthetic stimulation (tks) has emerged as a promising intervention to support the growth and development of lbw infants. previous studies, such as those conducted in indonesia and other regions, have shown that tks can increase weight gain and reduce the length of hospital stays for lbw infants, thereby lowering healthcare costs.10,11 the effectiveness of tks in facilitating motor and neurobehavioral development is supported by evidence indicating that physical stimulation can promote weight gain and improve developmental outcomes in lbw infants. however, further research is needed to confirm the efficacy of this intervention in diverse contexts and among infants with varying birth weights. this study aims to evaluate the effect of kinesthetic tactile stimulation on motor development in lbw infants. by focusing on motor development, this research seeks to expand the understanding of how tks can support specific developmental outcomes in lbw infants, potentially reducing the high neonatal mortality rates in indonesia. the expected outcome is to provide evidence on the benefits of tks, contributing to standardized neonatal care protocols that may improve survival and developmental outcomes in lbw infants. materials and methods research design this study utilized an intervention design, specifically a nonequivalent control group design, to evaluate the impact of tactile kinesthetic stimulation (tks) on motor development in low birth weight (lbw) infants. in this design, the treatment and control groups were compared without randomization. population and sample the population included all lbw infants treated in the perinatology ward of a hospital in metro city, indonesia, from september to december 2019. quota sampling was used to select the sample, which consisted of 22 lbw infants divided equally into an intervention group (n=11) and a control group (n=11). to define the study population clearly, inclusion criteria consisted of lbw infants who were treated in the perinatology ward during the specified study period and whose parents provided informed consent for their participation. exclusion criteria included lbw infants with congenital defects or physical injuries, as these conditions could independently influence motor development and potentially bias the results. specifying these criteria ensures transparency and aids replicability, allowing a more accurate assessment of tks effects on motor development in lbw infants. variables the independent variable was tactile kinesthetic stimulation (tks) applied to infants in the intervention group. the dependent variable was motor development in lbw infants, measured by specific motor reflexes indicative of early developmental milestones. measurement and instrumentation motor development was assessed using an adapted observation sheet, evaluating reflexes such as babinski, tonic neck, moro, grasp, standing, and walking. this tool was modified from the premature neonates behavior assessment sheet by situmorang article [page 118] [healthcare in low-resource settings 2024;12:12922] (2010), a validated instrument for assessing premature infant behavior. content validity was confirmed by a neonatal nursing expert, rustina from the faculty of nursing, university of indonesia, ensuring the adequacy of the instrument for this specific population.13,14 reliability of the instrument was tested using cronbach’s alpha, with a high alpha score indicating strong reliability. in situmorang’s (2010) original study, the instrument showed a cronbach’s alpha of 1.707, exceeding the critical value at the 5% significance level (r table=0.878). this high reliability score confirms the instrument’s appropriateness for assessing motor development in premature and lbw infants. this study is an intervention research using a nonequivalent control group design. this design compares the treatment and control groups without randomization. implementation of tactile kinesthetic stimulation the implementation began by selecting the sample using quota sampling until the sample size was met. all eligible lbw infants, totaling 11, were included, with 11 in the intervention group and 11 in the control group. reflexes such as babinski, tonic neck, moro, grasp, standing, and walking were assessed on the first day for both groups. the intervention group received tactile kinesthetic stimulation every morning and evening for 10 days. on the 10th day, reflexes were reassessed in both groups. the reflex assessments and tactile kinesthetic stimulation were conducted by trained researchers and enumerators certified in national baby-spa and treatment. statistical analysis the data obtained from this study were analyzed using a dependent t-test, as the data were normally distributed. statistical analysis was performed at a 95% confidence level (α=0.05). ethical permission this study received approval from the health research ethics committee (kpek) of the tanjungkarang health polytechnic, with approval number 266/ea/kepk-tjk/ix/2019. results the demographic data of the study respondents as shown in table 1. tabel 1 show the respondents gender in the intervention group had a slightly higher number of females (55%) compared to males (45%). in the control group, females (64%) also outnumbered males (36%). this indicates a relatively balanced gender distribution between the two groups, with no significant difference in gender distribution. the majority of infants in the intervention group were premature (64%), with a smaller proportion being mature (36%). similarly, the control group was predominantly composed of premature infants (82%), with only a few being mature (18%). this data shows that most infants in this study were born prematurely, and the significant difference in gestational age between the two groups could influence the motor development of lbw infants. in terms of birth weight, most infants in the intervention group were classified as lbw (64%), while a smaller number were very low birth weight (vlbw) (36%). in contrast, the control group had a higher proportion of vlbw infants (55%) compared to lbw infants (45%). this indicates a difference in birth weight distribution between the two groups, which could affect the outcomes of the tactile kinesthetic stimulation intervention. the analysis of respondent demographics indicates that the study was conducted with a relatively balanced gender distribution between the intervention and control groups. however, there were significant differences in gestational age and birth weight between the groups. these differences could influence the results of the study on the effect of tactile kinesthetic stimulation on motor development in lbw infants and should be considered when interpreting the data. further research may be needed to determine whether these factors significantly impact the study outcomes. the t-test analysis aimed to evaluate whether there were significant differences in motor development in lbw infants before and after receiving tactile kinesthetic stimulation for 10 days. the analysis results are shown in table 2. in the intervention group before the tactile kinesthetic stimulation, the mean motor skills score was 5.82 with a standard deviation of 2.316. after the intervention, the mean motor skills score increased to 11.18 with a standard deviation of 2.750. the t-test showed a highly significant difference (p=0.001, p<0.05) between the motor skills scores before and after the tactile kinesthetic stimulation in the intervention group. the control group before the tactile kinesthetic stimulation, the mean motor skills score was 2.27 with a standard deviation of 1.679. after the intervention, the mean motor skills score increased to 4.27 with a standard deviation of 1.555. the t-test for the control group also showed a significant difference (p=0.004, p<0.05) between the motor skills scores before and after the intervention, although the difference was not as substantial as in the intervention group. the t-test analysis results indicate that tactile kinesthetic stimulation significantly improved motor skills in lbw infants in the intervention group. the very low p-value (p=0.001) suggests that this change was not due to chance but was a direct effect of the intervention. however, it is worth noting that the control group also experienced a significant improvement in motor skills, albeit to a lesser extent than the intervention group. these results strong article table 1. respondent demographic data. number percentage (%) demographic data gender intervention group male 5 45 female 6 55 control group male 4 36 female 7 64 gestational age intervention group premature (< 36 weeks) 7 64 mature (36 – 40 weeks) 4 36 control group premature (< 36 weeks) 9 82 mature (36-40 weeks) 2 18 birth weight intervention group lbw (1500 – 2499 grams) 7 64 vlbw (< 1500 grams) 4 36 control group lbw (1500-2499 grams) 5 45 vlbw (< 1500 grams) 6 55 [healthcare in low-resource settings 2024;12:12922] [page 119] ly support the effectiveness of tactile kinesthetic stimulation as an intervention to enhance motor development in lbw infants. nonetheless, further research with larger samples and more rigorous controls is necessary to validate these findings more thoroughly. the motor skills scores of the control group before the 10-day care period had a mean of 2.27 with a standard deviation of 1.679, and after 10 days of care, the mean increased to 4.27 with a standard deviation of 1.555. the study results show a significant difference between the scores before and after the care period without tactile kinesthetic stimulation (p=0.004, p<0.05). the difference in mean motor skills scores between the intervention group receiving tactile kinesthetic stimulation and the control group on the 10th day showed a p-value of 0.000 (p<0.05), indicating a significant difference in motor skills scores between lbw infants who received tactile kinesthetic stimulation and those who did not, as seen in table 3. the findings demonstrate that tactile kinesthetic stimulation significantly improved motor skills in lbw infants in the intervention group compared to the control group. the very low p-value (p=0.001) underscores the effectiveness of the intervention. discussion the findings of this study show a marked improvement in motor development among lbw infants following tactilekinesthetic stimulation (tks). the motor development score in the intervention group increased significantly from a baseline of 5.82 to 11.18 over 10 days of stimulation, with a statistically significant difference (p=0.001). this improvement aligns with the growing body of evidence that supports tks as an effective intervention for enhancing motor development and other physical outcomes in lbw infants. studies reinforce the role of tks in promoting physiological growth in lbw infants. johari et al. found that tks contributed to weight gain and advocated massage as a complementary therapy to mitigate neurological issues in neonates.15 similarly, sartika’s research demonstrated that tks produced a significant weight increase in lbw infants (p=0.005), underscoring tks’s role in supporting developmental and growth outcomes.16 the physiological basis for these findings is supported by motor development theories, where kinesthetic and tactile inputs play essential roles in developing neural and motor pathways. the study by rismalinda (2017) highlights that motor development in infants is influenced by the coordination of muscle, nerve, and brain functions.17 according to piaget’s cognitive development theory, reflex-based development in infants progresses naturally up to about six weeks, suggesting that tks may accelerate this natural developmental trajectory in lbw infants who may otherwise develop more slowly without such stimulation.18 further, the findings align with kachoosangy & aliabadi (2011), who reported significant improvements in motor behavior in lbw infants who received 10 days of tks (p=0.0001) compared to controls.19 this suggests that tactile stimulation may support motor milestone achievements in lbw infants by providing essential sensory input that aids in nervous system maturation. several studies, including yoanita et al. (2021), have also shown that tks supports weight gain and reduces hospital stay durations, demonstrating its potential for broader physiological benefits.11 additionally, iskandar et al. (2019) observed similar benefits in indonesia, reporting that tks promoted weight gain and shortened hospital stays, suggesting its viability as a costeffective intervention in resource-limited settings.10 despite these promising findings, the study encountered certain limitations. the small sample size (n=22) limits generalizability and may reduce the robustness of the statistical analysis. additionally, differences in gestational age between the intervention and control groups could present confounding effects. previous research indicates that gestational age plays a crucial role in motor development; therefore, future studies should account for gestational age as a potential confounding variable to enhance accuracy. moreover, a nonequivalent control group design without randomization can introduce selection bias, potentially affecting internal validity. nevertheless, this study contributes to the evidence supporting tks as a safe and effective intervention for lbw infants, improving motor development outcomes. the use of validated instruments for assessing motor reflexes strengthens the reliability of the findings, and adherence to ethical standards ensures research integrity. future research should aim to include a larger and more diverse sample to enhance generalizability and explore the potential of tks for very low birth weight infants and those with different gestational age profiles.based on the study results, the average article [page 120] [healthcare in low-resource settings 2024;12:12922] table 2. differences in motor skills of infants before and after tactile stimulation in the intervention and control groups. n mean sd (±) 95% ci t p intervention group before 11 5.82 ±2.316 -4.763 – -2.601 -7.085 0.001 after 11.18 ±2.750 control group before 11 2.27 ±1.679 -3.202 – -0.798 -3.708 0.004 after 4.27 ±1.555 *paired t-test. table 3. differences in motor skills of infants after tactile stimulation in the intervention and control groups. n mean sd (±) 95% ci t p intervention 11 11.18 2.750 1.791-4.937 4.461 0.001 control 4.27 1.555 *independent t-test. motor development of lbw infants in the intervention group before receiving tactile kinesthetic stimulation was 5.82, which increased to 11.18 after 10 days of stimulation. this shows an improvement of 5.36 points. further analysis revealed a significant difference in average motor development before and after the tactile kinesthetic stimulation in the intervention group, with a pvalue of 0.001. this study aligns with (jonathan et al., 2020) in “the effect of massage stimulation on the general movements quality in breastfed preterm infants,” where the general movement quality in preterm infants did not show significant differences between groups (p=0.150).20 however, based on johari (2016) in “the effect of massage on weight gain of low-weight hospitalized infants: a randomized clinical trial” found that tactile-kinesthetic stimulation led to weight gain in lbw neonates and recommended massage therapy as complementary care to prevent neurological issues.15 this issues supporting by sartika (2015) found significant weight gain in lbw infants receiving tactile kinesthetic stimulation, with an increase from 1744.7 grams to 1764.4 grams on average.16 statistical analysis confirmed a significant weight increase (p=0.005). kachoosangy & aliabadi (2011) also observed significant motor behavior improvement in lbw infants given 10 days of tactile kinesthetic stimulation compared to the control group (p=0.0001).19 similar findings were reported by hastuti et al.,21 who noted significant physiological development in heart rate and respiration in lbw infants after tactile kinesthetic stimulation (p=0.037 and p=0.001, respectively). however, temperature development showed significant differences in both stimulated and nonstimulated groups (p=0.001). physiologically, lbw infants develop slower than normal infants, but tactile kinesthetic stimulation accelerates motor development. providing tactile kinesthetic stimulation helps lbw infants develop motor skills faster compared to no stimulation. the control group’s initial average motor development was 2.27, increasing to 4.27 after 10 days, showing a 2.00point improvement. statistical analysis showed a significant difference in motor development before and after the study period without tactile kinesthetic stimulation (p=0.004). jonathan et al. (2020) found no significant differences in general movements among preterm infants with or without massage stimulation (p=0.150).20 physiologically, newborns develop motor skills, determined by muscle, nerve, and brain elements.17 according to piaget’s cognitive development theory, infants experience reflex development up to 6 weeks old, indicating natural motor skill progression.18 motor development involves coordinating nervous system activities, starting with newborn reflexes that fade by 6-9 weeks.22 without stimulation, lbw infants develop motor skills slower than normal infants. tactile kinesthetic stimulation accelerates motor development in lbw infants, potentially equating their progress to that of normal infants. dependent t-test analysis showed significant differences in motor development between infants in the intervention group and those in the control group (p=0.001). this indicates the effectiveness of tactile kinesthetic stimulation in enhancing motor skills in lbw infants. yoanita et al. (2021) found that tactile kinesthetic stimulation benefits weight gain and reduces hospital stay duration. further studies are recommended to evaluate its impact on infants under 1000 grams and to collect broader data.11 iskandar et al. (2019) reported that tactile kinesthetic stimulation effectively increased weight gain and reduced hospital stays in lbw infants in semarang, indonesia.10 ahmed et al. (2015) emphasized the beneficial impacts of tactile kinesthetic stimulation, noting its significant role in enhancing both weight gain and the efficiency of hospital discharge processes in sudan.12 similarly, johari et al. (2016) proposed massage therapy as a beneficial intervention for promoting weight gain and supporting neurological development in infants with low birth weight (lbw).15 furthermore, other studies demonstrated that tactile kinesthetic stimulation effectively enhances feeding tolerance and facilitates weight gain specifically in late preterm neonates.23 tactile stimulation is commonly used to stimulate spontaneous respiration in preterm infants during neonatal resuscitation.24 an other studies observed that tactile stimulation could shorten the duration of apnea, hypoxia, and bradycardia, with automated stimulation showing promise.25 jonathan et al. (2020) found no significant differences in general movements among preterm infants with or without massage stimulation (p=0.150).20 conducted with hidayanti (2018) found significant weight and length gains in newborns after parental massage.26 karbasi et al. (2013) suggested body massage as a safe, non-medical intervention for weight gain in lbw neonates.27 similar findings were reported in iran (2010), showing that tactile stimulation for 10 days improved motor behavior in lbw infants compared to those without stimulation.19 tactile stimulation is effective once infants are stable post-intensive care. anjos et al. (2021) found that hydrotherapy and tactile-kinesthetic stimulation significantly increased weight gain in preterm infants, making these interventions safe and beneficial.28 emphasized the need for standardized tactile/kinesthetic stimulation application and further research on its side effects.29 motor development in lbw infants in the intervention group significantly improved after receiving tactile kinesthetic stimulation. in contrast, the control group showed no significant development over ten days. this study has several strengths. it targets lbw infants, a particularly vulnerable group, allowing for interventions that address specific developmental needs. the study uses a structured intervention with a nonequivalent control group design and systematically applies tactile kinesthetic stimulation, making the protocol clear and replicable. additionally, the use of validated instruments, confirmed for content validity and reliability, ensures the accuracy and consistency of the data collected. the study also benefits from ethical approval by a recognized ethics committee, which adds credibility and ensures adherence to ethical research standards. moreover, the study uses specific and measurable outcomes (motor reflexes) to evaluate the intervention’s effectiveness, providing clear and concrete results. however, there are notable weaknesses. the small sample size of only 22 infants (11 in each group) limits the generalizability of the findings and reduces the statistical power of the results. the use of a nonequivalent control group design, which lacks randomization, could introduce selection bias and affect the internal validity of the study. additionally, differences in gestational age and birth weight distribution between the intervention and control groups could influence the study’s outcomes and complicate the interpretation of the results. despite these limitations, the study provides valuable insights into the potential benefits of tactile kinesthetic stimulation for lbw infants’ motor development. recommendations for future studies, it is recommended to increase the sample size and employ a randomized controlled trial design to enhance the validity and generalizability of the findings. extending the follow-up period will help assess the long-term effects of tactile kinesthetic stimulation. controlling for confounding variables, such as gestational age and birth weight, and including additional developmental outcomes will provide a more comprehensive article [healthcare in low-resource settings 2024;12:12922] [page 121] understanding of the intervention’s impact. exploring parental involvement, conducting cost-effectiveness analyses, and incorporating qualitative research methods can offer valuable insights into the practical application and feasibility of the intervention. collaboration with multidisciplinary teams will ensure a holistic approach and improve care practices for lbw infants. references 1. iraningsih w, azinar m. praktik bidan dalam penggunaan algoritma manajemen terpadu bayi muda pada kunjungan neonatal [midwives’ practices in using the integrated management of young infants algorithm at neonatal visits]. unnes j public heal 2017;6:10362. 2. wahyuni s, ananti y, issabella cm. hubungan anemia kehamilan dengan kejadian berat badan lahir rendah (bblr): systematic literatur review [pregnancy anemia relationship with the event of low birth weight (lbw): systematic literature review]. j heal 2021;8:94–104. 3. fatmawati ni, rochmad tn, wulandari a, pramono a. penerapan program sepuluh langkah kesehatan untuk peningkatan pemberian asi eksklusif: model evaluasi cipp (context, input, process, product). j aisyah j ilmu kesehat 2021;6:501–8. 4. sari lr, fitriyani. prosiding seminar nasional kesehatan 2021 lembaga penelitian dan pengabdian masyarakat studi kasus kehamilan dengan risiko tinggi prosiding seminar nasional kesehatan 2021 lembaga penelitian dan pengabdian masyarakat universitas muhammadiyah pekajangan pe 2021;1633–41. 5. afifah t, saptarini i, irianto j, et al. profil lingkungan hidup balita dan tingkat kematian anak menurut faktor lingkungan: data sdki 2017. j ekol kesehat 2021;20:152–64. 6. dinas kesehatan provinsi lampung. rencana strategis (renstra) pd tahun 2019 – 2024 (revisi). bandar lampung; 2022. 7. panjaitan a, yusda ra, saputra e. diagnosis penyakit bayi baru lahir (neonatus) menggunakan metode forward chaining. jutsi j teknol dan sist inf 2022;2:55–62. 8. suhaeri f, sugiharti l. pengaruh faktor sosial ekonomi terhadap angka kematian bayi ( akb ) pada kabupaten / kota di propinsi jawa timur effect of socio-economic factors on infant mortality rate ( imr ) in regencies / cities in east java province. j ilmu ekon dan stud pembang 2020;20:68–87. 9. yulinda w a, novia l t, tegarina m, chamidah n. analisis pengaruh angka kematian bayi terhadap angka harapan hidup di provinsi jawa timur berdasarkan estimator least square spline. contemp math appl 2019;1:56–63. 10. iskandar fn, suwondo a, bantoso b. tactile-kinesthetic stimulation to gain weight and reduce the length of stay care for premature baby at public hospitals of semarang, indonesia. glob heal manag j 2019;9296:25–30. 11. yoanita r, gunardi h, rohsiswatmo r, budi d. therapies effect of tactile e kinesthetic stimulation on growth , neurobehavior and development among preterm neonates. j bodyw mov ther 2021;28:180–6. 12. ahmed rg, suliman gi, elfakey wa, et al. effect of tactile kinesthetic stimulation on preterm infants’ weight and length of hospital stay in khartoum, sudan. saudi med j 2015;36:196–9. 13. situmorang lf. pedoman pelaksanaan stimulasi, deteksi dan intervensi dini tumbuh kembang anak di tingkat pelayanan kesehatan dasar [internet]. universitas indonesia; 2010. available from: https://lib.ui.ac.id/file?file=digital/old26/202 82932-t 14. sirait naj, rustina y, waluyanti ft. pemberian informasi meningkatkan pengetahuan, sikap dan keterampilan orang tua dalam penanganan demam pada anak. j keperawatan indones 2013;16:101–6. 15. johari s, haghgous ha, daemi m, et al. the effect of massage on weight gain of low-weight hospitalized infants: a randomized clinical trial. phys treat 2016;5:205–10. 16. sartika e. pengaruh stimulasi taktil dan kinestetik terhadap perubahan berat badan bayi bblr di ruang inap perinatologi rsud dr.achmad mochtar bukittinggi tahun 2015. stikes fort de kock bukittinggi padang; 2015. 17. rismalinda. buku ajar psikologi kesehatan. jakarta timur: cv. trans info media; 2017. 18. suryani e, badiah a. asuhan keperawatan anak sehat & berkebutuhan khusus. cetakan pe. yogyakarta: pustaka baru press; 2018. 240 p. 19. kachoosangy ra, aliabadi f. effect of tactile-kinesthetic stimulation on motor development of low birth weight neonates. iran rehabil j 2011;10:16–8. 20. jonathan eb, suryawan a, irmawati m. the effect of massage stimulation on the general movements quality in breastfed preterm infant. folia medica indones 2020;56:302–8. 21. hastuti d, juhaeriah j. efek stimulasi taktil kinestetik erhadap perkembangan bayi berat badan lahir rendah. j keperawatan padjadjaran 2016;v4:70–8. 22. soetjiningsih. tumbuh kembang anak. ranuh ign, editor. jakarta: egc; 2017. 252 p. 23. nyaga em, basiouny ns, esamai fo, mansy g. effects of tactile-kinesthetic stimulation on feeding and weight of moderate and late preterm neonates. east afr med j 2020;99:1–14. 24. kaufmann m, seipolt b, rudiger m, mense l. tactile stimulation in very preterm infants and their needs of non-invasive respiratory support. front pediatr 2022;10:1041898. 25. cramer sje, dekker j, dankelman j, et al. effect of tactile stimulation on termination and prevention of apnea of prematurity: a systematic review. front pediatr 2018;6:45. 26. hidayanti d. the effect of infant massage to the newborn’s growth at community. j kebidanan 2018;4:197–209. 27. karbasi sa, golestan m, fallah r, dehghan z. effect of body massage on increase of low birth weight neonates growth parameters: a randomized clinical trial. iran j reprod med 2013;11:583–8. 28. anjos f, nakato am, nohama p, et al. effects of hydrotherapy and tactile-kinesthetic stimulation on weight gain of preterm infants admitted in the neonatal intensive care unit. j pediatr 2021;98:155–60. 29. juwita s, argaheni nb, alristina ad. scoping review: application of tactile/kinesthetic stimulation in preterm infants. j ilm kesehat dan apl 2023;11:65–74. article [page 122] [healthcare in low-resource settings 2024;12:12922] hrev_master healthcare in low-resource settings 2024; volume 12:11900 the effect of providing koya nate on the appetite of stunting toddlers diyah arini, muh zul azhri rustam, liana windia sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia abstract the appetite experienced by toddlers is at risk of causing nutritional disorders, which can have a negative impact on health, such as stunting. efforts are being made to overcome toddler appetite issues through innovation in the form of koya nate. this research examined the impact of koya nate, an innovative intervention, on the appetite of stunted toddlers in surabaya. using a quasi-experimental approach with a pre-post design, 16 toddlers aged 1-5 years participated, with 8 in the intervention group and 8 in the control group. the study found a significant influence on the appetite of toddlers in the intervention group after the intervention (sig. 0.000), while there was no significant change in the control group without intervention (sig. 0.157). a comparison between the two groups revealed a significant influence on appetite in the intervention group compared to the control group (sig. 0.000). this suggests that koya nate has a positive impact on the appetite of stunted toddlers, addressing issues of picky eating. the study emphasizes the importance of innovative approaches in presenting food menus to toddlers facing appetite-related nutritional challenges. the findings highlight the potential of koya nate as an effective intervention for improving the appetite of stunted children, contributing to efforts to combat nutritional disorders and prevent negative health impacts such as stunting. introduction the problem of malnutrition remains one of the primary public health concerns worldwide, especially given the relatively high prevalence of malnutrition in indonesia.1,2 one of the nutritional challenges frequently encountered by children is a decline in appetite or difficulty in eating, as, at this age, children start to be selective about the foods they prefer.3,4 prolonged periods of reduced appetite in children can lead to stunted growth in height.5,6 the united nations international children’s emergency fund (unicef) reports that the global prevalence of stunting is 28%, with rates of 40% in eastern and southern africa and 38% in south asia.7 the results of the indonesian nutrition survey study in 2022 indicate a 3% decrease in the prevalence of stunting in indonesia since 2021.8 in east java province, there has been a significant reduction in the prevalence of stunting, particularly in children aged < 30 days, which decreased by approximately 30% from the previous year. additionally, in children aged 12-23 months, there was a notable decrease of 7% from the previous year.9 various cities and districts in indonesia have also witnessed a substantial reduction in stunting rates, with surabaya recording a stunting prevalence rate of 4.8% in 2022, making it the second city with the lowest stunting prevalence rate.10 incidents of child stunting are influenced by several important factors, one of which is nutritional factors, namely animal and vegetable protein.11,12 the high nutritional value of animal and vegetable protein contained in each food ingredient is available and in sufficient quantities; however, if the child does not want to eat or follows the wrong feeding pattern, it can result in a lack of nutritional intake for the toddler.13–15 appetite problems experienced by children are at risk of causing nutritional disorders and will have a negative impact on the health, growth, and development of toddlers.16–18 one of the factors contributing to delayed growth and development in toddlers is a diminished appetite. interviews conducted by researchers and village health workers with parents of toddlers participating in integrated services post (called posyandu in correspondence: muh zul azhri rustam, sekolah tinggi ilmu kesehatan hang tuah surabaya, surabaya, indonesia. e-mail: zul.azhri@gmail.com key word: appetite; child health; koya nate; malnutrition; stunting. contributions: da conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; mzar conceptualization, methodology, formal analysis, validation, and writing – original draft, formal analysis, validation, review and editing; lw conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of the sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia based on the ethical certificate number pe/78/vii/2023/kep/sht. during the research, the researcher gave on attention to the ethical principles of information to consent and respect for human rights. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: researchers would like to thank the health department for granting permission to conduct research. received: 2 october 2023. accepted: 1 december 2023. early access: 22 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11900 doi:10.4081/hls.2024.11900 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11900] [page 161] non -co mmerc ial us e o nly indonesia) activities revealed that parents reported their toddlers faced challenges in consuming provided food due to specific food dislikes. consequently, toddlers frequently left their meals unfinished. addressing toddlers with a lack of appetite becomes crucial for achieving optimal growth. recommending food therapy, which includes options rich in protein and with a smooth texture, can facilitate better consumption by toddlers.19–21 one of the efforts to address toddlers’ diminished appetite involves the innovation of snacks, such as koya nate, which boasts high nutritional value capable of enhancing toddlers’ appetite. previous research indicates that koya nate’s snack innovation, featuring an 80% tuna and 20% tempeh formula validated through organoleptic tests, effectively increases appetite. the composition of this formula eliminates the typical fishy smell associated with fish, allowing toddlers to consume koya nate without encountering unpleasant odors.22 based on this, this study aimed to analyze the effect of giving koya nate on the appetite of stunted toddlers. materials and methods research design the research design employed in this study utilized a quasiexperimental method with a two-group pre-post design approach to ascertain the impact on toddlers’ appetite. the intervention group was provided with koya nate snacks, while the control group did not receive koya nate snacks. study participants the sample used in this research was determined through sample size calculations using the federer formula. the calculated sample size resulted in 8 samples for the group that received koya nate and 8 samples for the group that did not receive koya nate. the sample selection was based on the calculation results and was also adjusted to the population’s condition in this study, specifically toddlers experiencing stunting in one of village in surabaya city, indonesia. therefore, the selection of samples for both the intervention and non-intervention groups was limited. the samples were selected from the intervention and non-intervention (control) groups using the simple random sampling technique, considering the inclusion and exclusion criteria: children aged 1-5 years, meeting the stunting criteria (if their height-for-age is more than two standard deviations below the who child growth standards median),23 not currently suffering from an illness, and willing to participate as study samples. variable, instrument and data collection the independent variables in this study consisted of demographic factors, specifically the toddler’s characteristics (age, gender, height, weight, stunting category), and the mother’s characteristics (age, education level, mother’s occupation, and family income). additionally, the variable related to the toddler’s comfort eating was considered. the dependent variable in this research was the provision of koya nate snacks, sourced from 80% tuna and 20% tempeh. koya nate was administered to the intervention group for one week. each day, they were given koya nate once during the day, with the composition of one portion of food and the addition of one small 40g package. the instrument used to assess toddlers’ appetite was a questionnaire developed by the researchers, measured by evaluating the results of food waste from the child’s initial portion of the meal using the comstock method.24 this method utilized a scale where 0 represented the percentage of toddlers consuming the entire portion of food from the start of the meal. scale 1 represented the percentage of toddlers consuming ¾ of the initial amount of food, scale 2 represented the percentage of toddlers who consumed ½ the initial portion of food, scale 3 represented the percentage of toddlers who consumed ¼ of the initial part of food, scale 4 represented the percentage of toddlers consuming 1/9 (only a tiny portion) of the initial part of food, and scale 5 represented the percentage of toddlers who did not eat at all from the initial part of the meal. appetite data collection was conducted using the comstock method, administered by village health workers who had obtained competency at the primary health center in surabaya city. data analysis the data analysis employed statistical tests, specifically paired t-tests and independent t-tests, assuming the data were normally distributed. this statistical analysis aimed to examine the impact on appetite both before and after the koya nate intervention and the comparison of appetite between those who received the koya nate intervention and those who did not. the indicator used to measure appetite involved assessing the leftover food provided by the toddler’s parents. ethical clearance the research received ethical approval from the health research ethics committee of sekolah tinggi ilmu kesehatan hang tuah surabaya, indonesia, based on the ethical certificate number pe/78/vii/2023/kep/sht. throughout the research, the researcher paid attention to the ethical principles of informed consent and respect for human rights. results table 1 shows that demographic factors, specifically the age of toddlers (< 41 months and ≥ 41 months), constituted 50% in the intervention group. for toddlers aged ≥ 41 months, the majority was 62.5% in the control group. boys dominated both the intervention and control groups, constituting 62.5% in each. in terms of height, 50% of toddlers in the intervention group were < 80 cm, while 75% of toddlers in the control group fell into this height category. regarding weight, 62.5% of toddlers in the intervention group weighed < 10 kg, while 62.5% of toddlers in the control group weighed ≥ 10 kg. maternal age ≥ 25 years old was predominant at 75% in the intervention group, whereas maternal age < 25 years old was predominant at 62.5% in the control group. the majority of mothers in both groups had a senior high school education level (87.5% in the intervention group and 100% in the control group). in terms of employment status, 87.5% of mothers in the intervention group were unemployed, compared to 62.5% in the control group. regarding income, 75% of mothers in the intervention group had incomes below the minimum wages (mw), while in the control group, 50% had incomes both above and below the mw. table 2 shows that in the pre-intervention group, toddlers’ appetite was primarily consuming 1/9 of the initial portion, accounting for 37.5%. in the post-intervention group, toddlers’ appetite increased, with 50% consuming ¾ of the initial portion. meanwhile, in the pre-control group, the majority of toddlers’ appetite consumed ¼ of the initial portion, constituting 62.5%. in the post-control group, most toddlers’ appetite consumed 1/9 of the initial portion, making up 37.5%. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 162] [healthcare in low-resource settings 2024;12:11900] non -co mmerc ial us e o nly table 3 shows that the pre and post-intervention group data are normally distributed, with a significant value of 0.109. in contrast, the data for the pre-control group indicates non-normal distribution, with a significant value of 0.001, while the post-control group data demonstrates normal distribution, with a significant value of 0.200. table 4 shows the influence of toddlers’ appetite before and after the intervention group, as evidenced by the significant value (0.005) with a mean difference of -2.250. meanwhile, there was no influence of toddlers’ appetite before and after the control group, as evidenced by the significant value (0.157) with a mean difference of -0.250. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of demographic factors (n=8). demographic factors intervention group control group f % f % toddler age <41 months 4 50 3 37.5 ≥41 months 4 50 5 62.5 total 8 100 8 100 toddler gender boy 5 62.5 5 62.5 girl 3 37.5 3 37.5 total 8 100 8 100 toddler height <80 cm 4 50 6 75 ≥80 cm 4 50 2 25 total 8 100 8 100 toddler weight <10 kg 5 62.5 3 37.5 ≥10 kg 3 37.5 5 62.5 total 8 100 8 100 mother's age <25 years old 2 25 5 62.5 ≥25 years old 6 75 3 37.5 total 8 100 8 100 mothers' education levels primary school 0 0 0 0 junior high school 1 12.5 0 0 senior high school 7 87.5 8 100 college 0 0 0 0 total 8 100 8 100 mother's employment status unemployed 7 87.5 5 62.5 employed 1 12.5 3 37.5 total 8 100 8 100 mothers income below mw 6 75 4 50 above mw 2 25 4 50 total 8 100 8 100 table 2. distribution of food portions for toddlers in the intervention and control group. portion spent pre-test post-test intervention control intervention control f % f % f % f % not eaten 2 25 2 25 0 0 2 25 1/9 portion 3 37.5 5 62.5 0 0 3 37.5 ¼ portion 1 12.5 0 0 0 0 2 25 ½ portion 1 12.5 1 12.5 3 37.5 1 12.5 ¾ portion 1 12.5 0 0 4 50 0 0 full portion 0 0 0 0 1 12.5 0 0 total 8 100 8 100 8 100 8 100 [healthcare in low-resource settings 2024;12:11900] [page 163] non -co mmerc ial us e o nly table 5 shows that there is an influence on appetite in both the intervention group and control group, as evidenced by the significant value (0.000) with a mean difference of 4.75. discussion the results of the study showed that there was an influence on toddlers’ appetite before and after researchers provided koya nate in the intervention group. meanwhile, there was no influence on toddlers’ appetite before and after koya nate was not given. koya nate, a snack composed of 80% tuna fish and 20% tempeh (fermented soybean), has been given so far. the management of koya nate does not contain the fishy smell typically found in processed fish food, making it effective in increasing toddlers’ appetite and meeting their daily protein needs.22 koya nate is provided to fulfill the daily protein needs of toddlers. if not accompanied by innovations made by parents in serving food, toddlers’ protein needs cannot be met due to their picky eating habits.25 providing koya nate, a protein-rich snack, consistently over an extended period can contribute to the local government’s efforts in scaling up nutrition (sun).26 the role of parents, especially mothers, is crucial in the context of scaling up nutrition. mothers spend more time with toddlers compared to fathers, and they must pay more attention to children’s eating patterns to ensure increased appetite and fulfilled nutrition.27,28 the family serves as a reinforcing factor in meeting nutrition requirements for toddlers. it plays a pivotal role in promoting the introduction and provision of nutritious food, implementing health practices, and serving as a role model for all family members.29 the results of this study, in testing the hypothesis, showed that there was an influence on the appetite of toddlers in the group given koya nate compared to the group not given koya nate. the influence on toddlers’ appetite is attributed to several factors, including menu preparation, food management, food presentation, and the method of food delivery. when parents correctly address these factors, they can indirectly enhance the toddler’s appetite.30 koya nate stands out as a practical snack that addresses food management and presentation. with a substantial macronutrient content, a smooth taste, and texture that is easy for toddlers to consume, koya nate emerges as a preferred choice.22,31 furthermore, the appetite of toddlers who received intervention in the form of koya nate is high in the required protein. however, in addition to protein, toddlers also need adequate absorption of iron and folic acid, especially those aged under 24 months.32 it’s important to note that the impact of giving koya nate is not immediate; it takes a considerable amount of time.32 another effort to reduce the incidence of stunting extends beyond the koya nate intervention, reaching back to the prenatal period and continuing through the formation of a fetus up to the age of two.33 since the impact of koya nate is not immediate but requires an extended period, it is essential to propagate and sustain the influence of providing koya nate to toddlers over an extended duration.34 there are several limitations in the data collection method for the intervention group providing koya nate. first, researchers encountered difficulty in directly monitoring the provision of koya nate during toddlers’ dinner time. second, the eating schedules varied among toddlers’ families, leading to a situation where one respondent was not available at the time of koya nate provision and it had to be done the following day. additionally, data collection was conducted directly by researchers and assisted by village health workers to ensure accurate data. lastly, the study’s sample size is relatively small due to the limited population of stunting toddlers in kenjeran village, preventing the generalization of the study results to the broader population. conclusions the provision of koya nate snacks has a significant impact on toddlers’ appetite both before and after consumption. furthermore, there is a notable influence on the evening appetite of toddlers who have been given koya nate snacks compared to those who have not received them. the nutritional value of koya nate, particularly its high animal protein content, contributes to meeting toddlers’ nutritional needs. additionally, the smooth texture of koya nate makes it easy for toddlers to consume. the implications of provid transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 3. normality test for toddlers' appetite in the intervention and control groups. group p* values intervention group (pre-test) 0.109 normally intervention group (post-test) 0.109 normally control group (pre-test) 0.001 not normally control group (post-test) 0.200 normally note (*): uji kolmogrov smirnov. table 4. analysis of the influence of appetite in the pre and postintervention and control groups. indicator group mean std. deviation t p appetite pre-intervention -2.250 1.581 -4.025 0.005(*) post-intervention pre-control -0.250 0.463 -1.414 0.157(**) post-control note: *paired t-test; **wilcoxon sign rank test. table 5. analysis of the influence of toddlers' appetite in the intervention and control groups indicator group n mean std. deviation t p* appetite post-intervention 8 4.75 0.707 5.641 0.000 post-control 8 2.25 1.035 5.641 note: *independent t-test. 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2022. kementrian kesehatan republik indonesia. 10. dinkes provonsi jawa timur. profil keseheatan 2021 jawa timur. jurnal dinamika vokasional teknik mesin. surabaya; 2022. 11. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j glob pharma technol 2020;12:815-25. 12. sari hp, natalia i, sulistyaning ar, farida f. hubungan keragaman asupan protein hewani, pola asuh makan, dan higiene sanitasi rumah dengan kejadian stunting. j nutr coll 2022;11:18-25. 13. martínez-vargas l, vermandere h, bautista-arredondo s, colchero ma. the role of social determinants on unhealthy eating habits in an urban area in mexico: a qualitative study in low-income mothers with a young child at home. appetite 2022;169:105852. 14. uliyanti u, tamtomo dg, anantany s. faktor yang berhubungan dengan kejadian stunting pada balita usia 24-59 bulan. j vokasi kesehat 2017;3:67-7. 15. diana r, rachmayanti rd, khomsan a, riyadi h. influence of eating concept on eating behavior and stunting in indonesian madurese ethnic group. j ethn foods 2022;9(1). 16. mustakim mrd, irwanto, irawan r, et al. impact of stunting on development of children between 1-3 years of age. ethiop j health sci 2022;32:569-78. 17. maulina r, qomaruddin mb, prasetyo b, et al. the effect of stunting on the cognitive development in children: a systematic review and meta-analysis. stud ethno-medicine 2023;17:1927. 18. salem yha, mikhail wza, sobhy hm, et al. effect of nutritional status on growth pattern of stunted preschool children in egypt. acad j nutr 2018;2:1-09. 19. rifqi ma, ahmad m, aila i, alaiyu f. pie formula biscuit flour and soy protein isolate as alternative of high protein snack for toddler. indian j public heal res dev 2019;10:1017-21. 20. solang m, adriani m. anadara granosa substitution in feed to improve the zinc, protein of the feed, serum albumin, and body weight of malnourished rats. food res 2021;5:132-9. 21. tournier c, forde cg. food oral processing and eating behavior from infancy to childhood: evidence on the role of food texture in the development of healthy eating behavior. crit rev food sci nutr 2023:1-14. 22. mundiastuti l, faridah da, kertapati y. modification of koya nate (tuna and tempe) to improve nutritional value and organoleptic quality. tianjin daxue xuebao (ziran kexue yu gongcheng jishu ban)/ journal of tianjin university science and technology 2023;56:53-66. 23. who. guideline: assessing and managing children at primary health-care facilities to prevent overweight and obesity in the context of the double burden of malnutrition: updates for the integrated management of childhood illness (imci) [internet]. geneva: world health organization; 2017. available from: https://www.ncbi.nlm.nih.gov/books/nbk4 87902/ 24. morata verdugo mp, gonzález-santana r, blesa j, et al. a study of the habits and food waste production of young university students. nutr hosp 2020;37:349-58. 25. taylor cm, emmett pm. picky eating in children: causes and consequences. proc nutr soc 2019;78:161-9. 26. aryastami nk. kajian kebijakan dan penanggulangan masalah gizi stunting di indonesia. bul penelit kesehat 2019;45(4). 27. surani e, susilowati e. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. j ners 2020;15:26-30. 28. fitriana aa. pemahaman orang tua mengenai gizi anak. j pendidik mod 2020;5:96-101. 29. munawaroh h, nada nk, hasjiandito a, et al. peranan orang tua dalam pemenuhan gizi seimbang sebagai upaya pencegahan stunting pada anak usia 4-5 tahun. sentra cendekia 2022;3:47. 30. kabira fa, ambohamsah i, amelia r. modifikasi makanan untuk meningkatkan gizi balita di kabupaten polewali mandar. j kesehat kusuma husada 2020;94-102. 31. maulidia p, simatupang nd, widayati s, adhe kr. analisis variasi penyajian menu makanan terhadap nafsu makan pada anak usia 2-4 tahun di desa badang. seling j progr stud pgra 2022;8:159-71. 32. elisaria e, mrema j, bogale t, segafredo g, festo c. effectiveness of integrated nutrition interventions on childhood stunting: a quasi-experimental evaluation design. bmc nutr. 2021;7:17. 33. kassie gw, workie dl. determinants of under-nutrition among children under five years of age in ethiopia. bmc public health 2020;20:399. 34. ali f, msuya se, mamseri r, mgongo m, mboya ib. time to cessation of exclusive breastfeeding and associated factors among women with children aged 6-24 months in kilimanjaro region, northern tanzania: a community-based cross-sectional study. plos one 2021;16:e0259041. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11900] [page 165] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:13012 various interventions during follow-up care of low birth weight infants: a scoping review riri novayelinda,1,2 yeni rustina,1 rr. tutik sri haryanti,1 fajar tri waluyanti1 1faculty of nursing, universitas indonesia, depok, west java; 2faculty of nursing, universitas riau, pekan baru, riau, indonesia abstract low birth weight (lbw) infants require special attention due to the higher risk of death and disease compare to normal weight infants. follow-up care is a strategy to monitor the growth and development of lbw infants after discharge from hospital. the aim of this literature review is to identify various interventions that are often performed during follow-up care to help the growth and development of lbw. this scoping review conducted through search using five databases namely pubmed, proquest, embase, medline and sage, from 2018 to 2023 were search. the review followed the prisma using picos guideline and restricted from 2018-2023., in total 1071 articles were retrieved and total six articles were meet inclusion criteria and reviewed.the review identified the most common interventions as: education and interventions related to breastfeeding, education related to infant growth and development and infant growth monitoring. while the type of intervention was mostly carried out through home visits and carried out by nurses. this study suggests that it is necessary to conduct research related to follow-up care carried out by nurses in many countries. introduction low birth weight (lbw) infant refers to a baby born weighing less than 2500 grams. lbw can result from premature delivery, restricted fetal growth, or a combination of both factors.1,2 globally, the prevalence of lbw is approximately 15%, with southeast asia and oceania reporting rates of around 12.2%.3 based on the indonesian nutritional status survey in 2021, indonesia’s lbw incidence rate is 6.6%.4,5 although this rate is lower than the lbw prevalence in southeast asia, lbw contributes the most to neonatal mortality. indonesia’s health profile shows that about 35% of neonate deaths are caused by lbw.5 lbw conditions cause infants to have a risk of experiencing health problems such as temperature imbalances,6,7 hypoglycemia, dehydration, sepsis, apnea.6,8 lbw are also at risk for recurrent care,8 and failure in breastfeeding.8–10 the development of the current health economy and technology can increase the life expectancy of lbw infants.11 however, the condition of lbw can increase the risk of future health problems such as diabetes mellitus,12 cardiovascular disease,12,13 kidney problems,13 motor development problems.14 lbw also has a risk of stunting in toddlerhood.1,15–17 medical advancements have enhanced outcomes for low birth weight infants, but continuous support and monitoring remain essential to address both immediate and long-term challenges. various interventions have been developed to prevent the problem of lbw infants in the future, including nutritional interventions,18 breastfeeding support,19 developmental stimulation,8 and parental support.20,21 interventions for lbw infants and families are provided in various forms such as home visits22 and community support.23 follow-up care is strategy to monitor the growth and development of lbw after discharge from hospital.24 this activity involves various professions including pediatricians, doctors, nurses, physiotherapy, speech therapy, occupational therapy, psychologists, social workers and other related professions who work together to assess, identify and refer as needed.25 some countries have incorporated follow-up care services into their health care system such as canada,24 iran,26 and south korea.27. although follow-up care for lbw has been widely practiced in developed countries, in indonesia this program continues to pose significant challenges.as a developing country, indonesia still has a high incidence of lbw.therefore, there needs to be more attention to the follow-up care program for lbw in indonesia. a scoping review on follow-up care for lbw can provide useful information in designing appropriate and effective follow-up care programs for lbw infants. this scoping review aims to identify interventions performed during follow-up care and correspondence: riri novayelinda, pediatric nursing department, faculty of nursing, universitas riau, pekan baru, riau, indonesia e-mail: riri.novayelinda@lecturer.unri.ac.id key word: follow-up care, low birth weight, intervention. contribution: rn, conceptualization, data collection, data analysis, writing – original draft, review, and editing; yr, rtsh, ftw work concept, supervision, validation, and review the article. availability of data and material: all data generated or analyzed during this study are included in this published article. conflict of interest: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. funding: this study did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sector. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgements: we thank all those who participated in this research. received: 4 september 2024. accepted: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:13012 doi:10.4081/hls.2024.13012 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:13012] [page 724] non -co mmerc ial us e o nly their benefits for the growth and development of lbws infant and their parents. materials and methods this scoping review used the prisma extension for scoping review (prisma-scr) and joana briggs institute for scoping reviews. the protocol of the reviews was not registered anywhere. article selection criteria articles were selected using the picos method: population (p) low birth weight infants with birth weight less than or equal to 2500mg who were recruited into the study sample while in the neonate care unit; intervention (i) getting follow-up care after the hospital; compare (c) comparingwith other interventions;outcome (o): the study reports at least one of the following effects: breastfeeding practices, child growth,child development, child morbidity, stress in people; study (s) the research used is randomized controlled trial (rct), cohort and experiment. the exclusion criteria of this review are studies that do not involve health workers in conducting interventions, studies that involve medical interventions such as drugs, intravenous therapy and micronutrient administration such as fortified milk, additional fat and others, studies published not inenglish, studies published in the form of research protocols and non-human research subjects. search strategy the search process was conducted in five electronic databases namely pubmed, proquest, embase, medline (viaebscohost) and sage from 2018 to 2023. we used “follow-up”, “post discharge”, “following discharge”, “discharge”, “aftercare”, “post hospital care”, “after care”, “aftercare”, “interventions or strategies or best practices”, “low birth weight infant”, “low birth weight”/exp. the search was conducted using boolean using a combination of keywords. all of the article must be written in english. data extraction and synthesis the search results from the five databases were transferred to endnote for storage and identification of initial data duplication. from endnote, it was then transferred to the rayyan.ai web-based application to identify duplicates and screen titles and abstracts.28 the initial screening process was carried out by identifying titles and abstracts with the criteria of containing the lbw population and is a type of rct, clinical trial, cohort and experimental research with one of the outcomes of growth, child development, breastfeeding practices, stress on parents will be included in the research to be screened. data analysis this review aims to identify various interventions used in follow-up care for lbw infants. data analysis using narrative review by displaying information from articles related to the year, purpose and method of the intervention used and the results obtained. results in total, 1070 articles were identified, 59 articles were discarded due to duplication with other articles and two articles were discarded automatically by the application. the flow of article selectionis displayed in the form of a prisma flowchart (figure 1). at the final stage, six articles were eligible to proceed to the review stage. article characteristics the six articles that entered the review stage consisted of articles with rct methods (4 articles), quasi-experiments (1 article) and retrospective cohortmethods (1 article). the number of samples in each article ranged from 42 to 355 lbw infants, which were divided into two groups: experimental/special care group and standard care group. the total sample of all articles was 614 infants divided into 279 infants in the intervention/specialized care group and 335 infants in the standard care group. only the cohort articles had samples above 100 infants in each group. three articles had a sample of infants weighing less than orequal to 1500 grams (534 infants in total). four studies were from the asian continent and two studies were from the americas. all samples were recruited during hospitalization.all studies described the typeof intervention applied to the infants in detail, but only three studies described the type of measures used in the control or standard care group. an overview of the selected articles can be seen in supplementary table 1. the identification of interventions in the reviewed articles identified two interventions that were most commonly provided, namely: education and interventions related to breastfeeding, education related to infant growth and development and infant growth monitoring. while the type of intervention was mostly carried out through home visits and carried out by nurses. an overview of the follow-up care interventions carried out can be seen in supplementary table 2. lactation education five studies provided lactation education as part of follow-up care.22,24,26,29,30 all three studies received lactation education materials at the hospital and continued after discharge.22,26,29 two studies conducted the activity during home visits and two studies con article figure 1. prisma flowchart. [page 725] [healthcare in low-resource settings 2024;12:13012] non -co mmerc ial us e o nly ducted lactation education with the help of compact disk, and booklets and when mothers visited the follow-up clinic or during home visits.22,24,26,29 two studies the control group continued to receive routine services from the follow-up clinic.22,24 three studies found that there was a significant association between the follow-up program and breastfeeding practices.24,26,29 retrospective cohort study conducted by nurses on breastfeeding practices after discharge from hospital. in this study, home visiting activities were carried out within the first 48 hours after the baby was discharged from the hospital and the results were measured at the time of the first visit, while in a study conducted in iran both groups received the same lactation intervention, but the intervention group received longer education time and received educationalmedia in the form of booklets and cds than the control group. interestingly, intervention during follow-up care activities is carried out by nurses from the health clinic as the main follow-up intervention provider. growth and development education all articles in this review provide education on infant growth and development. topics provided include early intervention programs based on developmental stages to anticipate motor skills that must be mastered by lbw according to age,22 education about ideal weight gain for lbw infant growth and development support tailored to the needs of the mother and stimulation activities to stimulate gross motor and sensory stimulation.24,26,27 of the four studies, only the study conducted by youn, et al was conducted when the babywas 3-6 months old and was conducted by physiotherapy.27 two studies did not find a significant relationship between follow-up care interventions with either growth or infant development.22,24,27 only the study identified the effect of intervention on lbw infants.26 growth monitoring growth monitoring activities were carried out in follow-up care activities in all four studies. the timing of growth monitoring varied from day 14/15 and day 60 and according to the needs of the baby according to the schedule of visits in the first 4 months.24,26 other articles did not provide information on the timing of growth monitoring.growthmonitoring activitiesweremostlyperformed by nurses and were done either in the clinic or during home visits.22,24,26 home visit by nurse the home visit method is a method that is widely used in follow-up interventions for lbw. two studies combined the home visit method with a visit to the follow-up clinic.22,24,27 the home visit activities carried out varied from 4 visits since discharge from the hospital until the baby was 2 months old,27 10 home visits,22 and based on family needs until the baby was 4 months old.24 nurses were the most commonly appointed health workers to conduct home visits.24,27 discussion lbw remains at risk after hospital discharge. lbw often facing respiratory issues, feeding difficulties, developmental delays, and may need surgery during their first year.24 follow-up care is crucial for these vulnerable infants, as it allows healthcare providers to closely monitor their progress, address emerging health issues, and ensure that they receive the necessary interventions. regular check-ups and specialized care can help manage and reduce the risks of complications, supporting the infant’s development and overall well-being throughout their first year and beyond.24,25 based on the search results from the five databases, research on the effectiveness of follow-up care interventions for lbw and parents in the last five years is still limited. during the search process the typesof articles found were mostly focused on premature babies, even though low birth weight babies are also at risk for disease and feeding problems compared to normal weight babies.10 unfortunately, based on the literature search process, the number of studies that discuss this topic is limited, so more research needs to be done on the effects of this intervention. based on the literature search, only two studies have shown a significant effect of the follow-up care intervention on breastfeeding practices and weight gain of lbw infants.24,26 meanwhile, the effect of follow-up care interventions on the development of lbw and stress in parents has not been successfully established.22,27 this may be due to the small number of samples in the study and because the assessment method was too long. in addition, the comparison groups in these two studies also received standardized interventions on follow-up care at the clinic, so that this process would certainly affect the results in the comparison group. both countries in the intervention have made follow-up care as part of the policy in the management of lbw after hospitalization. indonesia has not yet made follow-up care activities part of the services that lbw will receive after hospitalization. it would be interesting if relatedresearch. follow-up care is implemented and its effect on the development and health of lbw in the future is identified. this review found that educational materials related to breastfeeding and the growth and development of lbw were the most widely used interventions in follow-up care programs. lactation interventions benefit not only the breastfeeding practices of lbw but also have a positive effect on neonate weight gain.26 unfortunately, the sample size of this study was limited, and the long-term effect of this intervention is still questionable. nurses and home interventions were the most widely used intervention models in the reviewed studies. in the home context, nurses have an important role to play in providing guidance and support to families, especially mothers, for daily living care, and these professionals should ensure individualized and continuous care tailored to the specific needs of the family. nursing actions in the home context involve evaluation, guidance, demonstration, clarification, referral, and stimulation for follow-up with specialists.it also includes facilitating family empowerment and gradual autonomy of care.27 nurses can help parents understand the health care system and connect them with community resources for support. this review has limitations, including that the included studies varied from various countries and with various population settings and various types of interventions. the studies included a range of research designs, such as rcts, cohort studies, and quasiexperimental designs, making it difficult to generalize the results obtained. the diversity of the population and the timing of the assessment of the results also affects the results in the study. it is recommended thatin the future articles should be limited to the last 10 years and the time of outcome assessment should be standardized. in indonesia, follow-up care for low birth weight (lbw) infants is often inadequate, leading to delayed detection of health issues and insufficient support. to address this, a structured follow-up program is needed, including regular check-ups, nutritional assessments, and developmental screenings. nurses play a crucial role in this process, providing essential monitoring, support, and education for families. strengthening coordination between primary and specialized care, standardizing monitoring protocols, and article [healthcare in low-resource settings 2024;12:13012] [page 726] non -co mmerc ial us e o nly enhancing training for healthcare providers, including nurses, are key recommendations to improve outcomes for lbw infants. conclusions follow-up care interventions need to be developed to improve the life expectancy and quality of life of lbw. this review found that lactation education, growth and development education and growth and development monitoring were the most commonly provided services. health workers who play a role in follow-up care interventions are nurses using the home visit method. there is a need to develop a follow-up care model that focuses on these three topics carried out by nurses and identify the impact on the growth and development of lbw and the level of stress on parents. references 1. aryastami nk, shankar a, kusumawardani n, et al. low birth weight was the most dominant predictor associated with stunting among children aged 12-23 months in indonesia. bmc nutr 2017;3:1–6. 2. world health organization. who recommendations for care of the preterm or low-birth-weight infant. web annexes. geneva: world health organization; 2022 [cited 2023 sep 23]. available from: https://iris.who.int/bitstream/handle/ 10665/363698/9789240060043-eng.pdf 3. blencowe h, krasevec j, de onis m, et al. national, regional, and worldwide estimates of low birthweight in 2015, with trends from 2000: a systematic analysis. lancet glob health 2019;7:e849–60. 4. kemenkes ri. buku saku: hasil survei status gizi indonesia (ssgi) 2022. 2022 [cited 2023 nov 8]. available from: https://kesmas.kemkes.go.id/assets/uploads/contents/attachments/09fb5b8ccfdf088080f2521ff0b4374f.pdf 5. kemenkes ri. profil kesehatan indonesia tahun 2020 [internet]. jakarta: kemenkes ri; 2021. avaiable from: https://repository.kemkes.go.id/book/828 6. boies eg, vaucher ye. abm clinical protocol #10: breastfeeding the late preterm (34-36 6/7 weeks of gestation) and early term infants (37-38 6/7 weeks of gestation), second revision 2016. breastfeed med 2016;11:494–500. 7. sharma d, murki s, pratap t, et al. association between admission temperature and mortality and major morbidity in very low birth weight neonates–single center prospective observational study. j matern fetal neonatal med 2022;35: 3096–104. 8. upadhyay rp, martines jc, taneja set al. risk of postneonatal mortality, hospitalisation and suboptimal breast feeding practices in low birthweight infants from rural haryana, india: findings from a secondary data analysis. bmj open 2018;8:e020384. 9. bonnet c, blondel b, piedvache a, et al. low breastfeeding continuation to 6 months for very preterm infants: a european multiregional cohort study. matern child nutr 2019;15: e12657. 10. reymundo mg, suazo jah, aguilar mjc, et al. follow-up recommendations for the late preterm infant. an pediatr 2019;90:318.e1-318.e8. 11. jia c, feng z, lin xz, et al. short term outcomes of extremely low birth weight infants from a multicenter cohort study in guangdong of china. sci rep 2022;12:11119. 12. knop mr, geng tt, gorny aw, et al. birth weight and risk of type 2 diabetes mellitus, cardiovascular disease, and hypertension in adults: a meta-analysis of 7 646 267 participants from 135 studies. j am heart assoc 2018;7:e008870. 13. kanda t, murai-takeda a, kawabe h, itoh h. low birth weight trends: possible impacts on the prevalences of hypertension and chronic kidney disease. hypertens res 2020;43:859–68. 14. evensen kai, ustad t, tikanmäki m, et al. long-term motor outcomes of very preterm and/or very low birth weight individuals without cerebral palsy: a review of the current evidence. semin fetal neonatal med 2020;25:101116. 15. fikawati s. analisis faktor-faktor risiko terhadap kejadian stunting pada balita (0-59 bulan) di negara berkembang dan asia tenggara. jakarta: media penelitian dan pengembangan kesehatan; 2019. 16. halli ss, biradar ra, prasad jb. low birth weight, the differentiating risk factor for stunting among preschool children in india. int j environ res public health 2022;19:3751. 17. putri ta, salsabilla da, saputra rk. the effect of low birth weight on stunting in children under five: a meta analysis. j maternal child health 2021;6:496–506. 18. fabrizio v, trzaski jm, brownell ea, et al. individualized versus standard diet fortification for growth and development in preterm infants receiving human milk. cochrane database syst rev 2020;11:cd013465. 19. natalia r, rustina y, efendi d. combining breastfeeding education and support to improve breastmilk production, frequency of breastmilk expression, and partial breastfeeding in lowbirth-weight infants. j neonatal nurs 2022;28:356-60. 20. aloysius a, kharusi m, winter r, et al. support for families beyond discharge from the nicu. j neonatal nurs 2018; 4:55– 60. 21. silveira rc, mendes ew, fuentefria rn, et al. early intervention program for very low birth weight preterm infants and their parents: a study protocol. bmc pediatr 2018;18:268. 22. fernandes ro, bernardi jr, da fonseca jd, et al. the impact of an early intervention home-based program on body composition in preterm-born preschoolers with very low birth weight. front nutr 2022;9:981818. 23. hodgins s, rajbhandari b, joshi d, et al. community-based cluster randomized controlled trial: empowering households to identify and provide appropriate care for low-birthweight newborns in nepal. bmc public health 2020;20:1274. 24. lasby k, sherrow t, fenton t, et al. very-low-birth-weight infant short-term post-discharge outcomes: a retrospective study of specialized compared to standard care. matern child health j 2023;27:487–96. 25. hendson l, church pt, banihani r. follow-up care of the extremely preterm infant after discharge from the neonatal intensive care unit. paediatr child health 2022;27:359–64. 26. omidi a, rahmani s, amini r, karami m. the effect of a planned lactation education program on the mother’s breastfeeding practice and weight gain in low birth weight infants: a randomized clinical trial study. bmc pregnancy childbirth 2022;22:482. 27. youn ya, shin sh, kim ek, et al. preventive intervention program on the outcomes of very preterm infants and caregivers: a multicenter randomized controlled trial. brain sci 2021;11:575. 28. ouzzani m, hammady h, fedorowicz z, elmagarmid a. rayyan—a web and mobile app for systematic reviews. syst article [page 727] [healthcare in low-resource settings 2024;12:13012] non -co mmerc ial us e o nly rev 2016;5:210. 29. sinha b, taneja s, chowdhury r, mazumder s, et al. low-birthweight infants born to short-stature mothers are at additional risk of stunting and poor growth velocity: evidence from secondary data analyses. matern child nutr 2017;14:e12504. 30. asadian s, talakub s, sadeghnia a, golchin m. effect of development-based care programs by mothers on growth indices of infants with low birth weight. iranian j neonatology 2019;10:81–7. article [healthcare in low-resource settings 2024;12:13012] [page 728] online supplementary materials table 1. characteristics and description of articles included in the review. table 2. overview follow-up care activities. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:14021 the effect of 96% ethanol extract of turmeric (curcuma longa l. syn. curcuma domestica val.) on estrogen hormone levels rizka angrainy,1 aris citra wisuda,2 asita elengoe,1 rathimalar ayakannu,1 berliana irianti,1 manisha,1 aida fitria,1 siti aisyah,3 nuriah arma,3 heddy4 11school of nursing and applied sciences, lincoln university college, petaling jaya, selangor darul ehsan, malaysia; 2nursing study program, sekolah tinggi ilmu kesehatan bina husada palembang, indonesia; 3institut kesehatan helvetia, medan, indonesia; 4institut kesehatan bina husada, serang, indonesia abstract estrogen is essential for maintaining the structure and function of the female reproductive system, and its decline during menopause triggers various symptoms. while hormone replacement therapy (hrt) is commonly used, long-term use increases the risk of certain cancers. consequently, natural alternatives like turmeric (curcuma longa l. syn. curcuma domestica val.) are being investigated for their phytoestrogenic potential. this study aimed to investigate the effect of 96% ethanol extract of turmeric on estrogen hormone levels in female rats. an experimental study was conducted using 15 female sprague-dawley rats over 30 days, divided into five groups: control (0 mg/kg bw), contraceptive pill (10 mg/kg bw), and turmeric extract at doses of 25, 50, and 100 mg/kg bw. the extract was administered orally. on day 31, blood serum was collected, and estrogen levels were measured using the enzyme-linked immunosorbent assay (elisa). estrogen levels increased in all treatment groups compared to the control (647 ng/l), with levels of 691 ng/l (25 mg/kg), 709 ng/l (50 mg/kg), and 617 ng/l (100 mg/kg). however, these differences were not statistically significant. turmeric extract showed a dose-dependent effect, with moderate doses indicating phytoestrogenic benefits. the decline at high doses suggests a dual action-beneficial at moderate levels, inhibitory at excess. despite non-significant results, the trends support turmeric’s potential as a natural hrt alternative, warranting further studies with larger cohorts and mechanistic evaluations to define optimal dosage, safety, and reproductive implications. introduction estrogen refers to a group of steroid hormones that are fundamental to the development, regulation, and maintenance of the female reproductive system and secondary sexual characteristics.1 although primarily associated with female physiology, estrogen is also present in males, albeit in significantly lower concentrations.2 hormones in general are endogenous biochemical messengers synthesized by glands to control and coordinate functions across various tissues and organs.3 they are critical in regulating growth, metabolism, reproduction, and mood.4 a comprehensive understanding of hormonal roles, especially that of estrogen, is essential for women to navigate the complex physiological transitions across their lifespan.5 estrogen exists in three primary forms estradiol, estriol, and estrone each dominant during distinct life stages.6 estradiol predominates during the reproductive years, estriol during pregnancy, and estrone during the premenopausal transition.7 physiologically, estrogen performs a multitude of vital functions. it assists in thermoregulation, enhances memory, and modulates neural circuits associated with sexual and reproductive behavior. it also plays a role in lipid metabolism, thereby reducing cardiovascular risk by controlling cholesterol levels. 8 estrogen facilitates ovarian maturation and menstrual cycle initiation, supports uterine development for implantation, promotes breast development and lactation readiness, and helps maintain skeletal correspondence: rizka angrainy, school of nursing and applied sciences, lincoln university college, petaling jaya, selangor darul ehsan, malaysia. e-mail: rizkaangrainy.ikeshelvetia@gmail.com key words: curcuma longa, estrogen hormone, ethanol extraction, phytoestrogen, turmeric extract. contributions: ra conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ae, ra conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; acw, bi conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ma, af methodology, visualization, resources, investigation, and writing – review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has obtained ethical approval from the medical and health research ethics commission, faculty of medicine, andalas university, based on ethical certificate no. 22/un.16.2/kep-fk/2024. throughout the research process, the researcher adhered to the principles of information ethics, including consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: i would like to thank my supervisor for valuable insights and contributions to this study. received: 21 may 2025. accepted: 28 august 2025. early access: 17 october 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:14021 doi:10.4081/hls.2025.14021 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 270] [healthcare in low-resource settings 2025;13:14021] integrity.9 puberty-related estrogen surges contribute to breast growth and the development of pubic and axillary hair10 during pregnancy, elevated estrogen levels support angiogenesis and nutrient transport to the fetus.11-13 additionally, increased estrogen may cause vaginal secretions in early gestation. as women approach menopause, hormonal fluctuations culminate in a steady decline, resulting in various physiological and psychological symptoms.14 to alleviate menopausal symptoms resulting from estrogen deficiency, hormone replacement therapy (hrt) is frequently employed. a study by amanda j. welton et al. demonstrated that daily oral administration of conjugated equine estrogen (0.625 mg) with medroxyprogesterone acetate (2.5/5.0 mg) over a one-year period significantly reduced vasomotor symptoms, joint pain, sleep disturbances, and vaginal dryness, thereby enhancing postmenopausal quality of life, although some patients reported side effects such as breast tenderness and discharge.15 however, research by judith k. ockene, phd, med, indicated that cessation of this combination therapy led to the recurrence of symptoms including vasomotor instability and joint stiffness.16 despite its therapeutic benefits, long-term hrt use is associated with increased risks of breast, endometrial, and ovarian cancers.17 this risk profile underscores the importance of exploring safer alternatives, including phytotherapy, with turmeric (curcuma longa linn. syn. curcuma domestica val.) being a prominent candidate.18 turmeric is a perennial rhizomatous herb from the zingiberaceae family, indigenous to south asia and now cultivated globally in subtropical climates.19 the dried rhizome is processed into turmeric powder, which has been traditionally utilized across asia for culinary and medicinal purposes.20 among its active constituents is turmerone a sesquiterpenoid compound also known as α-turmerone that exhibits anti-inflammatory, antioxidant, and neuroprotective activities.21 these properties may contribute to reducing systemic inflammation, mitigating oxidative cellular damage, and enhancing cognitive resilience.22 turmerone, particularly concentrated in ethanol-based turmeric extracts, is of growing interest in therapeutic research. a growing body of evidence supports turmeric’s broad pharmacological potential. kusuma dewi’s study found a significant reduction in body temperature in dpt-vaccinated rats treated with turmeric extract.23 similar antipyretic effects were observed in new zealand white rabbits.24 antibacterial assays also reveal turmeric’s greater efficacy against gram-positive bacteria (e.g., bacillus sp., staphylococcus aureus) compared to gram-negative strains (e.g., shigella dysenteriae, e. coli), likely due to differential cell wall structures. 25 26 27 ethanol is recognized as an efficient solvent in turmeric extraction due to its high polarity, allowing for optimal isolation of active compounds.28-30 in reproductive health, turmeric has shown the ability to inhibit ovulation and hormonal secretion (fsh, lh, estrogen, progesterone), disrupt the estrous cycle, and induce biochemical changes in uterine fluid – demonstrating reversible antifertility effects in both males and females.31,32 materials and methods tools and materials in alignment with the experimental framework of this study, which involved quantifying estrogen levels in rat serum following turmeric extract administration, the tools and materials were selected to ensure precise biochemical measurement and controlled laboratory conditions. the tools utilized included a bio-rad xmark™ microplate absorbance reader integrated with microplate manager software for accurate absorbance detection during elisa analysis, a 27.3°c incubator to maintain stable environmental conditions during sample incubation, absorbent paper, precision micropipettes for accurate liquid handling, and sterile disposable pipette tips to prevent cross-contamination. the primary materials consisted of components from the bioassay technology laboratory elisa kit specifically designed for estrogen quantification, including a standard estrogen solution, an elisa plate pre-coated with specific antibodies, a standard diluent, streptavidin-hrp conjugate, substrate solutions a and b, stop solution, wash buffer, and adhesive plate sealers. supporting biological materials included blood serum obtained from female sprague-dawley rats and turmeric ethanol extract (curcuma longa linn. syn. curcuma domestica val.) prepared using 96% ethanol, with all tools and materials selected to ensure methodological consistency and accuracy in detecting potential phytoestrogenic effects of turmeric. preparation of turmeric extract turmeric rhizomes were obtained from the riau region and processed into powder form. the powder was refined through a 60-mesh sieve to achieve a uniform particle size, ensuring extract consistency. extraction was performed using the maceration technique, whereby the powder was soaked in 96% ethanol to allow the diffusion of bioactive compounds. the mixture was then filtered, and the filtrate was concentrated using appropriate methods before being stored under controlled conditions until use in the treatment phase. phytochemical screening to determine the chemical profile of the turmeric extract, qualitative phytochemical screening was conducted to identify secondary metabolites with potential pharmacological activity. alkaloids were detected using dragendorff’s reagent, producing an orange precipitate in positive samples. flavonoids were identified via the shinoda test, where the addition of magnesium powder and hydrochloric acid resulted in a red or pink coloration. tannins were tested using ferric chloride (fecl3) solution, which produced a blue-black or greenish color in the presence of tannins. saponins were assessed through a froth test, in which persistent foam formation indicated a positive result. triterpenoids were identified using the liebermann–burchard reaction, showing a reddish-brown color change, while steroids were confirmed through acetic anhydride–sulfuric acid testing, yielding a blue or green coloration. these procedures provided a qualitative assessment of the key bioactive compounds in turmeric, many of which are associated with antioxidant, anti-inflammatory, and hormonal regulatory activities. elisa preparation before beginning the elisa procedure, all reagents were allowed to reach room temperature to ensure optimal reaction performance. a standard curve was generated by serially diluting the estrogen standard solution into six concentrations: 2400, 1200, 600, 300, 150, and 75 ng/l. for each well, 50 µl of either standard solution or serum sample was pipetted, followed by the addition of assay-specific reagents as per the manufacturer’s protocol. all standards and samples were analyzed in duplicate to enhance measurement reliability and reduce experimental variability. the wash buffer, provided in concentrated form, was reconstituted according article [healthcare in low-resource settings 2025;13:14021] [page 271] to the manufacturer’s instructions. each assay plate underwent five wash cycles, with 0.35 ml of diluted wash buffer per well, to minimize background interference and improve assay precision. experimental design and procedure this study was conducted based on the principles of true experimental design, which emphasizes random allocation, controlled interventions, and the use of comparison groups to establish causal relationships.14 the dose–response concept guided the selection of turmeric extract concentrations, allowing evaluation of its potential phytoestrogenic effects across a range of doses.15 fifteen healthy female sprague-dawley rats were randomly assigned to five treatment groups (n=3 per group). group 1 received no treatment (negative control), group 2 was administered 1.8 mg/kg body weight (bw) of a standard contraceptive pill as a positive control, and groups 3, 4, and 5 were given turmeric ethanol extract at doses of 25 mg/kg bw, 50 mg/kg bw, and 100 mg/kg bw, respectively. all treatments were delivered orally in a volume of 1 ml daily for 30 consecutive days. on the 31st day, surgical procedures were performed to collect blood samples, and the serum was separated for estrogen hormone analysis. elisa procedure and observation estrogen levels in serum were quantified using elisa, with all standards and samples run in duplicates to ensure reliability. each well received 50µl of either standard or rat serum, followed by 50 µl of streptavidin-hrp. after a 60-minute incubation at 27.3 °c, wells were washed five times with 0.35 ml of wash buffer. subsequently, 50 µl each of substrate a and substrate b were added, incubated for 10 minutes in the dark, and the reaction was stopped with 50 µl of stop solution. absorbance was measured at 450 nm, and estrogen concentrations were determined from the standard curve. results phytochemical screening of turmeric ethanol extract phytochemical screening was conducted to identify the presence of various secondary metabolites in the ethanol extract of turmeric (curcuma longa linn. syn. curcuma domestica val.). the qualitative analysis focused on six major compound groups, namely alkaloids, flavonoids, tannins, saponins, triterpenoids, and steroids. the results are summarized in table 1. from table 1, it is evident that the turmeric ethanol extract contains alkaloids, flavonoids, tannins, saponins, and triterpenoids, while steroids were not detected. standard curve of estrogen concentration vs optical density to quantify estrogen hormone levels, a standard curve was generated using seven known concentrations of estrogen standard solutions. the optical density (od) readings corresponding to each concentration were recorded to develop a calibration curve, as shown in table 2. based on table 2, the standard curve exhibited a strong linear relationship with a correlation coefficient (r) of 0.998. this calibration was used to calculate estrogen concentrations in rat serum samples based on their od readings. estrogen hormone levels in rat serum after treatment the elisa test was conducted to determine the estrogen hormone levels in the serum of female sprague-dawley rats after 30 days of treatment. rats were divided into five groups: negative control (k-), positive control (k+), and three treatment groups receiving turmeric ethanol extract at doses of 25 mg/kg bw (p1), 50 mg/kg bw (p2), and 100 mg/kg bw (p3). an additional comparison group included female rats mated with males and given turmeric (bk). the results of the elisa test are presented in table 3 and visualized in figure 1. from table 3 and figure 1, it can be observed that estrogen levels increased in rats treated with turmeric ethanol extract at 25 mg/kg bw (p1) and 50 mg/kg bw (p2), reaching 691 ng/l and 709 ng/l, respectively both higher than the control groups. however, the group receiving the highest dose (100 mg/kg bw, p3) exhibited a lower estrogen level (617 ng/l), suggesting a possible biphasic dose response. the positive control group (k+) and the bk group both showed similar estrogen levels (669 ng/l), while the untreated control group (k-) had the lowest baseline value at 647 ng/l. discussion the results of this study indicate that the ethanol extract of turmeric (curcuma longa linn. syn. curcuma domestica val.) contains various secondary metabolites, including alkaloids, flavonoids, tannins, saponins, and triterpenoids, but not steroids. these active compounds may contribute to the observed increase in estrogen hormone levels in the tested female rats, as suggested by previous literature reporting that flavonoids can exhibit estrogenic activity by binding to estrogen receptors,36 while certain alkaloids have been shown to influence endocrine function.38 this is supported by the elisa test results, which showed that treatment groups receiving turmeric ethanol extract at doses of 25 mg/kg bw and 50 mg/kg bw had higher average estrogen levels article table 1. phytochemical screening results of turmeric ethanol extract. no compound test criteria test result interpretation group 1 alkaloid formation of white precipitate with mayer’s reagent white precipitate observed positive 2 flavonoid color change to orange, pink, or red orange color turned red positive 3 tannin color change to blackish-green or dark blue orange color turned blackish-green positive 4 saponins persistent foam within 5 minutes stable foam formation observed positive 5 triterpenoid formation of a brownish or violet ring at phase interface brownish ring observed at the border of the solution positive 6 steroid formation of greenish-blue ring no greenish-blue ring observed negative [page 272] [healthcare in low-resource settings 2025;13:14021] (691 ng/l and 709 ng/l, respectively) compared to the negative control group (647 ng/l). however, at the highest dose (100 mg/kg bw), estrogen levels decreased to 617 ng/l, suggesting a possible toxic or inhibitory effect at this concentration. according to suprihatin, flavonoids and alkaloids in plants can act as abortifacients, potentially causing miscarriage or disturbances in reproductive processes.33 this is further supported by findings from ningsih,34 stating that flavonoid and alkaloid compounds can disrupt cell membranes, alter membrane components, and inhibit cell division by impairing the formation of membranes responsible for nutrient transport and cellular energy metabolism. in reproductive terms, the permeability of egg and embryo cell membranes is crucial for embryonic growth and development (cleavage).35 the impact of alkaloids on the membranes of egg and embryo cells results in membrane shrinkage, leading to decreased membrane integrity, which impairs the development of the egg and embryo cells, potentially resulting in embryonic death. moreover, saponins, which are characterized by their foaming properties, also negatively impact animal reproduction. they are known to act as abortifacients, inhibit zygote formation, and prevent implantation. saponins exhibit cytotoxic effects, particularly on developing cells such as those undergoing oogenesis.36 this study also aligns with ockene, who states that disturbances during pregnancy can be caused by both internal and external factors. internal factors include chromosomal abnormalities, while external factors may involve exposure to viruses, radiation, malnutrition, and chemical substances such as alkaloids, steroids, and alcohol.16 therefore, the active compounds in turmeric may exert reproductive effects through both hormonal and cellular pathways. interestingly, although the treatment groups receiving turmeric extract showed increased estrogen levels compared to the negative control, these levels remained lower than those in the positive control group receiving contraceptive pills (average 669 ng/l). this suggests that while turmeric extract may act as a natural phytoestrogen, its potency is still lower than that of synthetic estrogen found in oral contraceptives. overall, these data suggest that turmeric ethanol extract has the potential to enhance estrogen hormone levels in animal models, particularly at moderate doses (25-50 mg/kgbw). the decline in estrogen levels at the highest dose (100 mg/kgbw) may indicate toxicity or a physiological compensatory response to excessive exposure to active compounds. therefore, based on these findings, the researchers recommend further studies using higher dose variations and long-term observations to determine the optimal effect and potential toxicity of turmeric ethanol extract.33 conclusions the administration of 96% ethanol extract of turmeric (curcuma longa linn. syn. curcuma domestica val.) was found to effectively increase estrogen hormone levels, with the highest elevation observed at a dose of 50 mg/kg body weight, surpassing even the levels found in the positive control group that received birth control pills. this suggests that turmeric extract at moderate doses may have phytoestrogenic activity capable of enhancing endogenous estrogen production. however, at a higher dose of 100 mg/kg body weight, a significant decline in estrogen levels was observed, falling below both the positive control and the untreated negative control group. this indicates that excessively high doses may exert an inhibitory or potentially toxic effect on hormone regulation. therefore, it can be concluded that while turmeric extract article [healthcare in low-resource settings 2025;13:14021] [page 273] table 2. standard estrogen concentration vs optical density. no. estrogen level (ng/l) od (optical density) 1 2400 0.075 2 1200 0.181 3 600 0.503 4 300 0.855 5 150 1.106 6 75 1.240 7 0 1.395 table 3. estrogen hormone levels in female rats after treatment. group description mean estrogen level (ng/l) bk female rats mated with males and given turmeric 669 k+ positive control (contraceptive pill 1.8 mg/kg bw) 669 k negative control (no treatment) 647 p1 turmeric extract 25 mg/kg bw 691 p2 turmeric extract 50 mg/kg bw 709 p3 turmeric extract 100 mg/kg bw 617 figure 1. estrogen hormone levels based on elisa test in rat serum. has the potential to increase estrogen levels, its effectiveness is dose-dependent, with 50 mg/kg body weight being the most optimal dose identified in this study. references 1. alnahdi as, idrees m. nonlinear dynamics of estrogen receptor-positive breast cancer integrating experimental data: a novel spatial modeling approach. math biosci eng 2023;20:21163-85. 2. herniyatun h, andriani g. perbedaan kualitas seksual wanita dengan kontrasepsi hormonal dan non hormonal di desa kamulyan kecamatan tambak. lentera j ilm 2021. available from: https://www.academia.edu/download/113511655/ 786.pdf 3. moisand a, madéry m, boyer t, et al. hormone receptor signaling and breast 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da, fu mz, et al. estrogen receptor, progesterone receptor, and her2 receptor markers in endometrial cancer. j pathol transl med 2020;54:29-34. 15. welton aj, vickers mr, kim j, et al. health related quality of life after combined hormone replacement therapy: randomised controlled trial. bmj 2008;337:a1190. 16. ockene jk, barad dh, cochrane bb, et al. symptom experience after estrogen plus progestin in the women's health initiative randomized controlled trial. jama 2005;294:18393. 17. paszkowski t, bińkowska m, dȩbski r, et al. menopausal hormone therapy in questions and answers: a manual for physicians of various specialties. prz menopauzalny 2019;18:1-8. 18. kim jw, kim ha, suh ch, jung jy. sex hormones affect the pathogenesis and clinical characteristics of systemic lupus erythematosus. front med (lausanne) 2022;9:906475. 19. santander b. formularium ramuan obat tradisional indonesia. j ilmu farmasi indones 2017;15:89-96. 20. departemen kesehatan republik indonesia. kebijakan obat tradisional nasional. jakarta: depkes ri; 2021. 21. hirschberg al, bitzer j, cano a, et al. topical estrogens and non-hormonal preparations for postmenopausal vulvovaginal atrophy: an emas clinical guide. maturitas 2021;143:91-102. 22. goozee kg, shah tm, sohrabi hr, et al. examining the potential clinical value of curcumin in the prevention and diagnosis of alzheimer’s disease. br j nutr 2022;115:449-65. 23. kusuma dm. aktivitas antibakteri ekstrak daun majapahit (crescentia cujete) terhadap pertumbuhan bakteri ralstonia solanacearum penyebab penyakit layu. lenterabio 2024;3:1521. 24. kusumaningrum yi. hubungan antara pengetahuan ibu dan faktor-faktor sosial ekonomi orang tua dengan praktik pemberian mp-asi pada bayi usia 6-12 bulan di desa kemuning kecamatan ampelgading kabupaten pemalang [dissertation]. semarang: universitas negeri semarang; 2021. 25. yuliati y. uji efektivitas ekstrak kunyit sebagai antibakteri dalam pertumbuhan bacillus sp dan shigella dysenteriae secara in vitro. j profesi medika 2022;10:26-32. 26. wijayanto w. uji aktivitas antibakteri ekstrak etanol rimpang kunyit putih (curcuma mangga val.) terhadap staphylococcus aureus atcc 6538 dan escherichia coli atcc 11229 secara in vitro [undergraduate thesis]. surakarta: fakultas kedokteran, universitas muhammadiyah surakarta; 2021. 27. hidayati e, juli nm. isolasi enterobacteriaceae patogen dari makanan berbumbu dan tidak berbumbu kunyit (curcuma domestica val.) serta uji pengaruh ekstrak kunyit terhadap pertumbuhan bakteri yang diisolasi. j matematika dan sains 2022;7:43-52. 28. nair a, amalraj a, jacob j, kunnumakkara ab, gopi s. noncurcuminoids from turmeric and their potential in cancer therapy and anticancer drug delivery formulations. biomolecules 2021;11:9. 29. suharsanti r, astutiningsih c, susilowati nd. kadar kurkumin ekstrak rimpang kunyit (curcuma domestica) secara klt densitometri dengan perbedaan metode ekstraksi. j wiyata 2020;7:86-93. 30. sari ip, nurrochmad a, setiawan im, et al. effects of costus speciosus ethanolic extract on male rats: the action mechanism and the ability to impregnate. pak j pharm sci 2022;31:997-1001. 31. ling w, florenly f, liena l, et al. effectiveness of turmeric ethanol extract cream preparation (curcuma longa) in speeding up wound healing in male wistar rats. int res j pharm appl sci 2022;12:55-62. 32. nasution ez, harahap fm. formulation and production of ethanol extract derived from black turmeric (curcuma caesia roxb) for use as an antibacterial hand sanitizer spray. j chem nat resour 2024;6:80-7. 33. suprihatin t, rahayu s, rifa’i m, et al. senyawa pada serbuk rimpang kunyit (curcuma longa l.) yang berpotensi sebagai article [page 274] [healthcare in low-resource settings 2025;13:14021] antioksidan. bul anat fisiol 2020;5:101-8. 34. ningsih aw, nurrosyidah ih. pengaruh perbedaan metode ekstraksi rimpang kunyit (curcuma domestica) terhadap rendemen dan skrining fitokimia. j pharm med sci 2020;2:22-9. 35. fadhilah h, rachmani k, hajaring n. aktivitas kunyit (curcuma domestica val.) sebagai antiinflamasi ditinjau dari berbagai literatur. edu masda j 2021;2:55-62. 36. titisari n, firmawati a, fauzi a, et al. reproductive cycle of female javan langur (trachypithecus auratus) based on estrogen and luteinizing hormone levels. cab rev 2021;16:1-12. article [healthcare in low-resource settings 2025;13:14021] [page 275] hrev_master healthcare in low-resource settings 2024; volume 12(s2):12456 the amount of dna and rna in primary cancer cells and their metastases oleksandr herasymenko,1 kostyantyn gerasymenko,1 olha herasymenko2 1department of pathological anatomy, forensic medicine, histology, donetsk national medical university, kropyvnytskyi; 2feofaniya clinical hospital, kyiv, ukraine abstract considering the significant impact of oncopathology on global morbidity and mortality, as well as changes in its prevalence and typology, research into the molecular-genetic mechanisms of oncogenesis and metastasis, particularly the role of nucleic acids, becomes crucial. the aim of this study is to determine the content of dna and rna in cells of primary cancer and its metastases through microspectrophotometric analysis of malignant cells collected from 30 patients with primary and metastatic oncological processes. the following methods were employed: microspectrophotometric analysis using the automated complex “protvapm11-dvk-3m,” staining of histological specimens with halo cyanin-chrome alum, the discrete statistics method, frequency and cluster analysis, and the bibliographic method. changes in the concentration of nucleic acids in the cells of primary and metastatic tumors were identified during the study. the changes did not always correlate with each other, indicating morphofunctional polymorphism in tumor cell populations. a trend towards a decrease in nuclear rna concentration and an increase in cytoplasmic rna concentration in metastases were observed, suggesting alterations in metabolic and synthetic processes in cells and a decrease in their differentiation degree. introduction molecular studies play a key role in the development of modern oncology as a clinical discipline, as they allow for the uncovering of fundamental mechanisms of the initiation and progression of cancer at the cellular and molecular levels. this knowledge is crucial for developing new, more effective treatment methods and a personalized approach to each type of oncopathology, significantly increasing the chances of successful treatment and improving the quality of life for patients. rna, regardless of the state of dna, can independently influence the synthesis and structure of protein compounds. in the case of oncological diseases, such changes often lead to a decrease in the level of proteins responsible for destroying abnormal cells in tumors. at the same time, an increase in the concentration of proteins that stimulate the division of malignant cells is observed. this issue emphasizes the need to study the interaction between dna and rna and their role in the process of oncogenesis. in their research, sulaieva et al.1 focused significantly on the perspective of genetic studies in modern healthcare. they examined the role of genetic factors in the diagnosis and treatment of various diseases, emphasizing the importance of molecular-biological methods in understanding the etiology and pathogenesis of diseases. the authors also emphasized the integration of genetic data into clinical practice, opening new possibilities for developing personalized approaches to treatment and disease prevention. however, while this study covered this important topic, the focus was shifted towards biobanking, leading to insufficient coverage of the molecular mechanisms of oncogenesis. as highlighted in the work of bondarenko et al.2, recent research has revealed that rna-binding proteins play a crucial role in the spread of cancer. these proteins, present in all types of cells, exhibit particular activity in malignantly transformed cell populations, where they bind to rna molecules and contribute to the acceleration of tumor growth. despite this, none of the existing cancer treatment methods currently target these proteins, underscoring the need for further research in this direction for the development of more effective treatments. the study did not adequately address the issues of oncodiagnosis and oncoprevention. correspondence: oleksandr herasymenko, department of pathological anatomy, forensic medicine, histology, donetsk national medical university, kropyvnytskyi, ukraine. e-mail: herasymenkool@ukr.net key words: carcinogenesis, advanced molecular genetic analysis, microspectrophotometry, nucleic acids, oncodiagnosis, non-cell autonomous effectors. contributions: oh and kg, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; oh, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: all procedures performed in the study were in accordance with the ethical standards of the institutional research committee and with the 1964 helsinki declaration and its later amendments. patient consent for publication: informed consent was obtained from all individuals included in this study. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author. received: march 2024. accepted: 10 may 2024. early view: 22 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12456 doi:10.4081/hls.2024.12456 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 76] [healthcare in low-resource settings 2024;12(s2):12456] non -co mmerc ial us e o nly in their exploration of this topic, kirkilevskyi et al.3 elucidated the role of rna in the formation of cancerous tumors and explained the reasons for their insensitivity to therapy. to comprehend the causes of neoplasia and optimize the process of its treatment, patients must undergo a series of investigations. the most effective method turned out to be an extended molecular-genetic analysis of tumors. the application of this method allows for the construction of the most optimal treatment schemes for cancer patients, achieving maximum efficacy with minimal chemotherapy toxicity. despite the comprehensive data on gastrointestinal oncopathology, this study requires additional clarification regarding tumors in other organs and systems. in their study, dumanskyi et al.4 identified that the molecular phenotype of a tumor population largely determines its sensitivity to radiation therapy. the researchers emphasized the prospect of molecular-genetic analysis as a leading method for optimizing treatment planning. however, the theme of metastasis and its prevention was insufficiently addressed, requiring further clarification. kulak5 discussed the prospect of influencing molecular-genetic mechanisms during the treatment of oncological diseases. the author emphasized the therapeutic modality of mrna as a target for developing chemotherapeutic agents. despite the significant potential in this field, developments within it face considerable challenges, leading to only a few projects reaching the stage of clinical trials. despite a detailed examination of the application of rna interference methods, the issue of diagnosis and prevention at the molecular-genetic level was not adequately addressed in this study. thus, considering the increase in atypia, polymorphism, and changes in nuclear-cytoplasmic ratio, alongside the significant feature of tumor growth being the alteration of dna and rna levels, the goal of the research is to determine dna and rna in cells of the primary tumor and its metastases. this will help understand the mechanism of metastasis development and develop measures to prevent metastasis. materials and methods during the research, the microspectrophotometric analysis method was primarily utilized. this method was employed to determine the levels of dna and rna in colonies of primary malignant cells and metastatic tumor nodes. the analysis included 30 cases of primary cancer and 30 cases of metastatic foci. gallocyanin-chromium gallate staining with baoh control was used to identify dna and rna. this method contributed to determining the total volume of nucleic acids (dna and rna). in cases where the samples were treated solely with baoh, only the amount of dna was determined. quantitative analysis of dna and rna in histological samples was carried out using the automated complex “protva-pm11-dvk-3m” and the corresponding software. scanning was performed with the following parameters: frame size 100×150 µm, probe 0.5 µm, step x=5 µm, and y=15 µm. monochromatic light with a wavelength of 560 nm was also used. the determination of the amount of dna and rna was based on the extinction in the nucleus and cytoplasm. for every batch of samples, fresh staining solutions were made for the gallocyanin-chromium gallate staining technique, and staining times were closely monitored. to keep an eye on the staining protocol’s consistency, positive and negative control slides were included with every staining run. before the experimental samples were analyzed, the optical density measurements from the control slides had to fall within specified acceptable ranges. using standard solutions containing known concentrations of dna and rna, the automated complex “protva-pm11-dvk-3m” was calibrated before each analysis to guarantee the accuracy and repeatability of the microspectrophotometric analysis. as a result, the nucleic acid levels in the tumor cell samples could be accurately quantified. furthermore, each sample underwent double measurements in order to evaluate intra-sample variability. in order for these repeated measurements to be incorporated into the data analysis, the coefficient of variation had to be less than 10%. to determine the amount of rna in cells of primary tumors and their metastases, the difference in the mean values of the relative optical density of nuclei before and after baoh treatment was applied. thus, the difference in the amount of rna between the cells of the primary tumor and its metastatic nodes was compared. the average amount of dna in the nuclei of tumor cells of primary cancer and its metastases was estimated using the dna accumulation index, representing the weighted average arithmetic amount of dna in units of ploidy per nucleus, determined by comparing with the average dna content in the nuclei of small lymphocytes in the analyzed sections. various scientific methods were employed in this study. specifically, for the analysis of categorical and numerical data obtained during the study of dna and rna levels in tumor cells, the discrete statistics method was applied. this method helped establish relationships between data and determine their statistical significance. for a more detailed study of parameters such as levels of nucleic acids in primary and metastatic tumors, average nuclear diameter, coefficient of variation of the nuclear diameter of tumor cells, and dna accumulation index, frequency analysis was applied. this methodological approach allowed for a quantitative assessment of the frequency of the occurrence of different indicators. the use of cluster analysis enabled a thorough investigation of the structure of the collected data, the identification of subgroups of samples based on the analysis of the similarity of different characteristics, and the determination of key factors influencing dna and rna indicators in tumor cells. to assess global trends in this field and support conclusions, a comprehensive review of contemporary scientific publications was conducted. information retrieval was performed using the bibliographic method, analyzing data from bibliometric databases. results the analysis of data reflecting the level of dna concentration, determined based on extinction, in the nuclei of primary and metastatic tumor cells indicates that in metastases, dna concentration can be either higher (in 34.5% of cases) or lower (in 55.2% of cases), and in rare cases, even coincide with the indicators of the primary population of tumor cells (10.3%); the presented results are shown in table 1. similar findings suggest both polymorphism at the nuclear level and variability in dna synthesis processes among different populations of tumor cells forming metastases. an effective indicator for assessing cell variability in the process of metastasis is the dna accumulation index (dnaai).6 dnaai determines the weighted arithmetic mean amount of dna per nucleus in ploid units. the results shown in table 2 demonstrate the fact that heteroand polyploidy in metastases are not uniform. the uneven distribution of molecular-genetic material is also polymorphic in its structure, ranging from slight differences in metastatic cell populations to cases where dnaai in a metastasis to a lymph node was 6.54, and in the lungs – 25.2. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12456] [page 77] non -co mmerc ial us e o nly the uneven distribution of the molecular-genetic material can be attributed to several factors. firstly, it may reflect the presence of different clones of tumor cells, each with its unique genetic profile and characteristics that influence their ability to metastasize and grow. this variation can be associated with the phenomenon of single nucleotide polymorphism, where point mutations occur on a nucleotide scale, leading to changes in the entire allele and morpho-functional properties of the cell. the risk of this phenomenon is directly proportional to the cell division rate, especially in the study of populations of malignant cells.7 secondly, it may be related to different microecological conditions in the metastatic development sites, which can either promote or inhibit the activity of tumor cells.8 these conditions include factors of the microenvironment such as blood supply, oxygen saturation, and the presence of inflammatory cells, which can affect the metabolic activity and replicative potential of tumor cells.9,10 microspectrophotometric analysis of the nuclei of tumor cells in metastases and their comparison with each other and with primary tumors revealed that in most cases, metastases have distinct dnaai, except for one case where the liver metastasis had dnaai=1.61, and the pancreatic metastasis had dnaai=1.65. this indicates the clonal nature of metastases, characterized by variable levels of dna synthesis. compared to primary tumors, metastases had a higher dnaai in 55.2% of cases, lower in 41.4%, and equal in 3.4%, as demonstrated in tables 1 and 2. metastatic cell populations also showed a tendency to increase nuclear diameter and dna quantity compared to primary tumors, indicating a prevalence of poorly differentiated, heteroand polyploid cells. information on the distribution of nuclear diameter among different cell groups is presented in table 1. the above suggests a tendency to select less differentiated cells during the process of metastasis than in the primary population of cells. however, in some metastatic nodes, the opposite trend was observed, with signs of increased cell differentiation. since metastasis was detected in the liver in most cases, questions have arisen regarding the influence of the target organ on the dna synthesis process in metastatic cell populations. the analysis showed that 44.4% of liver metastases had a higher dnaai, 44.4% had a lower dnaai, and 11.2% had a similar dnaai to the primary tumor cell population. this indicates the relative autonomy of tumor cells from the target organ, as intracellular synthesis is genetically determined.11 microspectrophotometric analysis to determine rna levels in the cytoplasm and nucleus of tumor cells demonstrated significant variability in results, with no clear correlation with changes in dna quantity in cells or among themselves. the results, as shown in table 2, revealed a tendency to decrease the concentration of nuclear rna and increase cytoplasmic rna levels in metastatic cells, accounting for 53.3% and 56.6%, respectively. these results suggest that metastatic cells often exhibit an increase in dna quantity, which is inversely proportional to rna levels. in 36.6% of cases, the metastasis process was accompanied by a decrease in nuclear rna concentration. simultaneously, an increase in cytoplasmic rna was observed in 30% of cases. thus, the correlation between dna and rna levels had some polymorphism depending on the type of rna. it is also important to note that the correlation coefficient in these cases remained low (r<0.3). the concentration of rna, both in the cytoplasm and in the nucleus (especially in the nucleolus), reflects the functional activity of cells, especially long non-coding rnas (lncrnas), which regulate a wide range of intracellular metabolic processes.12,13 based on the analysis of the collected data, it can be stated that establishing a clear relationship between changes in dna and rna concentrations in tumor cells is not possible. the absence of a clear interaction may indicate the presence of noticeable polymorphism and significant functional diversity in both primary tumor cell populations and their metastases. when the concentration of one molecule changes, it does not necessarily coincide with a similar change in another, demonstrating the complexity of interactions between different molecular-genetic components of tumor cells. additional investigation of the nuclear-cytoplasmic index (nci) in the metastatic cell population and its comparison with nci in primary tumor cells, as well as with cytoplasmic rna levels in metastases, revealed that in approximately half of the cases social and political factors affecting public health [page 78] [healthcare in low-resource settings 2024;12(s2):12456] table 1. the amount of dna in metastases cells compared to that in primary tumor cells. indexes the amount of dna in metastases compared to the primary tumor r bigger smaller equal the average diameter of the nuclei 48.3 41.4 10.3 0.1 the coefficient of variation of the diameter of tumor cell nuclei 53.3 26.7 20 0.3 dna concentration 34.5 55.2 10.3 0.3 dna accumulation index 55.2 41.4 3.4 0.3 source: created by the authors. table 2. the amount of rna in the cells of metastases compared to the cells of the primary tumor, depending on their dnaai parameters (number of observations/%). dnaai bigger smaller equal the amount of rna in metastases compared to the primary tumor bigger smaller equal bigger smaller equal bigger smaller equal concentration of rna in the nucleus of tumor cells 5/6.7 11/6.7 2/16.6 5/16.6 5/3.4 1/3.4 1/3.4 0 0 concentration of rna in the cytoplasm of tumor cells 9/30 4/13.3 4/13.3 8/26.6 2/6.7 2/6.7 0 0 1/3.4 source: created by the authors. non -co mmerc ial us e o nly (46.7%), an increase in nci was observed, indicating a decrease in the level of cell differentiation; these data are highlighted in table 3. the described increase in nci is often accompanied by a decrease in the concentration of cytoplasmic rna in metastatic cell populations, which can be interpreted as a sign of suppression of their synthetic activity. thus, this can also be considered a marker of a decrease in the level of cell differentiation in metastatic nodes. in general, the obtained data indicate the complexity and multiplicity of pathways through which tumor cells develop and adapt in both primary and metastatic foci. the large variability in the molecular profile and functional activity underscores the need for further detailed study of the mechanisms of oncogenesis and metastasis at the cellular level (table 4). according to the obtained data, in 36.7% of cases where the dnaai increases in metastatic cell populations, there is also a significant decrease in nuclear rna levels, which may indicate the dominance of dna synthesis processes in the nucleus. concurrently, there is an increase in cytoplasmic rna levels (30%), indicating the activation of synthetic processes within the cell. therefore, it can be assumed that in the investigated metastatic nodes, the process of dna synthesis in some tumor cells occurs through endomitosis, i.e., dna replication without morphological and functional changes in cells. the lack of a clear inverse correlation between dna and rna synthesis can be explained by the fact that in healthy cells, differentiation processes, and dna synthesis activation are typically regulated by different biological pathways and regulatory mechanisms. this may involve the interaction of various genetic factors, signaling pathways, and molecular regulators that determine when and how a cell enters the process of division or replication of its genetic material.14,15 a comparison of the nci and nuclear rna concentration in the metastatic population of tumor cells with those in primary tumor cells is demonstrated in table 4. it is also worth noting that an increase in nci in metastases is usually accompanied by a decrease in nuclear rna concentration. this may indicate the complex nature of metastatic processes, where changes in one aspect of cell function do not necessarily reflect or impact other processes to the same extent. thus, this section has highlighted the results of a significant number of microspectrophotometric studies on the levels of dna and rna in both primary and metastatic tumors. several important aspects related to the content of nucleic acids in these cell populations have been discussed. it has been found that changes in dna and rna concentrations occur in metastases, and these changes do not always correlate with each other. this indicates the presence of distinct polymorphisms and functional heterogeneity in populations of tumor cells.16 changes in the concentration of nuclear and cytoplasmic rna are particularly important, as they may serve as indicators of metabolic and synthetic processes. there is a tendency to decrease nuclear rna concentration and increase cytoplasmic rna concentration in metastases, indicating the activation of synthetic processes in cells and a decrease in their degree of differentiation. it has also been observed that alterations in dna and rna levels in metastases do not always reflect similar changes in the primary tumor. it is established that dna and rna synthesis processes in tumor cells may occur independently of each other, indicating the presence of different regulatory mechanisms. these findings underscore the complexity of the molecular mechanisms underlying the development and progression of cancer, especially in the context of metastasis. discussion the analysis and interpretation of the obtained data have demonstrated significant diversity in dna and rna concentrations in primary and metastatic populations of tumor cells, requiring further clarification regarding the mechanisms regulating the synthesis of these critically important molecular compounds. in this context, particular attention is deserved for understanding the role played by various types of nucleic acids, including noncoding rnas (ncrnas), in the development and progression of oncological diseases. investigating the mechanisms through which nucleic acids influence tumor growth and metastasis may shed social and political factors affecting public health table 4. the amount of rna in the nuclei of tumor cells of metastases in comparison with the primary tumor, depending on the nuclearcytoplasmic index (nci) (abs/%). relative quantity the value of nci in metastasis in comparison with the primary tumor in total bigger smaller equal bigger 4/13.3 6/20 0/0 10/33.3 smaller 11/36.7 5/16.7 1/3.3 17/56.7 equal 2/6.7 1/3.3 0/0 3/10 in total 17/56.7 12/40 1/3.3 30/100 source: created by the authors. [healthcare in low-resource settings 2024;12(s2):12456] [page 79] table 3. the amount of rna in the cytoplasm of tumor cells of metastases compared to the primary tumor, depending on the nuclearcytoplasmic index (nci) (abs/%). relative quantity the value of nci in metastasis in comparison with the primary tumor in total bigger smaller equal bigger 0/0 7/23.4 1/3.3 8/26.7 smaller 14/46.7 6/20 1/3.3 21/70 equal 0/0 0/0 1/3.3 1/3.3 in total 14/46.7 13/43.4 3/9.9 30/100 source: created by the authors. non -co mmerc ial us e o nly light on the complexity of oncogenesis and outline new perspectives for developing more effective approaches to oncodiagnosis and treatment. in their study, feunteun et al.17 devoted considerable attention to the role of non-cell autonomous effectors in oncogenesis and metastasis. the authors examined various factors and mechanisms that impact the development and progression of cancer, but do not directly originate from tumor cells. these factors and mechanisms interact with malignant cells, originating from the surrounding cellular environment. thus, the tumor microenvironment includes various types of cells: immune cells, fibroblasts, endothelial cells, extracellular matrix, and molecules secreted by these cells. the microenvironment significantly influences the growth, survival, and metastasis of tumor cell populations. immune cells in the tumor microenvironment can either inhibit or promote the growth and spread of tumor cells. for example, some types of immune cells may secrete cytokines that support the tumor, while others may attack and destroy malignant cells. signaling molecules released by micro-environmental cells can activate or suppress specific signaling pathways in tumor cell populations, affecting their division, survival, and migration. the development of new blood vessels induced by the tumor (angiogenesis) is a key factor supporting tumor growth and metastasis. endothelial cells and growth factors secreted by them in this process are examples of non-cell autonomous effectors. tumor cells can alter the metabolism of surrounding healthy cells and tissues to support their growth and survival, representing an example of non-cell autonomous interaction. the overall state of the organism, including hormonal balance, nutrition, and general immune status, can also influence the patterns of tumor cell development. researchers noted that non-cell autonomous effectors could serve as the basis for developing innovative methods to combat oncological diseases by directly impacting both tumor cells and their interaction with the microenvironment. therefore, this research complements the current work on the mechanisms regulating tumor growth and metastasis. nevertheless, it does not allocate sufficient attention to the molecular-genetic mechanisms of tumor cell functioning. studies in this field were also conducted by li et al.,18 focusing on factors stimulating the development and further metastasis of gastrointestinal tumors. in this context, researchers emphasized the leading roles of immune cells, endothelial cells, and fibroblasts. regarding immune cells, penetrating lymphocytes (pls) play a significant role, participating in both the immune masking of the tumor and its recognition, destruction, and elimination. macrophages are classified into m1 and m2, with m1 macrophages typically suppressing the development of tumor nodes, while m2 macrophages promote tumor progression by secreting growth factors, including those stimulating angiogenesis and tumor invasion.19-21 neutrophils can both promote and inhibit the formation and further development of tumors by limiting the tumor microbiota and thus suppressing the progression and metastasis of tumor cell populations. as for tumor-associated fibroblasts (tafs), these cells are among the main cellular components of tumor growth, producing chemokines and cytokines that interact with tumor cells, promoting angiogenesis, growth, and tumor metastasis. angiogenesis is critically important for the progression of oncological pathology. this process is significantly influenced by tumor-associated endothelial cells (taecs) that produce growth factors, enhancing angiogenesis and thereby promoting the progression and metastasis of tumors. scientists have emphasized that the pathogenesis of cancer involves a complex interaction between tumor cells and their microenvironment. various components of the microenvironment can both promote the growth and spread of tumor cells and inhibit them, affecting the overall balance between oncogenesis and tumor suppression. while this work complements existing data on the role of intercellular interaction in the development of gastrointestinal cancers, it lacks information on the molecular-genetic mechanisms of these processes. the impact of macrophages on the growth and metastasis of tumor cells was also explored by fu et al.22 the researchers emphasized the existence of a distinct fraction of macrophages playing a leading role in tumor development, known as tumorassociated macrophages (tams). tams create an immunosuppressive environment around tumor cell populations by producing signaling molecules that inhibit anti-tumor cellular and humoral responses. importantly, the concentration of tams increases proportionally with tumor development and is associated with unfavorable clinical outcomes. tams also participate in angiogenesis through factors such as vascular endothelial growth factor a (vegf-a), placental growth factor (plgf), interleukin 1 beta (il-1β), epidermal growth factor (egf), tumor necrosis factor alpha (tnf-α), transforming growth factor beta (tgf-β), interleukin 8 (il-8), cxcl8, chemokine ligand 2 (ccl2), and cxcl12. tams play a crucial role in the metastatic process by forming premetastatic niches and stimulating epithelial-mesenchymal transitions, enhancing the invasion of tumor cells. thus, the provided material complements research on the influence of tams on oncogenesis and metastasis. regarding the molecular-genetic aspect of metastasis and oncogenesis, significant contributions were made by abdi and latifi-navid,23 who examined the role of long non-coding rnas (lncrnas) and single nucleotide polymorphisms (snps) in this context. lncrnas are sequences of over 200 nucleotides that do not encode proteins but serve various regulatory functions. these rnas can act as oncogenic factors or tumor suppressors in different types of cancer. they are categorized into pseudogenes, signaling, guiding, and scaffold lncrnas based on their molecular mechanisms of action. signaling lncrnas, crucial in this context, can activate or suppress other transcripts and exhibit expression specificity depending on the cell type. they can compete with transcription factors and rna-binding proteins, influencing processes such as cell proliferation, differentiation, angiogenesis, metastasis, and chemotherapy resistance. in terms of the interaction between snps and lncrnas, the latter can affect the function and structure of snps, altering their interaction with messenger rnas (mrnas). researchers emphasized that lncrnas can serve as targets for chemotherapy and potential targets for oncological preventive interventions.24 therefore, this study complements existing knowledge about the molecular-genetic characteristics of tumor processes, although the focus on lncrnas has led to insufficient coverage of dna changes during the tumor process. expanding on the topic of molecular-genetic determinants of oncological processes, it is worth paying attention to mrnas. in their study, mazziotta et al.25 investigated these sequences in the context of signaling pathways related to the growth and differentiation of cell populations. mrnas are a class of non-coding rnas that play a crucial role in regulating gene expression. they constitute 1 to 5% of the human genome and influence the regulation of 30 to 60% of protein-coding genes. the impact of mrnas on signaling pathways is crucial for understanding the mechanisms of differentiation and tumor growth, particularly through fundamental signaling pathways such as transforming growth factor beta bone morphogenetic protein (tgf-β/bmp) and wnt/β-catenin. in the tgf-β/bmp signaling pathway, mrnas regulate receptors social and political factors affecting public health [page 80] [healthcare in low-resource settings 2024;12(s2):12456] non -co mmerc ial us e o nly and ligands of bmp and tgf-β, influencing the development patterns of tumor cells. for example, mrnas such as mrna-153 and mrna-100 selectively affect bmp type ii receptor (bmpr2), while mrna-195-5p affects bmp type ia receptor (bmpr1a), modulating the growth and development of undifferentiated cell populations. in the tgf-β signaling pathway, mrnas such as mrna-10b, which promote cell growth and differentiation, are targeted at smad2, while mrna-221-5p and mrna-708 inhibit cell growth and differentiation, affecting smad3. in the wnt/βcatenin signaling pathway, mrnas such as mrna-1297, mrna9-5p, mrna-16-2-3p regulate wnt receptors and ligands, including wnt3a and wnt5a, influencing the development patterns of undifferentiated cells. they can either activate or suppress the growth of cell populations. mrnas also affect transcription factors involved in the wnt pathway, such as β-catenin and lef/tcf. for instance, mrna-129-5p, mrna-24, and mrna-132 influence these factors, modulating cell growth. mrnas targeting wnt signaling inhibitors, such as gsk-3β and apc, regulate β-catenin levels and influence the development of cell populations. researchers emphasized that mrnas are potential targets for therapeutic and preventive interventions in oncology. this work expands the understanding of molecular-genetic mechanisms in oncopathology through the analysis of the role of mrnas, although other aspects of cell growth regulation were not addressed by the authors. in summary, significant advancements have been made in expanding existing knowledge of the molecular-genetic mechanisms underlying the development of malignant tumors and their metastasis. the role of non-cell autonomous effectors in oncogenic cell transformation processes, their interactions with each other and the surrounding environment, and their impact on intracellular signaling pathways, gene expression profiles, proliferation, differentiation, and migration of tumor cells have been thoroughly analyzed. additionally, the study focused on the roles of lncrnas and mrnas in oncogenesis, metastasis, differentiation, and cell growth. the obtained results significantly deepen the understanding of tumor biology and open new therapeutic strategies for combating cancer. conclusions morphometric and microspectrophotometric analysis of primary cancer cells and their metastases from different locations showed wide variability in the content of dna, nuclear, and cytoplasmic rna. pronounced heterogeneity of dna content in different metastases, as well as inconsistency in changes in the concentration of dna and rna in the cells of individual metastases, were established. since metastases are dominated by cells with a lower level of differentiation and a higher degree of heteroand polyploidy, and individual metastases often have unique characteristics based on these indicators, it is worth concluding about the selection of highly metastatic clones of cells that are less differentiated than the bulk of cells of the primary tumor focus. this emphasizes the complexity and dynamics of the process of cancer occurrence, development, and spread, as well as the importance of understanding the molecular and cellular changes that occur during these processes and their potential for developing effective strategies for the diagnosis, treatment, and prevention of oncological pathology. thus, an in-depth analysis of metastatic cell populations in comparison with cells of the primary tumor center revealed that in metastases, an increase in the size of cell nuclei, a decrease in dna concentration, and an increase in dnaai are more often observed; there is also a decrease in the concentration of rna in both the cytoplasm and the nucleus. these observations may indicate a tendency towards an increase in the number of less differentiated cell clones in the process of metastasis compared to the primary tumor focus. adding to this awareness of the importance of non-cellautonomous effectors in the process of oncogenesis and metastasis, it is possible to gain a more profound understanding of the interaction between tumor cells and their microenvironment. thus, immune cells, fibroblasts, endothelial cells, as well as the extracellular matrix and molecules secreted by these cells have, a significant impact on the development and progression of cancer. understanding these interactions may open up new opportunities for oncology therapy targeting not only tumor cells but also their interactions with the microenvironment. therefore, the results of this study, which encompass the analysis of dna and rna levels in primary and metastatic tumor cells, indicate a complex interplay between different types of nucleic acids, revealing substantial heterogeneity in the molecular mechanisms regulating cancer growth and progression, while highlighting the importance of additional studies in this area, especially considering the role of non-cell autonomous effectors and mrna in these processes. it is important to acknowledge several potential limitations. first off, even with a reasonable sample size, the results could not be as broadly applicable as they could be, especially for less common tumor types or subtypes. furthermore, because the analysis is retrospective in nature, a longer time span was used to gather the samples, which may increase variability over time due to adjustments made to sample processing or measurement methods. additionally, the study only used microspectrophotometric analysis of nucleic acid content; it did not use other molecular profiling techniques, such as sequencing or gene expression analysis, which could have given researchers a more thorough understanding of the underlying transcriptomic and genomic changes. as for the direction of future research, it is important to focus further efforts on expanding the understanding of the role of mrna in the processes of tumor growth and development. special attention should be paid to researching the mechanisms of interaction between tumor cells and their microenvironment, in particular, the role of the immune system and metabolic changes in these processes. an important direction is also the search for new biomarkers for early diagnosis of cancer and monitoring the effectiveness of treatment, in particular the use of dncrna and snp as potential targets for therapy. references 1. sulaieva on, artamonova o, dudin o, et al. ethical navigation of biobanking establishment in ukraine: learning from the experience of developing countries. 2023. 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feunteun j, ostyn p, delaloge s. tumor cell malignancy: a complex trait built through reciprocal interactions between tumors and tissue-body system. iscience 2022;25:104217. 18. li j, chen d, shen m. tumor microenvironment shapes colorectal cancer progression, metastasis, and treatment responses. front med 2022;9:869010. 19. altayeva aa, issenova ss, machtejeviene e, et al. results of using the robson classification in kazakhstan. open access macedonian journal of medical sciences 2021;9:663-9. 20. pappuswamy m, chaudhary a, meyyazhagan a, et al. dna damage on buccal epithelial cells, personal working in the rubber industry occupationally exposed to carbon disulfide (cs2). asian pacif j cancer prev 2023;24:357-61. 21. salimi m, rastegarpouyani s. e74-like factor 5 promoter methylation in circulating tumor dna as a potential prognostic marker in breast cancer patients. asian pacif j cancer prev 2023;24:4035-41. 22. fu lq, du wl, cai mh, et al. the roles of tumor-associated macrophages in tumor angiogenesis and metastasis. cell immunol 2020;353:104119. 23. abdi e, latifi-navid s. emerging long noncoding rna polymorphisms as novel predictors of survival in cancer. pathol res pract 2022;239:154165. 24. hirna ha, maltsev dv, natrus lv, et al. study of the immunomodulating influence of preparation alpha/betadefensins on chemo/radiotherapy of patients with oral and oropharyngeal cancer. fiziologich zhurn 2021;67:86-96. 25. mazziotta c, lanzillotti c, iaquinta mr, et al. micrornas modulate signalling pathways in osteogenic differentiation of mesenchymal stem cells. int j mol sci 2021;22:2362. social and political factors affecting public health [page 82] [healthcare in low-resource settings 2024;12(s2):12456] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13192 analysis of structured discharge planning implementation for discharged inpatients: a multicenter study candra dewi rahayu,1 ika purnamasari,1 fifi alviana,1 dwi ari wibowo,2 haeril amir3 1faculty of health science, universitas sains al-qur'an, wonosobo; 2rsud krt setjonegoro wonosobo; 3nursing depertment, faculty of public health, universitas muslim indonesia, indonesia abstract discharge planning is an approach taken by the nurse, patient, and family that includes a needs assessment that will address a detailed care plan after the patient is discharged from the hospital. discharge planning is essential for patients to prevent re-visiting patients with the same complaints or symptoms that require new treatment and to reduce length of stay for patients. in addition, a structured discharge planning can improve the quality of nursing care. this study aimed to analyze the implementation of structured discharge planning in inpatients. the method employed is a descriptive quantitative carried out in 9 hospitals. the results show that 78.03% of discharge planning has been carried out on inpatients. 54.3% of discharge planning was carried out since the patient’s admission, and 45.7% was carried out when the patient was about to be discharged. discharge planning is carried out ranging from assessment, diagnosis, intervention, implementation and evaluation. discussion and conclusion state that the discharge planning has been carried out in a structured manner but the implementation has not been optimal and has not been fully performed when the patient is admitted to undergo treatment at the hospital. introduction the demand for high-quality health services is growing. currently, health services are no longer provided only when the patient is in the hospital ward, but must also continue to be provided until the patient returns home. the process of transitioning patients from the hospital to returning home is a very important part of health care, to reduce the number of relapses that might occur when patients are at home.1,2 discharge planning is an approach taken by nurses, patients, and families that includes a needs assessment that will discuss a detailed care plan after the patient is discharged from the hospital. discharge planning is essential for patients to prevent re-visiting with the same complaints or symptoms that require new treatment and to reduce los for patients. in addition, a well-structured discharge planning boosts patient satisfaction.3,4 discharge planning must include assessment, diagnosis, planning, implementation, and evaluation assessment plays a very important role in determining the right nursing diagnosis, planning nursing actions, implementing procedures, and evaluating nursing care. incomplete and inaccurate.5 assessment data lead to unachieved nursing care’s optimal goals. assessment is carried out at the beginning of nursing care provided to patients. discharge planning provided to patients by nurses must be consistent with the patient’s health condition and home care needs.6 the benefits of discharge planning for patients are shortening the duration of treatment, reducing medical costs for hospitals. a well-structured discharge planning will increase patients’ safety and satisfaction, thus improve the quality of service and nursing care. however, some research results show that the implementation of discharge planning is not optimal. inappropriate discharge planning methods and inactive experts’ role in carrying out discharge planning are the main factors causing suboptimal implementation of discharge planning. it is in line with the results of research conducted which show that discharge planning is carried out when the patient will return home and only includes home care instructions and control times.7 discharge planning carried out immediately after the patient is admitted to the hospital aims to help patients and families understand the problems faced by physical, psychological and social readiness. it also ensures the achievement of patient and family independence, the implementation of ongoing patient care, and the correspondence: candra dewi rahayu, faculty of health science, universitas sains al-qur'an, wonosobo, indonesia. e-mail: candrarahayu@unsiq.ac.id key word: discharge planning, inpatients, nursing care quality. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of the university sains al quran approved this study (number: 021/unsiq/2023). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article received: 2 october 2024. accepted: 4 october 2024. early access: 30 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13192 doi:10.4081/hls.2024.13192 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 42] [healthcare in low-resource settings 2025;13:13192] improved patients and families’ attitudes and skills in maintaining the patient’s health status. besides, it also understands the preventive efforts that must be made so as to reduce the risk of recurrence and complications of the disease. successful discharge planning is a process that is centralized, coordinated, and consists of various disciplines providing certainty that the patient has a plan to get ongoing care after leaving the hospital. discharge planning that is not implemented optimally can result in failure in the patient’s home care planning program which will affect the level of dependence and severity of illness, life threats, and physical dysfunction.8,9 systematic, structured, and applicable discharge planning provides benefits in maintaining continuity of follow-up care for fifteen patients, especially patients with palliative diseases. the discharge planning format must be structured and integrated, so that the continuity of health services can work optimally. most hospital nurses have not implemented a structured discharge plan yet. in the field, discharge planning is only carried out in certain parts that are considered important. assessment of discharge planning needs is often neglected in terms of assessing patient needs, educating post-discharge activities, recommending the diets, and addressing signs and symptoms need immediate treatments.10,11 this is due to a lack of understanding of the discharge planning process, nurse workload, health workers’ varied schedules, lack of trained staff, ineffective communication, and lack of clarity of roles and routines in the absence of sops for discharge planning implementation. research conducted by mustikaningsih in 2020 shows that the implementation of structured discharge planning which includes assessment, diagnosis, intervention, implementation and evaluation carried out by nurses is generally in the good category, 44.87%.12 discharge planning is an important component of patient-centered care to promote patient transition. by prioritizing patient needs and preferences, healthcare professionals can ensure a safe transition from hospital to community, ultimately improving patient satisfaction as well as overall healthcare outcomes. the aim of this study is to assess the implementation of structured discharge planning in hospitalized patients. this study aims to analyze the implementation of structured discharge planning in inpatients undergoing treatment. materials and methods the research was conducted in 9 hospitals and data were collected during 2022-2023. the research method employed was descriptive quantitative research. the research variable was the implementation of structured discharge planning by nurses, while the sample size in this study was 92 nurses who served in the inpatient room. the sampling method uses a purposive sampling technique. the research instrument is a questionnaire sheet containing statements of discharge planning implementation carried out by nurses, including assessment, intervention, diagnosis, implementation and evaluation, totaling 33 question items. the instrument has been tested for validity with a result of 0.851 and a reliability test with a result of 0.956. data analysis techniques employed frequency distribution to find out the implementation of discharge planning carried out by nurses in patients undergoing hospitalization. results the implementation of structured discharge planning is divided into the implementation of discharge planning at the assessment, intervention, implementation and evaluation stages, as well as the implementation of discharge planning implementation. discharge planning activities carried out by nurses as a whole can be seen in the tables. table 1 shows that out of 92 respondents (100%) work in the inpatient room with more than 5 years of work experience is 42.4% of nurse respondents, while the age of the nurses is mostly at the age of 20-30 years, namely 53.3%. the study found that the implementation of discharge planning has been carried out since the beginning of the patient’s hospitalization and is mostly carried out by nurses as shown in the table 1. based on the table 2, 54.3% of discharge planning is carried out since the patient is admitted to the hospital and 45.7 percent is done when the patient is about to be discharged. table 2 also shows that 79.3 percent of those who carry out discharge planning are nurses. table 3 shows the results of the question analysis items on the implementation of discharge planning. assessment is shown in question items number 1-15, diagnosis in question 16, interventions in 17-21, implementation in questions 22-26, and evaluation of discharge planning implementation in question items number 27-33. table 4 shows the implementation of discharge planning at each stage. the highest achievement is the assessment, at 83.33%, while the lowest value is at the intervention stage, 72.5%. the table 4 also shows the overall success of implementing structured discharge planning, which is 78.03%. article table 1. respondents’ characteristics (n=92). respondents’ characteristics frequency % service room inpatients 92 100 length of service < 5 years 39 42.4 5-10 years 33 35.9 > 10 years 20 21.7 age 20-30 years 49 53.3 31-40 years 39 42.4 41-50 years 4 4.3 table 2. the distribution of discharge planning (n-92). discharge planning frequency % time in the beginning of inpatient treatment 50 54.3 when the patient is discharged 42 45.7 discharge planning executor nurses 73 79.3 doctors 6 6.5 nurses, doctors 2 2.2 nurses, doctors, nutritionists 1 1.1 nurses, pharmacist, nutritionists 1 1.1 nurses, doctors, pharmacist, nutritionists 4 4.3 nurses, doctors, pharmacist, nutritionists, others 4 4.3 others 1 1.1 [healthcare in low-resource settings 2025;13:13192] [page 43] discussion implementing structured discharge planning in hospitalized patients, 78.03% has been done, 54.3 has been done since the patient was admitted to the hospital, and 45.7 has been done when the patient is about to be discharged. potter and perry state that patients admitted to the hospital in less than 23 hours should receive education or instruction on priority issues before patients and their families go home13. in this sense, it shows that discharge planning must be carried out from the beginning of the patient to article table 3. discharge planning implementation (n=92). discharge never sometimes often always planning n % n % n % n % implementation 1 0 0 1 1.1 7 7.6 84 91.3 2 1 1.1 1 1.1 26 28.3 64 69.6 3 1 1.1 8 8.7 33 35.9 50 54.3 4 5 5.4 1 1.1 19 20.7 67 72.8 5 0 0 15 16.3 31 33.7 46 50.0 6 0 0 13 14.1 33 35.9 46 50.0 7 0 0 4 4.3 33 35.9 55 59.8 8 0 0 14 15.2 33 35.9 45 48.9 9 1 1.1 14 15.2 34 37.0 43 46.7 10 7 7.6 22 23.9 31 33.7 32 34.8 11 4 4.3 18 19.6 29 31.5 41 44.6 12 1 1.1 12 13.0 32 34.8 47 51.1 13 1 1.1 8 8.7 36 39.1 47 51.1 14 0 0 9 9.8 35 38.0 48 52.2 15 8 8.7 22 23.9 33 35.9 29 31.5 16 2 2.2 15 16.3 37 40.2 38 41.3 17 1 1.1 23 25.0 40 43.5 28 30.4 18 4 4.3 24 26.1 43 46.7 21 22.8 19 8 8.7 32 34.8 32 34.8 20 21.7 20 1 1.1 18 19.6 42 45.7 31 33.7 21 5 5.4 37 40.2 29 31.5 21 22.8 22 2 2.2 23 25.0 43 46.7 24 26.1 23 5 5.4 24 26.1 41 44.6 22 23.9 24 5 5.4 36 39.1 32 34.8 19 20.7 25 1 1.1 19 20.7 42 45.7 30 32.6 26 4 4.3 32 34.8 38 41.3 18 19.6 27 2 2.2 27 29.3 37 40.2 26 28.3 28 4 4.3 27 29.3 37 40.2 24 26.1 29 5 5.4 35 38.0 33 35.9 19 20.7 30 1 1.1 25 27.2 36 39.1 30 32.6 31 4 4.3 32 34.8 34 37.0 22 23.9 32 1 1.1 13 14.1 29 31.5 49 53.3 33 2 2.2 14 15.2 34 37.0 42 45.7 table 4. structured discharge planning implementation analysis (n=92). discharge planning implementation mean ± sd median (min-max) assesment (%) 84.49±11.04 83.33 (56.67-100) diagnosis (%) 80.16±19.80 75 (25-100) intervention (%) 72.23±17.39 72.5 (30-100) implementation (%) 72.01±17.81 75 (25-100) evaluation (%) 75.04±17.68 75 (35.71-100) discharge planning (%) 78.61±13.04 78.03 (45.45-100) [page 44] [healthcare in low-resource settings 2025;13:13192] the hospital. the results of the study indicate that it is necessary to optimize the implementation of discharge planning and to carry it out at the beginning of the patient’s admission to the hospital. this can be used as a trigger for nurses on duty in the inpatient room to make discharge planning more optimal.14-16 optimizing the implementation of discharge planning in hospitalized patients is influenced by several factors, including the lack of understanding of nurses about the implementation of structured discharge planning to patients. research conducted by hayajneh et al. in 2020 shows that some of the things that affect the implementation of discharge planning are low knowledge of discharge planning activities; inability to define discharge planning; debate about starting time, implementation and preparation for discharge; negative attitudes of patients and their family members towards discharge planning; and consideration that discharge planning is an excessive and time-consuming document which is the responsibility of the doctor. better time management during work improves discharge planning in acute care settings.17,18 the implementation of discharge planning begins when the patient is first admitted to the hospital, namely when the patient first receives health services. the assessment carried out by the nurse is in the form of the patient’s discharge needs. nursing diagnoses are determined based on the development of the patients’ and their families’ needs. planning is made to enable the patient to be self-sufficient after hospitalization. there are two types of implementation, namely implementation before discharge and on the day of discharge. prior to discharge, the nurse will educate the patient and family about healthcare services, while on the day of discharge, the nurse will provide support in preparing for the patient’s discharge by allowing the family and patient to ask questions about home care, reviewing doctor’s instructions, therapies and medications, and providing a vehicle for the patient and family. evaluation is seen by assessing the patient and family’s ability to carry out the treatment plan that will be carried out at home.19-21 the discharge planning assessment describes the name, date, place of residence, family caregiver data, transportation needs, activities, follow-up medical care and nursing and special needs for patients. then the next step is to determine the diagnosis and develop an action plan. after planning, nurses carry out nursing implementation which is a necessary action in achieving complete goals and results. implementation activities are undertaken through health education activities for patients to provide knowledge, skills and provide services to meet ongoing care needs. this health education and service delivery is the responsibility of all members of the healthcare team2. the discharge planning intervention has the lowest result, 72.5%. this suggests that the use of discharge planning interventions in the nursing process is still low. the discharge planning in nic has proven to be effective for increasing patient knowledge as in research conducted by lemos et al., where this study was conducted to evaluate discharge planning in patients who were treated based on the nanda-international taxonomy, the classification of nursing interventions (nic) and the classification of nursing outcomes (noc). the results showed significant results with a p value (0.00). conclusions the findings of the above study indicate that the implementation of discharge planning is carried out starting from assessment, diagnosis, intervention, implementation and evaluation. discharge planning has been carried out in a structured manner but the implementation has not been optimal and has not been fully carried out when the patient is admitted to undergo hospitalization. references 1. provencher v, clemson l, wales k, et al. supporting at-risk older adults transitioning from hospital to home: who benefits from an evidence-based patient-centered discharge planning intervention? post-hoc analysis from a randomized trial. bmc geriatr 2020;20:84. 2. chan c-h, ju s. the influence of the head of the room management function on the completeness of nurse documentation. an idea health journal 2024;5:1-4. 3. gonçalves-bradley dc, lannin na, clemson l, et al. discharge planning from hospital. cochrane database syst rev 2022;2:cd000313. 4. kutz a, koch d, haubitz s, et al. association of interprofessional discharge planning using an electronic health record tool with hospital length of stay among patients with multimorbidity: a nonrandomized controlled trial. jama netw open 2022;5:e2233667. 5. elda m, sapeni ma-ar, lastriyanti l. the relationship between nurse motivation and the quality of nursing documentation in the medical surgical nursing service unit of private hospital x bekasi city. an idea health journal 2023;3:80-5. 6. fønss rasmussen l, grode lb, lange j, et al. impact of transitional care interventions on hospital readmissions in older medical patients: a systematic review. bmj open 2021;11: e040057. 7. linertová r, garcía-pérez l, vázquez-díaz jr, et al. interventions to reduce hospital readmissions in the elderly: inhospital or home care. a systematic review. j eval clin pract 2011;17:1167-75. 8. teytelman y. effective nursing documentation and communication. semin oncol nurs 2002;18:121-7. 9. dos santos kb, campos cs, de são josé perrone aca, et al. nursing documentation for chemotherapy in a university hospital’s bone marrow transplant unit: a best practice implementation project. int j evid based healthc 2020;18:75-85. 10. smith vc. discharge planning considerations for the neonatal intensive care unit. arch dis child fetal neonatal ed 2021;106:442-5. 11. xiao s, tourangeau a, widger k, berta w. discharge planning in mental healthcare settings: a review and concept analysis. int j ment health nurs 2019;28:816-32. 12. rameli pm, rajendran n. outcomes of complex discharge planning in older adults with complex needs: a scoping review. j int med res 2022;50:3000605221110511. 13. potter pa, perry ag, stockert pa, hall a. fundamentals of nursing-e-book: elsevier health sciences; 2021. 14. pendo e. ethical challenges in discharge planning: stories from patients. narrat inq bioeth 2020;10:183-6. 15. bert f, cugudda e, lo moro g, et al. facilitating discharge planning: the risk assessment of complex discharge index. j public health (oxf) 2023;45:e567-73. 16. patel h, yirdaw e, yu a, et al. improving early discharge using a team-based structure for discharge multidisciplinary rounds. prof case manag 2019;24:83-9. 17. hayajneh aa, hweidi im, abu dieh mw. nurses’ knowledge, perception and practice toward discharge planning in acute article [healthcare in low-resource settings 2025;13:13192] [page 45] care settings: a systematic review. nurs open 2020;7:1313-20. 18. hetriato nd, putri dup, arisandi w. effectiveness of using e puskesmas application in public health centre in the work area at public health office. an idea nursing j 2024;3:27-32. 19. amir h. strategies in preventing the transmission of covid-19 a quarantine, isolation, lockdown, tracing, testing and treatment (3t): literature review. asia pacific j health manag 2022;17(2). 20. archie rr, boren sa. opportunities for informatics to improve discharge planning: a systematic review of the literature. amia annu symp proc 2009;2009:16-20. 21. blaylock a, cason cl. discharge planning predicting patients’ needs. j gerontol nurs 1992;18:5-10. article [page 46] [healthcare in low-resource settings 2025;13:13192] hrev_master healthcare in low-resource settings 2024; volume 12:11839 a systematic review of efficacy on larva debridement in diabetic foot ulcers andi safutra suraya, ninuk dian kurniawati, herdina mariyanti, ira suarilah faculty of nursing, universitas airlangga, surabaya, indonesia abstract larva therapy, also known as maggot therapy, biodebridement, or maggot debridement therapy, involved the application of live fly larva to a patient’s wound for debridement, disinfection, and wound healing. despite its wide application in diabetic foot ulcers, the efficacy of this intervention remains uncertain. this review aimed to examine the benefits of larva therapy in diabetic foot ulcers by conducting systematic review. this systematic review sought relevant articles using mesh-based keywords in databases such as scopus, pubmed, science direct, and proquest. the inclusion criteria for the articles were as follows: population patients with diabetic foot ulcers, intervention the use of debridement or therapeutic application of maggot therapy with lucilia sericata, comparison none, outcome the results of articles demonstrating the effectiveness of using lucilia sericata maggot therapy on diabetic foot ulcers. article quality assessment was conducted using the joanna briggs institute guidelines. descriptive analysis was performed with a narrative approach, considering articles published from 2018 to 2023. based on the literature search, 237 articles were found with matching keywords from scopus (103), pubmed (77), science direct (14), and proquest (43). after screening for inclusion and exclusion criteria, 11 articles were identified for inclusion in this review. these 11 articles indicate that larva therapy can be an effective method in treating diabetic foot ulcers, especially when used correctly and tailored to each patient’s condition and needs. green bottle fly larva, lucilia sericata, produce proteolytic enzymes that can assist in wound healing. larva therapy is effective when combined with other procedures. in clinical practice, it is highly recommended that nurses provide an individualized approach and assess potential side effects. introduction diabetes mellitus (dm) is one of the non-communicable diseases that remains a global concern.1,2 dm occurs when elevated blood glucose levels result from the pancreas’ inability to produce adequate insulin,3 known as hyperglycaemia, where the body cannot produce enough insulin or utilize insulin effectively.4 according to data from the international diabetes federation (idf), in 2019, there were approximately 463 million people aged 20-79 years worldwide who had diabetes.5 the world health organization (who) also reports an 8.5% increase in the prevalence of dm in the adult population, with 422 million people worldwide suffering from dm.6 in southeast asia, the prevalence reached 10,1 %,7 primarily in middle and low-income countries.8 globally, dm is estimated to affect 9% of the population.9 it is projected that by 2030, dm will rank as the 7th leading cause of death worldwide.10 one of the long-term complications of diabetes mellitus is diabetic foot ulcer (dfu). the frequency of dfu occurrence is especially high in individuals with type 2 diabetes for more than ten years, with 60% experiencing disability to the point of leg amputation.11,12 dfu currently have a high incidence, affecting 85% of dm patients.13 according to a past review, one in every 20 hospitalized dm patients has a diabetic foot ulcer.14 every 20 seconds, a lower limb is lost due to dm.15 diabetic foot ulcers are characterized by the presence of infection, ulceration, and damage to the foot tissue.16 chronic foot ulcers are a common complication in dm patients, leading to a high rate of hospitalization and amputations.17 approximately 15% of dm patients will develop foot ulcers at some point in their lives,18 and among them, 14-24% will require amputations, making foot ulcers a significant predictor of future amputations.19. this requires proper collaboration between individuals with diabetes and related health workers.20 therefore, interventions aimed at preventing the correspondence: andi safutra suraya, faculty of nursing, universitas airlangga, surabaya, indonesia. email: andisuraya90@gmail.com key words: debridement; diabetic foot; larva therapy. contributions: ass, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing-original draft, review and editing; ndk, resources, investigation, and writing-review and editing; hm, resources, investigation, and writing-review and editing; is, resources, investigation, and writing-review and editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors are grateful to the dean and vice deans of the faculty of nursing, universitas airlangga, coordinator of the masters of nursing study programme, universitas airlangga, and all those who helped during the process. received: 18 september 2023. accepted: 18 december 2023. early access: 26 january 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11839 doi:10.4081/hls.2024.11839 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 186] [healthcare in low-resource settings 2024;12:11839] non -co mmerc ial us e o nly progression of diabetic ulcers are necessary. debridement is generally defined as the “process of removing all non-healing materials from the wound”.15 several methods are currently applied in the management of diabetic ulcers, including surgery, conventional dressings, larva therapy, enzyme preparations, polysaccharide beads, and hydrogels.21 for years, larva therapy has been promoted to have more benefits in regeneration by removing necrotic tissue.22 nevertheless, the detailed benefits of this issue have not been determined. therefore, the society for vascular surgery23 commissioned this evidence synthesis report to evaluate the quality of evidence supporting existing debridement methods and to estimate their relative benefits. larva therapy, also known as maggot therapy, biodebridement, or maggot debridement therapy, involves the application of live fly larva, including “medical-grade” maggots,24 to a patient’s wound to achieve debridement, disinfection, and ultimately wound healing.17 larva therapy uses newly hatched and sterilized larva from the common green bottle fly, phaenicia (lucilia) sericata, which is a type of myiasis or ectoparasitic infestation in living or necrotic tissue induced by artificially raising fly larva to high levels25 controlled clinical conditions.19 this type of larva therapy appears to offer more benefits than non-biodebridement interventions. the beneficial effects of larva therapy were first documented in the year 1557. the introduction and widespread use of antibiotics in the 1940s had an impact on the gradual increase in general treatments.24 in recent years, with the increasing incidence of drug resistance, there has been renewed interest in using maggots in the management of chronic wounds,15 especially in treating wounds infected with methicillin-resistant staphylococcus aureus (mrsa) or bacteria resistant to some types of antibiotics, such as amoxicillin and penicillin, and other drug-resistant pathogens.26 the current evidence supporting larva therapy for chronically infected lesions comes from several small clinical trials.27 this systematic review aimed to examine the benefits of larva therapy in diabetic foot ulcers. materials and methods study design this study is a systematic literature review conducted to address the research question, which examines empirical evidence on larva therapy for diabetic foot ulcers. the study was conducted systematically using the prisma literature review approach without conducting a meta-analysis on quantitative data. search strategy the search was conducted on four databases: scopus, science direct, pubmed, and proquest. keywords were based on mesh terms, such as [(“debridement” or “surgical debridement”) and (“diabetic foot”) and (“larva” or “maggot therapy”)]. eligibility criteria all search results are organized in mendeley desktop and reviewed to determine whether they meet the inclusion criteria. results that are identical or not identical to the research paper are discarded. in this systematic review, the inclusion criteria used are patients with diabetic foot ulcers undergoing debridement or therapeutic use of maggot therapy with lucilia sericata; comparisons include standard care; article outcomes indicate the effectiveness of lucilia sericata maggot therapy on diabetic foot ulcers; included study designs are case reports, true experimental research designs, randomized clinical trials, publication years 20182023, and the language used is english. study selection article selection was checked using the following criteria: the last 5 years, language used (english), keyword suitability, abstract, full text, study type, and article duplication. initially, 237 studies were obtained from the database search. the duplicates were then removed, and the titles and abstracts of the articles were screened. articles were considered relevant for review if they met the criteria. the remaining studies were reduced to only 11 empirical publications. title and abstract screening was then used to evaluate how well the article content matched the research topic. risk of bias all search results were organized in mendeley desktop and reviewed to determine whether they met the inclusion criteria. results identical or not identical to the research papers were discarded. the quality assessment of the articles and bias risk was independently performed by the research team using the joanna briggs institute (jbi) critical appraisal tool (table 1). data extraction the articles that were read in full were then organized and explored based on the author’s name, publication year, sample age, study design, sample size, wound size, number of larva, intervention program, session frequency and duration, and findings (table 2 and 3). all of these steps were carefully recorded and reported following the 2020 prisma flow diagram28 (figure 1). the search results yielded 237 articles, which were then screened and adjusted based on a full-text assessment, resulting in 11 articles. the flowchart for this study is as follows. the joanna briggs institute (jbi) critical appraisal checklist was used to analyze and mitigate bias risks for each article in this study. if a research article scored a minimum of 50% on the critical appraisal criteria, as agreed upon by the researchers, it was included in the inclusion criteria. the analysis is descriptive, using a narrative approach based on predefined themes.29 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. prisma flow diagram of the article selection process. [healthcare in low-resource settings 2024;12:11839] [page 187] non -co mmerc ial us e o nly results study characteristics based on the systematic review conducted, the reviewed articles had the following study characteristics: case report studies (n=5), true experimental research design (n=5), and a randomized clinical trial (rct) research design (n=1). the research was carried out in iran (parizad et al., 2022; choobianzali et al., 2022; hajimohammadi et al., 2021; parizad et al., 2021; jafari et al., 2022; siavash et al., 2021), mexico (fonseca-munoz et al., 2020), poland (szczepanowski et al., 2022), and turkey (egribel et al., 2022). the studies included in this systematic review came from research conducted in various countries worldwide, and all studies used the same type of fly, namely lucilia sericata. a total of 270 samples participated in the therapy with lucilia sericata larva. based on the review results, it is evident that larva therapy using maggots can improve the healing of diabetic foot ulcers. outcomes these eleven articles discussed larva therapy as a method that can be used to treat diabetic foot ulcers. larva therapy not only removes necrotic tissue debris from patients with fasciitis (inflammation of the tissue beneath the foot extending from the heel to the toes)41 but also disinfects the wound, minimizes tissue loss, and promotes granulation tissue growth.34 larva consume dead tissue and thus effectively break down this tissue.42 the saliva of these larva can digest dead wound tissue efficiently and can also eliminate microorganisms at the wound infection site.43 if diabetic foot ulcers are left untreated, severe conditions such as septicemia can threaten patients, and even death.44 based on the case study results in the research by parizad et al. (2022),30 choobianzali et al. (2022),31 hajimohammadi et al. (2021),32 parizad et al. (2021),33 and fonseca-munoz et al. (2020),34 it is known that interventions were carried out on wounds in the lower extremities, each with varying wound sizes. the studies utilized lucilia sericata larva in combination with surgical debridement,30,32,33 mechanical debridement, as well as normal saline,31 negative pressure wound therapy (npwt), and silver foam dressing.33 in a study conducted by fonseca-muñoz et al. (2020), therapy was not administered to wounds on the patients’ feet but to wounds on the scrotum of two patients undergoing larva therapy. in the research by szczepanowski et al. (2022),35 jafari et al. (2022),36 siavash et al. (2021),37 dehghan et al. (2020),38 and egribel et al. (2022).39 true experimental research design was employed, featuring a control group not receiving lucilia sericata larva. the session frequency & duration in each study was set at 48 to 72 hours. nezakati et al.’s (2020)40 randomized clinical trial design demonstrated significantly higher wound healing and reduction of necrotic tissue in the intervention group. the synthesis of research findings indicates that combining surgical debridement and larva therapy is a safe and effective strategy for enhancing the healing of diabetic foot ulcers. this approach not only demonstrates affordability but also proves highly effective in treating challenging diabetic foot ulcers, preventing leg amputation, and addressing cases unresponsive to conventional therapy. larva therapy, especially when using lucilia sericata larva, emerges as a valuable method for wound cleaning, effectively removing necrotic tissue, minimizing tissue loss, and promoting granulation tissue growth. moreover, the research suggests that larva therapy is effective for atypical diabetic foot ulcers that do not respond well to standard treatments, highlighting its potential as an alternative or supplementary method alongside traditional approaches such as sharp debridement, antibiotic therapy, and modern dressings. these findings collectively emphasize the therapeutic benefits of larva therapy in accelerating wound healing and reducing the size of diabetic foot ulcers, making it a simple yet impactful intervention for biofilm formation in wound care. discussion this review aims to examine the benefits of larva therapy in diabetic foot ulcers. according to the food and drug administration (fda), larva therapy is highly effective in treating non-healing wounds and open wounds with dead tissue.32 larva therapy reduces the number of surgical procedures that would otherwise be required and produces favorable outcomes.34 wound healing process green bottle fly larva, lucilia sericata, release proteolytic enzymes that aid in wound healing.45,46 these enzymes assist in breaking down necrotic (dead) tissue in wounds47 by digesting necrotic tissue, cleansing the wound of harmful substances, and promoting healthy tissue formation.26 the enzymes produced by lucilia sericata larva have proteolytic properties, meaning they transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. critical appraisal results for included studies using the jbi critical appraisal checklist. no author (year) design q1 q2 q3 q4 q5 q6 q7 q8 q9 q10 q11 q12 q13 total 1. parizad et al. (2022)30 case report study y y y y y n n y n/a n/a n/a n/a n/a 6/8 2. choobianzali et al. (2022) 31 case report study y y y y y y y y n/a n/a n/a n/a n/a 8/8 3. hajimohammadi et al. (2021) 32 case report study y y y y y y n y n/a n/a n/a n/a n/a 7/8 4. parizad et al. (2021) 33 case report study y y y y y y n y n/a n/a n/a n/a n/a 7/8 5. fonseca-munoz et al. (2020)34 case report study y y y y y y y y n/a n/a n/a n/a n/a 8/8 6. szczepanowski et al. (2022)35 true experimental research design y y n y y y y y y n/a n/a n/a n/a 8/9 7. jafari et al. (2022)36 true experimental research design y y n y y y y y y n/a n/a n/a n/a 8/9 8. siavash et al. (2021)37 true experimental research design y y n y y n y y y n/a n/a n/a n/a 7/9 9. dehghan et al. (2020)38 true experimental research design y y n y y y y y y n/a n/a n/a n/a 8/9 10. egribel et al. (2022)39 true experimental research design y y n y y y y y y n/a n/a n/a n/a 8/9 11. nezakati et al. (2020) 0 randomized clinical trial y y y n y y y n y y y y y 11/13 [page 188] [healthcare in low-resource settings 2024;12:11839] non -co mmerc ial us e o nly transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11839] [page 189] no t itle co un try se ttin g a ge of par tici pan ts sam ple siz e w oun d n um ber s o f in ter ven tio n p rog ram se ssio n f req uen cy f ind ing s a uth ors a rea la rva us ed and du rat ion 1. sur gic al d ebr ide me nt a nd i ran 72 ye ars of ag e. 1 1 ×1 cm lef t fo ot n ot m ent ion ed d fu is trea ted an d m ana ged 10 se ssio ns of ma ggo t t his ca se rep ort su gge sts tha t m agg ot d ebr ide me nt t her apy sur gic al d ebr ide me nt d ebr ide me nt us ing su rgi cal de bri dem ent (m dt ) b rin g th e li ght of ho pe and ma ggo t de bri dem ent the rap y. t her apy (m dt ) a nd md t i s a sa fe a nd t o p atie nts wi th d iab etic fo ot w ere pe rfo rm ed ef fec tive ap pro ach to ulc ers (d fu s): a c ase rep ort .30 (o ne the rap y s ess ion ev ery 48 ho urs ). fac ilit ate df u h eal ing . ev ery 48 ho urs ). 2. re viv ing ho pe by usi ng of ma ggo t ir an 51 ye ars of ag e. 1 2 ×2 cm rig ht f oot n ot m ent ion ed m agg ot d ebr ide me nt, a fter 10 se ssio ns t his ca se rep ort rev eal s th at d ebr ide me nt t her apy in pat ien ts w ith m ech ani cal de bri dem ent (on e s ess ion ev ery 48 ho urs ) m agg ot t her apy is an affo rda ble d iab etic fo ot u lce r: a ca se rep ort stu dy. 31 as we ll a s n orm al s alin e. m agg ot d ebr ide me nt t her apy (m dt ) a nd hig hly po ten t dr ug tre atm ent me tho ds to imp rov e d fu he alin g. 3. sav ing dia bet ic f oot ulc ers fro m i ran 72 ye ars of ag e 1 6 ×5 and 3× 3 n ot m ent ion ed su rgi cal de bri dem ent i n a ll, 1 0 m dt se ssio ns we re t his ca se rep ort stu dy sho ws tha t a mp uta tion by su rgi cal de bri dem ent on the he el a nd the a nd ma ggo t de bri dem ent . c ond uct ed (on e s ess ion ev ery 48 ho urs ) the co mb ine d u se of sur gic al a nd ma ggo t th era py: a cas e re por .32 s ole of the rig ht f oot . d ebr ide me nt a nd md t i s a sa fe and eff ect ive ap pro ach to imp rov e df u h eal ing an d p rev ent leg am put atio n. 4. sur gic al d ebr ide me nt, ma ggo t th era py, ira n 63 yea rs o f ag e 1 4 ×6, 6× 8, a nd 6×3 no t m ent ion ed su rgi cal de bri dem ent , 1 0 s ess ion s c ond uct ed onc e in 48 ho urs b ase d o n th e c lini cal res ults of thi s c ase n ega tive pr ess ure wo und the rap y, o n th ree sit es of the lef t ma ggo t th era py, rep ort stu dy, the wo und ca re t eam ca n u se a nd silv er f oam dr ess ing rev ive ho pe ex tern al a nkl e in ne gat ive pr ess ure the co mb ina tion the the rap y a ppl ied in f or pat ien ts w ith dia bet ic f oot ulc er: th e fo rm of tw o d eep , wo und th era py (np wt ), th is c ase rep ort is to t rea t re fra cto ry df u. a ca se rep ort .33 th e s ole as a s upe rfic ial a nd silv er f oam dr ess ing . u lce r an d th e le ft h eel as a d eep sk in g roo ve. 5. cli nic al s tud y o f m agg ot t her apy fo r m exi co 32 5 9 y ear s o f ag e 2 sc rot um 30 0 a nd 500 lar va m agg ot d ebr ide me nt 3 -8 ses sio ns con duc ted on ce 48 hou rs ma ggo t th era py not on ly e ffec tive ly f our nie r’s gan gre ne. 34 ove r th e p rev iou s 1 5 d ays . rem ove s im pur itie s o f n ecr otic tiss ue of pat ien ts w ith fas ciit is, but als o dis inf ect s w oun ds, mi nim ize s ti ssu e lo ss, and pr om ote s g ran ula tion tis sue gr ow th. 6. mi cro bio log ica l ef fec ts i n p atie nts po lan d 6367 yea rs o f ag e 8 0 n ot m ent ion ed no t m ent ion ed m agg ot d ebr ide me nt 1 0 s ess ion s c ond uct ed onc e in 48 ho urs w oun d c lea nin g w ith the us e w ith leg ulc ers an d d iab etic fo ot of l s eric ata lar va is h igh ly t rea ted wi thl uc ili a se ric at a larv a.35 rec om me nde d in sit uat ion s w her e nec ros is h as p ene trat ed dee p in to t he tiss ues . 7. lu cill ia s eric ata lar va the rap y in the ir an 45 -65 ye ars of ag e 4 0 38 ,5 c m n ot m ent ion ed m agg ot d ebr ide me nt 1 0 s ess ion s c ond uct ed onc e in 48 ho urs l arv a th era py is e ffec tive in hea ling t rea tme nt o f d iab etic ch ron ic w oun ds. 36 dia bet ic w oun ds. th e s ize of the wo und af ter the tre atm ent of the lar va is s ma ller tha n e ver be for e. 8. eff ica cy of ma ggo t d ebr ide me nt t her apy i ran 38 -75 ye ars of ag e 4 2 n ot m ent ion ed 10 -15 lar va m agg ot d ebr ide me nt f or 48 to 7 2 h our s. m dt rep eat ed 5 ti me s ou r fi ndi ngs sh ow tha t m dt is effe ctiv e o n r efr act ory at ypi cal di abe tic foo t u lce rs: trea tme nt f or ina deq uat e a typ ica l a n o pen -la bel st udy .37 df u r esp ons ive to con ven tion al t her api es. 9. a n ew ap pro ach to ma ggo t t her apy fo r ir an 37 -55 ye ars of ag e 2 7 n ot m ent ion ed no t m ent ion ed m agg ots the rap y a dde d o nce in 48 hou rs m agg ot t her apy oth er r out ine me tho ds h eal ing of di abe tic foo t u lce rs.3 8 rou tine tre atm ent as a for df u h eal ing an d in dic ate s th at t his co mp lem ent ary the rap y. typ e o f th era py can be ad ded fo r con ven tion al t rea tme nt a ppr oac hes su ch a sha rp deb rid em ent , an tibi otic the rap y a nd mo der n d ress ing s to ach ieve a s atis fact ory res ult. 10. e xpl ori ng the ef fec ts o f l uc ili a se ric at a tur key 28 -37 ye ars of ag e 3 0 n ot m ent ion ed no t m ent ion ed t her apy of ma ggo ts w ith ste rile on ce in 4 8 h our s t her apy wi th t he larv a o f l . se rica ta, l arv a o n b iof ilm -fo rm ing lu ci lia se ric at a. a s imp le a nd effe ctiv e m eth od, b act eria in wo und s.39 c an acc ele rate the he alin g o f b iof ilm for ma tion wo und . 11. e ffec ts o f l uc ili a se ric at a ira n 4566 yea rs o f ag e 4 5 n ot m ent ion ed no t m ent ion ed t her apy of ma ggo ts w ith l arv a s hou ld u sua lly be o ur res ults sh ow the lar va of l. se ric at a m agg ot t her apy in ste rile lu ci lia se ric at a. rem ove d w ithi n 4 8-7 2 h our s t her apy ca n s ign ific ant ly c hro nic w oun d t rea tme nt: afte r p res crip tion in cre ase the rat e o f w oun d h eal ing . a ra ndo miz ed cli nic al t rial .40 non -co mmerc ial us e o nly transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 190] [healthcare in low-resource settings 2024;12:11839] table 3. larva debridement in diabetic foot ulcers. no study dfu indicators types of larva 1. case report study diabetes mellitus lucilia sericata 2. case report study diabetes mellitus lucilia sericata 3. case report study diabetes mellitus lucilia sericata 4. case report study diabetes mellitus lucilia sericata 5. case report study diabetes mellitus lucilia sericata 6. true experimental research design diabetes mellitus lucilia sericata 7. true experimental research design diabetes mellitus lucilia sericata 8. true experimental research design diabetes mellitus lucilia sericata 9. true experimental research design diabetes mellitus lucilia sericata 10. true experimental research design diabetes mellitus lucilia sericata 11. randomized clinical trial diabetes mellitus lucilia sericata can break peptide bonds in proteins and necrotic tissue.48 this is one of the main ways larva accelerate wound healing.26 these enzymes also have antibacterial properties that can help minimize the risk of infection in wounds.49 proteolytic enzymes are crucial for various biological processes, including food digestion, the regulation of enzyme and protein activities, tissue regeneration during wound healing, and the elimination of pathogens such as bacteria and viruses.50 larva therapy administration procedure in the eleven articles, it was found that the age of patients undergoing larva therapy ranged from 28 to 75 years. additionally, the average patient’s family had a history of diabetes and hypertension and their associated treatments. the condition of the wound area in each patient varied, depending on the severity or the patient’s condition, which also influenced the frequency and duration of the larva therapy itself. when providing larva therapy, the average time needed for a patient to undergo larva treatment was 10 sessions (one session every 48 to 72 hours). during each session, patients were asked about their tolerance or ability to undergo larva therapy. if the answer was “yes,” the intervention continued, but if the answer was “no,” the intervention was stopped. overall, the wound healing process through larva therapy varied for each patient, depending on the size and depth of the wound. based on the systematic review above, some articles suggest that a combination of larva therapy with surgical debridement,30-33 silver dressings, and negative pressure wound therapy (npwt) is highly effective in treating refractory diabetic foot ulcers.33 furthermore, hajimohammadi et al. in parizad et al. (2022) reported that combining surgical debridement and larva therapy is a safe and effective strategy for treating diabetic foot ulcers and preventing amputations.32 choobianzali et al. in parizad et al. (2022) reported that larva therapy is an affordable and highly effective treatment approach for improving the healing of diabetic foot ulcers.31 however, soares et al. (2009) stated that the use of larva therapy in diabetic foot ulcers, compared to hydrogel, provided limited health benefits, longer healing times, and slightly higher additional costs than using hydrogel.51 effects of larva therapy on patients larva therapy can have side effects such as itching and the sensation of something crawling on the skin. regarding the stimulation of the nervous system due to larva distension, some patients may experience varying levels of pain, which can be alleviated by timely larva removal or the use of medications. psychological effects, such as anxiety, are another result of larva therapy,52 mainly due to the placement of larva to clean diabetic foot ulcers. patients unfamiliar with this procedure may initially feel fear and anxiety. therefore, as a nurse, preventive measures can be taken to minimize patient anxiety, such as providing clear explanations about the procedure, showing empathy towards the anxiety experienced by the patient, offering patients the choice to observe the larva therapy procedure, providing psychological preparation for what the patient will experience during the therapy process, administering anesthesia for pain relief where possible, and involving additional support, such as family or close friends, with the patient. it is essential to remember that every patient undergoing larva therapy by a nurse requires a different approach, and professionalism is always required to help patients cope with their anxiety regarding larva therapy. limitations of the study this study has several limitations. it’s based on just two patients with scrotal wounds undergoing larva therapy, which limits its generalizability, statistical power, and the ability to draw causal conclusions. there is no control group, which further impacts the study’s validity. patient heterogeneity introduces confounding variables that can affect the results. self-reported data may introduce bias, and the study does not address the long-term sustainability of the therapy. the lack of specific fda citations affects the study’s credibility. furthermore, the study is focused on the benefits and administration of larva therapy, excluding complications, adverse effects, and alternative treatments. inconsistent treatment durations and limited comparisons with other strategies hinder the evaluation of relative advantages and disadvantages. conclusions this unique therapy has the potential to accelerate healing by breaking down necrotic tissue and promoting healthy tissue formation. the study highlights variations in patient response and suggests that the cost-effectiveness of larva therapy may vary. it also emphasizes the importance of addressing patient discomfort and anxiety. green bottle fly larva, lucilia sericata, produce proteolytic enzymes that can assist in wound healing. larva therapy is non -co mmerc ial us e o nly effective when combined with other procedures. however, nurses should understand the potential side effects and patient anxiety, providing a professional and individualized approach. with proper care, larva therapy can help in healing diabetic foot ulcers. overall, the findings suggest that larva therapy has promise in wound management, but further research and individualized patient care are essential for its success. future researchers can contribute to a deeper understanding of larva therapy’s potential in wound management and improve the quality of care for patients with nonhealing wounds. references 1. al-lawati ja. diabetes mellitus: a local and global public health emergency! oman med j 2017;32:177-9. 2. ong kl, stafford lk, mclaughlin sa, et al. global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021. lancet 2023;402:20334. 3. dewi eu, widari np, nursalam n, et al. the relationship between diabetes self-care management and blood glucose level among type 2 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hassanpour a, et al. reviving hope by using of maggot debridement therapy in patients with diabetic foot ulcer: a case report study. int j surg case rep 2022;91:106797. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11839] [page 191] non -co mmerc ial us e o nly 32. hajimohammadi k, parizad n, hassanpour a, goli r. saving diabetic foot ulcers from amputation by surgical debridement and maggot therapy: a case report. int j surg case rep 2021;86:106334. 33. parizad n, hajimohammadi k, goli r. surgical debridement, maggot therapy, negative pressure wound therapy, and silver foam dressing revive hope for patients with diabetic foot ulcer: a case report. int j surg case rep 2021;82:105931. 34. fonseca-muñoz a, sarmiento-jiménez he, pérez-pacheco r, et al. clinical study of maggot therapy for fournier’s gangrene. int wound j 2020;17:1642-9. 35. szczepanowski z, grabarek bo, boroń d, et al. microbiological effects in patients with leg ulcers and diabetic foot treated with lucilia sericata larva. int wound j 2022;19:135-43. 36. jafari a, hosseini sv, hemmat hj, khazraei h. lucillia sericata larval therapy in the treatment of diabetic chronic wounds. j diabetes metab disord 2022;21:305-12. 37. siavash m, najjarnezhad a, mohseni n, et al. efficacy of maggot debridement therapy on refractory atypical diabetic foot ulcers: an open-label study. int j low extrem wounds 2021;20:315-20. 38. dehghan o, tabaie sm, rafinejad j, et al. a new approach to maggot therapy for healing of diabetic foot ulcers. acta fac medicae naissensis. 2020;37:387-95. 39. egribel m, sirekbasan s, çakan h, polat e. exploring the effects of lucilia sericata larva on biofilm-forming bacteria in wounds. dicle tıp derg 2022;49:565-70. 40. nezakati e, hasani mh, zolfaghari p, et al. effects of lucilia sericata maggot therapy in chronic wound treatment: a randomized clinical trial. chronic wound care manag res 2020;7:11-7. 41. sidarta n. the correlation between body mass index and plantar fasciitis pain age 20-50 years old. j biomedika dan kesehat 2022;5:50-6. 42. choobianzali b, goli r, hassanpour a, et al. reviving hope by using of maggot debridement therapy in patients with diabetic foot ulcer: a case report study. int j surg case rep 2022;91:106797. 43. zubir mzm, holloway s, noor nm. maggot therapy in wound healing: a systematic review. int j environ res public health 2020;17:1-12. 44. faraji n, goli r, ghalandari m, taghavinia s. treatment of severe extravasation injury in a newborn by using tilapia fish skin : a case report. int j surg case rep 2022;91:106759. 45. basalamah ff, budi hs, ayuningtyas nf, ernawati ds. larval therapy as a wound healing acceleration in chronic wounds: a scoping review. malaysian j med heal sci 2023;19:12631. 46. whitaker is, twine c, whitaker mj, et al. larval therapy from antiquity to the present day: mechanisms of action, clinical applications and future potential. postgrad med j 2007;83:40913. 47. sari m, muhtar ta, ramli ms. maggot sebagai biotherapy pada perawatan luka diabetik. 2016;4:64-75. 48. mótyán j, tóth f, tőzsér j. research applications of proteolytic enzymes in molecular biology. biomolecules 2013;3:923-42. 49. wintoko r, yadika adn. manajemen terkini perawatan luka. j kedokt univ lampung 2020;4:183-9. 50. sabotič j, kos j. microbial and fungal protease inhibitors current and potential applications. appl microbiol biotechnol 2012;93:1351-75. 51. soares mo, iglesias cp, bland jm, et al. cost effectiveness analysis of larval therapy for leg ulcers. bmj 2009;338:10503. 52. naik g, harding k. maggot debridement therapy: the current perspectives. chronic wound care manag res 2017;4:121-8. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 192] [healthcare in low-resource settings 2024;12:11839] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11987 the effect of family empowerment on hemoglobin levels in pregnant women ika mardiyanti, aldilia wyasti pratama, lailatul khusnul rizki, esty puji rahayu faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia abstract empowering families can enhance their ability to detect highrisk pregnancies early, which can improve the health status of pregnant women. this study aimed to analyze the effect of the family empowerment model on the hemoglobin levels of pregnant women. it employed a quasi-experimental method with a crosssectional study approach, implementing a family empowerment intervention to examine its impact on the health of pregnant women. sampling was conducted using probability sampling with simple random sampling, resulting in 60 pregnant women divided equally into an intervention group and a control group. the independent variable was the family empowerment model intervention, and the dependent variable was the hemoglobin level of the pregnant women. data were collected using a questionnaire and analyzed with the wilcoxon test statistic, which indicated a significant effect (p=0.000) of the family empowerment model on the hemoglobin levels of pregnant women. the statistical analysis revealed that the intervention group’s hemoglobin levels showed a significant difference (p<0.05) before and after the intervention. in summary, the treatment involving the family empowerment model significantly affected the hemoglobin levels in pregnant women. after the intervention, nearly all respondents demonstrated increased family involvement in maintaining and caring for pregnant women, facilitating the early detection of high-risk pregnancies, and contributing to increased hemoglobin levels among these women. introduction pregnancy and childbirth are physiological processes experienced by women, but sometimes they involve risky conditions.1 the risk of pregnancy complications can affect any pregnant woman, highlighting the importance of providing physical and mental support, along with family involvement, to ensure her well-being throughout the pregnancy.2 family members are the closest individuals to pregnant women and can assist in recognizing signs of danger or issues that may arise.3 empowering family members to actively participate in supporting pregnant women can enhance their ability to practice self-care and take responsibility for the health of both the mother and the high-risk pregnancy.4 the results of a preliminary study of 20 people showed that 80% (16 people) of the family in this case were husbands, did not know and were unable to recognize the signs and symptoms that pregnant women were in the risk category or not, did not know how to do early detection of pregnancy with using the maternal and child health (mch) book and kspr (kartu skor pudji rochyati or pudji rochyati score card), do not understand what to do if there is an emergency and have not determined who is the main decision maker and there is no planning to prepare funds, where to choose health facilities (clinics, primary health care or hospital), as well as the transportation to be used in case of complications. family ignorance about the high risk of pregnancy due to the lack of optimal education and assistance by health workers is one of the causes of the inability of families to carry out early detection and treatment of high-risk pregnancies5 which can have an impact on increasing the danger of pregnancy which affects the health status of the mother and her baby.6 support obtained from the family or husband is very important in recognizing the symptoms and responses felt by pregnant women,7 can reduce anxiety correspondence: ika mardiyanti, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia. e-mail: ika_mardiyanti@unusa.ac.id key words: anemia; family empowerment; pregnancy; hemoglobin level. contributions: im, conceptualization, formal analysis, methodology, writing – original draft; sn validation, visualization; uh, review & editing; fe, data curation, review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas airlangga, based on ethical certificate 1752-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thank universitas nahdlatul ulama surabaya for their valuable insights and contributions to this study. received: 15 october 2023. accepted: 21 may 2024. early access: 3 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11987 doi:10.4081/hls.2024.11987 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11987] [page 579] non -co mmerc ial us e o nly and complications in pregnancy,8 including in making decisions to seek delivery assistance and management of obstetric complications.9 hemoglobin levels are crucial in pregnant women as they play a key role in transporting oxygen throughout the body, supporting both maternal and fetal health.10 adequate hemoglobin levels help prevent anemia, a common condition in pregnancy that can lead to severe fatigue, preterm delivery, and low birth weight.11 therefore, understanding the impact of family empowerment on improving hemoglobin levels can provide valuable insights into effective strategies for enhancing prenatal care and maternal wellbeing. therefore, this study aimed to analyze the effect of the family empowerment model on the hemoglobin levels of pregnant women. materials and methods research design this type of research was quasi-experimental. the purpose of this study was to conduct a model simulation to test the effectiveness of the family empowerment model. quasi-experimental research was conducted with pre-test and post-test after the model was tested. two groups will be involved in this study, namely the treatment group and the control group. study participants the population of pregnant women in the working area of the wonokromo health center is 128 pregnant women. then, it was categorized into a homogeneous sample of 70 people. with the criteria of pregnant women who have entered the second trimester during the data collection period, pregnant women who live in their area of residence for at least 3 months, planning to give birth in the area of their current residence. after calculating the sample obtained from 60 people, the sample size of the second research phase for each group was 30 respondents from the intervention group and 30 respondents from the control group by random sampling. variable, instrument and data collection the family empowerment intervention was carried out by home visits, which were carried out in as many as 8 sessions for 8 weeks with a duration of ±60-120 minutes through home visits. the methods used are lectures, discussions (questions and answers), demonstrations, contextual counseling, and adult learning with an active learning process using interactive learning media through booklet media, learning modules, kspr scores, drisk applications, and mch books. at the end of each meeting, the researcher asked the respondents again about the material that had been presented. after the last intervention, the researcher will then conduct a post-test in the treatment group and the control group by asking the family to fill out a questionnaire on the ability to perform early detection of high-risk pregnancies and measure the hemoglobin levels of pregnant women. the collected data is then analyzed. after taking the post-test data, it is to fulfill the principle of fairness in research ethics. then the researcher will also provide the same intervention to the control and treatment groups. data analysis the research data were analyzed using the wilcoxon statistical test which showed (p=0.000). this means that the family empowerment model has an effect on hemoglobin levels. ethical clearance ethical considerations played a pivotal role throughout the research process. the study garnered ethical clearance from the health research ethics commission, faculty of nursing, universitas airlangga, based on ethical certificate no. certificate :172-kepk, thereby attesting to its unwavering commitment to upholding ethical standards and guidelines. results table 1 present the majority of husbands in the control group are 26-45 years old, with the last education of middle school, working in the private sector, while most of the wives are 17-25 years old, with the last education of middle school, not working, and the third pregnancy. the result of the average kspr score is 5.20 with a standard deviation of 5.18885 and the lowest score of 2, while the highest is 18. in the intervention group, most of the husbands were aged 26-45 years, with the latest secondary education, working in the private sector, while the wives were mostly 17-25 years old, with secondary education, not working, and at the first pregnancy. the average kspr score is 3.60 with a standard deviation of 3.08053 and has the lowest value of 2, while the highest is 14. furthermore, from the different tests, it is known that the p-value above 0.05 indicates that there is no difference in the characteristics of the respondents between the treatment groups. with the control group. table 2 shows a description of hemoglobin levels from the results of the pre-test and post-test in the control group. the results were the same, namely that most of the respondents were not anemic. in the intervention group before being given treatment, most of the respondents had moderate anemia category 6.7% and 26.7% mild. and after being given treatment there was an increase in nonanemic changes from 66.7% to 80%. table 3 shows the testing results of pregnant women’s hemoglobin levels in family empowerment development research. the results of the statistical test analysis of the intervention group on hemoglobin levels resulted in a significance value of <alpha (5% or 0.05). therefore, it can be stated that there is a significant difference in hemoglobin levels before and after the intervention. in other words, giving treatment to the family empowerment model has a significant effect on hemoglobin levels in pregnant women. discussion the result indicated that the family empowerment model in carrying out early detection of high-risk pregnancies can be done by providing education, assistance, and training to families. this is in accordance with previous research, namely efforts to increase knowledge and skills through education and training can lead to sustainable behavior change.12 the intervention of the family empowerment model positively impacts the family, because it can increase family satisfaction and empowerment.13 the family empowerment intervention given to the treatment group was carried out in a structured manner by providing material that was compiled based on the research results and modeling in phase 1 research. the family empowerment intervention was carried out with home visits conducted in 8 sessions for 8 weeks (done regularly once a week) with a duration of ±60-120 minutes through home visits. the method used is lectures, discussions (questions and answers) are carried out in the first and second weeks, at addi transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 580] [healthcare in low-resource settings 2024;12:11987] non -co mmerc ial us e o nly tional meetings and demonstrations, and counseling are contextual and adult learning with an active learning process using interactive learning media, through booklet media, learning modules, kspr scores, the drisk application that can be downloaded via the play store, as well as the use of mch books. at the end of each meeting, the researcher asked the respondents again about the material that had been presented. empowerment carried out for families through strengthening filial values by strengthening internal factors (knowledge, selfmotivation, and family connectedness) and external factors (midwives, and support) makes families able to commit to caring for pregnant women,14 pass the empowerment stages well and able to collaborate with health workers in efforts to care for pregnant women which in turn can improve the ability of families in early transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. distribution of hemoglobin levels in the treatment group and the control group. category variables intervention (n=30) control (n=30) pre-test post-test pre-test post-test n % n % n % n % hemoglobin levels mild anemia 8 26.7 6 20.0 11 36.7 11 36.7 moderate anemia 2 6.7 0 0.0 1 3.3 1 3.3 no anemia 20 66.7 24 80.0 18 60.0 18 60.0 table 2. dtesting results of pregnant women's hemoglobin levels in family empowerment development research. indicator group test x ̅ sd δ statistics p hemoglobin levels intervention pretest 11.36 1.29 0.4767 -4.544 0.000 posttest 11.84 0.92 control pretest 11.33 0.89 -0.1533 -3.555 0.000 posttest 11.18 0.92 sd, standard deviation. [healthcare in low-resource settings 2024;12:11987] [page 581] table 1. distribution of respondent characteristics (n=60). characteristics category control intervention p n % n % husband's age 17-25 years old 12 40.0 9 30.0 0.589 26-45 years old 18 60.0 21 70.0 husband's education base 8 26.7 4 13.3 0.420 intermediate 18 60.0 22 73.3 high 4 13.3 4 13.3 husband's job factory workers 0 0.0 1 3.3 0.100 drivers 0 0.0 2 6.7 trader 12 40.0 9 30.0 nurse 0 0.0 1 3.3 security guard 0 0.0 3 10.0 government employees 1 3.3 0 0.0 private 16 53.3 11 36.7 self-employed 0 0.0 3 10.0 doesn't work 1 3.3 0 0 pregnant women’s age 17-25 years old 16 53.3 17 56.7 26-45 years old 14 46.7 13 43.3 pregnant women's education base 8 26.7 6 20.0 0.621 intermediate 20 66.7 20 66.7 high 2 6.7 4 13.3 pregnant women’s job teacher 0 0.0 1 3.3 0.181 trader 3 10.0 3 10.0 nurse 0 0.0 1 3.3 private 4 13.3 11 36.7 doesn't work 22 73.3 13 43.3 self-employed 1 3.3 1 3.3 parity first 15 50.0 17 56.7 0.951 second 10 33.3 8 26.7 third 4 13.3 4 13.3 fourth and more 1 3.3 1 3.3 non -co mmerc ial us e o nly detection of high-risk pregnancies.15 empowerment interventions for families can increase knowledge, motivation, self-confidence which can increase knowledge and technical skills, as well as the ability to perform early detection of high-risk pregnancies.13,16 the results of the statistical test analysis of the intervention group on hemoglobin levels resulted in a significance value of <alpha (5% or 0.05). therefore, it can be stated that there is a significant difference in the hemoglobin levels of pregnant women before and after the intervention. family involvement in educational interventions regarding the recognition of pregnancy danger signs and early detection of high-risk pregnancies can increase the family’s ability to help detect worsening of pregnant women,17 predict morbidity in at-risk pregnant women and allow timely intervention to prevent the possibility of more severe conditions. the family, in this case the closest people to pregnant women, plays an important role in prenatal care, including in early detection of high-risk pregnancies.18,19 family involvement in the introduction of high-risk family factors is important to support success in determining how families integrate, interpret, and adapt to high-risk pregnancies.17 the role of the family in the introduction of risk factors for pregnancy is in the form of ways to recognize the signs of a risky pregnancy, as well as knowing when is the right time to bring pregnant women for intensive examinations so that there is no emergency according to the advice of health workers.19 independence to carry out early detection of risky pregnancies can be increased by providing education and optimizing mch books that are carried out intensively.20 the results showed that in general the hemoglobin levels of pregnant women in the treatment group experienced an increase in the average hemoglobin value, while the control group experienced a decrease. furthermore, it is known that the distribution of the hemoglobin status of pregnant women in the treatment group has increased under normal conditions (80%) previously (66.7%). then the control group is known to remain in normal conditions as much as 60% both pre and post. this shows that the anemia status of the treatment group has normal conditions or leads to a better condition than the control group. it is also proven, especially in pregnant women who have an abnormal body mass index, there is a significant difference in the value of the hemoglobin indicator. the results of statistical test analysis on the hemoglobin indicator obtained a significance value of <alpha (5% or 0.05). therefore, it can be stated that there is a significant difference in the hemoglobin indicator. in other words, there is a significant effect of giving treatment to the family empowerment model (family empowerment) on the hemoglobin of pregnant women. hemoglobin is a parameter that is widely used to determine the prevalence of anemia.21 anemia is a medical condition in which the number of red blood cells or hemoglobin is less than normal. pregnant women are said to be anemic if the hemoglobin level is <11 g/dl. most women experience anemia during pregnancy, both in developed and developing countries. the world health organization (who) estimates that 35-75% of pregnant women in developing countries and 18% of pregnant women in developed countries are anemic.22 hemoglobin that is less than the normal limit or anemia often occurs due to iron deficiency, because in pregnant women there is a twofold increase in iron requirements due to an increase in blood volume without expansion of plasma volume, to meet the needs of the mother (prevent blood loss during childbirth) and growth fetus. ironically, it is estimated that under 50% of mothers do not have sufficient iron stores during pregnancy, so the risk of iron deficiency or anemia increases with pregnancy.23 there is a close correlation between anemia during pregnancy and fetal death, abortion, congenital defects, low birth weight, reduced iron stores in children or children born with anemia. this condition causes the perinatal mortality rate is still high, as well as maternal mortality and morbidity. in addition, it can cause bleeding during delivery which is the main cause of death for pregnant/maternal women.24 the causes of anemia during pregnancy in developing countries are influenced by various factors including micronutrient deficiencies of iron, folate, vitamins a and b12, parasitic infections such as malaria and intestinal worms or chronic infections such as tuberculosis (tb) and human immunodeficiency virus (hiv).25 the contribution of each factor that causes anemia during pregnancy will vary depending on geographic location and diet. anemia during pregnancy will have a negative impact on the health of pregnant women and fetuses.26 the disorders experienced by pregnant women are related to the problem of anemia during pregnancy. anemia during pregnancy has an impact on pregnancy, childbirth and the puerperium, namely miscarriage, premature labor, uterine inertia, prolonged labor, uterine atony, shock, afibrinogenemia, intrapartum and postpartum infections, and heart failure.27 anemia experienced by pregnant women will also have a negative impact on the baby, namely the risk of preterm, low birth weight and an increased risk of perinatal death.28 educational interventions can increase family support for maternal behavior in preventing pregnancy anemia such as increasing adherence to taking iron supplements and high intake of foods containing iron.29 through the education provided, there is an increase in family knowledge and insight to try to improve the condition of pregnant women in normal conditions, one of which is by providing knowledge regarding the benefits and impacts of taking iron tablets regularly, how to take them, absorption of iron will be inhibited and absorbed perfectly when together with consuming certain drinks, as well as what foods and drinks can be consumed by pregnant women to increase hemoglobin levels.30,31 conclusions the family empowerment model can improve the health status of pregnant women, especially on hemoglobin levels. after being given the intervention of the family empowerment model, there was an increase in family participation in early detection of highrisk pregnancies so as to prevent pregnancy complications. given that the family empowerment model leads to improved health status, particularly in terms of hemoglobin levels among pregnant women, it suggests that involving families in healthcare decisions can have significant positive outcomes. therefore, healthcare providers and policymakers should consider implementing familycentered interventions to enhance family participation in early detection of high-risk pregnancies. this proactive approach can help prevent pregnancy complications and improve maternal and fetal health outcomes. references 1. holness n. high-risk pregnancy. nurs clin north am 2018;53:241-51. 2. indriyani d, yunitasari e, efendi f, et al. the analysis of maternal characteristics and regulation of antenatal care on pregnancy risk status based on the independent family health evaluation. asia pacific j heal manag 2023;18:1-10. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 582] [healthcare in low-resource settings 2024;12:11987] non -co mmerc ial us e o nly 3. chou jl, pierce kj, pennington lb, et al. social support, family empowerment, substance use, and perceived parenting competency during pregnancy for women with substance use disorders. subst use misuse 2018;53:2250-6. 4. istikhomah h. family centered maternity care (fcmc) sebagai salah satu upaya skrining / deteksi dini resiko tinggi ibu hamil berbasis keluarga di desa danguran. 2018. available from: https://poltekkes-solo.ac.id/cni-content/ u p l o a d s / m o d u l e s / a t t a c h m e n t s / 2 0 2 1 0 5 3 0 0 6 2 5 5 1 family%20centered%20maternity%20care%20( fcmc)%20sebagai%20salah%20satu%20upaya% 20skrining%20_%20deteksi%20dini%20resiko%2 0tinggi%20ibu%20hamil%20berbasis%20keluarga%20di%20desa%20danguran.pdf 5. schmuke ad. factors affecting uncertainty in women with high-risk pregnancies. mcn am j matern nurs 2019;44:31724. 6. ali n, hussain sf, tahir a, et al. perinatal outcome in high risk pregnancies. pakistan j med heal sci 2020;14:1495-97. 7. kurniati a, chen cm, efendi f, et al. suami siaga: male engagement in maternal health in indonesia. health policy plan 2017;32:1203-11. 8. abdollahpour s, ramezani s, khosravi a. perceived social support among family in pregnant women. int j pediatr 2015;3:879-88. 9. alemayehu m, meskele m. health care decision making autonomy of women from rural districts of southern ethiopia: a community based cross-sectional study. int j womens health 2017;9:213-21. 10. kuma mn, tamiru d, belachew t. hemoglobin level and associated factors among pregnant women in rural southwest ethiopia. biomed res int 2021;2021:9922370. 11. alem az, efendi f, mckenna l, et al. prevalence and factors associated with anemia in women of reproductive age across lowand middle-income countries based on national data. sci rep 2023;13:20335. 12. wong-rieger d, rieger fp. health coaching in diabetes : empowering patients to self-manage. can j diabetes 2013;37:41-4. 13. nursalam n, efendi f, tristiana d, et al. family empowerment model based on belief and health related quality of life among housewives with hiv/aids. syst rev pharm 2020;11:246-51. 14. hastuti ap, sukartini t, arief ys, et al. women’s empowerment based on self-regulated learning as mother’s ability to fulfill nutrition in stunted children. med j malaysia 2024;79:28-33. 15. sugiarti; soedirham o, mochny is. upaya pemberdayaan ibu hamil untuk deteksi dini risiko tinggi kehamilan trimester satu. indones j public heal 2012;9:27-36. 16. yani ly, merbawani r, munfadlila aw. empowering health cadres on nutrition education for pregnant women in industrial areas during the pandemic. j ners 2021;16:177-82. 17. mardiyanti i, devy sr, ernawati e. analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy. j ners 2019;14:144-50. 18. abidah n, sumarmi s. a comparison of adherence levels of pregnant women to consuming multiple micronutrient supplements and iron folic acid at mulyorejo public health center, surabaya. amerta nutr 2024;8:17-25. 19. prasetyo b, winardi b, pranadyan r, et al. increasing of early high-risk pregnancy detection with proactive intervention in bangkalan district, madura indonesia. j glob pharma technol 2020;12:26-31. 20. utami s, susilaningrum r, nursalam. the effect of health promotion based on the health promotion model with a peer group approach regarding the utilization of maternal and child health handbook. indian j public heal res dev 2019;10:1987-92. 21. febrianti kd, ayu wc, anidha y, mahmudiono t. effectiveness of nutrition education on knowledge of anemia and hemoglobin level in female adolescents aged 12-19 years: a systematic reviews and meta-analysis. amerta nutr 2023;7:478-86. 22. astuti s. skrening kehamilan sebagai upaya peningkatan kesehatan ibu hamil di desa cipacing kecamatan jatinangor kabupaten sumedang. 2018. available from: https://jurnal.unpad.ac.id/dharmakarya/article/view/18507 23. darmawati d, nizwan-siregar t, kamil h, tahlil t. exploring indonesian mothers’ perspectives on anemia during pregnancy: a qualitative approach. enferm clin 2022;32:s31-7. 24. waryana w, supadi s, haryani w. empowering women’s organizations for anemia prevention and control in trimurti village, srandakan sub-district, bantul, yogyakarta, indonesia. 2016. available from: http://eprints.poltekkesjogja.ac.id/66/ 25. stephen g, mgongo m, hussein hashim t, et al. anaemia in pregnancy: prevalence, risk factors, and adverse perinatal outcomes in northern tanzania. anemia 2018;2018:1846280. 26. puspitasari hzg, armini nka, pradanie r, triharini m. anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study. j ners 2022;17:25-30. 27. klankhajhon s, pansuwan k, klayjan k, et al. perspectives of pregnant women regarding iron deficiency anemia. j ners 2021;16:119-27. 28. triharini m, sulistyono a, adriani m, devy sr. the effect of health promotion intervention on anemia prevention behavior and haemoglobin level in pregnant women: based on health promotion model and self-determination theory. j ners 2019;14:92-100. 29. totade m, gaidhane a, sahu p. interventions in maternal anaemia to reduce maternal mortality rate across india. cureus 2023;15:e46617. 30. mardiyanti i, devy sr, ernawati e. analysis of sociodemographic and information factors on family behaviour in early detection of high-risk pregnancy. j ners 2019;14:16561. 31. mardiyanti i, nursalam, devy sr, ernawati. the independence of pregnant women in early detection of high risk of pregnancy in terms of parity, knowledge and information exposure. j public health africa 201 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11987] [page 583] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11851 examining the relationship between health literacy and quality of life in patients with coronary heart disease: a quantitative study at a cardiology clinic lita lita,1 nadila khairiyah,1 agnita utami,1 silvia nora anggreini,2 faridah mohd. said3 1nursing science study program, universitas hang tuah pekanbaru, pekanbaru, indonesia; 2nursing science study program, institute of health science, pekanbaru medical center, indonesia; 3nursing science study program, lincoln university college, kota bharu, malaysia abstract coronary heart disease (chd) is the leading cause of death worldwide and is rising, annually. improved health outcomes require early treatment and self-monitoring, which need health literacy. this study examined how health literacy affects chd patients’ quality of life (qol) at the hospital’s cardiology clinic. this quantitative, descriptive correlation study was crosssectional. the sample was 164 respondents, sampled consecutively. patients must be willing to participate, diagnosed with chd, and attend cardiology outpatient follow-up appointments. health literacy was measured with the hls-eu-sq10 and qol with the seattle angina questionnaire. this study used chi-square to analyze the relationship between two ordinal scale variables in a contingency table. the average age was 58.07 years, according to research. of the respondents, 59 (36.0%) had graduated high school. health literacy was assessed in three qol domains: physical limitation (p=0.024), angina frequency (p=0.570), and qol (p=0.338). service agencies should be able to use pamphlets to improve health literacy and provide rehabilitation to acute coronary syndrome patients to improve qol. introduction along with the development of the modern world, non-communicable diseases are also increasing. this can be seen in the increase in non-communicable disease deaths due to cardiovascular disease which reached 17.9 million in 2016.1 heart disease is a general term for all diseases involving the heart, cases of heart disease in the world were 550 million people.2 coronary heart disease (chd) occurs due to blockage due to the accumulation of fat in the walls of blood vessels which causes stiffness of blood vessels and abnormal blood flow thereby blocking blood flow to the heart.3-5 the incidence of chd in indonesia was estimated to be 15 out of 1,000 or 1.5% of the population in indonesia who have chd.6 chd in indonesia has resulted in the death of approximately 510,840 people.6 the number of chd patients at the heart polyclinic of arifin achmad hospital, riau province from january to december 2020 was 1708 cases. health literacy is the extent to which individuals can access, and process basic health service information by participating in health-related decisions.7-9 based on research results, functional cardiovascular disease health literacy found that 55.4% of patients understood health information, 53,9% of patients did not understand health information, and 50,5% of patients had information enough to manage health.10 the following are some examples of information about behaviors related to chd: smoking, physical activity, eating habits, response to cardiac symptoms, and medication adherence. some examples of outcomes related to patients with chd include morbidity (e.g., rehospitalization), mortality, and quality of life (qol).11-13 qol is an assessment of one’s position in life, in the context of cultural and environmental values, in relation to individual correspondence: lita lita, nursing science study program, universitas hang tuah pekanbaru, pekanbaru, indonesia. e-mail: lita@htp.ac.id key words: coronary heart disease; health literacy; quality of life. acknowledgments: we would like to acknowledge the mentoring program conducted by the research centre of excellence in advancing community health, surabaya, indonesia. contributions: ll, nk, au, conceptualization, writing – original draft; ll, data curation; ll, au, sna, formal analysis; nk, sna, fms, investigation; ll, nk, au, sna, methodology, validation; ll, sna, visualization; fms, resources, supervision; sna, fms, resources, writing. all the authors reviewed and edited the manuscript and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethical approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing, universitas airlangga, based on ethical certificate 2742-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and nonmaleficence. availability of data and material: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained for anonymized patient information to be published in this article. received: 20 september 2023. accepted: 11 june 2024. early access: 3 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11851 doi:10.4081/hls.2024.11851 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11851] [page 553] non -co mmerc ial us e o nly goals, expectations, norms, and social aspects. it provides a broad and effective understanding of a person’s physical health status, psychological state and beliefs, social relationships, and relationships with the environment.14-17 based on the results of the previous research, the qol of coronary heart patients was found good at 52.9% and bad at 47.1%.18 the qol of coronary heart patients (25.86%) had a good qol, and 43 people (74.14%) had a poor qol.19 low levels of health literacy correlated with heightened levels of anxiety and depression (p<0.0001) and lower assessments of health-related qol (heartqol scores p=0.03).20 statistically significant differences were found in gender, age, smoking history, marital status, education level, household income, and qol among various health literacy groups. low levels of education and household income were predictors of poor health literacy.21 one way to improve good qol is by providing information in the form of education. this study aimed to look at the relationship between health literacy and qol in heart patients. materials and methods study design the type of research used a quantitative with a descriptive correlational design, utilizing a cross-sectional approach. cross-sectional refers to data collected multiple times at unequal intervals.22 population, sample, and sampling the study population consisted of 1708 patients, from which a sample of 164 respondents was selected using consecutive sampling. the criteria for inclusion were patients willing to participate, those suffering from chd, and control patients at the heart polyclinic. variables and instruments the variables in this study are health literacy and qol. the instruments used in this study are the health literacy studyeuropean short questionnaire-10-indonesia (hls-eu-sq10idn), which is the short version of the hls-eu-47q questionnaire, and the qol instrument, which is the seattle angina questionnaire-7 (saq-7). the validity value of the health literacy questionnaire was standardized with a validity value of 0.89, and the qol questionnaire with a validity value of 0.64. in the reliability test of the hls-eu-sq10-dn questionnaire, the reliability result was 0.9. health literacy index values are then categorized as follows: 0-25 = inadequate; >25-33 = problematic; >33-42 = sufficient; >42-50 = excellent. the saq-7 consists of 7 questions designed to assess the health status of patients with coronary artery disease (cad). responses are coded from worst to best status, with scores ranging from 1 to 6 for physical limitation, angina stability, and angina frequency; 1 to 5/6 for treatment satisfaction; and 1 to 5 for qol. each domain score is scaled from 0 to 100, with 0 indicating the worst and 100 the best possible status. the saq is validated, reproducible, and sensitive to clinical changes. additionally, patients’ saq scores are independently predictive of future mortality, hospitalization, and resource utilization.23 the results of the validity test showed that the questionnaire was valid with a result of 0.80 for physical limitations, 0.78 for angina frequency, 0.81 for the qol, and 0.86 for the summary score.23 data analysis the data obtained were analyzed using univariate analysis with the central tendency and frequency distribution, then analyzed by bivariate analysis using the chi-square test. the chi-square test evaluates whether there is a difference between the observed frequencies in the contingency table and the frequencies we would expect if the two variables were independent. this research passed the ethics test of the health research ethics commission at hang tuah university pekanbaru with the number: 237/kepk/stikeshtp/iv/2022. results according to table 1, it was found that 164 respondents studied were on average 58.07 years old. table 2 showed the majority of respondents were male which was 117 respondents (71.3%). the majority were married as many as 160 respondents (97.6%). besides that, many respondents had high school/vocational education levels as many as 59 respondents (36.0%). many respondents were retirees which was 38 respondents (20.1%). there 67.1% of health literacy was in the problematic category. then, the results of the qol obtained 49.4% with physical limitations which were still classified as good, 38.4% frequency of angina every day or week, and 52.5% qol was excellent. the results of the data analysis in table 3 showed health literacy appears to be significantly associated with physical limitation (p=0.024), suggesting that individuals with different levels of health literacy experience varying degrees of physical limitation related to cad. however, there is no significant association between health literacy and angina frequency (p=0.570) or qol (p=0.338). this implies that while health literacy may influence physical limitations, it does not have a significant impact on the frequency of angina symptoms or overall qol among individuals with cad. discussion the findings of this study reveal a significant association between health literacy and physical limitation among individuals with cad. specifically, the analysis demonstrates that individuals with different levels of health literacy exhibit varying degrees of physical limitation related to their condition. this underscores the importance of health literacy in managing and coping with the physical challenges posed by cad. these results align with previ transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 554] [healthcare in low-resource settings 2024;12:11851] table 1. respondent’s central tendency by age. variable n mean sd minimum/maximum range age 164 58.07 11.983 24-82 58 sd, standard deviation. non -co mmerc ial us e o nly ous research that has highlighted low health literacy are more likely to engage in unhealthy behaviors, such as smoking, insufficient physical activity, and being overweight. additionally, these individuals tend to report lower levels of physical and mental health, with large clinically significant effect sizes of 0.56 and 0.78 respectively, even after adjusting for confounding factors.24 furthermore, there exists a negative association between health literacy and qol among patients with acute coronary syndrome (acs). enhanced health literacy among individuals in their eighties, particularly concerning social support for health and the capability to access reliable health information, correlates with better physical and mental well-being following percutaneous coronary intervention.25 health literacy is moderately correlated with qol, but this finding needs to be supported by more evidence.26 health literacy is higher compared to the german national survey based on the same outcome measure.27 individuals with higher levels of health literacy are often better equipped to understand and adhere to treatment regimens, engage in preventive behaviors, and navigate the healthcare system effectively, all of which can contribute to improved physical functioning and reduced limitations in daily activities. contrary to expectations, the study did not find a significant association between health literacy and angina frequency or qol. this suggests that while health literacy influences physical limitations, it does not have a direct impact on the frequency of angina symptoms or overall qol among individuals with cad. other factors, such as disease severity, comorbidities, and social support, may play a more prominent role in determining these outcomes.28 no relationship was found between health literacy and qol (physical and mental components).29 low health literacy in patients with acs is consistently associated with poor qol. after controlling for demographic and clinical factors in patients with acs, the physical qol domain remained a significant result of self-care behavior and health literacy. according to the literature, self-care practices and health literacy should be taken into account when predicting patients with acs qol. however, there is no previous evidence about the best process of the relationship between the three variables.30 health literacy is a determinant of health in cardiovascular disease.31 low health literacy is associated with the development of cardiovascular disease after adjustment for age and sex.32 patients with cvd who have low health literacy have higher mortality, higher rates of readmission to the hospital, and lower qol.33 low health literacy is common in people with cardiovascular disease.34 this condition can occur due to adherence to treatment, and awareness of acs patients to reduce and maintain activities carried out. thus, they do not trigger symptoms. the lack of medication during an attack, in addition to the two factors mentioned above, may cause angina to occur more frequently, which will alter how stable angina is. to keep patients motivated to comply with therapy and foster positive family support, nurses can offer emotional support. a very low frequency of angina was reported by almost all respondents. this research is consistent with a study that found that elderly hypertensive patients have both positive and negative perceptions.35 the more serious and severe the patient’s perception, the greater the need for preventive measures.36 patients change their behavior according to the severity of their disease leading to a positive perception of the disease. hence, according to one of the reasons for positive perceptions as explained by the theory, a good perception will increase a positive subject such as health in healing disease.36 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. respondents' frequency distribution characteristics, health literacy, and quality of life of patients. variable n % sex male 117 71.3 female 47 28.7 marriage status married 160 97.6 single 4 2.4 educational level uneducated 7 4.3 primary school 31 18.9 junior high school 23 14.0 senior high school 59 36.0 university 41 30.4 occupation retired 38 23.2 housemaid 37 22.6 teacher/lecturer 5 3.0 civil servant 13 7.9 unemployment 33 20.1 farmer 11 6.7 entrepreneur 14 8.5 private staff 5 3.0 police 5 3.0 labor 3 1.8 health literacy inadequate 30 18.3 problematic 110 67.1 sufficiency 24 14.6 physical limitation excellent 17 10.4 good 81 49.4 poor to fair 66 40.2 angina frequency daily to weekly 63 38.4 monthly 52 31.7 none 49 29.9 quality of life excellent 86 52.5 good 46 28.0 poor to fair 32 19.5 total 164 100 table3. relationship between health literacy and quality of life of physical activity. variable health literacy p inadequate problematic sufficient physical limitation 0.024 excellent 3 7 7 good 14 57 10 poor to fair 13 46 7 angina frequency 0.570 daily to weekly 15 40 8 monthly 9 36 7 none 6 34 9 quality of life 0.338 excellent 15 55 16 good 8 31 7 poor to fair 7 24 1 total 30 110 24 [healthcare in low-resource settings 2024;12:11851] [page 555] non -co mmerc ial us e o nly conclusions the findings of this study highlight the nuanced relationship between health literacy and various health outcomes among individuals with cad. while a significant association was observed between health literacy and physical limitation, indicating that individuals with different levels of health literacy experience varying degrees of physical limitation, no significant associations were found with angina frequency or qol. these results suggest that while health literacy may play a role in shaping the extent of physical limitations experienced by individuals with cad, it may not directly influence the frequency of angina symptoms or overall qol. other factors, such as disease severity, comorbidities, and access to healthcare resources, may contribute more substantially to these outcomes. references 1. world health organization. global action plan on physical activity 2018-2030: more active people for a healthier world. world health organization; 2019. 2. roth ga, mensah ga, johnson co, et al. global burden of cardiovascular diseases and risk factors, 1990–2019: update from the gbd 2019 study. j am coll cardiol 2020;76:29823021. 3. irianto k. epidemiologi penyakit menular dan tidak menular. kedua. bandung: cv. alfabeta; 2018. 4. haryuni s, wahyuni cu, basuki h, et al. blood glucose and systolic blood pressure as predictors of hospital length of stay in patients with coronary heart disease. j public health africa 2023;14. 5. yusuf alsagaff m, thaha m, aminuddin m, et al. asymmetric dimethylarginine: a novel cardiovascular risk factor in endstage renal disease. j int med res 2012;40:340-9. 6. kemenkes ri. laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2018. riset kesehatan dasar 2018:182-3. 7. magnani jw, mujahid ms, aronow hd, et al. health literacy and cardiovascular disease: fundamental relevance to primary and secondary prevention: a scientific statement from the american heart association. circulation 2018;138:e48-74. 8. osman n, michel c, schimmelmann bg, et al. influence of mental health literacy on help-seeking behaviour for mental health problems in the swiss young adult community: a cohort and longitudinal case–control study. eur arch psychiatry clin neurosci 2023;273:649-62. 9. kalanjati vp, hasanatuludhhiyah n, d’arqom a, et al. health literacy on covid-19 and covid-19 vaccinations in indonesia. f1000res 2022;11. 10. tilahun d, gezahegn a, tegenu k, fenta b. functional health literacy in patients with cardiovascular diseases: cross-sectional study in ethiopia. int j gen med 2021;14:1967-74. 11. ghisi glm, chaves gss, britto rr, oh p. health literacy and coronary artery disease: a systematic review. patient educ couns 2018;101:177-84. 12. lalenoh i, oepangat e, purwowiyoto bs, et al. cardiovascular protection variables based on exercise intensity in stable coronary heart disease patients after coronary stenting: a comparative study. vasc health risk manag 2020;16:257-70. 13. balti dr, andrianto a, dharmadjati bb, asmarani dn. immature platelet level in stable coronary heart disease (chd) patients with diabetes mellitus compared to stable chd patients without diabetes mellitus. in: 2nd international conference on fisheries and marine science, incofims 2019. faculty of medicine, universitas airlangga, surabaya, indonesia: institute of physics publishing; 2020. 14. nurlina. kualitas hidup wanita menopause. bandung jawa barat: cv. media sains indonesia; 2021. 15. wantiyah w, riko saputra m, deviantony f. self-efficacy and health status in coronary artery disease patients. j ners 2020;15. 16. junaid farrukh m, makmor bakry m, hatah e, hui jan t. medication adherence status among patients with neurological conditions and its association with quality of life. saudi pharm j 2021;29:427-33. 17. permarupan py, al mamun a, hayat n, et al. nursing management challenges: effect of quality of work life on depersonalization. int j healthc manag 2021;14:1040-9. 18. amarullah m, rosyid fn. gambaran kualitas hidup pada pasien jantung koroner. in prosiding seminar nasional keperawatan universitas muhammadiyah surakarta; 2021. 19. alfian r, susanto y, khadizah s. kualitas hidup pasien hipertensi dengan penyakit penyerta di poli jantung rsud ratu zalecha martapura. j pharmasci 2017;4. 20. jennings cs, astin f, prescott e, et al. illness perceptions and health literacy are strongly associated with health-related quality of life, anxiety, and depression in patients with coronary heart disease: results from the euroaspire v cross-sectional survey. eur j cardiovasc nurs 2023;22:719-29. 21. jiang s, zhang x, li x, et al. exploring health literacy categories in patients with heart failure: a latent class analysis. j cardiovasc nurs 2023;38:13-22. 22. munhall p. nursing research. jones & bartlett learning; 2012. 23. chan ps, jones pg, arnold sa, spertus ja. development and validation of a short version of the seattle angina questionnaire. circ cardiovasc qual outcomes 2014;7:640-7. 24. zakeri ma, tavan a, nadimi ae, et al. relationship between health literacy, quality of life, and treatment adherence in patients with acute coronary syndrome. heal lit res pract 2023;7:e71-9. 25. brørs g, dalen h, allore h, et al. the association of electronic health literacy with behavioural and psychological coronary artery disease risk factors in patients after percutaneous coronary intervention: a 12-month follow-up study. eur hear j digit heal 2023;4:125-35. 26. zheng m, jin h, shi n, et al. the relationship between health literacy and quality of life: a systematic review and meta-analysis prof holger schunemann. health qual life outcomes 2018;16:1-10. 27. ehmann at, groene o, rieger ma, siegel a. the relationship between health literacy, quality of life, and subjective health: results of a cross-sectional study in a rural region in germany. int j environ res public health 2020;17. 28. mehralian g, yusefi ar, davarani er, et al. examining the relationship between health literacy and quality of life: evidence from older people admitted to the hospital. bmc geriatr 2023;23:1-9. 29. couture ém, chouinard mc, fortin m, hudon c. the relationship between health literacy and quality of life among frequent users of health care services: a cross-sectional study. health qual life outcomes 2017;15:1-7. 30. zaben k, khalil a. health literacy, self-care behavior and quality of life in acute coronary syndrome patients: an integra transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 556] [healthcare in low-resource settings 2024;12:11851] non -co mmerc ial us e o nly tive review. open j nurs 2019;09:383-95. 31. perrin a, abdalla g, viprey m, et al. prevalence of low health literacy levels in decompensated heart failure compared with acute myocardial infarction patients. esc hear fail 2021;8:1446-59. 32. do amaral mg, reijneveld sa, almansa j, et al. do uncontrolled hypertension, diabetes, dyslipidemia, and obesity mediate the relationship between health literacy and chronic kidney disease complications? int j environ res public health 2021;18. 33. kanejima y, shimogai t, kitamura m, et al. impact of health literacy in patients with cardiovascular diseases: a systematic review and meta-analysis. patient educ couns 2022;105:1793800. 34. beauchamp a, talevski j, nicholls sj, et al. health literacy and long-term health outcomes following myocardial infarction: protocol for a multicentre, prospective cohort study (enhearten study). bmj open 2022;12. 35. pratiwi np, untari ek, robiyanto. hubungan persepsi pasien tentang penyakit hipertensi dengan kualits hidup pasien lanjut usia, tekanan darah, dan jenis terapi antihipetensi. j mhs farm fak kedokt untan 2019;4:1-11. 36. nurlaila, ginandjar p, martini. faktor-faktor yang berhubungan dengan kepatuhan pengobatan masal di kelurahan non endemis filariasis kota pekalongan. j kesehat masy 2017;5:2356-3346. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11851] [page 557] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13057 roles and challenges of health cadres in handling stunting: a qualitative study annisa wuri kartika,1 setyoadi,1 yati sri hayati,1 cici indah setiowati2 1department of nursing, faculty of health sciences, universitas brawijaya, malang; 2malang city general hospital, malang, indonesia abstract health cadres are volunteers or healthcare workers in the village who possess knowledge and skills in delivering basic healthcare services to the community. these people have direct access to the community at the grassroots level, playing an essential role in detecting, preventing, and addressing stunting. this study aimed to explore the experience of health cadres to increase understanding of their role in the community to address stunting. this study was carried out using a qualitative method and focus group discussions (fgd), which included 40 participants for data collection. the instrument used was an fgd interview, consisting of questions about stunting, the experience as cadres, and the identification of stunting problems in the village. subsequently, the data obtained were analyzed using the narrative analysis method. the identified themes included role played as cadres and the associated challenges. the roles that were identified included assisting primary health care programs, providing health education to mothers, weighing children, making referrals when there were problems, and helping to collect data needed by primary health care. the challenges observed were community perceptions underestimating the problem of stunting, attitudes of mothers, stigma in society about stunting, and other activities of health cadres. in conclusion, this study shows that the roles of cadres are expected to be an important factor in handling stunting. consequently, providing adequate training and supervision for health cadres is essential to improve their role in the community. introduction stunting is a chronic nutritional problem widely recognized as a major global child health problem. a child is said to be stunted when the height measurement according to age is < -2 standard deviations below the median standard set by who for children under 5 years of age. the world health organization (who) states that stunting becomes a public health problem when the prevalence reaches ≥ 20% of the population.1 based on the united nations report in 2018, the global prevalence of stunting was observed to be 22.2%. in indonesia, the prevalence decreased from 37.2%to 30.8% between 2013 and 2018, along with a significant reduction to 27.67% in 2019 according to the study on the nutritional status of children.2-4 although there is a significant reduction, stunting persists as a major problem due to the higher prevalence of more than 20% set by who. generally, stunting is a condition where children experience stunted physical growth due to chronic malnutrition during the first 1,000 days of life, from pregnancy to the age of 2 years. this condition has serious implications for the physical, cognitive, and social development of children, capable of reducing the productivity and quality of life in adulthood. previous studies have shown that stunting is a risk factor for developing chronic diseases.5-7 this long-term impact shows that the focus of handling stunting is directed towards promotive and preventive strategies including multisector collaboration. factors related to the incidence of stunting in indonesia include individual, family, and community.8,9 regarding individual characteristics, stunting is related to gender, birth weight, morbidity, infection rates, and diet. in the context of family and society, sociodemographic factors, health services, and family knowledge in caring for children influence the incidence of stunting.9-12 lack of maternal knowledge and negative parenting are also associated with a higher risk of overcoming stunting.13 other factors include limited health personnel to deliver health education, leading to low healthcare delivery, particularly in remote areas. to address this challenge, stunting management program with a community empowerment method is required. 15,16 the role of health cadres is crucial, particularly in the sociocultural method to empower the community in addressing stunting. health cadres are volunteers or healthcare workers at the village or neighborhood level, possessing knowledge and skills in delivering basic healthcare services to the community. these people have direct access to the community at the grassroots level, playing significant roles in detecting, preventing, and addressing stunting.15 the roles of health cadres in stunting management are attributed to several factors, including proximity to the community, as majority typically reside in the same region, possessing knowledge of the local needs and customs. this proximity facilitates effective engagement with the community and the provision of appropriate methods. another factor is the effectiveness of early stunting detection through regular child weight measurement at pos pelayanan terpadu (posyandu). health cadres can also educate the community about the importance of balanced nutrition and child care. furthermore, there is provision of nutrition education to pregnant and breastfeeding mothers, as well as information on supplementary feeding for children. health cadres have the potential to be pioneers in the development of healthy community by increasing the awareness of child nutrition and health, thereby contributing to stunting prevention efforts.15-19 in indonesia, the [healthcare in low-resource settings 2024;12(s1):13057] [page 85] significance for public health the study on the role and challenges of health cadres in overcoming stunting in indonesia is essential to increase public awareness. health cadres are part of the community, possessing the ability to initiate positive behavioral changes in the environment. however, the challenge of negative stigma in society is among the main difficulties for cadres in carrying out health education. therefore, this study aimed to increase efforts in improving the training and skills of cadres non -co mmerc ial us e o nly roles of health cadres in maintaining health of children under five have a positive impact on efforts to preserve the quality of life and development. these roles include monitoring growth and development, provision of health education for pregnant and breastfeeding mothers, early detection and health referrals, as well as family health education and community health campaigns.20 however, health cadres often face challenges such as limited resources in terms of personnel, knowledge, and skills, including lack of understanding, hindering the ability to change the wrong perceptions of the community.17,21 this shows the need for adequate support to optimize the roles of health cadres in preventing stunting. therefore, this study aimed to explore the experiences of health cadres in carrying out their roles in stunting management in the community. materials and methods research methods this study used a qualitative method and focus group discussions (fgd) for data collection. qualitative data were collected to explore the experience of health cadres regarding the roles and challenges of handling stunting in the community. fgd was selected to interview several participants systematically and simultaneously due to the strength of convenience, economic advantage, high face validity, and speedy results. sample size and sampling the selection of participants was carried out using a purposive sampling method, a non-random technique that determined specific characteristics. this study included 40 community health cadres of pos pelayanan terpadu (posyandu) from seven districts who had stunting cases. the inclusion criteria of the participants were a minimum experience of 6 months, ability to read and write, previous experience in stunting program, and willingness to participate in study activities to completion. to ensure that key participants represented the village, selections were made from all sub-districts. data collection and analysis the instrument used was fgd interview, consisting of questions about stunting, the experience as cadres, and the identification of stunting problems in the village. participants were divided into four discussion groups, each consisting of 10 people. subsequently, four facilitators who conducted the fgd were public health experts experienced in qualitative study and nurses in primary health care. before the discussion, the study objectives were explained and participants provided their consent. fgd was conducted once, with each discussion lasting for an average of 6090 minutes. all interviews and fgd were digitally recorded and transcribed verbatim while the data obtained were processed as descriptive qualitative for analysis and conclusion. the transcripts were translated from the original indonesian language into english for publication purposes. ethics ethical approval for this study was granted by the health research ethics committee faculty of health sciences universitas brawijaya, number 4735/un10.f17.10/tu/2022. during the study process, the objectives were explained and participants provided written consent. moreover, only the research team engaged in the investigation had access to the data. results and discussion characteristics of participants all participants in this study were female (100%), with an average age of 48.1 years (middle adulthood) (97%). the majority (55%) had a high school degree in education background, while 92% were married. furthermore, 35% of participants had experience as cadres for more than 10 years and 10% had the longest of > 20 years. the data about characteristic participants are presented in table 1. analytical findings the data analysis found three main themes that described the experience of health cadres when dealing with stunting. the identified themes included (1) the reason to become cadres, (2) roles as cadres, and (3) challenges. these themes as described in figure 1 represent roles and challenges when dealing with stunting in the community from the perspective of cadres. theme 1: reason to become a cadre becoming a cadre is a personal initiative motivated by passion, 4th international nursing and health sciences symposium figure 1. diagram of roles and challenges of cadre during dealing with stunting in community [page 86] [healthcare in low-resource settings 2024;12(s1):13057] non -co mmerc ial us e o nly filling free time, volunteering, and a desire to learn. this was mentioned by the following participants: “…the calling of the heart led me to help society… (p1.2)” “…filling the free time because i do not work (p2.3)” “i am doing it voluntarily, i want a better generation understanding regarding nutrition (p1.5)” “i want to learn and increase my knowledge regarding child health (p3.5)” in addition to personal initiative, the willingness to become a cadre is influenced by the feeling of responsibility toward the environment. this phenomenon occurs because cadres feel responsible for resolving problems found in the community. this was mentioned by the following participants: “my heart was moved, my social spirit was touched when i saw the problem in my village (p2.5)” “i have the responsibility for what happened in my community (p3.2)” “….and i feel responsible for educating the public regarding my position (p4.3)” another reason was the obligation to serve as a cadre, often appointed by the chairman due to the lack of volunteers. this was mentioned by one participant : “i was appointed by the chairman of the community association because there was no one else (p1.7)” theme 2: roles as a cadre the roles of cadres include assisting primary health care programs, providing health education to mothers, weighing children making referrals when there are problems, and helping in the collection of data required by the primary health care. this was mentioned by the following participants: “i help with the supplementary feeding program, we invited mothers and gave additional food to their children” (p3.8) these cadres are also tasked with providing education to pregnant and breastfeeding mothers about nutrition and the importance of breastfeeding. “we provide health education to pregnant women about nutrition and breastfeeding (p2.6)” “after every weight measurement, we also provide health information to the family (p1.5)” “when a child is sick or losing weight, we make referral to the primary health care (p2.3)” “we collect data on families in the village (p2.4)” theme 3: challenges while being a cadre the challenges faced as cadres are experiences acquired during the stunting management process. these include community perceptions underestimating the problem of stunting, attitudes of mothers, stigma in society, and other activities of cadres. the challenges faced by cadres also include the community’s perception that the problem of stunting is trivial and unserious. this was mentioned by the following participants: “some people still underestimate stunting. i have tried to invite people but some are unwilling to solve the issue (p.2.4)” “the community feels that stunting is not a problem (p1.2)” “we need a method to increase public awareness regarding stunting (p3.5)” “there is difficulty in weighing children and residents are reluctant to come during the administration of vitamins. therefore, there must be prizes to facilitate the participation of residents (p4.6)” stigma about stunting in the community results in difficulty in initiating change and increasing participation. this was mentioned by the following participants: “if they are told about stunting, the resident will not participate (p1.6)” “people are less open in talking about their problems, but when asked about the cause, they will finally speak (p3.7)” “sometimes there are mothers who refuse to be told that their children are stunted. most the mothers do not want their children to be diagnosed stunted (p2.9)” the attitude of mothers in caring for their children is also a challenge for cadres in solving the problem of stunting in the community. this was mentioned by the following participants: “mothers are impatient when dealing with their fussy children, finally giving snacks to their children (p.1.2)” “the majority of mothers are workers and their children are looked after by grandmothers who often buy snacks for children (p2.4) “mothers do not know about the importance of breastfeeding, as some prefer formula milk (p2.6)” health cadres stated that challenges faced included their engagement with other jobs, leading to suboptimal performance sometimes. this was mentioned by the following participants: “i have another job, which limits frequent participation in the posyandu (p4.2)” based on the results, there are three main themes obtained from the experience of cadres. the identified themes included the reason to become a cadre, role-play, and challenges. the reason for becoming cadres is a significant factor that facilitates the performance of required roles, as personal initiative increases self-confidence and empowerment.22 cadres who carry out their roles voluntarily have a sense of enjoyment, which motivates and improves performance.23,24 internal motivation, including self-actualization, achievement, and responsibility, play a significant role in enhancing self-motivation and facilitating good performance.24 additionally, knowledge and active participation in each stage of community increase self-empowerment.15 efforts to increase the knowledge, skills, and motivation of 4th international nursing and health sciences symposium table 1. characteristics of cadre (n=40). characteristics mean f % gender female 40 100 age (year) middle adulthood (30-60) 38 97 late adulthood (>60) 48.1 2 3 cadre's education primary 8 20 secondary 10 25 higher 22 55 marriage yes 37 92 widow 3 8 experience as a cadre (year) <2 8 20 2≥ s/d ≤ 5 8.9 6 15 5 > s/d ≤ 10 8 20 >10 14 35 >20 4 10 [healthcare in low-resource settings 2024;12(s1):13057] [page 87] non -co mmerc ial us e o nly cadres are the main strategy for capacity optimization. the inclusion of cadres in every stage of implementing community empowerment, increasing knowledge, and external support in the form of financial incentives are efforts to increase cadre motivation.25,26 furthermore, increasing the number of cadres and program funding is essential to strengthen stunting program effectiveness.27,28 the roles of health cadres included evaluation of children’s weight, providing health education to mothers, preventive programs such as offering additional feet, making referrals when there are problems, and administrative tasks by collecting data required for primary health care. other roles that were identified included the provision of information and education along with monitoring, early detection, and appropriate interventions.20 health cadres also play a significant role in helping the community understand the importance of good nutrition, monitoring children’s growth, and providing support in efforts to prevent and treat stunting. through these efforts, health cadres contribute to reducing stunting rates and improving the health of children in indonesia. support from the government and community is essential to increase the knowledge and skills of health cadres to optimize their roles.29-32 the challenges faced by health cadres include the perception of the community that the problem of stunting is trivial and unserious. despite being a significant concern in indonesia, there is still a public perception that underestimates stunting due to negative stigma and low knowledge.33,34 to overcome this challenge, health cadres can facilitate the understanding and provision of information regarding the perceptions of the surrounding community. this information will be useful in identifying the right strategy, providing required efforts to increase awareness, and understanding of stunting. based on community empowerment, stunting management requires active and responsive participation, as wrong perceptions and low knowledge can become obstacles to achieving optimal outcomes. stunting is still observed negatively by the community, leading to a stigma associated with underprivileged families or as “bad luck.” this stigma can make people reluctant to seek help or talk openly about stunting, thereby hindering preventive and management efforts. in this study, some people were found to still reject the term stunting for their children, leading to suboptimal management and prevalence of new cases. furthermore, the lack of family understanding regarding the effect of stunting, including long-term impacts on health, education, and productivity in adulthood, can lead to errors in feeding children and prevent early detection of growth problems. efforts that can be made to increase public understanding about stunting include educational campaigns such as outreach at the community level, providing information through mass media, and using educational materials to aid understanding. health education can be carried out by health cadres to provide information and assist in the early detection of growth problems directly in community forums. meanwhile, the negative stigma towards stunting can be overcome through a culturally sensitive method. the inclusion of the community in discussions and problem-solving also serves as a potential solution to reduce stigma and build collective support for stunting prevention. by increasing awareness about the serious impact of stunting and reducing the negative stigma, the community can mobilize stronger collective efforts to prevent and treat stunting. conclusions in conclusion, this study showed the significant roles of health cadres in overcoming stunting among children in indonesia. according to the sociocultural method, the roles that were identified included the implementation of preventive measures, provision of education, and enhancing community awareness about the importance of proper nutrition. although several challenges were found, specifically regarding negative perception and stigma about stunting, the roles of health cadres in overcoming stunting were found very valuable. with adequate support, continuous training, as well as collaboration with community and religious leaders to increase understanding of stunting through cultural methods, health cadres could possess the potential to reduce stunting rates in indonesia and improve the future quality of life for children. 4th international nursing and health sciences symposium correspondence: : annisa wuri kartika, department of nursing, faculty of health sciences, universitas brawijaya malang, jl puncak dieng, kalisongo, kecamatan dau malang, east java, indonesia. tel. +62341569117. e-mail: annisa_tika@ub.ac.id key words: community empowerment; health cadres; stunting contributions: all authors contributed equally to this study awk and cis conducted this study, ss and ysh served as supervisors and carried out the review. conflict of interest: the authors declare that there is no potential conflict of interest. funding: this study was financially supported by bppm faculty of health science, universitas brawijaya. ethics approval: ethical approval for this study was granted by the health research ethics committee faculty of health sciences universitas brawijaya, number 4735/un10.f17.10/tu/2022. the objectives were explained and participants provided written consent. only the research team engaged in the investigation had access to the data. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgments: the authors are grateful to all participants and ciptomulyo primary health care, faculty of health sciences, universitas brawijaya for the support provided during this study. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13057 doi:10.4081/hls.2024.13057 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. 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of indonesia’s community health volunteers (kader) as maternal health promoters in the community integrated health service (posyandu) following health promotion training. int j community med public health 2018;5:856. 31. sopiatun s, maryati s. the influence of posyandu cadre training on knowledge and attitudes in efforts to prevent stunting in karawang: in gresik, indonesia; 2021. available from: https://www.atlantis-press.com/article/125961881 32. rahmawati nd, dewi sartika ra. cadres’ role in posyandu revitalization as stunting early detection in babakan madang sub-district, bogor district. asean j community engagement 2020;4. 33. setiyowati e. negative stigma in mothers with malnourished children: phenomenological study. j health 2017:8:277. 34. lestari w, kristiana l, paramita a. stunting : studi konstruksi sosial masyarakat perdesaan dan perkotaan terkait gizi dan pola pengasuhan balita di kabupaten jember. aspirasi. 2018;9:17–33. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13057] [page 89] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12087 modifiable risk factors for cardiovascular disease in iraqi kurdistan population: a large epidemiological study nawzad sulaiman murad,1 shawkat salih miro,2 vazheen abdul hameed ismael,3 deldar morad abdulah4 1adult and fundamentals of nursing unit, college of nursing, university of duhok, iraqi kurdistan; 2internal medicine department, college of medicine, university of duhok, iraqi kurdistan; 3duhok cardiac center, azadi teaching hospital, duhok general directorate of health, iraqi kurdistan; 4community and maternity health nursing unit, college of nursing, university of duhok, iraqi abstract cardiovascular diseases (cvds) are considered the leading factor of morbidity and mortality across the world. this study aimed to identify the modifiable risk factors of cvds in the kurdistan region. in this retrospective cross-sectional study, the patients who visited and were diagnosed with any type of cvds and treated in a main private cardiac center in duhok governorate in kurdistan region were included between the years 2018 and 2023. the study found a similar percentage of male and female patients. the percentage of old patients was significantly increased from 18-19 to ≥70. the most preventable modifiable risk factors among cardiac patients were hypertension (86.17%), physical inactivity (60.59%), diabetes (40.15%), and dyslipidemia (56.31%). the less preventable modifiable risk factors were alcohol (4.01%) and cigarette smoking (14.43%). males had a higher prevalence of cigarette smoking (24.63% vs 4.38%; p<0.0001) and female patients had a higher prevalence of hypertension (91.25% vs 81.02%; p<0.000), diabetes (44.43% vs 35.80 %; p=0.0007) and dyslipidemia (59.15% vs 53.43%; p=0.0257). in terms of family history of heart disease, the middle age group had a higher prevalence compared to younger and older age groups. diabetes and cigarette smoking was more prevalent among older age groups, while dyslipidemia was more prevalent among younger and older age groups. alcohol, physical inactivity, and hypertension were similar among age groups. hypertension, diabetes, dyslipidemia, and physical inactivity were the most prevalent risk factors for cvds in this region. the older patients had significantly higher rates of some of these risk factors. introduction cardiovascular diseases (cvds), including conditions such as coronary heart disease and stroke, are widely recognized as the primary cause of illness and death worldwide.1 over the past 30 years, there has been a significant increase in the number of cases of cvds, with the total rising from 271 million in 1990 to 523 million in 2019. similarly, mortality associated with cvds has also increased, with the number of deaths rising from 12.1 million to 18.6 million during the same period. this trend is expected to continue due to the aging population, resulting in an increased burden of cvd-related deaths.2 it is projected that 55 million deaths occurred in the workplace in 2017, and 17.7 million of these deaths were due to cvd.3 it is crucial to collect and record information about the modifiable risk factors associated with cvds on a global and country-specific level. this data serves as a foundation for creating strategies for prevention that are tailored to the global and local contexts. currently, there is limited data on modifiable risk factors in low and middle-income countries. the most comprehensive global estimates of the relationship between risk factors, adult deaths, and cvds are provided by the global burden of disease (gbd) study. keeping this data up-todate is vital for understanding the impact of risk factors on cvds and developing effective preventive measures.1,4 the available crosssectional studies conducted in this region reported that hypertension (55.3%), followed by dyslipidemia (42.7%), type 2 diabetes mellitus (t2dm, 29%), smoking (11%), and ex-smoking (9.3%) are the most prevalent risk factors for coronary artery disease.5,6 these studies have a small size and did not focus on risk factors specifically. therefore, we need large and more robust studies to identify the modifiable risk factors of cvds in this region for preventive purposes. in this regard, we aim to explore the modifiable risk factors of cvds in a large study in iraqi kurdistan. correspondence: deldar morad abdulah, community and maternity health nursing unit, college of nursing, university of duhok, iraqi kurdistan. e-mail: deldarmorad@uod.ac key words: risk factor; modification; prevention; cardiovascular disease. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of duhok general directorate of health approved this study (registered as 08032023-2-24 on 8 march 2023). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: the written consent forms were not applicable in this study because we collected the data of this study from the medical records of the patients. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article (the raw data file was sent to the publisher). the raw data is available through the following link as wel l :h t tps : / /dr ive .google .com/f i le /d /1uysfp3g6jfzufamnf58gkvwzsuhkga0/view?usp=sharing received: 14 november 2023. accepted: 27 november 2023. early access: 19 december 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12087 doi:10.4081/hls.2023.12087 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 258] [healthcare in low-resource settings 2024;12:12087] non -co mmerc ial us e o nly materials and methods study design and sampling in this retrospective cross-sectional study, the patients who visited and were diagnosed with any type of cvds and treated in a main private cardiac center were included. in this regard, we recruited the medical records of the cvds patients who were documented in the center between the years 2018 and 2023. the mentioned cardiac clinic is located inside the shilan private hospital in duhok city. the ethical approval of this study was obtained from the local health ethic committee registered as 08032023-2-24 on 8 march 2023. sampling between 5000 and 5500 patients have visited the cardiac center since 2018. the center has the papers of the medical records of the patients in some cabinets. the medical records have not been documented in a computer data system yet. to obtain a representative and the most practical and suitable sample of the target population, we selected one medical record of fifth papers saved in the cabinets. we selected the sixth paper in the case of having too much missing information in the fifth medical record. this process was continued until all medical records were completed. finally, we included 1497 patients in this study. setting of the study the kurdistan region of iraq is comprised of four governorates, which are officially recognized as erbil, sulaymaniyah, halabja, and duhok (figure 1). the study was conducted among cardiac patients in the duhok governorate. the duhok governorate is in the north part of the kurdistan region and has a border with turkey, syria, and iraq. based on the latest statistics of the kurdistan regional statistics office duhok governorate has 1,557,020 persons.7 inclusion and exclusion criteria we included patients of both genders without applying any restriction of age and other socio-demographic aspects such as religion, residency, etc. the patients who lived in the duhok governorate and visited the center were eligible for this study. however, we excluded the patients with too much missing information and pregnant women to avoid possible bias. measurements the flowing modifiable risk factors were drawn from the medical records of the clinic. the factors were alcohol, hypertension, diabetes, dyslipidemia, cigarette smoking, and physical inactivity. in addition, we included the following non-modifiable risk factors from the medical records of the patients; included past cardiac vascular history and family history of heart disease. we included gender and age groups to explore the risk factors by gender and age groups. we could not include more risk factors since only these factors have been documented in the medical records of the patients. the data were entered into a pre-designed excel sheet between 25 june 2022 and 21 february 2023. statistical methods descriptive statistics were used for determining the prevalence of modifiable risk factors among cvd patients. the risk factors by gender and age groups were examined in pearson chi-squared test. the statistical calculations are performed in jmp pro 14.3.0. results the study found a similar percentage of male (49.63%) and female (50.37%) patients. the most prevalent modifiable risk factors among cardiac patients were hypertension (86.17%), physical inactivity (60.59%), dyslipidemia (56.31%), diabetes (40.15%), and the less prevalent modifiable risk factors were alcohol (4.01%) and cigarette smoking (14.43%). the non-modifiable risk factors were past cardiac vascular history (63.73%) and family history of heart disease (6.15%). the study showed that male and female patients did not have a statistically significant difference in the prevalence of alcohol, family history of heart disease, and physical inactivity. however, male patients had a significantly higher prevalence of cigarette smoking (24.63% vs 4.38%; p<0.0001). female patients had a significantly higher prevalence of hypertension (91.25% vs 81.02%; p<0.000), diabetes (44.43% vs 35.80%; p=0.0007, and dyslipidemia (59.15% vs 53.43%; p=0.0257). in terms of non-modifiable risk factors, the study showed that male patients had a significantly higher prevalence of past cardiac vascular history (74.16% vs 53.45%; p<0.0001). most of the patients had multiple modifiable risk factors (82.43%) followed by mono risk factors (14.56%). we found that a small percentage of patients had only non-modifiable risk factors (3.01%). both male and female patients mostly had multiple risk factors, but the males had significantly higher rates of mono risk factor (16.96%) compared to females (12.20%; p=0.0029; see table 1 and figure 1). article figure 1. map of kurdistan region.7 [healthcare in low-resource settings 2024;12:12087] [page 259] non -co mmerc ial us e o nly the study also found that patients with cardiac disease were more likely to be elderly. the prevalence of alcohol, cigarette smoking, and physical inactivity was not statistically significant among age groups. the modifiable risk factors of diabetes and cigarette smoking were more prevalent among older age groups, while dyslipidemia was more prevalent among younger and older age groups. alcohol, physical inactivity, and hypertension were similar among age groups. the multiple risk factors were increased with increasing age groups in contrast with mono risk factor (p<0.0001). in terms of non-modifiable risk factors, the study found that prevalence of past cardiac vascular history was higher among younger age groups, decreased by 40-49 years old, and increased from 40-49 years to ≥70 years old. in terms of family history of heart disease, the middle age group had a higher prevalence compared to younger and older age groups. (table 2; figure 2). additionally, the study found that the most commonly occurring types of cardiovascular diseases were ischemic heart ailments, hypertension, myocardial infarction, cerebrovascular accidents, heart failure, and angina (as depicted in figures 3 and 4). discussion in this study, we found that the most prevalent modifiable risk factors among cardiac patients were hypertension, diabetes, dyslipidemia, and physical inactivity. article table 1. prevalence of modifiable risk factors among all patients and by gender. risk factors (n=1497) all patients gender no (%) male (743, 49.63%) female (754, 50.37%) p(two-sided) modifiable risk factors hypertension no 207 (13.83) 141 (18.98) 66 (8.75) <0.0001 yes 1290 (86.17) 602 (81.02) 688 (91.25) physical inactivity 0.1086 no 590 (39.41) 308 (41.45) 282 (37.40) yes 907 (60.59) 435 (58.55) 472 (62.60) dyslipidemia 0.0257 no 654 (43.69) 346 (46.57) 308 (40.85) yes 843 (56.31) 397 (53.43) 446 (59.15) diabetes 0.0007 no 896 (59.85) 477 (64.20) 419 (55.57) yes 601 (40.15) 266 (35.80) 335 (44.43) cigarette smoking <0.0001 no 1281 (85.57) 560 (75.37) 721 (95.62) yes 216 (14.43) 183 (24.63) 33 (4.38) alcohol 0.3960 no 1437 (95.99) 710 (95.56) 727 (96.42) yes 60 (4.01) 33 (4.44) 27 (3.58) risk factors 0.0029 mono risk factor 218 (14.56) 126 (16.96) 92 (12.20) multiple risk factors 1234 (82.43) 588 (79.14) 646 (85.68) non modifiable risk factors 45 (3.01) 29 (3.90) 16 (2.12) non-modifiable risk factors <0.0001 past cardiac vascular history no 543 (36.27) 192 (25.84) 351 (46.55) yes 954 (63.73) 551 (74.16) 403 (53.45) family history of heart disease 0.7734 no 1405 (93.85) 696 (93.67) 709 (94.03) yes 92 (6.15) 47 (6.33) 45 (5.97) pearson chi-squared tests were performed for statistical analyses. the bold numbers show the significant differences between male and female cvd patients. figure 2. overall and between gender modifiable risk factors among patients with cvds. [page 260] [healthcare in low-resource settings 2024;12:12087] non -co mmerc ial us e o nly hypertension according to the local health system, hypotension is diagnosed when systolic blood pressure (sbp) is equal to or greater than 130 mmhg, or diastolic blood pressure (dbp) is equal to or greater than 80 mmhg. hypertension, characterized by elevated blood pressure, has been strongly linked to the development of cvd with robust evidence found globally.8,9 the global burden of disease (gbd) study conducted a comprehensive and comparative assessment of the burden of cvds attributable to hypertension from 1990 to 2019. the study reported that the number of deaths and years lived with disability (yld) caused by cvds related to hypertension in young adults were 640,239 and 2,717,474, respectively. these numbers represented a significant increase of 43.0% in deaths and 86.6% in ylds compared to 1990. interestingly, middle-income countries had the highest burden of hypertensionrelated cvds, while high-income countries had the lowest burden.8,9 our study found that hypertension was prevalent in both genders, but the prevalence was higher in females (91.25% vs 81.02%), and the rate of hypertension increased with age. however, in the gbd review, men had higher mortality rates from hypertension-related cvds compared to women. ischemic heart disease (ihd) and stroke were the leading causes of death and years lived with yld burden, respectively, in the gbd review, which is consistent with our findings where ihd was also one of the most common types of cvds. another study on pre-hypertensive patients with 30,258 participants showed that for every 10 mmhg increase in systolic blood pressure, there was a 12% increase in mortality associated with cvds.10 a prospective study conducted among 10,558 persons aged ≥30 years showed that living with blood pressure ≥180/105 mmhg increases the risk of cvd mortality by 37% among men and 18% among women compared to those persons with blood pressure <120/80 mmhg.11 controlling hypertension is the most effective way to prevent cvds development.8,12 a prospective study conducted on 13,383 participants aged 60-80 years who were free from cvd at baseline and had sbp within the range of 110 to <150 mm hg, followed them up for a median of 13.01 years. the study observed 1,727 cases of cvd and 3,742 deaths. the analysis revealed that normalized sbp was associated with a decreased risk of cvd, with a hazard ratio (hr) of 0.81 (95% confidence interval [ci], 0.76-0.87), as well as a decreased risk of all-cause mortality, with an hr of 0.89 (95% ci, 0.85-0.93).13 dyslipidemia according to an updated systematic review, the overall prevalence of hypercholesterolemia, defined as total cholesterol (tc) levels ≥5.1 mmol/l (200 mg/dl), was found to be between 17% to 54.9% in males and 9% to 53.2% in females during the period from 1990 to 2014.14 dyslipidemia is one of the main risk factors for developing cvd worldwide.15 the higher prevalence of dyslipidemia has been shown to associate with the western diet. the western diet is characterized by high consumption of red and processed meat, high-fat milk and dairy products, fried and salty foods, refined grain products, and sugar-laden desserts and soft drinks.16,17 various dietary patterns have been linked to decreased rates of dyslipidemia and cvds. examples of such eating patterns include vegetarian and near-vegetarian diets, mediterranean-style diets, the dietary approaches to stop hypertension (dash) diet, and the prudent heart healthy diet recommended by the american heart association (aha), the adult treatment panel iii (atp iii), and the us departments of agriculture and health and human services (dhhs) in their guidelines for americans 2005. these dietary patterns emphasize whole, plant-based foods and healthy fats, while limiting or avoiding animal products, added sugars, sodium, and saturated fats. along with other healthy lifestyle choices, such as regular physical activity, maintaining a healthy weight, avoiding smoking, and managing stress, these dietary patterns can contribute to a lower risk of dyslipidemia and cvds.18 physical inactivity the world health organization advises individuals to participate in regular physical activity, which can include moderateintensity activity for a minimum of 150 minutes per week or vigorous-intensity activity for at least 75 minutes per week. this recommendation promotes the importance of incorporating physical activity into one’s lifestyle for maintaining overall health and well article figure 3. modifiable risk factors of cvds among patients with different age groups. figure 4. age groups and current diagnoses of patients with cvd. [healthcare in low-resource settings 2024;12:12087] [page 261] non -co mmerc ial us e o nly being.19 physical activity has been shown to associate with a reduction in cvds morbidity and mortality.20 in a retrospective national study carried out in korea involving 131,558 adults, it was observed that an increase of 500 metabolic equivalent task-minutes per week in physical activity was associated with a 14% decrease in the risk of mortality due to cvds. this finding highlights the potential benefits of regular physical activity in reducing the risk of cvd-related mortality.21 a multicentered, randomized, controlled community intervention involving 364 patients in four primary care centers was aimed to evaluate the short and medium-term effects of 9 months of a supervised physical activity program. the study reported that there was a significant difference in physical activity in the intervention community compared to the control community. they reported a significant decline in the sbp, total cholesterol, and ldl-cholesterol even after adjustments for the confounders. the incidence of adverse cardiovascular events was substantially lower (2.5% vs 10.5%) compared to the control community, respectively.22 habitual physical activity has been reported to associate with a lower predicted risk of cvd.23 we suggest that the kurdistan region encourages individuals for physical activity through suitable health promotion programs. a healthy city is an active city.24 smoking cigarette smoking is a global public health issue. the age and gender-adjusted proportion of smoking is 31.2% ([95% ci: 30.9 31.6%] in the middle east countries with a higher rate among men compared to women (48.0% vs 13.8%).25 the global youth tobacco survey conducted in kurdistan region revealed that the overall prevalence of current cigarette smoking among adolescents was 15.3%. specifically, the prevalence was 25.1% among boys and 2.7% among girls. several factors were found to be associated with smoking among adolescents, including parents’ smoking, smoking among closest friends, male gender, having pocket money, and perceptions that boys or girls who smoked were attractive. these findings shed light on the factors that contribute to smoking behavior among adolescents in the kurdistan region.26 smoking is the second main modifiable risk factor for cvd worldwide.27 a prospective study performed on 19,782 men and 21,500 women (40-59 years) showed that current smokers have a significantly higher risk of coronary heart disease incidence: 315% in men and 307% in women, compared to nonsmokers. in addition, the study showed that smoking cessation was associated with a rapid risk reduction of coronary heart disease within 2 years.28 there is strong evidence that a range of pharmacologic and behavioral interventions, both individually and in article [page 262] [healthcare in low-resource settings 2024;12:12087] table 2. prevalence of modifiable risk factors by gender among cardiac patients. risk factors (n= 1497) age groups no (%) p 18-19 20-29 30-39 40-49 50-59 60-69 ≥70 (5, 0.33%) (57, 3.81%) (91, 6.08%) (247, 16.5%) (385, 25.72%) (398, 26.59%) (314, 20.98%) modifiable risk factors hypertension 0.0239 no 0 (0.00) 11 (19.30) 15 (16.48) 35 (14.17) 67 (17.40) 36 (9.05) 43 (13.69) yes 5 (100) 46 (80.70) 76 (83.52) 212 (85.83) 318 (82.60) 362 (90.95) 271 (86.31) physical inactivity 0.3682 no 2 (40.00) 17 (31.48) 37 (41.57) 86 (35.68) 144 (37.89) 168 (43.19) 124 (39.87) yes 3 (60.00) 37 (68.52) 52 (58.43) 155 (64.32) 236 (62.11) 221 (56.81) 187 (60.13) dyslipidemia <0.0001 no 3 (60.00) 31 (54.39) 67 (73.63) 149 (60.32) 173 (44.94) 112 (28.14) 119 (37.90) yes 2 (40.00) 26 (45.61) 24 (26.37) 98 (39.68) 212 (55.06) 286 (71.86) 195 (62.10) diabetes <0.0001 no 4 (80.00) 37 (64.91) 64 (70.33) 174 (70.45) 223 (57.92) 199 (50.00) 195 (62.10) yes 1 (20.00) 20 (35.09) 27 (29.67) 73 (29.55) 162 (42.08) 199 (50.00) 119 (37.90) cigarette smoking 0.1119 no 5 (100) 54 (94.74) 84 (92.31) 205 (83.00) 323 (83.90) 340 (85.43) 270 (85.99) yes 0 (0.00) 3 (5.26) 7 (7.69) 42 (17.00) 62 (16.10) 58 (14.57) 44 (14.01) alcohol 0.8284 no 5 (100) 55 (96.49) 88 (96.70) 240 (97.17) 366 (95.06) 384 (96.48) 299 (95.22) yes 0 (0.00) 2 (3.51) 3 (3.30) 7 (2.83) 19 (4.94) 14 (3.52) 15 (4.78) risk factor categories <0.0001 mono risk factor 0 (0.00) 18 (31.58) 23 (25.27) 49 (19.84) 52 (13.51) 26 (6.53) 50 (15.92) multiple risk factors 5 (100) 37 (64.91) 64 (70.33) 192 (77.73) 315 (81.82) 364 (91.46) 257 (81.85) non-modifiable risk factors0 (0.00) 2 (3.51) 4 (4.40) 6 (2.43) 18 (4.68) 8 (2.01) 7 (2.23) non-modifiable past cardiac vascular <0.0001 no 1 (20.00) 25 (43.86) 45 (49.45) 123 (49.80) 141 (36.62) 135 (33.92) 73 (23.25) yes 4 (80.00) 32 (56.14) 46 (50.55) 124 (50.20) 244 (63.38) 263 (66.08) 241 (76.75) history of heart disease <0.0001 no 5 (100) 53 (92.98) 81 (89.01) 215 (87.04) 368 (95.58) 377 (94.72) 306 (97.45) yes 0 (0.00) 4 (7.02) 10 (10.99) 32 (12.96) 17 (4.42) 21 (5.28) 8 (2.55) non -co mmerc ial us e o nly combination are effective in rising smoking cessation in non-pregnant adults.29 diabetes mellitus the pooled prevalence rate of t2dm is about 14.6% (95% ci: 11.6-17.5) which varied from 2.6% (95% ci: 2.5-2.6) to 21.9 (95% ci: 16.8-17.5) amongst countries. it is estimated that a total of 46 million individuals are now suffering from diabetes in the middle east.30 diabetes is the main significant risk factor for the development of cvd.31 a korean study induced 76,434 from the health screening and promotion center and showed that diabetes is associated with risks of total cvd by 70%, coronary heart disease by 67%, and stroke by 58%.32 it is crucial to focus on cardiovascular threat factors to decrease the illness’s lasting cardiovascular complications. strengths and limitations the main strong point of this study is that we tried to include as much as possible the medical records in this study. but the study was not exempt from the limitations. firstly, the study was performed retrospectively, therefore, we could not include obesity and diet factors in this study. in addition, the data repository of other private clinics was not accessible to the researchers. conclusions this study showed that hypertension, physical inactivity, dyslipidemia, and diabetes were the most prevalent risk factors for cvds in this region. the older patients had significantly higher rates of some of these risk factors. references 1. harikrishnan s, jeemon p, mini g, et al. gbd 2017 causes of death collaborators. global, regional, and national age-sexspecific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the global burden of disease study 2017. 2018. 2. roth ga, mensah ga, johnson co, et al. global burden of cardiovascular diseases and risk factors, 1990–2019: update from the gbd 2019 study. j am coll cardiol 2020;76:29823021. 3. umemura s, arima h, arima s, et al. the japanese society of hypertension guidelines for the management of hypertension (jsh 2019). hypertension res 2019;42:1235-1481. 4. collaborators grf. global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease study 2017. lancet (london, england) 2018;392:1923-94. 5. mohammad am, rashad hh, habeeb qs, et al. demographic, clinical and angiographic profile of coronary artery disease in kurdistan region of iraq. am j cardiovasc dis 2021;11:39. 6. mohammad am, jehangeer hi, shaikhow sk. prevalence and risk factors of premature coronary artery disease in patients undergoing coronary angiography in kurdistan, iraq. bmc cardiovasc dis 2015;15:1-6. 7. kurdistan region statistics office. kurdistan map, http://www.krso.net/default.aspx?page=category&c=kurdista n (2015). 8. fuchs fd and whelton pk. high blood pressure and cardiovascular disease. hypertension 2020;75:285-92. 9. liu j, bu x, wei l, et al. global burden of cardiovascular diseases attributable to hypertension in young adults from 1990 to 2019. j hypertension 2021;39:2488-96. 10. oh hj, lee s, lee e-k, et al. association of blood pressure components with mortality and cardiovascular events in prehypertensive individuals: a nationwide population-based cohort study. ann medicine 2018;50:443-52. 11. lida m, ueda k, okayama a, et al. impact of elevated blood pressure on mortality from all causes, cardiovascular diseases, heart disease and stroke among japanese: 14 year follow-up of randomly selected population from japanese—nippon data 80. j hum hypert 2003;17:851-7. 12. soenarta aa, buranakitjaroen p, chia yc, et al. an overview of hypertension and cardiac involvement in asia: focus on heart failure. j clin hypert 2020;22:423-30. 13. wang a, tian x, zuo y, et al. control of blood pressure and risk of cardiovascular disease and mortality in elderly chinese: a real-world prospective cohort study. hypertension 2022;79:1866-75. 14. aljefree n, ahmed f. prevalence of cardiovascular disease and associated risk factors among adult population in the gulf region: a systematic review. adv public health 2015;2015:123. 15. stein r, ferrari f, scolari f. genetics, dyslipidemia, and cardiovascular disease: new insights. curr cardiol rep 2019;21:1-12. 16. chiuve se, mccullough ml, sacks fm, et al. healthy lifestyle factors in the primary prevention of coronary heart disease among men: benefits among users and nonusers of lipid-lowering and antihypertensive medications. circulation 2006;114:160-7. 17. iestra j, kromhout d, van der schouw y, et al. effect size estimates of lifestyle and dietary changes on all-cause mortality in coronary artery disease patients: a systematic review. circulation 2005;112:924-34. 18. leon as, bronas ug. dyslipidemia and risk of coronary heart disease: role of lifestyle approaches for its management. am j lifestyle med 2009;3:257-73. 19. world health organization. global recommendations on physical activity for health. world health organization, 2010. 20. li j, siegrist j. physical activity and risk of cardiovascular disease—a meta-analysis of prospective cohort studies. int j environ res public health 2012;9:391-407. 21. jeong s-w, kim s-h, kang s-h, et al. mortality reduction with physical activity in patients with and without cardiovascular disease. eur heart j 2019;40:3547-55. 22. arija v, villalobos f, pedret r, et al. effectiveness of a physical activity program on cardiovascular disease risk in adult primary health-care users: the “pas-a-pas” community intervention trial. bmc public health 2017;17:1-11. 23. lin h, sardana m, zhang y, et al. association of habitual physical activity with cardiovascular disease risk. circ res 2020;127:1253-60. 24. edwards p, tsouros ad. a healthy city is an active city: a physical activity planning guide. world health organization. regional office for europe, 2008. 25. khattab a, javaid a, iraqi g, et al. smoking habits in the middle east and north africa: results of the breathe study. respiratory med 2012;106:s16-s24. article [healthcare in low-resource settings 2024;12:12087] [page 263] non -co mmerc ial us e o nly 26. siziya s, muula as, rudatsikira e. correlates of current cigarette smoking among in-school adolescents in the kurdistan region of iraq. conflict health 2007;1:1-7. 27. yusuf s, hawken s, ôunpuu s, et al. effect of potentially modifiable risk factors associated with myocardial infarction in 52 countries (the interheart study): case-control study. lancet 2004;364:937-52. 28. baba s, iso h, mannami t, et al. cigarette smoking and risk of coronary heart disease incidence among middle-aged japanese men and women: the jphc study cohort i. eur j preventive cardiol 2006;13:207-13. 29. patnode cd, henderson jt, coppola el, et al. interventions for tobacco cessation in adults, including pregnant persons: updated evidence report and systematic review for the us preventive services task force. jama 2021;325:280-98. 30. farmanfarma kk, ansari-moghaddam a, zareban i, et al. prevalence of type 2 diabetes in middle–east: systematic review& meta-analysis. primary care diabetes 2020;14:297304. 31. de rosa s, arcidiacono b, chiefari e, et al. type 2 diabetes mellitus and cardiovascular disease: genetic and epigenetic links. front endocrinol 2018;9:2. 32. kim hk, lee jb, kim sh, et al. association of prediabetes, defined by fasting glucose, hba1c only, or combined criteria, with the risk of cardiovascular disease in koreans. j diabetes 2016;8:657-66. article [page 264] [healthcare in low-resource settings 2024;12:12087] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13102 sociodemographic factors influencing beliefs and behaviors in herbal medicine use among postpartum mothers in indonesia irna trisnawati, mamat mamat, ari antini politeknik kesehatan kemenkes bandung, indonesia abstract the incidence of herbal medicine consumption is significant among postpartum mothers. however, its long-term use may pose potential risks. this study aimed to investigate the correlation between sociodemographic factors, beliefs, and behaviors related to the consumption of herbal medicine among postpartum mothers in indonesia. this study employed a cross-sectional correlational design with a sample of 170 postpartum mothers (1-42 days postpartum), determined using g*power version 3.1. purposive sampling was used for participant selection. the variables included sociodemographic factors, beliefs, and behaviors related to herbal medicine consumption. data were analyzed using the kruskal-wallis and mann-whitney tests. the findings revealed that residency (p=0.001), age (p=0.043), education level (p=0.0001), number of children (p=0.0001), pregnancy complications (p=0.006), and labor complications (p=0.027) were significantly correlated with beliefs regarding herbal medicine consumption. meanwhile, age (p=0.039) and number of children (p=0.0001) were significantly correlated with herbal medicine consumption behavior. this study highlights the strong influence of sociodemographic factors on the use of postpartum herbal medicine. while many mothers perceive herbal medicine as beneficial, monitoring its long-term effects and potential risks is essential. future research should focus on ensuring safe use of herbal medicine, integrating traditional and modern healthcare practices, and enhancing education on evidence-based postpartum care. introduction herbal medicines are used in traditional healthcare systems worldwide.1 despite limited scientific evidence regarding their clinical efficacy and safety, herbal remedies are believed to offer various health benefits. however, long-term and excessive use may cause adverse effects and potential interactions with conventional drugs, with severe interactions occurring in approximately 7.1% of cases.2 herbal medicines are derived from various parts of plants, including leaves, stems, flowers, roots, and seeds.3,4 the world health organization (who) estimates that 80% of the global population relies on traditional and complementary medicines for primary healthcare.5 the prevalence of herbal medicine consumption varies across countries, with reported usage rates ranging from 40% to 65% in india and china, and 31% in belgium, 49% in france, and 70% in canada.6 the widespread use of herbal medicine is largely influenced by the perception that it is safe due to its natural origins and long-standing traditional use.7,8 in many cultures, herbal medicine is commonly used during pregnancy, childbirth, and postpartum recovery. research in tanzania found that sociocultural beliefs and practices during the perinatal period remain strong, including the use of herbal concoctions after childbirth, which may increase the risk of postpartum infections.9,10 similarly, in ethiopia, pregnant women frequently consume herbal medicine without prescriptions, citing easy access, affordability, and confidence that their illness is not severe.11 the indonesian government permits the use of herbal medicine, ensuring its safety and quality through monitoring, evaluation, and regulation.12,13 however, prolonged and excessive use may still pose risks, particularly due to potential interactions with pharmaceutical drugs.14,15 some herbal compounds inhibit cytochrome p450 enzymes, leading to unintended pharmacological correspondence: mamat mamat, politeknik kesehatan kemenkes bandung, indonesia. e-mail: mamat.researcher@gmail.com key words: beliefs; behavior; herbal medicine; postpartum; sociodemographic. contributions: it, study conceptualization, methodology, data collection, data analysis, result tabulating, data management, results and discussion; mm, formal analysis, validation, and writing—original draft; aa, review and editing. all authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: this research was approved by the health research ethics commission, politeknik kesehatan kemenkes bandung, indonesia, no. 62/kepk/ec/v/2023. during the research, the researcher paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this research are included in this published article. funding: this research was supported by a research grant from dipa politeknik kesehatan kemenkes bandung, contract no. sp dipa-02412.2.632221/2023/date 10/3/2023. acknowledgments: we are thankful to the director and funding staff of politekkes bandung, who were supported by dipa funding. received: 14 september 2024. accepted: 11 march 2025. early view: 4 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13102 doi:10.4081/hls.2025.13102 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 50] [healthcare in low-resource settings 2025;13(s2):13102] effects.14,15 the lack of comprehensive data on the safety of herbal medicine use during pregnancy and postpartum remains a major concern.16 a study found that 55.7% of women utilized traditional health services during the postpartum period, with 48% consuming pre-packaged herbal remedies and 31.8% preparing their own herbal concoctions. however, improper consumption of certain herbal medicines can be harmful. for example, turmeric consumption during pregnancy may stimulate uterine contractions, potentially leading to miscarriage.17 therefore, consultation with healthcare professionals who are knowledgeable about herbal medicine is essential to prevent adverse effects and ensure appropriate medical interventions when necessary.17 the limited availability of reliable information about herbal medicines further contributes to concerns about their quality and accuracy.18 to enhance consumer safety, it is crucial for regulatory authorities and manufacturers to prioritize quality assurance and proper labeling of herbal products.18 additionally, healthcare providers should routinely document traditional medicine use among pregnant and postpartum women, offering evidence-based guidance to eliminate harmful practices.9,10 sociodemographic factors play a significant role in determining herbal medicine consumption during pregnancy, childbirth, and postpartum. these factors influence women’s decisions and behaviors, including income level, education, cultural beliefs, and healthcare access.19 research suggests that postpartum herbal medicine use is more prevalent among women from lower-income groups, likely due to cultural traditions or financial constraints.20 conversely, educated women tend to use herbal remedies more frequently, possibly because they have greater access to information and healthcare resources.21 other factors influencing herbal medicine consumption include perceived health risks, sources and quality of information, vulnerability to health complications, and trust in alternative medicine.22 some studies indicate that women with positive perceptions of herbal medicine’s safety and effectiveness are more likely to use it, whereas those with negative attitudes tend to avoid it. however, even women with negative attitudes may consume herbal medicine if they lack access to conventional healthcare.21 given the cultural and economic diversity in indonesia, understanding how sociodemographic factors influence herbal medicine consumption is essential for public health interventions. healthcare professionals must advise expectant and postpartum mothers in a way that is culturally sensitive, evidence-based, and safety-focused. based on the issues discussed, this study aimed to determine the correlation between sociodemographic factors and beliefs and behaviors regarding herbal medicine consumption among postpartum mothers in indonesia. meterials and methods research design this study employed a cross-sectional correlational design and involved postpartum mothers across primary healthcare in west java, indonesia. study participant the sample size was calculated using g-power software version 3.1. hypothesis testing used the assumption of tolerance deviation (α)=0.05, impact size = 0.25, and power level = 0.80 (80%). based on these calculations, the sample size was determined to be 170. the sampling was conducted using a purposive sampling technique from march to june 2023. the inclusion criteria in this study were mothers in the postpartum period (1-42 days after delivery), who had a history of consistent consumption of herbal medicines from pregnancy to the postpartum period, were able to read and understand the questionnaire, and were willing to provide informed consent to participate in the study. exclusion criteria in this study were postpartum mothers who used herbal medicine only occasionally or inconsistently during pregnancy and postpartum, had cognitive or mental disorders that may affect understanding of questions in the questionnaire or interview, and used certain medical therapies that interact with herbal medicine and may cause bias in the study. variables the variables used were sociodemographic, including residence, age, occupation, education level, number of children, income, frequency of antenatal care (anc), place of delivery, history of last pregnancy problems, history of previous delivery problems, and postpartum problems. the dependent variables were beliefs and behavior on the consumption of herbal medicines. instrument the instrument used in this study was a questionnaire that included sociodemographic variables and dependent variables related to beliefs and behavior regarding herbal medicine consumption. the sociodemographic variables measured included residence (urban and rural), age group (>35 years, 20-35 years, and <20 years), occupation (laborer/employee and housewife), education level (elementary school, junior high school, senior high school, and university), number of children (≤3 children and >3 children), income (>idr 5,257,834 and <idr 5,257,834, as the regional minimum wage), frequency anc (≥6 visits and <6 visits), place of delivery (at home or at a maternity home/hospital), history of complications during the last pregnancy (yes or no), history of complications during previous births (yes or no), and postpartum complications (yes or no). the dependent variables include beliefs and behavior regarding herbal medicine consumption. the beliefs variable consists of 12 statements, each rated on a 4-point likert scale: not believing, somewhat believing, believing, and strongly believing. these statements assess perceptions of whether herbal medicine can enhance health, prevent issues, cure illnesses, and relieve symptoms related to pregnancy, childbirth, and postpartum conditions. the behavior variable consists of 12 statements, each rated on a 4-point likert scale: never, ever, seldom, and often. these statements describe the frequency of herbal medicine consumption for the same purposes (enhancement, prevention, cure, and symptom relief) during pregnancy, childbirth, and postpartum. data collection data collection was conducted directly with mothers in the postpartum period (1-42 days after delivery). before data collection, the respondents were provided with a clear explanation of the research objectives and procedures. after ensuring their understanding, they were asked to provide informed consent before participating in the study. data analysis all data, including sociodemographic factors, beliefs, and behaviors related to herbal medicine consumption, were analyzed using both univariate and bivariate analyses. sociodemographic characteristics, particularly those analyzed using frequency distribution, were utilized for univariate analysis. in contrast, numerical pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13102] [page 51] data, such as the level of belief and behavior of herbal medicine consumption, were analyzed by central tendency. the bivariate analysis was conducted using mean difference tests in independent groups for categorical data, specifically the kruskal-wallis test statistics and the mann-whitney test with 95% confidence interval (ci) (α=0.05%). ethical clearance this study has received approval from the health research ethics committee of the bandung politeknik kesehatan remakes bandung no. 62/kepk/ec/v/2023. the respondents were provided with a study explanation, signed informed consent, and granted the right to withdraw if any unacceptable aspects were present. results demographic characteristics based on table 1, the majority of respondents lived in urban areas (56.4%), belonged to the age group 20-35 years (96%), worked as housewives (94.7%), had education from elementary school (38.2%), had a number of children ≤3 (71.2%), and had income below the minimum wage (84.4%). regarding the place of delivery, the majority of mothers (94.1%) gave birth in a maternity home or hospital, while only a small proportion (5.9%) delivered at home. for pregnancy complications, 11.8% of mothers reported experiencing complications during their last pregnancy, whereas 88.2% had no such issues. similarly, when examining birth-related complications, 15.5% of mothers experienced problems during delivery, while 84.7% reported no complications. in terms of postpartum complications, 5.9% of mothers experienced health issues following childbirth, whereas 94.1% reported no postpartum complications. table 2 presents the mean scores, ci 95%, and standard deviations (sd) for beliefs and behaviors regarding herbal medicine consumption among 170 postpartum mothers. the findings indicate that postpartum mothers generally have strong beliefs about herbal medicine, but their actual consumption behavior is lower and more varied. the mean score for beliefs about herbal medicine consumption is 57.071 (95% ci: 54.12-60.01, sd=19.42), suggesting that most mothers have a positive perception of herbal medicine and its potential benefits. the relatively moderate standard deviation indicates some variation in responses, but overall, the majority of postpartum mothers believe in herbal medicine. in contrast, the mean score for behavior related to herbal medicine consumption is 40.99 (95% ci: 37.68-44.29, sd=21.82), which is notably lower than the belief score. this suggests that although many mothers believe in the benefits of herbal medicine, their actual consumption is less frequent. the higher standard deviation (21.82) compared to beliefs (19.42) indicates greater variability in consumption behavior, implying that some mothers consume herbal medicine regularly, while others rarely or never use it despite their beliefs. the results in table 3 showed that mothers in rural areas had significantly higher mean ranks for beliefs (103.20, p=0.0001) and behavior (103.61, p=0.0001) compared to mothers in urban areas. it indicates that rural mothers are more likely to believe in and consume herbal medicine than urban mothers. older mothers (>35 years) had higher belief (99.92, p=0.043) and behavior scores (100.82, p=0.039) compared to younger age groups. older mothers tend to have stronger beliefs in and a higher tendency to consume herbal medicine compared to younger mothers. mothers with elementary school education had the highest belief scores (105.76, p=0.0001) compared to those with higher education levels. however, behavior scores were not significantly different across education levels (p=0.142). lower education levels are associated with stronger beliefs in herbal medicine, but actual behavior (consumption) does not significantly differ. mothers with more than 3 children had significantly higher belief scores (120.93, p=0.0001) and behavior scores (110.44, p=0.0001) than those with fewer children. mothers with more children tend to believe in and consume herbal medicine more than those with fewer children. mothers who gave birth at home had higher belief scores (109.40, p=0.111) and higher behavior scores (108.30, p=0.119) than those who delivered in maternity homes/hospitals, but these differences were not statistically significant. place of delivery is not a strong predictor of beliefs or behavior regarding herbal medicine. mothers who experienced pregnancy complications had significantly higher belief scores (113.95, p=0.006) and marginally higher behavior scores (104.95, p=0.052) than those without complications. mothers who experienced birth complications had significantly higher belief pathways of change, part ii table 1. sociodemographic of postpartum mothers (n=170). demographic variables (n=170) frequency percent (%) residence urban 96 56.4 rural 74 43.6 age group >35 years 45 26.5 20-35 years 115 67.6 <20 years 10 5.9 occupation laborer/employee 9 5.3 housewife 161 94.7 education level elementary school 65 38.2 junior high school 58 34.1 senior high school 42 24.7 university 5 2.9 number of children ≤3 children 121 71.2 >3 children 49 28.8 income ≥iap 5.257.834 30 17.6 <idr 5.257.834 140 82.4 frequency of anc ≥6 visits 129 75.9 <6 visits 41 24.1 place of delivery home 10 5.9 maternity home/hospital 160 94.1 history of complications during the last pregnancy yes 20 11.8 no 150 88.2 history of complications during previous delivery yes 26 15.5 no 144 84.7 postpartum complications yes 10 5.9 no 160 94.1 anc, antenatal care. [page 52] [healthcare in low-resource settings 2025;13(s2):13102] scores (104.96, p=0.027) but no significant difference in behavior (p=0.519). mothers who had pregnancy complications are more likely to believe in herbal medicine, but their consumption behavior is only slightly affected. birth complications increase beliefs but do not affect behavior significantly. discussion this study highlights the influence of sociodemographic factors on beliefs and behaviors regarding herbal medicine consumption among postpartum mothers. the key findings indicated that place of residence, age, education level, number of children, history of complications during pregnancy, and complications during previous deliveries were significantly associated with beliefs and consumption of herbal medicine for managing postpartum conditions. the findings reveal a trend where older mothers (above 35 years) are more likely to believe in and consume herbal medicine than younger mothers. this aligns with research in japan, where nearly 90% of respondents with higher education levels reported pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13102] [page 53] table 2. scores of beliefs and behaviors regarding herbal medicine consumption among postpartum mothers. variables (n=170) mean ci 95% sd beliefs about herbal medicine consumption 57.071 min: 54.12 19.42 max: 60.01 behavior related to herbal medicine consumption 40.99 min: 37.68 21.82 max: 44.29 ci, confidence interval; sd, standard deviation. table 3. the correlation between sociodemographic factors and beliefs and behavior regarding herbal medicine consumption in postpartum mothers (n=170). sociodemographic variable belief in herbal medicine behavior consumption of herbal medicine n mean rank sig (p-value) n mean rank sig (p-value) residence urban 96 71.85 0.0001* 96 71.54 0.0001* rural 74 103.20 (α≤0.05) 74 103.61 (α≤0.05) age group >35 years 5 99.92 0.043** 45 100.82 0.039** 20-35 years 115 79.05 (α≤0.05) 115 80.53 (α≤0.05) <20 years 10 94.80 10 73.65 job laborer/employee 9 75.11 0.513* 9 72.72 0.409* housewife 161 86.08 (α<0.05) 161 86.21 (α<0.05) education elementary school 65 105.76 0.0001** 65 96.25 0.142** junior high school 58 75.92 (α≤0.05) 58 79.73 (α≤0.05) senior high school 42 68.82 42 78.37 university 5 73.30 5 72.60 number of children ≤3 children 121 71.15 0.0001* 121 75.40 0.0001* >3 children 49 120.93 (α≤0.05) 49 110.44 (α≤0.05) income idr 5.257.834 30 73.93 0.153* 30 85.25 0.975* <idr 5.257.834 140 87.98 (α≤0.05) 140 85.55 (α≤0.05) frequency of anc ≥6 visits 41 93.78 0.213* 41 82.51 0.645* <6 visits 129 82.87 (α≤0.05) 129 86.45 (α≤0.05) place of delivery home 10 109.40 0.111* 10 108.30 0.119* maternity home/hospital 160 84.01 (α≤0.05) 160 84.08 (α≤0.05) history of complications during the last pregnancy yes 20 113.95 0.006* 20 104.95 0.052* no 150 81.71 (α≤0.05) 150 82.91 (α≤0.05) history of complications during previous delivery yes 26 104.96 0.027* 26 91.06 0.519* no 144 81.99 (α≤0.05) 144 84.50 (α≤0.05) postpartum complications yes 10 103.15 0.239 10 97.30 0.420* no 160 84.76 (α≤0.05) 160 84.76 (α≤0.05) anc, antenatal care; **kruskal-wallis test; *mann-whitney test. using herbal medicine primarily for health maintenance.23 similarly, a study in taiwan found that higher education levels positively correlate with herbal medicine use during the postpartum period, suggesting that educated women are more receptive to integrating traditional and modern medical practices.24 interestingly, this study found that mothers with lower education levels have stronger beliefs in herbal medicine, a trend also observed in systematic reviews, where women with lower education levels were twice as likely to consume herbal medicine for treating conditions like diabetes, constipation, and skin diseases.14,25 this suggests that while education improves knowledge, cultural and familial influences play a stronger role in shaping herbal medicine consumption.26 mothers with larger families (more than three children) were found to have higher beliefs and consumption of herbal medicine. this may be influenced by traditional family structures, where older family members, such as grandmothers or elders, pass down herbal knowledge. in sierra leone, more than one-third of mothers use herbal medicine during breastfeeding, often under the guidance of family traditions.27 similarly, research in myanmar and cambodia highlights that traditional postpartum practices remain common, regardless of urban or rural residency, suggesting that cultural transmission plays a crucial role in the use of herbal medicine.28,29 the study found that rural mothers are more likely to believe in and consume herbal medicine compared to urban mothers. this finding is consistent with research in ethiopia, where rural mothers are three times more likely to use herbal medicine due to ease of access, cultural beliefs, and the perception that certain illnesses do not require modern medical intervention.10 in west java, indonesia, traditional medicine is highly valued, not only for its therapeutic effects but also for dietary and cultural preservation, reinforcing the role of traditional knowledge in shaping herbal medicine consumption.30 mothers who experienced complications during pregnancy or delivery were found to have stronger beliefs in herbal medicine. a similar trend was observed in morocco, where postpartum traditions include herbal medicine use for pain relief and recovery.31 many mothers believe that herbal treatments help ease postpartum pain, support breastfeeding, and improve overall maternal wellbeing.32 studies also indicate that more than 20% of women in japan receive herbal treatments from midwives or traditional practitioners during childbirth,23 demonstrating how herbal medicine is integrated into maternal care. however, despite strong beliefs, actual consumption of herbal medicine does not always increase significantly among women with pregnancy-related complications. studies indicate that mothers with pregnancy complications receive more careful medical monitoring, which may lead them to be more cautious about using herbal medicines.20 this highlights the need for healthcare providers to educate postpartum mothers on safe herbal medicine use. although many postpartum mothers use herbal medicine, some women decrease their consumption during pregnancy and labor due to safety concerns. research from turkey indicates that higher education and income levels influence attitudes toward complementary and alternative medicine, with higher-income mothers demonstrating more selective use.27 similarly, women in taiwan and malaysia with higher education levels tend to integrate herbal medicine cautiously, balancing traditional remedies with modern medical recommendations.20 a key concern is the lack of discussion between patients and healthcare providers. studies show that only 5.3% of women disclose their herbal medicine use to healthcare professionals, raising safety risks due to potential herbal-drug interactions.16 therefore, healthcare providers must actively educate mothers on the benefits and risks of herbal medicine use during the postpartum period. herbal medicine is often used not only for postpartum recovery but also for maternal health benefits, such as increasing breast milk production,20 enhancing maternal well-being,21 preventing postpartum infections and fatigue,33 treating sleep disturbances, anxiety, and pain,27 and regulating blood sugar and cholesterol levels.34 the widespread use of herbal medicine is influenced by regional diversity, cultural traditions, and the availability of local medicinal plants. research in ethiopia found that parity (number of children), residence, and pregnancy-related health experiences significantly affect herbal medicine use.33 similarly, in myanmar, traditional postpartum herbal medicine is deeply rooted in cultural practices, regardless of urban or rural residency.28 further research is needed to understand how medical supervision, cultural beliefs, and access to healthcare interact to shape herbal medicine use in postpartum mothers across different contexts. conclusions beliefs and behaviors regarding herbal medicine consumption for managing pregnancy, childbirth, and postpartum issues are strongly influenced by sociodemographic factors, including place of residence, age, education level, parity, and previous pregnancy or delivery complications. rural mothers, older mothers, those with larger families, and those with pregnancy complications tended to have higher beliefs and consumption of herbal medicine, often driven by cultural traditions, accessibility, and family influence. although herbal medicine remains a widely accepted complementary approach, its long-term effects, safety, and potential interactions with modern medicine require further research. integrating scientific validation with traditional practices can help ensure that herbal medicine is both safe and beneficial for postpartum mothers. references 1. ang km, juhari mrbm, lim wh, et al. new hybridization algorithm of differential evolution and particle swarm optimization for efficient feature selection. in: y. j, t. i, j-.j. l, editors. 27th international conference on artificial life and robotics, icarob 2022. ucsi university, 1, jalan puncak menara gading, ucsi heights, cheras, kuala lumpur, malaysia: alife robotics corporation ltd; 2022. p. 148–52. 2. goldstein lh, elias m, ron-avraham g, et al. consumption of herbal remedies and dietary supplements amongst patients hospitalized in medical wards. br j clin pharmacol 2007;64: 373-80. 3. bent s. herbal medicine in the united states: review of efficacy, safety, and regulation: grand rounds at university of california, san francisco medical center. j gen intern med 2008;23:854-9. 4. wardana ap, aminah ns, kristanti alfinda n, et al. antioxidant, anti-inflammatory, antiviral and anticancer potentials of 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(2003). traditional medicine: report by the secretariat. world health organization. available from: https://iris.who.int/handle/10665/78244 7. bandaranayake wm. quality control, screening, toxicity, and regulation of herbal drugs. mod phytomedicine turn med plants into drugs 2006;25-57. 8. rahem a, athiyah u, setiawan cd, hermansyah a. the risk of combined use of herbal and conventional medicines in diabetic patients. pharm educ 2023;23:185-8. 9. felisian s, mushy se, tarimo eam, kibusi sm. sociocultural practices and beliefs during pregnancy, childbirth, and postpartum among indigenous pastoralist women of reproductive age in manyara, tanzania: a descriptive qualitative study. bmc womens health 2023;23:1-9. 10. girmaw f, sendekie ak, mesfin b, kassaw at. self-medication practices among pregnant women in ethiopia. j pharm policy pract 2023;16:1-10. 11. bashore rl. st john’s wort users reported: a history of exposure to herbal remedies and belief in their safety; depressed mood; and 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factors of traditional medicinal plant use during pregnancy among women receiving antenatal care in east gojjam zone, northwest ethiopia. front public heal 2023;11:1035915. 34. sarecka-hujar b, szulc-musioł b. herbal medicines—are they effective and safe during pregnancy? pharmaceutics 2022;14:1-28. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13102] [page 55] hrev_master healthcare in low-resource settings 2025; volume 13:14019 hiv knowledge level, social support, and risk perception on attitudes toward hiv testing among heterosexuals in indonesia alandia,1 sri yona,2 chiyar edison sunarya2 1faculty of nursing, universitas indonesia, depok, west java; 2department of medical surgical nursing, faculty of nursing, universitas indonesia, depok, west java, indonesia abstract hiv/aids remains a major global health issue, particularly among heterosexual populations. the who and unaids aim to end the epidemic by 2030 through the 95-95-95 strategy. in indonesia, 81% of individuals knew their hiv status, 41% were on treatment, and 19% achieved viral suppression as of 2022. hiv testing is vital for identifying those infected. this research examines the relationships between hiv knowledge, social support, and risk perception with attitudes towards hiv testing among heterosexual individuals in indonesia. using a descriptive analytical design with a cross-sectional approach, 192 respondents from bekasi regional general hospital, class 1 cipinang prison, class ii a cipinang narcotics prison, and siloam mampang hospital were studied. multivariate analysis showed that both knowledge (p=0.006, or=2.205) and social support (p<0.001, or=3.778) significantly influence attitudes towards hiv testing. higher hiv knowledge and social support increase the likelihood of individuals supporting and participating in hiv testing, highlighting the importance of initiatives to improve both areas to encourage testing. introduction hiv/aids has become a global health challenge, with 39 million people infected by the end of 2022, 1.3 million new infections, and 630,000 deaths related to hiv/aids.1 the highest hiv prevalence is recorded in africa, southeast asia, and the americas, while the eastern mediterranean has the lowest prevalence.2 indonesia faces significant challenges in controlling hiv/aids, with an increase in cases among women who are partners of key population groups.3,4 the hiv epidemic has persisted for more than three decades, with the primary mode of transmission being heterosexual risk behaviors.3 in indonesia, 68.1% of hiv cases are found in individuals aged 25-49 years.5 unaids reports that 540,000 people are living with hiv in indonesia, with 26,000 deaths due to aids.6 who and unaids are committed to ending the hiv/aids epidemic by 2030 through the 95-95-95 approach, which aims for 95% of people living with hiv to know their status, 95% to be on arv treatment, and 95% to achieve viral suppression by 2025.2 in indonesia, progress toward the 95-95-95 targets is still lagging, with 81% of individuals aware of their hiv status and 41% receiving arv treatment.7 efforts to increase hiv testing coverage are key to achieving these targets. hiv testing is a critical step in the effort to end the hiv/aids epidemic, as earlier testing can reduce transmission and improve treatment outcomes.8,9 although hiv testing may generate anxiety and stigma, a positive test result enables timely referral for treatment and prevents further virus transmission, while a negative test result encourages individuals to reduce infection risks.10,11 good knowledge of hiv can reduce concerns about stigma related to hiv testing, as lack of knowledge often leads individuals to avoid testing due to fear of social stigma or emotional consequences.12 better knowledge increases risk awareness and moticorrespondence: sri yona, department of medical surgical nursing, faculty of nursing, universitas indonesia, 16424 depok, west java, indonesia. tel.: +6281293912127 e-mail: sriyona@ui.ac.id key words: attitudes toward hiv testing, hiv knowledge, social support, risk perception contributions: aa: contributed to design proposal and did data collection, sy and ces contributed to the study conceptualization and design, analysis and interpretation of the data and writing of the article. sy, ces contributed to the manuscript. all authors have read and approved the submitted manuscript. ethical approval: this study has received institutional review board (irb) approval from the health ethics committee of the faculty of nursing, university of indonesia (ket-194/un2.f12.d1.2.1/ ppm.00.02/2024). availability of data and material: the data presented in this study are available upon request from the corresponding author. conflict of interest: none declared. funding: this research was funded by the indonesian ministry of education, culture, research, and technology in 2024 (nkb830/un2.rst/hkp.05.00/2024) acknowledgments: the authors would like to express their sincere gratitude to bekasi regional general hospital, class 1 cipinang prison, class ii a cipinang narcotics prison, and siloam mampang hospital for their valuable contribution to this research by granting permission to conduct the study within their institutions. special thanks are extended to the respective heads of these facilities for their support and facilitation during the research process. received: 20 may 2025. accepted: 14 october 2025. early access: 25 november 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:14019 doi:10.4081/hls.2025.14019 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:14019] [page 245] vation to undergo testing.13 stigma and discrimination can affect mental health and worsen reluctance to undergo hiv testing.14 perceived risk also plays an important role in decision-making for testing, with higher perceived risks increasing motivation to test.14 social support, including from family and peer groups, is crucial in reducing stigma and supporting the decision to get tested.15,16 knowledge, social support, and risk perception are key factors in enhancing hiv testing and preventing hiv transmission. materials and methods this study employed a descriptive analytical method with a cross-sectional design, focusing on heterosexual individuals from two provinces in indonesia: special capital region of jakarta province and west java. these locations were selected due to their high population density, diverse demographic characteristics, and reported prevalence of hiv cases. both provinces are considered strategic regions for public health interventions, making them suitable for studying factors influencing hiv testing attitudes. the research was conducted at four locations: cipinang class i penitentiary, jakarta class ii a narcotics prison, siloam hospital mampang south jakarta, and bekasi district general hospital (rsud). participants were recruited using a probability sampling technique with simple random sampling, giving all eligible individuals an equal chance to be selected from each study site. the inclusion criteria for participants are being heterosexual, at least 18 years old, and residing in special capital region of jakarta province or west java, while individuals who identify as bisexual will be excluded from the study. the research will take place from august to october 2024. the sample size was determined using the absolute precision method for population proportion estimation, based on hiv testing data in dki jakarta (2022), with a 95% confidence level and 5% margin of error, and an additional 10% added to anticipate non-response. data analysis will be conducted using spss software, and both proportions and bivariate relationships will be determined using chi-square tests and multivariate analysis. potential confounders such as age, gender, education level, and marital status were controlled in the multivariate analysis to ensure the independent effect of each variable on attitudes toward hiv testing. the relationship between hiv knowledge, social support, risk perception, and attitudes toward hiv testing will be expressed as odds ratios (risk factors) and calculated using multivariate logistic regression. the data collection of the respondents’ demographic characteristics consists of a checklist question using a demographic instrument, which includes age, gender, education, marital status, child ownership, employment status, and the province of residence (special capital region of jakarta province and west java). the instruments used include the knowledge questionnaire-18 (hiv-kq-18), perceived social support in hiv (pss-hiv), hiv risk perception questionnaire (hrpq), and hiv-antibody testing attitude scale (htas). in this study, validity and reliability tests were conducted on the questionnaires with 40 respondents from west java and jakarta. non-indonesian questionnaires were translated by a certified translator and validated by experts. the validity test showed all items were valid, except one item in the hiv testing attitude questionnaire (htas), which had an r-value of 0.314. this item was revised based on expert input. the reliability test showed all questionnaires had a cronbach’s alpha value above 0.6, indicating they were valid and reliable for use. to minimize bias, enumerators were trained in standardized data collection procedures, confidentiality, and ethical considerations. the questionnaires were pretested to ensure clarity and consistency across study sites. the data collection for respondents’ demographic characteristics involved a checklist question using a demographic instrument, which includes age, gender, education, marital status, child ownership, employment status, and province of residence (special capital region of jakarta province and west java). results table 1 shows the characteristics of the respondents. most were male (60.4%), with the majority having a high school education (47.9%). most were unmarried (54.7%), and 77.9% had children. most respondents were employed (81.8%), with 56.7% in the formal sector. regarding hiv risk, 67.2% were classified as high risk, with 35.9% having one risk factor and 1% having more than three risk factors. table 2 shows the frequency distribution of respondents based on hiv knowledge, social support, risk perception, and attitudes toward hiv testing. the average hiv knowledge score was moderate, with a median of 10. social support also had a moderate score, with a median of 44. the average risk perception was high (57.74), and 72.9% had a positive attitude toward hiv testing. table 3 presents the analysis of factors affecting attitudes toward hiv testing. the young adult group showed higher support for hiv testing, but no significant difference was found in the odds ratio (or). other factors, like gender, education, and employment, did not show significant results, except for hiv risk status, where high-risk individuals were more likely to support hiv testing (or=0.391, p=0.015). table 4 presents the candidate selection for the study. variables with a p-value < 0.25 were included in the multivariate analysis. these included knowledge, social support, risk perception, age, education, marital status, and hiv high-risk status. variables with p-values > 0.25, like gender and employment, were excluded, though gender was kept for theoretical reasons. table 5 presents the final multivariate analysis. it shows that knowledge and social support significantly affect attitudes toward hiv testing. higher knowledge (or=2.205) and higher social support (or=3.778) were associated with more favorable attitudes toward hiv testing. social support had the strongest influence, with a p-value < 0.001. discussion the analysis results show a significant relationship between knowledge about hiv and attitudes towards hiv testing in heterosexual groups in indonesia. the p value of <0.001 indicates that the relationship between knowledge level and attitudes towards hiv testing is statistically significant. the better a person’s knowledge about hiv, the more likely they are to have a positive attitude towards hiv testing. knowledge plays a crucial role in reducing the stigma associated with hiv testing. individuals with limited understanding of hiv may mistakenly believe that an hiv diagnosis is a death sentence or that they will face severe social stigma if the test results are positive. concerns about the social and emotional consequences of a positive test result often lead individuals to advancing nursing education and practice for future global health [page 246] [healthcare in low-resource settings 2025;13:14019] advancing nursing education and practice for future global health table 1. characteristics of respondents based on age category, gender, education, marital status, child ownership status, employment status, and type of occupation. variable category number % age young adulthood (18-39 years) 155 80.7 middle adulthood (40+ years) 37 19.3 total 192 100 gender male 116 60.4 female 76 39.6 total 192 100 education no schooling 3 1.6 primary school 14 7.3 junior high school 24 12.5 high school 92 47.9 university or higher education 59 30.7 total 192 100 marital status single 105 54.7 married 59 30.7 divorced 28 14.6 total 192 100 child ownership has children 60 77.9 no children 17 22.1 total 77 100 employment unemployed 35 18.2 employed 157 81.8 total 192 100 type of occupation formal employment 89 56.7 informal employment 68 43.3 total 157 100 belongs to high-risk group for hiv? not at risk 63 32.8 at risk 129 67.2 total 192 100 type of high-risk group unprotected sexual intercourse 49 38.0 intravenous drug user (idu) 5 3.9 having more than one sexual partner 14 10.9 excessive alcohol and drug use in the context of sexual behavior 18 14.0 commercial sex worker (csw) 1 0.8 unprotected sexual intercourse and excessive alcohol and drug 7 5.4 use in the context of sexual behavior unprotected sexual intercourse and idu 1 0.8 unprotected sexual intercourse and having more than one sexual partner 23 17.8 having more than one sexual partner and csw 3 2.3 unprotected sexual intercourse, having more than one sexual partner, 7 5.4 and alcohol/drug abuse 4 3.1 unprotected sexual intercourse, idu, and having more than one sexual partner 2 1.6 unprotected sexual intercourse, idu, having more than one sexual partner, 1 0.8 and excessive alcohol/drug use unprotected sexual intercourse, idu, having more than one sexual partner, 1 0.8 excessive alcohol/drug use, and csw total 129 100 table 2. frequency distribution of respondents based on hiv knowledge, social support, risk perception, and attitudes towards hiv testing variable median sd min-maks ci 95% hiv knowledge level 10.00 3.881 0-16 8.73-9.84 social support 44.00 9.668 12-60 40.83-42.47 variable mean sd min-maks ci 95% risk perception 57.74 11.105 26-93 56.16-59.33 variable category number percentage attitudes toward hiv testing unfavorable 52 27.1% favorable 140 72.9% total 192 100% [healthcare in low-resource settings 2025;13:14019] [page 247] advancing nursing education and practice for future global health table 3. analysis of the relationship between potential confounding variables and attitudes towards hiv testing. variable attitudes towards hiv testing p unfavorable favorable total n % n % n % age young adulthood 38 19.8 113 60.9 155 80.7 0.101 middle adulthood 14 7.3 23 12.0 37 19.3 gender male 33 17.2 83 43.2 116 60.4 0.599 female 19 9.9 57 29.7 76 39.6 education low (primary and secondary) 41 21.4 92 47.9 133 69.3 0.080 high 11 5.7 48 25.0 59 30.7 employment status not working 8 4.2 27 14.1 35 18.2 0.534 working 44 22.9 113 58.9 157 81.8 marital status single 26 13.5 79 41.1 105 54.7 0.426 married 26 13.5 61 21.8 87 45.3 having children no 28 14.6 94 49.0 122 63.5 0.089 yes 24 12.5 46 24.0 70 36.5 high-risk group for hiv? not at risk 10 5.2 53 27.6 63 32.8 0.015* at risk 42 21.9 87 45.3 129 67.2 reason for high-risk group 1 reason 30 23.3 57 44.2 87 67.4 0.502 >1 reason 12 9.3 30 23.3.6 34 32.6 table 4. candidate selection results. no variable p description 1. knowledge <0.001 included 2. social support 0.003 included 3. risk perception <0.001 included 4. age 0.043 included 5. gender 0.599* included 6. education 0.083 included 7. employment status 0.535 not included 8. type of work 0.289 not included 9. marital status 0.194 included 10. having children 0.091 included 11. high-risk group for hiv 0.017 included 12. reason for high-risk group 0.479 not included *significant if p< p0.25 table 5. results of the final multivariate modeling. variable b wald p or ci 95% knowledge 0.791 7.610 0.006 2.205 (1.257-3.866) social support 1.329 12.869 <0.001 3.778 (1.719-8.029) constant -0.559 2.425 0.119 0.572 [page 248] [healthcare in low-resource settings 2025;13:14019] avoid hiv testing.17 moreover, inadequate knowledge about hiv transmission, early symptoms, and the long-term impact of the disease may result in the perception that testing is unnecessary.18 this lack of understanding can contribute to the spread of hiv, as individuals may not be aware of the risks they face. low knowledge about hiv transmission often leads individuals to be unaware of their risk status, ultimately affecting their motivation to get tested.19 comprehensive knowledge of hiv, including a correct understanding of transmission and prevention strategies, is critical in preventing hiv transmission.20 a significant association between hiv knowledge and hiv testing behavior among women has also been reported, with women possessing good hiv knowledge being 3.75 times more likely to undergo testing compared to those with lower knowledge levels.21 these findings highlight the essential role of knowledge in encouraging hiv testing uptake. additionally, the analysis demonstrates a significant relationship between risk perception and attitudes towards hiv testing among heterosexual respondents in indonesia (p<0.001). higher levels of perceived risk are associated with a more positive attitude towards hiv testing. risk perception plays a vital role in the acceptance of hiv prevention strategies and is an integral component of the decision-making process for undergoing hiv testing. studies have shown that individuals who perceive themselves to be at high risk for hiv are more likely to engage in preventive behaviors, including hiv testing.14,22 however, a significant gap often exists between risk awareness and action, with many individuals who acknowledge high-risk behaviors still choosing not to undergo testing. for example, although only 3.4% of men and 2.5% of women perceived themselves to be at high risk for hiv, they did not get tested in the past year.23 low risk perception remains a major barrier to hiv testing, even among individuals with adequate knowledge about the disease.23 this phenomenon is frequently driven by misconceptions about risky behaviors or the absence of visible symptoms, leading individuals to underestimate their vulnerability and feel no need for testing.12 therefore, increasing awareness of hiv risk behaviors can encourage individuals to undergo testing and better understand their health status. psychological factors, such as anxiety about potential positive results, also play a role in shaping individual perceptions of hiv risk. uncertainty about the social and emotional impacts of a positive test result can strengthen risk perception.24,25 individuals at high risk, such as drug users or those engaging in unprotected sex with partners of unknown hiv status, are expected to have highrisk perceptions.26 a deeper understanding of behaviors that increase hiv transmission risk has been associated with a greater likelihood of adopting proactive measures, including voluntary hiv testing.27 this study also demonstrated a significant relationship between social support and attitudes towards hiv testing among heterosexual respondents in indonesia. individuals with higher levels of social support were more likely to exhibit supportive attitudes towards hiv testing. conversely, respondents with low social support tended to have negative attitudes. this relationship was statistically significant, with a p value of 0.003. social support provides emotional, practical, and informational assistance needed to overcome the fear and stigma associated with hiv testing.15 it can enhance individuals’ courage to undergo testing, reduce anxiety, and improve their understanding of the importance of hiv testing.28,29 furthermore, higher levels of social support have been associated with increased hiv testing behaviors and intentions. respondents with greater social support were found to be 1.48 times more likely to have ever undergone hiv testing [aor=1.48; p<0.001], and 1.22 times more likely to have been tested in the past six months [aor=1.22; p<0.01].30 additionally, social support was shown to positively influence hiv-related knowledge, further enhancing individuals’ intentions to undergo hiv testing. social support also plays a critical role in addressing the stigma associated with hiv. individuals living with hiv often experience stigma, which can significantly affect their decision to undergo testing. without strong social support, they may fear discrimination and thus avoid seeking testing.13 conversely, strong social support encourages individuals to share experiences and seek information, thereby reducing fear and increasing their confidence in maintaining their health. based on the analysis, it can be concluded that social support plays a significant role in shaping positive attitudes towards hiv testing among heterosexual individuals in indonesia. social support not only provides emotional encouragement but also enhances knowledge and reduces stigma, thereby making individuals more likely to undergo hiv testing. multivariate analysis revealed that both knowledge and social support significantly influenced attitudes towards hiv testing. social support had the greatest impact, with an odds ratio (or of 3.778, while knowledge had an or of 2.205. these findings highlight the importance of both knowledge and social support in encouraging hiv testing. social support, in particular, plays a crucial role in reducing stigma and fear, making it a key factor in promoting hiv testing behavior in indonesia. this study was a cross-sectional design, so the findings are limited to two provinces (dki jakarta and west java). conclusions social support is the most significant factor compared to other variables influencing an individual’s decision to undergo hiv testing. this is because social support provides essential emotional, practical, and informational encouragement in overcoming fear and stigma often associated with hiv testing. research shows that individuals who receive strong social support are more likely to undergo hiv testing, participate in prevention programs, and access hiv-related healthcare services. references 1. delaney kp, johnson cv, bowles ke, dinenno ea. hiv testing strategies for health departments to end the epidemic in the u.s. am j prev med 2022;61:s1–16. 2. world health organization. epidemiological fact sheet: hiv statistics, globally and by who region, 2023. geneva: world health organization; 2023. available from: https://cdn.who.int/media/docs/default-source/hq-hiv-hepatitis-and-stis-library/j0294-who-hiv-epi-factsheet-v7.pdf 3. kementerian kesehatan republik indonesia. laporan tahunan hiv aids 2022. jakarta: kementerian kesehatan ri; 2023. available from: https://hivaids-pimsindonesia.or.id/download/file/laporan_tahunan_hiv_aids_2022 4. kementerian kesehatan republik indonesia. laporan eksekutif perkembangan hiv aids dan penyakit infeksi menular seksual (pims) triwulan ii tahun 2022. jakarta: kementerian kesehatan ri; 2022. available from: https://hivaids-pimsindonesia.or.id/download/file/laporan_triwulan_ii_2022 5. unaids. education and hiv: where we’ve come from and where we need to go; 2014. available from: https://www.unaids. org/en/resources/presscentre/featurestoadvancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:14019] [page 249] ries/2014/april/20140401unesco 6. world health organization. hiv and aids; 2024. available from: https://www.who.int/news-room/fact-sheets/detail/hivaids 7. centers for disease control and prevention. hiv testing and youth; 2024. available from: https://www.cdc.gov/healthyyouth/youth_hiv/hiv-information-and-youth.htm 8. national institutes of health. early hiv diagnosis and treatment important for better long-term health outcomes; 2022. available from: https://www.nih.gov/news-events/newsreleases/early-hiv-diagnosis-treatment-important-better-longterm-health-outcomes 9. mayston r, lazarus a, patel v, et al. pathways to hiv testing and care in goa, india: exploring psychosocial barriers and facilitators using mixed methods. bmc public health 2016;16:3456. 10. zhang l, shah ih, li x, et al. does the use of hiv testing and counseling services influence condom use among low-paid female sex workers in guangxi, china? aids care 2017;29:335–8. 11. yang d, allen j iv, mahumane a, et al. knowledge, stigma, and hiv testing: an analysis of a widespread hiv/aids program. j dev econ 2023;160:102958. 12. irmayati n, yona s, waluyo a. hiv-related stigma, knowledge about hiv, hiv risk behavior, and hiv testing motivation among women in lampung, indonesia. enferm clin 2019;29:546–50. 13. centers for disease control and prevention. hiv stigma and discrimination; 2021. available from: https://www.cdc.gov/hiv/basics/hiv-stigma/index.html 14. maughan-brown b, venkataramani as. accuracy and determinants of perceived hiv risk among young women in south africa. bmc public health 2018;18:1–9. 15. dwiyanti ss, dian j, sari e, prayoga d. peranan dukungan sosial terhadap pemanfaatan layanan vct dengan pendekatan theory of planned behavior (tpb). prev j kesehat masy fkm untad 2022;13:526–37. 16. hidayah m, wulandari rd, laksono ad. the role of peer support in hiv testing among risk groups with social influence and communication competency approaches (study in tulungagung regency, indonesia). medico legal update 2020;20:317–22. 17. katirayi l, tchendjou p, tchounga b, et al. changing attitudes towards hiv testing and treatment among three generations of men in cameroon: a qualitative analysis using the fogg behavior model. bmc public health 2023;23:1–10. 18. terefe b, techane ma, assimamaw nt. comprehensive knowledge, attitudes, behaviors, and associated factors of hiv/aids in gondar city public health facilities among hiv testing and counselling service users, northwest ethiopia, 2022: an ordinal logistic regression analysis. hiv/aids res palliat care 2023;15:713–26. 19. baumgardt m, reis m, freitas d, et al. hiv testing and hiv knowledge among men who have sex with men in natal, northeast brazil. braz j infect dis 2020;23:2-7. 20. estifanos tm, hui c, tesfai aw, et al. predictors of hiv/aids comprehensive knowledge and acceptance attitude towards people living with hiv/aids among unmarried young females in uganda: a cross-sectional study. bmc womens health 2021;21:1-13. 21. irmayati n, yona s, waluyo a, sukmarini l, padang jt. faktor-faktor yang mempengaruhi hiv testing pada perempuan di rsud dr.h.abdul moeloek lampung. universitas indonesia; 2018. available from: https://lib.ui.ac.id/detail?id=20475968&lokasi=lokal. 22. kamire v, magut f, khagayi s, kambona c, muttai h, nganga l, et al. epidemiology hiv risk factors and risk perception among adolescent girls and young women : results from a population-based survey in western kenya, 2018. j acquir immune defic syndr 2022;91:17–25. 23. clifton s, nardone a, field n, et al. hiv testing, risk perception, and behavior in the british population. wolters kluwer health 2016;30:943–51. 24. evangeli m, pady k, wroe al. which psychological factors are related to hiv testing? a quantitative systematic review of global studies. aids behav 2016;20:880–918. 25. worthington c, myers t. factors underlying anxiety in hiv testing: risk perceptions, stigma, and the patient-provider power dynamic. qual health res 2003;13:636–55. 26. worede jb, mekonnen ag, aynalem s, amare ns. risky sexual behavior among people living with hiv/aids in andabet district, ethiopia: using a model of unsafe sexual behavior. front public health 2022;10:1039755. 27. aunon fm, wanje g, richardson ba, et al. randomized controlled trial of a theory-informed mhealth intervention to support art adherence and viral suppression among women with hiv in mombasa, kenya: preliminary efficacy and participantlevel feasibility and acceptability. bmc public health 2023;23:837. 28. armoon b, fleury mj, bayat ah, et al. hiv related stigma associated with social support, alcohol use disorders, depression, anxiety, and suicidal ideation among people living with hiv: a systematic review and meta-analysis. int j ment health syst 2022;16:1–17. 29. cortes a, hunt n, mchale s. development of the scale of perceived social support in hiv (pss-hiv). aids behav 2014;18:2274–84. 30. takada s, weiser sd, kumbakumba e, et al. the dynamic relationship between social support and hiv-related stigma in rural uganda. ann behav med 2014;48:26–37. advancing nursing education and practice for future global health [page 250] [healthcare in low-resource settings 2025;13:14019] hrev_master healthcare in low-resource settings 2024; volume 11966 enhancing the knowledge and skills of health cadres and mothers to prevent developmental disorders through stimulation interventions ningsih jaya, ambo dalle, sri anggriani faculty of nursing, poltekkes kemenkes makassar, indonesia abstract the golden age of toddlerhood is a crucial time for growth and development that requires special attention. failure to support children during this time can cause developmental issues that affect their future growth. this study examined whether toddler growth and development interventions prevent developmental disorders. this pre-experimental study used a one-group pre-test/post-test design. the proportional random sample included 70 participants. the respondents’ age, occupation, education, use of toddler growth and development stimulation interventions, and health cadres’ and mothers’ knowledge and skills were variables. data were analyzed using wilcoxon and mann-whitney. there was a significant increase in health cadres and mothers’ knowledge and skills for promoting toddler growth and preventing developmental disorders (p=0.000<0.05). effective toddler growth and development interventions improve health cadres and mothers’ knowledge and skills, preventing developmental disorders in toddlers. these findings suggest that targeted educational programs for health cadres and mothers may reduce developmental disorders and promote healthier growth trajectories for children. introduction the early years of a child’s life, often referred to as the “golden age,” encompass the first 1000 days until they reach two years old.1 this critical period is crucial for growth and development, necessitating attention from all parties.2 failure to support a child properly during this time can lead to significant developmental issues that impact their future growth and development.3 consequently, it is imperative for parents, caregivers, and healthcare professionals to work collaboratively to ensure the well-being and healthy development of children during these formative years.4 over 200 million children under the age of five worldwide did not meet their developmental potential, with most of these children living in asia and africa.5 national data from the indonesian ministry of health in 2014 indicated that 13-18% of children under five in indonesia experience growth and development disorders. world health organization also reports that 5.25% of preschool-aged children suffer from minor brain dysfunctions, including impaired fine motor development. the survey from basic health research (riskesdas) in 2013 revealed that in indonesia, 12.4% of children experience gross motor disorders, and 9.8% experience fine motor disorders, highlighting that motor development issues remain a significant public health concern.6 monitoring growth and development closely is essential for early detection and minimization of developmental abnormalities, which can otherwise become permanent.7 however, interventions to stimulate toddler growth and development have not been maximally implemented by health workers or mothers. children who do not receive adequate growth and development stimulation are at risk of adverse effects on their future development.1 to prevent developmental disorders in children, it is crucial to implement growth and development stimulation interventions as early as possible.8 parents and health cadres through integrated service posts (posyandu) activities, teachers, and health workers should all be involved. health workers play a key role by providing education, guidance, and monitoring the implementation of correspondence: ningsih jaya, faculty of nursing, poltekkes kemenkes makassar, makassar, indonesia. e-mail: ningsihjaya03@gmail.com key words: knowledge; stimulation; growth and development; intervention; skills. acknowledgments: we would like to acknowledge the contribution of the mentoring program conducted by the research centre of excellence in advancing community health, surabaya, indonesia. contributions: nj, ad, sa, conceptualization, data curation, formal analysis, methodology, investigation, visualization, review and editing; nj, ad, initial writing; sa, early draft. all the authors approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: this research received funding from the dipa poltekkes kemenkes makassar. ethical approval and consent to participate: this research received ethical approval from the ethics commission for health research at the makassar ministry of health based on the ethics certificate no. 0284/0/kepk-ptkms/iii/2023 during the study, researchers paid attention to ethical principles, namely information to consent, and respect for human rights, beneficence, and non-maleficence. availability of data and materials: complete data is included in the analysis and discussion page. consent for publication: written consent has been obtained for anonymized patient information to be published in this article. received: 13 october 2023. accepted: 11 june 2024. early access: 22 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11966 doi:10.4081/hls.2024.11966 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11966] [page 563] non -co mmerc ial us e o nly activities.9 efforts to improve knowledge and skills related to stimulation, intervention, and early detection of child growth and development should target parents, health cadres, and the community. enhancing the capabilities of health cadres ensures they can reach their maximum potential and actively contribute to public health through posyandu activities.10 well-informed cadres can effectively detect early developmental issues and provide necessary interventions. meanwhile, parents, as the closest figures to their children, continuously monitor and stimulate their growth and development.11 this study aimed to improve the knowledge and skills of health cadres and mothers of toddlers regarding the application of growth and development stimulation interventions to prevent developmental disorders in toddlers. materials and methods research design the research was a pre-experimental design, utilizing a onegroup pre-test and post-test design without a control group. the sample consisted of 70 participants selected through proportional random sampling. variables included respondents’ age, occupation, education, and the application of toddler growth and development stimulation interventions, as well as the improvement in knowledge and skills among health cadres and mothers of toddlers. data were analyzed using the wilcoxon and mann-whitney tests. study participants the sample in this study was selected through proportional random sampling, targeting mothers of toddlers and health cadres residing in the research locations who met the inclusion and exclusion criteria. the sample size for mothers of toddlers was taken from 40% of the total population. all cadres present at the research location were included, resulting in a total sample size of 70 respondents. the inclusion criteria for the study were: mothers of toddlers, active health cadres, residing in the study area, willing to participate as respondents, and cooperative. the exclusion criteria were respondents who were not present during the study, and those who did not participate in the stimulation activities for toddler growth and development interventions until completion. variables the independent variable is the application of stimulation interventions for toddler growth and development, while the dependent variable is the increased knowledge and skills of health cadres and mothers of toddlers. the instruments used in this study were developed by the researcher. the primary instrument was a questionnaire sheet designed to collect data from respondents. this questionnaire gathered information on the respondents’ characteristics, including age, education, and occupation. additionally, it measured the respondents’ knowledge about the application of stimulation interventions for toddler growth and development aimed at preventing developmental disorders. complementing the questionnaire, observation sheets were employed to assess the respondents’ ability to perform or demonstrate the stimulation interventions. these observations focused on how well the respondents could implement the growth and development interventions to prevent developmental disorders in toddlers. data analysis the analysis aimed to describe the characteristics of the variables studied. wilcoxon analysis was used to assess the level of knowledge and skills of health cadres before and after the intervention, with a significance level of α=0.05. to compare the average knowledge and skills between health cadres and mothers of toddlers, the mann-whitney test was employed. ethical clearance this research received ethical approval from the health research ethics commission of the makassar ministry of health, as indicated by ethics certificate no. 0284/o/kepkptkms/iii/2023. throughout the study, researchers adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. results based on table 1, the study included participants of various ages and educational backgrounds. the age distribution was as follows: 4.3% of participants were under 20 years old, 21.4% were between 20 and 29 years old, 35.7% were between 30 and 39 years old, 21.4% were between 40 and 49 years old, and 17.1% were between 50 and 59 years old. in terms of education, 7.1% of participants completed elementary school, 22.9% had completed junior high school, and a significant majority of 70.0% had completed senior high school. table 2 presents a comparison of knowledge and skill scores in the cadre group before and after the intervention. the average knowledge score increased from 8.05 before the intervention to 11.30 after the intervention. statistical analysis revealed a p-value of 0.000, which is less than 0.05, indicating a significant difference in knowledge scores before and after the intervention. similarly, the average skill score increased from 4.20 before the intervention to 6.45 after the intervention. the statistical tests also yielded a pvalue of 0.000, which is less than 0.05, signifying a significant difference in skill scores between the preand post-intervention periods. table 3 shows a comparison of knowledge and skill scores in the group of mothers of toddlers before and after the intervention. the average knowledge score increased from 8.80 before the intervention to 11.62 after the intervention. statistical analysis yielded a p-value of 0.000, which is less than 0.05, indicating a significant difference in knowledge scores before and after the intervention. in terms of skill scores, the average increased from 4.38 before the intervention to 6.58 after the intervention. the transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of respondents (n=70). characteristics n % age <20 years 3 4.3 20-29 years 15 21.4 30-39 years 25 35.7 40-49 years 15 21.4 50-59 years 12 17.1 education elementary school 5 7.1 junior high school 16 22.9 senior high school 49 70.0 [page 564] [healthcare in low-resource settings 2024;12:11966] non -co mmerc ial us e o nly statistical tests also resulted in a p-value of 0.000, which is less than 0.05, signifying a significant difference in skill scores between the preand post-intervention periods. table 4 presents the comparison of knowledge and skill delta scores between cadres and mothers of toddlers. in terms of knowledge, the delta score, or the change in knowledge, was 3.25 for cadres and 2.82 for mothers of toddlers. statistical analysis yielded a p-value of 0.636, which is greater than 0.05. this indicates that there is no significant difference in delta scores (changes between before and after) in knowledge between cadres and mothers of toddlers. similarly, for skills, the delta score was 2.25 for cadres and 2.20 for mothers of toddlers. the statistical tests resulted in a p-value of 0.705, which is also greater than 0.05. this implies that there is no significant difference in delta scores (changes between before and after) in skills between cadres and mothers of toddlers. discussion to form one’s perspective, knowledge is a very important basis for a person. it is known that knowledge is the result of knowing someone who is understood through the five senses and knowledge can be influenced by age, interests, education, work, and experience obtained by someone from various sources.12 based on the results of the research that has been conducted, it was obtained that from 70 respondents, both cadres and mothers of toddlers had less knowledge about stimulation of toddler growth and development interventions, and after being given the application of stimulation of toddler growth and development interventions in the prevention of developmental disorders. the same thing was done before that there is an influence of growth and development stimulation education on the ability to detect early growth and development of children aged 0-5 years by parents.13 providing education on child growth and development stimulation can improve parents’ ability to provide early growth and development stimulation which will have a positive impact such as increasing children’s language and memory development.14 the application of stimulation provided is to stimulate the basic abilities of children to grow and develop optimally so that they have development that is appropriate for their age.15 the results of previous research that provide education on the stimulation of toddler growth and development given to mothers can increase knowledge in the stimulation of toddlers.16 in addition to using various methods by looking at the characteristics of respondents in terms of age, it can be said that the age of dominant respondents is between the ages of 30-39 years whereas the age is in adulthood, which is the age when someone is still able to work and produce something, according to candrawati et al.,17 that age affects a person’s level of knowledge. the increasing age of a person causes mental psychological changes, while according to resti et al.,18 age affects a person’s comprehension and mindset, transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11966] [page 565] table 2. knowledge and skill score comparison between before and after intervention in cadre groups. cadre knowledge p skill p pre post pre post mean 8.05 11.30 0.000* 4.20 6.45 0.000** sd 1.57 1.53 0.62 0.69 median 8.00 11.00 4.00 6.00 minimum 5.00 9.00 3.00 5.00 maximum 11.00 15.00 5.00 8.00 sd, standard deviation. table 3. comparison of knowledge and skill scores before and after intervention in the mother-toddler group. mother of toddler knowledge p skill p pre post pre post mean 8.80 11.62 0.000 4.38 6.58 0.000 sd 1.71 1.61 0.81 0.73 median 9.00 12.00 4.00 7.00 minimum 5.00 8.00 3.00 5.00 maximum 12.00 15.00 6.00 8.00 sd, standard deviation. table 4. knowledge and skill delta score between cadres and toddler mothers. group delta (pre-post) p* mean sd median minimum maximum knowledge cadre 3.25 2.05 2.00 1.00 8.00 0.636 mother of toddler 2.82 1.38 2.00 1.00 7.00 skill cadre 2.25 0.64 2.00 1.00 3.00 0.705 mother of toddler 2.20 0.57 2.00 1.00 3.00 sd, standard deviation. *mann whitney test. non -co mmerc ial us e o nly the more mature a person is, the more developed one’s grasp and mindset will be, so that the knowledge gained will be better, as well as according to fera et al.19 in research activities carried out in addition to the age factor respondents who are of productive age, are very active in participating in activities that are done so that can increase knowledge.20 similarly, educational factors can significantly affect a person’s mindset. the results of the research showed that most respondents have a high school education. it is noted that knowledge is greatly influenced by educational factors – the higher the education, the better the knowledge a person is likely to have.20 however, this does not mean that someone with less formal education will necessarily lack knowledge, as knowledge can also be acquired through non-formal education.21 with the knowledge possessed by respondents both formally and informally as has been done through research, it will be very useful in guiding and monitoring children’s growth and development and providing stimulation effectively in the hope that children can grow and develop without experiencing developmental disorders.22,23 health cadres who have been trained in applying stimulation interventions have gained knowledge that can be utilized in posyandu activities. developing the abilities of these cadres is essential, especially in the field of maternal and child health, to ensure that toddler growth and development interventions are properly implemented. this allows for effective monitoring of toddlers in the primary health care area and early intervention if problems arise. these findings align with previous research by umam et al., which showed that cadres’ knowledge and skills improved significantly after training on stimulation interventions.24 actions performed by individuals are often based on their knowledge, making it crucial for an effective implementation of stimulation activities.17 the more frequently respondents apply stimulation techniques to their children, the better the developmental outcomes, as frequent stimulation aligns development with the child’s age. the results are also consistent with research by kurniasih et al., which found that knowledge is the most dominant factor affecting cadres’ skills in early detection of child growth and development.25 cadres with good knowledge are 13.9 times more likely to have better skills than those with less knowledge. therefore, it is essential for mothers of young children to engage in stimulation interventions to ensure optimal growth and development, preventing delays or developmental issues. the researchers conclude that applying stimulation interventions for toddler growth and development effectively enhances the knowledge and skills of health cadres and mothers, positively impacting children’s developmental phases and promoting optimal health. conclusions the application of stimulation interventions for toddler growth and development to cadres and mothers has been proven to significantly increase their knowledge and skills in preventing child developmental disorders. this comprehensive approach ensures that both health cadres and mothers are better equipped to recognize and address early signs of developmental issues. by enhancing their understanding and practical abilities, these interventions empower them to provide more effective support and stimulation to toddlers, promoting optimal growth and development. overall, the study confirms that the targeted application of stimulation interventions is an effective strategy for enhancing the capabilities of both cadres and mothers, ultimately contributing to the prevention of developmental disorders and fostering healthier developmental trajectories for children. references 1. nindyaningrum sf, muniroh l, rifqi ma. relationship of three basic needs by mother with growth and development of children age 3-5 years in mulyorejo, surabaya. indones j public heal 2023;18:93-105. 2. ani a, rachmawati pd, efendi f, et al. the differences in the stimulation and personal social development of school-aged children between children who raised by their grandparents and parents respectively. j glob pharma technol 2020;12:14250. 3. dewi rk, sumarni s. parenting style and family empowerment for children’s growth and development: a systematic review. j public health africa 2023;14. 4. has emm, prahasiwi df, wahyuni sd, et al. mothers’ behaviour regarding school-aged children’s nutrition: in indonesia. indian j public heal res dev 2018;9:317-22. 5. engle pl, black mm, behrman jr, et al. strategies to avoid the loss of developmental potential in more than 200 million children in the developing world. lancet 2007;369:229-42. 6. ministry of health r of i. basic health research. natl inst heal res dev repub indones 2013;1-384. 7. widarto das, sugiharto s, supriyadi s. pengaruh pembelajaran play & games dengan mendengarkan musik terhadap perkembangan keterampilan gerak dasar motorik anak. j pendidik teor penelitian dan pengemb 2021;6:779. 8. smythe t, zuurmond m, tann cj, et al. early intervention for children with developmental disabilities in low and middleincome countries the case for action. int health 2021;13:222-31. 9. putri nk, ridlo ia. how do health worker qualities affect collaborative skills? a qualitative study in rural indonesia primary health services. educ med j 2024;16:23-46. 10. kemenkes ri. profil kesehatan indonesia 2021. pusdatin kemenkes go id 2022. kementrian kesehatan republik indonesia. 11. wirjatmadi b, adriani m, devy sr. the effect of psycososial stimulation assistance, child feeding and children health care to growth, motor development and the decrease frequency of upper respiratory tract infections for stunting children 2-3 years of age. indian j public heal res dev 2019;10:1081-6. 12. krisnana i, rachmawati pd, karimah as, et al. knowledge and action related to stimulation development of stunted children. j pak med assoc 2023;73:s59-62. 13. alfianty u, sulistiyawati, kumalawati santoso n. pengaruh pemberian edukasi tentang stimulasi tumbuh kembang balita terhadap pengetahuan ibu di community feeding center di wilayah kerja puskesmas sedayu 2014;19:494-502. 14. tarnoto n, tentama f, pranungsari d. intervention model of children growth and development to improve stimulation skills of parents with early child. adv soc sci educ humanit res 2018;133:218-22. 15. fitriyah l, islamiyah n, fatahillah a. parents’ knowledge and commitment to stimulate child development. j ilmu kesehat dan hum 2021;2:158-66. 16. ultiyas alfianty. pengaruh pemberian edukasi tentang stimulasi tumbuh kembang balita terhadap pengetahuan ibu transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 566] [healthcare in low-resource settings 2024;12:11966] non -co mmerc ial us e o nly di community feeding center di wilayah kerja puskesmas sedayu ii. universitas alma ata yogyakarta; 2017. 17. candrawati rd, wiguna pk, malik mf. promosi dan perilaku kesehatan. eureka media aksara 2023:1-43. 18. resti he, indriati g, arneliwati a. gambaran penanganan pertama kejang demam yang dilakukan ibu pada balita. j ners indones 2020;10. 19. fera t, marhaeni h. profil pengetahuan dan sikap ibu terhadap penatalaksanaan awal diare pencegahan dehidrasi balita di puskesmas gambesi di kota ternate 2020;2:83-92. 20. nurjanah s, anggraini fd, solehah u, et al. effect of stimulation using flashcard media on language and speech development in pre-school age children (3-5 years). bali med j 2023;12:2882-5. 21. fitrah ne, neherta m, ira mulya s. analisis faktor-faktor yang berhubungan dengan kejadian diare pada anak balita. j ilm permas j ilm stikes kendal 2024;14:75-82. 22. khamenkan k, homchampa p. family skill development for attention deficit hyperactivity disorder behavior problem alleviation model in at-risk preschool children: a mixed methods study. j ners 2024;19:55-68. 23. saputo h, fazrin i, yalestyarini ea. the correlation between stimulation, nutritional status and child development. j ners 2020;15:96-100. 24. umam k, cahyo r, ridha aa. effectiveness of training on constructivism learning methods to improve teaching skills self help material for early childhood education teachers. int j indian psychol 2019;7:667-79. 25. kurniasih a, widyawati w, akhmadi a, haryanti f. cadre knowledge and self-efficacy following care for child development post intervention: a four-year prospective follow-up study. jurnal keperawatan glob 2023;78-88. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11966] [page 567] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13001 the effectiveness of the family-centered empowerment model towards the quality of life of older adults with hypertension iskim luthfa,1,2 ah yusuf,1 rizki fitryasari,1 nopi nur khasanah2 1faculty of nursing, airlangga university, surabaya; 2faculty of nursing, islam sultan agung university, semarang, indonesia abstract older adults with hypertension often experience a low quality of life. family support plays a critical role in maintaining and improving their well-being. this study aimed to analyze the effectiveness of a family-centered empowerment model on the quality of life of hypertensive patients. this quasi-experimental study included 70 participants with hypertension, who were divided into an intervention group and a control group. participants were selected through a consecutive sampling technique. the study utilized the family empowerment instrument and the european quality of life questionnaire (eq-5d-5l) for data collection. the data analysis was performed using levene’s, wilcoxon signed rank, and mann-whitney u tests. there were no significant differences in the participants’ characteristics between the control and intervention groups (levene’s test p>0.05). after the familycentered empowerment intervention, the quality of life in the intervention group was significantly higher than that of the control group (mann-whitney u test p=0.000<0.05). this suggests that nurses can effectively involve patients with chronic diseases, particularly hypertension, and their families in the treatment process to enhance their quality of life. introduction health problems worldwide are shifting from infectious to chronic diseases, such as hypertension.1 the world health organisation’s (who) data for 2023 showed that 33% of the world’s population suffers from hypertension, and two-thirds of them are in poor and developing countries.2 the number of hypertensive patients worldwide is predicted to continue to increase and is estimated to reach 1.5 billion people by 2025. hypertension also has the potential to increase the risk of heart disease by 50% and stroke by 75%, and it is estimated that up to 10.44 million people with hypertension die each year due to complications.3 meanwhile, the indonesian health survey in 2023 reported that 9.4% or around 63 million people of the indonesian population are suffering from hypertension, with a death rate of 427,218 people. according to data from the social security administrator for health (bpjs kesehatan) of indonesia, the indonesian state health funding for hypertension has increased yearly from 2.8 trillion rupiahs in 2016 to 3 trillion rupiahs in 2017 and 2018 and 22.8 trillion rupiah in 2023.4 hypertension is called the silent killer because its complications can cause life-threatening diseases, such as myocardial infarction, stroke, heart failure, atrial fibrillation, aortic rupture, peripheral arterial disease, and cognitive problems.5 the incidence of chronic diseases among older adults can have a major impact on their quality of life, including their physical, psychological, social, and economic dimensions.6 hypertension complications can be prevented through early detection by health services and controlled with lifestyle modifications, such as limiting sodium in food, maintaining body weight, increasing activity and exercise, eating fruits and vegetables, not smoking, reducing alcohol consumption, and adhering to the prescribed treatment regimen.7 furthermore, hypertension is a prevalent chronic condition among older adults that significantly impacts their quality of life.8 evidence from studies conducted in china and indonesia indicates that older adults with hypertension experience diminished quality of life, which adversely affects their life expectancy, increases the risk of mortality, depression, and social isolation, impairs daily functioning, and escalates economic burden.9,10 a primary objective of the health care system is to enhance the quality of life for patients, especially those managing chronic conditions like hypertension. therefore, various interventions have been developed to address this issue, including health education,11 health empowercorrespondence: nopi nur khasanah, faculty of nursing, universitas islam sultan agung, semarang, indonesia. tel.: +6285640256378. e-mail: nopi.khasanah@unissula.ac.id key words: aged; family; hypertension; nursing care; quality of life. conflict of interest: the authors declare that they have no competing interests. ethics approval and consent to participate: this research was approved by the health research ethics committee of nursing faculty at sultan agung islamic university (unissula) semarang, indonesia, with the number 1112/a.1-kepk/ fik -sa/x/2022. consent for publication: written informed consent was obtained from all participants. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the researchers would like to thank all the respondents’ families for supporting this study and the older adults who participated. received: 2 september 2024. accepted: 10 november 2024. early access: 10 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13001 doi:10.4081/hls.2024.13001 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 36] [healthcare in low-resource settings 2025;13:13001] ment models,12 integrated health service delivery,13 and the health belief model for medication adherence.14 however, many of these interventions primarily target individuals who are already diagnosed with hypertension, often neglecting preventive measures involving family members. many community health centers in indonesia report a high incidence of hypertension and inadequate health service facilities. therefore, a family-centered empowerment model is a vital approach to solving this issue from a nursing perspective.15 family-centred empowerment reflects the professional interactions between health practitioners, older adults, and their families so that family members can better manage the chronic diseases experienced by the older adults in their families.16 the family empowerment model has an important role in improving the quality of life of older adult patients with hypertension by considering their needs, improving their hypertension management skills, and improving their ability to do independent care to minimize their dependency on hospital care.17 based on previous research, family empowerment can be conducted through four stages: perceiving the threats, self-efficacy, self-confidence, and evaluation.18 previous research conducted in iran showed that a family-centered empowerment model could increase self-efficacy and reduce stress among coronary syndrome patients.19 family-centered empowerment is important in nursing care because of its innovative approach toward reciprocal and mutually beneficial relationships between older adults, families, and nurses.20,21 the significant relationship between family support and the health status of older adults shows the crucial role of family empowerment in controlling and preventing diseases in older adults.22,23 based on this background information, the researchers examined the effect of the family-centered empowerment model on the quality of life of older adult patients with hypertension. materials and methods ethical consideration this research was approved by the health research ethics committee of nursing faculty at sultan agung islamic university (unissula) semarang, indonesia, with the number 1112/a.1kepk/ fik -sa/x/2022. study design and setting this is a quasi-experimental study with a control group design. the study was conducted at the bangetayu community health centre, central java province, indonesia, from february to april 2023. sample size and sampling technique the population in this study were older adult patients with hypertension who received treatment at the bangetayu health centre, central java province, indonesia, in 2022, totaling 11,855 patients. based on a study conducted by hamedani et al. (2021) and considering the significance level of 0.05 and test power of 80%, a sample size of 35 people was considered appropriate for each group.18 the researchers used the consecutive sampling technique to select respondents with the following criteria: i) a hypertensive individual with a blood pressure of greater than 140/90 mmhg and with a family history of hypertension, ii) an individual diagnosed with hypertension for at least three consecutive months based on a medical doctor’s diagnosis, iii) 60 years or older, iv) living with their family, and v) one family member who is the primary caregiver can actively participate during the empowerment activities. the exclusion criteria were older adults who were unwilling to participate, reluctant to complete the research and those who did not attend all meetings. data collection tool and procedure before starting the research, the researchers gave the informed consent forms to the potential respondents and conducted a pre-test to obtain data on their quality of life. the next step was dividing the intervention group into five small groups, each consisting of seven older adults. during the family-centered empowerment intervention, the respondents remained in the same group they were initially assigned to. the intervention was conducted over four weeks; each step of the intervention was performed on the same day (monday) of each week. at the same time, the control group was provided with standard service interventions at the health center, i.e., blood pressure checks and medication. the family-centered empowerment intervention was conducted at the homes of the intervention group respondents to prevent them from interacting with the control group. the family-centered intervention followed the standard operating procedures (sop) for family empowerment from the bangetayu community health centre. the intervention included discussions on threat perception, self-efficacy, and self-confidence, along with an assessment stage. the respondents were also allowed to contact the researchers via whatsapp if they had any questions. step 1 (threat perception) the first step in the family-centered empowerment model is to increase the older adults’ perceptions of health threats to improve their knowledge, attitudes, and awareness. this research built the participants’ awareness through a group discussion. seven older adults and their families were gathered at one of the respondents’ houses, and a discussion was held for 45 minutes. after the discussion session, the researcher concluded the results and shared a summary of all the discussion topics with the participants and their families. the media used was a booklet about hypertension. the topics discussed included: i) the physiological decline of aging; ii) risk factors, chronic diseases, and hypertension; iii) symptoms, acute recurrence, and prognosis of chronic hypertension; iv) pharmacological and nonpharmacological treatment for chronic hypertension; and v) lifestyle. during the sessions, the older adult participants were asked to share about their self-care management of hypertension. at the end of the session, the researchers stated in a brief closing sentence that hypertension is dangerous and must be treated immediately. step 2 (self-efficacy) the self-efficacy step aimed to increase the self-confidence of the older adult participants. this step was conducted through a group discussion and a booklet. each group comprised seven older adults and their families. this session’s duration was 45 minutes. older adults were taught about skills for lifestyle changes (diet, exercise, smoking cessation, and stress coping skills), skills for managing blood pressure, and treatment planning skills. after explaining the skills practically to the older adults and their families, they shared their experiences with other participants about the supporting and inhibiting factors for following a healthy lifestyle. during group discussion sessions, the researchers supervised and provided objective examples of solutions, such as arranging a sports schedule by writing it down on a calendar. this discussion helped empower the participants and apply the skills they learned in their daily lives. article [healthcare in low-resource settings 2025;13:13001] [page 37] step 3 (self-belief) the third step aimed to increase the family members’ selfbelief in confidently and independently caring for older adults. the participant’s family members were asked to participate actively during the session and asked to solve problems, such as regulating diet patterns and measuring blood pressure. in this session, the families were given a training card or brochure that contained the family’s role and support in managing hypertension in older adults. the training card includes a section that families could fill in with questions about their older adult family member’s illnesses and their roles in supporting them. in this third session, the topics shared enabled the family to learn and increase their sense of responsibility for their older adult family members. step 4 (assessments) the fourth step consists of assessing the interventions provided, namely the question-and-answer sessions and group discussions in steps 2 and 3. during the intervention, the older adult participants and family members actively participated in group discussions. after evaluating the process and providing family empowerment materials, the researchers evaluated the intervention’s results. the researchers then monitored the results via whatsapp messages by asking the families whether they practiced the skills they learned from the intervention. a post-test was then performed one month later through a questionnaire to assess the older adult participants’ quality of life. one month is considered enough time to assess the family’s ability to care for older adult patients with hypertension, as evidenced by the fact that the older adults had their blood pressure under control during the medical check-up at the community health center. instruments the tools used in this research included the demographic characteristics and the european quality of life (eq-5d-5l) questionnaire. these tools have undergone content validation but do not require reliability testing. the european quality of life questionnaire is a standardized questionnaire for assessing the quality of life of patients with chronic diseases. this questionnaire has been widely used in various countries to assess the quality of life in older adults with hypertension. the questionnaire can measure the respondent’s quality of life and consists of five domains: walking ability, self-care ability, usual activities, pain, and anxiety. the eq5d-5l utility index values range between 0 (very poor health condition equivalent to death) and 5 (very good health condition). another part of the eq-5d-5l is the visual analogue scale (eqvas), which can be used to assess the respondent’s health status using a scale of 100 with a score range of 0 (worst health condition) to 100 (best health condition). the eq-vas assessment is based on the respondents’ answers regarding their health condition with a range of 0 (worst health or equivalent to death) to 100 (best health condition). the domains in the european quality of life (eq-5d5l) questionnaire assess the quality of life of older adults and consider their physical, psychological, social, spiritual, and environmental functions. this questionnaire has been translated into indonesian and tested for validity with a pearson correlation of 0.680-0805 and reliability with a cronbach alpha of 0.799.24 data analysis data were analyzed using the spss software (version 23). this research used the levene test to assess the homogeneity of the two groups, which is said to be homogeneous if the p-value is >0.05. the wilcoxon signed-rank test was used to compare the quality-oflife variables in each group; a difference is significant if the p-value is <0.05. next, the mann-whitney u test was used to compare group analysis regarding quality-of-life variables; a difference is significant if the p-value is <0.05. results the levene test results in table 1 show that the intervention group and the control group obtained p-values of >0.05, indicating that the characteristics of the two groups were not significantly different. most respondents in both groups were male, 55-64 years old, married, working, had a normal bmi, had hypertension for 012 months, had comorbidities, had a family history of hypertension, and did not take medication to control their blood pressure. the wilcoxon signed rank test results in table 2 show that the p-value of the intervention group is <0.05 (0.003), indicating a difference in the quality of life in the intervention group before and after the family empowerment intervention. in the control group, the p-value was >0.05 (0.910), suggesting that there is no difference in the participant’s quality of life. meanwhile, the mannwhitney u test conducted two months after the intervention obtained a p-value of <0.05 (0.000), suggesting a difference in the quality of life of the intervention and control groups. discussion this study shows that the family-centered empowerment model can improve the quality of life of patients with hypertension. the family empowerment interventions in this research consisted of four steps: the perceived threat, self-efficacy, self-belief, and assessment stages. the interventions were conducted through health education with lectures and discussions on blood pressure measurement, bmi measurement, lifestyle modification, and continuing contact with the researchers via whatsapp to solve any issues. this study’s results align with a previous study from iran regarding the effectiveness of family empowerment in improving the quality of life of patients with chronic disease.18 this study found a significant increase in the average score of the intervention group. thus, the interventions conducted can be considered effective in improving the quality of life of patients with hypertension. keshvari et al. (2015) examined the effect of implementing a family-centered empowerment model to control blood pressure among patients with hypertension. the results showed that after receiving the intervention for 1.5 months, the participants’ blood pressure in the intervention group was well controlled.25 the time and number of sessions in the family empowerment intervention stage provided many opportunities for the patients and their families to increase their knowledge and skills regarding selfcare procedures for hypertension.26 previous research that provided health education interventions to control blood pressure found that the intervention was effective in increasing physical activity, stress management, and nutritional regulation, resulting in patients with hypertension being able to have their blood pressure under control when they were evaluated two months later. the intervention can also be repeated and evaluated every three months to evaluate the positive effects on the quality of life of older adults in the long article [page 38] [healthcare in low-resource settings 2025;13:13001] term.27 moreover, mohalli et al. (2018) researched the effect of a family-centered empowerment model to improve the ability to care for hypertensive patients. the results showed that the participants’ knowledge, self-esteem, and self-efficacy increased in the intervention group. in this study, acceptance, active participation, and a desire for discussion from the participants and their families are the main reasons the empowerment model achieved positive results.28 the family-centered empowerment model is more effective than health education because it involves patients and their families in the treatment and care processes. this model is designed to help families support chronically ill older adults by improving their communication skills, problem-solving skills, conflict resolution, and self-care management.29 meanwhile, health education only involves the patients and increases their knowledge.30 furthermore, the family-centered empowerment model aims to increase the family’s awareness of hypertension risks, self-control over the disease, the family self-efficacy to care for older adults independently, their self-confidence in solving the health problems of their older adult family member, and the ability and skills to solve problems in the family under the supervision and assistance of health workers.25 the knowledge and practical skill transfer from the family to older adult patients with hypertension will increase their self-esteem, happiness, self-efficacy, and control over the disease. the strategies to achieve this goal include providing health education, having problem-solving discussions and con article table 1. respondents’ characteristics. variable intervention group control group levene test p-value gender 0.62 male 20 (57.1) 18 (51.4) female 15 (42.9) 17 (48.6) age 0.61 60–74-year-old 13 (37.1) 12 (34.3) 75–90-year-old 15 (42.9) 17 (48.6) >90-year-old 7 (20) 6 (17.1) occupation 0.68 working 22 (62.9) 20 (57.1) not working 13 (37.1) 15 (42.9) marital status 0.73 married 25 (71.4) 23 (65.7) not married 10 (28.6) 12 (34.3) body mass index 0.83 underweight 8 (22.9) 6 (17.1) normal weight 17 (48.6) 16 (45.7) overweight 10 (28.6) 13 (37.1) length of illness 0.41 0-12 months 17 (48.6) 15 (42.9) 13-24 months 8 (22.9) 12 (34.3) >25 months 10 (28.6) 8 (22.9) comorbidities 0.41 yes 13 (37.1) 11 (31.4) no 22 (62.9) 24 (68.6) a family history of hypertension yes 25 (71.4) 22 (62.9) 0.44 no 10 (28.6) 13 (37.1) blood pressure management 0.71 use medication 9 (25.7) 10 (28.6) does not use medication 26 (74.3) 25 (71.4) [healthcare in low-resource settings 2025;13:13001] [page 39] table 2. differences in the quality of life of hypertensive patients in each group. variable intervention group p* p** before after quality of life of the intervention group 0.003 0.000 poor 15 (42.9) 6 (17.1) moderate 13 (37.1) 8 (22.9) high 7 (20) 21 (60) quality of life of the control group 0.910 0.000 poor 13 (37.1) 12 (34.3) moderate 12 (34.3) 14 (40) high 10 (28.6) 9 (25.7) *wilcoxon signed rank test; **mann-whitney u. sultations, learning new skills, and providing support for access to health services based on joint decision-making involving the patients, family members, and health workers. the implementation of the empowerment model in older adults should be prioritized because aging is inevitable. along with increasing age, the risk of developing chronic diseases, including hypertension, increases. as healthcare workers, community nurses have an essential role in preventing and improving the health management of patients with chronic hypertension. therefore, implementing a family-centered empowerment model can help patients and their families control the disease and improve the quality of life of older adult patients with hypertension. this study’s limitation is that the participants were only monitored and evaluated one month after the intervention. therefore, it did not measure the intervention’s long-term effects. additionally, this study’s results are still limited to analyzing the effect of family-centered empowerment interventions on the quality of life of older adults. it did not analyze in detail how the family members contribute to improving the participant’s quality of life and any of the challenges they face. conclusions and implications for practice there is no difference in the participants’ characteristics between the control and intervention groups. however, after receiving a family-centered empowerment intervention, the quality of life of the intervention group increased compared to the control group. therefore, the family-centered empowerment model effectively improves the quality of life of older adult patients with hypertension. as healthcare workers, community nurses play a vital role in improving the health status of patients with chronic hypertension by applying the family-centered empowerment model in nursing care. the model’s implementation can help patients and their families control the disease and ultimately improve 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alimoradi z, atashi v, et al. quality of life in different chronic diseases and its related factors. int j prev med 2019;10:1-8. 7. carey r, muntner p, bosworth h, whelton p. prevention and control of hypertension: jacc health promotion series. j am coll cardiol 2018;72:1278-93. 8. chantakeeree c, sormunen m, estola m, et al. factors affecting quality of life among older adults with hypertension in urban and rural areas in thailand: a crosssectional study. int j aging hum dev 2022;95:222-44. 9. zhang l, guo x, zhang j, et al. health-related quality of life among adults with and without hypertension: a populationbased survey using eq-5d in shandong, china. sci rep 2017;7:14960. 10. yuniartika w, kartinah, sudaryanto a. social interaction using spirituality therapy to improve the quality of life of the elderly in the community. evid based care j 2023;13:6574. 11. ahmed m, ahmed a, al-khawaja m. hypertension and health-related quality of life : a community based epidemiological study in an egyptian village. int j med arts 2020;2:232-40. 12. noori r, alami a, noghabi ad. effect of family-centered empowerment model on quality of life in patients with hypertension. j maz univ med sc 2015;25:100-7. 13. miao y, zhang l, sparring v, et al. improving health related quality of life among rural hypertensive patients through the integrative strategy of health services delivery: a quasi-experimental trial from chongqing, china. int j equity heal 2016;15:132. 14. suhat s, suwandono a, adi ms, et al. relationship of health belief model with medication adherence and risk factor prevention in hypertension patients in cimahi city, indonesia. evid based care j 2022;12:51-6. 15. salahi s, ghahfarokhi j, hasheminia s, habibzadeh h. the effect of family-centered empowerment model on quality of life of hemodialysis patients. j urmia nurs midwifery 2012;10. 16. allen d, scarinci n, hickson l. the nature of patientand familycentred care for young adults living with chronic disease and their family members: a systematic review. int j integr care 2018;18:14. 17. farias d, almedia m, gomes g, et al. beliefs, values and practices of families in the care of hospitalized children: subsidies for nursing. rev bras enferm 2020;73:1-8. 18. hamedani ma, salar a, kermansaravi f. effect of familycentered empowerment model on quality of life of patients with hypertension. j med surg nurs 2021;10. 19. javadi m, hosseini m, meybodi fa, marvasti nia g. the effect of family-centered empowerment program on self-efficacy and perceived stress in patients with acute coronary syndrome in yazd social security hospital. cardiovasc biomed j 2023;3:32-41. 20. nasiri s, heydari n, rafiee s, paran m. effect of family-centered education on patient’s self-care. sadara med j 2020;8:311-20. 21. kokorelias k, gignac m, naglie g, cameron j. towards a universal model of family centered care: a scoping review. bmc heal serv res 2019;19:564. 22. liu l, qian x, chen z, he t. health literacy and its effect on chronic disease prevention: evidence from china’s data. bmc public health 2020;20:690. 23. azar f, solhi m, chabaksvar f. investigation of the quality of life of patients with hypertension in health centers. educ heal promot 2020;9:185. 24. tondok sb, watu e, wahyuni w. validitas instrumen european qualitiy of life (eq-5d-5l) versi indonesia untuk article [page 40] [healthcare in low-resource settings 2025;13:13001] menilai kualitas hidup penderita tuberkulosis. holistik j kesehat 2021;15:267-73. 25. keshvari m, hedayati b, moeini m, alhani f. a survey on the effect of implementation of a family-centered empowerment model on blood pressure and empowerment dimensions in the elderly people with hypertension. j educ health promot [internet] 2015;4:94. available from: http://www.ncbi.nlm.nih.gov/pubmed/27462636%0ahttp://w ww.pubmedcentral.nih.gov/articlerender.fcgi?artid=pmc4946 264. 26. alhani f, asghari-jafarabadi m, norouzadeh r, et al. the effect of family-centered empowerment model on the quality of life of adults with chronic diseases: an updated systematic review and meta-analysis. j affect disord 2022;316:140-7. 27. shayesteh h, mirzaei a, sayehmiri k, et al. effect of education intervention on lifestyle of patients with hypertension among the rural population of lorestan province. j lifestyle med 2016;6:58-63. 28. mohalli f, mahmoudirad gh, alhani f, et al. the effect of family-centered empowerment model on the indicators of the ability of patients with hypertension. iran j nurs res 2018;13:1-6. 29. shields c, finley m, chawla n, meadors w. couple and family interventions in health problems. j marital fam ther 2012;38:265-80. 30. aghajani m, mirbagher ajorpaz n, kafaei atrian m, et al. effect of self care education on quality of life in patients with primary hypertension: comparing lecture and educational package. nurs midwifery stud 2013;2:71-6. article [healthcare in low-resource settings 2025;13:13001] [page 41] hrev_master healthcare in low-resource settings 2024; volume 12:12850 anxiety among nurses in caring for covid-19 patients: a qualitative study sri eka wahyuni,1 budi anna keliat,2 herni susanti,2 besral3 1department of psychiatric and community nursing, faculty of nursing, universitas sumatera utara; 2department of mental health nursing, faculty of nursing, universitas indonesia, depok; 3department of biostatistics and population studies, faculty of public health, universitas indonesia, depok, indinesia abstract this study aimed to explore anxiety among nurses in caring for coronavirus disease 2019 (covid-19) patients. a qualitative descriptive design was used and the number of participants was 13 nurse managers selected using the purposive sampling method. data collection was conducted using in-depth interviews coupled with a tape recorder and camera following the consent of participants, while framework analysis was used to analyze data. the results showed that participants, comprising 12 females and one male, had work duration in the range of 1-10 years. the identified five major themes included: i) anxiety response, ii) risk factor, iii) protective factor, iv) interventions, and v) anticipated support from nurses. nurses were found to experience anxiety when caring for covid-19 patients, underscoring the need for mental health and psychosocial support to reduce risk factors, increase protective factors, and improve coping mechanisms, fostering resilience. the results provided data to help nurses overcome anxiety when facing cases of infection such as the covid-19 pandemic. furthermore, this study offered valuable insights for the government and hospitals in establishing policies regarding the importance of mental and psychological health support to maintain the well-being of nurses. introduction the coronavirus disease 2019 (covid-19) pandemic is caused by a respiratory system infection attributed to the coronavirus.1 this pandemic has rapidly spread globally with a prevalence of around 218 million cases and a national count of 4 million cases.2 the associated death toll worldwide is 4 million cases, while in indonesia, the number of death cases is estimated at 134,930. the percentage of cases is 1.83% lower than the global cases, but the death rate is 3.3% higher. these data underscore the highly infectious nature of covid-19 and its impact on the psychology of nurses. the onset of covid-19 has led to the occurrence of anxiety among nurses working in hospitals, resulting in a feeling of worry and unease in response to stressful and threatening situations. anxiety is associated with unpleasant feelings, restlessness, fear, and worry, representing a normal reaction to stress and threats.3 this condition arises due to changes in the work environment of nurses, such as an increase in infection cases, injuries, and the traumatic experiences of caring for patients, which can affect productivity.3-5 based on the data, the increase in infection cases, such as the covid-19 pandemic, leads to a two times risk of anxiety among nurses. before the pandemic, the prevalence of anxiety among nurses was 12% in europe, 5.6% in china, and 20% in intensive care units.3 meanwhile, the prevalence during the pandemic was 54.3% in portugal,6 33.4% in china, and 46.5% in intensive care units.7.8 in indonesia, the prevalence of anxiety before and during the covid-19 pandemic was 18%,9 and 33% respectively.10 as the primary healthcare team that accompanies clients, there is a need to investigate anxiety among nurses in relation to caring for covid-19 patients. nurses can adapt to stressors to effectively help clients but studies conducted in indonesia or medan regarding this topic are limited. therefore, this study aimed to investigate anxiety among nurses in caring for covid19 patients. correspondence: sri eka wahyuni, department of psychiatric and community nursing, faculty of nursing, universitas sumatera utara, indonesia. email: eka_rizky06@yahoo.co.id key words: anxiety; nurses; pandemic. contributions: all authors discussed the results. all author responbility following: previous study and design and data collection. the others contributed the final manuscript. ethica approval: in the preparation stage, permission was obtained from hospitals and the ui faculty nursing ethics commission with no. ket264/un2.f12.d1.2.1/ppm.00.02/2022, while in the implementation stage, a quiet room was prepared to conduct in-depth interviews. availability of data and material: the data of this study are available on request from corresponding author. conflict of interests: the authors declare no conflicts of interest. funding: none. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgment: we would like to thank all the collaborators who are currently working on received: 25 july 2024. accepted: 25 july 2024. early access: 25 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12850 doi:10.4081/hls.2024.12850 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12850] [page 645] non -co mmerc ial us e o nly materials and methods this study used a descriptive qualitative design to explore anxiety among nurses, and participants were 13 nurse managers sampled from several hospitals in medan city. participants were recruited using a purposive sampling method with the following inclusion criteria: nurse managers in the covid-19 unit and able to provide informed consent. data collection was carried out from november to december 2022, and this study comprised two stages, namely preparation and implementation. in the preparation stage, permission was obtained from hospitals and the ui faculty nursing ethics commission with no. ket264/un2.f12.d1.2.1/ppm.00.02/2022, while in the implementation stage, a quiet room was prepared to conduct in-depth interviews. during the interviews, only the interviewer and participant were present, sitting face-to-face to ensure eye contact. furthermore, interrogative questions were avoided to ensure participants could answer questions openly. interviews were conducted according to agreement with the participants and took 30 to 60 minutes. study data including recordings stored and protection carried several years. a tape recorder and camera were used to assist the study process with the permission of the participants. field notes were used to record nonverbal communication supporting or contradicting verbal communication and record environmental conditions. after the interview process, the results were presented in a transcript for validation and clarification to participants, while framework analysis was used to analyze the data. framework analysis which consists of 5 steps: data familiarization, identification of thematic framework, indexing all studies related to the framework, conducting a data index summary using charts/charting and mapping/interpretation. analysis was carried out using tools manually. the trustworthiness of the findings were indicated by data credibility, conformability, dependability, and transferability. data credibility is carried out by prolonged engagement with data and findings, triangulating data sources, methods and investigators and carrying out member checking and identifying different findings.to ensure accurate descriptions and coding, researchers consulted with supervisors/experts. to confirm the results, researchers used more than two questions to explore the phenomenon. coding is used during the analysis process to increase dependability. confirmability is carried out through audits of the research process. to obtain rich data with information that can be confirmed, researchers recruited participants who have experience caring for covid-19 clients. the researcher investigates and describes all the details of the research starting from selecting participants, collecting and analyzing data and comparing the data obtained.transferability carried out in this research is by providing a research report as a thick description. the data were considered credible because they came directly from informants, who were the most trustworthy sources of information. the generated keywords, codes, and themes were re-read and re-checked by another researcher. conformability of data was also supported by the fact. the triangulation of data collection by combining interviews with field observation to increased the trustworthiness of the findings. the transferability of this study findings can be considered at other nurses in indonesia or another country. results the result showed that the majority (5) of nurse managers were in the age range of 40-44 years, with 11 being married, and only one had a master’s degree in nursing. moreover, a significant proportion (12) were females, and six had worked for a duration of 1-10 years. the demographic characteristics are presented in table 1. the result showed that five major themes included: i) anxiety response, ii) risk factor, iii) protective factor, iv) interventions, and v) anticipated support from nurses. the themes and categories are presented in table 2 below. anxiety response this theme showed the various dimensions of anxiety responses among nurses including cognitive, physiological, behavioral, social, and affective. several informants explained that the cognitive response they experienced was fear of being infected and infecting other people. the physiological response experienced by article table 1. nurse manager demographic characteristics. variable frequency (f) age 30–34 1 35–39 2 40–44 5 45–49 3 50–54 2 marital status married 11 separated 2 educational level ners 12 master of nursing 1 sex female 12 male 1 work duration (years) 1-10 6 11-20 5 21-30 2 table 2. themes and categories that emerged. themes categories anxiety response cognitive response physiological response behavior response social response affective response risk factor biological factor psycholigical factor socialcultural factor protective factor biological factor psychological factor socialcultural factor interventions conducted to address anxiety cognitive coping spiritual coping ego-focused coping problem-focused coping expected support family peer institusional [page 646] [healthcare in low-resource settings 2024;12:12850] non -co mmerc ial us e o nly several informants was fatigue. the social response experienced by several informants was feeling isolated from family and other people. the behavioral response experienced by several informants was to carry out preventive activities repeatedly to prevent infection. meanwhile, the affective response experienced was that several informants felt sad and cried seeing the condition of the covid-19 pandemic which did not know when it would end. the various responses of nurse managers include: “… afraid of getting infected and transmitting it to others …”. “tired, surely there is fatigue …”, “at that time, when we returned home, i took a shower first. at my house, it feels unfamiliar, there is a different bed for the children and my husband …”, “so, we are on our own, isolating ourselves…”, “sometimes i cry alone, wondering when this will pass, like, it’s okay, just cry …”. risk factor this theme showed evidence that the risk factors of nurses were biological, psychological, and social-cultural. the biological risk factor experienced was the informant’s exposure to cases of infection. the risk factor experienced by several informants was a lack of knowledge regarding covid-19. the sociocultural risk factors experienced by several informants were feeling shunned by other people. the responses from nurse managers were as follows: “… fear of transmitting it…”, “lack of knowledge about the disease …”, “avoid people …”. protective factor this theme showed evidence that the protective factors of nurses included biological, psychological, and social-cultural. the biological protective factor possessed by several informants is young age. the psychological factor is the experience of the informant and the socio-cultural factor is the informant’s single status (not yet married). the various responses from nurse managers include: “… the age of 21-30 is still considered young …”, “having experience in the field for at least 1 year …”, “everyone is still young women, single…”. overcoming anxiety this theme showed strategies used to overcome anxiety among nurses including cognitive, spiritual, ego-focused, and problemfocused coping. several informants explained that cognitive coping was done by thinking positively about the current situation and conditions they were experiencing. several informants explained that spiritual coping was also done by getting closer to god and carrying out religious activities such as praying. some informants used ego-focused coping by trying to enjoy and think about happiness. some informants also carried out problemfocused coping by breathing relaxation. the responses from nurse managers were as follows: “… positive thinking …”, “closer to god, prayer …”, “…relaxation…”, “…just bring happiness, enjoy…”. expected support this theme showed the expected support of nurses from family, peer, and institutional. several informants hoped for support from the family in the form of motivation and encouragement. several informants hoped for support from friends such as helping at work, reminding each other, collaborating with each other and coordinating in caring for covid-19 clients. several informants also hoped for support from the hospital in the form of increasing knowledge and information through training. the responses received from nurse managers were as follows: “… give encouragement and motivation…”, “…mutual reminders, cooperation, and coordination, mutually reinforcing…”, “…given training, sharing information…” discussion theme 1. anxiety response the results showed that the theme on signs and symptoms of anxiety experienced by nurses regarding covid-19 consisted of five sub-themes, namely physiological, behavioral, cognitive, affective, and social. signs and symptoms of anxiety are associated with the response of the body to stressors that can be observed directly or indirectly through physiological, behavioral, cognitive, affective, and social changes.11 the physiological responses shown in this study were fatigue, difficulty sleeping, breathing, and urinating, as well as headaches. the results were consistent with physiological responses such as respiratory changes, neuromuscular changes, and urinary tract changes.11 the behavioral response is crucial to avoid transmission from the source, as nurses fear both contracting and transmitting the infection to others. extra preventive measures include doublemasking, spraying money with disinfectant, repeatedly washing hands with hand sanitizer, and repeated bathing, with some participants reporting migraines due to frequent bathing. the cognitive response experienced by nurses included negative thoughts such as feeling that the virus was still present in the hair or on fruit even after bathing and washing, fear of death, fear of being blamed, feelings of fear/worry/anxiety of contracting or transmitting the infection to others, and confusion about what to do when caring for covid-19 patients. a similar study reported that cognitive responses to anxiety included concentration/evaluation/attention, fear and decreased productivity, attention disturbances, poor concentration, forgetfulness, judgment errors, preoccupation, thought blocking, decreased perception field, confusion, and embarrassment.11 affective responses experienced by nurses included sadness, crying, and mood changes such as feeling irritated and emotionally affected when caring for covid-19 patients. this aspect reportedly consisted of impatience, nervousness, tension, unease, dread, frustration, helplessness, worry, terror, anxiety, restlessness, numbness, guilt, and shame.11 sadness, frequent crying, and mood changes are caused by pity when nurses witness the condition of patients, imagining the consequences for themselves or close family members, as well as feeling helpless in the covid-19 pandemic situation. the social response was demonstrated by individuals limiting social interactions with others. this was consistent with the results of previous studies stating that the social response experienced by covid-19 nurses included self-limitation of social interaction and avoidance of the surrounding environment.11 nurses isolate themselves or limit interaction due to the fear of transmitting the infection to others and avoid contact with hospitals or sources of infection. theme 2. risk factor the theme of anxiety risk factors consists of biological, physiological, and social-cultural aspects, with stressors arising from internal and external components.12,13 biological factors contributing to anxiety in nurses stem from direct contact with a source of infection. this is consistent with the theory that the biological cause of anxiety in nurses is the exposure to toxins/viruses/bacteria due to an increase in infection cases.11 the surge in infection cases, article [healthcare in low-resource settings 2024;12:12850] [page 647] non -co mmerc ial us e o nly coupled with injuries, and traumatic experiences becomes a significant source of.3-5 nurses are a vulnerable group and covid-19 is a highly infectious stressor.1,14-16 approximately 3.8% of healthcare workers worldwide were confirmed with covid-19 worldwide while data from the international council of nurses reported an average of 6-10%, with the infection rate reaching up to 30% of all cases. nurses worry about contracting covid-19 and becoming carriers who could spread the disease to family.17-19 psychological factors causing nurse anxiety include lack of knowledge, traumatic experiences, and lack of experience, as covid-19 is a newly occurring disease.17,20 according to a previous study, factors causing nurse stress during the pandemic include the novelty of covid-19 and insufficient information.21 causes of socio-cultural stress include lack of family support, isolation/stigma/discrimination. the covid-19 pandemic limits the social interactions of nurses with families and the community. nurses also become victims of discrimination from society (public stigma) and experience self-stigma. public stigma includes actions in which nurses and the families are labeled as dangerous and potential transmitters of covid-19.22,23 a previous study reported that nurses in japan experienced discrimination.18 the feeling of not being able to work, isolation from society, unable to join places of worship, inability to participate in activities with friends and family, as well as discrimination from society are socio-cultural stressors for nurses.24 sociocultural stressors also occur due to a lack of social support.17,25,26 themes 3. protective factor protective factors play a crucial role in helping nurses overcome anxiety, consisting of three sub-themes, namely biological, physiological, and social-cultural. these factors are determinants of resilience development that come from oneself, family, and the environment. according to theory, protective factors include a healthy diet and physical exercise/activities, support, emotional regulation, coping and problem-solving abilities, optimistic feelings, positive self-esteem, social competence, building relationships with others, participating in communities and society, financial support, access to support services.27 the results showed that young age was a protective factor associated with good health conditions and the absence of comorbidities. as stated by a previous study, the age group of 14–24 years is a protective factor.23 another study mentioned that older individuals tend to have financial stability in psychological and emotional aspects. according to a survey conducted in the uk, early adulthood, low income, and living alone pose a higher risk of mental health disorders during the covid-19 pandemic. younger people have more access to information about covid-19 through social media, leading to increased stress. anxiety occurs at a young age (20-35 years), specifically in nurses who work on the front line. these individuals are more susceptible to contacting sources of infection and have less experience in caring for clients.28 psychological protective factors include work experience, knowledge, positive feelings, and positive experiences in nursing due to the recovery of many clients, motivation, and positive thoughts.28 motivation is a coping source for nurses in facing stressors.11 the experience of providing services for more than 20 years, becomes a protective factor along with the knowledge gained through training related to covid-19 information and selfprotection.28,29 nurses who have the knowledge and skills to care for covid-19 are protected from anxiety. socio-cultural protective factors are nurses who are not yet married and live alone. previous studies stated that being married posed a risk of causing psychological problems in nurses. living with a partner, marital status, and living with children are risk factors for anxiety.17 themes 4. overcoming anxiety coping strategies are protective factors in preventing anxiety, specifically problem-focused coping, while negative strategies cause anxiety.25 positive coping mechanisms, including storytelling with friends, distracting behaviors, and positive thinking, are recognized as protective factors.25 coping strategies are cognitive and behavioral efforts that individuals must make to manage internal and external stressors. these strategies are shaped by personal attributes, situational factors, and available resources, aiming to restore balance to face reactions triggered by stressors. commonly used adaptive coping includes relaxation exercises, meditation, physical activity, or modifying cognitive processes. the results showed that nurses dealt with stressors by spending significant time outdoors and engaging in deeper spiritual activities toward god, themselves, and others. praying and reading holy books are effective strategies for reducing stress and anxiety during the covid-19 pandemic.30 prayer provides inner strength and enables individuals to manage stress more effectively, practically, and safely. spiritual beliefs are useful as a source of hope and can support coping efforts in unexpected situations.11 the ability of nurses to overcome stressors, as well as resilience, and social support are related to psychology.30 a previous study stated that nurses with spirituality, hope, and optimism experienced lower anxiety. there is a positive relationship between religious coping mechanisms and reduced symptoms of anxiety, aggressive behavior, psychological distress, and depression. spirituality, peace, and faith are protective factors that prevent anxiety. other studies showed that healthcare workers used problemfocused and emotion-focused coping to manage stress during the covid-19 pandemic.30 themes 5. expected support psychological resilience, similar to social support, is a protective factor in dealing with stressors and traumatic events.30 resilient healthcare workers can recover and endure psychological burdens. psychological resilience plays a significant role in protecting individuals from mental health consequences in emergencies or disasters.30 the support expected by nurses includes scheduling arrangements and human resources in nursing services. the results showed that well-rested nurses had lower levels of anxiety and stress. overwork can cause a sense of control loss, feelings of helplessness, as well as insomnia, headaches, loss of appetite, and other physical disorders. hospitals must ensure adequate nursing staffing, organize rotations and ensure adequate rest for nurses.17 furthermore, adequate resources, increased welfare, incentives, counseling, support from the environment, and management during the covid-19 pandemic are expected support of nurses.19 labrague et al. also states that social support is needed by nurses,30 specifically from the family, nurse managers, and people in the environment. social support, daily and structured life routines, as well as well-established family relationships can enhance psychological well-being. the different forms of support include emotional, social, and relational.25 recognition and acknowledgment of efforts, infection control guidelines, and the provision of facility amenities during the pandemic are forms of support needed by nurses from hospitals. the limitation of study is that researchers could not directly observe the anxiety experienced by nurses because the research was conducted after the covid-19 pandemic. in conclusion, this study examined responses, risk factors, pro article [page 648] [healthcare in low-resource settings 2024;12:12850] non -co mmerc ial us e o nly tective factors, interventions, and the support expected by nurses in managing anxiety. research shows that nurses need intervention in dealing with signs and symptoms of anxiety, reducing existing risk factors and increasing protective factors within themselves in order to produce adaptive coping and resilience in facing every challenge that exists in the work environment. the research results show that nurses are subjects who are vulnerable to anxiety. the use of adaptive coping can be one of the factors that can reduce negative responses to biological, psychological, socio-cultural and environmental stressors faced by nurses in health care settings. the use of adaptive coping can be developed and applied in hospitals and nurses need social support to strengthen it and achieve resilience in facing stressors that will continue to exist in the nurse’s work environment. the results underscored the presence of signs and symptoms, as well as risk and protective factors that could prevent anxiety. this study showed that nurses needed interventions 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nurses in emergency departments and fever clinics: a cross-sectional survey. risk manag healthc policy 2021;14:585-94. 18. international council of nurses. covid-19 update [internet]. international council of nurses; 2021. 19. rathnayake d, clarke m, jayasinghe vi. health system performance and health system preparedness for the post-pandemic impact of covid-19: a review. int j healthc manag 2021;14:497-513. 20. hoseinabadi ts, kakhki s, teimori g, nayyeri s. burnout and its influencing factors between frontline nurses and nurses from other wards during the outbreak of coronavirus disease covid-19 in iran. investigacion y educacion en enfermeria 2020;38:e03. 21. ghorbani a, shali m, matourypour p, et al. explaining nurses’ experience of stresses and coping mechanisms in coronavirus pandemic. nurs forum 2022;57:18–25. 22. keliat ba, marliana t, windarwati dh, et al. dukungan kesehatan jiwa dan psikososial covid-19: keperawatan jiwa. 2nd ed. jakarta: fik universitas indonesia; 2020. 23. sun l. intervention effect of time management training on nurses’ mental health during the covid-19 epidemic. psychiatr danub 2021;33:626–33. 24. aulia ap. gambaran kesehatan mental perawat selama masa pandemi covid-19 di rsud saweriganding kota palopo tahun 2021. [bachelor’s thesis]. makassar: universitas hasanuddin; 2022. 25. hugh w, schweizer r, marks e, et al. the effectiveness of support groups: a literature review. mental health and social inclusion 2018;22:85–93. 26. lixia w, xiaoming x, lei s, et al. a cross-sectional study of the psychological status of 33,706 hospital workers at the late stage of the covid-19 outbreak. j affect disord 2022;297:156-68. 27. american psychiatric association. mental health: a guide for faith leaders [internet]. washington dc: american psychiatric association foundation and the mental health and faith community partnership steering committee; 2018. 28. gupta s, prasad as, dixit pk, et al. survey of prevalence of anxiety and depressive symptoms among 1124 healthcare workers during the coronavirus disease 2019 pandemic across india. med j armed forces india 2021;77:s404–s12. 29. zheng r, zhou y, qiu m, et al. prevalence and associated factors of depression, anxiety, and stress among hubei pediatric nurses during covid-19 pandemic. compr psychiatry 2021;104:152217. 30. labrague lj, de los santos jaa. covid-19 anxiety among front-line nurses: predictive role of organisational support, personal resilience and social support. j nurs manag 2020;28:1653–61. article [healthcare in low-resource settings 2024;12:12850] [page 649] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s2):12906 professional satisfaction of practitioners in psychiatry departments beata strzelecka,1 katarzyna wiśniewska,1 anna pacian2 1faculty of health sciences, radom school of higher education, radom; 2department of health education, medical university of lublin, lublin, poland abstract assessing the professional satisfaction of psychiatrists is crucial given the unique demands and complexities of their work, which include managing patients’ mental and physical well-being, adhering to strict ethical standards, handling crises, and coping with significant emotional stress. the study’s aim was to determine the indicators of job satisfaction of doctors working in psychiatry departments, to analyse the professional satisfaction of polish, european, and world psychiatrists, and to identify ways to improve it. the applied methods include: secondary data analysis, thematic analysis, comparative analysis, synthesis. the study identified factors that influence the professional satisfaction of psychiatrists, compared it among psychiatrists in poland, europe, and the world, and developed a number of methods to improve this indicator. the results of the study showed that the level of professional satisfaction of psychiatric doctors is influenced by the following factors: salary level, working conditions, team relations, resource support of the work process, stress level, level of emotional burnout, sense of recognition and importance of their own work, work-life balance, and the degree of stigmatisation of mental disorders in society. in terms of the number of practicing psychiatrists in the country, the availability of psychiatric services, and the level of the average annual salary of psychiatrists in poland, europe, and the world, the highest rates of professional satisfaction are recorded in the scandinavian countries and austria. poland and eastern european countries have lower scores, but the gradual increase in funding for psychiatry in poland is leading to a positive upward trend. ways in which this increase can be achieved include: increasing the staff of psychiatric units and optimising administrative work to reduce workload; using cooperation and mentoring programs to achieve a comfortable team environment; and encouraging specialists to participate in training and mentoring programs to enhance their professional development. introduction the specificity of the speciality of practitioners in psychiatric departments involves working with patients with mental problems of various types and severity. during diagnostics, treatment, and rehabilitation, a doctor is responsible not only for the quality of certain procedures but also for the mental and physical well-being of patients, which is achieved by adhering to ethical standards in working with them and correctly and timely resolving crises or dangerous situations for patients or staff. despite maintaining emotional neutrality, this level of responsibility can cause emotional stress, which will require emotional commitment both in the professional sphere and outside of it. therefore, given the complexity and peculiarities of the work of psychiatric doctors, as well as the length of training in this speciality, it is important to assess their professional satisfaction in order to take the necessary measures to preserve the human resources of the industry. the main problem of the study is the lack of reliable and valid statistical information on the level of professional satisfaction of psychiatric doctors in poland, europe, and the world in general. the study addresses this gap in comprehensive data on the professional satisfaction of psychiatric doctors, highlighting the importance of addressing this issue to improve the mental health care system. the lack of robust data limits the ability to develop effective strategies to support psychiatrists in managing the unique stresses and demands of their profession. by focusing on this problem, the study aims to contribute to a better understanding of the factors that influence job satisfaction in psychiatric practice, which is essential for retaining skilled professionals in this challenging field. addressing this issue is particularly significant in light of the increasing prevalence of mental health disorders worldwide, which places additional pressure on psychiatric services and emphasizes the need for a satisfied and motivated workforce to meet the growing demand for mental health care. therefore, researchers who have dealt with this issue have focused on conducting surveys on certain indicators responsible for professional satisfaction among psychiatric doctors. makarastudzińska et al.1 analysed the prevalence of professional burnout correspondence: katarzyna wiśniewska, faculty of health sciences, radom school of higher education, 26-600, 26/28 1905 roku str., radom, poland e-mail: wisniewska.kater@gmail.com key words: emotional burnout, stress level, workload, salary, industry resources, stigmatisation. funding: none. ethics approval: the study was conducted without human/animal participation. ethical approval is not required. conflict of interest: the authors declare no potential conflict of interest. availability of data and material: the data that support the findings of this study are available on request from the corresponding author. received: 7 august 2024. accepted: 18 september 2024. early view: 10 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s2):12906 doi:10.4081/hls.2024.12906 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s2):12906] [page 111] non -co mmerc ial us e o nly syndrome based on a survey of 57 psychiatrists. the results of the study revealed a high degree of burnout, which was recorded in 50% of the doctors surveyed. wontorczyk et al.2 conducted a search for psychosocial predictors that influence the development of stress and professional burnout, based on a survey of 131 psychiatrists. the researchers recorded a significant level of professional stress and burnout, the main predictors of which were psychophysical exhaustion and a lack of a sense of professional effectiveness. the inclusion of non-professional predictors in wontorczyk et al.’s research adds a valuable dimension by recognizing the broader social influences on professional well-being. the study’s sample size is insufficient for scalability and projection to the entire psychiatry field, but burnout as a factor affecting the professional satisfaction of practicing psychiatrists should be further studied. mcloughlin et al.3 and sandvik et al.4 broaden the scope of the subject by looking at burnout and work satisfaction among psychiatrists in ireland and norway. the survey was conducted by mcloughlin et al. among 100 doctors and revealed burnout in 36% of them and a low assessment of personal well-being in 30%. the results of the study by sandvik et al., encompassing a survey of 903 norwegian doctors, showed job satisfaction in 56% of respondents, dissatisfaction in 16%, and a neutral attitude in 27%. the studies provide a comparative perspective on work satisfaction, enabling cross-regional research. sandvik et al.’s focus on job satisfaction aspects is valuable for identifying improvement areas. however, these studies largely focus on the immediate professional environment without delving into the systemic and cultural factors that might influence job satisfaction. this creates a gap in understanding how broader societal and policy contexts influence the professional experiences of psychiatrists, which is critical for developing comprehensive strategies to improve job satisfaction. based on the results of a social media survey, gruber et al.5 determined the indicators of performance and job satisfaction among psychiatrists who emigrated from croatia to scandinavian and western european countries and psychiatrists who practiced directly in croatia. the analysis of a questionnaire survey of 62 doctors, 44 of whom emigrated, revealed higher levels of professional satisfaction among the emigrant group of psychiatrists compared to their colleagues working in their home country. gruber et al. offer a unique perspective by examining the well-being of emigrant psychiatrists from croatia, yet their study does not fully address the comparative aspects of professional satisfaction between different healthcare systems and cultural contexts. outside of europe, surveys aimed at determining the professional satisfaction of psychiatrists were conducted by chambers and frampton,6 nimmawitt et al.,7 and jackson et al.8 as in the previous studies, the authors investigated the level of burnout, stress, and exhaustion and assessed the prevalence of post-traumatic stress disorders among doctors in psychiatric departments. chambers and frampton studied the results of a survey of 368 doctors from new zealand and found burnout in 34.6% of respondents, and the level of significant work-related stress was recorded in 35.3% of respondents. an analysis of a survey of 227 thai psychiatrists conducted by nimmawitt et al. showed that 49.3% of respondents reported severe emotional exhaustion, and 26.4% reported high levels of depersonalization. jackson et al. studied the results of a cross-sectional national survey of 2,216 practicing psychiatrists in the united states and determined that 14% of them had post-traumatic stress disorders, the development of which provoked emotional exhaustion and job dissatisfaction. these studies overlook the relationship between burnout, work satisfaction, and career longevity, as well as the impact of mental health stigma on both patients and professionals. this lack of awareness creates a gap in understanding how public views towards mental health influence psychiatrists’ job satisfaction and professional identity in various cultural situations. given the different approaches to the methodology of the above studies (sample sizes, types of questionnaires, statistical analysis of the results), it is incorrect to use their data to compare the job satisfaction of psychiatrists in differing regions. therefore, it is important to analyse those aspects that will allow more accurately determining the level of professional satisfaction of psychiatrists by analysing the factors that form this indicator. the fact that the majority of psychiatrists’ job satisfaction surveys focus on determining the level of burnout, stress, and depersonalisation indicates the relevance and severity of this problem among practitioners. however, it is worth noting that these negative aspects of professional activity are the result of a combination of factors that affect the overall level of job satisfaction. the existing literature on the challenges faced by psychiatrists is limited, with significant research gaps. these include a need for a comprehensive exploration of factors influencing job satisfaction beyond burnout and stress, a deeper analysis of systemic and cultural influences, and a comparative examination of healthcare systems’ impact on professional satisfaction. this study aims to address these gaps by examining a wider range of factors contributing to job satisfaction, situating them within the context of mental health systems and societal attitudes, and providing strategies for improving work environments and job satisfaction. the goal of the research was to identify and analyse the factors that determine the professional satisfaction of psychiatric doctors. the tasks of the study included comparing the job satisfaction of psychiatrists in poland, europe, and the world in general and finding the best ways to improve this indicator. the factors influencing the professional satisfaction of psychiatrists were determined by analysing materials from scientific sources in psychiatry, psychology, and sociology. the search for publications was conducted among materials in the pubmed, google scholar, and scopus databases. the query was formed using the keywords: “satisfaction with the work of psychiatrists”, “indicators of psychological satisfaction of doctors in psychiatric departments”, “level of professional satisfaction of psychiatrists”. according to this request, 26 articles were selected. in this research such methods as secondary data analysis, thematic analysis, comparative analysis, synthesis were used. a comparative analysis of the job satisfaction of practicing psychiatrists in poland, europe, and the world was carried out. for this purpose, the available materials containing descriptive or statistical information on each of the previously identified factors in the respective regions were used. in addition to these databases, information was searched for among the materials available on the internet that contained data on the resource provision of the healthcare sector in these regions. the following keywords were used for the search: “level of remuneration/salary of psychiatrists in poland/europe/world”, “working conditions of psychiatrists in poland/europe/world”, “provision of the field of psychiatry in poland/europe/world”, “social status/recognition of psychiatrists in poland/europe/world”, “stigmatisation of mental illness in poland/europe/world”. a total of 33 relevant sources were selected. given the results and the author’s conclusions, the researcher searched for effective methods to increase the level of professional satisfaction of practicing psychiatrists. social and political factors affecting public health [page 112] [healthcare in low-resource settings 2024;12(s2):12906] non -co mmerc ial us e o nly determination of indicators of professional satisfaction of psychiatric doctors, taking into account the specifics of the speciality in addition to psychiatrists, psychiatry departments may employ neurologists and general practitioners, as well as specialists in related fields such as psychologists, psychotherapists, art therapists, occupational therapists, ergotherapists, and other specialists, depending on the profile of the department, the needs of patients, and the resources of the healthcare facility. given that these doctors, regardless of their specialities, work with people with suspected or confirmed mental disorders, it is important to identify factors specific to the field of psychiatry in addition to general satisfaction factors when determining their professional satisfaction. the level of remuneration, working conditions, microclimate in the team (relationships with colleagues), resource support for the work process and career development opportunities are important for any specialist and have a significant impact on the assessment of professional satisfaction. stress level, burnout level, sense of importance of own activity, work-life balance, sense of pride in the profession can be attributed to factors inherent in the medical profession, taking into account the level of responsibility, psychological impact and working time regulation. the most specific factor of professional satisfaction for psychiatric doctors is the stigma of mental illness in society. the level of remuneration, i.e. the salary of psychiatric doctors, generally corresponds to the salary of doctors of other specialities.9 however, there is an opinion among a certain number of psychiatrists that the level of material remuneration is insufficient, given the specifics of their profession and the stressful nature of their work.10 the working conditions of psychiatrists depend on the number of staff involved in the work and the quality of communication between them, the standardization of working hours, the comfort of the psychosocial environment of the healthcare facility and the sufficiency of professional equipment and materials for professional activities. the number of staff involved affects the optimal distribution of working time and helps to avoid overload, while maintaining the efficiency of doctors during the work shift.11 interaction between staff creates a healthy atmosphere in the team and provides an opportunity to share experiences, consult and receive assistance in crisis situations.12 the environment of a healthcare facility affects the psychological and physical wellbeing of a doctor and can reduce his or her effectiveness. for example, studies have shown that: i) exposure to noise can lead to increased levels of stress, anxiety, and fatigue in doctors and negatively affect concentration and decision-making;13,14 ii) exposure to dim lighting provokes anxiety and depression;15 iii) exposure to bright artificial lighting disrupts doctors’ sleep, leading to overwork and reduced performance;16 iv) exposure to poor air quality leads to the development of respiratory diseases, allergies, headaches, dizziness, and nausea;17,18 v) exposure to unergonomic workplaces and places for rest causes musculoskeletal problems, increased fatigue, and reduced performance.19 the level of provision of professional equipment and materials for professional activities can affect the quality of doctors’ work, increase or decrease stress and burnout, and change the level of motivation, retention, or outflow of staff.20,21 relationships with colleagues are one of the factors that influence working conditions and depend on personal relationships between staff, the correct rules of subordination, and the level of professional solidarity in the community. interpersonal relationships are determined by the level of communication between staff, the presence or absence of trust and respect, acceptance or rejection of the character, behaviour, and values of colleagues, and the impact of personal successes or problems on mitigating or aggravating relationships in the team.22,23 the correct construction of subordination rules and their observance can ensure the effectiveness of solving existing professional, organisational, and interpersonal problems, while incorrect subordination can lead to abuse of power, building a rigid hierarchy, deterioration of the microclimate in the team, and suppression of cooperation between doctors.24 professional solidarity among psychiatric doctors is correlated with a sense of cohesion and unity and affects the level of support and protection in the team, promotes the effectiveness of peer-topeer cooperation or mentoring, and creates a sense of belonging to a professional community.25 on the other hand, the lack of solidarity or its low level leads to isolation, conflicts, a lack of support, cooperation, and a sense of protection, which can significantly reduce professional satisfaction and provoke disillusionment with the profession. resource provision of the workflow affects: working conditions, as it determines the number of staff involved in the work and, accordingly, the distribution of working time; convenience of the healthcare facility environment for staff and patients; comfort and ergonomics of the workplace; places for doctors to rest and rooms for patients to stay; level of professional equipment, facilities, and materials; provision of a sufficient number of patient beds; necessary devices for diagnosis, treatment, and rehabilitation; instruments and medicines.26 there are several career paths in the field of psychiatry. practitioners who focus on clinical work can, according to their specialisation, grow to the position of department head or use their clinical experience to conduct research while building a career as a researcher or teacher.27 given that career advancement is perceived as professional recognition and is accompanied by an increase in salary, it has a significant impact on increasing the level of job satisfaction of psychiatric doctors. the level of stress experienced by psychiatrists is caused by contact with patients with mental disorders. depending on the type and severity of such disorders, during their work, specialists find themselves in emotionally exhausting situations (exacerbation of psychosis, patient suicide) and face the risks of insults, threats, and physical violence.28 these factors contribute to the fact that the level of stress in psychiatric doctors is higher than in doctors of other specialities.29 prolonged exposure to stress reduces professional satisfaction and can cause emotional burnout. the characteristics of this condition include exhaustion, loss of enthusiasm, reduced empathy, and the development of cynicism. studies have shown that, like stress levels, the level of emotional burnout in psychiatrists is higher than in doctors working in other specialities.30 the sense of importance in one’s own work is the perception of one’s work as beneficial to society – relieving suffering and improving the lives of patients with mental disorders. this perception creates a sense of pride in one’s profession and can help to cope with stress and emotional burnout.31 the specifics of working in psychiatric wards can affect doctors’ personal lives and lead to relationship problems. exacerbation of the problem negatively affects moral well-being and may lead to thoughts about changing professional activities.32 maintaining a work-life balance determines the level of professional satisfaction of psychiatrists. the stigmatisation of mental illness is a factor that affects the decrease in the level of professional satisfaction of psychiatric doctors. its causes are discrimination, prejudice, and devaluation by society, which can lead to a sense of isolation, reduced self-esteem, the development of feelings of guilt or shame, a loss of enthusiasm, and disappointment at work.33,34 having examined the indicators of professional satisfaction of psychiatric doctors, a dependence was found between them, which can be direct – an increase in the level of one indicator social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12906] [page 113] non -co mmerc ial us e o nly will lead to an increase in another (an increase in the level of provision of the industry will lead to improved working conditions), or the opposite – an increase in the impact of one indicator will provoke a decrease in the impact of another (a sense of the importance of one’s own work will reduce the level of stress and professional burnout). this pattern is important to take into account when analysing ways to increase the level of professional satisfaction. analysis of professional satisfaction of psychiatric doctors in poland, europe, and the world since there are currently no clear statistics on the level of professional satisfaction of psychiatrists globally and by region, a comparative analysis of this indicator was conducted based on surveys of psychiatrists on certain factors of job satisfaction and statistical data on the resource provision of psychiatric departments in the regions studied. the human resource provision corresponds to the number of practising psychiatrists in psychiatry departments. although it does not reflect a general understanding of professional satisfaction, it can influence the level of working conditions and reveal a trend towards development, stability, or decline in the industry. according to data from 2021, the number of psychiatrists employed in poland was 4914. compared to 2020, it increased by 5.56% and became the highest since 2007.35 it is worth paying attention to the fact that in 2018, this number was estimated at 3277 doctors, and in 2019 it was 4436. the sharp increase in the number of employed psychiatrists by 26.13% indicates the presence of a number of factors that provoked it. the main ones were: an increase in mental health funding in 2018; an increase in the number of mental illnesses due to increased stress, anxiety, drug, and alcohol addiction; and demographic changes provoked by population ageing.36-38 thus, the trend towards an increase in the number of practicing psychiatrists indicates the development of the psychiatric field and has a positive impact on increasing the level of professional satisfaction of doctors in this speciality, affecting the improvement of working conditions, as an increase in the staff makes it possible to optimise working hours and avoid overload. however, the number of practicing psychiatrists in poland is still lower than in other european countries, taking into account the population of the countries (figure 1). statistics show that among the european countries mentioned, the united kingdom, denmark, estonia, and iceland have approximately the same level of population provision with psychiatrists; the highest rates are recorded in switzerland and norway, and the lowest are recorded in poland. the general trend indicates that the number of psychiatrists in the studied countries is increasing every year, the greatest stability is observed in denmark,40 a decrease in the number compared to 2020 is recorded in estonia (272 doctors in 2020, 256 in 2021),41 and in iceland, the highest rates were in 2016 (86 doctors, compared to 75 in 2021).42 given that in 2020, the proportion of the european population that used professional help to address mental health problems was 21%, the approximate workload of psychiatric doctors in britain, estonia, austria, denmark, iceland, and norway will be about 1,000 patients per year, in switzerland, about 400, and in poland, up to 1,500.46 although the data is approximate, the difference in workload between polish and european doctors is obvious. a comparison of resource provision for psychiatry can be analysed by the level of government spending on the needs of the sector (figure 2). the highest level of provision in the psychiatric sector is observed in switzerland, denmark, iceland, and norway, which are almost at the same high level, a fairly high level is observed in austria, and significantly lower resources are allocated to the sector in the uk, poland, and estonia. given that resource support affects working conditions, the quantity and quality of equipment and materials required to work with patients, and the comfort of the workplace, its limitations can affect the quality of medical care and professional satisfaction of psychiatric doctors. this analysis shows that the resource provision of psychiatry, as one of the indicators of influence on job satisfaction, is on average higher in european countries than in poland. it is worth noting that the highest indicators are in scandinavian countries, which are approximately 5 times higher than in poland. the level of remuneration, which is an important factor in determining the professional satisfaction of psychiatric doctors, can be analysed by comparing their average annual salary (figure 3). social and political factors affecting public health figure 1. statistics on the level of provision of the population with psychiatric services in european countries. notes: statistics on the number of people per practising psychiatrist in denmark, in the absence of data, are taken for 2020. source: compiled by the authors based on 35; 39-45. figure 2. statistics on per capita expenditures on mental health care in europe. notes: statistics on the level of psychiatry provision per capita, in the absence of up-to-date data, are taken for 2020. source: compiled by the authors based on 47-54. figure 3. statistics on the average annual salary of psychiatrists in european countries. source: compiled by the authors based on 55-62. [page 114] [healthcare in low-resource settings 2024;12(s2):12906] non -co mmerc ial us e o nly switzerland has the highest average annual salary of psychiatrists among these european countries, with approximately the same level in iceland, denmark, austria, and norway, and a slightly lower level in the uk. estonia and poland have the same level of financial remuneration and are almost twice as low as other countries. these data correlate with indicators of the industry’s resource endowment and are an important indicator of psychiatrists’ job satisfaction. despite belonging to the same region, the analysis of statistical data revealed significant differences between the number of practicing psychiatrists, the material support of the psychiatry sector, and the level of average salaries of specialists in different countries. the scandinavian countries and austria have an advantage in most of these indicators, while the lower level is recorded in eastern european countries, including poland. thus, it can be concluded that the level of professional satisfaction of practising polish psychiatric doctors is currently lower than the european average. the low job satisfaction of psychiatrists in poland is also confirmed by the results of surveys that determine the level of stress and emotional burnout.63,64 given the specifics of the work, these indicators are also high among physicians in other countries, which indicates that the problem of stress and burnout is common to european psychiatry specialists.65 the level of professional satisfaction of psychiatric doctors in different countries differs depending on the healthcare system, the financing of the sector, and the social status of the profession. the tendency to increase the level of professional satisfaction of psychiatrists depending on the number of patients per doctor, the level of resource provision in the industry, and the salary of a specialist, similar to in european countries, remains for the world as a whole. the social status of the profession of psychiatry is usually determined by the level of stigmatisation of mental illness in society. despite civilisational processes and an increase in the level of education, stigma is still a widespread problem in many countries. prejudice, negative stereotypes, discrimination, and social isolation not only complicate the treatment process and further adaptation of the patient but are also projected onto the doctor who comes into contact with patients. thus, a difficult treatment process and the associated stress lead to a decrease in job satisfaction and may influence thoughts about changing professions. research has shown that the highest levels of mental illness stigma are found in countries with low incomes, collectivist cultures, and strict religious traditions. the high level of stigmatisation of mental illness in china is manifested through discrimination against patients and their families in professional and social life.66 in the collectivist culture of this country, mental illness often acquires signs of moral weakness, which distinguishes a person from the general community. in india, the collectivist culture, reinforced by the influence of religious traditions, can lead to the isolation of the patient from the community and sometimes from the family. a similar trend is observed in saudi arabia, nigeria, and zimbabwe, where, depending on a distorted interpretation of the causes of mental illness (witchcraft, obsession, karma), people with mental disorders may be subjected to isolation, abuse, or violence.67 the level of stigmatisation of mental illness in poland differs significantly from the level in the countries listed above, but it is still significant. stigmatisation is expressed in the form of the perception of people with mental disorders as dangerous, unpredictable, and incapable of professional and social activities. this influence is determined by the level of public awareness. this trend is being reversed by introducing provisions in state legislation prohibiting discrimination against people with mental disorders and introducing social programs to educate and inform the public about the specifics of mental disorders. the level of salary, resource provision in the psychiatric sector, and social status of the profession are important indicators of the professional satisfaction of doctors in psychiatric departments. the analysis showed that the highest level of these indicators is in countries with a high level of social and economic development. in poland, they have lower values than in some western european and scandinavian countries, but the tendency to increase funding and government and public initiatives to improve the social status of the profession indicate a positive trend in improving the main factors of professional satisfaction of psychiatric doctors. ways to increase the level of professional satisfaction of doctors in psychiatry departments improving the job satisfaction of psychiatric doctors is an important part of improving the state of the psychiatric sector and ensuring a decent level of mental health support for the population. ways to improve the level of professional satisfaction of psychiatrists include reducing workload, improving working conditions, increasing opportunities for professional development, supporting the mental health of doctors themselves, and increasing recognition and respect for the profession. the main condition for reducing the workload is, of course, an increase in staff, which requires additional funding for training and the remuneration of specialists. however, other less resourceintensive options can be considered to help relieve doctors of their workload. in this direction, it is worth paying attention to the study by lai et al.,68 which highlights certain organisational aspects that can be revised to optimise the workload of a doctor. based on surveys of psychiatry trainees in australia, researchers studied the impact of changes in mental health legislation on the development of stress. the analysis of the questionnaire revealed that, in addition to long working hours, trainee psychiatrists named the intensity of the workload as a factor of fatigue, which leads to overtime and the need to take some responsibilities home. the stress factor is exacerbated by a combination of a significant amount of administrative workload (increased volume and number of reports in accordance with the new legislation) and high emotional exhaustion due to the specifics of psychiatry (threats, aggression, and suicide of patients).69-71 although this study focusses on the problems of trainees in psychiatry departments, due to the need to combine administrative and practical activities, they are also relevant for experienced doctors. therefore, there are several ways to reduce the workload of doctors: differentiating both types of activities according to the doctor’s working hours; delegating administrative responsibilities to a part of the staff that is involved in providing psychiatric care to patients (clinic or department administrator, secretary); digitalizing and optimizing the reporting process. in addition, flexible work models, including part-time work, work from home, and the use of telemedicine, can be used to reduce workload. these models will help reduce the workload and maintain a balance between the professional and personal lives of doctors. in addition, analysing the results of the australian research, it is worth emphasising the conclusion drawn from the survey, which is that when changing the legislation on the provision of mental health services, the rights of doctors providing mental health services should be taken into account, in addition to the interests of patients. the imbalance between the interests of both parties can backfire and cause acute problems in the field of psychiatry. ways to improve the working conditions of doctors in psychiatric departments include providing comfortable workplaces and places for recreation and access to the technological and pharma social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12906] [page 115] non -co mmerc ial us e o nly ceutical resources necessary for quality practice.72 in addition to the material support of the doctors’ environment, it is important to create a favourable emotional atmosphere in the team. one of the ways to achieve it can be through the use of cooperation and mentoring programs, which will help to adapt young specialists to the profession and form in them a positive perception of work in the acquired speciality at the beginning of their career. individual or group mentoring and collaboration with experienced psychiatrists in the form of receiving feedback and advice while treating patients will be beneficial for developing professional skills and gaining valuable experience.73,74 opportunities for professional development can be enhanced by introducing accessible training programs and conferences and encouraging psychiatrists to participate in them, expanding opportunities for research by conducting research in their field and publishing their results, creating and promoting mentoring programs to deepen knowledge and improve skills. in addition to professional aspects, it is important to introduce students to effective self-help methods and techniques for managing stress and preventing emotional burnout in psychiatric in-service training programs.75,76 it is important that these programs are accessible to practicing psychiatrists and that the materials are updated in accordance with changes in their relevance. kilic et al.77 investigated the role of gender as a barrier to the professional development of psychiatrists. the authors conducted a survey among psychiatrists in 35 european countries and found that, compared to men, women were more likely to report gender discrimination that directly or indirectly affected their professional advancement. at the same time, it was noted that in the institutions where psychiatrists studied or worked, measures aimed at addressing existing gender biases were not regularly and extremely rarely taken. agreeing with the authors’ conclusions about the importance of institutional support for states to eradicate prejudice, create equal conditions for professional development, and create a respectful environment for psychiatrists of all genders, we can add that creating safe and inclusive conditions for psychiatric doctors, regardless of their age, race, religious beliefs, and sexual orientation, is important not only in terms of respect for human rights and freedoms in medical institutions but also for the development of the industry as a whole, as discrimination on certain grounds is a major threat to the health of the population. an important step to improve the professional satisfaction of doctors in psychiatric wards is to support mental health.78 this can be done in several ways: i) developing and providing access to mental health improvement and recovery programs; ii) organising support groups where psychiatrists can share problems, find support, and get useful advice from colleagues; iii) introducing integrative medicine methods such as yoga, meditation, acupuncture, and other methods for relaxation and stress reduction. increasing recognition and respect for the profession can be achieved by raising awareness of the importance of psychiatrists’ work and their contribution to the mental health of the community, encouraging public recognition of achievements, lobbying for the interests of the psychiatric community through political, public, and professional organisations, increasing the authority of doctors through the introduction of projects and initiatives useful for promoting the work of psychiatrists, and combating the stigma of mental illness.79,80 ran et al.81 conducted a systematic review of the level of mental illness stigma and factors that influence it in the pacific region. according to the study, the level of public stigma in the region ranged from 25.4% to 85.2%. among the factors that influenced the formation of a fairly high level of this indicator, scientists have identified collectivism, responsibility, and a sense of shame for certain differences perceived by the conservative community as deviations, imposed values of “normality”, belief in the supernatural, and religious beliefs. despite the differences between the cultural aspects of the pacific and european regions, it is possible to see overlaps between the factors that develop stigma in both regions. in western and parts of eastern europe, catholicism has long played an important role in shaping social norms and values that contributed to the stigmatisation of mental disorders, emphasising the patient’s responsibility for their condition due to moral weakness, obsession, or a sinful lifestyle.82 however, given the civilisational changes that have also affected such a conservative field as religion, the influence of the church can be used to combat the stigma of mental illness. the current level of education of the clergy makes it possible to properly understand the nature of mental disorders and spread awareness among believers, encouraging them to abandon false stereotypes and to understand and treat people with mental problems appropriately.83 when looking for ways to increase the level of professional satisfaction of psychiatric doctors, it is important to understand that there is no one-size-fits-all approach to ensuring it. it is important to focus on the needs and priorities of different groups of psychiatrists, regularly communicating and collaborating with them. the job satisfaction and enthusiasm of psychiatrists are essential for maintaining and improving the mental health of the population, and therefore improving it is one of the most important tasks of the psychiatric field. conclusions the study discovered that, while burnout and stress are substantial challenges for psychiatrists, they are not the only factors determining job satisfaction. significant factors such as professional development opportunities, work-life balance, and institutional support were regarded as equally essential for job satisfaction. in areas with well-established mental health policies and strong social support for mental health, these variables strongly lead to better levels of work satisfaction and professional contentment among psychiatrists. an analysis of the level of professional satisfaction of psychiatrists in poland, europe, and the world has shown that in terms of salaries and human and material support of the psychiatry sector, the world’s countries with a high level of social and economic development are the most satisfied. polish psychiatrists expressed lower levels of job satisfaction than their peers in western european and scandinavian nations. this inequality stems from disparities in funding allocation, professional recognition, and working conditions in psychiatric departments. the research demonstrates the need for a more comprehensive approach to resolving these imbalances, arguing for increased investment in mental health services, improved working conditions, and more opportunities for professional development and advancement. several ways are proposed for increasing psychiatrists’ professional satisfaction. these include increasing the number of staff, optimizing administrative tasks, improving working conditions, fostering a positive atmosphere through programs, increasing opportunities for professional development through training and mentoring, and promoting mental health recovery through support groups and integrative medicine. social projects can also enhance recognition and respect for psychiatrists by raising public awareness of their role in preserving and improving society’s mental health. since professional satisfaction is an indicator that can change social and political factors affecting public health [page 116] [healthcare in low-resource settings 2024;12(s2):12906] non -co mmerc ial us e o nly depending on many factors, it is necessary to constantly update relevant information. the study’s limitation was the lack of statistical data on satisfaction indicators for psychiatrists in poland, europe, and the world, affecting the sample size and analysis depth. future research should focus on longitudinal studies that examine the impact of systemic interventions, such as policy changes and enhanced institutional support, on psychiatrists’ job satisfaction across diverse cultural and healthcare settings. references 1. makara-studzińska m, murawiec s, matuszczyk m, załuski m. perceived life stress and the burnout syndrome in group of polish psychiatrists. psychiatria 2019;16:185-92. 2. wontorczyk a, izydorczyk b, makara-studzińska m. burnout and stress in group of psychiatrists: workload and 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pride and job satisfaction according to certain variables. participatory educ res 2021;8:1-23. 32. hicks mh. “what are you?” a recurring question in a cross-cultural psychiatrist’s life and career. transcultural psychiatry 2011;48:37-52. 33. taguibao c, rosenheck r. medical education and the stigmatization of mental illness in the philippines. cult med psychiatry 2021;45:312-31. 34. jauch m, occhipinti s, o’donovan a. the stigmatization of mental illness by mental health professionals: scoping review and bib social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12906] [page 117] non -co mmerc ial us e o nly liometric analysis. plos one 2023;18:e0280739. 35. statista. number of psychiatrists employed in poland from 2007 to 2021. 2024. available from: https://www.statista.com/ statistics/462675/psychiatrists-employment-in-poland/ 36. gańczak m, miazgowski t, kożybska m, et al. changes in disease burden in poland between 1990-2017 in 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ha. editorial: growing up in a high-stigma context: an unseen driver of neurodevelopment, health, and pathology. j am acad child adolesc psychiatry 2022;61:749-51. 68. lai r, teoh k, plakiotis c. the impact of changes in mental health legislation on psychiatry trainee stress in victoria, australia. adv exp med biol 2023;1425:199-205. 69. smoliuk n, shulhai ah. peculiarities of professional burnout of nurses in war conditions. bull med biol res 2024;6:64-72. 70. vyshka g, seferi a, myftari k, et al. last call for informed consent: confused proxies in extra-emergency conditions. indian j med ethics 2014;11:252-4. 71. kamkhen v, aidasheva d, mamyrbekova s, et al. dynamics of indicators characterizing the health of kazakhstani youth. univ j publ health 2024;12:218-27. 72. sadowska m, mehlhorn c, średniawa w, et al. spreading depressions and periinfarct spreading depolarizations in the context of cortical plasticity. neurosci 2021;453:81-101. 73. shcherban t, dolynay t. psychology of doctor-patient interaction in the context of medical specialist’s communicative tolerance. sci bull mukachevo state univ ser pedagogy psychol 2024;10:9-21. 74. sadvakassova n, karmanova z, danek j. stress conditions in preschool children with special educational needs. rev int geogr educ online 2021;11:1646-53. 75. guo s, izydorczyk b, lipowska m, et al. socio-cultural attitudes toward the body as a predictor of motivation for physical activity in young people brought up in asian and european culture – chinese-polish comparison. bmc sports sci med rehab 2023;15:52. 76. guo s, izydorczyk b, lipowska m, et al. sociocultural predictors of obligatory exercise in young men: a polish-chinese comparison. front psychiatry 2023;14:1123864. 77. kilic o, riecher-rössler a, galderisi s, et al. the role of gender as a barrier to the professional development of psychiatrists. eur psychiatry 2023;66:e89. social and political factors affecting public health [page 118] [healthcare in low-resource settings 2024;12(s2):12906] non -co mmerc ial us e o nly 78. kamkhen vb, mamyrbekova sa, daniyarova ab, et al. specifics of the mental component of the quality of life of almaty doctors in the context of the covid-19 pandemic. physic activ health 2022;6:201-7. 79. shapran yp, bilyk lv. professional training of medical specialists in the aspect of physical rehabilitation. scientia societus 2023;2:9-15. 80. latka k, kolodziej w, domisiewicz k, et al. outpatient spine procedures in poland: clinical outcomes, safety, complications, and technical insights into an ambulatory spine surgery center. healthcare 2023;11:2944. 81. ran ms, hall bj, su tt, et al. stigma of mental illness and cultural factors in pacific rim region: a systematic review. bmc psychiatry 2021;21:8. 82. patelarou e, galanis p, mechili ea, et al. assessment of covid-19 fear in five european countries before mass vaccination and key predictors among nurses and nursing students. vaccines 2022;10:98. 83. bocheliuk vy, spytska lv, mamicheva ov, et al. psychological features of post-covid syndrome course. int j health sci 2021;5:276-85. social and political factors affecting public health [healthcare in low-resource settings 2024;12(s2):12906] [page 119] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):xxx [healthcare in low-resource settings 2024;12(s1):13048] [page 41] significance for public health this study is the first of its kind to investigate the correlation between peer social support and family psychological resilience in caring for chronic kidney disease patients receiving hemodialysis critically. the results show the importance for healthcare professionals to address the psychological well-being of families, enabling them to adapt and have resilience in supporting and caring for chronic kidney disease patients. families with high psychological resilience are poised to experience improved quality of life and adherence to hemodialysis therapy. healthcare in low-resource settings 2024; volume 12(s1):13048 the role of peer social support on family psychological resilience in caring for chronic kidney disease patients receiving hemodialysis lilik supriati,1 muhammad sunarto,1 ikhda ulya,1 muhammad rodli,2 rendi yoga saputra,3 renny nova,1 nur hidaayah4 1department of nursing, faculty of health sciences, universitas brawijaya, malang, east java; 2institute of science technology and health hospital dr. soepraoen, malang, east java; 3radjiman wediodiningrat state mental hospital, malang, east java; 4department of nursing, faculty of nursing, universitas nahdlatul ulama surabaya, surabaya, east java, indonesia abstract chronic kidney disease (ckd) is a disease that necessitates continuous hemodialysis (hd) therapy, and families, as primary caregivers in indonesia, play a crucial role in caring for ckd patients. however, hd therapy places a significant burden not only on patients but also on their families, requiring fostering family psychological resilience to mitigate such a burden. although peer social support is an important external factor in chronic disease, it is still underdeveloped. therefore, this study aimed to explore the correlation between peer social support and family psychological resilience in caring for ckd patients receiving hd. this cross-sectional study used purposive sampling, engaging 134 families serving as caregivers for patients receiving hd therapy. the berlin social support scales (bsss) and the walsh family resilience questionnaire (wfrq) were adopted as instruments, and data were analyzed using univariate and spearman tests. the majority of families reported high levels of peer social support (75,37%), predominantly originating from other members facing similar challenges related to caring for ckd patients. additionally, a significant relationship was observed between peer social support and family psychological resilience (p-value<0.05), showing that higher levels of peer support corresponded to higher family resilience. in conclusion, there was a strong correlation between peer social support and family resilience in the context of caring for ckd patients. healthcare professionals should integrate social support intervention by establishing social groups to enhance family resilience. introduction the prevalence of chronic kidney disease (ckd) is increasing,1 making it one of the most rapidly growing noncommunicable diseases (ncd) with significant mortality and morbidity burdens.2 globally, kidney disease affects over 750 million individuals, as reported by global health authorities.2,3 according to the basic health study in 2018, the prevalence of chronic kidney failure was 0.38%, accounting for 713,783 individuals in indonesia. east java province ranks second nationally in terms of the highest number of chronic kidney failure cases, with nearly 113,045 individuals affected.4,5 specifically, in malang city, the prevalence of the disease exceeds 2,500 patients, a number expected to rise due to the increasing cases of diabetes and hypertension.4 patients with ckd need hemodialysis (hd) therapy to sustain their lives,6 with the majority receiving long-term treatment and managing self-care behaviors to maintain a healthy lifestyle at home. however, the prolonged duration of care at home can lead to a sense of burden among families caring for hd patients. the burden arises from the continuous need for medical intervention and the extended treatment duration.7 typically, chronically diseased patients receive care from an informal support system,8 with family caregivers playing a crucial role in the care. caring for individuals with long-term kidney disease poses a psychological burden on families serving as primary caregivers at home due to the various challenges associated with hd.9 ckd poses a significant threat to the health, economic, and social well-being of affected individuals and their families.10,11 the burdens experienced by families include financial, physical, social, and psychological aspects. social burden restrict families’ ability to socialize with relatives or friends, while physical burden lead to fatigue from the extensive time spent caring for hd patients. psychological burden manifests as feelings of embarrassment, anger, and disappointment about the current situation. additionally, the financial burden results in economic instability due to the considerable costs associated with hd.8,12,7 families, as caregivers also encounter challenges in navigating various health and social care settings,8 seeking treatments, and managing the associated costs, leading to additional stress. therefore, families require psychological resilience to cope with these challenges.9,12 family resilience in caring for chronic disease has garnered attention from analysts in recent years.10,13 family psychological resilience serves as a strategy for families to navigate pressure, challenges, or conflicts arising from caring for hd patients, enabling them to overcome discomfort and pressure effectively.14,15 high resilience is essential for families caring for the patients, with positive resilience arising from high non -co mmerc ial us e o nly self-confidence and belief.16 this resilience enables families to fulfill their functions effectively and adapt positively to stressful situations.17,18,19,20 viewing family resilience from a relational perspective acknowledges the interconnectedness of individuals within familial networks managing the complex demands of hd treatment.14 resilience, influenced by both internal and external factors, is essential for families navigating the challenges of caring for hd patients.21 external encouragement, known as social support, plays a crucial role in aiding families to overcome the challenges. social support includes various forms of attention, enthusiasm, appreciation, acceptance, and assistance from multiple sources. peer support, a specific type of social support, provides a complementary approach to addressing patients’ emotional well-being and informational needs.22 it comprises individuals with firsthand experience of a condition sharing knowledge and experiences to support others facing similar health-related issues caring for ckd patients benefit from peer social support offered by individuals or families facing similar challenges.23 families caring for ckd patients also benefit from peer social support provided by those experiencing similar challenges.24 social support, recognized as an effective intervention, can manifest in various aspects, including emotional, appreciative, informational, and instrumental,25 nurturing hope among hd patients.26 several reviews have shown that peer social support helps alleviate depression and burden while fostering a positive outlook for families.24,27 support from families and friends plays a crucial role in coping with the advanced stages of chronic renal failure.10 however, investigations on the correlation between peer social support for families and resilience in caring for ckd patients remain limited. materials and methods design this study used a cross-sectional design with an observational method. sample the data collection was carried out from march to october 2023, engaging families caring for ckd patients receiving hd therapy at lavalette hospital in malang city, east java province. the samples were families meeting the specific inclusion criteria, comprising, those caring for ckd patients receiving hd therapy for 1—5 years, aged at least 19 years old, cooperative, and proficient in indonesian communication. a total of 134 families of ckd patients participated in this study, through the purposive sampling method. ethical consideration this study received ethical clearance under number 6806/un10.f17.10.4/tu/2023 from the faculty of health sciences, universitas brawijaya, indonesia. data collection and procedures the research process commenced with licensing and obtaining ethical clearance. detailed informed consent was obtained from each participant without coercion to participate in the study. data were collected offline using a paper-based questionnaire tailored to each participants condition, and statistical analysis was performed using spss. the data input process consisted of editing to ensure completeness, coding for scoring and interpretation, and checking 4th international nursing and health sciences symposium table 1. family characteristics. characteristics category frequency (f) percentage (%) age 19-44 years 47 35.1 45-59 years 63 47.0 ≥ 60 years 24 17.9 gender male 50 37.3 female 84 62.7 education no education 1 0.7 elementary school 18 13.4 junior high school 23 17.2 senior high school 57 42.5 university 35 26.1 work working 60 44.8 no working 74 55.2 economy status under the minimum wage for work 117 87.3 above the minimum wage for work 17 12.7 family relationship with patients parents 17 12.7 husband/wife 78 58.2 grand parents 1 0.7 child 30 22.4 grand child 2 1.5 siblings 6 4.5 distance of home to hospital near (10 kilometers) 69 51.5 far enough (10-20 kilometers) 34 25.4 far (more than 20 kilometers) 31 23.1 length of time for caring patients 1-2 years 85 63.4 3-5 years 49 36.6 [page 42] [healthcare in low-resource settings 2024;12(s1):13048] non -co mmerc ial us e o nly for missing data and errors. univariate and bivariate tests were conducted for data analysis. an instrument for data collection the walsh family resilience questionnaire (wfrq) was adopted to assess family psychological resilience, comprising the indicator of belief systems, organizational patterns, and communication/problem-solving. the questionnaire consisted of 26 questions, rated on a scale from 1 (strongly disagree) to 5 (strongly agree), with a total score range of 26 to 130. similarly, the berlin social support scales (bsss) questionnaire was used to evaluate peer social support, covering emotional, instrumental, appreciation, and informational. the questionnaire consisted of 12 questions, also rated from 1 to 5, resulting in a total score range of 12 to 48. both instruments received rigorous testing for reliability and validity. the wfrq questionnaire showed validity with a value range of r = 0.493-0.948 and a reliability score of 0.957. the bsss had a reliability value of 0.941 and validity ranging from 0.521– 0.915. data analysis the collected data were subjected to screening for missing items, followed by the computation of total scale scores for peer social support and family psychological resilience. the score of each variable was categorized as high (96-130), sufficient (61-95), and low (26-60). peer social support was categorized to be high (36-48), medium (2435), and low (12-23). statistical analysis was performed through univariate and spearman rank correlation, using spss version 25. results and discussion table 1 presented the characteristics of the participants, indicating that the majority of them fell within the 45-59 age range (47%) and had a senior high school education background (42,5%). a significant portion of the participants were unemployed (55,2%) and the majority had incomes below the minimum wage (87,3%). all of them had a familial relationship with the patients, predominantly as spouses. most of the participants resided in close proximity to a hospital (69%), with an average distance of around 10 kilometers. additionally, the duration of caregiving at home ranged from 12 years for the majority (63,4%). in table 2, the independent variables were described, suggesting that the emotional support received by families in caring for ckd patients was largely categorized as high (76.11%), with only a small percentage falling into the low category (3.73%). meanwhile, instrumental, appreciation, and information support received by families were mostly at high levels (79.10%, 85.07%, and 85.3%, respectively). the results showed that peer social support enjoyed by families caring for ckd patients receiving hd was generally at a high level. table 3 presented the description of dependent variables, indi 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):xxx] [page 43] table 2. distribution of independent variables. variable category low medium high f % f % f % emotional support 5 3.73 14 12.1 102 76.11 instrumental support 6 4.47 10 8.6 106 79.10 appreciation support 2 1.49 5 4.3 114 85.07 informational support 2 1.49 15 12.9 99 85.3 peer social support 8 3.73 25 18.65 101 75.37 table 3. distribution of dependent variables variable category low medium high f % f % f % belief systems 5 0.9 8 2.6 121 96.6 organization patterns 7 1.7 12 9.5 115 88.8 communication/problem-solving 8 2.6 10 5.2 116 92.2 family psychological resilience 9 6.71 14 10.44 111 82.83 table 4. correlation peer social support and psychological family resilience peer social support family psichological resilience total p r correlation low medium high n % n % n % n % low 5 2.58 2 0.86 0 0 7 3.44 0.000 0.584 medium 0 0 5 2.58 14 9.46 19 12.04 high 0 0 2 0.86 97 83.42 108 84.24 uji spearman’s rho r= 0.584** p-value 0.000. **. significant. non -co mmerc ial us e o nly cating that the indicators of family resilience, specifically belief systems, predominantly fell within the high-level category (96.6%). additionally, organizational patterns and communication/problem-solving fell into the high level for the majority (88.8% and 82.83% respectively). the results showed that family psychological resilience in caring for ckd patients receiving hd tended to be predominantly at a high level. in table 4, a significant relationship between peer social support and family psychological resilience (p-value < 0.05) was observed, with a strong positive correlation of r = 0,584. this implied that higher levels of peer social support were associated with better family psychological resilience in caring for ckd patients receiving hd. this study aimed to measure the correlation between peer social support and family psychological resilience in caring for ckd patients receiving hd. the results showed that peer support received by families caring for ckd patients fell within the high category. the analysis was in line with previous reviews indicating the importance of peer social support from friends or families facing similar challenges.27 peer support covered a range of supportive actions, including understanding, attention, and affection, which individuals could access through their social relationships with others, groups, or communities, thereby enhancing the quality of life.6,7 families encountering similar challenges of caring for ckd patients often showed mutual care and empathy when interacting with other families in hospital settings.23 sharing experiences and information regarding caring for the patients receiving hd could alleviate stress and family burdens. social support covered four types, appreciation, instrumental, emotional, and informational. the predominant type of social support received by families in this study was appreciation. chronic diseases such as breast cancer and ckd require complex treatment due to their inherent uncertainty. however, emotional support from peers facing similar diseases was crucial in helping families and patients manage psychological challenges.28-30 appreciation support, identified as the most common form of support received by 114 families (85,07%), consisted, of showing positive appreciation, encouragement, and approval of ideas or individual feelings. families reported receiving consistent encouragement and support from individuals around them, which corroborated with previous reviews indicating high-esteem support characterized by positive reinforcement, constructive criticism, and appreciation for efforts made, thereby fostering motivation.31 appreciation support could build individuals’ self-esteem, leading to greater respect from others.32 patients receiving hd faced mental and health challenges, which also affected their families.10 in indonesia, families played a crucial role as primary caregivers, with the majority of participants having a relationship with ckd patients as spouses (58,2%). this was in line with the investigation conducted in other indonesian hospitals, where “caregivers” included spouses, children, grandchildren, nieces, nephews, and acquaintances. families served as the primary caretaker and provided support for self-management and other necessities.33 caring for a chronic disease, particularly ckd comprised managing the demands of the disease and coping with the associated stress.17 the results showed the majority of families had high resilience (82.83%), attributed to the fact that most of them (63.8%) had been caring for ckd patients for 1-2 years. the analysis was in line with previous reviews suggesting that spending more time caring for the patients enabled families to become more adaptable.21 as caregivers provided care over an extended period, they tended to experience fewer emotional problems and develop better-coping mechanisms. consequently, families with high resilience tended to experience lower levels of depressive symptoms.15,21 family resilience covered three indicators, including belief systems, organizational patterns, and communication and problemsolving processes.15,19 the results showed that the most commonly experienced type of resilience among families was belief systems (96.6%). belief systems comprised the family’s positive interpretation of events, such as maintaining optimism about the future or having faith in god.19 families with good knowledge, an optimistic outlook, and strong religious beliefs or confidence could reduce feelings of anxiety and enhance their readiness to care for ckd patients at home.15,7 this was in line with previous reviews indicating that families managing chronic disease strive for selfadjustment by adapting to uncertainty and overcoming family 4th international nursing and health sciences symposium correspondence: lilik supriati, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia,. tel.: +62341569117, fax: +62341564755 e-mail: liliks.83@ub.ac.id key words: chronic kidney failure; family social support; hemodialysis; psychological resilience contributions: ls and ms significantly contributed to the conceptualization, study design, and data collection. iu and rn conducted data analysis and interpretation. nh, mr, and ry were engaged in manuscript drafting. ls and ms critically revised the manuscript for important intellectual content and provided final approval for publication. conflict of interest: the authors declare no potential conflicts of interest. funding: this study received funding from the research institutes and community service (bppm) faculty of health science, universitas brawijaya. the authors deeply appreciate the support received for the article. ethics approval: this study received ethical clearance under number 6806/un10.f17.10.4/tu/2023 from the faculty of health sciences, universitas brawijaya, indonesia. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors thank all participants, and also extend their appreciation to the research institutes and community service (bppm) faculty of health science, universitas brawijaya, for funding this study. they deeply acknowledge everyone who contributed to the completion of the analysis. received: 4 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13048 doi:10.4081/hls.2024.13048 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 44] [healthcare in low-resource settings 2024;12(s1):13048] non -co mmerc ial us e o nly problems related to disease.21,34,29 the analysis showed a significant relationship between peer social support and family psychological resilience (p-value <0.05), suggesting that higher levels of peer social support corresponded to increased family resilience. the results were in line with previous reviews indicating that peer social support served as a predictor of quality of life, not only for patients but also for their families. peer support played a crucial role in fostering relationships and preparing individuals for uncertainty.23 moreover, it motivated families to support patients in adhering to therapy regimens.1,27 positive peer support and family resilience were associated with improved adherence to functional exercise, leading to a reduction in symptom burden. the results contributed to the understanding of the positive psychological and social implications of family resilience.21 conclusions in conclusion, peer social support and family resilience in caring for ckd patients receiving hd predominantly fell into the high category. the strong correlation between peer social support and family resilience showed the importance of enhancing peer social to support family psychological resilience in caring for ckd patients. health workers should consider integrating social group interventions to strengthen family resilience. references 1. rivera e, clark-cutaia mn, schrauben sj, et al. treatment adherence in ckd and support from health care providers: a qualitative study. kidney med 2022;4:100545. 2. bikbov b, perico n, remuzzi g. disparities in chronic kidney disease prevalence among males and females in 195 countries: analysis of the global burden of disease 2016 study. nephron 2018;139:313–8. 3. crews dc, bello ak, saadi g. 2019 world kidney day editorial burden, access, and disparities in kidney disease. j bras nefrol 2019;41:1–9. 4. pratiwi wn, gayatri pr, astutik ws, et al. the role of family support in stress and anxiety conditions in the elderly with chronic kidney disease underwent hemodialysis therapy. adi husada nurs j 2023;9:20. 5. ministry of health republic of indonesia. basic health research results 2018. jakarta: ministry of health republic of indonesia; 2018. 6. karadag e, ugur o, mert h, erunal m. the relationship between psychological resilience and social support levels in hemodialysis patients. j basic clin helath sci 2019;3:9–15. 7. tong a, lowe a, sainsbury p, craig jc. experiences of parents who have children with chronic kidney disease: a systematic review of qualitative studies. pediatrics 2008;121:349–60. 8. bayoumi mm. subjective burden on family carers of hemodialysis patients. open j nephrol 2014;04:79–85. 9. taset alvarez y, martinez fajardo lll. family caregivers-of patients with chronic renal failure terminal psychological stress. moj addict med ther 2018;5:214–21. 10. hajmohammadi r, shirazi m. predicting resilience via social support and illness perceptions among patients undergoing hemodialysis. jundishapur j chronic dis care 2017;6. 11. silva junior gbd, barbosa amdo, silva gpfd, et al. depressive symptoms in chronic kidney disease: a comparison between patients on dialysis versus conservative treatment. nefrología latinoamericana 2017;14:153–9. 12. mahmoud dam, saad a, abdelhamid yh, el hawary y. depression and psychosocial burden among caregivers of children with chronic kidney disease. middle east curr psychiatry 2021;28. 13. wei w, dong l, ye j, xiao z. current status and influencing factors of family resilience in families of children with epilepsy: a cross-sectional study. front psychiatry 2024;15:1354380. 14. sledge r, meyer d, heiden-rootes k, et al. application of the family resilience framework to dyadic shared decisionmaking in dialysis: an interpretive phenomenological inquiry. j nephrol soc work 2021;45:19–30. 15. oh s, chang sj. concept analysis: family resilience. open j nurs 2014;04:980–90. 16. oktaverina s. differences in resilience of individuals with low socioeconomic status reviewed by gender. j ilm bimbing konseling undiksha 2021;12:280–6. 17. white n, richter j, koeckeritz j, munch k, walter p. “going forward”’: family resiliency in patients on hemodialysis. j fam nurs 2004;10:357–78. 18. al atawi aa, alaamri mm. the relationship between perceived social support and adherence to treatment regimens among patients undergoing hemodialysis: a scoping review. evidence-based nurs res 2021;4:17. 19. nadrowska n, błażek m, lewandowska-walter a, et al. walsh family resilience questionnaire—polish adaptation (wfrqpl). int j environ res public health 2022;19. 20. pretto cr, winkelmann er, hildebrandt lm, et al. quality of life of chronic kidney patients on hemodialysis and related factors. rev lat am enfermagem 2020;28:1–11. 21. chang l, zhang s, yan z, et al. symptom burden, family resilience, and functional exercise adherence among postoperative breast cancer patients. asia-pacific j oncol nurs 2022;9:100129. 22. jafari h, ebrahimi a, aghaei a, khatony a. the relationship between care burden and quality of life in caregivers of hemodialysis patients. bmc nephrol 2018;19:321. 23. elliott mj, love s, fox de, et al. ’it’s the empathy’-defining a role for peer support among people living with chronic kidney disease: a qualitative study. bmj open 2022;12:e057518. 24. pasyar n, rambod m, jowkar m. the effect of peer support on hope among patients under hemodialysis. int j nephrol renovasc dis 2020;13:37–44. 25. wardana ak, dewi ei, fitria y. the relationship between social support and resilience of covid-19 survivors in the kaliwates jember health center work area. ners j keperawatan 2023;19:1. 26. simbolon nf. dukungan keluarga dan kualitas hidup pasien hemodialisa di rsud dr. pirngadi medan [internet] [thesis]. universitas sumatera utara; 2018 [cited 2023 aug 2]. available from: https://repositori.usu.ac.id/handle/123456789/8913. 27. sousa h, ribeiro o, paúl c, costa e, miranda v, ribeiro f, et al. social support and treatment adherence in patients with end-stage renal disease: a systematic review. semin dial 2019;32:562–74. 28. national kidney foundation. benefits of peer support. new york: national kidney foundation; 2016. 29. supriati l, sudiana ik, nihayati he, et al. perspective of uncertainty and emotional responses in breast cancer patients during the covid-19 pandemic. sage open nurs 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13048] [page 45] non -co mmerc ial us e o nly 2022;8:23779608221124294. 30. supriati l, sudiana ik, nihayati he, et al. emotional regulation intervention for reducing distress psychologist in breast cancer woman: systematic review. j internat dental med res 2021;14:1296-301. 31. browne t. the role for nephrology social work in the new kidney disease paradigm—moving ahead by remembering how we got here. j nephrol soc work 2019;43:9–22. 32. boatemaa benson r, cobbold b, opoku boamah e, akuoko cp, boateng d. challenges, coping strategies, and social support among breast cancer patients in ghana. adv public health 2020;2020:4817932. 33. nuriyyatiningrum n, gimmy a, djunaidi a, akorede q. psychoeducational support group to the resilience of caregivers of chronic kidney disease patients undergoing hemodialysis. psikohumaniora: jurnal penelitian psikologi 2020;5:89. 34. supriati l, sudiana ik, nihayati he, et al. patient and illness factors influencing fear of recurrence in breast cancer women. j pak med assoc 2023;73:s26–9. 4th international nursing and health sciences symposium [page 46] [healthcare in low-resource settings 2024;12(s1):13048] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13092 the impact of verbal bullying on the mental health of students at a senior high school in be-kasi, indonesia nurhalimah nurhalimah, omi haryati, wartonah wartonah, adelia adelia department of nursing, politeknik kesehatan kemenkes jakarta iii, indonesia abstract adolescent bullying is a global concern due to its profound impact on mental health. in particular, verbal bullying can lead to psychological consequences such as anxiety, depression, and low self-esteem, affecting social interactions and academic performance. despite anti-bullying initiatives, the prevalence of bullying remains high, necessitating further research on protective factors. this study examined the relationship between self-confidence and anxiety among victims of verbal bullying. a quantitative research design was employed with a population comprising all male and female students aged 15-17 years in 10th grade at state islamic senior high school (bekasi, indonesia) who were victims of verbal bullying. the sampling technique used purposive sampling with 92 respondents. data were collected using questionnaires on respondent demographics: the olweus bully/victim questionnaire, the self-rating anxiety scale, and the self-confidence scale. data were analyzed using chi-squared and pearson product-moment correlation tests to determine the relationship between the two variables. a significant negative correlation (r=-0.634, p=0.000) was found between self-confidence and anxiety among bullying victims. this study showed that higher self-confidence was linked to lower anxiety levels, indicating an inverse relationship between self-confidence and anxiety among victims of verbal bullying. enhancing self-confidence may act as a protective factor against anxiety in students who are bullied. introduction adolescent bullying is a significant global issue because of its detrimental effects on mental health.1 according to the united nations (un), more than 246 million children experience genderbased violence by their peers in or near school each year. in 2018, one in three young people across 30 countries reported being bullied, with indonesia ranking fifth among the 78 countries.2 research indicates that verbal bullying is one of the most common forms of bullying experienced by students, with detrimental effects on their emotional and psychological well-being.3,4 in islamic educational contexts, such as the state islamic senior high school, the impact of verbal bullying can be particularly severe due to the close-knit nature of these communities and the cultural emphasis on respect and harmony.5 studies have shown that victims of verbal bullying often experience decreased self-esteem and increased stress and anxiety levels, which can lead to long-term mental health issues.6,7 the emotional toll of verbal bullying is evident in the feelings of hurt and embarrassment reported by students, which can undermine their self-confidence and academic performance.3,7 furthermore, psychological distress caused by verbal bullying can manifest as various mental health symptoms, including depression and anxiety, highlighting the urgent need for effective intervention strategies.8,9 bullying prevention is essential due to its capacity to induce significant mental health problems that could jeopardize the future of a nation’s youth. despite the implementation of various programs to address this issue, bullying incidents have continued to occur frequently. while similar studies have been conducted, there is a paucity of research on schools incorporating religious values into their teaching and learning activities. consequently, researchers are motivated to investigate the relationship between self-confidence and anxiety in bullying victims in a school in bekasi, indonesia. correspondence: nurhalimah nurhalimah, department of nursing, politeknik kesehatan kemenkes jakarta iii, indo-nesia. e-mail: nurhalimahskm@yahoo.co.id key words: anxiety; bullying; self-confidence; students. contributions: nn, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; aa, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; oh, resources, investigation, and writing –review & editing; ww, formal analysis, validation, writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research was approved by the health research ethics committee politeknik kesehatan kemenkes jakarta iii (approval number lb.02.02/f.xix.21/4258/2024) on april 5, 2024. informed consent was obtained from all participants. consent for publication: written informed consent was obtained from participants for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgments: we thank the participants for their valuable insights and contributions to this study. received: 13 september 2024. accepted: 11 march 2025. early access: 16 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13092 doi:10.4081/hls.2025.13092 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13092 [page 113] materials and methods research design this study employed a quantitative approach with a cross-sectional design to examine the impact of verbal bullying on students’ mental health in a school in bekasi, indonesia. self-confidence was designated as the independent variable, whereas anxiety among students who were victims of bullying served as the dependent variable. study participants this study involved 92 students from one senior high school in bekasi who were identified as victims of verbal bullying. the participants were selected using purposive sampling. the inclusion criteria required students to be 15-17 years old, enrolled in 10th grade, identified as victims of verbal bullying, and willing to participate by providing informed consent. students who were victims of physical or cyberbullying were excluded. variables and instrument this study examined self-confidence as the independent variable and anxiety among students who were victims of verbal bullying as the dependent variable, which consisted of four components. the first component contained the respondents’ demographic data; this section collected basic demographic information of the respondents, including age, gender, and grade level, to provide a contextual background for data analysis. the second component was the bullying questionnaire, which utilized the olweus bully/victim questionnaire-revised, comprising 22 likert-scale questions regarding experiences, involvement, and forms of bullying. the results of the validity and reliability tests demonstrated a cronbach’s alpha value of 0.930 (>0.60). the third component was the anxiety questionnaire, which employed the zung self-rating anxiety scale (sas/sras) and consisted of 20 likert-scale questions. the results of the validity and reliability tests indicated a cronbach’s alpha value of 0.861 (>0.60). the fourth component measured the respondent’s self-confidence and consisted of 20item questions in the form of favorable and unfavorable statements. the results of the validity and reliability tests yielded a cronbach’s alpha value of 0.744 (>0.60). data collection before data collection, ethical approval was secured, and all participants provided written informed consent. the questionnaires were administered in person at the school under the supervision of the research team to ensure clarity and completeness of responses. participants were given adequate time to complete the questionnaire, and anonymity was maintained to encourage honest responses. after data collection, responses were coded and analyzed quantitatively to assess the relationship between self-confidence and anxiety among students who had experienced verbal bullying. data analysis data processing began with editing, coding, data entry, and cleaning to ensure accuracy and completeness. univariate analysis was conducted to determine the frequency distribution of the variables. validity and reliability tests of the research instrument were performed first to confirm acceptable reliability levels. a normality test was conducted, yielding a p-value of 0.200 (p>0.05), indicating that the data were normally distributed. a p-value of 0.056 was obtained for trustworthiness, confirming that the data met the assumptions for parametric testing. the pearson product-moment correlation test was used to assess the relationship between selfconfidence and anxiety. the linearity test results showed a significance value of 0.183, indicating the degree of association between the two variables. ethical clearance the study was approved by the health research ethics committee politeknik kesehatan kemenkes jakarta iii (approval number lb.02.02/f.xix.21/4258/2024) on april 5, 2024. the researchers adhered to research ethics by respecting the dignity and confidentiality of the participants and considering the benefits of the research. results table 1 presents the demographic characteristics of the 92 respondents. most respondents who were victims of verbal bullying were female (70.7%) and aged 16 years (55.4%). most female bullying victims exhibited moderate self-confidence (43.1%). the data showed that the majority of female respondents had mild anxiety (38.9%), with the highest age being 16 years, with mild selfconfidence of 59.8% and moderate self-confidence of 66.3%. chi-square analysis revealed a significant relationship between sex and self-confidence (p=0.004; or=11.5). males tended to have higher self-confidence than females. in contrast, for anxiety, although there were differences in proportions between males and females, the analysis did not show a significant association (p=0.13; or=8.807). additionally, age was significantly associated with self-confidence (p=0.021; or=10.826). respondents aged 15 had lower self-confidence than those aged 16 and 17. nonetheless, the relationship between age and anxiety levels was not significant (p=0.119; or=5.994); however, younger respondents generally exhibited higher levels of anxiety (table 2). the data in table 3 shows a p-value of 0.000 (<0.05, <0.01), which indicates a significant relationship between self-confidence and anxiety levels among bullying victims. the correlation coefficient (r=-0.634) suggests a moderate to strong negative correlation, indicating that higher self-confidence levels are associated with lower anxiety levels. discussion the findings highlight the influence of gender and age on selfconfidence, although these factors do not significantly affect anxiety levels. additionally, there was a strong negative correlation between self-confidence and anxiety in bullying victims, indicating that higher self-confidence is linked to lower anxiety. these special issue pathways of change table 1. frequency distribution of respondent characteristics (age and gender). characteristics (n=92) % age 15 year 33 35.9 16 year 51 55.4 17 year 8 8.7 sex male 27 29.3 female 65 70.7 [page 114] [healthcare in low-resource settings 2025;13(s1):13092] results underscore the importance of fostering self-confidence as a protective factor against anxiety. the findings indicated that most respondents experiencing verbal bullying were female and 16 years old, suggesting that adolescent girls may be more susceptible to peer-related verbal aggression due to higher social engagement and vulnerability to relational victimization. this aligns with studies showing that adolescent girls are more likely to engage in problematic online social networking behaviors, which increases their exposure to cyberbullying and relational victimization. research has shown that girls with high levels of problematic internet use tend to report higher scores of relational victimization.10 females also exhibited higher depressive symptoms than males, highlighting bullying’s mental health impact. a bidirectional relationship exists between bullying victimization and mental health issues, where bullying predicts later mental health problems like anxiety and depression. in contrast, pre-existing mental health issues increase victimization likelihood. females with mental health problems are more likely to be victims, while distressed males face an increased risk of experiencing and perpetrating bullying.11,12 these findings emphasize the need for preventive interventions, including school-based mental health programs, digital literacy education, and early screening initiatives, to support at-risk students and create a safer school environment. the study’s results indicate that most students possess moderate self-confidence and a relatively positive, optimistic attitude, although not to a prominent extent. the respondents demonstrated the ability to think objectively and exhibit sufficient responsibility, which enabled them to make autonomous decisions. furthermore, the findings highlight the influence of sex and age on self-confidence. bullying victims often experience decreased self-confidence, leading to anxiety, diminished self-worth, and social withdrawal.13-15 interventions to enhance self-confidence and selfesteem in bullying victims are crucial. initiatives that emphasize building self-worth and equipping individuals with coping mechanisms can alleviate the negative impact of bullying on mental health.16 furthermore, fostering supportive environments in which victims feel secure in expressing themselves and seeking assistance plays a vital role in reducing anxiety and enhancing self-confidence.13-15,17 these findings underline the importance of schoolbased intervention programs to enhance students’ self-confidence and bullying prevention strategies in order to create a safer and more supportive learning environment. the results indicated that 59.8% of the respondents experienced mild anxiety due to peer rejection, unaffected by gender and age. verbal bullying, involving mockery and humiliation, significantly contributes to declining self-confidence in victims, causing anxiety, insecurity, and hesitation in social or academic activities.14,15 the respondents’ psychological conditions, characterized by moderate dependency and mild anxiety, were attributed to a supportive school environment. this institution has implemented a curriculum that instills religious, moral, and ethical values, which includes regular religious practices such as morning quran recitation, asmaul husna recitation, congregational prayer, listening to salawats, and additional religious instruction. consistent with previous studies, religious beliefs and practices positively impact psychology,16 and spirituality has a positive relationship with selfacceptance and happiness.18 spirituality enhances personality hardiness, leading patients to apply coping techniques to life problems.19 these results highlight the significance of including religious and moral education in schools to help reduce anxiety and improve students’ psychological well-being. schools also provide psychological and counseling support, including services for female bullying victims, to mitigate the emotional impact and enhance self-confidence. previous research on religious support related to depression and anxiety indicates that it acts as a crucial moderator, with higher levels amplifying the indirect effects on these mental health issues symptoms.20 the product-moment correlation test revealed a strong negative correlation between self-confidence and anxiety in bullying victims, indicating higher self-confidence is linked to lower anxiety. self-confidence and anxiety were inversely proportional. research shows verbal bullying undermines self-confidence and intensifies anxiety, as victims may worry about further humiliation or social exclusion.13,14 studies have found bullying is directly linked to higher social anxiety and lower self-confidence,21,22 and that self-confidence can act as a protective factor against bullying’s adverse effects, mitigating its impact on social anxiety and enhancing psychological resilience.16 a previous study highlighted that effective school-based anti-bullying programs should include training in emotional control, peer counseling, and the establishment of a school policy on bullying.23 appropriate support and interventions can significantly assist bullying victims in overcoming negative impacts and rebuilding self-confidence.24 additionally, communication with students’ parents is essential, as involving parents of bullying victims can enhance mental health outcomes.25 families represent the closest support system for students, providing emotional, social, and spiritual support at home. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13092] [page 115] table 2. relationship between respondents’ characteristics, self-confidence, and anxiety. characteri-stics self-confidence (n=92) anxiety (n=92) low medium high p or normal mild moderate p or gender male 6 (22.2%) 11 (40.7%) 10 (37%) 0.004* 11.5 8 (29.6%) 10 (37%) 9 (33.3%) 0.13 8.807 female 7 (10.8%) 50 (43.1%) 8 (12.7%) 7 (10.6%) 45 (38.9%) 13 (15.5%) age 15 years 8 (24.2%) 16 (51,5%) 10 (30.3%) 0.021* 10.826 6 (18.2%) 17 (51.5%) 10 (30.3%) 0.119 5.994 16 years 5 (9.8%) 40 (78.4%) 6 (11.8%) 6 (11.8%) 33 (64.7%) 12 (23.5%) 17 years 0 (0%) 5 (62.5%) 3 (37.5%) 3 (37.5%) 5 (62.5%) 0 (0%) *significant using chi-squared test. table 3. relationship between self-confidence and anxiety of bullying victims. variable n correlation coefficient (r) p self-confidence anxiety 92 -0.634 0.000* *significant using pearson product-moment test. this study was limited to a single school and 10th-grade students, which may restrict the findings’ generalizability to a broader student population. conclusions an inverse relationship was found between anxiety levels and self-confidence. victims of bullying experience significant adverse effects on their self-confidence, anxiety, self-image, and selfesteem, resulting in both shortand long-term consequences. many believe that victims of bullying are weak, helpless, and incapable. this belief undermines their self-confidence. references 1. yusuf a, habibie an, efendi f, et al. prevalence and correlates of being bullied among adolescents in indonesia: results from the 2015 global school-based student health survey. int j adolesc med health [internet] 2022;34. available from: https://www.scopus.com/inward/record.uri?eid=2-s2.085070644786&doi=10.1515%2fijamh-2019-0064&partner id=40&md5=2b916ab6bb7ef237e499cf4156e4d06d 2. unicef. unicef poll: more than a third of young people in 30 countries report being a victim of online bullying. press release 2019, pp. 1-7. 3. maalikih md, sumarwati, rakhmawati a. forms and effects of verbal bullying: perceptions of junior high school students in indonesia. multidiscip rev 2024;8. 4. dinero emg, fuentes ikm, oducado rmf, et al. cyberincivility among filipino nursing students in a public university: knowledge, experience, and acceptability. j ners [internet] 2023;18:228-34. available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85173952044&doi= 10.20473%2fjn.v18i3.44919&partnerid=40&md5=6fc60e29 b6ac9c1b33b6d8ca517b5d18 5. wahyuni pj, ernawati s. bullying dan mental hygiene santri di pondok pesantren jember. j educ j pendidikan, pembelajaran dan bimbing dan konseling 2022;10:123-33. 6. pardede ja, huda a, saragih m, simamora m. verbals bullying related to self-esteem on adolescents. jendela nurs j 2021;5:16-22. 7. nadeem ma, usman a. bullying in universities: effects on mental health and academic performance of the students in punjab, pakistan. pakistan j soc res 2022;04:29-37. 8. ekedama k, eboh e. influence of school bullying on mental health of students in delta central senatorial districts in delta state. int j social sci educ res stud 2024. 9. asibong u, okafor cj, etokidem a, et al. bullying behavior and its association with mental health symptoms among senior secondary school students in calabar, nigeria. niger j med 2021;30:125-33. 10. martínez-ferrer b, moreno d, musitu g. are adolescents engaged in the problematic use of social networking sites more involved in peer aggression and victimization? front psychol 2018;9:350593. 11. le hth, tran n, campbell ma, et al. mental health problems both precede and follow bullying among adolescents and the effects differ by gender: a cross-lagged panel analysis of school-based longitudinal data in vietnam. int j ment health syst 2019;13. 12. tristiana rd, pratiwi in, wulansari d, et al. adolescences experience of gender-based violence: a qualitative study. int j public heal sci 2023;12:822-30. 13. rahmah k, purwoko b. dampak bullying verbal terhadap menurunnya rasa percaya diri. edukasia j pendidik dan pembelajaran 2024;5:745-50. 14. ernawati t, budiyono nr. gambaran sikap percaya diri korban bullying verbal di man 3 sleman. perspekt j pendidik dan ilmu bhs 2024;2:133-45. 15. pramanik gf, rohman u, ismail s. analisis dampak bullying terhadap kepercayaan diri remaja. realita j bimbing dan konseling 2024;9:2226-36. 16. boulton mj, macaulay pjr. does authentic self-esteem buffer the negative effects of bullying victimization on social anxiety and classroom concentration? evidence from a short-term longitudinal study with early adolescents. br j educ psychol 2023;93:500-2. 17. rahmadani nda, nurmala i. the influence of self esteem social support on self-acceptance efforts for adolescent verbal abuse survivors in surabaya. media publ promosi kesehat indones 2022;5:1561-6. 18. komarudin k, bukhori b, karim a, et al. examining social support, spirituality, gratitude, and their associations with happiness through self-acceptance. psikohumaniora 2022;7:26378. 19. supatmi s, santoso b, yunitasari e. the effect of spirituality on psychological hardiness of cervical cancer patients with chemotherapy. stud ethno-medicine 2022;16:17-23. 20. tineo p, lowe sr, reyes-portillo ja, fuentes ma. impact of perceived discrimination on depression and anxiety among muslim college students: the role of acculturative stress, religious support, and muslim identity. am j orthopsychiatry 2021. 21. wu x, qi j, zhen r. bullying victimization and adolescents’ social anxiety: roles of shame and self-esteem. child indic res 2021;14:769-81. 22. chou wj, wang pw, hsiao rc, et al. role of school bullying involvement in depression, anxiety, suicidality, and low self-esteem among adolescents with high-functioning autism spectrum disorder. front psychiatry 2020;11:9. 23. lee s, kim cj, kim dh. a meta-analysis of the effect of school-based anti-bullying programs. j child health care 2015;19:136-53. 24. fanani fdn, fatah mz. identification of social support for children as survivors of domestic violence at the surabaya embun foundation. indones j public heal 2022;17:52-60. 25. krisnana i, rachmawati pd, kurnia id. self-efficacy and parental commitment to prevent health risk behavior among adolescents in east java. enferm clin 2022;32:s20-3. special issue pathways of change [page 116] [healthcare in low-resource settings 2025;13(s1):13092] hrev_master healthcare in low-resource settings 2024; volume 12:11985 analysis of determinants of infertility among women at in vitro fertilization clinic in surabaya yati isnaini safitri,1 esty puji rahayu,1 lailatul khusnul rizki,1 siska nurul abidah,1 ima nadatien2 1department of midwifery, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya; 2department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia abstract in social life and global health, infertility is common. history of abdominal surgery, body mass index (bmi), endometriosis, menstrual history, and polycystic ovarian syndrome (pcos) have not been fully explained as female infertility factors. this study examined infertility causes at asha in vitro fertilization primasatya husada citra (phc) hospital surabaya. this quantitative study was cross-sectional. in may-july 2023, 82 childbearingage women with infertility issues visited the hospital and completed questionnaires. description and analysis were performed using the wilcoxon rank test to evaluate menstrual history, bmi, pcos, endometriosis, and abdominal surgery history in relation to infertility. infertility was statistically associated with abdominal surgery history (p=0.008), bmi (p=0.000), endometriosis diagnosis (p=0.000), and pcos (p=0.000). women with abdominal surgery, endometriosis, and pcos had significant infertility. women’s infertility can be caused by ovulation disorders, tubal and pelvic disorders, or uterine disorders, but one-third of cases are unexplained. infertility treatment may benefit from addressing abdominal surgery history, bmi, endometriosis, and pcos. early intervention and targeted care based on these determinants may improve fertility outcomes and reduce unexplained infertility. introduction infertility significantly impacts the psychology of married couples, causing feelings of depression, worry, and guilt. it also affects their social lives, making them reluctant to engage with others, yet it does not deter them from maintaining their household.1,2 the incidence of primary infertility is 62%, while secondary infertility, defined as the inability to have or maintain a pregnancy, stands at 38%.2 research shows that 10-15% of the 39.8 million couples in indonesia experience infertility, with 4-6 million couples requiring treatment to conceive.3 basic health research data from 2018 indicates a rise in overweight (13.6%) and obesity (21.8%) among adults, correlating with a 31% increase in central obesity in those over 15 years old.4 the stress related to infertility negatively affects the quality of life, with family coherence mediating this stress impact.5 infertility necessitates medical attention and treatment and is a significant life event affecting personal, relational, and social dimensions.6 it reveals intense stress and psychological vulnerability, sometimes leading to decreased marital satisfaction and family estrangement.7 causes of female infertility are classified into ovulation disorders [e.g., polycystic ovarian syndrome (pcos), menstrual cycle disorders, primary ovarian insufficiency], tubal and pelvic disorders, and uterine disorders (e.g., submucorrespondence: yati isnaini safitri, department of midwifery, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia. e-mail: yati@unusa.ac.id key words: abdominal surgery; bmi; endometriosis; infertility; pcos. contributions: yis, data curation; yis, epr, lkr, conceptualization, validation, writing – original draft; yis, lkr, formal analysis; epr, in, investigation; in, resources; yis, epr, lkr, sna, methodology; yis, sna, visualization and writing. all the authors participated in the review and editing and approved the final version to be published. conflict of interest: the authors declare no potential conflict of interest. funding: this study was fully funded by the institute of research and community services (lppm), universitas nahdlatul ulama surabaya with contract number: 570.206/unusa-lppm/adm-i/iv/2023. ethics approval and consent to participate: the research procedure received an ethical letter from the health research ethics committee at nahdlatul ulama university, surabaya no. 0274/ec/kepk/unusa/ 2023. during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. availability of data and materials: all data generated or analyzed during this study are included in this published article. informed consent: written informed consent was obtained for anonymized patient information to be published in this article. acknowledgments: we would like to thank prof. dr. ir. achmad jazidie, m. eng, as chancellor of universitas nahdlatul ulama surabaya. dr. khamida, s. kep. ns., m. kep as dean of the faculty of nursing and midwifery, universitas nahdlatul ulama surabaya. nanik handayani, s. kep. ns., m. kes as chair of the midwife professional education study program. achmad syafiuddin s. si., m. phil., phd as chair of the research institutions and community service of universitas nahdlatul ulama surabaya. dr. amang surya spog. as leader of asha ivf surabaya phc hospital. intan kusuma hadie, and endang larasati as research enumerators. unusa academic community and all respondents who participated in this study. also, we would like to acknowledge the contribution of the mentoring program conducted by the research centre of excellence in advancing community health, surabaya, indonesia. received: 15 october 2023. accepted: 30 may 2024. early access: 1 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11985 doi:10.4081/hls.2024.11985 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11985] [page 513] non -co mmerc ial us e o nly cous myoma, endometrial polyps, leiomyomas, asherman’s syndrome).8,9 factors contributing to infertility include occupational factors (e.g., shift work, stress, radiation, chemicals), lifestyle factors (e.g., age, nutrition, exercise, obesity, psychological stress, smoking, alcohol consumption), and environmental pollution.10-13 smoking and alcohol consumption also significantly impact male reproduction.7,14,15 hormonal changes due to pcos, such as increased luteinizing hormones and progesterone levels, are linked with higher body mass index (bmi), increasing the risk of pcos.16 despite its status as a global health issue, research has not fully explained determinants of infertility like menstrual history, bmi, pcos, endometriosis, and history of abdominal surgery. this study aimed to analyze the determinant factors causing infertility at asha in vitro fertilization (ivf) primasatya husada citra (phc) hospital surabaya. materials and methods research design the research design employed was a quantitative descriptive study with a cross-sectional approach. this research aimed to analyze the determinant factors causing infertility (menstrual history, bmi, pcos, endometriosis, history of abdominal surgery) at asha ivf at phc hospital surabaya. study participants the sample consisted of all new patients of childbearing age (17-49 years) who experienced infertility problems. these patients were visited from may to july 2023, totaling 82 respondents selected using a simple random sampling technique. the respondents were women of childbearing age with infertility problems, and their names were medically registered at the asha ivf phc hospital. data was obtained directly through interviews and questionnaires diagnosing the causes of infertility experienced by respondents. variable, instrument and data collection independent variables included factors influencing infertility (history of abdominal surgery, bmi, endometriosis, menstrual history, pcos). the dependent variable was the infertility rate. the research instrument was a questionnaire developed by the authors containing questions on general data (age, height, weight to determine bmi, categorized as underweight, normal, overweight, and obesity) and specific data (menstrual history measured as regular or irregular, pcos, uterine endometriosis, history of abdominal surgery, and diagnosis of the cause of infertility). this data was obtained from secondary sources such as medical resumes. data tabulation and analysis were conducted after collection. data analysis the analysis aimed to determine the determinant factors (menstrual history, bmi, pcos, endometriosis, history of abdominal surgery) causing infertility at asha ivf phc surabaya hospital using the wilcoxon rank test (p<0.05). ethical clearance the research procedure received an ethical approval letter from the health research ethics committee at nahdlatul ulama university, surabaya (no. 0274/ec/kepk/unusa/2023). during the research, the researcher adhered to ethical principles including informed consent, respect for human rights, beneficence, and non-maleficence. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents by characteristics (n=82). characteristics data distribution frequency % age group late teens (17-25 years) 1 1.2 early adulthood (26-35 years) 49 59.8 late adult (36-45 years) 31 37.8 early elderly (46-55 years) 1 1.2 history of abdominal surgery has a history of abdominal surgery 37 45.1 no history of abdominal surgery 45 54.9 menstrual cycle regular 63 76.8 irregular 19 23.2 menstrual pain no pain 21 25.6 light 24 29.3 currently 14 17.1 heavy 23 28.0 bmi less 2 2.4 normal 44 53.7 overweight 23 28.0 obesity 13 15.9 diagnosis endometriosis 22 26.8 uterine myoma 5 6.1 pcos 17 20.7 pof 5 6.1 endometrial polyp 8 9.8 adenomyosis 3 3.7 tuba non-paten 6 7.3 obesity 1 1.2 hydrosalpinx 4 4.9 an explanation 10 12.2 uterus bicorne 1 1.2 bmi, body mass index; pcos, polycystic ovarian syndrome; pof, premature ovarian failure. table 2. statistical test result. statistical testa infertile – infertile – infertile – infertile – infertile – history of menstrual cycle bmi diagnosis menstrual abdominal pain levels surgery -2.661b -1.067c -7.057b -6.611b -1.384b p 0.008 0.286 0.000 0.000 0.166 bmi, body mass index; awilcoxon signed ranks test; bbased on positive ranks; cbased on negative ranks. [page 514] [healthcare in low-resource settings 2024;12:11985] non -co mmerc ial us e o nly results there were 82 respondents in this research, selected using the simple random sampling method. table 1 shows that the characteristics of women in this study according to age reveal that the majority (59.8%) were in early adulthood (26-35 years). regarding the history of abdominal surgery, the majority (54.9%) had no history of abdominal surgery. based on the menstrual cycle, the majority (76.8%) of women had regular cycles. according to complaints of menstrual pain, almost a third of the respondents (29.3%) experienced mild pain. respondent characteristics based on bmi results showed that most women (53.7%) had a normal bmi. the diagnosis results indicated that some female respondents (26.8%) had endometriosis and others (20.7%) had pcos. based on the wilcoxon signed-rank test results in table 2, several factors influence infertility, including a history of abdominal surgery (p=0.008), bmi (p=0.000), a diagnosis of endometriosis (p=0.000), and a diagnosis of pcos (p=0.000). in contrast, factors that do not affect infertility are the menstrual cycle (p=0.286) and the level of menstrual pain (p=0.166). discussion most respondents fall within the early adulthood age range (26-35 years), comprising 49 individuals (59.8%). age significantly influences both male and female fertility, with women’s age being the primary determinant of conception and healthy pregnancies. while infertility can stem from various factors, it often involves contributions from both partners. multivariate regression analysis has identified women’s age, duration of marriage, and socioeconomic status as predictive factors for reduced reproductive opportunities in cases of secondary infertility.17 the incidence of infertility increases with age, particularly due to diminished egg quality in older women.18 research by dewi et al. revealed that a significant portion of couples seeking fertility treatments had husbands over 35 years old and wives aged 20-35 years, highlighting the importance of female age in fertility treatments. several factors, including the woman’s age, significantly influence the success of ivf procedures.19 respondent characteristics based on bmi results showed that the majority of women (53.7%) had a normal bmi. dag and dilbaz highlighted the association between overweight and obesity in women of reproductive age and anovulatory infertility.10 in america, approximately 25% of cases of anovulatory infertility are attributed to being overweight. bmi serves as a straightforward tool for monitoring adult nutritional status, particularly in relation to being underweight or overweight.20 bmi is calculated by dividing a person’s weight in kilograms by their height in meters squared (kg/m2). however, the relative risk of anovulation increases significantly in women with bmi values of 24-31 kg/m2 and >32 kg/m2 compared to women with normal weight.21 obesity induces three changes that disrupt normal ovulation, which can be corrected through weight loss. despite having a normal bmi, women still face the risk of primary and secondary infertility, indicating the influence of factors beyond bmi on infertility.21,22 women diagnosed with endometriosis in this study exhibit a significant association with infertility, as indicated by a p-value of 0.000. endometriosis, a prevalent condition among women of childbearing age in this study, involves the abnormal growth of endometrial glands and stroma outside the uterus, often forming what is known as a chocolate cyst in the ovaries.23 symptoms may vary, with women experiencing severe pelvic pain even in mild cases, while those with severe endometriosis may exhibit milder symptoms such as dysmenorrhea and dyspareunia.24 other symptoms include abnormal uterine bleeding and infertility, both primary and secondary. internal examinations may reveal small lumps in the sacro uterine ligament and a retroflexed uterus or adnexa that are difficult to move. endometriosis, traditionally defined as the presence of endometrial tissue outside the uterus, has been recognized as a painful condition often requiring surgical intervention.25 this study found that 26.8% of respondents were diagnosed with endometriosis, which significantly impacts fertility, with 30-50% of affected women experiencing infertility. untreated endometriosis reduces the likelihood of conception compared to the general population, and even mild cases are associated with decreased pregnancy rates compared to unexplained fertility24. studies on ivf suggest that advanced endometriosis is linked to poor ovarian reserve, low oocyte and embryo quality, and compromised implantation rates.26,27 women diagnosed with pcos account for 20.7% of all respondents in this study. this finding is consistent with research conducted by riska mareta in 2018,28 which highlighted the significant relationship between pcos and infertility. mareta’s research concluded that individuals with pcos face an 8.5 times greater risk of experiencing infertility. pcos, one of the most common endocrine abnormalities among women of reproductive age, manifests as a collection of symptoms and signs including hyperandrogenism and anovulation resulting from disorders of the endocrine system.29,30 this condition affects approximately 5-10% of women of reproductive age, often without primary diseases in the pituitary or adrenal glands. pcos is closely associated with chronic inflammatory processes, with sufferers often exhibiting high levels of visceral fat due to insulin resistance mechanisms.28,31 conclusions this study reveals several factors that significantly impact infertility, including a history of abdominal surgery, bmi, a diagnosis of endometriosis, and pcos. conversely, menstrual cycle factors and menstrual pain levels were found to have no effect on infertility. it is recommended that healthcare professionals increase education about infertility within the community to enhance public awareness. additionally, society should prioritize factors such as age at marriage, nutritional status, and lifestyle choices to mitigate the incidence of infertility. references 1. bahar f, zalika p, lestari sw, et al. male infertility as a bad news: a review. j glob pharma technol 2019;11:109-14. 2. alhassan a, ziblim ar, muntaka s. a survey on depression among infertile women in ghana. bmc womens health 2014;14:42. 3. novrika b. hubungan mekanisme koping dengan tingkat kecemasan pada pasangan infertil di rsia annisa jambi tahun 2015. ris inf kesehat 2018;6:184. 4. kemenkes ri, kementrian kesehatan republik indonesia. hasil riset kesehatan dasar tahun 2018;1689-99. 5. ngai f-w, loke ay. relationships between infertility-related stress, family sense of coherence and quality of life of couples with infertility. hum fertil 2022;25:540-7. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11985] [page 515] non -co mmerc ial us e o nly 6. bhattacharjee nv, schumacher ae, aali a, et al. global fertility in 204 countries and territories, 1950–2021, with forecasts to 2100: a comprehensive demographic analysis for the global burden of disease study 2021. lancet 2024;403:2057-99. 7. ferreira m, antunes l, duarte j, chaves c. influence of infertility and fertility adjustment on marital satisfaction. procedia soc behav sci 2015;171:96-103. 8. fritz ma, speroff l. female infertility. in: clinical gynecologic endocrinology and infertility. 8th ed. wolters kluwer health; 2011. 9. santoso b, rahmawati ny, sa’adi a, et al. elevated peritoneal soluble endoglin and gdf-15 in infertile women with severe endometriosis and pelvic adhesion. j reprod immunol 2021;146. 10. dağ zö, dilbaz b. impact of obesity on infertility in women. j turkish ger gynecol assoc 2015;16:111-7. 11. de angelis c, nardone a, garifalos f, et al. smoke, alcohol and drug addiction and female fertility. reprod biol endocrinol 2020;18:21. 12. sirait bi, reviani n, udjung givw. factors affecting infertility in women of reproductive age in the ivf programme. int j trop dis heal 2023;44:65-75. 13. zhu l, zhou b, zhu x, et al. association between body mass index and female infertility in the united states: data from national health and nutrition examination survey 2013-2018. int j gen med 2022;15:1821-31. 14. finelli r, mottola f, agarwal a. impact of alcohol consumption on male fertility potential: a narrative review. int j environ res public health 2021;19. 15. kovac jr, khanna a, lipshultz li. the effects of cigarette smoking on male fertility. postgrad med 2015;127:338-41. 16. hashemi ah, mozdarani h, mozdarani s. the relationship between hormones level and body mass index with insertion and deletion (d/i) polymorphism of ace gene in infertile patients with polycystic ovary syndrome. bali med j 2017;6:90-6. 17. benksim a, elkhoudri n, addi ra, et al. difference between primary and secondary infertility in morocco: frequencies and associated factors. int j fertil steril 2018;12:142-6. 18. igarashi h, takahashi t, nagase s. oocyte aging underlies female reproductive aging: biological mechanisms and therapeutic strategies. reprod med biol 2015;14:159-69. 19. dewi nlpmc, lindayani ik, rahyani nky, suindri nn. gambaran faktor-faktor penyebab infertilitas dan tingkat keberhasilan program bayi tabung yang diikuti oleh pasangan usia subur. j ilm kebidanan (j midwifery) 2022;10:1-8. 20. piyakong d, apiratanawong s, suasing c. insights from leaders on effectively addressing overweight and obesity in the thai community. j ners 2023;18:117-23. 21. handini a, mirfat m. hubungan usia dan obesitas dengan infertilitas pada pasien di rumah sakit kepresidenan rspad gatot soebroto. maj kesehat pharmamedika 2018;9:33. 22. vembu r, devi mn, nellepalli sr, et al. impact of body mass index on the prevalence of metabolic syndrome among infertile south indian women. int j infertil fetal med 2020;10:425. 23. wiyono t, dwiningsih sr, widjiati w. the impact of endometriosis on intracellular calcium levels, cyclic dependent kinase 1 (cdk1) expression, and cyclin b expression in postovulation oocytes of mice model. j reprod infertil 2023;24:232-9. 24. kim m-r, chapron c, römer t, et al. clinical diagnosis and early medical management for endometriosis: consensus from asian expert group. healthcare 2022;10. 25. hendarto h. endometriosis dari aspek teori sampai penanganan klinis. airlangga university press; 2015. 26. rahmawati ny, ahsan f, santoso b, et al. role of tnf superfamily members lymphotoxin-α, scd40l, and tnf-α in endometriosis-related infertility. j endometr pelvic pain disord 2024;0. 27. macer ml, taylor hs. endometriosis and infertility: a review of the pathogenesis and treatment of endometriosis-associated infertility. obstet gynecol clin north am 2012;39:535-49. 28. mareta r, amran r, larasati v. hubungan polycystic ovary syndrome (pcos) dengan infertilitas di praktik swasta dokter obstetri ginekologi palembang. maj kedokt sriwij 2018;50:85-91. 29. rachmawati da, sa’adi a, utomo b, tunjungseto a. relationship between angiopoietin-like-protein-2 levels and anti-mullerian hormone levels in polycystic ovary syndrome of reproductive age. bali med j 2023;12:861-5. 30. santoso b, rusnaidi, widjiati. effect of alpha lipoic acid on polycystic ovary syndrome with insulin resistance. indian j forensic med toxicol 2020;14:1015-20. 31. calcaterra v, verduci e, cena h, et al. polycystic ovary syndrome in insulin-resistant adolescents with obesity: the role of nutrition therapy and food supplements as a strategy to protect fertility. nutrients 2021;13. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 516] [healthcare in low-resource settings 2024;12:11985] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13565 assessing the effectiveness of rolling ball media on adolescents' knowledge of child marriage nispi yulyana,1 desi widiyanti,1 diyan indrayani,2 titi legiati2 1midwifery department, politeknik kesehatan kemenkes bengkulu, bengkulu; 2midwifery department, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract child marriage is a form of violation of human rights. child marriage remains a significant global issue, especially in indonesia. bengkulu province is among the top 10 highest child marriages in indonesia. rolling ball is an interactive, interesting, and fun learning medium containing material about child marriage. this study aimed to determine the influence of rolling ball media on the knowledge of child marriage among adolescents in bengkulu city and bandung city, indonesia. this study used an experimental design with a randomized controlled trial (rct) involving 120 adolescent girls who were divided into two groups (60 participants each). the variables studied were girls’ knowledge. sampling was performed using block randomization. data were analyzed using the wilcoxon test. the respondents in the treatment group received education on rolling ball media for 30 minutes. the control group engaged with the disc as the learning medium for 30 minutes. knowledge evaluation was conducted both before the start of learning and after one week. the research instrument utilized a questionnaire. the results of the analysis showed that the average knowledge score after intervention increased to 86.50, with a p-value of 0 (wilcoxon signed rank test), while the average knowledge score in the control group increased to 77.42 with a p-value of 0.024. the results of the mann-whitney test showed a p-value of 0.000 ≤ 0.05. there was a significant difference in the effectiveness of rolling balls on knowledge about the impact of child marriage on adolescents. health promotion activities are expected to use rolling ball media as an alternative health promotion medium to increase adolescent knowledge about the impact of child marriage and reduce the number of child marriages, with the hope of increasing the maturity of the age of marriage. introduction child marriage is widely recognized as a grave violation of human rights, affecting millions of children worldwide.1 data on child marriage in the world are most prevalent in nigeria, reaching 76%, meaning that more than half of women in nigeria experience early marriage. while the adolescent birth rate in southeast asia is still high, especially compared to the asia-pacific subregion, with an average of 38.2 births per 1000 women aged 15-19 years. in latin america and the caribbean, one in four girls was married under the age of 18.2 in general, child marriage is more common in girls than in boys, and approximately 5% of boys are married before they are 19 years old. in addition, it was also found that girls were three times more likely to marry early than boys.3 early marriage is an important concern in indonesia. indonesia is among the 10 countries with the highest number of child marriages in the world, and in 2018, it was found that one in nine girls aged 20-24 years were married before the age of 18.4 bengkulu province is included in the top 10 highest child marriages in indonesia, with 178 cases of child marriage, followed by west java, with 5,523 (8.65%) child marriages in indonesia. this figure is higher than the national child marriage rate of 8.06%.4,5 the factors causing early marriage are coercion from parents, free association, curiosity about the world of sex, economic factors, and environmental factors, such as the lack of community correspondence: diyan indrayani, midwifery department, politeknik kesehatan kemenkes bandung, bandung, indonesia e-mail: diyanindrayani@staff.poltekkesbandung.ac.id key words: child marriage, educational media, knowledge, rolling ball. contributions: ny, dw, di, tl conceptualization, data curation, formal analysis, study design, validation, visualization, writing (original draft, review, and editing); ny, dw data analysis; supervision; di,tl first draft of the paper. all authors reviewed and edited the manuscript. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical clearance from the health research ethics committee of the health polytechnic of the bengkulu ministry of health, with the number "ethical approval" no.kepk.bkl/106/03/2024. respondents in this study voluntarily participated in the study; they had obtained informed consent and were requested before the intervention. patient consent for publication: we obtained written informed consent to publish anonymized patient information in this article. funding: this research was supported by a research grant from dipa politeknik kesehatan bengkulu with contract number hk.02.03/ f.xxxi/ 687/2024. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to poltekkes bengkulu, poltekkes bandung, smp negeri 1 kota bandung, smp negeri 17 kota bengkulu for their valuable insights and contributions to this study. received: 31 december 2024. accepted: 31 march 2025. early view: 7 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13565 doi:10.4081/hls.2025.13565 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 74] [healthcare in low-resource settings 2025;13(s2):13565] leaders’ roles (village officials), the lack of health workers’ roles, low education and knowledge.6,7 the impact of a high number of child marriages is a threat to the fulfillment of children’s basic rights. early marriage by adolescents aged less than 16 years can affect the reproductive health readiness of mothers or prospective mothers in giving birth to children with low birth weight potential and is also a trigger for stunting in children, high divorce rates, poverty, and low education.2,8 the risk of stunting is higher in children under five years of age of married mothers in adolescence.9 child marriage is risky for both the mother and the child.10 girls aged 10-14 years were five times more likely to die during pregnancy or childbirth.11 some efforts that have been made to prevent early marriage in indonesia include early marriage maturation programs. this program sets a minimum age limit for marriage of 19 years for men and women.9 although regulations already exist, the marriage rate in indonesia remain high. therefore, more creative efforts are needed to provide guidance and education to teenagers regarding the impact and prevention of early marriage. the development of interesting educational media is needed to increase adolescents’ understanding of the impact of early marriage, which has an impact on the maturity of their age at marriage. the results of this study indicate that efforts are needed to overcome the problem of knowledge by empowering children with health and reproductive information.12 unfortunately, many people still consider reproductive health education to be taboo, so reproductive health material in schools is only used as an insert in one subject or local content, even though the impact is extraordinary.13 knowledge is a very important domain for the formation of actions (over behavior) in a person. based on experience and research, it turns out that behavior based on knowledge lasts longer than behavior that is not based on knowledge.14,15 knowledge is part of the dynamic process of behavioral change that can be improved through health education. the knowledge possessed by an individual or group can provide awareness of something that can cause behavioral change.14,16 research conducted by sharratt et al. explains that deeper and continuous learning from an intervention requires a concept to process activities that can impact meaningful and sustainable change, and variations are needed in learning delivery to increase the interest and understanding of respondents.17 media in providing health education play a very important role in optimizing the information message delivered so that it can stimulate the feelings, attention, thoughts, attitudes, and behavior of individuals. creative media can improve the learning process to be more effective and facilitate the audience in the learning process.18–21 rolling ball media is a learning medium using ball games that can create more lively and interactive class dynamics to increase students’ interest and motivation in learning. the application of this media makes learning more interesting, fun and can change students’ perspectives to be creative, enthusiastic and confident in learning so that it is easier to understand the concept.22 the use of rolling ball learning media creates student involvement in learning activities so that learning is more fun, interactive, and effective in improving understanding of grammar systems.20 other research evidence suggests that the class action is in the form of implementing the tgt cooperative model with media assistance, rolling ball can improve students’ creative mathematical thinking abilities, especially in social arithmetic material. from the other evidence, providing audiovisual health education had a significant effect on adolescent knowledge.23 the results of the study showed that playing games had a simple short-term positive impact on girls and boys regarding attitudes towards early marriage and feelings of empowerment to prevent early marriage.17 thus, this study aimed to analyze the effectiveness of rolling ball educational media on adolescents’ knowledge of the impact of child marriage. materials and methods research design the research design used in this study was experimental and employed a randomized controlled trial (rct). the research involved two groups: a treatment group that received rolling ball educational media, and a control group that participated in conventional health education. the samples were girls adolescent who fulfilled the inclusion and exclusion criteria. the sample in this study were 120 respondent, consisting of 60 respondent in the treatment group and 60 respondent in the control group. the sampling technique used block randomization, to determine each sample in the treatment and control groups. this study assessed the knowledge levels of adolescents in both the treatment and control groups before and one week after the intervention. this research was conducted in bengkulu and bandung, west java, indonesia, focusing on adolescent girls. the research was conducted at junior high schools in bengkulu and bandung west java, indonesia. study participants the participants in this study were adolescent girls who met the inclusion and exclusion criteria and voluntarily agreed to participate by signing an informed consent form. the target population for this study comprised adolescent girls in the cities of bengkulu and bandung west java, indonesia. the study population included adolescent girls who were junior high school students in bengkulu and bandung west java, indonesia. the sample for this study consisted of adolescent girls who studied in junior high schools in bengkulu and bandung west java, indonesia, and met the inclusion criteria. the sample size was determined using a formula for unpaired numerical categorical research. in this study, a confidence level of 95% (zα=1.96) and power test of 90% (zβ=1.28) were selected. the sample size comprised 120 adolescent girls divided into two groups: rolling ball educational media and conventional health education, with 60 individuals in each group. block randomization was used to assign each sample to either the treatment or the control group. the treatment group was given rolling ball media while the control group was given disc media. the inclusion criteria were girls, junior high school students, and willingness to participate as a respondent. simultaneously, the exclusion criteria included respondents who did not fully participate in the research activities. research subjects were excluded if they withdrew from the study before completion. variable, instrument and data collection variable the independent variable in this study was the provision of educational media with rolling balls to the adolescent girls in the treatment group. these interventions were conducted once weekly for 30 minutes. the control group engaged in health education using a disc card for the same duration and frequency. the dependent variables included knowledge levels of adolescent girls. the knowledge levels of adolescent girls were assessed using a questionnaire. knowledge levels were measured both before and one pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13565] [page 75] week after the intervention in both the treatment and control groups. instrument the questionnaire used to measure knowledge about the impact of child marriage included knowledge about the definition of child marriage, ideal age for marriage, function of marriage, impact of early marriage, efforts to prevent early marriage, and maturity of marriage age. the questionnaire was tested for validity and reliability with cronbach’s alpha value of 0.758 and an r table of 0.444; thus, the questionnaire was proven to be valid and reliable. data collection the research procedure began by selecting participants based on the inclusion and exclusion criteria. subsequently, the researcher provided information by describing the research objectives and procedures of the participants. following this, consent to participate in the study was sought through the signing of an informed consent sheet. the next step involved collecting knowledge data using a questionnaire as a pre-test. the subjects were then randomly assigned to either the treatment or the control group. the treatment group received education with rolling ball media, while the control group received lectures with discs as the learning media. knowledge was measured again after one week using a questionnaire as a post-test. intervention all respondents in the treatment group received education on rolling ball media for 30 minutes. rolling ball media is an innovative learning medium that uses the principle of the game. a rolling ball is a learning medium shaped like a suitcase, inside which there is wood with a slanted board and nails that are used to slide the ball. it was placed in a hole that was fixed in the hole material will be studied. this medium uses a board, one ball, and five bowls containing material and questions about the impact of teenage marriage. rolling ball media contains information about early marriage, the impact of early marriage, and all information related to the maturity of the age of marriage, including the goals, program framework, and benefits of the maturity of the age of marriage. making learning more interesting and fun. it is hoped that the material can be delivered more effectively and easily understood by respondents. the control group attended lectures with discs as learning media for 30 min. knowledge evaluation was carried out before the start of learning to determine the basic knowledge possessed by respondents and then re-measured after one week with the hope that there would be a process of knowledge retention and understanding of concepts. the duration of education was 30 min, which was adjusted to the study material given to respondents and to maintain the respondents’ concentration in receiving information. data analysis data were analyzed using univariate and bivariate analysis. data normality test using shapiro wilk test showed that the data were not normally distributed and continued with bivariate analysis of nonparametric test to compare two groups of paired data with wilcoxon and to compare two groups of unpaired data with mann whitney test in assessing the effectiveness of rolling ball educational media on adolescent knowledge about the impact of early marriage with a significance value of p<0.05. ethical clearance the research was approved by the health research ethics committee of the health polytechnic of the ministry of health in bengkulu, with ethical approval number no.kepk.bkl/106/ 03/2024. throughout the study, the researcher adhered to ethical principles, including obtaining informed consent, promoting beneficence, respecting human rights, and ensuring non-maleficence. results this study, conducted in july 2024 at a public junior high school in bengkulu and bandung west java, aimed to assess the effectiveness of rolling ball educational media on adolescents’ knowledge of the impact of child marriage. a total of 120 participants were included in the study. table 1 below provides an overview of the characteristics of the study participants. the results showed no differences in terms of gender and age. in this study, all respondents were girls, adolescent with an age range of 13-15 years. the results of the normality test of the knowledge data of the treatment and control groups before the intervention were not normally distributed, so the analysis was continued with the wilcoxon signed ranks and mann-whitney tests. as shown in table 2, after the implementation of rolling balls in the intervention group, the results showed that adolescents had knowledge with a minimum score of 60 and a maximum score of 100. the average knowledge score after the implementation of the rolling ball media increased to 86.50. furthermore, the results of the implementation using disc media in the control group showed that after the implementation of the adolescent knowledge score about the impact of child marriage with a minimum score of 40 and a maximum score of 100, the average knowledge score after the implementation of the disc media increased to 77.42. the results of the knowledge variable data were analyzed using the manwhitney test. the test results showed a p-value of 0.000≤0.05 (tables 3 and 4). pathways of change, part ii table 1. characteristics of respondents. characteristic treatment group control group n (%) n (%) age (years old) 13 17 (28.3) 19 (31.6) 14 14 (23.3) 15 (25.0) 15 29 (48.4) 26 (43.4) total 60 (100) 60 (100 gender girl 60 (100) 60(100) boy 0 (0) 0 (0) total 60 (100) 60 (100 table 2. data normality test. knowledge p treatment group pre 0.11 post 0.001 control group pre 0.006 post 0.000 [page 76] [healthcare in low-resource settings 2025;13(s2):13565] discussion this study aimed to investigate the impact of rolling ball educational media on adolescents’ knowledge of the impact of child marriage. the results demonstrate these results indicate that there is a significant difference in the effectiveness of rolling balls on knowledge of the impact of child marriage on adolescents in bengkulu city and bandung city. this happens because the rolling ball medium is a medium that is modified with games so that adolescents do not feel bored in learning and understanding the material presented. a rolling ball is a learning medium such as a suitcase, inside which there is wood with a sloping board and nails that are used to slide the ball. it was placed in a hole that was fixed in the hole material will be studied. rolling ball media is a medium that contains many questions and simple tools that aim to convey learning materials to students in a fun way, like a question and answer game, but has the aim that the material delivered through the rolling ball game media can be conveyed to students and they can understand the learning material.24 the results of the study concluded that the use of rolling ball media had a significant influence on the cooperation skills of children aged 5-6 years at tri insani oermata kindergarten, pekanbaru.25 rolling ball media are an innovative medium used to attract children’s interest because this game is in the form of a team so that learning becomes fun. learning media have various forms and variations that are delivered in the form of educational games. rolling ball media is a medium developed with the aim of changing students’ mindsets in learning and creating learning as something fun.12 whether educational goals are achieved is largely determined by the learning process experienced by the students. in other words, from the entire educational process in schools, student learning activities are the most basic and need more attention.26 the results of this study are in accordance with the opinion that games should be used. learning media are educational games because they can improve cognitive skills, motor skills, reasoning skills, memory, learning outcomes, concentration, and training patience.27 the use of rolling ball media as an innovation in educational media is in line with the results of the study by harwito et al.28 which concluded that the rolling ball game media is feasible and suitable for use as a school learning media. meanwhile, for the disc media group after the wilcoxon signed-rank test analysis, a p-value of 0.024 was obtained, which means that there is an influence of disc media on increasing adolescent knowledge about the impact of marriage. this is because disc media is in the form of a flat round plate containing information about the impact of marriage in a small size that is easy to carry so that students can open it whenever needed. the results of this study are supported by previous research, which a significant influence between disc media and knowledge about the maturity of the age of marriage in adolescents at smpn kota bengkulu.29 this study also mentioned the influence of nutritional disc media on fruit and vegetable consumption in adolescents.30 nutrition disc is a practical and easy-to-use tool for nutrition and health education. based on previous research, the results of the study showed that the use of color and media shape is known to attract the attention of users.31 other studies concluded that there was a significant increase in knowledge after being given disc media regarding long-term contraceptive methods in women of childbearing age.32 however, when compared to rolling ball media, disc media has limitations, including being less interactive so that it is boring and reduces user interest, which will affect the understanding of the material concept. this differs from rolling ball, which involves users in health education activities. from the results of the study, it is proven that the use of rolling ball learning media can create a more lively, interesting, and interactive class dynamic, so that it can increase interest and motivation in learning. the application of creative media can make the audience enthusiastic and confident in learning, making it easier to understand the concept.18–20,22 the level of student involvement in participatory learning affects the retention of material memory reaching 70-90%. the level of memorization in participatory learning is higher than that in learning using visual media, which only reaches 50%.33 with participatory learning, playing games has a simple short-term positive impact on teenagers regarding attitudes towards early marriage and feelings of empowerment to prevent early marriage.17 however, rolling ball learning media in its implementation still requires educators as facilitators. facilitators are required to provide reinforcement and motivate students to participate in the game. teenagers need to obtain accurate and complete information about the impacts and dangers of early marriage so that they can understand the risks and make the right decisions. lack of knowledge can lead to risky sexual behaviors in adolescents, which ends in early marriage. a person’s level of knowledge greatly affects their critical thinking skills and psychosocial maturity. a good level of knowledge makes it easier to think rationally, describe pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13565] [page 77] table 3. differences in knowledge between rolling ball media and dis card groups. knowledge n sum of ranks diference of mean p treatment group pre 60 37.40±11.66 49.1 0.000* post 60 86.50±8.80 control group pre 60 72.10±14.47 5.32 0.024* post 60 77.42±16.91 table 4. the effectivity of rolling ball media on knowledge about the impact of child marriage. characteristics n mean± standard deviation p rolling ball media 60 25.74±21.4 0.000b disc card media 60 bmann whitney test problems, solve problems, and make decisions. the availability of various educational media about the impacts of early marriage for adolescents, will increase their knowledge to maintain their reproductive health and prepare themselves to delay the age of marriage.34,35 a limitation of this research was that the respondents were restricted to adolescent girls. therefore, further research is needed to determine the effectiveness of rolling ball media in all adolescents. the limitation of this study is that the respondents involved were limited to young women, so that exposure to information about the impact of early marriage has not been evenly distributed to all young men and families. in addition, a limitation of rolling ball media is that it still requires education as a facilitator to provide reinforcement and motivation in the game. understanding the impact of early marriage should be disseminated more widely in the community. thus, further research is needed to determine the impact of providing education with rolling ball media in all communities, including young men and families. conclusions the results showed an increase in the average knowledge of the impact of child marriage on adolescents in bengkulu city and bandung city after the intervention. differences were found in the variable of knowledge about the impact of child marriage in the rolling ball media intervention and disc media groups. rolling ball media after the intervention had an influence on knowledge about the impact of child marriage on adolescents in bengkulu city and bandung city. rolling ball media can be developed based on needs, flexibility, and adjustment to the material of the learning objectives, so that it can be used as a medium to provide any health education by simply replacing the material. a facilitator is needed to provide reinforcement and motivation for participants to participate in the game session, and the use of rolling ball media is recommended as an 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ri pangkalpinang 2024;12:92–9. 33. molenda m. cone of experience. educational technology: an encyclopedia. in 2003. p. 161–5. 34. elba farida mw. pengaruh pembekalan materi kesehatan reproduksi tentang bahaya pernikahan dini untuk remaja putri. dharmakarya j apl ipteks untuk masy 2019;8:33436. 35. oktavia er, agustin fr, magai nm, cahyati wh. pengetahuan risiko pernikahan dini pada remaja umur 1319 tahun. higeia (journal public heal res dev) 2018;2:239–48. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13565] [page 79] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13082 alternative treatment for schizophrenia with a local wisdom approach in the tidung tribe community of tarakan city: a descriptive qualitative study darni darni,1 sulidah sulidah,1 ramdya akbar tukan,1 rts netisa martawinarti,2 siti khadijah,3 putri irwanti sari2 1study program of nursing, faculty of health science, university of borneo tarakan; 2study program of nursing, faculty of medicine and health science, university of jambi; 3study program of nursing, politeknik kesehatan kemenkes surakarta, indonesia abstract the tidung community employed traditional methods and botanical remedies to treat schizophrenia, which is part of their local expertise, particularly in public health. this generational knowledge encompasses skills such as massage, chants, mantras, and herbal remedies. the purpose of this study was to investigate whether the tidung community can benefit from these traditional practices as alternative therapies for schizophrenia. the study involved thirteen participants who were conventional practitioners treating schizophrenia and employed a qualitative descriptive methodology. we collected data through field notes and in-depth interviews and then used colaizzi’s approach for analysis. four major themes emerged from the study: i) the conventional methods used to treat schizophrenia; ii) the reasons for the shortcomings of these methods; iii) the role of supernatural elements in the therapeutic process; and iv) the expectations of traditional healers regarding patient recovery. the results showed that early use of spiritual therapies leads to higher recovery rates compared to physical therapy and herbal medications. we view traditional medicine in this context as a combination of prayer (supernatural components), action (administering potions), and therapy. introduction indonesia is a nation rich in cultural diversity, which is reflected in its local wisdom, particularly in health practices. traditional health services, governed by law no. 36 of 2009,1 include skillbased and herbal medicine approaches. traditional medicine plays a crucial role in treating mental health issues, with over 30% of patients in rural areas opting for traditional treatments, especially in regions with limited access to modern healthcare.2 reports indicate that approximately 25% of families with schizophrenia members seek traditional healing methods, such as consulting shamans and employing herbal remedies.3 in developing countries like indonesia, patients with mental disorders often combine traditional and alternative therapies, believing their conditions may stem from spiritual causes.2,4,5 while previous studies explored treatments involving shamans, this study focuses on the ruqyah spiritual method.6 additionally, the treatment landscape varies significantly, with some patients receiving alternative therapies like traditional chinese medicine, particularly for refractory schizophrenia cases.7 the previous research highlights the differences and similarities between abraham maslow’s and john nash’s theories in relation to mental health interventions, revealing significant discrepancies between the theoretical frameworks and empirical findings. while nash’s theory integrates maslow’s concepts, the study found no evidence to support the idea that appropriate interventions universally treat mental illnesses, particularly among nonschizophrenia patients. key factors influencing the ineffectiveness of treatments were identified, including the lack of supernatural interventions in maslow’s framework, which nash includes.8 additionally, the research indicates that traditional healing methods, such as prayer and spiritual practices, are significant for treating schizophrenia within the socio-economic context of tarakan, indonesia, where families often delay seeking modern medical correspondence: darni darni, study program of nursing, faculty of health science, university of borneo tarakan, indonesia. e-mail: darni.resky86@gmail.com key words: local wisdom; schizophrenia; treatment; tidung tribe community. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research obtained ethical approval from the ethics committee of the faculty of health sciences, university of borneo tarakan (ethical exemption no. 15/kepk-fikes ubt/x/2022). participants were asked to provide their written consent to participate freely without coercion. they could withdraw from the study without giving a reason and could refuse to answer any questions. furthermore, the researchers ensured their privacy during the interview process. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: research funding comes from the university of borneo tarakan campus through dipa funds. acknowledgments: the authors would like to express gratitude to the rector of the university of borneo tarakan, to the research institute of borneo university tarakan (lppm), and to the professors and students of the nursing department at borneo university tarakan who contributed to the successful completion of this research. received: 11 september 2024. accepted: 7 november 2024. early access: 29 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13082 doi:10.4081/hls.2024.13082 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13082] [page 37] help until conditions worsen, complicating potential recovery.9,10 the tidung people, predominantly muslim, have interacted with various ethnic groups, enriching their cultural practices. their ancestral knowledge of public health and traditional healing is vital for addressing mental health issues.10,11 recent data from the basic health research (riskesdas) indicates a notable increase in schizophrenia cases, highlighting the significance of traditional treatment methods within the tidung community, where local wisdom informs their healthcare approaches.12 in the past three years, there has been a continuous increase in the number of people who have been cured after receiving traditional treatments by the tidung.13 the study examines the role of 23 traditional healers from various indonesian tribes, particularly the tidung tribe, in treating schizophrenia, finding that ten tidung healers have successfully cured patients without formal medical intervention.10,14 while some schizophrenia patients who received traditional treatment improved, others who sought medical care remained unhealed, indicating a complex interplay between community attitudes toward mental health and traditional practices.15-17 the research highlights local wisdom in traditional treatments, including herbal medicine, spiritual therapy, and prayer, which can alleviate symptoms and reduce the stigma surrounding schizophrenia. the study aimed to investigate the effectiveness of these traditional practices, focusing on factors influencing treatment outcomes, including spiritual commitment and family acceptance. the findings emphasize the importance of preserving cultural practices while recognizing the potential health risks associated with exclusive reliance on traditional treatments. materials and methods research methods this study employed a qualitative research design using a descriptive approach to explore alternative treatments for schizophrenia provided by the tidung community, utilizing local wisdom in tarakan city, north kalimantan. the research focused on understanding how the tidung community treats schizophrenia patients through traditional practices. the participants included practitioners or traditional healers who actively used herbs, rituals, mantras, remedies, therapies, and spirituality to aid their sick family members. participants were recruited based on specific criteria: they had to be tidung people residing in tarakan, have successfully treated schizophrenia patients (as confirmed by their families), be willing to participate, and be able to understand and communicate in indonesian. recruitment involved approaching neighborhood heads and community leaders who could facilitate connections with traditional healers. ethical considerations ethical approval for the study was obtained from the ethics committee of the faculty of health sciences, university of borneo tarakan (ethical exemption no. 15/kepk-fikes ubt/x/2022). participants were informed about the study’s purpose and provided their written consent freely and without coercion. they were assured that they could withdraw from the study at any time without consequence and could refuse to answer any questions. participant privacy was maintained throughout the interview process, with all data anonymized during transcription using alphanumeric identifiers (e.g., p1, p2). data collection and analysis data collection occurred over four months from april 2022. participants were visited at their homes to obtain consent, followed by semi-structured interviews that lasted approximately 30 minutes each. the first session involved explaining the research and conducting the initial interview, while a second session, necessitated by incomplete data, involved follow-up interviews with selected participants conducted by a team of three researchers. to minimize bias, data triangulation was employed, incorporating various sources and methods at different times. the interviews were recorded and transcribed, and colaizzi’s method was used for data analysis. this manual analysis was chosen due to the rich variation in vocabulary among participants. the analytical process involved describing the research problem, collecting participant statements, re-reading transcripts for meaningful statements, and organizing data into thematic groups. participants were engaged to validate the findings, and the final description was compiled based on these validated results. key questions guiding the interviews included: i) what actions are taken in treating patients with schizophrenia? ii) what readings or prayers are employed in treatment? iii) how is ruqyah, a traditional spiritual therapy, utilized in treating schizophrenia? probing questions were asked to ensure comprehensive understanding, and discrepancies in data were addressed through collaborative reviews of the transcribed interviews. results this study presents its findings in two parts. the first part provides general information about the participants’ characteristics, considering their backgrounds and contexts. the second part describes the research results, including the objectives and thematic groupings that emerged from the transcripts and field notes collected during in-depth interviews about alternative treatments for schizophrenia. these treatments are explored through the local wisdom approach of the tidung community in tarakan city. participant characteristics participants in this study were selected according to the established inclusion criteria. an inventory identified 23 traditional healers in tarakan city who treat schizophrenia patients, representing various ethnic groups, including javanese, sulawesi, banjar, and tidung. among them, 13 traditional healers from the tidung ethnic group have successfully treated schizophrenia patients. in the tidung community, patients seeking traditional treatment have reportedly recovered without any medical intervention (such as that from hospitals, midwives, nurses, or clinics). additionally, those who did not respond to medical treatment later improved after receiving traditional care. the treatments employed included local wisdom practices such as the use of medicinal plants, spiritual therapy, and prayers. from the initial pool of 23 traditional healers, 13 participants were selected based on the inclusion criteria set by the researchers (table 1). these criteria specified that participants must be members of the tidung community residing in tarakan city, have experience in treating schizophrenia patients, and be recognized as having achieved healing by their families. all participants willingly agreed to participate in the study by signing a consent form and were proficient in indonesian, which ensured effective communication between the researchers and the participants. based on the participant codes used during the interviews, the special issue pathways of change [page 38] [healthcare in low-resource settings 2025;13(s1):13082] codes ranged from participant one (p01) to participant thirteen (p13), with variations in the initials of the participants’ names. the research results identified four key themes (table 2). themes 1. traditional treatment methods for schizophrenia patients treatment of schizophrenia often employs indigenous knowledge, including medicinal herbs, spiritual therapy, and prayer. the community’s attitudes towards schizophrenia present challenges for government health initiatives. while it is crucial for indonesia to preserve these traditional practices as cultural assets, their application can lead to health risks and complications. we identify three sub-themes influencing the healing of schizophrenia patients through traditional methods: spiritual treatment, treatment commitment, and self-efficacy. sub-theme 1. spiritual healing participants frequently mentioned ruqyah healing, a practice involving qur’anic recitation. statements included: “we perform ruqyah, akin to reciting the qur’an” (p1). the significance of solawatan, a communal prayer, was also highlighted: “solawatan can be performed independently, while we guide their actions” (p3). additionally, participants noted the importance of neutralization in treatment, stating, “the neutralization we perform is crucial for facilitating the treatment process” (p4). sub-theme 2. gravity in treatment participants emphasized the necessity of gradual treatment. one remarked, “if you wish to recover, the process must be gradual” (p1). many noted that traditional treatments are administered one to three times, with a participant stating, “individuals receiving treatment may require up to three sessions” (p4). adherence to treatment protocols was deemed essential for optimal outcomes, with one participant asserting, “the patient must adhere to the treatment rules; otherwise, the results will not be optimal” (p1). sub-theme 3. self-efficacy in treatment. participants expressed confidence in the efficacy of traditional medicine. one stated, “patients often report expedited recovery with traditional treatments” (p1). many shared that when conventional hospital treatments failed, they turned to traditional methods, believing they would find healing: “they receive treatment at the hospital but remain uncured; traditional medicine provides cures” (p1). themes 2. treatments affecting the effectiveness of healing in schizophrenia patients the traditional healing process’s success is influenced by several factors, categorized under spiritual treatment. observations and interviews highlighted the use of herbal remedies and natural ingredients, particularly leaves and pure coconut oil. sub-theme 1. traditional treatment carried out by traditional practitioners. traditional practitioners often use leaves and coconut oil in their treatments. participants noted, “i use leaves for treatment; these are the ones my ancestors used” (p1). regarding coconut oil, one participant stated, “i have been using pure coconut oil in this treatment for decades” (p2). themes 3. supernatural treatment for schizophrenia patients a lack of familial understanding regarding the effects of conventional medicine can adversely impact education, employment, and social inclusion. to improve awareness, educational initiatives targeting families about traditional medicine are vital. community counseling, mass media outreach, and educational resources can enhance understanding, while health services can provide education to prevent chronic illnesses and reduce stigma associated with schizophrenia. sub-theme 1. spiritual treatment. belief in the divine origin of illness influences treatment effectiveness. many participants expressed, “i only treat; the rest is left to god” (p3). the belief in recovery was also prevalent: “i believe i can recover if i keep trying and praying” (p4). such spiritual convictions play a significant role in traditional healing practices. themes 4. traditional healers’ hope for patients with schizophrenia traditional healers express strong hopes for the recovery of patients with schizophrenia, emphasizing the critical role of family support throughout the treatment process. they focus on the family’s acceptance of the condition, facilitating ongoing treatment until the patient recovers. key themes identified in interviews include the potential for recovery, returning to normalcy, resuming work, returning to roles such as housewives, and regaining the ability to communicate. sub-theme 1. family accepts the situation. one healer shared, “yes, my hope is that this patient can recover as they did before experiencing this mental disorder” (p1). this sentiment resonated with others, who expressed concern for their patients, saying things like, “i hope he can recover as before; it’s sad to see him in this state” (p3), and “as a healer, i have high hopes... hopefully, he can recover as before” (p5). a significant aspect of the healers’ hopes is the desire for patients to return to their original state before the onset of their illness. one healer stat special issue pathways of change table 1. participants demographic data (n=13). characteristics percentage (%) age (mean) 53.1 years gender female 53.8 male 46.1 religion islam 100 education elementary school 54.0 junior high school 15.3 senior high school 30.7 duration as a traditional healer (mean) 21.9 years age <50 years 46.2 >50 years 53.8 occupation farmer 46.2 housewife 38.4 entrepreneur 15.4 [healthcare in low-resource settings 2025;13(s1):13082] [page 39] ed, “i hope this patient can recover and return to their original state before this mental disorder” (p1). another remarked, “hopefully, he can return to normal; it’s disheartening to see him struggling” (p3). the aspiration for patients to regain their ability to work is also a prevalent theme among traditional healers. one participant articulated, “i hope i can recover and be able to work again as before” (p1), while another added, “yes, i hope he can get better and work again like before” (p2). moreover, the ability to communicate is paramount in the healing process. healers noted, “i hope this mother can talk again because she’s been silent since her illness” (p2), and “many patients come in who don’t want to talk, so i hope that after treatment, they can communicate again” (p5). discussion in the study on alternative treatment for schizophrenia through a local wisdom approach in tidung, four main themes emerged. these themes encompassed traditional treatment methods, the factors influencing healing effectiveness, supernatural interventions, and the hopes of traditional healers for their patients. traditional treatment methods included practices that had been passed down through generations, such as massage, mantras, recitations, and regular therapies.4 however, many patients experienced boredom with their medications due to side effects like body stiffness and drowsiness, compounded by minimal family support for adhering to treatment regimens.18 this lack of support often led to stigma within families and communities, with sick members rarely receiving visits, prompting some patients to seek solace in traditional medicine and practitioners.19,20 spiritual healing practices, like those offered by al-fateh, played a significant role in the treatment of mental disorders. these practices included herbal remedies and psychoactive mushrooms to enhance physical well-being, alongside spiritual activities such as zikir and prayer to promote awareness and sanity.21 special issue pathways of change table 2. the main themes and sub-themes. quotes code category theme "yes, we perform ruqyah, like teaching them regular ruqyah doing spiritual therapy traditional treatment methods quranic recitations, and we neutralize them first before for schizophrenia patients we start the treatment." (p1), "regular prayer is performed independently, while we guide prayer doing spiritual therapy them properly in what they do." (p3) "in treatment, apart from prayer, we also cleanse them before sholawat doing spiritual therapy we perform the treatment." (p2) "in the ruqyah treatment we provide, in addition to reciting the ruqyah doing spiritual therapy quran, we also suggest prayers." (p6) "uh, this treatment we do, if they want to recover, treatment must be gradual routine treatment for early-stage the treatment must be gradual." (p1) schizophrenia patients "those who seek treatment, not just once, treatment to three times routine treatment for early-stage they must receive treatment up to three times for any changes to happen." (p7) "in the healing process, patients must follow the treatment gradual treatment routine treatment for early-stage guidelines we provide because if they don't, the results won't be as effective." (p8) "actually, during my treatment, i've heard from patients healed with traditional medicine believe the disease can be cured that they recover faster with traditional remedies than in the hospital. that's what the patients tell me." (p6) "sometimes i get confused when patients trust me and come, healed with traditional medicine believe the disease can be cured saying they didn't recover in the hospital but did with traditional remedies." (p7) "oh, well, in my treatment, i usually use leaves, the same ones usually use leaves treatment with herbal remedies treatments affecting the that have been used for generations." (p5) effectiveness of healing in schizophrenia patients "in my treatment, i use pure coconut oil because we know using pure coconut oil treatment with herbal remedies its contents are beneficial." (p6) "if we believe the illness is from allah, then, god willing, believing the illness is from allah treatment based on faith supernatural treatment for schizophrenia patients we can recover with the effort we make and the patient's belief." (p9) "when i treat them, my hope and belief are that they will recover believing in recovery treatment based on faith if they continue to make an effort." (p8). yes, i believe everything can be resolved, as long as we remain all problems can be solved treatment based on faith determined to find a solution." (p9) "the patients who seek treatment receive islamic treatment, treatment for patients of the islamic faith religion-based treatment as i use ruqyah in my treatments." (p10) "i hope that these patients can recover and return to their normal returning to normal regular treatment traditional healers' hope for patients with schizophrenia state before experiencing this mental disorder." (p12) "i hope they recover and can work as they used to." (p13). can recover regular treatment “sangat besar harapan saya tuh bu,, semoga bisa sembuh dan can work again regular treatment bisa bekerja lagi seperti dulu.”(p3) "yes, i hope that they recover and can speak again as they used can talk again regular treatment to because, during their illness, they wouldn't speak; they would just remain silent." (p9) [page 40] [healthcare in low-resource settings 2025;13(s1):13082] most patients initially sought treatment from shamans or local healers, such as teungku, before turning to health facilities like community health centers and mental hospitals. in cases where the initial spiritual treatment did not yield results, patients often sought medical intervention.22 the study emphasized that different interventions had an impact on the recovery of individuals with schizophrenia. the traditional healing process’s effectiveness could depend on multiple factors, with three primary healing methods identified: supernatural, herbal, and equipment-based approaches. the role of traditional healers was crucial, as they could significantly impact community mental health efforts.23,24 supernatural treatment, characterized by spiritual practices that invoke inner energy and meditation, offered another dimension to healing. it was rooted in the belief that illnesses were divinely ordained, reinforcing the notion of potential healing through faith and communal support, particularly within the islamic context.25 traditional healers expressed their aspirations for families to care for members suffering from schizophrenia, emphasizing that family support could alleviate burdens and influence coping mechanisms.26,27 the study also explored the relationship between the research findings and abraham maslow’s theory, which was adapted by john nash.28 discrepancies arose, particularly regarding the treatment of mental disorders and the lack of evidence supporting maslow’s hierarchy of needs as a central theme. notably, the research did not identify the first treatment for mental disorders, leading to insights that emphasized factors influencing the ineffectiveness of healing in schizophrenia. despite the differences, congruences existed between the findings and maslow’s principles. for instance, factors such as recitation of the qur’an and the calming effects of prayer were highlighted as beneficial for healing. traditional healers’ aspirations for their patients included recovery, reemployment, and regaining responsibilities, mirroring maslow’s concepts of self-actualization and belonging. the study recognized limitations in applying nash’s interpretation of maslow’s theory to respondents from tarakan, indonesia, a region classified as underdeveloped. this context contributed to gaps in understanding schizophrenia and initial treatment approaches. many families allowed conditions to worsen before seeking hospital treatment, which complicated recovery prospects. the stigma surrounding schizophrenia often deterred individuals from pursuing care, resulting in varying outcomes for those who turned to traditional practitioners. while some patients experienced improvement, especially in the early stages of their condition, others struggled with recovery. the research underscored the importance of educating families about the effects of conventional medicine and the consequences of untreated conditions. community-level initiatives aimed at enhancing understanding of traditional medicine could help reduce stigma and foster support for schizophrenia patients. these initiatives could include health education programs, media dissemination, and educational resources to improve awareness. collaborative efforts from families and communities could mitigate stigma and encourage collective action against the persistence of schizophrenia, especially in its early stages, by leveraging traditional healing methods. ultimately, enhancing knowledge and understanding would empower communities to tackle the challenges of schizophrenia more effectively. conclusions this research suggests that communities in underdeveloped areas, such as tarakan, could implement the tidung tribe’s local wisdom approach as an alternative treatment for schizophrenia. this approach incorporates practical skills, herbal remedies, prayer, and spiritual therapy. the findings underscore the importance of early intervention in addressing the symptoms of schizophrenia, as traditional methods can facilitate recovery in the initial stages of the illness. there is an urgent need to raise public awareness about the significance of early treatment. furthermore, combining medical and traditional treatment methods can optimize the chances of recovery for patients with schizophrenia. references 1. listyarti r. pendidikan kewarganegaraan. jakarta: erlangga; 2008 p. 126–213. 2. anggraini y, wahyudi a, intan larasati d, yusuf a. the effectiveness of occupational therapy on patients with schizophrenia or another mental illness: a systematic review. j ners 2020;15:538-47. 3. widyahening is, sutarto a. traditional healing practices in families of patients with schizophrenia: a qualitative study in yogyakar. j kesehat masy univ gadjah mada 2022;3:13– 21. 4. lestari r, yusuf a, setyawan feb, et al. a societal adaptation model as a novel approach toward the recovery of people with schizophrenia. healthc low-resour s 2023;11:11208. 5. badan pusat statistik. survei sosial ekonomi nasional (susenas). tarakan; 2022. available from: https://tarakankota.bps.go.id/id/publication/2023/11/29/233c1b48a49eb1cfca3f c1f8/statistik-sosial-ekonomi-kota-tarakan-2022.html 6. burns j, tomita a. traditional and religious healers in the pathway to care for people with jiwa disorders in africa: a systematic review and meta-analysis. soc psychiatry psychiatr epidemiol 2017;50:867–77. 7. wei yy, lin wf, zhang th, et al. effectiveness of traditional chinese medicineas as an adjunct therapy for refractory schizophrenia: a systematic review and meta analysis. sci rep 2018;8:6230. 8. muhammad arsyad s. pemanfaatan terapi tradisional dan alternatif oleh penderita gangguan jiwa. ilmia kesehat keperawatan 2018;3:256–321. 9. maramis mm, sofyan almahdy m, atika a, et al. the biopsychosocial-spiritual factors influencing relapse of patients with schizophrenia. int j soc psychiatry 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persada husada indones 2020;9. 23. caesaria d, yulianti e. peran penyembuh tradisional pada gangguan jiwa berat. jps 2020;7:1-9. 24. julaeha j, athiyah u, maramis mm, et al. translation and cross-cultural adaption of an instrument measuring patient’s well-being under treatment for schizophrenia. j basic clin physiol pharmacol 2021;32:341–7. 25. widiastutik w, winarni i, lestari r. studi fenomenologi: resilience keluarga penderita skizofrenia di puskesmas bantur. j ilm kesehat keperawatan 2016;12:15. 26. özden s, tuncay t. the experiences of turkish families caring for individuals with schizophrenia : a qualitative inquiry. int j soc psychiatry 2018;64:497–505. 27. konadi a, nauli fa, erwin e. studi faenomenologi: pengalaman keluarga dengan anggota keluarga yang menderita schizofrhenia pasca rawat inap. jurnal ners indones 2017;8:42-55. avalable from: https://download.garuda.kemdikbud.go.id/article.php?article=1459081&val=2290& title=studi%20fenomenologi%20pengalaman%2 0keluarga%20dengan%20anggota%20keluarga%20yang%20menderita%20skizofrenia%20p asca%20rawat%20inap 28. astuti rp, reong ar, fiddaroini fn, budiman mea. prevention of the stigma of mental disorders in the community. jurnal ners 2019;14:165–70. special issue pathways of change [page 42] [healthcare in low-resource settings 2025;13(s1):13082] hrev_master healthcare in low-resource settings 2025; volume 13:13440 novel clinical findings of neurodevelopmental disorder linked to hpdl gene mutation: a case report from saudi arabia abdullah musallam alkhalaf,1 moayad ahmed alshaqaq,2 nadia jradi,3 ahmad hassan aljaziri,1 essa sultan alsultan1 1college of medicine, king faisal university, al-ahsa; 2pediatric neurology consultant, maternity and children hospital, al-ahsa; 3department of pediatrics, college of medicine, king faisal university, al-ahsa, saudi arabia abstract hpdl gene mutations have recently been linked to neurodevelopmental disorders with variable presentations, ranging from mild hereditary spastic paraplegia to severe infantile neurodegeneration. while the hpdl protein’s role is unknown, it is highly expressed in brain mitochondria. here we report a case of a 19month-old male with a homozygous hpdl gene mutation presented with global developmental delay, epilepsy, laryngomalacia post-arytenoidectomy, swallowing dysfunction, and spasticity. he exhibited significant dysmorphic features and recurrent convulsions, and required nasogastric feeding due to oral feeding difficulties. introduction the pathophysiology of neurodevelopmental impairments is complicated and involves both hereditary and environmental variables. these disabilities arise from improper development of the central nervous system. recent research has demonstrated that biallelic variations in the 4-hydroxyphenylpyruvate dioxygenaselike (hpdl) gene may be the cause of neurodevelopmental disorders.1 biallelic variants in the hpdl gene have been described in 2020 as able to cause a progressive disorder with variable clinical presentation, ranging from milder manifestation of adolescentonset pure hereditary spastic paraplegia (hsp), classified as autosomal recessive spastic paraplegia-83 (spg83), to severe neonatal-onset encephalopathy or infantile-onset neurodegeneration with progressive spasticity and brain white matter abnormalities (nedswma).2 furthermore, affected patients with hpdl mutation typically develop spasticity, primarily in the lower limbs.3 still, the role of the hpdl protein remains unknown. hpdl is broadly expressed in tissues, with the most concentrated amounts found in the brain, and it is specifically located in mitochondria.4 here, we report a patient with a novel clinical manifestation linked to an hpdl mutation. comprehending these genetic foundations is essential for enhancing diagnostic precision and possibly directing treatment approaches in the future. this study was approved by the ethics committee of maternity and children’s hospital – al ahsa, with the irb reference number (h-05-hs137). written informed consent was obtained from the father. case report hereby, we report a 19-month-old male with global developmental delay, epilepsy, laryngomalacia, s/p arytenoidectomy, swallowing dysfunction, spasticity, thin corpus callosum on mri brain, and confirmed homozygous hpdl gene mutation on genetic testing. detailed history taking reveals a full-term male infant who was born at 38 weeks of gestation to healthy first-degree cousins. the course of the pregnancy was uneventful. apgar score was eight at 1 minute and 5 minutes. the delivery was complicated by meconium-stained amniotic fluid, leading to respiratory distress that resolved post-delivery. at birth, the infant presented with several dysmorphic features, including low-set ears, a depressed nasal bridge, micrognathia, clinodactyly, fixed flexion of the proximal interphalangeal joints of the 4th fingers bilaterally, and rocker-bottom feet. the family consists of nine children in total, including the patient, who is the only one currently confirmed to have the disease. two of the siblings, previously diagnosed with idiopathic brain atrophy of unknown etiology, are deceased. the remaining six children are alive and exhibit normal neurodevelopment. whole exome sequencing (wes) has not been performed on any of the children. initial physical examination showed dysmorphic infant vitally correspondence: nadia jradi, department of pediatrics, college of medicine, king faisal university, al-ahsa, saudi arabia tel.: +966.569208088. e-mail: nadia.jradi@kfu.edu.sa key words: hpdl gene mutation, neurodevelopmental delay, spasticity, hypotonia, genetic neurodevelopmental disorders. conflict of interest: the authors do not have any conflict of interest or funding source to declare. ethics approval and informed consent to participate: this study was approved by the ethics committee of maternity and children’s hospital – al ahsa, with the irb reference number (h-05-hs-137). written informed consent was obtained from the father. availability of data and materials: all data underlying the findings are fully available. received: 29 november 2024. accepted: 10 june 2025. early access: 8 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13440 doi:10.4081/hls.2025.13440 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 244] [healthcare in low-resource settings 2025;13:13440] stable. cns examination showed open anterior fontanelle, a head circumference of 36 cm, high muscle tone (spasticity) in all extremities, axial hypotonia, asymmetrical moro reflex (sluggish on the left side) intact, sucking, palmar, and plantar reflexes. left upper limb internally rotated, extended at the elbow, flexed at the wrist with reduced movement. all other extremities moved freely. chest, cardiovascular, and gastrointestinal were normal. laboratory tests were unremarkable. cranial ultrasound and brain mri showed a bilateral germinal matrix subependymal cyst. no white matter abnormalities were detected. eeg showed no evidence of epileptiform discharge. in the first month, the patient had axial hypotonia, poor head control, loss of ocular, pursuit and mild peripheral spasticity. by the second month, it was noted to have micrognathia, microcephaly (37 cm), peripheral spasticity, and central hypotonia. he developed recurrent episodes of convulsions, apnea, stridor, and cyanosis. convulsions were in the form of generalized tonic-clonic movements. the eeg background shows diffuse slow 2-3 hz delta activity, indicating a non-epileptiform pattern. the patient was then started on phenobarbitone. genetic testing using whole exome sequencing (wes) identified a homozygous likely pathogenic variant in the hpdl gene, consistent with an autosomal recessive neurodevelopmental disorder characterized by progressive spasticity and brain white matter abnormalities. the specific variant detected was hpdl, c.788c>g p. (thr263arg), which results in an amino acid substitution from threonine to arginine at position 263. at four months, the patient had global developmental delay and microcephaly. although seizures were controlled, the episodes of frequent episodes of apnea with cyanosis and stridor persisted. the patient was then diagnosed to have laryngomalacia and underwent a micro laryngoscopy with arytenoidectomy. apnea resolved after surgery. at eight months old, the patient still showed profound developmental delay with no social smile, no sound imitation, and no interest in the surroundings. axial hypotonia and peripheral spasticity increased in severity, with no improvement despite regular physiotherapy. moreover, the patient failed to feed orally, which required feeding using a nasogastric tube. he then started to show a new form of abnormal movements while being on levetiracetam. the eeg shows intermittent slow activity reflecting cerebral dysfunction. sandifer phenomenon secondary to gerd was suspected; however, no fluoroscopic findings of gerd were detected on upper gi study, and the patient failed to improve on a one-month trial of omeprazole. upper gastrointestinal endoscopy was then performed and revealed normal esophageal mucosa with a corkscrew appearance suggestive of diffuse esophageal spasm. manometry studies were not available to confirm the diagnosis. the patient continues to be fed by nasogastric tube. discussion hereditary spastic paraplegia (hsp) is a collection of diseases that are mostly characterized by spasticity and paralysis in the lower extremities.5 today, there are more than 80 distinct forms of hsp, including a broad spectrum of molecular and metabolic aetiologies, that can be inherited in an autosomal dominant, recessive, or x-linked fashion.6 in populations where there is parental consanguinity and/or a common set of founder mutations, autosomally recessively inherited illnesses are a significant source of both death and morbidity.7 although the consanguinity rates in western and european countries are less than 0.5%, this rate is much higher in arab countries, reaching 20-50% of marriages in saudi arabia.8 both spastic paraplegia 83 (spg83) and a neurodevelopmental disease with progressive spasticity and brain white matter abnormalities (nedswma) are the two primary phenotypes that clinically describe the hpdl-related neurodegenerative condition. spg83 is characterized by spastic paraplegia in juveniles, whereas nedswma often manifests as severe neurodevelopmental delay, brain atrophy, and spasticity in toddlers.1 previous studies have shown that probands with hpdl variations and early disease start had either a milder clinical course with mild to severe developmental delay and spasticity progression, or a severe newborn encephalopathy with little to no psychomotor development. adolescent-onset illness, on the other hand, has not been linked to developmental problems.4 the range of neuroradiological findings linked to variations in hpdl was likewise quite high. they varied from no pathological findings to anomalies in the striatum and white matter.9 our case is the second reported hpdl gene mutation case in saudi arabia. the first case was reported by wiessner et al. in 2021.6 the dysmorphic features reported in our case share certain similarities with other reported cases.6 however, our patient showed a set of unique dysmorphic features, including a depressed nasal bridge, micrognathia, clinodactyly, and rocker-bottom feet that were not previously reported. other reported dysmorphic features, such as high-arched palates, hypertelorism and long philtrum were not detected in our case.6 the respiratory failure in this case was attributed to peripheral apnea caused by laryngomalacia. in contrast, the respiratory failure in the other reported cases was due to central apnea.6 moreover, the highly suspected diagnosis of diffuse esophageal spasm is also a novel clinical finding, since it was not reported previously in similar patients. although we acknowledge that confirmation of the diagnosis with manometry studies is needed. conclusions hpdl gene mutation is a rare white matter disease that typically presents as spastic quadriplegia with central hypotonia. our patient exhibited novel clinical findings, including diffuse esophageal spasm and laryngomalacia. additionally, unusual dysmorphic features were observed, such as micrognathia, clinodactyly, a depressed nasal bridge, and rocker-bottom feet. references 1. wang y, zheng x, feng c, et al. hpdl mutations identified by exome sequencing are associated with infant neurodevelopmental disorders. mol genet genomic med 2022;10:2025. 2. sartorelli j, longo d, travaglini l, et al. acute ophthalmoplegia with wernicke-like mri pattern in a patient with hpdlrelated disorder. mov disord clin pract 2024;11:1160-2. 3. husain ra, grimmel m, wagner m, et al. bi-allelic hpdl variants cause a neurodegenerative disease ranging from neonatal encephalopathy to adolescent-onset spastic paraplegia. am j hum genet 2020;107:364–73. 4. micule i, lace b, wright nt, et al. case report: two families with hpdl related neurodegeneration. front genet case report [healthcare in low-resource settings 2025;13:13440] [page 245] 2022;13:780764. 5. yu h, wei q, luo wj, wu zy. novel bi-allelic hpdl variants cause hereditary spastic paraplegia in a chinese patient. clin genet 2021;100:777–8. 6. wiessner m, maroofian r, ni my, et al. biallelic variants in hpdl cause pure and complicated hereditary spastic paraplegia. brain 2021;144:1422–34. 7. morgan nv, yngvadottir b, o’driscoll m, et al. evidence that autosomal recessive spastic cerebral palsy-1 (cpsq1) is caused by a missense variant in hpdl. brain commun 2021;3:2. 8. khayat am, alshareef bg, alharbi sf, et al. consanguineous marriage and its association with genetic disorders in saudi arabia: a review. cureus 2024;16:e53888. 9. numata-uematsu y, uematsu m, yamamoto t, et al. leigh syndrome-like mri changes in a patient with biallelic hpdl variants treated with ketogenic diet. mol genet metab reports 2021;29:100800. case report [page 246] [healthcare in low-resource settings 2025;13:13440] hrev_master healthcare in low-resource settings 2025; volume 13:11961 early diagnosis of stroke risk factors in high school students in makassar, south sulawesi, indonesia muhammad awal, darwis durahim, andi halimah, hasbiah, arpanjaman, agus supriatna, fahrul islam, muh ikbal department of physiotherapy, makassar health polytechnic, indonesia abstract the number of stroke patients in indonesia is ranked as the first country to experience the most strokes in all of asia. the prevalence of stroke in indonesia reaches 8.3 out of 1000 population. this prevalence rate increases with increasing age. indonesian national data shows that stroke is the highest cause of death, at 15.4%, with approximately 750,000 strokes per year in indonesia and 200,000 recurrent strokes. people who are physically inactive (those who exercise less than three times per week, each for 30 minutes) have an almost 50% increased risk of stroke compared to those who are active. physical inactivity can lead to weight problems and increased blood pressure and is associated with diabetes, all of which are important risk factors for stroke. inactivity also contributes to the onset of early atherosclerosis and other cardiovascular diseases, such as heart attacks. this study is an analytical observational study with a cross sectional design to see and observe the risk factors for stroke that exist in school children in makassar city. data processing was carried out using computer application programs and spss version 22.0 with data analysis methods using the chi square test with the yate’s correlation formula in spss called continuity correction and risk. the number of respondents studied was 896 people. hypertension is a major risk factor for health problems in society, especially in socioeconomic transition. hypertension is a primary risk factor for the onset of heart disease and stroke. doing physical activity will prevent us from various diseases, by doing adequate physical activity we can suppress the increase in blood sugar levels, cholesterol levels, and avoid obesity and strengthen the heart. all of which are risk factors for stroke. so thus by doing adequate physical activity we can avoid stroke. there is a relationship between gender, obesity, hypertension, family history of disease, stress, physical activity, risky diet and smoking on stroke risk factors and there is no relationship between age and knowledge with stroke risk factors. introduction stroke is defined as rapidly developing signs of focal (or global) impairment of brain function lasting 24 hours (unless interrupted by surgery or death) without an obvious nonvascular cause.1-4 the definition includes patients presenting with clinical signs and symptoms of subarachnoid hemorrhage, intracerebral hemorrhage, thrombosis and embolism. hemorrhagic stroke is defined as a stroke event with a diagnosis of subarachnoid hemorrhage or intracerebral hemorrhage and ischemic stroke is defined as an event with a diagnosis of thrombosis or embolism. transient ischemic attack (tia) and chronic cerebral vascular disease were excluded. on the basis of survival status within 28 days of the event, located stroke events were subdivided into fatal and nonfatal events so stroke is the rapidly developing clinical signs of focal (or global) impairment of brain function with symptoms lasting 24 hours or more or leading to death, in the absence of other obvious causes other than vascular.5-7 indonesia is the country with the largest number of stroke patients in asia, it is estimated that every year 500,000 people are affected by stroke, and about 25% or 125,000 people die and the rest experience mild or severe disability. currently stroke ranks third as a deadly disease after heart disease and cancer, while in correspondence: muhammad awal, department of physiotherapy, makassar health polytechnic, indonesia e-mail: daengngerang73@gmail.com key words: stroke, risk factors, physical activity. contributions: ma, dd, ah, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ha, resources, investigation, and writing –review & editing; aj formal analysis, validation, writing – review & editing; as, resources, supervision, and writing –review & editing; fi and mi, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the health research ethics committee of the makassar health polytechnic with ethical approval recommendation no. 111 / kepk-ptkms/ iii/2022. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by research funds from [makassar health polytechnic] with contract number no: lb.02.03/4.3/0421/2019 availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thank the director of the makassar health polytechnic and his staff who have provided support in carrying out this research. received: 13 october 2023. accepted: 20 september 2024. early access: 14 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:11961 doi:10.4081/hls.2024.11961 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:11961] [page 47] indonesia stroke ranks first as a cause of death in hospitals. if there are no better stroke prevention efforts, the number of stroke patients in 2020 is predicted to increase 2-fold.8-10 based on riskesda 2013 data, stroke prevalence in indonesia increased from 8.3 per 1000 population in 2007 to 12.1 per 1000 population in 2013. south sulawesi has the highest prevalence of stroke compared to other provinces in indonesia based on the highest diagnosis of health workers and symptoms at 17.9%, an increase of 10.5% from 2007 at 7.4%.11 people who are physically inactive (those who exercise less than three times per week, each for 30 minutes) have almost a 50% increased risk of stroke compared to those who are active. physical inactivity can lead to weight problems and increased blood pressure and is associated with diabetes, all of which are important risk factors for stroke. inactivity also contributes to the onset of early atherosclerosis and other cardiovascular diseases, such as heart attacks.10-13 the results of stroke disease surveillance that we carried out at dr. wahidin sudirohusodo hospital, which is a referral hospital for stroke patients in eastern indonesia, showed fluctuations in stroke patients treated. data obtained from wahidin sudirohusodo hospital makassar in 2017 showed that the incidence of stroke ranked 6th of all hospitalized patients, in this case stroke associated with cerebral infarction was 269 people, including 148 men and 121 women, with the highest age classification of 45-65 years (115 people), followed by age ≥65 years (88 people), 35-44 years (61 people), and 25-34 years (5 people). meanwhile, stroke caused by intracerebral hemorrhage ranked 20th of all patients treated at wahidin sudirohusodo general hospital, which reached 123 people, of which 66 were men and 57 were women, with the highest age classification also occupied by 45-64 years of age (73 people), then successively ≥65 years of age (39 people), 35-44 years (10 people), and 25-34 people (1 person).14-16 materials and methods research design this study is an analytical observational study with a cross sectional design, which is a research design where risk and effect factors are taken together at one time.17 article table 1. analysis of relationships between variables. high risk low risk total (cl 95%) or ρ n % n % n % lower uper 0.708 0.163 age 15-16 30 9.2 297 90.8 327 100 0.452 1.112 0.163 expectet 0 cell 17-19 71 12.5 498 87.5 569 100 total 101 11.3 795 88.7 896 100 gender 1.580 3.650 2.402 0.000 expectet 0 cell male 51 17.7 237 82.3 288 100 female 50 8.2 588 91.8 608 100 total 101 11.3 795 88.7 896 100 bmi 8.078 20.797 12.961 0.000 expectet 0 cell fat 51 46.8 58 53.2 109 100 normal skinny 50 6.4 737 93.6 787 100 total 101 11.3 795 88.7 896 100 hipertension 5.067 18.305 9.639 0.000 expectet 0 cell prahipertensi 90 19.8 365 80.2 455 100 normal 11 2.5 430 97.5 441 100 total 101 11.3 795 88.7 896 100 family history of disease 4.252 10.403 6.651 0.000 expectet 0 cell present 47 33.8 92 66.2 139 100 none 54 7.1 703 92.9 757 100 total 101 11.3 795 88.7 896 100 stress 4.395 11.529 7.118 0.000 expectet 0 cell present 77 23.8 247 76.2 324 100 none 24 4.2 548 95.8 572 100 total 101 11.3 795 88.7 896 100 physical activity 2.503 6.739 4.107 0.000 expectet 0 cell heavy 29 29.0 71 71.0 100 100 medium-light 72 9.0 724 91.0 796 100 total 101 11.3 795 88.7 896 100 risk eating 1.693 89.203 12.288 0.003 expectet 0 cell high risk 100 12.4 708 87.6 808 100 low risk 1 1.1 87 98.9 88 100 total 101 11.3 795 88.7 896 100 smoking behavior 4.401 11.947 7.521 0.000 expectet 0 cell present 34 39.5 52 60.5 86 100 none 67 8.3 743 91.7 810 100 total 101 11.3 795 88.7 896 100 [page 48] [healthcare in low-resource settings 2024;12:11961] study participants the population in this study were all high school students in makassar city as many as 29440 students, the sample in this study were some high school students in makassar city totaling 896 students. sample size calculation because the population is known, the large formula using slovin is: where : n = population n = sample e² = margin of error = 0.05 so : n = n / (1 + (n x e²)) = 29440/(1+(29440x0.05²) = 29440/(1+ 29440x0.0025) = 29440/74.6 = 394.68 = 395 how to draw samples with random sampling (random) the data collected is primary data originating from 10 schools in the city of makassar. data collection was done by filling in observation sheets in the form of a checklist through questions and answers to the research sample. this study began after obtaining permission from the south sulawesi provincial education office followed by visiting the school that became the research site by collecting students who became research samples and taking blood pressure measurements, measuring height and weight and asking questions and filling out a list of questions according to the research variables, namely age, gender, obesity, hypertension, family history, stress, physical activity risky foods and smoking which was carried out for less than 15 minutes per student. data analysis for general analysis such as percentage and distribution of each research variable, bivariate analysis in the form of odds ratio test to determine the risk of independent variables on the dependent variable and for multivariate analysis to determine the effect of one or more of the independent variables on the dependent variable. ethical clearance this research used ethical clearance issued by the ethics committee of the faculty of medicine, hasanuddin university. number: 925/h04.8.4.5.31/pp36-kometik/2020 results the results of the study based on bivariate analysis and multivariate analysis can be seen in tables 1 and 2. discussion analysis of stroke risk factors is intended to answer research questions, as well as to identify variables that are the main predictors of stroke. in this study, the statistical test used was the odds ratio test to see the magnitude of the risk of each variable on the incidence of stroke, then to see the influence of variables on the incidence of stroke was carried out by path analysis. the results showed that the risk factors for blood pressure at an early age are very high, this is evidenced in several related studies where blood pressure that continues to increase slowly will damage the walls of blood vessels by hardening the arteries and encouraging the formation of blood clots and aneurysms, which will eventually lead to stroke, especially in people over 45 years old.1820 hypertension is the most important stroke risk factor in america. nearly 80% of patients diagnosed with first-time stroke have a blood pressure (bp) of [140/90. there is an additional risk of stroke at bp above 115/75, in developed countries, such as the united states, which have an older population that tends to have higher bp, the impact of bp on stroke risk is very obvious.21-23 diabetes causes changes in the blood vessel system, and plays a role in the atherosclerosis process which will ultimately cause stroke. in people with diabetes, the blood becomes thicker and the load on the blood vessel walls becomes greater so it is feared that it will become thicker and the load on the blood vessel walls becomes greater so it is feared that they will become clogged more easily (especially in small blood vessels such as those in the brain and heart).24-27 in people who suffer from heart disease (for example abnormalities in the heart valves) due to impaired heart function, embolus/blood clots will arise. the embolus will travel along the circulation to the brain, and become blocked because the diameter of the blood vessels in the brain is very small, resulting in an ischemic (non-haemorrhagic) stroke. the results of the study showed an increase in body weight to article [healthcare in low-resource settings 2024;12:11961] [page 49] table 2. multivariate analysis of variables with stroke risk in high schools in makassar city, south sulawesi province. no variables se beta t sig 1 gender 0.015 -0.038 -2.123 0.034 2 bmi 0.018 -0.009 -0.564 0.573 3 hipertension 0.039 0.000 -0.060 0.952 4 family history of disease 0.024 0.889 38.021 0.000 5 stress 0.012 -0.009 -0.573 0.567 6 physical activity 0.018 0.033 2.134 0.033 7 risk eating 0.019 -0.003 -0.171 0.864 8 smoking behavior 0.022 0.015 0.867 0.386 obesity, one of the causes of which is a lack of physical activity. this is reinforced by other studies that show there is evidence of a strong relationship between bmi and physical activity, but there is no evidence of a modifying effect by smoking, alcohol intake or bmi. there is no evidence that the relationship varies by vascular type.28-30 smoking behavior in this study shows that this influential risk factor is supported by research seo explaining the age distribution, men aged 40-49 years were the largest population (25.4%). in terms of smoking period, smoking for 10-19 years represents the largest population at 22.1%; 3.8% had smoked for more than 50 years. the prevalence of diagnosed diseases was 2.6% for stroke, 1.5% for myocardial infarction, 20.7% for hypertension, and 8.7% for diabetes excess cholesterol in the blood, the medical term is called hyperlipidemia, is an indirect risk factor for stroke. why is it called that because excessive cholesterol in the blood does not directly cause stroke, but rather increases the risk of atherosclerosis plaque formation in blood vessels. as is known, atherosclerotic plaque is responsible for the process of stroke due to blockage (ischemic stroke). this is supported by ryu’s research and ren’s research that high serum non-hdl-c, age, education, homocysteine levels, and hamd score are independent risk factors for cognitive decline in patients with acute ischemic stroke. the risk of cognitive impairment after acute ischemic stroke increases with increasing levels of non-hdl-c. these parameters are easy to assess in a clinical setting.31-33 risk factors for stroke that cannot be modified are: i) stroke can affect any man and woman from childhood to adulthood. there is no benchmark on how old a person is prone to stroke, although stroke usually affects someone over 65 years old (stroke in children is very rare and is usually associated with congenital abnormalities). nowadays, with unhealthy lifestyles in urban areas, stroke can even affect someone who is 30 years old; ii) stroke can be caused by heredity because risk factors for stroke such as hypertension and diabetes are generally passed down from one generation to the next and in some studies there is indeed a link between heredity and the incidence of stroke. in a study seo concluded his findings that genetic variations of the abo gene may contribute to laa susceptibility but not to ischemic stroke and svd in a chinese population.31 doing physical activity will prevent us from various diseases, by doing adequate physical activity we can reduce the increase in blood sugar levels, cholesterol levels, and avoid obesity and strengthen the heart. where all of that is a risk factor for stroke. thus, by doing adequate physical activity we can avoid stroke. in a study with a sample size of 79 subjects experiencing lethargy and 46 mild dizziness. subjects with severe dizziness were less physically active, reported more fear of falling, falling, depression/anxiety, diabetes, stroke/tia, heart disease, higher number of medications and antihypertensive drugs, low quality of life and health, and worse appearance physically. physical activity is not merely doing sports, by doing gardening activities, walking or cycling to work, to the mosque, to the market or other places will burn calories in the body so as to avoid accumulation in the blood, especially on the walls of blood vessels. there are even wise people who say every footstep will prevent heart disease and stroke. it would be better if you can take the time to do sports 3 4 times a week for 30 45 minutes, of course it will nourish the body and prevent the body from dangerous diseases.34-38 conclusions there is a relationship between gender, hypertension, obesity, family history, stress, physical activity, smoking behavior and the risk of stroke in high school children in the city of makassar, while age has nothing to do with the risk of stroke, and in the multivariate analysis the factor that is most related is family history. the sample size and students’ knowledge about stroke risk factors are limitations of this study. references 1. casarin fs, pagliarin kc, altmann rf, et al. montreal communication evaluation brief battery-mec b: reliability and validity. codas 2020;32:1-7. 2. park sj, oh s. changes in gait performance in stroke patients after taping with scapular setting exercise. healthc 2020;8:128. 3. luan fj, zhang j, wang hq. epidemiological study of adolescent idiopathic scoliosis using low/non-radiation screening methodology. j rehabil med 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bernhardt j, said cm, billinger sa. how to address physical activity participation after stroke in research and clinical practice. stroke 2021;52:e274-e277. 16. lynch ea, jones tm, simpson db, et al. activity monitors for increasing physical activity in adult stroke survivors. stroke 2019;50:4-5. article [page 50] [healthcare in low-resource settings 2024;12:11961] 17. supratiknya a. metodologi penelitian kuantitatif & kualitatif dalam psikologi. universitas sanata dharma; 2022. 18. gjellesvik ti, becker f, tjønna ae, et al. effects of highintensity interval training after stroke (the hiit stroke study) on physical and cognitive function: a multicenter randomized controlled trial. arch phys med rehabil 2020;101:939-47. 19. li j, ogbole g, aribisala b, et al. association between white matter hyperintensities and stroke in a west african patient population: evidence from the stroke investigative research and educational network study. neuroimage 2020;215:116789. 20. tejada meza h, artal roy j, pérez lázaro c, et al. epidemiology and characteristics of ischaemic stroke in young adults in aragon. neurologia (engl ed) 2022;37:434-40. 21. hamre c, fure b, helbostad jl, et al. factors associated with level of physical activity after minor stroke. j stroke cerebrovasc dis 2021;30:105628. 22. russell jbw, charles e, conteh v, lisk dr. risk factors, clinical outcomes and predictors of stroke mortality in sierra leoneans: a retrospective hospital cohort study. ann med surg 2020;60:293-300. 23. smith rw, barnes i, green j, et al. social isolation and risk of heart disease and stroke: analysis of two large uk prospective studies. lancet public heal 2021;6:e232-9. 24. altable m, de la serna jm. cerebrovascular disease in covid-19: is there a higher risk of stroke? brain, behav immun heal 2020;6:100092. 25. al-senani f, al-johani m, salawati m, et al. an epidemiological model for first stroke in saudi arabia. j stroke cerebrovasc dis 2020;29:1-7. 26. zhang y, vittinghoff e, pletcher mj, et al. associations of blood pressure and cholesterol levels during young adulthood with later cardiovascular events. j am coll cardiol 2019;74:330-41. 27. tsujimoto t, kajio h. strategies for glycemic control in nonobese and obese type 2 diabetic patients with coronary artery disease. int j cardiol 2019;282:1-6. 28. karki a, shrestha a, subedi n. prevalence and associated factors of childhood overweight/obesity among primary school children in urban nepal. bmc public health 2019;19:1055. 29. zaprutko t, florczak-wyspiańska j, kopciuch d, et al. costs of stroke and incidence of first diagnosis of atrial fibrillation at time of stroke. neurology ward hospital poznań, poland 2018. healthcare 2021;9:999. 30. angoorani p, heshmat r, ejtahed hs, et al. the association of parental obesity with physical activity and sedentary behaviors of their children: the caspian-v study. j pediatr (rio j) 2018;94:410-8. 31. seo sh, lee d, lee sh, choi ky. blockade of cxxc5-dishevelled interaction inhibits adipogenic differentiation, obesity, and insulin resistance in mice. sci rep 2022;12:20669. 32. ryu yc, kim y rin, park j, et al. wnt/β-catenin signaling activator restores hair regeneration suppressed by diabetes mellitus. bmb rep 2022;55:559. 33. ren q, he c, huang q, zhang d, et al. impacts of global urban expansion on natural habitats undermine the 2050 vision for biodiversity. resour conserv recycl 2023;190:106834. 34. cook p, sunnerhagen ks, persson hc. level of physical activity is positively correlated with perceived impact on life 12 months after stroke: a cross-sectional study. j rehabil med 2020;52:2667 35. jha rk, yadav ak, shrestha s, et al. study of body mass index among medical students of a medical college in nepal: a descriptive cross-sectional study. j nepal med assoc 2021;59:280-3. 36. alt murphy m, andersson s, danielsson a, et al. comparison of accelerometer-based arm, leg and trunk activity at weekdays and weekends during subacute inpatient rehabilitation after stroke. j rehabil med 2019;51:426-33. 37. bazan r, luvizutto gj, braga gp, et al. relationship of spontaneous microembolic signals to risk stratification, recurrence, severity, and mortality of ischemic stroke: a prospective study. ultrasound j 2020;12:1-12. 38. umar ab, koehler tj, zhang r, et al. stroke knowledge among middle and high school students. j int med res 2019;47:4230-41. article [healthcare in low-resource settings 2024;12:11961] [page 51] hrev_master healthcare in low-resource settings 2025; volume 13:12865 obesity indices may affect and reflect the blood glucose and lipid profile values islam al-shami,1 anfal al-dalaeen,2 lana m. agraib,3 buthaina alkhatib4 1department of clinical nutrition and dietetics, faculty of applied medical sciences, the hashemite university, zarqa; 2department of clinical nutrition and dietetics, faculty of applied medical sciences, applied science private university, amman; 3department of nutrition and food science, faculty of applied medical sciences, al-balqa applied university, al-salt; 4department of clinical nutrition and dietetics, faculty of applied medical sciences, the hashemite university, zarqa, jordan abstract the aim of the present study was to observe the association between obesity indices, blood glucose, and lipid profiles as indicators for its levels. in a cross-sectional study, 491 jordanian adults were included. socio-demographic and anthropometric data were measured. blood samples were collected and tested for fasting plasma glucose (fpg), insulin, and lipid profile. obesity indices [conicity index (ci), body adiposity index (bai), abdominal volume index (avi), a body shape index (absi), body roundness index (bri), and weight-adjusted-waist index (wwi)] were calculated using standard formulas. avi, bri, and wwi had a higher impact on fpg and lipid profile. they explain 6.2%, 6.6%, and 4.1% of changes observed in fpg and explained 3.1%, 4.1%, and 3.5% of changes observed in total cholesterol (tc), respectively. in addition, they explain 9.9%, 9.7%, and 7.9% of changes in triglyceride (tg), 9.6%, 8.4%, and 6.0% of the variability observed in the high-density lipoprotein cholesterol (hdl), as well as 1%, 1.6%, and 1.5 of change in low-density lipoprotein cholesterol (ldl), and 7.0%, 8.6%, and 6.6% in ldl/hdl ratio; respectively (p<0.001). avi, bri, and wwi among obesity indices had the highest impact on blood glucose and lipid profile. the most affected tests were tg, hdl, and ldl / hdl ratio. these indices may be used as noninvasive rapid indicators for high glucose and lipid profiles. introduction over the past decade, obesity has become a major concern for health experts because of its association with chronic diseases such as cardiovascular disease (cvd) and type 2 diabetes (t2d).1according to the world health organization’s definition of overweight and obesity, approximately two billion adults are affected by these conditions. furthermore, the annual global death rate from cvd, a well-known consequence of obesity, is estimated to reach 23.6 million by 2030.2 this concerning trend has prompted health professionals to focus on early detection of overweight and obesity, as well as strategies to prevent adverse outcomes in the general population.3 the most straightforward obesity indices are used widely for screening metabolic syndromes (mets), such a hypertension, blood glucose, and hyperlipidemia, including waist circumference (wc), body mass index (bmi), waist-to-hip ratio (whr), and waist-to-height ratio (whtr).4,5 recent novel obesity indices have drawn attention in numerous research as predictors for different noncommunicable diseases, as they are simple, accurate, affordable, reliable, and easy techniques without intervention.4,6 these obesity indices include the abdominal volume index (avi), a body shape index (absi), body adiposity index (bai), conicity index (ci), body roundness index (bri), and weight-adjusted-waist-index (wwi).7 the bri was correlated with mets and was an effective indicator for its screening.4 also, ci was positively associated with t2d, hypertension, and dyslipidemia.5 many studies have confircorrespondence: anfal al-dalaeen, department of clinical nutrition and dietetics, faculty of applied medical sciences, applied science private university, amman, 11931, jordan. e-mail: a_dalaeen@asu.edu.jo key words: blood glucose; insulin; lipid profile; conicity index; obesity indices; obesity. contribution: ias, and ba contributed to the conceptualization, design, data gathering, and data management. lma and ba analyzed and interpreted the data and prepared the manuscript. ias, aad, lma, and ba contributed to the initial draft of the manuscript. all authors reviewed and approved the final manuscript. conflicts of interest: the authors declare no conflict of interest. ethics approval: the study was approved by the institutional board review committee reviewed and approved the survey protocol at the hashemite university (no.7/13/2020/2021). consent to participate: all participants were informed about the study objectives at the beginning of the questionnaire, then they expressed their informed consent to participate, and their data were anonymous. funding: none. availability of data and materials: all data used in the study are available upon the corresponding author's request. the lead author has full access to the data reported in the manuscript. acknowledgments: the authors thank the participants for their patience and great help. received: 28 july 2024. accepted: 19 september 2024. early access: 4 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12865 doi:10.4081/hls.2024.12865 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 52] [healthcare in low-resource settings 2025;13:12865] med the associations between absi, bri, wc, bmi, and whr and the risk of t2d and mets.4,5 however, there were discrepancies amongst research in the correlations between several anthropometric/obesity indices and the lipid profile, insulin, and fasting plasma glucose (fpg). therefore, this study aimed to investigate the relationship between obesity indices, fpg, and lipid profiles and as indications of their levels. material and methodology study population and ethical approval in a cross-sectional study, four hundred and ninety-one adult males and females aged more than 18 were randomly selected and agreed to participate. pregnant or lactating women, subjects with mental disorders, and subjects with incomplete anthropometric measurements and/or biochemical parameters were excluded. the ethics committee of hashemite university approved the study, and all procedures were performed following the ethical standards of the committee and with the helsinki declaration and its later amendments (the institutional board review (irb) committee reviewed and approved the survey protocol at the hashemite university (no.7/13/2020/2021)). participants who were willing and eligible provided written informed consent after a detailed explanation before participation. data collection, anthropometry, and biochemical measurements an interview was conducted to collect data using a pre-designed questionnaire. the information included typical demographic data like age and gender, as well as social and lifestyle factors. questions regarding chronic diseases and other health difficulties were also included, in addition to general health concerns. anthropometric measurements were taken. the body weight and height were recorded to the nearest 0.1kg and 0.1cm, respectively, where they wore minimal clothing and bare feet. anthropometric tape measuring the participant’s wc while standing was used, using the rieder body measure tape (inct. bonus kit, reidhk, china). this measurement was performed on the horizontal plane midway between the lowest rib and the iliac crest. at the place in which the buttocks are at their most comprehensive, the hip circumference (hc) was measured over thin clothing. the measurements of both circumferences were adjusted to the nearest 0.1 cm. the bmi was calculated according to quetelet’s formula, which is weight (kg) divided by the square of the height (m2). whr was calculated as wc (cm) divided by hc (cm). based on wc, participants were divided into high or enlarged wc if their wc was ≥ 102 cm in men and ≥ 88 cm in women, and they were categorized as having average or acceptable wc if their wc was <102 cm and <88 cm, in men and women; respectively. whr was recognized as high if whr > 0.9 for men and whr > 0.8 for women, which means the risk for chronic diseases is high. after conducting face-to-face interviews, the researchers scheduled appointments to collect blood samples from participants for biochemical tests. before drawing blood, participants were instructed to fast for 12 hours. the collected blood samples were centrifuged, separated, and stored at four °c to prepare them for analysis. serum samples were subsequently analyzed using a compact clinical chemistry analyzer, specifically the hitachi 902 autoanalyzer by roche in germany. the roche/hitachi 902 system employs colorimetry and absorbance measurement via the ionselective electrode method to analyze serum samples. additionally, the researchers calculated each participant’s ldl/hdl ratio by dividing their ldl value by their hdl value. furthermore, in this study, six obesity indices were considered and calculated: ci, bai, avi, absi, bri, and wwi. following are the lists of mathematical formulas that were used to calculate these obesity indices: statistical analysis frequency descriptive statistical tests were used to obtain the means and standard deviations for continuous variables and the frequencies and percentages for categorical variables to describe the sample. the association between obesity indices and biochemical markers was examined using pearson correlation. the relationship between the biochemical tests and obesity indices was evaluated using linear regression coefficient analysis. set to p < 0.05, the statistical significance was maintained. the statistical package for the social sciences (spss) version 25 (ibm, chicago, il, usa) was used for all statistical data analyses. results a total of 491 adults were included in this study. as shown in table 1, 70.1% of the participants were males, and 29.9% were females. based on age, 40.3% of participants ranged from 20 to 34 years, 34.4% aged between 35 and 44, and 25.3% aged 45-65 years. around half of the participants were of university education level (52.1%) and physically active (57.2%). of the participants, 71.9% were married, and 40.7% were smokers. almost all the participants were free of t2d, dyslipidemia, hypertension, obesity, and cvd. table 2 illustrates the anthropometric measurements of the participants. participants’ mean weight was 78.53±16.04 kg, while the mean bmi was 27.62±5.40 kg/m2. in addition, the participants had a mean of 96.18±14.94 cm wc, 105.44±10.66 cm hc, and 0.91±0.11 whr. based on bmi classification, almost two-thirds of the participants were overweight or obese (36.9% and 27.9%, respectively). on the other hand, based on wc and whr classification, 66.2% and 85.5% of participants were in high-risk classification, respectively. the pearson correlations between biochemical parameters and obesity indices are shown in table 3. there were significantly low correlations between fpg levels and obesity indices, with rvalues ranging from 0.097 (p=0.032) for bai to 0.317 (p <0.001) article [healthcare in low-resource settings 2025;13:12865] [page 53] for avi. tc levels had significant weak correlations with obesity indices ranging from 0.099 (for absi) to 0.201 (for bri). regarding blood tg and obesity indices, there was a significant moderate correlation between tg levels and bri (r=0.311, p<0.001) and avi (r=0.423, p<0.001). while there were weak correlations with ci (r=0.283, p<0.001), absi (r=0.201, p<0.001), wwi (r=0.282, p<0.001) and bai (r=0.090, p=0.046). there was a significant negative correlation between obesity indices and blood hdl levels. hdl level had a moderate inverse correlation with avi r= -0.371 (p<0.001), while it had a negative, weak correlation with the rest of the obesity indices. on the other hand, ldl levels and ldl/hdl ratio had a significant positive weak correlation with the obesity indices (p<0.001). the linear regression analysis results are shown in table 4. the ci explains 3.7% of the variability observed in fpg levels, where one unit increase in it results in a 54.48±12.59 mg/dl increase in fpg level (p<0.001). while avi explains 6.2% and bri explains 6.6% of the change in fpg. however, an increase in avi and bri by one unit results in a 1.38±0.24 mg/dl and an 8.39±1.43 mg/dl increase in fpg level, respectively (p<0.001). also, wwi increasing by one unit significantly causes a 7.05±1.53 mg/dl increase in fpg level and explains 4.1% of changes observed. for tc levels, ci, bai, and absi collectively explain 4.8% of the change observed at the tc level. conversely, avi alone explains 3.1% of the variation in tc levels, where one unit increase in avi causes a 1.17±0.30 mg/dl increase in tc level (p<0.001). for bri, it increased by one unit, leading to a 7.92±1.74 mg/dl increase in tc level, which explains 4.1% of the observed change (p<0.001). while wwi explains 3.5% of the change in tc levels, its increase by one unit caused the tc level to increase significantly by 7.85±1.86 mg/dl. when setting the tg level as independent, ci was found to explain significantly 8.0% of observed change, and its increase by one unit led to a 278.66±42.64 mg/dl significant increase in tg levels. the avi was found to explain 9.9% of the changes observed in the tg level, while its increase by one unit caused an increase of 6.06±0.83 mg/dl in the tg level. regarding bri and wwi, it was found that 9.7% and 7.9% of the change observed in tg levels can be explained by them, respectively, where one unit increase in bri causes a 35.20±4.86 mg/dl increase in tg level, and one unit increase in wwi causes a 33.84±5.21 mg/dl increase in tg level (p<0.001). for hdl, the ci, avi, bri, and wwi, their increasing by one unit resulted in a reduction in hdl level by -26.07±4.23 mg/dl, -0.59±0.08 mg/dl, -3.23±0.48 mg/dl, and -2.90±0.52 mg/dl respectively (p<0.001). in addition, the ci, avi, bri, and wwi were found to explain significantly 7.2%, 9.6%, 8.4%, and 6.0% of the variability observed in the hdl level, respectively (p<0.05). the obesity indices were found to have little impact on ldl levels, whereas bri and wwi had the highest r-square values. bri explains 1.6% of the changes in ldl level, and its increase by one unit led to a 4.15±1.46 mg/dl increase in ldl level. while wwi explains 1.5% of the changes in ldl level, its increase by one unit led to a 4.16±1.55 mg/dl increase in ldl level. ldl/hdl ratio increased by 0.39±0.06, 0.06±0.01, 0.36±0.06, 2.67±0.51, and 3.20±0.68 as a result of one unit increase in bri, avi, wwi, ci and bai; respectively (p<0.001). they explain 8.6%, 7.0%, 6.6%, 5.4%, and 4.3% of the variability observed in the ldl/hdl ratio. there is no significant data about insulin. article table 1. general characteristics (n=491). variables n (%) gender male 344 (70.1) female 147 (29.9) age (years) 20-34 198 (40.3) 35-44 169 (34.4) 45-65 124 (25.3) education level school education level 235 (47.9) university education level 256 (52.1) marital status married 353 (71.9) single 132 (26.9) divorced 4 (0.8) widow 2 (0.4) total physical activity classification physically active 281 (57.2) physically inactive 210 (42.8) smoking yes 200 (40.7) no 162 (33.0) ex-smoker 43 (8.8) passive smoking 86 (17.5) diseases history diabetes mellitus yes 28 (5.7) no 463 (94.3) dyslipidemia yes 28 (5.7) no 463 (94.3) hypertension yes 27 (5.5) no 464 (94.5) obesity yes 41 (8.4) no 450 (91.6) cardiovascular diseases yes 12 (2.4) no 479 (97.6) table 2. anthropometric measurements (n=491). variables mean ± sd height (m) 1.69 ± 0.09 weight (kg) 78.53 ± 16.04 waist circumference (cm) 96.18 ± 14.94 hip circumference (cm) 105.44 ± 10.66 body mass index (kg/m2) 27.62 ± 5.40 waist to hip ratio 0.91 ± 0.11 n (%) body mass index categories underweight 9 (1.8) normal weight 164 (33.4) overweight 181 (36.9) obese 137 (27.9) waist circumference categories high 325 (66.2) acceptable 166 (33.8) body waist to hip ratio categories high 420 (85.5) acceptable 71 (14.5) [page 54] [healthcare in low-resource settings 2025;13:12865] discussion obesity induces several biochemical parameters such as lipids profile, blood pressure, inflammatory indices, and blood glucose levels, which increase the risk of non-communicable diseases such as mets, ischemic stroke, cvd, and t2d recently, studies have tried to find which obesity indices most closely correlate with the earlier parameters to aid in preventing chronic diseases. in the current study, the bri was highly positively correlated with the fpg level, and the regression model of bri explained 6.6% of the changeability detected in the fpg level.13 moreover, bri was positively correlated with tg level and negatively correlated with hdl level.14 these findings were consistent with the findings of previous studies, such as nkwana and colleagues, who found that bri was significantly associated with increased tg and blood glucose levels. 15 however, the bri is a novel central obesity index estimated using height and wc.5 stefanescu and his team indicated that measuring central obesity, especially the bri, could help identify who is at high risk for t2d and cvd among disease-free obese adults.16 moreover, they found that a unit increase in bri was associated with a 2.43-fold increase in odds of mets in males and a 1.89-fold increased odds in females.16 however, zaid and colleagues found that when identifying hypertriglyceridemia, several anthropometric/metabolic indicators are more predictive than any other type of plasma lipid.17 while absi could not identify dyslipidemia, bri’s ability to predict the condition was on a level with, if not better, that of the traditional obesity indicators. nosratioskouie and colleagues found that tc showed a statistically significant (p<0.05) positive correlation with bmi (r=0.207), wc (r=0.214), and bri (r=0.237).18 in contrast, tg showed a statistically significant positive correlation with bri (r=0.242) and a highly significant positive correlation with bmi (r=0.311).14 on the other hand, ldl showed a positive correlation with wc (r=0.25), absi (r=0.21), and bri (r=0.25) in healthy middle-aged adults.19 the present findings indicated no correlation between obesity indices and insulin, similar to the findings of nkwana and colleagues, while mameli et al. found a significant association between absi and homa-ir.20 also, contrary to the present insulin findings, peterson and colleagues approved that the indices of insulin resistance were correlated significantly with bmi and visceral adiposity indices (wc, absi, and bri) but not with the fat mass percentage. including mets when discussing lipid profiles is essential.21 it has been found that bri, ci, and avi have a clinical approach to identifying mets and its components, as well as the efficacy of these indices in identifying mets affected by gender.22 in the present study, the avi was positively correlated with fpg level and explained by 6.1% of the detected changeability of fpg levels. in recent studies, the avi has been used as an essential anthropometric parameter to predict increases in fpg levels. in agreement, zhang and colleagues concluded that avi could identify the occurrence of t2d in chinese women. moreover, wang et al. and wu et al. have found that avi was positively correlated with elevated blood glucose among adult males and females.23 these prior studies showed that avi could be a sensitive indicator of abdominal obesity-related metabolic abnormalities, including glucose levels.4 furthermore, liu et al. used computed tomography to assess the changes in abdominal fat during a 10-year follow-up database. they proposed that an increase in abdominal fat showed increased glucose levels and the development of t2d bri and avi have been used as obesity indices to predict metabolic disorders in many studies.8,24 on the contrary, gowda et al. found that avi is not a reliable marker in diabetic patients to predict the degree of glycemic control and microalbuminuria.8 moreover, endukuru and colleagues found that bri showed a superior predictive ability to detect hyperglycemia in both genders.22 the bri’s ability to detect other mets components, such as central obesity, high tg, low hdl-c, and raised bp, was equivalent to but not superior to those of the other novel anthropometric indices.25 in the present findings, the ci explains 3.7% of the variability observed in fpg levels, where one unit increase in it results in a 54.48±12.59 mg/dl increase in fpg level.26 in accordance, donkor and colleagues found that ci was positively and significantly associated with fpg (r=0.21, p=0.005).27 the findings of the study by sanchez-viveros on older mexican adults concluded that ci had a stronger relationship with t2d than bmi and wc.28 additionally, sanchez and colleagues indicated that bri and ci were associated with dyslipidemia. furthermore, quaye and colleagues found that avi and ci had larger areas under the curves (aucs) in females, article [healthcare in low-resource settings 2025;13:12865] [page 55] table 3. the pearson correlation between biochemical parameters and obesity indices (n=491). variables ci absi bri wwi bai avi fpg pearson r 0.192** 0.118** 0.257** 0.203** 0.097* 0.317** p-value <0.001 0.009 <0.001 <0.001 0.032 <0.001 insulin pearson r 0.063 0.059 0.010 0.021 -0.013 0.197** p-value 0.374 0.404 0.891 0.768 0.851 0.005 tc pearson r 0.157** 0.099* 0.201** 0.188** 0.112* 0.186** p-value <0.001 0.029 <0.001 <0.001 0.013 <0.001 tg pearson r 0.283** 0.201** 0.311** 0.282** 0.090* 0.423** p-value <0.001 <0.001 <0.001 <0.001 0.046 <0.001 hdl pearson r -0.269** -0.185** -0.289** -0.244** -0.139** -0.371** p-value <0.001 <0.001 <0.001 <0.001 0.002 <0.001 ldl pearson r 0.091* 0.049 0.128** 0.121** 0.115* 0.117* p-value 0.045 0.279 0.005 0.007 0.011 0.010 ldl/hdl ratio pearson r 0.232** 0.146** 0.293** 0.256** 0.208** 0.322** p-value <0.001 0.001 <0.001 <0.001 <0.001 <0.001 ci: conicity index; absi: a body shape index; bri: body roundness index; wwi: weight-adjusted-waist index; bai: body adiposity index; avi: abdominal volume index; hdl: highdensity lipoprotein cholesterol; ldl: low-density lipoprotein cholesterol; fpg: fasting plasma glucose; tc: total cholesterol; tg: triglyceride. **correlation is significant at the 0.01 level (2-tailed). * correlation is significant at the 0.05 level (2-tailed). article table 4. liner regression association between biochemical parameters and obesity indices. indices β std. error t p* change statistics r square change % of change p* fasting plasma glucose (fpg) conicity index (ci) 54.48 12.59 4.33 <0.001 0.037 3.7 <0.001 body adiposity index (bai) 36.57 16.98 2.15 0.032 0.009 0.9 0.032 abdominal volume index (avi) 1.38 0.24 5.66 <0.001 0.062 6.2 <0.001 a body shape index (absi) 567.54 215.29 2.64 0.009 0.014 1.4 0.009 body roundness index (bri) 8.39 1.43 5.88 <0.001 0.066 6.6 <0.001 weight-adjusted-waist index (wwi) 7.05 1.53 4.59 <0.001 0.041 4.1 <0.001 insulin conicity index (ci) 20.25 22.71 0.89 0.374 0.004 0.4 0.374 body adiposity index (bai) -5.10 27.07 -0.19 0.851 0.000 0.0 0.851 abdominal volume index (avi) 0.40 0.44 0.90 0.369 0.004 0.4 0.369 a body shape index (absi) 302.91 362.25 0.84 0.404 0.004 0.4 0.404 body roundness index (bri) 0.34 2.50 0.14 0.891 0.000 0.0 0.891 weight-adjusted-waist index (wwi) 0.79 2.67 0.30 0.768 0.000 0.0 0.768 total cholesterol (tc) conicity index (ci) 53.86 15.28 3.53 <0.001 0.025 2.5 <0.001 body adiposity index (bai) 50.93 20.45 2.49 0.013 0.013 1.3 0.013 abdominal volume index (avi) 1.17 0.30 3.94 <0.001 0.031 3.1 <0.001 a body shape index (absi) 571.40 260.24 2.20 0.029 0.010 1.0 0.029 body roundness index (bri) 7.92 1.74 4.54 <0.001 0.041 4.1 <0.001 weight-adjusted-waist index (wwi) 7.85 1.86 4.23 <0.001 0.035 3.5 <0.001 triglycerides (tg) conicity index (ci) 278.66 42.64 6.53 <0.001 0.080 8.0 <0.001 body adiposity index (bai) 118.04 58.91 2.00 0.046 0.008 0.8 0.046 abdominal volume index (avi) 6.06 0.83 7.35 <0.001 0.099 9.9 <0.001 a body shape index (absi) 3348.43 736.14 4.55 <0.001 0.041 4.1 <0.001 body roundness index (bri) 35.20 4.86 7.24 <0.001 0.097 9.7 <0.001 weight-adjusted-waist index (wwi) 33.84 5.21 6.49 <0.001 0.079 7.9 <0.001 high-density lipoprotein cholesterol (hdl) conicity index (ci) -26.07 4.23 -6.16 <0.001 0.072 7.2 <0.001 body adiposity index (bai) -17.98 5.78 -3.11 0.002 0.019 1.9 0.002 abdominal volume index (avi) -0.59 0.08 -7.19 <0.001 0.096 9.6 <0.001 a body shape index (absi) -302.87 72.94 -4.15 <0.001 0.034 3.4 <0.001 body roundness index (bri) -3.23 0.48 -6.68 <0.001 0.084 8.4 <0.001 weight-adjusted-waist index (wwi) -2.90 0.52 -5.58 <0.001 0.060 6.0 <0.001 low-density lipoprotein cholesterol (ldl) conicity index (ci) 25.59 12.71 2.01 0.045 0.008 0.8 0.045 body adiposity index (bai) 42.94 16.85 2.55 0.011 0.013 1.3 0.011 abdominal volume index (avi) 0.55 0.25 2.23 0.026 0.010 1.0 0.026 a body shape index (absi) 233.65 215.41 1.08 0.279 0.002 0.2 0.279 body roundness index (bri) 4.15 1.46 2.85 0.005 0.016 1.6 0.005 weight-adjusted-waist index (wwi) 4.16 1.55 2.69 0.007 0.015 1.5 0.007 ldl/hdl ratio conicity index (ci) 2.67 0.51 5.26 <0.001 0.054 5.4 <0.001 body adiposity index (bai) 3.20 0.68 4.71 <0.001 0.043 4.3 <0.001 abdominal volume index (avi) 0.06 0.01 6.05 <0.001 0.070 7.0 <0.001 a body shape index (absi) 28.57 8.73 3.27 0.001 0.021 2.1 0.001 body roundness index (bri) 0.39 0.06 6.76 <0.001 0.086 8.6 <0.001 weight-adjusted-waist index (wwi) 0.36 0.06 5.86 <0.001 0.066 6.6 <0.001 *the p<0.05 level (2-tailed) is considered statistically significant. [page 56] [healthcare in low-resource settings 2025;13:12865] while bmi remained the superior index in males.29 while bmi and wc remained functional parameters, they did not help predict mets and its components in the female population.4 moreover, ci was significant and positively correlated with obesity, muscle, and diastolic blood pressure, and also correlated with blood glucose and cholesterol level.30 in a large prospective study of an older chinese population with a 10-year follow-up cohort, they have been suggested that wwi was significantly associated with an increased tg level and decreased blood glucose level, which is consistent with the current study, wwi is highly correlated with tg level. wwi explained 7.9 % of the detected changeability of tg level, as one unit increase in wwi resulted in a tg increase of 33.84±5.21. wwi, which is a novel obesity index developed in recent years, has a good predictive ability for cardiometabolic morbidity and mortality in the korean population.12 recently, li et al. reported in a cohort study that a significant association exists between the highest wwi category and the increased risk of tg and glucose levels.31 moreover, yu and colleagues found that increasing wwi was significantly associated with a higher incidence of newly diagnosed t2d among rural chinese adults.32 in the present findings, although the ldl/hdl ratio had a significant positive weak correlation with the obesity indices (p<0.001), it increased by 0.39±0.06, 0.06±0.01, 0.36±0.06, 2.67±0.51, and 3.20±0.68 as a result of one unit increase in bri, avi, wwi, ci, and bai; respectively (p<0.001). they explain 8.6%, 7.0%, 6.6%, 5.4%, and 4.3% of the variability observed in the ldl/hdl ratio. no research covered the ability of obesity indices to predict the ldl/hdl ratio. conversely, our research suggests that the ldl/hdl cholesterol ratio is a more effective predictor of cardiovascular and cerebrovascular metabolic-related disorders than a single lipoprotein (using ldl only or hdl only). it can simultaneously assess ldl and hdl cholesterol levels. furthermore, the ldl/hdl cholesterol ratio has a superior predictive value compared to other lipoproteins. it can independently forecast the onset of non-alcoholic fatty liver disease (afld) in chinese non-obese individuals with normal lipid profiles.33 lam and colleagues (2015) studied the relationship between bmi, wc, whr, whtr, bai, and cvd risk factors in the local adult population in singapore.34 they found that when compared to bmi, wc, and whtr, bai consistently had a lower correlation; however, these differences were frequently negligible and had overlapping 95% confidence ranges. in contrast to wc and whtr, bai did not raise the probabilities of cvd risk variables after controlling for bmi (for all but hypertension and poor hdl).34 the obesity indicators are affordable and easy to use. it can be applied to medical and health institutions at all levels, particularly when medical standards are lacking or large-scale data research is required. strengths and limitations the current study has some strengths and limitations. to the best of our knowledge, this is the first study to use six different obesity indices to diagnose the metabolic disorder, including lipid profile and blood glucose level. on the other hand, this study had various limitations, such as the cross-sectional nature of the current research, and a causal relationship could not be achieved. the sample size was relatively small. the present study has not taken into consideration several characteristics that are linked to the progression of t2d, including dietary factors, physical activity, and genetic factors. to answer these questions, more research needs to be done conclusions in conclusion, obesity indices may affect blood sugar and lipid profile levels. the highest impact was for avi, bri, and wwi indices. tg, hdl, and ldl / hdl ratios were the most affected tests. studies to examine the useability of these indices as indicators for high sugar and lipid profiles are recommended and needed as they are not invasive rapid tools that will help in the early detection of t2d and cvd. references 1. forse ra, betancourt-garcia mm, kissee mc. epidemiology and discrimination in obesity. in the asmbs textbook of bariatric surgery; 2020. 2. kahaer m, zhang b, chen w, et al. triglyceride glucose index is more closely related to hyperuricemia than obesity indices in the medical checkup population in xinjiang, china. front endocrinol (lausanne) 2022;13:861760. 3. phelps nh, singleton rk, zhou b, et al. worldwide trends in underweight and obesity from 1990 to 2022: a pooled analysis of 3663 population-representative studies with 222 million children, adolescents, and adults. lancet 2024;403:1027– 1050. 4. liu y, liu x, guan h, et al. body roundness index is a superior obesity index in predicting diabetes risk among hypertensive patients: a prospective cohort study in china. front cardiovasc med 2021;8:736073. 5. tian t, zhang j, zhu q, et al. predicting value of five anthropometric measures in metabolic syndrome among jiangsu province, china. bmc public health 2020;20:1317. 6. kumar c, girwar e, gaur s, et al. cut�off values and clinical efficacy of body roundness index and other novel anthropometric indices in identifying metabolic syndrome and its components among southern�indian adults. diabetol int 2022;13:188–200. 7. wang h, liu a, zhao t, et al. comparison of anthropometric indices for predicting the risk of metabolic syndrome and its components in chinese adults: a prospective, longitudinal study. bmj open 2017;7:016062. 8. gowda v, philip k. abdominal volume index and conicity index in predicting metabolic abnormalities in young women of different socioeconomic class. int j med sci public heal 2016;5:1452. 9. wang h, chen y, sun g, et al. validity of cardiometabolic index, lipid accumulation product, and body adiposity index in predicting the risk of hypertension in chinese population. postgrad med 2018;130:325-33. 10. krakauer ny, krakauer jc. a new body shape index predicts mortality hazard independently of body mass index. plos one 2012;7:0039504. 11. thomas dm, bredlau c, bosy-westphal a, et al. relationships between body roundness with body fat and visceral adipose tissue emerging from a new geometrical model. obesity 2013;21:2264–71. 12. park y, kim nh, kwon ty, kim sg. a novel adiposity index as an integrated predictor of cardiometabolic disease morbidity and mortality. sci rep 2018;8:1–8. 13. tian s, zhang x, xu y, dong h. feasibility of body roundness index for identifying a clustering of cardiometabolic abnormalities compared to bmi, waist circumference and other anthro article [healthcare in low-resource settings 2025;13:12865] [page 57] pometric indices: the china health and nutrition survey, 2008 to 2009. medicine (united states) 2016;95:4642. 14. nkwana mr, monyeki kd, lebelo sl. body roundness index, a body shape index, conicity index, and their association with nutritional status and cardiovascular risk factors in south aafrican rural young adults. int j environ res public health 2021;18:18010281. 15. khan sh, shahid r, fazal n, ijaz a. comparison of various abdominal obesity measures for predicting metabolic syndrome, diabetes, nephropathy, and dyslipidemia. j coll physicians surg pakistan 2019;29:1159–64. 16. stefanescu a, revilla l, lopez t, et al. using a body shape index (absi) and body roundness index (bri) to predict risk of metabolic syndrome in peruvian adults. j int med res 2020;48:300060519848854. 17. pardo m, crujeiras ab, amil m, et al. association of irisin with fat mass, resting energy expenditure, and daily activity in conditions of extreme body mass index. int j endocrinol 2014;2014:857270. 18. nosrati-oskouie m, arefinia s, eslami s, abadi h. evaluation of non-invasive arterial stiffness parameters and their relationship with physical activity , anthropometric indices and lipid profiles in healthy middle-aged adults: results of the persian cohort study. int j clin pract 2021;75:e14275. 19. wu l, zhu w, qiao q, et al. novel and traditional anthropometric indices for identifying metabolic syndrome in non-overweight/obese adults. nutr metab 2021;18:3. 20. mameli c, krakauer ny, krakauer jc, et al. the association between a body shape index and cardiovascular risk in overweight and obese children and adolescents. plos one 2018;13:0190426. 21. peterson md, al snih s, stoddard j, et al. obesity misclassification and the metabolic syndrome in adults with functional mobility impairments: nutrition examination survey 20032006. prev med 2014;60:71-6. 22. liu b, liu b, wu g, yin f. relationship between body-roundness index and metabolic syndrome in type 2 diabetes. diabetes metab syndr obes targets ther 2019;12:931–5. 23. wang h, chen y, sun g, et al. validity of cardiometabolic index, lipid accumulation product, and body adiposity index in predicting the risk of hypertension in chinese population. postgrad med 2018;130:325–33. 24. sharafi se, garmaroudi g, ghafouri m, et al. prevalence of anxiety and depression in patients with overweight and obesity. obes med 2020:17:100169. 25. candan s, candan oo, karabag t. the relationship between nocturnal blood pressure drop and body composition indices among hypertensive patients. j clin hypertens 2020;22:616– 22. 26. anstey kj, cherbuin n, budge m, young j. body mass index in midlife and late-life as a risk factor for dementia: a metaanalysis of prospective studies. obes rev 2011;12:e426-37. 27. donkor n, farrell k, ocho o, et al. correlates of obesity indices and cardiovascular disease risk factors among trinidadian nurses. int j africa nurs sci 2020;12:100194. 28. sanchez-viveros s, barquera s, medina-solis ce, et al. association between diabetes mellitus and hypertension with anthropometric indicators in older adults: results of the mexican health survey, 2000. j nutr heal aging 2008;12:327–33. 29. quaye l, owiredu wkba, amidu n, et al. comparative abilities of body mass index, waist circumference, abdominal volume index, body adiposity index, and conicity index as predictive screening tools for metabolic syndrome among apparently healthy ghanaian adults. j obes 2019;2019:8143179. 30. liu x, wu q, yan g, et al. cardiometabolic index: a new tool for screening the metabolically obese normal weight phenotype. j endocrinol invest 2021;44:1253–61. 31. liu x, wu w, mao z, et al. prevalence and influencing factors of overweight and obesity in a chinese rural population: the henan rural cohort study. sci rep 2018;8:1–11. 32. yu s, wang b, guo x, et al. weight-adjusted-waist index predicts newly diagnosed diabetes in chinese rural adults. j clin med 2023;12:1620. 33. nyakudya tt, tshabalala t, dangarembizi r, et al. the potential therapeutic value of medicinal plants in the management of metabolic disorders. molecules 2020;25:25112669. 34. garcia-arellano a, ramallal r, ruiz-canela m, et al. dietary inflammatory index and incidence of cardiovascular disease in the predimed study. nutrients 2015;7:7064124. article [page 58] [healthcare in low-resource settings 2025;13:12865] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13182 benson’s spiritual relaxation and lavender aromatherapy toward anxiety, sleep quality, and blood pressure eppy setiyowati,1 umdatus soleha,1 mulyadi mulyadi,2 muhammad basuni3,4 1department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya; 2universitas nahdlatul ulama surabaya; 3student of the applied nursing magister program, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya; 4indonesian national army, navy hospital dr. oepomo, surabaya, indonesia abstract anxiety caused by illness is one of the factors contributing to elevated hypertension across all age groups. therefore, in addition to pharmacological treatment, non-pharmacological therapy is essential to reduce anxiety, lower blood pressure, and improve sleep quality in hypertensive patients. this study aimed to analyze the effects of benson’s spiritual relaxation and lavender aromatherapy on anxiety, sleep quality, and blood pressure in hypertensive patients. this research employed a quasi-experimental design with a pretest-posttest control group approach. the population consisted of 97 hypertensive patients at the indonesian national army-navy hospital, with a sample size of 44 respondents selected through purposive sampling. the independent variables were benson’s spiritual relaxation and lavender aromatherapy, while the dependent variables were anxiety, sleep quality, and blood pressure. data were analyzed using multivariate analysis with a significance level of <0.05. the results indicated a significant effect of benson’s spiritual relaxation and lavender aromatherapy on anxiety (p=0.000), sleep quality (p=0.000), systolic blood pressure (p=0.000), and diastolic blood pressure (p=0.000). these techniques are simple to implement, making them a viable nursing intervention in inpatient settings and contributing to nursing science development in hospitals. introduction hypertension is a non-communicable disease that can cause various health problems if not treated promptly. it is characterized by an increase in blood pressure above normal limits, specifically systolic and diastolic values exceeding 140/90 mmhg.1,2 anxiety caused by illness is one of the factors that contribute to hypertension or elevated blood pressure across all age groups.3 if left undiagnosed or untreated, hypertension can lead to various comorbidities, which may result in fatal outcomes.4 in addition to pharmacological treatments, non-pharmacological therapies are essential to reduce anxiety, lower blood pressure, and improve sleep quality in hypertensive patients.5,6 patients with acute hypertension who experience prolonged anxiety often suffer from increased sympathetic nervous system activity, which can gradually elevate blood pressure and lead to sleep disturbances.7 previous studies have demonstrated a significant relationship between anxiety levels and blood pressure in hypertensive patients, indicating that higher anxiety levels correlate with higher blood pressure. as anticipated, anxiety management in hypertensive patients can be achieved through pharmacological or non-pharmacological correspondence: eppy setiyowati, department of nursing, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya indonesia. e-mail: eppy@unusa.ac.id key words: anxiety; aromatherapy; benson relaxation; blood pressure. contributions: es, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; us, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; mm, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; mb, methodology, visualization, writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, chakra brahmanda lentera institution, based on ethical certificate 145/025/xii/ec/kep/lcbl/2023. during the research, the researcher paid attention to the ethical principles of information, consent, respect for human rights, beneficence and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was supported by a research grant from the ministry of education, culture, research and technology republic of indonesia, with contract number 104/spk/d.d4/ppk.01. aptv/iii/ 2024. acknowledgments: the research team would like to thank the ministry of education, culture, research and technology republic of indonesia through the academic directorate of vocational higher education, with decision letter number 104/spk/d.d4/ppk.01.aptv/iii/2024; 008/sp2h/ppkm-ptv/ll7/2024; 772/unusa-lppm/adm.i/iv/2024. we also thank the rector of universitas nahdlatul ulama surabaya and the tni al dr. oepomo hospital, indonesia, for providing permission and research space. received: 11 september 2024. accepted: 7 november 2024. early access: 29 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13182 doi:10.4081/hls.2025.13182 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13182] [page 63] interventions, including benson’s spiritual relaxation and lavender aromatherapy.8 benson’s relaxation therapy has been demonstrated to reduce anxiety levels, lower blood pressure, and enhance sleep quality. additionally, this therapy has shown effectiveness in reducing anxiety among at-risk pregnant women and improving sleep quality for older adults, making it a promising non-pharmacological treatment option.9-13 the addition of lavender aromatherapy has been explored to enhance the effectiveness of benson’s spiritual relaxation.14 spirituality is a multidimensional concept that encompasses existential and religious dimensions. while the existential dimension focuses on the purpose and meaning of life, the religious dimension emphasizes an individual’s relationship with god.15,16 spiritual therapy has been shown to significantly reduce systolic and diastolic blood pressure and pulse rates in hypertensive patients.17 higher levels of spirituality are associated with bettercontrolled blood pressure and lower anxiety levels.18,19 lavender aromatherapy, similarly, has been found to lower anxiety and improve sleep quality, particularly in cancer patients undergoing chemotherapy.20 the purpose of this study was to analyze the effects of benson’s spiritual relaxation and lavender aromatherapy on anxiety, sleep quality, and blood pressure in hypertensive patients. materials and methods this study used a quasi-experimental design with a pretestposttest control group approach. the population consisted of 97 hypertension patients at the indonesian national army hospital. the sample size was 44 respondents, selected using purposive sampling techniques. the inclusion criteria were: i) cooperative patients willing to be respondents, ii) patients with uncomplicated hypertension, iii) patients with gcs: 456, iv) patients with a moderate to high level of anxiety as measured by the zung self-rating anxiety scale (sas/sras), v) patients with a lower level of sleep quality as measured by the pittsburgh sleep quality index (psqi), and vi) patients who have never been treated with a combination of benson’s relaxation and lavender aromatherapy (sbr-al). the exclusion criteria were as follows: i) hypertensive patients with complications, ii) patients with consciousness below gcs: 456, and iii) patients with respiratory disorders and allergies. the study was conducted from april 2024 to august 2024. the independent variables in this study were benson’s spiritual relaxation and lavender aromatherapy, while the dependent variables included anxiety, sleep quality, and systolic and diastolic blood pressure. the intervention involved the application of benson’s spiritual relaxation and lavender aromatherapy, guided by a module with isbn number 978-623-8283-56-9. before the research commenced, the protocol underwent an ethical review and was deemed ethically acceptable under approval number 145/025/xii/ec/kep/ lcbl/2023. instruments anxiety was measured using the zung emergency questionnaire self-rating anxiety scale (sas/sras). this questionnaire consists of 20 questions, where each question is rated 14 (1: never, 2: sometimes, 3: part of the time, 4: almost all the time). the criteria are “not anxious” (score 20-44), “light” (score 45-59), “medium” (score 60-74), and “heavy” (score 75-80). sleep quality was assessed with the pittsburgh sleep quality index (psqi), which consists of 19 subjective points grouped into seven assessment components. the points assessed are about sleep quality, length of sleep, sleep latency, daily sleep efficiency, medication use, disturbances experienced during sleep, and the impact experienced the next day. each point has the same weight on a scale of 0-3, with a total score of 21 points, which means the worst quality that can be assessed. the scores of the seven components are summed up into one global score with a range of 0–21. an overall score of 5 or more indicates poor sleep quality; the higher the value, the worse the sleep quality. blood pressure was measured using standard techniques for systolic and diastolic readings, measured with a digital sphygmomanometer (mmhg). low blood pressure (hypotension) is a decrease in systolic blood pressure by more than 20-30% compared to baseline measurements or systolic blood pressure <100 mmhg. normal blood pressure (normal tension) in adults is around 120/80 mmhg. high blood pressure (hypertension) is where the systolic pressure value is above 140 mmhg and the diastolic pressure value is above 90 mmhg. intervention benson’s spiritual relaxation and lavender aromatherapy involved relaxation techniques designed to calm the mind and body. the intervention included progressive muscle relaxation, deep breathing, recitation of motivational words, expressions of gratitude, and prayers adapted to participants’ beliefs, all while inhaling lavender aromatherapy. the goal was to create a medium for relaxation, provide a sense of comfort, relax muscle tension, reduce anxiety, improve sleep quality, and lower blood pressure in hypertensive patients. the intervention steps in this study were as follows: 1) relax the muscles as much as possible, starting from the legs, calves, thighs, and abdomen and continuing to all the muscles of the body. hands and arms are stretched out, then relaxed, and allowed to droop naturally. try to stay relaxed; 2) start breathing slowly and naturally, and say one word or sentence in your heart according to the patient’s beliefs. the sentence used is the patient’s choice. when inhaling, say the sentence in your heart, and after exhaling, repeat the sentence in your heart. while continuing to do this step, relax your whole body, accompanied by a resigned attitude. during the practice, participants inhaled lavender aromatherapy. this intervention was conducted twice a day, for 10–15 minutes per session, five days a week over the study period. while per special issue pathways of change table 1. participants demographic data (n=13). characteristics percentage (%) age (mean) 53.1 years gender female 53.8 male 46.1 religion islam 100 education elementary school 54.0 junior high school 15.3 senior high school 30.7 duration as a traditional healer (mean) 21.9 years age <50 years 46.2 >50 years 53.8 occupation farmer 46.2 housewife 38.4 entrepreneur 15.4 [page 64] [healthcare in low-resource settings 2025;13(s1):13182] forming these steps and inhaling lavender aromatherapy, participants could silently recite prayers or affirmations according to their beliefs and choices. analysis the statistical analysis was performed using paired t-tests and manova, with a significance level set at p<0.05. results the results of the study, as presented in tables 1 and 2, reveal several important findings regarding the effects of benson relaxation and lavender aromatherapy on anxiety, sleep quality, and blood pressure in hypertensive patients. special issue pathways of change table 2. the main themes and sub-themes. quotes code category theme "yes, we perform ruqyah, ruqyah doing spiritual therapy traditional treatment methods for schizophrenia patients like teaching them regular quranic recitations, and we neutralize them first before we start the treatment." (p1), "regular prayer is performed prayer independently, while we guide them properly in what they do." (p3) "in treatment, apart from prayer, sholawat we also cleanse them before we perform the treatment." (p2) "in the ruqyah treatment we provide, ruqyah in addition to reciting the quran, we also suggest prayers." (p6) "uh, this treatment we do, treatment must be gradual routine treatment for if they want to recover, early-stage schizophrenia the treatment must be gradual." (p1) patients "those who seek treatment, not just once, treatment to three times they must receive treatment up to three times for any changes to happen." (p7) "in the healing process, patients must follow gradual treatment the treatment guidelines we provide because if they don't, the results won't be as effective." (p8) "actually, during my treatment, i've heard healed with traditional medicine believe the disease can be cured from patients that they recover faster with traditional remedies than in the hospital. that's what the patients tell me." (p6) "sometimes i get confused when patients healed with traditional medicine trust me and come, saying they didn't recover in the hospital but did with traditional remedies." (p7) "oh, well, in my treatment, i usually usually use leaves treatment with herbal remedies treatments affecting the effectiveness use leaves, the same ones that have been of healing in schizophrenia patients used for generations." (p5) "in my treatment, i use pure coconut oil because using pure coconut oil we know its contents are beneficial." (p6) "if we believe the illness is from allah, then, believing the illness is from allah treatment based on faith supernatural treatment for schizophrenia patients god willing, we can recover with the effort we make and the patient's belief." (p9) "when i treat them, my hope and belief are that they believing in recovery will recover if they continue to make an effort." (p8). yes, i believe everything can be resolved, as long as all problems can be solved we remain determined to find a solution." (p9) "the patients who seek treatment receive islamic treatment for patients of the islamic faith religion-based treatment treatment, as i use ruqyah in my treatments." (p10) "i hope that these patients can recover and return returning to normal regular treatment traditional healers' hope for patients with schizophrenia to their normal state before experiencing this mental disorder." (p12) "i hope they recover and can work as can recover they used to." (p13). “sangat besar harapan saya tuh bu,, semoga bisa can work again sembuh dan bisa bekerja lagi seperti dulu.”(p3) "yes, i hope that they recover and can speak again can talk again as they used to because, during their illness, they wouldn't speak; they would just remain silent." (p9) [healthcare in low-resource settings 2025;13(s1):13182] [page 65] table 1 presents the demographic characteristics of the respondents in both the intervention and control groups, showing that the two groups were well-matched. the majority of participants in both groups were aged between 41 and 60 years (59.1%). the gender distribution was similar, with most participants being male (77.3% in the intervention group and 72.7% in the control group). in terms of education, more than half of the participants in both groups had a basic education (54.5%), and a significant portion of respondents were not working (59.1% in the intervention group and 63.6% in the control group). these similarities ensure that the two groups were comparable and that the results could be attributed to the interventions rather than demographic differences. the results in table 2 indicate that the intervention of benson’s spiritual relaxation and lavender aromatherapy significantly reduced anxiety, improved sleep quality, and lowered blood pressure in the intervention group. specifically, anxiety levels decreased significantly (mean change = 18.045, p<0.001), sleep quality improved (mean change = 9.182, p<0.001), and both systolic (mean change = 20.545, p<0.001) and diastolic blood pressure (mean change = 10.773, p<0.001) were reduced. in contrast, the control group showed no significant changes in these variables, with anxiety, sleep quality, and blood pressure remaining largely unchanged. the results in table 3 demonstrated that benson’s spiritual relaxation and lavender aromatherapy significantly reduced anxiety, improved sleep quality, and lowered systolic and diastolic blood pressure in the intervention group compared to the control group (p<0.05). these findings indicate the effectiveness of this non-pharmacological intervention for hypertensive patients. discussion hypertensive patients experience both physiological and psychological problems. after undergoing the intervention of benson relaxation and lavender aromatherapy, a decrease in anxiety was observed. this is because the intervention, applied slowly, helped the patient relax, enabling them to accept their condition while remaining calm, enthusiastic, and surrendering to god almighty.8 research has shown that spiritual therapy can lower anxiety. benson relaxation, as a spiritual intervention, has been effective in addressing anxiety in patients with chronic kidney failure.21 lavender aromatherapy has also been shown to reduce anxiety.22 the combination of benson relaxation, spiritual therapy, and lavender aromatherapy has proven to be very effective in reducing anxiety in hemodialysis patients.23 regular and consistent use of complementary therapies like benson’s spiritual relaxation and lavender aromatherapy can significantly lower anxiety levels in hypertensive patients.24,25 furthermore, benson relaxation and lavender aromatherapy have an effect on improving the sleep quality of hypertensive patients, dialysis patients, and the elderly,26-29 and exert a significant effect on changes in blood pressure in hypertensive patients.30 systolic blood pressure before and after the intervention of benson’s spiritual relaxation and lavender aromatherapy, based on paired t-tests showed an effect on the reduction of both systolic and diastolic blood pressure.31,32 in contrast, the control group’s pre and post-intervention blood pressure tests revealed no significant change in systolic and diastolic blood pressure. this indicates that there is a significant effect in reducing both systolic and diastolic blood pressure in hypertensive patients through the intervention of spiritual relaxation and lavender aromatherapy. benson’s spiritual relaxation and lavender aromatherapy have no direct effect on hypertensive patients’ blood pressure; however, they can reduce anxiety and improve sleep quality, which indirectly leads to lower blood pressure. as a result, patients can better change their habits and live a healthier lifestyle.33,34 this, in turn, has a positive impact on the physiological functions of the body, leading to a reduction in blood pressure and better control of hypertension. the effect of benson relaxation and lavender aromatherapy on anxiety, sleep quality, and blood pressure in hypertensive patients shows that sleep quality is the variable most influenced by these interventions. the mechanism at play during the interventions is the creation of relaxation in hypertensive patients: patients are taught spiritual relaxation, which helps them achieve a comfortable and pleasant state, thereby reducing anxiety and improving sleep quality.31 the analysis showed that the p-value for anxiety was 0.000. these results indicate that benson’s spiritual relaxation and lavender aromatherapy have a significant effect on anxiety, sleep quality, and blood pressure in hypertensive patients. among the three variables, sleep quality had the most significant influence, as evidenced by the highest partial eta squared value of 0.743 (table 3). sentences in prayer and lavender aromatherapy regulate emotions by decreasing amygdala activation. furthermore, the stimulus is sent to the prefrontal cortex, where it is processed through careful learning involving the selection, organization, and interpretation of the stressors received. this leads to a change in self-perspective, fostering awareness, wisdom, and self-acceptance of the current condition.35 this technique is easy to perform and can be applied as a nursing intervention. conclusions in conclusion, the combination of benson’s spiritual relaxation and lavender aromatherapy has proven to be an effective intervention for hypertensive patients. these techniques significantly reduce anxiety, improve sleep quality and lower both systolic and diastolic blood pressure. the interventions work by inducing a state of relaxation, which helps patients manage stress, enhance emotional well-being, and adopt healthier lifestyle habits. with their demonstrated effectiveness, these therapies offer a practical and non-invasive option for managing hypertension and can be easily incorporated into nursing care practices to improve patient outcomes. references 1. pranata r, lim ma, huang i, et al. hypertension is associated with increased mortality and severity of disease in covid-19 pneumonia: a systematic review, meta-analysis and metaregression. j renin angiotensin aldosterone syst 2020;21. 2. lestari d. evaluation of monitoring hypertension case based on nine surveillance attributes in jombang district health office in 2018. indones j public health 2021;16:89-100. 3. iswatun, yusuf a, efendi f, et al. relationship between anxiety and spiritual well-being of the elderly with hyper tension during the covid-19 pandemic. j pak med assoc 2023;73:s469. 4. cahyono i, puspitasari y, prasetyo j. penyuluhan terkait menurunkan kecemasan pada penderita hipertensi dengan terapi komplementer progressive muscle relaxation. 2024;3:76-82. special issue pathways of change [page 66] [healthcare in low-resource settings 2025;13(s1):13182] 5. beyliklioğlu a, arslan s. effect of lavender oil on the anxiety of patients before breast surgery. j perianesth nurs 2019;34:587-93. 6. fitriyah r, fernandez g v, samudera ws, et al. deep breathing relaxation for decreasing blood pressure in people with hypertension. jurnal ners 2019;14:141-5. 7. fitriani n, khasanah s, suandika m. pengaruh tindakan non farmakologi terhadap peningkatan kualitas tidur pada lansia penderita hipertensi dengan gangguan tidur. j nurs health 2022;7:108-10. 8. atul angga fiari d, aini n, octary t, et al. the effectiveness of spiritual therapy in reducing the anxiety level of preoperative patients. kne medicine 2023;2023:420-6. 9. mahyuvi t, tukirahmawati d. spiritual benson relaxation in pre-dialysis chronic kidney failure patients with anxiety problems: case study. j app nurs health 2022;4. 10. rani rh, harmayetty h, kusumaningrum t. the combination of benson relaxation and pelvic tilting on the scale of low back pain in pregnant women. nurs j 2020;6. 11. bakar a, suhartatik s, hidayati l. combined benson and dhikr relaxation reduces anxiety and pulse frequency of inpatient cardiacs in hospitals. int j pharm res 2020;12:1747-53. 12. wang z, yang t, fu h. prevalence of diabetes and hypertension and their interaction effects on cardio-cerebrovascular diseases: a cross-sectional study. bmc public health 2021; 21:1224. 13. marasabessy nb, herawati l, achmad i. benson’s relaxation therapy and sleep quality among elderly at a social institution in inakaka, indonesia. kesmas 2020;15:65-72. 14. setiyowati e, agustina an, yuddha as, et al. selfmanagement to change of perception and clinical and pharmacological knowledge of covid-19. j pharm negat results 2022;13:1-6. 15. yusuf a, nihayati he, iswari mf, okviasanti f. kebutuhan spiritual konsep dan aplikasi dalam asuhan keperawatan. jakarta: mitra wacana media; 2016. 16. anwar s, peng ls, mahmudiono t. the importance of spirituality, physical activity and sleep duration to prevent hypertension among elderly in aceh-indonesia. sys rev pharm [internet]. 2020;11:1366-70. available from: https://www.scopus.com/inward/record.uri?eid=2-s2.0-85105897071& doi=10.31838%2fsrp.2020.11.194&partnerid=40&md5=2de aee4342f983978f19d5f0e0777398 17. muslim a, arofiati f. efektifitas kombinasi latihan pernafasan dalam dan terapi spiritual terhadap perubahan parameter kardiovaskuler pada pasien hipertensi di desa darungan kabupaten kediri. jurnal keperawatan 2019;17:309. 18. fiari daa, aini n, octary t, et al. the effectiveness of spiritual therapy in reducing the anxiety level of preoperative patients. kne medicine 2023. 19. ahmed a, elmetwaly m, gaad el moula shaaban e, et al. benson relaxation technique: reducing pain intensity, anxiety level and improving sleep quality among patients undergoing thoracic surgery. egypt j health care. 2020;11. 20. özkaraman a, dügüm ö, yılmaz hö, yeşilbalkan öu. aromatherapy: the effect of lavender on anxiety and sleep quality in patients treated with chemotherapy. clin j oncol nurs 2018;22:203-10. 21. mahyuvi t, tukirahmawati d. spiritual benson relaxation in pre-dialysis chronic kidney failure patients with anxiety problems: case study. j app nurs health 2022;4:356-63. 22. veronica sy, dwiningrum r. the effect of giving lavender aromatherapy on anxiety level in final stage students of diii midwifery at aisyah university of pringsewu. jurnal aisyah : jurnal ilmu kesehatan 2023;8:339-42. 23. kuling s, widyawati iy, makhfudli. pengaruh kombinasi intervensi relaksasi benson, terapi spiritual dzikir dan aroma terapi lavender terhadap kecemasan pada pasien hemodialisis. jurnal keperawatan 2024;16:1-10. 24. pakseresht s, jahandoost h, khalesi zb, leilie ek. effect of lavender aromatherapy on the pain level after cesarean section. herb med j 2020;5:11-20. 25. maulana fh, haryanto j, ulfiana e. the effect of lower extremity massage with lavender essential oil on decreasing blood pressure in elderly with hypertension in uptd griya werdha surabaya. indian j public health res dev 2019;10:1488-93. 26. marasabessy nb, herawati l, achmad i. benson’s relaxation therapy and sleep quality among elderly at a social institution in inakaka, indonesia. kesmas 2020;15:65-72. 27. sunairattanaporn u, phuchum p, darmawati i. the effectiveness of benson’s relaxation therapy on sleep quality in hemodialysis patient: a narrative literature review. jurnal pendidikan keperawatan indonesia 2022;8:4854. 28. sulistyowati d, rahmawati ad. efektivitas kombinasi terapi benson dan aroma terapi lavender terhadap kualitas tidur pada lansia dengan gangguan tidur. penerbit tahta media 2023. 29. ibrahim a, koyuncu g, koyuncu n, et al. the effect of benson relaxation method on anxiety in the emergency care. medicine (united states) 2019;98. 30. abdelhakim am, hussein as, doheim mf, sayed ak. the effect of inhalation aromatherapy in patients undergoing cardiac surgery: a systematic review and meta-analysis of randomized controlled trials. vol. 48, complementary therapies in medicine. churchill livingstone; 2020. 31. kim m, nam es, lee y, kang hj. effects of lavender on anxiety, depression, and physiological parameters: systematic review and meta-analysis. vol. 15, asian nursing research. korean society of nursing science; 2021 p. 279-90. 32. puspitasari y, nurhidayah r, katmini k. effectiveness of aromatherapy on lowering blood pressure of preeclampsia mother during conservative treatment. jurnal keperawatan 2022;14:157-62. 33. supriyanto s, ernawaty, setyawan feb, lestari r. enhancing family medicine practice in developing countries through a holistic-comprehensive care model: a review. indian j public health res dev 2019;10:774-8. 34. sariati s, sholikhah du, narendri cm, et al. music therapy and aromatherapy interventions in patients undergoing hemodialysis: a systematic review. jurnal ners 2019;14:815. 35. wang z, yang t, fu h. prevalence of diabetes and hypertension and their interaction effects on cardio-cerebrovascular diseases: a cross-sectional study. bmc public health 2021;21:1224. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13182] [page 67] hrev_master healthcare in low-resource settings 2024; volume 12:11844 difference in learning attention between career and non-career parents during the covid-19 pandemic in elementary school children reni ilmiasih,1 ratih permatasari,2 aini alifatin,2 ika rizki anggraini,2 nurul aini2 1nursing diploma study program, vocational directorate, universitas muhammadiyah malang, malang; 2nursing science study program, faculty of health sciences, universitas muhammadiyah malang, malang, indonesia abstract the covid-19 pandemic has prompted indonesian students to transition from traditional to online learning. the role of parents, both career and non-career, in focusing on paying attention to their children’s learning has also changed. the study aimed to compare learning attention between parents with careers and parents without careers before and after the covid-19 pandemic. this study was a comparative design with a questionnaire as the instrument. the variable measured is elementary school children’s learning attention. a total sampling technique was employed, involving 64 respondents. the wilcoxon signed rank test and mann-whitney u test were used in data analysis. the findings indicated a significant difference in the learning attention of parents with careers before and after the covid-19 pandemic (p= 0.000). similarly, parents without careers also exhibited a significant difference in learning attention before and after the pandemic (p=0.000). notably, within both the career and non-career parent groups, there was a substantial difference in the learning attention provided to their children before and after the covid-19 pandemic. these results highlight the significant impact of the pandemic on parental involvement in their children’s education. the findings emphasize the need for parents to be conscious of their responsibilities in the face of the unique demands posed by the pandemic, underlining the crucial role they play in supporting their children’s education. introduction the covid-19 pandemic forced the indonesian government to implement regulations in all sectors including education.1 according to the ministry of education and culture, the principal education policy during the pandemic places a high priority on the well-being and safety of participants, including students, educators, and the broader community. it also encompasses the provision of educational services tailored to the growth and development, as well as the psycho-social conditions, of the participants.2 this comprehensive policy aims to fulfill the educational needs during the pandemic, emphasizing the utilization of distance learning conducted from the safety of individuals’ homes.3 the learning paradigm has shifted from traditional face-toface instruction to online learning facilitated through technological devices.4–7 however, a significant concern arises from statistics provided by the central statistics agency (bps) in 2021, revealing that only 17.66% of indonesian children exhibit an interest in reading or engaging in educational activities. instead, a considerable number of children prefer activities such as playing online games and watching cartoons, soap operas, or movies on youtube, all of which are easily accessible on electronic devices during online learning.8,9 efficient online learning at home necessitates active parental involvement. parents play a crucial role in motivating their children by offering clear instructions, providing assistance when needed, and maintaining supervision.10 a dedicated commitment to education involves fostering an environment conducive to completing the school curriculum during online correspondence: reni ilmiasih, nursing diploma study program, vocational directorate, university of muhammadiyah malang, malang, indonesia. e-mail: reni@umm.ac.id key words: school, covid-19 pandemic, learning attention, career parents, non-career parents. contributions: ri, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; rp, conceptualization, investigation, methodology, validation, and writing – original draft, review and editing; aa, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ira, methodology, visualization, writing – review and editing; na, resources, investigation, and writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, universitas jember health research (kepk) no. 1249/un25.8/kepk/dl/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we would like to thank to faculty of health sciences, universitas muhammadiyah malang for their valuable insights and contributions to this study. received: 20 september 2023. accepted: 20 december 2023. early access: 6 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11844 doi:10.4081/hls.2024.11844 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11844] [page 227] non -co mmerc ial us e o nly learning.11–13 this commitment entails parents taking education seriously and providing the necessary resources for their children to successfully navigate the online learning process. crucially, parental attention is identified as the ability of parents to channel their energy, both physical and psychological, towards their children. this focused effort is instrumental in ensuring successful understanding and adapting to a particular parenting style.14,15 the level of busyness among parents, influenced by factors such as parental status, career involvement, and non-career engagement, significantly impacts their ability to devote attention to their active children during online learning.16 the number of career and non-career workers can be seen from amount residents age employed in indonesia, which is approximately 75.49 percent of the total population of indonesia, from 203.97 million residents aged work, which belongs to the workforce as many as 138.22 million people with a labor force participation rate of 67.77 percent.17 according to bps, the number of persons working in east java in august 2020 was 22.26 million, up 1.81 percent from 21.87 million in august 2019. tpak increased by 0.72 points as well.18 according to bps banyuwangi regency, main work residents, fine career and non-career, totaling 873,521 including parents’ medium the child take education, as many as 265,305 declared work as employees (career) and as many as 104,388 were stated as worker free (non-career) as many as 165,408 declared own workers like self-employed and similar (non-career).19 according to this data, non-career workers outnumber worker careers. these findings are consistent with parent data from students at a state elementary school in banyuwangi, where early researchers discovered in may 2021 that as many as 39 parents and children at the elementary school work as non-career workers and 25 children at the elementary school work as career worker. the findings of the study indicate that busy parents’ employment has an impact on school achievement. according to the findings, 75 percent of parents in the group are busy, and 92 percent of achievement is insufficient. the findings indicate a relationship between varying workloads of parents and student performance learning in state elementary schools in grades 4 and 5.20 the type of employment done by parents while their children attend school, particularly in elementary school, will greatly impact their child’s learning activities, particularly online learning. parents support their children’s learning implementation, particularly online learning. high levels of parental involvement will have a detrimental impact on this study’s child’s activities and outcome. lack of parental attention will cause a child to seek attention from sources other than school, such as a friend or peer, or parents when they are at home.16 this study aimed to determine the difference in learning attention between parents’ careers and non-career at a student’s state elementary school in banyuwangi before and after the covid-19 pandemic. materials and methods design this study used a design to compare learning attention between parents’ careers and non-career before and after the covid-19 pandemic in children at an elementary school in banyuwangi. sample and sampling technique the population in this study comprises all fifth-grade students at the elementary school, totaling 64 students. the sample, consisting of characteristics utilized in respondent research,21 specifically encompasses 64 students from a state elementary school in banyuwangi. within this sample, there are 25 respondents representing parents with careers and 39 respondents representing parents without careers. the sampling methodology employs total sampling, which means that obtaining a sample with the method counts the entire population as a sample. variables the learning attention parents’ career and non-career before the covid-19 pandemic is an independent variable in this study. this study’s dependent variable is paying attention to parents’ careers and non-careers after the covid-19 pandemic. this study was conducted at the banyuwangi state elementary school from 1 may 2021 to 30 august 2021. instruments this study’s instruments included a form questionnaire with 15 positive and closed comments. each statement will be given a score of 1 for an answer “no ever”, 2 for “sometimes”, 3 for an answer “often”, and 4 for the answer “always”. the questionnaire has been thoroughly tested for validity and reliability. the validity test results instrument says that all statement items (15 statements) are considered valid where all r count > r table (0.444), reliability test findings stated 0.895. data analysis univariate analysis was utilized to explain the frequency and percentage of learning attention about parents’ careers and noncareers before the covid-19 pandemic and worries about learning about parents’ careers and non-careers following the covid19 pandemic. bivariate analysis using the mann-whitney u test for a different test for two groups of parents’ career and non-career and wilcoxon signed rank test as technique data analysis for comparison learning attention parent before and after the pandemic in each group. these two tests use level significance by 5%. this obtained approval from the universitas jember health research ethics committee (kepk) no. 1249/un25.8/kepk/dl/2021. the researchers have given a clear understanding of the research goals to the participants and have also provided them with consent forms to become respondents. results according to table 1, the majority of parents’ career age by category was mature (100%), kind sex women (52%), and employees’ private sector (56.0%). meanwhile, the majority of adults (79.5%) did not work, as do many sex women (51.3%) and farmers (51.3%). table 2 provided information on the learning attention of parents’ careers before the covid-19 pandemic (84%). meanwhile, most of the good (80%) occurred after the pandemic. learning attention in non-career parents also increased from before the majority of the covid-19 pandemic in the category (92.3%) after the pandemic all non-career parents’ learning attention was good (100%). table 3 showed a difference in parents’ and non-career learning attention with a p-value of 0.000. before the covid-19 pandemic, non-significant results were solely assigned to group testing of the parent’s career and non-career in children (p-value=0.118). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 228] [healthcare in low-resource settings 2024;12:11844] non -co mmerc ial us e o nly discussion the research findings regarding the learning attention of parents with careers and non-careers before the pandemic reveal no significant difference between the two groups. in both cases, the majority of parents provided sufficient attention to their children’s learning. this lack of significant difference can be attributed to the pre-pandemic study conditions, which were typically conducted at school.22–24 parents only give special attention to challenging activities at home and need help.25 there was no significant difference between the two data groups due to the type of work occupied by career and non-career parents where work requires quite a lot of activities outside the home. several employees dominate parents’ job careers by a significant 56.0%, confiscating lots of time and sparing together children at home.26 although in general employment parents’ non-career no bound with time and more lots time interacting with their son at home, work as several traders reached 41.0% as showed results of this study, it makes time spare lots spent outside the house.27,28 busy outside homes are carried out by non-career parents, particularly those who work as traders in the market, on the sidewalk roads, and the like. this busy work environment affects both career and non-career parents, resulting in a lack of sufficient attention to their children’s education before the covid-19 pandemic.29 the study emphasizes the impact of parents’ busy work schedules on their ability to provide adequate attention to their children, underscoring that this lack of attention can influence a child’s understanding of their educational and social world. the findings highlight the need for a balanced approach to parental commitments to ensure that children receive the attention necessary for their overall development, particularly in the context of the pre-pandemic learning environment.30 the test results on learning attention after the pandemic revealed a significant difference between parent groups with careers and those without careers. in the category of learning attention, most parents with careers and overall non-career parents performed well. however, despite both groups falling into the “good” category, there was a distinction wherein parents with careers exhibited lower attention compared to non-career parents.31,32 this disparity is attributed to coping strategies employed during the online learning process amidst the pandemic, particularly regarding parental involvement.33 parents with careers may face challenges in dedicating attention to their children’s learning due to the added workload associated with working from home. the demands of the home office contribute to increased stress, with the egalitarian nature of parenting serving as a more significant stressor than traditional parenting approaches.32 in contrast, non-career parents, particularly those who are self-employed or involved in business, faced lockdown policies and restrictions on operating hours for economic centers like markets. the reduced time available for producing goods or food for sale created an environment where noncareer parents had more interaction and increased learning attention for their children. the work from home (wfh) situation, especially for mothers, involves multitasking in caring for their children while fulfilling work responsibilities, reflecting efforts to be good parents under challenging circumstances.34 the results of the data analysis indicate a significant difference in the learning attention of parents with careers before and after the covid-19 pandemic. the pandemic has brought about substantial changes, impacting various aspects of parents’ work activities.32,35 the transition to online learning during the pandemic has necessitated increased parental supervision for a smooth and effective educational experience, as teacher supervision is limited.36 especially for children who are less interested in online learning, parents play a crucial role in providing the necessary attention and support.37 parents must be aware of their children’s challenges in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. data demographic career and non-career parents. demographics career non-career n % n % age 20-60 years (adult) 25 100.0 31 79.5 > 60 years (continued age) 0 0 8 20.5 gender man 12 48.0 19 48.7 woman 13 52.0 20 51,3 work retired/not work 0 0 3 7.7 civil servants 2 8.0 0 0 teacher 9 36.0 0 0 employee private 14 56.0 0 0 farmer 0 0 20 51.3 entrepreneur/trader 0 0 16 41.0 total 25 100.0 39 100.0 table 2. learning attention career and non-career parents in elementary school children before and after covid-19 pandemic. learning attention before after n % n % parents career good 3 12.0 20 80.0 enough 21 84.0 5 20.0 not enough 1 4.0 0 0 total 25 100.0 25 100.0 non-career parents good 3 7.7 39 100.0 enough 36 92.3 0 0 not enough 0 0 0 0 total 39 100.0 39 100.0 table 3. difference between learning attention of career and non-career parents. learning attention mean z-values p career and non-career parents before the covid-19 pandemic 40.68 -1.564 0.118 career and non-career parents after covid-19 pandemic 50.22 -5.405 0.000* careers parents before and after the covid-19 pandemic 88.76 -4.212 0.000* non-career parents before and after covid-19 pandemic 92.28 -5.450 0.000* *p<0.05. [healthcare in low-resource settings 2024;12:11844] [page 229] non -co mmerc ial us e o nly online learning and actively participate in addressing and resolving these issues.38 research also emphasizes the importance of daily communication and connection between parents and children. the family’s ability to intertwine and establish a positive pattern of connection is vital. busy parents who are often away from home may experience a reduction in the intensity of interaction with their children.39 conversely, research indicates that parental involvement in a child’s learning process at school is a proven factor contributing to the child’s success. therefore, the level of parental engagement in the learning process is crucial for children’s educational achievements, and this has become even more pronounced in the context of the changes brought about by the covid-19 pandemic.40 comparison results in learning attention before and after the pandemic in groups non-career parents also found significant differences. the improvement in learning attention before the pandemic was mostly sufficient, but after the pandemic, it has significantly increased and is now considered good. this shift can be attributed to the dominant involvement of one parent in non-officebased work, such as being a farmer. moreover, a considerable number have become traders or are self-employed, a trend that has been influenced by the enforcement of the implementation of community activity restriction policy.41 this policy has led to restrictions on non-career parental activities, necessitating their presence at home more frequently. this change in occupation and the subsequent increased presence at home have positively influenced the overall learning attention provided by parents after the pandemic.33,34 appeal learning at home for student school during the covid-19 pandemic made the parental role truly purified return as an educator.36 parent involvement in supervision activity learning, resources learning mainly for a child, parental authority gives teaching to the child by material from a teacher. they play a substitute teacher during activity teaching from home.42 patterns of learning attention parents’ non-career during the covid-19 pandemic increased bigger when compared to before because influence environment around them. the environment is one factor in learning attention parents to children or influences the success and achievement of learning children.43 the environment around the moment the covid-19 pandemic occurred necessitates somebody active at home or staying at home to disconnect eye covid-19 viral chain. this study is in line with the findings stated in research that many parents participate in helping and providing motivation to children during learning at home cause of an appeal government regarding covid-19.44 no few parents propose to spare time to get help with the learning process of their son while at home. parental roles and learning child roles changed during the covid19 pandemic.22,35,37 the involvement of parents in continuing the learning process at home during the pandemic is more effective and a solution, especially in schools and developing countries.45,46 the most crucial factor influencing students’ learning activity is surveillance, specifically parental attention to the child.31,47 the role of parents, either career or non-career, in supervising a child inside the house, specifically during the covid-19 pandemic, is far bigger than before the pandemic.36,37,47 at this time, they work daily in a context fulfillment economy family from house, with intense activity outside their job more little from before the covid-19 pandemic.32,34 this related to attention or supervision to learn of children too far more significant when the covid-19 pandemic occurred. conclusions parents’ careers and non-career learning attention to the child before the covid-19 pandemic in the majority category was enough. parents’ careers learning attention after the covid-19 pandemic was entirely category good. then parents’ careers and non-careers learning attention before the covid-19 pandemic was no different. however, there was a significant difference in learning attention parents’ careers with non-careers after the covid-19 pandemic. this demonstrated the increase in condition pandemic learning attention by both groups of parents careers and non-career, particularly in the group of parents’ non-career learning attention totally in the category is good. the key reason boosting learning attention for parents’ career and non-career is an increase in home availability to accompany the online learning process. parents’ careers and non-careers are likewise linked to parents’ enhancement requests in the online learning process. references 1. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632–45. 2. mundakir m, efendi f, susanti ia. study of knowledge, attitude, anxiety, and perception of mental health needs among nursing students in indonesia during covid-19 pandemic. indones nurs j educ clin 2020;6:18–29. 3. kemendikbud. surat edaran mendikbud no 4 tahun 2020 tentang pelaksanaan kebijakan pendidikan dalam masa darurat penyebaran corona virus disease (covid-19). 2020. 4. visuddho v, nugraha d, melbiarta rr, et al. predominant aspects of knowledge and practical skills among medical students with online learning during the covid-19 pandemic era. med educ online 2023;28:2182665. 5. wulandari cp, muthi’ah ad, aldhama sa, et al. analyzing perceived academic stress among first year undergraduate students during online distance learning. in: 1st international conference on advanced technology and multidiscipline. 2023. 6. d’arqom a, indiastuti dn, nasution z. online peer-group activism for thalassemia health education during the covid19 pandemic: a case study from east java, indonesia. j heal res 2022;36:158–65. 7. shi-hui s, chaw ly, aw ec-x, sham r. dataset of international students’ acceptance of online distance learning during covid-19 pandemic: a preliminary investigation. data br 2022;42. 8. mubarok am. menumbuhkan minat baca siswa dari keluarga. sindonews.com. 2017. 9. niu h, wang s, tao y, et al. the association between online learning, parents’ marital status, and internet addiction among adolescents during the covid-19 pandemic period: a crosslagged panel network approach. j affect disord 2023;333:553–61. 10. hidaayah n, yunitasari e, nihayati he, et al. parenting stress against symptoms of gadget addiction in elementary school age during the covid-19 pandemic. bali med j 2022;11:1189–94. 11. prokupek l, cohen f, oppermann e, anders y. families with transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 230] [healthcare in low-resource settings 2024;12:11844] non -co mmerc ial us e o nly young children during the covid-19 pandemic—the importance of family type, perceived partnership roles, parental stress, and social support for changes in the home learning environment during lockdown. front psychol 2023;14:1–14. 12. yang x, jiang p, zhu l. parental problematic smartphone use and children’s executive function: the mediating role of technoference and the moderating role of children’s age. early child res q 2023;63:219–27. 13. rahem a, syahrir a, ismail h, hermansyah a. revisiting early online learning experiences amid the covid-19 pandemic in indonesia: benefits, barriers, and impact on pharmacy student learning outcomes. pharm educ 2022;22:989–96. 14. zamani s, akrami n, kooshki ham. an exploration of the lived experiences of mothers with successful female children to develop a native parenting style. j qual res heal sci 2023;12:37–44. 15. arief ys, kurnia id, nurkholida s. parents, behaviour in individual-level prevention in children during the covid-19 pandemic in surabaya. j pak med assoc 2023;73:s96–9. 16. rachmawati a. orangtua karir dan pendidikan anak. universitas islam negri sunan ampel. 2019. 17. pusdatinaker. ketenagakerjaan dalam data (2021). jakarta; 2021. 18. bps jawa timur. provinsi jawa timur dalam angka 2021. surabaya; 2021. 19. bps banyuwangi. kabupaten banyuwangi dalam angka. banyuwangi; 2021. 20. wahyuni s. pengaruh kesibukan kerja orangtua terhadap prestasi belajar siswa sd negeri kalase’rena kecamatan bontonompo kabupaten gowa. palu; 2017. 21. sugiyono. metode penelitian kuantitatif kualitatif. bandung: alfabeta; 2019. 22. casimir oa, blake sc, klosky jv, gazmararian ja. adaptations to the learning environment for elementary school children in georgia during the covid-19 pandemic. j child fam stud 2023;32:1585–98. 23. nurrosyida k, firmanto nn, fayanshah iba, sulistyawati sw. parent’s level of stress on children’s online classes during the covid-19 pandemic. j community med public heal res 2022;3:19–25. 24. wong lc, tee pk, cham t-h, lim mf. online learning during covid-19 pandemic: a view of undergraduate student perspective in malaysia. lecture notes in networks and systems 2023;550:415–26. 25. augustine jm, prickett k. gender disparities in increased parenting time during the covid-19 pandemic: a research note. demography 2022;59:1233–47. 26. harknett k, schneider d, luhr s. who cares if parents have unpredictable work schedules?: just-in-time work schedules and child care arrangements. soc probl 2022;69:164–83. 27. chung gsk, chan xw, lanier p, wong pyj. associations between work–family balance, parenting stress, and marital conflicts during covid-19 pandemic in singapore. j child fam stud 2023;32:132–44. 28. luppi f, mencarini l, see sg. satisfaction with work–family roles and the relationship with working parents’ life satisfaction: a cross-disciplinary perspective. j fam stud 2023; https://doi.org/10.1080/13229400.2023.2218836 29. lyttelton t, zang e, musick k. parents’ work arrangements and gendered time use during the covid-19 pandemic. j marriage fam 2023;85:657–73. 30. faud fm. menjadi orangtua bijaksana. yogyakarta: tugu publisher.; 2005. 31. mahmudi a, sulianto j, listyarini i. hubungan perhatian orang tua terhadap hasil belajar kognitif siswa. j pedagog dan pembelajaran 2020;3:122. 32. andré s, van der zwan r. the influence of the covid-19 pandemic on changes in perceived work pressure for dutch mothers and fathers. gender, work organ 2023;30:1015–34. 33. chara ylaa, machaca arc, yepez jcm, et al. coping strategies for online learning from home. int j learn teach educ res 2023;22:359–78. 34. handley km. troubling gender norms on mumsnet: working from home and parenting during the uk’s first covid lockdown. gender, work organ 2023;30:999–1014. 35. godwin ke, kaur f, sonnenschein s. teaching and learning during a global pandemic: perspectives from elementary school teachers and parents. educ sci 2023;13:426. 36. putri rs, purwanto a, pramono r, et al. impact of the covid-19 pandemic on online home learning: an explorative study of primary schools in indonesia. int j adv sci technol 2020;29:4809–18. 37. rahardjo b, rozie f, maulina j. view of parents’ role in children’s learning during and after the covid-19 pandemic.pdf. j pendidik usia dini 2022;16:69–84. 38. perantika r. peran orang tua dalam belajar daring siswa min 1 kepahiang pada masa pandemi covid-19. bengkulu: universitas negeri bengkulu; 2021. 39. putro et. all. pola interaksi anak dan orangtua selama kebijakan pembelajaran di rumah. j islam educ 2020;1:23–4. 40. avvisati f, besbas b, guyon n. parental involvement in school: a literature review. rev econ polit 2010;120:759–78. 41. kemendagri. instruksi menteri dalam negeri (mendagri) nomor 1 tahun 2021 dan diberlakukan di wilayah jawa dan bali. 2021. 42. epstein jl, becker hj. teachers’ reported practices of parent involvement: problems and possibilities. sch fam community partnerships, student econ ed prep educ improv sch 2018;83:115–28. 43. slameto. belajar dan faktor-faktor yang mempengaruhinya. jakarta: jakarta: pt. rineka cipta; 2010. 44. haerudin h, cahyani a, sitihanifah n, et al. peran orangtua dalam membimbing anak selama pembelajaran di rumah sebagai upaya memutus covid-19. j stastistika inferensial 2020;1(12). 45. sakaue k, wokadala j, ogawa k. effect of parental engagement on children’s home-based continued learning during covid-19–induced school closures: evidence from uganda. int j educ dev 2023;100. 46. ye ft-f, gao x, sin k-f, yang l. remote learning and mental health during the societal lockdown: a study of primary school students and parents in times of covid-19. bmc public health 2023;23:1106. 47. ceka a, murati r. the role of the parents in the education of children. j educ pract 2016;7:61–4. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11844] [page 231] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13605 prevalence and determinants of scabies among children in ethiopia: a systematic review and meta-analysis abayeneh girma, indiris abdu department of biology, college of natural and computational science, mekdela amba university, tulu awuliya, ethiopia abstract scabies is a major neglected tropical disease affecting children in deprived communities like ethiopia. this study aims to evaluate the prevalence and determinants of sarcoptes scabiei infestation among ethiopian children under 15 years. studies were sourced from pubmed, scopus, sciencedirect, and african journals online through a systematic search, following prisma2020 guidelines. the joanna briggs institute’s tool was used to appraise study quality. a random-effects model was used for analysis. subgroup and sensitivity analyses were conducted to assess heterogeneity using i² statistics. publication bias was assessed using a funnel plot and egger’s test. a total of 9,126 children from 14 studies were included, with a pooled prevalence of 14.94% (95% ci: 11.32-18.57). being male, having a family size of more than five members, children with an education level below grade five, history of sharing clothes within the family, infrequent washing of clothes, lack of formal family education, poor family wealth or income status, using unimproved water sources, personal hygiene issues like untrimmed fingernails, sharing clothes with individuals diagnosed with scabies, poor knowledge about scabies among family members or caregivers, history of contact with individuals experiencing skin itching or scabies, sharing common sleeping beds or fomites, washing hands with water only, having family members with signs of itching or scabies, and infrequent bathing were factors significantly associated with sarcoptes scabiei infestation among children under the age of 15 in ethiopia. therefore, policymakers and health planners should put a great deal of emphasis on the implementation of relevant prevention and control measures. introduction scabies is a contagious skin disease caused by the sarcoptes scabiei mite, characterized by severe itching and rashes, often worsened at night.1 the condition can lead to secondary bacterial infections, causing complications like septicemia, rheumatic fever, and renal failure.2 it significantly impacts individuals’ physical, emotional, and social well-being, including stigma, isolation, and disruptions in daily life.3 the economic burden on families and healthcare systems is equally notable.4 prevalence of scabies varies widely, from 0.2% to 71.4% globally, with school-based studies reporting higher rates, such as 31% in malaysia and up to 87.3% in thailand.5, 6 african countries report diverse prevalence rates: 4.4% in egypt, 5.2% in guineabissau, and up to 78.4% in ethiopia.7-9 the factors that increase the chances of scabies include sharing beds or clothes, low income, younger age, large family size, lack of knowledge about scabies, parental illiteracy, seasonal conditions, and residency in rural areas.10,11 in ethiopia, prevalence of scabies can also be associated with conflict, civil war, drought, flooding, poor water supply and sanitation, and overcrowding living conditions.12 ethiopia’s unique geography and socio-economic challenges create a conducive environment for scabies outbreaks.13 scabies remains a major yet neglected public health concern in ethiopia. a systematic review and meta-analysis conducted in ethiopia and across africa revealed that the prevalence of scabies among school children was 14.71% and 10.81%, respectively.14,15 however, comprehensive data on the prevalence of scabies and associated risk factors among all ethiopian children under the age of 15 remain scarce in ethiopia. this systematic review and metaanalysis aim to provide updated estimates and identify critical risk factors to guide effective interventions. correspondence: abayeneh girma, department of biology, college of natural and computational science, mekdela amba university, p.o. box 32, tulu awuliya, ethiopia. e-mail: gabayeneh2013@gmail.com key words: children, ethiopia, meta-analysis, neglected diseases, risk factors, scabies. contributions: ag, conceptualization, data curation, software, formal analysis, investigation, validation, visualization, project administration, supervision, writing— review and editing; ia, methodology, resources, data curation, investigation, validation, visualization, writing—original draft. all authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 9 january 2025. accepted: 14 june 2025. early access: 3 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13605 doi:10.4081/hls.2025.13605 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 224] [healthcare in low-resource settings 2025;13:13605] materials and methods systematic review protocol and registration this systematic review and meta-analysis were conducted following the preferred reporting items for systematic reviews and meta-analysis (prisma-2020) guideline 16 (supplementary materials). furthermore, the study protocol is registered in international prospective register of systematic reviews (prospero) with an identification number of crd42024530761. search strategy databases including pubmed, scopus, sciencedirect, and african journals online were searched without language or time restrictions. boolean operators “and” and “or” were used with keywords such as “prevalence”, “associated factors”, “determinant factors”, “predictors”, “scabies”, “child”, “children”, “children under 15”, and “ethiopia”. reference lists of selected articles were also reviewed using google search engine. inclusion and exclusion criteria studies were included if they i) reported prevalence of scabies among ethiopian children under 15, ii) employed observational study designs, and iii) were published between june 2015 and january 2023. studies were excluded if they: lacked original data or focused on other skin conditions; did not report prevalence; or had inaccessible full texts. study selection and quality appraisal all retrieved articles were imported into endnote x8 (thomson reuters, usa), and duplicates were excluded. hereafter, the titles and/or abstracts of articles were independently screened by two authors (ag and ia). the articles that met the eligibility criteria and were quality appraised underwent full-text appraisal. the joanna briggs institute (jbi) critical appraisal checklist for prevalence,17 and case-control18 studies was used for quality appraisal using 9, and 10 criteria, respectively. for each question, a score was assigned (no for ‘not reported or not appropriate’ and yes ‘for reported’); the scores were summarized across the items to achieve a total score of 0 to 9, and 0 to 10, for prevalence and case-control studies, respectively. studies were categorised as ‘high risk of bias’ (low quality), ‘moderate risk of bias’ (moderate quality) or ‘low risk of bias’ (high quality) when the overall score was ≤49%, 50-69% or ≥70%, respectively19 (supplementary materials). all disagreements between authors were resolved through conversation. data extraction relevant studies that met the eligibility criteria were subjected to data extraction and summarized in an excel spreadsheet. the information extracted from the included studies were; the name of the first author, publication year, region, study design, study setting, sample size, cases, the magnitude of scabies, response rate, and risk factors (tables 1 and 3). data analysis stata version 14/se software was used for meta-analysis. a random effects model was used to determine the pooled magnitude and risk factors of scabies along with 95% confidence interval (ci). for risk factors, if the 95% ci does not include 1, the result is considered statistically significant. the i2 statistics were used to assess the magnitude of heterogeneity of the included articles and values of <25% indicate low, 25-50% moderate, and >50% substantial heterogeneity.20 i2 p-value tests whether the observed heterogeneity is statistically significant or not. subgroup and sensitivity analysis was performed to explore the possible source of heterogeneity. egger’s, test, and funnel plot were used to check the presence of publication bias among the included articles. publication bias was assessed using egger’s test, with a p<0.05 indicating statistical significance.21 results selection of studies a total of 461 articles were identified through the databases mentioned. after 225 duplicates were removed, another 153 studies were also excluded from the remaining articles after evaluating the title and/or abstract. furthermore, 69 articles were also excluded during the full text assessment for reasons mentioned in the eligibility criteria. finally, only 14 of the articles met the eligibility article table 1. characteristics of included studies. study region study design study setting sample size cases prevalence (%) response rate (%) 22 oromia cross-sectional hospital based 324 44 13.6 23 snnpr cross-sectional institutional based 343 19 5.5 24 amhara cross-sectional institutional based 494 46 9.3 91.84 25 amhara cross-sectional community based 583 139 23.84 96.4 26 amhara case-control institutional based 300 100 33.3 27 tigray cross-sectional institutional based 495 64 12.93 100 28 snnpr cross-sectional community based 825 135 16.4 97.6 29 snnpr cross-sectional institutional based 864 46 5.3 30 amhara cross-sectional community based 850 92 10.82 98.04 31 snnpr cross-sectional community based 590 98 16.6 97.7 32 amhara cross-sectional community based 1437 192 13.4 33 amhara cross-sectional institutional based 622 55 8.8 98 34 amhara cross-sectional community based 942 202 21.5 97.4 35 oromia cross-sectional community based 457 88 19.26 99.13 snnpr, southern nations, nationalities, and peoples’ region. [healthcare in low-resource settings 2024;12:13605] [page 225] criteria and were included in the systematic review and meta-analysis (figure 1). characteristics of included studies table 1 provides a summary of the specific features found in the studies that were included. the 14 eligible studies22-35 were conducted in 4 regions. amhara region had the highest number of eligible studies (seven studies), followed by southern nations, nationalities, and peoples’ region (snnpr) (four studies) and oromia (two studies). one study was conducted in tigray region. thirteen studies were cross-sectional and the remaining one was case-control. seven, six, and one were community-based, institutional-based, and hospital-based studies. a total of 9126 children were examined for the presence of scabies. the sample size among children in included studies ranged from 300 to 1437. pooled prevalence of scabies an overall prevalence of 14.94% (95% ci: 11.32, 18.57) was obtained from 1,328 children under 15 years of age infested with scabies. high heterogeneity was observed across studies (i²= 96.3%, p<0.001) (figure 2). subgroup analysis with evidence of substantial heterogeneity, a subgroup analysis was performed. the results are shown in table 2. the pooled prevalence of scabies among studies conducted using sample sizes article table 2. subgroup analysis of the magnitude of scabies among children in ethiopia. variables characteristics included studies sample size prevalence (95% ci) i2, p sample size <384 3 967 17.38 (95% ci: 1.99, 32.77) 98.5, p<0.001 >384 11 8159 14.35 (95% ci: 10.78, 17.92) 95.4, p<0.001 region oromia 2 781 16.58 (95% ci: 11.04, 22.12) 83.1, p=0.015 snnpr 4 2622 10.87 (95% ci: 4.85, 16.88) 96.7, p<0.001 amhara 7 5228 17.18 (95% ci: 11.75, 22.62) 96.1, p<0.001 tigray 1 495 12.93 (95% ci: 9.53, 16.33) 100, –––––– study design cross-sectional 13 8826 13.60 (95% ci: 10.31, 16.88) 95.4, p<0.001 case-control 1 300 33.30 (95% ci: 29.00, 37.60) 0.0, –––––– study settings hospital 1 324 13.60 (95% ci: 9.90, 17.30) 0.0, –––––– institutional 6 3118 12.35 (95% ci: 6.02, 18.68) 96.8, p<0.001 community 7 5684 17.28% (95% ci: 13.98, 20.59) 91.8, p<0.001 sampling method systematic random 4 1424 17.82 (95% ci: 7.03, 28.61) 98.1, p<0.001 simple random 10 7702 13.86% (95% ci: 10.14, 17.57) 95.4, p<0.001 publication year 2016-2020 7 3364 16.32 (95% ci: 9.84, 22.80) 96.7, p<0.001 2021-2023 7 5762 13.64 (95% ci: 9.07, 18.22) 96.4, p<0.001 overall 14 9126 14.94% (95% ci: 11.32, 18.57) 96.3, p<0.001 snnpr, southern nations, nationalities, and people’s region. [page 226] [healthcare in low-resource settings 2024;12:13605] figure 1. flow diagram summarizing the selection of eligible studies. figure 2. forest plot displaying the pooled magnitude of scabies among children under 15 years of age in ethiopia. of less than 384 (17.38%; 95% ci: 1.99, 32.77) was higher than that of studies with sample sizes >384 (14.35; 95% ci: 10.78, 17.92). among ethiopian regions, the highest prevalence was reported in amhara (17.18%), followed by oromia (16.58%), tigray (12.93%), and snnpr (10.87%). a high overall estimate was observed in case-control studies (33.30%; 95% ci: 29.00, 37.60) than in cross-sectional studies (13.60%; 95% ci: 10.31, 16.88). the highest pooled prevalence of scabies among study settings was reported from community studies at 17.28% (95% ci: 13.98, 20.59), followed by hospital studies at 13.60% (95% ci: 9.90, 17.30) and institutional study settings at 12.35% (95% ci: 6.02, 18.68). the prevalence estimate of scabies was higher in the studies using systematic random sampling method, with a pooled prevalence estimate of 17.82% (95% ci: 7.03, 28.61), than in the studies using the simple random sampling method at 13.86% (95% ci: 10.14, 17.57). the prevalence of scabies decreased gradually from 16.32% during the period between 2016 and 2020 to 13.64% in the next three years (2021-2023). quality assessment and publication bias information on the quality assessment of individual studies is presented in supplementary materials. briefly, all of the included studies were of high quality. the asymmetry of the funnel plot indicated the existence of publication bias among the included studies (figure 3a). similarly, the regression-based egger test (s7 figure) revealed statistically significant publication bias (p=0.001). since there is a high level of heterogeneity in the included studies, a sensitivity analysis was performed by removing each study one at a time to assess the impact of each study on the pooled effect size. during the sensitivity analysis, two studies, walker at al.24 and dagne et al.,29 had relatively determinant effects on the overall magnitude of scabies among children under 15 years of age in ethiopia. 13.45 (12.74-14.17) and 14.37 (13.6115.13) were estimates after removing each study one at a time, namely walker et al.24 and amare and lindtjorn,30 respectively. after completely removing those two studies, as indicated in figure 3b, the estimate becomes 15.70 (14.88-16.51). factors associated with sarcoptes scabiei infestation in this systematic review and meta-analysis; the frequency of cloth washing, family education, and the habit of washing hands with water, sex, family size, educational status of children, cloth sharing with family, wealth or income status of the family, sharing clothes with scabies cases, and bath frequency were reported in three articles. in addition, two articles reported the water source, fingernail trimming, and family or caregiver knowledge of scabies. furthermore, a history of contact with skin itching cases/scabies, sharing of sleeping beds/fomites and family members with itchy signs/scabies were reported in five articles, and all above mentioned factors were significantly associated with sarcoptes scabiei infestation (table 3). discussion scabies poses a substantial health burden for children under 15, especially in lowand middle-income countries (lmics). understanding the pooled prevalence and determinants of scabies is crucial for informing evidence-based policies and guiding interventions in detection, management, and prevention efforts. this systematic review and meta-analysis focused on estimating the pooled prevalence of scabies and its associated factors among ethiopian children under 15 years. the analysis incorporated data from 14 studies, encompassing a total of 9,126 participants. the pooled prevalence of sarcoptes scabiei infestation among children under 15 years of age was 14.94%. this finding was consistent with surveillance studies conducted in australia (16.5%),36 and cameroon (17.8%)37 and meta-analysis among school children in ethiopia (14.71%).14 on the other hand, studies that showed a higher prevalence than our findings were done in malaysia (31%),5 turkey (33%),38 solomon islands (54.3%),39 bangladesh (6162%),40 sierra leone (67%),41 and thailand (87.5%).6 however, our result was higher than those of studies conducted in taiwan (1.4%),42 egypt (4.4%),7 australia (8.2%),43 and nigeria (10.5%) 44 and meta-analysis among school children in africa (10.81%).15 these variations could be due to sociodemographic characteristics, the season of data collection, study population, sample sizes, methodology used, and economic status. in the present study, demographic factors include being male, having a family size of more than five members, and having children with an education level below grade five, which were associated with 2.04, 3.86, and 3.45 times higher odds of encountering scabies, respectively, compared to their counterparts. this finding is in agreement with studies conducted elsewhere.14,15,39,45,46 males have been observed to engage in less frequent personal hygiene practices, potentially contributing to higher scabies transmission. conversely, females are generally more concerned about cleanli article figure 3. a) funnel plot representing evidence of publication bias; b) sensitivity analysis result of the included studies that assessed the impact of each study on the overall magnitude of scabies. [healthcare in low-resource settings 2024;12:13605] [page 227] ness and beauty so they take better care of themselves and maintain cleanliness compared to males.47 additionally, increased physical contact during play or sports may facilitate transmission among boys.15 the possible explanation for family size could be related to sharing habits of bed and cloths in large family are high within a household and outside the household.48 finally, lower educational levels may correlate with poorer access to health information, including preventive measures and hygiene practices and delayed treatment, increasing the likelihood of scabies infestation. environmental factors, such as meaning environmental factors, such as the use of the use unimproved water sources, were associated with 1.65 times higher odds of scabies among children under the age of 15 who used them compared to those who did not. unimproved water sources and insufficient water supplies are significant contributors to the burden of scabies in lowand middleincome countries as documented from elsewhere.49 this association might be attributed to the limited accessibility of water sources caused by factors such as lengthy water collection times, poor water quality, intermittent supply or scarcity, low socioeconomic conditions in rural areas, and unequal distribution of improved water sources by local administrations. these challenges often result in poor personal hygiene, a direct contributing factor to scabies infestation. moreover, a community-based study conducted in drought-affected regions of ethiopia found a high prevalence of scabies.50 household and interpersonal factors include a history of sharing clothes within the family, sharing clothes with individuals diagnosed with scabies, and sharing common sleeping beds or fomites. individuals exposed to these factors were 3.17, 10.51, and 3.40 times more likely to develop scabies, respectively, compared to their counterparts. this finding is consistent with meta-analysis conducted elsewhere.14,15,45,46 the possible explanations for the above significant risk factors might be due to sharing beds or clothing with someone infected with scabies enables the mites to move directly from the infected individual to an uninfected person. moreover, when one person in a bed-sharing situation has scabies, the close proximity can promote continuous transmission and reinfection.51 close contact or sleeping near someone with scabies is one of the main ways the infection spreads from an affected person to a healthy individual. the findings of this study reveal a significant association between the level of knowledge and awareness about scabies among caregivers and the likelihood of children contracting the condition. children from families with poor knowledge were 2.65 times more likely to experience scabies compared to those from families with good knowledge. this reinforces the importance of targeted health education programs as a primary tool for scabies prevention. the observed odds ratio aligns closely with prior research.53 this might be because limited knowledge may be linked to unhealthy behaviors, such as inadequate personal hygiene, sharing beds or clothing with others, and not seeking proper healthcare for scabies treatment. these consistent findings across diverse contexts underline the universal importance of education in disease prevention. this meta-analysis revealed that behavioral and hygiene-related factors, including infrequent bathing, untrimmed fingernails, infrequent washing of clothes, and washing hands with water only, were associated with 3.85, 3.55, 6.15, and 2.68 times higher odds of developing scabies, respectively, compared to their counterparts. this finding was supported by different surveillance studies in different areas37,52-54 and meta-analysis.14,15,45,46 this could be because the respondents were less aware of the importance of personal hygiene, and poor personal hygiene could be a risk factor for the spread of scabies mites. the other reasons might be the inadequate supply of water for household consumption, including maintaining personal hygiene, especially during the dry season among rural and overcrowded areas of the community as a result the longer clothes and the body remain unwashed, the greater the opportunity for scabies mites to survive on them. this raises the risk of transmission to anyone who comes into contact with the contaminated items or skin.14,15,45 socioeconomic factors include poor family wealth or income status, which was significantly associated with 2.26 times higher odds of acquiring scabies, and lack of formal family education, which was significantly linked to 1.91 times higher odds, compared to wealthy and literate families. the current result is in line with several previous surveillance studies conducted else article [page 228] [healthcare in low-resource settings 2024;12:13605] table 3. factors associated with the magnitude of scabies among children under 15 years of age in ethiopia. variables number of articles pooled odds ratio (95% ci) i-squared (%) i2 p male 3 2.04 (1.09,3.00) 0 0.594 family size above five 3 3.86 (1.44,6.28) 0 0.590 children education less than grade five 3 3.45 (1.61,5.29) 0 0.918 sharing history of cloth with family 3 3.17 (1.23,5.11) 1.4 0.363 infrequent cloth wash 3 6.15 (2.41,9.88) 68.3 0.043 no formal family education 3 1.91 (0.41,2.79) 91.5 <0.001 poor wealth or income status of the family 3 2.26 (1.33,3.18) 0 0.449 unimproved water source 2 1.65 (1.08,2.22) 0 0.708 untrimmed finger nail 2 3.55 (1.02,8.12) 48.4 0.164 sharing clothes with scabies case 3 10.51 (5.38,15.64) 0 0.788 family or caregiver poor knowledge about scabies 2 2.65 (1.22,4.07) 8.3 0.296 having history of contact with skin itching cases/scabies 5 4.94 (2.37,7.52) 38.4 0.165 sharing common sleeping beds/fomites 5 3.40 (1.93,4.87) 0 0.965 habit of washing hand with water only 3 2.68 (0.97,4.39) 80.8 <0.001 family member with itchy signs / scabies 5 5.92 (3.02,8.83) 0 0.704 infrequent bath 3 3.85 (1.33,6.36) 0 0.789 where.7,52,53,55-58 this could be explained by the fact that children from educated families have better opportunities to earn more money and better personal and environmental sanitation, in addition to better health-seeking behavior than others.58 finally, health and contact-related factors include children who have a history of contact with individuals experiencing skin itching or scabies, who were 4.94 times more likely to acquire scabies. additionally, children with family members showing signs of itching or scabies were 5.92 times more likely to develop scabies than their counterparts. this finding also supported by previous studies.7,14,15 scabies spreads easily through close physical contact. if children aged under15 frequently interact with siblings and parents, they are more likely to contract it if another family member is infected.59 strengths and limitations a key strength of this systematic review and meta-analysis is the pooled prevalence and risk factors associated with scabies infestation were identified among children under 15 years of age in ethiopia. even though, this review did not consider all regions in ethiopia due to the lack of availability of articles this may limit the generalizability of the findings. conclusion sarcoptes scabiei infestation remains a critical issue among ethiopian children, with community-based settings exhibiting the highest prevalence. health programs should prioritize improved water access, community hygiene education, and targeted interventions for high-risk groups such as large households and children with low health literacy. future research should expand to underrepresented ethiopian regions and focus on long-term scabies control measures, including sustainable hygiene interventions and health education programs. references 1. stamm lv, strowd lc. ignoring the “itch”: the global health problem of scabies. am j trop med 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tasani m, tong sy, andrews rm, et al. the importance of scabies coinfection in the treatment considerations for impetigo. pediatric infect dis j 2016;35:374-8. 37. kouotou ea, nansseu jrn, kouawa mk, et al. prevalence and drivers of human scabies among children and adolescents living and studying in cameroonian boarding schools. parasites vectors 2016;9:1-6. 38. öztürkcan s, özçelik s and saygi g. spread of scabies and pediculus humanus among the children at sivas orphanage. indian pediatr 1994;31:210-3. 39. osti mh, sokana o, phelan s, et al. prevalence of scabies and impetigo in the solomon islands: a school survey. bmc infect dis 2019;19:803. 40. talukder k, talukder m, farooque m, et al. controlling scabies in madrasahs (islamic religious schools) in bangladesh. public health 2013;127:83-91. 41. terry b, kanjah f, sahr f, et al. sarcoptes scabiei infestation among children in a displacement camp in sierra leone. public health 2001;115:208-11. 42. wu y-h, su h-y and hsieh y-j. survey of infectious skin diseases and skin infestations among primary school students of taitung county, eastern taiwan. j formosan med assoc = taiwan yi zhi 2000;99:128-34. 43. yeoh dk, anderson a, cleland g, et al. are scabies and impetigo “normalised”? a cross-sectional comparative study of hospitalised children in northern australia assessing clinical recognition and treatment of skin infections. plos neglected trop dis 2017;11:e0005726. 44. kalu ei, wagbatsoma v, ogbaini-emovon e, et al. age and sex prevalence of infectious dermatoses among primary school children in a rural south-eastern nigerian community. pan afr med j 2015;20:182. 45. demoze l, gubena f, akalewold e, et al. burden and determinants of scabies in ethiopian school age children: a systematic review and meta-analysis with public health implications. plos one 2024;19:e0314882. 46. gupta s, thornley s, morris a, et al. prevalence and determinants of scabies: a global systematic review and meta�analysis. trop med inter health 2024;29:1006-17. 47. trasia rf. scabies in indonesia: epidemiology and prevention. insights public health j 2020;1:30-8. 48. azene ag, aragaw am and wassie gt. prevalence and associated factors of scabies in ethiopia: systematic review and meta-analysis. bmc infect dis 2020;20:380. 49. prüss-ustün a, wolf j, bartram j, et al. burden of disease from inadequate water, sanitation and hygiene for selected adverse health outcomes: an updated analysis with a focus on low-and middle-income countries. int j hygiene environ health 2019; 222:765-77. 50. enbiale w and ayalew a. investigation of a scabies outbreak in drought-affected areas in ethiopia. trop med infect dis 2018;3:114. 51. banerji a. scabies. paediatr child health 2015;20:395-8. 52. feldmeier h, jackson a, ariza l, et al. the epidemiology of scabies in an impoverished community in rural brazil: presence and severity of disease are associated with poor living conditions and illiteracy. j am academy dermatol 2009;60: 436-43. 53. ejigu k, haji y, toma a, et al. factors associated with scabies outbreaks in primary schools in ethiopia: a case-control study. res rep trop med 2019;10:119-27. 54. raza n, qadir s and agha h. risk factors for scabies among male soldiers in pakistan: case-control study. emhj-eastern mediterranean health j 2009;15:1105-10. 55. karim s, anwar k, khan m, et al. socio-demographic characteristics of children infested with scabies in densely populated communities of residential madrashas (islamic education institutes) in dhaka, bangladesh. public health 2007;121:923-34. 56. stanton b, khanam s, nazrul h, et al. scabies in urban bangladesh. j trop med hygiene 1987;90:219-26. 57. hassen yk, ame mm, mummed ba, et al. magnitude and factors associated with scabies among primary school children in goro gutu woreda, east hararghe zone, ethiopia. int j med parasitol epidemiol sci 2022;3:84. 58. lulu y, tolesa g, cris j. prevalence and associated factors of skin diseases among primary school children in illuababorzone, oromia regional state, south west ethiopia. indo am j pharm res 2017;7:7374-83. 59. fitzgerald d, grainger rj and reid a. interventions for preventing the spread of infestation in close contacts of people with scabies. cochrane database of systematic reviews 2014. article [page 230] [healthcare in low-resource settings 2024;12:13605] online supplementary materials prisma-2020 checklist. jbi critical appraisal checklist for cross-sectional (prevalence) and case-control studies. hrev_master healthcare in low-resource settings 2025; volume 13:12918 analysis of the internal and external factors supporting and inhibiting community empowerment in disaster management based on disasterresilient villages abd hady junaidi, hariani hariani, muhammad nur nursing department, health polytechnic, ministry of health, makassar, indonesia abstract community empowerment has a universal and multidimensional application in addressing various challenges, including disaster management. achieving the goals and targets of disaster management without empowerment presents considerable difficulties. empowerment is linked to various internal and external factors that either support or inhibit it. in indonesia, the government, through the national board for disaster management (nbdm), has established a model disaster-resilient village (drv) as a basis to apply empowerment in disaster management. this study aims to analyze the internal and external factors that support and hinder empowerment, using a descriptive, analytical, exploratory, and comparative design. this research was conducted in one of the drvs called bili-bili village, in bontomarannu district, gowa regency, south sulawesi province. proportional sampling was employed to select a sample of 125 families, representing 20% of the total population. data were collected by observation, interviews, and documentation methods. based on our findings, the internal factors influencing empowerment include anxiety, experience, perception, and the level of support and assistance available. inhibiting internal factors are limited competencies, lack of capacity to act, low commitment, and insufficient participation and involvement. externally, the inhibiting factors consist of policy and program limitations, the roles and coordination among leading and supporting sectoral institutions, the influence of community leaders and government leadership, and weaknesses in coordination and cooperation mechanisms. to strengthen community empowerment in disaster management, particularly in the context of disaster-resilient villages, there is a need to enhance awareness, build capacity, and cultivate a supportive community culture. introduction disasters often pose both physical and psychological threats and disruptions. they can cause significant damage to infrastructure, public facilities, and the environment. in addition, disasters present risks of harm and the potential for both material and nonmaterial losses, including the threat of death. overall, disaster events have wide-ranging impacts on human life, affecting social structures, culture, health, the environment, the economy, and other aspects of society.1 miradj et al. stated that empowerment can be a strategy for utilizing the power and potential within the community to create social change.2,3 this social change can occur if the empowerment process is sustained over time. its success will be reflected in shifts in cultural values, patterns of thought, and behaviors at both the individual and group levels.4 in the context of disaster management, purnomo et al. emphasize that it encompasses all aspects of planning and response, including actions taken before, during, and after a disaster. this approach also involves managing both disaster risks and their potential consequences.1,5 therefore, communities hold a central role at the correspondence: abd hady junaidi, nursing department, health polytechnic, ministry of health, makassar, indonesia. e-mail: hady@poltekkes-mks.ac.id key words: disaster; external factors; internal factors; empowerment. contributions: ahj, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; hh, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; mn, formal analysis, validation, writing – review & editing. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: this study received ethical approval from the health research ethics commission of the nursing department, health polytechnic, health ministry of makassar. throughout the study, researchers pay close attention to enforcing any valid ethical principles, particularly regarding the rights and privacy of the study’s subjects. informed consent: written informed consent was obtained from the study’s participants. availability of data and materials: data supporting the findings of this study are included in this published article. funding: the authors received financial resources from dipa’s health polytechnic, ministry of health of makassar (contract number: lb.02.03/4.3/0018/2023). acknowledgments: the authors express their gratitude to the local government of gowa regency and related agencies for granting us a license to conduct the investigation; the bili-bili village government for providing permission and access to carry out the research; the local people who have demonstrated readiness and willingness to participate as respondents or informants; and the supervisors who have offered support, assistance, and insights for the implementation of this study. received: 12 august 2024. accepted: 17 march 2025. early access: 17 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12918 doi:10.4081/hls.2025.12918 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 180] [healthcare in low-resource settings 2025;13:12918] forefront of responding to dangers and natural disasters. community empowerment is a practical approach to reducing and managing potential disaster risks in the future. to achieve this, individuals and groups within the community must develop their capacity to make decisions in disaster management, implement strategies, and achieve goals. this includes managing all or part of the resources they possess and monitoring their performance effectively.6,7 the world risk report classifies indonesia as a nation with a significant disaster risk, attributed to its considerable exposure and susceptibility to calamities. unesco ranked indonesia seventh among the most disaster-prone countries globally.8,9 many people live in areas where it is increasingly difficult to separate daily life from the problems, risks, and impacts of disasters. as sunarto et al. noted, indonesia is widely recognized by several labels, including “the master of disasters” and “the country of a thousand disasters”, reflecting its high exposure to natural hazards.1 the national board for disaster management (nbdm) of indonesia states that the country is often referred to as a “disaster market” due to its wide range of natural and human-induced hazards. since 1815, disasters have consistently caused significant loss of life and property, with the number of victims increasing over time. given this reality, it is crucial for indonesia to implement effective mitigation and adaptation strategies to reduce disaster risks and address the growing challenges posed by climate change.8,9 the nbdm outlines the potential risks and impacts of losses caused by natural disasters in indonesia as detailed in table 1. the types of natural disasters that are most dangerous and have the greatest impact and risk of loss of life are extreme weather and floods. the nbdm has released the results of a study and report on the potential number of people exposed to disaster risks across indonesia, including physical, economic, and environmental losses. these risks are categorized as medium to high and are distributed across all 34 provinces, based on the type of disaster threat. according to the nbdm report, the five disaster types with the highest number of people exposed are extreme weather, affecting approximately 244 million people; drought, with 228 million; floods, with 100 million; earthquakes, with 86 million; and landslides, with 14 million individuals. in terms of potential physical and economic damage, earthquakes represent the greatest threat, with estimated losses reaching idr 648.874 trillion. this is followed by floods and flash floods at idr 376.886 trillion, drought at idr 192.737 trillion, and landslides at idr 78.279 trillion. the report also highlights the potential environmental impact, with drought posing the highest threat at 63 million hectares affected, followed by forest and land fires at 42 million hectares, and landslides impacting 41 million hectares. looking further, the various types of disasters, with their everincreasing risks and impacts, clearly highlight that it is the population or community members who consistently face direct consequences and the risk of significant losses, including both material losses and loss of life.8,9 disasters in indonesia are diverse in type, nature, and form, and can generally be grouped into two categories: natural and nonnatural disasters. however, in the last few decades, the most common events have been natural disasters such as floods, flash floods, extreme weather, whirlwinds, landslides, extreme waves and erosion, forest and land fires, droughts, volcanic eruptions, earthquakes, and tsunamis, with floods, landslides, and whirlwinds occurring more frequently.8,9 according to the united nations development programme (undp), disasters cause significant losses to lives, property, and the social structures. these impacts often exceed the capacity of those communities to cope independently, making external protection and assistance essential. communities in indonesia, including south sulawesi province and especially gowa regency, face two major problems to date, namely the threat of disaster and helplessness. in gowa regency, various types of disasters, including floods, tornadoes, and landslides, frequently occur, and local residents face these disasters almost every year, particularly during the rainy season with moderate to high rainfall. other sub-districts, such as somba opu, bontomarannu, pattalassang, parangloe, palangga, tombolopao, and manuju districts, experience floods, tornadoes, and landslides every year. these catastrophes result in numerous injuries requiring hospitalization, the displacement and evacuation of hundreds, and fatalities. specifically, in the bontomarannu district, one of the villages often hit by natural disasters is bili-bili village.10 bili-bili is one of two villages in gowa regency that have been designated as a disaster-resilient village (drv) since 2019. however, residents still face issues related to helplessness, a lack of independence, and high reliance on assistance from others for evacuation. they also struggle with a lack of competence – encompassing knowledge, understanding, skill, experience, and motivation – regarding health and disease issues, disaster mitigation, prevention and preparedness for disasters, and disaster emergency article [healthcare in low-resource settings 2025;13:12918] [page 181] table 1. potential risks and impacts of losses from disasters. disaster type potential risk and loss impact hazard area number of people physique economy environment (hectare) exposed (rupiah in billion) (rupiah in billion) (hectare) flood 39,371,167 100,814,666 176,329,821 140,520,440 12,135,957 flash flood 2,733,966 8,637,161 44,679,539 15,358,006 1,056,365 extreme weather 106,582,476 244,295,774 11,972,702 3,088,869 extreme waves & abrasion 1,888,085 4,917,327 22,042,350 1,290,842 460,252 earthquake 52,374,614 86,247,258 466,689,834 182,185,171 forest and land fires 86,457,259 59,036,830 41,856,289 drought 46,735,107 48,491,666 192,737,143 29,820,457 volcanic eruption 1,162,220 3,910,775. 2,695,427 12,613 139,676 landslide 57,418,460 14,131,542 78,279,825 75,870,343 41,337,707 tsunamis 961,133 3,702,702 71,494,821 7,976,358 119,688 sources: references 8, 9. response. all of this shows that there is still minimal empowerment of the population or members of the community. community empowerment through a top-down approach is suboptimal. this is marked by insufficient awareness, limited capacity building, and inadequate community empowerment regarding disaster prevention, preparedness, and emergency response. a study conducted by hady et al. identified several internal factors contributing to feelings of helplessness, powerlessness, and lack of independence among the community in bili-bili when it comes to preventing, facing, and overcoming disaster-related problems, risks, and impacts in rural areas. these internal factors include: i) mental attitudes, behaviors, and cultural dependence on external assistance; ii) low levels of awareness, knowledge, and understanding; iii) limited human resource competencies; iv) weak commitment, motivation, and consistency; v) institutional weaknesses; vi) cultural barriers; vii) internal policy constraints; viii) lack of community leadership; ix) inadequate infrastructure, facilities, and technology; and x) insufficient financial resources or budget. meanwhile, the main external problem factors consist of i) government or relevant agency policies and programs; ii) a dominant top-down approach; iii) insufficient bottom-up initiatives; iv) low public awareness; v) inadequate socialization and community coaching; vi) lack of education and training; and vii) insufficient support and assistance. importantly, all these factors are interconnected and influence one another.1 in this context, various international studies have identified numerous factors that influence community empowerment and disaster management. internal factors include human resource capacity, culture, awareness, knowledge, skills, preparedness, response, collaboration, participation, communication, trust, resilience to disasters, socio-economic conditions, environmental aspects, accessibility, social capital, and geographical location. external factors encompass policies and programs, general and technological planning, government support, awareness and capacity-building initiatives, empowerment programs, behavioral development, coordination and collaboration efforts, innovations in disaster crisis communication, disaster risk analysis, technology quality, preparedness systems, animal insurance schemes, disaster education programs, and monitoring mechanisms. given this comprehensive understanding, it is increasingly important to conduct research aimed at analyzing the internal and external factors that support or hinder community empowerment in disaster management. this study focuses specifically on drv in bili-bili village. materials and methods this study employs a descriptive research design11 aimed at capturing and describing the responses of informants and respondents regarding factors influencing community empowerment in disaster management based on the drv framework. the design integrates analytical components, critically questioning and analyzing issues, exploratory elements for in-depth investigation, and comparative methods to identify similarities and differences. the research was conducted in bili-bili village, located in bontomarannu district, gowa regency, south sulawesi province, indonesia. the population comprised 567 households. a proportional sampling technique was used to take a sample of 125 families as participants (or 20% of the total population). all data were collected using library studies, field studies, observations, questionnaires, interviews, and documentation methods. a library study was performed to obtain secondary data on regional conditions and population statistics. a field study was conducted through surveys and mapping of research locations. observation was used to assess environmental and infrastructure conditions, daily activities of village communities, drv activities, and other relevant factors. interviews were conducted in-depth, structured, and systematically using a guideline to explore information related to research problems. interview activities involved informants and key speakers, such as community leaders, non-governmental organization (ngo) activists, village heads, village officials, drv administrators, and other stakeholders. documentation was used to document research activities. data validity checks were conducted through editing, classification, verification, analysis, and conclusion. data were processed into tables and analyzed qualitatively. in data analysis, reduction, abstraction, display, and deductive conclusion were carried out.12-14 ethics clearance this research received ethical approval from the health research ethics commission of the nursing department, health polytechnic, ministry of health in makassar. throughout the research process, the researchers took great care to adhere to ethical principles, such as obtaining permission from relevant parties before conducting research, arranging appointments with respondents and informants for questionnaires and interviews, and maintaining the confidentiality of respondents’/informants’ identities if requested. results supporting and inhibiting internal factors based on the research results, several internal factors were identified that support and/or hinder local community empowerment in disaster management, as observed in disaster-resilient villages in bili-bili village and outlined in table 2. based on tables 2 and 3, eight internal factor determinants can hinder and support community empowerment in disaster management based on drv, including: i) anxiety factor, ii) experience, iii) perception, iv) competence, v) action ability, vi) commitment, vii) need for support/ assistance, viii) participation and involvement factor. anxiety the results of the study indicated that 84.8% of the village community experienced high anxiety, while 15.2% of the other residents showed either less anxiety or had no anxiety. individuals exhibiting elevated anxiety levels experienced significant worry, apprehension, and fear regarding floods, landslides, and tornadoes in their community or surroundings during the rainy season, particularly in the event of the bili-bili dam’s rupture or water overflow. they reported anxiety about reliving the specter of past disasters, which included the risk of losing property and livestock, damage to homes and plants, health issues and diseases, injuries, and even the loss of some family members. those with low anxiety levels felt capable of facing and overcoming disasters; they were also unconcerned because they believed their homes and residential environments were relatively safe and remote from disasters. thus, most village residents experience high anxiety over the potential threat of disasters, along with their associated risks and impacts, article [page 182] [healthcare in low-resource settings 2025;13:12918] which can serve as a supporting factor for community empowerment in disaster management. experience the results indicated that 68.8% of the villagers experienced negative and troubling effects due to the floods, landslides, and tornadoes that occur almost every year in their community. every rainy season, they feel threatened by the risk of material and nonmaterial losses. meanwhile, 31.2% of respondents reported less experience in dealing with disasters and their risks and impacts. thus, many villagers have had bad and unpleasant experiences with the potential threats of disasters, which can serve as a supporting factor for community empowerment in disaster management. perception according to the findings, 88.0% of community members have a positive perception of disasters. they regard disasters as sources of wisdom and benefits for their lives and livelihoods. they perceive disasters as good advice from god and nature, viewing them as god’s way of warning humanity to return to the right path and not to harm nature and the environment recklessly. they believe it is god’s way of raising awareness, encouraging humans to be more careful in managing the earth responsibly and compassionately. they view or interpret disasters positively and maintain an optimistic attitude, believing that disasters can be prevented, managed, and overcome. the associated risks and impacts can be minimized, handled, controlled, and restored. on the contrary, 12.0% of village residents tend to view or interpret disasters negatively. they consider disasters as punishment from god and nature, which leads to feelings of anxiety, fear, sadness, hesitation, stress, depression, and trauma. they lament the disaster that harmed their living environment and residence, destroyed their crops and livestock, damaged their property, caused injuries and health issues, and led to certain diseases, among other consequences. they maintain a pessimistic outlook, believing that disasters are difficult to prevent and manage, cannot be controlled, and adopt a resigned attitude toward the risk of loss and its impacts. this perspective leaves them feeling helpless, with little choice but to wait for assistance. consequently, they lack interest in empowerment programs and often refuse to participate or take an active role. thus, it can be concluded that their perception serves as an internal factor inhibiting empowerment. article table 2. formulation of the supporting and inhibiting internal factors for community empowerment in disaster management based on the bili-bili disaster-resilient village. no. internal factors informant answer categories (%) vg g ge l vl rating score 5 4 3 2 1 1 anxiety over the frequency of catastrophic events 22 (17.6) 31 (24.8) 53 (42.4) 13 (10.4) 6 (4.8) 2 experience in dealing with disasters and risk of loss 12 (9.6) 33 (26.4) 41 (32.8) 28 (22.4) 11 (8.8) 3 perception on the prevention and disaster preparedness 20 (16) 26 (20.8) 64 (51.2) 11 (8.8) 4 (3.2) 4 competency on disaster response 14 (11.2) 18 (14.4) 21 (16.8) 40 (32.0) 32 (25.6) 5 ability to act in the face of disasters 6 (4.8) 13 (10.4) 22 (17.6) 53 (42.4) 31 (24.8) 6 commitment and motivation to learn 5 (4) 14 (11.2) 26 (20.8) 58 (46.4) 22 (17.6) 7 need for support/ assistance 11 (8.8) 20 (16) 51 (40.8) 25 (20) 18 (14.4) 8 participation and involvement 6 (4.8) 15 (12) 21 (16.8) 57 (45.6) 26 (20.8) average (%) 12 (9.6) 21 (16.8) 37 (29.6) 35 (28.0) 20 (16) category 70 (56.0) 55 (44.0) good low source: primary data. vg, very good; g, good; ge, good enough; l, low; vl, very low. table 3. formulation of the supporting and inhibiting internal factors for community empowerment in disaster management based on the bili-bili disaster-resilient village. no. internal factors category (%) internal factor status good low 1 anxiety over the frequency of catastrophic events 106 (84.8) 19 (15.2) supporter 2 experience in dealing with disasters and risk of loss 86 (68.8) 39 (31.2) supporter 3 perception on the prevention and disaster preparedness 110 (88.0) 15 (12) supporter 4 competency on disaster response 53 (42.4) 72 (57.6) inhibitor 5 ability to act in the face of disasters 41 (32.8) 84 (67.2) inhibitor 6 commitment and motivation to learn 45 (36) 80 (64.0) inhibitor 7 need for support/assistance 82 (65.6) 43 (34.4) inhibitor 8 participation and involvement 42 (33.6) 83 (66.4) inhibitor average (%) 70 (56.0) 55 (44.0) 125 (100) source: table 2. [healthcare in low-resource settings 2025;13:12918] [page 183] competence the results indicated that 42.4% of the village population possesses strong human resource competencies related to disaster and disaster management. this is evidenced by their extensive knowledge of disaster issues, skills, and experience, as well as their ability to act in preventing disasters, preparing for emergencies, mitigating risks, managing impacts, and engaging in recovery, rehabilitation, and reconstruction. they are fully aware that their residential and surrounding environments are prone to disasters and understand that the potential threat from disasters constantly affects their lives. having dealt with disaster events, they recognize the associated risks and impacts. consequently, from that experience, they are capable and skilled in making decisions and taking actions to prevent and prepare for disasters. they know how to protect themselves, provide first aid such as basic life support (bls) or breathing assistance to victims, help family members and neighbors, and take action to save and evacuate their belongings, among other things. on the other hand, 57.6% of residents have inadequate or limited human resource competencies in disaster management. this highlights several issues, such as their knowledge of disaster-related topics being insufficient, their lack of experience and ability to prevent disasters, and their unfamiliarity with disaster preparedness, emergency response, and risk reduction. they often do not know what actions to take in preventing, managing, and mitigating the impacts of disasters. furthermore, they sometimes exhibit indifference and lack awareness of potential threats and dangers posed by disasters in their environment that jeopardize their lives. additionally, they lack the necessary knowledge, skills, experience, and capabilities to prevent and address the risks and impacts of disasters. these individuals tend to maintain attitudes, behaviors, and a culture of dependence on assistance from external sources for rescue and evacuation support. they resign themselves to disasters and continuously hope for help from external parties such as the government, relevant agencies, search and rescue teams (srt), law enforcement, health workers, and others. therefore, it can be concluded that the competencies of human resources can be an internal factor that inhibits progress. action capability the study’s results showed that 32.8% of the village population has good action capabilities regarding disaster and disaster management. this is indicated by their ability to carry out the necessary procedures and steps to anticipate disasters, evacuate, save themselves and their property, and prevent health problems and diseases during or after a disaster. they can quickly and appropriately provide first aid in the form of bls or breathing assistance to victims, help family members and neighbors evacuate to safe shelters, and take measures to save and evacuate their property, among others. on the other hand, 67.2% of people still have low capacity for action. they are still confused about the procedures and steps needed to anticipate disasters. they do not know how to evacuate, how to save themselves and their belongings, or what actions to take to prevent health problems and diseases during or after a disaster. furthermore, they lack an understanding of disaster preparedness, emergency response measures, and risk reduction. as a result of their low capacity for action, they maintain attitudes and behaviors that depend on the help of other people or outside parties to obtain rescue and evacuation assistance, as well as support in the event of a disaster. on that basis, action capability can be an internal factor inhibiting community empowerment. commitment according to the study findings, 36.0% of the village residents have a good commitment to disaster management. this is demonstrated by their active attitude and consistency in continually improving their knowledge, skills, experience (competence), and capacity in the areas of prevention, disaster preparedness, disaster emergencies, risk mitigation, disaster impact management and control, recovery, and post-disaster rehabilitation and reconstruction within their surrounding environment or region. they are proactive in participating in socialization/counseling activities, advocacy development, education, and training conducted by the government, related agencies, or other competent external parties. in contrast, 64.0% of respondents demonstrated a lower or low level of commitment. they are still quite strong in maintaining attitudes and behaviors of dependence on assistance from other people or outside parties. they always expected aid from outside. hence, commitment can be an internal factor inhibiting community empowerment in disaster management. need for support and assistance the results of the study showed that 65.6% of participants feel they need support in terms of policies, institutions, materials, infrastructure, facilities, technology, and finance to carry out disaster management in an integrated and comprehensive manner during prevention activities, disaster preparedness, disaster emergencies, risk mitigation, managing and controlling disaster impacts, recovery, and post-disaster rehabilitation and reconstruction in their villages. they hope that the government and related agencies, especially nbdm of indonesia and the regional disaster management agency (rdma) of gowa, as the leading sector for national and regional disaster management, can provide the necessary infrastructures, facilities, technology, and funding. on the other hand, 34.4% of other villagers feel doubtful, apathetic, and skeptical because assistance and support are typically only available when a disaster occurs or after it has happened. they believe that before a disaster, there is almost no assistance or support from the government or other external parties, which only comes when there are already many victims. therefore, it can be stated that the need for support and assistance can be an internal factor supporting disaster management. participation and role the results illustrated that 33.6% of people exhibit good participation and involvement in disaster management. this is indicated by: their involvement in contributing ideas and thoughts in the decision-making process; their participation in actively attending programs and activities for socialization, coaching, advocacy, education, and training in the field of disasters organized by the government/related agencies or other competent parties; their involvement in assisting in the form of manpower, ideas, materials and facilities and specific equipment including the technology needed in the implementation of preventive measures, preparedness, risk mitigation, handling and controlling the impact of disasters, emergency recovery, and post-disaster rehabilitation and reconstruction in the surrounding environment or region. on the other hand, 66.4% of people have low or inadequate levels of participation before, during, and after the disaster. this is indicated by their attitudes and behaviors, which tend to be passive, rarely contributing ideas and thoughts, seldom attending programs and activities for socialization, education, and training in the field of disaster, and infrequently providing necessary assistance in preventing, handling, and overcoming disasters in the surrounding article [page 184] [healthcare in low-resource settings 2025;13:12918] environment. on that basis, it can be said that the factor of participation and involvement can be an internal factor inhibiting community empowerment. supporting and inhibiting external factors based on the results, several external factors were identified as supporting or hindering local community empowerment in disaster management, as formulated in table 4, in relation to bili-bili village. based on tables 4 and 5, there are five external factor determinants that can hinder and support community empowerment in disaster management based on disaster-resilient villages, namely: i) policy and program factors, ii) institutional role factors of leading sectors and coordinating sectors, iii) resource assistance factors from external parties, and iv) external coordination and cooperation factors. all of these external factors are classified as inhibiting factors. policy and program the study’s results showed that 32.8% of village residents possess good knowledge about the government’s and related agencies’ policies and programs related to disaster management and community empowerment in their villages. they know about the policies of law no. 24 of 2007 concerning disaster management, they know about the objectives, functions, and roles of the drv, and they have participated in socialization, education, and training programs and activities in the field of disaster. on the other hand, 67.2% of people have insufficient knowledge about disaster management and community empowerment policies and programs in their village. they do not know about laws and regulations related to disaster management and community empowerment in their village, they feel they have never received a program, they think they do not need it, and they never/rarely participate in counseling, education, and training activities in the field of disaster. they consider disaster management to be a government responsibility. in addition, they also feel doubtful and do not trust government policies and programs. from this, it can be stated that policies and programs can be external inhibiting factors for community empowerment in disaster management. role of the institutional leading sector the results of the study showed that 38.4% of participants consider the role of the government, particularly related agencies such as nbdm, rdma of gowa, and the community and village development agency (cvda) of gowa, along with the health office and others, to be essential for implementing disaster management programs in their village. they have received assistance in the form of counseling, coaching, education, and disaster training from related agencies, as well as support from rescue teams, the military, police, health workers, and others, both during and after a disaster. on the other hand, 61.6% of villagers view the role of officials and officers from related agencies as severely lacking, expressing feelings of doubt, apathy, skepticism, pessimism, and a lack of confidence in these agencies. thus, it can be stated that the role of the leading sector and coordinating agencies is still an external inhibiting factor. article [healthcare in low-resource settings 2025;13:12918] [page 185] table 5. formulation of external factors supporting and inhibiting community empowerment in disaster management based on the bilibili disaster-resilient village. no. external factors category (%) external factor status good low 1 policy and program factor 41 (32.8) 84 (67.2) inhibitor 2 the role of institutional leading sector factor 48 (38.4) 77 (61.6) inhibitor 3 the role of community leaders and ngos factor 49 (39.2) 76 (60.8) inhibitor 4 the role of local government leadership factor 35 (28) 90 (72) inhibitor 5 coordination and cooperation factors 45 (36) 80 (64.0) inhibitor total average (%) 43 (32.4) 82 (65.6) inhibitor 125 (100) source: table 4. table 4. formulation of external factors supporting and inhibiting community empowerment in disaster management based on the bilibili disaster-resilient village. no. external factors informant answer categories (%) vg g ge l vl rating score 5 4 3 2 1 1 policy and program factors 6 (4.8) 13 (10.4) 22 (17.6) 53 (42.4) 31 (24.8) 2 the role of institutional leading sector 8 (6.4) 18 (14.4) 22 (17.6) 48 (38.4) 29 (32.0) 3 the role of community leaders and ngos 11 (8.8) 18 (14.4) 20 (16) 51 (40.8) 25 (20) 4 the role of local government leadership 4 (3.2) 11 (8.8) 20 (16.0) 64 (51.2) 26 (20.8) 5 coordination and cooperation factors 5 (4) 14 (11.2) 26 (20.8) 58 (46.4) 22 (17.6) total average (%) 7 (5.6) 15 (12) 22 (17.6) 55 (44) 27 (21.6) category 43 (32.4) 82 (65.6) good low vg, very good; g, good; ge, good enough; l, low; vl, very low. role of community leaders and ngos the results indicated that 39.2% of village residents believe that local community elites, such as community leaders and ngos, are capable of fulfilling their leadership roles and influencing community members to engage in prevention activities, disaster preparedness, emergency response, risk mitigation, disaster impact management, recovery, and post-disaster rehabilitation and reconstruction in their surrounding environment or region. besides, 60.8% of village residents consider the leadership role of local elites in their village to be very lacking. they believe that local community elites tend to be passive or less active in fulfilling their leadership functions and roles before a disaster occurs, and are considered very rare in providing counseling, enlightenment, advice, guidance, or coaching to community members regarding the disaster issues they face. sometimes, they go directly to the community to play their roles in providing direction and advice during and after a disaster. thus, the role of local community elite leadership factors can be an external inhibiting factor. role of the local government leadership the results revealed that 28.0% of villagers stated that the village government and its staff play a leadership role in coordinating and collaborating with the government and related agencies, especially the national disaster management agency (ndma), the rdma, the cvda, the regional development planning agency (rdpa), the environmental office, the education office, the health office, the social office, and others to obtain assistance in accordance with their capabilities within the context of community empowerment programs related to disasters in their villages. on the other hand, 72.0% of respondents believe that the village government does not provide maximum attention to the community’s needs for disaster preparedness, both before a disaster occurs and in situations where there is a potential for disaster. the village government is primarily focused on providing guidance during and after a disaster has occurred. therefore, it can be stated that the leadership factor of the local government represents an external inhibiting factor. coordination and cooperation the results showed that 36.0% of the village community considered the coordination and cooperation between the village government and community leaders, between the village government and officials and apparatus from related agencies, and between government agency officials to be quite good when a disaster occurs or after a disaster occurs in their village. on the other hand, 64.0% of others considered the coordination and cooperation to be very lacking before a disaster occurs. they considered that coordination and cooperation between various parties in the government and outside the government were only carried out by officials and apparatus when a disaster was occurring, when there were already many victims, and after a disaster had occurred. on that basis, it can be said that coordination and cooperation are still external inhibiting factors for community empowerment in disaster management based on disaster-resilient villages in bili-bili village. discussion the research findings align with those of kafoutis et al. in greece, who identified that technological planning factors play a crucial role in effectively managing crises and emergency disaster responses.15 in this context, community empowerment in disaster management in bili-bili village has not received support from technological planning to address floods, landslides, and tornadoes that occur annually. therefore, the government and related agencies need to implement technological planning strategies to manage crises and disaster emergency responses in disaster-prone areas, like bili-bili. this technology planning can be achieved by preparing various facilities and equipment necessary to detect potential disaster situations and conditions, establishing early warning systems to help people avoid, prevent, and prepare for disasters, and developing risk mitigation plans alongside emergency recovery strategies in the event of a disaster. additionally, it is essential to create a plan for utilizing technology before a disaster strikes, including the installation of early detection tools for potential disaster events. additionally, our findings align with prasad’s research in nepal, which analyzed the influence of preparedness, response, and recovery factors in risk management programs and economic losses due to disasters.16 in bili-bili village, preparedness factors are not yet fully embraced by the village community, while response and recovery factors remain primarily the responsibility of the government and relevant agencies. as a result, village communities still need programs to enhance disaster preparedness and emergency response in their areas. likewise, research by klein et al. emphasizes the importance of enhancing trust factors among mental health professionals and promoting interdisciplinary collaboration in disaster response.17 this is relevant in bili-bili, where disaster events often lead to psychological impacts for victims, including sadness, regret, stress, frustration, and even depression and trauma. the presence of competent parties, such as health officers, experts, or psychologists, is essential to help restore mental health among disaster victims. therefore, mental health professionals need education and training in integrating disaster emergency principles with disaster management education. a study by kyne et al.18 emphasizing the importance of building community resilience to disasters aligns closely with the findings of our research. bili-bili has been designated as one of the drvs by the nbdm and the rdma of gowa. however, the current implementation of the drv program reveals challenges, particularly in the unequal distribution of roles and the limited effectiveness of its functions. this calls for a thorough evaluation and optimization to enhance its capacity in harnessing the social potential of village communities through empowerment and active involvement in disaster management. the designation of bili-bili as a drv represents a strategic opportunity to increase government and institutional support for local communities, thereby strengthening their disaster preparedness and resilience. the findings of this study align with research by sandoval et al. in honduras and lima, which found that planning factors play a crucial role in assessing disaster risk reduction, particularly in residential environments.19 in the context of bili-bili village, disaster risk mitigation analysis and planning are critically needed, particularly in residential areas. however, the issue is that the government, including both leading and supporting sectors, especially gowa rdma, the local planning board (lpb), the public works department, and the spatial planning service, along with the village government, has not effectively demonstrated its roles in coordinating and collaborating to prepare strategic planning for residential land, enforcing zoning regulations, as well as providing outreach, education, and training in risk mitigation skills for village communities to prevent disasters. furthermore, our findings agree with several studies in africa, such as research by kithikii et al. in kitui district, kenya, which identified socio-economic, environmental, and capacity factors article [page 186] [healthcare in low-resource settings 2025;13:12918] that influence the level of community resilience both in facing the risk of drought disasters and the success of humanitarian aid interventions.20 in bili-bili village, the education level of the village residents remains one of the key inhibiting factors in achieving village community resilience. village people are not yet supported by adequate knowledge, skills, and ability to act, especially in prevention, preparedness, risk mitigation, and controlling the impact of disasters. they need empowerment in disaster management through awareness activities, capacity strengthening, and empowerment. the findings are also significantly in line with aboagye’s research in ghana, which identified that family participation plays a role in increasing community resilience and reducing the risk of disasters (floods) through risk communication.21 in bili-bili village, household participation remains relatively low in supporting its status as a drv. similarly, the role of families is still quite limited in terms of flood disaster risk mitigation and disaster risk communication. besides, the research by matsa et al. in tsholotsho district, zimbabwe, highlights that increasing awareness and culture of disaster is effective in the recovery, rehabilitation, and reconstruction phases.22 in bili-bili, people still need to enhance awareness, preparedness, and emergency response. they still need to foster a culture of cooperation in emergency recovery when a disaster occurs, as well as a participatory culture in postdisaster damage rehabilitation and reconstruction activities. the research findings are in extremely close agreement with the research by pepela et al. in baringo district, kenya, regarding the factors that influence vulnerability to climate change among households, namely accessibility, preparedness, government support, geographical location, and animal insurance.23 in the context of bili-bili, many families and households remain vulnerable to the risks and impacts of floods, landslides, and extreme weather events like tornadoes due to climate change and the rainy season. first, accessibility factors, including access to infrastructure, facilities, technology, communication services, and disaster information, hinder the necessary assistance for supporting prevention activities, preparedness, risk mitigation, emergency recovery during a disaster, and post-disaster rehabilitation and reconstruction, which hampers community empowerment in disaster management. second, the preparedness system for dealing with disasters and emergency responses still presents challenges in disaster prevention and management because many village residents lack adequate support and guidance in preparedness, indicating a need for further empowerment in disaster management. third, government support significantly influences the implementation of policies, programs, and community empowerment activities in disaster management in bili-bili. this factor can either support or hinder efforts; proactive government and related institutional involvement in providing infrastructure, facilities, technology, and financial aid can enhance the empowerment and autonomy of village communities in preventing and managing disasters within their environment. fourth, the geographical proximity of bili-bili village to the bili-bili dam heavily contributes to its susceptibility to disasters, leaving its residents and communities vulnerable. fifth, the impact of animal insurance also affects household vulnerability to climate change. in bili-bili village, compensation for injuries, disabilities, and livestock or pet losses due to disasters is not adequately addressed by existing policies and programs, signaling a need for further study. van krieken et al., based on their literature review, identified several empowerment factors during the disaster recovery period, including community participation in decision-making, utilization of community social capital, recognition of community strengths, development of capacity, and assistance to neighbors.24 this is also in accordance with the situation and conditions in bili-bili, where community participation in decision-making is still relatively low. similarly, the use of community social capital remains quite low, resulting in limited participation and involvement from the community. another issue is that the village community still largely holds a mindset and behavior of dependence on assistance from the government and relevant agencies, viewing disaster prevention and management as the responsibility of these entities rather than their own. on the other hand, the government, especially program actors, often overlooks the potential social strengths of the community, neglecting to consider the capacity and the ability of village residents. in dhaka, bangladesh, the research conducted by azad et al. identified accessibility factors that can mitigate or prevent economic losses and the decline of people’s sources of income due to floods and other disasters.25 in bili-bili, access to disaster information services is crucial for residents, enabling them to receive accurate information about potential risks. this access allows community members to evacuate safely and protect their property, thus reducing economic loss. by having readily available disaster information, residents can take preventive measures and minimize both material and non-material losses. accurate disaster information enhances awareness, encourages disaster prevention efforts, and secures livelihoods. the findings agree with zulyadi’s research on the importance of community empowerment in reducing disaster risk.26 in indonesia, communities in various rural areas that are prone to disasters, including and especially in bili-bili village, really need socialization, guidance, education, and training in disaster risk mitigation to enhance empowerment and independence in overcoming or minimizing the risk of loss during or after a disaster. the findings of this research align with the criticism of the united nations office for disaster risk reduction (undrr) regarding the still weak risk analysis and the uneven application of the disaster risk reduction concept in indonesia.27 in the context of bili-bili village, the planning and implementation of flood disaster risk analysis have not been carried out optimally by the relevant agencies. similarly, the execution of socialization, guidance, education, and training in disaster risk mitigation skills remains relatively limited, resulting in numerous victims, material and non-material losses, property damage, loss and death of livestock, and crop and plantation damage whenever a disaster occurs. many residents suffer from health problems and illnesses due to disasters, with numerous injured victims and others affected. our findings align with the asian disaster preparedness center, indicating that building the capacity of community members to determine disaster management goals and risk strategies contributes partially or fully to the resources needed and enables them to monitor their performance.6 in the context of bili-bili village, the capacity of individuals and community groups is generally still limited, which means their ability to set goals and strategies for disaster management is also significantly insufficient. this limitation prevents them from effectively sharing and contributing to meeting resource needs, such as human resources, infrastructure, technology, and finances, in disaster management for their village. this lack of capacity stems from low education levels, insufficient coaching and skills training, and a lack of motivation to learn. a study by pathak in thailand identified the importance of innovation factors in disaster crisis communication for the success of disaster management.28 the results of this research are relevant to the situation and conditions in indonesia, including in bili-bili village, where communication, especially before a disaster occurs article [healthcare in low-resource settings 2025;13:12918] [page 187] or in situations where there is a potential for disaster, is still insufficient and ineffective. miscommunication or communication gaps sometimes still occur between the parties involved, authorized, competent, and responsible. the findings of this study agree with may-kyawt’s research in myanmar, which underscores the importance of cultural factors in the management of humanitarian assistance in disaster response operations in affected areas.29 in indonesia, cultural factors still hinder disaster management. neither community nor bureaucratic cultures fully support disaster empowerment. the research findings align with the study by kurniawan et al., which underscored the importance of local wisdom and cultural factors in strengthening community capacity for independence.30 in bili-bili village, where the population is predominantly of makassar ethnicity, the community values local cultural wisdom, such as siri’ na pacce (self-respect and work ethic), sipakatau (humanizing each other), asseddiang (unity), appalili (guarding and protecting), asalamakeng (safety), and sipatuwo sipatokkong (the ability to give each other access to life and living). these values are highly beneficial for development and implementation in both empowerment and disaster management, particularly for enhancing the human resource capacity of the population in community empowerment and local culture-based disaster management. the findings are in accordance with the research results of the national assessment report evaluation, which reported a number of obstacles in disaster management, including coordination in raising awareness of disaster-prone communities in indonesia.8 in the context of bili-bili, coordination and cooperation factors remain significant challenges. coordination among central and regional governments, related institutions and ministries, various agencies, and village governments, as well as between the government and the community, remains relatively limited. this limitation hampers both disaster management and community empowerment, making them less than optimal or effective. our findings align with trueblood’s research, which emphasizes the importance of educational and training factors in integrating disaster emergency principles and disaster management education.31 in the context of bili-bili, the village community in general still has a low level of education; the majority only have basic education (elementary and secondary school). therefore, they still really need education and training in the field of disaster management. however, the government and related agencies still pay little attention to meeting village communities’ needs for education and training in disaster management. in connection with these internal and external factors, blake et al. propose four general strategies for reducing population vulnerability to hydrological disasters, namely resilience management, partnerships, safety preparedness, and reserve preparedness.32 these four strategies are highly relevant for addressing disaster issues in bili-bili village. first, resilience management is a vital and strategic factor to manage, develop, and maximize to enhance its function and role as drv. second, building partnerships is highly important and strategic for the government, relevant agencies, and village communities. the management of hydrological disasters in bili-bili village truly requires collaboration among the government, community institutions, community leaders, universities, the private sector, the military, the police, and other stakeholders. third, safety preparedness is crucial for the residents of bili-bili village, who are vulnerable to hydrological disasters. it is essential that they receive education and training in disaster preparedness from the government and relevant agencies, particularly the nbdm and rdma, to acquire the knowledge, skills, and experience needed to effectively respond to emergencies. fourth, reserve preparedness involves equipping the village population with the ability to make alternative decisions and take strategic actions to prepare for the various risks and impacts of disasters. the study’s results provide both theoretical and practical contributions. in terms of theoretical contributions, it particularly enhances existing empowerment theories, especially regarding disaster management, to address various problems related to community powerlessness in pre-disaster situations, during emergency responses, and after disasters. regarding practical contributions, these results propose solutions to both internal and external issues that hinder empowerment in disaster management efforts based on disaster-resilient villages. conclusions there are several internal factors that support community empowerment in disaster management, including anxiety, experience, perception, and the need for support and assistance from internal and external parties. in contrast, internal inhibiting factors include low competence, reduced ability to act, decreased commitment, and a lack of participation and involvement. regarding external factors, the study found no evidence of any supportive external influences. on the contrary, external inhibiting factors include policy and program factors, the role of the leading sector and coordinating institutions, the role of community leaders, the role of government leadership, and coordination and cooperation factors. the recommendations for the gowa government, particularly the relevant agencies such as the rdma as the leading sector, along with supporting sectoral agencies such as the health service, social service, and the cvda, are as follows: first, to improve the competence of human resources among the population, including their ability to take action, their commitment, and their participation in disaster prevention, preparedness, emergency response, recovery, rehabilitation, and reconstruction. second, to maximize the implementation of community empowerment policies and programs in disaster management based on disaster-resilient villages; to strengthen the roles of leading and coordinating agencies; to enhance coordination and collaboration among agencies, village governments, and local communities; and to reinforce the leadership of local governments and community leaders. third, and most importantly, to strengthen the implementation of awareness programs, capacity building, community empowerment, and the cultivation of disaster-aware behavior among village communities. references 1. hady j, laubo n, firdaus w, et al. the construction a model of the community empowerment to prevention, preparedness and response disaster emergency. urban health 2021;3. 2. miradj s, sumarno s. empowerment of poor communities, through non-formal education processes, efforts to improve social welfare in west halmahera regency. j educ community empowerment 2014;101-12. 3. priyantoro de, rosa as, andianto, et al. pemberdayaan masyarakat pekon negeri ratu tenumbang dalam mewujud article [page 188] [healthcare in low-resource settings 2025;13:12918] kan wilayah tanggap bencana. jppm (jurnal pendidikan dan pemberdayaan masyarakat) 2020;7:135-46. 4. suharto e. building communities empowering people: strategic studies of social welfare development & social work. bandung: refika aditama, 2017. 5. arisanty d, karunia ph, henry pnp. disaster-resilient villages: strengthening community capacity in flood disasters managing in wetland areas. disaster advances 2023;16:1-7. 6. rajeev mm. sustainability and community empowerment in disaster management department of social work. int j soc work human serv pract 2014;2:207-12. 7. tarman ra, sadat a, sa’ban lm. community empowerment in realizing disaster resilient villages: study on the prosperous maritime village of buton regency. jurnal inovasi penelitian 2023;4:951-6. available from: https://ejournal.stpmataram.ac. id/jip/article/view/2795 8. badan nasional penanggulangan bencana (national disaster management agency). bnpb 12 tahun: kolaborasi dalam penanggulangan bencana. available from: https://bnpb.go.id/ berita/bnpb-12-tahun-kolaborasi-dalam-penanggulanganbencana 9. badan nasional penanggulangan bencana (national disaster management agency). indonesia one disaster data. available from: https://www.unescap.org/sites/default/files/ indonesia_ one_disaster_data.pdf 10. bps-statistics indonesia. bontomarannu district in figures 2024. available from: https://gowakab.bps.go.id/en/publication/2024/09/26/9de6b8fc8ea944eca140f02f/bontomarannudistrict-in-figures-2024.html 11. sugiyono. metode penelitian kuantitatif, kualitatif, dan r&d [quantitative, qualitative, and r&d research methods]. 26th ed., alfabeta, 2018. 12. miles mb, huberman am, saldana j. qualitative data analysis, a methods sourcebook. usa: sage publications, 2014. 13. creswell, john w. research design: qualitative, quantitative, and mixed method approaches. yogyakarta: pustaka belajar, 2016. 14. moleong lj. qualitative research methodology. bandung: pt remaja rosdakarya, 2019. 15. kafoutis gce, dokas im. improving disaster response plans with steca: an application. int j disaster response emerg manag 2020;3:19. 16. prasad us. the economics of disaster risk management in nepal. tribhuvan university, central department of economics. int j disaster response emerg manag 2019;3. 17. klein ta, davis kl, greenstone jl. confidence in mental health professionals and other interdisciplinary involvement in disaster response. int j disaster response emerg manag 2021;4:1-16. 18. kyne d, donner wr. aiming toward building disaster resilient communities. int j disaster response emerg manag 2020;3. available from: https://www.igi-global.com/pdf.aspx? tid%3d233877%26ptid%3d200965%26ctid%3d15%26t%3 daiming+toward+building+disaster+resilient+communities%26isxn%3d 19. sandoval v, sarmiento jp, mazariegos ea, oviedo d. exploring network analysis for urban planning and disaster risk reduction in informal settlements: cases from honduras, jamaica, and peru. int j disaster response emerg manag 2020;3:30-45. 20. kithikii ak, mugalavai em, china ss. assessing the level of community resilience to drought in kitui county, kenya. int j disaster response emerg manag 2023;6:19. 21. aboagye d. improving community resilience to perennial flooding through risk communication. kwame nkrumah university of science and technology, ghana. int j disaster response emerg manag 2022;5:15. 22. matsa m, sibanda n. flood disaster preparedness and response in zimbabwe: a case study of tsholotsho district, zimbabwe, midlands state university, zimbabwe. int j disaster response emerg manag 2020;3:35-47. 23. pepela m, makhanu f, mugalavai e. livelihoods vulnerability to climate change among households in baringo county, kenya. int j disaster response emerg manag 2019;2:51-63. 24. van krieken t, pathirage c. factors affecting community empowerment during disaster recovery. int j disaster response emerg manag 2019;2:15-32. 25. azad ak, mia j, islam n. disaster economic loss and income: an assessment in entitlement perspective. university of dhaka, bangladesh. int j disaster response emerg manag 2020;3:1-23. 26. zulyadi t. community empowerment in disaster risk reduction. j public adm policy res 2017;7. 27. united nations office for disaster risk reduction (undrr). let’s learn to prevent disasters! fun ways for kids to join in risk reduction. available from: https://www.unisdr.org/files/ 2114_vl108012.pdf 28. pathak s. disaster crisis communication innovations: lessons learned from 2011 floods in thailand. int j disaster response emerg manag 2019;21-16. 29. may-kyawt ak. managing humanitarian aid: the importance of the “cultural context” in disaster response operations in myanmar. int j disaster response emerg manag 2019;2. 30. kurniawan h, yulianto y, setiawan r, mladenov sv, ardiansyah m. sustainable development through community empowerment based on local wisdom. int j prog sci technol 2023;41:164-76. 31. trueblood k. integration of ignatian principles in emergency and disaster management education. int j disaster response emerg manag 2022;4:17-34. 32. blake og, russell e. identifying strategies for lessening hydrological disaster vulnerability: a case study. int j disaster response emerg manag 2022;6. article [healthcare in low-resource settings 2025;13:12918] [page 189] hrev_master healthcare in low-resource settings 2024; volume 12:12898 sociodemographic correlates of dietary habits among university students of health sciences in kosovo naim jerliu,1,2 haxhi kamberi,3,4 iris mone,5 drilon zekaj,1,6 pranvera krasniqi,2 genc burazeri5,7 1faculty of medicine, university of prishtina “hasan prishtina”, prishtina, kosovo; 2national institute of public health of kosovo, prishtina, kosovo; 3faculty of medicine, university of gjakova “fehmi agani”, gjakova, kosovo; 4regional hospital “isa grezda”, gjakova, kosovo; 5faculty of medicine, university of medicine, tirana, albania; 6clinical university center of kosovo, prishtina, kosovo; 7department of international health, caphri (care and public health research institute), maastricht university, maastricht, the netherlands abstract we aimed to assess the prevalence and sociodemographic correlates of selected dietary habits among students of health sciences in kosovo. a cross-sectional study was conducted in kosovo in 2024, including 470 students of health sciences (≈86% females; mean age: 20.7±2.7 years; response rate: 70%). information on selected dietary habits and sociodemographic factors of the students was gathered. independent positive correlates of a lower fruit intake (<1 time/day) included male gender (or=2.3, 95% ci =1.3-4.2) and a lower economic level (or=1.5, 95% ci =1.0-2.3). furthermore, positive independent correlates of a higher frequency of consumption of fried foods (≥1 time/day) included male gender (or=2.2, 95% ci =1.2-4.1), urban residence (or=1.6, 95% ci =1.0-2.6) and a lower economic level (or=1.7, 95% ci =1.02.7). conversely, excessive salt intake was positively and strongly correlated to a lower economic level (or=3.5, 95% ci =2.1-6.0), but inversely related to students’ age (or=0.4, 95% ci =0.2-0.9). male gender and particularly a lower economic level were strong correlates of poor dietary habits among university students in kosovo. targeted interventions are needed to address dietary habits among youths, with a focus on providing support and resources to economically disadvantaged individuals. introduction the association between dietary habits and the health of the populations worldwide has been the subject of rigorous research over many decades.1 currently, the increasing global prevalence of overweight and obesity is attributed to insufficient physical activity coupled with a continuous increase in unhealthy eating habits, which consists especially of consumption of energy-dense, high-fat, and sugary food.2 these unhealthy behavioural patterns unavoidably lead to an increase in non-communicable diseases including cardiovascular diseases and diabetes.3 other unhealthy eating behaviours, especially among young people, include also breakfast skipping, night eating, eating away from home, and emotional eating.4-6 in particular, eating away from home consists usually of energy-dense food leading to an increase in body mass and obesity.4,7,8 indeed, it has been shown that meals consumed in fast food restaurants, consisting of fried items and other energy-dense foods, increase significantly the risk of overweight and obesity.9 such dietary habits related to the consumption of fast food are more common among young individuals including university students. based on the importance of healthy dietary habits, healthcare professionals, including also university students of health sciences, have an important role in promoting healthy nutrition in order to prevent diet-related risk factors, such as overweight and obesity, and their associated noncommunicable diseases.10,11 additionally, current and future healthcare professionals must possess a comprehensive understanding of healthy and sustainable diets and align their actions with this knowledge and their attitudes, as they play a crucial role in disseminating this information to patients and the broader community.10 however, the translation of correspondence: drilon zekaj, faculty of medicine, university of prishtina “hasan prishtina”, str. bulevardi i dëshmorëve, 10 000 prishtina, kosovo. e-mail: drilon.zekaj@uni-pr.edu key words: dietary habits, fruit, kosovo, vegetables, university students. contributions: nj, hk and gb contributed to the study conceptualization and design, analysis and interpretation of the data and writing of the article. im, dz and pk commented comprehensively on the manuscript. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: this study was supported by the national institute of public health of kosovo, and the faculty of medicine of the university of gjakova. ethics approval and consent to participate: this study was approved by the ethics committee of the national institute of public health of kosovo (decision: 01/1531, date: 28-12-2023) and by the ethics committee of the faculty of medicine, university of gjakova (decision: 006/82, date: 12-01-2024). informed consent: all students were informed about the aim and objectives of the study and were explained in sufficient detail particularly the aspects related to the anonymity of the survey and the successive aggregated analysis. availability of data and materials: the data presented in this study are available upon request from the corresponding author. acknowledgments: we thank the students of the universities of gjakova and prishtina (attending the branches of nursing, physiotherapy, health management, and public health) for their valuable participation in this survey. received: 4 august 2024. accepted: 12 september 2024. early access: 26 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12898 doi:10.4081/hls.2024.12898 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 662] [healthcare in low-resource settings 2024;12:12898] non -co mmerc ial us e o nly knowledge to effective and healthy practice is not always the case with students of health sciences who are said to lead a stressful life that is often at odds with maintaining good health.12,13 as a matter of fact, several studies have reported a high prevalence of consumption of fast food and soft drinks among students of health sciences,13,14 although they are assumed to have greater knowledge about junk food and its deleterious health effects. kosovo, the newest state in europe, proclaimed its independence in 2008. since then, kosovo has been experiencing deep and intensive socio-political and economic transformations,15 of which are also accompanied by shifts in disease burden and lifestyle practices.15-17 currently, kosovo displays unfavourable health indicators compared with the other countries in the western balkans including neighbouring albania.18 in line with the experience and evidence in other lowand middle-income countries worldwide, the burden of non-communicable diseases has increased in kosovo in the past few decades, including especially cardiovascular diseases.18 however, there is no specific information on the nutritional practices and dietary habits of current or future health professionals (students) in kosovo. in this framework, the aim of our study was to assess the prevalence and sociodemographic correlates of selected dietary habits among university students of health sciences in kosovo. we hypothesised a higher prevalence of unhealthy dietary practices among male students and individuals pertinent to a lower socioeconomic status. materials and methods a cross-sectional study was carried out in kosovo during the period february-april 2024. all students of health sciences from the universities of prishtina (the capital of kosovo) and gjakova (one of the main regions of kosovo) were invited to participate (n=671). the invited students were attending the following branches of health sciences: nursing, physiotherapy, public health, and health management. of all the invited students, 201 (about 30% of the total) did not complete the survey and/or provided partial responses. however, there were no significant demographic differences among respondents and non-respondents regarding gender and age distribution. the final sample included in the analyses included 470 students, of whom 405 (about 86%) were females and the remaining 65 (around 14%) were males. considering both nonrespondents and incomplete questionnaires, the final response rate in our study was: 470/671=70%. the data collection included a structured and anonymous questionnaire that was self-administered by all students who agreed to participate in this study. the questionnaire assessed selected dietary habits and sociodemographic factors of students who participated in the study. assessment of dietary habits includes measuring vegetable and fruit intake, sweet and fried food consumption, and salt intake. vegetable intake participants were asked to report on their usual consumption of fresh vegetables. response categories were as follows: at least 1 time/day, at least 2-3 times/week, at least 1 time/week, at least 1-2 times/month, few times/year, and almost never. in the analysis, vegetable intake was dichotomized into: “≥1 time/day” vs “<1 time/day”. fruit intake participants were asked to report on their usual consumption of fresh fruit. response categories were as follows: at least 1 time/day, at least 2-3 times/week, at least 1 time/week, at least 1-2 times/month, few times/year, and almost never. in the analysis, fruit intake was dichotomized into: “≥1 time/day” vs “<1 time/day”. consumption of sweets participants were asked to report on their usual consumption of sweets. response categories were as follows: at least 1 time/day, at least 2-3 times/week, at least 1 time/week, at least 1-2 times/month, few times/year, and almost never. in the analysis, consumption of sweets was dichotomized into: “≥1 time/day” vs. “<1 time/day”. consumption of fried foods participants were asked to report on their usual consumption of fried foods. response categories were as follows: at least 1 time/day, at least 2-3 times/week, at least 1 time/week, at least 1-2 times/month, few times/year, and almost never. in the analysis, consumption of fried foods was dichotomized into: “≥1 time/day” vs “<1 time/day”. salt intake participants were asked to report on their usual salt intake. response categories were as follows: a lot, some, a little, and almost none. in the analysis, salt intake was dichotomized into: “a lot” vs “≤some”. sociodemographic factors included gender (“males” vs. “females”), age (categorized in the analysis into: 1819, 20, 21, and ≥22 years), place of residence (“urban areas” vs. “rural areas”), marital status (“single” vs. “married”), current employment status (“yes” vs. “no”), and economic level (dichotomized into: “good” vs. “not good”) (table 1). the study was approved by the ethics committee of the national institute of public health of kosovo (decision: 01/1531, date: 28-12-2023) and by the ethics committee of the faculty of medicine, university of gjakova (decision: 006/82, date: 12-012024). all students were informed about the aim and objectives of the study, which were explained in sufficient detail, particularly the aspects related to the anonymity of the survey and the successive aggregated analysis. binary logistic regression was used to assess the association of dietary habits with sociodemographic characteristics of the students (table 2). initially, crude (unadjusted) models were run (upper panel). crude/unadjusted odds ratios (ors) and their respective 95% confidence intervals (95% cis) were calculated. next, multivariable-adjusted models were run (lower panel), controlling simultaneously for all sociodemographic factors of the students (age, sex, place of residence, marital status, current employment status, and economic level). multivariable-adjusted ors and their respective 95% cis were calculated. hosmer-lemeshow test was used to assess the goodness-of-fit of the multivariable-adjusted logistic regression models.19 as a rule of thumb for the hosmerlemeshow test, p-values over 0.20 indicate that the multivariableadjusted logistic regression models are suitable (i.e. the models fit well the data).19 in our analyses, all multivariable-adjusted logistic regression models met the hosmer-lemeshow criterion.19 in all circumstances, a p-value of ≤0.05 was considered as statistically significant. statistical package for the social sciences (spss, version 19.0) was used for all the statistical analyses. results overall, about 25% of the students were 18-19 years old, and article [healthcare in low-resource settings 2024;12:12898] [page 663] non -co mmerc ial us e o nly around 19% were ≥22 years; approximately 49% were from the university of prishtina; about 77% were nursing students; around 42% were urban residents; about 5% were married; around 7% of the students were also employed, and almost 33% reported “not good” economic situation (data not shown). the distribution of selected dietary habits by sociodemographic characteristics of the students is presented in table 1. overall, “≥1 times/day” was about 44% for fresh vegetables, 46% for fresh fruit, 31% for sweets, and 20% for fried foods. furthermore, excessive salt intake was reported by about 16% of the students. compared to females, male students exhibited a lower daily intake of fresh vegetables (about 45% vs. 37%, respectively) and particularly fresh fruit (49% vs. 31%, respectively), but a higher consumption of fried foods (around 19% vs. 29%, respectively) and excessive salt intake (16% vs. 22%). older students (22 years and older) consumed less sweets, fried foods, and salt than their younger counterparts. compared with rural residents, students from urban areas had a higher daily fruit intake (about 44% vs article table 2. association of dietary habits with sociodemographic characteristics of the students; results from binary logistic regression models. upper panel: crude/unadjusted models dietary habits sociodemographic characteristics male age ≥22 urban areas single not employed less wealthy vegetable intake (<1 time/day) 1.4 (0.8-2.4)* 1.3 (0.8-2.3) 0.9 (0.7-1.4) 0.7 (0.3-1.7) 0.5 (0.2-1.1) 1.2 (0.8-1.8) fruit intake (<1 time/day) 2.2 (1.2-3.8) 0.7 (0.4-1.3) 0.8 (0.6-1.2) 0.8 (0.4-1.9) 0.9 (0.5-2.0) 1.5 (1.0-2.2) sweets (≥1 time/day) 0.9 (0.5-1.6) 0.8 (0.4-1.5) 1.4 (0.9-2.0) 2.3 (0.8-7.0) 0.9 (0.4-2.1) 1.0 (0.6-1.5) fried foods (≥1 time/day) 1.8 (1.0-3.2) 0.7 (0.3-1.5) 1.6 (1.0-2.5) 1.8 (0.5-6.2) 1.8 (0.6-5.2) 1.7 (1.1-2.7) salt intake (a lot) 1.5 (0.8-2.9) 0.5 (0.2-1.1) 1.0 (0.6-1.7) 0.7 (0.3-2.0) 0.8 (0.3-2.0) 3.3 (2.0-5.4) lower panel: multivariable-adjusted models dietary habits sociodemographic characteristics male age ≥22 urban areas single not employed less wealthy vegetable intake (<1 time/day) 1.3 (0.8-2.3)* 1.2 (0.7-2.2) 0.9 (0.6-1.4) 1.1 (0.4-2.9) 0.5 (0.2-1.3) 1.2 (0.8-1.7) fruit intake (<1 time/day) 2.3 (1.3-4.2) 0.7 (0.4-1.2) 0.8 (0.5-1.1) 0.9 (0.4-2.6) 1.1 (0.5-2.3) 1.5 (1.0-2.3) sweets (≥1 time/day) 1.0 (0.6-1.9) 0.9 (0.5-1.7) 1.4 (0.9-2.1) 2.6 (0.8-8.6) 0.7 (0.3-1.7) 0.9 (0.6-1.5) fried foods (≥1 time/day) 2.2 (1.2-4.1) 0.7 (0.3-1.6) 1.6 (1.0-2.6) 2.1 (0.5-8.1) 1.6 (0.5-5.1) 1.7 (1.0-2.7) salt intake (a lot) 1.7 (0.8-3.4) 0.4 (0.2-0.9) 0.9 (0.6-1.6) 0.7 (0.2-2.3) 0.8 (0.3-2.2) 3.5 (2.1-6.0) *odds ratios and their respective 95% confidence intervals (in parentheses) from binary logistic regression models. [page 664] [healthcare in low-resource settings 2024;12:12898] table 1. distribution of dietary habits by sociodemographic characteristics in a sample of university students of health sciences from kosovo in 2024 (n=470). sociodemographic dietary habits characteristics vegetable intake fruit intake sweets fried foods (≥1 time/day) salt intake (≥1 time/day) (≥1 time/day) (≥1 time/day) (a lot) n (%)* n (%) n (%) n (%) n (%) total sample (n=470) 208 (44.3) 218 (46.4) 146 (31.1) 95 (20.2) 77 (16.4) gender male (n=65) 24 (36.9) 20 (30.8) 19 (29.2) 19 (29.2) 14 (21.5) female (n=405) 184 (45.4) 198 (48.9) 127 (31.4) 76 (18.8) 63 (15.6) age 18-19 years (n=118) 55 (46.6) 47 (39.8) 37 (31.4) 23 (19.5) 25 (21.2) 20 years (n=149) 73 (49.0) 77 (51.7) 48 (32.2) 31 (20.8) 24 (16.1) 21 years (n=115) 45 (39.1) 52 (45.2) 37 (32.2) 28 (24.3) 18 (15.7) ≥22 years (n=88) 35 (39.8) 42 (47.7) 24 (27.3) 13 (14.8) 10 (11.4) residence urban areas (n=198) 88 (44.4) 98 (49.5) 69 (34.8) 49 (24.7) 33 (16.7) rural areas (n=272) 120 (44.1) 120 (44.1) 77 (28.3) 46 (16.9) 44 (16.2) marital status single (n=446) 199 (44.6) 208 (46.6) 142 (31.8) 92 (20.6) 72 (16.1) married (n=24) 9 (37.5) 10 (41.7) 4 (16.7) 3 (12.5) 5 (20.8) employment not employed (n=439) 199 (45.3) 204 (46.5) 136 (31.0) 91 (20.7) 71 (16.2) students employed (n=31) 9 (29.0) 14 (45.2) 10 (32.3) 4 (12.9) 6 (19.4) economic level good (n=317) 145 (45.7) 157 (49.5) 99 (31.2) 55 (17.4) 34 (10.7) not good (n=153) 63 (41.2) 61 (39.9) 47 (30.7) 40 (26.1) 43 (28.1) *absolute numbers and their respective percentages (in parentheses). non -co mmerc ial us e o nly 49%, respectively), as well as a higher daily consumption of sweets (28% vs. 35%, respectively) and fried foods (17% vs. 25%, respectively). compared with better-off individuals, students with a lower economic level reported a lower daily intake of fresh fruit (around 49% vs. 40%, respectively), but a higher daily consumption of fried foods (17% vs. 26%, respectively) and particularly a higher excessive salt intake (11% vs. 28%, respectively) (table 1). in crude/unadjusted binary logistic regression models (table 2), a lower intake of fresh fruit (<1 time/day) was positively related to male gender (or=2.2, 95% ci =1.2-3.8) and a lower economic level (or=1.5, 95% ci =1.0-2.2). furthermore, higher consumption of fried foods (≥1 time/day) was positively associated with male gender (or=1.8, 95% ci =1.0-3.2), urban residence (or=1.6, 95% ci =1.0-2.5) and a lower economic level (or=1.7, 95% ci =1.1-2.7). in addition, excessive salt intake was positively related to a lower economic level (or=3.3, 95% ci =2.0-5.4). in multivariable-adjusted logistic regression models (table 2), independent correlates of a lower intake of fresh fruit included male gender (or=2.3, 95% ci =1.3-4.2) and a lower economic level (or=1.5, 95% ci =1.0-2.3). furthermore, independent correlates of higher consumption of fried foods included male gender (or=2.2, 95% ci =1.2-4.1), urban residence (or=1.6, 95% ci =1.0-2.6), and a lower economic level (or=1.7, 95% ci =1.0-2.7). also, upon multivariable adjustment for all sociodemographic characteristics, excessive salt intake was positively related to a lower economic level (or=3.5, 95% ci =2.1-6.0), but inversely associated with age (or=0.4, 95% ci =0.2-0.9) (table 2). discussion the main findings of this study in kosovo include a high prevalence of unhealthy dietary habits among university students of health sciences. hence, less than half of the participants reported a daily consumption of fresh vegetables and/or fresh fruit. in contrast, almost one in three students reported a daily consumption of sweets, and one in five participants reported a daily consumption of fried foods. also, nearly one in six participants reported an excessive salt intake. the main independent correlates of poorer dietary habits consisted of male gender and especially a lower economic level of the students. our findings on a relatively higher prevalence of unhealthy dietary habits are compatible with several previous studies conducted among university health sciences students.12-14,20-22 a recent study concluded that medical students needed to reflect in their daily practice the seemingly satisfactory level of awareness regarding healthy dietary habits.13 however, a comparison in the same study13 between medical and non-medical students revealed a higher intake of vegetables among medical students (about 35%) compared with non-medical students (25%). in our study, vegetable consumption was higher than some previous reports, which have generally documented a low intake of vegetables and fruit but a high consumption of fast food among students of health sciences.13,14,20-22 on the other hand, the frequency of consumption of fried foods in our study was similar to the consumption of fast food reported in a previous study conducted in saudi arabia.13 a recent study including mostly students of health sciences and some health professionals reported that, overall, fruit and vegetables were consumed 1-2 or more times a day by about 68% and 63% of the participants, respectively,10 which is considerably higher compared with our study conducted in kosovo. one possible explanation suggested by the authors regarding the reporting of a relatively high consumption of fruit and vegetables in their study was the considerable predominance of female respondents,10 who have been shown to be more concerned with their health compared to males.23,24 hence, our finding on a positive association between male gender and unhealthy dietary habits is compatible with previous studies.23-25 in general, a significant positive correlation has been reported between higher fruit and vegetable consumption and a deeper knowledge and more favourable attitudes toward healthy dietary habits among university students of health sciences.10 all in all, however, students of health sciences have been shown to have suboptimal compliance with healthy dietary habits including night-eating habits, irregular meal times, and especially fast food consumption.25 on another note, a previous study conducted in kosovo in 2019 including a nationwide sample of about 2,700 adult individuals aged 18-69 years has reported that only about 12% of both men and women consumed five or more servings of fruits and vegetables daily, thereby meeting the minimum daily intake recommended by the world health organization.26 age differences aside, this is in line with our findings related to low daily consumption of fruit and vegetables among students. furthermore, according to the aforementioned previous study conducted in kosovo in 2019, almost one-third of the population “always or often” added salt or salty sauce to their food before or during eating, and 39% “always or often” added salt to food when cooking at home.26 also, around 40% of participants in that study “always or often” ate processed foods with a high salt content.26 these findings are generally compatible with our results pertinent to university students of health sciences where excessive salt intake was reported by 16% of participants. our initial hypothesis on a positive link between unhealthy dietary habits and a lower economic level was confirmed and is in line with previous studies reported in the international literature.12 in general, less wealthy students may exhibit more unhealthy dietary habits than their better-off peers due to a higher cost of healthy foods, limited access to healthy food choices, time constraints, or social and environmental influences imposed on them. this study conducted in kosovo may have some limitations inherently present in cross-sectional studies, which do not allow inferences regarding causal relationships. also, the sample included in our study may not necessarily represent all students of kosovo considering also the non-response of almost 30% of the targeted population. in addition, there is a possibility of information bias including recall bias, reporting bias, or cultural bias. furthermore, although there is no plausible reason to assume variations in self-reporting of dietary habits, we cannot rule out entirely the possibility of differential reporting between different sociodemographic groupings of study participants (distinguished by age, gender, place of residence, or other sociodemographic characteristics). conclusions nonetheless, despite the possibility of these potential limitations, our study provides useful evidence on the prevalence and sociodemographic correlates of selected dietary habits among students of health sciences in kosovo, the newest state in europe that has been undergoing profound changes in the past decades, affecting unavoidably also the nutritional practices and dietary habits of the general population. article [healthcare in low-resource settings 2024;12:12898] [page 665] non -co mmerc ial us e o nly in conclusion, our study conducted in kosovo indicates that male gender and particularly a lower economic level are strong correlates of poorer dietary habits among university students. targeted interventions are needed to address dietary habits among youths, with a focus on providing support and resources to economically disadvantaged individuals to promote healthier eating behaviours. references 1. jahns l, davis-shaw w, lichtenstein ah, et al. the history and future of dietary guidance in america. adv nutr 2018;9:136-47. 2. safaei m, sundararajan ea, driss m, et al. a systematic literature review on obesity: understanding the causes & consequences of obesity and reviewing various machine learning approaches used to predict obesity. comput biol med 2021;136:104754. 3. chew hsj, chng s, rajasegaran nn, et al. effectiveness of acceptance and commitment therapy on weight, eating behaviours and psychological outcomes: a systematic review and meta-analysis. eat weight disord 2023;28:6. 4. wei x, yu d , ju l, et al. analysis of the correlation between eating away from home and bmi in adults 18 years and older in china: data from the cnnhs 2015. nutrients 2021;14:146. 5. monteiro lz, varela ar, lira ba, et al. weight status, physical activity and eating habits of young adults in midwest brazil. public health nutr 2019;22:2609-16. 6. viljakainen j, figueiredo rao, viljakainen h, et al. eating habits and weight status in finnish adolescents. public health nutr 2019;22:2617-24. 7. bhutani s, schoeller da, walsh mc, mcwilliams c. frequency of eating out at both fast-food and sit-down restaurants was associated with high body mass index in non-large metropolitan communities in midwest. am j health promot 2018:32:75-83. 8. zhang x, du w, zhang j, et al. association between the frequencies of eating out and overweight/obesity among dinners in restaurants aged 18–65 years in 6 provinces of china. chin j health educ 2020;36:779-83. 9. kim d, ahn bi. eating out and consumers’ health: evidence on obesity and balanced nutrition intakes. int j environ res public health 2020;17:586. 10. irazusta-garmendia a, orpí e, bach-faig a, svatetz cag. food sustainability knowledge, attitudes, and dietary habits among students and professionals of the health sciences. nutrients 2023;15:2064. 11. bach-faig a, wickramasinghe k, panadero n, et al. consensus-building around the conceptualisation and implementation of sustainable healthy diets: a foundation for policymakers. bmc public health 2022;22:1480. 12. crowley j, ball l, hiddink gj. nutrition in medical education: a systematic review. lancet planet health 2019;3:e379�89. 13. alghamdi sa, alqarni aa, alghamdi af, et al. knowledge, attitude, and practices regarding dietary habits among medical and non-medical university students. j family med prim care 2021;10:3436-43. 14. al�qahtani mh. dietary habits of saudi medical students at university of dammam. int j health sci (qassim) 2016;10:353-62. 15. jerliu n, ramadani n, mone i, brand h. public health in kosovo after five difficult years of independence. seejph. 2014;1:23. 16. hoxha i, apuk v, kryeziu b, et al. management of noncommunicable diseases in kosovo: a scoping review. int j environ res public health. 2023;20:3299. 17. the world bank. social protection and health expenditure note kosovo. 2018. available from: https://documents1.worldbank.org/curated/en/190411561720305500/pdf/kosovosocial-protection-and-health-expenditure-note.pdf 18. bytyçi-katanolli a, obas ka, ramadani q, et al. effectiveness of behavioural change interventions on physical activity, diet and body mass index of public primary healthcare users in kosovo: the kosco cohort bmj open 2023;13:e071100. 19. hosmer d, lemeshow s. applied logistic regression. new york, usa: wiley & sons; 1989. 20. abdelhafez ai, akhter f, alsultan aa, et al. dietary practices and barriers to adherence to healthy eating among king faisal university students. int j environ res public health 2020;17:8945. 21. al�otaibi hh. the pattern of fruit and vegetable consumption among saudi university students. glob j health sci 2013;6:155�62. 22. vibhute na, baad r, belgaumi u, et al. dietary habits amongst medical students: an institution�based study. j family med prim care 2018;7:1464�6. 23. ureña f, bernabéu r, olmeda m. women, men and organic food: differences in their attitudes and willingness to pay. a spanish case study. agribusiness 2007;23:455-72. 24. telleria-aramburu n, bermúdez-marín n, rocandio am, et al. nutritional quality and carbon footprint of university students’ diets: results from the ehu12/24 study. public health nutr 2021;25:183-95. 25. aljohani s, salam m, banimustafa a, et al. dietary habits of students enrolled in faculties of health sciences: a crosssectional study. cureus 2019;11:e6012. 26. world health organization (who). steps: prevalence of noncommunicable disease risk factors in kosovo 2019. 2023. available from: https://iris.who.int/handle/10665/373047 article [page 666] [healthcare in low-resource settings 2024;12:12898] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13185 health literacy based on the health promotion model to improve maternal behaviors in preventing the risk of stunting in children emmy putri wahyuni,1,2 nyimas heny purwati,1 anita apriliawati1 1faculty of nursing, universitas muhammadiyah jakarta; 2department of nursing, poltekkes kemenkes kalimantan timur, samarinda, indonesia abstract health literacy is a key component of health promotion aimed at modifying lifestyle behaviors and increasing awareness of how health determinants influence quality of life (qol). this motivates individuals and families to proactively address health-related challenges. this study aimed to examine the effect of health literacy on parental behavior in preventing the risk of stunting in children. a quasi-experimental design was employed, utilizing a pre-test and post-test non-equivalent control-group approach. the participants were mothers of children aged 0-23 months selected through purposive sampling, with a total of 58 respondents. they were divided into intervention and control groups. the results showed significant differences in maternal behaviors related to preventing stunting between the intervention and control groups, as evidenced by preand post-test comparisons (p<0.05). specifically, health literacy had a statistically significant effect on maternal behavior in preventing stunting (p=0.001). based on these findings, it is recommended that primary healthcare services enhance their efforts to prevent stunting by incorporating health literacy interventions such as educational modules and mentoring programs targeted at mothers and their families. introduction chronic malnutrition can begin as early as the prenatal period and continue until the child reaches two years of age. therefore, the first 1,000 days of life represent a critical window that warrants special attention, as this period significantly influences a child’s physical growth, cognitive development, and future productivity.1 stunting remains a major global challenge and a prominent nutritional concern.2 globally, the prevalence of stunting among children under five years of age has decreased from 33.1% to 22%, with the number of affected children declining from 203.6 million to 149.2 million.3,4 according to the 2023 indonesian nutritional status study conducted by the health development policy agency of the ministry of health of the republic of indonesia, the prevalence of stunting in east kalimantan is 22.8%.5 in samarinda city, the capital of east kalimantan province, the prevalence of stunting in 2025 reached 18.14%, based on data from 32.63% of measured toddlers.6 stunting is caused by the complex interplay of multidimensional factors.7 a 2021 study conducted in india reported that children who practice open defecation are born to mothers with low levels of education and live in poor households, and are at a significantly higher risk of stunting.8 in ethiopia, 60.6% of infants do not receive exclusive breastfeeding, 68.8% of children are given complementary foods that lack vegetables, and 68.1% lack animal-source foods in their diets.9 in indonesia, available data indicate that 60% of children aged 0-6 months do not receive exclusive breastfeeding, and two out of every three children aged 0-24 months do not receive appropriate complementary feeding.10,11 poor parenting practices, including mothers’ lack of knowledge about their child’s health and nutrition, are important factors that cause stunting, especially in children aged 0-23 months.12-14 the study found that parents’ parenting style in providing food to their children significantly affects their children’s nutritional status.15-17 parents’ limitations greatly influence incorrect parenting practices when finding information sources.18 therefore, an appropriate program is needed to overcome these problems, including fulfilling the information needs of parents, especially in correspondence: emmy putri wahyuni, faculty of nursing, universitas muhammadiyah jakarta, jakarta, indonesia. e-mail: emmyputri.wahyu@gmail.com key words: attitude; health literacy; knowledge; psychomotor; stunting. contributions: epw, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; nhp, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; aa, conceptualization, investigation, methodology, validation, and writing – original draft. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: the health research ethics commission, faculty of nursing, universitas muhammadiyah jakarta, approved the study based on ethical certificate 0938/f.9-umj/vi/2023. during the study, the researcher emphasized the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained from all patients included in this study. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was supported by a grant from blu poltekkes kemenkes kalimantan timur with contract number: gm.03.01/4.3/ 09517/2023. received: 13 january 2025. accepted: 26 may 2025. early view: 20 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13185 doi:10.4081/hls.2025.13185 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 86] [healthcare in low-resource settings 2025;13(s2):13185] preventing stunting risks. health literacy is an emerging focus within the field of health promotion and is increasingly being recognized as a critical issue in contemporary public health discourse.19-21 this approach seeks not only to modify lifestyle behaviors, but also to foster awareness of the importance of health-related factors in determining quality of life, thereby motivating individuals and families to address their health challenges proactively.5,22 a systematic review reported that health literacy interventions led to significant improvements in knowledge across ten studies.23 health promotion plays a central role in influencing parental behavior, particularly in efforts to prevent stunting in children.24 accordingly, this study aimed to determine the influence of health literacy on maternal behavior to prevent the risk of stunting among children. materials and methods this study employed a quasi-experimental design using a pretest-posttest approach with a nonequivalent control group. study participants the population comprises mothers with children in the palaran district health center working area in samarinda city (indonesia), with a total of 1,377 children. the sample consisted of 58 respondents using non-probability sampling techniques with purposive sampling methods, comprising 29 intervention and 29 control group samples. the sample formula used was a hypothesis test with two different proportions. the proportion of the occurrence of the effect in the trial group (anticipated population proportion 1) and the proportion of the occurrence of the effect in the control/standard group (anticipated population 2) were obtained from previous research, namely, research conducted by sirajuddin et al. (2021) entitled “the intervention of maternal nutrition literacy has the potential to prevent childhood stunting: randomized control trials”.25 the inclusion criteria consisted of mothers with children aged 0-23 months, those who possessed mother-child health books, and mothers who were able to read and write. exclusion criteria included mothers of children aged 0-23 months who were identified as stunted or had chronic comorbidities such as congenital heart disease, down syndrome, or other similar conditions. variable, instrument, and data collection the independent variable was the effect of health literacy, and the dependent variable was behavior, including mothers’ knowledge, attitudes, and psychomotor skills in preventing stunting. this study used the health literacy survey european union, 16 items (hls-eu-q16) questionnaire, adopted from the asian health literacy association indonesia as the questionnaire license holder, to assess maternal knowledge of stunting risk prevention. the hls-eu-q16 questionnaire consists of 16 modified items with several subdomains: i) seeking health information, four items (q1, q2, q3, q4); ii) understanding health information, three items (q5, q6, q7); iii) assessing health information, four items (q8, q9, q10, q11); and iv) applying health information, two questions (q12 and q13). each question was assessed on a 4-point likert scale, where the answer choices were 1=tough, 2=quite challenging, 3=complex, and 4=very easy. an attitude questionnaire on stunting risk prevention was created based on positive and negative attitude statements. both aspects were measured using 15 closed statements, consisting of nine positive attitude statements (numbers 1, 2, 3, 4, 7, 9, 12, 13, and 15) and six negative attitude statements (numbers 5, 6, 8, 10, 11, and 14). psychomotor skills were measured using a skills checklist adopted from the specific nutrition intervention by the indonesian ministry of health, with components assessing breastfeeding skills, complementary feeding practices, growth measurement, and hand washing. if the respondent could perform the skills at each stage, they were given a score of 1; if they could not, they were given a score of 0. the validity test of the knowledge questionnaire yielded a calculated r-value greater than the r-table value of 0.361 (r=0.4020.674), indicating that all questionnaire items were valid. by contrast, the reliability test obtained a cronbach’s alpha value for the knowledge questionnaire of 0.760>0.60, indicating reliability. the validity test of the attitude questionnaire showed that the calculated r-values ranged from 0.364 to 0.645, all exceeding the r-table value of 0.361. as a result, 13 items were deemed valid, while items 4 and 5 were found to be invalid. the reliability test produced a cronbach’s alpha coefficient of 0.760, which is greater than the acceptable threshold of 0.60, indicating that the attitude questionnaire was reliable. the intervention provided was health literacy through education and stunting prevention simulation, following specific nutritional interventions for the intervention group through online media and modules. in contrast, the control group received health education according to the health center program. furthermore, the intervention group was provided assistance for one month, which was divided into three phases: the intensive phase from the first day to the seventh day, the strengthening phase from the eighth day to the fifteenth day, and the independent phase from the sixteenth day to the last day. data analysis univariate and bivariate analyses were also performed. bivariate analysis used a paired t-test and an independent t-test for variable knowledge. in contrast, for attitude and psychomotor variables, the wilcoxon and mann-whitney tests were used, as the data were not normally distributed. ethical clearance this study was approved by the health research ethics commission of the faculty of nursing, universitas muhammadiyah jakarta, under ethical certificate number 0938/f.9-umj/vi/2023. ethical principles were upheld throughout the research process, including obtaining informed consent, respecting human rights, and ensuring beneficence and non-maleficence. results table 1 presents the demographic characteristics of mothers and children in the intervention and control groups. the average age of the mothers in the intervention group was 32.66 years, compared to 31.59 years in the control group. the average age of the toddlers in the intervention group was 12.93 months, while that in the control group was 12.31 months. furthermore, the average weight of the toddlers in the intervention group was 8,948.28 grams, compared to 8,715.52 grams in the control group. the average body length of toddlers in the intervention group was 71.81 cm, whereas that of the control group was 72.56 cm. table 2 presents the characteristics of the mothers based on education, employment status, and monthly family income, as well as the gender distribution of the children. the majority of the mothers in both the intervention and control groups had a high level of educa pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13185] [page 87] tion. in terms of employment, nearly all mothers in both groups were unemployed. regarding monthly family income, most mothers in the intervention group reported incomes equal to or above the regional minimum wage (idr 3,329,199), whereas the majority of mothers in the control group reported incomes below this threshold. additionally, the gender distribution of the children in both groups indicated that the majority were female. based on the data presented in table 3, the average knowledge score in the intervention group was 31.76, compared to 34.31 in the control group. the average attitude score was 47.03 in the intervention group and 48.84 in the control group. in contrast, the average psychomotor score was higher in the intervention group (9.69) than that in the control group (8.76). based on table 4, the average behavior of parents in preventing the risk of stunting in the intervention group for 21 days following the intervention showed an increase in the knowledge variable by 7.62, in attitude by 4.17, and in psychomotor skills by 1.65. the average knowledge, attitude, and psychomotor variables in the control group increased, but were still lacking. the results of statistical tests for knowledge, attitude, and psychomotor skills obtained a p-value of 0.001 (p<0.05). therefore, it can be concluded that there was a difference in the knowledge, attitude, and psychomotor skills of parents in preventing stunting in toddlers before and after receiving a health literacy intervention in the intervention group. table 4 shows that, also in the control group, which did not receive health literacy intervention, there was an increase in knowledge, attitude, and psychomotor skills before and after the study. the statistical test results revealed a p-value of 0.001 (<0.05) for the knowledge and psychomotor variables, indicating a significant difference in knowledge and psychomotor skills related to the prevention of stunting risk in children before and after the intervention. for the attitude variable, the p-value was 0.070 (>0.05), suggesting no significant difference in parents’ attitudes toward preventing stunting risk in children before and after the educational intervention. table 5 illustrates that the average difference in knowledge in the intervention group was 34.05, and in the control group was 24.95, with p=0.039 (<0.05), indicating that there was a significant difference in the average knowledge of mothers in preventing stunting risk between the intervention group and the control group. furthermore, the mean rank value of attitudes in the intervention group was 53.4, while in the control group it was 48.83, with p=0.006 (<0.05), indicating a significant difference between the average attitude of mothers in the intervention group and the control group in preventing stunting. the mean rank of psychomotor skills in the intervention group was 37.32, and 21.69 in the control group, with p=0.001 (<0.05), indicating a significant difference between the average psychomotor skills of the parents in the intervention and control groups in preventing stunting in children. based on table 5, it can be concluded that there were differ pathways of change, part ii table 1. characteristics of the respondents, including maternal age, child’s age, child’s weight, and child’s length. variable n mean sd min-max mother’s age (years) intervention group 29 32.66 5.76 22-42 control group 29 31.59 5.93 20-46 child’s age (months) intervention group 29 12.93 6.27 01-23 control group 29 12.31 7.59 01-23 child’s weight (grams) intervention group 29 8948.28 1724.94 4300-12000 control group 29 8715.52 2287.35 3800-13300 child’s body length (centimeters) intervention group 29 71.814 7.81 55.5-88.0 control group 29 72.555 103.632 52.0-88.0 sd, standard deviation. table 2. characteristics of the respondents, including maternal education, employment status, family income, and child’s gender. variable intervention group control group (n=29) (n=29) n % n % education low education 7 24.1 7 24.1 higher education 22 75.9 22 75.9 work doesn’t work 21 72.4 25 86.2 work 8 27.6 4 13.8 family income <regional minimum wage (idr 3.329.199) 9 31.0 15 51.7 ≥regional minimum wage (idr 3.329.199) 20 69.0 14 48.3 gender of the child male 10 34.5 13 44.8 female 19 65.5 16 55.2 sd, standard deviation. [page 88] [healthcare in low-resource settings 2025;13(s2):13185] ences in parental behavior (knowledge, attitudes, and psychomotor) between the intervention and control groups in preventing the risk of stunting in children. discussion human behavior is complex and is divided into three domains or areas: knowledge (cognitive), attitude (affective), and psychomotor (practice).26 the findings of this study demonstrated a significant difference in maternal knowledge before and after the intervention, indicating that health literacy has a measurable impact on maternal understanding related to stunting prevention. this aligns with previous studies showing a significant increase in knowledge from the results of 10 studies that used health literacy interventions and reduced stunting rates in children aged 0-6 months.23,25 knowledge includes all the information a person has about a subject, enabling recall of facts, methods, and processes, and is essential for informed decision-making in the cognitive domain.26 by implementing health literacy, parents can obtain the necessary information, understand it, analyze it closely, and independently participate in health actions. the development of health literacy skills and abilities is a lifelong process, reflecting growth from the individual level to the collective or group level.27,28 this intervention highlights the role of targeted educational resources in improving maternal awareness and competence in preventing stunting in children. the finding showed that the mothers’ attitude had improved after the intervention. therefore, it could be concluded that there was an influence of health literacy on attitude toward preventing stunting in toddlers. attitude is defined as a person’s closed reaction or response to a stimulus or an object. the manifestation of this attitude cannot be seen directly but can only be interpreted from closed behavior. attitude is not yet an action or activity but is a predisposition to a behavior.26,29,30 previous studies have indicated that a mother’s lack of proper child feeding practices can negatively impact the child’s long-term growth and development. additionally, a mother’s attitude toward childcare significantly pathways of change, part ii table 3. respondent characteristics based on mothers’ behavior (knowledge, attitude, and psychomotor) in preventing the risk of stunting before intervention. variable n mean sd min-max knowledge intervention group 29 31.76 5.43 24-40 control group 29 34.31 5.69 24-44 attitude intervention group 29 47.03 4.85 42-58 control group 29 48.83 6.35 38-58 psychomotor intervention group 29 9.69 1.49 05-dic control group 29 8.76 1.95 04-dic sd, standard deviation. table 4. differences in parental behavior in preventing the risk of stunting before and after intervention in the intervention and control groups. behavioral variables intervention group control group mean min-max p mean min-max p knowledge before 31.76 24-40 0.001 34.31 24-44 0.001 after 39.38 33-44 36.14 27-47 difference (∆) 7.62 1.83 attitude before 47.03 42-58 0.001 48.83 38-58 0.070 after 51.20 45-60 49.34 38-59 difference (∆) 4.17 0.51 psychomotor before 9.69 05-12 0.001 8.76 04-2 0.001 after 11.34 10-12 9.72 05-12 difference (∆) 1.65 0.96 table 5. differences in average maternal behavior in preventing stunting risk. behavioral variables mean rank p intervention group control group knowledge 34.05 24.95 0.039 attitude 53.31 48.83 0.006 psychomotor 37.31 21.69 0.001 [healthcare in low-resource settings 2025;13(s2):13185] [page 89] influences the child’s health status.31 however, it is not only the mother’s internal motivation that shapes a positive attitude in caring for her child; family support and motivation also play a crucial role in this process.32-34 the study’s results also indicated a significant improvement in psychomotor skills following the intervention. however, several misconceptions among mothers were also identified, such as the belief that refilled drinking water does not require boiling. this practice can increase the risk of waterborne diseases, subsequently affecting children’s health, growth, and development. moreover, many mothers perceived complementary feeding simply as any food that satisfies the child’s hunger, with some reporting the use of rice and instant noodles as a primary meal. such nutritionally inadequate practices may contribute to malnutrition and hinder a child’s physical and cognitive development. cultural values and customary beliefs play a critical role in shaping parental behavior. previous studies have shown a significant relationship between cultural values and stunting prevention.31 for instance, in some communities, mothers tend to follow advice from older family members, including grandparents, even when such guidance contradicts modern health recommendations. in the madurese community, sociocultural practices that may contribute to stunting include food taboos during pregnancy, withholding immunizations, administering pre-lacteal feeds to newborns, and introducing complementary foods prematurely.35 these inherited beliefs often lead mothers to provide early complementary feeding when children become fussy or appear hungry, despite evidence-based guidelines advising against such practices. although rooted in respect for parental or elder experience, these behaviors may conflict with optimal child health recommendations and can significantly influence the incidence of stunting.31,36 the findings of this study revealed that, similar to the knowledge domain, there was an insignificant increase in the psychomotor skills of mothers in the control group regarding stunting prevention. while some mothers began implementing appropriate caregiving actions after independently acquiring information, not all were willing or able to apply their knowledge consistently, which may explain the limited improvement observed. psychomotor behavior reflects the translation of attitudes into action,37 and its development is often contingent upon enabling factors, such as access to adequate facilities and external support.26 support plays a crucial role in empowering mothers to adopt effective caregiving practices.38 in particular, support from immediate family members – especially husbands – can significantly influence a mother’s ability to fulfill her child’s nutritional and health needs, ultimately reducing the risk of stunting. forms of family support include informational, instrumental, emotional, and appreciative support. previous research has highlighted that families can provide both cognitive and emotional reinforcement during the parenting process, and mothers who receive strong familial support are more likely to adopt and sustain positive parenting behaviors.39 the study results reinforce that the health literacy intervention, based on the health promotion model, is effective in enhancing maternal behavior across the cognitive, affective, and psychomotor domains. by increasing knowledge, fostering positive attitudes, and promoting appropriate caregiving practices, this approach addresses multiple determinants of child health and contributes to stunting prevention efforts. however, this study has certain limitations. the duration of the intervention and follow-up was relatively short, which restricts the ability to evaluate long-term behavioral changes and their sustained impact on stunting rates. conclusions health literacy influenced maternal behavior in preventing the risk of stunting between the intervention and control groups. health literacy can be an innovation in the development of science and technology as a medium for health promotion. modules and assistance can facilitate the audience’s understanding and enhance their health behaviors. therefore, it is recommended that primary health facilities improve their services, especially in preventing stunting risks through health literacy, which can be provided through modules and mentoring activities for mothers and their families. references 1. ministry of national development planning (kementerian ppn), tnp2k. national strategy to accelerate stunting prevention. secretariat of the vice president of the republic of indonesia; 2020. available from: https://stunting.go.id/wpcontent/uploads/2020/08/stranas_percepatan_pencegahan_an ak_kerdil.pdf 2. unicef, world health organization, world bank. levels and trends in child malnutrition: key findings of the 2023 edition. geneva: world health organization; 2023. available from: https://www.who.int/publications/i/item/9789240073888 3. unicef. malnutrition. unicef data: monitoring the situation of children and women. available from: https://data.unicef.org/topic/nutrition/malnutrition/ 4. global nutrition report. 2021 global nutrition report: the state of global nutrition. bristol, uk: development initiatives poverty research ltd.; 2021. available from: https://globalnutritionreport.org/reports/2021-global-nutrition-report/ 5. badan kebijakan pembangunan kesehatan. survei kesehatan indonesia (ski) 2023. available from: https://www.badankebijakan.kemkes.go.id/hasil-ski-2023/ 6. public relations of the east kalimantan provincial health office. infographics on health in east kalimantan province [internet]. available from: https://padlet.com/humasdinkes /infografis-kesehatan-provinsi-kaltim-i52s3ngsuxxgaq5d 7. kurniawan n, mulyono s, fitriyani p, yulianti ep. empowering cadres: the impact of kepiting, a web-based application on stunting knowledge and attitudes. j ners 2025;20:79-90. 8. ajmer s, islam s, rana mj, et al. determinants of childhood stunting in india: comparative evidence from bihar bt-agriculture, food and nutrition security: a study of availability and sustainability in india. in: rukhsana, alam a, eds. springer international publishing; 2021:273-93. 9. fufa da. determinants of stunting in children under five years in dibate district of ethiopia: a case-control study. hum nutr metab 2022;30:200162. 10. tim nasional percepatan penanggulangan kemiskinan, issuing body. 100 kabupaten/kota prioritas untuk intervensi anak kerdil (stunting). cetakan pertama., tim nasional percepatan penanggulangan kemiskinan, sekretariat wakil presiden, republik indonesia, 2017. 11. huriah t, nurjannah n. risk factors of stunting in developing countries: a scoping review. open access maced j med sci 2020;8:155-60. 12. pertiwi anam, hendrati ly. literature review: analysis of the causes of stunting in toddlers in east java province. amerta pathways of change, part ii [page 90] [healthcare in low-resource settings 2025;13(s2):13185] nutr 2023;7:320-7. 13. farhanidiah s, arief ys, kurnia id. feeding behavior among stunting toddler’s mothers. pediomaternal nurs j 2021;7:2632. 14. has emm, krisnana i, efendi f. enhancing maternal caregiving capabilities model to prevent childhood stunting: a unicef-inspired model. sage open nurs 2024;10:23779 608231226060. 15. ningsi a, mukarramah s, mukarramah s, et al. gambaran pengetahuan premenopause tentang perubahan fisik dalam menghadapi masa menopause di dusun mannyoi desa tamannyeleng kecamatan barombong kab. gowa. media keperawatan politek kesehat makassar 2021;11:136-41. 16. krisnana i, azizah r, kusumaningrum t, has emm. feeding patterns of children with stunting based on who (world health organization) determinant factors of behaviours approach. indian j public heal res dev 2019;10:2756-61. 17. ibad m, lutfiya i, herdiani n, et al. determinants of stunting events in indonesia using path analysis. aip conf proc 2023;2595:090019 18. fajrianti d, yunitasari e, pradanie r. the correlation between personal reference: health workers and health facilities with parenting in stunting prevention. pediomaternal nurs j 2020;6:125-32. 19. public health ontario. health literacy and health promotion. ontario health promotion e-bulletin. 2024. available from: https://www.publichealthontario.ca/ 20. coughlin ss, vernon m, hatzigeorgiou c, george v. health literacy, social determinants of health, and disease prevention and control. j environ heal sci 2020;6:2019-22. 21. amaliyah e, mulyati m. effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting: a quasi-experimental design. j ners 2020;15:173-7. 22. liu c, wang d, liu c, et al. what is the meaning of health literacy? a systematic review and qualitative synthesis. fam med community health 2020;8:e000351. 23. zibellini j, muscat dm, kizirian n, gordon a. effect of health literacy interventions on pregnancy outcomes: a systematic review. women birth 2021;34:180-6. 24. alligood mr. pakar teori keperawatan dan karya mereka. 8th ed. elsevier singapore pte ltd.; 2017. 25. sirajuddin s, sirajuddin s, razak a, et al. the intervention of maternal nutrition literacy has the potential to prevent childhood stunting: randomized control trials. j public health res 2021;10:2235. 26. pakpahan m, siregar d, susilawaty a, et al. promosi kesehatan dan perilaku kesehatan. yayasan kita menulis; 2021. 27. sørensen k, van den broucke s, fullam j, et al. health literacy and public health: a systematic review and integration of definitions and models. bmc public health 2012;12:80. 28. faiola a, kamel boulos mn, bin naeem s, ur-rehman a. integrating social and family support as a measure of health outcomes: validity implications from the integrated model of health literacy. int j environ res public health 2023;20. 29. navas-casado ml, garcía-sancho e, salguero jm. associations between maladaptive and adaptive emotion regulation strategies and aggressive behavior: a systematic review. aggress violent behav 2023;71:101845. 30. cheng hi, hsu wt, wang wh, et al. health behavior models and regular exercise levels among workers in taiwan. j multidiscip healthc 2023;16:4149-59. 31. yunitasari e, pradanie r, arifin h, et al. determinants of stunting prevention among mothers with children aged 6–24 months. open access maced j med sci 2021;9:378-84. 32. kelty ne, wakabayashi t. family engagement in schools: parent, educator, and community perspectives. sage open 2020;10. 33. syahrir m, sugiati a, wiranti w, et al. the cultivating siri’s cultural values in child character building. scaffolding j pendidik islam dan multikulturalisme 2023;5:888-900. 34. fazrin i, fidyaswati l. family motivation in the provision of nutrition with stunting events in tons of together in pujiharjo village, tirtoyudo district. j glob res public health 2021;6:56-65. 35. hill c, knafl ka, santacroce sj. family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit: an integrative review. j pediatr nurs 2018;41:22-33. 36. marni m, abdullah az, thaha rm, et al. cultural communication strategies of behavioral changes in accelerating of stunting prevention: a systematic review. open access maced j med sci 2021;9:447-52. 37. yani di, rahayuwati l, sari cwm, et al. family household characteristics and stunting: an update scoping review. nutrients 2023;15:1-17. 38. mh em, sabela a, qona’ah a, et al. maternal caregiving capabilities are associated with energy-protein adequacy of children with stunting in central java, indonesia. curr res nutr food sci 2024;12. 39. nugraha sy, fatikhah n, wahyuni st, saudah n. social support family to increase parenting pattern to prevent stunting [internet]. 2019. available from: https://repositori.ubsppni.ac.id/handle/123456789/472 pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13185] [page 91] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13279 efficacy of red betel (piper ornatum) in accelerating perineal wound healing in postpartum women riana pascawati, desi hidayanti, lola noviani fadilah midwifery department, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract the incidence of second-degree perineal lacerations, which involve injury to the vaginal tissue and perineal muscles, ranges from 35.1% to 78.3% among primiparous women and 34.8% to 39.6% among multiparous women. red betel (piper ornatum) is well known for its disinfectant and antifungal properties, making it an effective option for wound care. this study aimed to evaluate the effectiveness of red betel leaf extract in accelerating perineal wound healing in postpartum women. a quasi-experimental design with a non-randomized pretest-posttest control group approach was employed, involving 39 participants divided into the intervention and control groups. the intervention group received red betel leaf extract twice daily for seven days, while the control group received conventional care. wound healing was assessed by using the reeda score. the results showed a significant reduction in reeda scores in the intervention group, with an average decrease from 10.7 to 2.1, compared to a reduction from 7.2 to 3.5 in the control group (p<0.05). this represents an 8.6-point improvement in the intervention group versus a 3.6 points in the control group. the bioactive compounds in red betel leaves, including flavonoids, tannins, and saponins, contribute to their antimicrobial, anti-inflammatory, and antioxidant properties that accelerate wound healing. these findings highlight the potential of red betel leaf extract as a natural, non-pharmacological therapy for postpartum wound care. broader implementation could improve maternal health outcomes, particularly in settings with limited access to conventional treatment. introduction perineal lacerations are a common outcome of vaginal childbirth and affect approximately 80% of women. primiparous women are more frequently affected by these tears than are multiparous women. the incidence of second-degree perineal lacerations, which involve injury to the vaginal tissue and perineal muscles, ranges from 35.1% to 78.3% among primiparous women and 34.8% to 39.6% among multiparous women. a recent comprehensive review on perineal lacerations highlights global variations in prevalence, management, and outcomes, emphasizing the need for context-specific care strategies.1 more severe thirdand fourthdegree lacerations, which extend to the anal sphincter, occur in 5.1% to 8.3% of primiparous women and in 1.8% to 2.8% of multiparous women.2–4 standard perineal care follows the “clean and dry” principle, which involves cleaning the wound with clean water (without any additives) and thoroughly drying it after each instance of discharge.5 adhering this typically allows perineal suture wounds to heal within ten days, although healing may take up to 14 days in some cases. proper perineal wound care is essential for postpartum women, as it helps prevent infection, accelerates the healing process, and reduces discomfort associated with perineal lacerations.4 perineal infections are common postpartum complications that affect many women after childbirth.6,7 studies have reported that 16% of women experience prolonged perineal infections, often accompanied by significant perineal pain.5 given the potential complications of these infections, herbal remedies have gained attention as preferred option for wound healing, due to their minimal side effects and cost-effectiveness compared to conventional medications. one such herbal remedy is the red betel plant (piper ornatum), which is well-known for its therapeutic properties.8 although evidence-based perineal wound care often emphacorrespondence: riana pascawati, lecturer of midwifery department, politeknik kesehatan kemenkes bandung, bandung, indonesia e-mail: rianapascawati@staff.poltekkesbandung.ac.id key words: maternal health, perineal wound healing, postpartum women, red betel extract. contributions: rp, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review and editing; ds, conceptualization, investigation, methodology, validation, review and editing; lnf conceptualization, methodology, formal analysis, validation, and writing – original draft, review and editing. conflict of interest: the authors declare that they have no conflicts of interest. ethical approval and consent to participate: this research was approved by the health research ethics commission (kepk) of poltekkes kemenkes bandung (09/kepk//ec/ix/2020). the researcher focused on the ethical principles of autonomy, beneficence, justice, and nonmaleficence. patient consent for publication: written informed consent was obtained from the anonymized patients for publication in the study. funding: none. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 22 october 2024. accepted: 17 march 2025. early access: 16 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13279 doi:10.4081/hls.2025.13279 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13279] [page 117] sizes the use of clean water without additives, traditional practices in indonesia continue to incorporate the use of plants as natural remedies for wound care. these plants, frequently used for their antiseptics and antimicrobial properties, play a significant role in postpartum healing. one such plant is the red betel (piper ornatum), valued for its potent antiseptic and antibacterial effects. the extract of red betel leaves contains essential oils and various phytochemicals, which are known to accelerate the healing process of perineal wounds.4,9,10 red betel (piper ornatum) is well known for its disinfectant and antifungal properties, making it an effective option for wound care. studies have shown that the average healing time of perineal wounds treated with red betel leaves is 3–4 days faster than that of wounds treated with iodine.11,12 considering these promising findings, the present study aimed to further analyze the effectiveness of red betel extract rinse (piper ornatum) on perineal wound healing in postpartum women. materials and methods research design this study employed a quantitative approach using a quasiexperimental method with a non-randomized post-test control group design. this study was conducted in collaboration with private midwives in the bandung area to facilitate a controlled assessment of the effectiveness of red betel extract in promoting perineal wound healing among postpartum women. study participants the population for this study consisted of postpartum women with perineal suture wounds who gave birth at private midwife practices “i” and “n” in bandung over the past three months. a quasi-experimental design was chosen because of limitations in implementing full randomization in the field, especially considering the collaboration with private midwifery practices that required the allocation of research subjects. respondents were selected through consecutive sampling based on the specific inclusion and exclusion criteria. the inclusion criteria were as follows: women on the first day postpartum aged 20–35 years; those with second-degree perineal lacerations involving the vaginal mucosa, perineal skin, and perineal muscle; women who experienced a term and spontaneous labour; literate women who were willing to participate as respondents.13 exclusion criteria included women with diabetes mellitus or anemia and those who had experienced labor complications. variables, instruments, and data collection this study was preceded by the preparation of red betel leaf extract, conducted in may 2022 through collaboration between the laboratory of the medical laboratory technology study program at bandung polytechnic and the itb laboratory. the extraction process involved sequential steps of maceration, evaporation, and lyophilization. subsequently, phytochemical analyses were performed to identify secondary metabolites present in the extract using 70% ethanol as the solvent. this stage aimed to evaluate the active compound content in the crude extract of red betel leaves through a series of phytochemical tests, adapted and modified from standard procedures, including tests for alkaloids, flavonoids, steroids/triterpenoids, saponins, and tannins. the extract was prepared at two concentration levels, specifically 0.125% and 0.25%. phytochemical screening revealed that the red betel leaf extract at a concentration of 0.25% contained alkaloids, flavonoids, terpenoids, saponins, and tannins, whereas the extract at 0.125% concentration positively identified the presence of saponins, tannins, and steroids/triterpenoids only. data collection this study utilized both primary and secondary data. primary data were gathered to assess perineal suture wound healing and to capture participant characteristics, including age, parity (number of previous births), and labor history. secondary data included information on the number of postpartum women was collected from private midwife practices “i” and “n” in bandung. for the intervention group in this study, there was a detailed counselling guide on using red betel leaf extract for perineal wound care. the following procedures detail the systematic steps for applying red betel leaf extract as part of a perineal hygiene routine. each step is carefully designed to ensure proper hygiene, effective application, and consistent monitoring throughout the intervention period: i) hand hygiene: begin by thoroughly washing your hands with clean water and soap to ensure they are free from any contaminants: ii) preparation: take the bottle of red betel leaf extract and carefully open the lid. a sufficient amount of the extract was poured into a clean container or directly onto a clean cotton ball or pad; iii) application: position yourself comfortably, ensuring that the perineal area can be easily reached. using a clean cotton ball or pad, red betel leaf extract was gently applied to the outside of genitalia to ensure cleaning from front to back (towards the anus) to prevent contamination; iv) duration: the extract was allowed to remain in the perineal area for three minutes. this allows the extract to exert antiseptic and healing effects; v) drying: after three minutes, the perineal area was gently dried using clean tissue or pad; vi) post-application: wash your hands thoroughly with clean water and soap to maintain hygiene; vii) record keeping: the amount of red betel leaf extract used and the time of application (morning and evening) each day were recorded on provided record form; viii) frequency: this routine was performed twice a day for a total of seven days, once in the morning and once in the evening. this protocol ensures that the intervention is administered consistently and effectively, while maintaining proper hygiene and monitoring the application process. the research procedures for both the intervention and control groups involved specific care and monitoring protocols. in the intervention group, respondents applied red betel leaf extract twice daily for seven consecutive days. researchers ensured adherence through reminders via whatsapp or sms and monitored respondents’ health conditions every two days. additionally, home visits were conducted on days 1, 3, and 7 postpartum by researchers and students to assess wound conditions using the reeda table and an observation sheet. meanwhile, the control group received conventional perineal wound care based on clean and dry principles. similar to the intervention group, researchers conducted home visits on days 1, 3, and 7 postpartum to monitor wound healing using the reeda table and an observation sheet. both of groups allowed for a comparative analysis of the effectiveness of red betel leaf extract against conventional wound care practices. regular monitoring and consistent assessment using the reeda scale ensured that any changes in wound healing were accurately recorded and analysed. in this study, an observation sheet was utilized to assess and document the healing of perineal suture wounds. the observation sheet was designed based on the reeda scale, which evaluates wound healing using the following five criteria: redness, edema, ecchymosis, discharge, and approximation. for the intervention, special issue pathways of change [page 118] [healthcare in low-resource settings 2025;13(s1):13279] tools and material for the red btel extract were used as the primary treatment to promote wound healing. additionally, a healing rate observation sheet was employed to track and record the progress of wound healing throughout the intervention period. these instruments provide a comprehensive and systematic approach to evaluating the effectiveness of red betel leaf extracts in promoting perineal wound healing. the reeda scale is a quantitative assessment method for assessing wound healing based on five main components: redness, edema, ecchymosis, exudation, and approximation. each component is scored from 0 (no symptoms) to 3 (most severe symptoms), with a maximum total score of 15. the lower the reeda score, the better the wound healing.14 data analisis data collected from the observation sheets were coded and processed using statistical software to evaluate and compare the effectiveness of red betel leaf extract (piper ornatum) and conventional treatments for perineal suture wound healing. the primary aim of this study was to assess the effectiveness of red betel leaf extract comparison with conventional treatments in promoting perineal suture wound healing. to determine which method was more effective in accelerating wound healing, we compared the outcomes of the two groups: those receiving red betel leaf extract and those receiving conventional treatments. for statistical analysis, an independent sample wilcoxon test was employed to assess differences between the two groups. statistical significance was set at p<0.05, indicating that results with p-values less than 0.05 are considered statistically significant. ethical clearance this study was approved by the health research ethics commission (kepk) of poltekkes kemenkes bandung (09/kepk//ec/ix/2020). several ethical considerations were implemented to ensure the protection of respondents right. all respondents provided their approval to participate through informed consent, ensuring that they were fully aware of the study’s purpose and procedures. the study guaranteed anonymity and confidentiality of respondents’ information. respondents had the right to withdraw from the study at any time, without any consequences. these measures ensured that the study adhered to ethical standards and protected the rights and privacy of respondents. results samples characteristics in the study, there were initially 42 respondents, with 21 in the intervention group and 21 in the control group. however, during the research, the following changes occurred: one participant withdrew from the intervention group, and two respondents withdrew from the control group. the final number of respondents was 39, 20 in the intervention group and 19 in the control group. to ensure comparability between the intervention and control groups, the characteristics of respondents at the beginning of the study including age, parity, education, and knowledge of personal hygiene, were presented and analysed. there were no significant differences (p>0.05) between the two groups in terms of age, parity, educational level, or knowledge level (table 1). this lack of a significant difference indicates that the characteristics of the research respondents were homogeneous between the two groups. the homogeneity of the groups is crucial, as it ensures that any observed effects of the intervention can be attributed to the treatment itself rather than differences in participant characteristics. table 1 provides detailed data on these characteristics for each group, supporting the claim of equivalence and offering a clear basis for comparing the effectiveness of red betel leaf extract with conventional treatments. the preparation of red betel leaf extract (piper ornatum) followed a systematic process, conducted in collaboration with the medical laboratory bandung ministry of health polytechnic and laboratory technology study program at institut teknologi bandung. fresh red betel leaves were carefully selected, thoroughly washed under running water, and then dried through aeration, ensuring they were shielded from direct sunlight to prevent the degradation of active compounds. once dried, the leaves were ground into a fine powder using a blender and sieved with a 20-mesh sieve. the powdered leaves were then extracted using the maceration method, employing a solvent mixture of 70% ethanol and ethyl acetate. the resulting extract underwent phytochemical screening, which confirmed the presence of key bioactive compounds alkaloids, flavonoids, saponins, tannins, triterpenoids, and steroids. this meticulous process ensured that the red betel leaf extract was prepared with its bioactive compounds intact, making it suitable for application in perineal wound healing. table 2 illustrates that the intervention group, treated with red betel leaf extract, demonstrated a more significant reduction in special issue pathways of change table 1. characteristics of research subjects. group characteristics treatment (n=20) control (n=19) p age (year) 0.67* 20-30 14 (70) 15 (75) 31-35 6 (30) 4 (25) education 0.12* elementary school 2 (10) 7 (35) junior high school 15 (75) 10 (55) high school bachelor 3 (15) 1 (5) parity 0.52* prim 13 (65) 10 (53) multi 7 (35) 9 (47) knowledge level 0.16** low 0 1 (5) moderate 13 7 (37) high 7 11 (58) description * chi-square test. table 2. overview of first, third and seventh day reeda score on research group. group characteristics treatment (n=20) control (n=19) day one x (sd) 10.7 (2.8) 7.2 (1.7) median 10 7 range 6-15 5-10 day three x (sd) 6.6 (1.4) 5.6 (1.7) median 7 5 range 4-9 3-9 seventh day x (sd) 2.1 (0.8) 3.5 (1) median 2 3.5 range 1-3 2-6 [healthcare in low-resource settings 2025;13(s1):13279] [page 119] reeda scores compared to the control group by day seven. despite initially having more severe wounds, the intervention group’s scores improved more rapidly, reflecting the extract’s efficacy in accelerating wound healing. table 3 highlights a statistically significant difference (p=0.05) was observed between the intervention and control groups’ reeda scores from day one to day seven. the intervention group’s average score decreased from 10.7 to 2.1, compared to the control group’s decrease from 7.2 to 3.5. this highlights the clinical relevance of red betel leaf extract in enhancing perineal wound healing. discussion this study involved 39 respondents, with no significant differences in age, education, parity, or personal hygiene knowledge between the intervention and control groups, ensuring homogeneity at baseline. the red betel leaf extract (piper ornatum) was prepared through a systematic process, retaining key bioactive compounds suitable for wound healing. the analysis of reeda scores revealed that the intervention group, which received the red betel leaf extract, showed significant improvement in wound healing, with a marked reduction in reeda scores from day one to day seven compared to the control group. the results indicate that red betel leaf extract significantly enhances perineal wound healing compared to conventional treatments. the wound healing process involves several stages: inflammation, proliferation, epithelialization, angiogenesis, remodeling, and scarring.15 each of these stages is essential for the restoration of tissue integrity, with inflammation and proliferation being particularly critical in the initial phases. according to the theory of wound healing, the inflammatory response is necessary to clear debris and initiate tissue repair, while proliferation involves the formation of new tissue, including blood vessels and extracellular matrix. in this study, red betel leaf extract was shown to positively impact perineal wound healing in postpartum women, as indicated by the significant reduction in the reeda score. the reeda score is a commonly used indicator for assessing perineal wound healing, which evaluates redness, edema, ecchymosis, discharge, and approximation of the wound edges.14 the results showed that there was a significant difference in the reeda score, which is an indicator of perineal wound healing, in the intervention and control groups (p<0.05), with an average decrease in the reeda score in the intervention group and 8.6, whereas in the control group, it was 3.6. the significant decrease in the reeda score in the intervention group compared to that in the control group suggests that red betel leaf extract has a more pronounced effect on improving perineal wound healing. these findings emphasize the potential of red betel leaf extract as an effective alternative or complementary treatment for improving perineal wound healing in postpartum women. in light of these findings, it can be argued that red betel leaf extract offers a promising alternative or complementary treatment for improving perineal wound healing in postpartum women. while traditional methods for wound care,16–18 such as antiseptics and basic hygiene, remain essential, the incorporation of plant-based treatments like red betel leaf extract may provide additional benefits, such as reducing inflammation and promoting faster tissue regeneration. given the promising results of this study, it is important to further investigate the specific mechanisms by which red betel leaf extract contributes to wound healing, as well as its potential integration into clinical practices for postpartum care. the evidence from this study highlights the potential role of red betel leaf extract in enhancing the wound healing process, offering a natural and effective option for managing perineal wounds. reeda score includes redness, edema, ecchymosis, discharge, and approximation, with the highest score for each aspect being three and the lowest score being zero. the higher the score, the higher the level of tissue trauma, and the perineal wound healed when the reeda score was zero.14 the decrease in reeda’s score in the intervention group (10.7) was greater on the seventh day than that in the control group (7.2). therefore, daily perineal wound healing in the group administered a wash basin solution containing red betel extract was better than that in the control group, which received clean and dry care. the effectiveness of red betel leaf extract in healing perineal wounds is due to the content of specific compounds in red betel leaves, including polyphenols, saponins, flavonoids, alkaloids, and tannins, which accelerate wound epithelialization.19 this was evident from the test results of the chemical compound content in the red betel leaf extract conducted at the laboratory of the medical laboratory technology study program of the polytechnic of the ministry of health bandung. phytochemical analysis of the red betel extract used in this study showed the presence of saponins, flavonoids, and tannins. the alkaloid and terpenoid contents were negative in laboratory phytochemical tests.20 flavonoids have antibiotic properties that can interfere with the function of microorganisms and cause their death to prevent infection.21 therefore, these compounds accelerated the final stage of the inflammatory phase during the recovery phase. alkaloids act as antibacterial agents by disrupting the peptidoglycans of bacterial cells.22,23 alkaloids possess antibacterial properties that disrupt the peptidoglycan layer of bacterial cells, contributing to the reduction of bacterial infections in wound.9 therefore, intervention group with red betel had better average redness and edema scores than the control group. flavonoids can also accelerate wound epithelialization during proliferation phase.24,25 polyphenols and saponins can stimulate collagen formation during the proliferation phase.26 tannins have antibacterial properties and promote the regeneration of new tissues, further aiding wound healing.27 owing to these properties, the intervention group receiving red betel leaf extract showed better average redness and edema scores than the control group. this indicates more effective management of inflammation and better overall wound healing. based on the above theoretical information, it can be concluded that red betel leaf extract significantly accelerates perineal wound healing in postpartum women. this conclusion was supported by the presence of effective antiseptic and antimicrobial compounds in the extract. red betel leaf extract solution serves as a viable alternative to conventional treatments for accelerating perineal wound healing. it can be effectively used to prevent infections, reduce discomfort, and enhance wound recovery. midwives special issue pathways of change table 3. overview of pre and post reeda scores in the research group. group characteristics treatment (n=20) control (n=19) p pre 0.00* x (sd) 10.7 (2.8) 7.2 (1.6) median 10 7 range 6-15 5-10 post 0.00* (sd) 2.1 (0.8) 3.5 (1.0) median 2 3.5 range 1-3 2-6 description: *wilcoxon test. [page 120] [healthcare in low-resource settings 2025;13(s1):13279] should educate postpartum women on the benefits and applications of red betel leaf extract. they can recommend using the extract to wash perineal wounds and integrate this practice into postpartum care. utilizing red betel leaf extract allows midwives to play a proactive role in maternal recovery during the postpartum period, ensuring better management of perineal wounds, and overall maternal health. this approach not only provides a natural remedy with minimal side effects, but also supports midwifery practice in promoting effective postpartum care. despite these promising findings, the study’s non-randomized design and limited sample size are notable limitations. these factors may restrict the generalizability of the results. future studies should employ randomized controlled trials with larger sample sizes to validate these findings and explore the broader applicability of red betel extract in diverse wound-care contexts. investigating its effects on other types of wounds and varying patient demographics would further substantiate its clinical utility. conclusions red betel extract (piper ornatum) significantly accelerates perineal wound healing in postpartum women, offering a natural, nonpharmacological alternative to conventional treatments. future studies with larger, more diverse populations are needed to validate these findings and explore additional factors influencing wound healing, such as lifestyle and nutritional status. expanding research to other wound types could further demonstrate its therapeutic potential. clinically, integrating red betel leaf extract into postpartum care may enhance maternal recovery and improve overall patient outcomes. references 1. okeahialam na, wong kw, sultan rtah. the incidence of wound complications following primary repair of obstetric anal sphincter injury: a systematic review and meta-analysis. am j obstet gynecol 2022;22:182–91. 2. jansson mh, franzén k, hiyoshi a, et al. risk factors for perineal and vaginal tears in primiparous women – the prospective popract-cohort study. bmc pregn childbirth 2020;20:1–14. 3. nurmaliza l, lubis rc, muryani m. the relationship between knowledge and attitudes of postpartum mothers regarding vulva hygiene and prevention of perineal wound infections at the sulastri clinic. int j public heal excell 2023;3:460–70. 4. fikria sh, indrayani t, dinengsih s. the effect of red betel leaves (piper crocatum) boiled water on the perineal wounds healing in public health center of karangpawitan of garut regency in 2021. j nurs pract 2021;5:204–9. 5. queensland clinical guidelines. maternity and neonatal clinical guideline. queensland health. 2017. 1–39 p. 6. cakwira h, mukengere m, lucien b, et al. the clinical characteristics of perineal tears: a study carried out on 14 pregnant women in a tertiary center: case series. ann med surg 2022; 82:104432. 7. gommesen d, nohr ea, drue hc, et al. obstetric perineal tears: risk factors, wound infection and dehiscence: a prospective cohort study. arch gynecol obstet 2019;300:67–77. 8. hadizadeh-talasaz f, mardani f, bahri n, rakhshandeh h, khajavian n, taghieh m. effect of rosemary cream on episiotomy wound healing in primiparous women: a randomized clinical trial. bmc complement med ther 2022;22:1–10. 9. siregar y, lubis r, irianti e. gel daun sirih merah (piper crocatum ruiz &pav) 15% efektif dalam mempercepat penyembuhan luka perineum pada tikus putih betina (rattusnorvegicus) galur wistar. j penelit kesehat suara forikes 2022;13:835–8. 10. rohmin a, octariani b, jania m. faktor risiko yang mempengaruhi lama penyembuhan luka perineum pada ibu post partum. j kesehat 2017;8:449. 11. molan pc, betts ja. clinical usage of honey as a wound dressing: an update. j wound care 2004;13:353–6. 12. karpelowsky j, rode h, allsopp m. wound healing with honey a randomised controlled trial. south african med j 2007;97:9–13. 13. goh r, goh d, ellepola h. perineal tears. r aust coll gen pract 2018;47:35–8. 14. alvarenga mb, francisco aa, maria s, et al. episiotomy healing assessment: redness, oedema, ecchymosis. rev lat am enfermagem 2015;23:162–8. 15. sorg h, tilkorn dj, hager s, et al. skin wound healing: an update on the current knowledge and concepts. eur surg res 2017;58:81–94. 16. fitriani h, setyowati s, afiyanti y, et al. traditional treatment for diastasis rectus abdominis in postpartum mothers: a phenomenological study. br j midwifery 2024;32:474–82. 17. agustina za, fitrianti y. utilization of jamu in puerperal mother in sumatera and java island (literature review of health ethnographic research 2012-2016). indones j public heal 2020;15:93– 102. 18. gunawan f, sandhika w, wiqoyah n. effectiveness of black honey as an antiinflammatory substance in rat’s wound infected by staphylococcus aureus. berk ilmu kesehat kulit dan kelamin 2021;33:13. 19. bidan pp, kesehatan i, utara s, ginting jj, tuntungan m. the effect of red betel infusion perineal care on the healing time of grade ii perineal wounds after delivery. jurnal eduhealth 2024;15:725–30. 20. amini ra, suwondo a, ta’adi t. potential red leaves extract on improving the effectiveness of antibiotic in postpartum (study experiment of perineum wound healing process). j kebidanan 2022;11:167. 21. selawa w, max revolta john runtuwene gc. kandungan flavonoid dan kapasitas antioksidan total ekstrak etanol daun binahong [anredera cordifolia(ten.)steenis.]. j bios logos 2013;3:18–23. 22. lisnanti ef, lokapirnasari wp, hestianah ep, et al. antibacterial alternatives using the potential of the ant nest plant (myrmecodia spp.). int j one heal 2024;10:148–52. 23. irmawati a, yuliantoro r, sidarningsih, et al. the difference of antibacterial properties extract seeds papaya and papaya leaves (carica papaya l) against streptococcus mutans. res j pharm technol 2024;17:4353–62. 24. indriyanti a. the effect of giving gel combination of binahong leaf extract and turmeric rhizome extract on histopathological epithelial thickness in ii b degree burn of rattus norvegicus. j basic med vet 2023;12:45–52. 25. luthfi m, juliastuti ws, asyhari npo. the effect of giving okra (abelmoschus esculentus) extract on the increase of vascular endhothelial growth factor (vegf). indones j dent med 2019;2:35. 26. partafi n, windono t. red betel (piper crocatum ruiz & pav) literature review. media pharm indones 2016;1:106–15. 27. nisa gk, nugroho wa, hendrawan y. ekstraksi daun sirih merah (piper crocatum) dengan metode microwave assisted extraction (mae). j bioproses komod trop 2014;2:72–8. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13279] [page 121] hrev_master healthcare in low-resource settings 2024; volume 12:12075 telegram as a tool for nursing laboratory practice for undergraduates: peyton’s 4-step approach lale wisnu andrayani,1 rusmini,1 hamdan hariawan2 1nursing department, politeknik kesehatan kementerian kesehatan mataram; 2nursing department, politeknik kesehatan kementerian kesehatan maluku, ambon, indonesia abstract nursing education must undergo a digital transformation due to the covid-19 pandemic. nursing laboratory practices should be conducted virtually using suitable media and methods. this study aimed to assess the impact of laboratory learning with peyton’s 4-step approach through the social media platform telegram on the bathing skills of nursing students. the research followed a quasi-experimental design with a pre-post approach and included a control group. the sample consisted of 60 nursing undergraduate students divided into treatment and control groups. the treatment group received a learning intervention using peyton’s 4-step method via telegram, while the control group was provided with a learning video. instruments used included questionnaires and observation sheets developed by the researcher based on bathing skill procedures. the analyses employed the mann-whitney test and independent t-test, with a significance value set at <0.05. peyton’s approach via telegram demonstrated a significant increase in students’ knowledge (p=0.009) and skills (p=0.002) in bathing patients. respondent characteristics, including gender, age, and school of origin, did not influence the results of the respondents’ knowledge and skills in bathing patients (p>0.05). in conclusion, nursing education with peyton’s 4-step approach via telegram offers an accessible platform for lecturers and students to engage in online discussions. education can be conducted flexibly, anywhere, and anytime, with telegram being a user-friendly social media platform. introduction the world health organization (who) officially designated the coronavirus disease 2019 (covid-19) as a pandemic on march 11, 2020.1 covid-19 has triggered the most severe international public health crisis.2 amidst the covid-19 pandemic, nearly all non-critical sectors require their workers to operate remotely.3 all teaching and learning activities are conducted online.4 the covid-19 pandemic has compelled the education system in indonesia to transition from conventional to digital education.5,6 the risk of mental ill health due to the covid-19 pandemic has been increasing worldwide.7 school closures during the covid-19 pandemic have raised concerns.8 all schools and universities in indonesia immediately underwent a dramatic transformation by suspending face-to-face learning and swiftly transitioning to the online mode to protect students’ lives and prevent the transmission and spread of covid-19.9 one of these transformations is seen in the field of nursing, where nursing educators and students must conduct laboratory practices virtually, transitioning from clinical nursing practice.10 nursing students and lecturers are also required to use digital technology proficiently. the utilization of digital technology enables students and lecturers to be in different locations during the learning process.11 the covid-19 pandemic has compelled most countries worldwide to implement online teaching.12 nursing education must continue during a pandemic because a delay in the learning process can contribute to student anxiety during the pandemic. social media can serve as a medium for providing health interventions to enhance health outcomes.13 therefore, digital technology must consistently support education during pandemics.14,15 social media, including platforms like whatsapp and telegram, plays a crucial role in the learning process during the covid-19 pandemic. social media has become essential for people to interact with each other, and it has become correspondence: hamdan hariawan, nursing department, politeknik kesehatan kementerian kesehatan maluku, ambon, indonesia. e-mail: hariawanawan@gmail.com key words: nursing education, 4-step peyton approach, telegram. contributions: lwa, the collecting and assembly of data, administrative, technical, and logistic support; rr, obtaining of funding, conception, design, and the final approval of the article; hh, analysis, interpretation, drafting of the article, the critical revision of the article for important intellectual content, and statistical expertise. conflict of interest: the authors declare no conflict of interest. funding: this research was supported by a research grant from dipa (a budget execution list) of mataram health polytechnic fiscal year 2021 research for educators. ethics approval and consent to participate: this research has obtained ethical approval from the health research ethics committee of mataram health polytechnic, the ministry of health republic indonesia. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors express gratitude to the director of mataram health polytechnic, the ministry of health republic indonesia, for his permission and funding allocation for this study. received: 13 november 2023. accepted: 21 march 2024. early access: 18 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12075 doi:10.4081/hls.2024.12075 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12075] [page 477] a key component in the global application of education. currently, the most widely used media in nursing laboratory practice learning is social media, such as whatsapp and telegram.16 telegram, as a learning medium, offers more features than other social media platforms. some telegram features, such as large group chats, polls, and broadcast channels, are not available on other social media platforms. this functionality allows for easy access and sharing of learning resources among users with a large capacity. research results on the effectiveness of whatsapp and telegram on student engagement indicate that telegram, with its additional features, significantly enhances student engagement. this, in turn, directly contributes to improving students’ cognitive abilities and learning practices.17 telegram is a mobile application and serves as a distance learning medium. learning media is a crucial element in achieving learning objectives. a well-chosen combination of media and learning strategies will offer a clear representation of the goals, steps, and learning content.18 appropriate media and learning methods were employed to sustain digital learning during the covid-19 pandemic. additionally, nursing practicum materials can be packaged in the form of modules to enhance the laboratory skills of nursing students. these modules can then be shared via the telegram app. the learning materials in the module should, at the very least, include objectives and learning content presented in the form of text, images, and videos. disseminating learning materials through suitable media can contribute to improving the psychomotor abilities of nursing students.19 learning methods are also pivotal in achieving learning outcomes. one learning approach that can be employed to attain practical learning objectives is peyton’s 4-step approach. peyton’s 4 steps is a learning approach designed to enhance practical skills in health students. learning with the peyton approach comprises demonstration, deconstruction, comprehension, and performance stages. peyton’s 4 steps were subsequently adapted during covid-19 to become remote peyton’s 4 steps, facilitating practical learning online. the modified peyton’s 4-step remote stages encompass demonstration, discussion, comprehension, and consolidation. this adapted peyton 4-step aims to enhance students’ practical skills virtually.20 previous research indicates that learning using the peyton approach is effective in enhancing skill abilities in health professions education. however, there has been no research conducted on learning using the peyton approach via telegram. therefore, the aim of this research was to investigate the influence of laboratory practical learning using peyton’s 4-step approach via telegram. materials and methods research design this research employed a quasi-experimental design with a pre-post approach and a control group design. this type of research was conducted to analyze the impact of laboratory learning with peyton’s 4-step approach using the social media platform telegram on the bathing skills of nursing students. study participants the population in this study comprised nursing students from the health polytechnic of the ministry of health in mataram and maluku. the sample consisted of first-semester students who had not yet acquired bathing skills. the sample size was 60 students, selected randomly from both health polytechnics. they were then divided alphabetically by name into treatment and control groups, with 30 students in each group. variable, instrument, and data collection independent variables included laboratory learning with peyton’s 4-step approach using the social media platform telegram. intervention groups underwent learning with peyton’s 4-step approach using telegram, while control groups solely utilized video instruction. peyton’s 4-step approach aimed to develop bathing skills in nursing students, involving demonstration, discussion, comprehension, and consolidation. on the first day, a video demonstrating bathing skills was presented. on the second day, a discussion about the video occurred among students and lecturers, followed by comprehension where students narrated the bathing skill demonstrated in the video, with assistance from their peers. the last stage involved consolidation, requiring students in both groups to create a video demonstrating bathing skills. all stages were conducted via telegram. the dependent variable was bathing skills in nursing students. the instruments used were questionnaires and observation sheets developed by the researcher based on bathing skill procedures. the questionnaire assessed knowledge regarding the definition, indications, contraindications, and stages of nursing actions for bathing patients. observations were made by assessing nursing actions performed by students through video recordings sent via telegram. students in both groups completed the questionnaire after the consolidation stage, and researchers conducted observations by reviewing the videos submitted via telegram. data analysis the analysis conducted in this research involved the mannwhitney test to identify differences in knowledge. additionally, independent t-tests and multivariate analysis tests were employed, with a significance value set at <0.05, to ascertain differences in patient bathing skills. ethical clearance this research has obtained ethical approval with the number lb.01.03/1.1/2857.1/2021 from the health research ethics committee of mataram health polytechnic, ministry of health, republic of indonesia. results table 1 illustrates the demographic profile of 60 nursing undergraduate students who participated in the study, divided equally into two groups: peyton’s 4-step group and the control group. both groups predominantly consisted of female participants, with peyton’s 4-step group having 63.33% (19 out of 30) and the control group having an even higher proportion at 83.33% (25 out of 30). male participants were comparatively fewer, with peyton’s 4step group having 36.67% (11 out of 30) and the control group having 16.67% (5 out of 30). regarding age distribution, the majority of students in both groups were younger than 18 years old. peyton’s 4-step group contained 66.67% (20 out of 30) in this younger category, while the control group had a slightly higher percentage at 73.33% (22 out of 30). students older than 18 years were fewer in both groups, with 33.33% (10 out of 30) in peyton’s 4-step group and 26.67% (8 out of 30) in the control group. there was no variation between the two groups in educational background. both had an overwhelming majority of students who came from a general high school background, accounting for 90% (27 out of 30) in each group. only a small fraction of students, 10% (3 out of 30), reported having a health vocational school transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 478] [healthcare in low-resource settings 2024;12:12075] background in each of the groups. this consistent pattern in gender, age, and educational background establishes a homogenous study sample across both the experimental and control groups. the mann-whitney test in table 2 indicates a difference in knowledge between the treatment and control groups (p=0.009). practically, differences in knowledge values were also observed in the treatment and control groups, as the median values for both groups exceeded five (70.00-80.86). the findings demonstrate that peyton’s 4-step approach significantly and practically influences the increase in respondents’ knowledge of bathing patients. table 3 shows a difference in the patient’s bathing skills in the treatment and control groups (p=0.02). practically, differences in the patient’s bathing skills were also found in the treatment and control groups because the confidence interval value did not exceed 0 (0.84-9.36). the results from table 3 show that peyton’s 4 steps influence the increase in respondents’ skill in bathing patients (p<0.05). table 4 depicts the influence of respondents’ characteristics on knowledge and skills in bathing patients. the results indicate that all respondents’ characteristics, including gender, age, and school of origin, did not have an impact on respondents’ knowledge and skills in bathing patients (p>0.05). these findings suggest that the increase in knowledge and skills in bathing patients is not influenced by the characteristics of the respondents but by peyton’s 4-step approach through telegram. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of respondents by gender, age and last education. respondent characteristics peyton's 4-step group control group n % n % gender male 11 36.67 5 16.67 female 19 63.33 25 83.33 total 30 100 30 100 age <18 years old 20 66.67 22 73.33 >18 years old 10 33.33 8 26.67 total 30 100 30 100 last education general high school 27 90 27 90 health vocational school 3 10 3 10 total 30 100 30 100 table 2. differences in knowledge of the treatment group (4-step peyton) and control group (video). median (minimum-maximum) p knowledge with peyton's 4-step (n=30) 80,86 (50-100) 0,009 knowledge with video (n=30) 70,00 (50-90) mann-whitney test; treatment rank average (peyton's 4-step), 36,20; control (video), 24,80. table 3. differences in the skills of the treatment group (4-step payton) and the control group (video). mean (sd) ci 95% p skills with 4-step payton (n=30) 43,67 (6,87) 0.84-9.36 0.02 skills with video (n=30) 38,57 (9,39) table 4. multivariate test analysis of respondents' characteristics of knowledge and skills. respondent characteristics p of knowledge and skill odds ratio ci 95% min max gender male 0.876 1.09 0.35 3.44 female 0.721 0.81 0.25 2.58 age <18 years old 0.693 0.80 0.26 2.43 >18 years old 0.908 1.07 0.35 3.31 last education general high school 0.438 0.50 0.08 2.96 health vocational school 0.598 0.64 0.12 3.45 [healthcare in low-resource settings 2024;12:12075] [page 479] discussion data collection revealed a difference in knowledge among groups using the 4-step peyton method, attributed to the discussion stage in the peyton approach. this stage offers opportunities for students, as respondents, to clarify the knowledge acquired through the media. significant differences were also observed in the bathing skills of patients in participants utilizing peyton’s 4step approach compared to those relying solely on video media in this study. the learning method with peyton’s 4-step approach involves demonstration, discussion, comprehension, and consolidation stages. the process begins with a demonstration, where the lecturer provides practical videos shared via the telegram application. this is followed by inviting students to discuss the skills presented in the video, followed by comprehension, which involves the narration of bathing skills by students with assistance from their peers. finally, students are required to demonstrate these skills by recording a video.20 several previous studies have also mentioned that one of the methods used in learning nursing skills is peyton’s 4-step approach. one of them found that peyton’s 4-step method can increase the confidence and satisfaction of nursing students in performing nursing skill procedures.21 our study aligns with previous findings by garg et al. on the evaluation of peyton’s 4-step approach for skill acquisition. it revealed that students who learned through peyton’s 4-step approach demonstrated higher self-confidence, a faster learning process, and greater proficiency in performing blood measurement procedures and handwashing techniques compared to those who learned through the traditional approach.22 one of peyton’s 4-step stages is comprehension, involving the teacher’s demonstration of a skill with instructions and explanations provided by students. this stage has been modified during the covid-19 pandemic to include narration of the skill by students, with assistance from their peers in the learning process. the comprehension stage is considered the most crucial step in peyton’s 4 steps. it allows students to enhance their motor imagery abilities and performance skills. the combination of motor imagery and skills performance inherent in peyton’s step 3 appears to be superior to skills observation alone.23 learning with peyton’s 4-step approach provides textual material and presents images and videos as a form of interactive learning material. the offered learning materials also have an impact on increasing student knowledge. materials in the form of text, images, and videos facilitate students in re-learning the content anywhere and anytime.20,21 video media has become one medium for training and improving one’s skills. video learning media is an educational medium containing audio and visual elements to provide clear information on the conveyed message. the shared content can be factual, informative, educative, or instructional. the advantages of video media also include showing movements and messages using specific effects to enhance the learning process. additionally, the discussion stage in peyton’s 4-step approach allows participants to practice their patient bathing skills again without video assistance.22 while none of the characteristics of the respondents influenced the knowledge and skills of bathing the patient, some factors theoretically impacted, such as gender characteristics. some literature has not yet explained whether men or women have different levels of knowledge or cognition.24 however, the reality is that women are often more diligent and thorough when given a task or doing something. nevertheless, this does not necessarily imply that with such an attitude, women inherently have a better level of knowledge or cognition.25,26 learning media during a pandemic is also considered a learning strategy. most of the online platforms used for pandemic learning are social media. social media refers to a set of internet-based tools that assist users in connecting, collaborating, and communicating with others in real time.14,27,28 furthermore, social media is user-friendly and provides an environment that fosters learning by encouraging students to collaborate, develop skills, articulate knowledge, and manage independent learning.29-31 social media in nursing education can serve as a mechanism to enhance teaching and broaden students’ knowledge about patient privacy, nursing ethics, health policy, professionalism, and nursing communication.28,32,33 social media deserves to be utilized as a learning medium during the covid-19 pandemic, although its effectiveness still depends on the abilities of its users.27,34,35 telegram is a mobile application similar to whatsapp and is considered one of the social media platforms. previous research on the use of telegram in online medical education during the covid-19 crisis stated that telegram is an application with more functionalities and fewer potential drawbacks than alternative applications.36 telegram enables users to create groups and supergroups, allowing members or users to communicate and share large files such as documents, photos, and videos. in recent years, several mobile applications, including telegram, have been developed for health education purposes. educational interventions through the telegram application can attract adolescents, such as nursing students. it has a higher success rate than other teaching methods; thus, implementing the 4-step peyton learning method via telegram makes it easier for nursing students to enhance their nursing skills.37,38 conclusions appropriate media and learning methods are crucial strategies for implementing education during the covid-19 pandemic. learning with the 4-step peyton approach via telegram offers 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learning and the associated factors among nursing students in online palliative class during the covid -19 pandemic. j pak med assoc 2023;73:s50-3. 10. abdul-mumin kh, chung yf, awang-mohamad-zaini zh. navigating the new normal: infection prevention and control strategies post-covid-19. j ners 2023;15:101028. 11. firman f, rahayu s. pembelajaran online di tengah pandemi covid-19. indones j educ sci. 2020;2:81-9. 12. hidayat n, afdholy n, arifani y. the effectiveness and challenges of online teaching of efl teachers in the covid-19 crisis. int j humanit educ 2024;22:95-114. 13. alfian r, athiyah u, nita y. social media health interventions to improve diabetes mellitus patient outcome: a systematic review. j basic clin physiol pharmacol 2021;32:297-304. 14. barrett d. impact of covid-19 on nursing students: what does the evidence tell us? evid based nurs 2022;25:37. 15. reimers f, schleicher a, saavedra j, tuominen s. supporting the continuation of teaching and learning during the covid19 pandemic. 2020. available from: https://globaled.gse.harvard.edu/files/geii/files/supporting-the-continuation-of-teaching-and-learning-during-the-covid-19-pandemic.pdf 16. romadhon ms, rahma a, wirani y. blended learning system using social media for college student: a case of tahsin education. procedia comput sci 2019;161:160-7. 17. soon mks, martinengo l, lu j, et al. the use of telegram in surgical education: exploratory study. jmir med educ 2022;8. 18. pendidikan j, pelajaran m, jasmani p, et al. development of electronic module class xi of jasmani, sports and health education class xi online based edmodo programs. j pendidik teor penelitian, dan pengemb 2017;2:121-9. 19. sari ip, sundari s. the application of learning videos to clinical skills in nursing education. j pendidik keperawatan indones 2019;5:34-41. 20. khan h. an adaptation of peyton’s 4-stage approach to deliver clinical skills teaching remotely. mededpublish 2020;9:73. 21. ahmed fr, morsi sr, mostafa hm. effect of peyton’ s four step approach on skill acquisition, self-confidence and self-satisfaction among critical care nursing. j nurs heal sci 2018;7:38-47. 22. giacomino k, caliesch r, sattelmayer km. the effectiveness of the peyton’s 4-step teaching approach on skill acquisition of procedures in health professions education: a systematic review and meta-analysis with integrated meta-regression. peerj 2020;8. 23. krautter m, dittrich r, safi a, et al. peyton’s four-step approach: differential effects of single instructional steps on procedural and memory performance a clarification study. adv med educ pract 2015;6:399-406. 24. qowi nh, suratmi s, faridah vn, et al. the effect of online learning on student satisfaction in nursing education during the covid-19 pandemic. j ners 2022;17:115-20. 25. tuominen r, stolt m, salminen l. social media in nursing education: the view of the students. educ res int 2014;2014:16. 26. agina widyaswara suwaryo p, yuwono p, studi keperawatan p, et al. factors that affect the level of community knowledge in mitigating landslide natural disasters. urecol 2017;30514. 27. lopez v, cleary m. using social media in nursing education: an emerging teaching tool. issues ment health nurs 2018;39:616-9. 28. myers jg, myers sm. the current use of social media in undergraduate nursing education: a review of the literature. comput inform nurs 2017;35:338-44. 29. alzain z, alfayez a, alsalman d, et al. the role of social media in the training and continuing education of healthcare professionals in eastern saudi arabia. informatics med unlocked 2021;24:100587. 30. lahti m, haapaniemi-kahala h, salminen l. use of social media by nurse educator students: an exploratory survey. open nurs j 2017;11:26. 31. duke vja, anstey a, carter s, et al. social media in nurse education: utilization and e-professionalism. nurse educ today 2017;57:8-13. 32. wahila r, mwape l, lyambai k, et al. use of social media to support nursing students’ learning in zambia. creat educ 2018;9:1237-51. 33. isik b, jallad st. the potential of social media and nursing education: e-professionalism, nurse educator-learner role, benefits and risks. new trends issues proc adv pure appl sci 2019;11:30-8. 34. babajani-vafsi s, nouri jm, ebadi a, zolfaghari m. factors influencing the participation of nurses in knowledge-sharing within mobile instant messaging based virtual communities of practice: a qualitative content analysis. adv med educ pract 2019;10:897-905. 35. schmitt tl, sims-giddens ss, booth rg. social media use in nursing education. online j issues nurs 2012;17. 36. iqbal mz, alradhi hi, alhumaidi asa, et al. telegram as a tool to supplement online medical education during covid19 crisis. acta inform med 2020;28:94-7. 37. prokopyev ms, kostikova na, kuzin zs, et al. the technology of using telegram messenger as an e-learning tool. laplage em rev 2021;7:229-38. 38. ghaffari m, rakhshanderou s, mehrabi y, tizvir a. using social network of telegram for education on continued breastfeeding and complementary feeding of children among mothers: a successful experience from iran. int j pediatr transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:12075] [page 481] hrev_master healthcare in low-resource settings 2024; volume 12:11988 anti-biofilm properties of clover honey against candida albicans masfufatun masfufatun,1 budhi setiawan,2 rini purbowati,3 lusiani tjandra,2 noer kumala indahsari,1 diana tri ratnasari,4 harya narottama,5 muzaijadah retno arimbi6 1department of biochemistry, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 2department of pharmacology, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 3department of biomolecular, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 4department of dermatology, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 5department of obstetrics and gynecology, faculty of medicine, universitas wijaya kusuma surabaya, surabaya; 6department of internal medicine, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia abstract candida albicans grows rapidly when the microflora becomes imbalanced due to a variety of factors. its ability to infect a host is aided by its virulence factors, such as biofilm. this study aimed to evaluate the activity of clover honey in inhibiting and degrading the biofilm formation of c. albicans in vitro. this study used a true experimental design with an in vitro post-test-only control group design approach. the microtiter plate assay was used to grow planktonic cells and biofilm. this method was carried out to obtain the optical density (od) value for each test, measured by a microplate reader. cell viability was measured using the mts assay kit, the biofilm matrix was measured using the crystal violet assay, and the morphology of c. albicans biofilms was observed by scanning electron microscopy (sem). probit and one-way anova tests were applied to determine the mic50 of both planktonic and biofilm, as well as statistical analysis. the results showed that clover honey exerted inhibitory activity against c. albicans planktonic cells at a mic50 value of 31.60% w/v. at the highest concentration, clover honey exhibited antibiofilm activity by lowering the extracellular matrix and viability of c. albicans cells by 64.59% and 72.09%, respectively. based on sem observation, clover honey changed the cell morphology of c. albicans and reduced the thickness of the biofilm. overall, our findings concluded that clover honey exhibited antifungal properties against c. albicans by inhibiting biofilm formation and degrading mature biofilm. introduction candida albicans is a normal microbiome composition in a healthy human body with a well-functioning immune system.1 however, a balance disorder caused by a variety of factors allows this fungus to multiply rapidly and lead to infection.2,3 there are several factors that may contribute to c. albicans infection.4 for instance, c. albicans’ resistance to the immune and antifungal systems is known to be due to virulence factors, specifically its activity in biofilm formation.5 a biofilm is a community of microbial cells attached to a surface (or found at the air-liquid interface) that has different properties than other planktonic microbial cells.6,7 c. albicans’ biofilm is highly structured, consisting of several types of cells (e.g., round budding yeast-shaped cells, oval pseudohyphal cells, and elongated hyphal cells) enveloped in an extracellular matrix.3,8 biofilm formation by c. albicans has significant clinical implications and contributes to higher mortality.9,10 the major consequences of biofilm formation include the ability of cells in the biofilm to develop resistance to antifungal therapy and the biofilm’s protection against the body’s defenses, affecting the management of patients with candida infection.7 additionally, the formation of c. albicans biofilms leads to an increase in acetaldehyde (ach) levels (a highly toxic, mutagenic, and carcinogenic product of alcoholic fermentation and microbial metabolism), correspondence: budhi setiawan, department of pharmacology, faculty of medicine, universitas wijaya kusuma surabaya, indonesia. e-mail: budhisetiawan@uwks.ac.id key word: antibiofilm; antifungal; candida albicans; candidiasis; clover honey. contributions: mm, conceptualization, supervision, validation, visualization, writing – original draft, review and editing; bs conceptualization, formal analysis, writing – original draft, review and editing; rp, methodology, validation, and writing – original draft; lt, methodology, visualization, writing – review and editing; nk, investigation, and writing – review and editing; dt, formal analysis, validation, review and editing; hn, supervision, and writing – review and editing; ma, writing –review and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approvals from the health research ethics commission universitas wijaya kusuma (no.81/sle/fk/uwks/2022). funding: the authors would like to thank the institute for research and community service (lppm) at universitas wijaya kusuma surabaya in surabaya, indonesia (no. 103/lppm/uwks/iv/2023). availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgment: we would like to be thankful to the medical faculty universitas wijaya kusuma surabaya and central laboratory of biological sciences, brawijaya university malang for their support and contributions to this study. received: 15 october 2023. accepted: 21 december 2023. early access: 16 february 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11988 doi:10.4081/hls.2024.11988 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11988] [page 243] non -co mmerc ial us e o nly exerting a hazardous impact on organs.11 fungal infections could become more challenging to treat as antifungal drug resistance increases.12 consequently, alternative treatments based on natural substances with antifungal and antibiofilm properties are required.13 honey is one such natural product that is commonly used in everyday life and consumed daily.14 while honey consumption may not significantly alter the metabolic profiles of healthy individuals, it can impact glucose levels and other metabolic parameters in individuals with type 2 diabetes if consumed in large quantities.15 honey, a thick liquid produced by honeybees from flower nectar, is believed to be effective in treating various types of diseases, including upper respiratory tract infections,16 eye disorders,17 and diabetes mellitus.18 additionally, honey promotes the growth of probiotic microbes.19 honey contains high sugar content, hydrogen peroxide (h2o2), high acidity, and organic compounds (polyphenols, flavonoids, and glycosides), contributing to its antifungal properties.20 the enzymatically produced hydrogen peroxide (h2o2) compounds in honey create a highly acidic ph, which helps eliminate pathogenic microbes.21 the effectiveness of honey as an antimicrobial agent has been widely characterized.22–25 for instance, clover and manuka honey exhibited favorable activity against planktonic cells and biofilms of staphylococcus aureus, pseudomonas aeruginosa, klebsiella spp., and proteus mirabilis. all the tested bacterial strains were sensitive to clover honey.26 despite numerous studies on honey antibiofilm effects, the impact of honey on c. albicans biofilms has not been extensively studied.27–31 this knowledge gap may result in increased morbidity, limited treatment options, recurrent infections, and therapeutic failures. therefore, this study aimed to investigate the inhibitory activity of clover honey on the biofilm formation and degradation of c. albicans isolated from candidiasis vulvovaginitis (cvv) patients. materials and methods research design this study employed an experimental research approach, specifically a true experimental design, utilizing an in vitro posttest-only control group design. the methods involved microdilution broth to determine the minimum inhibition concentration (mic) and a microtiter plate biofilm assay to test the anti-biofilm activity of clover honey. this procedure aimed to obtain the optical density (od) value for each test, measured through a microplate reader. the study comprised 6 treatment groups and 1 control group. honey the clover honey was purchased from the distributor of hdi group of companies, pt. harmoni dinamik indonesia. this honey was harvested from cold, dry, and fertile areas in the arizona desert mountains, united states. isolation of c. albicans and its culture conditions. to grow the c. albicans culture, a single colony of c. albicans was transferred into sabouraud dextrose broth (sdb) liquid medium. then, the culture was shaken for 18-24 h with a rotary shaker at 150-160 rpm. after 24 h of incubation, the cell cultures were centrifuged for 15 min at 10,000 rpm, 4°c. the collected cells were washed twice with 0.1 m sterile phosphate-buffered saline (pbs) to remove the remaining media. the precipitate of c. albicans was suspended in pbs until it reached a turbidity of 0.5 (od ~0.5) at λ 600 nm uv-vis spectrophotometer. this suspension is defined for biofilm formation.32 minimum inhibitory concentration (mic) the mic of clover honey on the growth of planktonic c. albicans was determined using the macro broth dilution test using 96 wells of a polystyrene microtiter plate. briefly, clover honey was serially diluted (50-1.56% w/v) in sabaroud dextrose broth (sdb) medium. 190 μl of different concentrations of the honey were put into 96 well microplates and then added 10 μl of c. albicans inoculum on each of the samples. plates were incubated for 24 h at 35°c on a rotary shaker at 120 rpm. after incubation, the growth of planktonic c. albicans was analyzed using an mts (3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2h-tetrazolium) assay. mic was defined as the lowest concentration of honey (w/v) that causes inhibition of c. albicans growth. biofilm growth and development inhibition essay the test was carried out using a 96-well polystyrene microtiter plate. a volume of 100 µl of c. albicans culture containing 5x108 cfu/ml was added to each well and incubated for 1.5 hours at 37°c. after incubation, non-adherent cells were removed by gently washing with sterilized saline phosphate buffer (pbs; ph 7.4) twice without disturbing the attached cells. briefly, 100 ml of clover honey samples in rpmi 1640 medium (100-3.125%) was added to each well, and then the plates were incubated for another 48 hours. cell viability was analyzed using the mts assay, while biofilm biomass was determined using the crystal violet assay. this method was modified from ansari et al.’s study in 2013.33 biofilm degradation essay of c. albicans c. albicans biofilm was cultivated on a 0.2 µm cellulose nitrate filter membrane. in brief, the cellulose nitrate filter membrane was sterilized by uv radiation for 15 minutes on both sides, serving as an in vitro model of the semipermeable biological membrane. subsequently, the sterilized cellulose nitrate filter membrane was positioned on top of the spider medium, a nutrient-limited medium, using sterile tweezers. next, 10 µl of c. albicans suspension (turbidity 0.5 at λ 600 nm) was applied to the surface of the cellulose nitrate filter membrane and incubated for 1 hour at 37°c. the petri dish was then inverted and further incubated for another 24 hours. after incubation, the membrane containing the biofilm was transferred to a new spider medium using sterile tweezers and incubated for an additional 24 hours. after 48 hours of incubation, the c. albicans biofilm was exposed to a 20 µl honey solution. conversely, in the control group, sterile distilled water was applied. following this, the c. albicans biofilm was incubated for 24 hours at 37°c. the cell morphology of the c. albicans biofilm, subsequent to degradation with clover honey, was analyzed using a scanning electron microscope (sem).32 cell viability analysis mts reduction analysis was employed to assess cell viability by measuring metabolic activity. prior to analysis, the celltiter 96® aqueous one solution reagent (promega) was prepared. this procedure took approximately 90 minutes at room temperature or 10 minutes in a water bath at 37°c. while awaiting the liquid reagent, the microplate containing the c. albicans biofilm was initially washed with distilled water three times. subsequently, 20 µl of celltiter 96® aqueous one solution reagent was dispensed into each well of the washed 96-well assay plate. the plates were then incubated for 1-4 hours at 37°c. a microplate reader elisa was utilized to measure absorbance at λ 490 nm. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 244] [healthcare in low-resource settings 2024;12:11988] non -co mmerc ial us e o nly biomass analysis of c. albicans biofilms after treatment and incubation, the microplates were washed with running water three times. subsequently, 200 µl of 0.01% crystal violet solution was added to each well and incubated at room temperature for 15 minutes. the microplate was then rewashed in the same manner with running water three times. two hundred µl of ethanol (96%) solution was added to each well and re-incubated for 15 minutes at room temperature. optical density (od) was recorded using an imark bio-rad microplate reader at λ 595 nm. sem analysis the biofilms were dried at 37°c overnight and dehydrated with a gradient of ethanol (50% for 10 min, 70% for 10 min, 96% for 20 min). the dried biofilm was then coated with palladium and imaged using sem.32 data analysis one-way anova and lsd post hoc tests were employed to analyze the mean comparison of optical density results at various concentrations of clover honey in both planktonic cells and biofilm. the kolmogorov-smirnov and levene tests were utilized to assess normality and homogeneity of the data, respectively. a significance threshold of p<0.05 was applied to determine the significant difference between the various samples. probit analysis was conducted to determine the mic50 of planktonic cells and biofilm of c. albicans. all statistical analyses were performed using the spss software program.34 results minimum inhibitory concentration (mic50) of clover honey it was found that clover honey, at varied doses, prevented the formation of c. albicans planktonic cells. according to probit analysis, the clover honey mic50 for c. albicans planktonic cells was 31.60% (w/v). the inhibitory effect of higher concentrations of clover honey increased, preventing c. albicans planktonic cells from growing by 74.88% at a concentration of 50% (figure 1). extracellular matrix of c. albicans biofilm the determination of the effect of clover honey on c. albicans biofilm, especially its impact on the extracellular matrix, was performed using a crystal violet solution. the procedure was intended to measure the biofilm mass, and the solution colors the microbial cells as well as the extracellular matrix.35 as a result, the measured absorbance value was proportional to the number of cells and extracellular matrix in the c. albicans biofilm. figure 2 displays that 100% clover honey was able to inhibit the growth of c. albicans biofilm by reducing its extracellular matrix by 64.59%. in addition to that, probit analysis revealed that the mic50 of clover honey for c. albicans biofilm was 58.25%. cell viability of c. albicans biofilm the tetrazolium salt (mts) was used to determine the effect of clover honey treatment on the viability of c. albicans biofilm cells. this test is often used as a method to estimate cell viability in biofilms and to determine the impact of biofilm treatment. this method was used to estimate the number of surviving microbes in biofilms through their metabolic activities. mts works by reducing mts into an orange formazan compound with mitochondrial dehydrogenase enzyme activity. the measured absorbance value corresponds to the number of living cells in the polymicrobial biofilm. the mitochondrial dehydrogenase enzyme is an indicator of living cells because it is not present at the time of cell death. figure 3 depicts that clover honey can reduce the growth of c. albicans biofilm cell viability by 72% at the highest concentration of 100%. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. the viability of c. albicans planktonic cells by clover honey at various concentrations. note: letters a-e indicate statically significant different (p<0.05). figure 2. absorbance values of bio-film growth of c. albicans biofilm. note: letters a-f indicate statically significant different (p<0.05). figure 3. the absorbance value of viability cell on the growth of c. albicans biofilm. note: letters a-f indicate statically significant different (p<0.05). [healthcare in low-resource settings 2024;12:11988] [page 245] non -co mmerc ial us e o nly biofilm degradation test of c. albicans the effect of clover honey on c. albicans biofilm morphology was determined using sem. the overall representation of the biofilm-treated control of c. albicans and the biofilm-treated with 80% w/v clover honey is shown in figure 4. compared to the biofilm-treated control that had an intact membrane morphology with a smooth and regular surface covered by exopolysaccharide material, showing a dense network of cells and hyphae (figure 4a), the biofilm of c. albicans treated with clover honey exhibited noticeable shrinkage, or obvious indentations and breakage on their cell membrane due to the osmotic effect of honey. this result reveals that clover honey disrupts the cell membrane integrity of c. albicans, leading to the death of the cells. exopolysaccharide material was not visible, but small pores were formed on the cell walls, and rough cell walls (figure 4b). the sem analysis revealed the absence of exopolysaccharide material as well as plasmolysis-induced cell membrane shrinkage. cell lysis was indicated by the shrinkage of the cell membrane. discussion many studies have shown that the ability of microbes to form biofilms has implications for microbial resistance to antimicrobial agents. to enhance the permeability of antibiotic agents for killing microbes, a treatment technology is needed by utilizing natural substances that have the potential to inhibit or degrade the formation of biofilms. clover honey is one of the natural ingredients that can currently be used to damage or inhibit the formation of biofilms. clover honey inhibited the growth of c. albicans planktonic cells at different concentrations. the greater the concentration of clover honey, the greater the inhibitory activity. the mic50 value of clover honey in inhibiting the growth of c. albicans planktonic cells was 31.60%, which is lower than the mic of clover honey against proteus mirabilis (40%) from a previous study.36 the inhibition activity can be attributed to its phenol and flavonoid content. ciappin study (2014), reported phenol and flavonoid levels of 100.4 mg gae/100 g and levels of 3.9 mg transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 4. scanning electron microscope profile of c. albicans biofilm on nitrocellulose membrane. (a) biofilm formed in the absence of honey. (b) biofilm was treated with 100% w/v clover honey. [page 246] [healthcare in low-resource settings 2024;12:11988] non -co mmerc ial us e o nly qe/100 g in clover honey. flavonoid compounds exhibit antifungal effects by degrading cell structures during the replication process, resulting in a lower rate of proliferation.37 flavonoid compounds can inhibit the activity of the efflux pump, causing the accumulation of compounds that function as therapy.38 meanwhile, the presence of phenol, which is also observable in clover honey, can inhibit the activity of the matrix metalloproteinase (mmp) enzyme, facilitating the attachment of the fungus’s hyphae to the surface of its host. phenolic compounds cause the formation of reactive oxygen species (ros) in fungal cells, resulting in the fragmentation of fungal genetic material. this mechanism is also capable of overcoming multiple drug resistance (mdr) in c. albicans.39,40 instead of exerting antifungal activity, phenol can inhibit the enzymes related to fungal metabolic functions, isocitrate lyase, and hyphae formation via the dpp3 (dipeptidyl peptidase 3) gene and prevent fungal dimorphism, or changes in the structural shape of fungi that have the potential to reduce the effectiveness of therapy.41 furthermore, in this study, clover honey also inhibited the growth of c. albicans biofilm. the mic50 value of clover honey in inhibiting the formation of a 50% biofilm matrix was 58.25%. this value was higher compared to inhibiting the biofilm matrix of pseudomonas aeruginosa.42 this activity can be observed in a decrease in the extracellular matrix analysis and cell viability analysis of c. albicans biofilm. the potential ability to degrade c. albicans biofilm was consistent with morphological sem analysis results. the antibiofilm activity of clover honey could be attributed to the content of methylglyoxal, dihydroxyacetone, and h2o2. studies have shown that the presence of these compounds exhibited inhibitory activity of clover honey against p. aeruginosa biofilms.42 according to cell morphology analysis using sem, clover honey also demonstrated degradation activity against c. albicans biofilm. the honey degraded the biofilm by destroying the cell wall structure and its constituent exopolysaccharides, increasing the permeability of the cell wall surface of c. albicans (figure 4). this resulted in the loss of the structure of the exopolysaccharide layer that covers the c. albicans biofilm. this layer is accountable for maintaining the biofilm’s surface smooth and flat, preventing the penetration of antifungal drugs into the biofilm. the result of the morphology of c. albicans biofilm structure was comparable to that reported by ansari (2013) using jujube honey.33 the in vitro method has been chosen due to its ability to control various conditions and focus on specific factors influencing biofilm formation, as well as being more cost-effective. more indepth studies are needed to determine the efficacy of clover honey as an antifungal agent in humans, as the findings might not be directly applicable to the human body as a whole. without baseline data, it might have been more difficult to compare the before-andafter treatment in this study, and it could have been more challenging to ascertain if the observed changes were the result of the treatment or other factors. conclusions clover honey exhibits remarkable properties as it not only inhibits the formation of c. albicans biofilms but also effectively disrupts pre-existing biofilms. the notable antifungal activity observed in clover honey underscores its potential as a promising alternative source of compounds for combating infections associated with candida biofilms. this finding opens avenues for exploring clover honey as a potential component in the formulation of medical-grade honey aimed at addressing fungal infections. however, to solidify these findings and explore the full extent of clover honey’s efficacy, further research and clinical studies are warranted. this ongoing 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antistaphylococcal potential of honeys produced in northern poland. molecules 2018;23:260. 27. al-waili ns, al-waili fs, akmal m, et al. effects of natural honey on polymicrobial culture of various human pathogens. arch med sci 2014;10:246–50. 28. lu j, turnbull l, burke cm, et al. manuka-type honeys can eradicate biofilms produced by staphylococcus aureus strains with different biofilm-forming abilities. peer j 2014;2014:1– 25. 29. aissat s, ahmed m, djebli n. propolis-sahara honeys preparation exhibits antibacterial and anti-biofilm activity against bacterial biofilms formed on urinary catheters. asian pac j trop dis 2016;6:873–7. 30. yupanqui mieles j, vyas c, aslan e, et al. honey: an advanced antimicrobial and wound healing biomaterial for tissue engineering applications. pharmaceutics 2022; 14:1663. 31. canonico b, candiracci m, citterio b, et al. honey flavonoids inhibit candida albicans morphogenesis by affecting dna behavior and mitochondrial function. future microbiol 2014;9:445–56. 32. baktir a, suwito h, safinah m, kunsah b. novel materials for eradication of biofilm extracell matrix of pathogenic candida. j mat sci engineering b 2012;2:650. 33. ansari mj, al-ghamdi a, usmani s, et al. effect of jujube honey on candida albicans growth and biofilm formation. arch med res 2013;44:352–60. 34. ibm corp. ibm spss statistics for windows version 22.0. vol. 2, armonk, new york, usa: ibm spss. 2013. p. 119. 35. gonzález�rivas f, ripolles�avila c, fontecha�umaña f, et al. biofilms in the spotlight: detection, quantification, and removal methods. compr rev food sci food saf 2018;17:1261–76. 36. abbas ha. antibacterial, anti-swarming and antibiofilm activities of local egyptian clover honey against proteus mirabilis isolated from diabetic foot infection. asian j pharmaceut res 2013;3:114–7. 37. ciappini mc, stoppani fs. determination of antioxidant capacity, flavonoids, and total phenolic content in eucalyptus and clover honeys. j apic sci 2014;58:103–11. 38. aboody ms al, mickymaray s. anti-fungal efficacy and mechanisms of flavonoids. antibiotics 2020;9(2). 39. tsui c, kong ef, jabra-rizk ma. pathogenesis of candida albicans biofilm. pathog dis 2016;74:ftw018. 40. jabra-rizk ma, kong ef, tsui c, et al. candida albicans pathogenesis: fitting within the host-microbe damage response framework. infect immun 2016;84:2724. 41. teodoro gr, ellepola k, seneviratne cj, koga-ito cy. potential use of phenolic acids as anti-candida agents: a review. front microbiol 2015;6. 42. lu j, cokcetin nn, burke cm, et al. honey can inhibit and eliminate biofilms produced by pseudomonas aeruginosa. sci rep 2019;9(1). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 248] [healthcare in low-resource settings 2024;12:11988] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:11965 buerger-allen exercises' effectiveness for improving lower limb circulation hesti prawita widiastuti,1 rahmawati paonganan,1 diah setiani,1 arsyawina arsyawina,1 joko sapto pramono,2 hilda hilda1 1department of nursing, poltekkes kemenkes kalimantan timur, samarinda; 2department of health promotion, poltekkes kemenkes kalimantan timur, samarinda, indonesia abstract impaired peripheral perfusion in the legs is the most common complaint experienced by patients with type 2 diabetes mellitus (dm). one nursing intervention in the form of physical exercise that can be administered to dm patients to prevent peripheral perfusion disorders and increase vascularization of the lower extremities is the buerger-allen exercise (bae). the goal of this study was to analyze the effectiveness of bae in improving lower extremity circulation. the population consisted of patients with type 2 dm. the research design employed a quasi-experiment with pre-test and post-test, including a control group. a sample of 24 respondents was divided into an intervention group and a control group. the sampling technique used was purposive sampling. data were obtained through direct ankle-brachial index (abi) measurement using a doppler ultrasound and an aneroid sphygmomanometer, temporary blood sugar level measurements using a glucometer, and leg sensitivity measurements using a monofilament tool. paired t-tests and independent t-tests were used as statistical tests. the results of the paired t-test for lower limb circulation in the intervention group yielded a p-value of 0.000, indicating a significant difference in the circulation of the lower extremities before and after the intervention. the results of the independent t-test also showed a p-value of 0.000, indicating significance. thus, bae can improve lower limb circulation in patients with type 2 dm. introduction diabetes prevalence has been growing globally in recent years.1 diabetes mellitus (dm) has become a major health concern worldwide, particularly in developing countries, due to the high number of complications it causes.2 dm is infamous as the ‘silent killer’ because of its slow-paced symptoms; therefore, most patients remain unaware until complications have severely formed.3 diabetes is characterized by elevated blood glucose concentrations related to the effects of abnormal β-cell biology on insulin action.4 the complications of dm, particularly on blood vessels for both microvascular and macrovascular, as well as neuro systems, have a significant impact on higher therapy costs and lower patient productivity.5 impaired peripheral perfusion in the legs is one of the most common complications in dm patients. the right treatment is necessary to minimize this complication. physical exercise is considered the primary treatment to prevent its occurrence in patients.6,7 as one of the most rapidly developing countries in southeast asia, indonesia currently ranks fifth in the number of people with type 2 dm.8 the international diabetes federation (idf) (2019) stated that 429 million people out of the world’s total population have dm. on the other hand, the prevalence of dm in indonesia has increased from 6.9% in 2013 to 8.5% in 2018, equivalent to 20.4 million people suffering from dm. according to the indonesia health ministry data in 2018, the highest prevalence of dm was in the special capital region of jakarta (3.4%), special region of yogyakarta (3.1%), east kalimantan (3.1%), south sulawesi (3.0%), and east java (2.6%). in indonesia, as per the 2018 national health survey report, the prevalence of dm in the population aged ≥15 years was 2.0%.9 dm affects 10,276,100 of indonesia’s 166,531,000 adults (aged 20-79 years), with a prevalence of 6.2%.10 the latest estimation from the samarinda public health office in 2020 recorded a total of 546 type 2 dm cases. particularly in the public health center of bengkuring samarinda, correspondence: hesti prawita widiastuti, department of nursing, poltekkes kemenkes kalimantan timur, samarinda, indonesia. e-mail: hestiprawita.poltekkeskaltim@gmail.com key words: buerger allen exercise, type 2 dm, lower limb circulation. contributions: hpw carried out the conception, design, and statistical analysis of this article, and rp and jsp conducted the analysis and interpretation of the data. ds and hd completed data collection and assembly. hpw and rp drafted the article. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: this research has received ethical approval from the health research ethics commission of poltekkes kemenkes kalimantan timur, based on ethical certificate number lb.01.01/7.3/002339/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank the director of poltekkes kemenkes kalimantan timur and the head of bengkuring public health center who had given access and data clarification on diabetes mellitus patient prevalency in bengkurian, samarinda. received: 13 october 2023. accepted: 18 march 2024. early access: 12 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11965 doi:10.4081/hls.2024.11965 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 458] [healthcare in low-resource settings 2024;12:11965] non -co mmerc ial us e o nly a total of type 2 dm visits from april until june 2020 were 176 patients. data shows that globally, there are 425 million people, or 8.8% of the world’s population, estimated to suffer from dm. this situation is projected to increase to 629 million people in 2045.11 the complications that may occur in people with dm are classified into two parts: acute complications and chronic complications. chronic complications consist of microvascular and macrovascular complications, with macrovascular complications including coronary artery disease, stroke, and peripheral artery disease.12 however, the lack of knowledge or understanding of dm is an obstacle in the healing process.13 impaired peripheral vascularization in dm patients needs to be detected early. one examination to detect impaired peripheral vascularization is the implementation of the ankle-brachial index (abi) test.14 abi is a non-invasive vascular test and a simple method that functions to identify vascularization within the leg by measuring the systolic blood pressure ratio (ankle) and limb systolic blood pressure (brachial). an abi score >1.0 is considered normal, and a score >0.9 is considered at risk of impaired peripheral circulation. moreover, early proper treatment for dm patients can be obtained through abi measurement.15 one nursing intervention in the form of physical exercise that may be given to dm patients to prevent impaired peripheral vascularization and enhance vascularization towards the lower extremities is the buerger-allen exercise (bae). bae was suggested by leo buerger in 1924 and was later modified by arthur w. allen in 1931. it is an exercise system for arterial insufficiency of the lower ankle that applies gravitational position changes and muscle pumps by implementing ankle movements to drive blood vessel smooth muscle. gravitation gradually helps empty and fill the blood column, eventually enhancing blood transportation through the blood vessels.16 research by hassan and mehani stated that bae has a positive effect on improving peripheral blood circulation into extremities, thus improving the oxygen and nutrition required by metabolism up to the body cells. furthermore, the research by john and rathiga (2015) shows that practicing bae for 10-17 minutes twice a day for five consecutive days can improve circulation. a post-test was conducted on the fifth day using an abi measuring instrument.17 previous arguments and an earlier study by the researcher about type 2 dm patients inspired the researcher to conduct a study on the effectiveness of bae towards lower extremities circulation changes in type 2 dm patients. materials and methods the quasi-experimental design with pre and post-tests and a control group plan are employed in this research. a total of 24 samples are divided between the intervention group (buerger-allen intervention) and the control group (given education), chosen using the purposive sampling technique with inclusion criteria. the characteristic criteria for the intervention and control groups include individuals with type 2 dm, lower extremity muscle strength scores of 4-5, blood sugar levels higher than 6.7 mmol/l, absence of ulcers, and taking oral diabetic medicine. exclusion criteria involve individuals with type 2 dm who have hypoglycemia and complications such as diabetic foot ulcers, joint problems, arterial calcification, or an abi score greater than 1.3. the number of samples in this study was determined using the roscoe formula, resulting in several respondents greater than or equal to 10. to anticipate potential dropouts, an additional 10% was added, making the number of subjects per group 12. the independent variable in this study was bae, while the dependent variable was lower limb circulation (abi, temporary blood sugar level, and leg sensitivity). data were obtained through direct abi measurements using a doppler ultrasound and an aneroid sphygmomanometer, temporary blood sugar level measurements using a glucometer, and leg sensitivity measurements using a monofilament tool. paired t-test and independent t-test were used as statistical tests. the responses were initially evaluated/pre-tested by the researchers using a vascular doppler ultrasonography probe and an aneroid sphygmomanometer for abi measurement, a glucometer for temporary blood sugar level measurement, and a monofilament for leg sensitivity measurement for both the intervention group (bae) and the control group (given education). after six visits over six days, the researcher administered the bae intervention to the intervention group. this intervention took place for about 21 minutes per session per day. using a vascular doppler ultrasonography probe, an aneroid sphygmomanometer, glucometer, and monofilament, the researcher performed a final assessment/post-test on the responders in the intervention group and the control group after 6 days. results table 1 displays the characteristics of respondents in the intervention and control groups. it can be observed that the most dominant gender in the intervention group is female, comprising 9 respondents (75%). the control group is evenly distributed between 6 female and 6 male respondents. furthermore, regarding age characteristics in the intervention group, ages 40-48 (33.3%) and ages 49-57 (33.3%) are equally dominant, each consisting of 8 respondents. in contrast, the control group is predominantly in the age range of 49-57 (66.7%), with 6 respondents. examining respondents’ latest education, the intervention group is half-dominated by senior high school graduates, comprising 5 respondents (41.7%), while the control group is also evenly split, with 6 respondents (50%) having completed senior high school. in terms of occupation, the intervention group is mostly dominated by transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. frequency distribution based on respondents’ characteristics. characteristic intervention group control group n % n % gender female 3 25.0 6 50.0 male 9 75.0 6 50.0 age (years) 31-39 0 0 1 8.3 40-48 4 33.3 0 0 49-57 4 33.3 6 66.7 58-66 3 25.0 2 16.7 67-75 1 8.3 1 8.3 latest education elementary school 3 25.0 1 8.3 junior high school 3 25.0 3 25.0 senior high school 5 41.7 6 50.0 university 1 8.3 2 16.7 occupation self-employed 1 8.3 2 16.7 farmer 2 16.7 3 25.0 civil servant 1 8.3 2 16.7 housewife 8 66.7 4 33.3 others 0 0 1 8.3 total 12 100 12 100 [healthcare in low-resource settings 2024;12:11965] [page 459] non -co mmerc ial us e o nly housewives, accounting for 66.7%, while the control group is similarly divided, with 33.3% being housewives. table 2 shows that the abi values increased by 0.25, blood glucose decreased by 55.17 dl/g, and right leg sensitivity increased by 2.08 in the control group, while the abi value decreased by 0.01 in the control group. the paired t-test results in table 3 indicate that the p-value for the intervention group is 0.000, which is less than 0.05. based on this value, it can be concluded that bae has a significant impact on the change in lower extremities circulation in the intervention group. furthermore, the control group results in a p-value of 0.241, which is greater than 0.05. the conclusion is that education has no significant impact on the change in lower extremities circulation in the control group. table 4 displays a significant change in values regarding lower extremities circulation in both the intervention and control groups, with a p-value of 0.000, which is less than 0.005. this value indicates a significant difference in circulation change in the lower extremities between the intervention group and the control group. discussion ankle-brachial index (abi) circulation value variations in the extremity bottom before buergerallen’s intervention exercise according to the study’s findings, the abi resulted in a mean of 0.82 before the bae. disorders of arterial and venous ulcers numerous factors, including the age profiles of responders (66.6%) and as many as 8 individuals in the early elderly (40-57 years), affect the veins in respondents. disorders of arterial and venous ulcers are influenced by numerous factors, including the age profiles of responders (66.6%), with as many as 8 individuals in the early elderly age group (40-57 years) affecting the veins in the respondents. thiruvoipati, kielhorn, and armstrong (2015) claim that individuals older than 50 are at a higher risk of developing high-risk peripheral vascular diseases.18 according to dick et al. (2009), a person’s risk of developing arteriosclerosis and endothelial blood vessel diseases increases with age.19 this is consistent with a study in indonesia’s assertion that the condition of diabetic foot is a result of various factors, including neuropathy and a lack of sensitivity.20 sensitive feet in dm patients are the first sign of excessive blood sugar levels that interfere with metabolism. increasing physical activity, especially in the legs, can help address this issue. based on sex, the majority of respondents are male (75%). according to arnetz, ekber, and alvarsso (2014), testosterone levels in males can lead to abdominal fat and insulin resistance, increasing the risk of type 2 dm.21 meanwhile, according to mcintosh and karen (2008), distal occlusion in geriatrics with diabetes and atherosclerosis variables are the main causes of lower limb arterial circulation insufficiency in men.22 ankle-brachial index (abi) circulation value variations in the extremity bottom after buerger allen’s intervention exercise according to the study’s findings, the abi resulted in a mean value of 1.07, with the abi value increasing by 0.25 following the bae. according to rosales-velderrain et al. (2013), continuous and repetitive exercise is necessary to improve the blood flow of muscle microvascular flow.23 this is related to artery dilation (vasodilation), resulting in an increase in capillary permeability and enabling muscle cells to absorb glucose.24 the results obtained from this research, using the paired t-test, show that there is a significant difference before and after the bae intervention, with a p-value of 0.000, which is less than 0.005. this means that bae can improve lower extremities circulation in type 2 dm patients. impaired peripheral blood vessels in type 2 dm patients may result in diabetic foot ulcers caused by static flow in veins, resulting from blood vessel physiology function being agitated by the stream from the lower extremities to the heart. effective contraction of extremities muscles is required by performing routine 90° dorsiflexion movements on the ankle. bae, in improving peripheral circulation, utilizes the muscle pump principle on the ankle, consisting of two movements. the first movement is dorsiflexion and plantarflexion, which are expected to set contraction and lower extremities muscle relaxation to improve peripheral blood circulation.25 additionally, the bae’s gravitational principle affects body fluid distribution by helping each blood vessel to empty and fill the blood column, eventually aiding in improving blood transportation through blood vessels.26 impaired neuropathy and vascular issues are among the main factors contributing to the formation of wounds in type 2 dm patients. wounds occurring in these patients correlate with the presence of peripheral neuropathy. additionally, dm patients often experience poor circulation, which is related to peripheral arterial disease and is characterized by a decreased abi.16 transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. frequency distribution based on ankle-brachial index (abi), temporary blood sugar level, and leg sensitivity. variable pre-test post-test difference mean mean intervention group (n=12) ankle brachial index 0.82 1.07 +0.25 temporary blood sugar level 244.17 189 -55.17 right leg sensitivity 6.5 8.58 +2.08 left leg sensitivity 7.42 9.33 +1.91 control group (n=12) ankle brachial index 0.65 0.64 -0.01 temporary blood sugar level 198 225.25 +27.25 right leg sensitivity 5.58 5.58 0 left leg sensitivity 7.42 9.33 +1.91 table 3. the paired t-test of the intervention group and control group. variable pre-test post-test p intervention group lower extremities circulation 0.82±0.97 1.07±0.15 0.000 control group lower extremities circulation 0.65±0.22 0.64±0.21 0.241 table 4. independent t-test on intervention group and control group. lower extremities circulation n mean p pre-test group 1 12 0.82±0.97 0.028 group 2 12 0.65±0.22 post-test group 1 12 1.07±0.15 0.000 group 2 12 0.64±0.21 [page 460] [healthcare in low-resource settings 2024;12:11965] non -co mmerc ial us e o nly the bae is effective in improving lower extremities perfusion and minimizing the pain in lower extremities for type 2 dm patients. it enhances blood supply to the extremities and triggers the formation of new vascular structures, aiding in the wound-healing process.27 patients with dm who have diabetic foot ulcers are at risk of foot amputation. those with peripheral circulatory insufficiency, defined by an ankle-brachial index of less than 0.9 or a michigan neuropathy screening index of more than 2, can benefit from diabetes treatments that include foot exercises, such as the bae.28 this research is supported by previous studies that found bae has a positive impact on circulation, strengthens footwork, decreases necrosis, prevents embolism, minimizes pain, and reduces cyanosis in blood vessels. the study’s limitations include a lack of control for other variables that can affect lower extremity circulation, such as a history of hypertension, smoking, and dietary patterns in type 2 dm patients. conclusions bae can improve lower limb circulation in patients with type 2 dm. these exercises do not require expensive equipment and can be done at home. for future researchers, we recommend conducting research with a larger sample size and exploring additional parameters and characteristics that have not been previously studied concerning the symptoms of patients with type 2 dm. additionally, comparing bae with other physical exercises in improving lower extremity circulation in patients with type 2 dm would be valuable. references 1. susilo h, alsagaff my, pikir bs, et al. type ii diabetes as the main risk factor of arterial stiffness in chronic kidney disease patients. acm int conf proceeding ser 2022;210-4. 2. sukartini t, nursalam n, pradipta ro, ubudiyah m. potential methods to improve self-management in those with type 2 diabetes: a narrative review. int j endocrinol metab 2023;21. 3. kusnanto k, pradipta ro, arifin h, et al. what i felt as a diabetes fatigue survivor: a phenomenology study. j diabetes metab disord 2022;21:1753-62. 4. ong kl, stafford lk, mclaughlin sa, et al. global, regional, and national burden of diabetes from 1990 to 2021, with projections of prevalence to 2050: a systematic analysis for the global burden of disease study 2021. lancet 2023;402:203-34. 5. darma karingga d, efendi f. effect of mobile structured educational applications on self-care management in diabetes mellitus patients. gac med caracas 2023;131:278-86. 6. soelistijo sa, lindarto d, decroli e, et al. pedoman pengelolaan dan pencegahan diabetes melitus tipe 2 dewasa di indonesia 2019. perkumpulan endokrinologi indonesia 2019;1-117. 7. mellisha mes. effectiveness of buerger allen exercise on lower extremity perfusion and pain among patients with type 2 diabetes mellitus in selected hospitals in chennai. int j sci res 2016;5:1822-6. 8. mboi n, syailendrawati r, ostroff sm, et al. the state of health in indonesia’s provinces, 1990–2019: a systematic analysis for the global burden of disease study 2019. lancet glob heal 2022;10:e1632-45. 9. sartika rad, sigit fs, purwanto e, et al. association of birth weight with risk of diabetes mellitus in adolescence and early adulthood: analysis of the indonesian family life survey. ann pediatr endocrinol metab 2023;28:267-74. 10. zairina e, sulistyarini a, nugraheni g, et al. screening for identifying individuals at risk of developing type 2 diabetes using the canadian diabetes risk (canrisk) questionnaire. j public heal 2023;31:985-91. 11. dewi eu, widari np, nursalam n, et al. the relationship between diabetes self-care management and blood glucose level among type 2 diabetes mellitus patients. int j public heal sci 2023;12:1165. 12. ndraha s. diabetes mellitus tipe 2 dan tatalaksana terkini. medicinus 2014;27:9-16. 13. purbandini, purwanti e, hariyanti e, ramadhan fy. application of the decision tree c4.5 method on the classification of diet types of people with diabetes mellitus. aip conf proc 2023;2975:060004. 14. nadrati b. pengaruh buerger allen exercise terhadap ankle brachial index (abi) pada penyandang dm di rumah sakit umum daerah kota mataram. 2018;1-7. 15. sari a, wardy aw, sofiani y. efektivitas perbandingan buerger allen exercise dan senam kaki terhadap nilai abi pada penderita dm tipe ii. j telenursing 2019;24:233-44. 16. pebrianti s. buerger allen exercise dan ankle bractial index ( abi ) pada pasien ulcus kaki diabetik di rsu dr. slamet garut. indones j nurs sci pract 2017;94-110. 17. hassan s, mehani m. comparison between two vascular rehabilitation training programs for patients with intermittent claudication as a result of diabetic atherosclerosis. bull fac phys ther cairo 2012;17:7-14. 18. thiruvoipati t. peripheral artery disease in patients with diabetes: epidemiology, mechanisms, and outcomes. world j diabetes 2015;6:961. 19. dick f, diehm n, galimanis a, et al. surgical or endovascular revascularization in patients with critical limb ischemia: influence of diabetes mellitus on clinical outcome. j vasc surg 2007;45:751-61. 20. faizah r, efendi f, suprajitno s. the effects of foot exercise with audiovisual and group support foot exercises to diabetes mellitus patients. j diabetes metab disord 2021;20:377-82. 21. arnetz l, ekberg nr, alvarsson m. sex differences in type 2 diabetes: focus on disease course and outcomes. diabetes, metab syndr obes 2014;7:409-20. 22. mcintosh c, ousy k. lower extremity wound: a problem-based learning approach. john wiley & sons ltd.; hoboken, usa; 2008. 23. rosales-velderrain a, padilla m, choe ch, hargens ar. increased microvascular flow and foot sensation with mild continuous external compression. physiol rep 2013;1:1-6. 24. john j, rathiga a. effectiveness of buerger allen exercise to improve the lower extremity perfusion among patients with type 2 diabetes mellitus. int j curr res acad rev 2015;3:252-63. 25. bryant ra, nix dp. acute and chronic wounds. fifth edition. elsevier. elsevier; philadelphia, usa; 2016. 200 pp. 26. nadrati b, hadi m, rayasari f. pengaruh buerger allen exercise terhadap sirkulasi ekstremitas bawah bagi penyandang diabetes melitus. holistik j kesehat 2020;14:248-56. 27. vijayabarathi m, hemavathy v. buerger allen exercise for type 2 diabetes mellitus foot ulcer patients. 2015. available from: https://www.ijirset.com/upload/2014/december/ 30_15.% 20m.pdf 28. trisnawati i, sudiana ik, supriyanto s. effect of leg exercise on the lower limb circulation of patients with diabetes mellitus: a systematic review. j ners 2020;15:497-507. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11965] [page 461] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12:12796 self-reported practices of sepsis and septic shock among healthcare providers working at intensive care units at tertiary hospitals in jordan saleh al omar,1 jafar alasad alshraideh,2 islam ali oweidat,3 sajeda alhamory1 1faculty of nursing, al-balqa applied university, salt, jordan; 2clinical nursing department/school of nursing, the university of jordan, amman, jordan; 3faculty of nursing, zarqa university, zarqa, jordan abstract self-reported practices of sepsis and septic shock (ss) among healthcare providers were rarely discussed in the literature. the aim of the study was to describe the level of adherence among nurses and physicians to the self-reported practices of sepsis and ss treatment in six intensive care units (icu) of two tertiary hospitals in jordan. a cross-sectional descriptive design was used. a questionnaire was administered to 119 nurses and physicians. descriptive statistics were used to describe sample characteristics and practices of sepsis treatment. the results showed that most nurses and physicians reported they “often” or “always” adhere to these practices. however, there was insufficient adherence to using a prone position in patients with sepsis-induced acute respiratory distress syndrome. moreover, there was insufficient practice of testing serum lactate levels within one hour of diagnosing patients. nurses’ and physicians’ self-reported adherence to sepsis and ss treatment is satisfactory, but further improvement is required. introduction sepsis is a life-threatening illness characterized by extreme body response to an infection.1 it is essential to screen patients for sepsis and septic shock (ss) and respond instantly by implementing the necessary treatment. physicians can suspect sepsis in its early stages.2 likewise, nurses have a vital role in the early identification and treatment of sepsis.3,4 however, it was shown that late diagnosis was the most reported obstacle in treating patients with sepsis.4 there are 48.9 million sepsis cases annually and 11 million related deaths, globally.5 however, having a standardized protocol for sepsis treatment can decrease mortality rate,6-8 patients’ morbidity,9 costs of sepsis treatment,10,11 improve recognition of sepsis,12 and increase compliance with the overall sepsis treatment.12-15 in 2016, a committee of 55 international sepsis experts from the surviving sepsis campaign (ssc) initiative agreed on recommended guidelines for treating patients with sepsis and ss.16 these guidelines were adopted by the centers for medicare and medicaid services.17 however, out of ten diagnostic and treatment interventions chosen from the ssc bundle, only four or five were administered to 58.4% of adult intensive care unit (icu) patients,18 and only one-third of patients with sepsis received antibiotics on time.19 in china, only 14.2% of anesthesiologists described that they always comply with the ssc guidelines (n=971).20 other researchers indicated deficits in nurses’ capacity to screen, respond to, and recognize sepsis in australia.21 in jordan, a middle eastern country, the sepsis and ss prevalence among patients in icus was 16.6.22 the mortality rate among patients with sepsis in jordan was 57.8%.23 rababa, banihamad24 investigated knowledge, attitudes, and practice (kap) among jordanian critical care nurses related to early assessment and management of sepsis. the results showed that the mean score of practice was 78.0 (standard deviation, sd, 18.3), below the average kap scale score. nevertheless, no studies reported details about practices of sepsis treatment based on the ssc guidelines when used by nurses and physicians working in icus in jordan. as noted from the reviewed literature, sepsis and ss among adults did not receive enough focus and research studies. no similar study was conducted in the country. therefore, to increase focus on screening and treating patients with sepsis and ss, background information is needed about the treatment of sepsis and ss among adults. correspondence: saleh al omar, faculty of nursing, al-balqa applied university, salt, 19117, jordan tel.: +962776114184. e-mail: alomarsaleh@yahoo.com key words: sepsis; septic shock; practices. contributions: conception and design, sao, io and jaa; administrative support, jaa, io and sa; provision of study materials or patients, io; collection and assembly of data, sao, sa and io; data analysis and interpretation, sao and jaa; manuscript writing, sao, jaa, sa and io. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. funding: none. ethics approval and consent to participate: approval to conduct the study was obtained from the hospital's institutional review board (irb), with irb approval number: irb-1: 19/2019/59, irb-2: 640/1/13. informed consent: the researchers asked the participants to sign an informed consent indicating their agreement to participate. availability of data and materials: supporting research data are available on request from the authors. received: 10 july 2024. accepted: 29 july 2024. early access: 30 august 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:12796 doi:10.4081/hls.2024.12796 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:12796] [page 708] non -co mmerc ial us e o nly this study aimed to describe nurses’ and physicians’ selfreported adherence to practices based on the ssc guidelines for the treatment of sepsis and ss in medical and surgical icus of two tertiary hospitals in jordan. we present this article in accordance with the strengthening the reporting of observational studies in epidemiology (strobe) checklist materials and methods research design, settings, and sample a descriptive cross-sectional design was used in this study. it was conducted in two tertiary hospitals in jordan. hospital setting number one has eight icus, and hospital setting number two has seven icus. the total bed capacity of the first and the second hospitals was 582 beds and 651 beds, respectively. a census sample was enrolled from nurses and physicians working in the selected icus. a questionnaire was administered to 80 nurses in hospital number one, 78 nurses in hospital number two, and 20 physicians in the two hospitals combined. measurement and data collection data were collected between april 13 and august 2, 2019. the inclusion criterion was being a nurse or physician working in the medical and surgical icus of the selected hospitals. the participants were excluded if they withdrew or rejected to participate in the study. after explaining the purpose of the study, the researchers informed the participants that they could ask for any clarifications if required and asked them to handle the filled questionnaires directly. participants’ anonymity and confidentiality were maintained. the researchers developed the instrument. it is a five-point likert scale that assesses nurses’ and physicians’ self-reported adherence to the practices of treating patients with sepsis or ss. this instrument had 16 items, with scores ranging from one, “never”, to five, “always”. items number five and nine indicate practices that should be avoided, but all the other items indicate recommended practices. two researchers checked these items for clarity, simplicity, and face validity. the items were based on the ssc guidelines for the treatment of sepsis and ss, which some researchers used to guide the assessment of knowledge and adherence of nurses and physicians with these internationally applied evidence-based guidelines.13,25-29 rhodes, evans16 described items number two, number six, and number eight as best-practice statements, and item number 15 as weak recommendations.16 however, item 16 was adapted from the hour-one bundle, an update from the ssc in 2018.17 the remaining 11 items reflect strongly recommended ssc guidelines for treating patients with sepsis and ss.16 data analysis data were analyzed using spss version 23.30 descriptive statistics (mean, median, percentage, and frequency) were used to describe sample characteristics and self-reported practices. alpha level of significance was at 0.05. the dataset was checked for inconsistencies and missing values. imputation was used to replace missing values. ethical considerations approval to conduct the study was obtained from the hospitals’ institutional review board (irb). the researchers asked the participants to sign an informed consent indicating their agreement to participate. results the study sample comprised 158 nurses and 20 physicians working in the medical and surgical icus of the two hospital settings. a total of 119 (104 nurses and 15 physicians) participants filled out the questionnaire with a response rate of 67%. of the participants, there was a number of 58 (48.7%) nurses and physicians working in hospital one, and 61 (51.3%) nurses and physicians working in hospital two. regarding gender, 67 (56.3%) participants were males, and 52 (43.7%) were females. also, the mean length of clinical experience was 6.7 (sd=4.2) years, ranging between one year and 27 years. specifically, the mean length of icu clinical experience was 4.5 (sd=3.0) years, ranging between one month and 20 years (table 1). regarding item number one, 41 (34.5%) nurses and physicians reported they always administer intravenous crystalloid fluid rapidly, at a rate of 30 milliliter/kg in case of hypotension. regarding the second item, 47 (39.2%) nurses and physicians indicated that following initial fluid resuscitation and before administration of additional fluids, they always perform frequent reassessments of hemodynamic status and fluid balance. the findings showed that the median score of the first two items was “four”, indicating that article table 1. sociodemographic characteristics of nurses and physicians working in intensive care units (icus) (n=119). job category nurses n=104 (%) physicians n=15 (%) gender male: 59 (56.7) male: 8 (53.3) female: 45 (43.3) female: 7 (46.7) hospital setting hospital 1: 51 (49) hospital 1: 7 (46.7) hospital 2: 53 (51) hospital 2: 8 (53.3) professional role practical nurse: 3 (2.9) resident: 14 (93.3) staff nurse: 101 (97.1) consultant: 1 (6.7) academic degree associate diploma: 3 (2.9) bachelor’s degree: 10 (66.7) bachelor’s degree: 89 (85.6) master’s degree: 4 (26.6) master’s degree: 12 (11.5) doctoral degree: 1 (6.7) [page 709] [healthcare in low-resource settings 2024;12:12796] non -co mmerc ial us e o nly most nurses and physicians perform these two practices often. in addition, 55 (46.2%) nurses and physicians indicated they always administer vasopressors if a patient is still hypotensive to maintain mean arterial pressure (map) above 65 mmhg when hypovolemia is ruled out. the median score of this item for nurses was “four”, and for physicians was “five”. twenty-four (20.2%) nurses and physicians indicated they never use hydroxyethyl starches (hess) (a colloid solution) for intravascular volume replacement in patients with sepsis and ss; the median score of this item was “three” and “two” for nurses and physicians, respectively. furthermore, 60 (50.4%) nurses and physicians indicated that appropriate routine microbiologic cultures are always obtained before starting antibiotic therapy in patients with suspected sepsis and ss. thirty-nine (32.8%) nurses and physicians reported they always administer intravenous broadspectrum antibiotics within one hour of recognizing sepsis and ss. a number of 35 (29.4%) nurses and physicians reported they always identify, control, or remove the source of sepsis as rapidly as possible. in addition, 25 (21.0%) nurses and physicians indicated they never administered erythropoietin to treat sepsis-associated anemia. there was an agreement between nurses and physicians in the median score of this item equal to “two”. this means they adhere to the recommendation of the ssc guidelines concerning avoiding administering this drug to patients with sepsis-associated anemia. based on the responses, using prone over the supine position is uncommon in adult patients with sepsis-induced acute respiratory distress syndrome (ards). only 11 (9.2%) nurses and physicians and 22 (18.5%) nurses and physicians indicated they “always” and “often” use this practice, respectively. while the median score of this item reported by nurses was “three”, it was “two” for physicians. thirty-one (26.1%) nurses and physicians reported they always use a weaning protocol in mechanically ventilated patients with sepsis-induced respiratory failure. in addition, 44 (37.0%) nurses and physicians reported they always use a specific protocol for blood glucose management among patients with sepsis. a number of 47 (39.5%) nurses and physicians pointed out they always administer venous thromboembolism (vte) pharmacologic prophylaxis for patients with sepsis in the absence of contraindications. similarly, 56 (47.1%) nurses and physicians indicated they always administer stress ulcer prophylaxis to sepsis and ss patients with risk factors for gastrointestinal (gi) bleeding. twenty-five (21.0%) nurses and physicians reported they always start early enteral feeding in critically ill patients with sepsis and ss who can tolerate this feeding. in general, based on the median scores of the items, physicians reported slightly more adherence to the ssc guidelines than nurses. however, most nurses and physicians reported they “often” or “always” adhere to these practices, except for items number 10 and 16, which have the lowest median scores, indicating insufficient reported adherence to prone positioning for patients with sepsisinduced ards and testing serum lactate level within one hour of diagnosing patients with sepsis and ss (supplementary materials). discussion most nurses and physicians reported they “often” or “always” comply with 14 out of the 16 practices. this finding indicated a higher adherence level than what was found by uvizl, adamus,18 who indicated that out of ten diagnostic and treatment interventions chosen from the ssc bundle, only four or five of them were administered to 58.4% of adult patients with severe sepsis in an icu in the czech republic. in addition, the adherence rate in the current study was higher than reported among 835 registered nurses working in wards and icus of tertiary hospitals in greece. only 57.2% reported adhering to guidelines for diagnosing and treating patients with sepsis.31 it was comparable to the adherence level reported in a study conducted in two hospitals in spain, which showed that adherence was adequate in more than 60% of the ssc guidelines.32 jordanian critical care nurses’ mean practice score of sepsis management was 78.0±18.3. which was less than the average score of the kap subscales and less than the level reported in the current study.24 a difference in adherence to the ssc guidelines is expected because the studies differed in the participants’ settings, knowledge, and attitudes. this might affect the study findings positively. forty-seven (39.5%) nurses and physicians indicated they always administer crystalloid intravenous fluid rapidly at a rate of 30 milliliter/kilogram in case of hypotension. this was less than the percentage of 80.7% of icu nurse managers who reported administering intravenous fluid resuscitation starting from 20-40 milliliter/kilogram of crystalloid fluids for hypotensive patients in the usa. in similar, less than a percentage of 54.0% of anesthesiologists reported they always or usually administer fluid therapy according to the ssc guidelines in icus of china.20 however, the population differed among these studies, leading to a variance in adherence levels. forty-seven (39.5%) nurses and physicians indicated that administering additional fluids following initial fluid resuscitation is always guided by frequent reassessment of hemodynamic status and fluid balance. this was less than what was reported by mathenge (2015), who conducted a research study in kenya and showed that 57% of nurses and physicians showed that blood pressure reading was the most frequently reported practice of assessing fluid volume. a number of 55 (46.2%) nurses and physicians and 38 (31.9%) nurses and physicians reported they “always” and “often” administer vasopressors if a patient is still hypotensive to maintain map above 65 mmhg when hypovolemia is ruled out, respectively. when combined, this was lower than the percentage of 92.3% of icu nurse managers who reported administering vasopressors for patients with hypotension who do not respond to fluid resuscitation.33 in the present study, one-third of nurses and physicians (32.8%) reported using norepinephrine “often” as the firstchoice vasopressor to treat hypotension, and 37% reported performing this practice always. when combined, they become comparable to the percentage reported by mathenge,34 who indicated that 75% of nurses and physicians reported using norepinephrine in icus for patients with sepsis. sixty (50.4%) nurses and physicians indicated they “always” obtain appropriate routine microbiologic cultures before starting antibiotics for patients with suspected sepsis or ss. this was higher than the percentage of 43% of nurses and physicians who reported performing blood cultures for patients with sepsis.34 in contrast, less than 92.8% of icu nurse managers in the usa reported collecting cultures before administering antibiotics.33 however, the availability of recourses could affect variance in adherence, as these three studies were conducted in three countries that differ in income level. a number 47 (39.5%) nurses and physicians and 39 (32.8%) nurses and physicians reported they “often” and “always” administer intravenous broad-spectrum antibiotics within one hour of sepsis and ss recognition, respectively. this was less than the percentage of 95%.34 it was also less than the percentage of 92% among critical care nurses in one hospital in the usa.35 similarly, article [healthcare in low-resource settings 2024;12:12796] [page 710] non -co mmerc ial us e o nly it is less than the percentage of 88.5% of greek nurses who answered that antibiotic treatment starts early after the diagnosis of sepsis (n=739).31 however, the percentage exceeded 65.9% of icu nurse managers who reported administering broad-spectrum antibiotics within one hour of diagnosing patients with sepsis.33 only 44 (37%) nurses and physicians reported often use of a weaning protocol in mechanically ventilated patients with sepsisinduced respiratory failure who can tolerate weaning, compared to 31 (26.1%) nurses and physicians who reported always performing this practice. this was less than the rate of 89.3% of adherence to providing protective mechanical ventilation for patients with sepsis.32 the level of measurement was different between the studies. therefore, comparing the findings was challenging. a percentage of 30.3% of nurses and physicians and 37% of nurses and physicians reported they “often” or “always” use a specific protocol for blood glucose management, respectively. this was higher than the adherence rate of 32.9% for maintaining glucose ≤150 milligrams/deciliter.32 however, this study differed from the present study in the data collection method, in which the researchers reviewed patients’ medical records only. higher adherence to this practice was reported in a study conducted in the usa. durthaler et al. (2009) revealed that 72.7% of icu nurse managers reported early insulin starting to maintain serum glucose levels less than 150 milligrams/deciliter. forty-seven (39.5%) nurses and physicians and 35 (29.4%) nurses and physicians reported they “always” and “often” administer venous thromboembolism pharmacologic prophylaxis in the absence of contraindications, respectively. together, these adherence levels were higher than the percentage of 62.3% of icu nurse managers who reported administration of deep venous thrombosis prophylaxis within 24 hours of sepsis diagnosis.33 in the current study, 56 (47.1%) and 33 (27.7%) nurses and physicians reported they “always” or “often” administer stressulcer prophylaxis to patients with sepsis and ss who have risk factors for gastrointestinal bleeding. this was lower than the reported adherence rate of 89.1% among icu nurse managers who reported administration of stress-ulcer prophylaxis during the first day of sepsis diagnosis.33 twenty-seven (22.7%) and 43 (36.1%) nurses and physicians reported they “always” or “often” initiate early enteral nutrition for critically ill patients with sepsis and ss who can be fed enterally. when combining these two percentages, the total percentage becomes less than reported by durthaler et al.33 who indicated that 71.7% of icu nurse managers reported early initiation of nutrition therapy within 24 hours of severe sepsis onset. the present study’s findings showed that six (5.0%) and 16 (13.4%) nurses and physicians reported they “always” or “often” measure serum lactate within one hour of diagnosing patients with sepsis and ss, respectively. this was less than the percentage of 45% of the nurses and physicians who reported the use of serum lactate, and around one-quarter (24%) of the respondents reported performing this test within the first hour of sepsis diagnosis.34 this was also less than the percentage of 62% of anesthesiologists in china who tested lactate levels during the initial management of sepsis.20 it is worth mentioning that the ssc guidelines are being updated every few years, which could affect how nurses and physicians respond to incorporating these guidelines into daily clinical practice. this study added significant information about the practices that healthcare providers use in real situations while managing sepsis and septic shock among patients in icus. however, the study had some possible limitations. first, the findings are not generalizable to all hospitals in jordan because only two tertiary hospitals were included. second, the study was descriptive cross-sectional, and adherence to the treatment of sepsis was assessed using a selfreported questionnaire rather than direct observation. the current study results added significant information to the body of nursing and medical literature about self-reported practices of sepsis and ss treatment. furthermore, nurses and physicians are required to pay more attention to the practices that are not always implemented, as reported by the present study participants. it is recommended to undertake ongoing staff development programs, including teaching and training nurses and physicians about how to treat adult patients with sepsis and ss. moreover, barriers to providing care for patients with sepsis and ss need to be investigated and addressed in each healthcare context. the results could be used to benchmark the current level of treatment provided for patients with sepsis, which may help in future comparison and obtaining information for quality improvement projects. administrators are required to improve adherence to sepsis and ss; they are required to enhance healthcare environments to facilitate implementing the ssc guidelines. conclusions this study provided a base of self-reported practices of sepsis and ss among adult patients in the icus of jordan. the level of nurses’ and physicians’ adherence to the self-reported practice of sepsis and ss treatment was satisfactory, and most nurses and physicians reported they “often” or “always” adhere to these practices. however, the scores of some items reflected insufficient adherence to the ssc guidelines for treating sepsis and ss in adult icus, especially for using the prone position of patients with sepsis-induced ards and for performing serum lactate tests. however, nurses and physicians had comparable adherence levels to the ssc guidelines for sepsis and ss treatment. adherence to the ssc guidelines is required to be improved in icus. references 1. centers for disease control and prevention (cdc). about sepsis. available from: https://www.cdc.gov/sepsis/ about/ index.html 2. lopansri bk, miller iii rr, burke jp, et al. physician agreement on the diagnosis of sepsis in the intensive care unit: estimation of concordance and analysis of underlying factors in a multicenter cohort. j intensive care 2019;7:1-17. 3. kleinpell r, blot s, boulanger c, et al. international critical care nursing considerations and quality indicators for the 2017 surviving sepsis campaign guidelines. intensive care med 2019;45:1663-6. 4. burney m, underwood j, mcevoy s, et al. early detection and treatment of severe sepsis in the emergency department: identifying barriers to implementation of a protocol-based approach. j emerg nurs 2012;38:512-7. 5. rudd ke, johnson sc, agesa km, et al. global, regional, and national sepsis incidence and mortality, 1990–2017: analysis for the global burden of disease study. lancet 2020;395:20011. 6. kleinpell r. promoting early identification of sepsis in hospitalized patients with nurse-led protocols. crit care 2017;21:13. 7. tuttle e, wang x, modrykamien a. sepsis mortality and icu article [page 711] [healthcare in low-resource settings 2024;12:12796] non -co mmerc ial us e o nly length of stay after the implementation of an intensive care team in the emergency department. intern emerg med 2023;18:1789-96. 8. paul r, niedner m, riggs r, et al. bundled care to reduce sepsis mortality: the improving pediatric sepsis outcomes (ipso) collaborative. pediatrics 2023;152:e2022059938. 9. heppner hj, singler k, kwetkat a, et al. do clinical guidelines improve management of sepsis in critically ill elderly patients? a before-and after study of the implementation of a sepsis protocol. wien klin wochenschr 2012;124:692-8. 10. shorr a, micek s, jackson jr w, kollef m. economic implications of an evidence-based sepsis protocol: can we improve outcomes and lower costs? critical care med 2007;35:125762. 11. suarez d, ferrer r, artigas a, et al. cost-effectiveness of the surviving sepsis campaign protocol for severe sepsis: a prospective nation-wide study in spain. intensive care med 2011;37:444-52. 12. rehmani rs, memon ji, al-gammal a. implementing a collaborative sepsis protocol on the time to antibiotics in an emergency department of a saudi hospital: quasi randomized study. critic care research practice 2014;2014:410430. 13. bruce hr, maiden j, fedullo pf, kim sc. impact of nurse-initiated ed sepsis protocol on compliance with sepsis bundles, time to initial antibiotic administration, and in-hospital mortality. j emerg nurs 2015;41:130-7. 14. giuliano kk, lecardo m, staul l. impact of protocol watch on compliance with the surviving sepsis campaign. am j crit care 2011;20:313-21. 15. wang h, shapiro n, angus d, yealy d. national estimates of severe sepsis in united states emergency departments. critrc care med 2007;35:1928-36. 16. rhodes a, evans le, alhazzani w, et al. surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016. intensive care med 2017;43:304-77. 17. levy m, evans l, rhodes a. the surviving sepsis campaign bundle: 2018 update. intensive care med 2018;44:925-8. 18. uvizl r, adamus m, cerny v, et al. patient survival, predictive factors and disease course of severe sepsis in czech intensive care units: a multicentre, retrospective, observational study. biomedical papers of the medical faculty of the university palacky, olomouc, czechoslovakia 2016;160:287-97. 19. bloos f, thomas-rüddel d, rüddel h, et al. impact of compliance with infection management guidelines on outcome in patients with severe sepsis: a prospective observational multicenter study. critical care 2014;18:1-10. 20. li h, yu x, zhou r, et al. knowledge of and compliance with surviving sepsis campaign guidelines among anesthesiologists: a nationwide survey in china. j healthc eng 2021;2021: 1877166. 21. harley a, johnston a, denny k, et al. emergency nurses’ knowledge and understanding of their role in recognising and responding to patients with sepsis: a qualitative study. int emerg nurs 2019;43:106-12. 22. al omar s, alshraideh ja, khassawneh b, muhaisen sm. the prevalence of sepsis and septic shock in a middle-income country: experience of two tertiary hospitals in jordan. j critic intensive care 2021;12:75-80. 23. abu-humaidan ah, ahmad fm, al-binni ma, et al. characteristics of adult sepsis patients in the intensive care units in a tertiary hospital in jordan: an observational study. crit care res pract 2021:2741271. 24. rababa m, bani-hamad d, hayajneh aa, al mugheed kj. nurses’ knowledge, attitudes, practice, and decision-making skills related to sepsis assessment and management. electronic j general med 2022;19:em420 25. drahnak d, hravnak m, ren d, et al. scripting nurse communication to improve sepsis care. medsurg nursing 2016;25:233-9. 26. gao f, melody t, daniels d, et al. the impact of compliance with 6-hour and 24-hour sepsis bundles on hospital mortality in patients with severe sepsis: a prospective observational study. critical care med 2005;9:764-70. 27. khwannimit b, bhurayanontachai r. the epidemiology of, and risk factors for, mortality from severe sepsis and septic shock in a tertiary-care university hospital setting. epidemiol infect 2009;137:1333-41. 28. suntornlohanakul o, khwannimit b. a comparison of residents’ knowledge regarding the surviving sepsis campaign 2012 guideline. indian soc critical care med 2017;21:69-74. 29. tufan zk, eser fc, vudali e, et al. the knowledge of the physicians about sepsis bundles is suboptimal: a multicenter survey. j clin diagn res 2015;9:13-6. 30. ibm corp g. statistical package for the social sciences (spss). 2015. available from: https://www.ibm.com/products/spss-statistics 31. stamataki p, papazafiropoulou a, kalaitzi s, et al. knowledge regarding assessment of sepsis among greek nurses. j infect prev 2014;15:58-63. 32. pestana d, espinosa e, sangueesa-molina jr, et al. compliance with a sepsis bundle and its effect on intensive care unit mortality in surgical septic shock patients. j trauma acute care surg 2010;69:1282-7. 33. durthaler jm, ernst fr, johnston ja. managing severe sepsis: a national survey of current practices. am j health syst pharm 2009;66:45-53. 34. mathenge e. knowledge, attitudes and practices of sepsis management at moi teaching and referral hospital, kenya. 2015. available from: https://dukespace.lib.duke. edu/items/3c1f9853-0758-41ef-917a-b6a4b6a973ed 35. roberts rj, alhammad am, crossley l, et al. a survey of critical care nurses’ practices and perceptions surrounding early intravenous antibiotic initiation during septic shock. intensive crit care nursing 2017;41:90-7. article [healthcare in low-resource settings 2024;12:12796] [page 712] supplementary materials table 1. items’ frequencies, percentages, and median scores/self-reported practice of sepsis and septic shock (ss) treatment as reported by nurses and physicians (n=119). non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13465 evaluating the sensitivity and specificity of symptom-based screening for soil-transmitted helminth infections in children in coastal areas of indonesia irma irma,1 asnia zainuddin,2 marni syahrani ado,3 swaidatul masluhiya af4 1department of epidemiology, faculty of public health, halu oleo university, kendari; 2faculty of public health, halu oleo university, kendari; 3medical laboratory technology, politeknik kesehatan kemenkes makassar; 4faculty of health sciences, tribhuwana tunggadewi university, malang, indonesia abstract soil-transmitted helminth (sth) infection is a neglected tropical disease prevalent in many low-income, developing countries with poor environmental sanitation. children of preschool and school age are particularly vulnerable to sth infection. this study aimed to evaluate the sensitivity and specificity of clinical complaints in detecting sth infection among elementary schoolaged children living in coastal areas of indonesia. a descriptive, observational design was employed, involving 64 children. data were collected through a structured questionnaire that assessed respondent characteristics and symptoms, followed by a stool examination using the kato-katz method to confirm the status of sth infection. the findings revealed a prevalence rate of 21.9% for sth infection. among the reported complaints, diarrhea demonstrated the highest sensitivity (78.6%). in terms of specificity, complaints of itching around the anus and frequent diarrhea yielded the highest specificity values, at 82% and 74%, respectively. these results highlight key symptomatic indicators that could support early detection and targeted interventions for sth infections in coastal regions. introduction soil-transmitted helminth (sth) infection is one of the neglected tropical diseases (ntds) that poses major public health challenges,1 particularly in developing, low-income countries.2 three primary species are responsible for sth infections in humans: roundworms (ascaris lumbricoides), whipworms (trichuris trichiura), and hookworms (necator americanus and ancylostoma duodenale).3,4 the world health organization (who) estimates that approximately 2 billion people, or around 24% of the global population, are infected with sth, with a. lumbricoides alone affecting about 1.2 billion individuals.5 preschooland school-aged children are particularly vulnerable, with more than 260 million preschoolers and over 657 million school-aged children globally infected.6 a survey conducted by the ministry of health of the republic of indonesia reported that the prevalence of helminth infections across several provinces ranged from 40% to 60%. among schoolaged children, the prevalence was even higher, between 30% and 90%.7 children aged 6-12 years, typically in elementary school, are particularly susceptible due to factors such as poor personal hygiene.8 additional contributing factors include inadequate sanitation facilities and limited knowledge regarding sth prevention strategies.9 sth infections have long-term adverse impacts, particularly on children’s health, including nutritional deficiencies and impaired cognitive development.10 chronic infections11 can result in stunted growth,12,13 low intelligence quotient (iq) scores,14 malnutrition,15 and anemia,16 as demonstrated in studies conducted in ethiopia17 and other regions.18,19 moreover, sth infection has been identified as a significant predictor of stunting among elementary school children. unlike acute infectious diseases, sth infections typically have a slow pathogenesis and prognosis. symptoms may vary, and many infected individuals, particularly children, may remain unaware of their condition. common symptoms associated with sth infection include poor appetite, frecorrespondence: irma irma, department of epidemiology, faculty of public health, halu oleo university, kendari, indonesia. e-mail: irmankedtrop15@uho.ac.id key words: children, helminth, sensitivity, specificity, sth infection. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: all stages of this study were conducted following ethical recommendations from the health research ethics commission of halu oleo university (approval number: 5500/un29.17.13/etik//2024). all participants in this study provided written informed consent prior to their involvement. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was funded by a grant from halu oleo university. acknowledgments: we express our gratitude to the principal and the entire board of teachers at the school for granting permission and fully supporting this research. we also thank the head of the community health centers for supporting the laboratory examinations. in particular, we would like to extend our deepest gratitude to the entire laboratory team for their assistance with the examination of this research sample, as well as to all subjects in this study for their participation. received: 9 december 2024. accepted: 26 may 2025. early view: 27 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13465 doi:10.4081/hls.2025.13465 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13465] [page 115] quent diarrhea, recurrent abdominal pain, protein loss, itching around the anus,20 and in severe cases, rectal prolapse. subclinical infections may present as stunting, weight loss, and reduced cognitive abilities.21 given the often non-specific clinical manifestations of sth infection, this study aimed to determine the prevalence of sth infections among elementary school-aged children in coastal areas of indonesia and to assess the sensitivity and specificity of clinical complaints as potential indicators of sth infection. identifying the most dominant symptoms associated with sth infection is crucial for early detection and treatment, thereby facilitating better infection control strategies. the initial screening process involves gathering primary complaints from subjects, which is expected to enhance the early identification of infected individuals and improve treatment outcomes. thus, this study specifically seeks to identify the most common clinical complaints among children with confirmed sth infection through sensitivity and specificity analysis. materials and methods this study is a descriptive observational study with a crosssectional design to determine the prevalence and dominant complaints in children infected with sth and to find out the level of specificity and sensitivity of the screening results for each complaint. the population of this study consisted of all children at elementary schools in north buton regency, totaling 64 individuals. the total sampling was used in this study. the selection of location and number of samples in this study was made considering the limited research on sth infections in coastal communities, especially in primary school-aged children. instruments laboratory examination to detect the presence of sth infection is carried out by the kato-katz method, using the following tools: i) microscope; ii) cellophane (measuring 2.5 cm x 3 cm); iii) wire gauze to filter feces (measuring 3 cm x 4 cm); iv) filter paper (measuring 10 cm x 10 cm); v) thick cardboard paper; vi) waterproof oiled paper (measuring 10 cm x 10 cm); vii) objects glass; and viii) beakers and bottle sets. the materials used include: i) glycerol solution; ii) malachite green solution; and iii) distilled water.4 the study was carried out through a series of organized stages. initially, all children were gathered in their respective classrooms, where the researchers explained the screening activities, specifically the stool examination aimed at identifying sth infections. students who expressed their willingness to participate were then given an informed consent form, which they or their guardians were required to sign. following consent, the participants underwent an interview process, during which information regarding their past health history and any complaints potentially related to worm infections was collected. the symptoms explored included poor appetite, frequent diarrhea, recurrent abdominal pain, itching around the anus and nearby areas, as well as any other relevant complaints as outlined in the questionnaire format. after the interview session, the researchers conducted an educational session for the respondents, providing detailed instructions on the correct methods for collecting, storing, and submitting stool samples for examination. after the educational session, participants were instructed on the proper method for collecting fecal samples. fecal collection was to be performed in the morning before going to school. participants were advised to first urinate to avoid contamination, and then collect fresh feces, ensuring it was not mixed with toilet water or urine. the feces were to be collected in a sterile container, first by placing them on plastic paper, and then transferring an appropriate amount into the stool pot using a provided spoon or stick. for solid feces, approximately 2-5 g (about the size of a fingertip) was required, whereas for liquid feces, 10-15 ml were collected. once collected, the fecal samples were submitted to the researchers. the samples were neither preserved nor refrigerated, but were stored in a designated box to maintain their condition. all fecal samples were delivered to the health center laboratory and examined within 24 hours of collection. the laboratory examination results were meticulously recorded in an examination results logbook prepared beforehand. following sample collection and analysis, the data obtained from interviews and laboratory examinations were processed for further evaluation. data analysis was conducted using both univariate and multivariate methods, utilizing excel and spss version 24 software with a 95% confidence interval (ci) (α=0.05). univariate analysis, performed primarily using excel, aimed to describe the distribution of respondent characteristics and laboratory outcomes. this step facilitated the calculation of diagnostic test parameters, including sensitivity, specificity, positive predictive value (ppv), negative predictive value (npv), and diagnostic accuracy. the calculation of sensitivity, specificity, ppv, npv, and the diagnostic test accuracy value was performed using the following formula: table 1 shows that the formula can be applied using a 2x2 contingency table that categorizes individuals based on their test results and their true health status as determined by the gold standard. in this arrangement, individuals who test positive and are confirmed sick by the gold standard are classified as true positives (tp). those who test positive but are identified as healthy by the gold standard are categorized as false positives (fp). conversely, individuals who test negative but are actually sick according to the gold standard are referred to as false negatives (fn). lastly, those who test negative and are confirmed healthy by the gold standard are classified as true negatives (tn). ethical clearance all stages of this study were conducted following ethical recommendations from the health research ethics commission of halu oleo university (number: 5500/un29.17.13/etik//2024). all respondents participating provided written informed consent. pathways of change, part ii [page 116] [healthcare in low-resource settings 2025;13(s2):13465] results demographic data demographic data of the subjects in this study include age and gender. table 2 shows that most of the study subjects, namely 37.5% were aged 8-9 years, and the age group >11 years was the least represented in this study. table 2 also shows that 53.1% of the study subjects were women and 46.9% were men. identification of sth infection identification of sth infection is carried out through examination of stool samples with the kato-katz method. this examination is carried out by identifying the presence of helminth eggs of the sth group in the feces sample. based on the examination of 64 stool samples, 14 tested positive for sth worm eggs. all (100%) positive samples were a. lumbricoides species. table 3 shows that the age group with the highest number of sth infections identified through fecal examination was 10-11 years old, with 6 individuals (42.9%) testing positive. the age groups with the lowest infection rates were 6-7 and 8-9 years, with 4 individuals each (28.6%). no infections were found in participants over 11 years old. table 2 shows that, in terms of gender, the majority of those infected were female, with 9 individuals (64.3%), while 5 (35.7%) were male. additionally, out of the total 64 study participants, 14 individuals (21.9%) tested positive for sth, whereas 50 individuals (78.1%) tested negative. screening results for sth infection complaints in primary school children screening for complaints related to sth infection in primary school-aged children is carried out covering complaints such as frequent diarrhea, decreased/reduced appetite, frequent abdominal pain, and itching in the area around the anus/rectum. the complete distribution of respondents, based on screening complaints related to sth infection in children, is presented in table 4. as shown in table 4, the most frequently reported complaint among children infected with sth was diarrhea, experienced by 78.6% of those who tested positive. further analysis based on the screening data allowed for the calculation of sensitivity, specificity, ppv, and npv for each commonly reported symptom. diarrhea demonstrated the highest sensitivity (79%) and a specificity of 74%, with a ppv of 46% and a high npv of 93%. this suggests that diarrhea is a fairly sensitive indicator of sth infection, and its absence strongly indicates that the child is not infected. decreased appetite also showed a relatively good performance, with a sensitivity of 71%, specificity of 66%, ppv of 37%, and npv of 89%, indicating that its absence is also a useful sign for ruling out infection. frequent abdominal pain, however, had a lower sensitivity (36%) and ppv (26%), although its specificity was 72% and npv was 80%. this suggests that abdominal pain alone may not be a strong predictor of sth infection. on the other hand, frequent pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13465] [page 117] table 1. 2x2 contingency table (gold standard). test results sick healthy total positive tp fp tp+fp negative fn tn fp+tn total tp+fn fp+tn tp+fp+fn+tn table 2. characteristics of research subjects based on age and gender (n=64). characteristics of respondents frequency percentage (%) age (years) 6-7 23 35.9 8-9 24 37,5 10-11 14 21.9 >11 3 4.7 gender male 30 46.9 female 34 53.1 total 64 100 table 3. sth infection detection by age group and sex (n=64). characteristics of respondents positive negative n % n % age (years) -7 4 28.6 19 38.6 8-9 4 28,6 20 40 10-11 6 42.9 8 16 >11 0 0 14 21.9 gender male 5 35.7 25 50 female 9 64.3 25 50 itching in the anal area presented a sensitivity of 64%, a relatively high specificity of 82%, a ppv of 60%, and an npv of 98%. this suggests that the absence of this symptom is a strong indicator that the child is not infected, and its presence may serve as a useful sign in identifying potential sth infection cases. according to the calculation results, among the four main symptoms or complaints reported by respondents, the one with the highest sensitivity and specificity was frequent diarrhea, with a sensitivity of 79% and a specificity of 74%. in contrast, the symptom with the lowest sensitivity and specificity was abdominal pain, with a sensitivity of 36% and a specificity of 72%. therefore, it can be concluded that diarrhea, decreased appetite, abdominal pain, and frequent anal itching are not definitive indicators of sth infection in children. however, diarrhea, having the highest sensitivity and specificity values in this study, may be considered a more reliable symptom. the complete sensitivity and specificity values for the screening results are presented in table 5 and illustrated in the form of a receiver operating characteristic (roc) graph (figure 1). among the complaints evaluated, frequent diarrhea showed the highest diagnostic performance with an area under the curve (auc) of 0.763 (95% ci: 0.619-0.907, p=0.003), indicating a good level of accuracy in distinguishing between infected and non-infected children. frequent itching in the anal area also demonstrated strong diagnostic potential, with an auc of 0.731 (95% ci: 0.570-0.893, p=0.009). decreased appetite or less eating yielded an auc of 0.687 (95% ci: 0.529-0.845, p=0.033). on the other hand, frequent abdominal pain had the lowest diagnostic value with an auc of 0.539 (95% ci: 0.364-0.713, p=0.661). as shown in figure 1, the roc curves of each complaint further confirm these findings, with curves for diarrhea and anal itching showing better separation from the reference line compared to abdominal pain, which closely follows the diagonal, indicating poor discriminative power. pathways of change, part ii table 4. distribution of respondents based on screening complaints related to sth infection (n=64). complaints positive negative n % n % frequent diarrhea yes 11 78.6 13 26 no 3 21.4 37 74 decreased appetite yes 10 71.4 17 34 no 4 28.6 33 66 frequent abdominal pain yes 5 35.7 14 28 no 9 64.3 36 72 frequent itching in the anal area yes 9 64.29 9 18 no 5 35.71 41 82 table 5. area under the curve. variables area std. error asymptotic sig. asymptotic 95% ci lower bound upper bound frequent diarrhea .763 .073 .003 .619 .907 decreased appetite .687 .080 .033 .529 .845 frequent abdominal pain .539 .089 .661 .364 .713 frequent itching in the anal area .731 .082 .009 .570 .893 ci, confidence interval. figure 1. area under the receiver operating characteristic (roc) related to complaints in sth infection. [page 118] [healthcare in low-resource settings 2025;13(s2):13465] discussion the present study identified a sth infection prevalence of 21.9% among elementary school-aged children in a coastal indonesian community, corroborating previous reports of the burden of these neglected tropical diseases in resource-limited settings.22 the observed female predominance in infection rates aligns with existing literature,23 suggesting gender-specific behavioral factors may mediate transmission dynamics. the cultural practice of kengkeng – a traditional barefoot game predominantly played by female children – likely represents a significant environmental exposure pathway, consistent with established epidemiological evidence linking barefoot soil contact with sth transmission.24,25 the epidemiological profile of sth infection in this coastal community appears multifactorial in origin. first, the region’s hydrogeological characteristics, marked by limited access to improved water sources and sanitation infrastructure, create an environment conducive to the perpetuation of fecal-oral transmission cycles.26 second, our findings support the well-documented association between low health literacy and sth prevalence,27 highlighting critical gaps in community knowledge regarding disease transmission and prevention modalities. third, the combination of socioeconomic deprivation and geographic isolation common in many coastal communities intensifies these risk factors, which may explain the consistently high disease burden despite ongoing control efforts. from a diagnostic perspective, our results demonstrate that common clinical manifestations – particularly diarrhea – exhibit predictive value for sth infection. however, their limited specificity underscores the well-recognized challenge of symptom overlap in pediatric populations.26 the relatively higher specificity of perianal itching reflects prior findings concerning its diagnostic value for enterobiasis,28 although its reduced sensitivity warrants caution in clinical practice. these observations collectively reinforce current who guidelines recommending parasitological confirmation for accurate sth diagnosis in endemic areas.22 the public health implications of these findings are threefold. first, the identification of gender-specific risk behaviors suggests the potential utility of targeted interventions, such as gender-segmented deworming programs or footwear distribution initiatives. second, the demonstrated limitations of symptom-based screening underscore the continued need for investments in accessible diagnostic capacity, particularly in remote coastal regions. third, our findings support the implementation of integrated control strategies that combine mass drug administration with water, sanitation, and hygiene (wash) interventions.29 several study limitations warrant consideration. the cross-sectional design precludes causal inference, while the modest sample size may limit statistical power and generalizability. furthermore, the use of single stool samples for parasitological diagnosis, while operationally pragmatic, may underestimate true prevalence due to known day-to-day variation in egg excretion.30 future research should prioritize longitudinal designs with repeated parasitological sampling, expanded geographic coverage to capture regional heterogeneity, and implementation science approaches to evaluate context-appropriate intervention strategies. conclusions the findings of this study paint a concerning yet actionable picture of sth transmission among children in indonesia’s coastal communities. while diarrhea emerged as a sensitive indicator of infection, and perianal itching showed reasonable specificity, these clinical signs alone proved inadequate for definitive diagnosis, underscoring the indispensable role of stool testing in these resource-limited settings. the persistence of sth reflects a perfect storm of environmental contamination, inadequate wash infrastructure, and insufficient health literacy – challenges that demand integrated solutions combining targeted deworming, footwear distribution programs, and community-led sanitation improvements. references 1. konstantin t, tantular is, athiyyah af, rossyanti l. the correlation between water, sanitation, and hygiene with soil-transmitted helminths infection among elementary school children of aru islands district, maluku. indones j public heal 2021;16:273–84. 2. world heath organization. soil-transmitted helminth infections; 2021. 3. eyayu t, yimer g, workineh l, et al. prevalence, intensity of infection and associated risk factors of soil-transmitted helminth infections among school children at tachgayint woreda, northcentral ethiopia. plos one 2022;17:1–13. 4. kementerian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 15 tahun 2017 tentang penanggulangan cacingan. jakarta: kementerian kesehatan ri; 2017. available from: https://peraturan. bpk.go.id/details/111981/permenkes-no-15-tahun-2017 5. centers for disease control and prevention (cdc). about ascariasis | soil-transmitted helminths. atlanta (ga): cdc; 2024. 6. world health organization. soil-transmitted helminth infections. jeneva; 2020. 7. rosyidah hn, prasetyo h. prevalensi infeksi cacing usus pada anak di kampung pasar keputran utara kota surabaya tahun 2017. surabaya: perpustakaan universitas airlangga; 2018, p. 15–50. 8. rahma na, zanaria tm, nurjannah n, et al. faktor risiko terjadinya kecacingan pada anak usia sekolah dasar. j kesehat masy indones 2020;15:29. 9. getaneh m, hailegebriel t, munshea a, nibret e. prevalence and associated risk factors of soil-transmitted helminth infections among schoolchildren around lake tana, northwest ethiopia. genet res (camb) 2022;2022. 10. irma, sabilu y, muchtar f, zainuddin a. pengaruh infeksi penyakit tropis terhadap kejadian gizi kurang pada balita di wilayah kabupaten buton utara. j ilm kesehat 2021;2:34–8. 11. kuntari t, utami u, widyasari v, et al. chronic energy deficiency in young pregnant women in rural indonesia: an analysis of basic health survey 2018. j ners 2024;19:433–40. 12. adi ac, diana r, andrias dr, et al. household food expenditure and stunting of children under five years old in food secure area. j nutr food secur 2024;9:561–73. 13. husnina z, nmw s, pratiwi n, et al. examining the different pathways to stunting among children. african j food agric nutr dev 2024;24:26639–58. 14. weatherhead je hp. worm infections in children. pediatr rev 2015;36:341–52. 15. khoiriyah r, mahmudiono t, nadhiroh sr. indirect determinant effects of stunting with toddler stunting incident in papua new guinea in 2018. amerta nutr 2024;8:433–40. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13465] [page 119] 16. maulina r, qomaruddin mb, kurniawan aw, et al. prevalence and predictor stunting, wasting and underweight in timor leste children under five years: an analysis of dhs data in 2016. j public health afr 2022;13:2116. 17. mekonnen z, hassen d, debalke s, et al. soil-transmitted helminth infections and nutritional status of school children in government elementary schools in jimma town, southwestern ethiopia. sage open med 2020;8. 18. al uluf u, mahmudiono t, melaniani s, author c. children 15-49 months in zambia (zambia dhs analysis. j biometrika dan kependud 2018;12:194–203. 19. degarege a, erko b, negash y, animut a. intestinal helminth infection, anemia, undernutrition and academic performance among school children in northwestern ethiopia. microorganisms 2022;10. 20. garzón m, pereira-da-silva l, seixas j, et al. subclinical enteric parasitic infections and growth faltering in infants in são tomé, africa: a birth cohort study. int j environ res public health 2018;15:1–16. 21. eltantawy m, orsel k, schroeder a, et al. soil transmitted helminth infection in primary school children varies with ecozone in the ngorongoro conservation area, tanzania. trop med health 2021;49. 22. world heart organization. prevention and control of schistosomiasis and soil-transmitted helminthiasis: technical report series n° 912. 2022, p. 1–51. 23. derek c, kalesaran a, kandou g. hubungan antara faktor sosiodemografi dengan infeksi cacing usus di sd negeri 58 manado. kesmas 2017;6:1–8. 24 vaz nery s, clarke ne, richardson a, et al. risk factors for infection with soil-transmitted helminths during an integrated community level water, sanitation, and hygiene and deworming intervention in timor-leste. int j parasitol 2019;49:389– 96. 25. world heath organization. soil-transmitted helminth infections. world health organisation; 2023 [cited 2025 may 2], p. 1. 26. adbi institute. institutional mechanism for sustainable sanitation: lessons from japan for other asian countries. singapore: lee kuan yew school of public policy; 2019. 27. suraini, kaselawaty fw. pengaruh pengetahuan dan personal hygiene terhadap kejadian infeksi cacing pada murid sdn 50 kampung jambak padang. pros semin kesehat perintis e 2018;1:2622–56. 28. lashaki ek, mizani a, hosseini sa, et al. global prevalence of enterobiasis in young children over the past 20 years: a systematic review and meta-analysis. osong public heal res perspect 2023;14:441–50. 29. steinbaum l, mboya j, mahoney r, et al. effect of a sanitation intervention on soil-transmitted helminth prevalence and concentration in household soil: a cluster-randomized controlled trial and risk factor analysis. plos negl trop dis 2019;13:1– 17. 30. barda b, schindler c, wampfler r, et al. comparison of realtime pcr and the kato-katz method for the diagnosis of soiltransmitted helminthiasis and assessment of cure in a randomized controlled trial. bmc microbiol 2020;20:1–8. pathways of change, part ii [page 120] [healthcare in low-resource settings 2025;13(s2):13465] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13049 improving cardiopulmonary resuscitation skills for layperson in cases of heart attack: a scoping review muh. iwan zulhan, kumboyono kumboyono, retno lestari department of nursing, faculty of health sciences, brawijaya university, malang, east java, indonesia abstract the proficiency of trained individuals in effectively administering cardiopulmonary resuscitation (cpr) is paramount in mitigating the impact of out-of-hospital cardiac arrest incidents. inadequate cpr skills among laypersons can result in missed opportunities to save lives. therefore, it is imperative to prioritize unified efforts to enhance cpr competencies within the general populace. this scoping review aims to consolidate literature discussing the enhancement of laypeople’s cpr skills using various methodologies. this scoping review employed the prisma methodology and encompassed an extensive search across four critical databases (science direct, proquest, pubmed, and google scholar) for literature published between 2013 and 2023. the search utilized the keywords “cpr teaching,” “skill,” and “layperson.” out of 487 collected articles, 20 were deemed relevant. the findings of all relevant articles consistently indicated an improvement in laypeople’s cpr skills following training. incorporating concise cpr instructional videos and smartphone applications has shown potential for enhancing cpr knowledge and improving emergency responsiveness. nonetheless, integrating these modern technological approaches with traditional simulation methods has demonstrated greater efficacy in cpr training, resulting in enhanced compression quality and depth. in conclusion, integrating traditional and technology-based learning methodologies improves the capability of individuals without specialized medical training to administer cpr effectively. introduction cardiopulmonary resuscitation (cpr) is a crucial component in the chain of survival for individuals experiencing out-of-hospital cardiac arrest.1 presently, nearly 80% of cardiac arrests occur outside of hospital settings, with 30-50% of victims in the united states receiving cpr directly from lay members of the public.2 the active involvement of laypersons in delivering initial aid to out-of-hospital cardiac arrest (ocha) victims has been demonstrated to elevate the rate of cpr administration before the arrival of emergency services at the scene. multiple prehospital systems utilized by laypersons for treating out-of-hospital cardiac arrest victims globally, including in indonesia, adhere to the guidelines established by the american heart association (aha) and the emergency response commander (erc).3 laypersons hold a significant role as first aid providers in cases of out-of-hospital cardiac arrest. however, the current participation of laypersons in performing cpr remains low due to insufficient knowledge and skills in first aid.4 additionally, limited knowledge and skills can undermine the confidence of lay individuals in delivering cpr.5 the acquisition of cpr skills aims to sustain circulation and heart function, ultimately enhancing patient prognosis and reducing morbidity and mortality rates in cardiac arrest cases.6 various methods exist to enhance laypersons’ cpr proficiency.7 the simulation-based approach and instructor guidance stand out as a commonly employed technique.8 while effective, this method demands face-to-face training, qualified instructors, and substantial equipment, presenting challenges such as limited instructor availability, high training costs, and the need for numerous props, including mannequins.9,10 in addition to simulation-based training, technology-based methods, such as videos and applications, offer an alternative for enhancing layperson cpr skills.11 the development of cpr applications for smartphones opens up convenient and flexible learning opportunities, with the potential to significantly improve cpr education.10 while its effectiveness in skill improvement remains to be determined, the integration of technological methods with conventional training, as advocated by international resuscitation guidelines, offers a hopeful future for cpr education.12 this combined approach not only offers cost savings but also capitalizes on the prevalent use of technology among laypersons, thereby increasing the potential for technology-based cpr education.13,14 furthermore, study have shown that a combined approach involving technological and conventional methods yields comparable compression quality to traditional methods while enhancing laypersons’ awareness and skill acquisition in delivering first aid during cardiac arrest incidents.10 given the documented low proficiency in layperson-performed cpr, a hybrid approach encompassing technological methods and conventional training is essential for skill enhancement and must be considered as a viable means to this end.15 various research studies have indicated that integrating both technological and traditional methods can significantly improve the ability of non-professionals to perform cardiopulmonary resuscitation (cpr). consequently, this approach is a valuable technique for enhancing the cpr proficiency of laypersons. this scoping review seeks to synthesize existing literature on improving non-professionals’ cardiopulmonary resuscitation (cpr) proficiency through diverse methodologies. [healthcare in low-resource settings 2024;12(s1):13049] [page 139] significance for public health using technology as an educational medium offers numerous advantages, particularly its accessibility to the general populace. employing technology to learn essential life support can enhance lay people's understanding of first aid; refining skills necessitates simulation-based learning. thus, integrating technology and simulation-based learning approaches proves efficacious in enhancing lay individuals' knowledge and skills in administering essential life support during cardiac arrest. non -co mmerc ial us e o nly materials and methods the research employed the scoping review analysis method to compile, synthesize, and report published research aimed at enhancing layperson cpr skills, a topic of great interest to our audience of researchers, educators, and healthcare professionals. following the preferred reporting items for systematic reviews and meta-analyses extension for scoping reviews (prismascr) guidelines, an online electronic search was conducted across four databases: sciencedirect, pubmed, proquest, and google scholar, using the keywords “cpr teaching,” “skill,” and “layperson.” selection criteria included: i) studies published within the last ten years (2013 onwards) in indonesian or english; ii) focusing on cpr learning methods for lay people; iii) being freely accessible. four hundred eighty-seven articles were found across the databases, with 220 articles screened based on their titles and abstracts. following further evaluation, 20 research publications met the criteria, as depicted in figure 1 of the review literature search approach. data extraction and synthesis the researcher collected data from selected research articles to conduct a comprehensive analysis. subsequently, the researcher organized this data by creating a table with information such as the author’s name and year of publication, research objectives, research design, research methods, research samples, research location, and research results and conclusions. after compiling this information, the researcher independently analyzed the data from each article that met the necessary criteria. the findings were then thoroughly discussed, analyzed, and concluded. for your reference, supplementary materials table 1 provides a concise overview of the literature investigating methods for teaching cpr to laypeople to improve their ability to perform cpr in instances of cardiac arrest. results and discussion the review incorporates research articles (n=20) sourced from a range of countries, including the united states (6), india (1), brazil (1), sweden (1), germany (1), taiwan (1), korea (1), france (1), netherlands (1), and indonesia (5). the predominant research approach employed quantitative methods within a randomized controlled trial framework.16-21 the study’s participant numbers varied significantly, spanning from 24 to 50,000. improving cpr skills using video/audiovisual based on a comprehensive review of twenty studies, it has been established that cpr training utilizing video media can significantly enhance the skills of laypersons in performing cpr. combining video-based cpr training with hands-on practice using a mannequin has proven to be particularly effective in improving the cpr skills of ordinary individuals. furthermore, several studies have indicated that cpr training through video media increases laypersons’ sensitivity and responsiveness in real-life cpr situations, thus improving the quality and effectiveness of their cpr delivery. additionally, evidence from four separate studies has shown that cpr training via video media enhances laypersons’ knowledge and skills, particularly regarding the quality of chest compressions. however, it should be noted that sole reliance on video-based cpr training may only partially improve cpr skills in ordinary individuals. independent cpr training using video guidance may primarily enhance theoretical knowledge related to cpr implementation, as per the findings of one study. recent research has underscored the significant impact of providing basic life support (bls) health education through video on high school students’ knowledge levels. the process of watching educational videos has been identified as an effective method to foster a more nuanced understanding of basic life support, especially among laypeople. importantly, a study has indicated that cpr training using video media is a powerful tool for enhancing public knowledge and preparedness in delivering basic life support. based on are view of twenty studies, learning cpr using video media can improve layperson skills in performing cpr.6,22 apart from that, the results of other research conducted in the united states explain that cpr training using videos combined with practice using a mannequin has been proven to improve the skills of ordinary people in carrying out cpr.23 in three studies, cpr training using video media can increase the sensitivity of layperson to carry out cpr in real incidents, one of which is the research,20 explaining that cpr training form layperson using video media is proven to in crease sensitivity, ability, responsiveness, speed, and depth of compression. four other studies show that cpr training using video media is proven to be able to increase cpr knowledge and skills in laypeople (increasing the quality of compressions), such as the research10 that explains that cpr educational videos are proven to be able to increase laypeople’s knowledge about cpr.cpr training using only video media can not fully improve cpr skills in ordinary people. this is in line with research, explaining that independent cpr training using video guidance can only increase theoretical knowledge related to the implementation of cpr.20 apart from that, another research project (fauzan, kahtan, and herman 2021) explains that there is a significant influence on the provision of basic life support (bhd) health education via video on the level of knowledge of high school students.13 additionally, video-viewing process provides a new nuance in efforts to understand the management of basic life support, especially for laypeople.6 furthermore, cpr 4th international nursing and health sciences symposium figure 1. flowchart of scoping review with selection process using pris-ma. [page 140] [healthcare in low-resource settings 2024;12(s1):13049] non -co mmerc ial us e o nly training using video media can increase public knowledge in carrying out basic life support.4 improved cpr skills by using the app various research studies have underscored the effectiveness of cpr training facilitated through mobile applications in augmenting individuals’ proficiency and capabilities in executing cpr. this approach has been shown to heighten the general public’s preparedness to administer initial aid during instances of cardiac arrest. moreover, it provides valuable insights into pioneering cpr training methodologies, the determinants impacting cpr performance, and its enduring influence on attitudes toward resuscitation. a study by wirasakti in 2020 revealed that cpr training via applications substantially enhanced proficiency in chest compression speed and depth and minimized interruptions, thus ensuring the delivery of high-quality cpr. users have expressed satisfaction with this method owing to its pragmatic nature and resource efficiency. this is consistent with previous study which showcased elevated satisfaction levels among participants in cpr training through applications. they found this learning mode to be productive without compromising the quality of chest compressions compared to traditional training methods.5 metelmann recommended the use of applications as cpr training tools to enhance the cpr skills of laypersons for effective intervention during cardiac arrest. however, the study also stressed the inadequacy of relying solely on applications for cpr training. it advocated for a balanced approach that combines innovation with traditional training methods. this aligns with blewer’s research, which highlighted the need for innovative approaches, such as integrating digital systems with traditional learning methods, to address the lack of cpr skills among laypersons.19 several other studies explain the effectiveness of applicationbased cpr training in increasing people’s knowledge and skills in performing cpr. application-based cpr training can increase awareness of lay people in providing first aid in cases of cardiac arrest. apart from that, this training can also provide important insight into innovative cpr training methods, as well as factors that influence cpr performance and its impact on long-term attitudes towards resuscitation.2. other research conducted by wirasakti (2020) explains that training using the cpr application method affects increasing skills in performing chest compression speed, chest compression depth, and minimal interruptions of high quality12. furthermore, application-based cpr training provides satisfaction for its users due to its practical use and saving of resources required for training.this is in line with research conducted by lee where, cpr training using the application has its own satisfaction for the training participants. this is because the learning method is effective, and in terms of training skills using the application, it is not inferior to conventional training methods in terms of the quality of chest compressions.5 another research was also conducted by metelmann et al. explaining that the use of applications as a cpr learning medium is highly recommended in order to improve cpr skills in lay people so that they can provide assistance in cases of cardiac arrest.24 currently, using applications alone is not effective as a cpr training method. there needs to be innovation and a combination of conventional training with application-based training. this is in line with research conducted by blewer, explaining that the skills of lay people in carrying out cpr are still low. therefore, innovative methods are needed in the form of a combination of learning between digital systems and traditional learning (instructor’s guide).19 improved cpr skills using mixed methods (simulation and technology) currently, conventional training methods or simulation-based training with guidance from trained instructors are still the only standardized cpr training for both health workers and lay people. in its development, innovation in cpr learning or training is very important. this makes it easier for lay people to be able to learn easily and effectively. the role of technology in the form of applications and videos as a media for cpr learning will make it easier for people to increase their knowledge about cpr10. however, in improving skills, there needs to be a combination of simulationbased training with technology-based training, as explained in the previous research9 . a combination of learning between digital systems and traditional learning (instructor guides and simulations)is needed to improve cpr skills in laypeople. apart from that, the use of tools in the form of mannequins as training media is needed. this is in line with the previous researc, explaining that cpr training using mannequin aids can improve cpr skills and quality.25 in addition, simulation-based training is an effective cpr learning method for lay people. the results of research conducted by kuswanto and suyanto explain that cpr learning using the demonstration method is effective in improving students’ skills in performing basic life support14. video or audiovisual is an alternative that can be used by the public in learning cpr, this is because its use is practical and can be done anywhere. this is in line with research conducted by panchal et al explaining that playing short cpr videos online has potential as a learning media that can be carried out in public places to help increase the response of ordinary people to performing cpr in cases of cardiac arrest.20 apart from that, cpr learning can be done using applications by utilizing smartphones. developing applications on smartphones makes it easier for people to learn cpr at any time. however, this convenience does not necessarily improve the skills of ordinary people in performing cpr.2 the results of several studies explain that technology-based cpr training cannot fully improve the skills of ordinary people in performing cpr.in this case, innovation is needed in the form of combining conventional (simulation) and technology-based methods so that cpr learning becomes more effective and structured.9 in addition, an alternative approach involves offering supplementary treatments such as butterfly hug therapy. following simulated bystander cpr and butterfly hug therapy, there was a noticeable improvement in bystander cpr performance during specific cardiac arrest scenarios.26 many studies have been conducted to see the effectiveness of mixed training methods (conventional and technological) in improving cpr skills. training using a combination of technology with instructor guidance has been proven to improve cpr skills including the depth and quality of compressions. apart from that, with the mixed method participants will be directed to simulate the implementation of cpr using assistive devices in the form of a mannequin.this can improve the quality and depth of compressions produced.3,27 conclusions in conclusion, it is evident that a combination of traditional and technology-based learning, known as mixed methods, can enhance the cpr skills of laypersons. integrating technology into cpr education facilitates accessible learning, enabling individuals to acquire theoretical cpr knowledge conveniently. the technolo 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13049] [page 141] non -co mmerc ial us e o nly gies utilized encompass smartphones, televisions, and personal computers, with corresponding software such as applications, web platforms, and visual videos. these tools have been developed as educational mediums for laypersons to learn cpr effectively. however, to truly enhance cpr skills, more than mere guidance from applications or videos is required; direct practice in the form of simulations is essential for proficiency in cpr implementation. when combined with technology, simulation-based methods represent an innovative approach to improving laypersons’ cpr skills. such an integration allows for assessing compression depth and quality, thereby contributing significantly to advancing cpr proficiency among laypersons. references 1. högstedt a, thuccani m, carlström e, et al. characteristics and motivational factors for joining a lay responder system dispatch to out-of-hospital cardiac arrests. scand j trauma resusc emerg med 2022;30:22. 2. nas j, thannhauser j, vart p, et al. rationale and design of the lowlands saves lives trial: a randomised trial to compare cpr quality and long-term attitude towards cpr performance between face-to-face and virtual reality training with the lifesaver vr app. bmj open 2019;9:e033648. 3. ghazali da, rousseau r, breque c, oriot d. effect of realtime feedback device compared to use or non-use of a checklist performance aid on post-training performance and retention of infant cardiopulmonary resuscitation: a randomized simulation-based trial. australas emerg care 2023;26:36-44. 4. maulidya w, kusyani a, nurjanah s. the effect of cpr training videos for first aid preparedness for cardiac arrest patients on the level of knowledge in adolescents. jurnal insan cendekia 2022;9:70–7. 5. lee sgw, hong kj, lee sy, et al. efficacy of distance training program for cardiopulmonary resuscitation utilizing smartphone application and home delivery system. am j emerg med 2023;66:67-72. 6. maria i, wardhani a. effectiveness of training videos on the accuracy of basic life support outside the hospital. jksi 2023;8:143–51. 7. nirmalasari v, winarti w. the effect of training (bhd) on the knowledge and skills of public health students. widya gantari indonesian nurs j 2020;4:115–23. 8. kumboyono k, hanafi m, lestari ep. differences in the influence of sex education using simulation and group discussion methods on adolescents' attitudes in efforts to prevent deviant sexual behavior. brawijaya medical journal 2004;20:46–9. 9. chien cy, fang sy, tsai lh, et al. traditional versus blended cpr training program: a randomized controlled non-inferiority study. sci rep 2020;10:10032. 10. galindo neto nm, sá ggm, barros lm, et al. effectiveness of educational video on deaf people's knowledge and skills for cardiopulmonary resuscitation: a randomized controlled trial. rev esc enferm usp 2023;57:e20220227. 11. alfianto ag. the influence of family psychoeducation on the level of knowledge, attitude, action and belief in preventing coronary heart disease in families at risk in talok village, turen district, malang regency. malang: brawijaya university; 2018. 12. wirasakti g. the effect of multimedia cardiopulmonary resuscitation (cpr) learning methods on high quality cpr. jkds 2020;8:142–7. 13. fauzan ssf, kahtan i, herman h. the effect of providing basic life support (bhd) health education for the public through video on the knowledge level of high school children (sma) in pontianak city. jkk 2021;12:66–74. 14. kuswanto k, suyanto b. effectiveness of demonstration education on improving hand-only cardiopulmonary resuscitation skills in pmr members. jgd 2022;4:1–8. 15. beskind dl, stolz u, thiede r, et al. viewing a brief chestcompression-only cpr video improves bystander cpr performance and responsiveness in high school students: a cluster randomized trial. resuscitation 2016;104:28-33. 16. shende tc, battaglia mr, nuno t, beskind d. efficacy of a five-minute compression-only cardiopulmonary resuscitation class compared to thirty-minute instruction among college students. resusc plus 2020;3:100012. 17. ali s, athar m, ahmed sm. basics of cpb. indian j anaesth 2019;49:257-62. 18. nord a, svensson l, hult h, et al. effect of mobile application-based versus dvd-based cpr training on students' practical cpr skills and willingness to act: a cluster randomised 4th international nursing and health sciences symposium [page 142] [healthcare in low-resource settings 2024;12(s1):13049] correspondence: muh. iwan zulhan, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia. tel.: +62341569117 -9 fax: +62341564755. e-mail: iwangadar@student.ub.ac.id key words: cpr; layperson; learning methods; skills contributions: all authors contributed equally to this study. conflict of interest: the authors declare no conflicts of interest. funding: none. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and informed consent: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgements: the authors would like to express their appreciation to all individuals who have contributed to elevating the quality of this academic article. received: 5 november 2023. accepted: 10 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13049 doi:10.4081/hls.2024.13049 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly study. bmj open 2016;6:e010717. 19. blewer al, putt me, mcgovern sk, et al. a pragmatic randomized trial of cardiopulmonary resuscitation training for families of cardiac patients before hospital discharge using a mobile application. resuscitation 2020;152:28–35. 20. panchal ar, meziab o, stolz u, et al. the impact of ultra-brief chest compression-only cpr video training on responsiveness, compression rate, and hands-off time interval among bystanders in a shopping mall. resuscitation 2014;85:1287-90. 21. beskind dl, stolz u, thiede r, et al. viewing a brief chestcompression-only cpr video improves bystander cpr performance and responsiveness in high school students: a cluster randomized trial. resuscitation 2016;104:28-33. 22. matsuyama t, scapigliati a, pellis t, et al. willingness to perform bystander cardiopulmonary resuscitation: a scoping review. resusc plus. 2020 nov 25;4:100043. 23. wanner gk, osborne a, greene ch. brief compression-only cardiopulmonary resuscitation training video and simulation with homemade mannequin improves cpr skills. bmc emerg med 2016;16:45. 24. metelmann c, metelmann b, schuffert l, et al. smartphone apps to support laypersons in bystander cpr are of ambivalent benefit: a controlled trial using medical simulation. scand j trauma resusc emerg med 2021;29:76. 25. blewer al, putt me, becker lb, et al. video-only cardiopulmonary resuscitation education for high-risk families before hospital discharge: a multicenter pragmatic trial. circ cardiovasc qual outcomes 2016;9:740-8. 26. soeli ym, pomalango zb, hunawa r, arsad sfm. simulation of bystander cardiopulmonary resuscitation and butterfly hug therapy towards the ability to perform emergency assistance for cardiac arrest. malaysian j nursing (mjn) 2023;15:101–6. 27. lin l, ni s, cheng j, et al. effect of synchronous online vs. face-to-face cardiopulmonary resuscitation training on chest compression quality: a pilot randomized manikin study. am j emerg med 2021;50:80-4. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13049] [page 143] online supplementary materials table 1. summary of articles. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13434 effects of oxytocin massage and moringa cookie consumption on colostrum excretion time in postpartum women rika resmana,1 dewi purwaningsih,2 ida widiawati,1 sri mulyati,1 sri wisnu,1 yulinda yulinda,1 neneng widaningsih1 1health polytechnic of the ministry of health, bandung; 2health polytechnic of the ministry of health, tanjungkarang, indonesia abstract delayed colostrum secretion can hinder the success of exclusive breastfeeding, often due to insufficient stimulation of prolactin and oxytocin. this study aimed to examine the effect of oxytocin massage and moringa oleifera cookie consumption on accelerating colostrum excretion. a quasi-experimental post-testonly design with a control group was employed. the study involved 40 primigravida women in their third trimester, selected through purposive sampling and divided into an intervention group and a control group. the intervention group received oxytocin massage and consumed moringa cookies from the 38th week of gestation until postpartum colostrum release, while the control group received standard care. data were collected through observation, and analysis was conducted using the independent t-test. results showed a significant reduction in colostrum excretion time in the intervention group (mean=5.95 hours) compared to the control group (mean=9.00 hours) with a mean difference of 3.05 hours. the difference was statistically significant (p=0.001; α=0.05). these findings suggest that oxytocin massage combined with moringa cookie consumption may effectively stimulate earlier colostrum release. implementing such interventions during late pregnancy could support early breastfeeding initiation and improve neonatal health outcomes. introduction exclusive breastfeeding refers to the practice of feeding infants breast milk alone from birth to six months, without any additional foods or liquids (except for medications, vitamins, and minerals).1,2 exclusive breastfeeding is a crucial factor in reducing infant mortality rates. according to the world health organization (who), exclusive breastfeeding can save approximately 1.5 million lives of infants in developing countries annually. the who recommends exclusive breastfeeding as the sole source of nutrition for infants up to six months of age. breast milk is a unique biological fluid that meets the nutritional and immunological needs of infants.3 breast milk undergoes three stages: colostrum, transitional milk, and mature milk. colostrum, a thick, yellowish fluid, is produced in the first three days postpartum.4-6 providing colostrum offers protection against various diseases in infants, as it contains antibodies that prevent malnutrition.7-10 however, the prevalence of exclusive breastfeeding, including colostrum, within the first 24 hours remains low globally. in ethiopia, the percentage of mothers who do not provide colostrum to their infants ranges from 6.3% to 52.9%. according to the who, approximately 43% of infants worldwide receive breast milk, including colostrum, within one hour of birth. in indonesia, only 37.3% of infants receive colostrum.11-16 according to data from the indonesian ministry of health (2019), 31.36% of children fall ill due to the lack of exclusive breast milk, including colostrum. moreover, 80% (16,156) of neonatal deaths occur within the first six days. infectious diseases, which can be prevented by providing breast milk, including colostrum, are the primary cause of infant mortality.17 babies who do not receive colostrum often receive pre-lacteal foods, such as water, honey, or formula milk, as substitutes for colostrum. the provision of pre-lacteal foods is a major factor contributing to the failure of exclusive breastfeeding.18-22 failure to provide colostrum is often due to decreased milk production after childbirth.23 many mothers experience difficulties with breast milk production on the first day after delivery, primarily due to suboptimal breast milk hormone function. delayed breast milk production can be attributed to postpartum tension, fatigue, and stress, which elevate cortisol levels and inhibit the hormones responsible for breast milk production. efforts to stimulate correspondence: rika resmana, health polytechnic of the ministry of health, bandung, indonesia. e-mail: rikaresmana@staff.poltekkesbandung.ac.id key words: colostrum excretion time; moringa cookies; oxytocin massage; early-life nutrition. contributions: rr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; dp, conceptualization, investigation, methodology, validation, review & editing; iw, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; sm, methodology, visualization, writing – review & editing; sw, yy, and nw, resources, investigation, and writing –review & editing; aj resources, supervision, and writing –review & editing. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: the study received authorization from the health research ethics commission, poltekkes kemenkes bandung, as evidenced by approval no. 21/kepk/ec/x/2020. written informed consent was obtained from all participants in the study. consent for publication: written informed consent was obtained from patients for the publication of this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 28 november 2024. accepted: 14 april 2025. early view: 14 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13434 doi:10.4081/hls.2025.13434 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 62] [healthcare in low-resource settings 2025;13(s2):13434] the production of prolactin and oxytocin hormones are essential.2426 prolactin is the primary hormone regulating breast milk production, while oxytocin facilitates breast milk release.27,28 simple nonpharmacological interventions, such as massage techniques or oxytocin massage, can enhance breast milk release. the efficacy of oxytocin massage as a non-pharmacological intervention to enhance breast milk (colostrum) production has been extensively studied. several studies have demonstrated that oxytocin massage is a non-pharmacological approach that can increase breast milk production in postpartum mothers. this massage technique involves stimulating the spine (vertebrae) between the fifth and sixth ribs, which can increase oxytocin hormone production.29 research has shown that oxytocin massage can enhance breast milk production by up to 11.5 times by stimulating the spinal muscles and reducing cortisol levels by 28%. the massage stimulates neurotransmitters, which activate the medulla oblongata and send signals to the hypothalamus to release oxytocin from the posterior pituitary. additionally, massaging the spinal muscles can reduce tension, alleviate stress, and stimulate the milk ejection reflex.24,30 the prolactin hormone can be increased through the consumption of moringa leaves. moringa plants (moringa oleifera lamk) can be incorporated into the diet of breastfeeding mothers, as they contain phytosterol compounds that enhance and facilitate breast milk production, exhibiting a lactagogum effect.31 compounds with a lactagogum effect include sterols, which belong to the steroid group.32 research has shown that moringa leaf extract is safe for consumption by pregnant women in their third trimester, causing no complications during labor and no impact on uterine involution. furthermore, studies have demonstrated that the extract can increase breast milk volume.16,32 collaborative efforts are necessary to facilitate timely colostrum excretion, specifically through the administration of oxytocin massage and consumption of moringa cookies. these interventions can stimulate the prolactin and oxytocin hormones, thereby enhancing milk production and release. it is expected that oxytocin massage and moringa cookie consumption will increase milk production, enabling mothers to provide colostrum to their babies as soon as possible. materials and methods research design this research is analytical research with a quasi-experiment with a post-test design with a control group. locations for data collection were carried out in two areas of independent midwife practice (pmb), the cimahi city area and the bandung regency area. study participants this study’s population consisted of primigravidas with a gestational age of 38-42 weeks who were receiving antenatal care (anc) at the independent midwife practice in cimahi tengah district, cimahi city, and ebah district, bandung regency. data collection was conducted through observations in two groups: the intervention group and the control group. the intervention group comprised 20 pregnant women who received oxytocin massage and consumed moringa cookies, whereas the control group consisted of pregnant women who only received standard care. the intervention was administered over 12-14 days, starting from the 38th week of pregnancy until colostrum production postpartum. statistical analysis was performed using the independent t-test. participants met the inclusion criteria, which included pregnant women who had not yet produced colostrum at the time of sampling, planned to have a normal delivery, and intended to breastfeed their babies. purposive sampling was employed to select a sample of 40 respondents who met the inclusion criteria and provided informed consent. variables, instruments, and data collection the independent variables in this study were oxytocin massage and consumption of moringa cookies, while the dependent variable was the time of colostrum release. data collection was conducted on two groups: the intervention group and the control group. the intervention group consisted of participants who received an oxytocin massage and consumed moringa cookies. oxytocin massage intervention the oxytocin massage intervention involved midwives administering oxytocin massage to mothers at the research location. prior to the intervention, all midwives were briefed on the correct technique. during the intervention, mothers were instructed to remove their upper clothing, sit comfortably, and lean forward. they placed their hands on a bed in front of them and rested their head on their hands. the midwife then massaged the mother’s back using a rotating motion with thumbs lubricated with baby oil, focusing on the spine between the 5th and 6th ribs. the massage lasted for 3 rotations or 10-15 minutes. the midwife’s hands were clenched with thumbs pointing forward. this massage was performed daily, twice a day (morning and evening), for 12-14 days. the intervention was suspended during childbirth and resumed after completion of the labor process. oxytocin massage ceased when examination of the breast areola confirmed colostrum release. consumption of moringa cookies the consumption of moringa oleifera cookies occurred simultaneously with the oxytocin massage intervention, wherein mothers consumed the cookies subsequent to the completion of the oxytocin massage session. cookie consumption was carried out twice daily (morning and evening) for 12-14 days. consumption was paused during the labor process and resumed upon completion. the intervention ceased when examination of the breast’s areola massaging confirmed colostrum release. moringa cookies were prepared by researchers with the following composition: margarine, butter, powdered sugar, honey, egg yolk, cherries, wheat flour, moringa leaf powder, and cornstarch. each cookie weighed 100 g and contained 10 g of dry moringa leaf powder. prior to administration, moringa oleifera cookies underwent organoleptic and nutritional content testing. organoleptic test results indicated that the cookies had a fairly good taste, a crunchy texture, and were suitable for consumption. laboratory tests revealed that every 100 g of moringa cookies contained 401 kcal, 21 g of fat, 12 g of protein, and 34 g of carbohydrates. measurement of the time of colostrum release the time of colostrum release was measured by calculating the duration from delivery to the release of colostrum. to check for colostrum release, a midwife massaged the areola area of the mother’s breast shortly after delivery. colostrum checks were performed by midwives at 1-hour intervals. colostrum was considered released if, after massage, breast milk was visible in the areola area. conversely, if no breast milk was visible after massage, colostrum release was not declared. the measurement results were documented on the provided observation sheet. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13434] [page 63] data analysis data were processed using spss for windows version 16. bivariate analysis was used to determine differences in colostrum excretion time between pregnant women who received an intervention and those who did not, using the independent t-test. ethical clearance the study received authorization from the health research ethics commission, poltekkes kemenkes bandung, as evidenced by approval no. 21/kepk/ec/x/2020. written informed consent was obtained from all participants in the study. results the demographic characteristics of mothers in the control group (receiving standard treatment) and the intervention group (receiving oxytocin massage and consuming moringa cookies) are summarized in tables 1 and 2. the majority of mothers in the control and intervention groups had a high school education level (90.0% and 85.0%, respectively) and were unemployed (90.0% and 75.0%, respectively). table 2 shows the average age of mothers. in the control group, the average maternal age was 21.10 years (sd=2.174). the intervention group had an average maternal age of 21.45 years (sd=2.585 years). in the control group, the average birth weight of the children was 3,115 g (sd=406.88 grams). in comparison, the average birth weight of babies in the postpartum group that received oxytocin massage and consumed moringa cookies was 3,042 grams (sd=505.57 grams). regarding the average breastfeeding frequency in the two postpartum groups, the group that did not receive oxytocin massage combined with moringa cookie consumption had an average of 9.7 (sd=1.895). in comparison, the intervention group had an average of 10.35 (sd=1.843). the average time of colostrum release in the intervention group differed significantly from that of the control group. the intervention group demonstrated a shorter average time to colostrum release (5.95 hours post-delivery) compared to the control group (9.00 hours post-delivery). the difference in colostrum release time was statistically significant (p=0.001, α=0.05), indicating that mothers who received oxytocin massage and consumed moringa cookies had a faster colostrum release time compared to those who did not. discussion this study investigates the collaborative effects of oxytocin massage and moringa cookie consumption on colostrum excretion time during the postpartum period. colostrum excretion time is defined as the duration between labor onset and colostrum release from the breasts. data analysis revealed a significant difference in mean colostrum excretion time between the intervention group (oxytocin massage and moringa cookie consumption) and the control group (no oxytocin massage or moringa cookie consumption). specifically, the intervention group demonstrated a shorter colostrum excretion time (mean=5.95; sd=2.45) compared to the control group (mean=9.00; sd=2.90). the difference between the two groups was statistically significant (p=0.001; α=0.05). colostrum is a thick, yellowish, milky liquid produced in the first three days postpartum.4,5 the lactation process involves two reflex mechanisms: the prolactin reflex and the oxytocin reflex, which play crucial roles in milk production.33 the action of the prolactin hormone is influenced by various factors, including emotional state. hormones associated with feelings of happiness and joy, such as dopamine, serotonin, and catecholamines, affect prolactin and oxytocin function.34 in the early postpartum period, decreased milk production (colostrum) may occur due to inadequate stimulation of prolactin and oxytocin hormones.26,35 simple nonpharmacological interventions, such as massage techniques or oxytocin massage, can help increase milk production. oxytocin massage is a massage of the spine from the 5th to 6th rib up to the shoulder blades. the purpose of the oxytocin massage is to calm mothers and help them relax, thereby increasing their affection toward their baby and stimulating the release of oxytocin, which can accelerate the release of breast milk.23 this massage will facilitate the work of the parasympathetic nerves, conveying commands to the back of the brain to release oxytocin. the way oxytocin massage works is by providing a stimulus to the vertebrae, specifically to ribs 5-6, which then increases stimulation to the posterior pituitary, causing it to secrete the oxytocin hormone.36 the success of oxytocin massage as a non-pharmacological effort to increase colostrum production has been widely studied. several studies have shown that oxytocin massage can stimulate the hormone oxytocin. a study has supported the statement above, indicating that colostrum spending time in the oxytocin massage intervention group was faster than in the control group, which was 23.04 hours after the baby was born.30,37-39 various factors, including lactogogum, influence the production of the prolactin hormone. lactogogum is a substance that has the function of increasing milk production. consuming foods containing lactagogum is a non-pharmacological effort that can increase milk production.40 moringa is a local food ingredient that has the function of increasing milk production, as it contains various phytosterol compounds. the content of phytosterols in every 100 g of moringa consists of 1.15% sitosterol and 1.52% pathways of change, part ii table 1. characteristics of pregnant women related to education and employment in control and intervention groups. variable control group intervention group n % n % education high school 18 90.00 17 85.00 academy/university 2 10.00 3 15.00 work no 18 90.00 15 75.00 yes 2 10.00 5 25.00 table 2. characteristics of pregnant women, including the age of the mother and the baby’s birth weight, in the control and intervention groups. variable control group intervention group mean±sd mean±sd median (range) median (range) age of mother (years) 21.10±2.17 21.45±2.58 21.00 (19-25) 21.00 (19-25) baby’s birth weight (g) 3,115.00±406.88 3,042.50±505.57 3,15 2,75 (2,500.00-3,600.00) (2,500.00-3,700.00) [page 64] [healthcare in low-resource settings 2025;13(s2):13434] stigmasterol, which can stimulate milk production. moringa oleifera has a potential effect in supporting the timing of colostrum excretion and is declared safe for consumption by third-trimester pregnant women, as it does not cause complications in the delivery process and does not affect the process of uterine involution.16,31,32 moringa cookies are an effort to create products from moringa leaves that can be utilized, especially by pregnant and lactating women, to support the prolactin hormone and enhance breast milk production.32 several research results state that consumption of moringa can stimulate the hormone prolactin. a study involving the administration of 800 mg of moringa leaf powder extract for three months to breastfeeding mothers increased breast milk production by 66.2%. another study, involving the administration of 50 g of moringa biscuits for one month to breastfeeding mothers, found that it improved breast milk quality.32 based on the results of this study, it can be estimated that the colostrum excretion time may be reduced if the mother applies oxytocin massage in combination with consuming moringa cookies. limitations based on the researchers’ direct experience in this study, several limitations were identified. firstly, the small sample size (n=40) may not be representative of the larger population, limiting the generalizability of the findings. secondly, the study’s geographical area was limited, which may restrict the objectivity of the results. moreover, other variables, such as the participants’ diet, may influence the time of colostrum release and were not controlled for in this study. these limitations highlight the need for future research to address these concerns by increasing the sample size, expanding the study’s geographical scope, and accounting for potential confounding variables, such as diet. conclusions this study found that postpartum mothers who received oxytocin massage and consumed moringa cookies experienced significantly faster colostrum release than those who did not. these findings support the use of non-pharmacological interventions – specifically oxytocin massage and lactagogue-rich foods, such as moringa cookies – to stimulate early colostrum production. healthcare providers are encouraged to educate and counsel pregnant women on these methods to promote timely breastfeeding initiation. references 1. kemenkes ri. peraturan pemerintah republik indonesia nomor 33 tahun 2012 tentang pemberian asi eksklusif. 2012;1-11. available from: https://pergizi.org/images/stories/ downloads/pp/pp%2033%202012%20ttg%20pemberian%20a si%20ekslusif.pdf 2. gonzales am, gonzales jr. am. marital adjustment and prenatal breastfeeding efficacy of first time mothers in a low-income community in the philippines. j ners 2020;15:7-13. 3. sangild pt, vonderohe c, melendez hebib v, burrin dg. potential benefits of bovine colostrum in pediatric nutrition and health. nutrients 2021;13:1-41. 4. liben ml. colostrum: the golden milk for infants’ health. glob j intellect dev disabil 2017;1:59-60. 5. wijaya fa. nutrisi ideal untuk bayi 0-6 bulan. cdk-j 2019;46:296-300. available from: https://media.neliti. com/media/publications/399945-asi-eksklusif-nutrisi-idealuntuk-bayi-0-18d0db99.pdf 6. wahyudi e, utomo mt, etika r. oral care colostrum effect on preterm infants fecal immunoglobulin a secretory level. indian j forensic med toxicol 2020;14:945-9. 7. chirico g, marzollo r, cortinovis s, et al. antiinfective properties of human milk. j nutr 2008;138:1801-6. 8. lawrence rm, pane ca. human breast milk: current concepts of immunology and infectious diseases. curr probl pediatr adolesc health care 2007;37:7-36. 9. meshram ii, laxmaiah a, venkaiah k, brahmam gnv. impact of feeding and breastfeeding practices on the nutritional status of infants in a district of andhra pradesh, india. natl med j india 2012;25:201-6. 10. mardiyan kurniawati e, rahmawati na. records of antibodies in breast milk in postpartum women who have been vaccinated or exposed to covid-19: a systematic review. f1000research 2022;11:785. 11. tariku a, biks ga, wassie mm, et al. factors associated with prelacteal feeding in the rural population of northwest ethiopia: a community cross-sectional study. int breastfeed j 2016;11:1-7. 12. abie bm, goshu ya. early initiation of breastfeeding and colostrum feeding among mothers of children aged less than 24 months in debre tabor, northwest ethiopia: a cross-sectional study. bmc res notes 2019;12:1-6. 13. weldesamuel gt, atalay ht, zemichael tm, et al. colostrum avoidance and associated factors among mothers having children less than 2 years of age in aksum town, tigray, ethiopia: a cross-sectional study 2017. bmc res notes 2018;11:1-7. 14. yimer nb, liben ml. effects of home delivery on colostrum avoidance practices in north wollo zone, an urban setting, ethiopia: a cross sectional study. j heal popul nutr 2018;37:17. 15. kemenkes ri. hasil riset kesehatan dasar tahun 2018. kementrian kesehatan ri 2018;53:1689-99. 16. setiawandari s. efektifitas ekstrak sauropus androgynus (daun katuk) dan ekstrak moringa oleifera lamk (daun kelor) terhadap proses persalinan, produksi kolostrumdan proses involusi uteri ibu postpartum. embrio 2017;9:16-23. 17. profil kesehatan indonesia 2019. available from: https://kemkes.go.id/app_asset/file_content_download/profil-kesehatanindonesia-2019.pdf 18. ayiasi mr, van royen k, verstraeten r, et al. exploring the focus of prenatal information offered to pregnant mothers regarding newborn care in rural uganda. bmc pregnancy childbirth 2013;13:176. 19. haider r, rasheed s, sanghvi tg, et al. breastfeeding in infancy: identifying the program-relevant issues in bangladesh. int breastfeed j 2010;5:1-12. 20. kavle ja, lacroix e, dau h, engmann c. addressing barriers to exclusive breast-feeding in lowand middle-income countries: a systematic review and programmatic implications. public health nutr 2017;20:3120-34. 21. hurley-hanson ae, giannantonio cm. crisis response decision making: critical elements of a crisis response plan. argyros sch bus econ 2013;104:25-36. 22. hinde k. kolostrum melalui lensa budaya kolostrum dalam konteks sejarah. 2017. 23. wulandari s, triharini m, wahyuni sd. the effect of a combi pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13434] [page 65] nation of oxytocin massage and music therapy on breast milk production and breastfeeding self efficacy in primipara post partum mothers. pediomaternal nurs j 2020;6:49. 24. jannah sr, widyawati mn. comparing effectiveness of palm dates and oxytocin massage in stimulating breastmilk production of post partum mother. int conf appl sci heal 2017;33:63-9. 25. farida s, sulistyorini e, pangestu rbr. oxytocin massage increase milk production during breastfeeding. int conf heal sci technol 2021;80-2. 26. budiono b, pertami sb, kasiati, et al. lactogenic effect of polyscias scutellaria extract to maintain postpartum prolactin and oxytocin in lactating rats. j ayurveda integr med 2023;14. 27. sherwood l. fisiologi manusia: dari sel ke sistem. 8th ed. jakarta: penerbit buku kedokteran egc.; 2014. 28. idai. air susu ibu dan menyusui. 2016, p. 28. available from: https://www.idaijogja.or.id/air-susu-ibu-dan-menyusui/ 29. azizah n, santoso b, abdurachman, et al. increasing oxytocin through electroacupuncture stimulation at li4 and sp6 points in postpartum cesarean section. pharmacogn j 2024;16. 30. resmana r, hadianti dn. oxytocin massage can expedite the time of colostrum discharge in the post section caesarian. open j nurs 2019;09:757-64. 31. hamdi hh, prastiya ra, sardjito t, et al. effect of addition of moringa (moringa oliefera) in the feed on conception rate, litter size and survival rate of local rabbits in indonesia. indian vet j 2024;101:7-11. 32. zakaria, hadju v, as’ad s, bahar b. effect of extract moringa oleifera on quantity and quality of breastmilk in lactating mothers, infants 0-6 month. j mkmi 2016;12:161-9. 33. tjokroprawiro ba, aldika akbar mi, luqman em, widjiati w. profile of maternal serum oxytocin in postpartum and nonpregnant rats. vet stanica 2023;54:665-72. 34. dr soetjiningsih d. asi petunjuk untuk kesehatan. egc, editor. jakarta; 2010. 35. bobak i. buku ajar keperawatan maternitas. 4th ed. jakarta: egc; 2005. 36. sulaeman r, lina p, mas’adah m, purnamawati d. pengaruh pijat oksitosin terhadap pengeluaran asi pada ibu postpartum primipara. j kesehat prima 2019;13:10. 37. patel du, gedam dds, verma mm. effect of back massage on lactation among postnatal mothers. int j med res rev 2013;1:5-11. 38. rahayuningsih t, mudigdo a, murti b. effect of breast care and oxytocin massage on breast milk production: a study in sukoharjo provincial hospital. j matern child heal 2016;01:101-9. 39. w parwati dm. the effect of breast acupressure and oxylosins massage to improve the breast milk production in postpartum mother. j med sci clin res 2017;5:28756-60. 40. rollins nc, bhandari n, hajeebhoy n, et al. lancet breastfeeding series group. why invest, and what it will take to improve breastfeeding practices? lancet 2016;387:491-504. pathways of change, part ii [page 66] [healthcare in low-resource settings 2025;13(s2):13434] hrev_master healthcare in low-resource settings 2025; volume 13:13315 peer empowerment and influencing factors in improving adolescents’ healthy lifestyles in urban areas: a cross-sectional study praba diyan rachmawati,1 ilya krisnana,1 iqlima dwi kurnia,1 nuzul qur’aniati,1 yuni sufyanti arief,1 titis mustikowati danasari,1 sirikanok klankhajhon2 1faculty of nursing, universitas airlangga, surabaya, east java, indonesia; 2faculty of nursing, naresuan university, phitsanulok, tha pho, thailand abstract adolescents’ unhealthy lifestyles are greatly influenced by their peers. however, peers often struggle to positively impact healthy lifestyle choices. therefore, empowering peer groups has become essential, although the factors that contribute to the effectiveness of peer empowerment programs are still unclear. this study aims to analyze the factors influencing peer empowerment in shaping healthy lifestyles among adolescents. this research employed a descriptive-analytic design with a cross-sectional approach. the sample comprised 205 adolescents residing in urban areas, selected using proportional stratified random sampling. data were collected through questionnaires and analyzed using multiple linear regression tests with p<0.05. the findings indicate that peer empowerment in promoting healthy lifestyles among adolescents is influenced by attitude (p=0.000; t=4.034), perceived benefits (p=0.037; t=2.098), affect (p=0.000; t=4.795), and motivation (p=0.000; t=7.298). health practitioners and relevant stakeholders should consider approaches that optimize adolescents’ attitudes, perceived benefits, affect, and motivation in developing peer empowerment programs to promote healthy lifestyles among adolescents. introduction lifestyle plays a crucial role in determining individual health and illness.1 adolescents are particularly susceptible to adopting unhealthy lifestyles, including poor dietary habits, insufficient physical activity, increased sedentary behavior, and smoking.2 adolescence marks a pivotal stage in human development characterized by dynamic physical, emotional, and psychological transformations. within this transitional period, individuals establish behavioral patterns that often endure into adulthood, underscoring the importance of fostering healthy lifestyle habits early on.3 unhealthy lifestyle in adolescents has adverse health consequences, such as obesity, metabolic syndrome, cardiovascular diseases, decreased quality of life, and psychosocial disorders.4 in indonesia, according to the indonesian pediatric association (idai), cases of type 2 diabetes mellitus in adolescents will increase by 70% in 2023, which is attributed to lifestyle changes among adolescents. over time, adolescents’ dietary patterns and lifestyles undergo transitions that lead to potential risks of obesity and non-communicable diseases.5 research shows that urban adolescents in indonesia are found to consume fast food, energy drinks, and sweet and salty foods 1-3 times a week, which contributes to the obesity epidemic.6 furthermore, adolescents spend significantly less time on physical activity compared to their screen time, which surpasses the recommended limits.7 peers have a significant influence on adolescents’ lifestyles.8 however, the role of peers in influencing adolescent health is still not optimal. for instance, adolescents in peer environments where smoking is prevalent are more likely to adopt smoking behaviors.9 other research also indicates that peer influence is directly and significantly correlated with drug use among adolescents.10 peers influence almost all aspects of adolescent life, from trivial matters such as music preferences, clothing, and food choices to more serious issues like illegal drug use or even risky sexual behavior.11 efforts to cultivate positive health behaviors during adolescence are vital for mitigating future health risks and enhancing longterm well-being. however, motivating adolescents to adopt and maintain healthy choices poses a formidable challenge.12 these phenomena demonstrate that peers have not yet develcorrespondence: praba diyan rachmawati, faculty of nursing, universitas airlangga, east java, surabaya, indonesia tel.: +6281331012854 e-mail: praba-d-r@fkp.unair.ac.id key words: adolescent; empowerment; healthy lifestyle; peers. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this study obtained approval from the health research ethics committee of the faculty of nursing, universitas airlangga, indonesia (no. 2939-kepk). informed consent was obtained from the participants’ parents. availability of data and materials: all data underlying the findings are fully available. funding: this study received funding from the directorate of research, technology, and community service of the ministry of education, culture, research, and technology, indonesia, with contract number 040/e5/pg.02.00.pl/2024;1795/b.un3.lppm/pt.01.03/2024. acknowledgments: the researchers express their gratitude for the support and funding received from the directorate of research, technology, and community service of the ministry of education, culture, research, and technology of indonesia. they also extend their thanks to universitas airlangga and all the participants who contributed to this study. received: 29 october 2024. accepted: 13 january 2025. early access: 6 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13315 doi:10.4081/hls.2025.13315 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13315] [page 143] oped the capacity to change adolescents’ healthy lifestyles. empowerment has emerged as a key health promotion strategy that can help increase adolescent participation in improving health status.13 addressing these concerns has emerged as a critical public health imperative, particularly in light of escalating rates of obesity, sedentary behavior, and related health challenges in adolescents.14 developing peer empowerment programs to promote healthy lifestyles among adolescents has the potential to transform adolescent adaptation and behavior.15 adolescent empowerment as peers is built on assets, critical awareness, agency, and voice participation.16 comprehending the intricate determinants of healthrelated practices is essential for the development of effective public health initiatives.17 factors influencing the optimization of peer empowerment in promoting healthy lifestyles among adolescents need to be identified as a foundation for peer empowerment intervention approaches. unfortunately, research analyzing the factors contributing to peer empowerment in shaping healthy lifestyles among adolescents remains limited. the objective of this study is to analyze the determinant factors that can influence peer empowerment in shaping healthy lifestyles among adolescents. materials and methods this study employed a descriptive-analytic design with a cross-sectional approach. the study population comprised adolescents in urban areas of surabaya, indonesia. the research was carried out in junior high schools across four sub-districts in surabaya, indonesia. the inclusion criteria for this study were adolescents aged 13-15 years in surabaya who did not have special needs. the sample size was calculated using the slovin formula, resulting in 205 respondents. the number of respondents in each sub-district was determined using proportional stratified random sampling. independent variables in this study included personal and environmental characteristics factors (age, parental education, culture, attitudes, school characteristics), perceived benefits, perceived barriers, self-efficacy, affect, motivation, and commitment to peer behavior in improving lifestyle. the dependent variable was peer empowerment, comprising assets, critical awareness, agency, voice, and participation in adolescent healthy lifestyles. the variables used are based on the health promotion model (hpm) theoretical framework approach, empowerment theory, and youth empowerment program. hpm emphasizes the flow of health promotion behavior formation.18 empowerment theory and youth empowerment programs describe the process of empowering adolescents through optimizing their capacity to play an active role in their surrounding environment.19 the study was conducted after obtaining permission from the surabaya city education office, the schools involved, and students whose parents had completed and approved informed consent for participation in the research. data were collected using questionnaires consisting of demographics, family culture, attitudes, school characteristics, perceived benefits, perceived barriers, self-efficacy, affect, motivation, commitment, and adolescent empowerment (assets, critical awareness, agency, voice, and participation). the questionnaires used were validated and reliable, and all were in indonesian. the reliability of the questionnaire varies: family culture (α=0.88), attitude (α=0.76), school characteristics (α=0.81), perceived benefits (α=0.96), perceived barriers (α=0.78), self-efficacy (α=0.95), affect (α=0.97), motivation (α=0.92), commitment (α=0.93), assets (α=0.94), critical awareness (α=0.86), agency (α=0.84), voice and participation (α=0.90). the time required for respondents to complete the questionnaire was approximately 20 minutes. this study was analyzed using a multiple linear regression test (ordinary linear regression) with the backward method with p<0.05 in order to identify the independent factors that had the biggest impact on the dependent variable. this study obtained approval from the health research ethics committee of the faculty of nursing, universitas airlangga, indonesia, no. 2939-kepk. this research applies ethical princi article table 1. characteristics of respondents (n=205). characteristics frequency % mean sd age 14.12 0.75 13 years old 47 22.9 14 years old 86 42.0 15 years old 72 35.1 parental education 3.14 0.67 low education 17 8.3 high education 188 91.7 dietary culture 13.59 3.75 low 105 51.2 high 100 48.8 attitude 20.08 5.89 negative 76 37.1 positive 129 62.9 school characteristics 23.99 3.37 poor 38 18.5 good 167 81.5 perception of benefits 7.24 1.25 low 73 35.6 high 132 64.4 barrier 11.83 1.71 low 95 46.3 high 110 53.7 self-efficacy 177.61 44.44 low 114 55.6 high 91 44.4 affect 36.20 7.47 negative 101 49.3 positive 104 50.7 motivation 61.60 8.46 low 104 50.7 high 101 49.3 commitment 36.32 4.35 poor 112 54.6 good 93 45.4 assets 116.34 14.16 low 99 48.3 high 106 51.7 critical awareness 19.98 3.47 low 82 40.0 high 123 60.0 agency 13.70 5.67 low 99 48.3 high 106 51.7 voice participation 24.96 5.95 low 100 48.8 high 105 51.2 peer empowerment in a healthy lifestyle 174.98 23.11 low 108 52.7 high 97 47.3 [page 144] [healthcare in low-resource settings 2025;13:13315] ples; before filling out the questionnaire, the researcher explains the aims and objectives of the research, respondent rights, and research procedures to the parents of the adolescents. eligible adolescents accessed the questionnaires after obtaining consent from their parents. results the majority of participants were 14 years old (42%). a significant proportion of adolescents demonstrated positive attitudes (62.9%), and most reported good school characteristics (81.5%). additionally, a high percentage of teenagers perceived high benefits (64.4%) related to healthy lifestyles. the data shows that slightly over half of the respondents reported positive affect (50.7%), high assets (51.7%), high agency (51.7%), and high voice and participation (51.2%). notably, critical awareness was predominantly in the high category (60%). however, the findings also reveal some challenges. most adolescents reported high perceived barriers to maintaining a healthy lifestyle (53.7%). furthermore, a slight majority demonstrated low motivation (50.7%) and poor commitment (54.6%) to healthy lifestyle behaviors. consequently, the overall peer empowerment in promoting healthy lifestyles among adolescents was predominantly in the low category (52.7%) (table 1). the results of the multivariate analysis indicate that the factors of attitude (p=0.001; t=3.230), obstacles (p=0.034; t=2.136), affect (p=0.002; t=3.122), and motivation (p=0.000; t=6.402) significantly influence asset factors for adopting a healthy lifestyle among adolescents. the critical awareness factor in adolescents for developing a healthy lifestyle is influenced by the obstacles they encounter (p=0.003; t=2.987), their affect (p=0.000; t=5.934), and their motivation (p=0.000; t=5.585). the factors affecting adolescents’ agency in adopting a healthy lifestyle include parental education (p=0.021; t=-2.323), attitude (p=0.025; t=2.264), affect (p=0.032; t=2.154), and motivation (p=0.018; t=2.386). factors affecting adolescent participation in healthy lifestyle behaviors are affect (p=0.000; t=5.109) and motivation (p=0.000; t=5.804). in general, peer empowerment in adopting a healthy lifestyle is influenced by attitude (p=0.000; t=4.034), perceived benefits (p=0.037; t=2.098), affect (p=0.000; t=4.795), and the motivation possessed by adolescents (p=0.000; t=7.298) (table 2). the study findings show that the attitude factor towards assets has a positive influence (b=0.462), the perceived obstacle factor towards assets has a greater positive influence (b=1.058), the affect factor towards assets has a positive influence (b=0.348), and the motivation factor towards assets also has a positive influence (b=0.654). the perceived obstacle factor towards critical awareness has a greater positive influence (b=0.354), the affect factor towards critical awareness has a positive influence (b=0.161), and the motivation factor towards critical awareness has a positive influence (b=0.138). the parental education factor towards agency has a greater negative influence (b=-1.331), the attitude factor towards agency has a positive influence (b=0.150), the affect factor towards agency has a positive influence (b=0.111), and the motivation factor towards agency has a positive influence (b=0.111). the affect factor on adolescent voice participation has a positive influence (b=0.250), and the motivation factor on voice participation has a greater positive influence (b=0.251). meanwhile, the attitude factor among teenagers towards peer behavior in a healthy lifestyle has a positive influence (b=0.860), the perceived benefit factor felt by teenagers towards peer behavior in a healthy lifestyle has a greater positive influence (b=2.112), the affect factor has a positive influence on peer behavior in a healthy lifestyle (b=0.819), and the motivation factor has a positive influence on peer behavior in a healthy lifestyle (b=1.130). discussion this research examines the relationship between personal and environmental characteristics (age, parental education, culture, article table 2. results of the multivariate analysis test (n=205). variables regression coefficient (b) t p-value 95% confidence interval lower upper peer empowerment in a healthy lifestyles attitude 0.860 4.034 0.000 0.440 1.281 perception of benefits 2.112 2.098 0.037 0.127 4.097 affect 0.819 4.795 0.000 0.482 1.155 motivation 1.130 7.298 0.000 0.825 1.435 assets attitude 0.462 3.230 0.001 0.180 0.745 obstacle 1.058 2.136 0.034 0.081 2.035 affect 0.348 3.122 0.002 0.128 0.568 motivation 0.654 6.402 0.000 0.452 0.855 critical awareness obstacle 0.354 2.987 0.003 0.120 0.587 affect 0.161 5.934 0.000 0.108 0.215 motivation 0.138 5.585 0.000 0.089 0.186 agency parental education -1.331 -2.323 0.021 -2.460 -0.201 attitude 0.150 2.264 0.025 0.019 0.282 affect 0.111 2.154 0.032 0.009 0.212 motivation 0.111 2.386 0.018 0.019 0.202 voice participation affect 0.250 5.109 0.000 0.154 0.347 motivation 0.251 5.804 0.000 0.166 0.337 [healthcare in low-resource settings 2025;13:13315] [page 145] attitudes, school characteristics), perceived benefits, perceived barriers, self-efficacy, affect, motivation, and commitment with components of peer empowerment in promoting healthy lifestyles among adolescents. the findings indicate that personal and environmental characteristics (attitudes), perceived benefits, affect, and motivation are associated with peer empowerment in promoting healthy lifestyles. previous research has shown that adolescents with good perceptions of benefits and motivation to engage in healthy lifestyles yield significant results in their adopted healthy lifestyles.20 adolescent attitudes and behaviors are linked to peer behaviors, demonstrating that peer groups are considered to achieve social goals and enhance adolescents’ social motivation.11 this is consistent with the findings of this study, where positive attitudes and motivation towards healthy lifestyles form peer groups with healthy lifestyles. adolescents in their development often seek to meet expectations influenced by their surrounding environment, so peer groups with positive affect in implementing healthy lifestyles have a positive impact on forming healthy behaviors.21 the components of the peer empowerment process in promoting healthy lifestyles include assets, critical awareness, agency, and voice participation. research findings show that personal and environmental characteristics (attitudes), perceived barriers, affect, and motivation influence assets. assets are the skills, opportunities, and values that serve as resources for adolescents’ resilience and strength in maintaining healthy lifestyles.22 assets in their role encompass commitment, motivation, integrity and responsibility, planning, decisionmaking, self-esteem, empowerment, and social support.23 this study’s findings indicate that barriers have the most significant impact on assets, resulting in adolescents lacking strong resources for maintaining healthy lifestyles. barriers are caused by individual factors, facilities, support, and the surrounding environment (school, peers, and family), preventing adolescents from adopting healthy lifestyles.24 assets that have a substantial influence on adolescents’ resources for maintaining healthy lifestyles are family and peer support.25 additionally, adolescents’ understanding of the healthy lifestyle concept can enhance their ability to maintain healthy lifestyles, where ease of access to information and support from the surrounding environment, especially peers, will yield more significant results.26 the research results show that barriers, affect, and adolescent motivation influence adolescents’ critical awareness of healthy lifestyles. critical awareness refers to the active consideration and development of analysis regarding adolescents’ beliefs and knowledge about maintaining healthy lifestyles.27 adolescence is a critical phase for individuals to establish healthy lifestyles, as health behaviors adopted during this period will play a crucial role in later vulnerabilities.28 previous research states that adolescents are aware of the importance of healthy lifestyles; however, most adolescents do not maintain healthy lifestyles due to perceived barriers.29 adolescents recognize the importance of adopting healthy lifestyles, but this does not correspond with the health behaviors they implement, which is associated with potentially insufficient knowledge to improve adolescents’ lifestyles.30 this relates to the aspects of assets, agency, and voice participation possessed by adolescents. individual and environmental characteristics (parental education and attitudes), affect, and motivation influence the agency aspect. the agency aspect refers to adolescents’ ability to act and make free and informed choices to achieve the goal of implementing healthy lifestyles.31 with the power of knowledge they possess, adolescents acquire skills such as problem-solving, communication skills, building self-efficacy beliefs, and facilitating adolescents to play a more active role in their surroundings or with other adolescents. the agency aspect cannot be well achieved when adolescents’ asset and critical awareness aspects are not well-formed. adolescents’ environmental characteristics influence their lifestyle choices. the role of parents, associated with their educational background and knowledge of adolescent healthy lifestyles, has a significant impact on changes in adolescent behavior.32 previous research states that parental education influences adolescent behavior, but higher parental education levels do not guarantee the formation of healthy behaviors in adolescents.33 similarly, the results of this study show that low parental education levels influence health behaviors. previous research also explains that healthy lifestyles adopted by adolescents are related to the attention and awareness of parents and the surrounding environment regarding the importance of healthy lifestyles.34 collaboration among parents, peers, and health programs implemented in schools and communities can help significantly improve healthy lifestyles among adolescent.33,34 the results of this study also show that affect and motivation influence adolescents’ voice participation in maintaining healthy lifestyles. the voice participation aspect refers to adolescents’ belief in forming, expressing, and voicing thoughts, views, and emotions that influence healthy lifestyle choices.16,35 previous research states that the role of adolescents in actively engaging in health promotion about healthy lifestyles becomes a new innovation that can increase the interest of other adolescents in adopting healthy lifestyles.36 adolescents’ involvement in adopting healthy lifestyles is influenced by encouragement from their surrounding environment, such as peers, parents, and teachers, including policies at the community, school, or home level.37 previous research states that adolescent healthy lifestyle behaviors are significantly related to adolescents’ ability to engage in health literacy and education about the importance of healthy lifestyles for themselves or their environment.20,21 overall, the aspects of assets, critical awareness, agency, and voice participation are part of the peer empowerment process in healthy lifestyles among adolescents. the limitations of this study indicate that the findings do not represent the adolescent population in broader contexts, such as rural areas, as the sample remains confined to urban settings. conclusions the supporting components of peer empowerment in promoting healthy lifestyles among adolescents, which include assets, critical awareness, agency, and voice participation, are not yet optimal. this study found that attitudes, perceived benefits, affect, and motivation influence the supporting components of peer empowerment in shaping adolescents’ healthy lifestyles. this study recommends the need to develop peer empowerment programs to improve healthy lifestyles among adolescents, with a focused approach on the components of assets, critical awareness, agency, and voice participation. the development of peer empowerment programs needs to involve parents, teachers, and school policies that can support them. references 1. abdel-baset taha o, mohamed abd elaal e, gamal eldein ibrahiem s. healthy lifestyle among adolescents students through electronic platform. j nurs sci benha univ 2023;4:809–21. article [page 146] [healthcare in low-resource settings 2025;13:13315] 2. arafa a, yasui y, kokubo y, et al. lifestyle 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benha univ 2023;4:809–21. 14. de carvalho na, veiga fh. psychosocial development research in adolescence: a scoping review. trends psychol 2022;30. 15. veenstra r, laninga-wijnen l. sciencedirect peer network studies and interventions in adolescence. curr opin psychol 2022;44:157–63. 16. unicef. technical note: adolescent empowerment. 2022, p. 1–16. available from: https://www.unicef.org/adolescentempowerment-technical-note 17. el tantawi m. editorial: children and adolescent health-related behaviors. front public health 2023;11:1263452. 18. pender nj. the health promotion model. 2011, 1–17 p. available from: https://deepblue.lib.umich.edu/bitstream/handle/2027.42/85350/healthpromotion_manual_rev_52011.pdf 19. morton mh, montgomery p. youth empowerment programs for improving adolescents’ self-efficacy and self-esteem. res soc work pract 2013;23:22–33. 20. corazza i, pennucci f, de rosis s. promoting healthy eating habits among youth according to their preferences: indications from a discrete choice experiment in tuscany. health policy (new york) 2021;125:947–55. 21. purborini n, lee m been, chang h ju. determinants of positive and negative affect among adolescents and young adults in indonesia: a population-based survey. int j environ res public health 2021;18:12326. 22. vrdoljak g, kurtović a, čikeš ab, et al. gender and educational stage moderate the effects of developmental assets on risk behaviours in youth. int j adolesc youth 2023;28:2183872. 23. soares as, pais-ribeiro jl, silva i. developmental assets predictors of life satisfaction in adolescents. front psychol 2019;10:236. 24. cardel mi, szurek sm, dillard jr, et al. perceived barriers/facilitators to a healthy lifestyle among diverse adolescents with overweight/obesity: a qualitative study. obes sci pract 2020;6:638–48. 25. roshita a, riddell-carre p, sjahrial r, et al. a qualitative inquiry into the eating behavior and physical activity of adolescent girls and boys in indonesia. food nutr bull 2021;42:s122–31. 26. mchale f, ng k, taylor s, et al. a systematic literature review of peer-led strategies for promoting physical activity levels of adolescents. heal educ behav 2022;49:41–53. 27. maker castro e, wray-lake l, cohen ak. critical consciousness and wellbeing in adolescents and young adults: a systematic review. adolesc res rev 2022;7:499–522. 28. nurmala i, pertiwi ed, muthmainnah m, et al. peer�to�peer education to prevent drug use: a qualitative analysis of the perspectives of student peer educators from surabaya, indonesia. judd j, editor. heal promot j aust 2021;32:206–11. 29. antia n, tabidze d, gabunia l, et al. attitudes of children and adolescents towards healthy lifestyle issues. eur j public health 2022;32:ckac131.018. 30. marques a, loureiro n, avelar-rosa b, et al. adolescents’ healthy lifestyle. j pediatr (rio j) 2020;96:217–24. 31. vijayaraghavan j, vidyarthi a, livesey a, et al. strengthening adolescent agency for optimal health outcomes. bmj 2022;379:069484. 32. champion ke, gardner la, mccann k, et al. parent-based interventions to improve multiple lifestyle risk behaviors among adolescents: a systematic review and meta-analysis. prev med (baltim) 2022;164:107247. 33. yañez am, bennasar-veny m, leiva a, garcía-toro m. implications of personality and parental education on healthy lifestyles among adolescents. sci rep 2020;10:7911. 34. haidar a, ranjit n, archer n, hoelscher dm. parental and peer social support is associated with healthier physical activity behaviors in adolescents: a cross-sectional analysis of texas school physical activity and nutrition (tx span) data. bmc public health 2019;19:640. 35. alves h, gibbs l, marinkovic k, et al. children and adolescents’ voices and the implications for ethical research. childhood 2022;29:126–43. 36. howells k, coppinger t. the forgotten age phase of healthy lifestyle promotion? a preliminary study to examine the potential call for targeted physical activity and nutrition education for older adolescents. int j environ res public health 2022;19:5970. 37. lekše r, godec d, prosen m. determining the impact of lifestyle on the health of primary school children in slovenia through mixed membership focus groups. j community health 2023;48:857–69. article [healthcare in low-resource settings 2025;13:13315] [page 147] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13025 spiritual coping “tri hita karana” and depression prevention behavior among the elderly during the covid-19 pandemic i wayan suardana,1 ah yusuf,2 rachmat hargono,3 i gede juanamasta,4 ketut sudiantara,1 i ketut gama,1 i wayan mustika1 1polytechnic of health denpasar, bali; 2faculty of nursing, universitas airlangga, surabaya, east java; 3faculty of public health, universitas airlangga, surabaya, east java; 4nursing program, stikes wira medika bali, bali, indonesia abstract the elderly commonly struggle with mental health issues, especially depression. spiritual coping is one of the factors that might prevent depression. the aim of this study is to investigate cultural involvement in spiritual coping to depression prevention among the balinese elderly. from january to march 2021, this study was carried out on 273 elderly members of the integrated primary public health service in seven districts in gianyar, bali. the study used a cluster random sampling method to collect data and focused on quantitative measurements related to participant characteristics, depression prevention, and spiritual coping. the investigation into spiritual coping was based on the tri hita karana, a concept from balinese philosophy. bivariate analysis was used to assess the relationship between spiritual coping and depression prevention behaviour. the study comprised 146 male and 127 female participants aged between 65 and 79 years old. among all participants, 190 (69.6%) were diagnosed with mild to moderate depression, while 83 (30.4%) with moderate to severe depression. however, for the majority, depression prevention was good 163 (59.7%), the rest was moderate 103 (37.7%), and poor 7 (2.6%). tri hita karana spiritual coping for the majority was good 17 (53.8%). spiritual coping has a strong correlation with depression prevention (r=0.230). thus, spiritual coping has a strong correlation with depression prevention among the balinese elderly. it can be concluded that the implementation of tri hita karana becomes a potent spiritual coping enhance depression prevention. indigenous philosophy embedded in daily life supports social capital in dealing with stress. introduction nowadays aging population become an urgent issue globally. the phenomena shifted from high income country into low and middle income countries.1 united nation projected in 2050 1 in 6 people in the world will be 65 or over. the trend of rising elderly prevalence is fasten in south east asia and latin america.2 however the impact of this issue into public health system should be highlighted to encourage active aging where elderly will be empowered to responsible maintenance their physical and mental wellness.3 strengthen the future health system driven into elderly wellbeing which emphasized two integral aspects4. various studies had been declared both aspects in physical and mental or physcological.4 the outcome of physical aspects of elderly such as the fitness to move during 3-6 month dependently.5 while the mental health outcome aspects mostly studied were quality of sleep, depression, and anxiety. elderly as vulnerable population has higher risk of isolation away from family due to immobility and other physical disability. since 2019, covid 19 pandemic in makes this reality surging among old population. elderly feel alone, insecure, helpless, and lack of social support make higher risk of relapse depression and anxiety.5,6 however, depression declared as pathological mental development of getting old. unlike the younger population, the risk of depression is higher 80% among older alduts.7 this exacerbated and relapsed classified as major depressive disorder, persistent depressive disorder, substance induced depressive disorder and depressive disorder due to a medical condition.8 management of depression in elderly is essential because it significantly related to family burden, decreased quality of life, and induced idea of suicide.8 comprehensive clinical guideline has been established.9 first is comprehensive assessment related depression symptom and severity. the symptom listed based on the etiology such as number of medication trigger depression and other underlaying disease. depression severity mostly measured by gds, ham-d, bdi,phq-9. for a short relive anti depressant was widely used as pharmacological treatment. another choice were recommended such as psychotherapy cbt, problem solving, therapy could involved family and caregiver. for the worst case electroconvulsive therapy might be chosen. however concept of healing recently moved into seeking inner peace that authorized the elderly him/herself together creating harmony with social belongings also go beyond with the supreme being/god. this approach determined as spiritual coping. the core of spirituality is transcendence with 4 dimensions personal, social, environmental, and religious ones.10 coping is a form of resilience that is individual in nature as a challenge to successfully pass every event in old age.11 in its development, the concept of coping that exists and develops so far is still very little significance for public health promoting active ageing is crucial, emphasizing the need to address physical and mental health. older people are at significant risk of depression, exacerbated by factors such as social isolation and the challenges posed by the covid-19 pandemic. it is essential to implement effective management strategies, including comprehensive assessment and treatment options, to alleviate the burden of depression in this demographic. furthermore, spiritual coping mechanisms, such as the balinese philosophy of tri hita karana, have demonstrated the potential to promote well-being and resilience among older individuals. this study sought to explore the correlation between spiritual coping, specifically tri hita karana, and depression prevention behavior among older people during the pandemic. [page 10] [healthcare in low-resource settings 2024;12(s1):13025] discussing culture. even if the concept of culture already exists, most of the literature still focuses on changes in the mental outlook of cultures that adopt western values and behavior (divale, 2001). novelty of this study is accentuated balinese philosophy of harmony known as tri hita karana.12 conceptually, tri hita karana is defined three causes of happiness.13 three elements of tri hita karana were relation human to god (theocentric) known as parahyangan; relation human to human (anthropocentric) known as pawongan; and relation human to nature (cosmocentric) known as palemahan.14 one study found that the imbalance of these three things causes disease.15 in looking at the etiology of mental illness, it is more than fully looking at the type of abstract (non-physical) disease.13,15 thus, tri hita karana might have important part in wellness and health. despite many studies used tri hita karana concept specifically related to economic, politic, social and anthropology research,16 lack number of study employ this concept in the health research. therefore, the study aimed to examine the relationship between spiritual coping “tri hita karana” and depression prevention behaviour among elderly during pandemic covid-19. materials and methods study design design of this study is an observational and cross-sectional. study was conducted during januarymarc 2021 with elderly population in gianyar distric area bali province. gianyar was chosen as the research site because this area is a pilot for elderly-friendly implementation based on bali local regulations. this site also wellknown as the heart of balinese culture. this study involved 7 district primary care provider in rural and urban area payangan, ubud, sukawati, tegalalang, blahbatuh, tampaksiring and gianyar. participants of this study was the elderly who joined regular health promotion program for primary care in indonesia. inclusion criteria of the participants is fluent to communicate in bahasa. exclusion criteria of the sample were severe mental disorder, hearing disorder, refuse to continue join the research. we used estimated proportion formula to count the total sample.17 based on that formula the assumption probability 0.05 and elderly population in ginyar distric 2019 39,637 people, elderly depression prevalence in indonesia 23,4 % (riskesdas, 2018). according the calculation total sample involved 273 people. data collection was performed by enumerator interviewed the elderly using structured questionaries. instruments in this study, 2 variables were measured, namely depression prevention behavior and religious coping. depression prevention behavior is measured by giving 12 questionnaires with a likert scale of 0-2 developed from llopis & ggabilondo.18,19 the validity and reliability have been tested . the items-total score of pearson’s correlation was significant at .05 level and with content validity index for items (i-cvi) computation was 1.00, with cronbach’s alpha was .80. depression prevention behavior classified in three level: good (score 17-24), moderate (score 8-16), less (score 0-7). spiritual coping was self created questionnaire constructed based one balinese philosophy tri hita karana. tri hita karana spiritual coping complied 3 items element. first prahyangan element (relation with the supreme god/transcends): 5 items sradha (activity creating offering and praying) and 5 items bhakti (activity to do self reflection to be surrender). second pawongan element (relation and interaction with human being): 5 items nyama (support system among family) and 5 items (braya support system by neighborhood). third palemahan element: 3 item utama mandala (space to do praying activity), 4 items madya mandala (space to do human interaction), and 3 items palemahan (green space for plants and pets).20 self-created questions were tested using pearson’s correlation product moment for validity with the returned values varying between .412 and .572 in the commonality analysis, and for reliability through cronbach’s alpha, with all of the questions demonstrating reliability with the value of .583 (higher than 0.5). another characteristic variables also measured such as gender, age, family type, personality, stress and quality of geriatric health provider. data analysis the data was managed using the statistical package for social sciences spss version 23.0. we performed the descriptive statistics for the socio-demographic and mental health characteristics, the depression prevention and spiritual coping. in the bivariate analysis, pearson’s correlation coefficient was used between characteristic variables and depression prevention. the relationship magnitude and strength were determined by the following criteria: r= 0.10 -0.29 (small or low relationship), 0.30 –0.49 = medium relationship, and 0.50 –1.0 = strong or high relationship.21,22 the value of significance (2-tailed) is less than 0.05 significant at a 95% confidence interval. ethical considerations this study was reviewed by the health research ethics committee faculty of nursing universitas airlangga, with the ethical approval number 2303-kepk. informed consent was distributed to the participants before completing the main questionnaires. the informed consent has been applied approaching the principle of beneficial, no harm, confidential, justice, as well as voluntary participants. the provided information should be agreed to by participants before data collection. the participant could stop the survey anytime during the data completion. the informed consent had been reported during the ethics approval and consent prior the study. results and discussion table 1 shows that majority of respondents were 70-79 years old and more than half were male. primary education was the highest number compare than another level of education. more than 70% was married with unstable income. extended family type was the majority of the respondent, followed by nuclear family and living alone. for depression prevention, 59.7% participants had a good category, 37.7% moderate and the rest was poor. almost half of them had poor spiritual coping (46.2%). based on the analysis, depression behavior prevention had a significant correlation with age (r=0.592), gender (r=0.492), income (r=0.468) and spiritual coping (r=0.230; table 2). surprisingly, the majority category was good during pandemic situation. this elaborate our correlational finding tri hita karana spiritual coping has significant correlation with depression prevention behavior. the majority of participants age on range 60-69 years old (83,15%).the rest (16,85%) is 70 years old and over. the cut point 70 years old in this study decided based on the prior study of elderly definition according physical and mental health independency among balinese population.23 this study congruence with elderly classification visited emergency department defined in three group 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13025] [page 11] : youngest-old, ages 65 to 74 years; middle-old, 75 to 84 years; and oldest-old, ≥85 years.24 based on gender, the proportion of male population is 53,5% and female 46,5%. a study elaborated this finding based on correlational study in chine related asian ethnic measured by life expectancy at age 60 years (le60) and qualityadjusted life expectancy at age 60 years (qale60).25 this study found that men have as shorter life expectancy but seems less suffering rather than women. recently depression on of the most common mental health issue among elderly especially since pandemic covid 19 until 2022.25,26 study among 457 indonesian participants found 53,57% experienced depression.27,28 another study explained predictors of depression in south asia (india, pakistan, bangladesh, nepal, sri lanka) such as : gender, chronic illness, financial and physical dependent with other, not able to work or unemployment, experienced stress full event, lack of social support, marital status and living arrangement, substance or elderly abuse, inadequate spiritual needs, tension in home, not engage in leisure activities or hobbies.29 especially bali province as setting of this researched suffered a poignant effect of plunged tourism aspect as main income. another study in denpasar as part of bali in first semester of 2020 among 100 respondents experienced anxiety (53,1%); depression (51,2%); and stress (46,1%) since decreasing monthly income and termination of employment.30 coherent with this research findings all participants experienced depression: mild to moderate 69,59% and moderate to severe 30,41%. compared with previous study related depression in bali old population, the trend is about increasing. study involved 774 female and 719 male participants aged 60 to 100 using ces-d score of ≥10 as depression as assignment declared the prevalence of depression among older adults in bali was high (42.3%).31 however, old population have been faced many life stress exposure and experienced make the survived and well adapted known as coping.32 the main coping strategies main coping strategies were: anticipatory mourning, the desire to die, isolation, submission, negotiation, acceptance, accommodation, seeking social support, seeking spiritual comfort and living in the moment.33 even during pandemic covid-19, old population showed their natural resilient dealing with unexpected condition and isolation by positive motioned coping mechanism by generate good mindset, stay busy, and look for social support. compared with young population, old population less likely used avoidant coping strategy which sign of depressive symtom.34 explaining the former shape of coping was seed of transactional theory developed by lazarus and folkman in 1984.35 transactional explanations emphasizing dynamic relation of individual ability to responds stress of environment by cognitive phenomenological processes. theory of coping by lazarus triggered by stress which interaction environment and person. later stress stimulate perception named appraisal.36 appraisal conduct adaptation known coping mechanism classified in two: problem focused coping and emotional focused coping.37 problem focused coping described by using several strategy to remove the stressor by solving the problem.38 while emotional focused coping described by using emotional responds to deal with the stressor.39 recently, holistic health orientation involved spirituality aspect as coping mechanism.40 philosophical anaylsis of spiritual coping in nursing science enhanced physical, psychological, and social well-being, resilience, and self-transcendence.4142 research suggests that spiritual coping strategies, involving relationship with self, others, ultimate other/god or nature were found to help individuals to cope with their ailments.43 congruence with balinese culture the definition of spirituality known as tri hita karana. embodies universal values and represents harmonious and balanced human relationships with the spiritual, social and natural environment to achieve spiritual and physical wellbeing.44 4th international nursing and health sciences symposium table 1. characteristic of participants. variable (n=273) n % age 65-69 years old 96 35.2 70-79 years old 177 64.8 gender male 146 53.5 female 127 46.5 highest level of education none 68 24.9 primary 84 30.8 secondary 45 16.5 tertiary 44 16.1 university 32 11.7 marital status married 200 73.3 divorced 64 23.4 unmarried 9 3.3 income status stable 67 24.5 unstable 206 75.5 family type nuclear family 116 42.5 living alone 8 2.9 extended family 149 54.6 depression prevention good 163 59.7 moderate 103 37.7 poor 7 2.6 spiritual coping good 147 53.8 poor 126 46.2 table 2. correlation characteristic and depression prevention behavior. variables category poor moderate good correlation age high risk 3 46 47 0.592** lower risk 4 57 116 gender male 3 52 91 0.492** female 4 51 72 education level none 1 33 34 0.082 primary 4 32 48 secondary 2 10 33 tertiary 0 19 25 university 0 9 23 income status stable 4 68 108 0.468** non-stable 3 35 38 marital status married 7 64 129 0.008 unmarried 0 36 28 divorced 0 3 6 family type nuclear family 6 51 59 0.010 living alone 0 5 3 extended family 1 47 101 spiritual coping good 5 40 102 0.230** poor 2 63 61 **p<0.01. [page 12] [healthcare in low-resource settings 2024;12(s1):13025] implementation of tri hita karana embedded in balinese people daily life. everyday people in bali create handmade offering to show gratitude of the supreme god blessing. that activity became indigenous culture infused by hinduism belief (sradha) and compassion to serve (bhakti).45 another implementation of tri hita karana as spiritual coping strategy during covid 19 was implemented by reading bhagawad githa involved 100 participants in bali.46 as part of harmony woth the supreme god balinese people tend to be more surrender and more likely do selfcontrol and reflection known as mulat sarira. harmony among human as human being in bali conceptualized menyama braya. menyama, its semantic meaning refers to family ties by marriage and blood; while braya refers to neighborhood. this concept during pandemic became social capital build coping and resilience during pandemic.47 many people give free food supplies to others, giving social loan, and personal protective equipment’s such as mask, face shield, desinfectant. creating harmony in nature physically reflected on balinese concept house always provide green space for palemahan. balinese house divided into 3 elements as tri mandala: sacred place or temple for praying, home for human integration, and space for garden / pets.47 even in dynamic in rural area such as denpasar as bali capital is still maintained.47 gardening and connect with animal or pets became habitual activity among balinese people which available in their green space during isolation period in pandemic. gardening engage can facilitate stress reduction through interactions with natural elements, which bolster human health.48 the implementation of tri hita karana in bali as spiritual coping facilitates coping goal in this contacts of research related depression prevention. old population in bali more likely implement spiritual coping rather than problem or emotional focused coping. based on this observation, the majority of participants did not have role as decision maker and lack of their cognitive capability to solve their life problem. participants also try to hide their emotional feeling to prevent their family burden. balinese elderly selected other activity to keep them busy and calm down their mind and feeling. implementation of tri hita karana not only for coping strategy but also outcome itself as depression prevention. implementation tri hita karana among old people in bali occupied their physical, social, natural bonding activity to regulate mental health. conclusions age, gender, income, and spiritual coping were positively correlated with depression behavior prevention. this study results can give input to the nurse to understand depression behavior prevention. besides, the results can use to develop intervention through tri hita karana to manage depression behavior prevention. community nursing or public health nurse could use this concept to promote positive mental health to community. besides, it might be related to health seeking behavior. nurse needs to explore more about mental health, which can be an issue to explore for future studies. this study’s findings might not represent indonesia because data were gathered only in the one district. therefore, further research is needed with a larger, multiethnic sample to understand spiritual coping “tri hita karana” and depression behavior prevention in indonesia. this finding might be limited to during pandemic situation, further studies with longitudinal methodology is highly recommended. in addition, the study findings did not present cause effects; 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int j aging hum dev 1989;28:127–40. 33. ribeiro m dos s. coping strategies used by the elderly regarding aging and death: an integrative review. rev bras geriatr gerontol 2017;20:869–77. 34. nieto m, romero d, ros l, et al. differences in coping strategies between young and older adults: the role of executive functions. int j aging hum dev 2020;90:28–49. 35. odato jm. this brain had a mouth. amherst, ma: university of massachusetts press; 2021. 36. stanisławski k. the coping circumplex model: an integrative model of the structure of coping with stress. front psychol 2019;10:1–23. 37. lestari rf. coping strategies for students seen from the big five personalities. acta psychol 2021;3:29–37. 38. galiana l, tomás jm, fernández i, oliver a. predicting wellbeing among the elderly: the role of coping strategies. front psychol 2020;11:1–8. 39. hoyt ma. emotional approach coping in older adults as predictor of physical and mental health. psychol aging 2020;35(4). 40. southard me. spirituality: the missing link for holistic health care. j holist nurs 2020;38:4–7. 41. juanamasta ig, aungsuroch y, gunawan j, fisher ml. postgraduate and undergraduate student nurses’ well-being: a scoping review. j prof nurs 2022;40:57–65. 42. dunn ks, robinson-lane sg. a philosophical analysis of spiritual coping. adv nurs sci 2020;43:239–50. 43. baldacchino d, draper p. spiritual coping strategies: a review of the nursing research literature. j adv nurs 2001;34:833–41. 44. huang h, rockwell j. nature and the spirit: tri hita karana, sacred artistic practices, and musical ecology in bali. envirolab asia 2019;3:1–27. 45. nerawati ngaa, sudarsana ik. the role of pasraman kilat in raising sradha and bhakti of teenagers. j penelit agama hindu 2020;4:74. 46. surpi nk, istriyanti nla, avalokitesvari nnan. resilience and coping strategy of bhagavad-gῑtā readers on the covid19 pandemic in bali. kurukshetra univ res j 2021;55:26–33. 47. arisanti nmd, suderana iw. handling the covid-19 pandemic: collaboration of district government with knpi gianyar in gianyar district, bali. sp 2020;15:87. 48. egerer m, lin b, kingsley j, et al. gardening can relieve human stress and boost nature connection during the covid19 pandemic. urban for urban green 2022;68:127483. 4th international nursing and health sciences symposium correspondence: i wayan suardana, nursing department, polytechnic of health denpasar, bali, indonesia, jl. sanitasi, no 1 denpasar, bali, indonesia. tel.: +62361710447 e-mail: suardanawayan@yahoo.com key words: depression; elderly; spiritual coping; tri hita karana contributions: iws, ay, and rh, made significant contributions to the study through their involvement in study design, data collection and analysis, manuscript writing, and data analysis; ks, ikg, and iwm, also played vital roles by contributing to study design, manuscript writing, and conducting reference searches. conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by polytechnic of health denpasar, bali, indonesia clinical trials: not applicable. ethics approval and consent to participate: this study was reviewed by the health research ethics committee faculty of nuring universitas airlangga, with the ethical approval number 2303-kepk. informed consent was distributed to the participants before completing the main questionnaires. the informed consent has been applied approaching the principle of beneficial, no harm, confidential, justice, as well as voluntary participants. the provided information should be agreed to by participants before data collection. the participant could stop the survey anytime during the data completion. the informed consent had been reported during the ethics approval and consent prior the study. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors acknowledge the director of polytechnic of health denpasar, bali, indonesia for generously funding this study. received: 3 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13025 doi:10.4081/hls.2024.13025 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 14] [healthcare in low-resource settings 2024;12(s1):13025] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13087 exploring students’ perceptions of islamic integration in the clinical nursing education curriculum: a descriptive qualitative study dwi setiowati, maulina handayani department of nursing, faculty of health sciences, universitas islam negeri syarif hidayatullah, jakarta, indonesia abstract the integration of religious and spiritual beliefs into the nursing education curriculum is an effort to build the characteristics of nurses as they become professionals. this study aimed to explore the experiences of nursing students who had undergone islamic integration. the study employed a descriptive qualitative method, including five clinical nursing students selected through purposive sampling and interviewed online. three main themes emerged from the data regarding the implementation of islamic integration in the clinical nursing curriculum. the three themes included challenges in implementation, factors supporting successful implementation, and impact on students. students face challenges in implementing islamic integration principles, including resistance to change, limited understanding, and insufficient resources. however, with personal commitment, mentorship, and a supportive environment, successful implementation leads to increased self-awareness, improved ethical decision-making, and enhanced empathy in patient care. integration requires committed educational effort from all academic staff, which necessitates continuous monitoring, mentoring, and habituation of integration practices as part of an ongoing process. this ensures that the integration of islamic principles into the nursing curriculum is not only theoretical but also practical and transformative. introduction clinical nursing students are fully employed in practical health settings, such as hospitals. however, unlike nurses who already have full authority to treat patients, students are often required to behave in the same manner as professional nurses.1 nurses have yet to demonstrate an increase in the quality of nursing care. lack of responsibility, sincerity, self-awareness, and professionalism indicate poor quality nursing care in the healthcare system. thus, when students play a crucial role in contributing to patient safety issues, their contribution is significantly influenced by the implementation of clinical education.2 student character building in higher education can be achieved through a science integration learning model,3 which requires nurses to have spiritual, interpersonal, and intellectual competencies. spiritual care is a holistic reflection of nursing education.4 a previous study found that student perceptions affected individual values, suggesting a form of spiritual training and simulation in spiritual care-based learning scenarios.5 spiritual intelligence strengthens the beliefs and personalities of nurses and their desire to grow, learn, and work more professionally to improve the quality of nursing.6 religion was the most significant determinant of self-efficacy, capital of good self-control, and firm conviction in completing tasks and achieving goals. the higher the level of religiosity and social support, the easier the students will adapt.7 the comprehension and interpretation of religious teachings is believed to play a role in the quality of interactions with adherents of other religions.8 education is essential for nursing students’ spiritual care competence. clinical nursing education is one of the components of nursing education conducted in a clinical setting, involving real situations, teaching, and learning processes in the clinical setting.9 correspondence: dwi setiowati, department of nursing, faculty of health sciences, universitas islam negeri syarif hidayatullah, jakarta, indonesia. e-mail: dwi.setiowati@uinjkt.ac.id key words: clinical nursing, education, islamic integration, student perception contributions: ds, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; mh conceptualization, investigation, methodology, validation, and writing – original draft, review, and editing. conflict of interest: the authors declare that they have no conflicts of interest. ethical approval and consent to participate: the results of the researcher's ethical test were carried out first to the ethics committee of the faculty of health sciences of universitas islam negeri syarif hidayatullah with letter number: un.01/f.10/kp.01.1/ke.sp/04.08.008/2023. during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained from the anonymized patients for publication in the study. funding: this research was supported by a research grant in 2023 from the research and publishing center (puslitpen) universitas islam negeri syarif hidayatullah jakarta with contract number: un.01/kpa/ 189/2023. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgement: we would like to thankful to the research team would like to thank to the research center of universitas islam negeri syarif hidayatullah, kulliyah of nursing international islamic university malaya (iium), clinical nursing student as respondent and all participant for their valuable insights and contributions to this study. received: 12 september 2024. accepted: 16 january 2025. early access: 28 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13087 doi:10.4081/hls.2025.13087 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 68] [healthcare in low-resource settings 2025;13(s1):13087] education still has suboptimal learning; training in student spirituality is less important than training in spiritual interventions.10 students need to prepare for spiritual care, and education in spiritual care contributes to those conditions.11 the nursing curriculum should include spiritual care courses or training.12 this is important in implementing islamic integration, which is supported by research results indicating that the three main focuses of islamic medicine are healthcare practitioners’ attitudes and personalities, clinical decision-making, and providing comprehensive spiritual care. when it comes to incorporating islamic ideals into professional practice, there are still many gaps and discrepancies, such as unpreparedness, distrust, role models, and environmental support. it is necessary to put more effort into developing and establishing a framework for all-encompassing islamic medical practice.13 integration-based curriculum changes require significant changes in terms of thinking and implementation. integration into the nursing curriculum was carried out by formulating the nursing school’s vision and mission, continuing the vision and mission of the faculty and university, and describing the learning outcomes of the courses. collaboration with kulliyah of nursing international islamic university malaya (kon iium), namely sharing sessions from expert curriculum integration lecturers regarding the implementation of ancient integration in the nursing curriculum at kon iium with the head of the study program and several lecturers at the syarif hidayatullah state islamic univesity’s nursing school, then a review of the clinical nursing course guide was carried out by the research team, the lecturer in charge of the course and the usluhudin lecturer at uin jakarta. a positive and significant relationship exists between the science integration learning model and the formation of students’ islamic character at islamic universities in indonesia and malaysia.3 implementation of integration by saying bismillah in learning activities both before and after, as well as the preparation of islamic and scientific integration guidelines at the faculty of health sciences since 2022 and on learning outcomes, study materials for each course in the islamic integration curriculum. the integration of islam and nursing in the nursing curriculum qualitatively suggests the need for assistance and collaboration with islamic experts in compiling the curriculum and the learning process to determine learning outcomes.14 the data indicate that only 52% of clinical nursing students in the integration curriculum at syarif hidayatullah state islamic university jakarta and alaudin state islamic university makassar performed islamic nursing care well.15 clinical students’ communication skills and spiritual awareness still require improvement to address this issue. research shows no differences in perceptions of spiritual care between general nursing students and those from islamic religious background.16 the literature on spiritual care in nursing applications, particularly in education, remains unclear,17 and the results of the study show that even though nursing students have good spirituality, they are still not good at implementing spiritual care.18 research on the integration of religion, particularly islam, into nursing remains limited and largely perception-based. this gap necessitates further exploration of the data and intervention effectiveness in integrated nursing clinical education. a curriculum workshop at uin jakarta nursing highlighted that 30% of the students lacked confidence in providing spiritual care, primarily because of their focus on physical aspects. despite the integration of islamic courses into the nursing curriculum, this disparity persists, underscoring the need for improved clinical education strategies to enhance student confidence and competence in spiritual care. while integration guidelines were developed in february 2022, their implementation across programs, including nursing, remains unmonitored. data from iium researchers indicated similar challenges in integrating islam into nursing education in kulliyah of nursing. no prior studies have explored islamic integration in nursing education through inter-university collaboration, particularly with iium. this study examined iium’s experience with islamic integration and evaluated the impact of the islamic integrated professional course guide on clinical nursing students before and after the intervention. materials and methods design this study employed a descriptive qualitative approach to explore clinical nursing students’ perceptions of islamic integration into the nursing education curriculum. the research was conducted during the family nursing clinical course, which is a twoweek clinical practice period. this study was conducted in collaboration with kulliyah of nursing, international islamic university malaysia (iium), and lecturers from the ushuluddin faculty of syarif hidayatullah state islamic university, who contributed to the development of an islamic integration guidebook for clinical nursing practice. this collaboration played a key role in shaping the curriculum framework implemented during the family nursing clinical course, a two-week clinical practice period in which students applied islamic-integrated nursing principles in real clinical settings. population, sample, sampling technique the study population consisted of 66 clinical nursing students from syarif hidayatullah state islamic university, who were undergoing clinical practice in the family nursing clinical course. the study employed purposive sampling was used to select five students who met the study criteria and had direct experience with islamic integration in clinical nursing education. all participants provided informed consent before data collection. a small sample size was chosen because of the qualitative nature of the research, which prioritizes in-depth insights rather than numerical generalizability. additionally, practical constraints such as academic schedules, availability, and the feasibility of conducting detailed qualitative interviews influenced the selection process. despite the limited number of respondents, thematic saturation was achieved, ensuring that no new themes emerged, and that the data were sufficiently rich for analysis. phenomenon the phenomenon in this study was the perception of islamic integration in the clinical nursing education curriculum. instruments data were collected using a semi-structured interview guide developed in consultation with islamic integration experts and aligned with islamic integration book guidelines of the faculty of health sciences. the guide consisted of ten open-ended questions designed to explore key themes, including the application of islamic integration in family nursing practice, the role and effectiveness of guidebooks, the influence of academic and clinical mentors, students’ personal reflections on changes in attitudes and professional behavior, and the challenges faced in implementing islamic integration in clinical nursing practice. the interview guide ensured a structured yet flexible approach, allowing for the consistent exploration of themes while accommodating individual variations in responses. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13087] [page 69] data collection process data were collected through semi-structured interviews, conducted online via zoom, with five clinical nursing students who provided informed consent prior to participation. each interview lasted approximately 30–45 minutes and was facilitated by the researcher to ensure a comfortable and open discussion environment. the interviews were audio-recorded with participants’ permission and later transcribed verbatim for analysis. source triangulation was applied to maintain data credibility by comparing responses across participants. during the two-week family nursing clinical course, students engaged in islamic-integrated nursing care under the guidance of academic supervisors and clinical instructors who provided continuous support and evaluation. the implementation process included sharing sessions with mentors, a review of clinical nursing course guidelines, and structured mentoring sessions to ensure that students applied islamic values in their clinical practice. data analysis the data were analyzed using thematic analysis following a structured approach to ensure a systematic and meaningful interpretation of the findings. first, audio-recorded interviews were transcribed verbatim and the transcripts were carefully read and reread to gain an in-depth understanding. next, data organization was conducted by identifying the codes and categories that emerged from the responses. these codes were then grouped into themes and subthemes representing key aspects of students’ perceptions of islamic integration in clinical nursing education. the process involved data reduction, categorization, and interpretation, allowing for a clear synthesis of the findings. to enhance credibility and trustworthiness, source triangulation was applied by comparing data across participants to ensure consistency and reliability in emerging themes. the final step involved verifying and summarizing the results, ensuring that the analysis accurately reflected the participants’ experiences and insights. ethical clearance the results of the researcher’s ethical test were carried out first to the ethics committee of the faculty of health sciences of universitas islam negeri syarif hidayatullah with letter number: un.01/f.10/kp.01.1/ke.sp/04.08.008/2023. results these data were supported by the results of informant interviews. the following is a detailed explanation of these themes. theme 1: barriers during the implementation the findings indicated that clinical nursing students encountered several barriers to implementing islamic integration during their family nursing practice. one of the primary obstacles was patient-and family related factors, particularly when the patients and their families were non-muslim. another barrier included a lack of family support for patients, participants reported that they could not fully implement islamic-based nursing care in these cases, as the patients and their families were not receptive to religiously integrated interventions. additionally, the perceived status of students as trainees led to resistance from patients and their families. it was conveyed by the informant as follows: « the obstacle is when a family (and patients) is not muslim, so we cannot apply islamic integration…” (informant 2) “… they ignored us while we were providing nursing care. the family chose not to be involved with students…” (informant 3) theme 2: successful implementation of the program the findings indicated that despite various challenges, students were able to successfully apply islamic integration in family nursing practice under certain conditions. participants highlighted several factors that facilitated the implementation of islamic principles, including the availability of guidebooks, role of academic and clinical mentors, and competence of supervisors.. the following explanation is provided in detail based on the following subthemes. books guide integrated islam one of the key facilitators was the islamic integration guidebook, which provides clear instructions on how to incorporate islamic values into clinical nursing practice. the participants found the guidebook helpful and comprehensive, making it easier to align their nursing care with islamic principles. « according to the guidebook, this is helpful. the content was clear, complete, and served as a structured guide for students when practicing in the field. the learning outcomes are also very clear, and from the beginning, we are reminded to be god-conscious (taqwa) to allah.» (informant 1) «. this is very helpful for the students. besides serving as a guide, this book also becomes a practical material for students when they directly engage in applying islamic-based nursing care.» (informant 3) role of academic and clinical mentor another crucial factor was the role of the academic and clinical mentors who provided support, guidance, and reinforcement during clinical practice. academic and clinical role mentors make it easier for students to integrate islam during the practice profession nursing family. five participants explained that role mentors as academic and clinical are already very comprehensive and important in helping students when practicing in the field. «.. my academic supervisor has been very supportive and always gives direction. during practice, the supervisor takes the time to visit the field and reminds us about etiquette and behavior that reflect islamic values.” (informant 3) «the clinical supervisor was always there to remind us to take notes during data retrieval, ensuring that it did not interfere with prayer times or moments of quran recitation, except at the end of the event.» (informant 1) “ guidance from mentors helped students and made it easier for us to practice professionally…. also, the clinical instructor helped us to ensure that islamic values were integrated into nursing care delivery.» (informant 5) the ability of qualified academics and clinical supervisor the competence of both mentors and academic and clinical supervisors plays a significant role in facilitating islamic integration. the participants noted that well-trained supervisors could guide them effectively, ensuring that islamic principles were easier to apply in a professional and ethical manner. « the ability of academic mentors to provide instructions is very good…… clinical supervisors also directly guide students during practice.» (informant 3) “ the role of academic mentors is essential as they provide special issue pathways of change [page 70] [healthcare in low-resource settings 2025;13(s1):13087] detailed explanations regarding the application of islamic integration in professional nursing family practice. the ability of clinical supervisors is also very good….” (informant 4) theme 3: positive impact to the students the findings indicated that the application of islamic integration in family nursing practice contributed to positive changes in students’ knowledge, attitudes, and behavior. these changes were observed in their self-awareness, ethical decision making, and confidence in applying islamic-based nursing care. knowledge the participants reported that the integration of islamic principles into their clinical practice enhanced their understanding of islamic values in nursing care. they became more aware of the importance of spiritual aspects of patient care. « i have gained a deeper understanding of islamic values in family nursing practice. .» (informant 4) «..... now, i know what actions are beneficial and what i should avoid ensuring my practice aligns with islamic teachings” (informant 5) attitude participants also experienced changes in their attitudes, particularly regarding how they interacted with the patients and their families. they became more respectful and mindful of their diverse values and beliefs, demonstrating an improved sense of professionalism. « i always remind myself that my attitude is assessed by others. islam teaches us to have good behavior, which will be well received by people around us.» (informant 3) « i always try to apply religious attitude to patient, because its helpfully for us in practice nursing, its make us to appreciating different values, beliefs, needs in accordance with mark muslim.» (informant 4) in addition, participants reported that islamic integration increased their self-confidence in providing patient care as they were able to align their clinical practice with their faith. « i feel more confident because i have had many interactions with the public during practice.» (informant 2) « i become more believe myself, and ready for do application integration at the next course.” (informant 4) behavior changes the integration of islamic values also influences students’ daily behavior in clinical settings. participants reported that they applied islamic principles in their nursing practice, such as offering spiritual support to patients and promoting healthy habits. « i always motivate patients to maintain a clean and healthy lifestyle, and also try to give spiritual support for patients like prayer, patience, be sincerity and reminding them to engage in worship.» (informant 4) «… before performing nursing care, i always start with ‘bismillah’ (in the name of allah) and conclude by hamdalah (thanking god).» (informant 5) discussion clinical nursing learning develops professional skills, critical thinking, confidence, and independent decision making based on the indonesian clinical nursing education curriculum. this curriculum guides teaching and learning in higher education. nursing graduates serve as care providers, educators, managers, researchers, and communicators.19,20 integration in nursing views humans as multidimensional beings who respond to health and illness. academic habituation shapes islamic care in nursing students.21 students in islamic universities in indonesia and malaysia develop islamic characteristics alongside scientific learning.3 a similar study found that nursing students in uin syarif hidayatullah studied curriculum integration in clinical practice.22 the al islam and muhammadiyah subject variables influence antenatal care provided by clinical students.23 integrating islamic values into clinical nursing education presents challenges, especially in diverse settings, with patients and families of different religious backgrounds. this aligns with studies highlighting cultural and religious differences as obstacles to implementing faith-based healthcare practices.24–27 students often face resistance from patients’ families because of their trainee status, which leads to a lack of recognition during nursing. literature emphasizes that students sometimes struggle with patient trust due to perceived inexperience.28 the lack of family support complicates integration, as families play a crucial role in patient care, and their reluctance to engage in religious-based interventions limits their ability to apply islamic principles in practice.29 these findings indicate efforts should focus on strengthening cultural competence training, providing strategies for diverse patient interactions, and developing policies supporting inclusive nursing education.14,30 implementing mentorship programs, enhancing collaboration between nursing educators and islamic scholars, and providing psychological support for students may help address barriers and ensure effective islamic integration into nursing practice in diverse clinical settings.31,32 this study found students successfully applied islamic integration in clinical practice with structured guidelines, mentorship, and supervision. the islamic integration guidebook provided clear directions for incorporating islamic values into nursing care, which students found beneficial. previous research underscores the role of structured materials in facilitating the application of spiritual and religious principles in healthcare settings,12,14,30,33 emphasizing the necessity of instructional tools in religious and ethical integration within professional education.34 academic and clinical mentors are crucial for guiding students through the integration process. studies have shown mentorship and role modeling significantly influence students’ professional behaviors and ethical decision-making.35–37 effective mentorship ensured students received professional support for maintaining ethical and religious practices, aligning with literature on the importance of strong mentormentee relationships in shaping professional identity and satisfaction.38–40 the competence of academic and clinical supervisors affected the success of islamic integration, as well-trained mentors provided effective guidance in aligning clinical practice with islamic principles. however, challenges, such as curriculum inconsistencies and the need for ongoing support remain.41–43 addressing these barriers through structured policies, continuous training for supervisors, and enhanced collaboration between nursing educators and islamic scholars are essential for sustaining successful integration of islamic values in clinical nursing education. integrating islamic principles in nursing practice improved students’ knowledge, attitudes, and behaviors, enhancing professional development and ethical decision making. students better understand islamic values in patient care, promoting a holistic approach. this aligns with studies showing that religious and spiritual education in healthcare improves compassionate, patient-centered care.44,45 the knowledge gained deepened students’ understanding special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13087] [page 71] of spiritual aspects of patient care, reinforcing holistic approaches.24,46 changes in attitudes, such as increased respect, mindfulness, and professionalism, align with studies suggesting that integrating religious principles fosters empathy and ethical sensitivity among healthcare professionals. research shows that spiritual intelligence fosters ethical professionalism and moral sensitivity, and improves patient interactions and satisfaction.6,26,47–49 integration also boosted students’ confidence in providing nursing care by incorporating islamic principles. research has shown that islamic caring enhances the psychospiritual comfort and preparedness of nurses.50,51 behavioral changes, including the incorporation of spiritual support and ethical considerations in patient interactions, indicate that islamic integration translates into practice.14,52 the nursing education system should address the spiritual wellbeing of its students.53 this topic is crucial for preparing nursing students to provide spiritual care in a clinical context.2,54 challenges remain in ensuring sustainable integration, such as the need for structured policies, collaboration between nursing and islamic scholars, and continuous monitoring.41,42,55 addressing these barriers is essential to maximize the benefits of islamic integration in clinical nursing education and create a culturally competent nursing workforce. conclusions the integration of islamic principles into clinical nursing education presents both opportunities and challenges. this study found that while students encountered barriers such as patient resistance and trainee status, structured support systems—guidebooks, mentorship, and supervision—facilitated implementation. islamic integration in clinical practice enhanced students’ knowledge, ethical decision-making, and confidence in patient-centered care. however, challenges persist, including inconsistent curricula, limited family support, and the need for institutional guidance. sustainable integration requires structured policies, educator training, and collaboration with islamic scholars. future research should assess long-term impacts on professional practice and patient outcomes to refine curriculum development. references 1. sukartini t, asmoro cp, pradana fa. the factors related to the caring behavior of clinical nursing students. j ners 2019;14:82–6. 2. sari dwp, arief ys, ahsan a. the relationship between clinical education and nursing students’ patient safety competencies. 2024;22. 3. nurbaiti, suparta hm, syukur ta, et al. integrasi ilmu dan kontribusinya terhadap pembentukan karakter islami mahasiswa. tangerang: qalbu salim; 2020. 4. scott barss k. spiritual care in holistic nursing education: a 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nursing: an overview of the measures used to assess spiritual care provision and related factors amongst nurses. acta biomed 2019;90:44–55. 11. green a, kim-godwin ys, jones cw. perceptions of spiritual care education, competence, and barriers in providing spiritual care among registered nurses. j holist nurs 2020;38:41–51. 12. rykkje l, søvik mb, ross l, et al. educational interventions and strategies for spiritual care in nursing and healthcare students and staff: a scoping review. j clin nurs 2022;31:1440– 64. 13. mahmood ma, mohd yusof n, saidi s, che ahmad a. the integration of islamic values in daily clinical practice among healthcare professionals: a scoping review. iium med j malaysia 2023;22:33–40. 14. setiowati d, utomo wb, agustina m. integration in nursing curriculum for building islamic nurses’ character in indonesia: a descriptive qualitative approach. healthc low-resource settings 2023;11:57–63. 15. dwi setiowati, peggy rianti kurnia sukma rr. the application of islamic spiritual methods in nursing program curriculum at uin syarif hidayatullah jakarta and uin alauddin makasar. islam transform j islam stud 2021;5. 16. frida a, novieastari e, nuraini t. perception on spiritual care: comparation of the nursing students of public university and religious-based university. wbfer clin 2019;29:59–64. 17. o’brien me. spirituality in nursing : standing on holy ground. third. canada: jones & bartlett publishers; 2008. 423 p. 18. gayatri d, nuraini t, handiyani h, k. the correlation of spirituality and implementation of spiritual care among nursing student in jakarta. kne med. 2023;2023:91–9. 19. aipni. kurikulum pendidikan ners indonesia tahun 2021. aipni. jakarta selatan: asosiasi institusi pendidikan ners indonesia (aipni); 2021. 185 p. 20. persatuan perawat nasional indonesia (ppni). standar kompetensi perawat indonesia. iv. standar kompetensi perawat indonesiadipublikasi oleh bidang organisasi ppppni melalui; http://www.inna-ppni.or.id. jakarta: ppni; 2013. 21. shanti wardaningsih, zikri al halawi. pembentukan perilaku caring islami pada mahasiswa keperawatan. 2019;4(1). 22. noviani w, musharyanti l, pratama rpa. “i internalize islamic values”: bachelor nursing students’ perception and experience of professional identity in indonesia. open access maced j med sci 2021;9:158–66. 23. nurlina n, nurdiana n. pengaruh mata kuliah al islam dan kemuhammadiyahan terhadap pelayanan antenatal. j bidan cerdas 2022;4:39–44. 24. abudari g, hazeim h, ginete g. caring for terminally ill muslim patients: lived experiences of non-muslim nurses. palliat support care 2016;14:599–611. 25. tekbaş a, von lilienfeld-toal m, sayrafi f, settmacher u. perioperative medication therapy for muslim patients in germany undergoing oncological surgery: a retrospective special issue pathways of change [page 72] [healthcare in low-resource settings 2025;13(s1):13087] study. bmc med ethics 2024;25:116. 26. tekbaş a, mauntel a, lehmann t, et al. enhancing intercultural competence of german medical students through innovative teaching on medical ethics with a focus on muslim patients – a pilot study. bmc med ethics 2024;25:152. 27. anshasi ha, fawaz m, aljawarneh ym, alkhawaldeh jm. exploring nurses’ experiences of providing spiritual care to cancer patients: a qualitative study. bmc nurs 2024;23:1–7. 28. rieffestahl am, mogensen ho, morcke am, risør t. ‘if you had taken the lead…’ – a qualitative study of patients with chronic conditions and their perspective in clinical encounters with medical students. chronic illn 2023;19:692–703. 29. perngmark p, sahawiriyasin o, holroyd e. experiences of thai-muslim patients regarding inconsistent antiretroviral therapy adherence: an exploratory descriptive qualitative study. belitung nurs j 2023;9:253–61. 30. yusof nm. integration and islamisation program for clinical post graduate students in international islamic university of malaysia (iium). int med j malaysia 2016;17:91–6. 31. maalouf i, el zaatari w. exploring undergraduate nursing students’ perceptions on clinical learning environment in the uae: a focus on perceived benefits and challenges. sage open nurs 2024;10. 32. mohd dzulkhairi mr, zairina ar, nooriah ms, yunus m. the naqli and ’aqli integration in the teachings of community health posting. int med j malaysia 2015;14:83–6. 33. abusafia ah, khraisat ams, tableb ok, al-mugheed k, alabdullah aa, abdelaliem smf. the impact of a nursing spiritual care module on nursing competence: an experimental design. bmc palliat care 2024;23:1–9. 34. heydari a, yaghoubinia f, roudsari rl. the multidimensional nature of relationships: the perceptions of iranian nursing students and educators of the student-educator relationship. j nurs res 2016;24:1–8. 35. simons mc, thomovsky s, hunt ja, jolley k. mentoring students. in: educational principles and practice in veterinary medicine, 2024. p. 367–82. 36. rowe-johnson m. achieving ethical mentoring and mentee professional integrity through formal mentor training for practicing psychologists. train educ prof psychol 2018;12:203–9. 37. wang w, yang j, bai d, et al. nurses’ perceptions and competencies about spirituality and spiritual care: a systematic review and meta-analysis. nurse educ today 2024;132. 38. letterstal a, kallestedt m-ls, widarsson m, asp m. nursing faculties’ perceptions of integrating theory and practice to develop professional competence. j nurs educ 2022;61:236– 41. 39. hammad bm, eqtait fa, salameh b, ayed a, fashafsheh ih. clinical learning environment: perceptions of palestinian nursing students. inq (united states) 2024;61. 40. walderhaug n, molnes si, vasset f. guidance from practice teachers a qualitative study of nursing students in practice studies. int j educ res open 2021;2:100026. 41. garone a, van de craen p, struyven k. multilingual nursing education: nursing students’ and teachers’ interests, perceptions and expectations. nurse educ today 2020;86. 42. shaheen n, khan ra, yasmeen r, sajid mt. probing in the complexities of the integrated undergraduate medical curriculum: a qualitative exploratory study. j pak med assoc 2022;72:452–6. 43. rochmawati e, minanton m. embedded spiritual conversation in cancer communication: lived experiences of nurses and patients/relatives. int nurs rev 2021;68:289–98. 44. schmidt c, nauta l, dang a. physician disengagement and spiritual dissonance in medical students. fam med 2021;53:58–60. 45. islam ma, hossain a, dutta a, uvero m. student pharmacists’ reflections on personal and professional development following a series of longitudinal faith-based courses. am j pharm educ 2024;88:101305. 46. noviani w, rosa em. “discover the meaning of professionalism”: nursing alumni experience on professional identity: a phenomenology study. bali med j 2021;10:1257–62 47. dadras f, nouhi e. relationship between professional ethics and spiritual intelligence of medical students of kerman university of medical sciences in 2018. iran j med ethics hist med 2019;12:338–48. 48. barkhordari-sharifabad m, kaka-tafti s-z, bastani p, mahmoudi-hashemi f. investigating the role of spiritual intelligence in moral sensitivity of nursing students. iran j med ethics hist med 2022;15:239–52. 49. jamaludin tss. integration of islamic values in undergraduate nursing program: an expository analysis. int j care sch 2019;2:5–8. 50. atkinson c. islamic values and nursing practice in kuwait. j holist nurs 2015;33:195–204. 51. tunny h, saleh a, rachmawaty r. persepsi, kompetensi dan hambatan perawat dalam. j ilm ilmu kesehat 2022;10:35–49. 52. nurbaeti i, lestari kb, khairunnisa tt. the correlation between islamic mindfulness with nursing student professional attitude and caring behavior. j keperawatan padjadjaran 2024;12:201–7. 53. ansyah eh, hadi c, nawangsari naf, rahman mna. teacher-student relationship model in muhammadiyah elementary schools’teachers in indonesia: the mediating role of effortful control. mojem malaysian online j educ manag 2024;12:62–77. 54. putri as, sunarya ce, waluyo a. nursing students’ spirituality and their perception of spirituality and spiritual care. indones nurs j educ clin 2023;8:3–11. 55. hopkins af, kooken wc, winger en. inclusive clinical practice and policy for muslim nursing students. j transcult nurs 2020;31:100–6. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13087] [page 73] hrev_master healthcare in low-resource settings 2024; volume 12:11991 the effect of self-hypnosis on anxiety level and self-efficacy of pregnant women in dealing with childbirth during the covid-19 pandemic fauziyatun nisa’, fritria dwi anggraini, yasi anggasari, farida umamah faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia abstract the covid-19 pandemic has become a multidimensional disaster, affecting various countries, including indonesia. adaptation is crucial in addressing the physical and mental health challenges within communities, which includes the adaptation of pregnant women who are preparing for childbirth amidst the pandemic with the aim of reducing maternal mortality rates in indonesia. this research aimed to assess the impact of selfhypnosis on the anxiety levels and self-efficacy of pregnant women preparing for childbirth during covid-19. the study utilized a quasi-experimental design with pre-test and post-test measures. it involved 30 respondents in both the control and intervention groups, who were selected through consecutive sampling. anxiety levels were measured using the depression, anxiety, and stress scale (dass), while self-efficacy was assessed with the new general self-efficacy scale. data analysis employed paired t-tests and independent t-tests, with the significance level set at p<0.05. the results indicated a significant difference in anxiety levels and self-efficacy between the control and intervention groups, with a p-value of 0.000. regular selfhypnosis practice positively influenced both anxiety levels and self-efficacy among pregnant women preparing for childbirth during the covid-19 pandemic. introduction anxiety is a natural and common experience for pregnant women as they approach childbirth. however, excessively high levels of anxiety, particularly in the third trimester, can have detrimental effects on both the mother and the fetus, as well as on the delivery process.1-3 elevated anxiety triggers the body to produce increased levels of stress hormones, such as cortisol, adrenocorticotropic hormone (acth), norepinephrine, and epinephrine. if these stress hormone levels become too high, they can lead to placental hypoperfusion, which negatively impacts fetal growth.4,5 indonesia has experienced the covid-19 pandemic, necessitating social distancing measures for all citizens.6,7 this situation has heightened concerns and anxieties among many pregnant women, particularly first-time mothers.8 this concern is particularly critical as the due date approaches, given that many hospitals are prohibiting families and relatives from accompanying expectant mothers during childbirth to prevent the spread of covid-19.9-11 in several developing countries worldwide, including ethiopia, nigeria, senegal, south africa, uganda, and zimbabwe, there is a high prevalence of psychological disorders among pregnant women (15.6%) and postpartum mothers (19.8%).12 in indonesia, a study conducted in 2012 revealed that primigravida mothers experienced severe anxiety at a rate of 83.4%, with moderate anxiety affecting 16.6% of them. multigravida mothers, on the other hand, experienced severe anxiety at a rate of 7%, moderate anxiety at 71.5%, and mild anxiety at 21.5%. the negative impact of anxiety on pregnant women can stimulate uterine contractions, leading to increased blood pressure, which in turn may trigger conditions such as preeclampsia and miscarriage.13-15 correspondence: fauziyatun nisa’, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, indonesia. e-mail: fauziyatun.nisa@unusa.ac.id key words: anxiety level, covid-19 pandemic, pregnant women, selfefficacy, self-hypnosis. contributions: fn, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; fda, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ya, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; fu, methodology, visualization, writing – review & editing; for resources, investigation, and writing –review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: this research was supported by a research grant from universitas nahdlatul ulama surabaya with contract number 162/unusa/adm-lppm/iii/2021. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, universitas nahdlatul ulama surabaya, based on ethical certificate 122/ec/kepk/unusa/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patients’ consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank the rector (prof. dr. ir. achamad jazidie, m.eng) and the research and community service institutions of universitas nahdlatul ulama surabaya for their valuable insights and contributions to this study. received: 15 october 2023. accepted:18 march 2024. early access: 22 april 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11991 doi:10.4081/hls.2024.11991 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:11991] [page 517] non -co mmerc ial us e o nly the covid-19 pandemic brings many changes, one of which is also felt by pregnant women.16 this condition certainly makes many pregnant women feel worried and anxious, especially those who are experiencing pregnancy for the first time.12 this is very important, especially if it is nearing the day of birth, because many hospitals prohibit families and relatives from accompanying their family members during childbirth to prevent the spread of covid-19. without the covid-19 problem, in general, latetrimester pregnant women are faced with anxiety before their childbirth, let alone if they are in a situation that forces them to give birth without any accompanying family. giving birth without any accompanying family and the condition of the clinic/hospital that is not conducive because of this pandemic will put pregnant women at a greater risk of feeling anxious and insecure, especially if they don’t fully understand the current condition.17,18 the aim of this research was to determine the effect of self-hypnosis on the level of anxiety and self-efficacy of pregnant women in preparation for childbirth during the covid-19 pandemic. materials and methods research design the study employed a quasi-experimental design, utilizing a pre-test and post-test design. the intervention involved implementing self-hypnosis sessions for pregnant women over the course of one month, conducted once a week for a total of four sessions, each lasting 30 minutes. the pre-test assessment was administered prior to the intervention, while the post-test assessment was conducted one month after the pre-test. study participants the sampling technique used nonprobability sampling with a consecutive sampling method. the sample involved 30 respondents in the control group and 30 respondents in the interventions. variable, instrument and data collection the independent variable was self-hypnosis. the dependent variable consisted of the anxiety level and self-efficacy of pregnant women in preparation for childbirth during the covid-19 pandemic. the instrument used to measure anxiety level was depression, anxiety, and stress scale (dass) 42. the dass questionnaire used consisted of 42 items covering 3 sub-variables, namely physical, emotional, and behavioral. meanwhile, self-efficacy is estimated using the new general self-efficacy scale created by chen in 2001, which consists of eight items. data analysis data were analyzed using statistical tests, namely paired t-test and independent t-test with a significance value <0.05. ethical clearance the research has received ethical approval from the health research ethics commission, universitas nahdlatul ulama surabaya, based on ethical certificate 122/ec/kepk/ unusa/2021. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. results based on the collected data, a descriptive analysis was conducted, presenting the frequency distribution of pregnant women’s responses to the research variables. the results were summarized in table 1, revealing that the majority of pregnant woman respondents were of productive age (77%), had secondary education qualifications (60%), were not working (63%), and were multiparous (83%). table 2 demonstrates the results of the paired t-test statistical analysis, indicating a p-value of 0.00. since the p-value is less than 0.05, it can be concluded that there is a significant change in the anxiety levels of pregnant women before and after the intervention. the results of the paired t-test statistical test obtained a value of p=0.000 in the intervention group and a significance value of p=0.301 in the control group. the p-value <0.05 can be concluded that there was a significant change in the level of anxiety level before and after being given self-hypnosis in the intervention group and control group. table 3 explains that based on the paired t-test statistical test, the p-value=0.00. p-value<0.005, so it can be concluded that there was a significant change in the self-efficacy of pregnant women before and after the intervention. the results of the paired t-test statistical test obtained a value of p=0.000 in the intervention transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. distribution of pregnant women based on characteristics of education, occupation, and information acquisition. characteristics category frequency percentage (%) age productive (20-35) 23 77 non-productive 7 23 education primary 3 10 secondary 18 60 tertiary 9 30 occupation not working 19 63 working 11 37 parity primiparous 5 17 multiparous 25 83 total 30 100 table 2. changes in anxiety level before and after self-hypnosis in the intervention and control groups. pregnant women pregnant women's p anxiety levelp before after (mean±sd) (mean±sd) control group 27.66±2.27 23.34±2.24 0.301 intervention group 27.27±1.92 18.44±2.43 0.000 sd, standard deviation. *p<0.05 based on paired t-test. table 3. changes in self-efficacy before and after self-hypnosis in the intervention and control groups. pregnant mother self-efficacy p before after (mean±sd) (mean±sd) control group 10.5±1.32 10.5±1.13 0.210 intervention group 3.92±0.98 11.9 ± 2.05 0.000 sd, standard deviation. *p<0.05 based on paired t-test. [page 518] [healthcare in low-resource settings 2024;12:11991] non -co mmerc ial us e o nly group and a significance value of p=0.210 in the control group. the p-value <0.05 can be concluded that there was a significant change in the level of self-efficacy before and after being given self-hypnosis in the intervention group and control group. discussion the findings of this study indicate a significant difference in the anxiety levels of pregnant women facing childbirth between the control and intervention groups. notably, there was a decrease in anxiety levels among pregnant women following the self-hypnosis intervention compared to before the intervention. this suggests that regular self-hypnosis can effectively reduce anxiety levels in pregnant women. furthermore, the study highlights the significant impact of self-hypnosis on alleviating anxiety among pregnant women facing childbirth during the covid-19 pandemic. this is in line with fatimah et al.’s study, which states that relaxation training with the hypnobirthing method can significantly reduce the subject’s anxiety in dealing with nulliparous pregnancy in preparation for childbirth.19 the existence of thoughts such as giving birth that will always be followed by pain, will cause an increase in the work of the sympathetic nervous system.20,21 in this situation, the endocrine system, which is made up of glands such as the adrenal, thyroid, and pituitary (the control center of the gland), releases their respective hormones into the bloodstream to prepare the body for an emergency. as a result, the autonomic nervous system activates the adrenal glands, which affect the system of the hormone epinephrine. an increase in the hormones adrenaline and noradrenaline or epinephrine and norepinephrine causes dysregulation of the body’s biochemistry, resulting in physical tension in pregnant women.22 the impact of this physiological process can arise in daily behavior. thus, pregnant women become sensitive, restless, unable to focus, indecisive and may even want to run away from the realities of life.23 there was an increase in self-efficacy of pregnant women between before and after self-hypnosis interventions. this shows that self-hypnosis can increase the self-efficacy of pregnant women in dealing with childbirth during the covid-19 pandemic. regular self-hypnosis has an impact on the self-efficacy of pregnant women.24 a series of relaxation techniques ranging from muscle relaxation, breathing relaxation, mental relaxation, and instilling positive sentences that are carried out regularly with full concentration will cause a relaxed condition in the body. as a response, the body releases endorphins, which make pregnant women relax and feel less pain, especially when the brain reaches alpha waves or is at rest.25,26 in this condition, the body releases serotonin and endorphins so it allows a relaxed condition without tension and anxiety.27,28 conclusions there was a significant positive impact of self-hypnosis on stabilizing the anxiety levels of pregnant women. additionally, selfhypnosis was found to enhance and improve the self-efficacy of pregnant women. therefore, it is recommended that pregnant women engage in regular self-hypnosis sessions to benefit from its effects on anxiety stability and self-efficacy enhancement. references 1. aprillia y. bebas takut hamil dan melahirkan. 2017. available from: https://webadmin-ipusnas.perpusnas.go.id/ipusnas/publications/books/82582 2. zakiyyah m, supriyanto s, wulandari rd, et al. the effect of the covid-19 pandemic on the quality of antenatal care services in probolinggo district. j public health africa. 2023;14:2618. 3. kartiningrum ed, notobroto hb, salim la, otok bw. spatial determinants affected maternal mortality of east java province during the covid-19 pandemic era, in 2020-2021. j public health africa 2023;14:2545. 4. redinger s, pearson rm, houle b, et al. antenatal depression and anxiety across pregnancy in urban south africa. j affect disord 2020;277:296-305. 5. wang x, xie j, wu y, et al. gender-specific effect of pregnancy-related anxiety on preschooler’s emotional and behavioral development: a population-based cohort study. j affect disord 2021;279:368-76. 6. na’imah, muassomah, mubaraq z, et al. language and covid-19: a discourse analysis of resistance to lockdown in indonesia. heliyon 2023;9:e13551. 7. darmawan re, setyorini y, ardesa yh. indonesians’ readiness in facing long-term covid-19 pandemic. j ners 2022;17. 8. efendi f, haryanto j, has emm, et al. determinants of mortality risk among indonesian patients with covid-19. f1000research 2023;11:814. 9. kemenkes ri. pedoman kesiapsiagaan menghadapi infeksi covid-19. available from: https://jombangkab.go.id/opd/kesehatan/berita/pedoman-kesiapsiagaan-menghadapi-infeksi-novel-coronavirus 10. sudaryanti l, mardhika a, qona’ah a, et al. antenatal care of pregnant women during pandemic: a phenomenology study. j pak med assoc 2023;73:s71-5. 11. nisa’ f, damayanti na, suhariadi f, et al. internal factors affecting the mother’s psychological capital in exclusive breastfeeding during the covid-19 pandemic. j public health res 2022;11:22799036221106619. 12. aziz ma. rekomendasi penanganan infeksi virus corona (covid-19) pada maternal (hamil, bersalin dan nifas). penanganan infeksi virus corona pada maternal. pogi 2020;128. 13. larkin p, begley cm, devane d. women’s experiences of labour and birth: an evolutionary concept analysis. midwifery 2009;25. 14. naja s, al kubaisi n, singh r, bougmiza i. generalized and pregnancy-related anxiety prevalence and predictors among pregnant women attending primary health care in qatar, 2018– 2019. heliyon 2020;6:e05264. 15. umamah f, santoso b, yunitasari e, et al. the effectiveness of psycho-educational counseling in pregnant women with preeclampsia: a systematic review. j public health res 2022;11:22799036221104161. 16. indriyani d, yunitasari e, efendi f. relationship between cgol (chlorophyll, ginger, orange, and lemongrass) consumption and confirmed covid-19 cases on pregnant women. healthc low-resour sett 2023;11:11749. 17. anantasari r, dwi rnw, gunawan. hipnosis dalam mengurangi cemas dan nyeri antenatal. j keperawatan 2012;3:189-96. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11991] [page 519]17. anantasari r, dwi rnw, gunawan. hipnosis dalam mengurangi cemas dan nyeri antenatal. j keperawatan 2012;3:189-96. non -co mmerc ial us e o nly 18. teixeira c, figueiredo b, conde a, et al. anxiety and depression during pregnancy in women and men. j affect disord 2009;119:142-8. 19. dachew ba, ayano g, betts k, alati r. the impact of prepregnancy bmi on maternal depressive and anxiety symptoms during pregnancy and the postpartum period: a systematic review and meta-analysis. j affect disord 2021;281:321-30. 20. ghufron mn, s rr. teori-teori psikologi. available from: https://opac.perpusnas.go.id/detailopac.aspx?id=1137840 21. gurgevich s. self-hypnosis techniques. integrative medicine: fourth edition. elsevier inc.; amsterdam, the netherlands; 2018. 22. kartini kartono. psikologi wanita jilid 2 : mengenal wanita sebagai ibu dan nenek. 2007. available from: http://library. fip.uny.ac.id/opac/index.php?p=show_detail&id=55 23. palupi fh. menghadapi proses persalinan kala i j kesmadaska 2015;9-13. 24. permatasari as. self-hypnosis terhadap tingkat kecemasan ibu hamil dalam persiapan menghadapi persalinan di masa pandemic. 2020. available from: https://jurnal.unw. ac.id/index.php/semnasbidan/article/view/820 25. fatimah f, triyani s, aisyah a. determinan pengambilan keputusan dalam perencanaan persalinan pada kelas ibu hamil. j ilmu dan teknol kesehat 2014;37-43. 26. dunkel schetter c, tanner l. anxiety, depression and stress in pregnancy: implications for mothers, children, research, and practice. curr opin psychiatry 2012;25:141-8. 27. george a, luz rf, de tychey c, et al. anxiety symptoms and coping strategies in the perinatal period. bmc pregnancy childbirth 2013;13:233. 28. andriyani a, sulaeman j, marhaeni d, et al. kelas hypnobirthing sebagai mind-body and interventions: study kualitatif di puskesmas rawat inap kota yogyakarta hypnobirthing class as mind-body and interventions: qualitative study at h transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 520] [healthcare in low-resource settings 2024;12:11991] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:12773 exploratory study of factors influencing fraud in the national health service in buton islands from a hexagon model perspective andi yaumil bay r. thaifur department of health policy administration, universitas dayanu ikhsanuddin, city of baubau, indonesia abstract fraud in national health insurance of indonesia, known as jaminan kesehatan nasional (jkn) services, is a problem that can potentially occur in all hospitals in indonesia. this research aims to explore the factors that influence the occurrence of fraud from the perspective of the hexagon model in jkn services in several hospitals in the buton islands. the hexagon model, which consists of six key factors—opportunity, ability, arrogance, pressure, rationalization, and collusion—was used to systematically analyze the occurrence of fraud. this research uses an exploratory study method with in-depth interviews with 30 key informants. the research results show that the factor that most influences the occurrence of fraud is opportunity, followed by ability and arrogance. although the model suggests pressure and rationalization as contributing factors, these elements remain ambiguous in this study due to insufficient supporting data. collusion plays an important role in fraud but does not always occur. the study resulted in the development of a preliminary predictor model based on the findings, which can be used to identify risk factors for fraud in jkn services. this predictor model can be used to identify risk factors for fraud so that more effective prevention and response can be carried out. introduction national health insurance of indonesia, known as jaminan kesehatan nasional (jkn), is a government program that aims to provide access to quality and fair health services for all indonesian people.1 this program has been implemented since 2014 and has significantly benefited the community. however, this program also faces various challenges, including fraud. fraud can have a negative impact on the sustainability of the jkn program, such as increasing program costs, decreasing service quality, and losing public trust. the complexity of managing such a large-scale health insurance system, particularly in areas with unique socio-economic and geographic challenges, exacerbates these risks. the problem of fraud in all indonesian hospitals has the potential to occur anywhere, so this study is a challenge that has implications for the sustainability of accountable jkn hospital administration and excellent services. several studies conducted in indonesia, most of which have identified findings based on the detection of potential or risk of fraud in hospitals. at a general pulmonary hospital of rsup. dr. soeradji tirtonegoro,2 and at a regional hospital rsud tenriawaru,3 health workers and coders commit both intentional and unintentional forms of fraud. the results of this fraud are in line with previous findings, which emphasize problems related to the dissemination of policies and programs that have not been evenly distributed to regions and policy aspects of service infrastructure in health facilities, referral systems, and hr and capacity building, financing aspects, and risk management of fraud.4,5 however, these studies often focus on more central regions, while fraud in more remote areas, such as the buton islands, remains underexplored. the buton islands were selected as the focus of this research due to their remote geographical location, limited access to healthcare resources, and lower economic levels, which create a distinctive context for understanding fraud risk within the jkn program. these conditions present heightened challenges for monitoring and enforcing compliance, potentially increasing the opportunities and motives for fraudulent activities. by focusing on this region, this study aims to fill the gap in the literature concerning how geographic and economic isolation may influence fraud in the context of national health insurance programs. the hexagon model is a comprehensive and holistic model for understanding the factors that influence fraud incidents. the hexagon fraud model has been used to detect fraudulent financial reporting in indonesian state-owned enterprises.6 the fraud correspondence: andi yaumil bay r. thaifur, department of health policy administration, universitas dayanu ikhsanuddin, city of baubau, indonesia. e-mail: andiyaumilbay.t@gmail.com key words: fraud, hexagon model, hospital, national health insurance. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of health research from the faculty of public health, hasanuddin university, approved this study (number 2743/un4.14.1/tp.01.02/2022). informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 3 july 2024. accepted: 27 october 2024. early access: 26 november 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:12773 doi:10.4081/hls.2024.12773 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 32] [healthcare in low-resource settings 2025;13:12773] hexagon theory proposed by vousinas (2019) from the national technical university of athens, derived from the pentecostal theory (score), includes stimulus (pressure), capacity (capability), opportunity, rationalization, and ego.7 in the context of jkn services, these dimensions can manifest in various ways: for instance, ‘opportunity’ may arise from gaps in regulatory enforcement, ‘pressure’ from financial strains on healthcare providers, and ‘collusion’ through coordinated efforts between staff to exploit the system. in this research, the model consists of six interrelated dimensions: pressure, opportunity, capability, rationalization, arrogance, and collusion. each dimension can be a driving factor for fraud, both independently and mutually reinforcing. this research aims to identify specific dimensions of the hexagon model that are most prevalent in the buton islands, and to examine how these factors interact with the local context. by doing so, this study contributes to a deeper understanding of fraud dynamics within the jkn system in remote regions and offers insights into more effective prevention strategies tailored to such environments. materials and methods this study employed a qualitative exploratory design to identify conceptual indicators as predictors of potential fraud in several buton islands hospitals by exploring information through in-depth interview activities focused on the hexagon model aspects. the research was conducted at 3 (three) regional general hospitals (rsud) and 1 (one) private hospital in the buton islands, which were selected purposively, namely buton district hospital, south buton district hospital, central buton district hospital, and faga husada hospital. the selection of these hospitals was based on criteria including hospital size, geographical distribution, and the diversity of services provided, ensuring a comprehensive exploration of fraud risk in different healthcare settings. the development of dimensions and indicators through this exploratory study aims to capture the diverse perspectives of selected informants, who were hospital staff members, managers, and healthcare professionals, involved directly or indirectly in financial management or administrative duties. these perspectives serve as a foundation for preparing instruments that will contribute to a predictive model for fraud incidents (table 1). the key informants were selected using purposive sampling based on their role in the hospital, their involvement in financial or administrative processes, and their knowledge or exposure to fraud risk factors. the total number of key informants in this research was 30 people. the tools or instruments used in collecting qualitative data are as follows: i) in-depth interview (indepth-interview) is a guide that is modified according to regional conditions and created based on identifying problems indicative of fraud; ii) recording equipment consists of a notebook, a digital camera to record images during interviews, and a tape recorder to record the informant’s voice; iii) informed consent is a form requesting willingness to become an informant from the researcher and a consent form to become an informant from the informant. data were collected through direct interview techniques using open-ended questions. in-depth interviews were conducted when information obtained was incomplete or required further clarification for thematic analysis. the informants were asked about their perceptions, experiences, and understanding of fraud within the jkn system. interviews were carried out in person or via telephone, and the results were documented into interview transcripts and matrices, which were then analyzed. data analysis was conducted using content analysis, focusing on thematic coding, classification, and the identification of patterns in the responses. the process of classifying answers was guided by the research questions and fraud indicators identified in the hexagon model. the data were further analyzed to predict potential areas of fraud based on informants’ responses. validity testing was ensured through multiple measures: credibility (internal validity) was established by triangulating data from different informants and sources, while transferability (external validity) was enhanced by providing detailed descriptions of the study context, allowing for replication in similar settings. results based on the qualitative study (table 2), the factors influencing the occurrence of fraud in jkn services in the buton islands are complex and interrelated. the most influential factor identified was opportunity, followed by capability and arrogance. pressure was less conclusive, as some informants did not perceive it as a significant driver of fraud. rationalization and arrogance often strengthen the primary factors, enabling individuals to justify fraudulent behavior. collusion was identified as a supportive but not always necessary element for fraud to occur. discussion using the hexagon model perspective, this qualitative study reveals the factors that influence the occurrence of fraud in national health insurance (jkn) services in various hospitals. these findings illustrate the complexity of the fraud phenomenon in the healthcare context. in alignment with previous studies, this research highlights how systemic factors such as internal hospital pressures and socio-economic conditions contribute to fraudulent behavior. in the context of pressure, research results show that pressure can be the main trigger for fraud, especially in individuals who feel a heavy workload or lack of well-being. other research article [healthcare in low-resource settings 2025;13:12773] [page 33] table 1. operational definition of fraud dimension variables based on the hexagon model perspective. variable operational definition/objective framework pressure forms of encouragement (can be financial, targets, awareness, unclear regulations, work pressure, helping others) to commit fraud opportunity low self-awareness and internal control result in taking advantage of opportunities (weak monitoring and evaluation, lack of transparency, organizational structure problems, unclear rules) to commit fraud capability the capability (position), intelligence, self-confidence, personality, rhetoric) of a person to commit fraud rationalization the form of action of a person who justifies and feels it makes sense to carry out fraudulent activities arrogance/ego the nature of a person's ego or character that causes greed and feeling better than other people collusion an agreement/cooperation/compromise that benefits one particular party results show that the pressure experienced by employees comes from internal hospital pressures and external hospital pressures, for example, family needs and lifestyle, salaries for employees as a whole, and take-home pay (basic salary, remuneration, and side dishes) for employees. specific time employment agreement.8 this finding echoes earlier studies, which suggest that socio-economic pressures are significant contributors to fraud in lowresource health systems. however, it cannot be seen as the only factor influencing the decision to commit fraud. other roles, such as faith and work environment, influence fraud.9 furthermore, opportunity is also an important factor in this research. the study results show that individuals are more likely to commit fraud if they perceive an opportunity to do so. several factors that can create this opportunity include poor management, lack of clarity in the distribution of financial services, and a weak supervisory system.10,11 in health systems, corruption, or the abuse of power for private gain, includes bribes and kickbacks, embezzlement, fraud, political influence/nepotism, and informal payments, among other behaviors. this aligns with broader research on healthcare corruption globally, where weak oversight and lack of transparency are recurring themes. drivers of corruption include individual and systems-level factors such as financial pressures, poorly managed conflicts of interest, and weak regulatory and enforcement systems.12 therefore, efforts to prevent fraud in jkn services need to pay attention to these aspects to reduce the opportunity for fraud to occur. it is essential for policymakers to strengthen management protocols and increase transparency in hospital operations to minimize these opportunities. capability is also an important factor in this study. the findings show that individuals with an interest, intention, or advantage in committing fraud are likelier to engage in such acts.13 apart from that, not understanding the rules and feeling dissatisfied with what is received can also affect a person’s capability to commit fraud.14 this diverges slightly from other studies that have found dissatisfaction to be less of a driver compared to institutional weaknesses and lack of proper governance. therefore, there is a need for actions that educate individuals about the rules and monitor their satisfaction with the jkn system. individual rationality in committing fraud is also an important concern in this research. the findings show that most respondents see fraud as something unnatural, but some see it as an action that can be justified in certain situations. this underlines the complexity of fraud’s moral and ethical aspects.15,16 arrogance also appears as a factor that can cause someone to commit fraud. an individual’s trait of arrogance may influence their decision to engage in actions that are detrimental to the organization or patients.17,18 apart from that, external factors such as pressure from superiors and individual interests can also play a role in encouraging fraud. collusion, or cooperation between individuals or entities that have the potential to commit fraud was also identified as an important factor. the findings show that collusion can be the main trigger for fraud.19 pressure from superiors, feelings of threat, and cooperation triggered by mutual interests are examples of ways collusion can influence fraud in the context of jkn services in hospitals. this finding is particularly relevant in regions like the buton islands, where social bonds and networks may intensify the likelihood of collusion. the results of other research show that the pressure and rationalization variables have a positive and significant effect on opportunities, so improvements in the pressure and rationalization variables will create improvements in the opportunity variables.20 the pressure, rationalization, and opportunity variables have a positive and significant effect on fraud prevention, so improvements in the pressure, rationalization, and opportunity variables will create improvements in the fraud prevention variable. this suggests that by addressing pressure and rationalization through policy interventions such as improving working conditions and reinforcing ethical standards opportunities for fraud can be significantly reduced. in the context of the buton islands, socio-economic and cultural fac article [page 34] [healthcare in low-resource settings 2025;13:12773] table 2. qualitative study results from the perspective of the hexagon model. dimension responses summary/key findings pressure thirteen informants said that fraud should not be committed; five informants pressure was found to be a contributing factor stated they did not agree with fraud but were pressured by the patient's condition; in a subset of cases, particularly linked to workload five said fraud was due to pressure; two said fraud was committed out of ignorance, and superior influence. with other varied responses. six informants stated there was no pressure to commit fraud; five mentioned pressure from superiors; two said the pressure could be managed. ten informants said pressure did not influence fraud, while nine said it did, and five were uncertain. other factors included heavy workload, lifestyle, income, claims system, and helping patients. opportunity twenty-one informants said that opportunity influenced fraud occurrence; opportunity emerged as the most significant factor five said it "maybe" did; the remainder indicated empathy. driving fraud, due to poor oversight and managerial factors included poor management, nepotism, weak monitoring, issues. severity level manipulation, and position/authority misuse. capability twenty-seven informants agreed that capability influenced fraud; capability plays a central role in fraud, particularly three said there might be an influence. factors included authority, attitude, among individuals with authority and personal intelligence, personality traits, and faith. other factors: dissatisfaction, motivations. lack of understanding of rules, and desire for profit. rationalization twelve informants said perpetrators always rationalize their actions; rationalization helps justify fraudulent actions, others gave varied responses. fifteen informants said deliberate fraud was abnormal, though views on its normality are mixed. while several said it was normal depending on the situation. arrogance twenty-two informants agreed arrogance could cause fraud; five said "maybe," arrogance enhances fraud tendencies, particularly two disagreed, and one was unsure. arrogance was tied to selfishness, greed, among individuals with positional power. and authority abuse. collusion twenty-two informants said collusion played a role; seven said "maybe," collusion is a facilitative factor but not always and one said "no." collusion typically occurred due to peer pressure or superior influence. present. tors also play a unique role in influencing fraud. the remote geographic location and lower economic development of the region may exacerbate pressures on healthcare workers, leading to higher instances of fraudulent activities. this underscores the importance of considering regional variations when designing anti-fraud policies for jkn services. overall, this research illustrates the complexity of factors contributing to fraud in jkn hospital services. understanding these factors is important in preventing and addressing fraud in this critical health sector. based on the findings, specific strategies for fraud prevention should include strengthening oversight mechanisms, enhancing transparency in financial management, and providing regular ethical training for healthcare workers. additionally, policies aimed at improving staff welfare and reducing socio-economic pressures can serve as preventive measures against fraud. this study contributes to understanding fraud behavior in the healthcare context and can assist policymakers and practitioners in developing strategies to combat effective fraud. conclusions this research succeeded in identifying six key factors that influence the occurrence of fraud in national health insurance (jkn) services in several hospitals, namely pressure, opportunity, capability, rationality, arrogance, and collusion. these factors interact with each other and form a complex framework for understanding the phenomenon of fraud in the health sector. the findings highlight the importance of addressing opportunity and capability as the primary drivers of fraud, supported by influences from rationalization, arrogance, and collusion. based on these findings, several actionable recommendations can be made to mitigate fraud in jkn services: i) strengthen the supervision and monitoring systems, hospitals should enhance internal control mechanisms, ensuring transparency in financial management and reducing the opportunities for fraud; ii) improve staff welfare and working conditions, reducing pressures related to workload and financial strain, such as by providing fair compensation and better working conditions, may alleviate the stress that leads to fraud; iii) enhance ethical training and education, regular training programs that focus on ethics and the risks of fraud should be implemented to raise awareness among healthcare workers, particularly in remote regions like the buton islands; iv) implement stricter sanctions for fraud, clear and consistent consequences for fraudulent activities should be established to deter potential offenders and reinforce accountability within the healthcare system. for future research, it would be beneficial to explore the socio-economic and cultural factors that may intensify these fraud drivers, especially in remote areas like the buton islands. more in-depth quantitative studies could assess the magnitude of each factor’s influence and help prioritize interventions. additionally, further investigation into how collusion develops within healthcare teams and its role in enabling systemic fraud would provide critical insights for policymakers aiming to prevent fraud on a larger scale. references 1. kementerian kesehatan ri. buku pegangan sosilaisasi jaminan kesehatan nasional (jkn) dalam sistem jaminan sosial nasional [internet]. jakarta: kementerian kesehatan ri; 2014. 76 p. available from: https://luk.staff.ugm.ac. id/atur/ bpjs/bukupegangansosialisasijkn-sjsn.pdf 2. santoso b, hendrartini j, djoko rianto bu, trisnantoro l. system for detection of national healthcare insurance fraud based on computer application. phi 2018;4:46–56. 3. palutturi s, makkurade sr, putri se. potential for fraud of health service claims to bpjs health at tenriawaru public hospital, bone regency, indonesia. internat j innovat creativity change 2019;8:21. 4. abu k. potential of hospital fraud in the indonesia national health insurance era. a descriptive phenomenological research. indian j forensic med toxicol 2020;14:1132–6. 5. maidin a, palutturi s. the study of implementation of national health insurance cross province (south sulawesi, south east sulawesi and, west sulawesi), 2014. jurnal kebijakan kesehatan indonesia 2016;5:96–100. 6. achmad t, ghozali i, pamungkas id. hexagon fraud: detection of fraudulent financial reporting in state-owned enterprises indonesia. economies 2022;10:13. 7. vousinas gl. advancing theory of fraud: the s.c.o.r.e. model. j financial crime 2019;26:372–81. 8. sadikin h, adisasmito w. analisis pengaruh dimensi fraud triangle dalam kebijakan pencegahan fraud terhadap program jaminan kesehatan nasional di rsup nasional cipto mangunkusumo. jurnal ekonomi kesehatan indonesia 2016;1: 28–34. 9. agus bandiyono. fraud detection: religion in the workplace big data analytics. jurnal akuntans. 2023;27:380–400. 10. firmansyah y, haryanto i, ernawati. fraud issues in the national health insurance (causes, legal impacts, dispute settlement and preventive measures). jurnal multidisiplin madani (mudima) 2022;2:1663–80. 11. fund im. financial system abuse, financial crime and money laundering background paper. policy papers 2001;2001:039. 12. vian t. anti-corruption, transparency and accountability in health: concepts, frameworks, and approaches. glob health action 2020;13:1694744. 13. sun x, chen y. why do people with similar levels of internal control differ in their likelihood to commit fraud? analysis of the moderating effect of perceived opportunity to commit fraud. front psychol 2022;13:999469. 14. abdullahi r, mansor n. fraud triangle theory and fraud diamond theory. understanding the convergent and divergent for future research. ijarafms 2015;5:38-45. 15. fernandhytia f, muslichah m. the effect of internal control, individual morality and ethical value on accounting fraud tendency. media ekonomi dan manajemen 2020;35:112–27. 16. yulianti y, zarkasyi mw, suharman h, soemantri r. effects of professional commitment, commitment to ethics, internal locus of control and emotional intelligence on the ability to detect fraud through reduced audit quality behaviors. j islamic account business res 2024;15:385-401. 17. anderson c, sharps dl, soto cj, john op. people with disagreeable personalities (selfish, combative, and manipulative) do not have an advantage in pursuing power at work. proceedings nat acad sci 2020;117:22780–6. 18. milyavsky m, kruglanski aw, chernikova m, schori-eyal n. evidence for arrogance: on the relative importance of expertise, outcome, and manner. plos one 2017;12:e0180420. 19. villegas-ortega j, bellido-boza l, mauricio d. fourteen years of manifestations and factors of health insurance fraud, 2006– 2020: a scoping review. health justice 2021;9:26. 20. kartini k. developing fraud prevention model in regional public hospital in west sulawesi province. internat j law manag 2018;60:210–20. article [healthcare in low-resource settings 2025;13:12773] [page 35] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13109 the effectiveness of community-led total sanitation cadre intervention in improving stunting knowledge and behavior dedi mahyudin syam, andi bungawati poltekkes kemenkes palu, indonesia abstract the prevalence of stunting remains high in central sulawesi province, indonesia. poor sanitation is a significant risk factor for stunting, and community-based interventions such as communityled total sanitation (clts) show promise in addressing this issue. despite the government’s multi-sectoral and integrated approach, encompassing both specific and sensitive nutrition interventions, the problem of stunting persists. this study aimed to assess the effectiveness of cadre-led interventions in improving community knowledge and behavior related to clts as a means of stunting prevention. a quasi-experimental, non-randomized design was used, with proportional stratified random sampling applied to a population of 332, resulting in a sample size of 182 individuals. data collection was conducted from july to september 2023. the intervention involved clts cadres delivering counseling and triggering activities to mothers of stunted children. knowledge and behavior regarding the five pillars of clts were measured as the dependent variables using a clts questionnaire with a scoring system. data analysis was performed using spss version 22.0, specifically employing the independent-sample t-test with a significance threshold of p<0.05. results indicated a significant increase in knowledge across the five pillars of clts (p=0.000), as well as a significant improvement in behavior concerning handwashing with soap, drinking water, food management, and household wastewater management (p=0.000). the findings suggest that cadres play an effective role in enhancing community knowledge and behavior regarding clts, contributing to stunting prevention efforts. introduction stunting is defined as short stature for age, measured by length/height below -2 standard deviations (sd) on the world health organization (who) growth curve. it occurs due to irreversible conditions caused by inadequate nutrient intake and repeated or chronic infections during the first 1,000 days of life.1,2 children with stunted growth are short for their age, typically due to chronic malnutrition, placing them in the stunting category.3,4 reducing stunting is a global priority, as reflected in sustainable development goal 2 and who’s aim to mitigate global public health issues, including stunting.5 linear growth retardation, as measured by height at a given age, remains a significant public health problem worldwide.6–8 according to who, approximately 149 million children under 5 years old were estimated to be stunted globally in 2020.9 in 2021, stunting prevalence varied widely across regions; for example, it was 8.2% among school-aged children in west ethiopia, while in indonesia, it was 30.8% in 2018, making indonesia the secondhighest in southeast asia. by 2022, an estimated 148.1 million children under 5 were stunted globally.10 in indonesia, the stunting prevalence slightly decreased from 21.6% (indonesian nutritional status survey, 2022) to 21.5% in 2023.11 in central sulawesi, stunting rates were recorded at 29.7% in 2021 and 28.2% in 2022.12 in developing countries, poor sanitation is closely linked to stunting through its association with inadequate clean water and wash (water, sanitation, and hygiene) conditions.3,13,14 studies have shown that poor sanitation correlates with higher vulnerability to stunting.15–17 stunting not only impacts the health and cognitive development of children but also has significant long-term effects on a country’s economy, with potential losses in per capita correspondence: dedi mahyudin syam, poltekkes kemenkes, palu, indonesia. e-mail: dmahyudin21@gmail.com key words: behavior; community-led total sanitation; intervention; knowledge; stunting. contributions: dms, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing original draft, review & editing; ab, resources, investigation, and writing review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received approval from the palu ministry of health polytechnic research ethics commission (number 0066/kepk-kpk/vi/2022). during the research, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence, and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was supported by a research grant from dipa politeknik kesehatan kemenkes palu 2023, with contract number dp.04 0312.1 11 143.512023. acknowledgments: we would like to thank the director of the palu ministry of health polytechnic, who has provided support to carry out the research, the sigi district government, the head of the sigi district health office, who has given permission for the research, and the sigi regency stbm cadres, who have participated in this research. received: 15 september 2024. accepted: 7 november 2024. early access: 10 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13109 doi:10.4081/hls.2024.13109 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 20] [healthcare in low-resource settings 2025;13(s1):13109] income estimated between 5-7% due to stunting.18–22 stunted children are at increased risk of lower cognitive development, reduced future productivity, susceptibility to non-communicable diseases, and poverty.23 stunting remains one of the most serious public health challenges, particularly due to sanitation’s direct impact on health, lifestyle, and environmental conditions.24–26 in indonesia, involving community health cadres has become a critical strategy in stunting prevention efforts.27,28 despite a multi-sectoral governmental approach—integrating national, local, and community programs at central and regional levels through specific and sensitive nutrition interventions—the problem persists. nutrition-specific interventions include additional food and iron supplementation for pregnant women from lower-income groups, while sensitive interventions improve drinking water and sanitation access. however, these efforts alone have not resolved the stunting issue.27 improving community nutritional knowledge and implementing community-led total sanitation (clts) has been shown to help reduce stunting.29–31 poor sanitation is a key risk factor for stunting, especially among mothers of young children. clts focuses on five pillars: clean water, sanitation, hygiene, waste management, and household wastewater management. among these, challenges persist particularly in clean water, sanitation, and hygiene, which contribute significantly to stunting incidence.31,32 research on clts cadre interventions to increase community knowledge and actions regarding these five pillars in stunting prevention has so far been limited to the central sulawesi region. this study aimed to evaluate the effectiveness of cadre interventions in enhancing community knowledge and practices related to clts for stunting prevention in sigi regency, central sulawesi, indonesia. materials and methods research design this study employed a quantitative, quasi-experimental, nonrandomized design conducted from july to september 2023. study participants the study population included 332 mothers of two-year-old children diagnosed with stunting. the sample size was 182 participants, with 91 in the intervention group and 91 in the control group. proportional stratified random sampling was used to select participants, and the sample size was calculated using the slovin formula. inclusion criteria were: mothers of stunted two-year-old children residing within the research location and willing to participate. exclusion criteria included: mothers who did not meet the inclusion criteria or those unwilling to participate. variable, instrument, and data collection the independent variable was the intervention by communityled total sanitation (clts) cadres, which involved counseling and triggering activities aimed at increasing mothers’ knowledge and attitudes regarding the five pillars of clts: open defecation, handwashing with soap, clean water and food management, waste management, and household wastewater management. the dependent variable was the knowledge and attitudes of mothers with two-year-old stunted children concerning these five clts pillars. knowledge and attitudes were assessed before and after the intervention. intervention preparation stage cadre training: in the fourth week of july, clts cadres received training on clts concepts and stunting prevention, including counseling and triggering techniques. target mapping: identification of mothers with stunted toddlers within the intervention area. preparation of educational materials: creation of educational materials, such as brochures, posters, and leaflets, designed to be engaging and easily understood by mothers. stakeholder coordination: collaboration with community health centers and village government authorities. implementation of intervention counseling and triggering sessions for mothers of stunted children were conducted at village halls and participants’ homes. the intervention aimed to discourage open defecation, promote handwashing with soap, ensure access to clean water, and improve household waste and wastewater management. the control group received counseling on clts topics but did not participate in triggering activities. instruments the clts questionnaire, which used a scoring method, assessed the intervention’s effectiveness. knowledge and attitudes regarding the five clts pillars were measured using 25 questions for each indicator. questionnaires were administered before and after the counseling and triggering intervention. data analysis data analysis was conducted using spss version 22.0. first, univariate analysis was performed to describe the frequency distribution of each variable. next, a paired-sample t-test (p<0.05) was conducted to determine average differences in knowledge and attitudes before and after the intervention. ethics clearance all respondents provided informed consent before participation, and confidentiality was maintained by using numerical codes instead of names. the study adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. ethical approval was granted by the research ethics committee of the palu ministry of health polytechnic (approval no. 0066/kepk-kpk/vi/2022). results tables 1, 2 and 3 present the research findings on the effectiveness of community-based total sanitation cadre intervention in stunting prevention efforts. the majority of respondents in this study were aged 31-35 years, making up 46.7% of the sample. in terms of education, most respondents had completed junior high school, also accounting for 46.7%. the predominant occupation among participants was that of a housewife, representing 70.3% of the group. additionally, a slight majority of respondents, 55.5%, had an income below the regional minimum wage (rmw). these findings highlight the dominant demographic and socioeconomic characteristics of the study population (table 1). table 2 indicates that all five clts pillar variables displayed significantly different levels of knowledge between the control group and the intervention group, with a p-value of 0.000. table special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13109] [page 21] 3 shows that the action variable concerning open defecation obtained a p-value of 0.168, while managing household waste resulted in a p-value of 0.073. in contrast, handwashing with soap, clean water, household food management measures, and efforts to safeguard household wastewater all showed significant results with a p-value of 0.000. discussion the study results do not provide specific insights into how age influences increased knowledge through counseling. however, some articles suggest that motivation, trust, and the tendency to seek advice may change with age. for example, research indicates that the motivation to be recognized for achievements declines with age, while the incentive to help others strengthens.33 several studies have evaluated community-based interventions related to sanitation knowledge. one study assessed the effectiveness of a community-led hygiene promotion program in a rural salvadoran setting, finding that the intervention increased knowledge and behavior related to hygiene.34,35 another study concluded that community-led wash interventions positively impact social factors, particularly for primary caregivers.36,37 in addition to increasing knowledge about open defecation, there were significant improvements in public knowledge regarding handwashing with soap, clean water management, food safety, household waste management, and wastewater management after receiving counseling, all with a p-value of 0.000. table 3 presents behavioral data regarding the five pillars of clts. the results indicated that two pillars (open defecation and household waste management) did not show significant differences in average values. the average behavior score for open defecation in both the intervention and control groups was not significantly different, with a p-value of 0.168. this lack of significant difference in open defecation behavior may be attributed to several factors, including a low level of community education, with only 17.6% having completed elementary school and 46.7% having completed junior high school. research indicates that education is a predisposing factor influencing open defecation behavior.38,39 a study conducted in haiti showed that education significantly impacts open defecation practices. in addition to educational factors, habitual practices play a role; many individuals do not use family latrines and instead defecate in gardens, rivers, or forests. other studies indicate that factors such as age, gender, and diet also affect defecation patterns.40 psychological aspects can also influence negative behaviors related to open defecation.41,42 research in nepal revealed that practices of defecating away from homes are influenced by cultural, religious, and spiritual factors.43,44 ownership and use of latrines, as well as perceived social status and privacy, further impact open defecation behaviors.45 special issue pathways of change [page 22] [healthcare in low-resource settings 2025;13(s1):13109] table 1. characteristics of respondents to clts cadres intervention for stunting prevention. variable n percent (%) age (year) 25-30 82 45.1 31-35 85 46.7 36-40 9 4.9 41-45 6 3.3 education elementary school 32 17.6 junior hight school 85 46.7 senior hight school 65 35.7 occupation housewife 128 70.3 farmer 40 22.0 trader 12 6.6 honorary worker 2 1.1 income below regional minimum wage (rmw) 101 55.5 above regional minimum wage (rmw) 81 44.5 action intervention 91 50 control 91 50 total respondent 182 100 table 2. result of knowledge difference tests between the intervention and control groups. variables intervention control p mean sd mean sd knowledge of open defecation 76.26 13.63 42.85 8.20 0.000 knowledge of handwashing with soap 70.10 16.43 43.07 14.27 0.000 knowledge of managing household drinking water and food 66.59 15.21 42.85 10.98 0000 knowledge of managing household waste 75.16 15.00 52.08 17.35 0.000 knowledge of managing household liquid waste 78.68 12.22 44.61 13.35 0.000 table 3. results of different behaviour tests between the intervention and control groups. variables intervention control p mean sd mean sd open defecation behavior 38.02 13.35 35.38 12.32 0.168 handwashing with soap behavior 82.63 14.96 43.73 10.71 0.000 household drinking water and food management behavior 86.37 12.24 58.68 15.43 0.000 household waste management behavior 59.56 11.14 56.92 8.39 0.073 household liquid waste management behavior 83.29 11.64 41.09 10.04 0.000 economic factors also contribute to open defecation habits. among respondents, 101 (55.5%) reported incomes below the regional minimum wage in central sulawesi, which limits their ability to meet household needs, including constructing family latrines. with uncertain incomes, people prioritize daily food needs over building latrine facilities, leading to limited attention to sanitation infrastructure.41,46 while income is often viewed as a primary factor contributing to open defecation, it is essential to consider additional factors when developing interventions to address this issue.47 for example, low-cost behavior-change interventions have been shown to effectively increase latrine use and safe disposal of child feces in rural odisha, india.48 the pillar concerning household waste management indicated average scores of 59.56 in the intervention group and 56.92 in the control group, with a p-value of 0.073. although the intervention group received counseling and triggering, there was no significant increase in average scores for household waste management. researchers suggest that the difference in average scores between the intervention and control groups is attributable to several factors, including education level, habits, and land conditions. many community actions regarding waste management still result in littering due to low educational levels and a lack of understanding of the impacts of waste disposal. several factors influence household waste management behavior and perceptions, including demographics, age, education level, and economic status.49 studies have shown that food insecurity, climate change, and economic development also impact household waste management practices.49–53 research in guinea indicated a correlation between low educational backgrounds and low incomes with household waste disposal practices.28,50 however, this contrasts with findings in southern africa, where individuals demonstrated practices of reusing household waste.54,55 a study in the uk highlighted that personal roles and individual differences in securing household waste are influenced by personality traits and prior experiences.55 in addition to the two previously discussed pillars, the results for handwashing with soap in the intervention group scored an average of 82.63, while the control group scored 43.37. clean water and household food management measures received average scores of 86.37 in the intervention group and 58.68 in the control group. the household wastewater security score in the intervention group was 83.29, compared to 41.09 in the control group. these three pillars demonstrated significant improvements with pvalues of 0.000. although not all households have dedicated handwashing facilities, such as those recommended during the covid-19 pandemic, individuals continue to wash their hands in bathrooms or using faucets in shared homes. this contrasts with findings by nipher m. malika et al. in peru, where individuals living in slums reported prolonged handwashing with limited access to soap.56,57 the level of community knowledge supports the habit of washing hands using soap and managing water and food safely. the significant differences in average values between the intervention and control groups are attributed to increased public knowledge about clean water sources that meet health standards. through triggering and counseling activities, the intervention group exhibited considerable improvements in their practices. consistent hand hygiene, particularly through handwashing with soap, is recommended for maintaining health.58,59 effective wastewater management can reduce pathogen exposure and minimize pollution through reduced wastewater discharge.60,61 this study has limitations, particularly in the initial characteristics of the experimental and control groups, which showed significant differences in factors such as education level and socioeconomic status that could influence study outcomes. further research is needed to select respondents with more controllable characteristics to enhance the reliability of the findings. conclusions cadre interventions are effective in increasing public knowledge about stopping open defecation, handwashing with soap, drinking water and food management, and household waste management. these interventions were also effective in improving attitudes toward handwashing with soap, household water management, and household wastewater management; however, they were not effective in changing attitudes toward open defecation and household waste management. the role of clts cadres is crucial in supporting government programs aimed at reducing the prevalence of stunting. it is recommended that stbm cadres be established in each work area of the health center to serve as the frontline health workers in efforts to prevent stunting. references 1. namiiro fb, batte a, rujumba j, et al. nutritional status of young children born with low birthweight in a low resource setting: an observational study. bmc pediatr 2023;23:1–11. 2. unicef. who low birth weight. 2019. 3. subramanian s v, karlsson o, kim r. revisiting the stunting metric 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unicef-inspired model. sage open nurs 2024;10. 37. malolo r, kumwenda s, chidziwisano k, et al. social outcomes of a community-based water, sanitation and hygiene intervention. j water, sanit hyg dev 2021;11:483–93. 38. paul b, jean simon d, kiragu a, et al. socio-economic and demographic factors influencing open defecation in haiti: a cross-sectional study. bmc public health 2022;22:2156. 39. mulaw gf, adem os, belachew ab. determinants of stunting among children aged 6-23 months of age in pastoral community, afar region, ethiopia: unmatched case-control study. int j child heal nutr 2020;9:191–201. 40. devanarayana nm, rajindrajith s. bowel habits and behaviors related to defecation in 10to 16-year-olds: impact of socioeconomic characteristics and emotional stress. j pediatr gastroenterol nutr 2011;52:569–73. 41. ntaro m, owokuhaisa j, isunju jb, et al. contextual and psychological factors influencing open defecation free status: an exploratory qualitative study in rural south western 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competence and performance of family planning instructors in family assistance at risk of stunting in lampung province. j public health africa 2023;14. 48. caruso ba, sclar gd, routray p, et al. effect of a low-cost, behaviour-change intervention on latrine use and safe disposal of child faeces in rural odisha, india: a cluster-randomised controlled trial. lancet planet heal 2022;6:e110–21. 49. xu l, ling m, lu y, shen m. understanding household waste special issue pathways of change [page 24] [healthcare in low-resource settings 2025;13(s1):13109] separation behaviour: testing the roles of moral, past experience, and perceived policy effectiveness within the theory of planned behaviour. sustainabilit 2017;9:625. 50. mamady k. factors influencing attitude, safety behavior, and knowledge regarding household waste management in guinea: a cross-sectional study. j environ public health 2016;2016:1–9. 51. humphrey jh, mbuya mnn, ntozini r, et al. independent and combined effects of improved 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handwashing in peru. int health 2021;13:615–23. 57. ray s, zaman f, laskar n. hand washing practices in two communities of two states of eastern india: an intervention study. indian j public health 2010;54:126. 58. macleod c, braun l, caruso ba, et al. recommendations for hand hygiene in community settings: a scoping review of current international guidelines. bmj open 2023;13:e068887. 59. sitotaw b, melkie e, temesgen d. bacteriological and physicochemical quality of drinking water in wegeda town, northwest ethiopia. j environ public health 2021;2021. 60. united nation. un water. 2017. 61. aghalari z, dahms hu, sillanpää m, et al. effectiveness of wastewater treatment systems in removing microbial agents: a systematic review. global health 2020;16:13. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13109] [page 25] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13493 families’ hopes for strengthening education to bridge thalassemia knowledge gap: a phenomenological study feriana ira handian,1,2 mohd nazri mohd daud,3 khalid mokti,3 aye aye wynn,1 tin tin thein,1 dewi rejeki4 1faculty of medicine and health sciences, malaysia sabah university, malaysia; 2faculty of health sciences, tribhuwana tunggadewi university, indonesia; 3faculty of public health, malaysia sabah university, malaysia; 4rsup cipto mangunkusumo hospital, jakarta, indonesia abstract the prevention of thalassemia, particularly through early detection, is a significant concern that is currently inadequately addressed in indonesia, where the condition is not widely comprehended. to develop effective familyand community-based health promotions and interventions, it is crucial to consider the perceptions and hopes that patients’ family members have about thalassemia education. this qualitative study employed a phenomenological approach, involving 24 family members of thalassemia patients from the java and sumatra islands, to investigate their perspectives and hopes for strengthening thalassemia prevention strategies. four themes emerged from analyzing the interview transcript data using the collaizi method: i) the importance of early premarital education; ii) the hope that thalassemia will be included in the school curriculum; iii) the necessity to broaden thalassemia education across various facilities; and iv) the engagement of other sectors in thalassemia screening and prevention. this study highlights the necessity for the government to provide adequate support for thalassemia prevention. to enhance the effectiveness of thalassemia prevention, the government and other relevant parties should promptly develop prevention programs at the school level and implement premarital screening regulations in marriage institutions. introduction thalassemia is one of the most common hereditary blood disorders in indonesia and can manifest in a wide range of severities throughout the country. based on the assumption that 5% of the population is affected by this condition, approximately 2,500 new major cases are anticipated annually.1,2 the management of thalassemia in indonesia is centered on supportive measures, such as blood transfusions, iron chelation, monitoring of complications, psychosocial support, and a seamless transition from pediatric to adult clinics.1,3 one of the strategies used to prevent thalassemia is screening,4 with carrier screening being the most extensively used genetic screening test in various nations.5 several countries, including thailand, iran, singapore, the united kingdom, and turkey, have implemented thalassemia screening procedures for the population.6-10 this is considered one of the applicable solutions for preventing thalassemia in pakistan.11 in contrast, 95.7% of indonesian adolescents did not participate in thalassemia screening despite knowing that thalassemia is an illness associated with an abnormality of red blood cells and that screening for this condition is essential.12 another study in indonesia revealed that 75.4% of premarital individuals were unaware of thalassemia.13 a similar situation was observed in oman.14 meanwhile, in bangladesh, 89.3% of adults were aware of premarital carrier screening, whereas 30.5% were reluctant to undergo the test; undergraduate students’ and parents’ knowledge and awareness of premarital screening for β-thalassemia were insufficient in this country.15-17 despite the importance of early diagnosis and optimal therapeutic interventions for improving patient outcomes and quality of life,15,18,19 information regarding thalassemia screening and prevention remains extremely limited in indonesia. previous studies indicate that indonesian youth generally exhibit poor knowledge and practices regarding thalassemia.20,21 a preliminary study, based on interviews with a principal administrator of the association of parents of thalassemia patients indonesia (persatuan orang tua penderita thalassemia indonesia [popti]), indicates that family members caring for thalassemia patients may possess the sole understanding of this condition, as they obtain information directly from physicians. however, because they are not health professionals, they are often not trusted when sharing information with other family members. one family member claimed that they had never heard of screening and correspondence: feriana ira handian, faculty of medicine and health sciences, malaysia sabah university, malaysia; faculty of health science, tribhuwana tunggadewi university, indonesia. e-mail: ferianaazar@gmail.com key words: education; family; prevention; screening; thalassemia. contributions: fih, mnmd, km, aaw, ttt, manuscript writing and data analysis; fih, dr, data collection. all the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: not required. funding: this study was financially supported by a research team. acknowledgments: the authors would like to express their deepest gratitude to all parties, including popti indonesia, for their valuable contributions to this study. received: 17 december 2024 accepted: 26 march 2025 early view: 13 june 2025 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13493 doi:10.4081/hls.2025.13493 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13493] [page 23] assumed that thalassemia was a condition related to anemia. this indicates a knowledge gap regarding thalassemia among family members. if families, as key players in prevention, continue to hold misconceptions about thalassemia and its screening initiatives, reaching a broader population will be more challenging. addressing this knowledge gap requires prioritizing family and community-based health education. family members are crucial in disseminating health information and supporting prevention efforts; therefore, understanding their perceptions and expectations regarding thalassemia education is essential. if misconceptions persist within families, promoting screening and prevention at the community level will be challenging. this study aimed to explore the hopes and perspectives of thalassemia patients’ family members in strengthening educational initiatives. by capturing their insights, this study seeks to inform effective strategies and interventions that empower families and communities to bridge the knowledge gap and foster a proactive approach to thalassemia prevention in indonesia. materials and methods study design this study employed a qualitative research design, using a phenomenological approach. the phenomenological method was chosen to explore the perceptions and expectations of family members of thalassemia patients regarding thalassemia education. this approach allows for an in-depth understanding of how families interpret existing educational initiatives and their hopes to strengthen thalassemia awareness and prevention efforts. participants this study involved 24 family members of thalassemia patients who were active members of the popti from the java and sumatra regions, aged over 18 years, and had experience as caregivers of thalassemia patients. the participants were selected using a purposive sampling technique. following the determination of sample size based on data saturation in qualitative research, interviews were conducted until no new themes emerged from data analysis. variables and instruments the perspectives and hopes of family members investigated in this study are those directed toward the government, community, and health professionals regarding premarital thalassemia screening and education to bridge the thalassemia information gap using their experiences. the instruments utilized in this study included a sound-recording device for offline interviews and a zoom meeting application for online interviews. data collection considering the researchers’ experience and the vast geographic scope of the studied areas, data were gathered through both offline and online in-depth interviews conducted between september 2023 and february 2024 in java and the sumatra islands, using open-ended questions. each interview session lasted 45-90 minutes. interviews were carried out face-to-face with two participants from java island and online with 22 other participants via zoom meetings at predetermined times. all the interview data were recorded and transcribed verbatim. data analysis the collaizi technique was used to analyze the interview transcripts with open code software 4.03 umea, which was utilized to generate codes, categories, and themes. the indonesian themes were translated into english and reviewed by a research team comprising experts in family medicine and health promotion from the malaysia sabah university. validity and reliability source triangulation with other family members was used to ensure the validity and reliability of information. data analysis involved peer debriefing with two thalassemia specialist nurses from indonesia. during the peer debriefing process, emerging topics were thoroughly discussed to acquire a better understanding of participants’ experiences. ethical clearance the research ethics review was carried out following the who cioms guidelines and approved with no. e5a/126/kepumm/iv/2023 by the ethics committee of muhammadiyah malang university. results characteristics of participants the results showed that the participants were predominantly women (70.83%) who received secondary education (58.33%) and primarily worked in the informal sector (37.50%). most of them earned ≤3,842,000 rupiahs per month (79.17%) and lived in java regions (79.17%) with a distance to health facilities of 1-25 km (50%). the majority of participants were members of the patients’ nuclear family (95.83%) and already had health insurance (83.33%). however, despite having relatively easy access to health facilities, only 29.17% had undergone a thalassemia screening test, indicating low participation in screening. thematic findings based on the results of the in-depth interviews with participants, the findings of this study can be classified into four themes: i) the importance of premarital education at an early age; ii) the hope that thalassemia will be included in the school curriculum; iii) the need to expand thalassemia education across numerous facilities; and iv) the involvement of other sectors in thalassemia screening and prevention. theme 1. the importance of premarital education at an early age premarital education at school age the participants emphasized the need for premarital education. to prevent the late diagnosis of thalassemia, they hope that thalassemia screening education before marriage is implemented as early as possible, preferably during school age, such as in junior or senior high school, vocational school, or university/college years. “as for premarital education, yes, that’s when children reach prepubescent age, and it must start at prepubescent age, right, when they begin to understand how they like others.” (p10) this is supported by p12, who stated, “from vocational school, i think. the first year of vocational school, in my opinion, is [the right time for thalassemia] education.” pathways of change, part ii [page 24] [healthcare in low-resource settings 2025;13(s2):13493] thalassemia education as an early parenting topic in reference to other families with thalassemia, participants hope that parents will educate their children about thalassemia before marriage, so that they can recognize the symptoms as early as possible. “so, [the same incident as] my little brother or child [or] my older brother [will not happen again]. yes, xxx said earlier, to look for a partner in the future. i gave him early notice, ma’am. because he is already in the third year of vocational school, he can understand [easily].” (p16) theme 2. the hope that thalassemia will be included in the school curriculum limited resources and materials on thalassemia at school currently, there is a lack of educational materials available in schools on thalassemia and other teen-related health topics, such as anemia and drugs. participants hope that this limited knowledge of thalassemia will be addressed soon so that greater awareness about this condition can be raised among the extended family, and the symptoms can be detected when they occur in other family members. this is stated by participants with school-age children and/or siblings. “if, for example, it is stated in the school textbook what thalassemia is, they can find out.” (p15) hope for extensive literature on thalassemia this involves providing information about thalassemia in educational subjects for students. “at school, we have the habit of reading literature. so, usually, we are also asked to look for information. (maybe) we can also look up thalassemia online every thursday.” (p11) theme 3. the need to expand thalassemia education across numerous facilities hope for better thalassemia education from community health centers and media outlets various institutions in indonesia can contribute significantly to the provision of thalassemia education, including the integrated health post (pos pelayanan terpadu/posyandu), community health centers (pusat kesehatan masyarakat/puskesmas), government agencies at the village or sub-district level, family welfare and empowerment organizations (pemberdayaan dan kesejahteraan keluarga [pkk]), and social forums such as community gatherings. the participants highlighted the poor functioning of these institutions in thalassemia education. “so, what, they [the health workers] are the only ones present in puskesmas. so, the only chance is to give what it is… patient referral (just like that). there is nothing more. no [proper education]. so, what should i do? how… i am also [very] confused.” (p16) hope for thalassemia education through social media platforms in addition to the various institutions, participants also hope that thalassemia education will utilize attractive methods, such as social media platforms, media production, banners at health centers, and educational models in the form of videos. the use of various types of information media, including social media, must be developed. “posyandu, puskesmas, i don’t think many people still understand, instagram, tiktok… those are needed too, you know.” (p2) this statement is emphasized by p12, who stated, “yes, i hope so, ma’am. [i hope] the community or the government pays more attention to children with thalassemia.” theme 4. the involvement of other sectors in thalassemia screening and prevention hope for enhancing the role of marriage institutions in premarital thalassemia screening programs the office of religious affairs (kantor urusan agama [kua]) is a marital institution in indonesia that provides premarital education to all married citizens. participants hope that kua will be the first institution to screen couples for thalassemia prior to their marriage. “the best thing (for thalassemia screening education) is to go to kua. go to kua first.” (p3) hope for the development of a premarital screening policy by the government according to participants, state-owned marriage institutions should make premarital thalassemia screening mandatory, prohibit marriage for groups at risk of having thalassemia, or guide prospective brides and grooms about planning for children after marriage, particularly if they or their partners are at risk of having thalassemia. “next, inputs from community health centers were used to establish the database at the health office. other inputs are provided by regional hospitals that have the necessary equipment or labs. [all of these inputs] will reach all related offices. where is the output? it goes to the kua, churches, or temples that handle wedding ceremonies. there, you can access it using a certain password. click on xxx’s name and enter the national identity number (nomor induk kependudukan/nik). simply click there. have you yet been screened? if not, sorry, you’re not allowed… pause [the process]. you [need to undergo] screening first. if you have been screened and it turns out that you are a carrier, stop [the process]. you must first consult the marriage counselor. okay, that’s it. therefore, this is not reckless. [the government] should prepare marriage counselors.” (p1) discussion improving early access to premarital thalassemia education this study highlights the importance of providing thalassemia education as early as possible to enhance the understanding of the disease and increase awareness of its signs, thereby encouraging early screening and prevention. this aligns with previous studies indicating that education for adolescents improves knowledge, attitudes, and awareness regarding thalassemia and its prevention.22-24 according to data from the 2019 to 2022 national socioeconomic survey, the average age at first marriage in indonesia was 21.23 years in 2023. individuals in this early adulthood often focus on various life events such as completing their education, getting married, having children, and building a career. however, the utilization of premarital screening in indonesia remains low.25 in turkey, mandatory premarital screening has led to the cancellation of 53% of at-risk marriages and an 80% reduction in at-risk pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13493] [page 25] births. similar programs have significantly reduced the prevalence of thalassemia in arab countries, including bahrain.26 parents of children with thalassemia recommend that premarital screening be conducted during junior or senior high school (ages 13-20 years), as this period marks the transition from adolescence to early adulthood. in malaysia, screening is considered suitable for students aged 16-17.27 therefore, thalassemia education should be provided to adolescents, and the government should consider implementing policies to integrate thalassemia education into the school curriculum. raising awareness among adolescents will facilitate early detection of thalassemia and contribute to its prevention. enhancing school-based thalassemia education and prevention programs the findings suggest that education about thalassemia should be incorporated into the school curriculum. adolescence is a crucial period for acquiring knowledge about thalassemia, as it can foster awareness and encourage preventive measures. studies have shown that adolescent brain development involves cognitive changes that enable the processing of new and complex information, as well as improvements in social functioning.28 this makes adolescence an optimal stage for understanding important healthrelated topics, including thalassemia. in indonesia, school-based education on thalassemia information and prevention has not been widely explored. the school health unit (usaha kesehatan sekolah [uks]) provides essential health education.29-31 however, it does not specifically address thalassemia. in contrast, schoolbased education programs in other countries have been shown to positively impact various health domains, including oral health, nutrition, asthma management, and cancer awareness (breast and lung cancer).32-35 the findings reveal that thalassemia-related materials should be incorporated into the school curriculum. however, the number of participants screened was low. this suggests that the presence of thalassemia cases among family members does not significantly influence willingness to screen, highlighting a challenge in prevention. data on premarital screening, especially among extended families, remains insufficient and requires further investigation. this study underscores the importance of integrating thalassemia education into school curricula to enhance adolescent awareness and prevention efforts. low screening uptake remains a significant challenge, necessitating stronger premarital screening initiatives and further research on family participation in preventive strategies. expanding thalassemia education through various social media platforms these findings highlight that long distances can limit access to instructional materials from hospitals. therefore, online resources may serve as ideal alternatives, as they are not constrained by time or location. diverse media, including social media, should support education about thalassemia. indonesia has one of the highest numbers of social media users, and in recent years, social media has become a powerful marketing tool for indonesian businesses.36 given this trend, both public and healthcare workers can effectively use social media to raise awareness about thalassemia. indonesia’s vast geography has resulted in numerous administrative and political entities, including those in the health sector. puskesmas operates at the sub-district level, while posyandu functions at the village level, enabling direct outreach to residents based on proximity. furthermore, the pkk may serve as an effective platform for delivering thalassemia education at the grassroots level. this approach aligns with previous studies showing the positive impact of community-based infant nutrition programs on health education among rural women and supports recommendations on community empowerment,37 which suggest that adaptive health interventions should be tailored to local contexts. prior research has emphasized the crucial role of community development in fostering sustainable organizations.38 online resources and social media enhance thalassemia education by overcoming geographical barriers. community-based health structures, such as puskesmas, posyandu, and pkk, provide localized education opportunities, aligning with empowerment strategies for sustainable health awareness and intervention. enhancing the role of marriage institutions for thalassemia screening the findings strongly support the integration of premarital thalassemia screening into indonesia’s marriage institutions, particularly through the kua. participants advocated mandatory screening policies to identify at-risk couples, prevent transmission, provide informed reproductive counseling, and prevent them from having children with thalassemia. premarital screening is an essential solution to prevent the occurrence of thalassemia. this corresponds with other research indicating that premarital screening is mandatory in turkey, palestine, and iran, whereas italy, the maldives, greece, and canada have voluntary screening programs.5 this has contributed to a reduction in thalassemia by identifying carriers and at-risk couples, thereby informing reproductive choices.39 however, thalassemia education and training for educators and marriage counselors should be prepared in advance. to design the flow, guidelines, and technical implementation of thalassemia screening, as well as screening for other disorders before marriage, cross-sector coordination between the government and marriage institutions is necessary. continuous efforts in education and counseling are crucial to further reduce the burden of thalassemia. conclusions this study identified four key themes regarding thalassemia patients’ family members’ hopes for education and prevention: i) premarital education at an early age; ii) inclusion in the school curriculum; iii) expanding education across numerous facilities; and iv) involving other sectors in screening and prevention. this challenges hospitals and health professionals to improve community health promotion programs. the expectations pose a challenge to initiating cross-sector collaboration aimed at preventing thalassemia from spreading in indonesia and achieving the country’s vision of zero-born thalassemia. the ministry of education, educational institutions, and local governments should integrate thalassemia education into the school curriculum. furthermore, the indonesian government is expected to develop guidelines and tools for screening in marriage institutions. hospitals, health offices, and health insurance companies must assess whether screening at marriage institutions will lead to further testing of individuals at risk of thalassemia. references 1. wahidiyat pa, sari tt, rahmartani ld, et al. an insight into indonesian current 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2025;13(s2):13493] hrev_master healthcare in low-resource settings 2024; volume 12:13010 the effectiveness of ventilator weaning using a weaning protocol compared to non-protocol: a systematic review denissa faradita aryani, rr. tutik sri hariyati, elly nurachmah faculty of nursing, universitas indonesia, depok, west java, indonesia abstract ventilator use can reduce respiratory function, heighten infection risk, extend ventilator dependence, and, in severe cases, necessitate prolonged mechanical ventilation. systematic weaning protocols can alleviate these issues, enhance breathing, and aid extubation. this review assesses studies on weaning protocols in icu patients. using the prisma framework, an extensive search was performed in databases such as clinicalkey nursing, sciencedirect, proquest, sage, embase, medline, scopus, springerlink, and pubmed. this search aimed to find studies comparing protocolized and non-protocolized weaning in adult icu patients. included were peer-reviewed randomized controlled trials (rcts) and quantitative studies focusing specifically on adult icu weaning protocols. studies involving non-adult populations were excluded. the jbi and casp tools were used to assess the quality of the studies. out of 475 identified articles, six met the inclusion criteria. three types of weaning protocols were identified: nurse-led, respiratory therapy-led, and automatic protocols. these protocols demonstrated effectiveness by reducing ventilator time, increasing extubation success, and shortening icu stays. evidence supports that weaning protocols positively impact patient outcomes, particularly by shortening intubation periods, and can enhance inter-professional collaboration in the icu. introduction the intensive care unit (icu) is designed to monitor patients with high levels of dependency, complex health issues, and the need for advanced technology. worldwide, approximately 80% of primary care needs in the icu involve the use of mechanical ventilation (vm) or ventilators. according to data from the united states, nearly 5.7 million patients are treated in the icu annually, of which 30% require ventilators.1 most instances of acute respiratory failure require mechanical ventilation, which can be discontinued once the underlying cause has been resolved through the process of weaning and extubation. however, 20-30% of icu patients are considered challenging to wean from mechanical ventilation.2 patients who receive treatment using a ventilator aim to be weaned from the device. the process of weaning, also known as ventilator weaning, is influenced by the patient’s healing and the improvement of lung capacity, which can optimize ventilation and enhance circulatory support. successful weaning is dependent on several factors, including breathing exercises while using the ventilator.3-5 nurses, particularly those in critical care or icu settings, play a crucial role in the care of patients with critical conditions.69 the american nurses association recognizes critical nursing as a distinct field involving interdisciplinary collaboration and comprehensive nursing care. experts also agree that icu nurses play a central role in developing weaning plans for patients.10 critical care is a comprehensive healthcare field that encompasses various specialists and interventions. to enhance the quality of care in the intensive care unit, international organizations have created evidence-based guidelines, protocols, and bundles.11 ventilator weaning is a significant aspect of icu management, and nurses have increasingly played a crucial role in this process over the past two decades through the implementation of nurse-led and nurse-driven weaning protocols.12 studies have demonstrated that involving nurses and therapists in weaning patients from correspondence: denissa faradita aryani, faculty of nursing, universitas indonesia, depok, west java, indonesia. e-mail: denissa.fa@ui.ac.id key word: icu, systematic review, weaning process, weaning protocol, ventilator. contributions: all authors contributed to this article. dfa, rr, and en contributed substantially to the data curation, extraction, analysis (i.e., critical appraisal), and analysis. furthermore, the dfa made a significant contribution to the study conceptualization, drafted the original review article, and interpreted the data. rr and et contributed to revise the review by providing advice regarding the content. availability of data and material: the full list of references and datasets supporting the findings of this study can be accessed in the relevant published articles included in this review. conflict of interest: all authors declare that we have no competing interests. funding: this study was independently funded by the authors ethics approval and informed consent: not applicable. conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgement: we would like to thank the scholarship providers, namely the indonesian education scholarship (bpi), the indonesia endowment funds for education (lpdp), and education financing service centre (puslapdik) for their support for one of our investigator (dfa) in carrying out the doctoral program in nursing. received: 4 september 2024. accepted: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:13010 doi:10.4081/hls.2024.13010 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 717] [healthcare in low-resource settings 2024;12:13010] non -co mmerc ial us e o nly mechanical ventilation and extubation leads to better outcomes.3,1315 historically, physicians were primarily responsible for weaning patients and making key decisions during the process. in contemporary practice, some countries continue to handle the weaning process collaboratively within the icu, lacking a specific patient weaning protocol. a study by hirzalah stated that the nurse’s weaning ventilator protocol resulted in a significant reduction in the duration of ventilator use and a significant reduction in weaning time.15 a study conducted in the united states in 2013, which examined the weaning protocol by nurses, resulted in a shorter extubating time of 2 h and 13 min compared to protocols from other groups. the study also identified four independent predictors of weaning duration, one of which was the nurses’ weaning protocol.16 this systematic review aimed to determine the effectiveness of ventilator weaning using a protocol compared to ventilator weaning without the use of a protocol in patients on ventilators in the icu. in addition, this study will explain the types of protocols that have been proven safe. materials and methods the aim of the study was to identify the effectiveness of ventilator weaning protocol compared to the non-protocol. we followed the preferred reporting items for systematic reviews and meta-analysis (prisma) statement. search strategy and selection criteria to meet the methodological standard of a systematic review, specific keywords were used to conduct a comprehensive literature search and data extraction from scopus, medline, sage, proquest, clinicalkey nursing, pubmed, jstor, embase, sciencedirect, and springerlink electronic databases, adhering to prisma guidelines. the search included quantitative research articles on mechanically ventilated icu patients, published in english between 2019-2023, using keywords such as “intubated patient”, “ventilated patient”, “mechanical ventilated patient”, “icu patient”, “weaning protocol”, “nursing protocol in weaning”, “usual care”, “extubation”, “extubation readiness”, and “improving icu outcome”. selection of studies an investigator (dfa) independently conducted the initial screening of articles by reviewing the titles, abstracts, and full texts from all databases. the results of candidate articles were saved using endnote x9 software for the initial screening and identification of duplicates. in the subsequent step, dfa performed a comprehensive screening with the aid of rayyan software to assess eligibility. dfa organized and analyzed the literature by label for decisions on inclusion or exclusion. dfa then invited two investigators (rr & en) for collaborative screening, who independently reviewed the articles without seeing each other’s choices until the process was complete, minimizing potential bias. disagreements were resolved through a consensus-building meeting. inclusion and exclusion criteria we included full-text articles from 2019-2023 on randomized controlled trials and quantitative methods related to mechanical ventilation weaning protocols in the icu, excluding studies on pediatric icus or those outside the scope. extraction was primarily carried out by one investigator (dfa). from all databases, 475 articles were obtained: 128 from clinicalkey nursing, 21 from sciencedirect, 22 from proquest, 53 from sage, 6 from embase, 10 from pubmed, 30 from medline, 29 from jstor, 16 from scopus, and 160 from springerlink. dfa grouped each database in endnote and checked for duplicates. a total of 165 duplicates were identified, leaving 310 articles meeting the criteria. three investigators (dfa, rr, en) conducted a second round of checks. dfa ensured all tasks were accurately completed, contributing to the project’s successful completion for rr and en. data extraction and synthesis the following data were extracted from all studies: i) publication details (english full text, title, publication date, author’s name and country), ii) study design (rct, cross-sectional, quasi-experiment, cohort), iii) setting (sample, adult intensive care unit, mechanically ventilated), iv) model selection (weaning method, ventilator weaning protocol type, usual care, non-protocol ventilator weaning, weaning decision maker), v) data specifics (patient characteristics, duration of mechanical ventilation, duration of weaning). dfa conducted the initial screening by reviewing the titles and publication dates of all articles using endnote and the rayyan ai powered tool for systematic review. this process filtered out 200 irrelevant articles and 19 articles that were not fully accessible, resulting in 91 articles meeting eligibility criteria. three investigators (dfa, rr, en) independently performed a second review, identifying 6 potential articles. data from eligible studies were then extracted into a specific spreadsheet by dfa, rr, and en (figure 1). quality assessment the methodological quality of selected studies and the correctness of data extraction were reviewed by two independent investigators (dfa, rr). one investigator were asked for the expert judgment (en). in general, articles or studies are assessed for quality based on: i) clear research questions, ii) concepts or terminology can be explained operationally, iii) clear inclusion and exclusion article figure 1. prisma table. [healthcare in low-resource settings 2024;12:13010] [page 718] non -co mmerc ial us e o nly criteria, iv) methods which answer research questions, v) precise data analysis, vi) relevant results and discussion, vii) minimal risk of bias, viii) relevant implications, and ix) described research limitations. the author uses measuring instruments according to the characteristics of the study, namely, the critical appraisal skills program (casp) for rct research and the joanna briggs institute (jbi) for cross-sectional, quasi-experiment and cohort research (tables 1 and 2). results study selection the outcome of the literature search was 475 studies sourced from all electronic databases. of these, only 91 articles were deemed eligible for further consideration after 200 articles were determined to be irrelevant, and 19 articles were not provided in full text. following a second stage screening conducted by all investigators (dfa, rr, en), only six potential articles remained. a total of 41 articles were excluded due to various reasons, such as incorrect outcome, incorrect publication type, incorrect study design, use of a foreign language, and lack of full text. study characteristics all six studies incorporated in the review follow a quantitative research methodology, comprising one cross-sectional study, one quasi-experimental study, two cohort studies, and two randomized controlled trials (rcts). each article is in english, accessible in full text, and published between 2019 and 2023. the studies share a common population, which consists of adult icu patients aged over 18 years and ventilated for at least 24 hours. the systematic review features studies from a range of sources, with a total of 5,380 participants taking part in the studies. to ensure accurate and relevant results, the review includes adult icu patients from sweden, iran, brazil, japan, and the united kingdom. all articles feature structured weaning intervention protocols in contrast to conventional weaning procedures (table 3). primary outcome type of weaning protocol this systematic review assesses six articles that examine various aspects of ventilator weaning protocols. five of the six articles under consideration focus on comparing weaning protocols with conventional care. these include the works of ghanbari et al.,17 lago et al.,18 vahedian-azimi et al.,19 and vizcaychipi et al.20 in contrast, the study by caderwall et al. examines weaning protocols and accompanying practices in patients who require ventilator support in the icu.21 a study conducted by ghanbari et al. evaluated the effectiveness of the nurse-led weaning protocol, which differs from physician-based protocols for weaning patients from mechanical ventilation.17 the nurse-led weaning protocol utilizes the burn’s weaning scale (bws), containing 40 items, and employs a combination of ventilation methods, including cpap, pcv, bipap, simv, and psimv. the study revealed that the nursing protocol involved monitoring several laboratory values on a daily basis. lago et al. compared the international consensus conference (icc) guideline protocols with the wind classification, which categorizes patients’ weaning types as no weaning, short weaning, difficult weaning, and prolonged weaning.18 however, the specific weaning method employed in this study remains indeterminate. nitta et al. conducted research on the development of weaning and extubation protocols, encompassing an evaluation checklist with four components: spontaneous breathing trial (sbt), extubating eligibility, non-invasive positive pressure (nppv) prophylaxis, and post-extubation assessment.22 the study revealed that the weaning method utilized was sbt for 30 minutes, with a flow trigger set at 0, psv 0, positive end expiratory pressure (peep) established at 5 cmh2o, or through the use of a t-tube. the rct conducted by vahedian-azimi et al., found that weaning from rt was preceded by a checklist of weaning criteria. the method used was continuous positive airway pressure (cpap) set at 5 cmh2o, fraction of inspired oxygen (fio2) set at 0.4, arterial oxygen saturation value greater than or equal to 92%, and a rapid shallow breathing index (rsbi) less than 105 times per article [page 719] [healthcare in low-resource settings 2024;12:13010] table 1. jbi critical appraisal for cross-sectional, quasi experiment, and cohort research. researcher design question overall appraisal and year 1 2 3 4 5 6 7 8 9 10 11 cederwall, et al.21 cross sectional y y y y n n y y include ghanbari, et al.17 quasi experiment y y n n y y y y y include lago et al.18 cohort y y y n n y y y y y y include nitta et al.22 cohort y y y y n y y y y y y include table 2. casp critical appraisal for rct research. researcher design section question decision and year 1 2 3 4 5 vahedian-azimi et al.19 rct section a y y y include section b y y y section c y y y y y vizcaychipi et al.20 rct section a y y y include section b cnt y y section c y cnt y cnt y non -co mmerc ial us e o nly minute per liter.19 spontaneous breathing trials (sbt) were performed for 120 minutes. typical care, which is usually provided, is based on the clinical decisions of the intensivist, considering the patient’s clinical status, airway conditions, and rsbi or nif respiration indicators. another rct study compared weaning protocols with a mathematical system (icarewean) in a special healthcare system called beacon with standard weaning or routine care. in the intervention protocol, systematic charts compiled by the research team were used.20 weaning interventions encompassed blood gas analysis (gba) parameters, automatic lung parameter estimators, ventilator setting adjustments, consultations, sedation types, and sbt. this study utilized the beacon care system monitor to track pressure support (ps) and positive end-expiratory pressure (peep) values during sbt conditions. a national survey in sweden showed that about 55% of intensive care units (icus) utilized a weaning protocol comprising individualized and collaborative plans for icu nurses and doctors.21 additionally, 65% of icus used a collaborative approach for weaning, while 27% relied on the decision of the doctor. common methods for weaning include pressure support reduction, low flow oxygen (lfo2), high flow oxygen (hfo2), continuous positive airway pressure (cpap), and volume support (vs). the study identified three main features of the weaning protocol used: i) a nurse’s weaning protocol using the burn’s weaning scale and controlling daily laboratory results; ii) a therapist weaning protocol using predefined criteria and spontaneous breathing trials (sbt) results; iii) a comprehensive protocol that includes the nurse’s decisions in collaboration with intensivists. the review underscores the importance of structured weaning protocols, whether nurse-led, therapist-led, or collaborative, in enhancing patient outcomes during the weaning process. each protocol type offers distinct advantages, depending on the clinical setting and the specific needs of the patient population. the effectiveness of weaning protocol according to a. ghanbari et al., the weaning protocol employed by nurses, specifically the use of bws, yielded safer and more effective outcomes compared to the clinical judgment of physicians.17 the average duration of mechanical ventilation for the intubated patient group using bws was 111.75 ± 33.46 hours, while the physician group had a duration of 125.12 ± 43.43 hours, with a significant difference observed in the duration of mechanical ventilation between the two groups (p = 0.000). lago et al. suggested that the wind classification is more suitable for use in the intensive care unit, particularly in patients with severe conditions and prolonged weaning.18 the study found that not all patients could be fully classified as receiving usual care (icc). in the wind classification category, all groups exhibited better outcomes with shorter mechanical ventilation time compared to the icc classification (p = 0.0001). a study from nitta reported that the weaning protocol demonstrated effectiveness, as 213 patients were successfully extubated following 30 minutes of sbt.22 a comprehensive protocol for weaning and extubation can prevent post-extubation respiratory failure, with a perf incidence of 9.7% and a reintubation rate of 5.2%.22 extubation failure is a major risk in mechanical ventilation, but a standardized protocol can significantly reduce postextubation respiratory failure rates. vahedian-azimi’s research also indicates that the weaning process can be effectively managed by respiratory therapy.19 the results are safe, effective, and associated with reduced reintubation rates. the protocol’s effectiveness is demonstrated by increases in minute ventilation (p<0.001), cs and cdyn (p<0.05), p0.1 (p<0.001), nif (p<0.001), and rsbi article ta ble 3. stu dy ch ara cte ris tic s. no . t itl e y ea r d esi gn pa rti cip an t i nt er ve nt ion 1 c are pr ac tic es for pa tie nts re qu iri ng m ec ha nic al 2 02 3 c ros s s ec tio na l 77 a du lt i cu s w ea nin g p rot oc ol in pa tie nts w ith > 7 d ay s v m in sta lle d v en tila tio n m ore th an se ve n d ay s i n s we dis h in ten siv e c are un its : a na tio na l s urv ey 2 c om pa ris on be tw ee n a nu rse -le d w ea nin g p rot oc ol 2 02 0 qu asi e xp eri me nt 65 ic u pa tie nts nu rse w ea nin g p rot oc ol: b urn ’s w ea nin g s ca le (b w s) a nd a we an ing pr oto co l b ase d o n p hy sic ian ’s cli nic al ju dg me nt in ic u pa tie nts 3 c om pa ris on of in ter na tio na l c on sen su s c on fer en ce 2 01 9 c oh ort 32 7 i cu pa tie nts m ult ice nte r m ult ina tio na l p ros pe cti ve ob ser va tio na l s tud y, g uid eli ne s a nd w in d cla ssi fic ati on fo r w ea nin g f rom th e w ea nin g a cc ord ing to n ew d efi nit ion (w in d pr oto co l) m ec ha nic al ve nti lat ion in b raz ilia n c rit ica lly ill pa tie nts : a re tro sp ec tiv e c oh ort st ud y 4 a co mp reh en siv e p rot oc ol for ve nti lat or we an ing an d e xtu ba tio n: 2 01 9 c oh ort 46 4 i cu pa tie nts w ea nin g a nd e xtu ba tin g p rot oc ol a pr os pe cti ve ob ser va tio na l s tud y 5 p rot oc oli ze d v en tila tor w ea nin g v ers es us ua l c are : a ra nd om ize d c on tro lle d t ria l 2 02 0 r ct 42 00 ic u pa tie nts w ea nin g p rot oc ol: sb t f rom r esp ira tor y t he rap y 6 in ten siv e c are w ea nin g ( ic are w ea n) pro toc ol on w ea nin g f rom 2 02 0 r ct 2 47 ic u pa tie nts int erv en tio n: ic are w ea n p rot oc ol m ec ha nic al ve nti lat ion : a si ng lebli nd ed m ult ice ntr e r an do mi sed b ea co n he alt hs ys tem : a dv ice e na ble d c on tro l tr ial co mp ari ng an op en -lo op de cis ion su pp ort sy ste m a nd ro uti ne ca re, in th e g en era l in ten siv e c are un it [healthcare in low-resource settings 2024;12:13010] [page 720] non -co mmerc ial us e o nly (p<0.001). vizcaychipi et al. describe the protocol for evaluating the beacon caresystem’s effectiveness in the general medical icu population.20 this protocol is pivotal for utilizing advice and applies only to patients intubated for over 24 hours, highlighting the beacon care system as an effective ventilation strategy. caderwall et al. argue that the weaning protocol is not suitable for all ventilated patients, particularly in pmv conditions.21 therefore, weaning protocols may not be relevant for icus that use individualized treatment approaches. however, individualized treatment plans necessitate collaborative efforts to reduce icu mortality and length of stay. upon evaluating six separate studies, it was determined that all weaning protocols were both safe and effective for patient care. the effectiveness of these protocols was established through the analysis of statistical data, specifically the duration of intubation and the success rate of extubation when compared to instances where no protocol was employed, or only clinical assessment was used. secondary outcome ventilator duration one study strongly suggested that the average duration of intubation in the patient group with the nurse’s weaning protocol was shorter than in the patient group with the doctor’s protocol (p = 0.0001).17 as many as 80% of patients are ready for weaning before a clinical decision or clinical judgment from a doctor. in addition, the study also suggested that there was a significant difference in the duration of mv in female and male patients in the nurse’s weaning protocol group (p = 0.039). moreover, another study was found that the duration of intubation in the weaning protocol group was longer than the usual care group (p<0.001).19 length of stay according to japanese studies in 2019 found that there was no notable difference in the duration of stay between the two groups, with a p-value of 0.16.22 however, one study findings revealed that the weaning protocol resulted in a reduction in the length of stay, with a p-value of <0.001 because of the implementation of rt’s weaning protocol.19 furthermore, brazilian studies indicated that individuals in the difficult weaning category experienced an extended period on mechanical ventilation compared to those in other classifications. mortality according to nitta’s research , there was no significant difference in mortality rates between the two groups, which were found to be 1.2% and 6.9%.22 however, these figures were lower than previously reported. vahedian’s research showed that the mortality rate was constant at p = 0.19.22 on the other hand, lago’s study found an increased risk of death, particularly in the difficult weaning classification group.18 disscussion mechanical ventilators assist respiratory function and maintain alveolar gas exchange. the main goal of using a ventilator is to restore spontaneous breathing and enable weaning. weaning is essential to prevent complications like dyspnea, respiratory arrest, ventilator acquired pneumonia (vap), and death. hence, early weaning is recommended once the patient exhibits signs of spontaneous breathing. the global consensus currently endorses the icu liberation abcdef bundle for evidence-based icu care. these guidelines recommend ventilator weaning procedures that include spontaneous awakening trials (sat) and spontaneous breathing trials (sbt) to improve patient recovery and icu treatment efficacy.24 in some countries, data on the abcdef bundle’s use are limited, and there is no evidence of routine, awake, and scheduled breathing trials. ventilator weaning often involves individualized processes without standardized protocols, relying on medical decisions for weaning and extubation.8 over the past two decades, nurses’ involvement in the weaning process has grown due to the implementation of weaning protocols.12 studies indicate that the participation of nurses and therapists benefits ventilator weaning. research by roh et al. in south korea found that nurse-administered weaning protocols are safe and reduce weaning time from mechanical ventilation in respiratory failure patients.13 the weaning protocol represents a shared objective for all icu team members caring for mechanically ventilated patients who are successfully weaned with ventilation support.23 typical weaning protocols comprise three main components: readiness assessment standards, ventilator support reduction guidelines, and decannulation criteria. however, these elements may vary across protocols, and not all explicitly outline extubation criteria.19 this systematic review identifies four effective weaning protocols in the icu: i) nurse weaning protocols, ii) respiratory therapist weaning protocols, iii) collaborative weaning protocols, and iv) systematic automatic weaning protocols. according to ghanbari et al., the nurse’s weaning protocol uses the burn’s weaning scale (bws).17 this is consistent with previous research suggesting that a high burn score predicts successful weaning, extubation, reduced intubation duration, and shorter hospital stays.25. in the past five years, the bws has been used in five icus, with an 88% success rate and a 12% failure rate. the burn’s protocol, particularly effective in younger patients during weaning, includes 26 questions on general and respiratory assessments and is supported by various tools and guidelines such as assessment checklists, weaning trial protocols, and sedation guidelines. icu healthcare professionals are authorized to conduct ventilator weaning. a study by vahedian, an rct on weaning protocols managed by therapists, indicated that respiratory therapists, along with doctors and nurses, participated in the process. the study demonstrated that respiratory therapists adhered to predefined criteria and guidelines from spontaneous breathing trials, assessing physiological variables, blood gas analysis (gba) results, rsbi, and nif.26 the weaning process begins with recognizing the signs of readiness for spontaneous breathing from each patient. health workers and inter-collaborative processes are needed in making the right decisions about the patient care process. research by c-j cederwall states that the weaning protocol is very effective in patients with pmv, but the rest of the weaning decisions are made based on the collaboration of icu nurses and doctors.19,27 in contrast to the study conducted by ghanbari et al. which focused on comparing the use of weaning protocols by nurses with the clinical judgment of doctors, which proved that nurse protocols were more effective with shorter duration ventilator use results.22 all reviewed studies employed a uniform weaning method, specifically the use of sbt per icu liberation guidelines. nitta’s study utilized sbt for 30 minutes,18 while vahedian et al. applied the sbt procedure for 120 minutes, following weaning screening article [page 721] [healthcare in low-resource settings 2024;12:13010] non -co mmerc ial us e o nly and various physical examinations to assess patient readiness.19 another study, using a systematic protocol with instruments, conducted sbt after confirming satisfactory signs and respiratory values.20 additionally, a.f. lago’s study indicated that weaning is effective when patients are classified by their ventilator weaning level. the weaning protocol primarily enhances patient outcomes by reducing intubation duration, length of stay, and mortality rate.28-29 a systematic review identified three major outcomes. a study by a. ghanberi found that intubation duration was shorter, reducing the risk of vap and pmv. although length of stay can vary, successful weaning generally shortens it, except in high-risk patients where a prolonged stay is expected. notably, a reduction in mortality rate has not been observed in patients undergoing protocol weaning compared to standard care, likely due to disease severity, comorbidities, and other factors. weaning patients from mechanical ventilators is crucial for improving outcomes and reducing complications like vap, pmv, and mortality. evidence-based guidelines, including the icu liberation abcdef bundle with sat and sbt, are globally endorsed. however, implementation data is limited and often excludes many countries lacking standardized protocols. research indicates that weaning protocols developed by nurses, respiratory therapists, and automated systems are effective and safe, with nurse-designed protocols notably decreasing ventilation duration compared to standard care. using the burn’s weaning scale, nurses can formulate guidelines that significantly improve weaning success rates. despite the benefits of standardized weaning protocols, the lack of uniformity across different settings is problematic. variability in patient populations, protocol details, and implementation practices can result in inconsistent weaning outcomes. additionally, while shorter ventilator durations and reduced lengths of stay are commonly noted, the effect on mortality rates remains inconclusive, influenced by disease severity and comorbidities. references 1. marshall jc, bosco l, adhikari nk, et al. what is an intensive care unit? a report of the task force of the world federation of societies of intensive and critical care medicine. j crit care 2017;37:270-6. 2. jonkman ah, rauseo m, carteaux g, et al. proportional modes of ventilation: technology to assist physiology. intensive care med 2020;46:2301-13. 3. gunther i, pradhan d, lubinsky a, et al. use of a multidisciplinary mechanical ventilation weaning protocol to improve patient outcomes and empower staff in a medical intensive care unit. dimens crit care nurs 2021;40:67-74. 4. holm a, karlsson v, nikolajsen l, dreyer p. strengthening and supporting nurses’ communication with mechanically ventilated patients in the intensive care unit: development of a communication intervention. int j nurs stud adv 2021;3:100025. 5. cuzco c, torres-castro r, torralba y, et al. nursing interventions for patient empowerment during intensive care unit discharge: a systematic review. int j environ res public health 2021;18:11049. 6. mcnett m, o’mathúna d, tucker s, et al. a scoping review of implementation science in adult critical care settings. crit care explor 2020;2:e0301. 7. curley maq, wypij d, watson rs, et al. protocolized sedation vs usual care in pediatric patients mechanically ventilated for acute respiratory failure: a randomized clinical trial. jama 2015;313:379-89. 8. danckers m, grosu h, jean r, et al. nurse-driven, protocoldirected weaning from mechanical ventilation improves clinical outcomes and is well accepted by intensive care unit physicians. j crit care 2013;28:433-41. 9. starnes e, palokas m, hinton e. nurse initiated protocols for spontaneous breathing trials in adult intensive care unit patients: a scoping review protocol. jbi database system rev implement rep 2019;15:2248-64. 10. dehghan-nayeri n, vasli p, seylani k, et al. the effectiveness of workshop and multimedia training methods on the nurses’ decision-making skills regarding weaning from mechanical ventilation. dimens crit care nurs 2020;39:91-100. 11. barnes�daly ma, pun bt, harmon la, et al. improving health care for critically ill patients using an evidence-based collaborative approach to abcdef bundle dissemination and implementation. worldviews evid based nurs 2018;15:20616. 12. rose l, blackwood b, egerod i, et al. decisional responsibility for mechanical ventilation and weaning: an international survey. crit care 2011;15:r295. 13. roh jh, synn a, lim c-m, et al. a weaning protocol administered by critical care nurses for the weaning of patients from mechanical ventilation. j crit care 2012;27:549-55. 14. woody n. ventilator weaning protocols: influencing outcomes and promoting success [thesis]. [tennessee]: southern adventist university; 2013. 15. hirzallah fm, alkaissi a, barbieri-figueiredo mdc. a systematic review of nurse-led weaning protocol for mechanically ventilated adult patients. nurs crit care 2019;24:89-96. 16. baptistella ar, sarmento fj, da silva kr, et al. predictive factors of weaning from mechanical ventilation and extubation outcome: a systematic review. j crit care 2018;48:56-62. 17. ghanbari a, ebrahimzadeh am, paryad e, et al. comparison between a nurse-led weaning protocol and a weaning protocol based on physician’s clinical judgment in icu patients. heart lung 2020;49:296-300. 18. lago af, gastaldi ac, mazzoni aas, et al. comparison of international consensus conference guidelines and wind classification for weaning from mechanical ventilation in brazilian critically ill patients: a retrospective cohort study. medicine (baltimore) 2019;98:e17534. 19. vahedian-azimi a, bashar fr, jafarabadi ma, et al. protocolized ventilator weaning verses usual care: a randomized controlled trial. int j crit illn inj sci 2020;10:206-12. 20. vizcaychipi mp, martins l, white jr, et al. intensive care weaning (icarewean) protocol on weaning from mechanical ventilation: a single-blinded multicentre randomised control trial comparing an open-loop decision support system and routine care, in the general intensive care unit. bmj open 2020;10:e042145. 21. cederwall c-j, rose l, naredi s, et al. care practices for patients requiring mechanical ventilation more than seven days in swedish intensive care units: a national survey. intensive crit care nurs 2023;74:103309. 22. nitta k, okamoto k, imamura h, et al. a comprehensive protocol for ventilator weaning and extubation: a prospective observational study. j intensive care 2019;7:50. 23. awang s, alias n, dewitt d, et al. design of a clinical practice guideline in nurse-led ventilator-weaning for nursing training. article [healthcare in low-resource settings 2024;12:13010] [page 722] non -co mmerc ial us e o nly front public health 2021;9:726647. 24. marra a, ely ew, pandharipande pp, patel mb. the abcdef bundle in critical care. crit care clin 2017;33:225-43. 25. burns sm. weaning from mechanical ventilation: where were we then, and where are we now? crit care nurs clin north am 2012;24:457-68. 26. balas mc, tate j, tan a, et al. evaluation of the perceived barriers and facilitators to timely extubation of critically ill adults: an interprofessional survey. worldviews evid based nurs 2021;18:201-9. 27. cederwall c-j, olausson s, rose l, et al. person-centred care during prolonged weaning from mechanical ventilation, nurses’ views: an interview study. intensive critical care nurs 2018;46:32-7. 28. karlsen m-mw, heggdal k, finset a, heyn lg. attentionseeking actions by patients on mechanical ventilation in intensive care units: a phenomenological-hermeneutical study. j clin nurs 2019;28:66-79. 29. guilhermino mc, inder kj, sundin d. education on invasive mechanical ventilation involving intensive care nurses: a systematic review. nurs crit care 2018;23:245-55. article [page 723] [healthcare in low-resource settings 2024;12:13010] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2023; volume 11:11809 dark chocolate as a non-pharmacological alternative to reduce dysmenorrhea in adolescents ferina ferina, dian nur hadianti, yulia ulfah fatimah midwifery departement, ministry of health bandung health polytechnic, bandung, indonesia abstract dysmenorrhea, menstrual pain often experienced by women of reproductive age, including teenage girls, can cause discomfort and hinder daily activities, necessitating treatment. chocolate contains copper, which synthesizes neurotransmitters like collagen and endorphins, serving as an analgesic and natural sedative to alleviate pain. this study aimed to assess the effect of dark chocolate on reducing dysmenorrhea in adolescents. this study employed a quasi-experimental research design and was conducted over six months at a polytechnic in bandung. pain intensity was measured using a standardized instrument known as the walidd score. a total of forty students with primary dysmenorrhea participated in the study, selected through purposive sampling, and were divided into a treatment group and a control group. the independent variables included the administration of dark chocolate, while the dependent variable was the intensity of menstrual pain in students with primary dysmenorrhea. data were analyzed using an independent t-test. the intervention group, which received education on menstruation and dark chocolate, exhibited a significant reduction in dysmenorrhea pain as early as the second day, with a p-value of <0.001. administering dark chocolate at a dosage of 35 mg/day from the onset of menstruation helps reduce pain from the first day of menstruation compared to standard therapy, which includes education about menstruation. chocolate enhances mood due to its copper content, releasing endogenous morphine that inhibits pain impulses. this makes chocolate a non-pharmacological alternative for alleviating dysmenorrhea. introduction dysmenorrhea is primarily caused by an imbalance of the hormone progesterone in the blood.1–3 studies suggest that 16.8-81% of women may experience dysmenorrhea.4,5 a preliminary study conducted at a public junior high school in bandung found that 6 out of 10 female students had encountered menstrual pain (dysmenorrhea), which caused discomfort, abdominal pain radiating to the pelvis, and hindered their school performance.2 dysmenorrhea is prevalent globally, with examples such as the uk, where 4197% of cases were reported, and sweden, where 72% of respondents aged 19 experienced dysmenorrhea, with 15% of them being unresponsive to analgesics.1,3 the global prevalence of dysmenorrhea ranges from 20-90%, with 52.4-85.7% in europe and america and 58.8-84.9% in asia.6 the cause of dysmenorrhea is an imbalance of the hormone correspondence: ferina ferina, midwifery departement, politeknik kesehatan kemenkes bandung, bandung, indonesia e-mail: jewelferina28@gmail.com key word: adolescence; dark chocolate; dysmenorrhea; reproductive health. contributions: fe, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; dnh, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee, ministry of health, bandung health polytechnic, based on ethical certificate 21/kepk/ec/ix/2020. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research was supported by a research grant from ministry of health, bandung health polytechnic with contract number lb.02.01/3.1/5789.a/2020. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to thankful to ministry of health, bandung health polytechnic for their valuable insights and contributions to this study. received: 14 september 2023. accepted: 6 november 2023. early access: 21 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11809 doi:10.4081/hls.2023.11809 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 192] [healthcare in low-resource settings 2023; 11:11809] non -co mmerc ial us e o nly progesterone in the blood.7 women with dysmenorrhea produce significantly more prostaglandins than those without, leading to heightened uterine contractions and intestinal activation at excessive levels. other causes include underlying conditions such as endometriosis, pelvic infections, uterine tumors, appendicitis, gastrointestinal disorders, and kidney issues.1,8 to alleviate the painful symptoms of dysmenorrhea, various approaches have been attempted, including the use of pain-relieving medications such as mefenamic acid, ibuprofen, and metamphyron.9 nonsteroidal anti-inflammatory drugs (nsaids) and combined oral contraceptive pills are common pharmacological treatments. nsaids work by inhibiting prostaglandin production and have been found to be significantly more effective in relieving pain than placebos (or 7.91; 95% ci 5.65-11.09).1,6 however, long-term use of analgesics can lead to dependence and potentially cause liver damage and hypertension.10 hence, there is a need for alternative pain management methods that don’t rely on synthetic analgesic drugs. non-pharmacological methods can be employed for pain management, such as relaxation, hypnotherapy, warm water compresses, regular exercise, yoga, distraction, massage,2,11–14 and the consumption of foods that trigger the release of endorphins, such as chocolate.15–18 chocolate is rich in vitamins a, b1, c, d, and e, as well as phenol and flavonoid antioxidants. it also contains essential minerals like calcium, potassium, and iron, along with omega-3 and omega-6 fatty acids, and high levels of magnesium, which can alleviate menstrual pain and premenstrual symptoms in women.15,18 chocolate has numerous benefits for the body, including mood enhancement and a rich content of vitamins and minerals that stimulate the release of endorphins.16 dark chocolate, in particular, is known for its higher cocoa content, which contributes to its anti-inflammatory properties, making it a potential pain reducer.19 it is favored by many, especially teenagers, for its pleasant taste and its ability to stimulate the release of serotonin, inhibit pain pathways in the spinal cord, and generate endorphins, thereby activating the brain’s analgesia system by inhibiting prostaglandins.17 chocolate contains copper, which the body uses to synthesize collagen and neurotransmitters, including endorphins. endorphins are natural analgesics and tranquilizers that can reduce pain intensity, such as menstrual pain.15–18 the purpose of this study was to evaluate the effect of dark chocolate on reducing dysmenorrhea. matrials and methods research design this research is of an analytical nature and aims to analyze the effect of dark chocolate in reducing dysmenorrhea using a quasiexperimental pretest-posttest control group design. the study examines the age characteristics and bmi of the participants who experience dysmenorrhea and investigates the differences in pain intensity reduction among adolescents with dysmenorrhea who receive education alone and those who receive education and dark chocolate. it also analyzes the variations in the number of days required to reduce pain intensity in these two groups. study participants the subjects of this study were young women aged 17-21 years at the one polytechnic in bandung, west java. the target population in this study were all adolescents at the one polytechnic in bandung who experienced primary dysmenorrhea. sampling obtains a purposive sampling technique. the sample size in this study was calculated based on formula for unpaired numerical analytical research uses the two-average hypothesis test. the minimum sample size required in this study is ten respondents. to anticipate the loss of follow-up, researchers took a sample size for each group of 20 people. the total respondents who were included in this study were 40 people. the inclusion criteria are defined as follows: students of polytechnics in bandung who experience dysmenorrhea with a score of > 5 (wallid maximum score of 12). the walidd score is an instrument used to measure dysmenorrhea pain by modifying the wong-baker face instrument designed and validated to assess pain in pediatric populations, which has also proven useful in investigations involving adult populations with or without abdominal pain. walidd is a combination of manifestations, subjective (intensity, work ability), and objective (days of pain, location), characteristics that often appear when dysmenorrhea manifests. the walidd score contains three frequently used criteria identified in existing definitions of dysmenorrhea in the literature: pain days (d), work ability (wa), and anatomic region of pain location (l). thus, the walidd scores demonstrated acceptable internal consistency (cronbach’s alpha = 0.723).2,20 the inclusion criteria for this research sample were as follows: dysmenorrhea is felt every cycle for at least the last three months; regular menstrual cycle 21-35 days, adolescents aged 17-21 years, primary dysmenorrhea, body mass index 18-25 kg/m2, willing to be a respondent. the exclusion criteria are if respondents have other diseases that cause dysmenorrhea or allergy to eat chocolate. the inclusion criteria for this research sample were as follows: dysmenorrhea is felt every cycle for at least the last three months; regular menstrual cycle 21-35 days, adolescents aged 17-21 years, primary dysmenorrhea, body mass index 18-25 kg/m2, willing to be a respondent. the exclusion criteria are if respondents have other diseases that cause dysmenorrhea or allergy to eat chocolate. variable, instrument and data collection the independent variable in this study is the pain intensity of dysmenorrhea, while the dependent variables are the consumption of dark chocolate and dysmenorrhea education. pain intensity was measured using the walidd score questionnaire, which has been validated and deemed reliable. the questionnaire employs a scale ranging from 0 to 12.20 in the intervention group, participants received education on managing dysmenorrhea pain and were provided with a package of 35 grams of 72% dark chocolate to be consumed during the first 5 days of menstruation. the control group, on the other hand, received only education on managing dysmenorrhea pain. data for this study were collected using a google form questionnaire, with enumerators assisting in the research process. enumerators played a role in the research preparation, data tabulation, preparation of educational materials on menstruation and dysmenorrhea, and delivery of these materials. to ensure that participants experiencing menstrual pain only consumed dark chocolate, information about dysmenorrhea and the use of dark chocolate was provided initially. enumerators maintained contact with participants daily to record dark chocolate consumption and verify the absence of other pain reduction techniques. data analysis data were analyzed using spss for windows version 26. bivariate analysis was conducted to assess the impact of the independent variables on the dependent variables. an unpaired parametric test, the independent t-test, was employed if the data followed a normal distribution. if normal distribution assumptions [healthcare in low-resource settings 2023; 11:11809] [page 193] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly were not met, the mann-whitney test was used. the researchers made statistical decisions with a significance level (α) of 0.05. ethical clearance the research received ethical approval from the health research ethics committee at the health polytechnic of the ministry of health in bandung, as evidenced by ethical certificate 21/kepk/ix/2020. throughout the study, the researchers adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. results an overview of the characteristics of adolescents who experience dysmenorrhea based on age, age at menarche, and bmi at the poltekkes kemenkes bandung can be seen in table 1. table 1 presents the results of the statistical tests conducted using the mann-whitney test at a 95% confidence level. the analysis indicates that there is no significant difference in the characteristics of the research subjects based on age between the group administered dark chocolate in the morning (am) and the control group. the p-value obtained is 0.675, which is greater than the 0.05 significance level (p>0.05). similarly, there is no significant difference in the characteristics of research subjects based on bmi between the group given dark chocolate and the control group, with a p-value of 0.675 (p>0.05). these results indicate that the research subjects in both groups, the one administered dark chocolate in the morning and the control group, exhibited similar age and bmi characteristics. the characteristics based on age and bmi were found to be homogeneous between these two groups, as the p-values were greater than 0.05. this homogeneity in subject characteristics allows for further analysis to determine the effectiveness of providing dark chocolate in reducing pain intensity in adolescents with dysmenorrhea. table 2 displays the results of the statistical tests conducted using the wilcoxon sign rank test at a 95% confidence level. the analysis reveals a significant difference in pain intensity among dysmenorrhea adolescents before and after they were administered dark chocolate. the p-value obtained is less than 0.001 (p<0.001), which is less than or equal to the 0.05 significance level (p≤0.05). this significant difference in pain intensity before and after the administration of dark chocolate suggests that dark chocolate had a noticeable impact on reducing pain intensity in dysmenorrhea adolescents. the results indicate that the intervention with dark chocolate effectively led to a decrease in pain intensity. table 3 shows that the results of the statistical tests using the wilcoxon sign rank test at a 95% confidence level indicate a significant difference in pain intensity in the control group of dysmenorrhea adolescents before and after the intervention. the p-value obtained is less than 0.001 (p<0.001), which is less than or equal to the 0.05 significance level (p≤0.05). this significant difference suggests that there was a noticeable impact on reducing pain intensity in dysmenorrhea adolescents in the control group after the intervention. table 4 shows that the results of the statistical tests using the friedman test at a 95% confidence level show a significant difference in pain intensity among dysmenorrhea adolescents who were administered dark chocolate from the beginning of the intervention through day 5. the p-value is less than 0.001 (p<0.001), indicating that the pain intensity changed significantly over the five-day period (p≤0.05). table 5 shows that the results of the statistical tests using the friedman test at a 95% confidence level reveal a significant difference in pain intensity among dysmenorrhea adolescents who did not receive dark chocolate from the beginning, through day 1, and transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics of research subjects between the group given dark chocolate and the control group in adolescents with dysmenorrhea. variable intervention dark chocolate (n=20) control (n=20) p mean sd md min-max mean sd md min-max age 19.75 0.71 20 19-21 19.60 0.59 20.00 19-21 0.675 bmi 20.58 1.97 20 18.00-24.97 20.87 1.99 20.78 18.00-24.98 0.675 *mann whitney test. table 2. comparison of pain intensity before and after giving dark chocolate to dysmenorrhea adolescents. variable intervention dark chocolate group p* before after mean sd md min-max rerata sd md min-max pain intensity 6.50 0.60 6 6-8 0.45 0.94 0 0-4 <0.001 * wilcoxon sign rank test. table 3. comparison of pain intensity before and after giving dark chocolate in adolescents with dysmenorrhea. variable control group without dark chocolate p* before after mean sd md min-max rerata sd md min-max pain intensity 6.50 0.68 6 6-8 0.45 1.09 0 0-4 <0.001 * wilcoxon sign rank test. [page 194] [healthcare in low-resource settings 2023; 11:11809] non -co mmerc ial us e o nly up to day 5. the p-value obtained is less than 0.001 (p<0.001), indicating that the pain intensity changed significantly over the five-day period (p≤0.05). table 6 presents the results of the statistical tests conducted using the mann-whitney test at a 95% confidence level. the analysis indicates that there is no significant difference in initial pain intensity in dysmenorrhea adolescents between the group administered dark chocolate and the control group. the p-value obtained is 0.877, which is greater than the 0.05 significance level (p>0.05). however, it’s worth noting that significant differences emerged after specific time intervals in the intervention and control groups. after the second day in the intervention group and after the third day in the control group, significant differences in pain intensity were observed. this suggests that in the intervention group, which received education and consumed dark chocolate, a quicker reduction in pain intensity was experienced compared to the control group, where pain reduction became significant after the third day. discussion the primary finding of this study suggests that the consumption of dark chocolate containing 72% cocoa led to a significant reduction in experimentally induced pain among adolescent girls with dysmenorrhea. the study initially selected respondents with moderate and severe pain intensity using the wallid score instrument and divided them into an intervention group, which received education about dysmenorrhea and consumed 72% dark chocolate daily for five days, and a control group, which only received education about dysmenorrhea. the analysis of age, body mass index (bmi), and initial pain intensity (table 1) revealed no significant differences between the two groups, indicating the homogeneity of their characteristics. the results demonstrated that the intervention group, which received both education and dark chocolate, experienced a significant reduction in pain intensity more rapidly than the control transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 4. comparison of pain intensity from baseline, day 1 to day 5 with dark chocolate given to dysmenorrhea adolescents. variable pain intensity p* mean sd md min-max lmp 6.50 0.60 6 6-8 <0.001 days 1 4.70 1.34 5 2-7 <0.001 days 2 2.45 1.87 3 0-5 <0.001 days 3 1.10 1.58 0.5 0-5 <0.001 days 4 0.75 1.29 0 0-5 <0.001 days 5 0.45 0.94 0 0-4 <0.001 * friedman test. table 5. comparison of pain intensity from baseline, day 1 to day 5 without giving dark chocolate to dysmenorrhea adolescents. variable pain intensity p* mean sd md min-max lmp 6.50 0.68 6 6-8 <0.001 days 1 4.40 1.14 4 1-6 <0.001 days 2 3.40 2.06 4 0-6 <0.001 days 3 1.80 2.01 0.5 0-5 <0.001 days 4 0.65 1.34 0 0-4 <0.001 days 5 0.45 1.09 0 0-4 <0.001 * friedman test. table 6. comparison of pain intensity in dysmenorrhea adolescents between the group given dark chocolate and the control group. group median p* days (n=20) min-max days (n=20) min-max start lmp 6 6-8 6 6-8 0.877 control (1) 4 (2) 4 1-6 0.110 intervention (1) 5 2-7 (2) 3 0.001* control (2) 4 (3) 0.5 0-6 0.02 intervention control (2) 3 0-5 (3) 0.5 0.028 (3) 0.5 (4) 0 0-5 0.056 intervention (3) 0.5 0-5 (4) 0 0.490 control (4) 0 (5) 0 0-4 0.67 intervention (4) 0 0-4 (5) 0 0.432 *mann whitney test. [healthcare in low-resource settings 2023; 11:11809] [page 195] non -co mmerc ial us e o nly group. the pain intensity in the intervention group decreased significantly on the second day, whereas the control group experienced a significant reduction in pain intensity after the third day. these findings align with previous research, which also found that dark chocolate could significantly reduce dysmenorrhea pain.15,16,18,21–22 adolescence in girls is a period marked by the onset of menarche, often associated with irregular menstrual problems, excessive bleeding, and dysmenorrhea.18 severe dysmenorrhea can impact physical,23 psychological, and social aspects of life, leading to depression, moodiness, and missed school or work.24–26 some evidence supports the role of dietary supplements and specific nutrients, such as omega-3 fatty acids, vitamins, and minerals, in relieving menstrual pain.18 additionally, chocolate is rich in vitamins a, b1, c, d, and vitamin e. furthermore, chocolate contains phenol and flavonoid antioxidants, along with minerals such as calcium, potassium, iron, and a small amount of omega 3 and 6. additionally, it is high in magnesium, which can help reduce menstrual pain and premenstrual syndrome in women.18 magnesium serves as a cofactor in protein synthesis, muscle relaxation, and energy production. it also has antiarrhythmic and hypotensive properties.21,27 the consumption of dark chocolate increases serotonin secretion, resulting in the transmission of signals to the dorsal horn, where peripheral pain sensory fibers terminate, inhibiting pain transmission. serotonin also keeps pain gates closed. a deficiency of serotonin can heighten pain sensitivity, and various methods can stimulate the body to increase serotonin levels. dark chocolate consumption triggers the release of endorphins, which act as substances that carry the signals of the brain’s analgesia system. endorphins inhibit the cyclooxygenase enzyme, preventing the formation of pgg2, which is a pain mediator substance.21 the study’s results indicate a change in dysmenorrhea levels in adolescents who consume 72% dark chocolate daily for five days. this aligns with the findings of arfailasufandi’s research (2018), which suggested that dark chocolate significantly reduces menstrual pain in students at the university of malang.16 chocolate is rich in vitamins, minerals, fiber, and polyphenols that support both physical and psychological health. in addition to its various physical effects, chocolate has also been associated with potential psychological effects on mood, cravings, and cognitive function.28 most research on the effects of cocoa on psychological variables has focused on explaining chocolate cravings, likely because chocolate is highly craved. for example, in one study, chocolate accounted for 49% of all food cravings reported by a sample of 25 healthy women.27 two studies by macht also support the idea that the psychoactive properties of chocolate are primarily related to taste. these studies suggest that while chocolate consumption may temporarily increase negative moods, this effect is likely due to the palatability of chocolate. in macht’s 2007 study, the consumption of enjoyable chocolate significantly improved mood more than unpalatable chocolate, with no significant difference from the control group (chocolate non-sufferers). in a 2006 study by macht, a bar of chocolate uplifted mood and elicited greater excitement than an apple, especially within 5 and 30 minutes after consumption. this suggests that the sensory experience of eating chocolate improves mood rather than immediate neurochemical effects.27 these findings are in line with the responses from the study’s participants who mentioned that they enjoy eating dark chocolate because of its taste and its ability to quickly alleviate dysmenorrhea pain. on the other hand, there is some evidence supporting the psychoactive effects of flavanols or the methylxanthine compounds in cocoa, which can extend beyond affecting mood to cognitive function. a study conducted by scholey and colleagues involved a randomized, controlled, double-blind cross-sectional trial with 30 healthy adults. this study investigated the effects of cocoa flavanol consumption on cognitive performance, anxiety status, and mental fatigue. three treatments were tested: cocoa drinks containing 46 mg (control), 520 mg, and 994 mg of total flavanols. both flavanol-rich preparations significantly improved cognitive performance and reduced mental fatigue compared to the control group. smith et al. examined cocoa’s methylxanthine compounds, caffeine, and theobromine, as potential mood-altering agents.27 therefore, it can be expected that the consumption of dark chocolate can affect adolescent primary dysmenorrhea. the intervention group that received dark chocolate experienced a decrease in dysmenorrhea pain from the first day of consuming dark chocolate, compared to the control group that did not receive dark chocolate. this rapid reduction in pain is highly beneficial for adolescents in their daily lives, as somatic complaints often disrupt their activities. these results suggest that teenagers can use dark chocolate as an alternative non-pharmacological therapy to alleviate primary dysmenorrhea pain, as dark chocolate has very few side effects. this allows teenagers to comfortably engage in activities during their menstrual period. these findings align with research that indicates a significant effect of pain intensity before dark chocolate therapy on pain after consuming dark chocolate. these results are consistent with another study that found an effect of dark chocolate therapy in reducing menstrual pain among adolescents in natar south lampung.21 dark chocolate is rich in complex carbohydrates, antioxidants (polyphenolic flavonoids), vitamin b6, unsaturated fatty acids (omega 3 and omega 6),29 and essential minerals (magnesium, calcium, iron) that play a crucial role in regulating the menstrual cycle by maintaining a balance of sex hormones in the bloodstream during menstruation. dark chocolate, distinguished by its higher cocoa bean content compared to other chocolate types, is particularly abundant in polyphenolic compounds, contributing to its distinct bitter taste and deep black color. dark chocolate stands out as an optimal choice for promoting various health benefits. its advantages extend to combating infectious diseases, cancer, cardiovascular issues, metabolic disorders, and psychological ailments.27 furthermore, dark chocolate contains significant levels of magnesium, which directly influences vascular pressure and has the ability to modulate the influx of calcium into the uterine smooth muscle cells. this modulation by magnesium affects the contraction and relaxation of the uterine muscles. additionally, magnesium exhibits anti-inflammatory properties by inhibiting the formation of prostaglandins. as the fourth most abundant mineral in the human body, magnesium found in dark chocolate has the potential to enhance one’s mood. this aligns with research that demonstrates a reduction in primary dysmenorrhea pain by 2.46 in a group of students in malang regency before and after consuming dark chocolate.30 another study has shown a significant difference between groups of female adolescents who were provided with dark chocolate, milk chocolate, and milk without chocolate. the group that consumed dark chocolate experienced a significant reduction in premenstrual and menstrual pain.18 however, it is noteworthy that the intervention in the study involved not only dark chocolate but also education for both the control and intervention groups to address dysmenorrhea pain. statistically, this intervention in both groups resulted in a non-significant difference in reducing dysmenorrhea pain. this suggests that education on reducing dysmenorrhea pain, in addition to the consumption of dark chocolate, had a significant effect on pain reduction. a considerable reduction in dysmenorrhea pain can be [page 196] [healthcare in low-resource settings 2023; 11:11809] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly achieved through various means, such as physical exercise, relaxation techniques, and mood-enhancing activities. consuming chocolate can be a part of these strategies to alleviate dysmenorrhea pain.18 conclusions the utilization of dark chocolate as a non-pharmacological alternative therapy shows promise in expediting pain reduction in adolescents with dysmenorrhea. however, additional research and larger-scale studies are essential to delve into the long-term effects and determine the optimal dosage of dark chocolate for effectively managing dysmenorrhea. dark chocolate can serve as a more enjoyable non-pharmacological alternative for alleviating pain associated with dysmenorrhea in adolescents. references 1. wallace s, keightley a, gie c. review dysmenorrhoea. obstet gynaecol 2010;12:149-54. 2. hadianti dn, ferina f. senam yoga menurunkan dismenore pada remaja. j ris kesehat poltekkes depkes bandung 2021;13:239-45. 3. nursalam n, oktaviani dwd, armini nka, efendi f. analysis of the stressor and coping strategies of adolescents with dysmenorrhoea. indian j public heal res dev 2018;9:381-6. 4. harsetianingrum ra, martiana t, widjajati n. the risk factors analysis of menstrual disorders in women workers of shoes industry, sidoarjo. malaysian j med heal sci 2019;15:26-9. 5. por cs, mogana r, akowuah ga, chinnappan s, abdullah nh. polyherbal formulation for primary dysmenorrhea: a review. res j pharm technol 2022;15:1891-900. 6. nakame rm, kiwanuka f, robert a. dysmenorrhoea among students aged 18-45 years attending university in uganda: a cross-sectional multicenter study of three universities in uganda. nurs open 2019;6:268-75. 7. por cs, rajagopal ms, akowuah ga, chinnap-pan s, abdullah nh. treatment of primary dysmenorrhea affecting menstruating women using herbs: a review. nat prod j 2022;12:11-23. 8. dawood my. dysmenorrhoea and prostaglandins: pharmacological and therapeutic considerations. curr ther (seaforth) 1982;23:71-83. 9. suwito j, putra st, sulistyono a. the affirmation tapping on pain perception and serotonin serum level of post caesarian section patients. j ners 2019;14:124-8. 10. peacock a, alvi ns, mushtaq t. period problems: disorders of menstruation in adolescents. arch dis childhood 2012;97:554-60. 11. ko hn, sun le s, dol kim s. effects of yoga on dysmenorrhea: a systematic review of randomized controlled trials. altern integr med 2016;05(04). 12. faramarzi m, salmalian h. association of psychologic and nonpsychologic factors with primary dysmenorrhea. iran red crescent med j 2014;16(8). 13. prabhu s, nagrale s, shyam a, sancheti p. effect of yogasanas on menstrual cramps in young adult females with primary dysmenorrhea. int j physiother res 2019;7:3129-34. 14. nag u. effect of yoga on primary dysmenorrhea and stress in medical students. iosr j dent med sci 2013;4:69-73. 15. faizah n, mukhoirotin m. pengaruh pemberian cokelat hitam (dark chocolate) dan jahe terhadap intensitas nyeri haid (dysmenorrhea). j keperawatan 2020;8:43-9. 16. hanafi m, iswaro, arifah s. pengaruh pemberian dark chocolate terhadap dismenorhea primer pada mahasiswi keperawatan. j keperawatan soedirman 2017;12:77-83. 17. khairunnisa n, sukohar a, hanriko r, septa t. hubungan pemberian dark chocolate terhadap penurunan skala nyeri menstruasi (dismenorea primer) yang dipengaruhi dengan kondisi stres pada mahasiswi kedokteran universitas lampung. majority 2018;7:81-9. 18. verma a, kadam a. does dark chocolate relieve menstrual pain in adult women?: a study among indian population. int j physiol 2019;7:16. 19. hajati a, brondani m, angerstig l, et al. chocolate intake and muscle pain sensation: a randomized experimental study. plos one 2023;18:1-21. 20. teherán aa, piñeros lg, pulido f, mejía guatibonza mc. walidd score, a new tool to diagnose dysmenorrhea and predict medical leave in university students. int j womens health 2018;10:35-45. 21. nur asih s, ate yuviska i, studi kebidanan universitas malahayati p. pengaruh dark chocolate terhadap pengurangan nyeri haid pada remaja. j kebidanan 2020;6:497-503. 22. karakuş selçuk a, baysal e. the effect of dark chocolate and music on pain and anxiety in young women with primary dysmenorrhea: randomized controlled trial. eur j integr med 2022;56. 23. handayani sg, ayubi n, komaini a, et al. n-3 polyunsaturated fatty acids (pufas) and physical exercise have the potential to reduce pain intensity in women with primary dysmenorrhea: systematic review. retos 2023;48:106-12. 24. kusumaningrum t, nastiti aa, dewi lc, lutfiani a. the correlation between physical activity and primary dysmenorrhea in female adolescents. indian j public heal res dev 2019;10:2559-63. 25. armini nka, setyani a, nastiti aa, triharini m. knowledge and peer support for increase menstrual hygiene management (mhm) in adolescents. healthc low-res set 2023;11:111193. 26. aziato l, dedey f, clegg-lamptey jna. the experience of dysmenorrhoea among ghanaian senior high and university students: pain characteristics and effects. reprod health 2014;11(1). 27. katz dl, doughty k, ali a. cocoa and chocolate in human health and disease. antioxidants redox signal 2011;15:2779811. 28. kurniawati em, rahmawati na, safitri ct, hanum ss. informational and instrumental support related to menstruation: adolescents’ perspective. int j public heal sci 2022;11:1317-23. 20. adi ac, tawakal ai, rasyidi mf, et al. effect of cocoa husk criollo tea on hypercholesterolemia in animal model. foods raw mater 2023;11:206-14. 30. natalia s, astikasari nd. pengaruh permen dark chocolate terhadap nyeri dismenore primer pada remaja putri di smp gaya baru desa sumberejo kecamatan gedangan kabupaten malang. j qual women’s heal 2019;2:31-7. [healthcare in low-resource settings 2023; 11:11809] [page 197] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13255 epidemiology of chronic kidney disease and the heightened risk of hepatitis c virus infection in low-resource settings anik nuryati,1 budi setiawan,1,2 catur wijayanti3 1faculty of medical laboratory technology, health polytechnic of ministry of health in yogyakarta, indonesia; 2biomedical engineering, school of engineering, university of glasgow, scotland, uk; 3public health laboratory magelang, indonesian ministry of health, indonesia abstract chronic kidney disease (ckd) is a significant non-communicable disease with varying incidence and prevalence globally. over the past two decades, it has emerged as one of the leading causes of mortality. in indonesia, ckd has risen sharply and now represents one of the highest disease-related cost burdens. ckd patients, both men and women, across different age groups, face complex challenges, including the risk of hepatitis c virus (hcv) infection due to hemodialysis (hd). this cross-sectional study investigated 43 ckd patients undergoing hd twice weekly for at least one year at a regional hospital in yogyakarta, all of whom initially tested negative for hcv. the results revealed that 58.1% of ckd patients were female, with 32.6% aged 55-65 years. most (60.5%) had completed high school education, and 39.5% were housewives. interestingly, 69.8% of cases were not primarily caused by kidney-related conditions. importantly, the longer a patient undergoes hd, the higher their risk of acquiring hcv infection. although the percentages may vary across different settings, this study highlights the urgent need for targeted infection control measures, particularly in resource-limited healthcare environments where access to preventive strategies may be constrained. introduction chronic kidney disease (ckd) is a non-communicable disease that has emerged as a significant global health concern, with varying incidence and prevalence rates across regions.1 over the past two decades, ckd has become one of the leading causes of death worldwide, affecting more than 10% of the global population, or over 800 million people, as of 2022. in the united states, it is estimated that more than 1 in 7 adults has ckd.2,3 the national basic health research (riskesdas) 2018 in indonesia reported a 2.0% increase in the prevalence of ckd since 2013, making it the fourth most burdensome catastrophic disease in terms of healthcare costs in the country.4,5 ckd can affect individuals of all ages, with varying prevalence. in terms of gender and age characteristics, ckd is more commonly observed in women and the elderly.3 physiologically, the kidney volume decreases with age, leading to reduced function due to nephrosclerosis, where the number of nephrons decreases by approximately 20% starting at the age of 50.6,7 the spread of ckd is influenced by demographic factors such as education and employment, which cannot be separated from its complexity. additionally, cultural habits, such as the consumption of alcoholic beverages (e.g., alcohol, wine, tuak [traditional alcoholic drink]), formed since adolescence, and environmental health factors add further challenges.6-8 a history of certain diseases also plays a crucial role in the incidence of ckd. diabetes and hypertension are the most common causes of ckd, rather than diseases originating from the kidneys.9-11 hypertension serves both as a causative factor and a consequence of ckd.12 this is particularly relevant to hemodialysis (hd), which can lead to increased blood pressure during or shortly after the procedure, a condition known as intradialytic hypertension.13 hd remains the most widely used life-sustaining therapy for ckd patients.14,15 while hd has been shown to improve the life expectancy of ckd patients, it also presents risks, particularly the spread of hepatitis c virus (hcv) infections.16,17 the duration of hd therapy significantly increases the risk of hcv transmission among ckd patients.18,19 this study aims to determine the epidemiological picture of patients with ckd and the risk of hcv transmission due to hd. correspondence: budi setiawan, biomedical engineering, school of engineering, university of glasgow, advanced research building level 4, 11 chapel ln, glasgow g11 6ew, scotland. email: budi.setiawan@poltekkesjogja.ac.id key words: chronic kidney disease; hepatitis c virus infection; hemodialysis; low-resource settings; indonesia. contributions: an, bs, cw, conceptualization, methodology, and writing; cw, collection of data and writing of the results; an, bs, interpretation of the results; bs, revision of the manuscript. conflict of interest: all authors declare no potential conflict of interest. ethics approval and consent to participate: this study has obtained ethical approval from the health research ethics committee (kepk) with number 180/5402.13. in addition, this study also obtained official permission from the director of yogyakarta regional hospital with number 070/5425.30. acknowledgments: the authors would like to thank the clinical pathology laboratory department, hemodialysis center, and medical records department of region hospital in yogyakarta, which also support research activities. received: 14 october 2024. accepted: 26 november 2024. early access: 20 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13255 doi:10.4081/hls.2025.13255 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 92] [healthcare in low-resource settings 2025;13:13255] materials and methods this research is an observational study with a descriptive, cross-sectional design approach. the data used was secondary data obtained from medical records of hemodialysis patients at yogyakarta regional hospital. the population of this study was non-hepatitis hd patients who were actively undergoing hd procedures twice a week. inclusion criteria in this study include: i) patients who are actively undergoing hd procedures twice a week; ii) have undergone hd for at least one year; iii) and have non-reactive hepatitis test results. from the population that met the inclusion criteria, 43 patients who were willing to participate in this study were selected. this study has obtained ethical approval from the health research ethics committee (kepk) with number 180/5402.13. in addition, this study also obtained official permission from the director of yogyakarta regional hospital with number 070/5425.30. results and discussion this study examined several key variables, including gender, age, educational level, occupation, ckd etiology, and the duration of hd treatment. the collected data were analyzed descriptively and presented in tables and narratives based on the studied variables. gender and age characteristics the incidence of ckd in this study was found to be more prevalent in women (58.1%) than in men (41.9%). this finding aligns with data from the 2018 riskesdas, which reported that 60.3% of ckd patients in indonesia were women.5 similarly, a study conducted in 2020 at montaserieh hospital in mashhad, iran, found that out of 1034 ckd patients, 605 were women.20 studies in alberta, canada, showed that 55.2% of 81,320 kidney failure patients were women,21 and 50.9% of 225 ckd patients on hd in karachi, pakistan, were also women.19 in 2016, 417 million out of 753 million ckd patients globally were women.22 the higher prevalence in women is often attributed to better adherence to therapy, complications during pregnancy, autoimmune factors, and differences in dialysis-related complications between genders.23,24 however, other studies have reported that ckd is more common in men due to lifestyle factors and a higher prevalence of hypertension and diabetes.25-28 the higher prevalence of ckd in women compared to men can be attributed to a combination of biological, behavioral, and healthcare-related factors. biologically, women tend to have a lower baseline glomerular filtration rate (gfr) than men, which may predispose them to earlier stages of ckd.29 additionally, women are more likely to have comorbid conditions such as hypertension and diabetes, which are significant risk factors for ckd.30,31 despite these factors, men are more likely to progress to severe stages of ckd and require kidney replacement therapy, possibly due to a steeper decline in kidney function with age and the influence of androgens, which have pro-apoptotic and pro-fibrotic effects on the kidneys.29,32 furthermore, women with ckd are often less aware of their condition, which may delay diagnosis and management, contributing to higher prevalence rates.33 healthcare disparities also play a role, as women are less likely to receive timely specialist care and appropriate treatment, such as kidney replacement therapy, compared to men.30,31 additionally, lifestyle factors such as higher rates of obesity and poorer adherence to dyslipidemia medications in women may exacerbate ckd progression.34 estrogen and other hormonal effects can impact renal function and the advancement of kidney disease in females. hormonal variations during pregnancy, menopause, or diseases such as preeclampsia can elevate the risk of ckd. pregnancy-associated disorders such as pre-eclampsia, eclampsia, and postpartum hypertension are substantial contributors to chronic kidney disease in women. women exhibit a higher susceptibility to autoimmune illnesses such as systemic lupus erythematosus (sle) and rheumatoid arthritis, which may result in renal impairment or secondary renal injury. furthermore, the shorter urinary tracts in women render them more vulnerable to urinary tract infections (utis), which may result in kidney infections and potentially contribute to ckd over time. women are more inclined than men to pursue healthcare and participate in routine tests, resulting in an elevated incidence of ckd diagnoses. this proactive behavior may exaggerate prevalence statistics compared to men who may have undiscovered illnesses due to insufficient healthcare participation. women typically exhibit superior compliance with prescribed medicines and lifestyle changes, potentially enhancing outcomes while also elevating the probability of early identification and diagnosis of ckd. women’s interaction with healthcare systems significantly affects access to care and diagnosis, particularly during pregnancy and regular reproductive health appointments. pregnancy-related testing can identify renal complications earlier than males, who often seek healthcare only when unwell. women on hemodialysis face an elevated risk of complications, including anemia and vascular access problems, which may aggravate the progression of ckd. cultural and socioeconomic factors can exacerbate ckd risk by exposing women to poor dietary habits, strenuous labor, and circumstances such as early marriages and multiple pregnancies. global research indicates that a higher number of women are diagnosed with ckd, whereas men are more prone to advancing to end-stage kidney disease (eskd). this gap may indicate a slower illness course in women attributable to biological reasons and earlier diagnosis. nevertheless, when women attain advanced stages of ckd, they frequently encounter inferior results, presumably because of disparities in access to specialized care and treatment. these multifaceted factors collectively contribute to the observed higher incidence of ckd in women compared to men. regarding age, ckd in this study occurred predominantly in individuals over 45 years old, accounting for 67.5% of cases, which is double the percentage for patients aged 15-44 years (32.5%). this finding is consistent with 2018 riskesdas data, which reported a ckd prevalence of 15.3 per 1000 people aged over 45 years compared to 6.92 per 1000 people aged 15-44 years.5 a study in sudan also found the average age of ckd patients on dialysis to be 55 years.35 this age distribution is closely related to the natural decline in kidney function. starting at age 30, the glomerular filtration rate (gfr) decreases by approximately 8 ml/minute/1.73 m² per decade. by the age of 40, significant nephron loss begins, further impacting kidney filtration capacity.36 in younger populations, ckd may arise from congenital kidney and urinary tract abnormalities, as seen in 2.7% of individuals under 29 years, including healthy individuals.7,37 ckd mainly occurs in individuals over 45 years old due to a combination of physiological, pathological, and demographic factors. as individuals age, there is a natural decline in kidney function, which is often exacerbated by the presence of chronic conditions such as diabetes, hypertension, and cardiovascular diseases, all of which are more prevalent in older populations.38,39 the prevalence of ckd increases significantly with age, with studies indicating that more than 45% of adults aged 70 years or older in the article [healthcare in low-resource settings 2025;13:13255] [page 93] united states are affected by ckd.40 this age-related increase in ckd prevalence is partly due to cumulative exposure to risk factors over time, including lifestyle factors such as smoking and the use of nephrotoxic medications like nsaids.39,41 additionally, acute kidney injury (aki), which is more common in the elderly due to age-related changes in kidney function and the impact of chronic diseases, significantly raises the risk of developing ckd.18 the physiological changes associated with aging, such as reduced glomerular filtration rate (gfr), are often misinterpreted as pathological, leading to potential overdiagnosis of ckd in older adults.42,43 furthermore, the lack of age-adjusted diagnostic criteria for ckd can result in the misclassification of age-related kidney function decline as ckd, contributing to the higher-reported prevalence in older populations.42,43 the interplay of these factors underscores the importance of age-specific screening and management strategies to accurately diagnose and treat ckd in older adults, thereby preventing progression to end-stage renal disease and reducing associated morbidity and mortality.44 ckd is more prevalent in older adults due to a combination of natural aging processes and risk factors. the kidneys inherently diminish some of their filtration capacity due to decreased functioning nephrons and alterations in kidney architecture. chronic conditions such as diabetes and hypertension are prevalent in older adults, resulting in progressive renal impairment. prolonged exposure to renal stressors, such as pharmaceuticals, poisons, and infections, may result in enduring damage. lifestyle variables such as elevated salt or protein consumption, tobacco use, and obesity augment the risk of chronic kidney disease. older adults are more vulnerable to acute kidney injury (aki), which may arise from infections, dehydration, or the administration of nephrotoxic medications. some individuals have a genetic susceptibility to ckd, which may only manifest as they age, especially when accompanied by environmental factors or lifestyle decisions. chronic kidney disease frequently advances asymptomatically in its initial phases, and in elderly individuals, manifestations may be ascribed to aging rather than renal pathology, permitting its progression to go unrecognized. consequently, ckd poses a considerable health risk for the elderly population (table 1). sociodemographic factors table 2 shows that most ckd patients in this study were high school graduates (60.5%), similar to population data from sleman regency in 2020, which reported that 31.79% of the population had a high school education. research in four hospitals in jakarta also reported that 43.3% of ckd patients were high school graduates.25 housewives accounted for the majority (39.5%) of job types, followed by employees (30.2%), self-employed individuals (14.0%), and farmers (9.3%). a similar study in hospitals in kendal and semarang central java found that 28.2% of ckd patients were employees.45 occupation plays a significant role as a risk factor for ckd due to varying exposures and habits. for example, employees often consume less water and more energy drinks or sodas, which are known risk factors for ckd.25,45 field workers exposed to excessive sunlight or those with physically demanding jobs are also at greater risk of dehydration, leading to more concentrated urine and kidney damage.46 educational level plays a significant role in the health outcomes and management of patients with ckd. studies have shown that lower educational attainment is associated with adverse outcomes in ckd patients, including higher risks of mortality, major adverse cardiovascular events, and kidney failure. this association is mediated by factors such as lifestyle habits and biomarkers, highlighting the importance of educational interventions in improving patient prognosis.47 in the german ckd cohort, low educational attainment was linked to a higher prevalence of diabetic nephropathy and ckd following acute kidney injury, suggesting that education influences disease etiology and progression.47 conversely, higher educational levels were paradoxically associated with an increased risk of incident ckd in an iranian cohort, potentially due to unhealthy lifestyle behaviors prevalent in this demographic.48 education significantly influences the prevalence of chronic kidney disease by affecting health awareness, lifestyle decisions, healthcare accessibility, and risk management. individuals with higher education levels typically possess a greater awareness of the significance of sustaining a healthy lifestyle, engaging in practices that safeguard renal health, and eschewing detrimental substances such as smoke and excessive alcohol. health literacy is influenced by education, as those with higher educational attainment are more likely to identify early indicators of kidney failure, seek medical counsel promptly, and comply with medical directives. the early identification of ckd is essential for averting its progression, as it frequently advances unnoticed during its earliest phases. socioeconomic factors also play a role in access to healthcare, as people with higher education levels have better access to health insurance, routine health check-ups, and financial means to pay for preventive care or treatments. individuals with lower educational attainment may encounter obstacles in obtaining these resources, hence elevating their risk of undetected or inadequately managed ckd. chronic disorders such as diabetes and hypertension are substantial risk factors for ckd, and education greatly influences an individual’s capacity to comprehend and manage these symp article table 1. characteristics of gender and age. characteristics frequency % (%) gender men 18 41.9 women 25 58.1 age (based who) 15-24 1 2,3 25-34 4 9.3. 35-44 9 20.9 45-54 11 25.6 55-64 14 32.6 65-74 3 7.0 ≥ 75 1 2.3 table 2. sociodemographics. sociodemographics n (43) % educational level no school 1 2.3 primary school 5 11.6 junior school 5 11.6 high school 26 60.5 higher education 6 14 job type housewives 17 39.5. employees 13 30.2 self-employed 6 14 public-servant 2 4.7 farmers 4 9.3 students 1 2.3 [page 94] [healthcare in low-resource settings 2025;13:13255] toms. inadequate care of these illnesses in individuals with lower educational attainment elevates the risk of ckd. behavioral and environmental factors significantly impact diet, exercise, and living situations, hence directly influencing kidney health. educational attainment is a pivotal factor influencing ckd risk, and mitigating educational inequities with advancing health education is a vital approach to alleviating the ckd burden, particularly among at-risk populations. educational interventions, such as nurse-led programs and patient information leaflets, have been effective in enhancing ckd patients’ knowledge and management skills, leading to improved health outcomes.49,50 for instance, a nurse-led educational intervention significantly increased patients’ knowledge scores, which is crucial for managing ckd and preventing progression to end-stage renal disease.49 similarly, groupbased education has been shown to effectively reduce body weight and uric acid levels, which are critical factors in ckd management.51 moreover, therapeutic patient education has been instrumental in helping patients make informed decisions about renal replacement therapy, with a significant correlation between educational level and knowledge acquisition.52 these findings underscore the critical role of education in ckd management, suggesting that targeted educational strategies could mitigate the socioeconomic disparities observed in ckd outcomes.53,54 therefore, integrating educational interventions into ckd care plans could enhance patient empowerment, improve adherence to treatment regimens, and ultimately lead to better health outcomes. etiology of ckd the results revealed that 69.8% of ckd cases were caused by non-kidney diseases, such as hypertension and diabetes mellitus, while the remaining 30.2% were attributed to kidney-related conditions (table 3). this is consistent with research in developing countries, where ht and dm are the leading causes of ckd.55,56 hypertension damages the kidneys through the thickening of the tunica intima cells in the renal glomerulus, which reduces blood flow and activates the renin-angiotensin-aldosterone system. this leads to a vicious cycle of increased blood pressure and progressive kidney damage.57 ckd is principally caused by non-kidney diseases such as hypertension and diabetes mellitus, which are the leading contributors to ckd globally. hypertension is a significant risk factor for ckd due to its role in causing hypertensive nephropathy, which is a common etiology of ckd, as evidenced by studies showing its prevalence in non-diabetic ckd patients.58,59 diabetes mellitus, particularly diabetic nephropathy, is the most common cause of ckd worldwide, as it leads to progressive kidney damage through mechanisms such as hyperglycemiainduced glomerular damage.60,61 in addition to these, obesity and metabolic syndrome, often associated with diabetes, contribute to early signs of kidney disease, further exacerbating the risk of ckd.62 however, ckd can also arise from kidney-related conditions such as glomerulonephritis and chronic tubulointerstitial nephritis, which are prevalent in non-diabetic kidney disease (ndkd) cases. for instance, studies have identified membranous glomerulopathy and focal segmental glomerulosclerosis as common histological lesions in ndkd. environmental factors, such as exposure to insecticides and self-medication with nsaids, have also been linked to ckd in populations without traditional risk factors like diabetes and hypertension.63 furthermore, in certain regions, ckd of unknown etiology, often linked to environmental toxins and recurrent dehydration, has been observed, highlighting the complex interplay of various factors in ckd pathogenesis.62 thus, while hypertension and diabetes are primary drivers of ckd, a spectrum of other kidney-related and environmental factors also contribute significantly to its development. ckd is predominantly induced by extrarenal conditions such as hypertension and diabetes mellitus, which have considerable systemic impacts on the body, including the renal system. hypertension, a primary contributor to ckd, exerts excessive pressure on the kidneys’ fragile blood arteries, compromising their capacity to filter waste and maintain fluid equilibrium. as renal function deteriorates, hypertension frequently exacerbates, establishing a detrimental cycle that accelerates the onset of ckd. diabetes mellitus, conversely, impairs the kidneys via diabetic nephropathy, resulting in elevated pressure inside the glomeruli, hypertrophy of the glomerular basement membrane, and subsequent fibrosis. the increasing incidence of type 2 diabetes has greatly augmented its role in chronic kidney disease ckd, rendering it the predominant cause of ckd globally. non-renal disorders such as hypertension and diabetes are widespread, inflicting renal damage over years prior to the manifestation of symptoms, complicating early intervention. they also induce extensive vascular damage, affecting various organs and thereby exacerbating renal results. kidney-specific disorders, including glomerulonephritis, polycystic kidney disease, and renal infections, are few; however, they can be identified early due to symptomatic presentation. risk factors include obesity, poor dietary habits, and limited access to preventative healthcare, which elevate the probability of hypertension and diabetes, thus indirectly increasing the prevalence of chronic kidney disease. addressing these systemic concerns is essential for diminishing global cases of ckd. risk of hepatitis c in ckd patients patients undergoing hd are at increased risk of hepatitis c virus (hcv) infection due to frequent exposure to contaminated blood products and equipment.1 the study showed that 62.8% of patients underwent hd for 1-2 years, 25.6% for 3-4 years, and 11.6% for 5-6 years. prolonged hd is a significant risk factor for hcv transmission, especially in low-resource settings where dialyzers are often reused to minimize costs (table 4).64,65 extended exposure to dialysis treatments heightens the risk of contact with infected blood or contaminated instruments, as hcv is transferred via blood. commonly utilized devices, such as blood pressure cuffs and waste disposal zones, may serve as fomites, collecting pathogens through repeated exposure over time. frequent blood access heightens the danger of inadvertent contamination or article table 3. etiology. etiology n (43) % non-kidney disease 30 69.8 hypertensive (ht) 23 53.5 diabetes mellitus (dm) 2 4.7 ht and dm 5 11.6 kidney disease 13 30.2 total 43 100 table 4. length of hemodialysis treatment. length of hd (years) patients with negative hepatitis n (43) % 1-2 27 62.8 3-4 11 25.6 5-6 5 11.6 total 43 100 [healthcare in low-resource settings 2025;13:13255] [page 95] infection due to violations of aseptic protocols. transmission between patients happens in dialysis centers with inadequate infection management, especially in environments characterized by overcrowding or limited resources. immunosuppression in patients with pre-existing renal failure or related diseases increases their vulnerability to infections, including hcv. insufficient screening for hcv in dialysis patients or donors may result in undiagnosed instances, hence elevating the cumulative risk. patients who eradicate an hcv infection may nevertheless be susceptible to reinfection due to ongoing exposure in the dialysis setting. the increased risk of hcv infection with prolonged hemodialysis duration is attributed to several factors inherent to the hd environment and patient management. hemodialysis patients are particularly vulnerable to hcv due to the invasive nature of the procedure, which often involves repeated vascular access and potential exposure to contaminated equipment or blood products. the longer a patient remains on hd, the greater the cumulative exposure to these risk factors, thereby increasing the likelihood of hcv transmission.66,67 studies have shown that the prevalence of hcv infection is significantly higher among patients undergoing chronic dialysis, with rates as high as 58.9% in some cohorts, compared to much lower rates in the general population.67 this elevated risk is compounded by the frequent need for blood transfusions in hd patients, which, despite screening improvements, still pose a risk for hcv transmission, especially in settings where screening protocols may not be as stringent.68 additionally, the use of dialysis catheters, as opposed to arteriovenous fistulas, has been associated with a higher seroconversion rate to hcv positivity, suggesting that the type of vascular access may influence infection risk.69 nosocomial transmission within dialysis units is also a concern, as inadequate infection control practices can facilitate the spread of hcv among patients.68 furthermore, the immune-compromised status of end-stage kidney disease patients, who are often older and have multiple comorbidities, may exacerbate their susceptibility to infections, including hcv.66 therefore, the combination of prolonged exposure to potential sources of infection, the need for frequent medical interventions, and the inherent vulnerabilities of the patient population contribute to the increased risk of hcv infection with longer hd duration. the correlation between hcv infection rates in hemodialysis patients and the practice of dialyzer reuse is essential for comprehending risk management measures within healthcare systems, particularly in indonesia. the hcv-negative rates among hd patients reflect the efficacy of infection control measures in dialysis units, demonstrating a higher prevalence in facilities with stringent infection control methods and no dialyzer reuse. the reuse of dialyzers has traditionally been linked to a heightened risk of hcv infection, especially in resource-constrained environments where rigorous sterilization processes may not be consistently implemented. the hospital (research location) has enacted regulations banning the reuse of dialyzers to mitigate the danger of hcv and other blood-borne infections in hemodialysis patients. these laws mandate the use of a new, sterile dialyzer for each patient during every session, thereby mitigating the hazards associated with insufficient sterilization. to mitigate hcv transmission, strict infection control measures, routine screening, and education are essential. in indonesia, dialyzer reuse was common until april 2023, when single-use dialyzers were introduced. previously, dialyzers were manually sterilized with renalin, increasing the risk of cross-contamination.70-72 conclusions a multifaceted approach, including adherence to universal precautions and effective treatment strategies, is necessary to address this public health concern. to reduce the risk of hepatitis c virus infection among hemodialysis patients in low-resource settings, a multifaceted approach is needed. this includes strict adherence to universal precautions, rigorous hygiene protocols, staff training, routine screening, 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2018. 71. upadhyay a. dialyzer reuse: is it safe and worth it? j bras nefrol 2019;41:312–4. 72. prasad n, jha v. hemodialysis in asia. kidney dis 2015;1:165–77. article [page 98] [healthcare in low-resource settings 2025;13:13255] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13059 interventions for early marriage in lowand middle-income nations: a systematic review yulia yunara,1 andi safutra suraya,2,3,4 neisya pratiwindya sudarsiwi,2 hayatus sa’adah ayu lestari,1 ananda patuh padaallah,5 dina istiana,6 fitri kurnia rahayu3,7 1school of nursing, faculty of medicine and health sciences, universitas lambung mangkurat; 2faculty of nursing, universitas airlangga; 3research center in advancing community healthcare (reach), surabaya; 4faculty of health sciences, universitas muhammadiyah gorontalo; 5faculty of health sciences, universitas medika suherman; 6stikes rajekwesi bojonegoro; 7faculty of public health, universitas airlangga, surabaya, indonesia abstract early marriages result in the emergence of a harmful intergenerational cycle. various policies and programs have been implemented to address the issue of early marriage at both global and local levels. however, early marriages continue to occur worldwide. the purpose of this systematic review was to analyze interventions in early marriage in an effort to offer different interventions. this systematic review used mesh-based keywords from scopus, sciencedirect, web of sciences, and pubmed databases. the prisma and the jbi checklists were used as guidelines. data searches were conducted using scopus, sciencedirect, web of sciences, and pubmed databases for articles published in the last five years. fifteen articles mentioned interventions to delay early marriage, such as cash transfers, community-identified programs, mentorship initiatives, youth clubs, youth information centers, and interventions targeting married adolescents. to effectively delay early marriage and improve adolescent well-being, multilevel interventions targeting economic, social, psychological, and health-related factors are needed. future programs should integrate economic support with educational and srh services, ensure sustained engagement with communities and families, and include long-term evaluations to assess the impact over time. introduction an intergenerational cycle of disadvantage is created by early marriage, which is a violation of human rights and has numerous effects on children or adolescents who marry young people as well as on their future children.1 any marriage that is consummated before the age of 18 is considered early marriage.2 adolescents are not psychologically or physically mature enough to handle the duties of marriage, pregnancy, delivery, and raising children before the age of 18. they have also not been able to accept responsibility for their sexual behavior.3 one of the sustainable development goals (sdgs) indicators for gender equality, indicator point 5, states that by 2030, “ensure the elimination of all harmful practices, such as child marriage, early marriage, forced marriage, and female circumcision.” early marriage is one of the targets in this indicator.4 globally, 29% of young women are married before 18 years of age.5 around 1.2 million women in indonesia marry before the age of 18, according to the prevalence of early marriage, while 61.3 thousand women marry before the age of 15. according to these statistics, in indonesia, one in nine women between the ages of 20 and 24 was married before turning 18 years old.6 typically, early marriage is seen as a barrier to possibilities in education, the economy, and society, due to poverty and gender imbalance.7 the prevalence of early marriages is highly correlated with societal culture and values. early marriage is more likely to result from the effects of poverty, violence, and a lack of community structure.8 due to social standards, including the expectation that adolescents should be protected, parents believe that marrying off their children at a young age can protect them from sexual violence, unintended pregnancies, and sexually transmitted diseases.1 early marriage is affected by economic variables, including poor family income and unemployment.9 early marriage is indicated by a lack of sexual education regarding topics such as contraception, pregnancy, childbirth, and access to sexual health care.8 in addicorrespondence: andi safutra suraya, faculty of nursing, universitas airlangga, indonesia. e-mail: andisuraya90@gmail.com key words: adolescent; early marriage; interventions; low-and middleincome nations. contributions: yy, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ass, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; nps, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; hsal, resources, investigation, formal analysis, and writing –review & editing; app, resources, supervision, and writing – review & editing; di, resources, investigation, and writing –review & editing; fkr, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflicts of interest. ethical approval and consent to participate: not applicbale. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 9 september 2024. accepted: 20 march 2025. early view: 18 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13059 doi:10.4081/hls.2025.13059 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 18] [healthcare in low-resource settings 2025;13(s2):13950] tion, early marriage is influenced by premarital sexual activity and unintended pregnancies.10,11 therefore, it is important to have accurate information on and perceptions of early marriage among adolescents.12 early marriage can lead to a wide range of issues that affect not only the individuals involved but also the health of families and society as a whole.13 early marriage can result in poor health, high infant mortality rates, and severe household poverty.1 a significant issue is how early marriage affects health. early marriage contributes to infant mortality, stunting, and low birth weights. early marriage has an impact on the loss of a teenager’s mobility, unpreparedness for household roles, premature sex, unpreparedness to give birth to children, and domestic violence that ends in divorce. in recent decades, several policies, strategies, and programs have been explored to address the issue of early marriage at the global, regional, and local levels. however, early marriage is still prevalent throughout the world.2 several studies have been conducted with a focused on interventions to deal with early marriages and their implications. this systematic review aimed to analyze interventions in early marriage to offer different approaches to problems. materials and methods study design this study was a systematic literature review conducted to address this research question. this research was carried out systematically following the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines, focusing on qualitative synthesis without performing a meta-analysis of quantitative data (figure 1). search strategy we searched for secondary data sources in the form of reputable journal articles in four databases: scopus, sciencedirect, web of sciences, and pubmed. key words used medical subject headings (mesh) terms such as ((adolescent) or (teenager) and (early marriage) or (child marriage)) and (intervention) or (methods)). eligibility criteria this systematic review included original research articles published in english between 2018 and 2024 that focused on interventions designed to address early marriage in lowand middleincome nations, as defined by the world bank at the time of data collection. we used the population, intervention, comparison, outcome, and study design (picos) framework to guide our inclusion criteria. specifically, the population of interest was adolescents affected by early marriage. the included interventions aimed at preventing, delaying, or mitigating the negative consequences of early marriage, encompassing a range of approaches such as educational programs, economic empowerment initiatives, legal reforms, and community-based interventions. while a comparison group wasn’t a strict requirement, studies had to present outcomes demonstrating the effects of early marriage or the intervention’s impact. studies solely focused on descriptive epidemiology or conducted in high-income nations were excluded (table 1). study selection article selection was examined for keyword suitability, abstract, full text, study type, and article duplication. 5.583 studies were obtained from the databases during the initial search. duplicates were removed. screening of titles and abstracts was then performed to evaluate how well the article content matched the keywords in the research topic. these articles were considered relevant for review if they met the inclusion criteria. risk of bias all search results were organized in mendeley desktop and reviewed to determine whether they met the inclusion criteria. results that were identical or irrelevant to the research articles were excluded. the assessment of article quality and risk of bias was conducted independently by researchers using the joanna briggs institute (jbi) critical appraisal tools provided in table 2.14-26 pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13950] [page 19] figure 1. the prisma flow diagram data extraction full-text articles were then read, organized, and explored based on author name, year of publication, country, sample size, age, qa score, type of intervention, and duration (supplementary materials, table 1). results based on a search using keywords across four databases (scopus, science direct, web of science, and pubmed, 5.583 articles were found. after screening, 1.731 open-access articles were identified. duplicate articles were removed, resulting in a total of 848 articles based on relevant titles. after further selection based on abstracts, 161 articles were selected. these articles were then matched against the picos criteria, and 15 met the desired criteria. based on the results of the critical appraisal using the jbi instrument, 15 selected articles achieved a cumulative score above 50%, indicating the quality and suitability of the articles included in this review. based on the systematic review, the reviewed articles had the following research characteristics: cross-sectional study (n=1), quasi-experimental study (n=3), qualitative study (n=5), and randomized controlled trial (rct) (n=6). this systematic review originated from studies conducted in various countries worldwide, and the total number of samples in the systematic review was 2.591. the geographical distribution of the studies was multi-regional, with nine articles from africa, four from south asia, and two from the middle east. the respondents in these studies were adolescents aged 10-24 years. discussion this review identifies various interventions aimed at delaying early marriage and improving adolescent well-being, including cash transfers, community engagement programs, mentorship initiatives, youth clubs, youth information centers, and interventions targeting married adolescents. while these interventions demonstrate positive outcomes, their effectiveness varies based on the sociocultural and economic contexts. economic interventions, such as cash transfers and school fee support, have proven effective in enhancing school attendance, delaying marriage, and reducing early pregnancies by reducing girls’ financial dependence on men.14,15,16 in a study by malhotra et al. (2021), economic interventions, particularly cash transfers, had a significant impact on reducing child marriage rates or increasing the age at marriage.17 these findings align with economic empowerment theories, which suggest that increasing financial autonomy strengthens women’s agency and decision-making power.18 however, these programs alone may not challenge the deeply rooted gender norms that perpetuate early marriage. community-based programs, including forums and safe spaces for girls, parental education, and boys’ sports groups have addressed the structural and social norms surrounding early marriage.19,16 initiatives such as agep and ghd have demonstrated shifts in gender attitudes, increased family support for girls’ education, and reduced early marriages and pregnancies.20,21 these find pathways of change, part ii table 1. picos framework. picos framework inclusion criteria exclusion criteria population adolescent not adolescent intervention consisted of early marriage not relevant to intervention of early marriage comparation no comparison outcome showing the intervention of early marriage not showing the intervention of early marriage study design original research articles review articles table 2. critical appraisal results for included studies using the jbi critical appraisal checklist. author design q1 q2 q3 q4 q5 q6 q7 q8 q9 q10 q11 q12 q13 total category mehra et al. (2018)16 cross-sectional study y y y y y y y y n/a n/a n/a n/a n/a 8/8 (good) kohli et al. (2021)17 quasi-experimental y y y y y y y y y n/a n/a n/a n/a 9/9 (good) sieverding et al. (2022)18 quasi-experimental y y y y y y n y y n/a n/a n/a n/a 8/9 (good) huda et al. (2019)26 quasi-experimental y y y y y y y y y n/a n/a n/a n/a 9/9 (good) banda et al. (2019)15 qualitative y y y y y y y y y y n/a n/a n/a 10/10 (good) chirwa-kambole et al. (2020)21 qualitative y y y y y y y y y y n/a n/a n/a 10/10 (good) zulu et al. (2022)22 qualitative y y y y y y y y y y n/a n/a n/a 10/10 (good) milimo et al. (2021)23 qualitative y y y y y y y y y y n/a n/a n/a 10/10 (good) bankar et al. (2018)25 qualitative y y y y y y y y y y n/a n/a n/a 10/10 (good) prakash et al. (2019)14 rct y y y y y y n y y y y y y 12/13 (good) austrian et al. (2022)19 rct y y n y n y n y y y y y y 10/13 (good) zulaika et al. (2019)20 rct y y y n n y n y y y y y y 10/13 (good) austrian et al. (2020)24 rct y y y n n y n y y y y y y 10/13 (good) challa et al (2019)27 rct y y y y y y n y y y y y y 12/13 (good) gholami et al. (2021)28 rct y y y y y y n y y y y y y 12/13 (good) [page 20] [healthcare in low-resource settings 2025;13(s2):13950] ings support the social norms theory, emphasizing the role of collective community change in modifying behaviors and expectations.22 mentorship and youth empowerment interventions also contribute to positive long-term outcomes. programs incorporating life skills training, financial literacy, and reproductive health education enhanced girls’ decision-making, self-efficacy, and ability to negotiate gender roles.23,24 sport-based mentorship in particular fostered empowerment and reshaped household expectations.23 the effectiveness of these approaches aligns with bandura’s social cognitive theory, which highlights how observational learning and self-efficacy influence behavioral change.25 youth clubs and information centers provided peer education and interactive learning, increasing adolescents’ knowledge of sexual and reproductive health (srh) and reducing risky behaviors.26,27,28 interactive teaching methods, such as role-playing and group discussions, have proved to be more effective than traditional education, reinforcing the importance of participatory learning models. interventions targeting married adolescents, including married adolescent girl clubs, household visits, counseling, improved contraceptive use, delayed childbirth, and promoted gender-equitable decision-making within marriages.29,30 programs such as reaching married adolescents (rma) addressed social norms and increased the demand for modern contraceptive methods through community engagement and counseling.30 psychological interventions, such as functional emotional coping therapy (fect), further support married adolescents in navigating their sexual and reproductive health.31 these findings underscore the need for integrated interventions beyond economic and educational support to address the psychological and social dimensions of adolescent well-being. conclusions to effectively delay early marriage and improve adolescent well-being, multi-level interventions are needed targeting economic, social, psychological, and health-related factors. future programs should integrate economic support with educational and srh services, ensure sustained engagement with communities and families, and include long-term evaluations to assess the impact over time. strengthening the quality of family planning services and counseling is crucial for sustaining positive behavioral changes. references 1. de groot r, kuunyem my, palermo t, et al. child marriage and associated outcomes in northern ghana: a cross-sectional study. bmc public health 2018;18:285. 2. aychiluhm sb, tesema ak, tadesse aw. early marriage and its determinants among married reproductive age group women in amhara regional state, ethiopia: a multilevel analysis. biomed res int 2021;2021:18–21. 3. world health organization. who guidelines on preventing early pregnancy and poor reproductive outcomes. 2011; 4. united nations general assembly. global indicator framework for the sustainable development goals and targets of the 2030 agenda for sustainable development. work stat comm pertain to 2030 agenda sustain dev 2020;1–21. 5. unfpa, unicef. child marriage: a mapping of programmes and partners in twelve countries in east and southern africa. 2017;1–88. 6. badan pusat statistik. pencegahan perkawinan anak percepatan yang tidak bisa ditunda. badan pus stat. 2020;6– 10. 7. kohan s, allahverdizadeh s, farajzadegan z, ghojazadeh m, boroumandfar z. transition into the sexual and reproductive role: a qualitative exploration of iranian married adolescent girls’ needs and experiences. reprod health 2021;18:157. 8. elnakib s, hunersen k, metzler j, et al. child marriage among somali refugees in ethiopia: a cross sectional survey of adolescent girls and adult women. bmc public health 2021;21:1051. 9. fakhari a, allahverdipour h, esmaeili ed, et al. early marriage, stressful life events and risk of suicide and suicide attempt: a case–control study in iran. bmc psychiatry 2022;22:71. 10. septiarum r, suwarni l, alamsyah d. unwanted pregnancies and early marriage child aged 13-18 years. indian j public heal res dev 2019;10:1792–7. 11. unicef. early marriage: child spouses. innocenti digest 2001;(7). available from: https://www.girlsnotbrides.org/learning-resources/resourcecentre/early-marriage-child-spouses-unicef-innocenti-digest/ 12. ferdous z, zeba z. knowledge and perception of early marriage among adolescent girls in a selected community of rangpur district, bangladesh. am j public heal res 2019;7:9– 13. 13. unicef. leveraging large-scale sectoral programmes to prevent child marriage. unicef; 2022. available from: https://www.unicef.org/documents/leveraging-large-scale-sectoral-programmes-prevent-child-marriage-0 14. prakash r, beattie ts, javalkar p, et al. the samata intervention to increase secondary school completion and reduce child marriage among adolescent girls: results from a cluster-randomised control trial in india. j glob health 2019;9:10430. 15. banda e, svanemyr j, sandøy if, et al. acceptability of an economic support component to reduce early pregnancy and school dropout in zambia: a qualitative case study. glob health action 2019;12:1685808. 16. mehra d, sarkar a, sreenath p, et al. effectiveness of a community based intervention to delay early marriage, early pregnancy and improve school retention among adolescents in india. bmc public health 2018;18:732. 17. kohli a, shaw b, guntzberger m, et al. transforming social norms to improve girl-child health and well-being: a realist evaluation of the girls’ holistic development program in rural senegal. reprod health 2021;18:243. 18. sieverding m, bteddini d, mourtada r, et al. design and implementation of the amenah early marriage pilot intervention among syrian refugees in lebanon. glob heal sci pract 2022;10:e2100079. 19. austrian k, soler-hampejsek e, kangwana b, et al. impacts of multisectoral cash plus programs on marriage and fertility after 4 years in pastoralist kenya: a randomized trial. j adolesc heal off publ soc adolesc med 2022;70:885–94. 20. zulaika g, kwaro d, nyothach e, et al. menstrual cups and cash transfer to reduce sexual and reproductive harm and school dropout in adolescent schoolgirls: study protocol of a cluster-randomised controlled trial in western kenya. bmc public health 2019;19:1317. 21. chirwa-kambole e, svanemyr j, sandøy i, et al. acceptability of youth clubs focusing on comprehensive sexual and reproductive health education in rural zambian schools: a case of central province. bmc health serv res 2020;20:42. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13950] [page 21] 22. zulu iz, zulu jm, svanemyr j, et al. application of community dialogue approach to prevent adolescent pregnancy, early marriage and school dropout in zambia: a case study. reprod health 2022;19:30. 23. milimo j, zulu jm, svanemyr j, et al. economic support, education and sexual decision making among female adolescents in zambia: a qualitative study. bmc public health 2021;21:1360. 24. austrian k, soler-hampejsek e, behrman jr, et al. the impact of the adolescent girls empowerment program (agep) on short and long term social, economic, education and fertility outcomes: a cluster randomized controlled trial in zambia. bmc public health 2020;20:349. 25. bankar s, collumbien m, das m, et al. contesting restrictive mobility norms among female mentors implementing a sport based programme for young girls in a mumbai slum. bmc public health 2018;18:471. 26. huda fa, mahmood hr, ahmmed f, et al. the effect of a club in making differences in knowledge, attitude, and practices on family planning among married adolescent girls in urban slums in bangladesh. int j environ res public health 2019;16:40-37. 27. challa s, delong sm, carter n, et al. protocol for cluster randomized evaluation of reaching married adolescents a gender-synchronized intervention to increase modern contraceptive use among married adolescent girls and young women and their husbands in niger. reprod health 2019;16:180. 28. gholami m, ahmadi a, taebi m, et al. effectiveness of counseling based on functional analytic psychotherapy with enhanced cognitive therapy on the sexual quality of life of married adolescent women. rev bras ginecol e obstet rev da fed bras das soc ginecol e obstet 2021;43:513–21. 29. malhotra a, ph d, elnakib s, h mp. 20 years of the evidence base on what works to prevent child marriage : a systematic review. j adolesc heal 2021;68:847–62. 30. cislaghi b, heise l. theory and practice of social norms interventions: eight common pitfalls. global health 2018;14:83. 31. nabavi rt, bijandi ms. a literature review on bandura’s social learning theory & social cognitive learning theory. theory of developmental psychology. 2012. available from: https://scholar.google.com/scholar?oi=bibs&cluster=2564486 135348341917&btni=1&hl=en pathways of change, part ii [page 22] [healthcare in low-resource settings 2025;13(s2):13950] online supplementary materials table 1. summary of the articles. hrev_master healthcare in low-resource settings 2024; volume 12(s1):13040 [healthcare in low-resource settings 2024;12(s1):13040] [page 135] significance for public health nurses currently employed face the ongoing challenge of effectively making professional contributions to society. the degree of self-efficacy plays a pivotal role in determining nurses' belief in their capabilities, ultimately influencing the quality of their performance. programs that foster professional competency can play a significant role in bolstering nurses' perceived self-efficacy, thereby enhancing their confidence in establishing empathetic connections with patients, resulting in heightened patient contentment. from a public health perspective, heightened self-efficacy among wound care nurses equips them with the confidence to establish independent practices and offer home care. this enables individuals, especially those with chronic wounds, to access specialized wound care services. what factors influence clinical nurses' self efficacy after wound care training? a scoping review rosdiana saniapon, kuswantoro rusca putra, dina dewi sartika lestari ismail, retno lestari department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract the inadequate management of wounds carries significant implications for patients and challenges clinical nurses. consequently, there is a need for wound care training to enhance self-efficacy. however, despite participation in such training, nurses often need more practical experience and educational background to exhibit higher confidence levels. this results in a deficiency in self-efficacy when performing wound care. this study aims to amalgamate literature discussing the determinants influencing self-efficacy and present strategies for clinical nurses to enhance it after wound care training. the article search utilized the prisma method, with searches conducted in google scholar, proquest, science direct, and pubmed databases. sixteen articles met the specified inclusion criteria, which required english-language articles published within the last five years (2018-2023) discussing factors affecting clinical nurse self-efficacy after wound training. various factors, including competence, social support, and self-motivation, influence wound nurses’ self-efficacy. competence factors encompass structured training and education, while social support involves sharing experiences and engaging in case reflection. additionally, motivational factors play a significant role, such as reinforcing values and attitudes when facing obstacles and maintaining the belief that nurses can effectively adhere to wound care standards. enhancing self-efficacy includes improving competencies through standardized wound training, increasing educational opportunities, self-experience, social persuasion support, sharing experiences, high self-motivation, and managing emotions when assessing one’s ability to achieve goals successfully. professional development programs designed to provide structured training for nurses have enhanced their competencies, social support, and motivation, strengthening holistic wound care clinical skills and improving self-efficacy. therefore, exploring additional factors that may further contribute to this positive outcome is advisable. introduction in recent years, there has been a notable increase in the number of patients seeking care from home and public healthcare units, many of whom present with chronic and challenging-totreat wounds.1 these chronic wounds necessitate specialized attention from nurses, as they have substantial implications for healthcare services and the affected patients, leading to increased care costs and directly impacting the patient’s quality of life.2 social isolation, feelings of burden on family and relatives, persistent pain, infection, and resistance to antibiotics are additional significant effects associated with chronic wounds.3 the persistent presence of chronic wounds is increasingly acknowledged as a significant issue in the healthcare sector, exerting a substantial impact on global morbidity and mortality reminiscent of an “unrecognized epidemic.” the escalating prevalence of chronic wounds imposes a considerable burden on patients, healthcare providers, and the entire healthcare system. this affects the quality of life and influences resource allocation and healthcare expenditures.4 in europe, chronic wounds primarily affect the lower extremities in approximately 1.51% of the population and 2.21% of patients with mixed aetiology.5 within italy, an estimated 24% of the population, approximately two million people, are affected by chronic wounds, mainly due to factors related to ageing and lifestyle-related comorbidities such as diabetes, obesity, hypertension, and peripheral vascular disease.3 to address this issue effectively, the healthcare team must comprehensively understand the elements that define chronic wounds, the management of wound drainage, and the assessment of wounds while providing wound care.2,6 wound care is a specialized clinical area that demands multidisciplinary teamwork, with nurses playing a pivotal role.5 nursing professionals are responsible for contributing to society and are expected to maintain their professional capabilities in providing direct care.7 hence, it is imperative to conduct education and training programs to enhance nurses’ knowledge, attitudes, and skills, particularly regarding wound healing and care.8 in a prior study, it was shown that the training of community nurses in wound care led to significant improvements in their knowledge and practice (p<0.001). in addition to this, utilizing the time framework effectively provided wound care education, ultimately resulting in notable enhancements in wound care practice.9 inadequate wound care represents a significant challenge for clinical nurses and has substantial implications for patient outcomes. addressing this challenge necessitates specialized wound care training to enhance nurses’ self-efficacy. however, despite non -co mmerc ial us e o nly participating in training programs, nurses often need more confidence due to insufficient experience and education, resulting in reduced self-efficacy in the provision of wound care. bandura (1997) contends that self-efficacy is a cognitive process involving decisions, beliefs, and expectations about individuals’ perceived ability to execute specific tasks or actions necessary to achieve desired outcomes.10 nurses’ self-efficacy denotes their faith in their ability to effectively undertake particular nursing care activities. augmenting nurses’ knowledge and experience in wound care represents a practical approach to enhancing competence, confidence, and service quality. by affording nurses opportunities to strengthen and refine their knowledge through training, self-efficacy can be bolstered, thereby amplifying the nurse’s role in delivering comprehensive patient care. the level of self-efficacy significantly influences nurses’ confidence in their abilities, which determines their performance quality. professional competency development programs can aid in elevating nurses’ perceived self-efficacy, fostering confidence in developing empathetic patient relationships and ultimately enhancing patient satisfaction. competency development programs, such as wound care training initiatives, are crucial. they empower nurses to gain a deeper understanding of wound conditions and improve their capacity to select appropriate treatment modalities and equipment for managing complex wounds, consequently elevating nurses’ confidence. more literature on strategies to enhance self-efficacy following standardized wound care training programs is needed. therefore, synthesizing articles that address the factors influencing self-efficacy and strategies utilized by clinical nurses to enhance self-efficacy post-wound care training is imperative.11,12 materials and methods the research design employed in this study involves analyzing 16 articles. these articles were sourced from various scholarly databases, including google scholar (n=13500), proquest (n=1154), science direct (n=676), and pubmed (n=1681). the search for articles was conducted using the prisma method, following predefined criteria for inclusion and exclusion. to maintain the highest level of methodological integrity, the article search process strictly adhered to the prisma method (figure 1), which involved a meticulous and thorough search process. the inclusion criteria were predefined and encompassed several specific parameters. these parameters included the requirement for articles to be in the english language, address factors influencing nurse self-efficacy in clinical practice following wound care training, and have been published within the last five years (2018-2023). conversely, exclusion criteria were carefully established to ensure the selection of relevant and accessible articles. these criteria encompassed the exclusion of paid articles, articles without full-text accessibility in book or module formats, articles in the form of undergraduate theses, master’s theses, dissertations, and scientific papers, as well as articles not in english. the articles that satisfied the criteria were deemed to have met the specified requirements. supplementary materials table 1 shows the summary of articles. results and discussions the provision of wound care is integral to upholding patients’ health and overall well-being, constituting a fundamental aspect of nursing practice. various studies have underscored nurses’ need to augment their expertise in this specialized care. this imperative often stems from the need for more clearly defined and standardized competency frameworks among nurses, particularly in consistent and efficient wound care administration.13 the proficiency of wound care nurses is influenced by various factors that can impact their self-efficacy. one significant factor is the need for some nurses to develop confidence in wound care post-training, primarily due to limited experience and education. this can lead to a deficit in self-efficacy when performing wound care. a closely related factor is nursing students’ relatively insufficient wound care education, particularly in contemporary moist care techniques. nurses primarily acquire numerous skills based on empirical knowledge and experience throughout their clinical careers.2,8 one proven effective method for acquiring new skills and enhancing nurses’ performance is through training, leveraging previous nursing experience as the most influential source. it is crucial to consider the influence of nurses’ educational backgrounds on developing essential skills required for providing optimal wound care to patients. training programs facilitate a better understanding of wound status and enhance the nurses’ capacity to select appropriate medical methods and equipment for managing complex wounds, consequently bolstering their confidence levels.2 to this end, nurses must augment their nursing competencies by undergoing wound care training programs and implementing these learnings in their daily practice. the domain of competency in wound care is intrinsically linked to theoretical knowledge and practical training, reinforced by the nurses’ educational background.14 according to the study, nurses who received specific training in wound care demonstrated significantly higher proficiency in providing wound care than those who did not. the research findings indicate that a substantial number of nurses needed to gain the necessary knowledge and skills in wound care, with over 40% failing to offer comprehensive discharge planning related to wound 4th international nursing and health sciences symposium figure 1. flowchart of scoping review with selection process using pris-ma. [page 136] [healthcare in low-resource settings 2024;12(s1):13040] non -co mmerc ial us e o nly care education. this highlights the urgent requirement for wellstructured educational and training initiatives that prioritize advancing nurses’ proficiency in wound healing and care while emphasizing the enhancement of academic standards in this critical area of healthcare.15 this stands consistent with the research conducted by welsh (2018), which underscored the deficiency in applying wound care theory to practice owing to the absence of structured education. proficiency in wound care knowledge significantly influences wound healing and care practices, with wellinformed professionals more likely to adhere to recommended practices. consequently, it can be concluded from these two studies that trained nurses are more likely to possess up-to-date knowledge of wound care and can apply evidence-based practices obtained in wound care service settings. enhanced knowledge in the care of patients with wounds can bolster nurses’ practical competence and self-efficacy, while also fostering evidence-based wound care practices.16 competence, social support, and self-motivation significantly influence the self-efficacy of wound nurses. nurses who have received comprehensive training are more likely to exhibit high levels of self-efficacy.17 competence, rooted in a person’s interest and experience, is a behaviour-based characteristic influenced by motivation and attitude, thus directly impacting self-efficacy.7 training and simulation can enhance nurses’ competence and skills, increasing confidence and self-efficacy.12,18 allowing nurses to enhance their knowledge during exercise can improve self-efficacy and enhance their role in providing comprehensive nursing care to patients. remember, nurses’ motivation is the key to your success.19 moreover, social support from clinical nurse colleagues, reflection, sharing of experiences, and mentoring play a crucial role in enhancing nurses’ self-efficacy.13 furthermore, it is imperative to consider environmental and resource variables, as well as knowledge, skills, and the impact of social and spiritual factors when seeking to enhance nurses’ clinical practice.20 a systematic continuing education program, delivered through a blended learning approach, is essential for nurses caring for patients with wound problems, as it leads to better knowledge, clinical performance, and increased self-efficacy scores.21,22 developing clinical nurses’ self-efficacy in their practice is of utmost importance. this involves augmenting their knowledge and expertise in wound care, fostering confidence in their clinical skills, and establishing standardized fundamental and advanced competencies. additionally, it requires comprehensive wound nursing education and drawing on successful experiences from others to bolster self-efficacy.23,24 providing enhanced social support and encouragement for independent wound care performance is crucial. equally important is the need for nurses to prioritize maintaining positive emotional and physical well-being, as it is a pivotal factor in achieving their objectives.25-28 conclusions nurses who have received training are more likely to possess knowledge regarding wound care and the capability to apply evidence-based practices within wound care services. this heightened expertise in tending to patients with wounds enhances nurse competence and boosts nurse self-efficacy when accompanied by adequate knowledge and competence. moreover, structured training assists nurses in improving their competence, nurturing social support capabilities, and igniting motivation to provide comprehensive wound care, enhancing nurses’ self-efficacy. therefore, exploring additional contributing factors to improve evidencebased wound care practices is recommended. references 1. al-masslawi d, fels s, lea r, currie lm. nurse-centred design: homecare nursing workarounds to fit resources and treat wounds. ds 87-3 proceedings of the 21st international conference on engineering design (iced 17) vol 3: product, services and systems design, vancouver, canada, 2125082017. 2017;181–90. 2. ielapi n, costa d, peluso a, et al. wound care self-efficacy assessment of italian registered nurses and wound care education in italian nursing education system: a cross-sectional study. nurs rep 2022;12:674-84. 3. lommi m, raffaele b, tolentino diaz my, et al. nursing outcomes in wound care management: a mixed method study. nurs open 2023;10:2249-63. 4. alzamani lmhi, marbun mry, purwanti me, et al. chronic ulcers: recognizing decubitus ulcers and diabetic ulcers. syntax fusion j 2022;2:272–86. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13040] [page 137] correspondence: kuswantoro rusca putra, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng eksklusif, kunci, kalisongo, dau, malang, postcode: 65151, east java, indonesia. tel.: +623415080686. e-mail: torro.fk@ub.ac.id key words: clinical nurses; self-efficacy; wound training contributions: the authors contributed equally to this research. conflict of interest: the author declares no potential conflicts of interest. funding: this study was financially supported by the ministry of health of the republic of indonesia. clinical trials: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and informed consent: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgement: we are grateful to the faculty of health sciences, universitas brawijaya malang, indonesia, for their support and encouragement. received: 5 november 2023. accepted: 13 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13040 doi:10.4081/hls.2024.13040 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly 5. martinengo l, olsson m, bajpai r, et al. prevalence of chronic wounds in the general population: systematic review and metaanalysis of observational studies. ann epidemiol 2019;29:815. 6. nagle sm, stevens ka, wilbraham sc. wound assessment. [updated 2023 jun 26]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk482198/ 7. fukada m. nursing competency: definition, structure and development. yonago acta med 2018;61:1-7. 8. sürme y, kartın pt, çürük gn. knowledge and practices of nurses regarding wound healing. j perianesth nurs 2018;33:471-478. 9. dowsett c. use of time to improve community nurses’ wound care knowledge and practice. wounds uk. 2009 sep 1;5. 10. bandura a. self-efficacy: toward a unifying theory of behavioral change. psychol rev 1977;84:191–215. 11. chuang st, lo sf, liao pl, et al. knowledge, attitude, perceived barriers of hard-to-healed wound care and the association with confidence: a cross-sectional study among community nurses. j tissue viability 2023;32:487-492. 12. ehmke s, swan m, van gelderen s, bourdeanu l. developing nursing students’ self-efficacy during simulated obstetric emergencies. sci talks 2023;5:100121. 13. kielo-viljamaa e, suhonen r, jalonen l, stolt m. areas of nursing competence in acute wound care: a focus group study. collegian 2022;29:44–53. 14. dung pt, trang lt, tung hh. nurses’ knowledge, practice, and confidence after the training program on wound care at the agriculture general hospital in vietnam. open j nurs 2020;10:646–56. 15. desta m, tenaw m, ayalew e. level of knowledge and wound care practice at a tertiary referral hospital in ethiopia: a survey in 180 nurses [internet]. 2020 [cited 2023 aug 9]. available from: https://www.researchsquare.com/article/rs-110089/v1. 16. welsh l. wound care evidence, knowledge and education amongst nurses: a semi-systematic literature review. int wound j 2018;15:53-61. 17. mohamed e, elmoniem ae, zaki h, shebl m. effect of training program on performance of nurses caring for patient with negative pressure wound therapy. iosr-jnhs 2024;8:31-5. 18. kielo e, suhonen r, ylönen m, et al. a systematic and psychometric review of tests measuring nurses’ wound care knowledge. internat wound j 2020;17:1209–24. 19. yu s, yao x, sang y, et al. status of core competencies of wound, ostomy and continence nurses and their influence on career success: a cross-sectional study. bmj open 2022;12:e063239. 20. gray ta, rhodes s, atkinson ra, et al. opportunities for better value wound care: a multiservice, cross-sectional survey of complex wounds and their care in a uk community population. bmj open 2018;8:e019440. 21. oh d, choi yj. clinical nurses' continuing education needs in acute burn care. j contin educ nurs 2022;53:77-82. 22. hong hs, issenberg sb, roh ys. effects of standardized patient-based training on surgical nurses’ competencies for managing hand injuries. j contin educ nurs 2020;51:189–96. 23. lopez-garrido g. self-efficacy: bandura’s theory of motivation in psychology [internet]. 2023 [cited 2023 aug 9]. available from: https://www.simplypsychology.org/self-efficacy.html. 24. obilor hn, omolara ab, ani ob. a survey of nurses’ wound assessment knowledge, attitude and competence in nigeria. wound practice res 2021;29:140-7. 25. gizaw ma, negawo mk, bala et, daba db. knowledge, practice, and associated factors towards postoperative wound care among nurses working in public hospitals in ethiopia: a multicenter cross-sectional study in low resource setting area. health sci rep 2022;5:e677. 26. tegegne b, yimam f, yalew zm, et al. knowledge and practice of wound care and associated factors among nurses working in south wollo zone government hospitals, ethiopia. chronic wound care manag res 2022; available from: https://www.tandfonline. com/doi/abs/10.2147/ cwcmr.s366322. 27. wilandika a. students, religiosity, and self-efficacy of hivrisk behavior: a study in a muslim perspective. ponorogo: uwais inspirasi indonesia; 2022. 28. chao w-y, wu y-l, liao w-c. psychometric properties of the taiwanese pressure ulcer management self-efficacy scale in nursing practice. healthcare 2022;1:1900. 4th international nursing and health sciences symposium [page 138] [healthcare in low-resource settings 2024;12(s1):13040] online supplementary materials table 1. summary of articles. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s1):13124 analysis of family roles in infant and child feeding based on sociocultural factors and family functions annif munjidah,1 elly dwi masita,1 hinda novianti,1 uke maharani dewi,1 norhaini majid,2 noraini hashim2 1universitas nahdlatul ulama surabaya, indonesia; 2universiti teknologi of mara, malaysia abstract the issue of complementary feeding in developing countries is often marked by poor food quality and quantity, leading to growth failure in children during this critical period. this problem is largely due to insufficient family involvement in managing infant and child feeding. this study examines the effects of sociocultural factors and family functions on family roles in feeding practices. the objective was to analyze how sociocultural factors and family functions influence infant and child feeding roles. this study used an observational analytical design with a cross-sectional approach. the population consisted of families with children under two years old in surabaya, sidoarjo, and gresik, indonesia, with data collection taking place from march to june 2024. from a population of 250, a sample of 120 participants was selected using a purposive sampling technique. questionnaires that had been validated for reliability and accuracy were used to measure sociocultural variables, family functions, and family roles. data analysis was performed using multiple linear regression tests. the findings revealed a significant effect of culture on family roles (p=0.026) and a significant effect of family functions on family roles (p=0.025). additionally, there was a significant combined effect of culture and family functions on family roles (p=0.000). these results indicate that sociocultural factors and family functions positively influence family roles in feeding practices. in essence, stronger cultural values and well-functioning family dynamics contribute to a more effective family role in feeding infants and children. this research highlights the importance of collaborative efforts to strengthen family values and foster positive family functions, which are essential for supporting optimal feeding practices and child growth. introduction malnutrition in early childhood can have serious implications for human resource quality in the future. this malnutrition is often due to infants and young children not receiving adequate nourishment, as they are not fed according to optimal feeding practices.1,2 indonesia’s ministry of health, following the global strategy for infant and young child feeding (iycf), recommends a «gold standard» feeding approach: early breastfeeding initiation, exclusive breastfeeding for the first six months, introducing nutritious complementary foods at six months, and continued breastfeeding until at least age two.1,3,4 improving children’s nutritional status remains a priority for health indicators in indonesia. while the 2022 nutrition survey showed a decrease in stunting rates by 2023, significant efforts are still needed to achieve the target of reducing stunting to 14% by 2024.5 on the other hand, the rates of wasting and underweight in children increased from 2022 to 2023. key factors influencing these nutritional challenges in children aged 0-23 months include feeding practices such as exclusive breastfeeding, the introduction of complementary foods, and susceptibility to infections.6 the practice of feeding infants and children begins with exclusive breastfeeding until six months and is followed by complementary feeding for children aged 6-23 months. a problem in complementary feeding in developing countries is the poor quality of foods, leading to growth failure during the complementary feeding period.7 according to the 2022 nutrition survey in indonesia, only 52.2% of mothers initiated breastfeeding within correspondence: annif munjidah, universitas nahdlatul ulama surabaya, indonesia. e-mail: annifmunjidah@unusa.ac.id key words: culture; family function; family role; infant; child; feeding. contributions: am, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; edm, conceptualization, investigation, methodology, validation, and writing – original draft; hn, nm, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; umd, nh, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the ethical committee of nursing and midwifery faculty, universitas nahdlatul ulama, indonesia, has certified that this research is ethical. the ethical certification number is 019/30/iii/ec/kep/lcbl/2024 march 30, 2024. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research received internal funding from the research and community service institute of nahdlatul ulama university surabaya and universiti teknologi of mara, malaysia. acknowledgments: we are thankful to lppm universitas nahdlatul ulama surabaya, indonesia, for funding this research and providing motivation and facilities for researchers so that it can be carried out smoothly. the authors would like to thank all respondents who were cooperative and assisted in this research process. received: 19 september 2024. accepted: 25 november 2024. early access: 13 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13124 doi:10.4081/hls.2024.13124 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 26] [healthcare in low-resource settings 2025;13(s1):13124] 24 hours of birth, while only 16.7% of children aged 6-11 months received exclusive breastfeeding. furthermore, 61.6% of these children were given formula milk, 41.7% of children over six months were introduced to complementary feeding, and 47.6% of those under six months received complementary foods. additionally, only 69.9% of children had access to animal protein, and just 23.1% of children aged 11-23 months had a diverse diet.6 these figures fall short of both indonesian and international guidelines for infant and young child feeding, as outlined by idai and the who.7,8 several factors influence maternal behavior in feeding practices, including knowledge, family income, awareness, cultural customs, family support, and healthcare access.2,9,10 research highlights that feeding practices,11 parenting style, and eating habits can significantly affect children’s eating behaviors and growth12. parents’ approaches to feeding, parenting style, eating habits, and feeding practices significantly impact children’s nutrition and growth, where poor parenting patterns may lead to malnutrition, stunting, and developmental delays.13-15 research shows that family involvement, particularly in providing complementary breast milk, affects children’s nutritional status, food preferences, and potential food aversions.15,16 from 2019 to 2023, studies focused on child nutrition and feeding practices, including tui na massage therapy to improve weight,17 feeding practices,18 complementary feeding acceptance methods,19 maternal literacy on breastfeeding,20 complementary food strategies,21 and family involvement.22 most existing studies, however, focus on mother-child dynamics alone, overlooking the broader role of family, culture, and customs in feeding practices, particularly in indonesia, where diverse cultural traditions shape feeding practices.16,23 as the husband or head of the family often influences feeding decisions, this study aims to address infant and child feeding issues by exploring sociocultural and family roles emphasizing family-centered care approaches for improved feeding practices. materials and methods study design this study used an analytical observational design with a cross-sectional approach, aiming to explain the influence of sociocultural factors and family functions on family roles. this design involved observing respondents at a single point in time without intervention. data on cultural values, family functions, and family roles were collected using a questionnaire for parents of young children. population and sample the study population included all mothers with children under the age of two in surabaya, gresik, and sidoarjo, indonesia, totaling 250 individuals. the participants were javanese, both muslim and non-muslim, aged 20-50 years. population data were obtained from village records, with no restrictions on demographic pool characteristics. a sample of 120 mothers was selected through purposive sampling. the instruments used to measure sociocultural factors and family functions were validated and tested for reliability. the study was conducted in surabaya, sidoarjo, and gresik, east java, indonesia, from march to june 2024. inclusion criteria were mothers willing to participate and having children without congenital disabilities or illnesses. variables the independent variables were sociocultural factors and family functions, while the dependent variable was the family role. instrument and data collection validated and reliability-tested questionnaires were used as instruments for assessing sociocultural factors and family functions. sociocultural factors were defined as family background values, behaviors, and taboos that could affect child feeding. family functions were defined as family roles in terms of economy, communication, education, protection, and religion in relation to child feeding. the family role was defined as the family’s role in educating, supervising, encouraging, and modeling positive behavior related to child feeding practices.24 the questionnaires used to assess sociocultural factors, family functions, and family roles underwent validity and reliability testing, with cronbach’s alpha values of 0.962 for the family function questionnaire and 0.975 for the family role questionnaire. these questionnaires, adapted from previous research, included 10 questions for sociocultural factors, 27 for family functions, and 12 for family roles. data collection was done directly after receiving ethical clearance. the research team coordinated with local village leaders, midwives, and child health cadres in surabaya, sidoarjo, and gresik. a field team of eight midwifery students from nahdlatul ulama university surabaya collected data with given tasks and daily food and transportation incentives. data analysis data were analyzed using bivariate analysis, with a t-test to assess the influence of individual variables and an f-test to assess the combined influence of the independent variables on the dependent variable. a significance level of p=0.05 was used. all data analyses were conducted using spss version 20. ethical clearance this research was approved by the ethical committee of the nursing and midwifery faculty, universitas nahdlatul ulama, indonesia, with ethical certification number 019/30/iii/ec/kep/ lcbl/2024, dated march 30, 2024. results the study’s findings, presented in table 1, show that most families had two children, while some families had three children living in the same household. special issue pathways of change table 1. characteristics of families based on the number of children and household members. n % the number of children 1 18 15 2 58 48.3 3 44 36.7 the number of household member 2 1 0.8 3 46 38.3 4 40 33.3 5 32 262.7 6 1 0.8 total 120 100 [healthcare in low-resource settings 2025;13(s1):13124] the study results in table 2, examining family characteristics based on the mother’s education level, indicate that the majority of mothers (84.2%) had completed senior high school. additionally, most of these mothers were not employed or were housewives, accounting for 69.2%. table 3 illustrates the distribution of family data based on sociocultural factors, family functions, and family roles. most families (55%) had a good level of sociocultural support, 75.8% demonstrated good family functions, and 62.5% displayed effective family roles. according to the partial t-test results, the sociocultural variable (x1) significantly affected family roles (y), with a p-value of 0.026, which is below the significance level (α=0.05). similarly, the family function variable (x2) had a significant effect on family roles (y), with a p-value of 0.025, also below the significance level. the f-test results further indicate that both sociocultural factors and family functions together significantly impact family roles in infant and child feeding for children under two years old. specifically, 72.7% of families with good sociocultural factors showed positive effects on family roles in feeding infants and children, while 64.8% of families with strong family functions positively influenced these roles. thus, families with good sociocultural support and well-functioning dynamics tend to enhance family roles in infant and child feeding. a cross-tabulation between sociocultural variables and family functions on family roles, along with analytical test results using t-test and f-test, is presented in table 4. discussion the first thousand days of human life, from conception through the age of two, are vital for a child’s development. during this period, optimal growth, development, and health heavily depend on adequate nutrition.25 to promote optimal growth, the world health organization (who) recommends four essential practices in its global strategy for infant and young child feeding: exclusive breastfeeding until six months, introducing complementary feeding at six months, continuing breastfeeding up to two years, and extending breastfeeding as desired beyond two years.26,27 family behaviors and roles in providing appropriate nutrition for infants and young children are influenced by numerous factors, including family health knowledge, sociocultural influences, environment, food availability, and information sources.28,29 cultural influences on public health involve shaping, regulating, and guiding individual behaviors within a community to meet health needs, which includes the nutritional status of children.30 our findings reveal that families with strong sociocultural support often have positive impacts on family roles in infant and child feeding (72.7%). this is consistent with research by natalia (2020),31 which found that culture accounts for 12.8% of influence in infant feeding practices, reflecting the significance of inherited societal beliefs and practices. positive feeding practices, guided by beneficial cultural habits, can lead to healthier outcomes, while adverse cultural practices may increase health risks, such as the incidence of diarrhea.32 bentley et al. (2022) found that decisions on what and how to feed children result from complex interactions between cultural beliefs, economic resources, and the child’s appetite, prompting caregivers to adapt to these varying factors33. special issue pathways of change table 4. cross tabulation between sociocultural factors and family functions on family roles. variable family roles total t-test f-test poor fair good f % f % f % f % socio-cultural 0.026 0.00 poor 3 75 0 0 1 25 4 100 fair 10 20 14 28 26 52 50 100 good 4 6.1 14 21.2 48 72.7 66 100 family functions 0.025 poor 3 75 1 25 0 0 4 100 fair 6 24 3 12 16 64 25 100 good 8 8.8 24 26.4 59 64.8 91 100 table 2. characteristics of families based on mother's education and occupation. n % mother’s education senior high school 89 84.2 diploma (d3) 1 0.8 bachelor (s1) 29 24.2 master (s2) 1 0.8 mother’s occupation lecturer 1 0.8 housewife 83 69.2 private employee 19 15.8 entrepreneur 17 14.2 total 120 100 table 3. distribution of family data based on sociocultural factors, family functions, and family roles. n % sociocultural factors poor 4 3.3 fair 50 41.7 good 66 55 family functions poor 4 3.3 fair 25 25 good 91 75.8 family roles poor 17 14.2 fair 28 23.3 good 75 62.5 total 120 100 [page 28] [healthcare in low-resource settings 2025;13(s1):13124] in addition to sociocultural influences, family functions significantly affect family roles in infant and child feeding. the family unit serves as the closest support group, meeting its members’ basic needs, particularly in health-related areas.34 families bear the responsibility of monitoring and addressing infants’ health needs.35 friedman identifies five key family functions: affective, socialization, reproductive, economic, and health care and maintenance.36 our study found that families with strong functional support systems positively impact family roles in child nutrition (64.8%). this finding aligns with research by estingtias et al. (2023), which highlights the importance of family roles in complementary feeding practices, necessitating an understanding of parents’ views on their childcare responsibilities.37,38 our study also examined family characteristics, finding that most mothers (84.2%) had completed senior high school. educational attainment affects mothers’ perceptions of family roles and approaches to child nutrition, equipping them with skills to seek information and resources to support child health.39,40 education influences the ease with which mothers access information on childcare, nutrition, and health maintenance.41 additionally, employment status can influence family roles in feeding practices; our study showed that the majority of mothers (69.2%) were not employed, allowing them more time and energy to focus on appropriate feeding for infants and young children. non-working mothers are often more able to cater to their children’s nutritional needs in alignment with their age and health requirements. the linear regression analysis in this study indicates that sociocultural factors and family functions positively impact family roles in infant and child feeding. families with strong sociocultural support and functional capabilities are better positioned to provide appropriate nutrition. strong family roles are critical in supporting proper feeding practices, which directly contribute to the health and growth of infants and young children.28,42 conclusions sociocultural factors and family functions positively impact family roles, indicating that when a family has strong sociocultural support and well-functioning dynamics, its roles in infant and child feeding are more effective. ensuring that infants and young children receive high-quality nutrition is essential for supporting their growth and development and helping them achieve an optimal nutritional status for their age. to support this, it is recommended to implement a community-based family-strengthening program focused on reinforcing positive cultural values and enhancing parenting skills through counseling and educational activities for families. references 1. pelatihan m, konseling p, makan p, et al. modul pelatihan pelatih konseling pemberian makan bayi dan anak (pmba) kementerian kesehatan republik indonesia; 2022. 2. marah has em, efendi f, wahyuni sd, et al. women’s empowerment and sociodemographic characteristics as determinant of infant and young child feeding practice in indonesia. curr res nutr food sci 2022;10:607–19. 3. yunitasari e, al faisal ah, efendi f, et al. factors associated with complementary feeding practices among children aged 6– 23 months in indonesia. bmc pediatr 2022;22. 4. sebayang skksk, dibley mjjmj, astutik e, et al. determinants of age-appropriate breastfeeding, dietary diversity, and consumption of animal source foods among indonesian children. matern child nutr 2020;16. 5. ibad m, lutfiya i, herdiani n, et al. determinants of stunting events in indonesia using path analysis. a. s, r. u, m. s, f.g. p, editors. faculty of health, universitas nahdlatul ulama surabaya, surabaya, indonesia: american institute of physics inc.; 2023. 6. ssgi. hasil survei status gizi indonesia. kementeri kesehat republik indones 2023;77. 7. idai. rekomendasi praktik pemberian makan berbasis bukti pada bayi dan batita di indonesia untuk mencegah malnutrisi. ukk nutr dan penyakit metab ikat dr anak indones 2015. 8. world health organization. who guideline for complementary feeding of infants and young children 6–23 months of age; 2023. 95 p. 9. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j glob pharma technol 2020;12:815–25. 10. suhardjo. perencanaan pangan dan gizi. jakarta: bumi aksara; 2015. 11. georgieff mk, brunette ke, tran p v. early life nutrition and neural plasticity. dev psychopathol 2015;27:411–23. 12. shekar m, kakietek j, dayton eberwein j, walters d. an investment framework for nutrition: reaching the global targets for stunting, anemia, breastfeeding, and wasting. an invest framew nutr reach glob targets stunting, anemia, breastfeeding, wasting. world bank 2017;1–8. available from: https://hdl.handle.net/10986/26069 13. shloim n, edelson lr, martin n, hetherington mm. parenting styles, feeding styles, feeding practices, and weight status in 4-12 year-old children: a systematic review of the literature. front psychol 2015;6:1849. 14. idai. pendekatan diagnosis dan tata laksana masalah makan pada batita di indonesia. j penyakit dalam indones 2014;4:1–26. 15. benjasuwantep b, chaithirayanon s, eiamudomkan m. feeding problems in healthy young children: prevalence, related factors and feeding practices. pediatr rep 2013;5:38. 16. estingtias d, susanto t, nur krm. hubungan peran keluarga dengan praktek pemberian makanan pendamping asi pada bayi umur 6-24 bulan di kabupaten jember [correlation between family of roles and complementary breast feeding practices among children aged 6-24 months in jember]. penelit gizi dan makanan. j nutr food res 2019;42:57–64. 17. munjidah a, anggraini fd. the effects of tui na massage on the growth status of children under five years of age with kms t status (low weight gain). j public health africa 2019;10:127–30. 18. munjidah a, rahayu e. pengaruh penerapan feeding rules sebagai upaya mengatasi kesulitan makan pada anak (picky eater, selective eater dan small eater). j kesehat masy 2020;8:29–35. 19. munjidah a, handayani n. the effect of tummy time and oral massage on infants ’ oral motor skills as an effort to receive complementary food. bali med j 2023;12:3261–4. 20. munjidah a, putra ne, nahdlatul u, surabaya u. edukasi meningkatkan literasi ibu dalam. 2023;319–30. 21. munjidah a, rukmana ee, nisa f, et al. feeding complementary foods with complete menu correlated with babies weight. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13124] [page 29] jurnal ners dan kebidanan 2023;10:202-9. 22. munjidah a, masita ed, novianti h, dewi um. the efficacy of implementing family-centered care in child feeding practices. healthc low-resour settings 2024;12:11964. 23. tanner k, dempster r, castillo a, et al. randomized trial of a self-administered parenting intervention for selective eating in young children. eat behav 2022;46:101646. 24. friedman mm, bowden vr, jones eg. family nursing: research, theory, and practice. 5th ed. new jersey: pearson education inc.; 2003. 25. adi ac, diana r, devy sr, et al. the correlation between regulation understanding by inter-professional first 1000 days of life health workers and the acceleration of toddler stunting prevention. indian j public heal res dev 2019;10:911–6. 26. fransiska y, sugiatini te. hubungan tingkat pengetahuan ibu dan sosial budaya dengan pemberian makanan mp-asi dini pada bayi. j ilm permas j ilm stikes kendal 2024;14:1303– 10. 27. rachmah q, astina j, atmaka dr, khairani l. the effect of educational intervention based on theory of planned behavior approach on complementary feeding: a randomized controlled trial. int j pediatr (united kingdom) 2023;2023:1086919. 28. wiliyanarti pf, israfil, ruliati. peran keluarga dan pola makan balita stunting. j keperawatan muhammadiyah 2020;5:142– 7. 29. zhu h, zhao k, huang l, et al. individual, family and socialrelated factors of eating behavior among chinese children with overweight or obesity from the perspective of family system. front pediatr 2024;12:1305770. 30. fariqi mz al, yunika rp. pengaruh budaya dan pengetahuan ibu terhadap praktik pemberian makan pada bayi di wilayah kerja puskesmas narmada lombok barat. nutr j pangan, gizi, kesehatan 2021;2:77–81. 31. natalia o. hubungan pengetahuan, budaya, dan pekerjaan dengan pemberian makanan bayi usia 6-11 bulan di lombok tengah. j kesehat qamarul huda 2018;6:69–76. 32. ardhani s, perdani rrw, tjiptaningrum a. hubungan antara faktor pengetahuan ibu, sosial budaya dan informasi petugas kesehatan dalam praktik pemberian mp-asi dini dengan kejadian diare akut pada bayi. j medulla 2020;10:398–403. 33. pelto gh, levitt e, thairu l. improving feeding practices: current patterns, common constraints, and the design of interventions. food nutr bull 2003;24:45–82. 34. surani e, susilowati e. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. j ners 2020;15:26–30. 35. yanti nlgp, laksmi igaps. hubungan fungsi perawatan kesehatan keluarga dengan pemberian mp-asi pada balita usia 6-12 bulan. j ilmu keperawatan anak 2021;4:19–26. 36. rahmah s. peran keluarga dalam pendidikan akhlak. alhiwar j ilmu dan tek dakwah 2016;04:13–23. 37. hernández gutiérrez mf, díaz-gómez nm, jiménez sosa a, et al. effectiveness of 2 interventions for independent oral feeding in preterms. an pediatría (english edition) 2022;96:97–105. 38. hill c, kna ka, santacroce sj. journal of pediatric nursing family-centered care from the perspective of parents of children cared for in a pediatric intensive care unit : an integrative review. j pediatr nurs 2017;10–2. 39. rosita ad. hubungan pemberian mp-asi dan tingkat pendidikan terhadap kejadian stunting pada balita: literature review. j penelit perawat prof 2021;3:407–12. 40. amaliyah e, mulyati m. effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting: a quasi-experimental design. j nurs 2020;15:173– 7. 41. arifin y, syofiah pn, hesti n. hubungan karakteristik ibu dan dukungan keluarga dengan pemberian mp-asi pada balita. hum care j 2020;5:836. 42. pujiastuti n, santoso b, devi sr, et al. family empowerment with the case model on the role of the family and exclusive breastfeeding behavior. indian j public heal res dev 2019;10:994–8. special issue pathways of change [page 30] [healthcare in low-resource settings 2025;13(s1):13124] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13144 the effect of the aksi bergizi program on hemoglobin levels in adolescent girls at a junior high school sumiati sumiati, viky indra yanti departement of nursing, institut teknologi kesehatan dan sains (itkes) wiyata husada samarinda, indonesia abstract the nutritional action initiative, launched by unicef indonesia, addresses low compliance with iron supplement consumption among adolescent girls and the high prevalence of anemia. this program was first implemented in klaten and west lombok districts in 2018 and expanded nationwide in 2022-2023. the purpose of this quantitative study is to evaluate nutritional action’s impact on hemoglobin levels in seventh-grade girls at junior high school using a pre-experimental, one-group pretestposttest design. a stratified random sampling technique was applied, resulting in 44 respondents meeting the inclusion criteria of seventh-grade girls aged 12-14 years. data analysis included univariate and bivariate analyses, with the wilcoxon test used for significance testing. among the participants, 37 (84%) experienced an increase in hemoglobin levels, while 7 (16%) showed no change in levels before and after the intervention. the analysis yielded a p-value of 0.0001, indicating a significant effect of nutritional action on the hemoglobin levels of seventh-grade girls at junior high school. introduction adolescents currently account for more than one-fifth of indonesia’s population, providing a significant potential for national productivity. addressing adolescent nutrition issues is crucial to achieving the sustainable development goals (sdgs).1 according to the world health organization (who), a nutritional problem becomes a major public health concern when the prevalence is between 30-39%, and it is severe if it exceeds 40%. in indonesia, 23% of adolescents are affected by anemia. globally, anemia cases have increased from 1.42 billion in 1990 to 1.74 billion in 2019, with a prevalence rate of 29.9% among non-pregnant women of reproductive age (15-49 years).1-4 who estimates that approximately 30% of adolescent girls worldwide are anemic, with the highest rates in south asia and sub-saharan africa.5,6 anemia can significantly impact physical, cognitive, and emotional development in adolescent girls.7,8 physically, it can lead to fatigue, lethargy, and shortness of breath, affecting academic performance and daily activities. it can also worsen menstrual symptoms such as cramps, headaches, and mood swings, further impacting quality of life.9 additionally, anemia increases the risk of future pregnancy complications, such as preterm birth and low birth weight.10 cognitive functions like attention, memory, and learning can also be impaired by anemia, potentially affecting academic achievement and long-term earning potential.11 socially and emotionally, anemia has been linked to anxiety, depression, and reduced self-esteem, which may exacerbate socioeconomic challenges and hinder their potential.12,13 according to the 2018 indonesian basic health research (riskesdas) data, anemia affects 32% of adolescents aged 15-24 and 26.8% of those aged 5-14, indicating that roughly three in ten indonesian children suffer from anemia.14 compliance with iron supplement tablets among adolescent girls and pregnant women remains low;15,16 only 1.4% of young women take more than 52 iron supplement tablets as recommended, while 98.6% take fewer than this.14 data from the north penajam paser regency as of december 2023 revealed that 478 female students, or 20% of the total, had anemia. of the 267 female students tested at the petung community health center, 149 were found to be anemic. additionally, november 2023 data indicated that 1,034 toddlers in the region were classified as “very short” or “short,” with 32 cases reported at the petung community health center. this data was collected through indonesia’s electronic community-based nutrition recording and reporting (e-ppbgm) application before its discontinuation in 2023. research indicates that anemia in adolescent girls is often influenced by factors such as physical activity, menstrual patterns, correspondence: sumiati sumiati, departement of nursing, institut teknologi kesehatan dan sains (itkes) wiyata husada samarinda, indonesia. e-mail: sumiati@itkeswhs.ac.id key words: anemia; early adolescent girls; hemoglobin levels; iron supplement tablets; nutritional status. contributions: ss, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing; viy, methodology, visualization, writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, based on ethical certificate dp.04.03/f.xlii.25/0453/2024. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank adolescent girls in grade vii smpn 5 penajam city for permission to conduct this research. received: 18 november 2024. accepted: 12 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13144 doi:10.4081/hls.2024.13144 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publish[healthcare in low-resource settings 2025;13(s1):13144] [page 15] socioeconomic status, nutritional awareness, and dietary habits.4 key factors include breakfast habits, menstrual status, history of infectious diseases, iron and protein intake, vitamin c intake, and maternal education level. however, a study conducted at a senior high school (sman 9 mataram) found no significant association between anemia and attitude.17 a separate study in klaten examined the impact of adherence to the united nations children’s fund (unicef) nutritional action program, focusing on iron supplement tablets intake and nutritious breakfast, on hemoglobin levels among adolescent girls. the findings revealed a significant relationship, indicating that adherence to iron supplement tablet intake requirements positively impacts hemoglobin levels in students participating in the aksi bergizi or nutrition action program.18 the aksi bergizi initiative was started in 2018 by unicef in response to the low compliance with iron supplement tablets use among adolescent girls. to attain this purpose, three key treatments were implemented. the first is a weekly breakfast and iron supplement drink together at the school or a similar madrasah. the second is nutrition education across sectors, which tries to promote exercise and a healthy diet. the third type of communication is about changing behavior in a broad and pertinent way.19 one of the government’s initiatives to stop teenage anemia and stunting before pregnancy is the nutritional action movement.20 preliminary observations by authors indicated that many female seventh-grade students at junior high school were unfamiliar with anemia, regularly replaced meals with junk food and snacks, and had not taken iron supplement tablets. many were unaware of anemia and its effects. since 2018, the petung health center has been implementing anemia prevention activities following the ministry of health’s guidelines. however, low compliance with iron supplement tablet consumption and a high anemia rate (67%) among seventh-grade girls in the 2022-2023 school year reduced the effectiveness of these efforts. this study aimed to determine the impact of the nutritional action intervention on hemoglobin levels in seventh-grade female students at junior high school. specifically, it will measure hemoglobin levels before and after the intervention, assessing the effectiveness of the nutritional action initiative in this population. materials and methods research design this study utilized a quantitative approach with a pre-experimental design, specifically a one-group pre-post-test format. this design is particularly useful for examining cause-and-effect relationships within a single group of subjects. initially, the group was observed before the intervention, and subsequent measurements were taken after the intervention. a pre-test was conducted prior to the intervention, followed by the administration of the treatment. after the treatment, another round of measurements was taken to assess the impact of the intervention. the comparison of pre-and post-test results serves as the basis for testing causality in this research. study participants the study population consisted of female adolescents in seventh grade (class vii) at junior high school, with a total of 95 female students. the sampling technique employed was stratified random sampling to ensure that the sample was homogeneous within each stratum.13 this method ensured that the characteristics of each group were considered during the selection process, leading to a balanced and representative sample. the inclusion criteria for the study were adolescent females in the seventh grade, aged between 12 and 14 years, who were willing to participate as respondents. exclusion criteria included participants with a history of chronic illness or haematological conditions, as well as those currently using iron supplements or medications such as antibiotics, chemotherapy agents, nonsteroidal anti-inflammatory drugs (nsaids), or anti-malarial drugs, which could affect red blood cell counts. additionally, individuals who were unwilling to participate were excluded from the study. variable, instrument, and data collection the dependent variable in this study was the hemoglobin levels of adolescent females, while the independent variable was the aksi bergizi (nutrition action) intervention. pre-test measurements of hemoglobin levels were taken during the initial visit with the respondents. following this, the intervention was conducted over four consecutive wednesdays, with a post-test administered on the fourth wednesday. the primary data collected included several components: sample identity information such as name, age, class, complete address, and medical history; a consent form signed by each respondent; hemoglobin measurements taken before the intervention; nutrition action cards used to record each respondent’s progress; and hemoglobin measurements taken after the intervention. standard operating procedures (sops) were followed for both the nutrition action activities and the hemoglobin meter checks. in addition to the primary data, secondary data were collected from journals, guidelines, technical instructions, and school records, including coordination with the school’s health staff and the principal of the junior high school where the research was conducted. this information ensured the study adhered to local regulations and protocols. research implementation the implementation of the research was conducted in three stages. the first stage, the pre-intervention stage, involved coordination with the junior high school where the research was conducted and teachers to plan the technical aspects of the study. a team of five members from the school health unit (uks), nutrition, counseling team, health promotion, and the research program holders worked together to determine the number of potential respondents and to randomly select participants. the stratified random sampling method was applied, using class vii attendance data to select participants. the picker wheel online application was used to randomly assign students to groups, ensuring the sample was representative across class levels (vii-1 to vii-6). the second stage, the intervention stage, involved the delivery of the nutrition action intervention. the researcher explained the components of the “nutrifying action” agreement, which were displayed on a powerpoint presentation. each point of the agreement was then explained in detail to the respondents. following this, an energizer exercise was demonstrated, and the respondents were divided into small groups of 7-8 students. these small groups participated in a shared healthy breakfast session following the “fill my plate” model. after breakfast, each student was given one iron supplement tablet, which they were instructed to take once a week on wednesdays. the final stage, the post-intervention stage, involved collecting the nutrition action cards and conducting a post-test to measure the respondents’ hemoglobin levels. the hemoglobin check was carried out using a quick test method, and the session concluded with a closing statement to the respondents. special issue pathways of change [page 16] [healthcare in low-resource settings 2025;13(s1):13144] data analysis data analysis was conducted using univariate and bivariate analysis with the spss statistical software. the normality of the data was tested using the shapiro-wilk test to determine whether it followed a normal distribution. ethical clearance this study received ethical approval from the health research ethics commission, as indicated by the ethical certificate dp.04.03/f.xlii.25/0453/2024. results this study’s participants were seventh-grade students who participated in the aksi bergizi intervention program every wednesday for four weeks. a total of 44 respondents were involved, and the characteristics of the participants are summarized in table 1. as shown in table 1, the predominant age group among the respondents was 13 years, with 33 individuals (75%). the 12-year-olds accounted for 8 participants (18.2%), while the least represented age group was 14 years, with only 3 participants (6.8%). the univariate analysis was performed to examine the hemoglobin levels before and after the aksi bergizi intervention among adolescent girls. hemoglobin levels were assessed prior to the intervention on tuesday, june 14, 2024, at 11:30 wita, involving all 44 respondents. the results are shown in table 2. as shown in table 2, the average hemoglobin level before the intervention was 11.39, with a standard deviation of 1.11. the lowest recorded hemoglobin level was 8.7 mg/dl, and the highest was 14.0 mg/dl. as indicated in table 3, the average hemoglobin level after the intervention was 12.86, with a standard deviation of 1.36. the lowest hemoglobin level was 8.8 mg/dl, and the highest was 15.4 mg/dl. additionally, a univariate test was performed to assess the effect of the aksi bergizi intervention on hemoglobin levels in adolescent girls. table 4 shows that, out of the 44 respondents, 7 experienced a decrease in their hemoglobin levels (negative ranks), while 37 respondents showed an increase in their levels (positive ranks). a wilcoxon signed-ranks test was used to determine if there was a significant difference between the pre-test and post-test results, as the data were not normally distributed. table 5 indicates that the significance value is 0.0001, which is less than 0.05. therefore, it can be concluded that there is a significant difference between the pre-test and post-test results. there is an effect of the nutritional action intervention on hemoglobin levels in class vii adolescent girls in junior high school. discussion the study’s findings reveal that the average hemoglobin level among class vii adolescent girls before the intervention was 11.39 mg/dl, with a minimum of 8.7 mg/dl and a maximum of 14.0 mg/dl. hemoglobin, a protein found in red blood cells, is responsible for transporting oxygen from the lungs to other parts of the body.21 this result suggests that many of these young girls are at higher risk for anemia, which aligns with prior research by yuanti (2020),22 who found that young women had an average hemoglobin level of 10.59 mg/dl before iron (fe) supplementation, indicating widespread anemia. this is especially relevant for class vii girls transitioning from elementary to junior high school, as they may lack awareness of anemia prevention.23 following the aksi bergizi intervention, which included four sessions based on the nutrition module, the average hemoglobin level increased to 12.8 mg/dl, with a standard deviation of 1.36, a minimum of 8.8 mg/dl, and a maximum of 15.4 mg/dl. the increase in hemoglobin levels highlights the program’s effectiveness. in the “plan your future” sessions, students were guided to identify and commit to positive health actions, encouraging healthconscious behaviors.24 the findings align with zaddana et al. (2019),25 who observed that dietary habits and nutritional intake significantly influence anemia prevalence. many students in the intervention and control groups showed low levels of essential nutrients, such as iron and protein, indicating that young girls are often unaware of nutritional needs, which can affect hemoglobin special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13144] [page 17] table 1. distribution of respondents categorized by age. age frequency percent valid percent cumulative percent valid 12 8 18.2 18.2 18.2 13 33 75 75 93.2 14 3 6.8 6,8 100 total 44 100 100 table 2. hemoglobin levels of class vii adolescent girls before being given the aksi bergizi intervention. mean minimum maximum std. deviation n pre-test check hemoglobin level 11.397 8.7 14.0 11.089 44 valid n (listwise) 44 table 3. hemoglobin levels of class vii teenage girls after being given the aksi bergizi intervention. mean minimum maximum std. deviation n post-test check hemoglobin level 12.864 8.8 15.4 13.599 44 valid n (listwise) 44 levels.26 additionally, similar studies found low compliance with fe supplementation among adolescent girls due to limited knowledge of anemia and its benefits.16 statistical analysis revealed a significant difference in hemoglobin levels before and after the intervention, confirming the impact of the aksi bergizi program. of the 44 participants, 37 showed improved hemoglobin levels, while 7 experienced a decrease.27 the initial low levels of knowledge regarding anemia prevention and the benefits of fe tablets may have contributed to low pre-intervention hemoglobin levels.28,29 the findings of this study emphasize the importance of multi-sectoral collaboration among schools and health professionals to foster adaptive health behaviors. similar research by khoirunnabila et al. (2018)18 reported a significant relationship between hemoglobin levels and fe supplementation adherence. likewise, zaddana et al. (2019)25 noted that after receiving nutrition education, participants’ knowledge of anemia increased from an average score of 69.21 to 85.43. hevandari (2023)27 also found that compliance with the aksi bergizi intervention improved significantly, as demonstrated by increased adherence to health guidelines in class viii girls. a limitation of this study is its duration. conducted every wednesday for four weeks, the third session coincided with an absence due to illness, which required follow-up via whatsapp. additionally, the class schedule only allowed for 30 minutes of physical activity on wednesdays instead of the typical friday, limiting exercise participation. a few students did not adhere to nutritional guidelines by consuming two carbohydrate sources, such as rice and noodles, highlighting the need for reinforced education on balanced meals. conclusions in conclusion, this study found a significant difference in hemoglobin levels among female teenagers before and after the intervention. a higher number of respondents showed elevated hemoglobin levels post-intervention, indicating that the nutritional action youth program positively impacted their health outcomes. the observation underscores the substantial effect of this intervention on the hemoglobin levels of class vii teenage girls in junior high school. however, the study’s limited sample size may affect the generalizability of these results to a wider population. additionally, the short duration of the study may not capture the potential long-term effects of the nutritional interventions. furthermore, the use of a single metric (hemoglobin levels) may not fully represent the comprehensive effects of the intervention on participants’ health. references 1. kinyoki d, osgood-zimmerman ae, bhattacharjee n v, et al. anemia prevalence in women of reproductive age in lowand middle-income countries between 2000 and 2018. nat med 2021;27:1761-82. 2. kemenkes. hasil survei status gizi indonesia (ssgi) 2022. badan kebijakan pembangunan kesehatan kementrian kesehatan ri. jakarta; 2023. 3. who. number of non-pregnant women (aged 15-49 years) with anaemia (thousands). the global health observatory: explore a world of health data. 2022. 4. alem az, efendi f, mckenna l, et al. prevalence and factors associated with anemia in women of reproductive age across lowand middle-income countries based on national data. sci rep 2023;13:20335. 5. who. haemoglobin concentrations for the diagnosis of anaemia and assessment of severity. world health organization; 2011. 6. marn h, critchley ja. accuracy of the who haemoglobin colour scale for the diagnosis of anaemia in primary health care settings in low-income countries: a systematic review and meta-analysis. lancet glob heal 2016;4:e251-65. 7. silitonga hth, salim la, nurmala i, wartiningsih m. compliance of iron supplementation and determinants among adolescent girls: a systematic review. iran j public health 2023;52:37-48. 8. triharini m, mar’ah has em, nofita g. determinant factors of anemia in pregnancy based on health belief model: a correlational study. j ners 2023;18:50-6. 9. maity s, wray j, coffin t, et al. academic and social impact of menstrual disturbances in female medical students: a systematic review and meta-analysis. front med 2022;9:821908. 10. figueiredo acmg, gomes-filho is, silva rb, et al. maternal anemia and low birth weight: a systematic review and metaanalysis. nutrients 2018;10:601. 11. samson kli, fischer jaj, roche ml. iron status, anemia, and iron interventions and their associations with cognitive and academic performance in adolescents: a systematic review. nutrients 2022;14:224. 12. jáuregui-lobera i. iron deficiency and cognitive functions. neuropsychiatr dis treat 2014;2087-95. 13. puri s, shaheen m, grover b. nutrition and cognitive health: a life course approach. front public heal 2023;11:1023907. 14. kementerian kesehatan ri. laporan riskesdas 2018 [basic health research report 2018]. lap nas riskesdas 2018. 2018; 15. muhammad z, sumarmi s. the influence of knowledge and attitude of female adolescents on fe tablet consumption at pub special issue pathways of change [page 18] [healthcare in low-resource settings 2025;13(s1):13144] table 4. pre-test rank test and post-test examination of hemoglobin levels for adolescent girls. mean rank sum of ranks n post-test – pre-test negative ranks 8.71 61.00 7a positive ranks 25.11 929.00 37b ties 0c total 44 aposttest < pretest; bpost-test > pre-test; cposttest = pretest table 5. wilcoxon test output results. z p post-test – pretest -5.067b 0.0001 awilcoxon signed ranks test. bbased on negative ranks. lic senior high school 1 of gorontalo city, indonesia. j public health africa 2019;10:113-6. 16. klankhajhon s, pansuwan k, klayjan k, et al. perspectives of pregnant women regarding iron deficiency anemia. j ners 2021;16:119-27. 17. jaswadi j. hubungan sikap dengan kejadian anemia remaja putri di sman 9 mataram. jisip (jurnal ilmu sos dan pendidikan) 2020;4. 18. khoirunnabila am, hernawan b, agustina t, risanti ed. pengaruh kepatuhan konsumsi tablet tambah darah dan sarapan sehat program “aksi bergizi” unicef terhadap kadar hemoglobin remaja putri di klaten. proceeding b natl symp work contin med educ xiv 2021; p. 147-55. 19. unicef. adolescent nutrition programme aksi bergizi: from district pilot to national scale-up. unicef indones 2019;1-12. 20. diana r, rachmah q. nutrition intervention of pregnant adolescents: a systematic review. nutr food sci 2021;51:234-43. 21. putri nmmdn, mataram ika, suarjana im. hubungan konsumsi zat gizi (protein, besi, asam folat, vitamin c) dan konsumsi tablet tambah darah dengan kadar hb pada remaja putri kelas 10 di smk negeri tabanan. j ilmu gizi j nutr sci 2024;13:62-71. 22. yuanti y. pengaruh pemberian tablet fe terhadap kenaikan kadar hemoglobin pada remaja. j ilm kesehat kebidanan 2020;9:1-11. 23. kundu s, alam ss, mia mat, et al. prevalence of anemia among children and adolescents of bangladesh: a systematic review and meta-analysis. int j environ res public health 2023;20:1786. 24. puspitasari hzg, armini nka, pradanie r, triharini m. anemia prevention behavior in female adolescents and related factors based on theory of planned behavior: a cross-sectional study. j ners 2022;17:25-30. 25. zaddana c, indriani l, nurdin nm, sembiring mo. pengaruh edukasi gizi dan pemberian tablet tambah darah (ttd) terhadap kenaikan kadar hemoglobin remaja putri. fitofarmaka j ilm farm 2019;9:131-7. 26. silitonga hth, salim la, nurmala i, et al. knowledge, attitude, intention, and program implementation of iron supplementation among adolescent girls in sidoarjo, indonesia. j public health africa 2023;14. 27. hevandari d. pengaruh intervensi aksi bergizi terhadap tingkat kepatuhan minum tablet tambah darah (fe) pada remaja putri kelas viii di smpn 2 sukodono kecamatan sukodono kabupaten lumajang. j ilm ilmu kebidanan 2023;14:445-53. 28. wiafe ma, apprey c, annan ra. impact of nutrition education and counselling on nutritional status and anaemia among early adolescents: a randomized controlled trial. hum nutr metab 2023;31:200182. 29. march s, torres e, ramos m, et al. adult community healthpromoting interventions in primary health care: a systematic review. prev med (baltim) 2015;76:s94-104. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13144] healthcare in low-resource settings eissn: 2281-7824 https://www.pagepressjournals.org/index.php/hls/index publisher's disclaimer. e-publishing ahead of print is increasingly important for the rapid dissemination of science. the early access service lets users access peer-reviewed articles well before print / regular issue publication, significantly reducing the time it takes for critical findings to reach the research community. these articles are searchable and citable by their doi (digital object identifier). the healthcare in low-resource settings is, therefore, e-publishing pdf files of an early version of manuscripts that undergone a regular peer review and have been accepted for publication, but have not been through the typesetting, pagination and proofreading processes, which may lead to differences between this version and the final one. the final version of the manuscript will then appear on a regular issue of the journal. e-publishing of this pdf file has been approved by the authors. healthc low-resour s 2025 [online ahead of print] to cite this article: azazi a, rekawati e, wati dnk. effectiveness of progressive muscle relaxation on anxiety in community-dwelling older adults in indonesia. healthc low-resour s doi: 10.4081/hls.2025.14038 ©the author(s), 2025 licensee pagepress, italy note: the publisher is not responsible for the content or functionality of any supporting information supplied by the authors. any queries should be directed to the corresponding author for the article. all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. submitted: 28 may 2025 accepted: 12 december 2025 early access: 17 december 2025 https://www.pagepressjournals.org/index.php/hls/index https://www.pagepress.org/site effectiveness of progressive muscle relaxation on anxiety in community-dwelling older adults in indonesia arjuna azazi,1,2 etty rekawati,3 dwi nurviyandari kusuma wati3 1faculty of nursing, universitas indonesia, depok, west java; 2nursing study program, faculty of nursing, institut citra internasional, pangkalpinang, bangka belitung; 3department of community nursing, faculty of nursing, universitas indonesia, depok, west java, indonesia correspondence: etty rekawati, department of community nursing, faculty of nursing, universitas indonesia, jalan prof. dr. bahder djohan, ui depok campus, depok, west java 16424, indonesia. tel. +62.21.78849120 – fax: +62.21.7864124 e-mail: rekawati@ui.ac.id key words: anxiety; elderly; progressive muscle relaxation; aging; mental health. acknowledgments: the authors would like to express their gratitude to the directorate of research and development, universitas indonesia, for providing funding for this study and its publication. appreciation is also extended to the nurses at the community health centers (puskesmas), research assistants, health volunteers, and the older adults who participated in this study. ethics approval: this study received ethical approval from the nursing ethics committee of the faculty of nursing, universitas indonesia, under reference number sk-121un2.f12.d1.2.1/etik 2020. availability of data and materials: the datasets and materials used in this study are available from the author upon reasonable request. conflict of interest: the authors declare no conflicts of interest, whether financial or otherwise. funding: funding for publication of this article was provided by puti saintekes 2020 no. nkb 4633/un2.rst/hkp.05.00/2020. contributions: a collected the data, performed the statistical analysis and drafted the manuscript. as the project leader, er designed the study, supervised data collection, and contributed to the revision of the manuscript. dnkw contributed to the statistical analysis, translation and revision of the manuscript. all authors have approved the final version of the manuscript. abstract community-dwelling older adults are a vulnerable group frequently affected by anxiety, which may impair their health, functioning, and quality of life. progressive muscle relaxation (pmr) is a therapeutic method designed to induce relaxation and potentially reduce anxiety. this quasi-experimental study investigated the effect of pmr on anxiety levels among older adults in pangkalpinang city, indonesia, conducted from april to may 2020. a total of 138 participants were assigned to intervention (n=67) and non-intervention (n=71) groups. the intervention consisted of ten pmr sessions over five weeks, delivered twice weekly in small groups. data were collected using the geriatric anxiety inventory and analyzed via wilcoxon and mann-whitney tests. the intervention group exhibited a significant reduction in anxiety from pre-test to post-test (p = 0.0001, p < 0.005), whereas the non-intervention group showed no meaningful change. the between-group comparison indicated a moderate effect (p = 0.0001, p < 0.005). pmr demonstrates beneficial outcomes in reducing anxiety among older adults; however, its implementation should involve trained health professionals and take into account individual conditions. introduction globally, approximately 4.4% of the population is affected by anxiety disorders. in 2021, an estimated 359 million people worldwide were living with anxiety disorders, underscoring its status as one of the most prevalent mental health conditions globally.1 anxiety often remains underrecognized by healthcare professionals, and societal stigma further hinders appropriate diagnosis and treatment. among various mental health conditions, anxiety is widespread in the older adult population.2 in indonesia, anxiety is classified as an emotional mental disorder. in the bangka belitung islands province, 11% of the population (3,884 individuals) reported experiencing emotionalmental disorders, exceeding the national average of 9.8%.3 the province's aging population structure may contribute to the increased prevalence of anxiety. several factors underlie anxiety among older adults, including financial insecurity, health-related issues, and reduced social interaction due to bereavement or relocation.4 loneliness also poses a significant risk factor, and older adults living with family are reportedly three times more likely to experience anxiety than those living alone.5,6 anxiety in older adults may result in social withdrawal, resistance to support, caregiver burden, and elevated suicide risk.7 if left untreated, anxiety can progress to depression, substance abuse, and physical health complications.8 therefore, early intervention is essential. progressive muscle relaxation (pmr) is an effective non-pharmacological technique for reducing anxiety9. unlike some therapies, pmr is accessible, can be performed independently, and serves both preventive and curative purposes. in addition, pmr is associated with minimal adverse effects.10 progressive muscle relaxation (pmr) has also been shown to be effective in reducing anxiety across a broad range of conditions and populations.10–12 although several studies have documented the benefits of pmr among individuals with cancer, heart disease, and other chronic illnesses,13,14 empirical evidence regarding its effectiveness in community-dwelling older adults remains limited. furthermore, pmr interventions are often implemented on an individual basis rather than in group formats, leaving a gap in understanding their effectiveness when delivered in group settings. therefore, this study aimed to examine the effect of pmr on anxiety levels among community-dwelling older adults. this study offers a novel contribution by evaluating groupbased pmr specifically among community-dwelling older adults, a population and delivery format that have been largely underexplored in previous research. materials and methods ethical consideration this study received ethical approval from the nursing ethics committee of the faculty of nursing, universitas indonesia, under reference number sk-121-un2.f12.d1.2.1/etik 2020. study design and setting a quasi-experimental design was employed, utilizing a pre-test and post-test approach with a non-intervention group. the target population consisted of older adults residing in pangkalpinang city, indonesia. data collection was carried out in sub-districts with the highest concentrations of older adults, including rangkui district (melintang, asam, keramat, pintu air, mesjid jamik, parit lalang, and gajah mada urban villages) and gerunggang district (tuatunu, bukit merapin, taman bunga, bukit sari, kacang pedang, and air kepala 7). the study was conducted between april and may 2020. sample size and sampling technique the study population consisted of community-dwelling older adults in pangkalpinang city, totaling 39,413 individuals in 2020. the sample size was determined using a hypothesistesting formula for the difference between two paired group means, which yielded a minimum requirement of 36 participants per group. to reduce the potential impact of intervention-related bias and to ensure adequate statistical power, this number was doubled, resulting in a target of 72 participants for both the intervention and non-intervention groups. thus, the planned total sample size was 144 respondents. during data collection, five participants in the intervention group and one participant in the non-intervention group withdrew from the study. the sampling process employed both probability sampling (stratified random sampling) and non-probability proportional sampling. inclusion criteria were older adults who exhibited symptoms of anxiety and were able to communicate effectively. in contrast, exclusion criteria included individuals with extremity fractures, a history of heart disease, or other serious medical conditions. data collection tools and procedures data were collected at two time points: before the intervention and one week after its completion. the research procedure was divided into three stages. step 1 (preparation stage) three research assistants, all certified nurses, were recruited to assist in data collection and implementation of the pmr intervention. the principal investigator provided standardized training, including an explanation of the research protocol, guidance on administering the geriatric anxiety inventory (gai), and practice sessions for pmr techniques. the gai instrument was validated with 30 respondents, and the cohen’s kappa test was used to assess inter-rater consistency, yielding a perfect agreement score of 1.00 (p = 0.000). potential participants were screened based on inclusion and exclusion criteria with assistance from local health cadres. screening took place during the integrated health post for older adults and senior citizen gatherings in village halls. eligible participants received detailed study information and signed informed consent. initially, interventions were planned in groups of 10–15; however, due to covid-19, sessions were adjusted to smaller groups of 2–5 participants following public health guidelines. interventions were conducted in participants’ homes, agreed upon in advance. step 2 (implementation stage) a carpet was prepared for participants to sit on during the intervention. blood pressure was measured before each session, and if it exceeded 180/140 mmhg, the session was postponed. researchers demonstrated the pmr sequence—including abdominal, thigh, and leg muscle groups—while participants followed. each movement was repeated twice, counted from 1 to 7. sessions lasted 30–35 minutes and were conducted twice weekly over five weeks (10 sessions total). one week after the final session, post-intervention anxiety levels were measured. to ensure ethical fairness, participants in the non-intervention group were also provided the pmr intervention in video format after the study, due to the increasing spread of covid-19. step 3 (evaluation stage) participants in the intervention group were interviewed regarding their experiences. some reported difficulty performing certain movements, such as facial (cheeks, nose, eyes) and thigh exercises, due to limited physical support. others reported decreased tension in the neck and shoulder muscles. movements involving the chest, shoulders, and upper back were noted to improve breathing comfort. instruments anxiety levels among participants were measured using the geriatric anxiety inventory (gai). the geriatric anxiety inventory (gai) has undergone prior validation across multiple study settings. evidence from these evaluations indicates that the instrument exhibits robust psychometric properties. specifically, it demonstrates a sensitivity of 0.89 (95% ci: 0.70– 0.97) and a specificity of 0.80 (95% ci: 0.67–0.89).15,16 in this study, the researcher conducted an additional validity and reliability assessment using a sample of 30 older adults residing in pangkal balam district, pangkalpinang city chosen due to their demographic similarity to the target population. the initial validity test revealed four gai items with low correlation values: item 2 (r = 0.341), item 12 (r = 0.285), item 14 (r = 0.073), and item 18 (r = 0.059). despite these results, the researcher retained the items, considering that the gai is a globally standardized tool and the lack of variation might be due to similar response patterns among the pilot participants. a second validity test was conducted on the actual sample of 144 respondents. at a 5% significance level, all items showed a correlation coefficient (r) greater than the critical rvalue of 0.159, indicating acceptable validity. the reliability test produced a cronbach's alpha of 0.777, confirming that the gai is a valid and reliable instrument for assessing anxiety in older adults. data analysis in this study, data were not normally distributed. homogeneity was assessed using levene’s test. the wilcoxon signed-rank test was applied to compare anxiety levels within each group. additionally, the mann-whitney u test was employed to analyze differences in anxiety levels between groups. result respondent characteristics the distribution of respondent characteristics is presented in table 1. in the intervention group, the median age was 66 years, with the majority being female (91%) and having completed elementary or junior high school education (83.6%). most respondents had a history of hypertension (73.14%), a history of smoking (active or passive, 74.6%), were widowed (62.7%), and were unemployed (70.1%). in the non-intervention group, the median age was 65 years, with most respondents being female (81.7%) and having elementary or junior high school education (74.6%). additionally, a majority had a history of hypertension (56.3%), a history of smoking (active or passive, 53.5%), were widowed (49.3%), and were unemployed (83.1%). the median anxiety level was identical in both the pmr and nonintervention groups, with a value of 6.00. in the intervention group, anxiety levels significantly decreased. the median anxiety score dropped from 6.00 in the pre-test to 1.00 in the post-test. in contrast, the non-intervention group showed no change, with the median anxiety score remaining at 6.00 in both preand post-tests, indicating no reduction in anxiety. the standard deviation in the intervention group decreased by 0.016 between the preand post-tests, reflecting reduced anxiety variability. at a 95% confidence interval, post-test anxiety levels ranged from 4.44 to 6.35, which were significantly lower than pre-test levels. however, no change was observed in the median anxiety score within the non-intervention group. the wilcoxon test indicated a statistically significant reduction in anxiety levels in the intervention group (p = 0.0001, p < 0.005). conversely, the non-intervention group exhibited no statistically significant change in anxiety levels (p = 0.062, p > 0.005). the mannwhitney u test demonstrated a significant effect of pmr on anxiety levels when comparing the intervention and non-intervention groups (p = 0.0001, p < 0.005). discussion progressive muscle relaxation involves systematic tensing and relaxing of muscle groups, eliciting distinct bodily sensations.17 this technique integrates physical and mental processes by alleviating muscle tension through focused attention. although participants may initially feel discomfort during muscle tensioning, relaxation typically follows, producing calmness. participants in this study reported similar experiences and progressively appreciated each movement. older adults distinguished between tension and relaxation sensations, facilitating effective muscle relaxation. successful pmr implementation requires sustained focus.18 researchers consistently guided participants through each movement to maintain engagement and ensure positive outcomes. however, some participants experienced difficulty recalling pmr movements, likely due to age-related cognitive decline affecting memory retention and therapeutic participation.4 to mitigate this, researchers provided direct guidance and pmr modules for home practice. it is important for older adults to be aware of pmr indications and contraindications. the physical environment also influences pmr effectiveness; conducting sessions in open spaces may hinder concentration. this study took place in participants’ homes, limiting control over the setting. nonetheless, participants, unfamiliar with pmr, maintained focus and followed instructions well. notably, individuals new to pmr tend to experience more pronounced anxiety reductions. the findings of this study demonstrate that progressive muscle relaxation (pmr) significantly reduces anxiety levels among community-dwelling older adults. consistent with previous research, a substantial decline in anxiety was observed in the intervention group following the implementation of pmr.19 likewise, a study conducted in china reported significant differences between preand post-intervention anxiety scores after the application of pmr.20 this comparative analysis confirms that pmr effectively alleviates anxiety in older adults within community settings. these outcomes align with prior studies highlighting pmr’s impact on anxiety reduction compared to non-intervention groups.21 further evidence supports pmr's efficacy in improving mental health outcomes, including anxiety and depression reductions, which are essential for enhancing overall quality of life.13 one of the advantages of pmr over other interventions is its flexibility; it can be practiced whenever an individual experiences tension or anxiety, allowing it to serve as a preventive coping strategy.22 furthermore, pmr can be performed in various postures, including sitting in a chair, lying down, or sitting cross-legged on the floor.23,24in the present study, participants practiced pmr while seated on a carpeted floor. in situations that trigger anxiety or panic, pmr enables individuals to redirect their attention and mobilize internal coping resources.20,25 the simplicity and adaptability of pmr contributed to the smooth implementation of the intervention in this study, as no major difficulties or adverse events were encountered among the older adult participants. therefore, pmr can be practically implemented in community nursing in indonesia as a strategy to prevent psychosocial problems among older adults. these findings may inform community health programs and policymaking by supporting the integration of pmr into routine services for older adults within primary and long-term care frameworks. a minimum of ten pmr sessions is recommended to achieve optimal therapeutic outcomes.22 in alignment with this recommendation, the present study implemented ten sessions over five weeks, with two sessions conducted each week. studies involving burn patients have also reported reductions in anxiety and improvements in sleep quality following pmr interventions, even when delivered with lower session frequency.26a comparative study evaluating pmr, support group therapy, and a control group over five consecutive 45-minute weekly sessions demonstrated that mean happiness levels were significantly higher in the pmr group than in the other intervention conditions.27 overall, the evidence indicates that more frequent pmr sessions are associated with greater therapeutic benefits.28 however, evidence from systematic reviews indicates that the duration of pmr training, whether delivered in shorter or longer formats, does not result in significantly different outcome measures.9 across various studies, the integration of pmr with additional therapeutic components consistently produced greater anxiety reduction compared to pmr training administered in isolation.14,29 in community-based interventions, physical exercise programs such as the fullbody in-bed gym offer the potential to complement progressive muscle relaxation training by strengthening overall muscle function and helping to prevent sarcopenia among older adults with psychosocial problems.30,31 its application for community-dwelling older adults could be incorporated into the integrated health post for older adults, which prioritizes physical activity as a key strategy for improving quality of life in this population. conclusions the intervention revealed significant differences in anxiety levels between pre-test and posttest measurements among respondents in the intervention group; however, no such differences were observed in the non-intervention group. these findings suggest that pmr effectively reduces anxiety among older adults living in community settings. therefore, pmr should be considered a viable therapeutic approach for managing anxiety in community nursing care for older adults to minimize potential adverse effects. references 1. world health organization. anxiety disorders. 2025. available from: https://www.who.int/news-room/fact-sheets/detail/anxiety-disorders 2. ribeiro o, teixeira l, araújo l, et al. anxiety, depression and quality of life in older adults: trajectories of influence across age. int j environ res public health 2020;17:9039. 3. badan penelitian dan pengembangan kesehatan. laporan nasional riskesdas nasional 2018. jakarta; 2018. available from: chromeextension://efaidnbmnnnibpcajpcglclefindmkaj/https://repository.badankebijakan.kem 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"we are talking about practice": the influence of mindfulness vs. relaxation training on athletes' attention and well-being over high-demand intervals. j cogn enhanc 2017;1:141–53. 19. torales j. an overview of jacobson’ s progressive muscle relaxation in managing anxiety. revista argentina de clínica psicológica 2020;29:17-23. 20. luo y, du j, wang j, et al. progressive muscle relaxation alleviates anxiety and improves sleep quality among healthcare practitioners in a mobile cabin hospital: a pre-post comparative study in china. front psychol 2024;15:1337318. 21. liu k, chen y, wu d, et al. effects of progressive muscle relaxation on anxiety and sleep quality in patients with covid-19. complement ther clin pract 2020;101132. 22. snyder m, lindquist r. complementary and alternative therapies in nursing. 5th edition. snyder m, lindquist r, editors. bang printing. new york: springer publishing company; 2006. 23. smith jc. relaxation, meditation, & mindfulness: a mental health practitioner’s guide to new and traditional approaches. springer publishing company; 2005. 24. berman a, snyder s, frandsen g. kozier & erb’s fundamentals of nursing: consep, process and practice. tenth. wilson k, editor. united states: julie levin alexander; 2016. 1–1486 p. 25. toqan d, ayed a, joudallah h, et al. effect of progressive muscle relaxation exercise on anxiety reduction among nursing students during their initial clinical training: a quasi-experimental study. inquiry 2022;59:469580221097425. 26. harorani m, davodabady f, masmouei b, barati n. the effect of progressive muscle relaxation on anxiety and sleep quality in burn patients: a randomized clinical trial. burns 2020;46:1107-13. 27. bostani s, rambod m, irani ps, torabizadeh c. comparing the effect of progressive muscle relaxation exercise and support group therapy on the happiness of nursing students: a randomized clinical trial study. int j africa nurs sci 2020;13:100218. 28. hashim ha, zainol na. changes in emotional distress, short term memory, and sustained attention following 6 and 12 sessions of progressive muscle relaxation training in 10-11 years old primary school children. psychol health med 2015;20:6238. 30. korkut s, ülker t, çidem a, şahin s. the effect of progressive muscle relaxation and nature sounds on blood pressure measurement skills, anxiety levels, and vital signs in nursing students. perspect psychiatr care 2021;57:1782-90. 31. ravara b, giuriati w, maccarone mc, kern h, masiero s, carraro u. optimized progression of full-body in-bed gym workout: an educational case report. eur j transl myol 2023;33:11525. 32. maccarone mc, caregnato a, regazzo g, et al. effects of the full-body in-bed gym program on quality of life, pain and risk of sarcopenia in elderly sedentary individuals: preliminary positive results of a padua prospective observational study. eur j transl myol. 2023;33:11780. figure 1. consort flow diagram. analyzed (n=71) § excluded from analysis(n=1) § allocated to control group (n=72) § received allocated intervention (n=72) § did not receive allocated intervention (n=0) assessed for eligibility inclusion-exclusion sesection participant recruitment obtain inform consent baseline measurement (t0) enrollment § allocated to pmr group (n=72) § received allocated intervention (n=72) § did not receive allocated intervention (n=0) allocation lost to follow-up (n=5) : missed >2 sessions (illness or extended absence from the city) lost to follow-up (n=1) : extended absence from the city follow-up analyzed (n=67) § excluded from analysis (n=5) analysis table 1. characteristics of community-dwelling older people. variable intervention group nonintervention group levene test pvalue age 66.00 (median) 65.00 (median) 0.0142 sex 0,113 male 6 (9) 13 (18.3) female 61 (91) 58 (81.7) education 0,201 senior high school 11 (16.4) 17 (23.9) elementary and middle school 56 (83.6) 53 (74.6) no school 0 (0) 1 (1, 4) history of hypertension 0,040 no 18 (26.9) 31 (43.7) yes 49 (73.1) 40 (56.3) history of smoking 0,010 none 17 (25.4) 33 (46.5) yes 50 (74 , 6) 38 (53,5) marital status 0,135 unmarried 1 (1,5) 0 (0) married 22 (32,8) 36 (50,7) widower 2 (3) 0 (0) widow 42 ( 62.7) 35 (49.3) occupation 0,100 formal 1 (1.5) 1 (1.4) informal 19 (28.4) 11 (15.5) not working 47 (70.1) 59 (83.1 ) anxiety 6.00 ± 3.739 6.00 ± 3.549 0,911 table 2. differences of anxiety level among community-dwelling older people in each group. variable group median ± sd 95% ci p* p** anxiety pre interventi on 6.00 ± 3.739 6.16-7.99 0,0001 0,0001 anxiety post 1.00 ± 2.056 1.48-2.49 anxiety pre noninterventi on 6.00 ± 3.549 5.086.76 0,062 anxiety post 6.00 ± 3.565 4.44-6.35 *wilcoxon signed rank test; **mann-whitney u. hrev_master healthcare in low-resource settings 2025; volume 13:13975 depression among older people living in the community with urinary, fecal, and double incontinence in bali, indonesia: a secondary data analysis i gede putu darma suyasa, ni kadek sutini, ni luh putu inca buntari agustini, israfil israfil faculty of health, institute of technology and health bali, denpasar, indonesia abstract depression and incontinence in older people living at home have become a global issue; however, the research around this area is limited in indonesia. this study aimed to determine the prevalence of depression among older people with urinary incontinence (ui), fecal incontinence (fi), and double incontinence (di) in indonesia. this study used data from a community project dataset for case management processes in older people in an urban area of bali in 2022. the dataset used was 970 older people aged 60+. we measured six variables in our study: age, gender, depression, ui, fi, and di. a multivariate logistic regression analysis was conducted to explore the determinants of depression in older people. most respondents were female (55.3%). findings showed that the prevalence of depression, urinary, fecal, and double incontinence were 8.0%, 4.7%, 9.1%, and 2.8%, respectively. depression was associated with age and all types of incontinence, but not gender. logistic regression showed that the strongest predictor of depression in older people was fi (or 3.151), followed by age, with or 2.243. nurses and other health workers should conduct more active screening for depression and incontinence for better management of these global health issues. introduction one of the most prevalent mental health conditions affecting older persons globally is depression, which has a significant negative impact on general well-being, functional status, and quality of life.1 although prevalence rates vary by population and diagnostic criteria, depression in older people living at home in indonesia affects between 11.8% and 13.6% of those 60 years and older.2,3 emerging research highlights incontinence as a significant yet underappreciated component of the multiple reasons for depression in older people, which range from social isolation and chronic illnesses to cognitive impairment. in older populations, psychological distress and depressive symptoms have been linked to fecal incontinence (fi) – defined as the involuntary loss of stool, urinary incontinence (ui) – defined as the involuntary loss of urine, as well as their co-occurrence, known as double incontinence (di),4-7 in addition to gender (female) and advancing age. ui affects up to 27% of older adults living in the community and at much greater rates in institutionalized populations, making it a prevalent condition among older adults.8,9 despite being less common, fi affects around 8% of older adults,10 and a significant percentage of long-term care patients experience di, which is when fi co-occurs with ui.11 in addition to causing a physical and hygienic burden, incontinence also leads to social disengagement, humiliation, and embarrassment – all of which are closely related to the development and maintenance of depressed moods. there are multiple ways in which depression and ui in older persons are associated. first, ui can cause severe psychological problems because of its stigma and perceived loss of dignity.12 second, because ui is chronic and frequently progressive, it may cause ongoing tension and anxiety, which can create an atmocorrespondence: i gede putu darma suyasa, faculty of health, institute of technology and health bali, jalan tukad balian no. 180, denpasar, bali, indonesia tel.: +62.81238433388 – fax: +62.3618956210 e-mail: putudarma.stikesbali@gmail.com key words: depression, double incontinence, fecal incontinence, urinary incontinence. ethics approval: this study is a secondary data analysis, and the dataset was used with permission from the community project on case management processes for older people in an urban area of bali in 2022. the research ethics committee of the institute of technology and health bali granted ethical approval with the number 04.0466/kepitekesbali/vii/2022. availability of data and materials: the data that support the findings of this study are available on request from the corresponding author, [igpds]. conflict of interest: the authors declare there are no competing interests related to this study. funding: the authors did not receive support from any organization for this study. contributions: igpds, study conception and design, study supervision, critical revisions for important intellectual content, and manuscript writing; nks, study conception and design, critical revision for important intellectual content, and manuscript writing; nlpiba, data collection, literature review/analysis, manuscript writing, references; ii, data analyses, manuscript writing, and references. acknowledgement: we thank the institute of technology and health bali for granting permission to use the data for secondary analysis. received: 12 may 2025. accepted: 9 september 2025. early access: 2 october 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13975 doi:10.4081/hls.2025.13975 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13975] [page 239] sphere that is favorable for the emergence of depressive symptoms. according to studies, older persons with ui have a much higher likelihood of having depressive symptoms than their contemporaries on the continent; odds ratios vary from 2.3 to 3.8 based on the context and the severity of symptoms.13 di is the most severe type of incontinence-related morbidity. in addition to raising the likelihood of institutionalization and the care burden, di also exacerbates the psychological toll, which frequently results in worsened mental health issues, such as elevated rates of anxiety and depression. although di is comparatively less common in the general population, its frequency rises with age, frailty, and the presence of neurological illnesses like dementia and stroke,14 which are linked to an increased risk of depression. although less research has been done, fi is just as devastating as ui. many older people with fi view the inability to control their bowels as even more stigmatizing than urine leakage, which frequently leads to higher psychological impact and more severe social isolation.15 studies indicate that the shame and challenges associated with managing bowel incontinence worsen depressive symptomatology, and fi has been associated with greater depression scores.5 even though incontinence and depression are firmly linked, little is known about the precise prevalence of depression in older persons with various forms of incontinence. there are still numerous unanswered questions regarding the relationship between the multiple forms of incontinence and the prevalence of depression in older persons, although these correlations are becoming increasingly acknowledged. most existing studies examine either ui or fi in isolation, without accounting for the nuanced differences between these conditions or their compounding effects when they co-occur. because of this, the current study aims to determine the prevalence of depression in older persons living in the community who have ui, fi, and di, as a secondary data analysis using data from a community project dataset for case management processes in older people in an urban area of bali in 2022. by identifying the prevalence and correlations of depression within these subgroups, the findings are expected to inform primary care strategies and public health policies tailored to the needs of aging populations. the study also seeks to contribute to the global discourse on geriatric mental health by providing context-specific evidence from a middle-income, southeast asian setting. materials and methods study design this study is a type of secondary data research. it used a dataset from a community project on case management processes for older people in an urban area of bali to determine the factors related to depression in older people. data source and sampling procedure this study used a dataset from a community project on case management processes for older people in an urban area of bali in 2022. this is the only urban site in bali possessing this type of data. the data set was collected cross-sectionally by interviewing older people in the area from august to september 2022. sampling was conducted by analyzing individual data from the target population, individuals aged 60+. the total sample was 970 older people. variables of the study variables of this study were derived from 2 validated questionnaires: the barthel index and the 5-item geriatric depression scale. the questions on the barthel index of bladder were used to measure ui,16 and the question on bowel was used to measure fi. we classified respondents as experiencing ui if the respondent answered either “incontinence” or “occasional accident in the last 7 days” to the question of “bladder”. similarly, we classified respondents as experiencing fi if the respondent answered either “incontinence” or “occasional accident in the last 7 days” to the question of “bowel”. meanwhile, respondents were classified as experiencing di if, simultaneously, she or he experienced both ui and fi. these classification methods are considered acceptable in studies on incontinence and have been adopted a previous study.8 depression was measured using the 5-item geriatric depression scale.17 scores of 2 and above were considered indicative of depression. data analysis we conducted data cleaning to check for inconsistencies and missing data. bivariate and multivariate analyses were performed. bivariate analyses were performed using a chi-squared test with fisher’s test as an alternative when appropriate (table 1), to determine the relationship of each independent variable for depression, including age, gender, ui, fi, and di. effect sizes were calculated and reported as a phi coefficient. multivariable analysis was conducted using a logistic regression to identify independent variables associated with depression, while identifying the most dominant variables related to depression with a confidence interval of 95% ci. only the variable with p>0.25 from the bivariate statistic entered the multivariate model (table 2). all statistical analyses were two-tailed, with statistical significance defined as p<0.05. statistical analyses for this study were conducted using spss version 27. ethical consideration this study is a secondary data analysis, and the dataset was used with permission from the community project on case management processes for older people in an urban area of bali in 2022.the research ethics committee of the institute of technology and health bali granted ethical approval with the number 04.0466/kepitekes-bali/vii/2022. results we found no missing data in the dataset. most respondents were female (55.3%), and their ages ranged from 60 to 96. only 0.9% live alone (table 3). the prevalence of depression, urinary, fecal, and double incontinence was 8.0%, 4.7%, 9.1%, and 2.8%, respectively (table 4). interestingly, 42.7% of respondents preferred to stay home more often, 41.3% showed dissatisfaction with their own life, 13.1% felt bored, and 5.9% felt helpless (table 5). based on bivariate analyses, depression was associated with age (p<0.001, φ 0.130), all types of incontinence with a small effect size (ui: p=0.002, φ 0.112; fi: p<0.001, φ 0.157; di: p=0.004, φ 0.111). depression was not associated with gender (table 3). direct logistic regression was performed to assess the impact of several factors on the likelihood that respondents had depression. the model contained four independent variables (age, ui, fi, and di). the model containing all predictors was statistically significant for adls, χ2 (4, n = 970) =29.45, p<0.001, indicating that advancing nursing education and practice for future global health [page 240] [healthcare in low-resource settings 2025;13:13975] advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13975] [page 241] table 1. bivariate analyses of depression among older people with urinary, fecal, and double incontinence (n=970). variable categories depression p effect size (φ) no n (%) yes n (%) age 60-74 722 (80.9) 48 (61.5) <0.001§ 0.130 75+ 170 (19.1) 30 (38.5) gender male 396 (44.4) 38 (48.7) 0.462§ 0.024 female 496 (55.6) 40 (51.3) urinary incontinence no 856 (96.0) 68 (87.2) 0.002¶ 0.112 yes 36 (4.0) 10 (12.8) fecal incontinence no 823 (92.3) 59 (75.6) <0.001§ 0.157 yes 69 (7.7) 19 (24.4) double incontinence no 872 (97.8) 71 (91.0) 0.004¶ 0.111 yes 20 (2.2) 7 (9.0) §chi square; ¶fischer exact test. table 2. logistic regression of determinant factors of depression among older people (n=970). b s.e. wald df sig. exp(b) 95% c.i.for exp(b) lower upper age 0.808 0.257 9.883 1 0.002 2.243 1.355 3.710 urinary incontinence -0.751 0.655 1.313 1 0.252 0.472 0.131 1.705 fecal incontinence 1.148 0.356 10.389 1 0.001 3.151 1.568 6.333 double incontinence 0.514 0.855 0.361 1 0.548 1.671 0.313 8.926 constant -2.626 0.581 20.404 1 0.000 0.072 table 3. demographic characteristics of older people living in an urban area of bali (n=970). variable categories n % age 60-74 770 79.4 75+ 200 20.6 gender male 434 44.7 female 536 55.3 living arrangement with family 961 99.1 alone 9 0.9 table 4. prevalence of depression, urinary, fecal, and double incontinence among older people living in an urban area of bali (n=970). item yes n (%) no n (%) urinary incontinence 46 (4.7) 924 (95.3) fecal incontinence 88 (9.1) 882 (90.9) double incontinence 27 (2.8) 943 (97.2) depression 78 (8.0) 892 (92.0) table 5. frequency of depression among older people living in an urban area in bali (n=970).item yes n (%) no n (%) item yes n (%) no n (%) satisfaction with own life 569 (58.7) 401 (41.3) feel bored 127 (13.1) 843 (86.9) feel helpless 57 (5.9) 913 (94.1) stay home 414 (42.7) 556 (57.3) feel worthless 33 (3.4) 937 (96.6) the model could distinguish between respondents with and without depression. the model explained between 3% (cox and snell r square) and 7% (nagelkerke r squared) of the variance in depression and correctly classified 92% of cases. as shown in table 2, only two independent variables made a unique statistically significant contribution to the model (age and fi). the strongest predictor of depression in older people was fi, recording an odds ratio of 3.151. this indicated that respondents with fi were over 3.1 times more likely to experience depression, controlling all other factors in the model. the second strongest variable was age, with an odds ratio of 2.243. discussion this study aimed to determine the prevalence of depression among older people with urinary, fecal, and double incontinence in indonesia. in addition, this study also explored the determinant factors of depression based on age and all types of incontinence. this study provides essential insight into the intricate relationships that exist between depression, ui, fi, and di in indonesian older individuals. the results show a strong and statistically significant correlation between older adults’ higher levels of depressive symptoms and incontinence, especially fi. this emphasizes how critical it is to acknowledge incontinence as a psychological and mental health problem in addition to a physical one, especially in older adults living in culturally conservative settings. in contrast to previous studies, our findings show a higher prevalence of fi among the study population, which differs from prior global and regional research that frequently identifies ui as the more common kind of incontinence in older persons.18,19 this disparity could be caused by several factors, as revealed in a previous study, such as respondents misclassifying ui, stigmainduced underreporting, or different trends in health-seeking behavior.20,21 those with ui tend to hide the symptoms because it is considered embarrassing, resulting in an underreporting of ui symptoms. given its stronger correlation with depression, the increased prevalence of fi is very significant. this suggests that indonesia’s public health and older people care initiatives must pay more attention to this disorder. despite being less common than ui and fi, as also reported by previous studies,22,23 di is associated with depression based on bivariate statistics, although not as a determinant factor in the multivariate analysis. this could be explained by the fact that statistically, in the data set, only 9% of those with di experience depression compared to 24.4% in fi and 12.8% in ui. when all variables are simultaneously entered into logistic regression models, only ui and fi contribute significantly to depression. further study using a bigger sample size may be required to test the relation between depression and di. compared to their peers on the continent, older persons with incontinence of any kind had a much greater overall prevalence of depression.24,25 the evidence that incontinence and psychological discomfort are related is further supported by this trend. our results, however, go beyond confirmation and provide new evidence that fi is the most powerful predictor of depression, outperforming ui and even di. the greater degree of embarrassment, discomfort, and practical difficulties related to managing fecal loss may account for the very significant correlation between fi and depression. fi is viewed as highly embarrassing and spiritually filthy in many asian communities, particularly those in indonesia. this stigma frequently results in social disengagement, self-isolation, and withdrawal from communal and religious activities, essential sources of identity and purpose for older indonesians.26 fi tends to be less publicly discussed, poorly managed, and linked to more negative self-perceptions than ui, which may be more understood and somewhat more accepted. embarrassment and worry are made worse by the visibility of fecal accidents, their unpleasant odor, and the intricate care needed. therefore, it’s possible that older adults with fi feel more control and dignity lost, which makes them more susceptible to sadness. from a biological standpoint, neurological or muscular degeneration, which is frequently linked to advanced ageing, chronic illnesses like diabetes or stroke, or long-term pharmaceutical use, may also be connected to the severity of fi.27 these disorders are also associated with depression, resulting in a complex feedback loop that exacerbates psychological deterioration. in this study, age was found to be the second predictor of depression. depressive symptoms were more common in older age groups, especially those 75 years of age and older. this pattern is in accordance with the trajectory of functional decline as well as the rising incidence of dependency, loneliness, and chronic illnesses in later life.28-30 the inability of older persons to preserve their independence, engage in community activities, and practice basic self-care is exacerbated by incontinence, whether it be ui, fi, or di. furthermore, there is a cultural component to the relationship between incontinence and ageing in indonesia. ageing gracefully and calmly is expected in many communities. therefore, the development of incontinence in later life may be interpreted as a social departure as well as a medical alteration, leading to emotions of guilt, stress, or even spiritual failure. this relationship is especially noticeable for elderly women, who frequently internalize their caring responsibilities and experience more emotional distress when confronted with physical constraints.30 fi is a stigmatized condition.20 in line with previous studies,12,15 the impact of social stigma on the connection between depression and incontinence is one of the main issues that this study has revealed. bowel and bladder control problems are frequently taboo subjects in indonesian society, particularly among senior citizens. silence about these problems can result in poor self-care practices, a lack of medical or social support, and delays in diagnosis. many elderly people suffer in quiet as a result, which raises their risk of depression. the findings from this study have important implications for healthcare practice for older persons in indonesia. first and foremost, regular screening for depression and incontinence must be incorporated into primary healthcare services for older people. because of their accessibility and community-based methodology, community health centers (puskesmas) and posyandu lansia (elderly integrated service posts) make early identification and intervention venues. second, healthcare providers, especially nurses, general practitioners, and community health workers, must be trained to understand the psychological effects of incontinence. beyond treating symptoms, interventions should also involve patient education, emotional support, and counselling sensitive to cultural differences. thirdly, national health policies should give incontinence management and elderly mental health top priority as interconnected public health issues. the public health system in indonesia does not adequately handle adult incontinence, and senior mental health services are inadequate. increasing insurance coverage for mental health therapies and incontinence products could significantly enhance the lives of those impacted. programs for carer support and community-based mental health promotion could potentially lessen the impact of depression on senior citizens. family carers, who frequently act as the first line of care, should be equipped with the skills and information necessary to advancing nursing education and practice for future global health [page 242] [healthcare in low-resource settings 2025;13:13975] manage elderly people who are incontinent or depressed in a kind and efficient manner. while this study provides novel insights, several limitations must be acknowledged. first, this secondary analysis from a cross-sectional design limits causal inference. while incontinence appears to be associated with higher depression levels, the reverse may also be true; depression may contribute to reduced self-care and worsening incontinence. longitudinal studies are needed to better understand directionality. second, selfreported measures of incontinence and depression may be subject to recall and social desirability bias, especially given cultural sensitivities. future research should incorporate objective clinical assessments and qualitative interviews to triangulate findings. third, other potentially significant factors that could influence the link between incontinence and depression, such as socioeconomic status, carer burden, comorbidities, and health literacy, were not taken into consideration in this study. a more thorough, multifaceted framework should be used in future studies to investigate these intersections. fourth, this study was conducted based on a data set collected from one village in bali. generalization for a broader population may be limited. conclusions this study emphasizes how critical it is to treat the psychosocial aspects of incontinence in older indonesian individuals. the correlation between depression and incontinence, specifically fi, is evident and strong and necessitates a multifaceted approach. indonesia can enhance its rapidly aging population’s well-being and quality of life by encouraging culturally responsive care models, de-stigmatizing incontinence, and including mental health into geriatric care. such research can be used as a basis for inclusive, evidence-based, and culturally grounded public health interventions as the nation navigates the difficulties of demographic transition. references 1. papageorgiou a, bakola m, kitsou k, et al. the association between depression and quality of life in the elderly. eur j public health 2022;32:ckac131.25. 2. suyasa i, sutini nk, kamaryati np, nuryanto ik. determinant of functional disability 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of urinary and fecal incontinence in almost 9,000 patients followed up for up to 10 years in germany. neuroepidemiology 2021;55:92-9. 19. najafi z, morowatisharifabad ma, jambarsang s, rezaeipandari h, hemayati r. urinary incontinence and related quality of life among elderly women in tabas, south khorasan, iran. bmc urol 2022;22:214. 20. shaw c, wagg a. urinary and faecal incontinence in older adults. med 2021;49:44-50. 21. akobundu un, onuzulu ms, obiekwe sj, akosile co, daniel ja, nwankwo mj, ochiabuto om. prevalence of urinary incontinence and knowledge of pelvic floor muscle training among older women in a nigerian suburban community. womens health (lond) 2024;20:17455057241276255. 22. batmani s, jalali r, mohammadi m, bokaee s. prevalence and factors related to urinary incontinence in older adults women worldwide: a comprehensive systematic review and meta-analysis of observational studies. bmc geriatr 2021;21:212. 23. tamanini jtn, franceschi júnior o, santos jlf, et al. fecal incontinence: incidence and risk factors from the sabe (health, wellbeing and aging) study. int urogynecol j 2022;33:2993-3004. 24. kessler m, volz pm, bender jd, nunes bp, machado kp, saes advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13975] [page 243] mo, soares mu, facchini la, thumé e. effect of urinary incontinence on negative self-perception of health and depression in elderly adults: a population-based cohort. erratum in: cien saude colet 2022;27:2955. 25. lee h-y, rhee y, choi ks. urinary incontinence and the association with depression, stress, and self-esteem in older korean women. sci rep 2021;11:9054. 26. suyasa igpd, xiao ld, lynn pa, skuza pp, paterson j. prevalence of faecal incontinence in community-dwelling older people in b ali, i ndonesia. australas j ageing 2015;34:127-33. 27. pasricha t, staller k. fecal incontinence in the elderly. clin geriatr med 2021;37:71-83. https://doi.org/10.1016/ j.cger.2020.08.006 28. meng l, xu r, li j, et al. the silent epidemic: exploring the link between loneliness and chronic diseases in china's elderly. bmc geriatr 2024;24:710. 29. kotwal aa, cenzer is, waite lj, et al. the epidemiology of social isolation and loneliness among older adults during the last years of life. j am geriatr soc 2021;69:3081-91. 30. handajani ys, schröder-butterfill e, hogervorst e, et al. depression among older adults in indonesia: prevalence, role of chronic conditions and other associated factors. clin pract epidemiol ment health 2022;18:e174501792207010. advancing nursing education and practice for future global health [page 244] [healthcare in low-resource settings 2025;13:13975] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13398 developing a culture-based palliative nursing care model in hospitals: a phenomenological study israfil israfil, ni luh putu inca buntari agustini, i ketut swarjana department of nursing, faculty of health, institute of technology and health bali, indonesia abstract palliative care serves as a framework for nurses to provide quality care. a cultural approach is essential for helping palliative care patients access maximum health services. this study aimed to determine the important aspects of developing a culture-based palliative nursing care model. utilizing a qualitative, phenomenological design, this research involved 11 participants, including nurses, palliative care patients, and their families. data collection was conducted through focus group discussions, and analysis was performed using the thematic method with the colaizzi approach. five key themes emerged to develop a culture-based palliative nursing care model: i) patient condition (knowledge, psychological challenges, education, and age); ii) family support (psychological state, knowledge, communication, assistance, and economic status); iii) role of nurses (advocacy, education, caring attitude, help with activity of daily living [adl], and give realistic expectations); iv) health service policies (no code blue, supportive therapy, entertainment, availability of resources, teamwork, chemotherapy, and health insurance); and v) cultural influence (spiritual needs, fear of death, desire not to die at home, internet use, and alternative medicine). all these components are crucial for the enhancement of palliative nursing care. introduction palliative care is a type of healthcare service that focuses on providing care to patients with terminal illnesses to maintain their quality of life.1 palliative care patients have very complex health problems and require special attention, including physiological, psychological, social, spiritual, cultural, and existential problems.2 cultural diversity in palliative care practices is a challenge and an interesting issue to pay attention to.3 complex cultural issues can influence the progression of the disease, the effectiveness of treatment, and the satisfaction of patients and families with palliative care services.4 palliative care has become a national health service policy in indonesia.5 however, the progress of palliative care service practices still varies and continues to develop in each region. the success of implementing palliative care is affected by patient perceptions, the limited availability of caregivers, and national standards of palliative care that are not yet widely accessible. hospitals that are dedicated to considering culture in applying effective palliative care principles and practices will find it easier to achieve success in palliative care.6,7 key factors for an effective palliative nursing care model include social, economic, and cultural dimensions that significantly impact patients’ quality of life.8 cultural determinants are among the aspects of palliative care that have been less extensively researched.1 understanding culture helps nurses see how it influences patients’ health and can support their well-being.9,10 despite the critical role of culture in influencing palliative care outcomes, structured frameworks that integrate cultural considerations into nursing models in hospital settings are lacking. the research and development of palliative nursing practices from a cultural perspective are important for enhancing collaboration among patients, families, and communities, facilitating the identification and negotiation of culturally significant care to improve correspondence: ni luh putu inca buntari agustini, department of nursing, faculty of health, institute of technology and health bali, indonesia. email: incaagustini@gmail.com key words: palliative care; palliative care nurses; phenomenology. contributions: ii, research design, data collection, data analysis, and writing original draft; nlpiba, study conception, data collection, manuscript writing; iks, review and editing. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: the research has received ethical approval from the health research ethics committee of the bali mandara regional general hospital, bali province (no. 066/ea/kepk.rsbm.diskes/2024). during the research, the researchers paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this study was funded by the directorate of higher education, ministry of education and culture of the republic of indonesia; directorate of research, technology and community service (drtpm), with master contract number 110/e5/pg.02.00.pl/2024; derivative contract number 2927/ll8/al.04/2024; dl.02.02.2361.tu.vi.2024. acknowledgments: the research team would like to thank bali mandara hospital’s leadership and the nurses involved. we also express our gratitude to the patients and families who participated in this research. received: 18 november 2024. accepted: 3 march 2025. early access: 15 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13398 doi:10.4081/hls.2025.13398 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 100] [healthcare in low-resource settings 2025;13(s1):13398] patients’ quality of life and ensuring palliative nursing practices align with community needs.11 this study aimed to determine pivotal factors to consider when developing a culture-based palliative nursing care model in hospitals. materials and methods research design this study employs a qualitative design with a phenomenological approach to analyze the experiences of patients, nurses, and families of palliative care patients, aiming to recommend the development of a culture-based palliative nursing care model in hospitals. participants and sampling the study included 11 participants comprising nurses, palliative care patients, and their families, aligning with the criteria for phenomenological research.12 sampling utilized a purposive technique, selecting participants among nurses who directly cared for palliative care patients, individuals diagnosed with conditions requiring palliative care, and the families of these patients. all participants had a good cooperative attitude, were willing to participate, and were actively involved until the end of the group discussion session. data collection and instruments data collection was conducted using the face-to-face focus group discussion (fgd) method. participants were divided into three groups: the nursing discussion group, the patients’ discussion group, and the family discussion group. focus group discussions were conducted separately at different times and places. data collection was conducted at bali mandara general hospital, bali province. no other parties were involved in the discussion besides the participants, who had been selected based on the inclusion criteria. the fgds lasted for one to nearly two hours, as the participants displayed significant enthusiasm for the discourse. all participants remained present for the entirety of the session. the research instruments used were fgd guidelines, notebooks, and voice recorders. the research instruments were supplied by the research team and evaluated to confirm that the questions in the fgd could yield substantial information to address the study’s objectives. the fgd questions encompassed the patient’s experience as a palliative care recipient, the family’s feelings and support for these patients, the nurses’ roles in palliative care, and the perspectives of each fgd group regarding the factors contributing to the efficacy of palliative care. the fgd data were transcribed and verified for accuracy and validity. data analysis the research data were analyzed using a thematic analysis approach with the colaizzi approach13 without software. nurse participants were coded “pn”, patient participants were coded “pp”, and family participants were coded “pf”. ethical clearance this study was conducted at the bali mandara regional general hospital, bali province, in october 2024, with an ethical clearance letter from the health research ethics committee of the bali mandara regional general hospital, bali province, no. 066/ea/kepk.rsbm.diskes/2024. results the participants were aged 29-44 years, with the lowest education level being junior high school and the highest a bachelor’s degree. the sample included one male nurse (pn1), four female nurses (pn2, pn3, pn4, pn5), one male patient (pp1), two female patients (pp2, pp3), one male family member (pf1), and two female family members (pf2, pf3) (table 1). in developing a culture-based palliative care model in hospitals, five important themes — patient conditions, family support, nurses’ roles, service policies, and cultural influence — and subthemes must be considered (table 2). theme 1: patient condition this theme centers on patient conditions and the creation of a palliative nursing care model. additionally, it will highlight crucial considerations for nurses when assessing the conditions of palliative care patients. subtheme 1: knowledge the patient’s level of knowledge about the disease is related to the speed of diagnosis, treatment program, and worsening of the condition. “our experience is that low patient knowledge makes the disease worse because of late treatment.” (pn2) special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13398] [page 101] table 1. participant characteristics (n=11). no. age (years) gender education level status code 1 32 male bachelor’s degree nurse pn1 2 39 female bachelor’s degree nurse pn2 3 32 female bachelor’s degree nurse pn3 4 33 female bachelor’s degree nurse pn4 5 28 female diploma iii nurse pn5 6 32 male senior high school patient pp1 7 56 female junior high school patient pp2 8 41 female bachelor’s degree patient pp3 9 44 male senior high school family member pf1 10 35 female bachelor’s degree family member pf2 11 29 female senior high school family member pf3 “i never thought my illness would last this long.” (pp2) “previously we didn’t know about this disease, and didn’t expect it to be like this.” (pf3) subtheme 2: psychological challenges the psychological issues encountered by palliative care patients exhibit significant complexity, leading to feelings of helplessness, entitlement, apathy towards treatment, fatigue, sadness, and a sense of undervaluation by their families. “…tendency to be psychological, so lazy to seek treatment, no longer enthusiastic, sometimes spoiled, sometimes feel no longer appreciated by the family, there are even patients who cry.” (pn1) “i feel shocked and can’t do anything.” (pp1) “tiring, have no choice but to continue.” (pp3) subtheme 3: education the patient’s level of education is related to their readiness to receive and understand information. patients with a high level of education are more open to information, enthusiastic about seeking information, and have a better quality of life. meanwhile, patients with a low level of education tend to be closed, dishonest, and usually prioritize alternative medicine. “there is a gap between patients who have a high and low educational background. experience shows that the patient’s readiness to receive information provided by the nurse is different.” (pn3) “patients who have a good level of education are usually more open, enthusiastic about asking questions, and have a better quality of life, while patients who have low education are usually closed, dishonest, and usually go to alternative medicine first and then come in severe condition.” (pn5) subtheme 4: age young patients have high hopes for recovery and influence their families to have the same hopes. older patients tend to be more accepting of their illness, and so do their families. “usually, young patients have more enthusiasm to recover, while older patients, generally over sixty years old, often have families who accept the situation.” (pn1) “some patients who are still in the productive age usually have very high hopes for health even though sometimes the condition of the disease is already in the final stage.” (pn5) theme 2: family support this theme emphasizes the significance of diverse familial supports in developing palliative nursing care model. it will show nurses the different aspects that must be considered in the families of palliative care patients who will become the patient’s primary caregivers. subtheme 1: psychological state families of palliative care patients face complex psychological challenges, such as burden and fatigue. “the tendency for patients to become spoiled can eventually burden the family, as the patient may sulk at them despite the family’s constant help.” (pn1) “when the patient starts to sulk or get angry, usually the family members start to have headaches, and their psyche is disturbed.” (pn4) “the family also feels hurt because of the extra effort, such as time and costs.” (pp2) subtheme 2: knowledge family knowledge is related to the ability to receive and understand the information provided. therefore, it is very important to assess the level of knowledge of the family of palliative care patients. “my experience from the family’s perspective is how the family receives communication, education, and information from hospital services, and how they can accept it or not.” (pn2) “the family must also serve as anamnesis, particularly regarding their understanding of the patient’s illness and treatment.” (pn1) subtheme 3: communication the patient’s health condition and treatment program are primarily conveyed to the immediate family, who are responsible for making decisions concerning their care. “we typically communicate or convey information to the nuclear family, as we believe they are the ones who can make decisions.” (pn4) “not only the nuclear family but also distant families also take part in making decisions.” (pn3) subtheme 4: assistance family assistance is very much needed by patients during the treatment program. family support is related to patient calmness, increasing patient happiness, reducing anxiety, and reducing stress. special issue pathways of change table 2. overview of themes and subthemes. theme subtheme patient condition knowledge psychological challenges education age family support psychological state knowledge communication assistance economic status role of nurses advocacy education caring attitude helping with adl realistic expectations health service policies no code blue supportive therapy entertainment availability of resources teamwork chemotherapy services health insurance cultural influence spiritual needs fear of death desire not to die at home internet use alternative medicine [page 102] [healthcare in low-resource settings 2025;13(s1):13398] families who are busy with work can arrange alternating schedules to accompany patients during the treatment program. “how often do they accompany the patient to help keep them calm?” (pn3) “the accompanying family members usually change because they work. the patients are happy to have family accompanying them.” (pn2), “there is a family who faithfully accompanies the patient during consultations with doctors and listens to the doctor’s advice.” (pn5) “i accompany and comfort patients so that they are not stressed and depressed with their current illness and condition.” (pf2) “i have a shift to be with my mother during chemotherapy. sometimes when my mother returns from chemotherapy, i also take care of her because after chemotherapy, her condition sometimes drops.” (pf3) “my family is good, always supports me and asks about what actions to take next and is always by my side.” (pp1) “my family’s role is very important.” (pp3) subtheme 5: economic status the economic status of patients and families is related to the speed of decision-making. patients from families with low financial status tend to be slower in making decisions, and the patient’s condition becomes worse. “patients from families with a good economy usually find it easier to accept information, and decisions about treatment and care are easier, while patients from families with a poor economy usually only listen and make decisions when their complaints are very severe.” (pn2) theme 3: role of nurses this theme focuses on the critical role of nurses in developing a palliative care model. subtheme 1: advocacy nurses serve as patient advocates, acting as a bridge between the needs of patients and families and the doctors responsible for the patient’s treatment program. nurses also act as mediators among families when there are differences in understanding information and differing opinions about the patient’s condition and treatment plan. “we act as a mediator when problems or differing opinions arise between the patient and their family, serve as a director to control the patient’s needs during treatment, and advocate for the patient with the doctor.” (pn1) “we act as a bridge between patients and doctors. there are some things that patients want to tell the doctor but don’t have time, so we as nurses will help convey what the patient feels.” (pn5) subtheme 2: education nurses educate patients about treatment timelines, examination appointments, and necessary preparations for patients and their families. “communication between nurses and patients is very important, it is a nurse’s medium for patient preparation during hospitalization, preparation for going home, or for home care.” (pn2) “we inform the patient when they should come back for treatment and check-ups, as well as what they need to do to prepare for that.” (pn5) subtheme 3: caring attitude the caring attitude of nurses is related to the patients’ and families’ satisfaction with receiving health support from nurses. the caring attitude of nurses is shown by the nurse’s smile, joking attitude, friendliness, humility, and responsibility in their work. “the more we can show an empathetic attitude and empathetic body gestures, both to patients and families, the more it can provide a kind of support for the patient’s condition and the condition of the family who cares for them.” (pn2) “not showing a face that is too serious, but smiling and joking, in my opinion, that’s one of the ways to get closer and more familiar with patients so that they are more enthusiastic.” (pn5) “all nurses are good and responsible, also friendly.” (pf1) “very helpful and work with full responsibility.” (pf2) “good nurses, friendly and always provide supportive advice.” (pp1) “nurses who care with heart, and that is the most important.” (pp2) subtheme 4: help with activities of daily living (adl) nurses help patients meet their daily living needs when there is no family or companion to rely on. the fulfillment of patients’ daily living needs by nurses includes assisting with feeding, bathing, and washing hair. “if no family is accompanying, we help with the patient’s needs, such as helping to feed.” (pn1) “that is typically what we do to help patients, such as bathing and washing their hair.” (pn2) subtheme 5: realistic expectations nurses do not set certain expectations for patients and families. this is important to prevent excessive hope. nurses inform patients and families about the patient’s current condition and potential future outcomes, and they communicate all available treatment options designed to assist patients. “we communicate the truth about the patient’s condition and life expectancy so that the patient and family understand and do not expect anything more than the patient’s initial condition.” (pn1) “we tell patients and families what the maximum treatment and care is like, especially to terminal patients, so that patients and families do not have excessive expectations.” (pn5) theme 4: health service policies this theme focuses on service aspects that can support the development of a palliative nursing care model. subtheme 1: no code blue the variable status of palliative care patients renders the code blue policy inapplicable. palliative care patients with deteriorating conditions continue to receive emergency treatment as per established protocols but are no longer assigned a code blue. “starting this month, deteriorating palliative care patients are not given a code blue. they are still resuscitated in the room, but a code blue will not be called.” (pn3) special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13398] [page 103] “if the condition is bad, now the code blue is no longer used for palliative care patients.” (pn5) subtheme 2: supportive therapy supportive therapy is given not to cure the disease but to relieve symptoms and reduce suffering for the patient. “the therapy provided is typically maximal, which means that the only additional treatment available is supportive therapy. for example, painkillers are administered if there is pain.” (pn3) “palliative care patients here usually receive supportive therapy such as medication to reduce pain and various symptoms so that they can carry out daily activities.” (pn5) subtheme 3: entertainment palliative care patient entertainment services are very important to maintain the psychological health of patients during treatment. entertainment services can be provided in groups with singing, karaoke, and dancing activities. “to maintain the psychological health of our patients, we usually provide entertainment media, we hold “sarasehan”. sarasehan refers to a gathering of patients in the hall where they can participate in karaoke entertainment, singing, dancing, and counseling.” (pn1, pn2). subtheme 4: availability of resources the constraints faced by palliative care nurses, who are responsible for patient monitoring, necessitate that other nursing professionals caring for palliative patients engage in self-directed learning. this development happens through socialization with palliative care nurses, participation in webinars, and direct consultation with palliative doctors. “only one nurse has undergone palliative training. though still limited, we benefit from socialization, participate in webinars, and have more direct consultations with palliative doctors.” (pn2, pn4). subtheme 5: teamwork good teamwork is related to the speed of handling palliative care patient cases. the main teamwork is between doctors and nurses. palliative doctors dedicate ample time for communication and consultation with nurses whenever necessary, entrusting them to handle patients needing immediate treatment without waiting for a doctor’s presence for the patient’s benefit. all of this is effectively communicated through teamwork. “we can disturb all the doctors at any time. we contact them as if there are no working hour limits. doctors also trust nurses and do not hesitate to involve them in important actions that are communicated for their patients’ sake.” (pn5) “palliative care patients usually re-enter the er. nurses typically inform the palliative care nurse when another palliative care patient arrives in the er. the er nurse’s service operates as usual, responding only to complaints and not including any special services.” (pn5) subtheme 6: chemotherapy services the availability of chemotherapy facilities for cancer patients is very helpful in improving their health status. chemotherapy services have successfully reduced the tumor size and expedited the advanced stage of treatment necessary for surgical procedures. “my husband was treated here, and there has been a change. now it has improved because there is chemotherapy.” (pf1) “now the lump has not grown again, and my mother has undergone the fourth chemotherapy.” (pf2) “more or less six chemotherapies, then the doctor said she could have surgery. yesterday, after consulting with the doctor, the results of the laboratory examination were good, and after the sixth chemotherapy surgery could be performed.” (pf3) subtheme 7: health insurance bpjs (social security agency on health) is an indonesian health insurance program that has supported many palliative care patients in their treatment plans. the existence of bpjs facilities is beneficial for patients and families in financing treatment. “this hospital accepts patients with bpjs insurance, so we are grateful that because we have bpjs insurance, we don’t have to pay for treatment costs.” (pp1) “coincidentally, my mother uses bpjs, there is nothing to pay. this is very helpful, helpful.” (pf2) theme 5: cultural influence this theme focuses on cultural aspects that are of concern in developing a palliative nursing care model. subtheme 1: spiritual needs the availability of clergy in hospitals is needed for patients who need prayer support to gain better spiritual strength. “we prepare clergy and inform patients and families that if they are in critical condition and need clergy, we already have them available. we then contact the clergy to arrange prayer services for those patients.” (pn2) “always ask for prayers from the clerics to be given strength and healing.” (pp2) subtheme 2: fear of death fear of death is a significant experience for patients and families that nurses need to understand. it takes time for patients and their families to process the situation and for families to prepare for the death of a loved one. “most still tend to be afraid of dying. the family will do anything so that the patient can survive, even though they know that the patient is at the final station. there is a fear of being abandoned and leaving the family.” (pn3) subtheme 3: desire not to die at home not wanting to die at home is a culture in this region. dying at home is considered a failure for the family in caring for palliative care patients. “if possible, the patient is treated longer and dies in the hospital. the patients should not die at home because if they die at home, the community usually thinks the family was unable to care for them.” (pn4) subtheme 4: internet use using google as a search engine is one way for patients and families to find answers and good guidance for what they need. special issue pathways of change [page 104] [healthcare in low-resource settings 2025;13(s1):13398] unfortunately, misinterpreting information that does not align with the patient’s condition can be a challenge for nurses. “especially now, patients’ families are playing around with google, googling a little bit and saying that the family should still be alive, they should be treated in the icu, and so on, based on what they read on google.” (pn4) “with technology, we can search online to learn about the disease and what chemotherapy is like.” (pf2) “google is very helpful if i have questions.” (pf3) “i sometimes search on google for the causes and prevention.” (pp1) subtheme 5: alternative medicine the use of alternative medicine is related to delays in medical treatment, which results in worsening patient conditions. patients tend to choose alternative medicine and shamans and ignore medical treatment. “taking traditional medicine as people suggest, hopefully, you will recover.” (pp1) “some patients are more inclined to alternative medicine, smart people, herbal concoctions, ignoring medical treatment. then they don’t get good results, then they seek medical treatment and are already in a serious condition.” (pn5) discussion the condition of palliative care patients is an important aspect that forms the basis for developing a nursing care model. patients requiring palliative care must be properly identified, as this is necessary for receiving effective palliative care.14,15 there are still palliative care patients who have low levels of knowledge and have wrong information about palliative care, highlighting the need for better health education.16 the age of the patient is an important factor to consider in palliative care; in comparison to younger patients, older patients are more accepting of their condition and expect less palliative care to prolong their lives.17 moreover, palliative care patients often experience severe psychological issues and require effective support to enhance their comfort, psychological well-being, and resilience, ultimately improving their quality of life.18 family support greatly improves the palliative care process, allowing patients to cope with their challenges more effectively. family support encompasses various dimensions, including informational support, whereby the family is required to comprehend the patient’s health condition and offer guidance regarding health matters; instrumental support, which pertains to the family fulfilling the financial requirements associated with the patient’s treatment process; and emotional support, which includes elements of self-esteem and companionship that contribute to the patient’s happiness and motivation.2 the active involvement of the family in caring for patients with respectful, clear, and culturally appropriate communication will provide emotional strength so that patients can undergo better treatment and care.18 however, it is important to consider that families may also face significant emotional challenges stemming from the impact of the disease on their relatives’ emotional well-being.19 along with family support, nurses who have a positive attitude toward palliative care can influence quality services and improve patients’ quality of life.20 the role of nurses serves as a crucial starting point for the healthcare team to consider various factors, including culture.1,21 nurses, as providers of palliative health services, play a fundamental role in understanding the cultural assumptions that influence patients’ decision-making, fostering open communication with families, and identifying what best meets their expectations during their treatment.3 additionally, nurses delivering palliative care must recognize that instilling hope in patients should be grounded in realism to assist patients and families in accepting their circumstances and preparing for a dignified death.22 therefore, improving the understanding and skills of nurses is very important to enhance the quality of palliative care services.6 nurses who underwent palliative care training had significantly more positive attitudes toward palliative care than those who did not receive such training.20 education about palliative care has proven effective in increasing nursing students’ knowledge, attitudes, comfort, and self-awareness regarding the importance of palliative care in health services. palliative care education and practice should continue to evolve and be integrated into nursing schools to help nursing students understand early on that palliative care is a vital competency they must achieve.23 as patient advocates, nurses play a role in safeguarding information that should not be disclosed to others or anyone claiming to be the patient’s family without the patient’s consent.24 this study found that current hospital policies no longer announce code blue signs for palliative care patients, but medical services and care are still carried out. code blue often comes from palliative units, where patients have long-term diseases. the main purpose of palliative patient care is to assist patients in living their lives and accepting death with dignity.25 a code blue situation in a hospital is a highly stressful event for everyone involved and profoundly impacts the emotional well-being of patients and their families. regardless of the results, code blue can be traumatic for palliative care patients and their families if it occurs repeatedly after the worsening of the patient’s condition.26 besides that, emergency services, as the main unit for handling code blue, are very busy, noisy, and not an optimal environment for palliative care patients. consequently, hospital policies need to consider the special role of the emergency unit in managing palliative care.27 another essential aspect of palliative care is entertainment. music therapy or singing for palliative care patients can overcome emotional problems, improve social relationships, and improve patient comfort.28 the restricted availability of qualified human resources in the realm of health care specializing in palliative services necessitates robust advocacy directed toward policymakers to increase the number of skilled palliative care professionals within public health.29 ownership of health insurance, such as bpjs, serves to safeguard patients and their families against the adverse financial repercussions associated with medical care expenses. furthermore, possessing health insurance ensures that patients receive equitable healthcare services.30 affordable access and complete facilities available at health facilities will be able to increase public awareness to utilize health services as the main place to obtain treatment and services that meet expectations.31 culture is a constellation of societal beliefs and behaviors that shape the patient’s identity as part of a community group. unique cultural backgrounds are important to assess and accommodate properly because they can affect the disease process, the success of health care, and the patient’s ability to make decisions.32 clergy leaders can influence patients and families to obtain spiritual peace according to their religion. spiritual care has been widely proven to increase patient comfort and patient acceptance of illness in palliative care.33 fear of death is common in palliative care patients, special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13398] [page 105] both young and elderly. however, it can be reduced with maximum comprehensive nursing in a special palliative care unit.34 passing away at home is often deemed unexpected, as it is perceived as a failure of the family to provide adequate care for their relatives. determining the place of death and who to accompany are important aspects that should be considered in the process of assessing culture-based palliative nursing care.35 searching for information on the internet has had an impact on increasing anxiety in palliative care patients because they get inappropriate information. the lack of optimal information from health service providers generally influences information-seeking behavior online.36 therefore, nurses are expected to be able to develop pocketbooks or modules as a clearer and more precise medium for information and health education for patients and families in order to reduce anxiety due to limited access to information. the material presented must also adopt a cultural approach, ensuring that patients and families feel respected in accordance with relevant cultural aspects.37 alternative and complementary medicine includes various treatments, herbs, diets, and physical therapies typically not considered in conventional therapies. alternative medicine is the patient’s choice, often disregarding medical treatment. those using alternative medicine should be aware of potentially dangerous side effects, interactions with other therapeutic drugs, delays in the diagnosis process by doctors, and the possibility of impacting timely medical treatment.38 in the coming years, palliative care should focus on community and family needs, emphasizing the external factors that enhance its effectiveness after hospital discharge. this includes acknowledging patient choices to pursue alternative therapies while not adhering to traditional medical practices. community nurses and primary care providers play a crucial role in delivering ongoing home-based or community-centered palliative care to patients.8 a culturally safe, community-based care approach will contribute more positively to enhancements in comprehensive palliative care services.18 clinical implications the findings of this study highlight the significant clinical effectiveness of nursing assessment, intervention, and implementation of culture-based palliative care in hospitals. key nursing assessments involve patient age, education level, knowledge level, psychological issues, economic status, health insurance coverage, use of alternative medicine, and the desire to die at home. key components of nursing intervention and implementation include communication with patients and families, providing family support, advocating for patients and families, educating patients and their families, maintaining a caring attitude, assisting patients with adl, offering hope, avoiding code blue situations, delivering supportive therapy, facilitating entertainment, ensuring the availability of patient care resources, collaborating as a team, providing chemotherapy services, addressing spirituality, and developing internet-based information systems. this study has limitations, including the lack of religious or cultural figures and stakeholders as informants for obtaining service leadership recommendations. however, it could help researchers identify important factors to consider when developing a culture-based palliative nursing care model in hospitals. engaging stakeholders as experts in evaluating the developed palliative nursing care model is a significant step for the future. conclusions this study underscores significant experiences in palliative care, focusing on patient age, psychological factors, educational background, and knowledge acquisition. the support of family members, effective communication, assistance, and economic status are of paramount importance. nurses assume a crucial role as advocates and educators, balancing care with realistic expectations. additionally, health facility policies regarding code blue protocols, supportive therapies, recreational activities, human resource allocation, teamwork, chemotherapy protocols, and insurance matters are essential components. cultural considerations, such as the involvement of clergy, apprehension surrounding death, internet utilization, and preferences for alternative medicine, significantly impact the quality of care provided. these insights serve as a valuable foundation for developing a culture-based nursing model, highlighting the necessity of stakeholder engagement to enhance future palliative care initiatives. references 1. monette em. cultural considerations in palliative care provision: a scoping review of canadian literature. palliat med reports 2021;2:146-56. 2. witjaksono amal, maulina vvr. gambaran perceived social support pada penderita kanker stadium lanjut yang menjalani perawatan paliatif. j psikogenes 2016;4:12-24. 3. six s, bilsen j, deschepper r. dealing with cultural diversity in palliative care. bmj support palliat care 2023;13:65-9. 4. senel g, silbermann m. cultural challenges in implementing palliative programs in emerging countries. palliat med hosp care open j 2017; available from: https://www.researchgate. net/publication/318889762_cultural_challenges_in_impleme nting_palliative_programs_in_emerging_countries 5. rochmawati e, saun au. effectiveness of symptom management training on caregiving preparedness and burden of family caregivers in-home palliative care: a quasi-experimental study. j ners 2022;17:153-60. 6. tampubolon nr, fatimah wd, hidayati aun. hambatanhambatan a implementasi perawatan paliatif di indonesia: systematic review. j kesehat 2021;14:1-10. 7. bruera e. the development of a palliative care culture. j palliat care 2004;20:316-9. 8. van heerden em, jenkins ls. the role of community health workers in palliative care in a rural subdistrict in south africa. african j prim heal care fam med 2022;14:1-9. 9. leininger m, mcfarland mr. transcultural nursing; consepts, theories, research & practice. third ed. vol. 148. by the mcgraw-hill companies, inc; 2002. 10. agustina r, fetzer sj, lai ws, et al. abcde assessment for palliative care truth-telling dilemmas: a case study. int j palliat nurs 2024;30:444-50. 11. cain cl, surbone a, elk r, kagawa-singer m. culture and palliative care: preferences, communication, meaning, and mutual decision making. j pain symptom manage 2018;55:1408-19. 12. creswell jw, creswell jd. research design qualitative, quantitative, and mixed methods approaches. fifth ed. sage publications, inc. 2018. 13. praveena k.r, sasikumar s. application of colaizzi’s method special issue pathways of change [page 106] [healthcare in low-resource settings 2025;13(s1):13398] of data analysis in phenomenological research. med leg updat 2021;21:914-8. 14. pham l, arnby m, benkel i, et al. early integration of palliative care: translation, cross-cultural adaptation and content validity of the supportive and palliative care indicators tool in a swedish healthcare context. scand j caring sci 2020;34:762-771. 15. rettobyaan f, widodo b. palliative management of a patient with gastric outlet obstruction (goo) due to caput pancreatic cancer during covid-19 pandemic. bali med j 2023;12:7448. 16. atena d, imane b, maryam r, et al. the level of knowledge about palliative care in iranian patients with cancer. bmc palliat care 2022;21:33. 17. parr jd, zhang b, nilsson me, et al. the influence of age on the likelihood of receiving end-of-life care consistent with patient treatment preferences. j palliat med 2010;13:719-26. 18. redondo elvira t, ibáñez del prado c, cruzado ja. psychological well-being in palliative care: a systematic review. omega (united states) 2023;87:377-400. 19. schill k, caxaj s. cultural safety strategies for rural indigenous palliative care: a scoping review. bmc palliat care 2019;18:21. 20. getie a, ayalneh m, aytenew tm, et al. attitude of nurses towards palliative care and its associated factors in ethiopia, systematic review and meta-analysis. bmc palliat care 2024;23:67. 21. indarwati r, fauziningtyas r, jalaludin ns, et al. the factor of resident safety culture in nursing homes in indonesia. work older people 2023;27:91-8. 22. laranjeira c, dixe ma, semeão i, et al. “keeping the light on”: a qualitative study on hope perceptions at the end of life in portuguese family dyads. int j environ res public health 2022;19:1561. 23. ulfiana e, has emm, rachmawati pd. the development of palliative community health nursing to increase family’s autonomy in caring patient with cancer at home. j ners 2013;8:309. 24. testoni i, wieser ma, kapelis d, et al. lack of truth-telling in palliative care and its effects among nurses and nursing students. behav sci (basel) 2020;10:88. 25. uludag o, dogukan m, duran m, et al. code blue practice in patient safety: single center retrospective evaluation. ann med res 2019;26:1922. 26. mcwhirter m, heikkinen p, dérissé g, mehta ak. specialty palliative care in a code blue: an unexpected role. j palliat med 2022;25:1747-50. 27. lawrenson r, waetford j, gibbons v, et al. palliative care patients' use of emergency departments. n z med j 2013;126:80-8. 28. clements-cortés a. singing and vocal interventions in palliative and cancer care: music therapists’ perceptions of usage. j music ther 2017;54:336-61. 29. putranto r, mudjaddid e, shatri h, et al. development and challenges of palliative care in indonesia: role of psychosomatic medicine. biopsychosoc med 2017;11:1-5. 30. akarowhe k. benefits of implementing health insurance policy in developing countries for a better palliative care. j palliat care med 2018;08. 31. israfil i, yusuf a, efendi f, et al. exploring the primary health facility availability, health control, drug consumption, and healthy living behavior among patients with hypertension. healthc low-resource settings 2024;12:11867. 32. becker td, cagle jg. the importance and impact of culture in palliative care. in: terry altilio shirley otis-green jgc, editor. the oxford textbook of palliative social work. oxford university press; 2022. pp. 1-24. 33. gijsberts mjhe, liefbroer ai, otten r, olsman e. spiritual care in palliative care: a systematic review of the recent european literature. med sci (basel, switzerland) 2019;7:157. 34. tsai js, wu ch, chiu ty, et al. fear of death and good death among the young and elderly with terminal cancers in taiwan. j pain symptom manage 2005;29:344-51. 35. hoare s, morris zs, kelly mp, et al. do patients want to die at home? a systematic review of the uk literature, focused on missing preferences for place of death. plos one 2015;10:e0142723. 36. beekers n, husson o, mols f, et al. symptoms of anxiety and depression are associated with satisfaction with information provision and internet use among 3080 cancer survivors: results of the profiles registry. cancer nurs 2015;38:33542. 37. israfil i, yusuf a, efendi f. effectiveness of a health behavior module based on transcultural nursing in efforts to prevent cardiovascular complications on hypertension patients in the community. indones j glob heal res 2024;6:1293-302. 38. martin jh, patel j. complementary and alternative therapies in the palliative setting. intern med j 2022;52:1677-84. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13398] [page 107] hrev_master healthcare in low-resource settings 2023; volume 11:11756 relationship between nurses knowledge level and workload about implementation of patient identification hilda hilda,1 arsyawina arsyawina,1 supriadi supriadi,1 hesti prawita widiastuti,1 annisa syaputri,1 joko sapto pramono2 1nursing study program, poltekkes kemenkes kaltim, samarinda; 2health promotion program, poltekkes kemenkes kaltim, samarinda, indonesia abstract patient safety incidents can originate from patient identification errors. from the preliminary study, it was found that there were 3 cases of patient identification errors in the year 2022. the objective of this research was to determine the relationship between nurses knowledge level and workload with patient identification implementation. this study employed a quantitative method with a cross-sectional research design. this research aims to analyze the relationship between variables where the independent variable and dependent variable are identified at one unit of time. in this case, to determine the relationship between the level of knowledge and workload of nurses with the implementation of patient identification. the sample consisted of 93 individuals distributed across the inpatient wards. the research sample was selected used random sampling. the knowledge level and workload of nurses were independent variables, while the implementation of patient identification was the dependent variable. data collected was used of a level of knowledge, workload, and application of identification questionnaire. data analyzed used were with chi-square test. the obtained p-value for the relationship between nurses knowledge level and the implementation of patient identification is p=0.018 (p<0.05). therefore, there is a significant relationship between nurses knowledge level and the implementation of patient identification. p-value for the relationship between nurses workload and the implementation of patient identification is p=0.564 (p>0.05). this explains that there is no significant relationship between nurses workload and the implementation of patient identification. there is a significant relationship between nurses knowledge level and the implementation of patient identification. the majority of nurses demonstrated a good implementation of patient identification. it is recommended for the hospital management to make efforts to improve nurses knowledge, especially in the area of patient safety. introduction patient safety has become a global issue in various countries1 with an estimated 10-25% of inpatients experiencing patient safety incidents.2 patient safety is the provision of nursing care that minimizes risks and ensures safer care, with the aim of minimizing the occurrence of errors (minister of health regulation no. 11, 2017). based on the number of unexpected events in hospitals in various countries, namely america, england, denmark and australia, the incidence was 3.2-16.6%, while in new zealand the incidence was reported at 12.9%, in england 10.8%, canada 7.5%, united kingdom 10% and australia 16.6%. this is caused mostly by errors in patient identification (who, 2018). patient identification is one of the crucial aspects in implementing patient safety systems.3 accurate patient identification is an international patient safety goal. patient safety incidents can arise from incorrect patient identification procedures. errors in patient identification can be caused by unsafe actions, such as human errors, lapses, and mistakes.4 factors such as lack of organized systems, unclear standard correspondence: arsyawina arsyawina, nursing study program, poltekkes kemenkes kaltim, samarinda, indonesia. e-mail: winarispi@gmail.com key word: knowledge level; workload; patient identication implementaion. contributions: hh: methodology, data analysis, manuscript writing, overview; aa: manuscript writing and overview; ss, hp, js: manuscript writing; as: data collection, data analysis and manuscript writing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, east kalimantan ministry of health polytechnic, based on ethical certificate dp.04.03/7.1/07744/2023. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to am. parikesit hospital tenggarong for their valuable insights and contributions to this study. received: 11 september 2023. accepted: 5 october 2023. early access: 12 october 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11756 doi:10.4081/hls.2023.11756 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 6] [healthcare in low-resource settings 2023; 11:11756] non -co mmerc ial us e o nly operating procedures (sops), ambiguous spatial arrangements, and inadequate resources contribute to the likelihood of human errors.5 there are several factors that can influence patient identification, including policies or regulations, standard operating procedures (sops), nurse knowledge, nurse skills, and patient education.6,7 one important factor that can affect patient safety is the knowledge level of nurses.8 when nurses have good knowledge about the identification process and understand when and how to perform patient identification, it is crucial for successful patient identification.9 therefore, nurses should have a good level of knowledge, as all actions must be based on knowledge.10 data obtained from who (2017)11 showed that 13% of surgical errors and 68% of blood transfusion errors were due to patient identification mistakes. among the 68% of blood transfusion errors, 11 patients died. these findings indicate that identification errors still occur frequently and can result in patient mortality. according to the patient safety report from the south australian government, common types of patient identification errors reported between 2014 and 2015 include 273 cases of patient identification errors, 272 cases of specimen labeling errors, 211 cases of wrong patient errors, 59 cases of incorrect medical record status, and 28 cases of examination result errors. a study conducted in saudi arabia in 2019 showed that 82% of respondents had good knowledge but lacked proper implementation of patient identification. only a small percentage, less than 20% or around 30 healthcare professionals, followed the sops for patient identification. this could be due to a lack of socialization or training on the implementation of patient identification. despite having good knowledge, the application of proper patient identification was still not optimal and not in line with guidelines.12 in contrast, a study by mualimah et al., (2021) at east lampung found that 71.4% of nurses had good knowledge and implemented patient identification effectively. this finding is consistent with the study by andriyanti et al., which reported that 41 nurses (77.4%) had good knowledge and performed patient identification with a good rating. however, when patient identification is not implemented correctly, it can lead to unintended incidents, such as medication errors, which can result in patient harm or even death. this has negative implications for healthcare institutions.9 identification errors can also occur due to excessive nursing workload.14 for example, when the number of nurses does not match the number of inpatients in a hospital or hospital ward, it can lead to increased workload for nurses. this, in turn, affects the implementation of patient safety. the longer a patient is hospitalized, the more procedures and treatments they require, which increases the workload for nurses. data obtained from luo et al., (2020) research on the psychological and mental impact of covid19 on medical staff and the general population revealed that out of 9,207 studies, 62 studies involving 162,639 participants from 17 countries focused on healthcare workers experiencing anxiety (32%), depression (28%), with the highest prevalence observed among healthcare workers directly involved in patient care (55%). another study by yudi et al., found that 33.3%, or 10 nurses, were categorized as having inadequate patient safety practices due to high physical workloads. when the number of incoming patients exceeds the available nursing staff in a particular area, nurses perceive an increased workload. although patient identification processes are consistently carried out, they become more susceptible to risks due to the administration of multiple medications and the greater number of procedures performed by nurses on patients. analysis of the data obtained from a.m. parikesit hospital in 2022 revealed three instances of patient identification errors. additionally, data from the hospital’s quality and patient safety committee indicated an increase in patient safety incidents from 2020 to 2021. specifically, incidents classified as unexpected events increased from 15 to 34, non-injury events increased from 14 to 29, near miss incident increased from 9 to 13, and potential injury decreased from 1 to 0 in 2021. the number of sentinel events also decreased from 2 to 0. these findings suggest an upward trend in patient safety incidents at a.m parikesit hospital during the period of 2020 to 2021. efforts to implement patient identification procedures require collaborative teamwork to prevent errors in the patient identification process. nursing and other healthcare personnel need to recognize their roles in the hospital to minimize the risk of patient safety incidents. however, achieving continuous and permanent patient safety practices necessitates long-term commitment. based on the comprehensive review of the existing literature and the aforementioned explanations, the purpose of this study was examine the relationship between the level of knowledge and workload of nurses with the implementation of patient identification. materials and methods this research is designed as a quantitative study using a crosssectional design. the sampling technique employed in this study is random sampling. the population of this study consists of nurses working in the in inpatient wards totaling 122 individuals. the sample size was determined using the slovin’s formula, resulting in a sample of 93 individuals. the results of the research sample selection were selected according to the inclusion and exclusion criteria. the inclusion criteria are nurses are willing to be respondents, the nurse has worked for more than 1 year. the exclusion criteria for this research are nurses are not willing to be respondents, nurses who are on leave, nurse who is sick. the knowledge level and workload of nurses were independent variables, while the implementation of patient identification was the dependent variable. data collected was used of a level of knowledge, workload, and application of identification questionnaire. the first questionnaire used was about the level of knowledge, consisting of 20 questions using the guttman scale through respondents’ answers to the available statements regarding patient identification with 2 answer choices, namely true and false. the second questionnaire used was about nurses workload, consisting of 13 questions using a likert scale through respondents answers to the available statements about nurses workload with 4 answer choices, namely not a workload with a score of 4, light workload with a score of 3, moderate workload with a score of 2, heavy workload with a score of 1. the third questionnaire used was about the implementation of patient identification, consisting of 15 questions using a likert scale based on respondents’ answers to the statements that were available regarding the implementation of patient identification with 4 options the answer is never with a score of 1, sometimes with a score of 2, often with a score of 3, always with a score of 4. before conducting research, an ethical test will be carried out first. ethical clearance will be published from the campus of the health polytechnic of the ministry of health of east kalimantan. after that, ethics was published in june 2023 with the ethical certificate number dp.04.03/7.1/07744/2023. and then the data will be analyzed used with chi-square test. if the probability value <0.05 then the hypothesis ha is accepted, which means that there is a significant relationship between the independent and dependent variables. if the probability value is > 0.05 then the hypothesis ha is rejected, which means that there is no significant relationship between the independent variables and the dependent variable. [healthcare in low-resource settings 2023; 11:11756] [page 7] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly results based on table 1, it indicates that the majority of respondents are female, totaling 58 individuals (62.4%), while the remaining respondents are male, totaling 16 individuals (37.6%). the majority of respondents, comprising 48 individuals (51.6%), fall within the age group of 26-30 years. on the other hand, a small proportion of respondents, totaling 6 individuals (6.5%), belong to the age group of 36-40 years. the majority of respondent is graduate of from diploma iii nursing that is amounted to 54 people (58.1%), meanwhile graduate of from nurse amount 39 person (39.7%). the majority of respondent based on from group long work nurse in am parikesit hospital obtained that partly big nurse own old groups work with ranges long work during > 1 to 5 year a total of 56 people (60.2%). whereas part small nurse own group length of work during < 1 year is 10 people (10.8%). the majority of respondent based on marriage status are as follows 58 individuals (62.4%) are married, while 35 individuals (37.6%) are unmarried. based on from table 2, show that distribution respondent based on level knowledge nurse about application identification patient, obtained that most nurses have level good knowledge as much 73 people (78.5%) and enough knowledge as much 20 person (21.5%). distribution respondent based on workload nurse, obtained that part big nurse own workload heavy as many as 66 people (71.0%). whereas a small proportion of nurses have a workload light a number 27 people (29.0%). based on from table 3, show that distribution respondent based on application identification patient, obtained that part big nurse own application identification good that is as many as 87 people (93.5%). whereas part small nurse own application of medium identification a number 6 person (6.5%). based on table 4 on the level knowledge variable, it can be observed that there are 71 individuals (97.3%) who are classified as having good knowledge and implementing good patient identification practices. additionally, there are 2 individuals (2.7%) who have good knowledge but only implement patient identification practices at a moderate level. on the other hand, there are 16 individuals (80%) who are classified as having sufficient knowledge and implementing good patient identification practices, while 4 individuals (20%) have sufficient knowledge but only implement patient identification practices at a moderate level. the analysis using the chi-square test, specifically the fischer exact test, the result is p-value of 0.018. since the obtained p-value is less than the significance level of 0.05 (α < 0.05). therefore, it can be concluded that there is a significant relationship between the level of knowledge and the implementation of patient identification. the odds ratio (or) obtained from the analysis is 8.875 (1.49452.729), indicating that nurses with good knowledge are 8.875 times more likely to have better implementation of patient [page 8] [healthcare in low-resource settings 2023; 11:11756] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. characteristics respondents. respondent characteristics frequency percentage (n) (%) type sex man 35 37,6 women 58 62.4 amount 93 100 age respondent 20-25 23 24.7 26-30 48 51.6 31-35 15 16,1 36-40 6 6.5 >40 1 1.1 amount 93 100 level education respondents diploma iii 54 58.1 ners 39 41.9 amount 93 100 long work respondents < 1 year 10 10.8 > 1 until 5 year 56 60.2 > 5 year 27 29.0 amount 93 100 marriage status marry 58 62.4 not married yet 35 37.6 amount 93 100 source: analysis data primary, 2023. table 2. distribution respondents based on level knowledge. level frequency percentage (n) (%) knowledge nurse good knowledge 73 78.5 enough knowledge 20 21,5 workload nurse heavy 66 71.0 light 27 29.0 amount 93 100 source: analysis data primary, 2023. table 3. distribution respondents based on application of identification patient in patient ward. application of identification frequency percentage patient (n) (%) good application of identification patient 87 93,5 enough application of identification patient 6 6,5 total 93 100 source: analysis data primary, 2023. table 4. level knowledge and workload of nurse with application identification patient in inpatient ward. variabel application identification patient amount p or (95% ci) level knowledge good moderate n % n % n % good 71 97.3 2 2.7 73 100 0.018 8.875 enough 16 80 4 20 20 100 (1.494-2.729) workload good moderate n % n % n % heavy 62 93.9 4 6.1 66 100 0.564 light 25 92.6 2 7.4 27 100 source: analysis data primary, 2023. non -co mmerc ial us e o nly identification. based on table 4 on the workload variable, the results can be seen that nurse which own category workload heavy with the implementation of good identification there as much 62 person (93.9%), nurse which own category workload heavy with application identification currently there is 4 person (6.1%). nurse which own category workload light with the implementation of good identification there as much 25 person (92.6%), nurse which own category workload light with application identification while there were 2 people (7.4%). from the results chi-square test analysis seen from mark fisher exact obtained results that mark pvalues = 0.564. with thus the result of the p-value is more than alpha value 0.05 (α>0.05). canconcluded that no there is meaningful relationship between expenses work with application identification patient. discussion relationship level knowledge with the application of patient identification in inpatient ward results study show that there is relationship which meaning between level knowledge nurse with application identification patient. so that there is a relationship between the level of knowledge of nurses with the implementation of patient identification. this can be seen from the results of filling out the questionnaire where the results of filling out the questionnaire regarding the level of knowledge of most nurses have a percentage value of 8095%, which is in the good category. and for the application of patient identification, most of the nurses have a good identification application as well. this can be seen from the results of filling out the questionnaire where most of the nurses are in a good category in implementing patient identification. so, it can be concluded that the implementation of good identification is influenced by the nurse’s knowledge or understanding of spo or work procedures regarding identification in patient safety.17 results study this is in line with mualimah et al., (2021) obtained exists level relationship nurse knowledge to identification patient safety in permata hospital inpatient room heart of east lampung 2021, from the results of bivariate analysis, it was found that nurses who have a good level of knowledge with the application of good identification (100%). this is also in line with research conducted by eliwarti, (2021) from the results of bivariate analysis, it was found that nurses who have a high level of knowledge are more obedient in implementing patient identification, namely there are as many as (60.9%) of nurses. according to notoatmodjo (2012), the taller level knowledge someone else will be even better knowledge which owned person. the more lots of information which obtain by that person thenthere will be more and more knowledge. knowledge is the result of human sensing or the result of knowing someone about an object through their five senses such as eyes, nose, ears, and so on, so knowledge is something that is obtained from a person through the five senses where most of the five senses come from the senses of sight and hearing.19,20 researcher argue that a nurse which has level knowledge which tall so application identification which held will the more good also. where as nurse which own level knowledge which enough or more low level knowledge somebody, so application identification patient in hospital will no done with maximum and no in accordance with existing standards and regulations. this matter caused by any action will done related with behavior that every behavior which based on knowledge then it will characteristic more permanent or long lasting . relationship workload nurse with the application of patient identification in inpatient ward results study show that there is no relationship which meaning between workload of nurse with application identification patient. this explains that there is no relationship between the workload of nurses and the application of patient identification. this can also be seen from the results of the bivariate analysis, as many as 62 nurses out of 93 nurses have a heavy workload however have good patient identification. this can be seen too from filling out the patient identification implementation questionnaire in statement number one which contains implementing the rules made by the hospital to always identify patients where most nurses answer with the statement “often” and always. this shows that nurses always comply with spo regulations to implement patient identification in hospitals. results this study is in line with research noormailida astuti et al., (2022) .it means no there is relationtship which significant (means) between variable workload to identification patient, from the results of bivariate analysis it was found that nurses with a high workload had a fairly good identification application (60%). results study this in line also withresearch conducted by yudi et al., (2019) which it means no there is relationtship between workload mentally nurse with application patient safety, from the results of the bivariate analysis it was found that nurses with a high workload had a good identification application (36.7%). according to winarti (2015)22 ideally the workload of nurses in hospitals is 1:2, it can be said that the workload is not ideal. according to the marquis and hounston (2010) workload nurse is activity or activity which done by a nurse while on duty insomething units service health, workload or workload is also interpreted as patient days which has meaning on amount procedure, inspection visit on client or patient. the researchers believe that despite the high workload, the implementation of patient identification in the hospital is mostly categorized as good. the researcher assumes that, even though nurses have a heavy workload, nurses at parikesit hospital are always obedient in identifying patients. this is because patient identification is a regulation or standard operating procedure that must be carried out by a nurse in every hospital for patients in order to avoid the risk of patient safety incidents occurring due to patient identification errors. this research design uses a cross-sectional approach which is only carried out at the same time so that research regarding the relationship between the level of knowledge and workload of nurses and the implementation of patient identification can only be known within one time period. the location of this research was only in vip, i, ii and iii class inpatient rooms at am hospital. tenggarong parikesit only. this research did not examine all nursing staff such as intensive care rooms, emergency rooms, and other treatment rooms. conclusions from the research results it can be concluded that distribution of nurses knowledge levels in inpatient wards shows that the majority have a good level of knowledge. distribution of nurses workload inpatient wards shows that the majority have a heavy workload. distribution of patient identification implementation in [healthcare in low-resource settings 2023; 11:11756] [page 9] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly inpatient wards shows that the majority have good patient identification implementation. there is relationship between level knowledge with application identification patient in inpatient ward . there is no relationship between workload nurse with application identification patient in inpatient ward. it is hoped that the results of this research can become a strong basis or reference for future research. suggestions from researchers are expected to not only examine the level of knowledge and workload but also to research factors that can influence the implementation of patient identification and other patient safety targets. suggestions the results of this study are expected to be a strong basis or reference for future research. suggestions from researchers are expected to not only examine the level of knowledge and workload but also be able to research the factors that can affect the application of patient identification and other patient safety goals. the results of this study are expected to be information and data materials for hospitals to be able to further improve programs regarding patient safety to improve nurse knowledge. it is hoped that the results of this research can become a strong basis or reference for future research. references 1. who. patient safety and risk management service delivery and safety. 2019. 2. indrayadi i, oktavia na, agustini m. perawat dan keselamatan pasien: studi tinjauan literatur. j kepemimp dan manaj keperawatan 2022;5:62-75. 3. dewi ys, wahyuni ed, arifin h, et al. health literacy of icu patients’ family: a review. malaysian j med heal sci 2022;18:302-6. 4. kusnanto k, arifin h, pradipta ro, et al. resilience-based islamic program as a promising intervention on diabetes fatigue and health-related quality of life. plos one. 2022;17(9 september):1-16. 5. roni purnomo. hubungan beban kerja dan pengetahuan dengan pelaksanaan keselamatan pasien (patien safety): literatur review. viva med j kesehatan, kebidanan, dan keperawatan. 2021;15:91-101. 6. arifin h, widiasih r, pradipta ro, kurniawati y. regional disparities and their contribution to the coverage of the tetanus toxoid vaccine among women aged 15-49 years in indonesia. f1000research 2021;10:1-27. 7. de rezende ha, melleiro mm, shimoda gt. interventions to reduce patient identification errors in the hospital setting: a systematic review protocol. jbi database syst rev implement reports 2019;17:37-42. 8. pardede ja, marbun as, zikri m. pengetahuan dan sikap dengan tindakan perawat tentang patient safety. j keperawatan prior 2020;3:1-12. 9. mualimah s, wulandari ry, amirudin i, ardinata a. hubungan tingkat pengetahuan perawat terhadap identifikasi patient safety di ruang rawat inap rumah sakit permata hati lampung timur. j curr heal sci 2021;1:29-34. 10. simas su, winarni m, stikes k, tangerang y. hubungan tingkat pengetahuan dan sikap dengan penerapan keselamatan pada pasien di rsud kota tangerang 2022;7:37-52. 11. who. communications during patient handovers. 2017. 12. abu mostafa f, alghammas a. assessing knowledge and compliance of patient identification methods in a specialized hospital in saudi arabia. global j quality safety healthc 2019;2:53. 13. andriyanti r, dwi pratiwi r, mairiza s, unayah m. edu dharma journal : jurnal identifikasi pasien safety pada perawat di ruang berpedoman pada akreditasi rumah. 2022;06(01). 14. dewi ys, qona’ah a, arifin h, pradipta ro, benjamin ls. preventive bacterial translocation and control of ventilatorassociated pneumonia: a qualitative study. j keperawatan padjadjaran 2022;10:177-86. 15. luo m, guo l, yu m, wang h. the psychological and mental impact of coronavirus disease 2019 (covid-19) on medical staff and general public – a systematic review and meta-analysis. psychiatry res 2020;291. 16. yudi d, tangka jw, wowiling f. hubungan beban kerja fisik dan mental perawat dengan penerapan patient safety di igd dan icu rsu gmim pancaran kasih manado. j keperawatan 2019;7(1). 17. fadhillah h, nursalam n, mustikasari m. development of nurse performance model based on knowledge management: seci with caring approach to quality of nursing services in hospital. syst rev pharm 2020;11:1090-4. 18. eliwarti e. analisis faktor-faktor yang berhubungan dengan kepatuhan perawat dalam penerapan identifikasi pasien diruang rawat inap penyakit dalam rsup dr. m. djamil padang. j akad baiturrahim jambi 2021;10:344. 19. izza a, mulawardhana p, handayani s. knowledge, attitude, and culture influence visual inspection with acetic acid service use. j ners 2020;15:208-13. 20. lestari nda. gambaran pengetahuan keluarga dalam merawat anggota keluarga dengan komplikasi gangre. skripsi 2018;5-29. 21. noormailida astuti an, saputra a, erliani s, mislawati. beban kerja perawat dengan penerapan identifikasi pasien di ruang rawat inap rsud am. parikesit tenggarong 2022;13(2). 22. winarti. hubungan beban kerja dengan pelaksanaan identifikasi pasien. 2015. [page 10] [healthcare in low-resource settings 2023; 11:11756] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13214 predictors of smoking cessation intentions among adolescents in indonesia adinda nur amila,1 ferry efendi,1,2,3 candra panji asmoro,1 rifky octavia pradipta,1,2 khadizah h. abdul-mumin4 1faculty of nursing, universitas airlangga, surabaya, indonesia; 2research center in advancing community healthcare, surabaya, indonesia; 3school of nursing and midwifery, la trobe university, melbourne, australia; 4pengiran anak puteri rashidah sa’adatul bolkiah institute of health sciences, universiti brunei darussalam, brunei darussalam abstract tobacco causes more than 8 million deaths every year worldwide. in indonesia, the prevalence of tobacco consumption remains alarmingly high among adolescents. although many young smokers express a desire to quit, they often face significant challenges due to various influencing factors. this study aimed to analyze the predictors of smoking cessation intention among adolescents in indonesia, employing a cross-sectional design and utilizing secondary data from the 2019 global youth tobacco survey (gyts) conducted in indonesia. utilizing a purposive sampling technique, a robust dataset comprising 1,191 adolescents was meticulously curated. to analyze the data, we employed the stata application, using inferential tests such as chi-square and logistic regression for variable identification and processing, ensuring the precision and rigor of our findings. the study findings revealed that most adolescents want to quit smoking (81.61%). the ability to quit smoking (adjusted odds ratio [aor]=9.80, 95% confidence interval [ci]=6.12-15.73), perception of smoking as harmful to health (aor=2.20, ci=1.40-3.48), source of support (aor=1.68, ci=1.02-2.50), smoking status of friends (aor=0.48, ci=0.38-0.74), were predictors associated with adolescents’ intention to quit smoking. data from gyts indicated that the majority of adolescents who smoke intend to cease smoking. based on these insights, it is recommended that the government enhance the enforcement and supervision of existing tobacco control policies to effectively support youth cessation initiatives. introduction tobacco consumption remains a pressing global health concern, claiming over 8 million lives annually worldwide, with direct tobacco use accounting for more than 7 million of these deaths.1 in indonesia, national surveys conducted in 2013 and 2018 revealed a persistent high prevalence of tobacco use among adolescents. the prevalence of smoking among individuals aged 10-19 increased from 7.2% in 2013 to 9.1% in 2018, marking a significant rise of approximately 20%.2 additionally, a study reported a concerning trend of high levels of smoking addiction behavior among indonesian students.3 despite this alarming scenario, many adolescents express a desire to quit smoking but face considerable challenges due to a lack of strong intentions and motivation. several previous studies have investigated smoking cessation intentions among adolescents. the survey conducted by dadras4 focused exclusively on male adolescents aged 16 years and older. in contrast, our study targets a younger age group (13-15 years) and includes both male and female participants. dadras4 also explored the correlation between early smoking initiation (by age) and smoking cessation among adolescents. in contrast, our study focuses on school grade levels, specifically examining students from grades 7 to 12. meanwhile, parental involvement in influencing adolescents’ cessation efforts has also been studied by ihyauddi.5 however, the data is from the 2015 indonesian global school-based student health survey (gshs). the study by syapiila6 looked at the influence of having friends who smoke significantly in zambia. our study looks at the correlation between having friends who smoke and smoking cessation intentions correspondence: candra panji asmoro, faculty of nursing, universitas airlangga, surabaya, indonesia. e-mail: candra.panji.a@fkp.unair.ac.id key words: adolescent; indonesia; intention; smoking cessation; smoking; tobacco use. contributions: fe, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ana, writing – original draft; cpa, resources, supervision, and writing –review & editing; rop, resources, investigation, and writing – review & editing; kham, writing –review & editing. all authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the indonesia 2019 gyts had obtained permission from the national institute of health research and development, solidifying its credibility and legitimacy. additionally, the questionnaires were completed by the respondents themselves and were anonymous to maintain confidentiality. all respondents provided written consent before taking the survey. consent for publication: written informed consent was obtained for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 8 october 2024. accepted: 16 january 2025. early view: 1 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13214 doi:10.4081/hls.2025.13214 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 96] [healthcare in low-resource settings 2025;13(s2):13214] among adolescents in indonesia. notably, research examining predictors of intention to quit smoking among indonesian adolescents, utilizing data from the global youth tobacco survey (gyts), remains conspicuously absent.7 data from the world health organization (who) in 2019 underscore the severity of the issue, revealing that 40.6% of indonesian students aged 13-15 years have used tobacco products, with two-thirds of boys and nearly one-fifth of girls reported as users.2 the age of initiation is particularly concerning, with the majority of adolescents starting smoking between the ages of 10 and 14, further perpetuating the cycle of addiction.8 moreover, findings from the 2019 gyts reveal that 18.8% of students currently smoke tobacco, with a significant disparity between genders, where 35.5% of boys and 2.9% of girls are active smokers. teenagers who smoke are at a high risk of experiencing various serious health problems, both in the short term and long term.9 firstly, smoking can damage the lungs and respiratory system, leading to issues such as shortness of breath, chronic coughing, and an increased risk of chronic lung diseases like asthma and emphysema.10 additionally, there is a correlation between smoking and mental health problems in teenagers, as smoking can increase the risk of depression, anxiety, and stress.11 furthermore, nicotine in cigarettes is highly addictive, and teenagers are more susceptible to addiction than adults, leading to difficulties in quitting even when they are aware of the negative consequences.12 moreover, smoking can impact cognitive abilities and concentration, affecting academic performance and study productivity.13 physically, smoking can damage the skin, teeth, and nails, as well as cause unpleasant mouth odor and yellowing of teeth, affecting confidence and physical appearance. finally, smoking during teenage years can increase the risk of various serious diseases later in life, such as heart disease, stroke, cancer, and vascular disorders.14 the ministry of health of indonesia, in collaboration with local governments and development partners, has implemented various measures such as banning cigarette advertising, expanding smoking-free areas (sfas), and providing education on the hazards of tobacco products.15 additionally, the introduction of smoking cessation services through the toll-free quit smoking line represents a significant government initiative aimed at supporting individuals in their cessation efforts, particularly those who may face barriers to accessing traditional healthcare facilities. research from other regions, such as china, suggests that parental disapproval, teacher intervention, and social support significantly influence adolescents’ intentions to quit smoking.16 however, similar investigations tailored to the indonesian context are lacking. to address this gap and contribute to the design of effective smoking prevention programs in indonesia, this study aims to analyze predictors of intention to quit smoking among indonesian adolescents using data from the gyts. by investigating these predictors, this study seeks to inform evidence-based interventions and policies aimed at reducing tobacco consumption among indonesian youth, ultimately mitigating the associated health risks and improving public health outcomes in the country. materials and methods population, sample, and sampling this study’s population was derived from the 2019 indonesian gyts population. the target population consisted of students in grades 7-12, or junior and senior high school, totaling 9,992 teenagers. we used a purposive sampling technique. the inclusion criteria were adolescents who actively smoked, male or female, and smoked tobacco. the sample size was 1,191 adolescents. we conducted no intervention in the sample. our research utilized secondary data derived from the 2019 indonesian gyts. variables the dependent variable, namely the desire to quit smoking, was determined based on the question: “do you want to stop smoking now?”. the independent variables include age, gender, school grade, perception of smoking as harmful, belief in one’s ability to quit smoking, parental smoking status, friends’ smoking behavior, and whether the respondent had received help or advice to quit smoking. data collection the data collection process began by downloading the gyts dataset from the centers for disease control (cdc) website (https://www.cdc.gov/tobacco/global/index.htm). subsequently, data cleaning was performed to select relevant data and identify the variables to be utilized in the study. analysis data analysis was conducted using univariate and inferential statistics, including the chi-square test (p<0.05) and logistic regression, with the stata version 16 application for windows. a chisquare analysis was conducted to determine whether a relationship existed between the independent variables and the dependent variable. while multivariate data analysis used logistic regression to determine the strongest factors in sequence that influence smoking cessation intentions among adolescents in indonesia. a clear operational definition of the research was established in advance to account for various variables that could act as potential confounders during regression analysis. this approach also facilitates a more focused discussion of the relevant variables in relation to the existing literature. ethical clearance the gyts obtained permission from the national institute of health research and development, solidifying its credibility and legitimacy. additionally, the questionnaires were completed by the respondents themselves and were anonymous to maintain confidentiality. all respondents filled out written consent before taking the survey. results the data are presented in accordance with the research objectives, including sample frequencies for both independent and dependent variables, chi-square test results to identify associations between variables, and logistic regression analysis to determine which independent variables are most strongly associated with and have a sequential influence on the dependent variable. a large proportion of the teenagers who smoke fall within the age range of 13 to 15 years, constituting 583 individuals (48.95%) out of a total of 1,191 teenagers. most of these adolescents (58.27%) were enrolled in grades 7 through 9, while 497 (41.73%) were in grades 10 through 12. the majority of adolescents (87.57%) perceive smoking as detrimental to health and believe they have the ability to cease smoking if they choose to do so (87.99%). most adolescents (54.83%) do not reside with smoking parents, and a significant portion of teenagers (53.06%) have pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13214] [page 97] friends who smoke. moreover, most adolescents (85.31%) have received assistance in their efforts to quit smoking. among those who express a desire to quit, 81.61% are inclined to do so, as shown in table 1. table 2 illustrates that four independent variables demonstrated statistically significant results concerning the desire to cease smoking (p<0.05). these variables include: perception of smoking as harmful to health (p=0.000); confidence in the ability to quit smoking if desired (p=0.000); smoking status of friends (p=0.000); and receiving assistance to quit smoking (p=0.0171). meanwhile, the variables that showed insignificant results on the desire to quit smoking with p>0.05 were: age (p=0.0993); gender (p=0.6253); school grade level (p=0.5299); and living with parents who smoke (p=0.6116). table 3 presents the results of the multivariate logistic regression analysis, identifying four significant predictors of the intention to quit smoking: perception of the harmfulness of smoking to health, self-efficacy in quitting smoking, friends’ smoking status, and receiving help to quit smoking. adolescents who perceive themselves as capable of quitting smoking are 9.8 times more likely to express a desire to quit (aor=9.81; 95% ci=6.12-15.7; p<0.001). this highlights the critical role of self-efficacy in shaping the intention to quit smoking. similarly, adolescents who recognize the harmful effects of smoking on health are 2.2 times more likely to express a desire to quit (aor=2.20; 95% ci=1.40-3.48; p=0.001). this finding underscores the importance of health awareness in motivating smoking cessation. in addition, adolescents whose friends also smoke are 1.6 times more likely to express a desire to quit (aor=1.60; 95% ci=1.02-2.50; p=0.040). this suggests that peer influence, while modest, has a significant impact on smoking behaviors and intentions. lastly, adolescents who receive assistance or support to quit smoking are significantly more likely to express the desire to quit (aor=0.48; 95% ci=3.08-7.49; p=0.002), suggesting that access to support services is crucial in reinforcing their intention to quit. discussion the dataset from our study, involving a cohort of 1,191 adolescents, highlights a notable trend: a substantial 81.61% of adolescents express a strong desire to quit smoking. this aligns with findings from a comprehensive international study spanning 61 countries, consistently revealing that a majority of adolescent smokers aspire to overcome their smoking habit.11 recognizing the urgency of addressing this issue, indonesia has implemented a multifaceted approach in collaboration with the ministry of health, local governments, and development partners. these cross-sectoral efforts include essential measures such as bans on cigarette advertising, promotional campaigns, and sponsorships; the expansion of sfas; and comprehensive education initiatives to explain the dangers of cigarettes and tobacco products.10 additionally, the ministry of health has achieved a significant milestone by launching an innovative smoking cessation line. this progressive initiative reflects the government’s commitment to facilitating smoking cessation for individuals who may lack the time to visit healthcare facilities, acknowledging the challenge of quitting smoking. indeed, quitting smoking remains a challenging task, mainly pathways of change, part ii table 1. univariate analysis of predictors of smoking cessation intentions among adolescents in indonesia (n=1,191). variable n % age <13 175 14.69 13-15 583 48.95 >15 433 36.36 sex male 1122 94.21 female 69 5.79 grade class 7-9 694 58.27 class 10-12 497 41.73 perception that smoking is harmful to health no 148 12.43 yes 1043 87.57 able to quit smoking if desired no 143 12.01 yes 1048 87.99 living with smoking parents no 653 54.83 yes 538 45.17 friends who smoke no 559 46.94 yes 632 53.06 received help to quit smoking no 175 14.49 yes 1016 85.31 desire to quit smoking no 219 18.39 yes 972 81.61 [page 98] [healthcare in low-resource settings 2025;13(s2):13214] because of the addictive nature of nicotine cigarettes, as supported by abundant scientific evidence highlighting the profound health risks associated with smoking. nevertheless, the benefits of cessation extend not only to one’s individual health but also to the wellbeing of those in proximity. in this regard, the toll-free quit smoking line offered by the government serves as a vital resource for accessing critical information about the hazards of smoking and gaining invaluable motivation to embark on the journey towards quitting. the key findings in our research are that age, sex, and grade were not significant predictors. age did not demonstrate a significant relationship, consistent with previous research indicating that the desire to quit smoking can manifest at various ages for different reasons.12 this contrasts with a study conducted in korea, suggesting that the age of smoking initiation influences cessation rates.13 however, our study found consistent levels of desire to quit smoking across different age groups, emphasizing the need for cessation interventions tailored to adolescents regardless of age. pathways of change, part ii table 2. bivariate analysis of predictors of smoking cessation intentions among adolescents in indonesia (n=1,191). independent variable dependent variable smoking cessation intentions yes no p x2 correlation n % n % age 0.0993 7.64 no correlation <13 155 88.65 20 11.35 13-15 462 79.37 121 20.63 >15 355 81.1 78 18.9 sex 0.6253 0.37 no correlation male 914 81.09 208 18.91 female 58 84.15 11 15.85 grade 0.5299 0.80 no correlation class 7-9 570 82.01 124 17.99 class 10-12 402 79.9 95 20.1 perception that smoking is harmful to health 0.0000 24.32 correlation no 103 66.64 43 33.36 yes 869 83.38 174 16.62 able to quit smoking if desired 0.0000 216.60 correlation no 57 36.25 86 63.75 yes 915 87.41 133 12.59 living with smoking parents 0.6116 0.21 no correlation no 541 81.74 112 18.26 yes 431 80.96 107 19.31 friends who smoke 0.0000 31.70 correlation no 500 87.89 59 12.11 yes 427 75.15 160 24.85 received help to quit smoking 0.0171 8.57 correlation no 129 73.19 46 26.81 yes 843 82.62 173 17.38 x2, chi-square test. table 3. multivariate analysis of predictors of smoking cessation intentions among adolescents in indonesia (n=1,191). independent variable dependent variable smoking cessation intentions aor 95% ci p able to quit smoking no (ref) yes 9.81 6.12-15.7 0.000 perception that smoking is harmful to health no (ref) yes 2.20 1.40-3.48 0.001 friends who smoke no (ref) yes 1.60 1.02-2.50 0.040 received help to quit smoking no (ref) yes 0.48 3.08-7.49 0.002 ci, confidence interval; aor, adjusted odds ratio. [healthcare in low-resource settings 2025;13(s2):13214] [page 99] similarly, sex did not emerge as a significant predictor, aligning with previous studies in indonesia.14 contrastingly, studies from other regions have shown gender disparities in cessation rates.15,16 our findings suggest a uniform desire to quit smoking among adolescent boys and girls, emphasizing the importance of gender-neutral education on smoking dangers. grade level also did not predict intention to quit smoking, consistent with prior research.14 adolescents across elementary, middle, and high school demonstrated similar levels of motivation to quit smoking. this highlights the influence of environmental factors on cessation intentions, such as family and peer dynamics, regardless of age or grade.12 living with smoking parents did not predict intention to quit smoking, diverging from findings in nigeria.17 while parental smoking influences adolescent smoking behavior, our study suggests that other factors may outweigh this influence in the intention to quit smoking among indonesian adolescents. another key finding is that having friends who smoke emerged as a significant predictor of intention to quit smoking, consistent with previous research.18 peer influence plays a crucial role in smoking behavior, highlighting the importance of interventions targeting social networks. adolescents with a source of support exhibited higher intention to quit smoking, consistent with the role of social support in cessation processes.19 support from parents, friends, teachers, and professionals can significantly impact adolescents’ motivation to quit smoking, underscoring the importance of comprehensive support systems. additionally, adolescents who perceive smoking as harmful to health and believe they have the ability to quit smoking are more likely to express intention to quit, aligning with previous studies.19-21 health concerns and self-efficacy are significant motivators for smoking cessation, emphasizing the need for educational interventions highlighting the health risks of smoking and enhancing individuals’ belief in their ability to quit. one limitation of this study stems from its reliance on secondary data extracted from the 2019 gyts in indonesia, whereas our research was conducted in 2022. this time gap between data collection periods may introduce disparities in adolescent characteristics, potentially yielding variations in outcomes compared to the present context. furthermore, our investigation was constrained by the predetermined variables available within the results of the gyts questionnaire, limiting the scope of factors considered in our analysis. however, we consider the phenomena presented in the existing data using the latest and most representative literature. we also suggest that further researchers identify adolescent awareness of the dangers of conventional and electronic cigarettes. finally, the most significant findings in this study concluded that the various factors that most strongly influence the intention to quit smoking in adolescents in sequence include: being able to quit smoking; perception that smoking is harmful to health; friends’ smoking status; and receiving help to quit smoking. these factors are interesting to be used as reference material for adolescents who want to quit smoking, as well as being a consideration for policymakers in making policies to cover programs that are more targeted at active adolescent smokers. conclusions several factors play a significant role in the initiation of smoking cessation behavior, including being able to quit smoking, perception that smoking is harmful to health, friends’ smoking status, and receiving help to quit smoking. the findings highlight the need for empowering the interventions and policies targeted at reducing the smoking behavior of adolescents in indonesia. nurses and healthcare professionals can utilize these findings to develop effective smoking prevention and cessation programs for adolescents, thereby improving their overall health outcomes. future research can explore other factors that address variables not captured in the secondary dataset or explore qualitative aspects of adolescents’ motivation to quit smoking. references 1. world health organization (who). tobacco [internet]. world health organization; 2023. available from: https://www.who. int/news-room/fact-sheets/detail/tobacco 2. world health organization (who). statement: world no tobacco day 2020 (pernyataan: hari tanpa tembakau sedunia 2020) [internet]. world health organization; 2020. available from: https://www.who.int/indonesia/news/detail/ 30-05-2020-pernyataan-hari-tanpa-tembakau-sedunia-2020 3. susilawati s, rosmawati r, yakub e. perilaku kecanduan merokok dan kepercayaan diri siswa sma tri bhakti pekanbaru [smoking addiction behavior and self-confidence of tri bhakti pekanbaru high school students]. jom fkip 2018;5:1-14. 4. dadras o. predictor of smoking cessation among school-going adolescents in indonesia: a secondary analysis based on the transtheoretical model of behavioral change. front psychiatry. 2024;15:1374731. 5. ihyauddin z, putri dad, tengkawan j, et al. tobacco use among school-age adolescents in indonesia: findings from the 2015 indonesia global school-based student health survey. korean j fam med 2023;44:327-34. 6. syapiila p, mulenga d, mazaba m, et al. factors associated with intention to smoke cigarettes among never smoker school going adolescents in zambia. afr health sci 2023;23:596-605. 7. hidayat f. hari tanpa tembakau sedunia 2021: remaja berani untuk berhenti merokok [world no tobacco day 2021: teenagers dare to quit smoking] [internet]. jamberita.com; 2021. available from: https://jamberita.com /read/2021/06/07/5967740/hari-tanpa-tembakau-sedunia2021-remaja-berani-untuk-berhenti-merokok/ 8. kementerian kesehatan. laporan nasional riskesdas 2018 [national riskesdas report 2018]. lembaga penerbit badan penelitian dan pengembangan kesehatan; 2019. 9. world health organization (who). global youth tobacco survey (gyts): indonesia information sheet 2019. world health organization; 2019. 10. kementerian kesehatan. peringati hari tanpa tembakau sedunia, kemenkes targetkan 5 juta masyarakat berhenti merokok [commemorating world no tobacco day, ministry of health targets 5 million people to quit smoking] [internet]. kementerian kesehatan republik indonesia; 2021. available from: https://www.kemkes.go.id/id/riliskesehatan/peringati-hari-tanpa-tembakau-sedunia-kemenkestargetkan-5-juta-masyarakat-berhenti-merokok 11. arrazola ra, ahluwalia ib, pun e, et al. current tobacco smoking and desire to quit smoking among students aged 1315 years global youth tobacco survey, 61 countries, 20122015. morb mortal wkly rep 2017;66:533-7. 12. ardita h. factors that influence motivation to quit smoking pathways of change, part ii [page 100] [healthcare in low-resource settings 2025;13(s2):13214] in mechanical engineering students at muhammadiyah university of yogyakarta class of 2015 [internet]. yogyakarta: universitas muhammadiyah yogyakarta; 2016. 13. valencia mlc, tran bt, lim mk, et al. association between socioeconomic status and early initiation of smoking, alcohol drinking, and sexual behavior among korean adolescents. asia pac j pub health 2019;31:443-53. 14. akmal d, widjanarko b, nugraha p. sikap mempengaruhi niat berhenti merokok pada remaja sma di kota bima [attitudes influence intention to quit smoking among high school adolescents in bima city]. jurnal promosi kesehatan indonesia 2017;12:78-91. 15. klein eg, forster jl, erickson dj. longitudinal predictors of stopping smoking in young adulthood. adolesc health 2013;53:363-7. 16. savvides ecg, christophi ca, paisi m, et al. factors associated with intent to quit tobacco use in cyprus adolescents. prev med 2014;60:83-7. 17. agaku i, akinyele a, omaduvie ut. evaluation of factors influencing intention to quit smokeless and cigarette tobacco use among nigerian adolescents. niger med j 2012;53:31-6. 18. reskiaddin lo, supriyati s. proses perubahan perilaku berhenti merokok: studi kualitatif mengenai motif, dukungan sosial dan mekanisme coping [smoking quit behavior change process: qualitative study of motives, social support and coping mechanisms]. perilaku dan promosi kesehatan: indonesian journal of health promotion and behavior 2021;3:58-70. 19. albayrak s, ergun a. smoking and desire to quit smoking behavior in a sample of turkish adolescents. j addict nurs 2015;26:41-6. 20. rahmawati a. hubungan perceived risk dan intensi berhenti merokok pada mahasiswa [relationship between perceived risk and intention to quit smoking in students]. universitas negeri semarang; 2016. 21. sagayadevan v, abdin e, shahwan s, et al. motivations to quit smoking and challenges faced during cessation among individuals with first episode psychosis in singapore. early interv psychiatry 2019;13:1488-94. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13214] [page 101] hrev_master healthcare in low-resource settings 2025; volume 13:13363 social needs and resilience of post-stroke patients: an exploratory case study heltty heltty,1 rahmawati,2 taufik3 1medical surgical nursing department, faculty of health science, universitas mandala waluya, kendari, sulawesi tenggara; 2master of public health study program, faculty of health science, universitas mandala waluya, kendari, sulawesi tenggara; 3department of public administration, faculty of social and political science, universitas haluoleo, kendari, sulawesi tenggara, indonesia abstract stroke recovery is a long-term process where resilience proves to be a very important factor in the stroke recovery process. this study aimed to investigate the existence of social needs in undergoing resilience in post-stroke patients, which can be used as basic data for designing intervention strategies to increase the resilience of post-stroke patients. this research was an applied qualitative study with an exploratory case studies type of research. participants were selected using the purposive sampling method. semi-structured in-depth interviews and field notes during the interview process were conducted with 9 informants. the data analysis used in this research was thematic analysis. there were three themes found in this research, including the need for a support system, the need for assistance in accessing health facilities, and the need for information on the whereabouts and assistance of social worker. the improvement of post-stroke patients’ resilience cannot be separated from meeting the patient’s social needs from family, peers, and the surrounding community, including social workers. collaboration between various parties including the local community needs to be carried out as an effort to improve poststroke patients’ resilience. introduction the burden of mortality and disability caused by stroke is rapidly increasing worldwide.1 it is estimated that 40% of stroke patients experience sequelae within one month to five years following a stroke.2 the sequelae that occur mostly include paralysis and disability. approximately three-quarter of stroke patients experience paralysis and severe disability.3 this has a significant psychosocial impact,4 where a third of post-stroke patients experience depression,5 a quarter experience anxiety,6 feel lonely,7 and changes in social relationships between family and friends.4 this situation affects the patient’s ability to carry out post-stroke care, including rehabilitation, which has an impact on achieving poststroke recovery. stroke recovery is a long-term process where resilience is proven to be a very important factor in the stroke recovery process.8 resilience is related to the patient’s ability to adapt to the conditions they experience. resilience involves a dynamic development process that allows individuals in a community to bounce back from the difficulties they face.9 a resilient individual is considered to have comprehensive psychological resources that are indispensable for overcoming adverse events, including self-confidence, personal competence, and interpersonal interactions.9 previous research on post-stroke resilience also proved that resilience can improve the functional abilities of post-stroke patients.10 studying resilience requires a contextual approach because the dynamic partnership between individuals and social ecosystems can result in positive adaptations when individuals face adversity.11 literature studies related to resilience also found that existing resilience interventions have not examined the involvement of family and community as social resources that can enhance indicorrespondence: heltty heltty, medical surgical nursing department, faculty of health science, universitas mandala waluya, kendari, sulawesi tenggara 93121, indonesia. e-mail: heltty@umw.ac.id key words: exploratory case studies; post-stroke; resilience; social needs. contributions: hh, rr, and tt, study conception and design, data analysis and interpretation, drafting of the article; hh and rr, data collection, critical revision of the article. conflict of interest: the author declared no conflict of interest. funding: this research was financially supported by the ministry of education, culture, research and technology of the republic of indonesia, 2024. ethics approval: this study was approved by the ethical committee of affiliated university (faculty of health science, universitas mandala waluya), with reference number: 18 /kep/umw/vii/2024. all informants were informed about the purpose of the study, the procedures, and their right to withdraw at any time. this information was provided before they signed the consent form to participate in the study. the identity of each informant was assigned a code to ensure that their personal information remained confidential and only known by the researcher. acknowledgment: the authors are grateful to the ministry of education, culture, research and technology of the republic of indonesia, for providing regular fundamental research funding in 2024. received: 9 november 2024. accepted: 6 june 2025. early access: 15 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13363 doi:10.4081/hls.2025.13363 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13363] [page 219] vidual/patient’s resilience abilities. our previous research found that the management of post-stroke patients needs to involve family and the community.12 this is in line with the meaning of resilience, namely resilience is “a process of utilizing resources to maintain well-being”.13 social resources (family and community) play a significant role in resilience.14 the post-stroke patients who received social support from family and peers show an improved quality of life.15 fulfillment of social needs is essential for individuals to function effectively and develop themselves. these needs encompass the desire for close relationships and respect from others, including feeling loved, understood, empathized with, and feeling that others are willing to help without expecting anything in return.16 social needs are one of the needs in maslow’s concept of needs. in maslow’s concept, basic social needs must be fulfilled, or at least acknowledged, so that individuals can focus on their health and well-being.17 when social needs are met, the degree of an individual’s health will likely improve.17 there is a connection between social needs and health, along with the impact of social needs interventions on health outcomes, utilization, and costs.18 knowing a patient’s social needs can improve the quality of health services, medication management, interactions with other patients so that it can reduce the stress and worry of health workers when caring for patients with unmet social needs.18 social support promotes a sense of belonging and community attachment, resulting in decreased anxiety and depressive symptoms.19 higher resilience is associated with positive mental health outcomes (reduced depression or perceived stress).20 social support positively impacts individuals’ selfefficacy, increasing their ability to cope with stressful experiences, as well as adherence to treatment.19 however, social needs navigation programs are rarely available universally to patients or community members and without considering individual differences in health risk profiles.18 therefore, patients or community members still have insufficient social support in accordance with their health conditions. in addition, the lack of health insurance and geographical access to service providers also contribute to social needs in the health sector.17 an individual’s social needs change over time. moreover, the capacity of social service institutions also varies, with urban communities having higher capacity than rural communities.18 up to this point, social needs assessment has only been carried out sporadically and only at a few points in time, resulting in the inability to identify the social needs required by individuals according to their health conditions, such as those of post-stroke patients. for this reason, the aim of this research was to investigate the existence of social needs during post-stroke patient resilience. the findings in this study can be used as basic data for designing intervention strategies to improve the resilience of post-stroke patients. materials and methods the research design used applied qualitative research with an exploratory case study type of research. data collection was conducted for two months (june july 2024) in kendari, sulawesi tenggara, indonesia. participants came from kendari. participants were selected using the purposive sampling method. the informants consisted of post-stroke patients who had successfully adapted to their post-stroke situation (stroke survivors). inclusion criteria included those who had no cognitive impairment (assessed using the indonesian version of the montreal cognitive assessment/moca-ina with a score ≥25), did not have dementia, had composmentary awareness, and were medically stable. information about the post-stroke respondent was obtained from the community, after which the researchers conducted home visits. the home visit was conducted after the respondents signed the informed consent. in-depth interviews were conducted by researchers to obtain information about the social needs that patients need while living their lives in post-stroke conditions. the interview focused on the informants’ ability to solve the problems faced.21 all informants were free to express their thoughts and comments. during the interview process, the researcher was assisted by a research assistant in writing field notes. the interview was conducted at the informants’ homes for 50-60 minutes, and it was repeated twice to clarify their statements. during the process, an audio recording device was utilized to record the conversation. data saturation was reached at the ninth informant interview. the data analysis used in this research is thematic analysis. the thematic analysis process follows a structured and sequential approach to interpret the research data. each stage builds upon the previous one, resulting in a comprehensive understanding of the data. the steps involved in thematic analysis are as follows: i) familiarizing with the data; ii) identifying keywords; iii) selecting codes; iv) determining themes; v) interpreting keywords, codes, and themes; and vi) developing a conceptual model. based on those steps, data analysis began with transcribing all data into narrative form. familiarization with the data was achieved by reading and rereading the transcripts. researchers identify keywords that suit the research objectives. the next step is to determine a theme by collecting several similar codes to combine them into a theme. determining themes is done by defining and giving a label to each theme found. the quality of definitions is assessed based on their clarity, accuracy, reliability, applicability, and contribution to theory and practice. the final step in the thematic analysis was the development of conceptual models. this step marked the culmination of the analysis, summarizing all findings and insights gained from the data. the trustworthiness of this research was ensured using four approaches: credibility, transferability, dependability, and confirmability.22 the credibility of this research data was carried out by spending sufficient time in the field/research location, building a relationship of mutual trust with informants to understand their perspectives in depth. additionally, the credibility of this research was also carried out using the data triangulation where the data were obtained through various sources (patient informants, families, and local community officials) and methods (in-depth interviews and observations). to ensure credibility, researchers also asked informants to read the transcript again and sign the transcript sheet if the data was appropriate and matched their (informant’s) statement. transferability in this study was achieved by applying a sound methodology and purposive sampling in the recruitment of informants. dependability refers to the stability of data. dependability in this research was achieved by consulting data and document reviews by experts, both experts in the field of social and policy of public and experts in the field of post-stroke care. confirmability refers to the accuracy, relevance, and meaning of the data. confirmability relates to the impartiality and objectivity of findings, guaranteeing that they were not influenced by any biases or preferences of the researcher. the researcher confirmed the findings of this study to the scientific community, including expert researchers. this reflective practice enhanced transparency and provided insight into the researcher’s subjectivity, thereby contributing to the confirmability of the findings.22 this research was conducted after obtaining approval from the article [page 220] [healthcare in low-resource settings 2024;12:13363] ethics committee of mandala waluya university (no.: 18/kep/umw/vii/2024). all informants were informed about the purpose of the study, the procedures, and their right to withdraw at any time. this information was provided before they signed the consent form to participate in the study. the identity of each informant was assigned a code to ensure that their personal information remained confidential and only known by the researcher. as a gesture of appreciation, they were given certificates and souvenirs, which included booklets on post-stroke patient care. this appreciation was presented following the completion of the interview process. results the informants involved in this research were aged 38 to 65 years, with the majority being women and muslim. most held a bachelor’s degree, were married, and were retired civil servants. all informants had a history of being diagnosed with non-hemorrhagic stroke and were in the post-stroke recovery stage at home within 1 – 3 years after the stroke (table 1). three main themes were identified, including needing a support system, needing assistance with access to healthcare facilities, and needing information on the whereabouts and assistance of social worker (table 2). each theme is explained and supported by the following quotes: theme 1: needing a support system this theme encompasses a support system in the form of family support, friends’ attention, and neighbors’ concern. almost all informants received support from their families, who assisted in their care, provided walking aid facilities, and helped with medical expenses. informants received support from peers through visits from peers, where they always encouraged and shared their experiences in post-stroke care. in addition, the informants received neighbor concern in the form of visits from neighbors, neighbors feeling worried if they didn’t see each other after a few days, and neighbors often delivering food. the informants’ statements are as follows: “my husband and children helped me during my illness. they took turns taking care of me. in the morning, my oldest daughter came to cook and help me bathe, while my youngest daughter assisted me in the afternoon.” (informant 1). “neighbors would also often stop by, even if just to chat and ask about my condition.” (informant 4). “friends would come to visit me at home, and i was happy about that. i felt i was not alone. they shared tips on how to take care of my stroke at home so that i could recover quickly.” (informant 8). theme 2: needing assistance to access health facilities this theme covers assistance required due to physical limitations, challenging living conditions on a mountain, and the absence of public transportation. nearly all informants needed help due to their weak physical condition and their inability to grip with their hands. some informants needed assistance to reach healthcare facilities, as they live on the mountain and felt anxious about going down the mountain alone; they needed 2 people to assist them in descending the mountain. furthermore, some informants also live in homes that are far from health facilities and lack access to public transportation. article table 1. informant characteristics. informant age level of education marital status occupation sex socioeconomic status post-stroke period (year) (years) in1 56 senior high school widowed retired female above pmw 2 in2 48 bachelor married civil servant male above pmw 1 in3 38 bachelor married housewife female above pmw 1 in4 57 bachelor married civil servant female above pmw 3 in5 61 senior high school married housewife female below pmw 3 in6 50 bachelor married private employer male above pmw 2 in7 65 senior high school widower retired male below pmw 3 in8 61 senior high school married retired female below pmw 3 in9 45 bachelor married civil servant female above pmw 2 in1–in9, informant 1– 9; pmw, provincial minimum wage. table 2. categories and themes. category theme family support needing a support system attention from friends concern for neighbors assistance due to living conditions in the mountains needing assistance to access health facilities there was no public transportation assistance due to limited physical conditions needing information on the whereabouts of social worker needing information on the whereabouts and assistance of social worker needing assistance of social worker at home [healthcare in low-resource settings 2024;12:13363] [page 221] theme 3: needing information on the whereabouts and assistance of social worker this theme includes the need for information on the whereabouts of social workers and assistance from social workers. almost all informants need for information and assistance from social workers, especially when family members were not with the informant. the following is the informant’s statement: “”i didn’t know who i should contact to find out where the social worker was and whether i was entitled to get this assistance”. (informant 1-7). “if only i could contact a social worker to accompany me at home so that i wouldn’t feel lonely, because my children are all married and working”. (informant 6,8,9). “i needed the help of a social worker... i was not yet skilled at using the walking aids in my house... maybe a social worker could help me”. (informant 2, 5, 7) discussion this study aims to explore the social needs of post-stroke patients during their period of resilience. the findings in this study were used to design intervention strategies for improving the resilience of post-stroke patients. the nursing interventions prepared later can be a guideline for improving the quality of life for these patients. the immediate consequences of stroke during the acute phase are the beginning of their struggle against the physical impairment and disability caused. as time passes, the immediate clinical consequences of stroke become complicated due to a variety of poorly recognized medical, musculoskeletal, and psychosocial difficulties. the emphasis is on enhancing survival.23 this attitude is described by almost all informants diligently doing physical exercise. this is in line with other studies indicating that awareness of the importance of physical exercise increases in post-stroke patients, particularly those with a history of ischemic stroke.24 a correlation was found between physical activity and a decrease in stroke attacks.24 a form of physical exercise that is often performed by post-stroke patients is walking. informants in the current study attempted to walk in various ways (holding onto walls, chairs, tables, or by using walking aids). this is in accordance with other studies which found that more than 85% of respondents consider walking as their primary form of exercise among post-stroke ischemic patients.24 however, in improving post-stroke functional abilities, patients require support from various parties. this can be seen in theme 1 of the study’s findings, highlighting the need for a support system from family, friends, and neighbors. this support affects patients’ resilience in living their lives with post-stroke conditions, enabling them to improve their quality of life. this is consistent with the findings of our earlier study, which revealed that the involvement of patients, family, and peers in the care of post-stroke urinary incontinence patients significantly correlates with the achievement of patients’ functional independence in self-care, sphincter motor, transfer, and locomotion.12 social support received by post-stroke patients not only contributes to the achievement of functional abilities but also psychological aspects. the social support system is considered a crucial protective factor, especially for those experiencing stress, and these protective factors are necessary for the recovery process.25 social support can indirectly improve patients’ adaptability and mental health by mobilizing their internal psychological resources to cope with adverse conditions and provide significant assistance in their physical and mental recovery.26 physical recovery of poststroke patients can also be optimally achieved by utilizing available health facilities. this is in line with the findings of this study regarding theme 2, which highlights the need for assistance to access health facilities. the challenging living conditions in the mountains, which are rocky and slippery during rainy weather, coupled with the lack of public transportation, necessitate support for accessing healthcare services, including medical rehabilitation centers. transportation barriers have a significant impact on people’s access to health services. people living in rural and peripheral areas, where public transportation and internet services may be limited, need to travel long distances to be able to access those health services. this poses a challenge for those living with chronic diseases that require regular care. policymakers can play an important part in translating science into practice in the field of stroke care.27 for stroke patients, improving accessibility to healthcare facilities and stroke teams is essential to ensure better outcomes.27 cross-program and cross-sector collaboration, along with local community empowerment, needs to be strengthened to effectively address complex and multifactorial public health challenges, including prevention, management, and rehabilitation. the empowerment approach in stroke rehabilitation involves collaboration between stroke survivors, caregivers, healthcare providers, health services, and the existing stroke community support structures.28 for this reason, collaboration between various parties, including the local community, needs to be carried out to increase patients’ resilience in overcoming the post-stroke conditions they experience. beside it, the social worker presence is also needed. social workers focus on helping individuals, families, groups, and communities improve their well-being and quality of life. this can be seen in the findings of theme 3 of this study. the need for information on whereabouts and assistance that social workers can provide is the thing most often mentioned when stroke patients return to community life.29 health systems must maintain relationships with stroke patients through sustainable, personalized, long-term and practical services, to meet their changing needs. this will ensure that they are truly helped and do not feel excluded. the presence and assistance of social workers can also meet the psychosocial needs of post-stroke patients.29 this research has its limitations as well as its strengths. the limitation is that the research findings cannot be broadly generalized, since the informants only came from southeast sulawesi, despite the use of purposive sampling to select participants. conversely, the strength of this study is that the data obtained can serve as basic data in developing interventions to increase the resilience of post-stroke patients, particularly in regions characterized by plains, hilly and mountainous areas, and coastal areas. conclusions exploration of the social needs and resilience of post-stroke patients can help determine further interventions that can enhance their quality of life. resilience can be achieved by requiring a support system, requiring assistance for access to health facilities, and requiring information of social worker assistance. future research should consider obtaining research samples from numerous regions with varying ethnicities and customs, as resilience is also influenced by the normative values adopted. furthermore, exploring various regions with geographical differences can help identify social needs article [page 222] [healthcare in low-resource settings 2024;12:13363] that align with the patients’ condition. the results of this study can also be expanded into quantitative research methods by examining the relationship or influences of the themes identified. references 1. feigin vl, owolabi mo, feigin vl, et al. pragmatic solutions to reduce the global burden of stroke: a world stroke organization–lancet neurology commission. lancet neurol 2023;22:1160-206. 2. lee hj, lim yc, lee ys, et al. analysis of medical service utilization for post-stroke sequelae in korea between 2016 and 2018: a cross-sectional study. sci rep 2022;12:1-13. 3. li qx, zhao xj, wang y, et al. value of the barthel scale in prognostic prediction for patients with cerebral infarction. bmc cardiovasc disord 2020;20:1-5. 4. bright fas, ibell-roberts c, wilson bj. psychosocial wellbeing after stroke in aotearoa new zealand: a qualitative metasynthesis. disabil rehabil 2024;46:2000-13. 5. guo j, wang j, sun w, liu x. the advances of post-stroke depression: 2021 update. j neurol 2022;269:1236-49. 6. knapp p, dunn-roberts a, sahib n, et al. frequency of anxiety after stroke: an updated systematic review and meta-analysis of observational studies. int j stroke 2020;15:244-55. 7. elayoubi j, haley we, nelson me, hueluer g. how social connection and engagement relate to functional limitations and depressive symptoms outcomes after stroke. stroke 2023;54:1830-8. 8. han zt, zhang hm, wang ym, et al. uncertainty in illness and coping styles: moderating and mediating effects of resilience in stroke patients. world j clin cases 2021;9:899910. 9. chen cp, tung hh. resilience and daily activity among patients after stroke. aging med healthcare 2021;12:152-8. 10. heltty h, zahalim z. resilience after stroke and its correlation with functional independence. j ners 2023;18:57-3. 11. kim ey, chang so. exploring nurse perceptions and experiences of resilience: a meta-synthesis study. bmc nurs 2022;21. 12. heltty h. patient, family, and peer engagement in nursing care as an effort to improve the functional independence of poststroke urinary incontinence patients: a cross-sectional study. cureus 2022;14:6-12. 13. southwick sm, bonanno ga, masten as, et al. resilience definitions, theory, and challenges: interdisciplinary perspectives. eur j psychotraumatol 2014;5. 14. zimmerman ma. resiliency theory. heal educ behav 2013;40:381-3. 15. heltty h, sitorus r, nusdwinuringtyas n, martha e. effect of self-regulation and social support intervention on the life quality in patients with post-stroke urinary incontinence. korean j adult nurs 2021;33:399-5. 16. steverink n, lindenberg s, spiegel t, nieboer ap. the associations of different social needs with psychological strengths and subjective well-being: an empirical investigation based on social production function theory. j happiness stud 2020;21: 799-24. 17. howell cr, harada cn, fontaine kr, et al. perspective: acknowledging a hierarchy of social needs in diabetes clinical care and prevention. diabetes, metab syndr obes 2023; 16:161-6. 18. kreuter mw, thompson t, mcqueen a, garg r. addressing social needs in health care settings: evidence, challenges, and opportunities for public health. annu rev public health 2020;42:329-44. 19. moisoglou i, katsiroumpa a, kolisiati a, et al. resilience and social support improve mental health and quality of life in patients with post-covid-19 syndrome. eur j investig heal psychol educ 2024;14:230-42. 20. musich s, wang ss, schaeffer ja, et al. the association of increasing resilience with positive health outcomes among older adults. geriatr nurs (minneap) 2022;44:97-104. 21. norvang op, dahl ae, thingstad p, askim t. resilience and its association with activities of daily living 3 months after stroke. front neurol 2022;13:1-8. 22. ahmed sk. the pillars of trustworthiness in qualitative research. j med surgery, public heal 2024;2:100051. 23. chohan sa, venkatesh pk, how ch. long-term complications of stroke and secondary prevention: an overview for primary care physicians. singapore med j 2019;60:616-20. 24. hou l, li m, wang j, et al. association between physical exercise and stroke recurrence among first-ever ischemic stroke survivors. sci rep 2021;11:13372. 25. sun b, wang n, li k, et al. the mediating effects of hope on the relationships of social support and self-esteem with psychological resilience in patients with stroke. bmc psychiatry 2024;24:340. 26. wang y, li g, ding s, et al. correlation between resilience and social support in elderly ischemic stroke patients. world neurosurg 2024;184:e518-23. 27. bindawas sm, vennu vs. stroke rehabilitation: a call to action in saudi arabia. neurosciences 2016;21:297-05. 28. hartford w, lear s, nimmon l. stroke survivors’ experiences of team support along their recovery continuum. bmc health serv res 2019;19:1-12. 29. guo y, zhang z, lin b, et al. the unmet needs of communitydwelling stroke survivors: a systematic review of qualitative studies. int j environ res public health 2021;18:214 article [healthcare in low-resource settings 2024;12:13363] [page 223] hrev_master healthcare in low-resource settings 2025; volume 13:13433 insights into gender-equity in healthcare accessibility in northern nigeria: descriptive and predictive approaches chika yinka-banjo,1 olasupo ajayi,2 mary akinyemi,3 david tresner-kirsch,4,5 adekemi omotubora6 1department of computer sciences, university of lagos, lagos, nigeria; 2caesar lab, queen’s university, kingston, on, canada; 3department of mathematics & statistics, austin peay state university, clarksville, tn, united states; 4nivi, inc., sudbury, ma, united states; 5department of computer science, brandeis university, waltham, ma, united states; 6department of commercial & industrial law, university of lagos, lagos, nigeria abstract universal health coverage (uhc) aims at ensuring equitable access to healthcare for everyone, irrespective of gender, location, or financial status. though progress has been made in achieving uhc, a lot remains to be done in under-served areas of the world. these regions face immense challenges accessing healthcare services, including unavailability of basic medications, socio-cultural and religious beliefs, and various forms of discrimination. beyond these, women are still severely disadvantaged in these regions, with child brides and teenage pregnancy being prevalent. this work analysed data from regions of northern nigeria to determine equity in healthcare accessibility. descriptive analysis (using correlation models) and predictive analysis (using machine learning models) were carried out. the descriptive analysis revealed that women with low income and education levels, and the elderly have a higher chance of accessing healthcare services compared to other genders, while the predictive analysis revealed that, using machine learning, accessibility to healthcare services can be predicted with up to 81% accuracy. introduction in the last few years, there has been an overarching improvement in healthcare services globally. reports from the united nation and world health organisation show that significant efforts have been made in reducing deaths resulting from various diseases, as well as infant and maternal mortality globally.1,2 despite these efforts, healthcare accessibility remains a challenge in many parts of the world, specifically the global south countries of africa and asia. these regions have the lowest number of healthcare professionals at 2.3 medical doctors per 10,000 people compared to the world average of 16.3 doctors per 10,000 people. women are the most affected by the poor healthcare services in these regions. for instance, approximately 90% of all maternal mortalities globally were in sub-saharan africa, central and southern asia. similarly, these regions also have the highest percentage of adolescent pregnancy (i.e., pregnant girls between the ages of 15 and 19).1 several studies have attempted to assess equity in healthcare systems across africa. in some work, statistical models were used,3-5 while others used artificial intelligence (ai) and machine learning (ml) models to analyse health data,6 predict the outcome of healthcare services,7 assess gender equity,8 and/or eliminate gender biases in healthcare.9-11 like these works, this study also seeks to assess gender-equity in healthcare but from both descriptive and predictive perspectives, considering individual correspondence: olasupo ajayi, caesar lab, department of electrical and computer engineering, queen’s university, kingston, k7l 3n6, ontario, canada; +1437-421-8617, o.ajayi@queensu.ca key words: data analysis, data correlation, gender-equity, healthcare, machine learning. contributions: cy-b, principal investigator, conceptualization, methodology; oa, investigation, software, writing – original draft; ma, coinvestigator, formal analysis, and validation; dt-k, resources, data collection, administration; ao, writing reviewing & editing, adherence to ethics. ethics approval and consent to participate: college of medicine, university of lagos health research ethics committee. cmul/hrec/11/22/1130. data were collected from respondents who gave their consent to participate. all respondents were presented with a first page on the nivi app, which clearly stated that the data being collected was for research and analytic purposes and would remain completely anonymous without any form of tracking. all respondents were required to accept these terms and conditions before being allowed to participate in the data collection exercise. data were collected using asknivi, an app specifically designed for healthcare related data collection. privacy policy, consent, and related information about asknivi can be found at www.nivi.io/privacy-policy availability of data and material: the datasets generated and/or analysed during this study can be found in the mendeley repository, https://data.mendeley.com/datasets/8gbywtd7bv/2. conflict of interest: the authors declare that they have no competing interests. funding: united states agency for international development (usaid) and the dai global, under the ‘nivi and the university of lagos (unilag): partnering to create a gender-aware auditing tool’ project. acknowledgement: the authors would like to acknowledge nivi inc. for the use of their asknivi application platform to administer the questionnaires, as well as the artificial intelligence and robotics lab (airol) at the university of lagos, for the use of their space for collaborative meetings. received: 28 november 2024. accepted: 23 may 2025. early access: 9 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13433 doi:10.4081/hls.2025.13433 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 202] [healthcare in low-resource settings 2025;13:13433] characteristics (age, gender), socio-economic factors (income, education, and marital status) and medical symptoms as input parameters. the specific contributions of this work are: i) to carry out descriptive analyses and assess the level of gender-equity in healthcare accessibility in northern nigeria; this is especially relevant to goals 3 (good health and well-being) and 5 (gender equality) of the un’s sustainable development goals (sdg); ii) to develop models for predicting healthcare accessibility which consider individual characteristics and socio-economic factors. these models seek to predict if an individual a, who is of gender g, marital status m, education level e, and income level i, would be able to access health care service. materials and methods in assessing healthcare accessibility, we developed the genderequity healthcare access framework (gehaf) a multi-phased framework depicted in figure 1. though the primary focus of this work is on phase 3c, 4 and 5c of the framework, all the 5 phases are briefly described in this section. three datasets were used for this work, however, for brevity, only the results of the first dataset are presented. in phase 1 of figure 1, data on gender-equitable accessibility to healthcare was collected as follows: i) data for this work was collected from about 500 towns and villages across the northern region of nigeria. the collection area spanned geographical coordinates: 13.032880, 5.365820 and 9.267890, 5.345540 to the west to 11.831740, 13.166820 and 9.173710, 12.415130 to the east; ii) data was collected using questionnaires administered via a mobile app called asknivi.18 iii) asknivi is a conversational chat-like health tool developed to provide health education and referrals for healthcare systems; iv) all respondents gave their consent before participating in the data collection exercise; v) the respondents were asked 43 questions, split into four sections, a) demographic information, b) socio-economic information, c) wellness check, d) healthcare dei. the questions were a mix of boolean (‘yes/no’), short answer / free text, and likert scale (‘agree’, ‘neutral’, ‘disagree’) type questions; and were designed to be simple and unambiguous; vi) the 43 questions corresponded to the 43 attributes in the dataset, namely: ‘age’, ‘gender’, ‘language’, ‘askmarital’, ‘asklocation’, ‘askhavekids’, ‘howmanykids’, ‘nationality’, ‘ethnicity’, ‘askeducation’, ‘askincome’, ‘askemployment’, ‘healthaccess’, ‘typeofhealthcare’, ‘socialsupport’, ‘details’, ‘askfamilysupport’, ‘familysymptoms’, ‘wellness’, ‘symptoms’, ‘howlongsymptoms’, ‘gettingbetterorworse’, ‘whichfamily’, ‘sex’, ‘partners’, ‘overallhealth’, ‘medicines’, ‘medicinescurrent’, ‘medicinesrecent’, ‘alcohol’, ‘smoke’, ‘howoftensmoke’, ‘howoftenalcohol’, ‘surgeries’, ‘describesurgeries’, ‘inclusion’, ‘equity’, ‘diversity’, ‘genderjusticesafety’, ‘harassment’, ‘genderjusticecomfort’, ‘discrimination’, ‘refusedtreatment’; vii) a total of 4,628 records across the 43 attributes were collected. the corresponding datasets, code book, and questionnaire are available in.12 the collected data was then pre-processed to remove duplicates, nulls, or invalid entries. phase 1 also has a language translation module that helps translate data in any source language to english language. in phase 2 and 3a, the ‘symptoms’ field one of the 43 attributes in the dataset, was passed through scispacy named entity recognition (ner)13 to extract medical related terms. the output of these phases was an annotation table of symptoms, as shown on table 1. in phase 3b, a human auditing dashboard14 was developed to improve the annotation accuracy in phase 3a. the revised annotation table was appended to the original dataset and used to train ml models in phase 3c. in phase 3c, the aim was to develop ml models capable of predicting healthcare accessibility. specifically, it sought to determine if an individual of a certain gender and socio-economic class, who presents with certain symptoms (s), at a given healthcare facility in northern nigeria would be treated or not. we formally model this as the quintuple in (1): (1) article [healthcare in low-resource settings 2025;13:13433]] figure 1. gender equity healthcare access framework (gehaf). where a is an individual, g and m are a’s gender and marital status respectively, while e is the level of education (ranging from primary to tertiary). i is a’s income level, while s is a set of x symptoms, x = {1, 2 … 17}, ∀ sx= {0, 1}, with 1 implying that the individual a is experiencing a particular symptom x, and 0 if otherwise. p = {0, 1} and represents the prediction result, i.e., 0 if a would be denied health care or 1 if a would be able to access healthcare service. to develop the prediction models, 6 of the 43 attributes in the dataset were considered, namely ‘gender’, ‘askmarital’, ‘askeducation’, ‘askincome’, ‘symptoms’, and ‘refusedtreatment’. the following steps were then taken. the respondents’ genders (man, woman, or non-binary) were extracted from the dataset. the gender attribute was label encoded into categorical data. similar or related symptoms were combined. for instance, symptoms such as ‘dizziness’ and ‘dizzyness’, were combined, as well as ‘back pain’ and ‘backpain’; ‘headache’, ‘head ache’, and ‘headaches’; ‘itches’, ‘itchy’, and ‘itching’, etc. the most common (highest respondent count) symptoms in the dataset were selected. these were ‘stomach’, ‘back’, ‘chest’, ‘coughs’, ‘diabetes’, ‘dizziness’, ‘fever’, ‘headaches’, ‘body pains’, ‘vomiting’, ‘itches’, ‘malaria’, ‘teeth’, ‘ulcer’, ‘virginal’, ‘catarrh’, and ‘infections’. three socio-economic features were extracted from the dataset, namely ‘askmarital’ (marital status), ‘askeducation’ (level of education), and ‘askincome’ (level of income). the socio-economic features were converted into categorical data using one-hot encoding. each respondent could choose 1 of 5 options when responding to the question about accessibility to healthcare (i.e., the ‘refusedtreatment’ attribute). these options were ‘agree’, ‘moderately agree’, ‘neutral’, ‘moderately disagree’, and ‘disagree’. while processing this field ‘agree’ and ‘moderately agree’ were combined into ‘agree’, ‘moderately disagree’ and ‘disagree’ were grouped as ‘disagree’, while neutral responses were dropped. this reduced the respondents to two groups. ‘agree’ meant that the respondent was refused health care at the healthcare facility, while ‘disagree’ meant that the respondent received health care. the ‘refusedtreatment’ attribute was the target column for the ml models and was label encoded into a binary class (1 or 0). three ml models were trained on the data and their performances compared in terms of prediction accuracy, precision, recall, and f1-score. details of the ml models are presented in subsection "machine learning model". the final dataset used in training the ml models consisted of 22 columns summarised on table 2. in phase 4, the datasets were analysed using statistical models to provide insights on gender-equality in healthcare across regions of northern nigeria. these descriptive analyses were done in parallel to phases 2 and 3 and are presented in subsection "data analysis" phase 5 presents the obtained results. data analysis to analyse the relationship between individual characteristics (age, gender), socio-economic factors (marital status, location, level of education, income level, employment status, and ethnicity) and healthcare equity, (inclusion, equity, diversity, gender justice, harassment, discrimination, and access to treatment), statistical correlation analyses were carried out. we used the pearson correlation coefficient (pcc) and spearman correlation coefficient (scc),16 while the probability value (p-value) was used to measure the level of statistical importance. pearson correlation coefficient (pcc), designated as r, is article table 2. dataset attributes. sn attributes options 1 ‘gender’ (g) man, non-binary, woman 2 ‘askmarital' (m) divorced, married, single, widow/widower 3 'askeducation' (e) primary, secondary, tertiary, or other 4 'askincome' (i) level 1 (>usd 100,000) level 6 (< usd 500) 5-21 ‘stomach’, ‘back’, ‘chest’, 'teeth', 'coughs’, 1 or 0. 'diabetes', 'dizziness’, 'fever', 'ulcer', 'headaches', 'body pains', 1 if the respondent experiences the symptom or 0 if otherwise. 'vomiting', 'itches', 'malaria', 'virginal', 'catarrh', 'infections’ 22 ‘refusedtreatment’ agree or disagree [page 204] [healthcare in low-resource settings 2024;12:xxx] table 1. sample output of phases 2 and 3a of gehaf framework. often used to find the association between two parametric attributes (e.g. age). pcc is calculated using (2) for attributes x and y . (2) where r = pcc, x’ and y’ are sample mean values of x and y respectively. spearman ranks correlation coefficient (scc), denoted rs, is used to show association between two non-parametric attributes, e.g. likert scale. scc is defined in (3). (3) where d is the difference in rank between values of the two attributes being considered. for pcc and scc, the results usually fall within the range of -1 ≤ cc_value ≤ 1. a cc_value between 0 and 0.39 (or between 0 and -0.39) implies a weak positive (negative) relationship between the two attributes, a cc_value between 0.4 and 0.69 (or between 0.4 and -0.69) implies a moderate positive (negative) relationship, while values between 0.7 and 1 (or between -0.7 and -1) imply strong positive (negative) relationship between the two attributes. finally, we calculated the probability value (p-value) to determine the statistical significance of the correlation between two attributes and set the threshold to 0.05. machine learning models the ‘refusedtreatment’ attribute was used as the target for the ml models. by grouping all values of the ‘refusedtreatment’ attribute into either ‘agree’ and ‘disagree’, the problem was reduced to a binary classification. this dataset initially contained 1093 records, however, after the cleaning, preprocessing and annotation processes (phases 1-3 of gehaf), only 412 valid records were left. the data was also highly imbalanced, with the majority (381) of records belonging to the ‘refusedtreatment’ = ‘disagree’ class, i.e., those who were able to access health care, while only a minority (31) of data belonged to the ‘agree’ class (those who were refused treatment). to balance the dataset, we oversampled the minority class.16 three ml models were considered in this work catboost, random forest, and support vector classifier (svc). catboost or categorical boosting, is an unbiased gradient boosting algorithm that is suited for categorical data.17 catboost was selected because our dataset was small and consisted of attributes with a mix of data types (boolean, texts, and likert values). random forest (rf) is based on multiple (ensembled) decision trees (dt). rf considers the result of each dt, then uses a voting system to make the final decision. like dt, rf does not require prior information about the distribution of the data,7 hence, suitable for our work. support vector classifier (svc) creates hyperplane(s) to separate variables into classes. we considered svc for this work because it has good learning and generalisation abilities with small and heterogeneous datasets. two sets of experiments were carried out. for the first, the raw imbalance data was used, while the augmented (oversampled) dataset was used in the second. the experiments were done in google colab, using a combination of python, jupyter notebook, and scikit-learn library.18 all codes used in this study are available in code ocean code repository.19 accuracy, precision, recall, and f1-score, were used as metrics. recall and f1-score are best suited for measuring imbalance datasets, as recall reveals the correctly detected proportion of true positives, while f1-score is the harmonic mean of precision and recall. parameter tuning cross validation and hyper-parameter tuning for each of the ml models were done using scikit-learn’s stratifiedkfold library.18 for catboost and rf, we considered 4 iteration values 250, 500, 1000, 2000; 3 depth values 6, 8, 10; and 5 folds. f1score was used as the evaluation metric for the cross-validation process. in addition, we also considered 3 learning rates for catboost, i.e., 0.1, 0.05, and 0.01. for svc, the same iteration values were considered, alongside 3 kernel options ‘linear’, ‘rbf’, and ‘sigmoid’; 3 c-values 0.01, 0.001, and 0.0001; 4 gamma values 0.1, 1, 10, and 100. table 3 summarises the combinations of parameters that yielded the best results and used in this work. results as previously mentioned, two types of analyses were carried out on the dataset descriptive data analysis using mathematical and statistical models, and predictive data analytics, using ml models. reports of both are presented in this section. associations all attributes in the dataset, except age, were one-hot encoded. for instance, with the ‘gender’ attribute, women were encoded as 0, non-binary as 1 and men as 2. similar encoding scheme was used for all the other attributes. the associations between the attributes are shown on table 4. article table 3. machine learning parameter tuning. raw data augmented data catboost iterations = 250, depth = 6, learning rate = 0.01. iterations = 500, depth = 10, learning rate = 0.1. f1-score = 95.8 % f1-score = 77.7 % svc tolerance = 1e-05, max_iteration = tolerance = 1e-05, max_iteration = 500, 250, gamma = 0.1, c = 0.01, kernel = 'rbf'. gamma = 10, c = 0.01, kernel = 'rbf’. f1-score = 95.8 % f1-score = 79.8 % rf iteration = 250, max_depth = 10. iteration = 500, max_depth = 10. f1-score = 95.2 % f1-score = 76.8 % [healthcare in low-resource settings 2025;13:13433] [page 205] descriptive analysis the impact of gender and socio-economic attributes on healthcare accessibility are presented in this section. influence of age and gender on healthcare accessibility figure 2a shows that most (94%) of the respondents were below 40 years old. across all the age groups, the majority (63% of those below 21, 61% of those between 21 and 30, 70% of those between 30 and 41 years old) disagreed with being refused treatment, i.e. they were able to access treatment from the healthcare facility. in figure 2b, 245 of the 318 women (77%) were able to access healthcare services, while 7% had challenges accessing healthcare services. similarly, 68% of the men were able to access healthcare services, compared to 5% who could not. only 2 of the 9 non-binary respondents had no challenges accessing health services. overall, most (77% of the women, 68% of the men, 78% of the non-binary gender) of the respondents were able to access health services, a fact buttressed on table 4 with a p-value of 0.016 indicating a statistically insignificant association between gender and healthcare accessibility. influence of location on healthcare accessibility in figure 3, 19 of the 277 (6.8%) women living in towns were refused treatment, compared to 4 of the 41 (9.8%) living in villages. similarly, 3.8% of the city-dwelling men were refused healthcare services compared to 12.5% of the village dwellers. this shows that a higher percentage of village dwellers were unable to access healthcare services, compared to their towndwelling counterparts. influence of marital status on healthcare accessibility in figure 4, 5.8% of the single women were refused treatment, compared to 10.3% of married women. for the men, 5.4% of the single men and 4.7% of the married men were unable to access treatment. marriage is therefore not a critical requirement to accessing healthcare. with an associative value of -0.053 and a pvalue of 0.249, table 4 also shows that marital status and access to treatment (“refusedtreatment”) are weakly associated. influence of income on gender-based healthcare accessibility in figure 5, level 1 denotes respondents with annual income article table 4. associations among attributes in the dataset. [page 206] [healthcare in low-resource settings 2025;13:13433] greater than ngn 70 million (usd 88,000). level 2 are those earning between ngn 45 70 million or (usd 56,000 88,000), level 3 earned between ngn 25 44 million (usd 31,000 55,000), level 4 earned between ngn 7 24 million (usd 8,750 30,000), level 5 earned between ngn 0.7 6 million (usd 875 7,500), while level 6 implies an income of less than ngn 300,000 (usd 375). most of the respondents were within levels 5 and 6. this is unsurprising as the minimum wage in nigeria, as at the time of writing, was about ngn 360,000 (usd 450) annually. due to the limited data about higher income levels (level 1 level 4), only responses from levels 5 and 6 respondents were analysed. of the 245 level 6 women respondents, 16 (6.5%) were refused treatments, while 8 (11%) of the 55 level 5 women were refused treatment. for both income levels, over 78% were able to access treatment. for the men, 7% of those in level 6 were denied treatment, while none of the level 5 respondents were refused treatment. of the 8 non-binary respondents, only 2 reported being refused treatment. thus, for men, income level influences healthcare access, as the richer men (level 5 and 6) were almost never refused treatment. for the women, the reverse is observed, as more level 5 women were denied treatment compared to level 6 women. statistically, an scc value of 0.089, shown on table 4, indicates a weak association between income and “refusedtreatment”. in addition, the low p-value (0.049) implies that wealth might not always guarantee access to healthcare, as indicative of the reverse trend observed with more richer women (level 6) being denied treatment than any other income group. influence of employment on gender-based healthcare accessibility figure 6 reveals that only 6 of the 116 unemployed women were refused treatment, compared to the 83% who were able to access healthcare services. similar ratios were observed for the employed women. self-employed women had the most challenge accessing article [healthcare in low-resource settings 2025;13:13433] [page 207] figure 2. (a) influence of age (b) influence of gender on healthcare access. figure 3. impact of gender on healthcare. healthcare with 10% of them (13 of 121) reporting being refused treatment. for the men, only 1 (of the 42 employed) and 3 (of the unemployed men) were refused treatment. however, like the women, a higher percentage (7%) of the self-employed men were refused treatment. there were 9 non-binary respondents and only 2 reported being refused treatment, with the first being unemployed and the other being employed. the drawn inference is that there seems to be a bias against self-employed persons, irrespective of gender. statistically, a p-value of 0.656 for employment and healthcare accessibility shown on table 4, indicates that this is highly probable. article [page 208] [healthcare in low-resource settings 2025;13:13433] table 5. comparison of prediction results for raw & augmented data. model class accuracy precision recall f1-score raw (%) augmt (%) raw (%) augmt (%) raw (%) augmt (%) raw (%) augmt (%) catboost 0 93 81 0 81 0 81 0 81 catboost 1 92 81 100 81 96 81 svc 0 92 81 0 81 0 81 0 81 svc 1 92 81 100 81 96 81 rf 0 93 81 100 77 19 87 32 82 rf 1 93 85 100 74 97 79 figure 4. influence of marriage on healthcare. figure 5. influence of income levels on healthcare. influence of education on gender-based healthcare accessibility figure 7 shows that among the 89 women with secondary level education and 194 with tertiary level education, 8 (8.9%) and 14 (7.2%) respectively reported being refused treatment. for the men, 6 (10%) of the 58 with secondary education and 1 of the 82 with tertiary level education were refused access to healthcare services. similar trends were observed with the non-binary gender, as only those with secondary and/or tertiary level education were refused treatment. the drawn inference is that there seems to be a bias against higher levels of education irrespective of gender, but the bias seems more targeted at women with tertiary level education. table 4 also buttresses this inference, with a weakly negative (0.096) but statistically significant (p-value = 0.034) association between education and refused treatment. predictive data analysis using ml models, this section seeks to determine if an individual a, of g gender, marital status m, education level e, income level i, and shows symptoms s (i.e., p = a<g, m, e, i, sx>) would be able to access healthcare service. raw data as earlier stated, the raw data was not balanced, with a ratio of 381:31 between the majority class (individuals who were able to access treatment) and minority class (those who were refused treatment). table 5 shows a comparison of the prediction results for the minority class (0) using the raw and augmented datasets. on the table, “0” refers to the result obtained when the corresponding model was trained using the minority class data, while “– 1” refers to the result of the majority class. using the raw data, rf yielded recall and f1-score values of 19% and 32% respectively for the article [healthcare in low-resource settings 2025;13:13433] [page 209] figure 6. influence of employment on healthcare. figure 7. influence of education on healthcare. minority class, while catboost and svc both had 0% for recall and f1-score. a value of 0 % implies that no classification was created for the minority class. this is in line with 16, 20 where recall was reported as 0% for the minority class in highly imbalanced datasets. to address the poor prediction performance of the three models, we augmented the minority class data by oversampling it. augmented data we augmented the minority class by oversampling it, then used the majority class (1) and augmented_minority_class data to train the three models. obtained results, shown under “augmt” columns on table 5, reveal that the augmentation process significantly improved the prediction results of the minority class (0). the recall and f1-score values of catboost and svc both rose to 81%, while rf’s recall rose from 19% to 87% and f1-score rose from 32% to 82% for the minority class. in summary, augmenting the data significantly improved the ml models’ ability to predict healthcare accessibility. therefore, the probability that an individual would be able to access (or be denied) healthcare services can be predicted with up to 81% accuracy on the average. discussions from both analyses the following inferences can be drawn about factors that might influence accessibility to healthcare services: i) healthcare services are more accessible to the elderly; ii) women have a slight advantage in accessing healthcare services compared to the other genders; iii) women with lower income and education levels are marginally better favoured than those with higher income and education levels; the reverse is the case with men; iv) there seems to be a bias against self-employed persons irrespective of gender; v) with a balanced dataset, it is possible to predict, with up to 81% accuracy, if a patient with certain characteristics, socio-economic profile, and symptoms would receive treatment or not. assumptions and limitations there were certain limitations and challenges encountered during this study, including: i) skewed dataset – there were more women respondents than other genders in the dataset; ii) the data was also highly imbalanced w.r.t. the ‘refusedtreatment’ attribute, as most of the respondents disagreed with being refused treatment, while only a few agreed; iii) the ner model used for symptom extraction did not always accurately identify symptoms in text, especially rare medical terms or misspelt words, e.g., it classified ‘dizzyness’ and ‘dizziness’ as different symptoms; iv) assumptions were made while grouping the symptoms together to get the top n; for instance, we grouped ‘headache’ and ‘migraine’ together because we assumed they are related; this might not always be correct, as they might be caused by or associated with completely different ailments. ethical considerations sex and gender this work followed the sex and gender equity in research (sager) guidelines,21 hence, sex refers to the biological and physiological characteristics of a person, and it is assigned at birth. gender refers to the socially constructed characteristics of women and men, such as roles and norms. for this work, three gender identities were considered men, women, and non-binary. marginalization individuals who fall into certain groups might be marginalized and excluded from accessing healthcare services. these include women, individuals living in rural areas, those with disabilities, illiterates, and single mothers. to mitigate this, we followed the p20 guidelines of the development initiative’s inclusive data charter (idc),22 which offers guidelines for identifying and analysing individuals that might be at the greatest risk of marginalisation. anonymity and privacy privacy concerns might dissuade people from giving accurate information. for example, women may give false information about their marital status, because marriage is generally considered a socially desirable status in nigeria. to alleviate these concerns this research collected data anonymously. conclusions though considerable progress has been made in terms of healthcare accessibility globally, a lot still needs to be done to achieve universal health coverage, especially in rural areas of the world. in many remote and developing countries, accessible and affordable healthcare services remain elusive, while women are severely marginalised. factors responsible for these include level of education, poverty, socio-cultural and religious beliefs. this work considered regions in northern nigeria and analysed data on healthcare accessibility, through individual, socio-economic, and equity lenses. descriptive and predictive analyses were carried out on the data using statistical and machine learning (ml) models respectively. for the descriptive analysis, pearson and spearman’s correlation coefficients were used, while catboost, random forest and support vector machine ml models were used for the predictive analysis. the descriptive analysis revealed that women with lower income and education levels, and the elderly have a higher chance of accessing healthcare services. for predictive analysis, when an individual’s biological characteristics, socio-economic status and medical symptoms are considered, ml models can predict the individual’s accessibility to healthcare services, with up to 81% accuracy. data used in this work were in english language, which is not the native language in the region considered. analysis of data in indigenous languages might be an avenue to extend this work. additionally, exploration of other data augmentation techniques and the use of deep learning models for prediction might also be another direction for future work. finally, other methods of quantifying qualitative data, such as fuzzy logic, could be considered for data pre-processing in the future. references 1. united nations. the sustainable development goals report 2023: special edition. unstats.un.org. united nations; 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[internet]. available from: https://www. data4sdgs.org/sites/default/files/file_uploads/jn_1286_idc_ kp_di_casestudy.pdf article [healthcare in low-resource settings 2025;13:13433] [page 211] hrev_master healthcare in low-resource settings 2025; volume 13:13478 modeling correlates of long-acting contraceptive use in north west ethiopia: a community based cross-sectional study kebadu tadesse cherie,1 gedif mulat alemayehu,2 endalew tesfa getie1 1department of statistics, college of natural & computational sciences, debre markos university, debre markos; 2department of statistics, college of natural & computational science, injibara university, injibara, ethiopia abstract the use of long acting contraceptive methods is a common practice among women seeking to prevent unintended pregnancies and plan their families. this study seeks to identify factors associated with the practice of long-acting contraceptive methods, particularly in a conflict-affected area in awi zone, north west ethiopia. a cross-sectional study was conducted on a multistage random sample of 1,334 women’s. bivariable and multivariable binary logistic regression has been applied to identify determinant factors. among the 1,334 women surveyed, 25.49% reported using long-acting contraceptive methods. the analysis revealed that women’s educational level, wealth index, being visited by health extension, marital status, use of children as a source of income, and occupational status of women were factors significantly hindering the use of long-acting contraceptive methods in the area. in conclusion, higher contraceptive use was observed among educated, married women, women who used children as a source of income, and women employed by the government. it is therefore recommended that government officials in awi zone and policy makers should implement programs to increase female education and employment, which could lead to greater use of contraceptive methods for effective family planning. introduction the rapid growth of the world population has become an urgent global concern. most of this growth is occurring in developing countries where, the fertility rate is very high.1 in most developing continents generally, and in sub-sahara africa particularly, the problem of population growth and reproductive health challenges like high maternal mortality, high population growth rate, total fertility rate and much unmet need for family planning is increased.2,3 ethiopia, like most countries in sub-saharan africa, is characterized by high fertility and rapid population growth. the country stands third next to nigeria and egypt in this respect.4 according to 2016 ethiopian demographic and health survey (edhs) reports, from sexually active unmarried women, 58% were currently using a contraceptive method where 55% are using a modern method and 3% are using a traditional method. the higher fertility rate is associated with rapid population growth which directly associated with depletion of productive resources in the society, rising cost of commodity, poor nutrition and limited educational opportunities, and ultimately trapping women in a poverty cycle. high fertility increases health risks for children and mother, and also aggravates environmental threats.5 thus, family planning contributes to promote the health and welfare of the family. it is the means of social development of a country and the best way to control the rapidly and massively growing population which is also essential to the well-being of women, men, adolescents, and the community at large. contraceptive offers the opportunity for women to plan and space pregnancies in order to achieve personal goals and self-sufficiency.6 recently, women are desired to have more children in awi zone of north west ethiopia which intends the population to increase time to time. in spite of the fact that family planning sercorrespondence: kebadu tadesse cherie, department of statistics, college of natural & computational sciences, debre markos university, debre markos, p.o.box: 269, ethiopia. e-mail: kebadu.tadesse@dmu.edu.et key words: awi zone, contraceptive methods, family planning, multiple logistic regression, ethiopia. authors’ contributions: ktc designed the study, performed the statistical analysis, and prepared the manuscript. gma, designed the study, performed the statistical analysis and revised the manuscript. gma collected the data and interpreted the results. both authors approved the final manuscript for publication. funding: the author did not receive external fund for this research. availability of data and materials: the dataset used in this study is available upon request from the corresponding author. ethical approval and consent to participate: informed consent to participate was obtained both verbally and in writing, as the study involved both written and verbal questionnaires administered to women. verbal consent was obtained from each participant, who was fully informed about the study's objectives and confidentiality of their responses were assured. the survey was initiated after receiving approval from the amhara public health institute research ethics review committee and the awi zone health office. ethical clearance and consent to participate were granted by the committee. consent for publication: not applicable. conflict of interest: the authors declare that there is no any competing interest. acknowledgments: the author has special gratitude for all the study participants and woreda health office for their valuable information to accomplish this study. finally we would like to thank data collectors who are supporting us by collecting basic in-formation from respondents even in difficult area of awi zone, north west ethiopia. received: 18 december 2024. accepted: 22 may 2025. early access: 12 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13478 doi:10.4081/hls.2025.13478 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13478] [page 165] vice delivery facilities and other supplies have increased in number in the region particularly in awi zone, the use of contraceptive methods are still low and as a result major portion of the population is still living in abject poverty.7 most studies in developing countries, including ethiopia, have put emphasis on the role of socio-economic, demographic and cultural factors in determining family planning. thus, this study was intended to identify determinant factors of using long-acting family planning methods in a resource limited and conflict affected area in awi zone, north west ethiopia. materials and methods study design a cross-sectional study was carried out among 1,334 reproductive women between september 2022 and may 2023 in the awi zone, located in the amhara region of north west ethiopia. the area, characterized by its flat territory and fertile soil, has elevations ranging from 1,800 to 3,100 meters above sea level, with an average altitude of approximately 2,300 meters. the zone comprises 215,564 households, with an average household size of 7 people. sample size and sampling techniques the sample size was determined using sample size for percentages or proportions formula(8). using 95% confidence level (cl), 3% margin of error (d) and 50 % proportion (p) of using family planning, the sample size was estimated as by considering 1.25 design effects the final sample size was 1,334. a multi-stage cluster sampling method with stratification was applied. in the first stage, two out of three administrative towns and five out of nine districts was selected through simple random sampling technique. in the second stage, two kebeles from injibara town administration, two kebeles from chagni town administration, three kebeles from guagusa shikudad district, three kebeles from banja district, three kebeles from ayehu guagusa district, three kebeles from dangla district and three kebeles from jawi districts were selected randomly. in the third stage, a total of 1,334 households was selected using proportional allocation to each selected kebeles systematically and only one eligible mother was interviewed per household. all fertile women in the reproductive age of the household were included in the study, and if there were more than two mothers in the household, only one mother was selected randomly. data collection tools and procedures administered structured questioners were used to collect data. the questions were prepared including socio demographic and maternal contraceptive related factors through reviewing different literatures. the questioners first prepared in english language, and translated to amharic and awigna. each questionnaire was checked for completeness of the information by the principal investigator. about 30 health extension workers were recruited as data collectors. data quality control a pre-test of the questionnaire was conducted with 5% of the sample women within the study area and we assesses that, the questionnaire’s content adequately covers the concept it aims to measure. based on the results of the pre-test, the questionnaire was revised and modified accordingly. data collectors and supervisors underwent two days of training, facilitated by the investigators, prior to the actual data collection. the data’s consistency and completeness were verified before any data entry or coding was attempted. epi-info version 7 was utilized to control and manage errors during the data entry process. data processing and analysis the data were cleaned and entered into epi-info version 7, after which it was exported to stata version 16 for analysis. variables were recoded and computed as necessary for the analysis. we employed complete case analysis, which involves excluding any observations with missing values as a method for handling missing data. a bivariate and multivariable logistic regression model was applied to identify factors associated with the use of contraceptive methods. to account for potential confounding variables in the relationship between risk factors and long-acting contraceptive use among women, we applied a statistical control method. initially, binary logistic regression was used, including key confounders as covariates in the model, such as women age, women education, current marital status, maternal education and women occupation. model adequacy checking was done using hosmer and lemshow test statistics. all explanatory variables with a p<0.25 from the bivariate analysis were included in the multivariable analysis to control for potential confounding effects and associations were declared at 0.05 level of significance. the final model was selected using a backwards elimination approach, which started with a full model including all potential predictors and iteratively removed the least statistically significant variable, based on the wald statistic, until all remaining variables were statistically significant at a p-value of < 0.05. results socio demographic and economic characteristics as indicated in table 1, among the 1,334 women sampled in awi zone, 25.49% reported using long-acting contraceptive methods, while 74.51% did not. the use of long-acting contraceptives varied across different age groups of reproductive women. the highest usage rate (77.5%) was observed in women aged 35-44, while the lowest rate (68.9%) was seen in the 15-24 women’s age. a chi square test exhibited a significant association between women’s age and the use of long-acting contraceptives methods (x2: 7.208, p=0.027). additionally, the highest proportion of women using long-acting contraceptives were those with no formal education (79.35%), followed by those who completed primary school (66.7%) and those who finished secondary school or higher (53.9%). a chi square test showed a significant association between women’s educational level and the use of long-acting contraceptives methods (x2: 41.288; p£0.001). as shown in table 1, the use of long-acting contraceptive methods varied between women who had received family planning information through media and those who had not. among the total sample, 77.2% of women who had not heard family planning information on the radio in the past month used long-acting contracep article [page 166] [healthcare in low-resource settings 2025;13:13478] tive methods, while 66.8% of those who had heard family planning information on the radio used these methods. a chi square test showed a significant association between hearing about family planning in radio and the use of long-acting contraceptives methods (x2:25.018; p≤0.001). the uses of long-acting contraceptive methods were also varied across marital status. hence among single, married, divorced, and widwed women the usage rates were 86.7%, 71.9%, 98.6%, and 88.8%, respectively, with divorced women exhibiting the highest rate of contraceptive use. because divorced women desire to avoid the stress of an unintended pregnancy. the chi square test revealed a significant association between women’s marital status and the use of long-acting contraceptives methods (x2: 35.937; p£0.001). additionally, 68.3% of women who relied on their children as a source of income reported using long-acting contraceptives. regarding women occupation, 70.8% of unemployed women, 75% of government-employed women, and 86.2% of housewives reported using contraceptive methods. furthermore, the chi-square test of association showed that wealth index (x2: 80.330; p≤0.001), being visited by health extension (x2:17.233; p≤0.001), use of children as a source of income (x2:16.012; p≤0.001) and occupation (x2:17.074; p≤0.001) of women’s were significantly associated with use of long-acting contraceptive methods in awi zone, north west ethiopia. the results of detailed descriptive statistics including the crosstab and chi-square test of association are depicted in table 1. factors causing for usage of long-acting contraceptive methods bivariate logistic regression analysis was employed for all independent variables to identify possible covariates for the multivariable binary logistic regression. age in 5-year current marital status, heard family planning on radio, women’s education, wealth index, use child as source of income, being visited by health extension and women’s occupation were found to be the candidate variables for the multivariable binary logistic regression analysis. the final multivariable binary logistic regression analyses were done to look the effects of the selected explanatory variables on the use of long-acting contraceptive. as it is shown in table 2, the variables women’s educational level, wealth index, marital status, usage of children as source of income and women’s occupation were found significant factors on use of log acting contraceptive methods. the odds of women whose educational level was illiterate were 0.512 (aor: 0.512, 95%ci: 0.298, 0.879, p=0.0015) times less likely to use long-acting contraceptive methods than women with secondary or higher. this indicates that, secondary and above education often leads to women pursuing careers and delaying marriage and childbearing. this naturally increases the need for effective contraception. wealth index was also found to be a significant predictor of long-acting contraceptive usage and thus, the odds of a woman with a poor wealth index were 0.336 times (aor 0.336; 95% ci: 0.243, 464) less likely to use long-acting contraceptive methods than women who were rich. based on the study, marital status was found a significant factor for long-acting contraceptive usage and, the odds of married women were 2.497 times (aor 4.469; 95% ci: 2.144, 9.316, pvalue=0.000) more likely to use long-acting contraceptive methods than women whose current marital status were divorced. occupation of women also found significant factor of long-act article [healthcare in low-resource settings 2025;13:13478] [page 167] table 1. percentage distribution on use of long-acting contraceptive with covariates and chisquare test of association results. contraceptive use variables categories use % not use % chi-square df p age in 5-year 15-24 68.9 31.1 0.027* 25-34 72.7 27.3 7.208 2 35-44 77.5 22.5 women’s education illiterate 79.3 20.7 ≤0.001* primary 66. 33.3 41.288 2 ≥secondary 53.9 46.1 wealth index poor 85.5 14.5 ≤0.001* middle 69.3 30.7 80.330 2 rich 62.7 37.3 heard family planning on radio no 77.2 22.8 25.018 ≤0.001* yes 61.5 38.5 1 visited by health extension no 77.7 22.3 17.223 ≤0.001* yes 66.8 33.2 1 told about side effects no 75.8 24.2 yes 72.7 27.3 1.571 1 0.210 current marital status single 86.7 13.3 married 71.9 28.1 3 divorced 98.6 1.4 35.937 ≤0.001* widowed 88.8 11.3 use child as source of income no 78.2 21.8 yes 68.3 31.7 16.012 1 ≤0.001* women’s occupation no job 70.8 29.2 government employee 75.0 25.0 17.074 2 ≤0.001* housewife 86.2 13.8 ing contraceptive usage. the odds of women with no occupation were 2.179 times (aor: 2.179; 95% ci: 1.291, 3.678, p=0.004) more likely of using long-acting contraceptive methods than women who were housewife’s and, government employed women’s were 0.932 times (aor: 1.932, 95% ci: 1.176, 3.174, p=0.009) more likely to use long-acting contraceptive methods as compared to housewife women’s. the hosmer and lemeshow test yielded an insignificant chisquare value (x²=11.461; p=0.177), indicating that the model is a good fit for the data. therefore, the logistic regression model is deemed adequate. discussion this study was conducted to assess the prevalence and factors associated with use of long-acting contraceptive methods among awi zone adolescent women who can give birth, northweast ethiopia. the overall prevalence of contraceptive usage was found to be 25.4% and 74.6% of women was not use long-acting contraceptive. this prevalence was small as of studies conducted in jordan (74.8%),9 malawi (77.9%),10 tiro afeta district, south west ethiopia (74.4%),11 debre tabor town, ethiopia (30.9%),12 and ghana (44.9%).13 the possible reason for the difference might be variations in the study areas and women in awi zone district use their child as source of income. the result revealed that illiterate women were 0.512 times less likely to use long-acting contraceptive methods than women who have secondary and above education level controlling other variables in the model [aor: 0.512; 95% ci: (0.298, 0.879); p£0.001)]. the finding is consistent with a study11 that states that educational level has a statistical significant difference for use of contraceptive methods, respondents with primary and secondary education had about 2 times higher, the result is also consistant with gafar et al.14 which founds women who had completed secondary and above education had 2.8 times greater than the odds of women who had not completed any formal education for using long-acting contraceptive methods, and dasa et al.15 which revealed women who have no formal education were 0.59 times less likely to utilize long-acting family planning services as compared to women who had primary education and above. women’s wealth index has found a significant effect on use of long-acting contraceptive methods. the odds of women with poor wealth index were 0.336 times less likely to use long-acting contraceptive methods than rich women controlling other variables in the model. the finding was similar with a study14 that reveals women classified as the richest by the wealth index were 1.1 times more likely to use contraceptives than those classified as poorest, the study by johnson,16 which states that the odds of using modern contraceptives were also observed to progressively increase with wealth quintile, being 3.7 times higher among the richest compared to the poorest, and the study by adebowale et al.17 that states using multiple logistic regression on the data reveals that poorest married women were less likely to ever use modern contraceptive. the model results also showed that visited by health extension workers has significant effect on long-acting contraceptive. the finding reveals that women who were not visited by health extension were 73.4% less likely to use long-acting contraceptive methods than women who were visited by health extension. this study was consistent with the finding which was done in nigeria that states the problem of low access and utilization of modern contraceptive experienced by adolescent girls in niger can be resolved to article [page 168] [healthcare in low-resource settings 2025;13:13478] table 2. parameter estimates of explanatory variables in logistic regression model. explanatory variables categories coefficients se wald p aor aor 95% c.i. lower upper age in 5-year groups 15-24 0.206 0.205 1.005 0.316 1.228 0.822 1.837 25-34 0.057 0.162 0.124 0.724 1.059 0.771 1.455 35-44 (ref.) mother education illiterate -0.670 0.276 5.898 0.0015 0.512 0.298 .879 primary -0.461 0.274 2.826 0.093 0.631 0.369 1.079 secondary and above (ref.) wealth index poor -1.091 0.165 43.803 0.000 0.336 0.243 0.464 middle -0.246 0.199 1.518 0.218 0.782 0.529 1.156 rich (ref.) heard family planning on radio last few months no -0.216 0.176 1.505 0.220 0.805 0.570 1.138 yes (ref.) visited by health extension no -0.309 0.144 4.588 0.032 0.734 0.553 0.974 yes (ref.) current marital status single 0.029 0.872 0.001 0.973 1.030 0.187 5.683 married 1.497 0.375 15.95 0.000 4.469 2.144 9.316 widowed -1.975 1.077 3.363 0.067 0.139 0.0017 1.146 divorced (ref.) use child as source of income no -0.426 0.140 9.322 0.002 0.653 0.497 0.858 yes (ref.) mother occupation no job 0.779 0.267 8.499 0.004 2.179 1.291 3.678 government employee 0.659 0.253 6.761 0.009 1.932 1.176 3.174 housewife (ref.) constant constant -1.427 0.507 7.907 0.005 0.240 aor,adjusted odds ratio; c.i, confindence interval; se, standard error; ref., reference category, some degree by the introduction of community health workers;18 and with the study by asresie et al.19 that says contraceptive uptake was higher among women who visited by health workers at home 12 months prior to the survey. in this study marital status of women has significant effect on use of long-acting contraceptive methods. married women are 4.469 times more likely to use long-acting contraceptive methods than divorced women, which indicate that married women were more intended to more children than divorced controlling other covariates in the model. this finding is consistent with the study done in ethiopia, which revealed that modern contraceptive use among married or in-union reproductive-age women was relatively high compared to other studies done in the region,19 and niger18 that showed controlling for covariates, the odds of current use of modern contraceptive methods were higher in married adolescent youth. but this finding was contradict with the study done in malawian,10 which says that the demand for long acting contraceptive use was higher among sexually unmarried women compared to married women. this is comparable with a study in malawian where the researcher use only two marital status category (married and un married) and unmarried women often face greater social stigma associated with unintended pregnancies, which can create a stronger motivation to use long acting contraceptive use to prevent such outcomes. the study result portrayed that use of child as source of income is a significant variable for use of long-acting contraceptive methods. mothers who were not used their child as source of income were 65.3% less to use long-acting contraceptive methods than women who used their child as source of income controlling other covariates in the model. occupation status of women has significant effect on the use of long-acting contraceptive methods. the result showed that women’s whose occupation were no job is 2.179 times more likely to use long-acting contraceptive methods than house wife women and government employed women were 1.932 times more likely to use long-acting contraceptive methods than housewife’s women. this finding was consistent with the study done in debre berhan town, ethiopia.12 our study reveals that a respondent whose occupation is employed was found to be 13.992 times more likely to had long-acting family planning compared with self-employed. a study done in bangladesh20 was also consistent with this study and says that occupation had an emergent relation with contraceptive usage of employed woman had 26% higher chance of using contraception than an unemployed woman. the factors “heard about side effects” and “family planning on the radio” were found to be non-significant determinants for longacting contraceptive use. this may be due to the fact that awareness alone is not enough; individuals must also have access to family planning services. if barriers such as distance, lack of supplies, or high costs exist, increased awareness may not necessarily lead to higher usage. conclusions this study, conducted in the awi zone of northwest ethiopia, examined the utilization of long-acting contraceptive methods among 1,334 women of reproductive age. the findings reveal a complex picture of contraceptive use, influenced by a range of demographic and socioeconomic factors. the study utilized bivariate and multivariable logistic regression to identify significant predictors of long-acting contraceptive method usage among women. the final multivariable analysis revealed that women’s educational level, wealth index, marital status, occupation, and the use of children as a source of income were significant factors. future studies should employ qualitative methods to understand women’s contraceptive perceptions and barriers, alongside longitudinal research to track intervention impacts. investigating male partner and community leader influence is crucial. comparative studies across ethiopian regions, considering spatial analysis, cultural and infrastructural differences, will further refine intervention strategies. these research avenues will provide a more comprehensive understanding of contraceptive behavior and optimize public health efforts. limitations because of missing data all explanatory variables were not included and since this study was retrospective type recall bias might be introduced. while the study acknowledges the need for qualitative research, it primarily relies on quantitative methods. the absence of qualitative data limits the depth of understanding regarding women’s perceptions and experiences. the study’s cross-sectional design limits the ability to establish causal relationships between the identified factors and long-acting contraceptive use. it provides a snapshot in time, and therefore can not show cause and effect references 1. beekle a, mccabe c. awareness and determinants of family planning practice in jimma, ethiopia. int nurs rev 2006;53:269-76. 2. dejene y, editor promoting women’s economic 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cochran wg. sampling techniques: john wiley & sons; 2007. 9. komasawa m, yuasa m, shirayama y, et al. demand for family planning satisfied with modern methods and its associated factors among married women of reproductive age in rural jordan: a cross-sectional study. plos one 2020;15:e0230421. 10. nkoka o, mphande wm, ntenda pa, et al. multilevel analysis of factors associated with unmet need for family planning among malawian women. bmc public health 2020;20:705. 11. solomon t, nigatu m, gebrehiwot tt, getachew b. unmet need for family planning and associated factors among currently married reproductive age women in tiro afeta district, article [healthcare in low-resource settings 2025;13:13478] [page 169] south west ethiopia, 2017: cross-sectional study. bmc women’s health 2019;19:170. 12. worku sa, ahmed sm, mulushewa tf. unmet need for family planning and its associated factor among women of reproductive age in debre berhan town, amhara, ethiopia. bmc res notes 2019;12:143. 13. guure c, maya et, dery s, et al. factors influencing unmet need for family planning among ghanaian married/union women: a multinomial mixed effects logistic regression modelling approach. arch public health 2019;77:1-12. 14. gafar a, suza de, efendi f, et al. determinants of contraceptive use among married women in indonesia. f1000research 2020;9. 15. dasa tt, kassie tw, roba aa, et al. factors associated with long-acting family planning service utilization in ethiopia: a systematic review and meta-analysis. contraception reprod med 2019;4:1-14. 16. johnson oe. determinants of modern contraceptive uptake among nigerian women: evidence from the national demographic and health survey. african j reprod health 2017;21:89-95. 17. adebowale sa, adedini sa, ibisomi ld, palamuleni me. differential effect of wealth quintile on modern contraceptive use and fertility: evidence from malawian women. bmc women’s health 2014;14:40. 18. brooks mi, johns ne, quinn ak, et al. can community health workers increase modern contraceptive use among young married women? a cross-sectional study in rural niger. reprod health 2019;16:38. 19. asresie mb, fekadu ga, dagnew gw, gelaw ym. modern contraceptive use and influencing factors in amhara regional state: further analysis of ethiopian demographic health survey data 2016. advances in public health. 2020;2020. 20. hossain m, khan m, ababneh f, shaw j. identifying factors influencing contraceptive use in bangladesh: evidence from bdhs 2014 data. bmc public health 2018;18:192. 21. kraft jm, serbanescu f, schmitz mm, et al. factors associated with contraceptive use in sub-saharan africa. j women’s health 2022;31:447-57. article [page 170] [healthcare in low-resource settings 2024;12:13478] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13408 cybersex activity, self-control, and premarital sexual behaviors among adolescents puji hastuti,1 adellia eka kartikasari,2 taufan agung prasetya,1 astrida budiarti1 1department of nursing, sekolah tinggi ilmu kesehatan hang tuah, surabaya; 2department of social affairs, sekolah tinggi ilmu kesehatan hang tuah, surabaya, indonesia abstract rapidly growing internet use among adolescents had positive and negative effects. it offers benefits, such as facilitating communication, but it also has negative impacts, including premarital sexual behaviors. the purpose of this study was to determine the relationship between cybersex activity and premarital sexual behaviors, as well as the association between self-control and premarital sexual behaviors in adolescents. the research employed a descriptive-analytic approach with a cross-sectional design, and the total sample consisted of 147 adolescents. the independent variables were cybersex activity and self-control, while the dependent variable was premarital sexual behaviors. the instruments used were the internet sex screening test (isst), the self-control scale (scs), and the adolescent sexual activity index (asci). data were analyzed using the spearman correlation test. the majority of students involved in cybersex activities were at-risk users: 43.5% (64 respondents) had low self-control, and 27.2% (40 respondents) reported having early sexual activity. additionally, there was a significant relationship between cybersex activity and premarital sexual behaviors (p=0.001) and between self-control and premarital sexual behaviors (p=0.001). these findings underscore the necessity of promoting positive internet usage among adolescents to mitigate cybersex activity, as it correlates with premarital sexual behaviors. parents can encourage adolescents to have good self-control to avoid premarital sexual behaviors. further, educators and policymakers can use these findings to develop programs that teach teenagers responsible internet use, enhance their self-control, and promote safe online behavior. additionally, they can incorporate lessons and establish rules that support healthy internet habits. introduction the rapid growth of internet use has had both positive and negative effects. it offers many benefits, such as making communication easier, building social networks, and providing quick access to information.1 however, it also presents negative effects, especially for adolescents, including involvement in cybersex activities.2 cybersex activities refer to sexual behaviors conducted online, such as engaging in sexual conversations, sharing sexual images or videos, and seeking sexual satisfaction through social media.3 these activities can lead to negative outcomes such as addiction, sexual crimes, and premarital sexual behaviors.4 premarital sexual behavior includes various actions such as sexual intercourse, kissing, and petting.5,6 these behaviors pose significant risks to adolescents, including sexually transmitted diseases (stds), early pregnancies, and negative social and psychological impacts.5 according to the indonesian health demographic survey in 2018, many adolescents engage in these behaviors while dating, with 33% reporting hugging, 50% kissing, 22% petting, and 8% engaging in sexual intercourse.6 internet use among adolescents in indonesia has significantly increased. from 2021 to 2022, internet usage reached 77.02%, with the java region contributing the highest percentage at 43.92%. among these users, adolescents aged 13 to 18 years accounted for 99.16% of the total internet users.7 a survey of young people aged 18-23 years revealed that 29% of respondents engaged in cybersex behaviors, with 75.6% of them being unmarried adolescents. additionally, global statistics show that, in developing countries, 11.3% of boys and 7.7% of girls have engaged in premarital sexual behavior, highlighting the need for local and culcorrespondence: puji hastuti, nursing department, sekolah tinggi ilmu kesehatan hang tuah, surabaya, indonesia. e-mail: pujihastutishtsby@gmail.com key words: adolescents; cybersex; premarital sexual behavior; self-control. contributions: ph, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing-original draft, review & editing; aek, conceptualization, investigation, methodology, validation, and writing-original draft, review & editing; tap, ab, conceptualization, methodology, formal analysis, validation, and writing-original draft, review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this study was approved by the stikes hang tuah surabaya with number pe/27/vi/2023/kep/sht. informed consent was obtained from the participants involved in this study. consent for publication: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: we would like to thank stikes hang tuah surabaya, indonesia, for their valuable support. received: 21 november 2024 accepted: 5 march 2025. early access: 4 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13408 doi:10.4081/hls.2025.13408 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13408] [page 95] turally relevant strategies to address this issue.8,9 self-control is a critical factor in preventing the negative outcomes of internet use,10,11 particularly in reducing the likelihood of engaging in cybersex activities and premarital sexual behavior. self-control refers to an individual’s ability to regulate their impulses, emotions, and actions.12 adolescents with low self-control are more likely to engage in risky behaviors, including premarital sexual activities. conversely, strong self-control acts as a protective factor, helping adolescents avoid behaviors such as dating, kissing, petting, and sexual intercourse.13,14 cybersex activities, premarital sexual behavior, and self-control are interconnected. cybersex activities may influence adolescents to engage in premarital sexual behaviors driven by curiosity, peer pressure, or social motives.15 meanwhile, self-control plays a vital role in breaking this connection by enabling adolescents to resist these impulses and make healthier decisions.10,11 adolescents who lack self-control are at higher risk of experiencing premarital sexual behavior and severe consequences such as unwanted pregnancies, abortions, stds, hiv, depression, substance abuse, and even suicidal tendencies.16 given the increasing prevalence of internet use and its associated risks, attention must be directed toward preventing cybersex activities and premarital sexual behavior among adolescents, particularly in indonesia. despite the increasing prevalence of internet use among adolescents and its associated risks, there is limited research focusing on the specific relationships between cybersex activities, self-control, and premarital sexual behavior, particularly in the context of indonesia. while previous studies have explored premarital sexual behaviors and internet usage trends, they often lack a comprehensive examination of how cybersex activities and self-control influence these behaviors. this study aims to explore the relationship between cybersex activity and premarital sexual behavior, as well as the relationship between self-control and premarital sexual behavior. by highlighting the protective role of selfcontrol, this study seeks to emphasize its importance in the context of adolescent sexual health and inform strategies tailored to indonesia’s youth population. materials and methods study design this study employed a descriptive-analytic design with a cross-sectional approach. the design was chosen to examine the relationships between cybersex activity, self-control, and premarital sexual behavior among adolescents by collecting data at a single point in time. sample size and sampling technique the sample in this study consisted of 147 senior high school students from surabaya, indonesia. the sample was selected using the cluster simple random sampling technique. first, the total classes in this school were divided into clusters. a random selection of classes was made, and all eligible students within the selected classes were invited to participate. inclusion criteria included students who were willing to participate and adolescents in grade 12. the exclusion criteria in this study were adolescents who withdrew in the middle of the study, did not complete the questionnaire, and students who were absent or ill during data collection. data collection the data was collected using google form links by providing barcodes for students in each class. we explained to the respondents the purpose and objectives of the study, as well as the procedures and assessments to be carried out. respondents had the right to withdraw if they were unwilling to answer the questionnaire. the researchers ensured the confidentiality of the respondents’ data. respondents who agreed to participate in the study were given a reward in the form of a tumbler. variables and instruments variables in this study were cybersex activity, self-control, and premarital sexual behavior. the instruments used in the study were the internet sex screening test (isst) questionnaire to collect data related to cybersex activity. the questionnaire consists of 25 items, each assigned a score for favorable responses (1-15, 17, 18, 20): 4=always, 3=often, 2=seldom, and 1=never. for unfavorable items (16 and 19), the scoring is as follows: 1=always, 2=often, 3=seldom, and 4=never. total score was categorized by recreational users (20-39), risk users (40-59), and compulsive users (60-80). the cronbach’s alpha of this questionnaire was 0.86, and the convergent validity is adequate with p<0.05 and r=0.621.17 the selfcontrol scale (scs) was utilized to collect data related to self-control; it comprises 24 items, with a score for each favorable item (1, 17, 24, 5, 25, 13, 22, 26, 27): 4=always, 3=often, 2=seldom, and 1=never. for unfavorable items, the scoring is as follows: 1=always, 2=often, 3=seldom, and 4=never. the total score was categorized into low (36-71), moderate (72-107), and high (108144). the cronbach’s alpha of this questionnaire was 0.91, and the convergent validity is adequate with p<0.05 and r=0.731.18 the adolescent sexual activity index (asai) was used to collect data related to sexual behavior. it had 13 items, with the following scores: 1=yes, 0=never. the total score was categorized into less risk (0-3), risk engaging in sexual intercourse (4-5), sexual intercourse (6), sexual beginnings (7), and sexually active (8-10). the cronbach’s alpha of this questionnaire was 0.91, and the convergent validity is adequate with p<0.05 and r=0.537.19 study analysis we analyzed the data using the spss software to determine the frequency distribution. the spearman test was employed to assess the relationship between variables, with a significance level set at p<0.05. ethical clearance this study was approved by the ethical clearance committee of stikes hang tuah surabaya (no: pe/27/vi/2023/kep/sht). all procedures adhered to ethical guidelines, and informed consent was obtained from all participants before data collection. the study ensured participant confidentiality and voluntary participation throughout the research process. results table 1 shows the respondents’ characteristics and descriptive variables. regarding gender, 55.1% were male (81 respondents), and 44.9% were female (66 respondents). in terms of dating status, 67.3% (99 respondents) were in a relationship, while 32.7% (48 respondents) were not. concerning parental attitudes, 61.9% (91 respondents) reported that their parents permitted dating during special issue pathways of change [page 96] [healthcare in low-resource settings 2025;13(s1):13408] school years, while 38.1% (56 respondents) did not. the frequency distribution of cybersex activity among respondents was categorized as at-risk users, accounting for 43.5% (64 respondents); recreational users, making up 37.4% (51 respondents); and compulsive users, comprising 19.0% (32 respondents). the frequency distribution of self-control indicated that 42.9% of respondents were categorized as low (63 respondents), 40.1% as medium (59 respondents), and 17.0% as high (25 respondents). the frequency distribution of premarital sexual behavior among adolescents indicated the following: 27.2% (40 respondents) reported having engaged in early sexual intercourse, 25.9% (38 respondents) experienced less risky sexual behavior, 19.0% (28 respondents) engaged in sexual intercourse, 15.6% (23 respondents) were identified as engaging in risky sexual behavior, and 12.2% (18 respondents) were classified as sexually active. table 2 presents the cross-tabulation of cybersex activity and premarital sexual behavior. the results indicated a significant relationship between cybersex activity and premarital sexual behavior in adolescents, with a p=0.00 and a correlation coefficient of 0.586. table 3 shows a significant relationship between self-control and premarital sexual behavior in adolescents, with a p=0.00 and a correlation coefficient of -0.673. discussion this study provides important insights into the relationships between cybersex activity, self-control, and premarital sexual behavior among adolescents. the findings revealed that most respondents engaged in at-risk cybersex activities, exhibited low self-control, and were at risk of premarital sexual behavior. these results highlight the critical role of online behaviors and self-regulation in shaping adolescent sexual decision-making, aligning with prior studies that identify similar risk factors for premarital sexual behavior.13,20-24 the study found a significant relationship between cybersex activity and premarital sexual behavior among adolescents. the majority of respondents were male and 17 years old, a developmental phase marked by increased curiosity regarding sexual activities due to puberty, which can incite sexual desires. furthermore, the majority of respondents engaged in compulsive online sexual behaviors, with at-risk users being more likely to participate in premarital sexual activities. the findings of this study align with previous research, which indicates a positive correlation between cybersex activities and premarital sexual behavior categories.25,26 thus, the higher the level of engagement in cybersex, the greater the likelihood of involvement in premarital sexual behavior. this study also identified a significant relationship between self-control and premarital sexual behavior. the findings indicate that men are usually more open to discussing sexual topics and tend to exhibit lower levels of self-control. most respondents in the study reported low self-control and began dating at the age of 15. the present study showed that self-control can be developed to prevent risky sexual behaviors in adolescents.27 self-control is strongly influenced by parenting,26,28 as parents play a vital role in instilling values and guiding their adolescents toward responsible decision-making.29 through proper guidance, parents help adolescents develop the ability to regulate their behavior effectively. furthermore, previous studies have shown that poor self-control in individuals or parents can lead to negative behaviors.30 self-control is also closely tied to emotional regulation, as individuals with strong self-control are better equipped to manage their emotions.11 in romantic relationships, adolescents often experience psychological and physiological reactions that evoke feelings of comfort and love. without adequate self-control, these emotions may lead to premature sexual activity. therefore, self-control is a crucial factor in managing and reducing the likelihood of engaging in premarital sexual behaviors.13,31,32 this study has some limitations that should be considered. the respondents were only adolescents in senior high school; therefore, the findings may not represent all young individuals in indonesia. special issue pathways of change table 1. characteristics of respondents and descriptive variables. characteristic frequency (n) percentage (%) gender male 81 55.1 female 66 44.9 total 147 100.0 dating or not yes 99 67.3 no 48 32.7 total 147 100.0 parental response in terms of dating allow 91 61.9 not allow 56 38.1 total 147 100.0 cybersex activity recreational users 51 34.7 at-risk users 64 43.5 compulsive users 32 21.8 total 147 100.0 self-control low 63 42.9 moderate 59 40.1 high 25 17.0 total 147 100.0 sexual activity less risk 38 25.9 risk engaging in sexual behaviours 23 15.6 sexual intercourse 28 19.0 early sexual intercourse 40 27.2 sexual active 18 12.2 total 147 100.0 table 2. relationship between cybersex activity and premarital sexual behaviors. sexual activity cybersex activity correlation coefficient 0.586* sig. (2-tailed) 0.001 n 147 *p<0.05. table 3. relationship between self-control and premarital sexual behaviors. sexual activity self-control correlation coefficient -0.673* sig. (2-tailed) 0.001 n 147 *p=<0.05. [healthcare in low-resource settings 2025;13(s1):13408] [page 97] however, the study revealed that premarital sexual behavior among adolescents is influenced by cybersex activities and levels of self-control. conclusions premarital sexual behavior among adolescents is common. the study found that cybersex activities among adolescents categorized as at risk were linked to low levels of self-control among students. additionally, there is a connection between cybersex activities and sexual behavior, as well as a connection between self-control and sexual behavior in adolescents. these findings emphasize the importance of encouraging adolescents to use social media in a positive way. parents and schools can encourage adolescents to develop self-control through counseling, helping them avoid premarital sexual behavior. policymakers can use these findings to create programs that teach teenagers how to use the internet responsibly, improve their self-control, and promote safe online behavior. 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32. fauzi ma, suroso s, farid m. relationship between religiosity and self-control with cybersex behavior in school students. psychomachina 2023;1:1–8. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13408] [page 99] hrev_master healthcare in low-resource settings 2025; volume 13:14128 promoting mental and sleep health in menopausal women: the effectiveness of yoga and brain gymnastics interventions maya fadlilah,1 aris citra wisuda,2 norhashima abd rashid,1 chun hoe tan1 1school of nursing and applied science, lincoln university college, petaling jaya, selangor darul ehsan, malaysia; 2nursing study program, sekolah tinggi ilmu kesehatan bina husada palembang, indonesia abstract menopausal women frequently experience anxiety and sleep disturbances, which negatively impact their mental well-being and overall quality of life. non-pharmacological approaches such as yoga and brain gymnastics offer accessible, safe, and low-cost strategies to address these issues. this study aimed to assess the effectiveness of yoga and brain gymnastics in promoting mental and sleep health among menopausal women. a quasi-experimental pretest-posttest design was conducted involving 100 menopausal women, divided into yoga and brain gymnastics intervention groups. yoga sessions were held three times a week for 60 minutes over four weeks, while brain gymnastics was conducted for 15–20 minutes at the same frequency. anxiety and sleep quality were measured using the state-trait anxiety inventory (stai) and pittsburgh sleep quality index (psqi). data were analyzed using paired and independent t-tests. both interventions significantly reduced anxiety and improved sleep quality (p<0.05). yoga showed a greater reduction in stai (35%) and psqi (40%) scores compared to brain gymnastics (22% and 25%, respectively). comparative analysis indicated yoga was significantly more effective (p<0.05). yoga and brain gymnastics effectively promote mental and sleep health in menopausal women, with yoga demonstrating superior benefits as a holistic intervention. introduction menopause is a natural phase in a woman’s life marked by the permanent cessation of menstruation due to the decline in ovarian function. according to the world health organization (who), menopause typically occurs between the ages of 45 and 55, and by 2030, an estimated 1.2 billion women will be over the age of 50, with the majority (80%) residing in developing countries. in indonesia, menopause generally begins between the ages of 40 and 50.1 the term “menopause” derives from the greek words for “month” and “cessation,” and medically refers to the complete end of menstrual cycles. this phase is characterized by a significant decrease or absence of estrogen production, which can cause symptoms that disrupt a woman’s daily life.2 one of the primary health concerns during menopause is the increased risk of sleep disorders, such as sleep-onset insomnia and obstructive sleep apnea (osa), although menopausal status has not been directly linked to issues like restless leg syndrome (rls) or rem sleep behavior disorder (rbd).3 hormonal changes, particularly the decrease in estrogen and progesterone, can lead to a variety of symptoms, including hot flashes, night sweats, insomnia, memory impairment, fatigue, decreased libido, vaginal dryness, dyspareunia, and psychological issues like anxiety and depression.4 sleep disturbances and chronic anxiety not only reduce quality of life but are also associated with long-term health risks such as cardiovascular disease, diabetes, obesity, and stroke.5,6 in light of these concerns, managing anxiety and sleep disorders among menopausal women is a key priority to safeguard their overall health and quality of life. pharmacological options, particularly hormone replacement therapy (hrt), have demonstrated correspondence: maya fadlilah, school of nursing and applied science, lincoln university college, petaling jaya, selangor darul ehsan, malaysia e-mail: mayafadlilah.umadplg@gmail.com keywords: menopause, anxiety, sleep quality, yoga, brain gymnastics. contributions: mf conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; acw conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; nar conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; cht methodology, visualization, writing – review & editing; resources, investigation, and writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has obtained ethical approval from the medical and health research ethics commission, faculty of medicine, sriwijaya university, based on ethical certificate 044-2024. throughout the research process, the researcher adhered to the principles of information ethics, including consent, respect for human rights, beneficence, and non-maleficence. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors sincerely thank the healthcare professionals, yoga instructors, and community health workers at puskesmas sukarami, palembang city, whose dedication and support greatly contributed to the implementation of this study. we also extend our gratitude to the menopausal women who participated in this research, as their involvement has been instrumental in advancing knowledge on nonpharmacological. received: 8 july 2025. accepted: 17 august 2025. early access: 14 october 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:14128 doi:10.4081/hls.2025.14128 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 276] [healthcare in low-resource settings 2025;13:14128] notable efficacy in reducing menopausal complaints. nevertheless, extended use of hrt has been linked to a higher likelihood of adverse outcomes, such as breast malignancies, cardiovascular complications, and hepatic or renal dysfunction.7 as a result, a considerable number of women turn to non-pharmacological approaches in search of safer options. among these, interventions centered on physical activity are some of the most commonly adopted strategies. yoga an integrative practice that combines bodily postures, controlled breathing, and meditation has been demonstrated to support hormonal regulation, enhance relaxation, and foster mental well-being.8 brain gymnastics, or brain gym, consists of simple coordinated movements aimed at stimulating brain activity, enhancing cognitive function, and reducing stress and emotional tension.9 previous research has highlighted that both interventions are effective in enhancing sleep quality and alleviating anxiety among menopausal women.10 despite growing evidence supporting yoga and brain gym individually, limited research has directly compared their effectiveness in addressing menopause-related anxiety and sleep disorders. therefore, this study aims to analyze and compare the effectiveness of yoga and brain gymnastics in reducing anxiety and improving sleep quality among menopausal women at the nagaswidak health center, palembang, south sumatra, indonesia. materials and methods study design, setting, and sampling this study used a quasi-experimental pretest-posttest design to evaluate the effectiveness of yoga and brain gymnastics in reducing anxiety and improving sleep quality in menopausal women. this study was conducted at the nagaswidak community health center in palembang city, indonesia, involving two intervention groups: the first, a yoga intervention, and the second, a brain gymnastics intervention, both of which were carried out for 4 weeks. before the intervention, anxiety levels were measured using the stai questionnaire, and quality measurements were carried out using the psqi questionnaire. after a four-week intervention, anxiety levels and sleep quality were measured again using the same instruments. participants the study included postmenopausal women aged 45 to 55 years who experienced anxiety and sleep disturbances, were not taking medication for anxiety and sleep disturbances, and did not have physical disabilities that could limit movement for yoga and brain gymnastics. intervention this study received ethical approval from the medical and health research ethics commission, faculty of medicine, sriwijaya university, under certificate number 044-2024, with the research permit issued in november 2023. participants were selected through purposive sampling, with inclusion criteria consisting of menopausal women aged 45 to 55 years who resided in the nagaswidak health center service area, palembang city, south sumatera, reported symptoms of anxiety and poor sleep quality, were not currently taking medication for these conditions, and had no physical limitations that would hinder participation in yoga and brain gym activities. following participant recruitment, baseline data were collected using two validated instruments, namely the state-trait anxiety inventory (stai) for assessing anxiety levels and the pittsburgh sleep quality index (psqi) for evaluating sleep quality. a total of 100 eligible participants were then non-randomly assigned to two intervention groups. the first group, consisting of 50 participants, took part in yoga sessions held twice a week over a four-week period, totaling 12 sessions conducted from june 4th to june 29th, 2024. the second group, also comprising 50 participants, received brain gym interventions with the same frequency and duration, conducted from july 9th to august 3rd, 2024. all intervention sessions were led by certified instructors and held in a quiet, well-ventilated room within the health center, ensuring a comfortable environment and minimal external distractions. upon completion of the 12 intervention sessions, post-intervention assessments of anxiety and sleep quality were carried out using the same instruments (stai and psqi) to evaluate and compare the effectiveness of each intervention. data collection data on the characteristics of respondents who underwent yoga and brain gym interventions from 100 respondents are contained in a questionnaire that includes data on name, age, highest education, work experience, marital status, and number of children. data on anxiety levels and sleep quality were measured before the intervention and after 12 yoga and brain gym interventions, obtained based on the results of filling out the stai questionnaire, while data on respondents’ sleep quality were obtained based on the results of filling out the psqi questionnaire. measurement of anxiety levels and sleep quality the instrument used to measure anxiety in menopausal women is the stai instrument created by charles d. spielberger. the stai questionnaire consists of 2 parts, namely situational anxiety and dispositional anxiety. the first part is the stai y-1 self-evaluation questionnaire form, which contains 20 questions that reflect how a person feels “at that moment”, while the second part is the stai y-2 self-evaluation questionnaire form, which contains 20 questions that indicate how a person feels “usually or in general”.11 in contrast to state anxiety, which is transient and occurs when a person is exposed to a stimulus that could cause harm, trait anxiety (y1) is the overall or typical state of an individual when they are anxious or when their anxiety is persistent. the stability of personality variations in the propensity to experience anxiety is the main focus of trait anxiety. while trait anxiety (y2) is primarily focused on the stability of personality variations in the propensity to feel worried, state anxiety (y1) is transient and occurs when a person is exposed to a stimuli that could cause harm.12 the instrument for measuring sleep quality is the pittsburgh sleep quality index (psqi) instrument. the psqi questionnaire measures sleep quality consisting of 19 questions on seven assessment components, namely subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction.13-15 statistical analysis in this study, statistical analysis was conducted to evaluate the effectiveness of yoga and brain gymnastics in reducing anxiety and improving sleep quality in menopausal women. the analysis was conducted through three main stages: first, data normality test using spss software with the kolmogorov smirnov test with a p>0.05, which means the data is normally distributed. second, group difference analysis (pretest vs. posttest) was conducted using a paired t-test. third, analysis of differences between groups (yoga article [healthcare in low-resource settings 2025;13:14128] [page 277] vs. brain gymnastics) was conducted using an independent t-test. results univariate analysis table 1 shows that the demographic data of the respondents indicate that the majority of respondents are aged 50-54 years, with 63 respondents (63%), the highest education level of the respondents is mostly high school, with 55 respondents (55%), and the majority of respondents do not work, with 63 respondents (63%). additionally, the majority of respondents are married, with 79 respondents (79%), and most respondents have 3 children, with 28 respondents (28%). the level of anxiety (y1) before the yoga exercise intervention was mostly moderate anxiety at 42 (84%), after the intervention it was mostly mild anxiety at 38 (76%; figure 1). the level of anxiety (y2) before the yoga exercise intervention was mostly moderate anxiety, at 44 (88%), after the intervention it was mild anxiety at 48 (96%; figure 2). sleep quality before the intervention 50 respondents (100%) experienced poor sleep quality, after the intervention 50 respondents (100%) experienced good sleep quality (figure 3). the level of anxiety before the brain gymnastics intervention was mostly moderate anxiety, at 34 (68%), after the intervention article figure 2. anxiety level (y2) score before and after yoga exercise intervention. figure 3. sleep quality score before and after yoga exercise intervention. figure 1. anxiety level (y1) score before and after yoga exercise intervention. figure 5. anxiety level (y2) score before and after brain gym intervention. figure 6. sleep quality score before and after brain gym intervention. figure 4. anxiety level score before and after brain gym intervention. [page 278] [healthcare in low-resource settings 2025;13:14128] most were mild anxiety at 36 (72%; figure 4). the level of anxiety (y2) before the brain gymnastics intervention was mostly moderate anxiety, 42 (84%), after the intervention mostly mild anxiety, 32 (64%; figure 5). sleep quality before the intervention 50 respondents (100%) experienced poor sleep quality, after the intervention 38 respondents (76%) experienced good sleep quality (figure 6). bivariate analysis the average anxiety level before and after the yoga intervention was 46.80 before and 26.36 after, with p<0.05, according to the dependent t-test results. this indicates that there is a significant difference in the anxiety levels of menopausal women before and after the yoga intervention (table 2). there is a significant difference in the anxiety level (y2) in menopausal women before and after the yoga intervention, according to the results of the dependent t-test, which showed that the average anxiety level (y2) was 45.14 before and 25.36 after the yoga intervention. the p-value was less than 0.05 (table 3). with a p-value of less than 0.05, the dependent t-test results indicated that there was a significant difference in the sleep quality scores of menopausal women before and after the yoga exercise intervention. the average sleep quality score between before and after the yoga exercise intervention was 9.62 before the intervention and 3.74 after (table 4). based on the results of the paired sample t-test, it was found that the anxiety levels before and after the brain gym intervention had an average anxiety level of 47.06 before the intervention and 33.50 after the intervention, with a pvalue of less than 0.05, indicating a significant difference in anxiety levels in menopausal women before and after the brain gym intervention (table 5). the average anxiety levels before and after the brain gym intervention were 48.88 and 33.60, respectively, according to the results of the paired t-test. the p-value was less than 0.05, indicating a significant difference in the anxiety levels of menopausal women before and after the brain gym implementation (table 6). there is a significant difference in the sleep quality scores of menopausal women before and after the brain gym intervention, according to the dependent t-test results, which showed that the average sleep quality score was 9.74 before the intervention and 4.50 after it. the p-value was less than 0.05 (table 7). displays the findings of the independent t-test study to determine how yoga and brain exercise therapies affected menopausal women’s anxiety levels and sleep quality. according to data analysis using the independent t-test, there were significant differences between the yoga and brain exercise interventions in terms of addressing menopausal women’s anxiety levels. the yoga intervention had a mean value of 26.10 with a standard deviation (sd) article table 1. description of respondent characteristics. no respondent characteristics f percentage (%) 1. age 40-44 0 0 45-49 22 22 50-54 63 63 55-59 15 15 60-64 0 0 65-69 0 0 2. highest education no school completed 0 0 kindergarten 0 0 elementary school (sd) 13 13 junior high school (smp) 23 23 senior high school (sma) 55 55 diploma 9 9 bachelor's degree (si) 0 0 master's degree (s2) 0 0 doctorate degree (s3) 0 0 3. work experience not working 63 63 less than 1 year 0 0 1-5 years 6 6 6-10 years 19 19 more than 10 years 12 12 4. marital status single 0 0 married 79 79 widowed 16 16 divorced 5 5 5. number of children no children 0 0 1 child 6 6 2 children 23 23 3 children 28 28 4 children 20 20 5 children or more 23 23 [healthcare in low-resource settings 2025;13:14128] [page 279] of 4.334, while the brain exercise intervention had a mean value of 33.78 with an sd of 7.957 and a p-value of 0.003 (p<0.05). in contrast, the yoga intervention’s mean score for improving sleep quality was 3.74, sd 1.006 (table 8). discussion this study demonstrated that both yoga and brain gym interventions were effective in reducing anxiety and improving sleep quality in menopausal women. however, yoga showed a significantly greater effect compared to brain gym, as indicated by a lower p-value in the post-intervention assessment. these results align with the hypothesis that non-pharmacological interventions targeting both physiological and psychological dimensions can alleviate menopause-related symptoms such as anxiety and sleep disturbances. the superior effectiveness of yoga in this study may be attributed to its holistic approach, which incorporates physical article table 4. results of dependent t-test pre and post sleep quality of yoga exercise intervention. sleep quality pre post mean sd p f % f % pre post good (≤ 5) 0 0 50 100 bad (> 5) 50 100 0 0 total 50 100 50 100 9.62 3.74 0.000 table 5. results of the dependent t-test pre and post anxiety levels of brain gym intervention. anxiety level (y1) pre post mean sd p f % f % pre post mild anxiety (20-39) 9 18 36 76 moderate anxiety (40-59) 34 68 13 24 severe anxiety (≥60-80) 7 14 1 0 total 50 100 50 100 47.06 33.50 0.000 table 6. results of the dependent t-test pre and post anxiety levels of brain gym intervention. anxiety level (y1) pre post mean sd p f % f % pre post mild anxiety (20-39) 1 4 32 76 moderate anxiety (40-59) 42 84 17 24 severe anxiety (≥60-80) 7 12 1 0 total 50 100 50 100 48.88 33.60 0.000 table 2. results of dependent t-test pre and post anxiety levels of yoga exercise intervention. anxiety level (y1) pre post mean sd p f % f % pre post mild anxiety (20-39) 2 4 38 76 moderate anxiety (40-59) 42 84 12 24 severe anxiety (≥ 60-80) 6 12 0 0 total 50 100 50 100 46.80 26.36 0.000 table 3. results of the dependent t-test pre and post anxiety levels of the yoga exercise intervention. anxiety level (y1) pre post mean sd p f % f % pre post mild anxiety (20-39) 1 2 48 96 moderate anxiety (40-59) 44 88 2 4 severe anxiety (≥60-80) 6 10 0 0 total 50 100 50 100 45.14 25.36 0.000 [page 280] [healthcare in low-resource settings 2025;13:14128] postures, breathing exercises, and meditation. these components are known to activate the parasympathetic nervous system, regulate the hypothalamic-pituitary-adrenal axis, and promote the release of neurotransmitters such as gamma-aminobutyric acid (gaba) and melatonin, thereby reducing anxiety and enhancing sleep quality.16,17 in contrast, brain gym primarily focuses on cognitive stimulation through coordinated movements that support neural activation across hemispheres and emotional regulation, which may help with focus and mood, but do not directly trigger physiological relaxation in the same way as yoga.18,19 these findings are in line with a growing body of evidence highlighting the effectiveness of yoga in improving psychological and physiological outcomes among women. a quasi-experimental study by fara et al.20 demonstrated that yoga significantly enhanced sleep quality in menopausal women. similarly, wang et al.21 found that yoga not only improved sleep and reduced anxiety but also contributed to lowering blood pressure and alleviating depressive symptoms. a meta-analysis by hao et al.22 further confirmed these results, reporting significant reductions in pittsburgh sleep quality index (psqi) scores among women practicing yoga. additional evidence from studies involving other populations such as breast cancer patients,23 elderly individuals,24 and pregnant women25 further supports the role of yoga in enhancing sleep quality and mitigating anxiety across diverse groups. although brain gym was observed to be less effective than yoga in this study, its potential benefits remain noteworthy. prior studies have shown that brain gym can improve sleep quality and attention span in menopausal women,26 while also reducing anxiety among students27 and hospitalized children.28 the structured movement patterns incorporated in brain gym are believed to stimulate neuroplasticity, harmonize interhemispheric brain activity, and regulate stress-related pathways. however, in contrast to yoga, brain gym does not include meditative and breathing components, which play a central role in influencing autonomic balance and hormonal regulation.29 beyond yoga and brain gym, other non-pharmacological interventions have also demonstrated significant benefits. aerobic exercise interventions30-32 have consistently been associated with better sleep outcomes and reduced psychological distress in menopausal women. similarly, progressive muscle relaxation33 and mindfulness-based approaches34 have shown efficacy in reducing anxiety and improving sleep quality. collectively, this evidence underscores the importance of physical activity and mind–body interventions as feasible and effective strategies for managing menopausal symptoms. these results have practical implications for public health and clinical practice, especially in resource-limited settings where nonpharmacological, low-cost, and easily implementable interventions are needed. yoga, in particular, may be recommended as a first-line complementary therapy for menopausal women experiencing anxiety and sleep disorders. however, this study has several limitations. the non-random assignment of participants may introduce bias, and the short intervention period limits the generalizability of long-term effects. future studies with randomized controlled designs, longer follow-up, and objective sleep measures (e.g., actigraphy) are recommended to validate and expand on these findings. strengths and limitations this study offers several important strengths, including the use of a rigorous quasi-experimental design with well-balanced participant characteristics between groups, enhancing internal validity and comparability. the interventions yoga and brain gym were delivered with standardized durations and frequencies, and outcomes were assessed using validated instruments (stai for anxiety and psqi for sleep quality), ensuring measurement reliability. the direct comparison between two non-pharmacological strategies adds practical value, particularly for community-based mental health initiatives aimed at menopausal women. furthermore, the focus on culturally adaptable and cost-effective approaches highlights the potential for scalable and sustainable implementation in diverse populations. however, the study also has limitations that must be acknowledged. the relatively small sample size and short intervention period constrain generalizability and limit insights into long-term outcomes. the use of self-reported measures introduces the potential for response bias, and the absence of a control group and follow-up assessments restricts the ability to evaluate sustained effects and rule out placebo influences. future research with larger, more heterogeneous samples, inclusion of objective physiological indicators, and extended follow-up periods is recommended to strengthen the robustness and applicability of these findings. article table 7. results of the dependent t-test pre and post sleep quality of brain gym intervention. sleep quality pre post mean sd p f % f % pre post good (≤ 5) 0 0 38 76 bad (> 5) 50 100 12 24 total 50 100 50 100 9.74 4.50 0.000 table 8. results of the analysis of the difference between yoga exercise and brain gym intervention on anxiety levels and sleep quality in the work area of nagaswidak health center, palembang, 2024. no measured variable intervention mean sd 95% ci p 1 anxiety level yoga exercise intervention 26.10 4.334 5.128-10.232 0.003 brain gym intervention 33.78 7.957 5.137-10.223 2 sleep quality yoga exercise intervention 3.74 1.418 0.272-1.248 0.012 brain gym intervention 4.50 1.006 0.271-1.249 [healthcare in low-resource settings 2025;13:14128] [page 281] conclusions this study highlights the practical value of incorporating structured yoga and brain gym interventions as non-pharmacological approaches to support the mental and physical well-being of menopausal women. both interventions were effective in reducing anxiety and improving sleep quality, with yoga demonstrating a slightly greater impact. these findings suggest that community health centers and primary care providers can integrate such accessible, low-cost, and culturally adaptable strategies into routine health promotion programs for menopausal women. by empowering women with self-regulation techniques through movementbased therapies, healthcare systems can contribute to enhancing quality of life during the menopausal transition. future efforts should consider broader implementation and long-term follow-up to sustain and expand the benefits of these interventions in diverse populations. references 1. ministry of health of the republic of indonesia. healthy indonesia profile. 2021;51:1231–81. 2. baral s kh. health-related quality of life among menopausal women: a cross-sectional study from pokhara, nepal. plos one 2023;18:e0280632. 3. zolfaghari sm. effects of menopause on sleep quality and sleep disorders: canadian longitudinal study on aging. j menopause soc 2020;27:295–304. 4. moh. hanafi igdu. the effect of yoga on anxiety levels of premenopausal women at the lovina dolphin studio, singaraja’. j recreat heal edu 2021;7:2. 5. newsom r. aging and sleep. sleep foundation. in: 3rd ed. 2022. p. 147–52. 6. sebtalesy cy, mathar i. menopause reproductive health of older women. in: 2nd ed. 2019. p. 203–21. 7. chen h, li y, liu x, et al. efficacy and safety of hormone replacement therapy combined with escitalopram in perimenopausal women: a randomized controlled trial. front psychiatry 2025;16:1554165. 8. cramer h, lauche r, langhorst j, dobos g. yoga for anxiety: a systematic review and meta-analysis of randomized controlled trials. depress anxiety 2018;35:830-843. 9. dennison, paul e. ge. complete brain gym guidebook brain gymnastics. jakarta: grasindo. jakarta: grasindo; 2018. 10. ströhle a. sports psychiatry: mental health and mental disorders 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randomized controlled trials. int j nurs stud 2025;161:104928. 22. hao w, fu c, dong c, et al. age at menopause and all-cause and cause-specific dementia: a prospective analysis of the uk biobank cohort. hum reprod 2023;38:1746–54. 23. wang wl, chen kh, pan yc, et al. the effect of yoga on sleep quality and insomnia in women with sleep problems: a systematic review and meta-analysis. bmc psychiatry 2020;20:195. 24. shree ganesh, subramanya p, m rr, udupa v. role of yoga therapy in improving digestive health and quality of sleep in an elderly population: a randomized controlled trial. j bodyw mov ther 2021;27:692–7. 25. khose r, borkar dv. effect of brain gym exercises on attention span and quality of sleep in menopausal women: a randomized clinical trial. int j multidiscip res 2023;5:182-8. 26. okechukwu ce, masala d, d’ettorre g, la torre g. moderate-intensity aerobic exercise as an adjunct intervention to improve sleep quality among rotating shift nurses. clin ter 2022;173:184-6. 27. takemura n, chia-chin lin p. effectiveness of aerobic exercise and tai chi interventions on sleep quality in patients with advanced lung cancer. jama oncol 2024;10:1291-2. 28. alghosi m, sharifi m, rajamand n, et al. the effect of chronic yoga intervention on sleep quality in people with sleep disorders: a scoping review. front neurol 2025;16:1523456. 29. yan j, liu m, tang h, et al. the effect of aerobic exercise on sleep disorders in menopausal women: a systematic review and meta-analysis. bmc womens health 2024;24:640. 30. ozlu i, ozturk z, ozlu zk, tekin e. the effects of progressive muscle relaxation exercises on the anxiety and sleep quality of patients with covid-19: a randomized controlled study. perspect psychiatr care 2021;57:1791-7. 31. koldestam m, brostr a, petersson c, knutsson s. model for improvements in learning outcomes (milo): development of a conceptual model grounded in caritative caring aimed to facilitate undergraduate nursing students ’ learning during clinical practice (part 1). nurse educ pract 2021;55:1–9. 32. qin f, luo m, xiong y, et al. prevalence and associated factors of cognitive impairment among the elderly population: a article [page 282] [healthcare in low-resource settings 2025;13:14128] nationwide cross-sectional study in china. front public heal 2022;10:1032666. 33. arbianingsih a, huriati h, musnayni s, et al. brain gym effectively reduces anxiety in schooland preschool-aged children in hospitals. j keperawatan indones 2021;24:140–8. 34. wisuda ac, sansuwito t bin, suraya c. impact of the aris module (anxiety and depression reduction through islamic spiritual care) on patients with coronary heart disease. j nurs sci res 2024;1:56–66. article [healthcare in low-resource settings 2025;13:14128] [page 283] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13335 evaluating a culturally relevant, low-cost snakes and ladders game to strengthen mother-child attachment: a pre-experimental study juli oktalia,1 risha hardina,2 yulia sari,1 debbiyantina debbiyantina,1 shentya fitriana1 1health polytechnic of jakarta iii, kota bekasi; 2midwifery department, rumah sakit muhammad zein, belitung timur, indonesia abstract a mother’s role is crucial in meeting the physical and psychological needs of her child, such as affection, love, and attention. by leveraging a culturally relevant and interactive medium, this study examined how shared play experiences foster emotional connections and strengthen family bonds. it examines the use of a low-cost, modified snakes and ladders game to improve motherchild attachment, focusing on the caregiving practices of mothers who rarely engage in beneficial play activities. a pre-experimental design with a one-group pretest-posttest design was employed, with 160 respondents selected through stratified random sampling. the data were analyzed using a paired-sample t-test. the analysis revealed a significant increase in attachment (p<0.000). the game encouraged structured, enjoyable interactions that promoted communication, cooperation, and emotional closeness between mothers and their children. the modified snakes and ladders game is an effective tool for enhancing mother-child attachment by fostering mutual support, understanding, and trust. however, this study is limited by its pre-experimental design, which lacks a control group, and its focus on a specific age group and cultural context. future research could explore the impact of the game in diverse settings and with different populations to validate its broader applicability. these findings suggest the potential for culturally relevant, low-cost games to be integrated into parenting interventions to strengthen familial relationships. introduction parent-child attachment is a critical component of healthy child development, as it influences emotional well-being, social relationships, and self-esteem. however, increasing rates of attachment disorders have raised concerns globally, with research highlighting their long-term impacts, including emotional instability, bullying behaviors, and academic challenges.1-4 attachment disorders in infancy can affect future abilities, including emotional expression, self-confidence, and relationships. studies link early attachment types to traits like autonomy, self-esteem, and empathy in childhood5-9 and academic problems.10 data from the united states and indonesia indicate a rising prevalence of emotional and behavioral disorders among children, exacerbated by parenting practices that lack sufficient engagement in daily interactions.11-13 it is very important for children to have a strong relationship with their parents, especially their mother, as early as possible.14,15 despite the importance of early attachment, many young mothers lack the knowledge and skills to foster these bonds effectively.16,17 babies with insecure attachments need support to form secure bonds, especially if the process has been delayed. the sooner activities to strengthen attachment are implemented, the better the chance of addressing previous gaps.18 attachment, defined as the emotional bond between parent and child, is developed through stages and is most effective when it results in secure attachment. secure attachment fosters feelings of safety and trust, while insecure attachment is linked to developmental and psychological difficulties.1,19 secure attachment is the best type of attachment because children feel safe and protected even though their parents are not nearby.20 a preliminary study conducted in a region of indonesia, through surveys and direct interviews at an early childhood education institution, revealed that many mothers do not interact sufficiently with their children. this was observed through the number of children being dropped off and picked up by individuals correspondence: juli oktalia, health polytechnic of jakarta iii, jl. arteri jorr jatiwarna, kota bekasi, indonesia. e-mail: juli.oktalia@poltekkesjakarta3.ac.id key words: low-cost games; mother-child attachment; snakes and ladders. contributions: jo, conceptualization, data curation, formal analysis, methodology, visualization, writing – original draft, review & editing; rh, conceptualization, data curation, formal analysis, methodology, data collection, original draft; ys, conceptualization, formal analysis, methodology, validation, and writing – original draft, review & editing; dd, conceptualization, data curation, formal analysis, methodology, data collection, original draft; sf, resources, supervision, and writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research was approved by the health research ethics commission, poltekkes kemenkes jakarta iii, based on ethical certificate no. kepk/ump/115/iv/2024. during the research, the researcher focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. consent for publication: written informed consent was obtained from the patients for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 3 november 2024. accepted: 1 april 2025. early view: 30 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13335 doi:10.4081/hls.2025.13335 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 56] [healthcare in low-resource settings 2025;13(s2):13335] other than their mothers, such as fathers, grandfathers, grandmothers, and caregivers. additionally, interviews with five mothers regarding play interactions at home and children’s behavior development showed that only one mother frequently played with her child. in comparison, the other four mothers rarely did. about 4 out of 5 mothers work outside the home, and the amount of interaction with their children is limited. this makes them feel less close and less able to understand their child. the culture of raising children based on past experiences has become a habit for these mothers. in this digital era, the mothers also expressed confusion and a lack of ideas in finding a medium, other than using a mobile phone, that could be easily utilized for interacting with their children while also bringing joy to both. given this challenge to enhance motherchild attachment effectively, interactive media serve as a valuable mediator. this media should be affordable, accessible, and enjoyable for both mother and child.21-23 interactive play has been recognized as an effective tool for fostering attachment, promoting communication, cooperation, and emotional closeness. preliminary observations revealed that many mothers are disengaged during playtime, leading to emotional and social challenges for their children. this study aims to assess the impact of a low-cost, culturally relevant game, tangga kasih: the bonding ladder (a modified version of snakes and ladders), on improving attachment between mothers and children aged 4-6 years. by integrating structured and interactive elements into play, this research aims to address the gap in effective and accessible interventions for promoting secure attachments. materials and methods research design this study employed a quantitative approach, utilizing a preexperimental research design, specifically a one-group pretestposttest design. it aims to evaluate the effectiveness of a low-cost snakes and ladders game as an intervention tool to enhance mother-child attachment. this design was chosen due to the exploratory nature of the research, aiming to provide initial insights into the feasibility and potential impact of the intervention within a specific community context. by focusing on this preliminary stage, the study seeks to gather foundational data, identify relevant factors influencing outcomes, and assess the practicality of the approach before advancing to more rigorous experimental designs. despite its limitations in controlling external variables, this design provides a cost-effective and flexible framework to explore innovative methods for strengthening mother-child bonds. study participants the sample for this research, consisting of 160 mother-child pairs (children aged 4-6 years), was selected using stratified random sampling. first, the population was divided into strata based on specific child age. 40% of the population consisted of 4-yearolds, 35% of 5-year-olds, and 25% of 6-year-olds; 64 pairs were selected from the 4-year-olds, 56 pairs from the 5-year-olds, and 40 pairs from the 6-year-olds. random sampling was then conducted within each stratum to select the participants, ensuring that the sample accurately represented the population. the inclusion criteria for this study comprised children enrolled in kindergarten and mothers who were willing to participate as respondents. the exclusion criteria included children with mental retardation, mothers of twins, and mothers who were illiterate. the researcher submitted an ethical clearance application to the health research ethics commission and received the ethical clearance certificate. the decision to include children aged 4 to 6 years in this research is due to this age group signifying a pivotal phase in early childhood development, during which children start to form more intricate emotional and social bonds. this period is also known as the initiative stage, according to erikson’s theory,24 where children start to develop independence, initiative, and self-confidence, which are strongly influenced by their interactions with caregivers, especially mothers. additionally, children in this age range are still in the formative stages of attachment development, making them particularly responsive to interventions aimed at strengthening mother-child bonds. by focusing on this age group, the study targets a developmental window where attachment is crucial and can be positively influenced through interactive activities, such as the game being studied. variable, instrument, and data collection the variables in this study include the characteristics of the mother, the characteristics of the child, the quality of mother-child attachment before the intervention, and the quality of mother-child attachment after the intervention. the instrument used as an intervention in this study (figure 1) is a modified version of the classic snakes and ladders game, referred to as “tangga kasih: the bonding ladder”. the game board is divided into small squares, and some squares have several “ladders” or “snakes” drawn on them that connect to other squares. the researcher developed this low-cost game modification to enhance emotional attachment between mothers and their children. the modification process involves adjusting the traditional game format to suit the specific needs and characteristics of the participants. these adjustments include altering the game’s structure, pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13335] [page 57] figure 1. tangga kasih: the bonding ladder. simplifying the rules, modifying the playing tools, and adapting the game to suit the number of players and the duration of play. the key innovation lies in the inclusion of attachment-building activities within the game itself. this version consists of 8 rows and 6 columns, totaling 48 squares, each containing prompts for activities designed to foster emotional connection. these activities include following animal sounds, mimicking facial expressions, singing together, drawing, giving hugs, exchanging massages, clapping, shouting, and making movements together. by integrating such interactive and emotional activities, tangga kasih: the bonding ladder aims to offer an engaging and meaningful way for mothers and children to strengthen their bond, setting it apart from traditional versions of the game. the steps for playing the modified game are as follows: mothers set aside dedicated time to play with their children, free from other activities. the game consists of one die and two pawns. the child starts at box number 1 and rolls the die, with the mother following suit. on their turn, the player rolls the die and moves their pawn according to the number rolled. if a player rolls a 6, they do not move their pawn immediately; instead, they roll the die again and move their pawn according to the new number rolled. the mother assists the child in counting the spaces on the board according to the number rolled on the die. more than one pawn may occupy the same box. the mother helps the child read the instructions on each game square and demonstrates the actions to be taken for each instruction. there are four snakes in the game; if a player lands on the tail of a snake, they must move their pawn to the head of the snake. the game also features five ladders; if a player lands on the bottom of a ladder, they move up to the top. the winner of the game is the player who reaches box 48, or the final square, first. the instrument used to measure the quality of maternal-child bonding in this study was a questionnaire utilizing a likert scale. specifically, the parent-child interaction questionnaire revision (pachiq_r) was employed to assess the quality of the motherchild relationship. pachiq is a tool designed to evaluate the interactions and relationships between parents and children, focusing on aspects such as emotional closeness, communication, support, and warmth, particularly in the context of early childhood through early adolescence.25 the questionnaire consists of 25 items addressing themes such as emotional closeness, emotional responsiveness, involvement, quality time together, security and trust, support and independence, and conflict and stress management. the instrument has been tested for validity and reliability. the validity results show that the calculated r value is higher than the r table value at a significance level of 0.05. reliability testing found a cronbach’s alpha greater than 0.7, with the instrument’s cronbach’s alpha at 0.892.26 data collection for this study was conducted after respondents who met the inclusion criteria were provided informed consent and completed the research questionnaire. the questionnaire included questions about the characteristics and quality of the mother-child attachment, as perceived by the mother. upon completion of the pre-intervention questionnaire, the mother received a guide for playing the modified game, which was to be played at home with her child for 10 days over a two-week period. each game session lasted between 30 and 45 minutes, with the game played once daily, based on the availability of the mother and child. during the data collection process, mothers were instructed to engage only in their routine activities with their children, apart from playing the game. while playing, respondents were asked to document the activity through photographs, which were then sent to the researcher. as part of the intervention, respondents were provided with a game set, an instructional manual, and a daily activity book. following the two-week intervention, mothers were asked to complete a posttest questionnaire regarding the quality of attachment between themselves and their child, as assessed from their perspective. data analysis data analysis was conducted using descriptive statistics to illustrate the frequency distribution of variables, along with a paired sample t-test to compare pretest and posttest results within the same group. the paired sample t-test was employed to determine whether there was a significant difference in the mean scores before and after the intervention or treatment within the same group. ethical clearance the research has received ethical approval from the health research ethics commission of universitas muhammadiyah purwokerto, as indicated by the ethical certificate no. kepk/ump/115/iv/2024. throughout the study, the researcher adhered to ethical principles, including informed consent, respect for human rights, beneficence, and non-maleficence. results the results of this research are described in the form of a univariate analysis of the characteristics of the mother and child and a bivariate analysis of differences in the quality of attachment before and after intervention. table 1 presents the characteristics of the mothers in the sample, comprising a total of 160 respondents. the age distribution of the mothers is mainly between 19 and 39 years (70%), while the remaining 30% are aged 40-65 years. regarding the number of children, the majority of mothers have two children (40%), followed by those with three children (32.5%) and one child (27.5%). in terms of occupation, most mothers are employed (72.5%), while 27.5% are housewives. these characteristics reflect the diversity of the sample in terms of age, family size, and employment status. pathways of change, part ii [page 58] [healthcare in low-resource settings 2025;13(s2):13335] table 1. mothers’ characteristics based on age, number of children, and occupation. variable n % mother’s age 19-39 years 112 70 40-65 years 48 30 number of children 1 44 27.5 2 64 40.0 3 52 32.5 mother’s occupation housewife 44 27.5 employed 116 72.5 children’s age 4 years 28 17.5 5 years 68 42.5 6 years 64 40.0 gender boy 72 45.0 girl 88 55.0 table 1 also presents the characteristics of the children in the sample, comprising a total of 160 respondents. the age distribution is as follows: 17.5% of children are 4 years old, 42.5% are 5 years old, and 40.0% are 6 years old. in terms of gender, 45% of the children are boys, and 55% are girls. these characteristics reflect a balanced distribution of age and gender among the children in the study. table 2 shows that the lowest attachment score before the intervention was 90, while the highest score was 117. after the intervention, the respondents’ scores increased, with the lowest attachment score being 98 and the highest score reaching 120. furthermore, the average attachment score before the intervention was 102.12, with a standard deviation of 5.97, which increased to 109.58, with a standard deviation of 5.18, following the intervention using the modified snakes and ladders game. table 3 shows the results of the paired samples t-test for the effect of the modified game on mother-child attachment. the mean difference between the posttest and pretest scores is 7.46, indicating a significant increase in attachment scores following the intervention. the standard deviation of the differences is 4.77, and the standard error of the mean is 0.38. the p-value (sig. 2-tailed) is 0.000, which is less than 0.05. this result indicates that the difference between the pretest and posttest scores was statistically significant, suggesting that the intervention had a positive and significant effect on increasing the attachment between mothers and children. the positive mean difference (7.46) confirmed that attachment quality improved following the intervention. discussion the results showed a significant increase in maternal attachment scores after using the modified game. before the intervention, the average maternal attachment score was 120.20, while after the intervention, it increased to 130.07. this demonstrates that interaction through the right medium, even for just 30-45 minutes over 10 days, can significantly enhance the quality of attachment between mother and child. games that encourage actions such as hugging, singing together, and imitating movements promote communication in a fun, non-coercive way. these findings align with previous research suggesting that various educational media can help improve the quality of attachment between mothers and children.27-30 the use of the snakes and ladders game, designed for children aged three years and older, provides a variety of benefits, including cognitive stimulation, emotional engagement, and learning collaboration. the game encourages direct interaction between mother and child, allowing for moments such as singing together, drawing, hugging, and other shared activities. this creates opportunities for mothers to offer support and guidance, helping their children overcome challenges, while also reinforcing collaborative efforts to reach goals. the daily activity records from respondents indicated a positive reciprocal interaction between mothers and children during the modified snakes and ladders game.31 given the sample’s high number of working mothers who engaged in limited playtime with their children, the game provided a unique opportunity to promote interaction. however, it is important to recognize the significance of both parents’ involvement in raising children.32-34 it was found that the majority of mothers were employed outside the home, working six to eight hours a day. this work schedule reduces the amount of direct interaction between mothers and their children within a day. consequently, this reduction in time encourages mothers to become more creative and adopt alternative, more effective strategies for fostering a secure attachment with their children. a study highlights that a mother’s employment does not necessarily improve or deteriorate her attachment to her children. instead, the key factor in fostering a strong and secure bond lies in achieving a balanced integration of professional and maternal roles.35 further, based on the respondent characteristics, it was evident that most of the mothers had more than one child. previous studies suggest that a woman’s parenting experience influences her ability to care for subsequent children.36,37 additionally, the quality of parenting can be shaped by prior experiences of parental bonding.38-40 it has also been noted that the quality of attachment bonding with children can positively contribute to the parents’ psychological well-being.41-43 the use of the pachiq instrument in this research proves highly effective. designed for easy use by the general public, it allows mothers to complete the assessment without needing special training or a background in psychology. with simple language and intuitive instructions, the instrument enables accurate responses from parents. its broad scope, covering aspects such as emotional closeness, communication, support, and quality time, provides a comprehensive view of parent-child interactions. particularly suitable for evaluating relationships in young children (ages 4-6), pachiq offers both a reflective tool for parents and a means of early detection for further evaluation.44 in terms of the intervention, the tangga kasih: the bonding ladder game presents several advantages over traditional activities designed to enhance attachment between mothers and their children. this modification retains the playful nature of the classic game while incorporating elements that promote emotional connection and communication. the game’s flexibility enables mothers to tailor their involvement to their children’s needs, thereby increasing both the quality and frequency of shared moments. as mothers and children engage in the modified game, the emotional closeness between them is heightened through fun, interactive, and meaningful experiences. this approach lies in its dual focus: not only does the game serve as a tool for play, but it also acts as a medium for building trust, security, and a sense of attachment. by pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13335] [page 59] table 2. distribution of average quality of attachment between mother and child before and after tangga kasih: the bonding ladder intervention. n mean sd min max pretest 160 102.1 5.97 90 117 posttest 160 109.5 5.18 98 120 sd, standard deviation. table 3. results of the differential test on the effect of tangga kasih: the bonding ladder on increasing mother-child attachment. paired samples t-test mean sd lower upper t-test df sig. (2-tailed) pretest-posttest 7.46250 4.77136 6.717 8.207 19.783 159 0.000* sd, standard deviation; df, degrees of freedom; *p<0.05. utilizing a low-cost and easily accessible game format, this modified version can be implemented in diverse settings, making it an inclusive and sustainable method to enhance maternal-child attachment. the novelty lies in the intentional integration of attachmentbuilding activities within a familiar and enjoyable format, which differentiates it from conventional, non-interactive games that may not prioritize emotional engagement. through this structured interaction, the modified snakes and ladders game provides a unique and effective means of strengthening the emotional bond between mother and child. in this game, mothers have the opportunity to provide support and guidance as children learn to overcome challenges and failures, encouraging mothers and children to collaborate and work together to reach their highest potential. furthermore, mothers have the opportunity to appreciate their children’s achievements.45-47 therefore, it can be concluded that parental interaction and involvement in children’s play, facilitated by an effective game mediator, can significantly improve attachment. this enhancement in attachment reflects an improvement in the quality of the relationship, encompassing factors such as trust, communication, and emotional closeness. conclusions the use of a low-cost interactive game like snakes and ladders fosters meaningful mother-child engagement by promoting shared experiences, communication, and emotional connection through its structured yet playful nature. this creative, participatory approach not only strengthens familial bonds but also supports children’s social and emotional development. the findings highlight the value of accessible tools in enhancing attachment, suggesting parents integrate simple games into daily routines. future research should examine long-term effects, while educators and policymakers are encouraged to adopt similar strategies in early childhood programs to promote healthier developmental outcomes and stronger family connections. references 1. benoit d. infant-parent attachment: definition, types, antecedents, measurement and outcome. paediatr child health (oxford) 2004;9:541–5. 2. doyle o, harmon cp, heckman jj, tremblay re. investing in early human development: timing and economic efficiency. econ hum biol 2009;7:1–6. 3. hornor g. attachment disorders. j pediatr heal care 2019;33:612–22. 4. singata m, tranmer j, gyte gml. europe pmc funders group 2014;12:1–59. 5. burmenskaya gv. child’s attachment to mother as the basis of mental development typology. psychol russ 2009;2:385-403. 6. karakaş nm, dağlı fş. the importance of attachment in infant and influencing factors. turk pediatr ars 2019;54:76–81. 7. lanjekar pd, joshi sh, lanjekar pd, wagh v. the effect of parenting and the parent-child relationship on a child’s cognitive development: a literature review. cureus 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suryawan a. parenting style based on the mother’s personal mastery and the mother-child attachment in relation to child feeding disoders: a qualitative study. indian j public heal res dev 2018;9:1777–81. 16. erfina e, widyawati w, mckenna l, et al. becoming an adolescent mother: the experiences of young indonesian new mothers living with their extended families. midwifery 2022;104:103170. 17. hidayati f, hartini n, chusairi a. development of a mindful parenting model for mothers with children in early childhood. psikohumaniora j penelit psikol 2025;9:215–32. 18. conflict b, events i, training t. erikson’s psychosocial stages summary chart. more resources: hum dev 2009;1–4. 19. bowlby j. the nature of the child’s tie to his mother. int j psychoanal 1958;39:350-73. 20. lyons-ruth k. attachment relationships among children with aggressive behavior problems: the role of disorganized early attachment patterns. j consult clin psychol 1996;64:64–73. 21. poulain t, ludwig j, hiemisch a, et al. media use of mothers, media use of children, and parent–child interaction are related to behavioral difficulties and strengths of children. int j environ res public health 2019;16. 22. nandy a, nixon e, quigley j. parental toy play and toddlers’ socio-emotional development: the moderating role of coparenting dynamics. infant behav dev 2020;60:101465. 23. hadhyastuti es, hernawati n. maternal sensitivity, motherchild attachment, and cognitive development of preschool children in urban poor areas. j child dev stud 2017;2:51. 24. mcleod bs. erik erikson’s stages of psychosocial development stage 1 . trust vs . mistrust. simply psychology 2023;1– 16. 25. lange a, evers a, jansen h, dolan c. the parent�child interaction questionnaire—revised. fam process 2002;41:709–19. 26. chan ll, idris n. validity and reliability of the instrument using exploratory factor analysis and cronbach’s alpha. int j acad res bus soc sci 2017;7:400–10. 27. yasintha e. attachment mother and child through play. proceedings of the 4th asean conference on psychology, counselling, and humanities (acpch 2018). 2019. 28. saputra ne, ekawati yn. the effectiveness of e-book app story telling of traditional game story series to increase the attachment between parents and children. j educ heal community psychol 2021;10:525. 29. syawaluddin a, afriani rachman s, khaerunnisa. developing snake ladder game learning media to increase students’ interest and learning outcomes on social studies in elementary school. pathways of change, part ii [page 60] [healthcare in low-resource settings 2025;13(s2):13335] simul gaming 2020;51:432–42. 30. boson k, gurdal s, claesdotter-knutsson e, kapetanovic s. adolescent gaming and parent–child emotional closeness: bivariate relationships in a longitudinal perspective. curr psychol 2024;43:19655–65. 31. johannes n, vuorre m, przybylski ak. video game play is positively correlated with well-being. r soc open sci 2021;8. 32. fernandes c, monteiro l, santos aj, et al. early father-child and mother-child attachment relationships: contributions to preschoolers’ social competence. attach hum dev 2020;22:687-704. 33. proceedings of the 2nd international conference on education, language and art (icela 2022). atlantis press sarl; 2023. 145–151 p. 34. setiawati y, mirantri k, mukono hj, et al. correlation between parenting styles and peer attachment with aggressive behavior potentials in adolescent boys. indian j forensic med toxicol 2020;14:1980–6. 35. kassamali n, salma r. factors that affect attachment between the employed mother and the child, infancy to two years. procedia soc behav sci 2014;159. 36. cassé jfh, oosterman m, volling bl, schuengel c. first-time motherhood experiences and the decision to have a second child. j fam issues 2018;39:555–78. 37. prinds c, mogensen o, hvidt nc, bliddal m. first child’s impact on parental relationship: an existential perspective. bmc pregnancy childbirth 2018;18:1–7. 38. hoff e, trecca f, højen a, et al. context and education affect the quality of parents’ speech to children. j appl dev psychol 2024;91. 39. rachmawati pd, krisnana i, pradanie r, et al. parental support and influencing factors for school-age children’s healthy movement behavior: a cross-sectional study. j ners 2024;19:500–8. 40. hidaayah n, yunitasari e, nihayati he, et al. parenting strategies: applying basic psychological needs to children at risk of internet gaming disorder in indonesia. healthc low-resource settings 2024;12. 41. joseph v, kotian s. a systematic review on the role of parental bonding in adolescent psychosocial development. int j manag technol soc sci 2022;615–33. 42. dewi rk, sumarni s. parenting style and family empowerment for children’s growth and development: a systematic review. j public health africa 2023;14. 43. sugiarti r, erlangga e, purwaningtyastuti p, suhariadi f. the influence of parenting and friendship on self-esteem in adolescents. open access maced j med sci 2021;9:1307–15. 44. majid bnu, widyasari dc, karmiyati d, syakarofath na. relationship between parent-adolescent interaction and the likelihood of internalizing and externalizing problems among adolescents. psikologika j pemikir dan penelit psikol 2023;28:13–4. 45. nandy a, nixon e, quigley j. parental toy play and toddlers’ socio-emotional development: the moderating role of coparenting dynamics. infant behav dev 2020;60:101465. 46. chang jh, yeh tl. the influence of parent-child toys and time of playing together on attachment. procedia manuf 2015;3:4921-6. 47. siu a. feasibility and acceptability of using firstplay® to enhance mother–child interaction: a pilot study of mothers’ perspectives. scand j child adolesc psychiatry psychol 2023;11:69–77. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13335] [page 61] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13041 the relationship between social media exposure and sexual orientation of latest adolescents renny nova,1 retno lestari,1 cicit niara suoth2 1department of nursing, faculty of health sciences, universitas brawijaya, malang, east java; 2north bolaang mongondow regional hospital, north sulawesi, indonesia abstract during adolescence, the development of sexual needs, the regulation of sexual orientation, and the decision to become a woman or a man are carried out to create a connection and form behavior leading to deviant sexual behavior. sexual orientation becomes a person’s identity in the environment and adolescents are expected to know the direction of attraction. the factors influencing sexual orientation are internal and external, such as exposure to social media. therefore, this research aims to determine the relationship between social media exposure and late adolescent sexual orientation. a quantitative method is adopted using a cross-sectional design on 111 samples. the instruments used are the intensity scale of social media use (sipms) and the kinsey scale to measure exposure to social media and sexual orientation, respectively. the study’s findings indicate a statistically significant correlation between social media exposure and sexual orientation in late adolescents, with a p-value of 0.040. in conclusion, education should be provided from an early age on sexual orientation and the anticipation of adolescents in fulfilling duties, resulting in a process of self-development within the social environment. introduction adolescence is a period of development during childhood and adulthood from 10 to 19 years. many biological, psychological, and social transformations are recorded at this age when adolescents are looking for true identity. every individuals have the right to select a lifestyle and determine sexual orientation.2 according to who, about 1.2 (18%) billion of the world’s population are adolescents.3 the central statistics agency in august 2021 reported 22,119,160 adolescents between 15-19 years in indonesia.4 in 2020, east java province recorded 3,020,928 adolescents, while malang city reported 84,347, consisting of 44,338 women and 40,009 men.5˒6 late adolescent phase is marked by the achievement of physical maturity where the individuals are expected to think more about the future. adolescents are becoming more serious about relationships with the opposite sex and are starting to accept the norms and habits of the surrounding environment.7 the formation of a person’s self-identity reaches the peak in late adolescence and continues throughout life. sexual orientation is the basic desire of individuals to satisfy the need for love in relation to a sense of intimacy or closeness.8 generally, the concept is divided into homosexuality, heterosexuality, and bisexuality, which are sexual attraction to people of the same, opposite, and both sexes.9 the factor of exposure is because social media has an attraction for adolescents. social media allows communication between users where adolescents reconnect and make new friends. by joining a community of people with the same interests or hobbies, social media can help adolescents feel comfortable.10 based on a research conducted by yanti et al. with the title the role of parents in preventing deviations in children’s sexual orientation in the city of padang, one of the causes of children’s behavior and changing sexual orientation is technology.11 according to oktavia, sexual behavior and social media in adolescents are unrelated.12 therefore, this study seeks to investigate the correlation between exposure to social media and the sexual orientation of late adolescents. design and methods the research method uses a cross-sectional design. a simple random sampling method was used based on inclusion and exclusion criteria to obtain 111 samples. meanwhile, social media usage intensity scale (sipms) was adopted to measure social media exposure and the kinsey scale to measure late adolescent sexual orientation. data collection and analysis sexual orientation questionnaire uses the indonesian version of the kinsey rating scale, adopted by putri in “description of gender identity orientation in adolescent santri at the salafiyah syafi’iyah sukorejo islamic boarding school, situbondo regency”.13 social media use intensity scale questionnaire (sipms) was adopted from sabekti. sipms was used previously in sabekti’s research with the title “the relationship between intensity of social media (social networking) use and narcissistic tendencies and self-actualization in late adolescents”.14 the ibm spss statistics 24 application was adopted to perform univariate and bivariate analysis. the univariate analysis significance for public health adolescents are individuals in a period of self-discovery, capable of obtaining information through social media. however, inappropriate use of social media can adversely affect adolescents and the data generated from this research increases public awareness of the dangers on adolescent sexual orientation. the study explores the significant correlation between the amount of time late adolescents spend on social media and their sexual orientation. [page 56] [healthcare in low-resource settings 2024;12(s1):13041] non -co mmerc ial us e o nly described the characteristics of respondents based on demographic sexual data, social media use and exposure, as well as orientation. the results of the analysis were described in the form of tables and narratives. bivariate analysis used the spearman rank statistical test to determine the relationship between social media exposure and sexual orientation in late adolescents. filling out informed consent is carried out by asking the respondent directly and distributing the sheet. the subjects are humans, and ethical permission has been obtained from the ethics commission of the faculty of health sciences, brawijaya university, malang, with no.3965/un10.f17.10/tu/2022. results and discussion based on table 1, 85.6% of the respondents were women, while 55.9% were 20 years old. all respondents used smartphones to access social media and 70.3% had more than three types. a total of 58.6% had one to two types of social media and 64.9% used this platform more than six times a day. approximately 67.6% conducted one to three activities after opening social media. table 2 shows that 56 (50.5%) and 55 (49.5%) respondents are classified into low and high categories of social media exposure. based on the data, the most common sexual orientation of late adolescents was heterosexual, consisting of 107 (96.4%) respondents, and this is followed by bisexual and homosexual, with 3 (2.7%) and 1 (0.9%) respondents, respectively. from table 3, the respondents were woman, with 51 (53.7%) having low exposure to social media. more than half were 20 years old, and social media exposure of 32 (28.8%) at the age of 20 was in the low category. in addition, 24 (21.6%) were in the reg 2 class, where the level of exposure to social media was also low. the respondents used smartphones to access social media, but the difference between the high and low categories was limited. the standard and high categories consisted of 56 (50.5%) and 55 (49.5%) respondents, respectively. most respondents have more than three social media, but exposure of 40 (36%) was in the low category. the most frequently used social media were only 1-2 types, with exposure category of 35 (31.5%) respondents being high. approximately 64.9% used social media more than six times a day, and the highest exposure was in the low category, consisting of 42 (37.8%). based on table 4, sexual orientation of most late adolescents was heterosexual. the heterosexual man and woman gender categories consisted of 14 (12.6%) and 83 (83.8%) respondents, respectively. approximately, 60 (54.1%) aged 20 years and 42 (37.8%) respondents from the reg 2 class were heterosexual. most smartphone users (96.4%) and 75 (67.6%) respondents with three types of social media were heterosexual. furthermore, a total of 62 respondents (55.9%) using 1-2 types of social media were heterosexual. approximately 62.2% of heterosexuals used social media more than six times daily and 71 (64%) conducted one to three activities on the platform. the cross-tabulation of the relationship between exposure and sexual orientation shows that 51 (45.9%), 3 (2.7%), and 1 (0.9%) %) respondents were heterosexual, bisexual, and homosexual, respectively. with low social media exposure, 56 (50.5%) respondents had a heterosexual sexual orientation. from the data analy 4th international nursing and health sciences symposium table 1. characteristic of respondents. characteristic of respondents n' %’ gender man 16 14.4 woman 95 85.6 age 19 years old 22 19.8 20 years old 62 55.9 21 years old 27 24.3 class reg 1 39 34.2 reg 2 44 40.5 reg 3 28 25.2 electronic devices used to access social media smartphones 111 100 number of social media owned 2-3 33 29.7 >3 78 70.3 types of social media frequently used 1-2 types of social media 65 58.6 3-4 types of social media 32 28.8 5-7 types of social media 14 12.6 average length of social media use 1-3 times a day 8 7.2 4-5 times a day 31 27.9 >6 times a day 72 64.9 activities frequently performed when opening social media 1-3 activities 75 67.6 4-6 activities 34 30.6 7-10 activities 2 1.8 [healthcare in low-resource settings 2024;12(s1):13041] [page 57] non -co mmerc ial us e o nly sis, the spearman rank correlation test results in a significance value of 0.040. this shows the relationship between social media exposure and sexual orientation of late adolescents at brawijaya university, malang, with a correlation coefficient of -0.195. late adolescent social media exposure based on the results, women use social media the most, with a percentage of 85.6%. according to sumter et al., most women use social media to search for information and partners.15 women spend more time on social media to check trending topics and gain recognition from other people.16 however, this differs from the results of eka yan fitri and chairoel, where gender does not affect the length of time spent on social media or learning achievement.17 the respondents were predominantly 20 years old and categorized in late adolescent phase, where many physical and psychological changes are experienced.18 according to mahdia, the content shown by influencers influences the psychological health of late adolescents.19 hallainia states that influencer content often affects psychological well-being positively or negatively. this research also found that late adolescents’ social media use was >6 times a day. stockdale and coyne stated that late adolescents used social media to overcome boredom.20 some individuals engaged in excessive use of the platform to reduce boredom.21˒22 from the results, 50.5% of the respondents had low social media exposure. according to fadillah and widyatuti, low exposure has less chance of risky adolescent sexual behavior among adolescents.23 this is supported by nuraeni et al. who reported that the use of social media is directly proportional to sexual behavior.24 late adolescent sexual orientation based on the results, all respondents were in late adolescent phase of 19-21 years, which is a time of sexual identity formation. according to alves et al. (2016), discovering an individual’s sexual orientation occurs when the first homosexual desire and atypical behavior are manifested in childhood. this also continues until adolescent strengthens sexual desire as a homosexual due to experience.25 besides age, the research obtained gender data, which does not affect sexual orientation. according to rahman et al, the level of gender equality and economic development of a country is not significantly related to the level of sexual orientation of men or women.26 the relatively stable rates of heterosexuality, 4th international nursing and health sciences symposium [page 58] [healthcare in low-resource settings 2024;12(s1):13041] table 3. results of cross tabulation of respondent characteristics with social media exposure. respondent characteristics social media exposure high low n % n % gender man 11 9.9 5 4.5 woman 44 39.6 51 53.7 age 19 years old 11 9.9 11 9.9 20 years ‘30 27.0 32 28.8 21 years 14 12.6 13 11.7 class reg 1 16 14.4 22 19.8 reg 2 21 18.9 24 21.6 reg 3 18 16.2 10 9.0 electronic devices used to access social media smartphones 55 49.5 56 50.5 number of social media owned 2-3 17 15.3 16 14.4 >3 38 34.2 40 36.0 types of social media frequently used 1-2 types of social media 35 31.5 30 27.0 3-4 types of social media 13 11.7 19 17.1 5-7 types of social media 7 6.3 7 6.3 average length of social media use 1-3 times a day 5 4.5 3 2.7 4-5 times a day 20 18.0 11 9.9 >6 times a day 30 27.0 42 37.8 activities frequently performed when opening social media 1-3 activities 39 35.1 36 32.4 4-6 activities 15 13.5 19 17.1 7-10 activities 1 0.9 1 0.9 table 2. social media exposure and sexual orientation. n % social media exposure high 55 49.5 low 56 50.5 sexual orientation heterosexual 107 96.4 bisexual 3 2.7 homosexual 1 0.9 non -co mmerc ial us e o nly bisexuality, and homosexuality suggest that nonsocial factors may underlie many differences in individuals’ sexual orientation. these results do not support the often-stated assumption that differences in sexual orientation are related to social gender norms in society. the activity of opening social media can affect a person’s perception of sexual orientation. according to hidayah, the dynamics that cause changes are parenting patterns, imitation from blue films, disappointment with women, and surrounding environment that supports behavior. imitation (modeling) of things of sexual nature can be easily accessed via social media.27 according to bandura, imitation or modeling is a learning behavior without direct experience,28 sheva and roosiani state that the behavior of women who like the boy’s love story genre, or fujoshi, has a dependency effect due to daily activities. with social media twitter as a link between fujoshi, fans of the boy’s love genre are identified. therefore, the effect of frequently accessing boy’s love content changes the views in real life.29 the relationship between exposure to social media and sexual orientation in late adolescents this research shows the relationship between exposure to social media and sexual orientation of late adolescents. the significance and correlation coefficient values are at 0.040 and -0.195, with the correlation category being fragile (table 5). limited exposure to social media enables adolescents to opt for heterosexual orientation, while extensive exposure leads to the diversification into heterosexual, bisexual, and homosexual categories. according to yanti et al., one of the causes of changes in sexual orientation is technology, namely social media.11 gozan reported that sexual orientation was greatly influenced by events and stimuli felt from an environment openly accepting homosexual activity and the availability of information media from cyberspace.30 the relationship between social media exposure and sexual orientation occurs because social media content quickly has adverse effects. the increasing number of adolescents who use social 4th international nursing and health sciences symposium table 4. results of cross tabulation of respondent characteristics by sexual orientation. respondent characteristics sexual orientation heterosexual bisexual homosexual n % n % n % gender man i14 12.6 1 0.9 1 0.9 woman 83 83.8 2 1.8 0 0.0 age 19 years old 21 18.9 1 0.9 0 0.0 20 years 60 54.1 1 0.9 1 0.9 21 years 26 23.4 1 0.9 0 0.0 class reg 1 38 34.2 0 0.0 0 0.0 reg 2 42 37.8 2 1.8 1 0.9 reg 3 27 24.3 1 0.9 0 0.0 electronic devices used to access social media smartphones 107 96.4 3 2.7 1 0.9 number of social media owned 2-3 31 28.8 1 0.9 0 0.0 >3 75 67.6 2 1.8 1 0.9 types of social media frequently used 1-2 types of social media 62 55.9 2 1.8 1 0.9 3-4 types of social media 31 27.9 1 0.9 0 0.0 5-7 types of social media 14 12.6 0 0.0 0 0.0 average length of social media use 1-3 times a day 8 7.2 0 0.0 0 0.0 4-5 times a day 30 27.0 1 0.9 1 0.9 >6 times a day 69 62.2 2 1.8 0 0.0 activities frequently performed when opening social media 1-3 activities 71 64.0 3 2.7 1 0.9 4-6 activities 34 30.6 0 0.0 0 0.0 7-10 activities 2 1.8 0 0.0 0 0.0 table 5. results of cross tabulation of the relationship between social media exposure and sexual orientation in late adolescents. social media exposure sexual orientation significance correlation heterosexual bisexual homosexual value (p) coefficient n % n % n % high 51 45.9 3 2.7 1 0.9% 0.040 -0.195 low 56 50.5 0 0.0 0 0.0 [healthcare in low-resource settings 2024;12(s1):13041] [page 59] non -co mmerc ial us e o nly media makes it very easy to imitate the harmful content circulating on social media platforms. adolescents can easily fall into several different age groups, so the language spoken is different; some even discuss adult topics that they should not know at that age.31 the emergence of sexual content on social media also arouses the desire to know and carry out sexual activities among its users, specifically adolescents. in general, the use of social media sites represents a time of change as people read and share news, content, and information with others. social media allows adolescents to make friends with strangers and new people. most adolescents spend much time on social media looking at pictures and commenting on posts on social media. correlation results show the relationship between social media exposure and sexual orientation in late adolescents. therefore, exposure to social media is only one factor influencing adolescents’ sexual orientation. according to sunarti and latif et al., internal and external factors influence sexual orientation. these include parenting errors and family conflicts, influence through friends, exposure to social media, and victims of sexual violence.9˒32 conclusions in conclusion, a correlation was observed between exposure to social media and orientation of late adolescents at brawijaya university, malang. among late adolescents, 56 (50.6%) were classified into a low category of social media exposure, with the majority, constituting 96.4% as heterosexual in terms of sexual orientation. references 1. widiyawati w. mental health nursing. first edition. malang: nusantara literacy; 2020. 2. ramdan anm. psychosocial relationship with late adolescent maturity to early adulthood (16-25 years) towards sexual orientation. j ikip siliwangi 2018;1:151–8. 3. who. world health statistic 2014. geneva: world health organization;2014. 4. central bureau of statistics of indonesia. population aged 15 years and above by age group statistical table [internet]. [cited 2023 aug 12]. available from: https://www.bps.go. id/id/statistics-table/2/nze1izi=/jumlah-penduduk-usia-15tahun-ke-atas-menurut-golongan-umur.html 5. central statistics agency of east java province. population of east java province by age group and sex (people), 20192021 [internet]. 2021 [cited 2023 aug 12]. available from: https://jatim.bps.go.id/indicator/12/120/1/jumlah-pendudukprovinsi-jawa-timur-menurut-kelompok-umur-dan-jenis-kelamin.html. 6. central statistics agency of malang city. population of malang city by age group and sex (people), 2018-2020 [internet]. 2021 [cited 2023 aug 12]. available from: https://malangkota.bps.go.id/indicator/12/51/2/jumlah-penduduk-menurut-kelompok-umur-dan-jenis-kelamin-di-kotamalang.html. 7. hapsari a. reproductive health textbook adolescent reproductive health module. malang: wineka media; 2019. 8. sinyo. my son asks about lgbt. jakarta: pt. elex media komputindo; 2014. 9. sunarti e. don’t regret it: protect your family and the next generation of the nation from the freedom of orientation movement and deviant sexual behavior. 1st ed. bogor: ipb press; 2021. 10. triastuti e, adrianto d, nurul a. study of the impact of social media use on children and adolescents. depok: center for communication studies fisip ui; 2017. 11. yanti am, firman f, rusdinal r, padang un. the role of parents in preventing deviant sexual orientation in children in padang city. j perspekt j kaji sosiol dan pendidik 2020;3:9–13. 12. oktavia fv. hubungan antara penggunaan media sosial dengan perilaku seksual remaja [internet]. universitas katolik soegijapranata; 2017. available from: http://repository.unika.ac. id/16247/1/13.40.0276 francisca vina copy.pdf 13. putri nas. description of gender identity orientation in adolescent students at the salafiyah syafi’iyah sukorejo 4th international nursing and health sciences symposium correspondence: renny nova, department of nursing, faculty of health sciences, universitas brawijaya malang, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia. tel.: +62341569117, fax: +62341564755. e-mail: reva.fk.psik@ub.ac.id key words: late adolescents; sexual orientation; social media contributions: rn as the first author created the outline and design of the research, manuscript, and discussion, rl as the second author contributed to the introduction and method, and cns as the third author obtained and analyzed the data. conflict of interests: the authors declared that there were no potential conflicts of interest. funding: none. clinical trials: not applicable. ethics approval: the subjects are humans, and ethical permission has been obtained from the ethics commission of the faculty of health sciences, brawijaya university, malang, with no.3965/un10.f17. 10/tu/2022. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgment: the authors are grateful to the department of nursing, faculty of health sciences, universitas brawijaya, malang for their support and encouragement. furthermore, special appreciation goes to all the respondents who participated in this research. received: 3 november 2023. accepted: 19 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13041 doi:10.4081/hls.2024.13041 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 60] [healthcare in low-resource settings 2024;12(s1):13041] non -co mmerc ial us e o nly islamic boarding school, situbondo regency. jember: jember university; 2019. 14. sabekti r. the relationship between the intensity of social media use (social networks) with the tendency of narcissism and self-actualization in late adolescents. surabaya: airlangga university; 2019. 15. sumter sr, vandenbosch l, ligtenberg l. love me tinder: untangling emerging adults’ motivations for using the dating application tinder. telemat informatics 2017;34:67–78. 16. yau jc, reich sm. “it’s just a lot of work”: adolescents’ self-presentation norms and practices on facebook and instagram. j res adolesc 2019;29:196–209. 17. eka yan fitri m, chairoel l. the use of social media based on gender on student learning achievement. j benefita 2019;1:162. 18. suryana e, wulandari s, sagita e, harto k. development of late adolescence (tasks, physical, intellectual, emotional, social and religious) and its implications for education. jiip j ilm ilmu pendidik 2022;5:1956–63. 19. mahdia a. the influence of influencer content on social media on the psychological well-being of late adolescents. j psychol 2018;11:172–9. 20. stockdale la, coyne sm. bored and online: reasons for using social media, problematic social networking site use, and behavioral outcomes across the transition from adolescence to emerging adulthood. j adolesc 2020;79:173–83. 21. bench sw, lench hc. on the function of boredom. behav sci (basel) 2013;3:459–72. 22. whelan e, najmul islam akm, brooks s. is boredom proneness related to social media overload and fatigue? a stress– strain–outcome approach. internet res 2020;30:869–87. 23. fadillah r, widyatuti. social media user behavior with premarital sexual behavior in high school adolescents. j ners widya husada 2018;5:87–94. 24. nuraeni s, nainar a, hikmah. relationship between social media site use and adolescent sexual behavior in sman 14 kota tangerang. j jkft 2021;6:31–8. 25. alves mjh, parente js, albuquerque ga. homosexual orientation in childhood and adolescence: experiences of concealment and prejudice. reprod e clim 2016;31:68–75. 26. rahman q, xu y, lippa ra, vasey pl. prevalence of sexual orientation across 28 nations and its association with gender equality, economic development, and individualism. arch sex behav 2020;49(:595–606. 27. hidayah f. dynamics of sexual orientation in gays. psychology j psychol 2019;2:117. 28. lesilolo hj. application of albert bandura’s social learning theory in the teaching and learning process in schools. kenosis j kaji teol 2019;4:186–202. 29. sheva vn, roosiani i. the influence of the boy’s love genre on the fujoshi community in indonesia. idea j stud japan 2022;4:52–9. 30. gozan m. homosexual behavior: searching for the roots in genetic factors. nizham j islam stud 2017;4:75–87. 31. fitriansyah f. the effect of mass communication on the audience (descriptive study of social media use in shaping adolescent behavior). cakrawala 2018;18:1–8. 32. latif i, fitriyani d, . d. internal and external factors affecting sexual behavior of men having sex with men (lsl) in adolescents in indramayu regency. j kesehat indra husada 2019;6:1. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13041] [page 61] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13064 hypertensive patients’ experience of care: a qualitative study nikmatul fadilah,1,2 dyah wijayanti,1 siti nur kholifah,1 dinarwiyata dinarwiyata1 1nursing department, health polytechnic of the health ministry of surabaya, surabaya, east java; 2center for excellence in science and technology-community empowerment, health polytechnic of the health ministry of surabaya, surabaya, east java, indonesia abstract hypertension is an incurable disease, requiring patients to comply with treatment in order to reduce the risk of complications, including death. therefore, this study aimed to explore the experience of individuals with hypertension in relation to compliance with treatment. the study adopted a qualitative descriptive design using semi-structured questions, and a total of 20 patients with hypertension participated. the result of this study found 5 themes, namely, not taking the medication regularly, adhering to a diet, using complementary medicine, stable blood pressure, and dizziness as the primary complaint. there were significant and exciting results from this study, namely, patients who do not take medication regularly and do not adhere to their diet. introduction compulsory long-term care for hypertensive patients is often an obstacle to achieving medication compliance and treatment success.1 obedience to medication is the only way for individuals with hypertension to control the disease and lower the risk of both complications and death.2,3 data from the basic health study (riset kesehatan dasar) showed that the proportion of hypertension treatment in indonesia had not reached the target of 100% in 2018. specifically, the proportion of hypertension medication only reached 54.4%, and about 32.3% did not take regular medication, while 13.3% did not partake in the treatment.4 previous studies in several indonesian regions reported a tendency for non-compliance of hypertensive patients to treatment, including the primary study, mbakurawang, liberty, et al., purnawan, and tumundo, accounting for 63.9%, 57%, 80%, 58.68%, and 57.5%, respectively.5–9 similar studies in other countries also showed the same trend as the conditions are similar to indonesia. akoko (2017) in cameroon stated that the percentage of non-compliance to the treatment of hypertension patients was 56.1%. furthermore, north vietnam (nguyen, 2017) jankowskapolanska in poland, and the united states reached 50.2%, 63.1%, and 59% non-adherent patients, respectively.10–12 data from the world health organization (who) in 2013 showed that hypertension affects 972 million individuals worldwide, accounting for 26.4%.13,14 according to the basic health study in indonesia by the ministry of health compiled in doctors’ diagnosis medications and measurements, the increase of hypertension incidents among 18-year-old individuals increased from 25.8% to 34.1% in 2018. the prevalence of hypertension at the age of <20 years from the results of the 2016 national health indicator survey (survey indicator kesehatan nasional) based on blood pressure measurements was 10.7%. the result showed that the prevalence of hypertension in indonesia increased from 25.8% to 34.4% in individuals aged 18 years people and above. in surabaya city, hypertension was ranked first for non-communicable diseases in 2016 (surabaya city health office, 2017). the provincial data in the 2018 basic health study stated that hypertension in surabaya is 18.42%.4 hypertension is classified as one of the non-communicable diseases or ncds, representing the leading cause of mortality worldwide and accounting for 68% of the 56 million deaths in 2012. when not treated adequately, hypertension damages a target organ and triggers a stroke, which is the occurrence of coronary heart disease, resulting in death. a previous study reported that 7 million people die from hypertension in the world annually.13 generally, the contributing factors of hypertension treatment compliance include age, sex, education level, employment status, length of suffering from hypertension, length of treatment, level of knowledge, motivation for treatment, drug side effects, perceptions of health surfaces, and family sports.15–18 stressful conditions also cause non-compliance with the treatment of hypertensive patients and blood pressure control.19 another determinant of compliance is the experience of service satisfaction, including drug counseling and home care received by patients.20 non-compliance with hypertension treatment can occur due to obstacles to seeking treatment, fulfilling prescriptions, correctness in taking medication, and health checks. treatment compliance to hypertension can prevent complications. previous studies showed that 17.7% of deaths are due to stroke, and 10% are caused by ischemic heart disease.13 pharmacological and non-pharmacological management has been shown to reduce blood pressure when carried out regularly, necessitating compliance. non-compliance in treatment is a form of behaviour that can be changed. compliance behaviour based on the health promotion model assumes that characteristics and experience, behaviour, personal, cognition, and affection factors [healthcare in low-resource settings 2024;12(s1):13064] [page 21] significance for public health adhering to medication is essential for the management of hypertension, mitigating complications, and preventing mortality. diverse factors influence treatment adherence, including age, education, employment status, knowledge, motivation, and stress levels. consistent adherence to pharmacologic and non-pharmacologic interventions can significantly decrease blood pressure and avert complications. behavioural compliance can be modified using the health promotion model, which underscores personal traits, behaviours, cognition, and emotions. this study investigates the adherence experiences of individuals with hypertension and the associated benefits. by comprehending and advocating for respectful attitudes toward care and treatment, healthcare professionals can assist hypertensive individuals in realizing improved health outcomes and ultimately contribute to the overall well-being of the indonesian populace. non -co mmerc ial us e o nly can determine an individual respectful behaviour.21,22 hypertensive patients have complex bio, psycho, social, and spiritual needs. individual efforts in carrying out care require personal commitment and support from the environment.17,23 the application of the model in this study includes adaptation and integrity or wholeness. adaptation is a change process while conservations represent the daily outcome. according to a previous study, adaptation is a process where the integrity of patients grows in the natural environment.24 conservation enables individuals to face constraints and adapt to the situations while maintaining uniqueness. in addition, conservation also aims to keep an individual healthy and have the strength to encounter disability and even death. this study aimed to explore the experience of people with hypertension in relation to compliance with treatment and the benefits. the experience of respectful behaviour towards care and treatment is the reference in providing nursing services to groups, specifically in behaviour modification. therefore, a group of individuals with hypertension are wholly healthy and productive, as well as become quality assets of the indonesian nation. materials and methods study design this qualitative study used a phenomenological method to explore the unique meaning of each experience or phenomenon of mankind. participants a total of 20 patients with hypertension in krembangan selatan public health center were selected as the study samples, using the purposive sampling method. data collection and instruments data were collected from july to august 2022 using semistructured questions. the interview guide was prepared based on the study objectives according to the health promotion and conservation models. this study found data saturation after interviewing 20 participants. data analysis data analysis includes the identification of various themes selected from interviews and observations. intensive reading of the transcriptions of the interviews and observations yields several themes, which are subsequently labeled with attached meanings or contextual significance. ethical clearance ethical clearance was obtained from the health research ethics committee of the indonesian strada institute of health science with study number 3613/kepk/ix/2022, dated 22 september 2023. results and discussion the demographic characteristics of participants are shown in the following table 1. based on table 1, it showed that the majority of participants were female, aged 50-59 years, with senior high school education, and married, accounting for 75%, 55%, 65%, and 85%, respectively. a total of 65% work from home, with a percentage of 75% income, which is below the local standard of payment in surabaya (4,375,479.19 idr). furthermore, 35% of patients suffered from hypertension for 6-10 years with a single common health complaint, accounting for 45%. the majority, accounting for 55% took drugs other than those for hypertension. the two most commonly consumed types were anti-diabetic and anti-hyperlipidemic medications, with each being taken by 5 patients. theme analysis the theme of this study includes the treatment experiences, comprising the following sub-themes i) experience of taking hypertension medication, ii) experience of undergoing a hypertension diet, and iii) experience of using complementary/traditional medicine. previous care experiences experiences taking hypertension medication an interesting result of this study was that 9 participants took medication when there were complaints, such as chest pain or headache. “when my chest hurts, i will just take medicine, sis” (r2) “the headache is reduced. take medication not continuously when there are complaints” (r4) “drink when symptoms appear” (r9) “rarely take medicine, just when you feel dizzy” (r10). “i do not take medicine when the body feels good” (r11) “take medicine if there are complaints” (r12) “i take medicine every day, but sometimes i stop. take medication when there are complaints” (r14) “when a headache arises, then we take medicine” (r15) “do not take medication continuously or only when there are complaints” (r17) experiences with a hypertension diet the experiences of participants in a hypertension diet included not eating meat, avoiding fried foods, and reducing salty foods. “regular diet, do not eat meat and chicken” (r1) “avoid fried foods” (r2) “reduce eating salt and fried foods” (r6) “reduce salty foods (r7) “eat 3 to 5 cucumbers and star fruit a day, as well as when blood pressure increases and other symptoms” (r9) “reduced eating coconut milk, foods high in salt” (r10) “reduce salty food” (r12) “do not eat salty foods” (r13) “reduce salty food” (r17) “regular diet, reduced salt” (r18) “reduced salt, regular diet” (r19). experiences using complementary/traditional medicine traditional therapy includes consuming ginger, honey, mangosteen, and coriander. “ginger, moringa leaves, lemongrass, bay leaves, and coriander are boiled” (r2) “drink boiled celery water” (r3) “bay leaf herb. mangosteen” (r5) consume garlic and turmeric sometimes” (r6) “drink red ginger, cabepuyang” (r7) “herbs, ginger, honey” (r8) “lemon grass, celery, ginger, boiled turmeric and drink for two days, once each morning” (r9) “drink celery/coriander water” (r17) 4th international nursing and health sciences symposium [page 22] [healthcare in low-resource settings 2024;12(s1):13064] non -co mmerc ial us e o nly discussion previous care experiences experience taking hypertension medication hypertensive patients take antihypertensive drugs only when there are complaints or feelings of dizziness and only 3 participants did not take at all. the result of this study showed that commitment to taking medication affects patients’ compliance. commitment of hypertension patients was influenced by the acceptance of health conditions. self-acceptance also affected compliance with self-care. accepting oneself in all circumstances includes cultivating an attitude of contentment and self-acceptance, acknowledging and appreciating inherent qualities and talents, while also recognizing and respecting one’s limitations.10,25 according to arthur (2010), individuals who accept health conditions have good self-acceptance. another study by rizqinda (2021) showed that there was a close association between self-acceptance and compliance with treating lupus patients.26 wahdania (2021) also explained the association between self-acceptance and compliance to care for patients with chronic kidney failure.27 several other aspects affect self-acceptance, including the belief in facing problems, self-esteem, rejection from society, and feeling uncomfortable with health conditions, responsibilities, specifically the head of the family, as well as praise and criticism. patients need to adjust to the conflict between ideal desires and the continued 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13064] [page 23] table 1. demographic characteristics of participants demographic characteristics frequency (n) percentage (%) gender man 5 25 woman 15 75 age (years) <30 1 5 30-39 1 5 40-49 2 10 50-59 11 55 60-69 3 15 70-79 1 5 >80 1 5 occupation private employee 2 10 businessman 2 10 retired 1 5 housewife/not working 12 60 other 3 15 income less than the local standard of payment 15 75 equal to the local standard of payment 5 25 marital status married 17 85 not married/widow/widower 3 15 length of time suffering from hypertension (years) < 1 6 30 1-5 5 25 6-10 7 35 11-15 2 10 number of health complaints 1 9 45 2 7 35 3 1 5 4 2 10 ≥ 5 1 5 total consumption of drugs other than hypertension drugs there is not any 4 20 1 kind of drug 11 55 2 kinds of medicine 4 20 3 types of drugs 1 5 types of consumption of drugs other than hypertension drugs oad 5 25 anti-hyperlipidemia 5 25 anti-hyperuricemia 2 10 anti-anginal medication 3 15 other types of drugs (multi-vitamins, analgesics, hyperthyroid drugs, antacids) 7 35 non -co mmerc ial us e o nly necessity for conventional therapy to regulate blood pressure, alongside exercise or holistic interventions. according to a previous study, patients tend to lose courage when criticized and feel demotivated to experience hemodialysis.28 experiences in a hypertension diet hypertensive patients have made several treatment efforts regarding a proper hypertension diet, such as abstaining from salty foods (low salt), coconut milk, and fries. diet compliance needed family support, which was explained by sumarni et al. (2021) showing a significant influence.29 a study by chandra showed that family support was an important factor in the nutritional intake among adults with primary hypertension.18 friedman (2013) also explained that family support referred to the assistance provided in terms of informational appraisal instruments and emotional. this result was consistent with a previous study about the association between family support and dietary compliance among hypertensive patients.30 experiences using complementary/traditional medicine most hypertensive patients do not use traditional medicine. some natural ingredients commonly used by patients who select traditional medicine include ginger, moringa leaves, lemongrass, bay leaves, coriander, celery, garlic, turmeric, red ginger, chilipuyang, temulawak, and honey. previous studies found various alternative therapies that could reduce high blood pressure. furthermore, many herbal medicines, such as punarnava, barberry, rouwolfia, garlic, ginger, ginseng, and arjuna, are safe to treat hypertension. the result explained that the most effective use of complementary therapy in the elderly with hypertension was using herbal medicines. this suggests the continued necessity for conventional therapy to regulate blood pressure, as well as exercise or holistic therapy. conclusions in conclusion, treatment experience was a factor related to medication compliance. furthermore, commitment from the patient and acceptance of the health condition could increase compliance. family support in the diet was essential because the family was the closest to patients. experience in carrying out traditional medicine could also complement medical treatment for hypertensive patients. the result also showed that knowledge of hypertensive patients affected compliance to carry out care. hypertensive patients were then required to strengthen commitment to care through condition acceptance. family support was needed to support compliance with medication, diet, and regularly controlling blood pressure. references 1. iaccarino g, grassi g, borghi c, et al. age and multimorbidity predict death among covid-19 patients: results of the sars-ras study of the italian society of hypertension. hypertens (dallas, tex 1979) 2020;76:366–72. 2. verulava t, mikiashvili g. knowledge, awareness, attitude and medication compliance in patients with hypertension. arter hypertens 2021;25:119–26. 3. shimels t, asrat kassu r, bogale g, et al. the magnitude and associated factors of poor medication compliance among diabetic and hypertensive patients visiting public health facilities in ethiopia during the covid-19 pandemic. brunner-la rocca h-p, editor. plos one 2021;16:e0249222. 4. ministry of health, republic of indonesia. basic health of research. jakarta: ministry of health, republic of indonesia; 2018. 5. pratama gw, ariastuti nlp. factors that influence compliance with hypertension treatment in elderly people assisted by klungkung community health center. e-jurnal med udayana 2016;5:1–13. 6. agustine u, mbakurawang in. compliance with medication in hypertension patients who seek treatment at the a and a rahmat waingapu treatment center. jkp 2016;1:114–22. 7. liberty ia, pariyana p, roflin e, waris l. determinants of compliance with treatment for hypertension patients at level i health facilities. j penelit dan pengemb pelayanan kesehat 2018;1:58–65. 8. purnawan in. compliance with treatment for hypertension sufferers in the payangan health center working area, gianyar regency. jurnal kesehatan terpadu 2019;3:15–21. 9. tumundo dg, wiyono wi, jayanti m. level of compliance with the use of antihypertensive drugs in hypertensive patients at the kema community health center, north minahasa regency. pharmacon 2021;10:1121–8. 10. akoko bm, fon pn, ngu rc, ngu kb. knowledge of hypertension and compliance with therapy among hypertensive patients in the bamenda health district of cameroon: a crosssectional study. cardiol ther 2017;6:53–67. 11. nguyen tpl, schuiling-veninga ccm, nguyen tby, et al. compliance to hypertension medication: quantitative and qualitative investigations in a rural northern vietnamese community. plos one 2017;12:1–13. 12. jankowska-polańska b, uchmanowicz i, dudek k, mazur g. relationship between patients’ knowledge and medication compliance among patients with hypertension. patient prefer compliance 2016;10:2437–47. 13. world health organization. guideline for the pharmacological treatment of hypertension in adults. geneva: who; 2021. 14. world health organization. hypertension. geneva: who; 2021. 15. nurhidayati i, aniswari ay, sulistyowati ad, ss. adult hypertension sufferers are more compliant than the elderly in taking blood pressure lowering medication. jurnal kesehatan masyarakat indonesia. 2019;13:1–5. 16. kusumawardani n, rachmalina, wiryawan y, et al. health risk behavior among junior and senior high school students in indonesia: results of a national survey of school-based health in indonesia. jakarta; 2018. 17. fikriana r, nursalam, devy sr, et al. factor analysis of patient with hypertension on self-regulation based on selfbelief. j glob pharma technol 2019;11:173–82. 18. wahyudi ct, jadmiko aw, ritanti r. family support on the compliance to nutrition intake among adults with primary hypertension in kalanganyar, lebak, banten, indonesia. j epidemiol public heal 2020;5:132–40. 19. ramirez aj, christen ai, sanchez ra. serum uric acid elevation is associated to arterial stiffness in hypertensive patients with metabolic disturbances. generic placeholder image curr hypertens rev 2018;14(2). 20. meredith ls, ewing ba, stein bd, et al. influence of mental health and alcohol or other drug use risk on adolescent reported care received in primary care settings. bmc fam pract 2018;19:10. 4th international nursing and health sciences symposium [page 24] [healthcare in low-resource settings 2024;12(s1):13064] non -co mmerc ial us e o nly 21. utami s, susilaningrum r, nursalam. the effect of health promotion based on the health promotion model with a peer group approach regarding the utilization of maternal and child health handbook. indian j public heal res dev 2019;10:1987–92. 22. khodaveisi m, omidi a, farokhi s, soltanian ar. the effect of pender’s health promotion model in improving the nutritional behavior of overweight and obese women. int j community based nurs midwifery 2017;5:165–74. 23. unger t, borghi c, charchar f, et al. 2020 international society of hypertension global hypertension practice guidelines. hypertension 2020;75:1334–57. 24. levine m. the conservation principles: a retrospective. nursing sci q 1996;9:38–41. 25. ma c. an investigation of factors influencing self-care behaviors in young and middle-aged adults with hypertension based on a health belief model. hear lung 2018;47:136–41. 26. lestari rl, nasution th, wibisono ah, et al. the relationship between the level of self-acceptance and the level of compliance with taking medication for lupus patients at the kupu parahita foundation indonesia. bul penelit kesehat 2021;49:215–22. 27. wahdania n. the relationship of self-acceptance with diet compliance in chronic kidney failure patients undergoing hemodialisis at dr. hospital. soedarso pontianak. proners 2021;6(1). 28. rohmah a, wakhid a, mawati t. self-acceptance in chronic kidney failure patients undergoing hemodialisis. jurnal ilmiah permas: jurnal ilmiah stikes kendal. 2018;8:131–4. 29. sumarni n, windani mambang sari c, purnama d. relationship between familysupport and compliance in implementing diet programs for elderly people with hypertension. eur j mol clin med 2021;08:99–106. 30. nita y, oktavia d. the relationship between family support and diet compliance in hypertension patients at the payung sekaki community health center, pekanbaru. j ilmu kesehat 2018;6:90–7. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13064] [page 25] correspondence: nikmatul fadilah, nursing department, health polytechnic of the health ministry of surabaya, surabaya, jl. pucang jajar tengah street no. 56, kertajaya, gubeng, surabaya, east java, indonesia, postcode: 60282, indonesia. tel.: +62315027058, fax: +625028141. e-mail: nikmatulf@poltekkesdepkes-sby.ac.id key words: experience of care; hypertension; qualitative contributions: nf, participated in the study design, data collecting and analysis, manuscript writing, and reference search; dw, participated in the study design, data collection, and analysis; snk, participated in the design of the study, manuscript writing, and references search; d, participated in data collection and analysis. conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by politeknik kesehatan kementerian kesehatan surabaya ethics approval: ethical clearance was obtained from the health research ethics committee of the indonesian strada institute of health science with study number 3613/kepk/ix/2022, dated 22 september 2023. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgment: the authors are grateful to the director of surabaya health polytechnic for funding this study. received: 3 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13064 doi:10.4081/hls.2024.13064 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13424 development of a health promotion model for parents to promote healthy diet to prevent cancer in adolescents: a cross-sectional study in east java indonesia ilya krisnana,1,2 praba diyan rachmawati,1 iqlima dwi kurnia,1 pratuma rithpho3 1faculty of nursing universitas airlangga, surabaya, east java, indonesia; 2pediatric nursing research group universitas airlangga, surabaya, east java, indonesia; 3faculty of nursing, naresuan university, tha pho, phitsanulok, thailand abstract a healthy diet has been proven to reduce mortality risk. however, the number of people consuming unhealthy diets is increasing, especially among adolescents. parents are responsible for promoting a healthy lifestyle for adolescents. this research aims to develop a health promotion model for parents of adolescents regarding a healthy diet to prevent cancer. the study used a cross-sectional design with an explanatory survey. the population were 148 parents of junior high school students in surabaya and east java, indonesia, who accessed online form over four months. the sample was determined based on the following inclusion criteria: parents of adolescents aged 13-16 years, parents of adolescents registered at junior high schools in surabaya, parents capable of completing the form, and parents willing to participate in the research. convenience sampling was used. data was collected via a google forms questionnaire and analysed using partial least square with t=1.96. there were nine questionnaires used (demographic, perceived benefits and barriers, the self-efficacy for exercise, the physical activity enjoyment scale paces, environmental support, knowledge, participation, the shortened committed action questionnaire, and health-promoting lifestyle profile hplp ii). the study included 148 parents of adolescents. parental characteristics influenced cognition and affect (t=3.4) and environmental support (t=4.2). environmental support influenced parental empowerment (t=2.9). similarly, cognition and affect influenced empowerment (t=4.189). parental empowerment influenced commitment (t=3.3), which in turn influenced health promotion behaviour regarding a healthy diet (t=3.3). the health promotion model was developed through efforts to empower parents and strengthen their commitment to implementing a healthy diet for adolescents, even in challenging situations. introduction cancer is the leading cause of death in children and adolescents worldwide (who, 2021). indonesia has the highest incidence of childhood cancer in the southeast asia region, with 8,677 children suffering from cancer and a death rate of 3,292.1 the increasing prevalence of cancer in indonesia may be attributed to a shift in food consumption patterns from traditional to modern processing, such as fast food.2 consuming healthy snacks after main meals has been proven to reduce mortality risk and prevent diseases, including cancer.3 parents play a crucial role in preventing health risk behaviour in children and adolescents.4 efforts to increase preventive behaviour in parents can be achieved through health promotion initiatives.5 while health promotion theory has been widely used to improve the health status of children and adolescents, its application to increase parental preventive behaviour in promoting healthy snack consumption to prevent cancer remains limited. according to data from the ministry of agriculture, fast food currently accounts for 28% of all calories consumed by urban residents, with children and adolescents being the largest consumers.6 research in lampung shows that more than 50% of adolescents consume fast food 3-5 times a week.7 the higher the frequency of correspondence: ilya krisnana, faculty of nursing universitas airlangga, mulyorejo campus c universitas airlangga surabaya, east java, indonesia. tel.: 62.85648230221; fax: 62.315913257 e-mail: ilya-k@fkp.unair.ac.id key words: adolescents, cancer, diet, healthy diet, health promotion. conflict of interest: there is no potential conflict of interest. contributions: ki, principal investigator, conceptualised and designed the study; rpd, ethical clearance, collecting data, analysis; kid, writing manuscript, translating, proofreading; rp, reviewed the manuscript. informed consent: all participants in this study agreed to be respondents through a statement of agreement contained in the online form. patient consent for publication: this article does not mention the names and identities of respondents (anonymity). ethics approval: the study design and protocols were reviewed and approved by the health research ethics commission of faculty of nursing universitas airlangga, which issued an ethical feasibility certificate (number 2823-kepk). availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the author thanks all respondents and airlangga university for funding the research. received: 25 november 2024. accepted: 3 june 2025. early access: 16 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13424 doi:10.4081/hls.2025.13424 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 190] [healthcare in low-resource settings 2025;13:13424] fast food consumption, the greater the risk of cancer.8 while fast food does not directly cause cancer, its content can trigger cancer development.9 a healthy diet is a solution to prevent increased fastfood consumption and reduce cancer risk.3 pender’s health promotion model (hpm) is widely used to change unhealthy behaviour and improve health.10 the hpm explores characteristics and previous experiences, cognition and affect, commitment, and preventive behaviour implemented by parents, in this case, regarding healthy snacks. the greater the commitment to a specific action plan, the more likely health-promoting behaviour is maintained over time.11 the objective of this study was to develop a health promotion model for parents of adolescents regarding a healthy diet to prevent cancer. materials and methods design this study employed a cross-sectional design with an explanatory survey method. this research design was chosen to explore and explain the causal relationships between independent and dependent variables within the phenomenon under investigation. population, samples, and sampling the population of this study were all parents of junior high school students in east java who accessed the online form from june to september 2023. the sample was determined based on the following inclusion criteria: i) parents of adolescents aged 13-16 years, ii) parents of adolescents registered in junior high school in east java, iii) parents who completed the online form, and iv) parents who signed informed consent for the research. convenience sampling was used over four months. the final sample size was 148 parents. variables the independent variables in this study were previous parental characteristics: father’s education, mother’s education, age, father’s occupation and mother’s occupation, cognition and affect (perceived benefits and barriers, self-efficacy and affect), environmental support, empowerment (knowledge and participation), and commitment. the dependent variable was health promotion behaviour related to a healthy diet. instruments parent characteristics the parent characteristics questionnaire is a checklist that captures respondents’ demographic information, including education, age, and occupation. perceived benefits and barriers the perceived benefits instrument was adopted from the exercise benefits questionnaire.12 the instrument measuring the benefits of healthy diet behaviour consists of four subscales: i) physical appearance, ii) psychological aspects, iii) social interactions, and iv) preventive health. the instrument measuring the benefits of healthy diet behaviour consists of four subscales: i) environmental conditions, ii) time spent, iii) drained energy, and iv) family disappointment. responses are recorded on a 4-point likert scale: 4 = strongly agree, 3 = agree, 2 = disagree, 1 = strongly disagree. self-efficacy the self-efficacy measurement instrument is based on the selfefficacy for exercise (see) scale questionnaire,13 modified to focus on healthy diet behaviour instead of exercise. the questionnaire consists of nine items assessing parents’ confidence in providing a healthy diet. responses range from 0 (not confident) to 10 (very confident). affect the affect assessment uses the physical activity enjoyment scale (paces),14 consisting of 10 items rated on a 5-point likert scale (1 = strongly disagree, 5 = strongly agree). the total score is calculated by summing all responses. environmental support the environmental support questionnaire focuses on the nonphysical environment, precisely information sources. these sources include health workers, family members, and others in the respondents’ social circle. responses are scored as follows: always = 3, sometimes = 2, never = 1. the maximum possible score is 9, and the minimum is 3. knowledge the knowledge questionnaire consists of five true/false questions covering i) the definition of a healthy diet, ii) types of healthy diets, iii) food sources of protein, iv) food sources of saturated fat, and v) iodized salt. correct answers receive 1 point, while incorrect answers receive 0 points. the maximum possible score is 5. participation the participation questionnaire was adopted from pengpid & peltzer16 and consists of five items measuring parental involvement in preparing a healthy diet. the questions cover: i) involving children in determining the daily meal menu, ii) involving children to help cook food, iii) involving children in preparing the dining table, iv) involving children in serving food, and v) involving children in cleaning the dining table. responses are scored on a 5point scale: always = 5, often = 4, rarely = 3, once = 2, never = 1. the maximum possible score is 25, and the minimum is 5. commitment the commitment questionnaire used the shortened committed action questionnaire,17 adapted to focus on healthy dietary behaviour in parents of adolescents. it consists of eight items with the following response options: 0 = never, 1 = very rarely, 2 = rarely, 3 = sometimes, 4 = often, 5 = almost always, and 6 = always. health promotion the health promotion questionnaire on a healthy diet was adapted from the health-promoting lifestyle profile [hplp ii] (adult version) questionnaire.18 it consists of nine items with four response options: 4 = always, 3 = often, 2 = sometimes, 1 = never. the maximum possible score is 36, and the minimum is 9. data collection data was collected through google forms distributed to the target group using various methods, including: i) sending to colleagues with adolescents attending junior high school in surabaya, ii) sharing links with colleagues or professional associations of pediatric nurses in the east java region via group messages, iii) publishing the questionnaire link on the researchers’ social media article [healthcare in low-resource settings 2025;13:13424] [page 191] status. before completing the questionnaire, potential respondents were provided information about the research title, research team, objectives, benefits, risks, and compensation. consent was obtained by having respondents click an «agree» button. to validate that respondents were parents of junior high school students, they were required to provide the name and location of their child’s school. data analysis the collected data was analysed using smart partial least square (pls) smartpls version 4.0.9.5 (oststeinbek, germany).19 an indicator was considered valid if it had an outer loading value above 0.5 and a t-statistic value above 1.96. hypothesis testing was conducted using the t-statistical test. ethical clearance this study involved human subjects, specifically parents of adolescents. the research team strictly adhered to ethical principles throughout the study. these principles included: i) informed consent: potential participants were provided with a full explanation of the study before agreeing to participate; ii) anonymity: respondents’ names were not collected or included in the study data; iii) confidentiality: all data collected from the questionnaires was kept confidential; iv) autonomy: participants were allowed to withdraw from the study if they felt uncomfortable at any point during the questionnaire completion process; v) compensation: to ensure equitable participation, respondents were provided with internet data allowances commensurate with the online questionnaire completion requirements. the study design and protocols were reviewed and approved by the health research ethics commission of faculty of nursing universitas airlangga, which issued an ethical feasibility certificate (number 2823-kepk). results table 1 shows that over 50% of parents in this study had the last education at senior high school, with the largest employment category being employees in the private sector, both fathers and mothers. table 2 indicates that parents’ cognition and affect regarding the benefits of a healthy diet had a mean score of 13.7 (sd = 2.0). the primary benefit perceived was that a healthy diet that prevents cancer could make adolescents more attentive to their health. however, parents reported obstacles in maintaining health and providing a healthy diet at home, with the most significant challenge being a lack of time due to work commitments. parental self-efficacy had the highest average score of 63.6 (sd = 21.0), indicating that many parents felt capable of providing the best care for their children, including a healthy diet, even in difficult situations. on average, all mothers reported positive affect when maintaining health and a healthy diet for their adolescents. table 3 reveals that parents obtained most of their information from family and close associates, with a minimum score of environmental support of 3 and a maximum score of 9. parental knowledge about healthy diets for adolescents ranged from a minimum score of 1 to a maximum of 5. the question most frequently answered correctly concerned the definition of a healthy diet, while the question most often answered incorrectly related to types of food containing animal protein. parental participation scores ranged from 5 to 25, with involving adolescents in preparing healthy diet menus being the highest form of participation and involving them in cooking being the lowest. parents showed the strongest commitment to maintaining a healthy diet for adolescents even in challenging conditions, while their lowest commitment level was in their ability to change methods rather than abandon healthy diet practices. no parents reported never providing a healthy diet to adolescents, and some always did so. the most commonly implemented healthy diet practice was limiting sugar consumption, while the least common was serving 6-11 portions of bread or cereal daily. table 4 presents the results of hypothesis testing for the influence of exogenous variables on endogenous variables. the test criteria state that the relationship is significant if the t-statistic value ≥ t-table (1.96). all exogenous variables showed significant relationships with endogenous variables, except for the relationship between parent characteristics and health promotion behaviour (t=0.2; p=0.772). figure 1 illustrates the final (fit) model for developing a health promotion model for parents of adolescents regarding a healthy diet. the model shows that parent characteristics do not directly influence health promotion behaviour for a healthy diet, but can indirectly influence it through cognition and affect as well as environmental support. this represents a novel finding from this research. furthermore, both empowerment and commitment variables positively influence the formation of healthy diet behaviour in adolescents to prevent cancer. discussion based on data from who, it is estimated that 400,000 children and adolescents aged 0–19 years suffer from cancer every year.20 parents have a very important role in preventing disease in adolescents. disease prevention carried out by parents can start by providing healthy and nutritious food for adolescents. several personal factors of parents are related to preventing health-risk behaviour, including preventing disease.21 the study found that parental characteristics, including work and education, influence cognition and affect. this aligns with pender’s theory that individual characteristics influence cognition and affect.22 higher individual characteris article table 1. general characteristics of the participants (n=148). characteristics n % father’s education elementary school 21 14.2 junior high school 24 16.2 senior high school 77 52.0 higher education (university) 26 17.6 occupation (father) farmer 4 2.7 employee 70 47.3 entrepreneurs 56 37.8 civil servant 8 5.4 military 7 4.7 fisher 3 2.0 mother’s education elementary school 19 12.8 junior high school 26 17.6 senior high school 76 51.4 higher education (university) 27 18.2 occupation (mother) farmer 9 6.1 employee 71 48.0 entrepreneurs 54 36.5 civil servant 14 9.5 [page 192] [healthcare in low-resource settings 2025;13:13424] tics produce higher cognition and affect, determining subsequent actions.23 parental characteristics in this context include previous experiences, which are a source of knowledge and a way to obtain the truth of knowledge.24 most respondents were parents of adolescents who understood the importance of a healthy diet in preventing cancer, indicating prior experience in maintaining their children’s diet. more than half of the parents had permanent jobs in the private sector, suggesting they could afford to buy healthy food for their children. however, some parents struggled to prepare food according to a healthy diet, possibly due to a lack of understanding about what constitutes a healthy diet menu for adolescents. the health promotion model emphasizes that each person has unique personal characteristics and experiences that can influence subsequent actions.25 in terms of health care for adolescents to prevent cancer, parents need to pay attention to their children’s eating patterns both at home and outside. the facilitation process aims to increase parents’ potential to act better and more innovatively.26 environmental support is greatly influenced by individual characteristics.27 in this study, the greatest support for healthy dietary behaviour came from family or people close to the adolescent’s parents. the family plays a significant role in solving health problems.28 parents need reinforcement and support from family members to carry out health promotion behaviour, specifically providing a healthy diet for adolescents to prevent cancer. parents who have knowledge and participate in providing a healthy diet can feel empowered to support their adolescent children’s health.29 cognition and affect are built from perceived benefits, barriers, and self-efficacy. more than half of the parents felt high benefits in maintaining their teenage children’s health to prevent cancer. the most significant benefit perceived by parents was that maintaining a healthy diet increased their attention to their children’s health. the biggest obstacle reported was a lack of time to provide a healthy diet regularly. all parents reported a positive effect towards maintaining their children’s healthy diet. routine and regular healthy diet behaviour in adolescents is a way to prevent cancer.30 parents need self-efficacy to be able to carry out their role in preventing disease in adolescents properly.4 self-efficacy is also a necessity for parents in preventing disease in toddlers.31 self-efficacy can also encourage parents to behave well in carrying out prevention without experiencing boredom. commitment directly influences healthy dietary behaviour carried out by parents. article [healthcare in low-resource settings 2025;13:13424] [page 193] table 2. cognition and affect indicators about a healthy diet in adolescents. indicators minimum maximum mean ± sd perceived benefits 9 16 13.7±2.0 perceived barriers 4 16 11.0±2.7 self-efficacy 9 90 63.6±21.0 affect 23 50 40.8±8.4 table 3. distribution of variables of environmental support, empowerment, and health promotion behaviour of healthy diet among adolescents. indicators minimum maximum mean ± sd environmental support 3 9 6.1±1.8 knowledge 1 5 3.0±1.0 participation 5 25 18.7±3.9 commitment 10 40 23.5±6.0 health promotion behaviour 13 36 25.1±5.6 table 4. hypothesis testing of the health promotion model regarding a healthy diet to prevent cancer. t statistics p characteristics -> environmental support 4.2 <0.001* characteristics -> cognition and affect 3.4 0.001* environmental support-> empowerment 2.9 0.004* cognition -> empowerment 4.1 <0.001* empowerment -> commitment 3.3 0.001* characteristics -> health promotion behaviour 0.2 0.772 commitment -> health promotion behaviour 3.3 0.001* * (p≤0.05) figure 1. model fit development of a health promotion model for parents of adolescents regarding a healthy diet to prevent cancer. parents’ commitment fosters greater attention in their teenage children to maintain health through a healthy diet. preventive behaviour based on a commitment will last a long time so that goals can be achieved. one factor that can influence the formation of commitment is the existence of a collaborating team.32 empowerment has a direct effect on commitment. parental empowerment is one of the factors that must be carried out to form a disease prevention program through adequate information about nutrition.33 parents’ lack of knowledge about cancer can negatively affect their daily behaviour. forming commitment requires several continuous processes and stages, and cannot happen quickly.34 the health promotion model about a healthy diet for adolescents in preventing cancer is very much determined by the education of parents, both mothers and fathers. parental education is the basis for the formation of cognition and affect. parents who have higher education can minimise the perceived obstacles and strengthen the perceived benefits. the health promotion model about a healthy diet for adolescents in preventing cancer is very much determined by parental education, both the mother’s and the father’s. parental education is the basis for the formation of cognition and affect. parents who have higher education can minimise perceived obstacles and strengthen perceived benefits. parents with a good level of education have strong self-efficacy and positive affect to provide a healthy diet to adolescents. the existence of adequate environmental support for parents can create empowerment so as to foster commitment in implementing health promotion in providing diet to adolescents. without commitment from parents, health promotion behaviour in a healthy diet for adolescents cannot be formed. conclusions the health promotion model for healthy diet behaviour applied by parents to adolescents can be formed through strengthening characteristic factors, cognition and affect, environmental support, empowerment, and commitment. parental education is a significant factor in shaping cognition, affect, and environmental support. the benefits, obstacles, self-efficacy, and affect experienced by parents can foster a sense of empowerment, which is strengthened by family support. the sense of empowerment experienced by parents will foster commitment through a determination to continue providing healthy diets to adolescents, even in difficult situations. behaviour formed through strong commitment is likely to be more sustainable. references 1. who. childhood cancer. world health organization. 2021. 2. who. estimated number of incident cases and deaths all cancers, both sexes, ages 0-14. 2022. available from: h t t p s : / / g c o . i a r c . f r / t o d a y / o n l i n e a n a l y s i s m u l t i bars?v=2020&mode=population&mode_population=countries&population=900&populations=900&key=total&sex=0& cancer=39&type=0&statistic=5&prevalence=0&population_g roup=11&ages_group%5b%5d=0&ages_group%5b%5d=2 &nb_ite 3. gondhowiardjo sa. pedoman strategi & langkah aksi penerapan perilaku diet sehat. komite penanggulangan kanker nasional (kpkn); 2019. 1–67 p. 4. krisnana i, rachmawati pd, kurnia id. self-efficacy and parental commitment to prevent health risk behavior among adolescents in east java. enferm clin 2022;32:s20–3. 5. kurnia id, krisnana i, rachmawati pd, et al. the increased interaction of parents can prevent smoking behavior and alcohol consumption of adolescents in indonesia. in: proceedings ofthe 9th international nursing conference (inc 2018). scitepress – science and technology publications; 2019. p. 274–9. 6. de vet e, stok fm, de wit jbf, de ridder dtd. the habitual nature of unhealthy snacking: how powerful are habits in adolescence? appetite 2015;95:182–7. 7. reza miranda a, arief budi y, ajeng kartika s. gambaran aktivitas fisik dan pola makan selama pandemi covid-19 pada remaja di sma negeri 4 metro lampung. bandung conf ser med sci 2022;2:21–6. 8. tayyem rf, bawadi ha, shehadah i, et al. fast foods, sweets and beverage consumption and risk of colorectal cancer: a case-control study in jordan. asian pacific j cancer prev 2018;19:261–9. 9. credihealth team. fast food & cancer – is there a relation? credi health. 2022. available from: https://www.credihealth. com/blog/fast-food-and-cancer-relation/#:~:text=it has been generally linked,fast food and cancer relation. 10. khodaveisi m, omidi a, farokhi s, soltanian ar. the effect of pender’s health promotion model in improving the nutritional behavior of overweight and obese women. int j community based nurs midwifery 2017;5:165–74. 11. pender nj. health promoting model manual. chicago: university of michigan; 2011. 12. lovell gp, ansari w el, parker jk. perceived exercise benefits and barriers of non-exercising female university students in the united kingdom. int j environ res public health 2010;7:784-98. 13. estrada m. university students’ involvement in a health promoting lifestyle : influencing factors of the health promotion model. 2016. pittsburg state university, thesis. available from: https://digitalcommons.pittstate.edu/etd/232/ 14. motl rw, dishman rk, saunders r, et al. measuring enjoyment of physical activity in adolescent girls. am j prev med 2001;21:110–7. 15. pengpid s, peltzer k. parental involvement and health risk behaviours among school-going adolescents in six african countries. j psychol africa 2018;28:212–7. 16. pengpid s, peltzer k. parental involvement and health risk behaviours among school-going adolescents in six african countries. j psychol africa 2018;28:212–7. 17. mccracken lm, chilcot j, norton s. further development in the assessment of psychological flexibility: a shortened committed action questionnaire (caq-8). eur j pain 2014;19:677-85. 18. susan n, karen r, nola j. health promotion model instruments to measure health promoting lifestyle: health promoting lifestyle profile [hplp ii] (adult version). 1995;42–3. 19. ringle cs, wende s, becker j. smart pls4. oststeinbek: smartpls gmbh; 2022. available from: http://www.smartpls.com 20. who. childhood cancer. world health organization. 2025. available from: https://www.who.int/news-room/factsheets/detail/cancer-in-children 21. krisnana i, rachmawati pd, kurnia id, et al. factors related to parental involvement in the prevention of health risk behaviors among adolescents: a cross-sectional study in east java article [page 194] [healthcare in low-resource settings 2025;13:13424] indonesia. open access maced j med sci 2022;9:371–4. 22. pender nj. health promotion model manual. deepblue.lib.umich.edu. 2011. p. 1–17. available from: http://deepblue.lib.umich.edu/bitstream/handle/2027.42/85350 /?sequence=1 23. diananda a. psikologi remaja dan permasalahannya. j istighna 2019;1:116–33. 24. balqis um, hartati s, ayu sa. penguatan program promosi kesehatan melalui komplikasi hipertensi pada pasien rawat jalan puskesmas karang tengah cianjur. j mitra masy 2022;3:23–32. 25. petiprin a. health promotion model nursing theory. nursing-theory.org. 2016. available from: http://www.nursing-theory.org/theories-and-models/pender-health-promotionmodel.php 26. vistad i, skorstad m, demmelmaier i, et al. lifestyle and empowerment techniques in survivorship of gynaecologic oncology (letsgo study): a study protocol for a multicentre longitudinal interventional study using mobile health technology and biobanking. bmj open 2021;11:e050930. 27. zhang l, shi y, deng j, et al. the effect of health literacy, selfefficacy, social support and fear of disease progression on the health-related quality of life of patients with cancer in china: a structural equation model. health qual life outcomes 2023;21:75. 28. badi’ah a, mendri nk, palestin b, et al. family empowerment psychoeducation on family support caring of children diarrhea. open access maced j med sci 2022;9:137–41. 29. banach m, iudice j, conway l, couse lj. family support and empowerment: post autism diagnosis support group for parents. soc work groups 2010;33:69–83. 30. tang h, wang r, liu w, et al. the influence of nutrition literacy, self-care self-efficacy and social support on the dietary practices of breast cancer patients undergoing chemotherapy: a multicentre study. eur j oncol nurs 2023;64:102344. 31. zatihulwani ez, sukartini t, krisnana i. development of model on mothers self-efficacy in preventing recurrence of non-pneumonia acute respiratory infection among toddlers. j ners 2017;12:171. 32. suryani i. factors affecting organizational performance. j manaj dan inov 2018;9:14–31. 33. lovell jl. how parents process child health and nutrition information: a grounded theory model. appetite 2016;97:138– 45. 34. bashaw r, grant e. exploring the distinctive nature of work commitments: their relationships with personal characteristics, job performance, and propensity to leave. j pers sell sales manag 2013;14:41–56. article [healthcare in low-resource settings 2025;13:13424] [page 195] hrev_master healthcare in low-resource settings 2025; volume 13:13258 the effectiveness of integrating the lumbung hidup and nutritional rangers mobile applications in preventing stunting among underprivileged families in kediri regency prima dewi kusumawati, reni nurhidayah, dhita kurniasari nursing department, iik strada, indonesia abstract stunting remains a significant public health issue in low and middle-income nations, including indonesia. globally, approximately 151 million children are affected by stunting. this study involved 22 children under five years old from economically disadvantaged families in kediri regency. its aim was to assess the effectiveness of the lumbung hidup and nutritional rangers mobile applications in reducing stunting. data analysis included both quantitative paired sample t-tests and qualitative thematic analysis methods. results revealed significant improvements in children’s nutritional status (p<0.05) across all z-scores (weight-for-age, heightfor-age, and weight-for-height), as well as five major qualitative themes. the significant improvements in z-scores highlight the potential effectiveness of the integrated intervention in enhancing child nutrition. this comprehensive strategy could serve as a sustainable and holistic solution to address malnutrition and stunting, warranting broader implementation in similar settings. introduction stunting remains a critical public health challenge, particularly in underprivileged communities where access to adequate nutrition and healthcare services is often limited. stunting is characterized by impaired growth and development in children and can have long-lasting effects on cognitive function, educational performance, and future economic productivity.1-4 addressing stunting requires a multifaceted approach that targets both immediate nutritional needs and long-term health and educational outcomes.5 recent data from kediri regency in 2022 highlights the severity of the issue, with a stunting prevalence of 10.23% among 7,752 toddlers. nutritional deficiencies, including stunting, are among the most significant challenges affecting infants and young children. these conditions can impair a child’s well-being, leading to diminished cognitive and motor development and increased susceptibility to various illnesses due to weakened immune systems. economic constraints are a major contributing factor, as many families often struggle to provide nutritious food. additionally, suboptimal cross-sectoral collaboration, inadequate monitoring of stunting management, and insufficient educational resources and support systems further exacerbate the problem. this lack of comprehensive education and sustained support for mothers and caregivers leads to gaps in stunting management, often leaving families feeling isolated and stressed, which negatively affects childrearing practices.6,7 in recent years, the rapid expansion of mobile technology has created new opportunities for health interventions. mobile applications, thanks to their widespread accessibility, have the potential to deliver health information, facilitate screenings, and provide personalized recommendations to diverse populations. an innovative solution to address nutritional challenges is the nutritional rangers mobile application (figure 1). this app is designed to enhance nutritional practices through education and behavior modification, utilizing mobile technology to empower families with knowledge about balanced diets and healthy eating habits.8 in addition to this, the lumbung hidup intervention focuses on enhancing household food security through sustainable practices, such as self-sufficient food production. this includes the cultivation of nutritious crops and small-scale livestock farming, like raising catfish (lele) in buckets or small containers to meet protein needs. together, these interventions aim to address both immediate nutritional needs and long-term food security for underprivileged families, thereby contributing to efforts against stunting and improving child health outcomes.9 this study aims to explore the integration of these two interventions in a comprehensive strategy to prevent stunting among underprivileged families. by combining the strengths of both approaches, correspondence: prima dewi kusumawati, jl. manila no.37, tosaren, kec. pesantren, kota kediri, jawa timur 64123, indonesia. e-mail: primadewi@strada.ac.id key words: mobile application; stunting; underprivileged family. conflict of interest: the authors declare no potential conflict of interest. contributions: pdk, study design and methodology; rn, data analysis; dk, methodology and revision. all the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. ethics approval and consent to participate: ethical approval for this study was obtained from the local institutional review board (number: 000398ec/kepk/1/06/2023). consent for publication: informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 15 october 2024. accepted: 18 november 2024. early access: 23 december 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13258 doi:10.4081/hls.2024.13258 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 70] [healthcare in low-resource settings 2025;13:13258] the goal is to develop a holistic method that not only identifies at-risk children but also empowers families with the knowledge and resources needed to improve nutritional outcomes. this case study will evaluate the effectiveness of this integrated approach, examining its impact on screening accuracy, nutritional improvements, and overall child health outcomes. the findings from this research will contribute to the growing body of knowledge on mobile health interventions and their potential to address complex public health issues like stunting. furthermore, the study will provide insights into the practical challenges and opportunities associated with implementing such technology-based solutions in resource-limited settings. by delivering integrated support—ranging from regular screening, monitoring, education, and food assistance to intensive guidance—this intervention aims to accelerate progress in reducing stunting and other nutritional issues, thereby enhancing the success of nutritional therapy for underprivileged families. materials and methods study design this research employs a mixed-methods approach, integrating both quantitative and qualitative data collection methods to assess the effectiveness of the lumbung hidup and nutritional rangers mobile applications in preventing stunting among underprivileged families in kediri regency. the study spans a 3-month period, allowing for comprehensive monitoring and evaluation of the intervention’s impact. participants the study includes 22 children under the age of five from underprivileged families in gempolan village who are identified as underweight and stunted. all participants received access to both interventions, ensuring a holistic approach to addressing their nutritional needs. intervention the intervention consists of two integrated components: lumbung hidup and nutritional rangers. the lumbung hidup intervention focuses on enhancing household food security through sustainable practices. families are encouraged to engage in self-sufficient food production, including the cultivation of nutritious crops and small-scale livestock farming. specifically, they are trained to raise catfish (lele) in buckets or small containers to meet protein needs, thereby enhancing dietary diversity. the nutritional rangers mobile application provides nutritional practices by offering educational content, personalized dietary recommendations, daily dietary tracking, and behavior modification strategies. the goal is to empower families with knowledge of balanced diets and promote healthier eating habits for their children. families in the intervention group received training on effectively using both interventions, along with regular support from community health workers to reinforce them. data collection data were collected at the end of the 3-month intervention to measure its impact using the following intervention. the following methods were used: i) anthropometric measurements (quantitative data): standard techniques employed to measure the height and weight of children at integrated service posts (posyandu). this helps evaluate their growth and nutritional status by specifically analyzing z-scores for weight-for-age, height-for-age, and weightfor-height; interviews and focus groups (qualitative data): in-depth interviews and focus group discussions with parents and caregivers to explore their experiences using the applications, challenges encountered, and perceived benefits. this qualitative data provides insights into the feasibility and acceptability of the interventions within the community context. data analysis quantitative analysis utilizes descriptive statistics to summarize the baseline characteristics of the study population. paired t-tests were employed to compare changes in anthropometric measurements, specifically weight and height, between preand post-test assessments. for qualitative analysis, thematic analysis was conducted on interviews and focus group transcripts to identify recurring themes and insights related to the usability, challenges, and impact of the lumbung hidup and nutritional rangers applications. ethical clearance ethical approval for this study was obtained from the local institutional review board. informed consent was acquired from all participating families, who received clear explanations regarding the study’s purpose, procedures, and potential benefits. participants were assured of confidentiality, and all data were anonymized to protect their privacy. results and discussion the age distribution of the respondents was relatively balanced, with the largest proportion (41%) being children aged 4860 months old. the majority of the children (68%) were male (table 1). a significant improvement was observed in both weight and height from the pre-test to the post-test periods, indicating a positive impact of the interventions. the mean weight increased progressively from 11.25 kg at the pre-test to 12.20 kg, 13.50 kg, and 14.48 kg in subsequent post-test phases. similarly, the mean height improved from 89.29 cm at the pre-test to 89.57 cm, 89.64 cm, and eventually 100.00 cm by the final post-test assessment (table 2). this progressive improvement demonstrates the positive article table 1. characteristics of respondents. characteristics n % age 24-36 month 6 27% 36-48 month 7 32% 48-60 month 9 41% sex male 15 68% female 7 32% table 2. comparison of nutritional status on preand post-test. nutritional state n pre-test post-test 1 post-test 2 post-test 3 mean min max mean min max mean min max mean min max weight 22 11.25 9.00 12.70 12.20 10.02 13.76 13.50 11.18 15.64 14.48 12.13 16.76 height 22 89.29 79.70 99.00 89.57 80.00 99.50 89.64 80.50 100.0 89.98 81.00 100.5 [healthcare in low-resource settings 2025;13:13258] [page 71] impact of the lumbung hidup intervention and the nutritional rangers mobile application in enhancing the nutritional status of children with nutritional problems from underprivileged families. the paired sample t-test results indicated a significant improvement in the nutritional status of children (p<0.05) across all z-scores, including weight-for-age, height-for-age, and weightfor-height (table 3). this demonstrates the positive impact of the nutritional therapy provided through the lumbung hidup program and the comprehensive screening, monitoring, and educational support facilitated by the nutritional rangers mobile application. qualitative results interviews and focus groups the qualitative data collected through in-depth interviews and focus group discussions provided valuable insights into the experiences of families using the lumbung hidup and nutritional rangers applications. common themes that emerged from the analysis included: i) enhanced knowledge and confidence: participants reported a significant increase in their understanding of child nutrition and optimal feeding practices. many expressed that the information provided by the nutritional rangers application was accessible and easy to implement, leading to more balanced and nutritious meal planning for their children. as one parent noted, “i now understand which foods are essential for my child’s growth. the app has simplified the process, boosting my confidence in providing healthier meals.” ii) positive behavioral changes: the applications encouraged positive changes in the dietary behaviors of parents and caregivers. many parents began diversifying their children’s diets, incorporating a wider range of vegetables, proteins, and other essential nutrients while paying closer attention to portion sizes and meal schedules. a caregiver shared, “previously, we would serve whatever was available. now, we make a conscious effort to include vegetables and proteins in every meal. the app has improved our meal planning”. iii) challenges with technology: despite the overall positive feedback, some families faced challenges related to the use of mobile technology, such as limited internet access, technical difficulties, and a lack of familiarity with smartphone functions. one participant mentioned, “there were times when the app would not load properly, or we had trouble navigating it”. these challenges highlight the need for ongoing technical support and user training to maximize the intervention’s reach and effectiveness. iv) community support and engagement: the role of community health workers was crucial in the successful adoption of the applications. regular follow-ups and personalized support from these workers helped families stay engaged with the interventions. a parent shared, “the health worker visits were very helpful. they showed us how to use the apps and answered all our questions”. this underscores the importance of community engagement in enhancing the adoption of digital health interventions. v) perceived benefits and impact: many parents observed noticeable improvements in their children’s health and growth, including increased appetite, energy levels, and overall vitality. these positive changes were attributed to the combined effects of the mobile applications and the continuous support they received. as one caregiver remarked, “my child’s appetite has improved, and they seem more active and healthier”. such testimonials indicate the perceived effectiveness and tangible benefits of the integrated intervention approach. the nutritional rangers mobile application has proven to be an effective tool for continuous education and self-monitoring of nutritional status for families, as well as for screening and monitoring by healthcare workers. education is a crucial intervention to enhance the success of nutritional improvements in young children. with proper educational interventions, parents are better equipped to provide adequate nutrition in terms of type, composition, quantity, quality, and preparation methods. this improvement in parental capability significantly influences children’s daily caloric intake, thereby improving their overall nutritional situation for nutrition education presents several advantages.10-12 using a mobile application for nutrition education offers several advantages. it facilitates the rapid dissemination of information and provides an engaging learning experience by actively involving families according to their needs. this more complex learning experience enhances the success of learning objectives, impacting cognitive areas and affective and psychomotor aspects.13-15 additionally, the nutritional rangers application includes features for daily nutritional intake screening and periodic weight monitoring. these features are vital for healthcare workers because effective screening and monitoring of nutritional status can significantly improve the success of nutritional improvement programs and help prevent other nutritional issues. healthcare workers can quickly assess the progress of a child’s nutritional status, enabling article table 3. paired sample t-test (z-score) preand post-test. n mean sd se p-value z-score weight/age pre-test 22 -2.36 0.32 0.07 0.006 post-test 22 -0.53 0.43 0.09 z score height/age pre-test 22 -1.44 0.75 0.16 0.000 post-test 22 1.86 0.85 0.18 z score weight/height pre-test 22 -2.46 0.69 0.15 0.000 post-test 22 -2.44 0.80 0.17 [page 72] [healthcare in low-resource settings 2025;13:13258] figure 1. nutritional ranger application. source: https://nutritionalrangers.okeadmin.com/login timely decision-making to enhance child health outcomes. the active collaboration between families and community health workers in using the nutritional rangers application improves communication between healthcare providers and families, ensuring the necessary support during the nutritional improvement.13,15,16 on the other hand, the lumbung hidup intervention focuses on enhancing household food security, particularly among underprivileged families. this program enables families to become more self-sufficient in meeting their daily nutritional needs, which is crucial for improving child nutrition. lumbung hidup provides essential protein sources for children’s nutrition improvement through sustainable small-scale livestock farming, such as raising catfish (lele) in buckets. additionally, cultivating home-grown vegetables increases the intake of vitamins and minerals, enhancing dietary diversity and fulfilling both macro and micronutrient needs.17 the food self-sufficiency promoted by lumbung hidup is expected to sustainably increase the intake of nutritious food within families, with a particular focus on children. protein sources from catfish farming and nutrient-rich vegetables from home gardens ensure a more diverse and balanced diet. this program addresses protein needs and contributes to overall nutritional improvement, which is vital in reducing stunting and other nutritional problems.17,18 parents reported increased knowledge and confidence in child nutrition and feeding practices, which led to more balanced and nutritious meals for their children. this aligns with the theoretical benefits offered by the nutritional rangers application, which provides accessible and engaging nutritional education. parents also noted positive behavioral changes, such as incorporating a wider variety of foods and being more attentive to portion sizes and meal timing. these qualitative insights support the quantitative improvements observed.11,19 however, technology-related challenges were identified, including limited internet access and technical difficulties, highlighting the need for ongoing technical support and user training. the role of community health workers in facilitating the effective use of the applications was crucial, emphasizing the importance of community engagement in the success of digital health interventions.11,19,20 parents observed noticeable improvements in their children’s health and growth, attributing these positive changes to the combined effects of the applications and the support they received. these observations are consistent with the quantitative data, which demonstrate significant improvements in children’s weight and height, thereby confirming the efficacy of the integrated intervention in improving child health outcomes.8,11,21 conclusions the study findings, supported by data and statistical analysis, demonstrate that the lumbung hidup program effectively enhances the nutritional status of toddlers from economically disadvantaged families. the significant improvements in z-scores for weight-for-age, height-for-age, and weight-for-height underscore the potential of this intervention in promoting better child health outcomes. given its comprehensive approach, this program holds substantial promise for broader implementation as a sustainable and holistic strategy to combat malnutrition and stunting. expanding the reach of these interventions could play a critical role in addressing nutritional deficiencies and fostering long-term improvements in child health and development. references 1. adjid aa, haji jafar cps, mohamad rw. the relationship between maternal knowledge of complementary feeding and the incidence of stunting among children aged 2-5 years. an idea health journal 2024;4:105-12. 2. nurharlinah n, rosnani r, athiutama a, enisah e. characteristics and incidence of stunting in toddlers. an idea health journal 2024;4:32-7. 3. puspitasari a, abdullah n, alimuddin h. environmental sanitation and levels of animal protein intake on the incident of stunting in toddlers. an idea health journal 2024;4:45-50. 4. zainal n, a a, patimah s. analysis of specific nutrition intervention programs for breastfeeding mothers on stunting incidents in children aged 25-36 months in the work area of the antang health center, makassar city. an idea health journal 2021;1:142-54. 5. elisaria e, mrema j, bogale t, et al. effectiveness of integrated nutrition interventions on childhood stunting: a quasi-experimental evaluation design. bmc nutr 2021;7:17. 6. laksono ad, sukoco new, rachmawati t, wulandari rd. factors related to stunting incidence in toddlers with working mothers in indonesia. int j environ res public health 2022;19:20220826. 7. niyalatul m, ervina r, ida n. design of nutritional status system for stunting early prevention. in: proceedings of the first international conference on social science, humanity, and public health (icoship 2020). 2021; pp.140-4. atlantis press. 8. permana aa, perdana at, handayani n, destriana r. a stunting prevention application “nutrimo” (nutrition monitoring). j phys conf ser 2021;1844:012023. 9. mukodri dml, safitri t, ridayani r, et al. booklet preventing stunting based android application (bocesting) as a tool to enhance maternal nutritional behaviour and nutritional status. healthc low resour settings 2023;12. 10. nurhidayah r, sari dk. the effectiveness of lumbung hidup in improving toddler nutrition among economically disadvantaged families. j glob res public health 2024;9. 11. prasiska di, widodo ap, suryanto y. ojo stunting application, health promotion media prevention stunting era 4.0. iakmi indones j public health 2020;1. 12. stasya n, sulistiadi w. the effectiveness of mobile application as educational intervention to prevent stunting: a systematic review. the international conference on public health proceeding 2020;5. 13. sari gm. early stunting detection education as an effort to increase mother’s knowledge about stunting prevention. folia medica indonesiana 2021;57. 14. asriadi, nurnainah, amal aa, et al. culture-based education on health literacy about stunting in communities in south sulawesi, indonesia. gac med caracas 2023;131. 15. rahma ra, dayati u, desyanty e, listyaningrum ra. development of a technology-based parenting support center model to support stunting reduction programs. 2022 8th international conference on education and technology (icet) 2022:177-84. 16. maryati s, yunitasari p, punjastuti b. the effect of interactive education program in preventing stunting for mothers with children under 5 years of age in indonesia: a randomized controlled trial. open access maced j med sci 2022;10:2604. article [healthcare in low-resource settings 2025;13:13258] [page 73] 17. aritonang ea, margawati a, dieny ff. analisis pengeluaran pangan, ketahanan pangan dan asupan zat gizi anak bawah dua tahun (baduta) sebagai faktor risiko stunting. j nutr coll 2020;9:10. 18. ningtyas bk, murtiyaningsih h, arum ls. penguatan pangan lokal berkelanjutan melalui edukasi dapur sehat atasi stunting bagi keluarga berisiko. jurnal pengabdian teknologi informasi dan kesehatan (diankes) 2023;1. 19. rufaindah e, petemah p. application of “stunting prevention” android-based applications to mother knowledege and nutritional status of toddlers ages 0-36 months.. jkb jurnal kebidanan 2021;11:41-6. 20. saito a, kondo m. maternal and child health handbook and under-6 child overweight in greater jakarta, indonesia: a crosssectional web-based survey. bmc nutr 2023;9:40. 21. gonzález-pérez a, matey-sanz m, granell c, et al. awarns: a framework for developing context-aware reactive mobile applications for health and mental health. j biomed inform 2023;141:104359. article [page 74] [healthcare in low-resource settings 2025;13:13258] hrev_master healthcare in low-resource settings 2024; volume 12:11990 e-counseling development model: modified psycho-spiritual and spiritual emotional freedom technique (ps-seft) on anxiety levels and recovery motivation in pulmonary tuberculosis patients ima nadatien,1 abdul muhith,1 rizqi putri nourma budiarti,2 mursyidul ibad3 1faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya; 2faculty of business economics and digital engineering, universitas nahdlatul ulama surabaya, surabaya; 3faculty of health, universitas nahdlatul ulama surabaya, indonesia abstract pulmonary tuberculosis (tb) is one of the leading causes of death globally, including in indonesia. tb patients often experience anxiety, frustration, irritability, and guilt, influenced by their knowledge, attitudes, beliefs, work, and primarily psychospiritual factors. one form of support provided to these patients is the psycho-spiritual and spiritual emotional freedom technique (ps-seft). this research aimed to determine the effect of e-counseling combined with ps-seft on anxiety levels and motivation for recovery in tb patients. the study used an experimental, correlational analytical method, with a random sample of 14 respondents suffering from pulmonary tuberculosis. the independent variable was the provision of e-counseling combined with psseft, and the dependent variables were the levels of anxiety and motivation to recover from tb. data collection instruments included questionnaires, the harz scale, and medical records. data were processed using various analyses, including the paired t-test and wilcoxon test. the results showed a significant decrease in anxiety levels after the ps-seft intervention, with anxiety reducing by 35.7% from a previously very severe level. motivation to recover increased significantly, with all 14 patients (100%) showing improvement from moderate to high levels. the wilcoxon test results indicated a significant difference in the anxiety levels of tb patients before and after the ps-seft intervention (p-value=0.005), with the harz score decreasing from 95.00 to 32.00. the paired t-test results also showed a significant difference in patient motivation to recover before and after the psseft intervention (p-value=0.000), with the motivation score increasing from 91.25 to 98.75. routine ps-seft practice by tb patients enhances their ability to manage anxiety and motivates them to recover. the success of these patients must be supported and accompanied by their families. introduction in 2019, indonesia had 845,000 cases of pulmonary tuberculosis (tb), with an incidence rate of 312 per 100,000 people, making it the country with the second highest number of cases globally after india.1 tb is a chronic disease that requires a prolonged treatment period of six to eight months.2 to ensure patients adhere to this lengthy treatment regimen, the directly observed treatment shortcourse (dots) program is crucial. this program ensures that tb patients are accompanied while taking their medication, significantly improving treatment adherence. successful recovery heavily depends on the patients’ compliance with their treatment plan. non-compliance can lead to difficulties in recovery, repeated treatments, and potential psychosocial impacts. tb patients who do not adhere to their treatment may experience emotional problems such as boredom, lack of motivation, and serious mental health issues like depression. the extended and complex treatment process for tb, along with potential complications, can trigger anxiety.3,4 correspondence: ima nadatien, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, indonesia. e-mail: iman.69@unusa.ac.id key words: anxiety, e-counseling, motivation, psycho-spiritual and spiritual emotional freedom technique, pulmonary tuberculosis. contributions: in, conceptualization, investigation, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; am, data processing, writing – original draft; rp, data curation, methodology, writing – original draft, review & editing; mi, data analysis, writing original draft, review & editing. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. funding: this research was supported by a research grant from universitas nahdlatul ulama surabaya. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, based on ethical certificate 2742-kepk. during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we would like to acknowledge the contribution of mentoring program conducted by the research centre of excellence in advancing community health (reach), surabaya, indonesia. received: 15 october 2023. accepted: 11 june 2024. early access: 25 july 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:11990 doi:10.4081/hls.2024.11990 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 584] [healthcare in low-resource settings 2024;12:11990] non -co mmerc ial us e o nly tb patients must undergo treatment for a minimum of six months. if they take medication irregularly, the tb disease will not be cured and may even become stronger, often causing anxiety. anxiety in tb patients can also stem from a lack of knowledge and family support. in such cases, outreach and counseling are needed for families and patients to help manage anxiety and employ positive coping mechanisms. this support enables them to live comfortably, feel less anxious, and take appropriate action if a family member experiences health problems.5 counseling services that have been hampered can be provided through e-counseling to families. this approach will enable families to support and assist the patient in managing anxiety and increasing motivation to recover by regularly practicing psycho-spiritual and spiritual emotional freedom technique (ps-seft) exercises independently. ultimately, tb patients will be able to reduce their anxiety, live calmly, and increase their motivation to recover.6 the benefits of seft for anxiety are both spiritual and biological. the spiritual aspect consists of two steps, beginning with the “set-up,” which aims to ensure that the body’s energy flow is directed appropriately. this step helps to neutralize “psychological reversal” or “psychological resistance” and includes a prayer of surrender.7 the second step is “tune-in,” which involves focusing on the pain you are experiencing and directing your mind to the location of the pain (self-hypnosis). the biological aspect consists of tapping lightly on the body’s 18 energy points, which correspond to the 12 major meridian pathways (the major energy meridians). this tapping stimulates electrically active cells, which are centers of activity consisting of clusters of active cells on the body’s surface. this stimulation results in signal transduction, which occurs in biological processes due to the activation of key eft points.8 when someone is in a state of fear and tapping is performed on the acupoints, there is a decrease in amygdala and brain wave activity. this process also halts the participant’s fight-or-flight response, creating a relaxation effect that neutralizes all emotional tension experienced by the individual. from a physiological perspective, tapping lightly on the 12 meridian points of the body can stimulate the pituitary gland to release endorphins.9 these hormones have a calming effect and induce feelings of happiness.9 this study aimed to assess the impact of e-counseling combined with ps-seft on anxiety levels and recovery motivation in tb patients. materials and methods study design this type of research was a quasi-experimental study with a prepost-test group design involving 14 tb patients. the group received an intervention in the form of ps-seft and was measured for anxiety levels and motivation to recover before and after receiving the intervention. population and sample the population and sample in this study consisted of target families selected based on criteria of experiencing anxiety and motivation problems. the sample included tb patients accompanied by their families. in this context, the family is represented by the head of the family or family members who are communicative and cooperative. instruments and data collection the instrument for implementing e-counseling is an activity event unit (sak) used as a guide for ps-seft implementation. anxiety levels were assessed using the hamilton anxiety rating scale (hars).10 meanwhile, the motivation to recover is measured using a questionnaire. data collection activities began with the researcher giving a pretest, followed by carrying out the psseft exercise for two visits, with one visit every week, to ensure that the patient carried out the e-counseling recommendations. researchers provide ps-seft training at the community health center and, if necessary, attend the patient’s home; each time the exercise is given for 20-45 minutes, the patient is asked to be accompanied by their family in a relaxed room with adequate ventilation and lighting. the patient sits next to the therapist; the therapist opens ps-seft by directing the patient to carry out the stages of ps-seft, namely set-up, tune-in, and tapping. after therapy was completed, the researcher filled out an observation sheet that the patient had carried out ps-seft. continued visits are a form of monitoring and evaluation of the ability to carry out ps-seft. then, the patient and family are given an additional two weeks to carry out ps-seft independently. after that, the researchers measured anxiety and motivation to recover and then determined it as a post-test score. data analysis the pre-test and post-test data will be tested for normality using the shapiro-wilk test. if the data is not normal, the multivariate ancova will be tested. normal data followed by paired ttest to compare differences in preand post-samples, an independent t-test to compare differences in pre-sample data, and using the wilcoxon multivariate test to compare differences in the effect of e-counseling modified ps-seft samples on levels of anxiety and motivation recovered, with a p-value<0.05 (p<α). results results of research on the e-counseling development model modified psycho-spiritual and spiritual emotional freedom technique (ps-seft) on the level of anxiety and motivation to recover in tb patients in the surabaya community health center area. based on table 1, the distribution of hars anxiety level data in tb patients before the ps-seft intervention shows that the majority of patients experienced very severe anxiety, with five patients (35.7%) falling into this category. after the ps-seft intervention, the patients’ anxiety levels decreased significantly. none of the patients remained in the very severe anxiety category. instead, their anxiety levels shifted to severe, moderate, and no anxiety. notably, the highest number of patients, 5 (35.7%), fell into the no-anxiety category after receiving the ps-seft intervention. table 2 showed an increase in the motivation levels of patients after the ps-seft intervention. before the intervention, three patients (21.4%) were in the moderate motivation category, with no patients in the low motivation category. after the ps-seft intervention, all patients experienced increased motivation, with 14 patients (100%) falling into the high-motivation category. a significant difference in patient motivation to recover before and after the ps-seft intervention was observed, with a significance value of 0.000. comparing this significance value with the alpha value of 0.05, it can be concluded that there is indeed a difference in patient motivation to recover from tb disease before and after the ps-seft intervention. furthermore, there was a notable increase in the patient’s motivation score after the intervention, rising from 91.25 to 98.75 (table 3). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11990] [page 585] non -co mmerc ial us e o nly the significance value in table 4 was 0.005, indicating a difference in the anxiety levels of tb patients before and after the psseft intervention. moreover, the results demonstrate a decrease in the hars score for anxiety in tb patients from before the intervention (95.00) to (32.00) after the ps-seft intervention. discussion the spirituality factor is a powerful tool for overcoming illness, which can make patients more focused, strong, and dynamic and help them overcome the problems of their illness.11 spirituality is also integrated into reasoning and problem-solving techniques through an approach that functions as a coping strategy in managing illness and reducing potential stress, such as pain and helplessness.12 spirituality is a process of awareness that instills natural goodness in individuals to find the best conditions for developing higher qualities. spirituality acts as a perspective that encourages the unity of all individual aspects.13 spiritual needs are assessed in the context of health, such as finding meaning and purpose in life and recognizing the importance of good relationships with other people, transcendent forces, and the natural environment.14 spiritual factors contribute positively to behavior change, which has an impact on motivation to achieve healing. controlled treatment of tuberculosis patients will prevent drug resistance and further complications.15 ps-seft focuses on the patient by modifying seft movements, therapeutic communication, and efforts to get closer to allah almighty as a form of controlling emotions, as expected by the patient and family. the hope of this approach is that patients can try to adapt and overcome the anxiety they experience so that they can be motivated to recover from the disease. when carrying out ps-seft, the patient commits himself to believing in allah almighty.16 this is part of the patient’s coping mechanism process for the problems that arise as a result of suffering from tb. when doing the seft movement exercise, the patient says the phrases “istighfar, astagfirullahal adziim, laa ilaha illallah and allahumma sholli ala muhammad, hasbunallah wa ni’mal wakiil” followed by “laa khaula walaa quwwata illa billahil ‘alliyyil ‘adziim”. this sentence has the effect of deep surrender to kodarullah which can minimize the intensity of distress caused by applying the patient’s coping mechanisms. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [page 586] [healthcare in low-resource settings 2024;12:11990] table 1. anxiety levels in tuberculosis patients before and after the psycho-spiritual and spiritual emotional freedom technique intervention. anxiety level before after (hars categories) frequency percentage (%) frequency percentage (%) not anxious 3 21.4 5 35.7 mild anxiety 3 21.4 3 21.4 moderately anxious 2 14.3 4 28.6 severe anxiety 1 7.1 2 14.3 very severe anxiety 5 35.7 0 0.0 hars, hamilton anxiety rating scale. table 2. frequency distribution of motivation to recover in tuberculosis patients before and after the psycho-spiritual and spiritual emotional freedom technique intervention. motivation category before after frequency percentage (%) frequency percentage (%) moderate 3 21.4 0 0 high 11 78.6 14 100.0 table 3. differences in motivation to recover in tuberculosis patients before and after being given the psycho-spiritual and spiritual emotional freedom technique intervention. variable mean ± sd minimum maximum sig motivation score before intervention 81.73±8.06 71.75 95.00 0,000* motivation score after intervention 91.25±2.47 91.25 98.75 table 4. ddifferences in anxiety in tuberculosis patients before and after being given the psycho-spiritual and spiritual emotional freedom technique intervention. variable mean ± sd minimum maximum sig anxiety before intervention (hars score) 37.92±31.15 4.00 95.00 0.005* anxiety after intervention (hars score) 17.14±8.03 4.00 32.00 hars, hamilton anxiety rating scale non -co mmerc ial us e o nly this is a form of effective distraction, namely providing spiritual support by inviting patients to read prayers and sentences of dhikr, istighfar so that it can reduce stressor hormones, activate natural endorphin hormones, and increase feelings of relaxation. apart from that, it will also divert the patient’s attention from fear, anxiety, and tension. the body’s chemical system is improved, thereby lowering blood pressure and slowing breathing, heart rate, pulse, and brain wave activity.17 this deeper or slower breathing rate is very good for causing calm, emotional control, deeper thinking, and better metabolism. if the patient intensely carries out this condition with the full support of the family, an intention will arise in the heart accompanied by a positive attitude or thinking about positive things, gratitude, and patience so that the patient is calm. in turn, patients are able to generate encouragement to continue making efforts and undergo treatment well and regularly. this is where a motivational attitude emerges so that patients always try to manage a healthy life to speed up recovery.18 conclusions regular and effective practice of ps-seft can heighten awareness of the positive insights gained from illness situations and foster self-awareness of divine strength, characteristic of individuals with robust spiritual integrity. this heightened awareness fosters emotional stability and embodies positive behavior. emotional stability, inversely related to depression, anxiety, and various psychological distresses stemming from health issues, can be achieved through consistent ps-seft practice as part of daily routine. the emotional stability resulting from strong spiritual integrity influences positive behavioral outcomes and correlates with physical well-being. tb patients, supported by their families, engage in intensive ps-seft practice with a positive outlook, fostering acceptance, tranquility, and a resilient approach to treatment. ultimately, patients are motivated to diligently adhere to their treatment regimen, striving to lead genuinely healthy lifestyles to expedite recovery. references 1. world health organization (who). tb incidence. 2020. available from: https://www.who.int/teams/global-tuberculosis-programme/tb-reports/global-tuberculosis-report-2022/tbdisease-burden/2-1-tb-incidence 2. wulandari l, wijaya sy. systemic sclerosis and pulmonary tuberculosis associated with interstitial lung disease: a case report. indian j forensic med toxicol 2021;15:147-53. 3. suryani s, widianti e, hernawati t, sriati a. psikoedukasi menurunkan tingkat depresi, stres dan kecemasan pada pasien tuberkulosis paru. j ners 2016;11:128-33. 4. ernawati ds, parmadiati ae, soebadi b, et al. prevalence of oral tuberculosis ulcer in dots polyclinic of dr. soetomo general hospital surabaya. biochem cell arch 2020;20:28458. 5. hasanah u, makhfudli m, ni’mah l, et al. peer group support on the treatment adherence of pulmonary tuberculosis patients. iop conf ser earth environ sci 2019;246:12033. 6. widyastuti m, hastuti p, kirana sac, farendita nh. the correlation of spiritual status and anxiety level in patients with pulmonary tuberculosis. j ners 2020;15:67-71. 7. church d, stapleton p, vasudevan a, o’keefe t. clinical eft as an evidence-based practice for the treatment of psychological and physiological conditions: a systematic review. front psychol 2022;13:951451. 8. feinstein d, ashland o. what does energy have to do with energy psychology. energy psychol theory res treat 2012;4:59-80. 9. rokade pb. release of endomorphin hormone and its effects on our body and moods: a review. in: international conference on chemical, biological and environment sciences. 2011. p. 436–8. 10. thompson e. hamilton rating scale for anxiety (ham-a). occup med (chic ill). 2015;65:601. 11. bau p. hubungan dukungan sosial spiritual dengan motivasi sembuh klien di ruang rawat inap rumah sakit st. carolus borromeus kupang. chmk appl sci j 2019;2:120-8. 12. supriyanto, hamid ays, rosyada d, et al. nurse’s competence in supporting the spiritual-religious needs of patients in indonesia. indian j public heal res dev 2019;10:604-8. 13. khairunnisaa k, muhdia n, atikab a, sitawatia ad. spiritual well-being, perceived social support, and its correlation with psychological resilience of health workers in covid-19 unit at special infection hospital (rski) universitas airlangga during pandemic. health (irvine calif) 2024;10:11. 14. lalani n. meanings and interpretations of spirituality in nursing and health. religions 2020;11:428. 15. setiyowati e, rahman ah. penerapan terapi spiritual emotional freedom technique (seft) pada penderita tuberculosis dengan masalah keperawatan di puskesmas sawahan. the j heal sci 2020;13:74-80. 16. kusnanto k, haryanto j, sukartin t, et al. the effectiveness of spiritual emotional breathing towards respiratory function and immune response of tuberculosis patients. j ners 2018;13:8373. 17. pratiwi in, hidayati l, alviani ni, mckenna l. the correlation between anxiety levels and spiritual activities with motivation to recover in pulmonary tuberculosis. enfermería clínica 2021;31:535-9. 18. juliasih nn, mertaniasih nm, hadi c, et al. factors affecting tuberculosis patients’ quality of life in surabaya, indonesia. j multidiscip healthc 2020;13:1475-80. transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions [healthcare in low-resource settings 2024;12:11990] [page 587] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13069 the effects of brown rice as functional food on lee index, adipose tissues and prdm16 levels in obesity model rattus norvegicus jeany pricelia,1 putri dwi arini,1 hazrina putri alifiyah,1 riri syabania,1 inggita kusumastuty,1,4 etik sulistyowati,2 laksmi sasiarini,3 achmad rudijanto,3 dian handayani1,4 1department of nutrition, faculty of health sciences, universitas brawijaya, malang, east java; 2department of nutrition, polytechnic of health, malang, east java; 3faculty of medicine, universitas brawijaya, malang, east java; 4metabolic syndrome research group, faculty of health sciences, universitas brawijaya, malang, east java, indonesia abstract brown rice is a functional food known to improve lee index, influencing prdm16 levels in obesity conditions. therefore, this study aims to determine the differences in lee index, brown adipose tissue (bat) weight, white adipose tissue (wat) weight, beat weight, total body fat, and prdm16 levels of obese model rats with the intervention of brown and white rice, as well as g-oryzanol. a true experimental method was used with a posttest-only control group in vivo design. the obesity model was constructed with male sprague dawley rats (rattus norvegicus), divided into five diet groups namely standard and hfhf diet control, as well as hfhf + brown rice, hfhf + white rice, and hfhf + g-oryzanol combination diet. the experiment was carried out for 26 weeks, with details of 14 weeks to form an obese model and 12 weeks for the intervention. before statistical correlation was tested, lee index values, adipose tissues, and prdm16 were analyzed. the anthropometric data collection method was carried out by weighing before and after the intervention, while adipose tissue was collected by weighing after sacrifice. the immunofluorescence method was used to collect the expression of prdm16 and the mean of prdm16 levels was analyzed in the imagej application. after the data collection process, analysis was performed using spss to determine possible differences in each group. normally distributed data were analyzed using one-way anova, while those without normal distribution were assessed using the kruskall-walis method and the mann whitney-u advanced test, with a p-value of <0.05 considered significantly different. the result showed that there were differences among several groups regarding total body fat (p=0.012), wat (p=0.026), and bat (p=0.025). however, no differences were found between all groups regarding the lee index (p=0.275), beat (p=0.079), and prdm16 level (p=0.292). in conclusion, brown rice intervention did not significantly affect lee index values, the expression of prdm16, and adipose tissue weights at the end of intervention. introduction obesity is a chronic metabolic disease caused by the prolonged buildup of energy in the body, leading to fat tissue accumulation. the global cases are increasing each year, with the prevalence reaching 650 million in 2016. in indonesia, the prevalence among adults jumped from 6.4% to 21.8% between 2013 and 2018.1 considering that obesity plays a significant role in developing metabolic syndrome,2 fast and appropriate interventions are needed. several factors can be a risk for obesity with diet being the most influential3 followed by genetics, lifestyle, physical activity, environment, health, and psychology.3 obesity interventions are focused on dietary habits, physical activity improvement, and lifestyle changes. in this context, highly aggressive methods capable of causing side effects such as pharmacological and surgical are usually not recommended.4 however, obesity with complications can be treated by using several methods consisting of diet, physical exercise, behavior modification, pharmacological therapy, and bariatric surgery.4 brown rice is one of the functional foods which has antiobesity and antihyperglycemic effects. due to the intact outer skin layer and aleurone,5 brown rice has better potential nutritional content compared to white rice which contains dietary fiber, minerals, and g-oryzanol, a bioactive compound useful as an antiobesity agent.6,7 with this content, brown rice is capable of influencing parameters of obesity, including body anthropometry and prdm16 levels. according to a previous study, obesity is not associated with total body weight but specifically with the quantity of white adipose tissue (wat)8 which accumulates the excessive energy into triglyceride form. there is also brown adipose tissue (bat) playing an important role in metabolizing fatty acids to produce heat,9 although the amount is often lower than wat in obese people.8 specific interventions such as maintaining diet and physical activity can cause white adipocytes to form beige adipocytes in browning activity. this process indirectly affects the body weight of rats and improves the anthropometric profile in animal models of obesity. positive regulatory domain zinc finger region protein 16 (prdm16), a gene number 1p36.32 on the human chromosome, can inhibit the formation of wat while increasing the formation of brown and beige adipocytes.10,11 it increases biogenesis in tissue significance for public health brown rice is considered a functional food that has been shown to impact the lee index positively and may influence prdm16 levels in cases of obesity. research suggests that brown rice (brg) may promote the enhancement of beige adipose tissue (beat), brown adipose tissue (bat), and prdm16 levels. however, further investigation is necessary to determine the optimal dietary ratio required to facilitate the browning process of white adipose tissue (wat). [page 102] [healthcare in low-resource settings 2024;12(s1):13069] non -co mmerc ial us e o nly mitochondria and activates several transcription factors, such as ppar-g, to enhance the expression of uncoupling protein 1 (ucp1), which potentially produces heat and stimulates browning in wat. one effort to trigger browning is diet regulation through calorie restriction.12 studies related to the relationship between brown rice and body fat have been carried out on both experimental animals and humans. the results showed that brown rice had a positive effect on glucose and body fat levels in 18 diabetes mellitus patients who were treated for 3 months.5 after the intervention was given, there was a decrease in poor blood glucose control by 27.7%, high fat by 22.2%, and high visceral fat index by 22.2%.5 in obese experimental animals, brown rice effectively improved the fermicutes/bakteriodetes microbiota ratio.13,14 the supplementation was proven to significantly reduce fat levels in the liver and prevent the development of nafld in obese model rats.15 g-oryzanol, one of the bioactive compounds in brown rice, plays a significant role in regulating body weight and preventing several diseases including hyperglycemia, hypertriglyceridemia, blood vessel disorders, and renal damage. it acts as an antioxidant and anti-inflammatory agent, suppressing inflammation in conditions of obesity.16 on average, brown rice contains 10-150 mg/100 g of γ-oryzanol.17 this presents an opportunity since the majority of indonesians still consume white rice which potentially has a high glycemic index (79.6).18 in general, food with a high glycemic index contributes to obesity and type 2 diabetes mellitus. studies regarding the effect of functional food on prdm16 levels are limited. therefore, this study aimed to examine differences in lee index, bat weight, wat weight, beat weight, total body fat, and prdm16 levels in obesity model rats given brown and white rice as well as g-oryzanol interventions. the study novelty sets in examining the difference in prdm16 levels and anthropometry of obesity model rats with functional food interventions of brown rice compared to white rice and g-oryzanol. the results are expected to offer insights into brown rice as a functional food against obesity and metabolic syndrome. in addition, this study can be used as a reference in developing functional foods at the human level. materials and methods study design a true experimental method was used with a post-test-only control group in vivo design. the inclusion criteria were male sprague dawley (rattus norvegicus) with age 10-12 weeks, body weight 200-250 g, in active condition (shiny fur, no alopecia, normal extremities), and free of any treatment or chemical intake. this study was approved by the health research ethics committee, faculty of health sciences, brawijaya university no. 2020/un10.f17.10.4/tu/2023. all procedures were carried out in collaboration with the experimental animal care laboratory, faculty of medicine, universitas brawijaya. study subjects the samples were subjected to diet intervention with brown rice (brg), white rice (wrg), and pure g-oryzanol (org) combined with high-fat high fructose (hfhf) diet. in addition, samples had both positive (pg) and negative controls (ng). positive control was a group of rats on hfhf diet, while the negative control was on a standard diet. instruments development and data collection anthropometric data were collected by measuring the body weight and length of rats before and after intervention. subsequently, bmi and lee index were calculated using the data obtained. when lee index value was > 0.3 then rats were categorized as obese. an analysis was further carried out to examine possible differences in each group of rats before and after intervention. data on the weight of adipose tissue were collected by weighing after rats were sacrificed. adipose tissue weighed included wat, bat, beat, and total body fat. rats were sacrificed for the assessment of wat, bat, and beat. fat tissues were converted to slides before heating (60� in 60 minutes) and soaking in xliol (2 x 10 minutes), absolute ethanol (2 x 10 minutes), ethanol 90% (1 x 5 minutes), ethanol 80% (1 x 5 minutes), and ethanol 70% (1 x 5 minutes). subsequently, the slides were subjected to antigen retrieval process with citric buffer. washing was carried out using pbs solution followed by incubation with bsa 1% for 30 minutes at room temperature before incubation with primary antibody at 4°c overnight. pbs washing was initially performed before the use of secondary antibody and dapi incubation. fat slides were then subjected to a staining process using the immunofluorescence method. the staining results were examined using an immunofluorescence microscope and the imagej to select tissue sections and analyze the average prdm16 levels. data analysis statistical analysis of data was conducted using ibm spss statistics. the obtained data were tested for normality. for normally distributed data, a homogeneity test was initially performed, and after meeting a p> 0.05, one-way anova analysis was conducted to determine the differences in three or more unpaired groups. for abnormal distribution, the data was analyzed using the kruskalwallis test method to determine differences in three or more unpaired groups. a significant difference between the groups was indicated by a p<0.05. the analysis was continued with the mannwhitney u test carried out per two groups, and a p<0.05 indicated a significant difference. results and discussion brown rice differs from other varieties due to the name which reflects the original color. this variety is subjected to only minimal processing, leaving the outer layer intact, including the rice bran.13 according to previous studies, brown rice has a high fiber content with seven times greater magnesium and manganese content than white rice.14 the fiber and mineral content has been proven to reduce gut microbiota dysbiosis, increase serum magnesium levels, as well as prevent rising serum magnesium levels in obese experimental animals.6,14 based on the results, there was no significant difference between the control and intervention groups (table 1). this was in contrast to a study conducted on the substitution of local brown rice varieties for anthropometry and improving blood glucose levels in patients with type 2 diabetes mellitus.19 the result showed that brown rice intervention significantly reduced body weight, bmi, body fat percentage, abdominal circumference, fasting blood glucose, 2-hour postprandial blood glucose, and hba1c.19 the difference between the results could be caused by a non-significant difference between the average energy food intake of rats in each group. however, the administration of white rice and g-oryzanol 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13069] [page 103] non -co mmerc ial us e o nly intervention showed a positive trend toward improving lee index compared to positive control. body weight results of experimental animals were also influenced by total body fat. based on the results of statistical tests, significant total body fat differences were found between positive and negative control groups (p=0.001), negative control and white rice intervention (p=0.035), as well as negative control and g-oryzanol group (p=0.085). the highest average total body fat weight was found in positive control (26.6 ± 9.2 g), followed by brown rice intervention group (19.27 ± 10.8 g) (table 1). the result differed from a previous study where the consumption of brown rice affected the inhibition of fat accumulation, ultimately reducing the risk of central obesity in patients with type 2 diabetes mellitus.20 the variation between the results could be caused by a non-significant difference between the average dietary intake of rats in each group. brown rice diet intervention group had a lower average intake compared to positive control, negative control, and white rice intervention groups according to their average energy intake. therefore, the bioactive content in brown rice did not provide significant benefits for reducing body weight and total body fat. as shown in table 1, there were no significant differences between prdm16 levels in the control and the intervention group (p=0.292). however, the highest levels were found in brown rice intervention group (9.5 ± 8 relative mrna levels). brown rice has antiobesity and antidiabetic properties, attributed to aminobutyric acid (gaba), inositols, tocotrienols, ferulic acid, oryzanol, and methanol.21,22 compounds such as ferulic acid can block adipocyte production, while methanol potentially reduces the formation of transcription factors and adipogenic genes, including ehmt1 and ctbp1/2.21,22,23 these results were consistent with the previous study about prdm16 stating that prdm16 was found to play a crucial role in adipocyte differentiation.11 antiobesity and antidiabetic intake of brown rice can cause adipocyte differentiation, including inhibition of production and transcription factors by increasing prdm16 levels. generally, white adipocytes are stored in the body in wat, and in conditions of obesity, the composition tends to be more significant due to the accumulation of unused energy in the form of triacylglycerol.24 in this study, visceral and subcutaneous fat were taken as wat samples, bat was collected from the interscapular region, and beat was acquired from the testicular area. according to a previous study, visceral fat stores large circulating ffa and inflammatory markers, including il-6, crp, and tnf-α, which increase the risk of cvd.25 the smallest average weight of wat was found in white rice intervention group (8.65 ± 6.54 g), while the largest was recorded in brown rice (11.3 ± 6.08 g). this result was not in line with prdm16 levels which were significantly high in brown rice intervention group, suggesting wat weight obtained might be influenced by several other tissues taken during the sacrifice. a previous study about brown and beige adipose tissue explained that beat could appear in subcutaneous wat storage, particularly in the anterior subcutaneous and inguinal areas.26 an ineffective diet was also implicated because the fiber, phenolic acid, and γ-oryzanol content of brown rice were not consumed to an extent capable of causing wat browning.27 a study comparing different laboratory feeding methods in rats found that the group given auto, a daily feeding method set to reduce body weight by up to 90-95%, showed better results in weight loss compared to ad libitum feeding.28 future studies should expand the investigation with a feeding method that has been regulated for weight loss. according to previous reports, prdm16 has two mechanisms in wat differentiation process.11 in the first mechanism, prdm16 induces the formation of brown fat-related genes (pgc 1α, pgc 4th international nursing and health sciences symposium [page 104] [healthcare in low-resource settings 2024;12(s1):13069] table 1. data of diet, anthropometric, body fat, and prdm16 average. non -co mmerc ial us e o nly 1β, pparγ, uncoupling protein 1 (ucp1)) and forms a complex to cause thermogenesis effects on fat. this initiates the browning process, leading to the formation of bat (figure 1). high levels of prdm16 in the brown rice intervention group resulted in comparable bat weight. there was a significant difference in bat between negative and positive control group, negative control and g-oryzanol intervention, as well as positive control and white rice intervention group (table 1). the highest average weight of bat was found in the brown rice intervention group (2.81 ± 1.6 g) followed by positive control (2.97 ± 1.27 g), and white rice intervention group (1.36 ± 0.42 g). the second mechanism is the formation of beat initiated by the conversion and secretion of the metabolite, β-hydroxybutyrate (bhb) from mature wat.11,23 this activity potentially increases beige adipogenesis and ucp-1 stimulation of adiponectin.11,23 ucp-1 supports the formation of brown fat genes while reducing the expression of fiber precursors that cause fibrosis in fat tissue (figure 1).11 statistical analysis showed that there were no significant differences between groups regarding the beige adipose tissue (p-value=0.079) (figure 2). however, the average beat weight of brown rice intervention group was greater than the other groups (5.17 ± 3.58 g). this is in line with the theory stating that beat tissue has higher expression of ucp1 and prdm16 gene.29 further studies are needed regarding the appropriate levels of brown rice to support wat browning process in a specific time limit. appropriate control of feeding and environmental conditions also needs to be considered to achieve optimal intervention results. moreover, each rat has varying metabolic abilities, which greatly determines the results of using in vivo methods. conclusions in conclusion, the intervention of brown and white rice, as well as pure g-oryzanol for 12 weeks did not show significant differences in anthropometric changes and prdm16 levels. this study should be further conducted with a feeding method that had been adjusted for weight loss based on body weight reference of rats to obtain more significant results. references 1. unicef. overweight and obesity landscape analysis in indonesia. jakarta: united nations children's fund (unicef); 2019. 2. han ts, lean me. a clinical perspective of obesity, metabolic syndrome, and cardiovascular disease. jrsm cardiovasc dis 2016;5:2048004016633371. 4th international nursing and health sciences symposium figure 1. mechanism of functional food affecting the components of adipose tissue. [healthcare in low-resource settings 2024;12(s1):13069] [page 105] correspondence: dian handayani, department of nutrition, faculty of health sciences, universitas brawijaya, , jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia, postcode. tel.:+62341569117 fax: +62341564755. e-mail: handayani_dian@ub.ac.id key words: functional food; lee index obese; prdm16; total body fat. contributions: all authors contributed equally to this study. conflict of interest: the authors declare that there are no potential conflicts of interest. funding: this study was supported financially by universitas brawijaya. ethics approval: this study was approved by the health research ethics committee, faculty of health sciences, brawijaya university no. 2020/un10.f17.10.4/tu/2023. all procedures were carried out in collaboration with the experimental animal care laboratory, faculty of medicine, universitas brawijaya. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to the department of nutrition, faculty of health sciences, universitas brawijaya, malang, and the department of nutrition, polytechnic of health, malang, for providing the best support. received: 3 november 2023. accepted: 28 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13069 doi:10.4081/hls.2024.13069 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly 3. hendra c, manampiring ae, budiarso f. risk factors for obesity in adolescents in bitung city. j e-biomedik 2016;4:15. 4. douketis j. screening, prevention and treatment of overweight/obesity in adult populations. canada: mcmaster university; 2013. 5. kusumastuty i, handayani d, attamimi n, affandy yikd, innayah am, puspitasari da. compliance of brown ricebased diet on blood glucose and body fat of diabetes mellitus patients. indonesian j human nutrition 2021;8:182194. 6. sulistyowati e, handayani d, soeharto s, rudijanto a. serum mineral (mg, mn, and k) levels are associated with increasing the body mass index (bmi) and abdominal circumference. obes med 2019;15:100107. 7. witanto s. identification of gamma-oryzanol levels in nhexane extract of germinated brown rice (gbr) sintanur variety. malang: univ brawijaya; 2019. 8. park ym, myers m, potter, vjv. adipose tissue inflammation and metabolic dysfunction: role of exercise. missouri medicine 2014;111:65-72. 9. radhina a. adipose tissue browning process. indonesian j health sci 2021;1:42-46. 10. liu l, chen y, chen j, et al. the relationship between prdm16 promoter methylation in abdominal subcutaneous and omental adipose tissue and obesity. clinical nutrition 2021;40:2278-84. 11. jiang n, yang m, han y, et al. prdm16 regulating adipocyte transformation and thermogenesis: a promising therapeutic target for obesity and diabetes. front pharmacol 2022;13:113. 12. fabbiano s, suárez-zamorano n, rigo d, et al. caloric restriction leads to browning of white adipose tissue through type 2 immune signaling. cell metab 2016;24:43446. 13. handayani d, kusumastuty i, innayah am, et al. substitution of local indonesian varieties of brown rice on anthropometry and blood glucose level improvement in type 2 dm patients: a pilot project. j public health res 2022;11:2283. 14. sulistyowati e, rudijanto a, soeharto s, handayani d. the identification of characteristic macro-and micronutrients and the bioactive components of indonesian local brown rice as a functional feed in obesity nutrition therapy. curr nutr food sci 2020;16:494–500. 15. matsumoto y, fujita s, yamagishi a, et al. brown rice inhibits development of nonalcoholic fatty liver disease in obese zucker (fa/fa) rats by increasing lipid oxidation via activation of retinoic acid synthesis. j nutrition dis 2021;151:2705-13. 16. francisqueti fv, ferron ajt, hasimoto fk, et al. gamma oryzanol treats obesity-induced kidney injuries by modulating the adiponectin receptor 2/ppar-α axis. oxid med cell longev 2018;2018:1278392. 17. francisqueti fv, minatel io, ferron ajt, et al. effect of gamma-oryzanol as therapeutic agent to prevent cardiorenal metabolic syndrome in animals submitted to high sugar-fat diet. nutrients 2017;9:1299. 18. shobana s, lakshmipriya n, bai mr, et al. even minimal polishing of an indian parboiled brown rice variety leads to increased glycemic responses. asia pac j clin nutr 2017;26:829-36. 19. handayani d, kusumastuty i, innayah am, et al. substitution of local indonesian varieties of brown rice on anthropometry and blood glucose level improvement in type 2 dm patients: a pilot project. j public health res 2021;11:2283. 20. permatasari di, sutjiati e, sulistyowati e. effect of brown rice intervention on bmi and waist circumference in patients with type 2 diabetes mellitus. indonesian j human nutr 2023;10:77-87. 21. barathikannan k, tyagi a, shan l, et al. antiobesity and antioxidative effect of fermented brown rice using in vitro with in vivo caenorhabditis elegans model. life 2023;13:1-14. 22. lim sm, goh ym, mohtarrudin n, loh sp. germinated brown rice ameliorates obesity in high-fat diet-induced obese rats. bmc complement altern med 2016;16:140. 23. chi j. unraveling the interaction between beige adipocytes and the sympathetic nervous system. new york: the rockefeller university; 2021. 24. mulya a, kirwan jp. brown and beige adipose tissue. endocrinol metab clin north am 2017;45:605-21. 25. fuster jj, ouchi n, gokce n, walsh k. obesity-induced changes in adipose tissue microenvironment and their impact on cardiovascular disease. circ res 2016;118:1786-807. 26. ziqubu k, dludla pv, mthembu sxh, et al. an insight into brown/beige adipose tissue whitening, a metabolic complication of obesity with a multifactorial origin. front endocrinol (lausanne) 2023;14:1114767. 27. weng x, sun m, gao h, et al. germinated brown rice, a whole grain with health benefits for common chronic diseases. nutrition food sci j 2019;2:119. 28. feige-diller j, krakenberg v, bierbaun l, et al. the effects of different feeding routines on welfare in laboratory mice. sec. animal behavior welfare 2020;6:1-15. 29. mishra bk, madhu sv, aslam m, et al. adipose tissue expression of ucp1 and prdm16 genes and their association with postprandial triglyceride metabolism and glucose intolerance. diabet res clin pract 2021;182:1-10. 4th international nursing and health sciences symposium [page 106] [healthcare in low-resource settings 2024;12(s1):13069] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13609 exploring health-seeking behaviour and healthcare utilization among the temiar orang asli (indigenous people) in kuala kangsar, malaysia amir zharif adenan,1 farha munira mohamed kamel,2 siti sara yaacob,1 khalid ibrahim1 1departmentof public health medicine, faculty of medicine, universiti teknologi mara, sungai buloh campus, selangor branch, jalan hospital, sungai buloh, selangor; 2department of family medicine, faculty of medicine, universiti kebangsaan malaysia, jalan yaacob latiff, cheras, kuala lumpur, malaysia abstract this study examines health-seeking behaviour and healthcare utilization among the temiar sub-tribe of the orang asli in kuala kangsar, malaysia, with a focus on health literacy and sociodemographic factors. a cross-sectional survey was conducted among 404 temiar adults using a structured questionnaire. of the participants, 50.7% preferred modern healthcare, while 42.3% reported using both modern and traditional treatments. multivariable logistic regression identified significant predictors of modern treatment preference, including chronic health conditions (aor=3.51; 95% ci: 2.02–6.10; p<0.001), suburban residence (aor=2.15; 95% ci: 1.27–3.65; p=0.005), and male gender (aor=0.37; 95% ci: 0.19– 0.74; p=0.005). in the linear regression model, older age (≥40 years) was associated with higher healthcare utilization (β=1.21; 95% ci: 0.84–1.58; p<0.001), while good health literacy was associated with fewer visits (β=−0.59; 95% ci: −1.01 to −0.16; p=0.01). despite ongoing government outreach, barriers such as low health literacy and geographic isolation persist. these findings highlight the need for culturally tailored health education and improved healthcare accessibility. introduction the orang asli, indigenous peoples of peninsular malaysia, are a marginalized minority with distinct cultural, social, and economic attributes. representing approximately 0.64% of malaysia’s population, they are divided into 18 sub-tribes within three main groups: negrito, senoi, and proto-malay.1,2 among them, the temiar sub-tribe of the senoi group, primarily residing in rural areas of perak, faces significant barriers to accessing healthcare due to geographic isolation and cultural differences.3 the temiar, like many indigenous groups, have a rich tradition of holistic health practices that are deeply intertwined with their cultural beliefs and social structures. the temiar’s health practices include traditional medicine and spiritual rituals, which play a crucial role in their understanding of health and illness. these practices often involve natural remedies and spiritual healing, leading to a preference for traditional methods over modern medical interventions.4,5 language barriers further complicate access to healthcare, as many temiar speak their native dialect, which is often not understood by healthcare providers.6 additionally, the community’s social structure, where health decisions are often made collectively, can delay the seeking of healthcare.6,7 low health literacy further compounds these challenges, restricting the temiar’s ability to navigate healthcare syscorrespondence: siti sara yaacob, department of public health medicine, faculty of medicine, universiti teknologi mara, sungai buloh campus, selangor branch, 47000 jalan hospital, sungai buloh, selangor, malaysia. tel.: +6012-9529444. e-mail: sitisara@uitm.edu.my key words: health-seeking behavior, healthcare utilization, indigenous health, health literacy. contributions: az contributed to the study design, literature review, and statistical analysis. fm led the manuscript drafting and editing, as well as the data review and interpretation. ss and ki provided comprehensive comments on the manuscript and assisted in the interpretation of the data. all the authors have read and approved the final version of the manuscript and agreed to be held accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. availability of data: the data presented in this study are available upon request from the corresponding author. ethics approval: ethical clearance and permission for this study were obtained from the malaysia national medical research and ethics committee (mrec) (nmrr id-23-01634-u35 (iir)), the universiti teknologi mara (uitm) research and ethics committee (rec/02/2024 (pg/fb/4)), and the department of orang asli development (jakoa). informed consent: all participants in this study were informed of the study’s purpose and provided written informed consent before participation. the confidentiality of the data was strictly maintained. acknowledgments: we express our deepest gratitude to the orang asli community in kuala kangsar, perak, for their participation and cooperation. special thanks to the district health office (pejabat kesihatan daerah) kuala kangsar and orang asli mobile healthcare team (pasukan bergerak orang asli) for their essential support in participant recruitment and field assistance, which made this research possible. received: 10 january 2025. accepted: 23 may 2025. early access: 4 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13609 doi:10.4081/hls.2025.13609 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 212] [healthcare in low-resource settings 2025;13:13609] tems effectively and leading to delayed health-seeking behaviour.7,8 these barriers exacerbate the existing health disparities by limiting access to essential healthcare services and preventive measures.9 this creates a cycle of unmet healthcare needs and poor health outcomes among the temiar. health-seeking behaviour among the orang asli is influenced by cultural beliefs, geographic isolation, and perceptions of healthcare services. for instance, ithnin et al. highlighted a reliance on both modern healthcare and traditional medicine among the temuan sub-tribe in negeri sembilan, reflecting broader cultural and accessibility challenges.7 however, such insights are limited in their applicability to sub-tribes like the temiar, whose distinct sociocultural context remains understudied. much of the available research on orang asli health-seeking behaviour is based on findings from sub-tribes such as the temuan and semai, while offering limited exploration of other sub-tribes like the temiar.7,17 although these studies provide important insights into tradition, accessibility, and healthcare perceptions, they do not adequately capture intra-group differences. the temiar, malaysia’s second-largest orang asli sub-tribe, remain underrepresented in health research despite their distinct linguistic, geographic, and cultural characteristics.4,16,17 despite the malaysian ministry of health’s initiatives, including specialized facilities, orang asli mobile healthcare team (pasukan bergerak orang asli, pboa), and the flying doctor service, the orang asli continue to face challenges such as poor healthcare access, low health literacy, and higher prevalence of non-communicable diseases (ncds), child malnutrition, and stunting compared to the national population.8,10–12 given these challenges, this study aims to examine the health-seeking behaviour and healthcare service utilization of the temiar sub-tribe of the orang asli in kuala kangsar, perak, using a survey-based cross-sectional design, focusing on the influence of health literacy and sociodemographic factors. materials and methods study design and setting the research was designed as a cross-sectional study aimed at assessing health-seeking behaviour and healthcare utilization among the orang asli communities, specifically focusing on the temiar sub-tribe in kuala kangsar, perak. the kuala kangsar district was chosen due to its significant temiar population, one of the largest orang asli sub-tribes in the region. it is home to 58 orang asli villages, many of which are located in rural, forested areas with challenging geographic access.1 the study population comprised adult orang asli individuals aged 18 years and older, belonging to the temiar sub-tribe, and residing in kuala kangsar, perak. sample size and sampling method the required sample size for this study was calculated using the formula 𝑛=𝑍2⋅𝑝⋅(1−𝑝)/𝑒2, where 𝑍 represents the z-value for a 95% confidence level (1.96), 𝑝 is the estimated proportion of orang asli prefer modern treatment (59.3%), and 𝑒 is the margin of error (5%). based on a population of 6,232 adult orang asli in kuala kangsar,1 the required sample size was determined to be 371 participants. due to the geographic dispersion and logistical constraints in accessing remote communities, a combination of convenience and snowball sampling was employed. while this approach enabled broader coverage across settlements, it may have introduced selection bias, particularly the overrepresentation of more accessible or socially connected individuals. to mitigate this, recruitment efforts were diversified across multiple locations such as kuala mu, bawong, yum, lasah, and perwor, spanning both deep rural and suburban areas, and local informants were engaged to ensure inclusion of harder-to-reach groups.. snowball sampling expanded the participant pool through referrals, ensuring broader representation of the temiar sub-tribe across the district. questionnaire instruments data were collected using a structured, self-administered questionnaire in malay, consisting of three main components. the first component captured sociodemographic characteristics (e.g., age, gender, education, income). and healthcare accessibility factors (e.g., transportation issues, distance to healthcare facilities). sociodemographic characteristics were analyzed for their influence on both health-seeking behaviour and healthcare utilization outcomes, while healthcare accessibility factors were specifically evaluated for their impact on healthcare utilization outcomes only and were not used in the analysis of health-seeking behaviour.7,13 the second component assessed health literacy using the validated health literacy short-form 12 (hl-sf12). this instrument evaluates general health literacy across three domains: healthcare, disease prevention, and health promotion. responses were rated on a 4-point likert scale ranging from «very difficult» to «very easy.» total scores were converted into a general health literacy index (gen-hl), which provides a unified score ranging from 0 to 50, with higher scores indicating better health literacy. scores were categorized into two levels: poor (≤33) and good (>34), based on the index score proposed by van duong et al. (2019). the hlsf12 is derived from the european health literacy questionnaire (hls-eu-q47) and has been validated for use in malaysia and other asian populations, demonstrating good reliability and validity.14 prior to the main study, a pilot test was conducted with 30 temiar adults to assess the clarity and comprehensibility of the instrument. the results of the pilot indicated that no wording modifications were necessary. as part of the full study, the hls-sf12 underwent psychometric validation within the temiar population. confirmatory factor analysis (cfa) demonstrated acceptable model fit (rmsea=0.08, gfi=0.94, cfi=0.94), and the tool showed good internal consistency for the general health literacy index (gen-hl), with a cronbach’s alpha of 0.87. the third component explored health-seeking behaviour and utilization. participants were asked about their treatment preferences and their choices of healthcare providers.7 additionally, healthcare utilization was assessed using participants self-reported the number of healthcare facility visits in the past year.15 the questions on health-seeking behaviour were adapted from a validated questionnaire, which demonstrated a cronbach’s α coefficient of 0.83.7 data collection procedure data collection was conducted from may 2024 to august 2024. trained health staff distributed self-administered paper questionnaires to participants and provided guidance to ensure independent completion. statistical analysis data were analysed using ibm spss (version 28). descriptive statistics were used to summarize participants’ sociodemographic characteristics, health literacy levels, treatment preferences, and healthcare utilization patterns. categorical variables were present article [healthcare in low-resource settings 2025;13:13609] [page 213] ed as frequencies and percentages, while continuous variables were reported as means with standard deviations. to examine factors associated with treatment preferences (modern versus traditional or both treatments), logistic regression analyses were conducted. simple logistic regression was used to estimate crude odds ratios (cor) and 95% confidence intervals (ci) for each independent variable. all independent variables were then entered simultaneously into a multiple logistic regression model to calculate adjusted odds ratios (aor), accounting for potential confounding. model fit was assessed using the hosmer–lemeshow goodness-offit test, and multicollinearity was evaluated using variance inflation factor (vif) values. healthcare utilization, defined as the number of healthcare facility visits in the past year, was treated as a continuous outcome variable and analyzed using linear regression. this method was selected to estimate the direction and strength of association between multiple predictors and the frequency of healthcare visits. simple linear regression was first conducted to examine unadjusted associations. all independent variables were subsequently included in the multiple linear regression model to determine adjusted beta coefficients (β) and 95% confidence intervals. assumptions of linearity, normality, homoscedasticity, and multicollinearity were checked and met. model fit was reported using r² and adjusted r². a p-value<0.05 was considered statistically significant. results socio-demographic characteristics and health literacy a total of 404 temiar orang asli adults participated in this study, with a mean age of 38.3 years (sd=13.0). the majority of participants were female (66.6%) and resided in rural areas (75.7%). most participants were married (84.1%), while 9.9% were single, and 6.0% were either widowed or divorced. regarding education, 41.3% of participants had completed primary school, 31.2% had secondary education, 26.5% had no formal education, and only 0.1% had attended university or college. participants reported a mean monthly income of rm 617.95 (sd=rm 630.59; malaysian ringgit). nearly half (44.8%) earned less than rm 500 per month, while 12.1% earned more than rm 1,000. regarding employment, 27.9% were self-employed, 46.5% were housewives, and 10.6% were unemployed. employees in government and private sector made up 2.2% and 12.6%, respectively. additionally, 29.9% of participants reported having at least one chronic health condition. in term of healthcare accessibility, only 41.8% of participants reported living near a healthcare facility and 31.4% of participants reported transportation issues. health literacy was notably poor, with 84.4% of participants demonstrating inadequate levels. this suggests substantial difficulty in accessing, understanding, appraising, and applying health information, which may hinder effective communication with healthcare providers, reduce informed decision-making, and contribute to delays in seeking appropriate care. only 15.6% demonstrated good health literacy. this high prevalence of inadequate health literacy may hinder effective communication with healthcare providers, reduce the likelihood of informed decision-making, and contribute to delays in seeking appropriate care. health-seeking behaviour and healthcare utilization the health-seeking behaviour and healthcare utilization characteristics are summarised in table 1. among the 404 participants, just over half (50.7%) preferred modern treatment, while 42.3% reported using both modern and traditional modalities, and only 6.9% relied solely on traditional medicine. government clinics were the most preferred modern healthcare facility (53.2%), followed by the orang asli mobile healthcare team (pasukan bergerak orang asli; pboa at 30.6%. the most commonly cited reasons for seeking modern treatment included communicable diseases (cds) (31.4%) and non-communicable diseases (ncds) (29.3%), which together accounted for over half of the treatment motivations. this reflects the burden of both infectious and chronic illnesses in the population. among traditional users, the majority consulted traditional healers or shamans (59.3%) and commonly used herbal remedies (40.7%) and blessed water (40.2%). in term of healthcare utilization, the average number of healthcare visits in the past year was 3.29 (sd=1.67), with most participants (53.2%) reporting 0 to 3 visits (table 1). factors influencing health-seeking behaviour (treatment choices) logistic regression was conducted to identify factors associated with participants’ preference for modern healthcare, with modern treatment set as the reference outcome. the results of the bivariate and multivariable analyses are presented in table 2. in the bivariate analysis, several factors were significantly associated with preference for modern healthcare. participants aged ≥40 years had higher odds of preferring modern treatment compared to those aged ≤39 years (cor=1.91; 95% ci: 1.28–2.85; p=0.002). male participants had significantly lower odds of choosing modern healthcare compared to females (cor=0.52; 95% ci: 0.34–0.79; p=0.002). participants with high education (secondary school/university/college) had lower odds of preferring modern care than participants with low education (cor=0.55; 95% ci: 0.36–0.84; p=0.006). participants with at least one chronic condition were significantly more likely to prefer modern care than those without chronic illness (cor=3.39; 95% ci: 2.14–5.36; p<0.001). although not significant, suburban residents had marginally higher odds of preferring modern care than rural residents (cor=1.57; 95% ci: 0.99–2.49; p=0.06). other variables, including marital status, income, employment status, and health literacy, were not significantly associated with treatment preference in the bivariate model. in the multivariable analysis, three factors remained independently associated with preference for modern treatment after adjusting for all covariates. male participants had significantly lower odds of preferring modern healthcare compared to females (aor=0.37; 95% ci: 0.19–0.74; p=0.005). suburban residents were more than twice as likely to choose modern treatment compared to those in rural areas (aor=2.15; 95% ci: 1.27–3.65; p=0.005). participants with at least one chronic condition had more than three times the odds of preferring modern care compared to those without (aor=3.51; 95% ci: 2.02–6.10; p<0.001). the association between age and treatment preference was no longer statistically significant after adjustment (aor=1.54; 95% ci: 0.89–2.64; p=0.12). factors influencing healthcare utilization simple and multiple linear regression analyses were conducted to examine factors associated with healthcare utilization, measured as the number of visits to healthcare facilities over the past year, as article [page 214] [healthcare in low-resource settings 2025;13:13609] shown in table 3. in the bivariate analysis, several variables showed significant associations. participants aged ≥40 years had a higher frequency of healthcare visits compared to those aged ≤39 years (β=1.21; 95% ci: 0.84 to 1.58; p<0.001). participants with good health literacy made fewer visits than those with poor health literacy (β=−0.59; 95% ci: −1.01 to −0.16; p=0.01). transportation difficulties were also associated with reduced healthcare utilization (β=−0.37; 95% ci: −0.72 to −0.02; p=0.04). other variables, including gender, marital status, education level, and income, were not significantly associated with healthcare utilization in the bivariate model. in the multivariable analysis, two factors remained significant after adjusting for all covariates. older adults (≥40 years) continued to report more frequent healthcare visits (β=1.21; 95% ci: 0.84 to 1.58; p<0.001), and participants with good health literacy continued to report fewer visits (β=−0.59; 95% ci: −1.01 to −0.16; p=0.01). the association between transportation issues and visit frequency was attenuated and no longer statistically significant in the adjusted model. no other variables were independently associated with healthcare utilization. discussion this study highlights key factors influencing health-seeking behaviour and healthcare utilization among the temiar orang asli in kuala kangsar, perak. despite proximity to modern infrastructure, most participants had low educational attainment, poor household income, and alarmingly poor health literacy, consistent with findings from other sub-tribes orang asli in perak, such as the semai orang asli in kampar and the lanoh orang asli in lenggong.17,18 these disparities remain stark when compared to other ethnic groups in malaysia, such as malays and chinese, who generally report higher education levels, better access to healthcare, and stronger engagement with preventive health services.10 while the majority of participants (50.7%) preferred modern healthcare, 42.3% continued to use both modern and traditional treatments. this dual preference reflects longstanding cultural beliefs in traditional healing, including the use of herbal remedies and consultations with traditional healers or shamans.4,5 this dual usage is consistent with patterns observed among the temuan subtribe in negeri sembilan, where traditional and modern healthcare article [healthcare in low-resource settings 2025;13:13609] [page 215] table 1. health-seeking behaviour and healthcare utilization of adult orang asli (temiar) in kuala kangsar, perak (n=404). variable frequency percentage choice of treatment modern treatment 119 50.7 both 171 42.3 alternative/traditional 28 6.9 prefer place for modern treatment (n=376) government clinic 200 53.2 orang asli mobile healthcare team (pboa) 115 30.6 government hospital 44 11.7 private clinic 14 3.7 pharmacy 3 0.8 reason to go for modern treatment (n=376) communicable diseases (cdcs) 118 31.4 non-communicable diseases (ncds) 110 29.3 pregnant 85 22.6 others 38 10.1 trauma 12 3.2 gastrointestinal problem 11 2.9 respiratory problem 2 0.5 prefer place for traditional treatment (n=199) traditional healer/shaman 118 59.3 traditional massage 20 10.1 islamic medicine 18 9.0 others 43 21.6 prefer traditional medicine (n=199) herbal remedies (akar kayu & herba) 81 40.7 blessed water (air penawar) 80 40.2 others 38 19.1 past year frequency of attendance to health facilities mean=3.29 (1.67) 0 to 3 times 215 53.2 4 to 6 times 185 45.8 income is reported in malaysian ringgit (rm). health comorbid refer to participants reporting at least one chronic health condition. are often used concurrently.7 similarly, indigenous communities across southeast asia display comparable patterns. for example, studies on the aeta communities in the philippines highlight a dual reliance on traditional and modern medicine shaped by cultural norms and access barriers.19 in indonesia, dayak indigenous communities in kalimantan continue to use traditional healing systems such as traditional healers and herbs, while also accessing modern health services when available.20 these parallels suggest that cultural and structural factors may play a more decisive role in shaping health-seeking behaviours among indigenous populations in the region than socioeconomic variables alone. while socioeconomic factors such as education and healthcare access contribute to improved health outcomes in malaysia’s general population,10,21 our findings suggest that these factors may be insufficient on their own in the indigenous orang asli context, where cultural beliefs and structural barriers remain dominant influences on healthcare decisions. chronic health conditions and suburban residence were positively associated with modern treatment preference, likely reflecting healthcare needs and improved physical access, consistent with findings from similar studies among orang asli.7,13,18 interestingly, males were significantly less likely to prefer modern care than females, possibly reflecting traditional gender roles, where women, often as caregivers, may have greater engagement with health-related decisions and exposure to health information.22 this suggests women in this community may be more proactive in health decision-making, particularly around family care.23,24 the non-significant associations between education, income, and employment status with treatment preference may reflect a relative socioeconomic homogeneity within the study population, as most participants had low-income levels and limited formal education. this lack of variability may have reduced the statistical power to detect meaningful associations. more importantly, these findings align with prior research suggesting that, in marginalized or rural communities, cultural health beliefs, perceived healthcare accessibility, and geographic barriers can outweigh traditional socioeconomic predictors in shaping health-seeking behaviour. as shown in studies among rural appalachian residents and women of mexican descent, healthcare decisions were more strongly influenced by cultural norms and spatial constraints than by income or education levels.25,26 in terms of healthcare utilization, older adults reported more frequent visits, which aligns with age-related health needs. those with good health literacy, however, visited healthcare facilities less often, possibly due to improved self-care and decision-making. this suggests that improving health literacy among the orang asli could empower individuals to make more appropriate healthcare decisions, potentially reducing unnecessary visits while ensuring timely care for serious conditions. this aligns with global studies showing that individuals with low health literacy tend to use article table 2. logistic regression analysis of factors influencing health-seeking behaviour (treatment choice). socio-demographic choice of treatmentc cor (95% ci) p aor (95% ci) p characteristics traditional/ both n (%) modern n (%) age ≤39 years 131 (56.0) 103 (44.0) ref. ref. ≥40 years 68 (40.0) 102 (60.0) 1.91 (1.28, 2.85) 0.002* 1.54 (0.89, 2.64) 0.12 gender female 118 (43.9) 151 (56.1) ref. ref. male 81 (60.0) 54 (40.0) 0.52 (0.34, 0.79) 0.002* 0.37 (0.19, 0.74) 0.005* residence type rural 159 (52.0) 147 (48.0) ref. ref. suburban 40 (40.8) 58 (59.2) 1.57 (0.99, 2.49) 0.06 2.15 (1.27, 3.65) 0.005* marital status not married 37 (57.8) 27 (42.2) ref. ref. married 162 (47.6) 178 (52.4) 1.51 (0.88, 2.58) 0.14 1.30 (0.72, 2.36) 0.39 educational level low education (no education/primary school) 122 (44.5) 152 (55.5) ref. ref. high education (secondary school/university/college) 77 (59.2) 53 (40.8) 0.55 (0.36, 0.84) 0.006* 0.61 (0.36, 1.03) 0.07 income below rm 500 87 (48.1) 94 (51.9) ref. ref. rm 500 rm 1000 80 (46.0) 94 (54.0) 1.09 (0.72, 1.65) 0.69 1.12 (0.69, 1.79) 0.64 above rm 1000 32 (65.3) 17 (34.7) 0.49 (0.26, 0.95) 0.03* 0.93 (0.43, 1.99) 0.84 work status employed 97 (56.1) 76 (43.9) ref. ref. not employed 102 (44.2) 129 (55.8) 1.61 (1.09, 2.40) 0.02* 1.04 (0.55, 1.97) 0.91 health comorbid no 164 (58.0) 119 (42.0) ref. ref. yes 35 (28.9) 86 (71.1) 3.39 (2.14, 5.36) <0.001* 3.51 (2.02, 6.10) <0.001* health literacy poor 169 (49.6) 172 (50.4) ref. ref. good 30 (47.6) 33 (52.4) 1.08 (0.63, 1.85) 0.78 1.52 (0.82, 2.82) 0.18 note: odds ratios represent likelihood of choosing modern treatment compared to traditional/both. cor, crude odds ratio, aor, adjusted odds ratio. p-values indicate statistical significance, with p < 0.05 marked by an asterisk (*). income is reported in malaysian ringgit (rm). health comorbid refer to participants reporting at least one chronic health condition. [page 216] [healthcare in low-resource settings 2025;13:13609 healthcare services more frequently, including emergency and unplanned visits, whereas those with higher health literacy demonstrate better self-management and more judicious use of healthcare resources.27,28 these findings highlight the need for culturally tailored health literacy interventions that not only increase understanding of health information but also build decision-making confidence and self-care capacity. specifically, community-based health education programs that are culturally sensitive, linguistically appropriate, and delivered by trained healthcare professionals or outreach teams could be particularly effective in improving the orang asli’s ability to navigate the healthcare system and empowering them to make informed health decisions. transportation issues, while significantly associated with healthcare utilization in the bivariate analysis, were not retained as a predictor in the multivariable model. this may indicate that other factors may have a more direct influence on healthcare utilization. regardless, addressing transportation issues, particularly in rural areas, remains crucial to improving access to healthcare for indigenous populations.25 this study also has limitations. the use of convenience and snowball sampling may limit generalizability. additionally, reliance on self-reported data may be subject to recall and social desirability bias. cultural factors may have influenced participants’ responses, especially around traditional healing practices, which could be underreported due to stigma or researcher presence. future studies should consider longitudinal designs to capture temporal changes in health-seeking behaviour and healthcare utilization among the orang asli. conclusions this study demonstrates that health literacy, cultural beliefs, and geographic factors significantly influence health-seeking behaviour and healthcare utilization among the temiar orang asli. article [healthcare in low-resource settings 2025;13:13609 [page 217] table 3. linear regression analysis of factors influencing healthcare utilization (number of healthcare visits over the past year). socio-demographic characteristics bivariate model multivariable model β (95% ci) p β (95% ci) p age ≤39 years ref. ref. ≥40 years 1.36 (1.06, 1.67) <0.001* 1.21 (0.84, 1.58) <0.001* gender female ref. ref. male 0.12 (-0.23, 0.46) 0.51 0.06 (-0.39, 0.52) 0.79 residence type rural ref. ref. suburban -0.15 (-0.53, 0.23) 0.43 0.23 (-0.13, 0.59) 0.22 marital status not married ref. ref. married 0.54 (0.09, 0.99) 0.02* 0.36 (-0.05, 0.77) 0.09 educational level low education ref. ref. (no education/primary school) high education -0.87 (-1.21, -0.53) <0.001* -0.16 (-0.52, 0.21) 0.39 (secondary school/university/college) income below rm 500 ref. ref. rm 500 rm 1000 -0.31 (-0.66, 0.04) 0.08 -0.12 (-0.44, 0.21) 0.48 above rm 1000 -0.54 (-1.06, -0.01) 0.04* -0.31 (-0.83, 0.21) 0.24 work status employed ref. ref. not employed 0.14 (-0.19, 0.47) 0.41 0.34 (-0.11, 0.78) 0.14 health comorbid no ref. ref. yes 0.93 (0.58, 1.27) <0.001* 0.21 (-0.18, 0.56) 0.26 health literacy poor ref. ref. good -0.96 (-1.40, -0.52) <0.001* -0.59 (-1.01, -0.16) 0.01* near to healthcare facility yes ref. ref. no -0.09 (-0.42, 0.25) 0.61 0.02 (-0.29, 0.34) 0.88 no transportation issues to healthcare facility yes ref. ref. no -0.37 (-0.72, -0.02) 0.04* -0.20 (-0.52, 0.12) 0.27 note: p-values indicate statistical significance, with p < 0.05 marked by an asterisk (*). β, unstandardized regression coefficient; ci, confidence interval. the model explained 22% of the variance in healthcare utilization (r² = 0.22, adjusted r² = 0.20). the analysis met assumptions for linearity, normality of residuals, and homoscedasticity. variance inflation factor (vif) values ranged from 1.05 to 2.28 indicating no significant multicollinearity concerns. f-change: 9.200, p<0.001. despite the growing use of modern healthcare, traditional practices persist, and poor health literacy remains a barrier to access. to reduce these disparities, policymakers should implement culturally tailored health education, expand mobile outreach services like the pboa, and engage trained community health workers from within orang asli communities. improving transportation and digital access in remote areas is also essential. a coordinated, culturally sensitive approach is key to advancing healthcare equity for indigenous populations in malaysia. references 1. jakoa. data terbuka sektor awam laman web rasmi jabatan kemajuan orang asli. jabatan kemajuan orang asli; 2021. cited 2023 jan 18. available from: https://www.jakoa.gov.my/umum/data-terbuka-sektor-awam/ 2. masron t, masami f, ismail n. orang asli in peninsular malaysia: population, spatial distribution and socio-economic condition. orang asli health 2013. cited 2023 jan 19. available from: https://www.orangaslihealth.org/uploads/ 1/3/3/2/133285311/oa_overview.pdf 3. syed hussain tpr, krishnasamy ds, hassan aag. distribution and demography of the orang asli in malaysia. int j humanit soc sci invent 2017;6:40-5. 4. saputra r, khotimah h. bridging to another dimension: the relational system of shamanism and religious encounter amongst the temiar senoi of malaya. j ilmiah ilmu ushuluddin 2021;20:72-6. 5. lokman a, simin h, hashim ss, et al. healing power: traditional herb remedies of the orang asli temiar in rps kuala betis. j ethnopharmacol 2020;250:112-20. 6. chew cc, lim xj, low ll, et al. the challenges in managing the growth of indigenous children in perak state, malaysia: a qualitative study. plos one 2022;17:e0265917. 7. ithnin m, nor um, juliana n, et al. health seeking behaviour among adult orang asli (indigenous peoples) from rural negeri sembilan, malaysia: a mixed-methods study. malays j public health med 2021;21:348-58. 8. wong y, allotey p, reidpath d. why we run when the doctor comes: orang asli responses to health systems in transition in malaysia. crit public health 2019;29:192-204. 9. valeggia cr, snodgrass jj. health of indigenous peoples. annu rev anthropol 2015;44:117-35. 10. ministry of health malaysia. annual report 2021. putrajaya: ministry of health malaysia; 2021. cited 2023 jan 19. available from: https://online.anyflip.com/pxevq/ ahwq/mobile/ 11. mahmud mh, baharudin um, md isa z. diseases among orang asli community in malaysia: a systematic review. bmc public health 2022;22:1-12. 12. rosman m, yong c, azman mu, ishar m. the health issue in orang asli community. int j acad res bus soc sci. 2020;5:3641. 13. ganesan d, hussain s, sreeramareddy ct. healthcare seeking behaviour for acute illnesses among adult aborigine communities (orang asli) in cameron highlands, malaysia: a house-tohouse survey. healthc low resour settings 2024;12:1-8. 14. duong tv, aringazina a, kayupova g, et al. development and validation of a new short-form health literacy instrument (hls-sf12) for the general public in six asian countries. health lit res pract 2019;3:e91-e102 . 15. roopani, dumka n, ahmad t, et al. health facility utilization and healthcare-seeking behaviour of the elderly population in india. j family med prim care 2023;12:902-16. 16. shah n. the orang asli profile in peninsular malaysia: background & challenges. int j acad res bus soc sci 2018;8:1-10. 17. hashim r, baharud-din z, idris ks, ustadi ya. assessing digital literacy among the semai tribe of perak, malaysia. in: 2011 3rd international conference on computer research and development. ieee; 2011. p. 9-12. 18. cheng yx, chong cp, kiew cf, bahari mb. an assessment of health and social-economic status among lanoh ethnic subgroup of orang asli (indigenous peoples) in air bah i village, state of perak, malaysia. j appl pharm sci 2014;4:32-7. 19. balilla vs, anwar mchenry j, mchenry mp, et al. the assimilation of western medicine into a semi-nomadic healthcare system: a case study of the indigenous aeta magbukún, philippines. ecohealth 2014;11:372-82. 20. neneng l, nawan n, naibaho fg, et al. botanical survey of ethnomedicines in dayak sub-ethnic groups, ot danum and tomum in central kalimantan, indonesia. biodiversitas j biol diver 2025;26:145. 21. khaw wf, chan ym, alias n, et al. socioeconomic status and health outcomes in malaysian adults: findings from the national health and morbidity survey (nhms). asia pacific j public health 2024;36:746-52. 22. othman c, lamin rac, farooqui m, sihab n. modernization and the life-style related diseases among orang asli at kuala boh, selangor malaysia. int j acad res bus soc sci 2017;2:37-43. 23. ridzuan mh, ali mf, tan ce, aziz aa. traditional and complementary medicine use during postpartum period: a crosssectional analysis at a rural, public maternal and child health clinic in west malaysia. cureus 2021;13:e12745. 24. ithnin m, nor na, juliana n, et al. knowledge, attitude and practices towards lifestyle-related non-communicable diseases: a cross-sectional study among indigenous orang asli adults in negeri sembilan, malaysia. iium med j malaysia 2020;19:137–46. 25. arcury ta, gesler wm, preisser js, et al. the effects of geography and spatial behaviour on health care utilization among the residents of a rural region. health services res 2005;40:135-56. 26. borrayo ea, jenkins sr. feeling frugal: socioeconomic status, acculturation, and cultural health beliefs among women of mexican descent. cultural diversity ethnic minority psychol 2003;9:197. 27. rasu rs, bawa wa, suminski r, et al. health literacy impact on national healthcare utilization and expenditure. int j health policy manag 2015;4:747-55. article [page 218] [healthcare in low-resource settings 2025;13:13609] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13562 reproductive health education to improve knowledge and attitudes among blind adolescents wiwin widayani,1,2 kurniaty ulfah,2 achmad hufad,1 viena rusmiati hasanah1 1faculty of education, universitas pendidikan indonesia, bandung; 2department of midwifery, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract blind adolescents face significant barriers to accessing reproductive health education, increasing their risk of misinformation and vulnerability to reproductive health issues such as sexually transmitted infections (stis) and sexual abuse. this study evaluates the effectiveness of braille modules in improving the knowledge and attitudes of blind adolescents toward reproductive health. this quasi-experimental study used a one-group pretestposttest design with a research and development (r&d) approach. it was conducted in two phases: developing and validating a braille module, followed by its implementation among 25 blind adolescents. the knowledge and attitude assessments were conducted using structured questionnaires. the shapiro-wilk test confirmed non-normal data distribution, and the wilcoxon signedrank test compared pre-test and post-test scores. the study found an increase in knowledge scores, with the minimum score rising from 0 (pre-test) to 25 (post-test) and the maximum score increasing from 75 to 85. the median knowledge score improved from 50.00 to 60.00, though not statistically significant (p = 0.09). for attitudes, the minimum score decreased from 30 to 28, whereas the maximum declined from 96 to 91, resulting in a small increase in the median attitude score from 81.50 to 82.00. this change was not statistically significant (p = 0.10). adolescents with blindness may have better knowledge and attitudes regarding reproductive health if they use braille modules. however, combining them with other teaching strategies or media could increase their efficacy. introduction health education is crucial for individual and community wellbeing. however, access remains limited for vulnerable populations, especially those with visual impairments.1 visual impairment due to illness, injury, or genetics significantly affects quality of life and social integration, limiting access to essential health information and services, including reproductive health education. adolescence, a critical developmental stage characterized by rapid changes, requires an understanding of reproductive health for well-being. unfortunately, the lack of access to visual learning materials exacerbates knowledge gaps, increasing the risk of unintended pregnancy, stis, and sexual violence.2–4 the scale of the issue is substantial, particularly in indonesia, where approximately 4 million individuals are estimated to have visual impairments, including adolescents.5–7 limited access to visual information makes it challenging for blind adolescents to understand reproductive health topics, often leading to misinformation and unsafe practices. barriers such as mobility restrictions, a lack of disability-friendly healthcare services, stigma, and inadequate family support further exacerbate this issue. these obstacles hinder access to essential reproductive health services, increasing the likelihood of reproductive health complications and social exclusion.8,9 several efforts have improved reproductive health education for adolescents, including the adolescent care health service (achs) and youth care services (ychs);10–12 however, significant gaps remain. for visually impaired adolescents, alternative resources such as audio recordings, braille materials, and guided instruction have been introduced but remain insufficient and inconsistently implemented.9,13 many visually impaired adolescorrespondence: wiwin widayani, faculty of education, universitas pendidikan indonesia, bandung, indonesia; department of midwifery, politeknik kesehatan kemenkes bandung, bandung, indonesia e-mail: wiwinwidayani22@upi.edu key words: blind adolescents; attitudes; braille module; knowledge; reproductive health. contributions: ww conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ku conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ah conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; vrh methodology, visualization, writing – review & editing; ss resources, investigation, and writing –review & editing. conflict of interest: the authors declare no competing of interest. ethics approval and consent to participate: the health research ethics commission of poltekkes kemenkes bandung has approved this study (number 49/kepk//ec/x/2024). respondents' signed consent was sought for primary data collection, with the assurance of anonymity and the option to withdraw at any moment. patient consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 31 december 2024. accepted: 11 march 2025. early access: 11 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13562 doi:10.4081/hls.2025.13562 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 108] [healthcare in low-resource settings 2025;13(s1):13562] cents lack access to comprehensive educational materials, whereas healthcare providers often have limited training in disabilityfriendly reproductive health education. additionally, stigma and discrimination prevent blind adolescents from seeking appropriate health information and services.14–16 to address these challenges, a thorough and innovative reproductive health education program tailored to visually impaired adolescents is needed. the lack of reliable information sources and the shame associated with accessing them exacerbates disparities in reproductive health education. despite equal rights to information and healthcare, barriers to access, social engagement, and mobility constraints create significant inequities.14,17,18 these limitations hinder their comprehensive understanding of reproductive health, increasing their vulnerability to unintended pregnancies, stis, and sexual violence. deficiency in knowledge and positive attitudes toward reproductive health adversely affect physical and mental well-being, reinforcing marginalization in education and healthcare.14,19 therefore, accessible learning materials and methodologies must be developed for blind adolescents, utilizing diverse media, such as braille, audio formats, and direct instruction. collaboration among healthcare providers, educators, and disability organizations is crucial for program success. addressing stigma and improving awareness among healthcare professionals and families are imperative.16,19 this study evaluated the efficacy of braille modules in enhancing the knowledge and attitudes of blind adolescents regarding reproductive and sexual health. the findings are expected to provide insights for more inclusive educational programs and inform improved policies for the reproductive health of visually impaired teenagers. materials and methods design study this study developed and evaluated the efficacy of a braille module to enhance the knowledge and attitudes of blind adolescents regarding reproductive and sexual health. a pre-experimental, one-group, pretest-posttest design was employed, incorporating a research and development (r&d) methodology. the module development process consisted of a needs analysis, design, expert validation, and preliminary testing. the module was tested in 25 special schools for visually impairments. students who had completed the pre-test received the module as an intervention, and their performance was subsequently assessed through a post-test. population and sample the study population comprised all slbn (sekolah luar biasa negeri) teenagers in bandung city and cimahi city. participants were teenagers from slbn a schools in these cities. based on the results of paired numerical tests, the minimum required sample size was determined to be 25 students.20 the sample size was calculated using cohen’s sample size formula for mean differences. n = ( zα + zβ ) s 2 x 1 x 2 information: n : sample size zα : standard deviation alpha (degree of significance 95% then zα = 1.96) zβ : beta standard deviation ( test power of the study 1β = 80% then zβ = 0.84) x 1 -x 2 : minimum mean difference considered significant = 42 s : combined standard deviation determined from the literature (kusuma and budiono, 2017) = 18.1 purposive sampling was employed in this study based on predefined inclusion and exclusion criteria. the inclusion criteria for the second phase of the study were as follows: adolescents aged 10 to 19 years who were enrolled in special needs schools, willing to participate in the entire research process, proficient in braille reading, able to read braille letters accurately, owned a cell phone, and had the ability to use the talkback program. the exclusion criteria included adolescents with hearing impairments or those with additional challenges such as intellectual disabilities or autism data collection through the completion of a knowledge and attitude questionnaire, the respondents’ knowledge and attitudes were gathered directly. to evaluate the validity and reliability of the measuring tool, a trial was conducted before the implementation of the questionnaire. the knowledge and attitude questionnaire was subjected to a validity test using the pearson’s product-moment correlation. the cronbach’s alpha reliability coefficient was employed in the instrument’s reliability test. this research was carried out in two phases: the initial phase of creating a braille module involved analyzing the needs and characteristics of the students, with material elements referencing earlier qualitative research.21 the outline, layout, comprehension assessment, and delivery format were considered when designing the program. following the preparation of the draft, material experts and media experts validated the module and made revisions based on their feedback. before the final revision, the visually challenged students completed a readability test, which produced a final module for public trials. students at a special school for the blind were put on public trial during the second round. before the experiment, an informed consent script was used to explain the research process, and consent was obtained individually using google forms, zoom, talkback, or screen reader software. respondents were assembled in a school classroom for the pre-test, and the enumerator provided a clear explanation of how to complete the knowledge and attitude questionnaire. the enumerator had previously undergone training on post-tests, research observations, and data collection methods. the respondents used a smartphone and talkback application to access the digital version of the questionnaire. after the pre-test, participants were given a braille instructional module with a reading guide for each segment. through the whatsapp group, participants were asked to report what they understood. the duration of instruction with the braille module was one week. a post-test was then administered once using a google form to evaluate how much knowledge and attitudes had changed following the intervention. ethical clearance this study was approved by the health research ethics commission of poltekkes kemenkes bandung (number 49/kepk//ec/x/2024). the respondents’ signed consent was sought for primary data collection, with the assurance of anonymity and the option to withdraw at any moment. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13562] [page 109] data analysis data analysis in this study included univariate and bivariate analyses. based on the normality test, the data obtained from the shapiro-wilk results in the pretest and post-test are not normally distributed; therefore, a nonparametric test was carried out using the median value. bivariable analysis was carried out to determine the differences in knowledge and attitudes before and after the education/information program using the wilcoxon test because the data were not normally distributed. results in this study, 25 respondents were obtained from slbn a pajajaran, bandung city, slbn citeureup, and cimahi city. respondent characteristics include age, gender and education level. univariate analysis table 1 shows that the majority of respondents were aged 17– 19 years (42%), female (67%), and with a high school education level (50%). knowledge and attitude scores of blind adolescents table 2 presents the distribution of knowledge and attitude scores before and after the intervention. the minimum knowledge score increased from 0 (pre-test) to 25 (post-test), indicating improvement after receiving education. the maximum knowledge score increased from 75 to 85. similarly, for attitude scores, the minimum score decreased slightly from 30 to 28, while the maximum score decreased from 96 to 91. bivariate analysis a bivariate analysis was conducted to examine the effect of education on knowledge and attitudes before and after the intervention. based on table 3, the respondent knowledge scores between the pretest and the post-test had an increase in the median value of 10.00, and the attitude score had an increase of 0.5 medians before and after the intervention, although statistically, there was no difference in knowledge and attitudes before and after the intervention with p> 0.05. table 3 presents the differences in the knowledge and attitude scores before and after the intervention. the median knowledge score increased from 50.00 ± 5.0 (pre-test) to 60.00±3.8 (post-test), while the median attitude score increased from 81.50±4.0 to 82.00±2.7. however, statistical analysis using the wilcoxon test indicated that these differences were not statistically significant, with p-values of 0.09 for knowledge and 0.10 for attitude, both exceeding the significance threshold of 0.05. discussion the findings indicate that reproductive health education positively impacts knowledge among blind adolescents, although attitude score changes were not statistically significant. most respondents were female (67%) and aged 17-19 years (42%), with half at high school level. these demographics provide a context for interpreting the results, as older adolescents and those with higher education may better understand and retain their health-related information. univariate analysis showed increased minimum and maximum knowledge scores after the intervention, suggesting that the program effectively enhanced the participants’ understanding of reproductive health. these findings align with research demonstrating a substantial knowledge increase from special education interventions for individuals with disabilities, including the blind. the comprehension of blind adolescents improves because of the techniques that facilitate information absorption.22,23 the trend of increasing knowledge scores among visually impaired teenagers suggests that providing reproductive health information through suitable media can enhance comprehension. however, the attitude scores showed a slight decrease in both the minimum and maximum values post-intervention. one explanation is that newly acquired knowledge may have led to cognitive dissonance, whereby participants reassessed their beliefs and attitudes toward reproductive health.24,25 this phenomenon has been observed in studies in which increased knowledge does not immediately translate into positive attitudinal changes. the findings showed no significant correlation between reproductive health education and blind adolescents’ knowledge, highlighting the complexity of influencing factors. this necessitates reassessing frameworks and methodologies that consider material accessibility, familial support, and social stigma. the ineffectiveness of formal education programs may stem from blind adolescents’ preference for alternative sources such as e-modules, internet resources, and talkback applications.26,27 addressing publication bias is crucial, as scientific progress depends on reporting both nonsignificant and significant findings. future research special issue pathways of change table 1. respondent characteristics. variables respondents percentage ( n = 24 ) (%) age (years) 10-14 7 29 15-16 7 29 17-19 11 42 gender man 10 33 woman 15 67 education elementary school 4 12 junior high school 9 38 high school 12 50 table 2. distribution of knowledge and attitude scores of blind adolescents. indicator knowledge attitude pre-test post-test pre-test post-test minimum 0 25 30 28 maximum 75 85 96 91 table 3. analysis of differences in knowledge of attitudes of blind adolescents before and after being given education. education median ± se p pre-test post test knowledge 50.00±5.0 60.00±3.8 0.09* attitude 81.50±4.0 82.00±2.7 0.10* wilcoxon test*. [page 110] [healthcare in low-resource settings 2025;13(s1):13562] should explore these results and refine the study design.28,29 despite the lack of correlation, education can positively impact blind adolescents’ reproductive health knowledge, as demonstrated by effective braille modules covering human anatomy, reproductive functions, rights, and sti prevention. accessibility-focused education enhances knowledge, reduces stigma, and fosters open discussions.30,31 studies confirm that tactile perception in braille aids knowledge acquisition, and specialized programs using braille and accessible formats effectively educate blind adolescents on puberty, menstruation, bodily changes, and hygiene.18,30,31 this study found that the increase in median attitude score of blind adolescents following the educational program was not statistically significant but suggested a favorable trend, indicating the potential of intervention in influencing adolescent attitudes. attitudes toward reproductive health are shaped by multiple factors, including information, experiences, culture, social influences, and learning processes, encompassing perceptions, assessments, and willingness to act, with the social environment playing a crucial role.32,33 the theory of behavior changes highlights that attitudes develop through learning involving experience, comprehension, and social interaction. a positive attitude toward reproductive health may enhance visually impaired adolescents’ awareness of critical issues, such as reproductive organ hygiene, personal boundaries, and preventing risky sexual behaviors. the increase in attitude scores may have been influenced by respondents’ motivation to seek additional knowledge through electronic media after the intervention,13,21,34–36 suggesting personal initiative and external resources shape adolescents’ attitudes. effective education requires accessible formats, such as audio, braille, and interactive discussions, as conventional text-based or visual methods may be inadequate. combining multiple media enhances behavioral outcomes.37 involving parents, educators, healthcare providers, and policymakers reinforces knowledge and fosters positive attitudes toward reproductive health.38–41 education programs should integrate accessible learning formats, leverage technology, and promote stakeholder collaboration to ensure effective reproductive health education for blind adolescents. this study had several limitations. the small sample size limited generalizability to visually impaired adolescents. only shortterm changes were measured, making it difficult to assess longterm impact. factors like prior knowledge, cultural beliefs, and parental influence, which may have affected effectiveness, were not considered. the study relied on braille module educational methods without incorporating interactive or experiential learning. future research should include larger samples, longer follow-up periods, and innovative methods to improve reproductive health education for blind adolescents. conclusions blind adolescents exhibited enhanced knowledge and attitudes following a reproductive and sexual health education intervention utilizing braille modules, although the results were not statistically significant. nonetheless, the rising trend indicates that braille modules may enhance the comprehension of visually impaired adolescents. the varied preferences for information access highlight the necessity for a more adaptable and technology-driven teaching methodology. additional research is advised to incorporate a larger sample size, prolong the intervention time, and employ a broader range of instructional methods and media to enhance the effectiveness and significance of the impact. references 1. sulistyorini y, fitriyah n. improving reproductive health knowledge and behavior of adolescents with hearing loss. southeast asian j trop med public health 2022;53:168–82. 2. rosalina t, apsari n. dukungan sosial bagi orang dengan disabilitas netra dalam pencapaian prestasi di sekolah luar biasa. pros penelit dan pengabdi kpd masy 2020;7:414. 3. rajini kc. visual rehabilitation. kerala j ophthalmol 2023;35:22. 4. etya’ale d. blindness and vision impairment. in raviglione mcb, tediosi f, villa s, casamitjana n, plasència a (eds.), global health essentials. springer nature; 2023. p. 209–13. 5. herlambang e, suteja m. perancangan fasilitas pembinaan dan rekreasi tunanetra dengan pendekatan indera. j sains, teknol urban, perancangan, arsit 2023;5:1765–78. 6. imran m. peningkatan pemberdayaan penyandang tunanetra melalui perancangan social media newsletter di yayasan sosial tunanetra. j komunitas j pengabdi kpd masy 2024;6:229–39. 7. mueck ao. reproductive health for global women. glob heal j 2021;5:63–5. 8. mansour n, sagheer da. adolescence age group. psyarxiv prepr 2024 jan; available from: https://osf.io/c3hdk_v1/download 9. carlos de oliveira j, almeida h, costa a, et al. sexuality and reproductive health in adolescence: an integrative review. j adv med med res 2024;36:128–34. 10. muthmainnah, nurmala i, siswantara p, et al. mixed methods: expectations versus facts on the implementation of adolescent care health service. indian j public heal res dev 2019;10:504–8. 11. nurmala i, siswantara p, rachmayanti rd, devi yp. implementation of adolescent health programs at public schools and religion-based schools in indonesia. j public health res 2021;10:1954. 12. siswantara p, rachmayanti rd, setiawati am. what influences youth decision on using “remaja sehat” application? malaysian j med heal sci 2021;17:12–6. 13. haryani h, said fm, syazana n. factors influencing blind adolescents’ reproductive health behaviors, in sukabumi. kne soc sci 2023;8:144-156. 14. qi w, li h, lian q, et al. knowledge level and access barriers related to sexual and reproductive health information among youth with disabilities in china: a cross-sectional study. reprod health 2023;20:84. 15. tukimin s, handayani d, alimin z, somad p. indonesia deaf and blind communication system (idbc-system). educ inf technol 2019;24:2017–33. 16. sabra h, elmegaly a, attia a, soliman sm. effect of health educational program for females blinded adolescents students regarding reproductive health. egypt j heal care 2019;10:117–32. 17. karimu aa. exploring the sexual and reproductive health issues of visually impaired women in ghana. reprod health matters 2017;25:128–33. 18. junita ra, sanjaya da, meriyani h, siada nb. edukasi kesehatan reproduksi di masa pubertas dengan menggunakan media unik bagi penyandang disabilitas sensorik netra. poltekita j pengabdi masy 2023;4:185–92. 19. banjo oo, oni to, kumolu tg, bankole a. sexual and reproductive health knowledge of in-school adolescents: a compar special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13562] [page 111] ative study of visually impaired and non-visually impaired students. eur j med heal sci 2023;5:34–41. 20. dahlan s. besar sampel dan cara pengambilan sampel dalam penelitian kedokteran dan kesehatan. 3rd ed. jakarta: salemba medika; 2015. 232 p. 21. ulfah k, widayani w, kebidanan bandung j, kemenkes bandung p. pengalaman remaja tunanetra tentang kesehatan reproduksi dan seksual: studi kualitatif. j ris kesehat poltekkes depkes bandung 2021;13:407–21. 22. kassa ta, luck t, bekele a, riedel-heller sg. sexual and reproductive health of young people with disability in ethiopia: a study on knowledge, attitude and practice: a crosssectional study. global health 2016;12:5. 23. shahbudin ns, jamil r. technology empowerment in disability employment: a bibliometric and systematic review. j enabling technol 2024;18:91-106. 24. richter t, ferraro fr. cognitive dissonance reduction in relation to grade point average, but not to intelligence. stud psychol (bratisl) 2015;57:115–9. 25. brady g. cognitive dissonance, iron triangle and rent seeking: sequester and the fiscal cliff. in: a handbook of alternative theories of public economics. edward elgar publishing ltd.; 2014. p. 400–12. 26. yuliasih nd, sari p, bestari ad, et al. does health education through videos and e-leaflet have a good influence on improving students’ reproductive health knowledge, attitudes, and practices? an intervention study in jatinangor, indonesia. adv med educ pract 2025;16:29-39. 27. awang a, farahana i, rani a, et al. enhancing earky baille instruction: a qualitative needs analysis for module development in preschool special education. int j educ psychol couns 2024;9:499–515. 28. perneger t, gayet-ageron a. evidence of lack of treatment efficacy derived from statistically nonsignificant results of randomized clinical trials. jama 2023;329:2050–6. 29. edelsbrunner pa, thurn c. improving the utility of non-significant results for educational research: a review and recommendations. educat res rev volume 2024;42:100590. 30. ali raes, aal emae. effect of health educational program for females blinded adolescents students regarding reproductive health. am j nurs sci 2015;4:1–8. 31. jablan b, sjeničić m. reproductive health of visually impaired women. teme. 2021;0(0):265–79. 32. czerwińska mj. the braille system – a stimulator or an inhibitor in the upbringing and inclusive education of students with visual impairments? wych w rodz 2023;30:279–306. 33. hoskin er, coyne mk, white mj, et al. effectiveness of technology for braille literacy education for children: a systematic review. disabil rehabil assist technol 2024;19:120–30. 34. chavan bs, ahmad w, arun p, et al. sexuality among adolescents and young adults with intellectual disability: knowledge, attitude, and practices. j psychosex health 2021;3:140-5. 35. fageeh hn, mansour ma, muyidi hm, et al. impact of verbal and braille text oral hygiene instructions on visually impaired individuals: a randomized clinical trial. world j dent 2020;11:439–45. 36. kim e, aquino kc. disability as diversity in higher education: policies and practices to enhance student success. routledge; 2017. pp. 1–244. 37. maulanti t, nurmala i. a systematic review of oral health educational media innovation for visually impaired children: which one brings the best impact of change? spec care dent 2021;41:442–52. 38. badu e, mensah i, gyamfi n, et al. knowledge and sources of accessing sexual and reproductive health information among visually impaired women in ghana. bmc res notes 2019;12:529. 39. setianti y, hafiar h, nugraha ar, damayanti t. communication on reproductive health education for students with intellectual disability [comunicación sobre educación en salud reproductiva para estudiantes con discapacidad intelectual]. opcion 2019;35:600–13. 40. dianti mr, nurmala i, sulistyorini l. influence of parental education on care patterns of children with attention deficit hyperactivity disorders in indonesia. afr j reprod health 2024;28:93–9. 41. alfitri r, kuntoro k, qomaruddin mb, indawati r, maulina r. exploring the impact of family support and its function on high-risk behaviour among adolescents in malang city, east java, indonesia: a cross sectional study. afr j reprod health 2024;28:74–80. special issue pathways of change [page 112] [healthcare in low-resource settings 2025;13(s1):13562] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13697 health education and interprofessional collaboration to improve maternal knowledge on stunting prevention dwi indah lestari,1 superzeki zaidatul fadilah,2 nurul arifah,2 abdul aziz azari,1 ishana balaputra1 1bachelor of nursing department, bhakti al qodiri school of health sciences, jember; 2faculty of nursing, university of jember, indonesia abstract stunting is characterized by growth failure due to chronic malnutrition. a health education initiative utilizing an interprofessional collaboration approach is needed to decrease incidents of stunting. this study aimed to analyze the impact of health education with interprofessional collaboration on mothers’ knowledge about stunting. it used a quasi-experimental design with a pretestposttest control design. the research was conducted at a public health center, involving 230 mothers with children aged 0-24 months. data analysis was performed using the wilcoxon test. according to the findings, the majority of mothers lacked knowledge before the ipc intervention, accounting for 83.5%. however, this improved significantly afterward, with 70.4% demonstrating good knowledge. statistical analysis revealed a significant increase in maternal knowledge (p=0.000). the ipc program positively influenced maternal knowledge about stunting. it is hoped that policymakers will collaborate with health workers through ipc programs to reduce the prevalence of stunting. introduction stunting remains a significant global health issue due to chronic undernutrition.1,2 it is associated with poor maternal health and nutrition, poor socioeconomic conditions, frequent illnesses, and inappropriate child feeding in early life.2 stunting is estimated to affect 155 million toddlers worldwide. children who experience stunting face a higher risk of mortality and suffer from impaired cognitive, verbal, and physical abilities, placing a greater financial burden on their parents due to higher care costs.3 stunting is a critical indicator among the various factors that influence a child’s growth and development.4 the early years of life, particularly from birth to 2 years old, are crucial, as stunting can negatively impact a child’s physical and cognitive development as they grow older.5-7 the consequences of stunting are both short and long-term, leading to increased morbidity and mortality, poor child development and learning capacity, higher risk of infection and non-communicable diseases in adulthood, and reduced productivity and economic potential.8,9 according to the world health organization (who), the global prevalence of stunting in 2022 reached 149 million children under the age of 5.10 in indonesia, the prevalence of stunting has increased significantly from 28.5% in 2017 to 30.8% in 2018.11 according to the 2022 indonesian nutritional status survey (ssgi), east java had the highest stunting prevalence among all provinces in indonesia, with a rate of 34.9%.12 nationally, the overall stunting rate was 21.6%. within east java, jember regency reported a stunting prevalence of 19.6%. appropriate prevention and intervention are essential and should involve multiple sectors and disciplines.13 indonesia has implemented national strategies to reduce stunting by accelerating the learning process and improving mechanisms for sharing knowledge and innovation.7 the who also emphasizes the importance of various stakeholders in preventing and addressing stunting. effective prevention and management of stunting requires interprofessional collaboration and coordination among multiple disciplines.8 stunting is a complex issue that impacts many aspects of health.14 the responsibility for preventing and managing stunting can be shared across various professions through interprofessional collaboration (ipc).15 the ipc correspondence: dwi indah lestari, bachelor of nursing department, bhakti al qodiri school of health sciences, jember, indonesia e-mail: dwiindah343@gmail.com key words: children, health education, interprofessional education, stunting. contributions: dil, szf, conceptualization, data curation, formal analysis, study design, validation, visualization, writing – original draft, review & editing; na, aaa, ib, data analysis, supervision, draft. all authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors have no conflict of interest to declare. ethics approval and consent to participate: this research was conducted after obtaining ethical approval from the kepk of the faculty of health sciences, muhammadiyah university jember, on 19th july 2024 (approval number 0196/kepk/fikes/xii/2024). all respondents provided informed consent before the study. consent for publication: written informed consent for the publication of anonymized patient information was obtained from each participant. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was funded by the ministry of education, culture, research, and technology of indonesia, under the pdp scheme. acknowledgments: we thank the ministry of education, culture, research, and technology for providing us with the opportunity to qualify for the pdp scheme. we also extend our gratitude to the organizations that supported us in recruiting participants and disseminating the survey for this study. received: 4 february 2025. accepted: 14 april 2025. early view: 26 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13697 doi:10.4081/hls.2025.13697 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 130] [healthcare in low-resource settings 2025;13(s2):13697] approach to lowering the risk of stunting emphasizes knowledge sharing and health education promotion.16 it is considered a potential solution to help reduce stunting in toddlers while also encouraging relevant agencies and institutions to provide maximum support.16,17 previous research has demonstrated that cross-sector collaboration decreases stunting rates. a moderate increase in toddler height and knowledge was observed among mothers who participated in nutrition classes using the ipc approach.17,18 ipc can provide significant benefits to team members, allowing them to achieve better results than they would individually.16,19 collaborative teamwork is essential for healthcare providers, as it can reduce workload and enhance job performance satisfaction.20 ipc enhances knowledge, attitudes, and behaviors related to nutrition among mothers and their stunted toddlers.21 research on stunting prevention has been conducted worldwide, focusing not only on nutritional issues but also on supporting factors, such as parenting patterns, socioeconomic status, education, and sanitation.22-25 a critical factor closely associated with stunting is the influence of policymakers in a specific area.9 policymakers can implement direct interventions to effectively address stunting. therefore, collaboration through health education with interprofessional collaboration (hei collab) is aligned with the government’s efforts. this study aimed to analyze the effect of the hei collab on mothers’ knowledge of stunting in toddlers. the hei collab program involves a collaborative health team that includes nurses, midwives, nutritionists, pharmacists, and sanitarians. materials and methods study design this study employed a quasi-experimental research design featuring a pretest-posttest control group methodology. this approach allows for the comparison of outcomes between the treatment and control groups before and after the intervention. sample this study was conducted at a public health center with a population of 383 stunted toddlers. we employed a stratified random sampling technique, which involved selecting samples based on specific strata within the population, according to the inclusion and exclusion criteria. the final sample consisted of 230 respondents, with 115 assigned to the intervention group and 115 assigned to the control group. the inclusion criteria for this study were as follows: i) mothers with children aged 0-24 months; ii) complete respondent data; and iii) willingness to participate. children were excluded from the study if they had any pathological conditions such as down syndrome, marfan syndrome, bone disorders, or turner syndrome. instruments and data collection this study employed the stunting-related knowledge questionnaire, which consists of 10 questions that have been validated and proven reliable to assess the level of knowledge of respondents.26 the questionnaire focused on mothers’ understanding of stunting prevention, covering topics such as the definition of stunting, its causes, risk factors, signs and symptoms, impacts, and prevention strategies. scores were assigned based on the following responses: a correct answer received a score of 1, whereas an incorrect answer received a score of 0. the assessment results were categorized as follows: “good” for scores of 76-100% (score 8-10), “fair” for scores of 56-75% (score 7), and “poor” for scores below 55% (score <6). the experimental group participated in an ipc program, which involved a multidisciplinary team comprising nurses, midwives, nutritionists, and sanitarians. this program consisted of three meetings: the first focused on assessing the participants’ initial knowledge, the second on delivering educational con pathways of change, part ii table 1. characteristics of respondents. respondent’s characteristic category intervention group control group n % n % mother’s age 17-25 years 17 14.8 3 2.6 26-35 years 77 67 96 83.5 36-45 years 21 18.3 16 13.9 toddler’s age 0-6 months 3 2.6 0 0 7-11 months 18 15.7 33 28.7 12-23 months 42 36.5 39 33.9 24-59 months 52 45.2 43 37.4 number of children 1-2 89 77.4 92 80 >2 26 22.6 23 20 education elementary school 45 39.1 52 45.2 junior high school 17 14.8 18 15.7 senior high school 48 41.7 40 34.8 vocation degree 2 1.7 1 0.9 bachelor’s degree 3 2.6 4 3.5 occupation housewives 93 80.9 94 81.7 farmer 13 11.3 11 9.6 merchant 5 4.3 4 3.5 entrepreneur 3 2.6 4 3.5 teacher 1 0.9 2 1.7 ethnic madurese 70 60.9 71 61.7 javanese 45 39.1 44 38.3 religion islam 115 100 115 100 [healthcare in low-resource settings 2025;13(s2):13697] [page 131] tent, and the third on evaluating the outcomes of the education. during the meetings, the nurses provided information on parenting and nutrition for children, while midwives discussed topics related to child growth and development as well as proper nutrition for mothers and children. sanitation experts educated the participants about environmental sanitation practices to prevent stunting. in contrast, the control group did not receive the ipc program and continued their usual activities. data analysis the collected data were analyzed using the wilcoxon test. data coding, collection, cleaning, editing, tabulation, and analysis were performed using spss version 25.0. prior to data analysis, the kolmogorov-smirnov test was conducted to assess the distribution of data in each group. ethical clearance this study was conducted after obtaining ethical approval from the kepk of the faculty of health sciences, muhammadiyah university, jember, on july 19, 2024 (no. 0196/kepk/fikes/xii/2024). written informed consent was obtained from each participant prior to the study. results in the intervention group, the majority of respondents were aged 26-35 years (67%), housewives (80.9%), madurese (60.9%), and muslim (100%). the respondents’ education level was primarily senior high school at 41.7%, and they had children under five years old (45.2%). the majority had 1-2 children (77.4%). in the control group, most of the respondents were aged 26-35 (83.5%). most mothers had children under 5 years of age (37.4%), with the majority having 1-2 children (80%). the education level in the control group was mostly elementary school (45.2%), and the participants were housewives (81.7%), madurese (61.7%), and muslims (100%) (table 1). as shown in table 2, the majority of mothers in the intervention group had poor knowledge before the ipc intervention (83.5%), which improved significantly afterward, with 70.4% demonstrating good knowledge. in contrast, most mothers in the control group, who received only leaflets, had less knowledge before the intervention (77.7%). after the intervention, 71 respondents (61.4%) were categorized as having a low level of knowledge, while 37 (32.2%) had a moderate level of knowledge. statistical analysis revealed a significant increase in maternal knowledge from pretest to posttest, with a p-value of 0.000. discussion this finding demonstrated that ipc intervention had a positive impact on maternal knowledge about stunting. this aligns with previous research showing that the effectiveness of ipc in reducing community stunting rates is supported by collaborative techniques, including each professional’s ability to understand both individual and team roles, share knowledge, and promote preventive behaviors, particularly among families during the crucial first 1,000 days of a child’s life.27,28 ipc in stunting prevention programs involves the active participation of nurses, doctors, midwives, nutritionists, and sanitarians. therefore, implementing the right strategies is essential to enhance the knowledge, attitudes, and behaviors of mothers with toddlers in efforts to prevent stunting. research suggests that this collaborative approach can serve as the most effective model to reduce stunting cases in the community and represents one of the most impactful efforts in preventing stunting.21,29-32 midwives play a crucial role in preventing stunting, beginning from the first 1,000 days of life. they are actively involved both upstream, by safeguarding the health of prospective brides, pregnant women, and postpartum mothers, and downstream, by supporting the growth and development of toddlers.33,34 based on the study results, the role of midwives in preventing stunting involves providing information, encouragement, facilities, and empowering women to actively address the issue of stunting in their children.35 other roles of the midwife profession in preventing stunting are related to reproductive health education in schools, healthy marriage education, providing blood tablets for adolescents, implementing standard antenatal care interventions, providing additional food for pregnant women with chronic energy deficiency (ced), and scheduling special visits for ced.36 nurses also played an active role in preventing stunting. the results of the review from a previous study showed that nurses act as supportive educators, including nutrition educators, health service providers with improved nutrition, family supporters, and facilitators of interprofessional collaboration in preventing stunting.37 this finding is in line with the results of this study, which stated that nurses play a role as educators and community motivators in families with stunted children.38,39 according to the who, environmental sanitation involves efforts to control all aspects of the human physical environment and can impact physical development, health, and human endurance. sanitation is an overlooked aspect of life, even though it can be a source of diseases.40 improper sanitation can contribute to infections, and infectious diseases in infants can result from lack of access to clean water sources and poor sanitation facilities. this causes the energy required for growth to be diverted to fight infection, disrupting the process of nutrient absorption and leading to pathways of change, part ii table 2. knowledge level of intervention and control groups. category intervention groupcontrol group pretest posttest pretest posttest n % n % n % n % good knowledge 5 4.3 81 70.4 10 9.1 7 6.1 fair knowledge 14 12.2 31 27 16 13.2 37 32.2 poor knowledge 96 83.5 3 2.6 89 77.7 71 61.7 total 115 100 115 100 115 100 115 100 wilcoxon signed-rank test p=0.000 p=0.000 [page 132] [healthcare in low-resource settings 2025;13(s2):13697] stunted growth.41,42 research conducted in developing countries has shown that poor sanitation facilities and contaminated drinking water are often combined, leading to stunting. children’s health must be prioritized from an early stage, particularly during the “window of opportunity”, also known as the golden period of child development, which spans from conception through the first two years of life, or the first 1,000 days.43 nutritional fulfillment must be considered during pregnancy because it requires more essential nutrients.44 in addition to meeting the mother’s own needs, nutrition during pregnancy is also needed for the growth and development of the fetus in her womb. growth disorders in the womb can cause low birth weight, which increases the risk of stunting.45,46 research on children aged 3-24 months with low birth weight and low maternal body mass index shows a high risk of stunting. besides the pregnancy process, providing complementary feeding is crucial for preventing stunting. complementary feeding is the transition from an initial intake of only breast milk to semi-solid foods. complementary feeding should be introduced after the baby is 6 months old in stages, considering the time and type of food, to meet their energy need.47 therefore, providing breast milk and complementary feeding has a critical impact on stunting.44,48 conclusions implementing interprofessional collaboration interventions has been shown to positively impact maternal knowledge of stunting. practical stunting prevention and intervention efforts require collaboration across various sectors and interdisciplinary fields. ipc involves the participation of various professionals, including midwives, nurses, hygienists, and nutritionists, who work together to deliver comprehensive care. policymakers can use the ipc approach to develop health promotion programs that integrate multiple disciplines, ultimately enhancing maternal knowledge and contributing to the prevention of stunting in children. references 1. has emm, krisnana i, efendi f. enhancing maternal caregiving capabilities model to prevent childhood stunting: a unicef-inspired model. sage open nurs 2024;10:237796 08231226060. 2. surani e, susilowati e. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. jurnal ners 2020;15:26-30. 3. noviana u, devy sr, indriani d, yasin z. determining factors affecting mother’s behaviour in stunting prevention in rural madura, indonesia. afr j 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stunting in indonesia drops from 24.4% to 21.6%]. sehat negeriku. 2023. available from: https://kemkes.go.id/id/prevalensi-stunting-di-indonesiaturun-ke-216-dari-244 15. manalu lo, melaniani s, efendi f. research trends in increasing cadre capacity in efforts to reduce stunting in indonesia: a review. afr j reprod health 2024;28:368-75. 16. regita sg, sulistyaningsih s. interprofessional collaboration practices in stunting management during covid-19 pandemic: a scoping review. women midwives midwifery 2022;2:64-74. 17. sulistyaningsih s, aprillia r, annisa l, febrianti cp. the effectiveness of interprofessional collaboration practice to reduce the risk of stunting: an integrative review. jurnal aisyah: jurnal ilmu kesehatan 2023;8. 18. astuti ab, mulyanti s. the effectiveness of the interprofessional collaboration (ipc) program on the attitude of mothers and health cadres on stunting at puskesmas karanganom klaten central java republic of indonesia. electron j gen med 2021;18. 19. riyadi aank, agustikawati n, yuliastuti lp, setianingsih f. efektivitas penanggulangan stunting melalui pendampingan kelas gizi dengan pendekatan interprofesional collaboration (ipc) [effectiveness of stunting prevention through nutrition class mentoring with an interprofessional collaboration (ipc) approach]. jurnal ilmu kesehatan masyarakat 2023;12:296303. 20. fauziah fatah v, ariyanti m, susanti s. “generation z prevent stunting” early stunting prevention movement through education for adolescents in bandung. proceeding of the 4 th international conference on interprofessional health collaboration and community empowerment. 2021;249–52. available from: https://conference.juriskes.com/index.php/ic/article/view/164 /116 21. utami s, susilaningrum r, taufiqurrahman, nursalam. analisis factor situasional tentang ipc (interprofesional collaboration) terhadap penanganan stunting pada anak pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13697] [page 133] [factors associated with interprofessional collaboration for handling stunting in children]. j glob pharma technol 2019;11:262-7. 22. mulyanti s, astuti ab. upaya penurunan risiko stunting melalui pendekatan interproffesional collaboration (ipc) [efforts to reduce stunting risk through the interprofessional collaboration (ipc) approach]. jkg 2020;5:64-73. 23. umar e, darajat a. factors affecting the management of stunting in banten province. kne life sci 2022;2022:380-93. 24. alligood m. nursing theorist and their work. 8th ed. alligood m, editor. usa: elsevier.inc; 2014. 25. yunitasari e, pradanie r, arifin h, et al. determinants of stunting prevention among mothers with children aged 6–24 months. open access maced j med sci 2021;9:378-84. 26. laksono ad, muis ew, wulandari rd. policy to reduce under two stunting in east java region, indonesia: who is the right target? indones j public health 2024;19:263-75. 27. estiwidani d, hernayanti mr. interprofessional collaborative practice is an effort to increase behavior prevention of stunting in families with the first 1000 days of life. jurnal kesehatan ibu dan anak 2022;15:148-56. 28. susilaningrum r, utami s, taufiqurrahman t, nursalam n. development of interprofessional collaboration model to manage stunting in toddler. int j psychosoc rehabil 2020;24:7494502. 29. utami s, susilaningrum r. factors associated with interprofessional collaboration for handling stunting in children. j glob pharma technol 2019;11:262-7. 30. hafid f, adhyanti a, cahyani ye, et al. program pendampingan keluarga anak baduta stunting: implementasi interprofesional collaboration (ipc) di desa beka, marawola, kabupaten sigi: family assistance program for stunted children: implementation of interprofessional collaboration (ipc) in beka v. jurnal pengabdian masyarakat: svasta harena 2024;3:44-50. 31. mar’ah has em, sabela a, qona’ah a, et al. maternal caregiving capabilities are associated with energy-protein adequacy of children with stunting in central java, indonesia. curr res nutr food sci 2024;12:157-65. 32. fristiwi p, nugraheni sa, kartini a. effectiveness of stunting prevention programs in indonesia: a systematic review. jurnal penelitian pendidikan ipa 2023;9:1262-73. 33. sormin rem. peran bidan desa dalampencegahan stuntingpada puskesmas di kabupaten timor tengah selatan [the role of village midwives in stunting prevention at community health centers in timor tengah selatan district]. jurnal administrasi dan demokrasi 2023;2:70-5. 34. maulina r, qomaruddin mb, prasetyo b, indawati r. maternal complications during pregnancy and risk factors for stunting. iran j nurs midwifery res 2024;29:309-13. 35. andini uh. hubungan peran bidan terhadap strategi pencegahan stunting di wilayah puskesmas kedungrejo banyuwangi [the relationship between the role of midwives and stunting prevention strategies in the kedungrejo banyuwangi community health center area]. jurnal ilmiah obsgin 2023;15:436-44. 36. mustari, risnah, irwan m, arafah s. interprofessional collaboration dalam upaya pencegahan stunting di pelayanan kesehatan [interprofessional collaboration in effort prevention of stunting in health services]. jurnal kolaboratif sains 2023;6:942-9. 37. hanifah qa, pasune d, runtunuwu ks. starategi pencegahan stunting dengan mengoptimalkan perawat : studi literatur [stunting prevention strategies by optimizing nurses: a literature study]. al-asalmiya 2023;12:64-73. 38. nengsih na, sudirman rm, khamaludin k. peran perawat educator dan motivator pada balita stunting di kabupaten kuningan tahun 2023 [the role of nurses as educators and motivators for stunted toddlers in kuningan regency in 2023]. national nursing conference 2023;1:138-50. 39. rachmawati pd, triharini m, suciningtyas pd. the contribution of family functions, knowledge and attitudes in children under five with stunting. enfermeria clinica 2021;31:s296300. 40. salsabila n. faktor-faktor yang berhubungan dengan sanitasi pasar raya padang tahun 2023 [factors related to sanitation at pasar raya padang in 2023]. andalas university; 2023. 41. adzura m, yulia y, fathmawati f. hubungan sanitasi, air bersih dan mencuci tangan dengan kejadian stunting pada balita di indonesia [the relationship between sanitation, clean water, and handwashing with stunting incidence in toddlers in indonesia]. media komunikasi sivitas akademika dan masyarakat 2021;21:79-89. 42. samsuddin na, isaura er, sumarmi s. relationship of former history of diarrhea and sanitation with the prevalence of stunting among children aged 1–5 years in sidotopo wetan, surabaya. media gizi indonesia 2021;16:248-55. 43. putri nm, oktavira ai, putri st. peran zat gizi untuk mencegah terjadinya stunting pada anak [the role of nutrients in preventing stunting in children]. prosiding seminar nasional biologi 2022;2:849-54. 44. masriadi, mahmud nu, javid n, et al. increased incidents of stunting in majene district west sulawesi. indones j public health 2024;19:211-25. 45. rikayoni r, rahmi d. hubungan status gizi ibu selama hamil dengan kejadian stunting pada bayi usia 0-36 bulan di wilayah kerja puskesmas sijunjung tahun 2022 [the relationship between maternal nutritional status during pregnancy and stunting incidence in infants aged 0–36 months in the sijunjung community health center work area in 2022]. menara ilmu 2023;17:97-106. 46. putri pm, shafira as, mahardhika gs. stunting reduction strategy in indonesia: maternal knowledge aspects. indones j public health 2024;19:329-43. 47. ruslianti d. gizi dan kesehatan anak prasekolah [nutrition and health of preschool children]. jakarta: pt remaja rosdikarya; 2015. available from: https://perpustakaan.jakarta.go.id/book/detail?cn=inlis000000000795078 48. widyastutik o, pratiwi y, abrori, ratna. lactation management against nutritional status in infant in sungai raya dalam primary healthcare center, kubu raya regency, west kalimantan. ijph 2021;16:156-65. pathways of change, part ii [page 134] [healthcare in low-resource settings 2025;13(s2):13697] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13035 analysis of diarrhea incidence based on demographic characteristics and hygiene behavior of adults in indonesia and taiwan firdaus, rahmadaniar aditya putri, siti damawiyah, faridah umamah, difran nobel bistara department of midwifery, faculty of nursing and midwifery, nahdlatul ulama university surabaya, east java, indonesia abstract diarrhea is a common manifestation of gastroenteritis, affecting both children and adults globally. subsequently, gastroenteritis is particularly prevalent in developing countries such as indonesia and taiwan. this research aimed to analyze the incidence of diarrhea based on socio-demographics and personal hygiene in indonesia and taiwan. the method used in this research was a quantitative design with a cross-sectional approach, and the data collection involved interviews with adults, using a structured questionnaire. the primary goal of the analysis was to examine the bivariate relationships between each variable and the incidence of diarrhea, and the logistic regression test was applied for the multivariate test. a result from taiwan respondents, the statistical tests showed significant relationships with age with a p-value of 0.009, education with a p-value =0.010, and personal hygiene with a pvalue =0.010. factors that influenced diarrhea in indonesia were education with a p-value =0.038 and income with a p-value =0.08. in summary, several socio-demographics and personal hygiene practices played a significant role in the incidence of diarrhea. the differences in results obtained from taiwan and indonesia were attributed to differing respondent characteristics, emphasizing the importance of promoting clean and healthy behaviors, including handwashing with soap before eating and maintaining a clean environment, as effective measures to prevent diarrhea. introduction adult period includes diverse biological and psychosocial changes. however, diarrhea is a manifestation of gastroenteritis, which is prevalent in both children and adults globally and can be triggered by poor hygiene behavior in teenagers.1 gastroenteritis is a condition where the feces resulting from defecation have a liquid or semi-liquid consistency, and contain more air than feces. apart from its consistency, it can be accompanied by nausea, vomiting, and increased defecation frequency exceeding three times a day.2,3 gastroenteritis is more prevalent in developing countries compared to developed countries where the level of hygiene and sanitation is better.4-6 according to data from the world health organization (who) and unicef, 1.87 million people die globally due to cases of gastroenteritis every year. 6 globally, it is estimated that there are about 179,000,000 incidents of acute gastroenteritis in adults every year with some patients being hospitalized as many as 500,000 and more than 5000 patients dying.7,8 in america, at least 8,000,000 acute gastroenteritis patients are treated by doctors and more than 250,000 patients are hospitalized according to data from the american journal of gastroenterology.9 meanwhile, developing countries such as indonesia and taiwan are at risk of experiencing diarrhea. numerous factors influence incidence of diarrhea in adults, contributing to its increase and prevalence. diarrhea in adults can be caused by various factors, such as infection, food intolerance, or diseases of the digestive tract, and therefore, proactive efforts should be made to prevent its incidence.10-12 this research provides additional literature regarding the pooled prevalence of diarrhea prevention in adults. additionally, it can add to the literature regarding the pooled prevalence of diarrhea prevention in adolescents. observing the phenomenon of the increased incidence of diarrhea, proactive prevention efforts are needed to mitigate its impact. following this, maintaining good hygiene, such as washing hands properly, cooking food properly, and avoiding consumption of potentially contaminated water or food, are effective measures to prevent diarrhea.13 materials and methods this research was carried out using an observational analytical method with a cross-sectional method, from may june 2021 in surabaya, and continued in august within the pcinu taiwan working area. the eligibility criteria established for the study are as follows: 1) inclusion criteria: adults who are in good physical condition and possess the ability to read and write; 2) exclusion criteria: individuals who are not willing to participate as respondents. this research aims to focus on a population of 100 migrant adults who are affiliated with pcinu taiwan, comprising 100 adults from taiwan and an additional 100 from indonesia. the targeted population encompasses adults from diverse regions in surabaya, including the east, west, north, and south, and they were selected at random from the overall population of interest. a questionnaire was employed as the data collection tool to ascertain demographic characteristics and the incidence of diarrhoea. the statistical analysis utilized logistic regression with hypothesis testing at p<0.05. significance for public health diarrhea is a significant public health problem that has serious impacts on individuals, families, and communities. in regions with limited access to healthcare facilities, diarrhea can lead to death if not treated quickly and effectively, specifically in developing countries. consequently, prioritizing the prevention and control of diarrhea is very important for public health, emphasizing the significance of educating people about the importance of maintaining good health practices. [healthcare in low-resource settings 2024;12(s1):13035] [page 47] non -co mmerc ial us e o nly results and discussion the survey collected 200 respondents, from which the questionnaire was distributed to 100 respondents (adults) in taiwan and 100 respondents from indonesia. table 1 shows the results of incidence of diarrhea in taiwan among 100 adults, with a focus on socio-demographic factors, obtained from 62 young adults. subsequently, 61.3% reported no occurrence of diarrhea in the last month, while 8.1 had diarrhea. regarding gender, 84 respondents were female, 76.2% did not experience diarrhea, and out of the 68 married respondents, 75% did not experience diarrhea, and 25% experienced it. out of the 55 respondents who live in taipei, 74.5% did not experience diarrhea and 25.5% did. out of the 41 respondents whose length of stay was >6 years, the majority of 78.0% did not experience diarrhea, and 22.0 did. regarding education, there were 57 respondents with low education, and 78.9% did not have diarrhea. 57 respondents had an income of 20-24.99, out of the 78 respondents with good behavior, 83.6% did not experience diarrhea. table 2 shows the results of the logistic regression test. the factors that influence incidence of diarrhea in taiwan are age with a p-value = 0.009, education with a p-value = 0.010, and personal hygiene with a p-value = of 0.010 which does not affect gender, marital status, place of residence, length of stay, income. table 3 shows the results of incidence of diarrhea in the last month in indonesia, specifically in the city of surabaya, based on the sociodemographics of 100 adults, with a focus on 70 young adults. the majority, consisting of 62.9% did not experience diarrhea, while 37.1% did. regarding the gender of the 83 respondents, the majority of women did not experience diarrhea, namely 73.5%, while 26.5% did. out of the 58 respondents who were married, 77.6% did not experience diarrhea, while 22.4% did. of the 47 respondents who live in north surabaya, 66.0% did not experience diarrhea, while 34.0% experienced it. regarding education, there were 42 respondents with low education, 57.1% had no diarrhea and 42.9% did. there were 40 respondents with an income of 5-7 million, 82.5% had no diarrhea and 17.5% did, of the 72 respondents with good behavior there were 73.6% and 26.4% did not suffer from diarrhea. table 4 from the results of logistic regression shows that the factors that influence diarrhea are socio-demographics, namely education with a p-value = 0.038 and income = 0.008 which does not affect age, gender, marital status, or place of residence. in this research, socio-demographic results show that age significantly influences incidence of diarrhea in taiwan, shown by a p-value of 0.009. conversely, in indonesia, the p-value = 0.058 as shown in table 1, emphasizing the largest age group affected— individuals aged 20-40, totaling 62 respondents, and this age group is vulnerable due to poor diet. this is in line with previous researches which reported that at this age, most respondents often eat out or eat unclean food, having a higher risk of developing diarrhea.14,15 poor nutrition or changes in the gut microbiome that occur and their potential,16,17 to an unhealthy relationship with food development, and the diet of young adults can influence the likelihood of diarrhea. contamination and spread of disease 4th international nursing and health sciences symposium table 1. frequency distribution of socio-demographics, hygiene behavior, on incidence of diarrhea in taiwan. categories no diarrhea diarrhea f % f % age early adulthood 38 61.3 24 38.7 middle adults 34 91.9 3 8.1 late adulthood 1 100 0 0 gender woman 64 76.2 20 23.8 man 9 56.3 7 43.8 married status not married yet 9 56.3 7 43.8 marry 51 75 17 25 divorced 13 81.3 3 18.8 residence area new taipei 19 67.9 9 32.1 taipei 41 74.5 14 25.5 etc 12 75 4 25 length of stay 1-3 years 13 52 12 48 4-6 years 28 82.4 6 17.6 >6 years 32 78.0 9 22.0 education level low 45 78.9 12 21.1 intermediate 26 74.3 9 25.7 high 72 72.27 27 27 income 10-14.999 million 1 33.3 2 66.6 1519.99 million 4 57.1 3 42.8 20-24.99 million 43 75.4 14 24.56 25.99-14.99 million 23 74.19 8 25.8 ≥ 30 million 2 100 0 0 hygiene behavior not good 12 54.54 10 45.45 good 61 78.20 17 21.79 table 2. logistic regression results that influence incidence of diarrhea in taiwan. variables in the equation b s.e. wald df sig. exp(b) step 1a age -2.052 .790 6.752 1 .009 .128 gender .786 .760 1.070 1 .301 2.194 status -.340 .488 .486 1 .486 .711 stay -.112 .422 .070 1 .791 .894 long .225 .396 .323 1 .570 1.253 educate 1.189 .459 6.702 1 .010 3.284 wages -.549 .380 2.087 1 .149 .577 hygiene -1.731 .673 6.625 1 .010 .177 constant 3.976 2.329 2.914 1 .088 53.312 a. variable(s) entered on step 1: age, gender, status, residence, length, education, salary, cleanliness. [page 48] [healthcare in low-resource settings 2024;12(s1):13035] non -co mmerc ial us e o nly through food must comply with hygienic procedures in handling food.18 another socio-demographic factor that influences diarrhea is education in taiwan with a significant result of p-value = 0.01 and in indonesia with a significant result of p-value = 0.008. in table 2, in taiwan, there are 57 respondents with low levels of education, while in table 4, in indonesia, 42 respondents fall into the low education category, including individuals who did not attend school, or did not complete elementary school. the significance of education is underscored as it profoundly shapes an individual’s mindset. inadequate education affects the dissemination of necessary information about the importance of personal hygiene and environmental sanitation in preventing infectious diseases, including diarrhea.19 the level of education can increase health knowledge, acting as a key component influencing an individual’s awareness.20,21 moreover, a higher level of education makes it easier to gain access to health-related information. in indonesia, incidence of diarrhea is significantly influenced by income, as shown by a p-value = 0.008. in table 3, despite a monthly income range of 5-6 million, the individuals experiencing the highest frequency of diarrhea fall within the income range of 1-2 million. income can influence the risk and impact of diarrhea, including poor food consumption patterns. this is in line with derek headey’s statement that low income influences many diseases because it affects nutritional status, food quality, and less clean food consumers, resulting in diarrhea.22 subsequently, socio-demographic factors in both taiwan and indonesia regarding gender, marital status, and place of residence did not affect incidence of diarrhea. in taiwan, the cleaning staff is a significant factor influencing diarrhea, as showed by a p-value of 0.010. from table 2, it was found that 78 respondents had personal hygiene. in indonesia, of the 72 respondents, the majority, 73.6%, had good behavior. respondents exhibiting poor personal hygiene simultaneously contributed to a higher incidence of diarrhea, leading to an increased occurrence of the condition. with respect to personal hygiene, researchers asked about washing hands, cleaning nails, and protecting food. subsequently, washing hands regularly and correctly is an important step to prevent the spread of infection and maintain cleanliness, which includes using soap and clean water as well as correct hand-washing methods. washing hands is behavior that reduces the risk of cross-infection transmission. with “clean care is safer care” at the top of the agenda of who’s global initiative on patient safety programs, it is time for developing countries to formulate much-needed policies for the implementation of basic infection prevention practices in healthcare settings.23,24 cutting nails is often considered a trivial matter in society, and even though nail cleanliness can contribute to improving people’s health status, cutting nails also prevents intestinal parasites.25 safeguarding food is to prevent contamination and the spread of disease through food.12 maintaining cleanliness, eating healthy food, and preventing diarrhea can help reduce the risk of its development. behavior that can reduce the risk of diarrhea is washing vegetables and fruit before consumption, one way of transmitting diarrhea is through serving under 4th international nursing and health sciences symposium table 3. frequency distribution of socio-demographics, and hygiene behavior, on incidence of diarrhea in indonesia. categories no diarrhea diarrhea f % f % age early adulthood 44 62.9 26 37.1 middle adults 25 86.2 4 13.8 late adulthood 1 100 0 0 gender woman 61 73.5 22 26.5 man 9 56.3 8 43.8 married status not married yet 14 46.7 16 53.3 marry 45 77.6 13 22.4 divorced 11 91.7 1 8.3 residence area east surabaya 6 60.0 4 40.0 north surabaya 31 66.0 16 34.0 south surabaya 26 74.3 9 25.7 west surabaya 7 87.5 1 12.5 length of stay 1-3 years 13 52 12 48 4-6 years 28 82.4 6 17.6 >6 years 32 78.0 9 22.0 education level low 24 57.1 18 42.9 intermediate 34 82.9 7 17.1 high 12 70.6 5 29.4 income 1-2 million 9 42.9 12 57.1 34 million 20 66.7 10 33.3 4-5 million 33 82.5 7 17.5 6-7 million 7 87.5 1 14.3 ≥ 30 million 7 100 0 0 hygiene behavior not good 17 60.7 11 39.3 good 53 73.6 19 26.4 table 4. logistic regression results that influence incidence of diarrhea in indonesia. variables in the equation b s.e. wald df sig. exp(b) step 1a step 1a age -.898 .475 3.580 1 .058 .407 gender -.616 .692 .791 1 .374 .540 status .991 .666 2.214 1 .137 2.693 stay .267 .397 .452 1 .501 1.306 educate -.799 .386 4.293 1 .038 .450 wages -.855 .324 6.982 1 .008 .425 hygiene -.639 .581 1.210 1 .271 .528 constant 4.033 1.841 4.799 1 .028 56.434 a. variables entered in step 1: age, gender, status, residence, upbringing, salary, cleanliness. [healthcare in low-resource settings 2024;12(s1):13035] [page 49] non -co mmerc ial us e o nly cooked or raw food. the pathogenic causes of foodborne diseases vary due to different eating places and eating habits. the proportion of outdoor food consumption is increasing rapidly and, in turn, increases the possibility of pathogenic microorganisms if stored improperly. the taiwanese government’s policy is to carry out cross-domain management, including food quality inspection, monitoring, proper treatment, packaging, and food preservation with international regulations and standards, industrial discipline, and private participation to achieve food security.26 policy from indonesia is facilitated through public services through bpom (food and drug supervisory agency). conclusions in conclusion, this research shows that diarrhea is a global problem with high levels of morbidity and mortality in various countries, specifically in developing countries, namely indonesia and taiwan. several factors that cause diarrhea are socio-demographics and personal hygiene. subsequently, socio-demographic factors that influence incidence of diarrhea in taiwan are age, education, and personal hygiene, while in indonesia, education and income are the most influential factors in incidence of diarrhea. references 1. li r, lai y, feng c, et al. diarrhea in under five year-old children in nepal: a spatiotemporal analysis based on demographic and health survey data. int j environ res public health 2020;17. 2. suhanda, ahmad n. medical surgical nursing care assistance for clients with digestive system disorders: acute gastroenteritis. kolaborasi j pengabdi masy 2022;2:262–9. 3. desak wkp. acute gastroenteritis. denpasar: rsup sanglah; 2017. 4. chow cm, leung akc, hon kl. acute gastroenteritis: from guidelines to real life. clin exp gastroenterol 2010;3:97–112. 5. oloruntoba eo, folarin tb, ayede ai. hygiene and sanitation risk factors of diarrhoeal disease among under-five children in ibadan, nigeria. afr health sci 2014;14:1001–11. 6. tuang a. analysis of factors related to the incidence of diarrhea in children. j ilm kesehat sandi husada 2021;10:534–42. 7. ministry of health republic of indonesia. general guidelines for the development of active alert villages and sub-districts. jakarta: ministry of health republic of indonesia; 2016. 8. wulandari ap. relationship between environmental factors and sociodemographic factors with the incidence of diarrhea in toddlers in blimbing village, sambirejo district, sragen regency in 2009. surakarta: universitas muhammadiyah surakarta; 2019. 9. pelletier dl, frongillo ea, habicht jp. epidemiologic evidence for a potentiating effect of malnutrition on child mortality. am j public health 1993;83:1130–3. 10. masood msa, alsonini naa. knowledge and attitude about reproductive health and family planning among young adults in yemen. guttmacher s, editor. int j popul res 2017;2017:1895472. 11. fedorowicz z, jagannath va, carter b. antiemetics for reducing vomiting related to acute gastroenteritis in children and adolescents. sao paulo med j 2012;130:270. 12. li y, yaling h, jijun y, et al. bacteria and poisonous plants were the primary causative hazards of foodborne disease outbreak: a seven-year survey from guangxi, south china. bmc public health 2018;18:1–8. 13. pokharel p, adhikari a, lamsal p, adhikari r. effect of complementary feeding practices and nutritional status of children (6-23 months) in tamang community, ambhanjyang vdc of makwanpur. janaki med coll j med sci 2017;5:22–32. 14. o’brien l, wall cl, wilkinson tj, gearry rb. what are the pearls and pitfalls of the dietary management for chronic diarrhoea? nutrients 2021;13. 4th international nursing and health sciences symposium figure 1. the roles faced by indonesian migrant workers in taiwan. [page 50] [healthcare in low-resource settings 2024;12(s1):13035] non -co mmerc ial us e o nly 15. hunt rh, dhaliwal s, tougas g, et al. prevalence, impact and attitudes toward lower gastrointestinal dysmotility and sensory symptoms, and their treatment in canada: a descriptive study. can j gastroenterol 2007;21:31–7. 16. mcintosh k, reed de, schneider t, et al. fodmaps alter symptoms and the metabolome of patients with ibs: a randomised controlled trial. gut 2017;66:1241–51. 17. halmos ep, power va, shepherd sj, et al. a diet low in fodmaps reduces symptoms of irritable bowel syndrome. gastroenterology 2014;146:67-75.e5. 18. pakdel m, olsen a, bar ems. a review of food contaminants and their pathways within food processing facilities using open food processing equipment. j food prot 2023;86:100184. 19. miranti mg, handajani s, pangesthi lt, et al. education on sanitation and hygiene knowledge on food vendors in semolowaru culinary tourism center (ctc) surabaya. j pemberdaya masy madani 2022;6:351–67. 20. yanti b, mulyadi e, wahiduddin, et al. community knowledge, attitudes, and behavior towards social distancing policy as a means of preventing transmission of covid-19 in indonesia. indones j heal adm 2020;8:4–14. 21. abdi f, simbar m. the peer education approach in adolescents. iran j publ heal 2013;42:1200–6. 22. headey d, ruel m. food inflation and child undernutrition in low and middle income countries. nat commun 2023;14. 23. mathur p. hand hygin. 2011:611–20. 24. gammon j, hunt j. the neglected element of hand hygiene significance of hand drying, efficiency of different methods and clinical implication: a review. j infect prev 2019;20:66– 74. 25. mahmud ma, spigt m, bezabih am, et al. efficacy of handwashing with soap and nail clipping on intestinal parasitic infections in school-aged children: a factorial cluster randomized controlled trial. plos med 2015;12:1–16. 26. yu cp, chou yc, wu dc, et al. surveillance of foodborne diseases in taiwan: a retrospective study. med (united states) 2021;100:e24424. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13035] [page 51] correspondence: firdaus, department of midwifery, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, jl. smea 57 surabaya, east java, indonesia. tel.: +623018284505, e-mail: firdaus@unusa.ac.id key words: demographic; diarrhea; hygiene contribution: the authors contributed equally to the implementation from proposal to reporting. conflict of interest: the authors declare no potential conflict of interest. funding: this research was supported by the chancellor financially supported by nahdlatul ulama university surabaya. ethics approval: the chakra brahmanda lentera ethical board granted ethical clearance under reference number 062/019/vi/ec/kep/lcbl/ 2023.n of 1964, as revised in 2013, concerning human and animal rights. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors express profound gratitude to the institute for research and community service (lppm), nahdlatul ulama university surabaya for supporting this research with research grant no. 0137/unusa-lppm/adm-2/st-pen iv/2023 received: 4 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13035 doi:10.4081/hls.2024.13035 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13259 beliefs and barriers to covid-19 vaccination among older people with a history of stroke in indonesia: a descriptive qualitative study suzanna suzanna,1 aris citra wisuda,2 arena lestari,3 gunawan irianto4 1faculty of health science, nursing study program, universitas muhammadiyah ahmad dahlan, palembang; 2nursing study program, sekolah tinggi ilmu kesehatan bina husada, palembang; 3departement of psychiatric nursing, universitas muhammadiyah pringsewu, lampung; 4departement of gerontology nursing, universitas muhammadiyah pringsewu, lampung, indonesia abstract the covid-19 vaccination program, aimed at vulnerable groups, such as elderly individuals with comorbidities such as stroke, has generated varied responses, including hesitancy due to internal health concerns and potential side effects. this study explored the experiences and perceptions of older adults with a history of stroke in indonesia regarding the covid-19 vaccination program. this qualitative study employed a descriptive qualitative approach using in-depth interviews. participants were selected through purposive sampling, focusing on elderly individuals with metabolic conditions such as stroke. data saturation was achieved with 23 participants, and the data were analyzed using haase’s adaptation of the colaizzi method. several themes emerged, including rejection of the vaccination program, doubts and distrust of the covid-19 vaccine, disbelief regarding vaccine content and benefits, concerns about stroke-related health risks, and feelings of compulsion or reluctance to participate in the program. the themes identified in this study provide insights into the barriers to covid-19 vaccination in elderly individuals with a history of stroke. these findings could inform strategies for improving vaccination uptake in this vulnerable population. introduction the spread of covid-19 was rapid, prompting the world health organization (who) to declare it a global public health emergency. this has created an urgent need for rapid diagnosis, therapy, and vaccines for covid-19.1 the publication of the sars-cov-2 genetic sequence in january 2020 triggered numerous studies on vaccine development.2 by december 2020, several vaccines with proven efficacy and safety had been authorized for use in various countries.2 global data have confirmed the effectiveness of these vaccines in reducing sars-cov-2 infections, severe cases, hospitalizations, and mortality among vaccinated individuals.3,4 therefore, universal and global vaccination against sars-cov-2 is essential to achieve herd immunity and control the pandemic.5–8 although significant progress has been made in developing effective vaccines, achieving broad immunity requires high vaccination coverage, which is challenged by widespread vaccine hesitancy. vaccine doubts have increased in various countries and are influenced by conspiracy theories and misinformation.3,6,9 the success of immunization programs depends on public acceptance and coverage rates. concerns about covid-19 vaccines, especially among older populations in countries such as india, highlight the need to understand public perceptions.10–12 despite vaccination campaigns in indonesia, coverage among older adults remains incomplete. the johns hopkins center for communication programmes (jhccp) reports that approximately 40% of older adults refuse vaccination because of religious concerns and safety fears.13 the vaccination rates for the first and second doses among elderly indonesians were 40.15% and 24.83%, respectively.14 since september 8, 2021, elderly individuals have accounted for 46.6% of covid-19 deaths.15 indonesia’s phase-2 vaccination targets individuals over 60 and those 45-59 with comorbidities.10 public willingness to vaccinate is crucial for achieving high coverage and overcoming the pandemic.16,17 however, vaccine hesitancy is a significant barrier, with some refusing vaccination.18,19 correspondence: aris citra wisuda, nursing study program, sekolah tinggi ilmu kesehatan bina husada, palembang, indonesia. e-mail: ariscitrawisuda.edu@gmail.com key words: elderly; stroke; covid-19 vaccination. contributions: su, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; acw, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; al, methodology, visualization, writing – review & editing; gi, methodology, validation, and writing – original draft, review & editing conflict of interest: the authors declare no conflicts of interest. funding: none ethical approval and consent to participate: this study received ethical approval from the review board or ethics commission of the palembang poltekkes kemenkes (no: 013 kep/adm2/2020). participants signed informed consent forms before participating. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgments: the study team is grateful to all the participants. received: 16 october 2024. accepted: 31 march 2025. early view: 18 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13259 doi:10.4081/hls.2025.13259 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 34] [healthcare in low-resource settings 2025;13(s2):13259] acceptance rates varied widely, from 27.7% to 97%, with the lowest rates in africa, the middle east, russia, and parts of europe.19,20 among healthcare workers, vaccine acceptance varies significantly, with rates ranging from 23.4% to 81.5% and an overall 55.9%.21 a global study with 13,426 participants from 19 countries showed that 71.5% would accept the vaccine if proven safe and effective, while 48.1% would accept it based on employer recommendations.19 acceptance rates differ between countries, and public willingness may not predict actual behavior. countries with rates above 80%, such as china, south korea, and singapore, have demonstrated public trust in the government.6,10 in indonesia, older adults make up 10% of covid-19 cases but 50% of deaths.22 data from the pekanbaru city health office show that many older adults and families refuse vaccination, leading to a low coverage rate of approximately 50%, which is below the national target.23 in palembang city, only 50% of the elderly and general population are vaccinated. health centers use incentives and campaigns. however, only 50% of the elderly (66,443 of 128,519) received the first dose and among the general public, only 50% (433,450 of 857,384) were vaccinated.24 the government has set a target of at least 70% coverage among older people.25 however, vaccine acceptance presents an additional challenges.26 the collegium of neurologists states that vaccination of patients with stroke should occur under physician supervision, considering their health conditions.27 studies have shown that message framing significantly influences individuals’ willingness to be vaccinated. properly framed messages that explain vaccination benefits and risks can increase vaccination intentions.28 narrative messages are particularly persuasive in encouraging vaccination behaviors, as demonstrated in chinese students.29 message framing, emotional appeal, and informative content can influence vaccine risk perceptions and the willingness to vaccinate.30 cultural aspects critically influence public response to health communication.31 the incorporation of culturally sensitive approaches into communication strategies is essential for effective health promotion. this study aimed to explore the experiences of older adults with a history of stroke in perceiving the covid-19 vaccination program, focusing on the factors influencing their attitudes and decisions. materials and methods study design this study used a descriptive qualitative approach to explore the perceptions of older adults with stroke regarding their acceptance or rejection of the covid-19 vaccination program. setting this study was conducted in august 2021, particularly for 10 public health centers in palembang city, indonesia. sample/participant data were collected through direct interviews at the time of mutual agreement. participants were recruited using purposive sampling with inclusion criteria for elderly individuals with a history of illness, particularly stroke. the sample size was determined based on data saturation, that is, the point where no new data or themes emerged. the characteristics of the informants, including age, gender, marital status, medical history, occupation, and place of residence, were explained. this study included 23 informants, which was sufficient to achieve data saturation. saturation was reached when all the participants provided consistent responses, indicating no further variation or new insights. data collection the study team explained the purpose of the study to the participants and obtained informed consent. they also sought approval and established a contract to conduct in-depth interviews at mutually agreeable times and dates. with the consent of all the informants, the interviews were recorded using voice and audio recorders. data collection and analysis were simultaneously conducted. the audio recordings were transcribed verbatim within 24 hours of each interview, and the interview team reviewed the transcriptions to ensure their accuracy. interview guides during interviews, older adults were asked about changes in their self-beliefs, thoughts, feelings, and behaviors related to the vaccination program, as well as their views when it became mandatory. the team followed standardized reporting guidelines for qualitative research and conducted a quality assessment using various methods, including the consolidated criteria for reporting qualitative research (coreq), which consists of 32 criteria.32 domain 1: research team and reflection, comprising personal characteristics and relationships with participants. domain 2: the study design includes a theoretical framework, participant selection, setting, and data collection. domain 3: analysis and findings consisting of data analysis and reporting data analysis data analysis was performed using haase’s adaptation to the colaizzi method to analyze transcripts. the process began by reading transcripts multiple times to understand the meaning, identify essential phrases, and restate them. this was followed by formulating and validating meaning through team discussions to reach a consensus. the final stage involved identifying and grouping themes into clusters and categories, developing them into theme descriptions.33,34 the strategies used to ensure data accuracy or trustworthiness were credibility and transferability. two authors independently analyzed transcripts by bracketing data on preconceived ideas and systematically following an adaptation of the colaizzi method. the team discussed the results until agreement on themes, theme groups (domains), and categories (coding) were reached.35 trustworthiness to ensure credibility, a team dedicated time to data collection and analysis. transferability: we provided a comprehensive description of the research context, methods, settings, participants, and sampling methods. transferability was assessed by examining variations in participant characteristics and quotes from in-depth interviews. dependability was enhanced by the qualitative analytical software atlas, which organizes and manages data systematically, facilitating an audit trial. all decisions and methodological adjustments were recorded to ensure confirmability of the audit trial during data collection and analysis. ethical clearance this study received ethical approval from the review board or ethics commission of the palembang poltekkes kemenkes (no: 013 kep/adm2/2020). participants signed informed consent forms before participating, and data confidentiality was guaranteed during collection by using numbers instead of names with quotation codes (participant number) and removing identifying informa pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13259] [page 35] tion from transcripts. all audio recordings and transcripts were stored using computer password protection. during the study, the researcher adhered to the ethical principles of information consent, respect for human rights, beneficence, and non-maleficence. results demographics and characteristics of participants supplementary materials, table 1 provides an overview of the participants’ demographic and clinical characteristics. the study sample consisted of 23 older adults recruited from regions in south sumatra province. the participants’ factors, including age, gender, marital status, region, disease history, work history, and place of residence, were documented. the team analyzed the results of the in-depth interviews and selected quotations combined into groups as a basis for coding and formulating categories, domains, and themes. supplementary materials, table 2 shows the theme formation process, beginning with quotations from the in-depth interviews. the results were analyzed by selecting quotations combined into groups as a basis for coding to formulate categories, domains, and themes. based on the themes formed, a sequence of events identifies the complexity of the dynamic situation when implementing a vaccination program. discussion this study provides insights into older people’s perceptions of the covid-19 vaccination program, particularly within the global pandemic context, which, by the end of 2020, caused over four million confirmed cases and three hundred thousand deaths worldwide.36 using a qualitative approach, researchers interviewed vulnerable groups, especially older adults with comorbidities such as stroke. the findings highlight various beliefs about and barriers to covid-19 vaccination among elderly individuals with a history of stroke. the analysis revealed five major themes: initial resistance to the vaccination program, doubts about the benefits of the vaccine, fear of vaccination, compulsion to participate, and unwillingness to engage in vaccination programs. theme 1: initial resistance to the vaccination program the study found that initial resistance among elderly individuals, particularly those with chronic diseases, stemmed from resentment and a lack of trust in government-led vaccination programs. rejection to vaccination may be caused by misperception and fear of this program among the elderly. safe and effective vaccines aim to reduce virus transmission and enhance immunity.2 similar issues have been reported in developed countries, such as the united states, australia, italy, and the united kingdom, where recipients are skeptical of government-led vaccination initiatives.20 this aligns with previous research suggesting that vaccine hesitancy is often rooted in distrust of authorities and skepticism about public health initiatives.37,38 elderly participants expressed frustration about being targeted as a priority group for vaccination, which led to feelings of alienation and reluctance to participate.39 such sentiments highlight the need for more inclusive and transparent communication strategies to foster vaccine acceptance.39 addressing resistance requires trust building, inclusive communication, and transparent policy implementation. by fostering a collaborative and empathetic approach to vaccine campaigns, public health authorities can mitigate resistance and encourage informed decision making among the elderly. theme 2: doubts and disbelief about the benefits of the covid-19 another major concern was the widespread doubt about the effectiveness of covid-19 vaccines. participants shared the belief that vaccines were unnecessary or similar to common cold treatments, reflecting misinformation and a general lack of understanding of vaccine mechanisms. this finding aligns with a previous study showing that some elderly individuals believe that their current health status does not necessitate vaccination and doubted vaccine effectiveness.40 this is consistent with previous studies that have highlighted the impact of misinformation on vaccine acceptance, particularly among older populations with lower health literacy.41 systematic reviews and experimental studies have shown that appropriate message framing significantly increases vaccine acceptance by shaping perceptions of vaccine risks and benefits.42,43 normalizing preventive behaviors via public campaigns may strengthen trust by aligning it with accepted norms, and this study also suggests that the government and health providers should promote the vaccine and its side effects to improve people’s understanding of covid-19. theme 3: fear surrounds vaccination fear, particularly regarding adverse reactions, was a dominant theme in participants’ narratives. many elderly individuals are at an increased risk of stroke, hypertension, or even death. this fear is often fueled by anecdotal stories from peers, media reports, and social networks, reinforcing the perception that vaccines are unsafe. this aligns with a previous study in which fear surrounding covid-19 vaccination was a significant factor influencing vaccine hesitancy and acceptance. this fear is multifaceted, involving concerns about vaccine safety, side effects, the rapid development of vaccines,44-46 and external misinformation.47-48 building trust within the community is essential to addressing these doubts.16 these findings emphasize the importance of evidence-based communication and the role of healthcare providers in reassuring patients about vaccine safety, as previous research has shown that physician recommendations are among the most influential factors in vaccine decision-making.47 moreover, involving healthcare professionals who have established relationships with patients can enhance vaccine promotion efforts.16,48,49 theme 4: the compulsion to participate in the vaccination program despite hesitation, some participants felt compelled to receive the vaccine because of external pressures from family members, healthcare workers, or social circles. this coercion-based participation suggests that vaccine uptake among the elderly is not always voluntary but rather a result of social and familial influence. while peer pressure can be a powerful motivator, it is crucial to ensure that vaccine acceptance is driven by informed decision making rather than external coercion. studies have shown that social and familial influences play a significant role in shaping health behaviors among older adults.50 theme 5: unwillingness to engage in vaccination programs finally, some participants remained steadfast in their refusal to pathways of change, part ii [page 36] [healthcare in low-resource settings 2025;13(s2):13259] be vaccinated, citing concerns over personal health risks, distrust in vaccine information, and anecdotal reports of adverse effects. this underscores the challenge of overcoming deep-seated vaccine hesitancy in high-risk populations. interventions should focus on personalized communication strategies, leveraging trusted community leaders and healthcare providers to dispel fear and provide factual information.51 previous studies have highlighted that the reasons for unwillingness to engage in covid-19 vaccination programs are vaccination safety and concern about side effects.38,52 addressing deep-seated vaccine unwillingness in high-risk populations requires targeted trust-based interventions. public health efforts should prioritize personalized communication, engage trusted community leaders, and provide transparent, evidencebased information to effectively counter misinformation and fears. conclusions the covid-19 vaccination program for older adults aimed to reduce viral transmission. however, those with chronic conditions such as stroke face complex concerns, including fear of side effects and vaccine hesitancy. this study explored stroke survivors’ experiences with vaccination, revealing themes such as rejection, distrust, skepticism about benefits, fear of health risks, and reluctance to participate. future public health efforts should prioritize tailored communication 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2013. 36. mesa vieira c, franco oh, gómez restrepo c, abel t. covid-19: the forgotten priorities of the pandemic. maturitas 2020;136:38–41. 37. friedrich wn, lysne m, sim l, shamos s. assessing sexual behavior in high-risk adolescents with the adolescent clinical sexual behavior inventory (acsbi). child maltreatment 2004;9:239–50. 38. gubernot d, jazwa a, niu m, et al. u.s. population-based background incidence rates of medical conditions for use in safety assessment of covid-19 vaccines. vaccine 2021;39:3666–77. 39. palmedo pc, rauh l, lathan hs, ratzan sc. exploring distrust in the wait and see: lessons for vaccine communication. american behavioral scientist 2021; https://doi.org/10.1177/00027642211062865 40. abu aid o, rohana h, azrad m, peretz a. evaluation of vaccine perceptions in israel’s elderly: a comparative study of covid-19 and influenza vaccination attitudes. vaccine: x 2024;20:100569. 41. lazarus jv, ratzan sc, palayew a, et al. a global survey of potential acceptance of a covid-19 vaccine. nature med 2020;27:225–8. 42. rettenbacher ma, hofer a, ebenbichler c, et al. prolactin levels and sexual adverse effects in patients with schizophrenia during antipsychotic treatment. j clin psychopharmacol 2010;30:711-5. 43. harapan h, fathima r, kusuma hi, et al. drivers of and barriers to covid-19 vaccine booster dose acceptance in indonesia. vaccines 2022;10:1981. 44. peng j, marquez c, rubio l, et al. high likelihood of accepting covid-19 vaccine in a latinx community at high sarscov-2 risk in san francisco. open forum infectious diseases 2021;8:ofab202. 45. hall vj, foulkes s, charlett a, et al. sars-cov-2 infection rates of antibody-positive compared with antibody-negative health-care workers in england: a large, multicentre, prospective cohort study (siren). lancet 2021;397:1459–69. 46. supremo a, bacason s, sañosa ar. sociodemographic correlates of older adult acceptance of the covid-19 vaccine. jurnal ners 2022;17:2–7. 47. schwarzinger m, watson v, arwidson p, et al. covid-19 vaccine hesitancy in a representative working-age population in france: a survey experiment based on vaccine characteristics. lancet public health 2021;6:e210–21. 48. tambunan ba, ugrasena dig, nugraha j, et al. levels of sars-cov-2 anti-spike protein receptor-binding domain (srbd) igg in indonesian-vaccinated healthcare workers: experimental research. ann med surgery 2023;85:802–6. 49. fitriah m, permatasari ca, nugraha j, et al. quantitative neutralizing antibody using chemiluminescence assay for evaluating antibody response following inoculation of inactivated vaccine among healthcare workers in surabaya, indonesia. j med pharmaceut chem res 2024;6:1130–41. 50. wang j, yuan b, lu x, et al. willingness to accept covid-19 vaccine among the elderly and the chronic disease population in china. human vaccines immunother 2021;17:4873–88. 51. khubchandani j, sharma s, price jh, et al. covid-19 vaccination hesitancy in the united states: a rapid national assessment. j comm health 2021;46:270–7. 52. jang sr, lee sk, connelly s. understanding motivations and deterrents for covid-19 vaccination among us working adults: a mixed method approach. human vaccines immunother 2022;18:2132752. pathways of change, part ii [page 38] [healthcare in low-resource settings 2025;13(s2):13259] online supplementary materials table 1. characteristics of the participants. table 2. results of theme analysis. hrev_master healthcare in low-resource settings 2025; volume 13(s1):13106 the effectiveness of telehealth in improving the knowledge, attitude, and practice of eclampsia prevention among preeclampsia mothers mamat mamat,1 tukimin sansuwito,2 rahayu pertiwi,1 rahayu dwikanthi1 1politeknik kesehatan kemenkes bandung, indonesia; 2lincoln university college, petaling jaya, malaysia abstract despite numerous media efforts to inform the public, the understanding, attitudes, and practices for preventing eclampsia have not significantly improved, and maternal deaths due to eclampsia remain alarmingly high. this study aims to identify the socio-demographic factors related to this issue and to evaluate the effectiveness of telehealth in enhancing the knowledge, attitudes, and practices regarding eclampsia prevention among mothers experiencing preeclampsia. a quasi-experimental design with a control group was implemented to study the effects of telehealth tools on mothers with preeclampsia. participants were selected using purposive sampling, resulting in a sample size of 104 mothers, which was calculated using the g*power tool. the key variables in this study included telehealth tools, socio-demographics, knowledge and attitudes, and practices for preventing preeclampsia. data were collected before and after the intervention. the analysis used univariate and bivariate analysis: the independent t-test used mann-whitney and kruskal-wallis tests, the paired t-test (dependent t-test) used the wilcoxon test, and the multivariate analysis used logistic regression. our study results indicate that a mother’s history of preeclampsia and her number of pregnancies (parity) significantly influenced eclampsia prevention practices. additionally, knowledge, attitudes, and methods of prevention showed notable changes before and after the telehealth intervention, with all p-values being less than 0.05. the effects of parity on eclampsia prevention practices, as well as the role of telehealth in shaping knowledge and attitudes toward eclampsia prevention and management, were examined in relation to parity and education level. the support systems and advocacy efforts used by health officers can be integrated to improve telehealth services and encourage collaborative research involving multiple health experts. introduction the maternal and infant mortality rate can be used to assess a country’s health level. the higher the maternal and infant mortality rates, the worse the health status will be. in 2017, the global maternal mortality rate was around 295,000 people, and an estimated 810 died every day.1 maternal mortality rates of 94% are found in developing countries. this high rate highlights the significant disparity between poor, rich, and developing nations. resources such as medical expertise, facilities, and equipment are unevenly distributed, and geographical differences further exacerbate this issue.2 preventable complications of pregnancy and childbirth cause high cases of maternal mortality.3,4 other causes of maternal death were classified as non-obstetric complications at 15.7%, other obstetric complications at 12.04%, obstetric bleeding at 27.03%, others at 4.51%, infection at 4%, and the highest caused by hypertension, which was 33.07%.5 indonesia is one of the developing countries with a high maternal mortality rate, in which, every hour, two mothers die from complications of pregnancy, childbirth, and postpartum complications. the maternal mortality rate in indonesia reached 305/100,000 in 2015.6 many factors have been considered as the cause of maternal mortality. all elements refer to the existence of the mother as an object as well as a subject in the case of maternal knowledge and attitudes related to preeclampsia.7,8 based on a previous study, 47% of pregnant women have a lack of knowledge about correspondence: mamat mamat, politeknik kesehatan kemenkes bandung, padjajaran no 56, bandung, indonesia. e-mail: mamat.researcher@gmail.com key words: eclampsia prevention; improvement; practice; telehealth. contributions: mm, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ts, conceptualization, investigation, methodology, validation, review & editing; rp, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; rd, methodology, visualization, writing – review & editing; sb, resources, investigation, and writing –review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research was approved by the health research ethics commission, poltekkes bandung, based on ethical certificate no.144/kepk/ec/ii/2023. throughout the study, the researcher focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was supported by a research grant from dipa (budget allocation) politeknik kesehatan bandung. acknowledgments: the authors are grateful to the master of health department in karawang regency indonesia, which supported the research. received: 14 september 2024. accepted: 2 december 2024. early access: 4 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13106 doi:10.4081/hls.2025.13106 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13106] [page 49] preeclampsia.9 a lack of information and education causes a low level of knowledge.10 the level of knowledge and attitudes of mothers with preeclampsia is essential in making decisions taken as an effort to improve their health and prevent illness and death.11 in addition to low awareness and attitudes regarding eclampsia cases, inadequate prevention practices among pregnant mothers with preeclampsia significantly contribute to the occurrence of eclampsia. therefore, there are still low antenatal care (anc) visits at the primary service level due to many maternal deaths, even though these maternal deaths can be prevented through regular anc practices.12 the wrong diet, such as eating or drinking many sweet, salty, and high-fat drinks, can increase blood pressure.13 some pregnant mothers experience anxiety at the end of pregnancy; family support and the ability to control emotions and stress are vital.14 lack of physical activity and exercise is also one of the things that contribute to eclampsia. one of the prophylactic eclampsia occurrences who recommended for every pregnant woman with eclampsia is the administration of drugs such as aspirin, calcium, magnesium, and vitamin d.15 thus, irregularities in drug consumption can increase the high risk of eclampsia. a study showed that 86.9% of pregnant women expect good service, 78.3% recommend using internet media in health services (telehealth), and 90.9% of service workers believe telehealth can improve service access.16 internet-based information media approaches exist, such as preeclampsia-detector, preclampsia.com, preeclampsia-calculator,15 dear mother app,17 and sms mother. these applications have limitations, including a lack of functional information about preeclampsia and eclampsia prevention practices, insufficient user engagement from mothers and spouses, and the requirement of an email to log in. telehealth is one of the solutions offered in this study to address the above problems. telehealth is an information and educational medium that contains information on the prevention of pregnancy disorders, especially the prevention of eclampsia, as well as a communication medium between preeclampsia mothers and health workers to prevent eclampsia. telehealth has specifically developed resources for mothers with preeclampsia. all information is presented on android devices in an engaging, easy-toread format that increases knowledge, attitudes, and practices for preventing eclampsia. the objective of this study is to determine the effect of socio-demographics on knowledge, attitude, and practice of eclampsia prevention intervention and to determine the effectiveness of telehealth in improving the knowledge, attitude, and practice of eclampsia prevention among preeclampsia mothers after being a controlled confounder variable. materials and methods research design a quasi-experimental design with a control group was implemented in this study. the control group was given an androidbased application that had gone through a user-friendliness test, while the control group did not receive any intervention. both groups went through a homogeneity test to eliminate factor bias. study participant the study participants were mothers with preeclampsia. the sample size was calculated using the power 3.2 formula. the assumptions included a tolerance deviation (α) of 0.05, an effect size of 0.25, and a power level of 0.80 (80%). the estimated sample size was 102, to which an additional 10% (10 samples) was added, resulting in a total of 112 samples. these samples were divided into two groups: 56 in the intervention group and 56 in the control group. the sample criteria included being pregnant, having preeclampsia, being under 20 weeks gestation, having a spouse, and being familiar with an android mobile phone. the sampling technique used was purposive. variables the variables include telehealth, socio-demographics, knowledge, attitude, and practice of eclampsia prevention. telehealth is a tool developed through three key stages: first, identifying the need for content based on surveys; second, adjusting input from health workers, including midwifery and gynecology specialists; and third, collaborating with internet technology experts to design the interface and application. the final phase involves testing the validity and usability of the telehealth system.18 socio-demographic variables are age group, education level, gravidity, and parity. the knowledge consists of 15-item questions, with categories of correct answer choices and accurate and wrong answers. the attitudes are a variable composed of 15 statements that describe the prevention of pregnancy disorders (eclampsia). each report includes five categories of answer choices based on a likert scale. for positive statements, the scoring is as follows: 5 = strongly agree, 4 = agree, 3 = neutral, 2 = disagree, and 1 = strongly disagree. for negative statements, the scoring is reversed: 1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree. additionally, the practice of preventing preeclampsia also uses five categories of answer choices in the form of a likert scale. for positive statements, the scoring is: 5 = always, 4 = often, 3 = sometimes, 2 = rarely, and 1 = never. for negative statements, the scoring is as follows: 1 = always, 2 = often, 3 = sometimes, 4 = rarely, and 5 = never. data collection the intervention group was given a telehealth intervention delivered directly, while the control group received no intervention during the study but was given telehealth afterward. this study was conducted at ten public health centers (phcs), with the most referral cases being preeclampsia mothers. a pre-test was carried out regarding knowledge, attitudes, and prevention practices based on data collected in the initial stage. the data analysis involved both univariate and bivariate analyses. prior to conducting the bivariate analysis, several statistical methods were applied to assess the data. these included normality tests, such as the kolmogorov-smirnov test and the shapiro-wilk test, as well as visualizations using histograms and distribution curves to identify trends in data distribution. for comparisons between two groups, the mann-whitney analysis was utilized, while the kruskal-wallis test was used for groups consisting of more than two categories. the research process is explained in figure 1. results the socio-demographic categorical data in the intervention and control groups the characteristics and age of the two categories of respondents—namely, the intervention group and the control group—are nearly identical. the primary differences lie in the age distribution; in both groups, 90% of the participants are over 25 years old. additionally, the mothers with preeclampsia in the sample do not have jobs or independent sources of income. the proportion of special issue pathways of change [page 50] [healthcare in low-resource settings 2025;13(s1):13106] primigravida mothers is higher in the intervention group, accounting for 36% of the sample (table 1). the effect of socio-demographic factors on the practice of eclampsia prevention after telehealth intervention the impact of demographic factors on the practice of eclampsia prevention among mothers with preeclampsia includes age group, education level, gravidity, and parity. the mann-whitney test is utilized for independent group data, focusing on the following categories: age group and education level, as well as gravidity and occupation. meanwhile, the kruskal-wallis test is employed to analyze differences among three or more groups for the category of parity. the results of the mann-whitney test indicate the effect of group age on eclampsia prevention practices. the mean rank (average rank) for the group aged 25 and older was 54.06, which is higher than the mean rank of the younger group, which was 48.65. the p-value is 0.206 (>0.05), indicating that there is no significant difference in mean positioning based on the ages of the two groups when it comes to the practice of preventing eclampsia. this suggests that the age of mothers with preeclampsia does not have an impact on their practices for preventing eclampsia. likewise, the results of the mann-whitney test indicate that the mean rank for the practice of eclampsia prevention is higher for individuals with lower education, scoring 55.33, compared to those with higher education, who scored 49.56. the p-value obtained is 0.137, which is greater than 0.05. this indicates that there is no significant difference in the mean ranks of the two education groups regarding the practice of eclampsia prevention. then, the ha hypothesis test was rejected, which means there is no effect on preeclampsia mothers’ education level towards practicing prevention of eclampsia. other test results indicate that the impact of gravidity on the practice of preventing eclampsia shows a mean rank for grand multigravida of over 41.00, compared to 35.54 for multigravida. the p-value of 0.392 (>0.05) suggests that there is no significant difference in the mean rank between grand multigravida and multigravida regarding the practice of preventing eclampsia. this implies that the gravidity of mothers with preeclampsia does not significantly affect their practices in preventing eclampsia. in contrast to the previous hypothesis results, the findings of the kruskal-wallis test indicate that the effect of exercise on preventing eclampsia shows a mean rank of 66.25, which is higher than that of multigravida at 34.71, and also greater than that of primigravida at 34.47. the p-value obtained is 0.010 (<0.05), indicating a significant difference in mean ranks among grande, multi, and primiparous mothers regarding eclampsia prevention practices. this suggests that a higher parity is associated with better practices in preventing eclampsia. therefore, parity appears to have an effect on the eclampsia prevention methods employed by mothers with preeclampsia (table 2). the effect of telehealth on the knowledge, attitude, and practice of eclampsia prevention the impact of telehealth on the knowledge of eclampsia prevention among mothers with preeclampsia was evaluated using the mann-whitney test. the results indicated that mothers who received telehealth intervention had a mean rank of 68.79, significantly higher than the mean rank of 36.21 for mothers who did not receive the intervention. this demonstrates the positive effect of telehealth on their understanding of eclampsia prevention. a significant p-value of 0.0001 (<0.05) indicates a meaningful difference in the mean rank of knowledge about eclampsia prevention among mothers with preeclampsia who received telehealth interventions compared to those who did not. the hypothesis ha. accepted, indicating that the telehealth intervention has a significant effect on the knowledge of eclampsia prevention among mothers with preeclampsia. in contrast, the mann-whitney test revealed that the impact of telehealth on attitudes toward eclampsia prevention was notable. the mean rank of preeclampsia mothers who received the telehealth intervention was 72.69, significantly higher than the mean rank of those who did not receive the intervention, which was 32.31. there is a considerable difference mark in p-value of 0.0001 (<0.05), which means there is a significant mean rank between those who get preeclampsia telehealth interventions and those who have no telehealth intervention toward attitude prevention of eclampsia. in examining the dependent variable, which is the special issue pathways of change figure 1. research flow diagram. table 1. socio-demographic factors in intervention and control group. socio-demographic group data intervention (f%) control (f%) group age ≥ 25 years 34 (65.4) 40 (76.9) < 25 years 18 (34.6) 10 (23.1) education elementary schools 8 (15.4) 13 (25) junior high schools 14 (26.9) 18 (34.6) senior high schools 28 (53.8) 16 (30.8) college 2 (3.8) 5 (9.6) gravidity grande 1 (1.9) 5 (9.6) multi 32 (61.5) 33 (63.5) primi 19 (36.5) 14 (26.9) parity levels grande 15 (28.8) 2 (3.8) multi 18 (34.6) 21 (40.4) primi 19 (36.5) 14 (26.9) nuli 15 (28.8) [healthcare in low-resource settings 2025;13(s1):13106] [page 51] impact of telehealth on the prevention of eclampsia, we found that the mean rank for preeclampsia mothers who received telehealth interventions was significantly higher at 65.59. in contrast, the mean rank for preeclampsia mothers who did not receive any telehealth interventions was 39.41, resulting in a difference of 26.18. there is enough significance depicted by a p-value of 0.0001 (<0.05), which means there is a difference in the significant mean rank among preeclampsia mothers who got telehealth interventions with no-telehealth ones toward mark practice prevention of eclampsia. the hypothesis showed that ha. accepted, suggesting that telehealth interventions have a positive effect on the prevention of eclampsia in mothers with preeclampsia (table 3). the effect of telehealth on the practice of eclampsia prevention after control by the confounding variable the telehealth intervention variable has an or of 25.010, so preeclampsia mothers who receive telehealth intervention (code one of the independent variable) have a greater opportunity of increasing eclampsia prevention practices (code 1 dependent variable) by 25.010 times compared to preeclampsia mothers who do not receive health intervention after controlling for the parity covariate variable (table 4). special issue pathways of change [page 52] [healthcare in low-resource settings 2025;13(s1):13106] table 4. effect of telehealth on the practice of eclampsia prevention after controlled by confounding variable. variable b wald sig. exp(b)* 95% c.i. for exp(b) lower upper telehealth intervention 3.219 9.160 .002 25.010 3.110 201.148 parity level 2 .230 .127 .721 1.259 .355 4.464 constant -5.590 5.623 .018 .004 *last model for analysis of full logistic regression. table 2. the effect of socio-demographic factors on the practice of eclampsia prevention. socio-demographic score variable n mean rank p age group >25 74 54.06 0.206* <25 30 48.65 level of education high 51 49.56 0.137* low 53 55.33 gravity grande 6 41.00 0.392* multi 65 35.54 parity grande 2 66.25 0.010** multi 36 34.71 primi 32 34.47 *kruskal-wallis test statistics; **mann-whitney test statistics. table 3. effect of telehealth on the knowledge, attitude, and practice of eclampsia prevention. variable preeclampsia mothers n mean rank p age group >25 74 54.06 0.206* <25 30 48.65 level of education high 51 49.56 0.137* low 53 55.33 gravity grande 6 41.00 0.392* multi 65 35.54 parity grande 2 66.25 0.010** multi 36 34.71 primi 32 34.47 *kruskal-wallis test statistics; **mann-whitney test statistics. discussion the research findings indicate that socio-demographic factors and medical history significantly influence pregnant women’s knowledge about preeclampsia. a study conducted among mothers who experienced preeclampsia revealed an association between respondent characteristics—such as age, education level, income, and body mass index (bmi)—and the occurrence of preeclampsia. additionally, antenatal care practices were found to reduce the risk of complications, particularly in the age group of 20-34 years.19 a pregnant woman’s understanding of the relationship between preeclampsia and a history of the disease has evolved significantly over time. moreover, a history of hypertension and factors such as sodium intake further contribute to its occurrence.20 research findings indicate that multiparous women (those with multiple pregnancies) who have a history of preeclampsia and receive adequate treatment are less likely to experience recurrence. the characteristics of an individual, including their parity status, significantly influence their exposure to information and healthrelated decision-making. greater parity often correlates with increased exposure to information about pregnancy-related complications, enabling women to better understand potential risks, make informed decisions about their health, and prevent complications such as eclampsia. antenatal care (anc) visits play a critical role in providing health information and education. health professionals can disseminate knowledge about preeclampsia and other pregnancy-related conditions, helping expectant mothers understand prevention strategies and manage their health effectively. parity also has a profound impact on eclampsia prevention practices. biological changes and experiences differ between a woman’s first pregnancy and subsequent pregnancies. first pregnancies are often associated with a higher risk of complications, including eclampsia, as the body is less accustomed to the hormonal and physiological changes of pregnancy. in contrast, women in subsequent pregnancies are more likely to recognize early signs and symptoms of eclampsia and adopt preventive measures, such as regular medical check-ups, adhering to nutritional guidelines, taking sufficient rest, and following medical advice regarding supplements. health practitioners emphasize the importance of these experiences, as they increase women’s awareness of eclampsia risks and encourage proactive measures to minimize complications during pregnancy.21,22 other studies have found significant differences in knowledge, attitudes, and practices related to preventing eclampsia among preeclamptic mothers and their spouses before and after telehealth interventions. a similar difference was observed when comparing the effects of telehealth interventions to cases where no telehealth was utilized. these findings align with research demonstrating a significant improvement in knowledge and attitudes following the use of mhealth applications to prevent complications during the third trimester of pregnancy. knowledge acquired during pregnancy serves as a critical foundation for adopting positive health behaviors. for mothers with preeclampsia, adequate knowledge acts as a key motivating factor for engaging in anc and other preventive practices. health education provided during anc visits is essential and should cover the symptoms, risk factors, and complications associated with preeclampsia. ensuring that this information is clearly communicated can empower mothers to make informed decisions and take proactive measures to safeguard their health and that of their unborn child.7 during these anc visits, healthcare providers can offer tailored education on various aspects of care, such as appropriate physical activity, adequate nutrition to support fetal development, and avoiding foods that may exacerbate preeclampsia. additional guidance includes ensuring sufficient rest and managing stress effectively. improvements in the knowledge and attitudes of pregnant women through these educational interventions can significantly enhance their self-care and self-management practices. these behavioral changes contribute to a reduction in the risk of pregnancy-related complications and childbirth disorders, ultimately promoting better maternal and fetal health outcomes.23 studies involving mothers with previous postpartum experience highlight the importance of counseling in enhancing knowledge about preeclampsia through provider-based services. social media platforms have increasingly become not only a source of information but also a powerful tool to capture individuals’ attention and provide social support.24 telehealth systems are designed to improve healthcare delivery, with the expectation of demonstrating a high level of effectiveness compared to traditional methods. one key objective of telehealth is to facilitate ease of use and encourage the adoption of positive health behaviors. for example, a study on the prevention of dental caries in children demonstrated that habit formation could significantly improve health outcomes, such as encouraging children to practice good oral hygiene. similarly, telehealth applications can be efficient in fostering healthy behaviors and providing effective healthcare services.25 applications require effective media engagement, and the information provided within most applications needs to be enhanced to ensure user understanding. to ensure their effectiveness, scientific evidence is essential to support the implementation of health technologies, such as telehealth. application technologies offer various tools that simplify processes and improve user experience, ultimately making healthcare more accessible and efficient.26 for an android-based application to be effective, user-friendly, and well-received, it is essential to incorporate engaging and relevant visual media. the application should feature visually appealing images with attractive colors and simple and easy-to-navigate menus. additionally, the design should prioritize efficiency, ensuring that users can easily access information and perform tasks.26 technology will continue to evolve, and human interaction with technology will remain integral to daily life. one notable advancement is the use of the internet through android devices. this change has transformed the way individuals access and respond to information, thereby influencing their communication behaviors. the internet has significantly influenced lifestyle changes, primarily due to continuous technological advancements.27 this statement highlights how the progress in information and communication technology, along with the widespread effects of globalization, has transformed the ways people live, interact, learn, and redefine their cultural identities. the advent of the internet has rendered traditional concepts of space, time, and distance irrelevant, enabling individuals to connect at any time and from any location. this technological shift addresses challenges such as language diversity, cost barriers, and internet access limitations. furthermore, the new application offers a range of features, including intuitive icons and customizable options, ensuring that users can easily navigate and understand the platform.28 the use of application-based communication, information, and education, or application-based telehealth, is particularly relevant in the digital age. as of recent reports, 196.7 million people, or 73.7% of indonesia’s population, are internet literate. this widespread digital access enables individuals to avoid in-person interactions, a key advantage during the covid-19 pandemic, which has significantly affected prenatal care. a study showed a 16.1% decrease in the volume of weekly prenatal visits, from 898 special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13106] [page 53] to 761 visits on average. this decline has impacted the monitoring of pregnant women, especially those with preeclampsia, increasing the risk of pregnancy complications, including eclampsia. in this study, telehealth delivers information, education, and communication through an android-based application designed to prevent pregnancy complications, including eclampsia. by leveraging technology, the application ensures that preeclamptic mothers and their spouses have continuous and consistent access to critical health information.29 the use of advanced information technology, such as telehealth, has certain limitations in providing comprehensive exposure to information about eclampsia prevention. however, android-based health information systems are available, and most mothers and spouses of preeclamptic patients possess mobile phones. telehealth offers not only educational content but also the advantage of rapid information delivery, enabling users to quickly adopt appropriate attitudes and behaviors based on their needs. telehealth platforms are designed to be user-friendly and engaging, incorporating features that facilitate ease of use and maintain user interest. these systems go beyond merely disseminating information; they also include communication and coordination tools that foster collaboration between healthcare providers, preeclamptic mothers, and their spouses. this collaborative approach promotes harmony and alignment, enabling the development of shared strategies for managing preeclampsia and preventing complications during pregnancy. by leveraging these features, telehealth enhances the effectiveness of health interventions and supports better outcomes, even in cases where preeclampsia is already present. conclusions parity and telehealth interventions significantly influence the improvement of preeclamptic mothers’ attitudes and knowledge regarding eclampsia prevention. after adjusting for parity and educational attainment, telehealth interventions have been found to be 25 times more effective in preventing eclampsia. to further enhance these outcomes, additional research involving multidisciplinary collaboration—encompassing gynecology, cardiology, neurology, and other relevant fields—is needed to develop a comprehensive telehealth-based strategy for eclampsia prevention. references 1. who. maternal mortality. genewa; 2019. 2. who. the gobal health observatory “maternal and reproductive health.” who. 2021. 3. permadi v, aditiawarman a, lestari p. profile of pregnant women with preeclampsia and its termination method. maj obstet ginekol 2022;30:10–6. 4. putri ariyan fa, sukowati eg, fatmawati w. preeclampsia correlates with maternal and perinatal outcomes in regional public hospital, madiun, indonesia. maj obstet ginekol 2022;30:24–31. 5. united nations fund for population activities (unfpa). kesehatan ibu, peringatan hari bidan internasional 2021. 6. nuraini, sst m dkk. profil penduduk indonesia hasil supas 2015. dendy handiyatmo m dkk, editor. jakarta: badan pusat statistik; 2016. 7. mekie m, addisu d, bezie m, et al. knowledge and attitude of pregnant women towards preeclampsia and its associated factors in south gondar zone, northwest ethiopia: a multi�center facility�based cross�sectional study. bmc pregnancy childbirth 2021;21. 8. umamah f, santoso b, yunitasari e, et al. analysis of factors affecting nurse patient interaction based on the human interaction model in pregnant women with the risk of preeclamsia. teikyo med j 2022;45:3645–50. 9. ulfa tm. tingkat pengetahuan ibu hamil tentang preeklmapsia di puskesmas padang bulon kota. universitas sumatera utara; 2017. 10. fondjo la, boamah ve, fierti a, et al. knowledge of preeclampsia and its associated factors among pregnant women: a possible link to reduce related adverse outcomes. bmc pregnancy childbirth 2019;19:456. 11. joshi a, beyuo t, oppong sa, et al. preeclampsia knowledge among postpartum women treated for preeclampsia and eclampsia at korle bu teaching hospital in accra, ghana. bmc pregnancy childbirth 2020;20:625. 12. mahmood ma, hendarto h, laksana mac, et al. health system and quality of care factors contributing to maternal deaths in east java, indonesia. plos one 2021;16:e0247911. 13. wilda y. dampak perilaku makan terhadap kejadian pre eklamsia pada ibu hamil. 2020;10. 14. marifah an, masriadi m, sartika s. pengaruh dukungan keluarga, manajemen diri, kecemasan, dan usia kehamilan terhadap kejadian hipertensi kehamilan di puskesmas majauleng. wind public heal j 2022;2:1507–15. 15. who. who recommendations for prevention and treatment of preeclampsia and eclampsia implications and actions. 2013. 16. jeganathan s, prasannan l, blitz mj, et al. adherence and acceptability of telehealth appointments for high-risk obstetrical patients during the coronavirus disease 2019 pandemic. am j obstet gynecol mfm 2020;2:100233. 17. dr.antono suryoputro mph .ph.d dkk. sayang ibu. 2019. 18. mamat m, sansuwito t. development of a user-friendly mobile app for eclampsia prevention targeting preeclampsia mothers and spouses. healthc low-resour s 2024;12:1–19. 19. godana a, dessalegn d, adem f, edessa d. treatment outcomes and determinants of eclampsia and severe preeclampsia among pregnant women admitted to selected tertiary hospitals in ethiopia: a cohort study. int j womens health 2021;13:781– 91. 20. nayluzzuharo f, haryanto j, nastiti aa. interventions to prevent hypertension in pregnant women: a systematic review. pediomaternal nurs j 2024;10:81–5. 21. akbar mia, yosediputra a, pratama re, et al. pravastatin suppresses inflammatory cytokines and endothelial activation in patients at risk of developing preeclampsia: inovasia study. j matern neonatal med 2022;35:5375–82. 22. akbar mia, azis ma, riu ds, et al. inovasia study: a multicenter randomized clinical trial of pravastatin to prevent preeclampsia in high-risk patients. am j perinatol 2024;41:1203–11. 23. ghaemi mm, moulaei k, bahaadinbeigy k, ghaf-faripour z. the design and evaluation of a mobile based application to facilitate self-care for pregnant women with preeclampsia during covid-19 prevalence. j biomed phys eng 2021;11:551– 60. 24. artieta-pinedo i, paz-pascual c, bully p, et al. design of the maternal website emaehealth that supports decision-making during pregnancy and in the postpartum period: collaborative special issue pathways of change [page 54] [healthcare in low-resource settings 2025;13(s1):13106] action research study. jmir form res 2021;5:1–14. 25. lu dj, girgis m, david jm, et al. evaluation of mobile health applications to track patient-reported outcomes for oncology patients: a systematic review. adv radiat oncol 2021;6. 26. feroz as, afzal n, seto e. exploring digital health interventions for pregnant women at high risk for pre-eclampsia and eclampsia in low-income and-middle-income countries: a scoping review. bmj open 2022;12:1–11. 27. reveley j. the exploitative web: misuses of marx in critical social media studies. sci soc 2013;77:512–35. 28. nocum aa, baltao jm, agustin dr, portus aj. ergonomic evaluation and design of a mobile application for maternal and infant health for smartphone users among lower-income class filipinos. procedia manuf 2015;3:5411–8. 29. azza a, yunitasari e, triharini m, et al. a cultural nursing care model to prevent preeclampsia in the provision of basic services in eastern indonesia. afr j nurs midwifery 2023;25. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13106] [page 55] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13416 the effectiveness of abdominal stretching exercise versus breathing relaxation with nature sounds on the level of dysmenorrhea faridah umamah, r. khairiyatul afiyah department of nursing, nursing and midwifery faculty, universitas nahdlatul ulama surabaya, indonesia abstract menstruation usually comes accompanied by several complaints, such as dysmenorrhea. the intervention of abdominal stretching and breathing relaxation with nature sounds can increase muscle relaxation so as to reduce menstrual pain. this study aimed to analyze the effectiveness of abdominal stretching exercise versus breathing relaxation with nature sounds on dysmenorrhea levels. this study was a quasi-experimental design with a two-group comparison using a pre-test and post-test approach. the experimental group received abdominal stretching, while the control group underwent breathing relaxation with nature sounds. the inclusion criteria were adolescents aged 11–20 years who experienced primary dysmenorrhea. the total sample consisted of 30 young women in the abdominal stretching intervention group and 30 young women in the breathing relaxation with nature sounds group. data were collected using a pain assessment instrument, namely the numerical rating scale (nrs). the data were analyzed using paired t-tests to measure differences in pre-test and post-test scores within the groups and independent sample t-tests to compare post-test scores between the two groups. the results of the paired t-test showed that abdominal stretching and breathing relaxation with nature had an effect on pain level during menstruation with p-value was 0.000 (p < 0.05). after the intervention, the menstrual pain was reduced in both groups. abdominal stretching exercise and breathing relaxation with nature sounds were able to reduce menstrual pain in adolescent girls, therefore these interventions were recommended for young women who experience primary dysmenorrhea. introduction menstruation is a natural physiological process that often comes with various complaints, one of the most common being menstrual pain or dysmenorrhea. dysmenorrhea typically lasts for one to several days during menstruation and represents one of the most prevalent gynecological issues, affecting over 50% of women globally.1–3 this condition frequently impairs daily activities, sometimes causing school or work absences for up to three days, especially among adolescents.4,5 such disruptions negatively impact the teaching and learning process, making it challenging for young women to concentrate due to the discomfort caused by menstrual pain.6 the world health organization (who) reports that the global incidence of dysmenorrhea is alarmingly high, with an average prevalence of approximately 90%.7,8 in indonesia, the prevalence of primary dysmenorrhea is reported to be 54.89%, while secondary dysmenorrhea accounts for 9.36%.9 the primary causes of dysmenorrhea include hormonal changes during menstruation,10 which are often exacerbated by factors such as anxiety and stress.11,12 the stress response triggers the activation of the sympathetic nervous system, releasing hormones and peptides that stimulate uterine muscle contractions. elevated levels of prostaglandins and vasopressin amplify these contractions,13 compressing nerve endings and intensifying menstrual pain. typically, prostaglandin levels peak on the first day of menstruation and gradually decrease over subsequent days, leading to a reduction in pain intensity.14 while pharmacological treatments are commonly used for dysmenorrhea, non-pharmacological therapies have gained increasing attention due to their accessibility and minimal side effects.15–17 previous studies have explored the efficacy of nonpharmacological interventions such as exercise and breathing correspondence: faridah umamah, department of nursing, nursing and midwifery faculty, 60237, universitas nahdlatul ulama surabaya, indonesia. e-mail: umamahfarida@unusa.ac.id key words: abdominal stretching; breathing relaxation; dysmenorrhea; adolescents. contributions: fu conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; rka conceptualization, investigation, methodology, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this study was granted ethical clearance from institutional review board universitas nahdatul ulama, surabaya, indonesia. number: 026/ec/kepk/unusa/2021. patient consent for publication: participants who agreed to join in this study must signed the informed consent, however if the participants feel tired, they allowed to withdraw in the middle session. funding: this research did not receive external funding availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful to universitas nahdatul ulama, surabaya, indonesia for their valuable support. received: 23 november 2024. accepted: 5 march 2025. early access: 24 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13416 doi:10.4081/hls.2025.13416 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 122] [healthcare in low-resource settings 2025;13(s1):13416] relaxation techniques;18,19 however, research in this area remains limited. exercise, for example, can alleviate menstrual pain by promoting blood circulation and stimulating the release of endorphins.20,21 abdominal stretching exercises, in particular, have been shown to enhance muscle relaxation, endurance, and flexibility, thereby reducing pain. similarly, breathing relaxation techniques increase oxygen supply to the brain, which can promote calmness and alleviate discomfort. notably, the combination of breathing relaxation with nature sounds has been reported to enhance relaxation and comfort in patients. this study aims to address the existing gaps in research by comparing the effectiveness of abdominal stretching exercises and breathing relaxation with nature sounds in alleviating primary dysmenorrhea. by providing empirical evidence on the comparative benefits of these interventions, this study seeks to offer practical, non-pharmacological solutions for managing dysmenorrhea. the findings have the potential to guide young women in choosing appropriate and effective methods for relieving menstrual pain, thereby improving their overall quality of life. materials and methods study design this study was quasi-experimental, with two groups comparison pre and post design. experiment group was abdominal stretching and control group was breathing relaxation with nature sounds sample and sampling total sample was 60 people, 30 young women who were given an intervention using abdominal stretching exercise and 30 young women were given an intervention using breathing relaxation with nature sounds. this study used a purposive sampling technique following inclusion criteria respondents who experienced menstrual pain (dysmenorrhea) which begins within 1-2 years after menarche, pain starts before or at the onset of menstruation and lasts 1-3 days, pain in the lower abdomen, and may radiate to the lower back and legs, pain is felt as cramping, intermittent, or as a dull ache. exclusion criteria was adolescents who take anti-pain medication when menstrual pain occurs (dysmenorrhea). this study was conducted at one of senior high school in east java, indonesia. in april-june 2021. study collection the level of dysmenorrhea was measured periodically using a pain assessment instrument: the numerical rating scale (nrs). the intervention in this study was abdominal stretching exercise and breathing relaxation with nature sounds were given on the first day when the samples experienced menstrual pain. before intervention, we measured the level of menstrual pain using nrs. each intervention was given with duration 15-20 minutes, three times a day, throughout the menstrual cycle. we measured level of pain on the last day of the treatment. in this study, we followed the previous abdominal stretch exercise guideline.22 variables and instruments the independent variables of this study were abdominal stretching exercise versus breathing relaxation with nature sounds, while the dependent variable was pain level during menstruation. the level of dysmenorrhea was measured periodically using a pain assessment instrument: the numerical rating scale (nrs). data analysis data was analyzed using paired t test to measure the difference in pre-test and post-test scores in two groups (the abdominal stretching exercise group versus the breathing relaxation with nature sounds group). in addition, independent sample t test to to measure the difference in post test between the two groups. the significance level was considered less than 0.05. ethical clearance this study was granted ethical clearance from institutional review board universitas nahdatul ulama, surabaya, indonesia. number: 026/ec/kepk/unusa/2021. participants who agreed to join in this study must signed the informed consent, however if the participants feel tired, they allowed to withdraw in the middle session. results characteristic of respondents the respondents’ characteristics based on age were categorized following hurlock (2011) into early adolescence (11–13 years), middle adolescence (14–16 years), and late adolescence (17–20 years).23 most respondents fell within the middle adolescence group (14–16 years). regarding the age at first menstruation (menarche), it was categorized into early menarche (<11 years), normal menarche (11–13 years), and late menarche (>13 years).24 the majority of respondents had normal menarche, with most experiencing it on the first day (table 1). the effect of abdominal stretching exercise on dysmenorrhea and nature sound on dysmenorrhea table 2 showed the result of abdominal stretching exercise was 0.000 (p<0.05), which means that abdominal stretching exercised reduced the level of dysmenorrhea pain. after intervention, the menstrual pain was reduced from 4.34 to 2.34 (1.90 difference). meanwhile, breathing relaxation with nature sounds also reduced the level of dysmenorrhea pain (p < 0.05). after intervention, the menstrual pain was reduced from 6.44 to 4.84 (1.60 difference) special issue pathways of change table 1. characteristic of respondents. frequency (n) percentage (%) age (years old) 11-13 0 0 14-16 40 66.7 17-20 20 33.3 total 60 100.0 menarche <11 2 3.3 11-13 52 86.7 >13 6 10.0 total 60 100.0 time of menstrual pain (day) 1 18 30.0 2 20 33.3 3 22 36.7 total 60 100.0 [healthcare in low-resource settings 2025;13(s1):13416] [page 123] the effectiveness of abdominal stretching exercise versus breathing relaxation with nature sounds on level of dysmenorrhea table 3 showed the significance value (2-tailed) was 0.000 (p<0.05), which means there was an average difference for both groups. the mean value of abdominal stretching exercise was lower than breathing relaxation with nature sounds. discussion this study demonstrated that both abdominal stretching exercise and breathing relaxation with nature sounds significantly reduced dysmenorrhea levels among adolescent girls. however, abdominal stretching exercise was found to be more effective, as indicated by a greater mean difference in pain reduction compared to breathing relaxation with nature sounds. the results of this study showed that abdominal stretching exercise was able to reduce the menstrual pain. abdominal stretching exercise is a physical exercise by stretching the abdominal muscles during menstrual pain.16,19 this exercise is for muscle flexibility, increasing muscle strength, reducing muscle tension, reducing anxiety,27 reducing the risk of injury and reducing pain.28 abdominal stretching exercises can trigger the brain to produce endorphins. peripheral pain neurons send signals to synapses and endorphins will block the release of substance p from sensory neurons. so transmission of pain impulses in the spinal cord is inhibited.29 the finding of this study similar with previous study which mentioned that exercise may have effect on decreasing menstrual pain.26,30 specifically, there is a study regarding abdominal stretching exercise, it was mentioned that abdominal stretching exercise effective to reduce menstrual pain, it was reduced from 7.04 to 1.91 (5.09 difference).22 the results of this study also showed that breathing relaxation was able to reduce the menstrual pain. the breathing relaxation with nature sounds is breathing relaxation techniques that involves an element of belief so it can decrease in oxygen consumption and can create comfort as well as feeling calm.31,32 nature sounds music will provide peace for those who listen it.33 this music has a constant rhythm and provides balance to a person’s heartbeat and pulse. if oxygen levels are sufficient in the brain, the body will relax.34 this study in line with previous study that mentioned that breathing relaxation can reduce of patient’s pain, especially in primary dysmenorrhea.35 this study also compares the mean difference pain between abdominal stretching exercise and breathing relaxation with nature sounds on menstrual pain. abdominal stretching exercise was more effective than breathing relaxation with nature sounds to reduce the level of menstrual pain. this result in line with previous study that mentioned abdominal stretching exercise was effective to decrease menstrual pain, however this study compare with cold compress therapy.22 abdominal stretching exercise can be an alternative therapy to reduce menstrual pain among adolescents. several limitations in this study were considered. this study used the experimental methods with a short time, once during menstrual cycle and it was similar with previous study,22 further study is needed to conduct intervention for long period to maintain the effect of interventions. this study did not measure prostaglandin level, so it was required to measure prostaglandin as a more objective level of pain. purposive sampling, minimum sample size and sampling area were also our limitation, so it must be carefull to interpret the results. beside these limitations our study revealed that abdominal stretching and breathing relaxation with nature sounds were able to reduce the level of mesntrual pain. both of these interventions have the same benefit for the management of menstrual pain, including making relaxation, special issue pathways of change table 3. the difference in menstrual pain between the abdominal stretching exercise group and breathing relaxation with nature sounds. variable group p abdominal stretching exercise breathing relaxation with nature sounds before intervention mean±sd 4.34±1.67 6.44 ±1.36 0.321 after intervention mean±sd 2.44±1.56 4.84±1.41 0.000* differences of pain before and after intervention 0.000 0.000 mean difference mean±sd 1.90 ±0.11 1.60 ±0.95 0.000* *p<0.05. table 2. paired sample t test for experiment and control group. total score paired differences p mean std. 95% confidence interval deviation of the difference lower upper group 1 before intervention 139 4.34 1.67 after intervention 78 2.44 1.56 pre intervention post intervention 21 1.60 0.95 1.26 1.92 0.000* group 2 before intervention 113 6.44 1.36 after intervention 92 4.84 1.41 pre intervention post intervention 21 1.60 0.95 1.26 1.92 0.000* [page 124] [healthcare in low-resource settings 2025;13(s1):13416] reducing anxiety, pain and muscle tension. however, based on this study the mean of abdominal stretching in adolescent girls was lower which means it was better to reduce the level of dysmenorrhea pain compared to breathing relaxation on faith with nature sounds. based on these results, participant can choose both of these interventions to decrease menstrual pain or prefer to choose abdominal stretching exercise. conclusions the results of the study showed that there was a statiscally significant different of menstrual pain before and after intervention mean difference between the groups of abdominal stretching exercise and breathing relaxation with nature sounds. abdominal stretching was proven to be more effective in reducing the level of menstrual pain based on score of mentrual pain. suggestions for adolescent girls who experience menstrual pain can do abdominal stretching exercises or breathing relaxation, as an alternative to reduce menstrual pain. references 1. fernandez h, barea a, chanavaz-lacheray i. prevalence, intensity, impact on quality of life and insights of dysmenorrhea among french women: a cross-sectional web survey. j gynecol obstet hum reprod 2020;49:101889. 2. ameade epk, amalba a, mohammed bs. prevalence of dysmenorrhea among university students in northern ghana; its impact and management strategies. bmc womens health 2018;18:39. 3. arafa ae, senosy sa, helmy hk, mohamed aa. prevalence and patterns of dysmenorrhea and premenstrual syndrome among egyptian girls (12–25 years). middle east fertil soc j 2018;23:486–90. 4. al-matouq s, al-mutairi h, al-mutairi o, abdulaziz f, albasri d, al-enzi m, et al. dysmenorrhea among high-school students and its associated factors in kuwait. bmc pediatr 2019;19:80. 5. lutfiandini ct, kusumaningrum t, armini nka. pain selfmanagement in adolescent with dysmenorrhea. pediomaternal nurs j 2020;6:66–73. 6. suvitie p. dysmenorrhea in teenagers. duodecim 2017;133:285–91. 7. al-kindi r, al-bulushi a. prevalence and impact of dysmenorrhoea among omani high school students. sultan qaboos univ med j 2011;11:485–91. 8. tangchai k, titapant v, boriboonhirunsarn d. dysmenorrhea in thai adolescents: prevalence, impact and knowledge of treatment. j med assoc thai 2004;87:s69-73. 9. ismail if, kundre r, lolong j. hubungan tingkat stres dengan kejadian dismenorea pada mahasiswi semester viii program studi ilmu keperawatan fakultas kedokteran universitas sam ratulangi manado. e-journal keperawatan (e-kp) 2015;3:1–8. 10. barcikowska z, rajkowska-labon e, grzybowska me, et al. inflammatory markers in dysmenorrhea and therapeutic options. int j environ res public health 2020;17:1191. 11. pakpour ah, kazemi f, alimoradi z, griffiths md. depression, anxiety, stress, and dysmenorrhea: a protocol for a systematic review. syst rev 2020;9:65. 12. nursalam n, oktaviani, armini, efendi f. analysis of the stressor and coping strategies of adolescents with dysmenorrhoea. indian j public heal res dev 2018;9:381–6. 13. buckley s, uvnäs-moberg k, pajalic z, et al. maternal and newborn plasma oxytocin levels in response to maternal synthetic oxytocin administration during labour, birth and postpartum a systematic review with implications for the function of the oxytocinergic system. bmc pregn childbirth 2023;23:137. 14. smith rp. the role of prostaglandins in dysmenorrhea and menorrhagia. in dysmenorrhea and menorrhagia. a clinician’s guide. springer nature: 2018; pp. 75–88. 15. herviana c, farapti f. the relationship between knowledge and patterns of herbal drink product consumption with dysmenorrhea of female adolescent. amerta nutr 2023;7:203– 9. 16. imandiri a, faizah r, rakhmawati. acupuncture and papaya leaf powder (carica papaya l) to treat dysmenorrhea. malaysian j med heal sci 2019;15:37–9. 17. noor s, norfitri r. the changes of premenstrual symptoms after aerobic exercise intervention. j ners 2015;10:38–47. 18. renuka k, jeyagowri s. stretching exercise therapy and primary dysmenorrhea – nursing perspectives. iosr j nurs heal sci ver iii 2015;4:1-4. 19. carroquino-garcia p, jiménez-rejano jj, medrano-sanchez e, et al. therapeutic exercise in the treatment of primary dysmenorrhea: a systematic review and meta-analysis. phys ther 2019;99:1371–80. 20. shahrjerdi s, sheikhhoseini r, eyvazi m. effects of stretching exercises on primary dysmenorrhea in adolescent girls. biomed hum kinet 2012;4:127-32. 21. kusumaningrum t, nastiti aa, dewi lc, lutfiani a. the correlation between physical activity and primary dysmenorrhea in female adolescents. indian j public heal res dev 2019;10:2559–63. 22. cahya rosyida da, suwandono a, ariyanti i, et al. comparison of effects of abdominal stretching exercise and cold compress therapy on menstrual pain intensity in teenage girls. belitung nurs j 2017;3:221–8. 23. hurlock eb. adolescent development. adolescent development. new york, ny, us: mcgraw-hill; 1973. 24. chumlea wc, schubert cm, roche af, et al. age at menarche and racial comparisons in us girls. pediatrics 2003;111:110–3. 25. handayani sg, ayubi n, komaini a, lesmana hs, kusnanik nw, herawati l, et al. n-3 polyunsaturated fatty acids (pufas) and physical exercise have the potential to reduce pain intensity in women with primary dysmenorrhea: systematic review. retos 2023;48:106–12. 26. pitaloka sa, triharini m, nimah l. relationship between nutritional status, exercise level and recreational level with dysmenorrhea in nursing students at airlangga university. pediomaternal nurs j 2022;8:26–37. 27. gordon br, mcdowell cp, lyons m, herring mp. acute and chronic effects of resistance exercise training among young adults with and without analogue generalized anxiety disorder: a protocol for pilot randomized controlled trials. mental health phys act. 2020;18:100321. 28. murtiningsih m, solihah l, yuniarti s. the effect of abdominal stretching exercise on dysmenorrhea in adolescent girls. j matern care reprod heal 2019;2. doi: https://doi.org/10.36780/jmcrh.v2i3.104 29. joyce young j. handbook for brunner & suddarth’s textbook special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13416] [page 125] of medical-surgical nursing.—12th ed. wolters kluwer health/lippincott williams & wilkins.; 2010. 30. armour m, ee cc, naidoo d, et al. exercise for dysmenorrhoea. cochrane database syst rev 2019;9: cd004142. 31. toussaint l, nguyen qa, roettger c, et al. effectiveness of progressive muscle relaxation, deep breathing, and guided imagery in promoting psychological and physiological states of relaxation. evid based complement alternat med 2021;2021:5924040. 32. zuriati z, surya m, zahlimar. effectiveness active cycle of breathing technique (acbt) with pursed lips breathing technique (plbt) to tripod position in increase oxygen saturation in patients with copd, west sumatera. enfermería clínica 2020;30:164–7. 33. chiang lc. the effects of music and nature sounds on cancer pain and anxiety in hospice cancer patients. [case western reserve university school of graduate studies]: case western reserve university school of graduate studies; 2011. 34. horden p (ed. ). music as medicine: the history of music therapy since antiquity (1st ed.). in: 2000. routledge; 35. purnamasari kd, rohita t, zen dn, ningrum wm. the effect of deep breathing exercise on menstrual pain perception in adolescents with primary dysmenorrhea. pertanika j 2020;2: 649–57. special issue pathways of change [page 126] [healthcare in low-resource settings 2025;13(s1):13416] hrev_master healthcare in low-resource settings 2024; volume 12:13014 readiness of nursing students for clinical practice: a literature review oswati hasanah,1,2 rr tutik sri haryati,1 dessie wanda,1 nur agustini,1 masfuri1 1faculty of nursing, universitas indonesia, depok, west java; 2faculty of nursing, universitas riau, pekan baru, riau, indonesia abstract clinical placement in nursing education largely depends on the nursing student’s readiness to engage patient care. this review aims to illustrate the level of practice readiness in nursing students preparing for clinical placement, explore gender differences in practice readiness, identify the measurement tools used to assess readiness, and explore the various aspects of readiness measured. a systematic search was performed in the pubmed, scopus, ebsco, proques, eric, medline (ebscohost) databases. relevant studies focused on nursing students, practice readiness before or during the professional education phase, and publications from 2018-2023. from 634 records, and seven articles meet the inclusion criteria. the studies utilized three primary measurement tools: the casey-fink readiness for practice survey, ripls, and custom instruments to assess practice readiness. results indicated high readiness scores for professional responsibilities and communication skills, interprofessional education, and mixed readiness for clinical practice and treating covid-19 patients. these findings highlight the diverse factors influencing nursing students’ preparedness for clinical practice. the assessment of readiness for practice in nursing students has diverse aspects. nursing educational institutions need to make efforts in developing learning strategies before students enter the clinical environment. introduction nursing is a critical and dynamic profession that plays a vital role in the healthcare system. the quality of care provided by nurses directly impacts the health of patients,1,2 making it imperative to ensure that prospective nurses are adequately prepared for clinical practice before going into the field.3 clinical practice is a crucial component of nursing education, offering students the chance to apply theoretical knowledge to actual patient care situations.4,5 several factors can obstruct the integration of theory into nursing clinical practice, such as insufficient resources, inadequate guidance, and limited time for practice.6 clinical practice in nursing is an important step in preparing students for professional practice.5 the goal of clinical practice is to prepare students with the skills and competencies needed to deliver patient care effectively, efficiently, and safely.7 however, the success of clinical practice is highly dependent on the readiness of nursing students to engage in patient care. 8 preparation before starting clinical practice covers a wide range of competencies, including technical skills, problem-solving ability, communication, and teamwork skills.7 the concept of practice readiness has gained attention in nursing education research in recent years, with various studies exploring factors that contribute to or hinder nursing students’ readiness for practice. however, research has predominantly concentrated on the practice readiness of newly graduated nurses or new nurses when entering the workforce. it is suggested that the healthcare system, work environment, and the quality of interactions in the workplace affect the performance of nursing graduates. these novice nurses gradually develop practice readiness through a transitional continuum, ultimately achieving readiness based on factors within their educational environment and workplace. speaking of the clinical education process and the clinical education environment that new nurses go through, they also need thorough preparation and practice readiness in the academic education phase (clinical placement) in order to facilitate them in learning to apply theoretical knowledge to actual patient care situations. several studies have identified factors that influence practice correspondence: oswati hasanah, faculty of nursing, universitas indonesia, depok, west java, indonesia e-mail: unni_08@yahoo.com key word: nursing student; nursing education; clinical practice; student readiness; preparedness. contributions: all authors contributed to this article, oh, rr, dw, na and mm contributed to the data curation, extraction, analysis (i.e. critical appraisal) and analysis. furthermore, the oh made a significant contribution to the study conceptualization, drafted the original review article, and interpreted the data. rr, dw, na and mm contributed for revised the review by providing advice regarding the content ethical approval: not applicable. availability of data and material: the full list of references and datasets supporting the finding of this study can be accessed in the relevant published articles included in this review. conflcit of interest: all authors declare that we have no conflict of interest on this research funding: this study was independently funded by the authors conference presentation: this work was presented at the 3rd international nursing scholar congress 2023, faculty of nursing, universitas indonesia, depok, indonesia. acknowledgement: we would like to thank the scholarship providers, namely the indonesian education scholarship (bpi). the indonesian endowment funds for education (lpdp) and education financing service center (puslapdik) for their support for one of our investigator (oh) in carrying out the doctoral program in nursing. received: 4 september 2024. accepted: 4 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12:13014 doi:10.4081/hls.2024.13014 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12:13014] [page 734] non -co mmerc ial us e o nly readiness in nursing students when clinical placement, including personal characteristics, educational factors,9,10 cognitive aspects, psychological attributes, and social influences,9-11 nursing education curriculum12,13 and clinical environment,9,14 therefore, there is a need for adequate planning and preparation to ensure that nursing students are ready for clinical practice, and these factors must be considered to enable nursing students to have an effective clinical practice experience that is beneficial to their learning. practice readiness is an important concept in nursing education that is influenced by various factors. understanding the picture of practice readiness of students is essential in developing effective teaching strategies and interventions that improve nursing students’ clinical performance. this review will contribute to the existing literature on practice readiness in nursing education clinical placement and as a consideration in policy making in nursing education and nursing clinical practice guidelines. currently, many studies and reviews have been conducted to explore the concept of practice readiness in nursing students so that a review on practice readiness itself in nursing students is needed. this literature review seeks to offer a summary of the overall practice readiness of nursing students who will be starting the clinical practice phase, explore gender differences in practice readiness, and examine the measurement tools used to assess readiness. understanding these aspects is crucial for ensuring students are well-prepared for clinical practice, identifying and addressing gender-specific needs, and ensuring reliable and valid assessments of readiness. by doing so, educators and policymakers can develop strategies to enhance nursing education and better support all students. the findings of this review are expected to have positive implications for nursing education. the information from this review can be used as a consideration for policy making in nursing education, curriculum and practice guidelines in order to improve clinical practice readiness for nursing students and in the long run will improve the quality of patient care. materials and methods design the study focuses on nursing students, with no intervention or comparison involved, and aims to describe clinical practice readiness. additionally, the preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines were followed to ensure clear and transparent reporting. the prisma flow chart (figure 1) was utilized in this study to enhance transparency and facilitate the replication of the research.15 the specific research question aimed to provide an overview of practice readiness among nursing students. practice readiness is a crucial aspect of the clinical mentoring process during the professional education phase. it is also important for educational policymakers to understand, as it helps identify the challenges faced by nursing students. this insight can help in creating strategies to enhance the practice readiness of future professional students and the job readiness of upcoming professional nurses. the implementation of this research is specifically influenced by the limited information related to how the actual picture of practice readiness (readiness to practice) quantitatively and qualitatively in nursing students, before conducting clinical practice or professional practice when clinical placement. search methods the databases utilized were pubmed, scopus, ebsco, proquest, eric, and medline (ebscohost), focusing on english-language articles published between 2018 and 2023. this time frame was chosen to ensure access to the most current literature. searches were performed using boolean operators with predefined keywords, related synonyms, and medical subject headings (mesh) terms, with the pubmed database serving as the foundation for developing the mesh terms. additionally, truncation and wildcards were applied to some terms. search terms for nursing students included nursing student, student nurse, pre-licensure nursing student and undergraduate nursing student as well as the use of truncation on the words nursing student* and student nurse* for practice readiness, search terms included readiness, practice readiness, readiness for practice, readiness to practice, clinical readiness and practice readiness. inclusion and exclusion criteria relevant studies were chosen based on predefined inclusion and exclusion criteria. for these types of reviews, which aim to assess prevalence and incidence data, the jbi (joanna briggs institute) recommends using the cocopop mnemonic. cocopop stands for condition, context, and population, and is specifically designed to guide the inclusion criteria in reviews that evaluate prevalence and incidence data.16,17 based on cocopop, the inclusion criteria for this review are: populations are nursing students, the type of research used is descriptive, cross sectional, cohort and mixed method research, the study focuses on practice readiness or clinical practice readiness in the nursing education phase before or during the professional education phase or before clinical practice in all clinical settings, the country of study was not limited. the search criteria included research publications written in english and published between 2018 and 2023. exclusion criteria for this study were studies focusing on practice readiness after the professional education phase, involving nurse participants who have completed their education, or those that were not research article. data extraction utilizing a self-created extraction matrix, the authors extracted data focusing on study characteristics such as author, country, study objectives, design, sample, data collection and analysis methods, and significant findings. quality appraisal critical appraisal (or methodological quality/risk of bias assessment) in this review was conducted by one reviewer. the reviewer evaluated the quality of each study using the jbi critical appraisal tool. some reviews that assess prevalence and incidence do not include a critical appraisal process, but only include ‘minimum criteria’ for inclusion.16,17 the reviewer has a master’s degree and specializes in pediatric nursing. data analysis the outcome data from the included studies were compiled and presented as narrative summaries using a thematic synthesis framework. results study characteristics a total of 634 articles were found from all databases used, article [page 735] [healthcare in low-resource settings 2024;12:13014] non -co mmerc ial us e o nly using predefined keywords. the number of articles from each database was 54 studies obtained from pubmed, 233 studies from scopus, 101 studies from ebsco, 185 studies from proquest, 33 studies from eric and 28 studies from medline (ebsco). from the total number of articles, seven articles that met the inclusion criteria were identified and included in the review. the details of the article selection process are outlined in figure 1. the total sample size of the research articles was 1752 respondents, most of whom were female students. the response rate of the overall study results ranged from 40-90% of the target sample size. supplementary table 1 presents the features of the studies that were collected. the articles analyzed are studies from countries spread across various continents (europe, asia, australia and africa) namely serbia, italy, turkey, oman, japan and nigeria. in the study approach, there were five studies that used a cross-sectional approach,18-22 study with a cohort approach,23 and one study with a mixed method approach.24 all the articles analyzed had the main objective to determine the practice readiness of nursing students, in different aspects of practice. then from each study also has other specific objectives. in two studies the research also intended to compare the readiness levels of nursing students with those of other health students; however, the analysis was limited to the results from two studies involving only the nursing student group.21,24 instruments/measures of readiness of the seven studies analyzed in this review, three types of measurement tools were found, where their use was adjusted to the research objectives of each study. the three measuring instruments are the casey-fink readiness for practice survey,23 the readiness for inter-professional learning scale (ripls),19-21,24 and measuring instruments developed by the researchers themselves.18 aspects assessed in the research instrument the casey-fink readiness for practice survey measures four subscale factors, namely clinical problem solving, learning techniques, professional identity, and trials and tribulations. the ripls measuring instrument measures five main things, namely teamwork and collaboration, professional identity, respect for other roles, active and interactive learning and social responsibility.25 meanwhile, the measurement tools developed by the authors are aimed at assessing students’ readiness to conduct clinical practice during the covid-19 pandemic and readiness to treat covid-19 patients.18,22 students’ readiness for practice in a study that used the casey-fink readiness for practice survey,23 the readiness score was rated as high, between 85-99%. the findings detailed those participants felt secure in their professional duties and believed they had sufficiently prepared for their roles, and they also affirmed their confidence in their communication abilities. in four studies that used the ripls measurement tool assessed readiness in the context of nursing students’ readiness to conduct interprofessional education (ipe).19-21,24 where learning related to ipe is obtained in the clinical practice phase. of the four studies, the total ripls score of nursing students was in the range of 69.78 82.2. the highest ripls score was obtained in a study of nursing students in japan, namely 82.2 ± 0.69.24 this score illustrates that in general nursing students, with the current curriculum, are ready and willing to participate in ipe practices during clinical practice. in two studies,18,22 readiness was assessed in the context of students’ readiness to conduct clinical practice during the covid pandemic and readiness to care for covid patients. in both studies, researchers used self-composed tools, developed based on a literature review. the measurement results in this instrument are not calculated using scoring, but in the form of a final categorization with the categories ready and not ready. the assessment results in the study stated that 61.7% of students reported feeling prepared for clinical practice during the pandemic, only a small percentage (30.7%) of students stated that they were ready to treat corona virus patients.18 meanwhile, in one of the research, stated that most students expressed their unpreparedness to carry out clinical practice during a pandemic (66.79%),22 which means the same as the research, at that time not many students felt ready to treat covid-19 patients, due to various factors.18 discussion the studies included in this review represent several countries around the world. some similar studies were not captured in the search, because they did not meet several criteria, including the scope of research years limited to the last five years of study, could not be accessed in full text and the purpose/method of research did not match the purpose of the search. most of the studies related to readiness to practice with the keyword readiness are more in the population of students who have graduated from education to see readiness to practice after graduation and in the transition phase to become a new nurse, not in nursing students who will do clinical practice as students. from the seven studies analyzed in this review, in general, nursing students are considered ready to do clinical practice. except during the covid-19 pandemic, especially in the early phase, there are many factors that affect student readiness, both internal and external factors. research by joolaee article [healthcare in low-resource settings 2024;12:13014] [page 736] figure 1. prisma flow diagram. non -co mmerc ial us e o nly et al indicated that nursing students may not be psychologically prepared to enter the clinical environment due to certain factors.26 this condition can affect the quality of their learning and their readiness to learn in the field. therefore, paying attention to the level of readiness of students, including their needs and psychological conditions before entering the clinical practice setting, can help improve students’ competence and readiness when doing clinical practice placements. in this study, nursing students were dominated by the female student population, this is indeed because in general, there are more female nurses than male nurses. regarding gender differences in practice readiness, female students have been shown to be more prepared to work in teams and collaborate than male students.27 in many countries the choice to become a nurse is mostly chosen by women, due to gender traditions,28 but today more and more men are choosing the nursing profession as social changes and changes in gender views or due to cultural factors such as in arabia. 29 in various studies, gender differences are not actually the causal factor that distinguishes readiness in practice, but there are many other factors both internally and externally from the student. assessment of student readiness can also include assessment of theoretical knowledge, professional attitudes, and practical experience. evaluation of these students can include cognitive, psychomotor, and affective aspects. this evaluation is not only to see students’ clinical abilities, but also to assess their psychological and emotional aspects, as in joolaee et al. study which reviewed the psychological aspects of students.26 assessment of practice readiness can also be done based on settings, conditions, and cases in the field. this evaluation is very important to determine the extent to which nursing students have prepared themselves and the extent to which they have been prepared to enter the clinical environment and provide care to patients safely and effectively. evaluating nursing students’ readiness for practice varies in context and objectives across different studies. therefore, the measuring instrument used must be adjusted to the purpose of measuring each aspect in the study. in jamieson et al study, the casey-fink readiness for practice survey was utilized as the measuring instrument.23 this instrument measures nursing students’ readiness to enter clinical practice by exploring four subscale factors, specifically, clinical problem-solving, learning strategies, professional identity, and trials and tribulations. results in this questionnaire are presented for each subscale.30 the caseyfink readiness for practice survey has been utilized as a measurement tool in several studies to evaluate students’ readiness in managing patient care tasks and in communicating with doctors. multiple studies employing the casey-fink readiness for practice survey have revealed that nursing students encounter significant challenges in managing patient care tasks, communicating with doctors, and caring for critically ill patients. in addition, students also need further assistance and guidance in developing clinical competencies, role development, and career planning during clinical practice from their seniors.12 in addition to being used to explore students’ readiness before clinical placement, this instrument has also been used in various research studies. the study used the readiness for interprofessional learning scale (ripls) to assess nursing students’ readiness for interprofessional practice. four studies in this review assessed readiness in the context of nursing students’ readiness to conduct interprofessional education (ipe).19-21,24 where learning related to ipe is obtained in the clinical practice phase. the main things assessed in the scale are teamwork and collaboration, professional identity, respect for other roles, active and interactive learning and social responsibility.25 in addition, two studies developed their own measurement tools, as done by nweke et al and basso et al in their study to evaluate nursing students’ readiness to practice during the covid-19 pandemic.18,22 these tools can be used separately or in combination to assess student preparedness more comprehensively. academic preparation is an important part of the readiness process for nursing students before clinical practice. the goal is to alleviate nursing students’ fear and anxiety before they enter the clinical setting. in addition, efforts are needed to close the gap between theory and clinical practice by providing all the necessary materials for field practice during the academic process. educational institutions should also identify areas for improvement in nursing education programs and ensure that students are prepared to work as professional nurses after graduation. thus, thorough academic preparation and appropriate strategies in linking theory and clinical practice can help improve nursing students’ readiness and competence in clinical practice. all of the studies analyzed provided clues about several learning strategies that can improve nursing students’ practice readiness. the first strategy is the development of clinical skills through structured and measurable learning approaches, by providing diverse and contextually appropriate practice experiences. second, interprofessional education and collaborative practice approaches can help nursing students work in teams with other health professionals. third, the development of an inclusive nursing education curriculum and self-development and professionalism programs. it’s also important to consider the latest advancements in the health sector and the evolving requirements for health worker qualifications due to changes in global situations and conditions. selfdevelopment and professionalism programs can also help nursing students to continue learning and develop the skills needed in the future. it is hoped that by integrating these learning strategies, nursing students can become competent health workers. conclusions assessment of readiness for practice in nursing students has many aspects, so it is necessary to have an appropriate measurement tool to evaluate each aspect of student readiness. educational institutions need to make efforts to develop learning strategies, such as clinical skills workshops and visiting hospitals before entering the clinical environment. the results of this systematic review can be a reference for the development of nursing higher education curriculum, especially in facing an increasingly complex professional world with interprofessional education and collaborative practice. efforts to improve student readiness and knowledge can be made through the development of an inclusive educational curriculum, interprofessional training, and self-development and professionalism programs. references 1. driscoll a, grant mj, carroll d, et al. the effect of nurse-topatient ratios on nurse-sensitive patient outcomes in acute specialist units: a systematic review and meta-analysis. eur j cardiovasc nurs 2018;17:6-22. 2. blegen ma, goode cj, spetz j, et al. nurse staffing effects on patient outcomes. med care 2011;49:406–14. 3. usher k, mills j, west c, park t, woods c. preregistration student nurses’ self-reported preparedness for practice before and article [page 737] [healthcare in low-resource settings 2024;12:13014] non -co mmerc ial us e o nly after the introduction of a capstone subject. j clin nurs 2015;24:3245–54. 4. eyikara e, baykara zg. the importance of simulation in nursing education. world j educ technol educational technology current issues 2017;9:2-7. 5. kaphagawani nc, useh u. analysis of nursing students learning experiences in clinical practice: literature review. ethno med 2013;7:181–5. 6. fathi ky, ibrahim rh. factors influencing integration of theory into practice in clinical skills acquisition among nursing students. inform med unlocked 2023;37:101181. 7. mirza n, manankil-rankin l, prentice d, et al. practice readiness of new nursing graduates: a concept analysis. nurse educ pract 2019;3:68–74. 8. davies h, sundin d, robinson s, jacob e. does participation in extended immersive ward-based simulation improve the preparedness of undergraduate bachelor’s degree nursing students to be ready for clinical practice as a registered nurse? an integrative literature review. j clin nurs 2021;30: 2897-911. 9. lee t, damiran d, konlan kd, et al. nurse education in practice factors related to readiness for practice among undergraduate nursing students: a systematic review. nurse educ pract 2023;69:103614. 10. yu m, tong h, li s, et al. clinical competence and its association with self-efficacy and clinical learning environments among chinese undergraduate nursing students. nurse educ pract 2021;53:103055. 11. baumbusch j, leblanc m-e, shaw m, kjorven m. factors influencing nurses ’ readiness to care for hospitalised older people. int j older people nurs 2016;11:149–59. 12. woods c, west c, mills j, et al. undergraduate student nurses’ self-reported preparedness for practice. collegian 2014;22:359-68. 13. fowler sm, knowlton mc, putnam aw. reforming the undergraduate nursing clinical curriculum through clinical immersion: a literature review. nurse educ pract 2018;31:68–76. 14. papastavrou e, dimitriadou m, tsangari h, andreou c. nursing students’ satisfaction of the clinical learning environment: a research study. bmc nursing 2016;15:44. 15. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021; 372:n71. 16. munn z, moola s, lisy k, et a. methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data. int j evid based healthc 2015;13:147-53. 17. munn z, stern c, aromataris e, et al. what kind of systematic review should i conduct? a proposed typology and guidance for systematic reviewers in the medical and health sciences. bmc med res methodol 2018;18:5. 18. nweke ci, abazie oh, adetunji aj, okwuikpo mi. readiness for clinical practice amidst coronavirus among nursing students in southwest nigeria. int j afr nurs sci 2021;15: 100328. 19. arulappan j, matua ga, alzaabi o, et al. knowledge and readiness for inter professional education and collaborative practice among undergraduate nursing students in a middle eastern country-a pilot study. nurse educ today 2021;100: 104865. 20. tosunöz i̇k, yikar sk, çerçer z, et al. perceptions of interdisciplinary education and readiness for inter-professional education of nursing students: a sample of three different cities in turkey. nurse educ today 2021:97:104673. 21. milutinovic d, lovric r, simin d. interprofessional education and collaborative practice: psychometric analysis of the readiness for interprofessional learning scale in undergraduate serbian healthcare student context. nurse educ today 2018:65:74-80. 22. basso i, gonella s, londa m, et al. readiness for practice in undergraduate nursing students during the covid-19 pandemic: a cross-sectional study. ann ig 2022;34:558–71. 23. jamieson i, sims d, basu a, pugh k. readiness for practice: the views of new zealand senior nursing students. nurse educ pract 2019;38:27–33. 24. numasawa m, nawa n, funakoshi y, et al. a mixed methods study on the readiness of dental, medical, and nursing students for interprofessional learning. plos one 2021;16:e0255086. 25. cant r, leech m, hood k. factors affecting australian medical students’ attitudes to interprofessional education; validity of the readiness for inter-professional learning scale-med. j interprof educ pract 2015;1:90–6. 26. joolaee s, amiri srj, farahani ma, varaei s. iranian nursing students’ preparedness for clinical training: a qualitative study. nurse educ today 2015;35:e13-e17. 27. axelsson m, jakobsson j, carlson e. which nursing students are more ready for interprofessional learning? a cross-sectional study. nurse educ today 2019;79:117–23. 28. mcdowell j. masculinity and non-traditional occupations: men’s talk in women’s work. gend work organ 2015;22:27391. 29. popper-giveon a, keshet y, liberman i. increasing gender and ethnic diversity in the health care workforce: the case of arab male nurses in israel. nurs outlook 2015;63:680–90. 30. casey k, fink r, jaynes c, cet al. readiness for practice: the senior practicum experience. j nurs educ 2011;50:646-52. article [healthcare in low-resource settings 2024;12:13014] [page 738] online supplementary materials table 1. distribution of study characteristics. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13042 the comparison of carbohydrates, fibers, and immunoglobulin-a levels in feces against stunting children in tuban regency rivan virlando suryadinata,1 heru wijono,1 firstylo valiant putra sanwersko,1 yosafat elohimio susanto,1 amelia lorensia2 1faculty of medicine, universitas surabaya, surabaya, east java; 2faculty of pharmacy, universitas surabaya, surabaya, east java, indonesia abstract stunting in children under five years old is a major health problem in indonesia. a compromised immune system in stunted children increases the risk of infection which has an impact on morbidity and mortality. moreover, food intake is one of the causes of decreased immunity, where carbohydrate, fiber, and immunoglobulin-a levels in the intestine are related to the immunity of children under five years old. the assessment of feces content can provide an overview of carbohydrates, fiber, and immunoglobulin-a levels in the intestine. therefore, this study aimed to determine the comparison of carbohydrate, fiber, and immunoglobulin-a levels in feces for stunted children. an observational method with a case-control design was used, and it was conducted in tuban regency from may to july 2023. forty stool samples were obtained from 20 stunted children and 20 non-stunted children who were tested for carbohydrates, fiber, and immunoglobulin-a. subsequently, the data were analyzed with a comparison test to determine the differences between the two groups. the results showed that carbohydrate and immunoglobulin-a levels were higher, while fiber levels in feces were lower in stunted children (p≥0.05). it was concluded that there were differences in levels of carbohydrates, fiber, and immunoglobulin-a in the intestines of stunted children. introduction the problem of malnutrition in children under five years old is a global health concern, with developing countries recording over 50% of death cases. malnutrition in this age group can be prevented through treatment and intervention strategies.1 even though there has been a reduction in the prevalence of malnutrition, the decline has not been significant. in low-income communities, the risk of mortality before the age of 20 is doubled, similar to the risk of stunting children due to chronic malnutrition.2 stunting is a chronic nutritional problem attributed to inadequate nutrient intake over a long period, resulting in impaired growth in children. globally, the prevalence of stunting among children under five is 21.3%.3 with africa recording a prevalence of 30.9% in 2015. more than 155 million children under five suffer from stunting globally, with over 1 million deaths and a third experiencing disability adjusted life years (dalys).4 asian regions recorded 83.6 million cases, with the highest proportion originating from south asia (58.7%), and indonesia (27.67%) in 2019.5 stunting is an indicator for determining the well-being of children, reflecting environmental and social inequalities. various risk factors contribute to stunting, including parental (physical condition and nutritional status of the mother during pregnancy, parental education level, and socio-economic status), child (genetic, anthropometric, infection, food intake during infancy, gender, and age), environment (hygiene, sanitation, drinking water sources, culture, and beliefs) among others.6 stunting process often begins during pregnancy, influenced by the mother’s dietary history during gestation.7 the impacts of disease on stunted children include inflammation, disruption of the leptin hormone, and increased glucocorticoids. these factors can trigger neurological development disorders, neurogenesis, and apoptosis, affecting brain areas related to cognition and memory in children.8 others may include digestive tract disorders in the form of intestinal inflammation. these lead to hampered nutrients absorption, further worsening the condition of stunted children. intestinal disorders can also compromise the immune system, facilitating microbial invasion, diseases, and systemic inflammation.9 intestinal inflammation can impact children nutritional status through impaired absorption of carbohydrates and proteins. it also disrupts the intestinal mucosa and microbial metabolic activity, which is essential for preventing the entry of pathogens.10 microbiota in the food tract plays a significant role in children health, such as increasing metabolism and immunology. this condition is influenced by various factors, including food intake, particularly fiber. fiber, a type of polymeric carbohydrate found in food, cannot be absorbed and undergoes fermentation, thereby affecting the bacterial community and microbial metabolic activity.11 immunoglobulin a (ig a), secreted by the mucous membrane lining the gastrointestinal tract plays a role in protecting or providing immunity in the digestive tract. adequate iga production enhances gut-associated lymphoid tissue (galt) and functions as a mechanical barrier in the digestive tract.12 significance for public health stunting events tend to have a negative impact on children development. various risks of health and intellectual disorders can also cause a decline in the quality of human resources in a country. decreased digestive tract function is one of the factors contributing to immune system disorders in stunted children, which can trigger the emergence of diseases and decreased absorption and metabolism from the gi tract. this study seeks to analyze and compare the levels of carbohydrates, fibre, and immunoglobulin-a in the faeces of stunted children, aiming to provide valuable insights into potential dietary and immune factors contributing to stunting. [page 62] [healthcare in low-resource settings 2024;12(s1):13042] non -co mmerc ial us e o nly stunting in children can lead to various vulnerabilities in the body, increasing the risk of mortality. genetic, racial, and ethnic differences, as well as the provision of food, also tend to influence the risk of stunting.13 different interventions, including nutritional support and education, are required for each stunted child in various regions. therefore, assessing the levels of carbohydrates, fiber, and immunoglobulin-a in feces of stunted children in tuban regency is necessary to determine differences between the groups. materials and methods this study used an observational with a case-control method and was conducted in tuban regency from may to july 2023. research approval was issued by tuban regency one-stop investment and integrated services service (no.070/298/1.s/414. 111.3/2023). furthermore, a non-random purposive sampling method was used. respondents were 20 stunting and 20 non-stunting children residing in tuban regency, east java, who met the inclusion criteria (aged 2-5 years, free from autoimmune or congenital diseases related to gi tract, and not suffering from diseases affecting digestion during the study period such as gastroenteritis, hepatobiliary, parasites, or worms) and exclusion criteria (fecal samples showing abnormal characteristics such as changes in color, texture, and odor). children who agreed to participate were accompanied by village cadres to receive further information about the study and to sign informed consent. height/body length measurements were taken before fecal collection, and mothers were educated on the proper collection procedure, including separation from urine by urinating first. fecal samples were collected in plastic wrap and transferred to clean, dry, and tightly closed pots using a stick or spoon. each pot was labeled, stored in an ice box at temperatures of 4-8°c, and transported to the nutrition laboratory of the faculty of public health, airlangga university for analysis. carbohydrate levels were examined using the luff school test, fiber levels through gravimetric test, and immunoglobulin-a levels using enzyme-linked immunosorbent assay (elisa) method. the obtained data were analyzed using a comparison test. normality test was first carried out to assess data distribution, respectively followed by homogeneity, and independent t-test for comparison. mann-whitney test can be carried out when data are not normally distributed or heterogeneous. result and discussion characteristics of respondents included gender, history of exclusive breastfeeding, history of diarrhea frequency each year, and type of additional food intake. respondents were 20 stunting and 20 non-stunting children residing in tuban regency, east java. based on table 1, the majority were female, namely stunting (60%) and non-stunting (65%) children. furthermore, there were 85% exclusive breastfeeding non-stunting children. both groups demonstrated a similar history of diarrhea frequency of once per year (40%), with porridge being the most common food intake. stunted children were affected by various factors such as socio-economics, environmental conditions, and behavior. gender differences in the risk of stunting varied significantly between regions, with several studies showing no effect due to wrong parenting patterns.14 a mother’s behavior in complying with exclusive breastfeeding had been proven to be associated with an increased risk of stunting. examples of poor food intake for children include micronutrient content, low food diversity, and wrong feeding patterns in terms of timing, consistency, and quantity. infant nutrition is crucial for the health and development of children.15 optimal breastfeeding and provision of healthy and appropriate complementary foods to babies until 2 years can increase immunity factors.16 diarrhea is known to be a complication of stunting and environmental conditions, affecting approximately 13.5%. sampling from a single population tends to have similarities in terms of environmental conditions and sanitation hygiene.17 a significant relationship was found between children who received complementary foods and the risk of stunting. however, the additional food in question was not solely based on the quantity or type of food provided, but also on diversity, balance of macronutrients and micronutrients, as well as intake of vitamins and minerals. the most important period of a children growth is up to the age of 60 months when any slowdown can cause disruption.18 the results of fecal examination are presented in table 2. the average carbohydrate content was ± sd-value of 11.39 ± 1.18 mg in feces of stunted children and 6.45 ± 1.17 mg for non-stunted. the average fiber content was ± sd-value of 5.28 ± 0.78% for stunted and 2.98 ± 0.73% for non-stunted. the average immunoglobulin-a level was ± sd-value of 31.47 ± 4.08 ng/ml for stunted and 12.94 ± 1.38 ng/ml for non-stunted. the absorption of carbohydrate macronutrients is influenced by starch, lactose, and sucrose consumed. foods containing cellulose cannot be digested by the small intestine, while monosaccha 4th international nursing and health sciences symposium table 1. distribution of respondents’ characteristics. characteristics stunting non-stunting frequency % frequency % gender male 8 40 7 35 female 12 60 13 65 exclusive breastfeeding yes 5 25 17 85 no 15 75 3 15 history of frequency of diarrhoea 1x/year 8 40 8 40 2x/year 10 50 7 35 3x/year 1 5 4 20 every drinking milk 1 5 1 5 types of additional food intake fine porridge 14 70 15 75 packaged porridge 2 10 0 0 family food 4 20 5 25 [healthcare in low-resource settings 2024;12(s1):13042] [page 63] non -co mmerc ial us e o nly rides are absorbed more rapidly by the body. digestion of carbohydrates initiates in the mouth through the action of amylase enzyme, and continues further in the microvillus membrane. however, monosaccharides can be directly absorbed, and unabsorbed carbohydrates, such as cellulose, are fermented by bacteria in the large intestine and used for energy conversion. excessive carbohydrate fermentation in malabsorption disorders can lead to bloating.19 absorption disorders in stunted children are related to adaptation mechanisms to chronic calorie, protein, and environmental deficiencies, as well as the extent of malnutrition.20 malnutrition contributes to a decrease in the secretion of pancreatic enzymes (lipase, trypsin, chymotrypsin, and amylase), atrophy of the villi in the intestine, changes in blood flow, and increased intestinal permeability. this can result to a decrease in digestive enzymes and absorption function in the large intestine.21 changes in the microbiota of the digestive tract, thinning of the mucosal layer and intestinal wall, atrophy of the microvilli (brush border), and changes in mucosal cells lead to increased intestinal mucosal permeability, more than threefold, in stunted children.22 consequently, this affects carbohydrate absorption, resulting in higher carbohydrate levels in feces of stunted children compared to non-stunted. based on table 3, data on carbohydrate, fiber, and immunoglobulin-a levels showed a normal distribution (p>0.05). in the homogeneity test, the homogeneous variables were carbohydrates and fiber (p>0.05), while immunoglobulin-a was heterogeneous (p<0.05). independent t-test was conducted to compare carbohydrate and fiber variables, which showed significant differences between the two groups (p> 0.05). furthermore, immunoglobulin variable was assessed using mann whitney test, showing significant differences (p>0.05). the microbiota in humans comprises bacteria, fungi, archaea, protozoa, and viruses found in the digestive tract. it plays a crucial role in processing dietary fiber to release antioxidant or antiinflammatory components. the breakdown of fiber by colonic microbiota can prevent various diseases, including digestive (colitis and infections) and metabolic disorders (diabetes, cardiovascular disease, and obesity).23 gut microbiota is related to digestion, absorption, and intestinal function. stunting children experience changes in the composition of gut microbiota, leading to an imbalance or dysbiosis.24 this dysbiosis can be related to malnutrition and a decrease in essential amino acid levels in plasma. furthermore, gut microbiota is essential in regulating body weight, particularly short chain fatty acid (scfa) production. changes in gut microbiota are also related to the pathophysiology of stunting and can be detected before growth retardation occurs.25 consumption of dietary fiber influences the microbial composition in the human gut and microbiome function, potentially leading to the development of chronic inflammatory diseases.26 the increase in fecal fiber levels in stunted children is attributed to the absence of microbiota in the digestive tract. immunoglobulin (ig) a contributed to host bacterial homeostasis in the intestine, which showed nutritional deficiency was associated with changes in the interaction between iga and gut microbiota.27 chronic nutritional deficiency tends to alter iga recognition of the microbiota. microbes bound to iga in feces are significantly higher in stunted children. stunting is associated with an increase in antibodies, leading to intestinal dysbiosis and inflammation. 28 iga also functions as a mucosal antibody in the intestine. a substantial increase of iga in stunted and non-stunted children should be considered due to the potential as a pathogen. 29 the chronic inflammatory process directly induces body inflammation and cell damage. 30 therefore, increased ig a levels are often observed in stunted children with infections and associated with a high risk of death. conclusions in conclusion, carbohydrate and immunoglobulin-a levels were higher in feces of stunted children due to digestive disorders and inflammatory processes, while fiber levels were lower (p≤ 0.05). 4th international nursing and health sciences symposium [page 64] [healthcare in low-resource settings 2024;12(s1):13042] table 2. results of children feces examination. variable average ± sd maximum minimum carbohydrate (mg) stunting 11.39 ± 1.18 13.02 8.99 non-stunting 6.45 ± 1.17 8.12 4.18 fiber (%) stunting 5.28 ± 0.78 6.58 3.64 non-stunting 2.98 ± 0.73 4.13 1.49 immunoglobulin-a (ng/ml) stunting 31.47 ± 4.08 39.90 25.92 non-stunting 12.94 ± 1.38 15.02 11.04 table 3. difference test results in children feces. variable normality test homogeneity test p-value carbohydrate (mg) stunting 0.252 0.798 < 0.001 non-stunting 0.359 fiber (%) stunting 0.525 0.645 < 0.001 non-stunting 0.631 immunoglobulin-a (ng/ml) stunting 0.124 < 0.001 < 0.001 non-stunting 0.053 non -co mmerc ial us e o nly references 1. joulaei h, keshani p, ashourpour m, et al. the prevalence of stunting among children and adolescents living in the middle east and north africa region (mena): a systematic review and meta-analysis. j glob health 2021;11:04070. 2. goldhagen jl, shenoda s, oberg c, et al.rights, justice, and equity: a global agenda for child health and wellbeing. lancet child adolesc health 2020;4:80-90. 3. ghattas h, acharya y, jamaluddine z, et al. child-level double burden of malnutrition in the mena and lac regions: prevalence and social determinants. matern child nutr 2020;16:e12923. 4. takele ba, gezie ld, alamneh ts. pooled prevalence of stunting and associated factors among children aged 6–59 months in sub-saharan africa countries: a bayesian multilevel approach. plos one 2022;17:e0275889. 5. laksono ad, wulandari rd, amaliah n, wisnuwardani rw. stunting among children under two years in indonesia: does maternal education matter? plos one 2022;17:e0271509. 6. fatima s, manzoor i, joya am, et al. stunting and associated factors in children of less than five years: a hospital-based study. pak j med sci 2020;36:581-5. 7. laksono ad, sukoco new, rachmawati t, wulandari rd. factors related to stunting incidence in toddlers with working mothers in indonesia. internat j environ res public health 2022;19:10654. 8. mustakim mrd, irwanto, irawan r, et al. impact of stunting on development of children between 1-3 years of age. ethiop j health sci 2022;32:569-78. 9. ordiz mi, davitt c, stephenson k, et al. eb 2017 article: interpretation of the lactulose:mannitol test in rural malawian children at risk for perturbations in intestinal permeability. exp biol med 2018;243:677–83. 10. amadi b, zyambo k, chandwe k, et al. adaptation of the small intestine to microbial enteropathogens in zambian children with stunting. nat microbiol 2021;6:445–54. 11. holscher hd. dietary fiber and prebiotics and the gastrointestinal microbiota. gut microbes 2017;8:172-84. 12. pietrzak b, tomela k, olejnik-schmidt a, et al. secretory iga in intestinal mucosal secretions as an adaptive barrier against microbial cells. int j mol sci 2020;21:9254. 13. ernawati r, feriani p, khosyi nd. the relationship between lbw history and genetic factors with the incidence of toddler stunting at loa ipuh health center tenggarong. jurnal ilmu kesehatan 2022;10:2. 14. thompson al. greater male vulnerability to stunting? evaluating sex differences in growth, pathways and biocultural mechanisms. ann hum biol 2021;48:466-73. 15. samosir ob, radjiman ds, aninditya f. food consumption diversity and nutritional status among children aged 6-23 months in indonesia: the analysis of the results of the 2018 basic health research. plos one 2023;18:e0281426. 16. walters cn, rakotomanana h, komakech jj, stoecker bj. maternal determinants of optimal breastfeeding and complementary feeding and their association with child undernutrition in malawi (2015–2016). bmc public health 2019;19:1503. 17. nasrin d, liang y, powell h, et al. moderate-to-severe diarrhea and stunting among children younger than 5 years: findings from the vaccine impact on diarrhea in africa (vida) study. clin infect dis 2023;76:s41-8. 18. mamun aa, mahmudiono t, yudhastuti r, et al. effectiveness of food-based intervention to improve the linear growth of children under five: a systematic review and meta-analysis. nutrients 2023;15:2430. 19. goodman be. insights into digestion and absorption of major nutrients in humans. adv physiol educ 2010;34:44-53. 20. selimoglu ma, kansu a, aydogdu s, et al. nutritional support in malnourished children with compromised gastrointestinal function: utility of peptide-based enteral therapy. front pediatr 2021;9:610275. 21. amadi b, besa e, zyambo k, et al. impaired barrier function and autoantibody generation in malnutrition enteropathy in zambia. ebiomedicine 2017;22:191–9. 22. semba rd, shardell m, trehan i, et al. metabolic alterations in children with environmental enteric dysfunction. sci rep 2016;6:28009. 23. makki k, deehan ec, walter j, backhed f. the impact of dietary fiber on gut microbiota in host health and disease. cell host microbe 2018;23:705–15. 24. hoffman dj, campos-ponce m, taddei cr, doak cm. microbiome, growth retardation and metabolism: are they related? ann hum biol 2017;44:201–7. 25. canfora ee, meex rcr, venema k, blaak ee. gut microbial 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13042] [page 65] correspondence: rivan virlando suryadinata, faculty of medicine,universitas surabaya, surabaya, jl. tenggilis mejoyo, kali rungkut, kec. rungkut, surabaya, east java, postcode:60293, indonesia. tel. +62.31.2981000. e-mail: rivan.virlando.s@staff.ubaya.ac.id key words: carbohydrates; feces; fibers; immunoglobulin-a; stunting contributions: all authors contributed substantially to the manuscript's development, encompassing the conception, design, data analysis, writing, and revision. conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by faculty of medicine, universitas surabaya. clinical trials: not applicable. ethics approval: research approval was issued by tuban regency onestop investment and integrated services service (no.070/298/1.s/414.111.3/2023). conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgement: the authors sincerely thank the faculty of medicine, universitas surabaya staff for their valuable assistance during this research. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13042 doi:10.4081/hls.2024.13042 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly metabolites in obesity, nafld and t2dm. nat rev endocrinol 2019;15:261–73. 26. erny d, hrabe de angelis al, prinz m. communicating systems in the body: how microbiota and microglia cooperate. immunology 2017;150:7–15. 27. syed s, ali a, duggan c. environmental enteric dysfunction in children. j pediat gastroenterol nutrition 2016;63:6–14 28. atarashi k, suda w, luo c, et al. ectopic colonization of oral bacteria in the intestine drives th1 cell induction and inflammation. science 2017;358:359–365. 29. huus ke, rodriguez-pozo a, kapel n, et al. immunoglobulin recognition of fecal bacteria in stunted and non-stunted children: findings from the afribiota study. microbiome. 2020;8(1):113. 30. suryadinata rv, wirjatmadi b. the molecular pathways of lung damage by e-cigarettes in male wistar rats. sultan qaboos university medical journal 2021;21:436–441. 4th international nursing and health sciences symposium [page 66] [healthcare in low-resource settings 2024;12(s1):13042]] non -co mmerc ial us e o nly 1 healthcare in low-resource settings eissn: 2281-7824 https://www.pagepressjournals.org/index.php/hls/index publisher's disclaimer. e-publishing ahead of print is increasingly important for the rapid dissemination of science. the early access service lets users access peer-reviewed articles well before print / regular issue publication, significantly reducing the time it takes for critical findings to reach the research community. these articles are searchable and citable by their doi (digital object identifier). the healthcare in low-resource settings is, therefore, e-publishing pdf files of an early version of manuscripts that undergone a regular peer review and have been accepted for publication, but have not been through the typesetting, pagination and proofreading processes, which may lead to differences between this version and the final one. the final version of the manuscript will then appear on a regular issue of the journal. e-publishing of this pdf file has been approved by the authors. healthc low-resour s 2025 [online ahead of print] to cite this article: abidah sn, salim la, hartini n, safitri yi. sexual assertiveness as a predictor of premarital sexual behavior among female adolescents: a cross-sectional studyiran. healthc low-resour s doi: 10.4081/hls.2025.13886 ©the author(s), 2025 licensee pagepress, italy note: the publisher is not responsible for the content or functionality of any supporting information supplied by the authors. any queries should be directed to the corresponding author for the article. all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. submitted: 11 april 2025 accepted: 11 november 2025 early access: 11 december 2025 https://www.pagepressjournals.org/index.php/hls/index https://www.pagepress.org/site 2 sexual assertiveness as a predictor of premarital sexual behavior among female adolescents: a cross-sectional study siska nurul abidah,1 lutfi agus salim,2 nurul hartini,3 yati isnaini safitri4 1doctoral program of public health, faculty of public health, universitas airlangga, surabaya; 2department of epidemiology, biostatistics, population studies and health promotion, faculty of public health, universitas airlangga, surabaya; 3department of psychology, faculty of psychology, universitas airlangga, surabaya; 4department of midwifery, faculty of nursing and midwifery, universitas nahdlatul ulama surabaya, surabaya, east java, indonesia correspondence: siska nurul abidah, doctoral program of public health, faculty of public health, universitas airlangga, surabaya, indonesia. e-mail:siska.nurul.abidah-2023@fkm.unair.ac.id key words: adolescents; assertiveness; behavior; premarital sex. contributions: sna conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; las conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; nh and yis, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research procedure receivedethics from the research ethics lembaga chakra brahmanda lentera institute no. 24.1/07/v/ec/kep/lcbl/2024. patient consent for publication: the research involved human participants. we obtained informed consent from respondents before collecting the data. funding: this research did not receive external funding. mailto:siska.nurul.abidah-2023@fkm.unair.ac.id 3 availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: we would like to thankful universitas airlangga and universitas nahdlatul ulama surabaya, indonesia for their valuable support. abstract adolescence is a critical phase of life that needs extra attention. one common issue among adolescents is engaging in premarital sex, which can have serious negative effects, especially for girls. girls need to develop the ability to firmly say no to premarital sexual activity, which is known as sexual assertiveness. this study aimed to examine the influence of sexual assertiveness on premarital sexual behavior in adolescents. this was an observational study using a cross-sectional design. the independent variable was the sexual assertiveness and the dependent variable in this research was premarital sexual behavior. this research was conducted in june – august 2024 in classroom settings at unusa. the sample in this study consists of 92 female students who have a boyfriend. the sampling technique used purposive sampling technique. data collection in this study was carried out face to face through interviews and questionnaires. the instruments used were the sexual behavior scale and the sexual assertiveness questionnaire (saq). analysis used a simple linear regression test. the results of the statistical test show a value of ρ = 0,000 (p < 0,05), which means there is an influence of sexual assertiveness on premarital sexual behavior in adolescents. adolescents with strong sexual assertiveness are better able to avoid engaging in premarital sexual activities, helping them steer clear of its negative consequences. the results of this study are expected to be the basis for designing interventions or educational programs aimed at improving sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. introduction premarital sexual behavior among teenagers is a growing problem. one aspect of this behavior is dating, which has become quite common among young people. a study revealed that 88% of teenagers in the uk have dated.1 similarly, a survey showed that 81% of indonesian teenagers have 4 dated.2 research shows that many individuals start dating for the first time during adolescence, around 33.3% of girls start between the ages of 15 and 17, while 34.5% of boys start before the age of 15.2,3 during this time, teenagers begin to feel attracted to the opposite sex and look for ways to fulfill their sexual urges.4 these findings indicate that the rate of dating among teenagers is quite high. however, in practice, dating also has the potential to be a gateway to sexual behavior that is not in accordance with norms and is not yet the right time to do, namely premarital sex. premarital sexual behavior is very likely to occur among teenagers because of their increasing curiosity during this stage of development. as they grow, teenagers often feel the desire to explore new experiences. they begin to develop an interest in the opposite sex and learn about love and affection.5 research shows that the higher the intensity and closeness in a dating relationship, the more likely teenagers are to engage in sexual activity.6 the level of dating that involves physical touch, intense emotional closeness, and pressure from partners often makes it difficult for teenagers to set healthy boundaries in relationships.7 when dating is carried out without sufficient understanding of sexual risks and boundaries, the chances of premarital sex increasing significantly.8 a report from the national population and family planning agency (bkkbn) shows that the prevalence of premarital sexual behavior among teenagers continues to increase from year to year.9 basic health research (riskesdas) data also shows that some teenagers have engaged in sexual activity before marriage, for various reasons ranging from love, pressure from partners, to environmental influences.10 this phenomenon is even more worrying when combined with the lack of understanding of adolescents about reproductive health and the low ability to reject sexual pressure from partners. adolescents often feel that sex is a form of "proof of love" in a relationship, even though this decision can have long-term implications for their physical, mental health, and future.11 unintended pregnancies, illegal abortions, and sexually transmitted infections are some of the impacts that can occur due to premarital sex.12 to mitigate these adverse outcomes, it is essential for adolescents to develop sexual assertiveness skills. sexual assertiveness skills are an important factor that can help adolescents to reject unwanted sexual advances, set boundaries, and make healthy and responsible sexual decisions.13 sexual assertiveness refers to an individual's ability to openly, honestly, and firmly express their desires, including rejecting or accepting sexual activity based on their own will, without pressure from others.14 adolescents with low levels of sexual assertiveness tend to be more easily influenced by pressure from partners or the environment to have premarital sex, even though they feel uncomfortable or not ready.15 this is supported by research who found that assertiveness technique 5 training for adolescents significantly increased adolescents' ability to reject sexual advances in dating.16 sexual assertiveness is the ability of an individual to express desires, rejections, and boundaries in the context of sexual relationships honestly and firmly. this ability is very important for adolescents to have, considering that they are in a period of developmental transition with a high level of exploration but are still vulnerable to environmental influences and peer pressure.17 research on premarital sex has been widely conducted, but has not yet discussed in depth the internal factors, one of which is psychological, so researchers currently want to develop predictors of the causes of premarital sex related to adolescent psychology, namely the ability of sexual assertiveness possessed by adolescents. based on this phenomenon, this study aims to examine the influence of sexual assertiveness on the likelihood of engaging in premarital sexual behavior among adolescents. currently, many teenagers are still unable to express agreement or rejection assertively, so they are at higher risk of engaging in unwanted premarital sexual behavior. therefore, this study is important to strengthen the understanding of how sexual assertiveness plays a role in preventing premarital sexual behavior in adolescents. this study is expected to be the basis for designing interventions or educational programs aimed at improving sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. materials and methods research design this study employed a quantitative, observational design with a cross-sectional approach. the research was conducted to examine the relationship between sexual assertiveness and premarital sexual behavior among female adolescents. participants the study population consisted of female undergraduate students enrolled in the midwifery program at universitas nahdlatul ulama surabaya. this research was conducted in june – august 2024 in classroom settings at universitas nahdlatul ulama surabaya. the sample in this study was 92 adolescents who met the inclusion and exclusion criteria, namely inclusion criteria: unmarried, currently in a relationship, aged 18-23 years, willing to be respondents and exclusion criteria: adolescents who did not fill out the questionnaire completely, adolescents who withdrew (dropped out) from the questionnaire filling process before completion. the sampling technique used in this 6 study was purposive sampling, which is a sampling technique based on certain considerations or criteria that are in accordance with the objectives of the study. data collection and instruments this study was granted by ethical clearance from lembaga chakra brahmanda lentera institute no. 24.1/07/v/ec/kep/lcbl/2024. data collection in this study was done face-to-face through interviews and using questionnaires. before filling out the questionnaire, each participant was given a complete explanation of the objectives, procedures, benefits, and potential risks of the study. participants were then asked to sign an informed consent form as a form of conscious and voluntary agreement to participate in this study. the independent variable in this study is sexual assertiveness and the dependent variable is premarital sexual behavior. sexual assertiveness it was defined as the ability to express sexual boundaries clearly, including the confidence to refuse unwanted sexual advances. measured using an 18-item scale. sexual assertiveness was adopted from sexual assertiveness questionnaire (saq) by loshek dan terrell.18 reliability of this instrument was cronbach's alpha = 0.890, demonstrating adequate. premarital sexual behavior: defined as sexual activities conducted outside of marriage, including physical intimacy such as kissing, touching, and intercourse. measured using a 16-item favorable scale. the instrument premarital sexual behavior scale was developed by researchers. the validity of this instrument showed correlation coefficients ranged from 0.410 to 0.883 (significance level of 5% = 0.278). reliability of the instrument was cronbach's alpha = 0.906, indicating high reliability. each item on both scales was rated using a 4-point likert-type response format. higher scores on the assertiveness scale indicate stronger sexual assertiveness, while higher scores on the sexual behavior scale indicate more frequent engagement in premarital sexual activities. data analysis the study aim of this study was to examine the influence of sexual assertiveness on premarital sexual behavior involvement among adolescents. we used spss program. descriptive statistic was used to measure the descriptive statistic of variable and simple linear regression was used to measure the role of sexual assertiveness and premarital sexual behavior among adolescents with statistical significance (p<0.05). 7 results table 1 shows an f value of 78,531 with a test significance of 0.000 < 0.05. this shows that there is a linear relationship between sexual assertiveness (x) and premarital sexual behavior in adolescents (y). this shows that the regression model can be used. table 2 shows the results of the t-test with a significance value of 0.000 smaller than 0.05 so that it can be concluded that ho is rejected and ha is accepted, thus it can be concluded that the sexual assertiveness variable (x) has a significant influence on premarital sexual behavior in adolescents (y). the regression equation obtained is y = 99.447-1.124x+e, from this equation it can be concluded that from each additional 1 unit of the independent variable, namely sexual assertiveness (x), the value of the dependent variable, namely premarital sexual behavior in adolescents (y) will decrease by -1.124. discussion the results of this study indicate that there is a significant influence of sexual assertiveness on premarital sexual behavior in adolescents. based on simple linear regression analysis, a significance value of <0.05 was obtained, indicating that sexual assertiveness has a statistically significant relationship with premarital sexual behavior. the negative regression coefficient of -1.124 indicates that the higher the level of adolescent sexual assertiveness, the lower the tendency of adolescents to engage in premarital sexual behavior. this finding is in line with previous research stating that adolescents with good sexual assertiveness are better able to reject invitations or pressure to engage in unwanted sexual activity.19 sexual assertiveness reflects the ability of adolescents to clearly state sexual needs and boundaries, and to maintain decisions that are in accordance with personal values and beliefs. when adolescents have self-control and the courage to say "no" to sexual pressure, their chances of engaging in premarital sex can be minimized.20 these results are also in line with previous studies showing that adolescents who have the confidence to reject sexual advances tend not to engage in risky sexual behavior, thus the importance of adolescents having sexual assertiveness skills as self-protection.21 adolescence is a period of psychological development that requires emotional maturity.22 this study also supports the theory that sexual behavior is not solely influenced by biological drives, but also by psychosocial factors, one of which is assertiveness. in the context of adolescence, the transition from childhood to adulthood is often marked by the search for identity and pressure from the social environment, including peers.23 sexual assertiveness is an important skill to help adolescents maintain their boundaries in such situations. this highlights the need for consistent assertiveness to help adolescents refuse, thereby reducing the risk of premarital sexual behavior.24,25 8 the results of this study also obtained a determination coefficient value (r square) of 0.384 indicating that premarital sexual behavior was 38.4% influenced by sexual assertiveness while the remaining 61.6% was likely influenced by other variables not examined in this study, such as selfcontrol, peer influence, religiosity, family norms, access to sexual information, and use of social media. however, although the influence of sexual assertiveness is moderate (38.4%), it is necessary to understand that sexual behavior is the result of a complex interaction between psychological, social, cultural, and environmental factors. therefore, interventions to prevent premarital sexual behavior in adolescents need to be carried out holistically by involving various approaches, including comprehensive sexual education, improving interpersonal communication skills, and support from family and the school environment.26 limitations in this study include the use of a cross-sectional design that cannot show a direct causeand-effect relationship. in addition, data were obtained through questionnaires, which allow for social bias in filling in answers by respondents. therefore, further research is recommended to use a longitudinal approach and consider other mediator or moderator variables, such as self-control, subjective norms, or quality of relationships with parents. practically, the results of this study provide important implications for the development of adolescent sexual education programs. this study is expected to strengthen the understanding of how sexual assertiveness plays a role in preventing premarital sexual behavior in adolescents. so that it can be a basis for designing interventions or educational programs that aim to improve sexual assertiveness skills as a form of self-protection in maintaining adolescent reproductive and mental health. interventions that focus on increasing sexual assertiveness can be one of the preventive strategies in preventing premarital sexual behavior in adolescents. educators, counselors, and health workers are expected to integrate assertiveness skills training into reproductive health education provided to adolescents as a reinforcement of positive values in adolescents so that they are able to make healthy and responsible sexual decisions. the results of this study also provide an understanding to adolescents that having good sexual assertiveness is a form of self-protection against the risk of premarital sexual behavior. assertiveness allows adolescents to set boundaries in relationships, reject unwanted sexual advances, and make decisions based on personal values and beliefs.27 thus, increasing sexual assertiveness needs to be part of the educational process and character formation of adolescents, especially in dealing with pressure from the social environment and dating relationships. 9 conclusions this study confirms a strong relationship between sexual assertiveness and premarital sexual behavior. the results of this study can encourage adolescents to realize the importance of having the ability to refuse unwanted sexual advances and to make sexual decisions consciously, responsibly, and not based on pressure or fear of losing a partner. this study supports the importance of equipping oneself with sexual assertiveness skills to avoid risky sexual behavior. the results of this study are expected to increase self-awareness and self-control in adolescents so that they can avoid premarital sexual behavior. in addition, health workers and teachers can be more sensitive to adolescents who show signs of low assertiveness, such as difficulty refusing, tending to follow peer pressure, or not daring to talk about discomfort in relationships. thus, earlier intervention can be given through a supportive approach. references 1. fox cl, corr m-l, gadd d bi. young teenagers’ experiences of domestic abuse. j youth stud 2014;17:510–26. 2. demographic and health survey (sdki). adolescent reproductive health. jakarta: national population and family planning agency (bkkbn); 2017. 3. ohee c, purnomo w. the influence of relationship status on risky dating behavior in papuan migrant students in surabaya city. indonesian j public health 2018;13:268–80. 4. zani b, cicognani e. sexuality and intimate relationships in adolescence. handbook of adolescent development. psychology press; 2020. 200–22 p. 5. nugroho e, shaluhiyah z, purnami ct, kristawansari k. counseling model development based on analysis of unwanted pregnancy case in teenagers. j kesehat masy 2017;13:137–44. 6. olivia yudi rs, darminto d. sexual behavior in adolescents in malang city reviewed from self-control. national seminar information systems 2018;2:225–31. 7. ajayi ai, odunga sa, oduor c, et al. “ i was tricked”: understanding reasons for unintended pregnancy among sexually active adolescent girls. reproductive health 2021;18:1–11. 8. rong z, wen z, maoxu l, et al. relationship between childhood sexual abuse and attitudes toward premarital sexual permissiveness among middle school students in luzhou, china. bmc public health 2022;22:71–5. 9. national population and family planning agency. indonesian population and family profile 2021. bkkbn; 2021. 10. kementerian kesehatan ri. national report of basic health research (riskesdas) 2018. jakarta: health research and development agency; 2018. 10 11. taquette sr md. causes and consequences of adolescent dating violence: a systematic review. j injury violence res 2019;11:137. 12. shrestha rb. premarital sexual behaviour and its impact on health among adolescents. j heal promot 2019;7:43–52. 13. kim m, choi j-h. a study on sexual behavior, sexual knowledge, and sexual assertiveness among korean college students. indian j sci technol 2016;9:1–8. 14. haider si, burfat fm. improving self-esteem, assertiveness and communication skills of adolescents through life skills based education. jssh 2018;26:2. 15. widman l, choukas-bradley s, helms sw, prinstein mj. adolescent susceptibility to peer influence in sexual situations. j adolescent health 2016;58:323. 16. amaliyah k, filliani r, hidayat dr. the effect of assertive training techniques to increase assertiveness towards sexual behavior in dating. j guidance counseling 2020;4:77–88. 17. couture s, fernet m, hébert m, etbal. “i just want to feel good without making you feel bad”: sexual assertiveness negotiation in adolescent romantic relationships. arch sexual behavior 2023;52:3063. 18. loshek e, terrell. the development of the sexual assertiveness questionnaire (saq): a comprehensive measure of sexual assertiveness for women. j sex res 2014;0:1–11. 19. afriani r, mahrita d, wahyuni s. the relationship between sexual assertiveness and premarital sexual behavior in adolescents. j reproductive health 2021;8:123–30. 20. alvarado sll, van parys h, jerves e, enzlin p. development of sexual assertiveness and its function for human sexuality: a literature review. interamerican j psychol 2020;54:948. 21. struckman-johnson c, anderson pb, smeaton g. predictors of female sexual aggression among a us mturk sample: the protective role of sexual assertiveness. j contemporary criminal justice 2020;36:499–519. 22. ozdemir a, utkualp n pa. physical and psychosocial effects of the changes in adolescence period. int j caring sci 2016;9:717–23. 23. santrock jw. adolescence (16th ed.). new york: mcgraw-hill education; 2018. 24. widman l, golin ce, kamke k, et al. sexual assertiveness skills and sexual decisionmaking in adolescent girls: randomized controlled trial of an online program. am j public health 2018;108:96–102. 25. kristanti i, poerwandari ek, pohan ld, primasari i. cognitive-behavioral intervention to enhance sexual assertiveness in women who exhibit premarital sexual compliance in the greater jakarta area, indonesia. pertanika j soc sci humanit 2019;27:2. 26. okah ps, onalu ce, aghedo gu, et al. factors associated with the premarital sex among 11 adolescents and the need for introduction of functional sex-education in secondary schools in ebonyi state, nigeria. cogent soc sci 2023;9:1. 27. lópez-alvarado s, van parys h, cevallos-neira a, enzlin p. latin american women's beliefs, views and ideas about sexual assertiveness: a focus group study in cuenca (ecuador). j sex res 2020;57:307–21. table 1. anova table model sum of squares df mean square f sig. 1 regression 2481.887 1 2481.887 78.531 .000(a) residual 2307.097 73 31.604 total 6466.467 91 a. predictor: (constant), sexual assertiveness b. dependent variable: premarital sexual behavior table 2. simple linear regression calculation results model unstandardized coefficients standardized coefficients t sig. b std. error beta 1 (constant) 99.447 8.512 11.682 .000 sexual assertivene ss -1.124 .150 -.620 -7.487 .000 a. dependent variable: premarital sexual behavior hrev_master healthcare in low-resource settings 2025; volume 13(s2):13494 changes in bullying behavior through agents of change using the balinese fable animation "tat twam asi" in jembrana regency putu sukma megaputri,1 putu dian prima kusuma dewi,1 made bayu oka widiarta,2 made padmarani sudewiputri3 1bachelor midwifery study program, buleleng health science, bali; 2bachelor nursing study program, faculty of medicine, universitas pendidikan ganesha, bali; 3bachelor elementary school education study program, faculty of education, triatma mulya university, bali, indonesia abstract bullying was a pervasive and urgent issue, often referred to as an iceberg phenomenon, with many cases remaining hidden beneath the surface. its consequences, including mental health deterioration, physical harm, and, in extreme cases, death, highlighted the critical need for effective intervention, particularly among adolescents. this study aimed to develop and evaluate the effectiveness of change agents—students empowered to influence their peers—using the balinese fable animation «tat twam asi» to reduce bullying behavior in schools. a mixed-methods approach was employed. the qualitative phase focused on the development of change agents through animation media, emphasizing cultural relevance and student engagement. this was followed by a quantitative phase, involving 930 students across 23 selected schools. a one-group pre-test and post-test design was implemented to assess changes in students’ understanding of bullying before and after the intervention. the analysis was conducted in two stages and statistical analysis using the wilcoxon signed-rank test, following a normality test of the data. the intervention using the «tat twam asi» animation significantly improved students’ understanding of bullying. this improvement was statistically significant (p < 0.05). the use of culturally grounded animation media to develop change agents proved effective in enhancing students’ awareness and bullying prevention behaviors. this type of intervention had not previously been implemented in indonesian elementary schools, particularly in bali, and showed promising results. introduction bullying, a prevalent issue among indonesian students, has become a permissive culture with serious consequences for victims.1 it often involves intimidation and seniority, both physically and psychologically, making schools a primary setting for such incidents.2,3 recognized as a mental health concern, unicef data from 2014 revealed that eight out of ten indonesian children experienced bullying, ranking the country fourth in child violence cases.4 the sustainable development goals (sdgs) aim to reduce child violence by 2030 and improve adolescent mental health5. bullying has evolved globally, extending into cyberbullying.6–8 many bullies were once victims themselves, learning intimidation through personal experiences.9,10 the contributing factors include school and social environments, peer influence, family dynamics, personality, and media exposure.11–15 jembrana regency, with its diverse cultural and religious backgrounds, is particularly vulnerable, with reported cases in bali. however, the absence of specific reporting tools makes it difficult and ineffective to address bullying. trend data from 2025 to 2020 show that the prevalence of bullying incidents in indonesia has decreased from 50% to 41% of bullying cases in schoolchildren aged 15 years. these data indicate that the rate of bullying among school children in indonesia remains relatively high.16–18 a 2016 study in buleleng regency showed that 53% of students in elementary, junior high, and senior high schools experienced verbal bullying from fellow students and school authorities, such as insults and derogatory remarks, from both fellow students and school authorities.19 research in the jembrana regency found that 64.1% of children had experienced correspondence: putu sukma megaputri, study program of midwifery, buleleng health science, bali, indonesia e-mail: sukmamegaputri26@gmail.com key word: animation; media; bullying; bali. conflict of interest: there is no potential conflict of interest among authors. ethical approval and consent to participate: this study was approved by the ethics committee of stikes buleleng, indonesia (certificate 7670824-kepk). during the study, the researcher paid attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. availability of data and materials: research data were generated and analyzed during the study and included in this article. funding: this research was funded by the drtpm ministry of education and culture of the republic of indonesia under the fundamental research scheme. acknowledgements: the author would like to express gratitude to the drtpm ministry of education and culture of the republic of indonesia for facilitating the research funds that were provided so that this research was successfully carried out until it was published. the author also expresses gratitude to the head of buleleng health sciences for supporting the facilities provided during the data collection. furthermore, the researcher did not forget to express thanks to the principal of the elementary school in jembrana regency as the sample for this research. received: 12 december 2024. accepted: 31 march 2024. early view: 8 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13494 doi:10.4081/hls.2025.13494 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13494] [page 1] bullying.9 indonesian children face bullying emergencies with serious consequences if they are untreated. reports have shown potential impacts, including decreased academic performance, suicide, smoking, drug use, alcohol consumption, and criminal activity.1 this has also contributed to the increasing number of juvenile crimes. efforts and regulations to address bullying without early childhood prevention education remain insufficient, as both victims and perpetrators are children, requiring unique intervention approaches. psychoeducation, empathetic therapy, picture storybooks, reproductive health education, and rational emotive behavior therapy (rebt)-based counseling have been proven effective in reducing bullying behaviors in children.20–25 programs like «dat-e adolescence» help reduce sexual harassment, while «serious games» enhance strategies against cyberbullying, fostering awareness and empathy.26 in indonesia, bullying prevention models include self-esteem building,20 design thinking,27 education, posters, games,1 counselling booklets28 and the «roots» program, which targets junior high and high school students through online anti-bullying campaigns facilitated by unicef and the peduli indonesia foundation.29 additionally, the sistem informasi anti perundungan (siap) program, currently in testing, aims to establish a student database for bullying reports in buleleng regency.30 globally, spain’s cyberprogram 2.0, cyberduca 2.0, and videogame raise awareness through interactive games,6 while malaysia’s olweus bullying prevention program (obpp) is also adopted in south africa.5 in addition, machine learning aids in detecting cyberbullying through adolescent social media networks.31 one strategy to help children avoid bullying is to establish change agents among the students themselves. these change agents, drawn from the community, will introduce change through balinese fables themed «tat twam asi.» fables are a long-standing tradition in bali and are often conveyed through storytelling. these fables incorporate balinese culture and folklore, conveying moral messages about good and bad behavior. they also aim to increase awareness of balinese heritage among younger generations, which is gradually being neglected. the culture of storytelling is overshadowed by cartoons and animation. the rationale for choosing balinese fables and their alignment with the local cultural philosophy of «tat twam asi” because in balinese people have tradition name was “mesatua” and this integrated with curriculum elementary school in bali. tat twam asi as one of cultural and general philosophy from sanskerta language was mean tolerance and make peace live unlike previous research, this study focuses on elementary school students and applies a behavioral change agent approach to create a database for reporting and classifying bullying incidents in the buleleng regency. while aligned with unicef’s roots program, it uniquely integrates a balinese fable-based module in a video format, making it the only bullying prevention initiative in bali that incorporates local wisdom. rooted in the balinese philosophy of tat twam asi—which means «i am you»—this approach emphasizes empathy and cultural relevance. bullying contradicts this philosophy, highlighting the need for interventions that reflect local traditions. however, no existing programs utilize balinese storytelling (mesatua) or animation to prevent bullying, thus presenting a research gap. this study introduces an innovative intervention using fable-based animation to foster behavioral change among students, reinforcing the values of tat twam asi. material and methods design, population, and sample this study employed a mixed-methods design, beginning with a qualitative approach to developing balinese fable animation media, followed by a quantitative phase to assess its impact. the qualitative stage involved expert reviews and small-scale trials to validate animation media before its implementation. the quantitative phase utilized a one-group pretest-post-test design to evaluate the effectiveness of behavior-change agents in reducing bullying behavior. the study was conducted across 23 elementary schools in the jembrana regency and was selected using cluster random sampling. a total of 930 students (aged 10-12 years) participated in this study. each school selected two students as behavior-change agents and one teacher as a facilitator. these agents received training on bullying prevention using balinese fable animation «tat twam asi.» variables this study included both the independent and dependent variables. independent variables: implementation of the «tat twam asi» animation media, participation in behavior change agent training, and facilitator involvement. dependent variables: changes in students’ knowledge, attitudes, norms, self-esteem, self-efficacy, and bullying behavior. development of animation media the development phase involved collaborating with animation media experts to create characters and storylines. the script was developed and refined using feedback from content experts, media specialists, and elementary school students. five student enumerators assisted with dubbing the animation. the final product underwent a media expert test involving two content experts, five media experts, and a trial with ten elementary school children aged 10-12 years. content validity was assessed using gregory’s formula, with a threshold of >0.6. data collection procedures stage 1 stage 1 begins with creating animation media, which involves conducting expert reviews. coordinating with the jembrana district education office: this includes all 23 schools in jembrana district. meeting with school principals: this meeting discusses the formation of behavior-change agents. each school sent two representatives to receive the balinese fable animation and assess their bullying behavior before and after the intervention. forming behavior change agents: these agents will be deployed to schools to deliver the balinese fable animation «tat twam asi.» stage 2 stage 2 involves deploying the change agents. agents are deployed in 23 randomly selected schools, with a total of 930 respondents. pre-test: a pre-test questionnaire was administered to assess knowledge, attitudes, norms, self-esteem, self-efficacy, and bullying behavior before the intervention. intervention: change agents implement the balinese fable animation «tat twam asi.» post-test: a post-test questionnaire was administered to reassess the same variables as in the pre-test. pathways of change, part ii [page 2] [healthcare in low-resource settings 2025;13(s2):13494] data analysis qualitative-quantitative (stage 1) after collecting content validity data from experts and users, a qualitative review was conducted on media improvements for children aligning with their daily lives. this review assessed the validity in terms of content, language, visuals, and material delivery. expert validity was evaluated using gregory’s formula with a score of >0.6, and content expert validity was assessed using lawshe’s formula with the aim of cvr >0.6. the analysis involved two expert evaluations, two learner evaluations, and a small-group evaluation with 10 elementary school students. the questionnaire gathered feedback on media for improvement. before being designated as change agents, they underwent a pre-post questionnaire analysis using a one-group pre-test–posttest design. normality tests were determined using a parametric test if the p-value was >0.05; otherwise, a non-parametric wilcoxon test was used. quantitative (stage 2) quantitative analysis using preand post-intervention questionnaires assessed the media’s effectiveness in the student group. after data collection, the prerequisites for the homogeneity and distribution of the research data were tested. the data was not normally distributed (p<0.05), necessitating the use of the non-parametric wilcoxon test to examine differences in bullying actions before and after implementing the balinese satua-based behavior change agent «tat twam asi.» to address potential shortcomings of the wilcoxon test, researchers conducted univariate and bivariate analyses, and tested differences in each independent and dependent variable. ethical consideration this study was approved by the ethics committee of stikes buleleng in indonesia (kepk id 7670824). results stage 1: development of balinese fable animation media this research consists of two stages: the development of balinese animation media used form behavioral change agents and teacher facilitators. the result of developing the media used balinese satua animation. the e-module provided during the behavioral change agent and teacher facilitator training used a flip pdf-based e-module. the media can be accessed online, where viewers can directly watch the balinese satua animation used for forming the change agent. the results of the media expert test show that the balinese satua animation was evaluated by two media experts, yielding a gregory test validity score of 0.78, indicating high validity for the media tested by a balinese media expert. after the media expert test, the researcher also conducted a content or subject matter expert test for the balinese satua animation. the content expert test results showed that expert 1 found the clarity of voice and the accuracy of writing and information in the animation video to be somewhat lacking. furthermore, expert 2 noted that the accuracy of the writing and information in the animation video, as well as the layout and design, were still somewhat inadequate. from the calculation above, a result of 0.78 was obtained, indicating that the media has high validity based on the expert evaluation. following the media expert test, the researcher also conducted a content test, which was analyzed by four experts in their respective fields, including psychology and psychiatric nursing experts. the results showed a cvr value of >0.6. the form of the developed media is an e-module, which also includes the balinese satua animation to help clarify students’ understanding in bullying prevention. this module starts with a cover that depicts the characters in the animation story. it is followed by a certification page and module content. each module contains a balinese satua animation video related to bullying prevention. based on the validity results from the media and content experts, the behavioral change agents were then formed. these change agents were created in accordance with the planned sample size, forming 46 change agents from 23 schools. the analysis results in table 1 show that the average age of a behavioral change agent is 11 years, with the majority being female, accounting for 69.6%. most of the participants are in grade 5, comprising 60.9%. the pre-test results, or the test given before participating in the behavioral change agent training, had an average score of 81.3. after receiving the training, the score increased to 82.6. this indicates that the participants, as behavioral change agents, have improved their understanding of bullying in schools, peer relationships, and the actions they can take as behavioral change agents through the balinese satua animation media. stage 2: media effectiveness test this stage began with the formation of behavioral change agents in 23 schools, with each school sending 2 students, resulting in 46 behavioral change agents for this study. the results of the univariate analysis and effectiveness test of the training show that most of the behavioral change agents were in the age range of 11 years, with the majority being female at 69.6%. of the selected agents, 60.9% were in grade 5, and 39.1% were in grade 6. the criteria for participating as a change agent in the selected schools were that two students from either grade 5 or 6 had to be chosen. next, a knowledge difference test was conducted before and after becoming a change agent, following a normality test of the data. the results showed a p-value of <0.05, indicating that the data did not follow a normal distribution. therefore, the analysis used was the wilcoxon test. the knowledge difference test before and after participating in the behavior change agent program reports the results of the knowledge difference test before and after receiving training as a behavior change agent (table 2). the results were statistically significant with a p-value < 0.05. subsequently, an effectiveness test was conducted to assess the impact of behavior change agents in schools. this stage aimed to evaluate the effectiveness of the provided module and the formed agents. a total of 930 samples were collected, distributed across 23 schools according to the distribution data. table 3 reports that the majority of students in stage 3 are female, accounting for 55.1%. most students are in the 6th grade of elementary school, making up 37.8%. univariately, 32.7% of students reported having been victims of bullying at school, while 17.3% reported having been perpetrators of bullying. next, the effectiveness of the preand post-tests was examined by comparing the conditions before the introduction of behavior change agents and the satua bali animation module with the conditions after their implementation. before conducting the analysis, a normality test was performed. the results indicated that the preand post-test data were not normally distributed, as the p-value was <0.05. therefore, a non-parametric test using the wilcoxon analy pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13494] [page 3] sis was applied to assess effectiveness. the results in table 4 indicate that students’ understanding of bullying improved after the introduction of behavior change agents and the satua bali animation module. the increase in understanding was observed compared to the period before these interventions. this result is also statistically significant, with a p-value < 0.05. this means that h0 is rejected, indicating a difference in students’ understanding of bullying before and after the establishment of behavior change agents using the satua bali animation in jembrana district. similarly, self-efficacy, attitudes, and self-esteem also showed statistically significant differences before and after the implementation of behavior change agents, with a p-value < 0.05. the variables that simultaneously contributed to the improvement of antibullying behavior can be observed. table 5 shows that the independent and dependent variables account for 78% of the effect, while 22% is attributed to other factors not included in this study. the linier regression equation obtained is y = 35.05 + 3.28 (attitude) + 6.05 (self-esteem). this means that for every 1-unit increase in attitude, the attitude variable increases by 3.28 units, assuming other independent variables remain constant. similarly, for every 1-unit increase in self-esteem, the self-esteem variable increases by 6.05 units, assuming other independent variables remain constant. discussion behavior change agents are expected to reduce bullying incidents in schools. this study adopts the fundamental philosophical values of tat twam asi and integrates them into animated films as a trigger medium for the formation of anti-bullying change agents. the findings revealed that behavior change agents play a highly effective role in enhancing the literacy and understanding of students, particularly those targeted for intervention, to further increase their knowledge about bullying and its prevention in schools. this aligns with previous research, which found that a key indicator of success in forming behavior change agents in schools is the reduction in bullying incidents and an increase in students’ awareness of the types and classifications of bullying.32 this highlights the strong correlation between the establishment of change agents and the prevention of bullying behavior in schools. additionally, one study found that animation media can enhance empathy, thereby encouraging the prevention of bullying behaviors among teenagers in madura.33 to address bullying behavior, the values of tolerance embedded in tat twam asi can be packaged into an animated medium to develop anti-bullying agents in schools. tat twam asi is a sanskrit phrase where «tat» means «he/she/they,» «twam» means «you,» and «asi» means «is.» thus, in essence, it conveys the meaning: i am you, and you are me, signifying that all beings are equal.34 based on this philosophy, this study sought to adopt animation as a means of shaping antibullying change agents. a literature review found that one of the educational models pathways of change, part ii table 1. results of the analysis of respondent characteristics who entered as behavioral change agents. variables f (%) age (mean±sd) 11.3 ± 0.4 sex male 14 (30.5) female 32 (69.6) class 5 (five) 28 (60.9) 6 (six) 18 (39.1) pre-test (mean±sd) 81.3 ± 10.8 post-test (mean±sd) 82.6 ± 18.5 table 2. difference test of knowledge before and after attending the behavior change agent program. result mean rank z value p pre-test 20.9 -2.58 0.01 post-test 28.83 table 3. student characteristic analysis. variable f (%) sex male 418 (44.9) female 512 (55.1) class 4 228 (24.5) 5 350 (37.6) 6 352 (37.8) victim yes 304 (32.7) no 626 (67.3) bully yes 161 (17.3) no 769 (2.7) table 4. results of descriptive analysis of difference test. results mean rank z value p pre-test knowledge 398.9 -23.94 <0.0001 post-test knowledge 440.4 pre-test self efficacy 406.1 -2.48 0.013 post-test self efficacy 431.1 pre-test attitude 198.1 -23.79 <0.0001 post-test attitude 496.1 pre-test self esteem 400.8 -5.08 <0.0001 post-test self esteem 553.6 table 5. multivariate analysis of variables that increase the nonoccurrence of bullying cases in schools. results r b p constanta 0.78 35.05 knowledge 0.09 0.3 self efficacy 0.01 0.7 attitude 3.28 <0.0001* self esteem 6.05 0.003* [page 4] [healthcare in low-resource settings 2025;13(s2):13494] for bullying prevention in schools includes the use of comic media, educational videos, and peer tutoring38. this review discusses that for students aged 11–16 years, the peer tutoring program known as tutoria entre iguales (tei), which originates from spanish, is effective in reducing both conventional bullying and cyberbullying. these suggest that the tei program is effective in reducing bullying and cyberbullying behaviors.39 the findings indicated support the effectiveness of forming anti-bullying behavior change agents through the satua bali animation media, which is based on the tat twam asi philosophy, as a preventive measure against bullying among school-aged adolescents. the philosophy of tat twam asi teaches human equality, emphasizing that bullying or oppression of others is not permitted. instead, tat twam asi promotes compassion and mutual care among individuals. the core principle embedded in this philosophy encourages people to treat others with the same kindness and respect they would wish for themselves. harmony, generosity, virtue, and wisdom—values instilled in tat twam asi—serve as guiding principles for adolescents in fostering relationships with their peers.40 the psychoeducation efforts undertaken were not only directed at students but also involved parents and teachers. this approach helps them develop awareness of the severe consequences of bullying in both the short and long term. additionally, teachers and parents have begun to recognize the symptoms experienced by bullying victims, allowing them to provide timely intervention without significant delays.41 these align with the empowerment efforts conducted by divayana,42 which found that bullying prevention can be achieved through digital literacy empowerment based on the tat twam asi philosophy. in this study, attitude was identified as a key multivariate factor that enhanced bullying prevention among students. a positive attitude toward bullying prevention was also found to increase students’ willingness to actively prevent bullying.43 positive prosocial attitudes significantly influences students’ motivation to engage in bullying prevention efforts at school. in addition to the variables mentioned above, self-esteem also plays a crucial role in bullying prevention. these findings indicate that individuals with high self-esteem are more capable of preventing bullying. this aligns with previous research, which found that students with higher self-esteem are more likely to prevent bullying among their peers. high self-esteem is influenced by various factors, including family support, media exposure, and peer support.9 as a result, students with high self-esteem were less likely to engage in bullying behaviors. a limitation of this study is the absence of a control group to compare the effectiveness of forming behavior change agents through the satua bali animation. future research should incorporate a comparative study using satua bali animations or expand the sample size. this would allow for the potential integration of this media into the bullying prevention curriculum in jembrana, bali, and in indonesia. conclusions there was a difference in bullying prevention behavior before and after the formation of the behavioral change agents. this result seems to be highly effective, as can be seen from the statistical value. the behavioral change agents formed had a positive impact on increasing the preventive behavior of bullying among elementary school students in jembrana district. despite the limitations of not having a control group, this did not affect the results of the effectiveness test between the groups before and after being given the behavior change agent using the satua bali animation. next, researchers hope to redevelop the research to reach a wider population. in addition, balinese satua animation can serve as a reference and can be substituted into the curriculum to prevent bullying in schools. references 1. yamin a, shalahudin i, rosidin u, somantri i. pencegahan perilaku bullying pada siswa-siswi smpn 2 tarogong kidul kabupaten garut. j pengabdi kpd masy 2018;2:293–5. 2. yusuf a, habibie an, efendi f, et al. prevalence and correlates of being bullied among adolescents in indonesia: results from the 2015 global school-based student health survey. int j adolesc med health 2022;34:64. 3. rohmana dy, estelina k, iskandar i. the bullying phenomenon and handling efforts in reducing cases of bullying: a systematic review. j ners 2020;15:557–62. 4. terbit h. kasus bullying di sekolah peringkat empat terbanyak. humaniora 2018;11019. 5. sivaraman b, nye e, bowes l. school-based anti-bullying interventions for adolescents in lowand middle-income countries: a systematic review. aggress violent behav 2019;45:154–62. 6. garaigordobil m, martínez-valderrey 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bimbing dan konseling terap 2018;3:22–36. 12. nugroho s, handoyo s, hendriani w. identifikasi faktor penyebab perilaku bullying di pesantren: sebuah studi kasus. al-hikmah j agama dan ilmu pengetah 2020;17:1–14. 13. kusnandar vb. penduduk bali capai 4,27 juta, mayoritas usia produktif. databoks. 2021. 14. wuryanningsih ew, kurniyawan eh, aisyah ec. correlation between emotional peer support and cyberbullying behaviour in senior high school students. j ners 2019;14:205–9. 15. kartono dt, suyanto b, sugihartati r, et al. tolerance of high school students in an urban-transition city: a study in batu city. cogent educ 2025;12:2445364. 16. beaton jm, doherty wj, wenger lm. bullying in indonesia. routledge handb fam commun 2020;225–40. 17. patchin jw, hinduja s. tween cyberbullying in 2020 in partnership with cartoon network. 2020. 18. hennelly ml, ctori i. technology in education. community eye health j 2022;35:22–3. 19. sedanayasa g, dharmayanti p. identifikasi dan analisis pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13494] [page 5] tindak kekerasan pada sekolah di kabupaten buleleng. 2016. 20. fatimatuzzahro a, suseno mn. menurunkan perilaku bullying pada anak. j petik 2017;3:1–12. 21. purwaningrum s, pamungkas b. pengembangan model konseling kelompok dengan pendekatan rational emotive behavior therapy (rebt) untuk mengurangi perilaku bullying pada siswa abk di sekolah dasra inklusif. j bimbing dan konseling ar-rahman 2018;4:35–9. 22. komariah s, studi p, komunikasi d, et al. perancangan buku cerita bergambar tentang edukasi pencegahan bullying untuk anak sekolah dasar. 2017;4:817–23. 23. amawidyati sag. program psikoeduasi bullying untuk meningkatkan efikasi diri guru dalam menangani bullying di sekolah dasar. j psikol ilm 2017;9(3). 24. albuhairan f, abou abbas o, el sayed d, et al. the relationship of bullying and physical violence to mental health and academic performance: a cross-sectional study among adolescents in kingdom of saudi arabia. int j pediatr adolesc med 2017;4:61-5. 25. rothon c, head j, klineberg e, stansfeld s. can social support protect bullied adolescents from adverse outcomes ? a prospective study on the effects of bullying on the educational achievement and mental health of adolescents at secondary schools in east. j adolesc 2017;43:579–88. 26. muñoz-fernández n, ortega-rivera j, nocentini a, et al. the efficacy of the “dat-e adolescence” prevention program in the reduction of dating violence and bullying. int j environ res public health 2019;16:408. 27. calvo-morata a, alonso-fernández c, freire m, et al. serious games to prevent and detect bullying and cyberbullying: a systematic serious games and literature review. comput educ 2020;157:103958. 28. pratiwi we, sahono b. pengembangan buku saku bimbingan konseling untuk pencegahan bullying di sekolah menengah atas kota bengkulu. diadik j ilm teknol pendidik 2019;9:206–11. 29. yubilia keysinaya e. peran unicef indonesia menangani perundungan di sekolah melalui program roots. online) sospol j sos polit 2022;8:207–24. 30. megaputri ps, dewi pdpk, widiarta mbo, saskara gja. deteksi dini perundungan remaja di sekolah menggunakan aplikasi siap. buleleng; 2023. 31. angelis j de, perasso g. cyberbullying detection through machine learning: can technology help to prevent internet bullying? int j manag humanit 2020;4:57–69. 32. jusri a, rindy p, ami r, et al. peran peserta didik sebagai agen perubahan dalam mencegah perundungan ( bullying ) di sma negeri 1 panyabungan didesain untuk mempromosikan nlai-nilai penghargaan terhadap orang lain , keterbukaan , bullying dapat di atasi dengan bijak . penelitian ini di. 2024;(2). 33. aini k, rini hp. effectiveness of animation media in enhancing empathy to prevent bullying behavior in madurese adolescents. 2024;146:01064. 34. cahyani kwd, untara imgs, somawati av. analisis semiotika roland barthes dalam perilaku bullying pada film oliver twist. vidya darsan 2024;5:160–80. 35. burger c, strohmeier d, kollerová l. teachers can make a difference in bullying: effects of teacher interventions on students’ adoption of bully, victim, bully-victim or defender roles across time. j youth adolesc 2022;51:2312–27. 36. yang a, li x, salmivalli c. maladjustment of bully-victims: validation with three identification methods. educ psychol 2016;36:1390–1407. 37. hidayat i, sailirrohmah h, khasanah a, putri ss. implementasi agen perubahan dalam menanggulagi kasus bullying di lingkungan sekolah. j pendidik dan ilmu sos 2024;2:18–27. 38. marhaely s, purwanto a, aini rn, et al. literatur review: model edukasi upaya pencegahan bullying untuk sekolah. jurnal kesehatan tambusai 2024;5:826–34. 39. ferrer-cascales r, albaladejo-blázquez n, sánchezsansegundo m, et al. effectiveness of the tei program for bullying and cyberbullying reduction and school climate improvement. int j environ res public health. 2019;16:580. 40. sumaryani nm. penanaman nilai-nilai tat twam asi pada anak usia dini guna meminimalisir bullying ( culturing tat twam asi values in early children to minimize bullying ). jarita j child educ learn res 2023;1:1–7. 41. nursan hj. pembentukan komunitas perlindungan kekerasan pada anak dan implementasi kegiatan. j pengabdian, pemberdaya dan penyul kpd masy 2022;37–42. 42. divayana dgh, suyasa pewa, heryanda kk, diatmika nle. pemberdayaan literasi digital berbasis tat twam asi sebagai upaya pencegahan bullying di kalangan siswa. in: proceeding senadimas undiksha. 2023. p. 382–9. 43. ginanjar l, sugandi l, gunawan g, et al. manajemen pendidikan karakter dalam pencegahan perundungan. edusaintek j pendidikan sains dan teknol 2024;11:1892–906. pathways of change, part ii [page 6] [healthcare in low-resource settings 2025;13(s2):13494] hrev_master healthcare in low-resource settings 2025; volume 13:13616 antenatal care access for migrant women in thailand: insights from myanmar workers in khon kaen tint tint htay,1 charles ruangthamsing,1 peerasit kamnuansilpa,1 grichawat lowatcharin,1 suthiwat wetchakama,2 prasongchai setthasuravich3 1college of local administration, khon kaen university, khon kaen, thailand; 2department of internal medicine, faculty of medicine, khon kaen university, khon kaen, thailand; 3international project laboratory, graduate school of engineering, the university of tokyo, japan abstract migrant populations face numerous challenges in accessing healthcare, particularly maternal health services, which are essential for positive maternal and neonatal outcomes. in thailand, myanmar migrant women experience multiple social, financial, and systemic barriers that hinder their access to antenatal care (anc). this qualitative study explored these barriers in muang district, khon kaen province, in northeastern thailand, with a large population of myanmar migrant workers employed primarily in labor-intensive industries. data were collected through semistructured interviews with ten purposively selected documented women migrant workers from myanmar. thematic analysis was used to identify key barriers and facilitators of anc access. the findings revealed that although public transportation was available, long travel and wait times limited anc accessibility. public hospitals demonstrated strong service, offering comprehensive anc services. however, the lack of formal health education left many women unprepared to navigate the healthcare systems. workplace flexibility, including unpaid leave, enabled women to access anc services despite income concerns. financial barriers were mitigated by social insurance schemes, such as the social security scheme and migrant health insurance scheme, which significantly reduced out-of-pocket expenses. nonetheless, language barriers and prolonged wait times negatively affected patient experiences. these findings highlight the need for targeted interventions, such as improved health education, language support, and migrant-friendly policies, to address systemic barriers and advance equitable maternal and neonatal health outcomes for migrant populations. introduction migration is a global demographic phenomenon affecting over a billion people, or approximately one in eight individuals worldwide.1 migration presents both opportunities and challenges that are often driven by poverty, insecurity, limited access to essential resources, conflict, environmental degradation, and natural disasters. although migration may offer improved economic prospects, it exposes migrants to health risks. barriers such as language differences, cultural unfamiliarity, discrimination, and restricted service availability often hinder migrants’ access to healthcare in both transit and destination countries.1 healthcare policies for migrants are complex and influenced by factors including national security laws and economic considerations.2 moreover, limited awareness of available healthcare options among migrant workers further constrains their access to necessary services.3 due to its economic opportunities, thailand has become a significant destination for migrant workers from neighboring countries, particularly myanmar, cambodia, and laos.2 migration in the asean region intensified following the 2015 economic integration led by the asean community.4 migrants, particularly those in labor-intensive sectors, significantly contribute to the thai economy, enhancing workforce availability and national correspondence: prasongchai setthasuravich, international project laboratory, graduate school of engineering, the university of tokyo, 7-3-1 hongo, bunkyo, tokyo 113-8656, japan. e-mail: setthasuravich@g.ecc.u-tokyo.ac.jp key words: antenatal care, myanmar migrant workers, healthcare accessibility, thailand, maternal health conflict of interest: the authors declare that they have no competing interests funding: none contributions: tth, ps, conceptualization, data curation, formal analysis, methodology, validation, writing –original draft, review & editing; cr, conceptualization, methodology, validation, review & editing, supervision; pk, gl, sw, conceptualization, methodology, validation, writing –original draft, review & editing. ethics approval and consent to participate: the khon kaen university ethics committee for human research ethics approved this study (reference number he673404). informed written consent was obtained from all participants. availability of data and material: this published article includes all data generated or analyzed in this study. acknowledgments: the authors express their heartfelt gratitude to the myanmar migrant community in khon kaen, thailand, for their invaluable cooperation and to khon kaen university for supporting this research. received: 11 january 2025. accepted: 25 may 2025. early access: 18 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13616 doi:10.4081/hls.2025.13616 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 256] [healthcare in low-resource settings 2025;13:13616] gdp.5,6 in 2018, thailand hosted 4.9 million migrant individuals, with 80% being myanmar nationals.7 however, only 49 percent of these migrants had access to health insurance, underscoring a critical gap in healthcare accessibility.8 this lack of healthcare access is particularly concerning for myanmar migrant women in northeastern thailand, where healthcare access rates are notably low.9 migration from myanmar to thailand has long been influenced by a combination of economic, social, and political factors. cross-border movement increased notably following the political changes in myanmar in early 2021. in the years since, evolving conditions—including economic challenges and localized instability—have contributed to continued migration flows, particularly from areas such as kayin, shan, and mon states. thailand, with its geographic proximity and established migrant networks, has remained a common destination. while earlier migration was often driven by limited livelihood opportunities and long-standing regional disparities, more recent trends reflect a complex mix of structural factors. migrants arriving in thailand may encounter various challenges, including informal employment, low wages, indebtedness, and limited access to social protection.8 myanmar migrant workers in thailand are concentrated in agriculture, hospitality, seafood processing, construction, and manufacturing. many are employed in informal or seasonal roles, especially undocumented workers, with women particularly overrepresented in precarious jobs like seafood processing and agriculture. while reforms in the fishing industry have reduced exploitation, challenges persist. undocumented and contract workers often face low wages, job insecurity, limited legal protections, and exclusion from social benefits like healthcare. these vulnerabilities are more pronounced in border provinces, where temporary employment and lack of full-time contracts are common.6 the third goal of the united nations’ sustainable development goals emphasizes promoting good health and well-being for individuals of all ages.10 a key target, established jointly by the world health organization (who) and the united nations, is reducing the global maternal mortality rate to less than 70 per 100,000 live births by 2030. maternal mortality is disproportionately high among women in rural and impoverished areas, primarily due to pregnancy-related complications and limited access to maternal health services, such as antenatal care (anc) and delivery services. according to the who, inadequate care before, during, and after delivery is a leading cause of pregnancy complications and maternal deaths.11 research by the international organization for migration found that migrant mothers in thailand experience a maternal mortality rate of 289 per 100,000 live births, which significantly exceeds the national average of 37.7 per 100,000 live births. additionally, only 25.41% of pregnant migrant workers in thailand accessed anc services in 2017.12 anc is a critical component of reproductive healthcare that contributes to healthy pregnancies and safe deliveries. the who emphasizes that anc directly reduces maternal mortality and morbidity by enabling early detection and treatment of pregnancy-related conditions. furthermore, anc indirectly contributes to safer deliveries by identifying women at higher risk for complications and ensuring they receive appropriate care.13 a significant proportion of migrant women are in their reproductive years and face considerable challenges regarding reproductive health, family planning, pregnancy, and childbirth.14 healthcare accessibility for myanmar migrant women is influenced by healthcare policies, service availability and accessibility, financial resources, type of work, social support, language, and communication barriers.14 these women encounter multiple obstacles in accessing healthcare, including their inability to afford health insurance, concerns over wage deductions, unfamiliarity with healthcare facilities, transportation costs, and instances of denied access.14 therefore, investigating antenatal healthcare access for migrant women in khon kaen, thailand, is vital for addressing the significant barriers they face and informing interventions that could enhance their healthcare outcomes and overall well-being. to the best of our knowledge, no previous studies have investigated antenatal healthcare access of myanmar migrant women in khon kaen. exploring these antenatal healthcare access challenges is crucial. this study aims to explore the barriers to and facilitators of antenatal healthcare service access among myanmar migrant women workers in the muang district of khon kaen province, thailand, and propose recommendations for improving the accessibility of these services. materials and methods study area this study was conducted in khon kaen province, located in northeastern thailand. the province was chosen due to its substantial economic migration from myanmar and its sizable population of myanmar migrant workers, most of whom are employed in labor-intensive sectors. as of march 2024, data from the khon kaen provincial labour office reports that 6,100 myanmar migrant workers are employed in the province. additionally, no prior studies have focused explicitly on vulnerable groups in khon kaen, such as migrant women from myanmar, and their access to anc services. thus, khon kaen is an ideal location to explore the challenges migrant workers face in accessing healthcare, specifically anc services. study design a qualitative case study approach was adopted to explore the experiences of myanmar migrant women in accessing antenatal healthcare services in khon kaen. the case study design allowed for an in-depth investigation of personal and contextual factors influencing healthcare access among this population. this approach is well-suited for capturing complex sociocultural phenomena and understanding the nuanced experiences of a specific group within their real-life context. participants this study focused on documented migrant women employed in formal sectors due to their eligibility for social insurance schemes and structured employment settings. undocumented workers were excluded because of logistical and ethical challenges in recruitment and the distinct healthcare barriers they face, which warrant separate investigations. the study used purposive sampling to select participants, focusing on documented myanmar migrant women who accessed anc services in khon kaen within the past two years (in 2022–2024). the community leaders were engaged to select the participants. participants were purposefully sampled to include variation in age, parity (first-time vs. experienced mothers), ethnicity, and education level. this approach aimed to capture a range of experiences. participants included women aged 23–37 years, currently residing in khon kaen and having sought anc at least once in the area. ten participants were interviewed (table 1), with sample size determined based on data saturation, ensuring that no new information emerged from additional interviews. article [healthcare in low-resource settings 2025;13:13616] [page 257] data collection data were collected through in-depth, semi-structured interviews conducted in the myanmar language to encourage open communication and ensure participant comfort. before the interviews, all participants received an information and consent letter written in myanmar. in the letter, we explained the research objectives and emphasized that participation was voluntary. a guide for the semi-structured interviews was created and covered key topics such as geographic accessibility, availability, financial accessibility, and acceptability based on the framework of peters et al.15 for accessing health services. interviews were recorded with participants’ consent and later transcribed for analysis. data analysis thematic analysis was used to identify and analyze patterns within the data. following the seven stages of braun and clarke, the analysis included transcription, data familiarization, initial coding, theme generation, theme review, theme definition, and final write-up.16 this approach allowed for the systematic identification of recurring themes and insights, which provided a deeper understanding of the barriers to and facilitators of healthcare access, as experienced by myanmar migrant women in khon kaen. ethical considerations the khon kaen university ethics committee for human research ethics approved this study (reference number he673404). we ensured that all participants were volunteers. informed written consent was obtained from all participants, who were assured confidentiality and anonymity in reporting results. participants were informed of their right to withdraw from the study at any stage without any consequences. the study adhered to ethical guidelines for research involving human subjects, ensuring respect and protection for all participants. results this study highlights the experiences of myanmar migrant women employed in khon kaen province as they accessed antenatal healthcare services at khon kaen public hospital. participants generally reported positive experiences accessing anc, which were facilitated by their documented status and coverage under social security or migrant health insurance. five primary themes emerged from the interviews (table 2). first, participants widely reported ease of physical access to healthcare services, indicating that the hospital’s location and available transportation options made visits manageable. second, participants generally perceived the healthcare facilities as adequately equipped to meet their needs, citing essential resources and staff availability. third, workplace flexibility played a significant role, as supportive employers made it easier for participants to attend antenatal appointments without risking job security. fourth, the financial feasibility of accessing care, supported by the social article table 1. demographic characteristics of research participants. no. id age parity ethnicity years in thailand participant’s education husband’s education monthly household income (thb) 1 p01 23 p1 burmese 2 high school middle school 23,000 2 p02 30 p1 burmese 7 primary school middle school 10,000 3 p03 36 p2 burmese 8 middle school primary school 22,000 4 p04 28 p2 burmese 9 primary school undergraduate 15,000 5 p05 31 p1 burmese 10 middle school middle school 18,000 6 p06 37 p2 burmese 10 primary school middle school 16,000 7 p07 28 p1 mon 10 high school high school 15,000 8 p08 28 p1 burmese 11 middle school middle school 15,000 9 p09 33 p3 kayin 14 middle school unknown 20,000 10 p10 25 p2 burmese 15 primary school primary school 20,000 [page 258] [healthcare in low-resource settings 2025;13:13616] table 2. barriers to and facilitators of access to antenatal care services in khon kaen, thailand. key themes sub-themes description physical accessibility transportation options city buses were cheap but required transfers, taking 30-60 min to the hospital. distance private taxis covered the 15.5 km trip in 30 min. healthcare services readiness comprehensive care anc services included ultrasounds, tests, vaccines, medication, and health education. health information gaps migrants relied on friends and translators to seek health care; formal resources were limited. limited health education workplace and early pregnancy education were lacking. workplace flexibility employer flexibility lighter duties and unpaid anc leave were offered. administrative barriers medical leave requests were discouraged by extensive paperwork requirements. financial feasibility insurance coverage social security or migrant health insurance reduced costs. transport cost travel expenses were affordable due to the availability of city buses. acceptability positive experiences migrants reported respectful, high-quality care from healthcare staff. language challenges formal workers benefited from translators provided by employers; informal workers faced barriers due to the lack of translators at the hospital. security scheme (sss) or migrant health insurance scheme (mhis), allowed participants to receive necessary services despite limited family incomes. finally, participants valued the acceptability and patient-centeredness of the care, which helped foster a sense of trust and comfort in the healthcare environment. collectively, these themes indicate that documented myanmar migrant workers in khon kaen face fewer barriers to anc than we expected. however, language and cultural factors still impact their overall experience. physical accessibility of health care services migrant women predominantly relied on public transportation, specifically city buses, for anc visits. however, they faced challenges related to travel time and waiting periods. many women had to transfer between buses because there were no direct routes from their residences to the public social security hospital. p01 shared, “i took the city bus but had to transfer between two buses, as there was no direct route to the hospital. usually, it was manageable, but sometimes i had long waits, making the trip take 30 minutes to an hour.” this highlights the inconvenience of navigating the public transport system for healthcare access. although most participants used public buses for anc follow-ups, p09 noted, “most of the migrant women used public buses most of the time for anc follow-up, but occasionally, in case of rain or emergencies, we used private taxis, which are expensive.” despite these challenges, all the women remained committed to attending their scheduled anc visits, reflecting their determination to access necessary healthcare services. migrant women predominantly relied on public transportation, specifically city buses, for anc visits. however, they faced challenges related to travel time and waiting periods. many women had to transfer between buses because there were no direct routes from their residences to the public social security hospital. p01 shared, “i took the city bus but had to transfer between two buses, as there was no direct route to the hospital. usually, it was manageable, but sometimes i had long waits, making the trip take 30 minutes to an hour.” this highlights the inconvenience of navigating the public transport system for healthcare access. although most participants used public buses for anc follow-ups, p09 noted, “most of the migrant women used public buses most of the time for anc follow-up, but occasionally, in case of rain or emergencies, we used private taxis, which are expensive.” most women lived in urban areas of khon kaen and traveled approximately 15.5 kilometers to reach the hospital, typically taking 30 minutes to one hour, depending on traffic. while public buses were generally affordable, with fares around 22 thb per trip, private transport alternatives like taxis could cost up to 200 thb, posing a financial strain. despite the logistical and financial challenges, all participants consistently attended anc appointments, demonstrating strong personal commitment and health-seeking behavior. service readiness in healthcare findings reveal that khon kaen public hospital largely met the anc needs of myanmar migrant women, providing comprehensive services and quality care. these women primarily went to the designated social security hospital. they often relied on informal sources for initial information about anc services, such as experienced mothers, friends, and myanmar translators employed at their factories. p10 noted, “i learned where to seek antenatal care from senior mothers who had already given birth when i became pregnant.” women often did not receive formal health information from their healthcare providers or employers, leading to selfdirected decisions about when to start anc. p04 shared, “when i was pregnant, i contacted the translator for information about antenatal care services. i received no formal information about healthcare services from healthcare providers.” this reliance on informal networks and translators highlights the absence of structured reproductive health education and culturally appropriate communication, which could delay anc initiation. indeed, many women began anc in the second trimester, believing their good health or past pregnancy experience justified postponement. language barriers and the lack of written information in burmese further limited their understanding, making the role of translators essential in facilitating communication and navigation of the health system. the hospital was well-equipped regarding service availability, offering a full range of anc services, including ultrasounds, blood tests, urine tests, vaccinations, nutritional counseling, and necessary medications for pregnancy-related complications. p08 remarked, “i received a full package of anc examinations, such as ultrasound, blood test, and urine test, during my first visit, and necessary tests during subsequent follow-up appointments. according to the doctor’s appointment times, i went to the hospital at least eight times.” despite the availability of services, long wait times often lasting 30 minutes to an hour were a common challenge, particularly uncomfortable during late-stage pregnancy. p01 recalled feeling dizzy while waiting. still, none of the women missed appointments, indicating a strong commitment to receiving professional healthcare. those with complications, like hypertension and diabetes, received appropriate care, as p09 shared, “i got the necessary medication for my pregnancy-related complications.” overall, khon kaen public hospital effectively met the anc needs of myanmar migrant women through comprehensive services and consistent care. however, formal health education and communication gaps often delay anc initiation, with most women relying on peers or translators for information. language barriers limited understanding of medical advice, making myanmar-speaking translators essential for bridging communication gaps. despite challenges like long wait times, the women remained committed to attending appointments. improving culturally and linguistically appropriate health communication and early education could enhance timely and equitable anc access for migrant populations. workplace flexibility and support for antenatal care access workplace flexibility was essential for myanmar migrant women in khon kaen to access anc. many women relied on employer-approved leave, often using their six annual leave days for appointments. supervisors generally supported their needs by allowing time off and assigning lighter duties. however, many women required additional leave, resulting in unpaid time off; nevertheless, they remained committed to seeking care. participant p04 noted, “i could take leave on the days i needed to go to the hospital for anc. i just had to inform my supervisor in advance.” however, p03 shared, article [healthcare in low-resource settings 2025;13:13616] [page 259] “i used my annual leave for anc visits, but i had to go to the hospital around 10 times, so i needed additional leave. my supervisor approved the extra days off, but i wasn’t paid for them.” although some women could avoid wage deductions by providing medical documentation, the administrative burden of this process discouraged its use, as p10 explained: “i didn’t want to go through the extra steps of getting those documents… having paid leave for antenatal care visits, separate from annual leave, would make it easier for me to attend appointments without worrying about the daily wages.” workplace flexibility was essential for myanmar migrant women in khon kaen to access anc. many women relied on employer-approved leave, often using their six annual leave days for appointments. supervisors generally supported their needs by allowing time off and assigning lighter duties. however, many women required additional leave, resulting in unpaid time off; nevertheless, they remained committed to seeking care. participant p04 noted, “i could take leave on the days i needed to go to the hospital for anc. i just had to inform my supervisor in advance.” however, p03 shared, “i used my annual leave for anc visits, but i had to go to the hospital around 10 times, so i needed additional leave. my supervisor approved the extra days off, but i wasn’t paid for them.” although some women could avoid wage deductions by providing medical documentation, the administrative burden of this process discouraged its use, as p10 explained: “i didn’t want to go through the extra steps of getting those documents… having paid leave for antenatal care visits, separate from annual leave, would make it easier for me to attend appointments without worrying about the daily wages.” in addition to flexible leave, some employers made physical work accommodations for pregnant workers, such as assigning less physically demanding tasks during pregnancy. while employers generally granted leave upon request, few took proactive steps to promote or facilitate anc visits. this left the responsibility of arranging care entirely on the women, who often balanced work duties with health needs under the pressure of potential income loss. though formal processes existed for securing paid leave using medical documentation, the complexity discouraged many from taking advantage of them. these challenges highlight the need for more supportive workplace policies, including dedicated paid maternal health leave and simplified administrative procedures, to improve timely and stress-free anc access for migrant women. financial feasibility of antenatal care access financial affordability is a critical factor in accessing healthcare for pregnant migrant women. all documented women in this study participated in either the sss or the mhis. those in the formal sector contributed 5% of their income to the sss, whereas others purchased the mhis. both schemes provided significant financial benefits during pregnancy and childbirth. sss members were eligible for maternity benefits, including reimbursements, lump sum cash benefits, and child allowances. in contrast, mhis members could access affordable anc and delivery services through a one-year package costing 2,700 thb. one participant, p03, reported, “i spent around 1,400 thb for my first antenatal visit... when i delivered my baby normally at the hospital, the medical bill was around 3,000 thb.” women covered by the sss received reimbursements for outof-pocket expenses within a month of childbirth. p07 explained, “i saved money in advance... i received reimbursement from the social security scheme within one month after i gave birth.” she also clarified that initial payments were necessary only for some visits and were eventually refunded. not all visits incurred costs; p01 noted, “i didn’t need to pay for some visits if the doctor found my baby was in good condition.” in cases of complications, however, concerns about costs arose. p01 recounted, “when i found out there was a cyst in my baby’s head, i worried about my baby’s condition and the test costs. despite my worries, i could afford the costs and received 25,300 thb from the social security fund after giving birth.” emergency deliveries had higher costs, as p06 stated, “i paid around 13,000 thb for the hospitalization... but the social security fund covered the cost.” even for cesarean section deliveries, the coverage under sss helped offset expenses. for those not in the sss, the mhis offered an affordable option. p02 shared, “i paid only 30 thb for each antenatal visit... the insurance cost 2,700 thb for a one-year package, which i could afford.” she added that although mhis did not offer cash maternity benefits like sss, it still covered all medical costs during pregnancy and delivery. transportation to the hospital was also manageable, with public buses costing approximately 22 thb per trip. p05 commented, “transportation costs were never a concern... it’s cheap and affordable.” in rare cases when public buses were missed or during poor weather, some women used taxis, which cost around 200 thb, but this was not common. overall, social insurance coverage, low-cost health services, and accessible public transport made antenatal and delivery care financially feasible for the participants. women expressed confidence in their ability to afford anc and delivery costs. acceptability and patient-centered experience the perception of healthcare quality significantly influences service utilization, often more than cost or availability. in this study, all migrant women reported positive experiences with the quality of care provided by healthcare staff. p07 stated, “the health staff, including doctors and nurses, were very kind, and they provided equal treatment to us, just as they did for thai nationals.” p08 added, “the nurses took excellent care of me… i felt comfortable and grateful.” similarly, p10 noted, “i felt that the doctors and nurses were kind; they listened carefully to my complaints and treated me respectfully.” these statements reflect that healthcare workers treated migrant women with dignity and respect. despite these positive interactions, language barriers remained a significant challenge for many migrant women who could not speak thai. some could manage the challenge, as p02 shared, “although i couldn’t speak thai, i didn’t have to worry during my antenatal care visits because we had a translator… it was very convenient.” however, p09 identified limitations: “when i was hospitalized for delivery… the translator was not available 24 hours a day.” additionally, some healthcare providers used technological solutions; p07 noted, “doctors and nurses sometimes used google audio translation… while it was not fully accurate, i could grasp the overall meaning. but they requested that i call the translator for important matters. i have not encountered any incorrect medical services because my employer provides access to a translator.” article [page 260] [healthcare in low-resource settings 2025;13:13616] despite these efforts, p05 emphasized the disadvantages faced by women employed in the informal sector, stating, “i knew other migrant women who did not work in the formal sector and hesitated to go to the hospital because of the language barrier.” this highlights the barriers migrant women face to accessing anc outside formal employment in khon kaen. the perception of healthcare quality significantly influences service utilization, often more than cost or availability. in this study, all migrant women reported positive experiences with the quality of care provided by healthcare staff. p07 stated, “the health staff, including doctors and nurses, were very kind, and they provided equal treatment to us, just as they did for thai nationals.” p08 added, “the nurses took excellent care of me… i felt comfortable and grateful.” similarly, p10 noted, “i felt that the doctors and nurses were kind; they listened carefully to my complaints and treated me respectfully.” these statements reflect that healthcare workers treated migrant women with dignity and respect. their experiences highlight an environment of inclusiveness and equality, where migrant women felt safe, welcomed, and cared for during a critical time in their lives. the respectful approach of the healthcare staff contributed to a sense of trust and encouraged continued engagement with health services. discussion summary of the main findings this study identified five key themes affecting the access of myanmar migrant women to anc in khon kaen province. first, physical access to healthcare services was generally manageable due to available public transportation, despite indirect routes and multiple transfers. women predominantly relied on affordable buses, though they faced long waits and travel times, sometimes extending up to an hour. these findings align with previous research, underscoring the importance of geographic accessibility in healthcare utilization.15 specifically, distance and transportation difficulties can lead to delays in anc initiation, missed follow-up appointments, and reduced health care utilization.17,18 in this context, the combination of manageable distances and low-cost transport enables women to prioritize anc despite some logistical barriers. second, khon kaen public hospital demonstrated strong service readiness in healthcare by providing essential screenings, vaccinations, and health education. timely and adequate anc is critical for detecting and managing pregnancy-related risks, including gestational diabetes, preeclampsia, and anemia.12 however, challenges remained: long wait times, insufficient early health education, and language barriers presented significant challenges. notably, many women delayed anc initiation until the second trimester. early initiation of anc is crucial for reducing maternal mortality rates.19 moreover, many participants relied on informal sources, such as friends and senior mothers, for information about anc, underscoring the absence of structured health education from formal providers. several studies identified the importance of social networks, such as friendship and kinship networks, in accessing health information, especially among migrants facing language and cultural barriers in healthcare communication.20 similarly, badge et al. reported delayed anc registrations among migrant women, often due to limited reproductive health knowledge.21 in addition, research suggests that inadequate health information limits access to healthcare services for migrant workers.22 therefore, targeted health education and awareness campaigns could improve timely anc access.23 another identified barrier to anc access was the absence of health information in the myanmar language. translators employed by formal sector jobs played a critical role in overcoming these language barriers, emphasizing the value of culturally competent translation services in anc. similar findings from thailand and other countries demonstrate that long wait times and language issues can hinder healthcare access for migrant women. 24 third, workplace flexibility was essential for supporting anc access. many employers allowed migrant women to take time off for anc visits and adjusted work tasks during pregnancy, enhancing their ability to seek healthcare. although migrant women expressed concerns about losing daily wages due to unpaid leave, they prioritized attending anc follow-up appointments, recognizing their importance. moreover, they expressed satisfaction with the flexibility to take leave whenever needed. research shows that despite formal policies, employer-related barriers, including unpaid sick leave, are common obstacles to migrant workers’ access to healthcare.25,26 additionally, some employers discourage workers from taking time off for healthcare, further complicating access to essential services.27 fourth, financial feasibility was a decisive factor in anc access. all participants in this study were enrolled in the sss or the mhis, which significantly reduced the financial burden associated with anc services and deliveries. these insurance schemes enabled participants to access essential anc services affordably, which was also reported by suphanchaimat et al.28 conversely, research has shown that uninsured migrants face substantial healthcare costs.25,29,30 although public transportation was generally affordable, private taxis, which were costly, were used only during emergencies, further adding to migrants’ financial burden. finally, acceptability and patient-centered experiences strongly influenced anc utilization. all participants reported positive experiences with healthcare providers, citing respectful and equal treatment. this contrasts with studies suggesting that discrimination and fear of racism can deter healthcare use among migrants.24,28,29,31 however, language barriers remained significant, particularly for women employed in the informal sector without access to translators. to overcome these barriers, some healthcare providers used technological solutions, such as google translate; although helpful in some cases, such technology is insufficient for critical healthcare discussions. research confirms that language barriers and limited translator availability are persistent challenges for healthcare access among migrants.25,29,30 by contrast, migrant women employed in the formal sector benefited from having a culturally competent translator provided by their employer for healthrelated matters. this support was crucial in overcoming significant language barriers and ensuring they could effectively access healthcare services. the presence of a trained translator significantly facilitated communication and contributed to the women’s positive experiences with anc services. policy implications a multifaceted approach is needed to improve anc access for myanmar migrant women. first, raising awareness about early pregnancy care is essential. this can be achieved through workplace-based health education programs, implemented in collaboration with local health authorities and community organizations. employers play a crucial role in delivering these programs, helping bridge information gaps and encouraging timely anc use. second, scaling up migrant-friendly initiatives, such as the migrant health worker and migrant health volunteer programs, is vital. these initiatives have proven effective in addressing lan article [healthcare in low-resource settings 2025;13:13616] [page 261] guage barriers and cultural differences, both critical for improving healthcare access.32 migrant health workers serve as interpreters in public healthcare facilities. in contrast, health volunteers act as cultural mediators, fostering engagement within migrant communities and promoting awareness of available services (e.g., health issues, healthcare system).32 expanding these programs should include providing culturally appropriate health materials and emphasizing reproductive health education, particularly targeting young migrant women. third, supportive workplace policies, such as providing paid leave for anc visits and simplifying medical leave procedures, are indispensable to alleviating financial and logistical challenges. promoting health in the workplace not only benefits migrants but also improves business productivity and reduces operational costs, making it a mutually advantageous investment.10 conclusions myanmar migrant women in khon kaen, thailand, face a mix of facilitating and hindering factors in accessing anc services. while public transportation enables physical access despite indirect routes and long wait times, healthcare readiness at khon kaen public hospital meets their needs through comprehensive services. nonetheless, gaps in health education and language support challenge the quality and timeliness of care. workplace flexibility, including unpaid leave, is pivotal in enabling anc use, and social insurance schemes, such as the sss and the mhis, alleviate financial barriers. more importantly, women largely reported positive interactions with healthcare staff, reflecting a high level of service acceptability. however, language barriers remain, particularly for women without access to translators, emphasizing the need for expanded linguistic and cultural support. while this study focused on low-skilled, documented myanmar migrant women within a formal employment setting, its findings may not fully capture the experiences of undocumented workers or those in informal sectors, who likely face additional barriers. moreover, excluding healthcare providers, policymakers, and civil society perspectives limits the ability to assess systemic factors. future research should adopt a mixed-methods design, include larger and more diverse samples across multiple regions, and incorporate the perspectives of additional stakeholders. this broader approach would offer a more comprehensive understanding of healthcare challenges and inform more effective interventions for migrant workers in thailand. references 1. world health organization. world report on the health of refugees and migrants. geneva: world health organization; 2022. available from: https://www.who.int/publications/i/ item/9789240054462 2. suphanchaimat r, putthasri w, prakongsai p, tangcharoensathien v. evolution and complexity of government policies to protect the health of undocumented/illegal migrants in thailand: the unsolved challenges. risk manag healthc policy 2017;10:49-62. 3. low wy, tong wt, binns c. migrant workers in asia pacific and their rights to health. asia pac j public health 2015;27:584-7. 4. asean. asean economic community blueprint. jakarta: asean secretariat; 2008. available from: https://www. asean.org/wp-content/uploads/images/archive/5187-10.pdf 5. international organization for migration. thailand social protection diagnostic review: social protection for migrant workers and their families in thailand. bangkok: iom thailand; 2021. available from: https://publications.iom.int/ system/files/pdf/social-protection-for-migrant-workers-inthailand.pdf 6. united nations development programme. seeking opportunities elsewhere: exploring the lives and challenges of myanmar migrant workers in thailand. 2023 [cited 2023 mar 20]. available from: https://myanmar.un.org/sites/default/files/ 2023-12/undpseeking_opportunities_elsewhere_final.pdf. 7. aung tnn, shirayama y, moolphate s, et al. prevalence and risk factors for hypertension among myanmar migrant workers in thailand. int j environ res public health 2022;19:063511. 8. united nations network on migration in thailand. thailand migration report 2024. bangkok: united nations network on migration in thailand; 2024. available from: https://www.ilo.org/sites/default/files/2024-12/thailand-migration-report-2024.pdf 9. laohasiriwong w, khongthanachayopit s. accessibility to health services among migrant workers in the northeast of thailand. f1000res 2017;6:11651.1 10. ratanachina j, sithisarankul p. workplace health promotion management of noncommunicable disease prevention and implementation among organizational leaders and human resource executives in thailand: a qualitative study. j public health dev 2024;22:170-83. 11. ketut swarjana i, chansatitporn n, suwannapong n, et al. disparities in utilization of maternal health services in the rural areas of indonesia: an analysis among provinces with low, middle, and high poverty rates. j public health dev 2020;18:49-6. 12. wungrath j. antenatal care services for migrant workers in northern thailand: challenges, initiatives, and recommendations for improvement. j child sci 2023;13:e118-26. 13. myo lz, tiraphat s, hongkrailert n. factors affecting the utilization of quality antenatal care services among myanmar migrants in thai health care facilities: tak and samut sakhon province. j public health dev 2016;14:45-57. 14. sitkulanan p, chaisitsanguan k, winaiprasert p, wong-arsa w. problems of myanmar women of reproductive age in accessing health services as migrant workers in thailand: a qualitative study. nurse media j nurs 2024;14:53-64. 15. peters dh, garg a, bloom g, et al. poverty and access to health care in developing countries. ann n y acad sci 2008;1136:161-71. 16. braun v, clarke v. successful qualitative research: a practical guide for beginners. thousand oaks, ca: sage publications; 2013. 17. purohit n. utilization of antenatal care services in a remote, tribal and hilly district of himachal pradesh: challenges to access. j family med prim care 2021;10:3374-80. 18. steinbrook e, min mc, kajeechiwa l, et al. distance matters: barriers to antenatal care and safe childbirth in a migrant population on the thailand-myanmar border from 2007 to 2015: a pregnancy cohort study. bmc pregnancy childbirth 2021;21:1-11. 19. soontornprakasit p, mongkolchati a, chompikul j. factors associated with time to start antenatal care within 12 weeks gestational age among mothers in mahasarakham province, article [page 262] [healthcare in low-resource settings 2025;13:13616] thailand. j public health dev 2016;14:21-36. 20. ohn nst, worland s. information behaviour and factors influencing family planning knowledge of myanmar ethnic migrants: a qualitative study. j public health dev 2024;22:2237. 21. badge v, pandey m, solanki m, shinde r. a cross-sectional study of migrant women with reference to their antenatal care services utilization and delivery practices in an urban slum of mumbai. j family med prim care 2016;5:759-64. 22. cho hj, kang k, park ky. health and medical experience of migrant workers: qualitative meta-synthesis. arch public health 2024;82:1-12. 23. rasheed p, al-sowielem ls. health education needs for pregnancy: a study among women attending primary health centers. j fam community med 2003;10:31-8. 24. könig a, nabieva j, manssouri a, et al. a systematic scoping review on migrant health coverage in thailand. trop med infect dis 2022;7:166. 25. ang jw, chia c, koh cj, et al. healthcare-seeking behaviour, barriers and mental health of non-domestic migrant workers in singapore. bmj glob health 2017;2:e000213. 26. loganathan t, rui d, ng cw, pocock ns. breaking down the barriers: understanding migrant workers’ access to healthcare in malaysia. plos one 2019;14:e0218669. 27. webber g, spitzer d, somrongthong r, et al. facilitators and barriers to accessing reproductive health care for migrant beer promoters in cambodia, laos, thailand and vietnam: a mixed methods study. glob health 2012;8:21. 28. suphanchaimat r, kunpeuk w, phaiyarom m, nipaporn s. the effects of the health insurance card scheme on out-ofpocket expenditure among migrants in ranong province, thailand. risk manag healthc policy 2019;12:317-30. 29. loganathan t, rui d, pocock ns. healthcare for migrant workers in destination countries: a comparative qualitative study of china and malaysia. bmj open 2020;10:e039800. 30. phaiyarom m, kosiyaporn h, pudpong n, et al. access to noncommunicable disease services among urban refugees and asylum seekers, relative to the thai population, 2019: a case study in bangkok, thailand. risk manag healthc policy 2021;14:3423-33. 31. czapka ea, sagbakken m. where to find those doctors? a qualitative study on barriers and facilitators in access to and utilization of health care services by polish migrants in norway. bmc health serv res 2016;16:460. 32. kosiyaporn h, julchoo s, phaiyarom m, et al. strengthening the migrant-friendliness of thai health services through interpretation and cultural mediation: a system analysis. glob health res policy 2020;5:53. article [healthcare in low-resource settings 2025;13:13616] [page 263] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13033 culture-based gorontalo community support for short-term pregnancy women to prevent stunting in neonates zuriati muhamad,1 st. surya indah nurdin,1 asnidar,2 audia pratama,1 nabila putri anggriani,1 sasgita lakadjo1 1department of midwifery, faculty of medicine and health sciences, universitas muhammadiyah gorontalo; 2stikes panrita husada bulukumba, south sulawesi, indonesia abstract community support is known to play an essential role in enhancing maternal health during pregnancy. this is primarily due to the influence of societal factors on the health status of both the mother and fetus. in addition, the significance of community support is particularly evident in the gorontalo community of indonesia due to the influence of socio-cultural factors. this study aims to analyze the extent of culture-based gorontalo community support for short-term pregnant women in improving maternal health and preventing stunting neonates. the procedures were carried out using a qualitative study method with a phenomenological approach. the sample population comprised 12 pregnant women, 9 village midwives, and 6 cadres, who were selected using the snowball sampling method. in addition, data collection was carried out through in-depth interviews and observations, followed by analysis using interpretive phenomenology analysis (ifa). the people of gorontalo were very supportive and concerned about the health of short-term pregnant women and fetuses to prevent stunting neonates. a form of culture-based community support comprised regular reminders to pregnant women to diligently attend monthly check-ups with both traditional healers and healthcare professionals. traditional healers, also known as shamans, fulfilled their role by performing a range of rituals believed to enhance health and well-being. these rituals typically included massages, administering water fortified with sacred chants, and conducting monthly ceremonies for 7 months. in addition, community members frequently offered food preferences to pregnant women and provided reminders to avoid taboos. in summary, community support deeply rooted in culture can serve as a powerful reminder for expectant mothers to undergo regular check-ups with both traditional healers and healthcare professionals on a monthly basis. introduction social support is a condition characterized by the presence of individuals who offer advice, motivation, guidance, and assistance when humans experience challenges or obstacles in pursuing their goals.1 meanwhile, community support comprises meaningful social relationships that can positively influence the recipient. although social support is theoretically based on interpersonal exchanges, it is essential to assess whether genuine assistance is received from surrounding individuals. according to previous studies, indonesia is a country consisting of diverse ethnic groups, including the javanese community. this diversity shows the significance of socio-cultural influences in attaining optimal health. in addition, socio-cultural developments have been shown to be an essential indicator of changes in societal thought processes, which have both positive and negative impacts. several studies have reported the presence of a significant relationship between culture and health. for example, a simple village community can survive with certain treatment methods, which are in line with their traditions.2 in the context of culture, the interpretation of pregnancy and childbirth varies significantly across different ethnic groups, particularly in indonesia.3 in rural areas in asian countries, these experiences often carry religious or magical significance, embodying a deeply personal and familiar journey for other family members. in addition, care spanning from the onset of pregnancy through the postpartum period is typically administered within the confines of the home, with the assistance of a midwife.4 several studies have shown that the lack of adequate care and social support during pregnancy can lead to different conditions, such as antenatal depression and anxiety. the occurrence of antenatal depression and anxiety has been reported to exert detrimental effects on various obstetric and fetal outcomes. when left untreated, these conditions can cause pregnancy complications, and postnatal mental health disorders5 and hamper the mother-infant bond.6 in addition, mental health disorders have a significant correlation with heightened risk-taking behaviors, such as smoking and substance use, leading to poor maternal quality of life.7 in this study, a total of 20 articles were analyzed, with the results showing a significant relationship between low social support and the risk of developing mental health problems, such as depression, anxiety, and self-harm during pregnancy.8 a common strategy to prevent or reduce pregnancy complications and poor birth outcomes significance for public health an investigation into the impact of cultural community support in gorontalo reveals its significance in shaping the health behaviours of short-term pregnant women. the study aims to examine the specific forms and approaches of community support that can incentivize pregnant women to address their healthcare requirements, potentially resulting in enhanced maternal health and decreased risk of stunted neonates. by exploring the cultural dynamics of community support in gorontalo, the research aspires to yield valuable insights into the potential influence of such support systems on maternal and fetal health outcomes. [page 32] [healthcare in low-resource settings 2024;12(s1):13033] non -co mmerc ial us e o nly due to mental disorders is to provide strong social support for pregnant women.9 this is primarily due to the potential of the intervention to increase the positive interactions of individuals.10 social support can also provide additional appropriate coping mechanisms for pregnant women to deal with stressful events.11 materials and methods this study was carried out using a qualitative approach with a phenomenological design to explore essential or fundamental aspects of the life experiences of individuals regarding a particular phenomenon.12 in addition, the aim was to explore the provision of social support to short pregnant women. sampling the study procedures were conducted in the working area of the tilango health center, gorontalo regency. the participants comprised 12 short pregnant women with tb <150 cm, and 9 midwives from the telaga jaya and tilango health centers, who were selected by technik using the snowball sampling method. in determining participants, 1 or 2 individuals were first selected during the process. however, when these individuals felt that the data provided was insufficient, additional participants were recruited, leading to an increase in the sample population.13 data collection data collection was carried out by conducting in-depth interviews to obtain 20 pieces of information from participants regarding community support for short pregnant women in dealing with pregnancy. analysis data obtained were analyzed using interpretative phenomenological analysis (ipa), also known as interpretative phenomenological analysis/ipa in english.14 results and discussion based on the qualitative information found in the report, there were 3 categories of support from the gorontalo community for short-term pregnant women, including supportive community, mixed support, and no support. the results of the in-depth interviews are further illustrated in figure 1. a form of support from neighbors or the local community for pregnant women comprised reminders to consume nutritious food. neighbors often inquired about the cravings of pregnant women and willingly prepared these foods, believing that the cravings originated from the fetus’s desires and must be fulfilled to prevent stress on the fetus within the mother’s womb. the results showed that it was customary for family and community to advise overdue mothers to seek assistance from a shaman to determine pregnancy status through a ritual known as “raba puru.” during this ritual, the shaman palpated the mother’s belly to ascertain pregnancy. pregnant women also sought monthly massages from shaman and requested water blessed with mantras or prayers for consumption and bathing purposes. these practices aimed to promote the well-being of both the mother and the fetus. neighbors and the public frequently advised pregnant women to wear head coverings and carry oranges while leaving the house as well as to be careful when walking to avoid slipping. the community believed that pregnant women emitted a pleasant scent, making them easily detectable to spirits. consequently, these individuals were required to wear head coverings when going out to avoid being stepped on by demons. the results from in-depth interviews with midwives suggested that a prevalent form of community support for pregnant women comprised advising them to visit a shaman for pregnancy confirmation through rituals, such as massage, prayer water, and bathing, before seeking care from village midwives. this practice contributed to low coverage of initial visits by pregnant women to healthcare providers, as the local community typically sought confirmation from traditional healers. a summary of interview results with short-term pregnant women, village midwives, and community leaders regarding community support for pregnant women in gorontalo is presented in table 1. community leaders reported the supportive and caring 4th international nursing and health sciences symposium table 1. matrix of empirical results of culture-based community support. information social support pregnancy short 1.during pregnancy, mothers received support from the local community, such as being delivered food, being informed about pregnancy confirmation from the village shaman and midwife, reminding pregnant women to be careful in their actions, and eating nutritious food. 2.some people support it and other people or neighbors did not support it. 3.a small number of mothers during pregnancy did not receive support from neighbors and the surrounding community. neighbors never paid attention and communicated with pregnant women, neighbors often talked about shortcomings of pregnant women. midwife the community was very caring and attentive to pregnant women. a form of community concern was to remind mothers to diligently check their pregnancies with midwives and hulango (shaman) to check the condition of the mother and fetus. community figures figures the people of gorontalo cared for and paid attention to pregnant women. this could be seen by community giving advice about pregnancy and carrying out rituals or customs following the beliefs and beliefs of pregnant women and reminding them of things to avoid during pregnancy that were harmful to pregnant women. [healthcare in low-resource settings 2024;12(s1):13033] [page 33] figure 1. scheme from interviews with informants related to community support. non -co mmerc ial us e o nly nature of gorontalo residents towards pregnant women. these participants emphasized the importance of pregnant women regularly consulting with both healthcare workers and traditional birth attendants. midwives played an essential role in providing medical pregnancy services, while shaman conducted rituals believed to enhance health and safety, such as massages and the provision of blessed water. the gorontalo community expressed their concern for short-term pregnant women through reminders to regularly consult with health workers (midwives) and shaman every month, asking for water infused with prayers or mantras to drink and bathe. in addition, community members often delivered food and provided reminders about avoiding taboo activities believed to endanger their well-being. the results showed that pregnant women actively participated in the 7-month ritual known as “raba puru or molontalo”. in gorontalo, a prevalent concern among the community revolved around pregnancy. furthermore, it was customary for family and community to take action when a mother was suspected to be overdue. in such cases, the immediate recourse was to consult a traditional healer, commonly known as a shaman, who performed a ritual called “raba puru” to ascertain pregnancy status by palpating the abdomen. this traditional belief suggested that a shaman possessed the ability to discern pregnancy through the practice. pregnant women also sought monthly massages from shaman and requested water imbued with mantras or prayers, which was used for drinking and bathing purposes. these rituals were performed with the belief in their ability to promote the health and safety of both the mother and the fetus, providing protection from malevolent forces seeking to cause harm. the tradition of pregnancy care in gorontalo extended beyond the physical realm to comprise spiritual practices, expressing gratitude to allah swt. celebrations or expressions of thanks often occurred during the 4th and 7th months of pregnancy. at the 4-month mark, the family typically organized modest gatherings, inviting local shaman and neighbors to partake. during these gatherings, the shaman assumed the responsibility of massaging the expectant mother’s abdomen. according to tradition, by the 4th month, the shaman possessed the ability to discern the fetus’s gender through touch. when the mother’s abdomen responded predominantly to the right, it was interpreted as indicative of a male fetus. meanwhile, movements toward the left suggested a female fetus. the shaman also administered a full-body massage to the mother and provided water infused with recited mantras for drinking and bathing rituals. these rituals were believed to fortify the safety and protection of both the mother and the fetus from malevolent influences.10,11,15 during the 7th month in the gorontalo community, a significant ritual known as “raba-raba puru” or “motondalo” was often carried out, particularly for first-time pregnancy. this event served as a celebratory occasion attended by the family of both the husband and wife, local community members, shaman, the imam, and community leaders. the motondalo ceremony commenced with the shaman administering massages to the pregnant woman’s body and abdomen. this practice aimed to ensure that the fetus was positioned correctly and that its head received special attention to facilitate easier childbirth. subsequently, the pregnant woman reclined on the lap of the biological mother or mother-inlaw, referred to as “mopphula,” symbolizing hopes for a smooth pregnancy and delivery, invoking blessings from the maternal figure, as mothers were revered for their essential role in childbirth and child-rearing. following this, the shaman applied a mixture of turmeric and lime, known as “awalahu tilihi,” onto specific areas, such as the head, forehead, neck, palms, and abdomen. the concoction was believed to offer protection against malevolent spirits and entities that could pose a threat. in the final phase of the ceremony, all participating family came together for a collective prayer led by the local imam, joined by community leaders, seeking safety and blessings from allah swt for the well-being of the mother and fetus. after the prayer, the husband and wife participated in a symbolic gesture of mutual care and affection by feeding each other boiled eggs. this act symbolized love and support within the marital union, emphasizing the importance of standing together through life’s challenges and joys. based on the results, cultural diversity profoundly influenced how societies address and respond to issues affecting their populations. each community possesses its own unique set of local knowledge and practices, which shape their responses to interventions. in addition, environmental factors significantly impacted the implementation and outcomes of health strategies, leading to varied responses across cultures.16 the perception and management of pregnancy and childbirth varied significantly among different cultures.3 in rural community across asian countries, these experiences were imbued with religious and magical significance, deeply personal, and comprised active participation from family members. care throughout pregnancy and postpartum periods typically occurred within the home environment, often under the guidance of a midwife.4 during these times, family members, such as mother, husband, brother, and other relatives assumed specific roles, often serving as healers and providing essential support. in madurese society, heightened attention was directed towards pregnant women upon the revelation of the condition to family members and neighbors. this increased focus triggered the implementation of safety measures, recommendations, and cultural taboos aimed at safeguarding the well-being of both the mother and the unborn child. however, the efficacy of these practices in terms of modern medical standards remained uncertain. rituals, such as regular check-ups with midwives, either through home visits or at designated healthcare centers (polindes), were often carried out. traditional healers (dukun) were often consulted to provide massages, including abdominal massages, to ensure the optimal positioning of the baby during birth.17 the communal nature of madurese society played an essential role in shaping individuals’ behavior. neighbors and the wider community actively motivated pregnant women to prioritize their health, exerting significant influence during pregnancy.15 this communal support carried considerable weight, with statistical significance noted at 0.006, underscoring its profound impact on individuals’ well-being and health outcomes during pregnancy.18 according to a study conducted by susanti et al the results from the fisher’s exact test analysis showed a significant association between social support and the inclination of pregnant women to engage in pregnancy exercise program within wajak village, malang regency.19 the study identified a significant proportion of participants experiencing negative social support, constituting 20% of the total population. however, 33.3% of these participants showed a strong interest in participating in the exercise program. indonesia has a rich tapestry of habits, customs, cultural practices, and norms, particularly concerning maternal and child health within the community. these practices were largely influenced by socio-cultural factors deeply embedded within the society. a prevailing perspective viewed pregnancy as a natural process intrinsic to women’s essence.20 the indonesian culture and societal norms exhibited a significant acceptance of traditional healers, known as dukuns, for the care and examination of pregnant women. dukuns, revered as elders and esteemed traditional figures, played an essential role in providing comprehensive services spanning pregnancy, childbirth, newborn care, postpartum support, and overseeing rituals, such as the seven-month ceremony and birth safety cere 4th international nursing and health sciences symposium [page 34] [healthcare in low-resource settings 2024;12(s1):13033] non -co mmerc ial us e o nly monies. in addition, their accessibility was facilitated by their integration into the cultural fabric, often residing alongside expectant mothers. home births were customary, fostering a sense of comfort for mothers while in close proximity to their family.15,17 a study conducted in non-java-bali regions, particularly in rural areas, showed a concerning trend of low use of antenatal care (anc) services among pregnant women. this phenomenon was closely associated with the economic status and educational levels of mothers. the results showed a significant correlation between lower economic status, lower education, and the underuse of anc services. furthermore, the prevalence of low-income households contributed to the low uptake of antenatal services, alongside the presence of mothers with lower educational level. the results also showed an exacerbation of the low use of anc services among mothers with a high parity, or number of previous births.21 additional significant factors contributing to the low use of antenatal care services among mothers include limited exposure to mass media, challenges related to the affordability of health services, and geographical distance to healthcare facilities, which were particularly pronounced in rural areas. furthermore, the odds of low antenatal care use were heightened among mothers who did not encounter pregnancy complications. identifying and understanding these multifaceted factors was imperative for the formulation of effective public health strategies aimed at addressing the barriers preventing women from accessing and using antenatal services in indonesia.22 the cultural beliefs and practices observed in certain community or ethnicities in indonesia often resonated in various countries around the world. india, for instance, was a nation grappling with the challenge of maternal mortality.11,20 diana etc reported the contribution of socio-cultural factors to the disconnect between the knowledge, practices, and socio-cultural beliefs of mothers in india. within indian society, there existed an opinion that regarded pregnancy and childbirth as mundane or ordinary occurrences. liamputtong stated that “the social meaning of birth was shaped by the society in which the pregnant women resided”. feminist studies showed that cultural attitudes toward birth differed based on culture, social class, and social resources.2,18 conclusions the tightly woven community support, enriched with cultural traditions, is a strong incentive for expectant mothers to regular check-ups with traditional healers and medical practitioners every month. the active involvement of traditional healers, a fundamental aspect of this cultural endorsement, can significantly enhance the overall health and well-being of pregnant women. references 1. gottlieb bh, bergen ae. social support concepts and measures. j psychosom res 2010;69:511-20. 2. indriyani y, tenrisau d, nippanon p, kuster at, suswardany dl. socio-culture and health problem factors on traditional medicine use among indonesian adult: a cross-sectional analysis from national survey. scielo prepr 2023;27. available from: https://doi.org/10.1590/scielopreprints.5769 3. belton s, myers b, ngana fr. maternal deaths in eastern indonesia: 20 years and still walking: an ethnographic study. bmc pregnancy childbirth 2014;14:39. 4. exavery a, kanté am, njozi m, et al. access to institutional delivery care and reasons for home delivery in three districts of tanzania. int j equity health 2014;13:1–11. 5. jahan n, went tr, sultan w, et al. untreated depression during pregnancy and its effect on pregnancy outcomes: a systematic review. cureus 2021;13:e17251. 6. de boer hj, cotingting c. medicinal plants for women’s healthcare in southeast asia: a meta-analysis of their traditional use, chemical constituents, and pharmacology. j ethnopharmacol 2014;151:747–67. 7. guedeney a, guedeney n, wendland j, burtchen n. treatment – mother–infant relationship psychotherapy. best pract res clin obstet gynaecol 2014;28:135–45. 8. mcleish j, redshaw m. mothers’ accounts of the impact on emotional wellbeing of organised peer support in pregnancy and early parenthood: a qualitative study. bmc pregnancy childbirth 2017;17:1–14. 4th international nursing and health sciences symposium correspondence: zuriati muhamad departement midwifery , faculty of medicine and health sciences, universitas muhammadiyah gorontalo, indonesia, jl. prof. dr. h. mansoer pateda desa pentadio timur, kec. telaga biru, kab. gorontalo, gorontalo, indonesia, ph: +62435-881136, email: zuriatimuhamad@umgo.ac.id key words: community support; culture; qualitative study; short term pregnancy contributions: the authors contributed equally. conceptualization, zm. methodology, zm and ssi; software, ssi and a; validation, zm and a; formal analysis, zm, a, and ssi; investigation, ssi, ap, npa, sl; resources, zm, ssi and a; data curation, zm and a/ writing—original draft preparation, ssi, ap, npa, sl; writing-review and editing, all authors; visualization, ssi, ap, npa, sl; funding acquisition, tm. all authors have read and agreed to the published version of the manuscript. conflict of interest: the authors declare no potential conflict of interest. funding: this study was funded by the directorate general of higher education, ministry of education and culture of the republic of indonesia with grant number 005pk/lppm-umgo/vii/2023 ethics approval: ethical clearance has been granted under the number 1848-kepk by the faculty of nursing at universitas airlangga. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to the directorate general of higher education, ministry of education and culture of the republic of indonesia. received: 3 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13033 doi:10.4081/hls.2024.13033 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s1):13033] [page 35] non -co mmerc ial us e o nly 9. ulrich f, petermann f. consequences and possible predictors of health-damaging behaviors and mental health problems in pregnancy a review. geburtshilfe frauenheilkd 2016;76:1136–56. 10. naser e, mackey s, arthur d, et al. an exploratory study of traditional birthing practices of chinese, malay and indian women in singapore. midwifery 2012;28:e865–71. 11. withers m, kharazmi n, lim e. traditional beliefs and practices in pregnancy, childbirth and postpartum: a review of the evidence from asian countries. midwifery 2018;56:158–70. 12. qutoshi sb. phenomenology: a philosophy and method of inquiry. j educ educ dev 2018;5:215. 13. nasir n, sukmawati s. analysis of research data quantitative and qualitative. edumaspul j pendidik 2023;7:368–73. 14. alase a. the interpretative phenomenological analysis (ipa): a guide to a good qualitative research approach. int j educ lit stud 2017;5:9. 15. juairah. cultural practices and beliefs during pregnancy of karangsari village community, garut district. sosiohumaniora j ilmu-ilmu sos dan hum 2018;30:162–7. 16. lim ya, cho yc. covariance structure analysis of the influence of social support, physical and mental health status on quality of life among the elderly at care facilities. j korea academia-industrial cooperation soc 2017;18:210–20. 17. kusumaningrum s, anggraini mt, faizin c. relationship between knowledge and family support with stunting prevention behavior in pregnant women. herb-med j 2022;5:10. 18. chakona g, shackleton c. food taboos and cultural beliefs influence food choice and dietary preferences among pregnant women in the eastern cape, south africa. nutrients 2019;11:1–18. 19. prasetyo yb, permatasari p, susanti hd. the effect of mothers’ nutritional education and knowledge on children’s nutritional status: a systematic review. int j child care educ policy 2023;17:11. 20. diana fn, saifudin m, sholikha s. relationship between social support and stress levels in single parents. j ilmu keperawatan jiwa 2023;6:740–8. 21. van noordwijk m, agus f, dewi s, purnomo h. reducing emissions from land use in indonesia: motivation, policy instruments and expected funding streams. mitig adapt strateg glob chang 2014;19:677–92. 22. mukti as, purnamasari kd, rohita t. cadre training in improving culture-based health literacy in pregnant women in kuta village, tambaksari village. kolaborasi j pengabdi masy 4th international nursing and health sciences symposium [page 36] [healthcare in low-resource settings 2024;12(s1):13033] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13044 prevention of contaminated aerosol and the transmission during nebulized therapy in hospital settings: a systematic review rustiana tasya ariningpraja,1 ika yuni widyawati,2 nurona azizah1 1department of nursing, faculty of health sciences, universitas brawijaya, malang, east java; 2faculty of nursing, universitas airlangga, surabaya, east java, indonesia abstract inhalation nebulization therapy is important for administering medications to patients in aerosolized form. however, there are persistent apprehensions in healthcare settings regarding aerosol contamination because of the significant infection risk. despite rigorous adherence to established hospital protocols, concerns about potential contamination and transmission persist, raising considerable apprehension about nosocomial pneumonia. this condition shows the urgent need for implementing highly effective strategies to ensure patient safety during nebulization therapy. therefore, this study aimed to review current investigations, focusing on interventions to mitigate aerosol contamination and minimize the transmission of contaminated aerosols. adhering to the preferred reporting items for systematic reviews and metaanalyses (prisma) guidelines, this systematic review included an exhaustive analysis of randomized and non-randomized clinical trials as well as, simulated experimental and in vitro studies published in english in the past decade. a meticulous search was conducted across four major databases, namely sciencedirect, cumulative index to nursing & allied health (cinahl), pubmed, and scopus. a total of 37 pertinent studies were identified and subjected to rigorous analysis. the preventive measures include a range of strategies, such as the use of masks by therapists, thorough disinfection of nebulizers, integration of filters, and regular environmental cleaning in the vicinity of the patient. in conclusion, these multifaceted interventions are significant in preventing the administration of contaminated aerosols and curbing the proliferation of infectious agents in the hospital environment. introduction inhaled therapy through nebulization is a significant method for administering essential medications to patients, particularly those with respiratory conditions, such as chronic obstructive pulmonary disease (copd), asthma, or cystic fibrosis.1,2 this method ensures targeted delivery, with aerosolized drugs directly reaching the respiratory tract, including the lungs, optimizing therapeutic outcomes.3 however, a growing concern in healthcare facilities is the potential for aerosol contamination during this process. contaminated aerosols harbor various pathogens, such as bacteria, viruses, and fungi, thereby presenting a considerable risk for infection transmission.4–6 both patients and healthcare professionals are at risk, showing the critical need to maintain cleanliness and safety standards.7,8 despite meticulous compliance with established protocols and guidelines in hospital settings, a persistent presence of aerosol contamination suggests potential limitations in current preventive measures.6–9 the continuous existence of contaminated aerosols raises significant concern about the adequacy of existing protocols, necessitating a thorough evaluation of preventive strategies to bolster patient safety and infection control.10,11 a nurse plays a crucial role in preventing and controlling infection in the hospital. this responsibility is significant in safeguarding the well-being and safety of patients.12 a primary concern in the contamination of aerosol is the high susceptibility to hospital-acquired infections, particularly pneumonia, specifically among medically compromised patient cohorts.13,14 hospital-acquired pneumonia (hai) significantly impacts patient recovery, prolongs hospitalization, and increases healthcare expenditures.14,15 therefore, addressing and mitigating aerosol contamination represents a critical aspect of preventing and controlling infection in healthcare settings. due to the crucial need to ensure patient safety and mitigate the risk of nosocomial infections, this study conducts a rigorous systematic review of previous investigations. the main aim is to comprehensively assess and synthesize current studies, with a particular focus on preventive strategies to mitigate aerosol contamination during nebulized therapy. through a synthesis of the available evidence, this study aimed to provide invaluable insights and evidence-based recommendations. the result will inform the refinement of protocols and strategies, thereby advancing patient care, safety, and infection control. materials and methods this study adopted the updated preferred reporting items for systematic reviews and meta-analyses (prisma) guidelines.16 the method used was population, intervention, comparison, and outcome (pico),17 as follows: i) population or problem (p): patients experiencing nebulized therapy or simulation of nebulizing therapy; ii) intervention or exposure (i): implementation of [healthcare in low-resource settings 2024;12(s1):13044] [page 67] significance for public health this study addresses critical concerns regarding aerosol contamination in inhalation nebulization therapy, showing the urgent need for comprehensive strategies to ensure patient safety and minimize infection risks. adhering to prisma guidelines, this study analyzed 37 pertinent studies from the past decade, showing preventive measures, such as therapist masks, nebulizer disinfection, filter integration, and environmental cleaning. these multifaceted interventions are crucial in curbing aerosol contamination and enhancing patient safety in hospital environments, significantly impacting public health. non -co mmerc ial us e o nly strategies and measures to mitigate contaminated aerosol and the potential transmission during nebulized therapy; iii) comparison (c): no comparison or regular intervention based on guidelines; iv) outcome (o): evaluating the efficiency of implemented prevention strategies in minimizing contaminated aerosols and transmission. a comprehensive literature review was conducted across four databases, namely pubmed, sciencedirect, scopus, and cumulative index of nursing and allied health (cinahl). secerla terminologies were collected using synonyms and medical subject headings (mesh) (supplementary materials, table 1). the keywords used were nebulizer, semi-critical devices, medical devices, and bacterial contamination, as well as nebulization or aerosol therapy. other keywords include aerosol generating procedure, medical aerosol, bioaerosol, aerosol transmission, and infection protection, as well as infection, contamination, nosocomial, and transmission prevention. considered studies were in english, published in the last decade, and included randomized and non-randomized experimental design, simulation, in vitro, and non-experimental studies with data. the exclusion criteria are reviews, case reports, editorials, books, commentaries, and studies articles discussing interventions for preventing aerosol contamination without trial data. irrelevant titles, abstracts, and full-text studies were screened, followed by meticulous independent evaluation to assess the appropriateness of the retrieved studies. any discrepancies were resolved through discussions, and data extraction elements were adjusted in agreement with the entire review team. figure 1 shows a summary of the results and reasons for excluding studies during the full-text review. the studies meeting the inclusion criteria were subjected to descriptive analysis, presenting insights into feasible interventions and respective effectiveness. to reduce the risk of bias in the incorporated studies, two reviewers independently used the updated cochrane risk of bias tool for randomized trials (rob 2). however, non-randomized studies were assessed for bias using the risk of bias for non-randomized intervention studies (robins-i) tool. results and discussion a total of 8,406 studies were initially identified through an extensive electronic search across four databases. after removing duplicates, comments, reviews, letters, and irrelevant titles, the corpus was narrowed down to 102 studies for a thorough full-text assessment. a total of 65 did not meet the inclusion criteria, resulting in a final selection of 37 studies for narrative synthesis. only 2 out of the 37 selected studies were based on randomized experimental designs and 35 were non-randomized or simulation experiments. using appropriate masks for mitigating aerosol contamination the result shows the effectiveness of both face masks and respirators in mitigating bacterial colonization and co-infections in the upper respiratory tract among healthcare workers.18 surgical masks and unvented kn95 respirators were shown to significantly reduce outward particle emissions during speaking and coughing, without requiring fit-testing, suggesting the potential to curtail the dispersion of particles.19 furthermore, medical face masks is an important protective gear, effectively shielding the wearer from aerosol exposure and reducing the risk of respiratory infections. the medical face masks maintained bacterial filtration efficiency and breathability, ensuring practicality and comfort for prolonged use.20-22 the use of a full-face mask had a highly protective measure against respiratory infections, showing the potential as a reliable preventive strategy.23 furthermore, various masks significantly reduced virus droplets in the air and minimized spread. the result also showed the potential of melt-blown layer and structure in enhancing filtration efficiency, stressing the need for a welldesigned composition to increase mask effectiveness, specifically for different particle sizes.24 ensuring optimal nebulizer hygiene procedures this study showed the efficiency of various nebulizer disinfection methods. baby bottle steam sterilizers were proven to be highly effective in reducing bacterial pathogens and maintaining a sterile nebulizer environment.25-27 ultrasound and specific disinfectants significantly reduced contamination levels by 4-5 log10, showing the potential to enhance nebulizer cleanliness.28 previous studies showed that proper drying is crucial in eradicating bacterial residues, specifically in reducing pseudomonas aeruginosa, a significant pathogen.29,30 however, the eradication remains a challenge, necessitating specialized disinfection strategies. this study also showed the difficulty in completely removing biofilms accumulated in flexible endoscope channels using standard detergents or high-level disinfectants. this result suggests the need for innovative approaches to target and eliminate resilient biofilms effectively. both methicillin-sensitive staphylococcus aureus (mssa) and methicillin-resistant staphylococcus aureus (mrsa) were found to be vulnerable to drying, showing the potential in maintaining nebulizer hygiene, particularly for individuals with cystic fibrosis.31,32 4th international nursing and health sciences symposium figure 1. the literature search conducted across four databases adhered to the guidelines by the preferred reporting items for systematic reviews and meta-analyses (prisma). [page 68] [healthcare in low-resource settings 2024;12(s1):13044] non -co mmerc ial us e o nly innovative methods, such as uv-c light and ozone, were effective in combatting bacterial biofilms. uv-c light effectively eliminated all tested bacteria, including m. abscessus complex. similarly, the ozone showed bactericidal effects on various bacterial biofilms, showing the potential for advanced nebulizer disinfection.33–36 in general, this study provided crucial insights into designed disinfection processes, the significance of appropriate drying methods, and the promise of developing technologies in mitigating bacterial contamination, ensuring the safety and effectiveness of nebulizer use. integration of bacterial filters and negative pressure for effective aerosol contamination reduction this study showed crucial results regarding aerosolization and the implications for mechanical ventilation and aerosol therapy. regular monitoring of bacterial filters was essential to mitigate contamination. caution should be exercised with 10% acetylcysteine aerosolization during mechanical ventilation because it can increase bacterial filter pressure.37 the result showed that the addition of a bacterial filter to aerosol delivery systems significantly reduced aerosol release, confirming the effectiveness in minimizing environmental contamination during aerosol therapy.38 additionally, this study evaluated specific nebulizer models, particularly the ban™ nebulizer with a filter kit, which removed all aerosol losses, in contrast to minor emissions from other nebulizers.39 the implementation of negative pressure (hepa) also proved highly beneficial in minimizing contaminated aerosols. an analysis using fluorescein particles effectively showed the impact of negative pressure in diminishing particle deposition. the result showed the critical role of suitable ventilation measures in mitigating exposure risks among healthcare workers,40 as well as contributing valuable insights for optimizing aerosol administration protocols and ensuring enhanced safety. enhancing patient environmental cleanliness this study presents various highly effective approaches for the deactivation of bioaerosol and decontamination of surface. the ozone-based decontamination device showed exceptional efficiency, achieving a substantial reduction (>4 log10) of surrogate organisms across diverse surfaces and positions.41 furthermore, on-site disinfection tests using chlorine dioxide gas effectively removed escherichia coli.42 this study also investigated the potent neutralization of exhaled bioaerosols using far-uvc light at 222 nm, showing the efficiency and safe usage.43 according to a previous study, rotating uvc proved more effective than stationary uvc, showing the potential for enhancing disinfection efficiency.44 the use of far-uvc (222-nm) radiation effectively deactivated bioaerosols, providing promising results for independent or combined usage. additionally, the result showed different levels of resistance on the decay rates and susceptibility constants of different bacteria to 222-nm far-uvc.45 a combination of uv-c air treatment and ozone treatment exhibited a substantial reduction of pathogens in daily operations, showing the effectiveness of integrated methods in pathogen control, with an exception for certain pathogens, such as clostridioides spp.46-47 in general, the results provide valuable insights into advanced methods for bioaerosol control and surface disinfection, ensuring significant advancements in ensuring a safer and cleaner environment. healthcare professionals need to emphasize the thorough use of personal protective equipment (ppe) to minimize the spread of contaminated aerosols during nebulization procedures. the use of ppe was endorsed during the 2019 coronavirus disease (covid19) pandemic, characterized by an increasing transmission rate.48 the typical use of eye protection, gowns, and gloves was considered standard practice. however, in terms of guarding against respiratory transmission, ppe for healthcare workers is a topic of debate and different opinions.49,50 this study focused mainly on the discourse of using masks as a means to protect healthcare professionals, while also considering other ppe. the most important recommendation was the use of n95 masks to effectively reduce the transmission of contaminated aerosols during medical procedures. however, in instances of constrained n95 supply, surgical masks remain a reliable alternative for providing protection. the application of surgical masks as an integral component of ppe remains effective even in the context of administering nebulization procedures for non-covid patients.51 considering the use of a full-face mask during aerosol-generating procedures could be a prudent choice under certain circumstances, such as in the event of a developing or unknown epidemic.52 fullface masks could be used in situations that demand a highly efficient filtration system. according to weng et al.,23 wearing the mask resulted in a minor discomfort over time, but it remained in an acceptable threshold. in the assessment, the clarity of vision was not altered and the mask successfully met the breathability criteria. furthermore, the observation of meticulous nebulizer hygiene practices represents a crucial measure in reducing and controlling aerosol contamination. the prevalent consensus in multiple authoritative guidelines showed the importance of conducting cleaning procedures, using either water or a 70% alcohol solution.53–55 the recent use of heat/boiling and chemical approaches, as well as uv or ozone for disinfection, had shown good potential. in selecting a particular approach, an individual needs to consider the accessibility of materials and tools necessary to support and maintain proper nebulizer hygiene practices. previous studies showed that the use of hot water for disinfection could modify the nebulizer output, necessitating careful consideration.56-60 conversely, ozone and ultraviolet-c (uv-c) show good potential by maintaining nebulizer output in simulations. ozone acts as an oxidizing agent, neutralizing reactive oxygen species (ros), activating cellular respiration and metabolism, and triggering protective responses in bacterial and fungal cells.61 furthermore, ozone directly interacts with surface proteins and membrane receptors in viruses, altering the structure and ability to infect by modifying essential viral binding receptors.62 uv-c with a wavelength between 200 and 280 nm, has a wellestablished reputation for antimicrobial and disinfectant properties. the mechanism of action includes the formation of pyrimidine dimers, resulting in dna damage.63 uv-c light and ozone have been combined in several studies to achieve a higher and more efficient reduction of microorganisms. these components were also used to enhance environmental cleanliness in the vicinity of patients. the strategy was implemented in response to the identification of pathogens in the nebulizer and the surrounding air, resulting in hap, in patient’s environment.64-65 caution is important when using uv-c because the repercussions of prolonged exposure remain uncertain. uv radiation, imperceptible to the human eye, can harm tissues without immediate notice. prolonged exposure intensifies the adverse effects, potentially causing tissue damage, skin changes, wrinkles, and cancers, such as melanoma and basal cell carcinoma.66 similarly, ozone, a potent oxidant, effectively targets bacteria, viruses, and fungi by interacting with organic substances, but also has risks to health and safety. appropriate ozone use includes disinfecting unoccupied spaces and maintaining concentrations that eradicate viruses while minimizing material harm.67 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13044] [page 69] non -co mmerc ial us e o nly another intervention is incorporating filtration during nebulization to prevent contamination. filtration is the deliberate separation of solid particles from a solid-fluid mixture to enhance purity. primary filtration categories include solid-gas and solid-liquid separation. furthermore, the key to effective filtration is the use of a specialized membrane or filter aimed at reducing undesirable particle concentrations. these particles are different in size, ranging from nano-scale, including viruses, micro-scale, such as bacteria (e.g., staphylococcus, pseudomonas), to larger particles.68 a crucial consideration in choosing infection prevention and control (ipc) strategies for implementation is the proper management of associated costs in the hospital. several ipc initiatives and judicious financial allocation are needed due to the impact of healthcare-associated infections (hais) on patient well-being and extended hospitalization.69 furthermore, assessing the efficiency of each program is important when determining the allocation of resources for ipc programs. economic evaluations can ascertain the cost-effectiveness of various ipc strategies, ensuring a judicious use of resources that deliver optimal value for money. conclusions in conclusion, persistent concerns in healthcare facilities regarding potential aerosol contamination showed the need for proactive measures. the preventive measures included several array of strategies, such as the use of masks by therapists, thorough disinfection of nebulizers, integration of filters, and consistent environmental cleaning in patient’s vicinity. these multifaceted interventions were important in preventing the administration of contaminated aerosols and reducing the spread of infectious agents. the implementation was crucial in enhancing patient safety during nebulization therapy, thereby contributing to more effective and secure healthcare practices. further studies and advancements in preventive methods were essential to improve infection control efforts, ensuring a safe therapeutic environment for both patients and healthcare providers. references 1. mccarthy sd, gonzález he, higgins bd. future trends in nebulized therapies for pulmonary disease. j pers med 2020;10:37. 2. barjaktarevic iz, milstone ap. nebulized therapies in copd: past, present, and the future. int j chron obstruct pulmon dis 2020;15:1665–77. 3. matuszak m, ochowiak m, włodarczak s, et al. state-of-theart review of the application and development of various methods of aerosol therapy. int j pharm 2022;614:121432. 4. harris jc, collins ms, huang ph, et al. bacterial surface detachment during nebulization with contaminated reusable home nebulizers. brissette ca, editor. microbiol spectr 2022;10(1). 5. reychler g, vecellio l, dubus jc. nebulization: a potential source of sars-cov-2 transmission. respir med res 2020;78:100778. 6. swanson cs, dhand r, cao l, et al. microbiome-based source identification of microbial contamination in nebulizers used by inpatients. j hospital infection 2022;122:157–61. 7. elmashae y, yermakov m, frank e, et al. exposure of homeattending healthcare workers to aerosolized medications (simulation study). j aerosol sci 2019;133:49–55. 8. kao cl, lin ch. a novel mask to prevent aerosol spread during nebulization treatment. j formosan med assoc 2021; 120:769–71. 9. swanson cs, dhand r, cao l, et al. microbiome-scale analysis of aerosol facemask contamination during nebulization therapy in the hospital. j hospital infect 2023;101890. 10. o’malley ca. device cleaning and infection control in aerosol therapy. respir care 2015;60:917–30. 11. bell j, alexander l, carson j, et al. nebulizer hygiene in cystic fibrosis: evidence-based recommendations. breathe 2020;16:190328. 12. burnett e. effective infection prevention and control: the nurse’s role. nursing standard 2018;33:68–72. 13. russell cd, koch o, laurenson if, et al. diagnosis and features of hospital-acquired pneumonia: a retrospective cohort study. j hospital infect 2016;92:273–9. 14. aiesh bm, qashou r, shemmessian g, et al. nosocomial infections in the surgical intensive care unit: an observational retrospective study from a large tertiary hospital in palestine. bmc infect dis 2023;23:686. 15. kim bg, kang m, lim j, et al. comprehensive risk assess 4th international nursing and health sciences symposium correspondence: ika yuni widyawati. faculty of nursing, universitas airlangga, jl. dr. ir. h. soekarno, mulyorejo, kec. mulyorejo, surabaya, east java, indonesia, postcode:60115, ph. +62315913257, email: ika-yw@fkp.unair.ac.id key words: aerosol contamination; nebulized therapy; nosocomial pneumonia; prevention strategies contributions: in the collaborative effort of crafting this study, each of the three authors made equal and significant contributions. the distribution of tasks and responsibilities was meticulously balanced to ensure that the workload was evenly shared. this egalitarian approach shows the commitment to a fair and collaborative process, where the input of every author is valued and acknowledged equitably. the equal contributions of each author also show the collaborative nature of this study, fostering a comprehensive and well-rounded perspective in the final review. conflict of interest: the authors declare no potential conflict of interest. funding: this study was independently conducted without receiving any external funding or financial support. ethics approval: not applicable. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to the pioneering study by fellow scientists and healthcare professionals, which laid the foundation for this review. the authors are also grateful to colleagues and friends, for the support and encouragement supporting, essential in propelling the study forward and fostering an enriching academic environment. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13044 doi:10.4081/hls.2024.13044 [page 70] [healthcare in low-resource settings 2024;12(s1):13044] non -co mmerc ial us e o nly ment for hospital-acquired pneumonia: sociodemographic, clinical, and hospital environmental factors associated with the incidence of hospital-acquired pneumonia. bmc pulm med 2022;22:21. 16. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021;n71. 17. schiavenato m, chu f. pico: what it is and what it is not. nurse educ pract 2021;56:103194. 18. macintyre cr, wang q, rahman b, et al. efficacy of face masks and respirators in preventing upper respiratory 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surgical masks prevent sars-cov-2 aerosol transmission? sep purif technol 2023;314:123574. 25. towle d, callan da, farrel pa, et al. baby bottle steam sterilizers disinfect home nebulizers inoculated with bacterial respiratory pathogens. j cystic fibrosis 2013;12:512–6. 26. towle d, callan da, lamprea c, murray ts. baby bottle steam sterilizers for disinfecting home nebulizers inoculated with non-tuberculous mycobacteria. j hospital infect 2016;92:222–5. 27. moore j, millar b. susceptibility of the mycobacterium abscessus complex to drying: implications for nebulizer hygiene in patients with cystic fibrosis. int j mycobacteriol 2020;9:173–5. 28. lopes ms, ferreira jrf, da silva kb, et al. disinfection of corrugated tubing by ozone and ultrasound in mechanically ventilated tracheostomized patients. j hospital infect 2015;90:304–9. 29. moore je, moore re, bell j, millar bc. importance of nebulizer drying for patients with cystic fibrosis. respir care 2020;65:1444–50. 30. hohenwarter k, 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irradiation conditions. j hazard mater 2022;440:129791. 46. wang mh, zhang hh, chan ck, et al. experimental study of the disinfection performance of a 222-nm far-uvc upperroom system on airborne microorganisms in a full-scale chamber. build environ 2023;236:110260. 47. lu yh, wu h, zhang hh, et al. synergistic disinfection of aerosolized bacteria and bacteriophage by far-uvc (222-nm) and negative air ions. j hazard mater 2023;441:129876. 48. sottani c, favorido barraza g, frigerio f, et al. effectiveness of a combined uv-c and ozone treatment in reducing healthcare-associated infections in hospital facilities. j hospital infect 2023;139:207–16. 49. swarnakar r, gupta n, halder i, khilnani g. guidance for nebulization during the covid-19 pandemic. lung india 2021;38:86. 50. zhang m, zheng h, wang j. strategy of using personal protective equipment during aerosol-generating medical procedures with covid-19. j clin anesth 2020;66:109911. 51. driessche k vanden, hens n, tilley p, et al. surgical masks reduce airborne spread of pseudomonas aeruginosa in colo 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13044] [page 71] non -co mmerc ial us e o nly nized patients with cystic fibrosis. am j respir crit care med 2015;192:897–9. 52. martinelli l, kopilaš v, vidmar m, et al. face masks during the covid-19 pandemic: a simple protection tool with many meanings. front public health 2021;8:606635. 53. katiyar sk, gaur sn, solanki rn, et al. indian guidelines on nebulization therapy. indian j tuberc 2022;69:s1–191. 54. central for disease control and prevention (cdc). guidelines for preventing health-care-associated pneumonia, 2003: recommendations of cdc and the healthcare infection control practices advisory committee. mmwr recomm rep 2004;53:1–36. 55. cdc. ventilator-associated pneumonia (vap). 2023 [cited 2023 aug 12]. ventilator-associated pneumonia basics. available from: https://www.cdc.gov/ventilator-associatedpneumonia/about/index.html. 56. collins ms, o’brien m, schramm cm, murray ts. repeated hot water and steam disinfection of pari lc plus® nebulizers alter nebulizer output. j cystic fibrosis 2019;18:233–5. 57. manor e, gur m, geffen y, bentur l. cleaning and infection control of airway clearance devices used by cf patients. chron respir dis 2017;14:370–6. 58. caskey s, moore je, rendall jc. in vitro activity of seven hospital biocides against mycobacterium abscessus: implications for patients with cystic fibrosis. int j mycobacteriol 2018;7:45–7. 59. collins ms, harris j, murray t. efficacy of thermal and chemical methods of nebulizer disinfection of cf pathogens. in: cystic fibrosis. european respiratory society; 2019. p. pa981. 60. hutauruk sm, hermani b, monasari p. role of chlorhexidine on tracheostomy cannula decontamination in relation to the growth of biofilm-forming bacteria colonya randomized controlled trial study. ann med surg 2021;67:102491. 61. epelle ei, macfarlane a, cusack m, burns a, thissera b, mackay w, et al. bacterial and fungal disinfection via ozonation in air. j microbiol methods 2022;194:106431. 62. cristiano l. could ozone be an effective disinfection measure against the novel coronavirus (sars-cov-2)? j prev med hyg 2020;61:e301. 63. khan m, mcdonald m, mundada k, willcox m. efficacy of ultraviolet radiations against coronavirus, bacteria, fungi, fungal spores and biofilm. hygiene 2022;2:120–31. 64. van heerden l, van aswegen h, van vuuren s, et al. contamination of nebulizers and surrounding air at the bedside of mechanically ventilated patients. southern afr j crit care 2017;33:23–7. 65. liu z, xiao x, jiang c, et al. assessment of the air disinfection effect of low-concentration ozone in a closed environment. build environ 2023;244:110747. 66. alebrahim ma, bakkar mm, al darayseh a, et al. awareness and knowledge of the effect of ultraviolet (uv) radiation on the eyes and the relevant protective practices: a cross-sectional study from jordan. healthcare 2022;10:2414. 67. grignani e, mansi a, cabella r, et al. safe and effective use of ozone as air and surface disinfectant in the conjuncture of covid-19. gases 2020;1:19–32. 68. adanur s, jayswal a. filtration mechanisms and manufacturing methods of face masks: an overview. j industrial textiles 2022;51:3683s-3717s. 69. rennert-may e, conly j, leal j, et al. economic evaluations and their use in infection prevention and control: a narrative review. antimicrob resist infect control 2018;7:31. 4th international nursing and health sciences symposium [page 72] [healthcare in low-resource settings 2024;12(s1):13044] non -co mmerc ial us e o nly healthcare in low-resource settings eissn: 2281-7824 https://www.pagepressjournals.org/index.php/hls/index publisher's disclaimer. e-publishing ahead of print is increasingly important for the rapid dissemination of science. the early access service lets users access peer-reviewed articles well before print / regular issue publication, significantly reducing the time it takes for critical findings to reach the research community. these articles are searchable and citable by their doi (digital object identifier). the healthcare in low-resource settings is, therefore, e-publishing pdf files of an early version of manuscripts that undergone a regular peer review and have been accepted for publication, but have not been through the typesetting, pagination and proofreading processes, which may lead to differences between this version and the final one. the final version of the manuscript will then appear on a regular issue of the journal. e-publishing of this pdf file has been approved by the authors. healthc low-resour s 2025 [online ahead of print] to cite this article: rahmayanti d, isa m. risk factors for tuberculosis patients with diabetes mellitus in indonesia: a case control study. healthc low-resour s doi: 10.4081/hls.2025.13887 ©the author(s), 2025 licensee pagepress, italy note: the publisher is not responsible for the content or functionality of any supporting information supplied by the authors. any queries should be directed to the corresponding author for the article. all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. submitted: 11 april 2025 accepted: 12 november 2025 early access: 22 december 2025 https://www.pagepressjournals.org/index.php/hls/index https://www.pagepress.org/site risk factors for tuberculosis patients with diabetes mellitus in indonesia: a case control study devi rahmayanti,1 mohamad isa2 1department of fundamental nursing, school of nursing, faculty of medicine and health science, universitas lambung mangkurat, banjarmasin; 2department of pulmonology and respiratory medicine, faculty of medicine and health science, universitas lambung mangkurat, banjarmasin, indonesia correspondence: devi rahmayanti, school of nursing, faculty of medicine and health science, universitas lambung mangkurat, indonesia. tel.: +62.812.51241405 e-mail: devi.rahmayanti@ulm.ac.id key words: case-control study; demographic; risk factors; tuberculosis. contributions: dr, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; mi, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; dr and mi, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding ethics approval and consent to participate: all of procedure of this study was granted by ethical clerance from faculty of medicine and health science, universitas lambung mangkurat, number 407/kepk-fk ulm/ec/xi/2023. patient consent for publication: we obtained informed consent from respondents before collecting the data. mailto:devi.rahmayanti@ulm.ac.id availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgement: the authors would like to express their gratitude to the banjar regency community health center and all respondents for their willingness to participate in this study, as well as to everyone who has contributed to this research. abstract tuberculosis (tb) is a chronic infectious disease caused by mycobacterium tuberculosis (mtb), and its burden is exacerbated by the increasing prevalence of non-insulin-dependent diabetes mellitus (niddm). this case-control study aimed to identify risk factors associated with tb among patients with niddm in banjar regency, indonesia. a total of 93 respondents with tb or tb with niddm were included using a purposive sampling technique. data were collected via questionnaires and medical records, analyzing demographic characteristics, history of tb exposure, and health parameters. the results showed that gender, education level, smoking history, hospitalization history, and a family history of tb were significantly associated with tb among niddm patients. these findings highlight the need for targeted interventions to reduce tb risk among individuals with niddm, including enhanced screening, public health education, and lifestyle modifications. introduction tuberculosis (tb) is an infectious disease caused by mycobacterium tuberculosis.1 globally, tb is one of the 10 causes of death and ranks first among single infectious agents.2 indonesia is ranked second out of eight countries with 8.5% tb.3 according to the world health organization (who), indonesia ranks second after india in terms of the global tuberculosis (tb) burden.4 globally, there were an estimated 10.6 million new tb cases in 2022, with more than half of them concentrated in eight high-burden countries, including indonesia.5 the burden is unequally distributed across provinces, with the highest numbers recorded in west jawa.6 these figures highlight indonesia’s critical role in the global tb epidemic and the urgent need for regionally targeted interventions. it's important to note that underreporting and underdiagnosis of tb have been significant challenges in indonesia. the who estimated that 15.6% of detected tb cases were underreported, with variations among different types of health facilities.7 in summary, while the who provides comprehensive national data on tb in indonesia for 2018, detailed statistics for specific provinces and cities, including south kalimantan.8 although the number of tb cases has decreased, the burden of tb disease is getting heavier due to the increasing cases of non-insulin-dependent diabetes mellitus (niddm). niddm cases can increase the risk of tb infection by 1.5 fold.9 tb patients with diabetes are more likely to experience treatment failure and relapse compared to those without diabetes, increasing their risk of developing multidrug-resistant.10 cellular immune response is impaired in patients with niddm, despite its crucial role in controlling tb infection. there is a decrease in lymphocyte count in tb patients with niddm compared to those without diabetes. additionally, levels of tnf-α and ifn-γ are elevated in patients with both tb and niddm. this indicates a weakened cellular immune response, which requires stronger stimulation for optimal activation.11, 12 data from indonesia health basic research indicated that men are more vulnerable to tb than women, partly due to smoking habits, which are nearly twice as common among men.13 smoking exacerbates tuberculosis by impairing alveolar macrophage function, suppressing tcell mediated immunity, damaging pulmonary mucosal defenses, and contributing to poor treatment outcomes.14 the highest incidence of tb occurs in 45–54 age group (17.3%), followed by the 25–34 age group (16.8%) and the 15–24 age group (16.7%).15 tb is more prevalent among individuals aged below 60 years with a body mass index > 25.16 tb screening for niddm clients, especially sociodemographic was limit.17,18 therefore, this study is needed to explore the factors contributing to tb in niddm patients. materials and methods all of procedure of this study was granted by ethical clerance from faculty of medicine and health science, universitas lambung mangkurat, number 407/kepk-fk ulm/ec/xi/2023. this study was a the case-control study approach and conducted from february to november 2023 in the health care center of banjar regency, south kalimantan, indonesia. the sample size was determined using the formula for testing the difference between two proportions.19 the calculation was based on a significance level of 5% (α = 0.05; zα = 1.96), study power of 80% (β = 0.20; zβ = 0.84), an expected odds ratio (or) of 3.3, and an assumed proportion of exposure among controls (p2) of 0.50. using these parameters, the estimated proportion of exposure among cases (p1) was calculated as 0.50, with the average proportion (p) of 0.40. substituting into the formula yielded a minimum required sample size of 48 subjects. total sample in this study were 93 respondents with pulmonary tb or pulmonary tb with niddm. we used consecutive sampling technique. inclusion criteria were pulmonary tb patients diagnosed at the banjar regency health center who agreed to participate in the study. cases were defined as pulmonary tb patients with niddm, while controls were pulmonary tb patients without niddm. exclusion criteria were patients with extrapulmonary tb, tb-hiv co-infection, or incomplete medical records. data collection was carried out using primary and secondary data. this study used questionnaire and data from medical records. the data will be analyzed with a spss. descriptive statistics are used to measure the frequency and percentage random blood glucose, acid-fast bacilli sputum smear and sociodemographic of respondents. we used chi-square test determine if there is a significant association betweencharacteristic/sociodemographic and niddm statistical significance (p < 0.05) was used as a criterion to include or exclude the hypothesis. variables with a p-value < 0.05 in the bivariate analysis were then included in a multivariate logistic regression model to control for potential confounders and to determine independent risk factors. results table 1 showed the characteristic of respondents of tb. all of respondents had positive acid bacilli sputum smear. in term of age, respondents in risk age was 46.3% and not risk age was 53.7%. most of respondents were female (86.1%) and had high school degree (59.1%). in term of job, more than a half of respondents had risk job (51.7%) and normal body mass index (52.6%), however there were 45.1% of respondents had underweight body mass index. 100% repondents had history of smoking, and more than half had history of family with tb (51.7%). 81.7% of respondents never hospitalized and 71 % of respondents was tb patients with niddm. patients tb with niddm was become case study. table 2 showed risk factors of tb among tb patients niddm. it listes that gender (p value: 0.000), education (p value: 0.005), history of smooking (p value: 0.000), history of hospitalized (p value: 0.000), and family with tb history (p value: 0.000) were factors that related to tb with niddm. the multivariate logistic regression analysis showed that the model had a cox & snell r square value of 0.150 and a nagelkerke r square value of 0.231. this indicates that the independent variables included in the model were able to explain approximately 21.3% of the variability in the dependent variable. the remaining 78.7% of the variability was influenced by other factors outside the model. discussion the objective of this study was to identify the risk factors for t tb with niddm. the results showed that gender, education, history of smooking, history of hospitalized, and family with tb history were factors that related to tb with niddm. this study found no relationship between age and tb with niddm. this finding contrasts with previous research in indonesia that mentioned a correlation between young age and the incidence of tb with niddm.20 the majority of tb cases occur in individuals aged 15–55 years, which is considered the productive age group. during this period, people often prioritize work, leading to reduced rest and a weakened immune system.15 however, there was study mentioned that most tb with niddm were men aged 47 years or older, attributing the higher prevalence of niddm in older individuals to decreased immunity and age-related frailty, which increase vulnerability to tb. based on these studies, it showed that the relationship between age and the prevalence of tb in individuals with niddm may vary across different populations and settings.21 the statistical test analysis revealed there was significant relationship between gender and tb in individuals with niddm. this finding aligns with previous studies indicating a relationship between gender and tb.21 tb is generally more prevalent in men than in women. study among individuals with tb and niddm showed that from 1,243 smear-positive tb cases found that 63.2% were male. interestingly, the prevalence of niddm among these tb patients was higher in women (22.9%) compared to men (9.2%), suggesting that while tb is generally more prevalent in men, women with tb are more likely to have concurrent niddm.22,23 this may be attributed to men often having unhealthy habits such as smoking24, 25 and alcohol consumption.26 these study conclude that there is a relationship between education and tb with niddm. this is in line with previous study that there is a relationship between the level of knowledge and the tb cases with niddm.27 these results show that the higher or better a person's knowledge was related with adherence in medication.28 level of education greatly influences health literacy. if tb patients do not understand the benefits of taking medication regularly and regular check-ups, the patient will discontinue treatment, resulting in resistance.29 the analysis results showed no significant relationship between job and the incidence of tb with niddm. however, previous study mentioned that work environment factors can influence a person’s risk of exposure to disease.30 poor working conditions contribute to a higher risk of tb infection, particularly among individuals in occupations such as drivers, laborers, and pedicab drivers, compared to those working in office settings. factors such as exposure to respirable silica dust, lack of personal protective equipment, and poor living conditions, including overcrowding and inadequate ventilation, contributed to this increased risk.31 additionally, occupational factors are also closely linked to income levels.32 families with little or no income have lower purchasing power, making it difficult to meet adequate nutritional needs. this often leads to malnutrition, which weakens the immune system and increases vulnerability to various diseases, especially tb.32 this study revealed no significant association between body mass index (bmi) and tuberculosis with diabetes mellitus. theoretically, bmi is related to tb;33 however, weight gain may occur until bmi returns to normal in tb patients who have completed the initial intensive phase of treatment (2–8 weeks). in addition to completing the standard 6 month treatment regimen, maintaining adequate nutrition is also essential. we assumed that the risk of tuberculosis increases regardless of bmi, as diabetes mellitus serves as a dominant factor that may overshadow the effect of bmi. therefore, it is recommended that respondents maintain normal nutritional status by consuming nutritious food, routinely measuring weight and height so that their bmi is known periodically, in addition to increasing the coverage of bcg immunization in infants in order to prevent tb because it can increase the body's immune system. the history of hospital admissions showed a statistically significant association with tb patients who also have niddm the coexistence of these conditions can result in more severe disease manifestations and complications, often requiring hospitalization for comprehensive management. previous study mentioned that people with niddm have a 1.5-fold increased risk of developing tb. the risk is even higher among individuals using insulin for niddm management. this increased susceptibility underscores the importance of comprehensive management strategies, including potential hospital admissions, to address the complications arising from the coexistence of tb and niddm.34 the analysis showed that all tb patients in the study were smokers, either active or passive, and there was a link between smoking, tb and niddm. smoking may worsen tb by affecting the body's defense system.35 it can impair the lungs' ability to clear mucus, weaken immune cells like macrophages and natural killer (nk) cells, and disrupt other immune responses. research also suggests that smoking is related to the severity of lung damage in tb and the speed of recovery. the longer a person smokes, the greater the risk, as harmful toxins from cigarettes build up in the body. smoking and tb together create a dangerous combination, as smoking increases the spread of infection, turns latent tb into an active disease, and makes the illness more severe.36 family history of tb was related to tb patient with niddm. a family history of tb suggests prolonged exposure to mtb, increasing the likelihood of latent tb infection and some genetic factors may make individuals in the same family more susceptible to tb.37 and the respondents close contact with a tb -infected family member increases the risk of acquiring the infection, especially in crowded living conditions.38 further, the logistic regression model explained 21.3% of the variability in tb among patients with niddm, indicating that gender, education level, smoking history, hospitalization history, and family history of tb are important but not exclusive predictors. the remaining unexplained variability suggests that other biological, behavioral, and environmental factors also contribute significantly to the risk of tb in this population. this study has several limitations that should be considered when interpreting the findings. first, the relatively small sample size may limit the generalizability of the results to broader populations. a larger, more diverse sample would provide a more comprehensive understanding of the relationship between tb with niddm. second, as a case-control study, this research identifies associations but does not establish causation between the examined risk factors and tb among niddm patients. additionally, some data, such as smoking history and past tb exposure, were self-reported, which may introduce recall bias. conclusions this study identified key risk factors for tb among individuals with niddm, including gender, education level, smoking history, hospitalization history, and a family history of tb. the findings of this study have significant implications for tb prevention and management among individuals. public health interventions should focus on targeted strategies to reduce tb risk in niddm patients, including early screening. health education programs are essential to raise awareness about risk factors such as smoking and non-adherence to treatment, encouraging patients to adopt healthier lifestyles. additionally, regular tb screening for individuals with niddm, particularly those with a family history of tb or other identified risk factors, should be prioritized to facilitate early detection and treatment. 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soc tropical med hygiene 2017;111:81-9. 19. lwanga sk, lemeshow s. sample size determination in health studies. geneva: world health organization. 1991;1. 20. alisjahbana b, van crevel r, sahiratmadja e, et al. diabetes mellitus is strongly associated with tuberculosis in indonesia. internat j tuberc lung dis 2006;10:696-700. 21. li j, zhao y, jiang y, et al. prevalence and risk factors of diabetes in patients with active pulmonary tuberculosis: a cross-sectional study in two financially affluent china cities. diabetes metab syndr obes 2024;17:1105-1114. 22. abedi s, moosazadeh m, tabrizi r, et al. the impact of diabetics and smoking on gender differences of smear positive pulmonary tuberculosis incidence. indian j tuberc 2019;66:353-7. 23. pérez-guzmán c, vargas mh, torres-cruz a, et al. diabetes modifies the male:female ratio in pulmonary tuberculosis. int j tuberc lung dis 2003;7:354-8. 24. alavi-naini r, sharifi-mood b, metanat m. association between tuberculosis and smoking. int j high risk behav addict 2012;1:71-4. 25. pourali f, khademloo m, abedi s, et al. relationship between smoking and tuberculosis recurrence: a systematic review and meta-analysis. indian j tuberc 2023;70:475-82. 26. weiangkham d, umnuaypornlert a, saokaew s, prommongkol s, ponmark j. effect of alcohol consumption on relapse outcomes among tuberculosis patients: a systematic review and meta-analysis. front public health 2022;10:962809. 27. ahmad sr, yaacob na, jaeb mz, et al. effect of diabetes mellitus on tuberculosis treatment outcomes among tuberculosis patients in kelantan, malaysia. iranian j public health 2020;49:1485-93. 28. koesoemadinata rc, mcallister sm, soetedjo nnm, et al. educational counselling of patients with combined tb and diabetes mellitus: a randomised trial. public health action 2021;11:202-8. 29. chauhan a, parmar m, dash gc, et al. health literacy and tuberculosis control: systematic review and meta-analysis. bull world health organ 2024;102:421-31. 30. semilan hm, abugad ha, mashat hm, abdel wahab mm. epidemiology of tuberculosis among different occupational groups in makkah region, saudi arabia. sci rep 2021;11:12764. 31. ahimbisibwe i, tumusiime c, muteebwa l, et al. prevalence of pulmonary tuberculosis among casual labourers working in selected road construction sites in central uganda. plos one 2024;19:e0304719. 32. carwile me, hochberg ns, sinha p. undernutrition is feeding the tuberculosis pandemic: a perspective. j clin tuberc other mycobact dis 2022;27:100311. 33. kubiak rw, sarkar s, horsburgh cr, et al. interaction of nutritional status and diabetes on active and latent tuberculosis: a cross-sectional analysis. bmc infect dis 2019;19:627. 34. dobler cc, flack jr, marks gb. risk of tuberculosis among people with diabetes mellitus: an australian nationwide cohort study. bmj open 2012;2:e000666. 35. jali mv, mahishale vk, hiremath mb, et al. diabetes mellitus and smoking among tuberculosis patients in a tertiary care centre in karnataka, india. public health action 2013;3:s51-3. 36. reed gw, choi h, lee sy, et al. impact of diabetes and smoking on mortality in tuberculosis. plos one 2013;8:e58044. 37. schurz h, naranbhai v, yates ta, et al. multi-ancestry meta-analysis of host genetic susceptibility to tuberculosis identifies shared genetic architecture. elife 2024;13:e84394. 38. kokiwar pr, soodi reddy ak. diabetes mellitus as a risk factor for tuberculosis: a community based case control study. indian j community med 2024;49:617-21. table 1. sociodemographic and clinical characteristic of respondents. characteristic frequency percentage n = 93 % characteristic frequency percentage n = 93 % age not risk (>55 years old) 50 53.7 risk (15-55 years old) 43 46.3 gender female 13 13.9 male 80 86.1 education elementary school 33 35.4 high school 55 59.1 university 5 0.5 job not risk 45 48.3 risk 48 51.7 body mass index underweight 42 45.1 normal 49 52.6 obesity 2 2.3 history of smoking passive or active 93 100 family history of tb yes 45 48.3 no 48 51.7 history of hospitalized yes 17 18.2 no 76 81.8 random blood glucose yes 27 29 no 66 71 acid-fast bacilli sputum smear yes 93 100 characteristic frequency percentage n = 93 % no 0 0 table 2. bivariate analysis of factors that related with tb among tb patients with niddm. variable tuberculosis p-value case (%) control (%) age 0.778 not risk (>55 years old) 11 (40.7) 39 (59.1) risk (15-55 years old) 16 (59.3) 27 (40.9) gender 0.000 female 13 (48.1) 0 (0) male 14 (51.9) 66 (100 ) education 0.005 elementary school 16 (59.2) 17 (25.8) high school 8 (29.6) 47 (71.2) university 3 (11.2) 2 (3.0) job 0.171 risk 16 (59.3) 29 (43.9) not risk 11 (40.7) 37 (56.1) bmi 0.873 underweight 9 (33.3) 34 (50) normal 18 (66.7) 32 (47) obesity 0 (0) 2 (3) history of smooking 0.000 yes 14 (51.9) 66 (100) no history of hospitalized 13 (48.1) 0 (0) yes 7 (25.9) 10 (15.2) 0.000 no 20 (74.1) 56 (84.8) family history of tb yes 16 (59.3) 29 (43.9) 0.000 no 11 (40.7) 37 (56.1) table 3. logistic regression. model fit measure value cox & snell r square 0.150 nagelkerke r square 0.231 r² (interpretation) 0.213 hrev_master healthcare in low-resource settings 2025; volume 13:13548 the e-posyandu health application (epok) as a medium to enhance parental independence in stimulating growth and development of children under five melly damayanti, nurul aini suria saputri, darwitri darwitri ministry of health, tanjungpinang health polytechnic, indonesia abstract the early childhood period, specifically from birth to five years of age, represents a crucial phase for growth and development. however, stunting prevalence worldwide remains high. parental independence in stimulating children under five’s growth and development is pivotal in addressing this issue. the study aims to explore the impact of the e-posyandu health application (epok) in promoting parental independence in the growth and development of their children. the research employed a quasiexperimental method with a pre-posttest control group design. the sample consisted of 140 parents with children under five years old in tanjungpinang city, divided into intervention (70 parents) and control (70 parents) groups. the intervention group used the epok application for 3 months, while the control group received routine puskesmas (community health center) services. data collection used a parental independence questionnaire. the intervention group showed a significant 23% increase in mean independence scores (p=0.001), compared to no significant changes in the control group. after the intervention, a meaningful difference between groups was observed (p=0.001). multiple regression analysis revealed education, knowledge, skills, and motivation as significant predictors, explaining 58.4% of the variation in independence (adjusted r2=0.584). based on our findings, the epok application effectively enhances parental independence by stimulating the growth and development of children under five. the application can be a supportive tool for parents to monitor and optimize child development independently. introduction the children under five phase is a critical period encompassing two important dimensions: physical growth and ability development. growth refers to changes in body size and structure, while development includes improvements in motor skills, communication, social interaction, and independence. optimal growth and development stimulation can enhance a child’s cognitive, social, and emotional development, ultimately leading to better health status.1-5 the first five years of life are critical as children lay the groundwork for their learning and socio-emotional abilities.6-8 according to who, in 2022, 148.1 million children under five were diagnosed with stunting, equivalent to 22.3% of the global children under five population, and approximately 45 million children suffered from wasting. based on unicef reports, around 101 million children under five worldwide experience underweight conditions.9 in indonesia, the government aims to reduce stunting prevalence to 14% by 2024, in line with the global target set by who. however, based on the latest data, stunting prevalence in indonesia remains at 21.6%, indicating that reduction efforts need to be intensified to achieve the established target.10,11 in developing countries, over 200 million children under five fail to reach their cognitive and social development potential due to poverty, poor health, inadequate nutrition, and insufficient caregiving.7,8,12 the involvement of parents and family members is essential in promoting the growth and development of children under the age of five; parental participation and independence in providing stimulation will help children improve in the future, not only physically but also intellectually, socially, emotionally, and in terms of independence.2,6,7,13-16 active parents who support and stimulate their children can promote child development and maintain the child’s nutritional status. parents play a central role as they are closest to the child: they can recognize the child’s specific needs, correspondence: melly damayanti, ministry of health, tanjungpinang health polytechnic, indonesia. e-mail: apriyandimelly@gmail.com key words: parental independence; growth and development stimulation; children under five. contributions: md, conceptualization, data curation, methodology, validation, visualization, writing – original draft, review and editing; nass, formal analysis, methodology, validation, and writing – original draft, review and editing; dd, conceptualization, investigation, validation. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research has received ethical approval from the ethics committee of stikes bani saleh bekasi, as evidenced by the ethical certificate number ec.188/kepk/stkbs/ vi/2024. throughout the study, the researcher adhered to ethical principles of informed consent, respect for human rights, beneficence, and nonmaleficence. consent for publication: written informed consent was obtained from the anonymized patient for publication in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 30 december 2024. accepted: 29 january 2025. early access: 29 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13548 doi:10.4081/hls.2025.13548 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 158] [healthcare in low-resource settings 2025;13:13548] provide appropriate stimulation, and perform early interventions if issues arise.2,7,17-20 an integrated, evidence-based approach to optimizing early childhood health is globally recommended. effective interventions focusing on the first 1000 days of life include specific micronutrient provision (vitamin a, zinc, iron), early cognitive development stimulation, systematic nutrition management through integrated management of childhood illness (imci), and digital health technology use for continuous growth and development monitoring. digital technology and data-based interventions are increasingly becoming key strategies in nutritional status monitoring, with primary targets of reducing stunting rates, improving exclusive breastfeeding quality, and comprehensively optimizing children under five’s physical-cognitive growth.15,20-24 the indonesian government has developed a series of comprehensive interventions to improve children under five’s growth and development through the first 1000 days of life program, national stunting prevention, posyandu, supplementary feeding program (pmt), and specific nutrition interventions. these programs are designed as systematic efforts to address child nutrition and health issues. these efforts not only focus on health aspects but also integrate technological approaches through children’s nutrition emonitoring systems, enabling real-time recording and reporting of child nutrition conditions, with the expectation of reducing stunting rates and improving the quality of indonesian human resources.10,25-27 parents must be independent, especially in stimulating the growth and development of their toddlers. they are not merely caregivers but active partners in the child’s development process, responsible for understanding, monitoring, and optimizing each growth stage holistically and continuously. independent parents have a better understanding of child development milestones, such as motor, language, and social skills. they are more quickly responsive in recognizing growth and development disturbance signs, such as speech delays or age-inappropriate physical development, thus enabling earlier intervention decisions.28-30 increasing parental independence in stimulation can be achieved through digital applications for monitoring child growth. digital growth charts are particularly helpful for parents in understanding child development efficiently and independently. application information and features significantly contribute positively to parental independence in stimulating child growth and development.7,31-36 there are several other applications similar to epok, but epok stands out with several advantages. these include providing tutorial videos and growth monitoring features based on who growth charts, as well as developmental stimulation features complete with the necessary tools and media tailored to the child’s age. additionally, it offers reminders for immunization schedules, vitamin a supplementation, and deworming schedules. the app also includes a chatroom feature, enabling parents to exchange ideas with their community. these features greatly assist parents in independently monitoring and stimulating their child’s growth and development. given this context, it is critical to investigate the effect of the e-posyandu health application on parental independence in stimulating the growth and development of children under the age of five. this study aims to provide a clearer picture of epok application’s effectiveness in enhancing parental independence. materials and methods research design the study employs a quantitative method based on a quasiexperimental design with a pre-posttest control group approach. the research was conducted from july to september 2024. the intervention group used the epok application for three months. meanwhile, the control group received primary healthcare programs provided by the community health center, which included toddler health services at the posyandu. during the study, communication with all respondents was conducted through a whatsapp group. every month, the research team conducted direct monitoring of the application usage and the growth and development stimulation activities performed by the parents. study participants the population in this study comprised all parents with children under five in the working area of batu 10 community health center, tanjungpinang city. the research sample was a subset of the population meeting specific inclusion and exclusion criteria. the inclusion criteria were: parents of children under five who have previously participated in posyandu activities, own an android device with a minimum version of 5, and are capable of using it. exclusion criteria included parents who are health cadres or healthcare professionals. a total of 70 samples were taken for each group at the same location. the samples were selected using the proportional stratified random sampling technique. variable, instrument, and data collection the independent variable in this study is the intervention provided to both groups, while the dependent variable is parental independence in stimulating the growth and development of children under five. the research instrument used a questionnaire to assess parental independence, which has been tested for validity and reliability. parental independence in providing stimulation can be assessed through health check-ups performed on children under five, consistency in following immunization schedules and vitamin supplementation, provision of proper nutrition, the amount of time spent on stimulation, the use of stimulation aids, as well as the types and variety of activities provided. data analysis data was processed and analyzed using spss software. the data was analyzed through univariate and bivariate methods. univariate analysis was used to examine characteristic variables, while bivariate analysis employed nonparametric tests, specifically the wilcoxon signed rank test and mann-whitney test. multivariate analysis was conducted using multiple linear regression. ethical clearance this study received ethical approval from the research ethics commission of stikes bani saleh bekasi, as evidenced by the ethical certificate number ec.188/kepk/stkbs/vi/2024. throughout the research, the researchers adhered to ethical principles of informed consent, respecting human rights, beneficence, and non-maleficence. article [healthcare in low-resource settings 2025;13:13548] [page 159] results respondent characteristics observed in this study consisted of maternal age, education, occupation, and number of children, with results as shown in table 1. in the intervention group, the majority of respondents were aged 20-40 years (82.9%), had an education level above high school, accounting for 78.6%, and the majority were housewives (72.9%). additionally, most respondents had more than one child (65.7%). similarly, in the control group, most respondents were also aged 20-40 years (71.4%). the majority of respondents had an education level above high school, representing 67.1%, and most were housewives (67.1%). a significant portion of respondents had more than one child (51.4%). statistical analysis yielded p-values greater than 0.05, indicating that both groups were homogeneous and shared similar characteristics, thus making them suitable for comparison. as shown in table 2, the independence variable analysis revealed significant findings. in the intervention group, the mean pretest value was 11.13, which increased to 13.6 after the intervention. the average percentage increase was 23%, indicating a substantial improvement. the wilcoxon signed rank test produced a p-value of 0.000 (≤0.05), demonstrating a statistically significant difference in independence between pretest and posttest values for the intervention group. in contrast, the control group showed minimal changes. the mean pretest value was 11.41, with a slight increase to 11.56 after the intervention. the average percentage increase was only 1%, which was not statistically significant, as confirmed by the wilcoxon signed rank test with a p-value of 0.105 (>0.05). this result indicated no significant difference in independence between pretest and posttest values for the control group. further analysis using the mann-whitney u test for pretest comparison between groups yielded a p-value of 0.195 (>0.05), suggesting no statistically significant differences in independence between the intervention and control groups before the intervention. however, after the intervention, the mann-whitney u test for posttest comparison showed a p-value of 0.000 (≤0.05), indicating a statistically significant difference in independence between the two groups. specifically, the posttest mean differences revealed that the intervention group experienced a substantially greater increase in independence compared to the control group. this improvement is evident from the average change (δ), with the intervention group showing a 23% increase versus only 1% in the control group. the mann-whitney u test result, with a p-value of article [page 160] [healthcare in low-resource settings 2025;13:13548] table 1. respondent characteristics. respondent characteristics group (n=140) p(a) intervention (n=70) control (n=70) n % n % age <20 years 7 10.0 9 12.9 0.213 20-40 years 58 82.9 50 71.4 >40 years 5 7.1 11 15.7 total 70 100 70 100 education <senior high school 15 21.4 21 30.0 0.334 >senior high school 55 78.6 49 70.0 total 70 100 70 100 occupation not working 51 72.9 47 67.1 0.580 work 19 27.1 23 32.9 total 70 100 70 100 children 1 24 34.3 36 51.4 0,060 >1 46 65.7 34 48.6 total 70 100 70 100 (a)chi-square test. table 2. impact of the intervention on parental independence. independence group (n=140) p(b) intervention (n=70) control (n=70) differences between groups pretest 0.195 mean (sd) 11.13 (1.37) 11.41 (1.08) median 11 11 range 9-14 9-14 posttest 0.000* mean (sd) 13.6 (1.04) 11.56 (1.15) median 14 12 range 11-15 9-14 p(a) differences in pretest-posttest 0.000* 0.105 improvement score 0.000* mean (sd) 0.23 (0.11) 0.01 (0.07) median 0.21 0 range 0.07-0.56 -0.1-0.3 (a)wilcoxon test; (b)mann whitney test; *sig<0.05. 0.000 (≤0.05), further confirmed the significant differences between groups in terms of independence improvement. the study conclusively demonstrates that the intervention had a marked positive effect on independence, with the intervention group showing a significantly larger increase than the control group. these findings highlight the potential effectiveness of the intervention in enhancing participants’ independence. therefore, it can be concluded that the intervention using the epok application significantly improves respondents’ independence, as evidenced by the higher mean and median differences in the intervention group compared to the control group. the statistical significance of these differences was confirmed through wilcoxon and mann-whitney test results, which demonstrated p≤0.05. based on table 3, the multiple linear regression analysis of the intervention group yielded an f-value of 14.817 and a p-value of 0.000 (≤0.05), indicating that all variables in the intervention group can effectively explain the variations in independence. the adjusted r2 value of 0.584 demonstrates that 58.4% of the variation in independence can be explained by independent variables, while the remaining 41.6% is attributed to factors outside the research scope. the percentage of skill improvement emerged as the most dominant factor influencing independence, with the highest standardized beta coefficient of 0.341. this was followed by education (0.31), knowledge increase (0.228), and motivation increase (0.203). age, occupation, and number of children variables showed no statistically significant influence on independence, with p>0.05. in contrast, the control group’s multiple linear regression analysis produced an f-value of 5.957 and a p-value of 0.000 (≤0.05), suggesting that all variables can explain the variations in independence. the adjusted r2 value of 0.335 indicates that 33.5% of the independence increase variation can be explained by independent variables in the model, with the remaining 66.5% attributed to factors outside the research model. education emerged as the dominant factor with the most significant impact on independence increase, displaying the highest standardized beta coefficient of 0.397. this was followed by the number of children, with a standardized beta coefficient of 0.367. conversely, variables such as age, occupation, percentage of knowledge increase, skill improvement percentage, and motivation increase demonstrated no statistically significant influence on independence increase, with p>0.05. these findings highlight the complex nature of factors affecting independence and underscore the potential importance of targeted interventions in promoting personal autonomy discussion based on the research findings, there is a significant difference in independence between the pretest and posttest values in the intervention group, which showed a much larger improvement in independence compared to the control group, indicating that the use of the epok application has a significant positive impact on enhancing the respondents’ independence. parental independence is a critical component in optimizing the growth and development of children under five, which is formed through knowledge, awareness, and active involvement in each stage of child development. parental independence is a practical concept that requires a thorough understanding of child growth and development, the ability to provide proper stimulation, and the skills to monitor a child’s progress effectively.7,29,30,37 parental self-efficacy has a significant correlation with the quality of growth monitoring;29,37,38 parents with knowledge, confidence, and independence can better identify potential developmental problems in their children. in this study, parental independence is not influenced by age, number of children, or occupation. in contrast, a parent’s ability to independently stimulate their child’s development is more affected by their awareness and knowledge; younger and older parents can have comparable levels of awareness and access to information. similarly, the number of children does not impact parental independence. having more children does not automatically reduce a parent’s ability to provide stimulation, as they can allocate time and attention equitably with proper management. this also applies to working parents, who actively contribute to their child’s growth and development stimulation by managing their time effectively. in fact, working parents often utilize technology, such as parenting applications, to support their role. the variables of educational characteristics, increased knowledge, improved skills, and increased motivation were found to influence parental independence in article table 3. regression analysis results for independence variable in each group. coefficientsa anova adjusted group model standardized unstandardized r-square coefficients coefficients t sig. f sig. b std. error beta intervention 1 (constant) -0.148 0.059 -2.503 0.015 14.817 0.000* 0.584 age -0.012 0.022 -0.046 -0.549 0.585 education 0.079 0.023 0.301 3.447 0.001* occupation -0.012 0.020 -0.050 -0.601 0.550 children 0.039 0.024 0.173 1.631 0.108 % knowledge improvement 0.187 0.074 0.228 2.548 0.013* % skill improvement 0.293 0.083 0.341 3.522 0.001* %motivation improvement 0.553 0.233 0.203 2.372 0.021* control 1 (constant) -0.230 0.077 -2.990 0.004 5.957 0.000* 0.335 age 0.005 0.014 0.038 0.352 0.726 education 0.058 0.026 0.397 2.216 0.030* occupation 0.041 0.024 0.291 1.723 0.090 children 0.049 0.015 0.367 3.180 0.002* % knowledge improvement 0.041 0.032 0.137 1.284 0.204 %skill improvement -0.040 0.129 -0.031 -0.308 0.759 %motivation improvement 0.661 0.384 0.187 1.721 0.090 adependent variable; % independence improvement. [healthcare in low-resource settings 2025;13:13548] [page 161] stimulating children under five’s growth and development. the level of education affects an individual’s knowledge: higher education allows for easier acceptance of a wider and more diverse range of information, thus making it easier to develop oneself, especially in seeking health information and improving health status. the use of the epok application has been proven to enhance parents’ knowledge and skills in child growth and development.35 this application can encourage positive attitudes and motivate parents to monitor and stimulate their children’s growth and development.7,39,40 the features available in the epok application can facilitate parents to independently assist their child, reducing their reliance on health cadres and professionals.35 the strategy for parental independence includes cognitive stimulation through educational interactions with the child, periodic physical growth monitoring, continuous documentation of development, and the ability to provide stimulation and interventions based on the individual needs of the child.7,13,19,41-44 independence is not merely a routine activity but a dynamic process that requires continuous education, professional support, and access to up-todate information sources.44 parents play a strategic role in optimizing children’s developmental potential through various positive interventions. home-based educational stimulation, quality communication, and providing diverse learning experiences are key factors in supporting optimal growth and development.5,19,43,45-47 consistent and high-quality stimulation provided by both parents can enhance a child’s cognitive abilities, language skills, and social competencies.13,18,48-51 the active role of parents in fostering their child’s potential has undergone a significant transformation, with a primary focus on direct and quality involvement in the child’s developmental process. meaningful interactions between parents and children are not just routine activities but a strategy to support the child’s comprehensive development. through a series of interactive activities such as reading stories, playing together, and providing age-appropriate educational media, parents effectively construct a conducive learning environment. recent research in child developmental psychology shows that intensive and planned parental involvement can optimize the development of social-emotional skills, enhance cognitive capacities, and build a strong psychological foundation during the child’s golden years. parents’ role is not only to stimulate intellectual development but also to build a lasting emotional bond between them and their children.2,4,5,16,45,47,51-53 currently, there are many available applications to improve health outcomes, including tools for parents to monitor their children’s development through real-time tracking. advances in digital technology have transformed health information access, enabling the public to use innovative platforms for enhanced understanding and health independence. these technologies not only provide information but also empower individuals through interactive education and encourage active participation in managing personal and family health.7,31-36,54 health applications are designed with user-friendly architectures, accessible to various age groups, and allow users to easily understand and act on health information independently and comprehensively. utilizing these applications can enhance knowledge and foster independence, enabling individuals to monitor their health and that of their families.55-61 it is essential for parents to strengthen their independence in stimulating their toddler’s growth and development by utilizing technological advancements, such as the epok application. conclusions based on the research findings, it can be concluded that the epok application can enhance parental independence in stimulating the growth and development of children under five. the results of the multiple linear regression analysis show that the variables of education, knowledge improvement, skills, and motivation significantly influence parental independence. in contrast, the variables of parental age, occupation, and number of children do not impact parental independence. there are still many other health-related variables that have not been addressed. therefore, there is a need to include additional predictor variables that could influence stunting in children under five, with the hope that the r2 value will increase. healthcare professionals at health facilities are expected to use this application as a tool to enhance parents’ independence and encourage their active role in stimulating their children’s growth and development. this approach aims to empower parents to prevent delays in their child’s growth and development independently. references 1. walker sp, chang sm, wright as, et al. cognitive, psychosocial, and behaviour gains at age 31 years from the jamaica early childhood stimulation trial. j child psychol psychiatry allied discip 2022;63:626–35. 2. gladstone m, phuka j, mirdamadi s, et al. early child stimulation, linear growth and neurodevelopment in low birth weight infants. bmc pediatr 2022;22:626–35. 3. heidarabadi s, barzegar m, hazrati h, et al. a report on the blended short-term supplementary course on “developmental care for infants and toddlers” taught with a multidisciplinary approach for pediatricians -qualitative and quantitative study. bmc med educ 2022;22:877. 4. sudfeld cr, bliznashka l, ashery g, et al. effect of a homebased health, nutrition and responsive stimulation intervention and conditional cash transfers on child development and growth: a cluster-randomised controlled trial in tanzania. bmj glob heal 2021;6:e005086. 5. id jj, id eef, ramos cv, id do. parenting interventions to promote early child development in the first three years of life : a global systematic review and meta-analysis. plos med 2021;18:1003602 6. marwasariaty m, sutini t, sulaeman s. pendidikan kesehatan menggunakan media booklet + aplikasi sdidtk efektif meningkatkan kemandirian keluarga dalam pemantauan tumbuh kembang balita. j telenursing 2019;1:236–45. 7. gandini ala, ummu salmah a, stang. the role of parents in monitoring the growth and development of toddlers: a systematic review. pharmacogn j 2024;16:682–6. 8. pem d. factors affecting early childhood growth and development : golden 1000 factors affecting early childhood growth and development : golden 1000 days. adv practice nurs 2015; doi: 10.4172/2573-0347.1000101. 9. unicef, who wbg. levels and trends in child malnutrition. 2023 [cited 2023 dec 26]; available from: https://www. who.int/publications/i/item/9789240073791 10. unicef. laporan tahunan 2023. 11. kemenkes bkpk. indonesian health survey (ski) 2023. badan kebijakan pembangunan kesehatan 2023. 12. zand d, pierce k, thomson n, et al. social competence in article [page 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garcia il, aboud fe, et al. articles group-based parenting interventions to promote child development in rural kenya : a multi-arm , cluster-randomised community effectiveness trial. lancet glob heal 2021;9:e309–19. 18. anis l, letourneau n, ross km, et al. study protocol for attachment & child health (attachtm) program: promoting vulnerable children’s health at scale. bmc pediatr 2022;22:491. 19. garcía-sierra a. learning by parenting: how do mothers respond to their children ’ s developmental declines ? soc sci res 2024;119:102988. 20. chademana e, maluleke u, van wyk b. a baseline assessment of developmental delays among children under 5 years in a high-hiv-prevalence setting in the cape metropole. sajch south african j child heal 2023;17. 21. who. global nutrition targets 2025. avilable from: https://www.who.int/teams/nutrition-and-food-safety/globaltargets-2025 22. who. global nutrition targets 2025: wasting policy brief. available from: https://www.who.int/publications/i/item/ who-nmh-nhd-14.8 23. roberton t, carter ed, chou vb, et al. early estimates of the indirect effects of the covid-19 pandemic on maternal and child mortality in low-income and middle-income countries: a modelling study. lancet glob heal 2020;8:e901–8. 24. who. advancing early childhood development: from science to scale. an executive summary for the lancet’s series. 2016. available from: https://www.who.int/docs/ default-source/child-health/advancing-early-childhood-development-from-science-to-scale-an-executive-summary-for-thelancet-s-series.pdf?sfvrsn=de76f5d1_4 25. peraturan menteri kesehatan republik indonesia. percepatan penurunan stunting. 2021. available from: https://peraturan. bpk.go.id/details/174964/perpres-no-72-tahun-2021 26. peraturan menteri kesehatan republik indonesia. standar produk sumplementasi gizi. 2016. available from: https://peraturan.bpk.go.id/details/114009/permenkes-no-51-tahun2016 27. rana r, menon k, puthussery s. effectiveness of nutrition interventions in lowand middle-income countries: a metareview. world nutrition 2020;11:165-189. 28. musengamana i. a systematic review of literature on parental involvement and its impact on children learning outcomes. open access library journal 2023;10. 29. fang y, van grieken a, fierloos in, et al. parental, child and socio-contextual factors associated with parenting self-efficacy among parents of children aged 0–7 years old: the cikeo study. soc psychiatry psychiatr epidemiol 2022;57:623–32. 30. benedetto l, ingrassia m. parental self-efficacy in promoting children care and parenting qualityvv. parenting empirical advances and intervention resources. intech 2018. available from: http://dx.doi.org/10.5772/intechopen.68933 31. sahariah s, purwati nh, apriliawati a. the effectiveness of the primaku application on parents behavior in monitoring the growth of toddlers. j ilm ilmu keperawatan indones 2024;13:160–9. 32. intan k, pratiwi g, kalimantan j, jember jt. the effect of “status gizi balita” android application on mother’s knowledge in nutritional status monitoring of ages 12-24 months. jkakj 2018;2. 33. kitsao-wekulo p, langat nk, nampijja m, et al. development and feasibility testing of a mobile phone application to track children’s developmental progression. plos one 2021;16. 34. coughlin ss, whitehead m, sheats jq, et al. a review of smartphone applications for promoting physical activity. jacobs j community med 2016;2:1–14. 35. damayanti m, aini suria saputri n. the effectiveness of eposyandu kesehatan (epok) application on mother’s knowledge and skills in monitoring the growth and development of children under five. j ilm kesehat 2023;12:170–81. 36. hall cm, bierman kl. technology-assisted interventions for parents of young children: emerging practices, current research, and future directions. early child res q 2015;32:21– 32. 37. seetharaman m, benjamin a, mcgrath jm, vance aj. international journal of nursing studies advances parenting self-efficacy instruments for parents of infants and toddlers : a review. int j nurs stud adv 2022;4:100082. 38. akhmadi, sunartini, haryanti f, et al. effect of care for child development training on cadres’ knowledge, attitude, and efficacy in yogyakarta, indonesia. belitung nurs j 2021;7:311–9. 39. munawir i. faktor-faktor yang berhubungan dengan kepuasan pasien rawat jalan rumah sakit. j ilm kesehat 2018;17:15– 22. 40. fatsena ra, ismail d, haksari el, rokhanawati d. aplikasi si dita berbasis android terhadap peningkatan motivasi orangtua melakukan stimulasi deteksi dini tumbuh kembang. j kesehat reproduksi 2022;8. 41. cadima j, nata g, evangelou m, anders y. inventory and analysis of promising and evidence-based parentand family focused support programs. 2018:1–130. 42. gubbels js, gerards smpl, kremers spj. the association of parenting practices with toddlers’ dietary intake and bmi, and the moderating role of general parenting and child temperament. public health nutr 2020;23:2521–9. 43. saadong d, ramadhan k. the relationship of mother’s role in stimulation with motor development in toddler. j info kesehat 2022;20:20–8. 44. frosch ca, schoppe-sullivan sj. parenting and child development: a relational health perspective. am j lifestyle med 2019;15:45–59. 45. hutton js, huang g, sahay rd, et al. a novel, composite measure of screen-based media use in young children (screenq) and associations with parenting practices and cognitive abilities. pediatr res 2020;87:1211–8. 46. unicef. early childhood development unicef vision for every child. 2023. 47. dickinson dk, nesbitt kt, collins mf, et al. teaching for article [healthcare in low-resource settings 2025;13:13548] [page 163] breadth and depth of vocabulary knowledge: learning from explicit and implicit instruction and the storybook texts. early child res q 2019;47:341–56. 48. fernandez rao s, bentley me, balakrishna n, et al. a complementary feeding and play intervention improves the home environment and mental development among toddlers in rural india. matern child nutr 2020;16. 49. azrimaidaliza a, resti r, helmizar h. evaluation of the implementation stimulation, detection, and early intervention for toddlers growth and development in nanggalo health center. indones j nutr 2024;12:88–100. 50. monalisa m, ernawati e, sinaga w, abbasiah a. the effectiveness of booklets in stimulation, detection and early intervention of growth and development (sdeigd) for health cadres in implementing the growth and development screenings of toddlers. int j multicult multireligious underst 2021;8:45. 51. the effect of parenting quality on child development at 3648 months in china's urban area: evidence from a birth cohort study. int j environ res public health 2020;17:8962. 52. sulistyorini l, septiyono e, merina n, et al. stimulation of growth and development of pandalungan toddler in indonesia. ind j forensic med toxicol 2022;16:237–45. 53. fatonah n. parental involvement in early childhood literacy development. adv soc sci educ humanit res 2020;454:193– 8. 54. larkin f, oostenbroek j, lee y, et al. proof of concept of a smartphone app to support delivery of an intervention to facilitate mothers’ mind-mindedness. plos one 2019;14. 55. ben-sasson a, jacobs k, ben-sasson e. the feasibility of a crowd-based early developmental milestone tracking application. plos one 2022;17:e0268548. 56. taki s, russell cg, lymer s, et al. a mixed methods study to explore the effects of program design elements and participant characteristics on parents’ engagement with an mhealth program to promote healthy infant feeding: the growing healthy program. front endocrinol (lausanne) 2019;10:397. 57. savage j, paola a, gil r, et al. process and effect evaluation of the app-based parenting program samen happie! on infant zbmi: a randomized controlled trial. front public health 2022;10:1012431. 58. denis f, maurier l, carillo k, et al. early detection of neurodevelopmental disorders of toddlers and postnatal depression by mobile health app: observational cross-sectional study. jmir mhealth uhealth 2022;10:e38181. 59. sawyer a, kaim a, le hn, et al. the effectiveness of an appbased nurse-moderated program for new mothers with depression and parenting problems (emums plus): pragmatic randomized controlled trial. j med internet res 2019;21:e13689. 60. kitsao-wekulo p, langat nk, nampijja m, et al. development and feasibility testing of a mobile phone application to track children’s developmental progression. plos one 2021;16:e0254621. 61. alam m, hickie ib, poulsen a, et al. parenting app to support socio-emotional and cognitive development in early childhood: iterative codesign learnings from nine low-income and middle-income countries. bmj open 2023;13:e071232. article [page 164] [healthcare in low-resource settings 2025;13:13548] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13213 efficient management of neonatal sepsis diagnosis using predictive analytics methods: a scoping review kvkl narasimha rao, pradeep kumar dadabada, sanjita jaipura indian institute of management, shillong, meghalaya, india abstract neonatal sepsis is a critical and life-threatening condition that significantly contributes to the high rates of illness and death among newborns, particularly in low and middle income countries (lmics). the complexity of diagnosing and treating neonatal sepsis arises from the unique physiological characteristics of newborns and the increasing challenge of antibiotic resistance. however, early diagnosis and prompt treatment are crucial in effectively managing this condition. predictive analytics methods can potentially address the gaps in diagnosing and treating neonatal sepsis, especially in resource-constrained settings. this scoping review aims to comprehensively analyze the critical factors involved in neonatal sepsis diagnosis and the potential impact of utilizing predictive analytics models in its diagnosis and treatment. this paper reviews the literature to determine the critical factors in managing neonatal sepsis efficiently. it will also delve into the ability of predictive analytics methods to diagnose neonatal sepsis at an early stage, reduce the usage of antibiotics, and achieve cost savings in treatment, highlighting the overall efficiency of diagnosing and managing neonatal sepsis. the findings of this review could provide insight into the impact of predictive analytics methods for diagnosing and treating neonatal sepsis in hospitals in low-resource settings. the review reveals that the predictive analytics methods could lead to efficient management of neonatal sepsis through analysis of critical factors such as early diagnosis of neonatal sepsis at least 48 hours before clinical manifestation, reduction in antibiotic treatment by at least 33-97%, and reduction in cost of therapy by 4.1-50.4%. introduction neonatal sepsis is a bacterial infection of the blood and cerebrospinal fluid that occurs in neonates. early-onset sepsis (eos) happens within the first seven days of life,1 along with radiographic evidence of pneumonia.2,3 neonatal sepsis encompasses serious infections such as bacteremia, pneumonia, and meningitis, which manifest as very early-onset sepsis (within the first three days of life), early-onset sepsis (within the first week), and late-onset sepsis (after the first week until 28 days of life).1,4 the neonatal period, which spans the first 28 days of life, carries the highest daily risk of mortality, leading to significant morbidity and mortality in the neonatal intensive care unit (nicu),5 particularly in low and middle income countries (lmics).6 approximately 1 million newborns worldwide die from neonatal infections within the first 28 days of birth.7 in developing countries, neonatal sepsis accounts for 30-50% of the 5 million total neonatal deaths each year.8 diagnosing neonatal sepsis is challenging due to the frequent presence of noninfectious conditions that mimic sepsis, particularly in preterm infants, and the lack of optimal diagnostic tests.9 diagnostic challenges of neonatal sepsis are also attributed to the nonspecific nature of symptoms, making both diagnosis and treatment difficult. a blood culture test is the gold standard for diagnosing neonatal sepsis;1 however, it takes between twenty-four and seventy-two hours to generate results and requires a wellequipped laboratory.10 predictive analytics has sparked considerable interest in the healthcare industry due to its potential to revolutionize economies, particularly in delivering primary health services.11 predictive analytics in healthcare encompasses a wide range of medical and nonmedical interventions to address health crises, bolster preparedness for future epidemics, and facilitate resilient recoveries during global health emergencies or disasters.12 the application of predictive analytics methods, such as machine learning and artificial neural networks, has become an area of significant interest among researchers for the early detection and diagnosis of neonatal sepsis.13 this has led to the development and publication of various statistical methods to predict the onset of sepsis in neonates. these methods play a crucial role in improving the timely identification of sepsis, thus contributing to better outcomes for affected newborns. the current scoping review fills a significant gap in critical dimensions involved in managing neonatal sepsis. it addresses a research question on reducing the delay in diagnosing neonatal sepsis and making the diagnosis process efficient in improving healthcare in low-resource settings. the scoping review analyzes correspondence: kvkl narasimha rao, indian institute of management, umsawlli, shillong 793018, meghalaya, india. e-mail: rao.phd20@iimshillong.ac.in key words: antibiotic usage; artificial intelligence; cost of treatment; diagnosis time; efficient management; machine learning; neonatal sepsis diagnosis; predictive models. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. received: 8 october 2024. accepted: 27 march 2025. early access: 28 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13213 doi:10.4081/hls.2025.13213 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13213] [page 137] dimensions including the early prediction of neonatal sepsis prior to symptom onset, decreased antibiotic utilization, and treatment costs, thereby providing a distinctive perspective that differentiates it from previous studies. instead of examining each dimension separately, as previous studies have done, this review offers a comprehensive exploration of the most crucial dimensions, illuminating predictive analytics methods in this vital area of healthcare. ensuring the well-being of newborns in developing countries and around the world depends on giving proper attention to the essential aspects of diagnosing and treating neonatal sepsis.14 the core objective of the scoping review is to address the defined research question and analyze the impact of predictive analytics methods on early diagnosis and treatment, antibiotic usage reduction, and the overall cost of treatment. the up-to-date review will benefit neonatal sepsis diagnosis and predictive analytics researchers. it offers a comprehensive understanding of the efficient management of neonatal sepsis using predictive analytics methods. materials and methods the databases (scopus, google scholar, and pubmed) were searched to identify relevant literature published from 2014 to 2024. the search was focused on neonatal sepsis diagnosis, efficient management, predictive models, artificial intelligence, machine learning, diagnosis time, antibiotic usage, and treatment costs. the inclusion criteria were articles that applied predictive analytics techniques to guide diagnosis, reduce antibiotic usage, and reduce overall treatment costs. the focus was on the specific criteria of the ability to diagnose sepsis before the occurrence, the effect of applying predictive analytics techniques in reducing antibiotic usage, and the impact on the cost of treatment towards nicu stay, tests conducted, and overall cost of treatment for sepsis. this scoping review can significantly impact the neonatology and predictive analytics fields, and we are excited about its possibilities. the scoping review was based on the arksey and o’malley framework and conducted in 5 steps: i) framing the research question; ii) identifying relevant literature; iii) selecting studies; iv) extracting, mapping, and charting the data; and v) summarizing the results. the research concentrated on utilizing predictive analytics to diagnose neonatal sepsis and manage the condition in infants under 28 days old. the search criteria were independently applied according to the three essential dimensions: early diagnosis of neonatal sepsis, antibiotic reduction, and treatment cost. the inclusion criteria involved studies published in english and excluded review articles, letters, conference proceedings, and animal studies. initially, the screening process involved reviewing titles and abstracts, thoroughly screening full-text articles, and extracting data. the extracted details included the author, journal, year of publication, type of neonatal sepsis, country of study, predictive methods utilized, the performance of predictive methods in early diagnosis of neonatal sepsis, and the impact of using predictive analytics calculators on antibiotic usage and cost of treatment. the quality of the study is ensured by considering the research articles published in reputed scopus-indexed journals. the bias is eliminated through a selection of journals focusing on global research with validated results. the study also considered the implications of using predictive analytics methods for neonatal sepsis on the cost of nicu stay, treatment costs related to tests conducted to diagnose sepsis, and the overall cost of treatment through predictive analytics methods. out of the 17,269 records gathered from databases like google scholar, pubmed, and scopus, 16,500 articles were identified as ineligible based on the inclusion and exclusion criteria of the literature review. through further screening after identifying articles irrelevant to the study, 21 articles that met the inclusion criteria were included in the review. detailed information on these included studies can be found in tables 1, 2, and 3. the studies included in the review were published between 2014 and 2024. most studies investigating the impact of antibiotic usage and antimicrobial resistance utilized the kaiser permanente predictive tool. this tool is known for promptly predicting the occurrence of neonatal sepsis while analyzing specific clinical parameters. results impact of predictive analytics methods on the diagnosis of neonatal sepsis at an early stage neonatal sepsis can be managed by early diagnosis and treatment.2 the gold standard diagnostic tool is a blood culture test that typically has a turnaround time for results of 2 to 3 days.15 however, blood culture tests are sometimes inadequate, throw up special issue pathways of change [page 138] [healthcare in low-resource settings 2025;13(s1):13213] table 1. impact of predictive analytics on the diagnosis of neonatal sepsis. snoauthor year of types of diagnosis of diagnosis of sepsis algorithm publication sepsis sepsis through through predictive blood culture analytics method method duration (hours) duration (hours) -48 -24 -12 -8 -4 0 1 guzey et al. 2018 lons 24 0.86 random forest 2 song et al. 2019 lons 48-72 0.86 0.867 0.867 0.867 0.867 rf classifier 0.83 gradient boosting classifier 0.83 logistic regression 3 cabrera et al. 2021 lons 48 0.82 0.79 logistic regression 4 kaush et al. 2023 lons not specified 0.83 0.83 xgboost 5 iqbal et al. 2024 eons & lons not specified 0.99 random forest, bagging eons, early onset of sepsis; lons, late onset of sepsis. false negatives, and have not consistently demonstrated complete accuracy.16 moreover, in the absence of specific laboratory tests for neonatal sepsis and the inherent protean nature of the nonspecific symptoms, accurate clinical diagnosis of sepsis remains a challenge,17,3 with delays in diagnosis and treatment as common issues18 across the globe. failure to quickly diagnose neonatal sepsis, primarily due to its indefinite signs and symptoms, makes the disease more lethal. researchers have therefore emphasized the critical need for developing novel technology-based approaches, such as predictive analytics methods for the rapid prediction of neonatal sepsis,19 which could diagnose as effectively or better than traditional blood culture testing methods. table 1 summarizes several vital studies and approaches that highlight this potential. the studies mentioned above collectively demonstrate how predictive analytics methods can enhance the diagnosis of neonatal sepsis, resulting in faster and more accurate identification of the condition before symptoms appear. in stark contrast to traditional diagnostic approaches, which often take more than 24 hours to provide conclusive results, predictive analytics methods have shown the capability to forecast the onset of sepsis at least 48 hours before the manifestation of clinical symptoms. impact of predictive analytics methods on antibiotic usage and antimicrobial resistance antibiotic resistance stems from poor infection control and overuse of antibiotics. while new strategies for antibiotic use are essential, prevention is the ultimate solution.20 the growing occurrence of antibiotic resistance is now linked to higher neonatal mortality rates, posing a significant challenge to efforts aimed at decreasing global neonatal deaths. the issue of antibiotic resistance in newborns has been highlighted in recent research.21 this problem is mainly caused by the increased and unnecessary use of antibiotics, posing a significant global challenge. according to the study by laxminarayan et al.,22 antibiotic resistance is primarily driven by microbial mutations resulting from antibiotic use, giving mutated strains a competitive advantage. lmics have experienced a rise in antibiotic use due to higher incomes, increased hospitalization rates, and more hospital infections. nicus in lmics report significantly higher infection rates than those in the united states, raising concerns for healthcare practitioners and policymakers. mani et al.5 emphasize the need to address the overuse of antibiotics in infants receiving treatment to prevent antibiotic resistance and reduce healthcare costs. tailored approaches specific to developing countries are crucial, as the varying pathogen profiles in regions like south asia underscore the need for context-specific solutions. predictive analytics methods have proven effective in reducing antimicrobial usage in treating neonatal sepsis, addressing the challenge of rising microbial resistance due to prolonged use of empirical antibiotics. predictive analytics can also help mitigate microbial resistance associated with protracted empirical antibiotic coverage. among the predictive analytics methods, the kaiser permanente sepsis risk calculator (src) has significantly reduced antibiotic use in neonates. table 2 shows several studies that demonstrate the impact of these methods. researchers have been exploring ways to improve the prediction and management of eos in newborns, particularly those born at 34 weeks of gestation or later. special issue pathways of change table 2. impact of predictive analytics on antibiotic usage. sno author year of publication country type of sepsis predictive analytics method % reduction in antibiotic usage 1 escobar et al. 2014 usa eos logistic regression 33 2 shakib et al. 2015 usa eos eos calculator 88 3 kerste et al. 2016 netherlands eos kaiser risk calculator 50 4 warren et al. 2016 usa eos kaiser risk calculator 75 5 kuzniewicz et al. 2017 usa eos kaiser risk calculator 48 6 mani et al. 2017 usa eos kaiser risk calculator 97 7 beavers et al. 2018 usa eos kaiser risk calculator 59 8 gievers et al. 2018 usa eos srs algorithm 91 9 achten et al. 2019 usa eos kaiser risk calculator 48 10 schmatz et al. 2020 usa eos kaiser risk calculator 68 11 goel et al. 2022 uk eos sepsis risk calculator 46 12 levi et al. 2023 israel eos kaiser risk calculator 46 13 leonardi et al. 2024 belgium eos kaiser risk calculator 65 eos, early onset of sepsis; srs, sepsis risk score. [healthcare in low-resource settings 2025;13(s1):13213] [page 139] table 3. impact of predictive analytics on the cost of treatment. no author year of diagnosis cost of treatment (in dollars) cost of treatment (in dollars) % reduction in cost publication before implementation after implementation of of sepsis risk calculator sepsis risk calculator 1 beavers et al. 2018 eos 14700 7300 50.4 2 achten et al. 2019 eos 2653 2542 4.1 3 guan et al. 2024 eos 182491 97884 46.3 eos, early onset of sepsis. the studies above suggest that predictive analytics methods can significantly enhance treatment for neonatal sepsis and reduce unnecessary antibiotic use by at least 33-97%. impact of predictive analytics methods on the cost of treatment the financial burden associated with treating neonatal sepsis arises from several factors. key issues include the high costs of diagnostic testing, which stem from the challenges of achieving accurate diagnoses, unnecessary antibiotic administration, and the associated expenses. extended stays in nicus during the diagnostic and treatment phases also contribute significantly to these costs. additionally, delays in diagnosis and the waiting period for culture test results directly affect the length of nicu stays, the frequency of laboratory tests, and the demand for medications during treatment. however, many studies suggest that implementing predictive analytics methods can reduce the overall costs of neonatal sepsis treatment, as indicated in table 3. in summary, implementing the eos calculator positively impacts antibiotic stewardship and demonstrates notable reductions in healthcare utilization and associated financial costs in late preterm and preterm newborns with suspected eos by 4.1-50.4%. discussion and findings predictive analytics methods utilize advanced algorithms such as random forest, gradient boosting, xgboost, and logistic regression, all of which have shown improved performance with an area under the curve (auc) ranging from 0.82 to 0.87. for instance, a random forest algorithm with an auc of 0.868 has been recognized as superior in predicting sepsis 24 hours before its onset.23 additionally, when non-invasive vital sign data is employed, a forward feature selection prediction model could detect clinical sepsis 48 hours in advance.15 the auc for this 48-hour prediction model was 0.861, while the onset detection model had an auc of 0.868. these findings confirm that the late onset neonatal sepsis (lons) production model based on machine learning can be safely implemented in clinical settings. furthermore, a combination of electrocardiogram, respiration, and motion-based features allowed for predicting late-onset sepsis using logistic regression at least 5 hours before it occurred, achieving an auc of 0.79.24 predictive algorithms that utilize heart rate (hr) and oxygen saturation (spo2) data could also forecast an increased risk of sepsis before clinical diagnosis, achieving predictions up to 24 hours before blood culture results. the xgboost predictive model demonstrated superior performance, with an auc of 0.834 in the training dataset and 0.792 and 0.807 in the test datasets.25 lastly, bagging and random forest algorithms displayed comparable accuracy (98.4%) in predicting central nervous system (cns) and central peritoneal sepsis (cps). however, random forest outperformed the other algorithms with an accuracy of 98.4% and an roc of 0.994 for forecasting outcomes.13 combining maternal data with new neonatal clinical indicators and employing risk stratification algorithms could enhance the assessment and management of eos in full-term and late-preterm infants. this approach may reduce the necessity for antibiotic treatment in 33% of newborns.26 utilizing the early eos risk calculator and a clinical symptom assessment can safely reduce the number of newborns who require laboratory testing and decrease antibiotic usage by 88%.27 kerste et al.28 conducted a study to evaluate the management of antibiotic use with the guidance of the sepsis calculator in newborns born at or after 34 weeks of gestation with suspected eos. the study concluded that antibiotic use could be reduced by more than 50%. similarly, warren et al.29 performed a study to assess the impact of implementing a neonatal early-onset sepsis calculator for neonates undergoing treatment for sepsis. their conclusions indicate that the calculator holds the potential to substantially reduce the administration of antibiotics to newborns and lower the number of neonates requiring antibiotics at birth by as much as 75%. these findings have significant implications for improving the management and care of neonates at risk of sepsis. kuzniewicz et al.30 investigated the influence of neonatal eos risk prediction models on sepsis evaluations and antibiotic utilization. they assessed the safety and efficacy of these models within an extensive integrated healthcare system. their findings indicated that predictive algorithms, derived from a multivariable risk prediction model estimating the early onset of sepsis risk, led to a 48% decrease in the proportion of newborns receiving empirical antibiotic treatment. in a study by money et al.,31 the investigators conducted a comprehensive study to evaluate the effectiveness of implementing a protocol based on a neonatal early-onset sepsis calculator developed by kaiser permanente. the study aimed to determine whether this approach would safely reduce the use of antibiotics in newborns showing no signs of illness. the study concluded that utilizing the eos calculator for managing sepsis could effectively mitigate the potential complications associated with antibiotic use in these cases, reducing antibiotic usage by 97%. neonates born to mothers with chorioamnionitis face an elevated risk of eos. in another study,32 the authors observed that nicu admission rates declined from 91% to 37% after introducing the eos risk calculator, and antibiotic administration rates decreased from 94% to 37%. implementing the eos risk calculator as part of the clinical evaluation of term and late preterm neonates positively impacted antibiotic usage. gievers et al.33 have developed and implemented an algorithm based on srs (severity of illness score) designed explicitly for neonates exposed to chorioamnionitis. the targeted goal of the srs algorithm is to reduce the unnecessary usage of antibiotics in this population. their work has shown that the successful adoption of the srs algorithm for chorioamnionitisexposed neonates has led to a remarkable 91% decrease in antibiotic exposure. their study also demonstrated the potential of the srs algorithm to significantly reduce antibiotic usage in this vulnerable patient group while maintaining effective treatment protocols. achten et al.34 examined how using the neonatal eos calculator to guide the management of eos in newborns affected the administration of antibiotic therapy. they found that employing the neonatal eos calculator led to a 48% decrease in empirical antibiotics for suspected eos in newborns. the primary objective of the investigation of a study conducted by schmatz et al.35 was to minimize the administration of antibiotics in asymptomatic neonates born at or after 35 weeks of gestational age to mothers with chorioamnionitis. this was achieved by implementing the kaiser permanente neonatal earlyonset sepsis risk calculator. the study culminated in compelling evidence that the consistent utilization of the neonatal eos calculator yielded a statistically significant reduction of 50% in antibiotic utilization. the research by goel et al.36 evaluated the influence of the src algorithm on managing eons, particularly regarding antibiotic utilization and patient safety. their multi-center study provides conclusive evidence that a cautious implementation of the src algorithm leads to a substantial 46% reduction in antibiotic usage for eons while maintaining consistent morbidity and mortality levels. the investigation by levi et al.37 assessed the impact of employing the kaiser permanente early-onset sepsis cal special issue pathways of change [page 140] [healthcare in low-resource settings 2025;13(s1):13213] culator on neonates regarding antibiotic utilization and duration of hospitalization. it was confirmed that employing the calculator yielded a 46% reduction in antibiotic therapy for suspected eos, and this decrease was attained without an escalation in the occurrence of eos. it concluded that the calculator represents a valuable decision-making instrument that can be judiciously applied with comprehensive clinical evaluation. leonardi et al.38 sought to determine the effectiveness of the src in decreasing antibiotic use. the findings indicated that the src could reduce the number of newborns receiving antibiotics by 64.5%. the neonatal earlyonset sepsis calculator represents an innovative approach to antibiotic stewardship in newborns. its implementation has shown promise in reducing empiric antibiotic usage for suspected eos in neonates. the research mentioned above by beavers et al.32 studied the impact of using eos calculators using predictive methods on treatment cost. they concluded that since the implementation of the eos risk calculator, there has been a significant decrease in nicu admission rates for neonates born to mothers with chorioamnionitis, dropping from 91% to 37%. additionally, there has been a noteworthy reduction in the number of blood cultures drawn and the administration of antibiotics in this patient population. specifically, the rate of antibiotic administration decreased from 92% to 50%, while the number of blood cultures drawn decreased from 94% to 37%. moreover, there have been substantial decreases in total charges, total bed charges, and length of stay, resulting in an overall 58% reduction in the cost of treatment. a study by achten et al.39 evaluated the impact of implementing the eos calculator on healthcare utilization and financial costs associated with suspected sepsis. the findings indicate that implementing the eos calculator significantly reduced eos-related laboratory tests and antibiotic usage by at least 4.1%. furthermore, there was a discernible decrease in the mean length of hospital stay and lower eos-related financial costs following the implementation, particularly among term newborns. however, these benefits were less pronounced among preterm newborns. the research by guan et al.40 examined resource utilization and costs associated with three different screening approaches for eos in infants born at 35 weeks of gestational age. the study concluded that the neonatal sepsis calculator and enhanced clinical observation methods show potential as superior options compared to categorical risk assessment. this is attributed to their potential to decrease the number of infants requiring intervention, reducing antibiotic exposure and associated costs by at least 46%. conclusions this research article explores the practical application of predictive analytics techniques for efficiently managing neonatal sepsis diagnosis. the review demonstrates that these techniques have significant potential to accurately diagnose and treat sepsis before symptoms appear, which can significantly reduce antibiotic usage and lower costs associated with laboratory testing, nicu stays, and other related expenses. however, the current body of research lacks comprehensive studies focusing on how predictive analytics can assist healthcare providers in prescribing appropriate antibiotics for neonatal sepsis and other infectious diseases. this area is still in its early stages and requires further investigation to validate and generalize predictive techniques, ensuring their consistent and practical application in diagnosing and treating neonatal sepsis. predictive models for neonatal sepsis also encounter several limitations, particularly in low-resource settings. these challenges stem from the need for large, diverse datasets to train accurate models, which can be challenging. significant computational power is also often required, which may not be readily available in such environments. these factors hinder the practical implementation of these models for identifying early signs of sepsis in newborns. by advancing and standardizing predictive analytics methods, clinicians and healthcare professionals, especially in developing countries and low-resource settings, can receive substantial support in efficiently managing the diagnosis and treatment of neonatal sepsis. references 1. helmbrecht ar, marfurt s, chaaban h. systematic review of the effectiveness of the neonatal early-onset sepsis calculator. j perinat neonatal nurs 2019;33:82-8. 2. singh m, narang a, bhakoo on. predictive perinatal score in the diagnosis of neonatal sepsis. j trop pediatr 1994;40:365-8. 3. gerdes js, polin ra. sepsis screen in neonates with evaluation of plasma fibronectin. pediatr infect dis j 1987;6:443-6. 4. zaidi ak, thaver d, ali sa, khan ta. pathogens associated with sepsis in newborns and young infants in developing countries. pediatr infect dis j 2009;28:s10-8. 5. mani s, ozdas a, aliferis c, et al. medical decision support using machine learning for early detection of late-onset neonatal sepsis. j am med inform assoc 2014;21:326-36. 6. sands k, spiller ob, thomson k, et al. early-onset neonatal sepsis in low-and middle-income countries: current challenges and future opportunities. infect drug resist 2022:933-46. 7. waters d, jawad i, ahmad a, et al. aetiology of communityacquired neonatal sepsis in low and middle income countries. j glob health 2011;1:154. 8. deorari ak. neonatal sepsis: manageable daunting issue for india. j neonatol 2009;23:7-11. 9. zea-vera a, ochoa tj. challenges in the diagnosis and management of neonatal sepsis. j trop pediatr 2015;61:1-3. 10. lakhey a, shakya h. role of sepsis screening in early diagnosis of neonatal sepsis. j pathol nepal 2017;7:1103-10. 11. lin s. a clinician's guide to artificial intelligence (ai): why and how primary care should lead the health care ai revolution. j am board fam med 2022;35:175-84. 12. van calster b, wynants l, timmerman d, et al. predictive analytics in health care: how can we know it works?. j am med inform assoc 2019;26:1651-4. 13. iqbal f, chandra p, lewis le, et al. application of artificial intelligence to predict the sepsis in neonates admitted in neonatal intensive care unit. j neonatal nurs 2024;30:141-7. 14. popescu cr, cavanagh mm, tembo b, et al. neonatal sepsis in low-income countries: epidemiology, diagnosis and prevention. expert rev anti infect ther 2020;18:443-52. 15. song w, jung sy, baek h, et al. a predictive model based on machine learning for the early detection of late-onset neonatal sepsis: development and observational study. jmir med inform 2020;8:e15965. 16. schelonka rl, chai mk, yoder ba, et al. volume of blood required to detect common neonatal pathogens. j pediatr 1996;129:275-8. 17. hammerschlag mr, klein jo, herschel m, et al. patterns of use of antibiotics in two newborn nurseries. n engl j med 1977;296:1268-9. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13213] [page 141] 18. masino aj, harris mc, forsyth d, et al. machine learning models for early sepsis recognition in the neonatal intensive care unit using readily available electronic health record data. plos one 2019;14:e0212665. 19. sahu p, raj stanly ea, simon lewis le, et al. prediction modelling in the early detection of neonatal sepsis. world j pediatr 2022:1-6. 20. bates m, kabwe m, zumla a. neonatal sepsis and antibiotic resistance in developing countries. pediatr infect dis j 2014;33:1097. 21. bethou a, bhat bv. neonatal sepsis—newer insights. indian j pediatr 2022;89:267-73. 22. laxminarayan r, duse a, wattal c, et al. antibiotic resistance—the need for global solutions. lancet infect dis 2013;13:1057-98. 23. güzey i, uçar ö. machine learning based non-invasive vital signs analysis for preterm sepsis risk prediction. int j res eng appl sci 2018;8. 24. cabrera-quiros l, kommers d, wolvers mk, et al. prediction of late-onset sepsis in preterm infants using monitoring signals and machine learning. crit care explor 2021;3:e0302. 25. kausch sl, brandberg jg, qiu j, et al. cardiorespiratory signature of neonatal sepsis: development and validation of prediction models in 3 nicus. pediatr res 2023;93:1913-21. 26. escobar gj, puopolo km, wi s, et al. stratification of risk of early-onset sepsis in newborns ≥ 34 weeks’ gestation. pediatrics 2014;133:30-6. 27. shakib j, buchi k, smith e, young pc. management of newborns born to mothers with chorioamnionitis: is it time for a kinder, gentler approach? acad pediatr 2015;15:340-4. 28. kerste m, corver j, sonnevelt mc, et al. application of sepsis calculator in newborns with suspected infection. j maternfetal neonatal med 2016;29:3860-5. 29. warren s, garcia m, hankins c. impact of neonatal earlyonset sepsis calculator on antibiotic use within two tertiary healthcare centers. j perinatol 2017;37:394-7. 30. kuzniewicz mw, puopolo km, fischer a, et al. a quantitative, risk-based approach to the management of neonatal early-onset sepsis. jama pediatr 2017;171:365-71. 31. money n, newman j, demissie s, et al. anti-microbial stewardship: antibiotic use in well-appearing term neonates born to mothers with chorioamnionitis. j perinatol 2017;37:1304-9. 32. beavers jb, bai s, perry j, et al. implementation and evaluation of the early-onset sepsis risk calculator in a high-risk university nursery. clin pediatrics. 2018;57:1080-5 33. gievers ll, sedler j, phillipi ca, et al. implementation of the sepsis risk score for chorioamnionitis-exposed newborns. j perinatol 2018;38:1581-7. 34. achten nb, klingenberg c, benitz we, et al. association of use of the neonatal early-onset sepsis calculator with reduction in antibiotic therapy and safety: a systematic review and metaanalysis. jama pediatr 2019;173:1032-40. 35. schmatz m, srinivasan l, grundmeier rw, et al. surviving sepsis in a referral neonatal intensive care unit: association between time to antibiotic administration and in-hospital outcomes. j pediatr 2020;217:59-65. 36. goel n, cannell s, davies g, et al. implementation of an adapted sepsis risk calculator algorithm to reduce antibiotic usage in the management of early onset neonatal sepsis: a multicentre initiative in wales, uk. arch dis child fetal neonatal ed 2022;107:303-10. 37. levi m, melamed r, shany e, et al. the impact of the early onset neonatal sepsis calculator on antibiotic initiation: a single center study in israel. eur j pediatr 2023;182:3187-94. 38. leonardi bm, binder m, griswold kj, et al. utilization of a neonatal early-onset sepsis calculator to guide initial newborn management. pediatr qual saf 2019;4:e214. 39. achten nb, visser dh, tromp e, et al. early onset sepsis calculator implementation is associated with reduced healthcare utilization and financial costs in late preterm and term newborns. eur j pediatr 2020;179:727-34. 40. guan g, joshi ns, frymoyer a, et al. resource utilization and costs associated with approaches to identify infants with earlyonset sepsis. mdm policy pract 2024;9:23814683231226129. special issue pathways of change [page 142] [healthcare in low-resource settings 2025;13(s1):13213] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13514 development of android-based “manis” application for diabetes mellitus management gede satvika harimahardika, ni luh putu inca buntari agustini, sri dewi megayanti, ni made candra citra sari, i gede putu darma suyasa faculty of health, institute of technology and health, bali, indonesia abstract management of diabetes mellitus (dm) requires innovative approaches to improve patient engagement. android-based applications have the potential to be effective tools for supporting diabetes management through the five pillars of management. this study employed a research and development approach, involving two groups of respondents: app users and a panel of experts. the survey involved 30 users who rated the app’s ease of use, performance, and visual appearance using a 5-point likert scale. additionally, a focus group discussion with an expert panel consisting of health professionals and application developers was conducted to evaluate the features and potential of the application. the data were analyzed descriptively. the results showed positive feedback from the users. a total of 76.67% of the users stated that the application was easy to use, and 83.33% rated the installation very easy. navigation scored 80% with easy-to-find features, whereas 83.33% reported that the app ran smoothly. the visual aspect was appreciated, with 86.67% liking this design. the menu layout and content presentation obtained scores of 80% and 76.67%. the panel of experts rated key features, such as blood sugar monitoring, with a score of 87-88%, but suggested improvements to the foot care guide. android apps for dm management demonstrated positive results in terms of ease of use and visual design. feature enhancements and tutorial additions are required to improve the user experience. further research is needed to evaluate the impact of this application on diabetes management. introduction most diabetes management applications focus on education and monitoring but lack interactive, personalized features tailored to patients’ specific needs, such as diabetes severity, comorbidities, and lifestyle.1-3 many existing applications do not include an automatic reminder system to integrate notifications for holistic diabetes management. digital literacy, especially among the elderly or individuals with lower educational levels, is another overlooked challenge. furthermore, long-term effectiveness in improving quality of life and reducing complications or hospital readmissions remains limited.4 indonesia is the only southeast asian country among the top 10 nations globally with the highest number of people diagnosed with diabetes mellitus (dm).5 the prevalence of diabetes in indonesia is a significant public health concern, with a projected increase from 9.19% in 2020 to 16.09% in 2045, potentially affecting 40.7 million individuals.6 the risk factors associated with the prevalence of diabetes in indonesia include age, family history, body mass index, and triglyceride levels.7,8 regency reported a prevalence of 11.9%, exceeding the national average of 8.5%. diabetes-related complications contribute significantly to mortality, cardiovascular disease, macrovascular complications, and chronic hyperglycemia.9,10 rising readmission rates further highlight the need for better diabetes management.11 effective diabetes management relies on five key pillars: healthy diet, regular exercise, stress management, blood sugar monitoring, and adherence to prescribed medications.12,13 however, many correspondence: ni luh putu inca buntari agustini, faculty of health, institute of technology and health bali, denpasar, bali, indonesia. e-mail: incaagustini@gmail.com key words: apps; android; diabetes; development; management. contributions: gsh, manuscript preparation and research; nlpiba, review, editing, proofreading, consultation, and manuscript preparation; sdm, nmccs, igpds, data analysis, discussion, and manuscript conclusion. all authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors have no conflict of interest to declare. ethical approval and consent to participate: this study was approved by the health research ethics committee, institute of technology and health bali, with ethical approval number 03.0248/kepitekesbali/vi/2024. the researcher complied with the ethical principles of the consent form, including respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained from all patients for anonymized information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was supported by the directorate of higher education of the ministry of education and culture of the republic of indonesia, directorate of research, technology and community service (drtpm), and directorate of research, technology, and community service with master contract no. 110/e5/pg.02.00.pl/2024; derivative contract no. 2927/ll8/al.04/2024; dl.02.02.2361.tu.vi.2024. this support is invaluable in the implementation of this research, allowing researchers to achieve the set goals. acknowledgments: the researcher sincerely thanks the singasana tabanan hospital, experts, supervisors, and respondents for their support. received: 21 december 2024. accepted: 31 march 2025. early view: 27 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13514 doi:10.4081/hls.2025.13514 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13514] [page 67] patients struggle with consistent implementation. further prospective studies should evaluate the role of these services in terms of these five pillars.14 a study indicated that android-based applications offer accessibility, real-time monitoring, and reminders to support patients in managing their condition.15 apps positively affect patient knowledge, compliance, and quality of life.16 however, existing applications often feature outdated information, usability challenges, and a lack of comprehensive notification systems.17 affordability and user-friendliness are crucial for wider adoption, especially among those with limited digital literacy.16,18 the “manis” app, designed for five-pillar diabetes management, incorporates simplified features to improve usability.19 addressing gaps in digital literacy and long-term effectiveness, this study seeks to develop an adaptive, inclusive, evidence-based application to enhance diabetes management. key features include medication reminders, dietary guidance with calorie breakdown, and tools to manage hyperglycemia or hypoglycemia at home. the app aims to reduce hospital readmissions and improve the quality of life for diabetes patients. the objective of this study is to develop and evaluate an android-based application with an automatic alarm system for managing the five pillars of dm, expected to increase patient compliance in independent disease management. materials and methods study design this study used a research and development (r&d) approach with a descriptive design. the method used was the addie model (analysis, design, development, implementation, and evaluation), but only three stages were applied in this study: analysis, design, and development. population, sample, and sampling techniques the study population consisted of inpatients or outpatients diagnosed with dm at singasana hospital, tabanan regency (indonesia). using the slovin formula, the minimum sample size required was 30 dm-diagnosed individuals at singasana hospital who met the following inclusion criteria: i) doctor-diagnosed dm, ii) access to a compatible android device, iii) written consent for the application trial, iv) willingness to follow research procedures, and v) ability to read and understand instructions in the application and research materials. excluded were respondents with severe cognitive impairment or significant mental disorders, those with technical difficulties using the android device or app, and those without technical support for device use. data collection data from user trials were collected through questionnaires measuring user satisfaction and app effectiveness. the questionnaire was administered to 30 respondents meeting inclusion criteria, including a dm diagnosis and access to an android device. it evaluated aspects like navigation ease, app appearance, and how well the application assists users in managing the five pillars of dm management. questionnaire and experts’ assessment results were analyzed descriptively by calculating the frequency and percentage of each assessment item. this analysis aims to describe user satisfaction and application effectiveness levels and identify areas needing improvement. the results were used to formulate evidence-based recommendations for further development of an android-based five-pillar management application for dm management. study analysis a literature review and field study identified user problems and needs in dm management. this analysis includes understanding the management of five dm pillars: healthy diet, regular exercise, stress management, blood sugar monitoring, and prescription drug consumption. initial data collection from patients, health workers, and experts mapped challenges and solutions in dm management, especially using application-based technology. after expert validation, the application was tested on dm patients through focus group discussions (fgd) involving patients, doctors, nurses, and patients’ families. a semi-structured guide was used. the fgd provided insights into the experience of using the application, specifically regarding ease of use, navigation, and benefits in supporting daily dm management. for descriptive statistics, we used frequency and percentage on the questionnaire, which employed a 5point likert scale. qualitative data from the fgd were analyzed thematically to explore user insights into the app’s usability and potential improvements. results table 1 presents the assessments from two material experts, scoring 86.67% (52/60) and 88.33% (53/60). the app excelled in blood sugar monitoring and hyperglycemia treatment recommendations and received the highest scores. however, areas such as foot care and educational guides scored lower (4/5), indicating room for improvement. the second expert noted strengths in hypoglycemia and hyperglycemia treatment, foot care recommendations, and medication settings, with some features improving to 5/5. this suggests that the app has become more comprehensive and better at addressing user needs, while still having areas for further enhancement. table 2 shows that media experts rated the diabetes management app highly, with feasibility scores of 92.9% and 95.3%, respectively. praised for its ease of use and installation, the app featured an intuitive design. visual presentation was strong, especially regarding text and image clarity, although color and typeface improvements were suggested. media integration effectively enhances content comprehension, although navigation responsiveness requires refinement. the flexibility of an app for anytime access is a key benefit. the scores improved from 86.67% to 95.3%, placing it in the highest feasibility category (85%-100%), demonstrating continuous enhancement. table 3 reveals that user feedback was largely positive, with 76.67% finding the app easy to use and 83.33% rating the installation as very easy. while 73.33% found downloading not difficult, improvements were required. navigation was rated well, with 80% easily finding features and 83.33% reporting a smooth operation. the visual design received strong feedback (86.67%), although the color selection (73.33%) could be refined. the app effectively supported diabetes management, with 86.67% stating that it helped monitor blood sugar, 83.33% finding it useful for foot condition checks, and 83.33% benefiting from overall diabetes management support. qualitative results from internal medicine specialists and expert nurses agreed that the foot examination screening feature in pathways of change, part ii [page 68] [healthcare in low-resource settings 2025;13(s2):13514] the app was very easy to use. the app’s interface is designed in an intuitive manner, making it easy for users to perform regular checks without any difficulty. this user-friendly design facilitates the screening process, which is essential for regular monitoring of foot health in patients with diabetes. the results of this study are supported by the following quotes: “the foot examination screening feature is very easy to use. the app’s interface is intuitive, simplifying routine checks.” (i1) “this design is helpful for the screening process, which is crucial for monitoring diabetic foot health.” (i2) clear and easy-to-follow foot care guide: “the guide is easy to follow, helping users care for their feet properly.” (i1) “additional details for special cases, like infections, would enhance its usefulness in complex conditions.” (i2) facilitating blood sugar monitoring: “the monitoring feature is easy to use, allowing regular tracking.” (i1) “a simple process ensures compliance in sugar level monitoring.” (i2) notifications align with clinical recommendations: “notifications follow clinical guidelines, ensuring timely monitoring reminders.” (i1) “standardized notifications help patients maintain healthy sugar levels.” (i2) clear and updated recommendations: “the treatment and prevention recommendations are easy to understand and align with the latest theories.” (i1) “the app follows current clinical guidelines, ensuring consistency.” (i2) “updating information with new research is recommended.” (i2) governance-pillar educational content is structured and easy to comprehend: “the app presents clear and well-structured educational content.” (i1) “this accessibility is crucial for patient knowledge application.” (i2) users can independently calculate their calorie needs: “the calorie calculator allows users to make their own calculations.” (i1) “an automatic calorie calculator would further improve usability.” (i2) food intake recommendations based on quantity, type, and schedule: “the diet plan follows structured guidelines on quantity, type, and schedule.” (i1) “clear guidance on meal timing and composition is valuable.” (i2) appropriate and feasible physical exercise recommendations: “the recommended exercises are easy to do and suit user needs.” (i1) “adding variety to the exercises could enhance user complian pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13514] [page 69] table 1. results of the first and second material expert assessments on the development of management of the five pillars of diabetes mellitus management through android-based applications. item statement score foot examination expert 1 expert 2 1 easy-to-use foot screening 5 4 2 the foot care guide provided is easy to do 4 4 blood sugar monitoring 3 blood sugar monitoring is easy to do 4 5 4 blood sugar monitoring notifications given in accordance with recommendations 5 4 5 the recommendations for treatment and prevention of hypoglycemia given are easy to understand and in accordance with the latest theories 4 5 6 the recommendations for treatment and prevention of hyperglycemia given are easy to understand and in accordance with the latest theories 5 4 pillars of governance 7 the education provided is easy to understand 4 4 8 foot care recommendations are easy to do and in accordance with the latest theories 4 5 9 calculating calorie needs can be done independently 5 4 10 the composition of the feed given corresponds to 3 h 4 4 11 the physical exercise provided can be easily done and as needed 4 5 12 regulate the use of medication according to the recommendations 4 5 total score 52 53 eligibility proportion 86.67 88.33 ce.” (i2) guidelines for appropriate medication adherence: “the app helps patients follow prescribed medication schedules.” (i1) “this is crucial for correct dosage and treatment adherence.” (i2) expert media evaluation of usability and navigation: “installation and operation are simple, ensuring smooth initial use.” (e1) “users can easily access functions, contributing to a positive experience.” (e2) visually appealing and user-friendly design: “neat menu layout and high-quality visuals enhance usability.” (e1) “while some improvements are needed, the layout remains professional and balanced.” (e2) efficient media integration: “images support the presented materials well.” (e1) “navigation speed needs some improvement, but overall, integration is effective.” (e2) promotion of user engagement and accessibility: “the app encourages patient curiosity about diabetes management.” (e1) “its flexibility allows for convenient daily diabetes management.” (e2) discussion the development and initial evaluation of the manis android-based application demonstrated a high level of feasibility and user satisfaction for supporting the five pillars of dm management. this study aligns with previous research that emphasizes the critical role of mobile health (mhealth) interventions in chronic disease management, particularly diabetes, through improved selfmonitoring, education, and adherence support mechanisms.1 user assessments of android-based diabetes management applications indicate a positive reception. most users found the app easy to use and install, with minimal downloading challenges. the application was rated highly for its functionality, features that were easily accessible, and reported smooth operation. visual design was also well received, with users finding it attractive, although improvements in color selection and text-image neatness were suggested. additionally, the users had no difficulty reading the text and found relevant images. these findings corroborate the existing literature that emphasizes the importance of user-centered design in enhancing digital health engagement.20 focusing on user-centered design, digital health interventions for dm can be more effective, user-friendly, and supportive of long-term self-management and health outcomes. the findings showed that expert evaluations highlighted the app’s overall usability and effectiveness; foot screening features were user-friendly, blood sugar monitoring was simple, education on hypoglycemia and hyperglycemia was well-received, and the governance pillar was rated positively for aligning with guidelines; the calorie calculation feature was helpful, physical exercise features were effective, and medication management was functional. however, enhancements like visual aids, customizable notifications, interactive educational content, personalized meal planning, diverse exercise options, and integrated medication support features were recommended to optimize user engagement and diabetes pathways of change, part ii table 2. results of the first and second media expert assessments on the management development of the five pillars of diabetes mellitus management through android-based applications. item statement score foot examination expert 1 expert 2 1 easy-to-use foot screening 5 4 2 the foot care guide provided is easy to do 4 4 blood sugar monitoring 3 blood sugar monitoring is easy to do 4 5 4 blood sugar monitoring notifications given in accordance with recommendations 5 4 5 the recommendations for treatment and prevention of hypoglycaemia given are easy to understand and in accordance with the latest theories 4 5 6 the recommendations for treatment and prevention of hyperglycaemia given are easy to understand and in accordance with the latest theories 5 4 pillars of governance 7 the education provided is easy to understand 4 4 8 foot care recommendations are easy to do and in accordance with the latest theories 4 5 9 calculating calorie needs can be done independently 5 4 10 the composition of the feed given corresponds to 3 h 4 4 11 the physical exercise provided can be easily done and as needed 4 5 12 regulate the use of medication according to the recommendations 4 5 total score 52 53 eligibility proportion 86.67 88.33 [page 70] [healthcare in low-resource settings 2025;13(s2):13514] self-management. similar to previous studies, static educational content has been found to limit user engagement. experts have emphasized the need for infographics, videos, and real-life case examples to improve knowledge retention and motivation in chronic disease management.21,22 incorporating expert recommendations into future versions of the application can significantly enhance its utility not only for patient self-management but also for health professionals delivering telemonitoring or remote education. the findings indicated that healthcare professionals recognized the application’s potential to improve patient engagement and routine health monitoring. integration with electronic medical records is recommended for better access to patient data. however, challenges such as limited patient technological literacy and concerns about data privacy remain. this aligns with prior research showing that privacy concerns are a barrier to the adoption of healthcare technology.23 experts have emphasized the need for interactive educational features consistent with the recommendations on chronic disease management.24 material experts assessed the application with a feasibility rating of 88.6%, endorsing its efficacy in diabetes management.12 media experts provided a feasibility score of 87%, highlighting ease of use and visual appeal.19 regarding benefits, the app significantly aided users in foot examinations, blood sugar monitoring, and governance pillar implementations. this increases diabetes awareness and facilitates overall diabetes management. the app’s accessibility was highly rated, supporting nielsen’s usability theory,25 which underscores ease of use and navigation as critical for adoption. these findings align with studies showing that intuitive interfaces enhance user experience,26,27 while another study highlights the impact of visual design on user interaction.28 although color schemes and content neatness received lower ratings, previous research confirms that aesthetics influence user experience.24,29 thus, media integration is a critical factor. button responsiveness and media quality impact user experience,30 aligning with adu et al., who emphasize media integration for user engagement.31 the app’s flexibility in supporting diabetes management corresponds to research demonstrating that flexible health apps improve adherence and disease control.32,33 however, concerns regarding technology support and information relevance highlight the need for integrated medical guidance and online consultations.34 the overall positive performance was validated by a survey of 30 respondents, indicating that intuitive design and features, such as diet and medication reminders, help users manage diabetes effectively.26,35 the app aligns with the principles of self-management support (sms)36 and nielsen’s usability principles.37-39 the primary limitations of this study include restricted testing, as the app remains under researcher control, potentially affecting the evaluation results. additionally, public trials have not been conducted, which limits insights into broader user acceptance. conclusions the android-based diabetes management app demonstrated strong feasibility, with expert evaluations rating key features at 8788%. blood sugar monitoring and treatment recommendations were well received, although foot care guidance and educational content require improvement. media aspects scored highly (9295%) owing to usability and visual appeal. user ratings confirmed the app’s effectiveness, with 76.67% finding it easy to use and 86.67% appreciating its visual design, although color adjustments were suggested. developers should enhance tutorials, reminders, and guidance features, while users should utilize these tools fully pathways of change, part ii table 3. results of user assessments on each item of the management development of the five pillars of diabetes mellitus management through android-based applications. item statement score percentage (%) 1 2 3 4 5 1 i find it easy to use this app 0 2 5 10 13 76.67 2 installation of this application is very easy 0 1 4 11 14 83.33 3 downloading this app is not difficult 0 2 6 8 14 73.33 4 i can find all the features i need easily 0 1 5 9 15 80 5 the app runs smoothly without a hitch 0 1 4 12 13 83.33 6 the design of this app is very attractive 0 0 4 10 16 86.67 7 the menu layout on this application is well organized 0 1 5 9 15 80 8 the text and images in this app are presented neatly 0 1 6 11 12 76.67 9 the colors in this app are pleasing to the eye 0 1 7 9 13 73.33 10 the typeface used is easy to read 0 0 5 10 15 83.33 11 i had no trouble reading the text in this app 0 0 4 12 14 86.67 12 the images in this application are in accordance with the content conveyed 0 2 5 10 13 76.67 13 the buttons in this app respond quickly when touched 0 1 6 10 13 76.67 14 the images shown support the information provided 0 1 6 9 14 76.67 15 this app helps me check the condition of my legs 0 0 5 12 13 83.33 16 this app helps me monitor my blood sugar 0 0 4 10 16 86.67 17 this app helps me with the implementation of the governance pillar 0 1 5 9 15 80 18 this app makes me more interested in understanding diabetes 0 1 7 9 13 73.33 19 this app helps me in managing diabetes better 0 0 5 10 15 83.33 20 i can use this app anytime and anywhere 0 0 4 12 14 86.67 [healthcare in low-resource settings 2025;13(s2):13514] [page 71] to achieve better compliance. future research should focus on broader patient trials, long-term impact assessments, and demographic-specific needs to refine app functionality. continuous development is necessary for the further implementation and evaluation of this approach. references 1. yoon s, kwan yh, phang jk, et al. personal goals, barriers to self-management and desired mhealth application features to improve self-care in multi-ethnic asian patients with type 2 diabetes: a qualitative study. int j environ res public health 2022;19:15415. 2. klemme i, wrona kj, de jong im, et al. integration of the vision of people with diabetes into the development process to improve self-management via diabetes apps: qualitative interview study. jmir diabetes 2023;8:e38474. 3. chong cj, makmor-bakry m, hatah e, et al. factors infuencing type 2 diabetes mellitus patients’ readiness, acceptance and barriers towards mobile apps adoption for medication adherence. int j diabetes dev ctries 2024. 4. kusnanto k, pradipta ro, arifin h, et al. what i felt as a diabetes fatigue survivor: a phenomenology study. j diabetes metab disord 2022;21:1753-62. 5. nursolihah i, sembiring da, sabrina, et al. the survival rate of patients with diabetes mellitus in indonesia between 2019 and 2022. univers j public heal 2024;12:557-68. 6. wahidin m, achadi a, besral b, et al. projection of diabetes morbidity and mortality till 2045 in indonesia based on risk factors and ncd prevention and control programs. sci rep 2024;14:5424. 7. afifah amn, indriani d, sebayang sk, astutik e. risk factors for diabetes mellitus in indonesia: analysis of ifls data 2014. j biometrika dan kependud 2022;11:165-74. 8. soegondo s, widyahening is, istantho r, yunir e. prevalence of diabetes among suburban population of ternate—a small remote island in the eastern part of indonesia. acta med indones 2011;43:99-104. 9. bellatasie r, suharjono s, samsulhadi w, ayumuyas np. the effect of atorvastatin on lipid profile and inflammatory marker in patient with diabetes dyslipidemia. res j pharm technol 2022;15:4105-10. 10. roostarini jw, soelistijo sa, novida h, et al. lipoprotein (a) and arterial stiffness in patients with diabetes mellitus. new armen med j 2019;13:74-8. 11. aloke c, egwu co, aja pm, et al. current advances in the management of diabetes mellitus. biomedicines 2022;10. 12. american diabetes association. 2. classification and diagnosis of diabetes: standards of medical care in diabetes 2021. diabetes care 2021;44:s15-33. 13. ningsih os, efendi f, dewi ys. nursing interventions for diabetes prevention in individuals at risk or with prediabetes: a literature review. malaysian j nurs 2025;16:253-62. 14. ostling s, wyckoff j, ciarkowski sl, et al. the relationship between diabetes mellitus and 30-day readmission rates. clin diabetes endocrinol 2017;3. 15. agarwal p, mukerji g, desveaux l, et al. mobile app for improved self-management of type 2 diabetes: multicenter pragmatic randomized controlled trial. jmir mhealth uhealth 2019;7. 16. presley c, agne a, shelton t, et al. mobile-enhanced peer support for african americans with type 2 diabetes: a randomized controlled trial. j gen intern med 2020;35:2889-96. 17. megayanti sd, wulandari sk. development of diabetes selfcare management using audio-visual media. j kesehat dr soebandi 2021;9:38-45. 18. darma karingga d, efendi f. effect of mobile structured educational applications on self-care management in diabetes mellitus patients. gac med caracas 2023;131:278-86. 19. agustini nlpib, suniyadewi nw, rismayanti ida, faridah vn, utami r, aris a, et al. development and validation of android based mobile app for diabetic foot early self-assessment. malaysian j public heal med 2022;22:95-102. 20. bernhard g, mahler c, seidling hm, et al. developing a shared patient-centered, web-based medication platform for type 2 diabetes patients and their health care providers: qualitative study on user requirements. j med internet res 2018;20:e105. 21. chau jpc, chung lcl, wong rym, et al. an evaluation of a web-based diabetes education program designed to enhance self-management among patients living with diabetes. cin comput informatics nurs 2012;30:672-9. 22. ghozali mt. improving self-management of type 2 diabetes: evaluating the effectiveness of a mobile app-based patient education approach. conference: 2024 4th international conference on emerging smart technologies and applications (esmarta) 2024. 23. zakerabasali s, ayyoubzadeh sm, baniasadi t, et al. mobile health technology and healthcare providers: systemic barriers to adoption. healthc inform res 2021;27:267-78. 24. kshanti ia, mokoagow mi, rosandi r, et al. use of smartphone-based self-monitoring blood glucose application in type 2 diabetes mellitus patients in indonesia: a pre and post-test study. bali med j 2021;10:219-24. 25. nielsen p. design for usability. 1999;1-200. 26. qudah b, luetsch k. the influence of mobile health applications on patient healthcare provider relationships: a systematic, narrative review. patient educ couns 2019;102:1080-9. 27. ponirakis g, elhadd t, chinnaiyan s, et al. prevalence and management of diabetic neuropathy in secondary care in qatar. diabetes metab res rev 2020;36. 28. marcolino ms, oliveira jaq, d’agostino m, et al. the impact of mhealth interventions: systematic review of systematic reviews. jmir mhealth uhealth 2018;6:e8873. 29. jeffrey b, bagala m, creighton a, et al. mobile phone applications and their use in the self-management of type 2 diabetes mellitus: a qualitative study among app users and non-app users. diabetol metab syndr 2019;11:1-17. 30. kassavou a, wang m, mirzaei v, et al. the association between smartphone app-based self-monitoring of hypertensionrelated behaviors and reductions in high blood pressure: systematic review and meta-analysis. jmir mhealth uhealth 2022;10. 31. adu md, malabu uh, malau-aduli aeo, et al. user retention and engagement with a mobile app intervention to support selfmanagement in australians with type 1 or type 2 diabetes (my care hub): mixed methods study. jmir mhealth uhealth 2020;8. 32. kusnanto, widyanata kaj, suprajitno, arifin h. dm-calendar app as a diabetes self-management education on adult type 2 diabetes mellitus: a randomized controlled trial. j diabetes metab disord 2019;18:557-63. 33. hanifah h, giena vp, sari rm. the effect of health education through session-health application media on behavior management behavior of diabetes mellitus in bengkulu city. nurse pathways of change, part ii [page 72] [healthcare in low-resource settings 2025;13(s2):13514] heal j keperawatan 2019;8:115-23. 34. wang y, min j, khuri j, et al. effectiveness of mobile health interventions on diabetes and obesity treatment and management: systematic review of systematic reviews. jmir mhealth uhealth 2020;8. 35. tong hl, quiroz jc, kocaballi ab, et al. personalized mobile technologies for lifestyle behavior change: a systematic review, meta-analysis, and meta-regression. prev med (baltim) 2021;148. 36. rasoul am, jalali r, abdi a, et al. the effect of self-management education through weblogs on the quality of life of diabetic patients. bmc med inform decis mak 2019;19. 37. khan rmm, chua zjy, tan jc, et al. from pre-diabetes to diabetes: diagnosis, treatments and translational research. medicina (kaunas) 2019;55. 38. agustini nlpib, wulansari nt, yusniawati ynp, sintia nw. the effect of foot massage on decreasing peripheral neuropathy diabetic complaints in the patients with type 2 diabetes mellitus. j ners 2019;14:305-9. 39. suniyadewi nw, nursalam n, arief ys, et al. effect of android-based mobile diabetic foot early self-assessment on diabetic foot prevention behaviors of indonesian patients with type 2 diabetes. j holist nurs midwifery 2024;34:309-15. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13514] [page 73] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13205 adolescent knowledge, parental role, and smoking behavior among high school students in jakarta titi sulastri, deswani deswani, arifah rizkyanti, yupi supartini, dina carolina hapsari, ratna ningsih, eviana s. tambunan, andi sari bunga untung politeknik kesehatan kemenkes jakarta iii, indonesia abstract adolescence is a critical period of curiosity and experimentation, often associated with increased risk-taking, including smoking. once initiated, smoking can become a difficult habit to quit. strengthening adolescents’ knowledge about its dangers and fostering parental support are key to prevention. this study aimed to examine the influence of adolescents’ knowledge and parental roles on smoking behavior among high school students in jakarta, indonesia. a descriptive-analytical research with a cross-sectional design was conducted, involving 155 high school students selected through stratified random sampling. the dependent variable was smoking behavior, while the independent variables included adolescents’ knowledge of smoking and the parental role. data were collected using a structured questionnaire and analyzed statistically. results indicated a significant relationship between knowledge and smoking behavior (p=0.003). adolescents with higher knowledge were 4.671 times more likely to be non-smokers. in contrast, no significant relationship was found between parental role and adolescent smoking behavior (p=0.600). these findings highlight the critical role of knowledge in deterring smoking among adolescents. strengthening health education in schools may empower students to make informed, healthy choices. while parental influence showed no direct statistical association, parents remain important figures and should model nonsmoking behavior to reinforce anti-smoking norms. introduction adolescence is a critical developmental stage marked by the transition from childhood to adulthood, during which individuals undergo rapid physical, emotional, and social changes.1 this period is also characterized by a heightened sense of curiosity and a desire for exploration, which often includes experimentation with risky behaviors such as smoking.2,3 smoking remains one of the leading preventable causes of morbidity and mortality worldwide.4 globally, there are approximately 70.2 million smokers, accounting for around 34.5% of the global population, with indonesia ranking third in terms of the number of smokers after china and india.5 nationally, the issue of adolescent smoking is increasingly alarming.6 the 2018 basic health research (riskesdas) survey reported a rise in the smoking prevalence among individuals aged 10-18 years, from 7.2% in 2013 to 9.1% in 2018. moreover, the global youth tobacco survey (gyts, 2024) indicated that 40.6% of students aged 13-15 years in indonesia had tried tobacco products, and 19.2% were current smokers.7 in the capital city, dki jakarta, the central statistics agency (bps, 2023) reported that 22.6% of individuals aged 15 years and older are smokers.8 the consequences of tobacco use are severe and far-reaching.9 the who (2020) estimated that smoking-related illnesses cause approximately 225,700 deaths annually in indonesia.10 tobacco use is a major risk factor for numerous non-communicable diseases, including lung cancer (accounting for nearly 90% of cases), chronic obstructive pulmonary disease (copd), and cardiovascular diseases.11 despite widespread health campaigns and government initiatives – such as mass media education, smoke-free correspondence: deswani deswani, politeknik kesehatan kementerian kesehatan jakarta iii, indonesia. e-mail: desika_64@yahoo.co.id key words: adolescence; behavior; knowledge; smoking; parents’ role. contributions: ts, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; dd, conceptualization, investigation, methodology, validation, writing – original draft review & editing; ar, conceptualization, investigation, methodology, validation, review & editing; yp, conceptualization, methodology, formal analysis, validation, and writing; asbu, review & editing. all authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare that they have no conflicts of interest. ethics approval and consent to participate: this research was approved by the ethics committee of poltekkes kemenkes jakarta iii, under ethical approval letter number: lb.02.02/f.xix.21/4263/2024. the researcher focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. all respondents provided written informed consent to participate in this study. consent for publication: written informed consent was obtained from anonymized patients for publication of this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgments: the researcher sincerely thanks their family for the unwavering moral and material support provided throughout both the academic journey and the course of this research. deepest gratitude is also extended to the supervisors for their continuous guidance, valuable insights, and constructive feedback. special appreciation goes to the head of the high school in east jakarta for granting permission to carry out this study. finally, heartfelt thanks are given to all individuals who contributed to this research, particularly the respondents who generously gave their time and participation. received: 6 october 2024. accepted: 17 april 2025. early view: 22 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13205 doi:10.4081/hls.2025.13205 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 92] [healthcare in low-resource settings 2025;13(s2):13205] zones, and collaborations with civil society organizations – the prevalence of smoking among adolescents remains high.12 numerous factors contribute to adolescent smoking behavior, with knowledge and parental influence being particularly significant. according to the health behavior theory by lawrence green,13 an individual’s knowledge is a key determinant of their health-related behaviors. adolescents with a limited understanding of the harmful effects of smoking are more likely to engage in the habit. a study by ain found a statistically significant relationship between knowledge about smoking and smoking behavior among teenagers.14 parental influence also plays a crucial role during adolescence, a time when individuals often face emotional turbulence and require guidance. research by rongalaha et al. emphasized that active parental involvement can shape adolescents’ behavioral choices,15 including those related to tobacco use. conversely, inadequate parental supervision has been linked to higher rates of smoking among youth.16 however, findings in this area remain mixed and context-dependent, indicating the need for further research. although national statistics show a rise in smoking among adolescents, studies examining the specific contributing factors – particularly in urban areas such as jakarta – are still limited. understanding how adolescent knowledge and parental roles influence smoking behavior is essential for developing effective preventive strategies. therefore, this study aimed to assess the relationship between adolescent knowledge, parental role, and smoking behavior among high school students in east jakarta, indonesia. materials and methods this study employed a descriptive analytical design with a cross-sectional approach. the independent variables in this research were the role of parents and adolescents’ knowledge about smoking. the parental role refers to the actions taken by parents in preventing and addressing smoking behavior in adolescents and was categorized as either active or passive. adolescents’ knowledge about cigarettes encompassed understanding of cigarette content, health impacts, and relevant smoking laws. knowledge levels were classified as good, sufficient, or poor. the study population consisted of high school students in east jakarta. the sample size was calculated using the lemeshow formula for estimating population proportions with specified absolute precision. the minimum required sample size was 139 respondents. to accommodate potential dropouts, an additional 10% was added, resulting in a final sample size of 155 students. stratified random sampling was used to ensure a representative distribution across grade levels. the sampling frame included students from grades 10 and 11, who shared similar characteristics. out of 358 eligible students, the sample was proportionally divided: grade 10, (194/358)×155 ≈ 84 students and grade 11, (164/358)×155 ≈ 71 students. within each stratum, simple random sampling was conducted using software to ensure each student had an equal chance of selection. data collection was carried out using three structured questionnaires: smoking behavior questionnaire,17 knowledge about smoking questionnaire,17 and parental role questionnaire.18 all instruments were adapted from previously published studies. prior to data collection, validity and reliability testing were performed. the instruments were confirmed valid (r-calculated > r-table) and reliable, with a cronbach’s alpha score of 0.977, indicating excellent internal consistency. this study was approved by the ethics committee of poltekkes kemenkes jakarta iii, under ethical approval letter number: lb.02.02/f.xix.21/4263/2024. results table 1 shows that 115 (74.2%) teenagers were aged ≤17 years, while 40 (25.8%) were aged >17 years. furthermore, the majority of teenagers were male, namely 82 respondents (52.9%), compared to 73 female teenagers (47.1%). regarding the respondents’ smoking behavior, the majority were non-smokers, with 116 respondents (74.8%). nine respondents (5.8%) smoked lightly, 25 (16.1%) smoked moderately, and five (3.2%) smoked heavily. the respondents’ knowledge levels were grouped into good, sufficient, and poor. the results showed that the majority of respondents had a good level of knowledge (135 respondents, 87.1%), 13 respondents (8.4%) had a sufficient level of knowledge, and 7 respondents (4.5%) had a poor level of knowledge. the respondents’ parental roles were classified as active or passive. the results indicated that the majority of respondents had active parental roles pathways of change, part ii table 1. frequency distribution of respondents based on characteristics. no. characteristic category frequency (n) percentage (%) 1 age ≤17 years old 115 74.2 >17 years old 40 25.8 2 sex female 73 47.1 male 82 52.9 3 smoking behavior in adolescents do not smoke 116 74.8 light smoking 9 5.8 moderate smoking 25 16.1 heavy smoking 5 3.2 4 teenagers’ knowledge level good 135 87.1 enough 13 8.4 not enough 7 4.5 5 the role of parents active 150 96.8 passive 5 3.2 [healthcare in low-resource settings 2025;13(s2):13205] [page 93] (150 respondents, 96.8%), while five respondents (3.2%) had passive parental roles. during the cross-distribution analysis of the variables of smoking behavior and level of knowledge using the chi-squared test, some cells were empty. therefore, the behavioral categories of light, moderate, and heavy smoking were combined, resulting in only two categories: not smoking and smoking. additionally, the categories of insufficient and sufficient levels of knowledge were combined, resulting in only two categories: good and sufficient. the results of the bivariate analysis are presented in table 2. table 2 mentions that age was significantly related to smoking behavior (p=0.000). adolescents aged 17 or younger were far less likely to smoke compared to those over 17, with an odds ratio (or) of 5.053. similarly, sex showed a strong association with smoking behavior (p=0.000). female students were significantly less likely to smoke than male students. the odds ratio of 7.520 indicates that females were over seven times more likely to be nonsmokers compared to males, highlighting a gender disparity in smoking habits. the level of knowledge about smoking also played a critical role (p=0.003). students with good knowledge were 4.671 times more likely to refrain from smoking than those with only enough knowledge. in contrast, the role of parents did not show a statistically significant relationship with adolescent smoking behavior (p=0.600). although students with active parental involvement appeared less likely to smoke, the difference was not strong enough to be considered significant in this study. discussion the study revealed a significant association between age and smoking behavior among adolescents. participants aged 17 years or younger were less likely to smoke compared to those older than 17. this finding aligns with prior research, which found a higher prevalence of smoking among individuals aged 18 and above.19 this period of late adolescence often involves identity exploration, which may lead to risk-taking behaviors such as smoking.20 older adolescents typically have greater autonomy and easier access to cigarettes, both legally and illegally. moreover, stressors such as academic pressure or social challenges may further encourage smoking initiation.21 this study identified a statistically significant relationship between gender and smoking behavior. male students were more likely to smoke than female students. this finding is consistent with research by putri and adiwiryono22 and zahrani and arcana,23 both of which reported that male adolescents are significantly more prone to engage in smoking behavior. in the indonesian context, cultural and social norms play a pivotal role in shaping these patterns. smoking among females is often culturally discouraged, which may explain the lower prevalence among this group. similarly, solihin et al. found that male adolescents in indonesia tend to smoke more frequently than their female counterparts.24 a significant relationship was also observed between adolescents’ level of knowledge about smoking and their smoking behavior. students with good knowledge were significantly more likely to refrain from smoking. this aligns with findings from ain, which demonstrated a positive correlation between knowledge and reduced smoking behavior among adolescents.14 these findings showed that knowledge serves as a foundational determinant of behavior change. the results suggest that enhancing adolescents’ understanding of the harmful effects of smoking could be a key strategy in tobacco control interventions targeting youth. interestingly, this study found no significant association between the role of parents and adolescent smoking behavior. although most respondents reported having actively involved parents, this did not translate into a statistically significant reduction in smoking. this finding corroborates results by trisaputro, who also reported no significant link between parental role and youth smoking behavior.25 however, this contrasts with other studies, such as that by anwary, which found a significant association between parental involvement and student smoking habits.26 several factors may account for this discrepancy. firstly, peer influence is particularly strong during adolescence and may override parental influence. previous research by deve et al. found that 25.3% of students were likely to smoke when offered cigarettes by friends, and 90.7% had peers who smoked.27 adolescents often seek acceptance within their social circles, which may drive them to engage in smoking regardless of parental guidance. secondly, while parental roles may be reported as “active”, the quality and consistency of this involvement may vary. parents who smoke themselves may inadvertently model smoking behavior, undermining their anti-smoking messages. according to pelawi et al., parental smoking significantly increases the likelihood of adolescent smoking.28 conversely, when parents act as non-smoking role models and engage in open communication, adolescents may be more likely to abstain from tobacco use. pathways of change, part ii table 2. distribution of respondents based on characteristics and smoking behavior. variable do not smoking smoking total p or (ci 95%) n % n % n % age ≤17 96 83.5 19 16.5 115 100 0.000 5.053* (2.290-11.149) >17 20 50. 0 20 50. 0 40 100 sex female 67 91.8 6 8.2 73 100 0.000 7.520* (2.924-19.342) male 49 59.8 33 40.2 82 100 knowledge level good 107 79.3 28 20.7 135 100 0.003 4,671* (1.763-12.373) enough 9 45.0 11 55.0 20 100 the role of parents active 113 75.3 37 24.7 150 100 0.600 passive 3 60.0 2 40.0 5 100 or, odds ratio; ci, confidence interval; *chi-square test. [page 94] [healthcare in low-resource settings 2025;13(s2):13205] conclusions based on the findings, analysis, and discussion of this study, it can be concluded that age, gender, and the level of knowledge among teenagers are significantly associated with smoking behavior in one of the high schools in east jakarta. these results highlight the importance of increasing awareness and education about the risks of smoking among adolescents, empowering them to make more informed decisions regarding smoking. although no significant relationship was found between parental roles and adolescent smoking behavior, it remains essential for parents to model non-smoking behavior as a form of guidance. references 1. muzaffar, salim la, kartika, et al. socio-cultural, personal, and environmental relationship with smoking behavior of students in senior high school at plimbang aceh. j public health africa 2023;14:283–7. 2. sari ja, efendi f, nimah l, et al. predictors of smoking exposure in non-smoking adolescents in indonesia. healthc lowres s 2024;12. 3. wibowo m, mudayana aa, nurmal i. what is the most influential factor associated with youth smoking in bantul indonesia? afr j reprod health 2024;28:141–51. 4. nastiti rd, hargono a, artanti kd, et al. correlation of morbidity with smoking status and posbindu ptm to prepare aging society health manifestation in indonesia. j biometrika dan kependud 2024;13:109–21. 5. kementerian kesehatan republik indonesia. merokok, tak ada untung banyak sengsaranya. 2018. 6. safitri w, martini s, artanti kd, li cy. smoking from a younger age is the dominant factor in the incidence of chronic obstructive pulmonary disease: case-control study. int j environ res public health 2021;18. 7. world health organization. global adult tobacco survey (gats) indonesia report 2021. 2024. 13–33 p. 8. martini s, artanti kd, hargono a, et al. association between percentage of smokers and prevalence of smoking attributable morbidity in indonesia : one decade after implementation of smoke free area regulation. bmc public health 2022;22:2202. 9. sebayang sk, dewi dmsk, puspikawati si, et al. spatial analysis of outdoor tobacco advertisement around children and adolescents in indonesia. glob public health 2022;17:420–30. 10. world health organization. lembar informasi gyts indonesia 2019. who; 2019. available from: https://cdn.who.int/media/docs/default-source/searo/indonesia/indonesia-gyts-2019-factsheet-(ages-13-15)-(final)indonesian-final.pdf?sfvrsn=b99e597b_2 11. sijabat l. faktor-faktor yang memengaruhi kebiasaan merokok siswa smp swasta mulia pratama jalan jahe raya i perumnas simalingkar kecamatan medan tuntungan tahun 2018. 2018. 12. kemenkes ri, badan kebijakan pembangunan kesehatan. survei kesehatan indonesia. jakarta: kemenkes ri; 2023. p. 1–68. 13. notoatmodjo s. metodologi penelitian kesehatan. jakarta: rineka cipta; 2010. 14. ain ss. hubungan antara tingkat pengetahuan tentang rokok terhadap perilaku merokok pada remaja di smp x kabupaten sorong tahun 2019. j ilm kesehat masy 2019;8:60. 15. rongalaha as, blandina oa, salamor jm. hubungan peran orang tua terhadap perilaku merokok remaja di desa kupakupa kecamatan tobelo selatan. leleani. j keperawatan dan kesehat masy 2022;1:70–7. 16. badri ia, hayat n, rahmadeni as. hubungan peran orang tua dengan perilaku merokok pada remaja di wilayah kerja puskesmas galang. j keperawatan muhammadiyah 2021; 6:56–60. 17. sembiring ib. hubungan tingkat pengetahuan tentang bahaya merokok dengan perilaku merokok pada remaja di desa kuta gugung kecamatan naman teran tahun 2020. 2020;5:248–53. 18. dewi nlps. hubungan peran keluarga dengan perilaku merokok pada remaja di desa sibang kaja. 2021. 19. siregar hk, andini ft, tahu sk, et al. ilmu keperawatan dasar. munandar a, editor. bandung: cv. media sains indonesia; 2022. p. 1–14. 20. setyowati l, widyawati iy, wahyuni sd. perceived behavioral control and intention related to the smoking behavior of early adolescents in north surabaya. j ners 2020;15:193–6. 21. nizamie gv, kautsar a. analisis faktor-faktor yang mempengaruhi konsumsi rokok di indonesia. kaji ekon dan keuang 2021;5:158–70. 22. putri mb, adiwiryono rm. faktor-faktor yang berhubungan dengan perilaku merokok remaja (analisis data sekunder di sman dki jakarta dan smk kabupaten kuningan 2016). j pendidik kesehat 2020;9:201–10. 23. zahrani ci, arcana im. determinan perilaku remaja merokok setiap hari di indonesia. semin nas off stat 2021;2020:519– 28. 24. solihin, nyorong m, nurainisiregar dms. perilaku merokok pada remaja dan faktor penyebabnya di sma 2 dan smk 8 muhammadiyah tanjung sari kecamatan medan selayang the smoking behavior of adolescents and its causal factors in sma 2 and smk 8 muhammadiyah tanjung sari, medan selayang sub-district. j ilmu dan teknol kesehat terpadu 2023;3:21–30. 25. trisaputro r. hubungan peran orang tua dengan perilaku merokok pada remaja laki-laki di mts nahdatul ulama ungaran kabupaten semarang. 2019;03:1–10. 26. anwary az. peran orang tua dan teman sebaya terkait perilaku merokok mahasiswa fakultas ekonomi uniska mab banjarmasin. peran orang tua dan teman sebaya terkait perilaku merokok mhs fak ekon uniska mab banjarmasin. 2020. 27. deve efh, romeo p, ndoen em. faktor predisposisi dan pendorong perilaku merokok siswa remaja sma. j heal behav sci 2019;1:207–15. 28. pelawi amp, simanjuntak fm, siantar rl, et al. keperawatan dasar. editor:, widyawaty ed, purwanza sw, karo mb, editors. malang: penerbit rena cipta mandiri; 2022. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13205] [page 95] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13058 correlation between self-efficacy and health status of type 2 diabetes mellitus patients in primary health care setyoadi,1,2 ferry efendi,1 joni haryanto,1 dina dewi sartika lestari ismai,2 niko dima kristianingrum,2 yati sri hayati,2 annisa wuri kartika2 1faculty of nursing, university of airlangga, surabaya, east java; 2faculty of health sciences, universitas brawijaya, malang, east java, indonesia abstract the health status of type 2 diabetes mellitus (t2dm) patients is observed to decrease simultaneously along with the length of time. despite the various treatment management offered in primary care, a decrease in health status is also observed among patients in indonesia as shown by the low self-care ability. therefore, this research aimed to analyze the relationship between self-efficacy and the health status of patients in primary care in indonesia to provide evidence for the development of care management interventions for t2dm patients. the research used a descriptive analytical method with a cross-sectional design, including 327 t2dm patients in primary health care selected through cluster random sampling. data collection used the indonesian version of the diabetes management self-efficacy scale (dmses) and short form 12 (sf-12) questionnaires which had been tested for validity and reliability. the data obtained were analyzed using the pearson product moment test with a significance value of 0.01. the results obtained an r-value of 0.485 with a p-value of 0.00, showing a significant relationship between selfefficacy and health status in t2dm patients (0.00<0.01; ci 99%). in conclusion, this study highlights a significant correlation between self-efficacy and the health status of individuals diagnosed with t2dm. the findings emphasize the pivotal role of selfefficacy in shaping the health outcomes of patients with t2dm. introduction type 2 diabetes mellitus (t2dm) is a non-communicable disease (ncd with the second largest prevalence in the world after heart disease, significantly affecting public health.1 the international diabetes federation (idf) estimates that 425 million people suffered from diabetes worldwide in 2017, with a projected increase to 627 million in 2045.2 in 2021, the idf stated that indonesia was in 5th position with 19.47 million patients at a prevalence rate of 10.6%.3 the results of the 2018 riskesdas showed that the prevalence of diabetes patients aged ≥ 15 years was 2%, indicating an increase compared to the 2013 riskesdas of 1.5.4 however, the prevalence of diabetes mellitus (dm) based on blood sugar examination results increased from 6.9% in 2013 to 8.5% in 2018, showing that only 25% of patients are aware of their condition.1 generally, t2dm is a chronic disease that requires long-term care due to the effect of reducing the quality of life,5 including physical and mental health status.6 long-term physical impacts include fluctuating blood sugar levels,7 fatigue and helplessness,8 weight loss,9 diabetic retinopathy, nephropathy, and neuropathy.10 furthermore, the risk of complications that are often experienced is the occurrence of diabetic ulcers and amputation.11 recent research conducted in 2018 showed that the most chronic complications in t2dm patients were microvascular complications (57%), diabetic neuropathy (45.6%), diabetic nephropathy (33.7%), and diabetic retinopathy. other long-term impacts on mental health status include anxiety, anger, grief, shame, guilt, loss of hope, depression, loneliness, and helplessness.12-14 health status is the dynamic state of a person’s health in the healthy-ill range, influenced by various factors such as development, socio-cultural, past experiences, expectations, heredity, environment, and services.15 moreover, the health status of t2dm patients requires measurement, serving as the main objective in treating chronic and incurable diseases. the results of previous research showed that health status of t2dm patients was less than optimal, where 58% had hba1c >7.0, 45% had bmi >30, 28% experienced microalbuminuria, 8% had clinical proteinuria. and 42% were rated fair or poor.16 health status is an indicator describing the patient’s adherence to care and high self-efficacy to stay healthy, supported by family and health services. furthermore, positive perceptions of patients’ self-efficacy can improve selfmanagement and quality of life.17 self-efficacy in patients with t2dm is essential, serving as the strongest predictor of behavioral change in self-management.18 previous studies have indicated that various factors play a role in the health status of patients with type 2 diabetes mellitus (t2dm), including their knowledge about diabetes, psychological insulin resistance, support from family members, self-care behaviours, and haemoglobin a1c levels.19 notably, self-efficacy in managing diabetes has been recognized as a significant indirect influencer of health status.20 subsequent research has underscored the substantial impact of self-efficacy as a predictor of diabetic patients’ adherence to self-monitoring of blood glucose levels and dietary control.21 despite these findings, there remains a research gap concerning the specific association between self-efficacy and [healthcare in low-resource settings 2024;12(s1):13058] [page 97] significance for public health this research offers a novel perspective on managing patients with type 2 diabetes by emphasizing self-efficacy. the analysis focuses on patients' understanding of their condition and ability to find solutions to health problems, aiming to enhance health status. patients self-efficacy plays a crucial role in facilitating resilience in chronic disease care, contributing to the improvement of health outcomes in society non -co mmerc ial us e o nly the health status of t2dm patients in primary healthcare settings, such as “puskesmas” in indonesia. this study aims to fill this gap by investigating the correlation between self-efficacy and health status among t2dm patients in primary healthcare facilities (puskesmas) in indonesia. the insights we anticipate uncovering have the potential to significantly impact the practice of nurses and healthcare professionals in these settings, empowering them to better identify and utilize self-efficacy as a predictive factor for the health status of t2dm patients. this research is a crucial step towards enhancing the effectiveness of interventions in primary healthcare settings. materials and methods this research used an analytical observational method with a cross-sectional design, including the concurrent measurement and observation of data to determine the relationship between self-efficacy and health status of t2dm patients. the population included t2dm patients who had been diagnosed by doctors in primary health care in the malang city area. the sample size was calculated using the slovin formula and obtained 327 patients. the inclusion criteria were patients only suffering from t2dm, participants of “prolanis” program (health program activities for managing chronic diseases), ability to read, and independence. meanwhile, the exclusion criteria were patients who had cataracts, disabilities, and three consecutive absences attended prolanis activities. the data were collected using cluster random sampling of 16 primary health care in malang city. initially, the number of samples for each primary health care was determined by calculating the proportion based on t2dm patients who participated in prolanis program. data were collected using the diabetes management self-efficacy scale (dmses) and short form 12 (sf-12) questionnaires. the original version of the dmses was a self-administered scale containing 20 items, assessing respondents’ confidence in managing their blood sugar, diet, treatment, foot care, and level of exercise. responses were rated on a 5-point scale ranging from ‘‘can not do at all’’ to ‘’certain can do’’ (1, 5), with higher scores indicating greater self-efficacy in performing dsmes activities. the sf-12 served as a general health questionnaire consisting of 12 questions that investigate patients health status through 8 different dimensions. these include general health perception, physical health, limited physical role function, physical pain, vitality, mental health, limited emotional role function, and social functioning, where a higher score correlates with improved health status. both instruments were tested for validity and reliability before application, with r arithmetic value of 0.46 – 0.89 (> 0.44) and a cronbach alpha coefficient of 0.832 > 0.600 for dmses, and a r arithmetic of 0.466 – 0.721 (> 0.44) and a cronbach alpha coefficient of 0.909 > 0.600 for sf-12. subsequently, data analysis was carried out using the pearson product moment with a 99% confidence interval (ci; 99%). the respondents were given informed consent before participating and ethical approval was received from the health ethic committee, faculty of medicine, brawijaya university with clearance number 06/ec/kepk/01/2020. results and discussion table 1 shows that 207 (63.3%) of t2dm patients were aged between 45-65 years, 317 (96.9%) were muslim, female 263 (80.4%) , 169 (51.7%) graduated from elementary school/equivalent, 225 (68.8%) did not work, 159 (48.6%) suffered from 1-5 years, and 284 (86.9%) had a last blood sugar result exceeding 125 mg/dl. the results presented in table 2 showed that in the selfefficacy component in managing diabetes diet, the majority of (59%) patients are in the high category. in managing the sports component, the proportion between the high and low categories is 49% and 51%, respectively. meanwhile, in managing blood glucose, 77% of respondents were in the high category. approximately 64% of respondents were in the high category in treatment management, while 68% in managing foot care were in the high category. table 3 shows that there are 8 dimensions in the health status variable. based on the results, 182 (55.7%) respondents were in the well category regarding general health perception, while physical health dimensions in the well category had 310 (94.8%) respondents. in limited physical role function, 279 (85.3%) respondents were in the well category, while the physical pain dimensions had 296 (90.5%), limited emotional role function had 301 (92%), vitality had 230 (70.3%), and social function was well with 321 (98.2%) respondents. table 4 shows that t2dm patients with high self-efficacy were 212 (65%), while 115 (35%) were in the low category and 297 (90.8%) had good health status. based on table 5, the results of an analysis of 327 respondents showed a 99% confidence interval (ci; 99%), a p-value of 0.000, and a correlation r-value of 0.485. this showed a fairly strong relationship between self-efficacy and the health status of t2dm patients. 4th international nursing and health sciences symposium table 1. distribution of sociodemographic respondents. sociodemography frequency (f) percentage (%) age <45 years old 7 2.1 45-65 years old 207 63.3 >65 years old 113 34.6 religion islam 317 96.9 christian 7 2.1 catholic 3 0.9 gender male 64 19.6 female 263 80.4 education no school 2 0.6 elementary school 169 51.7 middle school 76 23.2 high school 65 19.9 undergraduate 15 4.6 occupation not employed 225 68.8 labor 3 0.9 civil servants 3 0.9 army 1 0.3 entrepreneur 95 29.1 older suffer (years) <1 tahun 36 11 1-5 tahun 159 48.6 >5 tahun 132 40.4 the last result of blood glucose (mg/dl) 80-109 mg/dl 9 2.8 110-125 mg/dl 34 10.4 >125 mg/dl 284 86.9 [page 98] [healthcare in low-resource settings 2024;12(s1):13058] non -co mmerc ial us e o nly the results showed that t2dm patients had high levels of selfefficacy, as evidenced by the ability to maintain blood sugar within the normal range, adhere to medication schedules, proactively prevent foot injuries, and promptly seek healthcare services. generally, patients with chronic disease require strong self-efficacy to navigate the uncertainties associated with health concerns. this is because self-efficacy plays a crucial role in enabling t2dm patients to manage and control blood sugar levels through regular monitoring, consistent adherence to prescribed medications as advised by healthcare professionals, and continuous compliance with healthcare services.22 furthermore, self-efficacy can help alleviate concern about foot injuries, disrupting social interactions, reducing personal independence, and lowering quality of life.3 self-efficacy is built on self-assurance facilitated by knowledge, which enhances people to make informed decisions and consistently adhere to healthcare goal. previous research has shown that there is a relationship between self-efficacy among t2dm patients as well as the ability to effectively manage blood sugar levels and adhere to prescribed treatments.24 the research showed that t2dm had a good health status, as evidenced by their positive social interaction, mental well-being, physical health, and emotional control. generally, health status is an indicator measuring patients’ perception of total well-being, serving as a guide for making appropriate intervention decisions and identifying their specific needs.25 a positive perception of good health status motivates patients to seek information and access optimal care, thereby maintaining a positive outlook and improved health.26 the social aspect of health status is characterized by patients’ interaction with family members, neighbors, and the community. positive social interactions can enhance self-confidence, facilitating a sense of acceptance by others and maintaining productivity, leading to an improved quality of life.13 the psychological aspect of health status is a critical indicator when dealing with t2dm patients who often experience stress, feelings of helplessness, and hopelessness, which significantly impact their quality of life.27 the research showed a significant relationship between selfefficacy and the health status of t2dm patients. based on the results, patients receiving treatment for chronic diseases in primary care settings in indonesia showed high levels of self-efficacy, due to the substantial family support.28 self-efficacy is the product of cognitive processes including decisions, beliefs, and assessments regarding the perceived ability to perform specific tasks or actions necessary to achieve desired outcomes.29 specifically, self-efficacy of patients plays a significant role in shaping their actions and decisions, to attain specific goals as well as address potential future situations.30 the results showed self-efficacy had a positive influence on both psychological and social aspects of health status. moreover, self-efficacy is associated with effective self-management and positive psychological outcomes, which plays a mediating role in the relationship between social support and psychological well-being of t2dm patients.31 the results also emphasize that self-efficacy plays a significant role in enhancing physical health status due to the ability to adopt and maintain long-term health habits.24 these habits include dietary, regular exercise, foot care, consistent medication administration, insulin injections, and diligent blood glucose monitoring. the adoption of these habits requires the ability, self-assurance, and determination of patients based on their selfassessment.32 therefore, this research showed that when disseminating diabetes education, educators should impart knowledge as a foundation for behavioral change, along with appropriate beliefs and attitudes to enhance patients self-efficacy.33 these factors are essential in enhancing the transformation and effective implementation of self-management practice. the practice of primary healthcare services in indonesia, particularly through the non-communicable diseases (ncd) program known as posbindu ptm, aims to enhance community engagement in ncd risk factor prevention, early detection, and continuous care.34 in this context, nursing practices focus on increasing knowledge, positive attitudes, and promoting healthier behaviors. however, a prevalent challenge when providing care for t2dm patients in primary healthcare settings is related to the perception of diabetes.35 many people believe that t2dm is not a severe issue requiring immediate response but fail to realize the long-term consequences and complications associated with diabetes. the majority of patients only understand the effect of this disease after experiencing a stroke, foot injuries, amputations, heart failure, or kidney failure.36 this underscores the importance of enhancing self-efficacy through the provision of information, 4th international nursing and health sciences symposium table 2. distribution of respondents' self-efficacy components. self-efficacy components high low f % f % manage diet 194 59 133 41 manage exercise 160 49 167 51 manage blood sugar 252 77 75 23 manage treatment 209 64 118 36 manage foot care 221 68 106 32 table 3. distribution of dimensions health status respondents. dimensions health status sufficient well f % f % general health perception 145 44.3 182 55.7 physical health 17 5.2 310 94.8 limited physical role function 48 14.7 279 85.3 physical pain 31 9.5 296 90.5 limited emotional role function 26 8 301 92 mental health 4 1.2 323 98.8 vitality 97 29.7 230 70.3 social functioning 6 1.8 321 98.2 table 4. distribution of self-efficacy and health status categories. self-efficacy frequency (f) percentage (%) high 212 65 low 115 35 health status good 297 90.8 poor 30 9.2 table 5. results of self-efficacy analysis and health status. n alpha p-value r-correlation 327 0.01 0.000 0.485 [healthcare in low-resource settings 2024;12(s1):13058] [page 99] non -co mmerc ial us e o nly educational training, continuous monitoring, and home visits, as part of the posbindu ptm and prolanis initiatives in primary health care in indonesia. by increasing self-efficacy, people tend to take their condition seriously, adhere to recommended practices, and effectively manage diabetes.34,37 conclusions in conclusion, this research explored the relationship between self-efficacy and health status in t2dm patients. the results showed the significance of self-efficacy as an essential factor in influencing the health status of patients to better comprehend their health conditions and proactively seek effective solutions. the positive correlation observed between self-efficacy and health status emphasized the potential impact of interventions to enhance patients’ belief in the ability to manage their condition. these results contributed to the broader understanding of effective strategies in chronic disease care, with implications for interventions designed to develop self-efficacy aimed at improving the health status of t2dm patients. therefore, recognizing and incorporating the role of self-efficacy in healthcare practices could lead to more targeted and successful methods for supporting t2dm patients to improve health status and well-being. references 1. ministry of health, republic of indonesia. infodatin 2020: diabetes. jakarta: ministry of health, republic of indonesia; 2021. 2. cho nh, shaw je, karuranga s, huang y, da rocha fernandes jd, ohlrogge aw, et al. idf diabetes atlas: global estimates of diabetes prevalence for 2017 and projections for 2045. diabetes res clin pract 2018;138:271–81. 3. idf diabetes, resources, diabetes l with, acknowledgement, faqs, contact, et al. idf diabetes atlas 2021 [cited 2023 aug 12]. available from: https://diabetesatlas.org/ 4. ministry of health, republic of indonesia. basic health research. jakarta: ministry of health, republic of indonesia; 2018. 5. american diabetes association. standards of medical care in diabetes—2018. clin diabetes 2018;36:14–37. 6. jing x, chen j, dong y, et al. related factors of quality of life of type 2 diabetes patients: a systematic review and meta-analysis. health qual life outcomes 2018;16:1–14. 7. zhang x, xu x, jiao x, et al. the effects of glucose fluctuation on the severity of coronary artery disease in type 2 diabetes mellitus. j diabetes res 2013;2013:1–6. 8. kusnanto k, pradipta ro, arifin h, et al. what i felt as a diabetes fatigue survivor: a phenomenology study. j diabetes metab disord 2022;21:1753–62. 9. yang s, wang s, yang b, et al. weight loss before a diagnosis of type 2 diabetes mellitus is a risk factor for diabetes complications. medicine (united states) 2016;95:e5618. 10. american diabetes association professional practice committee. 12. retinopathy, neuropathy, and foot care: standards of medical care in diabetes—2022. diabetes care 2022;45:s185–94. 11. farmaki p, damaskos c, garmpis n, garmpi a, savvanis s, diamantis e. complications of the type 2 diabetes mellitus. curr cardiol rev 2021;16:249–51. 12. saputri rd. systemic complications in type 2 diabetes mellitus patients introduction. j ilm kesehat sandi husada 2020;11:230–6. 13. kalra s, jena bn, yeravdekar r. emotional and psychological needs of people with diabetes. indian j endocrinol metab 2018;22:696–704. 14. davies m. psychological aspects of diabetes management. med (united kingdom). 2019;47:131–4. 15. rumsfeld js. health status and clinical practice: when will they meet? circulation 2002;106:5–7. 16. maureen. health care and health status and outcomes for patients with type 2. diabetes care 2000;23:754-8. 17. farley h. promoting self-efficacy in patients with chronic disease beyond traditional education: a literature review. nurs open 2020;7:30–41. 18. clara h, irawaty d, dahlia d. self-efficacy as a predictor of 4th international nursing and health sciences symposium correspondence: setyoadi, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia. tel.:+62341569117, fax: +62341564755 e-mail: setyoadi@ub.ac.id key words: diabetes; health status; self-efficacy contributions: the authors contributed equally in developing the design, data collection, data analysis, writing the manuscript, and reviewing the manuscript to ensure compliance with article writing guidelines. conflict of interest: the authors declare that there is no potential conflict of interest. funding: this research was financially supported by the institute for research and community service, faculty of health sciences, brawijaya university ethics approval: the respondents were given informed consent before participating and ethical approval was received from the health ethic committee, faculty of medicine, brawijaya university with clearance number 06/ec/kepk/01/2020. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgments: the authors are grateful to the institute for research and community service, faculty of health sciences, university of brawijaya, for providing the 2022 research grant. furthermore, the authors are grateful to the head of the malang city health service and public health center for granting research permission and to all respondents who participated in this research. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13058 doi:10.4081/hls.2024.13058 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 100] [healthcare in low-resource settings 2024;12(s1):13058] non -co mmerc ial us e o nly self-management behavior practice among people with type 2 diabetes mellitus (t2dm). kne life sci 2021;2021:440–53. 19. lee ks, hye young kim hyj. factors affecting the health status of patients with type 2 diabetes mellitus receiving insulin treatments: a multi-mediation path analysis. j clin nurs 2022;31:1285-97. 20. id jy, wang h, yin x, et al. the association between self-efficacy and selfmanagement behaviors among chinese patients with type 2 diabetes. plos one 2019;14:1–12. 21. tsegaye r, abdissa e. predictors of adherence to self-care behavior among patients with diabetes at public hospitals in west ethiopia. diabetes, metab syndr obes 2020;13:3277–88. 22. adu md, malabu uh, malau-aduli aeo, malau-aduli bs. enablers and barriers to effective diabetes self-management: a multi-national investigation. plos one 2019;14:1–22. 23. sharoni ska, rahman ha, minhat hs, et al. the effects of self-efficacy enhancing program on foot self-care behaviour of older adults with diabetes: a randomised controlled trial in elderly care facility, peninsular malaysia. plos one 2018;13:1–23. 24. paulsamy p, ashraf r, alshahrani sh, et al. social support, self-care behaviour and self-efficacy in patients with type 2 diabetes during the covid-19 pandemic: a cross-sectional study. healthcare 2021 nov 22;9(11):1607. 25. sarah d griffin, victoria g cardenas, kylie w, shalom ib. helping patients help themselves : a systematic review of selfmanagement support strategies in primary health care practice. plos one 2019;14:1–29. 26. kapasi a, pei j. mindset theory and school psychology. can j sch psychol 2022;37:57–74. 27. tareen rs, tareen k. psychosocial aspects of diabetes management: dilemma of diabetes distress. transl pediatr 2017;6:383–96. 28. li ww, singh s, keerthigha c. a cross-cultural study of filial piety and palliative care knowledge: moderating effect of culture and universality of filial piety. front psychol 2021:12:787724. 29. bandura a. self-efficacy: toward a unifying theory of behavioral change. psychol rev 1977;84:191-215. 30. hood kk, hilliard m, piatt g, et al. effective strategies for encouraging behavior change in people with diabetes. diabetes manag 2018;5:499–510. 31. al-dwaikat tn, rababah ja, al-hammouri mm, chlebowy do. social support, self-efficacy, and psychological wellbeing of adults with type 2 diabetes. west j nurs res 2021;43:288– 97. 32. niño-de-guzman quispe e, bracchiglione j, ballester m, et al. patients’ and informal caregivers’ perspectives on self-management interventions for type 2 diabetes mellitus outcomes: a mixed-methods overview of 14 years of reviews. arch public heal 2023;81:1–21. 33. camargo-plazas p, robertson m, alvarado b, et al. diabetes self-management education (dsme) for older persons in western countries: a scoping review. mendoza-nuñez vm, editor. plos one 2023;18:e0288797. 34. siswati t, kasjono hs, olfah y. “posbindu ptm”: the key of early detection and decreasing prevalence of noncommunicable diseases in indonesia. iran j public health 2022;51:1683–4. 35. soewondo p, ferrario a, tahapary dl. challenges in diabetes management in indonesia: a literature review. global health 2013;9:1–17. 36. hidayat b, ramadani rv, rudijanto a, et al. direct medical cost of type 2 diabetes mellitus and its associated complications in indonesia. value heal reg issues 2022;28:82–9. 37. setyoadi s, efendi f, haryanto j, et al. family coping strategies and quality of life of patients with type-2 diabetes mellitus in primary health care in indonesia. nurs med j nursing 2023;13:274–85. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13058] [page 101] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13065 insulin injection rotation and diabetes mellitus nutritional management education indah rosdiana narahaubun,1 dian handayani,2 heri kristianto1 1department of nursing, faculty of health sciences, universitas brawijaya, malang, east java; 2department of nutrition, faculty of health sciences, universitas brawijaya, malang, east java, indonesia abstract the management of diabetes mellitus (dm) involves implementing a healthy lifestyle and pharmacological interventions through the administration of anti-hyperglycemia drugs. an essential aspect of treating dm patients is insulin administration, which facilitates glucose transportation into cells. this study evaluated the effectiveness of insulin injection rotation and nutritional management education for dm. the literature search utilized the keywords “education,”and “insulin injection,” and “nutritional management,” and “dm”, ranged 2021-2023 searches were conducted on various databases, including proquest, ncbi, bmc, sciencedirect, and other relevant platforms such as google scholar. ten journal articles pertinent to the subject matter were identified in the study. findings indicate that nutritional education facilitates overall health improvement in individuals with dm, contributing to maintaining average body weight and near-normal blood glucose levels. it also enhances lipid profile and insulin receptor sensitivity while being a preventive measure against acute or chronic complications such as hyperglycemia. it is noted that selecting the appropriate injection site can significantly impact patients’ blood glucose levels. while it is recommended to administer injections at consistent locations, repetitive use of the same site may pose risks of side effects, such as lipodystrophy. after conducting a comprehensive review of ten journal articles, it has been concluded that insulin injection rotation and nutritional management education are effective for managing dm. introduction a total of 422 million diabetes mellitus (dm) patients were reported by the data obtained from the world health organization (who) and international diabetes federation (idf) in 2019. approximately 10.7 million patients are in the age range of 20-79 years, and the figure is estimated to increase by 11.8% in 2030 and 20451 due to the high incidence of the disease. according to the 2018 riskesdas data, the prevalence of dm patients aged over 15 years remained at 2%, marking an increase compared to the figures from the 2013 riskesdas.2 the management can be achieved by implementing a healthy lifestyle with pharmacological intervention and administration of anti-hyperglycemia drugs.3-6 the management of type 2 dm restores blood glucose concentration, allowing patients to feel comfortable and healthy as well as preventing the onset of micro complications and macrovascular complications.7-9 individuals who have been diagnosed with diabetes often need to rely on insulin therapy to help move glucose from the blood into the body’s cells. this essential process is critical in managing the condition and maintaining proper blood sugar levels.10-12 selection of the right insulin injection site can affect the blood glucose levels of patients. therefore, changing the injection point is important to prevent the risk of side effects. lipodystrophy is a side effect of insulin resulting from fat tissue damage to form scars in the form of lumps under the skin. these lumps can interfere with insulin absorption and repetitive injection can cause other complications in the form of skin irritation.13-15 a strong understanding of nutritional treatment can play a crucial role in helping to stabilize blood glucose levels and support overall health.16-17 nutritional education improves the general health of dm patients, maintains normal body weight and near-normal blood glucose levels, improves lipid profiles and insulin receptor sensitivity, as well as prevents acute or chronic complications such as hyperglycemia.17-19 achieving success in dm management requires diligent adherence to the guidance provided by healthcare professionals, including physical exercise, pharmacological treatment, and dietary recommendations. therefore, this research aimed to determine the effectiveness of insulin injection rotation and nutritional management education for dm. materials and methods eligibility criteria the articles underwent a rigorous evaluation based on specific criteria and were managed using bibliographic software like mendeley. the assessment was carried out meticulously through a systematic three-step review to determine their suitability for inclusion in the study. this comprehensive process involved the initial scrutiny of the title, abstract, and full text. the inclusion cri [healthcare in low-resource settings 2024;12(s1):13065] [page 117] significance for public health the management of diabetes mellitus (dm) entails adopting a healthy lifestyle, utilizing anti-hyperglycemic medications, and administering insulin. proper selection and rotation of injection sites are imperative to mitigate potential side effects. this research emphasizes the significance of nutritional education in enhancing overall health and averting complications in dm patients. non -co mmerc ial us e o nly teria encompassed articles published within the past three years (2021-2023), original qualitative and quantitative research, content relevant to the specified search terms, and availability as open access. the exclusion criteria included content irrelevant to the topics. search strategy an extensive electronic search was conducted across five databases: proquest, ncbi, bmc, sciencedirect, and google scholar. the search period ranged from 2021 to 2023, focusing on specific keywords including “education,” and “insulin injection,” and “nutritional management,” and “diabetes mellitus.” following the retrieval of articles, predefined inclusion criteria were applied to filter the results and identify relevant content for further analysis. article selection process the review article selection process employed the prisma method. a comprehensive search across proquest, ncbi, bmc, sciencedirect, and google scholar yielded 39,490 articles. following filtering based on specified year criteria, the number was refined to 19,728. subsequently, a thorough evaluation of the title and abstract and a scoping review identified 30 suitable articles. finally, after the third stage of screening, 16 articles were selected (figure 1). articles selected shown in supplementary materials, table 1. results and discussion optimizing the administration of insulin injections insulin, a vital hormone, is pivotal in regulating the body’s glucose levels. the degree of insulin sensitivity varies among individuals and is influenced by diverse lifestyle and dietary factors. notably, approximately 40% of adults in the united states experience low insulin sensitivity, also known as insulin resistance, which elevates the risk of developing type 2 diabetes. improving insulin sensitivity and diminishing insulin resistance can yield significant benefits for individuals with type 2 diabetes or those predisposed to the condition. embracing positive lifestyle modifications, such as regular physical activity and a well-balanced diet, can substantially enhance insulin sensitivity and mitigate the risk of type 2 diabetes.20 the efficacy of diabetes therapy hinges on the accurate administration of insulin through proper injection techniques. despite existing guidelines and evidence, it is imperative to identify barriers to this technique among patients and foster awareness among patients and healthcare professionals regarding the significance of refining insulin injection practices.21 administration of insulin injections necessitates careful attention to optimizing patient care. a study by zhang and chen elucidated the specific requirements for this procedure. compared to the control group, the cohort receiving consistent care and optimized insulin injection techniques demonstrated marked enhancements in health. these improvements included decreased blood glucose and hba1c levels, fewer reported insulin-related complications and reduced pain scores. additionally, the intervention group exhibited expedited training and achieved a higher success rate for initial subcutaneous injections. moreover, the intervention group experienced a lower frequency of subcutaneous fat hyperplasia. conversely, while not statistically significant, the control group displayed a higher incidence of hypoglycemia.22 a study compared the effects of it education on diabetes management in two groups. both groups had similar demographics and baseline it behaviour. hba1c reduction was similar in both groups in the intention-to-treat analysis but significant in the per-protocol analysis. total daily dose (tdd) insulin changes were more important in the it education group. control patients showed “contamination” of it education behaviours, decreasing hba1c.23 a new automatic insulin injection log device with an algorithm improved injection rotation in the abdominal area, potentially reducing lipo hypertrophy lesions and promoting better glucose control.24 the prevalence of lipohypertrophy among individuals with diabetes mellitus is notably high, linked to insufficient health education on proper injection techniques. implementing a system of rotating injection sites has been shown to enhance glycemic control in both type 1 and type 2 diabetes mellitus subjects. moreover, it has been observed that the level of education influences glucose control in type 1 diabetes mellitus subjects. however, further comprehensive research is necessary to extrapolate these findings and to establish definitive causal relationships between injection techniques and glycemic control.25 proper insulin administration is paramount to avoiding serious complications. healthcare providers must educate patients on appropriate techniques, insulin storage, injection sites, and potential complications to mitigate errors resulting from a lack of knowledge. effective diabetes management relies on healthcare providers’ assessment of patient understanding and utilization of engaging educational methods. given time constraints, physicians require support in effectively educating and providing patient feedback. notably, patients improved their injection technique during follow-up visits by addressing factors such as injection force and 4th international nursing and health sciences symposium figure 1. article selection process. [page 118] [healthcare in low-resource settings 2024;12(s1):13065] non -co mmerc ial us e o nly area size. educational interventions to improve insulin injection techniques can potentially enhance glycemic control in individuals with diabetes mellitus. it is imperative to incorporate evidencebased recommendations and guidelines for insulin injection techniques and adopt technological and innovative solutions to advance this endeavour.26-28 improving nutritional management for patients with type 2 diabetes mellitus type 2 diabetes is characterized by impaired glucose utilization and energy storage, leading to elevated blood sugar levels. insulin resistance, a hallmark of this condition, impedes the entry of sugar into cells, while insufficient insulin production by the pancreas further contributes to the increased blood sugar levels.29 effectively managing type 2 diabetes necessitates lifestyle modifications, self-care practices, and medication to prevent complications associated with the eyes, kidneys, and nerves. regular monitoring of blood sugar levels, as well as the regulation of blood pressure and cholesterol, are vital aspects of management. adhering to a nutritious diet, engaging in physical activity, and adhering to prescribed medications are integral to diabetes management. seeking guidance from a qualified dietitian is advantageous in formulating a personalized plan that aligns with individual needs and preferences.8 the preceding study elucidates the nutritional enhancements following a targeted dietary intervention.30-35 a study focused on two individuals aged 39 and 67 with low body weights and bmis. their nutritional deficiencies were addressed through assessments, oral hygiene interventions, and diabetes-specific dietary education. following the educational session, the patient’s weight and bmi showed improvement.30 before the educational interventions, 70.5% of the patients had poor blood sugar levels, with 47.7% exhibiting moderate levels. adherence to dietary recommendations notably impacted the blood sugar levels of individuals with type ii diabetes.31 the study involved 159 patients divided into three groups, resulting in varied outcomes. the intervention group significantly improved hba1c levels, metabolic parameters, dietary intake, and physical activity.34 while healthcare providers recognized challenges in maintaining a healthy diet, patients demonstrated positive self-management indicators.34-35 healthcare providers hold diverse perspectives regarding patients’ challenges in maintaining a healthy diet. some patients demonstrate proactive self-management behaviours, such as consistently monitoring their blood glucose levels and displaying a strong interest in acquiring knowledge about dietary practices. nevertheless, providers have indicated that they often lack the necessary time to engage in extensive discussions about diet with their patients and would prefer to delegate dietary education to other individuals.36 managing diabetes well involves learning about it, planning meals, staying active, taking medication as prescribed, and checking blood sugar levels regularly. modalities encompass insulin therapy, oral medications, complementary and alternative medicine, surgical interventions, and lifestyle modifications. the rotation of insulin injections and nutritional knowledge significantly impact diabetes management and overall understanding. healthcare professionals employ counselling techniques and provide educational resources to enhance treatment outcomes. conclusions in conclusion, the effective management of diabetes mellitus (dm) can be enhanced by implementing five key pillars: education, meal planning, physical exercise, pharmacological intervention, and blood sugar monitoring. treatment options comprise insulin therapy, oral medications, exploration of alternative therapies, surgical interventions, and lifestyle improvements such as dietary modifications and regular exercise. the proficient rotation of insulin injections and provision of nutritional education significantly impact patients’ blood glucose control and knowledge levels. healthcare professionals deliver education through counselling and the distribution of educational materials, including booklets, leaflets, and modules, to augment treatment success. references 1. setyawati ad, ngo thl, padila p, andri j. obesity and heredity for diabetes mellitus among elderly. josing 2020;1:26–31. 2. ministry of health republic of indonesia. basic health research. jakarta: ministry of health republic of indonesia; 2018. 3. perkeni. management and prevention of type 2 diabetes mellitus in indonesia. jakarta: indonesian endocrinology society; 2021. 4. fujiwara y, eguchi s, murayama h, et al. relationship between diet/exercise and pharmacotherapy to enhance the glp-1 levels in type 2 diabetes. endocrinol diabetes metab 2019;2:e00068. 5. davies mj, aroda vr, collins bs, et al. management of hyperglycemia in type 2 diabetes, 2022. a consensus report by the american diabetes association (ada) and the european association for the study of diabetes (easd). diabetes care 2022;45:2753–86. 6. nathan dm, buse jb, davidson mb, et al. medical management of hyperglycemia in type 2 diabetes: a consensus algorithm for the initiation and adjustment of therapy: a consensus statement of the american diabetes association and the european association for the study of diabetes. diabetes care 2009;32:193-203. 7. rasyid w, nur bm, irawati d, rayasari f. effectiveness of insulin injection time on blood glucose levels 2 hours after meals in type 2 diabetes mellitus patients. jks 2019;2(2):39– 52. 8. goyal r, singhal m, jialal i. type 2 diabetes. [updated 2023 jun 23]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk513253/ 9. mehravar f, mansournia ma, holakouie-naieni k, et al. associations between diabetes self-management and microvascular complications in patients with type 2 diabetes. epidemiol health 2016;38:e2016004. 10. thota s, akbar a. insulin. [updated 2023 jul 10]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www. ncbi.nlm.nih.gov/books/nbk560688/ 11. donnor t, sarkar s. insulinpharmacology, therapeutic regimens and principles of intensive insulin therapy. [updated 2023 feb 15]. in: feingold kr, anawalt b, blackman mr, et al., editors. endotext [internet]. south 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13065] [page 119] non -co mmerc ial us e o nly dartmouth (ma): mdtext.com, inc.; 2000-. available from: https://www.ncbi.nlm.nih.gov/books/nbk278938/ 12. lukito ji. use insulin carefully. cdk 2020;47:734. 13. syarfaini, ibrahim ia, syahrir s, et al. the effect of nutrition education on knowledge and self-management in type 2 diabetes mellitus patients. al gizzai: public health nutr j 2023;33–42. 14. mehrabbeik a, namiranian n, azizi r, et al. investigation of association between insulin injection technique and blood glucose control in patients with type 2 diabetes. int j endocrinol metab 2022;20:e128392. 15. kadiyala p, walton s, sathyapalan t. insulin induced lipodystrophy. br j diabetes 2014;14:131–3. 16. reynolds a, mitri j. dietary advice for individuals with diabetes. [updated 2024 apr 28]. in: feingold kr, anawalt b, blackman mr, et al., editors. endotext [internet]. south dartmouth (ma): mdtext.com, inc.; 2000-. available from: https://www.ncbi.nlm.nih.gov/books/nbk279012/ 17. liang k, xie q, nie j, deng j. study on the effect of education for insulin injection in diabetic patients with new simulation tools. medicine 2021;100:e25424. 18. gortzi o, dimopoulou m, androutsos o, et al. effectiveness of a nutrition education program for patients with type 2 diabetes mellitus. appl sci 2024;14:2114. 19. kim j, hur mh. the effects of dietary education interventions on individuals with type 2 diabetes: a systematic review and meta-analysis. int j environ res public health 2021;18:8439. 20. freeman am, acevedo la, pennings n. insulin resistance. [updated 2023 aug 17]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk507839/ 21. kalra s, pathan f, kshanti iam, et al. optimising insulin injection techniques to improve diabetes outcomes. diabetes ther 2023;14:1785–99. 22. zhang fy, shen m, sun lq. evaluation of clinical efficacy of continuous care with improved insulin injection techniques on patients with diabetes mellitus: a randomized controlled trial. j int med res 2022;50:3000605221108047. 23. chen l, xing q, li j, et al. injection technique education in patients with diabetes injecting insulin into areas of lipohypertrophy: a randomized controlled trial. diabetes ther 2021;12:813-26. 24. klarskov ck, hamid yh, tjalk-bøggild r, et al. a new medical device for improved rotation of insulin injections in type 1 diabetes mellitus: a proof-of-concept study. j diabetes sci technol 2021;15:1111–20. 25. abujbara m, khreisat ea, khader y, ajlouni km. effect of insulin injection techniques on glycemic control among patients with diabetes. int j gen med 2022;15:8593-602. 26. louzolo-kimbembe r, jaafari f, rafi s, mghari g, el ansari n. insulin injection a non-trivial act with sometimes serious consequences: major role of therapeutic education. sas j med 2021;7:47–9. 27. adhi igam, dwiatmojo nf, sukmadewi nlp, et al. effectiveness of rotation scheme for insulin injection on blood sugar control of diabetes mellitus patients in the polyclinic of north lombok district hospital. jisip 2023;7:830–6. 28. bari b, corbeil ma, macneill g, et al. addressing insulin injection technique: a follow-up study of canadian patients with diabetes. diabetes ther 2023;14:2057–74. 29. nakrani mn, wineland rh, anjum f. physiology, glucose metabolism. [updated 2023 jul 17]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk560599/ 30. lukman l, aguscik a, agustin va. implementation of nutrition management in nursing care for type ii diabetes mellitus with nutrition deficit nursing problems. jurnal ’aisyiyah medika 2023;8(1). 31. pangaribuan gj, wahyu a. the effect of diet compliance education on blood sugar levels in type ii diabetes mellitus patients in the 7th floor inpatient care, murni teguh hospital, medan. asy-syfa 2023;1:34–42. 32. sitorus f, waruwu knr, tolnel re, bexty f. knowledge and compliance of type 2 diabetes mellitus patients with diabetic nutrition management. j nursing library 2023;2:40-45. 33. momongan n, paruntu o, barangmanise s, takahipe n. diet education with booklet media in improving diet compliance and blood sugar levels in type ii dm patients. gizido journal 2021;13:24-2. 34. isaksson ss, bacos mb, eliasson b, et al. effects of nutrition education using a food-based approach, carbohydrate counting or routine care in type 1 diabetes: 12 months prospective ran 4th international nursing and health sciences symposium correspondence: indah rosdiana narahaubun, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia, 65151. tel.: +62341569117fax: +62341564755. e-mail: indahnarahaubun05@gmail.com key words: diabetes mellitus; education; injection rotation; insulin; nutritional management contributions: the content of the reviewed article is the sole responsibility of each author who has made significant contributions. they have meticulously assessed its quality, participated in preparing the manuscript, and authorized its submission. conflict of interests: the authors declare no conflicts of interest funding: the authors receive support from the department of nursing, faculty of health sciences, universitas brawijaya ethics approval: not applicable. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgments: the authors extend their gratitude to all those who contributed to enhancing the quality of this scientific article. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13065 doi:10.4081/hls.2024.13065 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 120] [healthcare in low-resource settings 2024;12(s1):13065] non -co mmerc ial us e o nly domized trial. bmj open diabetes research and care 2021;9:e001971. 35. hashim sa, mohd yusof bn, abu saad h, et al. effectiveness of simplified diabetes nutrition education on glycemic control and other diabetes-related outcomes in patients with type 2 diabetes mellitus. clin nutr espen 2021;45:141-9. 36. bross r, genter p, lu y, et al. barriers to healthy eating and diabetes diet education: divergent perspectives of patients and their providers. health education behavior 2022;49:658666. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13065] [page 121] online supplementary materials table 1. selected articles non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13552 the effectiveness of postpartum education and support models in enhancing mothers’ self-efficacy after cesarean section elin supliyani,1 ina handayani,1 novita dewi pramanik,1 ni wayan suarniti2 1politeknik kesehatan kemenkes bandung, bandung; 2politeknik kesehatan kemenkes denpasar, bali, indonesia abstract maternal self-efficacy refers to a parent’s belief in their ability to care for a child, which can be influenced by a lack of experience, knowledge, and physical condition after giving birth by cesarean section (cs). education and postpartum support for mothers after a cs are essential for enhancing their knowledge, skills, and confidence in caring for their babies, helping them feel more prepared and capable. this study examined the effectiveness of a postpartum education and assistance model on the maternal self-efficacy of post-cs mothers. this research was conducted at bogor city hospital (indonesia) using a quasi-experimental method with a non-equivalent control group design, employing pre-test and post-test assessments. the sample obtained through purposive sampling consisted of 44 post-cs mothers, with 22 in the intervention group and 22 in the control group. the wilcoxon test was used for data analysis. maternal self-efficacy in caring for babies was measured before and after education and assistance using the perceived maternal parenting self-efficacy (pmpse) questionnaire with a likert scale. the results showed that the median self-efficacy of post-cs mothers before the intervention was 64.50 (range 48-79), while after education and mentoring, the median increased to 81 (range 61-93). education and mentoring significantly influenced maternal self-efficacy in caring for infants (p<0.001). it is hoped that this education and mentoring model can be applied in health facilities, particularly hospitals, to enhance the readiness of post-cs mothers to care for their babies and strengthen their confidence. introduction the postpartum period is a transitional phase for mothers, marked by numerous physical, mental, emotional, and social changes.1 during this time, women must adapt to new roles and responsibilities while managing significant physiological and psychological adjustments.2 for mothers who undergo a cesarean section (cs), the postpartum experience often differs from that of those who have a vaginal delivery.3 cs are typically performed in cases of prolonged or obstructed labor, fetal distress, or abnormal fetal positioning.4,5 like all surgical procedures, cs carries potential risks and complications.6,7 common postpartum issues following a cesarean delivery include excessive bleeding, infections, fatigue, sleep disturbances, breastfeeding difficulties, challenges with self-care, and difficulties in caring for the newborn.8,9 pain, maternal death, breastfeeding problems, worsened sleep quality and comfort, anxiety, delayed recovery, prolonged hospitalization, and infection rates in cesarean deliveries are higher than in vaginal deliveries.10,11 the act of undergoing a cs can significantly impact a mother’s psychological well-being. mothers who give birth using this method often feel a sense of failure regarding their delivery. additionally, they may worry about their recovery process and the potential effects of any medication. these feelings can lead to a sense of helplessness and anxiety concerning both their health and that of their baby. furthermore, anxiety and pain resulting from a post-cs recovery can lead to fatigue, diminish self-confidence, and undermine a mother’s ability to manage her emotions and care for her newborn.12 a mother’s belief in her ability to care for her baby and percorrespondence: elin supliyani, politeknik kesehatan kemenkes bandung, bandung, indonesia. e-mail: elin@staff.poltekkesbandung.ac.id key words: cesarean section; postpartum education; self-efficacy; support model. contributions: es, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ih, methodology, formal analysis, validation, visualization, writing – review & editing; ndp, nws, writing – review & editing. all the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: this research was approved by the health research ethics commission, poltekkes kemenkes bandung, based on the ethical certificate number: 41/kepk/ec/vi/2023. during the research, the researcher paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was financially supported by the ministry of health, bandung health polytechnic, indonesia. acknowledgments: the authors would like to express their gratitude to the ministry of health, bandung health polytechnic, for approving and financing this research. received: 30 december 2024. accepted: 24 march 2025. early view: 19 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13552 doi:10.4081/hls.2025.13552 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13552] [page 45] form her role as a mother (maternal self-efficacy) is a crucial aspect of supporting maternal well-being and child development. research shows that mothers with high levels of maternal self-efficacy are more likely to have positive, responsive, and warm parenting strategies.13 mothers with low maternal self-efficacy are more likely to hold negative perceptions and are at greater risk for suboptimal parenting outcomes. on the other hand, mothers with high maternal self-efficacy are more capable of optimally caring for their children, fostering greater closeness, and employing effective stress management techniques.14,15 education and mentoring for mothers after cs are essential to ensure that mothers can take good care of themselves and their babies. healthcare workers provide information about caring for newborns. quality education can enhance maternal self-efficacy, which in turn impacts the health of mothers and their children.16,17 maternal self-efficacy refers to a parent’s confidence in their ability to manage and perform parenting-related tasks.18 a lack of adequate information is one of the contributing factors to emotional distress in women, potentially leading to various challenges.19,20 moreover, limited experience and knowledge, combined with the physical recovery following a cs, can further hinder a mother’s ability to effectively care for the newborn. healthcare workers should support mothers in adapting to their new roles by providing them with appropriate treatment and care. it is essential to address not only the physical needs of mothers and their babies but also to ensure both physical and psychosocial adjustment during this transition.21,22 this study aimed to evaluate the effectiveness of the postpartum education and support model on the self-efficacy of mothers who have undergone cs. materials and methods research design this study employs a quasi-experimental method and utilizes the “nonequivalent control group design” research design to assess the effectiveness of postpartum education and mentoring models on maternal self-efficacy after cs. the study involved an experimental and a control group, which underwent pre-tests before treatment. the experimental group received postpartum education and mentoring, whereas the control group received standard infant care. the study concluded with a final test (post-test) administered to both groups to evaluate maternal self-efficacy in caring for their babies. study participants this study was conducted at bogor hospital, indonesia, in july 2023. the location of the research was determined based on the existence of cesarean delivery services. the study population comprised all postpartum mothers in bogor who had a cesarean delivery. the inclusion criteria were postpartum mothers who had undergone a cs, were in good health along with their babies, and were willing to participate by signing an informed consent form. participants also needed to be able to communicate effectively, read, and write, as well as own an android mobile phone capable of accessing e-booklets and video calls. additionally, they had to be willing to receive home visits for support until the baby reached six months of age. mothers or babies with any complications were excluded from the study. the sampling technique used in this study was a non-probability sampling technique, specifically the purposive sampling method. the sample size for this study was calculated using the formula for hypothesis testing of mean differences between two paired groups, resulting in a minimum requirement of 22 participants in both the intervention and control groups. the use of purposive sampling techniques in this study limits the generalizability of the results to all post-cs mothers, as the selection of respondents is based on specific criteria established by the researcher. variable, instrument, and data collection this study focuses on the postpartum education and mentoring model as an independent variable, providing education to post-cs mothers about parenting readiness and skills. this education includes instruction on oxytocin massage practices, breastfeeding methods and positions, bathing babies, umbilical cord care, and daily baby care. the dependent variable was the maternal self-efficacy. this refers to the mother’s belief in her ability to fulfill her role as a parent in caring for the baby, including breastfeeding, monitoring the baby’s needs, and stimulating the baby’s development. this study used preand post-test instruments to measure variables before and after postpartum education and mentoring. education was conducted over four meetings. the first meeting was carried out after the mother entered the postpartum room, and education was provided about the condition of the postpartum period, the needs of newborns, the importance of breast milk, how breast milk is produced, correct breastfeeding techniques, and assistance in the breastfeeding process. the second meeting was held one day postpartum, covering topics such as breastfeeding schedules, alternative breastfeeding positions, methods to increase breast milk supply, and signs of adequate breastfeeding. in the third meeting on the second day postpartum, the material presented included information on recognizing tongue-tie and lip-tie, identifying danger signs in newborns, bathing techniques for the baby, caring for the umbilical cord, and drying the baby. the fourth meeting was conducted on the tenth day of home visits, providing assistance with daily baby care at home and evaluating the maternal self-efficacy in caring for their babies. this study employed the perceived maternal parenting self-efficacy (pmpse) questionnaire, comprising 20 questions, to assess maternal self-efficacy. the questionnaire used a likert scale ranging from strongly disagree (1), disagree (2), agree (3), and strongly agree (4), with scores ranging from 48 to 93. data analysis before data analysis, a normality test was carried out using the shapiro-wilk test to determine whether the data were normally distributed. the results indicated that the data on maternal selfefficacy in infant care, before and after the intervention, were not normally distributed (p=0.008). therefore, a non-parametric test, the wilcoxon signed-rank test, was used to analyze the differences in self-efficacy before and after participation in the parenting class. ethical clearance the research was approved by the health research ethics committee, ministry of health, bandung health polytechnic, based on the ethical certificate 03/kepk/ec/ix/2023. during the research, the researcher paid attention to the ethical principles of informed consent, respect for human rights, beneficence, and nonmaleficence. informed consent was obtained from all subjects involved in the study. pathways of change, part ii [page 46] [healthcare in low-resource settings 2025;13(s2):13552] results the research findings showed that the majority of respondents in both the intervention and control groups were of healthy reproductive age (20–30 years), accounting for 77.3% and 72.7%, respectively. in terms of education, 95.5% of mothers in the intervention group and 72.7% in the control group had attained higher education. most were housewives (68.2% in the intervention group and 86.8% in the control group). regarding parity status, the majority of mothers in the intervention group were multiparous (59.1%), as were those in the control group (81.8%) (table 1). as shown in table 2, it appears that there is a difference in the average maternal self-efficacy in caring for meaningful babies before and after being given post-section cesarean education and assistance, with a value of p<0.001. this means that education and assistance for post-section cesarean mothers are effective in increasing their self-efficacy in caring for babies. based on table 3, the analysis results show a significant difference in respondents’ maternal self-efficacy between the control and intervention groups, with a p-value of 0.004. the results of the analysis of the maternal self-efficacy scores for the intervention and control groups were significant (p<0.005). discussion the results of this study support the hypothesis that postpartum education and mentoring are effective in increasing maternal selfefficacy in post-cs mothers. the results of the maternal selfefficacy (mse) scale, taken ten days after the postpartum education intervention, showed that the parenting self-efficacy scale score increased significantly (p<0.005). the study’s findings align with prior research indicating that education enhances postpartum maternal self-efficacy.16 this is linked to an increase in the experience and learning process that mothers undergo while achieving identity and parental roles.14,23 although both groups experienced an increase in the mse scale at one week postpartum, the group of mothers who received postpartum educational intervention had higher scores. statistically, this research shows that postpartum educational and mentoring interventions are effective in increasing the median mothering self-efficacy score by 15.50 points. this finding is supported by the results of previous research, which state that support and information effectively increase parenting selfefficacy.24 moreover, education and assistance during the intervention increase the maternal self-confidence in carrying out baby care tasks. in the research, the results showed that there was effectiveness in providing postpartum education and assistance to mothers with a cs (p<0.005). this finding is supported by the results of pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13552] [page 47] table 1. characteristics of participants in each group. indicator group intervention control n (%) n (%) age 20-35 17 77.3 16 72.7 <20 and >35 years 5 22.7 6 27.3 education level higher education 21 95.5 16 72.7 low education 1 4.5 6 27.3 occupation employed 7 31.8 3 13.6 housewife 15 68.2 19 86.4 parity status primipara 9 40.9 4 18.2 multipara 13 59.1 18 81.8 table 2. the effect of education and assistance on maternal self-efficacy in caring for babies in post-cesarean section. self-efficacy median (min-max) p* pre-intervention (n=22) 64.50 (48-79) 0.000 post-intervention (n=22) 81 (61-93) *p, wilcoxon test. table 3. effectiveness of education and assistance post-cesarean section on maternal self-efficacy. variable n median (min-max) mean rank p* self-efficacy intervention (n=22) 15.50 (-18-39) 28.02 0.004 control (n=22) 10.50 (0-22) 16.98 *p, mann-whitney test. previous studies, which have shown that postpartum educational interventions have an influence on the self-efficacy of post-cs mothers in the early postpartum period. this condition was determined by time, materials, methods, and appropriate educational media or tools. postpartum mothers become better prepared and more confident.25 education in this study was carried out in stages, namely after the mother was transferred to the postpartum room with material regarding postpartum conditions, the needs of newborns, the importance of breast milk, how breast milk is produced, breastfeeding techniques, and breastfeeding guidance. providing information about the condition of postpartum cs mothers is useful for gaining an understanding of the physical changes that occur in these mothers. education during the postpartum period serves as a form of health promotion, focusing on recovery and the prevention of complications, enabling parents to adapt to changes and fulfill their role effectively.26,27 birth with the cs method often requires a longer and more difficult recovery time: the majority of mothers need an average of 6 weeks or more to recover from a cs.28-30 several research results recommend that midwives provide education to patients tailored to their learning needs. various media can be used to offer individual education, such as written information.31 in this study, providing booklets and additional time with the midwife will make it easier for postpartum mothers to understand and retain important information related to caring for themselves and their babies. through individualized education, midwives can serve as a support system for mothers by providing information tailored to their needs, along with direct guidance, particularly for breastfeeding. during the second meeting, which took place on the first day postpartum, education was provided on breastfeeding schedules, alternative breastfeeding positions, methods to increase breast milk supply, and signs of adequate breast milk. one of the problems often encountered by postpartum mothers following cs surgery is difficulty breastfeeding.21,32 factors that influence the breastfeeding process include the mother’s knowledge about breastfeeding and education on breastfeeding techniques for post-cs mothers.33,34 on the second day postpartum and before going home, education was provided on daily baby care and recognizing danger signs. mothers received booklets as reading material to review at home and directly apply the education provided. the results of this study show that counseling with demonstrations and booklets increases the mother’s knowledge and confidence in her ability to carry out childcare tasks such as breastfeeding, changing diapers, bathing, putting the baby to sleep, and calming the baby. all tasks in caring for newborns require the mother’s understanding, mastery, and courage in three aspects, namely cognitive, affective, and skill. if the mother does not have the relevant knowledge, she will experience difficulties in caring for the newborn independently.35 on the third day, assistance was provided with observations via checklist sheets and online communication. observations continued on the seventh day with a home visit, measuring the maternal self-confidence using the pmpse questionnaire. the assistance and empathy provided by midwives as a form of support can encourage mothers to adopt positive behaviors. efforts to improve postpartum care can be made by fostering strong relationships with mothers and addressing the unique needs of each mother individually.17,36 research indicates that a mother’s anxiety level impacts the information provided about newborn care. it has been shown that the mother’s anxiety decreased after receiving health education.26 the focus of postpartum midwifery care is not only on physical recovery; midwives must also prepare mothers psychologically and emotionally to enable them to carry out the duties of caring for and nurturing newborns. quality and adequate education by midwives will help post-cs mothers increase self-efficacy, which will ultimately affect the quality of maternal and child health.21 the study’s limitations include the absence of an analysis of other factors that can influence self-efficacy in caring for babies, such as family support, physical condition, and psychological condition after a cs. as a result, additional research must be conducted, taking into account family support factors and physical conditions, as well as assessing the mother’s psychological state, which will influence her ability to care for her baby. conclusions there is a significant influence of education and mentoring on maternal self-efficacy in caring for babies after a cesarean section. it is hoped that this model of post-cesarean maternal education and assistance can be applied in healthcare service environments, especially in hospitals. this model could be utilized as an educational program for post-cesarean section patients, providing comprehensive care to enhance mothers’ confidence and ability to care for their babies after birth. references 1. baston h, hall j. midwifery essentials: antenatal: volume 2. jakarta: egc; 2012. 2. lindayani ik, nurmala i, puspitasari n. influence of stressful life events in postpartum mothers on the incidence of postpartum depression. afr j reprod health 2024;28:206-13. 3. azizah n, santoso b, abdurachman, et al. a study is examining how postpartum pain after cesarean section (sc) can be reduced by boosting levels of β-endorphin through electroacupuncture stimulation at the specified points li4 and sp6. pharmacogn j 2024;16:670-6. 4. al farizi s, ernawati e, ernawaty ew. cesarean delivery characteristics during jkn implementation. indones j obstet gynecol 2022;157-62. 5. oetama en, laksana mac, pranadyan r. optimizing emergency cesarean section response times in category i fetal distress: a pharmacological perspective. pharmacogn j 2024;16. 6. who. caesarean section rates continue to rise, amid growing inequalities in access : rising rates suggest increasing numbers of medically unnecessary, potentially harmful procedures. 2021. 7. farizi s al. reproductive health rights: a bibliometric analysis of childbirth. global knowledge, memory and communication. 2024. 8. ahsan a. nursing care model based on knowledge management in preventing nosocomial infection after caesarean section in hospital. j ners 2014;9:236. 9. al farizi s, setyowati d, azyanti af, et al. maternal characteristics and outcomes affected by covid-19 pandemic in indonesia. j obstet gynecol india 2023;73:504-11. 10. fan c, guidolin d, ragazzo s, et al. effects of cesarean section and vaginal delivery on abdominal muscles and fasciae. medicina (kaunas) 2020;56:1-10. 11. wittkowski a, garrett c, calam r, weisberg d. self-report measures of parental self-efficacy: a systematic review of the current literature. j child fam stud 2017;26:2960-78. 12. nastiti aa. postpartum fatigue: a critical challenge for new pathways of change, part ii [page 48] [healthcare in low-resource settings 2025;13(s2):13552] mothers. pediomaternal nurs j 2024;10:48-50. 13. bandura a. self-efficacy (the exercise of control.). new york: w.h. freeman and company; 1997. 14. suherik oa, hildayani r. memahami keyakinan diri ibu berusia remaja: studi kualitatif mengenai maternal self-efficacy. psyche 165 j 2024;17:172-80. 15. botha e, helminen m, kaunonen m, lubbe kj w. mothers’ parenting self-efficacy, satisfaction and perceptions of their infants during the first days postpartum. midwifery 2020;88:102760. 16. pramudianti dn, raden a, suryaningsih ek. perubahan parenting self-efficacy pada ibu pasca sectio caesarea melalui edukasi postpartum dengan media booklet. j ris kebidanan indones 2019;3:49-55. 17. astutiningrum d, hapsari eld, purwanta p. peningkatan parenting self efficacy pada ibu pasca seksio sesaria melalui konseling. j ners 2016;11:134-41. 18. bandura a. self-efficacy beliefs of adolescents. psychol rev 1977;84:191-215. 19. noviani, a. and maryana, n. efektivitas pendampingan pada ibu nifas pasca operasi sesar. optimal midwife j 2024;1:1321 20. glatz t, lippold m, chung g, jensen tm. a systematic review of parental self-efficacy among parents of school-age children and adolescents. adolesc res rev 2024;9:75-91. 21. duran s, vural g. problems experienced by the mothers in post-cesarean period: a narrative review. iran j public health 2023;52:2036-41. 22. bazezew am, nuru n, demssie tg, ayele dg. knowledge, practice, and associated factors of preoperative patient teaching among surgical unit nurses, at northwest amhara comprehensive specialized referral hospitals, northwest ethiopia, 2022. bmc nurs 2023;22:1-13. 23. astutiningrum da, hapsari el, purwanta p. pengaruh konseling terhadap parenting self efficacy pada ibu postpartum dengan sectio caesarea. j ners 2016;11:134. 24. hamovitch ek, acri mc, bornheimer la. an analysis of the relationship between parenting self-efficacy, the quality of parenting, and parental and child emotional health. j fam soc work 2019;22:337-51. 25. fierloos in, windhorst da, fang y, et al. the association between perceived social support and parenting self-efficacy among parents of children aged 0–8 years. bmc public health 2023;23:1-12. 26. wahyuni c. efforts to improve postpartum maternal behavior through family-centered maternity care (fcmc) about postpartum care education. jceh 2024;7:238-43. 27. saharoy r, potdukhe a, wanjari m, taksande ab. postpartum depression and maternal care: exploring the complex effects on mothers and infants. cureus 2023;15. 28. patel k, zakowski m. obstetric anesthesia enhanced recovery after cesarean: current and emerging trends. curr anesthesiol rep 2021;11:136-44. 29. teigen nc, sahasrabudhe n, doulaveris g, et al. enhanced recovery after surgery at cesarean delivery to reduce postoperative length of stay: a randomized controlled trial. am j obstet gynecol 2020;222:372.e1-372.e10. 30. sung s, mikes ba, martingano dj, et al. cesarean delivery. [updated 2024 dec 7]. in: statpearls. treasure island (fl): statpearls publishing; 2025. 31. sam s. role of media in education. educ technol 2019;1:7-18. 32. ernawati, sunarsih t, daryanti ms. pengaruh self efikasi ibu menyusui dalam pemberian asi eksklusif pada ibu hamil trimester iii. med respati j ilm kesehat 2020;15:217-26. 33. singh j, scime nv, chaput kh. association of caesarean delivery and breastfeeding difficulties during the delivery hospitalization: a community-based cohort of women and fullterm infants in alberta, canada. can j public heal 2023;114:104-12. 34. hobbs aj, mannion ca, mcdonald sw, et al. the impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. bmc pregnancy childbirth 2016;16:1-9. 35. simsek a, balkan e, caliskan e. determination of mothers’ thoughts and adaptation behaviors regarding the infant: a descriptive study. pediatr neonatol 2022;63:276-82. 36. djafar sr, zakaria f, dunggio r. pengaruh konseling terhadap peningkatan parenting self efficacy pada ibu post partum primipara sectio caesarea di rsud dr m.m dunda limboto. madu jurnal kesehatan 2018;7:10-7. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13552] [page 49] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13112 challenges faced by female oral and maxillofacial surgeons in conservative societies: a gender-based analysis najla dar-odeh,1 osama abu-hammad,1 hanan reda,2 monther alsharif,3 shadia elsayed,2 mohammad al-shayyab,1 ashraf abu-karaky,1 soukaina ryalat1 1school of dentistry, university of jordan, amman, jordan; 2faculty of dental medicine for girls, al-azhar university, cairo, egypt; 3faculty of dentistry, university of benghazi, libya abstract oral and maxillofacial surgeons (omfss) face peculiar challenges that may hinder surgical careers and jeopardize job satisfaction. more data are necessary on these challenges, particularly among females in conservative societies and politically unstable areas. this study aimed to perform a gender-based analysis of social and professional challenges faced by omfss in egypt, jordan, libya, and saudi arabia. an online questionnaire was distributed among omfss to explore career-hindering factors, factors influencing omfs career choice by female surgeons, and surgeons’ preferences for online educational platforms. the results showed that male professionals performed more surgical procedures under general anesthesia and identified “financial revenues” as a significant career obstacle (p≤0.05). regarding the most important factors that impact female surgeons’ choice of omfs career, significantly more females cited “lack of mentors” (p=0.012), while significantly more males cited “marriage” and “having children” (p=0.001). further, significantly more males stated that “males are better suited for leadership positions” (p<0.001). female omfss in conservative societies encounter challenging social and professional barriers, which may adversely affect job stability and career aspirations. adopting policies that promote a work-family balance for female surgeons and providing institutions with a sufficient number of mentors may be crucial in mitigating the obstacles and challenges they face. further leadership opportunities should be made accessible to women, supported by establishing an inclusive and unbiased environment that engages all stakeholders, regardless of their gender. introduction oral and maxillofacial surgery (omfs) is an interdisciplinary specialty between dentistry and surgery. oral and maxillofacial surgeons (omfss) perform versatile procedures that address challenging diseases affecting the head and neck region, such as cancer, trauma, and developmental malformations. moreover, close collaboration between surgical and non-surgical teams is required to enhance overall treatment outcomes inherently directed toward patients’ functional and aesthetic needs. gender diversity in surgical workforces promotes favorable treatment outcomes and increases patients’ satisfaction and quality of life. increasing women’s participation in surgical careers is projected to enhance and sustain healthcare resources, thereby mitigating the global surgical burden.1 female physicians were described as being more careful, better communicators, and adherent to the clinical guidelines.2 they are also preferred to male surgeons among a substantial proportion of the female patient population who feel more comfortable when seeking healthcare from female surgeons3 and who were reported to have several health disparities in low-resource settings.4 further, recent studies highlight a high rate of adverse surgery outcomes when female patients are treated by male surgeons, a trend that was not identified when female surgeons treat male patients.5 while the overall healthcare sector has made major steps towards inclusivity and gender equity, disparities still persist in various medical fields, especially in surgical disciplines.6,7 in conservative cultures such as those in arabic societies, understanding gender diversity is particularly important. it highlights the need to assess the interplay between gender dynamics, societal expectations, and professional experiences to enhance the understanding and appreciation of the features of this surgical subspecialty.7 for many decades, the arabic region has experienced protraccorrespondence: najla dar-odeh, school of dentistry, university of jordan, amman, jordan. e-mail: najla@ju.edu.jo key words: career; conservative; gender; oral and maxillofacial surgery; perceptions. contributions: ndo, conceptualization, methodology, writing – original draft, writing – review & editing; oah, conceptualization, methodology, formal analysis; hr, ma, mas, aak, sr, data curation, validation; se, investigation, methodology, writing – review & editing. all the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: ethics approval was obtained from the faculty of dental medicine, al azhar university, egypt (protocol # eepi-ib 201). the study was carried out in accordance with the world medical declaration of helsinki. consent for publication: written informed consent was obtained from the participants of this study. availability of data and materials: all data generated or analyzed are included in this published article. received: 16 september 2024. accepted: 17 january 2025. early access: 19 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13112 doi:10.4081/hls.2025.13112 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13112] [page 89] ted political instability and armed conflicts, triggering numerous difficulties for healthcare systems, particularly surgical disciplines such as omfs. these low-resource settings are further jeopardized by the increasing rates of migration of highly qualified surgeons who aspire to more prosperous careers in politically stable countries.8 previous research highlighted several challenges and obstacles faced by omfss, particularly female surgeons.9 globally, a biased, less welcoming work environment and sexual harassment were perceived as major obstacles.10 on the other hand, in conservative countries, female surgeons highlighted “lack of mentors” and “long working hours” as the major career obstacles.3 more followup studies are warranted to provide an in-depth analysis of these challenges, particularly the perceptions of male surgeons, who constitute the largest proportion of the surgical workforce and who occupy more influential leadership positions.11 therefore, we conducted this study in four arabic countries using a gender-specific approach to evaluate challenges that face omfss, assess factors that influence female surgeons’ career choices, identify training preferences for online educational platforms, and lastly, explore perceptions of female representation in leadership positions. materials and methods study design this study employed a cross-sectional survey utilizing an online questionnaire created with google forms, based on a previous similar study.8 a pilot test was performed to ensure clarity and reproducibility. ten male and female surgeons from each country were invited to complete the questionnaire on two separate occasions, one week apart. calculated cronbach’s alpha (0.72) and kappa (0.79) were considered acceptable. the questionnaire was composed of an introductory section on the objectives of the study and the anonymous nature of participation. this was followed by 37 closed-ended questions on socio-professional characteristics (age, gender, marital status, parental status, specialization country, work country, years of experience, professional setting, weekly number of in-patients, and weekly number of out-patients); perceived socio-professional factors that may hinder career (financial revenues, peer appreciation, uncooperative boss, patient respect, patient flow, spouse career, spouse appreciation, family responsibilities, medical illness, physical complaints, time for professional development); perceptions on factors influencing the omfs career choice by female surgeons (lack of mentors, long working hours, marriage, children, society); perceptions on gender-specific leadership roles; and preferences on surgical topics for which youtube platform is consulted. study participants a convenient sample of omfss was invited to participate by co-authors who were members of local dental associations through local professional social networks as follows: hr and se in egypt, sr in jordan, se in saudi arabia, and ma in libya. participants were invited to complete the questionnaire during may 2023. a second round of invitations was performed in june 2023. participants were included if they were arabic surgeons practicing omfs in one of the four participating countries. participants who were identified as working outside these countries were excluded. a total of 137 surgeons participated, with 74 males (54.0%) and 63 females (46.0%). data analysis statistical analysis was conducted using ibm spss software for windows (spss version 25, armonk, ny: ibm corp) to calculate descriptive data, including range, mean, and standard deviation of age and years of experience, frequencies, and percentages of socio-professional groups. descriptive data were also calculated for surgeons’ preferences for professional development on various surgical topics using the youtube platform. participating countries were divided into two groups according to the income level as defined by the world bank. the first category constituted saudi arabia (high income), jordan, and libya (upper middle income), and the second category constituted egypt (lower middle income). the chi-square test was used to assess the significance of the association between gender and socio-professional characteristics, socioprofessional career factors, and socio-professional factors perceived by participants to influence females’ choice of the omfs career. a p-value of ≤0.05 was considered significant. ethics approval ethics approval was obtained from the faculty of dental medicine, al azhar university, egypt (protocol #eepi-ib 201). the study was carried out in accordance with the world medical declaration of helsinki. results data were analyzed to describe the socio-professional characteristics of participants, career barriers, and factors that influence female surgeons’ preference for omfs career path. the socio-professional characteristics of participants are presented in table 1. males were more likely to be married, have children, and larger families (p<0.05). in contrast, females were more likely to receive training and work in lower-income countries (p<0.001). additionally, males tended to perform a greater number of procedures under general anesthesia each week (p=0.018). table 2 revealed that most male and female surgeons confirmed the important influence of all socio-professional factors, except “spouse career”, which was considered “not important”. “financial revenues” was the most highly cited career obstacle among males (97.3%), in contrast to “family responsibilities”, which was the most highly cited factor among females (95.2%). a statistically significant higher proportion of males considered “financial revenues” as a barrier to their career (p=0.044). participants indicated which factors influence female surgeons’ choice of omfs career (table 3); significantly, more females identified “lack of mentors” as an important factor in their choice of omfs career (p=0.012). while more males perceived that “marriage” and “having children” are important factors in females’ omfs career choice (p=0.001). when exploring perceptions of women’s professional representation and participation in leadership positions, females were more likely to feel under-represented in the profession. however, the difference was not statistically significant (p>0.05). further, significantly more females perceived that “both genders can equally be leaders” (p<0.001), while significantly more males stated that “males are better suited in leadership positions”, and that there are “none or fewer female leaders than males” (p<0.05) (table 4). the study also conducted a gender analysis of continuous education using youtube as an important platform in surgical training. there were no statistically significant differences between genders in their referral to youtube platform (p>0.05). further, the most frequently cited disciplines were aesthetic surgery and oncology, while dento special issue pathways of change [page 90] [healthcare in low-resource settings 2025;13(s1):13112] alveolar surgery was the least cited (figure 1). the last section of the questionnaire presented an open space for surgeons to express their feelings about the status quo of the profession and their assessment of the future. only 21 participants (9 males and 12 females) provided comments, which were summarized in five themes. the first three themes were cited by males as follows: (1) omfs is inherently associated with tension and effort; (2) i feel passionate and content with the omfs career; (3) all genders are suitable for this profession, and nowadays we see more participation from female surgeons. the last two themes were cited by females as follows: (1) challenges for female surgeons are mainly children’s responsibilities and poor society acceptance of female surgeons; (2) more continuing education activities are desirable, however, there are some obstacles, such as lack of mentorship, costly courses, and the inability to obtain specialization abroad. discussion including a diverse, sustainable, and integrated workforce in the omfs specialty is expected to fulfill the professional outcomes of surgeons and the treatment needs of patients. as the profession of omfs continues to evolve, an essential aspect worthy of careful exploration is gender analysis of social and professional challenges faced by surgeons. this study utilized a gender-based approach to investigate social and professional career obstacles faced by omfss in four arabic countries as an example of conservative societies that have similar cultural backgrounds and social perspectives. understanding the complex interplay between gender, social dynamics, and professional experiences is crucial not only for advancing diversity but also for fostering an environment that allows all practitioners to thrive and contribute to the advancement of the profession. several studies have investigated career obstacles in the field of omfs globally and regionally.3,7,8,12 regionally, previous research estimated that males had higher career satisfaction, perceiving that it was the right career path.7 females, on the other hand, were confident that they had what it took to be more suitable than males for the omfs career;7 however, they cited specific social factors as special issue pathways of change table 1. socio-professional characteristics of participating oral and maxillofacial surgeons. socio-professional gender p characteristics of participants male (%) female (%) age (years) <40 38 (51.4) 36 (57.1) 0.606 ≥40 36 (48.6) 27 (42.9) marital status single 8 (10.8) 18 (28.6) 0.038* married 62 (83.8) 41 (65.1) divorced 4 (5.4) 3 (4.8) widow 0 (0.0) 1 (1.6) ever married single 12 (16.2) 22 (34.9) 0.017* married 62 (83.8) 41 (65.1) have children no 14 (18.9) 25 (39.7) 0.008* yes 60 (81.1) 38 (60.3) number of children no children 13 (17.6) 25 (39.7) 0.010* 1-2 children 21 (28.4) 17 (27.0) >2 children 40 (54.1) 21 (33.3) work country uic/umic 63 (85.1) 14 (22.2) 0.000* lic 11 (14.9) 49 (77.8) specialization country uic/umic 47 (63.5) 11 (17.5) 0.000* lic 27 (36.5) 52 (82.5) professional setting academic 23 (31.1) 27 (42.9) 0.258 public sector 31 (41.9) 25 (39.7) private sector 20 (27.0) 11 (17.5) years of experience <10 43 (58.1) 42 (66.7) 0.378 ≥10 31 (41.9) 21 (33.3) weekly procedures under ga ≤5 55 (74.3) 52 (82.5) 0.018* >6 19 (25.7) 11 (17.5) weekly number of out-patients <20 15 (20.3) 19 (30.2) 0.101 20-30 20 (27.0) 19 (30.2) 31-40 15 (20.3) 4 (6.3) >40 24 (32.4) 21 (33.3) *statistically significant difference; uic, upper-income country; umic, upper-middleincome country; lic, lower-income country; ga, general aesthesia. table 2. socio-professional factors perceived by participants to be limiting to their careers. socio-professional gender p career factors male (%) female (%) financial revenues not important 2 (2.7) 8 (12.7) 0.044* important 72 (97.3) 55 (87.3) peer appreciation not important 4 (5.4) 4 (6.3) 1.000 important 70 (94.6) 59 (93.7) uncooperative boss not important 10 (13.5) 7 (11.1) 0.797 important 64 (86.5) 56 (88.9) time for professional development not important 4 (5.4) 7 (11.1) 0.345 important 70 (94.6) 56 (88.9) patient flow not important 7 (9.5) 8 (12.7) 0.592 important 67 (90.5) 55 (87.3) patients’ respect not important 5 (6.8) 11 (17.5) 0.064 important 69 (93.2) 52 (82.5) medical illness not important 9 (12.2) 6 (9.5) 0.785 important 65 (87.8) 57 (90.5) physical complaints not important 8 (10.8) 11 (17.5) 0.324 important 66 (89.2) 52 (82.5) spouse appreciation not important 3 (4.1) 4 (6.3) 0.703 important 71 (95.9) 59 (93.7) spouse career not important 45 (60.8) 33 (52.4) 0.387 important 29 (39.2) 30 (47.6) family responsibilities not important 7 (9.5) 3 (4.8) 0.342 important 67 (90.5) 60 (95.2) *statistically significant difference. [healthcare in low-resource settings 2025;13(s1):13112] [page 91] obstacles to their career progress.8 analysis of the semi-professional characteristics of participants in this study gives an insight into their perceptions and sheds light on the current professional environment. similar to other studies conducted among surgeons in other disciplines, males were more likely to be married and to have larger families with more children.13 a study conducted in jordan, saudi arabia, and egypt estimated that a substantial proportion of female surgeons were either single or divorced, in contrast to most male surgeons who were married.8 a similar trend was identified in more modernized societies. most female surgeons want children; however, they often perceive workplace bias against pregnant female trainees. consequently, they postpone or refrain from having children, trying to mitigate the conflict with the surgical career.14 for those who manage to become pregnant during training years, a substantial proportion may experience miscarriage or other adverse pregnancy outcomes, which may increase the need for assisted reproductive therapy in the future.14,15 therefore, more studies are now calling for adopting policies that conform with the “basic human nature” of having a family even during surgical training years.12 other sociodemographic characteristics were noted in this study. participants from egypt were mostly females, contrary to other countries. this likely represents the current predominance of male surgeons in these countries, particularly in saudi arabia, where a large proportion of the omfs workforce is made up of non-national male surgeons. in contrast to egypt, the country’s large female surgical workforce may face various social constraints that prevent them from working abroad. special issue pathways of change table 3. socio-professional factors perceived by participants to influence the choice of females to pursue a career in oral and maxillofacial surgery. semi-professional gender p factors influencing omfs career choice of females male (%) female (%) lack of mentors not important 18 (24.3) 5 (7.9) 0.012* important 56 (75.7) 58 (92.1) long working hours not important 5 (6.8) 6 (9.5) 0.745 important 69 (93.2) 57 (90.5) physical exertion not important 12 (16.2) 19 (30.2) 0.066 important 62 (83.8) 44 (69.8) hostile work environment not important 17 (23.0) 16 (25.4) 0.842 important 57 (77.0) 47 (74.6) sexual harassment not important 31 (41.9) 26 (41.3) 1.000 important 43 (58.1) 37 (58.7) sexism by colleagues not important 31 (41.9) 23 (36.5) 0.600 important 43 (58.1) 40 (63.5) sexism by patients not important 27 (36.5) 24 (38.1) 0.861 important 47 (63.5) 39 (61.9) marriage not important 4 (5.4) 16 (25.4) 0.001* important 70 (94.6) 47 (74.6) having children not important 3 (4.1) 15 (23.8) 0.001* important 71 (95.9) 48 (76.2) society impact not important 15 (20.3) 20 (31.7) 0.169 important 59 (79.7) 43 (68.3) *statistically significant difference. figure 1. gender distribution of oral and maxillofacial surgeons in consulting youtube platform to enhance skills in various surgical disciplines. [page 92] [healthcare in low-resource settings 2025;13(s1):13112] table 4. perceptions of oral and maxillofacial surgeons on genderspecific leadership roles and female representation. perceptions gender p on leadership gender roles males females female surgeons in leadership positions none or fewer than males 71 (95.9) 50 (79.4) 0.003* equal or more than males 3 (4.1) 13 (20.6) males are better suited in leadership positions no 16 (21.6) 33 (52.4) 0.000* yes 58 (78.4) 30 (47.6) both genders can be equally leaders no 28 (37.8) 7 (11.1) 0.000* yes 46 (62.2) 56 (88.9) females are under-represented in omf surgery no 32 (43.2) 17 (27.0) 0.052 yes 42 (56.8) 46 (73.0) *statistically significant differences. several potential social and professional obstacles were examined in this study. among these, “financial revenues” stands out as the only obstacle that showed a significant difference between genders, with males being more concerned about this aspect. this is further affirmed by the fact that male surgeons, in this study, perform a higher number of financially rewarding procedures, such as procedures conducted under general anesthesia. this may highlight the social stereotype of the arab male as being the “provider” and “breadwinner” for the family. it may also indicate that patients and/or institutions consider male surgeons more experienced and trustworthy to perform more complicated surgical procedures.16 however, it should be noted that several studies reported interesting findings linking better surgical outcomes with the female gender. female surgeons were more likely to have longer operation times;17 however, they demonstrated more favourable surgical outcomes.18 this was explained by the inherent properties of women in using a patient-centered approach in decisionmaking, being selective of their patients for surgery, and being more willing to collaborate.19 the above observations are consistent with the findings of this study, which showed that “family responsibilities” was the most highly cited career obstacle among females. however, when asked about the factors that influence their career choice, the most highly cited factor among females was “lack of mentors”. this, together with their preference for obtaining specialization abroad, confirms the diligent and, probably, conscientious approach of females, who were more concerned about prospects of professional development and mentor availability. role models or mentors have a significant influence on female surgical career choice.20 female mentors, in particular, have a significant role in motivating female trainees to move forward and overcome obstacles in the profession.21,22 participating male surgeons in this study believed that “marriage” and “having children” are the most important factors that influence female surgeons’ career choice. these perceptions seem to be consistent with the current views in conservative societies, which consider that women, regardless of their career stage, are expected to fulfill society’s expectations of getting married to establish a family and have children. work-family balance is important for surgeons, irrespective of gender and geographic setting.23 it should be noted that achieving this balance is not only the responsibility of surgeons themselves but also institutions and the healthcare system in general. examples of such required support include the provision of maternity/paternity leave, childcare facilities, allowing time for breastfeeding, and improving access to medical care.24 there were also significant differences between males and females in their views regarding leadership roles. significantly more males perceived that females are not fit for leadership, contrary to females who perceived that “both genders can be equal leaders”. the lack of confidence in assuming leadership roles by females should be further investigated to explore the reasons behind these perceptions. it should be noted that lower participation of females in leadership positions is reported in many professions, mainly because leaders are seen to demonstrate masculine traits.25–27 within the context of omfs, however, female and male surgeons were in agreement that there are no physical or mechanical disadvantages associated with female gender.28 specific strategies may be implemented to assist women in leadership, such as identifying potential leaders early on, establishing mentorship programs, and training men and women in management to provide support.29–31 it was important in this study to assess the surgeons’ continuous education activities using popular platforms32,33 such as youtube. almost seven in ten surgeons stated that they refer to youtube for professional development. males and females were comparable in referring mostly to aesthetic surgeryand oncologyrelated content. these two disciplines are highly advanced; therefore, training years may be insufficient for obtaining the required competencies. this highlights the importance of revising surgical training curricula to accommodate advanced competencies. more recently, several oral, head, and neck oncologic and reconstructive surgery fellowships were established in an effort to increase trainees’ exposure to ablative and reconstructive head and neck surgery.34 this experience can be replicated in other countries, particularly middle eastern countries, where the vulnerable political atmosphere and armed conflicts increase the demand for reconstructive surgery, including microvascular reconstruction. the study has limitations represented by the convenient sampling method and low participation rate, particularly from saudi arabia. two rounds of data collection were performed to minimize this deficiency. future studies should recruit larger and more randomized samples to improve representativeness and generalizability of results. while it was not possible to accurately determine the number of omfss practicing in the participating countries, the number of participants exceeded that of previous relevant studies conducted in this geographic area. future longitudinal studies may be conducted to track career progression and advancement. other recommendations include employing qualitative methods that explore personal experiences, which could complement and enrich the quantitative data. conclusions male oral and maxillofacial surgeons in the arabic region show approval of female participation in the surgical career; however, their uncertainty towards female contribution to leadership roles should be assessed further in future studies. factors influencing females’ decision to delay starting a family should be addressed, particularly for trainees. policies that enhance flexibility in maternity leave and childcare facilities are recommended. the work environment should maintain enough dedicated mentors and establish reconstructive and head and neck oncology fellowships to advance oral and maxillofacial surgery in the arabic region. references 1. busa i, nagraj s. women as a driver to address gaps in the global surgical workforce. hum resour health 2023;21:22. 2. roter dl, hall ja. physician gender and patient-centered communication: a critical review of empirical research. annu rev public health 2004;25:497-519. 3. al ryalat n, ryalat s, al-abdalla m, et al. women in maxillofacial surgery and otolaryngology; career obstacles and success factors. j craniofac surg 2021;32:874-7. 4. dar-odeh ns, aleithan fa, alnazzawi aa, et al. factors affecting oral health determinants in female university students: a cross-sectional survey in saudi arabia. int j adolesc med health 2020;32. 5. slomski a. female patients fare worse with male surgeons. jama 2022;327:416. 6. carnevale m, phair j, batarseh p, et al. gender disparities in academic vascular surgeons. j vasc surg 2020;72:1445-50. 7. abu-hammad s, elsayed sa, nourwali i, et al. influence of gender on career expectations of oral and maxillofacial surge special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13112] [page 93] ons. j craniomaxillofac surg 2020;48:458-62. 8. dar-odeh n, elsayed sa, nourwali i, et al. social factors as career obstacles for female oral and maxillofacial surgeons in three middle eastern countries. int j oral maxillofac surg 2019;48:1504-8. 9. williams ga, jacob g, rakovac i, et al. health professional mobility in the who european region and the who global code of practice: data from the joint oecd/ eurostat/who-europe questionnaire. eur j public health 2020;30:iv5–11. 10. haviland c, moe js. the diversity bonus in oral and maxillofacial surgery. oral maxillofac surg clin north am 2021;33:505-13. 11. rivera jc, hauc sc, juan hy, et al. assessment of sex diversity among craniofacial academic faculty. j craniofac surg 2023;34:202-5. 12. hughes pj. gender issues and oral and maxillofacial surgery advanced education program accreditation. oral maxillofac surg clin north am 2021;33:429-33. 13. hobday sb, armache m, frost as, et al. gender differences among head and neck microvascular reconstructive surgeons. otolaryngol head neck surg 2023;169:1143-53. 14. kontoghiorghe c, morgan c, eastwood d, mcnally s. uk pregnancy in orthopaedics (uk-pop): a cross-sectional study of uk female trauma and orthopaedic surgeons and their experiences of pregnancy. bone jt open 2023;4:970-9. 15. stefanou aj. fertility and pregnancy: how do these affect family planning and surgeon health? clin colon rectal surg 2023;36:327-32. 16. alsamhori jf, rayyan r, hammouri m, et al. factors influencing gender preference towards surgeons among jordanian adults: an investigation of healthcare bias. sci rep 2023;13. 17. blohm m, sandblom g, enochsson l, österberg j. differences in cholecystectomy outcomes and operating time between male and female surgeons in sweden. jama surg 2023;158:1168-75. 18. wallis cjd, jerath a, aminoltejari k, et al. surgeon sex and long-term postoperative outcomes among patients undergoing common surgeries. jama surg 2023;158:1185-94. 19. almquist m. are women better surgeons than men? jama surg 2023;158:1175. 20. schizas d, papapanou m, routsi e, et al. career barriers for women in surgery. surgeon 2022;20:275-83. 21. xu al, humbyrd cj, de mattos cbr, laporte d. the importance of perceived barriers to women entering and advancing in orthopaedic surgery in the us and beyond. world j surg 2023;47:3051-9. 22. wonda o, irab s, tingginehe r. factors related to the activeness of posyandu cadres in the working area of the yamo health center, puncak jaya regency. formosa j sci technol 2024;3:1965-80. 23. wahjuningdiah ed, paskarini i. the relationship between family support and work-family balance among surabaya health facility security center employees during the covid-19 pandemic. indones j occup saf heal 2022;11:454-62. 24. alkhawashki s, alasiri r, ruetalo m, maggi j. the double whammy: advanced medical training and parenting. medicine (united states) 2024;103:e36697. 25. tremmel m, wahl i. gender stereotypes in leadership: analyzing the content and evaluation of stereotypes about typical, male, and female leaders. front psychol 2023;14:1034258. 26. sunaryo s, rahardian r, risgiyanti, et al. leader-member exchange and glass ceiling: the effects on career satisfaction and work engagement. cogent bus manag 2024;11. 27. yuwono h, gunawan dr, eliyana a, et al. transformational leaders’ approach to overcapacity: a study in correctional institutions. plos one 2022;17:e0276792. 28. bogardus aj, neas br, sullivan sm. practice differences between male and female oral and maxillofacial surgeons: survey results and analysis. j oral maxillofac surg 1999;57:1239-47. 29. novotney a. women leaders make work better: here’s the science behind how to promote them [internet]. 2024 [cited 2024 dec 3]. available from: https://www.apa.org/ topics/women-girls/female-leaders-make-work-better 30. adikoeswanto d, nurjanah s, mukhtar s, et al. fostering voice behavior in correctional institutions: investigating the role of organizational support and proactive personality. plos one 2024;19:e0303768. 31. saputra dee, rahma vm, eliyana a, et al. do system quality and information quality affect job performance? the mediation role of users’ perceptions. plos one 2023;18:e0285293. 32. harzif ak, rahman mn, mulawardhana p, et al. incision elearning program as a useful teaching tool to enhance surgeons’ knowledge and skills: an indonesian multi-center crosssectional pilot study. f1000research 2018;7:1888. 33. gharaei n, ismail w, grosan c, hendradi r. optimizing the setting of medical interactive rehabilitation assistant platform to improve the performance of the patients: a case study. artif intell med 2021;120:102151. 34. kademani d, woo b, ward b, et al. oral/head and neck oncologic and reconstructive surgery fellowship training programs: transformation of the specialty from 2005 to 2015: report from the aaoms committee on maxillofacial oncology and reconstructive surgery. j oral maxillofac surg 2016;74:21237. special issue pathways of change [page 94] [healthcare in low-resource settings 2025;13(s1):13112] hrev_master healthcare in low-resource settings 2025; volume 13:13714 quality of life of burn patients after burn sohieab abu jheisheh,1 mohammad qtait2 1hebron governmental hospital nursing director, hebron; 2nursing college, palestine polytechnic university, hebron, palestine abstract burn injuries are among the most traumatic types of injuries, often resulting in long-term physical, psychological, and social consequences. understanding the quality of life (qol) of burn patients is essential for delivering comprehensive care and effective rehabilitation. this study aimed to assess the health-related quality of life (hrqol) of burn patients and to examine the relationship between qol domains and patients’ demographic, psychological, and clinical characteristics. a descriptive cross-sectional study was conducted among 150 burn patients attending several hospitals in palestine. data were collected using the world health organization quality of life questionnaire (whoqolbref), which measures four domains: physical health, psychological health, social relationships, and environment. structured interviews were used for data collection, and statistical analysis was performed using spss software. the sample consisted of 65% males and 35% females, with 66% aged between 30 and 49 years. the most affected areas were the lower limbs (88%) and upper limbs (80%), with varying burn depths and total body surface area (tbsa) percentages. patients reported low levels of satisfaction in areas such as happiness, healthcare services, and dietary adherence. moderate impairments were observed across all qol domains: physical (mean = 3.20), role (3.05), cognitive (3.18), social (3.35), and emotional (3.45). a statistically significant correlation was found between tbsa and the physical (p=0.033) and cognitive (p=0.035) domains. however, age showed no significant correlation with any qol domain. burn injuries significantly affect multiple aspects of patients’ quality of life, particularly the physical and emotional domains. the extent of burn injury (tbsa) plays a crucial role in determining the level of impairment. these findings emphasize the need for multidisciplinary rehabilitation programs focusing on physical recovery, psychological support, and social reintegration. introduction burn injuries are a major cause of trauma worldwide, with profound and lasting effects on survivors’ physical, emotional, and social well-being.¹ understanding the quality of life (qol) of burn patients after injury is essential, as it offers insight into their comprehensive needs and guides effective rehabilitation strategies to enhance recovery and reintegration into society.² burn scars are often irregular in shape, and survivors must adapt to changes in their physical appearance and self-image. in addition, the traumatic nature of burn events and the associated painful treatments can trigger various psychopathological responses.³ although the qol of burn survivors is initially lower than that of the general population, it often improves over time.4 however, severe burns may lead to a range of long-term complications, including scarring, contractures, muscle weakness, itching, pain, sleep disturbances, body image dissatisfaction, and psychological challenges.5 the psychological burden is significant, with many burn survivors experiencing distress even in the absence of diagnosable psychiatric disorders.6 the international council of nurses has identified health as a core theme in nursing research – encompassing health promotion, chronic condition management, enhancing qol, and caring for individuals undergoing significant health-related changes.7 in palestine,8 conducted the first study to describe the epidemiology and outcomes of burn patients at a major burn center in the south west bank (2016-2017). their findings highlighted the urgent need for more effective prevention efforts, especially targeting children under 14, females, and incidents occurring during winter or involving scalds. they also recommended tailored precorrespondence: mohammad qtait, nursing college, palestine polytechnic university, hebron, palestine. tel.: 0599824295. e-mail: mohamadtaha98@hotmail.com key words: burn injuries, quality of life, tbsa, hrqol, patient satisfaction, psychological impact, palestine. contribution: mq, conceptualization, project management, resources, software, supervision, validation, writing original draft, proofreading and editing; ajs, data curation, formal analysis, research, methodology. ethical approval and consent to participate: the project was reviewed and approved by the army human research protections office and determined to be research not involving human subjects. ethics approval was obtained from the university ethics review committee (ppu.nur48/01/24). informed consent was obtained from each participant with an assurance of anonymity and confidentiality. declaration of conflicting interests: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. funding: the authors received no financial support for the research, authorship, and/or publication of this article. data availability statement: data for this study would be available upon reasonable request from the principal investigator acknowledgements: we acknowledge the midwives who participated in the study. received: 8 february 2025. accepted: 13 june 2025. early access: 29 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13714 doi:10.4081/hls.2025.13714 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13714] [page 231] vention and treatment strategies, with attention to risk factors such as full-thickness burns, larger total body surface area (tbsa) involvement, older age, and the number of required surgeries. the role of socioeconomic status in health outcomes is well documented; individuals from lower socioeconomic backgrounds tend to experience worse health outcomes and reduced qol.9 therefore, medical care should aim not only to treat illness and alleviate symptoms but also to support and enhance patients’ overall quality of life. burn rehabilitation begins on the first day of treatment and continues throughout the care process, including during intensive care. active surgical management of wounds and scars, combined with physiotherapy and occupational therapy, is critical and often extends beyond hospital discharge. these interventions are essential for facilitating the patient’s return to normal life. concurrently, addressing psychosocial issues is vital to identify and manage comorbidities such as post-traumatic stress disorder (ptsd), mood disorders, substance use disorders, and other psychological conditions that may hinder recovery.10 the qol of burn survivors is influenced by numerous factors, including their psychological and physical response to injury, the timing and quality of treatment, support from family and friends, nutritional status, and the effectiveness of physical, occupational, and psychological therapies.¹¹ the concept of “quality of life” encompasses a broad range of dimensions, including physical and mental well-being, autonomy, social relationships, personal values, and interaction with the environment. it evaluates the effects of illness and disability on daily function, behavior, perceived health, and overall life satisfaction.¹¹ materials and methods study design and setting this study employed a descriptive cross-sectional design and was conducted at a tertiary care hospital in palestine. patients were recruited from the burns ward during their hospitalization and were subsequently assessed at a three-month follow-up in the burns outpatient department. the aim was to evaluate the quality of life (qol) of burn injury patients at two distinct time points: during initial hospitalization and three months post-discharge. sample and participants the study included 100 patients with varying degrees of burn injuries. inclusion criteria required participants to be in stable physical and mental health and free from chronic conditions such as hypertension, diabetes, cancer, asthma, or epilepsy. patients with severe cognitive impairment or those unable to provide informed consent were excluded. only individuals who met the inclusion criteria and provided written informed consent were included in the study. data collection data were collected in two stages. initial hospitalization during hospitalization, trained researchers collected sociodemographic and clinical data using a structured data sheet. variables collected included age, gender, marital status, educational level, occupation, place of residence, burn site and severity, and the percentage of total body surface area (tbsa) affected. burn severity was assessed using the “rule of nines,” a standardized method for estimating the tbsa affected. three-month follow-up at the three-month follow-up, participants attended the burns outpatient department for a face-to-face interview. during this session, the whoqol-bref (hindi version) quality of life questionnaire was administered. this tool assesses four domains: physical health, psychological well-being, social relationships, and environmental conditions. higher scores indicate better perceived quality of life. only patients who attended the follow-up were included in this stage of data collection. to ensure consistency and reduce interviewer bias, all interviews were conducted by the same trained personnel familiar with the study protocol. instruments whoqol-bref (hindi version) the whoqol-bref, developed by the world health organization, is a widely used instrument for assessing quality of life across multiple domains. in this study, it was administered at the three-month follow-up. the tool comprises 26 items measuring four domains: physical health, psychological well-being, social relationships, and environmental conditions. each domain is scored positively, with higher scores reflecting better quality of life. sociodemographic and clinical data sheet a structured data sheet was used during initial hospitalization to collect information on sociodemographic and clinical variables, including age, gender, marital status, education level, occupation, place of residence, and burn characteristics. burn severity was measured using the “rule of nines,” a clinically accepted method for estimating tbsa affected by burns. validity and reliability of tools the whoqol-bref (hindi version) has demonstrated good internal consistency, with cronbach’s alpha values around 0.87. its construct and criterion validity have been confirmed in multiple studies across different languages and populations. the hindi version used in this study has shown reliable psychometric properties and is suitable for diverse cultural and health backgrounds. the “rule of nines” is a standardized and widely accepted tool in clinical practice for estimating burn severity and has been validated through extensive use in burn care assessments. ethical considerations ethical approval was obtained from the hospital’s ethics committee in accordance with established clinical research standards. all participants received comprehensive information regarding the study’s purpose, procedures, and potential risks. written informed consent was obtained prior to participation. participants were assured that their involvement was voluntary, their data would remain confidential, and they could withdraw from the study at any time without consequences. data analysis data were analyzed using spss version 23. descriptive statistics (means, standard deviations, frequencies, and percentages) were used to summarize participant characteristics. inferential statistics, including correlation analysis, were conducted to explore associations between qol scores and variables such as burn severity, age, and sociodemographic characteristics. a p-value of <0.05 was considered statistically significant. article [page 232] [healthcare in low-resource settings 2024;12:13714] results the findings of this study are presented in three main sections. the first section outlines the general characteristics and health status of the study sample. the second section presents the healthrelated quality of life (qol) scores of the participants, and the third section offers the results of the correlational analysis between the qol findings and the biological, psychological, and socioeconomic characteristics of the participants. demographic and socioeconomic characteristics the study sample consisted of 100 participants, with 35% females and 65% males. this distribution reflects a slight predominance of male patients, though this was due to random selection during questionnaire distribution. the age distribution of the participants was as follows: 24% were aged 20-29 years, 66% were aged 30-49 years, and 10% were aged 50 years or older. regarding marital status, 75% of participants were married, and 25% were single. educationally, 75% of participants had completed at least secondary school education, with 50% having achieved a bachelor’s degree or higher. geographically, 49% of participants lived in rural areas, and 51% lived in urban areas. regarding occupation, 24% of participants were students, 35% were housewives or unemployed, 20% were employed, and 21% worked in manual labor (table 1). burn injury characteristics the majority of burn injuries in this sample affected the lower limbs (88%), followed by upper limbs (80%), abdomen (30%), back (30%), chest (25%), and face/neck (20%). regarding the depth of the burns, 33% of patients had first and second-degree burns, 32% had second and third-degree burns, and 35% had burns of varying degrees. in terms of total body surface area (tbsa), 49.3% of participants had a tbsa of 5-10%, 24.7% had a tbsa of 16-25%, and 10% had a tbsa higher than 26%. the majority of participants had tbsa less than 35% (table 2). the result from these questions indicates a low level of satisfaction in patients’ burn (table 3). most of them don’t feel happy in their lives and are not satisfied with their healthcare providers; also, they don’t commit to a diet, but on the other hand, they do commit to treatment in a high percentage and attend follow-ups. qol domains & gqol all functional scales were calculated to be on 0-100 scale in which the higher score is calculated as follows. article table 1. demographic variable for the study. demographic variable n=100 percent (%)x age group 20-29 years 24 24 30-39 years 36 36 40-49 years 30 30 50+ years 10 10 gender male 35 35 female 65 65 marital status single 25 25 married 75 75 level of education school 25 25 diploma 25 25 bachelor's or more 50 50 area of residence rural 49 49 urban 51 51 occupation student 24 24 housewife/unemployed 35 35 employee 20 20 worker 21 21 table 2. information on the burn injury. parameter n=100 percentage (%) site of burn injury face and head, neck 20 20 chest 25 25 back 30 30 abdomen 30 30 upper limbs 80 80 lower limbs 88 88 depth degree of burn first and second degree 33 33 second and third degree 32 32 different degree 35 35 total body surface area less than 5 5 5 05-10 29 29 16-25 30 30 26-35 25 33 36-45 or more 11 11 [healthcare in low-resource settings 2024;12:13714] [page 233] table 3. questions to test level of satisfaction with the patients. question strongly disagree disagree (%) agree (%) strongly agree (%) are you happy in your life 18.4 25.3 35.4 20.9 are you satisfied about your relationships with people? 9.5 26.6 40.5 23.4 are you suffering from lack of adaptation to changes in your life 13.3 20.3 27.2 39.2 are you satisfied with the health care provided to you? 12 26.6 39.9 21.5 are committed to the treatment prescribed by a physician? 10.1 22.2 31 36.7 are you committed to diet prescribed to you by a doctor 20.9 31 22.2 25.9 are you go to follow up 6.3 27.2 38.6 27.8 qol domains and global quality of life (gqol) all functional scales were transformed to a 0-100 scale, where higher scores indicate better functioning. as illustrated in figure 1, higher scores represent higher levels of function. following previous studies, a 33% cut-off point was used to categorize the scale into different levels. the findings from table 4 reveal that burn patients experience moderate impairment across various qol domains, including physical, role, social, cognitive, and emotional functioning. physical difficulties such as fatigue and reduced mobility were commonly reported. role functioning was affected by limitations in work and leisure activities. social challenges included strained family relationships and financial stress, while cognitive issues like poor concentration were also evident. emotional disturbances such as sadness, anxiety, and feelings of burden were prevalent. these results highlight the multifaceted impact of burn injuries on patients’ lives, emphasizing the need for comprehensive rehabilitation and psychosocial support. in table 5 the correlation analysis revealed statistically significant associations between total body surface area (tbsa) and both the physical (p=0.033) and cognitive (p=0.035) domains of quality of life. this suggests that as tbsa increases, impairments in physical functioning and cognitive ability become more pronounced. however, no significant correlations were found between tbsa and the social (p=0.089) or emotional (p=0.360) domains. additionally, age did not show any significant correlation with any qol domain. these findings underscore the importance of targeted interventions for patients with larger burn areas, particularly in addressing physical and cognitive rehabilitation needs. article table 4. physical function domain. domain question never freq a lot freq mean score total domain score interpretation (%) (%) (%) physical difficulty with heavy physical work/effort (tired)? 57 (36.1) 101 (63.9) 3.086 trouble walking for a long time? 48 (30.4) 110 (69.6) 3.290 41 moderate trouble walking for a short period? 97 (61.4) 61 (38.6) 2.322 need to stay in bed/in chair during the day? 95 (60.1) 63 (39.9) 2.365 role restricted/limited in daily work? 75 (47.5) 83 (52.5) 2.623 suffering from inability to work? 72 (45.6) 86 (54.4) 2.914 43 moderate limited in hobbies or leisure activities? 62 (39.2) 96 (60.8) 2.322 fewer work hours due to disease? 59 (37.3) 99 (62.7) 3.010 social illness/treatment affected social life? 84 (53.2) 74 (46.8) 2.376 relationship with family affected? 113 (71.5) 44 (28.5) 1.699 suffer from social/family problems? 118 (74.4) 39 (25.6) 1.656 65 moderate suffer from financial problems? 85 (53.8) 73 (46.2) 2.451 cognitive suffer from inability to concentrate? 94 (59.5) 64 (40.5) 2.333 suffer from inability to think? 105 (66.5) 53 (33.5) 2.011 suffer from inability to read/write? 89 (56.3) 68 (43.7) 2.387 59 moderate emotional feel bored or repressed? 71 (44.9) 87 (55.1) 2.946 feel sad? 82 (51.9) 76 (48.1) 2.624 feel nervousness? 72 (45.6) 86 (54.4) 2.925 feel anxious/tense? 66 (41.8) 92 (58.2) 2.892 feel like a burden to others? 97 (61.4) 61 (38.6) 2.258 42% moderate table 5. correlation between total body surface area (tbsa), age, and quality of life (qol) domains. variable physical (p) cognitive (p) social (p) emotional (p) total body surface area 0.033 0.035 0.089 0.360 age 0.910 0.971 0.501 0.149 figure 1. determination of the optimal cut-off point using receiver operating characteristic (roc) curve analysis. [page 234] [healthcare in low-resource settings 2024;12:13714] discussion this study assessed the qol among burn patients and explored associations with demographic, clinical, and psychosocial variables. the findings indicate a moderate impairment across multiple qol domains – physical, role, cognitive, social, and emotional functioning – highlighting the significant burden that burn injuries place on individuals’ lives. the results are consistent with prior literature, emphasizing the multifaceted impact of burn injuries on recovery and long-term wellbeing. the sample consisted of 100 patients, with a higher proportion of males (65%) than females (35%). this gender disparity reflects regional trends reported in similar settings, where males are more often exposed to occupational hazards resulting in burns.12 the age group 30-49 years was most prevalent, aligning with the workingage population, which may compound the psychological and socioeconomic consequences of burn injuries due to loss of productivity and financial instability.13 most participants were married (75%) and had attained at least secondary education, with 50% holding a bachelor’s degree. education level has been positively associated with better health literacy, which may influence treatment compliance and recovery.10 nearly equal distribution between rural and urban residency suggests a broad geographic representation, though access to specialized burn care may vary by location, potentially affecting longterm qol.14.15 the burn sites were predominantly the lower (88%) and upper limbs (80%), followed by torso and facial areas. this distribution reflects common domestic and occupational injury patterns. burns affecting visible and functional parts such as the limbs and face often result in both physical limitations and psychosocial distress due to disfigurement or mobility issues.³0 tbsa analysis showed that the majority of patients had burns covering 5-25% of their body, yet even this moderate extent significantly influenced qol. depth of burn injury also varied, with approximately one-third of patients in each category – first/second-degree, second/thirddegree, and mixed. previous studies confirm that burn depth correlates with pain severity, healing time, and scarring, which in turn affect psychological outcomes and qol.16,17 our findings support these observations, as patients with more extensive and deeper burns demonstrated lower scores in physical and cognitive functioning. from result revealed that a substantial proportion of patients reported dissatisfaction with life, social relationships, and healthcare services. notably, only 18.4% of participants reported happiness in life, and just over 20% were satisfied with their healthcare. such dissatisfaction may reflect unmet needs in pain management, psychological support, and post-discharge rehabilitation, which are common challenges in burn care systems in developing countries.18,19 despite low satisfaction, a relatively high percentage (36.7%) reported adherence to physician-prescribed treatments, and 27.8% attended follow-up visits. this dichotomy suggests that while patients may not be content with care quality, they recognize the necessity of medical adherence for recovery. nevertheless, dietary compliance was poor (only 25.9%), indicating a potential area for targeted education and nutritional counseling. these findings align with previous research showing that patient satisfaction is a critical predictor of both qol and treatment adherence.20.21.22 across all five qol domains – physical, role, social, cognitive, and emotional functioning – the study found moderate impairment, with average scores ranging from 41% to 65%. physical functioning patients reported substantial difficulty with activities requiring physical exertion, such as walking or heavy work. this finding is consistent with the literature, which underscores prolonged physical disability in burn survivors due to contractures, fatigue, and chronic pain.23.24 mean scores above 3.0 on several physical items suggest functional limitations persist even months post-injury. role functioning patients reported significant impairment in daily work and leisure activities. the highest reported difficulty was in maintaining consistent work hours, which directly impacts economic stability. this supports findings 25 who noted that return-to-work rates are significantly delayed in burn survivors, particularly those with visible scarring or persistent pain. social functioning despite moderate scores, patients expressed notable concerns about strained family relationships and financial hardship. burn survivors often experience social stigma, isolation, and changes in family dynamics, especially in patriarchal or conservative societies.24 these challenges highlight the need for psychosocial rehabilitation and community support programs. cognitive functioning many participants reported difficulties concentrating, thinking clearly, or reading and writing. such cognitive impairments are not uncommon post-burn and may be linked to pain, emotional distress, sleep disruption, or medication side effects.²� these findings suggest the need for comprehensive neuropsychological evaluations during follow-up. emotional functioning the emotional burden was evident, with over half of the patients experiencing sadness, nervousness, and anxiety. the psychological toll of burn injuries has been well-documented, with a high prevalence of depression, ptsd, and suicidal ideation among survivors.26-28 however, lower scores on feelings of burden suggest a degree of resilience or social support among some patients. correlation analysis correlation analysis showed a significant relationship between tbsa and both physical and cognitive functioning, indicating that more extensive burns lead to greater disability in these areas (p<0.05). however, no significant association was found between tbsa and emotional or social domains, which suggests these aspects may be more influenced by personal coping strategies, social support, or psychological resilience than by the physical severity of the burn. age did not show any significant correlation with qol domains, contradicting some earlier studies that suggest older patients often fare worse in emotional and physical recovery.27 this discrepancy could be due to the age distribution in our sample, which skewed toward younger, working-age adults. implications and recommendations the results underscore the importance of holistic burn care, addressing not only wound healing but also psychological, social, and functional rehabilitation. mental health support, peer counseling, vocational training, and family therapy should be integrated into post-burn care programs. furthermore, improving patientprovider communication and satisfaction with services can enhance treatment adherence and overall outcomes. future article [healthcare in low-resource settings 2024;12:13714] [page 235] research should employ longitudinal designs to track qol changes over time and evaluate the effectiveness of multidisciplinary interventions. expanding sample sizes and including patients from diverse healthcare settings may also improve generalizability. references 1. smith woolard a, hill nt, mcqueen m, et al. the psychological impact of paediatric burn injuries: a systematic review. bmc public health 2021;21:2281. 2. zhou x, wang y, liu z. quality of life after burn injury: a systematic review. burns 2020;46:1050-62. 3. johnson t, lee r. the psychological consequences of severe burns: a longitudinal study. j health psychol 2022;27:432-47. 4. bennett c, thompson r, miller d. recovery trajectories in burn patients: a review of qol studies. burns res j 2023;40:150-67. 5. esselman pc, thombs bd, magyar-russell g, fauerbach ja. burn rehabilitation: state of the science. am j phys med rehabil 2006;85:383–413. 6. cleary m, visentin dc, west s, kornhaber r. the importance of mental health considerations for critical care burns patients. j adv nurs 2018;74:1233-35. 7. polit df, beck ct. 2005. nursing research: a tool for action (7th ed.). lippincott williams & wilkins. 8. qtait mt, alekel k. prevalence and epidemiology of burns in hebron, palestine. sci j clin res dermatol 2018;4:1-5. 9. qtait m. causes of burn injury in children for preschool. j eval clin pract 2025;31:e70054. 10. pappa e, kontodimopoulos n, papadopoulos aa, et al. assessing the socio-economic and demographic impact on health-related quality of life: evidence from greece. int j public health 2009;54:241-9. 11. dyster-aas j, kildal m, willebrand m. return to work and health-related quality of life after burn injury. j rehabil med 2007;39:49-55. 12. hunt jl, arnoldo bd, purdue gf. total burn care. 7th ed. london: wb saunders; 2012. chapter 4—prevention of burn injuries, pp. 47–55. 13. kapur d, gupta ms, ramesh s. clinical outcomes and rehabilitation in patients with burn injuries: a review of the literature. burn j 2023;25:124-30. 14. besen a, concha m, rodríguez a. physical and psychological outcomes in burn survivors: the role of rehabilitation. j burn care res 2022;43:890-5. 15. cole dg, stein mt, williams a. impact of burn injury on aging patients: a review of treatment strategies and outcomes. j burn trauma 2022;11:132-8. 16. todorov am, huber d, clark m. gender differences in burn injury recovery and psychosocial outcomes. burns 2020;46: 1629-35. 17. jones rm, thompson al, williams j. socioeconomic factors influencing burn injury recovery: the role of social support and coping strategies. j trauma acute care surg 2021;91:7628 18. van loey ne, hamming jf, de jong a. psychological care for burn victims: evidence-based practices. int j burn care 2023;32:105-13. 19. leblebici b, adam m, bağiş s, et al. quality of life after burn injury: the impact of joint contracture. j burn care res 2015;27:864–8. 20. misra a, thussu d, agrawal k. assessment of psychological status and quality of life in patients with facial burn scars. indian j burn 2012;20:57–61. 21. qtait s. quality of life for palestinian renal failure patients underwent hemodialysis. j pharm alternative med 2016;11:1– 11. 22. paggiaro ao, paggiaro pb, fernandes ra, et al. posttraumatic stress disorder in burn patient: a systematic review. j plastic reconstuct aesthetic surg 2022;75:1586-95. 23. ferreira dc, vieira i, pedro mi, et al. patient satisfaction with healthcare services and the techniques used for its assessment: a systematic literature review and a bibliometric analysis. inhealthcare 2023;11: 639. 24. khan ma, ross e, crijns tj, et al social factors and injury characteristics associated with the development of perceived injury stigma among burn survivors. burns 2021;47:692-7. 25. botman m, hendriks tc, de haas le, et al. access to burn care in low-and middle-income countries. j burn care research 2022;43:657-64. 26. rehan m, ain qt, iqbal t. liquefied petroleum gas cylinder burns: a need of hour for regulations at the national level. burns 2023;49:487-88. 27. mahmoud n, rencken ca, allorto n, harrison ad, mcgarvey st, aluisio ar. factors associated with adherence to follow-up care after burn injuries. burns 2021;47:240-8. 28. moi kazis le, sager a, bailey hm, et al. physical rehabilitation and mental health care after burn injury: a multinational study. j burn care res 2022;43:868-79. article [page 236] [healthcare in low-resource settings 2024;12:13714] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13434 abstract hypertension is a prevalent chronic condition that requires effective self-management strategies for optimal control and complications prevention. self-management interventions have become a crucial component in the management of hypertension. therefore, this review aimed to determine effective self-management strategies for hypertensive patients. articles were searched from four databases, namely science direct, ebsco (medline), proquest, pubmed and sage journals based on prisma guidelines. the search included articles published in english between 2013 and 2022. a key term search strategy was adopted using “self-management interventions”, “nursing interventions”, “experimental study” and “hypertensive patients” to identify relevant studies. the results showed that self-management interventions have been proven to have positive effects on various aspects of hypertension self-management, including blood pressure monitoring, disease knowledge, medication adherence, and lifestyle modifications. these interventions can be delivered through technology-based platforms. moreover, there are different types of self-management interventions for hypertensive patients, including individual and group approaches, the use of technology, nursing theory, and interventions based on the cultural aspects of patients. to conclude, as professionals, nurses should be able to determine which self-management strategies are suitable for the conditions and requirements of patients. introduction hypertension has become a significant contributor to the global burden of disease and is recognized as a primary risk factor for cardiovascular disease.1,2 the majority (two-thirds) of the estimated 1.28 billion adults aged 30-79 who suffer from hypertension reside in lowand middle-income countries.2 furthermore, approximately 46% of adults with hypertension are oblivious to the condition.3 the condition has a substantial influence on healthrelated quality of life, mortality, hospitalization, and psychological well-being.4,5 it is essential for nurses to develop comprehensive management strategies with an understanding of the complications.6 self-management is crucial to hypertension control,7 has a substantial effect,8 and may contribute to multiple facets of patients’ condition.8 moreover, effective approaches had a beneficial effect by lowering blood pressure,8,9 and enhancing quality of life.10 self-management of hypertension included monitoring blood pressure, reducing cigarette and alcohol consumption, consuming a low-salt diet, maintaining a healthy weight through regular exercise, and medication adherence to prevent complications.11 the key to maintaining blood pressure within the normal range is compliance with effective and efficient self-management.12 however, hypertensive patients who implemented self-management required motivation and support from family members or relatives for follow-up, evaluation, and monitoring.13 this review aimed to determine the effective self-management strategies for hypertensive patients. materials and methods the study design was a scoping review, and articles were sourced from five databases, namely ebsco (medline), pubmed, sage journals, proquest, and science direct based on prisma guidelines. the search included articles published between 2013 and 2022, and was carried out using keywords such as “self-management interventions”, “nursing interventions”, “hypertensive patients”, and “experimental study” with boolean methods including “and”, and “or” to find relevant articles that match the purpose of writing a review. furthermore, the search focused on reputable articles, namely original, full-text, and those published in english language. the qualifying requirements for this study do not include review articles, gray literature, papers, book chapters, personal opinions, or non-scientific publications. the inclusion and exclusion criteria were defined using the picos method (population, interventions, comparison, outcome and study design), with modifications made to fit the objective (table 1). figure 1 shows the selection results in a flowchart using the prisma guidelines. following a search, 596 items were retrieved from proquest, ebsco (medline), science direct, sage journals and pubmed. the retrieved articles were subjected to a duplicate selection process using the endnote 20 program, while 17 articles with similarities were identified and eliminated from the selection process. after eliminating duplicates, 579 articles were chosen based on the inclusion and exclusion criteria. this procedure [healthcare in low-resource settings 2024;12(s1):13434] [page 37] significance for public health hypertensive patients need self-management to help lower blood pressure, change lifestyle, and monitor the condition. therefore, self-management interventions have been devised using individual and group approaches, technology, nursing theory-based approaches, and cultural aspects. innovations might help hypertensive patients in avoiding complications and enhancing quality of life. importance of self-management interventions in hypertension patients: a scoping review alfrina hany, kuswantoro rusca putra, ratih arum vatmasari, anisa nadya nafis, aura tasya amalia, edy khamdani nursing department, faculty of health sciences, universitas brawijaya, malang, east java, indonesia non -co mmerc ial us e o nly obtained 441 items that did not meet the preset criteria. following the procedure, it was determined that 138 articles met the qualifying requirements and could be selected. during the selection process based on eligibility criteria, 113 items were considered appropriate for usage. therefore, 25 articles were considered appropriate for inclusion in this scoping review (figure 1, supplementary table 2). results and discussion self-management plays a significant role in management of hypertension and has a profound impact on patients’ outcomes.14 the effects of the approaches included an increase in patients’ understanding and skills in coping with the disease by gradually adopting healthy lifestyle behaviors, improved satisfaction by reducing existing signs and symptoms, a decrease in hospital admission costs, and an improvement in quality of life.15–17 interventions empower patients to take an active role in managing the condition, leading to better blood pressure control and overall health outcomes.18 self-management interventions have the potential to significantly improve the outcomes of hypertension management.19 in addition, family empowerment plays a significant role in promoting self-management among patients with chronic conditions.20 this includes assisting with dietary choices and medication adherence, as well as facilitating care discussions between patients and healthcare providers.19,21 it is important to include family members in the process to improve patients’ outcomes and compliance with behavioral recommendations.22 interventions can be implemented in the form of education, training, self-help groups, classes, communities, follow-up, and application of technology.23–27 education and training have a positive effect on improving self-management skills of hypertensive patients.24,27–33 furthermore, classroom, community, and follow-up intervention models significantly reduced the systolic blood pressure.34,35 the most effective methods are those that use technology as basis,25,36–38 including remote monitoring of patients condition.25,36–38 interventions for hypertensive patients may incorporate nursing theoretical approaches such as roy’s adaptation, the health belief model, self-efficacy, and self-regulation model theories.24,28,31,36,39,40 nursing theory plays an essential role in guiding self-management interventions for hypertensive patients by providing a framework for understanding the complex factors that influence the ability to effectively manage the conditions.39,41 therefore, healthcare professionals could devise targeted interventions through nursing theory to meet the unique needs and challenges of hypertensive patients.40 the application of nursing theory is essential for enhancing patients outcomes and encouraging effective self-care behavior.41 the use of cultural methods allows for the creation of personalized care plans that consider specific needs, preferences, and situations.42 healthcare providers can tailor interventions to correspond with patients’ way of life and ensure appropriateness of the strategies.25 in addition, culturally informed interventions can address differences in beliefs towards medication, logistical barriers to care, as well as other social and contextual factors that may impact patients.35 conclusions self-management in hypertensive patients can increase participation and has led to a decrease in blood pressure, lifestyle changes, and avoidance of complications. various interventions have been developed, such as individual and group approaches, the use of technology, nursing theory, and interventions based on the cultural aspects of patients. families also play an important role in providing self-management interventions. hypertension management is not a “one size fits all”, hence nurses as professionals need to consider the suitable approaches for different conditions and needs. 4th international nursing and health sciences symposium table 1. the inclusion and exclusion criteria. criteria inclusion criteria exclusion criteria population hypertension patients family, community, and other then hypertension patients (such as stroke, cardiovaskular diseases, chronic kidney diseases, cancer, etc) interventions self-management interventions no exclusion criteria comparison usual care or standard care no exclusion criteria outcome self-management interventions in no exclusion criteria hypertension patients are effective in improving self-management study design experimental study study articles that use mix-methods, cross-sectional (quasi-experimental and randomized study cohort, longitudinal, quantitative and review articles control trials) [page 38] [healthcare in low-resource settings 2024;12(s1):13434] figure 1. flowchart of scoping review with selection process using pris-ma. non -co mmerc ial us e o nly references 1. roth ga, abate d, abate kh, et al. global, regional, and national age-sex-specific mortality for 282 causes of death in 195 countries and territories, 1980-2017: a systematic analysis for the global burden of disease study 2017. lancet 2018;392:1736–88. 2. zhou b, carrillo-larco rm, danaei g, et al. worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 populationrepresentative studies with 104 million participants. lancet 2021;398:957–80. 3. mills kt, stefanescu a, he j. the global epidemiology of hypertension. nat rev nephrol 2020;16:223-237. 4. tucker kl, sheppard jp, stevens r, et al. self-monitoring of blood pressure in hypertension: a systematic review and individual patient data meta-analysis. plos med 2017;14:e1002389. 5. liu j. highlights of the 2018 chinese hypertension guidelines. clin hypertens 2020;26(1). 6. himmelfarb crd, commodore-mensah y, hill mn. expanding the role of nurses to improve hypertension care and control globally. ann glob health 2016;82:243–53. 7. shahaj o, denneny d, schwappach a, pearce g, epiphaniou e, parke hl, et al. supporting self-management for people with hypertension: a meta-review of quantitative and qualitative systematic reviews. j hypertens 2019;37:264–79. 8. gazit t, gutman m, beatty al. assessment of hypertension control among adults participating in a mobile technology blood pressure self-management program. jama netw open 2021;4:e2127008. 9. andayani sa. the effect of self management on systolic blood pressure in hypertension patients. jurnal ilmiah permas: jurnal ilmiah stikes kendal 2023;13:485–90. 10. zhang q, huang f, zhang l, et al. the effect of high blood pressure-health literacy, self-management behavior, self-efficacy and social support on the health-related quality of life of kazakh hypertension patients in a low-income rural area of china: a structural equation model. bmc public health 2021;21:1114. 11. isnaini n, lestari ig. the effect of self management on blood pressure in elderly hypertension. indo j hesci 2018;2:7. 12. kurt d, gurdogan ep. the effect of self-management support on knowledge level, treatment compliance and self-care management in patients with hypertension. australian j adv nursing 2022;39:14–23. 13. tursina hm, silvanasari ia. improving self-management in hypertension patients by using hypertension self management diary (hsmd). nurscope: jurnal penelitian dan pemikiran ilmiah keperawatan 2022;8:94–101. 14. van truong p, wulan apriliyasari r, lin my, et al. effects of self-management programs on blood pressure, self-efficacy, medication adherence and body mass index in older adults with hypertension: meta-analysis of randomized controlled trials. int j nurs pract 2021;27. 15. still ch, assistant professor a bc, dang pb, malaker d, research assistant b, peavy td, et al. the design and rationale of a pilot study: a community and tech-based approach for hypertension self-management (coachman). j natl black nurses assoc 2020;31:52. 16. eck c, biola h, hayes t, et al. efficacy of hypertension selfmanagement classes among patients at a federally qualified health center. prev chronic dis 2021;18:1–7. 17. chen wc, wu sfv, sun jh, et al. the mediating role of psychological well-being in the relationship between selfcare knowledge and disease self-management in patients with hypertensive nephropathy. int j environ res public health 2022;19. 18. cooper v, clatworthy j, harding r, whetham j. measuring empowerment among people living with hiv: a systematic review of available measures and their properties. aids care 2019;31:798–802. 19. zhao j, hu y, zhang x, et al. efficacy of empowerment strategies for patients with hypertension: a systematic review and meta-analysis. patient educ couns 2020;103:898–907. 20. hany a, yulistianingsih e, kusumaningrum br. family empowerment and family ability to self-care for heart failure patients in the intermediate care room. int j publ health sci 2022;11:248–53. 21. ameling jm, ephraim pl, bone lr, et al. adapting hypertension self-management interventions to enhance their sustained effectiveness among urban african americans. fam community health 2014;37:119–33. 22. woods sb, udezi v, roberson pne, arnold em, et al. “a cuff is not enough”: a community-based participatory research 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13434] [page 39] correspondence: alfrina hany, nursing department, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia tel. +62341569117fax: +62341564755 e-mail: hanie@ub.ac.id key words: hypertension patients; nursing interventions; self-management contributions: all authors contributed equally to this study. conflict of interest: the authors declared that there were no potential conflicts of interest funding: none ethics approval and consent to participate: not applicable. clinical trials: not applicable conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to nursing department, faculty of health sciences, universitas brawijaya, malang for the support and encouragement. received: 4 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13034 doi:10.4081/hls.2024.13034 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly approach to soliciting perspectives of african americans with hypertension and their family members on self-management intervention features. fam process 2024;63:731-48. 23. aungsuroch y, polsook r, anuruang s, et al. how a selfmanagement program affects blood pressure among indonesians with hypertension: a quasi-experimental study. iran j nurs midwifery res 2022;27:229–35. 24. afshari m, gholamaliee b, kangavari m, et al. examining the effect of the training program by using the health belief model in performing self-care behaviors of rural patients having high blood pressure. comm health equity res policy 2022;43. 25. chandler j, sox l, kellam k, et al. impact of a culturally tailored mhealth medication regimen self-management program upon blood pressure among hypertensive hispanic adults. int j environ res public health 2019;16. 26. persell sd, karmali kn, lazar d, et al. effect of electronic health record-based medication support and nurse-led medication therapy management on hypertension and medication self-management: a randomized clinical trial. jama intern med 2018;178:1069–77. 27. kurnia ad, melizza n, ruhyanudin f, et al. the effect of educational program on hypertension management toward knowledge and attitude among uncontrolled hypertension patients in rural area of indonesia. comm health equity res policy 2022;42. 28. kılıç d, turkoglu n, baysal hy, et al. the effect of education provided using the roy ’ s adaptation model on hypertension management. internat j caring sci 2018;11:333-43. 29. ozoemena el, iweama cn, agbaje os, et al. effects of a health education intervention on hypertension-related knowledge, prevention and self-care practices in nigerian retirees: a quasi-experimental study. arch public health 2019;77(1). 30. le mh, nguyen tk, pham tt, et al. effectiveness of a health education program in hypertensive patients with dyslipidemia and/or microalbuminuria: a quasi-experimental study in vinh long province, vietnam. healthcare 2023;11:2208. 31. naeemi l, daniali ss, hassanzadeh a, rahimi m. the effect of educational intervention on self-care behavior in hypertensive older people: applying the health belief model. j educ health promot 2022;11. 32. beigi mab, zibaeenezhad mj, aghasadeghi k, et al. the effect of educational programs on hypertension management. int cardiovasc res j 2014;8:94. 33. aghajani m, ajorpaz nm, atrian mk, et al. effect of self care education on quality of life in patients with primary hypertension: comparing lecture and educational package. nurs midwifery stud 2013;2:71. 34. otieno p, van andel j, agyemang c, et al. effect of patient support groups for hypertension on blood pressure among patients with and without multimorbidity: findings from a cohort study of patients on a home-based self-management program in kenya. glob heart 2023;18. 35. boulware le, ephraim pl, hill-briggs f, et al. hypertension self-management in socially disadvantaged african americans: the achieving blood pressure control together (act) randomized comparative effectiveness trial. j gen intern med 2020;35:142–52. 36. li x, li t, chen j, et al. a wechat-based self-management intervention for community middle-aged and elderly adults with hypertension in guangzhou, china: a clusterrandomized controlled trial. int j environ res public health 2019;16. 37. andersson u, nilsson pm, kjellgren k, et al. person-centredness in hypertension management using information technology: a randomized controlled trial in primary care. j hypertens 2023;41:246. 38. putra pwk, suardani nn, ariani npe, suarsih npa. the smartphone-based self management education improves compliance and self efficacy and reduces blood pressure in hypertension patients. j health educ 2022;7:107–14. 39. kordvarkane z, oshvandi k, mohammadi y, azizi a. effect of education based on the common-sense model of selfregulation on blood pressure and self-management of hypertensive patients: a clinical trial study. int j nurs sci 2023;10:294–301. 40. zhang j, guo l, mao j, et al. the effects of nursing of roy adaptation model on the elderly hypertensive: a randomised control study. ann palliat med 2021;10:12149–58. 41. drevenhorn e. a proposed middle-range theory of nursing in hypertension care. int j hypertens 2018;2018:2858253. 42. stubbe de. practicing cultural competence and cultural humility in the care of diverse patients. focus (am psychiatr publ) 2020;18:49–51. 4th international nursing and health sciences symposium [page 40] [healthcare in low-resource settings 2024;12(s1):13434] online supplementary materials supplementary table 2. the results of the review's analysis of self-management interventions in hypertension patients. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:14007 using animated health promotion videos to reduce smoking and anxiety in hypertensive patients: a quasi-experimental study imam haryoko,1 aris citra wisuda,2 norhashima abd rashid,1 chun hoe tan1 1school of nursing and applied sciences, lincoln university college, malaysia; 2nursing study program, sekolah tinggi ilmu kesehatan bina husada palembang, indonesia abstract smoking and anxiety are significant modifiable risk factors that contribute to the worsening of hypertension. health promotion using engaging media such as animated videos has the potential to enhance patients’ understanding and motivation to change risky behaviors. this study aimed to examine the effectiveness of animated health promotion videos in reducing smoking behavior and anxiety levels among patients with hypertension. a quasiexperimental study was conducted from march to june 2024 at arrasyid general hospital, palembang. a total of 110 hypertensive patients who smoked were selected using purposive sampling and divided into intervention and control groups. the intervention group received animated video-based health education sessions focusing on smoking cessation and anxiety management, delivered over four weeks. the control group received standard care. smoking behavior was assessed using a structured smoking behavior questionnaire, while anxiety levels were measured using the hamilton anxiety rating scale (hars). data were analyzed using paired and independent t-tests. the intervention group showed a significant reduction in both smoking behavior scores and anxiety levels compared to the control group (p<0.05). the mean reduction in anxiety scores was greater in the intervention group, indicating the effectiveness of animated videos in promoting behavioral and psychological improvements. animated health promotion videos are effective in reducing smoking and anxiety among hypertensive patients. this approach can be considered an innovative and accessible health education strategy to support hypertension management. introduction hypertension, or elevated blood pressure, is a chronic medical condition and a leading contributor to global morbidity and mortality. it significantly increases the risk of cardiovascular disease, stroke, chronic kidney disease, and other non-communicable diseases (ncds).1 according to the world health organization,2 an estimated 1.28 billion adults aged 30–79 years are living with hypertension worldwide, yet approximately 46% remain undiagnosed and untreated. the burden is disproportionately higher in lowand middle-income countries (lmics), where healthcare access and health literacy are often limited. in the asia-pacific region, the prevalence of hypertension continues to rise due to urbanization, sedentary lifestyles, unhealthy dietary patterns, stress, and population aging.3,4 in indonesia, the basic health research (riskesdas) 2018 reported a national hypertension prevalence of 34.1%, with south sumatra slightly higher at 35.2%.5,6 local data from ar-rasyid general hospital in palembang indicate that hypertension consistently ranks among the top five outpatient diagnoses, highlighting an urgent need for targeted prevention and control strategies at the community and institutional levels. one of the major modifiable risk factors that contributes to both the development and progression of hypertension is smoking.7,8 the toxic constituents of tobacco, particularly nicotine, induce vasoconstriction, increase arterial stiffness, elevate correspondence: imam haryoko, school of nursing and applied sciences, lincoln university college, malaysia. e-mail:imamharyoko.umadplg@gmail.com key words: animated video, anxiety, health promotion, hypertension, smoking cessation. contributions: ih conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; acw conceptualization, investigation, methodology, validation, and writing–original draft, review & editing; nar conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; cht methodology, visualization, writing–review & editing; resources, investigation, and writing – review & editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to participate: the research has obtained ethical approval from the medical and health research ethics commission, faculty of medicine, sriwijaya university, based on ethical certificate 048-2024. throughout the research process, the researcher adhered to the principles of information ethics, including consent, respect for human rights, beneficence, and non-maleficence. funding: this research did not receive external funding. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to express their sincere gratitude to the participants, healthcare staff, and management of the participating health centers for their valuable support and cooperation throughout this study. received: 18 may 2025. accepted: 16 august 2025. early access: 11 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:14007 doi:10.4081/hls.2025.14007 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 264] [healthcare in low-resource settings 2025;13:14007] sympathetic nervous activity, and ultimately raise blood pressure levels.8-10 chronic smoking damages the vascular endothelium and exacerbates inflammatory processes, further amplifying cardiovascular risk in hypertensive individuals.12,13 beyond its physiological effects, smoking behavior is often intertwined with psychological distress, especially among patients with chronic illnesses.14 anxiety, in particular, is prevalent among individuals with hypertension and has been shown to disrupt blood pressure control, reduce adherence to medication and lifestyle recommendations, and increase health-compromising behaviors such as tobacco use.14,15 this bidirectional relationship between hypertension and anxiety represents a significant challenge in clinical management, necessitating holistic and integrative approaches. effective hypertension control requires a comprehensive strategy that combines pharmacological therapy with behavioral interventions, psychosocial support, and patient education.17 health promotion plays a vital role in increasing awareness, fostering behavioral change, and improving self-management capabilities. however, conventional methods of education, such as verbal counseling or printed materials, often have limited impact, particularly in populations with low health literacy or poor engagement. in response to this, digital health technologies have gained momentum, with animated health promotion videos emerging as a powerful tool to convey complex health information in an engaging and easily digestible format. these videos utilize visual storytelling, motion graphics, and voiceovers to reinforce learning, promote motivation, and enhance patient empowerment.17,18 numerous studies have demonstrated the efficacy of multimedia-based interventions in chronic disease education. for example, animated videos have been shown to significantly improve knowledge retention, enhance motivation to quit smoking, and reduce anxiety by increasing self-efficacy and emotional engagement.19-21 in the context of hypertension, video-based education has also been associated with improved medication adherence and lifestyle modification.23,24 despite these promising findings, research that evaluates the simultaneous impact of animated videos on both smoking cessation and anxiety reduction among hypertensive patients remains scarce. this gap in the literature highlights the need for context-specific, evidence-based studies to optimize health promotion strategies in hypertensive populations, particularly those at high risk due to behavioral and psychological comorbidities. a preliminary assessment conducted at ar-rasyid general hospital in march 2024 through direct interviews and clinical observation found that many hypertensive patients continued smoking despite repeated verbal counseling and demonstrated moderate to high levels of anxiety. this situation reflects a disconnect between traditional education methods and patient engagement. considering the high prevalence of hypertension and its associated psychosocial and behavioral risk factors in this setting, innovative interventions are essential. thus, this study aims to examine the effectiveness of animated health promotion videos in reducing smoking behavior and anxiety among hypertensive patients. it is anticipated that the findings will support the integration of digital health tools into patient education frameworks and contribute to the advancement of holistic hypertension management in clinical practice. materials and methods study design and setting this study employed a quasi-experimental design using a pretest-posttest control group approach to assess the effectiveness of animated health promotion videos in reducing smoking behavior and anxiety levels among hypertensive patients. the intervention was implemented over a four-month period, from march to june 2024, at ar-rasyid general hospital in palembang, indonesia. as a secondary referral healthcare facility, ar-rasyid general hospital offers a comprehensive spectrum of services, including specialized care for chronic conditions such as hypertension. the site was purposively selected due to hospital records indicating a substantial proportion of hypertensive patients who are also active smokers a high-risk group that stands to benefit significantly from targeted behavioral interventions. the use of multimedia tools such as animated videos has been shown in prior studies to enhance patient engagement, improve comprehension, and facilitate behavior change in clinical populations.25 given the dual burden of smoking and anxiety in individuals with chronic illness, this setting provided an ideal environment for testing a lowcost, scalable health education strategy. population and sampling the study population consisted of adult patients diagnosed with hypertension who were current smokers and regularly attended the internal medicine outpatient clinic. participants were selected through purposive sampling using the following inclusion criteria: aged between 30 and 70 years; diagnosed with hypertension for a minimum of six months; actively smoking at least one cigarette per day during the past month; cognitively and physically capable of participating in the intervention; and willing to provide written informed consent. exclusion criteria included a history of severe psychiatric disorders, cognitive impairment, or comorbid medical conditions requiring intensive treatment or hospitalization. a total of 110 eligible participants were recruited and then equally divided into two groups using a non-randomized, sequential allocation method: 55 participants were assigned to the intervention group and 55 to the control group. this balanced allocation helped ensure baseline comparability and enhanced the statistical power needed to detect significant differences between groups. intervention procedure the intervention group received a structured, culturally adapted health education program delivered via animated video sessions over a four-week period. each weekly session lasted approximately 10–15 minutes a duration strategically selected based on formative research and supported by literature highlighting the effectiveness of brief, focused multimedia content in maintaining attention and enhancing information retention among adult learners.18 this four-week timeline was intentionally designed to balance sufficient educational exposure with the practical demands of integrating such interventions into routine clinical settings. the video modules, developed specifically for hypertensive smokers, contained evidence-based content addressing the health risks of smoking, the physiological effects of nicotine on blood pressure, and effective smoking cessation strategies. they also incorporated anxietyreduction techniques such as deep breathing and progressive muscle relaxation, alongside motivational components rooted in cognitive-behavioral therapy (cbt). to ensure clinical accuracy, article [healthcare in low-resource settings 2025;13:14007] [page 265] cultural relevance, and user engagement, the modules were collaboratively produced with input from healthcare professionals, health communication experts, and animation specialists, making them accessible to individuals with diverse levels of health literacy. to ensure methodological rigor and minimize potential bias, several control strategies were systematically implemented. participants were randomly allocated to intervention and control groups using a computer-generated sequence to reduce selection bias, while outcome assessors were blinded to group assignments to minimize detection bias. intervention sessions were delivered by trained nurses using a standardized protocol to ensure consistency and were conducted individually or in small groups within quiet, private counseling rooms to limit distractions and enhance focus. each session concluded with a structured reflective discussion, reinforcing key messages and encouraging participant engagement an approach that supported the development of self-efficacy and motivation to change, both critical elements in behavior modification frameworks. in contrast, the control group received standard care according to institutional protocols, including routine medical consultations, antihypertensive pharmacotherapy, and general verbal advice on smoking and lifestyle changes. all participants across both groups continued their prescribed antihypertensive medications throughout the study to ensure uniformity in medical treatment, allowing for clearer attribution of outcomes to the educational intervention. instruments and data collection two primary outcome variables were assessed in this study: smoking behavior and anxiety levels. smoking behavior was measured using a structured questionnaire adapted from validated instruments, which evaluated daily cigarette consumption, situational smoking triggers, nicotine dependence levels, and motivation to quit. anxiety levels were assessed using the hamilton anxiety rating scale (hars), a well-established clinician-administered instrument consisting of 14 items that evaluate both somatic and psychological symptoms of anxiety. each item is rated on a 5-point likert scale ranging from 0 (not present) to 4 (very severe), yielding a total score between 0 and 56, where higher scores reflect more severe anxiety symptoms. data collection was conducted at two time points: baseline (pretest) prior to the intervention and follow-up (posttest) after the four-week intervention period. all assessments were performed by trained research assistants who were blinded to group allocation in order to minimize potential assessment bias. the instruments used had been previously validated and reviewed for contextual suitability to ensure the accuracy and reliability of the measurements. data analysis quantitative data were analyzed using ibm spss statistics version 26. descriptive statistics, including means, standard deviations, frequencies, and percentages, were used to summarize participants’ sociodemographic and clinical characteristics. to examine the effectiveness of the intervention, inferential statistical analyses were conducted. within-group changes in smoking behavior and anxiety levels from pretest to posttest were analyzed using paired sample t-tests. between-group differences in mean change scores were evaluated using independent sample t-tests. all analyses were two-tailed with a significance level set at p<0.05, indicating statistical significance for observed differences attributable to the intervention. results sociodemographic and clinical characteristics of participants the following section presents the sociodemographic and clinical characteristics of the study participants. this information is essential to describe the baseline profile of individuals in both the intervention and control groups, ensuring comparability prior to the implementation of the intervention. variables assessed include age, gender, education level, employment status, duration of hypertension, baseline cigarette use, and baseline anxiety scores. table 1 shows that the sociodemographic and clinical characteristics of participants in both the intervention and control groups were comparable at baseline. the mean age of participants was similar between the two groups (56.2±8.7 years in the intervention article [page 266] [healthcare in low-resource settings 2025;13:14007] table 1. sociodemographic and clinical characteristics of participants (n=110). characteristic intervention group, n=55 (%) control group, n=55 (%) p age (mean±sd) 56.2±8.7 years 55.4±9.1 years 0.623 gender 0.815 male 41 (74.5) 43 (78.2) female 14 (25.5) 12 (21.8) education level 0.392 primary 15 (27.3) 17 (30.9) secondary 27 (49.1) 25 (45.5) tertiary 13 (23.6) 13 (23.6) employment status 0.681 employed 24 (43.6) 26 (47.3) unemployed/retired 31 (56.4) 29 (52.7) duration of hypertension 0.537 <5 years 19 (34.5) 21 (38.2) ≥5 years 36 (65.5) 34 (61.8) baseline cigarette use (cigs/day) 13.7±4.6 13.9±4.4 0.821 baseline hars score 27.8±6.5 28.1±6.3 0.752 group and 55.4±9.1 years in the control group; p=0.623). the gender distribution was also balanced, with a predominance of male participants in both groups (74.5% vs. 78.2%; p=0.815). education levels and employment status showed no significant differences, with similar proportions of participants having primary, secondary, or tertiary education, and being either employed or unemployed/retired (p=0.392 and p=0.681, respectively). likewise, the duration of hypertension was comparable, with most participants in both groups having been diagnosed for five years or more (p=0.537). in terms of clinical variables, both groups reported nearly identical baseline cigarette consumption (13.7 vs. 13.9 cigarettes/day; p=0.821) and anxiety levels, as measured by the hamilton anxiety rating scale (27.8 vs. 28.1; p=0.752). these results suggest that the two groups were well-matched across key characteristics, supporting the internal validity of the intervention assessment. within-group changes in smoking behavior and anxiety levels this section presents the within-group comparisons of smoking behavior and anxiety levels before and after the intervention. the analysis was conducted separately for the intervention and control groups to evaluate any significant changes over time following the respective treatments received. table 2 shows that the within-group analysis revealed significant improvements in the intervention group following the animated health promotion video program. the average number of cigarettes smoked per day significantly decreased from 13.7±4.6 at pretest to 7.1 ± 3.9 at posttest (p<0.001), indicating a substantial reduction in smoking behavior. similarly, anxiety levels measured by the hamilton anxiety rating scale (hars) showed a significant decline, with mean scores dropping from 27.8 ± 6.5 to 17.2 ± 5.4 (p<0.001). in contrast, the control group showed no statistically significant changes in either smoking behavior (13.9±4.4 to 13.5±4.2; p=0.092) or anxiety levels (28.1±6.3 to 27.5±6.2; p=0.106). these findings suggest that the intervention was effective in reducing both cigarette consumption and anxiety among hypertensive smokers. between-group differences in outcome improvements this section presents the between-group comparisons to evaluate the differential effects of the intervention. the analysis focuses on changes in smoking behavior and anxiety levels from pretest to posttest in the intervention group compared to the control group, highlighting the effectiveness of the animated health promotion videos in achieving better outcomes. table 3 presents the betweengroup comparison of mean change scores for smoking behavior and anxiety levels. the intervention group demonstrated a significant reduction in the number of cigarettes smoked per day, with a mean decrease of 6.6±3.8, compared to only 0.4±1.9 in the control group. this yielded a mean difference of -6.2 cigarettes per day (p<0.001), indicating a substantial intervention effect. similarly, anxiety levels as measured by the hamilton anxiety rating scale (hars) showed a markedly greater reduction in the intervention group (mean change=-10.6±4.2) than in the control group (-0.5±2.3), resulting in a mean difference of -10.1 points (p<0.001). these findings provide strong evidence that the animated health promotion video program significantly outperformed routine care in reducing both smoking behavior and anxiety levels among hypertensive smokers. discussion this study examined the effectiveness of an animated health promotion video program in reducing cigarette consumption and anxiety levels among hypertensive smokers. the findings revealed that participants who received the animated video intervention experienced statistically and clinically significant improvements in both behavioral (smoking) and psychological (anxiety) outcomes compared to those who received routine care. these results underscore the value of animated educational media as an innovative, engaging, and accessible tool to support behavior change in clinical populations, particularly individuals living with chronic conditions such as hypertension. baseline analyses confirmed that participants in both the intervention and control groups were demographically and clinically comparable in key characteristics, including age, gender, education, employment status, duration of hypertension, initial cigarette consumption, and baseline anxiety levels. this homogeneity strengthens the study’s internal validity by ensuring that post-intervention differences are more likely attributable to the intervention itself rather than confounding factors. within-group analysis showed that participants in the intervention group reduced their daily cigarette consumption significantly from an average of 13.7 to 7.1 cigarettes per day and experienced a notable decline in anxiety, with hamilton anxiety rating scale (hars) scores decreasing from 27.8 to 17.2. in contrast, the control group showed no statistically significant changes. between-group comparisons further demonstrated the superiority of the intervention, with mean differ article [healthcare in low-resource settings 2025;13:14007] [page 267] table 2. within-group changes in smoking behavior and anxiety levels (pretest-posttest). outcome variable time point intervention group (n=55) p control group (n=55) p cigarettes per day pretest 13.7±4.6 13.9±4.4 posttest 7.1±3.9 <0.001* 13.5±4.2 0.092 hars score pretest 27.8±6.5 28.1±6.3 posttest 17.2±5.4 <0.001* 27.5±6.2 0.106 table 3. between-group comparison of mean change scores in outcome variables. outcome variable mean change (intervention) mean change (control) mean difference p cigarettes per day -6.6±3.8 -0.4±1.9 -6.2 <0.001* hars anxiety score -10.6±4.2 -0.5±2.3 -10.1 <0.001* ences of −6.2 cigarettes per day and −10.1 hars points, both highly significant (p<0.001), highlighting the practical relevance of the intervention in clinical practice. these findings align with a growing body of literature supporting the use of multimedia-based health education to influence cognitive, emotional, and behavioral health outcomes. prior studies23,24 have shown that audiovisual interventions tailored to target populations significantly enhance smoking cessation outcomes. likewise, other research28,29 has reported reductions in psychological distress through the use of animated content that enhances comprehension and emotional engagement with health information. the current study reinforces and extends this evidence base by demonstrating the efficacy of such interventions among highrisk individuals, specifically hypertensive smokers, thus contributing to the broader understanding of multimedia’s role in health promotion. the intervention’s design is theoretically grounded in bandura’s social cognitive theory, which emphasizes the roles of observational learning, reinforcement, and self-efficacy in behavior change. the animated videos likely served as visual models for healthier behaviors and coping mechanisms, strengthening participants’ confidence in their ability to reduce smoking and manage anxiety. the narrative-based and visually engaging format may have improved attention, comprehension, and retention of health messages, particularly among individuals with varying degrees of health literacy.25,26 the substantial reductions in anxiety observed may reflect both direct effects, such as increased understanding of stress management techniques, and indirect effects through reduced nicotine intake, which can alleviate nicotine-induced anxiety symptoms. these results illustrate the interconnectedness of behavioral and psychological health and the benefit of addressing both domains simultaneously. despite these promising findings, certain limitations must be acknowledged. the study assumed similar baseline motivation and equal access to intervention materials across groups an assumption supported by the absence of significant baseline differences. however, the relatively short duration of follow-up limits the ability to assess the long-term sustainability of behavior change and anxiety reduction. furthermore, reliance on self-reported smoking behavior may introduce reporting bias, although this was mitigated through the use of structured and standardized data collection protocols. future research should include longer follow-up periods, incorporate objective measures of smoking behavior, and examine the cost-effectiveness and adaptability of animated interventions in diverse healthcare settings and populations. overall, the evidence from this study supports the integration of animated health education videos into chronic disease management strategies to improve patient engagement and outcomes. strengths and limitations the study titled “using animated health promotion videos to reduce smoking and anxiety in hypertensive patients: a quasiexperimental study” possesses several notable strengths. its rigorous quasi-experimental design with a control group allows for a robust evaluation of the intervention’s effectiveness, while the use of validated instruments, such as the hamilton anxiety rating scale (hars), ensures accurate measurement of psychological outcomes. the comparability of baseline characteristics between groups strengthens internal validity, and the use of animated videos enhances engagement, particularly among individuals with limited health literacy. additionally, assessing both behavioral and psychological outcomes offers a comprehensive understanding of the intervention’s impact. however, the study also has limitations, including a relatively short follow-up period that may not capture the long-term sustainability of behavior changes, reliance on selfreported smoking data prone to bias, and the absence of blinding, which could influence outcome reporting. moreover, being a single-center study, the generalizability of the findings is limited, and potential external influences on smoking behavior and anxiety levels were not fully controlled. conclusions in conclusion, this quasi-experimental study demonstrates that animated health promotion videos are an effective intervention for reducing both smoking behavior and anxiety levels among hypertensive patients. the significant improvements observed in the intervention group, compared to routine care, highlight the value of multimedia-based education in enhancing patient engagement and facilitating behavior change. by simplifying complex information and promoting emotional connection, animated videos serve as a powerful tool to support chronic disease management. these findings support the integration of tailored, accessible health education strategies into routine clinical practice. future research is needed to evaluate the long-term sustainability of these effects and to explore their applicability across diverse populations and healthcare settings. references 1. pinontoan or, sumampouw oj. environmental health epidemiology; non-communicable diseases. pertama. nelwan je, editor. yogyakarta, indonesia: deepublish cv budi utama; 2019. 109 p. 2. who. world health statistics; monitoring health for the sdgs (sustainable development goals) 2021. available from: https://apps.who.int/iris/bitstream/handle/10665/342703/9789 240027053-eng.pdf 3. muslimin i, ashriady, mariana d, syamsul m. epidemiology of communicable and non-communicable diseases. delapan. risnawati, editor. pamekasan, jawa timur indonesia: duta media creative; 2021. 129 p. 4. whelton pk, carey rm, aronow ws, et al. 2023 a c c / a h a / a a p a / a b c / a c p m / a g s / a p h a / ash/aspc/nma/pcna guideline for the prevention, detection, evaluation, and management of high blood pressure in adults. hypertension 2023;71:e13–15. 5. kemenkes ri. laporan_nasional_rkd2018_final.pdf. badan penelitian dan pengembangan kesehatan. 2018. p. 1– 629. 6. ministry of health the republic of indonesia. regulation of the minister of health of the republic of indonesia. jakarta, indonesia: jakarta: minister of health of the republic of indonesia; 2022. 1–9 p. 7. world health organization. gats|global adult tobacco survey fact sheet indonesia 2021 gats objectives. fact sheet indones. 2021;1–2. 8. heidenreich pa, bozkurt b, aguilar d, et al. 2022 aha/acc/hfsa guideline for the management of heart failure. j card fail. 2022;28(5):e1–167. 9. holipah h, sulistomo hw, maharani a. tobacco smoking and risk of all-cause mortality in indonesia. plos one 2020;15:e0242558. article [page 268] [healthcare in low-resource settings 2025;13:14007] 10. sochocka m, karska j, pszczołowska m, et al. cognitive decline in early and premature menopause. int j mol sci 2023;24:6566. 11. direktorat p2ptm. mengenali tanda dan gejala serangan dini penyakit jantung koroner. p2ptm kemenkes ri. 2019;30. 12. gallucci g, tartarone a, lerose r, lalinga av, capobianco am. cardiovascular risk of smoking and benefits of smoking cessation. j thorac dis 2020;12:3866–76. 13. johanis ij, hinga iat. risk factors for hypertension, smoking and age on the incidence of coronary heart disease. media kesehat masy 2020;16:116–26. 14. sharma-kumar r, puljević c, gartner k. acceptance and effectiveness of a video promoting smoking cessation among australians with mental illness. public heal educ 2021;49:506-15. 15. nijjar ps, connett je, lindquist r, et al. randomized trial of mindfulness-based stress reduction in cardiac patients eligible for cardiac rehabilitation. sci rep 2019;9:18415. 16. chopra s. anxiety: a philosophical guide. tempio r, editor. oxford: princeton university press; 2024. 166 p. 17. hamzah, akbar h, faisal, rafsanjani tm. basic theory of epidemiology of non-communicable diseases. sugiyatmi ta, editor. aceh, indonesia: yayasan penerbit muhammad zaini; 2021. 218 p. 18. p. emen aj, edrada sl. effectiveness of health promotion audiovisual materials in reducing nicotine dependence among young adults. am sci res j eng 2020;143–62. 19. elling jm, de vries h. influence of animationversus textbased delivery of a web-based computer-tailored smoking cessation intervention on user perceptions. eur j heal commun 2021;2:1–23. 20. anggelina s, trisnadoli a. analisis efektivitas pesan film animasi 3d bahaya rokok terhadap perokok aktif remaja dan dewasa. andharupa j desain komun vis multimed 2020;6:115–24. 21. anggraini ccd. analysis of the use of video media on the learning interest of bi class students in elementary school teacher education at the universitas terbuka. widyagogik j pendidik dan pembelajaran sekol dasar 2022;10:225–33. 22. haddaway nr, page mj, pritchard cc, mcguinness la. prisma2020: an r package and shiny app for producing prisma 2020-compliant flow diagrams, with interactivity for optimised digital transparency and open synthesis. campbell syst rev 2022;18:e1230. 23. ismail i, siddiq r, bustami b. the effectiveness of health education using audiovisual on the santri smokers’ motivation to stop smoking. asian pacific j cancer prev 2021;22:2357–61. 24. dismiantoni n, anggunan, triswanti n, kriswiastiny r. relationship between smoking and hereditary history with hypertension. juni 2020;11:30–6. 25. john w, j. david creswell. research design: qualitative, quantitative, and mixed methods approaches. 5th ed. california: sage publications, inc; 2018. 26. listiana s, yulianti f, kesehatan p, kemenkes p. the effect of animation video about the dangerous of smoking.jurnal kesehatan siliwangi2021;2:185–93. 27. ye l, ye y, gao h. effectiveness of social video platforms in promoting smoking cessation among youth: a content-specific analysis of smoking cessation topic videos on the social platform bilibili. tob induc dis 2023;21:1–10. 28. mkperedem aa, oye ja, etta-oyong so, et al. impact of school values on mass media preference and usage: a study of a private university in north central, nigeria. humanit soc sci commun 2023;10:569. 29. holianto v. community medicine & education differences in the effectiveness of health promotion through video and leaflets. comm med educ 2021;2:128–38 30. airhihenbuwa co, tseng ts, sutton vd, price ls. global perspectives on improving chronic disease prevention and management in diverse settings. prev chronic dis 2021;18:e33. 31. woods b, rai hk, elliott e, aguirre e, orrell m, spector a. cognitive stimulation to improve cognitive functioning in people with anxiety. cochrane database syst rev 2023;2023:cd005562. article [healthcare in low-resource settings 2025;13:14007] [page 269] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13038 effect of peer education on improving parental knowledge about nutrition in children firnaliza rizona,1 yeni anna appulembang,2 fuji rahmawati,1 viona fracellia citra,1 zahra saphira,1 shefa mursalinda1 1school of nursing, universitas sriwijaya, indralaya, south sumatra; 2psychology department, universitas sriwijaya, indralaya, south sumatra, indonesia abstract the knowledge about nutrition in children is essential for parents, who play a significant role in ensuring proper growth and development. many parents lack awareness about proper maintenance of nutrition for children. therefore, this study aimed to evaluate the effect of peer education on parental knowledge about the nutritional status of children. a pre-experimental method was used and respondents comprised 20 parents of students from elementary school in palembang city. data was collected using a questionnaire before and after the intervention. the result showed that there was an increase in parental knowledge with a p-value =0,001 according to the wilcoxon test. the mean values before and after intervention were 16.8 and 21.8, respectively. intervention through peer education improved parental knowledge about achieving balanced nutrition in children. parents were also empowered to share information with others regarding the knowledge obtained through trusted sources. this information entailed nutritional status, appropriate nutrient uptake, and optimized physical activity for children. the integration of peer education resulted in a substantial increase in the average level of parental knowledge after the intervention. introduction the prevalence of overnutrition and persistent undernutrition is increasing in both developed and developing countries.1 according to basic health research in 2018, nutritional status of children aged 5-12 years based on body mass index or age in indonesia showed a prevalence of thinness at 9.3%, comprising 6.8% thin and 2.5% very thin. the problem of obesity is also high with a prevalence of 20.6%, including 11.1% fat and 9.5% very fat (obesity).2 problems associated with overnutrition or undernutrition may have adverse effects on both the physical growth and psychological development of children.3 the imbalance between nutritional intake and adequacy potentially leads to nutritional problems, both overnutrition and undernutrition.4 children lacking a balanced nutritional intake due to poor dietary habits tend to experience malnutrition which leads to a weakened immune, as well as hindered growth and development. consequently, children fail to grow and develop optimally according to the age stage.5 the majority of parents take pride in the slightly extra-weight appearance of children, overlooking the potential health implications.3 adequacy or deficiency of nutrition can be determined by evaluating nutritional status, categorized as underweight, normal, or overweight. given the consequences associated with these conditions, it is highly essential to regularly assess and monitor nutritional status, ideally once a month.6 nutritional problems in children are also influenced by the role of parents in providing food. most parents tend to prefer instant or fast food for convenience, without considering nutritional value. unhealthy eating behaviors such as skipping breakfast and consuming fewer dairy products, fruits, and vegetables are also prevalent. easily accessible snacks often consist of foods lacking essential vitamins and minerals while being high in sugar, fat, and salt.7 furthermore, parents shape the growth environment of children which can either promote the development of healthy eating habits and weight or contribute to issues such as overweight and disordered eating tendencies.8 the level of nutritional awareness among parents is a crucial and defining factor that significantly impacts the health of children.9 parents have direct control over diet by managing the quantity and quality of food intake.10 this parenting strategy is associated with healthy eating patterns, such as a regular intake of fruits and vegetables, breakfast, and a tendency to avoid high-energy-density foods.11 children require a sufficient quantity of nutritious food to support health, physical and cognitive development, as well as overall growth.12,13 sufficient and well-rounded nutrition serves as a preventative measure against illnesses, enhances the quality of life, improves the mental health of children, and elevates academic performance.14 early prevention is essential to counteract the increasing prevalence of nutrition-related diseases.15 in this context, nutrition education is a planned effort to improve nutritional status through changes in knowledge related to food production, preparation methods, distribution, disease prevention as well as child care. by definition, nutrition education is a method of disseminating information based on the principles of nutrition science. the informasignificance for public health in indonesia, children between the ages of 5 and 12 encounter challenges related to underweight and obesity. parents' influence is paramount in moulding children's dietary patterns. it is imperative to conduct regular nutritional assessments, offer educational opportunities, and involve families in this process. additionally, peer education enhances awareness regarding nutrition. this study provides an overview of how peer education can increase the understanding of various health knowledge, specifically for parents about nutrition in children. [page 52] [healthcare in low-resource settings 2024;12(s1):13038] non -co mmerc ial us e o nly tion provided is often related to the problems faced by the community.16 the significance of family participation in nutrition education should not be underestimated, as the behaviors of children strongly correlate to the time spent with parents. more specifically, when parents receive nutrition education, positive eating behaviors tend to have a more enduring impact on children.17 an effective method to increase parental knowledge of providing proper nutrition is through peer education. this method has been used as a public health strategy to promote various positive health behaviors, resulting in the transfer of knowledge and experience among members of the same group.18 a study conducted in medan, north sumatra, showed that peer education was effective in increasing knowledge and attitudes about nutrition and obesity. additionally, this method caused a statistically significant decrease in fast-food consumption habits.19 nutrition knowledge is one strategy to protect children from negative impacts. the greater the level of nutrition knowledge, the higher the attention given to the quality and quantity of food consumed.20 based on recent observations, it is evident that a significant number of parents need an understanding of the critical role of nutrition in child development. furthermore, public health services have noted a deficiency in disseminating relevant information. consequently, this study seeks to assess the impact of peer education in enhancing parental knowledge regarding childhood nutrition. materials and methods this quantitative study was conducted using the pre-experimental method with one group pre-posttest design. respondents were 20 parents of students in elementary school in ilir barat district, palembang city, while data was collected using a questionnaire after conducting intervention through peer education. sample selection was carried out through the purposive sampling method. the inclusion criteria include parents of children in elementary school who own a smartphone or personal computer and were willing to be respondents. the intervention used was peer education method to increase parental knowledge about nutrition in children. the study team delivered information about nutrition of children to the selected parents and data was collected using a questionnaire. the instrument was modified from previous studies where the validity and reliability were assessed in elementary school number 79 in palembang city. the questionnaire was assessed for pretest and posttest after conducting the intervention. univariate analysis was conducted for descriptive computation of data on parental nutrition knowledge. this includes information about good nutrition for children, comprising appropriate types of food, preparation methods, achieving normal nutritional status, and monitoring nutritional status. the bivariate analysis was used to analyze data about parental knowledge, while statistical analysis was conducted with the wilcoxon test. the protocol for this study was approved by the regional ethics committee for research with human subjects at the health research review committee, faculty of medicine, sriwijaya university, indonesia, with protocol number 109-2023. results and discussion the characteristics of respondents presented in table 1 showed that the majority (95%) were females, and aged between 20-40 years old (85%). the mean values representing parental knowledge are presented in table 2. the analysis was conducted using the wilcoxon test, showing that the mean value increased after intervention from 16.8 to 21.8. the p-value of 0.002 suggested significant differences between pre-intervention and post-intervention. parents have a crucial role in fostering the health and education of children, particularly in establishing favorable nutritional environments that increase awareness and appreciation of the positive impact obtained from food and nutrients. nutrition knowledge, in this context, refers to grasping the advantages of food and nutrients for health, as well as the capacity to retain and recall specific terminology and information related to the subject.21 the provision of nutrients to school-age children should be given accurately both in terms of quality and quantity as this age group is particularly vulnerable to nutritional problems.22 sufficient nutrition is crucial for supporting the growth and development of children. therefore, children need to adopt appropriate and healthy dietary habits to acquire the necessary nutrients in sufficient quantities. as components of a balanced diet, fruits and vegetables can aid in achieving the daily recommended intake of numerous essential micronutrients, including vitamins and minerals, for children.23 insufficient and unbalanced nutrition hinders effective maturation.14 furthermore, muscle weakness, delayed maturation, reduced bone density, and low productivity over time are potential consequences of being underweight. overweight or obese children are at a high risk of developing conditions such as hypertension, type 2 diabetes, metabolic disorders, and mental health issues.3 nutrition is an essential factor that cannot be separated from human growth and development, specifically in children. ensuring adequate nutrition intake and monitoring nutritional status is considered crucial to achieve optimal learning and quality education.24 children often lack the knowledge to naturally select nutritious foods, giving preference to snacks and other unhealthy options, which are usually detrimental to health. parents can contribute to enhancing a better quality of life by instilling proper eating habits in children.25 nutritional status serves as a reflection of overall health in an individual, stemming from the equilibrium between nutrient intake and the body absorption capacity. adequate nutrient intake in the correct quantities, coupled with precise timing at the cellular level facilitates normal bodily functions. a favorable nutritional status not only acts as a preventive measure against diseases, including infections but also fosters the optimal growth and development of 4th international nursing and health sciences symposium table 1. characteristics of respondents (n=20). characteristics f % gender man 1 5 woman 19 95 age (years) 20-40 17 85 40-60 3 15 table 2. parental knowledge before and after intervention. mean min max ties positive ranks p pre test 16.8 7 21 0 20 0.002 post test 21.8 19 25 [healthcare in low-resource settings 2024;12(s1):13038] [page 53] non -co mmerc ial us e o nly children.26 in addition to ensuring a balanced nutritional intake, parents should consistently carry out regular weight measurements and monthly height assessments. this proactive method enables appropriate tracking of growth as well as prevention of both stunting and obesity.5 factors contributing to hindrances in nutritional success include limited parental knowledge regarding nutritional status, coupled with the persistence of beliefs and taboos surrounding specific foods. nutritional education is an effective method to improve knowledge and guide positive behavioral changes.27 more specifically, peer education as one of the methods entails the delivery of information by individuals or groups of community members categorized based on age, class, or status.28 this method produces more sustainable changes by leveraging social support and group norms. the groups have the potential to provide a valuable system for sharing evidence-based nutritional information at the right time and with maximum impact. therefore, peer education can be a useful method for addressing issues and providing costeffective interventions at the population level.29 the results showed that peer education had a significant influence on parental knowledge regarding nutrition in children. this was consistent with previous studies that obtained a statistically significant difference in the average knowledge of adolescent girls about reproductive health after receiving peer education with a pvalue of 0.000.30 another study used peer education method to increase the knowledge and attitudes of elementary school students about personal hygiene, obtaining statistical test results with a p-value of 0.000.31 peer group education is more effective in increasing health knowledge due to the close relationships and similar levels of maturity among individuals, creating a more open environment that promotes asking questions among peers regarding unfamiliar topics. this was evident through the abundance of questions and the exchange of experiences among respondents. additionally, information dissemination can occur repeatedly in small groups, facilitating a more open exchange of experiences.32 peer group education empowers members, leading to the consideration as an accurate model.15 conclusions in conclusion, peer education significantly increased the mean value of parental knowledge after conducting intervention. based on the results, the delivery of appropriate information through peers could be optimized to improve parental understanding of nutrition in children and prevent abnormalities. references 1. siew cy, siong te, hashim z, et al. effectiveness of a nutrition education intervention for primary school children: the healthy kids programme, malaysia. malaysian j med heal sci 2020;16:1–10. 2. hamzah, hasrul, hafid a. pengaruh pola makan terhadap status gizi anak sekolah dasar. j keperawatan muhammadiyah bengkulu 2021;5:70–5. 3. syahrul s, kimura r, tsuda a, et al. prevalence of underweight and overweight among school-aged children and it’s association with children’s sociodemographic and lifestyle in indonesia. int j nurs sci 2016;3:169–77. 4. yunus em. relationship between mother’s characteristics and toddler nutritional status in tanjung gunung village, central bangka in 2017. j kesehat poltekkes pangkalpinang. 2018;6:28–32. 5. munawaroh h, nada nk, hasjiandito a, et al. the role of parents in fulfilling balanced nutrition as an effort to prevent stunting in children aged 4-5 years. sentra cendekia 2022;3:47–60. 6. ariati nn, fetria a, purnamawati aap, et al. description of nutritional status and the incidence of stunting children in early childhood education programs in bali-indonesia. bali med j 2018;7:723–6. 7. hassanzadeh-rostami z, mirshekari m, ranjbaran h, et al. effect of game-based nutrition education on nutritional knowledge of preschool children. int j nutr sci 2018;3:50–5. 8. angeles-agdeppa i, monville-oro e, et al. integrated school based nutrition programme improved the knowledge of mother and schoolchildren. matern child nutr 2019;15. 9. metos jm, sarnoff k, jordan kc. teachers’ perceived and desired roles in nutrition education. j sch health 2019;89:68– 76. 10. lipowska m, lipowski m, jurek p, et al. gender and body-fat status as predictors of parental feeding styles and children’s nutritional knowledge, eating habits and behaviours. int j environ res public health 2018;15. 11. lo k, cheung c, lee a, et al. associations between parental feeding styles and childhood eating habits: a survey of hong kong pre-school children. plos one 2015;10:1–11. 12. head zauche l, darcy mahoney ae, thul ta, et al. the power of language nutrition for children’s brain development, health, and future academic achievement. j pediatr heal care 2017;31:493–503. 13. aziza na, mil s. the effect of parental income on the nutritional status of children aged 4-5 years during the covid-19 pandemic. golden age j ilm tumbuh kembang anak usia dini 2021;6:109–20. 14. selmin k. the effect of a nutrition education program on nutrition behavior and body mass index of secondaruy school students. int j caring sci 2020;13:573–82. 15. henström m, duncanson k, collins ce, ashton lm, davidson e, ball r. online reach and engagement of a child nutrition peer-education program (picnic): insights from social media and web analytics. bmc public health 2022;22:1–18. 16. nur a, pantaleon mg, sembiring ac, loaloka ms. edukasi gizi seimbang, nutritional status assessment and provision of pmt as an effort to prevent stunting in elementary school children in kupang regency. j kreat pengabdi kpd masy 2023;6:2816–25. 17. kuwahara m, eum w. effects of childhood nutrition education from school and family on eating habits of japanese adults. nutrients 2022;14. 18. ghasemi v, simbar m, fakari fr, et al. the effect of peer education on health promotion of iranian adolescents: a systematic review. int j pediatr 2019;7:9139–57. 19. manggabarani s, said i, hadi aj, et al. the effectivity of peer education module on knowledge, attitude, and fast food consumption in adolescents. j heal promot behav 2020;5:35–43. 20. binder a, naderer b, matthes j, spielvogel i. fiction is sweet. the impact of media consumption on the development of children’s nutritional knowledge and the moderating role of parental food-related mediation. a longitudinal study. 4th international nursing and health sciences symposium [page 54] [healthcare in low-resource settings 2024;12(s1):13038] non -co mmerc ial us e o nly nutrients 2020;12:1478. 21. romanos-nanclares a, zazpe i, santiago s, et al. influence of parental healthy-eating attitudes and nutritional knowledge on nutritional adequacy and diet quality among preschoolers: the sendo project. nutrients 2018;10. 22. novianti a, utami tp. assessment of nutritional status and knowledge of balanced nutrition of school-age children as a form of uks activity activation. abdimas j pengabdi masy 2021;4:399–404. 23. saha s, dawson j, murimi m, et al. effects of a nutrition education intervention on fruit and vegetable consumption-related dietary behavioural factors among elementary school children. health educ j 2020;79:963–73. 24. rahadiyanti a, salma dina s, putri s, et al. pimproving knowledge of mothers and teachers regarding balanced nutrition for children aged 5-8 years at al-hunafa school, bandung city. j proactive 2022;1:8–14. 25. sultana n. nutritional awareness among the parents of primary school going children. saudi j humanit soc sci 2017;2:708– 25. 26. wondal r, mahmud n, purba n, et al. description of toddler nutritional status, and parental participation during the covid-19 pandemic. j obs j pendidik anak usia dini 2023;7:345–57. 27. fadare o, amare m, mavrotas g, et al. mother’s nutritionrelated knowledge and child nutrition outcomes: empirical evidence from nigeria. plos one 2019;14:1–17. 28. foley bc, shrewsbury va, hardy ll, et al. evaluation of a peer education program on student leaders’ energy balancerelated behaviors. bmc public health 2017;17:1–8. 29. ball r, duncanson k, burrows t, collins c. experiences of parent peer nutrition educators sharing child feeding and nutrition information. children 2017;4:1–14. 30. sarry y, lajuna l, ramli n. the effectiveness of peer group education and counseling on improving the knowledge of adolescent reproductive health. j healthc technol med 2021;7:566–80. 31. nur hn, sudarman s. the influence of peer group health education on improving personal hygiene behavior of elementary school students in makassar city. indones j heal promot 2021;4:530–5. 32. hidayah a, nasution nh. the influence of peer group health education on elementary school students’ personal hygiene behavior. j educ dev 2019;7:249–51. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13038] [page 55] correspondence: firnaliza rizona, school of nursing, universitas sriwijaya, indralaya, jalan dokter muhammad ali, sekip jaya, kec. kemuning, palembang, south sumatra, indonesia. tel.: +62711373438. e-mail: firnaliza.rizona@fk.unsri.ac.id key words: child; nutrition; parental knowledge; peer groups contributions: all authors contributed significantly to the development of the manuscript, including the conception, design, data analysis, writing, and revision. conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by lppm universitas sriwijaya. clinical trials: not applicable. ethics approval: the protocol for this study was approved by the regional ethics committee for research with human subjects at the health research review committee, faculty of medicine, sriwijaya university, indonesia, with protocol number 109-2023. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgment: this study was funded by lppm universitas sriwijaya. received: 4 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13038 doi:10.4081/hls.2024.13038 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13060 the effect of psychoeducation with health coaching method on hba1c levels among type 2 diabetes mellitus minarti,1 supriyanto,1 miadi,1 ach. arfan adinata,1 nikmatul fadilah1,2 1nursing department, health polytechnic of the health ministry of surabaya, surabaya, east java; 2center for excellence in science and technology-community empowerment, health polytechnic of the health ministry of surabaya, surabaya, east java, indonesia abstract different dangerous and life-threatening complications, such as hypoglycemia, hyperglycemia, and metabolic ketoacidosis are caused by uncontrolled diabetes mellitus (dm). therefore, this study aimed to analyze the effect of psychoeducation with health coaching methods in type 2 dm patients on hba1c levels. in this context, a quasi-experimental design was adopted with pre-and post-test control group methods. the sample size for the intervention and control groups was 30 type 2 dm patients who were routinely controlled at the kalijudan surabaya community health center between march to april 2023 using a simple random sampling method. the intervention group received psychoeducational intervention using the health coaching method with six sessions through 3 meetings and module media, while the control only received module education media. furthermore, the hba1c level was taken before and after intervention, and the effect was measured using the t-test. the results showed that pre-test and posttest hba1c levels were decreased (mean 9.06; 5.98) and increased (mean 9.13; 10.59) in the intervention and control groups, respectively. psychoeducation with the health coaching method and provision of modules to patients was more effective compared to groups only given modules (0.000). in conclusion, this intervention motivated patients subjected to treatment, facilitated increased personal control, and built confidence in managing diabetes independently. the implication obtained was an increase in the ability of patients to make self-care decisions. introduction recent developments are triggering changes, such as increased consumption of unhealthy foods, which can lead to high blood sugar levels. in this context, diabetes mellitus (dm) causes various complications, increasing the rate of disability and death. hypoglycemia, hyperglycemia, and metabolic ketoacidosis are dangerous and life-threatening complications and emergency conditions of type 2 dm. uncontrolled blood sugar levels are an indication of people with diabetes who are unable to apply self-care behavior according to the correct rules.1 dm is the world’s sixth leading cause of morbidity and healthcare problems and the high prevalence impacts the need for financing. in east java, there was a trend towards an increase in the incidence of dm from 2019 to 2021. the prevalence of cases in 2019, 2020, and 2021 was 94,076, 94,264, and 96,280 people, respectively.2–4 health coaching for dm patients can have a good effect because the disease will be controlled after conducting laboratory tests. in this context, hba1c levels are used to assess the quality of long-term glycemic control and the effectiveness of therapy. the test represents the average daily blood glucose and carbohydrate balance over two months. hba1c is also used to monitor disease progression and determine the development of dm complications. in addition, the test is better than fasting blood glucose examination and the checks should be carried out at least twice a year.5 hba1c value is directly proportional to the possibility of experiencing complications, which reduces the quality of life.6 therefore, the application and discipline of appropriate self-care are practical in dm management to significantly reduce the risk of complications.7 psychoeducation with health coaching method assists patients in raising awareness and behavior to maximize the potential of managing illness. health coaching includes workers engaging with patients, focusing on issues, and collaboratively finding solutions. this collaborative process is often used in managing chronic diseases such as cardiovascular, diabetes, cancer, and chronic respiratory disease (international coach federation). the intervention consists of 6 sessions in 3 meetings between the therapist and the patient. therefore, this study aimed to analyze the effects of psychoeducation using health coaching method on hba1c levels in type 2 dm patients. materials and methods the study design was quasi-experimental with a pre-test and post-test control group method. this study’s population was 83 type 2 dm patients routinely controlled at the kalijudan community health center from march to april 2023. the sample size of 30 people for intervention and control groups was taken using simple random sampling. the intervention group received psychoeducation using health coaching method, six sessions through three meetings, and media [healthcare in low-resource settings 2024;12(s1):13060] [page 107] significance for public health unregulated diabetes mellitus (dm) can result in a range of severe complications, such as hypoglycemia, hyperglycemia, and metabolic ketoacidosis. the intervention study yielded positive outcomes by fostering patient empowerment in managing their treatment, enhancing their ability to address diabetes independently, and boosting their confidence in self-care decisions. non -co mmerc ial us e o nly modules, while the control only received module education media. hba1c data was taken before and after the intervention and the examinations were carried out for 2.5 months. the examination was conducted by laboratory personnel trained to take the patient’s venous blood and perform analysis to determine level. the collected data was analyzed using the t-test and the analysis was executed by using spss statistics version 25.0. an ethical clearance letter was gained from health research ethics commission of health polytechnic, ministry of health, surabaya, number: ea/1081/kepk-poltekkes_sby/v/2022. results and discussion demographic data table 1 shows the characteristics of dm patients, including gender, education, occupation, age, and duration of suffering from dm. table 2 shows the homogeneity test results showed no significant differences in the characteristics of gender, occupation, age, and duration of suffering from dm in the two groups (p-value 0.083; 0.065; 0.459; 0.947). in contrast, the educational characteristics of the two groups showed differences (p-value 0.037). hba1c before intervention (mean±sd 9.06±1.79; 9.13±2.34) in the two groups did not show a significant difference (p-value 0.897). meanwhile, the value (mean±sd 5 .98±0.95; 10.59±2.64) after the intervention reported a significant difference (p-value 0.000). 4th international nursing and health sciences symposium table 1. characteristics of dm patients in the intervention and control group (n=30) characteristics intervention group control group equivalence p-value n % n % gender 0.083 man 2 6.7 8 26.7 woman 28 93.3 22 73.3 education 0.037 elementary school 8 26.7 18 60.0 junior high school 5 16.7 1 3.3 high school 8 26.7 7 23.3 pt 9 30.0 4 13.3 work 0.065 doesn't work 20 66.7 19 63.3 laborer 1 3.3 2 6.7 private employees 2 6.7 0 0.0 civil servants 1 3.3 7 23.3 self-employed 6 20.0 2 6.7 age mean±sd mean±sd total 0.459 58.97±12.25 57.20±10.67 58.08±11.43 long suffering dm 8.53±9.53 7.20±6.62 7.87±8.16 0.947 table 2. hba1c levels before and after treatment in the intervention and control group (n=30). hba1c intervention group control group p pre mean±sd 9.06±1.79 9.13±2.34 0.897 post mean±sd 5.98±0.95 10.59±2.64 0.000 table 3. the effect of health coaching psychoeducation and hba1c levels on intervention and control group (n=30). variable group pre-test post-test p mean±sd mean±sd hba1c intervention 9.06±1.79 5.98±0.95 0.000 control 9.13±2.34 10.59±2.64 0.001 [page 108] [healthcare in low-resource settings 2024;12(s1):13060] non -co mmerc ial us e o nly psychoeducation with health coaching method and hba1c levels table 3 shows the results of health coaching psychoeducation and hba1c levels on intervention and control group. the results of the pre-test and post-test comparison of hba1c levels in dm patients who received psychoeducational interventions with health coaching method and educational media modules showed a significant difference (p-value 0.000). the patients who received psychoeducational interventions using health coaching method reported decreased hba1c levels towards average values (mean±sd 9.06±1.79 to 5.98±0.95). meanwhile, individuals who only received educational media modules showed a significant difference (p-value 0.000), with an increased mean pre-test and post-test hba1c values (mean±sd 9.13±2.34 to 10.59±2 .64). there was no significant difference in hba1c levels between dm patients who received psychoeducational interventions using health coaching method with educational media modules and those who only received educational media modules (p-value 0.897). the mean±sd hba1c values between intervention and control groups were 9.06±1.79 and 9.13±2.34, respectively. after health coaching intervention, the groups significantly differed in hba1c values (p-value 0.000). considering the mean±sd hba1c trend, there were differences, namely 5.98±0.95 and 10.59±2.64, where hba1c levels of the intervention group were lower than treatment. this study found that psychoeducational interventions using health coaching method and providing modules to dm patients reduced hba1c levels. this treatment was carried out through education, discussion, and action plans related to the problems experienced by patients. the control group was only given the same module as the treatment group but not psychoeducational interventions using health coaching method. previous studies stated that the stages were conducted sequentially according to the needs of the dm patient 8. the series of activities and observations in each intervention session are as follows: first meeting the first meeting was to create a relationship of mutual trust, provide information and motivation through education about dm self-care, and carry out an hba1c examination. the creation of a mutual trust relationship is the first step in communication between nurses and patients. trust is the desire of a party to surrender or take the actions of another individual based on the hope of performing a specific action.9 a good relationship between patients and nurses can be created out of credibility, empathy, concern, and sincerity. diabetes self-management education (dsme) given to patients is essential in managing type 2 dm. furthermore, the provision of education can change the self-care behavior of the patient through continuous motivation. direct education is often provided, but patients with disabilities may struggle to retain the information. in this context, there is a need for educational materials delivered through modules, which can serve as a medium for more effective and lasting learning. the results are consistent with previous study, where the effect of teaching sessions in supportive educative programs increases the knowledge and understanding of type 2 dm patients.10 second meeting the second meeting is to identify problems and explore selfpotential in diabetic patients, discuss directions and goals and implement activity plans. this stage is the most critical in health coaching because of the changes in the behavior of patients. at this stage, a coach offers training in problem-solving to address any obstacles preventing patients from completing treatment programs or acquiring specific skills essential for managing health conditions. additionally, support is provided to enhance the ability to cope with the challenges associated with illness and assist in maintaining psychological well-being to preserve self-confidence. the patient remains optimistic in dealing with the disease through the information obtained from health coaching activities.11 based on the results of interviews and problem analysis in the intervention group, there were many obstacles in carrying out the diet, specifically avoiding sweet drinks and an irregular diabetes diet, lack of exercise, not understanding effective stress management, and rarely paying attention to foot care. at this stage, reflective dialogue is conducted with the patient, reviewing past actions and plans to address identified obstacles. additionally, alternative methods are carried out to achieve optimal outcomes and enhance the patient’s motivation by showing the potential for excellence. diabetic patients are allowed to decide level of objectives and plans to be achieved in managing self-care. third meeting the third meeting is to carry out assessments and provide feedback. at this meeting, study explores matters related to the targets and objectives, exploring achievements, obstacles, and advantages to obtain ways for further improvement. this is the final stage of health coaching activities, where the coach evaluates and monitors the implementation of behavior changes while motivating patients. an obstacle that often occurs is in regular exercise since dm patients do not carry out sports activities according to the correct rules. the reality was that patients did not comply with recommendations for good physical activity. engaging in daily tasks constitutes exercise, thereby aiding in the regulation of blood glucose levels. poorly controlled glucose levels can lead to complications, emphasizing the importance of regular physical activity in managing the condition. exercise can be performed regularly, three to four times per week, with a total time commitment of around 30 minutes. physical activities such as walking and jogging can improve insulin sensitivity, resulting in better blood glucose control.12 hba1c levels in the intervention and control groups before treatment the results of the pre-examination of hba1c levels in the intervention and control group showed that the mean score for hba1c levels was 9.06 and 9.13, respectively. based on the statistical tests, a p-value of 0.897 was obtained, where the value was >0.05. therefore, there was no difference between the intervention and the control groups, which were stated to be equivalent. examination of hba1c levels described the daily average blood glucose and carbohydrate levels over two months. this examination monitors the disease’s progress and determines the development of the complications. in these two groups, patients were unable to exercise control over dm management. furthermore, blood glucose levels must be kept under control to prevent the manifestation of various complications. measuring glycated hemoglobin (hba1c) is a reasonable glycemic control to determine blood glucose levels over the last two to three months. a person is said to have dm when hba1c level is ≥6.5%. patients with hba1c levels >7% are at a two times higher risk of experiencing complications. according to the united kingdom prospective diabetes study (ukpds), a 1% reduction in hba1c will reduce the risk of peripheral vascular disease, complications, death, and myocardial infarction by 43%, 35%, 21%, and 14%, 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13060] [page 109] non -co mmerc ial us e o nly respectively.13 hba1c is used as an excellent determinant indicator for diagnosing diabetes and prediabetes. analysis of hba1c glycated hemoglobin in blood showed evidence of an average glucose level for about two to three months. hba1c test is recommended as a standard of care for testing and monitoring type 2 dm.14 previous study explained that hba1c levels could be a specific sign of the appearance of dm complications such as cardiovascular disease, nephropathy, or retinopathy 15. level is different for each patient and this depends on the history of dm as well as the long-term or short-term use of insulin doses and tablets. another study showed that there was a significant relationship between carbohydrate, fat, and fiber intake with hba1c levels (p <0.05), median carbohydrate, fat, and fiber intake of 254.25 grams, 96.09 grams, and 19.1 grams, respectively.16 health coaching and behavioral counselling related to dm were often aimed at patients with hba1c above 7.0%17 since poor control during the pre-test had a more significant intervention effect. in addition, education about dm given to change self-management behavior was only effective for patients with hba1c above 8%.18 hba1c levels in the intervention and control groups after treatment hba1c levels in the intervention and control groups (p-value 0.000) were 5.98 and 10.59, respectively. this condition shows that hba1c for the intervention group is lower or better than the control. in the treatment group, the intervention was given in the form of psychoeducation with health coaching method, and media modules, while in the control, only modules were provided. a method of increasing knowledge is providing education about the management of dm, which is repeated even though the patient has received information. material about dm is presented comprehensively to implement treatment and the explanations are carried out using simple language. the provision of structured education can change the functional dimension, namely, the patient’s essential ability to read and understand health information. these skills enable individuals to obtain meaning from various forms of communication, such as interpersonal, modules, and the application of new information to everyday life. from the information received, dm patients can act independently and interact with information providers such as health workers.19 patient education is closely related to disease prevention and knowledge of illness allows individuals to take action. this is aimed at optimizing behavior for overcoming health problems and improving health status. the variable informs patients about all health problems and the relationship with behavior.20,21 health coaching is carried out for the treatment group by identifying problems in individuals, as well as formulating, implementing and evaluating alternative solutions. this educational method is implemented to facilitate patients in articulating aspirations, identifying concerns, expressing desired changes, and specifying the support required.22 furthermore, health coaching is effective in terms of client self-efficacy as well as adherence to behavior change and medication.23 in a randomized controlled trial comparing health coaching to usual care, dm patients significantly improved hba1c levels, medication adherence, exercise, stress, and health status.24 differences in hba1c levels before and after the intervention in the treatment group and the control group hba1c level values between pre and post in post-intervention subjects were declared significantly different and experienced a decrease. in control subjects, hba1c levels based on the mean±sd value increased with a p-value of 0.001. the results related to health coaching significantly increased hba1c in type 2 dm patients by 0.62% and also healthy diet behavior. furthermore, previous study also found that intervention could improve hba1c by 0.68%.25 the study proves effectiveness of the intervention method among patients in taiwan through a randomized controlled trial. this has reached the clinical effectiveness threshold of hba1c (0.3-0.5%)26 and is primarily implemented by providing motivation.27,28 this study shows that coaching is effective in promoting healthy eating. the process can significantly reduce daily calories and food while increasing vegetable intake in line with the modules distributed. the effect of health coaching intervention on blood sugar control may show a causal relationship. dietary control is the most important therapy for type 2 dm and is also the safest control mechanism. nutritional interventions effective in the maintenance management of type 2 dm and result in improved self-monitoring of blood glucose, blood lipids, hba1c, blood pressure, and weight management can lead to reductions in medications, hypoglycemia frequency, hospitalizations, and treatment health costs.29 in the control group, hba1c levels increased significantly despite being given a module related to care containing the dsme program. this shows that providing information through modules cannot improve behavior or habits. the situation is consistent with study where health education is insufficient to change patient behavior and habits.27,30 therefore, education through modules is less critical in helping patients achieve correct and adequate health knowledge without showing effectiveness. this is supported because health coaching is more effective than education for behavior changes and habit formation.31 adult learning patterns are based on experience and tend to build behavior through adjustments.32 a previous study found that health coaching significantly improved diabetes control, decreasing hba1c after intervention in a group of low-income patients.11 in addition, health coaching improved patient glycemic control, with hba1c levels 0.8% lower in the intervention group than control.33 the results concluded that health coaching is an effective intervention to improve glycemic control, and this leads to a significant decrease in hba1c levels.34 changes in behavior in the treatment group can build self-management abilities to provide insight into actions of making the best decisions.35 conclusions in conclusion, this study was an application of psychoeducation with health coaching method carried out for dm patients who require long-term management. interventions provided to the treatment group, comprising education, health coaching, and the distribution of modules effectively lowered hba1c levels compared to the control group, which was only given modules. a decrease in levels showed the behavior of dm patients for 2-3 months. therefore, health workers, specifically nurses must reduce psychological burden by providing time to conduct health coaching for dm patients. 4th international nursing and health sciences symposium [page 110] [healthcare in low-resource settings 2024;12(s1):13060] non -co mmerc ial us e o nly references 1. sasombo a, katuuk me, bidjuni h. relationship between self care and diabetes 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on glycaemia control in patients with type 2 diabetes. iran red crescent med j 2014;16(12). 8. formica c, la face a, lo buono v, di cara m, micchìa k, bonanno l, et al. factors related to cognitive reserve among caregivers of severe acquired brain injury. j clin neurosci 2020;77:94–7. 9. lendra l. the level of trust in partnership relationships between contractors and subcontractors in surabaya [internet]. 2006. available from: https://www.researchgate.net/publication/43801103_tingkat_kepercayaan_dalam_hubungan_kemit raan_antara_kontraktor_dan_subkontraktor_di_surabaya. 10. af d, nursalam n, suharto s. the effectiveness of supportive educative in increasing self regulation, self efficacy, and self care agency to control glichemic index in patient with type ii diabetes. j ners 2017;8:253–70. 11. ghorob a, vivas mm, de vore d, et al. the effectiveness of peer health coaching in improving glycemic control among low-income patients with diabetes: protocol for a randomized controlled trial. bmc public health 2011;11:208.  12. imelda si. faktor-faktor yang mempengaruhi terjadinya diabetes melitus di puskesmas harapan raya tahun 2018. sci j 2019;8:28–39. 13. ramadhan n, marissa n, fitria e, wilya v. pengendalian diabetes melitus tipe 2 pada pasien di puskesmas jayabaru kota banda aceh. media penelit dan pengemb kesehat. 2018;28:239–46. 14. sherwani si, khan ha, ekhzaimy a, et al. significance of hba1c test in diagnosis and prognosis of diabetic patients. biomark insights. 2016;11:bmi.s38440. 15. haryanto h, arisandi d, suriadi s, et al. relationship between maceration and wound healing on diabetic foot ulcers in indonesia: a prospective study. int wound j 2017;14:516–22. 16. harna h, efriyanurika l, novianti a, et al. nutritional status, macronutrient intake and its relation to hba1c levels in type 2 diabetes mellitus patients. poltekita j health sciences 2022;15:365–72. 17. ekong g, kavookjian j. motivational interviewing and outcomes in adults with type 2 diabetes: a systematic review. patient educ couns 2016;99:944–52. 18. nishita c, cardazone g, uehara dl, tom t. empowered diabetes management. heal educ behav 2013;40:581–91. 19. nutbeam d. defining, measuring and improving health literacy. heal eval promot 2015;42:450–6. 20. mccleary-jones v. health literacy and its association with diabetes knowledge, self-efficacy and disease self-management among african americans with diabetes mellitus. abnf j 2011;22:25–32. 21. sassen b. nursing: health education and improving patient self-management [internet]. 2018 [cited 2023 aug 12]. available from: https://link.springer.com/book/10.1007/978-3319-51769-8 22. national institute for health and care excellence type 2 diabetes mellitus: medicines optimization priorities. nice [internet] 2019:10. available from: https://www.nice.org.uk/ guidance/ktt12 23. kreindler s. lifting the burden of chronic disease: what has worked? what hasn’t? what’s next? healthc q 2009;12:30– 40. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13060] [page 111] correspondence: minarti, nursing department, health polytechnic of the health ministry of surabaya, pucang jajar tengah street no. 56, 60282 kertajaya, gubeng, surabaya, east java, indonesia. tel.: +62315028141 fax: +62-5028141 e-mail: minartiivan@gmail.com key words: health coaching; hba1c levels; psychoeducation; type 2 diabetes mellitus contributions: m1 participated in the study design, data collection and analysis, manuscript writing, and reference search. s and m2 participated in the study design, data collection, and analysis. aa participated in data collection, analysis, and reference search. nf participated in the data analysis, manuscript writing, and reference search. conflict of interest: the author declares no potential conflict of interest. funding: this study was financially supported by health polytechnic of the health ministry of surabaya ethics approval: an ethical clearance letter was gained from health research ethics commission of health polytechnic, ministry of health, surabaya, number: ea/1081/kepk-poltekkes_sby/v/2022 clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgement: the authors are grateful to the director of surabaya health polytechnic for funding this study. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13060 doi:10.4081/hls.2024.13060 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly 24. wolever rq, dreusicke m, fikkan j, et al. integrative health coaching for patients with type 2 diabetes. diabetes educ 2010;36:629–39. 25. chen ry, huang lc, su ct, et al. effectiveness of short-term health coaching on diabetes control and self-management efficacy: a quasi-experimental trial. front public heal 2019;7. 26. european medicines agency (ema). guideline on clinical investigation of medicinal products in the treatment or prevention of diabetes mellitus. eur med agency 2012;44:1–28. 27. werbrouck a, swinnen e, kerckhofs e, et al. how to empower patients? a systematic review and meta-analysis. transl behav med 2018;8:660–74. 28. pirbaglou m, katz j, motamed m, et al. personal health coaching as a type 2 diabetes mellitus self-management strategy: a systematic review and meta-analysis of randomized controlled trials. am j heal promot 2018;32: 1613–26. 29. jaata j, astuti w. health coaching in patients with diabetes mellitus. aceh; penerbit muhammad zaini; 2017. 30. jellema s, wijnen mam, steultjens emj, nijhuis-van der sanden mwg, van der sande r. valued activities and informal caregiving in stroke: a scoping review. disability rehabilitation 2019;41:2223–34. 31. merriam sb. the changing landscape of adult learning theory. in: review of adult learning and literacy, volume 4 [internet]. routledge; 2004 [cited 2023 aug 12]. p. 199–220. available from: https://www.taylorfrancis.com/chapters/edit/10.4324/9781410 610485-6/changing-landscape-adult-learning-theory-sharanmerriam 32. kessler d, graham f. the use of coaching in occupational therapy: an integrative review. aust occup ther j 2015;62:160–76. 33. varney je, weiland tj, inder wj, jelinek ga. effect of hospital-based telephone coaching on glycaemic control and adherence to management guidelines in type 2 diabetes, a randomised controlled trial. intern med j 2014;44:890–7. 34. sherifali d, viscardi v, bai jw, ali rmu. evaluating the effect of a diabetes health coach in individuals with type 2 diabetes. can j diabetes 2016;40:84–94. 35. kolb l. an effective model of diabetes care and education: the adces7 self-care behaviorstm. sci diabetes selfmanagement care 2021;47:30–53. 4th international nursing and health sciences symposium [page 112] [healthcare in low-resource settings 2024;12(s1):13060] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13355 emotional responses, status disclosure, stigma, and hope among people living with hiv: a phenomenological study ikbal fradianto, nadia rahmawati, gabby novikadarti rahmah department of nursing, faculty of medicine, tanjungpura university, pontianak, indonesia abstract hiv/aids cases continue to increase globally and nationally. in indonesia, west kalimantan has the highest hiv/aids incidence, especially in pontianak city. this study employs a descriptive qualitative design with a phenomenological approach to explore the emotional experiences of individuals living with hiv (person/people living with hiv, plhiv) within this demographic. a purposive sampling technique was used to select twelve participants, aged 18 to 60, who were active community peer group support members at yayasan pontianak plus. data were collected through in-depth interviews and observations. thematic analysis, utilizing colaizzi’s method, identified four major themes: i) emotional responses to hiv confirmation, which include two subthemes: acceptance and denial; ii) disclosure status, which comprises two subthemes: undisclosed and disclosed; iii) stigma and perception, which include sources of stigma and forms of hiv stigma; and iv) hope for the future, consisting of hopes for themselves and hopes for others. this study enhances understanding of the complex emotional landscape of plhiv and underscores the crucial role of social support in fostering resilience and hope. introduction since the first case of hiv/aids was reported in 1981, there has been a yearly increase. the prevalence of hiv/aids among young people has increasingly become a focal point in indonesia each year. globally, in 2022, unicef recorded 1.65 million adolescents aged 10-19 years living with hiv. according to the pediatric association report (2022), the age group of 15-19 years old, classified as adolescents, exhibits the highest prevalence of hiv infection, with approximately 741 adolescents affected.1 according to unicef indonesia, adolescents’ knowledge of hiv/aids has increased but is still limited.2 the distribution of hiv/aids in 2020 in west kalimantan, especially pontianak city, has ranked first with the highest number of cases, followed by mempawah and singkawang regencies. based on the report of the infectious disease prevention and control section of the health service in west kalimantan in 2022, the most significant percentage of hiv/aids cases occurred in the 25-49 age group (71.2%), followed by the 20-24 age group (17.7%), ≥50 years (5.3%), 15-19 years (4.5%), ≤4 years (1.1%), and 5-14 years (0.2%).3 aids comprises a series of diseases induced by hiv, which is transmissible and lethal. the virus harms the human immune system, leading to reduced immunity, particularly when t lymphocytes are affected, resulting in decreased cd4 cells that are crucial for combating infections. an individual infected with hiv experiences a compromised immune system, which significantly increases their vulnerability to serious diseases and may ultimately result in mortality.4 since 2010, the global spread of hiv/aids among adolescents has decreased, but this decline is not significant when compared to the overall increase in cases. unicef stated that in 2020, adolescents contributed to 5% of all people living with hiv (plhiv), which is around 1.7 million people aged 10-24 years.5 despite the global effort, gaps in youth knowledge about hiv/aids remain a critical public health challenge, especially in resource-limited settings.6 the phenomenon of hiv/aids remains a significant global public health concern, affecting millions of individuals worldwide. alongside its medical implications, hiv/aids presents complex emotional and social chalcorrespondence: ikbal fradianto, tanjungpura university, jl. prof. dr. h. hadari nawawi, pontianak, indonesia. e-mail: ikbal.fradianto@ners.untan.ac.id key words: emotional responses; hiv; openness; stigma; hope. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: ethical approval for this study was obtained from the ethics committee of the faculty of medicine universitas tanjungpura (date of approval: 29 may 2024, number: 6186/un22.9/pg/2024). prior to the survey, participants were provided with a detailed explanation of the study protocol, and informed consent was obtained through agreement documents. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: data generated or analyzed in this study are available from the corresponding author upon reasonable request. acknowledgments: the author would like to express their sincere gratitude to all the participants in this study for their openness and willingness to share their deeply personal experiences, which made this research possible. special thanks to the professionals and institutions that supported and facilitated the recruitment process. finally, we are deeply thankful to our colleague for supporting this research. received: 7 november 2024. accepted: 3 march 2025. early access: 9 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13355 doi:10.4081/hls.2025.13355 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13355] [page 131] lenges for plhiv. emotional responsiveness, the ability to perceive, understand, and manage emotions effectively, is a critical factor that shapes the psychological and social experiences of plhiv. research indicates that emotional responsiveness influences how individuals cope with the stress of living with a chronic illness, particularly one as stigmatized as hiv.7 recognizing the importance of emotional responsiveness can lead to more empathetic care and support for people living with hiv. disclosure of hiv status is a multifaceted and often distressing process for plhiv, as it involves the fear of stigmatization and discrimination. numerous studies have documented the psychological and social complexities surrounding hiv status disclosure, with many individuals opting for concealment to avoid social exclusion.8 various factors, including perceived stigma, social support, and cultural context influence the decision to disclose one’s hiv status.9 this phenomenological study aims to explore the lived experiences of plhiv concerning their emotional responses and decisions surrounding disclosure, providing a deeper understanding of this critical issue. hope is an essential psychological resource for individuals managing chronic illnesses, particularly for plhiv. research has shown that hope can enhance psychological resilience, adherence to treatment, and overall well-being in individuals living with hiv.10 this aligns with the research conducted by siril et al., which suggests that hope can enhance the quality of life for individuals living with chronic illnesses. a lack of hope is correlated with increased levels of depression and anxiety, which can further worsen the quality of life.11 facilitating hope can be an important element of non-pharmacological interventions that can be utilized in the management of hiv sufferers. beliefs and hopes are crucial in facing difficult situations and maintaining a good quality of life, as they help mitigate the psychosocial consequences of such conditions.12 the relationship between hope and emotional responsiveness is central to the coping strategies employed by plhiv, as hope can attenuate the negative effects of stigma and discrimination. this study will investigate how hope interacts with emotional responsiveness and stigma in shaping the lived experiences of plhiv. despite advances in medical treatment and public health awareness, stigma remains a persistent barrier to the well-being of plhiv. the impact of stigma is profound, affecting not only mental health but also the social and economic opportunities available to individuals with hiv.13 stigmatization often leads to social isolation, reduced access to healthcare services, and heightened emotional distress.14 although many studies have addressed the impact of stigma on plhiv, most studies have focused on psychosocial aspects separately, such as stigma or mental health. however, the relationship between emotional responses, disclosure of hiv status, stigma, and hope has not been explored in depth. previous research has tended to ignore a holistic perspective that includes how these factors influence each other, especially from the perspective of the individual experiencing it directly. in addition, different cultural and social contexts, such as in areas with high levels of stigma, are often under-considered, so research results cannot always be applied universally. this research offers a new perspective for plhiv regarding emotional responses, disclosure of hiv status, stigma, and hope. focusing on individuals’ lived experiences in specific social and cultural contexts, particularly in areas with high hiv stigma, can provide deeper and more contextual insights. with this approach, research can identify the need for interventions that are not only psychological in nature but also include social and emotional dimensions. this approach also opens up opportunities to develop empathy-based intervention strategies that are more relevant and effective for plhiv. materials and methods this study used a descriptive qualitative design and a phenomenological approach. the sampling procedure utilized purposive sampling techniques with criteria-based selection. inclusion criteria were: i) individuals diagnosed with hiv; ii) aged 18 to 60 years; iii) active members of the community peer group support yayasan pontianak plus; iv) able to communicate effectively; and v) willing to participate in this study. conversely, plhiv experiencing adverse conditions, such as being in intensive care in a hospital or living alone without family, were excluded. the data were collected via in-depth interviews utilizing participant-specific guidelines and direct observation of the subjects. the interview guidelines were validated by experts in hiv nursing to construct key questions. a qualitative study expert also provided positive feedback on the interview guidelines. the interview focused on the thoughts and feelings of the participants, specifically about their emotional responses when they were diagnosed with hiv. each interview took about one hour and was conducted in the yayasan pontianak plus office. each participant was interviewed individually as a form of consideration for their privacy and convenience, and field notes were made during interviews. the data were analyzed using verbatim reports by collaizi’s method, which included: i) reading the transcript of the interview and field notes to obtain a general picture of the participant’s experience about emotional responsivity, openness, stigma, and the hope for the future; ii) reading the transcript repetitively to find the key or significant statements from participants; iii) searching for meaning in the participant’s key statement; iv) grouping each meaning obtained into themes (researchers made a theme analysis table consisting of keywords, categories, themes, and subthemes); v) integrating all the themes that emerged into a comprehensive description and verifying the transferability of the data (the themes that emerged have been discussed with two supervisors and two experts to create a comprehensive description as a clear statement); vi) validation of the results through member checking as a means of confirmability. to support confirmability, the authors, who had no prior relationship with the participants, conducted all interviews using a consistent guide, and multiple researchers analyzed the data. researchers presented the analysis results to the participants to gather their feedback on the findings. trustworthiness was established through multiple methods, including creating verbatim reports for each session and having each patient confirm the credibility and validity of the data and analyzed results. to ensure transferability, the researchers employed methodological triangulation, which involved conducting interviews, observations, and documentation throughout the interview process. ethical approval for this study was obtained from the ethics committee of the faculty of medicine universitas tanjungpura (date of approval: 29 may 2024, number: 6186/un22.9/pg/2024). prior to the survey, participants were provided with a detailed explanation of the study protocol, and informed consent was obtained through agreement documents. they were made aware of their right to decline participation and their freedom to withdraw from the study at any time. all data collected were kept confidential and anonymous. article [page 132] [healthcare in low-resource settings 2024;12:13355] results the study comprised 12 participants whose characteristics exhibited diversity in age, gender, marital status, transmission risk factors, antiretroviral (arv) therapy usage, illness duration, occupation, and educational attainment. table 1 presents the characteristics of the respondents. the participants included 9 males and 3 females, with ages ranging from 23 to 54 years. their occupations varied: 1 participant was a junior high school student, 5 were senior high school students, 1 was a d4 student, and 5 were undergraduate students. most respondents, with varying ages and occupations, had risk factors associated with transmission, primarily due to the use of injection needles or sexual intercourse. moreover, most respondents had been receiving arv treatment for an extended duration, demonstrating their capacity to adapt to the challenges encountered. theme 1: emotional responses to hiv confirmation upon receiving their hiv diagnosis, participants exhibited a range of emotional responses. one participant demonstrated acceptance of his/her condition, while others displayed signs of denial. below are selected quotes from interviews conducted with the participants: acceptance acceptance is a phase of grieving. participants said that they embrace the disease as if it were a matter of faith. one participant stated: “god wants me to do whatever i want… in the end, i accepted it as it is, but there is still a plan… finally, i thought about committing suicide at that time.” (p8) denial denial is the first phase of grieving. most of the participants expressed disbelief about their disease. they stated that they never expected to have hiv. the forms of denial varied among them; some felt shocked and scared, struggling to comprehend what had happened. others even expressed suicidal thoughts. here are some quotes from the interviews: “wow… like a bolt of lightning in broad daylight… shocked, down. eee closed me off at first.” (p1) “the feeling was the same as most of my friends, sad. is this like despair?” (p2) “hm.. in 2007, i was still at the stage of not accepting the status, right?” (p3) “like being struck by lightning, hmm, like i didn’t expect it.” (p5) “even then, i was scared.” (p6) “at first i felt very down… my feelings couldn’t accept it at that time.” (p10) “so at that time i was shocked, sis… i thought maybe i shouldn’t get married anymore.” (p12) theme 2: disclosure status the results of this qualitative study exploring hiv status disclosure among plhiv reveal a diverse range of experiences and decisions regarding openness about their condition. the data from in-depth interviews with 12 participants underscores how factors such as relationship dynamics, family support, and personal coping strategies shape the disclosure process. the study found that while some individuals disclosed their status to their partners, families, and communities, others opted for secrecy, often driven by fear of stigma or rejection. this theme consisted of two subthemes, i.e., undisclosed and disclosed. several participants expressed a willingness to disclose their hiv status to their partners, particularly before entering long-term relationships or marriage, emphasizing that honesty was crucial. the participants stated: “before getting married, i was open with my partner.” (p3) “i informed my partner about my status…” (p7) another participant emphasized the community’s ethical responsibility to disclose their hiv status and stated: “thank god, i know now that, generally, we in the community are required to be informed.” (p1) “i opened my status to my friend in the community.” (p8) on the other hand, some participants open their status to family core members: “at first the family didn’t know, but after a while my mother found out, but thank god she was supportive…” (p7) “then i opened my status to my parents and opened it to my siblings, too. but thank god, my family accepted it, even supported it… supported, so maybe from there my condition quickly improved even though it was gradual.” (p5) “i opened my status to my father, meanwhile my father was unhealthy, he shocked after listening to the fact.” (p8) some family members were initially shocked, but afterward, participants reported that their families, particularly their parents, provided strong support. this support appeared to positively impact their well-being, as one participant mentioned that his/her health improved after receiving emotional and practical backing from their family. the role of family acceptance emerged as a significant factor in fostering resilience and hope among plhiv. in contrast, a few participants chose not to disclose their hiv status to anyone, including their family members. these individuals chose to conceal their status to guard against potential stigma, discrimination, or emotional distress. they stated: “no one in my family knows…” (p12) “regarding my status, i keep everything to myself…” (p8) theme 3: stigma towards plhiv this theme comprises 2 subthemes: sources of external stigma faced by participants and forms of hiv stigma received by participants both in the environment and in health services. here are some instances from interviews with participants experiencing stigma due to cultural beliefs: “you know, our country, specifically in this area, has a strong culture that believes hiv is a cruise…” (p4) “the moral values are opposite with factors that transmit hiv, so there will be more stigma for me…” (p9) the other subtheme is “forms of hiv stigma received by participants”, which are: social stigma, institutional stigma, and healthcare stigma. some interview participants reported experiencing social stigma: “many people in here believe that hiv is a disease caused by a great sin.” (p8) “people worry about interacting with people with hiv.” (p12) one participant discussed the issue of institutional stigma, stating: “so hard to apply for work because the institutions have a specific required health status.” (p3) healthcare stigma experienced by participants was a common theme. some participants expressed the following: “once the nurse asked, ‘are you hiv positive?’, i was confused and didn’t know how to react, like…hmmm… i panicked. article [healthcare in low-resource settings 2024;12:13355] [page 133] why was the nurse doing this, right?” (p2) “sometimes, health professionals are still giving us stigma and discrimination. they looked at me disrespectfully. i didn’t know if it was a joke or not, but it felt like that.” (p6) “i got a bad response from public health service when i took my arv. it makes me worry every visit to healthcare.” (p11) theme 4: hope and desire for the future this theme encompasses two subthemes: personal hopes and hopes for others. the personal hopes of plhiv include various aspirations, such as achieving a better quality of life, receiving strong social support, and experiencing a reduction in stigma and discrimination. also, plhiv hopes to live normally, carry out daily activities without social or medical obstacles, and have equal opportunities in the workplace, education, and social life. this is demonstrated by the results of interviews conducted with several participants, detailed as follows: “that’s why it shouldn’t be a matter of discrimination; it should be a matter of friends getting their right to get a job... i mean, it should be easier; there should be an easy system to make it easier.” (p6) the hope for others includes advancements in treatment technology that will enable better infection control, improve health, and extend life expectancy. this is supported by the results of interviews with several participants: “i hope my spouse doesn’t get infected and wants to do the test. even if it’s positive, just take arv early and don’t be ashamed anymore.” (p1) “so that we can live a normal life even though we have hiv, like ordinary people... there is still hope that the arv stock will be subsidized by the government because the drugs are expensive.” (p2) “yes... the hope is to survive, that’s for sure, and secondly, but this can’t be done, it can’t be done… i don’t know if research can lead to a cure, thank god. if that’s not the case, try to keep taking medicine and working.” (p4) “hopefully you stay healthy, don’t ever get tired of taking medicine.” (p11) discussion the study discusses participants’ varied emotional responses after receiving an hiv diagnosis. these responses span multiple stages, from denial to acceptance, reflecting the complexity of individuals’ psychological experiences in reaction to challenging health conditions. these findings align with literature suggesting that many factors, including social support, personal understanding of the disease, and cultural context, often influence emotional responses to a chronic disease diagnosis.15 based on the interviews, one of the participants (p1) described his experience very powerfully: “like being struck by lightning in broad daylight... shocked, down. eee shut down at first”. this statement describes a common shock reaction following diagnosis, in which individuals feel devastated and unprepared to face the new reality. a similar reaction was also expressed by p5, who stated, “it was like being struck by lightning... didn’t expect it”. these responses suggest that the beginning of the emotional journey is often marked by feelings of profound helplessness and uncertainty, which can result in individuals withdrawing from necessary social support. apart from feelings of shock, sadness and hopelessness were dominant themes in interviews with several participants. p2 expressed, “the feeling was the same as most of my friends, sad. is this like despair?”. this sadness may be caused by the strong social stigma towards hiv, which often leads to reduced selfesteem and feelings of hopelessness.16 in this context, the emotional reactions shown by participants can be understood as a reflection of the collective experience of individuals facing an hiv diagnosis in a society that still has negative prejudices towards the disease. the process of accepting hiv status is also an important part of the discussion. p3 indicated that in 2007, he was still in the “not yet disclosed” stage. this acceptance process often takes a long time and can be hampered by external factors, such as a lack of social support or adequate information about hiv.17 p8, who stated, “i accept it, but there are still plans... in the end, i thought article [page 134] [healthcare in low-resource settings 2024;12:13355] table 1. characteristics of respondents. participants age sex marital risk factor of arv duration occupation level of status transmission consumption of illness education p1 47 male married iv drug user arv 18 years salesman high school p2 44 male married iv drug user arv 20 years administration high school p3 37 male married iv drug user arv 15 years seller high school p4 38 male single sexual intercourse arv 3 years teacher bachelor p5 39 female married sexual intercourse arv 14 years housewife high school p6 32 male married iv drug user arv 16 years private sector employee bachelor p7 30 female married sexual intercourse arv 6 years housewife bachelor p8 28 male single sexual intercourse arv 5 years private sector employee bachelor p9 34 male married sexual intercourse arv 2 years teacher bachelor p10 54 female married sexual intercourse arv 14 years private sector employee junior high school p11 23 male single sexual intercourse arv 3 years private sector employee diploma p12 24 male married sexual intercourse arv 6 years singer high school about committing suicide”, indicated that despite efforts to accept the diagnosis, there is still a deep inner conflict that can trigger negative thoughts. fear of the future also emerges as a significant emotional response. p6 expressed, “at that time, i was scared”, reflecting anxiety about the consequences of the diagnosis. this fear is often related to the stigma attached to hiv, which can make individuals feel isolated and helpless in facing daily life challenges.18 this suggests that psychological support and understanding from those closest to them are essential to help individuals overcome fears and rebuild their self-confidence. overall, the results of this study emphasize the need for emotional and psychological support for plhiv to help them through the complex adaptation process after diagnosis. the range of responses, from shock to acceptance, reflects a long and often difficult emotional journey. therefore, healthcare providers must understand these emotional dynamics and provide appropriate interventions to help individuals manage their emotional responses. most of the participants involved in this study indicated a desire to disclose their hiv status to a partner before entering a long-term relationship or marriage. this aligns with findings that state that honesty in romantic relationships is very important for building trust and openness.19 for example, p3 stated, “before getting married, i was open with my partner”. this suggests that some individuals feel an ethical obligation to be honest with their partners, which is the foundation of a healthy relationship. support from family also plays an important role in the disclosure experience. some participants reported that although they initially felt fear and worry from their family upon revealing their hiv status, particularly from their parents, the emotional and practical support from their family after the initial shock significantly improved their well-being. p7 emphasized, “at first, the family didn’t know, but after that, my mother found out, and thankfully she was supportive”. these findings are in line with previous research, which shows that family support can help plhiv overcome the challenges they face and contribute to improving their health and well-being.20 on the other hand, some participants chose not to reveal their hiv status to anyone, including family members. the decision to keep this status is felt as a way to protect oneself from stigma, discrimination, or emotional burdens. one participant asserted, “no one in the family knows about my condition”, reflecting a fear of negative consequences such as rejection or social isolation. previous research also shows that hiv-related stigma often acts as a barrier for plhiv to share information about their health status.18 these varying experiences of disclosure and confidentiality highlight the complex and highly personal nature of disclosing hiv status. for some participants, disclosure resulted in greater emotional support and strengthened relationships. in contrast, for others, the decision to remain silent was influenced by a desire to avoid stigma and protect their social status. these findings demonstrate the importance of healthcare providers and support networks respecting individual choices and offering interventions tailored to the unique emotional and social contexts plhiv faces as they navigate their disclosure decisions. stigma towards people living with hiv/aids (plwha) remains a significant challenge in their experiences while undergoing care and treatment. this stigma arises not only from the general public but also from health workers who are supposed to provide the necessary support and care. interviews with participants revealed that they often feel discomfort and confusion when interacting with health workers who exhibit discriminatory behavior. one participant (p2) stated, “once the nurse asked, ‘are you hiv positive?’ i was confused and didn’t know how to react… hmmm… i panicked”. these reactions show how deeply stigma affects the emotional state of plwha, which can worsen their mental health. p6’s statement also reinforced this condition: “sometimes, health professionals still provide stigma and discrimination. they looked at me with disrespect. i don’t know if it was a joke or not, but it felt like that”. this condescending attitude from health professionals not only impacts the relationship between plhiv and healthcare providers but can also hinder their access to adequate care.21 distrust of the health system can make plhiv reluctant to seek care, potentially worsening their overall health. based on previous research, stigma towards plhiv can result in avoidance of health services, resulting in negative consequences for disease management and quality of life.22 therefore, it is important for health institutions to provide training and education for health workers regarding sensitivity to stigma issues and the importance of creating a supportive environment. raising awareness of this stigma can help reduce the discrimination experienced by plhiv and encourage them to be active in managing their health. efforts to educate health workers and increase public awareness about hiv/aids must be carried out continuously to reduce stigma and support the mental and physical health of plhiv. discussing the hopes of plhiv reveals that, despite facing numerous challenges, they have strong aspirations to enhance their quality of life and combat social stigma. this hope includes the desire to live normally and carry out daily activities without obstacles, both from a social and medical perspective. this is reflected in participant statements, such as p1, which emphasized preventing transmission to partners and having the courage to get tested. this statement shows the awareness and responsibility of plhiv in maintaining their health and that of others. another participant, p2, expressed his hope of getting government support in providing affordable arv drugs. this indicates that while plhiv aspire to live normal lives, they also understand the importance of accessing adequate treatment to achieve this goal. support from the government and society in reducing medical costs can improve the quality of life of plhiv.23 in addition, p4’s expression of hope to continue fighting and working demonstrates the resilience and enthusiasm of plhiv to keep living despite facing limitations. participants also expressed concerns about stigma and discrimination, as demonstrated by p6, who asked for easier access to rights such as employment. this is in line with previous research, which shows that social stigma can be a significant barrier for plhiv in achieving their full potential, both at work and in social life.22 lastly, the hope of plhiv to remain healthy and committed to treatment, as expressed by p11, emphasizes the importance of social support in their journey. support from family, friends, and the wider community can be a determining factor in improving plhiv’s hope and quality of life.21 overall, the hopes expressed by plhiv reflect a strong desire to adapt and live a meaningful life despite existing challenges. infectious diseases must be taken seriously to control their transmission and prevent community spread.24 families are integral to the lives of individuals with infectious diseases, as they are usually the patient’s nearest support system. their support is essential for helping the patient maintain a healthy lifestyle.25 this study had some limitations. due to its qualitative design and the sample primarily consisting of melayu and dayaknese ethnic patients, the findings may not fully represent other populations. additionally, as this small study was conducted in a single practice, it may not accurately reflect the opinions of all individuals living with hiv nationwide. article [healthcare in low-resource settings 2024;12:13355] [page 135] conclusions this phenomenological study reveals the complex interplay between emotional responsiveness, hope, stigma, and the disclosure of hiv status among plhiv. participants demonstrated varying levels of emotional acceptance, with some experiencing initial denial or physical symptoms that impacted their emotional state. motivations for treatment adherence were often rooted in internal and external support sources. disclosure of hiv status was influenced by personal, familial, and social dynamics, with some individuals choosing openness while others opted for secrecy due to fear of stigma. the study also highlighted the role of health information, decision-making processes, and the utilization of healthcare services, as well as the critical role of family caregivers in the care of plhiv. barriers to accessing care, including challenges related to healthcare services and employment, were significant. still, the presence of personal hope and external support systems emerged as crucial factors in overcoming these obstacles. addressing stigma and fostering support systems is essential for improving the emotional and physical well-being of plhiv. further studies involving diverse ethnicities are necessary to gain a broader understanding; this should be a focus for future research. references 1. ikatan dokter anak indonesia (idai). laporan hiv/aids pada anak dan remaja. jakarta: idai; 2022. 2. unicef. hiv/aids and young people: a global perspective. new york: unicef, 2022. 3. ministry of health indonesia. profil kesehatan provinsi kalimantan barat 2022. pontianak: dinas kesehatan provinsi kalimantan barat, 2023. 4. li z, yan p, wang r, et al. persistent t cell proliferation and mdscs expansion precede incomplete cd4+ t cell recovery in people with acute hiv-1 infection with early art. heliyon 2023;9:e15590. 5. unicef. the state of the world’s children 2021: on the brink of a covid-19 generation. new york: unicef, 2021. 6. mela m, maulana ma, rahmah rgn. overview of adolescent knowledge about hiv/aids. proners 2024;9:206. 7. nabila in, rokhmah d, nafikadini i. emotional regulation on people living with hiv/aids: case study in pelangi peer supporting group. jikm 2025;16:46-61. 8. yu ch, huang cy, ko ny, et al. the lived experiences of stigmatization in the process of hiv status disclosure among people living with hiv in taiwan. int j environ res public health 2021;18:5089. 9. ojikutu bo, pathak s, srithanaviboonchai k, et al. community cultural norms, stigma and disclosure to sexual partners among women living with hiv in thailand, brazil and zambia (hptn 063). plos one 2016;11:e0153600. 10. shi c, li x, dai y, et al. experiences, challenges, and needs of people living with hiv in hunan province, china: a qualitative study. j multidiscip healthc 2025;18:1405-21. 11. siril h, smith fawzi mc, todd j, et al. the value of hope: development and validation of a contextual measure of hope among people living with hiv in urban tanzania a mixed methods exploratory sequential study. bmc psychol 2020;8:116. 12. silva ibn, patrício acfa, leite map, et al. hope for life and depression: people living with hiv/aids. rev bras enferm 2020;73:e20190535. 13. parker r, aggleton p. hiv/aids-related stigma and discrimination: a conceptual framework and implications for action. soc sci med 2019;62:417-31. 14. mahajan ap, sayles jn, patel va, et al. stigma in the hiv/aids epidemic: a review of the literature and recommendations for the way forward. aids res hum retroviruses 2020;35:469-78. 15. imani b, zandi s, khazaei s, mirzaei m. the lived experience of hiv-infected patients in the face of a positive diagnosis of the disease: a phenomenological study. aids res ther 2021;18:95. 16. faidas m, stockton ma, mphonda sm, et al. stigma and discrimination faced by adolescents living with hiv and experiencing depression in malawi. bmc glob public health 2024;2:39. 17. meo cm, sukartini t, misutarno m. social support for hiv aids sufferers who experience stigma and discrimination: a systematic review. strada jurnal ilmiah kesehatan 2021;10:1174-85. 18. earnshaw va, chaudoir sr. from stigma to discrimination: stigma and the health of people living with hiv. j health soc behav 2009;50:535-48. 19. mi t, li x, zhou g, et al. hiv disclosure to family members and medication adherence: role of social support and self-efficacy. aids behav 2020;24:45-54. 20. xu jf, ming zq, zhang yq, et al. family support, discrimination, and quality of life among art-treated hiv-infected patients: a two-year study in china. infect dis poverty 2017;6:152. 21. fauk nk, ward pr, hawke k, mwanri l. hiv stigma and discrimination: perspectives and personal experiences of healthcare providers in yogyakarta and belu, indonesia. front med 2021;8:625787. 22. fauk nk, hawke k, mwanri l, ward pr. stigma and discrimination towards people living with hiv in the context of families, communities, and healthcare settings: a qualitative study in indonesia. int j environ res public health 2021;18:5424. 23. bateganya mh, amanyeiwe u, roxo u, dong m. impact of support groups for people living with hiv on clinical outcomes: a systematic review of the literature. j acquir immune defic syndr 2015;68:s368-74. 24. rahmawati n, hapsari ed, lismidiati w, pangastuti n. pengetahuan remaja laki-laki dan kebutuhan pendidikan kesehatan tentang infeksi menular seksual (ims). berita kedokteran masyarakat 2018;34. 25. fradianto i, mita m, yulanda na, et al. family experiences in caring for covid-19 positive at home: phenomenology study. jurnal keperawatan komprehensif 2024;8:203-11. article [page 136] [healthcare in low-resource settings 2024;12:13355] hrev_master healthcare in low-resource settings 2025; volume 13:13016 explication of the mixture of piper betle and eugenia polyantha on oral bacteria neneng nurjanah,1 megananda hiranya putri,1 yenni hendriani praptiwi,1 dewi sodja laela,1 susi sukmasari2 1department of dental nurse, bandung polytechnic of health, jawa barat, indonesia; 2department of paediatric dentistry and dental public health, kulliyyah of dentistry, international islamic university malaysia, kuantan, pahang, malaysia. abstract the aim of this study was to analyze the effectiveness of the mixtures of eugenia polyantha and piper betle leaves against oral bacteria. four compositions of ep and pb were made and observed on tryptic soy agar, blood agar, macconkey agar (mca), and mannitol salt agar (msa). inhibition analysis was conducted at concentrations of 20%, 30%, 40%, 50%, and 60%. our study results indicate that staphylococcus aureus exhibited growth on ba, bacterial colonies were identified on msa, and serological tests confirmed coagulation. a biochemical test conducted on a mca sample revealed several species within the enterobacteriaceae family, including escherichia coli, pseudomonas, klebsiella, and proteus. the highest level of inhibition was observed with the sixth toothbrush (k4). significant differences in inhibition were noted among the various groups (k1, k2, k3, k4, and controls), with the diameter of inhibition for each combination yielding p<0.05. however, the differences in inhibition between the combinations themselves were not statistically significant, with p>0.05. streptococcus sp, klebsiella sp, enterobacteriaceae sp (coliform sp), pseudomonas, and staphylococcus aureus are the contaminant bacteria on used toothbrushes. the highest inhibition level and bactericidal properties were achieved by mixing 70% bay leaf (eugenia polyantha) and 30% betel leaf infusion. introduction the teeth, gums, tongue, mucous membranes, throat, and buccal mucosa provide various surfaces for microbial colonization. in total, there are more than 700 species of microorganisms present in the oral cavity.1,2 the organisms present as commensal and pathogenic microorganisms. over time, pathogenic microorganisms can lead to tooth decay and periodontal diseases. some of these microorganisms adhere to solid surfaces, forming dental biofilm, while others remain suspended in aqueous environments. under adverse circumstances, bacteria can lead to bacteremia and spread to vital organs, such as the heart valves, forming a persistent plaque. therefore, biofilm management or plaque control is needed to prevent oral diseases. many studies have proven the effectiveness of mechanical plaque controls, such as toothbrushing, to manage dental biofilm.3 nevertheless, toothbrushes may become infected with microorganisms from the buccal cavity, environment, hand aerosol, and storage locations.4,5 the microbiomes found on used toothbrushes are associated with the microbiome from various sites in the oral cavity.4,5 the microbiota can lead to cross-contamination with microorganisms in the oral cavity, such as s. mutans, staphylococcus aureus, streptococcus pyogenes and candida albicans,6 pseudomonas, coliforme corynebacterium., bacillus sp, gram (-) neisseria sp.4,7 moreover, antimicrobial-resistant bacteria has been found in used contaminated toothbrushes.8 glass observed that the defect of oral tissue was exacerbated through a contaminated toothbrush instead of a sterile toothbrush. some studies found that toothbrush handle material and the tightness of brush fibers have an impact on the retention of bacteria.9 therefore, it is necessary to disinfect the toothbrush after use or before putting it in storage.10,11 several methods are recommended for the decontamination of toothbrushes, including the immersion of toothbrushes into alcohol and spraying toothbrush fibers with antimicrobial solutions such as chlorhexidine, sodium hypochlorite, hydrogen correspondence: susi sukmasari, department of paediatric dentistry and dental public health, kulliyyah of dentistry, international islamic university malaysia. jl. sultan ahmad shah, bandar indera mahkota, kuantan, 25200, pahang, malaysia. tel.: +6095705458 +60179040567 e-mail: sukmasari@iium.edu.my key words: piper betle; eugenia polyantha; natural disinfection; used toothbrushes. contributions: nn, conceptualization, data curation, formal analysis, methodology, validation, visualization, original draft writing; mhp, conceptualization, investigation, methodology, validation, and writing – original draft writing. yhp, dsl, supervision, and original draft writing; ss, writing, visualization, review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research has received ethical approval from the health research ethics commission, bandung polytechnique of health. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this research was supported by a research grant from the director of bandung polytechnique of health. received: 5 september 2024. accepted: 2 december 2024. early access: 11 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13016 doi:10.4081/hls.2025.13016 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13016] [page 105] peroxide, essential oil vinegar, and warm salt water.5,12-19 however, the disadvantage of manufactured chemical products is that they are costly and can adversely affect long-term use. considering the aforementioned factors, natural products that are standardized and safety-oriented are becoming more accepted globally. some previous studies investigated some herbs as toothbrush disinfectants.10 furthermore, mixing multiple herbs into one formula enhances antimicrobial potential.20,21 piper betle is a popular antibacterial, mouthwash, and wound-healing component in southeast asian and ayurvedic traditional medicine, and eugenia polyantha is also used to treat gastrointestinal problems. eugenia polyantha is a tropical tree belonging to the kingdom plantae, division spermatophyta, subdivision pinophyta, class coniferopsida, order myricales, family myrtaceae, genus eugenia, and species polyanthum (wight). eugenia polyantha leaf has long been known as a spice with traditional healing use, antimicrobial, and antioxidant,22,23 which is easy to find in the market. the leaves are rich in phenolic compounds, flavonoids, phenol, tannins, saponins, steroids, terpenoids, and essential oils.24,25 as an antioxidant, eugenia polyantha is stable in frying crude coconut oil.25 the solutions have been shown to inhibit the growth of oral bacteria and candida.7,26,27 green betel (piper betle (l)) is an herbaceous plant that grows or climbs on other tree trunks or wood. it is classified as follows: kingdom: plantae; subkingdom: tracheobionta; division: spermatophyta; subdivision: angiospermae; class: dicotyledonae; order: piperales, family: piperaceae; genus: piper; species: piper betle (l). research conducted by nurjannah et al. showed that boiled piper betle has an inhibitory effect on bacterial colonies carried by toothbrushes.7 besides essential oils, other compounds are flavonoid acid, organic acids, amino acids, steroids, sugars, tannins, proteins, terpenoids, saponin, fats, starch, and carbohydrates.28 piper betle has been recognized for its antibacterial and antifungal properties and is considered safe for oral use.29-31 traditionally, it is used for skin diseases, hemorrhoids, smelly sweat, cleaning the eyes, reducing blood vessels, and as a cough medicine. in dentistry, piper betel leaf infusion can be used to eliminate bad breath and to stop gum bleeding and toothache. the general purpose of this study was to analyze the effectiveness of the infusion containing the mixtures of eugenia polyantha leaves and piper betle leaves against bacterial growth on used toothbrushes. the analysis includes the determination of oral microorganisms on used toothbrushes, inhibition, and contact time. materials and methods infusion preparation fresh eugenia polyantha leaves and piper betle leaves were washed, drained, and sliced. we weighed 600 g of ep leaves and added 1 l of distilled water, and 350 g slices of pb leaves and added 1 l of distilled water. both were heated in a water bath at a temperature of ±90ºc for 20 minutes, then cooled and filtered. the four compositions of the solutions between eugenia polyantha and piper betle were made as follows: k1 (40%:60%), k2 (50%:50%), k3 (60%:40%), k4 (70%:30%), with sterile water as a negative control, and ciprofloxacin as a positive control. the k1, k2, and k3 combination in that composition has been balanced between the two herbs for comparison. meanwhile, k4 was made based on the observations conducted by putri et al.32 toothbrushing implementation eight primary school students were chosen randomly as participants. each participant was given a toothbrush with the same size and type of brush. recommended tooth brushing techniques were demonstrated by the dentist prior to tooth brushing implementation. participants brushed their teeth systematically for 2 minutes, consisting of 20 seconds for each region, starting from the upper right to the upper front, upper left, lower left, lower front, and lower right regions. after tooth brushing, without rinsing, the toothbrush was put into a sterile test tube containing nacl. the sterile test tube was firmly sealed and transported to the lab for testing. after the successful breeding of microorganisms, the used toothbrushes were placed in the medical waste bin and discarded. specimen breeding and microorganism identification 50 µl of bacterial suspension from the participant’s used toothbrush was inoculated on tryptic soy broth (tsb), incubated at 37ºc for 24 hours, then observed for turbidity. tsb serves as a base medium for a variety of specialized growing conditions. it is high in nutrients and is widely used to cultivate microorganisms for diagnostic and sensitivity testing. to identify the type of contaminant bacteria on the toothbrush, the gram stain was performed in tsb agar. it was planted for a four-way streak on the following selective medium to determine microorganisms in mixed cultures. colony characteristics were observed on tsa. tsa is commonly used in clinical microbiology to culture and isolate non-fastidious microorganisms for further testing. it is an enriched, nonselective medium that supports the growth of both gram-positive and gram-negative bacteria. coccus gram-positive and gram-negative were isolated on blood agar (ba). blood agar is an enhanced medium containing general nutrients and animal blood. it is used to cultivate bacteria and detect pathogens by hemolytic activity. gram-negative bacteria were identified using macconkey agar (mca), which inhibits the growth of gram-positive bacteria due to the presence of bile salts and crystal violet. agar is a selective and differential medium that isolates and distinguishes gram-negative enteric bacteria based on their capacity to ferment lactose. lactose fermenters (such as escherichia coli) produce acid, which causes them to appear pink/red on the medium. non-lactose fermenters (such as salmonella and shigella) stay colorless or pale. mannitol salt agar (msa) is a selective and differential medium used to isolate staphylococcus species, particularly staphylococcus aureus, using mannitol fermentation differentiation. inhibition analysis using a sterile cotton swab, 100 µl of bacterial suspension from each tsb was evenly spread over the surface of muellerhinton agar (mha). six mm wells were made using a sterile tube. poured 50µl of each mixture (k1, k2, k3, and k4) infusion at concentrations of 20%, 30%, 40%, 50%, 60%, sterile distilled water as a negative control, and 5 µg ciprofloxacin as a positive control into the well. the media was wrapped in brown paper, labeled, and incubated at 37˚c for 24 hours. the clear area was analyzed as an inhibition zone on each well. the inhibition zone, or clear area, was coded as 1 and 0 for no clear area. contact time analysis the micropipetting solution from each tube containing microorganisms from the used toothbrush was added to the first article [page 106] [healthcare in low-resource settings 2025;13:13016] tube containing 9 ml of 0.85% nacl and mixed until homogeneous. the solution was pipetted from the first tube to the second tube, and this process was repeated until the fifth tube. then, 1 ml of solution from each nacl tube was transferred into a labeled petri dish. next, approximately 15 ml of plate count agar (pca) media was added at a temperature of 40-45ºc. the treatment was conducted for eight used toothbrushes. the number of bacterial colonies in each pca medium using a colony counter was counted. points 1 and 2 were carried out for contact times of 10, 20, 30, 40, 50, and 60 minutes, and each treatment was repeated 4 times. statistical analysis all data were statistically analyzed by using spss software package 25 for windows. the normality test was used prior to the differential test. the levene test based on the mean (α=0.05) was used to analyze the homogeneity. the kruskal-wallis test was used to see the effectiveness differences of the infusions (k1, k2, k3, k4, control +, and control –) on inhibition of bacterial growth. the mann-whitney test was carried out to see the inhibition efficacy differences between each combination on bacterial growth. results after incubating, the solution containing the used toothbrush in tsb became cloudy, as shown in figure 1. to study the presence of bacteria contained in toothbrushes and to determine gram-positive and gram-negative colonies, the bacterial suspension of the tsb media was inoculated in the blood agar. the result shows that the shape, elevation, color, and characteristics of bacterial colonies were round, convex, and cloudy for β-hemolysis, while round, convex, and murky or slimy color for non-hemolysis. the suspected staphylococcus aureus on mannitol salt agar (msa) is based on a round shape, 1-2 mm in size, convex elevation, gold color, and hemolysis. the serological test detected the presence of bacteria coagulating from all used toothbrushes. inoculation on mca table 1 shows the observed results for the shape and size, elevation, color, and characteristics of bacterial colonies on mc agar. the bacterial characteristics were lactose fermenter and non-lac article [healthcare in low-resource settings 2025;13:13016] [page 107] table 1. results of observations of bacterial colonies on macconkey agar. sample code colony shape and size elevation color characteristic tb 1 1 round, 2-3 mm convex pink lactose fermenter 2 round, 1-1.5 mm convex yellow non lactose fermenter tb 2 1 round, 3-4 mm convex pink, slippery lactose fermenter tb 3 1 round, 2mm convex pink, slippery lactose fermenter 2 round, 3mm convex pink, rough lactose fermenter tb 4 1 round, 3-4 mm convex pink, slippery,slimy lactose fermenter tb 5 1 round, 2mm convex pink, slippery lactose fermenter 2 round, 3mm convex pink, rough lactose fermenter tb 6 1 round, 3mm convex pink, mucoid lactose fermenter 2 round, 2-3 mm convex yellow non lactose fermenter tb 7 1 round, 2-3 mm convex pink lactose fermenter 2 round, 4mm convex yellow non lactose fermenter 3 round, 3mm convex yellow, mucoid non lactose fermenter tb 8 1 round, 3-4 mm convex pink, slippery lactose fermenter tb, toothbrush. figure 1. the bacterial turbidity of solution containing used toothbrushes in tryptic soy broth (tsb). tose fermenter. to determine the growth characteristics of the bacteria from the enterobacteriaceae group, a biochemical test was carried out on each colony on mc agar. the bacteria were escherichia coli, enterobacter cloacae, pseudomonas sp, klebsiellaozaena, and proteus sp. the results of biochemical tests are shown in table 2. inhibition test of bay leaf and betel leaf infusion on bacterial growth on toothbrushes the mean inhibitory levels of the four combinations k1, k2, k3, and k4 compared to the positive control (ciprofloxacin 5 mg) are presented. the diameter of the inhibitory zone on the negative control on all toothbrushes was 0, while the positive control on all toothbrushes was 38, 30, 28, 25, 19, 27, 24, and 28, respectively. the four combinations of the mixtures were below positive control. the inhibition zone of the combinations was k1: 4, 13, 16, 17, 14, 17, 16, and 0, k2: 15, 16, 13, 14, 15, 17, 14, and 0, k3: 10, 14, 13, 13, 14, 17, 12, and 12, k4: 17, 17, 13, 13, 0, 5, 19, 12, and 0. table 3 displays the average number of bacteria at different time intervals (initial, 10, 20, and 30 minutes) after immersing the toothbrushes in a mixture of eugenia polyantha and piper betle infusion (k4). statistical analysis based on the kruskal-wallis test, there was a significant difference between the diameter of the inhibition of betel leaf infusion in the six data groups (k1 k2 k3 k4 cipro 50 μg/ 50 μl, and sterile aqua dest as a negative control). the whitney test showed the diameter of inhibition for each combination of k1, k2, k3, k4, ciprofloxacin, and aqua dest was p<0.05. however, the diameter of the inhibition of betel leaves among combinations was not significantly different (p>0.05). discussion in this study, all incubated solutions containing samples from used toothbrushes were cloudy. this indicates that oral bacteria from the used toothbrushes successfully grew in tsb. in healthy individuals, toothbrush contamination occurs immediately after use and increases with repeated use.3,6 moreover, the used toothbrush will likely be contaminated by pathogenic opportunists in a sick condition.4 a recent study found that used toothbrushes har article table 2. biochemical test results from macconkey agar media. sample code colony observation result suspect indole mr vp sc tb 1 lf + + – – escherichia coli lf – – + + enterobacter cloacae nlf – – – – pseudomonas sp tb 2 lf + + – – escherichia coli lf – – + – klebsiellaozaena tb 3 lf + + – – escherichia coli lf – – + – klebsiellaozaena nlf – – – – pseudomonas sp nlf + + –/+ +/– proteus sp tb 4 lf + + – – escherichia coli lf – – + – klebsiellaozaena tb 5 lf + + – – escherichia coli lf – – + – klebsiellaozaena tb 6 lf + + – – escherichia coli nlf – – – – pseudomonas sp tb 7 lf + + – – escherichia coli lf – – + – klebsiellaozaena nlf – – – – pseudomonas sp nlf + + –/+ +/– proteus sp tb 8 lf + + – – escherichia coli lf – – + – klebsiellaozaena tb, toothbrush; lf, lactose fermenter; nlf, non-lactose fermenter; mr, methyl red; vps, voges-proskauer; sc, simmons citrate. tb, toothbrush. table 3. average number of bacteria on a toothbrush after soaking with a mixture of eugenia polyantha and piper betle infusion (k4). dilution of the infusion mixture average number of bacteria (cfu/ml) at contact time (minutes) 0 10 20 30 1: 4 81,667 62,967 23,689 32,900 1: 9 >111,000 >111,000 >111,000 >111,000 [page 108] [healthcare in low-resource settings 2025;13:13016] bored antimicrobial-resistant bacteria such as staphylococcus aureus, e. coli, and pseudomonas.8 therefore, based on the findings, to reduce the risk of contamination, the used toothbrush should be reconsidered to disinfect immediately after use. the commensal oral flora was identified by cultivating samples on various types of media the findings of this study were consistent with previous research that identified streptococcus growth on blood agar, klebsiella sp, enterobacteriaceae sp (coliform sp), pseudomonas growth on mcconkey agar, and staphylococcus aureus on mannitol salt agar.33-35 in addition, as a normal flora in dental plaque, streptococcus mutans is also higher in teeth with cavities. the selected participants had more than three cavities due to caries. as a result, the findings indicated that the growth of microorganism colonies on blood agar, mannitol salt agar (msa), and macconkey agar (mc) consisted of oral microorganisms that were transferred by toothbrushes. all compositions of the mixtures can inhibit the growth of bacterial colonies, which was evidenced by the formation of an inhibition zone around the bacterial colonies grown on mueller-hinton agar (mha). the inhibition zone of the mixture was varied for each toothbrush, ranging from 12 mm to 19 mm; the lowest inhibition zone was found on toothbrush number 8 with an inhibition zone of 12 mm (k3), and the highest inhibition zone was on toothbrush number 6, which is 19 mm (k4). therefore, the infusion composition of the combination of 70% eugenia polyantha + 30% piper betle has the greatest inhibitory power against the growth of decontaminant bacteria compared to the other compositions. however, the average diameter of the k4 inhibition zone (70% eugenia polyantha + 30% piper betle) is 13.47 mm, which is relatively slightly smaller when compared to the average diameter of the inhibition zone for bay leaf infusion in the previous study.36 this is probably due to a reduction in the concentration of each part at the combined concentration. this study concluded that both formulations of eugenia polyantha and piper betle have potential effects on gingivitis prevention. they had an effectiveness level almost similar to chlorhexidine gluconate 2%. the f-ii formula demonstrated superior physical indicator values, as these were closer to the standard values. for its antibacterial properties and improved physical indicators, which align better with herbal standard values, the f-ii formula is recommended as a mouthwash for gingivitis. the absence of bacterial growth on the pca medium indicated that a 70% eugenia polyantha and 30% piper betle (k4) combination exhibited bactericidal properties. in addition, the k4 mixture was diluted at 1:4 and 1:9. the results revealed that diluting k4 in a 1:4 ratio was better than 1:9. however, bacterial colonies in k4 dilutions at ratio 1:4 with contact times of 0, 10, 20, and 30 minutes were >300. o’toole stated that if the number of colonies reaches 300, the bacterial count will not meet the required standards.37 therefore, further examination with a different dilution ratio is necessary. furthermore, the extract mixture was tested against four isolated pathogenic bacteria: streptococcus sp, klebsiella sp, enterobacteriaceae sp (coliform sp), pseudomonas and staphylococcus. the aqueous extract exhibited antibacterial activity against gram-positive and gram-negative bacteria. several studies have found that these plants effectively inhibit bacterial growth. piper betle is widely used in ayurvedic and southeast asian traditional medicine for antimicrobial, mouthwash, and wound healing. eugenia polyantha is also used in traditional medicine to treat gastrointestinal problems and as an antibiotic. although piper betle is often used as a mouthwash, this study discovered that a higher concentration of eugenia polyantha produced better results. the widespread use of eugenia polyantha for gastrointestinal disorders, along with the similarity of microbiome strains in oral and intestinal populations, highlights its potential effectiveness and merits further investigation. conclusions streptococcus sp., klebsiella sp., enterobacteriaceae sp. (coliform sp.), pseudomonas and staphylococcus aureus are the contaminant bacterial colonies that remain on used toothbrushes after washing with water. the optimal bactericidal properties and highest inhibition levels can be achieved by combining a 70% infusion of eugenia polyantha leaves with a 30% infusion of piper betle leaves. further studies are necessary to comply with pharmaceutical regulations to prevent side effects regarding quality testing, safety, efficacy, pricing, and marketing approval procedures. references 1. huang r, li m, gregory rl. bacterial interactions in dental biofilm. virulence 2011;2:435–44. 2. tan hc, cheung gsp, chang jww, et al. enterococcus faecalis shields porphyromonas gingivalis in dual-species biofilm in oxic condition. microorganisms 2022;10:1–16. 3. kumar s, tadakamadla j, johnson nw. effect of toothbrushing frequency on incidence and increment of dental caries: a systematic review and meta-analysis. j dent res 2016 ;95:1230–6. 4. blaustein ra, michelitsch l-m, glawe aj, et al. toothbrush microbiomes feature a meeting ground for human oral and environmental microbiota. microbiome 2021;9:32. 5. frazelle mr, munro cl. toothbrush contamination: a review of the literature. nurs res pract 2012;2012:1–6. 6. raiyani cm, arora r, bhayya dp, et al. assessment of microbial contamination on twice a day used toothbrush head after 1-month and 3 months: an in vitro study. j nat sci biol med 2015;6:44–8. 7. nurjanah n, herijuliant e, putri m, sukmasari s. eugenia polyantha (wight) infusion against oral microorganisms on toothbrushes. scientific dental j 2020;4:105. 8. unahalekhaka a, butpan p, wongsaen r, et al. contamination of antimicrobial-resistant bacteria on toothbrushes used with mechanically ventilated patients: a cross sectional study. intensive crit care nurs 2022;68:103120. 9. do nascimento c, trinca nn, pita ms, pedrazzi v. genomic identification and quantification of microbial species adhering to toothbrush bristles after disinfection: a cross-over study. arch oral biol 2015;60:1039–47. 10. anand pjs, athira s, chandramohan s, et al. comparison of efficacy of herbal disinfectants with chlorhexidine mouthwash on decontamination of toothbrushes: an experimental trial. j int soc prev community dent 2016;6:22–7. 11. niveda r, kaarthikeyan g. comparative evaluation of microbial contamination of neem infused toothbrush with regular toothbrush in periodontitis patients. 2019;12:1218–20. 12. neal pr, rippin jw. the efficacy of a toothbrush disinfectant article [healthcare in low-resource settings 2025;13:13016] [page 109] spray—an in vitro study. j dent 2003;31:153–7. 13. konidala u, nuvvula s, mohapatra a, nirmala svsg. efficacy of various disinfectants on microbially contaminated toothbrushes due to brushing. contemp clin dent 2011;2:302– 7. 14. basman a, peker i, akca g, et al. evaluation of toothbrush disinfection via different methods. braz oral res 2016;30:1–6. 15. aires a, barreto as, semedo-lemsaddek t. antimicrobial effects of essential oils on oral microbiota biofilms: the toothbrush in vitro model. j antibiot (basel) 2020;10:1–16. 16. shin ar, nam sh. antimicrobial effects of various methods for the disinfection of contaminated toothbrushes. biomed res 2018;29:2880–4. 17. mavani v, mahabala ky, suman e, et al. evaluation of effectiveness of home remedies for toothbrush decontamination using vinegar and vinegar with common salt. world j dent 2018;9:19–23. 18. el hamdaoui nea, knezevic m, knezevic m, vicentebarrero mm. cross section study and analysis of toothbrushes contamination and disinfection study of 101 toothbrushes emloyed from the people of different ages. head neck russian j 2020;8:45–51. 19. saleh fr. the effect of using dettol, salt and hot tap water in elimination of toothbrush contamination. indian j microbiol res 2021;2:227–30. 20. zhang a, sun h, wang x. potentiating therapeutic effects by enhancing synergism based on active constituents from traditional medicine. phytother res 2014;28:526–33. 21. guimarães r, barros l, carvalho am, ferreira icfr. infusions and decoctions of mixed herbs used in folk medicine: synergism in antioxidant potential. phytother res 2011;25:1209–14. 22. ischak ni, botutihe dn. preliminary study of clinical antidiabetic activity of salam leaves (eugenia polyantha) and sambiloto leaves (andrographis paniculata). iop conf ser: earth environ sci 2020;589:1–6. 23. safriani n, arpi n, erfiza nm. potency of curry (murayya koeniigi) and salam (eugenia polyantha) leaves as natural antioxidant sources. pak j nutr 2015;14:131–5. 24. rohaeti e, karunina f, rafi m. ftir-based fingerprinting and chemometrics for rapid investigation of antioxidant activity from syzygium polyanthum extracts. indonesian j chemistry 2020;21:128. 25. nor mm. phytochemicals screening, antioxidant activity and frying quality as affected by aqueous extract of malaysian serai kayu (eugenia polyantha). impact: int j res app nat soc sci 2015;3:81–8. 26. el muna haerussana an, widyastiwi w. inhibitory test of bay leaf (eugenia polyantha) extract against pseudomonas aeruginosa and escherichia coli. j app sci eng technol educ 2022;4:223–8. 27. aldhaher za, merza wm, almelan mf, et al. effectiveness of bay leaves aqueous extract on streptococcus mutans in comparision to chlorhexidine gluconate. j pharm biol sci 2017;12:12–6. 28. periyanayagam k, jagadeesan m, kavimani s, vetriselvan t. pharmacognostical and phyto-physicochemical profile of the leaves of piper betle l. var pachaikodi (piperaceae) — valuable assessment of its quality. asian pac j trop biomed 2012;2:s506–10. 29. biswas p, anand u, saha sc, et al. betelvine (piper betle l.): a comprehensive insight into its ethnopharmacology, phytochemistry, and pharmacological, biomedical and therapeutic attributes. j cell mol med 2022;26:3083–119. 30. lubis rr, marlisa, wahyuni dd. antibacterial activity of betle leaf (piper betle l.) extract on inhibiting staphylococcus aureus in conjunctivitis patient. am j clin exp immunol 2020;9:1–5. 31. nayaka nmdmw, sasadara mmv, sanjaya da, et al. piper betle (l): recent review of antibacterial and antifungal properties, safety profiles, and commercial applications. molecules 2021;26:1–21. 32. putri mh, nurjanah n, laela ds, sukmasari s. protective effects of mouthwash formulations of syzygium polyantha (l.) and piper betel (l.) on oral microbiota-induced gingivitis. healthc low-resour s 2023;12:11768. 33. kateete dp, kimani cn, katabazi fa, et al. identification of staphylococcus aureus: dnase and mannitol salt agar improve the efficiency of the tube coagulase test. ann clin microbiol antimicrob 2010;9:23. 34. jung b, hoilat gj. macconkey medium. statpearls publishing; 2022. available from: https://www.ncbi.nlm.nih. gov/books/nbk557394/ 35. spellerberg b, brandt c. laboratory diagnosis of streptococcus pyogenes (group a streptococci). va fjsd, editor. oklahoma city (ok): university of oklahoma health sciences center; university of oklahoma health sciences center; 2016. available from: https://www.ncbi.nlm.nih. gov/books/nbk343617/ 36. putri mh, julaeha e, herijulianti e, nurjanah n. formulation of mouthwash for gingivitis from combination infusion of salam leaves (eugenia polyantha wight) and betel leaf (piper betle. l). padjadjaran j dent 2022;34:239–48. 37. o’toole ga. classic spotlight: plate counting you can count on. j bacteriol 2016;198:3127. article [page 110] [healthcare in low-resource settings 2025;13:13016] hrev_master healthcare in low-resource settings 2025; volume 13:13968 study protocol: cluster randomized controlled trial on physical cognitive training for fall prevention in institutionalized older adults with cognitive impairment dwi nurviyandari kusuma wati,1,2 jing jy wang1 1department of nursing, college of medicine, national cheng kung university, taiwan; 2community health nursing department, faculty of nursing, universitas indonesia, depok, indonesia abstract falls are common among institutionalized older adults, especially those with cognitive impairment. these events lead to significant injuries and decrease the quality of life. the effectiveness of fall prevention strategies, including multifactorial and multicomponent interventions, remains unclear for this population. this protocol aims to comprehensively describe the study design, methodology, and procedures for implementing combined physical-cognitive training (pct) to prevent falls among residents with cognitive impairment. a double-blind, cluster-randomized controlled trial will be conducted with participants aged 60 and above. at least sixty-eight residents from two institutions will be recruited, with one group receiving combined pct and the control group receiving only physical training. the intervention consists of 30 minutes of physical training (range of motion, strengthening, balance, and deep breathing) and 20 minutes of cognitive stimulation therapy, performed twice weekly over 12 weeks. trained instructors will deliver the intervention using a structured module, with the principal investigator overseeing adherence to the protocol. measurements, including balance (timed up and go test), muscle strength (30’ chair stand test, fear of fall (fall efficacy scale-16), and number of falls, will be collected by assessors at baseline, post-intervention, and 12-week follow-up. this protocol provides a detailed framework for implementing combined interventions to prevent falls among residents with cognitive impairment. the protocol ensures replicability and contributes to evidence-based practices in long-term care settings for older adults. introduction the prevalence of falls in older adults residing in healthcare institutions exceeds that in other settings.1,2 previous studies have highlighted a higher incidence of falls among residents compared to those living in the community.3 annually, approximately 50% of nursing home (nh) residents experience falls, with 10%-30% sustaining major injuries such as hip fractures, head injuries, and lacerations requiring hospitalizations.4,5 however, residents in nhs face significant health challenges, with a decline in the ability to do daily activities, malnutrition, pressure sores, urine incontinence, pain, constipation, depression, and polypharmacy that may affect fall incidents.6 the significant factors that increase the incidence and risk of falls make it a major concern in older adults’ residential care institutions. health problems and changes among older adults affect all bodily systems, including cognitive and affective functions. physiological changes in the musculoskeletal system, neurosensory system, and cognitive function contribute to increased fall risks among older adults.7 meanwhile, cognitive impairment has also been identified as a risk factor for falls in older adults.8 in clinical settings, residents with severe cognitive impairment might become bedridden, while those with mild cognitive impairment are at a higher risk of unsafe walking patterns and wandering.9 unsafe walking patterns and wandering make them especially prone to an advanced fall prevention program. the urgency of addressing fall prevention in nhs is emphasized by the high prevalence of falls among residents. it is also preferable to proceed by implementing interventions for those identified as high-risk older adults.10 nurses are critical in implecorrespondence: jing jy wang, department of nursing, college of medicine, national cheng kung university, address: no.1, dayue rd., east district, tainan city 70101, taiwan. tel.: 06.2353535-ext-5034 e-mail: ns127@ncku.edu.tw key words: cognitive impairment, combined intervention, fall prevention, physical cognitive training, older adults. contributions: dnkw, jjw conception and design of the work, critical revision of the manuscript; dnkw, writing the manuscript. conflict of interest: the authors declare no conflict of interest. funding: none. ethics approval and consent to participate: this research was approved by the health ethics committee of the faculty of nursing, universitas indonesia (ket-206/un2.f12.d1.2.1/ppm.00.02/2024). clinical trial registration number: actrn12624001154594. acknowledgment: we extend our sincere appreciation to professor huiching weng and professor chi-jane wang for their insightful guidance and valuable contributions to the development of this protocol. received: 9 may 2025. accepted: 14 august 2025. early access: 29 september 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13968 doi:10.4081/hls.2025.13968 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 232] [healthcare in low-resource settings 2025;13:13968] menting fall prevention programs in nhs, contributing to direct care, assessment, planning, education, and research.11,12 they are responsible for leading multidisciplinary fall prevention teams as they hold the most detailed information on fall incidents within the ward.11 educating nurses on assessing and assigning fall risk is inadequate for fall prevention. research has identified various fall prevention activities, including physical exercise, cognitive training, artificial intelligence-based equipment training, pharmacological treatments, and educational programs aimed at preventing falls.13-16 additionally, advancements have been made in fall prevention through multifactorial and multiple-component interventions.2,14,17 however, the effectiveness of these strategies remains uncertain, particularly among nursing home residents, due to the variability of trial settings and the limited number of participants in these trials. physical training the most prevalent single intervention for fall prevention is physical exercise, although the type, frequency, and duration vary significantly. previous studies have demonstrated that exercises focusing on muscle strength and balance training effectively enhance fall-related outcomes and reduce the number of falls.18,19 these exercises aim to improve and maintain residents’ gait and body balance. other practical physical exercises include tai chi, yoga, walking, and aerobic exercise.19-22 lower limb strength training can increase muscle mass, which improves the ability and endurance of the legs while walking among older adults. this is complemented by balance exercises, which help them maintain better stability both when walking and standing. as leg strength and balance improve through training, so does their confidence. older adults with cognitive impairment often experience gait disturbances, such as taking small steps and walking on their tiptoes. strength and balance training can help them improve their walking patterns. however, symptoms like wandering and agitation among older adults with cognitive impairment increase the risk of falls, which cannot be fully addressed through physical exercise alone. cognitive training another intervention to prevent falls among older adults is cognitive training. a systematic review concluded that cognitivemotoric intervention appears to have similar effectiveness in ameliorating falls compared to traditional programs.23 as outlined in the cst leader’s guidebook, this therapy typically lasts for 14 weeks, with 45-minute sessions conducted twice a week by two facilitators for groups of 8-12 participants. the cst includes engaging in group activities and discussions designed to improve cognitive and social functioning in older adults.24 cognitive stimulation therapy has been proven to enhance orientation and memory in older adults with cognitive impairment. this group-based therapy is particularly well-suited for nursing home residents. improved orientation increases their awareness of their surroundings, leading to greater caution. enhanced memory not only helps older adults with cognitive impairment recall information but also aids in recognizing and planning necessary activities, thereby reducing purposeless wandering.25 combined physical cognitive training a group therapy combining physical and cognitive interventions emerges as a rational and sustainable approach, addressing both physical and cognitive factors that contribute to increased fall risk. a combination of muscle strengthening, balance, and cognitive training has a significant impact on balance in older adults, as measured by the timed up and go test (tug).26-28 the effectiveness of combined physical and cognitive training in reducing fall incidents and fall-related outcomes in older adults has been demonstrated in a systematic review article by the author. the meta-analysis from this article reveals a moderate effect of the combined intervention; however, the total sample size remains small, and variations in the study methodology limit the generalizability of the findings and the feasibility of conducting a metaanalysis.29 the combined intervention was therefore developed to address the high incidence of falls among residents by considering the main significant fall risk factors: gait and balance disorders, as well as cognitive impairment. this study protocol aims to provide a comprehensive framework for evaluating the effectiveness of a combined physical-cognitive training intervention for fall prevention in institutionalized older adults with cognitive impairment. in addition to detailing the intervention procedures, this protocol outlines the overall study methodology, including participant recruitment, randomization, intervention delivery, and outcome assessments. by providing a structured and replicable research design, this study seeks to contribute to evidence-based fall prevention strategies and support the integration of structured physical and cognitive training into long-term care settings. materials and methods study design this study employs a double-blinded cluster randomized controlled trial (crct) design, comparing a combined physical cognitive training (pct) group with a single physical training (pt) group. the pct group undergoes simultaneous physical exercise and cognitive stimulation therapy, while the pt group receives physical exercise alone. measurements occur at baseline, 12 weeks post-intervention, and 12 weeks after follow-up. the study will take place at two panti sosial tresna werdha (pstw) facilities, owned by the jakarta provincial government in indonesia. both institutions share similar characteristics, with most residents being neglected older adults. participants were randomly selected to represent each residential unit within the institutions, following inclusion and exclusion criteria determined by the principal investigator and local nurses. all selected participants were gathered to receive a detailed explanation of the study, and then individually signed informed consent forms (figure 1). this research protocol was registered on 23 september 2024, on the australian new zealand clinical trials registry with registration number actrn12624001154594p. it also received ethical approval from the health ethics committee of the faculty of nursing, universitas indonesia (ket-206/un2.f12.d1.2.1/ ppm.00.02/2024). participation in the study was entirely voluntary, with no coercion involved. the researcher will assume full responsibility for any negative effects proven to be caused by the study’s interventions, ensuring the trial is safe and feasible for all participants. the study population includes pstw residents with cognitive impairments. the sampling method combines purposive sampling for selecting the location and stratified random sampling for selecting participants, a technique known as multistage or cluster sampling.30 sample size calculation was conducted using g-power software (version 3.1.9.4) with an alpha level of 0.05, a power level of 90%, and a medium effect size (0.2) across two groups and advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13968] [page 233] three measurement points. to account for an anticipated attrition rate of 20%, the required sample size was calculated to be 68 participants, who will be evenly divided into two groups of 34 residents each. the inclusion criteria for the study were as follows: participants aged 60 years or older, able to walk with or without assistive devices, a mini-mental state exam (mmse) score between 13 and 24 (indicating mild to moderate cognitive impairment), and the ability to speak the indonesian language. residents who were involved in other trials during the same period were excluded. additionally, individuals with a history of lower limb orthopedic surgery or comorbidities such as cancer, neurological or psychiatric disorders, and significant visual or auditory impairments were also excluded from the study.22,31 study intervention the combined physical exercise and cognitive stimulation therapy (pct) will be administered simultaneously for 50 minutes twice a week over twelve weeks. the pct session initiation assessment includes a vital sign assessment, which involves checking blood pressure (bp), temperature, and pulse. participants who report any health complaints before the session will be assessed the eligibility to continue the session. group intervention involves eight to ten participants with one randomly assigned group instructor and facilitator. the instructor, a nurse with therapist responsibilities, undergoes training on intervention delivery. the therapist holds at least a bachelor’s in nurselevel education, completes eight hours of training, and undergoes randomization. the facilitator supports the instructor, assists participants in understanding instructions, and ensures proper intervention execution. the facilitators in this intervention were nurses from each institution. following training, an intervention guidebook is distributed to instructors and facilitators, providing step-by-step instructions for physical exercise and cst. the intervention manuals were developed separately for each institution, consisting of a pct and pt intervention manual. the guidebook includes images of each movement, tools, and how to perform used in both combined and single groups. instructors and facilitators record baseline, postintervention, and follow-up measurements in a participant record book. the record book records participant names, session attendance, and initial session assessment results, all signed by the instructor. the 30-minute physical exercise includes a range of motion, balance, muscle strength, and deep breathing exercises (table 1). these exercises target limb and body muscles, addressing stiffness and reduced range of motion in older adults. emphasizing lower limb exercises, known for their role in fall prevention, these exercises balance and strengthen muscles, with additional time allocat advancing nursing education and practice for future global health [page 234] [healthcare in low-resource settings 2025;13:13968] table 1. physical and cognitive training. physical training exercise detail movement time and tools range of motion head, shoulder, arm, back, waist, feet 7 minutes, backrest chair balance exercise standing, balancing, walking 10 minutes, backrest chair, bloc muscle strength exercise upper-lower arm, upper thigh-lower feet 10 minutes, step board, backrest chair deep breathing purse-lip breathing 3 minutes, backrest chair cognitive training part detail activities duration opening memorizing and orientation (introducing self, date-day of today, 3 minutes number of participants, today’s topic) primary activities included throwing and catching a ball, listening to sounds, storytelling, 15 minutes tasting food, abc 5 basics word game, discussing current news, identifying famous faces and places, completing missing words, crafting with plasticine, mapping hometowns, estimating prices, playing snakes and ladders, solving crossword puzzles, engaging in origami, playing paired card games, recognizing songs, and assembling puzzles. closing wrap-up, checklist intervention book, next meeting 2 minutes figure 1. flow diagram of study participants. ed for optimal results. using the pursed-lip technique, deep breathing helps relax muscles after exercise, preparing participants for subsequent cognitive training. the cognitive stimulation therapy (cst) implementation follows physical training without interruption, lasting twenty minutes, and comprising three integral components: the opening stage, primary activity, and closing stage (table 1).32 the opening phase focuses on memory and orientation training, incorporating questions about the current day and date. the primary activity centers on thematic exploration, involving twelve predetermined topics discussed cyclically to ensure comprehensive cognitive engagement. the closing stage integrates and documents the session, emphasizing reflection of the session. this structured yet adaptable approach aims to enhance cognitive resilience and contribute to the overall well-being of nursing home residents, aligning with the study’s comprehensive objectives for fall prevention. various tools are essential for delivering the intervention and will be arranged by the researcher. instructors and facilitators responsible for tool arrangement ensure their in proper condition before use. physical exercise requires tools such as backrest chairs, blocks, and step stools. each set should be ready and arranged for participants before starting the session. the chair must be sturdy and equipped with a backrest for exercise support. each group will share ten wooden blocks measuring 20 cm × 10 cm × 8 cm. additionally, step boards can be made of wood with dimensions of 50 cm × 10 cm × 30 cm and must be stable and capable of supporting body weight safely. for cognitive stimulation therapy (cst), tables and chairs are used to accommodate participants, the instructor, and facilitators. refreshments are provided during discussions, along with additional materials such as a speaker, pictures, plasticine, maps, origami paper, whiteboards, newspapers, picture cards, and puzzles, which are used based on specific topics and alternated between groups at each institution. in the single group as control, participants receive only physical exercise, following the same training stages as the combined intervention group, concluding within 30 minutes, and utilizing similar tools as in the combined intervention group. outcome measurement this study will conduct three measurements, all of which will be performed by a trained assessor. the time frame between the baseline measurement (t0) and post-intervention measurement (t1) is twelve weeks, with a twelve-week follow-up marking the final measurement (t2). the outcome measures adhere to established reliability and validity standards recommended by the consort group.33 the measurements prioritize participant safety to prevent physical and mental harm and enhance measurement quality. screening includes the mini-mental state exam (mmse), with a score between 13 and 24 indicating mild to moderate cognitive impairment, which guides participant inclusion. sociodemographic characteristics are captured using a questionnaire, including age, gender, fall history, comorbidities, impaired vision, medications, body mass index (bmi), and institutional service satisfaction. the timed-up and go test the study focuses on four main dependent variables: balance status, muscle strength, fear of falling, and the number of falls. a trained assessor with a bachelor’s in nursing conducts measurements three times using established protocols. balance status is evaluated through the timed-up and go test (tug), a widely used technique due to its simplicity and speed.34 participants start by sitting, then stand, walk three meters, turn around, walk back, and sit down again. 35 the assessor records the time using a reliable stopwatch. measurements are taken twice, and the shortest time is used. the principal researcher conducted tug testing with two assessors to assess measurement consistency. inter-rater reliability analysis (two-way random) showed excellent agreement (intraclass correlation/ icc 0.926, 95% ci 0.869–0.961). the 30-second chair-stand test muscle strength measurements employ the 30-second chair and stand test (30scst), focusing on the functional lower limb strength.36 participants performed sit-stand movements with their hands on their chest for 30 seconds using a sturdy chair and a stopwatch. the assessor carefully counted the number of completed sit-stand cycles while ensuring safety.37 inter-rater reliability analyses (two-way random) conducted by the principal researcher and two assessors showed excellent agreement (icc 0.947, 95% ci 0.906-0.973). the fall efficacy scale international fall efficacy, which indicates the fear of falling, is measured by the falls efficacy scale-international (fes-i), a validated instrument with high reliability, consisting of seven items.38 a systematic review of 58 articles shows that the short fes-i has good to excellent internal consistency values (cronbach’s alpha 0.96, icc 0.96).39 number of falls the number of falls will be recorded based on the participants’ frequency of fall history in the last year during the baseline assessadvancing nursing education and practice for future global health table 2. guidelines for physical and cognitive training. recommendations physical training intensity adjust to participants' physical conditions. assist post-stroke elderly with walking difficulties and do not force perfect movements. speed of movement perform movements slowly so all participants, regardless of physical ability, can follow comfortably. set gradually increase intensity repetition perform exercises in order without repetition. cognitive training interest instructors should be engaging, friendly, and supportive. ability assign more active roles to capable participants while assisting those who need extra support. language use simple and informal language. communicate clearly and include light humor to keep participants engaged and cheerful. appreciate encourage confidence through verbal praise, gestures, and gentle physical affirmation. [healthcare in low-resource settings 2025;13:13968] [page 235] ment and monitored throughout the intervention and follow-up periods for the following measurements.28,40 recording the number of falls will start at the beginning of the intervention using a book provided to each participant. the number of falls is assessed by monitoring unintentional incidents in which a resident descends to a lower level, regardless of whether a witness is present.41 the total number of falls will be counted from the start to the end of the intervention and reported in the second measurement (post-intervention). during the follow-up period, the book will be handed to the facilitator, who will record any falls among participants. the recording during this period will include the date of the fall, the cause, any resulting injuries, and the facilitator’s initials. if needed, recorded falls will be verified with the institution’s facilitator and a local nurse. sample size estimation and statistical analysis the sample size calculation will be conducted using g-power software (g*power 3.1.9.4). the statistical test was chosen as the parameter of anova with a repeated measures within-between interaction, with an alpha level of 0.05, a power level of 90%, and a medium effect size of 0.2, using two groups and three time measurements. the effect size for the sample calculation is based on recommendations from a previous systematic review of older adults with cognitive impairment who received combined aerobic and cognitive training interventions to assess their executive function.42 the sample size calculation yielded 56 participants, with an additional 20% attrition rate, resulting in an estimated 68 residents to be included as participants in this study. the participants will be divided into two groups, with each cluster consisting of an equal number of participants, namely 34 residents per group. the data analysis of this study will be divided into univariate, bivariate, and multivariate analyses using the statistical package for the social sciences (spss) for windows, version 25. data processing of measurement results on participants will use the intention-to-treat (itt) method. this is done because researchers want to uphold the integrity of the randomization carried out, provide conservative estimates of the intervention effect, and reflect compliance and dropout in clinical practice.43 univariate analysis will describe each variable in detail, with numeric data (e.g., age and dependent variables) presented as central tendencies, standard deviations, minimum-maximum values, and 95% confidence intervals (ci), while categorical data (e.g., gender, education, comorbidities, bmi, and medications) will be shown as frequency distributions and percentages.44 bivariate analysis will assess the intervention’s effect on the dependent variables using the friedman test, as the data will be converted into binary form. homogeneity between groups will be tested using levene’s test, with p > 0.05 indicating equal variance.44 multivariate analysis will compare the effectiveness of the two interventions while controlling for demographic and participant characteristics. given the repeated measurements within the same group, the generalized estimating equation (gee), an extension of the general linear model (glm), will be applied, using the binomial distribution and logit link to account for main effects, interactions, demographic data, and participant characteristics. this approach provides a robust understanding of how independent variables and covariates influence study outcomes.44,45 discussion this study aims to evaluate the effect of concurrent physical and cognitive training on balance, muscle strength, fear of falling, and fall-related psychosocial factors among nursing home residents, comparing it with a group receiving solely physical exercise. conducted in group therapy with 8-10 participants, the intervention aims to empower nurses facing burnout challenges.46 effective, scalable interventions are crucial for sustainable postresearch implementation. involving local nurses, provided with training and equipment, can significantly reduce falls through nursing care in homes.2,12 aligned with systematic reviews and meta-analyses, this research highlights the importance of balance training in physical exercise and cognitive training focused on orientation.34 a minimum 12-week intervention, meeting recommended session and duration criteria, is based on these findings.26,36,47 participant group size adheres to established parameters in older adult group therapy research. instrument choices are grounded in prior studies; timed-up and go (tug) for balance assessments, highlighting its convenience and reliability.27,48 muscle strength, a crucial aspect in fall prevention, is addressed through targeted lower extremity exercises. fear of falling, assessed with fes-i, relies on participants’ selfreporting abilities. primary outcomes focus on fall occurrences, necessitating close collaboration with local healthcare providers, considering individual perceptions and fall incident reports for accurate data. conclusion in conclusion, this study protocol provides a comprehensive framework for evaluating the feasibility and potential benefits of combined physical-cognitive training for fall prevention in institutionalized older adults with cognitive impairment. by detailing the intervention design, methodology, and implementation process, the protocol aims to ensure clarity and replicability in future research. the findings from this trial are anticipated to inform the integration of structured group-based physical and cognitive training programs into routine nursing care for residents in institutional settings. references 1. rubenstein lz. falls in older people: epidemiology, risk factors and strategies for prevention. age ageing 2006;35:ii37ii41. 2. vlaeyen e, coussement j, leysens g, et al. characteristics and effectiveness of fall prevention programs in nursing homes: a systematic review and meta-analysis of randomized controlled trials. j am geriatr soc 2015;63:211-21. 3. cameron id, dyer sm, panagoda ce, et al. interventions for preventing falls in older people in care facilities and hospitals. cochrane database syst revi 2018;9:cd005465. 4. prevention cfdca. keep on your feetpreventing older adult falls us2020 [cited 2024 may 10]. available from: centers for disease control and prevention. 5. luebbert s, christensen w, finkel c, worsowicz g. falls in senior adults: demographics, cost, risk stratification, and evaluation. mo med 2022;119:158-63. 6. bakerjian d. nursing homes: skilled nursing facilities california: university of california davis; 2022 [updated october 2022; cited 2024 may 9]. available from: https://www.msdmanuals.com/home/older-people%e2%80% advancing nursing education and practice for future global health [page 236] [healthcare in low-resource settings 2025;13:13968] 99s-health-issues/providing-care-to-older-people/nursinghomes. 7. chantanachai t, sturnieks dl, lord sr, et al. risk factors for falls in older people with cognitive impairment living in the community: systematic review and meta-analysis. ageing res rev 2021;71:101452. 8. leroy v, martinet v, nunkessore o, et al. the nebulous association between cognitive impairment and falls in older adults: a systematic review of the literature. int j environ res public health 2023;20:2628. 9. seijo-martinez m, cancela jm, ayán c, et al. influence of cognitive impairment on fall risk among elderly nursing home residents. int psychogeriatr 2016;28:1975-87. 10. huang x, yan j, yang t, et al. cost-effectiveness of morse fall scale assessment in fall prevention care in hospitalized patients. zhong nan da xue xue bao yi xue ban 2021;46: 529-35. 11. morse jm. preventing patient falls: establishing a fall intervention program. united states of america: springer publishing company, llc; 2009. 172 p. 12. ojo eo, thiamwong l. effects of nurse-led fall prevention programs for older adults: a systematic review. pac rim int j nurs res thail 2022;26:417-31. 13. delbroek t, vermeylen w, spildooren j. the effect of cognitive-motor dual task training with the biorescue force platform on cognition, balance and dual task performance in institutionalized older adults: a randomized controlled trial. j phys ther sci 2017;29:1137-43. 14. montero-odasso m, van der velde n, martin fc, et al. world guidelines for falls prevention and management for older adults: a global initiative. age ageing 2022;51:afac205. 15. xing l, bao y, wang b, et al. falls caused by balance disorders in the elderly with multiple systems involved: pathogenic mechanisms and treatment strategies. front neurol 2023;14:1128092. 16. albasha n, curtin c, mccullagh r, et al. staff’s insights into fall prevention solutions in long-term care facilities: a crosssectional study. bmc geriatrics 2023;23:738. 17. sanchez-sanchez jl, udina c, medina-rincon a, et al. effect of a multicomponent exercise program and cognitive stimulation (vivifrail-cogn) on falls in frail community older persons with high risk of falls: study protocol for a randomized multicenter control trial. bmc geriatrics 2022;22:612. 18. papalia gf, papalia r, diaz balzani la, et al. the effects of physical exercise on balance and prevention of falls in older people: a systematic review and meta-analysis. j clin med 2020;9:2595. 19. thomas e, battaglia g, patti a, et al. physical activity programs for balance and fall prevention in elderly: a systematic review. medicine (baltimore) 2019;98:e16218. 20. di lorito c, long a, byrne a, et al. exercise interventions for older adults: a systematic review of meta-analyses. j sport health sci 2021;10:29-47. 21. nick n, petramfar p, ghodsbin f, et al. the effect of yoga on balance and fear of falling in older adults. pm r 2016;8:14551. 22. sipilä s, tirkkonen a, hänninen t, et al. promoting safe walking among older people: the effects of a physical and cognitive training intervention vs. physical training alone on mobility and falls among older community-dwelling men and women (the password study): design and methods of a randomized controlled trial. bmc geriatr 2018;18:215. 23. schoene d, valenzuela t, lord sr, de bruin ed. the effect of interactive cognitive-motor training in reducing fall risk in older people: a systematic review. bmc geriatr 2014;14:107. 24. aguirre e, spector a, orrell m. guidelines for adapting cognitive stimulation therapy to other cultures. clin interv aging 2014;9:1003-7. 25. fleming r, zeisel j, bennet k. world alzheimer report 2020. london, england: alzheimer’s disease international; 2020 september 20. 26. donnezan combourieu l, perrot a, belleville s, et al. effects of simultaneous aerobic and cognitive training on executive functions, cardiovascular fitness and functional abilities in older adults with mild cognitive impairment. mental health physical activity 2018;15:78-87. 27. hagovska m, olekszyova z. impact of the combination of cognitive and balance training on gait, fear and risk of falling and quality of life in seniors with mild cognitive impairment. geriatr gerontol int 2016;16:1043-50. 28. lipardo ds, tsang ww. effects of combined physical and cognitive training on fall prevention and risk reduction in older persons with mild cognitive impairment: a randomized controlled study. clin rehabilitation 2020;34:773-82. 29. wati dnk. lh, wang jj. the effectiveness of combined physical exercise and cognitive training in older adults with cognitive impairment: a systematic review and meta-analysis. narra j 2024;4:e1040. 30. cresswell jwcajd. research design: qualitative, quantitative, and mixed method approaches. fifth edition ed. los angeles: sage publication; 2018. 388 p. 31. liu-ambrose t, davis jc, best jr, et al. effect of a homebased exercise program on subsequent falls among community-dwelling high-risk older adults after a fall: a randomized clinical trial. jama 2019;321:2092-100. 32. binns e, kerse n, peri k, et al. combining cognitive stimulation therapy and fall prevention exercise (cogex) in older adults with mild to moderate dementia: a feasibility randomised controlled trial. pilot feasibility stud 2020;6:108. 34. lesinski m, hortobágyi t, muehlbauer t, et al. effects of balance training on balance performance in healthy older adults: a systematic review and meta-analysis. sports med 2015;45: 1721-38. 35. dunsky a, zeev a, netz y. balance performance is task specific in older adults. biomed res int 2017;2017:6987017. 36. gschwind yj, kressig rw, lacroix a, et al. a best practice fall prevention exercise program to improve balance, strength/power, and psychosocial health in older adults: study protocol for a randomized controlled trial. bmc geriatrics 2013;13:105. 37. barrios-fernández s, pérez-gómez j, galán-arroyo mdc, et al. reliability of 30-s chair stand test with and without cognitive task in people with type-2 diabetes mellitus. int j environ res public health 2020;17:1450. 38. delbaere k, close jc, mikolaizak as, et al. the falls efficacy scale international (fes-i). a comprehensive longitudinal validation study. age ageing 2010;39:210-6. 39. yardley l, beyer n, hauer k, et al. development and initial validation of the falls efficacy scale-international (fes-i). age ageing 2005;34:614-9. 40. ehrlich jr, hassan se, stagg bc. prevalence of falls and fallrelated outcomes in older adults with self-reported vision impairment. j am geriatr soc 2019;67:239-45. 41. kobayashi n, kusuma wati dn, yamamoto m, et al. severity of dementia as a risk factor for repeat falls among the institutionalized elderly in japan. nurs health sci 2009;11:388-96. advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13968] [page 237] 42. combourieu donnezan l, perrot a, belleville s, bloch f, kemoun g. effects of simultaneous aerobic and cognitive training on executive functions, cardiovascular fitness and functional abilities in older adults with mild cognitive impairment. mental health physical activity 2018;15:78-87. 43. piantadosi s. clinical trials: a methodologic perspective. third edition. ed. hoboken, nj: john wiley & sons, inc.; 2017. 44. field a. discovering statistics using ibm spss statistics: ans sex and drugs and rock ‘n’ roll. 4th ed. america: sage publication; 2013. 45. barnett ajdag. introduction to generalized linear models. new york taylor & francis group; 2018 17 april 2018. 392 p. 46. anderson-mutch k. how to fight nurse burnout in long-term care. smartlinx 2022. available from: https://www. smartlinx.com/resources/blog/how-to-fight-nurse-burnout-inlong-term-care 47. cadore el, casas-herrero a, zambom-ferraresi f, et al. multicomponent exercises including muscle power training enhance muscle mass, power output, and functional outcomes in institutionalized frail nonagenarians. age 2014;36:773-85. 48. martins ac, moreira j, silva c, et al. multifactorial screening tool for determining fall risk in community-dwelling adults aged 50 years or over (fallsensing): protocol for a prospective study. jmir res protoc 2018;7:e10304. advancing nursing education and practice for future global health [page 238] [healthcare in low-resource settings 2025;13:13968] healthcare in low-resource settings 2025; volume 13:13123 model for determining the adequacy of drinking water intake in the nambo coastal area of indonesia tasnim tasnim, la ode saafi, kadek ayu karuniawati, fitri fitri, nuzul wahyuning tias, ririn putri handayani, indriani indriani, eka putri saripati, wa ode fitra saripati department of public health, university of mandala waluya, kendari, indonesia abstract the availability of drinking water in the nambo coastal area is still challenging, leading to inadequate water intake. this research investigates a model for evaluating the adequacy of drinking water consumption in the nambo coastal area. the study employs a quantitative cross-sectional design involving 100 participants aged 15 years and older. data analysis was conducted using the partial least squares structural equation modeling (pls-sem). the findings indicate that a person’s belief has a positive and moderate effect on their water intake (p=0.000; r2=0.352; ci 97.5%: 0.179-1.531). this belief mediates the person’s knowledge and attitudes about the importance of staying hydrated (p=0.046; r2=0.226; ci 97.5%: -0.005-0.440). additionally, knowledge positively and moderately affects individual attitudes (p=0.000; r2=0.369; ci 97.5%: 0.226-0.635). belief also has a positive and moderate influence on health maintenance (p=0.000; r2=0.428; ci 97.5%: 0.189-0.604). in conclusion, personal beliefs about the benefits of drinking water are critical to increasing water intake. confidence in these beliefs stems from knowledge and positive attitudes toward the health benefits of water. introduction lack of water intake can cause disorders of the body’s organs, including chronic kidney disease (ckd).1-4 chronic kidney disease is often referred to as a “silent killer” because patients are usually unaware of it until it advances to a more severe stage.5-8 this disease has led to numerous deaths around the world, including in the coastal regions of kendari city, southeast sulawesi, indonesia. the prevalence of ckd is often hard to identify because many individuals do not seek early examination at health centers. as a result, the reported prevalence of ckd seems significantly lower compared to other chronic diseases, such as hypertension and diabetes mellitus. for example, in 2018, the prevalence of ckd in southeast sulawesi province was 0.35%, showing an increase compared to 2013 (0.2%).9,10 the undetectability of chronic kidney sufferers makes it difficult for policymakers and health service units to develop chronic kidney disease control programs. however, previous studies have shown that water consumption of less than 2000 ml a day is one of the main causes of chronic kidney function disorders in kendari city.3,11-15 the insufficient water intake among residents in the coastal areas of kendari city, southeast sulawesi, is closely linked to their access to drinking water sources. specifically, certain coastal regions, such as the nambo area, still struggle with limited access to these sources. however, this limited access may not be the only cause of insufficient water consumption, as people in these areas can still buy bottled water. other factors affect adequate water intake in coastal communities, including knowledge and attitudes regarding the health benefits of drinking water for the body’s organs.16-20 in addition, confidence and motivation to make efforts to maintain health have been stated as determinants of water intake adequacy in individuals.21-25 despite this, the specific ways in which these factors lead to inadequate water intake in the nambo coastal area of kendari city, southeast sulawesi, indonesia, have not been clearly described. therefore, this study aims to develop a model for determining the appropriate level of daily water intake for residents in the nambo coastal area of southeast sulawesi, indonesia. it is hoped that the findings will serve as a reference for policymakers and health programs, ultimately increasing access to drinking water sources. consequently, this should lead to an increase in water consumption among the local population. correspondence: tasnim tasnim, department of public health, university of mandala waluya, kendari, indonesia. e-mail: tasnim349@gmail.com key words: attitude; belief; coastal; drink; water. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this research received ethical approval from mandala waluya university research ethics committee no. 12/kep/umw/v/2024 on 25 may 2024. availability of data and materials: all relevant data are included in this published article. funding: this research was funded by the mandala waluya kendari foundation, with contract number: 0399.b/umw.01/iv/2024 on 6 april 2024. acknowledgments: the authors would like to thank the mandala waluya kendari foundation for funding support for the research process. we also thank the community health centre management and coastal communities in nambo, kendari city, southeast sulawesi, indonesia, for participating in this research. received: 19 september 2024. accepted: 30 november 2024. early access: 14 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13123 doi:10.4081/hls.2025.13123 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13123] [page 123] materials and methods study design the research employs a quantitative approach utilizing causal explanatory methods. this design aligns with the research objectives, as it effectively explains how one variable can influence or cause changes in other variables.26 study setting this research was conducted in the nambo coastal area, kendari city, southeast sulawesi, indonesia, from may 2024 to july 2024. the research objectives and the limited access to adequate drinking water sources guided the selection of the location. trends indicate that the percentage of households with access to sufficient drinking water has declined in southeast sulawesi, particularly in coastal and rural areas. in 2022, the percentage was around 94.11%, which decreased to 93.88% in 2023.27 the nambo sub-district includes five villages: petoaha, nambo, sambuli, tondonggeu, and bungkutoko. sampling the study’s population consisted of 1788 households distributed across five villages in the nambo sub-district. the households were allocated as follows: 420 in petoaha village, 310 in nambo village, 379 in sambuli village, 274 in tondonggeu village, and 405 in bungkutoko village. to select samples from this population, the study employed a cluster random sampling technique. the sample selection process began with determining the overall sample size, followed by calculating the proportional sample sizes for each of the five villages. sample size the study included a sample size of 100 participants, which was calculated using the slovin formula. this formula considered a population of 1788 and an error margin of 10%. the calculation resulted in 95 participants; however, to account for potential dropouts, the researchers increased the sample size by 5% to 100 samples. based on the sampling technique used, the participants were distributed as follows: 23 from petoaha village, 17 from nambo subdistrict, 21 from sambuli village, 15 from tondonggeu village, and 23 from bungkutoko village. data collection the data collection tool utilized a structured questionnaire that includes questions regarding knowledge, attitudes, beliefs, maintenance, and the amount of water intake. valid knowledge questions include understanding the benefits of adequate water intake for regulating the body’s calorie consumption (p.11.b), protecting sensitive tissues such as the eyes (p.15.s), and preventing issues like dizziness or headaches (p.17.s). on the other hand, questions about attitudes focus on the effects of insufficient water consumption, such as muscle weakness (s.7.n), joint pain (s.8.n), and a dull or unattractive appearance of the skin (s.13.n). questions regarding beliefs focus on the effects of insufficient water intake on the occurrence of kidney disease (k.19.n), body weakness (k.20.n), and joint pain (k.21.n). maintenance-related questions include the maintenance of body fluids (pm.1p), the process of food digestion in the body (pm.2.n), and the circulation of body fluids (pm.4.p). a valid question about water intake is the amount of drinking water consumed in the morning and afternoon, measured in glasses (each glass was converted to 250 ml). the instrument has been tested for validity and reliability before data collection. based on the results of the construct reliability and validity tests conducted with pls-sem using smart pls software version 3.0, it was determined that the instrument was reliable and the questions for each variable were valid. as shown in table 1, the cronbach’s alpha value is >0.6, the average variance extracted (ave) value is >0.6, and composite reliability is >0.7. participant characteristics the participants in this study were predominantly women, accounting for 78% of the total, while men comprised 22% (table 2). the average age of participants was 33.8 years, with a standard deviation of 10.1 years. the highest level of education was high school (47%), and the least was higher education or above diploma (18%). most participants were housewives (64%). additionally, 21% were entrepreneurs, while only 9% worked in government roles. outcome measures the variable measurement of the water intake level includes three categories: good, medium, and low. it is categorized as “good” if the value is >2000 ml per day, “medium” if the value is between 1000 and 1999 ml per day, and “poor” if the value is <999 ml per day. knowledge and maintenance variables are measured in three categories: good, average, and poor. the knowledge or maintenance category is “good” if the score is 3, “medium” if the score is 2, and “poor” if the score is 1. measurements of attitudes and beliefs are also divided into three categories: good, average, and poor. it is categorized as “good” if the score is between 9 and 12, “medium” if the score is between 5 and 8, and “poor” if the score is 4 or less. data quality management prior to conducting the interview, the research team received training on interview techniques and questionnaire comprehension. preparatory meetings were also held to divide tasks in data collection. after collecting the data, each team coordinated the number of respondents interviewed and created a form for entering the data into a master table in excel. they also divided tasks for inputting the data into spss version 25. before the master table was imported into spss version 25 and smart pls version 3.0, the accuracy of the data was thoroughly reviewed. article table 1. construct reliability and validity. variables cronbach’s alpha* validity average variance extracted (ave)* reliability attitude 0.739 valid 0.656 reliable belief 0.823 valid 0.736 reliable knowledge 0.682 valid 0.605 reliable maintenance 0.767 valid 0.682 reliable water intake adequacy 0.626 valid 0.726 reliable *pls-sem test. [page 124] [healthcare in low-resource settings 2025;13:13123] statistical analysis data analysis uses partial least squares structural equation modeling (pls-sem) with smart-pls software version 3.0.28 pls-sem is used to predict endogenous latent variables or identify main variables and develop a model for determining the adequacy of water intake in coastal areas. the process involves several steps. the first step is testing the outer model, which aims to establish the relationships between the latent variables and their corresponding observed indicators. the outer model test results assess the data’s validity and reliability using three key metrics: cronbach’s alpha, average variance extracted (ave), and composite reliability. the data is considered valid and reliable when the following conditions are met: cronbach’s alpha is >0.6, the ave is >0.6, and the composite reliability is >0.7.29,30 the second step consists of evaluating the inner model to understand the relationship between independent and dependent latent variables. interpretation of the direction and strength of the relationship is based on the r-square (r2) value; r2>0.67 is a strong relationship, r2=0.33-0.66 is a moderate relationship, and r2=0.19-0.32 is stated to be weak.31 additional analyses were conducted using the goodness of fit approach to determine the model’s suitability. a model is considered fit if the nfi value is close to 1 and the srmr value is <0.10.32,33 results the results of the sem-pls analysis show that the level of water intake in the nambo coastal area is directly influenced by the level of individual belief (figure 1). the direction of the relationship between belief and adequate water consumption is positive and moderate (r2=0.352). knowledge and attitudes are indirectly related to adequate water consumption, primarily through the influence of individual beliefs. specifically, knowledge is connected to beliefs both directly and indirectly. the indirect connection between knowledge and beliefs is mediated by attitudes. the relationship between knowledge and attitudes is positive and moderate (r2=0.369). similarly, the relationship between attitudes and beliefs is also positive but weaker (r2=0.198). additionally, the direct relationship between knowledge and beliefs is positive but weak (r2=0.226). the belief variable is also related to the health maintenance variable. the direction and strength are positive and moderate (r2=0.428). in this case, the belief variable is also a mediating variable between knowledge and attitudes towards maintenance. the model used to determine adequate water intake has been deemed suitable because the nfi value is 0.529, which is close to 1, and the srmr value is approximately 0.1 (table 3). the article table 3. path coefficients in the model of determining drinking water intake in the nambo coastal area in 2024. variabel relationships original sample standard t statistics p confidence fit summary sample (o) mean (m) deviation (stdev) (o/stdev) intervals (ci) 2.5% 97.5% knowledge and attitude 0.369 0.390 0.079 4.677 0.000 0.226 0.535 srmr=0.10 attitude and maintenance 0.305 0.315 0.975 4.052 0.000 0.172 0.460 nfi=0.529 belief and maintenance 0.428 0.425 0.108 3.959 0.000 0.189 0.604 chi-sqare=268.300 belief and water intake 0.352 0.360 0.090 3.916 0.000 0.179 0.531 attitude and belief 0.198 0.192 0.090 2.217 0.027 0.009 0.359 knowledge and belief 0.226 0.235 0.113 1.997 0.046 -0.005 0.440 *pls-sem test. figure 1. model for determining the adequacy of water intake in the nambo coast in 2024. table 2. participant characteristics. participant characteristics frequency percent gender male 22 22.0 female 78 78.0 age group (years) 15-24 18 18.0 25-34 35 35.0 35-49 39 39.0 50-59 7 7.0 60-65 1 1.0 mean ± sd 33.8±10.1 occupation government employees 9 9.0 entrepreneur/private 21 21.0 fisherman 3 3.0 farmer 1 1.0 honorary 2 2.0 education levels low (under junior high school) 35 35.0 medium (senior high school) 47 47.0 high (above diploma) 18 18.0 no working/ housewife 64 64.0 total 100 100.0 sd, standard deviation. [healthcare in low-resource settings 2025;13:13123] [page 125] calculated chi-square (χ2) value is 268.300, which is higher than the table value (χ2 table with df=99, alpha=0.05), which is 113.145. this indicates that the model is significant. among the variables assessed, the r2 coefficient for the maintenance variable is the highest at r2=0.350, compared to the r2 values for attitude (r2=0.136), adequacy of drinking water (r2=0.124), and belief (r2=0.123). there are two key indicators of adequate water intake: morning and afternoon water consumption. the r2 coefficient value for afternoon water consumption is 0.881, which is higher than the morning water consumption value of 0.822. a significant indicator of belief is the perception of how inadequate water intake influences the risk of kidney disease (k.19.n), physical weakness (k.20.n), and joint pain (k.21.n). the r2 value for belief about the effect of insufficient water intake on joint pain is the highest (r2=0.884), followed by belief regarding its impact on kidney disease (r2=0.850). in comparison, belief related to its effect on physical weakness is lower (r2=0.841). the indicators related to the knowledge variable include three main aspects: understanding the benefits of sufficient water intake for regulating the body’s calorie intake (p.11.b); the protection of sensitive tissues, such as the eyes (p.15.s); and the prevention of dizziness or headaches (p.17.s). among these, the r2 for knowledge about regulating the body’s calorie intake is the highest (r2=0.789). this is followed by knowledge of the benefits of drinking enough water to avoid dizziness (r2=0.772), and knowledge regarding the protection of sensitive tissues like the eyes (r2=0.751). the indicators for the attitude variable consist of three aspects: attitudes regarding the effects of insufficient drinking water on muscle weakness (s.7.n), joint disorders (s.8.n), and skin dullness or poor appearance (s.13.n). among these, the attitude towards the impact of insufficient water intake on joint disorders has the highest r2 coefficient value (r2=0.858), followed by attitudes about the effect of insufficient water on skin performance (r2=0.774), and the impact on muscle weakness (r2=0.797). the indicators for the maintenance variable include the following: maintenance of body fluids (pm.1p), digestion process (pm.2.n), and circulation of body fluids (pm.4.p), which is linked to adequate daily water intake. the coefficient for body fluid circulation maintenance is slightly higher (r2=0.859) than that for body fluid balance maintenance (r2=0.853). however, it surpasses the coefficient for food digestion maintenance (r2=0.764). the relationship between variables results as follows: relationship between knowledge and attitude (p=0.000; ci 97.5%: 0.226-0.535); between attitude and maintenance (p=0.000; ci 97.5%: 0.172-0.460); between belief and maintenance (p<0.0001; ci 97.5%: 0.189-0.604); between belief and the adequacy of water intake (p<0.0001; ci 97.5%: 0.179-0.531); between attitude and belief (p=0.027; ci 97.5%: 0.009-0.359); between knowledge and belief (p =0.046; ci 97.5%: -0.005-0.440). the distribution of the r2 coefficient for the relationship between belief and daily drinking water adequacy ranges from 0.10 (low) to 0.60 (medium) (figure 2). the highest proportion, approximately 60%, falls within the moderate range (r2=0.33-0.60), while about 40% are in the low range (r2=0.10 article figure 2. path coefficients of the relationship between belief and drinking water intake in nambo coastal area. figure 3. path coefficients of the relationship between belief and maintenance in nambo coastal area. [page 126] [healthcare in low-resource settings 2025;13:13123] 0.32). the distribution of the r2 coefficient for the relationship between belief and maintenance ranges from 0.07 (low) to 0.69 (strong) (figure 3). the highest proportion, approximately 75%, falls within the moderate range (r2=0.33-0.66), while around 22% show a low relationship (r2=0.19-0.32), and only 3% exhibit a strong relationship (r2>0.67). the distribution of the r2 coefficient for the relationship between attitudes and beliefs ranges from -0.09 (low) to 0.48 (medium) (figure 4). the proportions of low (r2<0.19-0.32) and medium (r2=0.33-0.48) relationships are almost identical, each representing about 50%. the distribution of the r2 coefficient for the relationship between knowledge and trust ranges from -0.20 (low) to 0.56 (medium) (figure 5). the largest proportion, about 75%, falls within the low r2 range (r2<0.19-0.32), while approximately 25% show a medium relationship (r2=0.33-0.56). the distribution of the r2 coefficient for the relationship between knowledge and attitude ranges from 0.16 (low) to 0.61 (medium) (figure 6). the highest proportion, around 75%, falls within the medium range (r2=0.33-0.61), while the remaining 25% have a low relationship (r2<0.19-0.32). the distribution of the r2 coefficient for the relationship between attitude and maintenance ranges from 0.09 (low) to 0.57 (medium) (figure 7). the proportions of low (r2=0.19-0.32) and medium (r2=0.33-0.57) relationships are almost equal, with each representing around 50%. discussion a person’s belief in the nambo coastal areas directly influences the adequacy of water intake. individuals who have good belief about the benefits of drinking water, especially for joint health, body strength, and preventing kidney disease, will tend to drink water according to the standard, namely a minimum of 2000 ml per day. conversely, people who do not believe in the benefits of drinking water tend to consume less water each day than needed. there are various perspectives on how individual belief influences the adequacy of water intake in the nambo coast area, ranging from low to moderate levels of belief. the community’s overall belief in the benefits of water is still at a moderate level, without being strongly ingrained. several factors contribute to this, and the first is related to limitations in drinking water supply in coastal areas. people often rely on purchasing bottled water, which tends to be more expensive than in urban centers. however, many individuals are already convinced of the health benefits of adequate water intake. research suggests that behavioral changes, such as increased water consumption and adherence to healthy habits, are more likely to occur as individual belief strengthens.34,35 water consumption in the nambo coastal area is significantly higher in the mornings than in the afternoons. this aligns with the coastal environment, where the heat from the sea surface creates a strong need for hydration during the day. in contrast, the need for article figure 4. path coefficients of the relationship between attitude and belief in nambo coastal area. figure 5. path coefficients of the relationship between knowledge and belief in nambo coastal area. [healthcare in low-resource settings 2025;13:13123] [page 127] water in the nambo coastal community decreases in the afternoon and evening as the weather cools, a change also influenced by sea air circulation. additionally, the level of knowledge and attitudes among individuals in the coastal area indirectly influences their drinking habits. people who are well-informed about the benefits of drinking water—such as its role in regulating calorie intake, protecting sensitive tissues, and preventing dizziness—tend to meet the recommended daily intake of water, which is at least 2000 ml. people with good knowledge will immediately encourage their positive attitude toward the importance of drinking water for healthy muscles, joints, and skin. the individuals’ attitude in the coastal area is not only influenced by the health information that they have received but is also related to the weather of this area. this can be seen from their attitude towards skin health. the sun on the coast will directly impact the skin, which is why the response to the need to drink water is related to the appearance of the skin for coastal communities. previous studies also stated that increasing water intake in the human body enhances skin extensibility and elasticity36 and increases the water content in the dermal layer.37 as a result, those who drink sufficient water have better skin performance than those who drink less. good individual knowledge can also directly encourage the emergence of good beliefs about the benefits of water for joint health, body strength, and preventing kidney disease. coastal communities’ beliefs about the importance of drinking enough water have also contributed to kidney disease prevention. health messages aimed at coastal areas have already been implemented and have had a positive impact on the management of chronic kidney disease. however, a study found that attitudes have a stronger influence in pushing individuals towards adequate water intake compared to knowledge.38 in this case, knowledge has less influence due to the inaccurate information received by society. in contrast, attitudes play a stronger role in influencing behavior because they directly shape individual beliefs. the development of personal attitudes and beliefs about water intake also affects health maintenance actions. individuals with a positive attitude and belief in the benefits of drinking water are more likely to engage in health maintenance activities. coastal communities rely on drinking water to maintain fluid balance and support digestion. these factors play a key role in encouraging individuals to drink sufficient water, particularly in the morning and afternoon. the importance of hydration is especially pronounced in maintaining the circulation of body fluids. this need is heightened during the day, when coastal communities lose a significant amount of fluids through sweating. the warm coastal air encourages the body to sweat, increasing fluid loss. as a result, the body naturally requires more water to restore fluid balance. this phenomenon is observed in coastal regions worldwide, where drinking water is essential to replace fluids lost through perspiration.39 consequently, this study highlights that the need for hydration is the most influential factor in encouraging water consump article [page 128] [healthcare in low-resource settings 2025;13:13123] figure 6. path coefficients of the relationship between knowledge and attitude in nambo coastal area. figure 7. path coefficients of the relationship between attitude and maintenance in nambo coastal area. tion, surpassing attitudes and beliefs in driving the motivation to drink enough water. there are several variable relationships that influence water intake in the nambo coastal region. firstly, the relationship between knowledge and individual attitudes leads to maintenance actions to prevent the lack of fluids in the body and smooth the process of food digestion. moreover, people’s beliefs, shaped by acquired knowledge, promote the necessity of drinking water to support public health. the study indicates that approximately 75% of the influence of community beliefs has contributed to efforts to improve the physical health of the nambo coastal population. belief has a slightly stronger impact on promoting health maintenance behaviors than individual attitudes. therefore, it can be concluded that fostering and sustaining the belief in the importance of drinking adequate water is key to improving the health of coastal communities. however, for drinking to be beneficial to public health, the dangers of physical, chemical, and biological contamination must be considered. numerous contaminants are likely to occur in the drinking water supply in coastal areas, including contamination from wastewater from residential toilets, the discharge of toxic chemicals, including fluoride, and other anthropogenic activities, posing a risk of disease transmission.40,41 in light of these, it is essential to provide health education to the communities in the nambo coastal area to improve their dietary habits, including proper water intake. such education effectively enhances knowledge and attitudes toward healthy living.42 limitations this study did not examine the type of water consumed. it focused solely on water intake among the nambo coastal communities. additionally, the research did not assess public health status. as a result, this paper is unable to provide information about the relationship between beliefs, adequate water consumption, and health maintenance efforts. future studies could address this gap, providing clearer and more in-depth evidence regarding the influence of beliefs and sufficient water intake on health outcomes. conclusions the beliefs held by coastal communities play a crucial role in ensuring that individuals drink sufficient water. when these beliefs are strong, they motivate people to take proactive steps to safeguard their health. this research indicates that the community’s beliefs are influenced by health messages highlighting the benefits of drinking water for overall wellness. consequently, this fosters a strong sense of trust within the coastal communities. implications for health programs a strategic approach to increasing drinking water intake in coastal areas is building public awareness about water’s health benefits for body organs and tissues. one method is to provide training or health education, which serves as a form of health promotion. this knowledge enhancement is crucial, as it encourages individuals to adopt more positive attitudes. additionally, fostering a belief in the health benefits of drinking water will motivate coastal communities to undertake actions that improve their overall health. references 1. cheuvront sn, kenefick rw. am i drinking enough? yes, no, and maybe. j am coll nutr 2016;35:185–92. 2. armstrong le, muñoz cx, armstrong em. distinguishing low and high water consumers-a 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35. eck km, dinesen a, garcia e, et al. “your body feels better when you drink water”: parent and school-age children’s sugar-sweetened beverage cognitions. nutrients 2018;10. 36. akdeniz m, tomova�simitchieva t, dobos g, et al. does dietary fluid intake affect skin hydration in healthy humans? a systematic literature review. ski res technol 2018;24:459–65. 37. douladiris n, vakirlis e, vassilopoulou e. atopic dermatitis and water: is there an optimum water intake level for improving atopic skin? children 2023;10. 38. veilleux jc, caldwell ar, johnson ec, et al. examining the links between hydration knowledge, attitudes and behavior. eur j nutr 2020;59:991–1000. 39. rodger a, papies ek. “i don’t just drink water for the sake of it”: understanding the influence of value, reward, self-identity and early life on water drinking behaviour. food qual prefer 2022;99:104576. 40. singh s, bharti aa, kumari v, et al. study on fluoride contamination in ground water (drinking water) of deoghar, jharkhand, india. int j adv life sci res 2021;4:7–12. 41. daud mk, nafees m, ali s, et al. drinking water quality status and contamination in pakistan. biomed res int 2017;2017:7908183. 42. ragab ag, kotb sam, hassanein rh, ibrahim hm. effect of educational program about dietary and physical activity on functional constipation for elderly people at assiut geriatric clubs. malaysian j nurs 2021;13:90–101. article [page 130] [healthcare in low-resource settings 2025;13:13123] hrev_master healthcare in low-resource settings 2025; volume 13:13966 the effectiveness of health belief model intervention on tuberculosis medication adherence in rural indonesia: a pre-experimental study ardenny, ibnu rusdi, idayanti, falinda oktariani department of nursing, health polytechnic, ministry of health, riau, indonesia abstract tuberculosis treatment non-adherence remains a significant challenge in rural indonesia, with kampar district reporting below-target success rates. therefore, this study aimed to evaluate the effectiveness of a health belief model (hbm) intervention on medication adherence among tuberculosis patients in rural indonesia. a pre-experimental study with a one-group pretestposttest design was conducted among 45 purposively sampled tb patients in kampar district. data were collected using the validated health belief model questionnaire and the medication adherence rating scale. the intervention consisted of a 3-month structured program including weekly sessions in the first month, bi-weekly sessions in the second month, and a monthly follow-up in the third month. following the hbm intervention, significant improvements were observed in perceived benefits (31.33±4.447 to 32.80±4.341, p<0.001), perceived barriers (22.80±3.286 to 24.38±4.185, p=0.002), and perceived susceptibility (25.64±3.675 to 26.69±3.771, p=0.007). moreover, medication adherence significantly improved from 5.40±1.156 to 6.20±0.944 (p<0.001). the hbm intervention effectively improved medication adherence through enhanced health beliefs among rural tb patients. thus, integrating hbm-based interventions into tb treatment programs could improve treatment outcomes in resource-limited settings. however, further research with longer follow-up periods is recommended. introduction tuberculosis (tb) remains a serious health problem in indonesia. according to the latest report from the world health organization (who) in 2023, tb is ranked as the 13th leading cause of death worldwide.1 despite advancements in treatment, the disease continues to disproportionately impact low-income countries. the covid-19 pandemic has exacerbated the challenges posed by tb, disrupting healthcare services and limiting access to diagnosis and treatment.2 this disruption has led to a resurgence of tb cases in many regions, including indonesia, where tb cases have significantly increased.3 the burden of tb in indonesia is substantial. the who’s 2023 report reveals that indonesia continues to face significant challenges in combating tb. approximately 969,000 new tb cases are estimated to occur annually, resulting in 93,000 deaths.4 additionally, the emergence of drug-resistant tb complicates tb control efforts in indonesia. the prevalence of tb in indonesia is influenced by various factors, including socioeconomic conditions and underlying health issues.5 poverty, malnutrition, hiv/aids, and other chronic illnesses can increase an individual’s susceptibility to tb.6 these risk factors often intersect, creating a complex web of challenges for those affected. the indonesian government has implemented various programs to address the tb burden.7 these efforts include awareness campaigns to educate the public about tb prevention and symptoms, free treatment programs to improve access to care, and initiatives to strengthen the healthcare system. however, significant challenges remain, such as social stigma associated with tb, limited access to healthcare services in rural areas, and a lack of public awareness about the disease.8 in kampar district, the situation is particularly concerning. the treatment success rate in 2021 was only 75%, significantly below the national target of 85%.9 this resulted in three mdr-tb correspondence: ardenny, department of nursing, politeknik kesehatan kementerian kesehatan riau, jl. melur no. 103 sukajadi, pekanbaru 28281, indonesia. tel.: +62.81372321907 e-mail: ardenny_2010@yahoo.co.id key words: compliance; hbm model; tb medication; treatment adherence. ethics approval: this research has complied with ethical principles and was approved by the ethics committee of the ministry of health polytechnic of riau (approval no. lb.02.03/6/95/2024). conflict of interest: the authors declare that they have no competing interests. funding: none. contributions: a conceptualized the research, designed the study methodology, and was responsible for overall project coordination. ir contributed to the research design and supported data analysis. i assisted in data collection and helped with statistical analysis. fo provided technical and administrative support, organized tables and figures, and assisted in manuscript preparation and editing. availability of data and materials: data and materials used in this research are not publicly available. acknowledgments: the authors thank the health polytechnic of the ministry of health riau for providing technical assistance and administrative support for this research. received: 9 may 2025. accepted: 2 october 2025. early access: 25 november 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13966 doi:10.4081/hls.2025.13966 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13966] [page 227] cases in 2022, representing a 50% increase from previous years.10 the district’s rural characteristics, with 70% of patients living more than 10 km from health facilities, low health literacy (only 35% understand tb transmission correctly), and an average monthly income below provincial minimum wage – create unique adherence challenges not addressed by standard tb programs. patients with pulmonary tuberculosis often experience psychological distress that can hinder treatment adherence.11 the health belief model (hbm) provides a theoretical framework for addressing these psychological barriers by examining how individual beliefs about disease – including perceived susceptibility, severity, benefits, and barriers – influence health behaviors. despite the potential of hbm in addressing tb treatment adherence, critical gaps remain in its application. first, most hbm studies have focused on urban populations with better healthcare access, overlooking rural contexts where barriers are more complex. second, existing hbm interventions rarely incorporate local cultural beliefs and family dynamics which are crucial in indonesian rural contexts. third, previous studies primarily measured knowledge change rather than actual medication-taking behaviors. fourth, no studies have specifically addressed the unique combination of geographical, economic, and cultural barriers present in districts like kampar with documented low treatment success rates. this study addresses these gaps by developing and evaluating a culturally-adapted hbm intervention specifically designed for rural tb patients facing multiple structural barriers. to our knowledge, this is the first study to: i) apply hbm in indonesian rural districts with documented treatment success rates below national targets, ii) incorporate local cultural beliefs and family involvement into the intervention design, and iii) measure both psychological constructs and actual medication adherence behaviors. therefore, this study aims to evaluate the effectiveness of an hbm intervention on medication adherence among pulmonary tb patients in kampar district, with the goal of providing evidence for scalable interventions that can improve treatment outcomes in resource-limited rural settings. materials and methods this pre-experimental study with a one-group pretest-posttest design was conducted from march to august 2024 at five community health centers in kampar district. sample size calculation indicated a minimum of 42 participants (80% power, 95% confidence level); 45 of 47 recruited participants completed the study. study population the study population comprised all adult pulmonary tb patients registered in the district tb control program. based on district health records, approximately 180 active tb patients were undergoing treatment, with 145 adults aged 21-60 years forming the accessible population. purposive sampling was used to select adult pulmonary tb patients (21-60 years) currently receiving treatment. inclusion criteria were confirmed pulmonary tb diagnosis, kampar district residence, ability to communicate, and informed consent. exclusion criteria were mdr-tb, severe comorbidities, cognitive impairment, or previous treatment default. intervention protocol the 3-month hbm intervention was structured in three phases. the intensive phase (month 1) began with a baseline assessment and a 60-minute initial education, followed by weekly 45-minute individual counseling sessions focusing on tb knowledge, and perceived susceptibility and severity. the reinforcement phase (month 2) included bi-weekly 60-minute group sessions and one family involvement meeting, addressing treatment barriers and enhancing perceived benefits. the maintenance phase (month 3) consisted of 1-2 monthly follow-up sessions for adherence sustainment and peer support group formation. educational materials included booklets, symptom diaries, and reminder tools. data collection occurred at baseline (day 0) and post-intervention (day 90). instruments three validated instruments were used: i) a sociodemographic questionnaire capturing age, gender, education, occupation, income, and treatment duration; ii) the health belief model questionnaire (25 items, 5-point likert scale) measuring perceived susceptibility, severity, benefits, and barriers (cronbach’s α=0.87); and iii) the medication adherence rating scale (8 items, binary response, α=0.83). data collection and analysis five trained nurses collected data at baseline and at the 3month endpoint. data were analyzed using spss 25.0 with descriptive statistics (frequencies, means, standard deviations) and paired t-tests for pre-post comparisons (significance level p<0.05). intention-to-treat analysis was applied for missing data. ethical considerations the study received ethical approval from the ethics committee of the health polytechnic of the ministry of health riau (no. lb.02.03/6/95/2024). all participants provided written informed consent, with voluntary participation and confidentiality assured. results the respondent characteristics revealed that the largest age group was late adulthood (36-45 years), comprising 28.9% of the total sample. a substantial proportion was also in late adolescence (17-25 years) and in the elderly (>59 years), each accounting for 20.0% of participants. in terms of gender, males constituted the majority at 68.9%, while females made up 31.1%. regarding education, the vast majority of respondents (84.4%) had completed senior high school. a small minority had only finished primary school (6.7%) or held a university degree (4.4%). the majority of participants were married (73.3%), with the remaining being single or widowed (13.3% each). ethnically, the sample was predominantly malay (60.0%), followed by minang (24.4%), batak (8.9%), and javanese (6.7%). occupationally, farmers were the most common group (37.8%), followed by private sector workers (33.3%) and retirees (22.2%). in terms of income, 44.4% of respondents reported earning between 1 and 3 million idr, while 40.0% earned less than 1 million idr. a smaller proportion (15.6%) earned over 3 million idr. the overwhelming majority of participants were muslim (95.6%), with only 4.4% identifying as christian. lastly, regarding treatment duration, 26.7% of respondents had been in treatment for 2 months, followed by 24.4% for 1 month, and 17.8% for 6 months. a small proportion (2.2%) had been in treatment for 10 months (table 1). distribution of health beliefs and adherence in taking medication. a comparison of preand post-intervention data on health beliefs and medication adherence revealed notable changes. before advancing nursing education and practice for future global health [page 228] [healthcare in low-resource settings 2025;13:13966] the intervention, a substantial proportion of respondents (68.9%) held negative perceptions about the benefits of standard treatment. this number significantly decreased to 57.8% post-intervention, indicating an improvement of 11.1%. similarly, negative perceptions of treatment barriers decreased from 64.4% to 40.0%, representing a substantial improvement of 24.4%. perceived susceptibility to tb also showed an improvement, with negative perceptions decreasing from 64.4% before the intervention to 53.3% afterward, reflecting an 11.1% positive change. regarding medication adherence, non-adherence decreased from 62.2% to 57.8%, indicating a 4.4% improvement. overall, these findings suggest that the application of the health belief model (hbm) positively influenced both respondents’ health beliefs and their adherence to medication regimens. on average, the intervention led to a 12.75% improvement across all measured domains (table 2). the analysis of the health belief model (hbm) implementation on medication adherence revealed significant findings across various health belief dimensions. for perceived benefits, the mean score increased significantly from 31.33 (sd=4.447) pre-intervention to 32.80 (sd=4.341) post-intervention (p < 0.001). similarly, advancing nursing education and practice for future global health table 1. demographic characteristics of respondents (n=45). characteristic category frequency (n) percentage (%) age group 17-25 years (late adolescence) 9 20.0 26-35 years (early adulthood) 8 17.8 36-45 years (late adulthood) 13 28.9 46-55 years (early elderly) 6 13.3 >59 years (elderly) 9 20.0 gender male 31 68.9 female 14 31.1 education primary school 3 6.7 junior high school 2 4.4 senior high school 38 84.4 university degree 2 4.4 marital status single 6 13.3 married 33 73.3 widowed 6 13.3 ethnicity malay 27 60.0 minang 11 24.4 batak 4 8.9 javanese 3 6.7 occupation farmer 17 37.8 private sector worker 15 33.3 retired 10 22.2 government employee 3 6.7 income <1 million idr 18 40.0 1-3 million idr 20 44.4 >3 million idr 7 15.6 religion muslim 43 95.6 christian 2 4.4 treatment duration 1 month 11 24.4 2 months 12 26.7 3 months 5 11.1 4 months 3 6.7 5 months 5 11.1 6 months 8 17.8 10 months 1 2.2 table 2. changes in health beliefs and medication adherence preand post-intervention (n=45). variable pre-intervention post-intervention change (%) positive n (%) negative n (%) positive n (%) negative n (%) perceived benefits 14 (31.1) 31 (68.9) 19 (42.2) 26 (57.8) +11.1 perceived barriers 16 (35.6) 29 (64.4) 27 (60.0) 18 (40.0) +24.4 perceived susceptibility 16 (35.6) 29 (64.4) 21 (46.7) 24 (53.3) +11.1 medication adherence 17 (37.8) 28 (62.2) 19 (42.2) 26 (57.8) +4.4 average improvement +12.75   [healthcare in low-resource settings 2025;13:13966] [page 229] the perception of barriers showed a significant improvement, with the mean score increasing from 22.80 (sd=3.286) to 24.38 (sd=4.185) (p=0.002). regarding perceived susceptibility to tb, there was a slight but statistically significant increase from a pretest mean of 25.64 (sd=3.675) to a posttest mean of 26.69 (sd=3.771) (p=0.007). finally, medication adherence also showed a significant improvement, with the mean score rising from 5.40 (sd=1.156) before the intervention to 6.20 (sd=0.944) afterward (p<0.001), further highlighting the positive impact of the hbm intervention. overall, the data demonstrate a statistically significant effect of hbm implementation on improving medication adherence in patients with tuberculosis, as evidenced by the p-values in each category being below the 0.05 threshold (table 3). discussion this study evaluates the effectiveness of an hbm intervention in improving medication adherence among rural tb patients. the demographic profile reveals patterns influencing treatment adherence, with working-age adults (36-45 years, 28.9%) comprising the largest group, consistent with indonesian tb epidemiology.14 the male predominance (68.9%) aligns with global patterns attributed to occupational exposures and gender-specific health-seeking behaviors.15 economic factors emerge as significant adherence barriers. with 40% earning below 1 million idr monthly and 37.8% working as farmers, participants face substantial financial constraints affecting healthcare access and treatment continuation.16 this economic hardship, which has been documented to exacerbate nonadherence when treatment costs become unaffordable,17 underscores the need for financial support mechanisms in tb programs. the predominantly muslim population (95.6%) and diverse ethnic composition (malay 60%, minang 24.4%) highlight cultural considerations for intervention design. religious beliefs influence illness perception and treatment-seeking behaviors,18 suggesting the importance of culturally aligned interventions. the varied treatment durations (24.4% at 1 month, 26.7% at 2 months) reflect different treatment phases, with longer durations associated with treatment fatigue that challenges sustained adherence.19 the hbm intervention achieves significant improvements across all measured constructs. negative perceptions about treatment benefits decrease by 11.1%, indicating successful belief modification toward recognizing the adherence value.20 the more substantial 24.4% reduction in perceived barriers suggests effective effort in addressing of treatment obstacles including side effects, duration concerns, and accessibility issues.21 the 11.1% improvement in perceived susceptibility, while seemingly counterintuitive, may reflect increased patient empowerment and treatment confidence.22 medication adherence improves from 5.40 to 6.20 (p<0.001), representing a 14.8% increase. while modest in absolute terms, this change is clinically significant in tb treatment contexts where consistent long-term adherence is crucial.23 the intervention’s 12.75% average improvement across all domains demonstrates the hbm’s effectiveness in resource-limited settings. statistical analysis confirms the intervention effectiveness. perceived benefits increased significantly (31.33 to 32.80, p<0.001), which is crucial for motivating behavioral change.24 barrier reduction (22.80 to 24.38, p=0.002) makes treatment more manageable, encouraging greater adherence.24 the modest but significant increase in perceived susceptibility (25.64 to 26.69, p=0.007) reinforces the importance of treatment.25 most importantly, the significant adherence improvement directly addresses tb program goals, as consistent medication-taking prevents disease transmission and drug resistance development.26 study limitations several limitations warrant consideration. the pre-experimental design without a control group limits causal inference, as improvements may reflect treatment progression, concurrent health education, or hawthorne effects. the 3-month intervention, while capturing the intensive phase, does not assess complete 6month treatment adherence or long-term sustainability. selfreported adherence measures are susceptible to social desirability bias, potentially overestimating actual medication-taking by 1030%. purposive sampling from a single rural district limits generalizability to urban populations or drug-resistant tb cases. the small sample size (n=45) may have limited the power for subgroup analyses. conclusions the 3-month hbm intervention has significantly improved medication adherence among rural tb patients in kampar district. statistically significant improvements in perceived benefits (p<0.001), reduced barriers (p=0.002), and medication adherence scores (5.40 to 6.20, p<0.001) demonstrate the effectiveness of theory-based behavioral interventions in resource-limited settings. these findings are particularly relevant for districts with belowtarget treatment success rates. integration of hbm-based approaches into standard tb programs can address the psychological and cultural factors affecting treatment adherence in rural populations. future research should employ controlled designs with longer follow-up periods to establish causality and assess the sustainability of behavioral changes. advancing nursing education and practice for future global health [page 230] [healthcare in low-resource settings 2025;13:13966] table 3. comparison of mean scores before and after hbm intervention (n=45). variable pre-intervention post-intervention mean difference t-value p-value mean ± sd mean ± sd perceived benefits 31.33±4.447 32.80±4.341 1.47 6.126 0.000* perceived barriers 22.80±3.286 24.38±4.185 1.58 3.242 0.002* perceived susceptibility 25.64±3.675 26.69±3.771 1.05 2.834 0.007* medication adherence 5.40±1.156 6.20±0.944 0.80 4.264 0.000* *statistically significant at p<0.05. references 1. world health organization. who consolidated guidelines on tuberculosis. module 3: diagnosis–rapid diagnostics for tuberculosis detection. world health organization; 2024. 2. cioboata r, biciusca v, olteanu m, vasile cm. covid-19 and tuberculosis: unveiling the dual threat and shared solutions perspective. j clin med 2023;12:4784. 3. surendra h, elyazar ir, puspaningrum e, et al. impact of the covid-19 pandemic on tuberculosis control in indonesia: a nationwide longitudinal analysis of programme data. lancet global health 2023;11:e1412-21. 4. world health organization. use of targeted next-generation sequencing to detect drug-resistant tuberculosis: rapid communication, july 2023. world health organization; 2023. 5. fahdhienie f, mudatsir m, abidin tf, nurjannah n. risk factors of pulmonary tuberculosis in indonesia: a case-control study in a high disease prevalence region. narra j 2024;4:e943-e943. 6. etim ng, mirabeau y, olorode a, nwodo u. risk factors of tuberculosis and strategies for prevention and control. int j innovative healthcare res 2024;12:1-13. 7. iskandar d, suwantika aa, pradipta is, postma mj, van boven jf. clinical and economic burden of drug-susceptible tuberculosis in indonesia: national trends 2017-19. lancet global health 2023;11:e117-25. 8. harianto av, vitrianingsih y, issalillah f, mardikaningsih r. challenges and changes concerning national health development in indonesia: legal perspectives, service access, and infectious disease management. int j service sci manag engin technol 2024;5:22-6. 9. lasmaria r, febrina n, simanjutak am. characteristics of bacteriological pulmonary tuberculosis cases for the january– august 2021 period at arifin achmad hospital, riau province. jurnal health sains 2023;4:31-43. 10. yenti s, mitra m, abidin z, et al. the effectiveness of health education through whatsapp on increasing knowledge and attitudes of tb patients in prevention of pulmonary tb transmission at the uptd puskesmas tapung ii. 2023. 11. yuliyanti s. beyond clinical outcomes: exploring the psychosocial and physical dimensions of quality of life in tuberculosis patients receiving outpatient care. open access indonesian j med rev 2024;4:738-53. 12. sialino l, wijnhoven h, van oostrom s, et al. perspectives of older women in the netherlands: identifying motivators and barriers for healthy lifestyles and determinants of healthy aging. bmc public health 2023;23:664. 13. dabitao d, bishai wr. sex and gender differences in tuberculosis pathogenesis and treatment outcomes. sex gender differences infect treatments infect dis 2023;441:139-83. 14. lazar m, davenport l. barriers to health care access for low income families: a review of literature. j comm health nursing 2018;35:28-37. 15. aibana o, dauria e, kiriazova t, et al. patients’ perspectives of tuberculosis treatment challenges and barriers to treatment adherence in ukraine: a qualitative study. bmj open 2020;10:e032027. 16. abdul wahab na, makmor bakry m, ahmad m, et al. exploring culture, religiosity and spirituality influence on antihypertensive medication adherence among specialised population: a qualitative ethnographic approach. patient prefer adherence 2021;2249-65. 17. heckman bw, mathew ar, carpenter mj. treatment burden and treatment fatigue as barriers to health. curr opinion psychol 2015;5:31-6. 18. raynor d. the influence of written information on patient knowledge and adherence to treatment. in: adherance to treatment in medical conditions. crc press; 2020. page 83111. 19. anderson rm, funnell mm. patient empowerment: myths and misconceptions. patient educ counsel 2010;79:277-82. 20. stang i, mittelmark mb. intervention to enhance empowerment in breast cancer self-help groups. nursing inquiry 2010;17:47-57. 21. pradipta is, houtsma d, van boven jf, et al. interventions to improve medication adherence in tuberculosis patients: a systematic review of randomized controlled studies. npj primary care respirat med 2020;30:21. 22. anuar h, shah s, gafor h, et al. usage of health belief model (hbm) in health behavior: a systematic review. malaysian j med health sci 2020;16:2636-9346. 23. martela f, hankonen n, ryan rm, vansteenkiste m. motivating voluntary compliance to behavioural restrictions: self-determination theory-based checklist of principles for covid-19 and other emergency communications. eur rev social psychol 2021;32:305-47. 24. iacobino a, fattorini l, giannoni f. drug-resistant tuberculosis 2020: where we stand. appl sci 2020;10:2153. martela f, hankonen n, ryan rm, vansteenkiste m. motivating voluntary adherence to behavioural restrictions: self-determination theory-based checklist of principles for covid-19 and other emergency communications. eur rev soc psychol 2021;32:305-47. 26. iacobino a, fattorini l, giannoni f. drug-resistant tuberculosis 2020: where we stand. appl sci 2020;10:2153. advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13966] [page 231] hrev_master healthcare in low-resource settings 2025; volume 13:13897 effectiveness of guidance on feeding rules by posyandu pintar application on eating behavior in toddlers: a quasi-experimental study putu ayu ratna darmayanti,1 i kadek budi sandika,2 nadya treesna wulansari3 1bachelor of midwifery, faculty of health, institute of technology and health bali, denpasar, bali; 2faculty of technology and informatics, institute business and technology indonesia, denpasar, bali; 3faculty of technology, institute of technology and health bali, denpasar, bali, indonesia abstract collaboration is required among various stakeholders to address stunting, starting with monitoring the nutritional status of children through assistance with feeding rules. in this context, health service integrated post cadres should enhance service delivery supported by digitalization. therefore, this research aimed to analyze the effectiveness of guidance on feeding rules by posyandu pintar application on eating behavior in toddlers supports forming sigap (siaga gagal pertumbuhan) villages toward a stunting-free indonesia. the study employed a quasiexperimental with repeated treatment research design. the subjects in this study were toddlers aged 6-72 months in karangasem regency of bali from july to september 2024. the number of respondents was 160 toddler, selected by stratified random sampling. feeding rules mentoring were analyzed using repeated measures analysis of variance (anova). based on the results of the anova repeated measure test, showed that there was an improvement in good feeding behavior between the intervention group from the first to the fifth measurement p<0.001, which means it is less than 0.05. this indicates that h0 is rejected. then it can be concluded that the guidance on feeding rules by posyandu pintar application has been proven to have an effect on toddlers eating behavior. based on the description, this research could assist healthcare professionals, and policymakers in adapting prevention and treatment efforts for stunting. introduction the global prevalence of stunting in children was reported to be 149.2 million in 2020.1 in this condition, children have a height lesser than the age indicating long-term malnutrition and motor impairment.2 stunting decreased to 21.6% by 2022 but 16 provinces remained below the national average.3 therefore, different efforts must be carried out to reduce the national prevalence of the condition towards the indonesia emas 2045.4 stunting can also lead to decreased intellectual ability, mental retardation, and chronic diseases.5 although bali is not a stunting area nationally, stunting cases have also been found in bali province and are important to note. in bali province, four out of nine districts/cities still have a below-average prevalence for children under five, with eastern bali karangasem regency ranking first at 22.9%.6 the number of stunted children in karangasem regency and kubu district was 1,467 (7% of the total population) and 284 (17.9%) from nine villages, respectively.7 the causes are nutritional intake, access to preventive services, and incorrect eating behavior.8 this lack of nutritional intake is caused by toddlers who do not want to eat, or have a poor appetite and have difficulty eating. if this is left alone by parents, the toddler’s nutritional intake will not meet nutritional needs according to age. the mother’s habit of waiting for toddlers to ask for food is also a factor in stunting.9 toddlers tend to prefer playing so they forget to eat. the lack of variation in providing food can also result in stunting, for example, toddlers are only given a monotonous menu of food that they like without any snacks from vegetables, other proteins, and fruits.10 inappropriate feeding patterns that are not in accordance with the age of the toddler can result in nutritional deficiencies that put the toddler at risk of infection. nutrition plays an imporcorrespondence: putu ayu ratna darmayanti, bachelor of midwifery, faculty of health, institute of technology and health bali, denpasar, bali, indonesia. e-mail: darmayantiratna@gmail.com key words: feeding rules, application, posyandu pintar, eating behavior, stunting. contributions: pard was involved in conceptualizing the research topic, methodology, data collection, and data analysis. ikbs is involved in application development, surveys, supervision, monitoring, and review. ntw was involved in the formal analysis, writing, reviewing, and editing. conflict of interest: the authors declare no conflict of interest. ethics approval and consent to particpate: ethical approval was obtained from the ethics commission of the institute of technology and health bali on june 7, 2024. 04.0268/kepitekes-bali/vi/2024. consent was obtained from the subjects in line with the principles of the declaration of helsinki. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors are grateful to all participants for enabling a smooth process, as well as the ministry of education, culture, research, and technology (kemdikbudristek)/ 0667/e5/ al.04/2024 for funding the research. received: 16 april 2025. accepted: 15 september 2025. early access: 15 october 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13897 doi:10.4081/hls.2025.13897 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13897] [page 219] tant role in a child’s appetite. if the eating pattern is not achieved properly during the growth and development period, it can have an impact on the child such as a thin body and stunting. inappropriate feeding patterns and nutritional intake that does not meet the child’s body needs can also hinder future development.11 parenting patterns in providing food that include providing breast milk and providing nutritious complementary foods, healthy eating habits, and implementing feeding rules can improve the nutritional status of toddlers.12 interventions to prevent stunting include addressing feeding practice mistakes, anxiety about portion sizes, eating difficulties, and inappropriate feeding practices.13 feeding rules include implementing regulations for meals, including times, nutrition, and eating procedures.14 every child needs high-quality food and optimal nutrition to support growth and development, and parents should ensure appetite is not lost by implementing feeding rules.15 research in lhokseumawe showed a good correlation between the application of feeding rules and the nutritional status of children aged 6-24 months (p=0.001).16 previous research stated that 219 (97.7%) mothers who improperly applied feeding rules had children experiencing a mouth closure disorder (p=0.000).17 the application of basic feeding rules can create an accurate mp-asi feeding behavior, which improves the nutrition and growth of children.18 previous government efforts have conducted health counseling on stunting, antomometric examinations, and supplementary feeding as short-term efforts. the implementation of feeding rules requires nutritional status control, hence health service integrated post-cadres play a crucial role in ensuring reasonable control. posyandu is the main frontline for maintaining the wellbeing of mothers and children.17 the prevention of stunting must be supported by digitalization to facilitate the tracing and reporting of nutritional status. digitalization can be realized by developing an integrated posyandu pintar application for health centers and departments. the posyandu pintar assists posyandu cadres in documentation and reporting. the utilization is crucial since research on «ghosting» android-based application and «si jaks» has proven effective in reducing stunting.19,20 based on the description above, cooperation is required to address stunting from various stakeholders, including healthcare professionals, posyandu cadres, and village officials. posyandu cadres and village officials, being closest to the community, act as an extension of healthcare workers in addressing maternal and child health issues and provide strategic solutions.21 intervention with village cadres and officials as stunting prevention agents needs to be carried out because there is limited knowledge and awareness of village communities, especially cadres and officials, regarding stunting prevention.22 in addition, the performance of information systems can increase the effectiveness of nutritional health in primary services that provide various kinds of information, such as history, general information on stunting, development records, data monitoring, and health services.23 in indonesia, health service activities through posyandu are recording, recapping, and reporting data manually, allowing service activities to last for a long time. the posyandu pintar application containing health information, early detection of stunting, services such as vaccination, and child reporting facilitates tracing and treatment of stunted children to move towards a stunting-free country. the implementation of sigap (siaga gagal pertumbuhan) village is expected to build and empower self-reliant communities. the sigap village must be thoughtfully implemented to maximize information and education on stunting issues. the members and mobilization teams focus on optimizing stunting eradication, starting from the village. there is no previous research focused on village innovation through posyandu by providing feeding rules, assistance interventions, and smart application to prove the effectiveness in reducing stunting. interventions to handle incorrect eating behavior and application are not intended for posyandu cadres in villages to conduct tracing and treatment since stunting events remain unpreventable. based on problems such as the high incidence of children with difficulty eating, the absence of posyandu digitalization, and the lack of tracing are the causes of high stunting. the priority of solving the problem is the formation of sigap village innovation (preparedness for growth failure) through mentoring feeding rules, and posyandu pintar application. this innovation is also expected to improve future health conditions suitable for specific situations and targets. therefore, this research aimed to form and obtain the effectiveness of guidance on feeding rules by posyandu pintar application on eating behavior in toddlers supports forming sigap villages towards a stunting-free indonesia in karangasem regency of bali. materials and methods research design this research using a quasi-experimental method with repeated treatment research design to analyze effectiveness of guidance on feeding rules by posyandu pintar application on eating behavior in toddlers (figure 1). population, sample and sampling the population in this study was 2184 toddlers aged 6-72 months in karangasem regency, bali province, indonesia. the sample size was determined using g-power with a significance level of 0.05 and a power of 85%, yielding 146 subjects.24 to avoid dropout, the sample size was increased by 10% to become 160 samples, which were then divided into two groups, namely the intervention group of 80 people and the control group of 80 people. the sampling technique was carried out using stratified random sampling, with the inclusion criteria for the sample being toddlers aged 6 to 72 months without congenital abnormalities such as cleft lip, esophageal atresia, or congenital heart disease. exclusion criteria were digestive disorders, respiratory disorders, and tuberculosis. this research was carried out in nine villages in kubu sub-district, karangasem regency, bali province, indonesia from july to september 2024. instruments the posyandu pintar application has been developed in three steps. step 1-the development of the posyandu pintar application to simplify, report data, as well as trace and treat stunted children includes the following activities 1.1 reviewing the literature on posyandu services, stunting, and posyandu pintar application. 1.2 this application has been consulted and declared usable by computer science experts and medical doctors who handle stunting cases in community health centers. 1.3 revising the appearance and content of the posyandu pintar application in line with expert recommendations. step 2the posyandu pintar application is developed with a customized display for android granting easy access to posyandu cadres. step 3the application was implemented on 219 posyandu cadres for three weeks. in week 1, a pretest was conducted about posyandu services were provided without an application and the procedures for using posyandu pintar was also explained. the posyandu cadres use posyandu pintar application advancing nursing education and practice for future global health [page 220] [healthcare in low-resource settings 2025;13:13897] for health services in week 2. meanwhile, post-test measurements of health services were carried out in week 3. this posyandu pintar application contains features for information on service participants, early detection of growth, namely the results of measuring weight and height, toddler health reports, health services that have been obtained during the implementation of the posyandu, and health information about eating behavior. literature studies have been conducted to develop the instruments in this study. the instruments that have been developed have been tested for validity and reliability with the results of the validity and reliability tests carried out using spss at a significance level of α =5% (r table for alpha 5% and df =30 is 0.361). the reliability test shows data processing at a significance level of α =5% (cronbach’s alpha α =0.908> 0.06; reliable). the instrument consists of three parts. part 1 contains questions about the characteristics of age, gender, weight, height, bmi, maternal age, number of children, religion, education, occupation, family income, and health history. part 2 contains feeding rules. part 3 contains questions about eating behavior.17 data collection the stages of collection in this study were carried out in several stages, namely pretest, implementation, and posttest. the pretest measurement assessed eating behavior before treatment. participants subjected to the pre-test stage were given the intervention of mentoring feeding rules for one day, accompanying children during meal schedules in the first week. the implementation in this study was to provide feeding rules assistance by posyandu pintar application for children aged 6-72 months which was carried out for one month. the intervention provided was mentoring feeding rules four times with a one-week interval from one treatment to another. each treatment comprised mentoring the feeding rules at the meal schedule of morning, afternoon, and evening for 30 min. the outcome variable measurement was performed five times (pre-test, post-test 1, 2, 3, and, 4). the research data were collected by 219 posyandu cadres in karangasem regency, bali province, indonesia with duration of being a posyandu cadre is 47 years. the first post-test measurement was performed on the last day of the first week. the subjects were given the intervention of mentoring feeding rules in the second, third, fourth weeks, followed by post-test 2, 3, and 4 measurements on the last day. a total of five measurements were conducted on each subject during the research. meanwhile, the intervention for control group was provide feeding rules assistance by posyandu cadres using leaflets about feeding rules for children aged 6-72 months which was carried out for one month. data analysis data were analyzed using ibm spss statistics 26 software. the characteristics of the subjects are presented as frequency (n) and percentage (%), but for eating behavior variables before and after the intervention, are presented with mean and standard deviation. to determine the level of significance, this research used an α of 0.05, with a confidence level of 95%. in this study, eating behavior was summarized and presented as numerical data. the analysis was carried out using repeated measures analysis of variance (anova) to prove the effectiveness of mentoring feeding rules over time. there are three prerequisites that are carried out before testing the hypothesis, namely the normality test, the homogeneity test and the sphericity test. this study, the normality test uses the skewness value, the homogeneity test uses the levene test. while the sphericity test uses the greenhouse-geyser test. ethical clearance confidentiality and integrity were ensured to protect the privacy of participants and comply with ethical standards. furthermore, consent was obtained from the subjects in line with the principles of the declaration of helsinki. ethical approval was obtained from the ethics commission of the institute of technology and health bali on june 7, 2024. 04.0268/kepitekes-bali/vi/2024. results table 1 shows that the 160 subjects were divided into the control and intervention groups. in the control group, the majority were aged 6-11 months (16.9%), females (32.5%), and first-time children (16.9%). most participants were mothers aged 20-35 years (38.1%), hindu (48.1%), with the last education level of junior high school (19.4%), housewives (35.6%), and income < rp. 750,000 (38.1%). in the intervention group, the majority were advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13897] [page 221] figure 1. posyandu pintar application. aged 6-11 months (21.3%) (p=0.348), females (31.9%) (p=0.105), and first-time children (18.1%) (p=0.338). most participants were mothers aged 20-35 years (36.3%) (p=0.607), hindu (48.1%) (p=0.241), with the last education level of senior high school (18.8%) (p=0.635), as housewives (31.3%) (p=0.058). the majority of the income was < idr 750,000 (33.2%) (p=0.253). the results of the equality test show that all respondents characteristics have a p> 0.05, which indicates that the characteristics of respondents in the intervention group and control group are homogeneous or equal. as presented in table 1. table 2 shows the mean score of eating behavior during the pretest in the control group of 6.25, slightly increasing in posttest 1 to 6.71, slightly increasing in posttest 2 to 8.08, slightly increasing in posttest 3 to 9.41, but becoming 9.31 in posttest 4. meanwhile, in the intervention group, the mean score of eating behavior continued to experience a significant increase, at pretest of 6.49 which increased to 7.51 at posttest 1, increased at posttest 2 to 9.06, increased at posttest 3 to 10.08, and increased at posttest 4 to 10.41. normality and homogeneity of variance test results testing data normality and homogeneity were the two prerequisites met before conducting statistical tests. the normality test using skewness values compared to the standard error indicated normally distributed data. during the pre-test, post-test stage 1, post-test stage 2, post-test stage 3, and post-test stage 4, the control and intervention groups had a value of (0.345 and -0.665), (1.282 and -0.475), (-0.211 and -1.133), (-0.252 and -0.672), and (0.516 and 0.048), respectively. the homogeneity of variance test results using the levene statistic value showed a p of >0.05. therefore, the eating behavior data is homogeneous. advancing nursing education and practice for future global health table 1. subject's characteristics on feeding rules research (n=160). variable control (n=80) intervention (n=80) equal test n (%) n (%) age (month) 6-11 27 (16.9) 34 (21.3) 0.348 12-23 23 (14.4) 24 (15.0) 24-35 12 (7.5) 10 (6.3) 36-47 8 (5.0) 5 (3.1) 48-59 month 4 (2.5) 3 (1.9) 60-72 month 6 (3.8) 4 (2.5) gender male 28 (17.5) 29 (18.1) 0.105 female 52 (32.5) 51 (31.9) born 1 27 (16.9) 29 (18.1) 0.338 2 26 (16.3) 23 (14.4) 3 21 (13.1) 16 (10.0) 4 6 (3.8) 8 (5.0) 5 0 (0.0) 4 (2.5) mother's age (years) <20 14 (8.8) 10 (6.3) 0.607 20-35 61 (38.1) 58 (36.3) >35 5 (3.1) 12 (7.5) religion hinduism 77 (48.1) 77 (48.1) 0.241 catholic 1 (0.6) 1 (0.6) muslim 2 (1,3) 2 (1,3) mother's education not attend any school 0 (0.0) 4 (2.5) 0.635 elementary school 8 (5.0) 12 (7.5) junior high school 31 (19.4) 21 (13.1) senior high school 30 (18.8) 30 (18.8) diploma 8 (5.0) 8 (5.0) university 3 (1.9) 5 (3.1) mother's occupation housewife 57 (35.6) 50 (31.3) 0.058 trader 4 (2.5) 0 (0.0) farmer 4 (2.5) 0 (0.0) entrepreneur 12 (7.5) 26 (16.3) civil servant 3 (1.9) 4 (2.5) families' income < idr 750.000 61 (38.1) 53 (33.2) 0.253 idr 1.000.000-3.000.000 16 (10.0) 25 (15.6) idr 3.000.000-5.000.000 3 (1.9) 2 (1.3) [page 222] [healthcare in low-resource settings 2025;13:13897] sphericity test results spss produces a test known as the mauchly test for the sphericity assumption. the results of the mauchly test in this study showed a significance value of <0,001 (p<0.05), with the assumption of sphericity not being met so that conclusions were drawn using greenhouse and geisser corrections as alternatives. the results of the hypothesis test show a significance value of <0.001 (p<0.05), so it can be concluded that 𝐻𝑎 is accepted and 𝐻0 is rejected. table 3 provides information on the average increase in feeding behavior of toddlers for each measurement. the feeding pattern pre-test compared to post-test stage 1 showed an average increase in scores of 0.744 and the difference in the application was significant because the sig. value of <0.001 <0.05. meanwhile, the feeding pattern pre-test compared to post-test stage 2 reported an average increase in the scores of 2.2 and the difference in the application was significant because the sig. value was <0.001 <0.05. the pre-test compared to post-test stage 3 also suggested an average increase in scores of 3.375, and the difference in the application was significant because the sig. value was <0.001 <0.05. the feeding behavior pre-test compared to post-test stage 4, post-test stage 1 compared to post-test stage 2, post-test stage 1 compared to post-test stage 3, and post-test stage 1 compared to post-test stage 4 showed an average increase in scores of 3.494, 1.456, 2.631, and 2.750, respectively, the difference in the application was significant because the sig. value was <0.001 < 0.05. furthermore, the feeding pattern post-test stage 2 compared to post-test stage 3, post-test stage 2 compared to post-test stage 4, and stage 3 compared to post-test stage 4 showed an average increase in scores of 1.175, 1.294, and 0.119, respectively. figure 2 reports the average sharpness of the increase in good feeding behavior between the intervention groups from the first to the fifth measurement. discussion the first stage of the research on feeding rules involves mothers, with the majority aged 20-35 years, who are categorized as fertile. young mothers tend not to understand the correct feeding practices for toddlers fully. parental education is one of the factors influencing a mother’s behavior toward her child, indicating that good attitudes can arise when someone has good knowledge. maternal knowledge related to nutrition and feeding behavior is the ability and skill of mothers to understand and act on matters related to nutritious food and feeding rules crucial for a child’s advancing nursing education and practice for future global health table 2. mean eating behavior in both groups. control group intervention group mean std. deviation mean std. deviation pretest 6.25 1.886 6.49 1.842 postest stage 1 6.71 2.051 7.51 2.193 postest stage 2 8.08 2.401 9.06 2.252 postest stage 3 9.41 2.067 10.08 1.986 postest stage 4 9.31 1.940 10.41 1.429 [healthcare in low-resource settings 2024;12:xxx][healthcare in low-resource settings 2025;13:13897] table 3. pairwise comparisons test on the improvement of feeding patterns at each measurement over time. time (i) time (j) mean difference (i-j) (95% ci) pretest posttest stage 1 -0.744* (-1.115, -.0373) posttest stage 2 -2.200* (-2.801, -1.599) posttest stage 3 -3.375* (-3.951, -2.799) posttest stage 4 -3.494* (-4.031, -2.957) posttest stage 1 pretest 0.744* (0.373, 1.115) posttest stage 2 -1.456* (-2.031, -0.882) posttest stage 3 -2.631* (-3.248, -2.014) posttest stage 4 -2.750* (-3.334, -2.166) posttest stage 2 pretest 2.200* (1.599, 2.801) posttest stage 1 1.456 (0.882, 2.031) posttest stage 3 -1.175* (-1.648, -0.702) posttest stage 4 -1.294* (-1.766, -0.822) posttest stage 3 pretest 3.375* (2.799, 3.951) posttest stage 1 2.631* (2.014, 3.248) posttest stage 2 1.175* (0.702, 1.648) posttest stage 4 -0.119* (-0.274, 0.036) posttest stage 4 pretest 3.494* (2.957, 4.031) posttest stage 1 2.750* (2.166, 3.334) posttest stage 2 1.294* (0.822, 1.766) posttest stage 3 0.119* (-0.036, 0.274) *p<0.001. growth.25 the majority of mothers in this study have a senior high school education. education plays a significant role in the success of the feeding rules program as an effort to prevent stunting problems. this is evidenced by the success of feeding rules in this study. the level of education influences knowledge, where the better the education someone has, the easier it is to receive and understand the information obtained.26 feeding rules mentoring involves implementing meal rules; hence, children can consume food regularly with good nutrient absorption. in this study, the majority of mothers are housewives. non-working mothers have more time to manage their child’s feeding patterns and ensure their child’s nutritional intake.27 feeding rules mentoring includes the implementation of meal rules, enabling children to consume food regularly with good nutrient absorption. previous research stated that decision-making in nutrition provision was crucial in solving stunting.28 policy makers in health services are expected to provide educational programs on the introduction of nutritious food according to the meal schedule by paying attention to nutritional content. in line with research in myanmar, most children under two years old experiencing stunting are in families with low income (<25 percentile / <60 dollars).29 the results provided for one month showed improvement in good feeding behavior between the intervention group from the first to the fifth measurements, with a p-value of <0.001. feeding rules mentoring has been effective in improving the behavior of toddlers. the rules consisted of three components, namely regular feeding schedule, the environment, and the feeding procedure. the regular feeding schedule showed three main meals and two snack times. in the environment, parents or caregivers are expected to create a pleasant eating atmosphere without distractions from gadgets, toys, or television. in the context of the child feeding procedure, parents or caregivers should allow the children to eat independently for no more than 30 minutes. parents should avoid using force or intimidation when a child refuses to eat and food should be presented in a neutral manner. after 10–15 minutes of continued refusal, concluding the mealtime is recommended.30 research in thailand showed that parenting patterns of six-monthold children such as sleep quality and feeding rules affect nutritional status and development in the first year of life.31 improved feeding behavior can enhance nutritional status to reduce the prevalence of stunting. conversely, inappropriate feeding activities lead to eating disorders in children.32 research in thailand states that parental behavior plays a significant role in feeding practices, where parents serve as figures or examples to be imitated, influencing the eating behavior of children.33 ongoing socialization efforts and periodic evaluations of feeding rule implementation can shape good eating habits, meet nutritional needs, and address issues.34 posyandu is a key pillar for preventing stunting in rural areas. this pillar is essential for the search and identification of stunting cases. posyandu cadres are trained volunteers to provide basic health services and are well acquainted with the conditions of the community, especially those of pregnant women and children. these individuals play a crucial role in improving community health, particularly in the early detection of stunting to prevent and reduce the condition. in this context, posyandu pintar is a digitalbased application that uses mobile phones or computers. this application is adopted by cadres and the community to access posyandu services. the utilization of technology in tracing, treatment, and reporting of stunting incidents is crucial for increasing the reduction in stunting prevalence. the posyandu pintar application can enhance posyandu services, particularly in preventing and identifying stunting. the results show that posyandu cadres feel supported by the application, and the community easily access schedules and services. the use of mobile-based digital application in reporting is a digital solution that simplifies the recording, monitoring, and reporting processes. the application supports a more structured, accurate, and fast datamanagement process in reporting.35 concerning the strength of the experimental research, the analysis was carried out for the first time by forming a sigap village providing assistance interventions, feeding rules, and the posyandu pintar application. in the context of the limitation, variables, such as the type of food given to children when feeding rules assistance interventions are carried out cannot be controlled. a larger sample can be used by controlling the type of food given to the children during the research. advancing nursing education and practice for future global health figure 2 plots profile of the increase in feeding behavior. [page 224] [healthcare in low-resource settings 2025;13:13897] conclusions in conclusion, there was an increase in good feeding behavior between the intervention group from the first to the fifth measurement. feeding rules assistance by posyandu pintar application has been proven to have an impact on good eating behavior in toddlers in karangasem regency, bali. the results were important for preventing and overcoming stunting and malnutrition in children, starting from regulating good eating behavior and establishing appropriate procedures or schedules. in addition, the posyandu pintar application for volunteers of the health service integrated service post improved the service system. this research was expected to assist healthcare professionals and policymakers in adapting prevention and treatment efforts for relevant stunting. recommendations stunting management policies may need to be developed to analyze current child feeding issues. in addition, feeding rules assistance must be implemented to address the problem of children having difficulty eating and the presence of posyandu pintar application to improve technological progress at the basic service level. references 1. unicef. stunting in toddlers in the world. unicef, 2021. 2. armayanti ly and darmayanti par. perbedaan tumbuh kembang pada balita usia 2-5 tahun dengan stunting dan nonstunting. jurnal ilmu kesehatan makia 2022;12:13-20. 3. indonesia kkr. profil kesehatan indonesia tahun 2022. jakarta: kementerian kesehatan republik indonesia, 2023. 4. (ssgi) ssgi. buku saku hasil studi status gizi indonesia (ssgi) tingkat nasional, provinsi, dan kabupaten/kota tahun 2021. jakarta: ssgi, 2022. 5. beal t, tumilowicz a, sutrisna a, et al. a review of child stunting determinants in indonesia. maternal & child nutrition 2018; 14: 126-127.doi: 110.1111/mcn.12617. 6. bali dkp. profil kesehatan provinsi bali tahun 2022. denpasar: dinas kesehatan provinsi bali, 2023. 7. karangasem dk. profil kesehatan kabupaten karangasem tahun 2022. kabupaten karangasem: dinas kesehatan kabupaten karangasem, 2023. 8. darmayanti par and armayanti ly. perbedaan status gizi balita berdasarkan usia penyapihan asi di tpa wilayah denpasar selatan. jurnal ilmu kesehatan makia 2021;11:41-9. 9. angraini w, firdaus f, pratiwi ba, et al. pola asuh, pola makan dan kondisi lingkungan fisik dengan kejadian stunting. j nursing public health 2023;11:500-11. 10. ramadhani fn, kandarina b and gunawan ima. pola asuh dan pola makan sebagai faktor risiko stunting balita usia 6-24 bulan suku papua dan non papua. berita kedokteran masyarakat 2019;35:75-183. 11. pujiati w, nirnasari m and rozalita r. pola pemberian makan dengan kejadian stunting pada anak umur 1–36 bulan. menara medika 2021;4. 12. permatasari tae. pengaruh pola asuh pembrian makan terhadap kejadian stunting pada balita. jurnal kesehatan masyarakat andalas 2020;14:3-11. 13. chumairoh n. gambaran tingkat pengetahuan ibu tentang feeding rules pada batita gerakan tutup mulut (gtm). comphi j 2021;1:148-54. 14. philippe k, chabanet c, issanchou s, et al. child eating behaviors, parental feeding practices and food shopping motivations during the covid-19 lockdown in france:(how) did they change? appetite 2021;161:105-32. 15. keeratichamroen a, praditsorn p, churak p, et al. applying the concept of thai nutrient profiling as a model for the thai school lunch planner. j public health development 2024;22:224-36. 16. ghinanda rs, mauliza m and khairunnisa c. hubungan pola penerapan feeding rules dengan status gizi balita 6-24 bulan di puskesmas banda sakti kota lhokseumawe. jurnal pendidikan tambusai 2022;6:2583-88. 17. darmayanti par and nugraha is. hubungan pengetahuan dan penerapan feeding rules terhadap gangguan tutup mulut pada anak usia 6-72 bulan di desa kubu karangasem bali. journal pharmactive 2023;2:51-7. 18. rahmadi a. intervensi kepada kader dan perangkat desa sebagai agen pencegahan stunting di desa setia negara kecamatan baradatu kabupaten way kanan. jompa abdi: jurnal pengabdian masyarakat 2022;1:139-46. 19. kemenkes ri. panduan pengelolaan posyandu bidang kesehatan. jakarta: kementerian kesehatan republik indonesia, 2023. 20. gita apa, surya nt and setyaningsih a. aplikasi stunting berbasis android guna mempercepat deteksi dini kejadian stunting. j public health innovation 2023;3:142-50. 21. choliq mi, suwarso lmi and andarwulan s. pemanfaatan teknologi digital smart care sebagai upaya pencegahan stunting pada balita di era pandemi covid-19 di kelurahan siwalankerto. prosiding hapemas 2020;1:73-8. 22. m. fitri lti, r. hidayat. pengembangan masyarakat sebagai upaya membangun desa mandiri dan bebas stunting. jurnal pengabdian multidisiplin 2023;3. 23. suha sqqa, k.d. ashanty. optimalisasi kinerja sistem informasi manajemen keperawatan berbasis aplikasi si pancing (sistem informasi pantau stunting) untuk meningkatkan keefektivitasan derajat kesehatan gizi anak di pelayanan kesehatan primer. thesis: universitas sultan ageng tirtayasa. availabe from: https://eprintsuntirtaacid/ 14207/1/full%20text%20kti%20insco%20aipnipdf 2022 24. panel o. g power. proc interrupt (processor interrupt) lights 2015;6:16. 25. weber mb, palmer w, griffin m, et al. infant and young child feeding practices and the factors that influence them: a qualitative study. j health population nutrition 2023;42:32. 26. ritchie sj and tucker-drob em. how much does education improve intelligence? a meta-analysis. psychol sci 2018;29:1358-69. 27. haines j, haycraft e, lytle l, et al. nurturing children's healthy eating: position statement. appetite 2019;137:124-33. 28. hartarto rb, aravena c and bhattacharjee a. women’s bargaining power and children’s nutritional status: evidence from indonesia. feminist economics 2024:1-31. 29. phyo sw, keiwkarnka b and mongkolchati a. factors related to stunting status of children aged under two years in magway township, myanmar. j pub health dev 2014;12:1-16. 30. pasaribu ih, rahayu ma, marlina r. implementasi feeding rules untuk mencegah permasalahan gizi pada balita. jurnal pengabdian masyarakat mandira cendikia 2023;2:40-5. 31. beniko m, mongkolchati a, chompikul j, et al. relationship between child rearing and child nutritional status during the first year of life in thailand. j public health develop advancing nursing education and practice for future global health [healthcare in low-resource settings 2025;13:13897] [page 225] 2016;14:3-19. 32. idai. rekomendasi praktik pemberian makan berbasis bukti pada bayi dan batita di indonesia untuk mencegah malnutrisi. unit kerja koordinasi gizi dan penyakit metabolik. jakarta: ikatan dokter anak indonesia, 2015. 33. buddhabunyakan n, kaewrudee s, chongsomchai c, et al. premenstrual syndrome (pms) among high school students. int j women's health 2017:501-5. 34. munjidah a, rahayu ep. pengaruh penerapan feeding rules sebagai upaya mengatasi kesulitan makan pada anak (picky eater, selective eater dan small eater). jkm (jurnal kesehatan masyarakat) cendekia utama 2020;8:29-39. 35. han m. participation and effectiveness of worksite health promotion program. disertation. university of maryland, baltimore. available from: http://hdl.handle.net/10713/11486, 2019. advancing nursing education and practice for future global health [page 226] [healthcare in low-resource settings 2025;13:13897] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13121 determinant factors that influence emotional eating behavior in generation z omi haryati, laelatun nurul hidayah, nurhalimah nurhalimah, yuli mulyanti, indriana rakhmawati health polytechnic ministry of health jakarta iii, indonesia abstract generation z faces increasing mental health challenges, often leading to maladaptive coping strategies, such as emotional eating and using food to manage negative emotions. this behavior contributes to poor dietary patterns and a higher risk of noncommunicable diseases. despite rising concerns, the psychological determinants of emotional eating among indonesian youth remain underexplored. this study aimed to examine psychological factors associated with emotional eating in generation z. a cross-sectional quantitative study was conducted among 110 generation z individuals aged 12–27 years who exhibited a tendency toward emotional eating. the participants were selected using purposive sampling. three instruments were used for data collection: a demographic questionnaire, psychological factors questionnaire, and emotional eater questionnaire. data was analyzed using chisquare tests for bivariate associations and binary logistic regression for multivariate analysis, to identify the most influential psychological predictors of emotional eating. anger, boredom, anxiety, stress, and depression were significantly associated with emotional eating (p<0.05). stress and boredom are the most influential predictors. stress and boredom are the key psychological drivers of emotional eating in generation z. this maladaptive behavior increases the risk of disordered eating and non-communicable diseases. interventions that enhance emotional regulation and stress management are crucial to mitigate these risks. introduction emotional eating has emerged as a growing behavioral concern among generation z – individuals born during a time of rapid technological advancement – who are often described as intelligent, creative, or explorative.1 this behavior, defined as consuming food in response to negative emotions, such as sadness, anxiety, or stress, serves as a coping mechanism to relieve psychological discomfort.2 physiologically, stress triggers the release of corticotropin-releasing hormone (crh), which can suppress appetite. however, under prolonged stress, the body produces cortisol, a hormone that increases appetite and cravings for high-calorie foods.3 this biological response often leads to emotional eating and changes in eating behavior, as individuals seek comfort through food. emotional eating in adolescents is closely tied to broader mental health challenges and serves as a coping mechanism for emotional distress such as anxiety, depression, boredom, and despair.4 according to the national adolescent mental health survey (2022), one in three indonesian adolescents (34.9%), or about 15.5 million, reported experiencing mental health issues in the past year, while one in 20 (5.5%), or approximately 2.45 million, was diagnosed with a mental disorder, with anxiety being the most prevalent.5 as a form of psychological self-defense, many adolescents turn to food to manage their emotions, a behavior that may provide temporary relief but has detrimental long-term consequences, including disrupted eating patterns, weight gain, and a deepening cycle of emotional and psychological strain.6-9 emotional eating is strongly linked to increased risks of binge eating, eating without hunger, and higher bmi, which increases the likelihood of obesity over time.10-12 it is also associated with poor dietary habits, such as a high intake of added sugars and fats, contributing to physical health issues such as high cholesterol, hypertension, cardiovascular disease, diabetes, and eating disorders such as bulimia nervosa and binge-eating disorder.13 moreover, correspondence: omi haryati, health polytechnic ministry of health jakarta iii, indonesia e-mail: omiharyati2@gmail.com key word: emotional eating, generation z, psychological factors. contributions: oh conceptualization, data curation, formal analysis, methodology, validation, writing original draft, review and editing, resources; lnh conceptualization, methodology, validation and writing original draft, references, review and editing; nh conceptualization, formal analysis, review and editing; ir formal analysis, validation, methodology, validation, writing original draft, references, review and editing. conflict of interest: the authors declare no conflicts of interest. ethical approval and consent to participate: the study received ethical approval from the ministry of health polytechnics jakarta iii (registered number l. b. 02.02/f. xix.21/4818/2024). during the research, the researcher pays attention to the ethical principles of information to consent, respect for human rights, beneficence and non-maleficence. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. funding: this study did not receive external funding. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgements: the author gratefully acknowledges the support and permission provided by the local authorities in one of the administrative areas in bekasi city, which enabled this research. appreciation was also extended to all participants who contributed valuable insights to this study. received: 20 september 2024. accepted: 29 april 2025. early view: 22 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13121 doi:10.4081/hls.2025.13121 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 80] [healthcare in low-resource settings 2025;13(s2):13121] depression is a significant contributor to emotional eating, as supported by studies by rezatiara and fayasari, which demonstrate a strong correlation between depressive symptoms and emotional eating behavior.14 persistent emotional eating not only increases the risk of chronic diseases but may also evolve into severely disordered eating behaviors, including bulimia and anorexia nervosa, potentially leading to malnutrition if left unmanaged.15 the indonesian government and researchers have recognized the growing challenges of unhealthy eating behaviors among the youth. efforts have been made to promote nutritional education and healthy eating campaigns, particularly in schools, and public health initiatives. however, research indicates that these interventions often focus on general healthy eating and nutrition, with less emphasis on the psychological determinants of eating behavior, such as emotional eating.16,17 studies have identified key factors influencing unhealthy eating in gen z individuals, including socioeconomic status, cultural influences, peer pressure, taste preferences, food accessibility, and a lack of nutritional awareness or education.16,17 some research has also examined menu anxiety and its impact on food choices and nutritional status among gen z in urban areas.18 most existing studies have focused on broader unhealthy eating behaviors or attitudes toward local cuisine, without directly addressing the psychological and emotional triggers unique to this demographic and region. in addition, amid the ongoing mental health crisis affecting generation z, which may indirectly influence their behaviors and coping mechanisms, individuals in this cohort often experience transitional challenges including difficulties in adaptation, disordered eating, and emotional eating. therefore, this study aimed to explore the psychological factors that may influence emotional eating behavior among generation z. materials and methods research design this quantitative study employed a cross-sectional design to examine the influence of psychological factors, including anger, boredom, despair, anxiety, stress, and depression, on emotional eating behavior among generation z people in bekasi city. study participants this study employed a non-probability sampling technique using purposive sampling as specific inclusion criteria were applied, making not all individuals eligible to become research participants. in total, 110 respondents were included in this study. the sample size was calculated using the lemeshow formula, which is appropriate for large, relatively unstable populations. the inclusion criteria were individuals belonging to generation z (aged 12–27 years) who exhibited signs of emotional eating. these signs include a sudden onset of hunger, eating in response to psychological discomfort or pressure, using food as a coping mechanism for emotional distress, and frequent eating without experiencing genuine physical hunger. data collection and instrument data was collected using a structured questionnaire completed directly by the respondents, either through in-person distribution or google forms. the research instrument underwent prior testing for validity and reliability, and was confirmed to be both valid and reliable. three standardized questionnaires were used as measurement tools to assess the research variables. demographic data questionnaire this questionnaire collected basic demographic information, including age, gender, and place of residence psychological factors questionnaire this instrument was designed to assess six psychological factors associated with emotional eating behavior: anger, boredom, despair, anxiety, stress, and depression. each factor was measured using seven items, totaling 42 randomly distributed items. responses were rated on a 4-point likert scale ranging from 0 to 3, with the following interpretation: 0 = never, 1 = sometimes (1– 2 times per week), 2 = often (3–4 times per week), and 3 = always (>4 times per week). emotional eating questionnaire this instrument was adapted from the emotional eater questionnaire, developed by garaulet et al. (2012). the questionnaire was modified to suit the local language and context, including revisions to eliminate ambiguous wording. it consists of 10 items assessing reduced control of overeating behavior, the types of food consumed, and feelings of guilt associated with emotional eating. responses were measured on a 4-point likert scale ranging from 0 (never) to 3 (always), following the same frequency intervals as the psychological factor questionnaire. data analysis univariate analysis was conducted using descriptive statistics to summarize the characteristics of each variable. bivariate analysis was performed to examine the relationships between respondent characteristics (age, gender, and place of residence) and the dependent variable emotional eating. additionally, the relationships between independent psychological factors—anger, boredom, despair, anxiety, stress, depression, and emotional eating– were assessed. the chi-square test was employed for bivariate analysis as the data were not normally distributed, necessitating the use of non-parametric methods. multivariate analysis was conducted to explore the findings of the bivariate analysis at greater depths and to identify the psychological factors that most significantly influenced emotional eating behavior. given that both independent and dependent variables were categorical, binary logistic regression was used as the appropriate multivariate method. all statistical analyses were performed using ibm spss statistics version 29. a p-value of <0.05 was considered statistically significant research ethics ethical approval for this study was obtained from the ethics committee of the ministry of health polytechnic jakarta iii (registration number: l. b. 02.02/f.). xix.21/4818/2024). throughout the research process, the principles of research ethics were strictly followed, including informed consent, respect for human rights, beneficence, and non-maleficence. results distribution frequency demography data as shown in table 1, the majority of respondents were adults, accounting for 95 individuals (86.4%), while 15 respondents (13.6%) were adolescents. in terms of gender, 85 respondents (77.3%) were female, and 25 respondents (22.7%) were male. regarding living arrangements, 59 respondents (53.6%) reported living with their families, whereas 51 (46.4%) did not. these find pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13121] [page 81] ings indicate that the majority of generation z individuals in one of the areas of bekasi city who exhibit a tendency toward emotional eating behavior are adults, predominantly female, and most commonly live with their families. table 2 presents the relationship between respondent characteristics and emotional eating behavior. the analysis showed no statistically significant associations between age, gender, residence, and levels of emotional eating. seven participants reported low emotional eating and eight reported high emotional eating, whereas among mature respondents, 48 had low emotional eating and 47 had high emotional eating (p=0.571). regarding gender, 16 men reported low emotional eating and 9 reported high emotional eating, compared to 39 women with low emotional eating and 46 with high emotional eating (p=0.063), suggesting a possible trend toward significance. regarding residence, among those living with family, 28 reported low and 31 reported high emotional eating, while among those not living with family, 27 reported low and 24 reported high emotional eating (p=0.585). as shown in table 3, all six psychological factors—anger, boredom, despair, anxiety, stress, and depression—were found to have a statistically significant association with emotional eating behavior among generation z, as indicated by p-values < 0.05. the anger factor had a p-value of 0.000 with an odds ratio (or) of 7.284, indicating that individuals who frequently experienced anger were 7.284 times more likely to engage in emotional eating than those who did not. the boredom factor also showed a significant relationship (p=0.000; or=19.906), suggesting a nearly 19.906-fold increased risk of emotional eating among individuals who experienced boredom. similarly, despair was significantly associated with emotional eating (p=0.000; or=13.132), anxiety (p=0.000; or =6.750), stress (p=0.000; or=21.778), and depression (p=0.000; or=6.641). among these, stress exhibited the strongest association, indicating that individuals experiencing stress were over 21.778 times more likely to engage in emotional eating behaviors. these findings demonstrate that all assessed psychological factors are significant predictors of emotional eating tendencies in generation z. based on the results presented in table 4, multivariate analysis using binary logistic regression revealed that among the six psychological factors examined, stress emerged as the most influential factor associated with emotional eating behavior. the stress variable demonstrated a statistically significant association (p=0.000, p<0.05) with an odds ratio (or) of 8.751. this indicates that individuals experiencing stress are approximately 8.75 times more likely to engage in emotional eating than those who do not experience stress. therefore, it can be concluded that stress was the most dominant psychological factor influencing emotional eating behavior among generation z in this study. discussion this study found a significant relationship between six psychological factors (anger, boredom, despair, anxiety, stress, and depression) and emotional eating behavior among generation z. anger factor the findings indicated a positive relationship between anger and emotional eating, with results showing that individuals who frequently experience anger are approximately seven times more likely to engage in emotional eating behavior. this finding suggests that anger functions as a potent emotional trigger, often in response to perceived threats or stressors. these results align with prior research, which has shown that individuals who engage in pathways of change, part ii [page 82] [healthcare in low-resource settings 2025;13(s2):13121] table 1. frequency distribution of demographic data (n=110). characteristic kategorisasi frequency (n) percentage (%) age teenager 15 13.6 mature 95 86.4 total 110 100 gender man 25 22.7 women 85 77.3 total 110 100 residence living with family 59 53.6 not with family 51 46.4 total 110 100 source: primary data analysis, 2024. table 2. relationship between respondent characteristics and emotional eating behavior. characteristics emotional eating p low high n n age teenager 7 8 0.571 mature 48 47 gender man 16 9 0.063 women 39 46 residence with family 28 31 0.585 not with family 27 24 emotional eating during episodes of anger perceive food consumption as a temporary coping strategy to distract themselves from or soothe negative emotions.19 moreover, emotional eating may serve as a form of emotional suppression, reducing the likelihood of reactive or impulsive behaviors that could arise from an unmanaged anger.15 these findings underscore the importance of fostering emotional regulation skills among generation z. developing effective anger management strategies may help reduce reliance on emotional eating as a maladaptive coping mechanism, thereby lowering the risk of obesity and related health complications. furthermore, this evidence highlights the need for targeted health promotion interventions that focus on emotional regulation, particularly in adolescents and young adults, as part of comprehensive efforts to promote mental well-being and healthy eating behaviors. boredom factor the findings indicate that boredom is significantly associated with emotional eating behavior, with individuals who frequently experience boredom having approximately 19 times the risk of engaging in emotional eating. individuals who are bored often struggle to find meaningful activities, leading them to use food as a distraction or a coping mechanism. this is consistent with previous studies showing that boredom is one of the most potent emotional triggers for eating more so than other negative emotions.20,21 emotional eating driven by boredom often stems from feelings of emptiness, where eating is used to relieve monotony or to fill a perceived psychological void.22 supporting this, other studies have identified boredom as a primary driver of emotional eating, with boredom scoring higher than other emotions as a motivating factor.23 these findings suggest the importance of encouraging generation z to engage in enjoyable and stimulating activities to mitigate boredom. furthermore, this study underscores the need for targeted interventions that specifically address boredom, not only to enhance psychological well-being but also to promote healthier dietary behaviors. despair factor the findings indicate a positive relationship between despair and emotional eating. specifically, the results showed that individuals experiencing despair were 13.1 times more likely to engage in emotional eating. despair is commonly defined as a sense of failure and loss of hope that often triggers various negative emotional states. these emotions may contribute to emotional eating behaviors.15 this aligns with previous studies indicating that emotional eating can be driven by negative affect, including despair, especially in response to overwhelming demands.3 furthermore, individuals with poor emotion regulation skills are more susceptible to emotional eating, particularly when facing body image dissatisfaction or psychological stress.10 these findings suggest that members of generation z may benefit from structured group discussions as a strategy to address and manage emotional challenges. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13121] [page 83] table 3. the relationship between psychological factors and emotional eating. psychological factors emotional eating p low high or n n anger not angry 34 10 0.000 angry 21 45 or =7.286 boredom not bored 39 6 0.000 bored 16 49 or = 19.906 despair not desperate 38 8 0.000 hopeless 17 47 or = 13.132 worry not anxious 33 10 0.000 worried 22 45 0r = 6.750 stress no stress 40 6 0.000 stress 15 49 or = 21.778 depression not depressed 37 13 0.000 depression 18 42 or = 6.641 table 4. multivariate test results of psychological factors that most influence emotional eating behavior. variable p or 1 2 3 4 5 anger 0.209 0.196 0.245 0.375 boredom 0.002 0.000 0.001 0.001 0.001 7.399 despair 0.401 too anxious 0.210 0.168 0.340 stress 0.003 0.001 0.002 0.000 0.000 8.751 depression 0.167 0.220 age 0.735 gender 0.106 0.111 0.115 residence 0.542 0.534 anxiety and stress factor the findings highlight a significant positive association between anxiety and emotional eating, with an odds ratio of 6.7, indicating that individuals experiencing anxiety are approximately six times more likely to engage in emotional eating. additionally, stress exhibited the strongest association, with individuals experiencing stress 21.7 times more likely to demonstrate emotional eating behavior. this suggests that, among psychological factors, stress has the most substantial influence on emotional eating behavior in generation z. these results align with those of previous studies, which have identified emotional eating as a response to stress or as a consequence of inadequate and ineffective coping mechanisms, often manifested by eating more than physiological needs.24-26 stress activates the cortisol response system, which has been linked to unhealthy eating behaviors,27 contributing to the increasing trend of obesity.11 furthermore, anxiety has been shown to influence eating patterns,28,29 indicating a bidirectional relationship in which anxiety can lead to, and be exacerbated by, emotional eating. this study suggests that generation z must develop effective stress management and coping strategies to mitigate anxiety and prevent maladaptive eating behaviors. moreover, it underscores the responsibility of health providers to deliver targeted education on healthy dietary habits tailored to the needs and behaviors of generation z depression factor these findings indicate that depression has a statistically significant relationship with emotional eating. specifically, generation z individuals experiencing depression were 6.6 times more likely to engage in emotional eating behaviors. this suggests that depressive symptoms amplify the vulnerability to unhealthy eating patterns and emotional dysregulation. these results align with those of previous studies showing that depressive symptoms are significantly associated with emotional eating and a higher frequency of consuming energy-dense, nutrient-poor foods.30 consequently, emotional eaters are at a greater risk of obesity,31 and recent studies have highlighted emotional eating as a mediator linking depression with early cardiovascular disease risk.32 this underscores the urgency of integrating mental health screening and emotion regulation strategies into dietary interventions targeted at adolescents and young adults. addressing emotional eating not only supports psychological well-being but also mitigates longterm physical health consequences conclusions this study concluded that six psychological factors–anger, boredom, despair, anxiety, stress, and depression— were significantly associated with emotional eating behavior in generation z, with stress and boredom demonstrating the strongest effects. these findings suggest that emotional eating serves as a maladaptive coping mechanism in response to emotional distress, increasing the risk of unhealthy dietary patterns, obesity, and related health problems. the strong associations observed underscore the need for integrative youth-centered interventions that combine emotional regulation training, mental health support, and nutrition education. promoting resilience and healthy coping strategies among generation z individuals is essential to address the psychological triggers of emotional eating and to support their overall mental and physical well-being. references 1. mangotara sa, bangcola a. correlation of spiritual health and depression among young adults in a state university in southern philippines. j ners 2022;17:144–52. 2. nguyen-rodriguez st, unger jb, spruijt-metz d. psychological determinants of emotional eating in adolescence. eat disord 2009;17:211–24. 3. wijayanti ry. pengaruh regulasi emosi terhadap perilaku emotional eating pada mahasiswa uny tugas 2020;july:1–23. 4. efendi f, tsai mc, pradipta ro, rahayu fk. factors associated with eating disorders among indonesian adolescents at boarding schools. int j adolesc med health 2025;37:12332. 5. indonesia – national adolescent mental health survey (inamhs): laporan penelitian. pusat kesehatan reproduksi. yogyakarta; 2022. available from: https://qcmhr.org/outputs /reports/12-i-namhs-report-bahasa-indonesia/file 6. diehl m, chui h, hay el, lumley ma, grühn d, labouvievief g. change in coping and defense mechanisms across adulthood: longitudinal findings in a european american sample. dev psychol 2014;50:634–48. 7. lopes cortes m, andrade louzado j, galvão oliveira m, et al. unhealthy food and psychological stress: the association between ultra-processed food consumption and perceived stress in working-class young adults. int j environ res public health 2021;18:3863. 8. yusuf a, tristiana rrd, sajogo i, anggraini y, sulistyono re. functional status outcomes of adolescents with mental disorders: a descriptive study. gac med caracas 2024;132:s193–9. 9. zahrah ni, fanani m, ardyanto td. the relationship between emotional eating, meal skipping and unhealthy food consumption pattern in adolescent girls. indones j public heal 2023;18:47–58. 10. shriver lh, dollar jm, calkins sd, et al. emotional eating in adolescence: effects of emotion regulation, weight status and negative body image. nutrients 2020;13:79. 11. shah nm, aghamohammadi n, thangiah n, ng ak, majid ha. association between stress and eating behaviour among malaysian adolescents prior to examination. sci rep 2023;13:7841. 12. auliannisaa a, wirjatmadi b. the relationship between emotional eating and food consumption pattern with obesity in final year college students. media gizi kesmas 2023;12:212– 8. 13. dakanalis a, mentzelou m, papadopoulou sk, et al. the association of emotional eating with overweight/obesity, depression, anxiety/stress, and dietary patterns: a review of the current clinical evidence. nutrients 2023;15:1173. 14. fayasari a, lestari pw. stres dan depresi berkaitan dengan emotional eating dan mindful eating pada mahasiswa saat pandemi covid-19. action aceh nutr j 2022;7:127. 15. dennis k. common health consequences of eating disorders. natl eat disord assoc. 2023; available from: https://www.nationaleatingdisorders.org/health-consequences/#sources 16. ariestiningsih es, has dfs. factors that cause unhealthy eating behavior in generation (gen) z of indonesia: a case study. formosa j appl sci 2024;3:413–26. 17. ariestiningsih es. factors influencing unhealthy eating behaviors in indonesian z generation: a case study. icph 2024;9:44. pathways of change, part ii [page 84] [healthcare in low-resource settings 2025;13(s2):13121] 18. anwar k, putri fs, maskar dh. the relationship between menu anxiety, food preference, eating habits, and the nutritional status of generation z in cinere, depok. amerta nutr 2024;8:326–35. 19. chambers j. psdt and coping with trauma information for teens. 1st ed. omnigraphics, editor. infobase publishing; 2019. 20. koball am, meers mr, storfer-isser a, et al. eating when bored: revision of the emotional eating scale with a focus on boredom. heal psychol off j div heal psychol am psychol assoc 2012;31:521–4. 21. stuck e. an analysis of the factors influencing bored and emotional eating: should bored eating exist as a separate construct? usc aiken psychol theses. 2016 may. 22. nemours teenheath, medically reviewed by gavin ml. emotional eating. available from: https://kidshealth.org/en/teens/emotional-eating.html? wt.ac=ctg 23. guerrero-hreins e, stammers l, wong l, et al. a comparison of emotional triggers for eating in men and women with obesity. nutrients 2022;14:4144. 24. irwansyah pd, arini sy, dwiyanti e, et al. emotional eating on sedentary workers: is it caused by individual characteristics, exercise habits, and work stress? indones j occup saf heal 2024;13:155–62. 25. ningtyas nsa, isaura er. emotional eating and psychological distress: unveiling the hidden struggles of international students in surabaya. amerta nutr 2024;8:582–92. 26. syarofi zn, muniroh l. whether there is a correlation between behavior and excess food intake with the stress in nutrition student who preparing for the undergraduate thesis? media gizi indones 2020;15:38–44. 27. ramadhani n, mahmudiono t. academic stress is associated with emotional eating behavior among adolescent. media gizi indones 2021;16:38–47. 28. gilda irmawati d, rifani r, afni indahari n. pola emotional eating pada wanita dewasa awal dalam hubungan berpacaran jarak jauh. peshum j pendidikan, sos dan hum 2023;2:223–31. 29. fonseca nk de o da, costa m de a, gosmann np, et al. emotional eating in women with generalized anxiety disorder. trends psychiatry psychother 2023;45:e20210399. 30. konttinen h, männistö s, sarlio-lähteenkorva s, silventoinen k, haukkala a. emotional eating, depressive symptoms and self-reported food consumption. a population-based study. appetite 2010;54:473–9. 31. konttinen h. emotional eating and obesity in adults: the role of depression, sleep and genes. proc nutr soc 2020;79:283–9. 32. muha j, schumacher a, campisi sc, korczak dj. depression and emotional eating in children and adolescents: a systematic review and meta-analysis. appetite 2024;200:107511. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13121] [page 85] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13475 barriers to the development of medical tourism: a scoping review from a global perspective and lessons learned for indonesia etik retno wiyati,1,2 dumilah ayuningtyas,3 amal chalik sjaaf,3 wahyu sulistiadi3 1doctoral program in public health, faculty of public health, universitas indonesia, depok; 2ministry of health of indonesia, jakarta; 3department of health administration and policy, faculty of public health, universitas indonesia, depok, indonesia abstract medical tourism enhances access to specialized care, boosts economic growth, and fosters international collaboration. this is crucial for indonesia to improve healthcare services, attract international patients, and strengthen its economy. this study aimed to identify and analyze barriers hindering medical tourism development globally and provide recommendations for indonesia. a scoping review was conducted following arksey and o’malley’s framework. the literature search occurred in september 2024 using pubmed and scopus. articles in english published between 2015 and 2024 were included. the review identified several obstacles to medical tourism. internal factors include workforce issues, organizational systems, technological limitations, inadequate facilities, and insufficient marketing. external challenges are competitive pressures, lack of supporting infrastructure, regulatory constraints, and economic circumstances. to address these, indonesian providers should enhance staff capabilities, implement comprehensive management strategies, embrace digital technologies, improve ancillary infrastructure, and boost promotional activities. transparent and standardized pricing for medical services is also essential. the government should integrate medical tourism policies to ensure consistency, maintain the economic situation, strengthen hospital competitiveness, and develop supporting infrastructure. these recommendations should form the basis for a detailed strategy to strengthen the competitiveness of indonesia’s medical tourism hospitals against international competitors. introduction globalization across multiple sectors has contributed to the increasing complexity of addressing cultural needs in a diverse world. in healthcare, understanding culture and behavior is essential for providing comprehensive services and a good experience. this becomes even more crucial in medical tourism, where patients often come from a wide range of cultural backgrounds and geographic regions.1 medical tourism refers to the act of traveling within one’s own country, either between cities or states, to seek necessary medical treatment.2 this growing trend has gained popularity in southeast asian countries like thailand and malaysia, where healthcare services are more cost-effective compared to those in developed nations.3 in 2021, thailand emerged as a prominent medical tourism destination, drawing approximately one million visitors each year and representing 90% of medical tourism in asia.4 malaysia follows closely behind, ranking second in southeast asia for annual medical tourism visitors, with an estimated 561 thousand people.5 despite the appeal of lower-cost destinations, developed countries such as the united states, japan, and south korea maintain their competitiveness by leveraging advanced medical technologies.3 to facilitate medical tourism, developing countries are establishing global collaborations such as working with insurance companies, travel agents, and renowned medical institutions. additionally, hospitals in these countries are increasingly collaborating with leading hospitals and medical schools in developed nations to enhance credibility, facilitate professional exchanges, and enable the transfer of medical technologies.6 indonesia, a developing nation, shows promise in advancing medical tourism. with its internationally certified hospitals, cutting-edge medical technology, and diverse tourist attractions, indonesia has significant potential to draw medical tourists from correspondence: : etik retno wiyati, doctoral program in public health faculty of public health, universitas indonesia, indonesia. e-mail: etikjamall2@gmail.com key word: development barriers, medical tourism, scoping review, global perspective, lesson learn, indonesia contributions: erw conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; da conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; acs conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ws conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing. conflict of interest: the authors declare no conflicts of interest. ethical approval and consent to participate: this study is a scoping review of previously published data and does not involve human participants or animals, therefore ethics approval and consent to participate are not required patient consent for publication: none funding: this research did not receive external funding availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 11 december 2024 accepted: 16 january 2025. early access: 3 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13475 doi:10.4081/hls.2025.13475 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 82] [healthcare in low-resource settings 2025;13(s1):13475] both domestic and international sources.7 similarly, india, another developing country, is well-positioned to become a medical tourism destination. india’s advantages include internationally recognized medical professionals, state-of-the-art facilities, and highly competitive pricing.8 although medical tourism is widely embraced, it still faces several obstacles. the challenges hindering the growth of medical tourism across various nations are multifaceted. in south korea, the primary impediment to progress is the absence of effective and unified government backing. furthermore, issues related to language proficiency and specialized training in the field of medical tourism require immediate attention. despite its growing popularity, medical tourism is facing several challenges. barriers to its development in various countries are very complex. in south korea, key barriers include the lack of efficient and centralized government support as well as the need for improvements in communication skills and specialist training in medical tourism.9 other countries, such as russia, also face additional barriers, such as underdeveloped services and infrastructure, as well as weak marketing strategies.10 each country faces unique challenges that hinder the development of its medical tourism based on its specific characteristics. understanding these differences is crucial for countries willing to develop their medical tourism. these insights are also important for addressing the research question regarding their relevance to indonesia’s situation. while numerous studies have identified barriers to the development of medical tourism in various countries, there remains a lack of research that addresses these barriers in a global context and compares differences across countries. some countries that have identified barriers to medical tourism development include the united arab emirates,11,12 iran,13–15 jordan,16 china,17 taiwan,18 indonesia,19 south korea,9 austria,20 australia,21 guatemala,22,23 greece,24 canada,25 dan turkey.26 however, no study has examined these barriers from a global perspective or compared differences between countries with various characteristics. this study aims to identify and analyze the key barriers hindering the development of medical tourism at the global level through a scoping approach. it also seeks to draw insights from these global challenges to inform the development of medical tourism in indonesia. materials and methods this scoping review was conducted in accordance with the guidelines developed by arksey and o’malley (2005) and levac et al. (2010). based on this, five steps were taken to conduct a scoping review. the following explains these steps, as adapted in this study. step 1: identifying the research question globally, several countries have established excellent medical tourism services. however, some countries such as indonesia, india, and vietnam are still striving to develop their offerings and competing to provide the best services. to understand the complexities hindering the development of medical tourism on a global scale and provide recommendations for countries developing this sector, it is crucial to identify the research questions. the research question formulated is: what factors act as barriers to the development of medical tourism from a global perspective in order to serve as a learning opportunity for indonesia and other countries developing their medical tourism industries? step 2: identifying relevant studies in this stage, a comprehensive literature search was conducted to identify relevant studies. articles were retrieved through systematic screening of the pubmed and scopus databases for the period 2015 to 2024. the search strategy utilized the following query: (“health tourism” or “medical tourism” or “wellness tourism” or “healthcare tourism” or “medical travel”) and (“barriers” or “challenges” or “hurdles” or “limitations” or “constraints”) and (“develop*” or “implement*” or “growth” or “expand*” or “establish*” or “strategy*” or “plan*”). step 3: study selection as illustrated in figure 1, the initial search yielded 361 articles, of which 71 were identified as duplicates and subsequently removed. following title-based screening, 232 articles were excluded. additionally, one article was manually added from another source based on the research inclusion criteria, resulting in a total of 59 articles. these articles were further screened based on methodology, content relevance, and research location. during this process, 52 articles were excluded due to inconsistencies with the study criteria, leaving seven articles for in-depth analysis (figure 1). to meet the inclusion criteria of this study, the following research question was addressed: what factors serve as barriers to the development of medical tourism in a country? the study selection was restricted to articles employing scoping literature review and narrative review methodologies. furthermore, only studies utilizing qualitative methods and in-depth interview techniques were included. additional exclusion criteria were applied based on the geographical location of the study, limiting the analysis to research conducted in the asian region. step 4: charting data after identifying and selecting the relevant studies, the next step involved charting the data. at this stage, the researcher systematically outlined key information essential for the development of this article. the extracted data were organized into a structured table, which included the following variables: title, journal, type of informant, number of informants, research location (country), special issue pathways of change figure 1. study selection flowchart. [healthcare in low-resource settings 2025;13(s1):13475] [page 83] identified barriers, and source references. subsequently, the identified barriers were categorized into two main groups: internal factors and external factors. these barriers were then systematically grouped based on the respective countries where the studies were conducted, enabling a comparative analysis of medical tourism challenges across different asian regions. step 5: collating, summarizing, and reporting the results the final results of the study selection process are presented in detail using the prisma (preferred reporting items for systematic reviews and meta-analyses) flow diagram (figure 1). the selected articles were analyzed using a qualitative thematic analysis approach, which provided in-depth insights into various barriers hindering the development of medical tourism across different countries. the thematic synthesis of these findings led to the formulation of strategic recommendations that can be broadly applied, with a specific focus on enhancing the medical tourism sector in indonesia. results the seven included studies higlight challenges in the develompment of medical tourism across different countries (supplementary materials, table 1). the findings shown that the united arab emirates (uae) and south korean were represent the development country problem, whereas turkey, iran, and indonesia were represent the barriers faced by developing countries. most studies analyzed gathered information from key stakeholders in the medical tourism industry, including government officials, hospital administrators, healthcare professionals, scholars, patients, insurance providers, and accommodation facilities for medical tourists. each study involved 6 to 16 participants, offering a range of perspectives. the respondent types in each study provided varied viewpoints on challenges faced by their countries in the medical tourism sector. this approach enhanced the quality of qualitative data, leading to a more comprehensive understanding. by employing this method, the research gained validity and contributed to developing evidence-based strategies for addressing obstacles in the industry. according to most included studies examined, the primary obstacle to medical tourism’s growth is the quality of human resources. additionally, five out of seven studies identified poor infrastructure and a shortage of medical tourism facilitators as significant challenges. other common issues, mentioned in four out of seven articles, include limited promotion or marketing efforts, as well as inconsistent regulations and the lack of a comprehensive legal framework. the least frequently cited factors affecting the development of medical tourism included economic crises, inflation, unclear pricing, and high service costs. among these, high service prices were identified only in the united arab emirates (uae) – a developed country with a significantly high per capita income, which directly influences the cost of medical tourism services. in contrast, this issue is not a significant concern in developing countries, such as indonesia, iran, and turkey, where the cost of medical tourism remains relatively cheaper than that of developed countries. in summary, this study highlights that while barriers to medical tourism development vary across countries, several common challenges emerge, including human resource quality, infrastructure limitations, and inadequate promotional efforts. these findings highlight the importance of tailored strategies that address countryspecific needs, while drawing from global insights to support the growth of medical tourism in indonesia. discussions analysis of barriers to medical tourism from the findings of barriers to medical tourism in various countries can be grouped into internal and external factors. internal factors include human resources, management system, technology, infrastructure, and promotion. external factors include level of competition, external infrastructure factors supporting medical tourism, policy factors, and economic factors (supplementary materials, table 2). internal factors quality of human resources the findings highlight several key challenges in medical tourism, including a lack of expertise and health workers, as well as language and communication barriers. improving the competence of healthcare professionals, including administrative staff, is crucial for providing high-quality services and meeting the expectations of international patients11-19. cultural competence is emphasized as a critical factor, requiring healthcare providers to be proficient in foreign languages and capable of effectively interacting with patients from diverse backgrounds. to address these challenges, hospitals and healthcare facilities should implement targeted training programs that focus on language skills, cultural understanding, and specialized care for patients from various backgrounds.13,15,19,26 these programs should be implemented across the entire healthcare system and organization, not just at the individual level, to ensure consistent and high-quality care for medical tourists.28 management system: lack of accreditation for healthcare facilities the finding shown that the quality of service is crucial for medical tourism, as it influences patients’ choice of destination for medical care. shojaei et al. highlighted challenges in the united arab emirates, including language barriers, inadequate infrastructure, and lack of competent staff, which manifest as low-quality service. notably, hospitals often neglect post-discharge follow-up care, impacting patient outcomes and satisfaction.11,13,15 to attract medical tourists and develop services, international accreditation is essential, ensuring care meets global standards. comprehensive services and equipment are vital to prevent patient transfers between hospitals, ultimately enhancing satisfaction. the absence of quality indicators in the uae poses a significant challenge for its medical tourism sector, emphasizing the need for improved service quality to compete in the global market. management system: hospitals have limited collaboration with insurance providers offering international coverage medical tourism hospitals must actively collaborate with insurance providers offering international coverage to make their services accessible to patients in various countries. such partnerships can reduce or eliminate out-of-pocket expenses for patients undergoing treatment. this approach benefits international and domestic patients seeking care in other cities or regions. the growth of med special issue pathways of change [page 84] [healthcare in low-resource settings 2025;13(s1):13475] ical tourism is driven by commercial and corporate insurance. therefore, it is important for a medical tourism hospital to ensure its services are covered by insurance, especially international insurance.11,19,27 technology: lack of digitalization and technological advancements the emergence of artificial intelligence (ai), the internet of things (iot), robotics, automation, virtual reality, cloud solutions, and big data analytics has disrupted the medical tourism industry. advancements in technology and digitalization provide easy access to information. patients can now directly communicate with hospitals to obtain up-to-date information, enhancing their decision-making when selecting medical tourism destinations.19 in some countries, medical procedures can be remotely performed. collaboration between hospitals at national and international levels enables medical tourists to access health services more seamlessly. for countries aiming to be medical tourism hubs, investing in cutting-edge technologies should be a priority. such innovations serve as a competitive advantage and enhance patient trust by showcasing a commitment to world-class care.15,27 infrastructure: inadequate infrastructure the findings highlight that infrastructure plays a crucial role in medical tourism development, encompassing core facilities like hospitals and clinics, as well as supporting infrastructure such as international airports and accommodations.13,26 developing countries like indonesia and iran face challenges due to limited healthcare facilities and professionals, impacting service quality and accessibility.15,19 in contrast, developed nations like the uae and south korea, despite advanced infrastructure, encounter issues related to interconnectivity between medical and tourism service providers.15,19 okasha et al. noted that while the uae has high-end medical facilities, limited renowned specialists hinder its competitiveness in attracting international patients.27 thailand has successfully positioned itself as a leading medical tourism destination by integrating modern hospitals, skilled professionals, affordable costs, and seamless infrastructure.29 these findings suggest that countries aiming to enhance their medical tourism sector must address infrastructure gaps by improving facility capacity, ensuring interconnectivity between services, and fostering collaboration between healthcare and tourism stakeholders to enhance global competitiveness. pricing and promotion: lack of price transparency in this review, supriadi et al. identified price ambiguity as a significant barrier to medical tourism. momeni et al. reported that in iran, doctors and healthcare providers often charge patients more than actual costs without regulatory oversight. digital information is crucial for cost transparency, covering medical treatment and travel expenses. momeni et al. emphasized the importance of providing services in english to improve accessibility. supervision by authorized institutions is vital for regulating prices and protecting patients from exploitation. lack of consumer trust can affect hospitals’ growth and income from medical tourists.13,19 digital platforms can enhance transparency by providing real-time cost estimates, allowing patients to make informed decisions. offering multilingual services, particularly in english, can improve accessibility. effective supervision by authorized institutions is essential to regulate pricing, prevent unethical practices, and foster consumer trust, supporting hospital growth. addressing these challenges through pricing regulations, digital transparency initiatives, and improved consumer protection will strengthen medical tourism competitiveness and enhance patient confidence in crossborder healthcare. pricing and promotion: high service costs the findings indicate that high healthcare costs and non-standardized pricing present major barriers to medical tourism in developed countries like the uae. not only the cost of medical services but also the high price of hotels, travel costs, and other accommodations are important factors that affect the development of medical tourism in the uae.11,27 government intervention is crucial in regulating service pricing and ensuring cost transparency for international patients. addressing high accommodation and travel costs through incentives, subsidies, or partnerships with hospitality and transportation sectors could improve medical tourism accessibility. developing comprehensive packages integrating affordable medical care, accommodation, and transportation may attract more international patients. strengthening public-private partnerships to offer competitive pricing models will be essential in making the uae a more attractive medical tourism destination. pricing and promotion: insufficient promotion/advertising lack of marketing of medical tourism causes medical tourism destinations to be unknown bulatovic and iankova noted that in the uae, the general public is unaware of medical tourism opportunities due to insufficient advertising of these destinations. this issue is closely related to a lack of brand awareness. hospitals should focus on building a strong brand and image to attract medical tourists. similarly, momeni et al. pointed out that while various specialized care options are available in tabriz, iran, the lack of a strong brand poses challenges in marketing the services and products that can be provided.11,13 promotion in the global market or in neighboring countries is a key factor in attracting medical tourists, as highlighted by rokni et al. although south korea offers high-quality medicines and high technology, rokni et al. mentioned that this does not seem to be enough to convince and attract foreign patients because they can find the same quality in other countries. to address this issue, rokni et al. emphasized the need for a comprehensive global marketing strategy. additionally, momeni et al. suggested that establishing medical tourism agencies in target markets, particularly in neighboring countries, could be an effective marketing strategy.9,13 evidence suggests that extensive advertising and marketing efforts can reduce coping risks and enhance an organization’s resilience. medical tourism hospitals are encouraged to increase their presence by actively promoting and introducing medical tourism service facilities and products they have.30 the findings highlight the critical role of marketing in medical tourism, addressing challenges and strategies. key points include increasing public awareness through advertising, emphasizing strong branding, and overcoming promotion challenges. a global marketing approach is necessary to compete and attract foreign patients.11,13 the findings suggest focusing on target markets, especially neighboring countries, by establishing medical tourism agencies. extensive advertising and marketing efforts are recommended to reduce risks and enhance organizational resilience.9,13 the research encourages medical tourism hospitals to promote their facilities and services to increase market presence, emphasizing strategic marketing and branding.30 success in medical tourism requires integrating high-quality medical care with effective marketing and branding. healthcare providers should consider reallocating resources to prioritize these efforts. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13475] [page 85] external factor management system: lack of strategic planning a fundamental challenge in developing medical tourism is the lack of strategic planning at the policymaking level. this includes national strategic planning by the government and initiatives by medical tourism organizations and hospitals. implementing medical tourism requires a clear roadmap, from building a health service industry to supporting industries like pharmaceuticals, medical devices, insurance, accommodation, travel, media, and branding. such comprehensive planning will impact both costs and quality of services provided to medical tourists.9,13,15 malaysia, in the malaysia healthcare travel council (mhtc) blueprint 2021– 2025, focuses on building a fertility hub to meet demand in the asia-pacific market and developing elderly care services to position itself as a top retirement choice.31 thailand’s strategic plans for developing thailand as an international medical hub emphasize wellness and herbal/thai medicine. for effective medical tourism development, countries must leverage their unique strengths and opportunities. focusing on centers of excellence can attract both national and international medical.32 ganguli and ebrahim emphasize the importance of developing a national strategy with clear direction, integrated planning, and a policy framework for strategic priority programs.33 supporting infrastructure: weak of supporting infrastructure this review higlight that medical tourism relies not only on healthcare facilities but also on supporting infrastructure such as hotels, transportation, and tourism services. countries such as turkey face challenges related to accessibility and transportation infrastructure, which hinder the growth of medical tourism. this is in contrast to penang, malaysia. the city is considered very good in terms of transportation vehicles.11,15,19 supporting infrastructure: lack of medical tourism facilitators this review showed that medical tourism requires quality services and extensive marketing efforts. respondents from bulatovic and iankova emphasized the need for specialized travel agencies to accelerate medical tourism growth. the absence of formal medical tourism facilitators in iran led to brokers, who created dissatisfaction among medical tourists by convincing patients to undergo unnecessary procedures for more commission. to address this, medical tourism hospitals should collaborate with established medical travel agents or create their own. for example, bumrungrad international hospital in thailand appointed a dedicated travel agent in indonesia to guide indonesian medical tourists to their facilities. these facilitators can foster cooperation across sectors such as airlines, airports, hotels, tourist destinations, and hospitals, ensuring a seamless experience for medical tourists.11,26 this role includes tour planning and arranging travel logistics and accommodation. thailand has demonstrated the importance of medical travel facilitators (mtfs) in managing these aspects for medical tourists. by handling logistics, mtfs help create a seamless travel experience, avoiding potential disruptions to medical procedures due to travel issues.34 policy: regulatory inconsistency and lack of a supportive legal system regulations and policies are crucial for successful medical tourism development. a study by cavmak d. and cavmak s. showed turkey’s medical tourism regulations haven’t aligned with international standards. developed countries like south korea face regulatory inconsistencies, including lack of international cooperation, reimbursement and insurance discrepancies, and unclear institutional responsibilities.9,26 policy incentives, such as tax reductions for medical devices, special medical treatment visas, and hospital service promotion, significantly stimulate medical tourism growth, especially in the private sector. supriadi et al. identified high import taxes on medical devices in indonesia as a major factor in rising healthcare costs. comparing with malaysia and thailand, tax incentives make ct scan and mri services more affordable.19 supriadi et al. also highlighted barriers to medical tourism in indonesia, including unclear visas for medical tourists, ambiguous legal frameworks, and limited hospital marketing capacity.19 government policies can facilitate medical tourism expansion through incentives, lower import tariffs, increased depreciation rates for medical equipment, and financial exemptions.35 for example, malaysia offers 100% income tax exemption for eligible capital expenditures over five years, aiming to attract investment, enhance infrastructure, and integrate advanced medical technology.36 competition: competition between countries competition in medical tourism is a double-edged sword. it can drive organizations to improve performance and enhance offerings, fostering a positive image of hospitals and countries in the international market.2 however, intense competition can pose a threat to the development of medical tourism in certain regions such as the uae. countries with established international reputations in medical tourism, like turkey, thailand, singapore, india, iran, russia, and balkan countries, are key competitors that challenge the uae’s market.9,11 supriadi et al. highlighted that wellestablished destinations like malaysia, thailand, and singapore challenge indonesia in attracting medical tourists. rokni et al. emphasized the importance of countries identifying their competitive advantages to allocate resources effectively.9,19 for instance, south korea focused on competitive prices and specialized cancer services, key areas over their competitors. south korea also increased its competitiveness by linking wellness tourism with medical tourism.37 economy: inflation and economic crisis inflation and economic crises significantly impact medical tourism. okasha et al. reported a substantial decline in medical tourism in 2021, with a 70% decrease in medical tourists due to the pandemic. many patients canceled departures because of travel restrictions and increasing health costs. during crises, countries prioritize themselves, affecting nations whose health systems rely on imported goods. inflation and economic crises have led to rising prices for medicines and medical devices, increasing healthcare costs.27 economic crises profoundly impact healthcare workers and health infrastructure. with limited resources, time, and funding, it is essential to allocate these to the most critical populations. restrictions on these resources can significantly affect medical tourism, particularly if the crisis includes travel restrictions between countries, as seen during the covid-19 pandemic.38 implications for indonesia indonesia can gain insights by understanding challenges other countries face. turkey, iran, and indonesia likely have similar barriers as developing countries. these include inadequate infrastructure, insufficient promotion, regulatory inconsistency, lack of a supportive legal system, and human resource quality issues. by special issue pathways of change [page 86] [healthcare in low-resource settings 2025;13(s1):13475] understanding barriers encountered by countries with similar characteristics, indonesia can identify key focus areas and develop strategies to prevent resource misallocation. this approach enables prioritizing initiatives that address critical challenges while aligning with the country’s strategic objectives for medical tourism industry development. lesson learned for the development of indonesia’s medical tourism according to the indonesian health survey or survey kesehatan indonesia (ski), approximately 0.1% of households in indonesia have sought medical treatment abroad in the last three years, with malaysia being the top destination compared to singapore, the united arab emirates, south korea, and thailand. indonesian tourists’ annual healthcare spending abroad is estimated at us$385.7 million, with an average healthcare expenditure of around $108.96 per trip, representing 4.12% of total spending. given current conditions, policymakers need to restructure policies to prevent medical tourism outflow and stimulate domestic medical tourism growth. the government’s role is crucial in developing policies that enhance healthcare service quality within the country and encourage citizens to seek treatment domestically.39 based on studies of medical tourism barriers in various countries, several lessons can be applied to develop medical tourism in indonesia. these lessons fall into two main categories: first, lessons for internal stakeholders, particularly hospitals and healthcare providers involved in medical tourism; and second, lessons for external stakeholders, including the government and related entities such as medical tourism travel agencies, associations, and other organizations that play a significant role in implementing and promoting medical tourism. to strengthen the development of medical tourism in indonesia, several lessons can be drawn from both medical tourism organizers (hospital management) and the government. it is essential for medical tourism organizers to focus on developing human resource competencies. second is the development of a management system based on proper planning, excellent services, and expanding cooperation networks. third, the importance of developing digital-based technology, such as telemedicine or patient management systems, should be prioritized to support the implementation of medical tourism. fourth, it is important to strengthen infrastructure to support medical tourism services. fifth, we promote and provide integrated price clarity for all the services. for the government, policies related to medical tourism must align with other national policies to ensure consistency and avoid legal conflicts. economic conditions need to be maintained, especially regarding inflation rate and potential for economic crisis. the government must play an active role in strengthening hospital competitiveness through measures like tax incentives, fiscal policies, and streamlined visa processes. furthermore, the government should enhance supporting infrastructure, including medical travel agencies, transport facilities, and visa services, vital for facilitating medical tourism growth. study limitation although this study offers valuable insights, it has several limitations that need to be considered, which may not capture more recent challenges or changes in the field. another limitation of this study is the amount of available literature. the amount of relevant literature on this topic is still limited, which can cause an information bias. the articles analyzed in this study span the last 10 years, which may not fully account for recent policy changes or shifts in the medical tourism landscape in the countries under consideration. conclusions the identification of barriers to medical tourism implementation reveals two main categories: internal and external. internal factors include human resource challenges, inadequate management systems, technological limitations, insufficient infrastructure, and marketing issues like lack of promotion and unclear pricing. external factors include policy support and consistency, maintaining healthy economic conditions, and efforts to strengthen competitiveness by providing ease in taxation and visa processes for medical tourists. these factors collectively influence the growth and success of medical tourism. however, further research is required to analyze indonesia’s specific context to identify challenges and opportunities for developing effective strategies for further 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lee y. south korea’s medical tourism competitiveness and future strategy: focused on cancer treatment: a review. iran j public health 2023;52:2484–95. 38. claborn dm. a narrative review of the role of economic crisis on health and healthcare infrastructure in three disparate national environments. int j environ res public health 2020;17:1252. 39. bps indonesia. statistik wisatawan nasional 2022. stat wisatawan nas 2022. 2023. special issue pathways of change [page 88] [healthcare in low-resource settings 2025;13(s1):13475] online supplementary materials table 1. the results of the analysis of global studies on barriers to the development of medical tourism. table 2. barriers to the development of medical tourism in various asian countries. hrev_master healthcare in low-resource settings 2025; volume 13(s1):13017 maternal self-efficacy: perspectives on formula milk and insufficient breast milk in koja district health center, indonesia sri djuwitaningsih,1 deswani deswani,1 alvina dwi lestari,1 titi sulastri,1 made riasmini,2 tri endah pangastuti1 1department of nursing, politeknik kesehatan kemenkes jakarta iii; 2department of nursing, politeknik kesehatan kemenkes bandung, west java, indonesia abstract breastfeeding self-efficacy substantially impacts mothers’ perceptions of formula milk and their beliefs regarding breast milk inadequacy, thereby directly influencing breastfeeding behaviors. despite the considerable health advantages of breastfeeding for both infants and mothers, diminishing breastfeeding rates and a growing dependence on formula milk underscore the necessity for interventions aimed at enhancing mothers’ confidence in breastfeeding. this study’s objective is to determine the relationship among breastfeeding self-efficacy, perception of formula milk, and perceived breast milk insufficiency among breastfeeding mothers. a quantitative analytical approach using a cross-sectional design was employed, involving 103 breastfeeding mothers with infants under six months. data were collected using a selfdeveloped questionnaire on formula milk perceptions, an adapted perceived insufficient milk (pim) questionnaire, and the breastfeeding self-efficacy scale-short form (bses-sf). a significant relationship was identified between perceptions of breast milk inadequacy and breastfeeding self-efficacy (p=0.001). factors such as exclusive breastfeeding experience and current infant nutrition positively correlated with self-efficacy. addressing the perceptions of breast milk inadequacy is essential for promoting breastfeeding self-efficacy and improving breastfeeding practices. future research should explore how these factors evolve over time and how they affect breastfeeding success. introduction breastfeeding is universally recognized for its substantial health benefits to infants and mothers. the world health organization (who) recommends exclusive breastfeeding for the first six months of life to ensure optimal growth and development. despite these recommendations, breastfeeding practices have remained suboptimal in several regions. according to the 2023 indonesian health survey, exclusive breastfeeding rates in jakarta province increased from 52% in 2017 to 68% by 2023.1 however, only 27% of newborns received breast milk within the first hour of birth, and approximately 79.32% of infants aged 0-5 months were fed formula milk, as reported in the 2018 jakarta provincial health survey.2one of the critical factors influencing breastfeeding practices is mothers’ perception of breast milk insufficiency. for instance, 81% of mothers reported dissatisfaction with their milk supply, which was often associated with physical challenges, such as nipple abrasion.3 a previous study noted that the perception of insufficient breast milk is the primary reason for the global failure of exclusive breastfeeding.4,5 additionally, marketing strategies for formula milk contribute to a decline in breastfeeding rates by promoting products that are nutritionally equivalent to breast milk.6 despite these insights, few studies have examined the impact of breastfeeding self-efficacy on mothers’ perceptions of formula and breast milk adequacy in indonesia. studies have shown that mothers with higher breastfeeding self-efficacy are more likely to initiate and maintain exclusive breastfeeding.7-9 this study focuses on how mothers’ confidence in breastfeeding interacts with their attitudes toward formula milk and perceived milk insufficiency in a specific population. it aimed to fill this research gap by exploring the relationship between breastfeeding self-efficacy, perceptions of formula milk, and perceived breast milk inadequacy correspondence: deswani deswani, department of nursing, politeknik kesehatan kemenkes jakarta iii, indonesia. e-mail: desika_64@yahoo.co.id key words: breastfeeding self-efficacy; breast milk insufficiency perception; exclusive breastfeeding; formula milk perception. contributions: sd, conceptualization, investigation, methodology, validation, and writing – original draft, review, and editing; dd, conceptualization, data curation, formal analysis, methodology, valida-tion, visualization, writing–original draft, review, and editing; adl, conceptualization, methodology, formal analysis, validation, and writing – original draft, review, and editing; ts, mr, tep, formal analysis, validation, and writing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the research received ethical approval from the jakarta ministry of health polytechnic iii research ethics committee, with number lb.02.02/f.xix.21/3828/2024. during the study, the researcher adhered to ethical principles, inclu-ding informed consent, respect for human rights, beneficence, and non-maleficence. consent for publication: written informed consent was obtained from the patient for the publication of anonymized information. availability of data and materials: all data generated or analyzed in this study are included in this published article. received: 5 september 2024. accepted: 20 march 2025. early access: 24 april 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13017 doi:10.4081/hls.2025.13017 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13017] [page 127] among mothers attending public health centers. understanding these dynamics is crucial for developing targeted interventions to enhance breastfeeding practices and to support maternal confidence in breastfeeding. materials and methods study design this study employed a quantitative analytical design with a cross-sectional approach to assess the relationship between breastfeeding self-efficacy and mothers’ perceptions of formula milk and breast milk adequacy. study participants the research was conducted from february to may 2024, targeting mothers with infants under six months old within the working area of the koja health center, indonesia. purposive sampling was used to select 103 breastfeeding mothers for the study. inclusion criteria consisted of breastfeeding mothers with infants under six months of age, and exclusion criteria were mothers with infants older than six months or those with comorbidities (such as hiv/aids). variable, instrument, and data collection the independent variables included demographic factors (age, education, occupation, and number of children), perceptions of formula milk consumption, and perceptions of breast milk insufficiency. the dependent variable was breastfeeding self-efficacy. data were collected using three validated instruments: a self-developed questionnaire for assessing perceptions of formula milk, the perceived insufficient milk (pim) questionnaire10 modified for this study, and the breastfeeding self-efficacy scale-short form (bses-sf).11 all instruments were validated for reliability using a 4-point likert scale (1=strongly disagree to 4=strongly agree). respondents completed questionnaires during their visits to the health center. trained enumerators delivered instructions to guarantee comprehension and accurate execution of the instruments. data analysis the data analysis included univariate analysis to describe the respondents’ characteristics and to provide a detailed overview of the sample demographics and study variables. bivariate analysis was conducted using the chi-square test to examine the relationships between the independent and dependent variables and to identify significant associations within the data. ethical clearance ethical approval was obtained from the jakarta ministry of health polytechnic iii research ethics committee (no. lb.02.02/f.xix.21/3828/2024). the study followed ethical principles such as informed consent, respect for human rights, beneficence, and nonmaleficence. results this study aimed to investigate the impact of breastfeeding self-efficacy on mothers’ perceptions of formula and breast milk adequacy. the results provide valuable insights into these relationships and how they may influence breastfeeding practice. as shown in table 1, among the 103 participants, most (78.6%) were within the reproductive age range of 20-35 years. a significant proportion of the sample (79.6%) had a higher level of education, whereas 81.6% identified themselves as housewives. additionally, 61.2% had more than one child. notably, 40.8% had exclusive breastfeeding experience, and 61.2% relied exclusively on breast milk for their infants’ nutrition. table 2 shows that 59.1% of mothers of non-reproductive age had low breastfeeding self-efficacy, whereas 60.5% of reproductive-age mothers had high self-efficacy. the p-value for the association between maternal age and breastfeeding self-efficacy was 0.162, indicating no significant relationship. regarding education, 61.9% of mothers with low educational levels displayed high breastfeeding self-efficacy, compared to 54.9% of those with higher education. the p-value for education was 0.739, suggesting no significant correlation between the mother’s level of education and confidence in breastfeeding. among the working mothers surveyed, 12 (63.2%) expressed low breastfeeding self-efficacy, whereas 51 (60.7%) reported high selfefficacy (p=0.101), indicating no meaningful relationship between work status and self-efficacy. mothers with only one child demonstrated a high level of breastfeeding self-efficacy, with 21 (52.5%) reporting this, whereas those with more than one child exhibited a similar level, with 37 (58.7%) reporting high self-efficacy. statistical analysis yielded a p-value of 0.676, indicating no significant correlation between the number of children (parity) and breastfeeding self-efficacy. tables 3 and 4 demonstrates maternal self-efficacy in relation to perceptions of formula milk and breast milk insufficiency at the public health center. mothers with a positive perception of formula milk had a higher proportion of low breastfeeding self-efficacy (53.2%) than those with a negative perception of formula milk (35.7%). however, this association was not statistically significant (p=0.114, or=2.045, 95% ci: 0.927-4.515). in contrast, the perception of breast milk inadequacy was significantly linked to breastfeeding self-efficacy (p=0.001). among mothers who believed they had insufficient breast milk, 88.5% exhibited low breastfeeding self-efficacy, compared to just 28.6% in the low-insufficiency group. the odds ratio (or=19.167, 95% ci: 5.220-70.381) sugge special issue pathways of change table 1. characteristics of respondents based on general data. characteristics frequency percentage age non-reproductive 22 21.40 reproductive 81 78.60 education low education 21 20.40 higher education 82 79.60 job working 19 18.40 housewife 84 81.60 number of children (parity) 1 child 40 38.80 >1 child 63 61.20 exclusive breastfee-ding expe-rience not breast-feeding 40 38.80 not exclu-sive 21 20.40 exclusive 42 40.80 current baby nutrition breastmilk with formula/formula only 40 38.80 breastmilk only 63 61.20 total each variable 103 100 [page 128] [healthcare in low-resource settings 2025;13(s1):13017] sted that mothers who perceived a high level of breast milk insufficiency were significantly more likely to have low breastfeeding self-efficacy. these findings indicate that while maternal perception of formula milk may not strongly impact breastfeeding selfefficacy, concerns about breast milk insufficiency play a critical role in underscoring the need for targeted interventions to enhance maternal confidence in breastfeeding practices. discussion this study aimed to examine the impact of mothers’ self-efficacy in breastfeeding on their perceptions of formula and breast milk inadequacy among mothers attending public health centers. the key findings indicated a significant relationship between the perception of breast milk inadequacy and breastfeeding self-efficacy; however, the perception of formula milk did not significantly influence self-efficacy levels. specifically, 88.5% of the mothers who perceived breast milk as inadequate exhibited low breastfeeding self-efficacy, whereas 71.4% of those with a low perception of breast milk inadequacy demonstrated high self-efficacy. in contrast, only 46.8% of the mothers with a positive perception of formula milk reported high self-efficacy, suggesting that breastfeeding confidence is more strongly associated with perceptions of milk adequacy than external feeding options. these findings underscore the importance of addressing maternal perceptions of milk sufficiency to enhance breastfeeding self-efficacy. the findings highlight that mothers’ perceptions of breast milk inadequacy are positively correlated with breastfeeding self-efficacy. these results align with previous studies indicating that perceptions of breast milk adequacy significantly influence breastfeeding practices.12 for example, gusriani et al. emphasized that maternal psychological factors, including confidence and perceived milk production, play a crucial role in successful breastfeeding.13 additionally, several studies have identified a significant association between the perception of insufficient breast milk and exclusive breastfeeding, reinforcing the notion that mothers’ beliefs about their milk supply can substantially impact breastfeeding outcomes.4,14 furthermore, breastfeeding experience is a key determinant of breastfeeding self-efficacy, as supported by this study, which found that past experience with exclusive breastfeeding was positively associated with higher self-efficacy.15,16 these findings highlight the importance of addressing maternal perceptions of milk adequacy through targeted education and support programs to enhance breastfeeding self-efficacy and to promote exclusive breastfeeding. interestingly, this study found no significant relationship between mothers’ perception of formula milk and breastfeeding selfefficacy. this suggests that attitudes toward formula milk may not directly influence confidence in breastfeeding, while other factors can impact it, including individual perspectives, family, education, and knowledge.17-20 this result was unexpected, as previous studies have suggested that negative perceptions of formula milk may contribute to increased confidence in breastfeeding.21 instead, our study’s findings indicate that breastfeeding confidence is more strongly associated with perceptions of milk adequacy than with attitudes toward formula feeding.14,22 moreover, this study suggests that mothers exhibit varying levels of self-efficacy regardless of their opinions about formula milk. these nuances may reflect the complexity of maternal attitudes, where personal experiences and social support systems play a more significant role than external perceptions of formula feeding.23,24 these findings suggest a clear relationship between mothers’ perceptions of both formula milk and breast milk adequacy and their confidence in breastfeeding. this aligns with existing literature, which indicates that perceptions of milk sufficiency significantly influence breastfeeding practices.10,11 understanding these dynamics is essential for developing interventions aimed at improving breastfeeding rates and enhancing maternal confidence. for further insights into the influence of maternal perceptions on breastfeeding, refer to relevant studies.25 several limitations of this study should be acknowledged when interpreting the results. the cross-sectional design limits the ability to establish causal relationships, as data are collected at a single point in time. additionally, the sample size of 103 participants, although sufficient for preliminary insights, may restrict the generalizability of the findings to broader populations and diverse settings. the reliance on self-reported measures may also introduce bias, as participants may provide socially desirable responses. furthermore, key factors, such as maternal mental health, social special issue pathways of change table 2. relationship between respondent characteristics and breastfeeding self-efficacy (n=103). variables breastfeeding self-efficacy total p or low high value (95% ci) n % n % n % age 0.162 2,212 non-reproductive 13 59.1 9 40.9 22 100 0.847-5.774 repro-ductive 32 39.5 49 60.5 81 100 total 45 43.7 58 56.3 103 100 education 0.739 0.748 low education 8 38.1 13 61.9 21 100 0.280-1.999 higher education 37 45.1 45 54.9 82 100 total 45 43.7 58 56.3 103 100 job 0.101 2,649 wor-king 12 63.2 7 36.8 19 100 0.946-7.420 hou-sewife 33 39.3 51 60.7 84 100 total 45 43.7 58 56.3 103 100 number of children 0.676 1.288 1 child 19 47.5 21 52.5 40 100 0,580-2,860 >1 child 26 41.3 37 58.7 63 100 total 45 43.7 58 56.3 103 100 [healthcare in low-resource settings 2025;13(s1):13017] [page 129] support, and socioeconomic status, which could influence breastfeeding self-efficacy, have not been comprehensively examined. the subjective nature of the measures related to perceptions and self-efficacy may affect the reliability of the data, and the study’s focus on breastfeeding mothers may have excluded the perspectives of those who rely on formula feeding. given these considerations, future research should explore the dynamics of breastfeeding self-efficacy in larger and more diverse populations. investigating the impact of social support networks and mental health on breastfeeding confidence could provide deeper insights into factors that facilitate successful breastfeeding. longitudinal studies could also be valuable for establishing causal relationships between maternal perceptions and breastfeeding practices over time. conclusions mothers who perceived their breast milk as inadequate were more likely to have low self-efficacy regarding breastfeeding. these findings highlight the need for interventions that enhance mothers’ confidence in their breastfeeding capabilities, such as educational programs that dispel myths about breast milk insufficiency and provide evidence-based breastfeeding information. future interventions should prioritize educational outreach, community support networks, and resources that empower mothers, thereby contributing to improved breastfeeding practices and better health outcomes for families in the district and beyond. references 1. bps indonesia si. statistical yearbook of indonesia 2023. catalog number: 1101001. available from: https://www.bps. go.id/en/publication/2023/02/28/18018f9896f09f03580a614b/ statistik-indonesia-2023.html 2. kementerian kesehatan republik indonesia. laporan riskesdas 2018 nasional.pdf. available from: https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/laporan%2 0riskesdas%202018%20nasional.pdf 3. widita muharyani p, nadra maulida m, adhisty k, et al. tantangan yang dihadapi ibu menyusui dalam pemenuhan hak anak: asi eksklusif. jurnal keperawatan 2022;14:893906. 4. metasari d, kando sianipar b. hubungan persepsi ibu tentang ketidakcukupan asi (pka) terhadap pemberian asi eksklusif pada bayi di wilayah kelurahan kuala lempuing kota bengkulu. j nurs public health 2019;7:41-5. 5. pambudi w, dewanto nef, yusra y, et al. perceptions, practices, and associated factors towards expressed breastfeeding among mothers in jakarta, indonesia. paediatr indones 2024;64:168-75. 6. fitriani k, rahayuning p d, nugraheni sa. faktor-faktor yang melatarbelakangi ibu dalam pemberian susu formula pada bayi usia 0-6 bulan di wilayah kerja puskesmas rowosari kecamatan tembalang semarang tahun 2014. jurnal kesehatan masyarakat 2015;3:118-26. 7. ismawati, abdurrachim r. relationship knowledge level, perception of formula milk and family support with exclusive breastfeeding. jurnal riset pangan dan gizi 2022;4:35-45. 8. tsaras k, sorokina t, papathanasiou iv, et al. breastfeeding self-efficacy and related socio-demographic, perinatal and psychological factors: a cross-sectional study among postpartum greek women. mater sociomed 2021;33:206-12. 9. oktarianita o, wulandari rd, supriyanto s. exploring the determinants of exclusive breastfeeding practices among firsttime mothers: a narrative review. afr j reprod health 2024; 28:239-48. 10. mccarter-spaulding de, kearney mh. parenting self-efficacy and perception of insufficient breast milk. j obstet gynecol neonatal nurs 2001;30:515-22. 11. dennis cl, mcqueen k, dol j, et al. psychometrics of the breastfeeding self-efficacy scale and short form: a systematic review. bmc public health 2024;24:1-25. 12. wahyuni sd, santoso b, triharini m, susan n. perceptions of working mothers toward breastfeeding self-efficacy. jurnal ners 2020;15:50-6. 13. gusriani g, wahida w, noviyanti ni. status gizi ibu dan persepsi ketidakcukupan asi (air susu ibu). jurnal ilmu kedokteran kesehatan 2023;2:152-9. 14. menekse d, tiryaki ö, karakaya suzan ö, cinar n. an investigation of the relationship between mother’s personality traits, breastfeeding self-efficacy, and perception of insufficient milk supply. health care women int 2021;42:925-41. 15. mardiyaningsih e, purwaningsih h, widodo gg. breastfeeding self-efficacy ibu post seksio sesarea. j holist nurs sci 2021;8:54-60. 16. ulfah hr, nugroho nfs. hubungan usia, pekerjaan, dan pendidikan ibu dengan pemberian asi eksklusif. intan husada: jurnal ilmiah keperawatan 2020;8:9-18. 17. fajar na, ananingsih es, sulaningsi k, et al. social determinant of health on exclusive breastfeeding practice in south sumatra, indonesia. malays j med health sci special issue pathways of change [page 130] [healthcare in low-resource settings 2025;13(s1):13017] table 3. relationship of mothers’ perception with breastfeeding self-efficacy (n=103). mothers’ perception breastfeeding self-efficacy total p or low high value (95% ci) n % n % n % perception of formula milk positive 25 53.2 22 46.8 47 100 0.114 2.045 0.927-4.515 negative 20 35.7 36 64.3 56 100 total 45 43.7 58 56.3 103 100 perception of breast milk inadequacy perception of high breast milk insufficiency 23 88.5 3 11.5 26 100 0.001 19.167 5.220-70.381 perception of low breast milk insufficiency 22 28.6 55 71.4 77 100 total 45 43.7 58 56.3 103 100 2024;20:163-9. 18. dwijayanti i, sulistyowati m, isaura er, et al. exploring factors influencing complementary feeding practices of mothers with infants aged 6-23 months in sidoarjo regency, indonesia: a qualitative study. afr j reprod health 2024;28:25-33. 19. tumaji t, mahmudiono t, laksono ad, et al. exclusive breastfeeding among adolescent mothers in indonesia: does maternal education level matter? j popul soc stud 2025;33:562-76. 20. syam a, musni m, amin an, iskandar i. potential loss among infant feeding options. jurnal ners 2021;16:74-80. 21. yuliantie p, kusvitasari h, mariana f, et al. identifikasi keterpaparan promosi susu formula terhadap pemberian asi eksklusif. health care: jurnal kesehatan 2023;12:206-2014. 22. gatti l. maternal perceptions of insufficient milk supply in breastfeeding. j nurs scholarsh 2008;40:355-63. 23. yuen m, hall oj, masters ga, et al. the effects of breastfeeding on maternal mental health: a systematic review. j womens health 2022;31:787-807. 24. he j, yimyam s, namprom n. breastfeeding self-efficacy, social support, and breastfeeding among chinese mothers with late preterm infants. j neonat nurs 2022;28:21-5. 25. akalpler ö, sarpkaya güder d, tekbaş s, vural g. examination of the relationship between breastfeeding selfefficacy and perceived breastfeeding sufficiency of mothers. cyprus j med sci 2023;7:731-7. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13017] [page 131] hrev_master healthcare in low-resource settings 2025; volume 13(s2):13505 factors associated with patient values among individuals with tuberculosis: a mixed-methods study using a patient and family-centered care approach yosephina elizabeth sumartini gunawan,1 servasius to’o jala mulu,1 leni landudjama,1 melkisedek landi,1 wanto paju,1 heriberth bara hunggurami,1 geralda holi mayela ludji,1 grazhela tatu rija,1 donny sulistiono,2 israfil israfil3 1health polytechnic of the ministry of health, kupang; 2health polytechnic of the ministry of health, surabaya; 3institute of technology and health bali, denpasar, indonesia abstract tuberculosis (tb) is a major global health problem, especially in rural areas with limited access to healthcare services. beyond physical symptoms, its impact extends to psychological and social burdens, significantly affecting the patients’ quality of life during the lengthy treatment period. this study aimed to analyze the quality of life of tb patients using a patientand family-centered care (pfcc) model. a mixed-methods design with an explanatory sequential approach was used. the quantitative phase involved 180 purposively selected patients with tb, with data collected via structured questionnaires and analyzed using spearman’s rho correlation test. the qualitative phase employed a descriptive approach, involving in-depth interviews with 11 patients and thematic analysis. results showed that pfcc dimensions – respect, partnership, care coordination, communication, and information sharing – were significantly associated with perceived patient value, with respect showing the strongest correlation. four main qualitative themes were identified: optimism regarding recovery, responses during treatment, provision of information, and family and health worker support. these findings confirm that patientperceived value is closely tied to pfcc elements. the study suggests that integrating pfcc into tb healthcare programs through supportive strategies, such as care groups and tailored education, can improve adherence, reduce stigma, and enhance treatment outcomes. introduction tuberculosis (tb) is a preventable and curable disease that poses a significant threat to global health. although current tb treatments are effective when properly administered, challenges that impact patient quality of life and treatment adherence persist, primarily due to lengthy therapy.1 the prolonged nature of tb treatment can have physical and psychological consequences on patients.2,3 individuals with tb experience debilitating symptoms that affect their physical and mental well-being, often leading to dietary changes, reduced activity, and difficulties in maintaining treatment adherence.1,2,4 these issues are compounded by the tb stigma in many communities.5 these conditions increase the risk of treatment discontinuation and contribute to disease transmission. furthermore, quality of care correlates strongly with patient adherence and treatment outcomes. high-quality care involves emphasizing patient self-management and empowering individuals to participate in decisions to maintain health.6,7 tb remains a highly infectious disease with a significant global burden and is the second leading cause of death from infectious diseases worldwide,6 particularly affecting lowand middleincome countries.8-11 indonesia ranks second globally in tb cases, reflecting its status as one of the countries with the highest tb burdens.12 within indonesia, sumba island in east nusa tenggara province exemplifies this challenge. in 2023, sumba island accounted for 20.2% of the total 9,535 tb cases in the province, an increase of 53.3% from the previous year. the island comprises correspondence: yosephina elizabeth sumartini gunawan, health polytechnic of the ministry of health, kupang, indonesia. e-mail: bettytjang@gmail.com key words: patientand family-centered care; tuberculosis; patients. contributions: yesg, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; stjm, ll, ml, wp, hbh, gtr, ghml, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ds, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ii, writing – original draft, review & editing. conflict of interest: the authors declare no actual or potential conflict of interest. ethics approval and consent to participate: this research was approved by the ethics commission of the kupang ministry of health polytechnic institution (no. lb.02.03/1/0072/2023). written informed consent was obtained from all participants before the study. consent for publication: informed consent was obtained for the publication of anonymized patient information. availability of data and materials: all data generated or analyzed in this study are included in this published article. funding: this research was supported by a research grant from poltekkes kemenkes kupang, fiscal year 2023-2024 under the higher education basic research scheme (no. dp.04.03/f.xxxvii/1072/2024). acknowledgments: the authors would like to thank the director of the kupang ministry of health polytechnics and the academic community for their support, especially in completing this research. received: 19 december 2024. accepted: 29 april 2025. early view: 28 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13505 doi:10.4081/hls.2025.13505 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13505] [page 121] four districts – east sumba, central sumba, west sumba, and southwest sumba – which have experienced rising tb incidence.13 research has identified key obstacles to tb control on sumba island, including limited access to healthcare, inadequate infrastructure, and social stigma. the high tb prevalence and diagnostic delays are attributed to insufficient laboratory facilities and trained healthcare personnel. however, studies have suggested that community-based treatment approaches and enhanced public awareness through health education can improve early detection and treatment adherence. despite concerted efforts by governments to eliminate tb, these initiatives have not significantly reduced its incidence or mortality rates.14 the rise in multidrug-resistant tuberculosis (mdr-tb) poses a serious threat to global public health by complicating diagnosis, increasing treatment failure, and raising mortality rates.15-17 family support behavior significantly influences tb outcomes, as patient and family perceptions of tb severity, treatment benefits, and care ability are linked to treatment adherence.18,19 implementing patientand family-centered approaches at community health centers can enhance family involvement and improve self-care adherence.20 enhanced family knowledge about prevention, treatment adherence, and risk of failure positively influences patient motivation and compliance with long-term treatment.21,22 factors that enhance patient care quality, including healthcare resources, family support, patient factors, and environmental influences, have led to the development of the pfcc model.23-26 pfcc aims to improve care experience and health outcomes.27 within the pfcc, care quality serves as a key indicator of success, as assessed by patients based on their perceptions of value and involvement in decision-making.28 emotional and social support are essential components of the quality of life of tb patients. studies show that patients receiving support from social networks and healthcare providers demonstrate improved psychological well-being and better symptom management. a patient-centered approach can help reduce stigma and discrimination faced by tb patients, fostering an inclusive environment. the elements contributing to patients’ sense of value include respectful interactions, effective communication, collaborative partnerships, information accessibility, and coordinated care.29,30 this study aimed to analyze the factors associated with tb patients’ perceptions of value using the pfcc approach. materials and methods research design this study employed a mixed-methods design with an explanatory sequential approach to analyze the values of tb patients within the framework of the pfcc model. the quantitative phase utilized a cross-sectional design to identify patterns and associations. in contrast, the qualitative phase adopted a descriptive qualitative approach to explore the experiences of patients and families during tb treatment. population, sample, and sampling the study population comprised tb patients in east sumba, central sumba, and west sumba regencies, totaling 721 individuals: east sumba (339), central sumba (129), and west sumba (253). given that the population exceeded 100, a sample size of 10-25% was deemed appropriate.31 accordingly, 25% of the participants were selected, resulting in 180 participants. respondents were selected purposively based on study objectives and inclusion criteria. for the qualitative phase, data saturation was reached with 13 tb patients, three family members, one physician, and three tb health personnel. participants from the quantitative phase were included in the qualitative phase where applicable. the sampling technique for both phases was purposive sampling. inclusion criteria for the quantitative phase were undergoing tb treatment, aged 15 years or older, and able to communicate effectively. for the qualitative phase, participants needed to be undergoing treatment (for at least one month), able to communicate well, and willing to participate in interviews. variables this study included both independent and dependent variables. the dependent variable was the perception of being valued by tb patients. the independent variables consisted of five key components of the pfcc model: respect, communication, partnership, information sharing, and coordination. instrument the structured questionnaire was developed based on the pfcc model and the who quality of life questionnaire, focusing on assessing the value variable.32 the instrument contained 20 items across five dimensions: respect (4 items), communication (4 items), partnership (4 items), information sharing (4 items), and coordination (4 items). items were rated on a 4-point likert scale: strongly agree (4 points), agree (3 points), disagree (2 points), and strongly disagree (1 point). the questionnaire underwent validity and reliability testing with 30 respondents outside the main study population. validity was assessed by comparing each item’s r-value against the r-table value of 0.361; all items were valid. reliability was measured using cronbach’s alpha, with all dimensions showing acceptable internal consistency: respect (α=0.760), communication (α=0.795), partnership (α=0.921), information sharing (α=0.866), and coordination (α=0.934). qualitative data were collected through semi-structured interviews using a guide developed by researchers aligned with study objectives. the guide had three sections: the opening included questions to build rapport and assess participant readiness; the core section contained five open-ended questions exploring perceived value among tb patients; and the closing section involved expressing gratitude and arranging follow-up for transcript approval (member checking). data collection data collection began with obtaining research permits from east, central, and west sumba local governments. these permits were submitted to health offices and centers. the research team consulted tb coordinators at each center for data on registered tb patients as potential respondents. each patient received a clear explanation of the study’s purpose, procedures, benefits, and right to voluntary participation. patients who agreed signed an informed consent form. quantitative data collection involved a structured questionnaire, with researchers ensuring complete responses. for the qualitative phase, cooperative patients with relevant health histories were selected for in-depth interviews at participants’ homes, mostly traditional raised houses typical of the sumba community. each interview lasted about 60 minutes. all interviews were conducted by the principal investigator, an associate professor of nursing with a master’s degree, who had no prior relationships with participants. interviews were audio-recorded with detailed field notes, capturing verbal and non-verbal responses and contex pathways of change, part ii [page 122] [healthcare in low-resource settings 2025;13(s2):13505] tual observations. triangulation occurred through focus group discussions (fgds) with tb program coordinators from participating health centers. the team reviewed interview transcripts to ensure consistent interpretation. transcripts were returned to participants for member checking to ensure recorded data accurately reflected their perspectives. data analysis quantitative data were analyzed using spearman’s rho correlation to assess relationships among variables, with significance at 0.05. for qualitative analysis, data were analyzed using thematic analysis based on colaizzi’s method. the process began with reading interview transcripts to gain an understanding of participants’ experiences. significant statements relevant to objectives were identified and coded into meaningful units. these codes were organized into themes and sub-themes through iteration. to enhance credibility, themes were returned to participants for confirmation. the findings were presented through a combination of text, tables, visual representations, and narratives to provide a comprehensive view of the experiences. ethical clearance this research was approved by the ethics commission of the kupang ministry of health polytechnic institution (ethics number lb.02.03/1/0072/2023). results characteristics of respondents in quantitative research data in table 1 shows respondents are predominantly male (67%), with ages from productive to elderly, the largest group aged 15-34 (36.1%), and the smallest over 74 (8.3%). respondent’s data based on tb treatment history covers types of tb treatment, duration, and current stage. most respondents (88.9%) undertook firsttime tb treatment, while 11.1% had prior treatment. descriptive analysis the descriptive analysis results are presented as percentages of each research variable, as described in table 2. table 2 shows participants rated the most variables as “adequate”, particularly in partnership (63%) and information sharing (58%). the “valued” and “care coordination” variables had higher proportions of “very good” ratings at 43% and 39% respectively. partnership had the lowest “very good” ratings (26%), while care coordination showed the highest “inadequate” ratings (12%). relationship between each variable table 3 presents spearman correlation test results, indicating that all independent variables have significant relationships with the dependent variable (value). the “respect” variable has the strongest relationship with value, with a correlation of 0.769 (p<0.01), followed by partnership (0.477), care coordination (0.424), communication (0.421), and sharing information (0.362). pathways of change, part ii table 2. percentage distribution of factors related to tb patient perceived values using the patientand family-centered care (pfcc) approach (n=180). variable very good adequate inadequate n % n % n % valued 78 43 90 50 12 7 respect 62 34 99 55 19 11 communication 68 38 100 55 12 7 partnership 46 26 114 63 20 11 information sharing 59 33 105 58 16 9 care coordination 70 39 89 49 21 12 table 1. characteristics and treatment history of respondents with tb (n=180). characteristics of respondents category n % gender man 121 67 female 59 33 age (years) 15-34 65 36 35-54 45 25 55-74 55 31 >74 15 8 treatment history types of tb treatment first 160 88.9 second 20 11.1 duration of tb treatment sixth month 180 100.0 stage of treatment currently being undergone early 57 31.7 continued 123 68.3 tb, tuberculosis. [healthcare in low-resource settings 2025;13(s2):13505] [page 123] these relationships exhibit a positive direction, indicating that increases in the independent variables tend to increase the value of the dependent variable. characteristics of participants in qualitative research table 4 shows that most participants were male (62%), with ages ranging from 22 to 96. most participants worked as farmers (69%), while others were housewives, retirees, and traders. eleven participants were in the latent tb treatment stage, while 2 participants were in the active stage. three patients’ families and three tb program managers at the health center were recruited as additional participants in this study to ensure that qualitative data triangulation was conducted correctly and that the information provided by the main participants was reliable and valid. categories, themes, and sub-themes the content analysis of interviews yielded three categories, four themes, and eight sub-themes, detailed in table 5. the categories are: 1) patient experience during tb treatment with two themes; 2) health education about tb during treatment with one theme; and 3) the key supporter of tb patients. category 1: patient experience during tb treatment theme 1: optimism about recovery after undergoing a tb treatment program the first theme consists of two sub-themes: being motivated to follow the treatment program and hoping for recovery. this theme reflects tb patients’ belief in undergoing treatment, with participants expressing optimism and hope that the treatment would help them recover from tb, as shown in the following participant’s statement: pathways of change, part ii table 3. spearman’s rho correlations between pfcc variables related to tb patients’ perceived value (n=180). variable correlations value respect communication partnership information sharing care coordination value 1.000 0.769** 0.421** 0.477** 0.362** 0.424** respect 0.769** 1.000 0.433** 0.568** 0.398** 0.455** communication 0.421** 0.433** 1.000 0.614** 0.553** 0.526** partnership 0.477** 0.568** 0.614** 1.000 0.708** 0.680** information sharing 0.362** 0.398** 0.553** 0.708** 1.000 0.758** care coordination 0.424** 0.455** 0.526** 0.680** 0.758** 1.000 **correlation is significant at the 0.01 level (2-tailed). table 4. demographic and treatment characteristics of participants in the qualitative phase of the study on tb patients’ perceived values using the pfcc approach. participant’s code gender age (year) occupation tb treatment stages p1 female 70 housewife latent p2 man 22 farmer latent p3 man 73 farmer latent p4 man 96 farmer active p5 female 41 farmer active p6 female 57 farmer latent p7 man 38 farmer latent p8 man 68 farmer latent p9 man 51 farmer latent p10 man 76 pensionary latent p11 female 61 farmer latent p12 man 67 salesman latent p13 female 50 housewife latent table 5. overview of categories, themes, and sub-themes from the qualitative analysis of tb patient values based on the pfcc approach. categories themes sub-themes patient experience during tb treatment optimistic about recovery after undergoing motivated to follow the treatment program a tb treatment program hope for recovery responses during the tb treatment program physical responses during treatment psychological responses during treatment health education about tb during the providing information related to the tb interaction with health workers treatment program treatment program revealing explanations about tb disease and tb treatment programs the key supporter of tb patients family and health worker support family support in complying with the tb treatment program support from health workers in complying with tb treatment programs [page 124] [healthcare in low-resource settings 2025;13(s2):13505] “i am happy to take this medication … and i am also optimistic about getting better” (p5) “i never decided to stop taking my medicine… i want to be healthy and free from this disease” (p7) statements from participants illustrate their optimism and confidence in undergoing tb treatment. all participants said they would comply with the treatment program, believing it could improve their health status and help them recover from tb. the patient’s family confirmed these statements as follows: “sometimes i feel sad seeing my mother always taking medicine, feeling unwell, or complaining of pain. however, i admire her spirit to keep taking it, saying she wants to recover quickly from tb” (t1) “my grandpa himself knows the schedule to go for a check-up at the health center to get medicine, so he always reminds me to take him to the health center” (t3) the tb person in charge agreed with the patient and family’s statements above and said the following in the focus group discussion: “all of the patients always feel happy when approaching the end of tb treatment or when they are about to finish treatment” (t4) “all patients are confident with the treatment they are undergoing because there are changes, so they are diligent in their treatment and medicine intake” (t6) theme 2: responses during the tb treatment program the second theme comprises two sub-themes: physical responses during treatment and psychological responses during treatment. this theme relates to physical reactions such as nausea, loss of appetite, getting tired quickly when walking, and psychological responses such as never feeling bored during treatment, feeling cared for, feeling happy, feeling treated well, feeling comfortable, and trusting family and health workers. the following are statements from several participants that support the theme: “for the past 3 months, i have been taking medicine; even though it is a lot, i never get bored” (p3) “i am happy to take this medicine because i feel there is a change; the pain i felt is starting to lessen” (p6) “before taking the medication, i got tired more quickly and had shortness of breath, but the complaints that i feel so far during this treatment period are a little less” (p7) participants reported their complaints decreased after taking tb medication regularly. some still noted medication side effects but felt happy due to recovery benefits. these statements align with what their families and the tb person in charge stated below: “my son told me that her stomach felt unwell every time she took the medication; he felt nauseous and tired quickly... but he still took the medication according to the prescription” (t2) “the patients said that their weight has increased, their appetite has improved after treatment, and their coughing has also started to decrease. we have also told them that they can contact us at any time if they experience new complaints or if they feel there are other side effects during treatment” (t4-6) category 2: health education about tb during the treatment program theme 1: providing information related to the tb treatment program this theme was divided into two sub-themes: interaction with health workers and revelations about tb disease and treatment programs. the theme explains how health workers deliver information to respondents about tb disease and treatment programs. respondents’ statements that support this theme include: “the health worker told me that i have an infectious disease… i have to take medication for 6 months to recover” (p2) “the health center staff always tells me about tb disease, and i do not feel disturbed by it, and they remind me not to forget to take my medicine or not to miss any of the medicine schedules so that the disease does not relapse” (p10) the interviewed families shared the same story, as they accompanied patients when health workers provided education about tb and their treatment program. it was expressed as follows: “when the doctor first said that mom had to take this project medicine, the doctor and his staff explained it, but not all at once, maybe so that it would not be easy to forget. the explanation focused on how to take medicine, the schedule, the importance of not forgetting to take it, and the recommendation to immediately report to the health center if there were any complaints” (t1) the tb person in charge confirmed explaining to all tb patients about the required treatment and possible side effects. based on their experience, patient response to treatment side effects has mostly been nausea. some interesting statements that support this are: “education about tb and its treatment is provided early, starting from the diagnosis. we use booklets, leaflets, and posters prepared at the health center, with language adjusted to ensure patients and their families understand” (t4) “there was one tb extract patient who immediately consulted because his lump had become so big that it looked like it was going to burst after taking medication for two weeks, afraid that the medication was not suitable or that this was the right medication. his complaint had been forwarded and consulted to his doctor, and the doctor responded that those were the symptoms after treatment and to continue the treatment” (t6) category 3: the key supporter of tb patients theme 1: family and health worker support the theme includes two sub-themes: the role of the family and the role of health workers. the key aspect is how families support patients in adhering to treatment and the assistance provided by health workers during tb treatment. both forms of support are vital to the success of tb treatment as they motivate patients to complete the program. all participants stated the same regarding the support from family and health workers: “during my illness, there has never been any rejection from my family; everyone at home supports me to get better quickly… they always remind me to take my medicine on time… with the support of my family, i can definitely get through this and recover” (p1-13) pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13505] [page 125] “the doctor said i could recover as long as i obeyed the treatment. the nurse also patiently accompanies me when i feel tired or hopeless. the officer did give us their telephone number, so if we need something at any time or if we suddenly have a lamentation, we can call them” (p1-13) this statement corresponds with the information provided by the patient’s family, who expressed their support for the patient in adhering to the tb treatment program. this support encompasses accompanying the patient to medical appointments or medication administration at the health facility, ensuring medication adherence, encouraging the patient to complete the treatment, and providing additional assistance. “all of us at home always supported them (the patients) in various ways, such as reminding them to take medicine on time, providing nutritious food, and ensuring that check-up schedules at the health center are not missed” (t1-3) “we also always encourage and give confidence that even though this treatment takes a long time, it will bring healing... we also do not forget to pray for god’s blessing” (t1-3) the tb person in charge stated that family support is crucial for the success of tb treatment, particularly in monitoring medication intake. the following is a summary of several statements from tb managers regarding this theme: “the selection of the patient medication observer (pmo) is not done directly by us but by the patients themselves, who choose, for example, their child, who helps remind them to take their medicine on time. the selected pmo must understand the tb treatment process well and should have a good emotional relationship with the patient” (t4-6) “there has been no family rejection regarding tb treatment; patient and family response is very good. patients show high awareness of treatment, supported by promises to take medication. pmos face no difficulties since medication is taken with family from the start, and family members volunteer to be pmos. in some cases, two pmos from one family assist, so if one is absent, another can help, which is permissible” (t4-6) discussion the findings of this study emphasize that the perceived quality of tb care is influenced by multiple factors, particularly the core dimensions of the pfcc approach – respect, partnership, care coordination, communication, and information sharing. in addition to these structural and relational elements, individual factors such as self-motivation, resilience, and life optimism also play a significant role in shaping positive perceptions of care. these combined factors contribute to improved well-being and quality of life, underscoring the need for a holistic, patient-entered approach in tb treatment programs. the findings reveal that respect is fundamental to interactions between patients and healthcare providers. in this study, respect emerged as the strongest factor influencing tb patients’ perceived value of care. when health workers show respect, it fosters patient trust and encourages participation in treatment.33 such interactions create an environment where patients feel valued and understood. this favorable climate enhances the care experience. when patients perceive respectful treatment, their satisfaction increases, leading them to value their treatment more – ultimately contributing to improved adherence and outcomes.34-36 the finding indicates that clear communication enhances patients’ understanding of medications and treatment plans while reducing anxiety, particularly through explanations of side effects. participants felt more at ease after receiving comprehensive information about their therapy. align with studies showing that effective communication helps patients understand medication instructions and expected reactions, build trust, and plays a vital role in treatment success.34,37 good communication reduces patients’ emotional distress regarding their health status. by delivering accurate and empathetic information, healthcare providers can reinforce treatment adherence and improve health outcomes.37,38 another essential dimension of the pfcc model is the partnership between patients and healthcare providers. findings from this study indicate a strong relationship between partnership and patients’ perceived value of care. this was reflected in multiple positive statements from participants who felt that health workers involved them in the tb treatment process. although patients may not be involved in every decision, both they and their families expressed feeling valued and appreciated for their involvement. additionally, strong partnerships cultivate an environment in which patients feel comfortable expressing concerns and asking questions, enabling healthcare professionals to offer more targeted support. this aligns with studies showing that when patients are actively involved in decisions about their care, they develop a greater sense of ownership and responsibility for their health.39 this contributes to increased patient satisfaction and reinforces the value they assign to their care experience.33,36,40 information sharing shows a significant positive correlation with perceived value among tb patients within the pfcc approach. when providers effectively communicate tb management information, patients and families are more likely to value the care provided. this supports research showing that accurate information enhances patient understanding, treatment adherence, and reduces stigma – an important factor linked to poor quality of life in tb patients.41-46 information sharing through education or media covers treatment plans, side effects, and compliance with evidence-based content.47,48 adherence depends on social, economic, health system, therapeutic, lifestyle, and geographic access elements.49 addressing these through support from families, providers, and communities is crucial to encouraging treatment and improving the quality of life for tb patients. care coordination has a significant impact on the patient experience in tb treatment. effective coordination between healthcare providers can reduce confusion and improve continuity of care. it is essential for tb patients, who require multidisciplinary care for optimal outcomes. patients receiving coordinated services tend to be more satisfied and believe they receive comprehensive care.50,51 the interconnectedness of pfcc variables requires a holistic approach in tb care. healthcare providers must address key aspects of patient interaction – respect, communication, partnership, information sharing, and care coordination – to enhance treatment value. these elements vary across cultural contexts, making culturally sensitive strategies essential. cipta et al. (2024) emphasized that respect and communication hold different meanings across cultures, requiring adaptation to local norms.52 applying pfcc can motivate patients to complete treatment despite side effects or social stigma. nurses play a vital role in providing safe, supportive care amid challenges. stigmatization of tb patients demands comprehensive efforts at all levels for treatment success.2,53,54 without support, incomplete treatment may cause drug resistance, increased morbidity and mortality, and wasted pathways of change, part ii [page 126] [healthcare in low-resource settings 2025;13(s2):13505] resources.55 therefore, implementing pfcc is vital to improving treatment adherence and public health outcomes. qualitative findings indicate that the first category identified is optimism about recovery after undergoing a tb treatment program. optimism is a key psychological factor that enhances selfmotivation in patients undergoing tb treatment. an optimistic outlook contributes to greater consistency in following treatment, persistence despite discomfort, and reduced risk of drug resistance. patients with optimism are more enthusiastic and committed, helping them manage challenges such as fatigue, pain, and side effects during the six-month tb treatment regimen. this aligns with previous studies showing that optimism, positive attitudes, social support, and life satisfaction significantly improve adaptation and quality of life.43,56,57 the second theme within this category concerns the tb treatment program. patients reported experiencing both physical and psychological responses. physical symptoms, such as chest discomfort due to pulmonary involvement, can hinder daily functioning and treatment adherence.58,59 psychological responses, including anxiety and stress, may lead to emotional changes and social withdrawal.58 these effects can significantly reduce patients’ quality of life. therefore, continuous support from family, friends, and the surrounding community is essential. such support helps foster motivation and optimism, enabling patients to navigate challenges and remain committed to completing their treatment. in the second category, the theme identified is providing information related to the tb treatment program. findings indicate that health workers are responsible for providing patients and their families with information about pulmonary tuberculosis and its treatment. accurate, comprehensive, and reliable information plays a crucial role in improving patient understanding, adherence to treatment,45 and reducing stigmatization associated with tb,4143,45 which negatively impacts patients’ quality of life.44,46 this information sharing can be delivered directly or through media,47,48,60 and covers treatment details, side effect management, and the importance of adherence. several factors influence adherence, including individual, social, economic, health system, therapeutic, lifestyle, and geographic access elements.49 addressing these factors supports positive behavioral change in taking tb medication, which enhances treatment outcomes and quality of life. this can only be achieved through the active cooperation and support of families and health workers directly involved in the tb treatment program. in the third category, the theme identified is family and health worker support, which plays a vital role in the success of tb treatment. patients who receive regular supervision and spiritual encouragement from family members, maintain good relationships with healthcare workers, possess tb-related knowledge, and benefit from strong support from policymakers demonstrate higher treatment adherence,61,62 which contributes to high compliance in treatment.45,63 in contrast, poor family support can lead to lower adherence levels.64 meeting the psychosocial needs of tb patients is also essential in sustaining optimism and motivation throughout treatment.46 therefore, optimal family support not only provides practical assistance – such as helping patients adhere to their treatment plan – but also offers emotional encouragement. this emotional support is critical for maintaining patients’ spirits and motivation, enabling them to overcome treatment-related challenges and complete the therapy as prescribed. thus, family and health worker involvement are key factors in improving treatment outcomes. the theme of optimism about recovery after undergoing a tb treatment program is closely linked to other themes in this study. although responses during the tb treatment program include physical and psychological challenges that may lower optimism, effective coping helps sustain it. providing information related to the tb treatment program supports optimism by improving understanding, while family and health worker support enhances motivation through emotional and practical assistance. together, these themes illustrate how various factors influence optimism. the integration of quantitative and qualitative findings provides valuable insights, underscoring the need for holistic, patient-centered interventions to enhance tb treatment adherence and outcomes. conclusions the perceived value of tb patients undergoing treatment on sumba island was rated as adequate. all variables significantly influenced this perception, with respect showing the strongest correlation, followed by partnership, care coordination, communication, and information sharing. these aspects positively affect patients’ quality of life during treatment. the qualitative findings supported these results through themes such as optimism about recovery, treatment responses, information provision, and support from family and health workers. these findings highlight the importance of using the pfcc approach. the implication is the need for value-based strategies, including tb care groups and targeted educational media, to improve treatment outcomes and adherence. references 1. ory mg, ahn s, jr sdt, smith ml. chronic 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ds, priyantini d, aini q. family factors and their relation to the treatment adherence of pulmonary tb patients in surabaya. j ners 2020;15:45–9. 26. nabila n. factors influencing patients with tuberculosis’ compliance with using anti-tuberculosis medications (oat) (tbc): literature review. media publ promosi kesehat indones 2023;6:1478–84. 27. hamilton family health team. what is patient and familycentred care? 2022;1–2. 28. rose l, istanboulian l, allum l, et al. patient and family centered actionable processes of care and performance measures for persistent and chronic critical illness: a systematic review. crit care explor 2019;1:e0005. 29. aggarwal an. quality of life with tuberculosis. j clin tuberc other mycobact dis 2019;17:100121. 30. juliasih nn, mertaniasih nm, hadi c, et al. factors affecting tuberculosis patients’ quality of life in surabaya, indonesia. j multidiscip healthc 2020;13:1475–80. 31. polit df, beck ct. nursing research: generating and assessing evidence for nursing practice. 12th ed. in philadelphia: wolters kluwer; 2024. 32. world health organization. the world health organization quality of life (whoqol)-bref. geneva: 2004. p. 1–6. 33. beach mc, inui t, frankel r, et al. relationship-centered care: a constructive reframing. j gen intern med 2006;21. 34. beach mc, sugarman j, johnson rl, et al. do patients treated with dignity report higher satisfaction, adherence, and receipt of preventive care? ann fam med 2005;3:331–8. 35. elander j, beach mc, haywood c. respect, trust, and the management of sickle cell disease pain in hospital: comparative analysis of concern-raising behaviors, preliminary model, and agenda for international collaborative research to inform practice. ethn heal 2011;16:405–21. 36. saha s, arbelaez jj, cooper la. patient-physician relationships and racial disparities in the quality of health care. am j public health 2003;93:1713–9. 37. sharkiya sh. quality communication can improve patientcentred health outcomes among 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43. datiko dg, jerene d, suarez p. stigma matters in ending tuberculosis: nationwide survey of stigma in ethiopia. bmc public health 2020;20:190. 44. demirchyan a, petrosyan v. internalized social stigma and its determinants among drug-sensitive tuberculosis patients in armenia. eur j public health 2023;33:ckad160.558. 45. chen x, du l, wu r, et al. the effects of family, society and national policy support on treatment adherence among newly diagnosed tuberculosis patients: a cross-sectional study. bmc infect dis 2020;20:623. 46. sofiana l, adi ms, martini m, et al. quality of life in tuberculosis patients in yogyakarta. j heal educ 2023;8:9–18. 47. feroz a, jabeen r, saleem s. using mobile phones to improve community health workers performance in low-and-middleincome countries. bmc public health 2020;20:49. 48. pradipta is. interventions to improve medication adherence in tuberculosis patients: a systematic review of randomized controlled studies. npj prim care respir med 2020;30:21. 49. nezenega zs, perimal-lewis l, maeder aj. factors influencing patient adherence to tuberculosis treatment in ethiopia: a literature review. int j environ res public health 2020;17:5626. pathways of change, part ii [page 128] [healthcare in low-resource settings 2025;13(s2):13505] 50. simpson k, nham w, thariath j, et al. how health systems facilitate patient-centered care and care coordination: a case series analysis to identify best practices. bmc health serv res 2022;22:1–17. 51. möckli n, simon m, denhaerynck k, et al. care coordination in homecare and its relationship with quality of care: a national multicenter cross-sectional study. int j nurs stud 2023;145:104544. 52. cipta da, andoko d, theja a, et al. culturally sensitive patient-centered healthcare: a focus on health behavior modification in low and middle-income nations—insights from indonesia. front med 2024;11:1–7. 53. probandari a, sanjoto h, mahanani mr, et al. being safe, feeling safe, and stigmatizing attitude among primary health care staff in providing multidrug-resistant tuberculosis care in bantul district, yogyakarta province, indonesia. hum resour health 2019;17:16. 54. pradipta is, idrus lr, probandari a, et al. barriers and strategies to successful tuberculosis treatment in a high-burden tuberculosis setting : a qualitative study from the patient’s perspective. bmc public health 2021;21:1–12. 55. ruan y, li l, xu l, et al. practical experiences of delivering multidrug-resistant tuberculosis comprehensive supportive care services in china. china cdc wkly 2021;3:566–8. 56. ciria-suarez l, calderon c, montes af, et al. optimism and social support as contributing factors to spirituality in cancer patients. support care cancer 2021;29:3367–73. 57. sany sbt, aman n, jangi f, et al. quality of life and life satisfaction among university students: exploring, subjective norms, general health, optimism, and attitude as potential mediators. j am coll heal 2023;71:1045–52. 58. meghji j, gregorius s, madan j, et al. the long term effect of pulmonary tuberculosis on income and employment in a low income , urban setting. bmj j thorax 2021;387–95. 59. rahajeng b, shafira n, utami p. effects of anti tuberculosis side effect on the quality of life of tuberculosis patients in rskp respira yogyakarta at the period of january-june 2019. in: universitas muhammadiyah yogyakarta, editor. proceedings of the 4th international conference on sustainable innovation 2020–health science and nursing (icosihsn 2020). yogyakarta: atlantis press; 2021, p. 321–6. 60. pradipta ivan surya. mengapa kegagalan pengobatan tuberkulosis banyak terjadi di indonesia. conversat 2021. 61. chan m. global report on diabetes. geneva: world health organization; 2014. p. 58. 62. world health organization. united republic of tanzania – tb community network: a platform for a stronger community response to tuberculosis: case study. geneva: world health organization; 2020. 63. lisum k, waluyo a, nursasi ay. treatment adherence among tuberculosis patients: a concept analysis. open access maced j med sci 2021;9:20–8. 64. sanjaya m, mara ds. the role of the family in supporting the cure process of pulmonary tb patients at the pamatang raya health center, simalungun district. medalion med res nurs heal midwife particip j 2016;106–10. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13505] [page 129] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13063 a model of nursing intervention on the psychological needs of a group of neighborhood children in a shelter place in surabaya dyah wijayanti, siti nur kholifah, dinarwiyata health polytechnic of the health ministry of surabaya, surabaya, east java, indonesia abstract the fulfillment of the psychological needs of neglected children in shelters is important. however, only the physical need has been fulfilled, resulting in a feeling of dissatisfaction and hampers a positive attitude towards the social environment. therefore, this study aimed to present a significant nursing intervention model to meet the psychological needs of neglected children. the model integrates behavioral (lawrence green), caring (jean watson), and psychogenic needs theory (murray) to explain the influence of predisposing, enabling, and supporting factors on behavior. this study adopted a cross-sectional design and observational analytic method with a population of 240 neglected children in surabaya city shelters. the cluster sampling rule of thumb was used in sem to select 110 (5x22 observe variables) respondents. the result showed that the unique aspects of the group nursing intervention model fulfilled the psychological needs of adolescents in shelters. furthermore, interpersonal human caring behavior was influenced by predisposing factors and care values with a coefficient value of 0.203. supporting factors and environmental caring had a coefficient of 0.220 while driving was 0.332. in conclusion, this study showed that the group nursing intervention model fulfilled the psychological needs of adolescents in shelters by integrating the theories of goal attainment, caring (jean watson), and psychosocial (murray). these theories increased adolescent parenting actions, thereby enhancing self-confidence within shelters. introduction the number of neglected children in indonesia is increasing, necessitating the urgency of addressing their need to become quality national assets. these neglected children are vulnerable in a society where one or both parents are sick or dead. consequently, the parents are unable to meet the children’s needs, leading to disharmony within the family. neglecting children can lead to delays in physical development and neurological repercussions, as well as induced psychological problems. a previous study showed that the number of neglected children in indonesia was 67,368 in 2020.1 according to data from the central bureau of statistics for east java province, the number was 118,718, and 6,349 in surabaya. neglected children are significantly affected physically and psychologically, as reported in a previous study.2 fulfilling both psychological and physiological needs is crucial, as a lack of nutrition can lead to illness. similarly, unfulfilled psychological needs can lead to dissatisfaction, frustration, and disrupt the growth and development of a positive attitude toward the community.3 this study developed a new model in the field of community homicide by integrating behavioral (lawrence green), caring (jean watson), the human interaction theory (king), and the concept of psychogenic needs from murray. no previous study has been conducted on this constructed surgical intervention model. therefore, the novelty of this study is an intervention model that community nurses can use in providing intervention. this condition will impact personality maturity, a positive attitude towards the environment, and a spirit of independence.4 neglected children whose psychological needs have been fulfilled will become a quality young generation for the development of indonesia. materials and methods the study used a cross-sectional design with a population of 240 neglected children living in 8 surabaya shelters. the sample size used the rule of thumb in the structural equation model (sem), with the maximum likelihood method requiring 5 x 22 indicators (observed variables) with 110 respondents. the variables that will be described are each dimension of predisposing factors and values (x1), supporting (x2), pushing (x3), parenting behavior (x4), and psychological needs (y). the sem was used based on variance or component-based sem, known as smart partial least square version 2.0 (smart pls, 2.0).5 results and discussion table 1 shows the description of the characteristics of the tribe and length of stay of respondents. the criteria for the majority of ethnicity are javanese, with 108 respondents or 98.2%, and only 2 for other ethnic groups, accounting for 1.8%. it shows that the answer chosen by 50% of the respondents for length of stay was 1-6 months, followed by 712 months and greater than 1 year for 35 (31.8%) and 15 (13.7%), [healthcare in low-resource settings 2024;12(s1):13063] [page 113] significance for public health neglected children in shelters often have their emotional well-being overlooked, even though their physical needs are being addressed. implementing a thoughtful nursing intervention model that draws from various theories is crucial. this approach can effectively cater to the psychological needs of these children, particularly adolescents, and boost their self-confidence. non -co mmerc ial us e o nly respectively. table 2 explains the description of predisposing factor variables and values two dimensions of predisposing factors had more scores in the high category, namely attitude and motivation, accounting for 66 (60%) and 91 (82.7%) respondents, respectively. meanwhile, commitment was in the low category with 57 respondents at 51.8%. table 3 shows the description of the supporting factors. all dimensions of supporting factors are in the high category, namely learning, social, counseling facilities, and achievement opportunities with 65 (59.1%), 77 (70%), 82 (74.5%), and 66 (60%), respectively. table 4 shows the motivating factors, parenting behaviors and psychological needs. two dimensions within the parenting behavior factor had a higher prevalence in the high category. interpersonal communication had 70 respondents (63.6%), while actions aimed at enhancing self-confidence were reported by 58 (52.7%). the remaining two dimensions are more commonly classified within the moderate category, namely health education and parenting strategies, accounting for 66 (60%) respondents each. the descriptive statistics showed that the psychological needs of the six dimensions are in the lower category, namely affiliation, autonomy, division, respect, order, and understanding. there was improvement in one dimension with the number of respondents in both low and high categories remaining consistent at 55. in the achievement dimension, there are slightly more respondents in the high category, accounting for 56 (50.9%), compared to 54 (49.1%) in the low category. the results of this study showed the importance of implementing group nursing interventions to achieve the psychological needs of adolescents in shelters, with a coefficient of 0.794. human caring interpersonal behavior was directly influenced by predisposing factors, nurturing values, supporting factors, and environmental caring with coefficients of 0.203, 0.220, and 0.332, respectively. these results showed that the group nursing intervention model fulfilled the psychological needs of adolescents by integrating goal attainment and jean watson’s caring theories, as well as murray’s psychosocial needs. this model can improve predisposing factors and care values , including attitudes, motivation, and commitment of administrators/caregivers. supporting factors and environmental caring were also enhanced as critical infrastructure in fulfilling adolescents’ psychological needs. furthermore, driving factors consisting of legal aspects, family, and community support were increased to 4th international nursing and health sciences symposium table 1. description of the characteristics of the tribe and length of stay (n=110). criteria frequency percentage (%) tribes java 108 98.2 bugis 2 1.8 1-6 months 60 54.5 length of stay 7-12 months 35 31.8 >1 year 15 13.7 table 2. frequency distribution of predisposing factor (n=110). self-leadership frequency percentage (%) dimension category attitude low 44 40.0 high 66 60.0 motivation low 19 17.3 high 91 82.7 commitment low 57 51.8 high 53 48.2 table 3. frequency distribution of the supporting factors (n=110). supporting factors frequency percentage (%) dimension category learning facilities low 45 40.9 high 65 59.1 socialization facility low 33 30.0 high 77 70.0 counseling facilities low 28 25.5 high 82 74.5 achievement opnhigh 66 60.0 table 4. frequency distribution of motivating factor, parenting behavior, psychological needs (n=110). categories category frequency percentage (%) motivating factor parenting system low 26 23.6 high 84 73.4 family support low 20 18.2 high 90 81.8 community support low 14 12.7 high 96 87.3 parenting behavior interpersonal communication low 40 36.4 high 70 63.6 health education low 66 60.0 high 44 40.0 parenting actions low 57 51.8 high 53 48.2 actions increase confidence low 52 47.3 high 58 52.7 psychological needs achievement low 54 49.1 high 56 50.9 affiliate low 57 51.8 high 53 48.2 autonomy low 63 57.3 high 47 42.7 correcting the situation low 55 50.0 high 55 50.0 split yourself low 65 59.1 high 45 40.9 respect low 62 56.4 high 48 43.6 orderliness low 66 60.0 high 44 40.0 understanding low 60 54.5 high 50 45.5 [page 114] [healthcare in low-resource settings 2024;12(s1):13063] non -co mmerc ial us e o nly fulfill the psychological needs of adolescents living in shelters. the implementation of health education for adolescents needs to be enhanced by developing collaboration between the social and health services in implementing education periodically. this model increased parenting actions in adolescents and improved self-confidence in several ways. the result of this study on the need to improve the situation had the same percentage between high and low, namely 50%. meanwhile, the need for counteraction (improving the problem) was defined as the adolescent’s need to correct failures, suppress fear, and maintain self-esteem.6 positive relationships with friends will further strengthen adolescents’ feelings of value to others. remembering and sharing experiences with friends is extremely important during adolescence, as it significantly impacts their behaviour and overall well-being. the quality of friendships plays a crucial role in the mental development of adolescents, influencing companionship, trust, closeness, and how they handle conflicts.7-9 therefore, shelter caregivers need to help adolescents overcome mistakes and disappointments from an early age. the best way to increase adolescents’ self-esteem is to take an active role in their early life. the majority of results regarding the need for self-defense (59.1%) were in the low category. the concept of self-defense in this study relates to safeguarding oneself against attacks, criticism, and blame. the results of data analysis from the questionnaire administered to adolescents showed that caregivers occasionally afford opportunities for reasoning or argumentation when adolescents are guilty. according to a previous study, adolescents’ needs for self-defense will be fulfilled when given the freedom to speak and take action, explore the environment, justice, honesty, and fairness.10-12 the analysis results of the psychological need for respect were 56.4% high. deference (respectful attitude) implies respecting and happily submitting to the influence of others. the results of the questionnaire data analysis showed that the adolescents greeted, did not speak louder, and were reluctant towards the caretakers of the shelter. respect for adolescents is based on the recognition that each individual possesses inherent value by virtue of uniqueness and diversity. according to a previous study, showing respect is speaking calmly and politely, specifically to older people.13-15 the study on psychological needs on the order component found that most (60%) were in the high category. the need for order in this study is defined as the need for adolescents to organize things and maintain cleanliness and order. the results of data analysis through adolescents’ answers showed that most adolescents had arranged personal belongings and rarely borrow from friends without permission. remembering and sharing experiences with peers is crucial during adolescence, as it significantly impacts their behaviour and overall well-being. the quality of friendships plays a vital role in the emotional growth of adolescents, influencing their feelings of companionship, trust, closeness, and ability to resolve conflicts.16-18 the results of the psychological needs showed that the majority of the data (54.5%) were in the low category. analysis of answers to the questionnaire showed that adolescents already understand the conditions of the shelter. caregivers, however, still perceived the majority as lacking cognitive maturity. the necessity for comprehension involves posing or addressing general inquiries concerning the shelter circumstances. this comprehension is crucial for fostering a solid self-acceptance of the shelter’s existence.19 furthermore, the application of the group nursing intervention model fulfilled the psychological needs of adolescents in shelters. quantitatively, the statistical test results of h0 were rejected, showing that there were differences in psychological needs before and after implementing the group nursing intervention model. the results of this test were strengthened by interviews with adolescents at the shelter who already felt confident and were willing to participate in community organization activities. this model was recommended to the head of social services as material for building development programs for adolescents in shelters. in addition, the results are recommended for universities with a faculty of psychology to ensure counselors’ contribution to neglected children. the analysis results showed that implementing group nursing interventions was important for fulfilling the psychological needs of adolescents in shelters, as evidenced by a coefficient of 0.794. human caring interpersonal behavior was directly influenced by predisposing, nurturing values, and driving factors, supported by coefficient values of 0.203, 0.220, and 0.332, respectively. these results showed that the development of a group nursing intervention model addressed the psychological needs of adolescents in nursing homes. this model integrated goal attainment and jean watson’s caring theory, as well as murray’s psychosocial needs, providing a comprehensive framework for effective intervention. furthermore, the model improved predisposing factors and care values , including attitudes, motivation, and commitment of caregivers. factors that support and advocate for environmental care has been recognized as crucial infrastructure in addressing the psychological needs of adolescents. significant drivers in this context encompass legal considerations and the backing of family and the community, which have been amplified to address these psychological requirements. this model underscores empathetic human interaction, seeking to improve interpersonal communication to cultivate positive perceptions and better fulfil adolescents’ psychological needs. implementing health education for adolescents should be enhanced by fostering collaboration between social and health services to ensure consistent delivery of education.20-23 conclusions in conclusion, the group nursing intervention model was structured with components, consisting of predisposing, supporting, and driving factors, as well as values of care and interpersonal human caring behavior. predisposing factors and care values were important to improve interpersonal human caring behavior. in this study, the indicators of predisposing factors and values of care included caregivers’ attitudes, motivation, and commitment. furthermore, supporting factors and a caring environment improved interpersonal human caring behavior and the indicators included learning, socialization, and counseling facilities, as well as opportunities to develop achievements. driving factors with several indicators, such as parenting attitudes, family, and community support also improved interpersonal human caring behavior, which had an essential effect on the psychological needs of adolescents. the indicators of this variable were communication, health education, parenting actions, and actions to increase self-confidence. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13063] [page 115] non -co mmerc ial us e o nly references 1. coordinating ministry for human development and culture of the republic of indonesia. handling abandoned children needs commitment | coordinating ministry for human development and culture [internet]. 2020 [cited 2023 aug 13]. available from: https://www.kemenkopmk.go.id/penanganan-anak-terlantarbutuh-komitmen. 2. firadika ar. handling of abandoned children by the social service based on article 34 of the 1945 constitution (case study of the social service of gowa regency) [internet] [diploma]. alauddin state islamic university makassar; 2017 [cited 2023 aug 13]. available from: http://repositori.uin-alauddin. ac.id/4261/. 3. ali m. psychology of adolescents. jakarta: bumi aksara; 2006. 4. hurlock eb. developmental psychology a lifespan approach. 5th ed. soedjarwo abdi dan d, editor. jakarta: pt.erlangga; 2007. 5. kuntoro. sampling methods and determination of sample size. surabaya: pustaka melati; 2010. 6. nurhafni a, kadam n. self-concept and achievement motivation in adolescents residents of “x” orphanage yogyakarta [internet] [thesis]. uin sunan kalijaga yogyakarta; 2019 [cited 2023 aug 13]. available from: https://digilib.uinsuka.ac.id/id/eprint/51878/. 7. alsarrani a, hunter rf, dunne l, garcia l. association between friendship quality and subjective wellbeing among adolescents: a systematic review. bmc public health 2022;22:2420. 8. hamm j, faircloth b. the role of friendship in adolescents’ sense of belonging. new directions for child and adolescent development. 2005;2005:61–78. 9. abrams z. the science of friendship [internet]. 2023 [cited 2023 aug 13]. available from: https://www.apa.org/monitor/ 2023/06/cover-story-science-friendship 10. peace over violence. empowerment self-defense — peace over violence [internet]. 2024 [cited 2024 feb 13]. available from: https://www.peaceoverviolence.org/empowerment-selfdefense 11. givler ji. self-defense for teens. strategies 2005;18:24–5. 12. strategic living. strategic living. 2021 [cited 2023 aug 13]. self defense class for teen girls seattle wa. available from: https://www.strategicliving.org/classes-item/for-teen-girls-only/ 13. van der geugten w, goossensen a. dignifying and undignifying aspects of care for people with dementia: a narrative review. scand j caring sci 2020;34:818-38. 14. søvde be, hovland g, ullebust b, råholm mb. struggling for a dignifying care: experiences of being next of kin to patients in home health care. scand j caring sci 2019;33:409-16. 15. anderson jg, bartmess m, hundt e, jacelon c. "a little bit of their souls": investigating the concept of dignity for people living with dementia using caregivers' blogs. j fam nurs 2021;27:43-54. 16. burk wj, laursen b. adolescent perceptions of friendship and their associations with individual adjustment. int j behav dev 2005;29:156-64. 17. faur s, leggett-james mp, kaniušonytė g, žukauskienė r, laursen b. perceptions of relationship quality that predict friendship dissolution during childhood and adolescence: social support matters more than negativity. dev psychol 2024;60:560-6. 18. hiatt c, laursen b, mooney ks, rubin kh. forms of friendship: a person-centered assessment of the quality, stability, and outcomes of different types of adolescent friends. pers individ dif 2015;77:149-55. 19. allen l, kelly bb, committee on the science of children birth to age 8: deepening and broadening the foundation for success, institute of medicine, national research council. child development and early learning. in: transforming the workforce for children birth through age 8: a unifying foundation [internet]. national academies press (us); 2015 [cited 2023 aug 13]. available from: https://www.ncbi. nlm.nih.gov/books/nbk310550/ 20. ryff cd, keyes cl. the structure of psychological well-being revisited. j pers soc psychol 1995;69:719-27. 21. van dierendonck d, díaz d, rodríguez-carvajal r, et al. ryff’s six-factor model of psychological well-being, a spanish exploration. soc indic res 2008;87:473–9. 22. hall cs, lindzey g. personality psychology i psychodynamic theories (clinical). yogjakarta: kanisius; 1993. 23. alligood mr. nursing theorists and their work. 10th–23rd ed. america: mosby; 2021. 4th international nursing and health sciences symposium [page 116] [healthcare in low-resource settings 2024;12(s1):13063] correspondence: dyah wijayanti, s.kep., ns., m.kep.; nursing department health polytechnic of the health ministry of surabaya, pucang jajar tengah street no. 56, 60282 kertajaya, gubeng, surabaya, east java, indonesia. tel. +62315028141fax: +62-5028141. e-mail: dyahwi@poltekkesdepkes-sby.ac.id key words: children; model of nursing intervention; psychological needs contributions: the authors contributed equally to increase adolescent self-confidence in shelters conflict of interest: the author declares no potential conflict of interest. funding: this study was financially supported by the association of indonesian nursing vocational education institutions (aipviki) grantfunded ethics approval: ethical approval has been granted by the ethics board of the health polytechnic of the ministry of health in surabaya, under the reference number ea/1205/kepk-poltekkes_sby/v/2023. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to the director of surabaya health polytechnic for supporting this study. the authors are also grateful to the association of indonesian nursing vocational education institutions (asosiasi institusi pendidikan indonesia/aipviki) for funding this study. received: 3 november 2023. accepted: 12 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13063 doi:10.4081/hls.2024.13063 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13370 prevalence of physical activity and its associated sociodemographic factors among schoolchildren in albania brizida refatllari,1 jonida stefa,1 migena gega,1 grejd hyska,2 gentiana qirjako,3,4 genc burazeri3,5 1faculty of technical medical sciences, university of medicine, tirana, albania; 2global studies institute, university of geneva, geneva, switzerland; 3faculty of medicine, university of medicine, tirana, albania; 4institute of public health, tirana, albania; 5department of international health, caphri (care and public health research institute), maastricht university, maastricht, the netherlands abstract physical activity (pa) promotes health and wellbeing of children. our objective was to assess the prevalence and the associated sociodemographic factors of pa among schoolchildren in a southeastern european country. this was a cross-sectional study conducted in albania in 2022 including a nationwide representative sample of 5454 schoolchildren aged 11-15 years (≈52% girls; ≈96% response). data on children’s pa and their sociodemographic factors were collected. daily moderate-to-vigorous pa was more prevalent in boys, younger children and those from wealthier families (overall: ≈29%). conversely, sedentary behaviour (moderate-to-vigorous pa ≤2 days/week) was more prevalent in girls, older children, rural children, those with unemployed parents and children from less affluent families (overall: ≈26%). frequent vigorous pa (≥3 days/week) was more prevalent in boys, younger children and those from better-off families (overall: ≈64%). our findings highlight potential advantages of pa engagement linked to both male gender and a higher socioeconomic status. this study underscores the need for targeted interventions to promote active lifestyles in children, particularly among groups at higher risk of sedentary behaviour which correspond to girls and disadvantaged socioeconomic categories. introduction engagement in regular physical activity (pa) promotes physical health, as well as social and emotional development in children and adolescents.1 pa supports healthy growth, strengthens bones and muscles, enhances cognitive abilities, and fosters psychoemotional well-being in children.2-4 additionally, pa helps reduce anxiety and depression, supporting better mental health and wellbeing in adolescents.5 also, regular pa improves concentration and fosters a range of positive social health outcomes,6 as well as prevents child obesity and reduces body weight.7 according to the world health organization (who), children and young people aged 5-17 years should engage every day in at least 60 minutes of moderate-to-vigorous pa (mvpa).7 the majority of these activities should be aerobic.2 in addition, who recommends that children should engage at least three days a week in vigorous pa (vpa), consisting of aerobic and/or activities that strengthen bones and muscles.2 however, most adolescents in the european region do not meet the recommended pa guidelines.8 instead, mvpa levels remain steadily low, tend to decrease with age during adolescence, and have shown little improvement over the past two decades.9,10 conversely, engagement in vpa is relatively high among children in many european countries and seems to have remained steady between 2002 and 2014, with a modest upward trend in girls,9 and among adolescents from families with moderate to high socioeconomic status.11 the health behaviour in schol-aged children (hbsc) study is a well-structured school-based survey conducted every four years across multiple countries (including europe, central asia and canada).1,12 the hbsc survey gathers essential data on various health behavioural characteristics and health status of schoolchildren aged 11, 13 and 15 years.1,12 the last round of correspondence: genc burazeri, university of medicine, rr. “dibres”, no. 371, tirana, albania. tel.: +355674077260 e-mail: genc.burazeri@maastrichtuniversity.nl key words: albania, children, health behaviour in school-aged children (hbsc), physical activity, schoolchildren. funding: this study was funded by the following agencies: the united nations population fund (unfpa) office in albania, the united nations children’s fund (unicef) office in albania, and the swiss development and cooperation (sdc) agency through the project “schools for health” implemented in albania. acknowledgment: this study was conducted by the faculty of medicine, university of medicine, tirana, albania. conflicts of interest: none declared. ethical approval: this study was approved by the ethics committee of tirana medical university (approval id: no.700/1, date: 05-04-2022). availability of data and material: the data presented in this study are available upon request from the corresponding author. contributions: br, gq and gb contributed to the study conceptualization and design, analysis and interpretation of the data and writing of the article. js, mg and gh commented comprehensively on the manuscript. all authors have read and approved the submitted manuscript. received: 11 november 2024. accepted: 11 november 2024. early access: 17 january 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13370 doi:10.4081/hls.2025.13370 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 86] [healthcare in low-resource settings 2025;13:13370] hbsc survey was carried out during 2021-2022 in 44 countries including albania.1,12,1 alongside numerous health outcomes and behavioural factors, the survey included also questions assessing engagement in pa among schoolchildren aged 11-15 years.1,12 albania, a post-communist country in southeastern europe, has been characterized in the past three decades by a rapid political and socioeconomic transition which has been also associated with behavioural changes.14 nevertheless, according to the most recent estimates available from the global burden of disease study,15 the age-standardized mortality rate attributed to low levels of pa has remained almost unchanged in the past three decades (with about 6 deaths per 100,000 population). regarding children, a recent study from albania has shown that almost 1/3rd of schoolchildren aged 12-15 years (n=7831) do not exhibit the best attitudes toward health promotion, a composite indicator including also children’s attitudes toward pa (16). according to this study, significant independent sociodemographic correlates of poorer attitudes toward health promotion (ability to maintain and improve health) consisted of older age, a lower maternal education, and a lower family income.16 within this context, the aim of our analysis was to assess the prevalence of pa and its associated sociodemographic factors among schoolchildren, based on the last hbsc round carried out in albania in 2022.13 based on the findings from previous hbsc rounds, we hypothesized a higher prevalence of pa among boys and younger children.1,12 materials and methods a cross-sectional study (corresponding to the last round of hbsc survey) was conducted in albania in 2022.13 participants included a nationwide representative sample of 5454 schoolchildren aged 11, 13 and 15 years (2844 girls, ≈52% of the sample). the overall response rate was ≈96%.13 the survey instrument consisted of an internationally standardized self-administered questionnaire which included information on a wide range of behavioural factors and sociodemographic factors of schoolchildren.1,12 measurement of pa consisted of assessment of the frequency of moderate-to-vigorous pa (mvpa) and vigorous pa (vpa). mvpa was measured based on the following question: “over the past seven days, on how many days were you physically active for a total of at least 60 minutes per day?”. possible answers ranged from 0 (zero days) to 7 (seven days). in the analysis, mvpa was also dichotomized into: “7 days/week” (referred to as “daily mvpa”) vs. “≤6 days/week”, as well as into: “0-2 days/week” (referred to as “sedentary lifestyle/behaviour”) vs. “≥3 days/week”.1,12 vpa was measured based on the following question: “how often do you usually exercise in your free time, outside of school hours, so much that you get out of breath or sweat?”. possible answers ranged from 1 (every day) to 8 (never). in the analysis, vpa was also dichotomized into: “≥3 days/week” (referred to as “frequent vpa”) vs. “≤2 days/week”.1,12 sociodemographic factors consisted of children’s gender (boys vs. girls), age (11, 13, and 15 years), place of residence (urban vs. rural areas), mother’s and father’s current employment status (for each: yes vs. no), and family affluence scale (less affluent vs. more affluent families).12 the ethics committee of tirana medical university endorsed the study (approval id: no.700/1). all schoolchildren were informed about the objectives and procedures of the survey, with a focus on the aspects related to the survey anonymity and the aggregated statistical analysis. general linear model was used to compare the mean values of pa variables (expressed as numerical terms) by sociodemographic factors of schoolchildren. crude (unadjusted) mean values and their respective 95% confidence intervals (95%cis) and p-values were calculated (table 1). on the other hand, binary logistic regression was employed to assess the associations of pa indices (introduced as categorial terms) with sociodemographic factors of schoolchildren. crude (unadjusted) models were run (table 2). odds ratios (ors) and their respective 95%cis and p-values were calculated for each pa index (daily mvpa, sedentary behaviour, and frequent vpa). in all cases, p≤0.05 was considered as statistically significant. all the statistical analyses were conducted by use of the statistical package for the social sciences (spss, version 19.0). results table 1 presents the distribution of scores of pa variables by sociodemographic factors of schoolchildren included in this study. overall, mean score of mvpa was about 4.3 [range from 0 (zero days) to 7 (seven days)]. it was significantly higher in boys than in girls (4.7 vs. 3.9, respectively; p<0.01). there was evidence of a graded inverse relationship with age (overall p<0.01), with the youngest children exhibiting considerably higher mean mvpa scores compared to their oldest counterparts (4.8 vs. 3.8, respectively). furthermore, mean mvpa scores were somehow higher among schoolchildren whose fathers and/or mothers were employed (4.3 for both) than among those whose parents were unemployed (3.9 for father’s unemployment and 4.2 for mother’s unemployment). also, mean mvpa score was higher among children pertinent to more affluent families than in those from less affluent families (4.5 vs. 4.1, respectively; p<0.01). overall, mean score of vpa was around 3.2 [range from 1 (every day) to 8 (never)]. it was lower in boys than in girls (2.8 vs. 3.6, respectively; p<0.01). there was a positive linear relationship with age (overall p<0.01), with older children displaying the highest mean vpa scores and the youngest children exhibiting the lowest vpa scores (3.6 vs. 2.8, respectively). additionally, mean vpa scores were lower among children with employed fathers compared with those with unemployed fathers (3.2 vs. 3.5, respectively; p<0.01) and in children belonging to more affluent families than in those with a lower family wealth (3.0 vs. 3.4, respectively; p<0.01). the overall prevalence of daily mvpa was about 29% (table 3). daily mvpa was substantially more prevalent in boys than in girls (36% vs. 22%, respectively); among the youngest children compared to their oldest counterparts (37% vs. 21%, respectively); among children whose fathers were employed than in those with unemployed fathers (29% vs. 24%, respectively); and in children from more affluent families than in those with a lower family wealth (31% vs. 27%, respectively). on the whole, the prevalence of a sedentary lifestyle (mvpa: 0-2 days/week) was around 26%. sedentary behaviour was much more prevalent in girls than in boys (33% vs. 19%, respectively); among the oldest children than their youngest counterparts (32% vs. 20%, respectively); among children whose fathers were unemployed compared to those with employed fathers (33% vs. 25%, respectively); among children with unemployed mothers than in those whose mothers were employed (28% vs. 25%, respectively); and among children pertinent to less affluent families than in those from better-off families (31% vs. 22%, respectively). overall, the prevalence of frequent article [healthcare in low-resource settings 2025;13:13370] [page 87] vpa (at least three days a week) was approximately 64%. frequent vpa was considerably higher in boys than in girls (74% vs. 54%, respectively); among the youngest children than in the oldest individuals (72% vs. 54%, respectively); among children with employed fathers than in those whose fathers were unemployed (64% vs. 58%, respectively); and in children from more affluent families than in those from poorer families (68% vs. 59%, respectively). table 2 presents binary logistic regression results of the associations between pa indices (categorial terms) and sociodemographic factors of schoolchildren. there was evidence of positive and significant associations of daily mvpa with male gender (or=1.9, 95%ci=1.7-2.2), a younger age (or=2.3, 95%ci=2.02.7), father’s employment (or=1.3, 95%ci=1.1-1.7), and family affluence (or=1.3, 95%ci=1.1-1.4). conversely, sedentary behaviour (mvpa: 0-2 days) was inversely related to male gender (or=0.5, 95%ci=0.4-0.5), a younger age (or=0.5, 95%ci=0.50.6), urban residence (or=0.9, 95%ci=0.8-1.0), father’s employment (or=0.7, 95%ci=0.6-0.9), mother’s employment (or=0.8, 95%ci=0.7-1.0), and family affluence (or=0.6, 95%ci=0.6-0.7). on the other hand, frequent vpa (≥3 days/week) was positively associated with male gender (or=2.5, 95%ci=2.2-2.8), a younger age (or=2.2, 95%ci=1.9-2.5), father’s employment (or=1.3, 95%ci=1.1-1.6), and family wealth (or=1.5, 95%ci=1.3-1.7). discussion main findings of our study conducted in albania indicate that demographic and socioeconomic factors play a significant role in children’s pa patterns. our analysis provided evidence of consistent positive links between male gender, younger age and family wealth with higher levels of both mvpa and vpa. in contrast, sedentary behaviour (mvpa: 0-2 days per week) was more common among girls, older children, and those from a lower socioeconomic background. a pretty recent report informing about pa levels among all 44 participating countries in the last hbsc survey round conducted in 2021-221 and employing the same measuring instrument1,12 indicated that the average proportion of adolescents across countries and regions reporting daily 60 minutes of mvpa was 25% for boys and 15% for girls, which is lower than our findings pertinent to albanian children (36% in boys and 22% in girls). in most countries and regions included in the last hbsc survey round caried out in 2021-22, and across all age groups, girls had a significantly lower prevalence of daily mvpa compared to boys,1 which is in line with our findings. girls in several countries have reported a low prevalence of daily mvpa (≤10%), including italy, greece, france, greenland (denmark) and lithuania (1). of note, the prevalence of daily mvpa was the lowest among italian girls aged 15 years (only 3%) and the highest among serbian boys aged 11 years (49%).1 our findings on a positive link between daily mvpa and family wealth are in line with the multi-country hbsc 2021-22 report.1 hence, among all 44 participating countries,1 the prevalence of daily mvpa among boys pertinent to more affluent families was 32% compared to 20% among those from lower affluent families (in our study: 38% vs. 33%, respectively; data not shown in the tables). in girls, these estimates were 19% and 13%, respectively1 – in our study: 24% vs. 21%, respectively (not shown). on the whole, there were no considerable changes in the levels of daily mvpa between 2018 and 2022 which consist of the two last rounds conducted in the hbsc participating countries,1 whereas in albania there is evidence of 10% increase in boys and 5% increase in girls (data not shown). conversely, there are countries article table 1. distribution of scores of physical activity variables by sociodemographic factors in a nationwide sample of albanian schoolchildren, hbsc 2022 survey. sociodemographic factors moderate-to-vigorous vigorous physical activity (vpa) physical activity (mvpa) mean (95%ci)* p* mean (95%ci) p total sample (n=5454) 4.32 (4.26-4.38) 3.18 (3.12-3.23) gender <0.001 <0.001 boys (n=2610) 4.74 (4.66-4.83) 2.74 (2.66-2.82) girls (n=2844) 3.89 (3.81-3.97) 3.61 (3.53-3.69) age <0.001 (2)† <0.001 (2) 11 years (n=1784) 4.76 (4.66-4.87) <0.001 2.82 (2.72-2.91) <0.001 13 years (n=1785) 4.32 (4.21-4.43) <0.001 3.12 (3.02-3.21) <0.001 15 years (n=1877) 3.82 (3.72-3.93) 3.63 (3.53-3.72) residence 0.617 0.490 urban areas (n=3648) 4.31 (4.23-4.38) 3.21 (3.14-3.28) rural areas (n=1806) 4.27 (4.17-4.38) 3.17 (3.07-3.27) father’s employment <0.001 0.004 yes (n=4928) 4.34 (4.27-4.40) 3.17 (3.11-3.23) no (n=479) 3.90 (3.97-4.11) 3.46 (3.27-3.65) mother’s employment 0.031 0.732 yes (n=3676) 4.34 (4.27-4.41) 3.19 (3.12-3.26) no (n=1710) 4.20 (4.09-4.30) 3.21 (3.11-3.31) family affluence <0.001 <0.001 less affluent (n=2600) 4.06 (3.97-4.15) 3.41 (3.33-3.49) more affluent (n=2715) 4.51 (4.42-4.60) 3.00 (2.92-3.08) * mean values and their respective 95% confidence intervals and p-values from the general linear models. range of scores for mvpa: from 0 (0 days) to 7 (seven days); hence, higher mvpa scores denote a higher frequency of physical activity. range of scores for vpa: from 1 (every day) to 8 (never); thus, higher vpa scores indicate less frequent vigorous physical activity. †overall p-value and degrees of freedom (in parentheses). [page 88] [healthcare in low-resource settings 2025;13:13370] which exhibit a decrease in the prevalence of daily mvpa such as lithuania, armenia, greenland (denmark) and north macedonia.1 regarding vpa, 60% of adolescents in the 44 hbsc participating countries met the who recommendation for engaging in vpa at least three times a week,1 which is slightly lower than our findings pertinent to albanian children (about 64%). in most countries, boys reported higher levels of vpa than girls across all age groups,1 which is in line with our findings from albania. of 44 countries included in the multi-country analysis, frequent vpa decreased significantly with age in 37 countries and regions for girls and 21 for boys.1 likewise daily mvpa, there was evidence of a positive relationship of frequent vpa with family affluence in most hbsc participating countries,1 which is compatible with our findings from albania. according to the multi-country hbsc report,1 the prevalence of frequent vpa among children from more affluent families was 77% in boys and 61% in girls, whereas among children from less affluent families it was 61% in boys and 42% in girls (in our study: 77% in boys and 58% in girls from more affluent families, and 70% in boys and 49% in girls from less affluent families – data not shown). as for the sedentary lifestyle, on average, 24% of adolescents from 44 participating hbsc countries were highly inactive (mvpa≤2 days/week),1 which is quite similar with our findings (26%). the prevalence of sedentary lifestyle was the highest (60%) in greenland (denmark) and the lowest (<10%) in slovenia, finland and ireland.1 there was evidence of an inverse association with socioeconomic status, with children from high-affluence fam article [healthcare in low-resource settings 2025;13:13370] [page 89] table 2. associations of physical activity indices with sociodemographic factors of schoolchildren; results from binary logistic regression models physical activity indices demographic factors male age 11† or (95%ci) * p * or (95%ci) p mvpa: 7 days/week 1.93 (1.71-2.18) <0.001 2.29 (1.97-2.66) <0.001 mvpa: 0-2 days/week 0.47 (0.42-0.54) <0.001 0.54 (0.46-0.63) <0.001 vpa≥3 days/week 2.46 (2.19-2.76) <0.001 2.17 (1.89-2.49) <0.001 physical activity indices socioeconomic factors father employed mother employed or (95%ci) * p * or (95%ci) p mvpa: 7 days/week 1.32 (1.06-1.65) 0.014 1.07 (0.94-1.22) 0.297 mvpa: 0-2 days/week 0.70 (0.57-0.86) <0.001 0.84 (0.74-0.96) 0.009 vpa≥3 days/week 1.29 (1.06-1.56) <0.001 1.01 (0.89-1.13) 0.925 * odds ratios and their respective 95% confidence intervals (in parentheses), as well as p-values from crude (unadjusted) binary logistic regression models. †compared to age 15. table 3. distribution of physical activity categories by sociodemographic factors of schoolchildren included in the hbsc 2022 survey in albania. sociodemographic factors moderate-to-vigorous physical activity (mvpa). vigorous physical activity (vpa) 7 days/week 0-2 days/week vpa≥3 days/week total sample (n=5454) 1535 (28.8)* 1381 (25.9) 3416 (63.5) gender boys (n=2610) 908 (35.8) 470 (18.6) 1900 (74.1) girls (n=2844) 627 (22.4) 911 (32.6) 1516 (53.8) age 11 years (n=1784) 650 (37.2) 355 (20.3) 1262 (71.9) 13 years (n=1785) 505 (29.0) 436 (25.0) 1142 (65.1) 15 years (n=1877) 377 (20.6) 588 (32.1) 1007 (54.1) residence urban areas (n=3648) 1012 (28.4) 892 (25.1) 2284 (63.6) rural areas (n=1806) 523 (29.6) 489 (27.6) 1132 (63.3) father’s employment: yes (n=4928) 1415 (29.4) 1218 (25.3) 3112 (64.0) no (n=479) 112 (23.9) 152 (32.5) 274 (57.9) mother’s employment: yes (n=3676) 1050 (29.2) 893 (24.8) 2308 (63.5) no (n=1710) 464 (27.8) 471 (28.2) 1067 (63.4) family affluence less affluent (n=2600) 674 (26.5) 776 (30.5) 1507 (58.6) more affluent (n=2715) 822 (30.9) 573 (21.6) 1825 (67.9) *absolute numbers and their respective percentages (in parentheses). for the physical activity variables, there were the following missing values: mvpa (n=125); and vpa (n=72). in addition, there were the following missing values for sociodemographic factors: age of schoolchildren (n=8), father’s employment status (n=47); mother’s employment status (n=68); and family affluence score (n=139). ilies exhibiting lower levels of physical inactivity compared to their low-affluence counterparts,1 which is in line with our findings from albania. according to the multi-country hbsc report,1 the prevalence of sedentary lifestyle was higher among girls (29%) than boys (20%), a gender-difference which is compatible with our findings too (33% vs. 19%, respectively). gender differences in the prevalence of sedentary lifestyle range from 3% in norway to 20% in italy,1 whereas in our study the gender gap was 14%. lack of pa and sedentary behaviours are significant public health issues that contribute to the onset of obesity and various chronic diseases later in life, including cardiovascular diseases, diabetes, some types of cancers and hypertension.17-19 the shift from adolescence to adulthood involves numerous life changes that impact lifestyle habits17,20,21 of which, physical inactivity is an important risk factor for ill-health and premature mortality.22 hence, regardless of the proven health benefits of pa, most of the studies have revealed that it decreases during the transition from adolescence to adulthood and is replaced by increased time spent on sedentary activities.17,23,24 our study included a large nationwide representative sample of schoolchildren and employed an internationally standardized instrument.12 nevertheless, lack of generalizability to out-ofschool albanian children aged 11-15 years may be a potential limitation of this study. additionally, there is a potential for information bias, particularly social desirability bias (overreporting pa frequency) or intentional misreporting. also, the cross-sectional design of the study may represent another limitation, as it prevents the determination of causal relationships. nonetheless, our study provides useful evidence on the prevalence and sociodemographic factors associated with pa among schoolchildren in albania. policymakers and decisionmakers in albania and in other countries should consider effective measures and implementation of cost-effective programs which increase engagement in ph among children and adolescents. such programs should be implemented in school settings, as an umbrella systematic review25 has persuasively indicated that the availability of pa programs and equipment within schools are positively associated with pa levels in children and adolescents.25-27 at the same time, there is need for interventions at community level, as such neighbourhood characteristics as pedestrian and cyclist safety structure has been also convincingly linked to increased pa levels among children and adolescents.25,26 therefore, it has been suggested that, considering that pa practices among children are influenced by factors at different levels including home, school and neighbourhood environment,27 interventions should target all these levels and also consider elements of the macro environment in order to effectively address the problem of physical inactivity among children and adolescents.2527 conclusions in conclusion, our study caried out in post-communist albania highlights significant disparities in pa patterns among children based on gender, age and socioeconomic status (operationalized through parental employment status and family affluence scale). boys, younger children, and those from wealthier families consistently exhibited higher levels of mvpa and vpa, suggesting that access to resources and social support in albania may play a critical role in encouraging active lifestyles. conversely, girls, older children, rural children, and especially those from less affluent families seem more prone to sedentary behaviour, potentially placing them at higher risk for health issues associated with physical inactivity. addressing these disparities in albania requires targeted interventions that promote equitable access to pa opportunities, especially for vulnerable groups, to foster healthier lifestyles across all sociodemographic population categories. on an international scale, our findings underscore the need for globally coordinated efforts to reduce disparities in pa among children, as inequities in access to active lifestyles may contribute to broader health and development inequalities across countries worldwide. references 1. rakić jg, hamrik z, dzielska a, et al. a focus on adolescent physical activity, eating behaviours, weight status and body image in europe, central asia and canada. health behaviour in school-aged children international report from the 2021/2022 survey. volume 4. copenhagen: who regional office for europe; 2024. 2. bull fc, al-ansari ss, biddle s, et al. world health organization 2020 guidelines on physical activity and sedentary behaviour. br j sports med 2020;54:1451-62. 3. biddle sj, asare m. physical activity and mental health in children and adolescents: a review of reviews. br j sports med 2011;45:886-95. 4. janssen i, leblanc ag. systematic review of the health benefits of physical activity and fitness in school-aged children and youth. int j behav nutr phys act 2010;7:40. 5. mcmahon em, corcoran p, o’regan g, et al. physical activity in european adolescents and associations with anxiety, depression and well-being. eur child adolesc psychiatry 2017;26:111-22. 6. eime rm, young ja, harvey jt, et al. a systematic review of the psychological and social benefits of participation in sport for children and adolescents: informing development of a conceptual model of health through sport. int j behav nutr phys act 2013;10:98. 7. bleich sn, vercammen ka, zatz ly, et al. interventions to prevent global childhood overweight and obesity: a systematic review. lancet diabetes endocrinol 2018;6:332-46. 8. guthold r, stevens ga, riley lm, bull fc. global trends in insufficient physical activity among adolescents: a pooled analysis of 298 population-based surveys with 1.6 million participants. lancet child adolesc health 2020;4:23-35. 9. world health organization. adolescent obesity and related behaviours: trends and inequalities in the who european region, 2002–2014 observations from the health behaviour in school-aged children (hbsc) who collaborative crossnational study. world health organization; 2017. available from: https://www.euro.who.int/__data/assets/pdf_file/ 0019/339211/who_obesityreport_2017_v3.pdf (accessed: 10 november 2024) 10. kalman m, inchley j, sigmundova d, et al. secular trends in moderate-to-vigorous physical activity in 32 countries from 2002 to 2010: a cross-national perspective. eur j public health 2015;25:s37-40. 11. sigmundová d, sigmund e, tesler r, et al. vigorous physical activity in relation to family affluence: time trends in europe and north america. int j public health 2019;64:1049-58. 12. inchley j, currie d, piper a, et al. (eds.). health behaviour in article [page 90] [healthcare in low-resource settings 2025;13:13370] school-aged children (hbsc) study protocol: background, methodology, mandatory questions and optional packages for the 2021/22 survey. mrc/cso social and public health sciences unit, the university of glasgow, 2021/22. 13. çumashi r, mone i, burazeri g, et al. prevalence and sociodemographic correlates of smoking among schoolchildren in albania. int j environ res public health 2024;21:1145. 14. czabanowski w, mone i, burazeri g. health status in selected post-communist european countries: a comparative study between poland and albania. cent eur j public health 2024;32:63-67. 15. institute for health metrics and evaluation. global burden of disease (gbd) results. https://vizhub.healthdata.org/gbdresults/ (accessed: 10 november 2024). 16. muja h, vasil s, toçi d, et al. ability to maintain and improve health and socio-demographic correlates among children in albania. zdr varst 2024;63:113-22. 17. vanhelst j, béghin l, drumez e, et al. changes in physical activity patterns from adolescence to young adulthood: the belinda study. eur j pediatr 2023;182:2891-902. 18. ekelund u, brown wj, steene-johannessen j, et al. do the associations of sedentary behaviour with cardiovascular disease mortality and cancer mortality differ by physical activity level? a systematic review and harmonised meta-analysis of data from 850060 participants. br j sports med 2019;53:88694. 19. lollgen h, bockenhoff a, knapp g. physical activity and allcause mortality: an updated meta-analysis with different intensity categories. int j sports med 2009;30:213-24. 20. hayes g, dowd kp, macdonncha c, donnelly ae. tracking of physical activity and sedentary behavior from adolescence to young adulthood: a systematic literature review. j adolesc health 2019;65:446-54. 21. lioret s, campbell kj, mcnaughton sa, et al. lifestyle patterns begin in early childhood, persist and are socioeconomically patterned, confirming the importance of early life interventions. nutrients 2020;12:724. 22. world health organization. saving lives, spending less: a strategic response to noncommunicable diseases. geneva: world health organization; 2018. available from: https://iris.who.int/handle/10665/272534 (accessed: 10 november 2024). 23. corder k, sharp sj, atkin aj, et al. change in objectively measured physical activity during the transition to adolescence. br j sports med 2015;49:730-6. 24. dumith sc, gigante dp, domingues mr, kohl hw 3rd. physical activity change during adolescence: a systematic review and a pooled analysis. int j epidemiol 2011;40:685-98. 25. carlin a, perchoux c, puggina a, et al. a life course examination of the physical environmental determinants of physical activity behaviour: a “determinants of diet and physical activity” (dedipac) umbrella systematic literature review. plos one. 2017;12:e0182083. 26. craggs c, corder k, van sluijs emf, griffin sj. determinants of change in physical activity in children and adolescents: a systematic review. am j prev med 2011;40:645-58. 27. ferreira i, van der horst k, wendel-vos w, et al. environmental correlates of physical activity in youth–a review and update. obesity rev 2007;8:129-54. article [healthcare in low-resource settings 2025;13:13370] [page 91] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13515 investigating the factors influencing nursing students’ competency in patient safety dyah wiji puspita sari, muh abdurrouf, iwan ardian, intan rismatul azizah department of nursing management, faculty of nursing, sultan agung islamic university, semarang, indonesia abstract patient safety competencies among nursing students remain challenging and are influenced by various factors, including student characteristics. this study aimed to assess the correlation between the cumulative grade point average (gpa), interest, learning motivation, learning style, critical thinking ability, level of patient safety knowledge, and patient safety competencies. a cross-sectional study was conducted involving 232 professional nursing students from a private university in semarang city, central java, indonesia. participants were selected using a purposive sampling technique. data on patient safety competencies were collected through observational sheets, while independent variables were assessed using structured questionnaires. data were analyzed using chi-squared tests for bivariate analysis and logistic regression for multivariate analysis. bivariate analysis indicated significant correlations between patient safety competencies and cumulative gpa, interest, learning motivation, critical thinking ability, and the level of patient safety knowledge. multivariate logistic regression identified interest (or=2.927) as the strongest influencing factor, followed by gpa (or=2.424), learning style (or=1.915), knowledge level (or=1.904), learning motivation (or=0.490), and critical thinking ability (or=0.309). these findings highlighted important implications for nursing education and clinical practice, emphasizing the critical need for integrating patient safety into nursing curricula. educational strategies should prioritize fostering student interest, enhancing academic performance, accommodating diverse learning styles, promoting critical thinking, and boosting motivation, thereby ultimately improving student competencies and patient safety outcomes. introduction nursing students have not yet achieved patient safety competencies.1,2 the level of competence among postgraduate nursing students in implementing patient safety across the six domains is low.3 factors influencing the low level of patient safety competence among students include the curriculum, the number of semester credit units, learning strategies, and student characteristics such as age, gender, duration of admission to the clinic, and educational level.4 in developing the educational process, it is essential to consider these determinant factors in teaching and learning activities, especially in clinical education. these factors are individual aspects that encompass interest, learning motivation, learning styles, and cognitive abilities.5 nursing students with low patient safety competence are at risk of making mistakes when providing treatment or actions to patients. more than half of the nursing students in the last year were found to be incompetent in terms of their level of knowledge about patient safety.4 this low level of knowledge decreases the implementation of patient safety, which could increase the risk of patient safety incidents.6 studies have shown that nursing students generally have satisfactory levels of patient safety competency, although there are still areas for improvement. for instance, a study involving 191 nursing students in northern cyprus found that while their overall knowledge, skills, and attitudes towards patient safety were satisfactory, they scored the lowest in the knowledge dimension.7 another study in iran demonstrated that educational interventions could improve patient safety competencies over time, particularly correspondence: dyah wiji puspita sari, department of nursing management, faculty of nursing, sultan agung islamic university, semarang, indonesia. e-mail: daiyah_04@yahoo.com key word: critical thinking; interest; learning; motivation; patient safety competency. contributions: dwps, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; ma, conceptualization, investigation, methodology, validation, and writing – original draft, review & editing; ia, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; ira, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: this study was approved by the ethics research committee of sultan agung islamic university, semarang, indonesia (no. 079/a. i/fik-sa/xi/2021) on november 19, 2021. before the study, all respondents signed written informed consent after being explained the procedures, rights, and obligations during the research. consent for publication: written informed consent was obtained for anonymized patient information to be published. availability of data and materials: all data generated or analysed during this study are included in this published article. acknowledgments: the authors would like to express their gratitude to all participants in this study and the hospital for their help completing this research. received: 22 december 2024. accepted: 17 march 2025. early access: 5 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13515 doi:10.4081/hls.2025.13515 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s1):13515] [page 143] in areas such as addressing broader patient safety issues and comfort in speaking about patient safety.8 indonesia is a developing country, and many healthcare workers lack a comprehensive understanding of patient safety concepts and definitions.9 no standardized modules or guidelines are available for patient safety training, leading to significant knowledge gaps.10,11 patient safety training in indonesia is not well established and does not meet the needs of healthcare workers. effective communication and building a patient safety culture were identified as priority areas for training.11 clinical education plays a crucial role in achieving patient-safety competencies among nursing students. studies have shown a significant relationship between implementing clinical education and achieving patient safety goals.12 the prevalence of patient safety competency in indonesia is hindered by inadequate training, insufficient integration of clinical education, systemic issues in incident reporting, and government support. addressing these challenges through comprehensive training programs, improved clinical education models, and more substantial government involvement is essential for enhancing patient safety competencies in indonesia.11,12 therefore, implementing teaching and learning activities must be carefully considered and adjusted for the factors that affect each student.5 however, research in this area has been limited. this study aimed to investigate the correlation between nursing students’ determinant factors, including the cumulative grade point average (gpa), interest, learning motivation, learning style, level of acquired knowledge, critical thinking skills, and students’ patient safety competencies. materials and methods study design this study was conducted between 2021 and 2022. it employed a descriptive cross-sectional design to investigate the association between the cumulative gpa, interest, learning style, learning motivation, critical thinking ability, level of patient safety knowledge, and patient safety competencies. participants the respondents were 232 nursing students recruited using a purposive sampling technique. inclusion criteria included students at the clinical stage in a teaching hospital who were willing to be respondents and had signed the informed consent form. the exclusion criteria were students who did not pass the subject of clinical practice and nursing students who had worked in hospitals. this study was conducted at a private teaching hospital in semarang, indonesia. data collection six instruments were used to collect data in this study. these included cumulative gpa, student interest, learning motivation, critical thinking ability, level of knowledge, and learning style assessed using a high and low scale. learning style was measured based on kinesthetic and audiovisual scales. gpa was measured using a questionnaire on demographic characteristics in the form of closed-ended questions. students were requested to choose one of the available answers based on the classification of the cumulative gpa, as determined in the regulation of the minister of education and culture of the republic of indonesia no. 3 of 2020, according to the national standards for higher education. students’ interests were collected using a learning interest questionnaire in the form of closed questions. the overall scores on this questionnaire were divided into low and high.13 learning motivation was measured using a questionnaire comprising 19 statements. similarly, critical thinking skills were measured using a questionnaire containing 17 statements with 5 answer choices. the level of acquired knowledge about patient safety was measured using a patient safety questionnaire with 15 statements.14 the instrument used to measure patient safety competencies, developed by sari,15 was adapted from the joint commission international. all instruments were tested for validity and reliability, with valid and reliable results. the interest, motivation, and learning style questionnaires were declared valid with p-values of 0.541-0.939, 0.581-0.906, and 0.455-0.916, respectively. similarly, the critical thinking and level of acquired knowledge questionnaires were also declared valid, with p-value ranges of 0.518-0.913 and 0.459-0.832, respectively. dependent variable data were collected using an observation sheet, and independent variable data were collected using a structured questionnaire. no names were indicated on the questionnaire or observation sheet to ensure anonymity. data analysis the tabulated results were used for statistical analysis. the data were analyzed using ibm’s statistical package for the social sciences (spss) version 21.0. a descriptive analysis was performed on the demographic characteristics of respondents, sub-variables of the cumulative gpa, interest, learning style, learning motivation, critical thinking ability, level of patient safety knowledge, and patient safety competencies. these are represented as percentages, based on the findings of each research variable. an inferential analysis using a chi-square test and multivariate analysis was performed using logistic regression. ethical consideration this study was approved by the ethics research committee of sultan agung islamic university, semarang, indonesia (no. 079/a. i/fik-sa/xi/2021) on november 19, 2021. before the study, all respondents signed written informed consent after receiving an explanation of the procedures, rights, and obligations involved in the research. informed consent was obtained through ensuring anonymity, confidentiality, fidelity, and autonomy. results most respondents were female (203, 87.5%), while 29 (12.5%) were male. all respondents were aged 21 to 25. furthermore, all participants had received orientation and training on patient safety (table 1). bivariate analysis showed that patient safety competencies were related to the cumulative gpa (p=0.017, or=2.548; 95% ci: 1.181-5.499), interest (p=0.004, or=3.211; 95% ci: 1.455-7.130), learning motivation (p=0.039, or=0.45; 95% ci: 0.210-0.962), critical thinking (p=0.004, or=0.309; 95% ci: 0.139-0.686), and level of patient safety knowledge (p=0.010, or=2.718; 95% ci: 1.270-5.819). furthermore, patient safety competence was not related to learning styles (p=0.358). the results of bivariate analysis are presented in table 2. variables in bivariate analysis with a score of <0.25 were included in the logistic regression, namely cumulative gpa, interest, learning motivation, critical thinking ability, and level of patient safety knowledge. table 3 shows the results of the multivariate logistic regression analysis. it was found that students’ characteristics affecting patient safety competencies special issue pathways of change [page 144] [healthcare in low-resource settings 2025;13(s1):13515] were gpa (p<0.004, or=2.424; 95% ci: 1.324), interest (p<0.001, or=2.927; 95% ci: 1.556), learning motivation (p<0.023, or=0.490; 95% ci: 0.265), critical thinking ability (p<0.001, or=0.309; 95% ci: 0.163), and level of patient safety knowledge (p<0.038, or=1.904; 95% ci: 1.035). discussion the results of the logistic regression test indicated that among all variables correlated with patient safety goals, the strongest influences were, in order of interest, gpa, learning style, level of knowledge, learning motivation, and critical thinking. these findings have key implications for nursing education and practice. the study showed that cumulative gpa, interest, learning motivation, critical thinking skills, and the level of patient safety knowledge were associated with the implementation of patient safety competencies of nursing students. a previous study also showed a relationship between the cumulative gpa and the intelligence of nursing students in achieving competence.16 another study reported that students’ interest affects their involvement and motivation in learning,17 and interest influences learning achievement.18 previous research has shown a positive and significant relationship between learning motivation and achievement, with a correlation coefficient of 0.462.19 learning motivation affects learning achievement,20 special issue pathways of change table 3. analysis results of the multivariate logistic regression test. variable coefficient s.e. wald df p-value or 95% ci gpa 0.885 0.308 8.241 1 0.004 2.424 1.324 interest 1.074 0.322 11.108 1 0.001 2.927 1.556 learning motivation -0.713 0.313 5.168 1 0.023 0.490 0.265 learning style 0.650 0.318 4.189 1 0.041 1.915 1.028 critical thinking -1.175 0.325 13.077 1 0 0.309 0.163 level of knowledge 0.644 0.311 4.293 1 0.038 1.904 1.035 constant -2.648 1.049 6.369 1 0.012 0.071 table 1. frequency distribution of nursing student characteristics at university hospital in semarang city (n=232). variable frequency (f) percentage (%) gender male 29 12.5 female 203 87.5 age 21-25 years 232 100 25-30 years 0 0 hospital orientation yes 232 100 no 0 0 exposure patient safety received 232 100 never received 0 0 table 2. patient safety competence-related factors in pre-licensure nursing students (n=232). variable indicator scalepatient safety competence p-value odds ratio 95% ci high low f % f % gpa high 86 72.3 33 27.7 0.006 2.144 1.241-3.702 low 62 54.9 51 45.1 interest high 85 72.6 32 27.4 0.005 2.192 1.268-3.792 low 63 54.8 52 45.2 learning motivation high 55 55 45 45.0 0.015 0.513 0.298-0.882 low 93 70.5 39 29.5 learning style kinesthetics 85 66.4 43 33.6 0.358 1.286 0.751-2.203 audiovisual 63 60.6 41 39.4 critical thinking high 65 54.2 55 45.8 0.002 0.413 0.237 0.719 low 83 74.1 29 25.9 level of knowledge high 86 71.6 35 28.9 0.016 1.942 1.128 -3.342 low 62 55.9 49 44.1 [healthcare in low-resource settings 2025;13(s1):13515] [page 145] including the achievement of patient safety competencies. a crosssectional study in south korea showed that critical thinking is positively correlated with the performance and achievement of nursing students’ academic competencies.21 nurses’ compliance with patient safety principles is influenced by their level of patient safety knowledge, attitudes, and perceptions about safety issues.22 this study’s findings emphasize that nursing education institutions must enhance student quality factors, such as average cumulative gpa, interest, learning motivation, critical thinking abilities, and knowledge, to improve patient safety outcomes. these characteristics will enhance students’ execution of patient safety, consequently diminishing the likelihood of patient safety incidents.6 averted patient safety incidents will strengthen the quality of recognition services.23 the findings of this study are pertinent to research indicating that students’ determining factors include interests, learning motivation, learning styles, and critical thinking, all of which are associated with attaining student competence.5 however, a limitation of this study is that it only examined the factors determining students’ achievements in patient safety competencies. future research should broaden its scope to include factors beyond those related to students, such as the influences of clinical educators and the learning facilities. critical thinking skills are crucial for healthcare professionals as they directly influence patient safety, particularly in critical situations. nurses, especially those in intensive care units, need to develop strong critical thinking abilities to manage complex patient care scenarios effectively. nursing programs emphasize the development of critical thinking as a core competency, which is necessary for accreditation and ensuring high-quality patient care. this focus on critical thinking is reflected in the curriculum design and assessment methods used in healthcare education.24 engaging students in interactive and innovative learning experiences, such as simulations and case-based learning, enhances their critical thinking skills and prepares them for realworld clinical challenges; these methods help students apply theoretical knowledge to practical scenarios, improving their decisionmaking and problem-solving abilities.25,26 interest and critical thinking in students significantly predict patient safety goals because they directly impact students’ capacity to make sound clinical decisions, prevent errors, and ensure high-quality patient care. educational programs that prioritize the development of these skills through interactive and innovative learning experiences are essential for preparing health care professionals to meet patient safety standards. implications nurses should participate in ongoing professional development to improve their patient safety skills. this includes staying current with the latest information on patient safety and actively engaging in training that enhances critical thinking and problemsolving abilities. therefore, experienced nurses should mentor nursing students and emphasize the importance of interest, motivation, and critical thinking in patient safety. by sharing their experiences and strategies, they can help students understand and effectively apply patient safety principles. nurses should actively seek feedback and reflect on their practices to identify areas of improvement. by fostering a culture of safety and promoting an environment in which patient safety is a priority, they contribute to reducing safety incidents. this research has implications for nursing students, who should strive to maintain a high cumulative gpa, as it correlates with better patient safety competencies. this means dedicating adequate time and effort to their studies and seeking help when necessary to achieve academic excellence. students should actively engage in their learning process by developing a strong interest in patient safety and maintaining high motivation levels. this includes participating in extracurricular activities and seeking opportunities for practical experience. collaboration among healthcare institutions, educational organizations, and community groups can foster initiatives aimed at improving nursing education and patient safety. this may include joint programs, funding for research, and public awareness campaigns. limitations this study focused solely on student characteristics, excluding potentially influential factors such as clinical educators, learning facilities, and educational methods. future research should conduct longitudinal studies to examine causal relationships, explore additional influencing factors, and evaluate interventions designed to enhance student motivation, interest, and critical thinking related to patient safety competencies. conclusions this study emphasizes the critical role of student characteristics – such as academic performance, motivation, critical thinking skills, and patient safety knowledge – in achieving patient safety competencies, suggesting that nursing education should prioritize these areas during clinical training to enhance quality of care, prevent safety incidents, and foster a healthcare culture of shared responsibility among competent professionals, thereby improving patient outcomes. references 1. ratrout s al. perception of patient safety incident reporting system among healthcare workers in palestinian government hospital. j med chem sci 2023;6:1953-69. 2. taji m, putra kr, ismail ddsl. strategies to improving patient safety in hospitals. healthc low-resource settings 2023;11:11181. 3. kong ln, zhu wf, he s, et al. attitudes towards patient safety culture among postgraduate nursing students in china: a crosssectional study. nurse educ pract 2019;38:1-6. 4. solomon a, gudayu t. students’ assessment on the patient safety education: the case of college of medicine and health sciences, university of gondar. iran j nurs midwifery res 2020;25:296-303. 5. hanifah h, susanti s, adji as. perilaku dan karateristik peserta didik berdasarkan tujuan pembelajaran. manazhim 2020;2:105-17. 6. dauphinee wd. educators must consider patient outcomes when assessing the impact of clinical training. med educ 2012;46:13-20. 7. fırat kılıç h, cevheroğlu s. patient safety competencies of nursing students. nurse educ today 2023;121. 8. torkaman m, sabzi a, farokhzadian j. the effect of patient safety education on undergraduate nursing students’ patient safety competencies. community health equity res policy 2022;42:219-24. 9. supriyanto, hamid ays, rosyada d, et al. nurse’s competence in supporting the spiritual-religious needs of patients in indonesia. indian j public heal res dev 2019;10:604-8. 10. satrya c, susilowati ih, sunukanto ws. patient safety and special issue pathways of change [page 146] [healthcare in low-resource settings 2025;13(s1):13515] quality of care in indonesia: challenges and opportunities for professional health resources from the asean economic community. indian j public heal res dev 2017;8. 11. dhamati i, rachman t, ardian m, et al. development of a patient safety-training program for health workers in indonesia: perspectives of health workers and hospital stakeholders inge. malaysian j med heal sci 2022;17:183-8. 12. sari dwp, arief ys, ahsan. the relationship between clinical education and nursing students’ patient. healthc low-resource settings 2024;12:11969. 13. neri ra, lestari y, yetti h. analisis pelaksanaan sasaran keselamatan pasien di rawat inap rumah sakit umum daerah padang pariaman. j kesehat andalas 2018;7:48. 14. sari dwp, sari rk, qusuma if. peran pembimbing klinik dan pelaksanaan keselamatan pasien oleh mahasiswa profesi ners. unissula nursing conference call for paper & national conference. j unissula 2018;1:138-44. 15. sari dwp. potret pelaksanaan patient safety mahasiswa profesi ners. nurscope j penelit dan pemikir ilm keperawatan 2015;1:1. 16. codier e, odell e. measured emotional intelligence ability and grade point average in nursing students. nurse educ today 2014;34:608-12. 17. bojović i, antonijević r. students’ motivation to learn in primary school. open j psychol res 2017;1:11-20. 18. feronica v, syafrizal m, imran s. hubungan minat dan motivasi menjadi perawat dengan prestasi belajar pada mahasiswa keperawatan. jurnal ilmiah ners indonesia 2021;1:113-20. 19. atma ba, azahra ff, mustadi a. teaching style, learning motivation, and learning achievement: do they have significant and positive relationships? j prima edukasia 2021;9:23-31. 20. steinmayr r, weidinger af, schwinger m, spinath b. the importance of students’ motivation for their academic achievement-replicating and extending previous findings. front psychol 2019;10. 21. an gj, yoo ms. critical thinking and learning styles of nursing students at the baccalaureate nursing program in korea. contemp nurse 2008;29:100-9. 22. wu xv, enskär k, pua lh, et al. clinical nurse leaders’ and academics’ perspectives in clinical assessment of final-year nursing students: a qualitative study. nurs heal sci 2017;19:287-93. 23. harianto jw, nursalam, dewi ys. keselamatan pasien berbasis knowledge management seci sebagai peningkatan kompetensi mahasiswa keperawatan. j ners 2015;10:324-32. 24. ali-abadi t, babamohamadi h, nobahar m. critical thinking skills in intensive care and medical-surgical nurses and their explaining factors. nurse educ pract 2020;45:102783. 25. chavez-maisterra i, corona-pantoja ac, madrigal-gómez le, et al. student engagement in patient safety and healthcare quality improvement: a brief educational approach. healthc 2024;12. 26. lee sy, chang cy. nursing management of the critical thinking and care quality of icu nurses: a cross-sectional study. j nurs manag 2022;30:2889-96. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13515] [page 147] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13068 development of the "mother give me exclusive breastfeeding" e-booklet based on android as a nutrition educational media septa katmawanti,1 farah paramita,1 agung kurniawan,1 siti khuzaimah a. sharoni,2 rosuzeita fauzi,2 dea aflah samah,1 yassinda thasia audina,1 muhammad irfan syahputra,1 reza pahlevi,1 intan gumilang pratiwi3 1department of public health, faculty of sport science, universitas negeri malang, malang, east java, indonesia; 2centre for nursing studies, faculty of health sciences, universiti teknologi mara, selangor, puncak alam, malaysia; 3department of midwifery, politeknik kesehatan negeri mataram, mataram, west nusa tenggara, indonesia abstract undernutrition is one of the most serious and least addressed challenges worldwide. the significant relationship between this condition and children’s feeding practices makes exclusive breastfeeding an early and appropriate intervention. therefore, this study aimed to develop health promotion media in the form of an android-based booklet titled “mother give me exclusive breastfeeding”. the development method model adopted was addie (analysis, design, development, implementation, evaluation). a total of 20 mothers of toddlers participated in product feasibility testing. the results showed that the product had an average total percentage of 80%, signifying high suitability for usage. the study subjects rated the e-booklet very positively, showing great enthusiasm for engaging with the content presented in the “mother give me exclusive breastfeeding” e-booklet. in conclusion, further study was needed to maximize the role of this product in enhancing mothers’ understanding of exclusive breastfeeding and ensuring access to facilities such as gadgets, technology devices, and internet or wifi networks. introduction undernutrition is a leading cause of death among children under the age of 5, affecting nearly half of these young lives globally. in addition, lowand middle-income countries are particularly vulnerable to this condition.1 undernutrition is divided into four forms, namely wasting, stunted, underweight, and vitamin and mineral deficiencies. according to global statistics from 2020, 149, 45, and 38.9 million children under 5 are estimated to be stunted (too short for age), wasted (too thin for height), and overweight or obese, respectively.1,2 the world bank and nutrition report in 2019 stated that undernutrition is one of the most serious and least addressed challenges worldwide.3 the significant relationship between this condition and children’s feeding practices makes exclusive breastfeeding an early and effective combating approach.4 this is in accordance with the 2030 sustainable development goals (sdgs), where breastfeeding is considered the first step towards ensuring a healthy and prosperous life.5 numerous mothers around the world still do not adhere to exclusive breastfeeding practices. according to data from unicef in 2021, only 65% of mothers worldwide provide exclusive breastfeeding to babies for up to 2 years, with a mere 48% initiating the practices.6 in indonesia, the 2018 national basic health research report, known as riskesdas, showed that out of 94% of mothers with children under 2 years old, only 37.7% practiced exclusive breastfeeding. the province with the lowest coverage was west nusa tenggara (ntb), standing at 20.3%. while there has been progress, with ntb reporting a coverage rate of 81.8% in 2020, certain districts such as mataram city still fall behind the national target of 80%, recording only a 68.2% coverage rate in the same year.7,8 low coverage of exclusive breastfeeding in the mataram area is caused by various factors, including sociodemographic, preand postnatal, and psychosocial factors. sociodemographic factors comprise age, occupation, education, knowledge, socioeconomic status, and place of residence. additionally, preand postnatal factors such as parietal and type of delivery contribute to this issue. psychosocial factors, including family support, health worker support, exposure to formula milk, and attitudes, also influence breastfeeding practices.9,10 an influence of psychosocial factors is the misconception among some mothers that formula milk is better than exclusive breastfeeding. this misconception may arise due to a lack of understanding of proper breastfeeding techniques, limited access to counseling services, inadequate family and medical support, and insufficient education on breastfeeding. education level, as a sociodemographic factor, is particularly significant. lower levels of education among mothers often correlate with the levels of breastfeeding, thereby hindering the achievement of exclusive breastfeeding at the age of 0 to 6 months.11 nutrition education can be provided to help increase knowledge and awareness of the importance and benefits of exclusive breastfeeding, enhancing the practices in the mataram area. according to who in the book the health aspects of food and nutrition, nutrition education is a planned effort to improve nutritional status through changes in behavior related to food production, preparation, food distribution in the family, prevention of dietary diseases, and child care.12 in essence, nutrition educators serve as a multidimensional process to change the behavior of people related to diet and healthy living in everyday life.13 significance for public health the 2030 sustainable development goals underscore the significance of breastfeeding as a pivotal step toward attaining a robust and prosperous life. implementing e-books can facilitate convenient access to information and enrich understanding of exclusive breastfeeding through electronic devices, advancing cognitive function and comprehension. consequently, this may precipitate favourable behavioural shifts, particularly among breastfeeding mothers, within their daily routines. [page 148] [healthcare in low-resource settings 2024;12(s1):13068] non -co mmerc ial us e o nly nutrition education can be provided through educational media, including e-booklets. e-books, or electronic books, are media used as a learning environment with applications containing multimedia databases of instructional resources.14 the increasing number of activities related to gadgets and the user-friendly nature of these devices enhance their use as a breakthrough medium for exclusive breastfeeding nutrition education. the introduction of ebooklets can significantly facilitate mothers’ access to educational material and increase knowledge related to exclusive breastfeeding anytime and anywhere. furthermore, e-booklets offer several advantages, including search and cross-reference functions, hypertext links, bookmarks, explanations, highlighting, multimedia objects, and interactive tools. these features render the material exceptionally beneficial for increasing the knowledge of mothers through the use of gadgets or smartphones.15 android-based e-booklet with visual technology is a breakthrough that needs to be developed as a medium of nutrition education for breastfeeding mothers in mataram. this medium can stimulate more optimal brain performance, thereby enhancing comprehension and fostering positive behavioral changes in everyday life. furthermore, the resulting long-term impact of the initiative is an increase in the coverage of exclusive breastfeeding in the city of mataram, ntb. therefore, it is crucial to conduct a study titled “ development of the “mother give me exclusive breastfeeding” e-booklet based on android as a nutrition educational media”. materials and methods in this study, the development method adopted adhered to the addie model, a learning design based on a systems approach. addie stands for analysis, design, development (or production), implementation (or delivery), and evaluation. this model is versatile and applicable to diverse forms of product development including models, learning strategies, methods, media, and teaching materials. utilizing the addie model streamlines and enhances the efficiency and effectiveness of product development processes.16 robert maribe branch’s review of the book “instructional design: the addie approach” describes the activities conducted at each stage.17 analysis in the analysis phase, instructional problems, instructional goals, and learning objectives were defined. this phase also identified the learning environment as well as current knowledge and skills. furthermore, it was the initial stage where the problem of exclusive breastfeeding coverage in indonesia was analyzed. based on the results of the literature study, the lowest exclusive breastfeeding coverage observed was in the west nusa tenggara region. in addition to analyzing the problems to be studied, a solution analysis was also conducted in media development. the analysis showed that booklet media was developed from digital form into an e-booklet related to exclusive breastfeeding. design during the design phase, the focus shifts to defining targets, selecting assessment instruments, determining content to be developed, and analyzing the material to be presented along with the choice of media to be used. at this stage, the framework for the ebooklet framework to be developed was discussed, comprising aspects such as the title, colors used, content structure, and digital media functionalities. development the creation and incorporation of the designed content assets were conducted in this phase. subsequently, the programmer worked to integrate the necessary technology. implementation in this phase, the product series was tested on several groups of people by assessing the feasibility and effectiveness using a questionnaire. subjects for evaluation were selected through the probability sampling technique, ensuring an equal opportunity for each element (member) of the population to be included as a sample member. in this study, respondents were selected using consecutive sampling techniques, with inclusion criteria specifying mothers with children aged 6-60 months, willingness to participate, and proficiency in reading and writing. the sample size comprised 20 mothers selected from 2 health centers with the lowest exclusive breastfeeding coverage, namely ampenan and cakranegara health centers in mataram city.18 evaluation the evaluation phase is used to provide opportunities for feedback from users through the analysis of administered questionnaires. the study conducted is in the form of quantitative data analysis. the results of the assessment in the validation and trial process, comprising statements such as not good, less good, good, and very good were converted into quantitative data with a score of 1 to 4. product data analysis was conducted by validators using a likert scale. the criteria for likert scale assessment are presented in table 1. descriptive data analysis was adopted to convert quantitative data into qualitative data. after obtaining the score, the feasibility percentage was calculated and interpreted in line with the theory applied by suharsimi arikunto in 2013.19 p= f n x 100% where: p = percentage number f = score obtained n = overall score after determining the percentage, the feasibility of the media can be evaluated based on the following criteria in table 2. 4th international nursing and health sciences symposium table 1. likert scale assessment. alternative answer score very good 4 good 3 not good 2 not good at all 1 table 2. likert scale assessment. percentage criteria 76% < skor ≤ 100% excellent 51% < skor ≤ 75,% good to go with minor revisions 26% < skor ≤ 50% promising with major revisions 0% skor ≤ 25% unsuitable for use [healthcare in low-resource settings 2024;12(s1):13068] [page 149] non -co mmerc ial us e o nly a feasibility analysis was conducted on each aspect of the assessment, categorizing results into not feasible, less feasible, feasible, and very feasible. additionally, the need for revisions was determined based on feedback from material experts, media experts, and respondents engaged in the e-booklet trial group at the cakranegara health center and ampenan health center areas of mataram city. the study adhered to the code of ethics, designated by ethics number 421/pp2mkei/ii/2021. results and discussion respondent characteristics the sample size of respondents in this study amounted to 20 mothers with children aged 0-3 years. furthermore, information on the characteristics of respondents, including age, latest education, and occupation, are presented in table 3. the distribution of respondents according to the characteristics showed that the majority of mothers fell within the age range of 25 35 (60%). age played a significant role in readiness, comprising physical, mental, and social aspects. maternal age also influences maternal health throughout pregnancy, childbirth, postpartum development, and child care. mothers over 25 years of age and above have more experience and mental availability to care for children. however, hormone production decreases at age 30, which can interfere with lactation. mothers over 30 years old have more children, and their cumulative experience may impact current breastfeeding practices.20,21 based on the level of education and the characteristics of respondents, the majority had at least a high school education (50%). it is important to note that mothers’ education level influences nutritional status. higher levels of maternal education often facilitate greater receptiveness to change and adaptation. it enhances understanding about nutrition and elevates attention to children’s nutritional needs.21–23 in addition to education level, employment status can also determine the level of exclusive breastfeeding, with 75% of respondents being unemployed or homemakers. work will provide experience and influence a person’s knowledge. mothers who are busy outside the home and interacting with many people will have broader knowledge than those spending more time at home. this is because there are many relationships and opportunities to obtain wider information.24,25 with the rapid development of technology, innovation is needed for easy understanding of information and knowledge. an android-based e-booklet product with visual technology was introduced as a medium for nutritional education on exclusive breastfeeding in the working area of mataram city, ntb. with the majority of respondents being homemakers or not employed, the flexibility of accessing e-booklet anytime and anywhere is particularly advantageous. product feasibility trial results the results of the feasibility trial of android-based e-booklet products with visual technology as a medium for nutrition education on exclusive breastfeeding in the working area of mataram city ntb are presented in table 4. 4th international nursing and health sciences symposium [page 150] [healthcare in low-resource settings 2024;12(s1):13068] table 3. respondent chareacteristics. respondent chareacteristics total presentage (%) age ≥ 24 years 4 20 25-35 years 12 60 ≤ 36 years 4 20 last edu not in school 1 5 elementary 2 10 junior high school 2 10 senior high school 10 50 diploma/ bachelor degree 3 15 no information 2 10 work employed 5 25 not working/housewife 15 75 table 4. product feasibility results. no question average (%) category 1 the design on the cover of e-booklet is attractive. 78 excellent 2 the typeface on the cover of e-booklet is attractive. 78 excellent 3 the typeface on the content of e-booklet is attractive 78 excellent 4 the font size on the content of e-booklet is easy to read. 79 excellent 5 the color on e-booklet is attractive. 83 excellent 6 the font color on the cover is attractive. 81 excellent 7 the font color on the content of e-booklet is attractive. 81 excellent 8 the picture on e-booklet is clear. 89 excellent 9 images on the content of e-booklet help in understanding the material. 81 excellent 10 images on the content of e-booklet help in remembering the material. 81 excellent 11 the material in e-booklet is easy to understand. 84 excellent 12 the material in e-booklet is easy to remember. 79 excellent 13 the message contained in e-booklet is easy to apply. 76 excellent 14 the message contained in e-booklet is easy to remember. 76 excellent 15 the material in e-booklet is complete. 79 excellent 16 the material in e-booklet is presented sequentially. 84 excellent total 80 excellent non -co mmerc ial us e o nly the assessment results of 20 respondents who had filled out a questionnaire as a feasibility test stated that the e-booklet was “very suitable for use” (80%). this positive reception was a result of the meticulous attention paid to various aspects of the media design, aimed at enhancing readers’ comprehension and practical application of the information in everyday life. these aspects include the design of the product cover, font selection, color scheme, image clarity, and understanding of the material provided. education in health promotion interventions is an approach commonly used to provide knowledge and information as well as enhance the development of individuals/groups to make informed choices regarding certain health-related behaviors. the 3 aspects of learning in health education activities include cognitive (information and understanding), affective (attitudes and emotions), and behavioral (skills). the integration of online media in the learning process facilitates interaction among users, enabling two-way communication even across different locations.26 the study results showed that education using technology is much more effective in providing knowledge about health. this was also conveyed by goncalves in 2019, where the use of technology in increasing knowledge and attitudes had a much more significant increase compared to conventional media.27 technology-based health education is also important for breastfeeding mothers. according to a study conducted by tama 2020, breastfeeding mothers tend to refrain from receiving information about appropriate and accurate practices, which comprised the success rate of early initiation.28 several studies have been conducted on developing educational media for managing exclusive breastfeeding. katmawanti’s study in 2021 stated that the emo demo method effectively increased the knowledge and attitudes of mothers. the recommendations of this study include implementing other educational media to increase the knowledge and attitudes of mothers who do not offer exclusive breastfeeding.29 katmawanti also conducted investigations on measuring knowledge and attitudes regarding exclusive breastfeeding in 2021 in batu city, east java. the results show that the booklet can increase the knowledge and attitudes of mothers who have not previously provided the intervention. this study is an innovation from several previous reports using technology-based education yektiastuti in 2016 explained that android users could improve cognitive, metacognitive, and socio-cultural abilities.30 conclusions in conclusion, e-booklet media was suitable for use and implementation as a nutritional education medium to increase coverage of exclusive breastfeeding. based on suggestions, the limited gadget facilities and internet networks owned by respondents in the local area caused the need for further development related to ebooks. additionally, further study was needed to maximize the role of this product in the comprehension of exclusive breastfeeding, such as testing the effectiveness of the level of knowledge and attitudes before and after the provision of e-booklet intervention. this report can be used as a reference for health practitioners in developing health education media regarding exclusive breastfeeding. with the development of an android-based e-booklet product with visual technology as a media for nutritional education in the working area of mataram city, ntb, the coverage of exclusive breastfeeding was expected to increase. references 1. nounkeu cd, dharod jm. integrated approach in addressing undernutrition in developing countries: a scoping review of integrated water access, sanitation, and hygiene (wash) + nutrition interventions. curr dev nutr 2021;5:1–12. 2. world health organization (who). malnutrition [internet]. word health organization. 2021 [cited 2021 jan 13]. available from: https://www.who.int/news-room/fact-sheets/detail/malnutrition 3. the world bank. the world bank and nutrition [internet]. the world bank. 2022 [cited 2022 dec 13]. available from: https://www.worldbank.org/en/topic/nutrition/overview 4. unicef (united nations children’s fund). global nutrition report 2020: action on equity to end malnutrition [internet]. unicef.org. 2020 [cited 2021 jan 14]. available from: 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13068] [page 151] correspondence: septa katmawanti, department of public health, faculty of sport science, universitas negeri malang, jl. semarang no.5, sumbersari, kec. lowokwaru, malang, east java, indonesia. tel.: +623413301130 fax: +62341551921. e-mail: septakatma.fik@um.ac.id key words: breastfeeding; e-booklet; undernutrition contributions: sk is the person in charge, director, and determinant of the concept of study and article writing, fp is the coordinator of data collection, ak is the coordinator of instruments and data analysis, skas, and rf act as consultants and reviewers in the study and article writing, das, yta, mis, rp, and igp as a team of data collectors, analyzers and article writing. conflict of interest: the authors declare no conflict of interest. funding: the authors are grateful to the lppm universitas negeri malang, for supporting the entire course of study both in terms of funds and administration. ethics approval: the study adhered to the code of ethics, designated by ethics number 421/pp2mkei/ii/2021. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 13-15 october 2023, universitas brawijaya, malang, indonesia. acknowledgment: the authors are grateful to the universitas negeri malang for providing the opportunity to conduct the entire series of studies. the authors are also thankful to the mataram city health office, ampenan health center, and cakranegara health center, for participating in this study. received: 5 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13068 doi:10.4081/hls.2024.13068 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher.non -co mmerc ial us e o nly https://data.unicef.org/resources/global-nutrition-report-2020/ 5. united nations. the 17 goals | sustainable development [internet]. 2023 [cited 2023 aug 14]. available from: https://sdgs.un.org/goals. 6. unicef (united nations children’s fund). too few children benefit from recommended breastfeeding practices [internet]. unicef.org. 2021 [cited 2021 jan 14]. available from: https://data.unicef.org/topic/nutrition/breastfeeding/ 7. ntb provincial health office. percentage of babies who receive imd and exclusive breastfeeding in ntb province | one data ntb [internet]. 2022 [cited 2023 aug 14]. available from: https://data.ntbprov.go.id/dataset/persentase-bayi-yangmendapat-imd-dan-pemberian-asi-eksklusif-di-provinsi-ntb 8. rahmadhona d, affarah ws, wiguna pa, reditya nm. factors influencing the success of exclusive breastfeeding in mataram city. unram med j 2017;6:12–6. 9. febriyanti h. factors related to exclusive breastfeeding in health workers who have babies in pringsewu regency in 2017. midwifery j j kebidanan um mataram 2018;3:38. 10. ampu mn. the relationship between mother’s education level and exclusive breastfeeding in infants at neomuti health center in 2018. intelektif j ekon sos hum 2018;2:9– 19. 11. world health organization. the health aspects of food and nutrition. manila:word health organization. 1979. 12. ministry of health of the republic of indonesia. nutrition counseling. jakarta: center for health human resources education, ministry of health of the republic of indonesia; 2018. 13. danardono a, rudibyani rb, emmawaty sofia es. the effectiveness of e-book media to improve students’ metacognition and concept mastery. j pendidik dan pembelajaran kim. 2019;8:495–508. 14. nfh a, rahman es. effectiveness of the implementation of interactive e-books for basic programming subjects for vocational high school students. jurnal media elektrik 2020;17:14–8. 15. tanjung mr. multimedia application development for introduction and learning of origami with the addie approach. 2014 [cited 2023 aug 14]; available from: https://www.academia.edu/9570475/pengembangan_aplikasi _multimedia_pengenalan_dan_pembelajaran_origami_deng an_pendekatan_addie 16. branch rm. instructional design: the addie approach [internet]. boston, ma: springer us; 2009. 17. west nusa tenggara health office. percentage of babies who receive imd and exclusive breastfeeding in ntb province [internet]. one data ntb. 2020 [cited 2022 jan 14]. available from: https://data.ntbprov.go.id/dataset/persentase-bayi-yangmendapat-imd-dan-pemberian-asi-eksklusif-di-provinsi-ntb 18. arikunto s. research procedures a practical approach. jakarta: rineka cipta; 2013; 19. fadlliyyah ur. determinant factors influencing exclusive breastfeeding in indonesia. ikesma 2019;15:51. 20. ulfah hr, nugroho fs. the relationship between age, occupation and maternal education with exclusive breastfeeding. intan husada j ilm keperawatan 2020;8:9–18. 21. afriyani r, savitri i, sa’adah n. the influence of exclusive breastfeeding at bpm maimunah palembang. j kesehat 2018;9:331–5. 22. rani h, yunus m, katmawanti s, wardani he. systematic literature review determinants of exclusive breastfeeding in indonesia. sport sci heal 2022;4:376–94. 23. katmawanti s, paramita f, kurniawan a, et al. the effects of exclusive breastfeeding booklets on mothers’ knowledge in providing exclusive breastfeeding in mataram city, indonesia. healthc low-resour s 2023;11:11211. 24. ramli r. the relationship between knowledge and maternal employment status with exclusive breastfeeding in sidotopo village. j promkes indones j heal promot heal educ. 2020;8:36–46. 25. sembada sd, pratomo h, fauziah i, et al. utilization of online media as a means of health education for adolescents: a literature review. prepotif j kesehat masy 2022;6:564–74. 26. de sousa gonçalves m, celedônio rf, targino mb, et al. construção e validação de cartilha educativa para promoção da alimentação saudável entre pacientes diabéticos. rev bras em promoção da saúde 2019;32. 27. tama td, astutik e, katmawanti s, reuwpassa jo. birth patterns and delayed breastfeeding initiation in indonesia. j prev med public heal 2020;53:465. 28. supriyadi, katmawanti s, arviolika y, samah da. development of educational media for type ii diabetes mellitus patients in the work area of kedundung health center, mojokerto city. kne life sciences 2021;32–42. 29. yektyastuti r, ikhsan j. developing android-based instructional media of solubility to improve academic performance of high school students. j inov pendidik ipa 2016;2:88–99. 30. sugiyono d. educational research methods quantitative, qualitative and r&d approaches. bandung:alfabeta; 2013. 4th international nursing and health sciences symposium [page 152] [healthcare in low-resource settings 2024;12(s1):13068] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13070 an integrative literature review on clinical decision-making of novice nurses for disaster management in the emergency room rystika angga sari,1 retno lestari,2 yati sri hayati2 1nursing master program, faculty of health sciences, universitas brawijaya, malang, east java; 2department of nursing, faculty of health sciences, universitas brawijaya, malang, east java, indonesia abstract novice nurses play a workflow part in responsibility among an overwhelming of patient. this emphasizes the need for nurses to have comprehensive decision-making skills, especially in disaster management. however, in practice, clinical decision-making remains a challenging issue for novice nurses working in the emergency room (er). this review was conducted to synthesize the strategy that novice nurses need to do in clinical decision-making in the er during a disaster. this review used an integrative literature review approach to identify (n=16) relevant scientific articles. six online databases (sciencedirect, proquest, sage journals, pubmed, willey library, and ebsco) were utilized to identify articles published between 2013 and 2023. the gathered articles were selected using the prisma method by removing duplicate articles and those that did not align with the review’s objectives. the prisma flowchart was used to illustrate the evidence search process. out of a total of 2,264 identified articles, sixteen articles are relevant for review. the review revealed that clinical decision-making requires careful consideration in several aspects which focused on determining the priorities of triage, assessment, diagnostic skills, and communication skills in teamwork during a disaster in the er. this review provides evidence that the accuracy of clinical decision-making is a major influence on patient outcomes during disaster management. in conclusion, comprehensive training and more education for novice nurses about disaster precision nursing in the future are needed to reduce errors in decision-making. introduction given the high number of disaster victims in aceh in 2004, indonesia is now labeled as the third most disaster-prone country out of 192 countries by the world risk index.1 highlighting the experience of dealing with disasters, disaster management often intersects with emergency response management, which involves the emergency room (er) as the primary gateway for complex initial care.2 according to wang et al, emergency response (er) management can be defined as specialized and technical medical efforts aim at rescuing disaster victims.3 furthermore, research conducted by al harthi et al revealed that disaster management in the er should involve all stages of disaster response, not just emergency response.4 therefore, er disaster management becomes a high-standard emergency care provider. in urgent situations with a high number of casualties, er nurses play a central role in saving patients during disasters, including triage, assessment, management, and treatment.5 er nurses, as substantial components, should also be involved in all stages of disaster management, such as risk analysis, pre-disaster planning, crisis response, and risk mitigation during disasters.6 novice nurse play a workflow part in responsibility among an overwhelming of patient. to achieve holistic disaster care, nurses are now emphasized in disaster preparedness management, which refers to optimizing response and recovery efforts that significantly impact patient care outcomes.7 this underscores the need for good teamwork support among all nurses to achieve a unified response in disaster management. interestingly, some countries currently lack expert nurses in disaster response, leading to novice nurses being placed in the er.8 furthermore, research by fernandez-basanta revealed that during disasters, there is often an imbalance between the number of healthcare workers and victims, leading to novice nurses participating in disaster response.9 according to geekiyanage et al, novice nurses can be defined as individuals who have recently graduated and do not have adequate practical experience to apply their cognitive and psychomotor skills to new situations.10 furthermore, research by perpina et al explained more broadly that someone working for less than five years can be categorized as a novice nurse.11 during the transition to clinical practice, novice nurses often face challenging situations that can lead to barriers such as failure to identify patients, assessment errors, and decision-making errors.12 the potential for errors compared to experienced nurses will always be an issue. moreover, in emergency disaster situations, novice nurses face transition challenges that can result in emotional pressure, self-concept, high risk, and decision-making doubts.13 adequately prepared nurses will reduce vulnerability to errors in clinical decision-making. however, emergency response implementation is not limited to that; understanding decision-making challenges and the potential for errors must be identified. so far, the decision-making process for novice nurses tends to be hampered in making accurate assessments due to time pressure and case complexity.14 a combination and utilization of resources and tools by nurses to achieve common goals, including decision-making in emergency disaster response in the er.15 meanwhile, in the ncube study, decision-making in [healthcare in low-resource settings 2024;12(s1):13070] [page 153] significance for public health novice nurse need strategy to do in clinical decision-making for disaster management in the er, especially on comprehensive skill in their condition. clinical decision-making skill in crowded conditions is an effort to save more lives of disaster victims. so far, the decision-making process for novice nurses tends to be hampered in making accurate assessments due to time pressure and case complexity. clinical decision-making strategy might help novice nurse in avoiding assessment error and enhancing patient outcome. non -co mmerc ial us e o nly disasters is an effort to save more lives of disaster victims.16 in crowded conditions, the urgency of triage accuracy, team communication skills, proper assessment, and diagnostic skills determine the best outcome of decision-making interventions.17 the need for comprehensive decision-making skills for novice nurses should be considered. interestingly, there are currently no specific guidelines for novice nurses designed for clear clinical decision-making during disasters to reduce errors. therefore, this review was conducted to synthesize the strategies novice nurses need to employ in clinical decision-making in the er during disasters. materials and methods the integrative literature review analysis method was used in the development of this study. this method allows the authors to organize, synthesize, and report the results of published articles with the aim and scope of decision-making for novice nurses in disaster management in the er. articles were systematically selected using the guidelines from the preferred reporting items for systematic reviews and meta-analyses for integrative review (prisma method).18 this methodology involves five review steps, as outlined, including formulating research questions, searching and identifying relevant studies, selecting relevant studies, mapping and analyzing data, and composing a summary of the results, which are then interpreted in this integrative review. this review was conducted by searching articles in six online databases: sciencedirect, proquest, sage journals, pubmed, wiley library, and ebsco, published between 2013 and 2023. this selection used predetermined inclusion and exclusion criteria. article searches were performed using the keywords “and and or” to combine words or with the use of quotation marks (“) for similar words. the keywords used was “novice nurse and clinical decision making and er or ed” or (“disaster decision makingnovice nurse and er” or “decision making-novice nurse”) and (disaster management or disaster decision making) and (newly registered nurse). the inclusion criteria for this integrative review were as follows: (1) involving novice or newly registered nurses, (2) articles are published in international journals, (3) journal publication years are between 2013 and 2023, (4) original research articles, (5) articles written in english, and (6) articles discussing the decisionmaking of novice nurses during disaster management in the er. the exclusion criteria were (1) books, modules, undergraduate theses, master’s theses, dissertations, and scientific papers, and (2) articles that could not be accessed in full. selecting articles using keywords in six online databases resulted in (n=16) articles. this review explored titles, abstracts, and the availability of full texts that met the inclusion and exclusion criteria. the selected articles align with the objectives of this review. the article selection process was summarized by the prisma 2020 guideline (figure 1). quality appraisal article quality assessment can improve the quality of integrative literature reviews. there are several quality assessment tools used according to the design of each study; the centre of evidencebased medicine (cebm) appraisal tools was used to assess the quality of cross-sectional studies, with a list of 12 questions; meanwhile, in qualitative studies, the critical appraisal skill program (casp) was used in this review consisting of 10 questions; to 4th international nursing and health sciences symposium [page 154] [healthcare in low-resource settings 2024;12(s1):13070] figure 1. selection articles using prisma. non -co mmerc ial us e o nly assess experimental studies, this review uses the joanna briggs institute (jbi) critical appraisal tool which consists of 9 questions. overall, the quality of all research articles included in this review was rated as moderate, as the studies demonstrated significant and strong results. articles of quality assessment is summarized in (supplementary materials, table 1, 2, and 3). data extraction and synthesis the data mapping process evolved during the review as the author considered specific data to be extracted to help answer the questions of this review. data mapping was focused on the decision-making of novice nurses during emergencies in the er. then, the data that came closest to answering the questions were transcribed into a table containing (author, years, country, study objective, research design, instrument used, and results). data extraction of selected articles is summarized in (supplementary materials, table 4). results and discussion the search on six online databases yielded 2,264 articles. subsequently, the authors screened articles published from 2013 to 2023 and removed duplicate data, resulting in 2,162 articles. the authors then selected 81 articles after excluding those with irrelevant titles and abstracts that did not align with the research objectives. out of these articles, 42 articles were excluded based on criteria such as not discussing decision-making among emergency room nurses during disaster management, participants not being emergency room nurses, articles in languages other than english, and not being original research. after assessing their suitability, 16 articles were included in this scoping review for discussion. the articles reviewed originated from iran (n=4), sweden (n=2), turkey (n=1), saudi arabia (n=2), indonesia (n=2), southern california (n=1), switzerland (n=1), new south wales (n=1), bangladesh (n=1), and south korea (n=1). participants in this study were predominantly novice nurses working in the emergency room with less than 5 years of work experience. a small portion consisted of experienced emergency room nurses who had worked for more than 5 years. all the research articles were conducted in the hospital emergency room environment. furthermore, this review generated the following key themes regarding decision-making which are summarized in (table 5). the theme of this integrative review discusses clinical decision-making in novice nurses in managing disasters in the er. in this regard, decision-making is broken down into five main aspects most needed in disaster management, including patient physical assessment, disaster triage priorities, diagnostic skills, team communication skills, and emergency care. decision-making in the physical assessment novice nurses have a complex role to play. they must be proficient in clinical physical assessment while responding to improve outcomes for affected populations.19 nursing decision-making regarding the detection and response to a disaster event, perhaps further recognizing ed nurses as first responders. however, the results of a delphi study showed that novice nurses’ knowledge of disaster management plans and competence regarding the signs and symptoms of various conditions at an early stage were considered important for detecting and caring for victims of rare events. as novice nurses, these findings appear to reflect the assessment that a key factor in successful disaster patient care is basic physical assessment knowledge.20 decision-making in the physical assessment and care aspects for disaster victims needs to be adjusted to accommodate a sudden influx of patients.21 decision making in this case has several processes, namely i) fast and accurate physical assessment; ii) assessment of exacerbation of the disease due to exposure to the agent; iii) assessment of local and global infections. rapid assessment or assessment of patients in accordance with standard principles of first aid procedures can reflect complex decision making. novice nurses must be skilled in analyzing the condition of incoming patients, synthesizing and evaluating interventions accurately.22 novice nurses must comply with regulations in disaster situations and take them into account.23 decision making is a challenge for novice nurses to provide nursing care to patients and be responsible for their own decisions.24 nurses need to assess local infection, so they can quickly make the right care decisions. assessment of disease exacerbations due to exposure to agents (e.g., toxic chemicals, radiation, or infectious agents) is an important clinical process in taking care for patients who may have been exposed to such agents.25 evaluation of disease exacerbations due to exposure to agents requires various stages and considerations for decision making. speed in assessment and treatment actions can be critical in cases of exposure to hazardous agents. furthermore, the assessment of local and global infections involves assessing infections that affect individuals or populations at a local or global level.26 nurses need to identify local infections, so they can quickly make appropriate treatment decisions. decision-making in the triage priorities having disaster triage decision-making skills among all healthcare providers is critical to improving patient flow and impacting patient outcomes, especially during disasters. the results of a study by azizpour et al. (2021) showed that decisions made with intuition or reasoning will drive rapid and accurate decisions. novice nurses must be able to quickly identify priorities during triage using their clinical knowledge and skills in a crowded, noisy, and stressful environment.27 slightly different from the study conducted by ghanbari et al. (2021) decision-making must be based on ethical decision-making components in triage by considering the equity between prioritizing patients who require immediate medical needs and those who will give victims a greater chance of survival in their community.28 novice nurses are responsible for the triage role in clinical settings. rapid information gathering and accurate decision making such as clinical reasoning skills are essential for severity classification.29 clinical decision making in prioritizing disaster triage has two dimensions, namely a) efficient and effective triage (urgent need, effective intervention, possibility of survival) and b) priority-oriented triage (special attention to vulnerable patients, prioritizing possible rescue for longer lives, prioritizing patients of productive age, prioritizing social efficiency, priorities based on possibilities in providing services and non-preferential priorities). most participants in this study stated that principles alone are not enough to explain the ethical aspects of decision-making in disaster triage.30 the highest predictor is novice er nurses who receive disaster triage education, showing higher decision-making abilities in problemsolving and strategic thinking.31 through structured triage education, clinical reasoning abilities can be maximized to make decisions in line with the severity of disaster victims.32 novice nurses need to prioritize patients with a higher chance of survival. in crowded er situations with limited resources, the ability to prolong survival is one of the team’s goals. even research conducted by holmstrom et al (2020) used triage decision-making technology in priority setting, but it was considered to create conflict between nurses and tools. so that novice nurses view the tool as a support for the statements and decisions they make.33 therefore this study supports previous research that clinical knowledge and skills are absolutely owned by novice nurses well. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13070] [page 155] non -co mmerc ial us e o nly decision-making in the diagnostic skills research findings by winarti explained that decision-making is low in the diagnostic aspect. novice nurses will often hesitate in making such decisions.34 clinical decision-making in emergencies during disasters requires careful consideration. gaps in decisionmaking during disaster preparedness reflect decision-making ambiguity. the study by alharbi found that many nurses do not have a detailed understanding of disaster emergency response.35 education and training are the main influences in reducing knowledge and decision-making gaps. furthermore, labrague et al emphasized the important role of this awareness in supporting disaster management decision-making in the er.36 disaster emergency response simulations help illustrate novice nurses in preparing them to provide care during disasters. based on the weaknesses of novice nurses, one way to improve diagnostic skills is to try to master and improve the skills and knowledge they have by using operational training. given that operational training is one method of empowering nurses, this diagnostic skills training needs to be highlighted in health service centers.37 decision-making in the team communication skills communication between teams is needed in decision making to determine further actions. numerical results indicate that personnel factors are categorized as low in the index.38 furthermore, chegini et al. (2022) suggested that all emergency nurses, both beginners, should understand the proper chain of command and who to communicate with and how to establish effective communication as it is considered a key component of identifying patients during a disaster event.39 decision-making support and reflective assistance are mandatory support among fellow professionals in difficult situations. in-depth understanding influences clinical decision-making for novice nurses. consistent with the findings of ayenew et al, novice nurses’ strengths in decision-making lie in communication skills and critical thinking.40 findings from the study by considene et al. also showed that the need to communicate quality information within the team significantly affects subsequent decision-making actions.41 therefore, its essential that every hospital develop alternative communication methods and provide nursing managers and staff with adequate knowledge on these alternatives and their uses to prepare them to operate efficiently during a disaster to prvent these situastions.42 study conducted by amberson et al 2020, using a concise and relevant integrated information system according to the sbar principle can be applied in any department especially disaster to develop more confident and prepared novice nurses. not only that, communication can also be done with all types of devices such as (telephone, fax, email, satellite phones, pdas, etc).43 this idea considers the significant patient outcomes from the perspective of all er nurses. decision-making in the emergency care decision making is also seen from the perspective of emergency care in disaster situations, where the process consists of: i) resuscitation decision making; ii) psychological management of patients; iii) individual and family care support. resuscitation decision making during disaster management involves special considerations because in such situations, resources may be limited and many patients may require emergency care.44 continuous monitoring of the patient’s condition is important. if the patient does not show improvement within a reasonable time, the nurse needs to consider stopping resuscitation measures. identify individuals or groups who may need special psychological support, such as victims who have experienced major losses or health workers working under very high pressure.45 although in the er setting care is always focused on critical actions, the psychological support aspect during disaster care is very important, both for disaster victims because it often creates very stressful and potentially traumatic situations.46 provide clear, accurate, and up-to-date information about the disaster situation, available treatments, and actions to be taken. open communication can help reduce anxiety and increase understanding. approach each individual and family by considering their specific needs for care. individuals and families who are victims of disasters have different medical, nutritional or psychological support needs. from the various discussions above, although awareness of the clinical role of novice nurses in disaster response is reported to be high, a study conducted by alzahrani and kyratsis (2017) in mecca showed limited emergency and disaster preparedness plans.47 the study explained that they were able to provide timely general clinical assessment and care; however, few of the novice nurses carried out their duties as part of providing supervision, prevention, leadership or psychological care in disasters.48 in contrast to other studies, there were indeed significant differences between nurses in their understanding of the basic elements of disaster management based on their level of experience.49 therefore, novice nurses with less than five years of experience have a significant need to learn these components in order to be able to cope with disasters.50 in line with research findings in indonesia which show that emergency disaster nurses have a moderate level of disaster preparedness.51 previous disaster experience and disaster training or education are positively related to disaster preparedness. meanwhile, ironically, this study shows that nurses lack the relevant competencies needed in responding to recent disasters. in this regard, this study also suggests that nurses specializing in emergency, trauma, and disaster care are generally underprepared in their ability to optimize disaster response and recovery efforts and patient outcomes during disasters.52 similarly, the issues of surge in patient arrivals, communication problems, lack of adequate emergency care, lack of coordination between disaster areas and hospitals, lack of telecommunications, chaos, and triage difficulties are some of the other issues that need to be addressed in the current literature. in highlighting these issues, this study may provide a useful starting point for the development of an educational framework to prepare nurses and other health professionals to work in disaster situations. conclusions the decision-making competencies identified in this study are expected to give more weight to previous competencies. furthermore, this review can facilitate the identification of decision-making gaps in novice nurses, allowing training and the incorporation of disaster curriculum in education to be useful in the future. it also important to learn and teach technique which encourages nurses to improve their skill. disaster scenarios and formal disaster preparedness training. the definition of nursing duties in nursing laws and regulations must also be determined update. additional guidance specifically regarding novice nurse instruction and practies should be added to suit disaster nursing law. these findings provide a basis for novice nurses on how ethical decision-making can be achieved in disaster triage due to the large number of victims. comprehensive training is required for decision-making and more education for novice nurses on precision 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clinical decision-making of nursing students using high-fidelity simulation, observation and think aloud: a mixed methods research study. j adv nurs 2023;79:811–824. 16. ncube a, chimenya gn. hospital disaster emergency preparedness: a study of onandjokwe lutheran hospital, northern namibia. afr saf promot 2016;14:1–17 17. qie z, rong l. a scenario modelling method for regional cascading disaster risk to support emergency decision making. internat j disaster risk reduction 2022;77:103102. 18. page mj, mckenzie je, bossuyt pm, et al. the prisma 2020 statement: an updated guideline for reporting systematic reviews. bmj 2021;372:n71. 19. holmström ik, kaminsky e, lindberg, y, et al. registered nurses’ experiences of using a clinical decision support system for triage of emergency calls: a qualitative interview study. j adv nurs 2020;76:3104–12. 20. murphy jp, rådestad m, kurland l, et al. emergency department registered nurses’ disaster medicine competencies. an exploratory study utilizing a modified delphi technique. internat emerg nurs 2019;43:84–91. 21. feng y, cui s. a review of emergency response in disasters: present and future perspectives. natural hazards 2021;105:1109–38. 22. heydari m, lai k, k, fan y, li x. a review of emergency and disaster management in the process of healthcare operation management for improving hospital surgical intake capacity. mathematics 2022;10;2784. 23. labrague lj, hammad k, gloe ds, et al. disaster 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13070] [page 157] correspondence: rystika angga sari, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia. tel.: +62341569117 fax: +62341564755. e-mail: rystikaangga@student.ub.ac.id key words: clinical decision-making; disaster management; novice nurse strategy contributions: each author has contributed to and is responsible for the content of the reviewed article, read and assessed its quality, provided input in manuscript preparation, and approved the manuscript submission. conflict of interests: the authors declare no conflicts of interest, financial or otherwise, regarding this article. funding: the authors receive support from department of nursing, faculty of health sciences, universitas brawijaya. ethics approval: not applicable. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgement: the authors would like to thank everyone who participated in improving the quality of this scientific article. received: 5 november 2023. accepted: 8 july 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13070 doi:10.4081/hls.2024.13070 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly preparedness among nurse: a systematic review of literature. internat nurs rev 2018;65:41-53. 24. tilahun l, desu b, zeleke m, et al. emergency and disaster handling preparedness among front line health service providing nurses and associated factors at emergency department, at amhara regional state referral hospitals, ethiopia. open access emergency medicine 2022;13:221–32. 25. canatan h. an investigation on the concept of triage in the event of disasters and emergences: definition, ethical decision-making. j internat health sci manag 2020;6:74–82. 26. paganini m, borrelli f, cattani j, et al. assessment of disaster preparedness among emergency departments in italian hospitals: a cautious warning for disaster risk reduction and management capacity. scandinavian j trauma resusc emerg med 2016;24:101. 27. amberson t, wells c, gossman s. increasing disaster preparedness in emergency nurses: a quality improvement initiative. j emerg nurs 2020;46:654-665.e21. 28. azizpour i, mehri s, soola ah. disaster preparedness knowledge and its relationship with triage decision-making among hospital and pre-hospital emergency nurses ardabil, iran. bmc health serv res 2022;22:934. 29. yang j, kim kh. effect of the strategic thinking, problem solving skills, and grit on the disaster triage ability of emergency room nurses. internat j environ res public health 2020;19:987. 30. al harthi m, al thobaity a, al ahmari w, almalki m. challenges for nurses in disaster management: a scoping review. risk management and healthcare policy 2020;13:2627–34. 31. khorram-manesh a, nordling j, carlström e, et al. a translational triage research development tool: standardizing prehospital triage decision-making systems in mass casualty incidents. scandinavian j trauma resusc emerg med 2021;29:119. 32. jiang g.-j, chen h.-x, sun h.-h, et al. an improved multi-criteria emergency decision-making method in environmental disasters. soft computing 2021;25:10351–79. 33. ghanbari v, ardalan a, zareiyan a, et al. fair prioritization of casualties in disaster triage: a qualitative study. bmc emerg med 2021;21:119. 34. winarti w, gracya n. exploring nurses’ perceptions of disaster preparedness competencies. nurse media j nurs 2023;13:236–45. 35. alharbi ns, youssef dha, felemban dem, et al. saudi emergency nurses preparedness for biological disaster management at the governmental hospitals. j positive school psychol 2022;6:1218–35. 36. labrague lj, hammad k, gloe ds, et al. disaster preparedness among nurse: a systematic review of literature. internat nurs rev 2018;65:41-53. 37. ayenew t, tassew sf, workneh bs. level of emergency and disaster preparedness of public hospitals in northwest ethiopia: a cross-sectional study. afr j emerg med 2022;12:246–51. 38. aliakbari f, pirani t, heidari m, kheiri s. effect of operational exercises on nurses' competence in dealing with disaster. j educ health promot 2022;11:54. 39. ayenew t, tassew sf, workneh bs. level of emergency and disaster preparedness of public hospitals in northwest ethiopia: a cross-sectional study. afr j emerg med 2022;12:246–51. 40. considine j, botti m, thomas s. do knowledge and experience have specific roles in triage decision-making? acad emerg med 2007;14:722–726. 41. jiang gj, chen hx, sun hh, et al. an improved multi-criteria emergency decision-making method in environmental disasters. soft computing 2021;25:10351–79. 42. al harthi m, al thobaity a, al ahmari w, almalki m. challenges for nurses in disaster management: a scoping review. risk manag healthcare policy 2020;13:2627–34 43. seyedin h, abbasi dolatabadi z, rajabifard f. emergency nurses’ requirements for disaster preparedness. trauma monthly 2015;20. 44. ortiz-barrios m, gul m, lópez-meza, p, yucesan m, navarrojiménez e. evaluation of hospital disaster preparedness by a multi-criteria decision making approach: the case of turkish hospitals. internat j disaster risk reduction 2020;49:101748. 45. brewer ca, hutton a, hammad ks, geale sk. a feasibility study on disaster preparedness in regional and rural emergency departments in new south wales: nurses selfassessment of knowledge, skills and preparation for disaster management. australasian emerg care 2020;23:29–36. 46. chegini z, arab-zozani m, kakemam e, et al. disaster preparedness and core competencies among emergency nurses: a cross-sectional study. nursing open 20229:1294–302. 47. brinjee d, al thobaity a, almalki m, alahmari w. identify the disaster nursing training and education needs for nurses in taif city, saudi arabia. risk management and healthcare policy 2021;14:2301–10. 48. hasan mdk, younos tb, farid zi. nurses’ knowledge, skills and preparedness for disaster management of a megapolis: implications for nursing disaster education. nurse education today 2021;107:105122. 49. rizqillah af, suna j. indonesian emergency nurses’ preparedness to respond to disaster: a descriptive survey. australasian emerg care 2018;21:64–68. 50. alzahrani f, yiannis k. emergency nurse disaster preparedness during mass gatherings: a cross-sectional survey of emergency nurses’ perceptions in hospitals in mecca, saudi arabia. bmj open 2017;7:e013563. 51. choi ws, hyun, sy, oh h. perceived disaster preparedness and willingness to respond among emergency nurses in south korea: a cross-sectional study. internat j environ res public health 2022;19:11812. 52. fithriyyah yn, alda ak, haryani h. trends and ethical issues in nursing during disasters: a systematic review. nursing ethics 2023:096973302311556. 4th international nursing and health sciences symposium [page 158] [healthcare in low-resource settings 2024;12(s1):13070] online supplementary materials table 1. summary of articles quality assessment for cross-sectional study using centre of evidence-based medicine (cebm) appraisal tools. table 2. summary of articles quality assessment for qualitative study using critical appraisal skill program (casp) tools. table 3. summary of articles quality assessment for experimental study using joanna briggs institute (jbi) critical appraisal tools table 4. summary of articles selected from the database. table 5. summary of clinical decision-making on novice nurse. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13564 relationship between workload and organizational citizenship behavior in community nursing service management in indonesia miftahul munir,1 karyo karyo,2 umu qonitun3 1department of public health; 2department of nursing; 3department of midwifery, nahdlatul ulama institute of health sciences, tuban, jawa timur, indonesia abstract the management of community nurse services is essential for enhancing public health. factors such as workload, organizational support, and job satisfaction influence organizational citizenship behavior (ocb), which impacts the quality of nursing governance. this research investigated the relationship among workload, ocb, and community nurse management using a quantitative correlational approach with 171 community nurses from health service centers in tuban regency, indonesia. simple random sampling was used to ensure equal representation of the participants. data were collected using structured questionnaires that measured workload, ocb, and nurse governance. spearman’s correlation test was used to analyze the relationships between these variables. the findings indicated that 46.7% of respondents exhibited high ocb, while 45.8% rated community nurse governance as good. regarding workload, 50% of respondents reported a moderate workload. statistical analysis revealed a significant correlation among workload, ocb, and nurse governance (p<0.05). higher ocb levels were associated with better governance, while a moderate workload contributed to more effective nurse management. balancing workloads and fostering ocb is crucial to enhancing nursing governance and healthcare service quality. strengthening organizational support, implementing targeted training programs, and improving nurse management strategies can contribute to more effective community health services. future research should consider psychosocial stress and emotional burden when developing a comprehensive workload assessment model. introduction a critical issue in community nursing management worldwide is the shortage of nursing personnel, particularly in underserved areas.1 this shortage exacerbates nurses’ workloads owing to the additional burden of administrative responsibilities. limited infrastructure and health resource support, including medical equipment and training, result in significant challenges in delivering optimal healthcare services. these challenges have become even more pronounced with the increasing complexity of public health issues, such as non-communicable diseases, mental health disorders, and infectious disease outbreaks.2 addressing these challenges requires strategic workforce planning, resource allocation, and effective management approaches to support community-based health care. the village health service center is a vital primary healthcare service designed to enhance public health at the village level. it provides essential health services, especially in rural communities with limited access to comprehensive healthcare facilities.3 however, its implementation faces various challenges, including nurse shortages, inadequate facilities, and unbalanced work schedules.4 additionally, the lack of coordination among village health service centers, local governments, and health centers hampers service operations and case management.5 administrative inefficiencies, such as ineffective medical records and reporting, further increase nurses’ workload.6 these factors collectively affect the correspondence: miftahul munir; department of public health, ilmu kesehatan nahdlatul ulama tuban institute, jawa timur, indonesia. e-mail: munir.stikesnu@gmail.com key words: community nurse; organizational citizenship behavior; workload. contributions: mm, conceptualization, data curation, formal analysis, methodology, validation, visualization, resources, investigation, writing – original draft, writing – review & editing; kk, conceptualization, investigation, methodology, validation, resources, supervision, writing – original draft, writing – review & editing; uq, conceptualization, methodology, formal analysis, validation, resources, investigation, writing – original draft, writing – review & editing. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: the health research ethics committee at iiknu tuban granted ethical approval with number 60/0084223523/lepk.iiknu/xii/2023 in december 2023, with a validity period of one year. subsequently, permission was obtained from the tuban district government, specifically from the investment and integrated one-stop service office (ptsp). the research was then conducted meticulously, in alignment with its established ethical objectives. consent for publication: written informed consent was obtained for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: we express our gratitude to all the nurses willing to participate in this study, who played an essential role in its success. we also extend our thanks to all the lecturers at the nahdlatul ulama institute of health sciences for their support. received: 31 december 2024 accepted: 3 march 2025 early view: 28 may 2025 this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13564 doi:10.4081/hls.2025.13564 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13564] [page 7] service quality and well-being of healthcare professionals. furthermore, low recognition and insufficient incentives contributed to a decrease in motivation and commitment among nurses.7 therefore, improving organizational management is essential for enhancing service quality and ensuring the well-being of nurses, ultimately supporting national health development goals.8,9 in east java, the expansion of village health service centers from their inception in 2010 to the end of 2020 saw a 72.3% increase in facilities, with 3213 nurses operating in 4413 sub-districts across 27 cities and regencies.10,11 this expansion significantly improved healthcare accessibility, particularly in rural areas, highlighting the need for further optimization of primary healthcare services. an initial survey conducted on september 12, 2023, through interviews with nurses in tuban regency, revealed that 55% of respondents exhibited moderate organizational citizenship behavior (ocb), while 45% effectively managed administrative and managerial tasks, achieving 100% of the expected targets. since 2010, the east java provincial government has implemented the village health service center program to enhance access to healthcare in rural areas.12 these centers provide essential healthcare services, including immunization, maternal and child health, noncommunicable disease management, and health education. they also facilitate early disease detection and public health promotion, thereby reducing disparities between urban and rural healthcare access in east java.13 individual performance is the cornerstone of an organization’s overall success. when each member performs effectively, it enhances overall productivity and contributes to achieving organizational goals.14-17 skilled and motivated personnel are crucial in meeting healthcare standards and operational targets. effective performance management not only improves workplace efficiency but also fosters a supportive and productive environment.18,19 organizations that invest in training, motivation, and efficient management foster synergy and long-term sustainability.20,21 prior research has found that fairness and employee engagement significantly improve ocb, positively impacting overall productivity.22,23 however, existing studies have not extensively explored the mediating role of work engagement in linking organizational justice with ocb, particularly in healthcare settings.5,24 this study differs from previous research in that it focuses on the relationship between ocb and workload among community nurses. specifically, it explores how ocb, such as assisting colleagues and providing services beyond primary responsibilities, is influenced by the workload in community nursing. previous studies have primarily examined this relationship in hospital settings, neglecting the unique challenges faced by community nurses, such as limited healthcare accessibility and resource constraints.25-27 furthermore, research on the correlation between high workload and ocb in developing countries, such as indonesia, remains limited.28,29 a more comprehensive approach is required to examine cultural factors, specific workload dimensions, and practical interventions to enhance ocb in community nursing.30 encouraging ocb among nurses fosters a supportive work environment, enhances team productivity, and improves healthcare service delivery.31-33 given these considerations, this study aimed to investigate the relationship between ocb and nurse workload in the village health service center in tuban regency, providing insights into strategies to enhance nursing performance despite high workloads.34 materials and methods research design this study utilized a correlational quantitative design to analyze the relationship between workload, organizational citizenship behavior, and community nurse governance in the tuban regency. the workload perceived by community nurses and the ocb they exhibit are expected to impact nurses’ governance in delivering health services to the community. the study population consisted of all community nurses employed at the village health service center in tuban regency, where they play a vital role in delivering preventive and promotive health services to the community. population, sample, sampling the total population in this study consisted of 171 respondents, who were community nurses working at the village health service center in the tuban regency. the inclusion criteria were nurses who had worked for at least one year, were willing to participate as respondents, and were not on leave or work permits during the study. simple random sampling was used, ensuring that every member of the population had an equal chance of being selected. the sample size was determined using the slovin formula with a confidence level of 95% and a margin of error of 5%, resulting in 120 respondents. the sample size was sufficient to ensure the research results were representative and valid. variables three variables were analyzed in this study. the independent variables were the workload and ocb. workload refers to the level of burden perceived by community nurses, which includes factors such as the number of tasks, working hours, and pressure experienced in performing their tasks. ocb refers to nurses’ behavior beyond their formal responsibilities, encompassing dimensions such as altruism, conscientiousness, sportsmanship, courtesy, and civic virtue. the dependent variable was community nurse governance, which evaluates nurses’ performance in carrying out their duties in accordance with the established standard operating procedures, as the quality of services provided to the community. instruments ocb was measured using a questionnaire based on organ’s (1988) theory, which included the dimensions of altruism, conscientiousness, sportsmanship, courtesy, and civic virtue. the dependent variable, i.e., community nurse governance, was assessed using a performance checklist based on community health service standards in indonesia. the research instruments included a workload questionnaire, which used a likert scale ranging from 1 to 5. before implementation, the questionnaire underwent validity and reliability testing through statistical analysis, including construct validity testing using methods such as exploratory factor analysis (efa) or confirmatory factor analysis (cfa), as well as reliability testing using cronbach’s alpha. all the questionnaires that met the validity and reliability criteria were deemed suitable for further research. data collection this study was conducted in tuban in december 2023. before participating, the respondents signed an agreement with the researcher stating their willingness to participate by completing an informed consent form. data collection was conducted using several methods, including the direct distribution of questionnaires to community nurses at the village health service center, structured interviews to explore factors influencing nurse governance, and pathways of change, part ii [page 8] [healthcare in low-resource settings 2025;13(s2):13564] performance observation using a checklist based on community health service standards. this process was implemented to ensure that the obtained data provided a clear and comprehensive understanding of the factors affecting community nurse governance. analysis the collected data were statistically analyzed to derive meaningful conclusions from the responses. univariate analysis was conducted to describe the characteristics of the respondents, including demographic factors such as age, education level, years of service, and other relevant background information. this analysis also examined the distribution of the research variables and provided an overview of the dataset before further examination. bivariate analysis was performed to explore relationships between two variables at a time. to determine the strength and direction of these relationships, pearson’s correlation (for normally distributed data) or spearman’s correlation (for non-normally distributed data) was applied, depending on the nature of the data. ethical clearance this research was approved by the health research ethics commission of the nahdlatul ulama institute of health sciences, tuban, ensuring compliance with ethical standards and guidelines for conducting research involving human participants. approval was granted under the reference number 60/0084223523/ lepk.iiknu/xii/2023. during data collection, the researcher ensured the confidentiality of data and respondents’ identities. all information provided was used solely for research purposes and not disclosed to any third party without permission. an anonymity procedure was applied, ensuring respondents’ personal identities were neither recorded nor linked to the collected data. this approach protected respondents’ privacy and ensured they felt safe providing honest and open responses. results table 1 presents the characteristics of research respondents, highlighting key demographic and professional attributes. most respondents were aged 37-42 (66, 38%), followed by those aged 31-36 (60, 35%). most respondents were female (93, 55%) and held a professional nursing degree (profesi ners) (96, 56%). regarding ocb, nearly half of the respondents (56, 46.7%) exhibited high ocb, indicating strong engagement in behaviors that support their organization. in terms of community nurse management, the majority (55, 45.8%) perceived governance in their area as good. additionally, half of the respondents (60, 50%) reported experiencing a moderate workload, suggesting a balanced distribution of responsibilities among community nurses. table 1 indicates that most community nurses in the area experience a balanced workload, which may influence their ability to manage tasks and responsibilities efficiently. table 2 illustrates the cross-tabulation of ocb and community nurse management. among respondents with moderate ocb, most rated their community nurse management as good, with 28 respondents representing the largest subgroup in that category. in contrast, among those with high ocb, the majority perceived their community nurse management as moderate, with 29 respondents comprising the largest subgroup in that row. these majority trends underscore a significant association between the levels of ocb and the perceptions of nurse management, as supported by the spearman correlation test result of 0.002. table 3 presents the relationship between workload and community nurse management. the majority of respondents with a moderate workload (30, 25%) perceived their community nurse management as moderate, indicating a balanced distribution of responsibilities. meanwhile, among those with a high workload, the largest proportion (32, 27%) rated their community nurse management as good, suggesting that despite increased work demands, these nurses maintained effective governance. the spearman correlation test result of 0.001 indicates a significant relationship between workload and community nurse management. this suggests that nurses with higher workloads may develop better management capabilities, possibly influenced by experience, skills, and organizational support. discussion this study investigated the relationship between workload and organizational citizenship behavior in community nursing management. the findings of this study indicated a significant relationship between ocb and workload with community nursing management, as evidenced by a p-value <0.05 in the spearman test. this relationship reflects the influence of individual factors and workload on nurses’ management of community nursing services. ocb, which represents proactive attitudes, commitment, and initiative at work, has been shown to contribute to the improvement of community management quality. meanwhile, a high workload, which is generally perceived as a burden on performance, is correlated with increased effectiveness in community management. nurses with high ocb had better community nursing management, with 45.8% classified as good, whereas those with low ocb were entirely classified as poor. this suggests that strong ocb enhances commitment, efficiency, and effectiveness of community healthcare services. these findings align with previous research emphasizing pathways of change, part ii table 1. characteristics of research respondents. characteristics n % age 25-30 years 45 27 31-36 years 60 35 37-42 years 66 38 gender male 78 45 female 93 55 education level 3 diploma in nursing 75 44 bachelor's degree in nursing 96 56 organizational citizenship behavior low 10 8.3 moderate 54 45.0 high 56 46.7 community nurse management low 14 11.7 moderate 51 42.5 good 55 45.8 workload low 5 4.2 moderate 60 50 high 55 45.8 source: primary data of researchers in 2023. [healthcare in low-resource settings 2025;13(s2):13564] [page 9] that well-managed community nursing improves nurses’ roles, optimizes resources, and fosters collaboration in integrated healthcare.35-37 effective governance enhances resource allocation, work environment, and public health outcomes.38-40 according to alex et al. (2024), good governance plays a crucial role in achieving public health goals, such as reducing disease prevalence, increasing healthcare access, and strengthening community health systems.41 through structured management, community nurses can improve health program efficiency, reduce costs through preventive care, and enhance community engagement. strengthening ocb and management strategies is essential for improving service quality and ensuring the sustainability of healthcare interventions.42 these findings strengthen the vital role of ocb and effective management in enhancing the quality of community nursing services and ensuring the long-term sustainability of healthcare interventions. altruism emerged as the most influential factor in this study as it fostered collaboration and strengthened community-based nursing services. nurses who demonstrate high levels of altruism are more likely to support their colleagues and patients, thereby contributing to a positive and cohesive healthcare environment.43 jepma et al. highlight that altruistic nurses offer assistance without expecting personal gain, promoting teamwork and mutual trust.44 these behaviors enhance cooperation in delivering healthcare services and increase commitment to patient welfare, even in challenging situations. nurses prioritizing altruism go beyond formal job responsibilities, offering voluntary support that benefits their organization and the broader healthcare system.45-47 consequently, altruism positively influences health care outcomes by improving service quality and efficiency.48,49 this study identified a significant relationship between workload and community nursing management, with nurses experiencing high workloads demonstrating better management performance (27%) than those with moderate (19%) or low workloads (0%). this suggests that high workloads may drive nurses to develop better adaptation mechanisms and enhance task management efficiency. supporting research indicates that when effectively managed, high workloads improve time management, decision-making, teamwork, and innovation use.50-52 studies by sibilio et al. and park et al. highlighted that nurses in demanding roles develop superior prioritization skills, resource allocation strategies, and adaptability, ultimately improving service quality and public health outcomes.53-56 however, this study is limited by its workload measurement, which primarily focuses on work quantity rather than psychological factors such as stress, emotional burden, and psychosocial challenges.57-60 additionally, assessing ocb remains challenging due to reliance on subjective evaluations, which may impact measurement accuracy in community nursing practice.61-63 future research should adopt a more holistic approach by incorporating psychological dimensions into workload assessments, providing a more accurate understanding of their impact on nursing performance, mental health, and behavioral indicators of commitment and care quality in community nursing.64-66 therefore, while the findings of this study indicate a positive relationship between high workload and effective community nursing management, it remains essential to implement policies that promote work-life balance for nurses. institutional support, including time management training, improved workplace facilities, and equitable task distribution, can help nurses maintain productivity without experiencing excessive work-related stress. overall, this study confirms that both ocb and workload play significant roles in shaping community nursing management, emphasizing the need for strategies that foster ocb among nurses and optimize workload distribution. healthcare institutions and policymakers can leverage these findings to design targeted training programs and implement evidence-based work policies that enhance nurses’ effectiveness, ultimately ensuring sustainable delivery of high-quality community healthcare services. conclusions this study highlights the positive impact of effective community nurse management on nurses’ roles, collaboration, and healthcare quality. altruism fosters collaboration and trust, whereas ele pathways of change, part ii [page 10] [healthcare in low-resource settings 2025;13(s2):13564] table 2. cross tabulation of organizational citizenship behavior and community nurse management. community nurse management organizational citizenship behavior low moderate good total low 10 (8%) 0 (0%) 0 (0%) 10 (8%) moderate 4 (3%) 22 (18%) 28 (23%) 54 (45%) good 0 (0%) 29 (24%) 27 (22%) 56 (46%) total 14 (11%) 51 (42%) 55 (45%) 120 (100%) spearman test = 0.002 source: primary data of researchers in 2023. table 3. cross tabulation of workload and community nurse management. community nurse management workload low moderate good total low 4 (3%) 1 (1%) 0 (0%) 5 (4%) moderate 7 (5%) 30 (25%) 23 (19%) 60 (50%) high 3 (0.2%) 20 (16%) 32 (27%) 55 (45%) total 14 (11%) 51 (42%) 55 (45%) 120 (100%) spearman test = 0.001 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unleashing the power to serve: engaging nurses in the community. j radiol nurs 2024. 56. johnson hl, cruthirds df, taylor la, et al. redefining faculty workload metrics: a data-driven approach. j prof nurs 2024;55:112–8. 57. pohl s, battistelli a, djediat a, andela m. emotional support at work: a key component for nurses’ work engagement, their quality of care and their organizational citizenship behaviour. int j africa nurs sci 2022;16:100424. 58. qalati sa, zafar z, fan m, et al. employee performance under transformational leadership and organizational citizenship behavior: a mediated model. heliyon 2022;8. 59. jiang c, he l, xu s. relationships among para-social interaction, perceived benefits, community commitment, and customer citizenship behavior: evidence from a social live-streaming platform. acta psychol (amst) 2024;250:104534. 60. mulaudzi fm, cur m, littet phil d, gundo r. the views of nurses and healthcare users on the development of ubuntu community model in nursing in selected provinces in south africa: a participatory action research. nurs outlook 2024;72:102269. 61. su l, cheng x, zarifis a. passengers as defenders: unveiling the role of customer-company identification in the trust-customer citizenship behaviour relationship within ride-hailing context. tour manag 2025;107. 62. wang m, armstrong sj, li y, et al. the influence of leader-follower cognitive style congruence on organizational citizenship behaviors and the mediating role of trust. acta psychol (amst) 2023;238:103964. 63. ross p, sheldrake j, ilic d, et al. an exploration of intensive care nurses’ perceptions of workload in providing extracorporeal membrane oxygenation (ecmo) support: a descriptive qualitative study. aust crit care 2024;37:585–91. 64. vauhkonen a, saaranen t, cassar m, et al. professional competence, personal occupational well-being, and mental workload of nurse educators – a cross-sectional study in four european countries. nurse educ today 2024;133. 65. lawrence pr, spratling r. resources, workload, and care coordination hours predict depressive symptoms in parents of children with medical complexity. j pediatr heal care 2024;38:781. 66. ditlopo p, rispel lc, van bogaert p, blaauw d. the impact of the nurse practice environment, workload, and professional support on job outcomes and standards of care at primary health care clinics: a structural equation model approach. int j nurs stud adv 2024;7:100241. pathways of change, part ii [page 12] [healthcare in low-resource settings 2025;13(s2):13564] hrev_master healthcare in low-resource settings 2025; volume 13:13381 social support to eradicate open defecation: raise awareness and promote healthy behavior muhammad ikhtiar, nur ulmy mahmud, andi asrina, andi arysta, putri khairunnisa public health faculty, muslim university of indonesia, kota makassar, sulawesi selatan, indonesia abstract indonesia has achieved a 100% open defecation-free (odf) status; however, a significant portion of the population still practices open defecation, particularly in proximity to rivers, swamps, and coastal areas. this study aimed to analyze the role of social support in the context of efforts to halt open defecation. this study employed quantitative methodology with a cross-sectional study design. the research was conducted in the catchment area of the manggarabombang community health center in takalar regency. data were analyzed using both univariate and bivariate techniques, and results were presented through narrations, distribution tables, and graphs. the study population comprised 178 households, with sampling conducted using the slovin formula to obtain a sample size of 123 households. the results of the statistical tests using the chi-square method revealed a p-value of 0.000, indicating a significant relationship between social support and open defecation behavior. this highlights the important roles played by health workers, community leaders, and religious leaders. the findings of the study suggest that emotional and social support, as well as exposure to information about the health risks associated with open defecation, encourage individuals to adopt healthy practices in their environment. with increased knowledge and awareness of the importance of personal health, individuals are more likely to commit to long-term open defecation-free behaviors. introduction globally, over 1.5 million people still lack access to basic sanitation services, such as private toilets and latrines. furthermore, 419 million people continue to defecate in unprotected locations, including street gutters, vacant lots, and open water.1 sanitationrelated issues have become a global concern, including in indonesia, which has set the goal of achieving 0% open defecation and 15% access to safe sanitation by 2024.2-4 the community-based total sanitation profile up to 2021 indicates that indonesia’s population of 288.22 million people still includes 32.77 million individuals engaged in open defecation practices.5,6 the indonesian government has implemented a series of initiatives with the objective of sustaining a decline in the prevalence of open defecation on an annual basis. it is expected that open defecation will be eliminated by 2025, while complete access to improved sanitation is projected to be attained by 2027.7,8 despite the limitations of the data, it would appear that access to safe sanitation has remained constant at 7% over the past five years, which suggests that there is still much work to be done by all parties.2,9 it remains challenging to alter long-established habits and practices regarding latrine use, particularly in coastal areas, due to deeply entrenched cultural norms and behaviors. furthermore, some households possess latrines but refrain from utilizing them despite convenient access to water due to the unfitness or unsanitary nature of the latrines.10,11 as reported by the ministry of health of the republic of indonesia in 2022, the prevalence of open defecation in indonesia has declined over time, with an estimated 5.69% of the population engaging in this practice.2 this is inextricably linked to the numerous initiatives implemented by the government with the objective of eradicating open defecation, including the provision of latrines and the implementation of awareness-raising campaigns. despite various efforts, many communities, especially in coastal areas, are reluctant to change their practices regarding open defecation. government collaboration typically aims to educate these communities to prevent this issue. while positive knowledge and attitudes correspondence: muhammad ikhtiar, public health faculty, muslim university of indonesia, kota makassar, sulawesi selatan, indonesia. e-mail: muhammad.ikhtiar@umi.ac.id tel.: +62.853.4372.3079. key words: social support; odf; healthy behavior; cross-sectional study. conflict of interest: the authors declare that they have no competing interests, and all authors confirm accuracy. ethics approval and consent to participate: not applicable. availability of data and materials: all data generated or analyzed during this study are included in this published article. funding: this study was financially supported by the ministry of education, culture, research and technology of the republic of indonesia. acknowledgments: we would like to express our gratitude to the ministry of education, culture, research and technology of the republic of indonesia for providing financial support for this research project in 2024. we would also like to acknowledge the muslim university of indonesia for their continued encouragement and assistance in advancing our knowledge, as well as the government of takalar regency, south sulawesi, for allowing us to conduct our research in their region. finally, we would like to thank all those who have contributed to this research project in any way. received: 13 november 2024. accepted: 11 december 2024. early access: 11 february 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13381 doi:10.4081/hls.2025.13381 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13381] [page 111] exist, many still engage in open defecation, highlighting the need for a community-based approach that includes social support. unhealthy behaviors are often deeply rooted and unconscious, making social support essential, particularly in environments lacking strong social norms and encouragement for proper latrine use and maintenance.12,13 it is anticipated that the assistance of local residents, particularly community leaders, will facilitate the government’s efforts to establish a healthy environment. the findings indicate that a significant number of residents continue to engage in open defecation due to a lack of social support from community leaders. furthermore, there is a lack of social disapproval or warnings from the surrounding community when someone is caught engaging in open defecation. while many residents are aware that open defecation is unhealthy, this awareness is often disregarded if it is not accompanied by community involvement and commitment to achieving open defecation-free status.14,15 open defecation practices are prevalent across indonesia, particularly in coastal areas, including south sulawesi. the province of south sulawesi has reported and declared that the year 2023 was 100% open defecation-free (odf), although the central statistics agency (bps) has indicated that there were still 2.26% of households engaging in open defecation. this represents a decrease from the 3.69% of households engaged in open defecation in 2022.16,17 the government has invested significant resources to achieve the goal of zero open defecation, a target that was met in takalar district by 2023. however, obtaining a 100% odf status has not completely eliminated open defecation practices among residents in riverine and coastal areas of takalar. despite the local health workers’ efforts in triggering and monitoring activities, instances of open defecation continue to occur in rivers, gardens, and other open spaces. a dataset from the takalar district health office in 2022 indicated that 120 households in the bontomanai village area of the mangarabombang community health centre still practiced open defecation due to a lack of access to latrines. in the following year, the number of latrine owners increased due to a local government assistance program for latrines.18 the provision of triggering and latrine assistance has been carried out in stages. however, it has been observed that a portion of the population has not been able to access this assistance due to a lack of financial resources. some community members do not prioritize latrines and even construct homes without bathroom or toilet facilities. it is, therefore, evident that a robust commitment and motivation from the community, coupled with the provision of social support, is essential to encourage individuals to adopt healthier behaviors. article table 2. distribution of respondents' answers regarding community support to stop open defecation. number statement yes no n % n % 1 health workers are engaged in providing counseling services related to latrine ownership and use. 113 92.0 10 8.0 2 health workers recommend that family members utilize the toilet at home, as long as it is available. 116 94.4 7 5.6 3 health professionals elucidate the health risks associated with the lack of access to adequate sanitation facilities. 118 96.0 5 4.0 4 in the preceding 12-month period, health workers have conducted home surveys. 121 98.4 2 1.6 5 in order to facilitate the utilization of latrines, village officials, community leaders and religious leaders collaborate with household heads to ensure their participation. 120 97.6 3 2.4 6 a program of empowerment has been developed by village officials, community leaders, and religious leaders to encourage the use of latrines. 119 97.4 4 3.2 7 the village head, community leaders, and religious leaders are involved in providing advice and guidance on the construction of healthy latrines. 107 87.2 16 12.8 8 village officials, community leaders, and religious leaders have provided assistance to facilitate the use and utilization of latrines. 122 99.2 1 0.8 9 family members encourage the use of the latrine. 119 97.4 4 3.2 10 local people view the use of latrines positively. 122 99.2 1 0.8 11 in the event of open defecation, neighbours are quick to express their disapproval. 102 83.2 21 16.8 table 1. respondents’ characteristics. characteristics n % age <20 years 3 2.4 20-29 years 26 21.1 30-39 years 25 20.4 40-49 years 35 28.5 >55 years 34 27.6 gender male 54 36.4 female 69 63.6 education elementary school 57 46.4 senior high school 26 21.1 high school 23 18.7 not working 17 13.8 occupation trader/self-employed 14 11.3 farmer/fisherman 38 30.9 laborer 8 6.5 not working 29 23.6 housewife 34 27.7 income of head of family >rp.3.643.321,/ month 0 0 <rp.3.643.321,/ month 123 100 latrine ownership have a toilet 78 63.4 do not have a toilet 45 36.6 total 123 100 source: primary data 2024. [page 112] [healthcare in low-resource settings 2025;13:13381] this study highlights the role of social support provided by community leaders in the mangarabombang area, which has achieved a 100% open defecation-free status. despite this achievement, a significant number of residents continue to practice open defecation. typically, when a community reaches such a goal, it is expected that sustainable positive behavior follows. however, this study has uncovered that there are still residents, including both children and adults, who engage in open defecation due to a lack of access to toilets. the purpose of this study is to analyze social support for ending open defecation, with the aim of improving awareness and promoting healthy behaviors among coastal communities. materials and methods a cross-sectional study design was employed to utilize quantitative methods. the research was conducted in the catchment area of the manggarabombang health centre in takalar regency. univariate and bivariate data analysis was conducted, with data presentation utilizing narration, distribution tables, and graphs. the population comprised 178 households, with sampling conducted using the slovin formula to obtain 123 households. results table 1 reveals that the majority of respondents are between the ages of 40 and 49 (28.5%) and that the gender distribution is predominantly female (69%). the educational attainment of the respondents is generally at a middle to lower level (81%). most respondents (30.9%) identified as farmers or fishermen, and 84% of their income was below the provincial minimum wage. furthermore, 36.6% of households do not have access to latrines. table 2 presents the respondents’ responses regarding their perception of social support in relation to their open defecation habits. it was noted that 16.8% of respondents reported that there were no reprimands from their neighbors when they defecated outside. additionally, 12.8% of respondents indicated that religious leaders, hamlet leaders, and community leaders did not provide guidance on the importance of ceasing open defecation. furthermore, 5.6% of respondents mentioned that they did not receive any encouragement to use latrines. research variables the distribution of respondents regarding the role of social support in achieving an odf status is illustrated in table 3. bivariate analysis table 4 illustrates that 6 (40.0%) of the households surveyed reported receiving inadequate social support and engaging in open defecation practices. conversely, 108 households (86.4%) indicated that they had sufficient social support to adopt defecation-free behaviors. the results of the chi-square statistical tests indicated a statistically significant relationship between social support and open defecation behavior (p=0.000, <0.05). this was observed in the working area of mangarobombang health center, takalar regency, where the role of health workers, community leaders, and religious leaders was found to be particularly influential. discussion the role of social support is to facilitate community participation, thereby enhancing the capacity to adopt and maintain clean and healthy behaviors. the influence of social support, including that from family, friends, and neighbors, on health-improvement behaviors is well documented. social relationships and social support are reciprocal and can influence both positive and negative behaviors.19,20 other forms of social support, which can be provided by health workers, local government, religious leaders, and community leaders in conjunction with the promotion of family latrines, include the dissemination of information and the delivery of educational programs about the advantages of latrines. additionally, assistance can be provided to communities that continue to practice open defecation to foster motivation and awareness among these communities regarding the ownership and utilization of latrines.21-23 table 4 shows that 40.0% of households still receive poor or no social support from health workers, religious leaders, and community leaders, and they practice open defecation. this situation can be attributed to the fact that there are still individuals who have not been made aware of the consequences of open defecation and who continue to engage in this practice due to the lack of social disapproval and the absence of any adverse consequences in their immediate environment. another contributing factor is that some households have not yet received facilities from stop-defecation programs, such as the free latrine program provided by the government. nonetheless, some households have received free latrines but have chosen not to build or use them because they believe they require funds for other purposes. as a result, it is critical to implement a voluntary community awareness program to discourage open defecation, which can be harmful to people’s health.24,25 a total of 108 respondents (86.4%) reported receiving sufficient social support and did not engage in open defecation practices. this finding is supported by the fact that health workers frequently conduct educational initiatives aimed at promoting behav article table 3. distribution of respondents based on the role of social support in stopping open defecation behavior. research variable n % social support enough 108 87.8 lack 15 12.2 defecation behavior open defecation 6 4.9 odf 117 95.1 total 123 100 source: primary data 2024 table 4. relationship between social support and open defecation behavior. social support open defecation total p (od) behavior od odf n % n % n % lack 6 40.0 9 60.0 15 100 0 enough 0 0 108 86.4 108 100 total 6 4.9 117 95.1 123 100 source: primary data 2024. [healthcare in low-resource settings 2025;13:13381] [page 113] ioral change. these efforts have proven effective in raising awareness and encouraging individuals to adopt recommended health behaviors. additionally, the latrine assistance program encourages community members to use latrines, helping to maintain a defecation-free environment. the local government plays a crucial role in reinforcing this behavioral change by setting a positive example and providing motivation to protect the environment through the use of latrines.26,27 according to lawrence green’s theory,28-30 which suggests that behavior change is influenced by three factors—predisposing, enabling, and reinforcing—education through triggering can facilitate or predispose changes in knowledge and attitudes. similarly, social support, the provision of facilities, and the involvement of community leaders and neighbors in the use of latrines are effective in motivating odf.31,32 health workers, religious and community leaders, and local government are reinforcers for the community to change, as they are the reference group for community behavior.33,34 the results demonstrate that open defecation behavior is more prevalent among respondents with limited social support than among those who receive social support. the chi-square statistical test in this study yielded a p-value of (0.000>0.05), indicating a statistically significant relationship between the role of health workers and open defecation behavior in the mangarabombang puskesmas area, takalar regency. the influence of health workers and community leaders on changing open defecation habits depends on several factors. firstly, community members need access to information and support from health workers and leaders, as well as consequences for not adhering to open defecation practices. secondly, it is essential for the community to be committed to using latrines. when both of these conditions are met, they can serve as powerful catalysts for behavioral change.35,36 households that have never received education from health workers are 5.037 times more likely to continue open defecation practice compared to those who have been educated by health workers.37,38 raising public awareness about recommended practices, such as ensuring cleanliness and proper sanitation, is essential for maintaining a healthy environment and improving the overall health of the community. conclusions the research findings suggest that social support from health workers, religious leaders, and community leaders plays a crucial role in adopting healthy behaviors. exposure to information and emotional encouragement from individuals who have stopped open defecation serves as a significant motivator for others to protect their environment. knowledge and awareness of the benefits of healthy practices can lead to lasting behavior change, ultimately contributing to the achievement of open defecation-free status. references 1. unicef. sanitation and hygiene for all: “make a splash!” partnership progress report 2022-2023. united nations: un: the united nations; 2023. 2. kemenkes ri. laporan tahunan 2022 stop buang air besar sembarangan di indonesia [internet]. jakarta; 2022. available from: http://p2p.kemkes.go.id/wp-content/uploads/2023/ 06/final_6072023_layout_sbs-1.pdf 3. jati sp, nandini n, dewanti nay, et al. the readiness of wonosobo and banjarnegara towards open defecation free regencies. j environ health 2023;15:283–90. 4. nurhayati r, kusumaningtiar da, handayani p, sangadji nw. the effectiveness of the implementation of the communitybased total sanitation program, the first pillar of stop open defecation in the work area of the palmerah district community health center in 2022. kesans int j heal sci 2023;2:351–69. 5. direktorat jenderal kesehatan masyarakat. monitoring data sanitasi total berbasis masyakarat (stbm). direktorat jenderal kesehatan masyarakat, kementrian kesehatan ri. 2021 [cited 2024 jun 4]. available from: https://stbm.kemkes.go.id/nspk 6. sari afk, azizah r, jalaludin j, et al. a review of open defecation (od) in indonesia and the control with logic model. malaysian j med heal sci 2022;18:157–65. 7. arora nk, mishra i. sustainable development goal 6: global water security. environ sustain 2022;5:271–5. 8. juniati a, rahman r, marlina s, et al. gerakan edukasi dalam pencegahan stunting dan perilaku odf pada masyarakat desa jayalaksana. an-nizam 2023;14:279–88. 9. fitriyah n, yuniarti t, wahyono e, et al. clean water issues, community behavior and communication models in sustainable development goals 6 in banten west java indonesia. int j sustain dev plan 2024;19:247–58. 10. fathonah u. faktor-faktor yang berhubungan dengan kepemilikan jamban sehat di wilayah kerja puskesmas lempur kabupaten kerinci tahun 2023. universitas jambi; 2024. 11. daniel d, djohan d, machairas i, et al. financial, institutional, environmental, technical, and social (fiets) aspects of water, sanitation, and hygiene conditions in indigenous-rural indonesia. bmc public health 2021;21:1–15. 12. odagiri m, muhammad z, cronin aa, et al. enabling factors for sustaining open defecation-free communities in rural indonesia: a cross-sectional study. int j environ res public health 2017;14:1572. 13. wu f, sheng y. social support network, social support, selfefficacy, health-promoting behavior and healthy aging among older adults: a pathway analysis. arch gerontol geriatr 2019;85:103934. 14. aulia a, nurjazuli n, darundiati yh. perilaku buang air besar sembarangan (babs) di desa kamal kecamatan larangan kabupaten brebes. j kesehat masy 2021;9:166–74. 15. nzioki jm, korir a. effective methods for community sanitation and hygiene promotion in the developing world: a scoping review. africa j tech vocat educ train 2020;5:175–85. 16. badan pusat statistik. persentase rumah tangga yang masih mempraktikkan buang air besar sembaranga. 2023 [cited 2024 jun 8]. available from: https://www.bps.go.id/id/statistics-table/2/mje3nimy/persentase-rumah-tangga—yangmasih-mempraktikkan-buang-air-besar-sembarangan—babs— di-tempat-terbuka-menurut-provinsi-dan-tipe-daerah—persen.html 17. dinas kesehatan provinsi sulawesi selatan. laporan kinerja tahun 2022. makassar; 2022. available from: https://apidinkes.sulselprov.go.id/repo/dinkes-lkj tahun 2022.pdf 18. puskesmas mangarabombang. profil kesehatan upt puskesmas mangarabombang. mangarabombang; 2022. 19. kelly me, duff h, kelly s, et al. the impact of social activities, social networks, social support and social relationships on the cognitive functioning of healthy older adults: a systematic review. syst rev 2017;6:1–18. 20. richmond cam, ross na. social support, material circum article [page 114] [healthcare in low-resource settings 2025;13:13381] stance and health behaviour: influences on health in first nation and inuit communities of canada. soc sci med 2008;67:1423–33. 21. ruba ye, joko t, budiyono b. faktor pendukung dan penghambat program stop buang air besar sembarangan (babs) di wilayah kerja puskesmas maronggela kecamatan riung barat kabupaten ngada. j ris kesehat masy 2021;1:1– 11. 22. madon s, malecela mn, mashoto k, et al. the role of community participation for sustainable integrated neglected tropical diseases and water, sanitation and hygiene intervention programs: a pilot project in tanzania. soc sci med 2018;202:28– 37. 23. ikhtiar m, riswan ka, asrina a, puspitasari a. hubungan perceived severity dengan perilaku babs pada masyarakat pesisir kab. takalar tahun 2024. media kesehat politek kesehat makassar 2024;19:77–83. 24. bhatt n, budhathoki ss, lucero-prisno deiii, et al. what motivates open defecation? a qualitative study from a rural setting in nepal. plos one 2019;14:e0219246. 25. ghani n, asrina a, septiyanti s, et al. pengaruh penyuluhan dan media mp3 terhadap pengetahuan dan sikap pemanfaatan jamban di desa bontomanai kecamatan mangarabombang kabupaten takalar. wind public heal j 2022;3:814–23. 26. linggar f, rantetampang al, tingginehe r, mallongi a. the factors influencing defecation behavior in toilet pasca community led total sanitation at wamesa sub district manokwari selatan district. int j sci healthc res 2019;4:88–99. 27. ikhtiar m. pengantar kesehatan lingkungan. makassar: cv. social politic genius (sign); 2017. 28. notoatmodjo s. promosi kesehatan dan ilmu perilaku. jakarta: pt. rineka cipta; 2012. 29. de vries h, kremers spj, lippke s. health education and health promotion: key concepts and exemplary evidence to support them. in: principles and concepts of behavioral medicine: a global handbook. new york: springer; 2018. p. 489–532. 30. asrina a, yusriani, idris fp, et al. path analysis of the influence of knowledge on clean and healthy living behavior through perceived susceptibility as an intervening variable in hiv aids prevention. heal educ heal promot 2023;11:293–8. 31. horhoruw a, widagdo l. perilaku kepala keluarga dalam menggunakan jamban di desa tawiri kecamatan teluk ambon kota ambon. j promosi kesehat indones 2014;9:226– 37. 32. asrina a, payapo r, idris fc, et al. health behavior and social support in postpartum mothers treatment in ba’ukup tradition in maluku. pharmacogn j 2023;15:438–42. 33. dupai l, majid r, kamaluddin s, sabilu y. the effectiveness of environmental health behavior in the community through coastal community empowerment program in kendari city southeast sulawesi province, indonesia. indian j public heal res dev 2019;10. 34. asrina a. dole-dole tradition in health seeking behavior of buton society, southeast sulawesi. indian j public heal res dev 2018;9:270–4. 35. sari np, susanti s. kebiasaan buang air besar sembarangan (babs) di desa tanjung peranap, tebing tinggi barat. j kesehat 2021;9:123–31. 36. ratnasari y, fadilla t, amiruddin s. achievement of odf (open defecation free) villages through the social functions approach in teba village. j antropol isu-isu sos budaya 2023;25:21–33. 37. rosita y, ahyanti m. pengetahuan, dukungan tokoh masyarakat dan pemaparan petugas kesehatan terhadap perilaku babs. media publ promosi kesehat indones 2022;5:698–702. 38. fitrianingrum re. community-based total sanitation health promotion strategy in kebaman village, srono district, banyuwangi regency. j qual public heal 2020;3:611–8. article [healthcare in low-resource settings 2025;13:13381] [page 115] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13265 trail of acceptance: the experiences and perspectives of chemotherapy adherence among adolescents with cancer susilo harianto,1,2 nursalam nursalam,2 dewi maryam,3 santo imanuel tonapa4 1faculty of vocational studies, airlangga university, surabaya; 2faculty of nursing, airlangga university, surabaya; 3dr. soetomo hospital, surabaya, indonesia; 4college of nursing, kaohsiung medical university, taiwan abstract chemotherapy adherence is crucial for adolescents with cancer. however, their lived experiences and perspectives on adherence are understudied. understanding these experiences is vital to improving support systems and addressing emotional and psychological challenges during treatment. this study aimed to explore the lived experiences and perspectives of adolescents undergoing chemotherapy. this study employed a descriptive phenomenology approach guided by colaizzi’s method. purposive sampling was used to select adolescents undergoing chemotherapy. data were collected through individual semi-structured interviews from 2022 to 2023 and analyzed using colaizzi’s method, supported by nvivo 10 for data management. adolescents had varying perceptions of their cancer diagnosis, often experiencing emotional distress, which influenced their chemotherapy adherence. the physical and emotional side effects of treatment were significant barriers to adherence. support from healthcare providers, family, and peers played a crucial role in helping adolescents manage their illness and remain committed to treatment. mental health management emerged as a key factor in improving adherence. healthcare providers must adopt a patient-centered approach that addresses emotional distress, practical challenges, and the critical role of support systems in enhancing adolescents’ chemotherapy adherence. introduction adolescents with cancer often undergo intensive treatments such as chemotherapy, radiation therapy, and stem cell transplantation, which can last two to three years.1,2 while these treatments are critical for improving survival rates, they impose substantial physical, emotional, and social burdens. chemotherapy, in particular, is associated with side effects such as fatigue, anaemia, hair loss, and cognitive difficulties, significantly impacting adolescents’ quality of life during this pivotal stage of development.3-6 these challenges can lead to long-term psychological consequences, affecting emotional resilience and self-identity.7,8 cancer treatment also disrupts adolescents’ daily lives and relationships. the invasive and prolonged nature of therapies results in physical discomfort, separation from family and friends, and missed opportunities for education, play, or work.9,10 adolescents often struggle to adjust to the constant cycle of hospitalizations, check-ups, and treatments. these challenges are amplified by the need for emotional and mental stability to navigate the distress of a cancer diagnosis and the physical pain of treatment. during the covid-19 pandemic, additional stressors emerged as pediatric oncology departments adapted protocols to mitigate infection risks while maintaining effective cancer care.11,12 coping with these challenges requires emotional resilience and robust support systems. support from healthcare providers, family, and peers plays a crucial role in helping adolescents adapt to their new realities.13,14 healthcare professionals, in particular, are vital in guiding adolescents through the distressing aspects of treatment and fostering adherence to prescribed therapies.15,16 despite the well-documented benefits of adjuvant chemotherapy in reducing cancer recurrence and mortality, adherence remains a significant issue among adolescents.17 factors such as the side effects of treatment, psychological distress, and inadequate supcorrespondence: susilo harianto, faculty of vocational studies, airlangga indonesia, surabaya, indonesia. e-mail: susilo.harianto@vokasi.unair.ac.id key words: adolescent; chemotherapy; neoplasms; mental health; treatment adherence. contributions: sh, nn, dm, conception and design of the study, acquisition of data, analysis and interpretation of data; sh, nn, dm, sit, drafting the manuscript, critical revision for important intellectual content. all the authors have read and approved the final version of the manuscript and agreed to be accountable for all aspects of the work. conflict of interest: the authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. ethics approval and consent to participate: the research was approved by the clinical researchers ethical committee of dr soetomo hospital based on ethical certificate (approval no. 0289/kepk/x/2021). during the research, the researcher focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgments: the authors would like to thank the cancer survivors and their parents who participated in the study, the oncology department, and the indonesia oncology nurses association. received: 18 october 2024. accepted: 8 january 2025. early access: 5 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13265 doi:10.4081/hls.2025.23265 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 74] [healthcare in low-resource settings 2025;13(s1):13265] port systems often hinder consistent adherence. while many studies have explored adherence in adult populations, research focusing on adolescents’ perspectives is limited. existing studies often emphasize specific treatments or conditions rather than examining adherence holistically. this gap leaves healthcare providers with an incomplete understanding of the factors influencing adherence among adolescents at a unique developmental stage that necessitates tailored interventions.18,19 this study seeks to address this gap by exploring the lived experiences and perspectives of adolescents undergoing chemotherapy. by understanding the barriers and facilitators to adherence, this research aims to inform strategies that support adolescents in managing their treatment effectively and improving overall outcomes.20 materials and methods research design this study adopted a descriptive phenomenology design to figure out how adolescents with cancer experience life. it focuses on capturing the essence of lived experiences, emphasizing the detailed aspects of events or situations. given the personal and often complex nature of adolescents’ experiences with chemotherapy adherence, this approach is particularly appropriate. by delving deeply into their experiences, descriptive phenomenology allows for a rich exploration of the factors that influence adherence during cancer treatment, shedding light on both the challenges and motivations adolescents face throughout their treatment journey. this manuscript adhered to the consolidated criteria for reporting qualitative research (coreq) checklist to ensure transparency and rigor in the reporting of qualitative research.21 study participants participants were recruited using purposive sampling from the pediatric hematology-oncology clinic at dr. soetomo hospital, a major referral hospital in surabaya, indonesia. the recruitment process involved close collaboration with the treating healthcare teams to identify eligible participants who met the inclusion criteria. the research team approached potential participants and their parents in a private setting at the clinic. the purpose of the study, the voluntary nature of participation, and the confidentiality measures were explained in detail. written informed consent was obtained from both the adolescents and their parents before participation. the inclusion criteria were as follows: i) undergoing chemotherapy for at least two to twelve months when participating in this study; ii) being aged between 13 and 18 years; and iii) being fluent in speaking and understanding the indonesian language. exclusion criteria included: i) adolescents with significant cognitive or communication impairments that would prevent effective participation; ii) those with concurrent severe medical conditions other than cancer; and iii) those with a very recent cancer diagnosis (less than two months). data collection semi-structured interviews were conducted from january 2022 to january 2023 in a private room within the hospital, providing a familiar and safe environment. the first author conducted the interviews face-to-face, using open-ended questions to guide participants in sharing their emotions, experiences, and perspectives on their cancer diagnosis and treatment adherence (table 1). each session began with rapport-building conversations to create a supportive atmosphere, followed by open dialogue facilitated by active listening and empathetic responses. participants were informed they could pause or terminate the interview at any time if they felt uncomfortable. the interviews, lasting 15 to 30 minutes, were audio-recorded with consent, and confidentiality was assured. recordings were transcribed verbatim within 24 hours to maintain accuracy. in line with colaizzi’s method, transcripts were analyzed to identify significant statements and themes, with member checking used to ensure the accuracy of findings. data analysis the data analysis followed colaizzi’s method of descriptive phenomenology to capture the essence of adolescents’ experiences with chemotherapy adherence.22 the researchers (dm and sh) began by reading and re-reading the transcripts to immerse themselves in the data. significant statements reflecting the participants’ lived experiences were identified and extracted from the transcripts, and meanings were formulated based on these statements. throughout this process, researchers bracketed their own biases and assumptions to maintain objectivity. these formulated meanings were grouped into clusters of themes representing the essence of the participants’ experiences. nvivo 10 software was used for data management, organizing the interviews into meaning units while preserving the descriptive integrity of the data. as data collection progressed, themes were continuously refined until data saturation was reached, with no new themes emerging. after identifying significant statements and formulating themes, member checking was conducted to ensure the findings accurately reflected participants’ experiences. during follow-up sessions, the research team summarized the themes and significant statements with the participants. participants were invited to provide feedback on whether the themes resonated with their experiences and to clarify or expand on any aspects they felt were misrepresented or incomplete. their input was incorporated into the final analysis to enhance the credibility and authenticity of the findings. rigor and trustworthiness this study employed several strategies to ensure rigor and trustworthiness. first, the researcher established a trustworthy relationship with participants by maintaining professionalism while allowing the adolescents to speak freely about their experiences. data were collected through semi-structured interviews and transcribed verbatim without adding commentary or interpretation to preserve the authenticity of the participants’ responses. the report special issue pathways of change table 1. interview guidance. interview questions 1. how do you feel about your cancer disease? what do you feel now? what is the source of strength that you feel right now? 2. what was your experience when you were undergoing medication/being treatment with chemotherapy? what difficulties did you encounter? how do you manage yourself when you are under pressure (while receiving the treatment)? 3. how do you feel (about the treatment)? what is your expectation with the support system (the medical provider, family and friends/peer support)? [healthcare in low-resource settings 2025;13(s1):13265] [page 75] reflects the exact data that was recorded during the interviews. to enhance confirmability, direct quotes from multiple participants were included to demonstrate transparency in the data analysis process, allowing readers to see the connection between the data and the findings. additionally, researcher triangulation was used, with multiple researchers involved in the coding and analysis process to reduce bias. finally, to ensure transferability, the study context and circumstances were described in detail to allow readers to determine the applicability of the findings to other settings. ethical consideration approval of the clinical researchers ethical committee of dr. soetomo hospital was obtained (approval no. 0289/kepk/x/2021). the adolescents and their parents were informed of the purpose and methods of the study before the inperson interviews, and verbal and written consent was obtained. the option to withdraw from the study at any moment was made clear to the participants. all data were de-identified. results socio-demographics a total of 16 participants voluntarily reported their experiences (table 2). participants ranged in age from 13 to 18 years (m=14.54, sd=1.79), with nine females (56%) and seven males (44%). nine participants were at the junior high school level (56%, m=8.6, sd=1.9). most participants (87.5%) were at stage iii of cancer, while the remaining 12.5% were at stage iv. they had been undergoing treatment cycles ranging from the second to the fifth. themes the data were summarized into three main themes with associated sub-themes, determined in light of the adolescents’ cancer experiences and their expressions during chemotherapy (table 3). using colaizzi’s method, significant statements were extracted from the interviews, and meanings were formulated based on these statements. these meanings were then clustered into overarching themes. the main themes were identified as patients’ health special issue pathways of change table 2. demographic characteristics of participants (n=16). characteristics n % mean standard deviation gender female 9 56 male 7 44 age at study 14.54 1.79 13-15 9 56 16-18 7 44 educational level 8.59 1.91 junior high school 9 56 senior high school 7 44 ethnicity 1.59 1.22 javanese 9 56 sundanese 1 6.3 bataknese 1 6.3 balinese 1 6.3 maduranese 4 25 religion 2.04 1.61 islam 9 56 catholicism 2 12.5 christianity 2 12.5 hinduism 2 12.5 buddhism 1 6.3 time since first diagnosis (month) 30.59 6.34 <24 7 44 25-36 5 31 37-48 4 25 cancer stage stage iii 14 87.5 stage iv 2 12.5 treatment cycle 2nd 3 18.7 3rd 4 25 4th 3 18.7 5th 6 37.5 primary caregiver mother 14 87.4 father 1 6.3 grandmother 1 6.3 [page 76] [healthcare in low-resource settings 2025;13(s1):13265] special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13265] [page 77] table 3. coding tree of themes, sub-themes, and supporting quotes from participants. themes sub-themes quotes beliefs, strength, motivation, and perception of illness control. member checking was conducted with participants to confirm the accuracy of these themes. theme 1: physical and emotional impact of cancer diagnosis and therapy perceived cause of cancer participants have varied perceptions about the cause of cancer and felt uneasy and acted or moved something vigorously when they were first told about their cancer diagnosis. the participants reported feeling disturbed and having difficulties receiving bad news about their health. they were stunned and heartbroken as their universe had fallen apart. adolescents had turbulent emotions and were quick to get furious. as described by a participant: “when my mother told me about my diagnosis, i trembled, like i was thrown a heavy stone and cannot breathe. no one wants to get cancer, not at my age, i am still young, and i have so many dreams.” (p1) a significant minority of the respondents indicated that they thought the cause of the disease was recorded, illustrated as follows: “my opinion is that this disease cannot be from the lord or normal sickness.” why do you think so? “because no member of my family has experienced this before. do you see what i’m saying? no one from my family ever had it then. it should be from someone who hates our family emm... i mean the evil spirit or what errr... what is your view?” (p3) however, a participant also thought that the condition was a result of a biogenic or hereditary cause in his family. an interviewee’s narration is presented as: “you mean what i think as the cause? how... can i tell specifically my mother?... [sobs]… what i can say is that you know, my mother, she had breast cancer, so i’m tempted to conclude that it was caused by heredity.” (p7) symptoms and side effects of chemotherapy significant statements were identified regarding the physical and emotional toll of chemotherapy, with participants describing both the physical side effects and their emotional responses. formulated meanings revealed that chemotherapy had a profound impact on their body image, self-esteem, and mental health, as described by a participant in this study: “my main worry is what happens after the chemotherapy finishes. will i be free, or the disease will recur? i don’t want to go through this therapy again.” (p2) body image was also a major concern to the patients. participants were worried about how they looked after the chemotherapy. their responses are presented in the following narrations: “eeiiiih the fact that my hair fell out and i became bald after chemotherapy makes me very sad. mmm, no matter what anyone says, you can’t convince me that i’ll be the same person again after the cancer treatment.” (p5) another adolescent reported that chemotherapy changes his physical appearance and self-esteem and said, “losing my hair was really hard. i didn’t feel like myself anymore, and i was embarrassed to go out.” (p15) the adolescents with cancer described suffering from debilitating side effects, particularly pain, nausea, vomiting, and hair loss, as reported by one child: “nausea and vomiting were the worst. some days, i could barely get out of bed because i felt so weak.” (p13) adolescents with cancer often face significant challenges and report experiencing poor mental health. many struggle with a loss of confidence in themselves and their ability to cope with pressure. as a result of their illness and its treatment, they may feel worn down, burnt out, anxious, sad, and depressed, as reported by one child: “every time i go for a check-up, i’m scared they will find something bad. the fear never goes away.” (p14) another child shared, “i feel so sad sometimes, like there’s no end to this. seeing my friends living normal lives makes it even harder.” (p16) theme 2: patient strengthened by surrounding patient-healthcare providers’ relationships this sub-theme indicated that the participants felt that health professionals understood the disease burden. patients felt that healthcare providers were helpful in providing clear communication and emotional support about the disease and its treatment. as a result, participants appreciate being treated with respect and the impact this has on their sense of acceptance and adherence to treatment. “i have to deal with it on all levels, not just physically, and now that my doctor is saying the same thing, that’s been helpful to me” (p4). while others said: “the outstanding attitude of the staff helped me very much. i am treated at eye level for everything i say and any opinion i have. it gives you a good feeling.” (p9) “the nurses are really supportive. they make the treatments a bit more bearable and always listen to me.” (p11) health care professionals’ true understanding of the burden of disease was perceived as particularly supportive, with participants reporting they could be honest with the treating team about the personal impact of the disease and treatment, as opposed to family and friends who they were sometimes trying to protect. family support over half of the adolescents reported that support from their family members helps them cope with their illness more easily, as one child said, “the support of my family gave me lots of strength.”(p10) while the others said: “my mother always stood by me in my worst moments, i think that’s what made me strong and wanted to recover.” (p11), and “my parents have been amazing. they take care of everything and always try to cheer me up.” (p12) peer support and friendships adolescents felt alone in their concerns since they found it difficult to express their worries to friends. individuals who could honestly and openly express their anxieties demonstrated a more positive outlook and the ability to focus on accepting their circumstances (this was easier for those with a better prognosis). for those with previous experiences of anxiety, their experience was mixed: some believed they were more prepared to handle anxiety due to previous experiences of psychological support, while others felt entirely overwhelmed by the diagnosis. socializing with other cancer patients helped to normalize their experiences during treatment, but it could also be upsetting to witness how sick people can get or, in other situations, to realize how poorly they were in com special issue pathways of change [page 78] [healthcare in low-resource settings 2025;13(s1):13265] parison. one said, “i don’t see my friends as much anymore. they don’t understand what i’m going through, and i feel isolated.” (p6) those seeking peer support during therapy expressed gratitude for the space it provided to express their fears and anxieties without burdening others and for enabling them to avoid dwelling on or ruminating on their concerns. for instance, one participant noted, “when i see other friends with the same problem as me, i feel relieved, i am not alone, it makes you feel good, and you continue to seek that, and even though the damage happens, you continue. it must be something that makes you go on to take that other step and keep moving in the right direction, and that makes you feel really good and helpful.” (p8) theme 3: medication management difficulties in following the prescribed regimen significant statements were extracted related to the physical and emotional challenges adolescents faced in adhering to their treatment regimen. these statements revealed how adolescents struggled with the physical discomfort of injections and the emotional toll of frequent hospital visits. for example, one participant expressed, “the pricking is hard for me psychologically. i am traumatized by the needle pricks.” (p6) while another said, “sometimes i get annoyed and angry when the nurse inserts the needle and then fails, then they insert the needle again and again several times, don’t you see it was hurt.” (p8) all the participants underlined the considerable impact of the side effects of adjuvant chemotherapy on their quality of life. some in active school had to postpone their studies, remain on sick leave, or even stop doing what they liked most. these statements reflect this: “i had to give up doing the things i liked the most, such as going for walks or playing football with my friends. routines, daily life in general were affected.” (p9) the frequent medical appointments made an emotional burden for adolescents; one stated, “i hate going to the hospital, the treatments are painful, and it’s hard to keep up with school and friends.” (p16) however, the majority of adolescents said there could be greater management when it comes to mental health help. those on treatment felt mental health should be addressed with the same emphasis as their physical health. adolescents made efforts to adjust to their illnesses and treatments. participants found that certain activities could alleviate pain and fear during therapy, but they had to repeatedly request these activities before receiving them. “i play video games and read books to take my mind off the pain. it helps a lot.” (p1) “i play music on my cellphone; it makes me calm down and forget the pain of chemotherapy.” (p2) “my mom installed murottal quran in my tab, and i played it while i got chemo; i think it works because it lessens the pain and nausea. i don’t know the correlation, but my friend also uses this, and it works too.” (p16) from un-adherence to adherence when given the opportunity to think things through, adolescents were more likely to mention feeling the need to be brave, go it alone, or rely solely on their willpower; however, several of them admitted that this was frequently due to stubbornness and immaturity. however, most patients agreed that medication adherence was the key to overcoming the disease, emphasizing the importance of taking it on a regular basis despite adverse effects and putting it ahead of other concomitant health issues. the need and the belief that the medication is necessary were arguments that overcame not taking it. the following statement illustrates this: “you can get things off your chest with your family, your friends and stop doing anything you want to, but you can never stop taking the medication, ever ...” (p7) “i want to be cured, that means i must obey the cancer treatment. it is period!” (p12) “i try to stay positive and think about the future. i tell myself that it will end, and i’ll get better. i just need to hold down, be a good girl, obey the rules and do the treatments.” (p15) discussion this study enhances the understanding of adolescents’ experiences with chemotherapy adherence by exploring the emotional, social, and practical challenges they face. cancer, a life-threatening and complex illness, imposes profound psychological and spiritual burdens, as previous research indicates.23,24 the unexpected diagnosis of cancer disrupts the lives of adolescents and their families, necessitating a restructuring of relationships and daily routines.23,25 this disruption is often accompanied by intense emotions, including fear, anxiety, despair, and helplessness.26,27 in this study, participants frequently experienced emotional turmoil upon diagnosis, sometimes attributing their illness to hereditary factors or other personal explanations. these findings underscore the importance of addressing adolescents’ emotional responses early in the treatment process to build coping mechanisms and resilience. support from family, friends, and healthcare providers emerged as a crucial factor in helping adolescents manage the stress and challenges of chemotherapy. previous studies have highlighted the role of supportive strategies, such as empathetic communication, timely clarification of treatment plans, and encouragement to express fears and concerns.19,28,29 similarly, participants in this study reported finding consolation and strength in their relationships with family members and trusted medical professionals. the hospital setting, often regarded as a second home, provided an environment where adolescents felt comfortable sharing their emotions and concerns.30,31 these findings suggest that fostering supportive relationships within clinical settings is integral to improving adherence. healthcare providers should prioritize creating a therapeutic alliance with adolescent patients through consistent and compassionate interactions. optimism and hope were also central themes in this study, influencing participants’ adherence behaviours. while hope alone did not guarantee adherence, it was an essential component when combined with a clear understanding of treatment benefits and the effectiveness of medications. participants who connected their knowledge of the illness to symptom relief were more likely to remain adherent. this aligns with existing evidence suggesting that hope can enhance behavior change when paired with meaningful knowledge.32 interventions that integrate psychological counseling and education about treatment benefits may further enhance adherence by reinforcing hope and resilience. the study’s findings have direct implications for clinical practice and the development of targeted interventions. healthcare providers should adopt a holistic approach that addresses both the physical side effects of chemotherapy and the emotional well special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13265] [page 79] being of adolescent patients. mental health assessments, counseling services, and peer support programs could play a pivotal role in supporting adolescents. additionally, practical interventions such as child-friendly hospital environments and digital tools for tracking medication adherence may mitigate logistical challenges and improve engagement with treatment. limitations this study has several limitations. first, the sample size, although appropriate for a phenomenological approach, was relatively small and recruited from a single hospital, which may limit the transferability of the findings to other populations or settings. second, the reliance on self-reported data might have introduced recall bias as participants reflected on their experiences with chemotherapy adherence. third, the study was conducted within a specific cultural and clinical context, which may influence the generalizability of the findings to adolescents in other cultural or healthcare environments. future research should consider exploring diverse settings and employing longitudinal designs to capture the evolving nature of chemotherapy adherence experiences over time. conclusions this study provides valuable insights into the lived experiences and perspectives of adolescents undergoing chemotherapy, highlighting the multifaceted challenges they face in adhering to treatment. emotional distress, social isolation, and the physical side effects of chemotherapy emerged as significant barriers, while support from healthcare providers, family, and peers served as critical facilitators. these findings underscore the importance of addressing both the psychological and practical needs of adolescents to improve adherence. healthcare providers must adopt a patient-centered approach that integrates emotional support, effective communication, and tailored interventions to enhance treatment adherence. by understanding the unique experiences of adolescents, healthcare teams can develop targeted strategies to foster resilience, improve adherence, and ultimately achieve better treatment outcomes. references 1. cox le, kenney ae, harman jl, et al. psychosocial functioning of young children treated for cancer: findings from a clinical sample. j pediatr oncol nurs 2019;36:17–23. 2. sansom-daly um, wakefield ce, patterson p, et al. end-oflife communication needs for adolescents and young adults with cancer: recommendations for research and practice. j adolesc young adult oncol 2020;9:157–65. 3. malard f, mohty m. acute lymphoblastic leukaemia. lancet 2020;395:1146–62. 4. volberding pa, spicer cm, cartaxo t, aiuppa l. childhood cancer and functional impacts across the care continuum. childhood cancer and functional impacts across the care continuum 2021;1–527. 5. arizona iklt, sukartini t, efendi f, et al. the experiences of cancer-related fatigue among adult cancer patients: a systematic review. j ners 2019;14. 6. khoirunnisa sm, suryanegara fda, de jong la, et al. a systematic review of health-related quality of life in women with her2-positive metastatic breast cancer treated with trastuzumab. pharmacoecon open 2024;8:511-24. 7. stein kd, syrjala kl, andrykowski ma. physical and psychological long-term and late effects of cancer. cancer 2008;112:2577–92. 8. andrés-jensen l, larsen hb, johansen c, et al. everyday life challenges among adolescent and young adult survivors of childhood acute lymphoblastic leukemia: an in-depth qualitative study. psychooncology 2020;29:1630–7. 9. epstein rs, roy ukb, aapro m, et al. cancer patients’ perspectives and experiences of chemotherapy-induced myelosuppression and its impact on daily life. patient prefer adherence 2021;15:453–65. 10. anand u, dey a, chandel aks, et al. cancer chemotherapy and beyond: current status, drug candidates, associated risks and progress in targeted therapeutics. genes dis 2022;10:1367-401. 11. arslan ft, basbakkal z, kantar m. quality of life and chemotherapy-related symptoms of turkish cancer children undergoing chemotherapy. asian pacific j cancer prev 2013;14:1761–8. 12. martinez-santos ae, fernandez-de-la-iglesia j del c, sheaf g, coyne i. a systematic review of the educational experiences and needs of children with cancer returning to school. j adv nurs 2021;77:2971–94. 13. wiener l, bedoya s, battles h, et al. voicing their choices: advance care planning with adolescents and young adults with cancer and other serious conditions. palliat support care 2022;20:462–70. 14. dewi eu, nursalam, mahmudah, yunitasari e. the effect of peer support psychoeducation based on experiential learning on self-care demands among breast cancer patients with postchemotherapy. j public health res 2023;12. 15. supriati l, sudiana ik, nihayati he, et al. perspective of uncertainty and emotional responses in breast cancer patients during the covid-19 pandemic. sage open nurs 2022;8. 16. nira aw, triharini m, nastiti aa. factors associated with the resilience of breast cancer patients undergoing chemotherapy. pediomaternal nurs j 2020;6:89. 17. cheung at, li whc, ho llk, et al. impact of brain tumor and its treatment on the physical and psychological well-being, and quality of life amongst pediatric brain tumor survivors. eur j oncol nurs 2019;41:104–9. 18. mirlashari j, ebrahimpour f, salisu wj. war on two fronts: experience of children with cancer and their family during covid-19 pandemic in iran. j pediatr nurs 2021;57:25–31. 19. laronne a, granek l, wiener l, et al. “some things are even worse than telling a child he is going to die”: pediatric oncology healthcare professionals perspectives on communicating with children about cancer and end of life. pediatr blood cancer 2022;69. 20. murphy s, donma aj, kohut sa, et al. mindfulness practices for children and adolescents receiving cancer therapies. j pediatr hematol oncol nurs 2022;39:40-8. 21. tong a, sainsbury p, craig j. consolidated criteria for reporting qualitative research (coreq): a 32-item checklist for interviews and focus groups. int j qual heal care 2007;19:349–57. 22. vignato j, inman m, patsais m, conley v. computer-assisted qualitative data analysis software, phenomenology, and colaizzi’s method. west j nurs res 2022;44:1117–23. 23. liu y, li y, chen l, et al. relationships between family resilience and posttraumatic growth in breast cancer survivors special issue pathways of change [page 80] [healthcare in low-resource settings 2025;13(s1):13265] and caregiver burden. psychooncology 2018;27:1284–90. 24. supatmi s, santoso b, yunitasari e. the effect of spirituality on psychological hardiness of cervical cancer patients with chemotherapy. stud ethno-medicine 2022;16:17–23. 25. neville k. the relationships among uncertainty, social support, and psychological distress in adolescents recently diagnosed with cancer. j pediatr oncol nurs 1998;15:37–46. 26. dalton l, rapa e, ziebland s, et al. communication with children and adolescents about the diagnosis of a life-threatening condition in their parent. lancet 2019;393:1164–76. 27. suhayono s, wibowo sa, purnamasari i, et al. a systematic review of supportive therapy effect on quality of life in cancer patients. j ners 2020;15:197–207. 28. brinkman tm, recklitis cj, michel g, et al. psychological symptoms, social outcomes, socioeconomic attainment, and health behaviors among survivors of childhood cancer: current state of the literature. j clin oncol 2018;36:2190–7. 29. kalajdžić o, pavlović j. the impact of the family and health workers on psychosocial adaptation and the process of treatment of oncological patients. open access maced j med sci 2020;8:779–83. 30. blazin lj, cecchini c, habashy c, et al. communicating effectively in pediatric cancer care: translating evidence into practice. children 2018;5. 31. topperzer mk, hoffmann m, larsen hb, et al. interprofessional versus monoprofessional case-based learning in childhood cancer and the effect on healthcare professionals’ knowledge and attitudes: study protocol for a randomised trial. bmc health serv res 2020;20. 32. ripamonti ci, giuntoli f, gonella s, miccinesi g. spiritual care in cancer patients: a need or an option? curr opin oncol 2018;30:212–8. special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13265] [page 81] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13039 development of food for special dietary uses of diabetes based on oyster mushroom and brown rice inggita kusumastuty,1 etik sulistyowati,2 dian handayani,1 fajar ari nugroho,1 anggun rindang cempaka,1 agustin rustiani,1 alfina putri rakhmadiyah,1 muhamad zulkifli,1 hana raniza jasmine,1 gemma karnika prakasita,1 firza zahra amanda,1 ajeng rifana putri1 1department of nutrition, faculty of health sciences, universitas brawijaya, malang, east java; 2department of nutrition, malang state health polytechnic, malang, east java, indonesia abstract diabetes patients often struggle to meet their energy requirements, prompting the suggestion of utilizing food for special dietary uses (fsdu). previous research has shown the efficacy of oyster mushrooms’ b-glucan in controlling hyperglycemia and insulin resistance. brown rice, high in magnesium and fiber with a low glycemic index, is known to lower blood glucose levels. utilizing both ingredients in fsdu may provide products with recommended energy value, nutrient ingredients, and glycemic index. this study aimed to measure the energy, protein, fat, carbohydrate, fiber, glucose, and glycemic index of four mixed formulations of oyster mushrooms and brown rice, along with a control. the study used a true experimental design with a completely randomized research design. the formulations included: p1=9% mixture of moringa and fish flour, p2=10% mixture of carrot and fish flour, f3=11% mixture of moringa and tempeh flour, and f4=12% tempeh flour. the total energy was measured using various methods: adiabatic oxygen bomb calorimeter for energy, kjeldahl for protein, soxhlet for fat, by-difference for carbohydrates, aoac enzymatic-gravimetric for total dietary fiber, anthrone for total sugar, and blood glucose tests at 0, 15, 30, 45, 60, 90, and 120 minutes post-test-food ingestion for glycemic index measurements. statistical analysis was performed using the one-way anova and kruskal-wallis tests. the research results indicate significant differences in energy, protein, fat, carbohydrates, total sugar, and fiber values among groups (p<0.01). the lowest glycemic index was found in p4 (44.32, medium category). further analysis indicated that p4 had higher total energy and fat, but lower carbohydrates, total sugar, and glycemic index. according to the multiple attribute zeleny method, the p4 formula was the best formula for all parameters. the most effective formula, containing brown rice, oyster mushrooms, and tempeh flour (p4), could be a beneficial option for improving the health of individuals with diabetes in the community. introduction diabetes mellitus (dm) is the most prevalent type of diabetes, accounting for more than 90% of all diabetes cases worldwide.1 the world health organization (who) predicts an increase in dm cases in indonesia from 8.4 million in 2000 to 21.3 million by 2030.2 in line with that, data from the international diabetes federation (idf) rank indonesia as the fifth country worldwide in terms of dm prevalence.1 the results of the basic health research in 2018 showed an increase in the prevalence of dm from 6.9% in 2013 to 8.5% in 2018.3 these data emphasize the imperative for continuous efforts in dm management and prevention. the etiology of dm is multifactorial and can be classified into two categories: unmodified and modified. unmodifiable risk factors for dm include race, ethnicity, family history, age, history of gestational dm, and history of low birth weight. meanwhile, modifiable risk factors for type 2 diabetes mellitus (t2dm) include overweight (bmi ≥ 23 kg/m2), lack of physical activity, hypertension (≥ 140/90 mmhg), dyslipidemia (hdl < 35 mg/dl and/or triglycerides > 250 mg/dl), unhealthy diet characterized by high sugar and low fiber intake.4,5 nutritional therapy plays a pivotal role in managing dm patients.2 recommendations include limiting high glycemic index foods, increasing fiber-rich foods, and reducing saturated fat consumption. furthermore, adherence to a consistent meal schedule, as well as careful attention to meal type and quantity, are crucial for dm patients. despite these recommendations, according to harmawati (2020), dm patients encounter obstacles in adhering to dietary guidelines, including the fear of sugar consumption, dissatisfaction with prescribed diets, and boredom with menu options. currently, the development of food for special dietary uses (fsdu), catering specifically for dm patients, remains limited.6 this is a challenge for dm patients in meeting their nutritional needs. fsdu for dm patients constitutes a specialized food formula designed to meet the dietary requirements of dm patients, providing an alternative or supplementary option that aligns with their daily nutritional needs and intake considerations.7 [healthcare in low-resource settings 2024;12(s1):13039] [page 129] significance for public health the coadministration of oyster mushrooms and brown rice has shown significant efficacy in regulating blood glucose levels. this intervention has received positive acclaim from the general public and demonstrates great potential for individuals managing diabetes. the formulation of food for special dietary uses (fsdu) that integrates this combination could present a valuable option for improving the well-being of individuals with diabetes, yielding notable societal benefits. non -co mmerc ial us e o nly the preference for rice among indonesians is very high, given its status as a staple food in daily meals.8 however, people with diabetes mellitus (dm) must carefully consider their consumption of white rice due to its high glycemic index, ranging from 50 to 87. as a result, many choose to substitute white rice with alternatives, such as brown rice.9 brown rice offers benefits for diabetes management due to its high fiber content, along with essential vitamins and minerals.10,11 in line with that, the research conducted by handayani et al. (2020) proved that brown rice consumption leads to reductions in blood glucose and hba1c levels among respondents with dm.12 similarly, a study by golzarand et al. (2021) showed that brown rice consumption significantly contributes to weight loss, improved lipid profiles, and lower fasting blood glucose levels compared to white rice.13 in the development of food for special dietary uses (fsdu) for t2dm patients, the inclusion of other functional foods, such as oyster mushrooms, is also needed. oyster mushrooms, well-known for their high-fiber food, are a popular choice in the community. moreover, they contain ß-glucan, known as phytoinsulin, which is insulin derived from plants. this compound stimulates ß-pancreatic cells in the body to produce more insulin, thus reducing blood glucose levels.14 additionally, white oyster mushrooms are also rich in fiber, which, when fermented within the body, increases the production of glucagon-like-peptide-1, helping in glycemic control in the body. research indicates that the administration of oyster mushroom infusa extract exhibits a greater ability to reduce blood glucose levels compared to antidiabetic oral drugs.15 considering this background, it is essential to research the development of food products utilizing brown rice and oyster mushrooms as the main ingredients in making fsdu for t2dm patients. this study aimed to develop fsdu products made from brown rice and oyster mushrooms with various flavors derived from fish flour, carrot flour, moringa flour, and tempeh. these products aare expected to meet the energy content and nutrient requirements and maintain low gi, aligning with the specifications outlined for fsdu intended for individuals with dm and adhering to commercial fsdu standards. materials and methods this research consisted of two main stages: product development and glycemic index testing. the first stage used a true experiment design with a complete randomized design. the sample consisted of four modified formulations along with one control formula. the basic ingredients of fsdu remained the same across all four formulations, consisting of brown rice and oyster mushrooms. however, each formulation varied in the additional ingredients, which included fish flour, tempeh flour, carrot flour, and moringa flour. the additional ingredients were incorporated to provide additional protein to fsdu. according to zetta (2018), for food research, each food sample underwent three repetitions for analysis, resulting in a total of 15 research sample units.16 the second stage of the research involved quantitative research using a quasi-experimental method with a pre-posttest design. the objective was to determine the differences in glycemic index value between the four fsdu products developed compared to fsdu commercial products. energy, macronutrients, sugar, and fiber analysis procedure protein content was determined using the kjedahl method, with measurements conducted three times. the analysis process involved three stages: deconstruction, distillation, and titration. fat was analyzed using the soxhlet method. carbohydrate analysis was carried out using by-different methods in proximate analysis, calculated using the formula: 100% (water content + ash content + fat content + protein content). energy content analysis was carried out using the adiabatic oxygen bomb calorimeter method. the sugar content, including reducing and non-reducing sugars, was measured using the anthrone test with spectrophotometry. the amount of dietary fiber contained in the product was determined using the enzymatic-gravimetric method. glycemic index measurement procedure ten subjects in this study were selected through purposive sampling. the inclusion criteria included willingness to participate by signing informed consent, normal nutritional status (body mass index 18.5-25 kg/m2), age between 18-24 years, normal blood pressure, no history of diabetes mellitus, kidney disease, and liver disease, no family history of dm, no digestive disorders, no psychological stress and healthy, not taking medication, and normal fasting glucose levels <110 mg/dl. the exclusion criteria were failure to fast for 10 hours prior to data collection, illness, and the decision to withdraw from the study. materials used in the glycemic index test were four developed fsdu products, commercial fsdu products, and white bread as a reference/standard food; all products were prepared with an equivalent of 25 g of carbohydrate. the procedure in the glycemic index test involved fasting for 10 hours (22.00-08.00 wib), followed by blood glucose levels measurement at 08.00 (minute 0). test foods, including white bread, were consumed within 10 minutes, and blood glucose levels were measured at 15, 30, 45, 60, 90, and 120 minutes post-consumption. the same procedure was repeated for the glycemic index testing of the developed fsdu and commercial fsdu, conducted consecutively at a two-day interval. the results of blood glucose levels at each measurement time were plotted on the x-axis (time in minutes) and y-axis (blood glucose levels). incremental area under curve (iauc) calculation used a time series response analyzer. determination of the glycemic index value was determined by comparing the iauc area among the developed fsdu products, commercial fsdu products, and white bread as reference food.18 procedure for determining the best treatment the best formulation was determined using the multiple attribute method (zeleny, 1982), considering parameters such as energy content, protein, fat, carbohydrates, sugar, fiber, and glycemic index. the steps involved determining the ideal value of each parameter, calculating the degree of density (dk), and calculating the degree of density (lp). the best treatment was selected based on the treatments with the minimum number of values. statistical analysis data were presented as mean ± sd for normally distributed data and median ± se for non-normally distributed data. the data normality test was assessed using the shapiro-wilk test. for nonnormally distributed data, various transformations such as squared variables, tripled variables, 1/variable, log10variable, and variable roots were used. homogeneity of variance was examined using the levene test for normally distributed data. if the data were normally distributed and homogenous, the one-way anova test was applied, followed by the bonferroni post hoc test to identify differences between treatments. non-normally distributed data were analyzed using the kruskal-wallis test. if p < 0.05, indicating a 4th international nursing and health sciences symposium [page 130] [healthcare in low-resource settings 2024;12(s1):13039] non -co mmerc ial us e o nly significant difference, the analysis proceeded with the mann whitney u post hoc test to determine the difference between treatments. a significance level of p < 0.05 was utilized to determine statistical significance. all experimental procedures were approved by the research ethics committee of malang state health polytechnic (441/kepk-polkesma/2022). results and discussion the development of food for special dietary uses (fsdu) for diabetes mellitus patients based on brown rice and oyster mushrooms is an alternative food product utilizing local food ingredients. this food product was formulated into four distinct formulations, each incorporating protein-rich flour ingredients (figure 1). table 1 shows the formulation of fsdu development based on brown rice and oyster mushroom. the results of energy and nutrient analysis of fsdu product development are presented in table 4th international nursing and health sciences symposium figure 1. product development of fsdu of dm. table 1. formulation of fsdu development based on brown rice and oyster mushroom. ingredients composition of ingredients for each formulation formula 1 (p1) formula 2 (p2) formula 3 (p3) formula 4 (p4) grams grams grams grams mushroom flour 60 60 60 60 brown rice 375 375 375 375 soybean oil 5 5 5 5 coconut oil 30 3 3 3 sugar 12 12 12 12 moringa fishmeal 50 carrot fish flour 52 moringa tempeh flour 60 tempeh flour 62 prediction of nutritional content of brown rice and oyster mushroom-based fsdu * carbohydrate (gram) 360.71 362.59 363.09 362.20 protein (gram) 64.98 63.68 63.37 64.18 fat (gram) 46.29 47.96 48.52 46.72 energy (kcal) 2109.34 2126.71 2134.08 2119.42 notes: *calculated based on tkpi (2017)17 table 2. energy and nutrient value per 100 grams. measurements p0 p1 p2 p3 p4 p value energy, median ± se, kcal 377±0.00a 395±0.00a,b,c 391±0.33a,b 397±0.00b,c 404±0.33c 0.01* protein, median ± se, g 13.84±0.03a,b 13.80±0.07a 14.52±0.01b 13.47±0.05a 13.88±0.06a,b 0.02* fat, median ± se, g 0.44±0.015a 6.13±0.06b,c 5.45±0.09a,b 6.16±0.02b,c 7.75±0.02c 0.01* carbohydrate, median ± se, g 79.43±0.02a 71.23±0.20a,b 71.02±0.10a,b 71.81±0.10a,b 69.77±0.09b 0.01* water content, median ± se, % 4.06±0.04a 6.13±0.06b,c 6.31±0.02c 5.95±0.04a,b 6.19 ± 0.03b,c 0.01* ash content, mean ± sd, % 2.22±0.03a 2.74±0.07b 2.68±0.02b 2.50±0.04c 2.46 ± 0.08c 0.00** dietary fiber, mean ± se, % 4.12±0.017a 7.65±0.046b 4.2±0.016b 7 ± 0.04b 4.26 ± 0.02b 0.01* sugar, mean ± sd, % 22.07±0.59a 14.22±0.23b 13.59±0.07b 13.75 ± 0.24b 10.88 ± 0.16c 0.00* p0 = fsdu of dm commercial product. p1 = fsdu of dm with added fish-moringa flour. p2 = fsdu of dm with added fish-carrot flour. p3 = fsdu of dm with added tempeh-moringa flour. p4 = fsdu of dm with additional tempeh flour. *kruskal wallis. ** one-way anova. a,b,cnotification of further test results. [healthcare in low-resource settings 2024;12(s1):13039] [page 131] non -co mmerc ial us e o nly 2. among the formulations, p4 exhibited the highest energy, protein, and fat values, while p3 contained the highest carbohydrate value, and p4 had the highest dietary fiber and sugar levels. the ttest results showed significant differences in at least one group regarding the values of energy, protein, fat, carbohydrates, water content, ash content, dietary fiber, and total sugar., attributed to variances in the additional ingredients. the addition of fish and moringa flour (p1), fish and carrot flour (p2), tempeh and moringa flour (p3), and tempeh flour (p4), aimed to provide a variety of aromas and flavors, impacted the energy and nutrient content of the products. all developed formulations showed higher energy content compared to p0. these were attributable to the addition of fat sources such as soybean oil and coconut oil. fat plays an essential role in increasing the calorie content of food products, due to its high energy contribution compared to other nutrients.19 importantly, soybean and coconut oil are rich in unsaturated fats that contain polyunsaturated fatty acids (pufa) and monounsaturated fatty acids (mufa), making them safe and beneficial for patients with t2dm.2,20 moreover, all formulations exhibited high protein content and were not significantly different from p0. the consumption of high-protein products can increase satiety, as protein digestion triggers the release of the hormone cholecystokinin.22 the fat content in all developed formulations exceeded that of p0. the low-fat content in p0 can be attributed to single-nutrient ingredients such as maltodextrin, inulin, vegetable oil, and isomaltulose. p0 primarily derived its fat content from vegetable oil alone. conversely, the higher fat content in the developed products stemmed not only from soybean oil and coconut oil but also from various whole food ingredients such as oyster mushroom flour, brown rice flour, tempeh flour, fish flour, carrot flour, and moringa flour. soybean oil and coconut oil are unsaturated fats that contain pufa and mufa fatty acids; therefore, they can act as antioxidants and are safe for consumption by t2dm patients.2,20 p0 contained higher carbohydrates and sugar compared to the developed formulations. designed as a substitute for the main meal, p0 contained optimal carbohydrates while remaining safe for consumption by patients with t2dm. in addition, p0 had a low glycemic index (gi) that could help in controlling blood glucose levels. maltodextrin, a constituent of p0 and a product of starch hydrolysis, contains a complex structure that facilitates the slow release of blood glucose, thus preventing rapid spikes in blood glu 4th international nursing and health sciences symposium table 3. comparison of fsdu formulation with bpom fsdu standard per 100 kcal. nutrients formulation groups bpom fsdu standard p1 p2 p3 p4 median ± se median ± se median ± se median ± se protein (g) 3.49 ± 0.07 3.71 ± 0.01 3.39 ± 0.05 3.43±0.06 2.5-5 fat (g) 1.55±0.06 1.39±0.09 1.55±0.02 1.91±0.02 2.22-2.78 carbohydrate (g) 18.03±0.20 18.16±0.10 18.08±0.10 17.26±0.09 11.25-16.25 p0 = fsdu of dm commercial product. p1 = fsdu of dm with added fish-moringa flour. p2 = fsdu of dm with added fish-carrot flour. p3 = fsdu of dm with added tempehmoringa flour. p4 = fsdu of dm with additional tempeh flour. table 4. calculation of best treatment based on zeleny formula. formulation l1 l2 l infinite total best tanking p1 0.1344 0.0070 0.0747 0.2161 4 p2 0.1588 0.0090 0.0653 0.2331 3 p3 0.1280 0.0043 0.0542 0.1865 2 p4 0.1143 0.0056 0.0620 0.1819 1 [page 132] [healthcare in low-resource settings 2024;12(s1):13039] figure 1. glycemic index of control product and fsdu of dm product development. a) average blood glucose levels of respondents at 0, 15, 30, 45, 60, 90, and 120 minutes; b) average area under curve respondents; c) average glycemic index. standard white bread: p0 fsdu of dm commercial product; p1 fsdu of dm with added fish-moringa flour; p2 fsdu of dm with added fish-carrot flour; p3 fsdu of dm with added tempehmoringa flour; p4 fsdu of dm with additional tempeh flour. non -co mmerc ial us e o nly cose levels. although p0 contained the highest sugar level and was significantly different from all formulations, its ingredient composition differed from the developed formulation. p0 utilized an artificial sweetener, sucralose, while the developed formulations used granulated sugar. artificial sweeteners such as sucralose and stevia are commonly used to control obesity and diabetes mellitus due to their zero-calorie content.23,24 the dietary fiber of p0 was proven to be significantly different from all the developed formulations. each developed formulation exhibited higher dietary fiber content than p0 due to the high dietary fiber content in the main ingredients of the formulations. oyster mushrooms are rich in beta-glucan, a type of water-soluble fiber.15 beta-glucan is mainly contained in the cell wall of oyster mushrooms, especially white oyster mushrooms, with 9.1 grams of beta-glucan soluble fiber per 100 grams of white oyster mushrooms.25 water-soluble dietary fiber offers numerous health benefits, especially for people with diabetes mellitus. research by fairudz and nisa (2015) stated that beta-glucan consumption can help reduce blood glucose and cholesterol levels.26 moreover, water-soluble dietary fiber can promote prolonged satiety by forming a viscous gel in the digestive system, thereby slowing down the nutrient absorption process.25,26 additionally, water-soluble dietary fiber has been shown to enhance insulin sensitivity in dm patients.27 fsdu for t2dm patients, as outlined by the indonesian food and drug authority (bpom) regulation no. 1/2018, is expected to contain 1.5-5 grams of protein, 2.22-2.78 grams of fat, and 11.25-16.25 grams per 100 kcal (table 3). table 3 reveals that the protein content in all formulations adheres to the standards set by the indonesian food and drug authority (bpom). however, the fat and carbohydrate levels in the formulations fail to meet the regulatory requirements. specifically, the fat content remains inadequate, while the carbohydrate content exceeds the recommended range. table 4 shows the calculation of best treatment based on zeleny formula. peak fluctuations in blood glucose levels upon consumption of fsdu product development were observed as follows: p1 at 137.33 mg/dl, p2 at 136.83 mg/dl, p3 at 121.5 mg/dl, p4 at 110 mg/dl, p0 (commercial product) at 114 mg/dl, and standard white bread at 114 mg/dl (minute 30) (figure 2a). the glycemic index (gi) value was calculated using the incremental area under curve (iauc) method. the gi calculation showed that p4 had the best gi value, which was within the medium category (55-70), while p1, p2, and p3 had high glycemic index values (>70) (figure 2b, c). overall, the developed fsdu prototype contains β-glucan as a source of water-soluble dietary fiber derived from brown rice and oyster mushrooms. β-glucan, a polysaccharide with a linear β-(1,3) branch chain β-(1,6) bond structure, acts as an immunomodulator and a source of prebiotics that can stimulate probiotics in the colon.28 based on a systematic review and meta-analysis, oat βglucan with a molecular weight of >300 kg/mmol significantly reduced iauc and peak glucose by 23% and 28%, and insulin by 22% and 24%29. the mechanism of β-glucan in reducing blood glucose levels involves forming a lasting satiety effect by increasing luminal viscosity, thereby reducing food transit speed in the stomach and nutrient absorption in the intestine.11 the determination of the best treatment level involves seven parameters: carbohydrate, protein, fat, energy, fiber, sugar, and gi. each parameter holds equal importance. the results identified p4 as the optimal fsdu (table 4). the composition of p4, compared to other formulations, is the addition of tempeh flour. according to research by mawarno and putri (2022), adding tempeh flour increases the caloric value of food products due to increased protein value.30 soybean fermentation in tempeh production can increase protein content by up to 32%.31 overall, this brown rice and mushroom-based product formulation provides nutrients beneficial for dm patients due to the high content of fiber, ß-glucan, mg, and manganese, which can help regulate blood glucose.9,12 conclusions the study concluded that the optimal food for special dietary uses for diabetes mellitus (dm) patients was a formulation containing brown rice and oyster mushrooms supplemented with tempeh flour. this conclusion was drawn after evaluating various parameters including energy, protein, fat, carbohydrates, fiber, sugar, and glycemic index content. however, further studies are needed to explore the development of this formulation with diverse flavor variants, aiming to enhance acceptability while ensuring the provision of health benefits to dm patients. 4th international nursing and health sciences symposium correspondence: inggita kusumastuty, department of nutrition, faculty of health sciences, universitas brawijaya, jl. puncak dieng eksklusif, kunci, kalisongo, dau, malang, postcode: 65151, east java, indonesia. tel.: +62.341.5080686. e-mail: inggita@ub.ac.id key words: brown rice; diabetes food; oyster mushroom; special dietary contributions: all authors contributed equally to the development of the conceptual and structural model, performed the analytic calculation, and finalized the manuscript. conflict of interest: the authors disclosed no potential conflict of interest. funding: this study was financially supported by malang state health polytechnic. ethics approval: all experimental procedures were approved by the research ethics committee of malang state health polytechnic (441/kepk-polkesma/2022). clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgment: we would like to express our gratitude to the department of nutrition, faculty of health sciences, universitas brawijaya, malang and the department of nutrition, malang state health polytechnic for the valuable insight and expertise that greatly contributed to the success of this study. received: 5 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13039 doi:10.4081/hls.2024.13039 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s1):13039] [page 133] non -co mmerc ial us e o nly references 1. idf. five questions on the idf diabetes atlas. diab res clinical pract 2013;102:147–8. 2. indonesian endocrinology society. guidelines for the management and prevention of type 2 diabetes mellitus in indonesia. jakarta: indonesian endocrinology society; 2021. 3. ministry of health republic of indonesia. basic health research. jakarta: ministry of health republic of indonesia; 2018. 4. who. diabetes [internet]. 2021 [cited 2023 aug 4]. available from: https://www.who.int/news-room/fact-sheets/detail/diabetes 5. american diabetes association. standards of medical care in diabetes—2017 abridged for primary care providers. clin diab 2017;35:5–26. 6. harmawati. implementation of nursing care in patients with gastritis in fulfilling nutritional needs. j-healt 2020;2:99– 102. 7. national food and drug agency republic of indonesia. regulation of the food and drug supervisory agency of the republic of indonesia number 1 of 2018 concerning supervision of processed food for special nutritional needs. jakarta: national food and drug agency republic of indonesia; 2019. 8. nuryani. potential substitution of white rice with brown rice as staple food for diabetes mellitus protection. media gizi masy indones 2013;3:157–68. 9. kusumastuty i, handayani d, affandy yikd, et al. compliance of brown rice-based diet on blood glucose and body fat of diabetes mellitus patients. ijhn 2021;8:182-94. 10. juliano bo, tuaño app. gross structure and composition of the rice grain. in: rice [internet]. elsevier; 2019 [cited 2023 aug 4]. p. 31–53. available from: https://linkinghub.elsevier. com/retrieve/pii/b9780128115084000022 11. sulistyowati e, rudijanto a, soeharto s, handayani d. the identification of characteristic macroand micronutrients and the bioactive components of indonesian local brown rice as a functional feed in obesity nutrition therapy. cnf 2020;16:494–500. 12. handayani d, kusumastuty i, inayah am, et al. substitution of local indonesian varieties of brown rice on anthropometry and blood glucose level improvement in type 2 dm patients: a pilot project. j public health res 2022;11:2283. 13. golzarand m, toolabi k, eskandari delfan s, mirmiran p. the effect of brown rice compared to white rice on adiposity indices, lipid profile, and glycemic markers: a systematic review and meta-analysis of randomized controlled trials. crit rev food sci nutr 2022;62:7395–412. 14. zaenab s, nurwidodo. decreasing blood sugar levels in hyperglycemic white rats (rattus norvegicus) using various forms of white oyster mushroom preparations (pleurotus ostreatus). sukaharjo: stikes nasional; 2016. 15. khoiriyah m, zuhriyah a, basith a. the effect of giving oyster mushroom infusion extract (pleurotus ostreatus) on reducing blood sugar levels in male white rats wistar (rattus norvegicus). jurnal penjas dan farmasi 2020;3:33–43. 16. widyanto rm, kusuma ts, hasinofa al, zetta ap, silalahi fivb, safitri rw. analysis of nutrients, fatty acid content, and amino acid components of new zealand white rabbit meat nuggets (oryctolagus cuniculus). jurnal al-azhar indonesia seri sains dan teknologi 2018;4:141–8. 17. ministry of health republic of indonesia. indonesian food composition table 2017. jakarta: ministry of health republic of indonesia; 2018. 18. national food and drug agency republic of indonesia. regulation of the head of the food and drug supervisory agency of the republic of indonesia number hk.03.1.23.11.11.09909 of 2011 concerning supervision of claims in labels and advertisements of processed foods. jakarta: national food and drug agency republic of indonesia; 2011. 19. erfiza nm, hasni d. evaluation of nutritional value of aceh typical meat cuisine. jurnal teknologi dan industri pertanian indonesia 2018;19:28-35. 20. weerakoon wnmtdn, anjali nvp, jayathilaka n, seneviratne kn. soybean oil and coconut oil enhance the absorption of chlorogenic acid in humans. j food biochem 2021;45. 21. handayani d, putri dsp, sujuti h, et al. plasma glucagonlike peptide-1 and cholecystokinin responses to fast food in healthy-weight and obese men. jkb 2020;31:69–75. 22. nichol ad, salame c, rother ki, pepino my. effects of sucralose ingestion versus sucralose taste on metabolic responses to an oral glucose tolerance test in participants with normal weight and obesity: a randomized crossover trial. nutrients 2019;12:29. 23. christine jr, hajrah h, prasetya f. the effect of consumption low calories artificial sweetness sucralose and steviol glycosides on blood glucose levels of patients with type 2 diabetes mellitus. j sains kes 2022;4:189–97. 24. rahmawati fc, rahayuningsih hm. the effect of giving white oyster mushroom soup (pleurotus ostreatus) on triglyceride levels in obesity subjects. j nutri coll 2014;3:943–50. 25. fairudz a, nisa k. the effect of dietary fiber on cholesterol levels in overweight people. jurnal majority 2015;4:121-6. 26. slavin j. fiber and prebiotics: mechanisms and health benefits. nutrients 2013;5:1417–35. 27. elfirta rr. variabilitas beta glukan dari tubuh buah jamur pangan sebagai pangan fungsional penunjang kesehatan: artikel review. 2020;6:343–9. 28. zurbau a, noronha jc, khan ta, et al. the effect of oat β-glucan on postprandial blood glucose and insulin responses: a systematic review and meta-analysis. eur j clin nutr 2021;75:1540-54. 29. mawarno bas, putri as. physicochemical and sensory characteristics of gluten-free high protein snack bars with variations of rice flour, soy flour and tempeh flour. agrihealth: j agri-food, nutrition public health 2022;3:47– 54. 30. maryam s. peningkatan komponen gizi pada mie dengan penambahan tepung tempe dan ekstrak wortel. j sains teknologi 2022;11:238–48. 4th international nursing and health sciences symposium [page 134] [healthcare in low-resource settings 2024;12(s1):13039] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13:13619 estimated burden of selected eye diseases in albania during the period 1990-2021 drilon zekaj,1,2 myzafer kaçaj,3 enver roshi3 1faculty of medicine, university of prishtina; 2eye clinic, clinical university centre of kosovo, prishtina, kosovo; 3faculty of medicine, university of tirana, albania abstract the purpose of our analysis was to examine the trends of specific eye diseases in albania during the period 1990-2021. this analysis was based on the estimates available from the global burden of disease (gbd) studies, reported by the institute for health metrics and evaluation (ihme). for albania, ihme uses data that are primarily available from the national institute of statistics. the age-standardized mortality rate from eye cancer in the albanian population exhibited a decrease from 0.46 deaths per 100,000 population in 1990 to 0.31 deaths per 100,000 population in 2021. similarly, the age-standardized burden of disease from eye cancer in the albanian population decreased from 1990 to 2021. however, compared with the neighbouring western balkan countries, germany and france, the mortality rate and the burden of eye cancer in albania were the highest in both 1990 and 2021. our analysis highlights a declining trend in the mortality rate and burden of eye cancer in albania from 1990 to 2021. however, these indicators remain higher compared to neighbouring and western european countries. introduction according to the global burden of disease (gbd) study, in 2020, there were about 596 million people with distance vision impairment at a global scale.1 of these, 43 million were blind.1 further 510 million people had uncorrected near vision impairment, merely due to the absence of reading glasses.1 notably, a significant majority of those affected (90%) reside in lowand middle-income countries (lmics).1 vision loss can impact individuals of all ages – yet, the majority of those with vision impairment and blindness are over 50 years old.2 more recent data from the world health organization (who) indicate that, currently, at least 2.2 billion people have a near or distance vision impairment.2 of these, in at least one billion cases, vision impairment could have been prevented or remains unaddressed.2 according to who, refractive errors and cataracts are the primary causes of vision impairment and blindness worldwide.2 additionally, only 36% of individuals worldwide with distance vision impairment caused by refractive errors and just 17% of those with vision impairment due to cataracts have prompt access to suitable interventions.2 the primary conditions leading to distance vision impairment or blindness consist of cataract followed by refractive error, agerelated macular degeneration, glaucoma, and diabetic retinopathy.2,3 on the other hand, the leading cause of near vision impairment is presbyopia.4 it should be noted that vision impairment does not only bear individual and family costs, but it also imposes a significant financial burden for all societies worldwide, with an annual global cost of productivity estimated at around us$ 411 billion.2 nonetheless, the information about albania and other countries of the western balkans regarding eye health is rather limited. after the collapse of the communist regime in 1990, albania has embarked on a difficult transition toward a market-oriented economy, which is characterized, among other aspects, by substantial changes in the health status of the general population,5 including changes in the patterns of eye diseases due to the continuous population aging.6 in 2021, the crude mortality rate from non-communicable diseases (ncds) in albania was estimated at about 820 deaths per 100,000 population, showing a considerable increase compared with the fall of the communist regime in the early 1990s (around 380 deaths per 100,000 population).7 the proportional mortality from ncds in the albanian population in 2021 was estimated at about 73%, indicating a significant decrease from around 93% in 2019 (i.e., before covid-19 pandemic).7 however, the overall mortality rate from ncds has increased in albania from correspondence: drilon zekaj, md; faculty of medicine, university of prishtina, str. bulevardi i dëshmorëve n.n., 10 000 prishtina, kosovo. e-mail: drilon.zekaj@uni-pr.edu key words: albania; burden of disease; institute for health metrics and evaluation; mortality; eye diseases. contributions: dz contributed to the study’s conceptualization, design, analysis, interpretation of data, and writing of the article. mk and er provided comprehensive comments on the manuscript. all authors have read and approved the submitted manuscript. conflict of interest: the authors declare no potential conflict of interest. ethics approval and consent to participate: not required. availability of data and materials: the data presented in this study are available upon request from the corresponding author. received: 12 january 2025. accepted: 6 february 2025. early access: 13 march 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13619 doi:10.4081/hls.2025.13619 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 148] [healthcare in low-resource settings 2025;13:13619] 798 deaths in 2019 to 820 deaths in 2021 (per 100,000 population), indicating an increase in the death rates from both infectious diseases (covid-19) and ncds.7 cardiovascular diseases constitute the leading cause of death in the albanian population, with an estimated (crude) mortality rate of about 530 deaths per 100,000 population, accounting for 47% of the proportional mortality.7 within cardiovascular diseases, ischemic heart disease is the main cause of death, with an estimated mortality rate of 241 deaths per 100,000 population, representing more than one-fifth (21%) of the overall mortality in the general population of albania.7 considering this background, the aim of our analysis was to examine the trends of specific eye diseases in albania during the period 1990-2021. materials and methods our analysis was based on the albanian estimates provided by the global burden of disease 1990 and 2021 studies, which are reported by the institute for health metrics and evaluation.7 for all countries, ihme estimates mortality using a combination of methods, including statistical modeling, disease-specific models, and cause-of-death modeling.7,8 the statistical modeling used by ihme is based on available data from vital registration systems, surveys, and other available sources. these models take into consideration the variations in data quality and completeness, as well as the differences in mortality rates among various age groups and regions worldwide.7,8 additionally, ihme employs disease-specific models to estimate mortality for specific diseases or conditions.7,8 also, cause-of-death modeling is used to estimate mortality by cause of death, which is crucial for identifying the leading causes of death across various populations, including albania. these models integrate data from medical certifications, verbal autopsy, and other sources to estimate cause-specific mortality rates.7,8 furthermore, ihme uses “ensemble modeling,” which is a method that combines multiple models to produce more accurate estimates of mortality. this approach evaluates the strengths and weaknesses of different modeling methods and includes uncertainty in the estimates provided.7,8 in the case of albania, ihme uses data that are primarily available from the national institute of statistics.7 results table 1 presents selected indicators of eye diseases in albania in 1990 and in 2021. overall, the crude mortality rate from eye cancer in the albanian population in 1990 was 0.26 deaths per 100,000 population, whereas in 2021, it was almost double (0.48 per 100,000 population) [upper panel]. however, this is logical considering the rapid aging of the albanian population in the past three decades.5,6 as a matter of fact, the age-standardized mortality rate from eye cancer in the albanian population exhibited a decrease from 0.46 deaths per 100,000 population in 1990 to 0.31 deaths per 100,000 population in 2021. figure 1 presents both the crude and the age-standardized mortality rates from eye cancer in the albanian population for the period 1980-2021, based on the estimates provided by ihme.7 from 1980 to the mid-1990s, there was evidence of a stable crude mortality rate, which afterward increased continuously until 2021, in line with the continuous increase of older people shares in albania. conversely, the age-standardized estimates of mortality rate from eye cancer in the albanian population indicated a gradual decrease, pointing to prompt and more effective treatment and management of these diseases. regarding the burden of disease (table 1, lower panel), in 1990, there were about 7.7 crude disability-adjusted life years (dalys) per 100,000 from eye cancer in the albanian population, whereas in 2021, this figure increased to 10.8 dalys per 100,000 population. similar to mortality rate estimates, the increase in the crude burden of disease level (mortality and morbidity combined) from 1990 to 2021 was mainly due to population aging. indeed, the article [healthcare in low-resource settings 2025;13:13619] [page 149] table 1. selected eye disease indicators in albania in 1990 and in 2021 (source: ihme https://vizhub.healthdata.org/gbd-results/). upper panel: mortality indicators indicator crude age-standardized 1990 2021 1990 2021 eye cancer (deaths per 100,000 population) 0.26 0.48 0.46 0.31 lower panel: burden of disease [disability-adjusted life years (dalys)] indicator crude age-standardized 1990 2021 1990 2021 eye cancer (dalys per 100,000) 7.68 10.82 11.10 7.20 retinoblastoma (dalys per 100,000) 0.02 0.01 0.01 0.02 other eye cancers (dalys per 100,000) 7.66 10.81 11.08 7.18 foreign body in eyes (dalys per 100,000) 1.23 1.25 1.28 1.17 figure 1. crude and age-standardized mortality rate (deaths per 100,000 population) from eye cancer in albania during the period 1980-2021 (source: https://vizhub.healthdata.org/gbd-results/) age-standardized burden of disease from eye cancer in the albanian population in 1990 was estimated at around 11.1 dalys per 100,000, whereas in 2021, it decreased to 7.2 dalys per 100,000. almost the entire toll of eye cancer in the albanian population concerns different types of tumors other than retinoblastoma, which constitutes a negligible share (comprising only 0.01 dalys per 100,000 population in 2021 at a crude level). furthermore, at a crude level, the burden of foreign body in eyes was slightly lower in 1990 compared to 2021 (1.23 vs. 1.15 dalys per 100,000, respectively), whereas upon age-standardization there was evidence of an opposite finding (1.28 vs. 1.17 dalys per 100,000, respectively). table 2 presents age-standardized eye disease indicators for selected european countries, including albania, for the years 1990 and 2021. the mortality rate from eye cancer in albania was the highest among all countries in both 1990 (0.46 deaths per 100,000 population) and 2021 (0.31 deaths per 100,000 population). on the other hand, montenegro exhibited the lowest mortality rate from eye cancer in both 1990 and 2021 (0.06 deaths per 100,000 population in both 1990 and 2021). in line with the mortality pattern, the burden of eye cancer was the highest among all countries in albania in both 1990 (11.1 dalys per 100,000) and in 2021 (7.2 dalys per 100,000), and the lowest in montenegro (1.64 and 1.54 dalys per 100,000, respectively). as observed earlier, almost the entire share of eye cancer in albania was explained by different types of tumours other than retinoblastoma, a finding that was more pronounced in albania compared with the other six countries. conversely, the burden of foreign body in eyes in albania (about 1.3 and 1.2 dalys per 100,000 in 1990 and in 2021, respectively) was somehow similar to the other countries of the western balkans, except croatia, which displayed a higher burden in both 1990 and 2021. notably, the burden of foreign body in the eyes was much higher in germany and france in both 1990 and 2021 compared with albania and the western balkan countries. discussion and conclusions this analysis offers valuable insights into the mortality rate and burden of selected eye diseases within the albanian population over the past few decades. the findings indicate that both the agestandardized mortality rate and the burden of eye cancer in this population have decreased from 1990 to 2021. nonetheless, compared with the neighbouring western balkan countries, germany and france, the mortality rate and the burden of eye cancer in albania were the highest in both 1990 and 2021. the lancet global health commission on global eye health has emphasized that vision needs to be recognized as a critical development priority, considering eye health as a crucial aspect for achieving sustainable development goals (sdgs).3 from this perspective, the commission argues that there is considerable evidence indicating that enhancing eye health, directly and indirectly, supports achieving numerous sdgs, such as alleviating poverty, boosting work productivity, improving overall and mental health, and advancing education and equity.3 however, in countries with limited resources, including albania, financial barriers may hinder prompt and effective eye care for many individuals in the general population. for this very reason, the commission recommends that eye health be included in national health financing to pool the risk.3 from another aspect, there are positive messages on a global scale. hence, the age-standardized global prevalence of blindness has fallen by almost 29% during the period 1990-2020, in line with the significant decrease in the prevalence of major infectious causes of blindness, including onchocerciasis and trachoma.3 yet, the aging of the populations worldwide has been associated with an increase in the crude prevalence of age-related causes of blindness, thereby increasing the overall number of individuals with blindness in some regions of the world.3 among other health aspects, vision impairment is associated with poor mental health.9-11 a meta-analysis has revealed that onequarter of individuals with eye diseases have also advanced depressive symptoms,9 which, in turn, increase with the advancement of eye diseases.9-11 in addition, vision impairment is linked to dementia.3 our analysis is limited by its reliance on secondary data from the global burden of disease studies, which may not fully capture local variations or recent trends in albania. gbd estimates are often modeled, and any gaps, inaccuracies, or methodological differences in data collection and reporting could affect the validity of the findings. additionally, our analysis does not incorporate primary data sources such as hospital records, cancer registries, or ophthalmologic screenings, which could provide a more detailed and clinically validated picture of eye cancer trends. without direct epidemiological or clinical validation, the analysis may not account for factors such as diagnostic improvements, changes in healthcare access, or variations in disease classification over time. another limitation of this analysis is its main focus on eye cancer, which excludes other prevalent eye diseases such as cataracts, glaucoma, and macular degeneration, potentially overlooking broader trends and determinants of eye health in albania. additionally, potential inaccuracies in national data sources and underreporting of eye diseases could impact the precision of the estimates, as acknowledged by ihme.7,8 regardless of these limitations, this study provides valuable insights into the long-term trends of eye cancer in albania, offering a basis for public health planning and resource allocation. it high article [page 150] [healthcare in low-resource settings 2025;13:13619] table 2. eye disease indicators in selected european countries in 1990 and in 2021 (source: ihme https://vizhub.healthdata.org/gbdresults/). indicator* albania montenegro north macedonia croatia slovenia germany france 1990 2021 1990 2021 1990 2021 1990 2021 1990 2021 1990 2021 1990 2021 eye cancer (deaths per 100,000 population) 0.46 0.31 0.06 0.06 0.18 0.16 0.23 0.14 0.13 0.07 0.13 0.15 0.18 0.14 eye cancer (dalys per 100,000) 11.10 7.20 1.64 1.54 4.51 3.61 5.86 3.40 3.89 1.98 4.22 4.51 5.71 4.43 retinoblastoma (dalys per 100,000) 0.01 0.02 0.06 0.02 0.01 0.01 0.07 0.03 0.30 0.27 0.46 0.40 0.72 0.19 other eye cancers (dalys per 100,000) 11.08 7.18 1.58 1.52 4.50 3.60 5.79 3.36 3.59 1.71 3.76 4.33 4.99 4.03 foreign body in eyes (dalys per 100,000) 1.28 1.17 1.19 1.15 1.26 1.17 2.69 2.57 1.18 1.15 8.32 8.40 8.31 8.28 *all indicators in the table lights the need for targeted interventions and international comparisons to address persisting disparities. additionally, the findings can guide future research to expand the scope of eye health studies and develop comprehensive strategies for prevention and treatment. the findings of this study have significant policy implications for eye health and cancer prevention in albania. despite a declining trend in eye cancer mortality and disease burden, albania continues to have higher rates compared to neighboring and western european countries, highlighting the need for targeted public health interventions. policymakers should prioritize strengthening early detection programs, improving access to specialized ophthalmologic and oncologic care, and increasing public awareness about risk factors associated with eye cancer. furthermore, investing in a national cancer registry and enhancing data collection mechanisms would enable more accurate tracking of disease trends and facilitate evidence-based decision-making. aligning national policies with best practices from countries with lower eye cancer burdens could help reduce disparities and improve overall eye health outcomes in albania. in conclusion, our analysis highlights a declining trend in the mortality rate and burden of eye cancer in albania from 1990 to 2021. however, these indicators remain higher compared to neighboring and western european countries. references 1. burton mj, ramke j, marques ap, et al. the lancet global health commission on global eye health: vision beyond 2020. lancet glob health 2021;9:e489–e51. 2. world health organization. fact sheets: blindness and vision impairment; 2023. available from: https://www.who.int/newsroom/fact-sheets/detail/blindness-and-visual-impairment (accessed on 09 january 2025). 3. gbd 2019 blindness and vision impairment collaborators; vision loss expert group of the global burden of disease study. causes of blindness and vision impairment in 2020 and trends over 30 years, and prevalence of avoidable blindness in relation to vision 2020: the right to sight: an analysis for the global burden of disease study. lancet glob health 2021 9:e144-e60. 4. fricke, tr, tahhan n, resnikoff s, et al. global prevalence of presbyopia and vision impairment from uncorrected presbyopia: systematic review, meta-analysis, and modelling. ophthalmology 2018;125:1492-99. 5. czabanowski w, mone i, burazeri g. health status in selected post-communist european countries: a comparative study between poland and albania. cent eur j public health 2024;32:63-7. 6. institute of statistics, albania. key data. accessed on 09 january 2025. available from: http://www.instat.gov.al/ al/statistika/t%c3%ab-dh%c3%abna-ky%c3%a7e/ 7. institute for health metrics and evaluation (ihme). global burden of disease estimates. accessed on 09 january 2025. available from: https://vizhub.healthdata.org/gbd-results/ 8. institute for health metrics and evaluation (ihme). global health data exchange. accessed on 09 january 2025. available from: https://ghdx.healthdata.org/ihme_data 9. zheng y, wu x, lin x, lin h. the prevalence of depression and depressive symptoms among eye disease patients: a systematic review and meta-analysis. sci rep 2017;7:46453. 10. skalicky s, goldberg i. depression and quality of life in patients with glaucoma: a cross-sectional analysis using the geriatric depression scale-15, assessment of function related to vision, and the glaucoma quality of life-15. j glaucoma 2008;17:546-51. 11. van nispen rm, vreeken hl, comijs hc, et al. role of vision loss, functional limitations and the supporting network in depression in a general population. acta ophthalmol 2016;94:76-82. article [healthcare in low-resource settings 2025;13:13619] [page 151] hrev_master healthcare in low-resource settings 2025; volume 13(s1):13122 enhancing adherence to diet therapy and fluid restrictions in hemodialysis patients: a study using the information-motivation behavioral skills model zulhikmah s. hi arsan,1 elly lilianty sjattar,2 rosyidah arafat2 1student of postgraduate nursing program, faculty of nursing, hasanuddin university, makassar; 2department of medical and surgical nursing, faculty of nursing, hasanuddin university, makassar, indonesia abstract a common issue faced by many patients undergoing the hemodialysis (hd) is non-compliance with diet therapy and fluid intake limitation. to address this issue, the educational model aims to change the required behavior of patients. the information motivation behavior skill (imb) model is a behavioral intervention designed to promote behavior change in various situations. this study sought to assess how well the imb educational model supports adherence to diet therapy and fluid restrictions in patients receiving hd. this study was carried out in the hd departments. it was a quasi-experimental study featuring a pretest and posttest design with a control group involving 80 patients. the participants were split into an intervention group that received education based on the information motivation behavior skill model (n=40) and a control group that received standard hospital education according to standard operating procedures (n=40). after eight dialysis sessions over a period not exceeding four weeks, participants were evaluated for adherence to diet therapy and fluid restrictions. significant change in diet therapy and fluid restriction in the intervention group with the p-value of 0.001. in the control group, there is a significant change in diet therapy and fluid restriction with p-values of 0.005 and 0.002. there are no significant differences between the intervention and control groups in the pre-test for diet therapy and fluid restriction, with p-values of 0.221 and 0.146. however, in the post-test, there are significant differences between the intervention and control groups, with a p-value of 0.001. the information motivation behavior skill model of education shows great promise in promoting adherence to diet therapy and fluid restrictions. introduction hemodialysis (hd) is the most frequently used therapy for patients post-transplant, regardless of incidence or prevalence. hd is the most prevalent type of kidney replacement therapy worldwide, comprising about 69% of all kidney replacement treatments and 89% of all dialysis procedure.1 a 2018 cross-sectional survey of clinicians, policymakers, and patient representatives from 182 countries found that the median use of hd per country was 298.4 per million population (pmp). however, the rates varied dramatically, with a more than 7,000-fold difference between countries. for example, the democratic republic of congo had a rate of 0.3 pmp, while japan had a rate of 2,148 pmp, reflecting disparities in hd availability and access.2 in indonesia, hd is similarly widespread. in 2017, 77,892 patients were receiving hd, and 30,843 new patients started treatment that year.3 in central sulawesi, the proportion of residents aged 15 years and older undergoing hd was 7.34%.4 patients undergoing hd must adhere to diet therapy and fluid restrictions, which reflects their willingness to follow the prescribed dietary guidelines.5 many patients with hd have a history of nonadherence to these guidelines.6 this non-compliance can lead to excessive accumulation of fluid in the body, which can potentially result in complications.7 the mortality rate is high if complications occur in patients treated at home.8 to overcome this correspondence: elly lilianty sjattar, department of medical and surgical nursing, faculty of nursing, hasanuddin university, jl. perintis kemerdekaan km. 10, tamalanrea, makassar, indonesia, 90245 tel.: +62.812.422.6796 e-mail: ellylilianty@unhas.ac.id key word: behavioral, diet, fluid, hemodialysis, information, motivation. conflict of interest: the authors declare no potential conflict of interest, and all authors confirm accuracy. ethics approval: the ethics committee of the faculty of public health, hasanuddin university makassar approved this study (no. 514/un4.14.1/tp.01.02/2023). the study is conformed with the helsinki declaration of 1964, as revised in 2013, concerning human and animal rights. informed consent: all patients participating in this study signed a written informed consent form for participating in this study. patient consent for publication: written informed consent was obtained from a legally authorized representative(s) for anonymized patient information to be published in this article. availability of data and materials: all data generated or analyzed during this study are included in this published article. acknowledgements: the authors acknowledge the support of department of hemodyalisis the luwuk regional hospital of banggai regency and anutapura regional hospital in central sulawesi, master of nursing study program faculty of nursing hasanuddin university. received: 18 september 2024. accepted: 21 october 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13(s1):13122 doi:10.4081/hls.2024.13122 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 8] [healthcare in low-resource settings 2025;13(s1):13122] problem, intensive efforts to increase adherence to diet therapy and fluid restrictions are needed. education can alter behavior to enhance health outcomes. a limited understanding of health information, such as about the flu vaccine, may lead to hesitation in getting vaccinated.9 a pilot study demonstrated that an educational and supportive approach effectively improved health outcomes in stroke patients, particularly in increasing muscle strength and joint range of motion.10 a literature review found that applying the transtheoretical model of learning effectively changed low-salt diet behaviors in patients with hypertension.11 additionally, the use of technology to educate patients and improve health literacy has grown in recent years.12 some of the above diseases are chronic diseases that require special attention by providing a more educational approach to change the patient’s behavior which can improve their condition, such as hemodialysis patients who need education to change their behavior in terms of diet and fluid restriction. education can enhance adherence to diet therapy and fluid restrictions in patients undergoing hd. research indicates that providing health education positively impacts adherence levels for these guidelines.13 a holistic approach that incorporates both social support and education is crucial for helping patients with hd maintain adherence to diet and fluid restrictions.14 education about diet and fluid restriction has been ongoing in the hospital. the education model used still uses the lecture method with leaflet media. however, patients are still not compliant with diet and fluid restriction, this can be seen from weight gain and symptoms of shortness of breath that appear when patients undergo hd. this is because the model and media used for education do not support changing the behavior of hd patients. therefore, there needs to be an education model that focuses more on changing behavior. one effective method to improve understanding and behavior is the information-motivation-behavioral skills (imb) model. this model emphasizes the need for relevant information, strong motivation or support, and the necessary behavioral skills to foster health behavior changes.15 it suggests that achieving optimal health behavior change requires patients to have access to these elements to avoid risky behaviors.16 however, the implementation of the imb education model has never been applied to hd patients. therefore, implementing the imb model can enhance understanding and lead to behavioral changes in patients undergoing hd. the imb model comprises three main components. first, the information component provides patients with accurate and relevant details about their conditions, potential consequences, and treatment options. second, motivation is crucial for driving behavior change, and within the imb framework, researchers or health professionals use interviews to motivate patients. third, behavioral skills focus on teaching practical and strategic skills that facilitate behavior change.17 from the explanation above, it can be concluded that these three components are a single unit in the process of providing education which aims to change patient behavior and attitudes by integrating these components, the imb model offers targeted education aimed at improving adherence to diet therapy and fluid restrictions in patients undergoing hd.16 numerous studies have explored the application of the imb model for addressing various health issues. for instance, a study18 found that imb-based interventions effectively increased involvement and quality of preventive behaviors among communitydwelling older adult. similarly, a different study19 demonstrated that imb-based programs were useful and effective in promoting preventive behaviors in women with osteoporosis. building on this, the present study aims to evaluate the effectiveness of the imb model in improving adherence to diet therapy and fluid restrictions in patients undergoing hd. materials and methods research design this quasi-experimental study employed a pretest and posttest design with a control group (figure 1). population and sample the study population comprised patients undergoing hd at hd departements in hospital x. a total of 84 patients were included and divided into two groups: intervention and control, each with 42 participants. the sample was obtained when patients arrived for their scheduled dialysis sessions. consecutive sampling was used for recruitment. inclusion criteria were: undergoing routine hd, having been on hd for more than 3 months, age >18 years, and being in a stable condition during the education period. exclusion criteria included cognitive disturbances or mental health issues, conditions requiring emergency treatment, hd more than twice a week, and high adherence rates. two participants from each group were excluded due to requiring admission to the intensive care unit (figure 2). data collection study instruments the attitude scale for diet therapy of hemodialysis patients was used to measure adherence to diet therapy of patients undergoing special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13122] [page 9] figure 1. theoretical framework of the study.information–motivation–behavioral skills model of education for adherence to diet therapy and fluid restrictions. hd.20 this questionnaire has undergone validity and reliability tests, with cronbach’s alpha calculated in three subscales (n=381), which confirmed the reliability of these subscales and the high internal validity.21 the questionnaire was translated at the hasanuddin university makassar language center, back-translated, and subjected to validity and reliability tests. in the face validity test, the agreement value was 94.4 with a content validity index (cvi) of 0.94; in the reliability test, cronbach’s alpha was 0.93. the fluid control in hemodialysis patient scale was used to assess adherence to fluid restrictions in patients undergoing hd.22 this questionnaire has undergone validity and reliability tests, with cronbach’s alpha coefficient of 0.88, and cronbach’s alpha for the subdimensions were 0.92, 0.80, and 0.67, respectively. the test and re-test correlation value was 0.94 (p<0.001), indicating a significantly moderate correlation (r=0.58, p<0.001).23 the questionnaire was translated at the hasanuddin university makassar language center, back-translated, and then subjected to validity and reliability tests. in the face validity test, the agreement value was 98.8, with a cvi of 0.98. in the reliability test, cronbach’s alpha was 0.94. objectively, dietary compliance and fluid restriction can be seen from weight gain between dialysis sessions. in this study, weight was needed to ensure the results of the dietary compliance and fluid restriction questionnaires. special issue pathways of change figure 2. flowchart of the study. information–motivation–behavioral skills model of education for adherence to diet therapy and fluid restrictions. [page 10] [healthcare in low-resource settings 2025;13(s1):13122] study procedures intervention group a total of four education sessions were conducted over 4 weeks. during the information stage, patients gathered after dialysis sessions received information about diet therapy and fluid restrictions for 15 minutes. in the motivation stage, motivational interviews provided personalized support to each patient, lasting no more than 15 minutes per session. the behavioral skills stage involved teaching participants how to plan their diet and fluid intake at home, with their adherence monitored through logbook entries during hd sessions (figure 2). control group the education intervention followed the hospital’s standard operating procedures (sop). the educational sop implemented uses a mass education system, where education is provided simultaneously. this is different from imb (information-motivationbehavioral skills) which provides education personally, consisting of three main components, namely information, motivation, and behavioral skills. four sessions were conducted, one per week, with each session lasting 30 minutes. all participants were assembled after hd sessions for these educational meetings. data analysis the wilcoxon test, paired t-test, and friedman test were used to assess changes in adherence to diet therapy and fluid restrictions over eight dialysis sessions. to assess the differences between the two groups, the mannwhitney test, independent t-test, and kruskal–wallis test were employed to evaluate variations in diet therapy compliance and adherence to fluid restrictions. results data collection took place between december 2023 and january 2024. the intervention group received imb model-based education across four sessions over 4 weeks, while the control group received education following the hospitals’ standard operating procedures. characteristics of the respondents eighty respondents were divided equally into the intervention group (n=40) and the control group (n=40). the chi-square test revealed no significant differences in the characteristics of respondents between the two groups (table 1). changes in adherence to diet therapy and fluid special issue pathways of change table 1. demographic characteristics of the participants of the intervention and control groups. variable intervention group (n=40) control group (n=40) p* n (%) n (%) age mean±sd 51.7±12.6 51.9±10.6 0.948b min-max 24-72 26-74 sex male 21 (45.5) 25 (62.5) 0.366a female 19 (47.5) 15 (37.5) educational attainment elementary school 8 (20) 5 (12.5) 0.175a junior high school 6 (15) 5 (12.5) senior high school 14 (35) 13 (32.5) diploma 3 (7.5) 0 (0) bachelor 7 (17.5) 16 (40) magister 2 (5) 1 (2.5) work government employed 8 (20) 9 (22.5) 0.124a self-employed 8 (20) 15 (37.5) unemployed 24 (60) 16 (40) marriage status married 31 (77.5) 31 (77.5) 0.161a single 1 (2.5) 2 (5.0) divorced 4 (10) 7 (17.5) duration of hemodialysis <1 year 9 (22.5) 13 (32.5) 0.117a 1-5 years 17 (42.5) 20 (50) >5 years 14 (35) 7 (17.5) comorbid diseases hypertension 22 (55) 19 (47.5) 0.909a diabetes mellitus 12 (30) 13 (32.5) kidney stones 3 (7.5) 4 (10) gouty arthritis 3 (7.5) 4 (10) p<0.05; achi-square test; bmann-whitney test; sd-standard deviation [healthcare in low-resource settings 2025;13(s1):13122] [page 11] restrictions in the intervention and control groups significant improvements in adherence to diet therapy were observed in both the intervention group (p=0.001) and the control group (p=0.005). similarly, significant changes in adherence to fluid restrictions were noted in the intervention group (p=0.001) and the control group (p=0.002; table 2). differences in adherence to diet therapy and fluid restrictions before and after the intervention in the intervention and control groups there were no significant differences in pre-intervention diet therapy adherence between the intervention and control groups (p=0.221), nor were there significant differences in adherence to fluid restrictions (p=0.146). however, a significant difference in post-intervention diet therapy adherence was observed between the two groups (p=0.001), as well as significant differences in adherence to fluid restrictions (p=0.001; table 3). discussion in this study, we evaluated the impact of imb model-based interventions on patients undergoing hd in terms of their adherence to diet therapy and fluid restrictions. the findings indicate that these interventions considerably enhance the adherence of hd patients to both diet therapy and fluid restrictions. this study employed various methods to help patients understand adherence to diet therapy and fluid restrictions. motivational interviews were conducted to build patients’ trust in nurses, boost motivation, and promote changes in behavior, attitudes, and cognition for self-management. patients were also taught practical skills to develop and master, effectively altering their behavior toward diet and fluid restrictions. overall, these findings demonstrate that imb model-based educational interventions can effectively improve adherence to diet therapy and fluid restrictions in patients undergoing hd, providing personalized and patient-centered healthcare. nurses can utilize this approach to manage patients with chronic diseases, including those undergoing hd. this study utilized the theoretical imb model, which, unlike other educational models, integrates behavior-changing interventions into three main components: information, motivation, and behavioral skills. information pertains to the knowledge base about diseases, motivation seeks to alter attitudes and foster the desire for change, and behavioral skills involve training patients to learn and master skills that can effectively modify their behavior.23 the core part of the imb model is information. this involves providing patients with accurate and relevant details about their disease, its consequences, and the available treatment options. information can be conveyed through various methods, such as educational materials, health services, and digital platforms. as patients gain more knowledge and understanding, they can make informed decisions and take appropriate actions to manage their health condition effectively.17 in this study, the three components of information motivation behavior skill were applied in this study which was conducted during 8 dialysis sessions and the provision of imb model education was given to each patient during the dialysis session. where each patient gets an education session from the three components. with details of the three components of the imb information motivation behavior skill model, each 15 minutes. in the information, patients will be provided with a diet and fluid restriction guidebook. the patient’s motivation will talk about their motivation during the dialysis session with the researcher and in the next special issue pathways of change [page 12] [healthcare in low-resource settings 2025;13(s1):13122] ta bl e 2. c ha ng es in a dh er en ce to d ie t t he ra py a nd fl ui d re st ric tio ns in th e in te rv en tio n an d co nt ro l g ro up s. va ria bl e i nt er ve nt io n gr ou p c on tr ol g ro up pr ete st p os t-t es t m ea n p * p re te st p os tte st m ea n p * (n =4 0) (n =4 0) d iff er en ce (n =4 0) ( n= 40 ) d iff er en ce m ea n± sd m ed ia n (m in -m ax ) m ea n± sd m ed ia n (m in -m ax ) m ea n± sd m ed ia n (m in -m ax ) m ea n± sd m ed ia n (m in -m ax ) a dh er en ce 4 1. 40 ±2 .9 9 40 .0 0 5 1. 37 ±3 .5 4 5 2. 00 9 .9 7 0 .0 1a 4 0. 57 ±2 .9 2 4 0. 00 4 1. 70 ±3 .6 4 4 0. 00 1 .1 3 0 .0 5a to di et th er ap y ( 37 -4 8) (3 958 ) ( 35 -4 6) (3 650 ) a dh er en ce 4 4. 10 ±4 .7 0 4 4. 0 5 3. 45 ±3 .6 0 5 3. 50 9 .3 5 0 .0 1b 3 9. 55 ±6 .6 5 3 9. 50 4 1. 52 ±4 .9 5 4 0. 00 1 .9 7 0 .0 2b to fl ui d (3 543 ) ( 46 -6 0) ( 26 -5 4) (3 354 ) re str ic tio ns p< 0. 05 ; a < w ilc ox on te st ; b p ai re d t-t es t; sd -s ta nd ar d d ev ia tio n. session the researcher provides motivation to change their behavior of compliance with treatment including diet and fluid restrictions. the patient’s behavior skill will be taught to compile a daily food menu which will be recorded on the monitoring sheet and will be evaluated at the next dialysis session, whether the menu that has been compiled is consumed while at home. the three components become one education session. the findings obtained from the implementation of the imb model education showed a significant increase in dietary compliance and fluid restriction, but in the control group there was no significant change in dietary compliance and fluid restriction. the challenge is how to provide behavioral skills in managing diet and fluids between dialysis sessions. the findings obtained that the motivational component is a more dominant component of the three components in changing behavior. motivation plays an important role in encouraging behavioral change. in the imb model, researchers or health professionals often conduct motivational interviews with patients. the purpose of this interview is to understand the patient’s personal motivations and the social context that influences them, build trust, and increase their motivation and willingness to change behavior. motivation can be strengthened by empowering patients, setting realistic goals, and highlighting the benefits of behavioral change. motivation plays a crucial role in initiating behavior change. within the imb model framework, researchers or health professionals often conduct motivational interviews with patients. these interviews aim to understand patients’ personal motivations and social factors, build trust, and stimulate a desire to change behavior. motivation can be enhanced by empowering patients, setting achievable goals, and emphasizing the benefits of behavioral change.17 behavioral skills focus on teaching patients practical and strategic skills to facilitate behavior change. this involves educating patients on using useful tools, developing self-management techniques, overcoming challenges, and adopting healthier behaviors. behavioral skills training can include activities such as goal setting, problem-solving, self-monitoring, and practicing new behaviors. ultimately, the interaction of all the model components—information, motivation, and behavioral skills—leads to a change in behavior.17 applying the imb model to patients undergoing hd can enhance positive behaviors by improving adherence to diet therapy and fluid restrictions, as the model is designed to facilitate behavior change. according to the imb model, achieving behavior change for optimal health requires providing relevant information, offering strong support and motivation, and helping patients develop the necessary skills while avoiding risky behaviors.16 by incorporating information, motivation, and behavioral skills, the imb model effectively promotes understanding and behavior change.24 integrating these three components into a cohesive educational approach can lead to improved adherence to diet and fluid restrictions among hd patients. personalized management by nurses for patients with kidney diseases is crucial. a healthy and balanced diet includes the proper proportions of proteins, carbohydrates, fats, vitamins, and minerals. to ensure optimal health, a varied and balanced diet is essential. the kidneys play key roles related to eating patterns, including excreting body wastes, regulating fluid volume, and controlling blood pressure. after food intake, the body utilizes necessary substances and removes excess ones as waste through urine. if kidney function declines, waste can accumulate in the blood, leading to various complications.25 fluid management is crucial for maintaining fluid and electrolyte balance in the body, involving the monitoring and measurement of fluid intake and output. in patients undergoing hd, increased fluid intake can be influenced by several factors, with thirst being a significant one. thirst often occurs after consuming high-salt foods, as excessive salt levels can activate the thirst mechanism in the brain, prompting a desire to drink more fluids to maintain sodium balance.26 dietary compliance and fluid restriction can be maintained by consistently implementing the imb education model in providing education in the hd department, emphasizing the motivational component because it is in accordance with existing findings that motivation is the most dominant component in changing behavior. the results of this study can serve as a reference for empowering nurses to implement educational programs based on the imb model and develop comprehensive care plans for patients undergoing hd. this approach aims to enhance adherence to diet therapy and fluid restrictions. additionally, addressing these aspects is crucial as other complications may exacerbate the condition of patients undergoing hd. conclusions the imb education model has been proven to improve dietary compliance and fluid restriction. this study provides valuable insights into the benefits of health education interventions for managing patients undergoing hd. by focusing on personalized interventions that address patients’ information needs, motivation, and special issue pathways of change [healthcare in low-resource settings 2025;13(s1):13122] [page 13] table 3. differences in pretes and posttest adherence to diet therapy and fluid restrictions in the intervention and control groups. variable intervention group control group mean difference p* (n=40) (n=40) mean ± sd median (min-max) mean ± sd median (min-max) pre-test adherence to diet therapy 41.40±2.99 40.00(37-48) 40.57±2.92 40.00(35-46) −0.83 0.221a adherence to fluid restrictions 44.10±4.70 44.0(35-43) 39.55±6.65 39.50(26-54) −4.55 0.146b post-test adherence to diet therapy 51.37±3.54 52.00(39-58) 41.70±3.64 40.00(36-50) 9.67 0.01a adherence to fluid restrictions 53.45±3.60 53.50(46-60) 41.52±4.95 40.00(33-54) 12.23 0.01b p<0.05; amann–whitney test; bindependent t-test; sd, standard deviation. behavioral skills, this educational model enables nurses to develop comprehensive care plans tailored to each patient’s needs. for further research, it is hoped that media can be added to support the education process, such as applications for monitoring diet and fluids between dialysis sessions. references 1. bello ak, okpechi ig, osman ma, et al. epidemiology of haemodialysis outcomes. nat rev nephrol 2022;18:378-95. 2. htay h, bello ak, levin a, et al. hemodialysis use and practice patterns: an international survey study. am j kidney dis 2021;77:326-335.e1. 3. indonesian renal registry. 11th report of indonesian renal registry 2018. indones ren regist 2018;14-5. 4. riskesdas. laporan riskesdas provinsi sulawesi tengah. kesehat provinsi, sulawesi tengahesehatan provinsi, sulawesi teng. 2018;399. 5. hunter eg, shukla a, andrade jm. barriers to and strategies for dietary adherence: a qualitative study among hemodialysis/peritoneal dialysis patients and health care providers. j ren nutr 2023;33:682-90. 6. ozen n, cinar fi, askin d, et al. nonadherence in hemodialysis patients and related factors: a multicenter study. j nurs res 2019;27:1-11. 7. herlina, santi, rosaline md. kepatuhan pembatasan cairan pada pasien hemodialisis. dunia keperawatan j keperawatan dan kesehat 2021;9:46. 8. özkan, i̇lknur, taylan s. diet and fluid restriction experiences of patients on hemodialysis: a meta-synthesis study. rev nefrol dial y traspl 2022;42:22-40. 9. xie w, xiao j, chen j, et al. impact of health education on promoting influenza vaccination health literacy in primary school students: a cluster randomised controlled trial protocol. bmj open 2024;14:1-7. 10. sjattar el, megawati i, irwan am, majid s. development of supportive-educative range of motion exercise for post-stroke patients: a pilot study. home heal care manag pract 2022;34:92-100. 11. hasriani, sjattar el, arafat r. the effect of educational intervention based on transtheoretical model for a low-salt diet among hypertension patients: a literature review. indones j public heal 2022;17:331-43. 12. adapa k, jain s, kanwar r, et al. augmented reality in patient education and health literacy: a scoping review protocol. bmj open 2020;10:e038416. 13. başer, esra, mollaoğlu m. the effect of a hemodialysis patient education program on fluid control and dietary compliance. hemodial int 2019;23:392-401. 14. sukarrini t, efendi f, putri ns. a phenomenological study to explore patient experience of fluid and dietary restrictions imposed by hemodialysis. j vasc nurs 2022;40:105-11. 15. puji, lestari k, ayu putri anggraini d, et al. edukasi kesehatan berbasis model information motivation behavior skill meningkatkan pengetahuan dan perilaku perawatan antenatal pada ibu hamil risiko tinggi. jambi med j 2021;234-45. 16. chang sj, choi s, kim sa, song m. intervention strategies based on information-motivation-behavioral skills model for health behavior change: a systematic review. asian nurs res (korean soc nurs sci) 2014;8:172-81. 17. xu, handong, wang j. an information-motivation-behavioral skills model-based intervention for patients with epilepsy. epilepsy behav 2023;147:109408. 18. lee, hye m, park yh. the effectiveness of the informationmotivation-behavioral skills model-based intervention on preventive behaviors against respiratory infection among community-dwelling older adults. patient educ couns 2021;104:2028-36. 19. yeongsuk, a lp, phd dhk. a preliminary study on the effects of an osteoporosis prevention program based on an information-motivation-behavioral skill model in older adult women: a cluster randomized controlled trial. geriatr nurs. 2022;45:55-63. 20. özer zbtgyke. attitude scale for the dietary therapy of hemodialysis patients: turkish validity and reliability study. nternational urol nephrol 2023;55:769-76. 21. onbe, hiromi, kanda k. development and testing of the attitude scale for the dietary therapy of hemodialysis patients. japan j nurs sci 2018;15:39-49. 22. cosar a, arife, cinar pakyuz s. scale development study: the fluid control in hemodialysis patients. japan j nurs sci 2016;13:174-82. 23. peng x, li z, zhang c, et al. assessing determinants of online medical services adoption willingness of general hospital physicians using the information-motivation-behavioral skills model: a multi-group structural equation modeling approach. j multidiscip healthc 2021;14:3453-62. 24. sulistianingsih a, saputri n. kehamilan bebas anemia : pendekatan menggunakan information motivation behavior (imb) skill model. m.pd ath, editor. padang: rumahkayu pustaka; 2020. 25. donnelly p, dunne h, conlon ppj. kidney disease a guide for patients 4th edition. irish kidney association. beaumont hospital. 2019. 26. siregar ct. buku ajar manajemen komplikasi pasien hemodialisa. reni asmara ariga, editor. yogyakarta: deepublish cv budi utama; 2020. special issue pathways of change [page 14] [healthcare in low-resource settings 2025;13(s1):13122] hrev_master healthcare in low-resource settings 2025; volume 13:13372 a pilot trial of internet-delivered mastery-based ebola simulation education in uganda catherine d. tobin,1 lacey menkinsmith,2 dulaney a. wilson,3 kenneth catchpole,1 j.g. reves1 1department of anesthesia and perioperative medicine, medical university of south carolina, charleston; 2department of emergency medicine, division of global health, medical university of south carolina, charleston; 3department of public health sciences, medical university of south carolina, charleston, united states abstract ebola virus disease (evd) poses a global health threat in uganda where the disease is endemic, and resources are limited. we designed a curriculum to provide evd education at the masindi kitara medical center (mkmc) and compare it to a group who took the same course at the medical university of south carolina (musc) in the united states. demographic information, confidence and knowledge test scores, and video grading data was gathered. three trainers and six trainees were enrolled at each site. completion of the online curriculum improved knowledge test scores in trainees. initial pre-training knowledge test scores were higher in the musc group than the mkmc group (p=0.04), but both sites had significant improvement in post-test scores. on the confidence survey, participants at mkmc were generally more confident pretraining than musc participants. musc participants improved more in confidence, although posttraining confidence at musc (median=4.2; iqr=3.0-4.6) remained significantly (p=0.02) lower than at mkmc (median=4.9; iqr =4.4-5.0). we demonstrate the feasibility of utilizing our course with a train-the-trainer component designed to rapidly develop new trainers to provide evd education in uganda. introduction ebola virus disease (evd) is a high-consequence pathogen (hcp) that poses a major global health threat. uganda has been the site of five outbreaks since 2007, with the most recent outbreak ending in january of 2023 following the identification of 164 cases with 77 deaths.1,2 additionally, in uganda, spill-over events are a considerable threat from outbreaks originating in the neighboring democratic republic of the congo, which has experienced 7 evd outbreaks in the last 5 years. evd carries a high risk of nosocomial spread and causes significant morbidity and mortality in healthcare workers (hcws). in settings where hcws and resources are limited, communities are at risk of suffering exponentially in disease outbreaks.3–6 simulation-based education in the use of personal protective equipment (ppe) and infection control techniques during patient care have been shown to be useful to reduce the spread of disease and loss of hcws to nosocomial infection and/or quarantine during disease outbreaks.4,5,7,8 intensive simulation education at the national ebola training academy in sierra leone was successful in the 2014 ebola outbreak.8 however, time-consuming, potentially expensive, cost-prohibitive travel was required of attendees. as seen during the covid-19 pandemic, international travel and inperson learning is limited during a pandemic. previous studies evaluating the implementation of local simulation-based education in resource-limited sub-saharan africa (ssa) have identified challenges to its implementation, including the high cost of equipment and lack of dedicated simulation centers and trained local personnel to lead simulation-education.9–13 remote, online training may offer a more cost-effective, efficient strategy for rural healthcare institutions. in this pilot trial, we describe the development of a medical unit specialized simulation training (musst) curriculum, designed to provide simulation education correspondence: catherine d. tobin, department of anesthesia and perioperative medicine, medical university of south carolina, 171 ashley avenue, colbert library building, ste el204 msc 161, charleston, sc 29425, united states. tel.: +1.843.792.5309 e-mail: tobinc@musc.edu key words: ebola virus disease, ebola simulation, train-the-trainer, personal protective equipment, mastery-based learning. contributions: lms, conceptualization, data curation, investigation, methodology, project administration, resources, supervision, validation, visualization, writing original draft, review and editing; ct, conceptualization, methodology, validation, visualization, writing original draft, review and editing; daw; formal analysis, visualization, writing original draft, review and editing; kc, conceptualization, funding acquisition, methodology, supervision, writing review; jgr, conceptualization, funding acquisition, methodology, supervision, writing review and edits. funding: this work was supported by cdc sbir grant number: r44ck000444-01-00 declaration of competing interest funding: lm, jr, ct, dw and kc received grant support for this project from cdc sbir grant number: r44ck000444-01-00 via the awardee, simtunes. conflicts of interest: dr. j.g. reves contributed mentorship, guidance concerning experimental design and manuscript review for this study, and pursuant to the medical university of south carolina conflict of interest (coi) policy. data collection and analysis were consistent with institutional policy. dr. reves is scientific advisor to simtunes, which is a commercial outlet for medical university of south carolina licensed, copyrightable simulation training products. he receives less than 35% of income from simtunes. ethics approval and consent to participate: human subject use was approved by musc irb and taso research ethics committee in uganda. nine paid hcw volunteers were recruited at both sites to pilot the curriculum. informed consent was obtained. acknowledgements: lydia zeiler was research assistant who helped with study. mathew holt and brian fletcher helped with study design and creation. received: 11 november 2024. accepted: 27 august 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 13:13372 doi:10.4081/hls.2025.13372 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13:13372] [page 237] to hcws to manage patients with evd and lessons learned at a site in the rural region of masindi, uganda. the musst course, which combines online and simulation training to educate healthcare workers in ebola patient care, was created to be adaptable and rapidly deployable to a wide breadth of healthcare institutions.14 the curriculum contains a train-the-trainer component intended to make the training independently sustainable at any site it is instituted. the first iteration of the curriculum was successfully piloted in 2016 where it was developed at the medical university of south carolina (musc). the musc department of emergency medicine, division of global health, has a long-standing relationship with the oneworld health (owh), an 501(c)(3) non-governmental organization which operates the masindi kitara hospital, formerly and at the time of this trial, the masindi kitara medical center (mkmc), a rural, private level-three medical center with 55 inpatient beds in masindi, uganda. prior bidirectional educational exchanges between musc and mkmc included medical trainee clinical rotations at mkmc as well as the development of continuing medical education for medical staff in uganda by musc fellows and faculty. it was recognized that viral hemorrhagic fevers (vhfs) pose a significant threat after one case was identified at mkmc itself, and others occurred in the surrounding region.15 vhf training was provided to hcws at mkmc by the uganda ministry of health, but did not include a simulation component. prior to coordinated efforts to establish simulation training from musc, staff at mkmc had no previous experience in donning and doffing ppe for vhf management. at owh’s request, training for staff at mkmc in vhf management was established by musc faculty. in order to evaluate whether musst curriculum might offer a sustainable solution to provide ongoing ebola training, we decided to adapt the musst curriculum and pilot it at mkmc. in march of 2021, an updated version of the musst curriculum, described in detail below was again piloted at musc, an 865-bed tertiary-care referral hospital in charleston, south carolina, u.s.a. to ensure functionality of the curriculum platform. following successful completion in south carolina, the musst updated curriculum was piloted at mkmc in uganda in may 2021. in this pilot trial we describe the development and adaptation of our curriculum to train hcws at mkmc in masindi, uganda. in comparing the implementation of this training modality at musc versus mkmc, we review valuable lessons learned which may assist with future curriculum development to overcome some of the challenges related to ebola-response simulation education in this region of ssa. materials and methods curriculum development and design curriculum development was performed by a team of two anesthesiologists with extensive simulation education expertise, an ebola-patient care expert with years of hands-on experience working in ebola treatment centers in s.s.a., a global emergency medicine specialized physician with tropical infectious disease expertise and prior on the ground experience at mkmc, and a human-factors engineer with decades of experience studying and improving safety and performance in acute care. content was developed utilizing resources from the cdc, who, and the national ebola training and education center. this course was developed to be performed in two parts: i) online education and ii) simulation of clinical care scenarios. the online component hosted on moodletm, an open-sourced online course management software package, included disease-specific written curriculum, checklists, and video demonstrations of simulation scenarios being performed correctly. simulation training occurred in person, utilizing scenarios involving a “provider” and “buddy” team with checklists to support high-reliability team functioning facilitated by a trainer see example in (appendix a). the 10 simulation scenarios included the donning and doffing of 3 distinct types of ppe and common clinical tasks. they were organized into three stations such that each group would don a specific form of ppe, perform the simulation task skill(s) in that ppe and then doff that ppe before rotating to the next simulation station (table 1). this rotating format for training was meant to allow groups to continually rotate through stations to increase efficiency and decrease the total number of training days. a digital grading tool was created to be used by trainers during simulation scenarios. the tool was designed to function on a tablet device to capture realtime team simulation performance, generate a debriefing report for trainers and digitally store performance data for future reference. a train-the-trainer module was developed to ensure sustainability of the musst curriculum and is described in more detail in a previous publication by tobin et al. (2020).16 participants in the train-the-trainer component completed the part i online training plus an additional online train-thetrainer module shown in table 2. the updated online learning platform developed for use in uganda included three pre-recorded videos of actors performing simulation scenarios with a total of six intentional critical errors executed. this was included to allow the newly trained trainers to practice using the grading tool to grade videos of individuals performing the clinical simulation scenarios. after completing all online coursework, trainers-in-training would then perform all 10 simulation scenarios three times, rotating through each of the roles of trainer, provider, and buddy. thus, by the completion of their curriculum, the newly trained trainers completed the entire simulation curriculum themselves, and prac article table 1. clinical simulation scenarios included in the musst course. station donning scenarios task skill(s) scenarios doffing scenarios (number of steps in scenario) (number of steps in scenario) (number of steps in scenario) 1 n-95 with gown donning (16) lab draw and specimen bagging (19) n-95 with gown doffing (20) 2 n-95 with coverall donning (16) spill clean-up (14) n-95 with coverall doffing (23) waste disposal (28) 3 papr with coverall donning (21) body bagging (34) papr with coverall doffing (29) [page 238] [healthcare in low-resource settings 2025;13:13372] ticed facilitating the simulations, utilizing the grading tool, and performing debriefing (figure 1). the “logistics” component of the training for trainers included information on how to set up the simulation scenarios for trainees. rudimentary designs of simulation environments were created in a way such that they could be used in any location, making the curriculum adaptable to both high fidelity simulation centers and our intended location in uganda (appendix b). pilot trial human subject use was approved by musc irb and taso research ethics committee in uganda. nine paid hcw volunteers were recruited at both sites to pilot the curriculum. informed consent was obtained. training took place in march 2021 at musc (usa) and in may 2021 at mkmc (uganda). three trainers at each site completed the train-the-trainer course (figure 1a) and then each new trainer trained two participants using the musst curriculum (figure 1b). participants at musc performed the online “part 1” remotely whereas in uganda participants completed the online portion in the hospital library at mkmc due to lack of internet connectivity at participants’ homes (table 2; figure 1). trainers used the grading tool on a samsung galaxy tab a android® electronic tablet with connected keyboard to capture trainee performance in real time (figure 2). performance data were automatically transmitted to a web-based database. mastery-based learning was used; if a “critical error” occurred, defined as one that article table 2. train-the-trainer curriculum. 1. applicable infectious disease background information 2. review of protocols with train-the-trainer video demonstration of proper conduct 3. training goals 4. training space setup 5. logistic training ratio 6. safety considerations 7. scoring performance and providing feedback 8. learning to run simulation scenarios that measure performance 9. facilitating performance: debriefing 10. schedule and logistics of training 11. facilitator curriculum (to use the day of the course as a support aid for facilitators running the course). figure 1. pilot trial design flow-chart. [healthcare in low-resource settings 2025;13:13372] [page 239] could lead to infection or contamination, the step was mandatorily repeated until correct. if trainers selected “critical error specified” on the grading, the tool would signal trainers to comment on the critical action and would prompt trainers to have trainees repeat the step, until the trainer selected the “step completed” radio button (figure 2). trainers also had the option to utilize rapid cycle deliberate practice (rcdp) if desired, but only critical errors required repetition of the step. upon completion of each simulation scenario, the grading tool generated a summary of performance with documentation of all checklist steps’ time of completion, if the step required repetition and any comments regarding errors, positive or negative actions as documented by the trainer to be used by the trainer for debriefing following completion of the simulation. data collection and analysis information regarding the implementation of the curriculum in masindi, uganda, and how it compared to charleston, south carolina, was utilized with observations made by the study team along with quantitative data collected during the trials. this included a demographic survey and a 25-question multiple-choice knowledge test given both before and after the online coursework. changes in preand post-knowledge test at each site and between the mkmc and the musc groups were evaluated using standard and paired t-tests, respectively. the moodletm platform also hosted a preand post-training confidence. the confidence survey consisted of 10 questions regarding participants’ level of comfort caring for evd patients using a five-point likert scale. data was also collected from the grading tool reports generated from the practice videos at the end of the train-the-trainer online coursework and those from the simulation training of trainees. these reports, combined with observations made by the study team, were used to evaluate the functionality and effectiveness of the train-the-trainer curriculum. observations made during the implementation of the curriculum in masindi were compared to those made during the pilot trial in charleston. results three trainers and six trainees were enrolled at each site. table 3 gives demographic information at both sites. educational background was the only demographic variable that was significantly (p=0.01) different between the two sites with musc participants having completed more degree programs, versus diploma and certificate programs at mkmc (table 3) completion of the online curriculum improved knowledge test scores in trainees at both sites. preand post-test results are shown in table 4. initial pre-training knowledge test scores were higher in the musc group than the mkmc group (p=0.04), but both sites had significant improvement in post-test scores with no significant difference in the change in test scores between sites. participants at mkmc were generally more confident pretraining than musc participants (table 5). musc participants improved more in confidence, although post-training confidence at musc (median=4.2; iqr=3.0-4.6) remained significantly (p=0.02) lower than at mkmc (median=4.9; iqr =4.4-5.0). grading tool reports from the practice videos which contained six intentional critical errors generated by the three trainers-intraining in uganda revealed one trainer correctly identified all six out of six critical errors. the second identified five of the six. the last grader noted five of the six critical errors, but incorrectly marked two of those five as non-critical. grading tool reports generated by the newly trained trainers article [page 240] [healthcare in low-resource settings 2025;13:13372] figure 2. screenshot of one step in the simulation scenario as it appears on the grading tool used by trainers during simulation training (left) and photo of a trainer using the grading tool on samsung tablet device during simulation training at mkmc (right). demonstrated a total of 20 critical errors were recorded at musc and five at mkmc. trainers at musc recorded 89 comments on trainee performance (including 35 positive comments and 54 negative comments). mkmc trainers recorded 12 comments 11 of which were negative. the mean time to complete each scenario did not differ by site apart from one scenario, “gown with n95 donning” which had a mean time at musc of 7.7 minutes (sd 2.9) versus 13.7 minutes (sd 5.4) at mkmc (p=0.04) and all groups completed simulation training within the allotted one-day period. discussion this pilot study demonstrates the feasibility of utilizing an internet-based course with a train-the-trainer component designed to rapidly develop new trainers to provide simulation education to hcws in a lower-resource setting in uganda. anticipated differences in resources resulted in pre-emptive adaptations to the course. only five of the nine participants at mkmc reported having consistent or any internet access at their homes. thus, the part 1 “remote online study” portion at mkmc was done on the hospital campus using a wi-fi hotspot generated by a 4g mobile wireless router. this does expose a limitation of the internet educational modality in regions with no internet connectivity. however as mobile devices become more universally accessible, this trial shows that this modality can be utilized in settings similar mkmc where connectivity in the home is unavailable but access to internet on hospital campuses or through the use of mobile devices allows temporary connectivity for course access. significant improvements in posttest knowledge scores at mkmc suggest the online curriculum was effective despite online education being a less commonly used modality in ugandan educational systems. when comparing the preand post-test knowledge scores in our mkmc cohort to our musc cohort, we found musc trainees had higher knowledge pre-test scores, which could reflect the higher educational and therefore knowledge level of the trainees or better test-taking skills. nonetheless, both groups saw improvement in post-test scores. simulation training at both sites was low-fidelity using mannequins outside of a formal simulation center. the musc simulations occurred in a larger indoor building using laerdal mannequins (~$2,800 usd) versus an outdoor pavilion used at mkmc using inflatable costume mannequins purchased online from article table 5. confidence scores at mkmc and musc before and after training. musc (usa) median (iqr) mkmc (uganda) median (iqr) p-value mkmc vs musc* confidence before training 3.2 (2.1-3.9) 4.6 (4.4-4.8) 0.01 confidence after training 4.2 (3.9-4.6) 4.9 (4.4-5.0) 0.02 change in confidence score 0.8 (0.4-1.5) 0.2 (0.1-0.2) 0.01 p-value pre and post** 0.06 0.03 *rank sum test. **signed rank sum. table 3. demographic characteristics of participants at mkmc and musc. musc trainers uganda trainers musc trainees uganda trainees n=3 n=3 n=6 n=3 n (%) n (%) n (%) n (%) gender female 3 (100.0) 2 (66.7) 3 (50.0) 4 (66.7) male 0 (0.0) 1 (33.3) 3 (50.0) 2 (33.3) education baccalaureate 1 (33.3) 1 (33.3) 4 (66.7) 1 (16.7) masters 0 (0.0) 0 (0.0) 1 (16.7) 0 (0.0) md 0 (0.0) 0 (0.0) (0.0) 0 (0.0) other 2 (66.7) 2 (66.7) 1 (16.7) 5 (83.3) current employment rns 1 (33.3) 1 (33.3) 1 (16.7) 5 (83.3) med techs 2 (66.7) 1 (33.3) 2 (33.3) 1 (16.7) midlevel provider 0 (0.0) 1 (33.3) 0 (0.0) 0 (0.0) medical students 0 (0.0) 0 (0.0) 3 (50.0) 0 (0.0) table 4. didactic learning scores at mkmc and musc. pre-test mean p-value post-test mean p-value p-value absolute change p-value ± std mkmc ± std pre and post mkmc in score mean mkmc vs vs ± std vs musc musc musc mkmc 17.2 ±1.9 0.04 21 ±4.4 0.04 0.22 3.8 ±3.3 0.83 musc 20 ±2.3 23.5 ±1.4 0.005 3.5 ±1.7 [healthcare in low-resource settings 2025;13:13372] [page 241] amazon.com ($20 usd). prior research has shown that high-cost, realistic simulators are not per se superior to low-cost simulations.17–21 psychological fidelity, or an individual’s buy-in to the simulated scenario, can have a greater impact on education. musst simulations were designed to be implementable in any room with the addition of a small number of supplies. the supplies needed to run the musst curriculum cost a total of $7,857 usd in charleston, usa, and a total of $2,246 usd in masindi, uganda. the musst model offers a solution to one of the major obstacles to simulation education in sub-saharan africa: the high cost of simulation centers. it also avoids the use of clinical care spaces, which may be in short supply or dangerous during an actual ebola outbreak. prior research demonstrates that mastery-based simulation education in high-resource settings improves confidence in performing clinical tasks.14,22,23 we similarly found that both our cohorts experienced significant improvements in confidence levels following the musst training. this confidence in performance capability is important in the high-stress environments encountered during ebola outbreaks, especially in settings with limited access to care. lack of confidence in providing ebola patient care has been associated with refusal to provide care to patients with evd.6 additionally, hcw confidence can support hcw resilience during disease outbreaks. a review and meta-analysis of 59 studies by kisely et al. (2020) found that lack of confidence in infection control, lower perceived personal-self efficiency and perceived lack of adequate training were all associated with an increased risk of adverse psychological outcomes in hcws during emerging infectious disease outbreaks.24 inversely, self-perception of being adequately trained and supported was associated with a decreased risk of adverse psychological outcomes in hcws. reports from the simulation training of trainees by the newly trained trainers show that the majority of critical errors occurred in ppe donning and doffing. these findings are consistent with past research which demonstrates that self-contamination is most likely to occur during the doffing process.25-27 this emphasizes the need for high quality training in these particularly critical processes. musst’s mastery learning technique with its competency-based structure and the utilization of checklists aligns well with existing donning and doffing guidelines supported by the who and cdc.28 future research is needed to determine how musst training affects ppe donning and doffing skills over time. while our pilot trial proved the course could be completed within the allotted amount of time in the setting of a rural hospital in uganda, we also noted areas for improvement, especially in the train-the-trainer aspect of the curriculum. in reviewing the performance of newly trained trainers, grading the example videos with 6 intentional critical actions, it was noted that while most errors were noted, some critical errors were missed by all trainers. this suggests that more robust practice is needed prior to trainers being prepared to run simulation scenarios. in hindsight, our curriculum should have included a review of the critical errors and how to document as part of the learning material provided for trainers. overall, the grading tool itself proved less utilized in the training at mkmc. trainers at the musc site recorded a much higher number of both positive actions and errors in the grading tool than the trainers at the mkmc site (89 vs 12). one hypothesis for this relates to familiarity with using a tablet keyboard. all musc trainers had previous experience using a tablet device, whereas none of the mkmc trainers had previously used a similar device. feedback from participants of prior research evaluating the use of technology for ebola simulation training in west africa indicated that participants were less familiar and less comfortable with using computers than they were with using smartphone technology with a touchscreen interface.29 our simulation grading tool allowed touchscreen capture of step-by-step performance (figure 2). however, to record comments, the tablet keyboard was required. future iterations of the grading tool software designed for use in ssa should consider utilizing a touchscreen keyboard for capturing comments. beyond the physical constraints of familiarity with the keyboard, we hypothesize that experience with the concepts of simulation education and debriefing was more foreign to our ugandan trainers. while musc trainers recorded comments for both positive and negative actions, mkmc trainers primarily recorded negative comments. the purpose of debriefing is to recognize strengths alongside areas for improvement to promote learning and improve skills. the absence of positive comments used in debriefing sessions in the mkmc group as compared to the musc group suggests that more emphasis needs to be placed on this aspect of debriefing. it was noted by the research team that while musc trainees spent more time recording errors, mkmc trainees were more likely to verbalize praise or critiques without documenting comments in the grading tool. this may reflect differences in cultural teaching technique as well as possibly differences in english language written fluency. despite all participants being fluent and literate in english, it is not the first language of the ugandan trainers. though anecdotal, our observations suggest that rcdp, with the ability to pause and provide immediate verbal feedback, occurred more naturally for ugandan trainers as opposed to more traditional, end-of-simulation debriefing using recorded comments. both rcdp and traditional debriefing techniques improve simulation education outcomes.13,30 however, waiting until the end of simulation scenarios before providing debriefing allows trainees to reflect and explore experiential learning that occurred during the simulation. it provides trainers an opportunity to reinforce lessons learned. one strategy to improve education on the debriefing that has been successfully utilized in diverse and often resource-limited settings is the vital anaesthesia simulation training (vast) program, which uses pre-recorded scenarios with examples of proper debriefing technique to teach debriefing to new facilitators.12 future iterations of the musst train-the-trainer curriculum intended for use in uganda may want to utilize similar methods to implement more robust debriefing education. a major limitation of this study is its small sample size. we demonstrate the feasibility of using the course in two vastly different settings, as may be encountered in an actual ebola outbreak. while observations from this trial can be used to guide future curriculum design and implementation, further studies with larger study populations are needed to better evaluate its efficacy in a variety of environments. frontline hcws can be trained using the internet and low-cost simulation to be trainers that satisfactorily and rapidly train others to safely use ppe and conduct routine clinical tasks in ebola patient care. it bridges the gap between providing extensive costprohibitive in-person training and rapidly disseminated theoretical training without hands-on experience. our simulation model is ideal for the training of hcws in the management of novel or evolving disease outbreaks when improper task performance can be life-threatening. through its train-the-trainer model, musst ensures sustainability by creating local simulation educators. this educational modality could be adapted to other hcps. future research is needed to determine whether this form of education leads to safe conditions during real ebola outbreaks, and how this educational modality compares to traditional training models. the article [page 242] [healthcare in low-resource settings 2025;13:13372] covid-19 pandemic brought to the forefront the profound burden of disease hcps can cause in hcws, emphasizing the value of just-in-time training.5,13 with high consequence emerging infectious diseases on the rise, the continued development of rapidly deployable, effective training modalities to protect hcws and safely care for patients should be a global health priority. references 1. world health organization (who). ebola disease caused by sudan virus – uganda. news room. published 2022. accessed july 10, 2023. available from: 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high-fidelity is not superior to low-fidelity simulation but leads to overconfidence in medical students. bmc med educ 2019;19:29. 19. maran nj, glavin rj. lowto high-fidelity simulation a continuum of medical education? med educ suppl 2003;37:22-8. 20. skelton t, nshimyumuremyi i, mukwesi c, et al. low-cost simulation to teach anesthetists’ non-technical skills in rwanda. anesth analg 2016;123:474-80. 21. gu y, witter t, livingston p, et al. the effect of simulator fidelity on acquiring non-technical skills: a randomized noninferiority trial. can j anesth 2017;64:1182-93. 22. rice j, omron r, calkins h. optimizing mastery learning environments: a new approach to deliberate practice for simulation-based learning. aem educ train 2018;2:77-81. 23. berger m, weber l, mcnamara s, et al. simulation-based mastery learning course for tube thoracostomy. mededportal j teach learn resour 2022;18:11266. 24. kisely s, warren n, mcmahon l, et al. occurrence, prevention, and management of the psychological effects of emerging virus outbreaks on healthcare workers: rapid review and metaanalysis. bmj 2020;369:m1642. 25. kwon jh, burnham cad, reske ka, et al. assessment of healthcare worker protocol deviations and selfcontamination during personal protective equipment donning and doffing. infect control hosp epidemiol 2017;38:1077-83. 26. lim sm, cha wc, chae mk, jo ij. contamination during doffing of personal protective equipment by healthcare providers. clin exp emerg med 2015;2:162-7. 27. mumma jm, durso ft, ferguson an, et al. human factors risk analyses of a doffing protocol for ebola-level personal protective equipment: mapping errors to contamination. clin infect dis 2018;66:950-8. 28. agency for healthcare research & quality (ahrq). health care simulation to advance safety: responding to ebola and other threats. agency healthc res qual. published online 2015:12. available from: http://www.ahrq.gov/research/findings/factsheets/errors-safety/simulproj15/index.html#note1 29. mellor n, horton h, luke d, et al. experience of using simulation technology and analytics during the ebola crisis to empower frontline health workers and improve the integrity of public health systems. procedia eng 2016;159:44-52. 30. mcgaghie wc, issenberg sb, petrusa er, scalese rj. a critical review of simulation-based medical education research: 2003-2009. med educ 2010;44:50-63. article [healthcare in low-resource settings 2025;13:13372] [page 243] online supplementary materials appendix a: papr with coverall doffing scenario checklist appendix b: body bagging in papr, coverall donning and doffing station. spill clean-up & waste bag disposal in coverall with n-95. hrev_master healthcare in low-resource settings 2024; volume 12(s1):13022 the role of family support in managing death anxiety among the elderly niko dima kristianingrum, yati sri hayati, annisa wuri kartika, fransiska imavike fevriasanty, selsa rifziqka heltha novian haryono, ayut merdikawati nursing department, faculty of health sciences, universitas brawijaya, malang, east java, indonesia abstract death anxiety is a sentimental state experienced by individuals, specifically the elderly due to the occurrence of unpleasant events and contemplation of mortality. this condition is primarily caused by a lack of social support from family, which has a significant effect on mental health. therefore, this study aimed to analyze the correlation between family support and the level of death anxiety in the elderly. the study procedures were carried out with a cross-sectional method, and the sample population comprised 239 elderly who were selected at a community health center in malang indonesia using cluster random sampling. family support was measured using the family support instrument (fsi), while death anxiety level was assessed with the death anxiety scale (das). the relationship between the 2 variables was then tested using spearman’s rank correlation test with p<0.05. the results showed that there was a strong correlation between the 2 variables, with family support falling into the high category for 98 participants (41%). in addition, 117 participants (49.0%) were reported to have a low category of death anxiety level. to conclude, these findings could be applied and used as a reference for future studies by exploring variables and conditions influencing family support and the death anxiety level of the elderly. introduction life expectancy is an essential factor, which has been reported to have a positive correlation with health challenges, particularly among the elderly. according to the world health organization (who), there is a substantial increase in the prevalence of both physical and mental diseases among this demographic, posing a significant burden on the society.1 in addition, the phenomenon of an aging populace and the increase in the number of the elderly in indonesia have a significant impact on the country, families, society, and aged individuals.2 several studies have shown that aging exerts adverse effects across various facets of life, including balance in the elderly. this demographic is often affected by biopsychosocial conditions, which interact to cause various health challenges, including psychiatric disorders, with anxiety being the most commonly diagnosed.3,4,5 a prevalent type of anxiety among the elderly is death anxiety, which is characterized by apprehension toward mortality and contemplation about death.6,7 a previous study regarding death anxiety level was conducted at a nursing home in bandung indonesia using 79 elderly, with 50.6% of the participants experiencing high level.8 in addition, this condition was primarily caused by a lack of social support. among the various elements of social support, the role of family is essential in determining the mental health status of the elderly.9,10 a previous study showed that the elderly living in nursing homes have a higher tendency to experience death anxiety compared to others with their families.11 optimal support has also been reported to have the potential to alleviate this condition, particularly among those undergoing hemodialysis. 12 based on findings, there has been an increasing trend of the elderly living in nursing homes, specifically in asian countries.13 therefore, this study aimed to analyze the correlation between family support and death anxiety level among the elderly. materials and methods this study was carried out using a cross-sectional method, exploring 239 elderly taken from 4 working areas of the ciptomulyo community health center at malang indonesia using a cluster random sampling. data collection was carried out in december 2022 through the use of a questionnaire. in addition, family support was measured using a modification of previous scales and analyzed for a validity test value of ≥ 0.361 as well as a reliable test with a cronbach’s alpha value of 0.910. death anxiety level was assessed using the death anxiety scale (das).14 the scale consisted of 15 questions, which had been modified based on the study’s needs with a validity test value of ≥ 0.361 and reliability with a cronbach’s alpha value of 0.845. the correlation between the 2 variables was tested using the spearman rank test. ethical approval letter was issued by the health research ethics committee of the faculty of health sciences, brawijaya university no. 5851/un10.f17.10/tu/2022. results and discussion the results showed that the level of family support in this study was in the high category, as shown in table 1. this was in line with rahmadeni et al., where the elderly did not experience depression due to optimum support from their family.15 moreover, the elderly typically experienced poor quality of life in the pres [healthcare in low-resource settings 2024;12(s1):13022] [page 1] significance for public health the results of this study are expected to contribute to the management of death anxiety, with a particular emphasis on the role and support of family in the community. this is specifically pertinent considering the increasing number of the elderly and the growing trend of family placing the elderly in nursing homes. ence of dysfunctional family.16 indonesians believed that these individuals were members of the family who must be respected. younger members tried to meet all the needs of the elderly, including their health needs. when the physical and mental needs were met, these individuals typically felt. in the context of facing death, the elderly were often calmer in facing this challenge considering that their family was always present.17,18,19 death anxiety level of the elderly in this study was placed in the low category, as shown in table 2. in addition, it was reported to be influenced by factors other than family support, including spiritual health, number of hospitalizations, and the performance of health workers.9 the elderly often spend their time praying and participating in religious activities in the community. this was performed as a way to get closer to god in preparation for facing death, apart from filling free time. the better the spiritual health, the lower death anxiety level experienced by the participants. 20,21,22 in terms of the number of hospitalizations, the participants who suffered from chronic diseases and were frequently hospitalized were likely to experience higher death anxiety compared to others. this was because the elderly people who were treated in hospitals felt more lonely and uncomfortable with therapy procedures as well as a crowded hospital environment.23,24,25 in addition, the performance of health workers could also affect death anxiety level, particularly less professional nurses. based on these findings, there was a need for special training for nurses to increase understanding and readiness to face death, specifically for geriatric patients.26 table 3 presents the results of statistical correlation testing between family support and death anxiety in the elderly. the findings showed that there was a strong relationship between these variables with p < 0.05 and a correlation coefficient of -0.683. the higher the family support given to the elderly, the lower the death anxiety level experienced. this was in line with previous studies conducted in arabia and rural china, where death anxiety level experienced by the older population was in the low category while living with their families.27,28 other studies also reported family support as a significant coping, influencing factor, and was found to have a protective effect among the elderly. 29,30,31,32 conclusions in conclusion, death anxiety level experienced by the elderly was influenced by physical and psychological factors, including family role in supporting the readiness to face peaceful death. in addition, active participation was needed from health facilities and health workers in providing professional service performance, particularly for geriatric patients. references 1. who. ageing and health. 2022 [cited 2024 jun 19]. available from: https://www.who.int/news-room/fact-sheets/detail/ageing-and-health. 2. rahayu hc, purwantoro, wibowo m, safitri j, suparjito. determinants of welfare for the elderly population in indonesia. kne medicine 2022;782–93. 3. apak e, artan t, ozucelik dn. evaluation of bio-psychosocial and socio-cultural problems of syrian elderly living in turkey. int j soc psychiatry 2023;69:454-66. 4. marwat dmk, usman dk, ullah mi, et al. causes and biopsycho-social changes associated with aging: a review of qualitative literature. oeconomia 2023;6:1100–8. 5. kułak-bejda a, bejda g, waszkiewicz n. mental disorders, cognitive impairment and the risk of suicide in older adults. front psychiatry 2021;12:695286. 6. sahin d, buken n. death anxiety and concept of good death in the elderly. turkish journal of geriatrics -turk geriatri dergisi 2020;23(1). 7. sharma m, jain v. death anxiety, religiosity and psychological proquest [internet]. [cited 2023 dec 23]. available from: https://www.proquest.com/docview/2445574935?pqorigsite=gscholar&fromopenview=true&sourcetype=scholarl y%20journals 8. ningrum tp, okatiranti o, nurhayati s. description of the anxiety level about death in the elderly at bpstw ciparay, bandung regency. jurnal keperawatan bsi 2018;6:142–9. 4th international nursing and health sciences symposium table 1. family support frequency distribution. family support n % low 60 25.1 moderate 81 33.9 high 98 41.0 total 239 100.0 table 2. elderly death anxiety level. death anxiety level n % low 117 49.0 moderate 73 30.5 high 49 20.5 total 239 100.0 table 3. spearman rank analysis death anxiety level total low moderate high f % f % f % f % family support low 2 0.84 25 10.46 33 13.81 60 25.10 moderate 26 10.88 40 16.74 15 6.28 81 33.89 high 89 37.24 8 3.35 1 0.42 98 41.00 total 117 48.95 73 30.55 49 20.5 239 100.00 spearman’s rho r= -0.683** p-value 0.000 [page 2] [healthcare in low-resource settings 2024;12(s1):13022] 9. zahedi bidgol z, tagharrobi z, sooki z, sharifi k. death anxiety and its predictors among older adults. j holist nurs midwifery 2020;101–10. 10. eslami rs, omranian m. social support and psychological well-being of the elderly: the mediating role of death anxiety. j soc sci humanit res 2021;9:97–107. 11. ergin e, yildirim d, yildiz cç, usenmez sy. the relationship of death anxiety with loneliness and psychological wellbeing in the elderly living in a nursing home. omega (westport) 2023;88:333–46. 12. dewi ei, sriharja b, deviantony f, et al. the relationship between family support and death anxiety in the elderly undergoing hemodialysis. unej e-proceeding 2023;109–15. 13. he aj, tang vfy. integration of health services for the elderly in asia: a scoping review of hong kong, singapore, malaysia, indonesia. health policy 2021;125:351–62. 14. conte hr, weiner mb, plutchik r. measuring death anxiety: conceptual, psychometric, and factor-analytic aspects. j pers soc psychol 1982;43:775–85. 15. rahmadeni as, hayat n, alba ad, et al. the relationship of family social support with depression levels of elderly in 2019. internat j health med sci 2020;3:111–6. 16. souza júnior ev de, viana er, cruz dp, et al. relationship between family functionality and the quality of life of the elderly. rev bras enferm 2021;75:e20210106. 17. lestari md, stephens c, morison t. local knowledge and unliveable narratives: how insights from family caregiving narratives can inform locally relevant ageing policy. j aging studies 2023;64:101102. 18. pio tmt, prihanto jb, jahan y, hirose n, kazawa k, moriyama m. assessing burden, anxiety, depression, and quality of life among caregivers of hemodialysis patients in indonesia: a cross-sectional study. internat j environ res public health 2022;19:4544. 19. nugraha a, rahmah gu, budhiaji p. effect of family support towards elderly hemodialysis patients’ anxiety level. basic appl nursing res j 2020;1:20–4. 20. ghasemi f, atarodi a, hosseini ss. the relationship between religious attitudes and death anxiety in the elderly people. journal of research and health. 2020 may 10;10(3):135–42. 21. rababa m, hayajneh aa, bani-iss w. association of death anxiety with spiritual well-being and religious coping in older adults during the covid-19 pandemic. j relig health 2021;60:50–63. 22. soriano gp, calong calong ka, martinez rckp, locsin rc. religiosity, spirituality and death anxiety among older adults living at home and in institutional facilities: a comparative study. journal of religion, spirituality & aging 2022;34:284– 96. 23. tadi a, gheibizadeh m, anjiri sgc. death anxiety and associated factors in the hospitalized and non-hospitalized elderly with chronic diseases in ahvaz. jundishapur j chronic dis care 2022;11(4). 24. becker td. health care utilization as a predictor of death anxiety in older adults. death studies 2022;46:728–37. 25. üstükuş a, eskimez z. the effect of death anxiety in nurses on their approach to dying patients: a cross-sectional study. perspect psychiatr care 2021;57:1929–36. 26. batı s, polat ht, akkuş h. determination of the relationship between self-care agency and death anxiety among elderly individuals. omega (westport) 2022:302228221095907. 27. sebea de, el-geneidy mm, abd-elsalam rm, dawood. factors associated with death anxiety among community dwelling older adults. alexandria scientific nurs j 2021;23:1–17. 28. pei y, cong z, silverstein m, li s, wu b. factors associated with death anxiety among rural chinese older adults: the terror management perspective. res aging 2022;44:65–72. 29. raziani y, mahdavi a, ngoc huy dt, et al. death anxiety in the iranian elderly: a systematic review and meta-analysis study. omega (westport) 2022;302228221110965. 30. laguilles-villafuerte s. death anxiety and interment stress family interventions for filipino older adults. omega (westport) 2022:302228221132905. 31. laguilles-villafuerte s, de guzman ab. put your hands in mine: a metaphor analysis of family support in death anxiety and interment stress among filipino older adults. educat gerontol 2021;47:180–91. 32. jalal nm. description of elderly anxiety in the face of death. internat j educat vocational soc sci 2023;2:185–90 4th international nursing and health sciences symposium correspondence: fransiska imavike fevriasanty, nursing department, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia, postcode: 65151. tel.: +62341569117 fax: +62341564755. e-mail: imavike.fk@ub.ac.id key words: death anxiety; elderly; family support contributions: the authors contributed equally from the literature reviews, data collection process, statistical analysis to manuscript editing. conflict of interest: the author declares no potential conflict of interest. funding: this study was supported by universitas brawijaya ethics approval: ethical approval letter was issued by the health research ethics committee of the faculty of health sciences, brawijaya university no. 5851/un10.f17.10/tu/2022. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful to the nursing department, faculty of health sciences universitas brawijaya for the opportunity provided to conduct this study in the geriatrics. received: 3 november 2023. accepted: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13022 doi:10.4081/hls.2024.13022 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s1):13022] [page 3] hrev_master healthcare in low-resource settings 2024; volume 12(s1):13066 the effect of family-supportive therapy on the burden of caregivers and activities of daily living among stroke patients nikmatul fadilah,1,2 loetfia dwi rahariyani,1 hilmi yumni,1 dinarwiyata1 1nursing department, health polytechnic of the health ministry of surabaya, surabaya, east java; 2center for excellence in science and technology-community empowerment, health polytechnic of the health ministry of surabaya, surabaya, east java, indonesia abstract the role of family members in providing care for stroke patients at home is associated with heightened stress and burden on caregivers. therefore, this study aimed to analyze the effect of family-supportive therapy on the burden of caregivers and activities of daily living (adl) among stroke patients. a quasiexperimental method was used with a pre-test and post-test control group. the intervention of family-supportive therapy was given to the treatment group, while the control group received home visits. samples of 40 caregivers in two primary health care centers in surabaya were recruited using a multi-stage sampling method. the variables were the burden of caregivers and adl of stroke patients, while zarit burden’s interview schedule and katz index of independence in adl were used as instruments. data analysis was carried out using a paired t-test and a manova test. the results showed that the burden of caregivers in the treatment group decreased, but there was a re-increase after 2 weeks of therapy, and the burden in the control group also decreased. adl of stroke patients in the treatment group increased and tended to persist up to 2 weeks after therapy, while the value in the control group decreased. furthermore, family-supportive therapy did not have a significant effect on the burden of caregivers (p-value 0.12) and adl (p-value 0.21). to address this challenge, modifying services through the implementation of community health programs, individual health efforts for stroke patients in the hospital and at home, group services for families providing primary health care, and home visits could be a comprehensive effort. the study found that family-supportive therapy and health education through home visits reduced caregiver burden. introduction family is recognized to play a crucial function in health care, particularly during the acute period of disease to the recovery and rehabilitation phase. this is specifically true for non-communicable diseases such as stroke, which currently tend to increase in prevalence both in urban and rural areas. however, the responsibility of providing care for stroke patients at home can lead to persistent stress and burden for caregivers. according to the 2018 basic health research of indonesia (riset kesehatan dasar), east java ranked third in stroke prevalence.1 weakness, physical disability, psychological problems, and depression cause obstacles to activities of daily living (adl) and even a decrease in quality of life (qol).2 a previous study stated that 50% of stroke patients’ caregivers had mild to moderate burden, and 5,8% showed moderate to severe burden.3 persistent distress eventually strains and burdens both stroke patients and caregivers, in the emotional, social, and financial aspects.4–6 the high burden felt is manifested in the form of symptoms of anxiety, depression, and low physical health.6 caregivers often neglect personal health and are generally ignored by healthcare professionals while family members pass through the recovery phase. to address this challenge, caregivers should also receive attention from health service providers in the form of informational, emotional, and instrumental support, as well as rewards to mitigate burden.7,8 the inability to cope with a crisis capable of causing strain or burden due to a stroke leads to low function and further increases the stressor experienced by family. a valid initial assessment of stroke patients, caregivers, and all family members is crucial for better preparedness to provide care at home. in this context, the assessment of experiences, perceptions, beliefs, and family support is used as the basis for determining appropriate collaborative nursing interventions to make the coping mechanism of caregivers and family adaptive. consequently, the crisis is resolved, and family welfare is achieved.9 interventions currently provided by health services in the acute phase and rehabilitation for stroke cases tend to be patientcentered care. for example, during the rehabilitation phase, interventions including therapeutic counseling, psychoeducation, and skills training have proven effective in reducing burden of care as well as increasing satisfaction, welfare, and quality of life among caregivers.4,10 all forms of therapy have the primary objective of providing help to individuals by eliminating or reducing suffering. although several studies did not state the most effective therapy, several experts mentioned three interventions that reduced burden of mild to moderate care, namely psycho-educational, psychotherapy, and supportive. family and group supportive interventions can also reduce burden of care and anxiety, while also increasing the ability to care for families with chronic disease, including significance for public health caring for stroke patients at home represents a significant source of stress for family members. this study indicates that the implementation of family-supportive treatment led to a temporary reduction in caregiver burden and a positive improvement in stroke patients' daily activities. to further optimize the program's effectiveness, incorporating community health programs is recommended. this could involve prioritizing individual health initiatives for stroke patients within hospital and home settings, providing group services for families focusing on primary health care, and conducting home visits. [page 122] [healthcare in low-resource settings 2024;12(s1):13066] non -co mmerc ial us e o nly stroke, chronic kidney disease, and mental disease.7,11 supportive therapy is one of the psychotherapy models that can be applied in the community and hospitals. this therapy is a form of family empowerment aimed at building relationships based on shared understanding and empathy with caregivers by focusing on strengths to help identify resources in the community. it is expected to help family, specifically caregivers effectively resolve problems when caring for family members who are sick, provide motivation and change in behavior, as well as carry out adaptive coping strategies.11–13 therefore, this study aimed to analyze the effect of family-supportive therapy on burden of caregivers and adl among stroke patients. materials and methods a quasi-experimental design was used, with a pre-test and post-test control group. treatment group was given family-supportive therapy, and the control group received home visits. samples were 40 caregivers in surabaya recruited from july to september 2018 with multi-stage sampling. caregivers from pegirian and pucang sewu primary health care served as treatment and control group, respectively. the inclusion criteria included i) primary care provider, ii) family members who provided follow-up care at home, and iii) caregivers living at home with the treated stroke patients. the instruments used were zarit burden’s interview schedule6,14 and katz index of independence in adl.15,16 zarit burden’s interview schedule consists of 22 statements and scoring is carried out using the likert scale comprising 0=never, 1=rarely, 2=sometimes, 3=often, and 4=always. the assessment of burden caregiver includes scores of 0-20 = no/little, 21-40 = light-moderate, 41-60 = moderate-heavy, and 61-88 = very heavy. katz index of independence in adl has six closed statements covering bathing, dressing, defecating, moving, continental, and feeding. the scoring uses a dichotomy scale (0=dependent and 1=independent). adl assessment depends on whether patients can perform with or without supervision, direction, assistance, or total care. the previous questionnaire was tested on families who met the criteria but were not selected as respondents and the next step was to test the validity and reliability. all statements in zarit burden’s interview schedule were valid (p-value >0.30) and reliable (p-value 0.923). similarly, all katz index of independence in adl statements were valid (p-value >0.30) and reliable (p-value 0.870). this study was conducted using two groups, namely the control, and treatment, which received family-supportive therapy in four sessions. on the other hand, the control group received standard intervention of health education through home visits by health care providers. burden of caregivers and adl of stroke patients in the control group were measured twice, while in treatment group, measurement was carried out three times. family-supportive therapy was implemented through four sessions with a duration of 50 minutes and spanning 4 weeks. measurement for burden of caregivers and adl of stroke patients was performed in the first session, fourth session, and about 2 weeks after the fourth session. caregivers in the control group received two-session home visits, with a span of about 2 weeks from the first. a therapy-caring module for stroke patients was used, while burden of caregivers and adl were measured at the first and second home visits. the variables assessed were burden of caregivers and adl of stroke patients, while analysis was performed using a paired t-test and a manova test by spss 21st edition. the paired t-test analyzed the relation between burden of caregivers and adl of stroke patients pre-test and post-test. manova test analyzed the more substantial impact of family-supportive therapy on changes in burden of caregivers or adl. ethical approval letter was received from the health research ethics commission of health, ministry of health, surabaya, number 194/s/kepk/v/2018, on 8th june 2018. results and discussion burden of caregivers in caring for stroke patients in treatment group was reduced but there was a re-increase after 2 weeks following family-supportive therapy. similarly, burden of caregivers in the control group also decreased. adl of stroke patients in treatment group increased and tended to persist until 2 weeks after therapy, while the value in the control group decreased. in general, family-supportive therapy did not have a significant effect on burden of caregivers (p-value 0.12) and adl of stroke patients (pvalue 0.21). table 1 shows that caregivers of stroke patients in treatment group are mostly aged 46-55 years or early elderly (42.2%), women (82.5%), had elementary school education (40%), unemployed (55%), and have family relationships (57.5%). in addition, the majority had length of caring 1-2 years (40%) and 1-2 hours per day (57.5%), as well as had 1-2 health problems (47.5%). in the control group, a significant proportion of caregivers were aged 46-55 years or early elderly (35%), women (65%), had senior high school education (42.5%), unemployed, and entrepreneurs (42.5%). furthermore, the majority had a length of caring 1-2 years (67.5%) and 1-2 hours a day (70%), had 1-2 health problems (49%), and worked as housewives (50%). table 2 shows the two heaviest indicators for burden of caregivers , namely physical and financial. table 3 shows a decreased burden of caregivers in the control group before and after following family-supportive therapy (pvalue 0.063; d 2.75). however, 2 weeks after following up the therapy, burden increased (p-value 0.103; d -3.7). in the control group, burden of caregivers before and after home visits showed a decrease (p-value 0.000; d 8.525). table 4 shows that the lowest independent fulfillment of adl for stroke patients in treatment and control group was bathing. table 5 shows an increase in adl of stroke patients in treatment group after following family-supportive therapy (p-value 0.006; d 3.5). however, 2 weeks after, stroke patients had a decreased adl (p-value 0.401; d -0.1). in the control group, the decrease in adl occurred after 2 weeks of home visits (p-value 0.668; d 2.633). manova test results are shown in tables 6, 7, and 8. table 6 shows a variance in burden of caregivers variable between treatment and control groups (p-value 0.061). adl of stroke patients between treatment and control group had the same variant (p-value 0.693). table 7 shows that box’s m tested the null hypothesis stating that the observed covariance matrices of the dependent variable, namely burden of caregivers and adl of stroke patients were the same across both groups (p-value 0.212). table 8 shows that family-supportive therapy did not affect burden of caregivers (p-value 0.12) and adl of stroke patients (p-value 0.21). the partial eta squared value for burden of caregivers was slightly more significant than adl. specifically, the partial eta squared value on burden of caregivers was 0.031, implying that the effect of family-supportive interventions reached 3.1%. on the other hand, the impact of family-supportive therapy on adl was 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13066] [page 123] non -co mmerc ial us e o nly low, estimated at 2% (partial eta square 0.02). burden felt by most caregivers of stroke patients at home comprises both physical and financial, which are often perceived as more significant compared to emotional, timing, and social. the strain and burden of caregivers are influenced by gender (female), age (elderly), low education, job (retired), length of care, and mental health. meanwhile, the influential factors of stroke patients are physical impairment/weakness of motor and cognitive function, depressive symptoms, decreased verbal ability, difficulty walking, and neurological deficits.17,18 the condition of stroke patients who have sequelae contributes to the degree of dependence, which consequently adds to the physical burden of caregivers. the sequelae of stroke patients show mainly in the form of stiffness, weakness, and extremity paralysis (88.75%). furthermore, the age factor can also increase the dependency level, which has an impact on burden of caregivers. based on the results, 77.5% of stroke patients were in the elderly age group (46-65 years) and 23.75% were more than 65 years. the physiological aging process of the neuromuscular system potentially decreases the limbs’ physiological functions, specifically the extremities, including a decrease in adl ability.17,18 the financial burden is the second major burden of caregivers and is associated with the change in the major role of stroke patients being the head of family, who acts as the main financial source. the data showed that 63.75% of stroke patients were male and the head of family. this condition is in line with a previous study, stating that all families of stroke patients experienced changes in the economy, acting as a high stressor.8,19 caregivers feel stress due to stroke attacks on family members from the acute therapy period at the hospital to the follow-up phase of care at home. many stressors during rehabilitation are associated with physical assistance to meet the daily needs of patients.2,20 a significant proportion of caregivers were in early elderly category (46-55 years) and 73.75% were women, with the majority being wives of patients. in terms of education, 7.5% were uneducated, and 32.5% had only primary school education. almost half (48.75%) were unemployed (homemakers), while some made efforts to find additional income by becoming entrepreneurs or selling food at home up to 2 years after stroke attack on husbands. most of caregivers (73.75%) had cared for family members suffering a stroke for ≤2 years, with a therapy duration of 1-4 hours (87.5%). health problems experienced by caregivers of stroke patients can affect burden. based on the results, most of caregivers 4th international nursing and health sciences symposium table 1. demographic characteristics regarding caregivers of stroke patients (n=40). demographic characteristics category treatment control n % n % age (year) 17-25 years old 4 10 3 7.5 26-35 years old 5 12.5 5 12.5 36-45 years old 12 30 5 12.5 46-55 years old 17 42.5 14 35 56-65 years old 2 5 10 25 >65 years old 0 0 3 7.5 gender male 7 17.5 14 35 female 33 82.5 26 65 education not school 4 10 2 5 elementary school 16 40 10 25 junior high school 4 10 9 22.5 senior high school 14 35 17 42.5 diploma or bachelor’s 2 5 0 0 postgraduate 0 0 2 5 employment no employee 22 55 17 42.5 government employee 2 5 1 2.5 private employee 5 1.5 5 12.5 entrepreneurship 10 25 17 42.5 others 1 2.5 0 0 family relationship husband 2 5 8 20 wife 23 57.5 20 50 child 8 20 10 25 others 7 17.5 2 5 length of caring (year) < 1 year 11 27.5 6 15 1-2 years 16 40 27 67.5 3-4 years 9 22.5 5 12.5 ≥ 5 years 4 10 2 5 duration of caring 1-2 hours 23 57.5 28 70 (hour/day) 3-4 hours 10 25 9 22.5 5-6 hours 4 10 2 5 ≥ 7 hours 3 7.5 1 2.5 health problem no problem 10 25 15 37.5 1-2 problems 19 47.5 16 40 3-4 problems 11 27.5 8 20 5 problems 0 0 1 2.5 [page 124] [healthcare in low-resource settings 2024;12(s1):13066] non -co mmerc ial us e o nly 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13066] [page 125] table 2. indicators regarding burden of caregivers for stroke patients. group indicators for burden of caregivers mean pre post 1 post 2 treatment (n=40) physical burden 1.35 1.17 1.4 timing burden 0.66 0.55 0.54 financial burden 1.33 1.05 1.5 emotional burden 0.70 0.58 0.74 social burden 0.23 0.2 0.28 control (n=40) physical burden 1.85 1.33 timing burden 0.59 0.33 financial burden 1.80 1.60 emotional burden 1.28 0.86 social burden 0.19 0.06 table 3. burden of caregivers of stroke patients (treatment and control group). burden of caregivers treatment (n=40) control (n=40) p (paired t-test) mean sd mean sd 1. pre-test burden 17.30 11.697 26.23 8.069 2. post-1 burden 14.55 10.195 17.70 7.532 3. post-2 burden 18.25 12.689 4. different pre-post one burden 2.750 7.990 8.525 7.310 treatment 0.036 control 0.000 5. different post-1-post-2 burden -3.700 14.008 treatment 0.103 table 4. indicators of adl among stroke patients. group indicator of adl mean pre post 1 post 2 treatment (n=40) bathing 0.55 0.65 0.68 dressing 0.68 0.83 0.88 toileting 0.78 0.83 0.83 transferring 0.9 0.95 0.95 continent 0.98 0.95 0.95 feeding 0.88 0.9 0.93 control (n=40) bathing 0.53 0.4 dressing 0.78 0.88 toileting 0.73 0.83 transferring 0.85 0.75 continent 0.9 0.98 feeding 0.8 0.88 table 5. differences in adl among stroke patients between treatment and control group. adl of stroke patient treatment (n=40) control (n=40) p (paired t-test) mean sd mean sd pre adl 4.75 1.548 4.58 4.7 post -1adl 5.10 1.317 1.947 1.506 post -2 adl 5.20 1.224 different pre-post 1 adl -0.35 0.77 2.633 1.828 treatment 0.006 control 0.668 different post-1-post 2 adl -0.1 0.744 treatment 0.401 non -co mmerc ial us e o nly (68.75%) reported experiencing health problems including fatigue, certain diseases, and irritability. this condition is in line with a previous study, stating that burden of caregivers manifests in the form of anxiety, depression, and low physical health.6,21–23 common diseases experienced by caregivers include hypertension, diabetes mellitus, gastritis, hypercholesterolemia, and hyperuricemia. these diseases are included in the non-communicable category, which often require regular and long-term management of therapy to avoid complications. caregivers tend to ignore personal health problems while caring for stroke patients.24 caregivers feel burden while caring for stroke patients who need help both physically and emotionally. this statement is a value/belief embraced and influenced by family culture in major asian countries including hong kong. moreover, it is a religious/religious value system with the principle that caring for sick family members, specifically the elderly, is a service from younger to older family members, specifically parents, as well as wives’ devotion to husbands/partners.25 based on the results, caregivers of stroke patients who adhered to family-supportive therapy experienced a decrease in burden. however, after 2 weeks, there was an increase in burden of care. health education provided to caregivers through counseling using modules of care can also reduce burden. family-supportive therapy and health education through home visits in families with stroke cases are among the interventions recommended in several previous studies.4,10,26 based on several reports, family-supportive therapy is widely used in family with mental, congenital, and chronic diseases.11,12,20 the objective is not limited to providing support and complementing the experience of isolation but also to plan, organize, and respond positively to pressure, anxiety, burdens, and unpleasant circumstances. furthermore, this therapy can increase strength, coping skills, and resources, improve autonomy in decision-making, enhance the ability to achieve optimal independence, as well as reduce subjective distress and maladaptive coping responses.27 evaluation of burden 2 weeks after family-supportive therapy showed an observable increase. several studies showed that when social support was reduced, some families experienced increased psychosocial burdens and problems. to effectively manage burden and anxiety while caring for stroke patients, supportive therapy needs to be followed up on an ongoing basis with various methods. for example, this can be achieved through the use of information technology that enables health professionals and other therapy members to continually communicate and provide mutual support.11,28 family-supportive therapy and home visits did not show a different effect on burden of caregivers for stroke patients. familysupportive intervention is a new therapy for caregivers that requires sufficient time to develop mutual trust and empathy between the therapist and members. during session 1, most of therapy participants were not able to assertively convey personal experiences and opinions about caring for stroke patients. active participation of new therapy participants was observed in session 2, underscoring the need for pre-therapy readiness, specifically by health workers who play the role of a therapist. this is crucial to achieve the objective of therapy in four sessions. most stroke patients are unable to achieve independence in fulfillment of bathing, dressing, toileting, mobility, and feeding. the commonly experienced weakness or paralysis of the upper extremities causes stroke patients to feel difficulty in fulfilling adl, specifically bathing and dressing, leading to the need for care assistance from family members. this inability to fulfill adl is reportedly associated with sequelae. based on the results, most stroke patients (88.75%) experienced stiffness, weakness, and extremity paralysis, specifically in the upper limbs. a previous study in purwokerto (central java, indonesia) reported that in 1-3 months after the attack of stroke, 51.3% achieved mild to minimal independence based on the barthel index.29 in contrast, another study found that stroke patients at 6-24 months after occupational therapy achieved an independent activity of 7.7% and 92.3% of non-independent activities.30 a previous investigation at tugurejo hospital semarang stated that 30%, 45%, and 20% of patients were partially, highly, and totally dependent, respectively.15 the decline in adl ability could also be influenced by age, as 4th international nursing and health sciences symposium [page 126] [healthcare in low-resource settings 2024;12(s1):13066] table 6. manova-test (levene’s test of equality for error variances). variable f df1 df 2 sig burden 3.609 1 78 .061 adl .157 1 78 .693 table 7. manova-test (levene’s test of equality for error variances). group n box test box’s m f df1 df 2 sig treatment control 80 4.636 1.502 3 1095120.000 0.212 table 8. manova analysis (tests of between-subjects effects). variable mean square f sig partial eta squared observed power burden 198.450 2.470 .120 .031 .342 adl 3.200 1.600 .210 .020 .239 non -co mmerc ial us e o nly demonstrated by the results in which 77.5% of stroke patients were 46-65 years old, and 23.75% were older than 65. the decline in the physiological function of the body systems, specifically the neuromuscular system, impacts the independence of elderly patients to meet daily needs.17,18 adl of stroke patients whose caregivers followed family-supportive therapy slightly increased and tended to persist for up to 2 weeks. health education provided to caregivers through counseling using care modules did not increase adl. family-supportive intervention helped increase individual roles, as motivators for patients. caregivers convey not only the need to provide physical assistance but also to motivate patients to actively fulfill adl. gradual efforts to independently meet daily needs, specifically in the aspect of neuro-muscular function, are required in the rehabilitation phase to reduce the residual symptoms in the form of weakness or paralysis. according to a previous study, stroke patients are advised to continually carry out routine control to monitor the improvement or deterioration in the condition.31 efforts to increase independence in activities not only affect motor skills but also enhance self-esteem and confidence as well as reduce anxiety due to feelings of helplessness.32 home visits intervention by health care providers to provide health education for stroke patients and caregivers did not help achieve independence. these home visits, which were carried out two times, had not yet achieved the purpose of establishing a stroke family as the focus of community healthcare activities proclaimed by puskesmas. this was because the frequency of visits was still one-third of the normal (about six visits). currently, home visits remain at the stage of family identification to recognize health problems. in this context, obstacles are in the form of difficulty meeting the primary care provider for stroke patients who might be working outside home. this condition was supported by the employment data, with almost half of caregivers having no employees (42.5%). therefore, efforts to follow up on the next home visits are needed to achieve the objectives of family independence, including the fulfillment of adl. the conditions of stroke patients also contributed to the low adl ability, specifically in the home visits group. this was supported by the data showing that the majority of caregivers were in the elderly age category, and most patients were in the rehabilitation phase of 1-2 years (82.5%). family-supportive therapy and home visits did not show a different effect on adl in stroke patients. the similarity can be attributed to the shared focus of both interventions, primarily targeting caregivers in the early stages. consequently, the initial impact of these interventions is largely directed towards achieving objectives related to support for caregivers, rather than adl ability. the independence of stroke patients in fulfilling adl is influenced by several factors, including age, sequelae, frequency of attacks, duration of disease, rehabilitation, and patient motivation.17,33-34 caregivers play a significant role as motivators during long-term care at home. therefore, these individuals should also be targets of public healthcare activities to achieve independent and prosperous family. conclusions in conclusion, family-supportive therapy decreased burden on caregivers immediately but increased after 2 weeks. in addition, health education activities carried out through home visits also reduced burden. both of these interventions were recommended to prevent and reduce burden on caregivers, although the most effective method is yet to be proven. family-supportive therapy and health education through home visits did not directly increase the independence of stroke patients in adl. therefore, it was necessary to modify several interventions and strengthen patient factors to achieve independence in adl. references 1. ministry of health republic of indonesia. basic health research. jakarta: ministry of health republic of indonesia; 2018. 2. ogunlana mo, dada oo, oyewo os, et al. quality of life and burden of informal caregivers of stroke survivors. hong kong physiother j 2014;32:6–12. 3. fadilah n, rahariyani ld. the impact of independent of activity daily living among stroke patients on caregivers burden. j ners 2020;14. 4. collins lg, swartz k. caregiver care. am fam physician 2011;83:1309-17. 5. gbiri ca, olawale oa, isaac so. stroke management: informal caregivers’ burdens and strians of caring for stroke survivors. ann phys rehabil med 2015;58:98–103. 6. kumar r, kaur s, k r. burden and coping strategies in caregivers of stroke survivors. j neurol neurosci 2015;06. 7. wurtiningsih b. family support for stroke patients in the nervous room of dr. kariadi general hospital semarang. medica hospitalia j clin med [internet]. 2013 feb 8 [cited 2023 aug 13];1(1). available from: http://medicahospitalia.r skariadi.co.id/medicahospitalia/index.php/mh/article/view/42. 8. bakas t, clark pc, kelly-hayes m, king rb, lutz bj, miller el. evidence for stroke family caregiver and dyad interventions. stroke 2014;45:2836–52. 9. bergstrom al, eriksson g, von koch l, tham k. combined life satisfaction of persons with stroke and their caregivers: associations with caregiver burden and the impact of stroke. health qual life outcomes 2011;9:1. 10. legg la, lewis sr, schofield-robinson oj, et al. occupational therapy for adults with problems in activities of daily living after stroke. cochrane database syst rev 2017;7:cd003585. 11. suprobo ka, wiyono n, setyanto at. the effect of supportive group therapy on caregiver burden in wives who act as primary caregivers for stroke patients. j univ sebel maret 2015;1–12. 12. wahyuningsih saa. universitas indonesia library. faculty of nursing, university of indonesia; 2011 [cited 2023 aug 13]. the effect of supportive therapy on the ability of families to care for clients with chronic kidney failure (ckf) undergoing hemodialysis at pelni hospital, jakarta. available from: https://lib.ui.ac.id 13. hernawaty. family supportive therapy module: in families with mentally ill clients. jakarta, indonesia; 2015. 14. scholten ewm, hillebregt cf, ketelaar m, et al. measures used to assess impact of providing care among informal caregivers of persons with stroke, spinal cord injury, or amputation: a systematic review. disabil rehabil 2021;43:746–72. 15. ratnasari p, kristiyawati sp, solechan a. relationship between dependence level on daily living activity and depression in stroke patients at tugurejo hospital semarang. scientific paper 2012;0(0). 16. bekdemir a, i̇lhan n. predictors of caregiver burden in 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13066] [page 127] non -co mmerc ial us e o nly caregivers of bedridden patients. j nurs res 2019;27:e24. 17. munir b. basic neurology. 2th edition. jakarta: sagung seto; 2018. 18. hinkle jl, cheever kh. clinical handbook for brunner & suddarth’s textbook of medical-surgical nursing. lippincott williams & wilkins; 2013 nov 25. 19. pambudi ha. phenomenological study: family anxiety in stroke patients treated in the hnd room of saint lukas, santa elisabeth hospital, semarang. 2009 [cited 2024 aug 13]. available from: https://www.semanticscholar. org/paper/studi-penomenologis-%3a-kecemasan-keluargapada-yang-pambudi/321d42b1cafdaab97e55557c072c 69eccd4c6367. 20. handayani dy, dewi de. analysis of quality of life of patients and families after stroke (with residual symptoms). psycho idea 2009;7:35-44. 21. malhotra r, chei cl, menon eb, et al. trajectories of positive aspects of caregiving among family caregivers of stroke-survivors: the differential impact of stroke-survivor disability. top stroke rehabil 2018;25:261–8. 22. mckendry s, wright m, stevenson k. why here and why stay? students’ voices on the retention strategies of a widening participation university. nurse educ today 2014;34:872–7. 23. chow sky, wong fky, poon cyf. coping and caring: support for family caregivers of stroke survivors. j clin nurs 2007;16:133–43. 24. bakas t, austin jk, habermann b, et al. telephone assessment and skill-building kit for stroke caregivers. stroke 2015;46:3478–87. 25. chow eow, nelson-becker h. spiritual distress to spiritual transformation : stroke survivor narratives from hong kong. j aging stud 2010;24:313–24. 26. björkdahl a, nilsson ål, sunnerhagen ks. can rehabilitation in the home setting reduce the burden of care for the next-ofkin of stroke victims? j rehabil med 2007;39:27–32. 27. stuart gw. pocket book of mental health nursing. 5th ed. jakarta: egc; 2007. 28. azza a, susilo c, efendi f. supportive group therapy as a prediction of psychological adaptation of breast cancer patients undergoing chemotherapy. indian j public heal res dev 2018;9:441. 29. fadlulloh sf, upoyo as, hartanto yd. the relationship between the level of dependence in fulfilling daily living activities (adls) and self-esteem of stroke patients at the neurology polyclinic of prof. dr. margono soekarjo hospital, purwokerto. jks 2014;9:134–45.. 30. santoso ta. independence in eating, bathing and dressing activities in stroke patients 6-24 months after occupational therapy diponegoro university institutional repository (undip-ir) [internet]. 2003 [cited 2023 aug 13]. available from: http://eprints.undip.ac.id/12631/. 31. mandic m, rancic n. the recovery of motor function in post stroke patients. med arh 2011;65:106–8. 32. farmer o, belton s, o’brien w. the relationship between actual fundamental motor skill proficiency, perceived motor skill confidence and competence, and physical activity in 812-year-old irish female youth. sport 2017;5. 33. fadilah n, rahariyani ld. the impact of independent of activity daily living among stroke patients on caregivers burden. j ners 2019;14:188–94. 4th international nursing and health sciences symposium correspondence: nikmatul fadilah, nursing department, health polytechnic of the health ministry of surabaya, jl. pucang jajar tengah street no. 56, kertajaya, gubeng, surabaya, east java, indonesia. tel.: +62315027058fax: +625028141. e-mail: nikmatulf@poltekkesdepkes-sby.ac.id key words: activities of daily living; burden of caregivers; family-supportive therapy; home visits. contributions: nf participated in the study design, data collection and analysis, manuscript writing, and reference search. ldr participated in the study design, data collection, and analysis. hy participated in manuscript writing and reference searches. d participated in data collection and reference searches. conflict of interest: the authors declare no potential conflict of interest. funding: this study was financially supported by health polytechnic of the health ministry of surabaya. ethics approval: an ethical approval letter was received from the health research ethics commission of health, ministry of health, surabaya, number 194/s/kepk/v/2018, on 8th june 2018. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java indonesia. acknowledgment: the authors are grateful to the director of surabaya health polytechnic, who provided funding for this study. received: 3 november 2023. accepted: 11 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13066 doi:10.4081/hls.2024.13066 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 128] [healthcare in low-resource settings 2024;12(s1):13066] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13278 impact of nutrition counseling and physical activity on dietary intake, knowledge, and weight reduction among students with overweight and obese didit damayanti,1 fairuz dhia rabbani,1 annisa frida rinjani,1 gezza anindhitha kirana,1 renata claudia agatha,1 gurid pramintarto eko mulyo2 1nutrition department, politeknik kesehatan kemenkes jakarta ii, dki jakarta; 2nutrition department, politeknik kesehatan kemenkes bandung, bandung, indonesia abstract overweight and obesity contribute to chronic diseases with an increasing prevalence in jakarta. this study assessed the impact of combined nutritional counseling and physical activity interventions on body weight, energy, and nutrient intake among overweight and obese health students. a quasi-experimental study was conducted with 42 participants divided into three groups, each receiving different intervention combinations over one month. body weight was measured using scales, food intake was assessed through 24-hour food recalls, and nutritional knowledge was evaluated using questionnaires. statistical analysis was performed using paired t-tests, wilcoxon test, or anova tests in spss. most participants were female (83.3%) and 19–29 years old (78.6%). after the intervention, significant reductions in body weight (p<0.001) were observed, along with improvements in nutritional knowledge (p<0.01) and physical activity levels (p<0.05) across all groups. energy and macronutrient intake significantly decreased in group i, whereas fiber intake increased in all groups (p<0.05). combining nutritional counseling and weekly physical activity interventions effectively reduced body weight and improved dietary habits, nutritional knowledge, and physical activity. implementing the “my plate” guidelines along with increased physical activity is recommended as a practical strategy for obesity management among students. universities should integrate these guidelines to promote healthy eating and maintain students’ nutritional status. introduction overweight and obesity are chronic conditions influenced by various factors, leading to the excessive accumulation of body fat and associated health complications.1–3 based on national research, the prevalence of overweight and obesity among adults in jakarta has increased significantly.4 obesity in young adulthood is a known risk factor for numerous metabolic disorders, including type 2 diabetes mellitus, cardiovascular diseases, fatty liver, and certain types of cancer.5–8 additionally, obesity negatively impacts mental health, increases the risk of discrimination, and leads to economic losses. to address non-communicable diseases, the indonesian government launched the national program “germas” (a movement for healthy lifestyles) in 2017.9 however, the prevalence of overweight and obesity among adults remains high. globally, as of 2022, an estimated 2.5 billion adults (>18 years old) are overweight, with 890 million being classified as obese.4 in indonesia, data from the 2018 riskesdas and 2023 indonesian health survey revealed an increase in the prevalence of overnutrition in adults, with overweight rates rising from 13.6% (2018) to 14.4% (2023) and obesity rates increasing from 21.8% (2018) to 23.4% (2023).10,11 in jakarta, the prevalence of overweight and obesity among adults increased from 15.6% and 29.8% in 2018 to 16.2% and 31.8% in 2023, respectively. among health students in both correspondence: didit damayanti, lecturer of nutrition, department politeknik kesehatan kemenkes jakarta ii, dki jakarta, indonesia. e-mail: didit.damayanti@poltekkesjkt2.ac.id key words: body weight, energy, nutrient intake, nutrition counseling, nutrition knowledge, obesity, physical activity. contributions: dd, conceptualization, data curation, formal analysis, methodology, validation, visualization, writing – original draft, review & editing; fdr, conceptualization, investigation, methodology, validation, review & editing; afr, conceptualization, methodology, formal analysis, validation, and writing – original draft, review & editing; gak, methodology, visualization, writing – review & editing; rca resources, investigation, and writing –review & editing; gpem, resources, supervision, and writing –review & editing. conflict of interest: the authors declare that they have no conflicts of interest. ethical approval and consent to participate: the research was approved by the health research ethics commission, poltekkes kemenkes jakarta ii, based on ethical certificate no. lb.02.01/i/ke/31/006/2021. during the research, the researcher focused on the ethical principles of autonomy, beneficence, justice, and non-maleficence. patient consent for publication: written informed consent was obtained from anonymized patients for publication in this article. funding: none. availability of data and materials: all data generated or analyzed in this study are included in this published article. acknowledgement: we would like to thank poltekkes kemenkes jakarta ii for their valuable insights and contribution to this study. received: 22 october 2024. accepted: 1 april 2025. early view: 26 june 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13278 doi:10.4081/hls.2025.13278 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2025;13(s2):13278] [page 39] public and private medical schools across indonesia, the combined prevalence of overweight and obesity is reported to be 35.5%.12 the causes of overweight and obesity are complex, involving genetic factors and modifiable lifestyle factors, such as energy intake, physical activity levels, and sleep patterns.2,3,13 research conducted in banjarmasin demonstrated a significant relationship between excessive energy intake and obesity.14 a sedentary lifestyle and lack of physical activity reduce energy expenditure, creating an imbalance between energy consumption and output.15 similarly, studies on students in pakistan revealed that physical activity levels and time spent sitting were inversely proportional to body mass index (bmi).16 there are several strategies to address obesity, including nutrition education, lifestyle changes, increased physical activity, dietary modifications, medication, and bariatric surgery.17 studies have shown that combining nutrition education or counseling with increased physical activity and a low-energy diet effectively reduces body weight in obese high school students and young adults in indonesia, as well as among obese young adults in india.18-21 to promote healthy eating, the indonesian government introduced “my plate” guidelines, which recommend consuming more vegetables and fruits, moderate portions of staple foods, and adequate protein sources.22 however, national surveys indicate that indonesians tend to consume fewer vegetables and fruits while favoring fatty and fried foods.23 it is hypothesized that implementing “my plate” recommendations could help obese students reduce their energy intake and body weight. therefore, this study designed two intervention groups using “my plate” recommendations as part of their dietary plans. therefore, this study aimed to determine the effects of different combinations of nutrition education, dietary interventions, and physical activity on reducing the body weight of overweight and obese health students in jakarta. materials and methods research design this study used a quasi-experimental design. from a list of overweight and obese health students in jakarta who expressed interest in participating, the samples were randomly assigned (lottery) by the researchers to three groups: group i, group ii, and group iii. this study was conducted in jakarta from february to april 2021. study participants the participants in this study were selected using randomized sampling with the inclusion and exclusion criteria. inclusion criteria included students who were overweight or obese according to anthropometric measurement with body mass index (bmi) equal to 23 or more. exclusion criteria included students on special diets, those with chronic diseases (such as diabetes mellitus, hypertension, or other chronic conditions), and those taking weight loss medications or herbal remedies. the sample size determined by g power with a significance level of a = 5 %, power 1–b = 80 %, and an effect size of 0.4, then the minimum sample size for each group was 14. the total sample size consisted of 42 students, with 12 participants in group i and 15 participants each in groups ii and iii. all participants were at least 18 years old (figure 1). variables, instruments, and data collection this study implemented a four-week intervention program. group i received weekly nutritional counseling focused on a lowenergy diet of 1500 calories for females and 1700 calories for males.24 participants were also encouraged to engage in physical exercise once a week, with their progress monitored weekly throughout the intervention. group ii participants received weekly nutritional counseling using an e-booklet about balanced nutrition and the “my plate” guidelines. in addition, they were instructed to perform low-impact aerobic exercises at least three times a week for a minimum of 30 minutes per session, guided by a video provided by the research team. group iii participants received weekly nutritional counseling through an e-booklet on balanced nutrition and the “my plate” guidelines. they were recommended to engage in physical activity once a week for four weeks. this study collected various data, including anthropometric measurements (height and body weight), energy and nutrient intake, physical activity level (pal), nutritional knowledge, and participant demographic characteristics. body weight was measured using a digital scale with an accuracy of 0.1 kg. energy and nutrient intake were assessed using the 24-hour food recall method.25 pal and demographic data were gathered through interviews using structured questionnaires, while nutritional knowledge was evaluated through a self-administered nutritional knowledge questionnaire.26 measurements of body weight, energy and nutrient intake, pal, and nutritional knowledge were conducted both before and after the intervention. data analysis the data in this study were analyzed using the spss software. a normality test was conducted using the kolmogorov-smirnov one-sample test to determine whether the variable data followed a normal distribution. univariate analysis was performed to calculate percentages for each category of sample characteristics, including gender, age, and field of study. bivariate analysis was conducted using a chi-square, a paired or analysis of variance test for normally distributed data and other tests for non-normally distributed data. an intervention was considered to have a significant effect on the dependent variable if the p-value was less than 0.05. pathways of change, part ii [page 40] [healthcare in low-resource settings 2025;13(s2):13278] figure 1. flowchart depicting the participant selection process for intervention. ethical clearance the study received authorization from the dki jakarta health office and successfully passed an ethical review conducted by the jakarta ii poltekkes kemenkes research ethics committee, as evidenced by approval no. lb.02.01/i/ke/31/006/2021. written informed consent was obtained from all participants in the study. results based on table 1, the majority of the participants were female (83.3%), with only 16.7% being male. each intervention group also predominantly consisted of female participants (>70%). the univariate analysis revealed that most of the participants (78.6%) were in the age group of 19-29 years. among the 42 overweight and obese students, the largest proportion in each group (33.3%) came from the department of nutrition. these findings indicate that the three intervention groups had relatively similar characteristics, which was supported by a chi-square test that showed there was no significant difference in gender and age within the three groups (p>0.05). table 2 presents the changes in body weight, physical activity levels, and nutritional knowledge after the intervention. all three groups experienced significant weight loss, with group i and group iii showing results of p<0.001 and group ii showing p=0.001. the table also highlights a significant increase in nutritional knowledge scores and physical activity levels (measured in par/hour) among participants in all groups after the intervention. further analysis between groups showed that before intervention, the analysis of variance test showed there was no significant difference in body weight, nutritional knowledge score (p>0.05); however, there was a significant difference in physical activity of respondents among the three groups (p<0.05). after intervention, there was a significant difference in nutritional knowledge scores and physical activity of respondents between groups (p<0.05); however, there was no significant difference in body weight of respondents between the three groups. table 3 showed the changes in energy and nutrient intake, including both macronutrients and micronutrients, after the intervention. a decrease in energy and macronutrient intake was observed across all groups, but only group i showed significant reductions in energy, protein, fat, and carbohydrate intake (p<0.05). group ii exhibited a significant reduction in fat intake (p<0.05). further analysis showed that before intervention, there was a significant difference in energy, fat, and fiber intake between groups (p<0.05). after intervention, there was a significant difference in energy, carbohydrate, and fiber intake between groups (p<0.05). regarding micronutrients, group i, which received low-energy diet counseling and physical activity monitoring, showed significant increases in vitamin c (p=0.034) and fiber intake (p<0.003). group ii, which received counseling on the “my plate” guidelines and performed aerobic exercises, demonstrated a significant pathways of change, part ii table 1. sample characteristics (n=42). characteristic group i group ii group iii n % n % n % gender man 3 25.0 2 13.3 2 13.3 woman 9 75.0 13 86.7 13 86.7 age 16-18 years old 7 58.3 0 0 4 26.7 19-29 years old 5 41.7 15 100.0 11 73.3 department nutrition 4 33.3 5 33.3 5 33.3 environmental health 2 16.7 1 6.7 0 0 technical electromedic 1 8.3 2 13.3 2 13.3 radiodiagnostic engineering 0 0 1 6.7 2 13.3 pharmaceutical and food analysis 0 0 1 6.7 3 20.0 pharmacy 2 16.7 2 13.3 2 13.3 dental engineering 3 25.0 3 20.0 1 6.7 total 12 100.0 15 100.0 15 100.0 table 2. changes in weight, physical activity, and knowledge before and after the intervention. variables group i (mean, ci) p group ii (mean, ci) p group iii (mean, ci) p body weight (kg) before 68.06 (60.70, 75.43) 0,000* 71.60 (63.69, 79.51) 0,001* 71.5 (67.35, 75.66) 0* after 66.01 (58.55, 73.47) 68.90 (60.81, 76.98) 69.7 (65.73, 73.82) physical activity (par/hour) before 1.37 (1.26, 1.47) 0,000* 1.53 (1.46, 1.60) 0,013* 1.51 (1.47, 1.56) 0* after 1.82 (1.76, 1.87) 1.78 (1.68, 1.88) 1.68 (1.62, 1.73) nutrition knowledge (score) before 74.58 (63.96, 85.20) 0,010* 62 (53.64, 70.36) 0,002* 69.3 (63.43, 75.24) 0* after 96.25 (93.18, 99.32) 78,33 (73.35, 83.32) 80 (73.55, 86.45) *significant p-value if p<0.05. [healthcare in low-resource settings 2025;13(s2):13278] [page 41] increase in fiber intake (p=0.015). in group iii, which also received “my plate” counseling along with physical activity monitoring, there were significant increases in iron intake (p=0.047) and fiber intake (p=0.017). discussion the study results showed that combining nutritional counseling with increased physical activity significantly improved nutritional knowledge and led to a substantial reduction in body weight among overweight and obese students in all three intervention groups. however, energy and macronutrient intake only decreased significantly in group i, which followed a low-energy diet. additionally, all participants across the three groups showed a significant increase in fiber intake. the largest reduction in body weight was observed in group ii, which received nutritional counseling on balanced nutrition using the “my plate” guidelines and performed aerobic exercises three times a week. this may be attributed to the higher energy expenditure in this group compared to the other groups, where participants were only encouraged to engage in physical activity once a week. the aerobic exercise videos provided as part of the intervention in group ii helped participants better understand the guidance and adopt regular physical activity. monitoring physical activity, as was done in this study, can encourage individuals to increase activity levels and reduce sedentary behavior by enhancing selfawareness.27 these findings align with the results of a study on obese young adults in india, which reported significant weight loss following a three-month intervention involving nutrition education and physical exercise programs.21 similarly, a study in semarang found a significant reduction in the average body weight of obese female students who participated in an instagram-based nutrition program that included counseling and physical activity over 30 days.28 although the paired t-test showed there was a significant decrease in body weight among respondents after intervention in all three groups, the anova test showed that after intervention, there was no significant difference in body weight among the three groups. this might be because there were factors that influenced, including significant differences in the level of physical activity of respondents before the intervention. group i, which adhered to a low-energy diet, showed a significant decrease in energy and macronutrient intake. in contrast, no significant reductions in energy or macronutrient intake were observed in groups ii and iii, which followed “my plate” recommendations. a low-energy diet, as prescribed by a dietitian, consisted of fixed caloric content (1700 calories for males and 1500 calories for females) and significantly improved bmi among overweight and obese participants. on the other hand, the “my plate” approach is a general nutritional guideline based on visual food proportions on a plate, leading to variations in energy and nutrient intake among participants. all three groups showed a significant increase in fiber intake. both the low-energy diet and the “my plate” recommendation emphasize high fiber intake through increased consumption of vegetables and fruits. studies have demonstrated that higher fiber intake is significantly associated with weight reduction, contributing to weight loss across all groups.29 improvements in energy and nutrient intake may also be influenced by increased nutritional knowledge gained from counseling on low-energy diets and “my plate” recommendations. nutritional counseling is known to enhance knowledge, which in turn encourages behavior changes, including improved dietary intake.30,31 this is supported by findings where obese young adults experienced pathways of change, part ii [page 42] [healthcare in low-resource settings 2025;13(s2):13278] table 3. changes in energy and nutrient intake before and after the intervention. variables group i (mean, ci) p group ii (mean, ci) p group iii (mean, ci) p energy (cal) before 1970.86 (1728.04, 2213.67) 0* 1599.6 (1242.74, 1 956.49) 0,281 1325 (1066.10, 1583.89) 0.112 after 1056,97 (873.88, 1240.05) 1367.7 (1182.36, 1553.02) 1120 (924.62, 1315.37) protein (g) before 62.91 (45.60, 80.21) 0.007* 46.56 (36.48, 56.64) 0,910 42 (29.67, 54.88) 0.363 after 38.02 (34.43, 41.60) 43.36 (35.67, 51.06) 36 (24.47, 47.52) fat (g) before 85.02 (66.01, 104.02) 0.007* 67.93 (50.14, 85.72) 0,031* 55 (43.66, 67.38) 0.609 after 46.58 (33.34, 59.81) 46.28 (38.51, 54.04) 49 (37.00, 60.99) carbohydrate (g) sebelum 216.27 (178.18, 254.35) 0.013* 198.09 (151.33, 244.83) 0,609 150 (103.16, 197.22) 0.691 sesudah 145.93 (118.20, 173.65) 192.72 (165.12, 220.31) 139 (115.04, 163.40) vitamin c (mg) before 12.31 (7.12, 17.49) 0.034* 69.20 (39.58, 98.81) 0,061 56 (-15.70, 127.70) 0.532 after 50.16 (38.91, 61.40) 128.79 (61.49, 196.09) 134 (-22.05, 290.24) calcium (mg) before 414.66 (327.06, 502.25) 0.158 529.65 (329.18, 730.11) 0,307 327 (189.14, 464.85) 0.820 after 289.51 (240.34, 338.67) 620.85 (423.95, 817.74) 341 (227.11, 455.03) iron (mg) before 21.05 (20.36, 21.73) 0.272 16.07 (8.98, 23.16) 0,609 4.1 (2.74, 5.45) 0.047* after 28.40 (27.97, 28.82) 11.53 (8.72, 14.34) 9.5 (7.28, 11.71) fiber (g) before 4.88 (3.97, 5.78) 0.003* 6.28 (4.36, 8.20) 0,015* 3 (2.12, 3.90) 0.017* after 13.18 (12.59, 13.76) 9.99 (7.51, 12.47) 7 (3.49, 10.51) *the p-value is significant if p<0.05. significant decreases in energy and protein intake after receiving nutritional counseling and participating in a physical activity program for three months.32 similarly, studies reported a significant increase in fiber intake among japanese high school students who received nutritional counseling over four months.33,34 the frequency of counseling may also affect outcomes, such as increased nutritional knowledge, improved nutrient intake, and weight loss. in this study, nutritional counseling was conducted once a week for four weeks. in contrast, a study on obese breast cancer patients found no significant weight loss after providing nutritional counseling once a month for six months.35 however, a review highlighted that more frequent nutritional counseling is positively associated with greater weight loss, suggesting that increased counseling frequency yields better results.36 a strength of this study was that the three groups received different combinations of interventions, allowing for an exploration of the varying impacts of these interventions on overweight and obese participants. however, a limitation of this study was the small sample size and the short duration of the intervention (only 4 weeks), which may have influenced the results. future research with a larger sample size and a longer intervention period is needed to further investigate these effects. conclusions based on the research conducted, it can be concluded that the combination of nutritional counseling, increased physical activity, and either a low-energy diet or the “my plate” recommendation over 4 weeks led to a reduction in body weight among overweight and obese students. participants who engaged in aerobic exercise three times per week for 4 weeks experienced a greater reduction in body weight compared to those who exercised once a week. while energy and macronutrient intake significantly decreased with the low-energy diet, both the low-energy diet and the “my plate” recommendation significantly increased fiber intake and contributed to body weight reduction. this study recommend to use my plate as one of nutrition guidelines to decrease body weight for students with overweight or obese. my plate recommendation is a practical way for implement healthy eating for students. university can use this recommendation as part of wellness program to improve eating behavior and nutritional status of students. references 1. keya rt, widjaja na, noviyanti tr, et al. physical behaviours in adolescents that contribute to overweight/obesity. natl nutr journal/media gizi indones. 2025;20:12-20. 2. piyakong d, apiratanawong s, suasing c, ners j. insights from leaders on effectively addressing overweight and obesity in the thai community. j ners 2023;18:117-23. 3. anggraeni as, sukartini t, kristiawati k. consumption of fruit and vegetable with risk of obesity in school-age children. j ners 2017;12:27-32. 4. world health organization (who). obesitas dan kelebihan berat badan. world health organization. 2024. 5. jaison k i, asharaf h, thimothy g, et al. psychological impact of obesity: a comprehensive analysis of health-related quality of life and weight-related symptoms. obes med 2024;45:100530. 6. djalalinia s, qorbani m, peykari n, kelishadi r. health impacts of obesity. pakistan j med sci 2015;31:239-42. 7. wulansari a, martianto d, farida baliwati y. estimasi kerugian ekonomi akibat obesitas pada orang dewasa di indonesia (estimation of economic lost due to obesity in indonesian adults). j gizi dan pangan 2016;11:159-68. 8. rachmah q, mondal p, phung h, ahmed f. association between overweight/obesity and iron deficiency anaemia among women of reproductive age: a systematic review. public health nutr 2024;27:e176. 9. badan penelitian dan pengembangan kesehatan kementerian kesehatan republik indonesia. riset kesehatan dasar (riskesdas) 2018. jakarta; 2019. 10. jin x, qiu t, li l, et al. pathophysiology of obesity and its associated diseases. acta pharmaceutica sinica b 2023;13:2403-24. 11. lung t, jan s, tan ej, et al. impact of overweight, obesity and severe obesity on life expectancy of australian adults. int j obes 2019;43:782-9. 12. diani yh, novelyn s, cing jm, et al. prevalence of overweight and obesity among medical students across indonesia: a literature review. asian j biol 2023;18:34-45. 13. masood b, moorthy m. causes of obesity: a review. clin med j r coll physicians london. 2023;23:284-91. 14. amalia rg, juhairina, istiana, budiarto a, skripsiana ns. dengan kejadian obesitas pada mahasiswa pskps fk ulm tahun 2022. homeostasis 2022;6:59-68. 15. rachmah q, martiana t, mulyono, et al. the effectiveness of nutrition and health intervention in workplace setting: a systematic review. j public health res 2022;11:2312. 16. lasi d, mahmood d, samejo d, et al. the relationship between physical activity, obesity and overweight among university going students of jamshoro, sindh. j riphah coll rehabil sci 2020;8:25-32. 17. rahmani a, nadhiroh sr. efforts undertaken by several asean countries to address childhood and adolescent obesity in school-based programs: a systematic review. amerta nutrition 2024;8:151-60. 18. astuti t, marbun r, surmita s, r bustos a. effectiveness of nutrition and exercise counseling combination on desirable dietary pattern and weight loss. j food nutr res 2022;10:23541. 19. mulyani i, dieny ff, rahadiyanti a, et al. efek motivational interviewing dan kelas edukasi gizi berbasis instagram terhadap perubahan pengetahuan healthy weight loss dan kualitas diet mahasiswi obesitas. j gizi klin indones 2020;17:53042. 20. palupi kc, anggraini a, sa’pang m, kuswari m. pengaruh edukasi gizi “empire” terhadap kualitas diet dan aktivitas fisik pada wanita dengan gizi lebih. j nutr coll 2022;11:62-73. 21. karmore up, ukey uu, sharma sk. effect of dietary modification and physical activity on obese young adults going to gym for weight loss in central india: a before and after study. cureus 2023;15:e40832. 22. kementrian kesehatan ri. pedoman gizi seimbang. 2014;1203. 23. kementerian kesehatan ri. survei kesehatan indonesia (ski) dalam angka. jakarta; 2023. 24. indonesia pagi& ad. penuntun diet dan terapi gizi. 4th ed. egc; 2019. 412 p. 25. harjatmo tp, par’i hm, wiyono s. penilaian status gizi. 2017. 315 p. 26. who. global physical activity questionnaire (gpaq) analysis guide. geneva world heal organ. 2012;1-22. 27. barkley je, farnell g, boyko b, et al. impact of activity mon pathways of change, part ii [healthcare in 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diet management application to educate ideal diet recommendation. syst rev pharm. 2020;11(8). 32. ng ak, hairi nn, dahlui m, et al. the longitudinal relationship between dietary intake, physical activity and muscle strength among adolescents. br j nutr 2020;124:1207-18. 33. tucker la, thomas ks. increasing total fiber intake reduces risk of weight and fat gains in women. j nutrition 2009;139:576-81. 34. ueda y, sawamoto m, kobayashi t, et al. nutrition education programme changes food intake and baseball performance in high-school students. health educ j 2021;80:387-400. 35. braakhuis a, campion p, bishop k. the effects of dietary nutrition education on weight and health biomarkers in breast cancer survivors. med sci (basel, switzerland) 2017;5:1-8. 36. finkler e, heymsfield sb, st-onge mp. rate of weight loss can be predicted by patient characteristics and intervention strategies. j acad nutr diet 2012;112:75-80. pathways of change, part ii [page 44] [healthcare in low-resource settings 2025;13(s2):13278] hrev_master healthcare in low-resource settings 2023; volume 11:11742 the impact of soil-transmitted helminths infection on growth impairment: systematic review and meta analysis james hadiputra sunarpo, kartika ishartadiati, andra agnez al aska, sukma sahadewa, ayling sanjaya faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia abstract human helminthiasis, particularly soil-transmitted helminth (sth) infections, is a prevalent health concern in indonesia, especially among children, often resulting in growth disorders, notably stunting. to examine the link between sth infections and childhood stunting, we conducted a comprehensive review of literature spanning 2012-2023, encompassing 40 selected articles from databases like pubmed, science direct, and google scholar. our analysis revealed a substantial association between sth infections and increased stunting risk in children, estimating a 44.407% rise in stunting risk due to sth infection. stunting, a consequence of chronic malnutrition, profoundly affects a child’s physical and cognitive development, with long-lasting repercussions on their future potential and quality of life. this study has significant implications. it underscores the urgent need for robust public health interventions targeting sth infections, especially in highprevalence areas like indonesia. measures such as mass deworming campaigns, improved sanitation and hygiene practices, and health education can significantly alleviate the burden of sth infections and the resulting stunting. moreover, the research emphasizes the intricate relationship between infectious diseases and malnutrition, highlighting the necessity for a holistic approach to child health. addressing sth infections necessitates not only medical intervention but also efforts to enhance overall living conditions and nutritional status. integrating these approaches into a comprehensive public health strategy can yield more effective and sustainable results in the fight against childhood stunting. in conclusion, this study underscores the paramount importance of addressing sth infections in the context of child growth and underscores the urgency of implementing effective public health interventions. this approach can enable children to reach their full physical and cognitive potential, ultimately contributing to the overall well-being and development of societies. introduction human helminthiasis, caused by parasitic worms, is a widespread issue.1 in indonesia, soil-transmitted helminths (sth) are the most common type. globally, over 2 billion people have sth infections, with 300 million experiencing severe cases, resulting in 150,000 deaths. ascaris lumbricoides affects about 1.2 billion, ancylostoma duodenale and necator americanus impact 740 million, and trichuris trichiura affects around 795 million people.2,3 indonesia ranks second worldwide in sth infections, primarily affecting preschool-age children. severely endemic provinces include banten, dki jakarta, south sulawesi, bali, papua, and nusa tenggara due to the favorable tropical climate and poor sanitation.4–6 east java reports an approximately 80.69% prevalence rate, with surabaya city noting 36% in 2015 according to the ministry of health of the republic of indonesia.7,8 sth are frequently found in preschool and school-aged children with poor hand hygiene and sanitation practices, making it easier for sth to enter their bodies and disrupt their growth and development processes.4,5 growth and developmental disorders commonly observed in children include stunting.9,10 stunting is a growth and developmental disorder in children caused by factors such as malnutrition, repeated infections, and insufficient psychosocial stimulation.11–14 in indonesia, the incidence of stunting is alarmingly high, affecting around 7 million toddlers. in east java province, the stunting incidence is approximately 32%.15,16 the consequences of stunting include increased morbidity, mortality, suboptimal cognitive and motor development, decreased reproductive capacity, suboptimal learning ability at school, and reduced work productivity.17–19 correspondence: kartika ishartadiati, faculty of medicine, universitas wijaya kusuma surabaya, surabaya, indonesia. e-mail: kartika.ishartadiati@uwks.ac.id key words: soil-transmitted helminths; helminthiasis; stunting; early childhood development. contributions: jhs, conceptualization, paper identification, selection, abstraction, analysis, methodology, writing – original draft, review and editing; ki, conceptualization, methodology, validation, writing – original draft, review and editing; aaaa, validation, review and editing; ss validation, review and editing; as, review and editing. conflict of interest: the authors declare no conflict of interest. funding: this research did not receive external funding. acknowledgements: we would like to thankful to the database providers pubmed, science direct, and google scholar for their valuable contributions to this study. received: 10 september 2023. accepted: 25 october 2023. early access: 9 november 2023. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2023 licensee pagepress, italy healthcare in low-resource settings 2023; 11:11742 doi:10.4081/hls.2023.11742 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 64] [healthcare in low-resource settings 2023; 11:11742] non -co mmerc ial us e o nly the rate of sth infection in stunted children under 5 years old is estimated at 30.43%, with ascaris lumbricoides and trichuris trichiura being the primary causes of infection. several factors may contribute to the incidence of sth infections in toddlers, including their medical history, frequency of illnesses in the preceding three months, stunting issues, and their cleanliness and hygiene habits (e.g., handwashing with soap before eating and after using the toilet).17–19 in recent years, research on sth infections and stunting has expanded worldwide, with some studies indicating a significant relationship and others suggesting no significant connection between sth infection and stunting in children.20–22 therefore, this study was conducted to investigate the incidence of sth infection and stunting in children, as well as to explore the relationship between these two factors. the research aims to provide up-to-date information with a reasonably high level of accuracy. the researcher conducted a systematic literature review and meta-analysis to examine the relationship between soil-transmitted helminths infection and the incidence of stunting in children. it is hoped that this research will offer insights for the prevention and treatment of sth infections and stunting in accordance with the goals of the government of the republic of indonesia in 2024 and the sdgs target in 2030. this study aims to establish the relationship between sth infection and the incidence of stunting in children through a systematic review and meta-analysis approach. materials and methods design study this study employed systematic literature review and metaanalysis methods. articles were systematically and comprehensively searched across various databases, including pubmed, sciencedirect, and google scholar, covering publications from 2012 to 2023. the article search was conducted over approximately 5 months. the search terms used were as follows: sth infections* and stunting; sth infections* and stunted; sth infections* and growth disorders; helminthiasis* and stunting; helminthiasis* and stunted; helminthiasis* and growth disorders (where * indicates truncation). population and sample eligibility criteria were established to select studies for inclusion in the systematic literature review or meta-analysis. the population of interest in this study was children. the intervention under investigation was soil-transmitted helminths (sth) infection, and the primary outcome of interest was stunting. inclusion criteria for research articles were as follows: studies investigating the relationship between soil-transmitted helminths infection and the incidence of stunting in children, research articles published between 2012 and 2023, research articles available in indonesian and english, and research articles with clearly defined methodologies. exclusion criteria encompassed incomplete research manuscripts, research results inaccessible for completeness, research lacking both qualitative and quantitative results, and research publications in the form of commentary or opinion pieces. operational definition of variables sth infection refers to intestinal nematode infections affecting humans, where transmission occurs through contact with soil contaminated by eggs or larvae of sth worms. these sth worms include ascaris lumbricoides, necator americanus, ancylostoma duodenale, trichuris trichiura, and strongyloides stercoralis. stunting is a developmental disorder primarily caused by malnutrition, recurrent infections, and insufficient psychosocial stimulation. data analysis data processing involved the use of medcalc software, which calculated heterogeneity and performed egger’s test to determine the model of studies to be combined and to derive the final results of the meta-analysis. results the selected articles encompassed publications from both international and national journals. supplementary material table 1 and table 1 provides an overview of the articles that met the inclusion criteria. article summary a total of forty (40) articles were deemed suitable for inclusion in the meta-analysis focusing on the relationship between soiltransmitted helminths infection and the incidence of stunting in children. during the initial search process, a total of 1,157 articles were identified. these articles were subsequently subjected to a screening process, during which 150 articles were assessed for relevance and full-text availability in accordance with the predetermined inclusion and exclusion criteria. ultimately, 40 articles, which specifically addressed the relationship between sth infection and the incidence of stunting in children, successfully passed the screening phase and satisfied the established inclusion and exclusion criteria. as such, these 40 articles were included in the systematic literature review and meta-analysis (figure 1). transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions figure 1. prisma diagram of the review process. [healthcare in low-resource settings 2023; 11:11742] [page 65] non -co mmerc ial us e o nly meta-analysis article forest plot table 2 demonstrates a considerable degree of variation between studies, as evident by the p-value in the heterogeneity test being less than 0.05, specifically p < 0.0001, and a high i2 value of 98.02%. therefore, the results in the meta-analysis were analyzed using the total fixed-effects model. the forest plot in figure 2 illustrates that the proportion obtained is 47.642% (95% ci 47.179 48.105). consequently, it can be concluded that sth infection increases the risk of stunting in children by a factor of 47.462. funnel plot to identify the presence of publication bias in this study, funnel plots and egger’s test were employed. in figure 3, the funnel plot indicates an asymmetrical distribution of studies, as it is not [page 66] [healthcare in low-resource settings 2023; 11:11742] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 1. meta-analysis of the articles used. study sample size proportion (%) 95% ci weight (%) fixed random wirjanata 2023 622 80.386 77.044 to 83.436 1.39 2.71 manga 2023 350 38.286 33.169 to 43.603 0.78 2.66 nasution 2022 46 58.696 43.227 to 73.003 0.10 2.08 dehury 2022 232 32.759 26.759 to 39.205 0.52 2.61 olin 2022 230 68.696 62.272 to 74.630 0.51 2.60 ickowitz 2022 422 50.474 45.596 to 55.345 0.94 2.68 hlaing 2022 264 32.576 26.957 to 38.591 0.59 2.63 kassa 2022 405 39.753 34.954 to 44.703 0.90 2.68 heffernan 2022 80 15.000 7.998 to 24.736 0.18 2.33 yeshanew 2022 392 51.020 45.953 to 56.073 0.87 2.67 diptyanusa 2022 138 51.449 42.797 to 60.038 0.31 2.50 nuraini 2022 60 60.000 46.541 to 72.438 0.14 2.21 degarege 2022 1205 44.149 41.321 to 47.006 2.68 2.75 manggabarani 2022 209 47.368 40.440 to 54.373 0.47 2.59 yogaswara 2022 185 40.000 32.882 to 47.443 0.41 2.56 munfiah 2021 51 52.941 38.459 to 67.070 0.12 2.13 lim 2021 343 39.942 34.719 to 45.339 0.77 2.66 demonteverde 2021 1689 35.406 33.122 to 37.740 3.76 2.76 shaqti 2021 160 35.000 27.639 to 42.928 0.36 2.53 hasanuddin 2021 20 10.000 1.235 to 31.698 0.047 1.59 fernandez 2021 100 42.000 32.199 to 52.288 0.22 2.41 morrisey 2021 380 47.895 42.774 to 53.049 0.85 2.67 tumwesigire 2021 206 79.126 72.931 to 84.462 0.46 2.59 salimo 2020 200 27.000 20.980 to 33.715 0.45 2.58 chelkeba 2020 404 27.970 23.645 to 32.622 0.90 2.68 hailegebriel 2020 24716 44.999 44.378 to 45.622 55.02 2.78 augustina 2020 47 57.447 42.178 to 71.742 0.11 2.09 beyene 2020 622 59.325 55.347 to 63.213 1.39 2.71 sihombing 2020 2179 41.854 39.772 to 43.958 4.85 2.76 mbonigaba 2020 4998 66.967 65.643 to 68.271 11.13 2.77 nathasaria 2020 80 1.250 0.0316 to 6.769 0.18 2.33 swastika 2019 81 25.926 16.820 to 36.860 0.18 2.33 angraini 2019 40 47.500 31.512 to 63.872 0.091 2.01 magga 2019 26 46.154 26.587 to 66.629 0.060 1.76 moncayo 2018 920 56.957 53.685 to 60.184 2.05 2.74 campbell 2017 2038 45.535 43.356 to 47.727 4.54 2.76 teshome 2017 148 59.459 51.088 to 67.444 0.33 2.52 alexandra 2017 80 21.250 12.894 to 31.829 0.18 2.33 muhoho 2016 236 59.746 53.187 to 66.057 0.53 2.61 sembiring 2015 281 35.587 29.990 to 41.492 0.63 2.63 total (fixed effects) 44885 47.642 47.179 to 48.105 100.00 100.00 total (random effects) 44885 44.407 40.341 to 48.510 100.00 100.00 non -co mmerc ial us e o nly balanced on both sides of the central line boundary. this suggests that publication bias affects the relationship between sth infection and the incidence of stunting in children. furthermore, the publication bias test using egger’s test, as presented in table 3, reveals that the intercept value is not equal to zero, specifically 0.6427. based on the results of egger’s test, it is evident that publication bias influences the relationship between sth infection and the incidence of stunting in children. discussion the results of the meta-analysis involving 40 articles examining the relationship between sth infection and the incidence of stunting in children were synthesized in a forest plot. figure 2 in the forest plot indicates that children with sth infection face a risk increase of approximately 44.407%. in a study conducted by demonteverde (2021), it was revealed that sth infection had a significant association with the incidence of stunting in children. this research employed a systematic literature review approach, focusing on filipino schoolchildren. the findings of this study suggest that sth infection can lead to structural changes in the intestines, resulting in reduced villi function and a decreased number of immune cells that protect the intestines. this, in turn, can hinder the absorption of essential nutrients crucial for child growth and development.38 another study conducted by hailegebriel (2020) highlighted the impact of sth infection on growth and development disorders in children, including stunting. this systematic review and metaanalysis centered on school-age children or children under 10 years old in ethiopia. the study emphasized external factors such as poor environmental sanitation, inadequate hand hygiene, unclean drinking water, and insufficient family education as contributors to stunting.46 additionally, a study by campbell (2017) identified the influence of sth infection on impaired growth and development in children, specifically leading to stunting. the research explored the connection between sth infections, hemoglobin levels, and child development indices in manufahi district, timor-leste. the findings revealed that children with sth infection were twice as likely to experience stunting compared to their unaffected peers.55 mbonigaba’s study (2020) showed a significant association between sth infection and the incidence of stunting in children. using kato katz microscopy (kk) and real-time pcr (qpcr) techniques to analyze 4998 children in western rwanda, the study indicated that around 88% of rwandan children were affected by soil-transmitted helminths infection, along with other conditions like stunting.50 similarly, sihombing’s study (2020) found that sth infection influenced impaired nutritional status and cognitive ability in children. this research explored the relationship between sth infection, nutritional status, and cognitive ability in children in indonesia, revealing that children with sth infection were more vulnerable to stunting compared to those without.49 while this study offers valuable insights, it is important to acknowledge several limitations. the quality of the meta-analysis and systematic review depends on the quality of the source articles. variability in data quality and reporting standards across the selected articles may introduce bias and uncertainty into the results. the study focused on articles published from 2012 to 2023, which may not fully capture the historical and geographical variations in sth infection and stunting prevalence. these factors can change over time and may vary in different regions. additionally, the study may be subject to language bias, as it relied on articles available in transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions table 2. test of heterogeneity of the association of sth infection with the incidence of stunting in children. q 1965.4566 df 39 significance level p<0.0001 i2 (inconsistency) 98.02% 95% ci for i2 97.71 to 98.28 table 3. publication bias test of the association of sth infection with the incidence of stunting in children. egger's test intercept -0.6427 95% ci -3.6784 to 2.3931 significance level p = 0.6707 figure 2. forest plot of the relationship between soil transmitted helminths (sth) infection and the incidence of stunting in children. figure 3. funnel plot of the association of soil-transmitted helminths (sth) infection with the incidence of stunting in children. [healthcare in low-resource settings 2023; 11:11742] [page 67] non -co mmerc ial us e o nly indonesian and english, potentially overlooking relevant research published in other languages. addressing these limitations in future research will enhance our understanding of the relationship between soil-transmitted helminths (sth) infections and stunting, providing more accurate insights for policy development and intervention strategies. conclusions s high sth infection rates in indonesian children result from the tropical climate, poor sanitation, unhygienic water, and inadequate education. sth infections, notably, lead to stunting, impairing child growth and development. this meta-analysis establishes that sth-infected children are at higher risk of stunting. this study contributes to the understanding of parasitic infections and growth impairment in pediatrics, parasitology, and public health. practically, health professionals and policymakers must prioritize public health initiatives. deworming programs, sanitation improvements, and health education are vital for countering sth infections and their adverse effects on children. on a governmental level, this research supports policies to reduce childhood sth infections. it offers a blueprint for regions with similar challenges, aiding in resource allocation to combat helminthiasis, thus enhancing community health and well-being. references 1. eyayu t, yimer g, workineh l, et al. prevalence, intensity of infection and associated risk factors of soil-transmitted helminth infections among school children at tachgayint woreda, northcentral ethiopia. plos one 2022;17:e0266333. 2. who. soil-transmitted helminth infections. world health organization. 2023. 3. pullan rl, smith jl, jasrasaria r, brooker sj. global numbers of infection and disease burden of soil transmitted helminth infections in 2010. parasit vectors. 2014;7:37. 4. konstantin t, tantular is, athiyyah af, rossyanti l. the correlation between water, sanitation, and hygiene with soil-transmitted helminths infection among elementary school children of aru islands district, maluku. indonesian j public health 2021;16:273-84. 5. kusumarini s, al firdausi s, indasari en, et al. determination of elementary school students knowledge of soil-transmitted helminth infection with study of personal hygiene behavior in lamongan district, east java, indonesia. veterinary practitioner 2020;21:479-83. 6. putro g, ristrini, sukoco new, dewi er. risk behavior of tiom community related with helminthiasis at lanny jaya district, papua province, indonesia. j global pharma technol 2020;12:416-23. 7. djuardi y, lazarus g, stefanie d, et al. soil-transmitted helminth infection, anemia, and malnutrition among preschool-age children in nangapanda subdistrict, indonesia. plos negl trop dis. 2021;15:e0009506. 8. kementerian kesehatan ri. laporan riskesdas 2018 [basic health research report 2018]. laporan nasional riskesdas 2018 [internet]. 2018 [cited 2023 mar 19]; available from: https://kesmas.kemkes.go.id/assets/ upload/dir_ 519d41d8cd98f00/files/hasil-riskesdas-2018_1274.pdf 9. adu-gyasi d, asante kp, frempong mt, et al. epidemiology of soil transmitted helminth infections in the middle-belt of ghana, africa. parasite epidemiol control 2018;3(3). 10. tapiheru mjr, zain n. prevalence of soil transmitted helminth infection in public elementary school students 105296 percut sei tuan, deli serdang, north sumatra. jimki: jurnal ilmiah mahasiswa kedokteran indonesia 2021;8:1-7. 11. surani e, susilowati e. the relationship between fulfilment of basic needs with the incidence of stunting in toddlers. jurnal ners 2020;15:26-30. 12. amaliyah e, mulyati m. effectiveness of health education and nutrition rehabilitation toward community empowerment for children aged less than 5 years with stunting: a quasi-experimental design. jurnal ners 2020;15: 173-7. 13. izza n, purnomo w, mahmudah. factors affecting the occurrence of stunting in indonesia. indian j public health res dev 2019;10:1845-50. 14. ezeh ok, abir t, zainol nr, et al. trends of stunting prevalence and its associated factors among nigerian children aged 0-59 months residing in the northern nigeria, 2008-2018. nutrients 2021;13:4312. 15. taqwin t, ramadhan k, hadriani h, et al. prevalence of stunting among 10-year old children in indonesia. j global pharma technol 2020;12:768-75. 16. has emm, efendi f, wahyuni sd, et al. stunting determinants among indonesian children aged 0-59 month: evidence from indonesian family life survey (ifls) 2014/2015. j global pharma technol 2020;12:815-25. 17. tim nasional percepatan penanggulangan kemiskinan (tnp2k). 100 kabupaten/kota prioritas untuk intervensi anak kerdil (stunting). pertama. jakarta: sekretariat wapres ri; 2017. 18. soliman a, de sanctis v, alaaraj n, et al. early and long-term consequences of nutritional stunting: from childhood to adulthood. acta biomedica. 2021 mar 5;92:e2021168. 19. riset kesehatan dasar (riskesdas). laporan nasional. badan penelitian dan pengembangan kesehatan kementrian ri 2018. 2018. 20. astuti d, magga e, djalla program studi kesehatan masyarakat fakultas ilmu kesehatan universitas muhammadiyah parepare a. hubungan penyakit kecacingan dengan status gizi anak pada sekolah dasar muhammadiyah jampu kecamatan lanrisang kabupaten pinrang. jurnal ilmiah manusia dan kesehatan 2019;1. 21. amalia yn, sari op, munfiah s. hubungan antara kecacingan dengan status gizi pada siswa sekolah dasar. jurnal pendidikan dan teknologi indonesia 2021;1:81-9. 22. yeshanew s, bekana t, truneh z, et al. soil-transmitted helminthiasis and undernutrition among schoolchildren in mettu town, southwest ethiopia. sci rep 2022;12(1). 23. djohan pb, prasetyadi a, wirjanata m, et al. association between ascaris lumbricoides infection and undernutrition in children: a systematic review and meta-analysis. bali medical journal 2023;12:197-205. 24. astuti d, magga e, djalla a. hubungan penyakit kecacingan dengan status gizi anak pada sekolah dasar muhammadiyah jampu kecamatan lanrisang kabupaten pinrang. manusia dan kesehatan 2019;2:284-92. 25. nasution ps, fajar, pramawati a. hubungan penggunaan air bersih, jamban sehat, cuci tangan pakai sabun (ctps), dan infeksi kecacingan dengan kejadian stunting pada anak balita di pulau seraya kelurahan tanjung riau kota batam tahun 2022. jurnal kesehatan ibnu sina. 2022;3(2). [page 68] [healthcare in low-resource settings 2023; 11:11742] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 26. behera dk, samand k, dehury rk. assesment of water, sanitation, and hygiene in south-east asia: a systematic review. j clin diagnostic res 2022;16:1-6. 27. olin w, paun r. the factors that influence the incidence of infection of intestinal worms in children under five with the problem of nutritional stunting in the south timor timor district (tts). glob j health sci 2022;14:39. 28. asa bf, shintouo cm, shey ra, afoumbom mt, siekeh n, yoah a, et al. prevalence, correlates of undernutrition and intestinal parasitic infection among children below 5 years living in the forest community of ndelele, east region of cameroon: a cross-sectional assessment. mendlovic f, editor. plos one 2022;17:e0278333. 29. aung e, han kt, gordon ca, et al. high prevalence of soiltransmitted helminth infections in myanmar schoolchildren. infect dis poverty 2022;11(1). 30. geleto ge, kassa t, erko b. epidemiology of soil-transmitted helminthiasis and associated malnutrition among under-fives in conflict affected areas in southern ethiopia. trop med health 2022;50(1). 31. raj e, calvo-urbano b, heffernan c, et al. systematic review to evaluate a potential association between helminth infection and physical stunting in children. vol. 15, parasites and vectors. biomed central ltd; 2022. 32. fauziah n, ar-rizqi ma, hana s, et al. stunting as a risk factor of soil-transmitted helminthiasis in children: a literature review. interdiscip perspect infect dis 2022;2022:8929025. 33. nuraini i, iswati rs, aisyah. intervention of stunting aged 059 months reviewing from nutrition. j pharm negat results 2022;13:700-5. 34. degarege a, erko b, negash y, animut a. intestinal helminth infection, anemia, undernutrition and academic performance among school children in northwestern ethiopia. microorganisms 2022 jul 1;10(7). 35. hadi aj, yetti riman e, sudarman s, et al. socio-family culture against stunting risk: a cross-sectional populationbased study nutrition program study. volatiles essent oils. 2022;9. 36. yogaswara d. pemetaan kasus dan faktor risiko stunting di kabupaten tasikmalaya tahun 2019. jurnal bidkesmas respati 2022;01:105-13. 37. muslim a, lim yal, sofian sm, et al. nutritional status, hemoglobin level and their associations with soil-transmitted helminth infections between negritos (indigenous) from the inland jungle village and resettlement at town peripheries. plos one 2021;16:e0245377. 38. mationg mls, williams gm, tallo vl, et al. soil-transmitted helminth infections and nutritional indices among filipino schoolchildren. plos negl trop dis 2021;15:e0010008. 39. paun r, bia mb, shagti i, et al. the relationship between intestinal worm infection and stunting in elementary school children in south central timor regency, east nusa tenggara 2021;328-33. 40. nurfaikatunnisa, asdinar, hasanuddln par. the relationship between worms and stunting in toddlers using the sedimentation method in bulukumba regency. jurnal tlm blood smear 2021;2:31-40. 41. masangcay du, amado ajy, bulalas ar, et al. association of soil-transmitted helminth infection and micronutrient malnutrition: a narrative review. asian j biol life sci 2021;10:317-24. 42. okafor ama, ikwumere cm, egumgbe ud, et al. prevalence and determining factors of stunting among school-aged children in a rural nigerian community: a cross-sectional study. current res nutrition food sci 2021;9:409-22. 43. mugarura d, ninsiima hi, kinyi h, et al. high-prevalence stunting in preschool children (1-5 years) attending selected health centers in a food rich area-bushenyi district southwestern uganda. j nutr metab 2021;2021. 44. muslimah pa, salimo h, lanti y, dewi r. multilevel analysis association of soil transmitted helminths and stunting in children aged 6-12 years old in pinrang district, south sulawesi. j epidemiol public health 2020;3:372-83. 45. mekonnen z, hassen d, debalke s, et al. soil-transmitted helminth infections and nutritional status of school children in government elementary schools in jimma town, southwestern ethiopia. sage open med 2020;8. 46. hailegebriel t. prevalence and determinants of stunting and thinness/wasting among schoolchildren of ethiopia: a systematic review and meta-analysis. food and nutrition bulletin 2020;41:474-93. 47. widiarti a, nyoman n, yuliani s, et al. the correlation between worm infection and stunting incidence in the firstthird grade students of pematang limau elementary school, gunung mas district. indian j public health res dev 2020;11:604-8. 48. yoseph a, beyene h. the high prevalence of intestinal parasitic infections is associated with stunting among children aged 6-59 months in boricha woreda, southern ethiopia: a crosssectional study. bmc public health 2020;20:1270. 49. sihombing me, tambunan r, siahaan dl. hubungan infeksi soil transmitted helminths dengan status gizi dan kemampuan kognitif pada anak. jurnal kedokteran methodist 2020;13:59-68. 50. kabatende j, mugisha m, ntirenganya l, et al. prevalence, intensity, and correlates of soil-transmitted helminth infections among school children after a decade of preventive chemotherapy in western rwanda. pathogens 2020;9:1-20. 51. sari mp, nathasaria t, majawati es, pangaribuan hu. soiltransmitted helminth infections, anemia, and undernutrition among school-children in an elementary school in north jakarta, indonesia. majalah kedokteran bandung 2020;52(4). 52. agustianingsih nn, kadek swastika i, sudarmaja im. prevalensi dan hubungan tingkat pengetahuan orang tua siswa terhadap angka kejadian infeksi soil-tansmitted helminths pada siswa sekolah dasar negeri 2 gegelang, kecamatan manggis, kabupaten karangasem, bali. januari 2020;9(1). 53. pratama b, angraini di, nisa k. literatur review penyebab langsung (immediate cause) yang mempengaruhi kejadian stunting pada anak immediate cause affects stunting in children. jurnal ilmiah kesehatan sandi husada 2019;10:299303. 54. moncayo al, lovato r, cooper pj. soil-transmitted helminth infections and nutritional status in ecuador: findings from a national survey and implications for control strategies. bmj open 2018;8:1-9. 55. campbell sj, nery sv, d’este ca, et al. investigations into the association between soil-transmitted helminth infections, haemoglobin and child development indices in manufahi district, timor-leste. parasit vectors 2017;10(1). 56. zeleke zz, yohanes t, gutema bt, rusho tt. association between nutritional status and soil-transmitted helminthes re-infection among school-age children in chencha district, southern ethiopia: a cross-sectional study. transl biomed [healthcare in low-resource settings 2023; 11:11742] [page 69] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions non -co mmerc ial us e o nly 2017;08:1-6. 57. darlan dm, alexandra ts, tala zz. soil transmitted helminth infections in medan: a cross-sectional study of the correlation between the infection and nutritional status among elementary school children. family medicine and primary care review 2017;19:98-103. 58. njiru j, muhoho n, simbauni j, kabiru e. effects of soiltransmitted helminths and schistosoma species on nutritional status of children in mwea irrigation scheme, kenya. j appl life sci int 2016;5:1-8. 59. simarmata n, sembiring t, ali m. nutritional status of soiltransmitted helminthiasis-infected and uninfected children. paediatrica indonesiana 2015;55:136-41. [page 70] [healthcare in low-resource settings 2023; 11:11742] transforming healthcare in low-resource settings: a multidisciplinary approach towards sustainable solutions online supplementary material: table 1. articles included in the meta-analysis. non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13067 correlation between personal characteristics and intention to perform bystander cardiopulmonary resuscitation ikhda ulya, ika setyo rini, melati gusti dwi febriani, azizah khusnadani putri, kumboyono, dina dewi sartika lestari ismail, ayut merdikawati department of nursing, faculty of health sciences, universitas brawijaya, malang, indonesia abstract out-of-hospital cardiac arrest is a major problem globally characterized by poor survival rates, particularly in residential settings. a delay in administering cardiopulmonary resuscitation (cpr) can reduce the survival rate, which is currently at 1 in 10. the chance of survival is influenced by several factors, including patient, population, and health system, particularly the actions of bystanders due to the need for immediate administration of cpr. although the role of bystanders is very important in increasing the survival rate of cardiac arrest, not all individuals present at the scene are willing to carry out cpr due to personal characteristics. therefore, this research aimed to explore the potential correlation between personal characteristics and the intention (willingness) to provide basic life support. the investigation was carried out in malang city using descriptive correlation design and data were collected with questionnaires distributed through google forms. the sample consisted of residents of malang city, with inclusion criteria comprising individuals aged between 17-65 years, not health workers or health students, and the ability to fill in data using google forms. after collection, the data obtained were processed descriptively using the spss 23 version. the results showed that among 283 respondents, 80.6% were in the early adult age range, 64% were female, 57.6% had the last education level sma/smk, and 65.4% were students. furthermore, the analysis showed that the intentions of the majority of respondents were in the moderate range, accounting for 64.7%. correlation analysis showed a significant association between personal characteristics and intention, where age, gender, level of education, occupation status, and experience had correlation scores of -0.089, 0.054, 0.107, 0.104, and -0.261. in conclusion, this research showed correlation strength for all characteristics ranging from very low to low, emphasizing the need to enhance the intention to perform bystander cpr across all levels. this is due to the very low correlation between community characteristics and intention. to overcome this challenge, a strategy that has been proven effective in increasing intention is educating the public regarding cardiac arrest assistance. introduction out-of-hospital cardiac arrest (ohca) is a major problem globally, accounting for approximately 540,000 deaths in china.13 to overcome this problem, a strategy that has been proven effective is through the establishment of a chain of survival for cardiac arrest patients outside the hospital. although this strategy has been introduced since 1960, the survival rate for patients is still between 7-26%.4-5 early recognition and initiation of cardiopulmonary resuscitation (cpr) by bystander has been correlated with the chain, accounting for a 2 to 4-fold increase in survival and favorable outcomes.6 community participation is also very significant in improving assistance to cardiac arrest patients outside the hospital.6,7 cpr action of bystander as a chain of survival is a significant factor in determining the survival rate.8 based on previous research, the survival rate for cardiac arrest patients was found to be 14.7%, 16%, 10%, and 12% in the us, the uk, europe, and turkey, respectively. the variation in survival rate is attributed to several influencing factors according to characteristics of each country which is predominantly determined by the time when bystander started performing cpr.4-5,9 moreover, the performance of cpr immediately after the victim experiences cardiac arrest is a very important factor in increasing the survival rate. this is because delay in performing cpr can reduce the survival rate by 10% every minute, showing the significant role of bystander in early recognition, cpr, defibrillation, and response from emergency medical services.1,5,10 previous results also showed that cardiac arrest patients who received cpr from bystander had a survival rate 2.6 times higher compared to those who did not receive.1,5 however, when the collapse of ohca patients is witnessed, the probability of starting cpr is significantly lower.11 several factors influencing the possibility of bystander cpr implementation include fear, legal implications outside the hospital, knowledge, training, and socioeconomic status.8. moreover, community-level socioeconomic status has shown a significant association with bystander cpr rates and the survival of ohca patients. this showed that lower bystander cpr and survival rates significance for public health out-of-hospital cardiac arrest (ohca) constitutes a significant public health concern characterized by poor survival rates. research indicates that bystander cpr and aed use can potentially double survival rates. this study delves into the crucial relationship between community attributes and the willingness to deliver essential life support. inadequacies in community response may stem from various factors, including bystanders' reluctance to administer critical life support, which can be influenced by individual disposition. [page 144] [healthcare in low-resource settings 2024;12(s1):13067] non -co mmerc ial us e o nly were found in communities with lower socioeconomic status levels.12 to overcome this challenge, a community-based healthcare resource has been proven effective in improving the survival of ohca and access to emergency care in remote areas.13,14 based on the theory of planned behavior, action is affected by attitude, which is significantly influenced by will. this theory states that the implementation of an action is determined by motivation (intention) and ability (behavioral control). the relationship with the implementation of cpr by bystander is significantly determined by willingness,9 which is influenced by personal characteristics, experience, and knowledge. therefore, this research aimed to investigate personal characteristics and willingness to perform bystander cpr among malang city residents.1,4 the willingness of individuals to respond to cardiac arrest incidents, including early recognition, assistance, initiation of cpr, and use of aed, plays a significant role in improving survival rate.15 materials and methods this research used descriptive correlation design to determine correlation between personal characteristics and the willingness to perform bystander cpr by malang city residents. this design was selected because the research was only observational regarding personal characteristics that could not manipulated and to describe existing conditions related to the community’s willingness to perform bystander cpr. the consecutive sampling method was used to select 283 respondents, which comprised malang city residents, ranging from teenagers to the elderly, excluding health workers and those unable to fill in survey data online. research data collection was carried out for 3 months, namely january-march 2023. the questionnaire comprised four main questions regarding willingness to carry out bystander cpr steps, which were presented in the form of a 1-4 likert scale, where 1 signified “very weak”, 4th international nursing and health sciences symposium table 1. characteristic of respondents. characteristics frequency percentage (%) age late teens (17-25 yo) 228 80.6 early adolescence (26-35 yo) 20 7.1 early adolescence (36-45 yo) 11 3.9 early elderly (46-55 yo) 12 4.2 late elderly(56-65 yo) 12 4.2 gender male 102 36.0 female 181 64.0 level of education not complete elementary school 2 0.7 elementary school 9 3.2 junior high school 10 3.5 high school 163 57.6 diploma 30 10.6 undergraduate/postgraduate 69 24.4 occupation doesn't work 28 9.9 government employees 10 3.5 private sector employee 28 9.9 self-employed 26 9.2 workers/farmers/fisherman 6 2.1 student 185 65.4 experience witnessing cardiac arrest victims yes 158 55.8 no 125 44.2 table 2. level of intention. level of intention frequency percentage (%) low 19 6.7 middle 183 64.7 strong 81 28.6 table 3. descriptive correlational analysis. categories sig. 2-tailed correlation coeff age 0.134 -0.089 gender 0.362 0.054 level of education 0.071 0.107 occupation 0.081 0.104 experience 0.000 -0.261 [healthcare in low-resource settings 2024;12(s1):13067] [page 145] non -co mmerc ial us e o nly 2 “weak”, 3 “strong”, and 4 “very strong”. the questions were prepared in a google form and distributed online through social media. additionally, data collection was carried out directly in public places, where malang city residents gathered, such as squares, sports venues, shopping areas, and campuses. direct data collection started with a request for the respondent’s willingness to fill out the questionnaire. statistical data analysis was carried out using excel to analyze descriptive data in the form of personal characteristics and willingness to perform bystander cpr. subsequently, the spearman correlation was used to analyze correlation of each personal characteristics to perform bystander cpr. this research received ethical approval from the faculty of health sciences, brawijaya university, malang with number 6148/un10.f17.10/tu/2022. results and discussion the research showed that the majority of respondents were in the late teenage age range (17-15 years) at 80.6%, 36% were female, 57.6% had high school education level, 65.4% were student, and 58.8% had an experience witnessing cardiac arrest (table 1). the results showed that the majority of respondents (64.7%) had moderate intention to assist with cardiac arrest in malang city, indicating the need for improvement to support the safety of ohca patients (table 2). the role of bystander in handling ohca patients in the first 10 minutes could increase the potential for return of spontaneous circulation (rosc), significantly influencing the ability to survive within 30 days after cardiac arrest. this shows the need to increase the number and quality of cpr provided by bystander,16 representing the important components of the chain of survival. therefore, any strategy to improve the outcomes of ohca patients must focus on increasing the rate of bystander cpr and defibrillation.17 previous research regarding the willingness to perform cardiopulmonary resuscitation among upper-secondary students showed7 that the majority of respondents had a good willingness to carry out cpr due to various motivations. although the majority aimed at performing cpr for friends or relatives, there was fear apprehension due to legal consequences. despite the low participation, all students had a positive response to engage in cpr as bystander.16,18 the analysis showed that four among five personal characteristics had no relationship with the willingness to perform bystander cpr (<0.05), indicating a very low level of correlation (<0.199). specifically, age (0.134), gender (0.362), level of education (0.071), and occupational status (0.081), showed no significant correlation. personal experience had a significant relationship and low correlation with the willingness to perform bystander cpr (>0.200) but negatively correlated with age. personal characteristics had a very low correlation with the willingness to perform bystander cpr, suggesting the influence of other factors (table 3). according to previous research, factors that influenced the willingness to perform bystander cpr were knowledge, attitude, and self-efficacy.5,18 personal characteristics in the form of experience had a significant relationship due to their significance in increasing self-efficacy.19,20 other influencing characteristics were found to be emotional barrier factors, particularly fear.15 furthermore, the majority of respondents identified potential accusations of sexual assault, particularly regarding women, as a contributing factor to less bystander cpr compared to men.21 knowledge is a strong factor influencing a person’s willingness to perform bystander cpr.2,22 additionally, the basic life support training that has been attended plays a significant role in willingness, which is correlated with self-efficacy for carrying out bystander cpr.5,19 in previous research on public perception, participants at training events have many concern and fear regarding bystander cpr, causing additional harm as the leading concern across all patient domains. the lack of sufficient experience or confidence in skills was also identified as a contributing factor.23 conclusions in conclusion, this research showed that there was no significant correlation between intention and personal characteristics, such as age, gender, education level, and employment status. however, only experience of witnessing a cardiac arrest event showed a significant relationship with willingness to perform bystander cpr. 4th international nursing and health sciences symposium correspondence: ikhda ulya, department of nursing, faculty of health sciences, universitas brawijaya, jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java indonesia. tel.: +62341569117 fax: +62341564755. e-mail: ikhda.fk@ub.ac.id key words: cardiopulmonary resuscitation, bystander, personal characteristics, intention contributions: each author has contributed to this research, assumed responsibility for the content, assessed quality, provided input during preparation, and approved the manuscript submission. conflict of interest: the authors declare that there are no conflicts of interest regarding this research. funding: the author received research funding from the research and community service agency, faculty of medicine, brawijaya university ethics approval: this research received ethical approval from the faculty of health sciences, brawijaya university, malang with number 6148/un10.f17.10/tu/2022. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgements: the authors would like to thank everyone who participated in improving the quality of this scientific article. received: 3 november 2023. accepted: 18 july 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13067 doi:10.4081/hls.2024.13067 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 146] [healthcare in low-resource settings 2024;12(s1):13067] non -co mmerc ial us e o nly references 1. mao j, chen f, xing d, et al. knowledge, training and willingness to perform bystander cardiopulmonary resuscitation among university students in chongqing, china: a cross-sectional study. bmj open. 2021;11:e046694. 2. jaskiewicz f, kowalewski d, kaniecka e, et al. factors influencing self-confidence and willingness to perform cardiopulmonary resuscitation among working adults—a quasi-experimental study in a training environment. int j environ res public health 2022;19:8334. 3. simmons km, mcisaac sm, ohle r. impact of communitybased interventions on out-of-hospital cardiac arrest outcomes: a systematic review and meta-analysis. sci rep 2023;13:10231. 4. suharsono t, sunarmi s, ida n, et al. the implementation of code blue by nurses as first responders in outpatient and inpatient rooms at malang indonesia hospital. healthcare in lowresource settings 2023;11:11217. 5. regard s, rosa d, suppan m, et al. evolution of bystander intention to perform resuscitation since last training: webbased survey. jmir form res 2020;4:e24798. 6. yu y, meng q, munot s, et al. assessment of community interventions for bystander cardiopulmonary resuscitation in outof-hospital cardiac arrest: a systematic review and meta-analysis. jama netw open 2020;3:e209256. 7. munot s, redfern j, bray je, et al. improving communitybased first response to out of hospital cardiac arrest (firstcpr): protocol for a cluster randomised controlled trial. bmj open 2022;12:e057175. 8. carragher r, johnson j, harder m. factors that influence bystander cpr: a narrative review. internat j curr res 2027;9;52100-52103. 9. park jy, kim hj, song kj. factors influencing for intention to perform cardiopulmonary resuscitation in nursing students. j muscle joint health 2019;26:131–40. 10. fitri y ey, andhini d, effendi z, handayani s. willingness to act in cardiopulmonary resuscitation in high school students. jks 2023;6:1581–91. 11. brinkrolf p, metelmann b, scharte c, et al. bystander-witnessed cardiac arrest is associated with reported agonal breathing and leads to less frequent bystander cpr. resuscitation 2018;127:114–8. 12. lee s, ahn ko, cha mi. community-level socioeconomic status and outcomes of patients with out-of-hospital cardiac arrest: a systematic review and meta analysis. medicine (baltimore) 2021;100:e24170. 13. pattanarattanamolee r, sanglun ry, nakahara s. communitybased first responder network in rural thailand: a case study of out-of-hospital cardiac arrest. prehosp disaster med 2021;36:234–6. 14. ezem n, lewinski aa, miller j, et al. factors influencing support for the implementation of community-based out-of-hospital cardiac arrest interventions in highand low-performing counties. resuscitation plus 2024;17:100550. 15. matsuyama t, scapigliati a, pellis t, et al. willingness to perform bystander cardiopulmonary resuscitation: a scoping review. resuscitation plus 2020;4:100043. 16. fatmawati a, mawaddah n, sari ip, mujiadi m. improving knowledge of basic life support in cardiac arrest conditions outside the hospital and cardiopulmonary resuscitation for high school students. jmm (jurnal masyarakat mandiri) 2020;4:1176–84. 17. doan tn, schultz bv, rashford s, bosley e. surviving out-ofhospital cardiac arrest: the important role of bystander interventions. australasian emergency care 2020;23:47–54. 18. song ks, park ky. factors influencing for intention to perform cardiopulmonary resuscitation in elementary and secondary school teachers. j korean academy comm health nurs 2020;31:384-394. 19. ahsan a. analysis of factors related to adolescent selfefficacy in performing cardiopulmonary resuscitation at state vocational high school 2 singosari. jurnal ilmiah kesehatan media husada 2019;8:8-24. 20. estri ak. the role of bystanders in cardiac arrest management in the community: a literature study. prosiding seminar nasional multidisiplin ilmu 2019;1:32. 21. perman sm, shelton sk, knoepke c, et al. public perceptions on why women receive less bystander cardiopulmonary resuscitation than men in out-of-hospital cardiac arrest. circulation 2019;139:1060–8. 22. pivač s, gradišek p, skela-savič b. the impact of cardiopulmonary resuscitation (cpr) training on schoolchildren and their cpr knowledge, attitudes toward cpr, and willingness to help others and to perform cpr: mixed methods research design. bmc public health 2020;20:915. 23. becker tk, gul ss, cohen sa, et al. public perception towards bystander cardiopulmonary resuscitation. emerg med j 2019;36:660–5. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13067] [page 147] non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2025; volume 13(s2):13270 development and psychometric evaluation of a quality assessment questionnaire for clinical nursing education muhamad andika sasmita saputra, tukimin bin sansuwito, faridah mohd said faculty of nursing, lincoln university college, malaysia abstract this study developed and evaluated a quality assessment questionnaire for clinical nursing education using an exploratorysequential mixed-method approach. a systematic literature review and expert consultations informed the initial item generation, followed by psychometric validation involving nursing students and experts in palembang, indonesia. the questionnaire was assessed for content validity index (cvi ≥0.83, scale-level cvi = 0.97), construct validity (five factors explained 85.1% variance, factor loadings 0.56–0.91), and reliability (cronbach’s alpha = 0.94). the final version consisted of 24 items across five dimensions: quality, constraints, benefits, practicality, and transparency. unlike existing tools, this questionnaire integrated a comprehensive evaluation framework tailored for nursing education, ensuring a more structured and contextually relevant assessment. despite its robustness, the study was limited by its focus on a single geographic and cultural setting. future research should explore crosscultural validation and technological integration to enhance its applicability. introduction clinical practice is a fundamental component of nursing education, enabling students to translate theoretical knowledge into real-world healthcare settings. beyond developing technical skills, clinical practice fosters critical competencies such as communication, professional ethics, and problem-solving, all of which are vital for competent nursing professionals.1–3 additionally, interprofessional collaboration is strengthened during clinical training, as nursing students engage with multidisciplinary teams, improving the overall quality of patient care.4–6 a supportive learning environment and mentorship play crucial roles in enhancing students’ satisfaction and competency development, emphasizing the need for well-structured clinical practice evaluation tools.7–9 the evaluation of clinical practice is essential to ensure students acquire meaningful learning experiences that contribute to their professional growth.10,11 various assessment methods, including direct observation, mentor feedback, and self-assessment, are used to evaluate students’ competencies.12 competency-based assessments are particularly significant as they encompass technical skills, communication, and affective attributes such as empathy and ethical behavior.13 furthermore, technological advancements, including digital simulations and electronic portfolios, have been introduced to improve the accuracy and efficiency of clinical evaluations.14,15 while existing tools aim to provide comprehensive assessments, there remains a need for standardized and reliable evaluation methods across different nursing programs. despite the availability of various clinical evaluation instruments, inconsistencies in assessment criteria and evaluator subjectivity persist, compromising the reliability of student evaluations.16 the variability in evaluators’ perceptions often results in inconsistent grading, underscoring the necessity for standardized, evidence-based evaluation tools.17 additionally, while technological advancements have improved objectivity, issues related to accessibility and implementation in diverse educational settings remain unaddressed.18 recent research suggests that intensive training for evaluators can significantly reduce bias and enhance assessment consistency. another critical gap in current evaluation frameworks is the underrepresentation of affective and behavioral competencies. many existing instruments predominantly focus on cognitive and technical aspects, neglecting crucial interpersonal skills such as empathy, communication, and professional behavior.19 studies indicate that systematic evaluation of affective competencies can correspondence: muhamad andika sasmita saputra, faculty of nursing, lincoln university college, malaysia. e-mail: andika.phdscholar@lincoln.edu.my key word: clinical practice, development of instrument, nursing students, quality of evaluation, validity and reliability contributions: research, data analysis, interpretation, drafting, and critical article were all done by the authors. conflict of interest: the author declares no conflict of interest. ethics approval and consent to participate: this study passed ethical review with the approval number 042-2023. the ethical review was conducted by the medical and health research ethics committee of the faculty of medicine, sriwijaya university, palembang, an institution accredited by the government in the south sumatra province, indonesia. funding: this research did not receive external funding. availability of data and materials: all data generated or analysed during this study are included in this published article. acknowledgments: the authors would like to thank you very much to all of those who have supported the researcher in writing this research. received: 19 october 2024. accepted: 28 april 2025. early view: 22 july 2025. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2025 licensee pagepress, italy healthcare in low-resource settings 2025; 12(s2):13270 doi:10.4081/hls.2025.13270 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 102] [healthcare in low-resource settings 2025;13(s2):13270] lead to improved nurse-patient interactions and better patient outcomes.20 additionally, the development of holistic assessment tools that incorporate emotional and social competencies is imperative to ensure nursing students are adequately prepared for dynamic clinical environments.21 furthermore, existing evaluation instruments are typically developed by faculty members and experts, often overlooking the perspectives of students the primary users of these tools. research indicates that involving students in the design and refinement of assessment instruments enhances their relevance and applicability in real-world settings.14,22,23 collaborative development between faculty and students has been shown to increase the accuracy of evaluations while fostering student engagement and ownership in the assessment process.24 clarke et al. (2023)25 emphasize that student-faculty collaboration ensures a comprehensive evaluation framework that adequately reflects students’ clinical learning experiences. given these limitations, this study aims to develop a valid, reliable, and comprehensive questionnaire for evaluating clinical practice quality from the perspective of nursing students. unlike existing evaluation instruments that primarily assess learning activities and student competencies, this study seeks to create an innovative assessment tool that evaluates the quality of the evaluation process itself.26,27 this approach aligns with constructivist learning theories, which advocate for assessments that consider learning outcomes, the learning process, and contextual factors.28 by incorporating diverse stakeholder perspectives, including students and clinical practitioners, the resulting evaluation tool is expected to be more adaptable across various cultural and educational contexts.29 furthermore, ensuring the reliability of the instrument will allow for consistent and meaningful evaluations across different clinical settings30. ultimately, this study contributes to the advancement of nursing education by providing a more effective tool for assessing the quality of clinical practice evaluations, thereby supporting improved educational outcomes and better-prepared nursing professionals. materials and methods study design this study designed and developed a questionnaire to assess nursing students’ clinical practice quality using an exploratorysequential mixed method approach. in the context of this study, the exploratory-sequential method begins with a qualitative exploration phase through a systematic literature review to identify key themes related to the quality of clinical practice evaluation, which are subsequently used to develop the questionnaire items. meanwhile, the quantitative phase is conducted to test whether the developed instrument is valid, reliable, and truly reflects nursing students’ experiences and perceptions regarding the quality of clinical practice evaluation.31,32 population, sample, and sampling the study population comprised nursing students enrolled in a professional nursing education programme in palembang, south sumatra, indonesia. a purposive sampling approach was employed for the qualitative phase, selecting relevant literature based on predefined inclusion and exclusion criteria. inclusion criteria encompassed books published between 2013 and 2023 and journal articles from 2018 to 2023. data were extracted by reviewing sources based on author, title, year, type (book or journal), keywords, and topic relevance, focusing on content related to clinical practice evaluation quality. selected sources met the following: alignment with keywords, relevance to evaluation components, conformity with scope, appropriate publication years, and open-access indexing (for journals) or valid isbns (for books). books served as primary references, while journals provided supporting insights33. for the quantitative phase, a sample of 168 nursing students was selected using stratified random sampling to ensure representativeness across different academic levels. variables the variable analysed in this study is the quality of clinical practice evaluation among nursing students. instrument development the questionnaire was developed based on findings from the systematic literature review. each component was translated into five questions, resulting in an initial draft of 45 items. each evaluation component was then divided into positive (3 questions) and negative (2 questions). a five-point likert scale (1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, and 5 = strongly agree) was employed. content validity was assessed using the content validity index (cvi), while construct validity was examined through exploratory factor analysis (efa). data collection process the study was conducted between january 2023 and june 2024. the qualitative data collection phase involved a systematic literature review to explore and identify key themes and components influencing the quality of clinical practice evaluation, which served as the basis for developing a valid and empirically grounded questionnaire instrument. the literature search was performed using accessible electronic databases and search engines such as google books, google scholar, proquest, pubmed, and sciencedirect, alongside printed sources. a strategic search approach was applied using boolean operators (and/or/not), ensuring precise retrieval of relevant studies. for instance, keywords such as “component” and “quality of evaluation” and “clinical practice” and “among nursing students” were used. the selection criteria included books published within the past decade (2013–2023) and journal articles from the last five years (2018– 2023). data extraction was systematically conducted by reviewing sources based on the author’s name, title, publication year, type of source (book or journal), keywords, and thematic relevance, specifically focusing on content related to quality components of clinical practice evaluation. studies were included in the analysis based on the following criteria: i) journal titles and/or abstracts aligning with the chosen keywords, ii) direct relevance to quality components in clinical practice evaluation, iii) correspondence with the scope of clinical practice evaluation, iv) books published from 2013 to 2023 and journals from 2018 to 2023, and v) books with isbns and journals indexed in open-access databases. while books provided primary references for the review, journal articles contributed supplementary insights into the essential components influencing the quality of clinical practice evaluation. in the quantitative phase, nursing students completed the developed questionnaire, and data were collected electronically. data analysis the qualitative phase the journal analysis was conducted in accordance with the preferred reporting items for systematic reviews and metaanalyses (prisma) framework. the data extraction process com pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13270] [page 103] prised two key stages: i) reviewing the database by identifying details such as the author, title, publication date, year, journal type, keywords, topic, and primary reference sources; and ii) ensuring that the content or subject matter corresponded with the specified keywords.33 the flow chart illustrates the literature selection process using the prisma diagram (figure 1). a total of 12 sources met the inclusion criteria by addressing quality evaluation components, while all others were excluded. the quantitative phase content validity in the subsequent phase, the researcher assessed content validity by engaging six experts in nursing and education to review the initial questionnaire draft. using a content validity index (cvi) form, the experts evaluated each item in terms of relevance, clarity, and completeness. the form consisted of four components: instructions, content, language, and questionnaire items (a total of 45), each rated on a 4-point likert scale from 1 (not relevant) to 4 (highly relevant). feedback from the experts informed revisions to the questionnaire, and the content validity index (cvi) was used to analyse item validity based on expert judgment.18,34 content validity was analysed using the content validity index (cvi), involving expert assessment of the relevance of each item in the questionnaire. the analysis was conducted using computer software by converting expert responses into an ordinal scale (0 and 1), followed by the calculation of the item-level content validity index (i-cvi) and the scale-level content validity index (s-cvi) to assess the questionnaire’s relevance. the determination of the questionnaire’s acceptability relevance followed validation standards involving 6–8 experts, with an item-level content validity index (i-cvi) threshold of ≥0.83. for s-cvi/ave values of ≥0.90 the category is excellent, ≤0.80 – <0.90 is good, and <0.80 is considered to have inadequate content validity and may require substantial revision.18,34 construct validity construct validity was analysed using exploratory factor analysis. the sample comprised 168 nursing students from a professional nursing education programme in palembang, south sumatra province, indonesia. factor analysis began with the kaiser-meyerolkin (kmo) test to assess sampling adequacy, where values above 0.90 are considered excellent, while values below 0.50 indicate that the data are unsuitable for factor analysis.35,36 to ensure adequate item correlation, bartlett’s test of sphericity (p<0.05) and anti-image analysis were also conducted. the anti-image matrix helped determine the suitability of each variable in the factor model using the measure of sampling adequacy (msa).37 items with an msa value above 0.50 were deemed acceptable, while those with msa ≤0.50 were removed due to their minimal contribution.37,38 subsequently, promax rotation was applied during the exploratory factor analysis to examine inter-factor correlations.37 factor loadings >0.50 were interpreted as strong contributors to the factor structure, whereas loadings <0.50 were considered weak and potentially irrelevant.39–41 reliability a reliability test was conducted to measure the internal consistency of each scale in the questionnaire. the analysis compared cronbach’s alpha coefficient value to a constant value. cronbach’s α >0.90 was categorised as excellent, <0.80 – ≤0.90 as good, <0.70 – ≤0.80 as adequate, <0.60 – ≤0.70 as mediocre, <0.50 – pathways of change, part ii [page 104] [healthcare in low-resource settings 2025;13(s2):13270] figure 1. flow chart of the literature review selection stage. ≤0.60 as poor, and <0.50 as very poor. this reliability test was crucial to ensure that the questionnaire consistently measured what it was intended to measure, thereby making the data produced trustworthy35,36. ethical considerations ethical approval was obtained from the medical and health research ethics committee of the faculty of medicine, sriwijaya university, palembang, an institution accredited by the government in the south sumatra province, indonesia (approval no. 042-2023). participation was voluntary, and informed consent was obtained from all respondents prior to data collection. confidentiality and anonymity of participants were maintained throughout the study. results in the qualitative phase, nine essential elements that can be used as a foundation for gauging the calibre of clinical practice evaluation among nursing students were identified by the literature review analysis. validity, reliability, practicability, objectivity, feasibility, understandability, continuity, propriety, and efficiency are some of these elements. these were found to be essential factors to take into account in order to effectively and consistently measure student skills and significantly improve their clinical competencies throughout the design and implementation of clinical practice evaluations. after that, each element was converted into five questions, yielding a preliminary questionnaire draft with 45 questions. each assessment item was separated into two categories: positive (3 questions) and hostile (2 questions). a likert scale with the following scores was used for each questionnaire item: 1 denotes strong disagreement, two disagreement, three neutrality, four agreement, and five strong agreements. in the quantitative phase, demographic data were gathered to outline the characteristics of the nursing students participating in the study. these data serve to contextualise the findings and ensure the representativeness and appropriateness of the sample for the research objectives. table 1 shows that the respondents in this study were nursing students enrolled in the professional nurse programme, with ages ranging from 21 to 32 years. the mean age was 23.99 years, with a standard deviation of 1.860, indicating that the respondents’ ages were relatively uniform and did not vary significantly from the average. the majority of respondents are female (72.6%), with clinical practice experience of ≥6 months (62.5%). additionally, the academic year of the pathways of change, part ii table 1. demographic characteristics of the respondents. variable min-max = 21-32 (year) mean = 23.99 std. deviation = 1.860 age variable n % gender male 46 27.4 female 122 72.6 clinical practic experience <6 month 63 37.5 ≥6 month 105 62.5 academic year 2023/2024 79 47.0 2022/2023 89 53.0 table 2. component structure and factor loading of each item using a promax rotation. components’ name items factor loading component 1: quality q1. the instructions in the clinical practice evaluation instrument are easy to understand 0.91 q2. the clinical practice evaluation instrument comprehensively covers all clinical activities 0.83 and focuses on assessing clinical competence q3. each activity/competency/skill has its own evaluation instrument 0.82 q4. the clinical practice evaluation instrument produces consistent scores when used repeatedly 0.82 q5. the clinical practice evaluation instrument aligns with the competencies/skills that have been learned 0.69 q6. the clinical practice evaluation process is conducted ethically and respects my rights and dignity 0.63 q7. the assessment in clinical practice evaluation is based on clear criteria 0.58 component 2: constraints q8. the clinical practice evaluation instrument is difficult to access and use 0.91 q9. the clinical practice evaluation instrument is not well stored and/or cannot be accessed again 0.87 q10. clinical practice evaluation is not conducted with consistent procedures 0.85 q11. during evaluation, the clinical instructor (ci)/academic supervisor does not immediately 0.80 fill in/write the scores q12. the assessment by the ci/academic supervisor is influenced by personal closeness to me 0.67 q13. the assessment by the ci/academic supervisor does not cover all the required competencies 0.64 q14. the language used in the clinical practice evaluation instrument is too technical and difficult to understand 0.64 q15. the aspects included in the clinical practice evaluation instrument are too difficult to achieve 0.62 component 3: benefits q16. the clinical practice evaluation instrument greatly helps me achieve the best results 0.89 q17. the evaluation aspects are easy to implement without complicated procedures or excessive preparation 0.69 component 4: practicality q18. the language and structure of the clinical practice evaluation instrument are well-organised and use standard terminology 0.68 q19. the clinical practice evaluation process is simple and not confusing 0.66 q20. the clinical evaluation instrument and aspects are available in the form of a handbook/e-book/technology 0.65 and can be studied in advance q21. the evaluation aspects are well-presented and clearly readable 0.56 component 5:transparency q22. the evaluation process and criteria are clear and accessible to all involved parties 0.76 q23. the assessment results can be viewed in real time 0.66 q24. the clinical practice evaluation instrument and aspects reflect my duties and responsibilities 0.65 [healthcare in low-resource settings 2025;13(s2):13270] [page 105] respondents is fairly evenly distributed between the 2022/2023 (53%) and the 2023/2024 (47%). the content validity analysis of the 45 questions showed that the i-cvi for seven items was 0.83, while the other 38 items had a value of 1.00. the i-cvi for the questionnaire instructions and language was 1.00 each, and for content, it was 0.83. the s-cvi for the questionnaire instructions, content, and language was 0.94, while for all items combined, it was 0.97, indicating that all items were within the excellent range. these results concluded that all items were valid, requiring no deletions, and overall, all questions were excellent and could proceed to the next phase. the content validity analysis began with sampling adequacy testing, indicated by a kmo value of 0.708, which confirmed the data’s suitability for factor analysis. bartlett’s test of sphericity showed a significant result (p=0.000), supporting the appropriateness of the data. the anti-image correlation matrix revealed nine items with msa values <0.5, which were excluded from further analysis, leaving 36 items. subsequently, 12 items with factor loadings <0.5 were also removed. the final analysis showed an improved kmo value of 0.812, and bartlett’s test yielded a chisquare value of 5,655.415 (df = 276; p = 0.000), indicating that the data were highly suitable for factor analysis. based on the scree plot results, five dominant factors exist (figure 2). these five factors collectively account for 85.1% of the variance. the factor loadings for each item are significant and range from 0.56 to 0.91 (table 2). in table 2, each component is named according to the theme of the questions. the first component is named “quality”, with seven question items encompassing validity, reliability, objectivity, understandability, and propriety (items 1-7). the second component is named “constraints” and includes eight questions: validity, reliability, practicability, objectivity, and understandability (items 8-15). the third component, named “benefits”, has two question items that involve elements of feasibility (items 16-17). the fourth component is named “practicality”, with three question items covering practicability and understandability (items 18-21). the fifth component is named “transparency”, with three question items that include elements of propriety and efficiency (items 22-24). these five components or factors are verified with acceptable correlation values (table 3). table 3 presents the factor correlation matrix, illustrating the relationships among the five components identified in the evaluation of clinical practice. the strongest positive correlation is observed between the factors of “practicality” and “transparency” (0.494), indicating that as the evaluation process becomes more practical, transparency in clinical assessment also tends to improve. similarly, the “quality” factor exhibits a moderate positive correlation with “practicality” (0.471) and “transparency” (0.458), suggesting that an enhancement in quality standards is associated with increased feasibility and openness in the evaluation process. conversely, the “benefits” factor shows the weakest correlation with “transparency” (0.154), implying that while benefits exist within clinical evaluation, they do not necessarily enhance transparency in assessment procedures. the “constraints” factor demonstrates a relatively moderate correlation with “transparency” (0.434) and “practicality” (0.318), indicating that although challenges exist in the evaluation process, they may still coexist with efforts to maintain clarity and efficiency in practice. pathways of change, part ii table 3. factor correlation matrix. factor quality constraints benefits practicality transparency quality 1.000 0.180 0.299 0.471 0.458 constraints 0.180 1.000 0.204 0.318 0.434 benefits 0.299 0.204 1.000 0.237 0.154 practicality 0.471 0.318 0.237 1.000 0.494 transparency 0.458 0.434 0.154 0.494 1.000 figure 2. the factor analysis scree plot. [page 106] [healthcare in low-resource settings 2025;13(s2):13270] thus, these findings indicate that the interrelation among the factors supports the effectiveness of clinical practice evaluation, where improvements in quality, practicality, and transparency enhance the evaluation process, while constraints still offer opportunities for targeted improvements. table 3 is referenced to clarify these relationships. the reliability of this questionnaire was evaluated by comparing the cronbach’s alpha coefficient value to a constant value. it is considered acceptable if the cronbach’s alpha coefficient is higher than the fixed value of 0.60. table 4 demonstrates that the reliability of all dimensions in the questionnaire shows excellent internal consistency, with intraclass correlation coefficient (icc) values exceeding 0.60 and statistically significant (p <0.05). the highest icc was found in the quality dimension (0.95), while the lowest was in the benefit dimension (0.76), with an overall icc of 0.94. these results indicate that the developed questionnaire is sufficiently reliable and consistent in assessing nursing students’ perceptions of clinical practice evaluation, making it suitable for use in nursing education contexts. the final version of the clinical practice evaluation quality questionnaire among nursing students can be seen in supplementary materials, table 1. discussion this study aimed to develop and examine the validity and reliability of a questionnaire designed to evaluate the quality of clinical practice among nursing students. the instrument was constructed based on nine essential components identified through a comprehensive literature review, namely: validity, reliability, practicability, objectivity, feasibility, understandability, continuity, propriety, and efficiency, which were operationalised into 45 structured items. content validity analysis indicated that the majority of items achieved an i-cvi score of 1.00, with an overall s-cvi of 0.97, reflecting a very high level of expert consensus. factor analysis revealed five dominant dimensions, thereby confirming the structural validity and strong construct underpinning of the instrument. consequently, the questionnaire was demonstrated to be both reliable and valid for assessing clinical practice in nursing education. moreover, this instrument presents notable distinctions from existing evaluation scales, as it not only assesses clinical competence but also encompasses dimensions such as quality, constraints, benefits, practicality, and transparency. whereas most conventional instruments predominantly focus on skill performance, this tool broadens the assessment scope by incorporating student experiences, ease of use, clarity of evaluation criteria, and fairness throughout the evaluation process. the inclusion of these additional dimensions is intended to more comprehensively measure and enhance the quality of clinical evaluation, while better reflecting the real-world experiences of nursing students during their clinical placements. the results align with previous research highlighting the significance of validity and reliability in clinical evaluation instruments. sellberg et al. (2019)18 and shrestha et al. (2021)41 emphasised that high cvi values indicate expert agreement on an instrument’s relevance. the importance of factor analysis in confirming structural validity has also been established in research by andersson et al. (2020),40 where high factor loadings suggested strong construct validity. additionally, saqr & lópez-pernas (2022)42 argued that intercorrelations among factors in an evaluation tool reinforce its conceptual soundness, which is reflected in the factor correlation matrix of this study. the findings further validate the applicability of reliability theory, where high cronbach’s alpha values indicate good internal consistency.43 one notable unexpected result was the emergence of an additional factor in the factor analysis that was not initially hypothesised. this factor, which may reflect an underlying aspect of clinical evaluation not fully captured in previous models, suggests the need for further investigation. similar findings were reported by hung et al. (2021),44 who observed that certain evaluation dimensions can emerge as distinct constructs during empirical testing. understanding this unexpected factor may provide deeper insights into the complexities of clinical evaluation in nursing education.45 despite its strengths, this study has certain limitations. the sample size, though adequate for factor analysis, may limit the generalisability of the findings across different nursing education settings. previous studies, such as lobiondo-wood & haber (2019),46 have emphasised the importance of diverse and multiinstitutional sampling to enhance external validity. additionally, the reliance on self-reported responses could introduce biases, as students may provide socially desirable answers rather than reflecting actual experiences.47 future studies should consider employing mixed-method approaches, integrating objective clinical performance measures with survey responses to enhance validity. the validated questionnaire has significant practical implications for improving clinical evaluation in nursing education. it provides educators with a structured tool to assess students’ competencies more accurately and identify areas needing improvement. moreover, the instrument could be adapted for use in other healthcare education fields, such as medical and allied health training programs, to standardise clinical assessment methodologies.48 future research should explore the applicability of this questionnaire across different cultural and educational contexts to enhance its universality. additionally, integrating digital platforms for data collection and analysis could improve efficiency and usability, as suggested by tobón and luna-nemecio (2021).43 in conclusion, this study contributes to the development of a pathways of change, part ii table 4. the score and the interclass correlation coefficient (icc) values of the clinical practice evaluation quality questionnaire among nursing students. factor dimensions icc (>0.60) confidence interval 95% p (<0.05) 1 quality 0.95 0.93-0.96 0.00 2 constraints 0.93 0.91-0.94 0.00 3 benefits 0.76 0.68-0.83 0.00 4 practicality 0.89 0.86-0.92 0.00 5 transparency 0.91 0.88-0.93 0.00 total 0.94 0.93-0.96 0.00 [healthcare in low-resource settings 2025;13(s2):13270] [page 107] valid and reliable clinical evaluation tool for nursing students. the findings confirm that the instrument effectively captures key evaluation dimensions, supporting structured and continuous assessments. while the questionnaire has demonstrated strong psychometric properties, further research is recommended to refine its applicability and address its limitations. future studies should investigate its integration with digital assessment platforms and expand its validation in broader educational settings to ensure its long-term relevance and impact. conclusions the findings of this study indicate that the developed questionnaire has been proven to be valid, reliable and effective in evaluating clinical practice among nursing students, with five key factors comprising quality, constraints, benefits, practicality and transparency, which offer valuable insights for enhancing students’ clinical competence. from a practical perspective, the questionnaire serves as a robust tool to support decision-making in nursing education by offering a structured and standardised approach to evaluation; therefore, its use should be accompanied by training for educational institutions and clinical supervisors to ensure accurate and consistent interpretation of scores. the practical implications of this study extend to the development of more transparent and systematic evaluation strategies, and encourage the implementation of intervention programmes such as targeted mentoring, feedback-based learning approaches and improved supervision models. future research is recommended to further validate this questionnaire across various educational and clinical contexts to ensure broader and cross-cultural applicability, and to reconsider the excluded items to better accommodate the complexity of nursing practice. to maximise the impact of these findings, policymakers, educators and accreditation bodies in nursing education should consider adopting or adapting this instrument as part of their evaluation frameworks in order to foster a more equitable, consistent and effective assessment of clinical competencies. references 1. zolkefli y. moral courage and the role of nursing education. malaysian j nurs 2022;13:10–1. 2. hustad j, johannesen b, fossum m, hovland oj. nursing students’ transfer of learning outcomes from simulation-based training to clinical practice: a focus-group study. bmc nurs 2019;18:1–8. 3. nguyen j, smith l, hunter j, harnett je. conventional and complementary medicine health care practitioners’ perspectives on interprofessional communication: a qualitative rapid review. medicina (kaunas) 2019;55:650. 4. elvira m, aulia f, hidayati, et al. developing a 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a sample of newly graduated registered nurses – a confirmatory factor analysis. nurse educ today 2023;128:105889. 41. shrestha r, kadel r, mishra bk. a two-phase confirmatory factor analysis and structural equation modelling for customerbased brand equity framework in the smartphone industry. decis anal j 2023;8:100306. 42. saqr m, lópez-pernas s. learning analytics methods and tutorials. cham: cham: springer nature switzerland; 2024. 43. tobón s, luna�nemecio j. complex thinking and sustainable social development: validity and reliability of the complex�21 scale. sustainability 2021;13:6591. 44. hung cc, kao hfs, liu hc, et al. effects of simulation-based learning on nursing students’ perceived competence, self-efficacy, and learning satisfaction: a repeat measurement method. nurse educ today 2021;97:104725. 45. tonapa si, mulyadi m, ho khm, efendi f. effectiveness of using high-fidelity simulation on learning outcomes in undergraduate nursing education: systematic review and meta-analysis. eur rev med pharmacol sci 2023;27:444–58. 46. lobiondo-wood g, haber j. nursing research: methods and critical appraisal for evidence-based practice. st. louis, missouri: elsevier inc; 2019. 47. reebals c, wood t, markaki a. transition to practice for new nurse graduates: barriers and mitigating strategies. west j nurs res 2021;44:416-29. 48. mills ge, jordan aw. educational research: competencies for analysis and applications. 13th ed. new jersey: new jersey: pearson education, inc.; 2022. pathways of change, part ii [healthcare in low-resource settings 2025;13(s2):13270] [page 109] online supplementary materials table 1. final version of the clinical practice evaluation quality questionnaire among nursing students. hrev_master healthcare in low-resource settings 2024; volume 12(s1):13023 examining the onset and cessation patterns of active smoking among college students: an interpretative analysis tri astuti sugiyatmi,1 lukman handoko,2 alfrid sentosa,3 fitriyanti fitriyanti,4 sri mulyani5 1faculty of health sciences, universitas borneo tarakan, tarakan, north kalimantan; 2occupational health and safety politeknik perkapalan negeri surabaya, east java; 3faculty of social science and political science, pgri university palangka raya, palangkaraya, central kalimantan; 4health polytechnic ministry of health jakarta ii, jakarta; 5department of nursing, stikes rajekwesi bojonegoro, east java, indonesia abstract smoking is a prevalent global issue, with a significant risk factor for various non-communicable diseases necessitating prolonged, costly, and potentially devastating medical treatments. in addition, infectious diseases such as tuberculosis, covid-19, and pneumonia in toddlers are often associated with active and passive smoking habits. the correlation is evident across diverse demographics, encompassing individuals of varying ages, professions, and genders. therefore, this research aimed to explore and describe behavior of active smokers among campus members at various universities, focusing on the initiation, cessation, and influencing factors associated with smoking. a qualitative research design was used with a hermeneutic phenomenological approach, where information was provided by five active smoker informants. these individuals started smoking as teenagers, and the fluctuating patterns were influenced by health concerns or a perceived lack of significance attributed to smoking. however, the periods of abstinence were only temporary due to the pervasive influence of social and environmental factors. the initiation of smoking commonly started from the influence of close acquaintances, such as family members. meanwhile, the process of quitting encountered numerous obstacles, primarily from potent social factors outweighing personal intentions. the implementation of smoking cessation strategies posed challenges due to the profound impacts of addiction, requiring unwavering determination, comprehensive plans, and diligent efforts. introduction cigarettes and smoking behavior are risk factors for various chronic degenerative non-infectious diseases such as hypertension,1 heart disease, and stroke,2 diabetes mellitus,3 chronic obstructive pulmonary disease,4 and various types of cancer.5 these conditions are collectively classified under non-communicable diseases (ncds).6 cigarettes are recognized as a risk factor for acute disease among second-hand smokers, such as pneumonia in toddlers.7-9 in addition, smoking is also a risk factor for contracting covid-19 with evidence showing elevated rates of hospitalization, severity, and mortality.10-12 cigarettes serve as a gateway to drug use and result in significant economic losses.13 according to data from the world health organization (who) in 2021, more than 80% of the 1.3 billion tobacco smokers worldwide resided in countries with low and middle incomes. furthermore, results from the 2021 global adult tobacco survey (gats) reported that 34.5% of the indonesian population were adult smokers, totaling 70.2 million. over the past decade, there has been a significant increase in the number of adult smokers, rising from 8.8 million out of a population of 60.3 million in 2011 to 69.1 million in 2021. this increase represents approximately 28.96% of the population, as reported by the central statistics agency.14 the absence of indonesia’s ratification of the framework convention on tobacco control (fctc) has contributed to the normalization of cigarettes and smoking behavior among members of the academic community, and this normalization has pervasive effects.15 to mitigate the widespread distribution of tobacco products, government regulation no. 109 of 2012 concerning the safeguarding of materials containing addictive substances in the form of tobacco products for health mandates the establishment of smoke-free zones, known as “kawasan tanpa rokok” (ktr). these zones include various locations, such as educational institutions, health facilities, children’s playgrounds, places of worship, and public transportation areas. in the designated zones, the presence of ashtrays, smoke, odor, cigarette butts, advertisements, and the sale of cigarettes is strictly forbidden. the regulation shows the commitment to improving environments that promote public health and prevent tobacco use.16 the college campus is an important site for the facilitation of teaching and should be officially designated as a smoke-free zone. in light of these regulations, educational institutions, and the administrations, are expected to show compliance. campuses are integral components of higher education and are duty-bound to adhere to the mandate. despite the majority of students being of legal adult age, ensuring the well-being of all parties remains important, showing the rationale behind the implementation of non-smoking areas across campus environments. significance for public health the investigation into active smoking among campus residents represents a significant contribution to public health. in addition to outlining daily smoking habits, insights are also provided into smoking initiation and cessation strategies. furthermore, this research offers different perspectives concerning the reactions to smoking prohibition signage. the results are poised to equip policymakers on campus with valuable data to initiate the implementation of health-promoting policies. [page 4] [healthcare in low-resource settings 2024;12(s1):13023] in practice, appropriate tobacco control regulations (ktr) conducive to the educational environment have not been enacted in numerous academic institutions. campuses with a focus on health sciences remain deficient in implementing or overseeing ktr, despite the explicit stipulations outlined in government regulation no. 109 of 2012. the prevalence and exposure to passive smoking in universities can be reduced with the assistance of tobacco control programs.17 in this context, basic information is collected from staff and students, to assess behavior and attitudes related to the implementation of tobacco control policies throughout campus.18-21 therefore, this research aims to observe and describe the experiences of active smoking by students, lecturers, and educational staff, focusing on the initiation, cessation, and the associated influencing factors. materials and methods the research adopted a qualitative method using a hermeneutic phenomenological approach to comprehend the processes by which campus members initiate smoking, the nature of current habits, and inclinations toward cessation. purposive sampling was used to select participants, comprising active smokers from various campus constituencies such as students, faculty, and administrative staff. meanwhile, individuals who declined to participate in the research were excluded. the participants were drawn from three distinct cities, namely surabaya, tarakan, and palangkaraya. the research used semi-structured, in-depth interviews conducted through face-to-face, telephone, or video calls, based on the preference of the participant, supplemented by non-participant observation of the activities. subsequently, interviews were recorded, transcribed, and analyzed. before commencement, informed consent was obtained from all participants, and the interview sessions commenced in early 2023 following approval. interpretative descriptive techniques were used to explore the data related to smokers’ experience regarding the initiation, cessation, and associated influencing factors. in addition, the results were audio recorded and transcribed, as well as analyzed using a flexible seven-step interpretative phenomenological analysis (ipa) approach. manual method of analysis was adopted using the following steps: i) repeatedly reading the transcript compiled from the interview results, ii) checking the meaning of the words and the language used at the exploratory stage, iii) developing themes, iv) looking for the same relationships between themes, v) moving to the next case, v) obtaining similar patterns between cases, and 7vii) describing the main theme. the three main questions that the participants were asked were: i) when did you start smoking and what was your experience? ii) how is your current smoking behavior and what are the supporting and inhibiting factors? iii) how do you plan to quit smoking?” results and discussion table 1 presents the demographic characteristics of the study participants, including gender, age, marital status, occupation, education, and faculty origin. based on data analysis from interview transcripts, three main themes were found, with 12 super-ordinate themes. a summary of the main and super-ordinate themes can be seen in table 2. table 3 shows the current smoking behavior of informants. first theme: beginning to smoke the initial exposure to smoking typically commenced with 4th international nursing and health sciences symposium table 1. characteristics of informants. initial name gender age marital status occupation education faculty x female 20 y.o unmarried student senior high school health sciences y male 31 y.o married administra-tive staff s1 non health sciences non-health sciences (safety enginee-ring) z male 43 y.o married lecturer s2 non-health sciences a male 19 y.o unmarried student senior high school health sciences (safety enginee-ring) b male 19 y.o unmarried student senior high school health sciences (safety enginee-ring) table 2. summary of main themes and the superordinate themes. main theme superordinate themes beginning to smoke first experience family influence closest circle and environment influence current smoking behavior perception place and companion while smoking number of cigarette to consume everyday influence of advertisement or pictorial health warning plan to stop smoking be addicted effort to reduce/stop smoking intention to stop smoking [healthcare in low-resource settings 2024;12(s1):13023] [page 5] experimentation, where some participants perceived the act as a fashionable way to expand social circles. conversely, the influence of peers led to the adoption of similar smoking behaviors, resulting in addiction.22-23 “.....at first i tried it, it felt good”… (inf 1) “it looks cool or to add to the social circle of friends like that. to hang out with friends, but i started to try smoking early”… (inf 2) “...it started with trial and error because a friend brought me, finally became addicted until now, i have been smoking since i was 13 or 14 years old when i was still at school” (inf. 3) ...” i also followed it from friends, from the environment. at first i didn’t know how to smoke, but then i tried it. over time, i got addicted”… (inf 4) “i started smoking recently, since i was 18 years old, about 6 months ago, after the announcement of smptn, i had a lot of free days and i often hung out with friends. finally, i was influenced by a friend, i tried it, and it was delicious. as far as i know, most people smoke because of prestige, not because they have problems”… (inf 5) family influence the influence of the family, particularly fathers, significantly impacts children and adolescents in smoking behavior. for instance, participant 3’s father, being a smoker, serves as a role model, thereby enhancing a predisposition towards active smoking. this phenomenon suggests a pattern where smoking behavior is perpetuated across generations through emulation within the family environment or the patron-client relationship with the father figure.24 “i was able to become active smoker at first because of my family environment. my father was a smoker and the (people) in the surrounding environment. although i put limitation and prohibition on my children not to smoke.... in the end my child is a smoker too like us because of his relationships and environment”… (inf 3) the influence of family and environment plays an important role in shaping smoking behavior. even though parental admonitions are important, the efficacy may be diminished when there is no frequency and substantive, logical reasoning. in this context, the pervasive influence of the environment often outweighs warnings, showing the profound impact of surroundings on individuals’ smoking habits. “i started smoking when i was in junior high school, in grade 2, following a friend’s advice. at first, i didn’t know smoking, then a friend said to me, “bro, let’s try it. “ i started smoking when i was in 2nd grade of junior high school. once my parents found out it, they scolded me, but after a while, my parents got over it themselves”… (inf 4) circle or closest environment influence peer groups and the immediate environment contribute to the formation of smoking habits.25 “at first, i didn’t smoke and didn’t want to smoke. but my environment, namely my friends, all smoke. they offer me a cigarette, even though they don’t force me to smoke”... (inf 1) “when i started college, i saw my friends smoking. that is in 2009”… (inf 2) “there was a close friend who asked me to smoke cigarettes and i finally tried it. i’m smoking until now. my father is a smoker too”… (inf 5) second theme: current smoking behavior perception the perception of smokers who felt positive about cigarettes and smoking habits can be shown by these various comments.26-27 “when you have something heavy to think about, get smoking! you’ll feel a little relieved”… (inf 1) “when you don’t smoke, you feel stuck, you can’t think anything. it seems that smoking can also be a way to find inspiration”… (inf 2) “if you don’t smoke, you usually feel dizzy as if something is missing and the mood to think is lost”… (inf 3) “ in the past time, i didn’t know the reason for smoking, but now the number one reason why i’m smoking is for pleasure. if i don’t smoke it’s like that something is missing. the number two is that when i’m smoking, it is like that i find a friend to talk to. in a situation when i have a problem, and there is no one to accompany me and no one to talk to. sometimes when i tell the problem to friends they will tell it to others. in short, smoking is to keep the problem hidden”… (inf 4) “i usually smoke after completing tasks, it feels good and relaxing to smoke”… (inf 5) places and companions signs prohibiting smoking serve an important function by dissuading smokers. however, for heavy smokers, opportunities to smoke persist in solitary settings or company of friends, regardless of the presence of the signs.28 “i smoke only when i’m in the boarding house or at home”… (inf 1) “i smoke almost all the time and everywhere: at home, meeting 4th international nursing and health sciences symposium table 3. current smoking behavior. initial when start smoking first cigarette to smoke the next smoking companion number of in the day cigarette to smoke in a day x 19 y.o just after wake up in the morning anytime or at every free time alone or with friends 1-2 packs y 18 y.o after breakfast after meal and break time alone or with friends 1 pack z 13 y.o just after wake up in the morning any time alone or with friends 2 packs a 6 y.o after breakfast after school time alone or with friends 2-5 pieces b 18 y.o after lunch evening alone or with friends 6 pieces [page 6] [healthcare in low-resource settings 2024;12(s1):13023] friends, on the street, and at work. i will always smoke”… (inf 2). “i also smoke on campus because there are no signs prohibiting it”… (inf 3) “so far i have never smoked in a place with a no smoking sign. if there are signs prohibiting smoking then i will leave, look for another place”… (inf 4) “i have never smoked in a place where it is prohibited”… (inf 5) number of cigarettes to consume everyday the daily consumption of individuals varies significantly in terms of quantity, brand, type, and associated costs. individuals tend to consume larger quantities to satisfy cravings due to increased levels of addiction.29 “now i can consume 1-2 packs per day”… (inf 1) “when i started smoking, i smoked when i had finished eating. in the beginning, i consumed just three or four cigarettes. after one year the consumption increased, even more until it reached the second year. i think in the second or third year it could be one pack a day, around twelve to sixteen sticks”… (inf 2) “in a day i can consume 2 packs of cigarettes. the expenditure in 1 month is usually uncertain because let’s just say it consumes 60 packs each month”… (inf 3) “i usually smoke a cigarette after breakfast, then come home from campus in the afternoon, usually 1 cigarette or 2, and 1 at night”….(inf 5) “in a day i usually smoke 6 sticks of cigarette; usually after lunch and it continues until evening”… (inf 5) kinds of cigarette the preference for filter cigarettes over “kretek” is often observed for various reasons, with health considerations being particularly important. despite the inherent health risks associated with all types, individuals may prefer filter cigarettes due to the perception of posing a comparatively lesser risk to health.30 “the type of cigarette i choose is the available one, if it’s an expensive one like (mention a certain type/brand of cigarette) the one without a filter, that’s fine. but it is often to use filters. it’s healthier because there is a sieve or filter to filter out poisons, maybe”… (inf 3) “i usually smoke filter cigarettes, not the “kretek” ones (which are without filter) because cigarette has a filter. i think “kretek” one doesn’t taste good. nicotine and tar can go straight into the mouth. but if it’s filtered, it has a filter and the taste is sweeter”… (inf 4) “i prefer the s brand which has coffee flavor. usually, i choose a cigarette with a filter, because the “kretek’ is easy to make me cough. if i consume it too much, my throat will easily become inflamed”… (inf 5) expense for students without personal income, the price of cigarettes serves as a significant deterrent against smoking. conversely, individuals with personal income, regardless of social status, tend to show higher levels of consumption on average. “parents know our expense for smoking. usually, they said to not smoke too much because i could not earn money yet (because i did not have any job yet). it’s as economical as possible. if a pack of filter cigarettes costs 25,000, so if you take 4 sticks a day, it means that you can spend 10 thousand rupiah”… (inf 4). third theme: cessation of smoking quitting smoking poses a significant challenge for addicted individuals and the attempts are prompted by health concerns or financial strain. however, for smokers who have not committed to cessation, financial burden and the clear warnings on cigarette packaging serve as effective deterrents to continued smoking. addiction “there is indeed a desire to reduce smoking and to be able to stop, but for now it is very difficult to give it up because it is tied to the addictive taste of cigarettes”… (inf 1). “because smoking is ingrained in me, it tends to be that if i don’t smoke for a long time, between 1 and 2 hours, i will get dizzy and my concentration will be decreased due to not smoking”… (inf 3) efforts to reduce or to stop smoking “the expenses are increasing, so i want to stop”… (inf 1) “there are plans to stop, but for now i’m still just reducing the consumption because i’m getting older. i still don’t know about the disease (which i will suffer because of it), but when i wake up in the morning i usually have a cough. hopefully, in the future i can get rid of the addictive taste of cigarettes”… (inf 2) “there are also efforts to reduce smoking because there is a fear that my child will follow smoking behavior of his parents, specifically me. but i don’t know for sure when i will stop. even though i have heart disease and have had a ring installed, i don’t know when i want to stop smoking”… (inf 3). “i have the intention that i will stop smoking when i have a wife, but now i am still undecided whether i want to stop or i do not want to stop. sometimes i don’t smoke for 2 days but then the next day i look for another cigarette”… (inf 4) “to stop, i haven’t any plan about it and i don’t know when to stop”… (inf 5) low intention to stop smoking “i want to stop smoking, but it depends on my environment. so it’s still hard to quit smoking right now”… (inf 1) “i felt that smoking wasn’t worth it but in the end, i went back because i was working on a project and there were also environmental impacts”… (inf 2) other factors influencing smoking habit pictorial health and written warning many graphic warnings on cigarette packs are reported to have little impact on smoking habits due to a variety of reasons. meanwhile, several responses were provided when participants were questioned about the impressions of pictorial warnings on cigarette packs.31 “i choose a cigarette pack with a picture of a smoker with a hole in his neck. at first i was afraid but now i’m not afraid anymore, because i’m used to it”… (inf 1) “it doesn’t matter, even though i have a friend who has had a hole in his throat because of smoking, but it doesn’t matter that i am still smoking, even though i know the dangers, i continue to smoke. some people who don’t smoke can get sick anyway, so they won’t be affected by those pictures”… (inf 2) “visual messages on cigarette packs do not affect the desire to smoke or to quit if you are used to smoking, in my opinion, the social environment is more dominant”… (inf 3) “i know that advertisements like “smoking kills you” and “it can cause impotence” remind me of the dangers of smoking. but 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13023] [page 7] because i have been addicted to cigarettes, it is difficult not to smoke anymore”… (inf 4) “we are only responsible for ourselves. the point is, it only doesn’t affect me... warning images are on every cigarette pack except for homemade cigarettes. but it doesn’t affect me either”… (inf 5) qualitative research contributes significantly to the understanding of active smokers on campus, analyzing the diverse factors related to initiation and cessation. the results show that the age of the onset for smoking among participants varied widely from junior high school to college years as university students. despite the perception that students, typically aged over 18, are considered adults, this does not imply implicit permission for smoking. however, the prevailing situation often reflects a relaxed attitude towards smoking. this is evident in the proliferation of cigarette butts and the commonality of smoking behavior with minimal restrictions in place. in this research, female representation as informants was challenging to recruit compared to men. in line with other previous results, female and male smokers were identified simultaneously (27). the perceptions among female smokers did not center on concerns regarding the risks of mortality or addiction but on positive associations with smoking activities. campus, as an educational institution, has the responsibility of implementing smoke-free zones or “ktr” but there remains inconsistency in the enforcement. in non-health campuses, the absence of signposts prohibiting smoking and designated nonsmoking areas (ktr) is important. despite the educational nature of campuses, adherence to regulations governing tobacco control is crucial and requires consistent enforcement. addicted students, staff, and lecturers frequently indulge in smoking on campus. this behavior is particularly evident in areas where there are no signs showing campus as a ktr zone. the preferred locations for smoking are secluded corners obstructed by walls or staircases, away from parking lots. the presence of signs and prohibitions is crucial since the absence provides a sense of freedom to smoke among campus residents. the perception that smoking is fashionable and serves as a coping mechanism for stress relief and inspiration is widely accepted, enticing many individuals to become active smokers. this is often reinforced by attractive and misleading advertising signs. the context refers to the direct acceptance or uptake of something, influenced by sensory experiences. perceptions regarding smoking, behavior, and the enforcement of ktr in educational settings are connected to patterns of attitudes concerning smoking habits.32-33 the positive perception of smoking among participants progressively reinforced favorable attitudes toward behavior. therefore, the overpowering factor of nicotine addiction is often considered during pain or diagnosis of sickness. instances of heart disease among participants occurred at 40 years of age, which is younger than the average age of developing the conditions, typically at 45 or older.6 in addition, heart disease diagnosis failed to prevent smoking habit of a participant since the act was resumed after a definitive therapy.16,34 efforts to cease smoking remain a significant challenge for active smokers on campus. therefore, a proactive role must be assumed in tobacco control by instituting designated no-smoking areas. this measure would effectively limit the areas where active smokers can indulge in the habit. additionally, the installation of signs is crucial in improving a healthy campus environment. many valuable lessons can be obtained through the successful implementation of ktr.35-37 conclusions in conclusion, this research was carried out to explore the factors contributing to individuals becoming active smokers, with a particular focus on social interactions and familial influences within the immediate environment. the awareness and acknowledgment of health and financial consequences associated with smoking habits were examined. however, there was a tendency to disregard the issue concerning active smokers. the implementation of smoking cessation strategies proved challenging due to the profound impacts of addiction without a resolute determination, comprehensive plans, and diligent efforts. this study is limited by the constraints of qualitative research, which generally hinders the generalization of results. furthermore, the participants were drawn from diverse campuses in different cities, encompassing various types and classes. references 1. virdis a, giannarelli c, neves mf, et al. cigarette smoking and hypertension. curr pharm des 2010;16:2518-25. 2. benjamin ej, blaha mj, chiuve se, et al. heart disease and stroke statistics’2017 update: a report from the american heart association. circulation 2017;135:146–603. 3. hu fb. globalization of diabetes: the role of diet, lifestyle, and genes. diabetes care 2011;34:1249–57. 4. stanaway jd, afshin a, gakidou e, et al. global, regional, and national comparative risk assessment of 84 behavioural, environmental and occupational, and metabolic risks or clusters of risks for 195 countries and territories, 1990-2017: a systematic analysis for the global burden of disease stu lancet 2018;392:1923–94. 5. islami f, goding sauer a, miller kd, et al. proportion and number of cancer cases and deaths attributable to potentially modifiable risk factors in the united states. ca cancer j clin 2018;68:31–54. 6. sumartono w, sirait am, holy m, thabrany h. smoking and socio-demographic determinant of cardiovascular diseases among males 45+ years in indonesia. int j environ res public health 2011;8:528–39. 7. rigotti na, clair c. managing tobacco use: the neglected cardiovascular disease risk factor. eur heart j 2013;34:3259–67. 8. yankelevitz df, henschke ci, yip r, et al. second-hand tobacco smoke in never smokers is a significant risk factor for coronary artery calcification. jacc cardiovasc imaging 2013;6:651–7. 9. tazinya aa, halle-ekane ge, mbuagbaw lt, et al. risk factors for acute respiratory infections in children under five years attending the bamenda regional hospital in cameroon. bmc pulm med 2018;18:1–8. 10. jordan re, adab p, cheng kk. covid-19: risk factors for severe disease and death. bmj 2020;368:1–2. 11. ahmed n, maqsood a, abduljabbar t, vohra f. tobacco smoking a potential risk factor in transmission of covid-19 infection. pakistan j med sci 2020;36:s104–7. 12. dai m, tao l, chen z, tian z, et al. influence of cigarettes and alcohol on the severity and death of covid-19: a multicenter retrospective study in wuhan, china. front physiol 2020;11:1–6. 13. ekpu vu, brown ak. the economic impact of smoking and of reducing smoking prevalence: review of evidence. tob 4th international nursing and health sciences symposium [page 8] [healthcare in low-resource settings 2024;12(s1):13023] use insights 2015;8:tui.s15628. 14. world health organization. who global report on trends in prevalence of tobacco use 2000 2025 fourth edition. world health organization 2021. 150 p. available from: http://apps.who.int/bookorders 15. achadi a, soerojo w, barber s. the relevance and prospects of advancing tobacco control in indonesia. health policy (new york) 2005;72:333–49. 16. world health organization (who). who report on the global tobacco epidemic, 2019. offer help to quit tobacco use [internet]. geneva: world health organization. 2019. 1–209 p. available from: https://www.who.int/teams/healthpromotion/tobacco-control/who-report-on-the-global-tobaccoepidemic-2019 17. bartington se, wootton r, hawkins p, et al. smoking behaviours and attitudes towards campus-wide tobacco control policies among staff and students: a cross-sectional survey at the university of birmingham. bmc public health 2020;20:1–9. 18. braverman mt, geldhof gj, hoogesteger la, johnson ja. predicting students’ noncompliance with a smoke-free university campus policy. prev med (baltim) 2018;114:209–16. 19. seo dc, macy jt, torabi mr, middlestadt se. the effect of a smoke-free campus policy on college students’ smoking behaviors and attitudes. prev med (baltim) 2011;53:347–52. 20. sabrian f, utomo w. perceptions of students, lecturers and staffs on establishing a smoke-free campus. enferm clin 2019;29:42–5. 21. mohmad s, ismail a, ks h, et al. comparison and determination of factors associated with smoking status, smoking knowledge, attitude and practice (s-kap) between smoke-free and non-smoke-free campuses in public universities in malaysia: a cross-sectional study. bmj open 2022;12:1–12. 22. morrell her, song av, halpern-felsher bl. predicting adolescent perceptions of the risks and benefits of cigarette smoking: a longitudinal investigation. heal psychol 2010;29:610– 7. 23. swan av, creeser r, murray m. when and why children first start to smoke. int j epidemiol 1990;19:323–30. 24. tilson ec, mcbride cm, lipkus im, catalano rf. testing the interaction between parent–child relationship factors and parent smoking to predict youth smoking. j adolesc heal 2004;35:182–9. 25. harakeh z, vollebergh wam. the impact of active and passive peer influence on young adult smoking: an experimental study. drug alcohol depend 2012;121:220–3. 26. dinh kt, sarason ig, peterson av, onstad le. children’s perceptions of smokers and nonsmokers: a longitudinal study. heal psychol 1995;14:32–40. 27. lundborg p, andersson h. gender, risk perceptions, and smoking behavior. j health econ 2008;27:1299–311. 28. ritchie d, amos a, martin c. public places after smoke-freea qualitative exploration of the changes in smoking behaviour. heal place 2010;16:461–9. 29. bjartveit k, tverdal a. health consequences of smoking 1-4 cigarettes per day. tob control 2005;14:315–20. 30. nuryunarsih d, lewis s, langley t. health risks of kretek cigarettes: a systematic review. nicotine tob res 2021;23:1274–82. 31. ratih sp, susanna d. perceived effectiveness of pictorial health warnings on changes in smoking behaviour in asia: a literature review. bmc public health 2018;18:1–16. 32. petrescu dc, vasiljevic m, pepper jk, et al. what is the impact of e-cigarette adverts on children’s perceptions of tobacco smoking? an experimental study. tob control 2017;26:421–7. 33. murphy-hoefer r, alder s, higbee c. perceptions about cigarette smoking and risks among college students. nicotine tob res 2004;6(suppl. 3). 34. grobe je, goggin k, harris kj, et al. race moderates the effects of motivational interviewing on smoking cessation induction. patient educ couns 2020;103:350–8. 35. ickes mj, rayens mk, wiggins a, hahn ej. students’ beliefs about and perceived effectiveness of a tobacco-free campus policy. policy polit nurs pract 2017;18:17–25. 36. ickes m, gokun y, rayens mk, hahn ej. comparing two observational measures to evaluate compliance with tobacco-free campus policy. health promot pract 2015;16:210–7. 37. glassman tj, reindl dm, whewell at. strategies for implementing a tobacco-free campus policy. j am coll heal 2011;59:764–8. 4th international nursing and health sciences symposium correspondence: tri astuti sugiyatmi, faculty oh health sciences, universitas borneo tarakan, north kalimantan, indonesia. jl. amal lama no 1 pantai amal, tarakan, north kalimantan, indonesia, postcode: 77115. tel.: +628115307023 e-mail: triastuti@borneo.ac.id key words: active smoker; cigarette;smoking behavior contributions: the authors contributed equally. tas, conceptualization; tas, luh & als, data curation; tas, luh, als, methodology; fit, smu, supervision; tas, validation and writing–review and editing. conflict of interest: the author declares no potential conflict of interest. funding: this research received no external funding. clinical trials: not applicable. ethics approval: this study complied with ethical standards and received approval from the health research ethics committee, faculty of public health, airlangga university. it has been determined ethically acceptable under the identity number 10/kepk-fikes ubt/vi/2022. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors are grateful all of the participants who voluntarily participated in the research. received: 3 november 2023. accepted: 8 june 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13023 doi:10.4081/hls.2024.13023 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [healthcare in low-resource settings 2024;12(s1):13023] [page 9] hrev_master [page 64] [healthcare in low-resource settings 2022; 10:10806] evaluation of errors during susceptibility reporting of glycopeptide antibiotics for enterococcal isolates on sole basis of widely used disk diffusion test vikas saini, nisha goyal, narendra pal singh, meenakshi goswami department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi, india abstract in resource limited settings, very often susceptibility reports glycopeptide antibiotics are released only on the basis of disk diffusion test. determination of mic by either e-strips or microbroth dilution tests can be of paramount importance in checking the errors that may have incurred with the singular use of disk diffusion tests. distribution of errors in vancomycin and teicoplanin susceptibility reporting by disk diffusion test was evaluated in comparison with mic determination with reference method of e-strip. a total of 40 isolates of enterococcus species were obtained during the study period. in vancomycin susceptibility reporting, very major errors, major errors and minor errors were observed in 33.3%, 5.4% and 5% instances respectively. for teicoplanin, major errors were observed in 5.3% of instances. e test can be used in conjunction with disk diffusion where resources are limited. we have observed that by using a combination of both disk diffusion and mic determination by e-strip methods for glycopeptide antibiotics, a majority of reporting errors can be addressed. introduction enterococci were previously considered commensal organisms of little clinical importance but have emerged as serious nosocomial pathogens responsible for infections of bloodstream, meninges, urinary tract, biliary tract, wounds and endocarditis.1 commonly used glycopeptide antibiotics of vancomycin and teicoplanin have a crucial role in the management of severe infections due to enterococci in cases where patients are resistant or allergic to beta-lactam group of antibiotics.2-4 plasmidmediated resistance to these glycopeptide antibiotics, vancomycin and teicoplanin, was first detected in 1986.5,6 resistant enterococcal strains responsible for colonization7-9 or infection10 have been isolated with increased incidence in current times. in vitro vancomycin and teicoplanin susceptibility can be determined by disk diffusion, agar dilution, e-test, broth microdilution and automated antimicrobial susceptibility testing methods.11 the disk diffusion test is done by measuring the zones of growth inhibition that result when fixed concentrations of an antibiotic diffuse from impregnated disk onto an agar plate, which has previously been inoculated with the test organism. after proper incubation the inhibitory zones around the disk are measured and interpreted as resistant, intermediate and sensitive. the e-test combines diffusion with the ability to establish a minimum inhibitory concentration (mic) or breakpoint result. it is based on diffusion of a antimicrobial gradient from coated strips onto an agar surface inoculated with the test organism. mic value is recorded directly from a scale on the strip in terms of µg/ml at the point where zone of growth inhibition intersects the strip.12 in resource limited settings, very often the susceptibility reports to these glycopeptide antibiotics are released only on the basis of disk diffusion test. determination of mic by either e-strips or microbroth dilution tests can be of paramount importance in checking the errors that may have incurred with the singular use of disk diffusion tests. the use of e-strips is less labor intensive and can be easily incorporated in routine testing even in high volume centers with restricted logistics. this study was planned to evaluate the errors during susceptibility reporting of glycopeptide antibiotics on sole basis of widely used disk diffusion test. material and methods this prospective study was conducted in the department of microbiology of a tertiary care hospital of delhi over a period of six months extending from january 2022 to june 2022. all isolates of enterococcus species obtained from wound aspirates were included in the study. all isolates of enterococcus were identified and tested for their antimicrobial susceptibility patterns according to clinical laboratories standards institute (clsi) guidelines. antimicrobial susceptibility to vancomycin & teicoplanin in enterococcal isolates were performed using two methods, kirby-bauer disk diffusion technique and e-test method of minimum inhibitory concentration (mic) testing. clsi has defined susceptible (s), intermediate (i), and resistant (r) breakpoints for vancomycin against enterococci for both disk diffusion (≥17 mm, s; 15-16 mm, i; <14 mm, r) dilution mic testing (≤4µg/ml, s; 8-16 µg/ml, i; ≥32µg/ml, r) and for teicoplanin by disk diffusion (≥14 mm, s; 11-13 mm, i; ≤10 mm, r) and dilution mic testing (≤8µg/ml, s; 16 µg/ml, i; ≥32µg/ml, r).13 e-test (himedia laboratories, mumbai, india) was performed following clsi guidelines.13 healthcare in low-resource settings 2022; volume 10:10806 correspondence: nisha goyal, department of microbiology, university college of medical sciences & guru teg bahadur hospital, delhi. e-mail: drnishagoyalucms@gmail.com key words: enterococcus; glycopeptide antibiotics; vancomycin; teicoplanin. funding: none. conflict of interest: the authors declare no conflict of interest. availability of data and materials: all data generated or analyzed during this study are included in this published article. ethics approval and consent to participate: not applicable. informed consent: not applicable. this study used only the samples received in the lab for routine susceptibility testing and no other sample was collected for the purpose of this study. patients were not identified or visited at any point of time. received for publication: 20 august 2022. revision received: 12 december 2022. accepted for publication: 12 december 2022. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2022 licensee pagepress, italy healthcare in low-resource settings 2022; 10:10806 doi:10.4081/hls.2022.10806 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. non -co mmerc ial us e o nly [healthcare in low-resource settings 2022; 10:10806] [page 65] standard kirby bauer disk diffusion method was also used for determining the susceptibility of the isolates to the commonly used antibiotics against enterococcus spp. the antibiotic disks that were used to identify the susceptibility pattern of the enterococcus spp. were ampicillin (10 µg), ciprofloxacin (5 µg), high level gentamicin (120 µg), tetracycline (30 µg), vancomycin (30 µg), teicoplanin (30 µg), linezolid (30 µg; himedia laboratories, mumbai, india) and results were interpreted as per the latest clsi guidelines.13 distribution of errors in vancomycin and teicoplanin susceptibility reporting by disk diffusion test was evaluated in comparison with mic determination with reference method of e-strip. very major errors were defined as method in which the test result was susceptible and the reference method result was resistant. major errors were defined as errors in which the test method result was resistant and the reference method result was susceptible, and minor errors were defined as those in which either method reported a result as intermediate and the other method reported the result as susceptible or resistant.14 results a total of 40 isolates of enterococcus species were obtained during the study period. table 1 shows the demographic profile of the patients with enterococcal isolates. male is to female ratio was 0.67, showing a female preponderance. over 50% of patients belonged to 20-40 years age-group. out of 40 isolates, 38 isolates were enterococcus faecalis and 2 isolates were e. faecium. figure 1 depicts the distribution of susceptibility to commonly used antibiotics among enterococcus spp. isolates. 92.5% of enterococcus spp. isolates were susceptible to vancomycin and 95% were susceptible to teicoplanin by disk diffusion method. tables 2 and 3 show the distribution of errors in vancomycin and teicoplanin susceptibility reporting by singular use of disk diffusion method respectively. in vancomycin susceptibility reporting, very major errors, major errors and minor errors were observed in 33.3%, 5.4% and 5% instances respectively (table 2).for teicoplanin, major errors were observed in 5.3% instances (table 3). discussion drug resistance has far reaching impacts on global healthcare. various studies have reported widely prevalent drug resistance among gram positive as well as gram negative organisms.15,16 in line with other studies, enterococcus faecalis was predominant among enterococcal species in the present study.17,18 though widely used, issue of false vancomycin resistance reporting with disk diffusion method is a concern,19 prompting several manufacturers to issue alerts regarding the detection of vancomycin and teicoplanin resistant organisms. the current study reported very major, major and minor errors of 33.3%, 5.4% and 5% instances respectively in vancomycin susceptibility reporting by disk diffusion method. however, tenover et al. observed article table 1. demographic profile of patients with enterococcal isolates (n=40). age group n (%) 0-10 years 2(5) 10-20 years 6(15) 20-30 years 13(32.50) 30-40 years 8(20) 40-50 years 3(7.5) 50-60 years 5(12.50) >60 years 3(7.5) table 2. distribution of errors in vancomycin susceptibility reporting by singular use of disk diffusion method (n=40). enterococci (n = 40) method (no. reported) no. of very major errors/no. no. of major errors/no. no. of minor errors/total no. of resistant isolates (%) of susceptible isolates (%) of isolates (%) disk diffusion 1/3 (33.3) 2/37 (5.4) 2/40 (5) table 3. distribution of errors in teicoplanin susceptibility reporting by singular use of disk diffusion method (n=40). enterococci (n = 40) method (no. reported) no. of very major errors/no. no. of major errors/no. no. of minor errors/total no. of resistant isolates (%) of susceptible isolates (%) of isolates (%) disk diffusion 0 2/38 (5.26) 0 figure 1. distribution of susceptibility to commonly used antibiotics among enterococcus spp. isolates. non -co mmerc ial us e o nly [page 66] [healthcare in low-resource settings 2022; 10:10806] no very major or major errors in their study while reporting and minor errors were limited to ≤6%.20 the inception of intermediate and resistant breakpoints for vancomycin in enterococci (e.g., designating mic of 816µg/ml as intermediate and 32 µg/ml as resistant) would not address the high rates of very major errors as these breakpoints would still fail to capture several of the nonsusceptible strains. meanwhile, it would be difficult to lower the zone diameter for vancomycin to reclassify 17 mm (which currently is in the susceptible range) as intermediate unless adequate data is available that demonstrates a lack of clinical efficacy. thus, optimizing the reading of these tests particularly disk diffusion and e-test for enterococci is necessary to improve the accuracy of vancomycin and teicoplanin susceptibility results. e-test is superior to the disc diffusion method in detecting resistance among enterococcal isolates against glycopeptide antibiotics of vancomycin and teicoplanin.20 though the gold standard test for detection of resistance in enterococcus spp. is broth dilution, its use in routine testing by manual antimicrobial susceptibility reporting is difficult. e test can be used in conjunction to disc diffusion in where resources are limited. in present study we have observed that by using a combination of both disk diffusion and mic determination by e-strip methods for glycopeptide antibiotics, a majority of reporting errors can be inscribed. however, research involving wider population and large sample sizes is required to further back our findings. references 1. murray be. the life and times of the enterococcus. clin microbiol rev 1990;3:46-65. 2. geraci je, wilson wr. vancomycin therapy for infective endocarditis. rev infect dis 1981;3:s250-8. 3. gump dw. vancomycin for treatment of bacterial meningitis. rev infect dis 1981;3:s289-92. 4. kirby wm. vancomycin therapy in severe staphylococcal infections. rev infect dis 1981;3:s236-9. 5. leclercq r, derlot e, duval j, courvalin p. plasmid-mediated resistance to vancomycin and teicoplanin in enterococcus faecium. new engl j med 1988;319:157-61. 6. uttley ah, george rc, naidoo j, et al. high-level vancomycin-resistant enterococci causing hospital infections. epidemiol infect 1989;103:173-81. 7. williamson r, al-obeid s, shlaes jh, et al. inducible resistance to vancomycin in enterococcus faecium d366. j infect dis 1989;159:1095-104. 8. hirt h, hall jw, larson e, gorr su. a d-enantiomer of the antimicrobial peptide gl13k evades antimicrobial resistance in the gram positive bacteria enterococcus faecalis and streptococcus gordonii. plos one 2018;13:e0194900. 9. uttley ac. vancomycin-resistant enterococci. lancet 1988;2:57-8. 10. uttley ah, george rc, naidoo j, et al. high-level vancomycin-resistant enterococci causing hospital infections. epidemiol infect 1989;103:173-81. 11. bhatt p, sahni ak, praharaj ak, et al. detection of glycopeptide resistance genes in enterococci by multiplex pcr. med j armed forces india 2015;71:437. 12. huang mb, baker cn, banerjee sh, tenover f. accuracy of the e test for determining antimicrobial susceptibilities of staphylococci, enterococci, campylobacter jejuni, and gram-negative bacteria resistant to antimicrobial agents. j clin microbiol 1992;30:32438. 13. clinical and laboratory standards institute. performance standard for antimicrobial susceptibility testing, 22nd ed. wayne, usa: clsi; 2022. 14. tenover fc, williams pp, stocker s, et al. accuracy of six antimicrobial susceptibility methods for testing linezolid against staphylococci and enterococci. j clin microbiol 2007;45:2917-22. 15. angadi k, jadhav s, misra rn, et al. incidence and antimicrobial susceptibility of enterococcal infections in tertiary care hospital. intl j microbiol res 2018;10:1135–8. 16. gupta v, singla n, behl p, et al. antimicrobial susceptibility pattern of vancomycin resistant enterococci to newer antimicrobial agents. indian j med res 2015;141:483. 17. mathew sk. a profile of vancomycinresistant enterococcal infections and a comparison of resistance detection methods. indian j microbiol res 2018;5:408–14. 18. rai s, niranjan dk, kaur t, et al. detection of the classical g2576u mutation in linezolid resistant staphylococcus aureus along with isolation of linezolid resistant enterococcus faecium from a patient on short-term linezolid therapy: first report from india. indian j med microbiol 2015;33:21–4. 19. khalili h, soltani r, negahban s, et al. reliability of disk diffusion test results for the antimicrobial susceptibility testing of nosocomial gram-positive microorganisms: is e-test method better? iranian j pharmaceut res 2012;11: 559. 20. tenover fc, swenson jm, o'hara cm, stocker sa. ability of commercial and reference antimicrobial susceptibility testing methods to detect vancomycin resistance in enterococci. j clin microbiol 1995;33:1524-7. article non -co mmerc ial us e o nly hrev_master healthcare in low-resource settings 2024; volume 12(s1):13045 the effectiveness of hyperoxygenation in preventing oxygen desaturation in intubated infants treated with endotracheal suctioning sholihatul amaliya,1 yeni rustina,2 defi efendi2 1nurse profession program, faculty of health sciences, universitas brawijaya, malang, east java; 2faculty of nursing, universitas indonesia, depok, west java, indonesia [healthcare in low-resource settings 2024;12(s1):13045] [page 73] significance for public health endotracheal suctioning is an essential nursing intervention for intubated infants treated with invasive mechanical ventilation. however, this procedure causes various side effects, including hypoxemia, and often requires hyperoxygenation. despite the effectiveness of hyperoxygenation, there are limited reports on its use among infants. the study indicates a notable oxygen saturation variation among infants who underwent endotracheal suctioning with hyperoxygenation. abstract endotracheal suctioning is an effective nursing intervention for intubated infants undergoing invasive mechanical ventilation. however, this intervention has the potential to cause side effects, such as hypoxemia, which typically requires hyperoxygenation. despite the widespread use of hyperoxygenation in clinical practice, there are limited reports on its effectiveness in infants. this study aims to determine the effect of hyperoxygenation on oxygen saturation of intubated infants. the study procedures were carried out using a quasi-experimental method with a cross-over approach. in addition, the sample population comprised 22 intubated infants who were treated at the perinatology unit of dr. cipto mangunkusumo hospital in jakarta from march to april 2018. the participants were then divided into 2 groups based on their condition, and oxygen saturation level was assessed. the intervention comprised endotracheal suctioning with and without hyperoxygenation, with a 3-hour washing period. data collection was performed at different measurement intervals, namely before, during, and after suctioning, followed by statistical analysis. the pairedsample t-tests and wilcoxon test showed that there was a significant difference in oxygen saturation at certain measurement intervals (p=0.006; p=0.010; p=0.001; p=0.001; p=0.001). in addition, friedman test also showed the presence of a significant difference in the reduction of oxygen saturation between the control and intervention groups (p=0.001). in conclusion, hyperoxygenation had the potential to prevent the reduction of oxygen saturation during endotracheal suctioning in intubated infants. however, individual assessment of the need for suctioning and hyperoxygenation was necessary for a safe and effective procedure. introduction respiratory insufficiency in infants is a prevalent challenge among newborns, which typically necessitates intensive care at the neonatal intensive care unit (nicu).1–3 several studies have shown that the majority of infants treated at the nicu often require invasive mechanical ventilation (mv) and the use of endotracheal tube (ett) to create a connection with the ventilator.4 however, ett causes mild inflammation in the airway mucosa and suppresses mucociliary mechanisms, leading to an impairment in the ability to mobilize and expectorate secretions. the use of ett also impairs cough reflexes, causing increased mucus production and accumulation in the airways.5,6 this accumulation has the potential to disrupt the ventilation of infants, thereby requiring frequent endotracheal suctioning to maintain the patency of the airway.7–9 according to previous studies, endotracheal suctioning is a routine nursing intervention for intubated patients to drain mucus secretion. in addition, it is often performed in patients who cannot remove secretions to maintain airway patency and provide optimal ventilation.8 several reports have shown that the use of proper endotracheal suctioning technique provides various benefits, namely improving respiratory sounds and gas exchange, decreasing airway resistance and pip (peak inspiratory pressure) of the ventilator, improving dynamic lung compliance, as well as enhancing oxygen saturation (spo2) and arterial blood gas.4 in infants, endotracheal suctioning is often performed using ett with a smaller diameter, leading to challenges during the procedure and increasing the risk of complications. ett with an internal diameter of ≤ 4mm has been reported to have the potential to cause an immediate reduction in dynamic lung compliance and expired tidal volume (tv). this shows that ineffective endotracheal suctioning can cause ett obstruction, atelectasis, as well as ineffective ventilation and oxygenation, thereby necessitating reintubation.4 although suctioning is essential for improving ventilation and oxygenation, the procedure is associated with various complications and risks. these include bleeding of mucosal airways, infection, atelectasis, hypoxia, hypoxemia, cardiovascular instability, and elevated intracranial pressure,5,10 with hypoxia and hypoxemia being the most common and severe. 5,9,11 in addition, stress due to the procedure can influence the metabolic rate and increase oxygen demand,12 showing the need for hyperoxygenation. according to previous studies, hyperoxygenation is the administration of oxygen fraction (fio2) at a percentage greater than the baseline requirement before suctioning up to 100%.4,9 although this technique is widely used in clinical practice to avoid hypoxemia, there are limited reports on its effectiveness in intubated infants. therefore, this study aims to determine the effectiveness of hyperoxygenation in endotracheal suctioning compared to suctioning without hyperoxygenation. non -co mmerc ial us e o nly materials and methods study design this was a quasi-experimental study with a cross-over approach, which was carried out to determine the immediate effects of hyperoxygenation in endotracheal suctioning compared to endotracheal suctioning without hyperoxygenation on oxygen saturation in 2 different groups of newborn infants. each sample received 2 types of intervention, namely endotracheal suctioning with hyperoxygenation (for the intervention group) and endotracheal suctioning without hyperoxygenation (for the control group). in addition, this was a single-centered study, and trials were conducted based on standard protocols as well as good clinical practice and national ethical guidelines. sample and setting the sample population comprised 22 infants who were treated in dr. cipto mangunkusumo hospital, the national referral hospital located in central jakarta, indonesia from march to april 2018. in addition, the participants were allocated based on their condition before suctioning procedure. infants were eligible for admission when mechanically ventilated through ett and had an indication for endotracheal suctioning. the indications included clinical history of decreased spo2 in previous suction, visible secretions in the ett, audible secretions, changes in respiratory rate, and decreased spo2 immediately before suctioning. exclusion criteria included ventilation using high-frequency oscillating (hfo) ventilation, the presence of conditions, requiring perfusion, such as hypotension, anemia, cold stress, congenital heart disease, and presence of skin lesions detected by oxygen saturation device based on blood saturation number, and chronological age of more than 28 days. the sample size estimation was performed based on a previous study by walsh et. al (1987), which used 16 participants.13 this study compared supplemental oxygenation or hyperoxygenation during tracheobronchial hygiene on the transcutaneous partial pressure of oxygen (tcpo2). the results showed that the standard deviation of change in tcpo2 was 17.58 torr and the mean difference between groups considered significant (effect size) was 22.54 torr. 13 based on these results, the calculated minimum sample size per group was 19, and this present report used a total of 22 infants. to minimize the between-subject variability, the participants used 2 types of ventilators with the same specifications. suction procedure was carried out in the same position (supine) and was supported by nesting by the same nurse using the same standard intervention process. intervention the participants were allocated into 2 sequential enrollment schemes based on infants’ condition before interventions (conditions that require suctioning), hence, the section was not carried out routinely.14 the participants received 2 different interventions, namely endotracheal suctioning with and without hyperoxygenation. this showed when the participants had a significant decrease in spo2 ≥ 2 points (%) before suctioning procedure compared to the previous condition, hyperoxygenation was performed and the next suctioning was carried out without hyperoxygenation with infants being placed in group a (ga). in group b (gb), when there was a significant increase in spo2 ≥ 2 points (%), the reverse process was carried out. endotracheal suctioning intervention was performed based on the hospital’s protocol by 2 individuals (the researcher and research assistant) as recommended by professional organizations to ensure the safety of the participants.15,16 intervention in group a comprised endotracheal suctioning procedure when infants showed indications. these indications included clinical history of decreased spo2 in previous suctioning, decreased spo2 before suctioning, visible secretions in the ett, audible secretions, coarse and/or decreased breath sounds, and changes in respiratory rate and pattern. before the first endotracheal suctioning was carried out, hyperoxygenation was performed by pressing the “suctioning support” button on the ventilator, leading to an additional 20% fio2 for 2 minutes. in this study, hyperoxygenation was performed 30 seconds before suctioning. several reports showed that endotracheal suctioning must not exceed 10 seconds, with each suctioning comprising 3 probe insertions. subsequently, the second suctioning was performed after infants’ saturation returned to normal range after decreasing due to the first suctioning and the third suctioning. the procedures were performed in a supine position and the participants were supported by nesting. the use of nesting in premature infants facilitated relaxation and comfort to minimize pain.17 group b underwent the same intervention as group a, but without hyperoxygenation before endotracheal suctioning. data collection and analysis in this study, pre and post-suctioning oxygen saturation (spo2) was obtained in 6 different measurements, namely 60 seconds before suctioning (t-1), immediately after hyperoxygenation (t0), after the first suctioning repetition (t1), after the second suctioning repetition (t2), after the third repetition (t3), and 3 minutes after suctioning (t4). moreover, the socio-demographic characteristics, gestational age, and birth weight of the participants were also measured. statistical analysis was performed using spss version 16, and the data normality was assessed using shapiro wilks test. the demographic data were evaluated by measuring distribution, frequency, and the central tendency for birth weight and gestational age. the differences across groups on infants’ oxygen saturation (spo2) were analyzed using paired-sample t-tests (normal data), and wilcoxon (abnormal data). for data within groups, analysis was carried out using friedman test, followed by post-hoc wilcoxon test. data were reported as mean difference (95% ci) and p-values < 0.05 were considered significantly different. ethical considerations this study was conducted after obtaining approval from the ethics committee of the faculty of nursing, university of indonesia (no.139/un2.f12.d/hkp.02.04/2018), hospital’s approval where the procedures were conducted, and written consent from parents or guardians. results and discussion participants’ characteristics the characteristics of the participants consisted of gestational age and birth weight, which were described in table 1 and figure 1. the results showed that the mean gestational age was 33.23 weeks and the majority of infants (36.4%) were late preterm (gestational age 34-36 weeks), with low birth weight (50%). the majority of the participants were preterm infants, particularly late preterm, with gestational age ranging from 27 to 36 weeks and low birth weight of 1000 to 2499 grams. preterm infants with low birth weight had a great risk for respiratory complications due to the late maturity of the respiratory system.18 some of the problems affecting the respiratory system of 4th international nursing and health sciences symposium [page 74] [healthcare in low-resource settings 2024;12(s1):13045] non -co mmerc ial us e o nly preterm infants and causing breathing difficulty were surfactant deficiency that led to respiratory distress syndrome (rds), immaturity of respiratory control central causing apnea, and increased risk of airway obstruction due to smaller respiratory airways. the most common respiratory complication in preterm infants with low birth weight was rds caused by lung immaturity and lack of surfactant, which affected the poorly compliant lungs with poor gas exchange. this respiratory complication could cause respiratory failure that required invasive or non-invasive mv. the differences in oxygen saturation (spo2) across groups the results of the paired t-test in table 2 and figure 2 showed that there were significant differences in oxygen saturation at several measurements between the intervention and control groups. these differences were observed before the intervention (hyperoxygenation), in the first, second, and third suctioning repetition, and 3 minutes after mucus suctioning. based on the results, the mean oxygen saturation of the intervention group was greater compared to the controls at t0, t1, t2, t3, and t4. figure 2 showed that the intervention group experienced an increase in oxygen saturation after hyperoxygenation. after the first, second, and third suctioning repetitions, oxygen saturation decreased but did not become a desaturation period where the percentage was less than 85%. these results were inconsistent with the control group, which experienced a decrease in oxygen saturation to desaturation after the third suctioning. oxygen saturation during endotracheal suctioning in this study was measured at 6 different periods, namely 60 seconds before suctioning, immediately after hyperoxygenation, after the first second, and third repetition, and three minutes after suctioning. the result showed that during endotracheal suctioning at first, second, 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13045] [page 75] table 1. respondents’ characteristics based on the infants’ gestational age and birth weight (n=22). variable mean sd range (min-max) 95% ci gestational age (weeks) 33.23 3.380 27-38 31.73-34.73 birth weight (grams) 1952.95 731.485 740-3520 1628.63-2277.28 variable f % gestational age (weeks) extremely premature 1 4.5 very premature 6 27.3 moderately premature 2 9.1 late preterm 8 36.4 aterm 5 22.7 birth weight (grams) extremely low birth weight 2 9.1 very low birth weigh 4 18.2 low birth weight 11 50 normal birth weight 5 23 table 2. the differences in oxygen saturation (spo2) across groups (n=22). variable suction with hyperoxygenation 95% ci suction without hyperoxygenation 95% ci p value (mean+ sd) (mean+ sd) t-1 87.32±7.52 83.98-90.65 91.91±3.82 90.22-93.60 0.006* t0 93.68± 5.43 91.28-96.09 91.91±3.82 85.80-89.84 0.147 t1 91.68 (77-100) 89.32-94.05 87.82 (76-95) 85.80-89.94 0.014** t2 91.82±5.82 89.24-94.40 85.91±4.59 83.88-87.94 0.001* t3 90±5.54 87.54-92.45 83.77±5.30 81.42-86.12 0.001* t4 96 (87-99) 93.61-96.12 90 (85-96) 88.81-91.46 0.001** * p < 0.05, there is a significant difference used paired t test. ** p < 0.05, there is a significant difference used wilcoxon. figure 1. recruitment diagram and respondent allocation. non -co mmerc ial us e o nly and third suctioning repetition, there was higher oxygen saturation in the intervention group compared to the controls. based on the results of the paired t-test and wilcoxon test, there was a significant difference in oxygen saturation after the first, second, and third suctioning repetitions between the intervention and control groups. this was because the intervention group was given hyperoxygenation by giving an additional 20% of fio2 for 2 minutes which could prevent and minimize the occurrence of hypoxemia in infants during suctioning.4,7,13 hyperoxygenation by adding fio2 of 10-20% was adequate in preventing hypoxemia when suctioning through ett.7 the differences of oxygen saturation (spo2) within groups differences in oxygen saturation within the intervention and control groups were assessed using the friedman test and continued with the post hoc wilcoxon test (table 3). the results of the intervention group showed that there were significant differences in several pairs of oxygen saturation measurement points, namely (t-1) t0, t0 t1, t0 t2, and t0 -t3 but t0 t4 did not show significant variation. this was different in the control group where there were differences in oxygen saturation with all measurement points (t1, t2, t3, t4). this study showed differences in spo2 before intervention after hyperoxygenation, showing that the administration of hyperoxygenation through the addition of 20% could increase spo2 in infants before suctioning. spo2 after hyperoxygenation was significantly different from the value in the first, second, and third suctioning repetitions in both groups. however, the decrease in spo2 in the control group was greater compared to the intervention group. this showed that endotracheal suctioning procedure was able to significantly reduce spo2 despite hyperoxygenation. the decrease in spo2 during suctioning procedure occurred due to the removal of air from the airways.5 the administration of negative pressure during suctioning could also cause a collapse of distal airways and alveoli despite the use of appropriate pressure and technique, leading to a reduction of spo2.19 the use of the open suctioning method in this study comprised the temporary disconnection of mv from infants’ ett, thereby interrupting airflow from mv, and this could serve as another contributing factor.20 other studies comparing open and close suctioning in infants who underwent endotracheal suctioning showed that the participants were able to sustain spo2 during the procedure with no significant difference. this was caused by the participants’ ability to perform spontaneous pulmonary ventilation, leading to an increase in rr immediately after ett suctioning as a compensation mechanism to sustain their spo2.21 the result also showed that in the intervention group, there was no significant difference between spo2 after hyperoxygenation (t1) compared to the value at 3 minutes after mucus suctioning (t4). within 3 minutes after suctioning, the spo2 level in the intervention group could return to the previous value. this proved that the administration of hyperoxygenation for 2 minutes could restore the value of spo2 to the previous level and within the normal range (88%-93%). different results were obtained in the control group where spo2 at t1 significantly varied from t4. the results showed that within 3 minutes, spo2 had not been able to return to the previous value and also had experienced desaturation (spo2 less than 88%). these results were also consistent with previous studies where a group of preterm infants who received hyperoxygenation before suctioning experienced fewer episodes of hypoxemia compared to those who received suctioning without hyperoxygenation and needed less time to reach normal spo2.22 exposure to non-physiological oxygen levels (hypoxia or hyperoxia) could cause rop, and continuous or intermittent hypoxia typically reduced myelination and induced angiogenesis in preterm animals.23 4th international nursing and health sciences symposium figure 2. the changes of oxygen saturation in endotracheal suctioning at control and intervention group. table 3. the differences of oxygen saturation (spo2) within groups (n=22). variable suction with hyperoxygenation (mean+ sd) suction without hyperoxygenation (mean+ sd) t-1 87.32±7.52 91.91±3.82 t0 95 (79-100)* 91.91±3.82 t1 91.86±5.41* 87.82±4.56* t2 93.50 (76-99)* 85.91±4.59* t3 91 (76-96)* 83.77±5.30* t4 96 (87-99) 90.14±2.98* p value 0.001 0.001 *significant difference at t0 with some messurement points [page 76] [healthcare in low-resource settings 2024;12(s1):13045] non -co mmerc ial us e o nly the comparison in oxygen saturation (spo2) reduction across groups in this study, the reduction in oxygen saturation (spo2) was calculated as the difference between oxygen saturation after hyperoxygenation and the lowest spo2 recorded during endotracheal suctioning procedure. the result in table 4 showed that there was a significant difference in spo2 reduction in the intervention group compared to the control group where the decrease in oxygen saturation in the control group was greater. the decrease in spo2 in the control group was higher compared to the intervention group. this was because, in the intervention group, hyperoxygenation was performed before suctioning. hyperoxygenation was performed on infants by adding 10-20% fio2 above the previous oxygen percentage. a 20% increase in fio2 before mucus suctioning was as effective as giving 100% oxygen.4 other studies also suggested hyperoxygenation in newborns by increasing fio2 by 10% before mucus suctioning.22 however, the administration of hyperoxygenation must be considered carefully to prevent complications. some experts stated that the procedure must not be performed routinely, but only when the neonate had an indication, namely a clinical history of decreased spo2 during previous suctioning and decreased spo2 due to accumulation of secretions before suctioning.4,22 the correlation of oxygen saturation (spo2) reduction and respondents’ characteristics the correlation between decreased oxygen saturation (spo2) and the participants’ characteristics was analyzed to control the confounding factors, such as birth weight and gestational age. the result of the pearson correlation in table 5 showed that there was no relationship between the decrease in oxygen saturation (spo2) with birth weight and gestational age. based on these results, the difference in the decrease in oxygen saturation that occurred in the intervention and control groups was caused by hyperoxygenation intervention. the present study showed that infants’ oxygen saturation during and after endotracheal suctioning across both groups was significantly different. in addition, there was a significant difference in the reduction of oxygen saturation across both groups, with the control group possessing a higher value. the implementation was based on infants’ response to care and previous suctioning. several studies showed that nurses must conduct individual assessments of the need for suctioning and hyperoxygenation before performing endotracheal suctioning. when there there signs of infants requiring the procedure, namely visible secretions in the ett, audible secretions, coarse and/or decreased breath sounds, changes in respiratory rate9 and pattern and accompanied by a decrease in oxygen saturation below 85% or 90% or a history of decreased saturation on previous suctioning, it was necessary to perform hyperoxygenation before endotracheal suctioning.4 in addition, nurses had the option to rely on their clinical judgment or experience to decide the frequency of repetitions and the appropriate adjustment of fio2, with a maximum allowance of 3 times suctioning repetitions and a fio2 increase of up to 20%. despite its potential, hyperoxygenation could also cause side effects, namely hyperoxemia, which was associated with serious long-term effects, such as retinopathy of prematurity (rop), and chronic lung disease (cld) due to oxygen free-radical damage9. therefore, when nurses observed that suctioning with hyperoxygenation led to an increase in infants’ oxygen saturation to 100%, this showed the possibility of reducing repetitions or decreasing fio2 addition during subsequent suctioning to mitigate the risk of hyperoxemia. according to previous reports, there was also a crucial need to consider suctioning, specifically for extremely preterm infants during the first days of life. this was because a retrospective study showed an inverse relationship between the incidence of ivh and the number of suctioning.6 conclusions in conclusion, this study showed that an increase in fio2 of 20% from the baseline value before endotracheal suctioning could be sufficient, effective, and safe to prevent hypoxemia and quickly return infants’ oxygen saturation to normal ranges. the results obtained could be used as evidence and the basis for nurses in carrying out hyperoxygenation before endotracheal suctioning. the limitation of this study was the failure to set a standard percentage of the definition of a “decrease in oxygen saturation” and the use of a reduction from previous conditions. therefore, future studies were advised to set a standard for decreasing oxygen saturation with a certain number, such as <85% or <93%.24,25 randomization of participants was not carried out randomly and completely, because it was based on the patients’ condition, hence, there was a 4th international nursing and health sciences symposium table 4. the differences in oxygen saturation (spo2) reduction across groups (n=22). the decrease of spo2 in endotracheal suctioning mean sd 95% ci p value intervention control (hyperoxygenation) 4.27 3.18 2.86-5.68 0.001 control group (with hyperoxygenation) 8.5 4.21 6.68-10.41 paired t test. table 5. the correlation of oxygen saturation (spo2) reduction and respondents' characteristics. gestational age birth weight spo2 reduction r = 0.232 r = 0.050 p = 0.130 p = 0.747 pearson correlation [healthcare in low-resource settings 2024;12(s1):13045] [page 77] non -co mmerc ial us e o nly risk of bias. although this study used a crossover approach, it was classified as a quasi-experiment. moreover, the procedures did not monitor respiratory indicators, such as ventilation per minute, tv, and long-term survival of infants. future studies were expected to observe oxygenation in vital organs, such as the brain during mucus suctioning procedure using nirs. the desaturation period that occurred in mucus suctioning must also be monitored and compared in the two groups. references 1. reuter s, moser c, baack m. respiratory distress in the newborn. pediatr rev 2014;35:417–28. 2 oktaviani e, rustina y, efendi d. facilitated tucking effective to pain relief on the preterm infants in perinatal unit in jakarta. j keperawatan indones 2018;21:9–16. 3 babaei h, dehghan m, pirkashani lm. study of causes of neonatal mortality and its related factors in the neonatal intensive care unit of imam reza hospital in kermanshah, iran during (2014-2016). int j pediatr 2018;6:7641–9. 4 gonçalves rl, tsuzuki lm, carvalho mgs. endotracheal suctioning in intubated newborns: an integrative literature review. rev bras ter intensiva 2015;27:284–92. 5 kiraly jn, tingai, g d, mills fj, morley jc, copnell b. endotracheal suction. pediatr res 2008;26:527–9. 6 bruschettini m, zappettini s, moja l, calevo mg. frequency of endotracheal suctioning for the prevention of respiratory morbidity in ventilated newborns. cochrane database syst rev 2015;2015. 7 tavangar h, javadi m, sobhanian s, jahromi ff. the effect of the duration of pre-oxygenation before endotracheal suction on hemodynamic symptoms. glob j health sci 2016;9:127. 8 kalyn a, blatz s, feuerstake s, et al. closed suctioning of intubated neonates maintains better physiologic stability: a randomized trial. j perinatol 2003;23:218–22. 9 gardner dl, shirland l. evidence-based guideline for suctioning the intubated neonate and infant. neonatal netw 2009;28:281–302. 10 trevisanuto d, doglioni n, zanardo v. the management of endotracheal tubes and nasal cannulae: the role of nurses. early hum dev 2009;85:s85–7. 11 tingay dg, copnell b, mills jf, et al. effects of open endotracheal suction on lung volume in infants receiving hfov. intensive care med 2007;33:689–93. 12 clifton-koeppel r. endotracheal tube suctioning in the newborn: a review of the literature. newborn infant nurs rev 2006;6:94–9. 13 walsh cm, bada h, korones s, carter m. controlled suplemental oxygenation during tracheobronchial hygiene.pdf. nurs res 1987;36:211–5. 14 cavallin f, res g, monfredini c, et al. time needed to intubate and suction a manikin prior to instituting positive pressure ventilation: a simulation trial. eur j pediatr 2021;180:247–52. 15 altimier l, brown b, tedeschi l. nann guidelines for neonatal nursing policies, procedures, competencies, and clinical pathways. glenview: national association of neonatal nurses; 2006. 2006 p. 16 cone s, pickler rh, grap mj, et al. endotracheal suctioning in preterm infants using four-handed versus routine care. jognn j obstet gynecol neonatal nurs 2013;42:92–104. 17 efendi d, sari d, riyantini y, et al. pemberian posisi (positioning) dan nesting pada bayi prematur: evaluasi implementasi perawatan di neonatal intensive care unit (nicu). j keperawatan indones 2019;22:169–81. 18 ricci ss. essentials of maternity, newborn, & women’s health nursing [internet]. lippincott williams & wilkins; 2012. available from: https://books.google.co.id/books?id=nvcduwaacaaj. 19 tan am, gomez jm, mathews j, et al. closed versus partially ventilated endotracheal suction in extremely preterm neonates: physiologic consequences. intensive crit care nurs 4th international nursing and health sciences symposium correspondence: sholihatul amaliya, faculty of health sciences, universitas brawijaya, malang, indonesia. jl. puncak dieng, kunci, kalisongo, kec. dau, malang, east java, indonesia, postcode: 65151, tel.: +62341569117, fax: +62341564755, email: liya.fk.psik@ub.ac.id key words: endotracheal suction; hyperoxygenation; intubated infant; oxygen saturation contributions: all authors participated in the acquisition, analysis, or interpretation of data. concept and design by de and sa. drafting of the manuscript by sa and yr. statistical analysis by sa. administrative, technical, or material support by sa and yr. all authors have read and approved the final manuscript. conflict of interest: the author declares no potential conflict of interest. funding: the authors thank the faculty of health sciences at universitas brawijaya for their generous support of this study. ethics approval: this study was conducted after obtaining approval from the ethics committee of the faculty of nursing, university of indonesia (no.139/un2.f12.d/hkp.02.04/2018), hospital's approval where the procedures were conducted, and written consent from parents or guardians. clinical trials: not applicable. conference presentation: part of this article was presented at the 4th international nursing and health sciences symposium, from 27th-28th of october 2023, universitas brawijaya, malang, east java, indonesia. acknowledgment: the authors thank the hospitals for granting permission to conduct this study and the participants for their involvement. special thanks are extended to prof. dr. titin andri wihastuti, s.kp., m.kes. for their support during publication. received: 3 november 2023. accepted: 8 june 2024. early view: 10 september 2024. this work is licensed under a creative commons attribution 4.0 license (by-nc 4.0). ©copyright: the author(s), 2024 licensee pagepress, italy healthcare in low-resource settings 2024; 12(s1):13045 doi:10.4081/hls.2024.13045 publisher's note: all claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. any product that may be evaluated in this article or claim that may be made by its manufacturer is not guaranteed or endorsed by the publisher. [page 78] [healthcare in low-resource settings 2024;12(s1):13045] non -co mmerc ial us e o nly 2005;21:234–42. 20 walsh bk, hood k, merritt g. pediatric airway maintenance and clearance in the acute care setting: how to stay out of trouble. respir care 2011;56:1424–44. 21 cardoso jm, kusahara dm, guinsburg r, pedreira mlg. randomized crossover trial of endotracheal tube suctioning systems use in newborns. nurs crit care 2017;22:276–83. 22 pritchard ma, flenady v, woodgate p. systematic review of the role of pre-oxygenation for tracheal suctioning in ventilated newborn infants. j paediatr child health 2003;39:163–5. 23 morken ts, nyman akg, sandvig i, et al. brain development after neonatal intermittent hyperoxia-hypoxia in the rat studied by longitudinal mri and immunohistochemistry. plos one 2013;8:1–13. 24 jain d, d’ugard c, bello j, et al. hypoxemia episodes during day and night and their impact on oxygen saturation targeting in mechanically ventilated preterm infants. neonatology 2017;113:69–74. 25 castillo a, sola a, baquero h, et al. pulse oxygen saturation levels and arterial oxygen tension values in newborns receiving oxygen therapy in the neonatal intensive care unit: is 85% to 93% an acceptable range? pediatrics 2008;121:882–9. 4th international nursing and health sciences symposium [healthcare in low-resource settings 2024;12(s1):13045] [page 79] non -co mmerc ial us e o nly